110 sys most of shift. no c/o chest tightness\\n\\nresp: desats more when lying down to 85 with out o2 and 93 lying flat with 5l nc o2. sat 98% on 5l sitting up. no sputum produced other than when vomiting and unable to get spec; need to use incent spirometry\\n\\ngi: no bm hypoactive snds, po intake needs much encouragement and judgement on nureses part. pt held down boost, toast, crqackers, soup and juice. compazine iv over 30 min did great in am to control nausea and vomited x2 since lunch only 100 cc. PR compazine given at 1530 and no further vomiting.\\n\\ngu: intake 3500+ cc and 1700cc out since midnight and ivs to kvo at 1200. no void, no str cath, urine is more yellow\\n\\naccess: lost lt anticub iv. using rt arm only and needs another iv.\\n\\nENDO: insulin gtt decreased to 5 units /hr when glu down to 90 and the stale glu 90-135 until 1430 to 74 and stopped insulin. pt took 240 cc oj and glucose is now on rise. plan to watch sugers for 1-2hr and restart on short acting insulin. orders need to be written.\\n\\nID: no exact organism identified yet but afeb on current antibx\\n\\nlabs: this am k 3.6 but hemolized will attempt to draw lytes this eve but pt tolerated oj which is high in potassium.\\n\\nplan: poss call out if on sc insulin. needs iv and lytes, oob to chair to improve resp status.\\n\\np\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2116-12-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309068,\n \"text\": \"Patient admitted from ED on at 2330 for ICU monitoring overnite and then transfer to medical floor in AM. Patient was diagnosed with pylonephrosis after coming to ER on with flank pain and chills and fever. A nephrostomy tube was placed on the left side on at 1030 am.\\n\\nNeuro: Patient is a very sweet, calm and cooperative young woman of 25 years of age. She was complaining of nausea and exhaustion. She was medicated with Ambien at 0100 for sleep.\\n\\nCardio: Normal sinus rhythm, SBP greater than 100 this shift. Afebrile at 98.6 PO. PEERL. No ectopy noted. Pt is IDDM for over 20 years. Her finger stick at 2350 was 133 and required no RHI. She did receive 17 units of MD order.\\n\\nPulm: Room air, sats >96%, respirations 16-20, lungs clear.\\n\\nGI: Sipping diet gingerale, medicated for nausea, emesis was clear mucous with scant green noted. Positive bowel signs and BM times 2 this shift. Unable to test stool due to menses discolored stool.\\n\\nGU: Patient feels that she has to urinate but when placed on bedside commode, she could not void. She has a left nephrostomy tube with 200 cc emptied upon admission to ICU. It was bloody. During the shift it cleared to amber color. Urine sample was sent to lab.\\n\\nLabs: Blood cultures are positive for gram negative rods.\\n\\nSkin Intact, no breakdown. Pt started menses while in ED.\\n\\nPlan: transfer to medical floor in am if stable.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2116-12-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309069,\n \"text\": \"pt is not called out as of 1600\\nNuero: pt a7o x3 MAE OOB to w/c for tests off floor. mentating with out problems\\n\\ncard: tachy with no ectopy\\n\\nresp: pt recieved on ra but when o2 sat checked at 1400 sat was in low 80's. o2 5l nc applied to raise =sat to 96%. no c/o sob or pain and HO made aware. cxr obtained at 1645 for low sat.\\n\\ngi: pt vomiting at lease q 1hr stomach contents or bile. medicated with reglan. anzemet, and compazine of which anzemet was most helpful. dose increased but nausea continues. pt had lg soft formed bm at 0830 and none since. bs hypoactive.\\n\\ngu: nephrostomy tube in place and draining yellow to brown apporx 1200 cc since admit to icu. foley placed for pos bladder retention as no void but no output via foley thus d/ced. nephrostomy tube ends in pt bladder and not flushed. bun and creat elevated but pt basseline not known. pt hydrated for low urine output for a total of 1500 cc ns\\n\\ngyn: pt has ovarian cyst 6x5 cm thought to be pressing on ureter causing hydronephrosis.\\n\\nlabs:mag down this pm to 1.7 and will need to be repleted. see labs\\n\\nid: gram pos rods in 4 of 4 cultures from . sent one set for bld culture today and was difficult stick. on 2 antibx. afebrile all shift\\n\\nendo: pt has not been able to hold down much fluid of food d/t nausea.\\n fingersticks are up and was covered with humalog insulin x2 but then started regular insulin gtt and currently gtt at 2 units /hr for most recent glu 207 at 1900. not clear if anion gap d/t elevated glu or d/t acute renal failure.\\n\\ntests: pt had renal ultsnd this am. went for abd MRI but could not tolerate due to nausea, and will poss get in am.\\n\\nplan: reeval need for iv fluids, may need a better iv liv=ne for hihg iv vol, manage nausea and monitor o2 sats\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-12-07 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 852521,\n \"text\": \" 8:06 AM\\n CHEST (PA & LAT) Clip # \\n Reason: evaluate for interval changes\\n Admitting Diagnosis: PYELONEPHRITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 25 year old woman with pyelonephritis, DKA, bacteremia who has worsening\\n pulmonary exam and CXR findings\\n REASON FOR THIS EXAMINATION:\\n evaluate for interval changes\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Respiratory distress.\\n\\n CHEST X-RAY: Comparison is made to study from one day earlier. The study is\\n limited by low lung volumes. Prominence of the cardiac silhouette is noted,\\n but again may be related to submaximum inspiration.\\n\\n There are small bilateral pleural effusions. Patchy increased density in both\\n lung bases may reflect associated atelectasis, although early/limited\\n pneumonia cannot be excluded.\\n\\n On the lateral view, there is a broad band-like density which projects over\\n the mid chest anteriorly, again most suggestive of subsegmental atelectasis.\\n There is no evidence of CHF.\\n\\n IMPRESSION: Small bilateral effusions and likely bibasilar atelectasis. Note\\n that pneumonia cannot be entirely excluded.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-12-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 852335,\n \"text\": \" 5:33 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: infiltrate?\\n Admitting Diagnosis: PYELONEPHRITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 25 year old woman with pyelonephritis, DKA now with acute desaturation\\n REASON FOR THIS EXAMINATION:\\n infiltrate?\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Chest radiograph.\\n\\n INDICATION: A 25-year-old woman with pyelonephrosis and DKA. Now acute\\n desaturation.\\n\\n TECHNIQUE: Portable erect chest radiograph was performed.\\n\\n COMPARISON: This study is compared to examination from .\\n Compared to that examination, there has now been a dramatic interval decline,\\n even allowing for suboptimal technique. There is now evidence of extensive\\n airspace consolidation within both lung fields. There is in addition,\\n obliteration of the right hemidiaphragm consistent with an extensive right\\n basilar pathology. In addition, silhouetting of the left hemidiaphragm is\\n also seen. No evidence of pneumothorax. Some ill-defined wires are again\\n identified in the patient's neck, of undetermined significance, but are\\n largely unchanged from previous.\\n\\n There is mild upper lobe venoud diversion consistant with fluid overload.\\n CONCLUSION:\\n\\n Dramatic interval decline, with development of bilateral airspace\\n consolidation, atelectasis and effusons bibasilarly. The visualized portions\\n of the central airways appear patent.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-12-06 00:00:00.000\",\n \"description\": \"MRI PELVIS W/O & W/CONTRAST\",\n \"row_id\": 852479,\n \"text\": \" 1:54 PM\\n MRI PELVIS W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \\n MR RECONSTRUCTION IMAGING\\n Reason: see below\\n Admitting Diagnosis: PYELONEPHRITIS\\n Contrast: MAGNEVIST Amt: 16CC\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 25 year old woman with pyleo and ureter obstruction. L ovarian mass on U/S,\\n please characterize ovarian mass and evaluate ureteral system.\\n REASON FOR THIS EXAMINATION:\\n see below\\n ______________________________________________________________________________\\n FINAL REPORT\\n MRI OF THE PELVIS.\\n\\n HISTORY: History of left flank pain, fever, nausea and vomiting. CT urogram\\n demonstrating acute left pyelonephritis with moderate left hydronephrosis and\\n hydroureter. Pelvic ultrasound demonstrating a left ovarian cyst with follow-\\n up recommended in weeks. Please characterize ovarian mass and evaluate\\n ureteral system.\\n\\n TECHNIQUE: Multiplanar T1- and T2-weighted MRI of the pelvis was performed\\n both prior to and following uneventful intravenous administration of\\n gadolinium.\\n\\n COMPARATIVE STUDIES: CT urogram from and pelvic ultrasound\\n from .\\n\\n FINDINGS:\\n\\n The distal third of the left ureter demonstrates the presence of a stent and\\n no evidence of dilatation currently. There is enhancement of the ureteral\\n wall. This is likely due to manipulation of the ureter during placement of\\n the stent. Less likely, this can be a result of inflammatory change. The\\n ureter can be traced all the way up to the urinary bladder without encasement\\n or mass lesions in its path.\\n\\n There is an exophytic cyst in relationship to the left ovary measuring 5.5 cm\\n which has an adjacent smaller 17-mm non-enhancing hemorrhagic cyst. The rest\\n of the left ovary and the right ovary are normal in appearance. There is a\\n small amount of free fluid in the pelvis.\\n\\n The uterus is normal in size and in signal characteristics. There is no\\n pelvic lymphadenopathy.\\n\\n Multiplanar reconstructions on the workstation were helpful in delineating the\\n above findings.\\n\\n IMPRESSION:\\n\\n 1) Stent is demonstrated throughout the length of the distal left ureter which\\n is not dilated. Enhancement of the wall of the left ureter may be a result of\\n (Over)\\n\\n 1:54 PM\\n MRI PELVIS W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \\n MR RECONSTRUCTION IMAGING\\n Reason: see below\\n Admitting Diagnosis: PYELONEPHRITIS\\n Contrast: MAGNEVIST Amt: 16CC\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n manipulation due to placement of the stent, or less likely, secondary to\\n inflammation. There is no encasement or mass involving the course of the left\\n ureter.\\n\\n 2) Large exophytic cyst related to the left ovary with a smaller adjacent non-\\n enhancing hemorrhagic cyst. Follow-up ultrasound in six weeks is suggested,\\n as also suggested on the ultrasound, to document disappearance of this cyst.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-12-04 00:00:00.000\",\n \"description\": \"RENAL U.S.\",\n \"row_id\": 852268,\n \"text\": \" 10:02 AM\\n RENAL U.S. Clip # \\n Reason: please assess kidney and bladder and also liver(area of hypo\\n Admitting Diagnosis: PYELONEPHRITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 25 year old woman with left hydronephrosis s/p nephrostomy tube\\n REASON FOR THIS EXAMINATION:\\n please assess kidney and bladder and also liver(area of hypodensity on CT)\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Evaluate for hydronephrosis post-nephrostomy tube placement.\\n\\n RENAL ULTRASOUND: The right kidney is normal without hydronephrosis, stones,\\n or mass. The right kidney measures 14 cm.\\n\\n A stent is in place within the left kidney. There is minimal fullness of the\\n left renal pelvis. There is no hydronephrosis. The left kidney measures 14.3\\n cm. Prominent columns of Bertin are noted. The urinary bladder appears\\n unremarkable.\\n\\n IMPRESSION:\\n No residual left hydronephrosis post-nephrostomy tube placement.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-12-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 852464,\n \"text\": \" 10:24 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Evaluate for changes in infiltrate\\n Admitting Diagnosis: PYELONEPHRITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 25 year old woman with pyelonephritis, DKA now with acute desaturation\\n\\n REASON FOR THIS EXAMINATION:\\n Evaluate for changes in infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: A 25-year-old with pyelonephritis and diabetic ketoacidosis, no\\n acute desaturation.\\n\\n Comparison is made to the prior study of two days earlier. Bilateral pleural\\n effusion and compression partial atelectasis of the lower lobes and bilateral\\n pulmonary vascular congestion are again noted.the Right pleural effusion is\\n slightly larger at this time.\\n\\n IMPRESSION:\\n\\n Some worsening in the right pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-12-03 00:00:00.000\",\n \"description\": \"INTRO CATH OR STENT INTO URETHER\",\n \"row_id\": 852111,\n \"text\": \" 7:42 AM\\n PERC NEPHROSTO Clip # \\n Reason: Needs perc. nephrostomy tube for drainage\\n Contrast: CONRAY Amt: 15\\n ********************************* CPT Codes ********************************\\n * INTRO CATH OR STENT INTO URETH INTRO CATH OR STENT TO URETHER *\\n * UD GUID FOR NEEDLE PLACMENT CATHETER, DRAINAGE *\\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 25 year old woman with L flank pain, evidence of pyelonephritis on CT scan,\\n obstruction.\\n REASON FOR THIS EXAMINATION:\\n Needs perc. nephrostomy tube for drainage\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 25-year-old female with left flank pain, fever, moderate\\n hydronephrosis on CT scan.\\n\\n PROCEDURE/FINDINGS:\\n\\n The procedure was performed by Drs. & , with Dr.\\n , the attending radiologist, present and supervising. After obtaining\\n written informed consent, the patient was placed supine on the angiographic\\n table. The left flank was prepped and draped in standard sterile fashion. A\\n preprocedure timeout was performed. Through an anesthtized skin approach and\\n with ultrasound guidance, a 21-gauge spinal needle was inserted into the renal\\n pelvis. Opacification of the renal system was performed with contrast and\\n air. Then, posterior local calix was selected, again with a 21-gauge spinal\\n needle. The inner stylet was removed and an Accustick wire was passed into\\n the renal collecting system. The needle was then exchanged for an Accustick\\n system, which was advanced over the wire. The Accustick outer dilator was\\n then exchanged for a 6 French angiographic sheath. The inner dilator of the\\n sheath was removed. A Kumpe catheter was advanced through the sheath into the\\n renal collecting system and the wire directed into the ureter and into the\\n urinary bladder. The Kumpe catheter and sheath were then removed, and an 8\\n French, 24-cm nephroureteric stent was advanced over the existing wire into\\n the urinary bladder. The inner metallic stiffener was removed. The pigtail\\n was then formed within the bladder and a second proximal in the renal pelvis.\\n The catheter was secured to the skin using a Stat-lock. Final contrast\\n injection demonstrated adequate placement of the stent. The stent was\\n connected to external bag drainage for 24 hours, secondary to blood clot seen\\n within the renal pelvis.\\n\\n COMPLICATIONS: None.\\n\\n IMPRESSION:\\n 1) Successful placement of 24-cm 8 French nephroureteral stent connected to\\n external bag drainage.\\n\\n 2) Culture & sensitivity urine sample sent.\\n (Over)\\n\\n 7:42 AM\\n PERC NEPHROSTO Clip # \\n Reason: Needs perc. nephrostomy tube for drainage\\n Contrast: CONRAY Amt: 15\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2116-12-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 190080,\n \"text\": \"Sinus rhythm\\nLow precordial lead voltages is nonspecific and probable within normal limits\\nSince previous tracing of , sinus tachycardia absent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2116-12-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 190081,\n \"text\": \"Sinus tachycardia\\nLow precordial lead voltages - is nonspecific and probable within normal limits\\nNo previous tracing for comparison\\n\\n\"\n }\n]"}}},{"rowIdx":24635,"cells":{"subject_id":{"kind":"number","value":23577,"string":"23,577"},"hadm_id":{"kind":"number","value":102904,"string":"102,904"},"target_text":{"kind":"string","value":"Overnight: Renal came to see patient and felt K was not the precipitant for these rhythyms. EP interogated his paced and found several episodes of VT and VF, many of the VT episodes were below his lower rate threshold to shock (> 188 bpm). His device was reprogrammed to treat VT at rate > 170 and record rates >150. There was no inappropriate function of ICD detected. We increased his toprol from 25 to 50, left his amio at 200 daily, plan for possible EPS in next few days. . A/P 42 yo M CAD s/p MI ', no significant dz on cath in ', EF 20%, ESRD on HD, presents with V-fib/v-tach arrest with delayed ICD response. 1. V-tach/v-fib: Interrogation of the device revealed that the pt had episodes of V-tach which degenerated into v-fib. The device was found to be functioning appropriately to the parameters with which it was programmed. The device was not programmed to detect V-tach so it only shocked him when it degenerated into v-fib. The EP consultant changed v tach sensing parameters to detect rates below 188 and added in anti-tachycardia pacing function. The device will try ATP twice, then shock. The pt underwent a prcedure for the generator change of the device. The pt underwent this procedure without complications. The pt remained stable without further episodes of arrhythmia during the hospitalization. . 2. CHF: pt currently well compensated. EF 20% by report. Echo was done at to eval cardiac fxn. The coumadin which the pt takes for mural thrombus and CHF was held for the EP procedure, then restarted afterwards. The pt was continued on his home medications. . 3. Renal failure Pt was found to be in metabolic acidosis with bicarb 17. K 6.3. Pt recieved calcium, insulin, bicarb, kayhexelate in ED. He was dialyzed while in the hospital. The AV graft was not functioning optimally for dialsis, with elevated pressures and suboptimal flow, although he was able dialyze. A AV fistulogram was obtained which revealed venous obstruction. Renal and transplant surgery teams followed the pt. The pt was informed of the need to see his regular renal physician for planning to revise the AVF. . 4. CAD: no active ischemia during hospitalization. ASA/statin/BB were continued . 5. ID: being treated for tunneled r IJ line infection. R IJ was pulled 2 weeks ago. Vanco with HD was recommended for an additional week, because a device was implanted. . 6. Ppx: heparin when INR <2 . 7. FEN: follow K, renagel 2400, NPO p MN"},"extractive_notes_summ":{"kind":"string","value":"The right ventricularcavity is now dilated with free wall hypokinesis.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a low risk (prophylaxis not recommended). cv=sr wo ectopy. Initial impression was VT/VF secondary to hyperkalemia. VT ablation vs. lead revision on hold until INR decreases.RESP: Lungs CTA bilaterally. The right ventricularcavity is mildly dilated with moderate global free wall hypokinesis. False LV tendon (normal variant).RIGHT VENTRICLE: Mildly dilated RV cavity. end-stage renal dz-?cause. Mild tomoderate (+) mitral regurgitation is seen. myoview=fixed anterior/ inferior defects extending to apex. REASON FOR THIS EXAMINATION: eval cardiomegaly, infiltrate, effusion FINAL REPORT INDICATION: Low ejection fraction, cardiac arrest this AM. Hypercoagulable state - PT/PTT/INR : 21.5/38.3/3.3 - EP study/ poss. ESRD on HD although occ. Moderate global RV free wallhypokinesis.AORTA: Mildly dilated aortic root. ck-407/12 w trop 0.18. gi=stool x2-#1 formed & #2 loose-both guiac neg. Borderline first degree A-V delay. There is a curvilinear opacity just below the termination of the ventricular lead, which likely represents calcification in an area of prior infarction. Left ventricular hypertrophy withST-T wave changes. COMPARISON: Chest x-ray dated . Mildly dilated ascending aorta. COMPARISON: Radiograph dated . There is mild symmetric leftventricular hypertrophy. Sinus rhythm with borderline 1st degree A-V block.Left axis deviation - consider left anterior fascicular blockPossible left ventricular hypertrophyLateral T wave changes are probably due to ventricular hypertrophySince previous tracing, A-V sequential pacing not present Normalaortic arch diameter. ep interrogated aicd-multiple episodes of vf/vt terminated via aicd- settings adjusted w plan to discuss in am rounds-?ablation vs increase in medical rx.o:neuro=alert/responsive/appropriate. CCU NPN: 7a-7pS: \"I feel wiped out ...\"O: See CareVue flowsheet for complete assessment detailsCV: HR 60s-70s, SR w/ rare PVC. Clinical correlation is suggested.Since the previous tracing of sinus bradycardia and further ST-T wavechanges are present. Theaortic root and ascending aorta are mildly dilated. SINGLE SUPINE AP PORTABLE CHEST: The right costophrenic angle is not fully visualized on this exam. Based on AHAendocarditis prophylaxis recommendations, the echo findings indicate a lowrisk (prophylaxis not recommended). Coronary artery disease.Height: (in) 74Weight (lb): 170BSA (m2): 2.03 m2BP (mm Hg): 132/87HR (bpm): 66Status: InpatientDate/Time: at 09:55Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:Lat and Septal wall e' = 0.06m/sThis study was compared to the report of the prior study (tape not available)of .LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. hypertension. Moderate PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. renal=bun/creat 92/16.5. Currently undergoing hemodialysis. MAE, +CSM. Physiologic (normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: The patient appears to be in sinus rhythm. Left atrial abnormality.Intraventricular conduction delay with left axis deviation - probably in part,due to left anterior fascicular block. There is moderate pulmonaryartery systolic hypertension. NPO in AM for poss. Sinus bradycardia. rsc line infection-abx w hd.-allergies:demerol.social:single. Poor R wave progression could be in part, due tointraventricular conduction delay/ left ventricular hypertrophy but consideralso prior anterior myocardial infarction. extubated self). k 4.6. id=afebrile. There is no pericardial effusion.Compared with the report of the prior study (tape unavailable for review) of, the left ventricular cavity is more dilated with further depressionof systolic function. voids - awaiting specimen for U/A. AM lytes: K+ 4.6, Mg+ 2.5. aicd for recurrent vt/vf on amiodarone/beta blocker. ep discussion re:increasing amiodarone vs attempting ablation. Question CHF. Mild [1+] TR. The left upper arm, in the area of the left AV fistula, was prepped and draped in a sterile fashion. pos ck/trop. There is now moderate pulmonary artery hypertension andthe severity of mitral regurgitation is slightly worse. Severeregional LV systolic dysfunction. BUN/Creat in AM: 92/16.5. Continue HD per pt. htn. No AR.MITRAL VALVE: Normal mitral valve leaflets. PA sys. The ST-T wave changes appear diffuse with prolongedQTc interval (although, is difficult to measure) - consider in part,metabolic/drug effect. H/H: 39.5/12.9. Clinical decisions regarding the need forprophylaxis should be based on clinical and echocardiographic data.Conclusions:The left and right atrium are moderately dilated. A catheter or pacingwire is seen in the RA and extending into the RV.LEFT VENTRICLE: Mild symmetric LVH. A right clavicular fixation plate and screws is again demonstrated. 911-transported to dnh & subsequently transfered to for further management. Mild to moderate (+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Clinical decisionsregarding the need for prophylaxis should be based on clinical andechocardiographic data.Compared with the report of the prior study (tape unavailable for review) of There is mild cardiomegaly. hemody stable. PATIENT/TEST INFORMATION:Indication: Left ventricular function. SBP stable - 110-130, MAP > 75. procedure . HTN, no pericardial effusion. Denies SOB, DOE. Vanco dosed per level (13.8 ) during HD (for h/o line infection).NEURO: Alert and oriented x3. The left ventricular cavity is severely dilated withsevere regional dysfunction. Severely dilated LV cavity. fx r-shoulder--plated. IMPRESSION: Fistulogram of the left AV fistula demonstrates patency of the fistula, with an approximately 5- to 6-cm area of axillary vein occlusion, (Over) 7:33 AM AV FISTULOGRAM SCH Clip # Reason: PLEASE EVALUATE FLOW THROUGH L. AV FISTULA, ESRD Admitting Diagnosis: S/P CARDIAC ARREST Contrast: OPTIRAY Amt: 75 FINAL REPORT (Cont) with extensive collateral formation and retrograde filling of the axillary vein beyond this area of obstruction."},"n_notes":{"kind":"number","value":9,"string":"9"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2186-09-04 00:00:00.000","description":"Report","row_id":1570656,"text":"ccu nsg admit note.\n43 yo male tansfered from s/p multiple episodes of vt/vf terminated by aicd.\n\npmh:cad=sp anterior mi ' w stenting x3 of lad. echo=ef 15-20% w apical thrombus, dilated lv, & mild mr/tr. myoview=fixed anterior/ inferior defects extending to apex. aicd for recurrent vt/vf on amiodarone/beta blocker.\n end-stage renal dz-?cause. hd 3x's/week (mon/wed/fri).\n hypertension.\n elevated cholesterol.\n fx r-shoulder--plated.\n rsc line infection-abx w hd.-\n\nallergies:demerol.\n\nsocial:single. lives @ home w mom/dad. significant other-girlfriend. disabled due to cad & end-stage renal failure---on list for kidney transplant. previous heavy drinker-presently social. past hx of cocaine use.\n\ncrf:cad. elevated cholesterol. htn. family sx. distant smoker & drug abuser.\n\npresent hx:sunday -multiple episodes of lightheadedness/loc w multiple shocks via aicd. 911-transported to dnh & subsequently transfered to for further management. admitted to ccu. ep interrogated aicd-multiple episodes of vf/vt terminated via aicd- settings adjusted w plan to discuss in am rounds-?ablation vs increase in medical rx.\n\no:neuro=alert/responsive/appropriate. cooperative.\n pulm=initially o2 via 100% nrb w sats 100% chged to 4l nc w sats remaining upper 90's. breath sounds=clear.\n cv=sr wo ectopy. hemody stable. continued on amiodarone 200 qd & metoprolol xl increased to 50 qd. ck-407/12 w trop 0.18.\n gi=stool x2-#1 formed & #2 loose-both guiac neg.\n renal=bun/creat 92/16.5. k 4.6.\n id=afebrile. bc x2 sent. vanco ordered w hd.\n\na:wo further episodes of vt/vf. pos ck/trop. k-wnl.\n\np:hd . ep discussion re:increasing amiodarone vs attempting ablation. continue present management. support as indicated.\n\n"},{"category":"Nursing/other","chartdate":"2186-09-04 00:00:00.000","description":"Report","row_id":1570657,"text":"CCU NPN: 7a-7p\n\nS: \"I feel wiped out ...\"\n\nO: See CareVue flowsheet for complete assessment details\n\nCV: HR 60s-70s, SR w/ rare PVC. SBP stable - 110-130, MAP > 75. ECHO revealed: EF < 20%, LV systolic dysfunction, + MR, +1 TR, mod. PA sys. HTN, no pericardial effusion. AM lytes: K+ 4.6, Mg+ 2.5. H/H: 39.5/12.9. Remains on Amiodarone 200mg PO daily - no further episodes of VT/VF after device interrogation . Hypercoagulable state - PT/PTT/INR : 21.5/38.3/3.3 - EP study/ poss. VT ablation vs. lead revision on hold until INR decreases.\n\nRESP: Lungs CTA bilaterally. Denies SOB, DOE. Weaned from NC to RA w/ O2 sats > 95%.\n\nGI/GU: Abd. soft, non-tender, non-distended. BS active x4 quadrants. NPO in AM for poss. EP procedure - tolerated renal diet thereafter. ESRD on HD although occ. voids - awaiting specimen for U/A. BUN/Creat in AM: 92/16.5. Currently undergoing hemodialysis. AV fistula w/ + thrill, bruit - per CCU team, sluggish flow - awaiting transplant surgery input. Vanco dosed per level (13.8 ) during HD (for h/o line infection).\n\nNEURO: Alert and oriented x3. Pleasant and cooperative. MAE, +CSM. Declined to get OOB as pt. stated he felt \"weak\". Asking appropriate questions re: plan of care.\n\nA/P: Collapsed at home w/ slow VT - required external shocks by EMS as well as internal defibrillations (ICD placed post-MI ' for CMP). S/P cardiac arrest in the field - intubated for airway protection (pt. extubated self). Initial impression was VT/VF secondary to hyperkalemia. Transferred to where ICD was interrogated w/ no further episodes of VT/VF. Awaiting EP procedure - VT ablation vs. lead revision - unable to have procedure today as INR 3.3. Plan for Vitamin K this PM to reverse INR and prepare for poss. procedure . Continue HD per pt. schedule - transplant team to evaluate decreased function of AV graft. Vanco dosed per serum level for potential line infection. Emotional support and comfort. Poss. transfer to floor if remains stable. Awaiting further plans from team.\n\n\n\n"},{"category":"Echo","chartdate":"2186-09-04 00:00:00.000","description":"Report","row_id":66264,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Coronary artery disease.\nHeight: (in) 74\nWeight (lb): 170\nBSA (m2): 2.03 m2\nBP (mm Hg): 132/87\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 09:55\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLat and Septal wall e' = 0.06m/s\nThis study was compared to the report of the prior study (tape not available)\nof .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH. Severely dilated LV cavity. Severe\nregional LV systolic dysfunction. No resting LVOT gradient. No LV\nmass/thrombus. False LV tendon (normal variant).\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV free wall\nhypokinesis.\n\nAORTA: Mildly dilated aortic root. Mildly dilated ascending aorta. Normal\naortic arch diameter. No 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm. Based on AHA\nendocarditis prophylaxis recommendations, the echo findings indicate a low\nrisk (prophylaxis not recommended). Clinical decisions regarding the need for\nprophylaxis should be based on clinical and echocardiographic data.\n\nConclusions:\nThe left and right atrium are moderately dilated. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity is severely dilated with\nsevere regional dysfunction. The basal inferoseptal, inferior, and\ninferolateral walls contract best. The remaining segments are near akinetic.\nNo masses or thrombi are seen in the left ventricle. The right ventricular\ncavity is mildly dilated with moderate global free wall hypokinesis. The\naortic root and ascending aorta are mildly dilated. The aortic valve leaflets\n(3) appear structurally normal with good leaflet excursion and no aortic\nregurgitation. The mitral valve leaflets are structurally normal. Mild to\nmoderate (+) mitral regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\nCompared with the report of the prior study (tape unavailable for review) of\n, the left ventricular cavity is more dilated with further depression\nof systolic function. There is now moderate pulmonary artery hypertension and\nthe severity of mitral regurgitation is slightly worse. The right ventricular\ncavity is now dilated with free wall hypokinesis.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\nCompared with the report of the prior study (tape unavailable for review) of\n\n\n\n"},{"category":"ECG","chartdate":"2186-09-05 00:00:00.000","description":"Report","row_id":136157,"text":"Sinus bradycardia. Borderline first degree A-V delay. Left atrial abnormality.\nIntraventricular conduction delay with left axis deviation - probably in part,\ndue to left anterior fascicular block. Left ventricular hypertrophy with\nST-T wave changes. The ST-T wave changes appear diffuse with prolonged\nQTc interval (although, is difficult to measure) - consider in part,\nmetabolic/drug effect. Poor R wave progression could be in part, due to\nintraventricular conduction delay/ left ventricular hypertrophy but consider\nalso prior anterior myocardial infarction. Clinical correlation is suggested.\nSince the previous tracing of sinus bradycardia and further ST-T wave\nchanges are present.\n\n"},{"category":"ECG","chartdate":"2186-09-03 00:00:00.000","description":"Report","row_id":136158,"text":"A-V sequential paced rhythm\nSince previous tracing, pacing new from previous\n\n"},{"category":"ECG","chartdate":"2186-09-03 00:00:00.000","description":"Report","row_id":136159,"text":"Sinus rhythm with borderline 1st degree A-V block.\nLeft axis deviation - consider left anterior fascicular block\nPossible left ventricular hypertrophy\nLateral T wave changes are probably due to ventricular hypertrophy\nSince previous tracing, A-V sequential pacing not present\n\n"},{"category":"Radiology","chartdate":"2186-09-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":880816,"text":" 5:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval cardiomegaly, infiltrate, effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with EF 15%, CAD, s/p cardiac arrest this am.\n REASON FOR THIS EXAMINATION:\n eval cardiomegaly, infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Low ejection fraction, cardiac arrest this AM.\n\n COMPARISON: Radiograph dated .\n\n SINGLE UPRIGHT VIEW OF THE CHEST: There is a dual lead pacemaker/ICD device\n in unchanged position. There is apparent interval increase in the size of the\n cardiac silhouette, partially due to AP portable technique. The lungs are\n clear. There is no pleural effusion. No evidence of pneumothorax. A right\n clavicular fixation plate and screws is again demonstrated.\n\n IMPRESSION: Apparent interval increase in size of the cardiac silhouette, at\n least partially due to AP portable technique. No pleural effusion or\n consolidation seen.\n\n\n"},{"category":"Radiology","chartdate":"2186-09-06 00:00:00.000","description":"INTRO DIALYSIS FISTULA","row_id":881184,"text":" 7:33 AM\n AV FISTULOGRAM SCH Clip # \n Reason: PLEASE EVALUATE FLOW THROUGH L. AV FISTULA, ESRD\n Admitting Diagnosis: S/P CARDIAC ARREST\n Contrast: OPTIRAY Amt: 75\n ********************************* CPT Codes ********************************\n * INTRO DIALYSIS FISTULA ART VENEOUS SHUNT *\n * C1769 GUID WIRES INCL INF C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with elevated pressures during HD\n REASON FOR THIS EXAMINATION:\n Please evaluate flow through L. AV fistula\n ______________________________________________________________________________\n FINAL REPORT\n\n\n\n\n\n\n\n\n\n INDICATION: History of elevated pressures during hemodialysis, evaluate flow\n through a left AV fistula.\n\n PHYSICIANS: The procedure was performed by Drs. , , and\n , with Dr. , the attending radiologist, being present and\n supervising throughout the procedure.\n\n PROCEDURE: Written informed consent was obtained prior to the procedure. A\n preprocedure timeout was performed prior to initiation of the procedure. The\n left upper arm, in the area of the left AV fistula, was prepped and draped in\n a sterile fashion. A 21-gauge needle was used to access the venous side of\n the AV fistula, immediately distal to the anastomosis. A 0.018 guide wire was\n advanced through the needle, which was then exchanged for a 7-French sheath.\n Intravenous contrast injected through the sheath demonstrates an approximately\n 5- to 6-cm area of occlusion of the left axillary vein distal to the AV\n fistula, with extensive collateral formation and retrograde filling of the\n axillary vein distal to the area of obstruction. A 0.035 Super Stiff guide\n wire was advanced through the sheath to the area of occlusion, but could not\n be passed through this. A 4-French multiholed catheter was advanced over the\n wire to this area, and contrast injection again demonstrated persistence of\n this area of occlusion. At this point, the exam was terminated, and the\n sheath and wire were removed. During the procedure, 2 mL of 1% lidocaine was\n injected subcutaneously for local anesthesia. No immediate complications were\n identified.\n\n IMPRESSION: Fistulogram of the left AV fistula demonstrates patency of the\n fistula, with an approximately 5- to 6-cm area of axillary vein occlusion,\n (Over)\n\n 7:33 AM\n AV FISTULOGRAM SCH Clip # \n Reason: PLEASE EVALUATE FLOW THROUGH L. AV FISTULA, ESRD\n Admitting Diagnosis: S/P CARDIAC ARREST\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n with extensive collateral formation and retrograde filling of the axillary\n vein beyond this area of obstruction. Results were discussed with the\n covering surgical staff.\n\n\n\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2186-09-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":881008,"text":" 7:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for CHF\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with EF 15%, CAD, s/p cardiac arrest this am.\n\n REASON FOR THIS EXAMINATION:\n please eval for CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 43-year-old man with EF of 15%, CAD, status post cardiac arrest\n this a.m. Question CHF.\n\n COMPARISON: Chest x-ray dated .\n\n SINGLE SUPINE AP PORTABLE CHEST: The right costophrenic angle is not fully\n visualized on this exam. There is an ICD device in place, with the leads in\n appropriate position. There is a curvilinear opacity just below the\n termination of the ventricular lead, which likely represents calcification in\n an area of prior infarction. There is mild cardiomegaly. Central pulmonary\n vessels look prominent, consistent with the patient's history of pulmonary\n arterial hypertension. There is no frank evidence of congestive heart\n failure. There is surgical hardware in the right clavicle.\n\n IMPRESSION: Stable cardiomegaly without evidence of congestive heart failure.\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2186-09-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1570656,\n \"text\": \"ccu nsg admit note.\\n43 yo male tansfered from s/p multiple episodes of vt/vf terminated by aicd.\\n\\npmh:cad=sp anterior mi ' w stenting x3 of lad. echo=ef 15-20% w apical thrombus, dilated lv, & mild mr/tr. myoview=fixed anterior/ inferior defects extending to apex. aicd for recurrent vt/vf on amiodarone/beta blocker.\\n end-stage renal dz-?cause. hd 3x's/week (mon/wed/fri).\\n hypertension.\\n elevated cholesterol.\\n fx r-shoulder--plated.\\n rsc line infection-abx w hd.-\\n\\nallergies:demerol.\\n\\nsocial:single. lives @ home w mom/dad. significant other-girlfriend. disabled due to cad & end-stage renal failure---on list for kidney transplant. previous heavy drinker-presently social. past hx of cocaine use.\\n\\ncrf:cad. elevated cholesterol. htn. family sx. distant smoker & drug abuser.\\n\\npresent hx:sunday -multiple episodes of lightheadedness/loc w multiple shocks via aicd. 911-transported to dnh & subsequently transfered to for further management. admitted to ccu. ep interrogated aicd-multiple episodes of vf/vt terminated via aicd- settings adjusted w plan to discuss in am rounds-?ablation vs increase in medical rx.\\n\\no:neuro=alert/responsive/appropriate. cooperative.\\n pulm=initially o2 via 100% nrb w sats 100% chged to 4l nc w sats remaining upper 90's. breath sounds=clear.\\n cv=sr wo ectopy. hemody stable. continued on amiodarone 200 qd & metoprolol xl increased to 50 qd. ck-407/12 w trop 0.18.\\n gi=stool x2-#1 formed & #2 loose-both guiac neg.\\n renal=bun/creat 92/16.5. k 4.6.\\n id=afebrile. bc x2 sent. vanco ordered w hd.\\n\\na:wo further episodes of vt/vf. pos ck/trop. k-wnl.\\n\\np:hd . ep discussion re:increasing amiodarone vs attempting ablation. continue present management. support as indicated.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2186-09-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1570657,\n \"text\": \"CCU NPN: 7a-7p\\n\\nS: \\\"I feel wiped out ...\\\"\\n\\nO: See CareVue flowsheet for complete assessment details\\n\\nCV: HR 60s-70s, SR w/ rare PVC. SBP stable - 110-130, MAP > 75. ECHO revealed: EF < 20%, LV systolic dysfunction, + MR, +1 TR, mod. PA sys. HTN, no pericardial effusion. AM lytes: K+ 4.6, Mg+ 2.5. H/H: 39.5/12.9. Remains on Amiodarone 200mg PO daily - no further episodes of VT/VF after device interrogation . Hypercoagulable state - PT/PTT/INR : 21.5/38.3/3.3 - EP study/ poss. VT ablation vs. lead revision on hold until INR decreases.\\n\\nRESP: Lungs CTA bilaterally. Denies SOB, DOE. Weaned from NC to RA w/ O2 sats > 95%.\\n\\nGI/GU: Abd. soft, non-tender, non-distended. BS active x4 quadrants. NPO in AM for poss. EP procedure - tolerated renal diet thereafter. ESRD on HD although occ. voids - awaiting specimen for U/A. BUN/Creat in AM: 92/16.5. Currently undergoing hemodialysis. AV fistula w/ + thrill, bruit - per CCU team, sluggish flow - awaiting transplant surgery input. Vanco dosed per level (13.8 ) during HD (for h/o line infection).\\n\\nNEURO: Alert and oriented x3. Pleasant and cooperative. MAE, +CSM. Declined to get OOB as pt. stated he felt \\\"weak\\\". Asking appropriate questions re: plan of care.\\n\\nA/P: Collapsed at home w/ slow VT - required external shocks by EMS as well as internal defibrillations (ICD placed post-MI ' for CMP). S/P cardiac arrest in the field - intubated for airway protection (pt. extubated self). Initial impression was VT/VF secondary to hyperkalemia. Transferred to where ICD was interrogated w/ no further episodes of VT/VF. Awaiting EP procedure - VT ablation vs. lead revision - unable to have procedure today as INR 3.3. Plan for Vitamin K this PM to reverse INR and prepare for poss. procedure . Continue HD per pt. schedule - transplant team to evaluate decreased function of AV graft. Vanco dosed per serum level for potential line infection. Emotional support and comfort. Poss. transfer to floor if remains stable. Awaiting further plans from team.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2186-09-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 66264,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Coronary artery disease.\\nHeight: (in) 74\\nWeight (lb): 170\\nBSA (m2): 2.03 m2\\nBP (mm Hg): 132/87\\nHR (bpm): 66\\nStatus: Inpatient\\nDate/Time: at 09:55\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLat and Septal wall e' = 0.06m/s\\nThis study was compared to the report of the prior study (tape not available)\\nof .\\n\\n\\nLEFT ATRIUM: Moderate LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\\nwire is seen in the RA and extending into the RV.\\n\\nLEFT VENTRICLE: Mild symmetric LVH. Severely dilated LV cavity. Severe\\nregional LV systolic dysfunction. No resting LVOT gradient. No LV\\nmass/thrombus. False LV tendon (normal variant).\\n\\nRIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV free wall\\nhypokinesis.\\n\\nAORTA: Mildly dilated aortic root. Mildly dilated ascending aorta. Normal\\naortic arch diameter. No 2D or Doppler evidence of distal arch coarctation.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets. Mild to moderate (+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\\nsystolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\\nphysiologic PR. Physiologic (normal) PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: The patient appears to be in sinus rhythm. Based on AHA\\nendocarditis prophylaxis recommendations, the echo findings indicate a low\\nrisk (prophylaxis not recommended). Clinical decisions regarding the need for\\nprophylaxis should be based on clinical and echocardiographic data.\\n\\nConclusions:\\nThe left and right atrium are moderately dilated. There is mild symmetric left\\nventricular hypertrophy. The left ventricular cavity is severely dilated with\\nsevere regional dysfunction. The basal inferoseptal, inferior, and\\ninferolateral walls contract best. The remaining segments are near akinetic.\\nNo masses or thrombi are seen in the left ventricle. The right ventricular\\ncavity is mildly dilated with moderate global free wall hypokinesis. The\\naortic root and ascending aorta are mildly dilated. The aortic valve leaflets\\n(3) appear structurally normal with good leaflet excursion and no aortic\\nregurgitation. The mitral valve leaflets are structurally normal. Mild to\\nmoderate (+) mitral regurgitation is seen. There is moderate pulmonary\\nartery systolic hypertension. There is no pericardial effusion.\\n\\nCompared with the report of the prior study (tape unavailable for review) of\\n, the left ventricular cavity is more dilated with further depression\\nof systolic function. There is now moderate pulmonary artery hypertension and\\nthe severity of mitral regurgitation is slightly worse. The right ventricular\\ncavity is now dilated with free wall hypokinesis.\\n\\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\\nindicate a low risk (prophylaxis not recommended). Clinical decisions\\nregarding the need for prophylaxis should be based on clinical and\\nechocardiographic data.\\n\\nCompared with the report of the prior study (tape unavailable for review) of\\n\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2186-09-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 136157,\n \"text\": \"Sinus bradycardia. Borderline first degree A-V delay. Left atrial abnormality.\\nIntraventricular conduction delay with left axis deviation - probably in part,\\ndue to left anterior fascicular block. Left ventricular hypertrophy with\\nST-T wave changes. The ST-T wave changes appear diffuse with prolonged\\nQTc interval (although, is difficult to measure) - consider in part,\\nmetabolic/drug effect. Poor R wave progression could be in part, due to\\nintraventricular conduction delay/ left ventricular hypertrophy but consider\\nalso prior anterior myocardial infarction. Clinical correlation is suggested.\\nSince the previous tracing of sinus bradycardia and further ST-T wave\\nchanges are present.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2186-09-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 136158,\n \"text\": \"A-V sequential paced rhythm\\nSince previous tracing, pacing new from previous\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2186-09-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 136159,\n \"text\": \"Sinus rhythm with borderline 1st degree A-V block.\\nLeft axis deviation - consider left anterior fascicular block\\nPossible left ventricular hypertrophy\\nLateral T wave changes are probably due to ventricular hypertrophy\\nSince previous tracing, A-V sequential pacing not present\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-09-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 880816,\n \"text\": \" 5:38 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval cardiomegaly, infiltrate, effusion\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 43 year old man with EF 15%, CAD, s/p cardiac arrest this am.\\n REASON FOR THIS EXAMINATION:\\n eval cardiomegaly, infiltrate, effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Low ejection fraction, cardiac arrest this AM.\\n\\n COMPARISON: Radiograph dated .\\n\\n SINGLE UPRIGHT VIEW OF THE CHEST: There is a dual lead pacemaker/ICD device\\n in unchanged position. There is apparent interval increase in the size of the\\n cardiac silhouette, partially due to AP portable technique. The lungs are\\n clear. There is no pleural effusion. No evidence of pneumothorax. A right\\n clavicular fixation plate and screws is again demonstrated.\\n\\n IMPRESSION: Apparent interval increase in size of the cardiac silhouette, at\\n least partially due to AP portable technique. No pleural effusion or\\n consolidation seen.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-09-06 00:00:00.000\",\n \"description\": \"INTRO DIALYSIS FISTULA\",\n \"row_id\": 881184,\n \"text\": \" 7:33 AM\\n AV FISTULOGRAM SCH Clip # \\n Reason: PLEASE EVALUATE FLOW THROUGH L. AV FISTULA, ESRD\\n Admitting Diagnosis: S/P CARDIAC ARREST\\n Contrast: OPTIRAY Amt: 75\\n ********************************* CPT Codes ********************************\\n * INTRO DIALYSIS FISTULA ART VENEOUS SHUNT *\\n * C1769 GUID WIRES INCL INF C1894 INT.SHTH NOT/GUID,EP,NONLASER *\\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 43 year old man with elevated pressures during HD\\n REASON FOR THIS EXAMINATION:\\n Please evaluate flow through L. AV fistula\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n INDICATION: History of elevated pressures during hemodialysis, evaluate flow\\n through a left AV fistula.\\n\\n PHYSICIANS: The procedure was performed by Drs. , , and\\n , with Dr. , the attending radiologist, being present and\\n supervising throughout the procedure.\\n\\n PROCEDURE: Written informed consent was obtained prior to the procedure. A\\n preprocedure timeout was performed prior to initiation of the procedure. The\\n left upper arm, in the area of the left AV fistula, was prepped and draped in\\n a sterile fashion. A 21-gauge needle was used to access the venous side of\\n the AV fistula, immediately distal to the anastomosis. A 0.018 guide wire was\\n advanced through the needle, which was then exchanged for a 7-French sheath.\\n Intravenous contrast injected through the sheath demonstrates an approximately\\n 5- to 6-cm area of occlusion of the left axillary vein distal to the AV\\n fistula, with extensive collateral formation and retrograde filling of the\\n axillary vein distal to the area of obstruction. A 0.035 Super Stiff guide\\n wire was advanced through the sheath to the area of occlusion, but could not\\n be passed through this. A 4-French multiholed catheter was advanced over the\\n wire to this area, and contrast injection again demonstrated persistence of\\n this area of occlusion. At this point, the exam was terminated, and the\\n sheath and wire were removed. During the procedure, 2 mL of 1% lidocaine was\\n injected subcutaneously for local anesthesia. No immediate complications were\\n identified.\\n\\n IMPRESSION: Fistulogram of the left AV fistula demonstrates patency of the\\n fistula, with an approximately 5- to 6-cm area of axillary vein occlusion,\\n (Over)\\n\\n 7:33 AM\\n AV FISTULOGRAM SCH Clip # \\n Reason: PLEASE EVALUATE FLOW THROUGH L. AV FISTULA, ESRD\\n Admitting Diagnosis: S/P CARDIAC ARREST\\n Contrast: OPTIRAY Amt: 75\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n with extensive collateral formation and retrograde filling of the axillary\\n vein beyond this area of obstruction. Results were discussed with the\\n covering surgical staff.\\n\\n\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-09-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 881008,\n \"text\": \" 7:21 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval for CHF\\n Admitting Diagnosis: S/P CARDIAC ARREST\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 43 year old man with EF 15%, CAD, s/p cardiac arrest this am.\\n\\n REASON FOR THIS EXAMINATION:\\n please eval for CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 43-year-old man with EF of 15%, CAD, status post cardiac arrest\\n this a.m. Question CHF.\\n\\n COMPARISON: Chest x-ray dated .\\n\\n SINGLE SUPINE AP PORTABLE CHEST: The right costophrenic angle is not fully\\n visualized on this exam. There is an ICD device in place, with the leads in\\n appropriate position. There is a curvilinear opacity just below the\\n termination of the ventricular lead, which likely represents calcification in\\n an area of prior infarction. There is mild cardiomegaly. Central pulmonary\\n vessels look prominent, consistent with the patient's history of pulmonary\\n arterial hypertension. There is no frank evidence of congestive heart\\n failure. There is surgical hardware in the right clavicle.\\n\\n IMPRESSION: Stable cardiomegaly without evidence of congestive heart failure.\\n\\n\"\n }\n]"}}},{"rowIdx":24636,"cells":{"subject_id":{"kind":"number","value":12348,"string":"12,348"},"hadm_id":{"kind":"number","value":149513,"string":"149,513"},"target_text":{"kind":"string","value":"The patient was admitted to the Surgical Intensive Care Unit on , for observation and consultation. The patient was admitted to the Surgical Intensive Care Unit and was aggressively hydrated and stabilized. Neurosurgery was consulted secondary to the intraparenchymal bleed as well as the compression fracture with bilateral upper extremity and lower extremity weakness. In the Intensive Care Unit, the patient was extubated and was awake, alert and oriented times three. He did have a waxing and mental status while in the Intensive Care Unit for two days, however, he remained stable throughout his stay in the Intensive Care Unit. Neurosurgery deemed that the patient was not an operable candidate. He was transferred to the floor. Upon arrival to the floor, the patient was stable. While on the floor, the patient developed an ileus as well as profuse vomiting. Abdominal CT scan revealed gallstones. Abdominal ultrasound revealed no pericholecystic fluid and no inflammation. He did have elevated total bilirubin as well as elevated alkaline phosphatase. However, the ultrasound showed no evidence of acute cholecystitis. On day six, the patient began to vomit violently. Abdominal flat plate was done and revealed ileus. The patient had nasogastric tube placed with the profuse vomiting. He also had a bout of hematemesis. His hematocrit remained stable and no transfusions were required. He was lavaged free and the nasogastric tube was discontinued the next day. Lovenox was stopped. He was then placed on subcutaneous Heparin for deep vein thrombosis prophylaxis. He never had any more episodes of vomiting. He has remained stable since then. He has been tolerating a p.o. diet without difficulty. He was treated for a cellulitis of his right lower extremity with Oxacillin for ten days. The patient had an inferior vena cava filter placed on ."},"extractive_notes_summ":{"kind":"string","value":"There are some nonenlarged mediastinal and retroperitoneal lymph nodes. Unremarkable abdominal and pelvic CT. A nondistended gallbladder is noted with extensive echogenic and posteriorly shadowing foci layering along the dependent portion of the gallbladder. CT PELVIS AFTER IV CONTRAST: There is some free fluid seen deep within the pelvis. Limited exam of the chest and pelvis. There superior portion of the chest is not visualized. MR THORACIC SPINE: This study is extremely limited by patient motion. The superior portion of the chest is not evaluated. FINDINGS: The left subclavian central venous catheter has been removed. IMPRESSION: Appearance consistent with paralytic ileus. Patient is intubated and extent of injuries is unclear. Sinus rhythmDiffuse nonspecific low-amplitude T wave - Clinical correlation is suggestedSince previous tracing of : U wave less prominent & T wave changes decreased CT PELVIS WITH INTRAVENOUS CONTRAST: Rectum, sigmoid colon, bladder and distal ureters are unremarkable. Fluid overload with small left pleural effusion. CT ABDOMEN WITH INTRAVENOUS CONTRAST: The lung bases demonstrate mild-to- moderate amount of pleural effusion bilaterally. Small amount of ascites and pelvic fluid. CONCLUSION: Mild spinal cord edema in the mid cervical region. There is minimal opacification of left mastoid air cells. Multilevel cervical and thoracic spondylosis, as described above. There are bibasilar minimal patchy opacities consistent with atelectasis. CHEST, SINGLE VIEW: The left subclavian catheter terminates at the junction of the left brachiocephalic vein and SVC. LEFT FEMUR, AP AND LATERAL VIEWS: This is a limited study with a poor exposure of the upper femur. An NG tube is terminating in the stomach, with a site for it not well visualized. There is a focal deformity along the distal shaft of the femur with slight anterior posterior hyperostosis. IMPRESSION: Left subclavian catheter terminates at the junction of brachiocephalic vein and SVC. There is edema within the T4/5 disc space, also likely post traumatic. Bilateral renal vein openings were localized. BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND: There is normal compressibility, flow and augmentation of the bilateral common femoral, superficial femoral and popliteal veins bilaterally. Check line position and r/o pneumothorax. The femoral head is poorly visualized. Again seen is cardiomegaly with left ventricular predominance. CT ABDOMEN AFTER IV CONTRAST: There are bilateral pleural effusions associated with collapse in the lower lobes, left greater than right. The lung volumes are decreased bilaterally, and there is no pneumothorax, effusions, or large areas of consolidation. Assess for intracranial bleed. Minor cervical spondylosis is noted at the C3/4, and levels. TECHNIQUE: Non-contrast CT exam of the head. The catheter sheath was removed and local hemostasis was performed by compression. The previously described compression fracture is poorly visualized on this study. 3:54 PM TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT) Clip # Reason: MVA FINAL ADDENDUM ADDENDUM: AP view of the chest: Examination is limited secondary to the trauma board. LYTES SENT, RESULTS PENDINGGI: ABD OBESE, SOFT, (+)BOWEL SOUNDS. PT WAS ELECTIVELY INTUBATED TO COMPLETE THE SCAN.CV: HR 80S, NSR WITH FREQ PAC'S, ATRIAL BIGEM. Limited mobility.P: Neuro checks q 1hr. Extubated in EW and admitted to T/SICU. Resp Care,Pt. NEURO:TALKING RAG TIME SINCE EXTUBATED,WILL FOLLOW COMMANDS.STRONG HAND GRIP ON L,WEAKER ON R.MOVES R FOOT MORE THAN L.ON ATIVAN Q6HRS. Ativan for DT prophylaxis. uo qs.gi lg amt of ng drainage, and liq brown stool spec sent for c diff. T-SICU NURSING PROGRESS NOTENEURO: AROUSABLE TO VOICE, ORIENTED TO SELF ONLY. Pt was transferred to after being paralyzed/sedated and intubated. Logroll precautions.Resp: Breathing unlabored. Today Pt was noted to have upper extremity weakness. She confirmed that pt has long history of etoh abuse. / to nailbed pressure. Sinus rhythmLong QTc intervalDiffuse nonspecific ST-T abnormalities with prominent U waves - considermetabolic/drug effect - clinical correlation is suggestedNo previous report available for comparison SKIN WARM, DRY, (+)PALP PULSES, TRACE PEDAL EDEMARESP: AS ABOVE, PT WAS ELECTIVELY INTUBATED TO COMPLETE MRI. to wean as tol. NSG NOTEROS: CV:SYS BP 150'S/70'S,IN SR WITH RARE APC'S.RR 21-33.T MAX 99.8 RESP:PPT EXTUBATED AT 3:30PM.SX FOR LARGE AMT THIN TAN SECRETIONS PRIOP TO EXTUB,MUCH LESS SECRETIONS NOW.SATS 99 ON 3L NP.ABGS 7.43-35-100. Abdomen is distended, but soft.GU: Foley to gravity. PT FITTED FOR COLLAR AND CHEST BRACE TO START REHABCONT TO LOGROLL TILL THENPT OT CONSULTCHANGE ATIVAN TO PRN GIVE HALDOL AS NEEDEDSTART TPNWATCH ANY S+S OF ORIENT PT FREQUENTLY Pt currently on PB 7200 with initial settings of SIMV/PSV/800/12/50%/+5/%ips, 02 sats 98%, awaiting a-line/ABG to titrate settings. R/T HEAD TRAUMA VS SEDATIVESP-CONT TO MONITOR NEURO EXAM,VS,MONITOR RESP QS AND PRN,I+O,O2 PRN,TPN/ORDERS,MONITOR SKIN INTEGRITY QS AND PRN. ALT NEURO STATUS C4-5 CONTUSION POSSIBLE CENTRAL CORD SYNDROME WITH EXTREMITY WEAKNESS BILAT, ALT MS ? afebrile. RELATED TO ATIVAN GIVENALT SKIN POSS. Pt placed on MRI vent for scan and transferred to T-SICU. PERRL. Backside inatct.Social: Daughter, , here when Pt arrived. He was admitted to an OSH. PRIOR TO INTUBATION, BREATH SOUNDS CLEAR IN UPPER LOBES, VERY DIMINISHED IN THE BASES BILAT. REMAINS IN C-COLLAR. RESP NOTE:PT EXTUBATED AS PER ORDER W/O INCIDENT,PLACED ON 3L/NC MAINTAINING SATS 97-100%.NO RESP DISTRESS NOTED,WILL CONTINUE TO MONITOR. nsg :neuro obeys commands but very confused. PT WAS SEDATED WITH FENTANYL AND MIDAZ. Respiratory CareRespiratory paged to MRI for intubation, pt orally intubated 7.5 ETT, 25 @ lip. MRI of spine. CELLULITISALT NUTRITIONAL STATUS HIGH NGT OUTPUT AND DIARRHEAETOH ABUSE+ SMOKERP. Follows commands. Pt confused. ABLE TO STATE THE NAME OF HIS CHILDREN AND THAT HE IS FROM , MA. weaned to CPAP IPS10.5/5peep this am. S. THE BROUGHT ME HERE IN A BOX I NEED SOME CLOTHESO.NEURO PT CONFUSED ALERT TO NAME RAMBLING PEARLA FC GOOD GRASPS BOTH HANDS RIGHT ARM ABLE TO COME UP 30 DEGREES LT 45 DEGREES STRENGHT SL. AFTER INTUBATION, PT WAS SUCTIONED FOR THICK, COPIOUS YELLOW SECRETIONS."},"n_notes":{"kind":"number","value":29,"string":"29"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2132-06-04 00:00:00.000","description":"ORBITS (WATERS, CALDWELL & LAT)","row_id":762021,"text":" 2:42 AM\n ORBITS (WATERS, & LAT) Clip # \n Reason: TWO VIEWS TO RULE OUT METAL IN ORBITALS BEFORE GOING TO MRI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with T7 compression fracture, s/p motorcycle accident \n REASON FOR THIS EXAMINATION:\n TWO VIEWS TO RULE OUT METAL IN ORBITALS BEFORE GOING TO MRI\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Evaluate for foreign bodies prior to MR exam.\n\n ORBITS, TWO VIEWS: No metallic foreign bodies.\n\n"},{"category":"Radiology","chartdate":"2132-06-11 00:00:00.000","description":"ABDOMEN (SUPINE & ERECT)","row_id":762673,"text":" 4:04 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: Projectile vomiting\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with projectile vomiting\n REASON FOR THIS EXAMINATION:\n Projectile vomiting\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Projectile vomiting.\n\n TECHNOLOGIST NOTE: Supine film could not be performed at this time due to\n patient condition.\n\n SUPINE ABDOMEN: There is gas contained throughout the colon from cecum to\n rectum. The transverse colon is somewhat prominent and the cecum is somewhat\n dilated. There is gas contained in multiple small bowel loops which are\n minimally dilated. There is no free air evident. Upright or decubitus films\n were not obtained, so the presence of air fluid levels cannot be assessed.\n\n IMPRESSION: Appearance consistent with paralytic ileus.\n\n"},{"category":"Radiology","chartdate":"2132-06-04 00:00:00.000","description":"MR L SPINE SCAN","row_id":762023,"text":" 3:39 AM\n MR L SPINE SCAN; MR THORACIC SPINE Clip # \n Reason: eval for nerve compression/infection\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with T7 compression fracture, s/p motorcycle accident\n REASON FOR THIS EXAMINATION:\n eval for nerve compression/infection\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n\n INDICATION: T7 compression fracture following MVA. Evaluate for nerve\n compression or infection.\n\n TECHNIQUE: Sagittal T1, T2 images of the cervical, thoracic and lumbar spine\n with additional inversion recovery sagittal images of the lumbar spine and\n gradient echo axial images of cervical spine. Additional turbo-spin echo\n axial images of the thoracic spine were performed.\n\n NR CERVICAL SPINE: This study is extremely limited due to gross patient\n motion. Minor cervical spondylosis is noted at the C3/4, and levels.\n The axial images of this region are uninterpretable. This study is\n insufficient for evaluation of neural foraminal narrowing or possible spinal\n stenosis.\n\n MR THORACIC SPINE: This study is extremely limited by patient motion.\n Increased inversion recovery signal is noted in the T4, 5.6 and 8 levels. No\n definite fracture line is observed. No gross spinal canal stenosis or neural\n foraminal narrowing is noted on this extremely limited study. There is loss\n of vertebral body height at multiple levels.\n\n IMPRESSION: Extremely limited study due to gross patient motion. Multilevel\n cervical and thoracic spondylosis, as described above. There is increased\n inversion recovery signal in multiple vertebral body levels and loss of\n vertebral body height, suggestive of acute injury-i.e. fracture. The\n previously described compression fracture is poorly visualized on this study.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2132-06-04 00:00:00.000","description":"MR CERVICAL SPINE","row_id":762106,"text":" 5:22 PM\n MR CERVICAL SPINE Clip # \n Reason: S/P MOTORCYCLE ACCIDENT; ARM AND LEG WEAKNESS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with T7 compression fracture, s/p motorcycle accident\n\n REASON FOR THIS EXAMINATION:\n with stir images to r/o ligmental injuries.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n HISTORY: T7 compression fracture.\n\n Repeat study attempted to improve image quality.\n\n TECHNIQUE: Multiplanar T1 and T2 weighted imaging of the cervical spine was\n performed.\n\n FINDINGS: Nearly all of the images are of equally limited resolution due to\n gross patient motion. However, there are a few sequences which are of\n excellent technical quality and it is on these image sequences that the\n following report is based.\n\n There is very slight elevated T2 signal within the mid cervical cord at the\n level of C4 and C5. The axial scans show mild spinal cord compression C5/6 due\n to a posterior spondylytic ridge with moderate bilateral C4/5 and prominent\n C5/6 bilateral neural foraminal encroachment due to uncovertebral spurs.\n\n There is more moderate spinal cord edema and spinal cord compression at the T4\n level due to a compression fracture. This finding was not as obvious on the\n prior study but the present image sequence clearly delineates this\n abnormality. There is edema within the T4/5 disc space, also likely post\n traumatic. No other definite abnormalities are seen.\n\n CONCLUSION: Mild spinal cord edema in the mid cervical region. 2) Spinal cord\n compression and edema due to a presumed traumatic compression fracture at the\n T4 level. We reached the trauma team to report the findings immediately.\n\n\n"},{"category":"Radiology","chartdate":"2132-06-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":762278,"text":" 2:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p Lt subclavian CVL placement. Check line position and r/o\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with\n REASON FOR THIS EXAMINATION:\n s/p Lt subclavian CVL placement. Check line position and r/o pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check central venous line placement.\n\n CHEST, SINGLE VIEW: The left subclavian catheter terminates at the junction\n of the left brachiocephalic vein and SVC. An NG tube is terminating in the\n stomach, with a site for it not well visualized. The cardiomediastinal\n contours appears prominent, may be associated with low lung volumes. There is\n evidence of fluid overload, evidenced by pulmonary vascularity prominence and\n perivascular haziness. There is also a small left pleural effusion.\n\n There is no pneumothorax.\n\n IMPRESSION: Left subclavian catheter terminates at the junction of\n brachiocephalic vein and SVC. No pneumothorax. Fluid overload with small\n left pleural effusion.\n\n"},{"category":"Radiology","chartdate":"2132-06-18 00:00:00.000","description":"INTERUP IVC","row_id":763202,"text":" 3:31 PM\n IVC GRAM/FILTER Clip # \n Reason: LONG TERM PE PREVENTION, HAS HO UGIB\n Contrast: OPTIRAY Amt: 80\n ********************************* CPT Codes ********************************\n * INTERUP IVC INTRO CATH SVC/IVC *\n * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT IVC FILTER *\n * IVC GRAM *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with BL LE PARALYSIS, WITH HO OF UGIB\n REASON FOR THIS EXAMINATION:\n LONG TERM PE PREVENTION, HAS HO UGIB\n ______________________________________________________________________________\n FINAL REPORT\n\n\n\n\n\n\n HISTORY:\n\n The patient is a 59 year old male who sustained thoracic vertebral compression\n fracture in motorcycle accident. IVC filter placement was requested by\n patient's physician.\n\n The risks and benefits were explained to the patient and the consent was\n obtained from the patient.\n\n TECHNIQUE: Patient was brought into the Angio Suite and placed supine on the\n angio table. His right groin was prepped and draped in sterile fashion. Local\n anesthesia was given using 1% lidocaine. The right common femoral vein was\n accessed using 19-gauge Seldinger needle and a 0.035 wire was advanced\n into the IVC. The needle was exchanged for a 4-French Omni Flush catheter\n over the wire. The catheter was placed into the left common iliac vein by\n using a Glidewire guidance. Venogram was performed using solely present non-\n ionic contrast and a power injection. Bilateral renal vein openings were\n localized. The the IVC was measured to confirm that a filter was\n appropriate and it was placed in the infrarenal position.\n\n FINDINGS: The bilateral iliac veins and IVC are patent with no evidence of\n filling defect. The IVC measures 18 mm in radius. Repeat venogram following\n filter placement demonstrates the filter is in good position with the tip at\n the opening of the renal veins into the IVC.\n\n The catheter sheath was removed and local hemostasis was performed by\n compression. Patient tolerated the procedure well with no immediate\n complications.\n\n IMPRESSION: Successful placement of an IVC filter.\n\n (Over)\n\n 3:31 PM\n IVC GRAM/FILTER Clip # \n Reason: LONG TERM PE PREVENTION, HAS HO UGIB\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2132-06-06 00:00:00.000","description":"P BILAT LOWER EXT VEINS PORT","row_id":762252,"text":" 9:48 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: SP TRAUMA,LEG SWELLING ,EVAL FOR DVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with\n REASON FOR THIS EXAMINATION:\n r/o dvt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma and immobilization.\n\n BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND: There is normal compressibility,\n flow and augmentation of the bilateral common femoral, superficial femoral and\n popliteal veins bilaterally.\n\n IMPRESSION: No ultrasound evidence of DVT bilaterally.\n\n"},{"category":"Radiology","chartdate":"2132-06-12 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":762753,"text":" 2:50 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: r/o obstruction\n Field of view: 44 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man s/p motorcycle accident\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motor vehicle accident.\n\n TECHNIQUE: Helically acquired axial images were obtained from the lung bases\n to pubic symphysis. 150 cc Optiray was given to the patient due to patient's\n status of debility.\n\n CT ABDOMEN WITH INTRAVENOUS CONTRAST: The lung bases demonstrate mild-to-\n moderate amount of pleural effusion bilaterally. The liver is unremarkable.\n There is evidence of multiple gallstones in the gallbladder, but no evidence\n of pericholecystitic fluid. The pancreas, spleen, kidneys and adrenal glands\n are unremarkable. The visualized small and large bowel loops are within normal\n limits. No evidence of retroperitoneal or mesenteric lymphadenopathy. There is\n no free air or free fluid within the abdomen.\n\n CT PELVIS WITH INTRAVENOUS CONTRAST: Rectum, sigmoid colon, bladder and distal\n ureters are unremarkable. No evidence of pelvic free fluid or pelvic\n lymphadenopathy.\n\n Bone windows demonstrate no evidence of lytic or blastic lesions.\n\n IMPRESSION: No evidence of small bowel obstruction. Unremarkable abdominal and\n pelvic CT.\n\n\n"},{"category":"Radiology","chartdate":"2132-06-03 00:00:00.000","description":"L FEMUR (AP & LAT) LEFT","row_id":762005,"text":" 7:10 PM\n FEMUR (AP & LAT) LEFT Clip # \n Reason: r/o fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with mvc\n REASON FOR THIS EXAMINATION:\n r/o fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motor vehicle accident with left leg pain.\n\n LEFT FEMUR, AP AND LATERAL VIEWS: This is a limited study with a poor exposure\n of the upper femur. The femoral head is poorly visualized. No fracture is seen\n within the femoral neck or shaft. There is a focal deformity along the distal\n shaft of the femur with slight anterior posterior hyperostosis. This likely\n represents a healed fracture. The patient is status post tricompartment left\n knee replacement. There is no evidence of hardware loosening. No joint\n effusion can be assessed given the straight leg.\n\n IMPRESSION: Limited study. No evidence of acute fracture.\n\n"},{"category":"Radiology","chartdate":"2132-06-03 00:00:00.000","description":"TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT)","row_id":761986,"text":" 3:54 PM\n TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT) Clip # \n Reason: MVA\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: AP view of the chest: Examination is limited secondary to the\n trauma board. An incidental left sided hip fracture is identified.\n\n\n 3:54 PM\n TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT) Clip # \n Reason: MVA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MVA.\n\n AP VIEW OF THE CHEST:\n\n Low lung volumes are demonstrated. The superior portion of the chest is not\n evaluated. The mediastinum appears widened. There is no free air.\n\n AP VIEW OF THE PELVIS:\n\n The pelvis is visualized distal to the hip to the hip joints. There are no\n fractures identified. This exam is extremely limited.\n\n IMPRESSION:\n\n 1. Limited exam of the chest and pelvis. There superior portion of the chest\n is not visualized. The mediastinum appears widened.\n\n 2. No fractures identified on this pelvis examination.\n\n\n"},{"category":"Radiology","chartdate":"2132-06-03 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":761990,"text":" 4:10 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Asses for intraabdominal bleed, Asses for bleed\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man s/p motorcycle accident\n REASON FOR THIS EXAMINATION:\n Asses for intraabdominal bleed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motorcycle accident five days previously. Transfer from outside\n hospital. Patient is intubated and extent of injuries is unclear. Assess for\n intraabdominal bleed.\n\n There is no prior study for comparison.\n\n TECHNIQUE: Axial images were obtained from the lung bases to the pubic\n symphysis after administration of 150 cc Optiray nonionic contrast. Optiray\n was administered given the trauma protocol and patient's intubated status.\n\n CT ABDOMEN AFTER IV CONTRAST: There are bilateral pleural effusions associated\n with collapse in the lower lobes, left greater than right. The liver and\n spleen are normal. There are no subcapsular splenic or hepatic hematomas.\n There is no active extravasation within these organs. The gallbladder contains\n layering high-density material and some radiopaque gallstones. The pancreas is\n normal. The adrenal glands and kidneys are normal. There are some nonenlarged\n mediastinal and retroperitoneal lymph nodes.\n No free air is seen within the abdomen. Loops of small bowel are mildly\n dilated but nonthickened. The dilatation extends into the cecum and large\n intestine.\n\n CT PELVIS AFTER IV CONTRAST: There is some free fluid seen deep within the\n pelvis. There are no pelvic masses or enlarged inguinal lymph nodes. The\n ureters and urinary bladder are within normal limits. Atherosclerotic changes\n are seen in the distal aorta and in the femoral vessels.\n\n No free air is seen within the abdomen or pelvis.\n\n Bone windows show a fracture of the most superior vertebral body imaged, this\n is likely the T6 vertebral body. There are lateral rib fractures of the 8th\n and 5th left ribs.\n\n IMPRESSION:\n\n 1. No evidence of injury to solid abdominal organs.\n\n 2. Small amount of ascites and pelvic fluid.\n\n 3. T6 or 7 vertebral body fracture. Left 8th and 5th rib fractures laterally.\n\n 4. Ileus pattern of the bowel.\n (Over)\n\n 4:10 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Asses for intraabdominal bleed, Asses for bleed\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2132-06-03 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":761991,"text":" 4:10 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Asses for intracranial bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man s/p motorcycle accident\n REASON FOR THIS EXAMINATION:\n Asses for intracranial bleed\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: S/P motorcycle accident. Assess for intracranial bleed.\n\n TECHNIQUE: Non-contrast CT exam of the head.\n\n FINDINGS: There are no previous exams for comparison. There is no evidence\n of acute intra or extraaxial hemorrhages. Noted are symmetric prominent\n extraaxial, likely subdural spaces adjacent to the frontal lobes. These spaces\n are of low attenuation (approximately 20 ) and resemble CSF. There is no\n effacement of the adjacent sulci or mass effect. The ventricles and cisterns\n are unremarkable. The -white matter differentiation is well preserved.\n\n No skull fractures are seen. There is minimal opacification of left mastoid\n air cells. Noted is moderate opacification of the ethmoid air cells. There is\n also mild mucosal thickening and air-fluid levels within the maxillary\n sinuses. Lamina papyreacea are difficult to evaluate due to anatomy. Nasal\n bone and septum appear to be intact though they are bowed to the right.\n\n IMPRESSION:\n\n 1. No evidence of acute intra or extraaxial hemorrhage.\n\n 2. Prominent frontal CSF spaces, which could represent CSF subdural\n collections or chronic subdural hematomas. Distinction can probably be made\n with MRI.\n 3. Mild to moderate opacification of the incompletely imaged paranasal\n sinuses. No fractures identified.\n\n The above findings were discussed with Dr. at the time of the exam.\n\n\n"},{"category":"Radiology","chartdate":"2132-06-17 00:00:00.000","description":"CHEST (SINGLE VIEW)","row_id":763136,"text":" 6:09 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: R arm dual lumen picc for long term IV abx. Please page \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with spinal cord injury\n REASON FOR THIS EXAMINATION:\n R arm dual lumen picc for long term IV abx. Please page with wet read as\n soon as available.\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATIONS: Spinal cord injury, PICC line placement.\n\n TECHNIQUE: Supine view of the chest.\n\n Comparison is made to previous films from .\n\n FINDINGS: The left subclavian central venous catheter has been removed. There\n has been interval placement of a right sided PICC line. The tip is in the\n proximal SVC. Again seen is cardiomegaly with left ventricular predominance.\n The aorta is unfolded. The lung volumes are decreased bilaterally, and there\n is no pneumothorax, effusions, or large areas of consolidation. There are\n bibasilar minimal patchy opacities consistent with atelectasis.\n\n IMPRESSION: Right PICC line with the tip in the proximal SVC.\n\n"},{"category":"Radiology","chartdate":"2132-06-11 00:00:00.000","description":"LIVER OR GALLBLADDER US (SINGLE ORGAN)","row_id":762695,"text":" 11:42 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ABD PAIN, R/O CHOLECYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with projectile vomiting, and Illeus\n REASON FOR THIS EXAMINATION:\n R/O cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Vomiting and ileus.\n\n LIVER OR GALLBLADDER ULTRASOUND: The study is limited by patient body habitus\n and a large amount of gas within the overlying loops of bowel. A nondistended\n gallbladder is noted with extensive echogenic and posteriorly shadowing foci\n layering along the dependent portion of the gallbladder. Although no\n intrahepatic ductal dilatation is noted the liver is suboptimally visualized.\n The common bile duct is not dilated, measuring approximately 6 mm in greatest\n diameter. No son sign was elicited. The wall of the\n gallbladder is not thickened and no pericholecystic fluid is detected.\n\n IMPRESSION: Extensive gallstones and sludge within the gallbladder, without\n evidence of cholecystitis or common duct obstruction.\n\n\n"},{"category":"ECG","chartdate":"2132-06-12 00:00:00.000","description":"Report","row_id":176198,"text":"Sinus rhythm\nDiffuse nonspecific low-amplitude T wave - Clinical correlation is suggested\nSince previous tracing of : U wave less prominent & T wave changes\n decreased\n\n"},{"category":"ECG","chartdate":"2132-06-05 00:00:00.000","description":"Report","row_id":176199,"text":"Sinus rhythm\nLong QTc interval\nDiffuse nonspecific ST-T abnormalities with prominent U waves - consider\nmetabolic/drug effect - clinical correlation is suggested\nNo previous report available for comparison\n\n"},{"category":"Nursing/other","chartdate":"2132-06-04 00:00:00.000","description":"Report","row_id":1423979,"text":"Respiratory Care\nRespiratory paged to MRI for intubation, pt orally intubated 7.5 ETT, 25 @ lip. Pt placed on MRI vent for scan and transferred to T-SICU. Pt currently on PB 7200 with initial settings of SIMV/PSV/800/12/50%/+5/%ips, 02 sats 98%, awaiting a-line/ABG to titrate settings. Suctioning thick yellow frequently. Will continue to follow.\n"},{"category":"Nursing/other","chartdate":"2132-06-05 00:00:00.000","description":"Report","row_id":1423980,"text":"S/P MOTORCYCLE MVA-HEAD/SPINE TRAUMA-T/SICU NPN7P-7A\nS-PT INTUBATED\n SEDATED ON PROPOFOL GTT 20-50MCG/KG/MIN,ATIVAN ATC.PT AWAKENS RESTLESS NODS APPROPRIATLY INCONSISTENTLY FOLLOWS COMMANDS MAE'S,HAND GRASP EQUALLY STRONG,ATTEMPTS TO BEND KNEES BILAT.WIGGLE TOES TO COMMAND.STRONG COUGH/GAG.PERRLA 2MM.\nCV-SBP 80'S-130'S ON , PLACED SBP 90'S-120'S.HR 50'S-70 NSR W/ FREQ PAC'S/PVC'S,REPLETING LYTES CONSTANTLY K+3.5->3.2.HCT DOWN TO 23 PT 1 UNIT PRBC THIS AM.\nRESP-PT INTUBATED IN MRI FOR STUDY,PT REMAINED INTUBATED OVER NOC PEND PLAN,SEE RESP FLOWSHEET FOR VENT DETAILS ABG DATA,PT Q 2-3 HRS FOR SM AMTS THICK CLEAR-WHITE SECRETIONS.PT COUGH STRONG.O2 SATS 96-100%.\nGI/GU-PT CONTS TO HAVE LARGE STOOL + NG OUTPUTS OVER NOC.,O/U 10-30CC/HR AMBER CLEAR URINE OVER NOC VIA FOLEY,FLUID BOLUS X 2 FOR LOW U/O.NPO,STOOL LIQ BROWN.C-DIFF SPEC SENT.\nSKIN-NO NEW SKIN INTEGRITY ISSUES,POST ECCYMOSSIS LUE,LLE.\nSOC-NO FAMILY CALLS OVER NOC.\nID-T MAX 99.3\nENDO-FS BS 90'S\nA-ALT NEURO STATUS R/T MVA SPINE TRAUMA.\nP-CONT NEURO MONITORING,SEDATION/ORDERS,VS,I+O,MONITOR LAB DATA QS AND PRN,FAMILY SUPPORT PRN,MONITOR SKIN INTEGRITY QS AND PRN.\n"},{"category":"Nursing/other","chartdate":"2132-06-05 00:00:00.000","description":"Report","row_id":1423981,"text":"Resp Care,\nPt. weaned to CPAP IPS10.5/5peep this am. VT 450, RR20. Cont. to wean as tol.\n"},{"category":"Nursing/other","chartdate":"2132-06-05 00:00:00.000","description":"Report","row_id":1423982,"text":"RESP NOTE:PT EXTUBATED AS PER ORDER W/O INCIDENT,PLACED ON 3L/NC MAINTAINING SATS 97-100%.NO RESP DISTRESS NOTED,WILL CONTINUE TO MONITOR.\n"},{"category":"Nursing/other","chartdate":"2132-06-05 00:00:00.000","description":"Report","row_id":1423983,"text":"SOCIAL WORK NOTE:\nPt remains disoriented to time and place. No contact with family by this SW today. Will remain involved as needed. Pager .\n"},{"category":"Nursing/other","chartdate":"2132-06-05 00:00:00.000","description":"Report","row_id":1423984,"text":"NSG NOTE\nROS:\n\n CV:SYS BP 150'S/70'S,IN SR WITH RARE APC'S.RR 21-33.T MAX 99.8\n\n RESP:PPT EXTUBATED AT 3:30PM.SX FOR LARGE AMT THIN TAN SECRETIONS PRIOP TO EXTUB,MUCH LESS SECRETIONS NOW.SATS 99 ON 3L NP.ABGS 7.43-35-100.\n\n NEURO:TALKING RAG TIME SINCE EXTUBATED,WILL FOLLOW COMMANDS.STRONG HAND GRIP ON L,WEAKER ON R.MOVES R FOOT MORE THAN L.\nON ATIVAN Q6HRS.\n\n GU:UO ACCEPTABLE,AMBER COLOR.RECEIVING 150CC HR BANANA BAG THEN NS WITH 20 KCL AT 150CC HR.\n\n GI:NPO,NGT DRAINING TONS BILIOUS FLD,DRAINING LARGE AMT LIQUID STOOL VIA RECTAL BAG AS WELL.\n\n ENDO:FS 91-87 NO INSULIN\n\n HEME:HCT 24,GIVEN 1U P CELLS,REPEAT HCT 30.2\n\n LYTES:K 3.5---GIVEN 40 KCL/500NS OVER 4HRS(3P-7P)\n\n SOCIAL:DAUGHTER CALLED,SPOKE TO T-SICU HO RE MRI FROM .\n\n"},{"category":"Nursing/other","chartdate":"2132-06-06 00:00:00.000","description":"Report","row_id":1423985,"text":"nsg :\nneuro obeys commands but very confused. will raise knees and wiggle toes. strong grasp but unable to lift arms very far. does not bend elbows.\n\nstable hemodynaically. afebrile. ivf at 150ccs per hr. uo qs.\n\ngi lg amt of ng drainage, and liq brown stool spec sent for c diff.\n"},{"category":"Nursing/other","chartdate":"2132-06-03 00:00:00.000","description":"Report","row_id":1423975,"text":"Nursing Admission Note\nPt is a 59yo male who was wearing a helmet and got into a motorcycle accident on . He was admitted to an OSH. Head CT (+) for bilateral small posterior parietal intraparenchymal bleed. Per report Pt was alert and oriented. Today Pt was noted to have upper extremity weakness. Repeat head CT did not show any change, but further w/u revealed T7 vetebral body compression fracture. Pt was transferred to after being paralyzed/sedated and intubated. Extubated in EW and admitted to T/SICU. Pt arrived on stretcher accompanied by physician. was awake, oriented to person, but otherwise confused. LR infusing and NGT clamped.\n\nPMH:\n-HTN\n-Gout\n-s/p multiple ORIF of LA and L leg d/t prior motorcycle accident.\n\nAllergies: no known medication allergies\n\nMedications: Indomethacin\n\nSocial: ppd smoker, (+) heavy ETOH use every day. Lives alone. Divorced. Has 2 daughters. Daughter, , was here when Pt was admitted.\n\nReview of Systems\nNeuro: Pt is awake and is able to tell me his name, but could not tell me where he was or what year it is. He talks outloud to persons who are not present and thought he was in a police station. Follows commands. PERRL. Can not raise arms independently off bed. He uses siderails to raise them, but can not hold them them in air. / to nailbed pressure. Cervical collar on. Logroll precautions.\n\nResp: Breathing unlabored. Sao2 on 4L NC=96%.\n\nCV: HR in the 80s. NSR. BP=138/57.\n\nGI: NGT to LCS drained 800cc bilious fluid after arival to ICU. Abdomen is distended, but soft.\n\nGU: Foley to gravity. Urine amber.\n\nID: Afebrile.\n\nSkin: Large hematoma present on left thigh. Backside inatct.\n\nSocial: Daughter, , here when Pt arrived. No belongings left at bedside.\n\nA: Hemodynmics stable. Pt confused. Limited mobility.\n\nP: Neuro checks q 1hr. Ativan for DT prophylaxis. ? MRI of spine. Monitor per plan\n"},{"category":"Nursing/other","chartdate":"2132-06-04 00:00:00.000","description":"Report","row_id":1423976,"text":"S/P MOTORCYCLE MVA HEAD/SPINE TRAUMA T/SICU\nNPN 11P-7A\nS-\"I'M ALRIGHT NOW BUT THIS WHOLE PLACE IS GONNA BLOW IN 2 HRS\"\nO-NEURO-PT A+O X OVER NOC,FOLLOWS SIMPLE COMMANDS MAE'S,SPASTIC GROSS MOTOR MOVEMENTS BILAT UPPER AND LOWER EXTREMITIES,HAND GRASPS 4+ STRENTGH BILAT,PERRLA 2-3MM.PT PERSEVERATING/RAMBLING SPEECH/OCCAS FOUL LANGUAGE,PT GIVEN TOTAL 3.5 MG ATIVAN OVER NOC.PT DOWN FOR MRI C-SPINE/T-SPINE THIS AM.\nCV-PT HR 80'S NSR W/ BURST SVT/SELF LIMITED X 2.SBP 110'S-130'S OVER NOC.\nRESP-PT LS CTA DECREASED BASES,O2 SATS 94-100% ON 4 L NC,O2 SATS 88-90% ON RA,RR 18-26,NARD.\nGI/GU-PT ABD OBESE SOFT +HYPOACTIVE BS,NPO,NGT DRAINING MOD -LARGE AMTS BILIOUS DRAINAGE.PT URINE CLEAR AMBER VIA FOLEY U/O ADEQ.LOOSE BROWN STOOL SM-MOD AMT X 2 OVER NOC,\nSKIN-NO NEW SKIN INTEGRITY ISSUES.\nSOC-PT'S DAUGHTER CALLED X 1 OVER NOC.\nA-ALT NEURO EXAM S/P T/SPINE TRAUMA.\nP-CONT MONITOR NEURO EXAM/ORDERS,F/U W/ TM RE: RESULT MRI,VS,I+O,O2 /ORDERS,MONITOR SKIN INTEGRITY QS AND PRN,FAMILY SUPPORT PRN,SOC WORK\n"},{"category":"Nursing/other","chartdate":"2132-06-04 00:00:00.000","description":"Report","row_id":1423977,"text":"SOCIAL WORK NOTE:\nPt known to this SW from ED arrival yesterday. Please see my printed OMR note in chart for further information. Pt seen in room today in T-SICU. He thought that is was and asked if we are going \"crabbing\". He stated that this SW has always gathered \"a couple barrels of crabs\". This SW phoned pt's dtr at home to offer continued support (spoke with her yesterday). She is greatly upset by pt's altered mental status but is glad that he is back in and more accessible for visiting. She reports that pt is on disability due to knee problems. She confirmed that pt has long history of etoh abuse. Medical team is aware of pt's long and active history of etoh abuse. Dtr given contact information for this SW and I will remain involved. Pager .\n"},{"category":"Nursing/other","chartdate":"2132-06-04 00:00:00.000","description":"Report","row_id":1423978,"text":"T-SICU NURSING PROGRESS NOTE\nNEURO: AROUSABLE TO VOICE, ORIENTED TO SELF ONLY. PT TALKING OUT LOUD, VERY CONFUSED, THINKS IT IS AND THAT HE IS AT THE POLICE STATION. ABLE TO STATE THE NAME OF HIS CHILDREN AND THAT HE IS FROM , MA. HAND GRASP BILAT, ABLE TO EXTEND BOTH ARMS BUT UNABLE TO FLEX OR HOLD UP ARMS. WIGLLES TOES TO COMMAND, ABLE TO PLANTAR FLEX BOTH FEET, LEFT FOOT STRONGER THAN RIGHT. PUPILS 3MM BILAT AND BRISKLY REACTIVE. REMAINS IN C-COLLAR. TAKEN BACK TO MRI AT 5:30PM D/T POOR QUALITY OF FIRST SCAN. PT WAS SEDATED WITH FENTANYL AND MIDAZ. PT WAS SLEEPY BUT D/T HIS BREATHING PATTERN THERE WAS TOO MUCH WALL MOTION AND SCAN QUALITY WAS POOR. PT WAS ELECTIVELY INTUBATED TO COMPLETE THE SCAN.\n\nCV: HR 80S, NSR WITH FREQ PAC'S, ATRIAL BIGEM. BP STABLE 120-140/70. SKIN WARM, DRY, (+)PALP PULSES, TRACE PEDAL EDEMA\n\nRESP: AS ABOVE, PT WAS ELECTIVELY INTUBATED TO COMPLETE MRI. PRIOR TO INTUBATION, BREATH SOUNDS CLEAR IN UPPER LOBES, VERY DIMINISHED IN THE BASES BILAT. AFTER INTUBATION, PT WAS SUCTIONED FOR THICK, COPIOUS YELLOW SECRETIONS. PRIOR TO INTUBATION SATS 96-98% ON 2LNC\n\nRENAL: URINE AMBER IN COLOR, BORDERLINE U/O ~ 25-40CC/HR. LYTES SENT, RESULTS PENDING\n\nGI: ABD OBESE, SOFT, (+)BOWEL SOUNDS. LIQUID BROWN STOOL, LARGE AMT, RECTAL BAG PLACED. REMAINS NPO. MODERATE NGT OUTPUT,\n\nHEME: HCT 26.1 (FROM 28), TEAM AWARE, NO SIGNS OF BLEEDING, WILL CONTINUE TO MONITOR\n\nID: T. MAX 99.5, NO ABX\n\nSKIN: LARGE HEMATOMA ALONG BACK OF LEFT LEG, ABRASIONS TO BILAT SHINS, BACK/BUTTOCKS INTACT. SKIN UNDER C-COLLAR INTACT\n\nSOCIAL: PT'S DAUGHTER CALLED X 2 TODAY, UPDATED ON PT'S CONDITION\n\nENDO: NO INSULIN COVERAGE REQUIRED\n\nA: ALTERED MENTAL STATUS, DECREASED STRENGTH ALL EXTS, ?T4-T7 INJURY--MRI RESULTS PENDING\n\nP: Q1H NEURO CHECKS, LOGROLL PRECAUTIONS, CONTINUE CURRENT PLAN, FOLLOW RESULTS OF MRI\n"},{"category":"Nursing/other","chartdate":"2132-06-06 00:00:00.000","description":"Report","row_id":1423986,"text":"S. THE BROUGHT ME HERE IN A BOX I NEED SOME CLOTHES\nO.NEURO PT CONFUSED ALERT TO NAME RAMBLING PEARLA FC GOOD GRASPS BOTH HANDS RIGHT ARM ABLE TO COME UP 30 DEGREES LT 45 DEGREES STRENGHT SL. BETTER IN LT, RT AND LT LEG MOVING ON BED, HALDOL 1MG IV X 1\nCARDIAC NSR OCC ECTOPY BP 130/-150/84 HCT 30.6 K 4.4 RT LEG WARM ERYTHEMATOUS ANT 2/3 UP, PAIN TO TOUCH US DONE PRELIM NEG BLOOD CLOT, STARTED ON KEFLEX CVP 9 CL PLACED LT SC TRIPLE LUMEN PP+2, SCAB BELOW RT KNEE UNCHANGED AND LT ANKLE LACERATION UNCHANGED BACITRACAN\nRESP 4LNP 7.40/31/84/20 LUNGS CTA COUGHING SWALLOWING SPUTUM\nGI NPO IV NS 150 Q HR ABD SOFT DISTENDED BS HYPERACTIVE NGT OUTPUT 1L BILIOUS STOOL GOLDEN TO TAR COLOR LIQ THIRD STOOL FOR CDIFF SENT LDH 395 TOTAL BILI 4.7 LACTIC ACID AST 45 ALT 28\nGU U/O > 60CC QHR AMBER\nNUTRITION TRIPLE LUMEN LT SC PLACED FOR TPN\nID WBC 10.8 BC X2 DRAWN KEFLEX IV STARTED\nA. ALT NEURO STATUS C4-5 CONTUSION POSSIBLE CENTRAL CORD SYNDROME WITH EXTREMITY WEAKNESS BILAT, ALT MS ? RELATED TO ATIVAN GIVEN\nALT SKIN POSS. CELLULITIS\nALT NUTRITIONAL STATUS HIGH NGT OUTPUT AND DIARRHEA\nETOH ABUSE\n+ SMOKER\nP. PT FITTED FOR COLLAR AND CHEST BRACE TO START REHAB\nCONT TO LOGROLL TILL THEN\nPT OT CONSULT\nCHANGE ATIVAN TO PRN GIVE HALDOL AS NEEDED\nSTART TPN\nWATCH ANY S+S OF \nORIENT PT FREQUENTLY\n\n\n"},{"category":"Nursing/other","chartdate":"2132-06-07 00:00:00.000","description":"Report","row_id":1423987,"text":"S/P MOTORCYCLE MVA/SPINE TRAUMA T/SICU NPN 7P-7A\nS-\"IT' \"\n0-NEURO-PT A+O X 0-2 NAME +/OR DATE(MONTH/YEAR)OVER NOC,MAE'S,HAND GRASPS STRONG BILAT,PT NOW ABLE TO RAISE BUE UP OFF BED W/ DIFF NOW ABLE TO ALSO BEND ELBOWS BILAT,PT MOVES TO COMMAND,^^ STRENGTH ABLE TO BEND KNEES UP OFF BED BILAT.STRONG GAG/COUGH EFFORT,PERRLA 2-3MM.\nCV-SEE FLOWSHEET FOR VS DETAILS,HR 60'S-90'S OVER NOC,SBP 120'S-160'S.+DP/PT \n LS CTA DECREASED SL BASES-O2 SATS 94-96% ON RA,O2 WEANED OFF.RR 16-24,PT C/ODIFF BREATHING @ 6A,RESOLVED W/ ORAL OF THICK WHITE MUCOUS.\nGI/GU-PT ABD SOFT OBESE + HYPOACTIVE BS,NGT CONTS TO DRAIN MOD AMTS BILIOUS FLUID CHANGED FROM LCWS->LIWS.U/O ADEQ AMBER CLEAR URINE VIA FOLEY.NPO.TPN CONTS.\nSKIN-NO NEW ISSUES\nSOC-PT DAUGHTER CALLED X 1 OVER NOC.\nID-T MAX 99.3\nENDO-BS WNL\nA-ALT MS ? R/T HEAD TRAUMA VS SEDATIVES\nP-CONT TO MONITOR NEURO EXAM,VS,MONITOR RESP QS AND PRN,I+O,O2 PRN,TPN/ORDERS,MONITOR SKIN INTEGRITY QS AND PRN.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-06-04 00:00:00.000\",\n \"description\": \"ORBITS (WATERS, CALDWELL & LAT)\",\n \"row_id\": 762021,\n \"text\": \" 2:42 AM\\n ORBITS (WATERS, & LAT) Clip # \\n Reason: TWO VIEWS TO RULE OUT METAL IN ORBITALS BEFORE GOING TO MRI\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with T7 compression fracture, s/p motorcycle accident \\n REASON FOR THIS EXAMINATION:\\n TWO VIEWS TO RULE OUT METAL IN ORBITALS BEFORE GOING TO MRI\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: Evaluate for foreign bodies prior to MR exam.\\n\\n ORBITS, TWO VIEWS: No metallic foreign bodies.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-06-11 00:00:00.000\",\n \"description\": \"ABDOMEN (SUPINE & ERECT)\",\n \"row_id\": 762673,\n \"text\": \" 4:04 PM\\n ABDOMEN (SUPINE & ERECT) Clip # \\n Reason: Projectile vomiting\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with projectile vomiting\\n REASON FOR THIS EXAMINATION:\\n Projectile vomiting\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Projectile vomiting.\\n\\n TECHNOLOGIST NOTE: Supine film could not be performed at this time due to\\n patient condition.\\n\\n SUPINE ABDOMEN: There is gas contained throughout the colon from cecum to\\n rectum. The transverse colon is somewhat prominent and the cecum is somewhat\\n dilated. There is gas contained in multiple small bowel loops which are\\n minimally dilated. There is no free air evident. Upright or decubitus films\\n were not obtained, so the presence of air fluid levels cannot be assessed.\\n\\n IMPRESSION: Appearance consistent with paralytic ileus.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-06-04 00:00:00.000\",\n \"description\": \"MR L SPINE SCAN\",\n \"row_id\": 762023,\n \"text\": \" 3:39 AM\\n MR L SPINE SCAN; MR THORACIC SPINE Clip # \\n Reason: eval for nerve compression/infection\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with T7 compression fracture, s/p motorcycle accident\\n REASON FOR THIS EXAMINATION:\\n eval for nerve compression/infection\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n\\n INDICATION: T7 compression fracture following MVA. Evaluate for nerve\\n compression or infection.\\n\\n TECHNIQUE: Sagittal T1, T2 images of the cervical, thoracic and lumbar spine\\n with additional inversion recovery sagittal images of the lumbar spine and\\n gradient echo axial images of cervical spine. Additional turbo-spin echo\\n axial images of the thoracic spine were performed.\\n\\n NR CERVICAL SPINE: This study is extremely limited due to gross patient\\n motion. Minor cervical spondylosis is noted at the C3/4, and levels.\\n The axial images of this region are uninterpretable. This study is\\n insufficient for evaluation of neural foraminal narrowing or possible spinal\\n stenosis.\\n\\n MR THORACIC SPINE: This study is extremely limited by patient motion.\\n Increased inversion recovery signal is noted in the T4, 5.6 and 8 levels. No\\n definite fracture line is observed. No gross spinal canal stenosis or neural\\n foraminal narrowing is noted on this extremely limited study. There is loss\\n of vertebral body height at multiple levels.\\n\\n IMPRESSION: Extremely limited study due to gross patient motion. Multilevel\\n cervical and thoracic spondylosis, as described above. There is increased\\n inversion recovery signal in multiple vertebral body levels and loss of\\n vertebral body height, suggestive of acute injury-i.e. fracture. The\\n previously described compression fracture is poorly visualized on this study.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-06-04 00:00:00.000\",\n \"description\": \"MR CERVICAL SPINE\",\n \"row_id\": 762106,\n \"text\": \" 5:22 PM\\n MR CERVICAL SPINE Clip # \\n Reason: S/P MOTORCYCLE ACCIDENT; ARM AND LEG WEAKNESS, NECK PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with T7 compression fracture, s/p motorcycle accident\\n\\n REASON FOR THIS EXAMINATION:\\n with stir images to r/o ligmental injuries.\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n HISTORY: T7 compression fracture.\\n\\n Repeat study attempted to improve image quality.\\n\\n TECHNIQUE: Multiplanar T1 and T2 weighted imaging of the cervical spine was\\n performed.\\n\\n FINDINGS: Nearly all of the images are of equally limited resolution due to\\n gross patient motion. However, there are a few sequences which are of\\n excellent technical quality and it is on these image sequences that the\\n following report is based.\\n\\n There is very slight elevated T2 signal within the mid cervical cord at the\\n level of C4 and C5. The axial scans show mild spinal cord compression C5/6 due\\n to a posterior spondylytic ridge with moderate bilateral C4/5 and prominent\\n C5/6 bilateral neural foraminal encroachment due to uncovertebral spurs.\\n\\n There is more moderate spinal cord edema and spinal cord compression at the T4\\n level due to a compression fracture. This finding was not as obvious on the\\n prior study but the present image sequence clearly delineates this\\n abnormality. There is edema within the T4/5 disc space, also likely post\\n traumatic. No other definite abnormalities are seen.\\n\\n CONCLUSION: Mild spinal cord edema in the mid cervical region. 2) Spinal cord\\n compression and edema due to a presumed traumatic compression fracture at the\\n T4 level. We reached the trauma team to report the findings immediately.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-06-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 762278,\n \"text\": \" 2:09 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p Lt subclavian CVL placement. Check line position and r/o\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with\\n REASON FOR THIS EXAMINATION:\\n s/p Lt subclavian CVL placement. Check line position and r/o pneumothorax.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Check central venous line placement.\\n\\n CHEST, SINGLE VIEW: The left subclavian catheter terminates at the junction\\n of the left brachiocephalic vein and SVC. An NG tube is terminating in the\\n stomach, with a site for it not well visualized. The cardiomediastinal\\n contours appears prominent, may be associated with low lung volumes. There is\\n evidence of fluid overload, evidenced by pulmonary vascularity prominence and\\n perivascular haziness. There is also a small left pleural effusion.\\n\\n There is no pneumothorax.\\n\\n IMPRESSION: Left subclavian catheter terminates at the junction of\\n brachiocephalic vein and SVC. No pneumothorax. Fluid overload with small\\n left pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-06-18 00:00:00.000\",\n \"description\": \"INTERUP IVC\",\n \"row_id\": 763202,\n \"text\": \" 3:31 PM\\n IVC GRAM/FILTER Clip # \\n Reason: LONG TERM PE PREVENTION, HAS HO UGIB\\n Contrast: OPTIRAY Amt: 80\\n ********************************* CPT Codes ********************************\\n * INTERUP IVC INTRO CATH SVC/IVC *\\n * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT IVC FILTER *\\n * IVC GRAM *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with BL LE PARALYSIS, WITH HO OF UGIB\\n REASON FOR THIS EXAMINATION:\\n LONG TERM PE PREVENTION, HAS HO UGIB\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n\\n\\n\\n\\n\\n HISTORY:\\n\\n The patient is a 59 year old male who sustained thoracic vertebral compression\\n fracture in motorcycle accident. IVC filter placement was requested by\\n patient's physician.\\n\\n The risks and benefits were explained to the patient and the consent was\\n obtained from the patient.\\n\\n TECHNIQUE: Patient was brought into the Angio Suite and placed supine on the\\n angio table. His right groin was prepped and draped in sterile fashion. Local\\n anesthesia was given using 1% lidocaine. The right common femoral vein was\\n accessed using 19-gauge Seldinger needle and a 0.035 wire was advanced\\n into the IVC. The needle was exchanged for a 4-French Omni Flush catheter\\n over the wire. The catheter was placed into the left common iliac vein by\\n using a Glidewire guidance. Venogram was performed using solely present non-\\n ionic contrast and a power injection. Bilateral renal vein openings were\\n localized. The the IVC was measured to confirm that a filter was\\n appropriate and it was placed in the infrarenal position.\\n\\n FINDINGS: The bilateral iliac veins and IVC are patent with no evidence of\\n filling defect. The IVC measures 18 mm in radius. Repeat venogram following\\n filter placement demonstrates the filter is in good position with the tip at\\n the opening of the renal veins into the IVC.\\n\\n The catheter sheath was removed and local hemostasis was performed by\\n compression. Patient tolerated the procedure well with no immediate\\n complications.\\n\\n IMPRESSION: Successful placement of an IVC filter.\\n\\n (Over)\\n\\n 3:31 PM\\n IVC GRAM/FILTER Clip # \\n Reason: LONG TERM PE PREVENTION, HAS HO UGIB\\n Contrast: OPTIRAY Amt: 80\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-06-06 00:00:00.000\",\n \"description\": \"P BILAT LOWER EXT VEINS PORT\",\n \"row_id\": 762252,\n \"text\": \" 9:48 AM\\n BILAT LOWER EXT VEINS PORT Clip # \\n Reason: SP TRAUMA,LEG SWELLING ,EVAL FOR DVT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with\\n REASON FOR THIS EXAMINATION:\\n r/o dvt\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Trauma and immobilization.\\n\\n BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND: There is normal compressibility,\\n flow and augmentation of the bilateral common femoral, superficial femoral and\\n popliteal veins bilaterally.\\n\\n IMPRESSION: No ultrasound evidence of DVT bilaterally.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-06-12 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 762753,\n \"text\": \" 2:50 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n CT 150CC NONIONIC CONTRAST\\n Reason: r/o obstruction\\n Field of view: 44 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man s/p motorcycle accident\\n REASON FOR THIS EXAMINATION:\\n r/o obstruction\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Motor vehicle accident.\\n\\n TECHNIQUE: Helically acquired axial images were obtained from the lung bases\\n to pubic symphysis. 150 cc Optiray was given to the patient due to patient's\\n status of debility.\\n\\n CT ABDOMEN WITH INTRAVENOUS CONTRAST: The lung bases demonstrate mild-to-\\n moderate amount of pleural effusion bilaterally. The liver is unremarkable.\\n There is evidence of multiple gallstones in the gallbladder, but no evidence\\n of pericholecystitic fluid. The pancreas, spleen, kidneys and adrenal glands\\n are unremarkable. The visualized small and large bowel loops are within normal\\n limits. No evidence of retroperitoneal or mesenteric lymphadenopathy. There is\\n no free air or free fluid within the abdomen.\\n\\n CT PELVIS WITH INTRAVENOUS CONTRAST: Rectum, sigmoid colon, bladder and distal\\n ureters are unremarkable. No evidence of pelvic free fluid or pelvic\\n lymphadenopathy.\\n\\n Bone windows demonstrate no evidence of lytic or blastic lesions.\\n\\n IMPRESSION: No evidence of small bowel obstruction. Unremarkable abdominal and\\n pelvic CT.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-06-03 00:00:00.000\",\n \"description\": \"L FEMUR (AP & LAT) LEFT\",\n \"row_id\": 762005,\n \"text\": \" 7:10 PM\\n FEMUR (AP & LAT) LEFT Clip # \\n Reason: r/o fx\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with mvc\\n REASON FOR THIS EXAMINATION:\\n r/o fx\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Motor vehicle accident with left leg pain.\\n\\n LEFT FEMUR, AP AND LATERAL VIEWS: This is a limited study with a poor exposure\\n of the upper femur. The femoral head is poorly visualized. No fracture is seen\\n within the femoral neck or shaft. There is a focal deformity along the distal\\n shaft of the femur with slight anterior posterior hyperostosis. This likely\\n represents a healed fracture. The patient is status post tricompartment left\\n knee replacement. There is no evidence of hardware loosening. No joint\\n effusion can be assessed given the straight leg.\\n\\n IMPRESSION: Limited study. No evidence of acute fracture.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-06-03 00:00:00.000\",\n \"description\": \"TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT)\",\n \"row_id\": 761986,\n \"text\": \" 3:54 PM\\n TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT) Clip # \\n Reason: MVA\\n ______________________________________________________________________________\\n FINAL ADDENDUM\\n ADDENDUM: AP view of the chest: Examination is limited secondary to the\\n trauma board. An incidental left sided hip fracture is identified.\\n\\n\\n 3:54 PM\\n TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT) Clip # \\n Reason: MVA\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: MVA.\\n\\n AP VIEW OF THE CHEST:\\n\\n Low lung volumes are demonstrated. The superior portion of the chest is not\\n evaluated. The mediastinum appears widened. There is no free air.\\n\\n AP VIEW OF THE PELVIS:\\n\\n The pelvis is visualized distal to the hip to the hip joints. There are no\\n fractures identified. This exam is extremely limited.\\n\\n IMPRESSION:\\n\\n 1. Limited exam of the chest and pelvis. There superior portion of the chest\\n is not visualized. The mediastinum appears widened.\\n\\n 2. No fractures identified on this pelvis examination.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-06-03 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 761990,\n \"text\": \" 4:10 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: Asses for intraabdominal bleed, Asses for bleed\\n Field of view: 48 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man s/p motorcycle accident\\n REASON FOR THIS EXAMINATION:\\n Asses for intraabdominal bleed\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Motorcycle accident five days previously. Transfer from outside\\n hospital. Patient is intubated and extent of injuries is unclear. Assess for\\n intraabdominal bleed.\\n\\n There is no prior study for comparison.\\n\\n TECHNIQUE: Axial images were obtained from the lung bases to the pubic\\n symphysis after administration of 150 cc Optiray nonionic contrast. Optiray\\n was administered given the trauma protocol and patient's intubated status.\\n\\n CT ABDOMEN AFTER IV CONTRAST: There are bilateral pleural effusions associated\\n with collapse in the lower lobes, left greater than right. The liver and\\n spleen are normal. There are no subcapsular splenic or hepatic hematomas.\\n There is no active extravasation within these organs. The gallbladder contains\\n layering high-density material and some radiopaque gallstones. The pancreas is\\n normal. The adrenal glands and kidneys are normal. There are some nonenlarged\\n mediastinal and retroperitoneal lymph nodes.\\n No free air is seen within the abdomen. Loops of small bowel are mildly\\n dilated but nonthickened. The dilatation extends into the cecum and large\\n intestine.\\n\\n CT PELVIS AFTER IV CONTRAST: There is some free fluid seen deep within the\\n pelvis. There are no pelvic masses or enlarged inguinal lymph nodes. The\\n ureters and urinary bladder are within normal limits. Atherosclerotic changes\\n are seen in the distal aorta and in the femoral vessels.\\n\\n No free air is seen within the abdomen or pelvis.\\n\\n Bone windows show a fracture of the most superior vertebral body imaged, this\\n is likely the T6 vertebral body. There are lateral rib fractures of the 8th\\n and 5th left ribs.\\n\\n IMPRESSION:\\n\\n 1. No evidence of injury to solid abdominal organs.\\n\\n 2. Small amount of ascites and pelvic fluid.\\n\\n 3. T6 or 7 vertebral body fracture. Left 8th and 5th rib fractures laterally.\\n\\n 4. Ileus pattern of the bowel.\\n (Over)\\n\\n 4:10 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: Asses for intraabdominal bleed, Asses for bleed\\n Field of view: 48 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-06-03 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 761991,\n \"text\": \" 4:10 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: Asses for intracranial bleed\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man s/p motorcycle accident\\n REASON FOR THIS EXAMINATION:\\n Asses for intracranial bleed\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: S/P motorcycle accident. Assess for intracranial bleed.\\n\\n TECHNIQUE: Non-contrast CT exam of the head.\\n\\n FINDINGS: There are no previous exams for comparison. There is no evidence\\n of acute intra or extraaxial hemorrhages. Noted are symmetric prominent\\n extraaxial, likely subdural spaces adjacent to the frontal lobes. These spaces\\n are of low attenuation (approximately 20 ) and resemble CSF. There is no\\n effacement of the adjacent sulci or mass effect. The ventricles and cisterns\\n are unremarkable. The -white matter differentiation is well preserved.\\n\\n No skull fractures are seen. There is minimal opacification of left mastoid\\n air cells. Noted is moderate opacification of the ethmoid air cells. There is\\n also mild mucosal thickening and air-fluid levels within the maxillary\\n sinuses. Lamina papyreacea are difficult to evaluate due to anatomy. Nasal\\n bone and septum appear to be intact though they are bowed to the right.\\n\\n IMPRESSION:\\n\\n 1. No evidence of acute intra or extraaxial hemorrhage.\\n\\n 2. Prominent frontal CSF spaces, which could represent CSF subdural\\n collections or chronic subdural hematomas. Distinction can probably be made\\n with MRI.\\n 3. Mild to moderate opacification of the incompletely imaged paranasal\\n sinuses. No fractures identified.\\n\\n The above findings were discussed with Dr. at the time of the exam.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-06-17 00:00:00.000\",\n \"description\": \"CHEST (SINGLE VIEW)\",\n \"row_id\": 763136,\n \"text\": \" 6:09 PM\\n CHEST (SINGLE VIEW) Clip # \\n Reason: R arm dual lumen picc for long term IV abx. Please page \\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with spinal cord injury\\n REASON FOR THIS EXAMINATION:\\n R arm dual lumen picc for long term IV abx. Please page with wet read as\\n soon as available.\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n INDICATIONS: Spinal cord injury, PICC line placement.\\n\\n TECHNIQUE: Supine view of the chest.\\n\\n Comparison is made to previous films from .\\n\\n FINDINGS: The left subclavian central venous catheter has been removed. There\\n has been interval placement of a right sided PICC line. The tip is in the\\n proximal SVC. Again seen is cardiomegaly with left ventricular predominance.\\n The aorta is unfolded. The lung volumes are decreased bilaterally, and there\\n is no pneumothorax, effusions, or large areas of consolidation. There are\\n bibasilar minimal patchy opacities consistent with atelectasis.\\n\\n IMPRESSION: Right PICC line with the tip in the proximal SVC.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-06-11 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 762695,\n \"text\": \" 11:42 PM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \\n Reason: ABD PAIN, R/O CHOLECYSTITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with projectile vomiting, and Illeus\\n REASON FOR THIS EXAMINATION:\\n R/O cholecystitis\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Vomiting and ileus.\\n\\n LIVER OR GALLBLADDER ULTRASOUND: The study is limited by patient body habitus\\n and a large amount of gas within the overlying loops of bowel. A nondistended\\n gallbladder is noted with extensive echogenic and posteriorly shadowing foci\\n layering along the dependent portion of the gallbladder. Although no\\n intrahepatic ductal dilatation is noted the liver is suboptimally visualized.\\n The common bile duct is not dilated, measuring approximately 6 mm in greatest\\n diameter. No son sign was elicited. The wall of the\\n gallbladder is not thickened and no pericholecystic fluid is detected.\\n\\n IMPRESSION: Extensive gallstones and sludge within the gallbladder, without\\n evidence of cholecystitis or common duct obstruction.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2132-06-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 176198,\n \"text\": \"Sinus rhythm\\nDiffuse nonspecific low-amplitude T wave - Clinical correlation is suggested\\nSince previous tracing of : U wave less prominent & T wave changes\\n decreased\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2132-06-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 176199,\n \"text\": \"Sinus rhythm\\nLong QTc interval\\nDiffuse nonspecific ST-T abnormalities with prominent U waves - consider\\nmetabolic/drug effect - clinical correlation is suggested\\nNo previous report available for comparison\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-06-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1423979,\n \"text\": \"Respiratory Care\\nRespiratory paged to MRI for intubation, pt orally intubated 7.5 ETT, 25 @ lip. Pt placed on MRI vent for scan and transferred to T-SICU. Pt currently on PB 7200 with initial settings of SIMV/PSV/800/12/50%/+5/%ips, 02 sats 98%, awaiting a-line/ABG to titrate settings. Suctioning thick yellow frequently. Will continue to follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-06-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1423980,\n \"text\": \"S/P MOTORCYCLE MVA-HEAD/SPINE TRAUMA-T/SICU NPN7P-7A\\nS-PT INTUBATED\\n SEDATED ON PROPOFOL GTT 20-50MCG/KG/MIN,ATIVAN ATC.PT AWAKENS RESTLESS NODS APPROPRIATLY INCONSISTENTLY FOLLOWS COMMANDS MAE'S,HAND GRASP EQUALLY STRONG,ATTEMPTS TO BEND KNEES BILAT.WIGGLE TOES TO COMMAND.STRONG COUGH/GAG.PERRLA 2MM.\\nCV-SBP 80'S-130'S ON , PLACED SBP 90'S-120'S.HR 50'S-70 NSR W/ FREQ PAC'S/PVC'S,REPLETING LYTES CONSTANTLY K+3.5->3.2.HCT DOWN TO 23 PT 1 UNIT PRBC THIS AM.\\nRESP-PT INTUBATED IN MRI FOR STUDY,PT REMAINED INTUBATED OVER NOC PEND PLAN,SEE RESP FLOWSHEET FOR VENT DETAILS ABG DATA,PT Q 2-3 HRS FOR SM AMTS THICK CLEAR-WHITE SECRETIONS.PT COUGH STRONG.O2 SATS 96-100%.\\nGI/GU-PT CONTS TO HAVE LARGE STOOL + NG OUTPUTS OVER NOC.,O/U 10-30CC/HR AMBER CLEAR URINE OVER NOC VIA FOLEY,FLUID BOLUS X 2 FOR LOW U/O.NPO,STOOL LIQ BROWN.C-DIFF SPEC SENT.\\nSKIN-NO NEW SKIN INTEGRITY ISSUES,POST ECCYMOSSIS LUE,LLE.\\nSOC-NO FAMILY CALLS OVER NOC.\\nID-T MAX 99.3\\nENDO-FS BS 90'S\\nA-ALT NEURO STATUS R/T MVA SPINE TRAUMA.\\nP-CONT NEURO MONITORING,SEDATION/ORDERS,VS,I+O,MONITOR LAB DATA QS AND PRN,FAMILY SUPPORT PRN,MONITOR SKIN INTEGRITY QS AND PRN.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-06-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1423981,\n \"text\": \"Resp Care,\\nPt. weaned to CPAP IPS10.5/5peep this am. VT 450, RR20. Cont. to wean as tol.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-06-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1423982,\n \"text\": \"RESP NOTE:PT EXTUBATED AS PER ORDER W/O INCIDENT,PLACED ON 3L/NC MAINTAINING SATS 97-100%.NO RESP DISTRESS NOTED,WILL CONTINUE TO MONITOR.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-06-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1423983,\n \"text\": \"SOCIAL WORK NOTE:\\nPt remains disoriented to time and place. No contact with family by this SW today. Will remain involved as needed. Pager .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-06-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1423984,\n \"text\": \"NSG NOTE\\nROS:\\n\\n CV:SYS BP 150'S/70'S,IN SR WITH RARE APC'S.RR 21-33.T MAX 99.8\\n\\n RESP:PPT EXTUBATED AT 3:30PM.SX FOR LARGE AMT THIN TAN SECRETIONS PRIOP TO EXTUB,MUCH LESS SECRETIONS NOW.SATS 99 ON 3L NP.ABGS 7.43-35-100.\\n\\n NEURO:TALKING RAG TIME SINCE EXTUBATED,WILL FOLLOW COMMANDS.STRONG HAND GRIP ON L,WEAKER ON R.MOVES R FOOT MORE THAN L.\\nON ATIVAN Q6HRS.\\n\\n GU:UO ACCEPTABLE,AMBER COLOR.RECEIVING 150CC HR BANANA BAG THEN NS WITH 20 KCL AT 150CC HR.\\n\\n GI:NPO,NGT DRAINING TONS BILIOUS FLD,DRAINING LARGE AMT LIQUID STOOL VIA RECTAL BAG AS WELL.\\n\\n ENDO:FS 91-87 NO INSULIN\\n\\n HEME:HCT 24,GIVEN 1U P CELLS,REPEAT HCT 30.2\\n\\n LYTES:K 3.5---GIVEN 40 KCL/500NS OVER 4HRS(3P-7P)\\n\\n SOCIAL:DAUGHTER CALLED,SPOKE TO T-SICU HO RE MRI FROM .\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-06-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1423985,\n \"text\": \"nsg :\\nneuro obeys commands but very confused. will raise knees and wiggle toes. strong grasp but unable to lift arms very far. does not bend elbows.\\n\\nstable hemodynaically. afebrile. ivf at 150ccs per hr. uo qs.\\n\\ngi lg amt of ng drainage, and liq brown stool spec sent for c diff.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-06-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1423975,\n \"text\": \"Nursing Admission Note\\nPt is a 59yo male who was wearing a helmet and got into a motorcycle accident on . He was admitted to an OSH. Head CT (+) for bilateral small posterior parietal intraparenchymal bleed. Per report Pt was alert and oriented. Today Pt was noted to have upper extremity weakness. Repeat head CT did not show any change, but further w/u revealed T7 vetebral body compression fracture. Pt was transferred to after being paralyzed/sedated and intubated. Extubated in EW and admitted to T/SICU. Pt arrived on stretcher accompanied by physician. was awake, oriented to person, but otherwise confused. LR infusing and NGT clamped.\\n\\nPMH:\\n-HTN\\n-Gout\\n-s/p multiple ORIF of LA and L leg d/t prior motorcycle accident.\\n\\nAllergies: no known medication allergies\\n\\nMedications: Indomethacin\\n\\nSocial: ppd smoker, (+) heavy ETOH use every day. Lives alone. Divorced. Has 2 daughters. Daughter, , was here when Pt was admitted.\\n\\nReview of Systems\\nNeuro: Pt is awake and is able to tell me his name, but could not tell me where he was or what year it is. He talks outloud to persons who are not present and thought he was in a police station. Follows commands. PERRL. Can not raise arms independently off bed. He uses siderails to raise them, but can not hold them them in air. / to nailbed pressure. Cervical collar on. Logroll precautions.\\n\\nResp: Breathing unlabored. Sao2 on 4L NC=96%.\\n\\nCV: HR in the 80s. NSR. BP=138/57.\\n\\nGI: NGT to LCS drained 800cc bilious fluid after arival to ICU. Abdomen is distended, but soft.\\n\\nGU: Foley to gravity. Urine amber.\\n\\nID: Afebrile.\\n\\nSkin: Large hematoma present on left thigh. Backside inatct.\\n\\nSocial: Daughter, , here when Pt arrived. No belongings left at bedside.\\n\\nA: Hemodynmics stable. Pt confused. Limited mobility.\\n\\nP: Neuro checks q 1hr. Ativan for DT prophylaxis. ? MRI of spine. Monitor per plan\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-06-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1423976,\n \"text\": \"S/P MOTORCYCLE MVA HEAD/SPINE TRAUMA T/SICU\\nNPN 11P-7A\\nS-\\\"I'M ALRIGHT NOW BUT THIS WHOLE PLACE IS GONNA BLOW IN 2 HRS\\\"\\nO-NEURO-PT A+O X OVER NOC,FOLLOWS SIMPLE COMMANDS MAE'S,SPASTIC GROSS MOTOR MOVEMENTS BILAT UPPER AND LOWER EXTREMITIES,HAND GRASPS 4+ STRENTGH BILAT,PERRLA 2-3MM.PT PERSEVERATING/RAMBLING SPEECH/OCCAS FOUL LANGUAGE,PT GIVEN TOTAL 3.5 MG ATIVAN OVER NOC.PT DOWN FOR MRI C-SPINE/T-SPINE THIS AM.\\nCV-PT HR 80'S NSR W/ BURST SVT/SELF LIMITED X 2.SBP 110'S-130'S OVER NOC.\\nRESP-PT LS CTA DECREASED BASES,O2 SATS 94-100% ON 4 L NC,O2 SATS 88-90% ON RA,RR 18-26,NARD.\\nGI/GU-PT ABD OBESE SOFT +HYPOACTIVE BS,NPO,NGT DRAINING MOD -LARGE AMTS BILIOUS DRAINAGE.PT URINE CLEAR AMBER VIA FOLEY U/O ADEQ.LOOSE BROWN STOOL SM-MOD AMT X 2 OVER NOC,\\nSKIN-NO NEW SKIN INTEGRITY ISSUES.\\nSOC-PT'S DAUGHTER CALLED X 1 OVER NOC.\\nA-ALT NEURO EXAM S/P T/SPINE TRAUMA.\\nP-CONT MONITOR NEURO EXAM/ORDERS,F/U W/ TM RE: RESULT MRI,VS,I+O,O2 /ORDERS,MONITOR SKIN INTEGRITY QS AND PRN,FAMILY SUPPORT PRN,SOC WORK\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-06-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1423977,\n \"text\": \"SOCIAL WORK NOTE:\\nPt known to this SW from ED arrival yesterday. Please see my printed OMR note in chart for further information. Pt seen in room today in T-SICU. He thought that is was and asked if we are going \\\"crabbing\\\". He stated that this SW has always gathered \\\"a couple barrels of crabs\\\". This SW phoned pt's dtr at home to offer continued support (spoke with her yesterday). She is greatly upset by pt's altered mental status but is glad that he is back in and more accessible for visiting. She reports that pt is on disability due to knee problems. She confirmed that pt has long history of etoh abuse. Medical team is aware of pt's long and active history of etoh abuse. Dtr given contact information for this SW and I will remain involved. Pager .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-06-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1423978,\n \"text\": \"T-SICU NURSING PROGRESS NOTE\\nNEURO: AROUSABLE TO VOICE, ORIENTED TO SELF ONLY. PT TALKING OUT LOUD, VERY CONFUSED, THINKS IT IS AND THAT HE IS AT THE POLICE STATION. ABLE TO STATE THE NAME OF HIS CHILDREN AND THAT HE IS FROM , MA. HAND GRASP BILAT, ABLE TO EXTEND BOTH ARMS BUT UNABLE TO FLEX OR HOLD UP ARMS. WIGLLES TOES TO COMMAND, ABLE TO PLANTAR FLEX BOTH FEET, LEFT FOOT STRONGER THAN RIGHT. PUPILS 3MM BILAT AND BRISKLY REACTIVE. REMAINS IN C-COLLAR. TAKEN BACK TO MRI AT 5:30PM D/T POOR QUALITY OF FIRST SCAN. PT WAS SEDATED WITH FENTANYL AND MIDAZ. PT WAS SLEEPY BUT D/T HIS BREATHING PATTERN THERE WAS TOO MUCH WALL MOTION AND SCAN QUALITY WAS POOR. PT WAS ELECTIVELY INTUBATED TO COMPLETE THE SCAN.\\n\\nCV: HR 80S, NSR WITH FREQ PAC'S, ATRIAL BIGEM. BP STABLE 120-140/70. SKIN WARM, DRY, (+)PALP PULSES, TRACE PEDAL EDEMA\\n\\nRESP: AS ABOVE, PT WAS ELECTIVELY INTUBATED TO COMPLETE MRI. PRIOR TO INTUBATION, BREATH SOUNDS CLEAR IN UPPER LOBES, VERY DIMINISHED IN THE BASES BILAT. AFTER INTUBATION, PT WAS SUCTIONED FOR THICK, COPIOUS YELLOW SECRETIONS. PRIOR TO INTUBATION SATS 96-98% ON 2LNC\\n\\nRENAL: URINE AMBER IN COLOR, BORDERLINE U/O ~ 25-40CC/HR. LYTES SENT, RESULTS PENDING\\n\\nGI: ABD OBESE, SOFT, (+)BOWEL SOUNDS. LIQUID BROWN STOOL, LARGE AMT, RECTAL BAG PLACED. REMAINS NPO. MODERATE NGT OUTPUT,\\n\\nHEME: HCT 26.1 (FROM 28), TEAM AWARE, NO SIGNS OF BLEEDING, WILL CONTINUE TO MONITOR\\n\\nID: T. MAX 99.5, NO ABX\\n\\nSKIN: LARGE HEMATOMA ALONG BACK OF LEFT LEG, ABRASIONS TO BILAT SHINS, BACK/BUTTOCKS INTACT. SKIN UNDER C-COLLAR INTACT\\n\\nSOCIAL: PT'S DAUGHTER CALLED X 2 TODAY, UPDATED ON PT'S CONDITION\\n\\nENDO: NO INSULIN COVERAGE REQUIRED\\n\\nA: ALTERED MENTAL STATUS, DECREASED STRENGTH ALL EXTS, ?T4-T7 INJURY--MRI RESULTS PENDING\\n\\nP: Q1H NEURO CHECKS, LOGROLL PRECAUTIONS, CONTINUE CURRENT PLAN, FOLLOW RESULTS OF MRI\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-06-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1423986,\n \"text\": \"S. THE BROUGHT ME HERE IN A BOX I NEED SOME CLOTHES\\nO.NEURO PT CONFUSED ALERT TO NAME RAMBLING PEARLA FC GOOD GRASPS BOTH HANDS RIGHT ARM ABLE TO COME UP 30 DEGREES LT 45 DEGREES STRENGHT SL. BETTER IN LT, RT AND LT LEG MOVING ON BED, HALDOL 1MG IV X 1\\nCARDIAC NSR OCC ECTOPY BP 130/-150/84 HCT 30.6 K 4.4 RT LEG WARM ERYTHEMATOUS ANT 2/3 UP, PAIN TO TOUCH US DONE PRELIM NEG BLOOD CLOT, STARTED ON KEFLEX CVP 9 CL PLACED LT SC TRIPLE LUMEN PP+2, SCAB BELOW RT KNEE UNCHANGED AND LT ANKLE LACERATION UNCHANGED BACITRACAN\\nRESP 4LNP 7.40/31/84/20 LUNGS CTA COUGHING SWALLOWING SPUTUM\\nGI NPO IV NS 150 Q HR ABD SOFT DISTENDED BS HYPERACTIVE NGT OUTPUT 1L BILIOUS STOOL GOLDEN TO TAR COLOR LIQ THIRD STOOL FOR CDIFF SENT LDH 395 TOTAL BILI 4.7 LACTIC ACID AST 45 ALT 28\\nGU U/O > 60CC QHR AMBER\\nNUTRITION TRIPLE LUMEN LT SC PLACED FOR TPN\\nID WBC 10.8 BC X2 DRAWN KEFLEX IV STARTED\\nA. ALT NEURO STATUS C4-5 CONTUSION POSSIBLE CENTRAL CORD SYNDROME WITH EXTREMITY WEAKNESS BILAT, ALT MS ? RELATED TO ATIVAN GIVEN\\nALT SKIN POSS. CELLULITIS\\nALT NUTRITIONAL STATUS HIGH NGT OUTPUT AND DIARRHEA\\nETOH ABUSE\\n+ SMOKER\\nP. PT FITTED FOR COLLAR AND CHEST BRACE TO START REHAB\\nCONT TO LOGROLL TILL THEN\\nPT OT CONSULT\\nCHANGE ATIVAN TO PRN GIVE HALDOL AS NEEDED\\nSTART TPN\\nWATCH ANY S+S OF \\nORIENT PT FREQUENTLY\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-06-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1423987,\n \"text\": \"S/P MOTORCYCLE MVA/SPINE TRAUMA T/SICU NPN 7P-7A\\nS-\\\"IT' \\\"\\n0-NEURO-PT A+O X 0-2 NAME +/OR DATE(MONTH/YEAR)OVER NOC,MAE'S,HAND GRASPS STRONG BILAT,PT NOW ABLE TO RAISE BUE UP OFF BED W/ DIFF NOW ABLE TO ALSO BEND ELBOWS BILAT,PT MOVES TO COMMAND,^^ STRENGTH ABLE TO BEND KNEES UP OFF BED BILAT.STRONG GAG/COUGH EFFORT,PERRLA 2-3MM.\\nCV-SEE FLOWSHEET FOR VS DETAILS,HR 60'S-90'S OVER NOC,SBP 120'S-160'S.+DP/PT \\n LS CTA DECREASED SL BASES-O2 SATS 94-96% ON RA,O2 WEANED OFF.RR 16-24,PT C/ODIFF BREATHING @ 6A,RESOLVED W/ ORAL OF THICK WHITE MUCOUS.\\nGI/GU-PT ABD SOFT OBESE + HYPOACTIVE BS,NGT CONTS TO DRAIN MOD AMTS BILIOUS FLUID CHANGED FROM LCWS->LIWS.U/O ADEQ AMBER CLEAR URINE VIA FOLEY.NPO.TPN CONTS.\\nSKIN-NO NEW ISSUES\\nSOC-PT DAUGHTER CALLED X 1 OVER NOC.\\nID-T MAX 99.3\\nENDO-BS WNL\\nA-ALT MS ? R/T HEAD TRAUMA VS SEDATIVES\\nP-CONT TO MONITOR NEURO EXAM,VS,MONITOR RESP QS AND PRN,I+O,O2 PRN,TPN/ORDERS,MONITOR SKIN INTEGRITY QS AND PRN.\\n\"\n }\n]"}}},{"rowIdx":24637,"cells":{"subject_id":{"kind":"number","value":85175,"string":"85,175"},"hadm_id":{"kind":"number","value":181238,"string":"181,238"},"target_text":{"kind":"string","value":"Admitted and went to surgery for Aortic Valve Replacement (#25mm St. Porcine Valve). See operative report for further details. He was transferred to the CVICU for hemodynamic monitoring. In first twenty four hours he was weaned from sedation, awoke neurologically intact and was extubated without complications. On postoperative day one he went into Atrial Fibrillation that was treated with amiodarone and lopressor. Overnight day 1 into day 2 he had pauses > 10 seconds and amiodarone was discontinued. He had no further prolonged pauses off amiodarone but remained in atrial fibrillation. He was started on coumadin for anticoagulation. Sleep consult was called due history of sleep apnea and he was placed on auto CPAP as tolerated. General Surgery consulted for abdominal distention and distended loops in bowel evident on KUB. He received bowels medications with flatus, bowel movements, and over few days the abdomen improved. His diet was progressed and he has been tolerating regular diet. EP consulted for rapid atrial fibrillation with rate not controlled with beta blockers, and diltiazem drip was started. His medications were adjusted to toprol XL in am and cardizem CD in pm with heart rate 70-100 atrial fibrillation. He was discharged home with his family and VNA services."},"extractive_notes_summ":{"kind":"string","value":"occassional etoh,gerd. Lethargic today, oriented to person and time. is p/w above impairments c/w c-v pump dysfunction and currently POD#2. Action: + flatus, Oob to commode. Nitro titrated. Lungs clear initially, crackles noted late am. Abdomen softly distended with +hypoactive bowel sounds. Reposition q 2 hrs. HR 70s- 80s post lopressor with minimal ectopy. Extubated . Transfers, Impaired Clinical impression / Prognosis: Pt. became nauseated with phlegm clearance Posture: forward head and rounded shoulders Range of Motion Muscle Performance WFL B grip strong B UE and LEs greater and/or = Motor Function: No abnormal movements noted Functional Status: Activity Clarification I S CG Min Mod Max Gait, Locomotion: Pt. Rate controlled. Acute Pain Assessment: Pt. Response: SR 70s. Atrial fibrillation (Afib) Assessment: Pt. Hydralazine and Lopressor given iv. Response: Pt. Lasix started iv. Plan: Valve replacement, aortic bioprosthetic (AVR) Assessment: Action: Response: Plan: Atrial fibrillation (Afib) Assessment: Afib with varying v response, occ pvc noted. I bed mobility c HOB flat 2. SBP low 100s to 130 Cardiac index >2. av paced for very slow underlying rythym? av paced for very slow underlying rythym? av paced for very slow underlying rythym? av paced for very slow underlying rythym? av paced for very slow underlying rythym? Response: Afib continues. Plan: Abg, enc cough and deep breathe, decrease fio2 requirements as tolerates. Valve replacement, aortic bioprosthetic (AVR) Assessment: Sleepy on propofol 10mg this am. Rolling: Supine / Sidelying to Sit: Transfer: Sit to Stand: T Ambulation: Stairs: Balance: Min A for static standing balance > 1 minute. occassional etoh,gerd. Action: + flatus, Oob to commode. Plan: Wean sedation to extubate in AM. Atrial fibrillation (Afib) Assessment: Afib with varying v response, occ pvc noted. Atrial fibrillation (Afib) Assessment: Pt remains in afib. Atrial fibrillation (Afib) Assessment: Pt remains in afib. Wean fio2 requirements as pt tolerates. Wean fio2 requirements as pt tolerates. Assessment: Pt. Rate controlled. Coumdain today. Coumdain today. Response: Afib continues. Response: Afib continues. BS WNL . Abd still distented. Neo & NTG titrated to on & off as needed to keep BP parameter. Between masks and pa aware. Between masks and pa aware. Chest tube drng. Metoprolol Tartrate 17. Action: Reglan given x2. ambulated 80ft pushing w/c with CGA. Furosemide 11. Hyperactive bs noted on assessment. Hyperactive bs noted on assessment. Plan: Valve replacement, aortic bioprosthetic (AVR) Assessment: Action: Response: Plan: Atrial fibrillation (Afib) Assessment: Afib with varying v response, occ pvc noted. pt. Pt. Pt. Pt. Pt. BP management with NTG/NEO. Ranitidine 23. in to evaluate pt. Plan: Lfts. Abdoment distented, bowel sounds present. Milk of Magnesia 18. Abdomen the same as assessment . Abdomen the same as assessment . CefazoLIN 8. 1:1 time with patient. + flatus. + flatus. Morphine Sulfate 19. Docusate Sodium 10. Metoclopramide 16. Response: Pt ahd a large bowel movement, soft/formed. HCT ~32. 0-20cc/hr. Pt to have KUB., LFTs.to be drawn. Pt cooperative on alternating. Pt cooperative on alternating. Abg sent see flowsheet. Constipation (Obstipation, FOS) Assessment: Pt has obese, firm and distended abdomen. Constipation (Obstipation, FOS) Assessment: Pt has obese, firm and distended abdomen. Plan: Abg, enc cough and deep breathe, decrease fio2 requirements as tolerates. Trace aortic regurgitation is seen.Trivial mitral regurgitation is seen. There are simple atheroma inthe descending thoracic aorta. Trace AR.MITRAL VALVE: Trivial MR.TRICUSPID VALVE: Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. There is mild aorticvalve stenosis (valve area 1.2-1.9cm2). Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT; ? The left basal opacities consistent with a combination of atelectasis and pleural effusion. PATIENT/TEST INFORMATION:Indication: Intraoperative TEE for aortic valve replacement.Height: (in) 70Weight (lb): 210BSA (m2): 2.13 m2Status: InpatientDate/Time: at 08:56Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RAand extending into the RV. PA and lateral upright chest radiographs were compared to . The left retrocardiac opacity, triangular in shape is most likely a combination of left lower lobe atelectasis and pleural effusion which is small and unchanged since the prior study. infiltrate Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT; ? 9:18 AM CHEST (PA & LAT) Clip # Reason: f/u effusions/atx Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT; ? Mildly dilated descending aorta. FINDINGS: In comparison with the study of , the endotracheal tube, mediastinal , and nasogastric tube have been removed. There issevere symmetric left ventricular hypertrophy. The ascending aorta is mildly dilated.The descending thoracic aorta is mildly dilated. 7:55 AM PORTABLE ABDOMEN Clip # Reason: evaluate dilated loops Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT; ?"},"n_notes":{"kind":"number","value":47,"string":"47"},"notes":{"kind":"list like","value":[{"category":"Nursing","chartdate":"2114-05-23 00:00:00.000","description":"Nursing Progress Note","row_id":674302,"text":"Atrial fibrillation (Afib)\n Assessment:\n Pt. went into fib rate 90\ns -120\ns at 0445. K 4.3. Ion ca++ > 1.12.\n Action:\n . IV lopressor 5mg IV (0600) dose given early.\n Response:\n Continues in afib 90\n 130s a times, BP 166/60\n Plan:\n start Amiodarone if rate uncontrolled,\n"},{"category":"Rehab Services","chartdate":"2114-05-23 00:00:00.000","description":"Physical Therapy Evaluation Note","row_id":674429,"text":"Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: AVR / 424.1\n Reason of referral: Eval and Treat\n History of Present Illness / Subjective Complaint: 77y/o male admitted\n s/p AVR (#25mm Porcine Valve) on and POD#2.\n CPBT 89min, XCT 52min. Pt. has fragile aorta and was not repaired.\n Extubated .\n Past Medical / Surgical History: AS, increase lipids, AAA 4.3x4.9cm,\n sleep apnea but doesnt use, arthritis, CHF recent admission 3 weeks\n ago, sinus infections, basal cell CA, L ear deafness, choley, back\n surgery, s/p removal cyst in leg, quit smoking 25yrs ago,wife passed\n away 6mnths ago, occasional ETOH, GERD, positional vertigo 07'\n Medications: acetaminophen, metoclopramide, nitroglycerin, ranitidine,\n simvastatin, furosemide, tramadol, hydralazine, amiodarone, metoprolol\n tartrate\n Radiology: CXR : pericardial gas; basilar opacifications consistent\n combination of atelectasis and pleural effusion especially at L base\n Labs:\n 33.8\n 11.5\n 106\n 13.5\n [image002.jpg]\n Other labs:\n Activity Orders: Per cardiac surgery guidelines\n Social / Occupational History: (Per dtr) Lives alone; supportive 5\n children\n Living Environment: (Per dtr) Lives in home; + stairs\n Prior Functional Status / Activity Level: (Per dtr) PTA I; drives; no\n falls\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt. lethargic, eyes\n closed, and slow to respond. Pt. oriented to year and that he is\n located in a hospital. Constant verbal & tactile cues to arouse and for\n eye opening. Follows simple commands with repeated cues and responds\n appropriately with increase response time verbally and physically\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n /\n Sit\n 95\n 133/62\n 20\n 98 (5L)\n Activity\n /\n 87 (RA)\n Stand\n /\n Recovery\n 86\n 131/69\n 19\n 93 (5L)\n Total distance walked: NA\n Minutes:\n Pulmonary Status: breathing pattern: even/nonlabored\n cough:strong,wet,productive\n Integumentary / Vascular: tele, sternal drsg c/d/i, foley, external\n pacer and wires, L A-line, L subclavian, L PIV, R PIV\n Sensory Integrity: intact to light touch; + DPP\n Pain / Limiting Symptoms: pain 0/10; c/o dizziness and nausea at times;\n pt. became nauseated with phlegm clearance\n Posture: forward head and rounded shoulders\n Range of Motion\n Muscle Performance\n WFL\n B grip strong\n B UE and LEs greater and/or = \n Motor Function: No abnormal movements noted\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt. presented seated in chair. Min A to lean forward\n and back in chair. Min A sit to stand x 2 with min A to maintain static\n standing > 1 minute. Pt. c/o nausea and dizziness with stance.\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n T\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Min A for static standing balance > 1 minute. No overt LOB.\n Education / Communication: c RN re pt status\n c pt and daughter re role of PT, , goals, d/c planning, education,\n importance of mobility\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n ADLs (Activities of Daily Living), Inability to perform\n 3.\n Arousal, Attention, and Cognition, Impaired\n 4.\n Balance, Impaired\n 5.\n Knowledge, Impaired\n 6.\n Posture, Impaired\n 7.\n Respiration / Gas Exchange, Impaired\n 8.\n Transfers, Impaired\n Clinical impression / Prognosis: Pt. is a 77y/o male s/p AVR. Pt. is\n p/w above impairments c/w c-v pump dysfunction and currently POD#2. Pt.\n extremely limited by lethargy and impaired cognition at this time. Pt.\n is functioning well below baseline; however, based on observation and\n mobility seen, anticipate that once patient is more aroused, will\n progress to a safe discharge home with 3-5 more PT treats for improving\n endurance, balance, arousal, and overall functional mobility. Pt. has\n family support for assist with discharge.\n Goals\n Time frame: 3-5x/wk\n 1.\n I bed mobility c HOB flat\n 2.\n I sit to stands\n 3.\n I amb 500ft\n 4.\n I with flight of stairs\n 5.\n A + O x 3 at all times; I with verbalizing sternal precautions\n 6.\n sp02 greater and/or = 92%RA at all times\n Anticipated Discharge: Home without PT\n Treatment :\n Frequency / Duration: 3-5x/wk x 1 week\n bed mobility, education, d/c planning, administer cardiac booklet, sit\n to stands, ambulate 500ft, stair negotiation, pulmonary exercises, wean\n 02 to RA\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"},{"category":"Nursing","chartdate":"2114-05-23 00:00:00.000","description":"Nursing Progress Note","row_id":674521,"text":"Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt lethargic most of morning. Napping fairly continuously. Oriented to\n place, person, year and events of having heart surgery. Constantly\n moaning.\n Action:\n Response:\n More alert during afternoon. Moaning decreased after pain med.\n Plan:\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Afib with varying v response, occ pvc noted. VSS.\n Action:\n Amio bolus given this am, drip started this afternoon.\n Response:\n Afib continues.\n Plan:\n Cont to monitor.\n"},{"category":"Physician ","chartdate":"2114-05-23 00:00:00.000","description":"ICU Note - CVI","row_id":674442,"text":"CVICU\n HPI:\n s/p AVR (#25mm St. porcine)-\n EF: >75% Cr:1.2 Ht: 71\" Wt:209 LB\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\n CPAP\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\n Inderal 40(2)\n Current medications:\n Acetaminophen, Amiodarone, Aspirin EC, Docusate Sodium, Furosemide,\n HydrALAzine, Insulin, Metoprolol Tartrate, Ranitidine, Simvastatin\n 24 Hour Events:\n Remains in ICU for pulmonary monitoring\n Atrial fibrillation increased betablockers\n Extubated and Chest tubes removed\n EXTUBATION - At 09:00 AM\n CHEST TUBE REMOVED - At 09:00 AM\n INVASIVE VENTILATION - STOP 09:00 AM\n CCO PAC - STOP 11:30 AM\n Post operative day:\n POD#2 - AVR # porcine valve, fragile aorta. out on neo\n propofol, 10 ml ct drainage. av paced for very slow underlying rythym?\n sb.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:00 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 05:32 PM\n Hydralazine - 06:52 PM\n Metoprolol - 04:50 AM\n Ranitidine (Prophylaxis) - 08:22 AM\n Furosemide (Lasix) - 08:24 AM\n Other medications:\n Flowsheet Data as of 01:35 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 37\nC (98.6\n HR: 87 (76 - 111) bpm\n BP: 129/65(82) {99/45(63) - 160/65(87)} mmHg\n RR: 23 (18 - 31) insp/min\n SPO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 71 Inch\n Total In:\n 637 mL\n 227 mL\n PO:\n Tube feeding:\n IV Fluid:\n 637 mL\n 227 mL\n Blood products:\n Total out:\n 1,415 mL\n 400 mL\n Urine:\n 1,245 mL\n 400 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n -778 mL\n -173 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SPO2: 93%\n ABG: 7.37/41/81./23/-1\n PaO2 / FiO2: 162\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bilateral bases left > right ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n hypoactive\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n Moves all extremities, can state in hospital and year but unable to\n name hospital and reason for being in hospital\n Labs / Radiology\n 106 K/uL\n 11.5 g/dL\n 135 mg/dL\n 1.5 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 35 mg/dL\n 107 mEq/L\n 140 mEq/L\n 33.8 %\n 13.5 K/uL\n [image002.jpg]\n 11:45 AM\n 11:50 AM\n 02:58 PM\n 06:07 PM\n 06:25 PM\n 12:31 AM\n 12:37 AM\n 08:31 AM\n 02:52 AM\n 03:09 AM\n WBC\n 10.7\n 8.9\n 13.5\n Hct\n 35.1\n 30.9\n 32.9\n 33.8\n Plt\n 141\n 120\n 106\n Creatinine\n 1.2\n 1.1\n 1.5\n TCO2\n 28\n 27\n 27\n 25\n 23\n 25\n Glucose\n 130\n 113\n 135\n Other labs: PT / PTT / INR:15.4/37.9/1.4, Mg:2.8 mg/dL\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, ADLS (ACTIVITIES OF DAILY\n LIVING), INABILITY TO PERFORM, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, POSTURE, IMPAIRED,\n RESPIRATION / GAS EXCHANGE, IMPAIRED, TRANSFERS, IMPAIRED, ATRIAL\n FIBRILLATION (AFIB), VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR),\n ACUTE PAIN, .H/O AORTIC STENOSIS\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, percocet and ultram,\n will hold and evaluate due to somnulence after percocet\n Cardiovascular: Aspirin, Beta-blocker, Statins, amiodarone for atrial\n fibrillation, acute on chronic diasystolic heart failure\n Pulmonary: IS, cough and deep breath, auto CPAP at night for sleep\n apnea - previous diagnosis but does not wear mask at home\n Gastrointestinal / Abdomen: bowel regimen\n Nutrition: Regular diet\n Renal: Foley, Adequate UO, discontinue foley, cr 1.5 baseline 1.2,\n monitor i/o with goal 500 ml negative\n Hematology: stable anemia\n Endocrine: RISS, goal BG < 150\n Infectious Disease: WBC 13 from 8, remove cordis, check urine culture -\n will recheck WBC in am no indication for antibiotics at this time\n Lines / Tubes / Drains: Foley, Pacing wires\n Wounds: Dry dressings\n Consults: P.T., sleep consult\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 11:30 AM\n Cordis/Introducer - 12:00 PM\n 20 Gauge - 06:44 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n"},{"category":"Nursing","chartdate":"2114-05-23 00:00:00.000","description":"Nursing Progress Note","row_id":674511,"text":"Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt lethargic most of morning. Napping fairly continuously. Oriented to\n place, person, year and events of having heart surgery. Constantly\n moaning.\n Action:\n Response:\n More alert during afternoon. Moaning decreased after pain med.\n Plan:\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2114-05-24 00:00:00.000","description":"Nursing Progress Note","row_id":674576,"text":"Respiration / Gas Exchange, Impaired\n Assessment:\n Pt requiring increasing o2 requirement. More confused and lethargic.\n Sats 91% on 4lnc.\n Action:\n Changed to open face tent, sats increased to 93% for a short time. Pa\n aware. Pt became more confused/agitated/combative. Pa\n at bedside, 2.5mg haldol given, and 20mg iv lasix. Sats 78%.\n Changed to closed aerosol face mask. Abg sent see flowsheet.\n Response:\n Sats increased to 95% on closed face mask. Pt slept for short period,\n while asleep sats 96%. Pt awoke moaning and groaning, agitated. Ripping\n at oxygen mask. Pa aware. Fair response to lasix overnight.\n Resend abg to monitor co2 levels. Still breathing using accessory\n muscles, and rr 20s\ns-30\ns with agitation. Pa aware.\n Plan:\n Abg, enc cough and deep breathe, decrease fio2 requirements as\n tolerates.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib overnight 80\ns-90\ns. Rate controlled. Amio drip at\n 1mg/min changed to 0.5mg/min at 2100.\n Action:\n Afib with pvc\ns pt had 10second pause with junctional escape beats. Pa\n aware. Amio drip off. Pacer pad at bedside due to wires due\n not capture or sense approp.\n Response:\n No more pauses overnight.\n Plan:\n Discontinue amio, pads at bedside for ectopy. Monitor heart rate.\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt is pod#3 from Avr replacement. Alert, oriented x2. States\n Are we\n on a boat?\n 1:1 time with patient. 2a/2v wres do not capture or sense.\n Wires secured and pa aware. Pt has soft but very distended\n abdomen. KUB done on evening. Family in/out through most of evening\n shift. Very nervous about father, reassured about care. ? social work\n consult. Lasix given at with no response. DTV at 2100. Foley\n reinserted pa aware 400cc out when foley placed. Left foley\n in overnight to monitor urine output.\n Action:\n + flatus, Oob to commode. Dulcolax given with no reponse, fleet enema\n given with some response, then soap suds enema given. Pt c/o incisional\n pain with turning Tylenol given.\n Response:\n Pt ahd a large bowel movement, soft/formed. Tylenol had fair response.\n Pa aware, ultram given with good relief.\n Plan:\n Safety precautions, Rate control afib, enc is.\n"},{"category":"Respiratory ","chartdate":"2114-05-24 00:00:00.000","description":"Respiratory Care Shift Note","row_id":674791,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt on BiPap 14/8 with some O2 added to keep O2 Sat > 92. Has a coarse\n cough occasionally productive. WILL go on\n BiPap to night at some time.\n, RRT 17:58\n"},{"category":"Nursing","chartdate":"2114-05-22 00:00:00.000","description":"Nursing Progress Note","row_id":674273,"text":"Acute Pain\n Assessment:\n Pt. constantly moaning; states that he\ns uncomfortable but can\n clearly describe what he\ns feeling. Can answer with short answers but\n then mumbles and moans in between.\n Action:\n Seen by , PA. discontinued morphine prn order and ordered\n one dose of Toradol 15mg IM. Ultram PRN ordered as well. Pt.\n repositioned and encouraged to relax. Spoke with daughter via phone re:\n moaning and coping.\n Response:\n Pt. stated some relief of pain from severe to moderate. Becomes anxious\n when repositioned and requires emotional reinforcement.\n Plan:\n Prn pain meds & assess by pain scale.. Provide other comfort measures:\n reposition, backrubs, cool clothes.\n"},{"category":"Physician ","chartdate":"2114-05-23 00:00:00.000","description":"Intensivist Note","row_id":674489,"text":"CVICU\n HPI:\n s/p AVR (#25mm St. porcine)-\n EF: >75% Cr:1.2 Ht: 71\" Wt:209 LB\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\n CPAP\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\n Inderal 40(2)\n Current medications:\n Acetaminophen, Amiodarone, Aspirin EC, Docusate Sodium, Furosemide,\n HydrALAzine, Insulin, Metoprolol Tartrate, Ranitidine, Simvastatin\n 24 Hour Events:\n Remains in ICU for pulmonary monitoring\n Atrial fibrillation increased betablockers\n Extubated and Chest tubes removed\n EXTUBATION - At 09:00 AM\n CHEST TUBE REMOVED - At 09:00 AM\n INVASIVE VENTILATION - STOP 09:00 AM\n CCO PAC - STOP 11:30 AM\n Post operative day:\n POD#2 - AVR # porcine valve, fragile aorta. out on neo\n propofol, 10 ml ct drainage. av paced for very slow underlying rythym?\n sb.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:00 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 05:32 PM\n Hydralazine - 06:52 PM\n Metoprolol - 04:50 AM\n Ranitidine (Prophylaxis) - 08:22 AM\n Furosemide (Lasix) - 08:24 AM\n Other medications:\n Flowsheet Data as of 01:35 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 37\nC (98.6\n HR: 87 (76 - 111) bpm\n BP: 129/65(82) {99/45(63) - 160/65(87)} mmHg\n RR: 23 (18 - 31) insp/min\n SPO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 71 Inch\n Total In:\n 637 mL\n 227 mL\n PO:\n Tube feeding:\n IV Fluid:\n 637 mL\n 227 mL\n Blood products:\n Total out:\n 1,415 mL\n 400 mL\n Urine:\n 1,245 mL\n 400 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n -778 mL\n -173 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SPO2: 93%\n ABG: 7.37/41/81./23/-1\n PaO2 / FiO2: 162\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bilateral bases left > right ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n hypoactive\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n Moves all extremities, can state in hospital and year but unable to\n name hospital and reason for being in hospital\n Labs / Radiology\n 106 K/uL\n 11.5 g/dL\n 135 mg/dL\n 1.5 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 35 mg/dL\n 107 mEq/L\n 140 mEq/L\n 33.8 %\n 13.5 K/uL\n [image002.jpg]\n 11:45 AM\n 11:50 AM\n 02:58 PM\n 06:07 PM\n 06:25 PM\n 12:31 AM\n 12:37 AM\n 08:31 AM\n 02:52 AM\n 03:09 AM\n WBC\n 10.7\n 8.9\n 13.5\n Hct\n 35.1\n 30.9\n 32.9\n 33.8\n Plt\n 141\n 120\n 106\n Creatinine\n 1.2\n 1.1\n 1.5\n TCO2\n 28\n 27\n 27\n 25\n 23\n 25\n Glucose\n 130\n 113\n 135\n Other labs: PT / PTT / INR:15.4/37.9/1.4, Mg:2.8 mg/dL\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, ADLS (ACTIVITIES OF DAILY\n LIVING), INABILITY TO PERFORM, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, POSTURE, IMPAIRED,\n RESPIRATION / GAS EXCHANGE, IMPAIRED, TRANSFERS, IMPAIRED, ATRIAL\n FIBRILLATION (AFIB), VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR),\n ACUTE PAIN, .H/O AORTIC STENOSIS\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, percocet and ultram,\n will hold and evaluate due to somnolence after percocet\n Cardiovascular: Aspirin, Beta-blocker, Statins, amiodarone for atrial\n fibrillation, acute on chronic diasystolic heart failure\n Pulmonary: IS, cough and deep breath, auto CPAP at night for sleep\n apnea - previous diagnosis but does not wear mask at home\n Gastrointestinal / Abdomen: bowel regimen\n Nutrition: Regular diet\n Renal: Foley, Adequate UO, discontinue foley, creatinine 1.5 baseline\n 1.2, monitor UOP with goal 500 ml negative\n Hematology: stable anemia\n Endocrine: RISS, goal BG < 150\n Infectious Disease: WBC 13 from 8, remove CVL, check urine culture -\n will recheck WBC in am no indication for antibiotics at this time\n Lines / Tubes / Drains: Foley, Pacing wires\n Wounds: Dry dressings\n Consults: P.T., sleep consult\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 11:30 AM\n Cordis/Introducer - 12:00 PM\n 20 Gauge - 06:44 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n"},{"category":"Physician ","chartdate":"2114-05-24 00:00:00.000","description":"ICU Note - CVI","row_id":674667,"text":"CVICU\n HPI:\n HD4\n POD3\n 77M s/p AVR (#25mm St. porcine)-\n EF: >75% Cr:1.2 Ht: 71\" Wt:209 LB\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\n CPAP\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\n Inderal 40(2)\n Current medications:\n Acetaminophen, Aspirin EC, Bisacodyl, Docusate Sodium, Heparin,\n Insulin, Metoprolol Tartrate, Milk of Magnesia, Ranitidine,\n Simvastatin, TraMADOL\n 24 Hour Events:\n Remains in ICU for pulmonary monitoring\n CPAP overnight required haldol for confusion\n Foley removed due to urinary retention reinserted 400ml\n Amiodarone stopped due to pauses remains in atrial fibrillation\n ARTERIAL LINE - STOP 02:23 PM\n Post operative day:\n POD#3 - AVR # porcine valve, fragile aorta. out on neo\n propofol, 10 ml ct drainage. av paced for very slow underlying rythym?\n sb.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 02:30 AM\n Haloperidol (Haldol) - 02:30 AM\n Heparin Sodium - 08:00 AM\n Other medications:\n Flowsheet Data as of 08:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.2\n T current: 35.9\nC (96.7\n HR: 99 (79 - 107) bpm\n BP: 133/72(83) {91/49(61) - 160/98(120)} mmHg\n RR: 17 (13 - 28) insp/min\n SPO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 71 Inch\n Total In:\n 535 mL\n 43 mL\n PO:\n 120 mL\n Tube feeding:\n IV Fluid:\n 415 mL\n 43 mL\n Blood products:\n Total out:\n 1,300 mL\n 410 mL\n Urine:\n 1,300 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -765 mL\n -367 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 93%\n ABG: 7.30/52/76./22/-1\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, bm \n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities, more alert and\n answering questions with sentences, aware in hospital for\n surgery\n Labs / Radiology\n 103 K/uL\n 10.5 g/dL\n 105 mg/dL\n 1.5 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 46 mg/dL\n 101 mEq/L\n 132 mEq/L\n 31.9 %\n 11.2 K/uL\n [image002.jpg]\n 06:07 PM\n 06:25 PM\n 12:31 AM\n 12:37 AM\n 08:31 AM\n 02:52 AM\n 03:09 AM\n 03:01 AM\n 03:04 AM\n 05:39 AM\n WBC\n 8.9\n 13.5\n 11.2\n Hct\n 30.9\n 32.9\n 33.8\n 31.9\n Plt\n 120\n 106\n 103\n Creatinine\n 1.1\n 1.5\n 1.5\n TCO2\n 27\n 25\n 23\n 25\n 27\n 27\n Glucose\n 113\n 135\n 268\n 105\n Other labs: PT / PTT / INR:16.3/37.9/1.5, ALT / AST:6/35, Alk-Phos / T\n bili:56/1.0, Amylase / Lipase:36/18, Albumin:3.6 g/dL, LDH:249 IU/L,\n Mg:2.7 mg/dL\n Imaging: cxr and kub pending\n Microbiology: mrsa no growth\n urine pending u/a negative\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, ADLS (ACTIVITIES OF DAILY\n LIVING), INABILITY TO PERFORM, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, POSTURE, IMPAIRED,\n RESPIRATION / GAS EXCHANGE, IMPAIRED, TRANSFERS, IMPAIRED, ATRIAL\n FIBRILLATION (AFIB), VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR),\n ACUTE PAIN, .H/O AORTIC STENOSIS\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, hold all narcotics\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue epicardial\n wires, increase betablocker for rate control, amiodarone stopped due to\n pauses overnight, remains in atrial fibrillation\n acute on chronic diasystolic heart failure\n Pulmonary: IS, cough and deep breath, increase ambulation, auto cpap at\n night for sleep apnea\n Gastrointestinal / Abdomen: bowel regimen, repeat Abdominal xray for\n dilated loops\n Nutrition: Clear liquids, no free water due to hyponatremia\n Renal: Foley, Adequate UO, goal fluid balance equal, maintain foley due\n to urinary retention will attempt removing \n Hematology: stable anemia\n Endocrine: RISS, goal BG < 150\n Infectious Disease: WBC 11 from 13, afebrile no evidence of infection\n Lines / Tubes / Drains: Foley, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today, KUB today\n Consults: P.T., Nutrition\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Cordis/Introducer - 12:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n"},{"category":"Physician ","chartdate":"2114-05-24 00:00:00.000","description":"ICU Note","row_id":674668,"text":"TITLE: Intensivist\n HPI:\n HD4\n POD3\n 77M s/p AVR (#25mm St. porcine)-\n EF: >75% Cr:1.2 Ht: 71\" Wt:209 LB\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\n CPAP\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\n Inderal 40(2)\n Current medications:\n Acetaminophen, Aspirin EC, Bisacodyl, Docusate Sodium, Heparin,\n Insulin, Metoprolol Tartrate, Milk of Magnesia, Ranitidine,\n Simvastatin, TraMADOL\n 24 Hour Events:\n Remains in ICU for pulmonary monitoring\n CPAP overnight required haldol for confusion\n Foley removed due to urinary retention reinserted 400ml\n Amiodarone stopped due to pauses remains in atrial fibrillation\n ARTERIAL LINE - STOP 02:23 PM\n Post operative day:\n POD#3 - AVR # porcine valve, fragile aorta. out on neo\n propofol, 10 ml ct drainage. av paced for very slow underlying rythym?\n sb.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:00 PM\n Other ICU medications:\n Furosemide (Lasix) - 02:30 AM\n Haloperidol (Haldol) - 02:30 AM\n Heparin Sodium - 08:00 AM\n Other medications:\n Flowsheet Data as of 08:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.2\n T current: 35.9\nC (96.7\n HR: 99 (79 - 107) bpm\n BP: 133/72(83) {91/49(61) - 160/98(120)} mmHg\n RR: 17 (13 - 28) insp/min\n SPO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 71 Inch\n Total In:\n 535 mL\n 43 mL\n PO:\n 120 mL\n Tube feeding:\n IV Fluid:\n 415 mL\n 43 mL\n Blood products:\n Total out:\n 1,300 mL\n 410 mL\n Urine:\n 1,300 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -765 mL\n -367 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 93%\n ABG: 7.30/52/76./22/-1\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, bm \n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities, more alert and\n answering questions with sentences, aware in hospital for\n surgery\n Labs / Radiology\n 103 K/uL\n 10.5 g/dL\n 105 mg/dL\n 1.5 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 46 mg/dL\n 101 mEq/L\n 132 mEq/L\n 31.9 %\n 11.2 K/uL\n [image002.jpg]\n 06:07 PM\n 06:25 PM\n 12:31 AM\n 12:37 AM\n 08:31 AM\n 02:52 AM\n 03:09 AM\n 03:01 AM\n 03:04 AM\n 05:39 AM\n WBC\n 8.9\n 13.5\n 11.2\n Hct\n 30.9\n 32.9\n 33.8\n 31.9\n Plt\n 120\n 106\n 103\n Creatinine\n 1.1\n 1.5\n 1.5\n TCO2\n 27\n 25\n 23\n 25\n 27\n 27\n Glucose\n 113\n 135\n 268\n 105\n Other labs: PT / PTT / INR:16.3/37.9/1.5, ALT / AST:6/35, Alk-Phos / T\n bili:56/1.0, Amylase / Lipase:36/18, Albumin:3.6 g/dL, LDH:249 IU/L,\n Mg:2.7 mg/dL\n Imaging: cxr and kub pending\n Microbiology: mrsa no growth\n urine pending u/a negative\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, ADLS (ACTIVITIES OF DAILY\n LIVING), INABILITY TO PERFORM, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, POSTURE, IMPAIRED,\n RESPIRATION / GAS EXCHANGE, IMPAIRED, TRANSFERS, IMPAIRED, ATRIAL\n FIBRILLATION (AFIB), VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR),\n ACUTE PAIN, .H/O AORTIC STENOSIS\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, hold all narcotics\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue epicardial\n wires, increase betablocker for rate control, amiodarone stopped due to\n pauses overnight, remains in atrial fibrillation\n acute on chronic diasystolic heart failure\n Pulmonary: IS, cough and deep breath, increase ambulation, auto cpap at\n night for sleep apnea\n Gastrointestinal / Abdomen: bowel regimen, repeat Abdominal xray for\n dilated loops\n Nutrition: Clear liquids, no free water due to hyponatremia\n Renal: Foley, Adequate UO, goal fluid balance equal, maintain foley due\n to urinary retention will attempt removing \n Hematology: stable anemia\n Endocrine: RISS, goal BG < 150\n Infectious Disease: WBC 11 from 13, afebrile no evidence of infection\n Lines / Tubes / Drains: Foley, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today, KUB today\n Consults: P.T., Nutrition\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Cordis/Introducer - 12:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor Time spent 31 min\n"},{"category":"Nursing","chartdate":"2114-05-22 00:00:00.000","description":"Nursing Progress Note","row_id":674249,"text":"POD 1 AVR porcine, extubated 0930 this am.\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Sleepy on propofol 10mg this am. Opened eyes to name. Followed\n commands.\n Lethargic today, oriented to person and time. Knows hospital.\n OOB to chair x2 today with 2 assist.\n SR low 100\ns this am with lots of apc\ns. SBP low 100\ns to\n 130\n Cardiac index >2.\n Chest tubes with minimal output.\n Lungs clear initially, crackles noted late am.\n ABG on cpap 5/5 acceptable for extubation.\n Sats 90% on 70% face tent post extubation.\n Abdomen softly distended with +hypoactive bowel sounds. Gag weak.\n Urine output low to marginal this am.\n Blood sugars 140-170.\n Action:\n Propofol off, pt extubated without incident.\n Nitro titrated. Hydralazine and Lopressor given iv.\n HR 70\ns- 80\ns post lopressor with minimal ectopy.\n PA line discontinued.\n Chest tubes discontinued.\n Nasal cannula added to face tent for sats in the mid 90\ns. Using\n incentive weakly to 250cc.\n Lasix started iv.\n Tolerating a few ice chips this afternoon.\n Blood sugars covered with regular insulin sliding scale.\n Response:\n SR 70\ns. BP one teens/60.\n Diuresed with lasix.\n Lungs clear this afternoon. Sats 97 on 5Lnc.\n Plan:\n Continue to monitor hemodynamics.\n Blood pressure control.\n Pulmonary hygiene.\n Reposition q 2 hrs.\n Monitor urine output closely.\n Acute Pain\n Assessment:\n Pt admitting to incisional pain, moaning.\n Action:\n Morphine given iv intermittently throughout day.\n Response:\n Pt not moaning after morphine given iv.\n Plan:\n Continue to monitor pain closely.\n Administer pain meds iv prn until pt able to tolerate po\n Frequent repositioning.\n"},{"category":"Nursing","chartdate":"2114-05-24 00:00:00.000","description":"Nursing Progress Note","row_id":674784,"text":"Atrial fibrillation (Afib) s/p AVR porcine\n Assessment:\n AF with frequent PVC\ns, rate 80-120 (patient has history of AF), 2A2V\n wires that neither sense nor pace\n Action:\n Lopressor increased from 25-50mg PO BID, amio stopped early this am due\n to 10 second pause with no NSR conversion, started on coumadin today,\n lytes checked, wires discontinued by NP \n Response:\n Patient remains in AF, lytes did not require repletion, patient\n remained in bed for an hour after wires discontinued without issues,\n VSS\n Plan:\n Continue to monitor VS, HR/rhythm, ectopy continue with lopressor as\n tolerated\n Posture, Impaired and inability to perform ADL\ns independently\n Assessment:\n Patient weak and deconditioned, patient lives alone in 2 story home\n with lots of stairs. Patient looks down and has eyes closed while\n walking or standing\n Action:\n OOB\nchair and back to bed, with 2-3 nurse assist, moves slow and\n reaches/leans for things instead of walking towards them, walked with\n Pt today\n Response:\n With much encouragement able to stand up straight and focus on good\n posture, but needs much encouragement, reassurance and emotional\n support\n Plan:\n Continue to monitor while up, ?? rehab before home.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Patient on Bipap at start of shift. Supposed to wear CPAP at night,\n but patient wont do it. He states\nits uncomfortable\n Sats at 92-94%\n patient calm and cooperative\n Action:\n Off bipap and placed on 4 liters NC, uses IS up to 500, CDB encouraged,\n calm quiet environment provided, with lots of emotional support,\n OOB\nchair, seen by MD\n Response:\n Sats around 92-93%, patient must wear CPAP at night ? sleep study by\n sleep MDs while inpatient\n Plan:\n Continue to monitor sats, encourage slow deep breaths and IS\n Constipation (Obstipation, FOS)\n Assessment:\n Firm distended abdomen, hyperactive BS, constant belching and +flatus\n Action:\n Regularly scheduled colace and reglan given, bisacodyl and soap suds\n enema given, adb XR and surgical GI consult obtained\n Response:\n Minimal output from interventions, XR showed multiple areas of dilated\n bowel, NP , GI-patient should remain NPO\n Plan:\n Continue with bowel regimen, NPO until further nontice\n"},{"category":"Rehab Services","chartdate":"2114-05-25 00:00:00.000","description":"Physical Therapy Progress Note","row_id":675023,"text":"Subjective:\n \"Are we going to walk today?\"\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: WBC 7.2 Hgb 10.3* Hct 31.1* Plt Ct 124*\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n T\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n T\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n T\n\n\n\n Ambulation:\n\n T\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Sit\n 100\n 111/72\n 26\n 93 (4L)\n Activity\n Stand\n 103\n 108/80\n 32\n 91 (6L)\n Recovery\n Supine\n 103\n 122/77\n 22\n 92 (4L)\n Total distance walked: 300 feet\n Minutes:\n Gait: Pt. presented in chair. CGA sit to stand. Able to ambulate 300ft\n pushing w/c with CGA and no deviations from path. Verbal cues for PLB.\n Balance: No overt LOB\n Education / Communication: c RN re pt status\n c pt re role of PT, , d/c planning, education, d/c planning\n Other: c/o pain in chest but unable to quantify\n Assessment: Pt. is a pleasant 77y/o male functioning well below\n baseline but displayed functional progression today with further\n ambulation c increasing steadiness and maintaining upright posture. Pt.\n most limited by impaired gas exhange and decrease balance which should\n improve with increase in activity. Given age, progression, and support\n available at home, anticipate that pt. will reach a safe level for\n discharge home when medically stable and with 2-3 more PT treats.\n Recommend home PT safety eval for balance, endurance, and maximizing\n independence.\n Anticipated Discharge: Home with Home PT\n : Administer cardiac booklet\n Education\n Wean 02 to RA\n Pulmonary exercises\n Ambulate 500ft c RW\n Stair negotiation\n d/c planning\n"},{"category":"Nursing","chartdate":"2114-05-25 00:00:00.000","description":"Nursing Transfer Note","row_id":675029,"text":"Constipation (Obstipation, FOS)\n Assessment:\n Firm, round, distended abdomen with hyperactive BS, +belching and +\n flatus, NPO since 1600 per GI surgical team\n Action:\n Continue with NPO, KUB obtained, reglan and docusate given as ordered\n Response:\n Patients abdomen appears softer than yesterday but still distended, no\n BM yet today\n Plan:\n Continue to monitor, ambulate as much as possible, maintain NPO status\n until further notice\n Respiration / Gas Exchange, Impaired\n Assessment:\n On 4 liters NC in the chair and overnight on bipap, patient is more\n comfortable with his breathing in the chair. Sats 92-96%, slightly SOB\n in bed, patient anxious and restless which adds to the SOB\n Action:\n In and OOB\nchair several times for comfort with breathing, IS\n encouraged along with CDB\n Response:\n Patient sats remain >92, no respiratory distress, continue with IS and\n encouragement\n Plan:\n Continue to monitor O2 sat and monitor for dyspnea, sleep MDs\n reevaluate\n Atrial fibrillation (Afib)\n Assessment:\n History of and currently in AF HR 90\ns, SBP>100 with frequent PVC\n Action:\n Lytes monitored, lopressor increased from to TID remains 50mg\n Response:\n No repletion necessary\n Plan:\n Continue to monitor VS HR and rhythm\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n AORTIC VALVE INSUFFICIENCY AORTIC VALVE REPLACEMENT; ? ASCE\n Code status:\n Height:\n 71 Inch\n Admission weight:\n 92.3 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Arrhythmias, CHF, Hypertension\n Additional history: AS,^lipids,AAA 4.3X4.9cm,sleep apnea_does not use\n apparatus,arthritis,chf-recent admission 3 weeks ago,sinus\n infections,basal cell ca,Left ear deafness,choley,back surgery, s/p\n removal cyst leg. retired,Quit smoking 25 years ago, wife passed away 6\n months. occassional etoh,gerd. positional vertigo'\n Surgery / Procedure and date: AVR porcine valve.\n *fragile aorta*- aorta not repaired. ez intubation, kefzol 2 gm @ 0800,\n ef 55%pre/post,act wnl, av paced with slow rythym underneath,cbp\n 89',xc52',cry 2500, 800 cellsaver, uo 170,out on neo+propofol, keep sbp\n <100, 10 ml ct drainage from or. CVICU, slow sb to asystole-pacer at\n times not sensing/capturing NO perfusion. likes pads 20's. adequate uo.\n 4 fluid. to remain sedated/intubated overnight. neuro not assessed.\n .\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:122\n D:77\n Temperature:\n 97.8\n Arterial BP:\n S:135\n D:80\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 98 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 92% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 24h total out:\n 490 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 06:08 AM\n Potassium:\n 4.4 mEq/L\n 06:08 AM\n Chloride:\n 106 mEq/L\n 06:08 AM\n CO2:\n 26 mEq/L\n 06:08 AM\n BUN:\n 53 mg/dL\n 06:08 AM\n Creatinine:\n 1.4 mg/dL\n 06:08 AM\n Glucose:\n 96 mg/dL\n 06:08 AM\n Hematocrit:\n 31.1 %\n 06:08 AM\n Finger Stick Glucose:\n 113\n 06:00 AM\n Valuables / Signature\n Patient valuables: home\n Other valuables:\n Clothes: Sent home with: family\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: family\n Jewelry: home\n Transferred from: \n Transferred to: 6\n Date & time of Transfer: 1200\n"},{"category":"Physician ","chartdate":"2114-05-25 00:00:00.000","description":"ICU Note - CVI","row_id":675031,"text":"CVICU\n HPI:\n HD5\n POD4\n 77M s/p AVR (#25mm St. porcine)-\n EF: >75% Cr:1.2 Ht: 71\" Wt:209 LB\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\n CPAP\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\n Inderal 40(2)\n Current medications:\n Acetaminophen, Aspirin EC, Docusate Sodium, Heparin, HydrALAzine,\n Insulin, Metoclopramide, Metoprolol Tartrate, Nitroglycerin, Potassium\n Chloride, Ranitidine, Simvastatin, Tamsulosin, Warfarin\n 24 Hour Events:\n Remained in ICU for monitoring\n Surgery consulted due to abdominal distention and air in loops with no\n improvement, NPO\n Post operative day:\n POD#4 - AVR # porcine valve, fragile aorta. out on neo\n propofol, 10 ml ct drainage. av paced for very slow underlying rythym?\n sb.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium - 08:00 AM\n Flowsheet Data as of 11:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98.1\n T current: 36.6\nC (97.8\n HR: 98 (89 - 111) bpm\n BP: 100/65(73) {94/59(67) - 130/77(88)} mmHg\n RR: 24 (14 - 26) insp/min\n SPO2: 90%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 71 Inch\n Total In:\n 143 mL\n PO:\n Tube feeding:\n IV Fluid:\n 43 mL\n Blood products:\n 100 mL\n Total out:\n 1,170 mL\n 460 mL\n Urine:\n 1,170 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,027 mL\n -460 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 90%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Distended, Tender: , BM \n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 124 K/uL\n 10.3 g/dL\n 96 mg/dL\n 1.4 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 53 mg/dL\n 106 mEq/L\n 142 mEq/L\n 31.1 %\n 7.2 K/uL\n [image002.jpg]\n 12:37 AM\n 08:31 AM\n 02:52 AM\n 03:09 AM\n 03:01 AM\n 03:04 AM\n 05:39 AM\n 01:46 PM\n 09:01 PM\n 06:08 AM\n WBC\n 13.5\n 11.2\n 7.2\n Hct\n 33.8\n 31.9\n 31.1\n Plt\n 106\n 103\n 124\n Creatinine\n 1.5\n 1.5\n 1.5\n 1.5\n 1.4\n TCO2\n 25\n 23\n 25\n 27\n 27\n Glucose\n 135\n 268\n 105\n 96\n Other labs: PT / PTT / INR:16.3/37.9/1.5, ALT / AST:20/50, Alk-Phos / T\n bili:64/1.0, Amylase / Lipase:34/35, Albumin:3.6 g/dL, LDH:253 IU/L,\n Ca:8.9 mg/dL, Mg:2.9 mg/dL, PO4:2.7 mg/dL\n Imaging: CXR small effusion\n Abd air in loops of bowel\n Microbiology: MRSA no growth\n urine no growth\n Assessment and Plan\n CONSTIPATION (OBSTIPATION, FOS), AEROBIC CAPACITY / ENDURANCE,\n IMPAIRED, ADLS (ACTIVITIES OF DAILY LIVING), INABILITY TO PERFORM,\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED,\n KNOWLEDGE, IMPAIRED, POSTURE, IMPAIRED, RESPIRATION / GAS EXCHANGE,\n IMPAIRED, TRANSFERS, IMPAIRED, ATRIAL FIBRILLATION (AFIB), VALVE\n REPLACEMENT, AORTIC BIOPROSTHETIC (AVR), ACUTE PAIN, .H/O\n AORTIC STENOSIS\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, denies pain except with abdominal\n palpitation\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, Statins,\n coumadin for atrial fibrillation, awaiting PT/INR to dose, no\n amiodarone due to pauses \n Pulmonary: IS, cough and deep breath, increase ambulation\n Gastrointestinal / Abdomen: follow up with surgery, Abd xray unchanged,\n serial abdominal exams\n Nutrition: Clear liquids\n Renal: Foley, Adequate UO, goal fluid balance equal\n Hematology: stable anemia\n Endocrine: RISS, goal BG < 150\n Infectious Disease: wbc 7, afebrile, all cultures negative, no evidence\n of infection\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: KUB today\n Consults: P.T., Nutrition\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Cordis/Introducer - 12:00 PM\n 20 Gauge - 02:23 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n"},{"category":"Physician ","chartdate":"2114-05-25 00:00:00.000","description":"ICU Note","row_id":675032,"text":"TITLE: Intensivist\n HPI:\n HD5\n POD4\n 77M s/p AVR (#25mm St. porcine)-\n EF: >75% Cr:1.2 Ht: 71\" Wt:209 LB\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\n CPAP\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\n Inderal 40(2)\n Current medications:\n Acetaminophen, Aspirin EC, Docusate Sodium, Heparin, HydrALAzine,\n Insulin, Metoclopramide, Metoprolol Tartrate, Nitroglycerin, Potassium\n Chloride, Ranitidine, Simvastatin, Tamsulosin, Warfarin\n 24 Hour Events:\n Remained in ICU for monitoring\n Surgery consulted due to abdominal distention and air in loops with no\n improvement, NPO\n Post operative day:\n POD#4 - AVR # porcine valve, fragile aorta. out on neo\n propofol, 10 ml ct drainage. av paced for very slow underlying rythym?\n sb.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:00 PM\n Other ICU medications:\n Heparin Sodium - 08:00 AM\n Flowsheet Data as of 11:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98.1\n T current: 36.6\nC (97.8\n HR: 98 (89 - 111) bpm\n BP: 100/65(73) {94/59(67) - 130/77(88)} mmHg\n RR: 24 (14 - 26) insp/min\n SPO2: 90%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 71 Inch\n Total In:\n 143 mL\n PO:\n Tube feeding:\n IV Fluid:\n 43 mL\n Blood products:\n 100 mL\n Total out:\n 1,170 mL\n 460 mL\n Urine:\n 1,170 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,027 mL\n -460 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 90%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Distended, Tender: , BM \n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 124 K/uL\n 10.3 g/dL\n 96 mg/dL\n 1.4 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 53 mg/dL\n 106 mEq/L\n 142 mEq/L\n 31.1 %\n 7.2 K/uL\n [image002.jpg]\n 12:37 AM\n 08:31 AM\n 02:52 AM\n 03:09 AM\n 03:01 AM\n 03:04 AM\n 05:39 AM\n 01:46 PM\n 09:01 PM\n 06:08 AM\n WBC\n 13.5\n 11.2\n 7.2\n Hct\n 33.8\n 31.9\n 31.1\n Plt\n 106\n 103\n 124\n Creatinine\n 1.5\n 1.5\n 1.5\n 1.5\n 1.4\n TCO2\n 25\n 23\n 25\n 27\n 27\n Glucose\n 135\n 268\n 105\n 96\n Other labs: PT / PTT / INR:16.3/37.9/1.5, ALT / AST:20/50, Alk-Phos / T\n bili:64/1.0, Amylase / Lipase:34/35, Albumin:3.6 g/dL, LDH:253 IU/L,\n Ca:8.9 mg/dL, Mg:2.9 mg/dL, PO4:2.7 mg/dL\n Imaging: CXR small effusion\n Abd air in loops of bowel\n Microbiology: MRSA no growth\n urine no growth\n Assessment and Plan\n CONSTIPATION (OBSTIPATION, FOS), AEROBIC CAPACITY / ENDURANCE,\n IMPAIRED, ADLS (ACTIVITIES OF DAILY LIVING), INABILITY TO PERFORM,\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED,\n KNOWLEDGE, IMPAIRED, POSTURE, IMPAIRED, RESPIRATION / GAS EXCHANGE,\n IMPAIRED, TRANSFERS, IMPAIRED, ATRIAL FIBRILLATION (AFIB), VALVE\n REPLACEMENT, AORTIC BIOPROSTHETIC (AVR), ACUTE PAIN, .H/O\n AORTIC STENOSIS\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, denies pain except with abdominal\n palpitation\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, Statins,\n coumadin for atrial fibrillation, awaiting PT/INR to dose, no\n amiodarone due to pauses \n Pulmonary: IS, cough and deep breath, increase ambulation\n Gastrointestinal / Abdomen: follow up with surgery, Abd xray unchanged,\n serial abdominal exams\n Nutrition: Clear liquids\n Renal: Foley, Adequate UO, goal fluid balance equal\n Hematology: stable anemia\n Endocrine: RISS, goal BG < 150\n Infectious Disease: wbc 7, afebrile, all cultures negative, no evidence\n of infection\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: KUB today\n Consults: P.T., Nutrition\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Cordis/Introducer - 12:00 PM\n 20 Gauge - 02:23 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code Time spent 32 min\n Disposition: Transfer to floor\n"},{"category":"Nursing","chartdate":"2114-05-24 00:00:00.000","description":"Nursing Progress Note","row_id":674605,"text":"Respiration / Gas Exchange, Impaired\n Assessment:\n Pt requiring increasing o2 requirement. More confused and lethargic.\n Sats 91% on 4lnc.\n Action:\n Changed to open face tent, sats increased to 93% for a short time. Pa\n aware. Pt became more confused/agitated/combative. Pa\n at bedside, 2.5mg haldol given, and 20mg iv lasix. Sats 78%.\n Changed to closed aerosol face mask. Abg sent see flowsheet.\n Response:\n Sats increased to 95% on closed face mask. Pt slept for short period,\n while asleep sats 96%. Pt awoke moaning and groaning, agitated. Ripping\n at oxygen mask. Pa aware. Fair response to lasix overnight.\n Resend abg to monitor co2 levels. Still breathing using accessory\n muscles, and rr 20s\ns-30\ns with agitation. Pa aware.\n Plan:\n Abg, enc cough and deep breathe, decrease fio2 requirements as\n tolerates.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib overnight 80\ns-90\ns. Rate controlled. Amio drip at\n 1mg/min changed to 0.5mg/min at 2100.\n Action:\n Afib with pvc\ns pt had 10second pause with junctional escape beats. Pa\n aware. Amio drip off. Pacer pad at bedside due to wires due\n not capture or sense approp.\n Response:\n No more pauses overnight.\n Plan:\n Discontinue amio, pads at bedside for ectopy. Monitor heart rate.\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt is pod#3 from Avr replacement. Alert, oriented x2. States\n Are we\n on a boat?\n 1:1 time with patient. 2a/2v wres do not capture or sense.\n Wires secured and pa aware. Pt has soft but very distended\n abdomen. KUB done on evening. Family in/out through most of evening\n shift. Very nervous about father, reassured about care. ? social work\n consult. Lasix given at with no response. DTV at 2100. Foley\n reinserted pa aware 400cc out when foley placed. Left foley\n in overnight to monitor urine output.\n Action:\n + flatus, Oob to commode. Dulcolax given with no reponse, fleet enema\n given with some response, then soap suds enema given. Pt c/o incisional\n pain with turning Tylenol given.\n Response:\n Pt ahd a large bowel movement, soft/formed. Tylenol had fair response.\n Pa aware, ultram given with good relief.\n Plan:\n Safety precautions, Rate control afib, enc is.\n"},{"category":"Nursing","chartdate":"2114-05-25 00:00:00.000","description":"Nursing Transfer Note","row_id":675007,"text":"Constipation (Obstipation, FOS)\n Assessment:\n Firm, round, distended abdomen with hyperactive BS, +belching and +\n flatus, NPO since 1600 per GI surgical team\n Action:\n Continue with NPO, KUB obtained, reglan and docusate given as ordered\n Response:\n Patients abdomen appears softer than yesterday but still distended, no\n BM yet today\n Plan:\n Continue to monitor, ambulate as much as possible, maintain NPO status\n until further notice\n Respiration / Gas Exchange, Impaired\n Assessment:\n On 4 liters NC in the chair and overnight on bipap, patient is more\n comfortable with his breathing in the chair. Sats 92-96%, slightly SOB\n in bed, patient anxious and restless which adds to the SOB\n Action:\n In and OOB\nchair several times for comfort with breathing, IS\n encouraged along with CDB\n Response:\n Patient sats remain >92, no respiratory distress, continue with IS and\n encouragement\n Plan:\n Continue to monitor O2 sat and monitor for dyspnea, sleep MDs\n reevaluate\n Atrial fibrillation (Afib)\n Assessment:\n History of and currently in AF HR 90\ns, SBP>100 with frequent PVC\n Action:\n Lytes monitored, lopressor increased from to TID remains 50mg\n Response:\n No repletion necessary\n Plan:\n Continue to monitor VS HR and rhythm\n"},{"category":"Nursing","chartdate":"2114-05-25 00:00:00.000","description":"Nursing Transfer Note","row_id":675008,"text":"Constipation (Obstipation, FOS)\n Assessment:\n Firm, round, distended abdomen with hyperactive BS, +belching and +\n flatus, NPO since 1600 per GI surgical team\n Action:\n Continue with NPO, KUB obtained, reglan and docusate given as ordered\n Response:\n Patients abdomen appears softer than yesterday but still distended, no\n BM yet today\n Plan:\n Continue to monitor, ambulate as much as possible, maintain NPO status\n until further notice\n Respiration / Gas Exchange, Impaired\n Assessment:\n On 4 liters NC in the chair and overnight on bipap, patient is more\n comfortable with his breathing in the chair. Sats 92-96%, slightly SOB\n in bed, patient anxious and restless which adds to the SOB\n Action:\n In and OOB\nchair several times for comfort with breathing, IS\n encouraged along with CDB\n Response:\n Patient sats remain >92, no respiratory distress, continue with IS and\n encouragement\n Plan:\n Continue to monitor O2 sat and monitor for dyspnea, sleep MDs\n reevaluate\n Atrial fibrillation (Afib)\n Assessment:\n History of and currently in AF HR 90\ns, SBP>100 with frequent PVC\n Action:\n Lytes monitored, lopressor increased from to TID remains 50mg\n Response:\n No repletion necessary\n Plan:\n Continue to monitor VS HR and rhythm\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n AORTIC VALVE INSUFFICIENCY AORTIC VALVE REPLACEMENT; ? ASCE\n Code status:\n Height:\n 71 Inch\n Admission weight:\n 92.3 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Arrhythmias, CHF, Hypertension\n Additional history: AS,^lipids,AAA 4.3X4.9cm,sleep apnea_does not use\n apparatus,arthritis,chf-recent admission 3 weeks ago,sinus\n infections,basal cell ca,Left ear deafness,choley,back surgery, s/p\n removal cyst leg. retired,Quit smoking 25 years ago, wife passed away 6\n months. occassional etoh,gerd. positional vertigo'\n Surgery / Procedure and date: AVR porcine valve.\n *fragile aorta*- aorta not repaired. ez intubation, kefzol 2 gm @ 0800,\n ef 55%pre/post,act wnl, av paced with slow rythym underneath,cbp\n 89',xc52',cry 2500, 800 cellsaver, uo 170,out on neo+propofol, keep sbp\n <100, 10 ml ct drainage from or. CVICU, slow sb to asystole-pacer at\n times not sensing/capturing NO perfusion. likes pads 20's. adequate uo.\n 4 fluid. to remain sedated/intubated overnight. neuro not assessed.\n .\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:100\n D:65\n Temperature:\n 97.8\n Arterial BP:\n S:135\n D:80\n Respiratory rate:\n 24 insp/min\n Heart Rate:\n 98 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 90% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 24h total out:\n 460 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 06:08 AM\n Potassium:\n 4.4 mEq/L\n 06:08 AM\n Chloride:\n 106 mEq/L\n 06:08 AM\n CO2:\n 26 mEq/L\n 06:08 AM\n BUN:\n 53 mg/dL\n 06:08 AM\n Creatinine:\n 1.4 mg/dL\n 06:08 AM\n Glucose:\n 96 mg/dL\n 06:08 AM\n Hematocrit:\n 31.1 %\n 06:08 AM\n Finger Stick Glucose:\n 113\n 06:00 AM\n Valuables / Signature\n Patient valuables: none\n Other valuables: none\n Clothes: Sent home with: family\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: family\n Jewelry: none\n Transferred from: \n Transferred to: \n Date & time of Transfer: 1200\n"},{"category":"Rehab Services","chartdate":"2114-05-24 00:00:00.000","description":"Physical Therapy Progress Note","row_id":674746,"text":"Subjective:\n \"I am weak.\"\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: 5.14 WBC 11.2* Hgb 10.5* Hct 31.9* Plt Ct 103*\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n T\n\n\n Ambulation:\n\n T\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Sit\n 87\n 123/80\n 23\n 91 (3L)\n Activity\n Stand\n 104\n 152/99\n 31\n 83 (6L)\n Recovery\n Sit\n 112\n 123/62\n 23\n 93 (4L)\n Total distance walked: 80feet\n Minutes:\n Gait: Pt. ambulated 80ft pushing w/c with CGA. Pt. required sit to\n stand. Patient required constant cues for upright posture, PLB, and\n pacing. No deviations from pathway. C/o lightheadedness at times.\n Balance: No overt LOB.\n Education / Communication: c RN re pt status\n c pt re role of PT, , d/c planning, education, goals\n Other: Pain 0/10\n Question accuracy of 02 sat secondary to no patient complaints\n of labored breathing and pleth not evenly distributed.\n Assessment: Pt. is a pleasant 77y/o male s/p AVR and functioning well\n below baseline. Pt. limited by decrease endurance, balance, and overall\n mobility, but has progressed functionally since evaluation. Pt. has\n great potential to reach baseline with continued activity and\n ambulation. Given PLOF, age, and support available at home, anticipate\n that pt. will be able to reach a safe discharge home with 24 hour\n assist and home PT safety eval. If patient lacks continuing\n progression, will recommend rehab.\n Anticipated Discharge: Home with Home PT\n : bed mobility\n education\n administer cardiac booklet\n ambulate with RW >200ft\n wean 02 to RA\n pulmonary exercises\n balance and endurance training\n"},{"category":"Nursing","chartdate":"2114-05-24 00:00:00.000","description":"Nursing Progress Note","row_id":674753,"text":"Atrial fibrillation (Afib) s/p AVR porcine\n Assessment:\n AF with frequent PVC\ns, rate 80-120 (patient has history of AF)\n Action:\n Lopressor increased from 25-50mg PO BID, amio stopped early this am due\n to 10 second pause with no NSR conversion, started on coumadin today,\n lytes checked\n Response:\n Patient remains in AF, lytes did not require repletion\n Plan:\n Continue to monitor VS, HR/rhythm, ectopy continue with lopressor as\n tolerated\n Posture, Impaired and inability to perform ADL\ns independently\n Assessment:\n Patient weak and deconditioned, patient lives alone in 2 story home\n with lots of stairs. Patient looks down and has eyes closed while\n walking or standing\n Action:\n OOB\nchair and back to bed, with 2-3 nurse assist, moves slow and\n reaches/leans for things instead of walking towards them\n Response:\n With much encouragement able to stand up straight and focus on good\n posture, but needs much encouragement, reassurance and emotional\n support\n Plan:\n Continue to monitor while up, needs to get PT eval, ?? rehab before\n home.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Patient on Bipap at start of shift. Supposed to wear CPAP at night,\n but patient wont do it. He states\nits uncomfortable\n Sats at 92-94%\n patient calm and cooperative\n Action:\n Off bipap and placed on 4 liters NC, uses IS up to 500, CDB encouraged,\n calm quiet environment provided, with lots of emotional support,\n OOB\nchair\n Response:\n Sats around 92-93%, patient must wear CPAP at night\n Plan:\n Continue to monitor sats, encourage slow deep breaths and IS\n Constipation (Obstipation, FOS)\n Assessment:\n Firm distended abdomen, hyperactive BS, constant belching and +flatus\n Action:\n Regularly scheduled colace and reglan given, bisacodyl and soap suds\n enema given, adb XR and GI consult obtained\n Response:\n Minimal oputput from interventions, XR showed multiple areas of dilated\n bowel, NP \n Plan:\n Continue with bowel regimen, awaiting GU consult\n"},{"category":"Nursing","chartdate":"2114-05-24 00:00:00.000","description":"Nursing Progress Note","row_id":674731,"text":"Atrial fibrillation (Afib)\n Assessment:\n AF with frequent PVC\ns, rate 80-120\n Action:\n Lopressor increased from 25-50mg PO BID, amio stopped early this am due\n to 10 second pause with no NSR conversion, started on coumadin today,\n lytes checked\n Response:\n Patient remains in AF, lytes repleted PRN\n Plan:\n Continue to monitor VS, HR/rhythm, ectopy continue with lopressor as\n tolerated\n Posture, Impaired and inability to perform ADL\ns independently\n Assessment:\n Patient weak and deconditioned, patient lives alone in 2 story home\n with lots of stairs. Patient looks down and has eyes closed while\n walking or standing\n Action:\n OOB\nchair and back to bed, with 2-3 nurse assist, moves slow and\n reaches/leans for things instead of walking towards them\n Response:\n With much encouragement able to stand up straight and focus on good\n posture, but needs much encouragement, reassurance and emotional\n support\n Plan:\n Continue to monitor while up, needs to get PT eval, ?? rehab before\n home.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Patient on Bipap at start of shift. Supposed to wear CPAP at night,\n but patient wont do it. He states\nits uncomfortable\n Sats at 92-94%\n patient calm and cooperative\n Action:\n Off bipap and placed on 4 liters NC, uses IS up to 500, CDB encouraged,\n calm quiet environment provided, with lots of emotional support,\n OOB\nchair\n Response:\n Sats around 92-93%, patient must wear CPAP at night\n Plan:\n Continue to monitor sats, encourage slow deep breaths and IS\n"},{"category":"Nursing","chartdate":"2114-05-25 00:00:00.000","description":"Nursing Progress Note","row_id":674876,"text":"Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib. No pauses this shift. Frequent pvc\ns. Sbp\n 100\ns-120\ns. Pt is alert, oriented x3, no confusion. NO NARCOTICS,\n Tylenol for pain as needed\n Action:\n Lopressor dose was increased on day shift to 50mg po bid.\n Response:\n Pt tolerating lopressor dose with sbp >100. Afin still not rate\n controlled has bursts into 120\ns-130\ns at times.\n Plan:\n ? increase lopressor dose for rate control. Coumdain today. Pt\ns family\n informed of need for electric razor while on coumdain.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Pt sats 92-96% on 4l nc while in chair. When in bed pt has difficulty\n breathing due to obese abdomen. Sats drop to 92% while in bed laying\n doen, and pt states\nI feel winded.\n Action:\n Pa aware, bipap placed on pt, pt a little hesitant to wear\n states\nit feels like a hurricane against my face.\n Response:\n Pt tolerated bipap for 2 hours then insists on taking off mask. In and\n out bed and chair all night long. While in chair wears 4lc sats 95%,\n while in bed wears bipap for short time and then closed face mask at\n 50% humidification. Pt cooperative on alternating. Between masks and pa\n aware.\n Plan:\n Bipap at night if pt tolerates, ? nose piece instead of mask if\n tolerates. Wean fio2 requirements as pt tolerates.\n Constipation (Obstipation, FOS)\n Assessment:\n Pt has obese, firm and distended abdomen. Hyperactive bs noted on\n assessment. + flatus.\n Action:\n Gi surgery team consulted, npo until further notice today. Reglan\n started x4 doses. No bowel meds.\n Response:\n Pt passing gas from below, no belching this shift. Abdomen the same as\n assessment . No nausea or vomiting.\n Plan:\n Plan f/u kub this am, surgery consult reccomendations.\n"},{"category":"Respiratory ","chartdate":"2114-05-25 00:00:00.000","description":"Respiratory Care Shift Note","row_id":674873,"text":"Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Comments:\n Pt on and off Bipap 14/8 with up to 15L O2 to maintain sats of 94%.\n Does not tolerate for very long.\n"},{"category":"Nursing","chartdate":"2114-05-23 00:00:00.000","description":"Nursing Progress Note","row_id":674518,"text":"Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt lethargic most of morning. Napping fairly continuously. Oriented to\n place, person, year and events of having heart surgery. Constantly\n moaning.\n Action:\n Response:\n More alert during afternoon. Moaning decreased after pain med.\n Plan:\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Afib with varying v response, occ pvc noted. VSS.\n Action:\n Amio bolus given this am, drip started this afternoon.\n Response:\n Afib continues.\n Plan:\n Cont to monitor.\n"},{"category":"Nursing","chartdate":"2114-05-25 00:00:00.000","description":"Nursing Progress Note","row_id":674921,"text":"Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib. No pauses this shift. Frequent pvc\ns. Sbp\n 100\ns-120\ns. Pt is alert, oriented x3, no confusion. NO NARCOTICS,\n Tylenol for pain as needed\n Action:\n Lopressor dose was increased on day shift to 50mg po bid.\n Response:\n Pt tolerating lopressor dose with sbp >100. Afin still not rate\n controlled has bursts into 120\ns-130\ns at times.\n Plan:\n ? increase lopressor dose for rate control. Coumdain today. Pt\ns family\n informed of need for electric razor while on coumdain.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Pt sats 92-96% on 4l nc while in chair. When in bed pt has difficulty\n breathing due to obese abdomen. Sats drop to 92% while in bed laying\n doen, and pt states\nI feel winded.\n Action:\n Pa aware, bipap placed on pt, pt a little hesitant to wear\n states\nit feels like a hurricane against my face.\n Response:\n Pt tolerated bipap for 2 hours then insists on taking off mask. In and\n out bed and chair all night long. While in chair wears 4lc sats 95%,\n while in bed wears bipap for short time and then closed face mask at\n 50% humidification. Pt cooperative on alternating. Between masks and pa\n aware.\n Plan:\n Bipap at night if pt tolerates, ? nose piece instead of mask if\n tolerates. Wean fio2 requirements as pt tolerates.\n Constipation (Obstipation, FOS)\n Assessment:\n Pt has obese, firm and distended abdomen. Hyperactive bs noted on\n assessment. + flatus.\n Action:\n Gi surgery team consulted, npo until further notice today. Reglan\n started x4 doses. No bowel meds.\n Response:\n Pt passing gas from below, no belching this shift. Abdomen the same as\n assessment . No nausea or vomiting.\n Plan:\n Plan f/u kub this am, surgery consult recommendations.\n"},{"category":"Respiratory ","chartdate":"2114-05-21 00:00:00.000","description":"Respiratory Care Shift Note","row_id":674014,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Double Lumen\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n :\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n"},{"category":"Nursing","chartdate":"2114-05-22 00:00:00.000","description":"Nursing Progress Note","row_id":674073,"text":"Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt. remains Intubated & sedated in order to keep tight control of BP\n with SBP ~95-100. SVO2 >60% with CI ~2.0 or better. Chest tube drng.\n 0-20cc/hr. HCT ~32. AV-pacing rate at 96.\n Action:\n AV- pacing maintained due to very slow underlying rhythm <40. Neo & NTG\n titrated to on & off as needed to keep BP parameter. Propofol on at\n 40mcq/kg; weaned to 10 mcq earlier in the evening wake-up in order to\n assess neuro status. Insulin infusing and titrated per protocol.\n Response:\n CI 2.2. SBP ~100-110 off vasoactive agents. Pt. was able to open eyes\n and nod his head to ???? and follow simple commands ( ie: wiggle toes).\n BS WNL . ABG WNL on present vent settings 50%fio2, IMV 16 Tv 600cc Peep\n 5cm.\n Plan:\n Wean sedation to extubate in AM. BP management with NTG/NEO. Glucose\n control hourly. Pain management.\n"},{"category":"Physician ","chartdate":"2114-05-22 00:00:00.000","description":"ICU Note - CVI","row_id":674169,"text":"CVICU\n HPI:\n HD2\n POD#1\n 77M s/p AVR (#25mm St. porcine)-\n EF: >75% Cr:1.2 Ht: 71\" Wt:209 LB\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\n Inderal 40(2)\n :\n PMHx:\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\n CPAP\n Current medications:\n . Acetaminophen 5. Aspirin EC 6. Calcium Gluconate 7. CefazoLIN 8.\n Dextrose 50% 9. Docusate Sodium 10. Furosemide 11. HydrALAzine 12.\n Insulin 13. Magnesium Sulfate 14. Metoprolol Tartrate 15.\n Metoclopramide 16. Metoprolol Tartrate 17. Milk of Magnesia 18.\n Morphine Sulfate 19. Nitroglycerin 20. Oxycodone-Acetaminophen 21.\n Potassium Chloride 22. Ranitidine 23. Simvastatin\n 24 Hour Events:\n OR RECEIVED - At 11:30 AM\n INVASIVE VENTILATION - START 11:30 AM\n CCO PAC - START 11:30 AM\n ARTERIAL LINE - START 11:30 AM\n EKG - At 11:45 AM\n Deferred due to slow underluying rythym\n CORDIS/INTRODUCER - START 12:00 PM\n Post operative day:\n HD2\n POD#1\n 77M s/p AVR (#25mm St. porcine)-\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 08:37 AM\n Other ICU medications:\n Ranitidine (Prophylaxis) - 10:16 PM\n Morphine Sulfate - 06:36 AM\n Hydralazine - 08:34 AM\n Metoprolol - 09:25 AM\n Furosemide (Lasix) - 10:30 AM\n Flowsheet Data as of 11:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n HR: 96 (78 - 108) bpm\n BP: 114/52(67) {85/46(58) - 130/67(85)} mmHg\n RR: 30 (12 - 36) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 20 (10 - 22) mmHg\n PAP: (33 mmHg) / (18 mmHg)\n CO/CI (Fick): (6.7 L/min) / (3.1 L/min/m2)\n CO/CI (CCO): (6.6 L/min) / (3.1 L/min/m2)\n SvO2: 67%\n Mixed Venous O2% sat: 76 - 76\n Total In:\n 8,890 mL\n 438 mL\n PO:\n Tube feeding:\n IV Fluid:\n 8,090 mL\n 438 mL\n Blood products:\n 800 mL\n Total out:\n 1,058 mL\n 552 mL\n Urine:\n 718 mL\n 382 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 7,832 mL\n -114 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PPS\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 330 (330 - 957) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 32\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 18 cmH2O\n SPO2: 94%\n ABG: 7.31/44/86./23/-4\n Ve: 11.1 L/min\n PaO2 / FiO2: 174\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 120 K/uL\n 11.0 g/dL\n 113 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 26 mg/dL\n 110 mEq/L\n 138 mEq/L\n 32.9 %\n 8.9 K/uL\n [image002.jpg]\n 11:45 AM\n 11:50 AM\n 02:58 PM\n 06:07 PM\n 06:25 PM\n 12:31 AM\n 12:37 AM\n 08:31 AM\n WBC\n 10.7\n 8.9\n Hct\n 35.1\n 30.9\n 32.9\n Plt\n 141\n 120\n Creatinine\n 1.2\n 1.1\n TCO2\n 28\n 27\n 27\n 25\n 23\n Glucose\n 130\n 113\n Other labs: PT / PTT / INR:15.4/37.9/1.4\n Assessment and Plan\n VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR), ACUTE PAIN, .H/O\n AORTIC STENOSIS\n Assessment and Plan: 77yo man s/p AVR-tissue. Hemodynamically\n stable-extubated\n Neurologic: Pain controlled, Percocet-prn\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor\n Pulmonary: IS, d/c chest tubes\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, start diuretics to get net negative 1-1.5 liters\n Hematology: stable hct\n Endocrine: RISS\n Infectious Disease: no active issues\n afebrile, normal wbc\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today, after chest tube removal\n Consults: CT surgery\n ICU Care\n Nutrition: ADAT\n Glycemic Control: Regular insulin sliding scale\n Lines:\n CCO PAC - 11:30 AM\n Arterial Line - 11:30 AM\n 16 Gauge - 11:30 AM\n Cordis/Introducer - 12:00 PM\n Prophylaxis:\n DVT: (ambulate today)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full\n Disposition: ICU\n"},{"category":"Respiratory ","chartdate":"2114-05-22 00:00:00.000","description":"Respiratory Care Shift Note","row_id":674117,"text":"Demographics\n Day of intubation: 2\n Day of mechanical ventilation: 2\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Elective\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: wean and extubate if indicated on rounds\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Unable to do RSBI as NO Spont resp this morning\n"},{"category":"Nursing","chartdate":"2114-05-23 00:00:00.000","description":"Nursing Progress Note","row_id":674527,"text":"Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt lethargic most of morning. Napping fairly continuously. Oriented to\n place, person, year and events of having heart surgery, knows family\n and is appropriate. Constantly moaning. Medicated for pain x1 this am\n with good effect.\n Response:\n More alert during afternoon. Moaning decreased after pain med.\n Plan:\n Plan for rest periods alternating with family visits. Pt to try bipap\n (Nasal Mask) tonoc. Hold pain meds.\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n OOB to chair, two person assist, tolerated well. Lasix with fair\n response. Albumen 25% given without incident. Abdoment distented, bowel\n sounds present. pt. c/o nausea. 12pm BS 112.\n Action:\n Reglan given x2. in to evaluate pt. Pt to have KUB.,\n LFT\ns.to be drawn.\n Response:\n Nausea relieved. Abd still distented.\n Plan:\n Lft\ns. cont to evaluate abd.\n Atrial fibrillation (Afib)\n Assessment:\n Afib with varying v response, occ pvc noted. VSS.\n Action:\n Amio bolus given this am, drip started this afternoon.\n Response:\n Afib continues.\n Plan:\n Cont to monitor.\n"},{"category":"Nursing","chartdate":"2114-05-21 00:00:00.000","description":"Nursing Progress Note","row_id":674056,"text":"77 year old male with worsening DOE, + AS , AVR with fragile aorta\n .H/O aortic stenosis\n Assessment:\n sbp <100, av paced with slow rythym to asystole without perfusion,\n sedated on propofol, neo @.5mcq, min ct drainage , marginal uop,\n glucose >120, pt warm and dry. Mvo2 76/svo2 60\ns, ci>2.0.^ pvcs noted.\n Hct 35-30.\n Action:\n Kept sbp<100 transient neo/ntg, av paced with not 100% sensing\n /capturing, pads high teens to low 20\ns, 4 l fluid, fluid changed to\n ns due to ^ k, propofol ^ to 40 mcq, 1 mg morphine iv. K pending .\n insulin gtt . 2 gm magnesium up and infusing.\n Response:\n Remains av paced however morphology of complex has changed NP \n aware, + pvc\ns. neo @ .75 mcq to keep sbp>90, sedated on propofol,\n marginal uo last 2 hours, insulin gtt remains on.\n Plan:\n Monitor comfort, hr and rythym- ekg to be done when rythym\n returns-monitor vea, sbp\nkeep sbp<100, ci,svo2,dsgs,ct drainage, pp,\n resp status-abg pending- to remain Intubated and sedated overnight,\n neuro status-to remain on propofol, i+o-uo, labs pending. As per\n orders.\n"},{"category":"Nursing","chartdate":"2114-05-24 00:00:00.000","description":"Nursing Progress Note","row_id":674721,"text":"Atrial fibrillation (Afib)\n Assessment:\n AF with frequent PVC\ns, rate 80-120\n Action:\n Lopress\n Response:\n Plan:\n Posture, Impaired and inability\n Assessment:\n Action:\n Response:\n Plan:\n Respiration / Gas Exchange, Impaired\n Assessment:\n Patient on Bipap at start of shift. Supposed to wear CPAP at night,\n but patient wont do it. He states\nits uncomfortable\n Sats at 92-94%\n patient calm and cooperative\n Action:\n Off bipap and placed on 4 liters NC, uses IS up to 500, CDB encouraged,\n calm quiet environment provided, with lots of emotional support,\n OOB\nchair\n Response:\n Sats around 92-93%, patient must wear CPAP at night\n Plan:\n Continue to monitor sats, encourage slow deep breaths and IS\n"},{"category":"Nutrition","chartdate":"2114-05-24 00:00:00.000","description":"Clinical Nutrition Note","row_id":674722,"text":"Patient has been NPO and/or on unsupplemented clear liquid diet for 3\n days. If patient's diet is not able to be advanced and tolerated,\n for nutrition support\n Comments:\n Patient s/p AVR on , remains in the ICU for pulm monitoring.\n Patient is slightly confused and lethargic at this time, clear liquid\n diet order, will f/u re diet advance/tol. If unable to diet adv, will\n need tube feed/tpn, will f/u re plan of care. Please page if has\n question.\n"},{"category":"Nursing","chartdate":"2114-05-21 00:00:00.000","description":"Nursing Progress Note","row_id":674050,"text":"77 year old male with worsening DOE, + AS , AVR with fragile aorta\n .H/O aortic stenosis\n Assessment:\n sbp <100, av paced with slow rythym to asystole without perfusion,\n sedated on propofol, neo @.5mcq, min ct drainage , marginal uop,\n glucose >120, pt warm and dry. Mvo2 76/svo2 60\ns, ci>2.0. pvcs noted.\n Action:\n Kept sbp<100 transient neo/ntg, av paced with not 100% sensing\n /capturing, pads high teens to low 20\ns, 4 l fluid, fluid changed to\n ns due to ^ k, propofol ^ to 40 mcq, 1 mg morphine iv. K pending .\n insulin gtt\n Response:\n Remains av paced however morphology of complex has changed NP \n aware, + pvc\ns. neo @ .3 mcq to keep sbp>90, sedated on propofol,\n marginal uo last 2 hours, insulin gtt remains on.\n Plan:\n Monitor comfort, hr and rythym- ekg to be done when rythym returns, sbp\nkeep sbp<100, ci,svo2,dsgs,ct drainage, pp, resp status-abg pending-\n to remain Intubated and sedated overnight, neuro status-to remain on\n propofol, i+o-uo, labs pending. As per orders.\n"},{"category":"Nursing","chartdate":"2114-05-24 00:00:00.000","description":"Nursing Progress Note","row_id":674724,"text":"Atrial fibrillation (Afib)\n Assessment:\n AF with frequent PVC\ns, rate 80-120\n Action:\n Lopressor increased from 25-50mg PO BID, amio stopped early this am due\n to 10 second pause with no NSR conversion, lytes checked\n Response:\n Patient remains in AF, lytes repleted PRN\n Plan:\n Continue to monitor VS, HR/rhythm, ectopy continue with lopressor as\n tolerated\n Posture, Impaired and inability to perform ADL\ns independently\n Assessment:\n Patient weak and deconditioned, patient lives alone in 2 story home\n with lots of stairs. Patient looks down and has eyes closed while\n walking or standing\n Action:\n OOB\nchair and back to bed, with 2-3 nurse assist, moves slow and\n reaches/leans for things instead of walking towards them\n Response:\n With much encouragement able to stand up straight and focus on good\n posture, but needs much encouragement, reassurance and emotional\n support\n Plan:\n Continue to monitor while up, needs to get PT eval, ?? rehab before\n home.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Patient on Bipap at start of shift. Supposed to wear CPAP at night,\n but patient wont do it. He states\nits uncomfortable\n Sats at 92-94%\n patient calm and cooperative\n Action:\n Off bipap and placed on 4 liters NC, uses IS up to 500, CDB encouraged,\n calm quiet environment provided, with lots of emotional support,\n OOB\nchair\n Response:\n Sats around 92-93%, patient must wear CPAP at night\n Plan:\n Continue to monitor sats, encourage slow deep breaths and IS\n"},{"category":"Echo","chartdate":"2114-05-21 00:00:00.000","description":"Report","row_id":79927,"text":"PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for aortic valve replacement.\nHeight: (in) 70\nWeight (lb): 210\nBSA (m2): 2.13 m2\nStatus: Inpatient\nDate/Time: at 08:56\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Severe symmetric LVH. Normal LV cavity size. Normal regional LV\nsystolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated ascending aorta. Mildly dilated descending aorta. Simple\natheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic\nvalve leaflets. Mild AS (area 1.2-1.9cm2). Trace AR.\n\nMITRAL VALVE: Trivial MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient.\n\nConclusions:\nPRE-BYPASS: No atrial septal defect is seen by 2D or color Doppler. There is\nsevere symmetric left ventricular hypertrophy. The left ventricular cavity\nsize is normal. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. The ascending aorta is mildly dilated.\nThe descending thoracic aorta is mildly dilated. There are simple atheroma in\nthe descending thoracic aorta. There are three aortic valve leaflets. The\naortic valve leaflets are severely thickened/deformed. There is mild aortic\nvalve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen.\nTrivial mitral regurgitation is seen. There is no pericardial effusion.\n\nPOST-BYPASS: The patient is AV paced. Biventricular function is preserved. The\naorta is intact. The aortic valve has been replaced with a bioprothesis. The\nleaflets are moving well. There is no AI. The peak gradient through the valve\nis approximately 15mmHg. The Swan Ganz catheter is in the proximal right\npulmonary artery. The remainder of the examination is unchanged.\n\nDr. was notified in person of the results in the operating room.\n\n\n"},{"category":"Radiology","chartdate":"2114-05-24 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":1078369,"text":" 7:21 AM\n PORTABLE ABDOMEN Clip # \n Reason: evaluate for ileus\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with s/p avr\n REASON FOR THIS EXAMINATION:\n evaluate for ileus\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old man status post aortic valve replacement. Evaluate\n for ileus.\n\n COMPARISON: Abdominal radiographs of .\n\n PORTABLE SUPINE VIEW OF THE ABDOMEN: The diaphragms have been excluded from\n view. There is continued air-filled loops of large and small bowel. Multiple\n linear densities and wires seen overlying the upper abdomen are likely\n external to the patient. A twisted piece of wire remains overlying the lower\n abdomen, unchanged.\n\n IMPRESSION: Continued ileus, not significantly changed since the prior\n study.\n\n"},{"category":"Radiology","chartdate":"2114-05-21 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1077856,"text":" 12:18 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pleural effusion, pulmonary edema, tamponade, pneumothorax.\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with AVR\n REASON FOR THIS EXAMINATION:\n Pleural effusion, pulmonary edema, tamponade, pneumothorax. Pt in OR 2 and will\n be in CSRU in 90 mins.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after aortic valve\n replacement.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is approximately 6 cm above the carina. The Swan-Ganz\n catheter tip is at the level of right ventricle outflow tract. The NG tube\n \ttip is relatively proximal with the side hole at the level of\n gastroesophageal junction. Mediastinal drains are in expected position.\n\n The widening of the mediastinum is most likely related to recent surgery, but\n should be closely followed. The left basal opacities consistent with a\n combination of atelectasis and pleural effusion. Pericardial air is\n demonstrated related to recent surgery. No pneumothorax has been\n demonstrated. There is no evidence of failure.\n\n\n\n"},{"category":"Radiology","chartdate":"2114-05-26 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":1078785,"text":" 10:48 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval for ileus\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n eval for ileus\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL RADIOGRAPH\n\n INDICATION: Ileus.\n\n FINDINGS: A nonspecific, nonobstructed bowel gas pattern is visualized, with\n gas within nondistended loops of small and large bowel. Stomach is mildly\n distended. Scattered air-fluid levels are present on the decubitus view.\n There is no evidence of free intraperitoneal air. Atelectasis and effusions\n at the lung bases are seen to better detail on recent chest radiograph.\n\n\n"},{"category":"Radiology","chartdate":"2114-05-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1078015,"text":" 9:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ptx\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man s/p chest tube removal\n REASON FOR THIS EXAMINATION:\n eval for ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube removal, to evaluate for pneumothorax.\n\n FINDINGS: In comparison with the study of , the endotracheal tube,\n mediastinal _____, and nasogastric tube have been removed. The widening of\n the mediastinum again is most likely related to the recent surgery. Basilar\n opacifications, especially at the left, are consistent with a combination of\n atelectasis and pleural effusion. Some pericardial gas is again seen related\n to recent surgery. No evidence of pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2114-05-25 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":1078573,"text":" 7:55 AM\n PORTABLE ABDOMEN Clip # \n Reason: evaluate dilated loops\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with s/p avr\n REASON FOR THIS EXAMINATION:\n evaluate dilated loops\n ______________________________________________________________________________\n WET READ: JKSd FRI 10:05 AM\n Continued loops of airfilled large and small bowel. Air seen in rectum.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old man status post aortic valve replacement. Evaluate\n dilated loops.\n\n COMPARISON: Multiple abdominal radiographs, most recent of .\n\n UPRIGHT AND SUPINE VIEWS OF THE ABDOMEN: The upright view demonstrates the\n entire chest, although please note that this is not exposed for proper\n evaluation of the lung parenchyma. No free air is seen beneath the\n diaphragms. Bilateral pleural effusions are noted, along with atelectasis at\n the bases. Midline sternotomy wires remain intact. Air-filled loops of large\n and small bowel are again seen with air down the level of the rectum. The\n overall appearance is not significantly changed since the prior study. The\n left flank has been excluded from view.\n\n IMPRESSION: Persistent air-filled loops of large and small bowel, not\n significantly changed since prior study.\n\n\n"},{"category":"Radiology","chartdate":"2114-05-24 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1078368,"text":" 7:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? infiltrate\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with s/p avr\n REASON FOR THIS EXAMINATION:\n ? infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Questionable pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the Swan-Ganz catheter\n inserted over the left subclavian vein has been completely removed. The\n introduction sheath, however, is still in place. The size of the cardiac\n silhouette has not increased, however, a large retrocardiac atelectasis is now\n visible. There are minimal signs of overhydration. Focal parenchymal\n opacities suggesting pneumonia have not occurred.\n\n\n"},{"category":"Radiology","chartdate":"2114-05-23 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":1078314,"text":" 6:33 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o ileus\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with s/p avr\n REASON FOR THIS EXAMINATION:\n r/o ileus\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old man status post aortic valve replacement. Rule out\n ileus.\n\n COMPARISON: None.\n\n SINGLE SUPINE PORTABLE VIEW OF THE ABDOMEN: Multiple prominent air-filled\n loops of small and large bowel are seen. Air is seen down to the level of the\n rectum. Surgical clips are noted in the right upper quadrant. A twisted\n piece of thin wire is noted in the midline of the lower abdomen. Degenerative\n changes are noted throughout the visualized lumbar spine.\n\n IMPRESSION: Generalized prominent air-filled loops of small and large bowel\n consistent with ileus.\n\n\n"},{"category":"ECG","chartdate":"2114-05-29 00:00:00.000","description":"Report","row_id":212431,"text":"Atrial fibrillation with rapid ventricular response with ventricular premature\ncomplex couplet\nConsider LVH with secondary repolarization abnormality\nAnterolateral ST-T changes may be due to hypertrophy and/or ischemia\nSince previous tracing of , atrial fibrillation with rapid ventricular\nresponse is new\n\n"},{"category":"Radiology","chartdate":"2114-05-27 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1078889,"text":" 9:18 AM\n CHEST (PA & LAT) Clip # \n Reason: f/u effusions/atx\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with s/p avr\n REASON FOR THIS EXAMINATION:\n f/u effusions/atx\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after aortic valve replacement.\n\n PA and lateral upright chest radiographs were compared to .\n\n The cardiomediastinal silhouette is stable. The left retrocardiac opacity,\n triangular in shape is most likely a combination of left lower lobe\n atelectasis and pleural effusion which is small and unchanged since the prior\n study. The right pleural effusion is also small and unchanged. There is no\n pneumothorax. There is no evidence of failure.\n\n\n"}],"string":"[\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 674302,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n Pt. went into fib rate 90\\ns -120\\ns at 0445. K 4.3. Ion ca++ > 1.12.\\n Action:\\n . IV lopressor 5mg IV (0600) dose given early.\\n Response:\\n Continues in afib 90\\n 130s a times, BP 166/60\\n Plan:\\n start Amiodarone if rate uncontrolled,\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2114-05-23 00:00:00.000\",\n \"description\": \"Physical Therapy Evaluation Note\",\n \"row_id\": 674429,\n \"text\": \"Attending Physician: \\n Referral date: \\n Medical Diagnosis / ICD 9: AVR / 424.1\\n Reason of referral: Eval and Treat\\n History of Present Illness / Subjective Complaint: 77y/o male admitted\\n s/p AVR (#25mm Porcine Valve) on and POD#2.\\n CPBT 89min, XCT 52min. Pt. has fragile aorta and was not repaired.\\n Extubated .\\n Past Medical / Surgical History: AS, increase lipids, AAA 4.3x4.9cm,\\n sleep apnea but doesnt use, arthritis, CHF recent admission 3 weeks\\n ago, sinus infections, basal cell CA, L ear deafness, choley, back\\n surgery, s/p removal cyst in leg, quit smoking 25yrs ago,wife passed\\n away 6mnths ago, occasional ETOH, GERD, positional vertigo 07'\\n Medications: acetaminophen, metoclopramide, nitroglycerin, ranitidine,\\n simvastatin, furosemide, tramadol, hydralazine, amiodarone, metoprolol\\n tartrate\\n Radiology: CXR : pericardial gas; basilar opacifications consistent\\n combination of atelectasis and pleural effusion especially at L base\\n Labs:\\n 33.8\\n 11.5\\n 106\\n 13.5\\n [image002.jpg]\\n Other labs:\\n Activity Orders: Per cardiac surgery guidelines\\n Social / Occupational History: (Per dtr) Lives alone; supportive 5\\n children\\n Living Environment: (Per dtr) Lives in home; + stairs\\n Prior Functional Status / Activity Level: (Per dtr) PTA I; drives; no\\n falls\\n Objective Test\\n Arousal / Attention / Cognition / Communication: Pt. lethargic, eyes\\n closed, and slow to respond. Pt. oriented to year and that he is\\n located in a hospital. Constant verbal & tactile cues to arouse and for\\n eye opening. Follows simple commands with repeated cues and responds\\n appropriately with increase response time verbally and physically\\n Hemodynamic Response\\n Aerobic Capacity\\n HR\\n BP\\n RR\\n O[2 ]sat\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Supine\\n /\\n Rest\\n /\\n Sit\\n 95\\n 133/62\\n 20\\n 98 (5L)\\n Activity\\n /\\n 87 (RA)\\n Stand\\n /\\n Recovery\\n 86\\n 131/69\\n 19\\n 93 (5L)\\n Total distance walked: NA\\n Minutes:\\n Pulmonary Status: breathing pattern: even/nonlabored\\n cough:strong,wet,productive\\n Integumentary / Vascular: tele, sternal drsg c/d/i, foley, external\\n pacer and wires, L A-line, L subclavian, L PIV, R PIV\\n Sensory Integrity: intact to light touch; + DPP\\n Pain / Limiting Symptoms: pain 0/10; c/o dizziness and nausea at times;\\n pt. became nauseated with phlegm clearance\\n Posture: forward head and rounded shoulders\\n Range of Motion\\n Muscle Performance\\n WFL\\n B grip strong\\n B UE and LEs greater and/or = \\n Motor Function: No abnormal movements noted\\n Functional Status:\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Gait, Locomotion: Pt. presented seated in chair. Min A to lean forward\\n and back in chair. Min A sit to stand x 2 with min A to maintain static\\n standing > 1 minute. Pt. c/o nausea and dizziness with stance.\\n Rolling:\\n\\n\\n\\n\\n\\n\\n Supine /\\n Sidelying to Sit:\\n\\n\\n\\n\\n\\n Transfer:\\n\\n\\n\\n\\n\\n Sit to Stand:\\n\\n\\n T\\n\\n\\n Ambulation:\\n\\n\\n\\n\\n\\n Stairs:\\n\\n\\n\\n\\n\\n Balance: Min A for static standing balance > 1 minute. No overt LOB.\\n Education / Communication: c RN re pt status\\n c pt and daughter re role of PT, , goals, d/c planning, education,\\n importance of mobility\\n Intervention:\\n Other:\\n Diagnosis:\\n 1.\\n Aerobic Capacity / Endurance, Impaired\\n 2.\\n ADLs (Activities of Daily Living), Inability to perform\\n 3.\\n Arousal, Attention, and Cognition, Impaired\\n 4.\\n Balance, Impaired\\n 5.\\n Knowledge, Impaired\\n 6.\\n Posture, Impaired\\n 7.\\n Respiration / Gas Exchange, Impaired\\n 8.\\n Transfers, Impaired\\n Clinical impression / Prognosis: Pt. is a 77y/o male s/p AVR. Pt. is\\n p/w above impairments c/w c-v pump dysfunction and currently POD#2. Pt.\\n extremely limited by lethargy and impaired cognition at this time. Pt.\\n is functioning well below baseline; however, based on observation and\\n mobility seen, anticipate that once patient is more aroused, will\\n progress to a safe discharge home with 3-5 more PT treats for improving\\n endurance, balance, arousal, and overall functional mobility. Pt. has\\n family support for assist with discharge.\\n Goals\\n Time frame: 3-5x/wk\\n 1.\\n I bed mobility c HOB flat\\n 2.\\n I sit to stands\\n 3.\\n I amb 500ft\\n 4.\\n I with flight of stairs\\n 5.\\n A + O x 3 at all times; I with verbalizing sternal precautions\\n 6.\\n sp02 greater and/or = 92%RA at all times\\n Anticipated Discharge: Home without PT\\n Treatment :\\n Frequency / Duration: 3-5x/wk x 1 week\\n bed mobility, education, d/c planning, administer cardiac booklet, sit\\n to stands, ambulate 500ft, stair negotiation, pulmonary exercises, wean\\n 02 to RA\\n T Patient agrees with the above goals and is willing to participate in\\n the rehabilitation program.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 674521,\n \"text\": \"Arousal, Attention, and Cognition, Impaired\\n Assessment:\\n Pt lethargic most of morning. Napping fairly continuously. Oriented to\\n place, person, year and events of having heart surgery. Constantly\\n moaning.\\n Action:\\n Response:\\n More alert during afternoon. Moaning decreased after pain med.\\n Plan:\\n Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Atrial fibrillation (Afib)\\n Assessment:\\n Afib with varying v response, occ pvc noted. VSS.\\n Action:\\n Amio bolus given this am, drip started this afternoon.\\n Response:\\n Afib continues.\\n Plan:\\n Cont to monitor.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-05-23 00:00:00.000\",\n \"description\": \"ICU Note - CVI\",\n \"row_id\": 674442,\n \"text\": \"CVICU\\n HPI:\\n s/p AVR (#25mm St. porcine)-\\n EF: >75% Cr:1.2 Ht: 71\\\" Wt:209 LB\\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\\n CPAP\\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\\n Inderal 40(2)\\n Current medications:\\n Acetaminophen, Amiodarone, Aspirin EC, Docusate Sodium, Furosemide,\\n HydrALAzine, Insulin, Metoprolol Tartrate, Ranitidine, Simvastatin\\n 24 Hour Events:\\n Remains in ICU for pulmonary monitoring\\n Atrial fibrillation increased betablockers\\n Extubated and Chest tubes removed\\n EXTUBATION - At 09:00 AM\\n CHEST TUBE REMOVED - At 09:00 AM\\n INVASIVE VENTILATION - STOP 09:00 AM\\n CCO PAC - STOP 11:30 AM\\n Post operative day:\\n POD#2 - AVR # porcine valve, fragile aorta. out on neo\\n propofol, 10 ml ct drainage. av paced for very slow underlying rythym?\\n sb.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 05:00 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 05:32 PM\\n Hydralazine - 06:52 PM\\n Metoprolol - 04:50 AM\\n Ranitidine (Prophylaxis) - 08:22 AM\\n Furosemide (Lasix) - 08:24 AM\\n Other medications:\\n Flowsheet Data as of 01:35 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.1\\nC (98.7\\n T current: 37\\nC (98.6\\n HR: 87 (76 - 111) bpm\\n BP: 129/65(82) {99/45(63) - 160/65(87)} mmHg\\n RR: 23 (18 - 31) insp/min\\n SPO2: 93%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Height: 71 Inch\\n Total In:\\n 637 mL\\n 227 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 637 mL\\n 227 mL\\n Blood products:\\n Total out:\\n 1,415 mL\\n 400 mL\\n Urine:\\n 1,245 mL\\n 400 mL\\n NG:\\n 50 mL\\n Stool:\\n Drains:\\n Balance:\\n -778 mL\\n -173 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SPO2: 93%\\n ABG: 7.37/41/81./23/-1\\n PaO2 / FiO2: 162\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Irregular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Diminished: bilateral bases left > right ), (Sternum: Stable )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\\n hypoactive\\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\\n Moves all extremities, can state in hospital and year but unable to\\n name hospital and reason for being in hospital\\n Labs / Radiology\\n 106 K/uL\\n 11.5 g/dL\\n 135 mg/dL\\n 1.5 mg/dL\\n 23 mEq/L\\n 4.3 mEq/L\\n 35 mg/dL\\n 107 mEq/L\\n 140 mEq/L\\n 33.8 %\\n 13.5 K/uL\\n [image002.jpg]\\n 11:45 AM\\n 11:50 AM\\n 02:58 PM\\n 06:07 PM\\n 06:25 PM\\n 12:31 AM\\n 12:37 AM\\n 08:31 AM\\n 02:52 AM\\n 03:09 AM\\n WBC\\n 10.7\\n 8.9\\n 13.5\\n Hct\\n 35.1\\n 30.9\\n 32.9\\n 33.8\\n Plt\\n 141\\n 120\\n 106\\n Creatinine\\n 1.2\\n 1.1\\n 1.5\\n TCO2\\n 28\\n 27\\n 27\\n 25\\n 23\\n 25\\n Glucose\\n 130\\n 113\\n 135\\n Other labs: PT / PTT / INR:15.4/37.9/1.4, Mg:2.8 mg/dL\\n Assessment and Plan\\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, ADLS (ACTIVITIES OF DAILY\\n LIVING), INABILITY TO PERFORM, AROUSAL, ATTENTION, AND COGNITION,\\n IMPAIRED, BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, POSTURE, IMPAIRED,\\n RESPIRATION / GAS EXCHANGE, IMPAIRED, TRANSFERS, IMPAIRED, ATRIAL\\n FIBRILLATION (AFIB), VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR),\\n ACUTE PAIN, .H/O AORTIC STENOSIS\\n Assessment and Plan:\\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, percocet and ultram,\\n will hold and evaluate due to somnulence after percocet\\n Cardiovascular: Aspirin, Beta-blocker, Statins, amiodarone for atrial\\n fibrillation, acute on chronic diasystolic heart failure\\n Pulmonary: IS, cough and deep breath, auto CPAP at night for sleep\\n apnea - previous diagnosis but does not wear mask at home\\n Gastrointestinal / Abdomen: bowel regimen\\n Nutrition: Regular diet\\n Renal: Foley, Adequate UO, discontinue foley, cr 1.5 baseline 1.2,\\n monitor i/o with goal 500 ml negative\\n Hematology: stable anemia\\n Endocrine: RISS, goal BG < 150\\n Infectious Disease: WBC 13 from 8, remove cordis, check urine culture -\\n will recheck WBC in am no indication for antibiotics at this time\\n Lines / Tubes / Drains: Foley, Pacing wires\\n Wounds: Dry dressings\\n Consults: P.T., sleep consult\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Arterial Line - 11:30 AM\\n Cordis/Introducer - 12:00 PM\\n 20 Gauge - 06:44 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: Transfer to floor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 674511,\n \"text\": \"Arousal, Attention, and Cognition, Impaired\\n Assessment:\\n Pt lethargic most of morning. Napping fairly continuously. Oriented to\\n place, person, year and events of having heart surgery. Constantly\\n moaning.\\n Action:\\n Response:\\n More alert during afternoon. Moaning decreased after pain med.\\n Plan:\\n Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Atrial fibrillation (Afib)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 674576,\n \"text\": \"Respiration / Gas Exchange, Impaired\\n Assessment:\\n Pt requiring increasing o2 requirement. More confused and lethargic.\\n Sats 91% on 4lnc.\\n Action:\\n Changed to open face tent, sats increased to 93% for a short time. Pa\\n aware. Pt became more confused/agitated/combative. Pa\\n at bedside, 2.5mg haldol given, and 20mg iv lasix. Sats 78%.\\n Changed to closed aerosol face mask. Abg sent see flowsheet.\\n Response:\\n Sats increased to 95% on closed face mask. Pt slept for short period,\\n while asleep sats 96%. Pt awoke moaning and groaning, agitated. Ripping\\n at oxygen mask. Pa aware. Fair response to lasix overnight.\\n Resend abg to monitor co2 levels. Still breathing using accessory\\n muscles, and rr 20s\\ns-30\\ns with agitation. Pa aware.\\n Plan:\\n Abg, enc cough and deep breathe, decrease fio2 requirements as\\n tolerates.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt remains in afib overnight 80\\ns-90\\ns. Rate controlled. Amio drip at\\n 1mg/min changed to 0.5mg/min at 2100.\\n Action:\\n Afib with pvc\\ns pt had 10second pause with junctional escape beats. Pa\\n aware. Amio drip off. Pacer pad at bedside due to wires due\\n not capture or sense approp.\\n Response:\\n No more pauses overnight.\\n Plan:\\n Discontinue amio, pads at bedside for ectopy. Monitor heart rate.\\n Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n Pt is pod#3 from Avr replacement. Alert, oriented x2. States\\n Are we\\n on a boat?\\n 1:1 time with patient. 2a/2v wres do not capture or sense.\\n Wires secured and pa aware. Pt has soft but very distended\\n abdomen. KUB done on evening. Family in/out through most of evening\\n shift. Very nervous about father, reassured about care. ? social work\\n consult. Lasix given at with no response. DTV at 2100. Foley\\n reinserted pa aware 400cc out when foley placed. Left foley\\n in overnight to monitor urine output.\\n Action:\\n + flatus, Oob to commode. Dulcolax given with no reponse, fleet enema\\n given with some response, then soap suds enema given. Pt c/o incisional\\n pain with turning Tylenol given.\\n Response:\\n Pt ahd a large bowel movement, soft/formed. Tylenol had fair response.\\n Pa aware, ultram given with good relief.\\n Plan:\\n Safety precautions, Rate control afib, enc is.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2114-05-24 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 674791,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 0\\n Ideal body weight: 78 None\\n Ideal tidal volume: mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation:\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type:\\n Size:\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 20 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Comments:\\n Secretions\\n Sputum color / consistency: /\\n Sputum source/amount: /\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n Pt on BiPap 14/8 with some O2 added to keep O2 Sat > 92. Has a coarse\\n cough occasionally productive. WILL go on\\n BiPap to night at some time.\\n, RRT 17:58\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 674273,\n \"text\": \"Acute Pain\\n Assessment:\\n Pt. constantly moaning; states that he\\ns uncomfortable but can\\n clearly describe what he\\ns feeling. Can answer with short answers but\\n then mumbles and moans in between.\\n Action:\\n Seen by , PA. discontinued morphine prn order and ordered\\n one dose of Toradol 15mg IM. Ultram PRN ordered as well. Pt.\\n repositioned and encouraged to relax. Spoke with daughter via phone re:\\n moaning and coping.\\n Response:\\n Pt. stated some relief of pain from severe to moderate. Becomes anxious\\n when repositioned and requires emotional reinforcement.\\n Plan:\\n Prn pain meds & assess by pain scale.. Provide other comfort measures:\\n reposition, backrubs, cool clothes.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-05-23 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 674489,\n \"text\": \"CVICU\\n HPI:\\n s/p AVR (#25mm St. porcine)-\\n EF: >75% Cr:1.2 Ht: 71\\\" Wt:209 LB\\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\\n CPAP\\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\\n Inderal 40(2)\\n Current medications:\\n Acetaminophen, Amiodarone, Aspirin EC, Docusate Sodium, Furosemide,\\n HydrALAzine, Insulin, Metoprolol Tartrate, Ranitidine, Simvastatin\\n 24 Hour Events:\\n Remains in ICU for pulmonary monitoring\\n Atrial fibrillation increased betablockers\\n Extubated and Chest tubes removed\\n EXTUBATION - At 09:00 AM\\n CHEST TUBE REMOVED - At 09:00 AM\\n INVASIVE VENTILATION - STOP 09:00 AM\\n CCO PAC - STOP 11:30 AM\\n Post operative day:\\n POD#2 - AVR # porcine valve, fragile aorta. out on neo\\n propofol, 10 ml ct drainage. av paced for very slow underlying rythym?\\n sb.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 05:00 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 05:32 PM\\n Hydralazine - 06:52 PM\\n Metoprolol - 04:50 AM\\n Ranitidine (Prophylaxis) - 08:22 AM\\n Furosemide (Lasix) - 08:24 AM\\n Other medications:\\n Flowsheet Data as of 01:35 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.1\\nC (98.7\\n T current: 37\\nC (98.6\\n HR: 87 (76 - 111) bpm\\n BP: 129/65(82) {99/45(63) - 160/65(87)} mmHg\\n RR: 23 (18 - 31) insp/min\\n SPO2: 93%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Height: 71 Inch\\n Total In:\\n 637 mL\\n 227 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 637 mL\\n 227 mL\\n Blood products:\\n Total out:\\n 1,415 mL\\n 400 mL\\n Urine:\\n 1,245 mL\\n 400 mL\\n NG:\\n 50 mL\\n Stool:\\n Drains:\\n Balance:\\n -778 mL\\n -173 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SPO2: 93%\\n ABG: 7.37/41/81./23/-1\\n PaO2 / FiO2: 162\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Irregular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Diminished: bilateral bases left > right ), (Sternum: Stable )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\\n hypoactive\\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\\n Moves all extremities, can state in hospital and year but unable to\\n name hospital and reason for being in hospital\\n Labs / Radiology\\n 106 K/uL\\n 11.5 g/dL\\n 135 mg/dL\\n 1.5 mg/dL\\n 23 mEq/L\\n 4.3 mEq/L\\n 35 mg/dL\\n 107 mEq/L\\n 140 mEq/L\\n 33.8 %\\n 13.5 K/uL\\n [image002.jpg]\\n 11:45 AM\\n 11:50 AM\\n 02:58 PM\\n 06:07 PM\\n 06:25 PM\\n 12:31 AM\\n 12:37 AM\\n 08:31 AM\\n 02:52 AM\\n 03:09 AM\\n WBC\\n 10.7\\n 8.9\\n 13.5\\n Hct\\n 35.1\\n 30.9\\n 32.9\\n 33.8\\n Plt\\n 141\\n 120\\n 106\\n Creatinine\\n 1.2\\n 1.1\\n 1.5\\n TCO2\\n 28\\n 27\\n 27\\n 25\\n 23\\n 25\\n Glucose\\n 130\\n 113\\n 135\\n Other labs: PT / PTT / INR:15.4/37.9/1.4, Mg:2.8 mg/dL\\n Assessment and Plan\\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, ADLS (ACTIVITIES OF DAILY\\n LIVING), INABILITY TO PERFORM, AROUSAL, ATTENTION, AND COGNITION,\\n IMPAIRED, BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, POSTURE, IMPAIRED,\\n RESPIRATION / GAS EXCHANGE, IMPAIRED, TRANSFERS, IMPAIRED, ATRIAL\\n FIBRILLATION (AFIB), VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR),\\n ACUTE PAIN, .H/O AORTIC STENOSIS\\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, percocet and ultram,\\n will hold and evaluate due to somnolence after percocet\\n Cardiovascular: Aspirin, Beta-blocker, Statins, amiodarone for atrial\\n fibrillation, acute on chronic diasystolic heart failure\\n Pulmonary: IS, cough and deep breath, auto CPAP at night for sleep\\n apnea - previous diagnosis but does not wear mask at home\\n Gastrointestinal / Abdomen: bowel regimen\\n Nutrition: Regular diet\\n Renal: Foley, Adequate UO, discontinue foley, creatinine 1.5 baseline\\n 1.2, monitor UOP with goal 500 ml negative\\n Hematology: stable anemia\\n Endocrine: RISS, goal BG < 150\\n Infectious Disease: WBC 13 from 8, remove CVL, check urine culture -\\n will recheck WBC in am no indication for antibiotics at this time\\n Lines / Tubes / Drains: Foley, Pacing wires\\n Wounds: Dry dressings\\n Consults: P.T., sleep consult\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Arterial Line - 11:30 AM\\n Cordis/Introducer - 12:00 PM\\n 20 Gauge - 06:44 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: Transfer to floor\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-05-24 00:00:00.000\",\n \"description\": \"ICU Note - CVI\",\n \"row_id\": 674667,\n \"text\": \"CVICU\\n HPI:\\n HD4\\n POD3\\n 77M s/p AVR (#25mm St. porcine)-\\n EF: >75% Cr:1.2 Ht: 71\\\" Wt:209 LB\\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\\n CPAP\\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\\n Inderal 40(2)\\n Current medications:\\n Acetaminophen, Aspirin EC, Bisacodyl, Docusate Sodium, Heparin,\\n Insulin, Metoprolol Tartrate, Milk of Magnesia, Ranitidine,\\n Simvastatin, TraMADOL\\n 24 Hour Events:\\n Remains in ICU for pulmonary monitoring\\n CPAP overnight required haldol for confusion\\n Foley removed due to urinary retention reinserted 400ml\\n Amiodarone stopped due to pauses remains in atrial fibrillation\\n ARTERIAL LINE - STOP 02:23 PM\\n Post operative day:\\n POD#3 - AVR # porcine valve, fragile aorta. out on neo\\n propofol, 10 ml ct drainage. av paced for very slow underlying rythym?\\n sb.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 05:00 PM\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 02:30 AM\\n Haloperidol (Haldol) - 02:30 AM\\n Heparin Sodium - 08:00 AM\\n Other medications:\\n Flowsheet Data as of 08:57 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 36.8\\nC (98.2\\n T current: 35.9\\nC (96.7\\n HR: 99 (79 - 107) bpm\\n BP: 133/72(83) {91/49(61) - 160/98(120)} mmHg\\n RR: 17 (13 - 28) insp/min\\n SPO2: 93%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Height: 71 Inch\\n Total In:\\n 535 mL\\n 43 mL\\n PO:\\n 120 mL\\n Tube feeding:\\n IV Fluid:\\n 415 mL\\n 43 mL\\n Blood products:\\n Total out:\\n 1,300 mL\\n 410 mL\\n Urine:\\n 1,300 mL\\n 410 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -765 mL\\n -367 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SPO2: 93%\\n ABG: 7.30/52/76./22/-1\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), (Sternum: Stable )\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, bm \\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\\n (Responds to: Verbal stimuli), Moves all extremities, more alert and\\n answering questions with sentences, aware in hospital for\\n surgery\\n Labs / Radiology\\n 103 K/uL\\n 10.5 g/dL\\n 105 mg/dL\\n 1.5 mg/dL\\n 22 mEq/L\\n 4.2 mEq/L\\n 46 mg/dL\\n 101 mEq/L\\n 132 mEq/L\\n 31.9 %\\n 11.2 K/uL\\n [image002.jpg]\\n 06:07 PM\\n 06:25 PM\\n 12:31 AM\\n 12:37 AM\\n 08:31 AM\\n 02:52 AM\\n 03:09 AM\\n 03:01 AM\\n 03:04 AM\\n 05:39 AM\\n WBC\\n 8.9\\n 13.5\\n 11.2\\n Hct\\n 30.9\\n 32.9\\n 33.8\\n 31.9\\n Plt\\n 120\\n 106\\n 103\\n Creatinine\\n 1.1\\n 1.5\\n 1.5\\n TCO2\\n 27\\n 25\\n 23\\n 25\\n 27\\n 27\\n Glucose\\n 113\\n 135\\n 268\\n 105\\n Other labs: PT / PTT / INR:16.3/37.9/1.5, ALT / AST:6/35, Alk-Phos / T\\n bili:56/1.0, Amylase / Lipase:36/18, Albumin:3.6 g/dL, LDH:249 IU/L,\\n Mg:2.7 mg/dL\\n Imaging: cxr and kub pending\\n Microbiology: mrsa no growth\\n urine pending u/a negative\\n Assessment and Plan\\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, ADLS (ACTIVITIES OF DAILY\\n LIVING), INABILITY TO PERFORM, AROUSAL, ATTENTION, AND COGNITION,\\n IMPAIRED, BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, POSTURE, IMPAIRED,\\n RESPIRATION / GAS EXCHANGE, IMPAIRED, TRANSFERS, IMPAIRED, ATRIAL\\n FIBRILLATION (AFIB), VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR),\\n ACUTE PAIN, .H/O AORTIC STENOSIS\\n Assessment and Plan:\\n Neurologic: Neuro checks Q: 4 hr, hold all narcotics\\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue epicardial\\n wires, increase betablocker for rate control, amiodarone stopped due to\\n pauses overnight, remains in atrial fibrillation\\n acute on chronic diasystolic heart failure\\n Pulmonary: IS, cough and deep breath, increase ambulation, auto cpap at\\n night for sleep apnea\\n Gastrointestinal / Abdomen: bowel regimen, repeat Abdominal xray for\\n dilated loops\\n Nutrition: Clear liquids, no free water due to hyponatremia\\n Renal: Foley, Adequate UO, goal fluid balance equal, maintain foley due\\n to urinary retention will attempt removing \\n Hematology: stable anemia\\n Endocrine: RISS, goal BG < 150\\n Infectious Disease: WBC 11 from 13, afebrile no evidence of infection\\n Lines / Tubes / Drains: Foley, Pacing wires\\n Wounds: Dry dressings\\n Imaging: CXR today, KUB today\\n Consults: P.T., Nutrition\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Cordis/Introducer - 12:00 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: Transfer to floor\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-05-24 00:00:00.000\",\n \"description\": \"ICU Note\",\n \"row_id\": 674668,\n \"text\": \"TITLE: Intensivist\\n HPI:\\n HD4\\n POD3\\n 77M s/p AVR (#25mm St. porcine)-\\n EF: >75% Cr:1.2 Ht: 71\\\" Wt:209 LB\\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\\n CPAP\\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\\n Inderal 40(2)\\n Current medications:\\n Acetaminophen, Aspirin EC, Bisacodyl, Docusate Sodium, Heparin,\\n Insulin, Metoprolol Tartrate, Milk of Magnesia, Ranitidine,\\n Simvastatin, TraMADOL\\n 24 Hour Events:\\n Remains in ICU for pulmonary monitoring\\n CPAP overnight required haldol for confusion\\n Foley removed due to urinary retention reinserted 400ml\\n Amiodarone stopped due to pauses remains in atrial fibrillation\\n ARTERIAL LINE - STOP 02:23 PM\\n Post operative day:\\n POD#3 - AVR # porcine valve, fragile aorta. out on neo\\n propofol, 10 ml ct drainage. av paced for very slow underlying rythym?\\n sb.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 05:00 PM\\n Other ICU medications:\\n Furosemide (Lasix) - 02:30 AM\\n Haloperidol (Haldol) - 02:30 AM\\n Heparin Sodium - 08:00 AM\\n Other medications:\\n Flowsheet Data as of 08:57 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 36.8\\nC (98.2\\n T current: 35.9\\nC (96.7\\n HR: 99 (79 - 107) bpm\\n BP: 133/72(83) {91/49(61) - 160/98(120)} mmHg\\n RR: 17 (13 - 28) insp/min\\n SPO2: 93%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Height: 71 Inch\\n Total In:\\n 535 mL\\n 43 mL\\n PO:\\n 120 mL\\n Tube feeding:\\n IV Fluid:\\n 415 mL\\n 43 mL\\n Blood products:\\n Total out:\\n 1,300 mL\\n 410 mL\\n Urine:\\n 1,300 mL\\n 410 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -765 mL\\n -367 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SPO2: 93%\\n ABG: 7.30/52/76./22/-1\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), (Sternum: Stable )\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, bm \\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\\n (Responds to: Verbal stimuli), Moves all extremities, more alert and\\n answering questions with sentences, aware in hospital for\\n surgery\\n Labs / Radiology\\n 103 K/uL\\n 10.5 g/dL\\n 105 mg/dL\\n 1.5 mg/dL\\n 22 mEq/L\\n 4.2 mEq/L\\n 46 mg/dL\\n 101 mEq/L\\n 132 mEq/L\\n 31.9 %\\n 11.2 K/uL\\n [image002.jpg]\\n 06:07 PM\\n 06:25 PM\\n 12:31 AM\\n 12:37 AM\\n 08:31 AM\\n 02:52 AM\\n 03:09 AM\\n 03:01 AM\\n 03:04 AM\\n 05:39 AM\\n WBC\\n 8.9\\n 13.5\\n 11.2\\n Hct\\n 30.9\\n 32.9\\n 33.8\\n 31.9\\n Plt\\n 120\\n 106\\n 103\\n Creatinine\\n 1.1\\n 1.5\\n 1.5\\n TCO2\\n 27\\n 25\\n 23\\n 25\\n 27\\n 27\\n Glucose\\n 113\\n 135\\n 268\\n 105\\n Other labs: PT / PTT / INR:16.3/37.9/1.5, ALT / AST:6/35, Alk-Phos / T\\n bili:56/1.0, Amylase / Lipase:36/18, Albumin:3.6 g/dL, LDH:249 IU/L,\\n Mg:2.7 mg/dL\\n Imaging: cxr and kub pending\\n Microbiology: mrsa no growth\\n urine pending u/a negative\\n Assessment and Plan\\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, ADLS (ACTIVITIES OF DAILY\\n LIVING), INABILITY TO PERFORM, AROUSAL, ATTENTION, AND COGNITION,\\n IMPAIRED, BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, POSTURE, IMPAIRED,\\n RESPIRATION / GAS EXCHANGE, IMPAIRED, TRANSFERS, IMPAIRED, ATRIAL\\n FIBRILLATION (AFIB), VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR),\\n ACUTE PAIN, .H/O AORTIC STENOSIS\\n Assessment and Plan:\\n Neurologic: Neuro checks Q: 4 hr, hold all narcotics\\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue epicardial\\n wires, increase betablocker for rate control, amiodarone stopped due to\\n pauses overnight, remains in atrial fibrillation\\n acute on chronic diasystolic heart failure\\n Pulmonary: IS, cough and deep breath, increase ambulation, auto cpap at\\n night for sleep apnea\\n Gastrointestinal / Abdomen: bowel regimen, repeat Abdominal xray for\\n dilated loops\\n Nutrition: Clear liquids, no free water due to hyponatremia\\n Renal: Foley, Adequate UO, goal fluid balance equal, maintain foley due\\n to urinary retention will attempt removing \\n Hematology: stable anemia\\n Endocrine: RISS, goal BG < 150\\n Infectious Disease: WBC 11 from 13, afebrile no evidence of infection\\n Lines / Tubes / Drains: Foley, Pacing wires\\n Wounds: Dry dressings\\n Imaging: CXR today, KUB today\\n Consults: P.T., Nutrition\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Cordis/Introducer - 12:00 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: Transfer to floor Time spent 31 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 674249,\n \"text\": \"POD 1 AVR porcine, extubated 0930 this am.\\n Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n Sleepy on propofol 10mg this am. Opened eyes to name. Followed\\n commands.\\n Lethargic today, oriented to person and time. Knows hospital.\\n OOB to chair x2 today with 2 assist.\\n SR low 100\\ns this am with lots of apc\\ns. SBP low 100\\ns to\\n 130\\n Cardiac index >2.\\n Chest tubes with minimal output.\\n Lungs clear initially, crackles noted late am.\\n ABG on cpap 5/5 acceptable for extubation.\\n Sats 90% on 70% face tent post extubation.\\n Abdomen softly distended with +hypoactive bowel sounds. Gag weak.\\n Urine output low to marginal this am.\\n Blood sugars 140-170.\\n Action:\\n Propofol off, pt extubated without incident.\\n Nitro titrated. Hydralazine and Lopressor given iv.\\n HR 70\\ns- 80\\ns post lopressor with minimal ectopy.\\n PA line discontinued.\\n Chest tubes discontinued.\\n Nasal cannula added to face tent for sats in the mid 90\\ns. Using\\n incentive weakly to 250cc.\\n Lasix started iv.\\n Tolerating a few ice chips this afternoon.\\n Blood sugars covered with regular insulin sliding scale.\\n Response:\\n SR 70\\ns. BP one teens/60.\\n Diuresed with lasix.\\n Lungs clear this afternoon. Sats 97 on 5Lnc.\\n Plan:\\n Continue to monitor hemodynamics.\\n Blood pressure control.\\n Pulmonary hygiene.\\n Reposition q 2 hrs.\\n Monitor urine output closely.\\n Acute Pain\\n Assessment:\\n Pt admitting to incisional pain, moaning.\\n Action:\\n Morphine given iv intermittently throughout day.\\n Response:\\n Pt not moaning after morphine given iv.\\n Plan:\\n Continue to monitor pain closely.\\n Administer pain meds iv prn until pt able to tolerate po\\n Frequent repositioning.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 674784,\n \"text\": \"Atrial fibrillation (Afib) s/p AVR porcine\\n Assessment:\\n AF with frequent PVC\\ns, rate 80-120 (patient has history of AF), 2A2V\\n wires that neither sense nor pace\\n Action:\\n Lopressor increased from 25-50mg PO BID, amio stopped early this am due\\n to 10 second pause with no NSR conversion, started on coumadin today,\\n lytes checked, wires discontinued by NP \\n Response:\\n Patient remains in AF, lytes did not require repletion, patient\\n remained in bed for an hour after wires discontinued without issues,\\n VSS\\n Plan:\\n Continue to monitor VS, HR/rhythm, ectopy continue with lopressor as\\n tolerated\\n Posture, Impaired and inability to perform ADL\\ns independently\\n Assessment:\\n Patient weak and deconditioned, patient lives alone in 2 story home\\n with lots of stairs. Patient looks down and has eyes closed while\\n walking or standing\\n Action:\\n OOB\\nchair and back to bed, with 2-3 nurse assist, moves slow and\\n reaches/leans for things instead of walking towards them, walked with\\n Pt today\\n Response:\\n With much encouragement able to stand up straight and focus on good\\n posture, but needs much encouragement, reassurance and emotional\\n support\\n Plan:\\n Continue to monitor while up, ?? rehab before home.\\n Respiration / Gas Exchange, Impaired\\n Assessment:\\n Patient on Bipap at start of shift. Supposed to wear CPAP at night,\\n but patient wont do it. He states\\nits uncomfortable\\n Sats at 92-94%\\n patient calm and cooperative\\n Action:\\n Off bipap and placed on 4 liters NC, uses IS up to 500, CDB encouraged,\\n calm quiet environment provided, with lots of emotional support,\\n OOB\\nchair, seen by MD\\n Response:\\n Sats around 92-93%, patient must wear CPAP at night ? sleep study by\\n sleep MDs while inpatient\\n Plan:\\n Continue to monitor sats, encourage slow deep breaths and IS\\n Constipation (Obstipation, FOS)\\n Assessment:\\n Firm distended abdomen, hyperactive BS, constant belching and +flatus\\n Action:\\n Regularly scheduled colace and reglan given, bisacodyl and soap suds\\n enema given, adb XR and surgical GI consult obtained\\n Response:\\n Minimal output from interventions, XR showed multiple areas of dilated\\n bowel, NP , GI-patient should remain NPO\\n Plan:\\n Continue with bowel regimen, NPO until further nontice\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2114-05-25 00:00:00.000\",\n \"description\": \"Physical Therapy Progress Note\",\n \"row_id\": 675023,\n \"text\": \"Subjective:\\n \\\"Are we going to walk today?\\\"\\n Objective:\\n Follow up PT visit to address goals of: . Patient seen today\\n for balance training, patient education\\n Updated medical status: WBC 7.2 Hgb 10.3* Hct 31.1* Plt Ct 124*\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Rolling:\\n T\\n\\n\\n\\n\\n\\n Supine/\\n Sidelying to Sit:\\n\\n\\n T\\n\\n\\n Transfer:\\n\\n\\n\\n\\n\\n Sit to Stand:\\n\\n T\\n\\n\\n\\n Ambulation:\\n\\n T\\n\\n\\n\\n Stairs:\\n\\n\\n\\n\\n\\n Aerobic Activity Response:\\n Position\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Rest\\n Sit\\n 100\\n 111/72\\n 26\\n 93 (4L)\\n Activity\\n Stand\\n 103\\n 108/80\\n 32\\n 91 (6L)\\n Recovery\\n Supine\\n 103\\n 122/77\\n 22\\n 92 (4L)\\n Total distance walked: 300 feet\\n Minutes:\\n Gait: Pt. presented in chair. CGA sit to stand. Able to ambulate 300ft\\n pushing w/c with CGA and no deviations from path. Verbal cues for PLB.\\n Balance: No overt LOB\\n Education / Communication: c RN re pt status\\n c pt re role of PT, , d/c planning, education, d/c planning\\n Other: c/o pain in chest but unable to quantify\\n Assessment: Pt. is a pleasant 77y/o male functioning well below\\n baseline but displayed functional progression today with further\\n ambulation c increasing steadiness and maintaining upright posture. Pt.\\n most limited by impaired gas exhange and decrease balance which should\\n improve with increase in activity. Given age, progression, and support\\n available at home, anticipate that pt. will reach a safe level for\\n discharge home when medically stable and with 2-3 more PT treats.\\n Recommend home PT safety eval for balance, endurance, and maximizing\\n independence.\\n Anticipated Discharge: Home with Home PT\\n : Administer cardiac booklet\\n Education\\n Wean 02 to RA\\n Pulmonary exercises\\n Ambulate 500ft c RW\\n Stair negotiation\\n d/c planning\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-25 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 675029,\n \"text\": \"Constipation (Obstipation, FOS)\\n Assessment:\\n Firm, round, distended abdomen with hyperactive BS, +belching and +\\n flatus, NPO since 1600 per GI surgical team\\n Action:\\n Continue with NPO, KUB obtained, reglan and docusate given as ordered\\n Response:\\n Patients abdomen appears softer than yesterday but still distended, no\\n BM yet today\\n Plan:\\n Continue to monitor, ambulate as much as possible, maintain NPO status\\n until further notice\\n Respiration / Gas Exchange, Impaired\\n Assessment:\\n On 4 liters NC in the chair and overnight on bipap, patient is more\\n comfortable with his breathing in the chair. Sats 92-96%, slightly SOB\\n in bed, patient anxious and restless which adds to the SOB\\n Action:\\n In and OOB\\nchair several times for comfort with breathing, IS\\n encouraged along with CDB\\n Response:\\n Patient sats remain >92, no respiratory distress, continue with IS and\\n encouragement\\n Plan:\\n Continue to monitor O2 sat and monitor for dyspnea, sleep MDs\\n reevaluate\\n Atrial fibrillation (Afib)\\n Assessment:\\n History of and currently in AF HR 90\\ns, SBP>100 with frequent PVC\\n Action:\\n Lytes monitored, lopressor increased from to TID remains 50mg\\n Response:\\n No repletion necessary\\n Plan:\\n Continue to monitor VS HR and rhythm\\n Demographics\\n Attending MD:\\n R.\\n Admit diagnosis:\\n AORTIC VALVE INSUFFICIENCY AORTIC VALVE REPLACEMENT; ? ASCE\\n Code status:\\n Height:\\n 71 Inch\\n Admission weight:\\n 92.3 kg\\n Daily weight:\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH:\\n CV-PMH: Arrhythmias, CHF, Hypertension\\n Additional history: AS,^lipids,AAA 4.3X4.9cm,sleep apnea_does not use\\n apparatus,arthritis,chf-recent admission 3 weeks ago,sinus\\n infections,basal cell ca,Left ear deafness,choley,back surgery, s/p\\n removal cyst leg. retired,Quit smoking 25 years ago, wife passed away 6\\n months. occassional etoh,gerd. positional vertigo'\\n Surgery / Procedure and date: AVR porcine valve.\\n *fragile aorta*- aorta not repaired. ez intubation, kefzol 2 gm @ 0800,\\n ef 55%pre/post,act wnl, av paced with slow rythym underneath,cbp\\n 89',xc52',cry 2500, 800 cellsaver, uo 170,out on neo+propofol, keep sbp\\n <100, 10 ml ct drainage from or. CVICU, slow sb to asystole-pacer at\\n times not sensing/capturing NO perfusion. likes pads 20's. adequate uo.\\n 4 fluid. to remain sedated/intubated overnight. neuro not assessed.\\n .\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:122\\n D:77\\n Temperature:\\n 97.8\\n Arterial BP:\\n S:135\\n D:80\\n Respiratory rate:\\n 23 insp/min\\n Heart Rate:\\n 98 bpm\\n Heart rhythm:\\n AF (Atrial Fibrillation)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 92% %\\n O2 flow:\\n 4 L/min\\n FiO2 set:\\n 50% %\\n 24h total in:\\n 24h total out:\\n 490 mL\\n Pertinent Lab Results:\\n Sodium:\\n 142 mEq/L\\n 06:08 AM\\n Potassium:\\n 4.4 mEq/L\\n 06:08 AM\\n Chloride:\\n 106 mEq/L\\n 06:08 AM\\n CO2:\\n 26 mEq/L\\n 06:08 AM\\n BUN:\\n 53 mg/dL\\n 06:08 AM\\n Creatinine:\\n 1.4 mg/dL\\n 06:08 AM\\n Glucose:\\n 96 mg/dL\\n 06:08 AM\\n Hematocrit:\\n 31.1 %\\n 06:08 AM\\n Finger Stick Glucose:\\n 113\\n 06:00 AM\\n Valuables / Signature\\n Patient valuables: home\\n Other valuables:\\n Clothes: Sent home with: family\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with: family\\n Jewelry: home\\n Transferred from: \\n Transferred to: 6\\n Date & time of Transfer: 1200\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-05-25 00:00:00.000\",\n \"description\": \"ICU Note - CVI\",\n \"row_id\": 675031,\n \"text\": \"CVICU\\n HPI:\\n HD5\\n POD4\\n 77M s/p AVR (#25mm St. porcine)-\\n EF: >75% Cr:1.2 Ht: 71\\\" Wt:209 LB\\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\\n CPAP\\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\\n Inderal 40(2)\\n Current medications:\\n Acetaminophen, Aspirin EC, Docusate Sodium, Heparin, HydrALAzine,\\n Insulin, Metoclopramide, Metoprolol Tartrate, Nitroglycerin, Potassium\\n Chloride, Ranitidine, Simvastatin, Tamsulosin, Warfarin\\n 24 Hour Events:\\n Remained in ICU for monitoring\\n Surgery consulted due to abdominal distention and air in loops with no\\n improvement, NPO\\n Post operative day:\\n POD#4 - AVR # porcine valve, fragile aorta. out on neo\\n propofol, 10 ml ct drainage. av paced for very slow underlying rythym?\\n sb.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 05:00 PM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium - 08:00 AM\\n Flowsheet Data as of 11:59 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 36.7\\nC (98.1\\n T current: 36.6\\nC (97.8\\n HR: 98 (89 - 111) bpm\\n BP: 100/65(73) {94/59(67) - 130/77(88)} mmHg\\n RR: 24 (14 - 26) insp/min\\n SPO2: 90%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Height: 71 Inch\\n Total In:\\n 143 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 43 mL\\n Blood products:\\n 100 mL\\n Total out:\\n 1,170 mL\\n 460 mL\\n Urine:\\n 1,170 mL\\n 460 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,027 mL\\n -460 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SPO2: 90%\\n ABG: ///26/\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Irregular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), (Sternum: Stable )\\n Abdominal: Soft, Distended, Tender: , BM \\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n Moves all extremities\\n Labs / Radiology\\n 124 K/uL\\n 10.3 g/dL\\n 96 mg/dL\\n 1.4 mg/dL\\n 26 mEq/L\\n 4.4 mEq/L\\n 53 mg/dL\\n 106 mEq/L\\n 142 mEq/L\\n 31.1 %\\n 7.2 K/uL\\n [image002.jpg]\\n 12:37 AM\\n 08:31 AM\\n 02:52 AM\\n 03:09 AM\\n 03:01 AM\\n 03:04 AM\\n 05:39 AM\\n 01:46 PM\\n 09:01 PM\\n 06:08 AM\\n WBC\\n 13.5\\n 11.2\\n 7.2\\n Hct\\n 33.8\\n 31.9\\n 31.1\\n Plt\\n 106\\n 103\\n 124\\n Creatinine\\n 1.5\\n 1.5\\n 1.5\\n 1.5\\n 1.4\\n TCO2\\n 25\\n 23\\n 25\\n 27\\n 27\\n Glucose\\n 135\\n 268\\n 105\\n 96\\n Other labs: PT / PTT / INR:16.3/37.9/1.5, ALT / AST:20/50, Alk-Phos / T\\n bili:64/1.0, Amylase / Lipase:34/35, Albumin:3.6 g/dL, LDH:253 IU/L,\\n Ca:8.9 mg/dL, Mg:2.9 mg/dL, PO4:2.7 mg/dL\\n Imaging: CXR small effusion\\n Abd air in loops of bowel\\n Microbiology: MRSA no growth\\n urine no growth\\n Assessment and Plan\\n CONSTIPATION (OBSTIPATION, FOS), AEROBIC CAPACITY / ENDURANCE,\\n IMPAIRED, ADLS (ACTIVITIES OF DAILY LIVING), INABILITY TO PERFORM,\\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED,\\n KNOWLEDGE, IMPAIRED, POSTURE, IMPAIRED, RESPIRATION / GAS EXCHANGE,\\n IMPAIRED, TRANSFERS, IMPAIRED, ATRIAL FIBRILLATION (AFIB), VALVE\\n REPLACEMENT, AORTIC BIOPROSTHETIC (AVR), ACUTE PAIN, .H/O\\n AORTIC STENOSIS\\n Assessment and Plan:\\n Neurologic: Neuro checks Q: 4 hr, denies pain except with abdominal\\n palpitation\\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, Statins,\\n coumadin for atrial fibrillation, awaiting PT/INR to dose, no\\n amiodarone due to pauses \\n Pulmonary: IS, cough and deep breath, increase ambulation\\n Gastrointestinal / Abdomen: follow up with surgery, Abd xray unchanged,\\n serial abdominal exams\\n Nutrition: Clear liquids\\n Renal: Foley, Adequate UO, goal fluid balance equal\\n Hematology: stable anemia\\n Endocrine: RISS, goal BG < 150\\n Infectious Disease: wbc 7, afebrile, all cultures negative, no evidence\\n of infection\\n Lines / Tubes / Drains: Foley\\n Wounds: Dry dressings\\n Imaging: KUB today\\n Consults: P.T., Nutrition\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Cordis/Introducer - 12:00 PM\\n 20 Gauge - 02:23 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: Transfer to floor\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-05-25 00:00:00.000\",\n \"description\": \"ICU Note\",\n \"row_id\": 675032,\n \"text\": \"TITLE: Intensivist\\n HPI:\\n HD5\\n POD4\\n 77M s/p AVR (#25mm St. porcine)-\\n EF: >75% Cr:1.2 Ht: 71\\\" Wt:209 LB\\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\\n CPAP\\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\\n Inderal 40(2)\\n Current medications:\\n Acetaminophen, Aspirin EC, Docusate Sodium, Heparin, HydrALAzine,\\n Insulin, Metoclopramide, Metoprolol Tartrate, Nitroglycerin, Potassium\\n Chloride, Ranitidine, Simvastatin, Tamsulosin, Warfarin\\n 24 Hour Events:\\n Remained in ICU for monitoring\\n Surgery consulted due to abdominal distention and air in loops with no\\n improvement, NPO\\n Post operative day:\\n POD#4 - AVR # porcine valve, fragile aorta. out on neo\\n propofol, 10 ml ct drainage. av paced for very slow underlying rythym?\\n sb.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 05:00 PM\\n Other ICU medications:\\n Heparin Sodium - 08:00 AM\\n Flowsheet Data as of 11:59 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 36.7\\nC (98.1\\n T current: 36.6\\nC (97.8\\n HR: 98 (89 - 111) bpm\\n BP: 100/65(73) {94/59(67) - 130/77(88)} mmHg\\n RR: 24 (14 - 26) insp/min\\n SPO2: 90%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Height: 71 Inch\\n Total In:\\n 143 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 43 mL\\n Blood products:\\n 100 mL\\n Total out:\\n 1,170 mL\\n 460 mL\\n Urine:\\n 1,170 mL\\n 460 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,027 mL\\n -460 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SPO2: 90%\\n ABG: ///26/\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Irregular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), (Sternum: Stable )\\n Abdominal: Soft, Distended, Tender: , BM \\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n Moves all extremities\\n Labs / Radiology\\n 124 K/uL\\n 10.3 g/dL\\n 96 mg/dL\\n 1.4 mg/dL\\n 26 mEq/L\\n 4.4 mEq/L\\n 53 mg/dL\\n 106 mEq/L\\n 142 mEq/L\\n 31.1 %\\n 7.2 K/uL\\n [image002.jpg]\\n 12:37 AM\\n 08:31 AM\\n 02:52 AM\\n 03:09 AM\\n 03:01 AM\\n 03:04 AM\\n 05:39 AM\\n 01:46 PM\\n 09:01 PM\\n 06:08 AM\\n WBC\\n 13.5\\n 11.2\\n 7.2\\n Hct\\n 33.8\\n 31.9\\n 31.1\\n Plt\\n 106\\n 103\\n 124\\n Creatinine\\n 1.5\\n 1.5\\n 1.5\\n 1.5\\n 1.4\\n TCO2\\n 25\\n 23\\n 25\\n 27\\n 27\\n Glucose\\n 135\\n 268\\n 105\\n 96\\n Other labs: PT / PTT / INR:16.3/37.9/1.5, ALT / AST:20/50, Alk-Phos / T\\n bili:64/1.0, Amylase / Lipase:34/35, Albumin:3.6 g/dL, LDH:253 IU/L,\\n Ca:8.9 mg/dL, Mg:2.9 mg/dL, PO4:2.7 mg/dL\\n Imaging: CXR small effusion\\n Abd air in loops of bowel\\n Microbiology: MRSA no growth\\n urine no growth\\n Assessment and Plan\\n CONSTIPATION (OBSTIPATION, FOS), AEROBIC CAPACITY / ENDURANCE,\\n IMPAIRED, ADLS (ACTIVITIES OF DAILY LIVING), INABILITY TO PERFORM,\\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED,\\n KNOWLEDGE, IMPAIRED, POSTURE, IMPAIRED, RESPIRATION / GAS EXCHANGE,\\n IMPAIRED, TRANSFERS, IMPAIRED, ATRIAL FIBRILLATION (AFIB), VALVE\\n REPLACEMENT, AORTIC BIOPROSTHETIC (AVR), ACUTE PAIN, .H/O\\n AORTIC STENOSIS\\n Assessment and Plan:\\n Neurologic: Neuro checks Q: 4 hr, denies pain except with abdominal\\n palpitation\\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, Statins,\\n coumadin for atrial fibrillation, awaiting PT/INR to dose, no\\n amiodarone due to pauses \\n Pulmonary: IS, cough and deep breath, increase ambulation\\n Gastrointestinal / Abdomen: follow up with surgery, Abd xray unchanged,\\n serial abdominal exams\\n Nutrition: Clear liquids\\n Renal: Foley, Adequate UO, goal fluid balance equal\\n Hematology: stable anemia\\n Endocrine: RISS, goal BG < 150\\n Infectious Disease: wbc 7, afebrile, all cultures negative, no evidence\\n of infection\\n Lines / Tubes / Drains: Foley\\n Wounds: Dry dressings\\n Imaging: KUB today\\n Consults: P.T., Nutrition\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Cordis/Introducer - 12:00 PM\\n 20 Gauge - 02:23 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code Time spent 32 min\\n Disposition: Transfer to floor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 674605,\n \"text\": \"Respiration / Gas Exchange, Impaired\\n Assessment:\\n Pt requiring increasing o2 requirement. More confused and lethargic.\\n Sats 91% on 4lnc.\\n Action:\\n Changed to open face tent, sats increased to 93% for a short time. Pa\\n aware. Pt became more confused/agitated/combative. Pa\\n at bedside, 2.5mg haldol given, and 20mg iv lasix. Sats 78%.\\n Changed to closed aerosol face mask. Abg sent see flowsheet.\\n Response:\\n Sats increased to 95% on closed face mask. Pt slept for short period,\\n while asleep sats 96%. Pt awoke moaning and groaning, agitated. Ripping\\n at oxygen mask. Pa aware. Fair response to lasix overnight.\\n Resend abg to monitor co2 levels. Still breathing using accessory\\n muscles, and rr 20s\\ns-30\\ns with agitation. Pa aware.\\n Plan:\\n Abg, enc cough and deep breathe, decrease fio2 requirements as\\n tolerates.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt remains in afib overnight 80\\ns-90\\ns. Rate controlled. Amio drip at\\n 1mg/min changed to 0.5mg/min at 2100.\\n Action:\\n Afib with pvc\\ns pt had 10second pause with junctional escape beats. Pa\\n aware. Amio drip off. Pacer pad at bedside due to wires due\\n not capture or sense approp.\\n Response:\\n No more pauses overnight.\\n Plan:\\n Discontinue amio, pads at bedside for ectopy. Monitor heart rate.\\n Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n Pt is pod#3 from Avr replacement. Alert, oriented x2. States\\n Are we\\n on a boat?\\n 1:1 time with patient. 2a/2v wres do not capture or sense.\\n Wires secured and pa aware. Pt has soft but very distended\\n abdomen. KUB done on evening. Family in/out through most of evening\\n shift. Very nervous about father, reassured about care. ? social work\\n consult. Lasix given at with no response. DTV at 2100. Foley\\n reinserted pa aware 400cc out when foley placed. Left foley\\n in overnight to monitor urine output.\\n Action:\\n + flatus, Oob to commode. Dulcolax given with no reponse, fleet enema\\n given with some response, then soap suds enema given. Pt c/o incisional\\n pain with turning Tylenol given.\\n Response:\\n Pt ahd a large bowel movement, soft/formed. Tylenol had fair response.\\n Pa aware, ultram given with good relief.\\n Plan:\\n Safety precautions, Rate control afib, enc is.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-25 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 675007,\n \"text\": \"Constipation (Obstipation, FOS)\\n Assessment:\\n Firm, round, distended abdomen with hyperactive BS, +belching and +\\n flatus, NPO since 1600 per GI surgical team\\n Action:\\n Continue with NPO, KUB obtained, reglan and docusate given as ordered\\n Response:\\n Patients abdomen appears softer than yesterday but still distended, no\\n BM yet today\\n Plan:\\n Continue to monitor, ambulate as much as possible, maintain NPO status\\n until further notice\\n Respiration / Gas Exchange, Impaired\\n Assessment:\\n On 4 liters NC in the chair and overnight on bipap, patient is more\\n comfortable with his breathing in the chair. Sats 92-96%, slightly SOB\\n in bed, patient anxious and restless which adds to the SOB\\n Action:\\n In and OOB\\nchair several times for comfort with breathing, IS\\n encouraged along with CDB\\n Response:\\n Patient sats remain >92, no respiratory distress, continue with IS and\\n encouragement\\n Plan:\\n Continue to monitor O2 sat and monitor for dyspnea, sleep MDs\\n reevaluate\\n Atrial fibrillation (Afib)\\n Assessment:\\n History of and currently in AF HR 90\\ns, SBP>100 with frequent PVC\\n Action:\\n Lytes monitored, lopressor increased from to TID remains 50mg\\n Response:\\n No repletion necessary\\n Plan:\\n Continue to monitor VS HR and rhythm\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-25 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 675008,\n \"text\": \"Constipation (Obstipation, FOS)\\n Assessment:\\n Firm, round, distended abdomen with hyperactive BS, +belching and +\\n flatus, NPO since 1600 per GI surgical team\\n Action:\\n Continue with NPO, KUB obtained, reglan and docusate given as ordered\\n Response:\\n Patients abdomen appears softer than yesterday but still distended, no\\n BM yet today\\n Plan:\\n Continue to monitor, ambulate as much as possible, maintain NPO status\\n until further notice\\n Respiration / Gas Exchange, Impaired\\n Assessment:\\n On 4 liters NC in the chair and overnight on bipap, patient is more\\n comfortable with his breathing in the chair. Sats 92-96%, slightly SOB\\n in bed, patient anxious and restless which adds to the SOB\\n Action:\\n In and OOB\\nchair several times for comfort with breathing, IS\\n encouraged along with CDB\\n Response:\\n Patient sats remain >92, no respiratory distress, continue with IS and\\n encouragement\\n Plan:\\n Continue to monitor O2 sat and monitor for dyspnea, sleep MDs\\n reevaluate\\n Atrial fibrillation (Afib)\\n Assessment:\\n History of and currently in AF HR 90\\ns, SBP>100 with frequent PVC\\n Action:\\n Lytes monitored, lopressor increased from to TID remains 50mg\\n Response:\\n No repletion necessary\\n Plan:\\n Continue to monitor VS HR and rhythm\\n Demographics\\n Attending MD:\\n R.\\n Admit diagnosis:\\n AORTIC VALVE INSUFFICIENCY AORTIC VALVE REPLACEMENT; ? ASCE\\n Code status:\\n Height:\\n 71 Inch\\n Admission weight:\\n 92.3 kg\\n Daily weight:\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH:\\n CV-PMH: Arrhythmias, CHF, Hypertension\\n Additional history: AS,^lipids,AAA 4.3X4.9cm,sleep apnea_does not use\\n apparatus,arthritis,chf-recent admission 3 weeks ago,sinus\\n infections,basal cell ca,Left ear deafness,choley,back surgery, s/p\\n removal cyst leg. retired,Quit smoking 25 years ago, wife passed away 6\\n months. occassional etoh,gerd. positional vertigo'\\n Surgery / Procedure and date: AVR porcine valve.\\n *fragile aorta*- aorta not repaired. ez intubation, kefzol 2 gm @ 0800,\\n ef 55%pre/post,act wnl, av paced with slow rythym underneath,cbp\\n 89',xc52',cry 2500, 800 cellsaver, uo 170,out on neo+propofol, keep sbp\\n <100, 10 ml ct drainage from or. CVICU, slow sb to asystole-pacer at\\n times not sensing/capturing NO perfusion. likes pads 20's. adequate uo.\\n 4 fluid. to remain sedated/intubated overnight. neuro not assessed.\\n .\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:100\\n D:65\\n Temperature:\\n 97.8\\n Arterial BP:\\n S:135\\n D:80\\n Respiratory rate:\\n 24 insp/min\\n Heart Rate:\\n 98 bpm\\n Heart rhythm:\\n AF (Atrial Fibrillation)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 90% %\\n O2 flow:\\n 4 L/min\\n FiO2 set:\\n 50% %\\n 24h total in:\\n 24h total out:\\n 460 mL\\n Pertinent Lab Results:\\n Sodium:\\n 142 mEq/L\\n 06:08 AM\\n Potassium:\\n 4.4 mEq/L\\n 06:08 AM\\n Chloride:\\n 106 mEq/L\\n 06:08 AM\\n CO2:\\n 26 mEq/L\\n 06:08 AM\\n BUN:\\n 53 mg/dL\\n 06:08 AM\\n Creatinine:\\n 1.4 mg/dL\\n 06:08 AM\\n Glucose:\\n 96 mg/dL\\n 06:08 AM\\n Hematocrit:\\n 31.1 %\\n 06:08 AM\\n Finger Stick Glucose:\\n 113\\n 06:00 AM\\n Valuables / Signature\\n Patient valuables: none\\n Other valuables: none\\n Clothes: Sent home with: family\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with: family\\n Jewelry: none\\n Transferred from: \\n Transferred to: \\n Date & time of Transfer: 1200\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2114-05-24 00:00:00.000\",\n \"description\": \"Physical Therapy Progress Note\",\n \"row_id\": 674746,\n \"text\": \"Subjective:\\n \\\"I am weak.\\\"\\n Objective:\\n Follow up PT visit to address goals of: . Patient seen today\\n for balance training, patient education\\n Updated medical status: 5.14 WBC 11.2* Hgb 10.5* Hct 31.9* Plt Ct 103*\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Rolling:\\n\\n\\n\\n\\n\\n Supine/\\n Sidelying to Sit:\\n\\n\\n\\n\\n\\n Transfer:\\n\\n\\n\\n\\n\\n Sit to Stand:\\n\\n\\n T\\n\\n\\n Ambulation:\\n\\n T\\n\\n\\n\\n Stairs:\\n\\n\\n\\n\\n\\n Aerobic Activity Response:\\n Position\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Rest\\n Sit\\n 87\\n 123/80\\n 23\\n 91 (3L)\\n Activity\\n Stand\\n 104\\n 152/99\\n 31\\n 83 (6L)\\n Recovery\\n Sit\\n 112\\n 123/62\\n 23\\n 93 (4L)\\n Total distance walked: 80feet\\n Minutes:\\n Gait: Pt. ambulated 80ft pushing w/c with CGA. Pt. required sit to\\n stand. Patient required constant cues for upright posture, PLB, and\\n pacing. No deviations from pathway. C/o lightheadedness at times.\\n Balance: No overt LOB.\\n Education / Communication: c RN re pt status\\n c pt re role of PT, , d/c planning, education, goals\\n Other: Pain 0/10\\n Question accuracy of 02 sat secondary to no patient complaints\\n of labored breathing and pleth not evenly distributed.\\n Assessment: Pt. is a pleasant 77y/o male s/p AVR and functioning well\\n below baseline. Pt. limited by decrease endurance, balance, and overall\\n mobility, but has progressed functionally since evaluation. Pt. has\\n great potential to reach baseline with continued activity and\\n ambulation. Given PLOF, age, and support available at home, anticipate\\n that pt. will be able to reach a safe discharge home with 24 hour\\n assist and home PT safety eval. If patient lacks continuing\\n progression, will recommend rehab.\\n Anticipated Discharge: Home with Home PT\\n : bed mobility\\n education\\n administer cardiac booklet\\n ambulate with RW >200ft\\n wean 02 to RA\\n pulmonary exercises\\n balance and endurance training\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 674753,\n \"text\": \"Atrial fibrillation (Afib) s/p AVR porcine\\n Assessment:\\n AF with frequent PVC\\ns, rate 80-120 (patient has history of AF)\\n Action:\\n Lopressor increased from 25-50mg PO BID, amio stopped early this am due\\n to 10 second pause with no NSR conversion, started on coumadin today,\\n lytes checked\\n Response:\\n Patient remains in AF, lytes did not require repletion\\n Plan:\\n Continue to monitor VS, HR/rhythm, ectopy continue with lopressor as\\n tolerated\\n Posture, Impaired and inability to perform ADL\\ns independently\\n Assessment:\\n Patient weak and deconditioned, patient lives alone in 2 story home\\n with lots of stairs. Patient looks down and has eyes closed while\\n walking or standing\\n Action:\\n OOB\\nchair and back to bed, with 2-3 nurse assist, moves slow and\\n reaches/leans for things instead of walking towards them\\n Response:\\n With much encouragement able to stand up straight and focus on good\\n posture, but needs much encouragement, reassurance and emotional\\n support\\n Plan:\\n Continue to monitor while up, needs to get PT eval, ?? rehab before\\n home.\\n Respiration / Gas Exchange, Impaired\\n Assessment:\\n Patient on Bipap at start of shift. Supposed to wear CPAP at night,\\n but patient wont do it. He states\\nits uncomfortable\\n Sats at 92-94%\\n patient calm and cooperative\\n Action:\\n Off bipap and placed on 4 liters NC, uses IS up to 500, CDB encouraged,\\n calm quiet environment provided, with lots of emotional support,\\n OOB\\nchair\\n Response:\\n Sats around 92-93%, patient must wear CPAP at night\\n Plan:\\n Continue to monitor sats, encourage slow deep breaths and IS\\n Constipation (Obstipation, FOS)\\n Assessment:\\n Firm distended abdomen, hyperactive BS, constant belching and +flatus\\n Action:\\n Regularly scheduled colace and reglan given, bisacodyl and soap suds\\n enema given, adb XR and GI consult obtained\\n Response:\\n Minimal oputput from interventions, XR showed multiple areas of dilated\\n bowel, NP \\n Plan:\\n Continue with bowel regimen, awaiting GU consult\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 674731,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n AF with frequent PVC\\ns, rate 80-120\\n Action:\\n Lopressor increased from 25-50mg PO BID, amio stopped early this am due\\n to 10 second pause with no NSR conversion, started on coumadin today,\\n lytes checked\\n Response:\\n Patient remains in AF, lytes repleted PRN\\n Plan:\\n Continue to monitor VS, HR/rhythm, ectopy continue with lopressor as\\n tolerated\\n Posture, Impaired and inability to perform ADL\\ns independently\\n Assessment:\\n Patient weak and deconditioned, patient lives alone in 2 story home\\n with lots of stairs. Patient looks down and has eyes closed while\\n walking or standing\\n Action:\\n OOB\\nchair and back to bed, with 2-3 nurse assist, moves slow and\\n reaches/leans for things instead of walking towards them\\n Response:\\n With much encouragement able to stand up straight and focus on good\\n posture, but needs much encouragement, reassurance and emotional\\n support\\n Plan:\\n Continue to monitor while up, needs to get PT eval, ?? rehab before\\n home.\\n Respiration / Gas Exchange, Impaired\\n Assessment:\\n Patient on Bipap at start of shift. Supposed to wear CPAP at night,\\n but patient wont do it. He states\\nits uncomfortable\\n Sats at 92-94%\\n patient calm and cooperative\\n Action:\\n Off bipap and placed on 4 liters NC, uses IS up to 500, CDB encouraged,\\n calm quiet environment provided, with lots of emotional support,\\n OOB\\nchair\\n Response:\\n Sats around 92-93%, patient must wear CPAP at night\\n Plan:\\n Continue to monitor sats, encourage slow deep breaths and IS\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 674876,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n Pt remains in afib. No pauses this shift. Frequent pvc\\ns. Sbp\\n 100\\ns-120\\ns. Pt is alert, oriented x3, no confusion. NO NARCOTICS,\\n Tylenol for pain as needed\\n Action:\\n Lopressor dose was increased on day shift to 50mg po bid.\\n Response:\\n Pt tolerating lopressor dose with sbp >100. Afin still not rate\\n controlled has bursts into 120\\ns-130\\ns at times.\\n Plan:\\n ? increase lopressor dose for rate control. Coumdain today. Pt\\ns family\\n informed of need for electric razor while on coumdain.\\n Respiration / Gas Exchange, Impaired\\n Assessment:\\n Pt sats 92-96% on 4l nc while in chair. When in bed pt has difficulty\\n breathing due to obese abdomen. Sats drop to 92% while in bed laying\\n doen, and pt states\\nI feel winded.\\n Action:\\n Pa aware, bipap placed on pt, pt a little hesitant to wear\\n states\\nit feels like a hurricane against my face.\\n Response:\\n Pt tolerated bipap for 2 hours then insists on taking off mask. In and\\n out bed and chair all night long. While in chair wears 4lc sats 95%,\\n while in bed wears bipap for short time and then closed face mask at\\n 50% humidification. Pt cooperative on alternating. Between masks and pa\\n aware.\\n Plan:\\n Bipap at night if pt tolerates, ? nose piece instead of mask if\\n tolerates. Wean fio2 requirements as pt tolerates.\\n Constipation (Obstipation, FOS)\\n Assessment:\\n Pt has obese, firm and distended abdomen. Hyperactive bs noted on\\n assessment. + flatus.\\n Action:\\n Gi surgery team consulted, npo until further notice today. Reglan\\n started x4 doses. No bowel meds.\\n Response:\\n Pt passing gas from below, no belching this shift. Abdomen the same as\\n assessment . No nausea or vomiting.\\n Plan:\\n Plan f/u kub this am, surgery consult reccomendations.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2114-05-25 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 674873,\n \"text\": \"Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Comments:\\n Pt on and off Bipap 14/8 with up to 15L O2 to maintain sats of 94%.\\n Does not tolerate for very long.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 674518,\n \"text\": \"Arousal, Attention, and Cognition, Impaired\\n Assessment:\\n Pt lethargic most of morning. Napping fairly continuously. Oriented to\\n place, person, year and events of having heart surgery. Constantly\\n moaning.\\n Action:\\n Response:\\n More alert during afternoon. Moaning decreased after pain med.\\n Plan:\\n Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Atrial fibrillation (Afib)\\n Assessment:\\n Afib with varying v response, occ pvc noted. VSS.\\n Action:\\n Amio bolus given this am, drip started this afternoon.\\n Response:\\n Afib continues.\\n Plan:\\n Cont to monitor.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 674921,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n Pt remains in afib. No pauses this shift. Frequent pvc\\ns. Sbp\\n 100\\ns-120\\ns. Pt is alert, oriented x3, no confusion. NO NARCOTICS,\\n Tylenol for pain as needed\\n Action:\\n Lopressor dose was increased on day shift to 50mg po bid.\\n Response:\\n Pt tolerating lopressor dose with sbp >100. Afin still not rate\\n controlled has bursts into 120\\ns-130\\ns at times.\\n Plan:\\n ? increase lopressor dose for rate control. Coumdain today. Pt\\ns family\\n informed of need for electric razor while on coumdain.\\n Respiration / Gas Exchange, Impaired\\n Assessment:\\n Pt sats 92-96% on 4l nc while in chair. When in bed pt has difficulty\\n breathing due to obese abdomen. Sats drop to 92% while in bed laying\\n doen, and pt states\\nI feel winded.\\n Action:\\n Pa aware, bipap placed on pt, pt a little hesitant to wear\\n states\\nit feels like a hurricane against my face.\\n Response:\\n Pt tolerated bipap for 2 hours then insists on taking off mask. In and\\n out bed and chair all night long. While in chair wears 4lc sats 95%,\\n while in bed wears bipap for short time and then closed face mask at\\n 50% humidification. Pt cooperative on alternating. Between masks and pa\\n aware.\\n Plan:\\n Bipap at night if pt tolerates, ? nose piece instead of mask if\\n tolerates. Wean fio2 requirements as pt tolerates.\\n Constipation (Obstipation, FOS)\\n Assessment:\\n Pt has obese, firm and distended abdomen. Hyperactive bs noted on\\n assessment. + flatus.\\n Action:\\n Gi surgery team consulted, npo until further notice today. Reglan\\n started x4 doses. No bowel meds.\\n Response:\\n Pt passing gas from below, no belching this shift. Abdomen the same as\\n assessment . No nausea or vomiting.\\n Plan:\\n Plan f/u kub this am, surgery consult recommendations.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2114-05-21 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 674014,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 1\\n Ideal body weight: 78 None\\n Ideal tidal volume: mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation:\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Double Lumen\\n Size: 8mm\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: /\\n Sputum source/amount: /\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n :\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\\n Underlying illness not resolved\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 674073,\n \"text\": \"Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n Pt. remains Intubated & sedated in order to keep tight control of BP\\n with SBP ~95-100. SVO2 >60% with CI ~2.0 or better. Chest tube drng.\\n 0-20cc/hr. HCT ~32. AV-pacing rate at 96.\\n Action:\\n AV- pacing maintained due to very slow underlying rhythm <40. Neo & NTG\\n titrated to on & off as needed to keep BP parameter. Propofol on at\\n 40mcq/kg; weaned to 10 mcq earlier in the evening wake-up in order to\\n assess neuro status. Insulin infusing and titrated per protocol.\\n Response:\\n CI 2.2. SBP ~100-110 off vasoactive agents. Pt. was able to open eyes\\n and nod his head to ???? and follow simple commands ( ie: wiggle toes).\\n BS WNL . ABG WNL on present vent settings 50%fio2, IMV 16 Tv 600cc Peep\\n 5cm.\\n Plan:\\n Wean sedation to extubate in AM. BP management with NTG/NEO. Glucose\\n control hourly. Pain management.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-05-22 00:00:00.000\",\n \"description\": \"ICU Note - CVI\",\n \"row_id\": 674169,\n \"text\": \"CVICU\\n HPI:\\n HD2\\n POD#1\\n 77M s/p AVR (#25mm St. porcine)-\\n EF: >75% Cr:1.2 Ht: 71\\\" Wt:209 LB\\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\\n Inderal 40(2)\\n :\\n PMHx:\\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\\n CPAP\\n Current medications:\\n . Acetaminophen 5. Aspirin EC 6. Calcium Gluconate 7. CefazoLIN 8.\\n Dextrose 50% 9. Docusate Sodium 10. Furosemide 11. HydrALAzine 12.\\n Insulin 13. Magnesium Sulfate 14. Metoprolol Tartrate 15.\\n Metoclopramide 16. Metoprolol Tartrate 17. Milk of Magnesia 18.\\n Morphine Sulfate 19. Nitroglycerin 20. Oxycodone-Acetaminophen 21.\\n Potassium Chloride 22. Ranitidine 23. Simvastatin\\n 24 Hour Events:\\n OR RECEIVED - At 11:30 AM\\n INVASIVE VENTILATION - START 11:30 AM\\n CCO PAC - START 11:30 AM\\n ARTERIAL LINE - START 11:30 AM\\n EKG - At 11:45 AM\\n Deferred due to slow underluying rythym\\n CORDIS/INTRODUCER - START 12:00 PM\\n Post operative day:\\n HD2\\n POD#1\\n 77M s/p AVR (#25mm St. porcine)-\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 08:37 AM\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 10:16 PM\\n Morphine Sulfate - 06:36 AM\\n Hydralazine - 08:34 AM\\n Metoprolol - 09:25 AM\\n Furosemide (Lasix) - 10:30 AM\\n Flowsheet Data as of 11:46 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n HR: 96 (78 - 108) bpm\\n BP: 114/52(67) {85/46(58) - 130/67(85)} mmHg\\n RR: 30 (12 - 36) insp/min\\n SPO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 20 (10 - 22) mmHg\\n PAP: (33 mmHg) / (18 mmHg)\\n CO/CI (Fick): (6.7 L/min) / (3.1 L/min/m2)\\n CO/CI (CCO): (6.6 L/min) / (3.1 L/min/m2)\\n SvO2: 67%\\n Mixed Venous O2% sat: 76 - 76\\n Total In:\\n 8,890 mL\\n 438 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 8,090 mL\\n 438 mL\\n Blood products:\\n 800 mL\\n Total out:\\n 1,058 mL\\n 552 mL\\n Urine:\\n 718 mL\\n 382 mL\\n NG:\\n 50 mL\\n Stool:\\n Drains:\\n Balance:\\n 7,832 mL\\n -114 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n Ventilator mode: CPAP/PPS\\n Vt (Set): 600 (600 - 600) mL\\n Vt (Spontaneous): 330 (330 - 957) mL\\n PS : 5 cmH2O\\n RR (Set): 16\\n RR (Spontaneous): 32\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 22 cmH2O\\n Plateau: 18 cmH2O\\n SPO2: 94%\\n ABG: 7.31/44/86./23/-4\\n Ve: 11.1 L/min\\n PaO2 / FiO2: 174\\n Physical Examination\\n General Appearance: No acute distress, Well nourished\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Diminished: bases), (Sternum: Stable )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n Moves all extremities\\n Labs / Radiology\\n 120 K/uL\\n 11.0 g/dL\\n 113 mg/dL\\n 1.1 mg/dL\\n 23 mEq/L\\n 4.7 mEq/L\\n 26 mg/dL\\n 110 mEq/L\\n 138 mEq/L\\n 32.9 %\\n 8.9 K/uL\\n [image002.jpg]\\n 11:45 AM\\n 11:50 AM\\n 02:58 PM\\n 06:07 PM\\n 06:25 PM\\n 12:31 AM\\n 12:37 AM\\n 08:31 AM\\n WBC\\n 10.7\\n 8.9\\n Hct\\n 35.1\\n 30.9\\n 32.9\\n Plt\\n 141\\n 120\\n Creatinine\\n 1.2\\n 1.1\\n TCO2\\n 28\\n 27\\n 27\\n 25\\n 23\\n Glucose\\n 130\\n 113\\n Other labs: PT / PTT / INR:15.4/37.9/1.4\\n Assessment and Plan\\n VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR), ACUTE PAIN, .H/O\\n AORTIC STENOSIS\\n Assessment and Plan: 77yo man s/p AVR-tissue. Hemodynamically\\n stable-extubated\\n Neurologic: Pain controlled, Percocet-prn\\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor\\n Pulmonary: IS, d/c chest tubes\\n Gastrointestinal / Abdomen:\\n Nutrition: Advance diet as tolerated\\n Renal: Foley, start diuretics to get net negative 1-1.5 liters\\n Hematology: stable hct\\n Endocrine: RISS\\n Infectious Disease: no active issues\\n afebrile, normal wbc\\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\\n mediastinal, Pacing wires\\n Wounds: Dry dressings\\n Imaging: CXR today, after chest tube removal\\n Consults: CT surgery\\n ICU Care\\n Nutrition: ADAT\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n CCO PAC - 11:30 AM\\n Arterial Line - 11:30 AM\\n 16 Gauge - 11:30 AM\\n Cordis/Introducer - 12:00 PM\\n Prophylaxis:\\n DVT: (ambulate today)\\n Stress ulcer: H2 blocker\\n VAP bundle: HOB elevation, Mouth care\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2114-05-22 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 674117,\n \"text\": \"Demographics\\n Day of intubation: 2\\n Day of mechanical ventilation: 2\\n Ideal body weight: 78 None\\n Ideal tidal volume: mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location: OR\\n Reason: Elective\\n Tube Type\\n ETT:\\n Position: 23 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 8mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 20 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Comments:\\n Secretions\\n Sputum color / consistency: /\\n Sputum source/amount: / Scant\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Not triggering\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\\n Comments: wean and extubate if indicated on rounds\\n Reason for continuing current ventilatory support: Sedated / Paralyzed\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n Unable to do RSBI as NO Spont resp this morning\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 674527,\n \"text\": \"Arousal, Attention, and Cognition, Impaired\\n Assessment:\\n Pt lethargic most of morning. Napping fairly continuously. Oriented to\\n place, person, year and events of having heart surgery, knows family\\n and is appropriate. Constantly moaning. Medicated for pain x1 this am\\n with good effect.\\n Response:\\n More alert during afternoon. Moaning decreased after pain med.\\n Plan:\\n Plan for rest periods alternating with family visits. Pt to try bipap\\n (Nasal Mask) tonoc. Hold pain meds.\\n Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n OOB to chair, two person assist, tolerated well. Lasix with fair\\n response. Albumen 25% given without incident. Abdoment distented, bowel\\n sounds present. pt. c/o nausea. 12pm BS 112.\\n Action:\\n Reglan given x2. in to evaluate pt. Pt to have KUB.,\\n LFT\\ns.to be drawn.\\n Response:\\n Nausea relieved. Abd still distented.\\n Plan:\\n Lft\\ns. cont to evaluate abd.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Afib with varying v response, occ pvc noted. VSS.\\n Action:\\n Amio bolus given this am, drip started this afternoon.\\n Response:\\n Afib continues.\\n Plan:\\n Cont to monitor.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 674056,\n \"text\": \"77 year old male with worsening DOE, + AS , AVR with fragile aorta\\n .H/O aortic stenosis\\n Assessment:\\n sbp <100, av paced with slow rythym to asystole without perfusion,\\n sedated on propofol, neo @.5mcq, min ct drainage , marginal uop,\\n glucose >120, pt warm and dry. Mvo2 76/svo2 60\\ns, ci>2.0.^ pvcs noted.\\n Hct 35-30.\\n Action:\\n Kept sbp<100 transient neo/ntg, av paced with not 100% sensing\\n /capturing, pads high teens to low 20\\ns, 4 l fluid, fluid changed to\\n ns due to ^ k, propofol ^ to 40 mcq, 1 mg morphine iv. K pending .\\n insulin gtt . 2 gm magnesium up and infusing.\\n Response:\\n Remains av paced however morphology of complex has changed NP \\n aware, + pvc\\ns. neo @ .75 mcq to keep sbp>90, sedated on propofol,\\n marginal uo last 2 hours, insulin gtt remains on.\\n Plan:\\n Monitor comfort, hr and rythym- ekg to be done when rythym\\n returns-monitor vea, sbp\\nkeep sbp<100, ci,svo2,dsgs,ct drainage, pp,\\n resp status-abg pending- to remain Intubated and sedated overnight,\\n neuro status-to remain on propofol, i+o-uo, labs pending. As per\\n orders.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 674721,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n AF with frequent PVC\\ns, rate 80-120\\n Action:\\n Lopress\\n Response:\\n Plan:\\n Posture, Impaired and inability\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiration / Gas Exchange, Impaired\\n Assessment:\\n Patient on Bipap at start of shift. Supposed to wear CPAP at night,\\n but patient wont do it. He states\\nits uncomfortable\\n Sats at 92-94%\\n patient calm and cooperative\\n Action:\\n Off bipap and placed on 4 liters NC, uses IS up to 500, CDB encouraged,\\n calm quiet environment provided, with lots of emotional support,\\n OOB\\nchair\\n Response:\\n Sats around 92-93%, patient must wear CPAP at night\\n Plan:\\n Continue to monitor sats, encourage slow deep breaths and IS\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2114-05-24 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 674722,\n \"text\": \"Patient has been NPO and/or on unsupplemented clear liquid diet for 3\\n days. If patient's diet is not able to be advanced and tolerated,\\n for nutrition support\\n Comments:\\n Patient s/p AVR on , remains in the ICU for pulm monitoring.\\n Patient is slightly confused and lethargic at this time, clear liquid\\n diet order, will f/u re diet advance/tol. If unable to diet adv, will\\n need tube feed/tpn, will f/u re plan of care. Please page if has\\n question.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-21 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 674050,\n \"text\": \"77 year old male with worsening DOE, + AS , AVR with fragile aorta\\n .H/O aortic stenosis\\n Assessment:\\n sbp <100, av paced with slow rythym to asystole without perfusion,\\n sedated on propofol, neo @.5mcq, min ct drainage , marginal uop,\\n glucose >120, pt warm and dry. Mvo2 76/svo2 60\\ns, ci>2.0. pvcs noted.\\n Action:\\n Kept sbp<100 transient neo/ntg, av paced with not 100% sensing\\n /capturing, pads high teens to low 20\\ns, 4 l fluid, fluid changed to\\n ns due to ^ k, propofol ^ to 40 mcq, 1 mg morphine iv. K pending .\\n insulin gtt\\n Response:\\n Remains av paced however morphology of complex has changed NP \\n aware, + pvc\\ns. neo @ .3 mcq to keep sbp>90, sedated on propofol,\\n marginal uo last 2 hours, insulin gtt remains on.\\n Plan:\\n Monitor comfort, hr and rythym- ekg to be done when rythym returns, sbp\\nkeep sbp<100, ci,svo2,dsgs,ct drainage, pp, resp status-abg pending-\\n to remain Intubated and sedated overnight, neuro status-to remain on\\n propofol, i+o-uo, labs pending. As per orders.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-05-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 674724,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n AF with frequent PVC\\ns, rate 80-120\\n Action:\\n Lopressor increased from 25-50mg PO BID, amio stopped early this am due\\n to 10 second pause with no NSR conversion, lytes checked\\n Response:\\n Patient remains in AF, lytes repleted PRN\\n Plan:\\n Continue to monitor VS, HR/rhythm, ectopy continue with lopressor as\\n tolerated\\n Posture, Impaired and inability to perform ADL\\ns independently\\n Assessment:\\n Patient weak and deconditioned, patient lives alone in 2 story home\\n with lots of stairs. Patient looks down and has eyes closed while\\n walking or standing\\n Action:\\n OOB\\nchair and back to bed, with 2-3 nurse assist, moves slow and\\n reaches/leans for things instead of walking towards them\\n Response:\\n With much encouragement able to stand up straight and focus on good\\n posture, but needs much encouragement, reassurance and emotional\\n support\\n Plan:\\n Continue to monitor while up, needs to get PT eval, ?? rehab before\\n home.\\n Respiration / Gas Exchange, Impaired\\n Assessment:\\n Patient on Bipap at start of shift. Supposed to wear CPAP at night,\\n but patient wont do it. He states\\nits uncomfortable\\n Sats at 92-94%\\n patient calm and cooperative\\n Action:\\n Off bipap and placed on 4 liters NC, uses IS up to 500, CDB encouraged,\\n calm quiet environment provided, with lots of emotional support,\\n OOB\\nchair\\n Response:\\n Sats around 92-93%, patient must wear CPAP at night\\n Plan:\\n Continue to monitor sats, encourage slow deep breaths and IS\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2114-05-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 79927,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Intraoperative TEE for aortic valve replacement.\\nHeight: (in) 70\\nWeight (lb): 210\\nBSA (m2): 2.13 m2\\nStatus: Inpatient\\nDate/Time: at 08:56\\nTest: TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\\nand extending into the RV. No ASD by 2D or color Doppler.\\n\\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\\nimages. Severe symmetric LVH. Normal LV cavity size. Normal regional LV\\nsystolic function. Overall normal LVEF (>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Mildly dilated ascending aorta. Mildly dilated descending aorta. Simple\\natheroma in descending aorta.\\n\\nAORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic\\nvalve leaflets. Mild AS (area 1.2-1.9cm2). Trace AR.\\n\\nMITRAL VALVE: Trivial MR.\\n\\nTRICUSPID VALVE: Mild [1+] TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. The patient was under\\ngeneral anesthesia throughout the procedure. No TEE related complications. The\\npatient appears to be in sinus rhythm. Results were personally reviewed with\\nthe MD caring for the patient.\\n\\nConclusions:\\nPRE-BYPASS: No atrial septal defect is seen by 2D or color Doppler. There is\\nsevere symmetric left ventricular hypertrophy. The left ventricular cavity\\nsize is normal. Regional left ventricular wall motion is normal. Overall left\\nventricular systolic function is normal (LVEF>55%). Right ventricular chamber\\nsize and free wall motion are normal. The ascending aorta is mildly dilated.\\nThe descending thoracic aorta is mildly dilated. There are simple atheroma in\\nthe descending thoracic aorta. There are three aortic valve leaflets. The\\naortic valve leaflets are severely thickened/deformed. There is mild aortic\\nvalve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen.\\nTrivial mitral regurgitation is seen. There is no pericardial effusion.\\n\\nPOST-BYPASS: The patient is AV paced. Biventricular function is preserved. The\\naorta is intact. The aortic valve has been replaced with a bioprothesis. The\\nleaflets are moving well. There is no AI. The peak gradient through the valve\\nis approximately 15mmHg. The Swan Ganz catheter is in the proximal right\\npulmonary artery. The remainder of the examination is unchanged.\\n\\nDr. was notified in person of the results in the operating room.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-05-24 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 1078369,\n \"text\": \" 7:21 AM\\n PORTABLE ABDOMEN Clip # \\n Reason: evaluate for ileus\\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old man with s/p avr\\n REASON FOR THIS EXAMINATION:\\n evaluate for ileus\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 77-year-old man status post aortic valve replacement. Evaluate\\n for ileus.\\n\\n COMPARISON: Abdominal radiographs of .\\n\\n PORTABLE SUPINE VIEW OF THE ABDOMEN: The diaphragms have been excluded from\\n view. There is continued air-filled loops of large and small bowel. Multiple\\n linear densities and wires seen overlying the upper abdomen are likely\\n external to the patient. A twisted piece of wire remains overlying the lower\\n abdomen, unchanged.\\n\\n IMPRESSION: Continued ileus, not significantly changed since the prior\\n study.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-05-21 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1077856,\n \"text\": \" 12:18 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: Pleural effusion, pulmonary edema, tamponade, pneumothorax.\\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old man with AVR\\n REASON FOR THIS EXAMINATION:\\n Pleural effusion, pulmonary edema, tamponade, pneumothorax. Pt in OR 2 and will\\n be in CSRU in 90 mins.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of the patient after aortic valve\\n replacement.\\n\\n Portable AP chest radiograph was compared to .\\n\\n The ET tube tip is approximately 6 cm above the carina. The Swan-Ganz\\n catheter tip is at the level of right ventricle outflow tract. The NG tube\\n \\ttip is relatively proximal with the side hole at the level of\\n gastroesophageal junction. Mediastinal drains are in expected position.\\n\\n The widening of the mediastinum is most likely related to recent surgery, but\\n should be closely followed. The left basal opacities consistent with a\\n combination of atelectasis and pleural effusion. Pericardial air is\\n demonstrated related to recent surgery. No pneumothorax has been\\n demonstrated. There is no evidence of failure.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-05-26 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 1078785,\n \"text\": \" 10:48 AM\\n PORTABLE ABDOMEN Clip # \\n Reason: eval for ileus\\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old man s/p AVR\\n REASON FOR THIS EXAMINATION:\\n eval for ileus\\n ______________________________________________________________________________\\n FINAL REPORT\\n ABDOMINAL RADIOGRAPH\\n\\n INDICATION: Ileus.\\n\\n FINDINGS: A nonspecific, nonobstructed bowel gas pattern is visualized, with\\n gas within nondistended loops of small and large bowel. Stomach is mildly\\n distended. Scattered air-fluid levels are present on the decubitus view.\\n There is no evidence of free intraperitoneal air. Atelectasis and effusions\\n at the lung bases are seen to better detail on recent chest radiograph.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-05-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1078015,\n \"text\": \" 9:10 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for ptx\\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old man s/p chest tube removal\\n REASON FOR THIS EXAMINATION:\\n eval for ptx\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Chest tube removal, to evaluate for pneumothorax.\\n\\n FINDINGS: In comparison with the study of , the endotracheal tube,\\n mediastinal _____, and nasogastric tube have been removed. The widening of\\n the mediastinum again is most likely related to the recent surgery. Basilar\\n opacifications, especially at the left, are consistent with a combination of\\n atelectasis and pleural effusion. Some pericardial gas is again seen related\\n to recent surgery. No evidence of pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-05-25 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 1078573,\n \"text\": \" 7:55 AM\\n PORTABLE ABDOMEN Clip # \\n Reason: evaluate dilated loops\\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old man with s/p avr\\n REASON FOR THIS EXAMINATION:\\n evaluate dilated loops\\n ______________________________________________________________________________\\n WET READ: JKSd FRI 10:05 AM\\n Continued loops of airfilled large and small bowel. Air seen in rectum.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 77-year-old man status post aortic valve replacement. Evaluate\\n dilated loops.\\n\\n COMPARISON: Multiple abdominal radiographs, most recent of .\\n\\n UPRIGHT AND SUPINE VIEWS OF THE ABDOMEN: The upright view demonstrates the\\n entire chest, although please note that this is not exposed for proper\\n evaluation of the lung parenchyma. No free air is seen beneath the\\n diaphragms. Bilateral pleural effusions are noted, along with atelectasis at\\n the bases. Midline sternotomy wires remain intact. Air-filled loops of large\\n and small bowel are again seen with air down the level of the rectum. The\\n overall appearance is not significantly changed since the prior study. The\\n left flank has been excluded from view.\\n\\n IMPRESSION: Persistent air-filled loops of large and small bowel, not\\n significantly changed since prior study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-05-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1078368,\n \"text\": \" 7:21 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? infiltrate\\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old man with s/p avr\\n REASON FOR THIS EXAMINATION:\\n ? infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Questionable pneumonia.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, the Swan-Ganz catheter\\n inserted over the left subclavian vein has been completely removed. The\\n introduction sheath, however, is still in place. The size of the cardiac\\n silhouette has not increased, however, a large retrocardiac atelectasis is now\\n visible. There are minimal signs of overhydration. Focal parenchymal\\n opacities suggesting pneumonia have not occurred.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-05-23 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 1078314,\n \"text\": \" 6:33 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: r/o ileus\\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old man with s/p avr\\n REASON FOR THIS EXAMINATION:\\n r/o ileus\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 77-year-old man status post aortic valve replacement. Rule out\\n ileus.\\n\\n COMPARISON: None.\\n\\n SINGLE SUPINE PORTABLE VIEW OF THE ABDOMEN: Multiple prominent air-filled\\n loops of small and large bowel are seen. Air is seen down to the level of the\\n rectum. Surgical clips are noted in the right upper quadrant. A twisted\\n piece of thin wire is noted in the midline of the lower abdomen. Degenerative\\n changes are noted throughout the visualized lumbar spine.\\n\\n IMPRESSION: Generalized prominent air-filled loops of small and large bowel\\n consistent with ileus.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2114-05-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 212431,\n \"text\": \"Atrial fibrillation with rapid ventricular response with ventricular premature\\ncomplex couplet\\nConsider LVH with secondary repolarization abnormality\\nAnterolateral ST-T changes may be due to hypertrophy and/or ischemia\\nSince previous tracing of , atrial fibrillation with rapid ventricular\\nresponse is new\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-05-27 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1078889,\n \"text\": \" 9:18 AM\\n CHEST (PA & LAT) Clip # \\n Reason: f/u effusions/atx\\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old man with s/p avr\\n REASON FOR THIS EXAMINATION:\\n f/u effusions/atx\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of a patient after aortic valve replacement.\\n\\n PA and lateral upright chest radiographs were compared to .\\n\\n The cardiomediastinal silhouette is stable. The left retrocardiac opacity,\\n triangular in shape is most likely a combination of left lower lobe\\n atelectasis and pleural effusion which is small and unchanged since the prior\\n study. The right pleural effusion is also small and unchanged. There is no\\n pneumothorax. There is no evidence of failure.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":24638,"cells":{"subject_id":{"kind":"number","value":50141,"string":"50,141"},"hadm_id":{"kind":"number","value":182345,"string":"182,345"},"target_text":{"kind":"string","value":"43 yo M with PMHx sig. ESRD s/p failed transplant and subsequent nephrectomy in who p/w abdominal pain, found to have pericardial effusion without tamponade physiology. Pericardiocentesis performed and 1200cc fluid removed; drain placed and later removed. Hospital course complicated by thrombus on tip of tunnel cath seen during echo, but subsequently not present on dedicated catheter study. Hospital course also c/b episode of hemoptysis in setting of heparin drip (PTT>150) for suspected thrombus. . # Hemoptysis: This has occured to pt during previous hospitalization. Isolated incident. No findings on CT of the chest. Pulmonary was consulted and felt that suspicion for TB was very low. Etiology most likely related to to supratherapeutic PTT>150 from heparin drip. Pt was sceduled with outpt follow-up in the pulmonary clinic. . # Pericardial effusion: DDx includes uremia VS malignant effusion VS idiopatic. Patient's cultures and acid fast/TB negative. No evidence of malignancy on CT chest/abdomen/pelvis. Cytology of pericardial fluid negative for malignant cells. Repeat echo x2 showing minimal effusion, much decreased s/p drainage. Pericardial drain removed without complications. Pt has appt for f/u ECHO as outpt, and has f/u scheduled with cardiology. . # HD Catheter Thrombus: noted on ECHO . Subsequent dedicated catheter flow study did not detect thrombus. In the interim, pt was anticoagulated, but no indication to anticoagulate at the time of discharge. . # Rhythm - patient had several short runs of NSVT on which were attributed to electrolyte changes post-dialysis. This again occured on post-dialysis. Dialysis bath was altered to include more K and NSVT did not recur. . # Hct drop (28-->20): CT of abdomen showed no evidence of bleed. Guiaic negative. IV iron therapy to be started at dialysis. Source of Hct drop not found. Hemolysis labs negative. Pt received total of 3 units of blood and Hct responded appropriately. Hct was 28.5 at time of discharge. . # Ascites/ Hepatitis: LFTs with mild elevation. This transaminitis may be fleeting and secondary to recent pericardial effusion presentation vs. worsening Hep C. Given increased INR and low albumin, may represent worsening cirrhosis--Pt will f/u in hepatology clinic where he is followed for his Hep C. . # ESRD s/p failed transplant and subsequent nephrectomy in :"},"extractive_notes_summ":{"kind":"string","value":"ESRD s/p failed transplant and subsequent nephrectomy in who p/w abdominal pain, found to have pericardial effusion with tamponade physiology on bedside ECHO. Found to have new onset systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia. Found to have new onset systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia. Found to have new onset systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia. Found to have new onset systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia. Found to have new onset systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia. Abd CT in ED revealing ascites and large pericardial effusion w/ signs of tamponade physiology per ECHO. Abd CT in ED revealing ascites and large pericardial effusion w/ signs of tamponade physiology per ECHO. Abd CT in ED revealing ascites and large pericardial effusion w/ signs of tamponade physiology per ECHO. Abd CT in ED revealing ascites and large pericardial effusion w/ signs of tamponade physiology per ECHO. Abd CT in ED revealing ascites and large pericardial effusion w/ signs of tamponade physiology per ECHO. Plan: Contin titration of meds to maint appropriate systolic bp. SVT: Resolved after IV metoprolol, likely in setting of uremia and electrolyte imbalance -- Continue beta blocker . Pain likely referred from pericardial distention -- Serial abdominal exams . # Hepatitis C: check LFTs . Heart failure (CHF), Systolic, Acute Assessment: LS: diminished at bases. .H/O transplant, kidney (Renal transplant) Assessment: Pt had a Action: Response: Plan: .H/O abdominal pain (including abdominal tenderness) Assessment: Action: Response: Plan: Anxiety Assessment: Action: Response: Plan: Ascites Assessment: Action: Response: Plan: Chest pain Assessment: Action: Response: Plan: Fistula, acquired arteriovenous (AV Fistula) Assessment: Action: Response: Plan: Fever, unknown origin (FUO, Hyperthermia, Pyrexia) Assessment: Action: Response: Plan: Hyperkalemia (high Potassium, Hyperpotassemia) Assessment: Action: Response: Plan: .H/O hypertension, benign Assessment: Pt is on home bp meds Action: Response: Plan: Mild (1+) aortic regurgitation is seen. The right ventricular cavity is mildly dilated with mild globalfree wall hypokinesis. The right ventricularcavity is moderately dilated with mild global free wall hypokinesis. There is a small pericardial effusion.IMPRESSION: Small residual pericardial effusion following needlepericardiocentesis. Mild (1+) aorticregurgitation is seen. There is a mildresting left ventricular outflow tract obstruction. Moderate global left ventricular systolic dysfunction. There is moderatepulmonary artery systolic hypertension. Mild aortic regurgitation. Moderate (2+) mitral regurgitation is seen.Moderate [2+] tricuspid regurgitation is seen. Mild rightventricular systolic dysfunction. Moderate tricuspid regurgitation. Moderate [2+] tricuspid regurgitation is seen. Estimated cardiacindex is normal (>=2.5L/min/m2).RIGHT VENTRICLE: Mildly dilated RV cavity. Mild PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Mild PR.PERICARDIUM: Large pericardial effusion. There are noechocardiographic signs of tamponade.IMPRESSION: Mild global biventricular systolic dysfunction. Moderate global LV hypokinesis.LV WALL MOTION: Regional LV wall motion abnormalities include: basalanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; midinferoseptal - hypo;RIGHT VENTRICLE: Mildly dilated RV cavity. Small to moderatepericardial effusion with stranding located mainly around the lateral andinferior left ventricle without echocardiographic evidence of tamponade.Moderate mitral and tricuspid regurgitation. Mild resting LVOT gradient.RIGHT VENTRICLE: Moderately dilated RV cavity. There is mild symmetric leftventricular hypertrophy. The right atrium is markedly dilated.The right atrial pressure is indeterminate. Normal RV systolic function.Abnormal diastolic septal motion/position consistent with RV volume overload.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Normal aortic valve leaflets (3). Moderate (2+) mitral regurgitationis seen. Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Moderate PA systolic hypertension.PERICARDIUM: Small pericardial effusion.Conclusions:There is mild to moderate global left ventricular hypokinesis (LVEF = 35-40%).The right ventricular cavity is mildly dilated with mild global free wallhypokinesis. Pericarditis.Height: (in) 73Weight (lb): 150BSA (m2): 1.91 m2BP (mm Hg): 130/80HR (bpm): 86Status: InpatientDate/Time: at 01:22Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with 35-50%decrease during respiration (estimated RA pressure (0-10mmHg).LEFT VENTRICLE: Mild symmetric LVH. IMPRESSION: Cardiomegaly with moderate-sized left effusion and probable adjacent compression atelectasis and small right effusion. Moderate-sized left pleural effusion and probable compression atelectasis is noted with a small right effusion noted on the lateral view. Left ventricularhypertrophy with secondary ST-T wave changes. Prolonged QTc interval.Lateral ST-T wave changes which may be related to left ventricular hypertrophy.Compared to the previous tracing of QTc interval prolongation is new.Clinical correlation is suggested. Bilateral compression atelectasis is noted with the remaining aerated lung parenchyma appearing otherwise unremarkable. Compared to the previous tracing of nosignificant change. Moderate-to-large amount of intrapelvic ascites has developed. Marked ST-T wave changes mostprominent in the anterior and anterolateral leads. Cardiac echo recommended. Prolonged Q-T interval. Sinus bradycardia. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Left ventricular hypertrophy. There has been interval development of a moderate to large amount of intra-abdominal ascites. Marked ST-T wave changes most prominently in the anteriorand anterolateral leads. Compared to the previous tracing ventricular ectopyis somewhat less.TRACING #3 Sinus rhythmLeft atrial abnormalityProminent QRS voltages suggests left ventricular hypertrophyDiffuse ST-T wave abnormalitiesProlonged Q-Tc intervalFindings are nonspecific but clinical correlation is suggested for possible inpart drug/metabolic/electrolyte effect, possible ischemia or central nervoussystem eventSince previous tracing of , ST-T wave changes less prominent Probable atrial fibrillation with frequent ventricular ectopy. Findings are as described on the previous tracing of andare without significant change except, that ST-T wave changes appear lessprominent. Ventricular ectopy. mod b/l effusions. Marked ST-T wave changes, particularly in theanterior and anterolateral leads. Interval development of a large amount of intra-abdominal/intrapelvic ascites and moderate-to-large pericardial effusion with CT findings suggesting a component of tamponade. Compared to the previous tracing there is nosignificant change.TRACING #2 Frequent premature atrial contractions. Moderate-sized bilateral pleural effusions. Compared to the previoustracing ventricular ectopy has resolved.TRACING #4 REASON FOR THIS EXAMINATION: S/p pericardiocentesis. decreased size to RLQ collection at ste of prior xplant. TheQTc interval is somewhat shorter.TRACING #1 PFI REPORT Left lower lobe retrocardiac opacity has worsened, likely atelectasis."},"n_notes":{"kind":"number","value":48,"string":"48"},"notes":{"kind":"list like","value":[{"category":"Nursing","chartdate":"2161-10-04 00:00:00.000","description":"Nursing Progress Note","row_id":417523,"text":"Hypertension, benign\n Assessment:\n Known hypertensive. Systolic to 180\n Action:\n Captopril increased to 50mg tid & Metoprolol xl chged to Metoprolol\n 50mg .\n Response:\n Systolic bp running in 140\ns. to receive 1^st dose to captopril 50mg @\n 0600.\n Plan:\n Contin titration of meds to maint appropriate systolic bp.\n Anemia, other\n Assessment:\n Hct trending down w am hct-20.5. wo obvious source. Hemody stable.\n Action:\n Echo done early into shift-sm pericardial effusion wo increase. Hct\n recked-remains 20\ns. fem site-c&d wo ooze/ hematoma. To image w ct in\n am. Tx w 1urbc.\n Response:\n Plan:\n Tx urbc. Reck hct. ?hct goal.\n Chest pain\n Assessment:\n Co cp @ site of pericardial drain insertions. Does not increase w\n respirations. Wo pulsus paradox.\n Action:\n Repositioned & med w oxycodone as ordered.\n Response:\n Gains relief from med, but requesting med q4hrs.\n Plan:\n Contin assess as indicated. Med prn.\n"},{"category":"Physician ","chartdate":"2161-10-02 00:00:00.000","description":"Physician Resident Progress Note","row_id":417169,"text":"Chief Complaint: Patient with episode of narrow complex tachycardia at\n 3:30 am\n -- Given IV Metoprolol 5mg IV x 2 with resolution\n Nausea, given Zofran. Did not tolerate Kayexalate\n Renal team ready to dialize today\n 24 Hour Events:\n Allergies:\n Codeine\n Unknown;\n Dilaudid (Injection) (Hydromorphone Hcl/Pf)\n Lightheadedness\n Ciprofloxacin\n itching;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 73 (73 - 155) bpm\n BP: 136/99(108) {108/76(86) - 144/109(113)} mmHg\n RR: 19 (17 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 60 mL\n Urine:\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n 0 mL\n -60 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 474 K/uL\n 8.0 g/dL\n 131 mg/dL\n 12.1 mg/dL\n 26 mEq/L\n 6.2 mEq/L\n 65 mg/dL\n 93 mEq/L\n 133 mEq/L\n 25.4 %\n 7.1 K/uL\n [image002.jpg]\n 02:24 AM\n WBC\n 7.1\n Hct\n 25.4\n Plt\n 474\n Cr\n 12.1\n Glucose\n 131\n Other labs: PT / PTT / INR:18.7/31.4/1.7, Differential-Neuts:76.0 %,\n Lymph:15.6 %, Mono:6.4 %, Eos:1.5 %, Ca++:9.6 mg/dL, Mg++:2.4 mg/dL,\n PO4:4.7 mg/dL\n Assessment and Plan\n 43 yo M with PMHx sig. ESRD s/p failed transplant and subsequent\n nephrectomy in who p/w abdominal pain, found to have pericardial\n effusion with tamponade physiology on bedside ECHO.\n .\n # Pericardial effusion: Stable overnight, without clinical signs of\n tamponade; no hypotension, pulsus paradoxus or decompensated failure.\n DDx includes uremia, malignant effusion, infectious/tuberculous\n effusion.\n -- Follow pulsus\n -- Plan for cardiac cath in AM per Cardiology\n -- Hold ACE-I\n -- Continue beta blocker per home regimen\n .\n # Abdominal pain: CT scan did not show an infectious process. Pain\n likely referred from pericardial distention\n -- Serial abdominal exams\n .\n # Ascites: Likely secondary to pericardial effusion leading to right\n sided congestion\n -- Continue to monitor\n .\n # Infiltrated IV: Exam is benign. Plastics has evaluated.\n - elevated arm, warm compressess\n - Plastics following, appreciate recs.\n .\n # Systolic CHF: As above, will hold ace inhibitor for now\n -- Monitor volume status, to be controlled by dialysis\n .\n # ESRD / Hyperkalemia: Unable to give Kayexalate given nausea. Patient\n will need electrolyte disorder corrected\n - HD today\n - renally dose meds\n .\n #. SVT: Resolved after IV metoprolol, likely in setting of uremia and\n electrolyte imbalance\n -- Continue beta blocker\n .\n # Hematuria: This has been ongoing since nephrectomy. Followed by Dr.\n in Urology.\n - check U/A, urine culture\n - f/u as outpatient.\n .\n # HTN: Given concern for hemodynamic decompensation, will hold\n antihypertensives with exception of short acting metoprolol\n .\n # Anemia: Previously noted to be iron deficient. Also likely from\n ESRD.\n - cont. iron\n .\n # Depression/Insomnia:\n - cont. home imipramine, citalopram, and clonazepam\n .\n # Hepatitis C: check LFTs\n .\n FEN: no IVFs, electrolyte mgmt per HD, renal diet\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:59 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2161-10-04 00:00:00.000","description":"Nursing Transfer Note","row_id":417596,"text":"43 yo male w/ PMH significant for ESRD s/p failed renal transplant w/\n subsequent nephrectomy who p/w abdominal pain, nausea,\n decreased appetite x 5 days. Felt so poorly that he missed his dialysis\n yesterday. Abd CT in ED revealing ascites and large pericardial\n effusion w/ signs of tamponade physiology per ECHO. Admit to CCU for\n further monitoring w/ K 6.2.\n HPI: Was recently hospitalized in for worsening SOB/ abdominal\n pain with chest pain - admitted to MICU. Found to have new onset\n systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia.\n Course c/b gram positive bacteremia- thought likely from HD line-\n treated w/ 2 week course IV vanco.\n Today, HD completed over 3.5 hrs, removed ml fluid. Bld cxs sent\n x 2 from HD line. To cardiac cath lab 13:00 for RHC/pericardial\n drain- Returned at 17:30 s/p RHC w/ equalization of pressures,\n pericardial tap for 1200ml serous fluid, placement of pericardial\n drain.\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Fistula, acquired arteriovenous (AV Fistula)\n Assessment:\n Action:\n Response:\n Plan:\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2161-10-04 00:00:00.000","description":"Nursing Transfer Note","row_id":417601,"text":"43 yo male w/ PMH significant for ESRD s/p failed renal transplant w/\n subsequent nephrectomy who p/w abdominal pain, nausea,\n decreased appetite x 5 days. Felt so poorly that he missed his dialysis\n yesterday. Abd CT in ED revealing ascites and large pericardial\n effusion w/ signs of tamponade physiology per ECHO. Admit to CCU for\n further monitoring w/ K 6.2.\n HPI: Was recently hospitalized in for worsening SOB/ abdominal\n pain with chest pain - admitted to MICU. Found to have new onset\n systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia.\n Course c/b gram positive bacterrmia- thought likely from HD line-\n treated w/ 2 week course IV vanco.\n HD completed over 3.5 hrs, removed ml fluid. Bld cxs sent x 2\n from HD line. To cardiac cath lab for RHC/pericardial drain-\n Returned at 17:30 s/p RHC w/ equalization of pressures, pericardial tap\n for 1200ml serous fluid, placement of pericardial drain.\n Hypertension, benign\n Assessment:\n Bp >150\n Action:\n BP MEDS\n Response:\n Bp now 120\n Plan:\n Continue to give bp meds and monitor fluid intake note pt\ns fluid\n restrictions.\n Fistula, acquired arteriovenous (AV Fistula)\n Assessment:\n +thrill, +bruit maturing well\n Plan:\n Continue to monitor for +thrill, +bruit\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Pt c/o pain in lower abdomen\n Action:\n Bowel regimen meds pain meds\n Response:\n Pt feels less pain\n Plan:\n Continue with bowel regimen\n Anemia\n Assessment:\n Hct 20\n Action:\n Iunit prbc\n Response:\n Hct increased to 23.4\n Plan:\n Continue to monitor serial hct\n"},{"category":"Nursing","chartdate":"2161-10-04 00:00:00.000","description":"Nursing Transfer Note","row_id":417597,"text":"43 yo male w/ PMH significant for ESRD s/p failed renal transplant w/\n subsequent nephrectomy who p/w abdominal pain, nausea,\n decreased appetite x 5 days. Felt so poorly that he missed his dialysis\n yesterday. Abd CT in ED revealing ascites and large pericardial\n effusion w/ signs of tamponade physiology per ECHO. Admit to CCU for\n further monitoring w/ K 6.2.\n HPI: Was recently hospitalized in for worsening SOB/ abdominal\n pain with chest pain - admitted to MICU. Found to have new onset\n systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia.\n Course c/b gram positive bacteremia- thought likely from HD line-\n treated w/ 2 week course IV vanco.\n Today, HD completed over 3.5 hrs, removed ml fluid. Bld cxs sent\n x 2 from HD line. To cardiac cath lab 13:00 for RHC/pericardial\n drain- Returned at 17:30 s/p RHC w/ equalization of pressures,\n pericardial tap for 1200ml serous fluid, placement of pericardial\n drain.\n Today, HD completed over 3.5 hrs, removed ml fluid. Bld cxs sent\n x 2 from HD line. To cardiac cath lab 13:00 for RHC/pericardial\n drain- Returned at 17:30 s/p RHC w/ equalization of pressures,\n pericardial tap for 1200ml serous fluid, placement of pericardial\n drain.\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Fistula, acquired arteriovenous (AV Fistula)\n Assessment:\n Action:\n Response:\n Plan:\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2161-10-04 00:00:00.000","description":"Nursing Transfer Note","row_id":417646,"text":"43 yo male w/ PMH significant for ESRD s/p failed renal transplant w/\n subsequent nephrectomy who p/w abdominal pain, nausea,\n decreased appetite x 5 days. Felt so poorly that he missed his dialysis\n yesterday. Abd CT in ED revealing ascites and large pericardial\n effusion w/ signs of tamponade physiology per ECHO. Admit to CCU for\n further monitoring w/ K 6.2.\n HPI: Was recently hospitalized in for worsening SOB/ abdominal\n pain with chest pain - admitted to MICU. Found to have new onset\n systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia.\n Course c/b gram positive bacterrmia- thought likely from HD line-\n treated w/ 2 week course IV vanco.\n HD completed over 3.5 hrs, removed ml fluid. Bld cxs sent x 2\n from HD line. To cardiac cath lab for RHC/pericardial drain-\n Returned at 17:30 s/p RHC w/ equalization of pressures, pericardial tap\n for 1200ml serous fluid, placement of pericardial drain.\n Hypertension, benign\n Assessment:\n Bp >150\n Action:\n BP MEDS\n Response:\n Bp now 120\n Plan:\n Continue to give bp meds and monitor fluid intake note pt\ns fluid\n restrictions.\n Fistula, acquired arteriovenous (AV Fistula)\n Assessment:\n +thrill, +bruit maturing well\n Plan:\n Continue to monitor for +thrill, +bruit\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Pt c/o pain in lower abdomen\n Action:\n Bowel regimen meds pain meds\n Response:\n Pt feels less pain\n Plan:\n Continue with bowel regimen\n Anemia\n Assessment:\n Hct 20\n Action:\n Iunit prbc\n Response:\n Hct increased to 23.4\n Plan:\n Continue to monitor serial hct\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n PERICARDIAL EFFUSION\n Code status:\n Full code\n Height:\n 73 Inch\n Admission weight:\n 72.5 kg\n Daily weight:\n Allergies/Reactions:\n Codeine\n Unknown;\n Dilaudid (Injection) (Hydromorphone Hcl/Pf)\n Lightheadedness\n Ciprofloxacin\n itching;\n Precautions: No Additional Precautions\n PMH: Anemia, Hepatitis, Renal Failure\n CV-PMH: Arrhythmias, CAD, CHF, Hypertension\n Additional history: hemodialysis x3 days a week, persistent abdominal\n pain, exertional dyspnea, orthopnea, failed kidney transplant- removed\n , hepatitis C+, congenital single kidney, REM behavior disorder,\n s/p MVA\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:144\n D:84\n Temperature:\n 98.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 11 insp/min\n Heart Rate:\n 62 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Non-rebreather\n O2 saturation:\n 100% %\n O2 flow:\n 100 L/min\n FiO2 set:\n 24h total in:\n 1,239 mL\n 24h total out:\n 0 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 11:05 AM\n Potassium:\n 3.6 mEq/L\n 11:05 AM\n Chloride:\n 96 mEq/L\n 11:05 AM\n CO2:\n 31 mEq/L\n 11:05 AM\n BUN:\n 25 mg/dL\n 11:05 AM\n Creatinine:\n 7.0 mg/dL\n 11:05 AM\n Glucose:\n 153 mg/dL\n 11:05 AM\n Hematocrit:\n 23.4 %\n 11:27 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: ccu\n Transferred to: 3\n Date & time of Transfer: 12:00 AM\n"},{"category":"Nursing","chartdate":"2161-10-04 00:00:00.000","description":"Nursing Transfer Note","row_id":417594,"text":"Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Fistula, acquired arteriovenous (AV Fistula)\n Assessment:\n Action:\n Response:\n Plan:\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2161-10-02 00:00:00.000","description":"Nursing Progress Note","row_id":417136,"text":".H/O transplant, kidney (Renal transplant)\n Assessment:\n Pt had a failed kidney transplant in \n Action:\n Response:\n Pt requiring to start hemodialysis\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Pts abdomen soft distended tender when touched pt guards his stomach\n Action:\n Pt repositioned on side and given pain med\n Response:\n Less painful\n Plan:\n Continue to keep pain free prn oxycodone\n Anxiety\n Assessment:\n It makes me nervouse when I feel the chest pain\n Action:\n Rn explained to pt why he is experiencing chest pain and explained in\n little detail about possible pericardial drain in cath lab in am and pt\n should feel much better\n Response:\n Pt appeared less nervous and wanted to rest\n Plan:\n Emotional support\n Ascites\n Assessment:\n Tender abd, ct showed asites\n Action:\n Pain meds for aching pain per pt repositioning side to side\n Response:\n Pt feels less pain\n Plan:\n Pain meds\n Chest pain\n Assessment:\n Pt c/o chest pain c exertion when he walked from stretcher to bed pain\n lasted 3min approx\n Action:\n Pt rested, ekg obtained\n Response:\n Pt pain went away with rest\n Plan:\n Limit ambulating or exertion\n Right forearm av fistula\n Assessment:\n + thrill\n Action:\n Av fistula appears to be developing well\n Response:\n Plan:\n Continue to monitor av fistula for thrill\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 99.5 oral\n Action:\n Md notified, fan in room\n Response:\n Pt more comfortable cooler\n Plan:\n Continue to monitor temp , keep col and comfortable\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K 6.5 no hemodialysis \n Action:\n Pt is unable to drink kaxalate r/t nausea abd pain\n Response:\n K >6\n Plan:\n Pt will have hemodialysis today\n .H/O hypertension, benign\n Assessment:\n Pt is on home bp meds\n Action:\n Continue with bp meds\n Response:\n Bp stable\n Plan:\n ? hold bp meds if going to hemodialysis today pt is 4kg above his dry\n weight if pt will be dialyzed late after cath lab post pericardial\n drain placement may want to give lopressor in am as scheduled\n"},{"category":"Nursing","chartdate":"2161-10-02 00:00:00.000","description":"Nursing Progress Note","row_id":417138,"text":".43yo male c esrd s/p failed transplant and subsequent nephrectomy in\n . admitted for large pericardial effusion also asites abd pain. Pt\n reports that he hasn\nt eaten in 5 days r/t pain and nausea.\n .H/O transplant, kidney (Renal transplant)\n Assessment:\n Pt had a failed kidney transplant in \n Action:\n Response:\n Pt requiring to start hemodialysis\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Pts abdomen soft distended tender when touched pt guards his stomach\n Action:\n Pt repositioned on side and given pain med\n Response:\n Less painful\n Plan:\n Continue to keep pain free prn oxycodone\n Anxiety\n Assessment:\n It makes me nervouse when I feel the chest pain\n Action:\n Rn explained to pt why he is experiencing chest pain and explained in\n little detail about possible pericardial drain in cath lab in am and pt\n should feel much better\n Response:\n Pt appeared less nervous and wanted to rest\n Plan:\n Emotional support\n Ascites\n Assessment:\n Tender abd, ct showed asites\n Action:\n Pain meds for aching pain per pt repositioning side to side\n Response:\n Pt feels less pain\n Plan:\n Pain meds\n Chest pain\n Assessment:\n Pt c/o chest pain c exertion when he walked from stretcher to bed pain\n lasted 3min approx\n Action:\n Pt rested, ekg obtained\n Response:\n Pt pain went away with rest\n Plan:\n Limit ambulating or exertion\n Right forearm av fistula\n Assessment:\n + thrill\n Action:\n Av fistula appears to be developing well\n Response:\n Plan:\n Continue to monitor av fistula for thrill\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 99.5 oral\n Action:\n Md notified, fan in room\n Response:\n Pt more comfortable cooler\n Plan:\n Continue to monitor temp , keep col and comfortable\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K 6.5 no hemodialysis \n Action:\n Pt is unable to drink kaxalate r/t nausea abd pain\n Response:\n K >6\n Plan:\n Pt will have hemodialysis today\n .H/O hypertension, benign\n Assessment:\n Pt is on home bp meds\n Action:\n Continue with bp meds\n Response:\n Bp stable\n Plan:\n ? hold bp meds if going to hemodialysis today pt is 4kg above his dry\n weight if pt will be dialyzed late after cath lab post pericardial\n drain placement may want to give lopressor in am as scheduled\n"},{"category":"Nursing","chartdate":"2161-10-02 00:00:00.000","description":"Nursing Progress Note","row_id":417139,"text":".43yo male c esrd s/p failed transplant and subsequent nephrectomy in\n . admitted for large pericardial effusion also asites abd pain. Pt\n reports that he hasn\nt eaten in 5 days r/t pain and nausea.\n .H/O transplant, kidney (Renal transplant)\n Assessment:\n Pt had a failed kidney transplant in \n Action:\n Response:\n Pt requiring to start hemodialysis\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Pts abdomen soft distended tender when touched pt guards his stomach\n Action:\n Pt repositioned on side and given pain med\n Response:\n Less painful\n Plan:\n Continue to keep pain free prn oxycodone\n Anxiety\n Assessment:\n It makes me nervouse when I feel the chest pain\n Action:\n Rn explained to pt why he is experiencing chest pain and explained in\n little detail about possible pericardial drain in cath lab in am and pt\n should feel much better\n Response:\n Pt appeared less nervous and wanted to rest\n Plan:\n Emotional support\n Ascites\n Assessment:\n Tender abd, ct showed asites\n Action:\n Pain meds for aching pain per pt repositioning side to side\n Response:\n Pt feels less pain\n Plan:\n Pain meds\n Chest pain\n Assessment:\n Pt c/o chest pain c exertion when he walked from stretcher to bed pain\n lasted 3min approx\n Action:\n Pt rested, ekg obtained\n Response:\n Pt pain went away with rest\n Plan:\n Limit ambulating or exertion\n Right forearm av fistula\n Assessment:\n + thrill\n Action:\n Av fistula appears to be developing well\n Response:\n Plan:\n Continue to monitor av fistula for thrill\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 99.5 oral\n Action:\n Md notified, fan in room\n Response:\n Pt more comfortable cooler\n Plan:\n Continue to monitor temp , keep col and comfortable\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K 6.5 no hemodialysis \n Action:\n Pt is unable to drink kaxalate r/t nausea abd pain\n Response:\n K >6\n Plan:\n Pt will have hemodialysis today\n .H/O hypertension, benign\n Assessment:\n Pt is on home bp meds\n Action:\n Continue with bp meds\n Response:\n Bp stable\n Plan:\n ? hold bp meds if going to hemodialysis today pt is 4kg above his dry\n weight if pt will be dialyzed late after cath lab post pericardial\n drain placement may want to give lopressor in am as scheduled\n"},{"category":"Nursing","chartdate":"2161-10-02 00:00:00.000","description":"Nursing Progress Note","row_id":417140,"text":".43yo male c esrd s/p failed transplant and subsequent nephrectomy in\n . admitted for large pericardial effusion also asites abd pain. Pt\n reports that he hasn\nt eaten in 5 days r/t pain and nausea.\n .H/O transplant, kidney (Renal transplant)\n Assessment:\n Pt had a failed kidney transplant in \n Action:\n Response:\n Pt requiring to start hemodialysis\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Pts abdomen soft distended tender when touched pt guards his stomach\n Action:\n Pt repositioned on side and given pain med\n Response:\n Less painful\n Plan:\n Continue to keep pain free prn oxycodone\n Anxiety\n Assessment:\n It makes me nervouse when I feel the chest pain\n Action:\n Rn explained to pt why he is experiencing chest pain and explained in\n little detail about possible pericardial drain in cath lab in am and pt\n should feel much better\n Response:\n Pt appeared less nervous and wanted to rest\n Plan:\n Emotional support\n Ascites\n Assessment:\n Tender abd, ct showed asites\n Action:\n Pain meds for aching pain per pt repositioning side to side\n Response:\n Pt feels less pain\n Plan:\n Pain meds\n Chest pain\n Assessment:\n Pt c/o chest pain c exertion when he walked from stretcher to bed pain\n lasted 3min approx\n Action:\n Pt rested, ekg obtained\n Response:\n Pt pain went away with rest\n Plan:\n Limit ambulating or exertion\n Right forearm av fistula\n Assessment:\n + thrill\n Action:\n Av fistula appears to be developing well\n Response:\n Plan:\n Continue to monitor av fistula for thrill\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 99.5 oral\n Action:\n Md notified, fan in room\n Response:\n Pt more comfortable cooler\n Plan:\n Continue to monitor temp , keep col and comfortable\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K 6.5 no hemodialysis \n Action:\n Pt is unable to drink kaxalate r/t nausea abd pain\n Response:\n K >6\n Plan:\n Pt will have hemodialysis today\n .H/O hypertension, benign\n Assessment:\n Pt is on home bp meds\n Action:\n Continue with bp meds\n Response:\n Bp stable\n Plan:\n ? hold bp meds if going to hemodialysis today pt is 4kg above his dry\n weight if pt will be dialyzed late after cath lab post pericardial\n drain placement may want to give lopressor in am as scheduled\n"},{"category":"Nursing","chartdate":"2161-10-02 00:00:00.000","description":"Nursing Progress Note","row_id":417141,"text":".43yo male c esrd s/p failed transplant and subsequent nephrectomy in\n . admitted for large pericardial effusion also asites abd pain. Pt\n reports that he hasn\nt eaten in 5 days r/t pain and nausea. Pt had one\n episode of svt hr 160\ns pt responded well to 10mg ivp (5mg x2)\n lopressor to break svt now pt in nsr. Bp remained stable while in svt.\n Pt will be going to cath lab today for pericardial drain then he will\n need hemodialysis.\n .H/O transplant, kidney (Renal transplant)\n Assessment:\n Pt had a failed kidney transplant in \n Action:\n Response:\n Pt requiring to start hemodialysis\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Pts abdomen soft distended tender when touched pt guards his stomach\n Action:\n Pt repositioned on side and given pain med\n Response:\n Less painful\n Plan:\n Continue to keep pain free prn oxycodone\n Anxiety\n Assessment:\n It makes me nervouse when I feel the chest pain\n Action:\n Rn explained to pt why he is experiencing chest pain and explained in\n little detail about possible pericardial drain in cath lab in am and pt\n should feel much better\n Response:\n Pt appeared less nervous and wanted to rest\n Plan:\n Emotional support\n Ascites\n Assessment:\n Tender abd, ct showed asites\n Action:\n Pain meds for aching pain per pt repositioning side to side\n Response:\n Pt feels less pain\n Plan:\n Pain meds\n Chest pain\n Assessment:\n Pt c/o chest pain c exertion when he walked from stretcher to bed pain\n lasted 3min approx\n Action:\n Pt rested, ekg obtained\n Response:\n Pt pain went away with rest\n Plan:\n Limit ambulating or exertion\n Right forearm av fistula\n Assessment:\n + thrill\n Action:\n Av fistula appears to be developing well\n Response:\n Plan:\n Continue to monitor av fistula for thrill\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 99.5 oral\n Action:\n Md notified, fan in room\n Response:\n Pt more comfortable cooler\n Plan:\n Continue to monitor temp , keep col and comfortable\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K 6.5 no hemodialysis \n Action:\n Pt is unable to drink kaxalate r/t nausea abd pain\n Response:\n K >6\n Plan:\n Pt will have hemodialysis today\n .H/O hypertension, benign\n Assessment:\n Pt is on home bp meds\n Action:\n Continue with bp meds\n Response:\n Bp stable\n Plan:\n ? hold bp meds if going to hemodialysis today pt is 4kg above his dry\n weight if pt will be dialyzed late after cath lab post pericardial\n drain placement may want to give lopressor in am as scheduled\n"},{"category":"Nursing","chartdate":"2161-10-02 00:00:00.000","description":"Nursing Progress Note","row_id":417123,"text":".H/O transplant, kidney (Renal transplant)\n Assessment:\n Pt had a\n Action:\n Response:\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n Anxiety\n Assessment:\n Action:\n Response:\n Plan:\n Ascites\n Assessment:\n Action:\n Response:\n Plan:\n Chest pain\n Assessment:\n Action:\n Response:\n Plan:\n Fistula, acquired arteriovenous (AV Fistula)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O hypertension, benign\n Assessment:\n Pt is on home bp meds\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2161-10-02 00:00:00.000","description":"Nursing Progress Note","row_id":417225,"text":"43 yo male w/ PMH significant for ESRD s/p failed renal transplant w/\n subsequent nephrectomy who p/w abdominal pain, nausea,\n decreased appetite x 5 days. Felt so poorly that he missed his dialysis\n yesterday. Abd CT in ED revealing ascites and large pericardial\n effusion w/ signs of tamponade physiology per ECHO. Admit to CCU for\n further monitoring w/ K 6.2.\n HPI: Was recently hospitalized in for worsening SOB/ abdominal\n pain with chest pain - admitted to MICU. Found to have new onset\n systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia.\n Course c/b gram positive bacteremia- thought likely from HD line-\n treated w/ 2 week course IV vanco.\n Today, HD completed over 3.5 hrs, removed_______ml fluid. Bld cxs sent\n x 2 from HD line. To cardiac cath lab for RHC/LHC/pericardial drain.\n Pericardial effusion (without tamponade)\n Assessment:\n c/o substernal chest pain worse w/ inspiration. Hemodynamically stable.\n Pulsus Parodoxus 6.\n Action:\n Oxycodone 5mg for pain. Pericardial drain placement.\n Response:\n Plan:\n Continue to monitor for s/s hemodynamic instability.\n Abdominal pain (including abdominal tenderness)\n Assessment:\n +Ascites per abd CT. Pt describes as\nachiness\n across entire abdomen.\n Severity , worse w/ palpation and reportedly after eating though\n pt NPO today. BS hyperactive. Abd soft, distended.\n Action:\n Medicated as above.\n Response:\n Pt temporarily decreases to tolerable level after po medication.\n Plan:\n Frequent pain assessment.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: diminished at bases. O2 sat down 85-95% 2L NC , 5 pillow orthopnea\n at home per pt report, +ascites per abdominal CT.\n Action:\n O2NC increased as needed- team notified. Team concerned re: etiology\n of new onset HF (worse over past month). LHC to evaluate for coronary\n arteries as source.\n Response:\n SPO2 increased appropriately.\n Plan:\n Will start heart failure medication regimen once stable post cath/\n drain placement.\n Impaired Skin Integrity\n Assessment:\n PIV L AC infiltrated in ED . Site benign, OTA.\n Action:\n Seen by plastics.\n Response:\n Stable site.\n Plan:\n Will continue to closely monitor.\n"},{"category":"Nursing","chartdate":"2161-10-02 00:00:00.000","description":"Nursing Progress Note","row_id":417124,"text":".H/O transplant, kidney (Renal transplant)\n Assessment:\n Pt had a failed kidney transplant in \n Action:\n Response:\n Pt requiring to start hemodialysis\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Pts abdomen soft distended tender when touched pt guards his stomach\n Action:\n Response:\n Plan:\n Anxiety\n Assessment:\n Action:\n Response:\n Plan:\n Ascites\n Assessment:\n Action:\n Response:\n Plan:\n Chest pain\n Assessment:\n Action:\n Response:\n Plan:\n Fistula, acquired arteriovenous (AV Fistula)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O hypertension, benign\n Assessment:\n Pt is on home bp meds\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2161-10-02 00:00:00.000","description":"Nursing Progress Note","row_id":417132,"text":".H/O transplant, kidney (Renal transplant)\n Assessment:\n Pt had a failed kidney transplant in \n Action:\n Response:\n Pt requiring to start hemodialysis\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Pts abdomen soft distended tender when touched pt guards his stomach\n Action:\n Pt repositioned on side and given pain med\n Response:\n Less painful\n Plan:\n Continue to keep pain free prn oxycodone\n Anxiety\n Assessment:\n It makes me nervouse when I feel the chest pain\n Action:\n Rn explained to pt why he is experiencing chest pain and explained in\n little detail about possible pericardial drain in cath lab in am and pt\n should feel much better\n Response:\n Pt appeared less nervous and wanted to rest\n Plan:\n Emotional support\n Ascites\n Assessment:\n Tender abd, ct showed asites\n Action:\n Pain meds for aching pain per pt repositioning side to side\n Response:\n Pt feels less pain\n Plan:\n Pain meds\n Chest pain\n Assessment:\n Pt c/o chest pain c exertion when he walked from stretcher to bed pain\n lasted 3min approx\n Action:\n Pt rested, ekg obtained\n Response:\n Pt pain went away with rest\n Plan:\n Limit ambulating or exertion\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O hypertension, benign\n Assessment:\n Pt is on home bp meds\n Action:\n Response:\n Plan:\n"},{"category":"Social Work","chartdate":"2161-10-02 00:00:00.000","description":"Social Work Admission Note","row_id":417246,"text":"Family Information\n Next of :\n Health Care Proxy appointed: Yes - But NO copy of signed proxy form in\n medical record\n Family Spokesperson designated:\n Communication or visitation restriction:\n Patient Information:\n Previous living situation:\n Previous level of functioning:\n Previous or other hospital admissions:\n Past psychiatric history:\n Past addictions history:\n Employment status:\n Legal involvement:\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment:\n Clergy Contact:\n Communication with Team:\n Plan / Follow up:\n"},{"category":"Nutrition","chartdate":"2161-10-02 00:00:00.000","description":"Clinical Nutrition Note","row_id":417258,"text":"Subjective: pt off floor, unable to interview.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 185 cm\n 72.5 kg\n 21.8\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 83.5 kg\n 82%\n 68.5 est. dry wt.\n 106%\n Diagnosis: Pericardial Effusion\n PMH : ESRD s/p failed renal trx with subsequent nephrectomy c/p\n gram + bactremia, ascites, on HD\n Food allergies and intolerances: NKFA\n Pertinent medications: Colace, Senna, others noted\n Labs:\n Value\n Date\n Glucose\n 131 mg/dL\n 02:24 AM\n BUN\n 65 mg/dL\n 02:24 AM\n Creatinine\n 12.1 mg/dL\n 02:24 AM\n Sodium\n 133 mEq/L\n 02:24 AM\n Potassium\n 6.2 mEq/L\n 02:24 AM\n Chloride\n 93 mEq/L\n 02:24 AM\n TCO2\n 26 mEq/L\n 02:24 AM\n Calcium non-ionized\n 9.6 mg/dL\n 02:24 AM\n Phosphorus\n 4.7 mg/dL\n 02:24 AM\n Magnesium\n 2.4 mg/dL\n 02:24 AM\n WBC\n 7.1 K/uL\n 02:24 AM\n Current diet order / nutrition support: NPO\n GI: distended with ascites\n Assessment of Nutritional Status\n Malnourished\n Pt at risk due to: low % IBW, ESRD on HD, current symptoms, possible\n prolonged NPO\n Estimated Nutritional Needs\n Calories: 2055-2400 (BEE x or / 30-35 cal/kg)\n Protein: 75-89 (1.1-1.3 g/kg)\n Fluid: per team\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 43 y.o. M with ESRD on HD, adm with abd pain, nausea & poor appetite,\n found to have large ascites and pericardial effusion with tamponade\n physiology. Pt is currently off floor at cath lab, thus unable to\n interview. Pt is NPO x2days; if unable to advance diet in the next \n days, recommend considering enteral nutrition. Pt is at high\n nutritional risk due to current medical problems and low admit weight.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Advance diet as able.\n 2) If pt unable to take po\ns in the next 47-72hrs, consider\n enteral nutrition via post pyloric FT. TF goal would be Novasource\n Renal @45cc/hr (2160 kcals, 80g protein).\n 3) Multivitamin / Mineral supplement: Nephrocaps\n Will follow- please page if ?\ns \n"},{"category":"Nursing","chartdate":"2161-10-02 00:00:00.000","description":"Nursing Progress Note","row_id":417313,"text":"43 yo male w/ PMH significant for ESRD s/p failed renal transplant w/\n subsequent nephrectomy who p/w abdominal pain, nausea,\n decreased appetite x 5 days. Felt so poorly that he missed his dialysis\n yesterday. Abd CT in ED revealing ascites and large pericardial\n effusion w/ signs of tamponade physiology per ECHO. Admit to CCU for\n further monitoring w/ K 6.2.\n HPI: Was recently hospitalized in for worsening SOB/ abdominal\n pain with chest pain - admitted to MICU. Found to have new onset\n systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia.\n Course c/b gram positive bacteremia- thought likely from HD line-\n treated w/ 2 week course IV vanco.\n Today, HD completed over 3.5 hrs, removed ml fluid. Bld cxs sent\n x 2 from HD line. To cardiac cath lab 13:00 for RHC/pericardial\n drain- Returned at 17:30 s/p RHC w/ equalization of pressures,\n pericardial tap for 1200ml serous fluid, placement of pericardial\n drain.\n Pericardial effusion (without tamponade)\n Assessment:\n c/o substernal chest pain worse w/ inspiration. Hemodynamically stable.\n Pulsus Parodoxus 6, increased to 16 by 12noon- team aware.\n Action:\n Oxycodone 5mg for pain. Pericardial drain placement, drained 1200ml\n fluid.\n Response:\n Improved hemodynamics.\n Plan:\n Continue to monitor drainage amout and color per hosp policy. Assess\n site frequently. Follow hemodynamics.\n Abdominal pain (including abdominal tenderness)\n Assessment:\n +Ascites per abd CT. Pt describes as\nachiness\n across entire abdomen.\n Severity , worse w/ palpation and reportedly after eating though\n pt NPO today. BS hyperactive. Abd soft, distended.\n Action:\n Medicated as above.\n Response:\n Pain temporarily decreased to tolerable level after po medication.\n Plan:\n Frequent pain assessment. Reassess if current regimen not working.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: diminished at bases. O2 sat down 85-95% 2L NC , 5 pillow orthopnea\n at home per pt report, +ascites per abdominal CT.\n Action:\n O2NC increased as needed- team notified. Team concerned re: etiology\n of new onset HF (worse over past month). LHC to evaluate for coronary\n arteries as source.\n Response:\n SPO2 increased appropriately.\n Plan:\n Will start heart failure medication regimen once stable post cath/\n drain placement. Initial heart failure teaching done w/ pt. Needs\n reinforcement.\n Impaired Skin Integrity\n Assessment:\n PIV L AC infiltrated in ED . Site benign, OTA.\n Action:\n Seen by plastics.\n Response:\n Stable site.\n Plan:\n Will continue to closely monitor.\n"},{"category":"Nursing","chartdate":"2161-10-03 00:00:00.000","description":"Nursing Progress Note","row_id":417461,"text":"? new pericardial effusion\n Assessment:\n Pulsus 6 before pericardial drain removed this afternoon around 1330 pt\n felt chest pain after procedure and received morphine 2mg with good\n relief . Pt then c/o same chest pain he experienced c prior pericardial\n effusion new pulsus was 5 at 1730\n Action:\n Assess for pericardial effusion\n Response:\n Pulsus 5\n Plan:\n Continue to monitor for new pericardial effusion pulsus q 2hrs\n Chest pain\n Assessment:\n Pt experiencing chest pain after completion of hemodialysis pt had many\n pvc then vtach ? torsades, bp >180\n Action:\n Repleat mag 4grams, ekg\n Response:\n Pt feeling better no more chest pain, bp 147/60\n Plan:\n Monitor hemodynamics\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp spiked acutely after c/o hd tx 99.5 pt had chills and shivers\n Action:\n Remove blankets cool cloth to head\n Response:\n Pt felt less shivers felt better\n Plan:\n Monitor temp blood cultures x2 have been sent\n"},{"category":"Nursing","chartdate":"2161-10-03 00:00:00.000","description":"Nursing Progress Note","row_id":417344,"text":"Pericardial effusion (without tamponade)\n Assessment:\n s/p pericardiocentesis for 1.2L of bloody drainage per cath report\n with pt. reporting decrease abdominal pressure. Afeb. VSS.\n Tolerating lopressor po. Pulsus 6\n Action:\n Able to aspirate 70cc at 1800 RN. Attempted aspiration of drain\n q4hr for 0cc each time. Flushed with heparinized saline per protocol.\n Total 150cc in drainage bag.\n Response:\n No c/o pain with aspiration. Site D/I. fluid Is seroussang.\n Plan:\n Plan repeat echo in AM. Cultures pnd. Contin. drain care per protocol\n Abdominal pain (including abdominal tenderness)\n Assessment:\n c/o mild abd pain but stating that it is much improved since pc\n centesis. Abd soft, pos. BS.\n Action:\n Oxycodone 5mg po x2\n Response:\n Pt. states fair relief.\n Plan:\n Monitor abd exam. Oxycodone for pain prn.\n"},{"category":"Nursing","chartdate":"2161-10-03 00:00:00.000","description":"Nursing Progress Note","row_id":417337,"text":"Pericardial effusion (without tamponade)\n Assessment:\n Action:\n Response:\n Plan:\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Echo","chartdate":"2161-10-02 00:00:00.000","description":"Report","row_id":63422,"text":"PATIENT/TEST INFORMATION:\nIndication: S/p pericardial tap of 1200 cc. Assess residual effusion while in cath lab\nHeight: (in) 73\nWeight (lb): 150\nBSA (m2): 1.91 m2\nBP (mm Hg): 148/58\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 16:46\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\n\nLEFT VENTRICLE: Mild-moderate global left ventricular hypokinesis.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nTRICUSPID VALVE: Moderate [2+] TR. Moderate PA systolic hypertension.\n\nPERICARDIUM: Small pericardial effusion.\n\nConclusions:\nThere is mild to moderate global left ventricular hypokinesis (LVEF = 35-40%).\nThe right ventricular cavity is mildly dilated with mild global free wall\nhypokinesis. Moderate [2+] tricuspid regurgitation is seen. There is moderate\npulmonary artery systolic hypertension. There is a small pericardial effusion.\n\nIMPRESSION: Small residual pericardial effusion following needle\npericardiocentesis. Moderate tricuspid regurgitation. Moderate pulmonary\nhypertension.\n\nCompared with the prior study (images reviewed) of , most of the\npericardial fluid has been drained. Ventricular interdependence is no longer\ndemonstrated.\n\n\n"},{"category":"Echo","chartdate":"2161-10-05 00:00:00.000","description":"Report","row_id":63374,"text":"PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion s/p pericardiocentesis.\nHeight: (in) 73\nWeight (lb): 150\nBSA (m2): 1.91 m2\nBP (mm Hg): 136/69\nHR (bpm): 57\nStatus: Inpatient\nDate/Time: at 11:05\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. Normal IVC diameter\n(<2.1cm) with <35% decrease during respiration (estimated RA pressure\nindeterminate).\n\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Normal\nregional LV systolic function. [Intrinsic LV systolic function likely\ndepressed given the severity of valvular regurgitation.] Estimated cardiac\nindex is normal (>=2.5L/min/m2).\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\nAbnormal diastolic septal motion/position consistent with RV volume overload.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild to\nmoderate [+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Small pericardial effusion. Effusion circumferential. No\nechocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Results were personally reviewed with the MD caring for the\npatient. Results were reviewed with the Cardiology Fellow involved with the\npatient's care. Bilateral pleural effusions.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is markedly dilated.\nThe right atrial pressure is indeterminate. Left ventricular wall thicknesses\nare normal. The left ventricular cavity is mildly dilated. Regional left\nventricular wall motion is normal. [Intrinsic left ventricular systolic\nfunction is likely more depressed given the severity of valvular\nregurgitation.] The estimated cardiac index is normal (>=2.5L/min/m2). Right\nventricular chamber size is mildly increased with normal free wall motion.\nThere is abnormal diastolic septal motion/position consistent with right\nventricular volume overload. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are structurally normal.\nThere is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen.\nThere is moderate pulmonary artery systolic hypertension. There is a small\ncircumferential pericardial effusion. There are no echocardiographic signs of\ntamponade.\n\nCompared with the prior study (images reviewed) of , the effusion is\nminimally smaller with slightly improved systolic function.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"},{"category":"Echo","chartdate":"2161-10-03 00:00:00.000","description":"Report","row_id":63375,"text":"PATIENT/TEST INFORMATION:\nIndication: Tamponade.\nHeight: (in) 73\nWeight (lb): 150\nBSA (m2): 1.91 m2\nBP (mm Hg): 136/69\nHR (bpm): 61\nStatus: Inpatient\nDate/Time: at 12:07\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\nA mass/thrombus associated with a catheter/pacing wire in the RA or RV.\n\nLEFT VENTRICLE: Mild global LV hypokinesis. Mild resting LVOT gradient.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV free wall\nhypokinesis. Prominent moderator band/trabeculations are noted in the RV apex.\n\nAORTA: Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Increased\ntransaortic velocity related to increased stroke volume due to AR. Mild to\nmoderate (+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Severe PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. The end-diastolic PR velocity is increased c/w PA diastolic\nhypertension.\n\nPERICARDIUM: Small to moderate pericardial effusion. Stranding is \nwithin the pericardial space c/w organization. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nA very small (0.4 x 0.1 cm) mobile mass/thrombus associated with a\ncatheter/pacing wire is seen in the right atrium and/or right ventricle. There\nis mild global left ventricular hypokinesis (LVEF = 45 %). There is a mild\nresting left ventricular outflow tract obstruction. The right ventricular\ncavity is moderately dilated with mild global free wall hypokinesis. The\naortic valve leaflets (3) are mildly thickened. There is no valvular aortic\nstenosis. The increased transaortic velocity is likely related to increased\nstroke volume due to aortic regurgitation. Mild to moderate (+) aortic\nregurgitation is seen. The mitral valve leaflets are structurally normal.\nThere is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen.\nModerate [2+] tricuspid regurgitation is seen. There is severe pulmonary\nartery systolic hypertension. The end-diastolic pulmonic regurgitation\nvelocity is increased suggesting pulmonary artery diastolic hypertension.\nThere is a small to moderate sized pericardial effusion. Stranding is\n within the pericardial space c/w organization. There are no\nechocardiographic signs of tamponade.\n\nIMPRESSION: Mild global biventricular systolic dysfunction. Small to moderate\npericardial effusion with stranding located mainly around the lateral and\ninferior left ventricle without echocardiographic evidence of tamponade.\nModerate mitral and tricuspid regurgitation. Severe pulmonary hypertension.\nSmall, mobile mass attached to the right atrial catheter.\nCompared with the prior study (images reviewed) of , a small mobile\nmass/thrombus attached to a right atrial catheter is now seen. The pericardial\neffusion is smaller. Left ventricular function appears more vigorous.\nPulmonary hypertension is severe.\n\n\n"},{"category":"Echo","chartdate":"2161-10-02 00:00:00.000","description":"Report","row_id":63376,"text":"PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Pericarditis.\nHeight: (in) 73\nWeight (lb): 150\nBSA (m2): 1.91 m2\nBP (mm Hg): 130/80\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 01:22\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with 35-50%\ndecrease during respiration (estimated RA pressure (0-10mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH. Moderate global LV hypokinesis.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\nanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid\ninferoseptal - hypo;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Mild PR.\n\nPERICARDIUM: Large pericardial effusion. Sgnificant, accentuated respiratory\nvariation in mitral/tricuspid valve inflows, c/w impaired ventricular filling.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\nLeft pleural effusion.\n\nConclusions:\nThe estimated right atrial pressure is 0-10mmHg. There is mild symmetric left\nventricular hypertrophy. There is moderate global left ventricular hypokinesis\n(LVEF = 35%). The right ventricular cavity is mildly dilated with mild global\nfree wall hypokinesis. There are three aortic valve leaflets. The aortic valve\nleaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation\nis seen. There is mild pulmonary artery systolic hypertension. There is a\nlarge circumferential pericardial effusion. There is significant, accentuated\nrespiratory variation in mitral/tricuspid valve inflows, consistent with\nimpaired ventricular filling.\n\nIMPRESSION: Large pericardial effusion with evidence of impaired ventricular\nfilling. Moderate global left ventricular systolic dysfunction. Mild right\nventricular systolic dysfunction. Mild aortic regurgitation. Moderate mitral\nregurgitation. Mild pulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , pericardial\neffusion size is much larger, and there is now evidence of some ventricular\ninterdependence, likely indicating elevated intrapericardial pressure.\n\n\n"},{"category":"Radiology","chartdate":"2161-10-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1037810,"text":" 10:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: S/p pericardiocentesis.\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with pericardial effusion s/p pericardiocentesis.\n REASON FOR THIS EXAMINATION:\n S/p pericardiocentesis.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SAT 2:22 PM\n Left lower lobe retrocardiac opacity has worsened, likely atelectasis. Small\n left pleural effusion is probably unchanged. Enlarged cardiac silhouette is\n minimally decreased in size. Right pleural effusion has increased.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: S/P pericardiocentesis.\n\n Comparison is made with prior study, .\n\n Left lower lobe retrocardiac opacity has worsened, likely atelectasis. Small\n left pleural effusion is unchanged. Small right pleural effusion has\n increased. Enlarged cardiac silhouette minimally decreased in size. Left\n supraclavicular catheter remains in place. No pneumothorax.\n\n\n DR. \n"},{"category":"Radiology","chartdate":"2161-10-04 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1037984,"text":", S. 9:17 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Please evaluate for RP bleed and interval change in ascitic\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with ESRD failed transplant now s/p nephrectomy p/w pericardial\n tamponade now with Hct decrease.\n REASON FOR THIS EXAMINATION:\n Please evaluate for RP bleed and interval change in ascitic fluid.\n CONTRAINDICATIONS for IV CONTRAST:\n ESRD;;esrd\n ______________________________________________________________________________\n PFI REPORT\n No retroperitoneal bleeding, complete resolution of the pericardial effusion,\n and interval increase in bilateral pleural effusion.\n\n"},{"category":"Radiology","chartdate":"2161-10-07 00:00:00.000","description":"CVL INJ/EVAL INCLUDES FLUORO/IMAGES/REPORT","row_id":1038660,"text":" 10:02 AM\n UNILAT SUBCLAV Clip # \n Reason: Pt discussed between IR and renal: need to differentiate bet\n Admitting Diagnosis: PERICARDIAL EFFUSION\n Contrast: OPTIRAY Amt: 60\n ********************************* CPT Codes ********************************\n * CVL INJ/EVAL INCLUDES FLUORO/I *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with mobile mass on end of tunneled catheter.\n REASON FOR THIS EXAMINATION:\n Pt discussed between IR and renal: need to differentiate between fibrin sheath\n and thrombus at end of tunneled catheter.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 43-year-old male with question of thrombus at the end of tunneled\n catheter.\n\n RADIOLOGISTS: Dr. , , and attending radiologist, Dr. , who\n was present and supervised the entire procedure.\n\n PROCEDURE AND FINDINGS: The risks and benefits of the procedure were\n explained to the patient, and informed consent was obtained. A preprocedure\n timeout was performed to identify the patient by name, medical record number,\n date of birth, and the nature of the procedure to be performed. The patient\n was placed supine on the angiographic table.\n\n Scout image demonstrates the tip of a tunneled left internal jugular\n hemodialysis line terminating in the right atrium. Prior to proceeding with a\n flow study, each port of the hemodialysis catheter was successfully aspirated\n and flushed. Next, 30 cc of IV Optiray contrast was injected into each port of\n the catheter which demonstrated no fibrin sheath or significant thrombus.\n Given normally functioning catheter and lack of significant clot or fibrin\n sheath, no intervention was performed. Each port of the hemodialysis catheter\n was flushed and heplocked.\n\n IMPRESSION: Flow study demonstrates no fibrin sheath or significant thrombus\n of existing left-sided tunneled hemodialysis catheter.\n\n\n\n"},{"category":"Radiology","chartdate":"2161-10-04 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1037983,"text":" 9:17 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Please evaluate for RP bleed and interval change in ascitic\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with ESRD failed transplant now s/p nephrectomy p/w pericardial\n tamponade now with Hct decrease.\n REASON FOR THIS EXAMINATION:\n Please evaluate for RP bleed and interval change in ascitic fluid.\n CONTRAINDICATIONS for IV CONTRAST:\n ESRD;;esrd\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FBr SUN 3:31 PM\n No retroperitoneal bleeding, complete resolution of the pericardial effusion,\n and interval increase in bilateral pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 43-year-old man with failed renal transplant and hematocrit drop.\n Please evaluate retroperitoneal bleeding.\n\n TECHNIQUE: Axial MDCT images were acquired from the thoracic inlet to the\n pubic symphysis with no IV contrast administration. No oral contrast was\n used. Multiplanar reformatted images were acquired.\n\n CT OF THE CHEST WITH NO IV CONTRAST: There has been an interval increase in\n the size of moderate right and small left pleural effusions, with worsening\n atelectasis of the lower lobes. There has been interval decrease in the size\n of previously seen large pericardial effusion. Bullous changes of the right\n lung apex. There is a calcified granuloma in the left lung (2: 22). No\n central pathologically enlarged nodes. The distal tip of the left IJ line is\n in the right atrium. There is cardiomegaly.\n\n Noncontrast evaluation of the liver, gallbladder, spleen, and adrenal glands\n is unremarkable. Both kidneys are severely atrophied. Duodenal loops of small\n bowel and large bowel are unremarkable. Moderate degree of simple ascitic\n fluid is noted within the abdomen. No pathologically enlarged nodes.\n\n CT OF THE PELVIS: The rectum, sigmoid colon, urinary bladder, distal ureters,\n prostate, and seminal vesicles are unremarkable. Ascitic fluid in the pelvis.\n No pathologically enlarged pelvic or inguinal nodes. No retroperitoneal\n bleeding is noted. Mild haziness around the right common femoral artery and\n common femoral vein.\n\n BONE WINDOWS: No concerning lytic or sclerotic lesions.\n\n IMPRESSION:\n 1. No retroperitoneal bleed.\n 2. Interval decrease in size of the pericardial effusion, now small.\n 3. Interval increase in bilateral pleural effusions, moderate on the right\n and small on the left, with associated atectasis at the lung bases.\n (Over)\n\n 9:17 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Please evaluate for RP bleed and interval change in ascitic\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2161-10-05 00:00:00.000","description":"CHEST (LAT DECUB ONLY)","row_id":1038273,"text":" 5:13 PM\n CHEST (LAT DECUB ONLY); CHEST (PA & LAT) Clip # \n Reason: question whether effusions are loculated. please compare to\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with pleural effusion, previously with pericardial effusion\n REASON FOR THIS EXAMINATION:\n question whether effusions are loculated. please compare to supine films.\n ______________________________________________________________________________\n WET READ: JXKc MON 9:20 PM\n Moderate bilateral pleural effusions that appear to layer on the lateral\n decubitus views without definite signs to suggest loculation. There is\n associated atelectasis of the adjacent lung. Left subclavian catheter tip\n terminates in the low right atrium, unchanged in position. -jkang\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pleural effusion.\n\n FINDINGS: In comparison with the study of , lateral decubitus view shows\n that there is a small amount of free pleural fluid on the left and a\n substantially larger amount of free pleural fluid on the right. Pulmonary\n vascular congestion persists.\n\n\n"},{"category":"Radiology","chartdate":"2161-10-08 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1038837,"text":" 12:05 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o PNA\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with new onset fever\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON \n\n HISTORY: New onset of fever, rule out pneumonia.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Small bilateral pleural effusions have decreased, moderate enlargement of the\n cardiac silhouette due to cardiomegaly and/or pericardial effusion is\n diminished, interstitial edema is cleared and bibasilar opacification has\n improved. Overall findings are consistent with resolved pulmonary edema.\n Cystic structure at the right lung apex now contains fluid, probably edema\n fluid in a bulla, not concerning for infection. Dual-channel supraclavicular\n left-sided central venous catheter projects over the upper right atrium. No\n complications.\n\n\n"},{"category":"Radiology","chartdate":"2161-10-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1037811,"text":", S. 10:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: S/p pericardiocentesis.\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with pericardial effusion s/p pericardiocentesis.\n REASON FOR THIS EXAMINATION:\n S/p pericardiocentesis.\n ______________________________________________________________________________\n PFI REPORT\n Left lower lobe retrocardiac opacity has worsened, likely atelectasis. Small\n left pleural effusion is probably unchanged. Enlarged cardiac silhouette is\n minimally decreased in size. Right pleural effusion has increased.\n\n\n"},{"category":"Radiology","chartdate":"2161-10-01 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1037449,"text":" 3:00 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for infiltrate, mediastinum\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with shortness of breath\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, mediastinum\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 43-year-old man with shortness of breath.\n\n Comparison is made to CT and chest radiograph.\n\n PA AND LATERAL CHEST RADIOGRAPHS\n\n FINDINGS: The heart remains enlarged and there is prominence to the pulmonary\n arteries bilaterally. Moderate-sized left pleural effusion and probable\n compression atelectasis is noted with a small right effusion noted on the\n lateral view. Left-sided dialysis catheter is stable with its tip in the\n right atrium. No pneumothorax or focal consolidations to suggest pneumonia.\n\n IMPRESSION:\n\n Cardiomegaly with moderate-sized left effusion and probable adjacent\n compression atelectasis and small right effusion.\n\n\n"},{"category":"Radiology","chartdate":"2161-10-01 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":1037467,"text":" 4:48 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: assess for infection/abscess\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with ESRD s/p transplant neprhotomy on now with abd pain\n x 2 weeks\n REASON FOR THIS EXAMINATION:\n assess for infection/abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 8:37 PM\n new large pericardial effusion with ct findings suggesting component of\n tamponade (mass effect on RV). mod b/l effusions. new mod/large amount of\n ascites. decreased size to RLQ collection at ste of prior xplant.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Complicated cardiac and renal history with known cardiac dysfunction\n status post transplant nephrectomy due to failure in with\n recurrent right lower quadrant abdominal pain. No leukocytosis with mild\n elevation of ALT/AST but normal alk phos.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\n pelvis with intravenous and oral contrast. Coronal and sagittal reformations\n were evaluated.\n\n Comparison is made to ultrasound dated and CT dated .\n\n CT OF THE ABDOMEN WITH INTRAVENOUS AND ORAL CONTRAST: There are bilateral\n moderate simple pleural effusions and a new large pericardial effusion which\n displays some tamponade effect on the right ventricle which appears compressed\n in addition to mass effect on the entire heart with abnormal leftward\n deviation/angulation of the intraventricular septum. Bilateral compression\n atelectasis is noted with the remaining aerated lung parenchyma appearing\n otherwise unremarkable. The gallbladder displays some third spacing/wall\n edema but appears otherwise unremarkable as does the liver, spleen, stomach,\n small bowel, pancreas, adrenal glands, and atrophic appearing kidneys. No\n pathologically enlarged abdominal lymph nodes are identified and there is no\n free air. There has been interval development of a moderate to large amount\n of intra-abdominal ascites.\n\n CT OF THE PELVIS WITH INTRAVENOUS AND ORAL CONTRAST: Intrapelvic bowel,\n prostate, and urinary bladder are unremarkable. No significant bowel wall\n edema is identified. Moderate-to-large amount of intrapelvic ascites has\n developed. Previously identified collection within the right lower quadrant\n at site of prior transplant has decreased in size measuring approximately 1.7\n x 2.2 cm, prior 2.6 x 2.8cm with continued mild rim enhancement but no\n internal foci of air.\n\n BONE WINDOWS: No malignant appearing osseous lesions are identified.\n\n IMPRESSION:\n (Over)\n\n 4:48 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: assess for infection/abscess\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Interval development of a large amount of intra-abdominal/intrapelvic\n ascites and moderate-to-large pericardial effusion with CT findings suggesting\n a component of tamponade. Cardiac echo recommended. Moderate-sized bilateral\n pleural effusions.\n\n 2. Continued decrease in size to a small rim enhancing likely post-operative\n collection at site of prior right lower quadrant transplant kidney.\n\n 3. No findings of colitis.\n\n Please note during the examination the patient experienced a IV infiltration\n of intravenous contrast and saline. It is estimated that 70 mL of Optiray\n contrast infiltrated at the patient's IV site. Immediately after exam patient\n displayed no neurological deficits, intact distal pulses and brisk capillary\n refill. Plastics consult was recommended to the ER staff caring for the\n patient.\n\n Above findings were discussed with Dr. shortly after exam acquisition at\n 8:30 p.m.\n\n"},{"category":"ECG","chartdate":"2161-10-08 00:00:00.000","description":"Report","row_id":126592,"text":"Normal sinus rhythm. Prolonged Q-T interval. Low voltage in the standard\nleads. Left ventricular hypertrophy. Non-specific ST-T wave changes in\nleads I, aVL and V2-V6. Compared to the previous tracing of no\nsignificant change. The non-specific T wave changes are similar. The\nQTc interval is somewhat shorter.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2161-10-07 00:00:00.000","description":"Report","row_id":126593,"text":"Sinus rhythm. Findings are as described on the previous tracing of and\nare without significant change except, that ST-T wave changes appear less\nprominent.\n\n"},{"category":"ECG","chartdate":"2161-10-06 00:00:00.000","description":"Report","row_id":126594,"text":"Sinus rhythm\nLeft atrial abnormality\nProminent QRS voltage suggests left ventricular hypertrophy\nDiffuse ST-T wave abnormalities\nProlonged Q-Tc interval\nFindings are nonspecific but clinical correlation is suggested for possible in\npart drug/metabolic/electrolyte effect, possible ischemia or central nervous\nsystem event\nSince previous tracing of the same date, no significant change\n\n"},{"category":"ECG","chartdate":"2161-10-06 00:00:00.000","description":"Report","row_id":126595,"text":"Sinus rhythm\nLeft atrial abnormality\nProminent QRS voltages suggests left ventricular hypertrophy\nDiffuse ST-T wave abnormalities\nProlonged Q-Tc interval\nFindings are nonspecific but clinical correlation is suggested for possible in\npart drug/metabolic/electrolyte effect, possible ischemia or central nervous\nsystem event\nSince previous tracing of , ST-T wave changes less prominent\n\n"},{"category":"ECG","chartdate":"2161-10-01 00:00:00.000","description":"Report","row_id":126603,"text":"Sinus rhythm. The Q-T interval is prolonged. Non-specific ST-T wave\nchanges. Low voltage in the limb leads. Compared to the previous tracing\nthere is no significant change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2161-10-03 00:00:00.000","description":"Report","row_id":126596,"text":"Sinus rhythm. The Q-T interval is prolonged. Marked ST-T wave changes most\nprominent in the anterior and anterolateral leads. Compared to the previous\ntracing ventricular ectopy has resolved.\nTRACING #4\n\n"},{"category":"ECG","chartdate":"2161-10-03 00:00:00.000","description":"Report","row_id":126597,"text":"Sinus rhythm. Ventricular ectopy. The Q-T interval is prolonged\nat 520 milliseconds. Marked ST-T wave changes most prominently in the anterior\nand anterolateral leads. Compared to the previous tracing ventricular ectopy\nis somewhat less.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2161-10-03 00:00:00.000","description":"Report","row_id":126598,"text":"Probable atrial fibrillation with frequent ventricular ectopy. The\nQ-T interval is prolonged. Marked ST-T wave changes, particularly in the\nanterior and anterolateral leads. Compared to the previous tracing ventricular\nectopy is new.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2161-10-03 00:00:00.000","description":"Report","row_id":126599,"text":"Sinus rhythm. The Q-T interval is prolonged at approximately 560 milliseconds.\nMarked ST-T wave changes predominantly in the anterior and anterolateral\nleads. Compared to the previous tracing the Q-T interval is longer and\nST-T wave changes are more diffuse and more severe.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2161-10-02 00:00:00.000","description":"Report","row_id":126600,"text":"Sinus bradycardia. Frequent premature atrial contractions. Left ventricular\nhypertrophy with secondary ST-T wave changes. Prolonged QTc interval.\nLateral ST-T wave changes which may be related to left ventricular hypertrophy.\nCompared to the previous tracing of QTc interval prolongation is new.\nClinical correlation is suggested.\n\n"},{"category":"ECG","chartdate":"2161-10-02 00:00:00.000","description":"Report","row_id":126601,"text":"Sinus rhythm. The Q-T interval is prolonged. Left axis deviation.\nNon-specific ST-T wave changes. Low voltage in the limb leads. Compared to\nthe previous tracing left axis deviation is new.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2161-10-02 00:00:00.000","description":"Report","row_id":126602,"text":"Sinus rhythm. The Q-T interval is prolonged. Non-specific ST-T wave changes.\nLow voltage in the limb leads. Compared to the previous tracing there is no\nsignificant change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2161-10-09 00:00:00.000","description":"Report","row_id":126554,"text":"Compared to tracing #1 the T wave changes are less prominent in leads V2-V5.\nOtherwise, no significant change.\nTRACING #2\n\n"}],"string":"[\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-10-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417523,\n \"text\": \"Hypertension, benign\\n Assessment:\\n Known hypertensive. Systolic to 180\\n Action:\\n Captopril increased to 50mg tid & Metoprolol xl chged to Metoprolol\\n 50mg .\\n Response:\\n Systolic bp running in 140\\ns. to receive 1^st dose to captopril 50mg @\\n 0600.\\n Plan:\\n Contin titration of meds to maint appropriate systolic bp.\\n Anemia, other\\n Assessment:\\n Hct trending down w am hct-20.5. wo obvious source. Hemody stable.\\n Action:\\n Echo done early into shift-sm pericardial effusion wo increase. Hct\\n recked-remains 20\\ns. fem site-c&d wo ooze/ hematoma. To image w ct in\\n am. Tx w 1urbc.\\n Response:\\n Plan:\\n Tx urbc. Reck hct. ?hct goal.\\n Chest pain\\n Assessment:\\n Co cp @ site of pericardial drain insertions. Does not increase w\\n respirations. Wo pulsus paradox.\\n Action:\\n Repositioned & med w oxycodone as ordered.\\n Response:\\n Gains relief from med, but requesting med q4hrs.\\n Plan:\\n Contin assess as indicated. Med prn.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2161-10-02 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 417169,\n \"text\": \"Chief Complaint: Patient with episode of narrow complex tachycardia at\\n 3:30 am\\n -- Given IV Metoprolol 5mg IV x 2 with resolution\\n Nausea, given Zofran. Did not tolerate Kayexalate\\n Renal team ready to dialize today\\n 24 Hour Events:\\n Allergies:\\n Codeine\\n Unknown;\\n Dilaudid (Injection) (Hydromorphone Hcl/Pf)\\n Lightheadedness\\n Ciprofloxacin\\n itching;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:21 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 37.5\\nC (99.5\\n HR: 73 (73 - 155) bpm\\n BP: 136/99(108) {108/76(86) - 144/109(113)} mmHg\\n RR: 19 (17 - 24) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 73 Inch\\n Total In:\\n PO:\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 0 mL\\n 60 mL\\n Urine:\\n NG:\\n 60 mL\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -60 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 96%\\n ABG: ///26/\\n Physical Examination\\n General Appearance: No acute distress, Thin\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition\\n Lymphatic: Cervical WNL\\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 474 K/uL\\n 8.0 g/dL\\n 131 mg/dL\\n 12.1 mg/dL\\n 26 mEq/L\\n 6.2 mEq/L\\n 65 mg/dL\\n 93 mEq/L\\n 133 mEq/L\\n 25.4 %\\n 7.1 K/uL\\n [image002.jpg]\\n 02:24 AM\\n WBC\\n 7.1\\n Hct\\n 25.4\\n Plt\\n 474\\n Cr\\n 12.1\\n Glucose\\n 131\\n Other labs: PT / PTT / INR:18.7/31.4/1.7, Differential-Neuts:76.0 %,\\n Lymph:15.6 %, Mono:6.4 %, Eos:1.5 %, Ca++:9.6 mg/dL, Mg++:2.4 mg/dL,\\n PO4:4.7 mg/dL\\n Assessment and Plan\\n 43 yo M with PMHx sig. ESRD s/p failed transplant and subsequent\\n nephrectomy in who p/w abdominal pain, found to have pericardial\\n effusion with tamponade physiology on bedside ECHO.\\n .\\n # Pericardial effusion: Stable overnight, without clinical signs of\\n tamponade; no hypotension, pulsus paradoxus or decompensated failure.\\n DDx includes uremia, malignant effusion, infectious/tuberculous\\n effusion.\\n -- Follow pulsus\\n -- Plan for cardiac cath in AM per Cardiology\\n -- Hold ACE-I\\n -- Continue beta blocker per home regimen\\n .\\n # Abdominal pain: CT scan did not show an infectious process. Pain\\n likely referred from pericardial distention\\n -- Serial abdominal exams\\n .\\n # Ascites: Likely secondary to pericardial effusion leading to right\\n sided congestion\\n -- Continue to monitor\\n .\\n # Infiltrated IV: Exam is benign. Plastics has evaluated.\\n - elevated arm, warm compressess\\n - Plastics following, appreciate recs.\\n .\\n # Systolic CHF: As above, will hold ace inhibitor for now\\n -- Monitor volume status, to be controlled by dialysis\\n .\\n # ESRD / Hyperkalemia: Unable to give Kayexalate given nausea. Patient\\n will need electrolyte disorder corrected\\n - HD today\\n - renally dose meds\\n .\\n #. SVT: Resolved after IV metoprolol, likely in setting of uremia and\\n electrolyte imbalance\\n -- Continue beta blocker\\n .\\n # Hematuria: This has been ongoing since nephrectomy. Followed by Dr.\\n in Urology.\\n - check U/A, urine culture\\n - f/u as outpatient.\\n .\\n # HTN: Given concern for hemodynamic decompensation, will hold\\n antihypertensives with exception of short acting metoprolol\\n .\\n # Anemia: Previously noted to be iron deficient. Also likely from\\n ESRD.\\n - cont. iron\\n .\\n # Depression/Insomnia:\\n - cont. home imipramine, citalopram, and clonazepam\\n .\\n # Hepatitis C: check LFTs\\n .\\n FEN: no IVFs, electrolyte mgmt per HD, renal diet\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:59 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-10-04 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 417596,\n \"text\": \"43 yo male w/ PMH significant for ESRD s/p failed renal transplant w/\\n subsequent nephrectomy who p/w abdominal pain, nausea,\\n decreased appetite x 5 days. Felt so poorly that he missed his dialysis\\n yesterday. Abd CT in ED revealing ascites and large pericardial\\n effusion w/ signs of tamponade physiology per ECHO. Admit to CCU for\\n further monitoring w/ K 6.2.\\n HPI: Was recently hospitalized in for worsening SOB/ abdominal\\n pain with chest pain - admitted to MICU. Found to have new onset\\n systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia.\\n Course c/b gram positive bacteremia- thought likely from HD line-\\n treated w/ 2 week course IV vanco.\\n Today, HD completed over 3.5 hrs, removed ml fluid. Bld cxs sent\\n x 2 from HD line. To cardiac cath lab 13:00 for RHC/pericardial\\n drain- Returned at 17:30 s/p RHC w/ equalization of pressures,\\n pericardial tap for 1200ml serous fluid, placement of pericardial\\n drain.\\n Hypertension, benign\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Fistula, acquired arteriovenous (AV Fistula)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Abdominal pain (including abdominal tenderness)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Anemia, other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-10-04 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 417601,\n \"text\": \"43 yo male w/ PMH significant for ESRD s/p failed renal transplant w/\\n subsequent nephrectomy who p/w abdominal pain, nausea,\\n decreased appetite x 5 days. Felt so poorly that he missed his dialysis\\n yesterday. Abd CT in ED revealing ascites and large pericardial\\n effusion w/ signs of tamponade physiology per ECHO. Admit to CCU for\\n further monitoring w/ K 6.2.\\n HPI: Was recently hospitalized in for worsening SOB/ abdominal\\n pain with chest pain - admitted to MICU. Found to have new onset\\n systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia.\\n Course c/b gram positive bacterrmia- thought likely from HD line-\\n treated w/ 2 week course IV vanco.\\n HD completed over 3.5 hrs, removed ml fluid. Bld cxs sent x 2\\n from HD line. To cardiac cath lab for RHC/pericardial drain-\\n Returned at 17:30 s/p RHC w/ equalization of pressures, pericardial tap\\n for 1200ml serous fluid, placement of pericardial drain.\\n Hypertension, benign\\n Assessment:\\n Bp >150\\n Action:\\n BP MEDS\\n Response:\\n Bp now 120\\n Plan:\\n Continue to give bp meds and monitor fluid intake note pt\\ns fluid\\n restrictions.\\n Fistula, acquired arteriovenous (AV Fistula)\\n Assessment:\\n +thrill, +bruit maturing well\\n Plan:\\n Continue to monitor for +thrill, +bruit\\n Abdominal pain (including abdominal tenderness)\\n Assessment:\\n Pt c/o pain in lower abdomen\\n Action:\\n Bowel regimen meds pain meds\\n Response:\\n Pt feels less pain\\n Plan:\\n Continue with bowel regimen\\n Anemia\\n Assessment:\\n Hct 20\\n Action:\\n Iunit prbc\\n Response:\\n Hct increased to 23.4\\n Plan:\\n Continue to monitor serial hct\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-10-04 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 417597,\n \"text\": \"43 yo male w/ PMH significant for ESRD s/p failed renal transplant w/\\n subsequent nephrectomy who p/w abdominal pain, nausea,\\n decreased appetite x 5 days. Felt so poorly that he missed his dialysis\\n yesterday. Abd CT in ED revealing ascites and large pericardial\\n effusion w/ signs of tamponade physiology per ECHO. Admit to CCU for\\n further monitoring w/ K 6.2.\\n HPI: Was recently hospitalized in for worsening SOB/ abdominal\\n pain with chest pain - admitted to MICU. Found to have new onset\\n systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia.\\n Course c/b gram positive bacteremia- thought likely from HD line-\\n treated w/ 2 week course IV vanco.\\n Today, HD completed over 3.5 hrs, removed ml fluid. Bld cxs sent\\n x 2 from HD line. To cardiac cath lab 13:00 for RHC/pericardial\\n drain- Returned at 17:30 s/p RHC w/ equalization of pressures,\\n pericardial tap for 1200ml serous fluid, placement of pericardial\\n drain.\\n Today, HD completed over 3.5 hrs, removed ml fluid. Bld cxs sent\\n x 2 from HD line. To cardiac cath lab 13:00 for RHC/pericardial\\n drain- Returned at 17:30 s/p RHC w/ equalization of pressures,\\n pericardial tap for 1200ml serous fluid, placement of pericardial\\n drain.\\n Hypertension, benign\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Fistula, acquired arteriovenous (AV Fistula)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Abdominal pain (including abdominal tenderness)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Anemia, other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-10-04 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 417646,\n \"text\": \"43 yo male w/ PMH significant for ESRD s/p failed renal transplant w/\\n subsequent nephrectomy who p/w abdominal pain, nausea,\\n decreased appetite x 5 days. Felt so poorly that he missed his dialysis\\n yesterday. Abd CT in ED revealing ascites and large pericardial\\n effusion w/ signs of tamponade physiology per ECHO. Admit to CCU for\\n further monitoring w/ K 6.2.\\n HPI: Was recently hospitalized in for worsening SOB/ abdominal\\n pain with chest pain - admitted to MICU. Found to have new onset\\n systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia.\\n Course c/b gram positive bacterrmia- thought likely from HD line-\\n treated w/ 2 week course IV vanco.\\n HD completed over 3.5 hrs, removed ml fluid. Bld cxs sent x 2\\n from HD line. To cardiac cath lab for RHC/pericardial drain-\\n Returned at 17:30 s/p RHC w/ equalization of pressures, pericardial tap\\n for 1200ml serous fluid, placement of pericardial drain.\\n Hypertension, benign\\n Assessment:\\n Bp >150\\n Action:\\n BP MEDS\\n Response:\\n Bp now 120\\n Plan:\\n Continue to give bp meds and monitor fluid intake note pt\\ns fluid\\n restrictions.\\n Fistula, acquired arteriovenous (AV Fistula)\\n Assessment:\\n +thrill, +bruit maturing well\\n Plan:\\n Continue to monitor for +thrill, +bruit\\n Abdominal pain (including abdominal tenderness)\\n Assessment:\\n Pt c/o pain in lower abdomen\\n Action:\\n Bowel regimen meds pain meds\\n Response:\\n Pt feels less pain\\n Plan:\\n Continue with bowel regimen\\n Anemia\\n Assessment:\\n Hct 20\\n Action:\\n Iunit prbc\\n Response:\\n Hct increased to 23.4\\n Plan:\\n Continue to monitor serial hct\\n Demographics\\n Attending MD:\\n S.\\n Admit diagnosis:\\n PERICARDIAL EFFUSION\\n Code status:\\n Full code\\n Height:\\n 73 Inch\\n Admission weight:\\n 72.5 kg\\n Daily weight:\\n Allergies/Reactions:\\n Codeine\\n Unknown;\\n Dilaudid (Injection) (Hydromorphone Hcl/Pf)\\n Lightheadedness\\n Ciprofloxacin\\n itching;\\n Precautions: No Additional Precautions\\n PMH: Anemia, Hepatitis, Renal Failure\\n CV-PMH: Arrhythmias, CAD, CHF, Hypertension\\n Additional history: hemodialysis x3 days a week, persistent abdominal\\n pain, exertional dyspnea, orthopnea, failed kidney transplant- removed\\n , hepatitis C+, congenital single kidney, REM behavior disorder,\\n s/p MVA\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:144\\n D:84\\n Temperature:\\n 98.7\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 11 insp/min\\n Heart Rate:\\n 62 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n Non-rebreather\\n O2 saturation:\\n 100% %\\n O2 flow:\\n 100 L/min\\n FiO2 set:\\n 24h total in:\\n 1,239 mL\\n 24h total out:\\n 0 mL\\n Pertinent Lab Results:\\n Sodium:\\n 135 mEq/L\\n 11:05 AM\\n Potassium:\\n 3.6 mEq/L\\n 11:05 AM\\n Chloride:\\n 96 mEq/L\\n 11:05 AM\\n CO2:\\n 31 mEq/L\\n 11:05 AM\\n BUN:\\n 25 mg/dL\\n 11:05 AM\\n Creatinine:\\n 7.0 mg/dL\\n 11:05 AM\\n Glucose:\\n 153 mg/dL\\n 11:05 AM\\n Hematocrit:\\n 23.4 %\\n 11:27 AM\\n Valuables / Signature\\n Patient valuables:\\n Other valuables:\\n Clothes: Transferred with patient\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: ccu\\n Transferred to: 3\\n Date & time of Transfer: 12:00 AM\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-10-04 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 417594,\n \"text\": \"Hypertension, benign\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Fistula, acquired arteriovenous (AV Fistula)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Abdominal pain (including abdominal tenderness)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Anemia, other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-10-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417136,\n \"text\": \".H/O transplant, kidney (Renal transplant)\\n Assessment:\\n Pt had a failed kidney transplant in \\n Action:\\n Response:\\n Pt requiring to start hemodialysis\\n Plan:\\n .H/O abdominal pain (including abdominal tenderness)\\n Assessment:\\n Pts abdomen soft distended tender when touched pt guards his stomach\\n Action:\\n Pt repositioned on side and given pain med\\n Response:\\n Less painful\\n Plan:\\n Continue to keep pain free prn oxycodone\\n Anxiety\\n Assessment:\\n It makes me nervouse when I feel the chest pain\\n Action:\\n Rn explained to pt why he is experiencing chest pain and explained in\\n little detail about possible pericardial drain in cath lab in am and pt\\n should feel much better\\n Response:\\n Pt appeared less nervous and wanted to rest\\n Plan:\\n Emotional support\\n Ascites\\n Assessment:\\n Tender abd, ct showed asites\\n Action:\\n Pain meds for aching pain per pt repositioning side to side\\n Response:\\n Pt feels less pain\\n Plan:\\n Pain meds\\n Chest pain\\n Assessment:\\n Pt c/o chest pain c exertion when he walked from stretcher to bed pain\\n lasted 3min approx\\n Action:\\n Pt rested, ekg obtained\\n Response:\\n Pt pain went away with rest\\n Plan:\\n Limit ambulating or exertion\\n Right forearm av fistula\\n Assessment:\\n + thrill\\n Action:\\n Av fistula appears to be developing well\\n Response:\\n Plan:\\n Continue to monitor av fistula for thrill\\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\\n Assessment:\\n Temp 99.5 oral\\n Action:\\n Md notified, fan in room\\n Response:\\n Pt more comfortable cooler\\n Plan:\\n Continue to monitor temp , keep col and comfortable\\n Hyperkalemia (high Potassium, Hyperpotassemia)\\n Assessment:\\n K 6.5 no hemodialysis \\n Action:\\n Pt is unable to drink kaxalate r/t nausea abd pain\\n Response:\\n K >6\\n Plan:\\n Pt will have hemodialysis today\\n .H/O hypertension, benign\\n Assessment:\\n Pt is on home bp meds\\n Action:\\n Continue with bp meds\\n Response:\\n Bp stable\\n Plan:\\n ? hold bp meds if going to hemodialysis today pt is 4kg above his dry\\n weight if pt will be dialyzed late after cath lab post pericardial\\n drain placement may want to give lopressor in am as scheduled\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-10-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417138,\n \"text\": \".43yo male c esrd s/p failed transplant and subsequent nephrectomy in\\n . admitted for large pericardial effusion also asites abd pain. Pt\\n reports that he hasn\\nt eaten in 5 days r/t pain and nausea.\\n .H/O transplant, kidney (Renal transplant)\\n Assessment:\\n Pt had a failed kidney transplant in \\n Action:\\n Response:\\n Pt requiring to start hemodialysis\\n Plan:\\n .H/O abdominal pain (including abdominal tenderness)\\n Assessment:\\n Pts abdomen soft distended tender when touched pt guards his stomach\\n Action:\\n Pt repositioned on side and given pain med\\n Response:\\n Less painful\\n Plan:\\n Continue to keep pain free prn oxycodone\\n Anxiety\\n Assessment:\\n It makes me nervouse when I feel the chest pain\\n Action:\\n Rn explained to pt why he is experiencing chest pain and explained in\\n little detail about possible pericardial drain in cath lab in am and pt\\n should feel much better\\n Response:\\n Pt appeared less nervous and wanted to rest\\n Plan:\\n Emotional support\\n Ascites\\n Assessment:\\n Tender abd, ct showed asites\\n Action:\\n Pain meds for aching pain per pt repositioning side to side\\n Response:\\n Pt feels less pain\\n Plan:\\n Pain meds\\n Chest pain\\n Assessment:\\n Pt c/o chest pain c exertion when he walked from stretcher to bed pain\\n lasted 3min approx\\n Action:\\n Pt rested, ekg obtained\\n Response:\\n Pt pain went away with rest\\n Plan:\\n Limit ambulating or exertion\\n Right forearm av fistula\\n Assessment:\\n + thrill\\n Action:\\n Av fistula appears to be developing well\\n Response:\\n Plan:\\n Continue to monitor av fistula for thrill\\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\\n Assessment:\\n Temp 99.5 oral\\n Action:\\n Md notified, fan in room\\n Response:\\n Pt more comfortable cooler\\n Plan:\\n Continue to monitor temp , keep col and comfortable\\n Hyperkalemia (high Potassium, Hyperpotassemia)\\n Assessment:\\n K 6.5 no hemodialysis \\n Action:\\n Pt is unable to drink kaxalate r/t nausea abd pain\\n Response:\\n K >6\\n Plan:\\n Pt will have hemodialysis today\\n .H/O hypertension, benign\\n Assessment:\\n Pt is on home bp meds\\n Action:\\n Continue with bp meds\\n Response:\\n Bp stable\\n Plan:\\n ? hold bp meds if going to hemodialysis today pt is 4kg above his dry\\n weight if pt will be dialyzed late after cath lab post pericardial\\n drain placement may want to give lopressor in am as scheduled\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-10-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417139,\n \"text\": \".43yo male c esrd s/p failed transplant and subsequent nephrectomy in\\n . admitted for large pericardial effusion also asites abd pain. Pt\\n reports that he hasn\\nt eaten in 5 days r/t pain and nausea.\\n .H/O transplant, kidney (Renal transplant)\\n Assessment:\\n Pt had a failed kidney transplant in \\n Action:\\n Response:\\n Pt requiring to start hemodialysis\\n Plan:\\n .H/O abdominal pain (including abdominal tenderness)\\n Assessment:\\n Pts abdomen soft distended tender when touched pt guards his stomach\\n Action:\\n Pt repositioned on side and given pain med\\n Response:\\n Less painful\\n Plan:\\n Continue to keep pain free prn oxycodone\\n Anxiety\\n Assessment:\\n It makes me nervouse when I feel the chest pain\\n Action:\\n Rn explained to pt why he is experiencing chest pain and explained in\\n little detail about possible pericardial drain in cath lab in am and pt\\n should feel much better\\n Response:\\n Pt appeared less nervous and wanted to rest\\n Plan:\\n Emotional support\\n Ascites\\n Assessment:\\n Tender abd, ct showed asites\\n Action:\\n Pain meds for aching pain per pt repositioning side to side\\n Response:\\n Pt feels less pain\\n Plan:\\n Pain meds\\n Chest pain\\n Assessment:\\n Pt c/o chest pain c exertion when he walked from stretcher to bed pain\\n lasted 3min approx\\n Action:\\n Pt rested, ekg obtained\\n Response:\\n Pt pain went away with rest\\n Plan:\\n Limit ambulating or exertion\\n Right forearm av fistula\\n Assessment:\\n + thrill\\n Action:\\n Av fistula appears to be developing well\\n Response:\\n Plan:\\n Continue to monitor av fistula for thrill\\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\\n Assessment:\\n Temp 99.5 oral\\n Action:\\n Md notified, fan in room\\n Response:\\n Pt more comfortable cooler\\n Plan:\\n Continue to monitor temp , keep col and comfortable\\n Hyperkalemia (high Potassium, Hyperpotassemia)\\n Assessment:\\n K 6.5 no hemodialysis \\n Action:\\n Pt is unable to drink kaxalate r/t nausea abd pain\\n Response:\\n K >6\\n Plan:\\n Pt will have hemodialysis today\\n .H/O hypertension, benign\\n Assessment:\\n Pt is on home bp meds\\n Action:\\n Continue with bp meds\\n Response:\\n Bp stable\\n Plan:\\n ? hold bp meds if going to hemodialysis today pt is 4kg above his dry\\n weight if pt will be dialyzed late after cath lab post pericardial\\n drain placement may want to give lopressor in am as scheduled\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-10-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417140,\n \"text\": \".43yo male c esrd s/p failed transplant and subsequent nephrectomy in\\n . admitted for large pericardial effusion also asites abd pain. Pt\\n reports that he hasn\\nt eaten in 5 days r/t pain and nausea.\\n .H/O transplant, kidney (Renal transplant)\\n Assessment:\\n Pt had a failed kidney transplant in \\n Action:\\n Response:\\n Pt requiring to start hemodialysis\\n Plan:\\n .H/O abdominal pain (including abdominal tenderness)\\n Assessment:\\n Pts abdomen soft distended tender when touched pt guards his stomach\\n Action:\\n Pt repositioned on side and given pain med\\n Response:\\n Less painful\\n Plan:\\n Continue to keep pain free prn oxycodone\\n Anxiety\\n Assessment:\\n It makes me nervouse when I feel the chest pain\\n Action:\\n Rn explained to pt why he is experiencing chest pain and explained in\\n little detail about possible pericardial drain in cath lab in am and pt\\n should feel much better\\n Response:\\n Pt appeared less nervous and wanted to rest\\n Plan:\\n Emotional support\\n Ascites\\n Assessment:\\n Tender abd, ct showed asites\\n Action:\\n Pain meds for aching pain per pt repositioning side to side\\n Response:\\n Pt feels less pain\\n Plan:\\n Pain meds\\n Chest pain\\n Assessment:\\n Pt c/o chest pain c exertion when he walked from stretcher to bed pain\\n lasted 3min approx\\n Action:\\n Pt rested, ekg obtained\\n Response:\\n Pt pain went away with rest\\n Plan:\\n Limit ambulating or exertion\\n Right forearm av fistula\\n Assessment:\\n + thrill\\n Action:\\n Av fistula appears to be developing well\\n Response:\\n Plan:\\n Continue to monitor av fistula for thrill\\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\\n Assessment:\\n Temp 99.5 oral\\n Action:\\n Md notified, fan in room\\n Response:\\n Pt more comfortable cooler\\n Plan:\\n Continue to monitor temp , keep col and comfortable\\n Hyperkalemia (high Potassium, Hyperpotassemia)\\n Assessment:\\n K 6.5 no hemodialysis \\n Action:\\n Pt is unable to drink kaxalate r/t nausea abd pain\\n Response:\\n K >6\\n Plan:\\n Pt will have hemodialysis today\\n .H/O hypertension, benign\\n Assessment:\\n Pt is on home bp meds\\n Action:\\n Continue with bp meds\\n Response:\\n Bp stable\\n Plan:\\n ? hold bp meds if going to hemodialysis today pt is 4kg above his dry\\n weight if pt will be dialyzed late after cath lab post pericardial\\n drain placement may want to give lopressor in am as scheduled\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-10-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417141,\n \"text\": \".43yo male c esrd s/p failed transplant and subsequent nephrectomy in\\n . admitted for large pericardial effusion also asites abd pain. Pt\\n reports that he hasn\\nt eaten in 5 days r/t pain and nausea. Pt had one\\n episode of svt hr 160\\ns pt responded well to 10mg ivp (5mg x2)\\n lopressor to break svt now pt in nsr. Bp remained stable while in svt.\\n Pt will be going to cath lab today for pericardial drain then he will\\n need hemodialysis.\\n .H/O transplant, kidney (Renal transplant)\\n Assessment:\\n Pt had a failed kidney transplant in \\n Action:\\n Response:\\n Pt requiring to start hemodialysis\\n Plan:\\n .H/O abdominal pain (including abdominal tenderness)\\n Assessment:\\n Pts abdomen soft distended tender when touched pt guards his stomach\\n Action:\\n Pt repositioned on side and given pain med\\n Response:\\n Less painful\\n Plan:\\n Continue to keep pain free prn oxycodone\\n Anxiety\\n Assessment:\\n It makes me nervouse when I feel the chest pain\\n Action:\\n Rn explained to pt why he is experiencing chest pain and explained in\\n little detail about possible pericardial drain in cath lab in am and pt\\n should feel much better\\n Response:\\n Pt appeared less nervous and wanted to rest\\n Plan:\\n Emotional support\\n Ascites\\n Assessment:\\n Tender abd, ct showed asites\\n Action:\\n Pain meds for aching pain per pt repositioning side to side\\n Response:\\n Pt feels less pain\\n Plan:\\n Pain meds\\n Chest pain\\n Assessment:\\n Pt c/o chest pain c exertion when he walked from stretcher to bed pain\\n lasted 3min approx\\n Action:\\n Pt rested, ekg obtained\\n Response:\\n Pt pain went away with rest\\n Plan:\\n Limit ambulating or exertion\\n Right forearm av fistula\\n Assessment:\\n + thrill\\n Action:\\n Av fistula appears to be developing well\\n Response:\\n Plan:\\n Continue to monitor av fistula for thrill\\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\\n Assessment:\\n Temp 99.5 oral\\n Action:\\n Md notified, fan in room\\n Response:\\n Pt more comfortable cooler\\n Plan:\\n Continue to monitor temp , keep col and comfortable\\n Hyperkalemia (high Potassium, Hyperpotassemia)\\n Assessment:\\n K 6.5 no hemodialysis \\n Action:\\n Pt is unable to drink kaxalate r/t nausea abd pain\\n Response:\\n K >6\\n Plan:\\n Pt will have hemodialysis today\\n .H/O hypertension, benign\\n Assessment:\\n Pt is on home bp meds\\n Action:\\n Continue with bp meds\\n Response:\\n Bp stable\\n Plan:\\n ? hold bp meds if going to hemodialysis today pt is 4kg above his dry\\n weight if pt will be dialyzed late after cath lab post pericardial\\n drain placement may want to give lopressor in am as scheduled\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-10-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417123,\n \"text\": \".H/O transplant, kidney (Renal transplant)\\n Assessment:\\n Pt had a\\n Action:\\n Response:\\n Plan:\\n .H/O abdominal pain (including abdominal tenderness)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Anxiety\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Ascites\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Chest pain\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Fistula, acquired arteriovenous (AV Fistula)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hyperkalemia (high Potassium, Hyperpotassemia)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O hypertension, benign\\n Assessment:\\n Pt is on home bp meds\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-10-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417225,\n \"text\": \"43 yo male w/ PMH significant for ESRD s/p failed renal transplant w/\\n subsequent nephrectomy who p/w abdominal pain, nausea,\\n decreased appetite x 5 days. Felt so poorly that he missed his dialysis\\n yesterday. Abd CT in ED revealing ascites and large pericardial\\n effusion w/ signs of tamponade physiology per ECHO. Admit to CCU for\\n further monitoring w/ K 6.2.\\n HPI: Was recently hospitalized in for worsening SOB/ abdominal\\n pain with chest pain - admitted to MICU. Found to have new onset\\n systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia.\\n Course c/b gram positive bacteremia- thought likely from HD line-\\n treated w/ 2 week course IV vanco.\\n Today, HD completed over 3.5 hrs, removed_______ml fluid. Bld cxs sent\\n x 2 from HD line. To cardiac cath lab for RHC/LHC/pericardial drain.\\n Pericardial effusion (without tamponade)\\n Assessment:\\n c/o substernal chest pain worse w/ inspiration. Hemodynamically stable.\\n Pulsus Parodoxus 6.\\n Action:\\n Oxycodone 5mg for pain. Pericardial drain placement.\\n Response:\\n Plan:\\n Continue to monitor for s/s hemodynamic instability.\\n Abdominal pain (including abdominal tenderness)\\n Assessment:\\n +Ascites per abd CT. Pt describes as\\nachiness\\n across entire abdomen.\\n Severity , worse w/ palpation and reportedly after eating though\\n pt NPO today. BS hyperactive. Abd soft, distended.\\n Action:\\n Medicated as above.\\n Response:\\n Pt temporarily decreases to tolerable level after po medication.\\n Plan:\\n Frequent pain assessment.\\n Heart failure (CHF), Systolic, Acute\\n Assessment:\\n LS: diminished at bases. O2 sat down 85-95% 2L NC , 5 pillow orthopnea\\n at home per pt report, +ascites per abdominal CT.\\n Action:\\n O2NC increased as needed- team notified. Team concerned re: etiology\\n of new onset HF (worse over past month). LHC to evaluate for coronary\\n arteries as source.\\n Response:\\n SPO2 increased appropriately.\\n Plan:\\n Will start heart failure medication regimen once stable post cath/\\n drain placement.\\n Impaired Skin Integrity\\n Assessment:\\n PIV L AC infiltrated in ED . Site benign, OTA.\\n Action:\\n Seen by plastics.\\n Response:\\n Stable site.\\n Plan:\\n Will continue to closely monitor.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-10-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417124,\n \"text\": \".H/O transplant, kidney (Renal transplant)\\n Assessment:\\n Pt had a failed kidney transplant in \\n Action:\\n Response:\\n Pt requiring to start hemodialysis\\n Plan:\\n .H/O abdominal pain (including abdominal tenderness)\\n Assessment:\\n Pts abdomen soft distended tender when touched pt guards his stomach\\n Action:\\n Response:\\n Plan:\\n Anxiety\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Ascites\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Chest pain\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Fistula, acquired arteriovenous (AV Fistula)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hyperkalemia (high Potassium, Hyperpotassemia)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O hypertension, benign\\n Assessment:\\n Pt is on home bp meds\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-10-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417132,\n \"text\": \".H/O transplant, kidney (Renal transplant)\\n Assessment:\\n Pt had a failed kidney transplant in \\n Action:\\n Response:\\n Pt requiring to start hemodialysis\\n Plan:\\n .H/O abdominal pain (including abdominal tenderness)\\n Assessment:\\n Pts abdomen soft distended tender when touched pt guards his stomach\\n Action:\\n Pt repositioned on side and given pain med\\n Response:\\n Less painful\\n Plan:\\n Continue to keep pain free prn oxycodone\\n Anxiety\\n Assessment:\\n It makes me nervouse when I feel the chest pain\\n Action:\\n Rn explained to pt why he is experiencing chest pain and explained in\\n little detail about possible pericardial drain in cath lab in am and pt\\n should feel much better\\n Response:\\n Pt appeared less nervous and wanted to rest\\n Plan:\\n Emotional support\\n Ascites\\n Assessment:\\n Tender abd, ct showed asites\\n Action:\\n Pain meds for aching pain per pt repositioning side to side\\n Response:\\n Pt feels less pain\\n Plan:\\n Pain meds\\n Chest pain\\n Assessment:\\n Pt c/o chest pain c exertion when he walked from stretcher to bed pain\\n lasted 3min approx\\n Action:\\n Pt rested, ekg obtained\\n Response:\\n Pt pain went away with rest\\n Plan:\\n Limit ambulating or exertion\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hyperkalemia (high Potassium, Hyperpotassemia)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O hypertension, benign\\n Assessment:\\n Pt is on home bp meds\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Social Work\",\n \"chartdate\": \"2161-10-02 00:00:00.000\",\n \"description\": \"Social Work Admission Note\",\n \"row_id\": 417246,\n \"text\": \"Family Information\\n Next of :\\n Health Care Proxy appointed: Yes - But NO copy of signed proxy form in\\n medical record\\n Family Spokesperson designated:\\n Communication or visitation restriction:\\n Patient Information:\\n Previous living situation:\\n Previous level of functioning:\\n Previous or other hospital admissions:\\n Past psychiatric history:\\n Past addictions history:\\n Employment status:\\n Legal involvement:\\n Mandated Reporting Information:\\n Additional Information:\\n Patient / Family Assessment:\\n Clergy Contact:\\n Communication with Team:\\n Plan / Follow up:\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2161-10-02 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 417258,\n \"text\": \"Subjective: pt off floor, unable to interview.\\n Objective\\n Height\\n Admit weight\\n Daily weight\\n Weight change\\n BMI\\n 185 cm\\n 72.5 kg\\n 21.8\\n Ideal body weight\\n % Ideal body weight\\n Adjusted weight\\n Usual body weight\\n % Usual body weight\\n 83.5 kg\\n 82%\\n 68.5 est. dry wt.\\n 106%\\n Diagnosis: Pericardial Effusion\\n PMH : ESRD s/p failed renal trx with subsequent nephrectomy c/p\\n gram + bactremia, ascites, on HD\\n Food allergies and intolerances: NKFA\\n Pertinent medications: Colace, Senna, others noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 131 mg/dL\\n 02:24 AM\\n BUN\\n 65 mg/dL\\n 02:24 AM\\n Creatinine\\n 12.1 mg/dL\\n 02:24 AM\\n Sodium\\n 133 mEq/L\\n 02:24 AM\\n Potassium\\n 6.2 mEq/L\\n 02:24 AM\\n Chloride\\n 93 mEq/L\\n 02:24 AM\\n TCO2\\n 26 mEq/L\\n 02:24 AM\\n Calcium non-ionized\\n 9.6 mg/dL\\n 02:24 AM\\n Phosphorus\\n 4.7 mg/dL\\n 02:24 AM\\n Magnesium\\n 2.4 mg/dL\\n 02:24 AM\\n WBC\\n 7.1 K/uL\\n 02:24 AM\\n Current diet order / nutrition support: NPO\\n GI: distended with ascites\\n Assessment of Nutritional Status\\n Malnourished\\n Pt at risk due to: low % IBW, ESRD on HD, current symptoms, possible\\n prolonged NPO\\n Estimated Nutritional Needs\\n Calories: 2055-2400 (BEE x or / 30-35 cal/kg)\\n Protein: 75-89 (1.1-1.3 g/kg)\\n Fluid: per team\\n Estimation of previous intake: Inadequate\\n Estimation of current intake: Inadequate\\n Specifics:\\n 43 y.o. M with ESRD on HD, adm with abd pain, nausea & poor appetite,\\n found to have large ascites and pericardial effusion with tamponade\\n physiology. Pt is currently off floor at cath lab, thus unable to\\n interview. Pt is NPO x2days; if unable to advance diet in the next \\n days, recommend considering enteral nutrition. Pt is at high\\n nutritional risk due to current medical problems and low admit weight.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n 1) Advance diet as able.\\n 2) If pt unable to take po\\ns in the next 47-72hrs, consider\\n enteral nutrition via post pyloric FT. TF goal would be Novasource\\n Renal @45cc/hr (2160 kcals, 80g protein).\\n 3) Multivitamin / Mineral supplement: Nephrocaps\\n Will follow- please page if ?\\ns \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-10-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417313,\n \"text\": \"43 yo male w/ PMH significant for ESRD s/p failed renal transplant w/\\n subsequent nephrectomy who p/w abdominal pain, nausea,\\n decreased appetite x 5 days. Felt so poorly that he missed his dialysis\\n yesterday. Abd CT in ED revealing ascites and large pericardial\\n effusion w/ signs of tamponade physiology per ECHO. Admit to CCU for\\n further monitoring w/ K 6.2.\\n HPI: Was recently hospitalized in for worsening SOB/ abdominal\\n pain with chest pain - admitted to MICU. Found to have new onset\\n systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia.\\n Course c/b gram positive bacteremia- thought likely from HD line-\\n treated w/ 2 week course IV vanco.\\n Today, HD completed over 3.5 hrs, removed ml fluid. Bld cxs sent\\n x 2 from HD line. To cardiac cath lab 13:00 for RHC/pericardial\\n drain- Returned at 17:30 s/p RHC w/ equalization of pressures,\\n pericardial tap for 1200ml serous fluid, placement of pericardial\\n drain.\\n Pericardial effusion (without tamponade)\\n Assessment:\\n c/o substernal chest pain worse w/ inspiration. Hemodynamically stable.\\n Pulsus Parodoxus 6, increased to 16 by 12noon- team aware.\\n Action:\\n Oxycodone 5mg for pain. Pericardial drain placement, drained 1200ml\\n fluid.\\n Response:\\n Improved hemodynamics.\\n Plan:\\n Continue to monitor drainage amout and color per hosp policy. Assess\\n site frequently. Follow hemodynamics.\\n Abdominal pain (including abdominal tenderness)\\n Assessment:\\n +Ascites per abd CT. Pt describes as\\nachiness\\n across entire abdomen.\\n Severity , worse w/ palpation and reportedly after eating though\\n pt NPO today. BS hyperactive. Abd soft, distended.\\n Action:\\n Medicated as above.\\n Response:\\n Pain temporarily decreased to tolerable level after po medication.\\n Plan:\\n Frequent pain assessment. Reassess if current regimen not working.\\n Heart failure (CHF), Systolic, Acute\\n Assessment:\\n LS: diminished at bases. O2 sat down 85-95% 2L NC , 5 pillow orthopnea\\n at home per pt report, +ascites per abdominal CT.\\n Action:\\n O2NC increased as needed- team notified. Team concerned re: etiology\\n of new onset HF (worse over past month). LHC to evaluate for coronary\\n arteries as source.\\n Response:\\n SPO2 increased appropriately.\\n Plan:\\n Will start heart failure medication regimen once stable post cath/\\n drain placement. Initial heart failure teaching done w/ pt. Needs\\n reinforcement.\\n Impaired Skin Integrity\\n Assessment:\\n PIV L AC infiltrated in ED . Site benign, OTA.\\n Action:\\n Seen by plastics.\\n Response:\\n Stable site.\\n Plan:\\n Will continue to closely monitor.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-10-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417461,\n \"text\": \"? new pericardial effusion\\n Assessment:\\n Pulsus 6 before pericardial drain removed this afternoon around 1330 pt\\n felt chest pain after procedure and received morphine 2mg with good\\n relief . Pt then c/o same chest pain he experienced c prior pericardial\\n effusion new pulsus was 5 at 1730\\n Action:\\n Assess for pericardial effusion\\n Response:\\n Pulsus 5\\n Plan:\\n Continue to monitor for new pericardial effusion pulsus q 2hrs\\n Chest pain\\n Assessment:\\n Pt experiencing chest pain after completion of hemodialysis pt had many\\n pvc then vtach ? torsades, bp >180\\n Action:\\n Repleat mag 4grams, ekg\\n Response:\\n Pt feeling better no more chest pain, bp 147/60\\n Plan:\\n Monitor hemodynamics\\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\\n Assessment:\\n Temp spiked acutely after c/o hd tx 99.5 pt had chills and shivers\\n Action:\\n Remove blankets cool cloth to head\\n Response:\\n Pt felt less shivers felt better\\n Plan:\\n Monitor temp blood cultures x2 have been sent\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-10-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417344,\n \"text\": \"Pericardial effusion (without tamponade)\\n Assessment:\\n s/p pericardiocentesis for 1.2L of bloody drainage per cath report\\n with pt. reporting decrease abdominal pressure. Afeb. VSS.\\n Tolerating lopressor po. Pulsus 6\\n Action:\\n Able to aspirate 70cc at 1800 RN. Attempted aspiration of drain\\n q4hr for 0cc each time. Flushed with heparinized saline per protocol.\\n Total 150cc in drainage bag.\\n Response:\\n No c/o pain with aspiration. Site D/I. fluid Is seroussang.\\n Plan:\\n Plan repeat echo in AM. Cultures pnd. Contin. drain care per protocol\\n Abdominal pain (including abdominal tenderness)\\n Assessment:\\n c/o mild abd pain but stating that it is much improved since pc\\n centesis. Abd soft, pos. BS.\\n Action:\\n Oxycodone 5mg po x2\\n Response:\\n Pt. states fair relief.\\n Plan:\\n Monitor abd exam. Oxycodone for pain prn.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-10-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417337,\n \"text\": \"Pericardial effusion (without tamponade)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Abdominal pain (including abdominal tenderness)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2161-10-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 63422,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: S/p pericardial tap of 1200 cc. Assess residual effusion while in cath lab\\nHeight: (in) 73\\nWeight (lb): 150\\nBSA (m2): 1.91 m2\\nBP (mm Hg): 148/58\\nHR (bpm): 78\\nStatus: Inpatient\\nDate/Time: at 16:46\\nTest: Portable TTE (Focused views)\\nDoppler: Limited Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\\n\\nLEFT VENTRICLE: Mild-moderate global left ventricular hypokinesis.\\n\\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\\nhypokinesis.\\n\\nTRICUSPID VALVE: Moderate [2+] TR. Moderate PA systolic hypertension.\\n\\nPERICARDIUM: Small pericardial effusion.\\n\\nConclusions:\\nThere is mild to moderate global left ventricular hypokinesis (LVEF = 35-40%).\\nThe right ventricular cavity is mildly dilated with mild global free wall\\nhypokinesis. Moderate [2+] tricuspid regurgitation is seen. There is moderate\\npulmonary artery systolic hypertension. There is a small pericardial effusion.\\n\\nIMPRESSION: Small residual pericardial effusion following needle\\npericardiocentesis. Moderate tricuspid regurgitation. Moderate pulmonary\\nhypertension.\\n\\nCompared with the prior study (images reviewed) of , most of the\\npericardial fluid has been drained. Ventricular interdependence is no longer\\ndemonstrated.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2161-10-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 63374,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Pericardial effusion s/p pericardiocentesis.\\nHeight: (in) 73\\nWeight (lb): 150\\nBSA (m2): 1.91 m2\\nBP (mm Hg): 136/69\\nHR (bpm): 57\\nStatus: Inpatient\\nDate/Time: at 11:05\\nTest: TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Moderate LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. Normal IVC diameter\\n(<2.1cm) with <35% decrease during respiration (estimated RA pressure\\nindeterminate).\\n\\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Normal\\nregional LV systolic function. [Intrinsic LV systolic function likely\\ndepressed given the severity of valvular regurgitation.] Estimated cardiac\\nindex is normal (>=2.5L/min/m2).\\n\\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\\nAbnormal diastolic septal motion/position consistent with RV volume overload.\\n\\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Mild (1+) AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Moderate (2+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild to\\nmoderate [+] TR. Moderate PA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR.\\n\\nPERICARDIUM: Small pericardial effusion. Effusion circumferential. No\\nechocardiographic signs of tamponade.\\n\\nGENERAL COMMENTS: Results were personally reviewed with the MD caring for the\\npatient. Results were reviewed with the Cardiology Fellow involved with the\\npatient's care. Bilateral pleural effusions.\\n\\nConclusions:\\nThe left atrium is moderately dilated. The right atrium is markedly dilated.\\nThe right atrial pressure is indeterminate. Left ventricular wall thicknesses\\nare normal. The left ventricular cavity is mildly dilated. Regional left\\nventricular wall motion is normal. [Intrinsic left ventricular systolic\\nfunction is likely more depressed given the severity of valvular\\nregurgitation.] The estimated cardiac index is normal (>=2.5L/min/m2). Right\\nventricular chamber size is mildly increased with normal free wall motion.\\nThere is abnormal diastolic septal motion/position consistent with right\\nventricular volume overload. The aortic valve leaflets (3) appear structurally\\nnormal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic\\nregurgitation is seen. The mitral valve leaflets are structurally normal.\\nThere is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen.\\nThere is moderate pulmonary artery systolic hypertension. There is a small\\ncircumferential pericardial effusion. There are no echocardiographic signs of\\ntamponade.\\n\\nCompared with the prior study (images reviewed) of , the effusion is\\nminimally smaller with slightly improved systolic function.\\n\\nCLINICAL IMPLICATIONS:\\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\\nfor prophylaxis should be based on clinical and echocardiographic data.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2161-10-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 63375,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Tamponade.\\nHeight: (in) 73\\nWeight (lb): 150\\nBSA (m2): 1.91 m2\\nBP (mm Hg): 136/69\\nHR (bpm): 61\\nStatus: Inpatient\\nDate/Time: at 12:07\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\\nA mass/thrombus associated with a catheter/pacing wire in the RA or RV.\\n\\nLEFT VENTRICLE: Mild global LV hypokinesis. Mild resting LVOT gradient.\\n\\nRIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV free wall\\nhypokinesis. Prominent moderator band/trabeculations are noted in the RV apex.\\n\\nAORTA: Normal ascending aorta diameter.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Increased\\ntransaortic velocity related to increased stroke volume due to AR. Mild to\\nmoderate (+) AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Moderate (2+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Severe PA\\nsystolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR. The end-diastolic PR velocity is increased c/w PA diastolic\\nhypertension.\\n\\nPERICARDIUM: Small to moderate pericardial effusion. Stranding is \\nwithin the pericardial space c/w organization. No echocardiographic signs of\\ntamponade.\\n\\nGENERAL COMMENTS: Left pleural effusion.\\n\\nConclusions:\\nA very small (0.4 x 0.1 cm) mobile mass/thrombus associated with a\\ncatheter/pacing wire is seen in the right atrium and/or right ventricle. There\\nis mild global left ventricular hypokinesis (LVEF = 45 %). There is a mild\\nresting left ventricular outflow tract obstruction. The right ventricular\\ncavity is moderately dilated with mild global free wall hypokinesis. The\\naortic valve leaflets (3) are mildly thickened. There is no valvular aortic\\nstenosis. The increased transaortic velocity is likely related to increased\\nstroke volume due to aortic regurgitation. Mild to moderate (+) aortic\\nregurgitation is seen. The mitral valve leaflets are structurally normal.\\nThere is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen.\\nModerate [2+] tricuspid regurgitation is seen. There is severe pulmonary\\nartery systolic hypertension. The end-diastolic pulmonic regurgitation\\nvelocity is increased suggesting pulmonary artery diastolic hypertension.\\nThere is a small to moderate sized pericardial effusion. Stranding is\\n within the pericardial space c/w organization. There are no\\nechocardiographic signs of tamponade.\\n\\nIMPRESSION: Mild global biventricular systolic dysfunction. Small to moderate\\npericardial effusion with stranding located mainly around the lateral and\\ninferior left ventricle without echocardiographic evidence of tamponade.\\nModerate mitral and tricuspid regurgitation. Severe pulmonary hypertension.\\nSmall, mobile mass attached to the right atrial catheter.\\nCompared with the prior study (images reviewed) of , a small mobile\\nmass/thrombus attached to a right atrial catheter is now seen. The pericardial\\neffusion is smaller. Left ventricular function appears more vigorous.\\nPulmonary hypertension is severe.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2161-10-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 63376,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Pericardial effusion. Pericarditis.\\nHeight: (in) 73\\nWeight (lb): 150\\nBSA (m2): 1.91 m2\\nBP (mm Hg): 130/80\\nHR (bpm): 86\\nStatus: Inpatient\\nDate/Time: at 01:22\\nTest: Portable TTE (Focused views)\\nDoppler: Limited Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with 35-50%\\ndecrease during respiration (estimated RA pressure (0-10mmHg).\\n\\nLEFT VENTRICLE: Mild symmetric LVH. Moderate global LV hypokinesis.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\\nanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid\\ninferoseptal - hypo;\\n\\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\\nhypokinesis.\\n\\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\\nleaflets. Mild (1+) AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\\nsystolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Mild PR.\\n\\nPERICARDIUM: Large pericardial effusion. Sgnificant, accentuated respiratory\\nvariation in mitral/tricuspid valve inflows, c/w impaired ventricular filling.\\n\\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\\nLeft pleural effusion.\\n\\nConclusions:\\nThe estimated right atrial pressure is 0-10mmHg. There is mild symmetric left\\nventricular hypertrophy. There is moderate global left ventricular hypokinesis\\n(LVEF = 35%). The right ventricular cavity is mildly dilated with mild global\\nfree wall hypokinesis. There are three aortic valve leaflets. The aortic valve\\nleaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. The\\nmitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation\\nis seen. There is mild pulmonary artery systolic hypertension. There is a\\nlarge circumferential pericardial effusion. There is significant, accentuated\\nrespiratory variation in mitral/tricuspid valve inflows, consistent with\\nimpaired ventricular filling.\\n\\nIMPRESSION: Large pericardial effusion with evidence of impaired ventricular\\nfilling. Moderate global left ventricular systolic dysfunction. Mild right\\nventricular systolic dysfunction. Mild aortic regurgitation. Moderate mitral\\nregurgitation. Mild pulmonary hypertension.\\n\\nCompared with the prior study (images reviewed) of , pericardial\\neffusion size is much larger, and there is now evidence of some ventricular\\ninterdependence, likely indicating elevated intrapericardial pressure.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-10-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1037810,\n \"text\": \" 10:31 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: S/p pericardiocentesis.\\n Admitting Diagnosis: PERICARDIAL EFFUSION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 43 year old man with pericardial effusion s/p pericardiocentesis.\\n REASON FOR THIS EXAMINATION:\\n S/p pericardiocentesis.\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SAT 2:22 PM\\n Left lower lobe retrocardiac opacity has worsened, likely atelectasis. Small\\n left pleural effusion is probably unchanged. Enlarged cardiac silhouette is\\n minimally decreased in size. Right pleural effusion has increased.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: S/P pericardiocentesis.\\n\\n Comparison is made with prior study, .\\n\\n Left lower lobe retrocardiac opacity has worsened, likely atelectasis. Small\\n left pleural effusion is unchanged. Small right pleural effusion has\\n increased. Enlarged cardiac silhouette minimally decreased in size. Left\\n supraclavicular catheter remains in place. No pneumothorax.\\n\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-10-04 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1037984,\n \"text\": \", S. 9:17 AM\\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \\n CT PELVIS W/O CONTRAST\\n Reason: Please evaluate for RP bleed and interval change in ascitic\\n Admitting Diagnosis: PERICARDIAL EFFUSION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 43 year old man with ESRD failed transplant now s/p nephrectomy p/w pericardial\\n tamponade now with Hct decrease.\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for RP bleed and interval change in ascitic fluid.\\n CONTRAINDICATIONS for IV CONTRAST:\\n ESRD;;esrd\\n ______________________________________________________________________________\\n PFI REPORT\\n No retroperitoneal bleeding, complete resolution of the pericardial effusion,\\n and interval increase in bilateral pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-10-07 00:00:00.000\",\n \"description\": \"CVL INJ/EVAL INCLUDES FLUORO/IMAGES/REPORT\",\n \"row_id\": 1038660,\n \"text\": \" 10:02 AM\\n UNILAT SUBCLAV Clip # \\n Reason: Pt discussed between IR and renal: need to differentiate bet\\n Admitting Diagnosis: PERICARDIAL EFFUSION\\n Contrast: OPTIRAY Amt: 60\\n ********************************* CPT Codes ********************************\\n * CVL INJ/EVAL INCLUDES FLUORO/I *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 43 year old man with mobile mass on end of tunneled catheter.\\n REASON FOR THIS EXAMINATION:\\n Pt discussed between IR and renal: need to differentiate between fibrin sheath\\n and thrombus at end of tunneled catheter.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 43-year-old male with question of thrombus at the end of tunneled\\n catheter.\\n\\n RADIOLOGISTS: Dr. , , and attending radiologist, Dr. , who\\n was present and supervised the entire procedure.\\n\\n PROCEDURE AND FINDINGS: The risks and benefits of the procedure were\\n explained to the patient, and informed consent was obtained. A preprocedure\\n timeout was performed to identify the patient by name, medical record number,\\n date of birth, and the nature of the procedure to be performed. The patient\\n was placed supine on the angiographic table.\\n\\n Scout image demonstrates the tip of a tunneled left internal jugular\\n hemodialysis line terminating in the right atrium. Prior to proceeding with a\\n flow study, each port of the hemodialysis catheter was successfully aspirated\\n and flushed. Next, 30 cc of IV Optiray contrast was injected into each port of\\n the catheter which demonstrated no fibrin sheath or significant thrombus.\\n Given normally functioning catheter and lack of significant clot or fibrin\\n sheath, no intervention was performed. Each port of the hemodialysis catheter\\n was flushed and heplocked.\\n\\n IMPRESSION: Flow study demonstrates no fibrin sheath or significant thrombus\\n of existing left-sided tunneled hemodialysis catheter.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-10-04 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1037983,\n \"text\": \" 9:17 AM\\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \\n CT PELVIS W/O CONTRAST\\n Reason: Please evaluate for RP bleed and interval change in ascitic\\n Admitting Diagnosis: PERICARDIAL EFFUSION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 43 year old man with ESRD failed transplant now s/p nephrectomy p/w pericardial\\n tamponade now with Hct decrease.\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for RP bleed and interval change in ascitic fluid.\\n CONTRAINDICATIONS for IV CONTRAST:\\n ESRD;;esrd\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): FBr SUN 3:31 PM\\n No retroperitoneal bleeding, complete resolution of the pericardial effusion,\\n and interval increase in bilateral pleural effusion.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 43-year-old man with failed renal transplant and hematocrit drop.\\n Please evaluate retroperitoneal bleeding.\\n\\n TECHNIQUE: Axial MDCT images were acquired from the thoracic inlet to the\\n pubic symphysis with no IV contrast administration. No oral contrast was\\n used. Multiplanar reformatted images were acquired.\\n\\n CT OF THE CHEST WITH NO IV CONTRAST: There has been an interval increase in\\n the size of moderate right and small left pleural effusions, with worsening\\n atelectasis of the lower lobes. There has been interval decrease in the size\\n of previously seen large pericardial effusion. Bullous changes of the right\\n lung apex. There is a calcified granuloma in the left lung (2: 22). No\\n central pathologically enlarged nodes. The distal tip of the left IJ line is\\n in the right atrium. There is cardiomegaly.\\n\\n Noncontrast evaluation of the liver, gallbladder, spleen, and adrenal glands\\n is unremarkable. Both kidneys are severely atrophied. Duodenal loops of small\\n bowel and large bowel are unremarkable. Moderate degree of simple ascitic\\n fluid is noted within the abdomen. No pathologically enlarged nodes.\\n\\n CT OF THE PELVIS: The rectum, sigmoid colon, urinary bladder, distal ureters,\\n prostate, and seminal vesicles are unremarkable. Ascitic fluid in the pelvis.\\n No pathologically enlarged pelvic or inguinal nodes. No retroperitoneal\\n bleeding is noted. Mild haziness around the right common femoral artery and\\n common femoral vein.\\n\\n BONE WINDOWS: No concerning lytic or sclerotic lesions.\\n\\n IMPRESSION:\\n 1. No retroperitoneal bleed.\\n 2. Interval decrease in size of the pericardial effusion, now small.\\n 3. Interval increase in bilateral pleural effusions, moderate on the right\\n and small on the left, with associated atectasis at the lung bases.\\n (Over)\\n\\n 9:17 AM\\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \\n CT PELVIS W/O CONTRAST\\n Reason: Please evaluate for RP bleed and interval change in ascitic\\n Admitting Diagnosis: PERICARDIAL EFFUSION\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-10-05 00:00:00.000\",\n \"description\": \"CHEST (LAT DECUB ONLY)\",\n \"row_id\": 1038273,\n \"text\": \" 5:13 PM\\n CHEST (LAT DECUB ONLY); CHEST (PA & LAT) Clip # \\n Reason: question whether effusions are loculated. please compare to\\n Admitting Diagnosis: PERICARDIAL EFFUSION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 43 year old man with pleural effusion, previously with pericardial effusion\\n REASON FOR THIS EXAMINATION:\\n question whether effusions are loculated. please compare to supine films.\\n ______________________________________________________________________________\\n WET READ: JXKc MON 9:20 PM\\n Moderate bilateral pleural effusions that appear to layer on the lateral\\n decubitus views without definite signs to suggest loculation. There is\\n associated atelectasis of the adjacent lung. Left subclavian catheter tip\\n terminates in the low right atrium, unchanged in position. -jkang\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Pleural effusion.\\n\\n FINDINGS: In comparison with the study of , lateral decubitus view shows\\n that there is a small amount of free pleural fluid on the left and a\\n substantially larger amount of free pleural fluid on the right. Pulmonary\\n vascular congestion persists.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-10-08 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1038837,\n \"text\": \" 12:05 AM\\n CHEST (PA & LAT) Clip # \\n Reason: r/o PNA\\n Admitting Diagnosis: PERICARDIAL EFFUSION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 43 year old man with new onset fever\\n REASON FOR THIS EXAMINATION:\\n r/o PNA\\n ______________________________________________________________________________\\n FINAL REPORT\\n PA AND LATERAL CHEST ON \\n\\n HISTORY: New onset of fever, rule out pneumonia.\\n\\n IMPRESSION: PA and lateral chest compared to :\\n\\n Small bilateral pleural effusions have decreased, moderate enlargement of the\\n cardiac silhouette due to cardiomegaly and/or pericardial effusion is\\n diminished, interstitial edema is cleared and bibasilar opacification has\\n improved. Overall findings are consistent with resolved pulmonary edema.\\n Cystic structure at the right lung apex now contains fluid, probably edema\\n fluid in a bulla, not concerning for infection. Dual-channel supraclavicular\\n left-sided central venous catheter projects over the upper right atrium. No\\n complications.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-10-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1037811,\n \"text\": \", S. 10:31 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: S/p pericardiocentesis.\\n Admitting Diagnosis: PERICARDIAL EFFUSION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 43 year old man with pericardial effusion s/p pericardiocentesis.\\n REASON FOR THIS EXAMINATION:\\n S/p pericardiocentesis.\\n ______________________________________________________________________________\\n PFI REPORT\\n Left lower lobe retrocardiac opacity has worsened, likely atelectasis. Small\\n left pleural effusion is probably unchanged. Enlarged cardiac silhouette is\\n minimally decreased in size. Right pleural effusion has increased.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-10-01 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1037449,\n \"text\": \" 3:00 PM\\n CHEST (PA & LAT) Clip # \\n Reason: eval for infiltrate, mediastinum\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 43 year old man with shortness of breath\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate, mediastinum\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 43-year-old man with shortness of breath.\\n\\n Comparison is made to CT and chest radiograph.\\n\\n PA AND LATERAL CHEST RADIOGRAPHS\\n\\n FINDINGS: The heart remains enlarged and there is prominence to the pulmonary\\n arteries bilaterally. Moderate-sized left pleural effusion and probable\\n compression atelectasis is noted with a small right effusion noted on the\\n lateral view. Left-sided dialysis catheter is stable with its tip in the\\n right atrium. No pneumothorax or focal consolidations to suggest pneumonia.\\n\\n IMPRESSION:\\n\\n Cardiomegaly with moderate-sized left effusion and probable adjacent\\n compression atelectasis and small right effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-10-01 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 1037467,\n \"text\": \" 4:48 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: assess for infection/abscess\\n Field of view: 36 Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 43 year old man with ESRD s/p transplant neprhotomy on now with abd pain\\n x 2 weeks\\n REASON FOR THIS EXAMINATION:\\n assess for infection/abscess\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: 8:37 PM\\n new large pericardial effusion with ct findings suggesting component of\\n tamponade (mass effect on RV). mod b/l effusions. new mod/large amount of\\n ascites. decreased size to RLQ collection at ste of prior xplant.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Complicated cardiac and renal history with known cardiac dysfunction\\n status post transplant nephrectomy due to failure in with\\n recurrent right lower quadrant abdominal pain. No leukocytosis with mild\\n elevation of ALT/AST but normal alk phos.\\n\\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\\n pelvis with intravenous and oral contrast. Coronal and sagittal reformations\\n were evaluated.\\n\\n Comparison is made to ultrasound dated and CT dated .\\n\\n CT OF THE ABDOMEN WITH INTRAVENOUS AND ORAL CONTRAST: There are bilateral\\n moderate simple pleural effusions and a new large pericardial effusion which\\n displays some tamponade effect on the right ventricle which appears compressed\\n in addition to mass effect on the entire heart with abnormal leftward\\n deviation/angulation of the intraventricular septum. Bilateral compression\\n atelectasis is noted with the remaining aerated lung parenchyma appearing\\n otherwise unremarkable. The gallbladder displays some third spacing/wall\\n edema but appears otherwise unremarkable as does the liver, spleen, stomach,\\n small bowel, pancreas, adrenal glands, and atrophic appearing kidneys. No\\n pathologically enlarged abdominal lymph nodes are identified and there is no\\n free air. There has been interval development of a moderate to large amount\\n of intra-abdominal ascites.\\n\\n CT OF THE PELVIS WITH INTRAVENOUS AND ORAL CONTRAST: Intrapelvic bowel,\\n prostate, and urinary bladder are unremarkable. No significant bowel wall\\n edema is identified. Moderate-to-large amount of intrapelvic ascites has\\n developed. Previously identified collection within the right lower quadrant\\n at site of prior transplant has decreased in size measuring approximately 1.7\\n x 2.2 cm, prior 2.6 x 2.8cm with continued mild rim enhancement but no\\n internal foci of air.\\n\\n BONE WINDOWS: No malignant appearing osseous lesions are identified.\\n\\n IMPRESSION:\\n (Over)\\n\\n 4:48 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: assess for infection/abscess\\n Field of view: 36 Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 1. Interval development of a large amount of intra-abdominal/intrapelvic\\n ascites and moderate-to-large pericardial effusion with CT findings suggesting\\n a component of tamponade. Cardiac echo recommended. Moderate-sized bilateral\\n pleural effusions.\\n\\n 2. Continued decrease in size to a small rim enhancing likely post-operative\\n collection at site of prior right lower quadrant transplant kidney.\\n\\n 3. No findings of colitis.\\n\\n Please note during the examination the patient experienced a IV infiltration\\n of intravenous contrast and saline. It is estimated that 70 mL of Optiray\\n contrast infiltrated at the patient's IV site. Immediately after exam patient\\n displayed no neurological deficits, intact distal pulses and brisk capillary\\n refill. Plastics consult was recommended to the ER staff caring for the\\n patient.\\n\\n Above findings were discussed with Dr. shortly after exam acquisition at\\n 8:30 p.m.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2161-10-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126592,\n \"text\": \"Normal sinus rhythm. Prolonged Q-T interval. Low voltage in the standard\\nleads. Left ventricular hypertrophy. Non-specific ST-T wave changes in\\nleads I, aVL and V2-V6. Compared to the previous tracing of no\\nsignificant change. The non-specific T wave changes are similar. The\\nQTc interval is somewhat shorter.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2161-10-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126593,\n \"text\": \"Sinus rhythm. Findings are as described on the previous tracing of and\\nare without significant change except, that ST-T wave changes appear less\\nprominent.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2161-10-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126594,\n \"text\": \"Sinus rhythm\\nLeft atrial abnormality\\nProminent QRS voltage suggests left ventricular hypertrophy\\nDiffuse ST-T wave abnormalities\\nProlonged Q-Tc interval\\nFindings are nonspecific but clinical correlation is suggested for possible in\\npart drug/metabolic/electrolyte effect, possible ischemia or central nervous\\nsystem event\\nSince previous tracing of the same date, no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2161-10-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126595,\n \"text\": \"Sinus rhythm\\nLeft atrial abnormality\\nProminent QRS voltages suggests left ventricular hypertrophy\\nDiffuse ST-T wave abnormalities\\nProlonged Q-Tc interval\\nFindings are nonspecific but clinical correlation is suggested for possible in\\npart drug/metabolic/electrolyte effect, possible ischemia or central nervous\\nsystem event\\nSince previous tracing of , ST-T wave changes less prominent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2161-10-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126603,\n \"text\": \"Sinus rhythm. The Q-T interval is prolonged. Non-specific ST-T wave\\nchanges. Low voltage in the limb leads. Compared to the previous tracing\\nthere is no significant change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2161-10-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126596,\n \"text\": \"Sinus rhythm. The Q-T interval is prolonged. Marked ST-T wave changes most\\nprominent in the anterior and anterolateral leads. Compared to the previous\\ntracing ventricular ectopy has resolved.\\nTRACING #4\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2161-10-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126597,\n \"text\": \"Sinus rhythm. Ventricular ectopy. The Q-T interval is prolonged\\nat 520 milliseconds. Marked ST-T wave changes most prominently in the anterior\\nand anterolateral leads. Compared to the previous tracing ventricular ectopy\\nis somewhat less.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2161-10-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126598,\n \"text\": \"Probable atrial fibrillation with frequent ventricular ectopy. The\\nQ-T interval is prolonged. Marked ST-T wave changes, particularly in the\\nanterior and anterolateral leads. Compared to the previous tracing ventricular\\nectopy is new.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2161-10-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126599,\n \"text\": \"Sinus rhythm. The Q-T interval is prolonged at approximately 560 milliseconds.\\nMarked ST-T wave changes predominantly in the anterior and anterolateral\\nleads. Compared to the previous tracing the Q-T interval is longer and\\nST-T wave changes are more diffuse and more severe.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2161-10-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126600,\n \"text\": \"Sinus bradycardia. Frequent premature atrial contractions. Left ventricular\\nhypertrophy with secondary ST-T wave changes. Prolonged QTc interval.\\nLateral ST-T wave changes which may be related to left ventricular hypertrophy.\\nCompared to the previous tracing of QTc interval prolongation is new.\\nClinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2161-10-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126601,\n \"text\": \"Sinus rhythm. The Q-T interval is prolonged. Left axis deviation.\\nNon-specific ST-T wave changes. Low voltage in the limb leads. Compared to\\nthe previous tracing left axis deviation is new.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2161-10-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126602,\n \"text\": \"Sinus rhythm. The Q-T interval is prolonged. Non-specific ST-T wave changes.\\nLow voltage in the limb leads. Compared to the previous tracing there is no\\nsignificant change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2161-10-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126554,\n \"text\": \"Compared to tracing #1 the T wave changes are less prominent in leads V2-V5.\\nOtherwise, no significant change.\\nTRACING #2\\n\\n\"\n }\n]"}}},{"rowIdx":24639,"cells":{"subject_id":{"kind":"number","value":47841,"string":"47,841"},"hadm_id":{"kind":"number","value":103650,"string":"103,650"},"target_text":{"kind":"string","value":"Pt was admitted to pre-op holding in anticipation of an EVAR for an enlarging AAA. She underwent endovascular repair of abdominal aortic aneurysm with modular endograft, but her operative course was complicated by partial covering of the origin of the right renal artery requiring renal angioplasty and stenting, dissection of the right common femoral artery with occlusionas a result of percutaneous access requiring groin exploration, endarterectomy and vein patch repair. She tolerated the procedure well, though given her complicated operative course, she remained intubated overnight in the CVICU. She was extubated without difficulty the following morning, and transferred to the VICU later that day. On POD 2, her hct had dropped to 24, and she was given 1u PRBCs. Her hct responded nicely to above 30. Her A-line was removed and she was getting out of bed. The remainder of her post-operative course of unremarkable, and she was deemed ready for discharge on POD 3. She will follow up with Dr. in 3 weeks, with a CTA to be done beforehand."},"extractive_notes_summ":{"kind":"string","value":"Pt remained intubated overnight d/t copd .H/O alcohol abuse Assessment: Action: Response: Plan: Aortic aneurysm, abdominal without rupture (AAA) Assessment: Action: Response: Plan: Pt remained intubated overnight d/t copd .H/O alcohol abuse Assessment: Action: Response: Plan: Aortic aneurysm, abdominal without rupture (AAA) Assessment: Action: Response: Plan: Chlorhexidine Gluconate 0.12% Oral Rinse 3. CVICU HPI: HD2 POD 1 80 y.o F now s/p EVAR, right renal stent, right femoral endarterectomy and patch angioplasty Chief complaint: PMHx: COPD, HTN, Chol, former tobacco, POLYMYALGIA RHEUMATICA, DIVERTICULOSIS, hypothyroid, GERD Current medications: Calcium Gluconate 2. .H/O alcohol abuse Assessment: Action: Response: Plan: Aortic aneurysm, abdominal without rupture (AAA) Assessment: Action: Response: Plan: clear lungs FINAL REPORT HISTORY: Status post EVAR, for ET tube placement. pt with + pp by doppler. pt with + pp by doppler. goal sbp 100-140. awake hypertensive on propofol, 100mcg fentanly given ivp. MethylPREDNISolone Sodium Succ 10. Pt with 1 breif episode of mild tremors in arms this am. Pt with 1 breif episode of mild tremors in arms this am. Pt is on Propofol. Phenylephrine 13. Nitroglycerin 12. Hyperglycemia Assessment: BS >120 Action: BS checked Q6 Response: Treated with s/s insulin Plan: Continue per protocol .H/O alcohol abuse Assessment: Per note on careweb pt drinks moderate amount of alcohol Action: Ativan ordered PRN Response: No sign of withdrawal Plan: Medicate PRN Demographics Day of intubation: Day of mechanical ventilation: 1 Ideal body weight: 51.5 None Ideal tidal volume: mL/kg Tube Type ETT: Position: 19 cm at teeth Route: Type: Standard Size: 7mm Lung sounds RLL Lung Sounds: Clear RUL Lung Sounds: Rhonchi LUL Lung Sounds: Rhonchi LLL Lung Sounds: Clear Comments: Secretions Sputum color / consistency: White / Thick Sputum source/amount: Suctioned / Scant Ventilation Assessment Level of breathing assistance: Continuous invasive ventilation Visual assessment of breathing pattern: Normal quiet breathing Trigger work assessment: Not triggering Plan Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated Reason for continuing current ventilatory support: Sedated / Paralyzed Comments: 80yr female s/p repair of AAA with complicated intra-operative progress. + hypoactive bs, tolerating clear this afternoon. + hypoactive bs, tolerating clear this afternoon. Action: Monitor CIWA scale Monitor for sign and symptoms of withdrawal Response: Besides 1 episode of mild tremors this am, no sign of withdrawals Plan: CIWA scale, monitor for signs of withdrawals, ativan prn Aortic aneurysm, abdominal without rupture (AAA) Assessment: Pt Intubated and sedated this am. Action: Monitor CIWA scale Monitor for sign and symptoms of withdrawal Response: Besides 1 episode of mild tremors this am, no sign of withdrawals Plan: CIWA scale, monitor for signs of withdrawals, ativan prn Aortic aneurysm, abdominal without rupture (AAA) Assessment: Pt Intubated and sedated this am. Aortic aneurysm, abdominal without rupture (AAA) Assessment: s/p endovascular AAA repair/femoral cut down/femoral embolectomy/femoral angioplasty. Demographics Day of intubation: Day of mechanical ventilation: 2 Ideal body weight: 51.5 None Ideal tidal volume: mL/kg Airway Airway Placement Data Known difficult intubation: Procedure location: Reason: Tube Type ETT: Position: 19 cm at teeth Route: Oral Type: Standard Size: 7mm Cuff Management: Vol/Press: Cuff pressure: cmH2O Cuff volume: 8 mL / Airway problems: Comments: Lung sounds RLL Lung Sounds: Clear RUL Lung Sounds: Clear LUL Lung Sounds: Clear LLL Lung Sounds: Clear Comments: Secretions Sputum color / consistency: White / Thick Sputum source/amount: Suctioned / Scant Comments: Ventilation Assessment Level of breathing assistance: Continuous invasive ventilation Visual assessment of breathing pattern: Normal quiet breathing Assessment of breathing comfort: Non-invasive ventilation assessment: Invasive ventilation assessment: Trigger work assessment: Triggering synchronously Dysynchrony assessment: Comments: Pt remains stable on full vent support Plan Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as tolerated, Adjust Min."},"n_notes":{"kind":"number","value":10,"string":"10"},"notes":{"kind":"list like","value":[{"category":"Nursing","chartdate":"2133-05-07 00:00:00.000","description":"Nursing Progress Note","row_id":454935,"text":"Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n s/p endovascular AAA repair/femoral cut down/femoral\n embolectomy/femoral angioplasty.\n Action:\n Remained intubated overnight to keep pt from moving around per\n attending\n Response:\n pt has alcohol history and is restless at baseline\n Plan:\n Extubate this am. Pt with history of COPD, receiving 3 doses of\n methylprednisone.\n Hyperglycemia\n Assessment:\n BS >120\n Action:\n BS checked Q6\n Response:\n Treated with s/s insulin\n Plan:\n Continue per protocol\n .H/O alcohol abuse\n Assessment:\n Per note on careweb pt drinks moderate amount of alcohol\n Action:\n Ativan ordered PRN\n Response:\n No sign of withdrawal\n Plan:\n Medicate PRN\n"},{"category":"Nursing","chartdate":"2133-05-07 00:00:00.000","description":"Nursing Transfer Note","row_id":455022,"text":"The patient had back pain from a fall -> pt present for treatment and\n was incidentially found to have a infranrenal AAA.\n s/p endovascular AAA repair/femoral cut down/femoral\n embolectomy/femoral angioplasty, right renal stent.\n Pt remained intubated overnight d/t copd\n .H/O alcohol abuse\n Assessment:\n Pt report that\nI drink 2 drinks a day\n. Pt with 1 breif episode of\n mild tremors in arms this am. Pt denies hallucinations. No seizure\n activity. Pt alert and orientated x3.\n Action:\n Monitor CIWA scale\n Monitor for sign and symptoms of withdrawal\n Response:\n Besides 1 episode of mild tremors this am, no sign of withdrawals\n Plan:\n CIWA scale, monitor for signs of withdrawals, ativan prn\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Pt Intubated and sedated this am. PERRL. Pt remains in NSR, no ectopy\n noted. HR 50-80\ns. SBP ~ 90-150\ns. LS coarse with dim bases. pt with +\n pp by doppler. + hypoactive bs, tolerating clear this afternoon. Foley\n draining clear yellow urine. UO adequate. Pt with DSD over right groin\n and left grion\n Action:\n Sedation weaned to off this am -> pt weaned to CPAP 50% with\n 5 peep and 5 PS -> ABG WNL -> pt extubated at 09:20 this am -> placed\n on 50% face mask\n Pt up to chair this am\n Pt given nebs/inhailers as ordered\n Response:\n Pt alert and orientated x3. Able to MAE and follow commands. Pt weaned\n to room air this afternoon, o2 sats ~ 95-98%\n Plan:\n BP goal -> SBP 100-140\ns per team, pulm toleit, pain control, advance\n diet and activity as tolerated\n Demographics\n Attending MD:\n FRANK B.\n Admit diagnosis:\n ABDOMINAL AORTIC ANEURYSM/SDA\n Code status:\n Full code\n Height:\n 63 Inch\n Admission weight:\n 72.3 kg\n Daily weight:\n 58.4 kg\n Allergies/Reactions:\n Adhesive Tape (Topical)\n \"it rips my ski\n Precautions:\n PMH: COPD, ETOH\n CV-PMH: PVD\n Additional history: severe COPD, hyperlipidemia, HTN, osteoporosis,\n hypothyrodism, reflux, s/p excision leasion, s/p shoulder\n arthroscopy\n Surgery / Procedure and date: s/p endovascular AAA repair/femoral\n cut down/femoral embolectomy/femoral angioplasty, right renal stent.\n remained intubated d/t copd. 700cc ebl. 1u prbc given. 3l\n crystaloid. to cvicu on propofol 50mcg/kg/min. goal sbp 100-140.\n awake hypertensive on propofol, 100mcg fentanly given ivp.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n 98.6\n Arterial BP:\n S:124\n D:52\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 85 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 10 L/min\n FiO2 set:\n 24h total in:\n 1,082 mL\n 24h total out:\n 1,573 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 04:14 AM\n Potassium:\n 4.0 mEq/L\n 04:14 AM\n Chloride:\n 106 mEq/L\n 04:14 AM\n CO2:\n 23 mEq/L\n 04:14 AM\n BUN:\n 12 mg/dL\n 04:14 AM\n Creatinine:\n 0.5 mg/dL\n 04:14 AM\n Glucose:\n 145 mg/dL\n 04:14 AM\n Hematocrit:\n 27.0 %\n 04:14 AM\n Finger Stick Glucose:\n 128\n 12:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n right radial A line. left 16 guage PIV and 18 guage PIV placed on\n \n Valuables / Signature\n Patient valuables: Dentures: (Upper, Lower )\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: \n Transferred to: VICU\n Date & time of Transfer: 17:00 pm\n"},{"category":"Respiratory ","chartdate":"2133-05-07 00:00:00.000","description":"Respiratory Care Shift Note","row_id":454921,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 51.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments: Pt remains stable on full vent support\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Adjust Min. ventilation to control pH, Increase ventilatory\n support at night\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Cannot protect airway, Cannot manage\n secretions, Underlying illness not resolved; Comments: Due to severity\n of OR procedures, pt remained fully sedated on ventilator. Pt is on\n Propofol. No issues this shift, along with no spontaneous\n respirations. Pt has clear lung sounds and required minimal\n suctioning. PT to be assessed by MD team for further weaning. Pt to\n continue current support.\n BEDSIDE RSBI- No spontaneous respirations.\n"},{"category":"Nursing","chartdate":"2133-05-07 00:00:00.000","description":"Nursing Transfer Note","row_id":455011,"text":".H/O alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2133-05-07 00:00:00.000","description":"Nursing Transfer Note","row_id":455012,"text":"The patient had back pain from a fall -> pt present for treatment and\n was incidentially found to have a infranrenal AAA.\n s/p endovascular AAA repair/femoral cut down/femoral\n embolectomy/femoral angioplasty, right renal stent.\n Pt remained intubated overnight d/t copd\n .H/O alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2133-05-07 00:00:00.000","description":"Nursing Transfer Note","row_id":455013,"text":"The patient had back pain from a fall -> pt present for treatment and\n was incidentially found to have a infranrenal AAA.\n s/p endovascular AAA repair/femoral cut down/femoral\n embolectomy/femoral angioplasty, right renal stent.\n Pt remained intubated overnight d/t copd\n .H/O alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2133-05-07 00:00:00.000","description":"Nursing Transfer Note","row_id":455017,"text":"The patient had back pain from a fall -> pt present for treatment and\n was incidentially found to have a infranrenal AAA.\n s/p endovascular AAA repair/femoral cut down/femoral\n embolectomy/femoral angioplasty, right renal stent.\n Pt remained intubated overnight d/t copd\n .H/O alcohol abuse\n Assessment:\n Pt report that\nI drink 2 drinks a day\n. Pt with 1 breif episode of\n mild tremors in arms this am. Pt denies hallucinations. No seizure\n activity. Pt alert and orientated x3.\n Action:\n Monitor CIWA scale\n Monitor for sign and symptoms of withdrawal\n Response:\n Besides 1 episode of mild tremors this am, no sign of withdrawals\n Plan:\n CIWA scale, monitor for signs of withdrawals, ativan prn\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Pt Intubated and sedated this am. PERRL. Pt remains in NSR, no ectopy\n noted. HR 50-80\ns. SBP ~ 90-150\ns. LS coarse with dim bases. pt with +\n pp by doppler. + hypoactive bs, tolerating clear this afternoon. Foley\n draining clear yellow urine. UO adequate. Pt with DSD over right groin\n and left grion\n Action:\n Sedation weaned to off this am -> pt weaned to CPAP 50% with\n 5 peep and 5 PS -> ABG WNL -> pt extubated at 09:20 this am -> placed\n on 50% face mask\n Pt up to chair this am\n Pt given nebs/inhailers as ordered\n Response:\n Pt alert and orientated x3. Able to MAE and follow commands. Pt weaned\n to room air this afternoon, o2 sats ~ 95-98%\n Plan:\n BP goal -> SBP 100-140\ns per team, pulm toleit, pain control, advance\n diet and activity as tolerated\n"},{"category":"Respiratory ","chartdate":"2133-05-06 00:00:00.000","description":"Respiratory Care Shift Note","row_id":454873,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 51.5 None\n Ideal tidal volume: mL/kg\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Comments:\n 80yr female s/p repair of AAA with complicated intra-operative\n progress. Wean as appropriate.\n"},{"category":"Physician ","chartdate":"2133-05-07 00:00:00.000","description":"Intensivist Note","row_id":454963,"text":"CVICU\n HPI:\n HD2\n POD 1\n 80 y.o F now s/p EVAR, right renal stent, right femoral endarterectomy\n and patch angioplasty\n Chief complaint:\n PMHx:\n COPD, HTN, Chol, former tobacco, POLYMYALGIA RHEUMATICA,\n DIVERTICULOSIS, hypothyroid, GERD\n Current medications:\n Calcium Gluconate 2. Chlorhexidine Gluconate 0.12% Oral Rinse 3.\n Clopidogrel 4. Esmolol 5. Fentanyl Citrate\n 6. FoLIC Acid 7. Lorazepam 8. Magnesium Sulfate 9. MethylPREDNISolone\n Sodium Succ 10. Multivitamins\n 11. Nitroglycerin 12. Phenylephrine 13. Potassium Chloride 14. Propofol\n 15. Thiamine\n 24 Hour Events:\n OR RECEIVED - At 05:51 PM\n ARTERIAL LINE - START 05:54 PM\n INTUBATION - At 06:27 PM\n INVASIVE VENTILATION - START 06:27 PM\n Post operative day:\n 1\n Allergies:\n Adhesive Tape (Topical)\n \"it rips my ski\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 08:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36\nC (96.8\n T current: 35.9\nC (96.6\n HR: 61 (54 - 86) bpm\n BP: 126/57(83) {87/45(61) - 149/70(102)} mmHg\n RR: 32 (12 - 32) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 58.4 kg (admission): 72.3 kg\n Height: 63 Inch\n Total In:\n 686 mL\n 909 mL\n PO:\n Tube feeding:\n IV Fluid:\n 686 mL\n 909 mL\n Blood products:\n Total out:\n 338 mL\n 447 mL\n Urine:\n 338 mL\n 447 mL\n NG:\n Stool:\n Drains:\n Balance:\n 348 mL\n 462 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 644 (326 - 644) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 10 cmH2O\n Plateau: 14 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 100%\n ABG: 7.42/37/166/23/0\n Ve: 5.8 L/min\n PaO2 / FiO2: 415\n Physical Examination\n General Appearance: No acute distress, intubated, following commands\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Absent), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 177 K/uL\n 9.3 g/dL\n 145 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 12 mg/dL\n 106 mEq/L\n 136 mEq/L\n 27.0 %\n 7.4 K/uL\n [image002.jpg]\n 06:13 PM\n 06:27 PM\n 12:34 AM\n 04:14 AM\n WBC\n 6.1\n 7.4\n Hct\n 28.1\n 27.0\n Plt\n 178\n 177\n Creatinine\n 0.5\n 0.5\n TCO2\n 28\n 25\n Glucose\n 141\n 145\n Other labs: PT / PTT / INR:14.1/38.5/1.2, Differential-Neuts:86.1 %,\n Lymph:9.7 %, Mono:3.1 %, Eos:0.8 %, Ca:7.7 mg/dL, Mg:2.3 mg/dL, PO4:3.9\n mg/dL\n Assessment and Plan\n HYPERGLYCEMIA, .H/O ALCOHOL ABUSE, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA)\n Assessment and Plan: HD2\n POD 0\n 80 y.o F now s/p EVAR, right renal stent, right femoral endarterectomy\n and patch angioplasty\n Neurologic: Pain controlled, awake, alert\n Cardiovascular: hemodynamically stable, restart b blocker and statin\n Pulmonary: IS, Extubate today, extubate now, intubated perioperatively\n Gastrointestinal / Abdomen:\n Nutrition: NPO, Advance diet as tolerated\n Renal: Foley, Adequate UO, lasix for diuresis\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Vascular surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:54 PM\n 18 Gauge - 05:54 PM\n 16 Gauge - 06:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"},{"category":"Radiology","chartdate":"2133-05-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1074663,"text":" 6:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman s/p EVAR, check ETT placement\n REASON FOR THIS EXAMINATION:\n eval ETT\n ______________________________________________________________________________\n WET READ: MBue WED 8:53 PM\n ETT terminating approx 4.6 cm above carina. clear lungs\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post EVAR, for ET tube placement.\n\n FINDINGS: In comparison with the study of , there has been placement of\n an endotracheal tube that lies approximately 4.6 cm above the carina.\n Otherwise, there is no interval change. No evidence of acute focal pneumonia,\n vascular congestion, or pleural effusion. The suggested scar at the left base\n on the previous study is not appreciated at this time.\n\n\n"}],"string":"[\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2133-05-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 454935,\n \"text\": \"Aortic aneurysm, abdominal without rupture (AAA)\\n Assessment:\\n s/p endovascular AAA repair/femoral cut down/femoral\\n embolectomy/femoral angioplasty.\\n Action:\\n Remained intubated overnight to keep pt from moving around per\\n attending\\n Response:\\n pt has alcohol history and is restless at baseline\\n Plan:\\n Extubate this am. Pt with history of COPD, receiving 3 doses of\\n methylprednisone.\\n Hyperglycemia\\n Assessment:\\n BS >120\\n Action:\\n BS checked Q6\\n Response:\\n Treated with s/s insulin\\n Plan:\\n Continue per protocol\\n .H/O alcohol abuse\\n Assessment:\\n Per note on careweb pt drinks moderate amount of alcohol\\n Action:\\n Ativan ordered PRN\\n Response:\\n No sign of withdrawal\\n Plan:\\n Medicate PRN\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2133-05-07 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 455022,\n \"text\": \"The patient had back pain from a fall -> pt present for treatment and\\n was incidentially found to have a infranrenal AAA.\\n s/p endovascular AAA repair/femoral cut down/femoral\\n embolectomy/femoral angioplasty, right renal stent.\\n Pt remained intubated overnight d/t copd\\n .H/O alcohol abuse\\n Assessment:\\n Pt report that\\nI drink 2 drinks a day\\n. Pt with 1 breif episode of\\n mild tremors in arms this am. Pt denies hallucinations. No seizure\\n activity. Pt alert and orientated x3.\\n Action:\\n Monitor CIWA scale\\n Monitor for sign and symptoms of withdrawal\\n Response:\\n Besides 1 episode of mild tremors this am, no sign of withdrawals\\n Plan:\\n CIWA scale, monitor for signs of withdrawals, ativan prn\\n Aortic aneurysm, abdominal without rupture (AAA)\\n Assessment:\\n Pt Intubated and sedated this am. PERRL. Pt remains in NSR, no ectopy\\n noted. HR 50-80\\ns. SBP ~ 90-150\\ns. LS coarse with dim bases. pt with +\\n pp by doppler. + hypoactive bs, tolerating clear this afternoon. Foley\\n draining clear yellow urine. UO adequate. Pt with DSD over right groin\\n and left grion\\n Action:\\n Sedation weaned to off this am -> pt weaned to CPAP 50% with\\n 5 peep and 5 PS -> ABG WNL -> pt extubated at 09:20 this am -> placed\\n on 50% face mask\\n Pt up to chair this am\\n Pt given nebs/inhailers as ordered\\n Response:\\n Pt alert and orientated x3. Able to MAE and follow commands. Pt weaned\\n to room air this afternoon, o2 sats ~ 95-98%\\n Plan:\\n BP goal -> SBP 100-140\\ns per team, pulm toleit, pain control, advance\\n diet and activity as tolerated\\n Demographics\\n Attending MD:\\n FRANK B.\\n Admit diagnosis:\\n ABDOMINAL AORTIC ANEURYSM/SDA\\n Code status:\\n Full code\\n Height:\\n 63 Inch\\n Admission weight:\\n 72.3 kg\\n Daily weight:\\n 58.4 kg\\n Allergies/Reactions:\\n Adhesive Tape (Topical)\\n \\\"it rips my ski\\n Precautions:\\n PMH: COPD, ETOH\\n CV-PMH: PVD\\n Additional history: severe COPD, hyperlipidemia, HTN, osteoporosis,\\n hypothyrodism, reflux, s/p excision leasion, s/p shoulder\\n arthroscopy\\n Surgery / Procedure and date: s/p endovascular AAA repair/femoral\\n cut down/femoral embolectomy/femoral angioplasty, right renal stent.\\n remained intubated d/t copd. 700cc ebl. 1u prbc given. 3l\\n crystaloid. to cvicu on propofol 50mcg/kg/min. goal sbp 100-140.\\n awake hypertensive on propofol, 100mcg fentanly given ivp.\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:\\n D:\\n Temperature:\\n 98.6\\n Arterial BP:\\n S:124\\n D:52\\n Respiratory rate:\\n 23 insp/min\\n Heart Rate:\\n 85 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 96% %\\n O2 flow:\\n 10 L/min\\n FiO2 set:\\n 24h total in:\\n 1,082 mL\\n 24h total out:\\n 1,573 mL\\n Pertinent Lab Results:\\n Sodium:\\n 136 mEq/L\\n 04:14 AM\\n Potassium:\\n 4.0 mEq/L\\n 04:14 AM\\n Chloride:\\n 106 mEq/L\\n 04:14 AM\\n CO2:\\n 23 mEq/L\\n 04:14 AM\\n BUN:\\n 12 mg/dL\\n 04:14 AM\\n Creatinine:\\n 0.5 mg/dL\\n 04:14 AM\\n Glucose:\\n 145 mg/dL\\n 04:14 AM\\n Hematocrit:\\n 27.0 %\\n 04:14 AM\\n Finger Stick Glucose:\\n 128\\n 12:00 PM\\n Additional pertinent labs:\\n Lines / Tubes / Drains:\\n right radial A line. left 16 guage PIV and 18 guage PIV placed on\\n \\n Valuables / Signature\\n Patient valuables: Dentures: (Upper, Lower )\\n Other valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry: none\\n Transferred from: \\n Transferred to: VICU\\n Date & time of Transfer: 17:00 pm\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2133-05-07 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 454921,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 2\\n Ideal body weight: 51.5 None\\n Ideal tidal volume: mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation:\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: 19 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: 8 mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Scant\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment:\\n Comments: Pt remains stable on full vent support\\n Plan\\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\\n tolerated, Adjust Min. ventilation to control pH, Increase ventilatory\\n support at night\\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\\n Intolerant of weaning attempts, Cannot protect airway, Cannot manage\\n secretions, Underlying illness not resolved; Comments: Due to severity\\n of OR procedures, pt remained fully sedated on ventilator. Pt is on\\n Propofol. No issues this shift, along with no spontaneous\\n respirations. Pt has clear lung sounds and required minimal\\n suctioning. PT to be assessed by MD team for further weaning. Pt to\\n continue current support.\\n BEDSIDE RSBI- No spontaneous respirations.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2133-05-07 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 455011,\n \"text\": \".H/O alcohol abuse\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Aortic aneurysm, abdominal without rupture (AAA)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2133-05-07 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 455012,\n \"text\": \"The patient had back pain from a fall -> pt present for treatment and\\n was incidentially found to have a infranrenal AAA.\\n s/p endovascular AAA repair/femoral cut down/femoral\\n embolectomy/femoral angioplasty, right renal stent.\\n Pt remained intubated overnight d/t copd\\n .H/O alcohol abuse\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Aortic aneurysm, abdominal without rupture (AAA)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2133-05-07 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 455013,\n \"text\": \"The patient had back pain from a fall -> pt present for treatment and\\n was incidentially found to have a infranrenal AAA.\\n s/p endovascular AAA repair/femoral cut down/femoral\\n embolectomy/femoral angioplasty, right renal stent.\\n Pt remained intubated overnight d/t copd\\n .H/O alcohol abuse\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Aortic aneurysm, abdominal without rupture (AAA)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2133-05-07 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 455017,\n \"text\": \"The patient had back pain from a fall -> pt present for treatment and\\n was incidentially found to have a infranrenal AAA.\\n s/p endovascular AAA repair/femoral cut down/femoral\\n embolectomy/femoral angioplasty, right renal stent.\\n Pt remained intubated overnight d/t copd\\n .H/O alcohol abuse\\n Assessment:\\n Pt report that\\nI drink 2 drinks a day\\n. Pt with 1 breif episode of\\n mild tremors in arms this am. Pt denies hallucinations. No seizure\\n activity. Pt alert and orientated x3.\\n Action:\\n Monitor CIWA scale\\n Monitor for sign and symptoms of withdrawal\\n Response:\\n Besides 1 episode of mild tremors this am, no sign of withdrawals\\n Plan:\\n CIWA scale, monitor for signs of withdrawals, ativan prn\\n Aortic aneurysm, abdominal without rupture (AAA)\\n Assessment:\\n Pt Intubated and sedated this am. PERRL. Pt remains in NSR, no ectopy\\n noted. HR 50-80\\ns. SBP ~ 90-150\\ns. LS coarse with dim bases. pt with +\\n pp by doppler. + hypoactive bs, tolerating clear this afternoon. Foley\\n draining clear yellow urine. UO adequate. Pt with DSD over right groin\\n and left grion\\n Action:\\n Sedation weaned to off this am -> pt weaned to CPAP 50% with\\n 5 peep and 5 PS -> ABG WNL -> pt extubated at 09:20 this am -> placed\\n on 50% face mask\\n Pt up to chair this am\\n Pt given nebs/inhailers as ordered\\n Response:\\n Pt alert and orientated x3. Able to MAE and follow commands. Pt weaned\\n to room air this afternoon, o2 sats ~ 95-98%\\n Plan:\\n BP goal -> SBP 100-140\\ns per team, pulm toleit, pain control, advance\\n diet and activity as tolerated\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2133-05-06 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 454873,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 1\\n Ideal body weight: 51.5 None\\n Ideal tidal volume: mL/kg\\n Tube Type\\n ETT:\\n Position: 19 cm at teeth\\n Route:\\n Type: Standard\\n Size: 7mm\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Clear\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Scant\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Trigger work assessment: Not triggering\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Sedated / Paralyzed\\n Comments:\\n 80yr female s/p repair of AAA with complicated intra-operative\\n progress. Wean as appropriate.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2133-05-07 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 454963,\n \"text\": \"CVICU\\n HPI:\\n HD2\\n POD 1\\n 80 y.o F now s/p EVAR, right renal stent, right femoral endarterectomy\\n and patch angioplasty\\n Chief complaint:\\n PMHx:\\n COPD, HTN, Chol, former tobacco, POLYMYALGIA RHEUMATICA,\\n DIVERTICULOSIS, hypothyroid, GERD\\n Current medications:\\n Calcium Gluconate 2. Chlorhexidine Gluconate 0.12% Oral Rinse 3.\\n Clopidogrel 4. Esmolol 5. Fentanyl Citrate\\n 6. FoLIC Acid 7. Lorazepam 8. Magnesium Sulfate 9. MethylPREDNISolone\\n Sodium Succ 10. Multivitamins\\n 11. Nitroglycerin 12. Phenylephrine 13. Potassium Chloride 14. Propofol\\n 15. Thiamine\\n 24 Hour Events:\\n OR RECEIVED - At 05:51 PM\\n ARTERIAL LINE - START 05:54 PM\\n INTUBATION - At 06:27 PM\\n INVASIVE VENTILATION - START 06:27 PM\\n Post operative day:\\n 1\\n Allergies:\\n Adhesive Tape (Topical)\\n \\\"it rips my ski\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Flowsheet Data as of 08:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 36\\nC (96.8\\n T current: 35.9\\nC (96.6\\n HR: 61 (54 - 86) bpm\\n BP: 126/57(83) {87/45(61) - 149/70(102)} mmHg\\n RR: 32 (12 - 32) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 58.4 kg (admission): 72.3 kg\\n Height: 63 Inch\\n Total In:\\n 686 mL\\n 909 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 686 mL\\n 909 mL\\n Blood products:\\n Total out:\\n 338 mL\\n 447 mL\\n Urine:\\n 338 mL\\n 447 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 348 mL\\n 462 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 450 (450 - 450) mL\\n Vt (Spontaneous): 644 (326 - 644) mL\\n PS : 5 cmH2O\\n RR (Set): 16\\n RR (Spontaneous): 17\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI Deferred: No Spon Resp\\n PIP: 10 cmH2O\\n Plateau: 14 cmH2O\\n Compliance: 50 cmH2O/mL\\n SPO2: 100%\\n ABG: 7.42/37/166/23/0\\n Ve: 5.8 L/min\\n PaO2 / FiO2: 415\\n Physical Examination\\n General Appearance: No acute distress, intubated, following commands\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender\\n Left Extremities: (Edema: Absent), (Temperature: Cool), (Pulse -\\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\\n Right Extremities: (Edema: Absent), (Temperature: Cool), (Pulse -\\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: Follows simple commands, Moves all extremities\\n Labs / Radiology\\n 177 K/uL\\n 9.3 g/dL\\n 145 mg/dL\\n 0.5 mg/dL\\n 23 mEq/L\\n 4.0 mEq/L\\n 12 mg/dL\\n 106 mEq/L\\n 136 mEq/L\\n 27.0 %\\n 7.4 K/uL\\n [image002.jpg]\\n 06:13 PM\\n 06:27 PM\\n 12:34 AM\\n 04:14 AM\\n WBC\\n 6.1\\n 7.4\\n Hct\\n 28.1\\n 27.0\\n Plt\\n 178\\n 177\\n Creatinine\\n 0.5\\n 0.5\\n TCO2\\n 28\\n 25\\n Glucose\\n 141\\n 145\\n Other labs: PT / PTT / INR:14.1/38.5/1.2, Differential-Neuts:86.1 %,\\n Lymph:9.7 %, Mono:3.1 %, Eos:0.8 %, Ca:7.7 mg/dL, Mg:2.3 mg/dL, PO4:3.9\\n mg/dL\\n Assessment and Plan\\n HYPERGLYCEMIA, .H/O ALCOHOL ABUSE, AORTIC ANEURYSM, ABDOMINAL WITHOUT\\n RUPTURE (AAA)\\n Assessment and Plan: HD2\\n POD 0\\n 80 y.o F now s/p EVAR, right renal stent, right femoral endarterectomy\\n and patch angioplasty\\n Neurologic: Pain controlled, awake, alert\\n Cardiovascular: hemodynamically stable, restart b blocker and statin\\n Pulmonary: IS, Extubate today, extubate now, intubated perioperatively\\n Gastrointestinal / Abdomen:\\n Nutrition: NPO, Advance diet as tolerated\\n Renal: Foley, Adequate UO, lasix for diuresis\\n Hematology: stable\\n Endocrine: RISS\\n Infectious Disease: no issues\\n Lines / Tubes / Drains: Foley\\n Wounds: Dry dressings\\n Imaging:\\n Fluids: KVO\\n Consults: Vascular surgery\\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Arterial Line - 05:54 PM\\n 18 Gauge - 05:54 PM\\n 16 Gauge - 06:00 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 33 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2133-05-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1074663,\n \"text\": \" 6:22 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval ETT\\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman s/p EVAR, check ETT placement\\n REASON FOR THIS EXAMINATION:\\n eval ETT\\n ______________________________________________________________________________\\n WET READ: MBue WED 8:53 PM\\n ETT terminating approx 4.6 cm above carina. clear lungs\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post EVAR, for ET tube placement.\\n\\n FINDINGS: In comparison with the study of , there has been placement of\\n an endotracheal tube that lies approximately 4.6 cm above the carina.\\n Otherwise, there is no interval change. No evidence of acute focal pneumonia,\\n vascular congestion, or pleural effusion. The suggested scar at the left base\\n on the previous study is not appreciated at this time.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":24640,"cells":{"subject_id":{"kind":"number","value":46228,"string":"46,228"},"hadm_id":{"kind":"number","value":151469,"string":"151,469"},"target_text":{"kind":"string","value":"HOSPITAL COURSE: This is a 61 year old gentleman with PMHx of polysubstance abuse, who is quite well known to the emergency department, who presented to the ED in the setting of alcohol intoxication, status post intubation for airway protection. He was admitted to the medical intensive care unit for management of his airway. He was extubated within 24 hours. Due to his frequent admissions for alcohol detoxication and significant risk of death associated with his frank inability to care for himself secondary to severe alcohol dependance, a section 35 was obtained to evaluate for mandated medical detox and substance abuse rehabilitation. . ALCOHOL INTOXICATION: The patient was intubated in the field for alcohol detoxication. He was extubated withing 24 hours. A psychiatric evaluation was performed, there was no evidence of mental illness other than severe alcohol dependance. The patient was treated with valium for management of alcohol withdrawal symptoms and was medically stable at the time of discharge. He was given a multivitamin, folic acid and thiamine prior to discharge. . DISPOSITION: Since , the patient was seen in the emergency department 33 times for alcohol related visits with 24 admissions to a medical unit for management of alcohol dependance, withdrawal symptoms. In the last week (starting ) he was seen in the ED 3 times with 3 admissions for alcohol intoxication, the last resulting in intubation. The patient has been seen by social work during his multiple admissions where there documented that the patient has no insignt into his alcohol depenance, does not admit that his intoxication led to this admission. The patient has repeatedly rejected any SW intervention to deal with substance abuse and refuses to speak or commit to any other support for sobriety. Given the frequency of admissions for alcohol dependance and his high risk of death due to consequences of his substance abuse. A section 35 was obtained, and the patient was transported by police escort to court. It is strongly recommended that the patient have medical detox and prolonged substance abuse rehabilitation. . FACIAL FRACTURE: CT sinus revealed a new minimally displaced comminuted fractures involving the right maxillary sinus and the right orbital floor and junction of the maxilla and zygomatic arch. Plastic surgery was consulted who recommended treatment with Augmentin for 7 days and follow-up in plastic surgery clinic. He was recommended to use afrin twice daily and sudafed daily for four days as sinue precautions. . HYPERTENSION: Home dose of amlodipine initially held and then restarted. . TRANSITIONS OF CARE: - Section 35 court - Continue Augmentin x 7 days, afrin twice daily and sudafed daily for 4 days"},"extractive_notes_summ":{"kind":"string","value":"New minimally displaced comminuted fractures involving the right maxillary sinus and the right orbital floor and junction of the maxilla and zygomatic arch. FINDINGS: Minimally displaced fractures involving the anterior and lateral walls of the right maxillary sinus are noted (since ). CT Head from . Mildly displaced comminuted fractures involving the right maxillary sinus and right orbital floor, and nasal and ethmoid bones as described above with near-complete opacification of the sinuses and nasopharynx. The cardiac, mediastinal and hilar contours are unremarkable, and the lungs appear clear. There is an ET tube and NG tube in place. bleed FINAL REPORT (Cont) IMPRESSION: 1. Fracture fragments are displaced into the sinus. Secretions in the nasopharynx. Secretions in the nasopharynx. Comminuted fracture of the nasal bones with near opacification of the nasopharynx are noted with anterior ethmoid fractures. The mastoid air cells are completely opacified on the left and partially aerated on the right. The ventricles and sulci are mildly prominent consistent with atrophy. These extend into the right lateral orbital floor and to the junction of the maxilla and the zyogmatic arch. Fractured nasal bones. Opacification of sinuses as seen on prior studies. IMPRESSION: Status post endotracheal intubation. There is complete opacification of the left maxillary sinus and near complete opacification of the right maxillary sinus. Sinus rhythm. There are minimally displaced comminuted fractures involving the anterior wall of the right maxillary sinus extending into the orbital floor as well as the posterior wall of the maxillary sinus, with fracture fragments displaced into the sinus. COMPARISONS: CT head and CT C-spine from . The vertebral body heights and disc spaces are grossly maintained. There is hypodensity of the periventricular white matter, most consistent with chronic small vessel ischemic disease. Opacification of the right and left mastoid air cells. There are secretions within the oropharynx. The nasal cavity is completely opacified. Coronal and sagittal reformats were completed. Coronal and sagittal reformats were completed. Small vessel ischemic disease. Small vessel ischemic disease. Bilateral anterior nasal bone fractures. Displaced comminuted fractures of the right maxillary sinus involving the anterior wall/orbital floor adjacent to the zygomatic arch and the posterior wall with complete opacification of the bilateral maxillary sinuses. Old nasal bone deformity. neck: ?fx MEDICAL CONDITION: History: 62M with altered MS, unknown trauma REASON FOR THIS EXAMINATION: Head: ?ICH. TECHNIQUE: Chest, portable AP supine. Displaced fractures of the right maxillary sinus involving the anterior wall/orbital floor adjacent to the zygomatic arch and the posterior wall with complete opacification of the bilateral maxillary sinuses. Coronal reformats were completed. Chronic sinus disease with likely some component of hemorrhage in the right maxillary sinus. Normal sinus rhythm. Compared to the previous tracing of no change. Findings suggesting small vessel ischemic disease. There is mucosal thickening involving the ethmoid sinuses. IMPRESSION: 1. There is ethmoidal mucosal thickening. Complete opacification of the left maxillary sinus as well as near opacification of the right maxillary sinus is mostly chronic, however there is likely a small component of hemorrhage on the right. Patient is intubated, an ET tube and NG tube are present. There is a small right extraconal hematoma but no orbital fat herniation or globe hemorrhage or rupture. 2:43 PM CHEST (PORTABLE AP) Clip # Reason: ?tube placement MEDICAL CONDITION: History: 62M with intubated due to altered MS REASON FOR THIS EXAMINATION: ?tube placement No contraindications for IV contrast FINAL REPORT CHEST RADIOGRAPH HISTORY: Altered mental status. No evidence of acute intracranial process. bleed MEDICAL CONDITION: History: 62M with ams REASON FOR THIS EXAMINATION: ? The thyroid gland is unremarkable. Normal tracing. Normal tracing. TECHNIQUE: Contiguous axial images obtained through the cervical spine without the administration of intravenous contrast material. A nasogastric tube has been passed into the stomach. Fractures of the nasal bone are chronic. FINDINGS: An endotracheal tube has been placed, terminating approximately 5 cm above the carina. 3:03 PM CT C-SPINE W/O CONTRAST Clip # Reason: Head: ?ICH. Compared to the previous tracingof there is no significant change. 5:52 PM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # Reason: characterize fractures MEDICAL CONDITION: History: 62M with facial trauma REASON FOR THIS EXAMINATION: characterize fractures No contraindications for IV contrast WET READ: RJab WED 7:57 PM minimally displaced comminuted fractures of the right maxillary sinus involving the anterior wall and right inferior orbial floor as well as the posterior and medial walls. No acute intracranial hemorrhage or infarction. No acute intracranial hemorrhage or infarction. COMPARISONS: None. COMPARISONS: None. COMPARISONS: None. No evidence of acute disease. FINDINGS: There is no acute fracture, malalignment or prevertebral soft tissue swelling. 3. 3. TECHNIQUE: MDCT axial images were obtained through the facial bones without the administration of intravenous contrast material."},"n_notes":{"kind":"number","value":6,"string":"6"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2186-05-31 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":1242559,"text":" 3:03 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: Head: ?ICH. neck: ?fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 62M with altered MS, unknown trauma\n REASON FOR THIS EXAMINATION:\n Head: ?ICH. neck: ?fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RJab WED 4:05 PM\n No acute fracture or malalignment of the cervical spine\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old man with altered mental status, unknown trauma,\n question neck fracture.\n\n COMPARISONS: None.\n\n TECHNIQUE: Contiguous axial images obtained through the cervical spine\n without the administration of intravenous contrast material. Coronal and\n sagittal reformats were completed.\n\n FINDINGS: There is no acute fracture, malalignment or prevertebral soft\n tissue swelling. The vertebral body heights and disc spaces are grossly\n maintained. There is calcification of the anterior longitudinal ligament\n spanning C5, C6 and C7. There is an ET tube and NG tube in place. The\n visualized lung apices are clear. The thyroid gland is unremarkable. There\n are secretions within the oropharynx.\n\n IMPRESSION: No evidence of acute fracture or traumatic malalignment.\n\n"},{"category":"Radiology","chartdate":"2186-05-31 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1242564,"text":" 3:31 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 62M with ams\n REASON FOR THIS EXAMINATION:\n ? bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RJab WED 5:50 PM\n 1. No acute intracranial hemorrhage or infarction. Small vessel ischemic\n disease.\n 2. Displaced comminuted fractures of the right maxillary sinus involving the\n anterior wall/orbital floor adjacent to the zygomatic arch and the posterior\n wall with complete opacification of the bilateral maxillary sinuses. Fractured\n nasal bones. Secretions in the nasopharynx.\n\n WET READ VERSION #1\n WET READ VERSION #2 RJab WED 3:57 PM\n 1. No acute intracranial hemorrhage or infarction. Small vessel ischemic\n disease.\n 2. Displaced fractures of the right maxillary sinus involving the anterior\n wall/orbital floor adjacent to the zygomatic arch and the posterior wall with\n complete opacification of the bilateral maxillary sinuses. Secretions in the\n nasopharynx.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old man with altered mental status, question bleed.\n\n COMPARISONS: None.\n\n TECHNIQUE: Contiguous axial imaging was obtained through the brain without\n the administration of intravenous contrast material. Coronal and sagittal\n reformats were completed.\n\n FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or large\n territorial infarction. The ventricles and sulci are mildly prominent\n consistent with atrophy. There is hypodensity of the periventricular white\n matter, most consistent with chronic small vessel ischemic disease. The\n mastoid air cells are completely opacified on the left and partially aerated\n on the right.\n\n There are minimally displaced comminuted fractures involving the anterior wall\n of the right maxillary sinus extending into the orbital floor as well as the\n posterior wall of the maxillary sinus, with fracture fragments displaced into\n the sinus. There is complete opacification of the left maxillary sinus and\n near complete opacification of the right maxillary sinus. Comminuted fracture\n of the nasal bones with near opacification of the nasopharynx are noted with\n anterior ethmoid fractures. There is mucosal thickening involving the ethmoid\n sinuses.\n\n (Over)\n\n 3:31 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? bleed\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n\n 1. No evidence of acute intracranial process. Findings suggesting small\n vessel ischemic disease.\n\n 2. Mildly displaced comminuted fractures involving the right maxillary sinus\n and right orbital floor, and nasal and ethmoid bones as described above with\n near-complete opacification of the sinuses and nasopharynx.\n\n 3. Opacification of the right and left mastoid air cells.\n\n"},{"category":"Radiology","chartdate":"2186-05-31 00:00:00.000","description":"CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST","row_id":1242581,"text":" 5:52 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: characterize fractures\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 62M with facial trauma\n REASON FOR THIS EXAMINATION:\n characterize fractures\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RJab WED 7:57 PM\n minimally displaced comminuted fractures of the right maxillary sinus\n involving the anterior wall and right inferior orbial floor as well as the\n posterior and medial walls. Bilateral anterior nasal bone fractures.\n Opacification of sinuses as seen on prior studies.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old male with facial trauma, characterize fractures.\n\n COMPARISONS: CT head and CT C-spine from . CT Head from .\n\n TECHNIQUE: MDCT axial images were obtained through the facial bones without\n the administration of intravenous contrast material. Coronal reformats were\n completed.\n\n FINDINGS: Minimally displaced fractures involving the anterior and lateral\n walls of the right maxillary sinus are noted (since ). These\n extend into the right lateral orbital floor and to the junction of the maxilla\n and the zyogmatic arch. Fracture fragments are displaced into the sinus. There\n is a small right extraconal hematoma but no orbital fat herniation or globe\n hemorrhage or rupture. Fractures of the nasal bone are chronic. Complete\n opacification of the left maxillary sinus as well as near opacification of the\n right maxillary sinus is mostly chronic, however there is likely a small\n component of hemorrhage on the right. The nasal cavity is completely\n opacified. There is ethmoidal mucosal thickening. Patient is intubated, an\n ET tube and NG tube are present.\n\n IMPRESSION:\n 1. New minimally displaced comminuted fractures involving the right maxillary\n sinus and the right orbital floor and junction of the maxilla and zygomatic\n arch.\n 2. Old nasal bone deformity.\n 3. Chronic sinus disease with likely some component of hemorrhage in the\n right maxillary sinus.\n\n"},{"category":"Radiology","chartdate":"2186-05-31 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1242552,"text":" 2:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 62M with intubated due to altered MS\n REASON FOR THIS EXAMINATION:\n ?tube placement\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n HISTORY: Altered mental status.\n\n COMPARISONS: None.\n\n TECHNIQUE: Chest, portable AP supine.\n\n FINDINGS: An endotracheal tube has been placed, terminating approximately 5\n cm above the carina. A nasogastric tube has been passed into the stomach.\n The cardiac, mediastinal and hilar contours are unremarkable, and the lungs\n appear clear. There are no pleural effusions or pneumothorax.\n\n IMPRESSION: Status post endotracheal intubation. No evidence of acute\n disease.\n\n\n"},{"category":"ECG","chartdate":"2186-05-31 00:00:00.000","description":"Report","row_id":307523,"text":"Normal sinus rhythm. Normal tracing. Compared to the previous tracing\nof there is no significant change.\n\n"},{"category":"ECG","chartdate":"2186-05-29 00:00:00.000","description":"Report","row_id":307524,"text":"Sinus rhythm. Normal tracing. Compared to the previous tracing of \nno change.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-05-31 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 1242559,\n \"text\": \" 3:03 PM\\n CT C-SPINE W/O CONTRAST Clip # \\n Reason: Head: ?ICH. neck: ?fx\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n History: 62M with altered MS, unknown trauma\\n REASON FOR THIS EXAMINATION:\\n Head: ?ICH. neck: ?fx\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: RJab WED 4:05 PM\\n No acute fracture or malalignment of the cervical spine\\n\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 62-year-old man with altered mental status, unknown trauma,\\n question neck fracture.\\n\\n COMPARISONS: None.\\n\\n TECHNIQUE: Contiguous axial images obtained through the cervical spine\\n without the administration of intravenous contrast material. Coronal and\\n sagittal reformats were completed.\\n\\n FINDINGS: There is no acute fracture, malalignment or prevertebral soft\\n tissue swelling. The vertebral body heights and disc spaces are grossly\\n maintained. There is calcification of the anterior longitudinal ligament\\n spanning C5, C6 and C7. There is an ET tube and NG tube in place. The\\n visualized lung apices are clear. The thyroid gland is unremarkable. There\\n are secretions within the oropharynx.\\n\\n IMPRESSION: No evidence of acute fracture or traumatic malalignment.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-05-31 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1242564,\n \"text\": \" 3:31 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: ? bleed\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n History: 62M with ams\\n REASON FOR THIS EXAMINATION:\\n ? bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: RJab WED 5:50 PM\\n 1. No acute intracranial hemorrhage or infarction. Small vessel ischemic\\n disease.\\n 2. Displaced comminuted fractures of the right maxillary sinus involving the\\n anterior wall/orbital floor adjacent to the zygomatic arch and the posterior\\n wall with complete opacification of the bilateral maxillary sinuses. Fractured\\n nasal bones. Secretions in the nasopharynx.\\n\\n WET READ VERSION #1\\n WET READ VERSION #2 RJab WED 3:57 PM\\n 1. No acute intracranial hemorrhage or infarction. Small vessel ischemic\\n disease.\\n 2. Displaced fractures of the right maxillary sinus involving the anterior\\n wall/orbital floor adjacent to the zygomatic arch and the posterior wall with\\n complete opacification of the bilateral maxillary sinuses. Secretions in the\\n nasopharynx.\\n\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 62-year-old man with altered mental status, question bleed.\\n\\n COMPARISONS: None.\\n\\n TECHNIQUE: Contiguous axial imaging was obtained through the brain without\\n the administration of intravenous contrast material. Coronal and sagittal\\n reformats were completed.\\n\\n FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or large\\n territorial infarction. The ventricles and sulci are mildly prominent\\n consistent with atrophy. There is hypodensity of the periventricular white\\n matter, most consistent with chronic small vessel ischemic disease. The\\n mastoid air cells are completely opacified on the left and partially aerated\\n on the right.\\n\\n There are minimally displaced comminuted fractures involving the anterior wall\\n of the right maxillary sinus extending into the orbital floor as well as the\\n posterior wall of the maxillary sinus, with fracture fragments displaced into\\n the sinus. There is complete opacification of the left maxillary sinus and\\n near complete opacification of the right maxillary sinus. Comminuted fracture\\n of the nasal bones with near opacification of the nasopharynx are noted with\\n anterior ethmoid fractures. There is mucosal thickening involving the ethmoid\\n sinuses.\\n\\n (Over)\\n\\n 3:31 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: ? bleed\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n IMPRESSION:\\n\\n 1. No evidence of acute intracranial process. Findings suggesting small\\n vessel ischemic disease.\\n\\n 2. Mildly displaced comminuted fractures involving the right maxillary sinus\\n and right orbital floor, and nasal and ethmoid bones as described above with\\n near-complete opacification of the sinuses and nasopharynx.\\n\\n 3. Opacification of the right and left mastoid air cells.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-05-31 00:00:00.000\",\n \"description\": \"CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST\",\n \"row_id\": 1242581,\n \"text\": \" 5:52 PM\\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \\n Reason: characterize fractures\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n History: 62M with facial trauma\\n REASON FOR THIS EXAMINATION:\\n characterize fractures\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: RJab WED 7:57 PM\\n minimally displaced comminuted fractures of the right maxillary sinus\\n involving the anterior wall and right inferior orbial floor as well as the\\n posterior and medial walls. Bilateral anterior nasal bone fractures.\\n Opacification of sinuses as seen on prior studies.\\n\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 62-year-old male with facial trauma, characterize fractures.\\n\\n COMPARISONS: CT head and CT C-spine from . CT Head from .\\n\\n TECHNIQUE: MDCT axial images were obtained through the facial bones without\\n the administration of intravenous contrast material. Coronal reformats were\\n completed.\\n\\n FINDINGS: Minimally displaced fractures involving the anterior and lateral\\n walls of the right maxillary sinus are noted (since ). These\\n extend into the right lateral orbital floor and to the junction of the maxilla\\n and the zyogmatic arch. Fracture fragments are displaced into the sinus. There\\n is a small right extraconal hematoma but no orbital fat herniation or globe\\n hemorrhage or rupture. Fractures of the nasal bone are chronic. Complete\\n opacification of the left maxillary sinus as well as near opacification of the\\n right maxillary sinus is mostly chronic, however there is likely a small\\n component of hemorrhage on the right. The nasal cavity is completely\\n opacified. There is ethmoidal mucosal thickening. Patient is intubated, an\\n ET tube and NG tube are present.\\n\\n IMPRESSION:\\n 1. New minimally displaced comminuted fractures involving the right maxillary\\n sinus and the right orbital floor and junction of the maxilla and zygomatic\\n arch.\\n 2. Old nasal bone deformity.\\n 3. Chronic sinus disease with likely some component of hemorrhage in the\\n right maxillary sinus.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-05-31 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1242552,\n \"text\": \" 2:43 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?tube placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n History: 62M with intubated due to altered MS\\n REASON FOR THIS EXAMINATION:\\n ?tube placement\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n HISTORY: Altered mental status.\\n\\n COMPARISONS: None.\\n\\n TECHNIQUE: Chest, portable AP supine.\\n\\n FINDINGS: An endotracheal tube has been placed, terminating approximately 5\\n cm above the carina. A nasogastric tube has been passed into the stomach.\\n The cardiac, mediastinal and hilar contours are unremarkable, and the lungs\\n appear clear. There are no pleural effusions or pneumothorax.\\n\\n IMPRESSION: Status post endotracheal intubation. No evidence of acute\\n disease.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2186-05-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 307523,\n \"text\": \"Normal sinus rhythm. Normal tracing. Compared to the previous tracing\\nof there is no significant change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2186-05-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 307524,\n \"text\": \"Sinus rhythm. Normal tracing. Compared to the previous tracing of \\nno change.\\n\\n\"\n }\n]"}}},{"rowIdx":24641,"cells":{"subject_id":{"kind":"number","value":57091,"string":"57,091"},"hadm_id":{"kind":"number","value":165797,"string":"165,797"},"target_text":{"kind":"string","value":"54 yo male with progressive IPF undergoing transplant evaluation at admitted with worsening hypoxia and dyspnea on exertion, found to have progression of IPF on chest CT."},"extractive_notes_summ":{"kind":"string","value":"FINDINGS: Previously reported pneumomediastinum has resolved. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Minor right ventricular conduction delay. No contraindications for IV contrast FINAL REPORT CT CHEST, . ECG: NSR, nl axis, nl intervals, poor R wave progression, TWI V2-3 (new), no ST changes compared to prior. ECG: NSR, nl axis, nl intervals, poor R wave progression, TWI V2-3 (new), no ST changes compared to prior. He denied PND, worsening orthopnea, LE swelling. He denied PND, worsening orthopnea, LE swelling. IMPRESSION: Mild-moderate pulmonary artery systolic hypertension suggestive of a primary pulmonary process. IMPRESSION: Mild-moderate pulmonary artery systolic hypertension suggestive of a primary pulmonary process. Recently admitted with pneumomediastinum his sever IPF. Recently admitted with pneumomediastinum his sever IPF. Left upper pole renal mass, previously shown to be complex by recent ultrasound examination. Left upper pole renal mass, previously shown to be complex by recent ultrasound examination. Resolution of pneumomediastinum. Interstitial Lung Disease (ILD including IPF, UIP, NSIP, DIP, LIP, etc) Assessment: Patient received on 2.5l n/c with stas @ 94-96%, RR 20-30, lungs sound rhonchus, patient says that sats are at baseline but continues SOB on exertion, no ABS at this time [ received levoquin in ED] Action: Sats satisfactory n/c continues at 2.5l Response: Sats 97% rr 20-30 Plan: Wean fio2 as tolerated, encourage /deep breath ? He then represented to on for spontaneous pneumomediastinum of unclear etiology. He then represented to on for spontaneous pneumomediastinum of unclear etiology. He then represented to on for spontaneous pneumomediastinum of unclear etiology. Review of systems: Constitutional: Fatigue Cardiovascular: Chest pain, Palpitations, No(t) Edema, Tachycardia, No(t) Orthopnea Respiratory: , Dyspnea, Tachypnea, No(t) Wheeze Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis, No(t) Diarrhea, No(t) Constipation Genitourinary: No(t) Dysuria, No(t) Foley Musculoskeletal: No(t) Joint pain Integumentary (skin): No(t) Jaundice Heme / Lymph: No(t) Lymphadenopathy Neurologic: No(t) Numbness / tingling, No(t) Headache Pain: No pain / appears comfortable Flowsheet Data as of 03:38 AM Vital Signs Hemodynamic monitoring Fluid Balance 24 hours Since 12 AM Tmax: 37.2C (98.9 Tcurrent: 37.2C (98.9 HR: 79 (79 - 98) bpm BP: 122/69(82) {122/69(82) - 128/80(92)} mmHg RR: 30 (18 - 30) insp/min SpO2: 99% Heart rhythm: SR (Sinus Rhythm) Height: 67 Inch Total In: 124 mL PO: TF: IVF: 124 mL Blood products: Total out: 0 mL 0 mL Urine: NG: Stool: Drains: Balance: 0 mL 124 mL Respiratory O2 Delivery Device: Nasal cannula SpO2: 99% Physical Examination General Appearance: Well nourished Eyes / Conjunctiva: PERRL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Breath Sounds: Crackles : velcro-like, No(t) Bronchial: , No(t) Wheezes : , Diminished: poor inspiratory efforts) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right: Absent, Left: Absent Skin: Warm Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Labs / Radiology 2 98 3.8 139 41.4 12.5 [image002.jpg] Other labs: PT / PTT / INR://1.4, Lactic Acid:1.1 Imaging: CXR: extensive fibrotic changes Chest CT: IMPRESSION: 1."},"n_notes":{"kind":"number","value":8,"string":"8"},"notes":{"kind":"list like","value":[{"category":"Nursing","chartdate":"2141-02-01 00:00:00.000","description":"Nursing 0100 - 0700","row_id":556417,"text":"Interstitial Lung Disease (ILD including IPF, UIP, NSIP, DIP, LIP, etc)\n Assessment:\n 54 year old male with a history of sever IPF. Recently admitted with\n pneumomediastinum his sever IPF. Pt is being followed up at the\n hospital for work up of lung transplant. At baseline pt does\n wear portable O2 of 2-3L NC. Upon arrival to the unit pt was on 4L NC,\n with a SpO2 of 95-97%. Pt states no symptoms of SOB and was able to\n transfer self from ED stretcher to bed. Lung sounds in all fields have\n a\nVelcro\n sounds to them. Pt with strong cough. Pt states that he has\n had this\ntickling\n in the back of his throat for several days. Pt\n denies any chest pain or discomfort. A-febrile, and has not been around\n any person with respiratory infections.\n Action:\n O2 decreased to 2.5L NC.\n Response:\n Pt 2 97-99%\n Plan:\n Monitor pt respiratory status, and Provide continuous O2. Provide\n emotional support to both pt and family.\n"},{"category":"Nursing","chartdate":"2141-02-01 00:00:00.000","description":"Nursing Transfer Note","row_id":556455,"text":"54 y/o M w/IPF, called today with worsening dyspnea x 3 days. He had\n been in unusal state of health at baseline resp status (using 4L NC at\n rest and 6L NC with exertion) when 3 days PTA, he hugged his cousin who\n has rats for pets and also the heat came up from the basement of his\n house. He feels that with these two events, he breathing became acutely\n worse and is concerned for allergen exposure. He denies any sick\n contacts, fevers, chills, worsening /productive , rhinorrhea.\n He did receive flu and pneumovax.\n .\n He has had a recent admissions in /09 with progressive DOE. CT\n revealed increased ground glass opacity in LL superimposed on pulmonary\n fibrosis with elevated eosinophils peripherally (12%). A BAL was also\n positive for eosinophils. He was started on high dose steroids\n (prednisone 60mg) with plan for close outpatient follow up for\n eosinophilic lung disease. He was discharged on on 2-3L NC. He then\n represented to on for spontaneous pneumomediastinum of\n unclear etiology.\n .\n On day of admission, Pt called pulmonologist (Dr. c/o worsening\n shortness of breath since Saturday . Yesterday he was at pulmonary\n rehab and desaturated to the 70s on 6L with minimal exertion, and he is\n currently on 4L NC at rest. No sick\n contacts recently and has not changed. He was asked to go to ED\n given concern for either acute exacerbation of underlying IPF vs\n superimposed infection vs pneumothorax. Patient is currently being\n worked up at for lung tx\n .\n In the ED, initial vs were: 98.3, 96, 144/97, 24, 97% 6L NC. Patient\n was given levoquin X 1 and was sent to floor. Of note, by transfer to\n ICU, his sats in ED were near baseline at 96% 4L NC.\n Interstitial Lung Disease (ILD including IPF, UIP, NSIP, DIP, LIP, etc)\n Assessment:\n Patient received on 2.5l n/c with stas @ 94-96%, RR 20-30, lungs sound\n rhonchus, patient says that sats are at baseline but continues SOB on\n exertion, no ABS at this time [ received levoquin in ED]\n Action:\n Sats satisfactory n/c continues at 2.5l\n Response:\n Sats 97% rr 20-30\n Plan:\n Wean fio2 as tolerated, encourage /deep breath ? to commence\n steriods/ABS, await CXR review\n Demographics\n Attending MD:\n \n Admit diagnosis:\n DYSPNEA\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 64 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Unknown;\n Precautions:\n PMH:\n CV-PMH:\n Additional history: pneumomediastinum\n severe IPF\n left upper pole renal mass\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:116\n D:76\n Temperature:\n 97\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 30 insp/min\n Heart Rate:\n 87 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 387 mL\n 24h total out:\n 1,150 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:47 AM\n Potassium:\n 4.4 mEq/L\n 04:47 AM\n Chloride:\n 101 mEq/L\n 04:47 AM\n CO2:\n 31 mEq/L\n 04:47 AM\n BUN:\n 12 mg/dL\n 04:47 AM\n Creatinine:\n 0.9 mg/dL\n 04:47 AM\n Glucose:\n 99 mg/dL\n 04:47 AM\n Hematocrit:\n 39.1 %\n 04:47 AM\n Valuables / Signature\n Patient valuables: with patient\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: micu 6\n Transferred to: cc7\n Date & time of Transfer: \n"},{"category":"Physician ","chartdate":"2141-02-01 00:00:00.000","description":"Physician Resident/Attending Admission Note - MICU","row_id":556462,"text":"Chief Complaint: DOE\n HPI:\n 54 y/o M w/IPF, called today with worsening dyspnea x 3 days. He had\n been in unusal state of health at baseline resp status (using 4L NC at\n rest and 6L NC with exertion) when 3 days PTA, he hugged his cousin who\n has rats for pets and also the heat came up from the basement of his\n house. He feels that with these two events, he breathing became acutely\n worse and is concerned for allergen exposure. He denies any sick\n contacts, fevers, chills, worsening /productive , rhinorrhea.\n He did receive flu and pneumovax.\n .\n He has had a recent admissions in /09 with progressive DOE. CT\n revealed increased ground glass opacity in LL superimposed on pulmonary\n fibrosis with elevated eosinophils peripherally (12%). A BAL was also\n positive for eosinophils. He was started on high dose steroids\n (prednisone 60mg) with plan for close outpatient follow up for\n eosinophilic lung disease. He was discharged on on 2-3L NC. He then\n represented to on for spontaneous pneumomediastinum of\n unclear etiology.\n .\n On day of admission, Pt called pulmonologist (Dr. c/o worsening\n shortness of breath since Saturday . Yesterday he was at pulmonary\n rehab and desaturated to the 70s on 6L with minimal exertion, and he is\n currently on 4L NC at rest. No sick\n contacts recently and has not changed. He was asked to go to ED\n given concern for either acute exacerbation of underlying IPF vs\n superimposed infection vs pneumothorax.\n .\n In the ED, initial vs were: 98.3, 96, 144/97, 24, 97% 6L NC. Patient\n was given levoquin X 1 and was sent to floor. Of note, by transfer to\n ICU, his sats in ED were near baseline at 96% 4L NC.\n .\n On the floor, he reports feeling comfortable. He denies any complaints\n except that with exertion he has noticed left sided chest pain, that\n does not radiate to jaw or arm. He also notes occasional palpitations\n (rapid, regular) which have been lasting up to 1 hour ocuring more\n frequently. He denied PND, worsening orthopnea, LE swelling.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Levofloxacin - 01:11 AM\n Infusions:\n Other ICU medications:\n Other medications:\n HOME\n Acetylcysteine 600 mg TID\n Acetaminophen 500 mg PRN\n Calcium 500 mg TID\n Vitamin D 400 \n Past medical history:\n Family history:\n Social History:\n # IPF\n # HTN\n Brother: died \n Occupation:\n Drugs: none\n Tobacco: Smoked for 19 yrs but quit 19yrs ago\n Alcohol: . No EtOH use for 20 years\n Other: Currently not working but previously worked as a painter as well\n as sandblasting for 4 yrs during the (wore respirator but\n beard prevented tight seal). Occasionally travels overseas to\n and but states not a/w Sx. No known asbestos exposure.\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Chest pain, Palpitations, No(t) Edema, Tachycardia,\n No(t) Orthopnea\n Respiratory: , Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Jaundice\n Heme / Lymph: No(t) Lymphadenopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Pain: No pain / appears comfortable\n Flowsheet Data as of 03:38 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 79 (79 - 98) bpm\n BP: 122/69(82) {122/69(82) - 128/80(92)} mmHg\n RR: 30 (18 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 124 mL\n PO:\n TF:\n IVF:\n 124 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 124 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Crackles : velcro-like, No(t)\n Bronchial: , No(t) Wheezes : , Diminished: poor inspiratory efforts)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 2\n 98\n 3.8\n 139\n 41.4\n 12.5\n [image002.jpg]\n Other labs: PT / PTT / INR://1.4, Lactic Acid:1.1\n Imaging: CXR: extensive fibrotic changes\n Chest CT:\n IMPRESSION:\n 1. New pneumomediastinum, possibly spontaneous in the setting of\n diffuse pulmonary fibrosis, but correlation with clinical history\n recommended to exclude other potential causes such as esophageal or\n airway perforation, particularly if the patient has undergone recent\n intervention.\n 2. No change in severe pulmonary fibrosis or associated ground-glass\n attenuation since recent CT of .\n 3. Left upper pole renal mass, previously shown to be complex by recent\n ultrasound examination. This could be further evaluated by MRI.\n .\n ECHO: The left atrium and right atrium are normal in cavity\n size. Left ventricular wall thickness, cavity size and regional/global\n systolic function are normal (LVEF >55%). Tissue Doppler imaging\n suggests a normal left ventricular filling pressure (PCWP<12mmHg).\n Right ventricular chamber size and free wall motion are normal. The\n aortic arch is mildly dilated. The aortic valve leaflets (3) appear\n structurally normal with good leaflet excursion and no aortic\n regurgitation. The mitral valve appears structurally normal with\n trivial mitral regurgitation. There is no mitral valve prolapse. There\n is mild-moderate pulmonary artery systolic hypertension. There is no\n pericardial effusion.\n IMPRESSION: Mild-moderate pulmonary artery systolic hypertension\n suggestive of a primary pulmonary process. Mildly dilated aortic arch.\n Normal biventricular cavity sizes with preserved global and regional\n biventricular systolic function.\n ECG: NSR, nl axis, nl intervals, poor R wave progression, TWI V2-3\n (new), no ST changes compared to prior.\n Assessment and Plan\n This is a 54 y/o M hx IPF, recent admission for spontaneous\n pneumomediastinum, who now presents with DOE X 3 days\n .\n .\n # Hypoxic respiratory distress/\n INTERSTITIAL LUNG DISEASE (ILD\n INCLUDING IPF, UIP, NSIP, DIP, LIP, ETC):\n DDx most likely includes exacerbation of underlying IPF or pulm\n infection/pna. Based on CXR, no pneumomediastinum/PTX. Also, no clear\n infiltrate, no fevers, leukocytosis or worsening to suggest\n pneumonia, so I strongly suspect exacerbation of IPF especially given\n hx of exposure to allergens. Low clinical suspicion for pulmonary\n edema/CHF or PE\n - continue NAC TID\n - consider trial of steroids, although during recent admission, he had\n no significant improvement on steroids\n - consider repeat chest CT; however, most recent in \n - no clinical signs for pna, would not continue empiric Abx\n - if oxygenation worsens would intubate\n - email Dr. in AM\n .\n # CP: He is currently pain free; however, hx of left sided CP with\n exertion is strongly concerning for angina. EKG not suggestive of ACS\n today\n - stress test\n - CE X 3 to ROMI\n - would advise starting low dose ASA\n - check lipids in AM\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis:\n - Subcutaneous heparin\n - no need for PPI\n - bowel regimen\n .\n # Access: peripherals\n .\n # Code: FULL\n .\n # Communication: Patient\n .\n # Disposition: ICU for monitoring of resp status\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:10 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n ------ Protected Section ------\n ATTENDING ADDENDUM:\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n Key Points:\n No clear explanation for transient hypoxemia except for possibly acute\n response to exposure to rat dander and dust. Now on baseline\n supplemental oxygen, feeling well, no resp distress.\n Safe to transfer to ICU.\n ------ Protected Section Addendum Entered By: , MD\n on: 10:22 ------\n"},{"category":"Physician ","chartdate":"2141-02-01 00:00:00.000","description":"Physician Resident Admission Note","row_id":556384,"text":"Chief Complaint: DOE\n HPI:\n 54 y/o M w/IPF, called today with worsening dyspnea x 3 days. He had\n been in unusal state of health at baseline resp status (using 4L NC at\n rest and 6L NC with exertion) when 3 days PTA, he hugged his cousin who\n has rats for pets and also the heat came up from the basement of his\n house. He feels that with these two events, he breathing became acutely\n worse and is concerned for allergen exposure. He denies any sick\n contacts, fevers, chills, worsening /productive , rhinorrhea.\n He did receive flu and pneumovax.\n .\n He has had a recent admissions in /09 with progressive DOE. CT\n revealed increased ground glass opacity in LL superimposed on pulmonary\n fibrosis with elevated eosinophils peripherally (12%). A BAL was also\n positive for eosinophils. He was started on high dose steroids\n (prednisone 60mg) with plan for close outpatient follow up for\n eosinophilic lung disease. He was discharged on on 2-3L NC. He then\n represented to on for spontaneous pneumomediastinum of\n unclear etiology.\n .\n On day of admission, Pt called pulmonologist (Dr. c/o worsening\n shortness of breath since Saturday . Yesterday he was at pulmonary\n rehab and desaturated to the 70s on 6L with minimal exertion, and he is\n currently on 4L NC at rest. No sick\n contacts recently and has not changed. He was asked to go to ED\n given concern for either acute exacerbation of underlying IPF vs\n superimposed infection vs pneumothorax.\n .\n In the ED, initial vs were: 98.3, 96, 144/97, 24, 97% 6L NC. Patient\n was given levoquin X 1 and was sent to floor. Of note, by transfer to\n ICU, his sats in ED were near baseline at 96% 4L NC.\n .\n On the floor, he reports feeling comfortable. He denies any complaints\n except that with exertion he has noticed left sided chest pain, that\n does not radiate to jaw or arm. He also notes occasional palpitations\n (rapid, regular) which have been lasting up to 1 hour ocuring more\n frequently. He denied PND, worsening orthopnea, LE swelling.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Levofloxacin - 01:11 AM\n Infusions:\n Other ICU medications:\n Other medications:\n HOME\n Acetylcysteine 600 mg TID\n Acetaminophen 500 mg PRN\n Calcium 500 mg TID\n Vitamin D 400 \n Past medical history:\n Family history:\n Social History:\n # IPF\n # HTN\n Brother: died \n Occupation:\n Drugs: none\n Tobacco: Smoked for 19 yrs but quit 19yrs ago\n Alcohol: . No EtOH use for 20 years\n Other: Currently not working but previously worked as a painter as well\n as sandblasting for 4 yrs during the (wore respirator but\n beard prevented tight seal). Occasionally travels overseas to\n and but states not a/w Sx. No known asbestos exposure.\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Chest pain, Palpitations, No(t) Edema, Tachycardia,\n No(t) Orthopnea\n Respiratory: , Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Jaundice\n Heme / Lymph: No(t) Lymphadenopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Pain: No pain / appears comfortable\n Flowsheet Data as of 03:38 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 79 (79 - 98) bpm\n BP: 122/69(82) {122/69(82) - 128/80(92)} mmHg\n RR: 30 (18 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 124 mL\n PO:\n TF:\n IVF:\n 124 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 124 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Crackles : velcro-like, No(t)\n Bronchial: , No(t) Wheezes : , Diminished: poor inspiratory efforts)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 2\n 98\n 3.8\n 139\n 41.4\n 12.5\n [image002.jpg]\n Other labs: PT / PTT / INR://1.4, Lactic Acid:1.1\n Imaging: CXR: extensive fibrotic changes\n Chest CT:\n IMPRESSION:\n 1. New pneumomediastinum, possibly spontaneous in the setting of\n diffuse pulmonary fibrosis, but correlation with clinical history\n recommended to exclude other potential causes such as esophageal or\n airway perforation, particularly if the patient has undergone recent\n intervention.\n 2. No change in severe pulmonary fibrosis or associated ground-glass\n attenuation since recent CT of .\n 3. Left upper pole renal mass, previously shown to be complex by recent\n ultrasound examination. This could be further evaluated by MRI.\n .\n ECHO: The left atrium and right atrium are normal in cavity\n size. Left ventricular wall thickness, cavity size and regional/global\n systolic function are normal (LVEF >55%). Tissue Doppler imaging\n suggests a normal left ventricular filling pressure (PCWP<12mmHg).\n Right ventricular chamber size and free wall motion are normal. The\n aortic arch is mildly dilated. The aortic valve leaflets (3) appear\n structurally normal with good leaflet excursion and no aortic\n regurgitation. The mitral valve appears structurally normal with\n trivial mitral regurgitation. There is no mitral valve prolapse. There\n is mild-moderate pulmonary artery systolic hypertension. There is no\n pericardial effusion.\n IMPRESSION: Mild-moderate pulmonary artery systolic hypertension\n suggestive of a primary pulmonary process. Mildly dilated aortic arch.\n Normal biventricular cavity sizes with preserved global and regional\n biventricular systolic function.\n ECG: NSR, nl axis, nl intervals, poor R wave progression, TWI V2-3\n (new), no ST changes compared to prior.\n Assessment and Plan\n This is a 54 y/o M hx IPF, recent admission for spontaneous\n pneumomediastinum, who now presents with DOE X 3 days\n .\n .\n # Hypoxic respiratory distress/\n INTERSTITIAL LUNG DISEASE (ILD\n INCLUDING IPF, UIP, NSIP, DIP, LIP, ETC):\n DDx most likely includes exacerbation of underlying IPF or pulm\n infection/pna. Based on CXR, no pneumomediastinum/PTX. Also, no clear\n infiltrate, no fevers, leukocytosis or worsening to suggest\n pneumonia, so I strongly suspect exacerbation of IPF especially given\n hx of exposure to allergens. Low clinical suspicion for pulmonary\n edema/CHF or PE\n - continue NAC TID\n - consider trial of steroids, although during recent admission, he had\n no significant improvement on steroids\n - consider repeat chest CT; however, most recent in \n - no clinical signs for pna, would not continue empiric Abx\n - if oxygenation worsens would intubate\n - email Dr. in AM\n .\n # CP: He is currently pain free; however, hx of left sided CP with\n exertion is strongly concerning for angina. EKG not suggestive of ACS\n today\n - stress test\n - CE X 3 to ROMI\n - would advise starting low dose ASA\n - check lipids in AM\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis:\n - Subcutaneous heparin\n - no need for PPI\n - bowel regimen\n .\n # Access: peripherals\n .\n # Code: FULL\n .\n # Communication: Patient\n .\n # Disposition: ICU for monitoring of resp status\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:10 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n"},{"category":"Nursing","chartdate":"2141-02-01 00:00:00.000","description":"Nursing Progress Note","row_id":556379,"text":"Interstitial Lung Disease (ILD including IPF, UIP, NSIP, DIP, LIP, etc)\n Assessment:\n 54 year old male with a history of sever IPF. Recently admitted with\n pneumomediastinum his sever IPF. Pt is being followed up at the\n hospital for work up of lung transplant. At baseline pt does\n wear portable O2 of 2-3L NC. Upon arrival to the unit pt was on 4L NC,\n with a SpO2 of 95-97%. Pt states no symptoms of SOB and was able to\n transfer self from ED stretcher to bed. Lung sounds in all fields have\n a\nVelcro\n sounds to them. Pt with strong cough. Pt states that he has\n had this\ntickling\n in the back of his throat for several days. Pt\n denies any chest pain or discomfort. A-febrile, and has not been around\n any person with respiratory infections.\n Action:\n O2 decreased to 2.5L NC.\n Response:\n Pt 2 97-99%\n Plan:\n Monitor pt respiratory status, obtain CXR, and Provide continuous O2.\n Provide emotional support to both pt and family\n"},{"category":"Radiology","chartdate":"2141-01-31 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1062054,"text":" 10:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pna, ptx, pmediastinum\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with ipf, h/o pneumomediastinum, low sats\n REASON FOR THIS EXAMINATION:\n eval pna, ptx, pmediastinum\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST AT 2211 HOURS.\n\n HISTORY: Interstitial pulmonary fibrosis and history of pneumomediastinum\n with low oxygen saturation.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Lung volumes are markedly diminished. There are extensive fibrotic\n changes at the lung bases, grossly stable from the prior exam. Less traumatic\n opacifications are noted in the more cephalad lungs. Grossly, there is no\n superimposed acute process that can be identified when comparing to multiple\n remote studies. The mediastinum is grossly unremarkable and stable. No\n definite effusion or pneumothorax is noted.\n\n IMPRESSION: Extensive baseline disease with fibrotic changes at the lung\n bases and scattered mostly peripheral opacities in the upper lungs. No\n definite superimposed process identified.\n\n\n"},{"category":"ECG","chartdate":"2141-01-31 00:00:00.000","description":"Report","row_id":222654,"text":"Sinus rhythm. Minor right ventricular conduction delay. Otherwise, within\nnormal limits. Compared to the previous tracing of the heart rate is\nreduced. Otherwise, no major change.\n\n"},{"category":"Radiology","chartdate":"2141-02-01 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1062227,"text":" 4:10 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Evaluate for cause of worsening hypoxia including progressio\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with IPF admitted with increasing dyspnea and hypoxia on\n exertion.\n REASON FOR THIS EXAMINATION:\n Evaluate for cause of worsening hypoxia including progression of disease,\n infection, or other pathology.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST, .\n\n COMPARISON: .\n\n INDICATION: IPF. Worsening hypoxia.\n\n TECHNIQUE: Volumetric, multidetector CT of the chest was performed without\n intravenous or oral contrast. Images are presented for display in the axial\n plane at 5-mm and 1.25-mm collimation.\n\n FINDINGS: Previously reported pneumomediastinum has resolved. Widespread\n interstitial lung disease is largely unchanged compared to the recent study\n except for a few minimal areas of progression with similar morphology and\n distribution to the previous examination. There are no new superimposed\n findings to suggest an active pulmonary infection.\n\n Enlarged mediastinal lymph nodes are again demonstrated and are likely\n hyperplastic in the setting of diffuse lung disease. The main pulmonary\n artery remains enlarged. The heart size is normal.\n\n Exam was not tailored to evaluate the subdiaphragmatic region, and only a\n small portion of the abdomen is included on the study, but no concerning\n abnormalities are evident on this limited assessment.\n\n Skeletal structures demonstrate no suspicious lytic or blastic skeletal\n lesions.\n\n IMPRESSION:\n\n 1. Slight progression of widespread interstitial pulmonary fibrosis, likely\n due to acute exacerbation of IPF as reported on the earlier CT of \n .\n\n 2. Resolution of pneumomediastinum.\n\n (Over)\n\n 4:10 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Evaluate for cause of worsening hypoxia including progressio\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"}],"string":"[\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-02-01 00:00:00.000\",\n \"description\": \"Nursing 0100 - 0700\",\n \"row_id\": 556417,\n \"text\": \"Interstitial Lung Disease (ILD including IPF, UIP, NSIP, DIP, LIP, etc)\\n Assessment:\\n 54 year old male with a history of sever IPF. Recently admitted with\\n pneumomediastinum his sever IPF. Pt is being followed up at the\\n hospital for work up of lung transplant. At baseline pt does\\n wear portable O2 of 2-3L NC. Upon arrival to the unit pt was on 4L NC,\\n with a SpO2 of 95-97%. Pt states no symptoms of SOB and was able to\\n transfer self from ED stretcher to bed. Lung sounds in all fields have\\n a\\nVelcro\\n sounds to them. Pt with strong cough. Pt states that he has\\n had this\\ntickling\\n in the back of his throat for several days. Pt\\n denies any chest pain or discomfort. A-febrile, and has not been around\\n any person with respiratory infections.\\n Action:\\n O2 decreased to 2.5L NC.\\n Response:\\n Pt 2 97-99%\\n Plan:\\n Monitor pt respiratory status, and Provide continuous O2. Provide\\n emotional support to both pt and family.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-02-01 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 556455,\n \"text\": \"54 y/o M w/IPF, called today with worsening dyspnea x 3 days. He had\\n been in unusal state of health at baseline resp status (using 4L NC at\\n rest and 6L NC with exertion) when 3 days PTA, he hugged his cousin who\\n has rats for pets and also the heat came up from the basement of his\\n house. He feels that with these two events, he breathing became acutely\\n worse and is concerned for allergen exposure. He denies any sick\\n contacts, fevers, chills, worsening /productive , rhinorrhea.\\n He did receive flu and pneumovax.\\n .\\n He has had a recent admissions in /09 with progressive DOE. CT\\n revealed increased ground glass opacity in LL superimposed on pulmonary\\n fibrosis with elevated eosinophils peripherally (12%). A BAL was also\\n positive for eosinophils. He was started on high dose steroids\\n (prednisone 60mg) with plan for close outpatient follow up for\\n eosinophilic lung disease. He was discharged on on 2-3L NC. He then\\n represented to on for spontaneous pneumomediastinum of\\n unclear etiology.\\n .\\n On day of admission, Pt called pulmonologist (Dr. c/o worsening\\n shortness of breath since Saturday . Yesterday he was at pulmonary\\n rehab and desaturated to the 70s on 6L with minimal exertion, and he is\\n currently on 4L NC at rest. No sick\\n contacts recently and has not changed. He was asked to go to ED\\n given concern for either acute exacerbation of underlying IPF vs\\n superimposed infection vs pneumothorax. Patient is currently being\\n worked up at for lung tx\\n .\\n In the ED, initial vs were: 98.3, 96, 144/97, 24, 97% 6L NC. Patient\\n was given levoquin X 1 and was sent to floor. Of note, by transfer to\\n ICU, his sats in ED were near baseline at 96% 4L NC.\\n Interstitial Lung Disease (ILD including IPF, UIP, NSIP, DIP, LIP, etc)\\n Assessment:\\n Patient received on 2.5l n/c with stas @ 94-96%, RR 20-30, lungs sound\\n rhonchus, patient says that sats are at baseline but continues SOB on\\n exertion, no ABS at this time [ received levoquin in ED]\\n Action:\\n Sats satisfactory n/c continues at 2.5l\\n Response:\\n Sats 97% rr 20-30\\n Plan:\\n Wean fio2 as tolerated, encourage /deep breath ? to commence\\n steriods/ABS, await CXR review\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n DYSPNEA\\n Code status:\\n Full code\\n Height:\\n 67 Inch\\n Admission weight:\\n 64 kg\\n Daily weight:\\n Allergies/Reactions:\\n Penicillins\\n Unknown;\\n Precautions:\\n PMH:\\n CV-PMH:\\n Additional history: pneumomediastinum\\n severe IPF\\n left upper pole renal mass\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:116\\n D:76\\n Temperature:\\n 97\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 30 insp/min\\n Heart Rate:\\n 87 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 97% %\\n O2 flow:\\n 3 L/min\\n FiO2 set:\\n 24h total in:\\n 387 mL\\n 24h total out:\\n 1,150 mL\\n Pertinent Lab Results:\\n Sodium:\\n 139 mEq/L\\n 04:47 AM\\n Potassium:\\n 4.4 mEq/L\\n 04:47 AM\\n Chloride:\\n 101 mEq/L\\n 04:47 AM\\n CO2:\\n 31 mEq/L\\n 04:47 AM\\n BUN:\\n 12 mg/dL\\n 04:47 AM\\n Creatinine:\\n 0.9 mg/dL\\n 04:47 AM\\n Glucose:\\n 99 mg/dL\\n 04:47 AM\\n Hematocrit:\\n 39.1 %\\n 04:47 AM\\n Valuables / Signature\\n Patient valuables: with patient\\n Other valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: micu 6\\n Transferred to: cc7\\n Date & time of Transfer: \\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-02-01 00:00:00.000\",\n \"description\": \"Physician Resident/Attending Admission Note - MICU\",\n \"row_id\": 556462,\n \"text\": \"Chief Complaint: DOE\\n HPI:\\n 54 y/o M w/IPF, called today with worsening dyspnea x 3 days. He had\\n been in unusal state of health at baseline resp status (using 4L NC at\\n rest and 6L NC with exertion) when 3 days PTA, he hugged his cousin who\\n has rats for pets and also the heat came up from the basement of his\\n house. He feels that with these two events, he breathing became acutely\\n worse and is concerned for allergen exposure. He denies any sick\\n contacts, fevers, chills, worsening /productive , rhinorrhea.\\n He did receive flu and pneumovax.\\n .\\n He has had a recent admissions in /09 with progressive DOE. CT\\n revealed increased ground glass opacity in LL superimposed on pulmonary\\n fibrosis with elevated eosinophils peripherally (12%). A BAL was also\\n positive for eosinophils. He was started on high dose steroids\\n (prednisone 60mg) with plan for close outpatient follow up for\\n eosinophilic lung disease. He was discharged on on 2-3L NC. He then\\n represented to on for spontaneous pneumomediastinum of\\n unclear etiology.\\n .\\n On day of admission, Pt called pulmonologist (Dr. c/o worsening\\n shortness of breath since Saturday . Yesterday he was at pulmonary\\n rehab and desaturated to the 70s on 6L with minimal exertion, and he is\\n currently on 4L NC at rest. No sick\\n contacts recently and has not changed. He was asked to go to ED\\n given concern for either acute exacerbation of underlying IPF vs\\n superimposed infection vs pneumothorax.\\n .\\n In the ED, initial vs were: 98.3, 96, 144/97, 24, 97% 6L NC. Patient\\n was given levoquin X 1 and was sent to floor. Of note, by transfer to\\n ICU, his sats in ED were near baseline at 96% 4L NC.\\n .\\n On the floor, he reports feeling comfortable. He denies any complaints\\n except that with exertion he has noticed left sided chest pain, that\\n does not radiate to jaw or arm. He also notes occasional palpitations\\n (rapid, regular) which have been lasting up to 1 hour ocuring more\\n frequently. He denied PND, worsening orthopnea, LE swelling.\\n Allergies:\\n Penicillins\\n Unknown;\\n Last dose of Antibiotics:\\n Levofloxacin - 01:11 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n HOME\\n Acetylcysteine 600 mg TID\\n Acetaminophen 500 mg PRN\\n Calcium 500 mg TID\\n Vitamin D 400 \\n Past medical history:\\n Family history:\\n Social History:\\n # IPF\\n # HTN\\n Brother: died \\n Occupation:\\n Drugs: none\\n Tobacco: Smoked for 19 yrs but quit 19yrs ago\\n Alcohol: . No EtOH use for 20 years\\n Other: Currently not working but previously worked as a painter as well\\n as sandblasting for 4 yrs during the (wore respirator but\\n beard prevented tight seal). Occasionally travels overseas to\\n and but states not a/w Sx. No known asbestos exposure.\\n Review of systems:\\n Constitutional: Fatigue\\n Cardiovascular: Chest pain, Palpitations, No(t) Edema, Tachycardia,\\n No(t) Orthopnea\\n Respiratory: , Dyspnea, Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, No(t) Foley\\n Musculoskeletal: No(t) Joint pain\\n Integumentary (skin): No(t) Jaundice\\n Heme / Lymph: No(t) Lymphadenopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 03:38 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.2\\nC (98.9\\n Tcurrent: 37.2\\nC (98.9\\n HR: 79 (79 - 98) bpm\\n BP: 122/69(82) {122/69(82) - 128/80(92)} mmHg\\n RR: 30 (18 - 30) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Total In:\\n 124 mL\\n PO:\\n TF:\\n IVF:\\n 124 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 124 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 99%\\n Physical Examination\\n General Appearance: Well nourished\\n Eyes / Conjunctiva: PERRL\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Breath Sounds: Crackles : velcro-like, No(t)\\n Bronchial: , No(t) Wheezes : , Diminished: poor inspiratory efforts)\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: Absent, Left: Absent\\n Skin: Warm\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 2\\n 98\\n 3.8\\n 139\\n 41.4\\n 12.5\\n [image002.jpg]\\n Other labs: PT / PTT / INR://1.4, Lactic Acid:1.1\\n Imaging: CXR: extensive fibrotic changes\\n Chest CT:\\n IMPRESSION:\\n 1. New pneumomediastinum, possibly spontaneous in the setting of\\n diffuse pulmonary fibrosis, but correlation with clinical history\\n recommended to exclude other potential causes such as esophageal or\\n airway perforation, particularly if the patient has undergone recent\\n intervention.\\n 2. No change in severe pulmonary fibrosis or associated ground-glass\\n attenuation since recent CT of .\\n 3. Left upper pole renal mass, previously shown to be complex by recent\\n ultrasound examination. This could be further evaluated by MRI.\\n .\\n ECHO: The left atrium and right atrium are normal in cavity\\n size. Left ventricular wall thickness, cavity size and regional/global\\n systolic function are normal (LVEF >55%). Tissue Doppler imaging\\n suggests a normal left ventricular filling pressure (PCWP<12mmHg).\\n Right ventricular chamber size and free wall motion are normal. The\\n aortic arch is mildly dilated. The aortic valve leaflets (3) appear\\n structurally normal with good leaflet excursion and no aortic\\n regurgitation. The mitral valve appears structurally normal with\\n trivial mitral regurgitation. There is no mitral valve prolapse. There\\n is mild-moderate pulmonary artery systolic hypertension. There is no\\n pericardial effusion.\\n IMPRESSION: Mild-moderate pulmonary artery systolic hypertension\\n suggestive of a primary pulmonary process. Mildly dilated aortic arch.\\n Normal biventricular cavity sizes with preserved global and regional\\n biventricular systolic function.\\n ECG: NSR, nl axis, nl intervals, poor R wave progression, TWI V2-3\\n (new), no ST changes compared to prior.\\n Assessment and Plan\\n This is a 54 y/o M hx IPF, recent admission for spontaneous\\n pneumomediastinum, who now presents with DOE X 3 days\\n .\\n .\\n # Hypoxic respiratory distress/\\n INTERSTITIAL LUNG DISEASE (ILD\\n INCLUDING IPF, UIP, NSIP, DIP, LIP, ETC):\\n DDx most likely includes exacerbation of underlying IPF or pulm\\n infection/pna. Based on CXR, no pneumomediastinum/PTX. Also, no clear\\n infiltrate, no fevers, leukocytosis or worsening to suggest\\n pneumonia, so I strongly suspect exacerbation of IPF especially given\\n hx of exposure to allergens. Low clinical suspicion for pulmonary\\n edema/CHF or PE\\n - continue NAC TID\\n - consider trial of steroids, although during recent admission, he had\\n no significant improvement on steroids\\n - consider repeat chest CT; however, most recent in \\n - no clinical signs for pna, would not continue empiric Abx\\n - if oxygenation worsens would intubate\\n - email Dr. in AM\\n .\\n # CP: He is currently pain free; however, hx of left sided CP with\\n exertion is strongly concerning for angina. EKG not suggestive of ACS\\n today\\n - stress test\\n - CE X 3 to ROMI\\n - would advise starting low dose ASA\\n - check lipids in AM\\n .\\n # FEN: No IVF, replete electrolytes, regular diet\\n .\\n # Prophylaxis:\\n - Subcutaneous heparin\\n - no need for PPI\\n - bowel regimen\\n .\\n # Access: peripherals\\n .\\n # Code: FULL\\n .\\n # Communication: Patient\\n .\\n # Disposition: ICU for monitoring of resp status\\n .\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:10 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: Transfer to floor\\n ------ Protected Section ------\\n ATTENDING ADDENDUM:\\n I saw and examined the patient, and was physically present with the ICU\\n resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n Key Points:\\n No clear explanation for transient hypoxemia except for possibly acute\\n response to exposure to rat dander and dust. Now on baseline\\n supplemental oxygen, feeling well, no resp distress.\\n Safe to transfer to ICU.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 10:22 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-02-01 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 556384,\n \"text\": \"Chief Complaint: DOE\\n HPI:\\n 54 y/o M w/IPF, called today with worsening dyspnea x 3 days. He had\\n been in unusal state of health at baseline resp status (using 4L NC at\\n rest and 6L NC with exertion) when 3 days PTA, he hugged his cousin who\\n has rats for pets and also the heat came up from the basement of his\\n house. He feels that with these two events, he breathing became acutely\\n worse and is concerned for allergen exposure. He denies any sick\\n contacts, fevers, chills, worsening /productive , rhinorrhea.\\n He did receive flu and pneumovax.\\n .\\n He has had a recent admissions in /09 with progressive DOE. CT\\n revealed increased ground glass opacity in LL superimposed on pulmonary\\n fibrosis with elevated eosinophils peripherally (12%). A BAL was also\\n positive for eosinophils. He was started on high dose steroids\\n (prednisone 60mg) with plan for close outpatient follow up for\\n eosinophilic lung disease. He was discharged on on 2-3L NC. He then\\n represented to on for spontaneous pneumomediastinum of\\n unclear etiology.\\n .\\n On day of admission, Pt called pulmonologist (Dr. c/o worsening\\n shortness of breath since Saturday . Yesterday he was at pulmonary\\n rehab and desaturated to the 70s on 6L with minimal exertion, and he is\\n currently on 4L NC at rest. No sick\\n contacts recently and has not changed. He was asked to go to ED\\n given concern for either acute exacerbation of underlying IPF vs\\n superimposed infection vs pneumothorax.\\n .\\n In the ED, initial vs were: 98.3, 96, 144/97, 24, 97% 6L NC. Patient\\n was given levoquin X 1 and was sent to floor. Of note, by transfer to\\n ICU, his sats in ED were near baseline at 96% 4L NC.\\n .\\n On the floor, he reports feeling comfortable. He denies any complaints\\n except that with exertion he has noticed left sided chest pain, that\\n does not radiate to jaw or arm. He also notes occasional palpitations\\n (rapid, regular) which have been lasting up to 1 hour ocuring more\\n frequently. He denied PND, worsening orthopnea, LE swelling.\\n Allergies:\\n Penicillins\\n Unknown;\\n Last dose of Antibiotics:\\n Levofloxacin - 01:11 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n HOME\\n Acetylcysteine 600 mg TID\\n Acetaminophen 500 mg PRN\\n Calcium 500 mg TID\\n Vitamin D 400 \\n Past medical history:\\n Family history:\\n Social History:\\n # IPF\\n # HTN\\n Brother: died \\n Occupation:\\n Drugs: none\\n Tobacco: Smoked for 19 yrs but quit 19yrs ago\\n Alcohol: . No EtOH use for 20 years\\n Other: Currently not working but previously worked as a painter as well\\n as sandblasting for 4 yrs during the (wore respirator but\\n beard prevented tight seal). Occasionally travels overseas to\\n and but states not a/w Sx. No known asbestos exposure.\\n Review of systems:\\n Constitutional: Fatigue\\n Cardiovascular: Chest pain, Palpitations, No(t) Edema, Tachycardia,\\n No(t) Orthopnea\\n Respiratory: , Dyspnea, Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, No(t) Foley\\n Musculoskeletal: No(t) Joint pain\\n Integumentary (skin): No(t) Jaundice\\n Heme / Lymph: No(t) Lymphadenopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 03:38 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.2\\nC (98.9\\n Tcurrent: 37.2\\nC (98.9\\n HR: 79 (79 - 98) bpm\\n BP: 122/69(82) {122/69(82) - 128/80(92)} mmHg\\n RR: 30 (18 - 30) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Total In:\\n 124 mL\\n PO:\\n TF:\\n IVF:\\n 124 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 124 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 99%\\n Physical Examination\\n General Appearance: Well nourished\\n Eyes / Conjunctiva: PERRL\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Breath Sounds: Crackles : velcro-like, No(t)\\n Bronchial: , No(t) Wheezes : , Diminished: poor inspiratory efforts)\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: Absent, Left: Absent\\n Skin: Warm\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 2\\n 98\\n 3.8\\n 139\\n 41.4\\n 12.5\\n [image002.jpg]\\n Other labs: PT / PTT / INR://1.4, Lactic Acid:1.1\\n Imaging: CXR: extensive fibrotic changes\\n Chest CT:\\n IMPRESSION:\\n 1. New pneumomediastinum, possibly spontaneous in the setting of\\n diffuse pulmonary fibrosis, but correlation with clinical history\\n recommended to exclude other potential causes such as esophageal or\\n airway perforation, particularly if the patient has undergone recent\\n intervention.\\n 2. No change in severe pulmonary fibrosis or associated ground-glass\\n attenuation since recent CT of .\\n 3. Left upper pole renal mass, previously shown to be complex by recent\\n ultrasound examination. This could be further evaluated by MRI.\\n .\\n ECHO: The left atrium and right atrium are normal in cavity\\n size. Left ventricular wall thickness, cavity size and regional/global\\n systolic function are normal (LVEF >55%). Tissue Doppler imaging\\n suggests a normal left ventricular filling pressure (PCWP<12mmHg).\\n Right ventricular chamber size and free wall motion are normal. The\\n aortic arch is mildly dilated. The aortic valve leaflets (3) appear\\n structurally normal with good leaflet excursion and no aortic\\n regurgitation. The mitral valve appears structurally normal with\\n trivial mitral regurgitation. There is no mitral valve prolapse. There\\n is mild-moderate pulmonary artery systolic hypertension. There is no\\n pericardial effusion.\\n IMPRESSION: Mild-moderate pulmonary artery systolic hypertension\\n suggestive of a primary pulmonary process. Mildly dilated aortic arch.\\n Normal biventricular cavity sizes with preserved global and regional\\n biventricular systolic function.\\n ECG: NSR, nl axis, nl intervals, poor R wave progression, TWI V2-3\\n (new), no ST changes compared to prior.\\n Assessment and Plan\\n This is a 54 y/o M hx IPF, recent admission for spontaneous\\n pneumomediastinum, who now presents with DOE X 3 days\\n .\\n .\\n # Hypoxic respiratory distress/\\n INTERSTITIAL LUNG DISEASE (ILD\\n INCLUDING IPF, UIP, NSIP, DIP, LIP, ETC):\\n DDx most likely includes exacerbation of underlying IPF or pulm\\n infection/pna. Based on CXR, no pneumomediastinum/PTX. Also, no clear\\n infiltrate, no fevers, leukocytosis or worsening to suggest\\n pneumonia, so I strongly suspect exacerbation of IPF especially given\\n hx of exposure to allergens. Low clinical suspicion for pulmonary\\n edema/CHF or PE\\n - continue NAC TID\\n - consider trial of steroids, although during recent admission, he had\\n no significant improvement on steroids\\n - consider repeat chest CT; however, most recent in \\n - no clinical signs for pna, would not continue empiric Abx\\n - if oxygenation worsens would intubate\\n - email Dr. in AM\\n .\\n # CP: He is currently pain free; however, hx of left sided CP with\\n exertion is strongly concerning for angina. EKG not suggestive of ACS\\n today\\n - stress test\\n - CE X 3 to ROMI\\n - would advise starting low dose ASA\\n - check lipids in AM\\n .\\n # FEN: No IVF, replete electrolytes, regular diet\\n .\\n # Prophylaxis:\\n - Subcutaneous heparin\\n - no need for PPI\\n - bowel regimen\\n .\\n # Access: peripherals\\n .\\n # Code: FULL\\n .\\n # Communication: Patient\\n .\\n # Disposition: ICU for monitoring of resp status\\n .\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:10 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: Transfer to floor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-02-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 556379,\n \"text\": \"Interstitial Lung Disease (ILD including IPF, UIP, NSIP, DIP, LIP, etc)\\n Assessment:\\n 54 year old male with a history of sever IPF. Recently admitted with\\n pneumomediastinum his sever IPF. Pt is being followed up at the\\n hospital for work up of lung transplant. At baseline pt does\\n wear portable O2 of 2-3L NC. Upon arrival to the unit pt was on 4L NC,\\n with a SpO2 of 95-97%. Pt states no symptoms of SOB and was able to\\n transfer self from ED stretcher to bed. Lung sounds in all fields have\\n a\\nVelcro\\n sounds to them. Pt with strong cough. Pt states that he has\\n had this\\ntickling\\n in the back of his throat for several days. Pt\\n denies any chest pain or discomfort. A-febrile, and has not been around\\n any person with respiratory infections.\\n Action:\\n O2 decreased to 2.5L NC.\\n Response:\\n Pt 2 97-99%\\n Plan:\\n Monitor pt respiratory status, obtain CXR, and Provide continuous O2.\\n Provide emotional support to both pt and family\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2141-01-31 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1062054,\n \"text\": \" 10:11 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval pna, ptx, pmediastinum\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man with ipf, h/o pneumomediastinum, low sats\\n REASON FOR THIS EXAMINATION:\\n eval pna, ptx, pmediastinum\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP PORTABLE CHEST AT 2211 HOURS.\\n\\n HISTORY: Interstitial pulmonary fibrosis and history of pneumomediastinum\\n with low oxygen saturation.\\n\\n COMPARISON: Multiple priors, the most recent dated .\\n\\n FINDINGS: Lung volumes are markedly diminished. There are extensive fibrotic\\n changes at the lung bases, grossly stable from the prior exam. Less traumatic\\n opacifications are noted in the more cephalad lungs. Grossly, there is no\\n superimposed acute process that can be identified when comparing to multiple\\n remote studies. The mediastinum is grossly unremarkable and stable. No\\n definite effusion or pneumothorax is noted.\\n\\n IMPRESSION: Extensive baseline disease with fibrotic changes at the lung\\n bases and scattered mostly peripheral opacities in the upper lungs. No\\n definite superimposed process identified.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2141-01-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 222654,\n \"text\": \"Sinus rhythm. Minor right ventricular conduction delay. Otherwise, within\\nnormal limits. Compared to the previous tracing of the heart rate is\\nreduced. Otherwise, no major change.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2141-02-01 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1062227,\n \"text\": \" 4:10 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: Evaluate for cause of worsening hypoxia including progressio\\n Admitting Diagnosis: DYSPNEA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man with IPF admitted with increasing dyspnea and hypoxia on\\n exertion.\\n REASON FOR THIS EXAMINATION:\\n Evaluate for cause of worsening hypoxia including progression of disease,\\n infection, or other pathology.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT CHEST, .\\n\\n COMPARISON: .\\n\\n INDICATION: IPF. Worsening hypoxia.\\n\\n TECHNIQUE: Volumetric, multidetector CT of the chest was performed without\\n intravenous or oral contrast. Images are presented for display in the axial\\n plane at 5-mm and 1.25-mm collimation.\\n\\n FINDINGS: Previously reported pneumomediastinum has resolved. Widespread\\n interstitial lung disease is largely unchanged compared to the recent study\\n except for a few minimal areas of progression with similar morphology and\\n distribution to the previous examination. There are no new superimposed\\n findings to suggest an active pulmonary infection.\\n\\n Enlarged mediastinal lymph nodes are again demonstrated and are likely\\n hyperplastic in the setting of diffuse lung disease. The main pulmonary\\n artery remains enlarged. The heart size is normal.\\n\\n Exam was not tailored to evaluate the subdiaphragmatic region, and only a\\n small portion of the abdomen is included on the study, but no concerning\\n abnormalities are evident on this limited assessment.\\n\\n Skeletal structures demonstrate no suspicious lytic or blastic skeletal\\n lesions.\\n\\n IMPRESSION:\\n\\n 1. Slight progression of widespread interstitial pulmonary fibrosis, likely\\n due to acute exacerbation of IPF as reported on the earlier CT of \\n .\\n\\n 2. Resolution of pneumomediastinum.\\n\\n (Over)\\n\\n 4:10 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: Evaluate for cause of worsening hypoxia including progressio\\n Admitting Diagnosis: DYSPNEA\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n }\n]"}}},{"rowIdx":24642,"cells":{"subject_id":{"kind":"number","value":8916,"string":"8,916"},"hadm_id":{"kind":"number","value":132667,"string":"132,667"},"target_text":{"kind":"string","value":"A/P: 86yo man with h/o prostate CA, presumed plasmacytoma of L3 vert, admitted for urinary incontinence with stable MRI with cord compression and N/V with normal head CT. . # Urinary incontinence - known spinal cord compression on exam but stable since last imaging, pt without new weakness or saddle anesthesia and good rectal tone so may be related to prostate pathology instead; UA neg for infxn - have d/c'd decadron - bladder scan showed 750cc urine - need to place foley . # N/V- CT head neg, could be increased narcotic use and anxiety - d/c dilaudid - LFTs slightly , /lipase wnl - reglan w/meals - anzemet IV or compazine PO PRN - monitor symptom . # Pain mgmt- difficult b/c pt appears in pain at times, but as per family he is anxious and cannot easily express this. Also he appears to be having narcotic toxicity - increase fentanyl patch to 50mcg - d/c dilaudid as may be cause of confusion and nausea - oxycodone for BT - Ativan PRN for anxiety . # Prostate CA - concern for disease progression as as pt with urinary retention - urology consult . # Plasmacytoma - concern for spinal cord compression, but MRI does not show change from prior - Ortho Spine performed decompression of L3 lesion with posterior stabilization from L1-5. Incisions were clean and dry upon discharge. Follow up will occur in two weeks in the ortho Spine clinic. Call for an appointment. - mgmt per Dr. . # CAD- cont ASA 81mg and placed pt on metoprolol in place of atenolol. Will hold on lipitor. . # B12 deficiency- pt no longer deficient, will d/c supplementation . # CKD - at baseline creatinine . # FEN- cardiac diet as tolerated, replete lytes prn, no need for IVFs for now . # PPx- SC heparin, bowel reg, PPI . #Code: Full . #Contact: daughter in law cell, home"},"extractive_notes_summ":{"kind":"string","value":"Lopressor iv started.GI/GU- Abd soft, +BS. Sinus rhythm with atrial premature depolarizations. Baseline artifactSinus bradycardiaConsider left ventricular hypertrophyST-T wave configuration suggests in part early repolarization patternSince previous tracing of , atrial ectopy absent Compared to the previous tracing of cardiacrhythm now sinus mechanism. Dilaudid dose x 1 given with longer effect. Hct down to 26 and PRBCs #1 being transfused, 2u ordered. Afebrile. initially bradycardic. MAEs well.Resp- Lungs clear to coarse with diminished bases. ABGs WNL. Attempts to wean propofol down made pt. Foley patent, UO as mentioned. Will occ cough, nonproductive.CV- HTN in 170s, HR 80-90s with freq PACs. SBP 100-120s, into 160s when agitated. Skin w/d/i. Rt groin art line just starting to become dampened.Resp- Gd color all shift. Hemovac drain as noted above. Sinus rhythmSupraventricular extrasystolesInferior + anterior T wave change may be due to myocardial ischemiaEarly transitionSince previous tracing, T wave changes, and atrial premature complexes noted Lungs hard to auscultate anteriorly, coarse posteriorly.CV- SR with freq PVCs. Pt. Pt. Pt. Pt. Hypoactive bowel sounds.Access:2 Right PIVS #18 and 16 2 pivs on the left #18 and 20.right femerol aline.Integ Elastoplast dsg from or on lumbar spinal area D+I. Afeb. sat=100.gi/gu foley with marginal uop. MD aware. Atrial fibrillation with rapid ventricular responseEarly precordial QRS transition - is nonspecificConsider left ventricular hypertrophyDiffuse nonspecific ST-T wave abnormalitiesSince previous tracing of , rapid atrial fibrillation and further ST-Twave changes now present Hemovax in place 25cc out for 24h.GI/GU- Abd soft, +BS. Fusion of L1-L5.See assessment for HX.Neuro: Admitted on Propofol and remains sedated on propofol. need for prbc transfusion. The aorta is ectatic with calcification along its walls. 9:23 AM L-SPINE (AP & LAT) IN O.R. Gd color. Hemovac from incision has drained avg. Original post op dressing over back incision. wake abruptly (on 10mcgs). since arrival. 75cc/hr. FINDINGS: The prior study is from . There are multiple granulomas again seen. noted to move all extremities spontaneously when not sedated.cv/resp NSR. MAEs. Now with oral Temp=96.Plan. Diffuserepolarization abnormalities. excellent abgs. Intermittantly allows mouth care. Fent settles pt for short periods of time. COMPARISON: L-spine from . Barrel Chest. Sinus rhythm with PACsSeptal T wave changes are nonspecificEarly R wave progressionSince previous tracing of , atrial fibrillation not present The ETT tube remains at 3.6 cm of the carina. T max 101.8, blood and urine cx sent and tylenol given. medicated for pain frequently with mod effect. Maintance remains at 80cc/h. Abd with +BS, flat.GU- Marginal most of shift with slightly better hours occ.Heme- Improved Hct after 2 units packed cells.ID- Cefazolin doses complete. When pt light and moving in bed RR remains<10. Pt later changed to MMV with no change in #s. Sats 100% and ABGs wnl. One liter LR fluid bolus given for low uop and low BP. Plan extubation tomorrow if stable coming off sedation. RR 18 and sats 98%. Mag and K repleted during shift. Only able to get O2 sat occasionally, when possible sats are adequate. Posterior lumbar fusion hardware is incompletely assessed as it extends off the inferior aspect of this single view of the chest. Scattered aortic calcifications are noted. Scattered aortic calcifications are noted. Again seen are areas of low attenuation within the periventricular and subcortical white matter, consistent with change from chronic microvascular angiopathy. There is severe canal stenosis, which is unchanged from the previous examination. As compared to the prior images from , there has been interval removal of the endotracheal tube. There is probable diffuse osteopenia. NON-CONTRAST HEAD CT: Comparison with . There is limited evaluation of intrathecal contents on CT. Again seen is lytic and sclerotic change within the L3 vertebral body with associated cortical irregularity and destruction, consistent with the known mass seen on prior studies. Bilateral pleural effusions and adjacent atelectasis. Moderate generalized atrophy and chronic micro-ischemic change in subcortical and periventricular white matter. The patient is seen to be posterior osseous and metallic lumbar fusion. IMPRESSION: Again seen is a soft tissue mass at the L3 level with associated osseous destruction of the L3 vertebral body. There are bilateral pleural effusions and adjacent atelectasis. Lytic lesion in right iliac bone, not fully evaluated. Degenerative narrowing at multiple disc levels noted. There is limited evaluation of intraspinal and intrathecal contents on CT secondary to artifact from adjacent hardware. There are bilateral pleural effusions and associated adjacent atelectasis. Allowing for patient positioning, hardware and spinal alignment is nominal. There is uniform prominence of the extra-axial CSF spaces, the sulci and fissures and the ventricles, representing generalized atrophy. Interval removal of the endotracheal tube. Prominence of the left petrous/mastoid is again noted, unchanged. Diagnostic quality is limited by patient motion. REASON FOR THIS EXAMINATION: r/o intracranial bleed. While this is possibly degenerative, the kyphosis appears more prominent in comparison to the prior C-spine radiographs from , and an underlying ligamentous injury is not excluded. The posterior disc osteophyte complex at the C5/6 level abuts the anterior aspect of the cord, without any definite indentation. The lateral left aspect of the L3 vertebral body appears markedly destroyed, with extension of the mass into the paraspinal soft tissues. r/o fracture. r/o fracture. r/o fracture. There is relatively mild focal and confluent FLAIR hyperintensity in bihemispheric subcortical and periventricular white matter, representing chronic microischemic change. There is limited evaluation of intrathecal contents on CT, however, the contour of the thecal sac is within normal limits. Unremarkable cranial MRA. Laminectomy and spinal stabilization procedure, in nominal alignment, with osseous destruction of L3. IMPRESSION: Limited study secondary to patient motion. There is associated neural foraminal narrowing at the C3/4 level bilaterally, C5/6 level. There are destructive changes of the L3 vertebral body. A paravertebral mass on the left is again identified. The lungs are clear except for a left upper lobe granuloma. 7:29 PM CT HEAD W/O CONTRAST Clip # Reason: r/o intracranial bleed."},"n_notes":{"kind":"number","value":26,"string":"26"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2139-09-18 00:00:00.000","description":"Report","row_id":1380151,"text":"Elderly Russian Speaking man admitted to on . Now comes to Trauma Sicu Post-op Spinal tumor resection. Fusion of L1-L5.\nSee assessment for HX.\nNeuro: Admitted on Propofol and remains sedated on propofol. Also is wearing fentanyl patch 50mcg/hr due to be changed tomorrow. Attempts to wean propofol down made pt. wake abruptly (on 10mcgs). Pt. thrashing and not able to open eyes to command. (language barrier noted) Sedated with increasing propofol dose back to 30. Pt. noted to move all extremities spontaneously when not sedated.\ncv/resp NSR. initially bradycardic. now in the high 60's with pac's.\nVented on AC ventilation. excellent abgs. Not breathing over vent on propofol. Lungs clear. on 35%fio2. sat=100.\ngi/gu foley with marginal uop. One liter LR fluid bolus given for low uop and low BP. 6pm hct pending ? need for prbc transfusion. Hemovac from incision has drained avg. 75cc/hr. since arrival. NPO with no gastric intubation at this time. Hypoactive bowel sounds.\nAccess:2 Right PIVS #18 and 16 2 pivs on the left #18 and 20.\nright femerol aline.\nInteg Elastoplast dsg from or on lumbar spinal area D+I. Hemovac drain as noted above. stockings and compression sleeves on.\nBair hugger on arrival for hypothermia. Now with oral Temp=96.\nPlan. Monitor for bleeding/hypovolemia. Keep intubated and sedated overnight. Plan extubation tomorrow if stable coming off sedation.\n"},{"category":"Nursing/other","chartdate":"2139-09-19 00:00:00.000","description":"Report","row_id":1380152,"text":"NPN 1900-0700\n pt on propofol gtt and PRN fentanyl. Attempted again to wean propofol but pt easily awakens and very restless twisting in bed and bending legs (has R groin aline). ? pain as cause. Fent settles pt for short periods of time. Dilaudid dose x 1 given with longer effect.\n\n Pt changed to PS 5/5. TV 600-1Liter with RR 4-8. When pt light and moving in bed RR remains<10. HO aware. Pt later changed to MMV with no change in #s. Sats 100% and ABGs wnl. Lungs hard to auscultate anteriorly, coarse posteriorly.\n\nCV- SR with freq PVCs. SBP 100-120s, into 160s when agitated. Low UO for several hours which did not respond to fluid bolus x 2. Maintance remains at 80cc/h. UO improved at 6am. Hct down to 26 and PRBCs #1 being transfused, 2u ordered. Afebrile. Mag and K repleted during shift. Lopressor iv started.\n\nGI/GU- Abd soft, +BS. Foley patent, UO as mentioned. No BM.\n\nSocial- no contact with family overnight.\n\nPlan- Most likely try to extubate this am. need to change pain management.\n\n\n"},{"category":"Nursing/other","chartdate":"2139-09-19 00:00:00.000","description":"Report","row_id":1380153,"text":"NPN 1900-0700\nAddendum\n\nPt propofol off at 0645, by 7am awake, opening eyes and very restless in bed. MAEs. Extubated without incident and on FT 40%. RR 18 and sats 98%.\n"},{"category":"Nursing/other","chartdate":"2139-09-19 00:00:00.000","description":"Report","row_id":1380154,"text":"T/SICU NPN:\nBrief ROS:\nNeuro- Family in to visit pt. today, they believe him to be alert and oriented. He responded appropriately to questions during entire visit. Pt. moves all extremities, gd strength. He has been slightly restless and pulled at etc.. but appears mostly purposeful with moving. He (through his family) has complained mostly of his legs being uncomfortable, behind his knees, left more than the rt. He does not c/o back () pain. Pupils are reactive to light, when pt. allows nurse to check pupils(he's clamped eyes closed with flashlight). Pt. has had fentanyl IV, 50mcg every 3-4 hrs today, which does settle him for a short amt of time. He also started a fentanyl patch today, as he had at home.\n\nCV- BP intermittantly has been high throughout shift today, mostly r/t agitation or stimulation. When he's quiet and restful, his BP is 140's- 160 systolic. HR has been in the 80's, with frequent APC's. Skin warm and dry. Difficult to palpate periph pulses, gd nail bed blanching. Gd color. Rt groin art line just starting to become dampened.\n\nResp- Gd color all shift. Only able to get O2 sat occasionally, when possible sats are adequate. Bilat breath sounds are coarse to clear throughtout. RR 20's down to 8 when he's asleep.\n\nGI- NPO as yet, he has not been cooperative consistantly enough to start po's. Intermittantly allows mouth care. Abd with +BS, flat.\n\nGU- Marginal most of shift with slightly better hours occ.\n\nHeme- Improved Hct after 2 units packed cells.\n\nID- Cefazolin doses complete. Afeb.\n"},{"category":"Nursing/other","chartdate":"2139-09-20 00:00:00.000","description":"Report","row_id":1380155,"text":"NPN 1900-0700\nNeuro- Russian speaking only. Awake most of night and restless. medicated for pain frequently with mod effect. When touch pt tends to yell out in Russian. With turning trys to pinch and hit staff. MAEs well.\n\nResp- Lungs clear to coarse with diminished bases. Barrel Chest. ABGs WNL. FT changed to 3lnc and sats 98%. Will occ cough, nonproductive.\n\nCV- HTN in 170s, HR 80-90s with freq PACs. Lopressor increased to 5mg IV q6h with little effect on bp and HR. MD aware. T max 101.8, blood and urine cx sent and tylenol given. Skin w/d/i. Original post op dressing over back incision. Hemovax in place 25cc out for 24h.\n\nGI/GU- Abd soft, +BS. Pt yells out when abd palpated but also yells when touch legs. No BM. Foley patent with light yellow urine.\n\n transfer to floor, may require a sitter. OOB to chair with brace.\n\n\n"},{"category":"ECG","chartdate":"2139-10-07 00:00:00.000","description":"Report","row_id":270892,"text":"Sinus rhythm with atrial premature depolarizations. Otherwise, without\ndiagnostic abnormality. Compared to the previous tracing of cardiac\nrhythm now sinus mechanism.\n\n"},{"category":"ECG","chartdate":"2139-10-06 00:00:00.000","description":"Report","row_id":270893,"text":"Atrial fibrillation with a mean ventricular response, rate 136. Diffuse\nrepolarization abnormalities. Compared to the previous tracing of \ncardiac rhythm is now rapid atrial fibrillation.\n\n"},{"category":"ECG","chartdate":"2139-10-04 00:00:00.000","description":"Report","row_id":271118,"text":"Baseline artifact\nSinus bradycardia\nConsider left ventricular hypertrophy\nST-T wave configuration suggests in part early repolarization pattern\nSince previous tracing of , atrial ectopy absent\n\n"},{"category":"ECG","chartdate":"2139-09-23 00:00:00.000","description":"Report","row_id":271119,"text":"Sinus rhythm with PACs\nSeptal T wave changes are nonspecific\nEarly R wave progression\nSince previous tracing of , atrial fibrillation not present\n\n"},{"category":"ECG","chartdate":"2139-09-22 00:00:00.000","description":"Report","row_id":271120,"text":"Atrial fibrillation with rapid ventricular response\nEarly precordial QRS transition - is nonspecific\nConsider left ventricular hypertrophy\nDiffuse nonspecific ST-T wave abnormalities\nSince previous tracing of , rapid atrial fibrillation and further ST-T\nwave changes now present\n\n"},{"category":"ECG","chartdate":"2139-09-15 00:00:00.000","description":"Report","row_id":271121,"text":"Sinus rhythm\nSupraventricular extrasystoles\nInferior + anterior T wave change may be due to myocardial ischemia\nEarly transition\nSince previous tracing, T wave changes, and atrial premature complexes noted\n\n"},{"category":"Radiology","chartdate":"2139-09-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":932461,"text":" 5:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate CA, plasmacytomoa of L3, to go for surgery to\n remove spinal tumor tomorrow\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: ETT placement.\n\n FINDINGS: The prior study is from . There are multiple\n granulomas again seen. The cardiac silhouette is normal. The aorta is\n ectatic with calcification along its walls. The lung transparency is normal.\n The ETT tube remains at 3.6 cm of the carina. Old fractures of the ribs are\n seen on the right side.\n\n IMPRESSION: ETT tube in place, no acute cardiopulmonary process.\n\n\n"},{"category":"Radiology","chartdate":"2139-09-18 00:00:00.000","description":"O L-SPINE (AP & LAT) IN O.R.","row_id":932357,"text":" 9:23 AM\n L-SPINE (AP & LAT) IN O.R. Clip # \n Reason: FUSION, DISCECTOMY L1-L5\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post fusion and discectomy of L1 through L5.\n\n COMPARISON: L-spine from .\n\n FINDINGS: Two intraoperative lateral radiographs of the lumbar spine were\n obtained without a radiologist present, which demonstrates posterior fusion\n with placement of bilateral pedicle screws in L1, L2, L4, L5. For further\n details, please refer to the operative note.\n\n"},{"category":"Radiology","chartdate":"2139-09-14 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":931825,"text":" 11:03 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: H/O PROSTRAT CA, L3 MASS.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate ca and L3 mass, with new incontinence and now\n nausea and vomiting\n REASON FOR THIS EXAMINATION:\n evaluate for intracranial pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ACKe MON 11:32 PM\n no significant change since \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New nausea and vomiting. History of prostate cancer.\n\n NON-CONTRAST HEAD CT: Comparison with . Prominence of sulci\n and ventricles is similar to the previous exam. No new hydrocephalus, shift\n of normally midline structures, intra- or extra-axial hemorrhage, or acute\n major vascular territorial infarct is identified. Hypodensity in corona\n radiata and centra semiovale as well as small lacunes in insular cortex and\n basal ganglia reflect chronic microvascular change. Imaged sinuses appear\n clear. External auditory canals are patent. No fractures are seen.\n\n Prominence of the left petrous/mastoid is again noted, unchanged.\n\n IMPRESSION: No acute intracranial hemorrhage or mass effect.\n\n\n"},{"category":"Radiology","chartdate":"2139-09-15 00:00:00.000","description":"MR L-SPINE W & W/O CONTRAST","row_id":931829,"text":" 12:32 AM\n MR W & W/O CONTRAST Clip # \n Reason: evalaute for new changes in mass since last MRI\n Contrast: MAGNEVIST Amt: 16\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with known L3 mass with xrt p/w continued low back pain and leg\n pain/weakness and 2 episodes of urine incontinence, nl tone, no saddle\n anesthesia.\n REASON FOR THIS EXAMINATION:\n evalaute for new changes in mass since last MRI\n ______________________________________________________________________________\n WET READ: ACKe TUE 2:48 AM\n Positive for mass emanating from the L3 vertebrae and extending into the\n epidural space causing very severe canal and nerve root compression.\n\n MD\n\n I agree with above and add that exam looks very similar to that of . MD\n WET READ VERSION #1 DJD TUE 1:51 AM\n Positive for mass emanating from the L3 vertebrae and extending into the\n epidural space causing very severe canal and nerve root compression.\n\n MD\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: L3 mass status post radiation therapy with continued\n low back pain and leg pain, weakness and urinary incontinence.\n\n MRI OF THE LUMBAR SPINE WITH GADOLINIUM.\n\n Exam was compared to prior study of .\n\n FINDINGS: Again is noted the mass within the body of the L3 lumbar vertebra\n extending into the epidural space and involving the pedicle on the left side.\n A paravertebral mass on the left is again identified. There is severe canal\n stenosis, which is unchanged from the previous examination. There are no\n definite changes from the previous examination. There is no definite evidence\n of involvement of additional vertebra.\n\n IMPRESSION: Large mass at L3 with features as discussed above. There is\n severe canal stenosis. There is no definite change from prior study.\n\n\n"},{"category":"Radiology","chartdate":"2139-09-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":932846,"text":" 12:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: rule out PE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate CA, plasmacytomoa of L3, to go for surgery to\n remove spinal tumor tomorrow\n REASON FOR THIS EXAMINATION:\n rule out PE\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Rule out pulmonary embolism (PE) in an 86-year-old man with\n plasmacytoma localized in L3 and with prostate cancer, scheduled for spinal\n surgery tomorrow.\n\n COMPARISON: Prior chest x-ray from three days ago.\n\n TECHNIQUE AND FINDINGS: A single view frontal x-ray of the chest was obtained\n in upright position.\n\n As compared to the prior images from , there has been interval\n removal of the endotracheal tube. The appearance of the cardiomediastinal\n silhouette remains unchanged. As before, tortuosity and calcification of the\n aorta are noted, multiple old, healed rib fractures are seen on the right\n side, and metallic orthopedic hardware is present at the level of the upper\n lumbar spine. A small radiopaque band is seen just above the left\n costophrenic angle, likely representing focal atelectasis. Otherwise, the\n transparence of the lung fields is symmetric.\n\n CONCLUSION: Focal band of atelectasis at the left lung base. Otherwise,\n unchanged appearance of the chest since . Interval removal of\n the endotracheal tube.\n\n"},{"category":"Radiology","chartdate":"2139-09-30 00:00:00.000","description":"MR HEAD W/O CONTRAST","row_id":934005,"text":" 1:05 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: Eval for stroke\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with persistent delerium and ? aphasia\n REASON FOR THIS EXAMINATION:\n Eval for stroke\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 86-year-old male with persistent delirium and ? aphasia; evaluate\n for stroke.\n\n TECHNIQUE: Routine non-contrast MRI and MRA of the brain was performed.\n\n FINDINGS: The study is compared with recent non-contrast head CT dated\n . There is no evidence of focally decreased diffusion to indicate\n acute infarction and the major intracranial vascular flow voids are preserved\n (see MRA, below). Though the susceptibility-weighted sequence is motion\n degraded, there is no evidence of large acute or chronic hemorrhage. There is\n uniform prominence of the extra-axial CSF spaces, the sulci and fissures and\n the ventricles, representing generalized atrophy. There is relatively mild\n focal and confluent FLAIR hyperintensity in bihemispheric subcortical and\n periventricular white matter, representing chronic microischemic change.\n\n There is normal flow-related enhancement in the included intracranial portions\n of both internal carotid and proximal middle and anterior cerebral arteries,\n with normal, symmetric arborization of MCA branches and no flow-limiting\n stenosis or aneurysm. There is normal flow-related enhancement in the distal\n vertebral and the basilar and bilateral posterior cerebral arteries, with\n probable fetal-type left PCA, and no flow-limiting stenosis or aneurysm.\n\n IMPRESSION:\n 1. No evidence of acute intracranial process; specifically, there is no\n evidence of acute infarction.\n 2. Moderate generalized atrophy and chronic micro-ischemic change in\n subcortical and periventricular white matter.\n 3. Unremarkable cranial MRA.\n\n"},{"category":"Radiology","chartdate":"2139-10-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":934569,"text":" 3:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: consolidation? infiltrate?\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate CA, chordoma L3 with new unresponsiveness,\n food particles in mouth\n REASON FOR THIS EXAMINATION:\n consolidation? infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Prostate cancer.\n\n Cardiomediastinal contours are normal. Nodular opacity projecting over the\n left lower lung is not immediately apparent on . The finding may\n represent nipple shadow. There is no effusion. No pneumothorax. Trachea is\n midline. Posterior lumbar fusion hardware is incompletely assessed as it\n extends off the inferior aspect of this single view of the chest. The aorta\n is tortuous. No pneumothorax. No consolidation.\n\n IMPRESSION:\n\n 1. No consolidation. No effusion.\n\n 2. Nodular opacity projecting over the left lung base is not evident on the\n chest radiograph of . The finding may simply represent nipple\n shadow. It clinically indicated, repeat chest radiograph with nipple marker\n in place could be performed to exclude pulmonary nodule.\n\n\n"},{"category":"Radiology","chartdate":"2139-10-04 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":934567,"text":" 3:20 PM\n PORTABLE ABDOMEN Clip # \n Reason: obstruction, free air\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate cancer, new onset abd pain. difficult to arouse.\n\n REASON FOR THIS EXAMINATION:\n obstruction, free air\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pain.\n\n Single portable radiograph of the abdomen is submitted. Diagnostic quality is\n limited by patient motion. Normal air and stool filled loops of bowel are\n evident. The patient is seen to be posterior osseous and metallic lumbar\n fusion. The hip and sacroiliac joint spaces are not well assessed secondary\n to motion, but there is likely bilateral degenerative change of both hips. No\n fracture is identified, although subtle fracture is not excluded given the\n degree of patient motion.\n\n IMPRESSION:\n\n Limited study secondary to patient motion. Normal bowel gas pattern.\n\n\n"},{"category":"Radiology","chartdate":"2139-09-27 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":933620,"text":" 8:16 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o fracture, instabliity\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate CA s/p L3 lesion resection (? plasmacytoma),\n stabilization of L1-5, POD 9, s/p fall out of chair. r/o fracture.\n REASON FOR THIS EXAMINATION:\n r/o fracture, instabliity\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old man with prostate cancer status post L3 lesion\n resection and stabilization of L1-5, status post fall. Evaluate for fracture,\n instability.\n\n COMPARISON: Plain radiographs of the cervical spine from .\n\n TECHNIQUE: Axial images of the cervical spine were obtained with coronal and\n sagittal reformatted images.\n\n CT C-SPINE: No fracture is identified. Extensive degenerative changes are\n seen, predominantly at the C4-6 levels. Additionally, there is grade I\n anterolisthesis of C4 on 5 of approximately 3 mm with slight kyphotic\n angulation. There are extensive facet degenerative changes at these levels as\n well. There is mild spinal canal narrowing, predominantly at the C5/6 and\n C6/7 levels. There is facet hypertrophy and degenerative change at several\n levels as well. There is associated neural foraminal narrowing at the C3/4\n level bilaterally, C5/6 level. There is limited evaluation of intrathecal\n contents on CT. The posterior disc osteophyte complex at the C5/6 level abuts\n the anterior aspect of the cord, without any definite indentation. The\n contour of the thecal sac is within normal limits at the remaining levels. No\n prevertebral soft tissue swelling is seen. Within the visualized portion of\n the lung apices, no pneumothorax or pleural effusion is seen.\n\n IMPRESSION:\n\n 1. Extensive degenerative changes are seen, as described above.\n\n 2. There is no fracture.\n\n 3. There is a 3 mm grade I anterolisthesis of C4 on C5 with focal kyphotic\n angulation. There is no associated prevertebral soft tissue abnormality.\n While this is possibly degenerative, the kyphosis appears more prominent in\n comparison to the prior C-spine radiographs from , and an underlying\n ligamentous injury is not excluded. Clinical correlation is recommended, and\n further evaluation with an MRI could be obtained if indicated.\n\n\n NOTE ADDED AT ATTENDING REVIEW: I agree that there is more subluxation and\n kyphosis now than on the prior study. I also agree that this change may be\n acute or chronic. Note that there is very little information about intraspinal\n (Over)\n\n 8:16 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o fracture, instabliity\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n soft tissue abnormalities. The need for MR will depend on the clinical\n presentation, but it would be the best way to evaluate possible ligamentous\n injury.\n\n"},{"category":"Radiology","chartdate":"2139-09-27 00:00:00.000","description":"CT T-SPINE W/O CONTRAST","row_id":933621,"text":" 8:16 PM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: r/o fracture\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate CA s/p L3 lesion resection (? plasmacytoma),\n stabilization of L1-5, POD 9, s/p fall out of chair. r/o fracture.\n REASON FOR THIS EXAMINATION:\n r/o fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86 year old man with prostate cancer status post L3 resection,\n status post fall. Evaluate for fracture.\n\n COMPARISON: Prior CT scan from .\n\n TECHNIQUE: Axial images of the thoracic spine were obtained with coronal and\n sagittal reformatted images.\n\n CT T-SPINE: No fracture or subluxation is identified. Minimal degenerative\n changes are seen at several levels. Bony mineralization is stable in\n comparison to the prior study. There is limited evaluation of intrathecal\n contents on CT, however, the contour of the thecal sac is within normal\n limits.\n\n There are bilateral pleural effusions and associated adjacent atelectasis.\n Scattered aortic calcifications are noted. There is a prominent subcarinal\n lymph node measuring 15 mm in short axis diameter. The liver demonstrates\n slightly increased parenchymal density on this noncontrast study, which may be\n related to prior treatment.\n\n IMPRESSION:\n\n 1. No fracture or subluxation of the thoracic spine is identified.\n\n 2. Bilateral pleural effusions and adjacent atelectasis.\n\n 3. Slightly increased density of the liver parenchyma is noted, and may\n reflect changes related to prior treatment or transfusion.\n\n\n"},{"category":"Radiology","chartdate":"2139-09-27 00:00:00.000","description":"CT L-SPINE W/O CONTRAST","row_id":933622,"text":" 8:16 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: r/o fracture\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate CA s/p L3 lesion resection (? plasmacytoma),\n stabilization of L1-5, POD 9, s/p fall out of chair. r/o fracture.\n REASON FOR THIS EXAMINATION:\n r/o fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 86 year old man with prostate cancer status post L3 resection,\n fell out of a chair, evaluate for fracture.\n\n COMPARISON: MRI study from .\n\n TECHNIQUE: Axial images of the lumbar spine were obtained with coronal and\n sagittal reformatted images.\n\n CT L-SPINE: There has been interval placement of posterior paraspinal fusion\n rods and pedicle and vertebral body screws in the L1-2 and L4-5 vertebral\n bodies. Multiple small bone graft chips can be seen along the fusion rods.\n Again seen is lytic and sclerotic change within the L3 vertebral body with\n associated cortical irregularity and destruction, consistent with the known\n mass seen on prior studies. There appears to be normal alignment of the\n lumbar vertebral column. The lateral left aspect of the L3 vertebral body\n appears markedly destroyed, with extension of the mass into the paraspinal\n soft tissues. There is limited evaluation of intraspinal and intrathecal\n contents on CT secondary to artifact from adjacent hardware. Post-surgical\n changes are seen within the posterior soft tissues from recent surgery.\n\n There are bilateral pleural effusions and adjacent atelectasis. Scattered\n aortic calcifications are noted. There is a large hypodensity arising off of\n the right kidney, which is not completely characterized on this study.\n\n IMPRESSION: Again seen is a soft tissue mass at the L3 level with associated\n osseous destruction of the L3 vertebral body. The patient has undergone\n interval placement of posterior fusion hardware from L1-5. There is no\n evidence of spondylolisthesis.\n\n NOTE ADDED AT ATTENDING REVIEW: Note that the images are so limited for\n intraspinal soft tissue that we cannot evaluate the possibility of cauda\n equina compromise due to mass or hematoma. There are no large osseous\n fragments in the canal. Smaller fragments might be missed due to artifact.\n\n"},{"category":"Radiology","chartdate":"2139-09-27 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":933618,"text":" 7:29 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o intracranial bleed.\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate CA, plasmacytoma of L3 vertebrae s/p\n decompression of L3 lesion with posterior stabilization of L1-5. With fall from\n chair at 7pm. + head trauma, needs NCHCT to r/o intracranial bleed, SDH, SAH.\n REASON FOR THIS EXAMINATION:\n r/o intracranial bleed.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old man with history of prostate cancer and plasmacytoma\n of L3 vertebral body, status post decompression of the L3 lesion and posterior\n stabilization, status post fall from chair. Evaluate for intracranial\n hemorrhage.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n CT HEAD WITHOUT IV CONTRAST: No intracranial hemorrhage is identified. The\n ventricles are symmetric, and there is no shift of normally midline\n structures. The -white matter differentiation is preserved. Again seen\n are areas of low attenuation within the periventricular and subcortical white\n matter, consistent with change from chronic microvascular angiopathy. Soft\n tissue and osseous structures are stable in appearance. The visualized\n portions of the paranasal sinuses are well aerated.\n\n IMPRESSION: No hemorrhage is identified.\n\n"},{"category":"Radiology","chartdate":"2139-10-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":934148,"text":" 10:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: effusion, consolidate.\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate CA, chordoma L3 with fever, crackles.\n REASON FOR THIS EXAMINATION:\n effusion, consolidate.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Fever and crackles in a patient after orthopedic\n surgery for L3 chordoma.\n\n The heart size is normal. The aorta is tortuous including the ascending and\n descending part. The lungs are clear. The pleural surfaces are smooth with\n no pleural effusion.\n\n IMPRESSION: No evidence of acute cardiopulmonary process.\n\n\n"},{"category":"Radiology","chartdate":"2139-10-05 00:00:00.000","description":"L-SPINE (AP & LAT)","row_id":934653,"text":" 10:43 AM\n L-SPINE (AP & LAT) Clip # \n Reason: s/p L3 decompression and fusion; evaluate alignment\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with\n REASON FOR THIS EXAMINATION:\n s/p L3 decompression and fusion; evaluate alignment\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post L3 decompression and fusion, evaluate alignment.\n\n TWO VIEWS OF THE LOWER LUMBAR SPINE. The technologist notes that the patient\n was unable to cooperate.\n\n There is evidence of laminectomy, with bilateral pedicle screws at L1, L2, L4,\n and L5 and a crossbar at the level of L4. ? morselized bone graft, faintly\n visualized due to technique. There are destructive changes of the L3 vertebral\n body. Allowing for patient positioning, hardware and spinal alignment is\n nominal. There is probable diffuse osteopenia.\n\n There is a defect in the right iliac bone of uncertain etiology or\n significance, not fully evaluated here.\n\n IMPRESSION:\n 1. Laminectomy and spinal stabilization procedure, in nominal alignment, with\n osseous destruction of L3. Degenerative narrowing at multiple disc levels\n noted.\n 2. Lytic lesion in right iliac bone, not fully evaluated. Is this the site\n of previous surgical intervention?\n\n"},{"category":"Radiology","chartdate":"2139-09-17 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":932227,"text":" 11:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pre-op xray\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate CA, plasmacytomoa of L3, to go for surgery to\n remove spinal tumor tomorrow\n REASON FOR THIS EXAMINATION:\n pre-op xray\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Pre-operative evaluation before L3 surgery.\n\n Portable AP chest radiograph compared to . The heart size is\n normal. The aorta is tortuous and calcified. There is no congestive heart\n failure. The lungs are clear except for a left upper lobe granuloma. The\n pleural surfaces are smooth with no pleural effusion. Old fractures of the\n right ribs are again demonstrated.\n\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2139-09-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1380151,\n \"text\": \"Elderly Russian Speaking man admitted to on . Now comes to Trauma Sicu Post-op Spinal tumor resection. Fusion of L1-L5.\\nSee assessment for HX.\\nNeuro: Admitted on Propofol and remains sedated on propofol. Also is wearing fentanyl patch 50mcg/hr due to be changed tomorrow. Attempts to wean propofol down made pt. wake abruptly (on 10mcgs). Pt. thrashing and not able to open eyes to command. (language barrier noted) Sedated with increasing propofol dose back to 30. Pt. noted to move all extremities spontaneously when not sedated.\\ncv/resp NSR. initially bradycardic. now in the high 60's with pac's.\\nVented on AC ventilation. excellent abgs. Not breathing over vent on propofol. Lungs clear. on 35%fio2. sat=100.\\ngi/gu foley with marginal uop. One liter LR fluid bolus given for low uop and low BP. 6pm hct pending ? need for prbc transfusion. Hemovac from incision has drained avg. 75cc/hr. since arrival. NPO with no gastric intubation at this time. Hypoactive bowel sounds.\\nAccess:2 Right PIVS #18 and 16 2 pivs on the left #18 and 20.\\nright femerol aline.\\nInteg Elastoplast dsg from or on lumbar spinal area D+I. Hemovac drain as noted above. stockings and compression sleeves on.\\nBair hugger on arrival for hypothermia. Now with oral Temp=96.\\nPlan. Monitor for bleeding/hypovolemia. Keep intubated and sedated overnight. Plan extubation tomorrow if stable coming off sedation.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2139-09-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1380152,\n \"text\": \"NPN 1900-0700\\n pt on propofol gtt and PRN fentanyl. Attempted again to wean propofol but pt easily awakens and very restless twisting in bed and bending legs (has R groin aline). ? pain as cause. Fent settles pt for short periods of time. Dilaudid dose x 1 given with longer effect.\\n\\n Pt changed to PS 5/5. TV 600-1Liter with RR 4-8. When pt light and moving in bed RR remains<10. HO aware. Pt later changed to MMV with no change in #s. Sats 100% and ABGs wnl. Lungs hard to auscultate anteriorly, coarse posteriorly.\\n\\nCV- SR with freq PVCs. SBP 100-120s, into 160s when agitated. Low UO for several hours which did not respond to fluid bolus x 2. Maintance remains at 80cc/h. UO improved at 6am. Hct down to 26 and PRBCs #1 being transfused, 2u ordered. Afebrile. Mag and K repleted during shift. Lopressor iv started.\\n\\nGI/GU- Abd soft, +BS. Foley patent, UO as mentioned. No BM.\\n\\nSocial- no contact with family overnight.\\n\\nPlan- Most likely try to extubate this am. need to change pain management.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2139-09-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1380153,\n \"text\": \"NPN 1900-0700\\nAddendum\\n\\nPt propofol off at 0645, by 7am awake, opening eyes and very restless in bed. MAEs. Extubated without incident and on FT 40%. RR 18 and sats 98%.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2139-09-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1380154,\n \"text\": \"T/SICU NPN:\\nBrief ROS:\\nNeuro- Family in to visit pt. today, they believe him to be alert and oriented. He responded appropriately to questions during entire visit. Pt. moves all extremities, gd strength. He has been slightly restless and pulled at etc.. but appears mostly purposeful with moving. He (through his family) has complained mostly of his legs being uncomfortable, behind his knees, left more than the rt. He does not c/o back () pain. Pupils are reactive to light, when pt. allows nurse to check pupils(he's clamped eyes closed with flashlight). Pt. has had fentanyl IV, 50mcg every 3-4 hrs today, which does settle him for a short amt of time. He also started a fentanyl patch today, as he had at home.\\n\\nCV- BP intermittantly has been high throughout shift today, mostly r/t agitation or stimulation. When he's quiet and restful, his BP is 140's- 160 systolic. HR has been in the 80's, with frequent APC's. Skin warm and dry. Difficult to palpate periph pulses, gd nail bed blanching. Gd color. Rt groin art line just starting to become dampened.\\n\\nResp- Gd color all shift. Only able to get O2 sat occasionally, when possible sats are adequate. Bilat breath sounds are coarse to clear throughtout. RR 20's down to 8 when he's asleep.\\n\\nGI- NPO as yet, he has not been cooperative consistantly enough to start po's. Intermittantly allows mouth care. Abd with +BS, flat.\\n\\nGU- Marginal most of shift with slightly better hours occ.\\n\\nHeme- Improved Hct after 2 units packed cells.\\n\\nID- Cefazolin doses complete. Afeb.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2139-09-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1380155,\n \"text\": \"NPN 1900-0700\\nNeuro- Russian speaking only. Awake most of night and restless. medicated for pain frequently with mod effect. When touch pt tends to yell out in Russian. With turning trys to pinch and hit staff. MAEs well.\\n\\nResp- Lungs clear to coarse with diminished bases. Barrel Chest. ABGs WNL. FT changed to 3lnc and sats 98%. Will occ cough, nonproductive.\\n\\nCV- HTN in 170s, HR 80-90s with freq PACs. Lopressor increased to 5mg IV q6h with little effect on bp and HR. MD aware. T max 101.8, blood and urine cx sent and tylenol given. Skin w/d/i. Original post op dressing over back incision. Hemovax in place 25cc out for 24h.\\n\\nGI/GU- Abd soft, +BS. Pt yells out when abd palpated but also yells when touch legs. No BM. Foley patent with light yellow urine.\\n\\n transfer to floor, may require a sitter. OOB to chair with brace.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2139-10-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 270892,\n \"text\": \"Sinus rhythm with atrial premature depolarizations. Otherwise, without\\ndiagnostic abnormality. Compared to the previous tracing of cardiac\\nrhythm now sinus mechanism.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2139-10-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 270893,\n \"text\": \"Atrial fibrillation with a mean ventricular response, rate 136. Diffuse\\nrepolarization abnormalities. Compared to the previous tracing of \\ncardiac rhythm is now rapid atrial fibrillation.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2139-10-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 271118,\n \"text\": \"Baseline artifact\\nSinus bradycardia\\nConsider left ventricular hypertrophy\\nST-T wave configuration suggests in part early repolarization pattern\\nSince previous tracing of , atrial ectopy absent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2139-09-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 271119,\n \"text\": \"Sinus rhythm with PACs\\nSeptal T wave changes are nonspecific\\nEarly R wave progression\\nSince previous tracing of , atrial fibrillation not present\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2139-09-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 271120,\n \"text\": \"Atrial fibrillation with rapid ventricular response\\nEarly precordial QRS transition - is nonspecific\\nConsider left ventricular hypertrophy\\nDiffuse nonspecific ST-T wave abnormalities\\nSince previous tracing of , rapid atrial fibrillation and further ST-T\\nwave changes now present\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2139-09-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 271121,\n \"text\": \"Sinus rhythm\\nSupraventricular extrasystoles\\nInferior + anterior T wave change may be due to myocardial ischemia\\nEarly transition\\nSince previous tracing, T wave changes, and atrial premature complexes noted\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-09-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 932461,\n \"text\": \" 5:14 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ETT placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with prostate CA, plasmacytomoa of L3, to go for surgery to\\n remove spinal tumor tomorrow\\n REASON FOR THIS EXAMINATION:\\n ETT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: ETT placement.\\n\\n FINDINGS: The prior study is from . There are multiple\\n granulomas again seen. The cardiac silhouette is normal. The aorta is\\n ectatic with calcification along its walls. The lung transparency is normal.\\n The ETT tube remains at 3.6 cm of the carina. Old fractures of the ribs are\\n seen on the right side.\\n\\n IMPRESSION: ETT tube in place, no acute cardiopulmonary process.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-09-18 00:00:00.000\",\n \"description\": \"O L-SPINE (AP & LAT) IN O.R.\",\n \"row_id\": 932357,\n \"text\": \" 9:23 AM\\n L-SPINE (AP & LAT) IN O.R. Clip # \\n Reason: FUSION, DISCECTOMY L1-L5\\n Admitting Diagnosis: BACK PAIN\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Status post fusion and discectomy of L1 through L5.\\n\\n COMPARISON: L-spine from .\\n\\n FINDINGS: Two intraoperative lateral radiographs of the lumbar spine were\\n obtained without a radiologist present, which demonstrates posterior fusion\\n with placement of bilateral pedicle screws in L1, L2, L4, L5. For further\\n details, please refer to the operative note.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-09-14 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 931825,\n \"text\": \" 11:03 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: H/O PROSTRAT CA, L3 MASS.\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with prostate ca and L3 mass, with new incontinence and now\\n nausea and vomiting\\n REASON FOR THIS EXAMINATION:\\n evaluate for intracranial pathology\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: ACKe MON 11:32 PM\\n no significant change since \\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: New nausea and vomiting. History of prostate cancer.\\n\\n NON-CONTRAST HEAD CT: Comparison with . Prominence of sulci\\n and ventricles is similar to the previous exam. No new hydrocephalus, shift\\n of normally midline structures, intra- or extra-axial hemorrhage, or acute\\n major vascular territorial infarct is identified. Hypodensity in corona\\n radiata and centra semiovale as well as small lacunes in insular cortex and\\n basal ganglia reflect chronic microvascular change. Imaged sinuses appear\\n clear. External auditory canals are patent. No fractures are seen.\\n\\n Prominence of the left petrous/mastoid is again noted, unchanged.\\n\\n IMPRESSION: No acute intracranial hemorrhage or mass effect.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-09-15 00:00:00.000\",\n \"description\": \"MR L-SPINE W & W/O CONTRAST\",\n \"row_id\": 931829,\n \"text\": \" 12:32 AM\\n MR W & W/O CONTRAST Clip # \\n Reason: evalaute for new changes in mass since last MRI\\n Contrast: MAGNEVIST Amt: 16\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with known L3 mass with xrt p/w continued low back pain and leg\\n pain/weakness and 2 episodes of urine incontinence, nl tone, no saddle\\n anesthesia.\\n REASON FOR THIS EXAMINATION:\\n evalaute for new changes in mass since last MRI\\n ______________________________________________________________________________\\n WET READ: ACKe TUE 2:48 AM\\n Positive for mass emanating from the L3 vertebrae and extending into the\\n epidural space causing very severe canal and nerve root compression.\\n\\n MD\\n\\n I agree with above and add that exam looks very similar to that of . MD\\n WET READ VERSION #1 DJD TUE 1:51 AM\\n Positive for mass emanating from the L3 vertebrae and extending into the\\n epidural space causing very severe canal and nerve root compression.\\n\\n MD\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INFORMATION: L3 mass status post radiation therapy with continued\\n low back pain and leg pain, weakness and urinary incontinence.\\n\\n MRI OF THE LUMBAR SPINE WITH GADOLINIUM.\\n\\n Exam was compared to prior study of .\\n\\n FINDINGS: Again is noted the mass within the body of the L3 lumbar vertebra\\n extending into the epidural space and involving the pedicle on the left side.\\n A paravertebral mass on the left is again identified. There is severe canal\\n stenosis, which is unchanged from the previous examination. There are no\\n definite changes from the previous examination. There is no definite evidence\\n of involvement of additional vertebra.\\n\\n IMPRESSION: Large mass at L3 with features as discussed above. There is\\n severe canal stenosis. There is no definite change from prior study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-09-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 932846,\n \"text\": \" 12:15 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: rule out PE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with prostate CA, plasmacytomoa of L3, to go for surgery to\\n remove spinal tumor tomorrow\\n REASON FOR THIS EXAMINATION:\\n rule out PE\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Rule out pulmonary embolism (PE) in an 86-year-old man with\\n plasmacytoma localized in L3 and with prostate cancer, scheduled for spinal\\n surgery tomorrow.\\n\\n COMPARISON: Prior chest x-ray from three days ago.\\n\\n TECHNIQUE AND FINDINGS: A single view frontal x-ray of the chest was obtained\\n in upright position.\\n\\n As compared to the prior images from , there has been interval\\n removal of the endotracheal tube. The appearance of the cardiomediastinal\\n silhouette remains unchanged. As before, tortuosity and calcification of the\\n aorta are noted, multiple old, healed rib fractures are seen on the right\\n side, and metallic orthopedic hardware is present at the level of the upper\\n lumbar spine. A small radiopaque band is seen just above the left\\n costophrenic angle, likely representing focal atelectasis. Otherwise, the\\n transparence of the lung fields is symmetric.\\n\\n CONCLUSION: Focal band of atelectasis at the left lung base. Otherwise,\\n unchanged appearance of the chest since . Interval removal of\\n the endotracheal tube.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-09-30 00:00:00.000\",\n \"description\": \"MR HEAD W/O CONTRAST\",\n \"row_id\": 934005,\n \"text\": \" 1:05 PM\\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \\n Reason: Eval for stroke\\n Admitting Diagnosis: BACK PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with persistent delerium and ? aphasia\\n REASON FOR THIS EXAMINATION:\\n Eval for stroke\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 86-year-old male with persistent delirium and ? aphasia; evaluate\\n for stroke.\\n\\n TECHNIQUE: Routine non-contrast MRI and MRA of the brain was performed.\\n\\n FINDINGS: The study is compared with recent non-contrast head CT dated\\n . There is no evidence of focally decreased diffusion to indicate\\n acute infarction and the major intracranial vascular flow voids are preserved\\n (see MRA, below). Though the susceptibility-weighted sequence is motion\\n degraded, there is no evidence of large acute or chronic hemorrhage. There is\\n uniform prominence of the extra-axial CSF spaces, the sulci and fissures and\\n the ventricles, representing generalized atrophy. There is relatively mild\\n focal and confluent FLAIR hyperintensity in bihemispheric subcortical and\\n periventricular white matter, representing chronic microischemic change.\\n\\n There is normal flow-related enhancement in the included intracranial portions\\n of both internal carotid and proximal middle and anterior cerebral arteries,\\n with normal, symmetric arborization of MCA branches and no flow-limiting\\n stenosis or aneurysm. There is normal flow-related enhancement in the distal\\n vertebral and the basilar and bilateral posterior cerebral arteries, with\\n probable fetal-type left PCA, and no flow-limiting stenosis or aneurysm.\\n\\n IMPRESSION:\\n 1. No evidence of acute intracranial process; specifically, there is no\\n evidence of acute infarction.\\n 2. Moderate generalized atrophy and chronic micro-ischemic change in\\n subcortical and periventricular white matter.\\n 3. Unremarkable cranial MRA.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-10-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 934569,\n \"text\": \" 3:29 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: consolidation? infiltrate?\\n Admitting Diagnosis: BACK PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with prostate CA, chordoma L3 with new unresponsiveness,\\n food particles in mouth\\n REASON FOR THIS EXAMINATION:\\n consolidation? infiltrate?\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Prostate cancer.\\n\\n Cardiomediastinal contours are normal. Nodular opacity projecting over the\\n left lower lung is not immediately apparent on . The finding may\\n represent nipple shadow. There is no effusion. No pneumothorax. Trachea is\\n midline. Posterior lumbar fusion hardware is incompletely assessed as it\\n extends off the inferior aspect of this single view of the chest. The aorta\\n is tortuous. No pneumothorax. No consolidation.\\n\\n IMPRESSION:\\n\\n 1. No consolidation. No effusion.\\n\\n 2. Nodular opacity projecting over the left lung base is not evident on the\\n chest radiograph of . The finding may simply represent nipple\\n shadow. It clinically indicated, repeat chest radiograph with nipple marker\\n in place could be performed to exclude pulmonary nodule.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-10-04 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 934567,\n \"text\": \" 3:20 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: obstruction, free air\\n Admitting Diagnosis: BACK PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with prostate cancer, new onset abd pain. difficult to arouse.\\n\\n REASON FOR THIS EXAMINATION:\\n obstruction, free air\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Pain.\\n\\n Single portable radiograph of the abdomen is submitted. Diagnostic quality is\\n limited by patient motion. Normal air and stool filled loops of bowel are\\n evident. The patient is seen to be posterior osseous and metallic lumbar\\n fusion. The hip and sacroiliac joint spaces are not well assessed secondary\\n to motion, but there is likely bilateral degenerative change of both hips. No\\n fracture is identified, although subtle fracture is not excluded given the\\n degree of patient motion.\\n\\n IMPRESSION:\\n\\n Limited study secondary to patient motion. Normal bowel gas pattern.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-09-27 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 933620,\n \"text\": \" 8:16 PM\\n CT C-SPINE W/O CONTRAST Clip # \\n Reason: r/o fracture, instabliity\\n Admitting Diagnosis: BACK PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with prostate CA s/p L3 lesion resection (? plasmacytoma),\\n stabilization of L1-5, POD 9, s/p fall out of chair. r/o fracture.\\n REASON FOR THIS EXAMINATION:\\n r/o fracture, instabliity\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 86-year-old man with prostate cancer status post L3 lesion\\n resection and stabilization of L1-5, status post fall. Evaluate for fracture,\\n instability.\\n\\n COMPARISON: Plain radiographs of the cervical spine from .\\n\\n TECHNIQUE: Axial images of the cervical spine were obtained with coronal and\\n sagittal reformatted images.\\n\\n CT C-SPINE: No fracture is identified. Extensive degenerative changes are\\n seen, predominantly at the C4-6 levels. Additionally, there is grade I\\n anterolisthesis of C4 on 5 of approximately 3 mm with slight kyphotic\\n angulation. There are extensive facet degenerative changes at these levels as\\n well. There is mild spinal canal narrowing, predominantly at the C5/6 and\\n C6/7 levels. There is facet hypertrophy and degenerative change at several\\n levels as well. There is associated neural foraminal narrowing at the C3/4\\n level bilaterally, C5/6 level. There is limited evaluation of intrathecal\\n contents on CT. The posterior disc osteophyte complex at the C5/6 level abuts\\n the anterior aspect of the cord, without any definite indentation. The\\n contour of the thecal sac is within normal limits at the remaining levels. No\\n prevertebral soft tissue swelling is seen. Within the visualized portion of\\n the lung apices, no pneumothorax or pleural effusion is seen.\\n\\n IMPRESSION:\\n\\n 1. Extensive degenerative changes are seen, as described above.\\n\\n 2. There is no fracture.\\n\\n 3. There is a 3 mm grade I anterolisthesis of C4 on C5 with focal kyphotic\\n angulation. There is no associated prevertebral soft tissue abnormality.\\n While this is possibly degenerative, the kyphosis appears more prominent in\\n comparison to the prior C-spine radiographs from , and an underlying\\n ligamentous injury is not excluded. Clinical correlation is recommended, and\\n further evaluation with an MRI could be obtained if indicated.\\n\\n\\n NOTE ADDED AT ATTENDING REVIEW: I agree that there is more subluxation and\\n kyphosis now than on the prior study. I also agree that this change may be\\n acute or chronic. Note that there is very little information about intraspinal\\n (Over)\\n\\n 8:16 PM\\n CT C-SPINE W/O CONTRAST Clip # \\n Reason: r/o fracture, instabliity\\n Admitting Diagnosis: BACK PAIN\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n soft tissue abnormalities. The need for MR will depend on the clinical\\n presentation, but it would be the best way to evaluate possible ligamentous\\n injury.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-09-27 00:00:00.000\",\n \"description\": \"CT T-SPINE W/O CONTRAST\",\n \"row_id\": 933621,\n \"text\": \" 8:16 PM\\n CT T-SPINE W/O CONTRAST Clip # \\n Reason: r/o fracture\\n Admitting Diagnosis: BACK PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with prostate CA s/p L3 lesion resection (? plasmacytoma),\\n stabilization of L1-5, POD 9, s/p fall out of chair. r/o fracture.\\n REASON FOR THIS EXAMINATION:\\n r/o fracture\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 86 year old man with prostate cancer status post L3 resection,\\n status post fall. Evaluate for fracture.\\n\\n COMPARISON: Prior CT scan from .\\n\\n TECHNIQUE: Axial images of the thoracic spine were obtained with coronal and\\n sagittal reformatted images.\\n\\n CT T-SPINE: No fracture or subluxation is identified. Minimal degenerative\\n changes are seen at several levels. Bony mineralization is stable in\\n comparison to the prior study. There is limited evaluation of intrathecal\\n contents on CT, however, the contour of the thecal sac is within normal\\n limits.\\n\\n There are bilateral pleural effusions and associated adjacent atelectasis.\\n Scattered aortic calcifications are noted. There is a prominent subcarinal\\n lymph node measuring 15 mm in short axis diameter. The liver demonstrates\\n slightly increased parenchymal density on this noncontrast study, which may be\\n related to prior treatment.\\n\\n IMPRESSION:\\n\\n 1. No fracture or subluxation of the thoracic spine is identified.\\n\\n 2. Bilateral pleural effusions and adjacent atelectasis.\\n\\n 3. Slightly increased density of the liver parenchyma is noted, and may\\n reflect changes related to prior treatment or transfusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-09-27 00:00:00.000\",\n \"description\": \"CT L-SPINE W/O CONTRAST\",\n \"row_id\": 933622,\n \"text\": \" 8:16 PM\\n CT L-SPINE W/O CONTRAST Clip # \\n Reason: r/o fracture\\n Admitting Diagnosis: BACK PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with prostate CA s/p L3 lesion resection (? plasmacytoma),\\n stabilization of L1-5, POD 9, s/p fall out of chair. r/o fracture.\\n REASON FOR THIS EXAMINATION:\\n r/o fracture\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n INDICATION: 86 year old man with prostate cancer status post L3 resection,\\n fell out of a chair, evaluate for fracture.\\n\\n COMPARISON: MRI study from .\\n\\n TECHNIQUE: Axial images of the lumbar spine were obtained with coronal and\\n sagittal reformatted images.\\n\\n CT L-SPINE: There has been interval placement of posterior paraspinal fusion\\n rods and pedicle and vertebral body screws in the L1-2 and L4-5 vertebral\\n bodies. Multiple small bone graft chips can be seen along the fusion rods.\\n Again seen is lytic and sclerotic change within the L3 vertebral body with\\n associated cortical irregularity and destruction, consistent with the known\\n mass seen on prior studies. There appears to be normal alignment of the\\n lumbar vertebral column. The lateral left aspect of the L3 vertebral body\\n appears markedly destroyed, with extension of the mass into the paraspinal\\n soft tissues. There is limited evaluation of intraspinal and intrathecal\\n contents on CT secondary to artifact from adjacent hardware. Post-surgical\\n changes are seen within the posterior soft tissues from recent surgery.\\n\\n There are bilateral pleural effusions and adjacent atelectasis. Scattered\\n aortic calcifications are noted. There is a large hypodensity arising off of\\n the right kidney, which is not completely characterized on this study.\\n\\n IMPRESSION: Again seen is a soft tissue mass at the L3 level with associated\\n osseous destruction of the L3 vertebral body. The patient has undergone\\n interval placement of posterior fusion hardware from L1-5. There is no\\n evidence of spondylolisthesis.\\n\\n NOTE ADDED AT ATTENDING REVIEW: Note that the images are so limited for\\n intraspinal soft tissue that we cannot evaluate the possibility of cauda\\n equina compromise due to mass or hematoma. There are no large osseous\\n fragments in the canal. Smaller fragments might be missed due to artifact.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-09-27 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 933618,\n \"text\": \" 7:29 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: r/o intracranial bleed.\\n Admitting Diagnosis: BACK PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with prostate CA, plasmacytoma of L3 vertebrae s/p\\n decompression of L3 lesion with posterior stabilization of L1-5. With fall from\\n chair at 7pm. + head trauma, needs NCHCT to r/o intracranial bleed, SDH, SAH.\\n REASON FOR THIS EXAMINATION:\\n r/o intracranial bleed.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 86-year-old man with history of prostate cancer and plasmacytoma\\n of L3 vertebral body, status post decompression of the L3 lesion and posterior\\n stabilization, status post fall from chair. Evaluate for intracranial\\n hemorrhage.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Non-contrast head CT.\\n\\n CT HEAD WITHOUT IV CONTRAST: No intracranial hemorrhage is identified. The\\n ventricles are symmetric, and there is no shift of normally midline\\n structures. The -white matter differentiation is preserved. Again seen\\n are areas of low attenuation within the periventricular and subcortical white\\n matter, consistent with change from chronic microvascular angiopathy. Soft\\n tissue and osseous structures are stable in appearance. The visualized\\n portions of the paranasal sinuses are well aerated.\\n\\n IMPRESSION: No hemorrhage is identified.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-10-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 934148,\n \"text\": \" 10:40 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: effusion, consolidate.\\n Admitting Diagnosis: BACK PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with prostate CA, chordoma L3 with fever, crackles.\\n REASON FOR THIS EXAMINATION:\\n effusion, consolidate.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Fever and crackles in a patient after orthopedic\\n surgery for L3 chordoma.\\n\\n The heart size is normal. The aorta is tortuous including the ascending and\\n descending part. The lungs are clear. The pleural surfaces are smooth with\\n no pleural effusion.\\n\\n IMPRESSION: No evidence of acute cardiopulmonary process.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-10-05 00:00:00.000\",\n \"description\": \"L-SPINE (AP & LAT)\",\n \"row_id\": 934653,\n \"text\": \" 10:43 AM\\n L-SPINE (AP & LAT) Clip # \\n Reason: s/p L3 decompression and fusion; evaluate alignment\\n Admitting Diagnosis: BACK PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with\\n REASON FOR THIS EXAMINATION:\\n s/p L3 decompression and fusion; evaluate alignment\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post L3 decompression and fusion, evaluate alignment.\\n\\n TWO VIEWS OF THE LOWER LUMBAR SPINE. The technologist notes that the patient\\n was unable to cooperate.\\n\\n There is evidence of laminectomy, with bilateral pedicle screws at L1, L2, L4,\\n and L5 and a crossbar at the level of L4. ? morselized bone graft, faintly\\n visualized due to technique. There are destructive changes of the L3 vertebral\\n body. Allowing for patient positioning, hardware and spinal alignment is\\n nominal. There is probable diffuse osteopenia.\\n\\n There is a defect in the right iliac bone of uncertain etiology or\\n significance, not fully evaluated here.\\n\\n IMPRESSION:\\n 1. Laminectomy and spinal stabilization procedure, in nominal alignment, with\\n osseous destruction of L3. Degenerative narrowing at multiple disc levels\\n noted.\\n 2. Lytic lesion in right iliac bone, not fully evaluated. Is this the site\\n of previous surgical intervention?\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-09-17 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 932227,\n \"text\": \" 11:51 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pre-op xray\\n Admitting Diagnosis: BACK PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with prostate CA, plasmacytomoa of L3, to go for surgery to\\n remove spinal tumor tomorrow\\n REASON FOR THIS EXAMINATION:\\n pre-op xray\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Pre-operative evaluation before L3 surgery.\\n\\n Portable AP chest radiograph compared to . The heart size is\\n normal. The aorta is tortuous and calcified. There is no congestive heart\\n failure. The lungs are clear except for a left upper lobe granuloma. The\\n pleural surfaces are smooth with no pleural effusion. Old fractures of the\\n right ribs are again demonstrated.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":24643,"cells":{"subject_id":{"kind":"number","value":17421,"string":"17,421"},"hadm_id":{"kind":"number","value":171993,"string":"171,993"},"target_text":{"kind":"string","value":"Patient had her pre-operative work-up as an out patient and was a same day admit. On she was brought directly to the operating room where she underwent an Aortic Valve Replacement. Please see op note for surgical details. She tolerated the procedure well and was brought to the CSRU in stable condition on minimal Inotropic support. Patient was transfused to keep hct approximately 30. Later on op day she was weaned from sedation, awoke neurologically intact and was extubated. Inotropes were weaned by post-op day one and she was started on a Nitro gtt for hypertension. B blockers and diuretics were initiated and she was gently diuresed throughout her post-op course. Chest tubes were removed on post-op day one and she was then transferred to the cardiac surgery step-down unit. Pre-operative medications were started for her Polycythemia and Myelodysplastic Syndrome. Her labs were stable throughout her hospital course with slight increase in her creatinine that came down to baseline at time of discharge. Also, her WBC remained quite elevated throughout hospital course (reaching over 70,000 on POD#2) and eventually coming down to 47,000 at time of discharge. Her epicardial pacing wires were removed on post-op day three. Physical therapy followed her during entire post-op course for strength and mobility. She improved rather well and was at level 5 by post-op day 4. She remained slightly above her pre-op weight and was discharged with diuretics. She was discharged home on post-op day four with VNA services and appropriate follow-up appointments."},"extractive_notes_summ":{"kind":"string","value":"1+ edema in BLE. Mild (1+) MR.TRICUSPID VALVE: Mild [1+] TR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Mild (1+) mitral regurgitationis seen. CXR REPORTED TO SHOW R MAIN BRONCHIAL INTUBATION. IMPRESSION: Trace right apical pneumothorax and bibasilar atelectasis. Normal ascending aorta diameter. The mitral annulus measures 3.1 cm.There is mild tricuspid regurgitation.There is a trivial/physiologic pericardial effusion.Post bypassBiprosthetic valve seen in the aortic position. Lung sounds cta, diminished in bases.Gi/Gu: Tol clear liquids. OP DAY AVR W/CE VALVE REPLACEMENTUPON ADMISSION CCO CALIBRATED. Titrating nitro gtt to keep SBP <120. Lytes WNL. Hypoactive bowel sounds. INDICATION: Pneumothorax. Mild tomoderate (+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. ?change zantac to pre-op PPI. Postoperative study. Normalaortic arch diameter.AORTIC VALVE: Moderately thickened aortic valve leaflets. PERRLA. There is trace Aortic insufficiency. FINDINGS: Nasogastric tube, Swan-Ganz catheter, and endotracheal tube have been removed. 1 PRBC GIVEN. The patient isreceiving a phenylephrine infusion at 0.5mcg/kg/min.LV and RV function is preserved.Aorta appears intact postdecannulation.Mild MR persists post bypass BILATERAL BREATHSOUNDS PRESENT. Additionally, there is trace right apical pneumothorax, a portion of which has collected along the azygos fissure. Mild to moderate (+) aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. IVP mso4 & PO percocet w/good effect.Skin: See carvue for incisions.ID: Afebrile. PATIENT/TEST INFORMATION:Indication: Pt having aortic valve replacement for Severe Aortic StenosisBP (mm Hg): 156/67HR (bpm): 89Status: InpatientDate/Time: at 12:53Test: Portable TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Taught IS, C&DB w/encouragement. There has been interval decrease in size of a right apical pneumothorax with a minimal pneumothorax remaining. Endotracheal tube tip in the right main stem bronchus. Filling pressures slightly low & decreased HUO-fluid bolus MD w/increase in filling pressures & slight increase in HUO. Wean nitro gtt as tol. COMPARISON: Preoperative study of . COMBIVANT GIVEN, LUNGS CLEAR. EXTUBATION TO 4L NC BUT MOUTH BREATHING. The patient is status post sternotomy. IMPRESSION: 1. C/O THIRST. NEO AND NITRO USED TO MAINTAIN SBP WITHIN GOAL. Pulmonary toilet. PLAN TO KEEP SBP 110-120. PT NPO TILL MORINING. SEE MORPHINE ON EPISODE OF FACIAL DIAPHORESIS. The mediastinum is prominent likely related to postoperative change. GOAL TO KEEP SBP 110-120. COMPARISON: . ABDOMEN SOFT NON-DISTENED.URINE OUTPUT ADEQUATE.PT ON STEROIDS PRE-OP. C/O PAIN. MAE x4. BRUISED R UNDERSIDE OF TONGUE NOTED. Pacer @ A-demand. No deficit noted.C/V: NSR 80s. The patient was under general anesthesia throughout theprocedure. Pulmonary edema. SVO2s 60s. Incidental note is made of an azygos lobe. PT APPEARS FLUSHED. The MR iscentral. HUO decreased <30, improved w/fluid bolus, started to decrease again. Cardiac and mediastinal contours are stable. Atrial paced rhythmTher may also be ventricular pacer activity with pseudofusion complexesLeft anterior fascicular blockSince previous tracing of , pacer activity present PLAN TO CONTINUE WITH HOURLY DEEP BREATHING X 10. ?dc swan. PT DENIES USUALLY APPEARING FLUSHED. The endotracheal tube tip is in the right main stem bronchus, extending 2 cm from the carina. NC MOVED TO MOUTH WITH SPO2 UP FROM 89% TO 93%.OGT DRAINED MINIMAL BILIOUS PRIOR TO REMOVAL.BOWEL SOUNDS HYPOACTIVE. APACED/UNDERLYING RHYTHM SR 70S, NO ECTOPICLUNGS I/E WHEEZING FROM OR. ETT PULLED BACK 4CM TO 22CM AT THE LIP. CI >2 by CCO thermo. Bibasilar atelectatic changes are noted with interval improvement in the left lower lobe and no significant change in the right lower lobe. ?tx to F2 if able to wean nitro gtt off. There is severe aorticvalve stenosis. PLAN TO CONTINUE STEROIDS. Pain management. PT DENIES PAIN. I certifyI was present in compliance with HCFA regulations. Neuro: A&Ox3. The NG tube tip is in the stomach. No ASD by 2D or colorDoppler.LEFT VENTRICLE: Normal regional LV systolic function. Creat increased to 1.4-IVP lasix MD .Comfort: Increased mediastinal pain, ?CT. AP CHEST RADIOGRAPH: Interval placement of prosthetic aortic valve with mediastinal clips and sternal wires are seen. There are two mediastinal drains. 12:52 PM CHEST PORT. 2. These findings were discussed with on at 1:20 p.m. Swan-Ganz catheter via the right internal jugular vein is present with its tip in the left main pulmonary artery. SBP increasing on 2.25mcg/kg/min nitro gtt, IVP lopressor & PO lopressor started MD w/good effect. Overall normal LVEF(>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. Overall left ventricularsystolic function is normal (LVEF>55%).The LV is symmetrically hypertrophied (1.5cm).Right ventricular chamber size and free wall motion are normal.The aortic valve leaflets are moderately thickened. ROOM HEAT TURNED DOWN. OOB to chair. Results were personally reviewed with the MD caring for thepatient.Conclusions:Prebypass studyNo atrial septal defect is seen by 2D or color Doppler.Regional left ventricular wall motion is normal. HEMATOLOGY REQUEST HCT AROUND 30. Severe AS. AFEBRILE.NEXT OF \"SISTER-IN-LAW \" CALLED FOR PHONE REPORT AND SPOKE WITH DR. . On IV cefazolin.Endo: Blood sugars treated per CSRU sliding scale.Social: Sister in law called & updated by RN.A/P: Monitor urine output. Increase diet as tol. Leaflets move well and thevalve appears well seated. The pulmonary vascularity is prominent centrally. Lung volumes are lower than on the prior exam, resulting in crowding of vascular markings at both lung bases. SEE HYDROCORTISONE ORDER.GLUCOSE HAS NOT REQUIRED INSULIN IN CSRU.ORIENTED X 3. Follow up chest radiograph before the patient is discharged is recommended to ensure that this is not increasing in size. 9:47 AM CHEST (SINGLE VIEW) Clip # Reason: assess ptx Admitting Diagnosis: CHF\\AORTIC VALVE REPLACEMENT/SDA MEDICAL CONDITION: 63 year old woman s/p AVR REASON FOR THIS EXAMINATION: assess ptx FINAL REPORT PORTABLE CHEST COMPARISON: ."},"n_notes":{"kind":"number","value":7,"string":"7"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2196-03-14 00:00:00.000","description":"Report","row_id":74665,"text":"PATIENT/TEST INFORMATION:\nIndication: Pt having aortic valve replacement for Severe Aortic Stenosis\nBP (mm Hg): 156/67\nHR (bpm): 89\nStatus: Inpatient\nDate/Time: at 12:53\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\naortic arch diameter.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Severe AS. Mild to\nmoderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. Results were personally reviewed with the MD caring for the\npatient.\n\nConclusions:\nPrebypass study\nNo atrial septal defect is seen by 2D or color Doppler.\n\nRegional left ventricular wall motion is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%).\nThe LV is symmetrically hypertrophied (1.5cm).\n\nRight ventricular chamber size and free wall motion are normal.\n\nThe aortic valve leaflets are moderately thickened. There is severe aortic\nvalve stenosis. Mild to moderate (+) aortic regurgitation is seen.\n\nThe mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation\nis seen. There is no structural deformity in the mitral leaflets. The MR is\ncentral. The mitral annulus measures 3.1 cm.\n\nThere is mild tricuspid regurgitation.\n\nThere is a trivial/physiologic pericardial effusion.\n\nPost bypass\n\nBiprosthetic valve seen in the aortic position. Leaflets move well and the\nvalve appears well seated. There is trace Aortic insufficiency. The patient is\nreceiving a phenylephrine infusion at 0.5mcg/kg/min.\n\nLV and RV function is preserved.\n\nAorta appears intact postdecannulation.\n\nMild MR persists post bypass\n\n\n"},{"category":"ECG","chartdate":"2196-03-14 00:00:00.000","description":"Report","row_id":166548,"text":"Atrial paced rhythm\nTher may also be ventricular pacer activity with pseudofusion complexes\nLeft anterior fascicular block\nSince previous tracing of , pacer activity present\n\n"},{"category":"Radiology","chartdate":"2196-03-16 00:00:00.000","description":"CHEST (SINGLE VIEW)","row_id":904554,"text":" 9:47 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: assess ptx\n Admitting Diagnosis: CHF\\AORTIC VALVE REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p AVR\n REASON FOR THIS EXAMINATION:\n assess ptx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: .\n\n INDICATION: Pneumothorax.\n\n There has been interval decrease in size of a right apical pneumothorax with a\n minimal pneumothorax remaining. Cardiac and mediastinal contours are stable.\n Bibasilar atelectatic changes are noted with interval improvement in the left\n lower lobe and no significant change in the right lower lobe. There is\n otherwise no significant change since the recent radiograph of one day\n earlier.\n\n\n"},{"category":"Radiology","chartdate":"2196-03-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":904409,"text":" 12:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p d/c chest tubesr/o ptx\n Admitting Diagnosis: CHF\\AORTIC VALVE REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p AVR- page # with abnormalities\n\n REASON FOR THIS EXAMINATION:\n s/p d/c chest tubesr/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aortic valve repair, status post chest tube removal.\n\n COMPARISON: .\n\n FINDINGS: Nasogastric tube, Swan-Ganz catheter, and endotracheal tube have\n been removed. The patient is status post sternotomy. Lung volumes are lower\n than on the prior exam, resulting in crowding of vascular markings at both\n lung bases. Additionally, there is trace right apical pneumothorax, a portion\n of which has collected along the azygos fissure.\n\n IMPRESSION: Trace right apical pneumothorax and bibasilar atelectasis. Follow\n up chest radiograph before the patient is discharged is recommended to ensure\n that this is not increasing in size. Findings were called to nurse\n practitioner at 2:40 p.m., .\n\n"},{"category":"Radiology","chartdate":"2196-03-14 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":904267,"text":" 12:52 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film\n Admitting Diagnosis: CHF\\AORTIC VALVE REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p AVR- page # with abnormalities\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Aortic valve replacement. Postoperative study.\n\n COMPARISON: Preoperative study of .\n\n AP CHEST RADIOGRAPH: Interval placement of prosthetic aortic valve with\n mediastinal clips and sternal wires are seen. The endotracheal tube tip is in\n the right main stem bronchus, extending 2 cm from the carina. These findings\n were discussed with on at 1:20 p.m.\n\n Swan-Ganz catheter via the right internal jugular vein is present with its tip\n in the left main pulmonary artery. There are two mediastinal drains. The NG\n tube tip is in the stomach. There is no pneumothorax. Incidental note is\n made of an azygos lobe. The pulmonary vascularity is prominent centrally. The\n mediastinum is prominent likely related to postoperative change.\n\n IMPRESSION:\n 1. Endotracheal tube tip in the right main stem bronchus.\n 2. Pulmonary edema.\n\n\n"},{"category":"Nursing/other","chartdate":"2196-03-14 00:00:00.000","description":"Report","row_id":1490479,"text":"OP DAY AVR W/CE VALVE REPLACEMENT\nUPON ADMISSION CCO CALIBRATED. GOAL TO KEEP SBP 110-120. NEO AND NITRO USED TO MAINTAIN SBP WITHIN GOAL. HEMATOLOGY REQUEST HCT AROUND 30. 1 PRBC GIVEN. APACED/UNDERLYING RHYTHM SR 70S, NO ECTOPIC\n\n\nLUNGS I/E WHEEZING FROM OR. CXR REPORTED TO SHOW R MAIN BRONCHIAL INTUBATION. ETT PULLED BACK 4CM TO 22CM AT THE LIP. BILATERAL BREATHSOUNDS PRESENT. COMBIVANT GIVEN, LUNGS CLEAR. EXTUBATION TO 4L NC BUT MOUTH BREATHING. NC MOVED TO MOUTH WITH SPO2 UP FROM 89% TO 93%.\n\nOGT DRAINED MINIMAL BILIOUS PRIOR TO REMOVAL.BOWEL SOUNDS HYPOACTIVE. PT NPO TILL MORINING. C/O THIRST. BRUISED R UNDERSIDE OF TONGUE NOTED. PT DENIES PAIN. ABDOMEN SOFT NON-DISTENED.\n\nURINE OUTPUT ADEQUATE.\n\nPT ON STEROIDS PRE-OP. SEE HYDROCORTISONE ORDER.\n\nGLUCOSE HAS NOT REQUIRED INSULIN IN CSRU.\n\nORIENTED X 3. C/O PAIN. SEE MORPHINE ON EPISODE OF FACIAL DIAPHORESIS. PT APPEARS FLUSHED. ROOM HEAT TURNED DOWN. PT DENIES USUALLY APPEARING FLUSHED. AFEBRILE.\n\nNEXT OF \"SISTER-IN-LAW \" CALLED FOR PHONE REPORT AND SPOKE WITH DR. . PT REPORTS THAT HER HEALTH CARE PROXY IS HER BROTHER WHO LIVES IN . PT LIVES BY HERSELF. PT WILL NEED EVALUATION FOR DISCHARGE TO HOME.\n\nPT BELONGINGS JUST DELIVERED FROM SAME DAY SURGERY. PT DENIES HAVING WALLET, CREDIT CARDS OR JEWELRY IN PERSONAL BELONGINGS.\n\nPLAN TO MONITOR CLOSELY. PLAN TO KEEP SBP 110-120. PLAN TO CONTINUE STEROIDS. PLAN TO CONTINUE WITH HOURLY DEEP BREATHING X 10.\n\n\n"},{"category":"Nursing/other","chartdate":"2196-03-15 00:00:00.000","description":"Report","row_id":1490480,"text":"Neuro: A&Ox3. PERRLA. MAE x4. No deficit noted.\n\nC/V: NSR 80s. No ectopy. Lytes WNL. Titrating nitro gtt to keep SBP <120. SBP increasing on 2.25mcg/kg/min nitro gtt, IVP lopressor & PO lopressor started MD w/good effect. SVO2s 60s. CI >2 by CCO thermo. Filling pressures slightly low & decreased HUO-fluid bolus MD w/increase in filling pressures & slight increase in HUO. Pacer @ A-demand. 1+ edema in BLE. CT to SX w/min serosanginous output.\n\nResp: NC increased to 6L, sats >96%. Taught IS, C&DB w/encouragement. Lung sounds cta, diminished in bases.\n\nGi/Gu: Tol clear liquids. Hypoactive bowel sounds. No c/o n/v. HUO decreased <30, improved w/fluid bolus, started to decrease again. Creat increased to 1.4-IVP lasix MD .\n\nComfort: Increased mediastinal pain, ?CT. IVP mso4 & PO percocet w/good effect.\n\nSkin: See carvue for incisions.\nID: Afebrile. On IV cefazolin.\nEndo: Blood sugars treated per CSRU sliding scale.\nSocial: Sister in law called & updated by RN.\n\nA/P: Monitor urine output. Wean nitro gtt as tol. ?dc swan. OOB to chair. Pulmonary toilet. Pain management. Increase diet as tol. ?tx to F2 if able to wean nitro gtt off. ?change zantac to pre-op PPI.\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2196-03-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 74665,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Pt having aortic valve replacement for Severe Aortic Stenosis\\nBP (mm Hg): 156/67\\nHR (bpm): 89\\nStatus: Inpatient\\nDate/Time: at 12:53\\nTest: Portable TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\\nDoppler.\\n\\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\\n(>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\\naortic arch diameter.\\n\\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Severe AS. Mild to\\nmoderate (+) AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Mild [1+] TR.\\n\\nPERICARDIUM: Trivial/physiologic pericardial effusion.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. No TEE related\\ncomplications. The patient was under general anesthesia throughout the\\nprocedure. Results were personally reviewed with the MD caring for the\\npatient.\\n\\nConclusions:\\nPrebypass study\\nNo atrial septal defect is seen by 2D or color Doppler.\\n\\nRegional left ventricular wall motion is normal. Overall left ventricular\\nsystolic function is normal (LVEF>55%).\\nThe LV is symmetrically hypertrophied (1.5cm).\\n\\nRight ventricular chamber size and free wall motion are normal.\\n\\nThe aortic valve leaflets are moderately thickened. There is severe aortic\\nvalve stenosis. Mild to moderate (+) aortic regurgitation is seen.\\n\\nThe mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation\\nis seen. There is no structural deformity in the mitral leaflets. The MR is\\ncentral. The mitral annulus measures 3.1 cm.\\n\\nThere is mild tricuspid regurgitation.\\n\\nThere is a trivial/physiologic pericardial effusion.\\n\\nPost bypass\\n\\nBiprosthetic valve seen in the aortic position. Leaflets move well and the\\nvalve appears well seated. There is trace Aortic insufficiency. The patient is\\nreceiving a phenylephrine infusion at 0.5mcg/kg/min.\\n\\nLV and RV function is preserved.\\n\\nAorta appears intact postdecannulation.\\n\\nMild MR persists post bypass\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2196-03-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 166548,\n \"text\": \"Atrial paced rhythm\\nTher may also be ventricular pacer activity with pseudofusion complexes\\nLeft anterior fascicular block\\nSince previous tracing of , pacer activity present\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-03-16 00:00:00.000\",\n \"description\": \"CHEST (SINGLE VIEW)\",\n \"row_id\": 904554,\n \"text\": \" 9:47 AM\\n CHEST (SINGLE VIEW) Clip # \\n Reason: assess ptx\\n Admitting Diagnosis: CHF\\\\AORTIC VALVE REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old woman s/p AVR\\n REASON FOR THIS EXAMINATION:\\n assess ptx\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST\\n\\n COMPARISON: .\\n\\n INDICATION: Pneumothorax.\\n\\n There has been interval decrease in size of a right apical pneumothorax with a\\n minimal pneumothorax remaining. Cardiac and mediastinal contours are stable.\\n Bibasilar atelectatic changes are noted with interval improvement in the left\\n lower lobe and no significant change in the right lower lobe. There is\\n otherwise no significant change since the recent radiograph of one day\\n earlier.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-03-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 904409,\n \"text\": \" 12:27 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p d/c chest tubesr/o ptx\\n Admitting Diagnosis: CHF\\\\AORTIC VALVE REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old woman s/p AVR- page # with abnormalities\\n\\n REASON FOR THIS EXAMINATION:\\n s/p d/c chest tubesr/o ptx\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Aortic valve repair, status post chest tube removal.\\n\\n COMPARISON: .\\n\\n FINDINGS: Nasogastric tube, Swan-Ganz catheter, and endotracheal tube have\\n been removed. The patient is status post sternotomy. Lung volumes are lower\\n than on the prior exam, resulting in crowding of vascular markings at both\\n lung bases. Additionally, there is trace right apical pneumothorax, a portion\\n of which has collected along the azygos fissure.\\n\\n IMPRESSION: Trace right apical pneumothorax and bibasilar atelectasis. Follow\\n up chest radiograph before the patient is discharged is recommended to ensure\\n that this is not increasing in size. Findings were called to nurse\\n practitioner at 2:40 p.m., .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-03-14 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 904267,\n \"text\": \" 12:52 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: postop film\\n Admitting Diagnosis: CHF\\\\AORTIC VALVE REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old woman s/p AVR- page # with abnormalities\\n REASON FOR THIS EXAMINATION:\\n postop film\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Aortic valve replacement. Postoperative study.\\n\\n COMPARISON: Preoperative study of .\\n\\n AP CHEST RADIOGRAPH: Interval placement of prosthetic aortic valve with\\n mediastinal clips and sternal wires are seen. The endotracheal tube tip is in\\n the right main stem bronchus, extending 2 cm from the carina. These findings\\n were discussed with on at 1:20 p.m.\\n\\n Swan-Ganz catheter via the right internal jugular vein is present with its tip\\n in the left main pulmonary artery. There are two mediastinal drains. The NG\\n tube tip is in the stomach. There is no pneumothorax. Incidental note is\\n made of an azygos lobe. The pulmonary vascularity is prominent centrally. The\\n mediastinum is prominent likely related to postoperative change.\\n\\n IMPRESSION:\\n 1. Endotracheal tube tip in the right main stem bronchus.\\n 2. Pulmonary edema.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2196-03-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490479,\n \"text\": \"OP DAY AVR W/CE VALVE REPLACEMENT\\nUPON ADMISSION CCO CALIBRATED. GOAL TO KEEP SBP 110-120. NEO AND NITRO USED TO MAINTAIN SBP WITHIN GOAL. HEMATOLOGY REQUEST HCT AROUND 30. 1 PRBC GIVEN. APACED/UNDERLYING RHYTHM SR 70S, NO ECTOPIC\\n\\n\\nLUNGS I/E WHEEZING FROM OR. CXR REPORTED TO SHOW R MAIN BRONCHIAL INTUBATION. ETT PULLED BACK 4CM TO 22CM AT THE LIP. BILATERAL BREATHSOUNDS PRESENT. COMBIVANT GIVEN, LUNGS CLEAR. EXTUBATION TO 4L NC BUT MOUTH BREATHING. NC MOVED TO MOUTH WITH SPO2 UP FROM 89% TO 93%.\\n\\nOGT DRAINED MINIMAL BILIOUS PRIOR TO REMOVAL.BOWEL SOUNDS HYPOACTIVE. PT NPO TILL MORINING. C/O THIRST. BRUISED R UNDERSIDE OF TONGUE NOTED. PT DENIES PAIN. ABDOMEN SOFT NON-DISTENED.\\n\\nURINE OUTPUT ADEQUATE.\\n\\nPT ON STEROIDS PRE-OP. SEE HYDROCORTISONE ORDER.\\n\\nGLUCOSE HAS NOT REQUIRED INSULIN IN CSRU.\\n\\nORIENTED X 3. C/O PAIN. SEE MORPHINE ON EPISODE OF FACIAL DIAPHORESIS. PT APPEARS FLUSHED. ROOM HEAT TURNED DOWN. PT DENIES USUALLY APPEARING FLUSHED. AFEBRILE.\\n\\nNEXT OF \\\"SISTER-IN-LAW \\\" CALLED FOR PHONE REPORT AND SPOKE WITH DR. . PT REPORTS THAT HER HEALTH CARE PROXY IS HER BROTHER WHO LIVES IN . PT LIVES BY HERSELF. PT WILL NEED EVALUATION FOR DISCHARGE TO HOME.\\n\\nPT BELONGINGS JUST DELIVERED FROM SAME DAY SURGERY. PT DENIES HAVING WALLET, CREDIT CARDS OR JEWELRY IN PERSONAL BELONGINGS.\\n\\nPLAN TO MONITOR CLOSELY. PLAN TO KEEP SBP 110-120. PLAN TO CONTINUE STEROIDS. PLAN TO CONTINUE WITH HOURLY DEEP BREATHING X 10.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2196-03-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490480,\n \"text\": \"Neuro: A&Ox3. PERRLA. MAE x4. No deficit noted.\\n\\nC/V: NSR 80s. No ectopy. Lytes WNL. Titrating nitro gtt to keep SBP <120. SBP increasing on 2.25mcg/kg/min nitro gtt, IVP lopressor & PO lopressor started MD w/good effect. SVO2s 60s. CI >2 by CCO thermo. Filling pressures slightly low & decreased HUO-fluid bolus MD w/increase in filling pressures & slight increase in HUO. Pacer @ A-demand. 1+ edema in BLE. CT to SX w/min serosanginous output.\\n\\nResp: NC increased to 6L, sats >96%. Taught IS, C&DB w/encouragement. Lung sounds cta, diminished in bases.\\n\\nGi/Gu: Tol clear liquids. Hypoactive bowel sounds. No c/o n/v. HUO decreased <30, improved w/fluid bolus, started to decrease again. Creat increased to 1.4-IVP lasix MD .\\n\\nComfort: Increased mediastinal pain, ?CT. IVP mso4 & PO percocet w/good effect.\\n\\nSkin: See carvue for incisions.\\nID: Afebrile. On IV cefazolin.\\nEndo: Blood sugars treated per CSRU sliding scale.\\nSocial: Sister in law called & updated by RN.\\n\\nA/P: Monitor urine output. Wean nitro gtt as tol. ?dc swan. OOB to chair. Pulmonary toilet. Pain management. Increase diet as tol. ?tx to F2 if able to wean nitro gtt off. ?change zantac to pre-op PPI.\\n\"\n }\n]"}}},{"rowIdx":24644,"cells":{"subject_id":{"kind":"number","value":82024,"string":"82,024"},"hadm_id":{"kind":"number","value":136432,"string":"136,432"},"target_text":{"kind":"string","value":"The patient was admitted to the General Surgical Service for evaluation and treatment on . She was initially admitted to the ICU for hemodynamic monitoring. She was NPO/IVF and started on vanc/cipro/flagyl. She was transfused 1 unit of blood for a HCT of 27.8, which bumped appropriately to 29.8. Troponin was elevated to 0.53 upon admission, so heparin gtt was started but this was discontinued the next day per cardiology recs. BP was low initially in the ICU, with SBP in the 80s, but this responded appropriately to fluid boluses. The patient was transferred to the floor on HD2 and she was hemodynamically stable at that time. The patient was restarted on her beta , , and statin per cardiology and ECHO was performed on HD3, which showed new hypokinesis in the LAD distribution. From a GI perspective, CT scan showed leakage of the colonic stump/abscess and she was initially started on vanc, cipro, and flagyl, and the vanc was ultimately discontinued. Her diet was advanced to clears HD3 and subsequently to regular diet on HD 4, which the patient tolerated well without increase in abdominal pain. Her urine output was approx 20cc/hr, but she did require intermittent 250cc boluses to keep her Uop up. Foley was discontinued on HD4 and patient voided on her own. The patient was initially scheduled to go to rehab on , but cardiology re-assessed the patient and decided that cardiac catheterization might be necessary given new changes to ECHO and the elevated troponins. The patient was taken to the cath lab on , however after further discussion with patient and family, cardiology felt the bump in troponins was more likely from previous hypovolemia and not acute plaque rupture, so the cath was deferred. At the time, however, patient was clinically overloaded, with stable pressures, and so she recieved 10mg IV lasix twice, with good response. . At the time of discharge on HD6, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.She will continue with 10 more days of cipro and flagyl for her intraabdominal collection."},"extractive_notes_summ":{"kind":"string","value":"There is a trivial/physiologic pericardialeffusion.IMPRESSION: Moderate regional left ventricular systolic dysfunction, c/w CAD.Dilated right ventricle with normal systolic function. Mild (1+) aortic regurgitation is seen. Moderate mitral annularcalcification. Moderate mitral and tricuspidregurgitation. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) mitral regurgitation is seen.Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonaryartery systolic hypertension. The right ventricular cavity is mildly dilatedwith normal free wall contractility. Left ventricular wall thicknesses and cavity size are normal.There is moderate regional left ventricular systolic dysfunction with mid- todistal anterior and septal hypokinesis, c/w LAD disease. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.Conclusions:The left atrium is mildly dilated. Moderate (2+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. ModeratePA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. TASPEnormal (>=1.6cm)AORTA: Normal aortic diameter at the sinus level. Moderate pulmonary hypertension. Tricuspid annular plane systolicexcursion is normal (2.9 cm) consistent with normal right ventricular systolicfunction. Moderately thickened aortic valveleaflets. Calcific aortic valvedisease with mild stenosis/mild regurgitation. Moderate regional LVsystolic dysfunction. The ascending aorta is mildly dilated. Premature ventricular contractions.Low QRS voltage in the precordial leads. Normal RV systolic function. Non-specific T wave changes.Compared to the previous tracing of a ventricular premature beat isnew. Mild AS (area 1.2-1.9cm2). Moderate [2+] TR. Myocardial infarction.Height: (in) 60Weight (lb): 113BSA (m2): 1.47 m2BP (mm Hg): 102/48HR (bpm): 61Status: InpatientDate/Time: at 11:04Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Lowvoltage in the precordial leads. Sinus rhythm with atrial premature beats. Low QRS voltages in the limb leads. There is significant focal thickening and immobilization of theright coronary cusp of the aortic valve, resulting in mild stenosis (valvearea 1.2-1.9cm2). There areassociated T wave inversions in the same leads. Left ventricular function. Sinus rhythm. Sinus rhythm. Sinus rhythm. Mildly dilated ascendingaorta.AORTIC VALVE: Three aortic valve leaflets. Non-specific ST-T wave changes. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -hypo; mid anteroseptal - hypo; anterior apex - hypo; septal apex - hypo;inferior apex - hypo; apex - hypo;RIGHT VENTRICLE: Mildly dilated RV cavity. No ASD by 2D or colorDoppler.LEFT VENTRICLE: Normal LV wall thickness and cavity size. Right bundle-branch block. Right bundle-branch block. Right bundle-branch block. The mitral valveleaflets are mildly thickened. Inferolateral T wave changeswhich are non-specific. Compared to the previous tracing of ST segment elevation is no longer identified and QRS voltage is less in theanterior leads. Slight ST segment elevation inleads I, II, aVL and V2-V6 suspicious for myocardial ischemia. The T waves are now upright in lead V2. Compared to theprevious tracing of there is no significant diagnostic change. Coronary artery disease. No LV mass/thrombus. There are three aortic valveleaflets. PATIENT/TEST INFORMATION:Indication: Aortic valve disease. No atrial septal defect is seen by 2D orcolor Doppler. Compared to the previous tracing of thereare suggestions of ongoing myocardial ischemia in the distribution of the LAD.Clinical correlation and repeat tracing are strongly suggested. Criteria are met for rightbundle-branch block as well."},"n_notes":{"kind":"number","value":5,"string":"5"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2160-12-23 00:00:00.000","description":"Report","row_id":68054,"text":"PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Coronary artery disease. Left ventricular function. Myocardial infarction.\nHeight: (in) 60\nWeight (lb): 113\nBSA (m2): 1.47 m2\nBP (mm Hg): 102/48\nHR (bpm): 61\nStatus: Inpatient\nDate/Time: at 11:04\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderate regional LV\nsystolic dysfunction. No LV mass/thrombus. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nhypo; mid anteroseptal - hypo; anterior apex - hypo; septal apex - hypo;\ninferior apex - hypo; apex - hypo;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. TASPE\nnormal (>=1.6cm)\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Mild AS (area 1.2-1.9cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thicknesses and cavity size are normal.\nThere is moderate regional left ventricular systolic dysfunction with mid- to\ndistal anterior and septal hypokinesis, c/w LAD disease. No masses or thrombi\nare seen in the left ventricle. The right ventricular cavity is mildly dilated\nwith normal free wall contractility. Tricuspid annular plane systolic\nexcursion is normal (2.9 cm) consistent with normal right ventricular systolic\nfunction. The ascending aorta is mildly dilated. There are three aortic valve\nleaflets. There is significant focal thickening and immobilization of the\nright coronary cusp of the aortic valve, resulting in mild stenosis (valve\narea 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen.\nModerate [2+] tricuspid regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension. There is a trivial/physiologic pericardial\neffusion.\n\nIMPRESSION: Moderate regional left ventricular systolic dysfunction, c/w CAD.\nDilated right ventricle with normal systolic function. Calcific aortic valve\ndisease with mild stenosis/mild regurgitation. Moderate mitral and tricuspid\nregurgitation. Moderate pulmonary hypertension.\n\n\n"},{"category":"ECG","chartdate":"2160-12-25 00:00:00.000","description":"Report","row_id":149751,"text":"Sinus rhythm. Right bundle-branch block. Inferolateral T wave changes\nwhich are non-specific. Low QRS voltages in the limb leads. Compared to the\nprevious tracing of there is no significant diagnostic change.\n\n"},{"category":"ECG","chartdate":"2160-12-23 00:00:00.000","description":"Report","row_id":149752,"text":"Sinus rhythm. Right bundle-branch block. Non-specific ST-T wave changes. Low\nvoltage in the precordial leads. Compared to the previous tracing of \nST segment elevation is no longer identified and QRS voltage is less in the\nanterior leads.\n\n"},{"category":"ECG","chartdate":"2160-12-22 00:00:00.000","description":"Report","row_id":149753,"text":"Sinus rhythm with atrial premature beats. Slight ST segment elevation in\nleads I, II, aVL and V2-V6 suspicious for myocardial ischemia. There are\nassociated T wave inversions in the same leads. Criteria are met for right\nbundle-branch block as well. Compared to the previous tracing of there\nare suggestions of ongoing myocardial ischemia in the distribution of the LAD.\nClinical correlation and repeat tracing are strongly suggested.\n\n"},{"category":"ECG","chartdate":"2160-12-21 00:00:00.000","description":"Report","row_id":149754,"text":"Sinus rhythm. Right bundle-branch block. Premature ventricular contractions.\nLow QRS voltage in the precordial leads. Non-specific T wave changes.\nCompared to the previous tracing of a ventricular premature beat is\nnew. The T waves are now upright in lead V2.\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2160-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 68054,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Aortic valve disease. Coronary artery disease. Left ventricular function. Myocardial infarction.\\nHeight: (in) 60\\nWeight (lb): 113\\nBSA (m2): 1.47 m2\\nBP (mm Hg): 102/48\\nHR (bpm): 61\\nStatus: Inpatient\\nDate/Time: at 11:04\\nTest: TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Mild LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\\nDoppler.\\n\\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderate regional LV\\nsystolic dysfunction. No LV mass/thrombus. No resting LVOT gradient.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\\nhypo; mid anteroseptal - hypo; anterior apex - hypo; septal apex - hypo;\\ninferior apex - hypo; apex - hypo;\\n\\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. TASPE\\nnormal (>=1.6cm)\\n\\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\\naorta.\\n\\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\\nleaflets. Mild AS (area 1.2-1.9cm2). Mild (1+) AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\\ncalcification. Moderate (2+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate\\nPA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR.\\n\\nPERICARDIUM: Trivial/physiologic pericardial effusion.\\n\\nConclusions:\\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\\ncolor Doppler. Left ventricular wall thicknesses and cavity size are normal.\\nThere is moderate regional left ventricular systolic dysfunction with mid- to\\ndistal anterior and septal hypokinesis, c/w LAD disease. No masses or thrombi\\nare seen in the left ventricle. The right ventricular cavity is mildly dilated\\nwith normal free wall contractility. Tricuspid annular plane systolic\\nexcursion is normal (2.9 cm) consistent with normal right ventricular systolic\\nfunction. The ascending aorta is mildly dilated. There are three aortic valve\\nleaflets. There is significant focal thickening and immobilization of the\\nright coronary cusp of the aortic valve, resulting in mild stenosis (valve\\narea 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve\\nleaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen.\\nModerate [2+] tricuspid regurgitation is seen. There is moderate pulmonary\\nartery systolic hypertension. There is a trivial/physiologic pericardial\\neffusion.\\n\\nIMPRESSION: Moderate regional left ventricular systolic dysfunction, c/w CAD.\\nDilated right ventricle with normal systolic function. Calcific aortic valve\\ndisease with mild stenosis/mild regurgitation. Moderate mitral and tricuspid\\nregurgitation. Moderate pulmonary hypertension.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2160-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 149751,\n \"text\": \"Sinus rhythm. Right bundle-branch block. Inferolateral T wave changes\\nwhich are non-specific. Low QRS voltages in the limb leads. Compared to the\\nprevious tracing of there is no significant diagnostic change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2160-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 149752,\n \"text\": \"Sinus rhythm. Right bundle-branch block. Non-specific ST-T wave changes. Low\\nvoltage in the precordial leads. Compared to the previous tracing of \\nST segment elevation is no longer identified and QRS voltage is less in the\\nanterior leads.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2160-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 149753,\n \"text\": \"Sinus rhythm with atrial premature beats. Slight ST segment elevation in\\nleads I, II, aVL and V2-V6 suspicious for myocardial ischemia. There are\\nassociated T wave inversions in the same leads. Criteria are met for right\\nbundle-branch block as well. Compared to the previous tracing of there\\nare suggestions of ongoing myocardial ischemia in the distribution of the LAD.\\nClinical correlation and repeat tracing are strongly suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2160-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 149754,\n \"text\": \"Sinus rhythm. Right bundle-branch block. Premature ventricular contractions.\\nLow QRS voltage in the precordial leads. Non-specific T wave changes.\\nCompared to the previous tracing of a ventricular premature beat is\\nnew. The T waves are now upright in lead V2.\\n\\n\"\n }\n]"}}},{"rowIdx":24645,"cells":{"subject_id":{"kind":"number","value":28300,"string":"28,300"},"hadm_id":{"kind":"number","value":110122,"string":"110,122"},"target_text":{"kind":"string","value":"She was seen by neurology preoperatively to assess stroke risk. She awaited several days off of plavix prior to be taken to the operating room on where she underwent a CABG x 3. She was transferred to the ICU in critical but stable condition on neosynephrine, propofol and insulin. She was extubated later that same day. She was transferred to the floor on POD #1. On POD #2, she vomited, KUB showed no obstruction and LFTs were normal. Her vomiting rosolved with IV protonix. She did well postoperatively and was ready for discharge home on POD #4."},"extractive_notes_summ":{"kind":"string","value":"There are simpleatheroma in the descending thoracic aorta. Normal aortic arch diameter. Normal regional LV systolic function. FINDINGS: In the right internal capsule, again identified is an area of encephalomalacia and decreased density consistent with remote infarct. Trace aorticregurgitation is seen. No AS.Trace AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. Normal LV inflowpattern for age.TRICUSPID VALVE: Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. The mitral valve appears structurally normal withtrivial mitral regurgitation. Normal ascending aortadiameter.AORTIC VALVE: Normal aortic valve leaflets. Two mediastinal drains and a left chest tube are seen in unchanged position. There has been interval removal of an endotracheal tube. TECHNIQUE: Non-contrast head CT. Left-sided chest tube and two mediastinal tubes are in place. IMPRESSION: Chest and mediastinal tubes removed, no pneumothorax. IMPRESSION: Changes consistent with an area of remote infarct in the right internal capsule. Otherwise, essentially unchanged radiographic chest. Left ventricular function. Mild degenerative spurring of the thoracic spine is noted. The patientappears to be in sinus rhythm.Conclusions:The left atrium is normal in size. ?# aortic valve leaflets. Otherwise, normal ECG. PATIENT/TEST INFORMATION:Indication: Coronary artery diseaseHeight: (in) 56Weight (lb): 175BSA (m2): 1.68 m2BP (mm Hg): 110/50HR (bpm): 62Status: InpatientDate/Time: at 17:17Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size. HCT stable. F/U CT DRAINAGE. Heart size is borderline, with a left ventricular configuration. REASON FOR THIS EXAMINATION: r/o PTX/Effusion. There is no pericardial effusion.PostBypass:Normal biventricular systolic function. CXR DONE. RECIEVED PT S/P CX3. Compared to previoustracing of no diagnostic change. The patientappears to be in sinus rhythm. Denies nauseaGU: Foley patent. Adequate pulse oximetry values maintained on 2 lpm N.C. The mitral valve appears structurally normal with trivial mitralregurgitation. NEED EKG. There has been interval placement of a left subclavian PICC line with its radiodense guidewire tip projecting over the right atrium. Dopplerable pedal pulse rt foot, palp on lt. Cuff and aline correlate. No restingLVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Simpleatheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Preoperative assessment.Height: (in) 56Weight (lb): 175BSA (m2): 1.68 m2BP (mm Hg): 118/62HR (bpm): 45Status: InpatientDate/Time: at 16:40Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: DefinityTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the report of the prior study (images notavailable) of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%). On the right, the peak systolic velocities are 48/20 in the proximal ICA, 71/31 in the mid ICA, and 87/41 in the distal ICA. Chest tubes dry. Compared to the previous tracingof no diagnostic interim change.TRACING #1 FINAL REPORT INDICATION: Status post CABG. Titrated per protocol. Widening of the mediastinum is likely postoperative as patient is status post median sternotomy and CABG. CHEST ONE VIEW: Lung volumes are low. No spontaneous echo contrast or thrombus in theLA/LAA or the RA/RAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolicfunction (LVEF>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending aorta diameter. LINE PLACEMENT Clip # Reason: r/o PTX/Effusion. IMPRESSION: Interval placement of a left subclavian PICC line with its radiodense guidewire tip projecting over the right atrium; recommend withdrawal by 4 cm. OGT TO LCSXN. Low precordial lead voltage. Low precordial lead voltage. CT NO DRAINAGE-TEAM ROUND AWARED. Sinus rhythm without diagnostic abnormality. REspiratory CarePt extubated earlier in shift without incident. Sinus rhythm. ARRIVED SEDATED ON PROPOFOL. Pt placed on nasal cannula. Reglan given this am. The aortic valve leaflets (3) aremildly thickened but aortic stenosis is not present. There is mild age- inappropriate prominence of the frontal sulci. 2:36 PM ABDOMEN (SUPINE & ERECT) Clip # Reason: Boswle distension? CHEST The tip of the PICC line is unchanged in position since the prior chest x-ray and lies in the right atrium. On the left, the peak systolic velocities are 75/30 in the proximal ICA, 70/24 in the mid ICA, 72/26 in the distal ICA. HYPOTHERMIC->WARM BLANKET APPLIEDA/P: CON'T MONITOR- REVERSAL AND FAST TRACK WEANING PER PROTOCOL. Deline this am if appropriate per team, after femoral aline dc, OOB. TRAUMA LINE AND R FEM ARTERIAL LINE.LS CTA. On B-mode imaging, there is only minimal plaque in the distal CCA and proximal ICA. Regional left ventricular wall motion is normal. COMPARISON: CXR, . The visualized paranasal sinuses and mastoid air cells are well aerated. Lung sounds clear. There is ex vacuo dilatation of the adjacent frontal of the right lateral ventricle. Restart plavix in am. Lungs diminished at bases bilaterally. IMPRESSION: Unremarkable abdomen. Toradol given per Dr. and changed to dilaudid with good response. Right ventricularchamber size and free wall motion are normal. The right greater saphenous vein measures the following in diameter beginning at the saphenofemoral junction extending distally in cm: 0.61, 0.42, 0.41, 0.55, 0.35, 0.39, 0.24 and 0.16."},"n_notes":{"kind":"number","value":18,"string":"18"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2177-08-11 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":970834,"text":" 7:21 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: pre-op CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with CAD, pre-op CABG this admission.\n REASON FOR THIS EXAMINATION:\n pre-op CABG\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CAD, preop CABG.\n\n CHEST, TWO VIEWS.\n\n Heart size is borderline, with a left ventricular configuration. There is no\n CHF, focal infiltrate or effusion. Mild degenerative spurring of the thoracic\n spine is noted.\n\n Please see the chest CT report from , which describes a 3 mm right\n middle lobe nodule and left upper lobe calcification -- these are not\n visualized on today's study due to the technical limitations of radiographs\n as opposed to CT.\n\n\n"},{"category":"Radiology","chartdate":"2177-08-16 00:00:00.000","description":"ABDOMEN (SUPINE & ERECT)","row_id":971596,"text":" 2:36 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: Boswle distension?\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with abdominal tenderness, vomiting\n REASON FOR THIS EXAMINATION:\n Boswle distension?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Abdominal tenderness and vomiting.\n\n Four views. The bowel gas pattern is unremarkable. No free air is\n identified. Soft tissue shadows are not well demonstrated. No significant\n intra-abdominal calcifications are seen. Surgical clips overlie the left hip\n and proximal left thigh. A vascular stent is present in the left upper\n quadrant.\n\n IMPRESSION: Unremarkable abdomen. CT is recommended if further evaluation is\n required.\n\n"},{"category":"Radiology","chartdate":"2177-08-11 00:00:00.000","description":"PR VENOUS DUP EXT UNI (MAP/DVT) PORT RIGHT","row_id":970804,"text":" 3:09 PM\n VENOUS DUP EXT UNI (MAP/DVT) PORT RIGHT Clip # \n Reason: Evaluate B GSV. preop for CABGKnown hx of PVD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with CAD, preop CABG\n REASON FOR THIS EXAMINATION:\n Evaluate B GSV. preop for CABGKnown hx of PVD\n ______________________________________________________________________________\n FINAL REPORT\n VEIN MAPPING:\n\n REASON: 52-year-old woman with CAD. Preop for CABG.\n\n FINDINGS: Venous duplex evaluation was performed on the right lower extremity\n venous system greater saphenous vein for the purpose of obtain diameters for\n vein mapping.\n\n The right greater saphenous vein measures the following in diameter beginning\n at the saphenofemoral junction extending distally in cm: 0.61, 0.42, 0.41,\n 0.55, 0.35, 0.39, 0.24 and 0.16.\n\n FINDINGS: The right greater saphenous vein is widely patent throughout its\n length with the above-mentioned diameters.\n\n\n"},{"category":"Radiology","chartdate":"2177-08-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":971470,"text":" 11:54 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p ct d/c\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p picc line placement\n\n REASON FOR THIS EXAMINATION:\n s/p ct d/c\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: PICC line placed, left chest tube pulled.\n\n CHEST\n\n The tip of the PICC line is unchanged in position since the prior chest x-ray\n and lies in the right atrium.\n\n Left chest tube has been removed and there is no evidence of pneumothorax.\n Atelectasis in the left lower lobe is again noted.\n\n The mediastinal tubes have also been discontinued. The right lung remains\n clear.\n\n IMPRESSION: Chest and mediastinal tubes removed, no pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2177-08-15 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":971446,"text":" 9:21 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 44cm left basilic vein\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p picc line placement\n REASON FOR THIS EXAMINATION:\n 44cm left basilic vein\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post PICC line placement.\n\n COMPARISON: .\n\n CHEST ONE VIEW: Lung volumes are low. There has been interval placement of a\n left subclavian PICC line with its radiodense guidewire tip projecting over\n the right atrium. Two mediastinal drains and a left chest tube are seen in\n unchanged position. There has been interval removal of an endotracheal tube.\n A right internal jugular catheter is again seen with its tip projecting\n outside the chest over the superior edge of the right clavicle. There is\n persistent post-operative widening of the mediastinum. Within the limitation\n of low lung volumes no focal consolidation or pneumothorax is seen.\n\n IMPRESSION: Interval placement of a left subclavian PICC line with its\n radiodense guidewire tip projecting over the right atrium; recommend\n withdrawal by 4 cm. Otherwise, essentially unchanged radiographic chest.\n\n These results were communicated to the IV access team at 11a by\n Dr for Dr .\n\n"},{"category":"Radiology","chartdate":"2177-08-12 00:00:00.000","description":"CAROTID SERIES COMPLETE","row_id":970906,"text":" 8:54 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: Evaluate for carotid stenosis; Pt has known PVD and LM disea\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with CAD, preop CABG\n REASON FOR THIS EXAMINATION:\n Evaluate for carotid stenosis; Pt has known PVD and LM disease on cath\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID DUPLEX\n\n REASON: 52-year-old woman with CAD. Pre-op CABG, evaluate for carotid\n stenosis.\n\n FINDINGS: Duplex evaluation was performed on the bilateral carotid arteries.\n On B-mode imaging, there is only minimal plaque in the distal CCA and proximal\n ICA.\n\n On the right, the peak systolic velocities are 48/20 in the proximal ICA,\n 71/31 in the mid ICA, and 87/41 in the distal ICA. There is a velocity of\n 57/18 in the CCA and 103 in the ECA. The ICA/CCA ratio is 1.5 and this is\n consistent with a less than 40% right ICA stenosis.\n\n On the left, the peak systolic velocities are 75/30 in the proximal ICA, 70/24\n in the mid ICA, 72/26 in the distal ICA. There is a velocity of 76/34 in the\n CCA and 110 in the ECA. The ICA/CCA ratio is 0.98 and this is consistent with\n a less than 40% left ICA stenosis.\n\n There is antegrade flow in both vertebral arteries.\n\n IMPRESSION: There is a less than 40% right ICA stenosis and a less than 40%\n left ICA stenosis with antegrade flow in both vertebral arteries\n\n\n\n\n"},{"category":"Radiology","chartdate":"2177-08-13 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":971174,"text":" 8:17 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: baseline assessment prior to CABG \n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with DM, HTN, PAD, CAD, prior CVA x2 ' (last head CT was\n '). Neurology consult requests non-contrast head CT prior to CABG to\n delineate anomalies.\n REASON FOR THIS EXAMINATION:\n baseline assessment prior to CABG \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old with diabetes, hypertension, coronary artery and\n peripheral vascular disease. Baseline assessment prior to CABG.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: In the right internal capsule, again identified is an area of\n encephalomalacia and decreased density consistent with remote infarct. There\n is ex vacuo dilatation of the adjacent frontal of the right lateral\n ventricle. No intra- or extra-axial hemorrhage, shift of normally midline\n structures, mass effect or hydrocephalus is identified. There is mild age-\n inappropriate prominence of the frontal sulci. The basal cisterns are not\n effaced. The visualized paranasal sinuses and mastoid air cells are well\n aerated.\n\n IMPRESSION: Changes consistent with an area of remote infarct in the right\n internal capsule. No acute vascular infarct or intracranial hemorrhage.\n\n"},{"category":"Radiology","chartdate":"2177-08-14 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":971353,"text":" 6:09 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX/Effusion.\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with CAD s/p CABG. Please page at with\n abnormalities.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG.\n\n COMPARISON: CXR, .\n\n PORTABLE CHEST: An endotracheal tube terminates approximately 33 mm above the\n carina. The nasogastric tube courses below the diaphragm with its proximal\n side port beyond the gastroesophageal junction, but its tip projecting below\n the edge of the film. Left-sided chest tube and two mediastinal tubes are in\n place. The tip of a right sided internal jugular catheter projects over the\n right brachiocephalic vein.\n Widening of the mediastinum is likely postoperative as patient is status post\n median sternotomy and CABG. There is no evidence of pneumothorax or sizable\n effusion. Lung volumes are low, which limits evaluation of lung parenchyma,\n however, no focal consolidation is identified.\n\n IMPRESSION: Satisfactory placement of multiple lines and tubes status post\n CABG.\n\n"},{"category":"Echo","chartdate":"2177-08-14 00:00:00.000","description":"Report","row_id":70001,"text":"PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease\nHeight: (in) 56\nWeight (lb): 175\nBSA (m2): 1.68 m2\nBP (mm Hg): 110/50\nHR (bpm): 62\nStatus: Inpatient\nDate/Time: at 17:17\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter. Normal aortic arch diameter. Simple\natheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The TEE probe was passed\nwith assistance from the anesthesioology staff using a laryngoscope. The\npatient was under general anesthesia throughout the procedure. The patient\nappears to be in sinus rhythm. Results were personally reviewed with the MD\ncaring for the patient.\n\nConclusions:\nPRE-BYPASS:\nThe left atrium is normal in size. No spontaneous echo contrast or thrombus is\nseen in the body of the left atrium/left atrial appendage or the body of the\nright atrium/right atrial appendage. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and systolic function (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. There are simple\natheroma in the descending thoracic aorta. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. No aortic regurgitation\nis seen. The mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no pericardial effusion.\n\nPost_Bypass:\nNormal biventricular systolic function. LVEF 55%\nTrivial MR, TR.\nAortic contour is intact.\n\n\n"},{"category":"Echo","chartdate":"2177-08-12 00:00:00.000","description":"Report","row_id":70041,"text":"PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Preoperative assessment.\nHeight: (in) 56\nWeight (lb): 175\nBSA (m2): 1.68 m2\nBP (mm Hg): 118/62\nHR (bpm): 45\nStatus: Inpatient\nDate/Time: at 16:40\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Definity\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). Normal regional LV systolic function. No resting\nLVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets. ?# aortic valve leaflets. No AS.\nTrace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Normal LV inflow\npattern for age.\n\nTRICUSPID VALVE: Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. The patient\nappears to be in sinus rhythm.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets appear\nstructurally normal with good leaflet excursion. The number of aortic valve\nleaflets cannot be determined. There is no aortic valve stenosis. Trace aortic\nregurgitation is seen. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. The pulmonary artery systolic pressure could not\nbe determined. There is an anterior space which most likely represents a fat\npad.\n\nCompared with the report of the prior study (images unavailable for review) of\n, left ventricular wall thickness has increased. Otherwise, the\nfindings are similar.\n\n\n"},{"category":"Nursing/other","chartdate":"2177-08-15 00:00:00.000","description":"Report","row_id":1631876,"text":"Neuro: Pt reversed and woken easily. PERRLA. Follows commands. MAE. Post extubation pt had pain issues of lt shoulder pain due to chest tubes and incisional pain with movement and coughing. Poor response to morphine. Toradol given per Dr. and changed to dilaudid with good response. Pt sleeping of and on overnight. Pt oriented x3.\nCV: Initially HR 70's to 80's, post extubation pt tachy 100-110 nsr. IVF given with no response to HR. CVP 12-17. Pt given lopressor 2.5 mg iv at 0500 HR<100. pt had been on neo/ntg overnight, now off. Chest tubes dry. No leak. HCT stable. Dopplerable pedal pulse rt foot, palp on lt. Cuff and aline correlate. See flowsheet for blood pressure trend. To restart plavix for CVA history this am.\nRESP: Pt initially orally intubated. Once pt awake , vent weaned and pt extubated without difficulty. Pt placed on nasal cannula. On 2L nc sats>97%. On RA 92-95%. Pt feels better with O2 on while in bed. Lungs diminished at bases bilaterally. IS to 500.\nGI: OGT discontinued with extubation. Abd soft, nontender. No BS. Reglan given this am. Pt tolerating ice chips. Denies nausea\nGU: Foley patent. UOP initially good, then dropped to <30cc/hr. Pt given additional LR 1L with good response, tapering off again. Will continue to assess\nEndo: remained on insulin gtt overnight. Titrated per protocol. See flowsheet\nSocial: No family contact. Pt states she lives with her significant other whom she like to be her spokesperson.\nPlan: Cont assess cardio/resp status. Deline this am if appropriate per team, after femoral aline dc, OOB. Wean o2 and advance activity and diet as tolerated. Restart plavix in am. Follow UOP. Continue hourly blood sugars while on insulin gtt. ? transfer to F2 if appropriate.\n"},{"category":"Nursing/other","chartdate":"2177-08-14 00:00:00.000","description":"Report","row_id":1631873,"text":"pt recieved from OR without incidence, plan is to wean through evening as tollerated towards extubation.\n"},{"category":"Nursing/other","chartdate":"2177-08-14 00:00:00.000","description":"Report","row_id":1631874,"text":"RECIEVED PT S/P CX3. ARRIVED SEDATED ON PROPOFOL. PERRL 3MM. APACED AND NEO TO BP KEEP SBP>90/MAP>60. INSULIN GTT. CVP 13-14. NO SWAN. CT NO DRAINAGE-TEAM ROUND AWARED. CONNECTED TO VENT SIMV 100/500X14/5. TRAUMA LINE AND R FEM ARTERIAL LINE.\nLS CTA. CXR DONE. OGT TO LCSXN. BELLY SOFT. HYPOTHERMIC->WARM BLANKET APPLIED\n\nA/P: CON'T MONITOR- REVERSAL AND FAST TRACK WEANING PER PROTOCOL. NEED EKG. F/U CT DRAINAGE. NO FAMILY CALL OR VISIT YET\n"},{"category":"Nursing/other","chartdate":"2177-08-15 00:00:00.000","description":"Report","row_id":1631875,"text":"REspiratory Care\nPt extubated earlier in shift without incident. Airway assessed for positve signs of cuff leak, cough and gag prior to extubation. Adequate pulse oximetry values maintained on 2 lpm N.C. Lung sounds clear.\n"},{"category":"ECG","chartdate":"2177-08-15 00:00:00.000","description":"Report","row_id":153321,"text":"Sinus tachycardia with increase in rate compared to the previous tracing\nof . Low precordial lead voltage. Otherwise, no diagnostic interim\nchange.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2177-08-14 00:00:00.000","description":"Report","row_id":153322,"text":"Sinus rhythm. Low precordial lead voltage. Compared to the previous tracing\nof no diagnostic interim change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2177-08-14 00:00:00.000","description":"Report","row_id":153323,"text":"Sinus bradycardia. Otherwise, normal ECG. Compared to prior tracing\nof no significant change is seen.\n\n"},{"category":"ECG","chartdate":"2177-08-11 00:00:00.000","description":"Report","row_id":153324,"text":"Sinus rhythm without diagnostic abnormality. Compared to previous\ntracing of no diagnostic change.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2177-08-11 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 970834,\n \"text\": \" 7:21 PM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: pre-op CABG\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 52 year old woman with CAD, pre-op CABG this admission.\\n REASON FOR THIS EXAMINATION:\\n pre-op CABG\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: CAD, preop CABG.\\n\\n CHEST, TWO VIEWS.\\n\\n Heart size is borderline, with a left ventricular configuration. There is no\\n CHF, focal infiltrate or effusion. Mild degenerative spurring of the thoracic\\n spine is noted.\\n\\n Please see the chest CT report from , which describes a 3 mm right\\n middle lobe nodule and left upper lobe calcification -- these are not\\n visualized on today's study due to the technical limitations of radiographs\\n as opposed to CT.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2177-08-16 00:00:00.000\",\n \"description\": \"ABDOMEN (SUPINE & ERECT)\",\n \"row_id\": 971596,\n \"text\": \" 2:36 PM\\n ABDOMEN (SUPINE & ERECT) Clip # \\n Reason: Boswle distension?\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 52 year old woman with abdominal tenderness, vomiting\\n REASON FOR THIS EXAMINATION:\\n Boswle distension?\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Abdominal tenderness and vomiting.\\n\\n Four views. The bowel gas pattern is unremarkable. No free air is\\n identified. Soft tissue shadows are not well demonstrated. No significant\\n intra-abdominal calcifications are seen. Surgical clips overlie the left hip\\n and proximal left thigh. A vascular stent is present in the left upper\\n quadrant.\\n\\n IMPRESSION: Unremarkable abdomen. CT is recommended if further evaluation is\\n required.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2177-08-11 00:00:00.000\",\n \"description\": \"PR VENOUS DUP EXT UNI (MAP/DVT) PORT RIGHT\",\n \"row_id\": 970804,\n \"text\": \" 3:09 PM\\n VENOUS DUP EXT UNI (MAP/DVT) PORT RIGHT Clip # \\n Reason: Evaluate B GSV. preop for CABGKnown hx of PVD\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 52 year old woman with CAD, preop CABG\\n REASON FOR THIS EXAMINATION:\\n Evaluate B GSV. preop for CABGKnown hx of PVD\\n ______________________________________________________________________________\\n FINAL REPORT\\n VEIN MAPPING:\\n\\n REASON: 52-year-old woman with CAD. Preop for CABG.\\n\\n FINDINGS: Venous duplex evaluation was performed on the right lower extremity\\n venous system greater saphenous vein for the purpose of obtain diameters for\\n vein mapping.\\n\\n The right greater saphenous vein measures the following in diameter beginning\\n at the saphenofemoral junction extending distally in cm: 0.61, 0.42, 0.41,\\n 0.55, 0.35, 0.39, 0.24 and 0.16.\\n\\n FINDINGS: The right greater saphenous vein is widely patent throughout its\\n length with the above-mentioned diameters.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2177-08-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 971470,\n \"text\": \" 11:54 AM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: s/p ct d/c\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n s/p picc line placement\\n\\n REASON FOR THIS EXAMINATION:\\n s/p ct d/c\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: PICC line placed, left chest tube pulled.\\n\\n CHEST\\n\\n The tip of the PICC line is unchanged in position since the prior chest x-ray\\n and lies in the right atrium.\\n\\n Left chest tube has been removed and there is no evidence of pneumothorax.\\n Atelectasis in the left lower lobe is again noted.\\n\\n The mediastinal tubes have also been discontinued. The right lung remains\\n clear.\\n\\n IMPRESSION: Chest and mediastinal tubes removed, no pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2177-08-15 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 971446,\n \"text\": \" 9:21 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: 44cm left basilic vein\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n s/p picc line placement\\n REASON FOR THIS EXAMINATION:\\n 44cm left basilic vein\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post PICC line placement.\\n\\n COMPARISON: .\\n\\n CHEST ONE VIEW: Lung volumes are low. There has been interval placement of a\\n left subclavian PICC line with its radiodense guidewire tip projecting over\\n the right atrium. Two mediastinal drains and a left chest tube are seen in\\n unchanged position. There has been interval removal of an endotracheal tube.\\n A right internal jugular catheter is again seen with its tip projecting\\n outside the chest over the superior edge of the right clavicle. There is\\n persistent post-operative widening of the mediastinum. Within the limitation\\n of low lung volumes no focal consolidation or pneumothorax is seen.\\n\\n IMPRESSION: Interval placement of a left subclavian PICC line with its\\n radiodense guidewire tip projecting over the right atrium; recommend\\n withdrawal by 4 cm. Otherwise, essentially unchanged radiographic chest.\\n\\n These results were communicated to the IV access team at 11a by\\n Dr for Dr .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2177-08-12 00:00:00.000\",\n \"description\": \"CAROTID SERIES COMPLETE\",\n \"row_id\": 970906,\n \"text\": \" 8:54 AM\\n CAROTID SERIES COMPLETE Clip # \\n Reason: Evaluate for carotid stenosis; Pt has known PVD and LM disea\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 52 year old woman with CAD, preop CABG\\n REASON FOR THIS EXAMINATION:\\n Evaluate for carotid stenosis; Pt has known PVD and LM disease on cath\\n ______________________________________________________________________________\\n FINAL REPORT\\n CAROTID DUPLEX\\n\\n REASON: 52-year-old woman with CAD. Pre-op CABG, evaluate for carotid\\n stenosis.\\n\\n FINDINGS: Duplex evaluation was performed on the bilateral carotid arteries.\\n On B-mode imaging, there is only minimal plaque in the distal CCA and proximal\\n ICA.\\n\\n On the right, the peak systolic velocities are 48/20 in the proximal ICA,\\n 71/31 in the mid ICA, and 87/41 in the distal ICA. There is a velocity of\\n 57/18 in the CCA and 103 in the ECA. The ICA/CCA ratio is 1.5 and this is\\n consistent with a less than 40% right ICA stenosis.\\n\\n On the left, the peak systolic velocities are 75/30 in the proximal ICA, 70/24\\n in the mid ICA, 72/26 in the distal ICA. There is a velocity of 76/34 in the\\n CCA and 110 in the ECA. The ICA/CCA ratio is 0.98 and this is consistent with\\n a less than 40% left ICA stenosis.\\n\\n There is antegrade flow in both vertebral arteries.\\n\\n IMPRESSION: There is a less than 40% right ICA stenosis and a less than 40%\\n left ICA stenosis with antegrade flow in both vertebral arteries\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2177-08-13 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 971174,\n \"text\": \" 8:17 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: baseline assessment prior to CABG \\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 52 year old woman with DM, HTN, PAD, CAD, prior CVA x2 ' (last head CT was\\n '). Neurology consult requests non-contrast head CT prior to CABG to\\n delineate anomalies.\\n REASON FOR THIS EXAMINATION:\\n baseline assessment prior to CABG \\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 52-year-old with diabetes, hypertension, coronary artery and\\n peripheral vascular disease. Baseline assessment prior to CABG.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Non-contrast head CT.\\n\\n FINDINGS: In the right internal capsule, again identified is an area of\\n encephalomalacia and decreased density consistent with remote infarct. There\\n is ex vacuo dilatation of the adjacent frontal of the right lateral\\n ventricle. No intra- or extra-axial hemorrhage, shift of normally midline\\n structures, mass effect or hydrocephalus is identified. There is mild age-\\n inappropriate prominence of the frontal sulci. The basal cisterns are not\\n effaced. The visualized paranasal sinuses and mastoid air cells are well\\n aerated.\\n\\n IMPRESSION: Changes consistent with an area of remote infarct in the right\\n internal capsule. No acute vascular infarct or intracranial hemorrhage.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2177-08-14 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 971353,\n \"text\": \" 6:09 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: r/o PTX/Effusion.\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 52 year old woman with CAD s/p CABG. Please page at with\\n abnormalities.\\n REASON FOR THIS EXAMINATION:\\n r/o PTX/Effusion.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post CABG.\\n\\n COMPARISON: CXR, .\\n\\n PORTABLE CHEST: An endotracheal tube terminates approximately 33 mm above the\\n carina. The nasogastric tube courses below the diaphragm with its proximal\\n side port beyond the gastroesophageal junction, but its tip projecting below\\n the edge of the film. Left-sided chest tube and two mediastinal tubes are in\\n place. The tip of a right sided internal jugular catheter projects over the\\n right brachiocephalic vein.\\n Widening of the mediastinum is likely postoperative as patient is status post\\n median sternotomy and CABG. There is no evidence of pneumothorax or sizable\\n effusion. Lung volumes are low, which limits evaluation of lung parenchyma,\\n however, no focal consolidation is identified.\\n\\n IMPRESSION: Satisfactory placement of multiple lines and tubes status post\\n CABG.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2177-08-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 70001,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Coronary artery disease\\nHeight: (in) 56\\nWeight (lb): 175\\nBSA (m2): 1.68 m2\\nBP (mm Hg): 110/50\\nHR (bpm): 62\\nStatus: Inpatient\\nDate/Time: at 17:17\\nTest: TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the\\nLA/LAA or the RA/RAA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\\nfunction (LVEF>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal ascending aorta diameter. Normal aortic arch diameter. Simple\\natheroma in descending aorta.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\\nphysiologic PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. The TEE probe was passed\\nwith assistance from the anesthesioology staff using a laryngoscope. The\\npatient was under general anesthesia throughout the procedure. The patient\\nappears to be in sinus rhythm. Results were personally reviewed with the MD\\ncaring for the patient.\\n\\nConclusions:\\nPRE-BYPASS:\\nThe left atrium is normal in size. No spontaneous echo contrast or thrombus is\\nseen in the body of the left atrium/left atrial appendage or the body of the\\nright atrium/right atrial appendage. There is mild symmetric left ventricular\\nhypertrophy with normal cavity size and systolic function (LVEF>55%). Right\\nventricular chamber size and free wall motion are normal. There are simple\\natheroma in the descending thoracic aorta. The aortic valve leaflets (3) are\\nmildly thickened but aortic stenosis is not present. No aortic regurgitation\\nis seen. The mitral valve appears structurally normal with trivial mitral\\nregurgitation. There is no pericardial effusion.\\n\\nPost_Bypass:\\nNormal biventricular systolic function. LVEF 55%\\nTrivial MR, TR.\\nAortic contour is intact.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2177-08-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 70041,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Coronary artery disease. Left ventricular function. Preoperative assessment.\\nHeight: (in) 56\\nWeight (lb): 175\\nBSA (m2): 1.68 m2\\nBP (mm Hg): 118/62\\nHR (bpm): 45\\nStatus: Inpatient\\nDate/Time: at 16:40\\nTest: TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: Definity\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the report of the prior study (images not\\navailable) of .\\n\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\\nsystolic function (LVEF>55%). Normal regional LV systolic function. No resting\\nLVOT gradient.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter.\\n\\nAORTIC VALVE: Normal aortic valve leaflets. ?# aortic valve leaflets. No AS.\\nTrace AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Normal LV inflow\\npattern for age.\\n\\nTRICUSPID VALVE: Indeterminate PA systolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\\n\\nPERICARDIUM: There is an anterior space which most likely represents a fat\\npad, though a loculated anterior pericardial effusion cannot be excluded.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. The patient\\nappears to be in sinus rhythm.\\n\\nConclusions:\\nThe left atrium is normal in size. There is mild symmetric left ventricular\\nhypertrophy with normal cavity size and regional/global systolic function\\n(LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular\\nchamber size and free wall motion are normal. The aortic valve leaflets appear\\nstructurally normal with good leaflet excursion. The number of aortic valve\\nleaflets cannot be determined. There is no aortic valve stenosis. Trace aortic\\nregurgitation is seen. The mitral valve appears structurally normal with\\ntrivial mitral regurgitation. The pulmonary artery systolic pressure could not\\nbe determined. There is an anterior space which most likely represents a fat\\npad.\\n\\nCompared with the report of the prior study (images unavailable for review) of\\n, left ventricular wall thickness has increased. Otherwise, the\\nfindings are similar.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2177-08-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1631876,\n \"text\": \"Neuro: Pt reversed and woken easily. PERRLA. Follows commands. MAE. Post extubation pt had pain issues of lt shoulder pain due to chest tubes and incisional pain with movement and coughing. Poor response to morphine. Toradol given per Dr. and changed to dilaudid with good response. Pt sleeping of and on overnight. Pt oriented x3.\\nCV: Initially HR 70's to 80's, post extubation pt tachy 100-110 nsr. IVF given with no response to HR. CVP 12-17. Pt given lopressor 2.5 mg iv at 0500 HR<100. pt had been on neo/ntg overnight, now off. Chest tubes dry. No leak. HCT stable. Dopplerable pedal pulse rt foot, palp on lt. Cuff and aline correlate. See flowsheet for blood pressure trend. To restart plavix for CVA history this am.\\nRESP: Pt initially orally intubated. Once pt awake , vent weaned and pt extubated without difficulty. Pt placed on nasal cannula. On 2L nc sats>97%. On RA 92-95%. Pt feels better with O2 on while in bed. Lungs diminished at bases bilaterally. IS to 500.\\nGI: OGT discontinued with extubation. Abd soft, nontender. No BS. Reglan given this am. Pt tolerating ice chips. Denies nausea\\nGU: Foley patent. UOP initially good, then dropped to <30cc/hr. Pt given additional LR 1L with good response, tapering off again. Will continue to assess\\nEndo: remained on insulin gtt overnight. Titrated per protocol. See flowsheet\\nSocial: No family contact. Pt states she lives with her significant other whom she like to be her spokesperson.\\nPlan: Cont assess cardio/resp status. Deline this am if appropriate per team, after femoral aline dc, OOB. Wean o2 and advance activity and diet as tolerated. Restart plavix in am. Follow UOP. Continue hourly blood sugars while on insulin gtt. ? transfer to F2 if appropriate.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2177-08-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1631873,\n \"text\": \"pt recieved from OR without incidence, plan is to wean through evening as tollerated towards extubation.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2177-08-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1631874,\n \"text\": \"RECIEVED PT S/P CX3. ARRIVED SEDATED ON PROPOFOL. PERRL 3MM. APACED AND NEO TO BP KEEP SBP>90/MAP>60. INSULIN GTT. CVP 13-14. NO SWAN. CT NO DRAINAGE-TEAM ROUND AWARED. CONNECTED TO VENT SIMV 100/500X14/5. TRAUMA LINE AND R FEM ARTERIAL LINE.\\nLS CTA. CXR DONE. OGT TO LCSXN. BELLY SOFT. HYPOTHERMIC->WARM BLANKET APPLIED\\n\\nA/P: CON'T MONITOR- REVERSAL AND FAST TRACK WEANING PER PROTOCOL. NEED EKG. F/U CT DRAINAGE. NO FAMILY CALL OR VISIT YET\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2177-08-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1631875,\n \"text\": \"REspiratory Care\\nPt extubated earlier in shift without incident. Airway assessed for positve signs of cuff leak, cough and gag prior to extubation. Adequate pulse oximetry values maintained on 2 lpm N.C. Lung sounds clear.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2177-08-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 153321,\n \"text\": \"Sinus tachycardia with increase in rate compared to the previous tracing\\nof . Low precordial lead voltage. Otherwise, no diagnostic interim\\nchange.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2177-08-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 153322,\n \"text\": \"Sinus rhythm. Low precordial lead voltage. Compared to the previous tracing\\nof no diagnostic interim change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2177-08-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 153323,\n \"text\": \"Sinus bradycardia. Otherwise, normal ECG. Compared to prior tracing\\nof no significant change is seen.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2177-08-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 153324,\n \"text\": \"Sinus rhythm without diagnostic abnormality. Compared to previous\\ntracing of no diagnostic change.\\n\\n\"\n }\n]"}}},{"rowIdx":24646,"cells":{"subject_id":{"kind":"number","value":27661,"string":"27,661"},"hadm_id":{"kind":"number","value":108415,"string":"108,415"},"target_text":{"kind":"string","value":"79 yo male s/p with multiple medical problems, s/p trach placement in , vent-dependent, who was recently discharged from after being treated for pneumonia, admitted for persistent fevers and increased lethargy, being treated for VAP, now with intermittently decreasing HCT and severe AS. . Preoperatively, Balancing blood pressure with volume overload was challenging, as diuresis limited by hypotension. Hypotension improved with decreased PEEP. It was felt that his volume overload and hypotension were most likely secondary to his atrial fibrillation and severe aortic stenosis. Cardiac surgery was consulted who felt that valve replacement had only approximately a 30% chance of success but agreed to perform the procedure. Prior to surgery he was placed on a lasix drip to attempt to remove some volume with modest success. He was transferred to the CCU prior to valve replacement. His platelet count dropped and he had a negative HIT/SRA. Patient with slow GI bleed throughout this hospitalization with black tarry stool. He had evidence of gastritis and duodenotis on EGD on without evidence of active bleeding. He had multiple blood transfusions. He underwent colonoscopy on which showed evidence of diverticulosis but no evidence of active bleeding. His trach was changed 3x secondary to persistent leak, tracheomalacia extending to both mainstem bronc's noted, currently with 8.0 . He had evidence of a resistant pseudomonal VAP sensitive to imipenim and cefepime from culture results from and . Treated with imipenem and then cefepime for total of 14d pseudomonal coverage. Also treated MRSA given sensitivities of sputum culture from OSH (Was on bactrim , vanc ). His sputum has continued to grow the same pansensitive organism as previously, likely colonization. On he was taken tot he operating room where he underwent AVR with 21mm biocor valve. He was transferred to the ICU in critical but stable condition. He was transfused several times. His #8 trach was replaced on . His vasoactive drips were weaned to off by POD #4. Aggressive diuresis continued. Over the next week he continued to be diuresed and his betablockers were restarted. Post operatively the patient was seen by the GI service as he had intermittant guiac positive stool but no melana or bleeding, he was transfused w/PRBC's and PPI was changed to dosing. He was scoped from above and below just before surgery, at that time he was found to have diverticulosis and mild gastritis. By POD13 it was felt the patient was stable and ready for discharge to Center."},"extractive_notes_summ":{"kind":"string","value":"PORTABLE AP VIEW OF THE CHEST There has been interval central clearing of the diffuse infiltrative abnormality in the right lung field. Increased bilateral pleural effusions, bibasilar consolidation, mild-to-moderate congestive failure. Mild volume loss in the right hemithorax is also unchanged as well as bilateral small pleural effusions, right greater than left. IMPRESSION: Some improvement in right-sided pulmonary edema. FINDINGS: A right IJ Swan-Ganz catheter is present. IMPRESSION: Occlusive thrombus within the more superficial right brachial vein. Widespread heterogeneous combined alveolar and interstitial opacities are again demonstrated bilaterally, with some interval clearing within the left lung, but no substantial change within the right lung. FINDINGS: -scale and Doppler son of the right jugular, subclavian, axillary, brachial, basilic, and cephalic veins were obtained. Lung volumes remain low with unchanged bilateral pleural effusions (left greater than right) and diffuse parenchymal opacities. Right PIC catheter terminates in unchanged position in the proximal SVC. There has been interval removal of the right internal jugular Swan-Ganz catheter. CHEST, SINGLE AP PORTABLE VIEW: There is rotated positioning and low inspiratory volumes. The bilateral pulmonary edema is of unchanged stability. Since the prior radiograph of , mild-to-moderate pulmonary edema has developed, superimposed on the diffuse interstitial disease. The cardiac silhouette is grossly enlarged but stable. The cardiac silhouette remains grossly enlarged, though stable. IMPRESSION: Probable, overall slight worsening of pulmonary edema and right lower lobe consolidation. Bilateral small pleural effusions (left greater than right) and diffuse parenchymal opacity. Stable diffuse interstitial disease. SYSTOLIC BP LABILE. extrem w/d. Resp. Resp Care,Pt. care note - Pt. TRACHE CARE DONE, INNER CANNULA CHANGED.CO2 57. PALP PP. sternal, mediastinal incisions cdi.Resp: ls course, bases dim. Bs with scattered rhonchi. PVC'S NOTED. BS+GU: FOLEY IN PLACE. +pp. CO2 57.P: MONITOR COMFORT, HR AND RHTYHYM-? WITH TRACH. PT. PT. PT. Wean as Afebrile. AFEBRILE. AFEBRILE. AT THIS POINT PT. HYPOTENSIVE TO 75/39. TOLERATING WELL. PERL. WEAN VENT AS TOLERATED. REHAB: ? occas. Will wean as tolerated. +bs. abd soft, nt, nd. continue with current plan of care. LASIX GTT OFF. Otherwise on full vent support. CONTINUES IN AF. COMPLETE DISCHARGE SUMMARY. REMAINS WITH TOTAL BODY ANASARCA. REPLETE LYTES AS NEEDED. RESP: VENT SETTINGS AND ABG PER FLOW. RESP CARE: Pt remains /on vent,cuff pressure 28cmH20. cont imipenem and vanc.GI: +BS, abd soft dist. creat down to 1.3.endo: stim test done. lowgrade temp, 99.4. adequate uo, moderate diuresis after earlier lasix. PT IS DILT WELL, DIURESE. restart TF ?Lasix gtt T q2, sxn prn IV abx as ordered pt has had hx of hematuria. (REMAIN SON LASIX GTT)ACCESS: R AC PICCPLAN: PT. 3 rd admit to since with prob VAP. A -line placed and pt has been normotensive since its insertion. HAS BEEN NPO FOR COLONOSCOPY THIS AM. 79 yr old pt with pseudomonas PNA, s/p mva and and pegged since . poss trach change and poss endoscopy in am. Trach care done, sm amt bldy dng. endoscopy for cont GI bldg. BS with occ rhonchi. SKIN WDI- PULSES PALPABLE.RESP: PT. 4+ PITTING/WEEPING EDEMA REMAINS PRESENT. Resp Care,Pt. Moves extrem only slightly, heavy c edema. MRSA in sputum.GI: +BS, abd obese, distended. progress note:neuro: pt nodding appropriatly after much encouragment. LL ecchymotic. LUNGS CLEAR IN RUL, COURSE IN LUL, DIMINISHED IN BASES. HR 84-97, freq pvcs. On vanco and imipenem. Resp CarePt remians with #8.0 TTS H2O cuff on a/c. FS ~ 120.Gi: Abd obese, soft distended, +BS. SEE CAREVUE FOR COAG'S. CT MD IN TO SEE PT. Pt has had small reoccurring cuff leak, pt exhaling during inspiration and has been tachypnnic. SBP stable 99-132, on dilt 30mg q6hrs. FALLING HCT.P--TX 1 U PRBC. Sats cont 97 or > remainder of noc. Replete lytes prn. HR 90-110 a-fib w/PVC's noted. Pt fld balance + 3.8L los.Endo: Receiving humalog for SSI, FS 228, and glargine.ID: Tmax 100 ax. HCT DOWN TO RECEIVE 1U PRBC.RESP--SX Q2 HRS FOR THICK TAN SPUTUM. rehab in am. Remains in a-fib, but off coumadin d/t drop in hct to 19.9.Neuro: Alert, awake, follows simple commands. Bilat lower legs ecchymotic, L>R. On miripenim and bactrim. Resp CarePt transfer from OSH. ABD DISTENDED. REMAINS WITH CUFF LEAK. High Hco3 and Paco2 in abgs. ABG reveals compensated resp acidosis. ABG WNL, but maintained by large minute ventilation. On a/c minute volume being maintained in th 9-10L range. placed on vent ( see carvue for settings) Pt has a # 7 shiley trach. spec sent.GI - Abd soft - hypoactive BS. + pitting edema remains in extremities despite diuresis. tmax 99.3. generalized +3 edema. LS clear and diminished w/ some upper airway congestion noted prior to suctioning.CV: HR 85-95 afib w/ occ. EXTREMS W/D. Right picc line with tip in SVC. AFEBRILE.NEURO: WITHDRAWN. NO SSI REQUIRED.ID: PEG DRSG -PURELENT DRAINAGE NOTED-SENT FOR CX. REMAINS IN AF WITH GOOD RATE CONTROL WITH DILT. RESP CARE: Pt remains /on vent on PSV 10/5/.40. foley output 60-200cc/hr clear yellow.GI/Endo: abd firm/distended. PLAN TO D/C TO REHAB . AfebrileCV: Stable. REVIEW OF SYSTEMS:RESP: BRIEF CHANGE OVER TO PS THIS AM-POOR TOLERANCE. ABD SOFT, NT, ND. STILL 4+ EDEMATOUS.CV: BP FAIRLY WELL CONTROLLED X FOR BRIEF DROP. TRACHE CARE DONE BY RT. Mild (1+) mitral regurgitation is seen. Mild(1+) aortic regurgitation is seen. Mild mitralannular calcification. Mild mitralannular calcification. There is moderate symmetric left ventricularhypertrophy. LS clear to coarse upper, diminished @bases w/occasional wheeze.GI/Endo: Firm distended abd w/+BS. There is mild symmetric left ventricularhypertrophy. BS diminished and coarse bilaterally which clears with suctioning. Focal calcifications in aortic root.Normal ascending aorta diameter. There are simpleatheroma in the descending thoracic aorta. Normal RVsystolic function.AORTA: Mildly dilated aortic sinus. Mild [1+]TR. Mild [1+] TR. Trivialmitral regurgitation is seen. Mild (1+) AR.MITRAL VALVE: Moderately thickened mitral valve leaflets. Normal tricuspid valvesupporting structures. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild (1+) MR.TRICUSPID VALVE: Physiologic TR.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above."},"n_notes":{"kind":"number","value":143,"string":"143"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2129-08-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":977189,"text":" 7:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate catheter placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and elevated PA pressures. w/ swan\n\n REASON FOR THIS EXAMINATION:\n please evaluate catheter placement\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Portable film of the chest on at 0802 hours. No change\n since previous films. Tracheotomy tube is in good position. The pulmonary\n artery line introduced via the right jugular route extends into the right main\n pulmonary artery. There appears to be small effusions and the previously\n demonstrated diffuse pulmonary parenchymal disease.\n\n CONCLUSION: No change or superimposed acute process when compared to previous\n studies.\n\n"},{"category":"Radiology","chartdate":"2129-07-29 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":976426,"text":" 3:21 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval for evidenec of pneumothorax and evaluate line p\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach, AS s/p PA line placement\n REASON FOR THIS EXAMINATION:\n please eval for evidenec of pneumothorax and evaluate line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate pulmonary artery line placement.\n\n Comparison is made to a film of approximately six hours earlier.\n\n PORTABLE UPRIGHT VIEW OF THE CHEST AT 3:40 P.M: A new right internal jugular\n Swan-Ganz catheter terminates in the right pulmonary artery. There is no\n pneumothorax. There has been no other interval change. No change in\n pulmonary edema and pleural effusions.\n\n\n"},{"category":"Radiology","chartdate":"2129-07-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":976531,"text":" 1:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and elevated PA pressures.\n REASON FOR THIS EXAMINATION:\n Please eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, SINGLE VIEW, AT 1348 HOURS.\n\n CLINICAL INFORMATION: 79-year-old male with tracheostomy and elevated\n pulmonary artery pressures. Evaluate for interval change.\n\n COMPARISON STUDY: .\n\n FINDINGS:\n\n Tracheostomy is in midline. Right Swan-Ganz catheter tip is in the right\n pulmonary artery. Right PICC line appears to terminate in the superior vena\n cava.\n\n Heart is enlarged. There is central pulmonary vascular prominence and\n congestion consistent with mild congestive failure.\n\n There is elevation of the right hemidiaphragm with right basilar atelectasis.\n There is mild left basilar atelectasis as well. There is diffuse underlying\n interstitial pulmonary disease. There are small bilateral pleural effusions.\n\n IMPRESSION:\n\n No interval change since the prior study.\n\n\n"},{"category":"Radiology","chartdate":"2129-08-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":976739,"text":" 8:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for edema, infiltrate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and elevated PA pressures.\n\n REASON FOR THIS EXAMINATION:\n assess for edema, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, SINGLE VIEW, AT 09:37\n\n CLINICAL INFORMATION: Tracheostomy; question edema, infiltrate.\n\n COMPARISON STUDY: .\n\n FINDINGS:\n\n A right IJ Swan-Ganz catheter is present. Tracheostomy is in the midline. A\n right subclavian line is present, but the tip is not clearly seen due to\n overlying additional leads. It is presumed to terminate in the superior vena\n cava based on the study from yesterday.\n\n The left costophrenic study is omitted from the study. There is diffuse\n vascular congestion consistent with mild-to-moderate congestive failure. This\n is unchanged. There are small bilateral pleural effusions with probable mild\n bibasilar atelectasis. There are patchy airspace opacities in the right upper\n lobe and probably within the left lower lobe concerning for superimposed\n aspiration or pneumonia. These appear somewhat worse today than yesterday.\n\n IMPRESSION:\n\n 1. Mild-to-moderate congestive failure, stable.\n\n 2. Worsening right upper lobe, left lower lobe, right lower lobe patchy\n airspace disease concerning for superimposed aspiration versus pneumonia.\n\n 3. Small bilateral pleural effusions.\n\n\n"},{"category":"Radiology","chartdate":"2129-08-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":977634,"text":" 7:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate effusions s/p diuresis\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and elevated PA pressures. w/ increased\n pleural effusions on last CXR\n REASON FOR THIS EXAMINATION:\n evaluate effusions s/p diuresis\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Elevated pulmonary artery pressures. Evaluate pleural effusions.\n\n Tracheostomy tube remains in standard position. Widespread pulmonary\n opacities are present with both alveolar and interstitial components. The\n alveolar opacities are most prominent in the upper and mid lungs and have\n progressed since the recent study. Considering waxing- appearance on\n serial radiographs, they probably represent pulmonary edema superimposed upon\n more chronic underlying interstitial lung disease. Small right pleural\n effusion is unchanged, but small-to-moderate left pleural effusion is\n increased.\n\n\n"},{"category":"Radiology","chartdate":"2129-08-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":977779,"text":" 8:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for edema, infiltrates\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and elevated PA pressures.\n REASON FOR THIS EXAMINATION:\n assess for edema, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF .\n\n INDICATION: Elevated pulmonary artery pressures.\n\n Tracheostomy tube remains in place as well as a right PICC line.\n Cardiomediastinal contours are stable in appearance. Widespread heterogeneous\n combined alveolar and interstitial opacities are again demonstrated\n bilaterally, with some interval clearing within the left lung, but no\n substantial change within the right lung. Mild volume loss in the right\n hemithorax is also unchanged as well as bilateral small pleural effusions,\n right greater than left.\n\n\n"},{"category":"Radiology","chartdate":"2129-08-06 00:00:00.000","description":"RP UNILAT UP EXT VEINS US RIGHT PORT","row_id":977565,"text":" 1:47 PM\n UNILAT UP EXT VEINS US RIGHT PORT Clip # \n Reason: PLEASE EVALUATE FOR DVT, SWELLING\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with R> L swelling\n\n REASON FOR THIS EXAMINATION:\n please evaluate for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right greater than left swelling.\n\n COMPARISON: left upper extremity ultrasound, .\n\n FINDINGS: Grayscale and color Doppler imaging of the right internal jugular,\n subclavian, axillary, basilic, and brachial veins were performed. The\n cephalic vein is not well visualized. Normal compressibility, waveforms, flow\n were demonstrated in the right internal jugular, subclavian, axillary, and\n basilic veins. The more superficial brachial vein does not compress and also\n lacks flow within, consistent with occlusive thrombus. The more deep brachial\n vein appears patent.\n\n IMPRESSION: Occlusive thrombus within the more superficial right brachial\n vein.\n\n"},{"category":"Radiology","chartdate":"2129-07-29 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":976353,"text":" 8:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach, AS, failure to wean, ? interval change\n\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Failure to wean patient with tracheostomy and AS.\n\n SINGLE AP PORTABLE VIEW OF THE CHEST: Compared to multiple prior studies\n including most recent one performed a day earlier.\n\n Cardiomediastinal contour is unchanged. Tracheostomy tube remains in place.\n Right subclavian catheter is in unchanged position in the proximal SVC. Small\n bilateral pleural effusions are unchanged. Diffuse peripheral patchy\n opacities are stable.\n\n IMPRESSION: No short interval changes.\n\n"},{"category":"Radiology","chartdate":"2129-07-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":976175,"text":" 5:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach, AS, failure to wean, ? interval change\n\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE FILM OF THE CHEST ON AT 0503 HOURS: There has been no change in\n the appearance of the chest over the last several examinations, the most\n recent being on . The tracheostomy tube is in good position. Right PICC\n line appears to be into the superior vena cava. The right hemidiaphragm is\n elevated, and the parenchymal lung changes bilaterally persist.\n\n CONCLUSION: No improvement or change in the appearance of the chest.\n\n\n"},{"category":"Radiology","chartdate":"2129-07-26 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":975938,"text":" 3:03 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: pre-op study, please assess for arterial calcification\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with critical AS, intubated for respiratory distress, pre-op\n study for aortic valve replacement\n REASON FOR THIS EXAMINATION:\n pre-op study, please assess for arterial calcification\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST\n\n REASON FOR EXAM: Critical AS. Pre-op evaluation.\n\n TECHNIQUE: Multidetector CT through the chest was acquired without contrast.\n Five, 1.25 mm collimation images and coronal reformations were reviewed.\n\n FINDINGS: Tracheostomy tube is in place. There is pooling of secretions above\n the endotracheal tube cuff. There is an increased number of mediastinal lymph\n nodes located in all of the mediastinal stations, measuring up to 12 mm in the\n subcarinal station. The aorta is normal in caliber, measures 39 x 38 mm,\n transverse by AP in the ascending portion. There is mild calcification of the\n aortic arch. There is no calcification in the ascending aortal wall. The\n aortic valve has dense calcification. Mild to moderate calcifications are in\n the LAD and left circumflex a's. There are small bilateral pleural effusions.\n The airways are patent to the subsegmental levels. There is diffuse ground\n glass opacity associated with interlobular septal thickening. Some of the\n pleural effusion tracks in the major fissures bilaterally. Dense\n peribronchial multifocal infiltration is greater in the right lower lobe\n\n There is moderate ascites.\n\n Artifact from low position of the arms, limits the abdomen assessment. There\n are healed fractures in the lateral aspect of the fifth and sixth right ribs.\n\n IMPRESSION:\n\n 1. Dense calcification of the aortic valve.\n\n 2. Pulmonary edema. A component of chronic interstitial lung disease may be\n present\n\n\n\n\n\n\n\n\n\n (Over)\n\n 3:03 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: pre-op study, please assess for arterial calcification\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2129-08-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":978297,"text":" 12:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for infiltrate or effusion\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and AS, plan for aortic valve repair on \n\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrate or effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Aortic stenosis, evaluation for aortic valve repair, evaluate for\n infiltration or effusion.\n\n Single supine portable chest radiograph is compared to study dated , . There is interval increase in the bilateral alveolar and\n interstitial opacities, more pronounced in the right upper lung. Bilateral\n pleural effusions are unchanged. Tracheostomy tube is in standard position.\n Right PICC is likely unchanged in position. The cardiac silhouette is\n enlarged, unchanged.\n\n IMPRESSION: Interval increase in bilateral alveolar and interstitial\n opacities; bilateral pleural effusions.\n\n"},{"category":"Radiology","chartdate":"2129-07-31 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":976605,"text":" 7:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and elevated PA pressures.\n REASON FOR THIS EXAMINATION:\n please evaluate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, SINGLE VIEW, AT 09:11 HOURS\n\n CLINICAL INFORMATION: 79-year-old male with tracheostomy and elevated PA\n pressures.\n\n COMPARISON STUDY: .\n\n Since the prior study, there is overall worsening of the appearance of the\n chest. Heart is enlarged. Mediastinum probably within normal limits. Swan-\n Ganz catheter is present. Tracheostomy is midline. There are bilateral\n pleural effusions, increased in size. There is increased bibasilar\n atelectasis versus consolidation. There is increased pulmonary congestion\n consistent with mild-to-moderate failure.\n\n IMPRESSION:\n\n Interval worsening. Increased bilateral pleural effusions, bibasilar\n consolidation, mild-to-moderate congestive failure.\n\n\n"},{"category":"Radiology","chartdate":"2129-07-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":974710,"text":" 5:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and RLL PNA\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Interval change in patient with multiple\n consolidations.\n\n Portable AP chest radiograph compared to .\n\n Tracheostomy is in good unchanged position. The right PICC line tip\n terminates in mid SVC. The heart size is enlarged but unchanged. The\n mediastinal contours are stable. Persistent diffuse airspace and interstitial\n opacities are unchanged, right greater than left. Small bilateral pleural\n effusions cannot be excluded. The right hemidiaphragm is continuing to be\n elevated.\n\n IMPRESSION: No interval change.\n\n\n"},{"category":"Radiology","chartdate":"2129-07-15 00:00:00.000","description":"UNILAT UP EXT VEINS US","row_id":974408,"text":" 2:00 PM\n UNILAT UP EXT VEINS US Clip # \n Reason: PLEASE EVALUATE FOR DVT/RUE SWELLING\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with R> L swelling\n\n REASON FOR THIS EXAMINATION:\n please evaluate for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old man with right arm swelling.\n\n COMPARISON: Right arm ultrasound, .\n\n FINDINGS: -scale and Doppler son of the right jugular, subclavian,\n axillary, brachial, basilic, and cephalic veins were obtained. There is\n normal compressibility, flow and augmentation down to the level of the\n axillary and brachial veins. Limited views were obtained in this area due to\n the patient's present PICC line and bandage. No occlusive DVT was identified\n on this limited study.\n\n IMPRESSION: Study technically limited due to the presence of PICC line and\n bandage but no DVT identified.\n\n\n"},{"category":"Radiology","chartdate":"2129-07-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":973742,"text":" 5:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and new RLL PNA\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Followup right pneumonia.\n\n Comparison is made with prior studies including and .\n\n Diffuse pulmonary process greater in the right side has not significantly\n changed from , but has worsened from . It is due to bilateral\n pulmonary edema and consolidation in the right lung. Mild cardiomegaly is\n unchanged. Small bilateral pleural effusions. Tracheostomy tube is in\n adequate position. Right PICC is in standard placement. There is no\n pneumothorax. Rib fracture with irregularity in the lateral aspect of a mid\n right rib is present since .\n Conclusion:New changes suggesting increase in pulmonary edema.\n\n"},{"category":"Radiology","chartdate":"2129-07-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":974157,"text":" 10:37 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: collapse, new infiltrate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and RLL PNA. Now desaturating after bronchoscopy.\n\n REASON FOR THIS EXAMINATION:\n collapse, new infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old male desaturating after bronchoscopy. Evaluate for\n infiltrate or collapse.\n\n Comparison is made to multiple prior chest radiographs dating back to , .\n\n SINGLE PORTABLE CHEST RADIOGRAPH\n\n FINDINGS: Diffuse airspace process involving the right hemithorax may be\n slightly worsened from most recent examination but clearly progressed from\n examination with persistent retrocardiac opacity obscuring the\n left hemidiaphragm. Parenchymal opacity involving the left hemithorax is not\n significantly changed as is probable small bilateral pleural effusions and\n amount of vascular engorgement. Low lung volumes persist and there is no\n evidence of pneumothorax with tracheostomy tube remaining in standard\n position.\n\n IMPRESSION:\n\n Slight interval progression to diffuse right hemithorax opacity which has\n worsened since examination with no significant interval change in\n left lower lobe opacity and amount of vascular engorgement.\n\n\n"},{"category":"Radiology","chartdate":"2129-07-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":974475,"text":" 5:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and RLL PNA, now s/p trach replacement.\n\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY\n\n CLINICAL INDICATION: 79-year-old man with trach and right lower lobe\n pneumonia, now status post trach replacement, evaluate for interval change.\n\n A single portable image of the chest is compared to the prior examination\n dated demonstrating no significant interval change. Low lung volumes\n are again noted. Persistent diffuse airspace opacities are again noted, right\n greater than left. The left hemithorax is not included on this examination.\n There is persistent prominence of the bronchopulmonary vasculature that\n remains indistinct likely secondary to underlying interstitial edema. A\n stable retrocardiac opacity is noted. The right-sided PICC line is unchanged\n in position.\n\n IMPRESSION: Stable examination.\n\n\n"},{"category":"Radiology","chartdate":"2129-07-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":974340,"text":" 5:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and RLL PNA.\n\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate interval change, history of pneumonia and recent\n bronchoscopy.\n\n Comparison is made to portable films dating back to .\n\n PORTABLE AP VIEW OF THE CHEST\n\n There has been interval central clearing of the diffuse infiltrative\n abnormality in the right lung field. Clearing over the past 48 hours likely\n represents improvement of asymmetrical edema, which had been superimposed over\n right lower lobe consolidation. There may be a left pleural effusion, although\n the retrocardiac opacity makes it difficult to evaluate. Again seen are low\n lung volumes and a tracheostomy tube in good position.\n\n IMPRESSION: Some improvement in right-sided pulmonary edema. No change in\n bilateral lower lobe opacities. Likely pleural effusion on the left side.\n\n"},{"category":"Radiology","chartdate":"2129-07-24 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":975566,"text":" 5:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach, AS, failure to wean\n\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trach, AS, failure to wean, interval change.\n\n CHEST, SINGLE AP PORTABLE VIEW:\n\n There is rotated positioning and low inspiratory volumes. Allowing for\n differences in technique, overall appearance is similar to . There may\n be slight improvement in the right upper zone consolidation with some\n increased consolidation in the left upper zone and slight decrease in left\n pleural effusion. Tracheostomy tube noted. PICC line present, tip not well\n visualized.\n\n"},{"category":"Radiology","chartdate":"2129-07-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":973882,"text":" 6:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and new RLL PNA\n\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with new right lower lobe\n pneumonia.\n\n Portable AP chest radiograph compared to .\n\n The tracheostomy is in unchanged position. The diffuse pulmonary process,\n more severe in right lung, has not significantly changed since the previous\n exam but overall is gradually worsening since . The bilateral\n pulmonary edema is of unchanged stability. The mild cardiomegaly is stable.\n\n Small bilateral pleural effusions are again noted, although cannot be\n precisely appreciated due to the fact that the most lateral costophrenic\n angles were not included in the field of view.\n\n IMPRESSION: Probable, overall slight worsening of pulmonary edema and right\n lower lobe consolidation.\n\n"},{"category":"Radiology","chartdate":"2129-07-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":975334,"text":" 5:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval changes\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and RLL PNA\n\n REASON FOR THIS EXAMINATION:\n please eval for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess for interval change.\n\n SEMI-ERECT PORTABLE CHEST RADIOGRAPH\n\n Comparison is made to and 22, .\n\n Lung volumes remain low with unchanged bilateral pleural effusions (left\n greater than right) and diffuse parenchymal opacities. There is questionable\n increased density noted over the right upper lobe. A tracheostomy tube and a\n right PICC catheter remain in unchanged position.\n\n IMPRESSION:\n 1. No significant _____.\n 2. Bilateral small pleural effusions (left greater than right) and diffuse\n parenchymal opacity. Questionable increased density noted over the right\n upper lobe can be followed up on subsequent examinations.\n\n\n"},{"category":"Radiology","chartdate":"2129-07-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":973646,"text":" 10:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and persistent fevers\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:17 P.M.\n\n HISTORY: Tracheostomy tube. Persistent fevers.\n\n IMPRESSION: AP chest compared to through :\n\n Severe consolidation in the right lung has worsened since . Milder\n interstitial abnormality in the left lung probably represents residual edema\n or scarring. Moderate cardiomegaly unchanged. Pleural effusion may be\n present, but is not appreciable in size. Tracheostomy tube in standard\n placement. No pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2129-08-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":977898,"text":" 7:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for edema, infiltrate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and elevated PA pressures.\n REASON FOR THIS EXAMINATION:\n assess for edema, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Portable chest.\n\n CLINICAL INDICATION: 79-year-old man with trach and elevated PA pressures,\n assess for edema and infiltrate.\n\n FINDINGS: A single portable image of the chest is compared to the prior\n examination dated . Allowing for slight differences in technique\n there is no significant interval change. The tracheostomy tube and right PICC\n line remain in place. The cardiomediastinal silhouette is grossly unchanged.\n Diffuse heterogenous alveolar and interstitial opacities are again noted\n bilaterally right greater than left. Persistent bilateral effusions are noted\n right greater than left.\n\n IMPRESSION: Stable examination as above.\n\n\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2129-08-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":977362,"text":" 8:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate catheter placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and elevated PA pressures. w/ swan\n\n REASON FOR THIS EXAMINATION:\n please evaluate catheter placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup evaluation.\n\n Comparison is made to films dating back to and a CT chest of\n .\n\n Portable upright view of the chest at 8:30 a.m.: The tracheostomy tube\n remains in unchanged position approximately 2-3 cm above the carina. There\n has been interval removal of the right internal jugular Swan-Ganz catheter.\n Since the prior radiograph of , mild-to-moderate pulmonary edema\n has developed, superimposed on the diffuse interstitial disease. There are no\n obvious areas of new consolidation. The cardiomediastinal silhouette is\n unchanged.\n\n IMPRESSION: Interval development of mild-to-moderate pulmonary edema. Stable\n diffuse interstitial disease.\n\n"},{"category":"Radiology","chartdate":"2129-07-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":974030,"text":" 5:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and new RLL PNA\n\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Follow up right pneumonia and pulmonary edema.\n\n Comparison is made to prior studies including most recent one performed a day\n earlier.\n\n There are low lung volumes. Right pleural effusion is small. Probable small\n left pleural effusion. Tracheostomy tube is seen in standard position.\n Moderate cardiomegaly is unchanged. There is no pneumothorax. Allowing the\n rotation of the patient, there is less aeration in the left upper lobe. The\n diffuse pulmonary process most severe in the right lung has not significantly\n changed with mild to moderate pulmonary edema and patchy consolidation in the\n right lung.\n\n"},{"category":"Radiology","chartdate":"2129-07-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":975034,"text":" 6:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and RLL PNA\n\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup of pneumonia.\n\n Portable semi erect view of the chest: Compared to the prior film of\n , there appears to be a new tracheostomy tube that extends further\n into the trachea, terminating approximately 2.5 cm above the carina, in\n satisfactory position. Diffuse patchy bilateral airspace disease is\n unchanged. There is no obvious pleural effusion. Cardiovascular status is\n difficult to assess with high diaphragms and overlying airspace disease, but\n heart appears borderline enlarged. The right PICC remains in good position.\n\n IMPRESSION: Diffuse lung abnormalities consistent with pneumonia are\n unchanged. CHF is unlikely.\n\n"},{"category":"Radiology","chartdate":"2129-07-19 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":974934,"text":" 11:57 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for bleed, stroke\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with AS, hypotension, afib and PNA who developed visual field\n defects and not tracking to right\n REASON FOR THIS EXAMINATION:\n evaluate for bleed, stroke\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT\n\n HISTORY: 79-year-old man with hypotension, AFib, and pneumonia with visual\n field defects, assess for stroke or bleed.\n\n TECHNIQUE: Contiguous 5-mm axial images were obtained from the skull base to\n the vertex.\n\n FINDINGS: Comparison is made to .\n\n This study is limited by patient motion. No intracranial hemorrhages or\n masses are seen. The /white matter differentiation is maintained. The\n ventricles and extraaxial CSF spaces are within normal limits.\n\n The visualized orbits are normal.\n\n Again seen is mucosal thickening involving the left sphenoid air cell as well\n as ossification of the right mastoid air cells as before.\n\n No suspicious bony abnormalities are seen.\n\n IMPRESSION: Limited somewhat by motion, but no acute intracranial\n abnormalities.\n\n MR is more sensitive study to assess for acute infarcts.\n\n\n"},{"category":"Radiology","chartdate":"2129-08-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":978566,"text":" 7:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with AVR w/ hx of pna prior to surgery\n\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: AVR with history of pneumonia prior to surgery.\n\n COMPARISON: at 18:27 hours.\n\n TECHNIQUE: Single AP portable supine chest.\n\n FINDINGS: An endotracheal tube is in place with tip terminating 4.1 cm above\n the carina. Pulmonary artery catheter enters via left internal jugular\n approach and the tip, though not well seen, is located in the region of the\n main pulmonary artery. A nasogastric tube extends below the diaphragm with\n tip below the borders of the radiograph. Two mediastinal drains are in\n unchanged position. A right-sided PICC line with tip in the expected location\n of the SVC is in unchanged position. Since the previous examination, there is\n little change in bilateral interstitial opacities, with possible mild\n improvement in right base opacity. No pneumothorax. Multiple right- sided\n rib fractures again noted but better appreciated on the prior radiographs.\n\n IMPRESSION:\n 1. Lines and tubes in satisfactory position.\n 2. Bilateral interstitial opacities, likely reflecting CHF or pneumonia; mild\n improvement in right lower lobe consolidation.\n\n\n\n"},{"category":"Radiology","chartdate":"2129-08-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":979435,"text":" 4:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p AVR w/hypotension-r/o PTX\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with AVR w/ hx of pna prior to surgery\n\n REASON FOR THIS EXAMINATION:\n s/p AVR w/hypotension-r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pneumonia and AVR surgery.\n\n FINDINGS: In comparison with the study of , the patient is no longer\n obliqued. There is again evidence of median sternotomy and aortic valve\n replacement. The cardiac silhouette remains grossly enlarged, though stable.\n There is again prominence of interstitial markings. Elevation of the right\n hemidiaphragm is again seen, making it difficult to evaluate the lung behind\n it. Probable small bilateral pleural effusions.\n\n Tracheostomy tube remains in place. Right central catheter extends to just\n above the carina.\n\n IMPRESSION: Little overall interval change.\n\n\n DR. \n"},{"category":"Radiology","chartdate":"2129-08-17 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":979153,"text":" 10:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for effusions/infiltrates\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with AVR w/ hx of pna prior to surgery\n\n REASON FOR THIS EXAMINATION:\n assess for effusions/infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old man with aortic valve replacement and history of\n pneumonia prior to surgery. Evaluate for interval change.\n\n COMPARISON: AP semi-upright portable chest x-ray dated .\n\n AP SEMI-UPRIGHT PORTABLE CHEST X-RAY: A left internal jugular Swan-Ganz\n catheter has been removed in the interval. A tracheostomy tube is in place.\n Right PIC catheter terminates in unchanged position in the proximal SVC. The\n patient is status post median sternotomy and aortic valve replacement. The\n cardiac silhouette is grossly enlarged but stable. Prominence of the\n interstitial markings and small bilateral effusions persist and limit\n evaluation of underlying pneumonia. There are no new consolidations. Multiple\n right sided rib fractures are again noted and appear partially healed on CT\n Chest from .\n\n IMPRESSION: No significant interval change in the appearance of the chest.\n\n"},{"category":"Radiology","chartdate":"2129-08-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":978693,"text":" 9:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ct removal\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with AVR w/ hx of pna prior to surgery\n\n REASON FOR THIS EXAMINATION:\n ct removal\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Chest tube removal.\n\n A single AP view of the chest is obtained on at 09:40 hours and is\n compared with the prior morning's radiograph. ET tube has been removed and a\n tracheostomy tube placed. Tip lies approximately 4.8 cm above the carina.\n Nasogastric tube and Swan-Ganz catheter are unchanged. Mediastinal drains are\n not visible, presumably have been removed. There is no evidence of\n pneumothorax. Bilateral interstitial opacities persist and likely represent\n failure or less likely pneumonia. Increasing retrocardiac density on the left\n side is consistent with worsening atelectasis at the left base. Haziness and\n obscuration of the diaphragm on the left likely represents pleural effusion.\n\n\n"},{"category":"Nursing/other","chartdate":"2129-07-12 00:00:00.000","description":"Report","row_id":1624042,"text":"Patient has # 7 Shiley with layer of secretion on inner wall of trach MDs notified.Plan to change trach tube under bronchoscopic view due to the presence of a suture thread coming from the stoma.\n"},{"category":"Nursing/other","chartdate":"2129-07-14 00:00:00.000","description":"Report","row_id":1624047,"text":"Nsg.notes 1900-0700hrs\n\nAllergies:haldol and heparin.\n\nNeuro:Alert,following commands,unable to assess orientation.stiff body and hands.slept well with Inj.Ativan.\n\nResp:,vented,AC/20/10/450/40. BLOOD GAS X2.am ABG report 7.4/54/116/38/11/.tachypoenic always,RR >30's .trache changed yesterday.slept after ativan and RR >22/min when sleeping.LS coarse.suctioned yellow to blood stained secretions.trache care given.cuff leak present,cuff inflated more per RT.sats 92-96%\n\nCVS:HR 84-100/MIN,Afib,no ectopics noted.ABP 100-120'S SYS. edematous extremities.pedal pulse difficult to palpate on post tibial.boots on.\nblood c/s sent.\n\nGU/GI:Abdomen obese,bowel sounds hypo,PEG in place,feed neutran pulmonary 50ml/hr,tolerating well,no BM this shift.on lasix BD ,urine output adequate.\n\nIntegu:impaired ,duoderm on upper back,hygenic needs attended and position changed.afebrile.\n\nIV access:A line on Lt.radial,patent.Rt.midline cath double lumen .\n\nSocial: by family early shift and updated.calm and co operative.full code ,on contact precautions for MRSA.\n\nPlan:trache care.watch for bleeding and leaking.continue present care.\n\n\n"},{"category":"Nursing/other","chartdate":"2129-07-14 00:00:00.000","description":"Report","row_id":1624048,"text":"Respiratory Care:\n\nPatient with 7.O Portex. Trach changed yesterday due to partial occlusion. Peep ^ 10 with improved PaO2(116) and later weaned back to 8 due to low BP. Current vent settings Vt 450, A/C 14, Fio2 40% and Peep 8. BS few faint expiratory wheezes L lung, slightly coarse R lung. Sx'd for bloody clots. Albuterol/Atrovent MDI's given Q4hr. Wheezes resolving. No further changes made.\nPlan: Continue with mechanical support. See Carevue for RSBI and ABG's.\n"},{"category":"Nursing/other","chartdate":"2129-07-14 00:00:00.000","description":"Report","row_id":1624049,"text":"resp care - Pt remains and vented on full vent support. Persistent cuff leak exists despite high cuff pressure. BLBS were coarse t/o. Pt was suctioned for copious amounts of thick, blood tinged secretions x 2. PEEP was decreased to 5 during rounds, but was increased to 8 in PM when Sat dropped and BP increased. Pt given meds as ordered. Continued resp care planned.\n"},{"category":"Nursing/other","chartdate":"2129-07-14 00:00:00.000","description":"Report","row_id":1624050,"text":"NPN\n\nNeuro: Pt is awake and alert, slowly following simple commands, conts to have jerking movements which per his family have been with him since his accident.\n\nCV: Tolerating his dilt, remains in afib, his coumadin was d/ced do to his drop in his HCT to 19.9. He is receiving 3 units of FFP and 2 bags of PRBCs.\n\nResp: LS with rales in the bases, 02 SATs dropped to 93-94% and had coarse BS throughout this afternoon after he had recieved 2 of his 5 blood products. His PEEP was increased back to 8 - it was decreased during rounds and he was given an additional 40mg of IV lasix. He has a cuff leak, his cuff pressure is 30, repositioning it does not change the leak, his VTs are 300s-low 400s.\n\nGI: His HCT was 19.9 this morning, he had dark brown stool yesterday x2 which were OB pos, FFP and PRBC were ordered, also given vit K, ASA and comadin were d/ced, pneumoboots were placed, GI notified.\n\nGU: He is presently 330cc pos since MN, he conts on lasix, his u/o has been 250-40cc/hr.\n\nSoc: Family called, they took the day off today and will be in tomorrow.\n\nID: T max 101 and he has remain febrile all day on Tylenol, WBC down today from yest, blood c/x sent, BAL, urine, and stool sent yest with his elevated WBC, no antibiotics were ordered.\n\n"},{"category":"Nursing/other","chartdate":"2129-07-28 00:00:00.000","description":"Report","row_id":1624110,"text":"ADDENDUM TO NPN 7P-7A\nLASIX GTT BACK ON AT 4MG/HR AS BP HAS IMPROVED\n"},{"category":"Nursing/other","chartdate":"2129-07-13 00:00:00.000","description":"Report","row_id":1624043,"text":"Nsg.notes 1900-0700hrs\n\nShift uneventful\n\nNeuro:alert,obeying and following commands,denies any pain.slept on and off.\n\nResp:,vented,AC,/14/40/5/40%/trache care given,suctioned thick yellow secretions.sats 94-98%.\n\nCVS:HR 100-110,a fib,with occasional PVC'S .vital signs remains stable,A line on Lt hand,ABP 110-130/60-70mm of hg.A line pressure kit changed.\n\nGU/GI:PEG in place,on neutran pulmonary 40ml/hr,tolerating well.no BM this shift,on foley cath,urine output adequate.\n\nIntegu:skin impaired uppper back,duoderm present.position changed and hygenic needs attended.edematous and stiff,difficult to fold his hands and legs.\n\nIV access:Rt midline 2 lumen cath.site cleaned and dressing changed.\n\nSocial:calm and co operative.no family contact during night.full code,on contact precautions\n\nPlan:pulmonary toileting and airway clearence.may change trache today.emotional support to pt and family,continue present treatment.\n"},{"category":"Nursing/other","chartdate":"2129-07-13 00:00:00.000","description":"Report","row_id":1624044,"text":"RESP CARE NOTE\nRECEIVED PT ON AC WITH NO CHANGES OVERNIGHT. BREATH SOUNDS ESSENT CLEAR. ALB/ATR GIVEN Q4. RSBI 111 THIS AM. AMBU AT BEDSIDE.\nPLAN: ? TRACH CHANGE TODAY, WEAN TO PSV AS TOLERATED, CONT MDI'S AS ORDERED.\n"},{"category":"Nursing/other","chartdate":"2129-07-13 00:00:00.000","description":"Report","row_id":1624045,"text":"NPN\n\nNeuro: Pt was sleeping this morning but then woke and was alert until he was sedated for the bronch.\n\nCV: Tolerating 30 mg of dilt QID, remains on coumadin for his afib - INR was 2.2., his heart rate has been 80s-1teens. k was replaced today, lytes due to be checked this afternoon.\n\nResp: Remains vented on A/C, no changes were made, he was tried on PSV during rounds but his RR increased from 20 to the 30s and his pC02 was in the 60s and on A/C his pC02 was in the 50s. His trache was changed to a portex, fenistrated with an intercanula, he was also bronched and a lg plug was suctioned out. A BAL sputum was sent as well. WBC count up to 14 today, he has been afebrile but was pan clx.\n\nGI: He has had 2 lg dark brown, loose, OB pos stools today, this was sent for cdif. His TF was increased to 50cc/hr per nutrition recs.\n\nGU: Now on lasix 40mg per GT, he has put out ~ 400cc so far today for the lasix.\n\nSoc: Son in to visit, we cont to work on finding him a rehab, he may be ready to go this week.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2129-07-13 00:00:00.000","description":"Report","row_id":1624046,"text":"Trach changed from Shiley to portex # 7. Bronchoscopic procedure done,suctioned for copious amount of thick bloody secretion.Weaned on PSV for short periods of time desaturated to 88% pre-oxygenate responded quickly to 02 therapy.ABG sent to lab will continue to follow patient.\n"},{"category":"Nursing/other","chartdate":"2129-07-28 00:00:00.000","description":"Report","row_id":1624111,"text":"Resp Care,\nPt. remains on A/C overnoc, no vent changes this shift. Suctioned small amount thick yellow . attempted, RR>35. Maintain current vent settings.\n"},{"category":"Nursing/other","chartdate":"2129-08-21 00:00:00.000","description":"Report","row_id":1624112,"text":"Neuro: pt withdrawn, visually acknowledges caregiver, otherwise no interaction. does not follow commands. moves/tenses extremities w/tactile stimulation. grimaces with turns and during skin care. perrl.\nCv: af 80s-100s. occas. pvc's. bp 100s-130s. briefly hypotensive, MD aware, no tx ordered, pt returned to baseline within 15 minutes, continuing to monitor. +pp. extrem w/d. compression sleeves on. low grade temp 100.4, tylenol given w/good effect. sternal, mediastinal incisions cdi.\nResp: ls course, bases dim. no vent changes overnoc. continues on cpap 40% 5peep, 8ps, tv 300s-500s. rr 20s-30s. sxn'd sm-mod amts thk yellow secretions occas. pCo2 50s.\nGi/gu: tolerating tf fs replete w/fiber @ goal=80cc/hr via peg-no resids. +bs. no bm. abd soft, nt, nd. huo adequate-clr yellow.\nEndo: rssi per ss.\nSkin: see carevue.\nPlan: continue monitoring cardioresp status, labs, sxn prn. continue support pt/family. continue with current plan of care.\n"},{"category":"Nursing/other","chartdate":"2129-08-21 00:00:00.000","description":"Report","row_id":1624113,"text":"RESP CARE: Pt remains /on vent,cuff pressure 28cmH20. Remained on PSV 8/5/.40. ABGs comp resp acidosis/good oxygenation. Vts 330-500/RR 20-35. Lungs bilat rhonchi, sxd small amts thick yellow /white . AM -95. Wean as \n"},{"category":"Nursing/other","chartdate":"2129-08-21 00:00:00.000","description":"Report","row_id":1624114,"text":"ALTERED RESPIRATORY STATUS\nO: CARDIAC: AF WITH VENTRICULAR RESPONSE 70'S-80'S. PVC'S NOTED. K AT 11AM NOT RUN CALLED LAB AND RAN AT 1400 3.7 RECIEVING 20 MEQ KCL X2. SBP 90'S-162 WITH COUGHING. AFEBRILE. EXTREMITIES WARM AND DRY. PALP PP. OOB TO CHAIR VIA X3 HOURS.\n RESP: VENT SETTINGS AND ABG PER FLOW. BS COURSE UPPER -CLEARS WITH COUGHING. RR TWENTIES - THIRTIES. SUCTIONED FOR A SMALL AMOUNT OF THICK TO THIN WHITE . TRACHE CARE DONE, INNER CANNULA CHANGED.CO2 57.\n NEURO: OPEN EYES TO COMMAND, INCONSISTENTLY WILL WIGGLE FINGERS AND TOES TO COMMAND, CLOSES EYES AND MOUTH WHEN ATTEMPTING TO ASSESS PUPILS AND OR MOUTH CARE. PERL.\n GI: TF AT GOAL, ABD SOFT, NONTENDER, SMALL AMOUNT OF SOFT BROWN QUIAC NEGATIVE STOOL.\n GU: MARGINAL UO\n ENDO: HAS NOT RECEIVED SSI .\n PAIN: SHOOK HEAD NO TO PAIN.\n SOCIAL: DAUGHTER INTO VISIT AND UPDATED.\n REHAB: ? PLAN TO DISCHARGE TO REHAB .\nA: TOLERATED OOB X 3 HOURS. CONTINUES IN AF. CO2 57.\nP: MONITOR COMFORT, HR AND RHTYHYM-? COUMADIN, SBP, RESP STATUS-PULM TOILET-ABG, NEURO STATUS-REORIENTE PRN, I+O, LABS AS PER ORDERS. PREPARE FOR REHAB . DC ALINE. COMPLETE DISCHARGE SUMMARY. AS PER ORDERS.\n"},{"category":"Nursing/other","chartdate":"2129-08-21 00:00:00.000","description":"Report","row_id":1624115,"text":"Resp. care note - Pt. remaines and vented, no vent changes made at this time.\n"},{"category":"Nursing/other","chartdate":"2129-07-27 00:00:00.000","description":"Report","row_id":1624108,"text":"0700-1900\nneuro: lethargic, easily aroused, follows commands, moves upper extremities, pt very weak\n\ncv: hr a-fib(70's-80's), no ectopy, sbp stable(90-134), po digoxin\n\nresp: placed on cpap today, well, now back on AC due to sedation for colonoscopy, bs+ all lobes & course, sux sm/mod amt thick yellow , sat 95-100, no resp distress noted\n\ngi: pt npo today for colonoscopy, procedure done @ 1700, TF resumed @ 1800, mushroom cath draing lg amt clear liquid stool, po prevacid\n\ngu: foley patent, clear yellow urine, continues on lasix gtt to keep hourly uo 150 cc's, lasix now @ 4 mg/hr\n\nother: son called & updated on pt's condition, son-in-law in to visit, no c/o pain, 1500 labs sent, K+ 3.6, needs repletion, am K+ of 3.6 tx with 40 kcl po, colonoscopy negative, no bleeding areas noted\n\nplan: continue with ventilatory support, wean to cpap as tolerated, continue lasix gtt, goal uo 150 cc/hr, ? tx to CCU tomorrow for possible AVR on Tuesday\n"},{"category":"Nursing/other","chartdate":"2129-07-28 00:00:00.000","description":"Report","row_id":1624109,"text":"NPN 7P-7A\nBRIEFLY THIS IS A PT. ADMITTED ON FROM WITH SEPSIS. HE HAS AN EXTENSIVE PMH. IS A CHRONIC VENT PATIENT. HIS GREATEST ISSUE HAS BEEN HIS FLUID VOLUME STATUS D/T AV STENOSIS. HAS BEEN ON LASIX GTT TO TRY TO ATTEMPT WEANING. PT.'S FAMILY DECIDED THEY WANTED AGGRESSIVE TREATMENT AND PT. IS NOW TO GO WEST FOR AVR. THE PROCEDURE IS GOING TO BE DONE NEXT TUESDAY. GOAL IS TO TRANSFER PT. TO CCU OR CSRU WITHING THE NEXT COUPLE OF DAYS\n\nCOLONOSCOPY DONE YESTERDAY TO R/O GIB. RESULTS NEGATIVE. AT THIS POINT PT. AWAITING TRANSFER WEST.\n\nNEURO: PT. ALERT. OPENS EYES AND NODS HEAD YES AND NO TO QUESTIONS ASKED. PUPILS EQUAL AND REACTIVE. OOB TO CHAIR WITH HOYAR ASSIST.\n\nRESP: PT. WITH TRACH. ON AC 30%/500/20/5. PT. TOLERATED PRESSURE SUPPORT YESTERDAY FOR MOST OF DAY. BREATH SOUNDS COARSE BILAT. SUCTIONED FOR VERY THICK YELLOW SECRETIONS.\n\nCV: PT. IN AFIB WITH RATE 70'S TO 90'S. SYSTOLIC BP LABILE. AT APPROX. 0400 PT. HYPOTENSIVE TO 75/39. LASIX GTT OFF. ( MD'S, LASIX OFF OF SBP <90 OR MAP <65). PT. REMAINS WITH TOTAL BODY ANASARCA. + PULSES. AFEBRILE. PM K+ 3.6 REPLETED WITH 40MEQ IVPB\n\nGI: PT. WITH PEG. ON TFEEDS AT GOAL RATE OF 40CC/HR. TOLERATING WELL. MUSHROOM CATH IN DRAINING LIQUID BROWN STOOL. ABD. SOFT. BS+\n\nGU: FOLEY IN PLACE. GOOD OUTPUT.\n\nACCESS: R AC PICC\n\nPLAN: TRANSFER TO WITHIN NEXT DAY OR TWO. ? RESTART LASIX GTT IF BP PERMITS. WEAN VENT AS TOLERATED. REPLETE LYTES AS NEEDED. AM LABS PENDING. FULL CODE.\n"},{"category":"Nursing/other","chartdate":"2129-07-23 00:00:00.000","description":"Report","row_id":1624087,"text":"Respiratory Care\nRemains intubated and ventilated on a/c mode with no remarkable changes overnight. Suctioned for moderated amounts of thick tan .Pt gets very bronchospastic with suctioning/coughing. Unable to obtain due to tachypnea when put on psv.\n"},{"category":"Nursing/other","chartdate":"2129-07-11 00:00:00.000","description":"Report","row_id":1624036,"text":"pt remained on full vent support through shift, sx'd for moderate amount of secretions, plan to be evaluated during rounds. AM RSBI was 104\n"},{"category":"Nursing/other","chartdate":"2129-07-23 00:00:00.000","description":"Report","row_id":1624088,"text":"npn 7p-7a (please also see carevue flownotes for objective data)\n\nPt s/t 2 trials PS yesterday, returned to A/C for tachypnea, tachycardia, resp distress;\n\nOn Lasix gtt for urine output goal of 100 cc/hr; recieved on 3.5 mg/hr, increased gently to avoid b/p lability;\n\nB/p remained in acceptable range this night; Diltiazem 30 mg given at 19:30, 6 hrs later pt still w/ borerline b/p and v-response still in 80's, therefore waited until v-response started increasing before giving again; at 04:00 v-response in low 90's after suctioning, therefore dilt given at that time; b/p and v-response remained in acceptable ranges in the two hours following;\n\nPt received full bed bath this night, all IV lines changed;\nRemains on tube feeding as ordered, w/out diarrhea;\n\nThis a.m. serum Na 139--?need for 150 cc's free H20 q 4 hrs?--?decrease volume, or ?decrease frequency;\na.m. serum K+ 3.3, pt received 20 meQ KCL in 50 cc x2, at 05:15 amd 06:16; ordered for third--?check serum level K+ first;\n\nPLAN:\n1) check w/ MD team re interval of diltiazem\n2) check w/ MD team re free water boluses\n3) check serum K+ before more serum K+\n4) dressing changes\n5) further plan per a.m. rounds\n"},{"category":"Nursing/other","chartdate":"2129-07-23 00:00:00.000","description":"Report","row_id":1624089,"text":"resp Care\n\nPsv wean attempted; on 25 of ps with volumes in the high 300's low 400's. Will wean as tolerated. Otherwise on full vent support. Bs with scattered rhonchi. Suctioning thick yellow .\n"},{"category":"Nursing/other","chartdate":"2129-07-23 00:00:00.000","description":"Report","row_id":1624090,"text":"NPN 0700-1900\nNeuro: Awake, alert, more interactive today w/nods, occasional smile. Move LUE, wiggles toes. Gag/cough intact. Will not squeeze hand ?too much fluid. Afebrile. OOB to chair via lift and 3 assists\n\nCV: Continues in afib w/occ PVC's but rate stable 80's-90's. Remains on dilt which is a QID drug so no changes to med order just hold when SBP low. SBP in 100's to low 110's throughout shift. Lasix gtt now @ 5mg/hr, new hold orders are for SBP <90, now diuresing @ ~100cc/hr.\nRepleting K\nResp: Currently tolerating PS 40/5/25 w/RR 30-35bpm. Pt appears comfortable. LS coarse in RUL but currently clear in remaining lobes. Decrease in amt of secretions from yesterday.\n\nGI/Endo: Required no additional insulin coverage today, TF at goal of 50cc/hr w/ no residual. Soft distended abd, +BS, +BM x1 soft, dark brown.\n\nGU: patent foley now draining clear light yellow urine @~125cc/hr.\n\nSocial: daughter and son in law in today with several ?'s about POC, state that they are happy with our medical care, still hoping for possibility of minimally invasive valvoplasty, get fluid off pt and have him return to rehab.\n\nPlan: Lasix gtt for >100cc u/o per hour\n Check K\n TF, Glargine due @ 2200\n Dilt for rate control, hold when necessary\n Encourage deep breathing\n"},{"category":"Nursing/other","chartdate":"2129-07-11 00:00:00.000","description":"Report","row_id":1624037,"text":"NPN\n\nNeuro: Pt is alert, follows simple commands but not able to participate in his care significantly.\n\nCV: Remains in afib, occ PVCs. He was started on dilt PO this afternoon, 30mg QID down from the 60 mg that he received yesterday. BP has been stable 100s-130s. If his BP tolerates the dilt than we will cont to try and diurese him.\n\nResp: Remains vented A/C 450x14/5/.4, he over breathes by , PSV was tried briefly during rounds but he did not tolerate it. He has a lot of thick yellow secreations, requiring q1-3 hr suctioning.\n\nGI: Tolerating his TF at the goal rate of 40cc/hr, had a sm BM which was OB pos, sent for cdif.\n\nGU: Tried to gently diurese him today, he is even for the day, an additional dose of lasix will be given this evening his his BP tolerates it.\n\nSoc: One of his 4 daughters was in today, she met with case mangagement and SS.\n"},{"category":"Nursing/other","chartdate":"2129-07-11 00:00:00.000","description":"Report","row_id":1624038,"text":"Patient remains on mechanical ventilation;does not tolerate PSV,RSBI 104.Febrile,follows simple commands, but still passive.BS coarse,suctioned for small clear sputum will continue to follow.\n"},{"category":"Nursing/other","chartdate":"2129-07-12 00:00:00.000","description":"Report","row_id":1624039,"text":"NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 108/61-154/86. A-FIB WITH HR RANGING FROM 102-117 WITH OCC PVC'S. REMAINS ON DILT PO.\n\nNEURO: ALERT. UNABLE TO DETERMINE ORIENTATION AS PT IS . DOES NOD HEAD YES AND NO. FOLLOWS SIMPLE COMMANDS. ALSO GRIMMACES WITH CARE BUT DENIES DISCOMFORT.\n\nRESP: AC 40%/450/14/5. RSBI 140.7. LUNGS COARSE THROUGHOUT. SOO2 91-98%. RR 19-34. SX Q 3-4HR FOR THICK WHITE SECRETIONS.\n\nGI: ON NUTREN PULM AT 40CC HR AND WELL. NO STOOL THIS SHIFT.\n\nGU: FOLEY CATH PATENT AND DRAINING URINE WHICH WAS AMBER IN COLOR BUT PROGRESSED TO LIGHT RED WITH FEW SM CLOTS. FOLEY IRRIGATED.\n\nSKIN: DUODERM INTACT ON MID BACK.\n\nPLAN: CONT TO MONITOR VS AND LABS AND REPLENISH LYTES AS NEEDED. PT IS DILT WELL, DIURESE. PROVIDE UPDATES IN PT CONDITION TO FAMILY.\n"},{"category":"Nursing/other","chartdate":"2129-07-12 00:00:00.000","description":"Report","row_id":1624040,"text":"RESP CARE NOTE\nRECEIVED PT ON AC WITH NO CHANGES OVERNIGHT. BREATH SOUNDS ARE WITH COARSE CRACKLES. SUCTIONING SMALL AMOUNTS OF THICK WHITE SECRETIONS. ALB/ATR GIVEN INLINE Q4. TRACH IS PATENT AND SECURE. CUFF PRESSURE 27. RSBI 141 THIS AM. WILL CONT TO FOLLOW.\nPLAN: CONT FULL VENT SUPPORT\n"},{"category":"Nursing/other","chartdate":"2129-07-12 00:00:00.000","description":"Report","row_id":1624041,"text":"NPN\n\nneuro: pt remains alert, following simple commands, not able to do any ADLs. He is very stiff and bearly able to bend his arms and legs.\n\nCV: Remains on dilt, conts in afib with a rate of 80s-1teens. BP 110s-130s/70s. He conts on coumadin, his INR was 2.3 this morning.\n\nResp: Remains , sx for thick yellow sputum, his trache has tans secreations on the inside of the lumen, to have ENT to come see him for a possible new trache. He was placed on PSV of 15/5,.4, ABG 7.38/62/67. His rate and VTs are about the same on PSV vs A/c, though his HR increased to the 100s-1teens. T max 100.0, gent was d/ced, he conts on imipenum and PO bactrim.\n\nGI: Conts on TF, no stool today.\n\nGU: Given 40 mg of IV lasix, he is presently 125cc neg since MN.\n\ndispo: To be screaned by heb reb, family is aware.\n"},{"category":"Nursing/other","chartdate":"2129-07-27 00:00:00.000","description":"Report","row_id":1624105,"text":"NPN 7P-7A\nTHIS MAN WAS ADMITTED HERE ON FROM WITH A DIAGNOSIS OF SEPSIS. HE HAS AN EXTENSIVE PMH INCLUDING AV STENOSIS WHICH HAS IMPEEDED EQUALIZING HIS FLUID BALANCE. DECISION WAS MADE BY PT.'S FAMILY, AFTER HAVING DONE RESEARCH IN THE INTERNET, TO HAVE PERCUTANEOUS VALVULOPLASTY DONE AFTER LABOR DAY WEEKEND IN HOPES THAT PT.'S FLUID OVERLOAD WILL IMPROVE, LEADING TO SUCCESSFUL VENT WEANING. CARDIOTHORACICS TALKED WITH FAMILY EXTENSIVELY REGUARDING THE RISKS OF THIS PROCEEDURE. FAMILY HAS DECIDED TO MOVE FORWARD WITH AGGRESSIVE TREATMENT. PLAN IS TO TRANSFER TO CCU HOPEFULLY BEFORE THIS WEEKEND.\n\nYESTERDAY PT. HAD CT OF ABDOMEN FOR PRE-PROCEDURE WORKUP. PT. WILL ALSO NEED DENTAL XRAYS TO R/O POSSIBLE ABSCESSES. PT. ALSO TO HAVE COLONOSCOPY DONE THIS AM AS HE HAS BEEN HAVING TARRY STOOLS. GOLYTLY 6L GIVEN THIS SHIFT IN PREPARATION FOR COLONOSCOPY THIS AM.\n\nNEURO: PT. ALERT. NODS HEAD YES AND NO TO QUESTIONS ASKED. PURPOSEFUL MOVEMENT NOTED. NO C/O PAIN. OOB TO CHAIR WITH ASSIST DURING DAY.\n\nRESP: REMAINS VENTED WITH TRACH. ON AC: 30%/500/5/20. BREATH SOUNDS COARSE. SUCTIONED FOR THICK TAN/GREEN SECRETIONS. + PSEUDOMONAS PNEUMONIA. REMAINS ON LASIX GTT HOPING OT DIURESE AND WEAN OFF VENT.\n\nCV: PT. IN AFIB WITH RATE 70'S TO 90'S. SOME RARE PVC'S NOTED. SBP HIGH 80'S TO LOW 110'S. TOTAL BODY ANASARCA. + PULSES. AFEBRILE.\n\nGI: PT. WITH PEG. HAS BEEN NPO FOR COLONOSCOPY THIS AM. MUSHROOM CATH PLACED AFTER CHANGING BED 6 TIMES FOR INCONTINENT STOOLS FROM GOLYTLY. DRAINING LIGHT BROWN LIQUID STOOLS. MDS AWARE.\n\nGU: FOLEY IN PLACE DRAINING CLEAR YELLOW URINE. GOOD OUTPUT. (REMAIN SON LASIX GTT)\n\nACCESS: R AC PICC\n\nPLAN: PT. TO HAVE COLONOSCOPY IN AM. AM LABS PENDING. WILL NEED TO REPLETE LYTES AS NEEDED. CONTINUE WITH CURRENT POC. TRANSFER TO CCU IN NEAR FUTURE FOR PROCEDURE. NO CONTACT WITH FAMILY THIS SHIFT. FULL CODE\n"},{"category":"Nursing/other","chartdate":"2129-07-27 00:00:00.000","description":"Report","row_id":1624106,"text":"Resp Care\nRemains intubated and ventilated on a/c 500 x 20 30% +5 with no remarkable changes overnight. Continues to have thick yellow , often coughing up into vent tubing. O2 sats 99-100. stopped this morning due to increased resp rate (>35). Pt scheduled to have colonoscopy later today.\n"},{"category":"Nursing/other","chartdate":"2129-07-27 00:00:00.000","description":"Report","row_id":1624107,"text":"Respiratory Care\nPatient placed on CPAP/PSV at noon. Suctioning moderated amounts of thick yellow secreations frequently, q2-3hrs. Breath sounds diminished, coarse throughout. MDI's given as ordered.\n"},{"category":"Nursing/other","chartdate":"2129-07-10 00:00:00.000","description":"Report","row_id":1624034,"text":"NPN M/SICU ICU day 2 (0700 -1900)\n\nEvents: Recieved 3L NS bolus r/t hypotension with good effect. A line inserted. TPA instilled into obstructed port and now flushes and draws appropriately. Repleted K w/ 40meq PO. No other significant events.\n\nReview of Systems:\n\nNeuro: Alert opens eyes spontaneously and nods head appropriately in response to simple questions, PEARL, MAE on bed, able to track and follows commands consistently. No c/o pain but obvious facial grimace upon repositioning.\n\nCV: Afib with occasional ventricular ectopy, rate well controlled w/ PO dilt. Pt became hypotensive to low 70's recieved 3 liters NS w/ good effect. A -line placed and pt has been normotensive since its insertion. Anasarca persists. Please refer to carevue for objective data.\n\nResp: 7.0, vent dependent on A/C 40% 450 x 14 PEEP 5, overbreaths vent by 10 - 14 BPM, most recent ABG 7.50/49/72 (team aware). LS coarse throughout, suctioned for copious amounts of thick yellow secretions q 1 hr.\n\nGU/GI: TF started this evening (nutren pulmonary) @ 10cc/hr goal rate is 50cc/hr and can be advanced @ 20:00. Abd soft/NT/ND, +BS, large loose BM x 1 (stool sent for C-Dif). Patent foley draining >30cc/hr however pt remains 2.6 liters positive since midnight.\n\nAccess: R DL power picc, all ports flush and draw appropriately.\n\nPlan: Family @ bedside this afternoon, and spoke @ length with RN in regards to POC. Cont Abx Tx and tx hypotension w/ NS fluid boluses . Cont to monitor/maintain heme/resp status, wean vent support as tolerated. Update family on POC as it develops.\n"},{"category":"Nursing/other","chartdate":"2129-07-17 00:00:00.000","description":"Report","row_id":1624060,"text":"NPN 1900-0700\nEvents: Became hypotensive to 66-70s via ABP after turning to R side following bathing pt. NBP slightly higher. No drop in sats (99-100) or change in RR, low 20s. No change in HR 90s-100s, a-fib, occ to freq pvcs. Gave 2 500ml fld boluses and started Neo at 1mcg/kg/min, with good response, sbp up to 100. Hct sent, 23, stable, but team wanted to transfuse anyway, so one unit pc given. Trying to wean neo, currently at .6mcg/kg/min.\n\nNeuro: Clonepin .5mg given po prior to above event, doubt it was related, but pt more lethargic during above episode, ? if lethargy was related to conepin or hypotension. Pt more awake few hrs after. Slept in short naps. Denies pain. Pt follows simple commands inconsistently.\n\nCV: HR 89-104, a-fib, freq multifocal pvcs. Dilt held all noc. Maintaining sbp >100 c Neo. EKG done, no changes. Troponin levels sent. Vit K given for INR 1,6. 40meq kcl given for K 3.8. Free water increased to 150mls q4hrs due to Na 147. Repeat labs in am with vanco trough. +pp.\n\nResp: Resp pattern appeared comf all noc, RR low 20s, sats 99-100, VT 400-450. Peep was dropped from 12 to 10 due to hypotension s problem.\nLS coarse, dim in bases. Sx somewhat more freq for mod amt thick, tan to yellow secretions.\n\nID: Afebrile, no incr in wbc. Bld and urine cx sent. cont imipenem and vanc.\n\nGI: +BS, abd soft dist. TF at goal, incr free water. No stools.\n\nGu: U/o 30-80mls/hr clear, yellow urine.\n\nSkin: Intact except for upper back pressure sore covered c duoderm.\nGeneralized edema t/o body.\n\nPlan: Titrate neo to BP. Evaluate dilt with team. Monitor hct, lytes, replete as needed. monitor for black stools, freq turning and skin care.\n\n"},{"category":"Nursing/other","chartdate":"2129-07-17 00:00:00.000","description":"Report","row_id":1624061,"text":"Resp Care,\nPt. remains on A/C overnoc. Peep decreased to 10 this shift, following episode of hypotension. PO2 acceptable. Suctioned for moderate amount thick yellow sputum, MDI's as ordered. Cuff pressure 40cm, 13 cc air in cuff. RSBI not done due to peep level. See carevue.\n"},{"category":"Nursing/other","chartdate":"2129-07-17 00:00:00.000","description":"Report","row_id":1624062,"text":"Addendum\nAt 6am, pt had medium, black, tarry stool, OB+. Also, FSBS was 82, will repeat in one hour.\n"},{"category":"Nursing/other","chartdate":"2129-07-17 00:00:00.000","description":"Report","row_id":1624063,"text":"79 yr old pt with pseudomonas PNA, s/p mva and and pegged since . 3 rd admit to since with prob VAP. trach changed on and again on . events today: neo stopped 0930 after on for approx 12 hr for bp drop to 60's sys. continues to have black tarry hem pos stool, last transfused early am and crit bumped . 1500 labs pending\n\nneuro: pt somulent, aroused with stim and answered questions appropriatley. still quiet groggy . clonazapam d/ced last dose 20 . lorazapam d/ced and last dose 0800 am > 24 hr ago.\nPERL. lt arms moving less than yesterday independently. no independent\nmovement rt arm of legs.\n\nresp: no changes in vent settings. mod amt secretions suctioned about 5x by this nurse. sent. sat 98-100 gas improving to ph 7.43/ 46/114 . resp rate 25-28 comfortable. poss change trach to bovina with foam cuff for persistant cuff leak.\n\ncard : afib rate 90-104 range. neo off since 0930. pvcs were up to 16/min this am and seemed to decrease after neo off with current pvc's / min. bp 107-130's off neo and dilt dose given at 1300. bp stable since. feet and rt hand cool, good pulses by . ck repeated at 1500. total body anasarca\n\ngi: crit up after last unit of bld and repeat crit at 1500 pending. mod amt black tarry hem pos stool at 11:00. pt has had tarry stool since noted at and has had total 6 units prbcs since combined from and . poss to have endoscopy tommorrow.\ntube feeds at goal pos hyperactive snds. 150 cc h20 q 4hr free water.\n\ngu: urine started to have visible red cells at approx 1000 md made aware. pt has had hx of hematuria. inr 1.3.\n\nrenal: urine 40-80 cc/hr. creat down to 1.3.\n\nendo: stim test done. glaucose level low all shift 80-90 range. glargene decreased from 32 to 30 units.\n\nID: afeb for > 24 hrs wbc up to 11.3 today. no change in antibx. vanco dose given for level 15/1 this am.\n\nskin: no breakdown other than ulcer on back covered with dueoderm. elevated rt arm on pillows for edema.\n\nsocial: son in today and updated him as well. family stil concerned with lethargy.\n\nplan: monitor labs from 1500 and cont bp monitor. poss trach change and poss endoscopy in am.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2129-07-17 00:00:00.000","description":"Report","row_id":1624064,"text":"resp care - pt remains on full vent support. No changes made this shift. ABG showed compensated resp acidosis with good oxygenation. BLBS were coarse t/o, clearing slightly on suctioning of varying amounts of thick, yellow secretions. MDIs given as ordered. See carevue for more detail.\n"},{"category":"Nursing/other","chartdate":"2129-08-25 00:00:00.000","description":"Report","row_id":1624131,"text":"ekg afib, rate 90s, occ pvcs. sbp stable. lowgrade temp, 99.4. adequate uo, moderate diuresis after earlier lasix. breath sounds clear, decreased at bases, trach suctioned for mod to copious amts thick yellow/white secretions. small amt yellow exudate around trach site. remains on cpap. no vent changes overnight. chest dressing dry, changed. abd soft, bowel soinds +, mod soft formed stool x 1. tolerating tf, replete with fiber at 80 cc/hr. feet warm, dp and pt pulses bilat, wearing csl and waffle boots. allevyn dressing to mid back is intact, groin rash is pink, improved. opens eyes to voice, sometimes speaker, but is very deaf. did move feet and l hand asked. plan to move to rehab to day.\n"},{"category":"Nursing/other","chartdate":"2129-08-25 00:00:00.000","description":"Report","row_id":1624132,"text":"pt stable, transferred to rehab @ 1500 via ambulance\n"},{"category":"Nursing/other","chartdate":"2129-07-18 00:00:00.000","description":"Report","row_id":1624068,"text":"NPN 0700-1900\nFull code, contact precautions\n\nNeuro: Pt alert for most of day, flat affect, occasional head nod or smile. Able to move LUE purposefully. Afebrile. Rec'd Ativan 1mg x1 increased gagging after trach change w/good effect. Rec'd 2mg midaz/50mcg fent during endoscopy with very good effect.\n\nCV: Pt in afib with occasional PVC's, diltazem for rate control which has been in 80's and 90's throughout shift. BP's stable, even throughout endoscopy, see carevue. 3+ pitting edema in all extremities. Echo done today, results pending, Hct now stable @ 27, endoscopy unrevealing, no tarry stool this shift: probable lasix gtt to start to begin diuresis. Art line to be d/c'd pt noted to have cool L hand, brachial pulse palpable. Fibrinogen to be drawn next rounds.\n\nResp: Improving RLL psedomonas PNA on Vanc and Imipenim. RR in 20's, sats >95% on CMV 40%/500/10 PEEP. Trach changed today to decrease leak size and improve tidal vol's. Pt now has flexi phlange hyperflex trach #8. Additional trach on order from . ABG wnl this pm, see carevue\n\nGI: TF was at goal of 50 with no residual, +BS in firm/distended, nt adb. Became NPO for endoscopy this pm, expect to restart TF. No stool this shift. Endoscopy showed clean PEG insertion, diverticulosis x1 but no active bleeding evident.\n\nGU: Patent foley draining amber clear urine @ 30cc/hr.\n\nSkin: tear on L forearm; dressing on upper back placed last night and should not be changed until . PICC dressing to be changed @ 0000.\n\nLines: PICC patent, draws. Art line to be d/c'd\n\nSocial: Daughter and her 3 teen children for !2hrs today. Pt minimally interactive. Family to discuss code status later this wk\nPlan: Monitor and support hemodynamics\n Fibrinogen draw next rounds\n ? restart TF\n ?Lasix gtt\n T q2, sxn prn\n IV abx as ordered\n"},{"category":"Nursing/other","chartdate":"2129-07-19 00:00:00.000","description":"Report","row_id":1624069,"text":"Nursing Note:\n\nNeuro: pt alert, opens eyes, follows commands inconsistantly. occasionally nods head or gives facial expressions. pos gag and strong cough. received 1mg prn ativan overnight, does not respond to pain assessment, does not appear in any pain/distress.\n\nResp: trach intact (8.0 TTS water seal cuff), no vent changes ovenright. remains on AC 22/500 PEEP 10, FIO2 0.40. sats 97-100. lungs clear/coarse upper/diminished lower. suctioned for moderate amts thick white/tan. spare trach x2 at bedside.\n\nCV: HR 85-110 afib w/ occ PVC's. NBP 90-115/60-75, systolic BP noted to be in 80's occasionally when sleeping, MAP >60. diltiazem held @ MN (MD aware). pt has +3 generalized pitting edema. pos distal pulses.\n\nGU: pt started on lasix gtt overnight for low UO (goal 30-40cc/hr). presently at 2mg/hr. UO 20-35cc/hr clear amber. MD aware.\n\nGI: abd firm/distended, pos bowel sounds, TF @ goal of 50/hr via PEG, pt tolerating well, minimal residuals (<10cc). sm soft black stool x1 overnight, guiac pos.\n\nIV: r brachial PICC remains WNL, dressing/stat lock and caps changed overnight.\n\nSkin: dressing on upper back remains intact. no further skin breakdown noted. pt turned and repositioned off back. SCD's on legs.\n\nSocial: no calls/visits from family overnight.\n\nPlan:\ncont. to monitor hemodynamics, resp status (suction prn), urine output w/ lasix gtt.\n\ncont to assess potential for pain, anxiety, cont to provide updates on pt on plan of care, procedures.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2129-07-11 00:00:00.000","description":"Report","row_id":1624035,"text":"NSG.NOTES 1900-0700HRS\n\nNeuro:alert,responding to commands and obeying.denies any pain,comfortable on bed.generalised edema.\n\nResp:,vented,AC/14/450/5/40%/.suctioned large thick secretions.sats >95%.LS coarse throughout.trache care given.\n\nCVS:HR 90-100/min,afib,no ectopics noted.BP 110-130/60-70 mm of hg.A line on Lt radial,patent,slight bleeding from site,dresing changed.\n\nGU/GI:PEG present,BS hypo,feed advanced to goal rate of 40ml/hr,and flush with water50ml q6h.tolerating feeds.had large black loose stool.\non foley cath,urine output adequate,amber clear.\n\nIntegu:pressure sore on upper back,cleaned and duoderm applied.edema ++.bath given and position changed.on bactrim,genta and imipenam\n\nIV access:Rt midline double lumen cath,one port patent.dressing changed.A line on Lt radial.\n\nsocial:no family contact during the shift.calm and co operative.full code.on contact precautions for MRSA PNA\n\nPlan:pulmonary toileting and airway management.care of skin.emotional support.\n\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2129-07-25 00:00:00.000","description":"Report","row_id":1624099,"text":"Shift Note: 0700-1900\nNeuro: Pt alert, and vented. Opening eyes spontaneously and following commands consistently. Shakes and nods head appropriately. Continues w/ profound generalized weakness. OOB to chair X 5-6hr today via lift and tolerated well. Pt denies pain t/o shift, appears calm and relaxed and remains free of distress.\n\nResp: Vented AC 500/5 X 20 FiO2 30% though tolerated CPAP/PS 25/5 X 3-4hr today when OOB to chair. BBS course to somewhat diminshed at bilat bases. Snx q3-4hr for small to moderate amounts thick white secretions. Pt remains afebrile.\n\nCV: HR 70's to 80's afib w/ occasional PVC. BP 89/60 to 117/62. Continues on lasix gtt at 4mg/hr. Hct stable at 23.8 though pt continues w/ occasional loose black tarry stools. Team - aware/. CT MD in on consult today, discussed pt status and goals of care w/ family. Plan for pt to be transferred to CCU r/t plan for valve replacement after labor day. Family updated on pt status and discussed POC w/ Dr. today and family reports that the risks of valve replacement have been \"well explained.\" Family to discuss plan w/ pt later this week.\n\nFEN: Pt tolerating TF at goals. Abd soft, non-tender w/ BS present. Plan to change TF to nutren 2.0 w/ and new goal rate will be 40ml/hr. TF to be sent to unit from dietary. FSBS has remained stable 70's though new TF formula w/ >50% carbohydrate load compared to current feeding so anticipate higher blood glucose levels. Glargine dose has been decreased to 26units per orders. Foley catheter patent and draining clear yellow urine 80 to 120ml/hr. K 3.8 was repleated previous shif per report and orders.\n\nSocial: Family has been in to visit and discussed plan w/ team and CT MD as above. Information reinforced by this RN. Family very appreciative of care.\n\nPlan: Continue to monitor VS and labs. Continue Po dilt and lasix gtt as ordered and per written parameters. Monitor for s/s bleeding and follow hct. Anticipate PRBC tx to elevate hct prior to procedure. Continue OOB to chair as tolerates during day w/ CPAP/PS as tolerated. transfer to CCU.\n\n"},{"category":"Nursing/other","chartdate":"2129-07-25 00:00:00.000","description":"Report","row_id":1624100,"text":"Resp Care\nPt remians with #8.0 TTS H2O cuff on a/c. pt got up to chair today and was switched to PSV 25/5 for >3hours while in chair, he was switched back to a/c due to decreased vts and tachypnia. BLBS course, suctioned for thick pale yellow secretions. plan to remain on a/c overnight and trial psv tomorrow as tolerated.\n"},{"category":"Nursing/other","chartdate":"2129-07-26 00:00:00.000","description":"Report","row_id":1624101,"text":"NPN 7P-7A\nTHIS IS A 79YO WITH EXTENSIVE PMH ADMITTED FROM WITH SEPSIS. PT. FOUNT TO HAVE PSEUDOMONAS IN . HE IS VENT DEPENDENT. AT TIME OF ADMISSION PT. FOUND TO BE IN RAPID AFIB. SINCE ADMISSION HAS BEEN TREATED WITH MULTIPLE ANTIBIOTICS, FLUIDS AND DILTIAZEM. RECENTLY HAS BEEN HAVING BLACK TARRY STOOLS WITH HCT DROPS. FAMILY DECLINING COLONOSCOPY AT THIS TIME. ALTHOUGH, FAMILY HAS BEEN INQUIRING ABOUT A 'PERCUTANEOUS VALVULOPLASTY PROCEDURE' THEY HAD LOOKED UP AND FOUND ON INTERNET. RISKS OF THIS PROCEDURE HAVE BEEN EXPLAINED TO PT.'S FAMILY. PLAN IS TO HAVE HIM TRANSFERRED TO CCU AT SOME POINT BEFORE LABOR DAY WEEKEND.\n\nNEURO: PT. ALERT. NODS HEAD YES AND NO APPROPRIATELY TO QUESTIONS ASKED. DOES FOLLOW SIMPLE COMMANDS. APPEARS VERY FRUSTRATED. OOB TO CHAIR X 5 HOURS YESTERDAY VIA LIFT.\n\nRESP: PT. WITH TRACH AND ON AC: 30%/500/20/5. TOLERATED CPAP+PS X 4 HOURS YESTERDAY. BREATH SOUNDS CLEAR. DIMINISHED IN BASES. CAN BE COARSE AT TIMES, HOWEVER, CLEARS WITH COUGHING. SUCTIONED FOR MODERATE AMOUNTS OF THICK WHITISH .\n\nCV: HR 70'S TO 80'S AFIB. SOME RARE PVC'S NOTED. BP 80'S/40'S TO 110'S/70'S. LASIX GTT OFF AT START OF SHIFT AS BP WAS LOW. GIVEN ALBUMIN X2 AND 2U PRBC'S FOR HCT OF 20. + PULSES. 4+ PITTING/WEEPING EDEMA REMAINS PRESENT. AFEBRILE. CT MD IN TO SEE PT.'S FAMILY TODAY TO DISCUSS PT.'S PLANNED PROCEDURE AND GOALS OF CARE. RISKS WERE 'WELL EXPLAINED' AND FAMILY CONTINUES TO BE VERY AGGRESSIVE WITH CARE.\n\nFEN: TOLERATES TFEEDS AT GOAL RATE OF 40CC/HR. ABD. SOFT. BS+ . NO BM THIS SHIFT. FSBS HAVE REMAINED STABLE. FOLEY IN PLACE DRAINING CLEAR YELLOW URINE. ? RESTART LASIX GTT WHEN BP IMPROVES.\n\nPLAN: CONTINUE TO MONITOR RESP/HEMODYNAMIC STATUS CLOSELY. AM LABS PENDING. REPLETE BLOOD PRODUCTS AS NEEDED. ? RESTART LASIX GTT IF BP IMPORVES OVER THE NEXT FEW HOURS. CONTINUE TO WEAN VENT AS TOLERATED. TRANSFER TO CCU\n"},{"category":"Nursing/other","chartdate":"2129-07-26 00:00:00.000","description":"Report","row_id":1624102,"text":"Resp Care\nRemains and ventilated on a/c 500 x 20 30% +5 with no remarkable changes overnight. Strong spontaneous cough, suctioned for thick yellow . Failed again (142)\n"},{"category":"Nursing/other","chartdate":"2129-07-26 00:00:00.000","description":"Report","row_id":1624103,"text":"MICU EAST NPN 0700-1900\n\nPlease see flowsheet for further details.\n\nAlert. Nods head appropriatly. Denies pain.\n\nAnasarca. Lasix gtt resumed and currently a rate of 4mg/hr. No improvement in UO as yet.He is currently ~550cc positive since midnight. Goal is 6mg/hr of Lasix. Plan to continue to titrate as by BP >90sys.\n\n\nCurrently recieving Golytely prep for colonoscopy tomorrow. No stools at present. Rectal bag on. NPO except for meds. Pt needs colonoscopy before surgery can be done. No noted bleeding this shift. Did not get OOB-chair d/t colonoscopy prep and travel to CT.\n\nNo vent changes. Suction freq for sm thick yellow . Maintaining\ngd O2sats.\n\nAfebrile.\n\nPre-op Chest CT done. Needs dental x rays but may be difficult as pt must be able to sit up. Ventilator also poses a problem per radiology tech. Team to consult radiology/dentist. ? if pt is aware of surgery. His son said he didn't want him to know until later d/t his anxiety.\n\nSon most of afternoon but has gone back to .\n"},{"category":"Nursing/other","chartdate":"2129-07-26 00:00:00.000","description":"Report","row_id":1624104,"text":"Respiratory Care\nPatient remains on full ventilatory support. Suctioned for moderate amounts of thick yellow secreations on a frequent basis. Breath sounds coarse. Transported to CT for thoracic scan and returned without incident.\n"},{"category":"Nursing/other","chartdate":"2129-07-16 00:00:00.000","description":"Report","row_id":1624056,"text":"NPN 1900-0700\n79 yo ma s/p MVA on , has been vent dependent since with trach and peg. Adm on for hypotension sepsis, now stable VS. Trach was changed to larger trach c improved comfort. Black tarry stools with hct drop req transfusion over last few days, hct stable o/n.\n\nNeuro: Alert, follows commands inconsistently, does not always answer questions with full nod, does not appear to have pain by VS or grimace. Lorazepam 1mg given x2 c good effect. Barely able to move extremities due to edema.\n\nCV: Cont in A-fib. Coumadin and ASA were d/c'd #days ago due to hct drop. HR 84-97, freq pvcs. SBP 85-132. SBP dropped to high 80s after po Dilt dose given, remained high 80s for ~ one hr. Hct o/n stable at 23.4, am labs pending.\n\nResp: On AC 40%/500x20, peep8, overbreathing vent by 0-5. Sats 96-99, Sx ~q2hrs for mod amt thick, tan to bld tinged sputum. LS coarse, dim at bases. Trach care done, sm amt bldy dng. Much improved night with this trach.\n\nID: Afebrile. On vanco and imipenem. MRSA in sputum.\n\nGI: +BS, abd obese, distended. TF at goal 50mls/hr per peg. No stools this shift, passing flatus.\n\nGU: Lasix d/c'd due to incr in cr to 1.5. Pt anasarca, 3+ fld. +1.3L , 4.7L los. U/o now 35-40mls/hr, clear, amber urine.\n\nSkin: Lower legs ecchymotic, L foot colder than R foot, +pp. Pressure sore in upper back covered by duoderm, 1cm round opening, washed c saline. Extremeties heavy with fld.\n\nAccess: a-line, L picc.\n\nSocial: Daughter updated by Dr. .\n\nPlan: F/u on am hct, lytes. transfuse for hct 21. monitor temps, suction prn, maintain pt's comfort and support to family.\n"},{"category":"Nursing/other","chartdate":"2129-07-16 00:00:00.000","description":"Report","row_id":1624057,"text":"RESPIRATORY CARE:\n\nPt remains , vent supported. No changes made overnight. BS's coarse at times. Sxing thick white/tan secretions. Administering Albuterol and Atrovent MDI's in line with vent, as ordered. RSBI=85 this am. See flowsheet for further pt data. Will follow.\n"},{"category":"Nursing/other","chartdate":"2129-07-16 00:00:00.000","description":"Report","row_id":1624058,"text":"Resp Care\nPt remains on CMV via trach. Pt has had small reoccurring cuff leak, pt exhaling during inspiration and has been tachypnnic. Peep was increased, pt seems more comfortable on vent. Cuff has been inflated with 13cc's pressure 45, team is aware. Plan to monitor resp status and eval trach.\n"},{"category":"Nursing/other","chartdate":"2129-07-16 00:00:00.000","description":"Report","row_id":1624059,"text":"progress note:\n\nneuro: pt nodding appropriatly after much encouragment. seems depressed flat affect. pt almost in tears this am but clearly shook head no when asked if wanted to stop tx. able to lift lt arm purposefully. family feels pt is much less interactive and somulent and requested to stop lorazopam and clonazapam as pt had been snowed and acting \" loopy\" with mind altering drugs in other hosp.\n\nresp: this am pt in distress with RR to 35 and audible cuff leak on end inspiration. air added to cuff and lorazapam 1 mg given and pt settled to rr 24 hr down to 80\" from 110\"s, gas redrawn and alkalosis still seen. cuff leak present again after a few hrs and pt only tv of 340-380 of set 500 cc. resp rate up again to >30 and made vent setting changes to hopefully compensate for tv not delivered. per resp therapist pt still having leak and losing approx 100 cc of tv so increased peep to 12 and pt much more comfortable. gas did not improve much other than inc in p02 and slight decrease in pco2. suctioned several times tan thick secretions. rr currently in 24-28 range with sxat 100 %\n\ncard: a fib with occasional pvcs, hr lower to 80's after ativan otherwise in high 90-11- range. bp 91 sys lowest after ativan and high to 130/91. all doses dilt given. crit 1500 24.2 goo Perp pulses. general anasarca. did not diuresis d/t renal function impairment. but did just start acetazolimide.\n\ngu: pos 800 cc since midnight. urine is less concentrated and apporx 35-40 cc/hr out\n\ngi: no bm pos bs, no flatus. abd distended soft. tf at goal\n\nskin: no further breakdown\n\naccess picc rt arm with swelling no dvt as per ultsnd . flushed with ns the unused port without resisatnce today\n\nsocial: pt daughter in to see him and feel pt is much o=more somulent and weak. she was updated with resp status and progress.\n\nplan: monitor resp status, poss discuss intreventional pulmonology to recheck trach and poss change again. monitor blood gas. skin care\n"},{"category":"Nursing/other","chartdate":"2129-08-24 00:00:00.000","description":"Report","row_id":1624126,"text":"NEURO: PT. ALERT, UNABLE TO ASSESS ORIENTATION, WITHDRAWN AT TIMES, SPONTANEOUSLY MOVES ALL EXTREMITIES WITH NO PURPOSE TO HIS MOVEMENTS. PT. DOES NOT FOLLOW COMMANDS. DOES RESPOND TO PAINFUL STIMULI (NAIL BED).\n\nCV: PT. AFIB, HR 80'S, SBP 110-130, RARE TO OCCASIONAL PVC'S NOTED. SEE CAREVUE FOR COAG'S. SKIN WDI- PULSES PALPABLE.\n\nRESP: PT. LUNGS CLEAR IN RUL, COURSE IN LUL, DIMINISHED IN BASES. SEE CAREVUE FOR VENT SETTINGS AND ABGS. PT. +GAG, +COUGH, SUCTIONED VIA ETT FOR THICK, YELLOW SECRETIONS OF SMALL TO MODERATE AMT.\n\nGI/GU/ENDO: PT. ABD SOFT, +BS, BM X2- BROWN, SOFT, MUCOUSY STOOL, GUIAIC NEGATIVE. TUBE FEEDS (REPLETE WITH FIBER) AT GOAL OF 80CC/HR VIA PEG. FOLEY DRAINING CLEAR TO SEDIMENT, YELLOW URINE. LYTES REPLETED. BLOOD SUGARS TREATED PER RISS.\n\nPLAN: REHAB TODAY?, WEAN MECHANICAL VENTILATION, SKIN INTEGRITY.\n"},{"category":"Nursing/other","chartdate":"2129-07-18 00:00:00.000","description":"Report","row_id":1624065,"text":"NPN 1900-0700\n79 yo ma s/p MVA on , mostly vent dependent since then, except for few periods of few weeks off. and pegged in , pseudomonas PNA, RLL. Trach changed on and again on . Pt cont to have sm trach leak but much improved. Also has had black tarry stools since noted at , had 6-7 units prbc total between here and there.\n\nNeuro: Alert, follows simple commands inconsistently. Appears withdrawn/?depressed, on celexa. Difficult to get pt to nod adequately to questions. Moves extrem only slightly, heavy c edema. Pt not given any ativan and clonapan d/c'd. Pt appears comfortable without meds.\n\nCV: HR 82-108, a-fib, occ multiform pvcs. No coumadin or ASA. SBP stable 99-132, on dilt 30mg q6hrs. Last hct 26.1, am labs pending. +pp.\n\nResp: No vent changes, peep cont 10. LS coarse t/o. RR 22-25, appears comfortable. Sx ~q1hr for mod amt thick, yellow secr. Discussion of changing trach to bovina with foam cuff.\n\nID: tmax 99.1 ax. Pt dislikes temp by mouth. On vanc and imipenem.\n\nEndo: Glargine decreased to 30units last noc. FS ~ 120.\n\nGi: Abd obese, soft distended, +BS. 50mls goal of TF via peg, 150mls water q4hrs. Had two mod-lge black tarry stools hem+.\n\nGu: Bloody urine noted , now pink/. 30-60mls/hr. Cr has been dropping, 1.3 .\n\nSkin: Pressure sore on upper back, ~2cm round, dsg changed, washed c saline covered c duoderm. LL ecchymotic. general anasarca, Rarm > L. R arm us done, neg.\n\nSocial: Pt has 5 children, they take turns visiting. They have been concerned that pt has been lethargic, concerned re sedative meds.\n\nPlan: Follow up on am labs, hct, lytes. Monitor BP HR. ? endoscopy for cont GI bldg. ? trach change.\n\n\n"},{"category":"Nursing/other","chartdate":"2129-07-18 00:00:00.000","description":"Report","row_id":1624066,"text":"Resp Care,\nPt. remains on A/C overnoc, no vent changes this shift. #8 Portex trach with occasional cuff leak. Cuff pressure 35cm. Suctioned for thick yellow , MDI's as ordered. No RSBI due to peep level. See carevue.\n"},{"category":"Nursing/other","chartdate":"2129-07-18 00:00:00.000","description":"Report","row_id":1624067,"text":"Respiratory Care\nPatient received on AC 500x20 10 PEEP 40%, wearing an 8 Portex, breath sounds bilaterally clear but expiratory grunting heard, suctioned intermittently for moderate amounts of thick yellowish secretions,was afebrile, into chronic A-fib, had occasional, frequent and rare PVCs, Blood Pressure stable all day long, patient had trach tube change around 1300, the 8 Portex has been replaced with bronchoscopy support by an 8 TTS water-sealed cuff, 12 at the flange, initial cuff pressure was 22 CmH2O,the leak persisted in spite of the trach change, patient also had a negative endoscopy today, has been treated with Albuterol and atrovent inhalers, ABGs at 1238 was good, no vent changes have been made, will continue to be provided with mechanical ventilatory support, treatments and close monitoring.\n"},{"category":"Nursing/other","chartdate":"2129-07-15 00:00:00.000","description":"Report","row_id":1624054,"text":"Resp Care\n\nPt remains on full vent support. MV being maintained in the 10-13L range. Trach changed to # 8 portex non-fenestrated. Cuff pressure 30. Minimal leak. BS with occ rhonchi. Suctioning thick tan sputum.\n"},{"category":"Nursing/other","chartdate":"2129-08-24 00:00:00.000","description":"Report","row_id":1624127,"text":"resp care - Pt is and on PSV. No changes were made in vent settings this shift. Pt was suctioned for moderate to copious amounts of thick, yellow secretions. Meds were given as ordered. Plan is for transfer to rehab.\n"},{"category":"Nursing/other","chartdate":"2129-08-24 00:00:00.000","description":"Report","row_id":1624128,"text":"0700-1900\nneuro: awake, alert, follows some commands, pt very withdrawn, , po celexa started, moves extremites on bed, pt very weak\n\ncv: hr a-fib, rare pvc, sbp stable(117-137), po lopressor\n\nresp: no vent changes, continues on 40% cpap ps, sux sm/mod amt loose thick yellow , bs+ all lobes, course, decreased to bases, inhalers by R.T., no resp distress noted\n\ngi: goal TF well, no N/V or stool, iv protonix \n\ngu: foley patent, clear yellow urine, good uo, iv lasix \n\nother: daughter in & updated on pt's condition, no c/o pain\n\nplan: continue with ventilatory support, po antibiotics as ordered, tx to rehab when bed available\n\n\n"},{"category":"Nursing/other","chartdate":"2129-08-24 00:00:00.000","description":"Report","row_id":1624129,"text":"FULL CODE Contact precautions\nAllergies: Haldol, heparin (+HIT)\n\n\nNeuro: AA, occ follows commands, nods approp to questions.\n\nCV: HR=90-100s, afib. BO=120-140s/50s. +palp pedal pulses. +generalized edema.\n\nResp: Trach CPAP 40% w/ 02sat 98%. Lund w/ crackles in RLL and LUL/LLL, RUL clear. lasix 20mg IVP given as scheduled. RR=22-28. Sx for yellow .\n\nGI/GU: Abd soft/distended, +BS. TF Replete w/ Fiber at 80cc/hr=goal w/ min resid. Large soft-formed BM. Foley cath w/ amber clear urine.\n\nPain: denies discomfort by shaking head \"no\" to question.\n\nSkin: generalized edema. Allevyn dressing intact on upper back.\n\nAccess: R rad a-line and R antecub PICC double lumen. IVF infusing via one port and second port is difficult to flush.\n\nPlan: rehab placement. Continue to monitor resp/cardiac/neuro status. Wean vent as . Update family on status.\n"},{"category":"Nursing/other","chartdate":"2129-08-25 00:00:00.000","description":"Report","row_id":1624130,"text":"Resp Care\nRemains and ventilated on cpap/psv wiht no remarkable changes overnight. ABGs within normal limits but maintained with high minute ventilation. Albuterol/atrovent inhalers given q4. Suctioned for thick yellow . = 109.\n"},{"category":"Nursing/other","chartdate":"2129-07-15 00:00:00.000","description":"Report","row_id":1624055,"text":"MICU NPN 11AM-7PM:\nEvents of the day:\n\nTrach changed at bedside, upsized to #8 portex no-fenestrated trach. Tolerated this well with 100mcg IV fentanyl.\n\nTransfused with one unit PRBC's over three hours tolerated well. Post hct up to 23.5 from 21.8. Please recheck hct at 2200.\n\nVanco IV added to antibiotic regimen.\n\nNeuro: Sleepy after given the fentanyl for the trach change but more awake and seems restless this afternoon. Nods head to simple questions. Hates to have his PO temp checked. Tylenol given once for generalized discomfort.\n\nCV: Vital signs are essentially stable but BP noted to drop to 90's after getting PO diltiazem. HR 90-110 a-fib w/PVC's noted. BP 90-130/60.\n\nResp: Vent currently on AC 20, 500TV 40% FIO2 with 8cm peep. Less air leak noted after trach change. Trach care done twice for small amts bleeding around site after changing trach. Moderate amts thick tan/bloody secretions. Lungs coarse and deminished throughout.\n\nGI: Tolerating tube feeds at goal. No stool. Abdomen is soft non-tender.\n\nGU: Voiding good amts via foley catheter. Lasix stopped because creatinine rising slightly.\n\nID: Low grade fever this afternoon. On vanco/Immepenum IV.\n\nSocial: Daughter updated by Dr. at length today.\n\nEndo: Blood glusose running 150's and no sliding scale ordered unless glucose is greater than 160.\n\nPlan: Holding off on further aggressive diuresis in hoped that creatinine settles down, follow hct this eve at 2200 with goal hct >21. Continue to follow vital signs closely and keep pt/family involved in plan of care.\n\n\n\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2129-08-23 00:00:00.000","description":"Report","row_id":1624120,"text":"MRSA and VRE precautions\n\nNeuro: pt responds to verbal stimuli by opening eyes.. sometimes it looks he follows you with his eyes, but does not respond when asked to shake his head, wiggle his toes or move his extremities\n\nResp: vented and , see Flow Sheet for increased settings D/T rapid RR's acidotic ABG, ABG better with changes, lungs coarse bilat and diminished at bases, suctioning for thick tan secretions\n\nCardiac: hypotensive at times, fluid challange X1 with good results, afib with rare to frequent PVC's, repleated K+ X1\n\nGI: + BS, + medium soft brown BM X1, TF at goal, no residuals\n\nGU: foley to gravity, good output with lasix, VRE of urine\n\nEndo: SSRI per \n\nsocial: family called and updated X1\n\nPlan: follow labs and vitals and treat as indicated and as ordered, OOB with , ? screen for rehab, MRSA and VRE precautions\n"},{"category":"Nursing/other","chartdate":"2129-08-23 00:00:00.000","description":"Report","row_id":1624121,"text":"RESP CARE: Pt remains /on vent, settings per carevue. PS increased for hypercarbia. AM ABG improved. Lungs coarse bilat. Sxd small amts thick yellow. AM -148. Pt remains vent dependent\n"},{"category":"Nursing/other","chartdate":"2129-08-23 00:00:00.000","description":"Report","row_id":1624122,"text":"0700-1500\nneuro: awake, alert, follows most commands, moves extremities on bed, pt very weak\n\ncv: hr a-fib, no ectopy, sbp stable(119-137), po lopressor\n\nresp: continues on 40% cpap ps, bs+ all lobes, course, diminished to bases, sux sm/mod amt loose thick yellow , inhalers by R.T., sat 100, no resp distress noted\n\ngi: goal TF well, no N/V or stool, po colace, iv protonix increased to today(am hct 22.7), GI consult in, giuac neg brown stool noted via rectal exam\n\ngu: foley patent, clear yellow urine, good uo, iv lasix \n\nother: type & screen sent today, pt to get tx with 2 u pc's when blood products ready, no c/o pain\n\nplan: continue with ventilatory support, po antibiotics as ordered, tx 2 u pc's, continue rehab discharge planning\n"},{"category":"Nursing/other","chartdate":"2129-08-23 00:00:00.000","description":"Report","row_id":1624123,"text":"resp care - Pt is and remains on PSV. No changes made this shift. BLBS are coarse; pt was suctioned for varying amounts of thick, yellow secretions. Transfer to rehab planned for tomorrow.\n"},{"category":"Nursing/other","chartdate":"2129-08-23 00:00:00.000","description":"Report","row_id":1624124,"text":"3p to 7p: did get 2 units of blood, vitals wnl's, placed bed on automatic side to side turn, no other changes; plan: ? rehab in am.\n"},{"category":"Nursing/other","chartdate":"2129-08-24 00:00:00.000","description":"Report","row_id":1624125,"text":"Respiratory Care\nPt on vent support. no vent setting changes made this shift. ABG WNL, but maintained by large minute ventilation. Sx for mod to lg amounts thick yellow secretions. BS mostly clear. AM 106.\nPlan is to discharge pt to rehab facility, possibly later today.\n"},{"category":"Nursing/other","chartdate":"2129-07-10 00:00:00.000","description":"Report","row_id":1624031,"text":"Nsg.admission notes 2130-0700hr\n\nAllergies:HALDOL,HEPARIN.(heparin induced thrombocytopenia)\n\n79yo male pt from HC,third admission to , and vented,vent dependent from ,a case of TCP,depression,s/p valvuloplasty,pleural effusion,MRSA PNA,T9 compression Fx,c to MICU for increasing lethargy ,temps,VAP and also family request.blood c/s +ve staph,sputum c/s +ve pseudomonas,was on vanco,may need to continue ,started meropenam.\n\nNeuro:alert,responding to call and commands,not mouthing words.lethargic.generalised edema.\n\nResp:,vented,AC,14/450/10/405.SATS >95%.suctioned thick yellow secretions.sputum c/s sent.LS coarse throughout.\n\nCVS:HR 100-120's,ST-NSR.no ectopics noted.received 2unit blood transfusions in for low crit.Blood c/s 2 samples sent.Blood gas done .pneumoboots to be applied.both LE black coloured,more on Lt.leg.boots on,pulse easily palpable on Rt leg,and difficult on left leg.\n\nGU/GI:abdomen obese,bowel sounds hypo,PEG ,site cleaned and dressing applied.NPO.Had BM,large black loose stool.on foley cath,amber clear urine.received 20mg iv lasix with minimum effect\n\nIntegu:skin impaired on spine,duoderm .temps 101.3 on admission.sponge bath given and positioned.\n\nSocial:no family contact or during the shift.MRSA on contact precautions.full code.\n\nIV access:PICC on Rt ante cub,red port is patent,flushing well and good blood flow,purple port unable to flush,informed ,may need TPA to maintain patency.\n\nEndo:on SSI,Not covered.\n\nPlan:pulmonary toilet.\nantibiotics,Temp's,and control infection.\n"},{"category":"Nursing/other","chartdate":"2129-07-10 00:00:00.000","description":"Report","row_id":1624032,"text":"Resp Care\nPt transfer from OSH. placed on vent ( see carvue for settings) Pt has a # 7 shiley trach. suctioned for thick copious blood tinged pluggy secretons, sample sent. Xray show, bilateral infiltrates and small lung fields. High Hco3 and Paco2 in abgs. Decreased fio2 and increased peep to help in ventilaton. Mdis started: notable decrease vent pressures. Will continue to monitor.\n"},{"category":"Nursing/other","chartdate":"2129-07-10 00:00:00.000","description":"Report","row_id":1624033,"text":"Respiratory Care:\nPt remains and vented. PEEP decreased to 5 from 10 d/t hypotension.ABG showed non-compensated metabolic alkalosis with mild hypoxemia. Lung sounds coarse. Suctioned moderate to copious thick yellow secretions. MDIs given per order. Will follow.\n"},{"category":"Nursing/other","chartdate":"2129-07-24 00:00:00.000","description":"Report","row_id":1624091,"text":"\u0013npn 7p-7a (please also see careevue flownotes for objective data)\n\nAfebrile, vss; v-response remains in 80's, diltiazem held approx every other dose, receiving approx q 12 hrs instead of q 6 hrs;\n\ndx: sepsis; resp failure; transfer from \n\nOn A/C from approx 22:00-05:30; switched to PS again at 05:30;\n\nMajor goal at this time is to continue diuresing this pt; lasix gtt at 4 mg/hr most of this 12 hrs, decreased from 5/hr at 19:00, for fear of diuresing too fast;\n\nPt continues to receive K+ supplement d/t loosing 2/t lasix being non K+ sparing;\n\nReceiving Gargine at HS; FS's have been in good range;\n\nPt more alert and responsive with eye contact/tracking, smiles, gestures; did not sleep much this night;\n\nPLAN:\nContinue current POC;\nfurther plan per rounds\n\n\n"},{"category":"Nursing/other","chartdate":"2129-07-15 00:00:00.000","description":"Report","row_id":1624051,"text":"NPN 1900-0700\n79 yo ma s/p MVA , vent dependent since. Remains in a-fib, but off coumadin d/t drop in hct to 19.9.\n\nNeuro: Alert, awake, follows simple commands. Difficult moving extrem c lge amt edema. Does not appear to be having pain per VS, grimace scale and non-.\n\nCV: HR 102-112, a-fib c occ pvcs. SBP 102-158. Received 2 units pc yest for hct 19.9, up to 24, am lab pending. Received 3 u total FFP. K 3.8, repleted c 40meq kcl in 500mls.\n\nResp: Received on AC/40%/450x20/8peep. At 8pm, tachy and hypertensive to 158, RR 36. Sx few times, thick, bld tinged sputum. Desated to 88 x2. Peep incr to 10 and fio2 to 50% c improved VS. Pco2 up to 63, so TV incr to 500 and fio2 back to 40%. Sats cont 97 or > remainder of noc. pco2 down to usual 52. placed back on 8 pep at 0400, cont good sats and RR 25-30. LS coarse, sx ~q2-3 hrs.\nCont to have cuff leak on this trach, ? needs larger trach.\n\nGI: ABD obese, +BS. TF at goal of 50mls/hr via peg. Had one soft, black tarry stool, OB+, also passing flatus.\n\nGU: Receiving lasix 40mg c fair response. Urine yellow to amber, clear, adequate vols. Pt fld balance + 3.8L los.\n\nEndo: Receiving humalog for SSI, FS 228, and glargine.\n\nID: Tmax 100 ax. On miripenim and bactrim. MRSA prec.\n\nSkin: Duoderm intact on upper back pressure sore. Bilat lower legs ecchymotic, L>R. L foot colder than R. 3+ edema all extrem and body.\n\nSocial: Family will be in tomorrow, no calls tonight.\n\nPlan: Monitor RR, abgs, wean vent as . Replete lytes prn. ? further lasix.\n\n\n\n\n\n\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2129-07-15 00:00:00.000","description":"Report","row_id":1624052,"text":"Respiratory Care:\n\nPatient with 7.0 Portex. changed . Increased cuff pressure to 50cm/H20 to seal trach. Positional leak at times. Pt. desating to 88%. Sx'd for thick blood tinged secretions. O2 sats improving to low 90's. Peep ^ 10cm/Fio2 ^ 50% and later weaned back to now current settings. PaCo2 rising to 63. Vt ^ 500. Current settings Vt 500, A/c rate 20, Fio2 40% and Peep 8. ABG reveals compensated resp acidosis. BS coarse bilaterally. Albuterol/Atrovent MDI's given q4hr.\nSx'd for sm-moderate amounts of thick blood tinged secretions. No further changes made.\nPlan: Continue with mechanical support.\n"},{"category":"Nursing/other","chartdate":"2129-07-15 00:00:00.000","description":"Report","row_id":1624053,"text":" 4 NURSING PROGRESS NOTE 0700-1100\nNEURO--PT ALERT, NODDING HEAD TO SIMPLE QUESTIONS. SQUEEZES HANDS TO COMMAND. PT IS VERY STIFF AND NEEDS ASSIST OF 3 PERSONS TO TURN. PT WANTS TO WATCH RED SOX AT 1100.\n\nCARDIAC--REMAINS IN AFIB WITH RATE 90-110. RARE UNIFOCAL PVC'S. RECEIVED KCL REPLACEMENT THAT WAS STARTED ON NIGHTS. HCT DOWN TO RECEIVE 1U PRBC.\n\nRESP--SX Q2 HRS FOR THICK TAN SPUTUM. REMAINS WITH CUFF LEAK. PLAN IS TO CHANGE TRACH LATER TODAY. BILATERAL BREATH SOUNDS ARE COARSE. SAO2 >97%.\n\nGI--. TUBE FEEDS AT GOAL. STOOL X1. ABD DISTENDED. +BS. STOOL IS BLACK , TARRY AND GUIAC +.\n\nGU--FOLEY CATH PATENT. RECEIVED 40 MG IV LASIX WITH GOOD DIURESIS.\n\nENDO--UNREMARABLE AT PRESENT.\n\nSKIN--DUODERM ON BACK INTACT. BUTTOCKS WITHOUT BREAKDOWN. ORAL CAVITY DRY.\n\nPAIN--DENIES PAIN WHEN ASKED.\n\nID--AFEBRILE. REMAINS ON ABX.\n\nCOPING--NO FAMILY MEMBERS HAVE PHONED OR AS OF THIS TIME.\n\nA--LEAK IN TRACH. FALLING HCT.\n\nP--TX 1 U PRBC. CON'T TO MONITOR. ? WHETHER TO SCOPE TO FIND SOURCE OF BLEED.\n"},{"category":"Nursing/other","chartdate":"2129-07-24 00:00:00.000","description":"Report","row_id":1624092,"text":"resp care\nPt initially on psv25/peep5 and 40%. Changed to a/c to rest overnight after pt c/o of sob. BS coarse bil. Suct for thick yellow sput.Alb/atro mdi given as ordered. Fio2 weaned to 30% per order. done >100. Will cont to follow.\n"},{"category":"Nursing/other","chartdate":"2129-07-24 00:00:00.000","description":"Report","row_id":1624093,"text":" enetered @1400 on was actually done at 0600. Data could not be entered due to time restrictions in carvue. No value for because numver > than limit of formula value. (JP).\n"},{"category":"Nursing/other","chartdate":"2129-07-24 00:00:00.000","description":"Report","row_id":1624094,"text":"Resp Care\n\nPt placed on cpap/psv during at 1630 while up in chair. On a/c minute volume being maintained in th 9-10L range. BS with scattered rhonchi and suctioning thick yellow .\n"},{"category":"Nursing/other","chartdate":"2129-07-24 00:00:00.000","description":"Report","row_id":1624095,"text":"NPN 0700-1900\nFull code All: Haldol\n\nNeuro: Alert, appears oriented, participating in mouth care, interactive with staff/family although less so than yesterday. Of note, pt reportedly had very little sleep overnoc so that may be why he is less animated today. Afebrile\n\nCV: Stable. Afib, rare to occasional PVC's, rate consistently in 80's/90's. SBP 89-1teen's with MAP>61 throughout shift. Lasix gtt remains @ 4mg/hr. + pitting edema remains in extremities despite diuresis. Denies CP.\n\nResp: Alternating PS and CMV. Currently OOB in chair and tolerating CPAP @ 30%/. Frequent sxn for small amts white to yellow , also pt continues to cough up mucous on his own. Appears to be slightly less productive than . Will attempt deep brthing if encouraged.\n\nGI/Endo; TF well @ 50cc/hr. FS @ 1800 58 mistakenly left off since OOB to chair. amp D50, MD aware. Glargine has been decreased to 28units @ HS. BM x2 soft, brown, guaiac +.\n\nLines: PICC in R patent, dressing changed today.\n\nSocial: one daughter , another daughter/soninlaw phoned/\n\nPlan: Continue diuresis, pt will be able to dispo when fluid removed\n PS as \n RISS/ TF\n Encourage c/db, interaction\n\n"},{"category":"Nursing/other","chartdate":"2129-07-25 00:00:00.000","description":"Report","row_id":1624096,"text":"npn 7p-7a (please also see carevue flownotes for objective data)\n\ndx: sepsis; resp failure/vent dependency\n transfer from for lethargy, persistent fevers\n\n79M w/ pmhx AS s/p valvuloplasty, IDDM, PAF, MRSA pna and c-diff, MVA w/ long hospitalization and Hosp in VT, w/ long hosp course resulting in trach/PEG ;\npt has also been having chronic anemia, family has declined colonoscopy;\n\n recently discharged from after being admitted for hypotension, fevers; Pt was discharged to for further tx and abx, completed abx , spiked fever , abx started/re-started; cx's sent, cx w/ evidence of pseudomonas; pt also w/ episode rapid a-fib, started on diltiazem;\n\n pt returned to per request of family, admitted to 4, for lethargy, fevers, w/u. Has been receiving abx, IVF hydration.\n\nMost recent goal have been for pt to wean from A/C/ vent assist to PS, pt has been needing assist to diurese excesss body fluids;\npt has tremendous interstitial edema, skin taught;\nresp cx's & 21 both + pseudomonas\n\ntoday pt remains on lasix at 4 mgs per hour, with good hourly ourput of 100-160 cc/hr; also continues to received K+ supplementation, this a.m.'s serum K+ is 3.8, same as yesterday eve draw at 19:00--pt received 40 mEq KCL after result available.\n\npt ordered for diltiazem 30 mg po q 6 hrs, has been having good v-response control, has been receiving approx q 12 hrs d/t held doses re b/p given effect of diuresis also on b/p;\n\nduoderm dressg on mid upper back intact, dated ;\nRt a.c. double lumen PICC drssg intact, both ports intact;\n\ntolerating tube feedings w/out emesis or diarrhea;\nhas been stooling mod soft stools;\nblood sugars/FS have been decreasing, pt may need more decrease on hs glargine (was decreased by 2 units )\n\nOOB to reclining chair about 2 p.m. , returned to bed per approx 22:30;\n\npt has been more alert/interactive the past two days, remains nonverbal, but w/ more eye contact and facial expressions/smiles;\n\nfamily has asked staff regarding a 'percutaneous valvuloplasty procedure' they had looked up and found on in the internet; MDs state does not do that procedure, family stated they will look for a hospital that does and will accept pt; in the meantime, reportedly plan is to continue to diurese pt to assist wean on vent, and continue w/ discharge planning--?return to ;\n\nPLAN:\n1) continue current POC\n2) diuresis, goal approx 100 cc/hr\n3) cont to wean on vent, progressing to more time on PS instead of A/C\n4) electrolyte repletion as needed and as ordered\n5) follow FS's, ? decrease glargine dose hs\n6) OOB to cardiac/reclining chair during the day per lift\n7) CT surgery consult in a.m. 8/27 per family's request\n8) MRSA precautions, s/t hx MRSA pna\n9) pt remains FULL CODE\n10) family coomunication: daughter , has been making some decisions re pt's care, even though not official HCP\n11) labs only q 24\n"},{"category":"Nursing/other","chartdate":"2129-07-25 00:00:00.000","description":"Report","row_id":1624097,"text":"(Continued)\n hrs if possible, to avoid blood loss d/t anemia\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2129-07-25 00:00:00.000","description":"Report","row_id":1624098,"text":"resp care\nPt initially on psv25/peep5 and 30% while up in the chair.Placed back on a/c 500x20 5peep 30% when placed back in bed.Peak/plat 34/28. BS coarse at times. suct for thick pale yellow sput. Alb/atro mdi given as ordered.Will cont to follow and wean back to psv when in a chair. >100.\n"},{"category":"Nursing/other","chartdate":"2129-08-22 00:00:00.000","description":"Report","row_id":1624116,"text":"NEURO: PT ALERT, DOZED ON/OFF THIS SHIFT, AROUSES TO VOICE EASILY. VISUAL ACKNOWLEDGEMENT OF CAREGIVER, BUT WITHDRAWN-VERY LITTLE INTERACTION. FOLLOWS COMMANDS INCONSISTENTLY-SQUEEZED RT HAND X1, OTHERWISE NO COMMANDS FOLLOWED. RESISTS MOUTH CARE, CLENCHING TIGHTLY. EXTREMITIES TENSE DURING SIDE TO SIDE TURNS. NO OBJECTIVE INDICATIONS OF PAIN-ASSESSED BY VITALS & GRIMACE.\n\nCV: AF, HR 70s-80s. ? START COUMADIN. BP 100s-110s, UP TO 150s W/ACTIVITY OR WHEN SXN'D. +PP. EXTREMS W/D. COMPRESSION SLEEVES ON. AFEBRILE.\n\nRESP: LS COURSE BILATERALLY, O2SATS >97%. NO VENT CHANGES THIS SHIFT-REMAINED ON CPAP/PS 40/5/10. TV 300s-500s. RR 20s-30s. OCCAS. SXN'D SM-MOD AMTS THK YELLOW SECRETIONS. TRACHE CARE DONE BY RT. SEE CAREVUE FOR LATEST ABGs.\n\nGI/GU: TOLERATING FS REPLETE W/FIBER @ GOAL=80cc/hr VIA PEG; NO RESIDS. +BS. ABD SOFT, NT, ND. LG BROWN SOFT FORMED STOOL X1. HUO ADEQUATE, CLR YELLOW W/SEDIMENT.\n\nENDO: RSSI PER SS-COVERAGE REQUIRED OVERNOC.\n\nSOCIAL: ? PLAN TO D/C TO REHAB . D/C PAPERS TO BE COMPLETED. NO TELEPHONE CALLS FROM FAMILY THIS SHIFT.\n\nPLAN: CONTINUE MONITORING CARDIORESP STATUS, LABS. PULM TOILET. ?START COUMADIN; ? TRANSFER TO REHAB , COMPLETE D/C DOCUMENTS. SUPPORT/UPDATE FAMILY RE: PLAN OF CARE.\n\n\n"},{"category":"Nursing/other","chartdate":"2129-08-22 00:00:00.000","description":"Report","row_id":1624117,"text":"RESP CARE: Pt remains /on vent on PSV 10/5/.40. Vts 300s/RR 30s.Lungs rhonchi L>R. Sxd small amts thick yellow . MDIs given per POE with little effect noted. AM -126.\n"},{"category":"Nursing/other","chartdate":"2129-08-22 00:00:00.000","description":"Report","row_id":1624118,"text":"Respiratory Care\nPt weaned on PSV to attempts to wean to resulted in a PH of 7.29, psv increased to with resulting abg 731/59/83/31/0/94. mdi as ordered, suctioned for mod amts of frofty white secrections. Pt planning on going to rehab. ? tommorrow.\n"},{"category":"Nursing/other","chartdate":"2129-08-22 00:00:00.000","description":"Report","row_id":1624119,"text":"Neuro: More alert in PM, still blank stares @ speaker, not follwoing any commands, LE's withdraw to nail bed pressure bilat, but not UE's; PERRL 3mm brisk\n\nCV: Afberile, A fib 80's, SBP labile, 80's when sleeping, hypertensive to 170's when family is here, lopressor dose changed to 25mg TID, weak palpable pulses x4, 1 episode of hypotension after vent change in PM, 250 ml NS fluid bolus given with effect; K repleted; no coumadin NP \n\nResp: Lung coarse all over, received on CPAP , wean PS to 5 @ one point, became more acidotic, PS @ 8 currently, ABG acceptable, Pa CO2 @ pt's baseline; suctioned with thick tan secretion\n\nGI: Abd soft, non-tender, BM x3, soft, brown formed stool, tolerating TF replete with fiber @ goal 80 ml/hr, minimal residual\n\nGU: Foley draining clear/sedimentary yellow urine, restarted on lasix 20 mg , foley changed today due to +urine culture for VRE on specimen\n\nPain: no pain noted\n\nEndo: COver per CSRU protocol\n\nID: +VRE in urine from specimen, foley changed\n\nInteg: upper back wound assessed by wound care nurse, allevyn dressing changed, wound healing per wound care nurse\n\nActivity: OOB to chair via for 2 hours\n\nSocial: Daughter in for visit, met with NP , agreed to look @ Rehab today\n\nPlan: Monitor hemodynamics, resp status, labs; wean vent as ; DC planning; wound care\n\n"},{"category":"Radiology","chartdate":"2129-08-12 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":978512,"text":" 5:56 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: pleural effusion, pulmonary edema, tamponade, pneumothorax,\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with AVR\n REASON FOR THIS EXAMINATION:\n pleural effusion, pulmonary edema, tamponade, pneumothorax, Page \n with issues. . Pt will be in csru in 90 minutes.\n ______________________________________________________________________________\n WET READ: JRCi 10:54 PM\n tracheostomy tube removed and patient intubated with ETT in adequate\n position. There is increased lung volumes and aeration. Swanz ganz catheter\n with tip in the expected region of the main pulmonary artery. Right picc line\n with tip in SVC. No pneumothorax. Small left effusion . Interstitial\n opacities remain.\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Pleural effusion, pulmonary edema.\n\n A single AP view of the chest is obtained on at 1815 hours and\n compared with the prior afternoon's radiograph. Allowing for technical\n differences, there likely is no significant change in the appearance of the\n bilateral alveolar and interstitial opacities and likely bilateral pleural\n effusions. Tracheostomy has been replaced with an endotracheal tube, the tip\n of which is approximately 4 cm above the carina. Swan-Ganz is present with\n its tip in the main pulmonary artery. Patient has just had a cardiac surgery\n with sternal and skin sutures present. A right-sided PICC line is unchanged\n in position.\n\n IMPRESSION:\n\n Stable appearance to the chest with bilateral interstitial and alveolar\n opacities. Intubation with ET tube in satisfactory position.\n\n\n"},{"category":"Nursing/other","chartdate":"2129-07-19 00:00:00.000","description":"Report","row_id":1624070,"text":"Pt is on AC vent RR 20, New # 8 with water cuff is in place, marker is . There is no identifyable leak but Vte is lower than VTi. Pt getting alb/atr MDI Q 4 hrs. Pt sx for smal amts yellow secretions.\n"},{"category":"Nursing/other","chartdate":"2129-07-19 00:00:00.000","description":"Report","row_id":1624071,"text":"Respiratory Care\nPatient remains on full ventilatory support. Suctioning moderate amounts of thick yellow secreations. MDI's given as ordered. Breath sounds coarse throughout. Transported without incident to CT for scan of the head.\n"},{"category":"Nursing/other","chartdate":"2129-07-19 00:00:00.000","description":"Report","row_id":1624072,"text":"NPN 0700-1900\nNeuro: Alert for most of day, continues to have flat affect, be minimally interactive. ?visual field defect, head ct w/o contrast neg. Will move L hand purposefully. Strong gag/cough effort. Afebrile.\n\nCV: Afib, occasional PVC's each hour, HR consistently 80's-90's. Rate controlled with Dilt 30mg QID, noon dose held for BP<100, 1800 dose administered. HR up slightly as pt has begun to cough more in late afternoon. 3+ pitting edema in all extremities but +PP's b/l. SBP>90 all shift. Cardiolgy to consult re: AS and how to maintain intravascular vol, fluid shifts.\n\nResp: A/C 40%, TV 500, Peep decreased to 5 today. LS coarse throughout, increasing creamy/thick secretions this afternoon, Dr aware. Trach site clean\n\nGI: Obese abd with pos bs, no TF residuals. TF Nutren Pulm FS at goal of 50cc/hr. Soft dark brown stool mod x2, guaiac pos.\n\nGU: Patent foley draining amber colored urine with occasional sediment 2 >30cc/hr. Lasix gtt off.\n\nID: ABX changed today to Cefepime, first dose done, continuing on Vanc\nLine: PICC patent, dressing CDI and not to be changed until \nSocial: no family contact this shift\n\nPlan: Sxn prn\n Monitor and support hemodynamics, Dilt for rate control\n Turn q2h\n IV abx as ordered\n\n\n\n"},{"category":"Nursing/other","chartdate":"2129-07-20 00:00:00.000","description":"Report","row_id":1624073,"text":"Nsg Progress Note 1900-0700\n\nCV - Pt hemodynamically stable. BP drops to 90's sys after med with ativan but returns to normal shortly. IVF at KVO via right AC PICC line.\n\nResp - BS course bilat. Remains on a ventilator with no changes to settings. Pt initially suctioned for mod to large amt creamy secretions. Amount of secretions decreased signif over course of the night. spec sent.\n\nGI - Abd soft - hypoactive BS. No BM. Tolerating TF's very well. Continues to recieve H2O bolus q 4 hours.\n\nGU - Foley cath draining adequate amt cl yellow urine. Scrotum grossly edematous.\n\nNeuro - Pt able to communicate with nods. Does not move extremities on his own. Pt denies pain but did request ativan so he could rest.\n\nSocial - no contact from family.\n\nSkin - turned as tolerated - no signs of breakdown noted. Back dsg dry and intact.\n\nDr. would like to speak to the family when they come in.\n\n"},{"category":"Nursing/other","chartdate":"2129-07-20 00:00:00.000","description":"Report","row_id":1624074,"text":"Respiratory Care:\n\nPt remain on full/ assist ventilatory support via traheotomy tube ( TTS ~12 cm; water seal). No vent changes done. He was unable to complete , ask for exemption. BS are coarse bil, No wheezes. MDI's adm as ordered with No changes noted in BS. We are sxtn for scant to mod amt of thick whitish to yel secretions, active cough. Plan: awaiting family meeting & will Continuen present ICU monitoring. Will follow.\n"},{"category":"Nursing/other","chartdate":"2129-07-21 00:00:00.000","description":"Report","row_id":1624081,"text":"Respiratory care\n\n Pt continues on full ventilatory support. Sx'd for sm thick yellow. MDI's as ordered. Will continue to follow closely.\n"},{"category":"Nursing/other","chartdate":"2129-07-21 00:00:00.000","description":"Report","row_id":1624082,"text":"REVIEW OF SYSTEMS:\nRESP: BRIEF CHANGE OVER TO PS THIS AM-POOR TOLERANCE. NO FURTHER VENT CHANGES. SUCTIONED FOR THICK YELLOW SECRETIONS, COPIOUS AT TIMES. SATS REMAIN IN HIGH 90'S.\nGI: TF'INGS WELL. NO STOOL TODAY. MIN RESIDUALS. \u0013\nRENAL: CONT. ON LASIX GTT, BUT TITRATED TO BP. OFF BRIEFLY FOR BP IN 70'S BUT RESTARTED SOON AFTERWARDS. PRESENTLY AT 2MG/HR. U/O'S RANGING FROM 80CC-240CC/HR. PT. STILL 4+ EDEMATOUS.\nCV: BP FAIRLY WELL CONTROLLED X FOR BRIEF DROP. REMAINS IN AF WITH GOOD RATE CONTROL WITH DILT. OCCASS PVC'S.\nENDOC: K+ 3.7 AND REPLETED WITH 40MEQ KCL VIA PEG. NO SSI REQUIRED.\nID: PEG DRSG -PURELENT DRAINAGE NOTED-SENT FOR CX. CONT. ON ANTIBIOTICS. ESS. AFEBRILE.\nNEURO: WITHDRAWN. NODS APPROPRIATELY AT TIMES. ABLE TO MOVE DIGITS WHEN ASKED AND DID RAISE HIS LEFT ARM ON HIS OWN THIS PM.\nHEM: HCT SLIGHTLY DECREASED FROM YESTERDAY.\nSOCIAL: NO CONTACT FROM FAMILY TODAY.\nPLAN: NEEDS PT CONSULT TO HELP WITH TRANSFER TO CHAIR.\n"},{"category":"Nursing/other","chartdate":"2129-07-22 00:00:00.000","description":"Report","row_id":1624083,"text":"Nursing Note:\n\nNeuro: pt awake most of night, appears withdrawn, nods head occasionally and inconsistantly follows commands, would not sqeeze hands on request, and occasionally cooperative w/ mouth care. some movement of left arm and legs noted. received 0.5 mg ativan prn overnight.\n\nResp: remains w/ vent support. vent AC 20/500 PEEP 5, FIO2 0.40. sats 95-100. suctioned for sm/moderate thick tan. LS clear and diminished w/ some upper airway congestion noted prior to suctioning.\n\nCV: HR 85-95 afib w/ occ. tolerated 30mg PO diltiazem well overnight. PVC's. NBP 90-120/50-70. tmax 99.3. generalized +3 edema. pos distal pulses.\n\nGU: remains on lasix gtt @ 2mg/hr. foley output 60-200cc/hr clear yellow.\n\nGI/Endo: abd firm/distended. pos bowel sounds, TF at goal of 50/hr, minimal residuals (<5cc). received dose of lantus insulin overnight, no coverage w/ RISS. no BM as of present overnight.\n\nIV: left brachial PICC remains WNL.\n\nSkin: duoderm intact on wound on upper back, no further skin breakdown noted. repositioned off back.\n\nSocial: no contact from family overnight.\n\nPlan: continue to monitor resp status (trach site, suctioning), hemodynamics, mental status, labs.\n\ncont. to monitor urine output and lasix gtt.\n\n? need for PT consult r/t immobility.\n"},{"category":"Nursing/other","chartdate":"2129-07-22 00:00:00.000","description":"Report","row_id":1624084,"text":"RESPIRATORY CARE NOTE\n\nPatient remains with TTS adjustable length trach tube. This is a sterile H2O cuff. No vent changes made during the night. Unable to complete d/t tachypnea on PS 5. Sxn for scant to small amount thick yellow secretions. Plan to wean as tolerated.\n\n , RRT\n"},{"category":"Nursing/other","chartdate":"2129-07-22 00:00:00.000","description":"Report","row_id":1624085,"text":"Respiratory Care Note\nPt received on AC as noted. BS diminished and coarse bilaterally which clears with suctioning. MDI's given a/o - MDI's changed to prn. Pt suctioned for moderate amts thick, yellow secretions. Attempted PSV 22/5 at 12noon, but placed pt back on AC secondary to tachypnea with a RR 38-40 and VT 275-300. Attempted PSV again at 4pm and increased PEEP to 8cm with the same result. Pt is now on AC. Plan to continue on current settings at this time.\n"},{"category":"Nursing/other","chartdate":"2129-07-22 00:00:00.000","description":"Report","row_id":1624086,"text":"NPN 0700-1900\nFull code All: Haldol\n\nNeuro: Alert throughout shift, occasional nod, participated in mouth care today. Minimally interactive w/ daughter and son when they today. Moves LUE only, good cough/gag. Lowgrade temp throughout shift of 99+ ax.\n\nCV: HR in 90's to low 100's, afib with occasional PVC's. SBP>95. Diuresing gently with Lasix gtt, currently @ 3mg/hr. 3+pitting edema in all extremities, + and easily palpable pp's b/l\n\nResp: A/C 40%/5Peep, TV set @ 500--pt vols running 375-450ml/breath. Continues to have thick white-tan secretions which he can cough up but sxn'd q2h. LS clear to coarse upper, diminished @bases w/occasional wheeze.\n\nGI/Endo: Firm distended abd w/+BS. Guaiac + dark brown-green stool x2 today. TF remain 2 goal of 50cc/hr w/ no residual. Required no additional insulin coverage today.\n\nGU: Patent foley draining dark yellow urine with some sediment at >40cc/hr. Titrating Lasix for u/o of ~100cc/hr.\n\nSkin: CDI\n\nSocial: Family meeting today. Family wishes to continue aggressive care. Believe pt is a candidate for a type of percutaneous cardiac repair not done @ and hope to find another facility that performs procedure and is willing to accept pt. Hence, pt remains full code.\n\nPlan: Monitor afib/BP's, Dilt as ordered as \n Monitor resp status, sxn prn\n ROM of extremities, PT reviewed case and pt not candidate for PT care\n OOB to chair as \n Glargine HS, RISS\n Encourage interaction\n"},{"category":"Nursing/other","chartdate":"2129-07-20 00:00:00.000","description":"Report","row_id":1624075,"text":"Nursing progress note: Full Code\n\nNeuro: able to communicate needs w/ nods. Does not move any of his exts. OOB to chair w/ lift. Denies any pain, no ativan given for my shift.\n\nPulm: PSV 23/5, Suctioned for thick yelllow secretions q-23hrs in small-moderate amts. RR regular. Maintaining stable svo2.\n\nCV: Afib w/ HR 89-108, BP 96-68 - 148/71. Afebrile. Gross generalized edema. Restarted lasix gtt at 2mg/hr. + palp. peripherial pulses x 4.\n\nGI/GU: + hypoactive bs. Abd is soft, distended. NT. TF'ing of nutren pulmonary at goal rate (50cc/hr), tolerating well. BM x 2 of dark black soft stool guaiac +. Scheduled for colonscopy and needs to be prep'd onced back in bed w/ golytley. Foley w/ uo > 30cc/hr on lasix 2mg/hr.\n\nSKIN: Back dressing in place. NO other breakdown noted.\n\nAccess: PICC line to RAC\n\nSOCIAL: Family meeting w/ Dr. today. Updated about pt. condition and plan of care.\n\nPLAN: Monitor per protocol. Replete lytes as needed. HCT up to 26.9.\n"},{"category":"Nursing/other","chartdate":"2129-07-20 00:00:00.000","description":"Report","row_id":1624076,"text":"Resp. care note - Pt. remaines and vented, weaned to PSV then placed back on AC for SOB.\n"},{"category":"Nursing/other","chartdate":"2129-07-20 00:00:00.000","description":"Report","row_id":1624077,"text":"Addendum:\n\nGolytly prep cancelled for tonight due to daughter refusing to consent for colonscopy at this time. Will readdress in am w/ Dr. . Pt. back to bed via . HCT up to 25.9. Tolerating lasix gtt at 2mg/hr w/ adequate uo.\n"},{"category":"Nursing/other","chartdate":"2129-07-21 00:00:00.000","description":"Report","row_id":1624078,"text":"NPN 1900-0700\nNeuro: Nods appropriately to questions at times, other times will barely nod. Moves LUE more than R, minimal movement of legs. Appears comfortable, denies pain. Slept off and on during noc. No ativan given.\n\nResp: On AC o/n, no changes, 500x20/40%/5. RR low 20s, regular, appears comfortable. sats 97-99, Sx q1-3hrs for sm-mod amt thick, yellow. Sx more freq when awake or after turning. LS coarse/clear upper, coarse/diminished lower.\n\nCV: HR stable 80s-90s, a-fib, occ pvcs, multifocal. SBP 88-125. Team increased lasix up to 6mg/hr, but said to drop it back if sbp dropped <90. Did drop dose a few times, but back up to 6mg currently. BP adequate for Dilt dose x2. Am hct 24.2 from 26.9, but in pts usual range. Afebrile. Repleted c 20meq kcl due to lasix.\n\nGI: +BS, abd soft,distended, nt. TF at goal of 50mls/hr, water 150 q4hrs. No stools this shift.\n\nGu: Foley c u/o 120-180mls/hr on lasix 6mg/hr, yellow, clear urine.\n\nskin: Back dsg changed, washed c saline, duoderm applied. Appears slightly improved. No dng. Few sm skin tears noted on abd and L arm, washed, open to air.\n\nAccess: L picc. Flushes ok but very difficult drawing bld from either port this am. Will request TPA from team.\n\nSocial: No calls o/n.\n\nPlan: Monitor am labs, replete lytes. watch sbp and map c lasix, may need to reduce dose. Cont to wean vent as .\n"},{"category":"Nursing/other","chartdate":"2129-07-21 00:00:00.000","description":"Report","row_id":1624079,"text":"Respiratory Care:\n\nPt remain on full ventilatory support. No vent changes. We are sxtn for small to mod amt of thick whiote secretions. MD team asked for NIF ~13 cmH20, thru vent. Plan: PSV trial. Will follow.\n"},{"category":"Nursing/other","chartdate":"2129-07-21 00:00:00.000","description":"Report","row_id":1624080,"text":"Addendum\n1mg TPA placed into blue port of cath at 0600. Additional 40 meq kcl given at 0600 for K of 3.6.\n"},{"category":"Echo","chartdate":"2129-08-19 00:00:00.000","description":"Report","row_id":83126,"text":"PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. H/O cardiac surgery. Left ventricular function.\nHeight: (in) 76\nWeight (lb): 266\nBSA (m2): 2.50 m2\nBP (mm Hg): 131/71\nHR (bpm): 84\nStatus: Inpatient\nDate/Time: at 11:27\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Marked LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). Increased AVR\ngradient.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve\nsupporting structures. Mild [1+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\nviews.\n\nConclusions:\nThe left atrium is markedly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nOverall left ventricular systolic function is normal (LVEF 70%). There is no\nventricular septal defect. Right ventricular chamber size is normal. Right\nventricular systolic function is normal. The aortic root is mildly dilated at\nthe sinus level. A bioprosthetic aortic valve prosthesis is present. The\ntransaortic gradient is higher than expected for this type of prosthesis. The\nmitral valve leaflets are mildly thickened. There is no mitral valve prolapse.\nMild (1+) mitral regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , the aortic valve has been replaced.\n\n\n"},{"category":"Echo","chartdate":"2129-08-12 00:00:00.000","description":"Report","row_id":83127,"text":"PATIENT/TEST INFORMATION:\nIndication: avr\nStatus: Inpatient\nDate/Time: at 13:51\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in the RAA.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thickness and cavity size. Mildly depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -\nhypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -\nhypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -\nhypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter. Normal descending aorta diameter.\nSimple atheroma in descending aorta.\n\nAORTIC VALVE: ?# aortic valve leaflets. Severely thickened/deformed aortic\nvalve leaflets. Severe AS (AoVA <0.8cm2). Mild (1+) AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. The TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\ncomplications.\n\nConclusions:\nNo spontaneous echo contrast is seen in the left atrial appendage. Left\nventricular wall thicknesses and cavity size are normal. Overall left\nventricular systolic function is mildly depressed (LVEF= XX %). Right\nventricular chamber size and free wall motion are normal. There are simple\natheroma in the descending thoracic aorta. The number of aortic valve leaflets\ncannot be determined. The aortic valve leaflets are severely\nthickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Mild\n(1+) aortic regurgitation is seen. The mitral valve leaflets are moderately\nthickened. Mild (1+) mitral regurgitation is seen. There is no pericardial\neffusion.\n\n\n"},{"category":"Echo","chartdate":"2129-07-18 00:00:00.000","description":"Report","row_id":83128,"text":"PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Left ventricular function.\nHeight: (in) 72\nWeight (lb): 242\nBSA (m2): 2.31 m2\nBP (mm Hg): 112/62\nHR (bpm): 92\nStatus: Inpatient\nDate/Time: at 15:03\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root.\nNormal ascending aorta diameter. Focal calcifications in ascending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS\n(AoVA <0.8cm2). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild [1+]\nTR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nGENERAL COMMENTS: Suboptimal image quality - ventilator. The rhythm appears to\nbe atrial fibrillation.\n\nConclusions:\nThe left atrium is elongated. There is moderate symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nTissue Doppler imaging suggests an increased left ventricular filling pressure\n(PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal.\nThe aortic root is mildly dilated at the sinus level. The aortic valve\nleaflets are severely thickened/deformed. There is severe aortic valve\nstenosis (area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Trivial\nmitral regurgitation is seen. There is mild pulmonary artery systolic\nhypertension.\n\nCompared with the prior study (images reviewed) of , the degree of\naortic stenosis has increased. There is now mild pulmonary artery systolic\nhypertension and a suggestion of an increased left ventricular filling\npressure.\n\n\n"},{"category":"ECG","chartdate":"2129-08-12 00:00:00.000","description":"Report","row_id":227874,"text":"Sinus rhythm. Low amplitude P waves. A-V conduction delay. Left anterior\nfascicular block. Prior anterior myocardial infarction. Compared to the prior\ntracing of sinus rhythm has appeared. Ventricular ectopy is absent.\nOtherwise, no diagnostic interim change.\n\n"},{"category":"ECG","chartdate":"2129-07-29 00:00:00.000","description":"Report","row_id":227875,"text":"Atrial fibrillation with a single ventricular premature beat. Intraventricular\nconduction delay. Left axis deviation. ST-T wave abnormalities. Since the\nprevious tracing of the rate is slower and the QRS interval is wider.\n\n"},{"category":"ECG","chartdate":"2129-07-19 00:00:00.000","description":"Report","row_id":227876,"text":"Atrial fibrillation\nVentricular premature complex\nModest intraventricular conduction delay\nDelayed R wave progression with late precordial QRS transition\nConsider left ventricular hypertrophy\nNonspecific ST-T wave changes\nThese findings are nonspecific but clinical correlation is suggested\nSince previous tracing of , no significant change\n\n"},{"category":"ECG","chartdate":"2129-07-17 00:00:00.000","description":"Report","row_id":228103,"text":"Atrial fibrillation\nVentricular premature complex\nModest intraventricular conduction delay\nDelayed R wave progression with late precordial QRS transition\nConsider left ventricular hypertrophy\nNonspecific ST-T wave changes\nThese findings are nonspecific but clinical correlation is suggested\nSince previous tracing of , ventricular ectopy present\n\n"},{"category":"ECG","chartdate":"2129-07-16 00:00:00.000","description":"Report","row_id":228104,"text":"Atrial fibrillation\nModest intraventricular conduction delay\nDelayed R wave progression with late precordial QRS transition\nConsider left ventricular hypertrophy\nNonspecific ST-T wave changes\nThese findings are nonspecific but clinical correlation is suggested\nSince previous tracing of , ventricular ectopy absent\n\n"},{"category":"ECG","chartdate":"2129-07-10 00:00:00.000","description":"Report","row_id":228105,"text":"Atrial fibrillation with controlled ventricular response. Occasional\nventricular premature beats. Underlying intraventricular conduction delay.\nCompared to tracing of no definite change.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-08-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 977189,\n \"text\": \" 7:28 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate catheter placement\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach and elevated PA pressures. w/ swan\\n\\n REASON FOR THIS EXAMINATION:\\n please evaluate catheter placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION: Portable film of the chest on at 0802 hours. No change\\n since previous films. Tracheotomy tube is in good position. The pulmonary\\n artery line introduced via the right jugular route extends into the right main\\n pulmonary artery. There appears to be small effusions and the previously\\n demonstrated diffuse pulmonary parenchymal disease.\\n\\n CONCLUSION: No change or superimposed acute process when compared to previous\\n studies.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-07-29 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 976426,\n \"text\": \" 3:21 PM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: please eval for evidenec of pneumothorax and evaluate line p\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach, AS s/p PA line placement\\n REASON FOR THIS EXAMINATION:\\n please eval for evidenec of pneumothorax and evaluate line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Evaluate pulmonary artery line placement.\\n\\n Comparison is made to a film of approximately six hours earlier.\\n\\n PORTABLE UPRIGHT VIEW OF THE CHEST AT 3:40 P.M: A new right internal jugular\\n Swan-Ganz catheter terminates in the right pulmonary artery. There is no\\n pneumothorax. There has been no other interval change. No change in\\n pulmonary edema and pleural effusions.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-07-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 976531,\n \"text\": \" 1:45 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please eval for interval change.\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach and elevated PA pressures.\\n REASON FOR THIS EXAMINATION:\\n Please eval for interval change.\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST, SINGLE VIEW, AT 1348 HOURS.\\n\\n CLINICAL INFORMATION: 79-year-old male with tracheostomy and elevated\\n pulmonary artery pressures. Evaluate for interval change.\\n\\n COMPARISON STUDY: .\\n\\n FINDINGS:\\n\\n Tracheostomy is in midline. Right Swan-Ganz catheter tip is in the right\\n pulmonary artery. Right PICC line appears to terminate in the superior vena\\n cava.\\n\\n Heart is enlarged. There is central pulmonary vascular prominence and\\n congestion consistent with mild congestive failure.\\n\\n There is elevation of the right hemidiaphragm with right basilar atelectasis.\\n There is mild left basilar atelectasis as well. There is diffuse underlying\\n interstitial pulmonary disease. There are small bilateral pleural effusions.\\n\\n IMPRESSION:\\n\\n No interval change since the prior study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-08-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 976739,\n \"text\": \" 8:44 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess for edema, infiltrate\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach and elevated PA pressures.\\n\\n REASON FOR THIS EXAMINATION:\\n assess for edema, infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST, SINGLE VIEW, AT 09:37\\n\\n CLINICAL INFORMATION: Tracheostomy; question edema, infiltrate.\\n\\n COMPARISON STUDY: .\\n\\n FINDINGS:\\n\\n A right IJ Swan-Ganz catheter is present. Tracheostomy is in the midline. A\\n right subclavian line is present, but the tip is not clearly seen due to\\n overlying additional leads. It is presumed to terminate in the superior vena\\n cava based on the study from yesterday.\\n\\n The left costophrenic study is omitted from the study. There is diffuse\\n vascular congestion consistent with mild-to-moderate congestive failure. This\\n is unchanged. There are small bilateral pleural effusions with probable mild\\n bibasilar atelectasis. There are patchy airspace opacities in the right upper\\n lobe and probably within the left lower lobe concerning for superimposed\\n aspiration or pneumonia. These appear somewhat worse today than yesterday.\\n\\n IMPRESSION:\\n\\n 1. Mild-to-moderate congestive failure, stable.\\n\\n 2. Worsening right upper lobe, left lower lobe, right lower lobe patchy\\n airspace disease concerning for superimposed aspiration versus pneumonia.\\n\\n 3. Small bilateral pleural effusions.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-08-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 977634,\n \"text\": \" 7:51 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate effusions s/p diuresis\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach and elevated PA pressures. w/ increased\\n pleural effusions on last CXR\\n REASON FOR THIS EXAMINATION:\\n evaluate effusions s/p diuresis\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST, \\n\\n COMPARISON: .\\n\\n INDICATION: Elevated pulmonary artery pressures. Evaluate pleural effusions.\\n\\n Tracheostomy tube remains in standard position. Widespread pulmonary\\n opacities are present with both alveolar and interstitial components. The\\n alveolar opacities are most prominent in the upper and mid lungs and have\\n progressed since the recent study. Considering waxing- appearance on\\n serial radiographs, they probably represent pulmonary edema superimposed upon\\n more chronic underlying interstitial lung disease. Small right pleural\\n effusion is unchanged, but small-to-moderate left pleural effusion is\\n increased.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-08-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 977779,\n \"text\": \" 8:43 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess for edema, infiltrates\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach and elevated PA pressures.\\n REASON FOR THIS EXAMINATION:\\n assess for edema, infiltrates\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST OF .\\n\\n INDICATION: Elevated pulmonary artery pressures.\\n\\n Tracheostomy tube remains in place as well as a right PICC line.\\n Cardiomediastinal contours are stable in appearance. Widespread heterogeneous\\n combined alveolar and interstitial opacities are again demonstrated\\n bilaterally, with some interval clearing within the left lung, but no\\n substantial change within the right lung. Mild volume loss in the right\\n hemithorax is also unchanged as well as bilateral small pleural effusions,\\n right greater than left.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-08-06 00:00:00.000\",\n \"description\": \"RP UNILAT UP EXT VEINS US RIGHT PORT\",\n \"row_id\": 977565,\n \"text\": \" 1:47 PM\\n UNILAT UP EXT VEINS US RIGHT PORT Clip # \\n Reason: PLEASE EVALUATE FOR DVT, SWELLING\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with R> L swelling\\n\\n REASON FOR THIS EXAMINATION:\\n please evaluate for DVT\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Right greater than left swelling.\\n\\n COMPARISON: left upper extremity ultrasound, .\\n\\n FINDINGS: Grayscale and color Doppler imaging of the right internal jugular,\\n subclavian, axillary, basilic, and brachial veins were performed. The\\n cephalic vein is not well visualized. Normal compressibility, waveforms, flow\\n were demonstrated in the right internal jugular, subclavian, axillary, and\\n basilic veins. The more superficial brachial vein does not compress and also\\n lacks flow within, consistent with occlusive thrombus. The more deep brachial\\n vein appears patent.\\n\\n IMPRESSION: Occlusive thrombus within the more superficial right brachial\\n vein.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-07-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 976353,\n \"text\": \" 8:15 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach, AS, failure to wean, ? interval change\\n\\n REASON FOR THIS EXAMINATION:\\n assess interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: Failure to wean patient with tracheostomy and AS.\\n\\n SINGLE AP PORTABLE VIEW OF THE CHEST: Compared to multiple prior studies\\n including most recent one performed a day earlier.\\n\\n Cardiomediastinal contour is unchanged. Tracheostomy tube remains in place.\\n Right subclavian catheter is in unchanged position in the proximal SVC. Small\\n bilateral pleural effusions are unchanged. Diffuse peripheral patchy\\n opacities are stable.\\n\\n IMPRESSION: No short interval changes.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-07-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 976175,\n \"text\": \" 5:27 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach, AS, failure to wean, ? interval change\\n\\n REASON FOR THIS EXAMINATION:\\n ? interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE FILM OF THE CHEST ON AT 0503 HOURS: There has been no change in\\n the appearance of the chest over the last several examinations, the most\\n recent being on . The tracheostomy tube is in good position. Right PICC\\n line appears to be into the superior vena cava. The right hemidiaphragm is\\n elevated, and the parenchymal lung changes bilaterally persist.\\n\\n CONCLUSION: No improvement or change in the appearance of the chest.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-07-26 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 975938,\n \"text\": \" 3:03 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: pre-op study, please assess for arterial calcification\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with critical AS, intubated for respiratory distress, pre-op\\n study for aortic valve replacement\\n REASON FOR THIS EXAMINATION:\\n pre-op study, please assess for arterial calcification\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT CHEST\\n\\n REASON FOR EXAM: Critical AS. Pre-op evaluation.\\n\\n TECHNIQUE: Multidetector CT through the chest was acquired without contrast.\\n Five, 1.25 mm collimation images and coronal reformations were reviewed.\\n\\n FINDINGS: Tracheostomy tube is in place. There is pooling of secretions above\\n the endotracheal tube cuff. There is an increased number of mediastinal lymph\\n nodes located in all of the mediastinal stations, measuring up to 12 mm in the\\n subcarinal station. The aorta is normal in caliber, measures 39 x 38 mm,\\n transverse by AP in the ascending portion. There is mild calcification of the\\n aortic arch. There is no calcification in the ascending aortal wall. The\\n aortic valve has dense calcification. Mild to moderate calcifications are in\\n the LAD and left circumflex a's. There are small bilateral pleural effusions.\\n The airways are patent to the subsegmental levels. There is diffuse ground\\n glass opacity associated with interlobular septal thickening. Some of the\\n pleural effusion tracks in the major fissures bilaterally. Dense\\n peribronchial multifocal infiltration is greater in the right lower lobe\\n\\n There is moderate ascites.\\n\\n Artifact from low position of the arms, limits the abdomen assessment. There\\n are healed fractures in the lateral aspect of the fifth and sixth right ribs.\\n\\n IMPRESSION:\\n\\n 1. Dense calcification of the aortic valve.\\n\\n 2. Pulmonary edema. A component of chronic interstitial lung disease may be\\n present\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n (Over)\\n\\n 3:03 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: pre-op study, please assess for arterial calcification\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-08-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 978297,\n \"text\": \" 12:43 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please eval for infiltrate or effusion\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach and AS, plan for aortic valve repair on \\n\\n REASON FOR THIS EXAMINATION:\\n Please eval for infiltrate or effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Aortic stenosis, evaluation for aortic valve repair, evaluate for\\n infiltration or effusion.\\n\\n Single supine portable chest radiograph is compared to study dated , . There is interval increase in the bilateral alveolar and\\n interstitial opacities, more pronounced in the right upper lung. Bilateral\\n pleural effusions are unchanged. Tracheostomy tube is in standard position.\\n Right PICC is likely unchanged in position. The cardiac silhouette is\\n enlarged, unchanged.\\n\\n IMPRESSION: Interval increase in bilateral alveolar and interstitial\\n opacities; bilateral pleural effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-07-31 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 976605,\n \"text\": \" 7:33 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach and elevated PA pressures.\\n REASON FOR THIS EXAMINATION:\\n please evaluate\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST, SINGLE VIEW, AT 09:11 HOURS\\n\\n CLINICAL INFORMATION: 79-year-old male with tracheostomy and elevated PA\\n pressures.\\n\\n COMPARISON STUDY: .\\n\\n Since the prior study, there is overall worsening of the appearance of the\\n chest. Heart is enlarged. Mediastinum probably within normal limits. Swan-\\n Ganz catheter is present. Tracheostomy is midline. There are bilateral\\n pleural effusions, increased in size. There is increased bibasilar\\n atelectasis versus consolidation. There is increased pulmonary congestion\\n consistent with mild-to-moderate failure.\\n\\n IMPRESSION:\\n\\n Interval worsening. Increased bilateral pleural effusions, bibasilar\\n consolidation, mild-to-moderate congestive failure.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-07-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 974710,\n \"text\": \" 5:37 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach and RLL PNA\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Interval change in patient with multiple\\n consolidations.\\n\\n Portable AP chest radiograph compared to .\\n\\n Tracheostomy is in good unchanged position. The right PICC line tip\\n terminates in mid SVC. The heart size is enlarged but unchanged. The\\n mediastinal contours are stable. Persistent diffuse airspace and interstitial\\n opacities are unchanged, right greater than left. Small bilateral pleural\\n effusions cannot be excluded. The right hemidiaphragm is continuing to be\\n elevated.\\n\\n IMPRESSION: No interval change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-07-15 00:00:00.000\",\n \"description\": \"UNILAT UP EXT VEINS US\",\n \"row_id\": 974408,\n \"text\": \" 2:00 PM\\n UNILAT UP EXT VEINS US Clip # \\n Reason: PLEASE EVALUATE FOR DVT/RUE SWELLING\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with R> L swelling\\n\\n REASON FOR THIS EXAMINATION:\\n please evaluate for DVT\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 79-year-old man with right arm swelling.\\n\\n COMPARISON: Right arm ultrasound, .\\n\\n FINDINGS: -scale and Doppler son of the right jugular, subclavian,\\n axillary, brachial, basilic, and cephalic veins were obtained. There is\\n normal compressibility, flow and augmentation down to the level of the\\n axillary and brachial veins. Limited views were obtained in this area due to\\n the patient's present PICC line and bandage. No occlusive DVT was identified\\n on this limited study.\\n\\n IMPRESSION: Study technically limited due to the presence of PICC line and\\n bandage but no DVT identified.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-07-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 973742,\n \"text\": \" 5:21 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate for interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach and new RLL PNA\\n REASON FOR THIS EXAMINATION:\\n please evaluate for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST.\\n\\n REASON FOR EXAM: Followup right pneumonia.\\n\\n Comparison is made with prior studies including and .\\n\\n Diffuse pulmonary process greater in the right side has not significantly\\n changed from , but has worsened from . It is due to bilateral\\n pulmonary edema and consolidation in the right lung. Mild cardiomegaly is\\n unchanged. Small bilateral pleural effusions. Tracheostomy tube is in\\n adequate position. Right PICC is in standard placement. There is no\\n pneumothorax. Rib fracture with irregularity in the lateral aspect of a mid\\n right rib is present since .\\n Conclusion:New changes suggesting increase in pulmonary edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-07-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 974157,\n \"text\": \" 10:37 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: collapse, new infiltrate\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach and RLL PNA. Now desaturating after bronchoscopy.\\n\\n REASON FOR THIS EXAMINATION:\\n collapse, new infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 79-year-old male desaturating after bronchoscopy. Evaluate for\\n infiltrate or collapse.\\n\\n Comparison is made to multiple prior chest radiographs dating back to , .\\n\\n SINGLE PORTABLE CHEST RADIOGRAPH\\n\\n FINDINGS: Diffuse airspace process involving the right hemithorax may be\\n slightly worsened from most recent examination but clearly progressed from\\n examination with persistent retrocardiac opacity obscuring the\\n left hemidiaphragm. Parenchymal opacity involving the left hemithorax is not\\n significantly changed as is probable small bilateral pleural effusions and\\n amount of vascular engorgement. Low lung volumes persist and there is no\\n evidence of pneumothorax with tracheostomy tube remaining in standard\\n position.\\n\\n IMPRESSION:\\n\\n Slight interval progression to diffuse right hemithorax opacity which has\\n worsened since examination with no significant interval change in\\n left lower lobe opacity and amount of vascular engorgement.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-07-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 974475,\n \"text\": \" 5:10 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate for interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach and RLL PNA, now s/p trach replacement.\\n\\n REASON FOR THIS EXAMINATION:\\n please evaluate for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST X-RAY\\n\\n CLINICAL INDICATION: 79-year-old man with trach and right lower lobe\\n pneumonia, now status post trach replacement, evaluate for interval change.\\n\\n A single portable image of the chest is compared to the prior examination\\n dated demonstrating no significant interval change. Low lung volumes\\n are again noted. Persistent diffuse airspace opacities are again noted, right\\n greater than left. The left hemithorax is not included on this examination.\\n There is persistent prominence of the bronchopulmonary vasculature that\\n remains indistinct likely secondary to underlying interstitial edema. A\\n stable retrocardiac opacity is noted. The right-sided PICC line is unchanged\\n in position.\\n\\n IMPRESSION: Stable examination.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-07-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 974340,\n \"text\": \" 5:21 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate for interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach and RLL PNA.\\n\\n REASON FOR THIS EXAMINATION:\\n please evaluate for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Evaluate interval change, history of pneumonia and recent\\n bronchoscopy.\\n\\n Comparison is made to portable films dating back to .\\n\\n PORTABLE AP VIEW OF THE CHEST\\n\\n There has been interval central clearing of the diffuse infiltrative\\n abnormality in the right lung field. Clearing over the past 48 hours likely\\n represents improvement of asymmetrical edema, which had been superimposed over\\n right lower lobe consolidation. There may be a left pleural effusion, although\\n the retrocardiac opacity makes it difficult to evaluate. Again seen are low\\n lung volumes and a tracheostomy tube in good position.\\n\\n IMPRESSION: Some improvement in right-sided pulmonary edema. No change in\\n bilateral lower lobe opacities. Likely pleural effusion on the left side.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-07-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 975566,\n \"text\": \" 5:20 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach, AS, failure to wean\\n\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Trach, AS, failure to wean, interval change.\\n\\n CHEST, SINGLE AP PORTABLE VIEW:\\n\\n There is rotated positioning and low inspiratory volumes. Allowing for\\n differences in technique, overall appearance is similar to . There may\\n be slight improvement in the right upper zone consolidation with some\\n increased consolidation in the left upper zone and slight decrease in left\\n pleural effusion. Tracheostomy tube noted. PICC line present, tip not well\\n visualized.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-07-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 973882,\n \"text\": \" 6:02 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess for interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach and new RLL PNA\\n\\n REASON FOR THIS EXAMINATION:\\n assess for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of a patient with new right lower lobe\\n pneumonia.\\n\\n Portable AP chest radiograph compared to .\\n\\n The tracheostomy is in unchanged position. The diffuse pulmonary process,\\n more severe in right lung, has not significantly changed since the previous\\n exam but overall is gradually worsening since . The bilateral\\n pulmonary edema is of unchanged stability. The mild cardiomegaly is stable.\\n\\n Small bilateral pleural effusions are again noted, although cannot be\\n precisely appreciated due to the fact that the most lateral costophrenic\\n angles were not included in the field of view.\\n\\n IMPRESSION: Probable, overall slight worsening of pulmonary edema and right\\n lower lobe consolidation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-07-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 975334,\n \"text\": \" 5:33 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval for interval changes\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach and RLL PNA\\n\\n REASON FOR THIS EXAMINATION:\\n please eval for interval changes\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Assess for interval change.\\n\\n SEMI-ERECT PORTABLE CHEST RADIOGRAPH\\n\\n Comparison is made to and 22, .\\n\\n Lung volumes remain low with unchanged bilateral pleural effusions (left\\n greater than right) and diffuse parenchymal opacities. There is questionable\\n increased density noted over the right upper lobe. A tracheostomy tube and a\\n right PICC catheter remain in unchanged position.\\n\\n IMPRESSION:\\n 1. No significant _____.\\n 2. Bilateral small pleural effusions (left greater than right) and diffuse\\n parenchymal opacity. Questionable increased density noted over the right\\n upper lobe can be followed up on subsequent examinations.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-07-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 973646,\n \"text\": \" 10:59 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: infiltrate\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach and persistent fevers\\n REASON FOR THIS EXAMINATION:\\n infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 10:17 P.M.\\n\\n HISTORY: Tracheostomy tube. Persistent fevers.\\n\\n IMPRESSION: AP chest compared to through :\\n\\n Severe consolidation in the right lung has worsened since . Milder\\n interstitial abnormality in the left lung probably represents residual edema\\n or scarring. Moderate cardiomegaly unchanged. Pleural effusion may be\\n present, but is not appreciable in size. Tracheostomy tube in standard\\n placement. No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-08-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 977898,\n \"text\": \" 7:45 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess for edema, infiltrate\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach and elevated PA pressures.\\n REASON FOR THIS EXAMINATION:\\n assess for edema, infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION: Portable chest.\\n\\n CLINICAL INDICATION: 79-year-old man with trach and elevated PA pressures,\\n assess for edema and infiltrate.\\n\\n FINDINGS: A single portable image of the chest is compared to the prior\\n examination dated . Allowing for slight differences in technique\\n there is no significant interval change. The tracheostomy tube and right PICC\\n line remain in place. The cardiomediastinal silhouette is grossly unchanged.\\n Diffuse heterogenous alveolar and interstitial opacities are again noted\\n bilaterally right greater than left. Persistent bilateral effusions are noted\\n right greater than left.\\n\\n IMPRESSION: Stable examination as above.\\n\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-08-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 977362,\n \"text\": \" 8:05 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate catheter placement\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach and elevated PA pressures. w/ swan\\n\\n REASON FOR THIS EXAMINATION:\\n please evaluate catheter placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Followup evaluation.\\n\\n Comparison is made to films dating back to and a CT chest of\\n .\\n\\n Portable upright view of the chest at 8:30 a.m.: The tracheostomy tube\\n remains in unchanged position approximately 2-3 cm above the carina. There\\n has been interval removal of the right internal jugular Swan-Ganz catheter.\\n Since the prior radiograph of , mild-to-moderate pulmonary edema\\n has developed, superimposed on the diffuse interstitial disease. There are no\\n obvious areas of new consolidation. The cardiomediastinal silhouette is\\n unchanged.\\n\\n IMPRESSION: Interval development of mild-to-moderate pulmonary edema. Stable\\n diffuse interstitial disease.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-07-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 974030,\n \"text\": \" 5:51 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate for interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach and new RLL PNA\\n\\n REASON FOR THIS EXAMINATION:\\n please evaluate for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST.\\n\\n REASON FOR EXAM: Follow up right pneumonia and pulmonary edema.\\n\\n Comparison is made to prior studies including most recent one performed a day\\n earlier.\\n\\n There are low lung volumes. Right pleural effusion is small. Probable small\\n left pleural effusion. Tracheostomy tube is seen in standard position.\\n Moderate cardiomegaly is unchanged. There is no pneumothorax. Allowing the\\n rotation of the patient, there is less aeration in the left upper lobe. The\\n diffuse pulmonary process most severe in the right lung has not significantly\\n changed with mild to moderate pulmonary edema and patchy consolidation in the\\n right lung.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-07-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 975034,\n \"text\": \" 6:02 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess for interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with trach and RLL PNA\\n\\n REASON FOR THIS EXAMINATION:\\n assess for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Followup of pneumonia.\\n\\n Portable semi erect view of the chest: Compared to the prior film of\\n , there appears to be a new tracheostomy tube that extends further\\n into the trachea, terminating approximately 2.5 cm above the carina, in\\n satisfactory position. Diffuse patchy bilateral airspace disease is\\n unchanged. There is no obvious pleural effusion. Cardiovascular status is\\n difficult to assess with high diaphragms and overlying airspace disease, but\\n heart appears borderline enlarged. The right PICC remains in good position.\\n\\n IMPRESSION: Diffuse lung abnormalities consistent with pneumonia are\\n unchanged. CHF is unlikely.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-07-19 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 974934,\n \"text\": \" 11:57 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: evaluate for bleed, stroke\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with AS, hypotension, afib and PNA who developed visual field\\n defects and not tracking to right\\n REASON FOR THIS EXAMINATION:\\n evaluate for bleed, stroke\\n CONTRAINDICATIONS for IV CONTRAST:\\n ARF\\n ______________________________________________________________________________\\n FINAL REPORT\\n HEAD CT\\n\\n HISTORY: 79-year-old man with hypotension, AFib, and pneumonia with visual\\n field defects, assess for stroke or bleed.\\n\\n TECHNIQUE: Contiguous 5-mm axial images were obtained from the skull base to\\n the vertex.\\n\\n FINDINGS: Comparison is made to .\\n\\n This study is limited by patient motion. No intracranial hemorrhages or\\n masses are seen. The /white matter differentiation is maintained. The\\n ventricles and extraaxial CSF spaces are within normal limits.\\n\\n The visualized orbits are normal.\\n\\n Again seen is mucosal thickening involving the left sphenoid air cell as well\\n as ossification of the right mastoid air cells as before.\\n\\n No suspicious bony abnormalities are seen.\\n\\n IMPRESSION: Limited somewhat by motion, but no acute intracranial\\n abnormalities.\\n\\n MR is more sensitive study to assess for acute infarcts.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-08-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 978566,\n \"text\": \" 7:09 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with AVR w/ hx of pna prior to surgery\\n\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: AVR with history of pneumonia prior to surgery.\\n\\n COMPARISON: at 18:27 hours.\\n\\n TECHNIQUE: Single AP portable supine chest.\\n\\n FINDINGS: An endotracheal tube is in place with tip terminating 4.1 cm above\\n the carina. Pulmonary artery catheter enters via left internal jugular\\n approach and the tip, though not well seen, is located in the region of the\\n main pulmonary artery. A nasogastric tube extends below the diaphragm with\\n tip below the borders of the radiograph. Two mediastinal drains are in\\n unchanged position. A right-sided PICC line with tip in the expected location\\n of the SVC is in unchanged position. Since the previous examination, there is\\n little change in bilateral interstitial opacities, with possible mild\\n improvement in right base opacity. No pneumothorax. Multiple right- sided\\n rib fractures again noted but better appreciated on the prior radiographs.\\n\\n IMPRESSION:\\n 1. Lines and tubes in satisfactory position.\\n 2. Bilateral interstitial opacities, likely reflecting CHF or pneumonia; mild\\n improvement in right lower lobe consolidation.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-08-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 979435,\n \"text\": \" 4:54 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p AVR w/hypotension-r/o PTX\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with AVR w/ hx of pna prior to surgery\\n\\n REASON FOR THIS EXAMINATION:\\n s/p AVR w/hypotension-r/o PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Pneumonia and AVR surgery.\\n\\n FINDINGS: In comparison with the study of , the patient is no longer\\n obliqued. There is again evidence of median sternotomy and aortic valve\\n replacement. The cardiac silhouette remains grossly enlarged, though stable.\\n There is again prominence of interstitial markings. Elevation of the right\\n hemidiaphragm is again seen, making it difficult to evaluate the lung behind\\n it. Probable small bilateral pleural effusions.\\n\\n Tracheostomy tube remains in place. Right central catheter extends to just\\n above the carina.\\n\\n IMPRESSION: Little overall interval change.\\n\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-08-17 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 979153,\n \"text\": \" 10:06 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess for effusions/infiltrates\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with AVR w/ hx of pna prior to surgery\\n\\n REASON FOR THIS EXAMINATION:\\n assess for effusions/infiltrates\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 79-year-old man with aortic valve replacement and history of\\n pneumonia prior to surgery. Evaluate for interval change.\\n\\n COMPARISON: AP semi-upright portable chest x-ray dated .\\n\\n AP SEMI-UPRIGHT PORTABLE CHEST X-RAY: A left internal jugular Swan-Ganz\\n catheter has been removed in the interval. A tracheostomy tube is in place.\\n Right PIC catheter terminates in unchanged position in the proximal SVC. The\\n patient is status post median sternotomy and aortic valve replacement. The\\n cardiac silhouette is grossly enlarged but stable. Prominence of the\\n interstitial markings and small bilateral effusions persist and limit\\n evaluation of underlying pneumonia. There are no new consolidations. Multiple\\n right sided rib fractures are again noted and appear partially healed on CT\\n Chest from .\\n\\n IMPRESSION: No significant interval change in the appearance of the chest.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-08-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 978693,\n \"text\": \" 9:07 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ct removal\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with AVR w/ hx of pna prior to surgery\\n\\n REASON FOR THIS EXAMINATION:\\n ct removal\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION: AP chest.\\n\\n INDICATION: Chest tube removal.\\n\\n A single AP view of the chest is obtained on at 09:40 hours and is\\n compared with the prior morning's radiograph. ET tube has been removed and a\\n tracheostomy tube placed. Tip lies approximately 4.8 cm above the carina.\\n Nasogastric tube and Swan-Ganz catheter are unchanged. Mediastinal drains are\\n not visible, presumably have been removed. There is no evidence of\\n pneumothorax. Bilateral interstitial opacities persist and likely represent\\n failure or less likely pneumonia. Increasing retrocardiac density on the left\\n side is consistent with worsening atelectasis at the left base. Haziness and\\n obscuration of the diaphragm on the left likely represents pleural effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624042,\n \"text\": \"Patient has # 7 Shiley with layer of secretion on inner wall of trach MDs notified.Plan to change trach tube under bronchoscopic view due to the presence of a suture thread coming from the stoma.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624047,\n \"text\": \"Nsg.notes 1900-0700hrs\\n\\nAllergies:haldol and heparin.\\n\\nNeuro:Alert,following commands,unable to assess orientation.stiff body and hands.slept well with Inj.Ativan.\\n\\nResp:,vented,AC/20/10/450/40. BLOOD GAS X2.am ABG report 7.4/54/116/38/11/.tachypoenic always,RR >30's .trache changed yesterday.slept after ativan and RR >22/min when sleeping.LS coarse.suctioned yellow to blood stained secretions.trache care given.cuff leak present,cuff inflated more per RT.sats 92-96%\\n\\nCVS:HR 84-100/MIN,Afib,no ectopics noted.ABP 100-120'S SYS. edematous extremities.pedal pulse difficult to palpate on post tibial.boots on.\\nblood c/s sent.\\n\\nGU/GI:Abdomen obese,bowel sounds hypo,PEG in place,feed neutran pulmonary 50ml/hr,tolerating well,no BM this shift.on lasix BD ,urine output adequate.\\n\\nIntegu:impaired ,duoderm on upper back,hygenic needs attended and position changed.afebrile.\\n\\nIV access:A line on Lt.radial,patent.Rt.midline cath double lumen .\\n\\nSocial: by family early shift and updated.calm and co operative.full code ,on contact precautions for MRSA.\\n\\nPlan:trache care.watch for bleeding and leaking.continue present care.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624048,\n \"text\": \"Respiratory Care:\\n\\nPatient with 7.O Portex. Trach changed yesterday due to partial occlusion. Peep ^ 10 with improved PaO2(116) and later weaned back to 8 due to low BP. Current vent settings Vt 450, A/C 14, Fio2 40% and Peep 8. BS few faint expiratory wheezes L lung, slightly coarse R lung. Sx'd for bloody clots. Albuterol/Atrovent MDI's given Q4hr. Wheezes resolving. No further changes made.\\nPlan: Continue with mechanical support. See Carevue for RSBI and ABG's.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624049,\n \"text\": \"resp care - Pt remains and vented on full vent support. Persistent cuff leak exists despite high cuff pressure. BLBS were coarse t/o. Pt was suctioned for copious amounts of thick, blood tinged secretions x 2. PEEP was decreased to 5 during rounds, but was increased to 8 in PM when Sat dropped and BP increased. Pt given meds as ordered. Continued resp care planned.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624050,\n \"text\": \"NPN\\n\\nNeuro: Pt is awake and alert, slowly following simple commands, conts to have jerking movements which per his family have been with him since his accident.\\n\\nCV: Tolerating his dilt, remains in afib, his coumadin was d/ced do to his drop in his HCT to 19.9. He is receiving 3 units of FFP and 2 bags of PRBCs.\\n\\nResp: LS with rales in the bases, 02 SATs dropped to 93-94% and had coarse BS throughout this afternoon after he had recieved 2 of his 5 blood products. His PEEP was increased back to 8 - it was decreased during rounds and he was given an additional 40mg of IV lasix. He has a cuff leak, his cuff pressure is 30, repositioning it does not change the leak, his VTs are 300s-low 400s.\\n\\nGI: His HCT was 19.9 this morning, he had dark brown stool yesterday x2 which were OB pos, FFP and PRBC were ordered, also given vit K, ASA and comadin were d/ced, pneumoboots were placed, GI notified.\\n\\nGU: He is presently 330cc pos since MN, he conts on lasix, his u/o has been 250-40cc/hr.\\n\\nSoc: Family called, they took the day off today and will be in tomorrow.\\n\\nID: T max 101 and he has remain febrile all day on Tylenol, WBC down today from yest, blood c/x sent, BAL, urine, and stool sent yest with his elevated WBC, no antibiotics were ordered.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624110,\n \"text\": \"ADDENDUM TO NPN 7P-7A\\nLASIX GTT BACK ON AT 4MG/HR AS BP HAS IMPROVED\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624043,\n \"text\": \"Nsg.notes 1900-0700hrs\\n\\nShift uneventful\\n\\nNeuro:alert,obeying and following commands,denies any pain.slept on and off.\\n\\nResp:,vented,AC,/14/40/5/40%/trache care given,suctioned thick yellow secretions.sats 94-98%.\\n\\nCVS:HR 100-110,a fib,with occasional PVC'S .vital signs remains stable,A line on Lt hand,ABP 110-130/60-70mm of hg.A line pressure kit changed.\\n\\nGU/GI:PEG in place,on neutran pulmonary 40ml/hr,tolerating well.no BM this shift,on foley cath,urine output adequate.\\n\\nIntegu:skin impaired uppper back,duoderm present.position changed and hygenic needs attended.edematous and stiff,difficult to fold his hands and legs.\\n\\nIV access:Rt midline 2 lumen cath.site cleaned and dressing changed.\\n\\nSocial:calm and co operative.no family contact during night.full code,on contact precautions\\n\\nPlan:pulmonary toileting and airway clearence.may change trache today.emotional support to pt and family,continue present treatment.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624044,\n \"text\": \"RESP CARE NOTE\\nRECEIVED PT ON AC WITH NO CHANGES OVERNIGHT. BREATH SOUNDS ESSENT CLEAR. ALB/ATR GIVEN Q4. RSBI 111 THIS AM. AMBU AT BEDSIDE.\\nPLAN: ? TRACH CHANGE TODAY, WEAN TO PSV AS TOLERATED, CONT MDI'S AS ORDERED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624045,\n \"text\": \"NPN\\n\\nNeuro: Pt was sleeping this morning but then woke and was alert until he was sedated for the bronch.\\n\\nCV: Tolerating 30 mg of dilt QID, remains on coumadin for his afib - INR was 2.2., his heart rate has been 80s-1teens. k was replaced today, lytes due to be checked this afternoon.\\n\\nResp: Remains vented on A/C, no changes were made, he was tried on PSV during rounds but his RR increased from 20 to the 30s and his pC02 was in the 60s and on A/C his pC02 was in the 50s. His trache was changed to a portex, fenistrated with an intercanula, he was also bronched and a lg plug was suctioned out. A BAL sputum was sent as well. WBC count up to 14 today, he has been afebrile but was pan clx.\\n\\nGI: He has had 2 lg dark brown, loose, OB pos stools today, this was sent for cdif. His TF was increased to 50cc/hr per nutrition recs.\\n\\nGU: Now on lasix 40mg per GT, he has put out ~ 400cc so far today for the lasix.\\n\\nSoc: Son in to visit, we cont to work on finding him a rehab, he may be ready to go this week.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624046,\n \"text\": \"Trach changed from Shiley to portex # 7. Bronchoscopic procedure done,suctioned for copious amount of thick bloody secretion.Weaned on PSV for short periods of time desaturated to 88% pre-oxygenate responded quickly to 02 therapy.ABG sent to lab will continue to follow patient.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624111,\n \"text\": \"Resp Care,\\nPt. remains on A/C overnoc, no vent changes this shift. Suctioned small amount thick yellow . attempted, RR>35. Maintain current vent settings.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624112,\n \"text\": \"Neuro: pt withdrawn, visually acknowledges caregiver, otherwise no interaction. does not follow commands. moves/tenses extremities w/tactile stimulation. grimaces with turns and during skin care. perrl.\\nCv: af 80s-100s. occas. pvc's. bp 100s-130s. briefly hypotensive, MD aware, no tx ordered, pt returned to baseline within 15 minutes, continuing to monitor. +pp. extrem w/d. compression sleeves on. low grade temp 100.4, tylenol given w/good effect. sternal, mediastinal incisions cdi.\\nResp: ls course, bases dim. no vent changes overnoc. continues on cpap 40% 5peep, 8ps, tv 300s-500s. rr 20s-30s. sxn'd sm-mod amts thk yellow secretions occas. pCo2 50s.\\nGi/gu: tolerating tf fs replete w/fiber @ goal=80cc/hr via peg-no resids. +bs. no bm. abd soft, nt, nd. huo adequate-clr yellow.\\nEndo: rssi per ss.\\nSkin: see carevue.\\nPlan: continue monitoring cardioresp status, labs, sxn prn. continue support pt/family. continue with current plan of care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624113,\n \"text\": \"RESP CARE: Pt remains /on vent,cuff pressure 28cmH20. Remained on PSV 8/5/.40. ABGs comp resp acidosis/good oxygenation. Vts 330-500/RR 20-35. Lungs bilat rhonchi, sxd small amts thick yellow /white . AM -95. Wean as \\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624114,\n \"text\": \"ALTERED RESPIRATORY STATUS\\nO: CARDIAC: AF WITH VENTRICULAR RESPONSE 70'S-80'S. PVC'S NOTED. K AT 11AM NOT RUN CALLED LAB AND RAN AT 1400 3.7 RECIEVING 20 MEQ KCL X2. SBP 90'S-162 WITH COUGHING. AFEBRILE. EXTREMITIES WARM AND DRY. PALP PP. OOB TO CHAIR VIA X3 HOURS.\\n RESP: VENT SETTINGS AND ABG PER FLOW. BS COURSE UPPER -CLEARS WITH COUGHING. RR TWENTIES - THIRTIES. SUCTIONED FOR A SMALL AMOUNT OF THICK TO THIN WHITE . TRACHE CARE DONE, INNER CANNULA CHANGED.CO2 57.\\n NEURO: OPEN EYES TO COMMAND, INCONSISTENTLY WILL WIGGLE FINGERS AND TOES TO COMMAND, CLOSES EYES AND MOUTH WHEN ATTEMPTING TO ASSESS PUPILS AND OR MOUTH CARE. PERL.\\n GI: TF AT GOAL, ABD SOFT, NONTENDER, SMALL AMOUNT OF SOFT BROWN QUIAC NEGATIVE STOOL.\\n GU: MARGINAL UO\\n ENDO: HAS NOT RECEIVED SSI .\\n PAIN: SHOOK HEAD NO TO PAIN.\\n SOCIAL: DAUGHTER INTO VISIT AND UPDATED.\\n REHAB: ? PLAN TO DISCHARGE TO REHAB .\\nA: TOLERATED OOB X 3 HOURS. CONTINUES IN AF. CO2 57.\\nP: MONITOR COMFORT, HR AND RHTYHYM-? COUMADIN, SBP, RESP STATUS-PULM TOILET-ABG, NEURO STATUS-REORIENTE PRN, I+O, LABS AS PER ORDERS. PREPARE FOR REHAB . DC ALINE. COMPLETE DISCHARGE SUMMARY. AS PER ORDERS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624115,\n \"text\": \"Resp. care note - Pt. remaines and vented, no vent changes made at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624108,\n \"text\": \"0700-1900\\nneuro: lethargic, easily aroused, follows commands, moves upper extremities, pt very weak\\n\\ncv: hr a-fib(70's-80's), no ectopy, sbp stable(90-134), po digoxin\\n\\nresp: placed on cpap today, well, now back on AC due to sedation for colonoscopy, bs+ all lobes & course, sux sm/mod amt thick yellow , sat 95-100, no resp distress noted\\n\\ngi: pt npo today for colonoscopy, procedure done @ 1700, TF resumed @ 1800, mushroom cath draing lg amt clear liquid stool, po prevacid\\n\\ngu: foley patent, clear yellow urine, continues on lasix gtt to keep hourly uo 150 cc's, lasix now @ 4 mg/hr\\n\\nother: son called & updated on pt's condition, son-in-law in to visit, no c/o pain, 1500 labs sent, K+ 3.6, needs repletion, am K+ of 3.6 tx with 40 kcl po, colonoscopy negative, no bleeding areas noted\\n\\nplan: continue with ventilatory support, wean to cpap as tolerated, continue lasix gtt, goal uo 150 cc/hr, ? tx to CCU tomorrow for possible AVR on Tuesday\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624109,\n \"text\": \"NPN 7P-7A\\nBRIEFLY THIS IS A PT. ADMITTED ON FROM WITH SEPSIS. HE HAS AN EXTENSIVE PMH. IS A CHRONIC VENT PATIENT. HIS GREATEST ISSUE HAS BEEN HIS FLUID VOLUME STATUS D/T AV STENOSIS. HAS BEEN ON LASIX GTT TO TRY TO ATTEMPT WEANING. PT.'S FAMILY DECIDED THEY WANTED AGGRESSIVE TREATMENT AND PT. IS NOW TO GO WEST FOR AVR. THE PROCEDURE IS GOING TO BE DONE NEXT TUESDAY. GOAL IS TO TRANSFER PT. TO CCU OR CSRU WITHING THE NEXT COUPLE OF DAYS\\n\\nCOLONOSCOPY DONE YESTERDAY TO R/O GIB. RESULTS NEGATIVE. AT THIS POINT PT. AWAITING TRANSFER WEST.\\n\\nNEURO: PT. ALERT. OPENS EYES AND NODS HEAD YES AND NO TO QUESTIONS ASKED. PUPILS EQUAL AND REACTIVE. OOB TO CHAIR WITH HOYAR ASSIST.\\n\\nRESP: PT. WITH TRACH. ON AC 30%/500/20/5. PT. TOLERATED PRESSURE SUPPORT YESTERDAY FOR MOST OF DAY. BREATH SOUNDS COARSE BILAT. SUCTIONED FOR VERY THICK YELLOW SECRETIONS.\\n\\nCV: PT. IN AFIB WITH RATE 70'S TO 90'S. SYSTOLIC BP LABILE. AT APPROX. 0400 PT. HYPOTENSIVE TO 75/39. LASIX GTT OFF. ( MD'S, LASIX OFF OF SBP <90 OR MAP <65). PT. REMAINS WITH TOTAL BODY ANASARCA. + PULSES. AFEBRILE. PM K+ 3.6 REPLETED WITH 40MEQ IVPB\\n\\nGI: PT. WITH PEG. ON TFEEDS AT GOAL RATE OF 40CC/HR. TOLERATING WELL. MUSHROOM CATH IN DRAINING LIQUID BROWN STOOL. ABD. SOFT. BS+\\n\\nGU: FOLEY IN PLACE. GOOD OUTPUT.\\n\\nACCESS: R AC PICC\\n\\nPLAN: TRANSFER TO WITHIN NEXT DAY OR TWO. ? RESTART LASIX GTT IF BP PERMITS. WEAN VENT AS TOLERATED. REPLETE LYTES AS NEEDED. AM LABS PENDING. FULL CODE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624087,\n \"text\": \"Respiratory Care\\nRemains intubated and ventilated on a/c mode with no remarkable changes overnight. Suctioned for moderated amounts of thick tan .Pt gets very bronchospastic with suctioning/coughing. Unable to obtain due to tachypnea when put on psv.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624036,\n \"text\": \"pt remained on full vent support through shift, sx'd for moderate amount of secretions, plan to be evaluated during rounds. AM RSBI was 104\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624088,\n \"text\": \"npn 7p-7a (please also see carevue flownotes for objective data)\\n\\nPt s/t 2 trials PS yesterday, returned to A/C for tachypnea, tachycardia, resp distress;\\n\\nOn Lasix gtt for urine output goal of 100 cc/hr; recieved on 3.5 mg/hr, increased gently to avoid b/p lability;\\n\\nB/p remained in acceptable range this night; Diltiazem 30 mg given at 19:30, 6 hrs later pt still w/ borerline b/p and v-response still in 80's, therefore waited until v-response started increasing before giving again; at 04:00 v-response in low 90's after suctioning, therefore dilt given at that time; b/p and v-response remained in acceptable ranges in the two hours following;\\n\\nPt received full bed bath this night, all IV lines changed;\\nRemains on tube feeding as ordered, w/out diarrhea;\\n\\nThis a.m. serum Na 139--?need for 150 cc's free H20 q 4 hrs?--?decrease volume, or ?decrease frequency;\\na.m. serum K+ 3.3, pt received 20 meQ KCL in 50 cc x2, at 05:15 amd 06:16; ordered for third--?check serum level K+ first;\\n\\nPLAN:\\n1) check w/ MD team re interval of diltiazem\\n2) check w/ MD team re free water boluses\\n3) check serum K+ before more serum K+\\n4) dressing changes\\n5) further plan per a.m. rounds\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624089,\n \"text\": \"resp Care\\n\\nPsv wean attempted; on 25 of ps with volumes in the high 300's low 400's. Will wean as tolerated. Otherwise on full vent support. Bs with scattered rhonchi. Suctioning thick yellow .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624090,\n \"text\": \"NPN 0700-1900\\nNeuro: Awake, alert, more interactive today w/nods, occasional smile. Move LUE, wiggles toes. Gag/cough intact. Will not squeeze hand ?too much fluid. Afebrile. OOB to chair via lift and 3 assists\\n\\nCV: Continues in afib w/occ PVC's but rate stable 80's-90's. Remains on dilt which is a QID drug so no changes to med order just hold when SBP low. SBP in 100's to low 110's throughout shift. Lasix gtt now @ 5mg/hr, new hold orders are for SBP <90, now diuresing @ ~100cc/hr.\\nRepleting K\\nResp: Currently tolerating PS 40/5/25 w/RR 30-35bpm. Pt appears comfortable. LS coarse in RUL but currently clear in remaining lobes. Decrease in amt of secretions from yesterday.\\n\\nGI/Endo: Required no additional insulin coverage today, TF at goal of 50cc/hr w/ no residual. Soft distended abd, +BS, +BM x1 soft, dark brown.\\n\\nGU: patent foley now draining clear light yellow urine @~125cc/hr.\\n\\nSocial: daughter and son in law in today with several ?'s about POC, state that they are happy with our medical care, still hoping for possibility of minimally invasive valvoplasty, get fluid off pt and have him return to rehab.\\n\\nPlan: Lasix gtt for >100cc u/o per hour\\n Check K\\n TF, Glargine due @ 2200\\n Dilt for rate control, hold when necessary\\n Encourage deep breathing\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624037,\n \"text\": \"NPN\\n\\nNeuro: Pt is alert, follows simple commands but not able to participate in his care significantly.\\n\\nCV: Remains in afib, occ PVCs. He was started on dilt PO this afternoon, 30mg QID down from the 60 mg that he received yesterday. BP has been stable 100s-130s. If his BP tolerates the dilt than we will cont to try and diurese him.\\n\\nResp: Remains vented A/C 450x14/5/.4, he over breathes by , PSV was tried briefly during rounds but he did not tolerate it. He has a lot of thick yellow secreations, requiring q1-3 hr suctioning.\\n\\nGI: Tolerating his TF at the goal rate of 40cc/hr, had a sm BM which was OB pos, sent for cdif.\\n\\nGU: Tried to gently diurese him today, he is even for the day, an additional dose of lasix will be given this evening his his BP tolerates it.\\n\\nSoc: One of his 4 daughters was in today, she met with case mangagement and SS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624038,\n \"text\": \"Patient remains on mechanical ventilation;does not tolerate PSV,RSBI 104.Febrile,follows simple commands, but still passive.BS coarse,suctioned for small clear sputum will continue to follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624039,\n \"text\": \"NARRATIVE NOTE:\\n\\nCV: B/P HAS RANGED FROM 108/61-154/86. A-FIB WITH HR RANGING FROM 102-117 WITH OCC PVC'S. REMAINS ON DILT PO.\\n\\nNEURO: ALERT. UNABLE TO DETERMINE ORIENTATION AS PT IS . DOES NOD HEAD YES AND NO. FOLLOWS SIMPLE COMMANDS. ALSO GRIMMACES WITH CARE BUT DENIES DISCOMFORT.\\n\\nRESP: AC 40%/450/14/5. RSBI 140.7. LUNGS COARSE THROUGHOUT. SOO2 91-98%. RR 19-34. SX Q 3-4HR FOR THICK WHITE SECRETIONS.\\n\\nGI: ON NUTREN PULM AT 40CC HR AND WELL. NO STOOL THIS SHIFT.\\n\\nGU: FOLEY CATH PATENT AND DRAINING URINE WHICH WAS AMBER IN COLOR BUT PROGRESSED TO LIGHT RED WITH FEW SM CLOTS. FOLEY IRRIGATED.\\n\\nSKIN: DUODERM INTACT ON MID BACK.\\n\\nPLAN: CONT TO MONITOR VS AND LABS AND REPLENISH LYTES AS NEEDED. PT IS DILT WELL, DIURESE. PROVIDE UPDATES IN PT CONDITION TO FAMILY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624040,\n \"text\": \"RESP CARE NOTE\\nRECEIVED PT ON AC WITH NO CHANGES OVERNIGHT. BREATH SOUNDS ARE WITH COARSE CRACKLES. SUCTIONING SMALL AMOUNTS OF THICK WHITE SECRETIONS. ALB/ATR GIVEN INLINE Q4. TRACH IS PATENT AND SECURE. CUFF PRESSURE 27. RSBI 141 THIS AM. WILL CONT TO FOLLOW.\\nPLAN: CONT FULL VENT SUPPORT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624041,\n \"text\": \"NPN\\n\\nneuro: pt remains alert, following simple commands, not able to do any ADLs. He is very stiff and bearly able to bend his arms and legs.\\n\\nCV: Remains on dilt, conts in afib with a rate of 80s-1teens. BP 110s-130s/70s. He conts on coumadin, his INR was 2.3 this morning.\\n\\nResp: Remains , sx for thick yellow sputum, his trache has tans secreations on the inside of the lumen, to have ENT to come see him for a possible new trache. He was placed on PSV of 15/5,.4, ABG 7.38/62/67. His rate and VTs are about the same on PSV vs A/c, though his HR increased to the 100s-1teens. T max 100.0, gent was d/ced, he conts on imipenum and PO bactrim.\\n\\nGI: Conts on TF, no stool today.\\n\\nGU: Given 40 mg of IV lasix, he is presently 125cc neg since MN.\\n\\ndispo: To be screaned by heb reb, family is aware.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624105,\n \"text\": \"NPN 7P-7A\\nTHIS MAN WAS ADMITTED HERE ON FROM WITH A DIAGNOSIS OF SEPSIS. HE HAS AN EXTENSIVE PMH INCLUDING AV STENOSIS WHICH HAS IMPEEDED EQUALIZING HIS FLUID BALANCE. DECISION WAS MADE BY PT.'S FAMILY, AFTER HAVING DONE RESEARCH IN THE INTERNET, TO HAVE PERCUTANEOUS VALVULOPLASTY DONE AFTER LABOR DAY WEEKEND IN HOPES THAT PT.'S FLUID OVERLOAD WILL IMPROVE, LEADING TO SUCCESSFUL VENT WEANING. CARDIOTHORACICS TALKED WITH FAMILY EXTENSIVELY REGUARDING THE RISKS OF THIS PROCEEDURE. FAMILY HAS DECIDED TO MOVE FORWARD WITH AGGRESSIVE TREATMENT. PLAN IS TO TRANSFER TO CCU HOPEFULLY BEFORE THIS WEEKEND.\\n\\nYESTERDAY PT. HAD CT OF ABDOMEN FOR PRE-PROCEDURE WORKUP. PT. WILL ALSO NEED DENTAL XRAYS TO R/O POSSIBLE ABSCESSES. PT. ALSO TO HAVE COLONOSCOPY DONE THIS AM AS HE HAS BEEN HAVING TARRY STOOLS. GOLYTLY 6L GIVEN THIS SHIFT IN PREPARATION FOR COLONOSCOPY THIS AM.\\n\\nNEURO: PT. ALERT. NODS HEAD YES AND NO TO QUESTIONS ASKED. PURPOSEFUL MOVEMENT NOTED. NO C/O PAIN. OOB TO CHAIR WITH ASSIST DURING DAY.\\n\\nRESP: REMAINS VENTED WITH TRACH. ON AC: 30%/500/5/20. BREATH SOUNDS COARSE. SUCTIONED FOR THICK TAN/GREEN SECRETIONS. + PSEUDOMONAS PNEUMONIA. REMAINS ON LASIX GTT HOPING OT DIURESE AND WEAN OFF VENT.\\n\\nCV: PT. IN AFIB WITH RATE 70'S TO 90'S. SOME RARE PVC'S NOTED. SBP HIGH 80'S TO LOW 110'S. TOTAL BODY ANASARCA. + PULSES. AFEBRILE.\\n\\nGI: PT. WITH PEG. HAS BEEN NPO FOR COLONOSCOPY THIS AM. MUSHROOM CATH PLACED AFTER CHANGING BED 6 TIMES FOR INCONTINENT STOOLS FROM GOLYTLY. DRAINING LIGHT BROWN LIQUID STOOLS. MDS AWARE.\\n\\nGU: FOLEY IN PLACE DRAINING CLEAR YELLOW URINE. GOOD OUTPUT. (REMAIN SON LASIX GTT)\\n\\nACCESS: R AC PICC\\n\\nPLAN: PT. TO HAVE COLONOSCOPY IN AM. AM LABS PENDING. WILL NEED TO REPLETE LYTES AS NEEDED. CONTINUE WITH CURRENT POC. TRANSFER TO CCU IN NEAR FUTURE FOR PROCEDURE. NO CONTACT WITH FAMILY THIS SHIFT. FULL CODE\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624106,\n \"text\": \"Resp Care\\nRemains intubated and ventilated on a/c 500 x 20 30% +5 with no remarkable changes overnight. Continues to have thick yellow , often coughing up into vent tubing. O2 sats 99-100. stopped this morning due to increased resp rate (>35). Pt scheduled to have colonoscopy later today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624107,\n \"text\": \"Respiratory Care\\nPatient placed on CPAP/PSV at noon. Suctioning moderated amounts of thick yellow secreations frequently, q2-3hrs. Breath sounds diminished, coarse throughout. MDI's given as ordered.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624034,\n \"text\": \"NPN M/SICU ICU day 2 (0700 -1900)\\n\\nEvents: Recieved 3L NS bolus r/t hypotension with good effect. A line inserted. TPA instilled into obstructed port and now flushes and draws appropriately. Repleted K w/ 40meq PO. No other significant events.\\n\\nReview of Systems:\\n\\nNeuro: Alert opens eyes spontaneously and nods head appropriately in response to simple questions, PEARL, MAE on bed, able to track and follows commands consistently. No c/o pain but obvious facial grimace upon repositioning.\\n\\nCV: Afib with occasional ventricular ectopy, rate well controlled w/ PO dilt. Pt became hypotensive to low 70's recieved 3 liters NS w/ good effect. A -line placed and pt has been normotensive since its insertion. Anasarca persists. Please refer to carevue for objective data.\\n\\nResp: 7.0, vent dependent on A/C 40% 450 x 14 PEEP 5, overbreaths vent by 10 - 14 BPM, most recent ABG 7.50/49/72 (team aware). LS coarse throughout, suctioned for copious amounts of thick yellow secretions q 1 hr.\\n\\nGU/GI: TF started this evening (nutren pulmonary) @ 10cc/hr goal rate is 50cc/hr and can be advanced @ 20:00. Abd soft/NT/ND, +BS, large loose BM x 1 (stool sent for C-Dif). Patent foley draining >30cc/hr however pt remains 2.6 liters positive since midnight.\\n\\nAccess: R DL power picc, all ports flush and draw appropriately.\\n\\nPlan: Family @ bedside this afternoon, and spoke @ length with RN in regards to POC. Cont Abx Tx and tx hypotension w/ NS fluid boluses . Cont to monitor/maintain heme/resp status, wean vent support as tolerated. Update family on POC as it develops.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624060,\n \"text\": \"NPN 1900-0700\\nEvents: Became hypotensive to 66-70s via ABP after turning to R side following bathing pt. NBP slightly higher. No drop in sats (99-100) or change in RR, low 20s. No change in HR 90s-100s, a-fib, occ to freq pvcs. Gave 2 500ml fld boluses and started Neo at 1mcg/kg/min, with good response, sbp up to 100. Hct sent, 23, stable, but team wanted to transfuse anyway, so one unit pc given. Trying to wean neo, currently at .6mcg/kg/min.\\n\\nNeuro: Clonepin .5mg given po prior to above event, doubt it was related, but pt more lethargic during above episode, ? if lethargy was related to conepin or hypotension. Pt more awake few hrs after. Slept in short naps. Denies pain. Pt follows simple commands inconsistently.\\n\\nCV: HR 89-104, a-fib, freq multifocal pvcs. Dilt held all noc. Maintaining sbp >100 c Neo. EKG done, no changes. Troponin levels sent. Vit K given for INR 1,6. 40meq kcl given for K 3.8. Free water increased to 150mls q4hrs due to Na 147. Repeat labs in am with vanco trough. +pp.\\n\\nResp: Resp pattern appeared comf all noc, RR low 20s, sats 99-100, VT 400-450. Peep was dropped from 12 to 10 due to hypotension s problem.\\nLS coarse, dim in bases. Sx somewhat more freq for mod amt thick, tan to yellow secretions.\\n\\nID: Afebrile, no incr in wbc. Bld and urine cx sent. cont imipenem and vanc.\\n\\nGI: +BS, abd soft dist. TF at goal, incr free water. No stools.\\n\\nGu: U/o 30-80mls/hr clear, yellow urine.\\n\\nSkin: Intact except for upper back pressure sore covered c duoderm.\\nGeneralized edema t/o body.\\n\\nPlan: Titrate neo to BP. Evaluate dilt with team. Monitor hct, lytes, replete as needed. monitor for black stools, freq turning and skin care.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624061,\n \"text\": \"Resp Care,\\nPt. remains on A/C overnoc. Peep decreased to 10 this shift, following episode of hypotension. PO2 acceptable. Suctioned for moderate amount thick yellow sputum, MDI's as ordered. Cuff pressure 40cm, 13 cc air in cuff. RSBI not done due to peep level. See carevue.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624062,\n \"text\": \"Addendum\\nAt 6am, pt had medium, black, tarry stool, OB+. Also, FSBS was 82, will repeat in one hour.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624063,\n \"text\": \"79 yr old pt with pseudomonas PNA, s/p mva and and pegged since . 3 rd admit to since with prob VAP. trach changed on and again on . events today: neo stopped 0930 after on for approx 12 hr for bp drop to 60's sys. continues to have black tarry hem pos stool, last transfused early am and crit bumped . 1500 labs pending\\n\\nneuro: pt somulent, aroused with stim and answered questions appropriatley. still quiet groggy . clonazapam d/ced last dose 20 . lorazapam d/ced and last dose 0800 am > 24 hr ago.\\nPERL. lt arms moving less than yesterday independently. no independent\\nmovement rt arm of legs.\\n\\nresp: no changes in vent settings. mod amt secretions suctioned about 5x by this nurse. sent. sat 98-100 gas improving to ph 7.43/ 46/114 . resp rate 25-28 comfortable. poss change trach to bovina with foam cuff for persistant cuff leak.\\n\\ncard : afib rate 90-104 range. neo off since 0930. pvcs were up to 16/min this am and seemed to decrease after neo off with current pvc's / min. bp 107-130's off neo and dilt dose given at 1300. bp stable since. feet and rt hand cool, good pulses by . ck repeated at 1500. total body anasarca\\n\\ngi: crit up after last unit of bld and repeat crit at 1500 pending. mod amt black tarry hem pos stool at 11:00. pt has had tarry stool since noted at and has had total 6 units prbcs since combined from and . poss to have endoscopy tommorrow.\\ntube feeds at goal pos hyperactive snds. 150 cc h20 q 4hr free water.\\n\\ngu: urine started to have visible red cells at approx 1000 md made aware. pt has had hx of hematuria. inr 1.3.\\n\\nrenal: urine 40-80 cc/hr. creat down to 1.3.\\n\\nendo: stim test done. glaucose level low all shift 80-90 range. glargene decreased from 32 to 30 units.\\n\\nID: afeb for > 24 hrs wbc up to 11.3 today. no change in antibx. vanco dose given for level 15/1 this am.\\n\\nskin: no breakdown other than ulcer on back covered with dueoderm. elevated rt arm on pillows for edema.\\n\\nsocial: son in today and updated him as well. family stil concerned with lethargy.\\n\\nplan: monitor labs from 1500 and cont bp monitor. poss trach change and poss endoscopy in am.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624064,\n \"text\": \"resp care - pt remains on full vent support. No changes made this shift. ABG showed compensated resp acidosis with good oxygenation. BLBS were coarse t/o, clearing slightly on suctioning of varying amounts of thick, yellow secretions. MDIs given as ordered. See carevue for more detail.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624131,\n \"text\": \"ekg afib, rate 90s, occ pvcs. sbp stable. lowgrade temp, 99.4. adequate uo, moderate diuresis after earlier lasix. breath sounds clear, decreased at bases, trach suctioned for mod to copious amts thick yellow/white secretions. small amt yellow exudate around trach site. remains on cpap. no vent changes overnight. chest dressing dry, changed. abd soft, bowel soinds +, mod soft formed stool x 1. tolerating tf, replete with fiber at 80 cc/hr. feet warm, dp and pt pulses bilat, wearing csl and waffle boots. allevyn dressing to mid back is intact, groin rash is pink, improved. opens eyes to voice, sometimes speaker, but is very deaf. did move feet and l hand asked. plan to move to rehab to day.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624132,\n \"text\": \"pt stable, transferred to rehab @ 1500 via ambulance\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624068,\n \"text\": \"NPN 0700-1900\\nFull code, contact precautions\\n\\nNeuro: Pt alert for most of day, flat affect, occasional head nod or smile. Able to move LUE purposefully. Afebrile. Rec'd Ativan 1mg x1 increased gagging after trach change w/good effect. Rec'd 2mg midaz/50mcg fent during endoscopy with very good effect.\\n\\nCV: Pt in afib with occasional PVC's, diltazem for rate control which has been in 80's and 90's throughout shift. BP's stable, even throughout endoscopy, see carevue. 3+ pitting edema in all extremities. Echo done today, results pending, Hct now stable @ 27, endoscopy unrevealing, no tarry stool this shift: probable lasix gtt to start to begin diuresis. Art line to be d/c'd pt noted to have cool L hand, brachial pulse palpable. Fibrinogen to be drawn next rounds.\\n\\nResp: Improving RLL psedomonas PNA on Vanc and Imipenim. RR in 20's, sats >95% on CMV 40%/500/10 PEEP. Trach changed today to decrease leak size and improve tidal vol's. Pt now has flexi phlange hyperflex trach #8. Additional trach on order from . ABG wnl this pm, see carevue\\n\\nGI: TF was at goal of 50 with no residual, +BS in firm/distended, nt adb. Became NPO for endoscopy this pm, expect to restart TF. No stool this shift. Endoscopy showed clean PEG insertion, diverticulosis x1 but no active bleeding evident.\\n\\nGU: Patent foley draining amber clear urine @ 30cc/hr.\\n\\nSkin: tear on L forearm; dressing on upper back placed last night and should not be changed until . PICC dressing to be changed @ 0000.\\n\\nLines: PICC patent, draws. Art line to be d/c'd\\n\\nSocial: Daughter and her 3 teen children for !2hrs today. Pt minimally interactive. Family to discuss code status later this wk\\nPlan: Monitor and support hemodynamics\\n Fibrinogen draw next rounds\\n ? restart TF\\n ?Lasix gtt\\n T q2, sxn prn\\n IV abx as ordered\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624069,\n \"text\": \"Nursing Note:\\n\\nNeuro: pt alert, opens eyes, follows commands inconsistantly. occasionally nods head or gives facial expressions. pos gag and strong cough. received 1mg prn ativan overnight, does not respond to pain assessment, does not appear in any pain/distress.\\n\\nResp: trach intact (8.0 TTS water seal cuff), no vent changes ovenright. remains on AC 22/500 PEEP 10, FIO2 0.40. sats 97-100. lungs clear/coarse upper/diminished lower. suctioned for moderate amts thick white/tan. spare trach x2 at bedside.\\n\\nCV: HR 85-110 afib w/ occ PVC's. NBP 90-115/60-75, systolic BP noted to be in 80's occasionally when sleeping, MAP >60. diltiazem held @ MN (MD aware). pt has +3 generalized pitting edema. pos distal pulses.\\n\\nGU: pt started on lasix gtt overnight for low UO (goal 30-40cc/hr). presently at 2mg/hr. UO 20-35cc/hr clear amber. MD aware.\\n\\nGI: abd firm/distended, pos bowel sounds, TF @ goal of 50/hr via PEG, pt tolerating well, minimal residuals (<10cc). sm soft black stool x1 overnight, guiac pos.\\n\\nIV: r brachial PICC remains WNL, dressing/stat lock and caps changed overnight.\\n\\nSkin: dressing on upper back remains intact. no further skin breakdown noted. pt turned and repositioned off back. SCD's on legs.\\n\\nSocial: no calls/visits from family overnight.\\n\\nPlan:\\ncont. to monitor hemodynamics, resp status (suction prn), urine output w/ lasix gtt.\\n\\ncont to assess potential for pain, anxiety, cont to provide updates on pt on plan of care, procedures.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624035,\n \"text\": \"NSG.NOTES 1900-0700HRS\\n\\nNeuro:alert,responding to commands and obeying.denies any pain,comfortable on bed.generalised edema.\\n\\nResp:,vented,AC/14/450/5/40%/.suctioned large thick secretions.sats >95%.LS coarse throughout.trache care given.\\n\\nCVS:HR 90-100/min,afib,no ectopics noted.BP 110-130/60-70 mm of hg.A line on Lt radial,patent,slight bleeding from site,dresing changed.\\n\\nGU/GI:PEG present,BS hypo,feed advanced to goal rate of 40ml/hr,and flush with water50ml q6h.tolerating feeds.had large black loose stool.\\non foley cath,urine output adequate,amber clear.\\n\\nIntegu:pressure sore on upper back,cleaned and duoderm applied.edema ++.bath given and position changed.on bactrim,genta and imipenam\\n\\nIV access:Rt midline double lumen cath,one port patent.dressing changed.A line on Lt radial.\\n\\nsocial:no family contact during the shift.calm and co operative.full code.on contact precautions for MRSA PNA\\n\\nPlan:pulmonary toileting and airway management.care of skin.emotional support.\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624099,\n \"text\": \"Shift Note: 0700-1900\\nNeuro: Pt alert, and vented. Opening eyes spontaneously and following commands consistently. Shakes and nods head appropriately. Continues w/ profound generalized weakness. OOB to chair X 5-6hr today via lift and tolerated well. Pt denies pain t/o shift, appears calm and relaxed and remains free of distress.\\n\\nResp: Vented AC 500/5 X 20 FiO2 30% though tolerated CPAP/PS 25/5 X 3-4hr today when OOB to chair. BBS course to somewhat diminshed at bilat bases. Snx q3-4hr for small to moderate amounts thick white secretions. Pt remains afebrile.\\n\\nCV: HR 70's to 80's afib w/ occasional PVC. BP 89/60 to 117/62. Continues on lasix gtt at 4mg/hr. Hct stable at 23.8 though pt continues w/ occasional loose black tarry stools. Team - aware/. CT MD in on consult today, discussed pt status and goals of care w/ family. Plan for pt to be transferred to CCU r/t plan for valve replacement after labor day. Family updated on pt status and discussed POC w/ Dr. today and family reports that the risks of valve replacement have been \\\"well explained.\\\" Family to discuss plan w/ pt later this week.\\n\\nFEN: Pt tolerating TF at goals. Abd soft, non-tender w/ BS present. Plan to change TF to nutren 2.0 w/ and new goal rate will be 40ml/hr. TF to be sent to unit from dietary. FSBS has remained stable 70's though new TF formula w/ >50% carbohydrate load compared to current feeding so anticipate higher blood glucose levels. Glargine dose has been decreased to 26units per orders. Foley catheter patent and draining clear yellow urine 80 to 120ml/hr. K 3.8 was repleated previous shif per report and orders.\\n\\nSocial: Family has been in to visit and discussed plan w/ team and CT MD as above. Information reinforced by this RN. Family very appreciative of care.\\n\\nPlan: Continue to monitor VS and labs. Continue Po dilt and lasix gtt as ordered and per written parameters. Monitor for s/s bleeding and follow hct. Anticipate PRBC tx to elevate hct prior to procedure. Continue OOB to chair as tolerates during day w/ CPAP/PS as tolerated. transfer to CCU.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624100,\n \"text\": \"Resp Care\\nPt remians with #8.0 TTS H2O cuff on a/c. pt got up to chair today and was switched to PSV 25/5 for >3hours while in chair, he was switched back to a/c due to decreased vts and tachypnia. BLBS course, suctioned for thick pale yellow secretions. plan to remain on a/c overnight and trial psv tomorrow as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624101,\n \"text\": \"NPN 7P-7A\\nTHIS IS A 79YO WITH EXTENSIVE PMH ADMITTED FROM WITH SEPSIS. PT. FOUNT TO HAVE PSEUDOMONAS IN . HE IS VENT DEPENDENT. AT TIME OF ADMISSION PT. FOUND TO BE IN RAPID AFIB. SINCE ADMISSION HAS BEEN TREATED WITH MULTIPLE ANTIBIOTICS, FLUIDS AND DILTIAZEM. RECENTLY HAS BEEN HAVING BLACK TARRY STOOLS WITH HCT DROPS. FAMILY DECLINING COLONOSCOPY AT THIS TIME. ALTHOUGH, FAMILY HAS BEEN INQUIRING ABOUT A 'PERCUTANEOUS VALVULOPLASTY PROCEDURE' THEY HAD LOOKED UP AND FOUND ON INTERNET. RISKS OF THIS PROCEDURE HAVE BEEN EXPLAINED TO PT.'S FAMILY. PLAN IS TO HAVE HIM TRANSFERRED TO CCU AT SOME POINT BEFORE LABOR DAY WEEKEND.\\n\\nNEURO: PT. ALERT. NODS HEAD YES AND NO APPROPRIATELY TO QUESTIONS ASKED. DOES FOLLOW SIMPLE COMMANDS. APPEARS VERY FRUSTRATED. OOB TO CHAIR X 5 HOURS YESTERDAY VIA LIFT.\\n\\nRESP: PT. WITH TRACH AND ON AC: 30%/500/20/5. TOLERATED CPAP+PS X 4 HOURS YESTERDAY. BREATH SOUNDS CLEAR. DIMINISHED IN BASES. CAN BE COARSE AT TIMES, HOWEVER, CLEARS WITH COUGHING. SUCTIONED FOR MODERATE AMOUNTS OF THICK WHITISH .\\n\\nCV: HR 70'S TO 80'S AFIB. SOME RARE PVC'S NOTED. BP 80'S/40'S TO 110'S/70'S. LASIX GTT OFF AT START OF SHIFT AS BP WAS LOW. GIVEN ALBUMIN X2 AND 2U PRBC'S FOR HCT OF 20. + PULSES. 4+ PITTING/WEEPING EDEMA REMAINS PRESENT. AFEBRILE. CT MD IN TO SEE PT.'S FAMILY TODAY TO DISCUSS PT.'S PLANNED PROCEDURE AND GOALS OF CARE. RISKS WERE 'WELL EXPLAINED' AND FAMILY CONTINUES TO BE VERY AGGRESSIVE WITH CARE.\\n\\nFEN: TOLERATES TFEEDS AT GOAL RATE OF 40CC/HR. ABD. SOFT. BS+ . NO BM THIS SHIFT. FSBS HAVE REMAINED STABLE. FOLEY IN PLACE DRAINING CLEAR YELLOW URINE. ? RESTART LASIX GTT WHEN BP IMPROVES.\\n\\nPLAN: CONTINUE TO MONITOR RESP/HEMODYNAMIC STATUS CLOSELY. AM LABS PENDING. REPLETE BLOOD PRODUCTS AS NEEDED. ? RESTART LASIX GTT IF BP IMPORVES OVER THE NEXT FEW HOURS. CONTINUE TO WEAN VENT AS TOLERATED. TRANSFER TO CCU\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624102,\n \"text\": \"Resp Care\\nRemains and ventilated on a/c 500 x 20 30% +5 with no remarkable changes overnight. Strong spontaneous cough, suctioned for thick yellow . Failed again (142)\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624103,\n \"text\": \"MICU EAST NPN 0700-1900\\n\\nPlease see flowsheet for further details.\\n\\nAlert. Nods head appropriatly. Denies pain.\\n\\nAnasarca. Lasix gtt resumed and currently a rate of 4mg/hr. No improvement in UO as yet.He is currently ~550cc positive since midnight. Goal is 6mg/hr of Lasix. Plan to continue to titrate as by BP >90sys.\\n\\n\\nCurrently recieving Golytely prep for colonoscopy tomorrow. No stools at present. Rectal bag on. NPO except for meds. Pt needs colonoscopy before surgery can be done. No noted bleeding this shift. Did not get OOB-chair d/t colonoscopy prep and travel to CT.\\n\\nNo vent changes. Suction freq for sm thick yellow . Maintaining\\ngd O2sats.\\n\\nAfebrile.\\n\\nPre-op Chest CT done. Needs dental x rays but may be difficult as pt must be able to sit up. Ventilator also poses a problem per radiology tech. Team to consult radiology/dentist. ? if pt is aware of surgery. His son said he didn't want him to know until later d/t his anxiety.\\n\\nSon most of afternoon but has gone back to .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624104,\n \"text\": \"Respiratory Care\\nPatient remains on full ventilatory support. Suctioned for moderate amounts of thick yellow secreations on a frequent basis. Breath sounds coarse. Transported to CT for thoracic scan and returned without incident.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624056,\n \"text\": \"NPN 1900-0700\\n79 yo ma s/p MVA on , has been vent dependent since with trach and peg. Adm on for hypotension sepsis, now stable VS. Trach was changed to larger trach c improved comfort. Black tarry stools with hct drop req transfusion over last few days, hct stable o/n.\\n\\nNeuro: Alert, follows commands inconsistently, does not always answer questions with full nod, does not appear to have pain by VS or grimace. Lorazepam 1mg given x2 c good effect. Barely able to move extremities due to edema.\\n\\nCV: Cont in A-fib. Coumadin and ASA were d/c'd #days ago due to hct drop. HR 84-97, freq pvcs. SBP 85-132. SBP dropped to high 80s after po Dilt dose given, remained high 80s for ~ one hr. Hct o/n stable at 23.4, am labs pending.\\n\\nResp: On AC 40%/500x20, peep8, overbreathing vent by 0-5. Sats 96-99, Sx ~q2hrs for mod amt thick, tan to bld tinged sputum. LS coarse, dim at bases. Trach care done, sm amt bldy dng. Much improved night with this trach.\\n\\nID: Afebrile. On vanco and imipenem. MRSA in sputum.\\n\\nGI: +BS, abd obese, distended. TF at goal 50mls/hr per peg. No stools this shift, passing flatus.\\n\\nGU: Lasix d/c'd due to incr in cr to 1.5. Pt anasarca, 3+ fld. +1.3L , 4.7L los. U/o now 35-40mls/hr, clear, amber urine.\\n\\nSkin: Lower legs ecchymotic, L foot colder than R foot, +pp. Pressure sore in upper back covered by duoderm, 1cm round opening, washed c saline. Extremeties heavy with fld.\\n\\nAccess: a-line, L picc.\\n\\nSocial: Daughter updated by Dr. .\\n\\nPlan: F/u on am hct, lytes. transfuse for hct 21. monitor temps, suction prn, maintain pt's comfort and support to family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624057,\n \"text\": \"RESPIRATORY CARE:\\n\\nPt remains , vent supported. No changes made overnight. BS's coarse at times. Sxing thick white/tan secretions. Administering Albuterol and Atrovent MDI's in line with vent, as ordered. RSBI=85 this am. See flowsheet for further pt data. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624058,\n \"text\": \"Resp Care\\nPt remains on CMV via trach. Pt has had small reoccurring cuff leak, pt exhaling during inspiration and has been tachypnnic. Peep was increased, pt seems more comfortable on vent. Cuff has been inflated with 13cc's pressure 45, team is aware. Plan to monitor resp status and eval trach.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624059,\n \"text\": \"progress note:\\n\\nneuro: pt nodding appropriatly after much encouragment. seems depressed flat affect. pt almost in tears this am but clearly shook head no when asked if wanted to stop tx. able to lift lt arm purposefully. family feels pt is much less interactive and somulent and requested to stop lorazopam and clonazapam as pt had been snowed and acting \\\" loopy\\\" with mind altering drugs in other hosp.\\n\\nresp: this am pt in distress with RR to 35 and audible cuff leak on end inspiration. air added to cuff and lorazapam 1 mg given and pt settled to rr 24 hr down to 80\\\" from 110\\\"s, gas redrawn and alkalosis still seen. cuff leak present again after a few hrs and pt only tv of 340-380 of set 500 cc. resp rate up again to >30 and made vent setting changes to hopefully compensate for tv not delivered. per resp therapist pt still having leak and losing approx 100 cc of tv so increased peep to 12 and pt much more comfortable. gas did not improve much other than inc in p02 and slight decrease in pco2. suctioned several times tan thick secretions. rr currently in 24-28 range with sxat 100 %\\n\\ncard: a fib with occasional pvcs, hr lower to 80's after ativan otherwise in high 90-11- range. bp 91 sys lowest after ativan and high to 130/91. all doses dilt given. crit 1500 24.2 goo Perp pulses. general anasarca. did not diuresis d/t renal function impairment. but did just start acetazolimide.\\n\\ngu: pos 800 cc since midnight. urine is less concentrated and apporx 35-40 cc/hr out\\n\\ngi: no bm pos bs, no flatus. abd distended soft. tf at goal\\n\\nskin: no further breakdown\\n\\naccess picc rt arm with swelling no dvt as per ultsnd . flushed with ns the unused port without resisatnce today\\n\\nsocial: pt daughter in to see him and feel pt is much o=more somulent and weak. she was updated with resp status and progress.\\n\\nplan: monitor resp status, poss discuss intreventional pulmonology to recheck trach and poss change again. monitor blood gas. skin care\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624126,\n \"text\": \"NEURO: PT. ALERT, UNABLE TO ASSESS ORIENTATION, WITHDRAWN AT TIMES, SPONTANEOUSLY MOVES ALL EXTREMITIES WITH NO PURPOSE TO HIS MOVEMENTS. PT. DOES NOT FOLLOW COMMANDS. DOES RESPOND TO PAINFUL STIMULI (NAIL BED).\\n\\nCV: PT. AFIB, HR 80'S, SBP 110-130, RARE TO OCCASIONAL PVC'S NOTED. SEE CAREVUE FOR COAG'S. SKIN WDI- PULSES PALPABLE.\\n\\nRESP: PT. LUNGS CLEAR IN RUL, COURSE IN LUL, DIMINISHED IN BASES. SEE CAREVUE FOR VENT SETTINGS AND ABGS. PT. +GAG, +COUGH, SUCTIONED VIA ETT FOR THICK, YELLOW SECRETIONS OF SMALL TO MODERATE AMT.\\n\\nGI/GU/ENDO: PT. ABD SOFT, +BS, BM X2- BROWN, SOFT, MUCOUSY STOOL, GUIAIC NEGATIVE. TUBE FEEDS (REPLETE WITH FIBER) AT GOAL OF 80CC/HR VIA PEG. FOLEY DRAINING CLEAR TO SEDIMENT, YELLOW URINE. LYTES REPLETED. BLOOD SUGARS TREATED PER RISS.\\n\\nPLAN: REHAB TODAY?, WEAN MECHANICAL VENTILATION, SKIN INTEGRITY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624065,\n \"text\": \"NPN 1900-0700\\n79 yo ma s/p MVA on , mostly vent dependent since then, except for few periods of few weeks off. and pegged in , pseudomonas PNA, RLL. Trach changed on and again on . Pt cont to have sm trach leak but much improved. Also has had black tarry stools since noted at , had 6-7 units prbc total between here and there.\\n\\nNeuro: Alert, follows simple commands inconsistently. Appears withdrawn/?depressed, on celexa. Difficult to get pt to nod adequately to questions. Moves extrem only slightly, heavy c edema. Pt not given any ativan and clonapan d/c'd. Pt appears comfortable without meds.\\n\\nCV: HR 82-108, a-fib, occ multiform pvcs. No coumadin or ASA. SBP stable 99-132, on dilt 30mg q6hrs. Last hct 26.1, am labs pending. +pp.\\n\\nResp: No vent changes, peep cont 10. LS coarse t/o. RR 22-25, appears comfortable. Sx ~q1hr for mod amt thick, yellow secr. Discussion of changing trach to bovina with foam cuff.\\n\\nID: tmax 99.1 ax. Pt dislikes temp by mouth. On vanc and imipenem.\\n\\nEndo: Glargine decreased to 30units last noc. FS ~ 120.\\n\\nGi: Abd obese, soft distended, +BS. 50mls goal of TF via peg, 150mls water q4hrs. Had two mod-lge black tarry stools hem+.\\n\\nGu: Bloody urine noted , now pink/. 30-60mls/hr. Cr has been dropping, 1.3 .\\n\\nSkin: Pressure sore on upper back, ~2cm round, dsg changed, washed c saline covered c duoderm. LL ecchymotic. general anasarca, Rarm > L. R arm us done, neg.\\n\\nSocial: Pt has 5 children, they take turns visiting. They have been concerned that pt has been lethargic, concerned re sedative meds.\\n\\nPlan: Follow up on am labs, hct, lytes. Monitor BP HR. ? endoscopy for cont GI bldg. ? trach change.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624066,\n \"text\": \"Resp Care,\\nPt. remains on A/C overnoc, no vent changes this shift. #8 Portex trach with occasional cuff leak. Cuff pressure 35cm. Suctioned for thick yellow , MDI's as ordered. No RSBI due to peep level. See carevue.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624067,\n \"text\": \"Respiratory Care\\nPatient received on AC 500x20 10 PEEP 40%, wearing an 8 Portex, breath sounds bilaterally clear but expiratory grunting heard, suctioned intermittently for moderate amounts of thick yellowish secretions,was afebrile, into chronic A-fib, had occasional, frequent and rare PVCs, Blood Pressure stable all day long, patient had trach tube change around 1300, the 8 Portex has been replaced with bronchoscopy support by an 8 TTS water-sealed cuff, 12 at the flange, initial cuff pressure was 22 CmH2O,the leak persisted in spite of the trach change, patient also had a negative endoscopy today, has been treated with Albuterol and atrovent inhalers, ABGs at 1238 was good, no vent changes have been made, will continue to be provided with mechanical ventilatory support, treatments and close monitoring.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624054,\n \"text\": \"Resp Care\\n\\nPt remains on full vent support. MV being maintained in the 10-13L range. Trach changed to # 8 portex non-fenestrated. Cuff pressure 30. Minimal leak. BS with occ rhonchi. Suctioning thick tan sputum.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624127,\n \"text\": \"resp care - Pt is and on PSV. No changes were made in vent settings this shift. Pt was suctioned for moderate to copious amounts of thick, yellow secretions. Meds were given as ordered. Plan is for transfer to rehab.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624128,\n \"text\": \"0700-1900\\nneuro: awake, alert, follows some commands, pt very withdrawn, , po celexa started, moves extremites on bed, pt very weak\\n\\ncv: hr a-fib, rare pvc, sbp stable(117-137), po lopressor\\n\\nresp: no vent changes, continues on 40% cpap ps, sux sm/mod amt loose thick yellow , bs+ all lobes, course, decreased to bases, inhalers by R.T., no resp distress noted\\n\\ngi: goal TF well, no N/V or stool, iv protonix \\n\\ngu: foley patent, clear yellow urine, good uo, iv lasix \\n\\nother: daughter in & updated on pt's condition, no c/o pain\\n\\nplan: continue with ventilatory support, po antibiotics as ordered, tx to rehab when bed available\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624129,\n \"text\": \"FULL CODE Contact precautions\\nAllergies: Haldol, heparin (+HIT)\\n\\n\\nNeuro: AA, occ follows commands, nods approp to questions.\\n\\nCV: HR=90-100s, afib. BO=120-140s/50s. +palp pedal pulses. +generalized edema.\\n\\nResp: Trach CPAP 40% w/ 02sat 98%. Lund w/ crackles in RLL and LUL/LLL, RUL clear. lasix 20mg IVP given as scheduled. RR=22-28. Sx for yellow .\\n\\nGI/GU: Abd soft/distended, +BS. TF Replete w/ Fiber at 80cc/hr=goal w/ min resid. Large soft-formed BM. Foley cath w/ amber clear urine.\\n\\nPain: denies discomfort by shaking head \\\"no\\\" to question.\\n\\nSkin: generalized edema. Allevyn dressing intact on upper back.\\n\\nAccess: R rad a-line and R antecub PICC double lumen. IVF infusing via one port and second port is difficult to flush.\\n\\nPlan: rehab placement. Continue to monitor resp/cardiac/neuro status. Wean vent as . Update family on status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624130,\n \"text\": \"Resp Care\\nRemains and ventilated on cpap/psv wiht no remarkable changes overnight. ABGs within normal limits but maintained with high minute ventilation. Albuterol/atrovent inhalers given q4. Suctioned for thick yellow . = 109.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624055,\n \"text\": \"MICU NPN 11AM-7PM:\\nEvents of the day:\\n\\nTrach changed at bedside, upsized to #8 portex no-fenestrated trach. Tolerated this well with 100mcg IV fentanyl.\\n\\nTransfused with one unit PRBC's over three hours tolerated well. Post hct up to 23.5 from 21.8. Please recheck hct at 2200.\\n\\nVanco IV added to antibiotic regimen.\\n\\nNeuro: Sleepy after given the fentanyl for the trach change but more awake and seems restless this afternoon. Nods head to simple questions. Hates to have his PO temp checked. Tylenol given once for generalized discomfort.\\n\\nCV: Vital signs are essentially stable but BP noted to drop to 90's after getting PO diltiazem. HR 90-110 a-fib w/PVC's noted. BP 90-130/60.\\n\\nResp: Vent currently on AC 20, 500TV 40% FIO2 with 8cm peep. Less air leak noted after trach change. Trach care done twice for small amts bleeding around site after changing trach. Moderate amts thick tan/bloody secretions. Lungs coarse and deminished throughout.\\n\\nGI: Tolerating tube feeds at goal. No stool. Abdomen is soft non-tender.\\n\\nGU: Voiding good amts via foley catheter. Lasix stopped because creatinine rising slightly.\\n\\nID: Low grade fever this afternoon. On vanco/Immepenum IV.\\n\\nSocial: Daughter updated by Dr. at length today.\\n\\nEndo: Blood glusose running 150's and no sliding scale ordered unless glucose is greater than 160.\\n\\nPlan: Holding off on further aggressive diuresis in hoped that creatinine settles down, follow hct this eve at 2200 with goal hct >21. Continue to follow vital signs closely and keep pt/family involved in plan of care.\\n\\n\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624120,\n \"text\": \"MRSA and VRE precautions\\n\\nNeuro: pt responds to verbal stimuli by opening eyes.. sometimes it looks he follows you with his eyes, but does not respond when asked to shake his head, wiggle his toes or move his extremities\\n\\nResp: vented and , see Flow Sheet for increased settings D/T rapid RR's acidotic ABG, ABG better with changes, lungs coarse bilat and diminished at bases, suctioning for thick tan secretions\\n\\nCardiac: hypotensive at times, fluid challange X1 with good results, afib with rare to frequent PVC's, repleated K+ X1\\n\\nGI: + BS, + medium soft brown BM X1, TF at goal, no residuals\\n\\nGU: foley to gravity, good output with lasix, VRE of urine\\n\\nEndo: SSRI per \\n\\nsocial: family called and updated X1\\n\\nPlan: follow labs and vitals and treat as indicated and as ordered, OOB with , ? screen for rehab, MRSA and VRE precautions\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624121,\n \"text\": \"RESP CARE: Pt remains /on vent, settings per carevue. PS increased for hypercarbia. AM ABG improved. Lungs coarse bilat. Sxd small amts thick yellow. AM -148. Pt remains vent dependent\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624122,\n \"text\": \"0700-1500\\nneuro: awake, alert, follows most commands, moves extremities on bed, pt very weak\\n\\ncv: hr a-fib, no ectopy, sbp stable(119-137), po lopressor\\n\\nresp: continues on 40% cpap ps, bs+ all lobes, course, diminished to bases, sux sm/mod amt loose thick yellow , inhalers by R.T., sat 100, no resp distress noted\\n\\ngi: goal TF well, no N/V or stool, po colace, iv protonix increased to today(am hct 22.7), GI consult in, giuac neg brown stool noted via rectal exam\\n\\ngu: foley patent, clear yellow urine, good uo, iv lasix \\n\\nother: type & screen sent today, pt to get tx with 2 u pc's when blood products ready, no c/o pain\\n\\nplan: continue with ventilatory support, po antibiotics as ordered, tx 2 u pc's, continue rehab discharge planning\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624123,\n \"text\": \"resp care - Pt is and remains on PSV. No changes made this shift. BLBS are coarse; pt was suctioned for varying amounts of thick, yellow secretions. Transfer to rehab planned for tomorrow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624124,\n \"text\": \"3p to 7p: did get 2 units of blood, vitals wnl's, placed bed on automatic side to side turn, no other changes; plan: ? rehab in am.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624125,\n \"text\": \"Respiratory Care\\nPt on vent support. no vent setting changes made this shift. ABG WNL, but maintained by large minute ventilation. Sx for mod to lg amounts thick yellow secretions. BS mostly clear. AM 106.\\nPlan is to discharge pt to rehab facility, possibly later today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624031,\n \"text\": \"Nsg.admission notes 2130-0700hr\\n\\nAllergies:HALDOL,HEPARIN.(heparin induced thrombocytopenia)\\n\\n79yo male pt from HC,third admission to , and vented,vent dependent from ,a case of TCP,depression,s/p valvuloplasty,pleural effusion,MRSA PNA,T9 compression Fx,c to MICU for increasing lethargy ,temps,VAP and also family request.blood c/s +ve staph,sputum c/s +ve pseudomonas,was on vanco,may need to continue ,started meropenam.\\n\\nNeuro:alert,responding to call and commands,not mouthing words.lethargic.generalised edema.\\n\\nResp:,vented,AC,14/450/10/405.SATS >95%.suctioned thick yellow secretions.sputum c/s sent.LS coarse throughout.\\n\\nCVS:HR 100-120's,ST-NSR.no ectopics noted.received 2unit blood transfusions in for low crit.Blood c/s 2 samples sent.Blood gas done .pneumoboots to be applied.both LE black coloured,more on Lt.leg.boots on,pulse easily palpable on Rt leg,and difficult on left leg.\\n\\nGU/GI:abdomen obese,bowel sounds hypo,PEG ,site cleaned and dressing applied.NPO.Had BM,large black loose stool.on foley cath,amber clear urine.received 20mg iv lasix with minimum effect\\n\\nIntegu:skin impaired on spine,duoderm .temps 101.3 on admission.sponge bath given and positioned.\\n\\nSocial:no family contact or during the shift.MRSA on contact precautions.full code.\\n\\nIV access:PICC on Rt ante cub,red port is patent,flushing well and good blood flow,purple port unable to flush,informed ,may need TPA to maintain patency.\\n\\nEndo:on SSI,Not covered.\\n\\nPlan:pulmonary toilet.\\nantibiotics,Temp's,and control infection.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624032,\n \"text\": \"Resp Care\\nPt transfer from OSH. placed on vent ( see carvue for settings) Pt has a # 7 shiley trach. suctioned for thick copious blood tinged pluggy secretons, sample sent. Xray show, bilateral infiltrates and small lung fields. High Hco3 and Paco2 in abgs. Decreased fio2 and increased peep to help in ventilaton. Mdis started: notable decrease vent pressures. Will continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624033,\n \"text\": \"Respiratory Care:\\nPt remains and vented. PEEP decreased to 5 from 10 d/t hypotension.ABG showed non-compensated metabolic alkalosis with mild hypoxemia. Lung sounds coarse. Suctioned moderate to copious thick yellow secretions. MDIs given per order. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624091,\n \"text\": \"\\u0013npn 7p-7a (please also see careevue flownotes for objective data)\\n\\nAfebrile, vss; v-response remains in 80's, diltiazem held approx every other dose, receiving approx q 12 hrs instead of q 6 hrs;\\n\\ndx: sepsis; resp failure; transfer from \\n\\nOn A/C from approx 22:00-05:30; switched to PS again at 05:30;\\n\\nMajor goal at this time is to continue diuresing this pt; lasix gtt at 4 mg/hr most of this 12 hrs, decreased from 5/hr at 19:00, for fear of diuresing too fast;\\n\\nPt continues to receive K+ supplement d/t loosing 2/t lasix being non K+ sparing;\\n\\nReceiving Gargine at HS; FS's have been in good range;\\n\\nPt more alert and responsive with eye contact/tracking, smiles, gestures; did not sleep much this night;\\n\\nPLAN:\\nContinue current POC;\\nfurther plan per rounds\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624051,\n \"text\": \"NPN 1900-0700\\n79 yo ma s/p MVA , vent dependent since. Remains in a-fib, but off coumadin d/t drop in hct to 19.9.\\n\\nNeuro: Alert, awake, follows simple commands. Difficult moving extrem c lge amt edema. Does not appear to be having pain per VS, grimace scale and non-.\\n\\nCV: HR 102-112, a-fib c occ pvcs. SBP 102-158. Received 2 units pc yest for hct 19.9, up to 24, am lab pending. Received 3 u total FFP. K 3.8, repleted c 40meq kcl in 500mls.\\n\\nResp: Received on AC/40%/450x20/8peep. At 8pm, tachy and hypertensive to 158, RR 36. Sx few times, thick, bld tinged sputum. Desated to 88 x2. Peep incr to 10 and fio2 to 50% c improved VS. Pco2 up to 63, so TV incr to 500 and fio2 back to 40%. Sats cont 97 or > remainder of noc. pco2 down to usual 52. placed back on 8 pep at 0400, cont good sats and RR 25-30. LS coarse, sx ~q2-3 hrs.\\nCont to have cuff leak on this trach, ? needs larger trach.\\n\\nGI: ABD obese, +BS. TF at goal of 50mls/hr via peg. Had one soft, black tarry stool, OB+, also passing flatus.\\n\\nGU: Receiving lasix 40mg c fair response. Urine yellow to amber, clear, adequate vols. Pt fld balance + 3.8L los.\\n\\nEndo: Receiving humalog for SSI, FS 228, and glargine.\\n\\nID: Tmax 100 ax. On miripenim and bactrim. MRSA prec.\\n\\nSkin: Duoderm intact on upper back pressure sore. Bilat lower legs ecchymotic, L>R. L foot colder than R. 3+ edema all extrem and body.\\n\\nSocial: Family will be in tomorrow, no calls tonight.\\n\\nPlan: Monitor RR, abgs, wean vent as . Replete lytes prn. ? further lasix.\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624052,\n \"text\": \"Respiratory Care:\\n\\nPatient with 7.0 Portex. changed . Increased cuff pressure to 50cm/H20 to seal trach. Positional leak at times. Pt. desating to 88%. Sx'd for thick blood tinged secretions. O2 sats improving to low 90's. Peep ^ 10cm/Fio2 ^ 50% and later weaned back to now current settings. PaCo2 rising to 63. Vt ^ 500. Current settings Vt 500, A/c rate 20, Fio2 40% and Peep 8. ABG reveals compensated resp acidosis. BS coarse bilaterally. Albuterol/Atrovent MDI's given q4hr.\\nSx'd for sm-moderate amounts of thick blood tinged secretions. No further changes made.\\nPlan: Continue with mechanical support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624053,\n \"text\": \" 4 NURSING PROGRESS NOTE 0700-1100\\nNEURO--PT ALERT, NODDING HEAD TO SIMPLE QUESTIONS. SQUEEZES HANDS TO COMMAND. PT IS VERY STIFF AND NEEDS ASSIST OF 3 PERSONS TO TURN. PT WANTS TO WATCH RED SOX AT 1100.\\n\\nCARDIAC--REMAINS IN AFIB WITH RATE 90-110. RARE UNIFOCAL PVC'S. RECEIVED KCL REPLACEMENT THAT WAS STARTED ON NIGHTS. HCT DOWN TO RECEIVE 1U PRBC.\\n\\nRESP--SX Q2 HRS FOR THICK TAN SPUTUM. REMAINS WITH CUFF LEAK. PLAN IS TO CHANGE TRACH LATER TODAY. BILATERAL BREATH SOUNDS ARE COARSE. SAO2 >97%.\\n\\nGI--. TUBE FEEDS AT GOAL. STOOL X1. ABD DISTENDED. +BS. STOOL IS BLACK , TARRY AND GUIAC +.\\n\\nGU--FOLEY CATH PATENT. RECEIVED 40 MG IV LASIX WITH GOOD DIURESIS.\\n\\nENDO--UNREMARABLE AT PRESENT.\\n\\nSKIN--DUODERM ON BACK INTACT. BUTTOCKS WITHOUT BREAKDOWN. ORAL CAVITY DRY.\\n\\nPAIN--DENIES PAIN WHEN ASKED.\\n\\nID--AFEBRILE. REMAINS ON ABX.\\n\\nCOPING--NO FAMILY MEMBERS HAVE PHONED OR AS OF THIS TIME.\\n\\nA--LEAK IN TRACH. FALLING HCT.\\n\\nP--TX 1 U PRBC. CON'T TO MONITOR. ? WHETHER TO SCOPE TO FIND SOURCE OF BLEED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624092,\n \"text\": \"resp care\\nPt initially on psv25/peep5 and 40%. Changed to a/c to rest overnight after pt c/o of sob. BS coarse bil. Suct for thick yellow sput.Alb/atro mdi given as ordered. Fio2 weaned to 30% per order. done >100. Will cont to follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624093,\n \"text\": \" enetered @1400 on was actually done at 0600. Data could not be entered due to time restrictions in carvue. No value for because numver > than limit of formula value. (JP).\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624094,\n \"text\": \"Resp Care\\n\\nPt placed on cpap/psv during at 1630 while up in chair. On a/c minute volume being maintained in th 9-10L range. BS with scattered rhonchi and suctioning thick yellow .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624095,\n \"text\": \"NPN 0700-1900\\nFull code All: Haldol\\n\\nNeuro: Alert, appears oriented, participating in mouth care, interactive with staff/family although less so than yesterday. Of note, pt reportedly had very little sleep overnoc so that may be why he is less animated today. Afebrile\\n\\nCV: Stable. Afib, rare to occasional PVC's, rate consistently in 80's/90's. SBP 89-1teen's with MAP>61 throughout shift. Lasix gtt remains @ 4mg/hr. + pitting edema remains in extremities despite diuresis. Denies CP.\\n\\nResp: Alternating PS and CMV. Currently OOB in chair and tolerating CPAP @ 30%/. Frequent sxn for small amts white to yellow , also pt continues to cough up mucous on his own. Appears to be slightly less productive than . Will attempt deep brthing if encouraged.\\n\\nGI/Endo; TF well @ 50cc/hr. FS @ 1800 58 mistakenly left off since OOB to chair. amp D50, MD aware. Glargine has been decreased to 28units @ HS. BM x2 soft, brown, guaiac +.\\n\\nLines: PICC in R patent, dressing changed today.\\n\\nSocial: one daughter , another daughter/soninlaw phoned/\\n\\nPlan: Continue diuresis, pt will be able to dispo when fluid removed\\n PS as \\n RISS/ TF\\n Encourage c/db, interaction\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624096,\n \"text\": \"npn 7p-7a (please also see carevue flownotes for objective data)\\n\\ndx: sepsis; resp failure/vent dependency\\n transfer from for lethargy, persistent fevers\\n\\n79M w/ pmhx AS s/p valvuloplasty, IDDM, PAF, MRSA pna and c-diff, MVA w/ long hospitalization and Hosp in VT, w/ long hosp course resulting in trach/PEG ;\\npt has also been having chronic anemia, family has declined colonoscopy;\\n\\n recently discharged from after being admitted for hypotension, fevers; Pt was discharged to for further tx and abx, completed abx , spiked fever , abx started/re-started; cx's sent, cx w/ evidence of pseudomonas; pt also w/ episode rapid a-fib, started on diltiazem;\\n\\n pt returned to per request of family, admitted to 4, for lethargy, fevers, w/u. Has been receiving abx, IVF hydration.\\n\\nMost recent goal have been for pt to wean from A/C/ vent assist to PS, pt has been needing assist to diurese excesss body fluids;\\npt has tremendous interstitial edema, skin taught;\\nresp cx's & 21 both + pseudomonas\\n\\ntoday pt remains on lasix at 4 mgs per hour, with good hourly ourput of 100-160 cc/hr; also continues to received K+ supplementation, this a.m.'s serum K+ is 3.8, same as yesterday eve draw at 19:00--pt received 40 mEq KCL after result available.\\n\\npt ordered for diltiazem 30 mg po q 6 hrs, has been having good v-response control, has been receiving approx q 12 hrs d/t held doses re b/p given effect of diuresis also on b/p;\\n\\nduoderm dressg on mid upper back intact, dated ;\\nRt a.c. double lumen PICC drssg intact, both ports intact;\\n\\ntolerating tube feedings w/out emesis or diarrhea;\\nhas been stooling mod soft stools;\\nblood sugars/FS have been decreasing, pt may need more decrease on hs glargine (was decreased by 2 units )\\n\\nOOB to reclining chair about 2 p.m. , returned to bed per approx 22:30;\\n\\npt has been more alert/interactive the past two days, remains nonverbal, but w/ more eye contact and facial expressions/smiles;\\n\\nfamily has asked staff regarding a 'percutaneous valvuloplasty procedure' they had looked up and found on in the internet; MDs state does not do that procedure, family stated they will look for a hospital that does and will accept pt; in the meantime, reportedly plan is to continue to diurese pt to assist wean on vent, and continue w/ discharge planning--?return to ;\\n\\nPLAN:\\n1) continue current POC\\n2) diuresis, goal approx 100 cc/hr\\n3) cont to wean on vent, progressing to more time on PS instead of A/C\\n4) electrolyte repletion as needed and as ordered\\n5) follow FS's, ? decrease glargine dose hs\\n6) OOB to cardiac/reclining chair during the day per lift\\n7) CT surgery consult in a.m. 8/27 per family's request\\n8) MRSA precautions, s/t hx MRSA pna\\n9) pt remains FULL CODE\\n10) family coomunication: daughter , has been making some decisions re pt's care, even though not official HCP\\n11) labs only q 24\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624097,\n \"text\": \"(Continued)\\n hrs if possible, to avoid blood loss d/t anemia\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624098,\n \"text\": \"resp care\\nPt initially on psv25/peep5 and 30% while up in the chair.Placed back on a/c 500x20 5peep 30% when placed back in bed.Peak/plat 34/28. BS coarse at times. suct for thick pale yellow sput. Alb/atro mdi given as ordered.Will cont to follow and wean back to psv when in a chair. >100.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624116,\n \"text\": \"NEURO: PT ALERT, DOZED ON/OFF THIS SHIFT, AROUSES TO VOICE EASILY. VISUAL ACKNOWLEDGEMENT OF CAREGIVER, BUT WITHDRAWN-VERY LITTLE INTERACTION. FOLLOWS COMMANDS INCONSISTENTLY-SQUEEZED RT HAND X1, OTHERWISE NO COMMANDS FOLLOWED. RESISTS MOUTH CARE, CLENCHING TIGHTLY. EXTREMITIES TENSE DURING SIDE TO SIDE TURNS. NO OBJECTIVE INDICATIONS OF PAIN-ASSESSED BY VITALS & GRIMACE.\\n\\nCV: AF, HR 70s-80s. ? START COUMADIN. BP 100s-110s, UP TO 150s W/ACTIVITY OR WHEN SXN'D. +PP. EXTREMS W/D. COMPRESSION SLEEVES ON. AFEBRILE.\\n\\nRESP: LS COURSE BILATERALLY, O2SATS >97%. NO VENT CHANGES THIS SHIFT-REMAINED ON CPAP/PS 40/5/10. TV 300s-500s. RR 20s-30s. OCCAS. SXN'D SM-MOD AMTS THK YELLOW SECRETIONS. TRACHE CARE DONE BY RT. SEE CAREVUE FOR LATEST ABGs.\\n\\nGI/GU: TOLERATING FS REPLETE W/FIBER @ GOAL=80cc/hr VIA PEG; NO RESIDS. +BS. ABD SOFT, NT, ND. LG BROWN SOFT FORMED STOOL X1. HUO ADEQUATE, CLR YELLOW W/SEDIMENT.\\n\\nENDO: RSSI PER SS-COVERAGE REQUIRED OVERNOC.\\n\\nSOCIAL: ? PLAN TO D/C TO REHAB . D/C PAPERS TO BE COMPLETED. NO TELEPHONE CALLS FROM FAMILY THIS SHIFT.\\n\\nPLAN: CONTINUE MONITORING CARDIORESP STATUS, LABS. PULM TOILET. ?START COUMADIN; ? TRANSFER TO REHAB , COMPLETE D/C DOCUMENTS. SUPPORT/UPDATE FAMILY RE: PLAN OF CARE.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624117,\n \"text\": \"RESP CARE: Pt remains /on vent on PSV 10/5/.40. Vts 300s/RR 30s.Lungs rhonchi L>R. Sxd small amts thick yellow . MDIs given per POE with little effect noted. AM -126.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624118,\n \"text\": \"Respiratory Care\\nPt weaned on PSV to attempts to wean to resulted in a PH of 7.29, psv increased to with resulting abg 731/59/83/31/0/94. mdi as ordered, suctioned for mod amts of frofty white secrections. Pt planning on going to rehab. ? tommorrow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624119,\n \"text\": \"Neuro: More alert in PM, still blank stares @ speaker, not follwoing any commands, LE's withdraw to nail bed pressure bilat, but not UE's; PERRL 3mm brisk\\n\\nCV: Afberile, A fib 80's, SBP labile, 80's when sleeping, hypertensive to 170's when family is here, lopressor dose changed to 25mg TID, weak palpable pulses x4, 1 episode of hypotension after vent change in PM, 250 ml NS fluid bolus given with effect; K repleted; no coumadin NP \\n\\nResp: Lung coarse all over, received on CPAP , wean PS to 5 @ one point, became more acidotic, PS @ 8 currently, ABG acceptable, Pa CO2 @ pt's baseline; suctioned with thick tan secretion\\n\\nGI: Abd soft, non-tender, BM x3, soft, brown formed stool, tolerating TF replete with fiber @ goal 80 ml/hr, minimal residual\\n\\nGU: Foley draining clear/sedimentary yellow urine, restarted on lasix 20 mg , foley changed today due to +urine culture for VRE on specimen\\n\\nPain: no pain noted\\n\\nEndo: COver per CSRU protocol\\n\\nID: +VRE in urine from specimen, foley changed\\n\\nInteg: upper back wound assessed by wound care nurse, allevyn dressing changed, wound healing per wound care nurse\\n\\nActivity: OOB to chair via for 2 hours\\n\\nSocial: Daughter in for visit, met with NP , agreed to look @ Rehab today\\n\\nPlan: Monitor hemodynamics, resp status, labs; wean vent as ; DC planning; wound care\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2129-08-12 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 978512,\n \"text\": \" 5:56 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: pleural effusion, pulmonary edema, tamponade, pneumothorax,\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with AVR\\n REASON FOR THIS EXAMINATION:\\n pleural effusion, pulmonary edema, tamponade, pneumothorax, Page \\n with issues. . Pt will be in csru in 90 minutes.\\n ______________________________________________________________________________\\n WET READ: JRCi 10:54 PM\\n tracheostomy tube removed and patient intubated with ETT in adequate\\n position. There is increased lung volumes and aeration. Swanz ganz catheter\\n with tip in the expected region of the main pulmonary artery. Right picc line\\n with tip in SVC. No pneumothorax. Small left effusion . Interstitial\\n opacities remain.\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION: AP chest.\\n\\n INDICATION: Pleural effusion, pulmonary edema.\\n\\n A single AP view of the chest is obtained on at 1815 hours and\\n compared with the prior afternoon's radiograph. Allowing for technical\\n differences, there likely is no significant change in the appearance of the\\n bilateral alveolar and interstitial opacities and likely bilateral pleural\\n effusions. Tracheostomy has been replaced with an endotracheal tube, the tip\\n of which is approximately 4 cm above the carina. Swan-Ganz is present with\\n its tip in the main pulmonary artery. Patient has just had a cardiac surgery\\n with sternal and skin sutures present. A right-sided PICC line is unchanged\\n in position.\\n\\n IMPRESSION:\\n\\n Stable appearance to the chest with bilateral interstitial and alveolar\\n opacities. Intubation with ET tube in satisfactory position.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624070,\n \"text\": \"Pt is on AC vent RR 20, New # 8 with water cuff is in place, marker is . There is no identifyable leak but Vte is lower than VTi. Pt getting alb/atr MDI Q 4 hrs. Pt sx for smal amts yellow secretions.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624071,\n \"text\": \"Respiratory Care\\nPatient remains on full ventilatory support. Suctioning moderate amounts of thick yellow secreations. MDI's given as ordered. Breath sounds coarse throughout. Transported without incident to CT for scan of the head.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624072,\n \"text\": \"NPN 0700-1900\\nNeuro: Alert for most of day, continues to have flat affect, be minimally interactive. ?visual field defect, head ct w/o contrast neg. Will move L hand purposefully. Strong gag/cough effort. Afebrile.\\n\\nCV: Afib, occasional PVC's each hour, HR consistently 80's-90's. Rate controlled with Dilt 30mg QID, noon dose held for BP<100, 1800 dose administered. HR up slightly as pt has begun to cough more in late afternoon. 3+ pitting edema in all extremities but +PP's b/l. SBP>90 all shift. Cardiolgy to consult re: AS and how to maintain intravascular vol, fluid shifts.\\n\\nResp: A/C 40%, TV 500, Peep decreased to 5 today. LS coarse throughout, increasing creamy/thick secretions this afternoon, Dr aware. Trach site clean\\n\\nGI: Obese abd with pos bs, no TF residuals. TF Nutren Pulm FS at goal of 50cc/hr. Soft dark brown stool mod x2, guaiac pos.\\n\\nGU: Patent foley draining amber colored urine with occasional sediment 2 >30cc/hr. Lasix gtt off.\\n\\nID: ABX changed today to Cefepime, first dose done, continuing on Vanc\\nLine: PICC patent, dressing CDI and not to be changed until \\nSocial: no family contact this shift\\n\\nPlan: Sxn prn\\n Monitor and support hemodynamics, Dilt for rate control\\n Turn q2h\\n IV abx as ordered\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624073,\n \"text\": \"Nsg Progress Note 1900-0700\\n\\nCV - Pt hemodynamically stable. BP drops to 90's sys after med with ativan but returns to normal shortly. IVF at KVO via right AC PICC line.\\n\\nResp - BS course bilat. Remains on a ventilator with no changes to settings. Pt initially suctioned for mod to large amt creamy secretions. Amount of secretions decreased signif over course of the night. spec sent.\\n\\nGI - Abd soft - hypoactive BS. No BM. Tolerating TF's very well. Continues to recieve H2O bolus q 4 hours.\\n\\nGU - Foley cath draining adequate amt cl yellow urine. Scrotum grossly edematous.\\n\\nNeuro - Pt able to communicate with nods. Does not move extremities on his own. Pt denies pain but did request ativan so he could rest.\\n\\nSocial - no contact from family.\\n\\nSkin - turned as tolerated - no signs of breakdown noted. Back dsg dry and intact.\\n\\nDr. would like to speak to the family when they come in.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624074,\n \"text\": \"Respiratory Care:\\n\\nPt remain on full/ assist ventilatory support via traheotomy tube ( TTS ~12 cm; water seal). No vent changes done. He was unable to complete , ask for exemption. BS are coarse bil, No wheezes. MDI's adm as ordered with No changes noted in BS. We are sxtn for scant to mod amt of thick whitish to yel secretions, active cough. Plan: awaiting family meeting & will Continuen present ICU monitoring. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624081,\n \"text\": \"Respiratory care\\n\\n Pt continues on full ventilatory support. Sx'd for sm thick yellow. MDI's as ordered. Will continue to follow closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624082,\n \"text\": \"REVIEW OF SYSTEMS:\\nRESP: BRIEF CHANGE OVER TO PS THIS AM-POOR TOLERANCE. NO FURTHER VENT CHANGES. SUCTIONED FOR THICK YELLOW SECRETIONS, COPIOUS AT TIMES. SATS REMAIN IN HIGH 90'S.\\nGI: TF'INGS WELL. NO STOOL TODAY. MIN RESIDUALS. \\u0013\\nRENAL: CONT. ON LASIX GTT, BUT TITRATED TO BP. OFF BRIEFLY FOR BP IN 70'S BUT RESTARTED SOON AFTERWARDS. PRESENTLY AT 2MG/HR. U/O'S RANGING FROM 80CC-240CC/HR. PT. STILL 4+ EDEMATOUS.\\nCV: BP FAIRLY WELL CONTROLLED X FOR BRIEF DROP. REMAINS IN AF WITH GOOD RATE CONTROL WITH DILT. OCCASS PVC'S.\\nENDOC: K+ 3.7 AND REPLETED WITH 40MEQ KCL VIA PEG. NO SSI REQUIRED.\\nID: PEG DRSG -PURELENT DRAINAGE NOTED-SENT FOR CX. CONT. ON ANTIBIOTICS. ESS. AFEBRILE.\\nNEURO: WITHDRAWN. NODS APPROPRIATELY AT TIMES. ABLE TO MOVE DIGITS WHEN ASKED AND DID RAISE HIS LEFT ARM ON HIS OWN THIS PM.\\nHEM: HCT SLIGHTLY DECREASED FROM YESTERDAY.\\nSOCIAL: NO CONTACT FROM FAMILY TODAY.\\nPLAN: NEEDS PT CONSULT TO HELP WITH TRANSFER TO CHAIR.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624083,\n \"text\": \"Nursing Note:\\n\\nNeuro: pt awake most of night, appears withdrawn, nods head occasionally and inconsistantly follows commands, would not sqeeze hands on request, and occasionally cooperative w/ mouth care. some movement of left arm and legs noted. received 0.5 mg ativan prn overnight.\\n\\nResp: remains w/ vent support. vent AC 20/500 PEEP 5, FIO2 0.40. sats 95-100. suctioned for sm/moderate thick tan. LS clear and diminished w/ some upper airway congestion noted prior to suctioning.\\n\\nCV: HR 85-95 afib w/ occ. tolerated 30mg PO diltiazem well overnight. PVC's. NBP 90-120/50-70. tmax 99.3. generalized +3 edema. pos distal pulses.\\n\\nGU: remains on lasix gtt @ 2mg/hr. foley output 60-200cc/hr clear yellow.\\n\\nGI/Endo: abd firm/distended. pos bowel sounds, TF at goal of 50/hr, minimal residuals (<5cc). received dose of lantus insulin overnight, no coverage w/ RISS. no BM as of present overnight.\\n\\nIV: left brachial PICC remains WNL.\\n\\nSkin: duoderm intact on wound on upper back, no further skin breakdown noted. repositioned off back.\\n\\nSocial: no contact from family overnight.\\n\\nPlan: continue to monitor resp status (trach site, suctioning), hemodynamics, mental status, labs.\\n\\ncont. to monitor urine output and lasix gtt.\\n\\n? need for PT consult r/t immobility.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624084,\n \"text\": \"RESPIRATORY CARE NOTE\\n\\nPatient remains with TTS adjustable length trach tube. This is a sterile H2O cuff. No vent changes made during the night. Unable to complete d/t tachypnea on PS 5. Sxn for scant to small amount thick yellow secretions. Plan to wean as tolerated.\\n\\n , RRT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624085,\n \"text\": \"Respiratory Care Note\\nPt received on AC as noted. BS diminished and coarse bilaterally which clears with suctioning. MDI's given a/o - MDI's changed to prn. Pt suctioned for moderate amts thick, yellow secretions. Attempted PSV 22/5 at 12noon, but placed pt back on AC secondary to tachypnea with a RR 38-40 and VT 275-300. Attempted PSV again at 4pm and increased PEEP to 8cm with the same result. Pt is now on AC. Plan to continue on current settings at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624086,\n \"text\": \"NPN 0700-1900\\nFull code All: Haldol\\n\\nNeuro: Alert throughout shift, occasional nod, participated in mouth care today. Minimally interactive w/ daughter and son when they today. Moves LUE only, good cough/gag. Lowgrade temp throughout shift of 99+ ax.\\n\\nCV: HR in 90's to low 100's, afib with occasional PVC's. SBP>95. Diuresing gently with Lasix gtt, currently @ 3mg/hr. 3+pitting edema in all extremities, + and easily palpable pp's b/l\\n\\nResp: A/C 40%/5Peep, TV set @ 500--pt vols running 375-450ml/breath. Continues to have thick white-tan secretions which he can cough up but sxn'd q2h. LS clear to coarse upper, diminished @bases w/occasional wheeze.\\n\\nGI/Endo: Firm distended abd w/+BS. Guaiac + dark brown-green stool x2 today. TF remain 2 goal of 50cc/hr w/ no residual. Required no additional insulin coverage today.\\n\\nGU: Patent foley draining dark yellow urine with some sediment at >40cc/hr. Titrating Lasix for u/o of ~100cc/hr.\\n\\nSkin: CDI\\n\\nSocial: Family meeting today. Family wishes to continue aggressive care. Believe pt is a candidate for a type of percutaneous cardiac repair not done @ and hope to find another facility that performs procedure and is willing to accept pt. Hence, pt remains full code.\\n\\nPlan: Monitor afib/BP's, Dilt as ordered as \\n Monitor resp status, sxn prn\\n ROM of extremities, PT reviewed case and pt not candidate for PT care\\n OOB to chair as \\n Glargine HS, RISS\\n Encourage interaction\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624075,\n \"text\": \"Nursing progress note: Full Code\\n\\nNeuro: able to communicate needs w/ nods. Does not move any of his exts. OOB to chair w/ lift. Denies any pain, no ativan given for my shift.\\n\\nPulm: PSV 23/5, Suctioned for thick yelllow secretions q-23hrs in small-moderate amts. RR regular. Maintaining stable svo2.\\n\\nCV: Afib w/ HR 89-108, BP 96-68 - 148/71. Afebrile. Gross generalized edema. Restarted lasix gtt at 2mg/hr. + palp. peripherial pulses x 4.\\n\\nGI/GU: + hypoactive bs. Abd is soft, distended. NT. TF'ing of nutren pulmonary at goal rate (50cc/hr), tolerating well. BM x 2 of dark black soft stool guaiac +. Scheduled for colonscopy and needs to be prep'd onced back in bed w/ golytley. Foley w/ uo > 30cc/hr on lasix 2mg/hr.\\n\\nSKIN: Back dressing in place. NO other breakdown noted.\\n\\nAccess: PICC line to RAC\\n\\nSOCIAL: Family meeting w/ Dr. today. Updated about pt. condition and plan of care.\\n\\nPLAN: Monitor per protocol. Replete lytes as needed. HCT up to 26.9.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624076,\n \"text\": \"Resp. care note - Pt. remaines and vented, weaned to PSV then placed back on AC for SOB.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624077,\n \"text\": \"Addendum:\\n\\nGolytly prep cancelled for tonight due to daughter refusing to consent for colonscopy at this time. Will readdress in am w/ Dr. . Pt. back to bed via . HCT up to 25.9. Tolerating lasix gtt at 2mg/hr w/ adequate uo.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624078,\n \"text\": \"NPN 1900-0700\\nNeuro: Nods appropriately to questions at times, other times will barely nod. Moves LUE more than R, minimal movement of legs. Appears comfortable, denies pain. Slept off and on during noc. No ativan given.\\n\\nResp: On AC o/n, no changes, 500x20/40%/5. RR low 20s, regular, appears comfortable. sats 97-99, Sx q1-3hrs for sm-mod amt thick, yellow. Sx more freq when awake or after turning. LS coarse/clear upper, coarse/diminished lower.\\n\\nCV: HR stable 80s-90s, a-fib, occ pvcs, multifocal. SBP 88-125. Team increased lasix up to 6mg/hr, but said to drop it back if sbp dropped <90. Did drop dose a few times, but back up to 6mg currently. BP adequate for Dilt dose x2. Am hct 24.2 from 26.9, but in pts usual range. Afebrile. Repleted c 20meq kcl due to lasix.\\n\\nGI: +BS, abd soft,distended, nt. TF at goal of 50mls/hr, water 150 q4hrs. No stools this shift.\\n\\nGu: Foley c u/o 120-180mls/hr on lasix 6mg/hr, yellow, clear urine.\\n\\nskin: Back dsg changed, washed c saline, duoderm applied. Appears slightly improved. No dng. Few sm skin tears noted on abd and L arm, washed, open to air.\\n\\nAccess: L picc. Flushes ok but very difficult drawing bld from either port this am. Will request TPA from team.\\n\\nSocial: No calls o/n.\\n\\nPlan: Monitor am labs, replete lytes. watch sbp and map c lasix, may need to reduce dose. Cont to wean vent as .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624079,\n \"text\": \"Respiratory Care:\\n\\nPt remain on full ventilatory support. No vent changes. We are sxtn for small to mod amt of thick whiote secretions. MD team asked for NIF ~13 cmH20, thru vent. Plan: PSV trial. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2129-07-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624080,\n \"text\": \"Addendum\\n1mg TPA placed into blue port of cath at 0600. Additional 40 meq kcl given at 0600 for K of 3.6.\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2129-08-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 83126,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Aortic valve disease. H/O cardiac surgery. Left ventricular function.\\nHeight: (in) 76\\nWeight (lb): 266\\nBSA (m2): 2.50 m2\\nBP (mm Hg): 131/71\\nHR (bpm): 84\\nStatus: Inpatient\\nDate/Time: at 11:27\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Marked LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\\n\\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Suboptimal\\ntechnical quality, a focal LV wall motion abnormality cannot be fully\\nexcluded. Overall normal LVEF (>55%). No resting LVOT gradient. No VSD.\\n\\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\\nsystolic function.\\n\\nAORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root.\\n\\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). Increased AVR\\ngradient.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\\nof papillary muscles. No MS. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve\\nsupporting structures. Mild [1+] TR. Moderate PA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\\nviews.\\n\\nConclusions:\\nThe left atrium is markedly dilated. There is mild symmetric left ventricular\\nhypertrophy. The left ventricular cavity size is normal. Due to suboptimal\\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\\nOverall left ventricular systolic function is normal (LVEF 70%). There is no\\nventricular septal defect. Right ventricular chamber size is normal. Right\\nventricular systolic function is normal. The aortic root is mildly dilated at\\nthe sinus level. A bioprosthetic aortic valve prosthesis is present. The\\ntransaortic gradient is higher than expected for this type of prosthesis. The\\nmitral valve leaflets are mildly thickened. There is no mitral valve prolapse.\\nMild (1+) mitral regurgitation is seen. There is moderate pulmonary artery\\nsystolic hypertension. There is no pericardial effusion.\\n\\nCompared with the findings of the prior study (images reviewed) of , the aortic valve has been replaced.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2129-08-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 83127,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: avr\\nStatus: Inpatient\\nDate/Time: at 13:51\\nTest: TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in the RAA.\\n\\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\\nimages. Normal LV wall thickness and cavity size. Mildly depressed LVEF.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\\nhypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -\\nhypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\\nhypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -\\nhypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -\\nhypo;\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal ascending aorta diameter. Normal descending aorta diameter.\\nSimple atheroma in descending aorta.\\n\\nAORTIC VALVE: ?# aortic valve leaflets. Severely thickened/deformed aortic\\nvalve leaflets. Severe AS (AoVA <0.8cm2). Mild (1+) AR.\\n\\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Physiologic TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. The patient was under\\ngeneral anesthesia throughout the procedure. The TEE probe was passed with\\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\\ncomplications.\\n\\nConclusions:\\nNo spontaneous echo contrast is seen in the left atrial appendage. Left\\nventricular wall thicknesses and cavity size are normal. Overall left\\nventricular systolic function is mildly depressed (LVEF= XX %). Right\\nventricular chamber size and free wall motion are normal. There are simple\\natheroma in the descending thoracic aorta. The number of aortic valve leaflets\\ncannot be determined. The aortic valve leaflets are severely\\nthickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Mild\\n(1+) aortic regurgitation is seen. The mitral valve leaflets are moderately\\nthickened. Mild (1+) mitral regurgitation is seen. There is no pericardial\\neffusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2129-07-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 83128,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Aortic valve disease. Left ventricular function.\\nHeight: (in) 72\\nWeight (lb): 242\\nBSA (m2): 2.31 m2\\nBP (mm Hg): 112/62\\nHR (bpm): 92\\nStatus: Inpatient\\nDate/Time: at 15:03\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Elongated LA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\\n\\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Suboptimal\\ntechnical quality, a focal LV wall motion abnormality cannot be fully\\nexcluded. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root.\\nNormal ascending aorta diameter. Focal calcifications in ascending aorta.\\n\\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS\\n(AoVA <0.8cm2). Trace AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\\nannular calcification. Trivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild [1+]\\nTR. Mild PA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\\nphysiologic PR.\\n\\nGENERAL COMMENTS: Suboptimal image quality - ventilator. The rhythm appears to\\nbe atrial fibrillation.\\n\\nConclusions:\\nThe left atrium is elongated. There is moderate symmetric left ventricular\\nhypertrophy. The left ventricular cavity size is normal. Due to suboptimal\\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\\nTissue Doppler imaging suggests an increased left ventricular filling pressure\\n(PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal.\\nThe aortic root is mildly dilated at the sinus level. The aortic valve\\nleaflets are severely thickened/deformed. There is severe aortic valve\\nstenosis (area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve\\nleaflets are mildly thickened. There is no mitral valve prolapse. Trivial\\nmitral regurgitation is seen. There is mild pulmonary artery systolic\\nhypertension.\\n\\nCompared with the prior study (images reviewed) of , the degree of\\naortic stenosis has increased. There is now mild pulmonary artery systolic\\nhypertension and a suggestion of an increased left ventricular filling\\npressure.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2129-08-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 227874,\n \"text\": \"Sinus rhythm. Low amplitude P waves. A-V conduction delay. Left anterior\\nfascicular block. Prior anterior myocardial infarction. Compared to the prior\\ntracing of sinus rhythm has appeared. Ventricular ectopy is absent.\\nOtherwise, no diagnostic interim change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2129-07-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 227875,\n \"text\": \"Atrial fibrillation with a single ventricular premature beat. Intraventricular\\nconduction delay. Left axis deviation. ST-T wave abnormalities. Since the\\nprevious tracing of the rate is slower and the QRS interval is wider.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2129-07-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 227876,\n \"text\": \"Atrial fibrillation\\nVentricular premature complex\\nModest intraventricular conduction delay\\nDelayed R wave progression with late precordial QRS transition\\nConsider left ventricular hypertrophy\\nNonspecific ST-T wave changes\\nThese findings are nonspecific but clinical correlation is suggested\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2129-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 228103,\n \"text\": \"Atrial fibrillation\\nVentricular premature complex\\nModest intraventricular conduction delay\\nDelayed R wave progression with late precordial QRS transition\\nConsider left ventricular hypertrophy\\nNonspecific ST-T wave changes\\nThese findings are nonspecific but clinical correlation is suggested\\nSince previous tracing of , ventricular ectopy present\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2129-07-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 228104,\n \"text\": \"Atrial fibrillation\\nModest intraventricular conduction delay\\nDelayed R wave progression with late precordial QRS transition\\nConsider left ventricular hypertrophy\\nNonspecific ST-T wave changes\\nThese findings are nonspecific but clinical correlation is suggested\\nSince previous tracing of , ventricular ectopy absent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2129-07-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 228105,\n \"text\": \"Atrial fibrillation with controlled ventricular response. Occasional\\nventricular premature beats. Underlying intraventricular conduction delay.\\nCompared to tracing of no definite change.\\n\\n\"\n }\n]"}}},{"rowIdx":24647,"cells":{"subject_id":{"kind":"number","value":92317,"string":"92,317"},"hadm_id":{"kind":"number","value":144189,"string":"144,189"},"target_text":{"kind":"string","value":"Patient was admitted to Neurosurgery on for further management. He was started on a short course of prednisone for mild cerebral edema with MLS. The following day patient had a repeat head CT which showed stable subacute SDH and shift. He remained stable neurologically. Surgical intervention was discussed with the patient in the setting of cerebral edema and midline shift on CT. He agreed to undergo evacuation which was scheduled for . He remained neurologically stable awaiting the OR and was prepped accordingly. He was taken to the OR and he underwent R frontal craniotomy and tolerated the procedure well with no complications. Post operatively he was transferred to the ICU for further care including SBP control and neurochecks, his post op exam remained non focal. Postoperative head CT shows good evacuation of SDH, no significant change in midline shift. The subdural drain was removed on postoperative day 1 and his diet and activity were advanced. He was transferred to the regular floor where he continued to do well and mobilize. Now DOD, patient is afebrile, VSS, and neurologically stable. Patient's pain is well-controlled and the patient is tolerating a good oral diet. Patient is ambulating without issues. He is set for discharge home in stable condition and will follow-up accordingly."},"extractive_notes_summ":{"kind":"string","value":"The mediastinal and hilar contours appear within normal limits. Compared to the previous tracingof no change. Mild mass effect on the right cerebral convexities and leftward shift of the midline structures is not significantly changed. There is associated mass effect with effacement of the right cerebral sulci and leftward shift of normally midline structures by 8 mm, also unchanged. Moderate-sized right subdural hematoma with associated effacement of the right cerebral convexity sulci and 8 mm leftward shift of the normally-midline structures, overall unchanged from the most recent prior study performed 18 hours ago. The ventricles and sulci are unchanged in size or configuration without evidence of hydrocephalus. The -white matter differentiation is preserved without evidence of acute major vascular territorial infarct. Normal tracing. TECHNIQUE: MDCT-acquired axial images were obtained through the head without intravenous contrast. No new hemorrhage is identified. No new hemorrhage is identified. Within normal limits. FINDINGS: There has been interval right-sided craniotomy with decompression of the right subdural hematoma with small residual present. FINDINGS: The heart is normal in size. In comparison to the prior MRI, there has been no significant change in the size of the subdural hematoma or the shift of the midline structures. FINDINGS: There is a moderate-sized right subdural hematoma extending along the entire right cerebral convexity, measuring 9 mm in maximal depth, not significantly changed from the most recent prior study performed 18 hours earlier. The remainder of the visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The appearance is grossly unchanged from the prior MRI obtained approximately two hours prior. The visualized paranasal sinuses, middle ear cavities and mastoid air cells are clear bilaterally. IMPRESSION: No evidence of acute disease. The bony calvaria appear intact. No fracture is identified. There is no pleural effusion or pneumothorax. Recent right-sided subdural hematoma with associated effacement of the adjacent sulci and 9 mm of leftward shift of the normal midline structures. The lungs appear clear. The visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. The ventricles and sulci are stable in configuration and size. COMPARISON: Non-contrast head CT last performed on and outside MRI of the brain performed at on . TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. TECHNIQUE: Continuous axial MDCT images were obtained through the brain without administration IV contrast. No evidence of new hemorrhage is present. In comparison to the prior MRI, there has been no significant change and no evidence of new hemorrhage. The right lateral ventricle is somewhat compressed but patent. No evidence of new hemorrhage. IMPRESSION: 1. IMPRESSION: 1. TECHNIQUE: Chest, PA and lateral. There is mild mucosal thickening within the ethmoidal air cells. COMPARISON: NECT of the head on . There is expected pneumophalus. Sinus rhythm. Sinus rhythm. No evidence of new hemorrhage, central herniation, or major vascular territorial infarct. Pre-operative examination. The basal cisterns are patent. Slight degenerative changes are noted along the lower thoracic spine. No previous tracing available for comparison. COMPARISONS: None. The suprasellar and basilar cisterns are patent. 2:08 PM CT HEAD W/O CONTRAST Clip # Reason: please do CT to eval for SDH, per neurosurgery MEDICAL CONDITION: History: 58M with subdural reported on OSH MRI REASON FOR THIS EXAMINATION: please do CT to eval for SDH, per neurosurgery No contraindications for IV contrast WET READ: KMTd TUE 2:40 PM 1. IMPRESSION: Expected post-surgical changes from craniotomy of moderate-sized subdural hematoma. There is mass effect with effacement of the adjacent sulci and leftward shift of the normal midline structures by 9 mm. There is associated mass effect with efacement of the adjacent sulci and 9 mm of leftward shift of the midline structures. FINDINGS: There is a right-sided hyperdense subdural hematoma overlying the frontal, parietal, occipital and temporal lobes measuring 10 mm in widest dimension. Assess for interval change. 2. 2. Large right subdural hematoma measuring 8mm in the widest dimension. COMPARISONS: MRI 11:56 a.m. 8:00 PM CT HEAD W/O CONTRAST Clip # Reason: assess SDH evacuation Admitting Diagnosis: SUBDURAL HEMATOMA MEDICAL CONDITION: 58 year old man s/p craniotomy and decompression of R SDH REASON FOR THIS EXAMINATION: assess SDH evacuation No contraindications for IV contrast FINAL REPORT INDICATION: Recent craniotomy and decompression for subdural hematoma. Sagittal, coronal, and thin slice bone image reformats were obtained and reviewed. WET READ VERSION #1 FINAL REPORT INDICATION: Subdural hematoma reported on outside hospital MRI. Evaluate for change. 7:41 AM CT HEAD W/O CONTRAST Clip # Reason: f/u interval progression Admitting Diagnosis: SUBDURAL HEMATOMA MEDICAL CONDITION: 58 year old man with right SDH REASON FOR THIS EXAMINATION: f/u interval progression No contraindications for IV contrast FINAL REPORT INDICATION: 58-year-old male with right subdural hematoma status post fall five weeks ago, here to evaluate for interval changes."},"n_notes":{"kind":"number","value":6,"string":"6"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2139-04-22 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1238194,"text":" 7:41 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: f/u interval progression\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with right SDH\n REASON FOR THIS EXAMINATION:\n f/u interval progression\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old male with right subdural hematoma status post fall\n five weeks ago, here to evaluate for interval changes.\n\n COMPARISON: Non-contrast head CT last performed on and outside MRI of\n the brain performed at on .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the head without\n intravenous contrast.\n\n FINDINGS: There is a moderate-sized right subdural hematoma extending along\n the entire right cerebral convexity, measuring 9 mm in maximal depth, not\n significantly changed from the most recent prior study performed 18 hours\n earlier. There is associated mass effect with effacement of the right\n cerebral sulci and leftward shift of normally midline structures by 8 mm, also\n unchanged. The suprasellar and basilar cisterns are patent. No new\n hemorrhage is identified. The -white matter differentiation is preserved\n without evidence of acute major vascular territorial infarct. The ventricles\n and sulci are unchanged in size or configuration without evidence of\n hydrocephalus. The visualized paranasal sinuses, middle ear cavities and\n mastoid air cells are clear bilaterally. The bony calvaria appear intact.\n\n IMPRESSION:\n 1. Moderate-sized right subdural hematoma with associated effacement of the\n right cerebral convexity sulci and 8 mm leftward shift of the normally-midline\n structures, overall unchanged from the most recent prior study performed 18\n hours ago.\n 2. No evidence of new hemorrhage, central herniation, or major vascular\n territorial infarct.\n\n"},{"category":"Radiology","chartdate":"2139-04-24 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1238502,"text":" 8:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess SDH evacuation\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p craniotomy and decompression of R SDH\n REASON FOR THIS EXAMINATION:\n assess SDH evacuation\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent craniotomy and decompression for subdural hematoma.\n Assess for interval change.\n\n TECHNIQUE: Continuous axial MDCT images were obtained through the brain\n without administration IV contrast.\n\n COMPARISON: NECT of the head on .\n\n FINDINGS: There has been interval right-sided craniotomy with decompression\n of the right subdural hematoma with small residual present. There is expected\n pneumophalus. Mild mass effect on the right cerebral convexities and leftward\n shift of the midline structures is not significantly changed. No new\n hemorrhage is identified. The ventricles and sulci are stable in\n configuration and size. The visualized paranasal sinuses, mastoid air cells\n and middle ear cavities are clear.\n\n IMPRESSION: Expected post-surgical changes from craniotomy of moderate-sized\n subdural hematoma.\n\n"},{"category":"Radiology","chartdate":"2139-04-21 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1238122,"text":" 2:08 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please do CT to eval for SDH, per neurosurgery\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 58M with subdural reported on OSH MRI\n REASON FOR THIS EXAMINATION:\n please do CT to eval for SDH, per neurosurgery\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KMTd TUE 2:40 PM\n 1. Large right subdural hematoma measuring 8mm in the widest dimension. There\n is associated mass effect with efacement of the adjacent sulci and 9 mm of\n leftward shift of the midline structures. In comparison to the prior MRI,\n there has been no significant change and no evidence of new hemorrhage.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subdural hematoma reported on outside hospital MRI. Evaluate for\n change.\n\n COMPARISONS: MRI 11:56 a.m.\n\n TECHNIQUE: Contiguous axial MDCT images were obtained through the brain\n without the administration of IV contrast. Sagittal, coronal, and thin slice\n bone image reformats were obtained and reviewed.\n\n FINDINGS: There is a right-sided hyperdense subdural hematoma overlying the\n frontal, parietal, occipital and temporal lobes measuring 10 mm in widest\n dimension. There is mass effect with effacement of the adjacent sulci and\n leftward shift of the normal midline structures by 9 mm. The right lateral\n ventricle is somewhat compressed but patent. The basal cisterns are patent.\n In comparison to the prior MRI, there has been no significant change in the\n size of the subdural hematoma or the shift of the midline structures. No\n evidence of new hemorrhage is present. No fracture is identified. There is\n mild mucosal thickening within the ethmoidal air cells. The remainder of the\n visualized paranasal sinuses, mastoid air cells, and middle ear cavities are\n clear.\n\n IMPRESSION:\n 1. Recent right-sided subdural hematoma with associated effacement of the\n adjacent sulci and 9 mm of leftward shift of the normal midline structures.\n The appearance is grossly unchanged from the prior MRI obtained approximately\n two hours prior.\n 2. No evidence of new hemorrhage.\n\n"},{"category":"Radiology","chartdate":"2139-04-22 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":1238255,"text":" 4:09 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: SUBDURAL HEMATOMA\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with r SDH and need for craniotomy\n REASON FOR THIS EXAMINATION:\n eval pre-op\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPHS\n\n HISTORY: Right subdural hematoma with need for craniotomy. Pre-operative\n examination.\n\n COMPARISONS: None.\n\n TECHNIQUE: Chest, PA and lateral.\n\n FINDINGS: The heart is normal in size. The mediastinal and hilar contours\n appear within normal limits. There is no pleural effusion or pneumothorax.\n The lungs appear clear. Slight degenerative changes are noted along the lower\n thoracic spine.\n\n IMPRESSION: No evidence of acute disease.\n\n\n"},{"category":"ECG","chartdate":"2139-04-24 00:00:00.000","description":"Report","row_id":267954,"text":"Sinus rhythm. Within normal limits. Compared to the previous tracing\nof no change.\n\n"},{"category":"ECG","chartdate":"2139-04-21 00:00:00.000","description":"Report","row_id":267955,"text":"Sinus rhythm. Normal tracing. No previous tracing available for comparison.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-04-22 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1238194,\n \"text\": \" 7:41 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: f/u interval progression\\n Admitting Diagnosis: SUBDURAL HEMATOMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with right SDH\\n REASON FOR THIS EXAMINATION:\\n f/u interval progression\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 58-year-old male with right subdural hematoma status post fall\\n five weeks ago, here to evaluate for interval changes.\\n\\n COMPARISON: Non-contrast head CT last performed on and outside MRI of\\n the brain performed at on .\\n\\n TECHNIQUE: MDCT-acquired axial images were obtained through the head without\\n intravenous contrast.\\n\\n FINDINGS: There is a moderate-sized right subdural hematoma extending along\\n the entire right cerebral convexity, measuring 9 mm in maximal depth, not\\n significantly changed from the most recent prior study performed 18 hours\\n earlier. There is associated mass effect with effacement of the right\\n cerebral sulci and leftward shift of normally midline structures by 8 mm, also\\n unchanged. The suprasellar and basilar cisterns are patent. No new\\n hemorrhage is identified. The -white matter differentiation is preserved\\n without evidence of acute major vascular territorial infarct. The ventricles\\n and sulci are unchanged in size or configuration without evidence of\\n hydrocephalus. The visualized paranasal sinuses, middle ear cavities and\\n mastoid air cells are clear bilaterally. The bony calvaria appear intact.\\n\\n IMPRESSION:\\n 1. Moderate-sized right subdural hematoma with associated effacement of the\\n right cerebral convexity sulci and 8 mm leftward shift of the normally-midline\\n structures, overall unchanged from the most recent prior study performed 18\\n hours ago.\\n 2. No evidence of new hemorrhage, central herniation, or major vascular\\n territorial infarct.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-04-24 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1238502,\n \"text\": \" 8:00 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: assess SDH evacuation\\n Admitting Diagnosis: SUBDURAL HEMATOMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man s/p craniotomy and decompression of R SDH\\n REASON FOR THIS EXAMINATION:\\n assess SDH evacuation\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Recent craniotomy and decompression for subdural hematoma.\\n Assess for interval change.\\n\\n TECHNIQUE: Continuous axial MDCT images were obtained through the brain\\n without administration IV contrast.\\n\\n COMPARISON: NECT of the head on .\\n\\n FINDINGS: There has been interval right-sided craniotomy with decompression\\n of the right subdural hematoma with small residual present. There is expected\\n pneumophalus. Mild mass effect on the right cerebral convexities and leftward\\n shift of the midline structures is not significantly changed. No new\\n hemorrhage is identified. The ventricles and sulci are stable in\\n configuration and size. The visualized paranasal sinuses, mastoid air cells\\n and middle ear cavities are clear.\\n\\n IMPRESSION: Expected post-surgical changes from craniotomy of moderate-sized\\n subdural hematoma.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-04-21 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1238122,\n \"text\": \" 2:08 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: please do CT to eval for SDH, per neurosurgery\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n History: 58M with subdural reported on OSH MRI\\n REASON FOR THIS EXAMINATION:\\n please do CT to eval for SDH, per neurosurgery\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: KMTd TUE 2:40 PM\\n 1. Large right subdural hematoma measuring 8mm in the widest dimension. There\\n is associated mass effect with efacement of the adjacent sulci and 9 mm of\\n leftward shift of the midline structures. In comparison to the prior MRI,\\n there has been no significant change and no evidence of new hemorrhage.\\n\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Subdural hematoma reported on outside hospital MRI. Evaluate for\\n change.\\n\\n COMPARISONS: MRI 11:56 a.m.\\n\\n TECHNIQUE: Contiguous axial MDCT images were obtained through the brain\\n without the administration of IV contrast. Sagittal, coronal, and thin slice\\n bone image reformats were obtained and reviewed.\\n\\n FINDINGS: There is a right-sided hyperdense subdural hematoma overlying the\\n frontal, parietal, occipital and temporal lobes measuring 10 mm in widest\\n dimension. There is mass effect with effacement of the adjacent sulci and\\n leftward shift of the normal midline structures by 9 mm. The right lateral\\n ventricle is somewhat compressed but patent. The basal cisterns are patent.\\n In comparison to the prior MRI, there has been no significant change in the\\n size of the subdural hematoma or the shift of the midline structures. No\\n evidence of new hemorrhage is present. No fracture is identified. There is\\n mild mucosal thickening within the ethmoidal air cells. The remainder of the\\n visualized paranasal sinuses, mastoid air cells, and middle ear cavities are\\n clear.\\n\\n IMPRESSION:\\n 1. Recent right-sided subdural hematoma with associated effacement of the\\n adjacent sulci and 9 mm of leftward shift of the normal midline structures.\\n The appearance is grossly unchanged from the prior MRI obtained approximately\\n two hours prior.\\n 2. No evidence of new hemorrhage.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-04-22 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 1238255,\n \"text\": \" 4:09 PM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: SUBDURAL HEMATOMA\\n Admitting Diagnosis: SUBDURAL HEMATOMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with r SDH and need for craniotomy\\n REASON FOR THIS EXAMINATION:\\n eval pre-op\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPHS\\n\\n HISTORY: Right subdural hematoma with need for craniotomy. Pre-operative\\n examination.\\n\\n COMPARISONS: None.\\n\\n TECHNIQUE: Chest, PA and lateral.\\n\\n FINDINGS: The heart is normal in size. The mediastinal and hilar contours\\n appear within normal limits. There is no pleural effusion or pneumothorax.\\n The lungs appear clear. Slight degenerative changes are noted along the lower\\n thoracic spine.\\n\\n IMPRESSION: No evidence of acute disease.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2139-04-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 267954,\n \"text\": \"Sinus rhythm. Within normal limits. Compared to the previous tracing\\nof no change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2139-04-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 267955,\n \"text\": \"Sinus rhythm. Normal tracing. No previous tracing available for comparison.\\n\\n\"\n }\n]"}}},{"rowIdx":24648,"cells":{"subject_id":{"kind":"number","value":26572,"string":"26,572"},"hadm_id":{"kind":"number","value":127201,"string":"127,201"},"target_text":{"kind":"string","value":"83M with hx of COPD, afib now in ICU for hypotension found to have abdominal pain and elevated LFTs . # Shock: Volume depletion vs sepsis vs adrenal insufficiency or combination. Volume depletion likely due to 2 weeks of loose stools and decreased po intake. Sepsis also likely given lactate of 4.8, possible pneumonia and possible intra-abd source. Adrenal insufficiency was impossible to test given that pt received solumedrol in ED. Cardiogenic shock not likely given lack of EKG changes and negatige enzymes and TTE showed preserved systolic function. Patient was given fluids and started on dopamine to maintain MAPs>60. Steroids were changed to decadron to perform stim test but initial level was 40 so stim was not performed. Steroids were d/c'd. Pt was weaned off dopamine on hospital day #2 and BPs remained stable. BB was resumed for rate control and verapamil was restarted. SBPs remained 120s-140s. . # Sepsis: Possible sources include lung, urine, abdomen. CXR with possible infiltrate so started levaquin/flagyl. UA was clean and urine culture was negative. blood cultures remain negative. Pt remained afebrile with elevated WBC count, attributed to possible PNA and steroids. His WBC should be followed in rehab to make sure it is trending down. . # Transaminitis: ALT and AST equally elevated to the on admission. Ddx of this includes right heart failure (which may explain elevated BNP), shock liver, viral hepatitis (which could explain pt's abd pain, nausea, diarrhea), med related (he is on 650mg standing tylenol TID), budd chiari. No hx of etoh abuse. RUQ US was normal without evidence of clot and tylenol level was neg. PAtient's HepAV Ab was positive, IgM is pending. We will continue to hold his statin and she should not be on standing tylenol. His LFTs should also be trended to make sure they are trending down. . # Abd Pain/diarrhea: Stool was sent for E. coli 0157 given h/o diarrhea and ARF. C diff also sent. Patient's diarrhea resolved as did his abdominal pain. As above, his abd U/S was negative. It may be secondary to hepatitis A but IgM was pending on time of discharge. . # Tachypnea/COPD: Likely that pt has an underlying pneumonia causing an exacerbation of his underlying COPD. He was given standing nebs along with oxygen. His breathing improved dramatically over the first few hours of his hospital stay. He should continue on albuterol and atrovent inhalers. He also should continue to wear oxygen at rest and with ambulation. He was started on advair. He may benefit from an outpatient pulmonary appointment along with PFTs. He may also need additional medications including tiotropium. . # CHF: By report only. Echo was normal with preserved funciton. BNP elevated to 18,000 on admission but appeared dry on exam so he improved with fluids. He was continued on his beta blocker after BP normalized. . # Afib: Patient was in NSR on admission and converted to a-fib while in MICU with HR 100's-120's. He is not anticoagulated likely due to fall risk. He is rate controlled with beta blocker and verapamil. . # ARF: Baseline is unknown. Urine lytes showed FeNa of 0.9% indicating pre-rernal etiology verses acute tubular necrosis from hypotension. Creatinine peaked at 2.8 from 1.9 on admission and is now trending down. This should be followed and medications adjusted for creatinine clearance. . # Glucse Intolerance: Pt was covered with insulin sliding scale but required none. . # Code: Pt is DNR/DNI, confirmed with PCP . # Comm: nephew , ; PCP "},"extractive_notes_summ":{"kind":"string","value":"Pt rec'd Vanco and ceftriaxone in ED. LS clear, diminished at bases. PT C/O GENERALIZED WEAKNESS THROUGH OUT.RESP: PT REMAINS 3L NC. Abd soft with hypoactive bowel snds. Pt has gen edema with +2 pitting edema to lower ext's. Right ventricular chamber size and free wall motion arenormal. Mild mitral annularcalcification. soft, NT, and ND.GU: Foley cath. PT IS A DNR/DNI. Mild [1+] TR. Baseline artifactProbable atrial flutterVentricular premature complexModest nonspecific ST-T wave changesSince previous tracing of the same date, bradyarrhythmia absent PT NPO, EXCEPT MEDS. Patent hepatic vasculature. atelectasis.CV: HR 66-78SR with occas PAC's and rare PVC's. Pt placed on non-rebreather mask and rec'd solumedrol for resp distress. Rt leg with only + pulses to . Trace ascites. Trace aortic regurgitation is seen. Trace AR.MITRAL VALVE: Normal mitral valve leaflets. if pt may have been hypotensive d/t a poss. Pt remains off dopamine. Mild PAsystolic hypertension.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Frequent atrial premature beats. Mild to moderate(+) mitral regurgitation is seen. There is no pericardial effusion.IMPRESSION: Preserved global and regional biventricular systolic function.Mild-moderate mitral regurgitation. He stated lower abd pain improved, not worsened with palpation.Resp: VBG on admit on non-rebreather mask was 7.21/53/221. Pt needs a stool sample.ID)LA down to 1.7 (4.4). Sinus rhythmAtrial premature complexesModest nonspecific ST-T wave changesSince previous tracing of the same date, atrial flutter absent Congestive heart failure.Height: (in) 68Weight (lb): 144BSA (m2): 1.78 m2BP (mm Hg): 104/37HR (bpm): 91Status: InpatientDate/Time: at 10:52Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). BS's still course with a fair to poor cough. Based on AHAendocarditis prophylaxis recommendations, the echo findings indicate a lowrisk (prophylaxis not recommended). Mg replaced this am and no mg level until am MD. Mild to moderate (+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. As a result he recieved only one neb. in AFIB, rare to occas. Pt rec'd fluid bolus of 1 liter NS for vol repletion. Pt is HOH.Resp: LS to Bilateral UL clear, crackles to RLL and clear to LLL- team aware. Denies any pain.Resp - Maintained on 3 L NC with RR 15-25 and 02 sats > 95%. IMPRESSION: Small left pleural effusion. Abd discomfort lessened, and pt attributed this to antiemetic he rec'd in ED. septic state. Unremarkable liver echotexture. Pt on flagyl. Pt now on reg. Pulmonary artery systolic hypertension.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a low risk (prophylaxis not recommended). Given neb. Pt is in NSR with freq PAC's. There is mild pulmonary artery systolichypertension. positive pedal pulses bil with doppler.GI: pos. The left, middle, and right hepatic veins are patent. Pt cont. Pt is on Flagyl, Levo and vanco IVabx.Pain)Pt denies any discomfort.GU)Good U/O via foley catheter. Neb tx ATC. Ext's remain sl cool to touch, but this is baseline per pt.RESP)Ls dimminished throughout this am and now with cx's to RLL and coarse LS to LLL. ABG's as noted in carevue.GI)Abd soft and non-tender to touch. Normal regional LV systolic function.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). + congested cough, pt states only expectorates when he awakens in the am.C-V - HR 105-120 afib with occas pvc's. CXR showed L pleural effusion and ? The main, left, and right hepatic arteries are patent. US of abd done and NL. CHEST AP: Heart size is at upper limits of normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosisis not present. Dopamine titrated to present rate 4mcg/kg/min.Review of Systems:Neuro: Pt X 3, pleasant. Urine remains yellow and cloudy.soc)Pt is DNR / DNI. Simple-appearing cyst of the mid left kidney. IMPRESSION: 1. OOB to chair with minimal assist x several hrs. Pt needs to be inc to DB&C.. CXR with no CHF even though BNP . Rx with flagyl and levoflox.Social - No phone calls or visitors.A+P - Pt hemodynamically stable. NBP 120-140/60-70. PT HAS A PRODUCTIVE CONGESTED COUGH.CV: EARLY IN SHIFT HR SWITCHING BETWEEN AFIB AND NS. In , pt hypotensive to SBP 50's, HR 40's. His chest is with coarse BS's with a fair NPC. NEEDS STOOL SAMPLE WHEN PT GOES. AM labs included Hct 31.8(34.2), Mg 1.6, LDH 2325.GI: NPO. LEFT PEDAL PULSES NONDOPPLERABLE, TEAM AWARE. shocked liver low BP hypovolemia diarrhea. 7p to 7a Micu Progress NoteNeuro - Pt alert and oriented x 3. ABLE TO WEAN OFF DOPAMINE AT 2230. Pt is currently NPO ? NURSING MICU NOTE 7P-7ANEURO: PT 3, COOPERATIVE. Lactate was 4.4->pt pan-cx'd.PMH: COPD, CHF, AF, spinal stenosis, anemia, PVD, HTN.Events: On admit to MICU, resp distress resolved and pt on NC. lbm soft formed, no further c/o abd pain.gu: voiding per urinal clear yellow urine, 200-250 q 4 hoursid: afebrile, cont on antb. Gallbladder is normal without evidence of stones. ULTRASOUND OF LOWER EXTREMITIES. There is a left lower lobe opacity and small left pleural effusion. L pupil 4mm/R 2mm. levofloxacin and flagyl,plan: transfer to 7 for cont of care. Regional left ventricularwall motion is normal. NO EVIDENCE OF SWELLING, WARM TO TOUCH.GI/GU: ABD SOFT, +BS, NO BM. Good pulses to touch to bil rad pulses. The inferior vena cava is patent as well. Urine sent for osmolality and lytes. he has fallen in past per his pcp.cad hr remains afib with pvc's rate in the 100's, lopresssor increased to 100 mg tid, needs to be restarted on baseline verapamil.resp: ls . PT DENIES ANY PAIN. Am blood lytes pend.ID - Afeb. BP 103/38-124/41. Abd. Nsg transfer note updated. clear, remains on 3l nc, desat to 83% with o2 off. IF PT ABLE TO GO TO FLOOR TODAY. O2 sats between 92-96% on 3 liters NC.CV: BP 100's-130's/50's-70's, HR 110's-130's. Pt will become SOB with minor activity."},"n_notes":{"kind":"number","value":16,"string":"16"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2199-08-19 00:00:00.000","description":"Report","row_id":1609882,"text":"7am to 7pm:\n\nNeuro)\nPt has been awake, alert and O x 3 throughout the day.\n\nCV)\nPt was on Dopamine gtt this am and has been off since 3pm. Bp 99-112 with goal MAP >60. Mg replaced this am and no mg level until am MD. Echo done this am and results pending. Pt has gen edema with +2 pitting edema to lower ext's. Pt is in NSR with freq PAC's. Nailbeds are no longer blue and lower ext's are no longer mottled. Good pulses to touch to bil rad pulses. Rt leg with only + pulses to . Ext's remain sl cool to touch, but this is baseline per pt.\n\nRESP)\nLs dimminished throughout this am and now with cx's to RLL and coarse LS to LLL. Pt present with a very loose congested prod cough with thick tan scretions. Pt needs to be inc to DB&C.. CXR with no CHF even though BNP . Pt will become SOB with minor activity. 96-98% on 2 liter NP. Neb tx ATC. ABG's as noted in carevue.\n\nGI)\nAbd soft and non-tender to touch. No N/V/D at this time. US of abd done and NL. LFT's elevated ? shocked liver low BP hypovolemia diarrhea. Pt is currently NPO ? advance in diet. Pt reports a decreased appetite and last good meal was Tuesday per pt. Hepatitis panel pending. Pt needs a stool sample.\n\nID)\nLA down to 1.7 (4.4). Pt has Bc, urine and sputum culture pending. Pt is on Flagyl, Levo and vanco IVabx.\n\nPain)\nPt denies any discomfort.\n\nGU)\nGood U/O via foley catheter. Urine remains yellow and cloudy.\n\nsoc)\nPt is DNR / DNI.\n\n\n"},{"category":"Nursing/other","chartdate":"2199-08-19 00:00:00.000","description":"Report","row_id":1609883,"text":"Respiratory Care:\npt seems in good spirits today. Went on a road trip today with RN and\nupon return has beenc sleeping most of the day. As a result he recieved only one neb. Tx. His chest is with coarse BS's with a fair NPC. please see carevue for details.\n"},{"category":"Nursing/other","chartdate":"2199-08-20 00:00:00.000","description":"Report","row_id":1609884,"text":"NURSING MICU NOTE 7P-7A\n\nNEURO: PT 3, COOPERATIVE. PT DENIES ANY PAIN. PT C/O GENERALIZED WEAKNESS THROUGH OUT.\n\nRESP: PT REMAINS 3L NC. O2 SATS 88-95%. LS RHONCHI AT BASES, CLEAR ABOVE. PT HAS A PRODUCTIVE CONGESTED COUGH.\n\nCV: EARLY IN SHIFT HR SWITCHING BETWEEN AFIB AND NS. PT HAS SPENT TO REST OF OVERNIGHT AFIB HR 90-130'S. ABLE TO WEAN OFF DOPAMINE AT 2230. PT HAS REMAINED OFF THROUGH OUT NIGHT. GOAL MAPS 55. LEFT PEDAL PULSES NONDOPPLERABLE, TEAM AWARE. ? ULTRASOUND TODAY. NO EVIDENCE OF SWELLING, WARM TO TOUCH.\n\nGI/GU: ABD SOFT, +BS, NO BM. PT DENIES ANY N/V, NO ABD PAIN. PT IS PASSING GAS. PT NPO, EXCEPT MEDS. FOLEY INTACT DRAINING YELLOW CLOUDY URINE. UNABLE TO OBTAIN STOOL SAMPLE.\n\nDISPO: ? ULTRASOUND OF LOWER EXTREMITIES. NEEDS STOOL SAMPLE WHEN PT GOES. NEPHEW CALLED OVERNIGHT FOR UPDATE. ? IF PT ABLE TO GO TO FLOOR TODAY. PT IS A DNR/DNI.\n\n\n"},{"category":"Nursing/other","chartdate":"2199-08-20 00:00:00.000","description":"Report","row_id":1609885,"text":"Respiratory Care:\nPt took one A/A tx via neb with a mouth piece and liked this much better....vs. a CFM. BS's still course with a fair to poor cough.\n"},{"category":"Nursing/other","chartdate":"2199-08-19 00:00:00.000","description":"Report","row_id":1609881,"text":"Nursing Admit/Progress note -0700\nThis 83yo man admitted via ED from House for C/O resp distress, and diarrhea/cramping X 2weeks. In , pt hypotensive to SBP 50's, HR 40's. Pt rec'd total 2liters fluid IV and started on Dopamine qtts @ 25mcg/kg/min. Pt placed on non-rebreather mask and rec'd solumedrol for resp distress. Lactate was 4.4->pt pan-cx'd.\nPMH: COPD, CHF, AF, spinal stenosis, anemia, PVD, HTN.\n\nEvents: On admit to MICU, resp distress resolved and pt on NC. Abd discomfort lessened, and pt attributed this to antiemetic he rec'd in ED. Dopamine titrated to present rate 4mcg/kg/min.\n\nReview of Systems:\n\nNeuro: Pt X 3, pleasant. L pupil 4mm/R 2mm. Turns self STS in bed but prefers supine position with HOB elevated 45degrees. He stated lower abd pain improved, not worsened with palpation.\n\nResp: VBG on admit on non-rebreather mask was 7.21/53/221. O2 sat 93-100% (pleth irreg) on 3 l NC with RR 14-28 and regular. Lung snds coarse with crackles @ bases and rare I/E wheezes. Strong cough raising large amts sputum which is tan/thick. CXR showed L pleural effusion and ? atelectasis.\n\nCV: HR 66-78SR with occas PAC's and rare PVC's. BP 103/38-124/41. Dopamine Qtts presently 4mcg/kg/min with MAP>60. Toes and fingertips blue, unable to obtain pedal pulses by doppler but + popliteal pulses bilat by doppler. Pt rec'd fluid bolus of 1 liter NS for vol repletion. AM labs included Hct 31.8(34.2), Mg 1.6, LDH 2325.\n\nGI: NPO. Abd soft with hypoactive bowel snds. No BM since admit.\n\nGU: Foley draining yellow/cloudy urine @ 10-35ml/hr.\n\nID: Afebrile. Pt rec'd Vanco and ceftriaxone in ED. AM WBC 11.4(13.2) and Lactate 4.4->4.8->3.3.\n\nSocial: Contact is nephew . from House called for update last pm.\n\nPlan: Abd US today. Cont antibiotic tx and await results of pan-culturing, and hepatitis and tylenol screens.\n\n"},{"category":"Nursing/other","chartdate":"2199-08-20 00:00:00.000","description":"Report","row_id":1609886,"text":"Nursing progress note (7am-7pm):\n\n\nEvents: Increase in HR 110's-130's. Started on p.o metropolol at 50mg and then increased to 100mg this afternoon. Given 1 time 5mg IV dose of metropolol as well. Pt is c/o to floor this eve...waiting for a bed.\n\nNeuro: A&O x 3. pleasant and cooperative. Pt is HOH.\n\nResp: LS to Bilateral UL clear, crackles to RLL and clear to LLL- team aware. Given neb. tx by RT. Productive cough- mostly saliva, occas. yellow...no sputum sample sent out yet. O2 sats between 92-96% on 3 liters NC.\n\nCV: BP 100's-130's/50's-70's, HR 110's-130's. Pt cont. in AFIB, rare to occas. PVCs. No c/o CP. Pt started on po metropolol as stated above. positive pedal pulses bil with doppler.\n\nGI: pos. BS, BM x1...sent stool sample for E.coli 0157:H7....? if pt may have been hypotensive d/t a poss. septic state. Pt on flagyl. Pt now on reg. diet, no N/V. Abd. soft, NT, and ND.\n\nGU: Foley cath. removed this afternoon. Pt voided 50cc of clear yellow urine following removal of cath. at 1300....keep an eye on U/O.\n\nsocial: pt's nephew called, may be in this eve after work or tomorrow...he is aware that the pt will be transferred to floor at some point.\n\nPlan: transfer to floor, monitor HR, U/O and resp. status, monitor labs.\n\n\n\n\n\n\n\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2199-08-21 00:00:00.000","description":"Report","row_id":1609887,"text":"7p to 7a Micu Progress Note\n\nNeuro - Pt alert and oriented x 3. MAE. OOB to chair with minimal assist x several hrs. Denies any pain.\n\nResp - Maintained on 3 L NC with RR 15-25 and 02 sats > 95%. Sat fell to 89% when 02 removed. LS clear, diminished at bases. + congested cough, pt states only expectorates when he awakens in the am.\n\nC-V - HR 105-120 afib with occas pvc's. NBP 120-140/60-70. Lopressor 100 mg initiated with no adverse effect on BP. Pt remains off dopamine. Hct stable at 32.3\n\nGI - Tolerating house diet without difficulty. No n/v/d. No abd discomfort. Last BM on previous shift.\n\nF/E - Voiding adeq amts of clear yellow urine with urinal. Urine sent for osmolality and lytes. Am blood lytes pend.\n\nID - Afeb. WBC 16.6, previously 21.2. Rx with flagyl and levoflox.\n\nSocial - No phone calls or visitors.\n\nA+P - Pt hemodynamically stable. Called - out to floor, awaiting bed. Nsg transfer note updated.\n"},{"category":"Nursing/other","chartdate":"2199-08-21 00:00:00.000","description":"Report","row_id":1609888,"text":"npn\nreport called to 7 nurse\n\nneruo:aox3, very pleasant gentleman, HOH, \"doesn't want to bother anyone\" be careful he may do something independently when he should ask for hlep. he has fallen in past per his pcp.\n\ncad hr remains afib with pvc's rate in the 100's, lopresssor increased to 100 mg tid, needs to be restarted on baseline verapamil.\n\nresp: ls . clear, remains on 3l nc, desat to 83% with o2 off. probably should have o2 at baseline but refuses to use it.\n\ngi; tolerating diet. lbm soft formed, no further c/o abd pain.\n\ngu: voiding per urinal clear yellow urine, 200-250 q 4 hours\n\nid: afebrile, cont on antb. levofloxacin and flagyl,\n\nplan: transfer to 7 for cont of care. ? if pt will return to house with vna services or be dc'd to rehab for further\n"},{"category":"Echo","chartdate":"2199-08-19 00:00:00.000","description":"Report","row_id":79989,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Congestive heart failure.\nHeight: (in) 68\nWeight (lb): 144\nBSA (m2): 1.78 m2\nBP (mm Hg): 104/37\nHR (bpm): 91\nStatus: Inpatient\nDate/Time: at 10:52\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild mitral annular\ncalcification. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Frequent atrial premature beats. Based on AHA\nendocarditis prophylaxis recommendations, the echo findings indicate a low\nrisk (prophylaxis not recommended). Clinical decisions regarding the need for\nprophylaxis should be based on clinical and echocardiographic data.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Regional left ventricular\nwall motion is normal. Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis\nis not present. Trace aortic regurgitation is seen. The mitral valve leaflets\nare structurally normal. There is no mitral valve prolapse. Mild to moderate\n(+) mitral regurgitation is seen. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Preserved global and regional biventricular systolic function.\nMild-moderate mitral regurgitation. Pulmonary artery systolic hypertension.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"},{"category":"ECG","chartdate":"2199-08-21 00:00:00.000","description":"Report","row_id":209775,"text":"Atrial fibrillation with rapid ventricular response\nSince previous tracing of , no significant change\n\n"},{"category":"ECG","chartdate":"2199-08-20 00:00:00.000","description":"Report","row_id":209776,"text":"Atrial fibrillation with rapid ventricular response\nSince previous tracing of , atrial fibrillation now present\n\n"},{"category":"ECG","chartdate":"2199-08-18 00:00:00.000","description":"Report","row_id":209779,"text":"Baseline artifact\nRegular wide complex bradycardia - may be junctional rhythm with atrial\nmechanism uncertain and baseline artifact makes assessment difficult\nNonspecific ST-T wave changes\nQ-Tc interval appears prolonged but is difficult to measure\nClinical correlation is suggested\nNo previous tracing available for comparison\n\n"},{"category":"ECG","chartdate":"2199-08-18 00:00:00.000","description":"Report","row_id":209777,"text":"Sinus rhythm\nAtrial premature complexes\nModest nonspecific ST-T wave changes\nSince previous tracing of the same date, atrial flutter absent\n\n"},{"category":"ECG","chartdate":"2199-08-18 00:00:00.000","description":"Report","row_id":209778,"text":"Baseline artifact\nProbable atrial flutter\nVentricular premature complex\nModest nonspecific ST-T wave changes\nSince previous tracing of the same date, bradyarrhythmia absent\n\n"},{"category":"Radiology","chartdate":"2199-08-19 00:00:00.000","description":"ABDOMEN U.S. (COMPLETE STUDY)","row_id":920368,"text":" 11:22 AM\n ABDOMEN U.S. (COMPLETE STUDY); -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOPP ABD/PEL\n Reason: please use doppler to assess flow; assess architecture of li\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with hx of CHF, afib now with hypotension, 2 weeks of diarrhea\n and abd pain, found to have markedly elevated LFTs into \n REASON FOR THIS EXAMINATION:\n please use doppler to assess flow; assess architecture of liver\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Congestive heart failure and atrial fibrillation, now with\n hypotension. Patient had two weeks of diarrhea and abdominal pain and\n markedly elevated LFTs into the . Assess flow.\n\n There are no prior studies for comparison.\n\n ABDOMEN ULTRASOUND: The liver echotexture is normal. There are no focal\n liver lesions or intrahepatic biliary ductal dilatation. Gallbladder is\n normal without evidence of stones. The common duct is not dilated, measuring\n 3-5 mm. The right kidney measures 10.3 cm. The left kidney measures 9.5 cm.\n There is no hydronephrosis, stone, or solid renal mass. There is a\n simple-appearing cyst arising from the left mid kidney measuring up to 3.8 cm\n in diameter. The spleen is small in size, but otherwise normal. The pancreas\n and aorta are not well visualized due to overlying bowel gas. There is a\n trace amount of ascites fluid within the abdomen.\n\n LIVER DOPPLER: The main, right anterior, right posterior, and left portal\n veins are patent with the appropriate direction of flow. The main, left, and\n right hepatic arteries are patent. The left, middle, and right hepatic veins\n are patent. The inferior vena cava is patent as well.\n\n IMPRESSION:\n 1. Patent hepatic vasculature.\n 2. Unremarkable liver echotexture.\n 3. Trace ascites.\n 4. Simple-appearing cyst of the mid left kidney.\n\n\n"},{"category":"Radiology","chartdate":"2199-08-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":920286,"text":" 4:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o cardiopulm process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with +SOB,+DOE &CP\n REASON FOR THIS EXAMINATION:\n r/o cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 83-year-old man with shortness of breath, dyspnea on exertion, and\n chest pain.\n\n CHEST AP:\n\n Heart size is at upper limits of normal. The aorta is calcified and tortuous.\n Pulmonary vasculature is unremarkable. There is a left lower lobe opacity and\n small left pleural effusion. Left lower lobe opacity could represent\n atelectasis; however, pneumonia cannot be excluded.\n\n IMPRESSION: Small left pleural effusion. No evidence of CHF.\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2199-08-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1609882,\n \"text\": \"7am to 7pm:\\n\\nNeuro)\\nPt has been awake, alert and O x 3 throughout the day.\\n\\nCV)\\nPt was on Dopamine gtt this am and has been off since 3pm. Bp 99-112 with goal MAP >60. Mg replaced this am and no mg level until am MD. Echo done this am and results pending. Pt has gen edema with +2 pitting edema to lower ext's. Pt is in NSR with freq PAC's. Nailbeds are no longer blue and lower ext's are no longer mottled. Good pulses to touch to bil rad pulses. Rt leg with only + pulses to . Ext's remain sl cool to touch, but this is baseline per pt.\\n\\nRESP)\\nLs dimminished throughout this am and now with cx's to RLL and coarse LS to LLL. Pt present with a very loose congested prod cough with thick tan scretions. Pt needs to be inc to DB&C.. CXR with no CHF even though BNP . Pt will become SOB with minor activity. 96-98% on 2 liter NP. Neb tx ATC. ABG's as noted in carevue.\\n\\nGI)\\nAbd soft and non-tender to touch. No N/V/D at this time. US of abd done and NL. LFT's elevated ? shocked liver low BP hypovolemia diarrhea. Pt is currently NPO ? advance in diet. Pt reports a decreased appetite and last good meal was Tuesday per pt. Hepatitis panel pending. Pt needs a stool sample.\\n\\nID)\\nLA down to 1.7 (4.4). Pt has Bc, urine and sputum culture pending. Pt is on Flagyl, Levo and vanco IVabx.\\n\\nPain)\\nPt denies any discomfort.\\n\\nGU)\\nGood U/O via foley catheter. Urine remains yellow and cloudy.\\n\\nsoc)\\nPt is DNR / DNI.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2199-08-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1609883,\n \"text\": \"Respiratory Care:\\npt seems in good spirits today. Went on a road trip today with RN and\\nupon return has beenc sleeping most of the day. As a result he recieved only one neb. Tx. His chest is with coarse BS's with a fair NPC. please see carevue for details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2199-08-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1609884,\n \"text\": \"NURSING MICU NOTE 7P-7A\\n\\nNEURO: PT 3, COOPERATIVE. PT DENIES ANY PAIN. PT C/O GENERALIZED WEAKNESS THROUGH OUT.\\n\\nRESP: PT REMAINS 3L NC. O2 SATS 88-95%. LS RHONCHI AT BASES, CLEAR ABOVE. PT HAS A PRODUCTIVE CONGESTED COUGH.\\n\\nCV: EARLY IN SHIFT HR SWITCHING BETWEEN AFIB AND NS. PT HAS SPENT TO REST OF OVERNIGHT AFIB HR 90-130'S. ABLE TO WEAN OFF DOPAMINE AT 2230. PT HAS REMAINED OFF THROUGH OUT NIGHT. GOAL MAPS 55. LEFT PEDAL PULSES NONDOPPLERABLE, TEAM AWARE. ? ULTRASOUND TODAY. NO EVIDENCE OF SWELLING, WARM TO TOUCH.\\n\\nGI/GU: ABD SOFT, +BS, NO BM. PT DENIES ANY N/V, NO ABD PAIN. PT IS PASSING GAS. PT NPO, EXCEPT MEDS. FOLEY INTACT DRAINING YELLOW CLOUDY URINE. UNABLE TO OBTAIN STOOL SAMPLE.\\n\\nDISPO: ? ULTRASOUND OF LOWER EXTREMITIES. NEEDS STOOL SAMPLE WHEN PT GOES. NEPHEW CALLED OVERNIGHT FOR UPDATE. ? IF PT ABLE TO GO TO FLOOR TODAY. PT IS A DNR/DNI.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2199-08-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1609885,\n \"text\": \"Respiratory Care:\\nPt took one A/A tx via neb with a mouth piece and liked this much better....vs. a CFM. BS's still course with a fair to poor cough.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2199-08-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1609881,\n \"text\": \"Nursing Admit/Progress note -0700\\nThis 83yo man admitted via ED from House for C/O resp distress, and diarrhea/cramping X 2weeks. In , pt hypotensive to SBP 50's, HR 40's. Pt rec'd total 2liters fluid IV and started on Dopamine qtts @ 25mcg/kg/min. Pt placed on non-rebreather mask and rec'd solumedrol for resp distress. Lactate was 4.4->pt pan-cx'd.\\nPMH: COPD, CHF, AF, spinal stenosis, anemia, PVD, HTN.\\n\\nEvents: On admit to MICU, resp distress resolved and pt on NC. Abd discomfort lessened, and pt attributed this to antiemetic he rec'd in ED. Dopamine titrated to present rate 4mcg/kg/min.\\n\\nReview of Systems:\\n\\nNeuro: Pt X 3, pleasant. L pupil 4mm/R 2mm. Turns self STS in bed but prefers supine position with HOB elevated 45degrees. He stated lower abd pain improved, not worsened with palpation.\\n\\nResp: VBG on admit on non-rebreather mask was 7.21/53/221. O2 sat 93-100% (pleth irreg) on 3 l NC with RR 14-28 and regular. Lung snds coarse with crackles @ bases and rare I/E wheezes. Strong cough raising large amts sputum which is tan/thick. CXR showed L pleural effusion and ? atelectasis.\\n\\nCV: HR 66-78SR with occas PAC's and rare PVC's. BP 103/38-124/41. Dopamine Qtts presently 4mcg/kg/min with MAP>60. Toes and fingertips blue, unable to obtain pedal pulses by doppler but + popliteal pulses bilat by doppler. Pt rec'd fluid bolus of 1 liter NS for vol repletion. AM labs included Hct 31.8(34.2), Mg 1.6, LDH 2325.\\n\\nGI: NPO. Abd soft with hypoactive bowel snds. No BM since admit.\\n\\nGU: Foley draining yellow/cloudy urine @ 10-35ml/hr.\\n\\nID: Afebrile. Pt rec'd Vanco and ceftriaxone in ED. AM WBC 11.4(13.2) and Lactate 4.4->4.8->3.3.\\n\\nSocial: Contact is nephew . from House called for update last pm.\\n\\nPlan: Abd US today. Cont antibiotic tx and await results of pan-culturing, and hepatitis and tylenol screens.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2199-08-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1609886,\n \"text\": \"Nursing progress note (7am-7pm):\\n\\n\\nEvents: Increase in HR 110's-130's. Started on p.o metropolol at 50mg and then increased to 100mg this afternoon. Given 1 time 5mg IV dose of metropolol as well. Pt is c/o to floor this eve...waiting for a bed.\\n\\nNeuro: A&O x 3. pleasant and cooperative. Pt is HOH.\\n\\nResp: LS to Bilateral UL clear, crackles to RLL and clear to LLL- team aware. Given neb. tx by RT. Productive cough- mostly saliva, occas. yellow...no sputum sample sent out yet. O2 sats between 92-96% on 3 liters NC.\\n\\nCV: BP 100's-130's/50's-70's, HR 110's-130's. Pt cont. in AFIB, rare to occas. PVCs. No c/o CP. Pt started on po metropolol as stated above. positive pedal pulses bil with doppler.\\n\\nGI: pos. BS, BM x1...sent stool sample for E.coli 0157:H7....? if pt may have been hypotensive d/t a poss. septic state. Pt on flagyl. Pt now on reg. diet, no N/V. Abd. soft, NT, and ND.\\n\\nGU: Foley cath. removed this afternoon. Pt voided 50cc of clear yellow urine following removal of cath. at 1300....keep an eye on U/O.\\n\\nsocial: pt's nephew called, may be in this eve after work or tomorrow...he is aware that the pt will be transferred to floor at some point.\\n\\nPlan: transfer to floor, monitor HR, U/O and resp. status, monitor labs.\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2199-08-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1609887,\n \"text\": \"7p to 7a Micu Progress Note\\n\\nNeuro - Pt alert and oriented x 3. MAE. OOB to chair with minimal assist x several hrs. Denies any pain.\\n\\nResp - Maintained on 3 L NC with RR 15-25 and 02 sats > 95%. Sat fell to 89% when 02 removed. LS clear, diminished at bases. + congested cough, pt states only expectorates when he awakens in the am.\\n\\nC-V - HR 105-120 afib with occas pvc's. NBP 120-140/60-70. Lopressor 100 mg initiated with no adverse effect on BP. Pt remains off dopamine. Hct stable at 32.3\\n\\nGI - Tolerating house diet without difficulty. No n/v/d. No abd discomfort. Last BM on previous shift.\\n\\nF/E - Voiding adeq amts of clear yellow urine with urinal. Urine sent for osmolality and lytes. Am blood lytes pend.\\n\\nID - Afeb. WBC 16.6, previously 21.2. Rx with flagyl and levoflox.\\n\\nSocial - No phone calls or visitors.\\n\\nA+P - Pt hemodynamically stable. Called - out to floor, awaiting bed. Nsg transfer note updated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2199-08-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1609888,\n \"text\": \"npn\\nreport called to 7 nurse\\n\\nneruo:aox3, very pleasant gentleman, HOH, \\\"doesn't want to bother anyone\\\" be careful he may do something independently when he should ask for hlep. he has fallen in past per his pcp.\\n\\ncad hr remains afib with pvc's rate in the 100's, lopresssor increased to 100 mg tid, needs to be restarted on baseline verapamil.\\n\\nresp: ls . clear, remains on 3l nc, desat to 83% with o2 off. probably should have o2 at baseline but refuses to use it.\\n\\ngi; tolerating diet. lbm soft formed, no further c/o abd pain.\\n\\ngu: voiding per urinal clear yellow urine, 200-250 q 4 hours\\n\\nid: afebrile, cont on antb. levofloxacin and flagyl,\\n\\nplan: transfer to 7 for cont of care. ? if pt will return to house with vna services or be dc'd to rehab for further\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2199-08-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 79989,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Congestive heart failure.\\nHeight: (in) 68\\nWeight (lb): 144\\nBSA (m2): 1.78 m2\\nBP (mm Hg): 104/37\\nHR (bpm): 91\\nStatus: Inpatient\\nDate/Time: at 10:52\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Mild LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\\n(LVEF>55%). Normal regional LV systolic function.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic root diameter.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild mitral annular\\ncalcification. Mild to moderate (+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\\nsystolic hypertension.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Frequent atrial premature beats. Based on AHA\\nendocarditis prophylaxis recommendations, the echo findings indicate a low\\nrisk (prophylaxis not recommended). Clinical decisions regarding the need for\\nprophylaxis should be based on clinical and echocardiographic data.\\n\\nConclusions:\\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\\nsize, and systolic function are normal (LVEF>55%). Regional left ventricular\\nwall motion is normal. Right ventricular chamber size and free wall motion are\\nnormal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis\\nis not present. Trace aortic regurgitation is seen. The mitral valve leaflets\\nare structurally normal. There is no mitral valve prolapse. Mild to moderate\\n(+) mitral regurgitation is seen. There is mild pulmonary artery systolic\\nhypertension. There is no pericardial effusion.\\n\\nIMPRESSION: Preserved global and regional biventricular systolic function.\\nMild-moderate mitral regurgitation. Pulmonary artery systolic hypertension.\\n\\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\\nindicate a low risk (prophylaxis not recommended). Clinical decisions\\nregarding the need for prophylaxis should be based on clinical and\\nechocardiographic data.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2199-08-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 209775,\n \"text\": \"Atrial fibrillation with rapid ventricular response\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2199-08-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 209776,\n \"text\": \"Atrial fibrillation with rapid ventricular response\\nSince previous tracing of , atrial fibrillation now present\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2199-08-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 209779,\n \"text\": \"Baseline artifact\\nRegular wide complex bradycardia - may be junctional rhythm with atrial\\nmechanism uncertain and baseline artifact makes assessment difficult\\nNonspecific ST-T wave changes\\nQ-Tc interval appears prolonged but is difficult to measure\\nClinical correlation is suggested\\nNo previous tracing available for comparison\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2199-08-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 209777,\n \"text\": \"Sinus rhythm\\nAtrial premature complexes\\nModest nonspecific ST-T wave changes\\nSince previous tracing of the same date, atrial flutter absent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2199-08-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 209778,\n \"text\": \"Baseline artifact\\nProbable atrial flutter\\nVentricular premature complex\\nModest nonspecific ST-T wave changes\\nSince previous tracing of the same date, bradyarrhythmia absent\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-08-19 00:00:00.000\",\n \"description\": \"ABDOMEN U.S. (COMPLETE STUDY)\",\n \"row_id\": 920368,\n \"text\": \" 11:22 AM\\n ABDOMEN U.S. (COMPLETE STUDY); -59 DISTINCT PROCEDURAL SERVICE Clip # \\n DUPLEX DOPP ABD/PEL\\n Reason: please use doppler to assess flow; assess architecture of li\\n Admitting Diagnosis: HYPOTENSION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 83 year old man with hx of CHF, afib now with hypotension, 2 weeks of diarrhea\\n and abd pain, found to have markedly elevated LFTs into \\n REASON FOR THIS EXAMINATION:\\n please use doppler to assess flow; assess architecture of liver\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Congestive heart failure and atrial fibrillation, now with\\n hypotension. Patient had two weeks of diarrhea and abdominal pain and\\n markedly elevated LFTs into the . Assess flow.\\n\\n There are no prior studies for comparison.\\n\\n ABDOMEN ULTRASOUND: The liver echotexture is normal. There are no focal\\n liver lesions or intrahepatic biliary ductal dilatation. Gallbladder is\\n normal without evidence of stones. The common duct is not dilated, measuring\\n 3-5 mm. The right kidney measures 10.3 cm. The left kidney measures 9.5 cm.\\n There is no hydronephrosis, stone, or solid renal mass. There is a\\n simple-appearing cyst arising from the left mid kidney measuring up to 3.8 cm\\n in diameter. The spleen is small in size, but otherwise normal. The pancreas\\n and aorta are not well visualized due to overlying bowel gas. There is a\\n trace amount of ascites fluid within the abdomen.\\n\\n LIVER DOPPLER: The main, right anterior, right posterior, and left portal\\n veins are patent with the appropriate direction of flow. The main, left, and\\n right hepatic arteries are patent. The left, middle, and right hepatic veins\\n are patent. The inferior vena cava is patent as well.\\n\\n IMPRESSION:\\n 1. Patent hepatic vasculature.\\n 2. Unremarkable liver echotexture.\\n 3. Trace ascites.\\n 4. Simple-appearing cyst of the mid left kidney.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-08-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 920286,\n \"text\": \" 4:07 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o cardiopulm process\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 83 year old man with +SOB,+DOE &CP\\n REASON FOR THIS EXAMINATION:\\n r/o cardiopulm process\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 83-year-old man with shortness of breath, dyspnea on exertion, and\\n chest pain.\\n\\n CHEST AP:\\n\\n Heart size is at upper limits of normal. The aorta is calcified and tortuous.\\n Pulmonary vasculature is unremarkable. There is a left lower lobe opacity and\\n small left pleural effusion. Left lower lobe opacity could represent\\n atelectasis; however, pneumonia cannot be excluded.\\n\\n IMPRESSION: Small left pleural effusion. No evidence of CHF.\\n\\n\"\n }\n]"}}},{"rowIdx":24649,"cells":{"subject_id":{"kind":"number","value":29615,"string":"29,615"},"hadm_id":{"kind":"number","value":118254,"string":"118,254"},"target_text":{"kind":"string","value":"Madelyne is a 68 year old female with hypertension, hyperlipidemia, history of smokin, with known 3 vessel disease and history of multiple , who presented for cardiac catheterization and re-stenting of the proximal and distal circumflex artery. Her procedure was complicated by a retroperitoneal bleed, prompting admission and monitoring in the CCU. . # Retroperitoneal bleed: Patient became hypotensive s/p elective catheterization, and was found to have a laceration of the left inferior epigastric artery. A stat Hct was approx. 24, and contrast study showed laceration and retroperitoneal bleeding. Venous access obtained on right and balloon tamponade was maintained to stop bleeding. ABG demonstrated pH 7.25, with normal CO2/o2 and decreased bicarb, and hct 24. The patient was placed on Dopamine to maintain her pressures, but was quickly weaned with hemostasis. Patient transfused 4U PRBC, post transfusion hct 35. The patient was transferred to the CCU for observation overnight. Blood pressures returned to sBP 150s, and she was started on nitro gtt. A non-contrast CT body was obtained which showed large RP bleed surrounding the rectum. Pain management with Percocet 5/325 PO PRN, with morphine PRN for breakthrough pain. . # CAD s/p in LAD and LCX: Ms. presents with longstanding CAD with multiple stents (app. 6). Patient underwent elective catheterization for 2 weeks exertional CP after negative stress test, which showed 70-80% re-stenosis of LXC . Two were placed at the distal and mid-portion LXC. Patient noted pre-procedural CP had resolved. She was continued on home ASA, Plavix, Atorvastatin. Her home metoprolol and Imdur were held post-procedurally, and restarted after observation overnight. . # Hypertension: The patient became acutely hypotensive s/p cath, related to bleeding. She was transfused 4 units. She was started on a dopamine drip briefly in lab but was quickly weaned off. After cath, she was hypertensive sBP 150s so a nitro drip was started for better control of BP in setting of possible re-bleed. The nitro drip was weaned and she was restarted on her home doses of metoprolol. She will restart her quinapril and isosorbide the day after discharge. She will need to follow up with her PCP /or cardiologist for blood pressure monitoring. . # Diabetes: DM typically controlled at home with glipizide and diet. Insulin Sliding Scale started for acute managment in hospital. On discharge, patient was restarted on home medication of glipizide. # Hypothyroidism: Ms. has a history of hypothyroidism, treated with Synthroid. C/o fatigue for last several weeks, likely related to cardiac symptoms. However, patient should have TSH checked on outpatient basis to make sure Synthroid in therapeutic range. . The patient was full code for this admission."},"extractive_notes_summ":{"kind":"string","value":"Probable small right adrenal adenoma, as above. A thin rim of slightly dense material is noted along the right perihepatic region, possibly representing hemorrhage related to retroperitoneal hematoma described below. Np pleural effusions. Left femoral vessel catheters are noted. Mutliple prominent portocaval lymph nodes are noted. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Prominent portocaval lymph nodes, as above. The left adrenal gland is slightly hyperplastic but maintains its adreniform shape. The superior aspect of the hematoma is just below the aortic bifurcation. Large retroperitoneal hematoma exerting mild mass effect on the bladder as described above, with a small area of hyperdense material which may reflect more acute bleeding. Probable gallbladder sludge. The bladder is decompressed. FINDINGS: LOWER CHEST: The visualized portion of the lungs appears unremarkable. It extends superiorly to the anterior aspect of the left psoas muscle and inferiorly to the left prerectal space. There is a rounded low density nodule in the right adrenal gland (2; 25) measuring approximately 9mm with a of less than 10, likely representing a small adenoma. A well-circumscribed hypodensity in the upper pole of the right kidney is too small to characterize, but most likely a cyst. ABDOMEN AND PELVIS: Limited evaluation of the solid organs without contrast. Compared to theprevious tracing the P-R interval is shorter.TRACING #2 Also of note is sigmoid diverticulosis without evidence of diverticulitis. Serial hematocrit checks are encouraged. Calcified atherosclerotic disease is noted in the coronary arteries. The right lobe measures 10 cm x 4.5 cm (2;69). One measuring approximately 12 mm in short axis (2; 30). Left bundle-branch block. Left bundle-branch block. IMPRESSION: 1. The left lobe of the hematoma measures 8.5 x 3 cm, and at its posterior aspect lies some hyperdense material that may reflect a componenet of acute bleeding. The P-R interval is prolonged. The P-R interval is prolonged. WET READ VERSION #1 JEKh FRI 9:51 PM Retroperitoneal hematoma exerting mild mass effect on the bladder; small area of dense material may reflect more acute bleeding. 3. Left bundle-branch block.Compared to the previous tracing there is no significant change.TRACING #1 2. 4. The kidneys enhance and excrete contrast symmetrically. Calcified atherosclerotic disease is noted throughout the abdominal aorta into the iliac branches. STUDY: CT of abdomen and pelvis without contrast. TECHNQUE: Axial images from the lung bases to the proximal femurs were obtained with coronal and sagittal reformatted images. No IV contrast. Compared to the previous tracingthere is no significant change.TRACING #3 Left bundle-branch block.Compared to the previous tracing the P-R interval is longer.TRACING #4 Foley balloon is noted inside the bladder. The small and large bowel are of normal caliber without evidence of obstruction. The gallbladder demonstrates increased density, likely sludge. No pelvicaliectasis. No pericardial effusion. No intrahepatic biliary dilatation. Artifact is present. Discussed with at 21:52 on . Discussed with at 21:52 on . The bladder is distorted by a bilobed retroperitoneal high density most (Over) 5:12 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: assess retroperitoneal bleed s/p cardiac cath w/attempted ba Admitting Diagnosis: CHEST PAIN\\CARDIAC CATH FINAL REPORT (Cont) consistent with hematoma. There is no free air. BONES: There are no aggressive-appearing lytic or sclerotic lesions seen. 5:12 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: assess retroperitoneal bleed s/p cardiac cath w/attempted ba Admitting Diagnosis: CHEST PAIN\\CARDIAC CATH MEDICAL CONDITION: 68 year old female with multiple cardiac risk factors including HTN, Hypercholesterolemia, and prior tobacco abuse, 3 vessel disease s/p multiple presenting s/p cath and re-stenting of proximal and distal circ complicated by RP bleed REASON FOR THIS EXAMINATION: assess retroperitoneal bleed s/p cardiac cath w/attempted balloon tamponade CONTRAINDICATIONS for IV CONTRAST: renal insufficiency WET READ: JEKh FRI 9:59 PM Retroperitoneal hematoma exerting mild mass effect on the bladder; small area of dense material may reflect more acute bleeding, so serial hematocrit checks are encouraged."},"n_notes":{"kind":"number","value":5,"string":"5"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2103-08-17 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":1154018,"text":" 5:12 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: assess retroperitoneal bleed s/p cardiac cath w/attempted ba\n Admitting Diagnosis: CHEST PAIN\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old female with multiple cardiac risk factors including HTN,\n Hypercholesterolemia, and prior tobacco abuse, 3 vessel disease s/p multiple\n presenting s/p cath and re-stenting of proximal and distal circ complicated by\n RP bleed\n REASON FOR THIS EXAMINATION:\n assess retroperitoneal bleed s/p cardiac cath w/attempted balloon tamponade\n CONTRAINDICATIONS for IV CONTRAST:\n renal insufficiency\n ______________________________________________________________________________\n WET READ: JEKh FRI 9:59 PM\n Retroperitoneal hematoma exerting mild mass effect on the bladder; small area\n of dense material may reflect more acute bleeding, so serial hematocrit checks\n are encouraged. Discussed with at 21:52 on .\n WET READ VERSION #1 JEKh FRI 9:51 PM\n Retroperitoneal hematoma exerting mild mass effect on the bladder; small area\n of dense material may reflect more acute bleeding.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 60-year-old a female status post catheterization and stenting of the\n coronary arteries, complicated by retroperitoneal bleed.\n\n STUDY: CT of abdomen and pelvis without contrast.\n\n TECHNQUE: Axial images from the lung bases to the proximal femurs were\n obtained with coronal and sagittal reformatted images. No IV contrast.\n\n FINDINGS:\n\n LOWER CHEST: The visualized portion of the lungs appears unremarkable. Np\n pleural effusions. No pericardial effusion. Calcified atherosclerotic disease\n is noted in the coronary arteries.\n\n ABDOMEN AND PELVIS: Limited evaluation of the solid organs without contrast.\n No intrahepatic biliary dilatation. A thin rim of slightly dense material is\n noted along the right perihepatic region, possibly representing hemorrhage\n related to retroperitoneal hematoma described below. The gallbladder\n demonstrates increased density, likely sludge. The left adrenal gland is\n slightly hyperplastic but maintains its adreniform shape. There is a rounded\n low density nodule in the right adrenal gland (2; 25) measuring approximately\n 9mm with a of less than 10, likely representing a small adenoma.\n\n No pelvicaliectasis. The kidneys enhance and excrete contrast symmetrically.\n A well-circumscribed hypodensity in the upper pole of the right kidney is too\n small to characterize, but most likely a cyst.\n Foley balloon is noted inside the bladder. The bladder is decompressed.\n\n The bladder is distorted by a bilobed retroperitoneal high density most\n (Over)\n\n 5:12 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: assess retroperitoneal bleed s/p cardiac cath w/attempted ba\n Admitting Diagnosis: CHEST PAIN\\CARDIAC CATH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n consistent with hematoma. The right lobe measures 10 cm x 4.5 cm (2;69). The\n left lobe of the hematoma measures 8.5 x 3 cm, and at its posterior aspect\n lies some hyperdense material that may reflect a componenet of acute bleeding.\n The superior aspect of the hematoma is just below the aortic bifurcation. It\n extends superiorly to the anterior aspect of the left psoas muscle and\n inferiorly to the left prerectal space.\n\n The small and large bowel are of normal caliber without evidence of\n obstruction. Also of note is sigmoid diverticulosis without evidence of\n diverticulitis.\n\n Calcified atherosclerotic disease is noted throughout the abdominal aorta into\n the iliac branches. Left femoral vessel catheters are noted.\n\n There is no free air. Mutliple prominent portocaval lymph nodes are noted. One\n measuring approximately 12 mm in short axis (2; 30).\n\n BONES: There are no aggressive-appearing lytic or sclerotic lesions seen.\n\n IMPRESSION:\n 1. Large retroperitoneal hematoma exerting mild mass effect on the bladder as\n described above, with a small area of hyperdense material which may reflect\n more acute bleeding. Serial hematocrit checks are encouraged. Discussed with\n at 21:52 on .\n 2. Prominent portocaval lymph nodes, as above.\n 3. Probable small right adrenal adenoma, as above.\n 4. Probable gallbladder sludge.\n\n"},{"category":"ECG","chartdate":"2103-08-18 00:00:00.000","description":"Report","row_id":223493,"text":"Sinus rhythm. The P-R interval is prolonged. Left bundle-branch block.\nCompared to the previous tracing the P-R interval is longer.\nTRACING #4\n\n"},{"category":"ECG","chartdate":"2103-08-17 00:00:00.000","description":"Report","row_id":223494,"text":"Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\nthere is no significant change.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2103-08-17 00:00:00.000","description":"Report","row_id":223495,"text":"Artifact is present. Sinus rhythm. Left bundle-branch block. Compared to the\nprevious tracing the P-R interval is shorter.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2103-08-17 00:00:00.000","description":"Report","row_id":223496,"text":"Sinus rhythm. The P-R interval is prolonged. Left bundle-branch block.\nCompared to the previous tracing there is no significant change.\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-08-17 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 1154018,\n \"text\": \" 5:12 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: assess retroperitoneal bleed s/p cardiac cath w/attempted ba\\n Admitting Diagnosis: CHEST PAIN\\\\CARDIAC CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 68 year old female with multiple cardiac risk factors including HTN,\\n Hypercholesterolemia, and prior tobacco abuse, 3 vessel disease s/p multiple\\n presenting s/p cath and re-stenting of proximal and distal circ complicated by\\n RP bleed\\n REASON FOR THIS EXAMINATION:\\n assess retroperitoneal bleed s/p cardiac cath w/attempted balloon tamponade\\n CONTRAINDICATIONS for IV CONTRAST:\\n renal insufficiency\\n ______________________________________________________________________________\\n WET READ: JEKh FRI 9:59 PM\\n Retroperitoneal hematoma exerting mild mass effect on the bladder; small area\\n of dense material may reflect more acute bleeding, so serial hematocrit checks\\n are encouraged. Discussed with at 21:52 on .\\n WET READ VERSION #1 JEKh FRI 9:51 PM\\n Retroperitoneal hematoma exerting mild mass effect on the bladder; small area\\n of dense material may reflect more acute bleeding.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 60-year-old a female status post catheterization and stenting of the\\n coronary arteries, complicated by retroperitoneal bleed.\\n\\n STUDY: CT of abdomen and pelvis without contrast.\\n\\n TECHNQUE: Axial images from the lung bases to the proximal femurs were\\n obtained with coronal and sagittal reformatted images. No IV contrast.\\n\\n FINDINGS:\\n\\n LOWER CHEST: The visualized portion of the lungs appears unremarkable. Np\\n pleural effusions. No pericardial effusion. Calcified atherosclerotic disease\\n is noted in the coronary arteries.\\n\\n ABDOMEN AND PELVIS: Limited evaluation of the solid organs without contrast.\\n No intrahepatic biliary dilatation. A thin rim of slightly dense material is\\n noted along the right perihepatic region, possibly representing hemorrhage\\n related to retroperitoneal hematoma described below. The gallbladder\\n demonstrates increased density, likely sludge. The left adrenal gland is\\n slightly hyperplastic but maintains its adreniform shape. There is a rounded\\n low density nodule in the right adrenal gland (2; 25) measuring approximately\\n 9mm with a of less than 10, likely representing a small adenoma.\\n\\n No pelvicaliectasis. The kidneys enhance and excrete contrast symmetrically.\\n A well-circumscribed hypodensity in the upper pole of the right kidney is too\\n small to characterize, but most likely a cyst.\\n Foley balloon is noted inside the bladder. The bladder is decompressed.\\n\\n The bladder is distorted by a bilobed retroperitoneal high density most\\n (Over)\\n\\n 5:12 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: assess retroperitoneal bleed s/p cardiac cath w/attempted ba\\n Admitting Diagnosis: CHEST PAIN\\\\CARDIAC CATH\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n consistent with hematoma. The right lobe measures 10 cm x 4.5 cm (2;69). The\\n left lobe of the hematoma measures 8.5 x 3 cm, and at its posterior aspect\\n lies some hyperdense material that may reflect a componenet of acute bleeding.\\n The superior aspect of the hematoma is just below the aortic bifurcation. It\\n extends superiorly to the anterior aspect of the left psoas muscle and\\n inferiorly to the left prerectal space.\\n\\n The small and large bowel are of normal caliber without evidence of\\n obstruction. Also of note is sigmoid diverticulosis without evidence of\\n diverticulitis.\\n\\n Calcified atherosclerotic disease is noted throughout the abdominal aorta into\\n the iliac branches. Left femoral vessel catheters are noted.\\n\\n There is no free air. Mutliple prominent portocaval lymph nodes are noted. One\\n measuring approximately 12 mm in short axis (2; 30).\\n\\n BONES: There are no aggressive-appearing lytic or sclerotic lesions seen.\\n\\n IMPRESSION:\\n 1. Large retroperitoneal hematoma exerting mild mass effect on the bladder as\\n described above, with a small area of hyperdense material which may reflect\\n more acute bleeding. Serial hematocrit checks are encouraged. Discussed with\\n at 21:52 on .\\n 2. Prominent portocaval lymph nodes, as above.\\n 3. Probable small right adrenal adenoma, as above.\\n 4. Probable gallbladder sludge.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2103-08-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 223493,\n \"text\": \"Sinus rhythm. The P-R interval is prolonged. Left bundle-branch block.\\nCompared to the previous tracing the P-R interval is longer.\\nTRACING #4\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2103-08-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 223494,\n \"text\": \"Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\\nthere is no significant change.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2103-08-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 223495,\n \"text\": \"Artifact is present. Sinus rhythm. Left bundle-branch block. Compared to the\\nprevious tracing the P-R interval is shorter.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2103-08-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 223496,\n \"text\": \"Sinus rhythm. The P-R interval is prolonged. Left bundle-branch block.\\nCompared to the previous tracing there is no significant change.\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":24650,"cells":{"subject_id":{"kind":"number","value":96579,"string":"96,579"},"hadm_id":{"kind":"number","value":129045,"string":"129,045"},"target_text":{"kind":"string","value":"The patient was admitted to the general surgery service on and had a minimally invasive esophagectomy. The patient tolerated the procedure well. Initially through POD 3 he was kept in the ICU to monitor and control his blood pressure. His SBP goal was 100-150 and it was adequately controlled with lopressor and clonidine IV. An NG tube was used to decompress the conduit and the patient was maintained on mIVF postoperatively until tolerating tube feeds. On POD 4 the patient had an esophogram that showed there was no leak at the site of the esophagogastrectomy and he was transferred to the floor where his diet was advanced and where he was transitioned to PO medications."},"extractive_notes_summ":{"kind":"string","value":"Minimal atelectasis at the right lung base. Minimal retrocardiac atelectasis is seen. Again seen is a tiny left apical pneumothorax. Tiny left apical pneumothorax unchanged. Prominence of mediasitum likely post surgical is unchanged compared to prior. A right chest tube, skin staples and clips overlying the central mediastinum are unchanged. Equivocal tiny left apical pneumothorax is suggested. Sutures and focal soft tissue prominence seen in the right paratracheal region, unchanged. The appearance of the neo-esophagus is unchanged. Suspect tiny left apical pneumothorax. Minimal pleural fluid or thickening tracks along the right chest wall and right lung apex. Right chest tube remains in place without evidence of pneumothorax. The right chest is grossly unchanged. Unchanged size and shape of the cardiac silhouette. There is opacity in the right lung, slightly less compared with earlier the same day. Linear opacity at the right lung apex likely represents the prior course of the chest tube. A right-sided chest tube is again seen. SINGLE UPRIGHT VIEW OF THE CHEST AT 17:06 HOURS: The right apical chest tube and the enteric tube have been removed. Patchy opacity at the left base and minimal blunting of the left costophrenic angle is unchanged. The endotracheal tube has been removed. There has been interval improvement in retrocardiac opacity, now mild. There is some residual atelectasis at the right base. Cardiac silhouette remains enlarged with some retrocardiac atelectasis. CHSET, 1 VW The patient is status post apparent esophagectomy -- this likely accounts for the vertical tubular lucency and peripheral density seen in the right chest medially. Less parenchymal opacity on the right, but with some residual atelectasis. Compared with at 7:32 a.m., again seen is retrocardiac density with obscuration of the left hemidiaphragm, overall similar to the earlier film. Clips are unchanged in the left upper quadrant. An ET tube has been placed in the interim, the tip lies approximately 3.7 cm above the carina in satisfactory position. Previously identified left apical pneumothorax not visualized at this time. A right-sided chest tube is present. IMPRESSION: Improved aeration following right chest tube removal. Status post chest tube removal. The cardiomediastinal silhouette is unchanged. Asymmetric CHF is considered much less likely. Skin staples overlying the left clavicle remain in place. Following administration of Optiray contrast medium is seen passing through the oropharynx into the cervical esophagus and neoesophagus without obstruction. An NG tube is present -- its tip lies beneath the diaphragm. FINDINGS: In comparison with the study of , there is little change in the appearance of the right chest tube and no convincing evidence of pneumothorax. FINDINGS: Lucency along the lateral margin of the liver suggests pneumoperitoneum, likely postoperative. Nasogastric tube is again seen. The cardiomediastinal silhouette demonstrates mild cardiomegaly. An enteric tube again traverses the neo-esophagus, with the tip terminating at the level of the medial left hemidiaphragm. SINGLE SUPINE VIEW OF THE CHEST: The endotracheal tube terminates approximately 6 cm from the carina, at the thoracic inlet. FINDINGS: No relevant change as compared to the previous examination. There are findings consistent with esophagectomy and gastric pull-through. The right chest tube is stable. IMPRESSION New diffuse opacity right lung, probably interstitial, developed since . An NG type tube is present, with tip beneath diaphragm. The subcutaneous emphysema seen along the right chest on the earlier film is not visible on today's examination. Patchy opacity left base, unchanged. Compared to the previous tracing of no significant change. Change in the appearance of the right chest, as described. IMPRESSION: No significant change compared with . Low inspiratory volumes and slightly rotated positioning. IMPRESSION: Probable pneumoperitoneum, likely postoperative. Recent esophagogastrectomy. There is a mild delay of contrast emptying from the stomach into the small bowel that is not unexpected in this post-surgical patient. FINAL REPORT HISTORY: Status post esophagectomy. Retrocardiac density is suggestive of left lower lobe atelectasis. Minimal pleural air inclusion in the right apex cannot be excluded, but a larger pneumothorax is not present. Surgical emphysema in the axilla is small in volume. Otherwise unchanged as compared to . There is patchy opacity at the left base, unchanged. TECHNIQUE: Single contrast examination of the neoesophagus was performed using Optiray and thin barium contrast media to assess for leak. Lungs are well aerated and clear without consolidation or pleural effusion. IMPRESSION: Compared with one day earlier, there has been slight improvement in the right lung opacity. CHEST, SINGLE AP PORTABLE VIEW. CHEST, SINGLE AP PORTABLE VIEW. CHEST, SINGLE AP VIEW. Nasogastric tube again extends into the neo-esophagus with the side hole at the mid cardiac level and the tip positioned just below the hemidiaphragm. No pneumothorax or other complication. REASON FOR THIS EXAMINATION: interval eval FINAL REPORT HISTORY: Esophageal CA, statuses post XRT. FINDINGS: As compared to the previous radiograph, there is no evidence of a larger right pneumothorax. Skin staples noted over left lung. FINDINGS: In comparison with the study of , there is little overall change. Skin staples, mediastinal clips, and an apparent mediastinal drain are noted. No gross effusion. COMPARISON: Prior radiograph dated . Patient status post esophagectomy. No newly appeared focal parenchymal opacities. Normal tracing. Right paratracheal density at the site of esophageal resection, is most likely postoperative but warrants further attention on surveillance radiography. The cardiac size is normal. LLL collpase/consolidation again seen, possibly slightly worse. Calcifications are again noted at the aortic arch. Another wide bore tube arises from the neck and terminates at the level of T12 in the midline and could be within the neoesophagus. Pulmonary vascularity is normal. Sinus rhythm. No obvious pneumothorax is detected. The NG tube extends along the expected course of the gastric pull-through."},"n_notes":{"kind":"number","value":15,"string":"15"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2138-10-17 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1158276,"text":" 2:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess position of chest tube, presence of effusion and degr\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with esophageal cancer s/p minimally invasive esophagectomy\n REASON FOR THIS EXAMINATION:\n assess position of chest tube, presence of effusion and degree of PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Esophageal carcinoma, recent esophagectomy, evaluate position of\n chest tube.\n\n COMPARISON: Prior radiograph dated .\n\n FINDINGS: Lucency along the lateral margin of the liver suggests\n pneumoperitoneum, likely postoperative. Surgical emphysema in the axilla is\n small in volume. Right paratracheal density at the site of esophageal\n resection, is most likely postoperative but warrants further attention on\n surveillance radiography. There is no evidence of pneumothorax. No pleural\n effusions are seen. Retrocardiac density is suggestive of left lower lobe\n atelectasis. The cardiac size is normal. Surgical clips are projected over\n the left upper quadrant.\n\n A right chest drain enters the lateral chest wall at the level of the right\n 6th intercostal space, coils in the right apeax and terminates at the level of\n the right lateral heart border. Another wide bore tube arises from the neck\n and terminates at the level of T12 in the midline and could be within the\n neoesophagus.\n\n IMPRESSION: Probable pneumoperitoneum, likely postoperative.\n No evidence of pneumothorax, satisfactory position of chest drain.\n\n"},{"category":"Radiology","chartdate":"2138-10-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1158475,"text":" 1:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval eval\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with r chest tube\n REASON FOR THIS EXAMINATION:\n interval eval\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right chest tube interval, evaluate.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n Compared with at 17: 05 pm and allowing for technical differences, I\n doubt significant interval change. Again seen is a tiny left apical\n pneumothorax. The increased interstitial density in the right mid and lower\n zones is similar, as is the appearance of the gastric pull-through and right\n chest tube. There is also patchy opacity at the left base, essentially\n unchanged.\n\n IMPRESSION:\n\n No significant change compared with . Tiny left apical pneumothorax\n unchanged.\n\n Presence of the pneumothorax was discussed with Dr. on the afternoon\n of .\n\n"},{"category":"Radiology","chartdate":"2138-10-22 00:00:00.000","description":"BAS/UGI AIR/SBFT","row_id":1158964,"text":", F. SICU-B 10:20 AM\n BAS/UGI AIR/SBFT Clip # \n Reason: ? leak, please adjust study to esophogram if necessary\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n Contrast: OPTIRAY Amt: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 M POD5 from egophagogastrectomy.\n REASON FOR THIS EXAMINATION:\n ? leak, please adjust study to esophogram if necessary\n ______________________________________________________________________________\n PFI REPORT\n No leak or obstruction at the anastomotic site.\n\n"},{"category":"Radiology","chartdate":"2138-10-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1159030,"text":" 4:46 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? ptx, please obtain at 1700, thank you.\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 s/p esophago-gastrectomy, S/P R chest tube removal\n REASON FOR THIS EXAMINATION:\n ? ptx, please obtain at 1700, thank you.\n ______________________________________________________________________________\n WET READ: WED 8:34 PM\n No evidence of large pneumothorax , trachea midline. Prominence of mediasitum\n likely post surgical is unchanged compared to prior.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55-year-old man status post right chest tube removal. Recent\n esophagogastrectomy.\n\n COMPARISON: Chest radiograph approximately 11 hours earlier.\n\n SINGLE UPRIGHT VIEW OF THE CHEST AT 17:06 HOURS: The right apical chest tube\n and the enteric tube have been removed. Skin staples overlying the left\n clavicle remain in place.\n\n Lungs are well aerated and clear without consolidation or pleural effusion.\n There is no pneumothorax. Linear opacity at the right lung apex likely\n represents the prior course of the chest tube. The appearance of the\n neo-esophagus is unchanged. Pulmonary vascularity is normal. The heart size\n is normal. There is no new hilar or mediastinal enlargement. Calcifications\n are again noted at the aortic arch.\n\n IMPRESSION:\n Improved aeration following right chest tube removal. No pneumothorax or\n other complication.\n\n"},{"category":"Radiology","chartdate":"2138-10-22 00:00:00.000","description":"BAS/UGI AIR/SBFT","row_id":1158963,"text":" 10:20 AM\n BAS/UGI AIR/SBFT Clip # \n Reason: ? leak, please adjust study to esophogram if necessary\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n Contrast: OPTIRAY Amt: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 M POD5 from egophagogastrectomy.\n REASON FOR THIS EXAMINATION:\n ? leak, please adjust study to esophogram if necessary\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf WED 1:54 PM\n No leak or obstruction at the anastomotic site.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Postop day five from the esophagogastrectomy with gastric pull-\n up, evaluate for leak.\n\n TECHNIQUE: Single contrast examination of the neoesophagus was performed\n using Optiray and thin barium contrast media to assess for leak.\n\n FINDINGS: On the scout images, patient's right-sided chest tube,\n nasointestinal tube and postoperative surgical clips and staples are seen.\n The heart is mildly enlarged. Following administration of Optiray contrast\n medium is seen passing through the oropharynx into the cervical esophagus and\n neoesophagus without obstruction. The anastomosis site is well visualized and\n no leak is identified. There is a mild delay of contrast emptying from the\n stomach into the small bowel that is not unexpected in this post-surgical\n patient.\n\n IMPRESSION: No leak or obstruction at the anastomotic site.\n\n"},{"category":"Radiology","chartdate":"2138-10-23 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1159132,"text":" 9:41 AM\n CHEST (PA & LAT) Clip # \n Reason: Chest tube pulled , please evaluate for any change\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man s/p minimally invasive esophagectomy\n REASON FOR THIS EXAMINATION:\n Chest tube pulled , please evaluate for any change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Minimally invasive esophagectomy. Status post chest tube\n removal.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no evidence of a\n larger right pneumothorax. Minimal atelectasis at the right lung base.\n Otherwise unchanged as compared to .\n\n\n"},{"category":"Radiology","chartdate":"2138-10-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1158922,"text":" 4:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man s/p esophagogastrectomy, recently bronched for collapsed left\n lower lobe\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Esophagogastrectomy with recent bronchoscopy for left lower lobe\n collapse.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. The prominence of the mediastinum persists consistent with the\n surgical procedure. Cardiac silhouette remains enlarged with some\n retrocardiac atelectasis. Indistinct pulmonary vessels, especially on the\n right, raise the possibility of asymmetric edema.\n\n Right chest tube remains in place without evidence of pneumothorax.\n Nasogastric tube is again seen.\n\n\n"},{"category":"Radiology","chartdate":"2138-10-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1158351,"text":" 3:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval eval\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55M w/ hx of esophageal ca, s/p XRT, now s/p lap esophagogastrectomy.\n REASON FOR THIS EXAMINATION:\n interval eval\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Esophageal CA, statuses post XRT.\n\n CHSET, 1 VW\n\n The patient is status post apparent esophagectomy -- this likely accounts for\n the vertical tubular lucency and peripheral density seen in the right chest\n medially. An NG type tube is present, with tip beneath diaphragm.\n\n There is patchy opacity at the left base, unchanged. There is some increased\n interstitial opacity diffusely throughout the right lung, which appears new\n compared with one day earlier. This raises the question of a diffuse\n inflammatory or infectious process or aspiration. Asymmetric CHF is\n considered much less likely. No gross effusion. Clips noted over left\n subclavian region. The subcutaneous emphysema seen along the right chest on\n the earlier film is not visible on today's examination. No conventional\n pneumothorax is detected.\n\n IMPRESSION\n\n New diffuse opacity right lung, probably interstitial, developed since\n . ? inflammation or infection, aspiration, or assymetric CHF.\n\n"},{"category":"Radiology","chartdate":"2138-10-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1158746,"text":" 3:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man s/p esophagectomy, R chest tube\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: To evaluate chest tube and interval change.\n\n FINDINGS: In comparison with the study of , there is little change in\n the appearance of the right chest tube and no convincing evidence of\n pneumothorax. The endotracheal tube has been removed. Nasogastric tube again\n extends into the neo-esophagus with the side hole at the mid cardiac level and\n the tip positioned just below the hemidiaphragm.\n\n There is continued enlargement of the cardiac silhouette. Widening of the\n superior mediastinum on the right is again seen. Minimal retrocardiac\n atelectasis is seen.\n\n\n"},{"category":"Radiology","chartdate":"2138-10-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1158429,"text":" 4:53 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: chest tube just placed to water seal\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man s/p esophagogastrectomy for esophageal ca\n REASON FOR THIS EXAMINATION:\n chest tube just placed to water seal\n ______________________________________________________________________________\n WET READ: DLrc SAT 6:00 PM\n Low lung volumes. Patient status post esophagectomy. Peripheral oriented\n vertical opacification, likely atelectasis. No evidence of pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post esophagectomy. Chest tube placed to waterseal.\n\n CHEST, SINGLE AP VIEW.\n\n Low inspiratory volumes and slightly rotated positioning. There are findings\n consistent with esophagectomy and gastric pull-through. An NG tube is\n present, the tip overlying upper abdomen. A right-sided chest tube is again\n seen. No obvious pneumothorax is detected. There is opacity in the right\n lung, slightly less compared with earlier the same day. Patchy opacity at the\n left base and minimal blunting of the left costophrenic angle is unchanged.\n Sutures and focal soft tissue prominence seen in the right paratracheal\n region, unchanged. Skin staples noted over left lung. Equivocal tiny left\n apical pneumothorax is suggested. Clips noted over mediastinum.\n\n IMPRESSION:\n\n Compared with one day earlier, there has been slight improvement in the right\n lung opacity. Suspect tiny left apical pneumothorax. Patchy opacity left\n base, unchanged.\n\n\n"},{"category":"Radiology","chartdate":"2138-10-25 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1159519,"text":" 2:09 PM\n CHEST (PA & LAT) Clip # \n Reason: apical ptx previously increased\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with esophageal 55M with T2NO adenoCA of distal esophagus s/p\n pre-op chemo/XRT and feeding jejunostomy, now s/p minimally-invasive \n esophagectomy \n REASON FOR THIS EXAMINATION:\n apical ptx previously increased\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post esophageal surgery.\n\n COMPARISON: .\n\n FINDINGS: No relevant change as compared to the previous examination.\n Minimal pleural air inclusion in the right apex cannot be excluded, but a\n larger pneumothorax is not present. No newly appeared focal parenchymal\n opacities. No evidence of tension. Unchanged size and shape of the cardiac\n silhouette.\n\n"},{"category":"Radiology","chartdate":"2138-10-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1158592,"text":" 3:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with LLL collapse s/p bronch\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55-year-old man, followup evaluation. Esophageal cancer with recent\n esophagectomy.\n\n COMPARISON: .\n\n SINGLE SUPINE VIEW OF THE CHEST: The endotracheal tube terminates\n approximately 6 cm from the carina, at the thoracic inlet. A right chest\n tube, skin staples and clips overlying the central mediastinum are unchanged.\n An enteric tube again traverses the neo-esophagus, with the tip terminating at\n the level of the medial left hemidiaphragm. Clips are unchanged in the left\n upper quadrant.\n\n There has been interval improvement in retrocardiac opacity, now mild. There\n is no new consolidation or pleural effusion. There is no pneumothorax. The\n cardiomediastinal silhouette demonstrates mild cardiomegaly.\n\n IMPRESSIONS: Improved aeration bilarerally, with marked improvement in\n basilar atelectasis.\n\n"},{"category":"Radiology","chartdate":"2138-10-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1158501,"text":" 9:13 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man s/p esophagogastrectomy, with LLL collapse now s/p bronch\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post esophagogastrectomy status post bronch for left lower\n lobe collapse, question interval change.\n\n CHEST, TWO VIEWS.\n\n Compared with at 7:32 a.m., again seen is retrocardiac density with\n obscuration of the left hemidiaphragm, overall similar to the earlier film.\n There may have been slight increase in the degree of aeration in the left mid\n zone. The right chest is grossly unchanged. The cardiomediastinal silhouette\n is unchanged.\n\n An ET tube has been placed in the interim, the tip lies approximately 3.7 cm\n above the carina in satisfactory position. The NG tube extends along the\n expected course of the gastric pull-through. The right chest tube is stable.\n No pneumothorax is identified on the current film.\n\n Findings discussed with Dr. on the day of the exam.\n\n"},{"category":"Radiology","chartdate":"2138-10-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1158491,"text":" 7:22 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: reason for acute resp distress\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with acute resp distress s/p gastrectomy\n REASON FOR THIS EXAMINATION:\n reason for acute resp distress\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Acute respiratory distress status post gastrectomy.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n Compared with 5:25 a.m. the same day, the gas-distended gastric pull-through\n and associated thickened wall is no longer visualized -- ? decompressed. The\n diffuse density in the right lung has improved progressively since the morning\n of at 4:40 a.m. There is some residual atelectasis at the right\n base. A right-sided chest tube is present. Minimal pleural fluid or\n thickening tracks along the right chest wall and right lung apex. LLL\n collpase/consolidation again seen, possibly slightly worse. No obvious\n pneumothorax is seen on either side at this time. Skin staples, mediastinal\n clips, and an apparent mediastinal drain are noted. An NG tube is present --\n its tip lies beneath the diaphragm.\n\n IMPRESSION:\n 1. Continued left lower lobe collapse and/or consolidation, possibly slightly\n worse.\n 2. Previously identified left apical pneumothorax not visualized at this\n time.\n 3. Change in the appearance of the right chest, as described. Less\n parenchymal opacity on the right, but with some residual atelectasis.\n\n\n\n"},{"category":"ECG","chartdate":"2138-10-17 00:00:00.000","description":"Report","row_id":225564,"text":"Sinus rhythm. Normal tracing. Compared to the previous tracing of \nno significant change.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-10-17 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1158276,\n \"text\": \" 2:38 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess position of chest tube, presence of effusion and degr\\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old man with esophageal cancer s/p minimally invasive esophagectomy\\n REASON FOR THIS EXAMINATION:\\n assess position of chest tube, presence of effusion and degree of PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Esophageal carcinoma, recent esophagectomy, evaluate position of\\n chest tube.\\n\\n COMPARISON: Prior radiograph dated .\\n\\n FINDINGS: Lucency along the lateral margin of the liver suggests\\n pneumoperitoneum, likely postoperative. Surgical emphysema in the axilla is\\n small in volume. Right paratracheal density at the site of esophageal\\n resection, is most likely postoperative but warrants further attention on\\n surveillance radiography. There is no evidence of pneumothorax. No pleural\\n effusions are seen. Retrocardiac density is suggestive of left lower lobe\\n atelectasis. The cardiac size is normal. Surgical clips are projected over\\n the left upper quadrant.\\n\\n A right chest drain enters the lateral chest wall at the level of the right\\n 6th intercostal space, coils in the right apeax and terminates at the level of\\n the right lateral heart border. Another wide bore tube arises from the neck\\n and terminates at the level of T12 in the midline and could be within the\\n neoesophagus.\\n\\n IMPRESSION: Probable pneumoperitoneum, likely postoperative.\\n No evidence of pneumothorax, satisfactory position of chest drain.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-10-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1158475,\n \"text\": \" 1:43 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval eval\\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old man with r chest tube\\n REASON FOR THIS EXAMINATION:\\n interval eval\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Right chest tube interval, evaluate.\\n\\n CHEST, SINGLE AP PORTABLE VIEW.\\n\\n Compared with at 17: 05 pm and allowing for technical differences, I\\n doubt significant interval change. Again seen is a tiny left apical\\n pneumothorax. The increased interstitial density in the right mid and lower\\n zones is similar, as is the appearance of the gastric pull-through and right\\n chest tube. There is also patchy opacity at the left base, essentially\\n unchanged.\\n\\n IMPRESSION:\\n\\n No significant change compared with . Tiny left apical pneumothorax\\n unchanged.\\n\\n Presence of the pneumothorax was discussed with Dr. on the afternoon\\n of .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-10-22 00:00:00.000\",\n \"description\": \"BAS/UGI AIR/SBFT\",\n \"row_id\": 1158964,\n \"text\": \", F. SICU-B 10:20 AM\\n BAS/UGI AIR/SBFT Clip # \\n Reason: ? leak, please adjust study to esophogram if necessary\\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\\n Contrast: OPTIRAY Amt: 50\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 M POD5 from egophagogastrectomy.\\n REASON FOR THIS EXAMINATION:\\n ? leak, please adjust study to esophogram if necessary\\n ______________________________________________________________________________\\n PFI REPORT\\n No leak or obstruction at the anastomotic site.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-10-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1159030,\n \"text\": \" 4:46 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: ? ptx, please obtain at 1700, thank you.\\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 s/p esophago-gastrectomy, S/P R chest tube removal\\n REASON FOR THIS EXAMINATION:\\n ? ptx, please obtain at 1700, thank you.\\n ______________________________________________________________________________\\n WET READ: WED 8:34 PM\\n No evidence of large pneumothorax , trachea midline. Prominence of mediasitum\\n likely post surgical is unchanged compared to prior.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 55-year-old man status post right chest tube removal. Recent\\n esophagogastrectomy.\\n\\n COMPARISON: Chest radiograph approximately 11 hours earlier.\\n\\n SINGLE UPRIGHT VIEW OF THE CHEST AT 17:06 HOURS: The right apical chest tube\\n and the enteric tube have been removed. Skin staples overlying the left\\n clavicle remain in place.\\n\\n Lungs are well aerated and clear without consolidation or pleural effusion.\\n There is no pneumothorax. Linear opacity at the right lung apex likely\\n represents the prior course of the chest tube. The appearance of the\\n neo-esophagus is unchanged. Pulmonary vascularity is normal. The heart size\\n is normal. There is no new hilar or mediastinal enlargement. Calcifications\\n are again noted at the aortic arch.\\n\\n IMPRESSION:\\n Improved aeration following right chest tube removal. No pneumothorax or\\n other complication.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-10-22 00:00:00.000\",\n \"description\": \"BAS/UGI AIR/SBFT\",\n \"row_id\": 1158963,\n \"text\": \" 10:20 AM\\n BAS/UGI AIR/SBFT Clip # \\n Reason: ? leak, please adjust study to esophogram if necessary\\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\\n Contrast: OPTIRAY Amt: 50\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 M POD5 from egophagogastrectomy.\\n REASON FOR THIS EXAMINATION:\\n ? leak, please adjust study to esophogram if necessary\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf WED 1:54 PM\\n No leak or obstruction at the anastomotic site.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Postop day five from the esophagogastrectomy with gastric pull-\\n up, evaluate for leak.\\n\\n TECHNIQUE: Single contrast examination of the neoesophagus was performed\\n using Optiray and thin barium contrast media to assess for leak.\\n\\n FINDINGS: On the scout images, patient's right-sided chest tube,\\n nasointestinal tube and postoperative surgical clips and staples are seen.\\n The heart is mildly enlarged. Following administration of Optiray contrast\\n medium is seen passing through the oropharynx into the cervical esophagus and\\n neoesophagus without obstruction. The anastomosis site is well visualized and\\n no leak is identified. There is a mild delay of contrast emptying from the\\n stomach into the small bowel that is not unexpected in this post-surgical\\n patient.\\n\\n IMPRESSION: No leak or obstruction at the anastomotic site.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-10-23 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1159132,\n \"text\": \" 9:41 AM\\n CHEST (PA & LAT) Clip # \\n Reason: Chest tube pulled , please evaluate for any change\\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old man s/p minimally invasive esophagectomy\\n REASON FOR THIS EXAMINATION:\\n Chest tube pulled , please evaluate for any change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Minimally invasive esophagectomy. Status post chest tube\\n removal.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, there is no evidence of a\\n larger right pneumothorax. Minimal atelectasis at the right lung base.\\n Otherwise unchanged as compared to .\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-10-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1158922,\n \"text\": \" 4:01 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old man s/p esophagogastrectomy, recently bronched for collapsed left\\n lower lobe\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Esophagogastrectomy with recent bronchoscopy for left lower lobe\\n collapse.\\n\\n FINDINGS: In comparison with the study of , there is little overall\\n change. The prominence of the mediastinum persists consistent with the\\n surgical procedure. Cardiac silhouette remains enlarged with some\\n retrocardiac atelectasis. Indistinct pulmonary vessels, especially on the\\n right, raise the possibility of asymmetric edema.\\n\\n Right chest tube remains in place without evidence of pneumothorax.\\n Nasogastric tube is again seen.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-10-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1158351,\n \"text\": \" 3:46 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval eval\\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55M w/ hx of esophageal ca, s/p XRT, now s/p lap esophagogastrectomy.\\n REASON FOR THIS EXAMINATION:\\n interval eval\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Esophageal CA, statuses post XRT.\\n\\n CHSET, 1 VW\\n\\n The patient is status post apparent esophagectomy -- this likely accounts for\\n the vertical tubular lucency and peripheral density seen in the right chest\\n medially. An NG type tube is present, with tip beneath diaphragm.\\n\\n There is patchy opacity at the left base, unchanged. There is some increased\\n interstitial opacity diffusely throughout the right lung, which appears new\\n compared with one day earlier. This raises the question of a diffuse\\n inflammatory or infectious process or aspiration. Asymmetric CHF is\\n considered much less likely. No gross effusion. Clips noted over left\\n subclavian region. The subcutaneous emphysema seen along the right chest on\\n the earlier film is not visible on today's examination. No conventional\\n pneumothorax is detected.\\n\\n IMPRESSION\\n\\n New diffuse opacity right lung, probably interstitial, developed since\\n . ? inflammation or infection, aspiration, or assymetric CHF.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-10-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1158746,\n \"text\": \" 3:58 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval interval change\\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old man s/p esophagectomy, R chest tube\\n REASON FOR THIS EXAMINATION:\\n eval interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: To evaluate chest tube and interval change.\\n\\n FINDINGS: In comparison with the study of , there is little change in\\n the appearance of the right chest tube and no convincing evidence of\\n pneumothorax. The endotracheal tube has been removed. Nasogastric tube again\\n extends into the neo-esophagus with the side hole at the mid cardiac level and\\n the tip positioned just below the hemidiaphragm.\\n\\n There is continued enlargement of the cardiac silhouette. Widening of the\\n superior mediastinum on the right is again seen. Minimal retrocardiac\\n atelectasis is seen.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-10-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1158429,\n \"text\": \" 4:53 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: chest tube just placed to water seal\\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old man s/p esophagogastrectomy for esophageal ca\\n REASON FOR THIS EXAMINATION:\\n chest tube just placed to water seal\\n ______________________________________________________________________________\\n WET READ: DLrc SAT 6:00 PM\\n Low lung volumes. Patient status post esophagectomy. Peripheral oriented\\n vertical opacification, likely atelectasis. No evidence of pneumothorax.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post esophagectomy. Chest tube placed to waterseal.\\n\\n CHEST, SINGLE AP VIEW.\\n\\n Low inspiratory volumes and slightly rotated positioning. There are findings\\n consistent with esophagectomy and gastric pull-through. An NG tube is\\n present, the tip overlying upper abdomen. A right-sided chest tube is again\\n seen. No obvious pneumothorax is detected. There is opacity in the right\\n lung, slightly less compared with earlier the same day. Patchy opacity at the\\n left base and minimal blunting of the left costophrenic angle is unchanged.\\n Sutures and focal soft tissue prominence seen in the right paratracheal\\n region, unchanged. Skin staples noted over left lung. Equivocal tiny left\\n apical pneumothorax is suggested. Clips noted over mediastinum.\\n\\n IMPRESSION:\\n\\n Compared with one day earlier, there has been slight improvement in the right\\n lung opacity. Suspect tiny left apical pneumothorax. Patchy opacity left\\n base, unchanged.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-10-25 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1159519,\n \"text\": \" 2:09 PM\\n CHEST (PA & LAT) Clip # \\n Reason: apical ptx previously increased\\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old man with esophageal 55M with T2NO adenoCA of distal esophagus s/p\\n pre-op chemo/XRT and feeding jejunostomy, now s/p minimally-invasive \\n esophagectomy \\n REASON FOR THIS EXAMINATION:\\n apical ptx previously increased\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Status post esophageal surgery.\\n\\n COMPARISON: .\\n\\n FINDINGS: No relevant change as compared to the previous examination.\\n Minimal pleural air inclusion in the right apex cannot be excluded, but a\\n larger pneumothorax is not present. No newly appeared focal parenchymal\\n opacities. No evidence of tension. Unchanged size and shape of the cardiac\\n silhouette.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-10-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1158592,\n \"text\": \" 3:50 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old man with LLL collapse s/p bronch\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 55-year-old man, followup evaluation. Esophageal cancer with recent\\n esophagectomy.\\n\\n COMPARISON: .\\n\\n SINGLE SUPINE VIEW OF THE CHEST: The endotracheal tube terminates\\n approximately 6 cm from the carina, at the thoracic inlet. A right chest\\n tube, skin staples and clips overlying the central mediastinum are unchanged.\\n An enteric tube again traverses the neo-esophagus, with the tip terminating at\\n the level of the medial left hemidiaphragm. Clips are unchanged in the left\\n upper quadrant.\\n\\n There has been interval improvement in retrocardiac opacity, now mild. There\\n is no new consolidation or pleural effusion. There is no pneumothorax. The\\n cardiomediastinal silhouette demonstrates mild cardiomegaly.\\n\\n IMPRESSIONS: Improved aeration bilarerally, with marked improvement in\\n basilar atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-10-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1158501,\n \"text\": \" 9:13 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: interval change\\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old man s/p esophagogastrectomy, with LLL collapse now s/p bronch\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post esophagogastrectomy status post bronch for left lower\\n lobe collapse, question interval change.\\n\\n CHEST, TWO VIEWS.\\n\\n Compared with at 7:32 a.m., again seen is retrocardiac density with\\n obscuration of the left hemidiaphragm, overall similar to the earlier film.\\n There may have been slight increase in the degree of aeration in the left mid\\n zone. The right chest is grossly unchanged. The cardiomediastinal silhouette\\n is unchanged.\\n\\n An ET tube has been placed in the interim, the tip lies approximately 3.7 cm\\n above the carina in satisfactory position. The NG tube extends along the\\n expected course of the gastric pull-through. The right chest tube is stable.\\n No pneumothorax is identified on the current film.\\n\\n Findings discussed with Dr. on the day of the exam.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-10-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1158491,\n \"text\": \" 7:22 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: reason for acute resp distress\\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 55 year old man with acute resp distress s/p gastrectomy\\n REASON FOR THIS EXAMINATION:\\n reason for acute resp distress\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Acute respiratory distress status post gastrectomy.\\n\\n CHEST, SINGLE AP PORTABLE VIEW.\\n\\n Compared with 5:25 a.m. the same day, the gas-distended gastric pull-through\\n and associated thickened wall is no longer visualized -- ? decompressed. The\\n diffuse density in the right lung has improved progressively since the morning\\n of at 4:40 a.m. There is some residual atelectasis at the right\\n base. A right-sided chest tube is present. Minimal pleural fluid or\\n thickening tracks along the right chest wall and right lung apex. LLL\\n collpase/consolidation again seen, possibly slightly worse. No obvious\\n pneumothorax is seen on either side at this time. Skin staples, mediastinal\\n clips, and an apparent mediastinal drain are noted. An NG tube is present --\\n its tip lies beneath the diaphragm.\\n\\n IMPRESSION:\\n 1. Continued left lower lobe collapse and/or consolidation, possibly slightly\\n worse.\\n 2. Previously identified left apical pneumothorax not visualized at this\\n time.\\n 3. Change in the appearance of the right chest, as described. Less\\n parenchymal opacity on the right, but with some residual atelectasis.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2138-10-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 225564,\n \"text\": \"Sinus rhythm. Normal tracing. Compared to the previous tracing of \\nno significant change.\\n\\n\"\n }\n]"}}},{"rowIdx":24651,"cells":{"subject_id":{"kind":"number","value":5691,"string":"5,691"},"hadm_id":{"kind":"number","value":104316,"string":"104,316"},"target_text":{"kind":"string","value":"77 year old female with extensive PMH who was admitted with PNA and pulmonary edema, requiring non-invasive ventilation. She was initially in the intensive care unit until her breathing status improved. In the ICU, the patient was diuresed with IV Lasix and received antibiotics for her PNA. Initially, she was on BiPAP but improved throughout her course of stay until she was saturating comfortably on room air. On admission the patient had a surgical eval for abdominal distention which resolved w/o intervention, her imaging was negative for SBO. She was transferred to the floor for further management. On exam, the patient had dyspnea and fever felt most likely secondary to a factor of both CHF and PNA noted on CXR. The patient was treated with levofloxacin for a likely community acquired pneumonia. She was also treated initially with IV Lasix as her xray seemed consistent with a degree of heart failure. The patient has a history of multiple SBOs in the setting of numerous abdominal surgeries. She denied any vomiting, though she did have some mild nausea at the beginning of her hospitalization. Her last BM was the day before admission and she denies passing flatus since. She says that her current abdominal distention is not comparable to previous SBOs. Of note, she was started on iron supplements approximately one week ago and has noted constipation with this. The patient was treated with an aggressive bowel regimen. For her chronic polycystic kidney disease s/p transplant, the patient was treated with her usual dose of prednisone and a slightly decreased dose of CellCept given her neutropenia. Her polycystic liver disease was stable. She did have a RUQ US which showed dilation of her common bile duct. LFTs and exam remained stable throughout her hospital course and she was discharged to follow this finding up with her PCP. The patient has a history of hypertension for which she was taking atenolol and diltiazem as an outpatient. Her blood pressure was markedly elevated upon arrival. Per her history, the patient has had problems with hypertensive urgency in the past. She was initially treated with metoprolol and diltiazem with PRN hydralazine. Doxazosin was introduced once the patient was called out to the floor, however, the patient experienced relative hypotension likely causing a bump in her creatinine. The doxazosin was discontinued with a slow improvement in her creatinine. Her outpatient Lasix was held and she was advised to discuss restarting this medication with her primary care doctor. The patient was continued on her outpatient Epogen regimen for her anemia. She received one unit of packed red blood cells as well as six infusions of IV Ferrlecit. The patient was continued on her outpatient regimens for her spinal stenosis, depression, anxiety and insomnia with the following medications Neurontin, Tramadol, Zoloft, Klonopin and Ambien. # Communication: (daughter) ; (son) . # Code: FULL (confirmed with patient and daughter)"},"extractive_notes_summ":{"kind":"string","value":"noted L mastect, however right has av fistula .SKIN: intactID: bc, urine culture pending. LS coarse throughout.CV: HR 59 -70 SB/SA/NR with frequent PAC, AM EKG ? CXR- in edema, inc in right PNA. Sat's 93-98%-inc when turning/deep breathing. Reports comfortable and denies pain t/o shift. no nausea complaintENDO: BS WNL, ON PREDNISONE will ask for sliding scale. Pulmonary edema.Height: (in) 66Weight (lb): 132BSA (m2): 1.68 m2BP (mm Hg): 150/75HR (bpm): 71Status: InpatientDate/Time: at 11:20Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%). sbp 180's given hydralazine IV 10 x1 with good result.now 132. fatigue. The amounts of mitral regurgitation,tricuspid regurgitation, and estimated pumonary artery systolic pressure haveincreased. Transmitral Doppler and TVI c/w Grade II(moderate) LV diastolic dysfunction. R AV fistula + thrill, + bruit.GI: + BS, soft distended abd with mult liver cysts, acities, s/p mult sx for SBP. CXR at that time revealing inc in right PNA. states last BM yest small amt. 1+ pitting ankle edema, mild general dependent edema. T spike to 101.4 rectal -tx with tylenol-no further intevention. clear, urine and C& S pending. Transmitral Doppler and tissue velocity imaging are consistentwith Grade II (moderate) LV diastolic dysfunction. Cont monitor resp status, pulm toilet, titrate O2 as tolerated.2. Mild dependent hip edema. CXR, episode resolving slowly. Lytes stable per am labs. Moderate (2+) mitralregurgitation is seen. Pt tolerated well.Resp: Pt continues w/ FiO2 2L via NC. Moderate (2+)MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Started on aggressive bowel regiman but with no BM today.GU - UO marginal - started back on PO lasix to gently diurese.IV - Pt has very poor venous access - one hep lock to left upper arm is only access.Neuro - Pt very pleasant and cooperative. No BM, + lg amt flattus, goal Lactulose until BM. Lactulose + flattus no BM. general dependant edema. The tricuspid valve leaflets are mildly thickened.Moderate [2+] tricuspid regurgitation is seen. s/o mult sx SBO- abd tender to palpation in epigastric area. less dyspnea after lasix. The mitral valve leaflets are mildlythickened. There is a trivial/physiologic pericardialeffusion.Compared with the prior study (images reviewed) of , left ventriculardiastolic function has worsened. Probable right ventricular hypertrophy.Compared to the previous tracing the findings are similar. SBP to 170's this am, tx w/ hydralazine 10mg IV X 1 w/ good effect. Nurse Progress Note 0700-1900Events: Minimally able to titrate down O2 requirement. Tolerating PO's well. Cont monitor resp status, encourage cough/deep breath, titrate O2 as tolerated, pul toilet2. HR NSR with PAC's.Resp - BS course upper and diminished at bases. trying to unsuccessfully wean oxygen.GU/GI: foley with fair response of 200cc after lasix IV. Mildly dilated ascendingaorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). 1900-0700 npnNEURO: intact , pleasant and cooperativeCV: afebrile, sinus rate 60-80, sys to 170, periph pulses intact. Suboptimalimage quality - poor suprasternal views.Conclusions:The left atrium is mildly dilated. AM mild HA -resolving with in BP and 325mg Acetaminophen. BBS remain somewhat course t/o. Son @ bedside, updated pt condition and . 20mg IV Lasix with minimal effect- goal neg 500cc. Weak cough, encourage deep breathing. Barrier crea-elbows/heals elevated. \"I feel better than when I first came in\"CV: 59-78 SB/SA/ NRS with frequent PAC's, irregular @ time but no AFib noted. The ascending aorta is mildly dilated.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is notpresent. card enzymes neg.RESP: rec'd on bipap 100%. sinus with little ectopy. Bedside echo, liver/gallbladder US. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Resuming to titrate down O2 requirement. Echo: EF 55-60%, 2+ MR, 2+ TR, mild LVH, grade II diastolic disfunction, sever pulm HTN. BP 129-171/53-85 MAP 70-90's post Lasix/hydral BP 130-140's/. Toleraing thin liquids/pills-NPO.GU: Clear-pale yellow urine via foley. lasix given x 1 with fair response at 1 hr. admitted with complex medical hx, c/o sob,dyspnea.NEURO: AO x 3, mae, cataracts bil.CV: tmax 101.4 oral, responsive to tylenol. Metolazone was given; however, renal MD then recommended holding lasix, and orders obtained from team to hold lasix. 1800 labs pending.ID: T amx 97.2 Ax, inc PO Levoflox to QD, Cellcept.Skin: General dry, thin skin chronic steroids. LS coarse/wheezing throughout. pt continues on lopressor and diltiazem as ordered.FEN: Pt tolerating full liquid diet well. pulm toilet, waffle boots on, skin care caution due to long term pred. Pt has since reported SBP 170 too be well within her baseline. There is mild symmetric left ventricularhypertrophy with normal cavity size and regional/global systolic function(LVEF>55%). negative I/O for last 24 hrsRESP: abd breathing no dyspnea, lungs coarse, cough non productive, no distress but cont. C+DB, and IS encouraged and pt is practicing these techniques q1hr WA. BP AM 160/70's -starting Dilt 60mg QID( Procardia 240mg XL @ home) BP 129-152/ 48-73 MAP 68-95. There is a late transitionwith anterior Q waves consistent with probable prior anterior myocardialinfarction. Right axis deviation. Sinus rhythm. abd rounded now softer than prev. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Pt remains free of s/s distress.CV: HR 50's to 60's, SR to SB w/ frequent PAC's. tol po fluid and takes pill easily. Sinus rhythmAtrial premature complexesLeft atrial abnormalityLow limb lead QRS voltagesIndeterminate axisDelayed R wave progression with late precordial QRS transitionModest inferior inferior in lead V2Findings are nonspecific but clinical correlation is suggested for possible inpart chronic pulmonary disease and possible prior septal myocardial infarctionSince previous tracing of 4, atrial ectopy now present, QRS voltages less prominent and prominent Twave amplitude decreased will hold on po bowel program until 0900 US of abd reveals no obstruction."},"n_notes":{"kind":"number","value":12,"string":"12"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2165-05-26 00:00:00.000","description":"Report","row_id":1336652,"text":"Nursing Prorgess Note:\n77 year old female with extensive PMH admitted with pna and CHF; difficulty diuresing during this admission d/t elevated BUN/cr with lasix; resp status with overall improvement, remains on fac tent with NC; probable c/o to floor; no events overnight\n\nNKDA\n\nFULL CODE\n\nNEURO: A+Ox3, follows commands, denies pain, blind in right eye, moves all extrmities; able to turn with min assist\n\nCV: HR remains in 50's-60's with PAC's; SBP 165-153, pt reports baseline is 170's; MAP's>60; +PP; no CP; am labs pending; evening lytes per Careview no sig change; AV fistula +bruit/thrill but no longer in use\n\nRESP: LS clear at apices, coarse at bases; sats 97-100% on 50% face ten and 5L NC; RR regular 15-20; denies SOB, dyspnea; CDB/IS enc\n\nGI/GU: +BS, no stool, received dulcolax/senna tonight, no results; abd firm distended, pt with ascites; advance to reg diet tomorrow; foley in place draining clear yellow urine 15-25cc/hr; BUN/Cr elevated and starting to trend down, so cont unable to diurese with lasix\n\nIV: 20g IV LUE WNL\n\n: possible c/o to floor; wean O2 as tolerate, cont CDB/IS, gentle diuresis as possible with goal 500cc-1L negative, cont levaquin, lytes; CXR in am; reg diet in am and cont bowel reg.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2165-05-26 00:00:00.000","description":"Report","row_id":1336653,"text":"Nursing Prorgess Note:\n CXR with worsening failure, no CXR planned for \n"},{"category":"Nursing/other","chartdate":"2165-05-26 00:00:00.000","description":"Report","row_id":1336654,"text":"Nsg Progress Note 0700-1900\n\nCV - Afebrile. Hemodynamically stable. HR NSR with PAC's.\n\nResp - BS course upper and diminished at bases. Started on albuterol treatments to loosen secretions. Also started on robitussin to attempt to get secretions moving. O2 at 4L via NC. Pt feels that breathing has improved. Pt went to radiology for chest PA and Lat today. Results pending.\n\nGI - Abd continues to be firm and distended but with no pain or discomfort. Tolerating PO's well. Started on aggressive bowel regiman but with no BM today.\n\nGU - UO marginal - started back on PO lasix to gently diurese.\n\nIV - Pt has very poor venous access - one hep lock to left upper arm is only access.\n\nNeuro - Pt very pleasant and cooperative. A & O X3. Very cooperative with care and asking appropriate questions about .\n\nSocial - Very supportive and large family. Sister and in to visit today. Has received many phone calls also.\n\nPlan - Transfer to regular bed when available.\n"},{"category":"Nursing/other","chartdate":"2165-05-25 00:00:00.000","description":"Report","row_id":1336650,"text":"Nursing Progress Note:\n77 year old female with extensive PMH admitted for mgt of chf and bilateral pna, t spike >104\n\nFULL CODE\n\nNKDA\n\nNeuro: pt pleasant, A+Ox3; follows commands; blind in right eye s/p cataract surgery; denies pain except at blood pressure cuff site; moves all extremities, able to turn side to side with 1 assist\n\nCV: HR 50's-60's sinus with PAC's; given lopressor and dilt as ordered; SBP 156-136, MAP's >60; +PP to palpation; am labs pending\n\nRESP: pt cont on hi flow neb and NC 2L, attempted to wean to 35% but sats dropped to 88-89% at rest, so turned back to 50%; desats to 80's with activity; tacypneic with activity, denies SOB/dyspnea, reports overall improvement in breathing since admission; LS coarse throughout; cont on PO levaquin; CDB with no sputum\n\nGI: abd soft distened; BM x2; tolerating soft diet with good PO intake\n\nGU: foley in place draining clear yellow urine 15-30c/hr; BUN/Cr elevated and trending up, ? d/c lasix, received 1 dose yesterday on days but did not have significant diuresis, goal 1L neg/day not met\n\nID: sputum cx not sent, pt unable to expectorate; afebrile; cont on PO levaquin\n\nACCESS: 2 peripheral IV's in left arm infilatrated d/t pressure cuff and unable to place on right arm d/t AV fistula, so BP cuff on thigh; IV RN placed 20g in left upper arm tongiht, and said pt has no other access\n\n: ? change in cardiac meds to dose pt takes at home; cont to wean O2 as toilerated, pulm toilet as tolerated, cont levaquin; bowel regimen as needed; pain mgt for back pain\n"},{"category":"Nursing/other","chartdate":"2165-05-25 00:00:00.000","description":"Report","row_id":1336651,"text":"Shift Note: 0700-1900\nNeuro: Pt A+OX3, pleasant and cooperative. Reports comfortable and denies pain t/o shift. Pt OOB to chair X 4 hr today w/ min-mod 2 assist. Pt tolerated well.\n\nResp: Pt continues w/ FiO2 2L via NC. FM changed to facetent. C+DB, and IS encouraged and pt is practicing these techniques q1hr WA. Pt reports breathing continues to improve. BBS remain somewhat course t/o. SpO2 remains >92%. Pt remains free of s/s distress.\n\nCV: HR 50's to 60's, SR to SB w/ frequent PAC's. Lytes stable per am labs. SBP to 170's this am, tx w/ hydralazine 10mg IV X 1 w/ good effect. Pt has since reported SBP 170 too be well within her baseline. pt continues on lopressor and diltiazem as ordered.\n\nFEN: Pt tolerating full liquid diet well. Remains free of N/V. Foley catheter patent and draining clear yellow urine w/ borderline output. Initial plan for pt to receive metolazone w/ lasix. Metolazone was given; however, renal MD then recommended holding lasix, and orders obtained from team to hold lasix. Pt's wgt remains stable at 59kg.\n\nSocial: pt's son, daughter and priest have been in to visit. Priest pt this am.\n\nPlan: Continue to monitor respiratory status closely. Wean FiO2 as able. Encourage PO intake and increase activity as tolerated. Anticipate call out to floor if pt remains stable.\n"},{"category":"Nursing/other","chartdate":"2165-05-23 00:00:00.000","description":"Report","row_id":1336646,"text":"1900-0700 npn\nPt. admitted with complex medical hx, c/o sob,dyspnea.\n\nNEURO: AO x 3, mae, cataracts bil.\n\nCV: tmax 101.4 oral, responsive to tylenol. lasix given x 1 with fair response at 1 hr. pp intact. general dependant edema. sinus with little ectopy. sbp 180's given hydralazine IV 10 x1 with good result.\nnow 132. fatigue. card enzymes neg.\n\nRESP: rec'd on bipap 100%. transferred to face tent at 10 liters and 6 liters nasal cannula. less dyspnea after lasix. able to speak in long sentences cough non productive. do need to send sputum sample when avail. lung field coarse on right, almost no air movement on left. will introduce IS this am. abg improved. trying to unsuccessfully wean oxygen.\n\nGU/GI: foley with fair response of 200cc after lasix IV. clear, urine and C& S pending. abd rounded now softer than prev. passing some flatus. pt. states last BM yest small amt. recently started iron. was planned to have soap suds enema, however due to recent rectal with repair of prolapse will hold for now. tol po fluid and takes pill easily. will hold on po bowel program until 0900 US of abd reveals no obstruction. no nausea complaint\n\nENDO: BS WNL, ON PREDNISONE will ask for sliding scale. tol full liquids, swallows pills well, safe swallow noted. NPO after mn for am US of abd.\n\nPAIN: denies\n\nACCESS: added #18 g to 20 g in left arm. noted L mastect, however right has av fistula .\n\nSKIN: intact\n\nID: bc, urine culture pending. levafoxacin po started in ER.\n\nSOCIAL: lives with husband who has recently had hip . dtr and son very supportive. Dtr in .\n\nPLAN: vigorous pulm toilet, introduce and teach Incentive spirometer, f/u cultures, treat fevers, mobilize asap, US abd scheduled for 0900 then address nutritional needs.\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2165-05-23 00:00:00.000","description":"Report","row_id":1336647,"text":"Nurse Progress Note 0700-1900\n\nEvents: 11AM episode tachypnic, hypertensive, drop sat's mid 80's-tx with 40mg IV Lasix, inc Fio2 to 100%-highflow @ 100%, cont hypertensive 10mg IV hydral, -no BiPAP. CXR, episode resolving slowly. Resuming to titrate down O2 requirement. CXR- in edema, inc in right PNA. Bedside echo, liver/gallbladder US. T spike to 101.4 rectal -tx with tylenol-no further intevention. See carvue for details.\n\nNeuro/Pain: Alert, oriented, engaging in conversation, using callbell approp. H/A when hypertensive, initally respoling, returing \"pain the the back of my head/neck\" repositioned and given 325mg Tylenol, declined 650mg. Pain . + gag/cough. MAE.\n\nResp: Resp rate regular in AM, sat's >95% on 40% face tent, 6L NC able to speak in full sentences-tolerating off face tent for pills. Approx 11 AM during echo inc in SOB and work of breathing RR 30-33/labored- titrating up face tent then and placed 100% high flow mask, albuterol/atrovent nebs, Bp 160-171/70's, given 40 mg IV Lasix, cont hypertensive 10mg IV Hydral BP down to 130/60's. Dyspnea resolving and resting comfortably. CXR at that time revealing inc in right PNA. Currently high flow @ 50%, titrating down NC to 4L. Sat's 93-98%-inc when turning/deep breathing. 90-92% off mask-no IS at this time. LS coarse/wheezing throughout. \"I feel better than when I first came in\"\n\nCV: 59-78 SB/SA/ NRS with frequent PAC's, irregular @ time but no AFib noted. BP 129-171/53-85 MAP 70-90's post Lasix/hydral BP 130-140's/. Echo: EF: 55-60%, mild LVH, 2+ MR, 2+ TR, grade II LV diastolic dysfunction. 1+ pitting ankle edema, mild general dependent edema. s/p L masectomy, R AV fistula + thrill, + bruit.\n\nGI: + BS, lg abd- liver US/gallbladder: numerous liver cysts, dilated extrahepatic common bile duct, ascities. s/o mult sx SBO- abd tender to palpation in epigastric area. Lactulose + flattus no BM. No enema-cont Lactulose. Toleraing thin liquids/pills-NPO.\n\nGU: Clear-pale yellow urine via foley. Post 40mg IV Lasix 200cc within 1hr approx 100cc/hr x3 hrs then tapering off. Neg 1360 past 24hrs, neg 1640 LOS.\n\nFEN/ENDO: No IVF. 1700 repete labs pending.\n\nID: T max 99.1 Ax/101.4 rectal-given 325mg tylenol, 97.2 Ax. Cont on Levoflox.\n\nSkin: Very think skin chronic steroid \"my skin breaks easily, I bruise everywhere\". Mult bruising IV access, R eye bruising \"I ahd that at home\". No active breakdown in skin integrity noted. Barrier crea-elbows/heals elevated. Waffel boots on.\n\nSocial: Daughter called and updated , pt condition. Son @ bedside, updated pt condition and . Full Code.\n\n\n1. Cont monitor resp status, encourage cough/deep breath, titrate O2 as tolerated, pul toilet\n2. Comt monitor skin integrity\n3. Cont all routine ICU care\n"},{"category":"Nursing/other","chartdate":"2165-05-24 00:00:00.000","description":"Report","row_id":1336648,"text":"1900-0700 npn\nNEURO: intact , pleasant and cooperative\n\nCV: afebrile, sinus rate 60-80, sys to 170, periph pulses intact. negative I/O for last 24 hrs\n\nRESP: abd breathing no dyspnea, lungs coarse, cough non productive, no distress but cont. to use high flow oxygen without being able to wean. long recovery times for sats after any activity\n\nGU/GI: foley ave 35 cc. 2 small semiformed brwn hem neg stool. BT active. no nausea, tol. full liquids well.\n\nPAIN: none\n\nENDO: full liquids, now states she is hungry\n\nACCESS: 2 piv. lla redressed x 2 for leakage at junction\n\nSKIN: no breaks in skin noted. waffle boots deferred per pt wishes til am.\n\nSOCIAL: dtr to visit. good support from family.\n\nPLAN: wean oxygen to nasal cannula as able. add IS when able. antibiotics. pulm toilet, waffle boots on, skin care caution due to long term pred. use.\n"},{"category":"Nursing/other","chartdate":"2165-05-24 00:00:00.000","description":"Report","row_id":1336649,"text":"Nurse Progress Note 0700-1900\n\nEvents: Minimally able to titrate down O2 requirement. Inc Levoflox QD, Cellcept for PNA-unable to obtain sputum cx. 20mg IV Lasix with minimal effect- goal neg 500cc. See carevue for details.\n\nNeuro/Pain: Alert, oriented enaging in conversation. Sleeping in short naps throughout day. AM mild HA -resolving with in BP and 325mg Acetaminophen. Mild tender if palpating abd other wise denies pain/discomfort. + gag, weak cough.\n\nResp: Resp rate regular, minlabored resting in bed. With eating/turning mild fatigue o2 sat's drop 88-90% will trend up slowly. While eating on 10L NC-tolerating Sat 90-93%. Currently highflow 40%, 6L, 2L NC. Weak cough, encourage deep breathing. Scant nonproductive cough-unable to tolerate induced sputum. Able to talk in short sentences with minimal dyspnea. LS coarse throughout.\n\nCV: HR 59 -70 SB/SA/NR with frequent PAC, AM EKG ? transient AFIB-not noted on EKG. Atrial couplets. BP AM 160/70's -starting Dilt 60mg QID( Procardia 240mg XL @ home) BP 129-152/ 48-73 MAP 68-95. 20 mg IV Lasix with minimal effect-goal diuresis 500 neg/day. Awaiting repete lyyes before further diuresis. Echo: EF 55-60%, 2+ MR, 2+ TR, mild LVH, grade II diastolic disfunction, sever pulm HTN. Mild dependent hip edema. R AV fistula + thrill, + bruit.\n\nGI: + BS, soft distended abd with mult liver cysts, acities, s/p mult sx for SBP. No BM, + lg amt flattus, goal Lactulose until BM. Tolerating full liquid diet.\n\nGU: Clear yellow urine via foley. UOP 30-45 cc/hr. S/p renal transplant-renal following. Cr 2.4 (baseline ? 1.7-1.9) neg 90 cc past 24 hrs, neg 1870 LOS.\n\nFEN/ENDO: No IVF. Tolerating full liquid diet. 1800 labs pending.\n\nID: T amx 97.2 Ax, inc PO Levoflox to QD, Cellcept.\n\nSkin: General dry, thin skin chronic steroids. Barrier cream, heels/elboes elevated. Mult bruising IV access \"I have bruises from home\". No active breakdown noted.\n\nSocial: Daughter (HCP), husband and daughter in law in to visit pt- all updated pt condition, medications and . Full Code.\n\n\n1. Cont monitor resp status, pulm toilet, titrate O2 as tolerated.\n2. Cont monitor skin integrity\n3. Monitor renal recs/diuresis as toelrated-goal neg 500cc\n4. Cont emotional support of pt and family\n5. Cont all routine ICU care\n\n\n"},{"category":"Echo","chartdate":"2165-05-23 00:00:00.000","description":"Report","row_id":103864,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pulmonary edema.\nHeight: (in) 66\nWeight (lb): 132\nBSA (m2): 1.68 m2\nBP (mm Hg): 150/75\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 11:20\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). Transmitral Doppler and TVI c/w Grade II\n(moderate) LV diastolic dysfunction. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate (2+)\nMR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\nSevere PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Suboptimal\nimage quality - poor suprasternal views.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent\nwith Grade II (moderate) LV diastolic dysfunction. Right ventricular chamber\nsize and free wall motion are normal. The ascending aorta is mildly dilated.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. No aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. Moderate (2+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nModerate [2+] tricuspid regurgitation is seen. There is severe pulmonary\nartery systolic hypertension. There is a trivial/physiologic pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , left ventricular\ndiastolic function has worsened. The amounts of mitral regurgitation,\ntricuspid regurgitation, and estimated pumonary artery systolic pressure have\nincreased.\n\n\n"},{"category":"ECG","chartdate":"2165-05-24 00:00:00.000","description":"Report","row_id":298614,"text":"Artifact is present. Sinus rhythm. Atrial ectopy. There is a late transition\nwith anterior Q waves consistent with probable prior anterior myocardial\ninfarction. Right axis deviation. Probable right ventricular hypertrophy.\nCompared to the previous tracing the findings are similar.\n\n"},{"category":"ECG","chartdate":"2165-05-22 00:00:00.000","description":"Report","row_id":298615,"text":"Sinus rhythm\nAtrial premature complexes\nLeft atrial abnormality\nLow limb lead QRS voltages\nIndeterminate axis\nDelayed R wave progression with late precordial QRS transition\nModest inferior inferior in lead V2\nFindings are nonspecific but clinical correlation is suggested for possible in\npart chronic pulmonary disease and possible prior septal myocardial infarction\nSince previous tracing of 4\n, atrial ectopy now present, QRS voltages less prominent and prominent T\nwave amplitude decreased\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-05-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1336652,\n \"text\": \"Nursing Prorgess Note:\\n77 year old female with extensive PMH admitted with pna and CHF; difficulty diuresing during this admission d/t elevated BUN/cr with lasix; resp status with overall improvement, remains on fac tent with NC; probable c/o to floor; no events overnight\\n\\nNKDA\\n\\nFULL CODE\\n\\nNEURO: A+Ox3, follows commands, denies pain, blind in right eye, moves all extrmities; able to turn with min assist\\n\\nCV: HR remains in 50's-60's with PAC's; SBP 165-153, pt reports baseline is 170's; MAP's>60; +PP; no CP; am labs pending; evening lytes per Careview no sig change; AV fistula +bruit/thrill but no longer in use\\n\\nRESP: LS clear at apices, coarse at bases; sats 97-100% on 50% face ten and 5L NC; RR regular 15-20; denies SOB, dyspnea; CDB/IS enc\\n\\nGI/GU: +BS, no stool, received dulcolax/senna tonight, no results; abd firm distended, pt with ascites; advance to reg diet tomorrow; foley in place draining clear yellow urine 15-25cc/hr; BUN/Cr elevated and starting to trend down, so cont unable to diurese with lasix\\n\\nIV: 20g IV LUE WNL\\n\\n: possible c/o to floor; wean O2 as tolerate, cont CDB/IS, gentle diuresis as possible with goal 500cc-1L negative, cont levaquin, lytes; CXR in am; reg diet in am and cont bowel reg.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-05-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1336653,\n \"text\": \"Nursing Prorgess Note:\\n CXR with worsening failure, no CXR planned for \\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-05-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1336654,\n \"text\": \"Nsg Progress Note 0700-1900\\n\\nCV - Afebrile. Hemodynamically stable. HR NSR with PAC's.\\n\\nResp - BS course upper and diminished at bases. Started on albuterol treatments to loosen secretions. Also started on robitussin to attempt to get secretions moving. O2 at 4L via NC. Pt feels that breathing has improved. Pt went to radiology for chest PA and Lat today. Results pending.\\n\\nGI - Abd continues to be firm and distended but with no pain or discomfort. Tolerating PO's well. Started on aggressive bowel regiman but with no BM today.\\n\\nGU - UO marginal - started back on PO lasix to gently diurese.\\n\\nIV - Pt has very poor venous access - one hep lock to left upper arm is only access.\\n\\nNeuro - Pt very pleasant and cooperative. A & O X3. Very cooperative with care and asking appropriate questions about .\\n\\nSocial - Very supportive and large family. Sister and in to visit today. Has received many phone calls also.\\n\\nPlan - Transfer to regular bed when available.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-05-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1336650,\n \"text\": \"Nursing Progress Note:\\n77 year old female with extensive PMH admitted for mgt of chf and bilateral pna, t spike >104\\n\\nFULL CODE\\n\\nNKDA\\n\\nNeuro: pt pleasant, A+Ox3; follows commands; blind in right eye s/p cataract surgery; denies pain except at blood pressure cuff site; moves all extremities, able to turn side to side with 1 assist\\n\\nCV: HR 50's-60's sinus with PAC's; given lopressor and dilt as ordered; SBP 156-136, MAP's >60; +PP to palpation; am labs pending\\n\\nRESP: pt cont on hi flow neb and NC 2L, attempted to wean to 35% but sats dropped to 88-89% at rest, so turned back to 50%; desats to 80's with activity; tacypneic with activity, denies SOB/dyspnea, reports overall improvement in breathing since admission; LS coarse throughout; cont on PO levaquin; CDB with no sputum\\n\\nGI: abd soft distened; BM x2; tolerating soft diet with good PO intake\\n\\nGU: foley in place draining clear yellow urine 15-30c/hr; BUN/Cr elevated and trending up, ? d/c lasix, received 1 dose yesterday on days but did not have significant diuresis, goal 1L neg/day not met\\n\\nID: sputum cx not sent, pt unable to expectorate; afebrile; cont on PO levaquin\\n\\nACCESS: 2 peripheral IV's in left arm infilatrated d/t pressure cuff and unable to place on right arm d/t AV fistula, so BP cuff on thigh; IV RN placed 20g in left upper arm tongiht, and said pt has no other access\\n\\n: ? change in cardiac meds to dose pt takes at home; cont to wean O2 as toilerated, pulm toilet as tolerated, cont levaquin; bowel regimen as needed; pain mgt for back pain\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-05-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1336651,\n \"text\": \"Shift Note: 0700-1900\\nNeuro: Pt A+OX3, pleasant and cooperative. Reports comfortable and denies pain t/o shift. Pt OOB to chair X 4 hr today w/ min-mod 2 assist. Pt tolerated well.\\n\\nResp: Pt continues w/ FiO2 2L via NC. FM changed to facetent. C+DB, and IS encouraged and pt is practicing these techniques q1hr WA. Pt reports breathing continues to improve. BBS remain somewhat course t/o. SpO2 remains >92%. Pt remains free of s/s distress.\\n\\nCV: HR 50's to 60's, SR to SB w/ frequent PAC's. Lytes stable per am labs. SBP to 170's this am, tx w/ hydralazine 10mg IV X 1 w/ good effect. Pt has since reported SBP 170 too be well within her baseline. pt continues on lopressor and diltiazem as ordered.\\n\\nFEN: Pt tolerating full liquid diet well. Remains free of N/V. Foley catheter patent and draining clear yellow urine w/ borderline output. Initial plan for pt to receive metolazone w/ lasix. Metolazone was given; however, renal MD then recommended holding lasix, and orders obtained from team to hold lasix. Pt's wgt remains stable at 59kg.\\n\\nSocial: pt's son, daughter and priest have been in to visit. Priest pt this am.\\n\\nPlan: Continue to monitor respiratory status closely. Wean FiO2 as able. Encourage PO intake and increase activity as tolerated. Anticipate call out to floor if pt remains stable.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-05-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1336646,\n \"text\": \"1900-0700 npn\\nPt. admitted with complex medical hx, c/o sob,dyspnea.\\n\\nNEURO: AO x 3, mae, cataracts bil.\\n\\nCV: tmax 101.4 oral, responsive to tylenol. lasix given x 1 with fair response at 1 hr. pp intact. general dependant edema. sinus with little ectopy. sbp 180's given hydralazine IV 10 x1 with good result.\\nnow 132. fatigue. card enzymes neg.\\n\\nRESP: rec'd on bipap 100%. transferred to face tent at 10 liters and 6 liters nasal cannula. less dyspnea after lasix. able to speak in long sentences cough non productive. do need to send sputum sample when avail. lung field coarse on right, almost no air movement on left. will introduce IS this am. abg improved. trying to unsuccessfully wean oxygen.\\n\\nGU/GI: foley with fair response of 200cc after lasix IV. clear, urine and C& S pending. abd rounded now softer than prev. passing some flatus. pt. states last BM yest small amt. recently started iron. was planned to have soap suds enema, however due to recent rectal with repair of prolapse will hold for now. tol po fluid and takes pill easily. will hold on po bowel program until 0900 US of abd reveals no obstruction. no nausea complaint\\n\\nENDO: BS WNL, ON PREDNISONE will ask for sliding scale. tol full liquids, swallows pills well, safe swallow noted. NPO after mn for am US of abd.\\n\\nPAIN: denies\\n\\nACCESS: added #18 g to 20 g in left arm. noted L mastect, however right has av fistula .\\n\\nSKIN: intact\\n\\nID: bc, urine culture pending. levafoxacin po started in ER.\\n\\nSOCIAL: lives with husband who has recently had hip . dtr and son very supportive. Dtr in .\\n\\nPLAN: vigorous pulm toilet, introduce and teach Incentive spirometer, f/u cultures, treat fevers, mobilize asap, US abd scheduled for 0900 then address nutritional needs.\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-05-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1336647,\n \"text\": \"Nurse Progress Note 0700-1900\\n\\nEvents: 11AM episode tachypnic, hypertensive, drop sat's mid 80's-tx with 40mg IV Lasix, inc Fio2 to 100%-highflow @ 100%, cont hypertensive 10mg IV hydral, -no BiPAP. CXR, episode resolving slowly. Resuming to titrate down O2 requirement. CXR- in edema, inc in right PNA. Bedside echo, liver/gallbladder US. T spike to 101.4 rectal -tx with tylenol-no further intevention. See carvue for details.\\n\\nNeuro/Pain: Alert, oriented, engaging in conversation, using callbell approp. H/A when hypertensive, initally respoling, returing \\\"pain the the back of my head/neck\\\" repositioned and given 325mg Tylenol, declined 650mg. Pain . + gag/cough. MAE.\\n\\nResp: Resp rate regular in AM, sat's >95% on 40% face tent, 6L NC able to speak in full sentences-tolerating off face tent for pills. Approx 11 AM during echo inc in SOB and work of breathing RR 30-33/labored- titrating up face tent then and placed 100% high flow mask, albuterol/atrovent nebs, Bp 160-171/70's, given 40 mg IV Lasix, cont hypertensive 10mg IV Hydral BP down to 130/60's. Dyspnea resolving and resting comfortably. CXR at that time revealing inc in right PNA. Currently high flow @ 50%, titrating down NC to 4L. Sat's 93-98%-inc when turning/deep breathing. 90-92% off mask-no IS at this time. LS coarse/wheezing throughout. \\\"I feel better than when I first came in\\\"\\n\\nCV: 59-78 SB/SA/ NRS with frequent PAC's, irregular @ time but no AFib noted. BP 129-171/53-85 MAP 70-90's post Lasix/hydral BP 130-140's/. Echo: EF: 55-60%, mild LVH, 2+ MR, 2+ TR, grade II LV diastolic dysfunction. 1+ pitting ankle edema, mild general dependent edema. s/p L masectomy, R AV fistula + thrill, + bruit.\\n\\nGI: + BS, lg abd- liver US/gallbladder: numerous liver cysts, dilated extrahepatic common bile duct, ascities. s/o mult sx SBO- abd tender to palpation in epigastric area. Lactulose + flattus no BM. No enema-cont Lactulose. Toleraing thin liquids/pills-NPO.\\n\\nGU: Clear-pale yellow urine via foley. Post 40mg IV Lasix 200cc within 1hr approx 100cc/hr x3 hrs then tapering off. Neg 1360 past 24hrs, neg 1640 LOS.\\n\\nFEN/ENDO: No IVF. 1700 repete labs pending.\\n\\nID: T max 99.1 Ax/101.4 rectal-given 325mg tylenol, 97.2 Ax. Cont on Levoflox.\\n\\nSkin: Very think skin chronic steroid \\\"my skin breaks easily, I bruise everywhere\\\". Mult bruising IV access, R eye bruising \\\"I ahd that at home\\\". No active breakdown in skin integrity noted. Barrier crea-elbows/heals elevated. Waffel boots on.\\n\\nSocial: Daughter called and updated , pt condition. Son @ bedside, updated pt condition and . Full Code.\\n\\n\\n1. Cont monitor resp status, encourage cough/deep breath, titrate O2 as tolerated, pul toilet\\n2. Comt monitor skin integrity\\n3. Cont all routine ICU care\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-05-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1336648,\n \"text\": \"1900-0700 npn\\nNEURO: intact , pleasant and cooperative\\n\\nCV: afebrile, sinus rate 60-80, sys to 170, periph pulses intact. negative I/O for last 24 hrs\\n\\nRESP: abd breathing no dyspnea, lungs coarse, cough non productive, no distress but cont. to use high flow oxygen without being able to wean. long recovery times for sats after any activity\\n\\nGU/GI: foley ave 35 cc. 2 small semiformed brwn hem neg stool. BT active. no nausea, tol. full liquids well.\\n\\nPAIN: none\\n\\nENDO: full liquids, now states she is hungry\\n\\nACCESS: 2 piv. lla redressed x 2 for leakage at junction\\n\\nSKIN: no breaks in skin noted. waffle boots deferred per pt wishes til am.\\n\\nSOCIAL: dtr to visit. good support from family.\\n\\nPLAN: wean oxygen to nasal cannula as able. add IS when able. antibiotics. pulm toilet, waffle boots on, skin care caution due to long term pred. use.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-05-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1336649,\n \"text\": \"Nurse Progress Note 0700-1900\\n\\nEvents: Minimally able to titrate down O2 requirement. Inc Levoflox QD, Cellcept for PNA-unable to obtain sputum cx. 20mg IV Lasix with minimal effect- goal neg 500cc. See carevue for details.\\n\\nNeuro/Pain: Alert, oriented enaging in conversation. Sleeping in short naps throughout day. AM mild HA -resolving with in BP and 325mg Acetaminophen. Mild tender if palpating abd other wise denies pain/discomfort. + gag, weak cough.\\n\\nResp: Resp rate regular, minlabored resting in bed. With eating/turning mild fatigue o2 sat's drop 88-90% will trend up slowly. While eating on 10L NC-tolerating Sat 90-93%. Currently highflow 40%, 6L, 2L NC. Weak cough, encourage deep breathing. Scant nonproductive cough-unable to tolerate induced sputum. Able to talk in short sentences with minimal dyspnea. LS coarse throughout.\\n\\nCV: HR 59 -70 SB/SA/NR with frequent PAC, AM EKG ? transient AFIB-not noted on EKG. Atrial couplets. BP AM 160/70's -starting Dilt 60mg QID( Procardia 240mg XL @ home) BP 129-152/ 48-73 MAP 68-95. 20 mg IV Lasix with minimal effect-goal diuresis 500 neg/day. Awaiting repete lyyes before further diuresis. Echo: EF 55-60%, 2+ MR, 2+ TR, mild LVH, grade II diastolic disfunction, sever pulm HTN. Mild dependent hip edema. R AV fistula + thrill, + bruit.\\n\\nGI: + BS, soft distended abd with mult liver cysts, acities, s/p mult sx for SBP. No BM, + lg amt flattus, goal Lactulose until BM. Tolerating full liquid diet.\\n\\nGU: Clear yellow urine via foley. UOP 30-45 cc/hr. S/p renal transplant-renal following. Cr 2.4 (baseline ? 1.7-1.9) neg 90 cc past 24 hrs, neg 1870 LOS.\\n\\nFEN/ENDO: No IVF. Tolerating full liquid diet. 1800 labs pending.\\n\\nID: T amx 97.2 Ax, inc PO Levoflox to QD, Cellcept.\\n\\nSkin: General dry, thin skin chronic steroids. Barrier cream, heels/elboes elevated. Mult bruising IV access \\\"I have bruises from home\\\". No active breakdown noted.\\n\\nSocial: Daughter (HCP), husband and daughter in law in to visit pt- all updated pt condition, medications and . Full Code.\\n\\n\\n1. Cont monitor resp status, pulm toilet, titrate O2 as tolerated.\\n2. Cont monitor skin integrity\\n3. Monitor renal recs/diuresis as toelrated-goal neg 500cc\\n4. Cont emotional support of pt and family\\n5. Cont all routine ICU care\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2165-05-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 103864,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Pulmonary edema.\\nHeight: (in) 66\\nWeight (lb): 132\\nBSA (m2): 1.68 m2\\nBP (mm Hg): 150/75\\nHR (bpm): 71\\nStatus: Inpatient\\nDate/Time: at 11:20\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Mild LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\\n\\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\\nsystolic function (LVEF>55%). Transmitral Doppler and TVI c/w Grade II\\n(moderate) LV diastolic dysfunction. No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\\naorta.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate (2+)\\nMR.\\n\\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\\nSevere PA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\\nPhysiologic PR.\\n\\nPERICARDIUM: Trivial/physiologic pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Suboptimal\\nimage quality - poor suprasternal views.\\n\\nConclusions:\\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\\nhypertrophy with normal cavity size and regional/global systolic function\\n(LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent\\nwith Grade II (moderate) LV diastolic dysfunction. Right ventricular chamber\\nsize and free wall motion are normal. The ascending aorta is mildly dilated.\\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\\npresent. No aortic regurgitation is seen. The mitral valve leaflets are mildly\\nthickened. There is no mitral valve prolapse. Moderate (2+) mitral\\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\\nModerate [2+] tricuspid regurgitation is seen. There is severe pulmonary\\nartery systolic hypertension. There is a trivial/physiologic pericardial\\neffusion.\\n\\nCompared with the prior study (images reviewed) of , left ventricular\\ndiastolic function has worsened. The amounts of mitral regurgitation,\\ntricuspid regurgitation, and estimated pumonary artery systolic pressure have\\nincreased.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2165-05-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 298614,\n \"text\": \"Artifact is present. Sinus rhythm. Atrial ectopy. There is a late transition\\nwith anterior Q waves consistent with probable prior anterior myocardial\\ninfarction. Right axis deviation. Probable right ventricular hypertrophy.\\nCompared to the previous tracing the findings are similar.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2165-05-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 298615,\n \"text\": \"Sinus rhythm\\nAtrial premature complexes\\nLeft atrial abnormality\\nLow limb lead QRS voltages\\nIndeterminate axis\\nDelayed R wave progression with late precordial QRS transition\\nModest inferior inferior in lead V2\\nFindings are nonspecific but clinical correlation is suggested for possible in\\npart chronic pulmonary disease and possible prior septal myocardial infarction\\nSince previous tracing of 4\\n, atrial ectopy now present, QRS voltages less prominent and prominent T\\nwave amplitude decreased\\n\\n\"\n }\n]"}}},{"rowIdx":24652,"cells":{"subject_id":{"kind":"number","value":12155,"string":"12,155"},"hadm_id":{"kind":"number","value":173946,"string":"173,946"},"target_text":{"kind":"string","value":"1. Respiratory: was in room air throughout her entire Neonatal Intensive Care Unit admission. She had no episodes of spontaneous apnea. 2. Cardiovascular: maintained normal heart rates and blood pressures. During admission there were no cardiovascular issues. 3. Fluids, electrolytes and nutrition: Enteral feedings were started on day 1 of life. She has been on all p.o. feedings during admission. She takes approximately 150-174 cc per kg per day of Enfamil 20. Recent weight is 1.875 kg with a length of 43.8 cm and a head circumference of 32 cm. 4. Infectious disease: Due to the preterm labor, was evaluated for sepsis. A white blood cell count was 12,200 with a differential of 37% polys, 5% bands. A blood culture was obtained and was no growth at 48 hours. 5. Hematologic: Birth hematocrit was 49.6%. did not receive any transfusions of blood products. 6. GI: required treatment for unconjugated hyperbilirubinemia with phototherapy. Her peak serum bilirubin occurred on day of life two with a total of 9.1/0.3 direct mg per dL. She received phototherapy for approximately 72 hours. Her rebound bilirubin on was 7.8 total with 0.2 direct mg per dL. 7. Neurology: has maintained a normal neurological examination during admission and there are no neurological concerns at the time of discharge. 8. Sensory: Hearing screening was performed with automated auditory brainstem responses. passed in both ears."},"extractive_notes_summ":{"kind":"string","value":"infant willbottle again at next care. Waking q3-4h for feeds.Temps stable in off isolette. Baby toleratingfeeds well. NPN 0700-This RN assessed infant and agrees with the above note by ; co-worker.Formula changed to E20. A:tol feeds wellP:cont to monitor infant#2DEVE: temp stable. a: stable#3 parentingno contact with thus far this shift.#4 hyperbilpt remains under single phototherapy with eye inplace. A: allpo's for now P: need ngt placed, follow weight andtolerance to feeds#2 Temps stable on warmer-weaned x 1. Arrived to NICU pink and perfused with stable vital signs. P: Continue to monitor weight, POfeed ad lib amts w/ min 120cc/k/d.2. A:AGA P:cont to support g/d of infant#3PARENTING: no contact thus far this shift. Updated by RN. voidingand stooling qdiaper change. set tempweaned x2. Baby was dried and bulb sxn'd, min BBO2. P: Cont to provide devappropriate care.3. BILIO: Received infant under single phototherapy. will get rebound in a.m. A:hyperbilirubinemiaP:cont to monitor infant repeat bili pending. tf remains at min120cc's/kg/d ofPE20. Infant PO feeding Q4 hours, waking on own. P: Cont tomonitor, check rebound bili in am.See flowsheet for details. Cont to gain wgt. Bili this am =7.9/0.2. Mom D/C'ed hometoday. Po fed well.A: AGA. Bath done and D/C teaching begun; see NICU d/c instruction form. A: Tolerating feeds. A: Gainingweight.PO feding well. DEVO: is /active with cares. Will continue to monitor temp. abdbenign. waking onown for feedings. Neonatology Attending Progress NoteNow day of life 4.Cardiorespiratory status remains stable in RA.No apnea and bradycardia.RR - 30-60s.HR 150-180sBP 62/39 46Wt. A: Resolving hyperbilirubinemia. Is passing meconium. Continue with current feeding plan.DEV: Baby moved to OAC from off isolette at 12pm.Tolerating well. Co-Worker Note 0700-19001. Asking appropriatequestions. O: Mom in throughout shift to bottle . feeds well. 1840gm(25%) Lt. 43cm(25%) HC 32cm(75%)HEENT - AF soft and flat, prominent molding, sutures mobile, palate intactResp - breath sounds clear and equal.CVS - S1 S2 normal intensity, no murmur, perfusion good, pulses normal.Abd - soft with normal bowel sounds, no organomegalyGU - normal femaleAnus - slightly small and anteriorly placed, appearst to be patentNeuro - tone excellent, symmetrical movement of upper and lower extremitiesDS - 84cbc, diff pendingAssessment/plan:Well appearing 34 week gestation female infant with stable cardiorespiratory status thus far.Will observe/monitor for possible apnea of prematurity, temp control.Feedings to be initiated this evening.At slightly increased risk for sepsis with preterm labor and twin gestation. A/P:cont tosupport family#4BILI: infant remains off phototherapy. P: Contto educate and support family.4. Voiding andstooling (heme-). NNP Physical ExamPE: pink, jaundiced, AFOF, breath sounds clear/equal with easy WOB, no murmur, abd soft, non distended, + bowel sounds, active with good tone. A: AGA. wt. Bottling ability isslowly improving. Passed hearing screen. FENO: TFmin 120cc/kg/d of PE20 po. P: Support developmental needs.3. NPN DAYSI have examined and agree with above note by , co-worker. Passed carseat test. suckin on binki and hands. DS 53 + 58.Has not voided yet this shift. adjsuting well, will plan to follow as needed. Nested.In servo isolette. Abd benign, veg/stlgqs. need NG tube if she does not make her minimum intakerequirement.Alt in Dev: Temp stable in servo isolette, changed to airisolette. Cont to support, update, andeducate . Infant meeting min fluidreq by bottle. To check bili inthe am. Wakes for feeds q2-4hrs. Waking for feeds Q4hr, and active. Abd exam benign. Stable temp on off warmer. A: elevated bili P: repeat bili in am. Resting well inbetween cares. independent with infant cares. Neonatology - NNP Progress Note is active with good tone. ABdomen bneign. Mom . Temp stable on off warmer. NeonatologyDoing well. Abd benign. Took in 66cc/k yest. Trace stool x2. Infant waking Q4hrand taking 44-47cc well. Temp stable swaddled in OC. NPN#1 cont on 100cc/k/d PE20. A: PO's well. Belly benign. Belly benign. She is tolerating enteral feeds @ ad-lib amts. Min. Nursing Progress Note#1-O/A- TF=60cc/kg/d min of PE20. A: feeding fairly well P: Follow weight andoffer po's as tol#2 Temps slightly elevated in crib. Sucks on pacifier.P- Cont to assess for G&D needs.#3-O/A- Parents in to visit with updates given. in to visit and updated on plan of care. Will check bili.Will continue to assess ability to take in adeuqate pos. Will continue to monitor temp. NPN 0700-1. P-Cont to assess for FEN needs.#2-O/A- cont to be awake and active with clustercares. Waking for feeds, fairly calm with cares.sucks well on pacifier. Parentsheld infant. Swaddled. Comfortable appearing.Wt 1800 down 40. Waking on her ownprior to feeding times. Voiding and passing lgamts mec stool. Neonatology-NNP Progress NotePE: remains in her isolette, under single pt, eye covering on, in room air, bbs cl=, rrr s1s 2no murmur, abd soft, nontender, cord drying V&S, afso, active with careSee attending note for plan P- Cont to enc parentalcalls and visits.See flowsheet for further details. NPN 7p-7a#1 TF's min 60cc/k=18cc q 4hrs. Will continue toprovide for developmental needs.Alt in Parenting: Parents up to visit and participating incares, see siblings note.Bili: remains under single phototherapy. Stoolx2. Will increase minimum to 60 cc/kg/d.ID: WBC benign, blood cx NGSF, not on antibiotics. Tolerating feeds. RA. Will continueto provide for developmental needs.Alt in Parenting: Mom and dad in to visit. 4 BiliREVISIONS TO PATHWAY: 4 Bili; added Start date: Wakes q2.5-3hrs for feeds. Will continue to follow blood cx results off antibiotics.ENV'T: Stable temp wrapped with warmer off. Needs to burp frequently. Please refer to neonatology attending note for detailed plan. Attempting to achieveminimal intake with po feeds. AFOf. Loves her pacifier. Abd soft, active bowel sounds, no loops. NNP Physical ExamPE: pink, mild jaundice, AFOF, breath sounds clear/equal with easy WoB, no murmur, abd soft, non distended, active with good tone. Neonatology Attending Progress NoteNow day of life 6.CA 4/7 weeks.Cardiorespiratory status stable in RA.No apnea and bradycardiaHR 140-170sWt. Neonatology Attending Progress NoteNow day of life 3.Baby's respiratory status stable in RA.RR 20-60, no apnea and bradycardia.O2 sat >96 HR 130-160sWt."},"n_notes":{"kind":"number","value":30,"string":"30"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2130-07-22 00:00:00.000","description":"Report","row_id":1850676,"text":"Neonatology Attending Admission Note\n\nBaby is a 34 week female admitted to the NICU because of prematurity.\n\nPediatrician - Dr. .\n\nMother is 32 old G2 P0-2.\nPNS: HBSAg neg, RPR NR, O pos, Ab neg, RI, GBS - neg.\n\nPregnancy achieved with IVF assistance - dichorionic, diamniotic twins. Pregnancy was uncomplicated until when mother developed elevated .\n\nShe went into labor today and delivery was by NSVD with epidural anesthesia. No maternal fever. SROM at 1:00 AM almost 16 hours PTD.\n\nApgars 8,9. She was treated with bulb suction and blow by O2 briefly.\n\nPE - Baby pink breathing comfortably in RA.\nVS T 99.2 HR 150 RR 50 BP 67/31 44\nWt. 1840gm(25%) Lt. 43cm(25%) HC 32cm(75%)\nHEENT - AF soft and flat, prominent molding, sutures mobile, palate intact\nResp - breath sounds clear and equal.\nCVS - S1 S2 normal intensity, no murmur, perfusion good, pulses normal.\nAbd - soft with normal bowel sounds, no organomegaly\nGU - normal female\nAnus - slightly small and anteriorly placed, appearst to be patent\nNeuro - tone excellent, symmetrical movement of upper and lower extremities\n\nDS - 84\ncbc, diff pending\n\nAssessment/plan:\nWell appearing 34 week gestation female infant with stable cardiorespiratory status thus far.\nWill observe/monitor for possible apnea of prematurity, temp control.\nFeedings to be initiated this evening.\nAt slightly increased risk for sepsis with preterm labor and twin gestation. Will check cbc diff and blood culture. Will hold on antibiotic therapy unless cbc is abnormal, culture is positive or clinical signs of sepsis develop.\nFather updated at bedside.\n\n\n"},{"category":"Nursing/other","chartdate":"2130-07-27 00:00:00.000","description":"Report","row_id":1850697,"text":"coworker 1900-0700\n\n\n#1FEN: wt. 1835 up25g. tf remains at min120cc's/kg/d of\nPE20. infant is taking 40-50cc's thus far. infant will\nbottle again at next care. abd benign, belly is soft and\nround, +bowel sounds, no loops, no spits thus far this\nshift, voiding and stooling; heme neg. A:tol feeds well\nP:cont to monitor infant\n\n#2DEVE: temp stable. infant is swaddled in the off isolette.\ninfant is waking for feeds and is and active with\ncares. font are soft and flat. mae. infant sleeps well in\nbetween cares. A:AGA P:cont to support g/d of infant\n\n#3PARENTING: no contact thus far this shift. A/P:cont to\nsupport family\n\n#4BILI: infant remains off phototherapy. infant is slightly\njaundice. will get rebound in a.m. A:hyperbilirubinemia\nP:cont to monitor infant\n\n\n"},{"category":"Nursing/other","chartdate":"2130-07-27 00:00:00.000","description":"Report","row_id":1850698,"text":"npn 7p7a\n\n\nAgree with the above note written by co-worker.\n\n\n"},{"category":"Nursing/other","chartdate":"2130-07-27 00:00:00.000","description":"Report","row_id":1850699,"text":"Neonatology Attending Progress Note\n\nNow day of life 5 for this 34 week gestation infant.\n\nCardiorespiratory status stable in RA.\nNo apnea and bradc\n140-170s 61/34 43\n\nWt. 1835 up 25gm on ad lib volumes of feedings - took in 173cc/kg/d of PE\nFeedings are very well tolerated.\nNormal urine and stool output.\n\nBili 7.8 - off phototherapy\n\nAssessment/plan:\nPreterm female with excellent progress.\nWill plan on discharge to home tomorrow if continues to do well.\nDischarge screening - car seat testing and hearing to be done.\n"},{"category":"Nursing/other","chartdate":"2130-07-27 00:00:00.000","description":"Report","row_id":1850700,"text":"Co-worker Progress Note-DAYS\n\n\nFEN: TF min 120cc/kg/day (34cc q 4) of PE 20. Botlled 44cc\nand 50cc at 8am and 12pm. Had large spit at 12pm feeding.\nVoiding and stooling X2 thus far, hem -. Baby tolerating\nfeeds well. Continue with current feeding plan.\n\nDEV: Baby moved to OAC from off isolette at 12pm.\nTolerating well. Will continue to monitor temp. Wakes for\nfeeds and enjoys sucking on hands and pacifier. Continue to\nmonitor and support developmental needs.\n\nParenting: Mother called this am, stating she would not be\nable to visit this morning but that would be in at 2pm\nand stay for following cares. Continue to provide support\nand provide encouragement to .\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2130-07-27 00:00:00.000","description":"Report","row_id":1850701,"text":"NPN 0700-\nThis RN assessed infant and agrees with the above note by ; co-worker.\nFormula changed to E20. Passed hearing screen. aware of possible D/C home tomorrow. Mom got readmitted to hospital for 24hr of IV abx. Bath done and D/C teaching begun; see NICU d/c instruction form. Cont to prepare for possible D/C home tomorrow.\n"},{"category":"Nursing/other","chartdate":"2130-07-28 00:00:00.000","description":"Report","row_id":1850702,"text":"NICU NPN\n\n1. Infant PO feeding Q4 hours, waking on own. Taking 38-50cc\ntoday of E20cal without problem. feeds well. No spit,\nvoiding and stooling. Weight 1875g, up 40g today. A: Gaining\nweight.PO feding well. P: Continue to monitor weight, PO\nfeed ad lib amts w/ min 120cc/k/d.\n\n2. O: Swaddled, in open crib, with side rolls. Passed car\nseat test. Awake before feeding time, vigorous. Po fed well.\nA: AGA. P: Support developmental needs.\n\n3. O: No contact from as of this time. A/P: Support\nand keep informed with contact.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2130-07-26 00:00:00.000","description":"Report","row_id":1850691,"text":"npn 1900-0700\n\n\n#1 fen\ntf min 120cc/kg of pe20 po . wt. 1.810kg 9+20gms). abd\nbenign. voiding and stooling transitional guiac neg stools.\nno spits. dstic 78. a: good coordination with bottling.\ntolerating feedings well.\n#2 g&d\npt in air control isolette with stable temps. set temp\nweaned x2. and awake, irritable with cares. waking on\nown for feedings. suckin on binki and hands. maew.\nfontanelles soft and flat. a: stable\n#3 parenting\nno contact with thus far this shift.\n#4 hyperbil\npt remains under single phototherapy with eye in\nplace. repeat bili pending. skin slightly jaundice. voiding\nand stooling qdiaper change.\n\n\n"},{"category":"Nursing/other","chartdate":"2130-07-26 00:00:00.000","description":"Report","row_id":1850692,"text":"Social Work\n\n\nFamily meeting yesterday, mother remains in house due to infection.\nMedical issues reviewed, coping well, with good questions. Delighted with how well babies are doing, planning to bottle feed and be involved in cares.\nParent packet given with parking information. adjsuting well, will plan to follow as needed.\n"},{"category":"Nursing/other","chartdate":"2130-07-26 00:00:00.000","description":"Report","row_id":1850693,"text":"Neonatology Attending Progress Note\n\nNow day of life 4.\nCardiorespiratory status remains stable in RA.\nNo apnea and bradycardia.\nRR - 30-60s.\nHR 150-180s\nBP 62/39 46\n\nWt. 1810gm up 20gm on 120cc/kg/d of PE\nTook in 123cc/kg/d in past 24 hours - all po.\nNormal urine and stool output.\nDS 78\n\nBili - 7.9/0.2 on single phototherapy\n\nAssessment/plan:\nVery nice progress continues.\nWill continue with current feedings.\nPhototherapy dc'ed today - rebound tomorrow.\n"},{"category":"Nursing/other","chartdate":"2130-07-26 00:00:00.000","description":"Report","row_id":1850694,"text":"Co-Worker Note 0700-1900\n\n\n1. FEN\nO: TFmin 120cc/kg/d of PE20 po. Bottling 25-30cc q3h this\nshift. Abd exam benign, +BS, no loops. No spits. Voiding and\nstooling (heme-). Cont to gain wgt. A: Tolerating feeds. P:\nCont to monitor nutritional status, wgt gain, po intake.\n\n2. DEV\nO: is /active with cares. Waking q3-4h for feeds.\nTemps stable in off isolette. Sleeping well b/w care times.\nBrings hands to face. A: AGA. P: Cont to provide dev\nappropriate care.\n\n3. \nO: Mom in throughout shift to bottle . Mom D/C'ed home\ntoday. In w/grandmother and @ 1600. Asking appropriate\nquestions. Mom expressed concern about leaving today w/o her\nbabies. Updated by RN. A: Attentive, loving family. P: Cont\nto educate and support family.\n\n4. BILI\nO: Received infant under single phototherapy. Bili this am =\n7.9/0.2. Phototherapy D/C'ed @ 1200 as ordered. Remains sl.\njaundiced. A: Resolving hyperbilirubinemia. P: Cont to\nmonitor, check rebound bili in am.\n\nSee flowsheet for details.\n\n\n"},{"category":"Nursing/other","chartdate":"2130-07-26 00:00:00.000","description":"Report","row_id":1850695,"text":"NPN DAYS\nI have examined and agree with above note by , co-worker.\n"},{"category":"Nursing/other","chartdate":"2130-07-26 00:00:00.000","description":"Report","row_id":1850696,"text":"NNP Physical Exam\nPE: pink, jaundiced, AFOF, breath sounds clear/equal with easy WOB, no murmur, abd soft, non distended, + bowel sounds, active with good tone.\n"},{"category":"Nursing/other","chartdate":"2130-07-22 00:00:00.000","description":"Report","row_id":1850677,"text":"Admission Note\nBaby Girl #1 () was admitted to NICU at 1740 from L&D after spont vaginal delivery. Infant is 34 5/7 weeks gestation. Baby was dried and bulb sxn'd, min BBO2. Arrived to NICU pink and perfused with stable vital signs. No resp distress. Infant cried and was and active. Baby cares were given and blood was drawn for CBC and blood cx. DS=84. Dad stopped by to see infant. Infant voided and bottled 20cc of PE20.\nSee flowsheet for further details.\n"},{"category":"Nursing/other","chartdate":"2130-07-23 00:00:00.000","description":"Report","row_id":1850678,"text":"NPN 7p-7a\n\n\n#1 TF's 40cc/k=12cc q 4hrs. Has po fed volumes of 10cc of\nPE20 then 16cc overnight thus far. Bottling ability is\nslowly improving. Abdominal exam unremarkable. DS 53 + 58.\nHas not voided yet this shift. Is passing meconium. A: all\npo's for now P: need ngt placed, follow weight and\ntolerance to feeds\n\n#2 Temps stable on warmer-weaned x 1. Likes pacifier.\nNudgey at times. Nested on sheepskin with boundaries in\nplace. A: AGA P: support developmental needs\n\n#3 Mom and Dad in x 1 with multiple family members to visit.\nUpdate provided. Very excited their daughters have arrived.\nA: loving folks P: cont to orient to the NICU environment\nand offer support\n\n\n"},{"category":"Nursing/other","chartdate":"2130-07-23 00:00:00.000","description":"Report","row_id":1850679,"text":"NICU Attending Note\n\nDOL # 1 34 5/7 weeks with apparently mature lungs, learning to PO feed.\n\nFull NNP Rivers\n\nCVR/RESP: No murmur, BS clear/=, in RA, NO A/B. Will continue to monitor.\n\nFEN: Birth weight 1840 gm, abd benign, on minimum of 40 cc/kg/d PE 20, slightly exceeding minimum D sticks in 50's. Will increase minimum to 60 cc/kg/d.\n\nID: WBC benign, blood cx NGSF, not on antibiotics. Will continue to follow blood cx results off antibiotics.\n\nENV'T: Stable temp wrapped with warmer off. Will continue to monitor temp.\n"},{"category":"Nursing/other","chartdate":"2130-07-23 00:00:00.000","description":"Report","row_id":1850680,"text":"Nursing Progress Note\n\n\n#1-O/A- TF=60cc/kg/d min of PE20. Infant meeting min fluid\nreq by bottle. Abd exam benign. Voiding and stooling. P-\nCont to assess for FEN needs.\n#2-O/A- cont to be awake and active with cluster\ncares. Wakes for feeds q2-4hrs. Sleeps well between cares.\n Temp stable on off warmer. Swaddled. Sucks on pacifier.\nP- Cont to assess for G&D needs.\n#3-O/A- Parents in to visit with updates given. Parents\nheld infant. Loving interaction. P- Cont to enc parental\ncalls and visits.\nSee flowsheet for further details.\n\n\n"},{"category":"Nursing/other","chartdate":"2130-07-23 00:00:00.000","description":"Report","row_id":1850681,"text":"Neonatology - NNP Progress Note\n\n is active with good tone. AFOf. She is pink, well perfused, no murmur auscultated. She is comfortable in room air. Breath sounds clear and equal. No spells. She is tolerating enteral feeds @ ad-lib amts. Abd soft, active bowel sounds, no loops. Voiding and stooling. Stable temp on off warmer. Please refer to neonatology attending note for detailed plan.\n"},{"category":"Nursing/other","chartdate":"2130-07-24 00:00:00.000","description":"Report","row_id":1850682,"text":"NPN 7p-7a\n\n\n#1 TF's min 60cc/k=18cc q 4hrs. Took in 66cc/k yest. Weight\ndown 40g from BW. Bottle feeding almost Q 2-4hrs overnoc for\nvolumes of 15-16cc q feed. Needs to burp frequently. DS 71.\nAbdominal exam unremarkable overnoc. Voiding and passing lg\namts mec stool. A: feeding fairly well P: Follow weight and\noffer po's as tol\n\n#2 Temps slightly elevated in crib. Hat and sheepskin\nremoved. Frequently fussy. A: AGA P: Support developmental\nneeds\n\n#3 No parental contact thus far overnight.\n\n\n"},{"category":"Nursing/other","chartdate":"2130-07-28 00:00:00.000","description":"Report","row_id":1850703,"text":"Neonatology Attending Progress Note\n\nNow day of life 6.\nCA 4/7 weeks.\n\nCardiorespiratory status stable in RA.\nNo apnea and bradycardia\nHR 140-170s\n\nWt. 1875gm up 40gm - taking 145cc/kg/d of E20\nFeedings going well by bottle.\nNormal urine and stool output.\n\nBili - 7.8 yesterday - rebound\n\nDischarge teaching and screening in progress.\nPassed car seat and hearing screens.\n\nAssessment/plan:\nVery nice progress continues.\nWill plan on discharge to home today or tomorrow.\nAwaiting further word on mother's status.\n\n\n"},{"category":"Nursing/other","chartdate":"2130-07-28 00:00:00.000","description":"Report","row_id":1850704,"text":"NPN 0700-\n\n\n1. Min. TF 120cc/k/d of E20= 38cc Q4hr. Infant waking Q4hr\nand taking 44-47cc well. Abd benign. Voiding and no stool\nthus far. Taking good PO's without spits. Cont to monitor\nFEN in newborn nursery.\n\n2. Temp stable swaddled in OC. Waking for feeds Q4hr,\n and active. Resting well inbetween cares. MAE,\nbrings hands to face. Cont to promote development in\nnewborn nursery.\n\n3. in to visit and updated on plan of care. Mother\nremains and will be transferred to 5 later\ntoday. aware that both girls will be transferred to\nnewborn nursery on this afternoon. \nindependent with infant cares. Cont to support, update, and\neducate .\n\n\n"},{"category":"Nursing/other","chartdate":"2130-07-28 00:00:00.000","description":"Report","row_id":1850705,"text":"NNP Physical Exam\n\nPE: pink, mild jaundice, AFOF, breath sounds clear/equal with easy WoB, no murmur, abd soft, non distended, active with good tone.\n"},{"category":"Nursing/other","chartdate":"2130-07-24 00:00:00.000","description":"Report","row_id":1850683,"text":"Neonatology\nDoing well. RA. No spells. Comfortable appearing.\n\nWt 1800 down 40. ABdomen bneign. Tolerating feeds. Took in 66 cc/k/d yesterday. Will increase min to 80 cc/k/d.\n\nJaundiced this am. Will check bili.\n\nWill continue to assess ability to take in adeuqate pos.\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2130-07-24 00:00:00.000","description":"Report","row_id":1850684,"text":"NPN DAYS\n\n\nAlt in FEN: TF increased to 100cc/kg/day PE20. Baby\ncurrently taking all feeds po. Belly benign. No spits. Stool\nx2. Will continue to encourage po feeds and place NG if baby\ntires.\n\nAlt in Dev: Recieved baby in open crib with temp stable.\nPlaced in isolette at 4pm r/t need for bili lights. Nested.\nIn servo isolette. Wakes q2.5-3hrs for feeds. Awake and\nactive with cares. Sleeps well between cares. Will continue\nto provide for developmental needs.\n\nAlt in Parenting: Mom and dad in to visit. Dad fed baby x1.\nExplained phototherapy to the parents and what the girls\nneed to be doing before they are dc'd home. Mom . She\nwill be dc'd home tomorrow and would like a family meeting\nat 3pm. Will continue to encourage parents participation in\nthe babies cares.\n\n\n"},{"category":"Nursing/other","chartdate":"2130-07-24 00:00:00.000","description":"Report","row_id":1850685,"text":"4 Bili\n\nREVISIONS TO PATHWAY:\n\n 4 Bili; added\n Start date: \n\n"},{"category":"Nursing/other","chartdate":"2130-07-25 00:00:00.000","description":"Report","row_id":1850686,"text":"NPN\n\n\n#1 cont on 100cc/k/d PE20. Waking q3-4hrs, she has\nbottled 2 feeds taking 35cc each feed. Abd benign, veg/stlg\nqs. A: PO's well. P: no change at present\n#2 stable in servo heat isolette due to need for\nphototherapy. Waking for feeds, fairly calm with cares.\nsucks well on pacifier. A: AGA P: cont to support\ndevelopment\n#3 No contact with family thusfar in shift.\n#4 cont under single phototherapy, eyes covered, sl\njaundice. A: elevated bili P: repeat bili in am.\n\n\n"},{"category":"Nursing/other","chartdate":"2130-07-25 00:00:00.000","description":"Report","row_id":1850687,"text":"Neonatology Attending Progress Note\n\nNow day of life 3.\nBaby's respiratory status stable in RA.\nRR 20-60, no apnea and bradycardia.\nO2 sat >96 HR 130-160s\n\nWt. 1790gm down 10gm on PE20 - ad lib volumes - took in >100cc/kg/day\nNormal urine and stool output.\n\nBili 8.9 on phototherapy.\n\nAssessment/plan:\nVery nice progress continues.\nWill continue to encourage feedings as tolerated.\nFU bili planned in 2 days.\nFamily meeting planned for this afternoon.\n\n\n"},{"category":"Nursing/other","chartdate":"2130-07-25 00:00:00.000","description":"Report","row_id":1850688,"text":"Neonatology-NNP Progress Note\nPE: remains in her isolette, under single pt, eye covering on, in room air, bbs cl=, rrr s1s 2no murmur, abd soft, nontender, cord drying V&S, afso, active with care\n\nSee attending note for plan\n\n\n"},{"category":"Nursing/other","chartdate":"2130-07-25 00:00:00.000","description":"Report","row_id":1850689,"text":"Family Meeting\n\nMet with both parents and , Social Work.\nReviewed baby's course thus far and goals for discharge.\n\nMet with parents for approximately 35 minutes.\n\n\n"},{"category":"Nursing/other","chartdate":"2130-07-25 00:00:00.000","description":"Report","row_id":1850690,"text":"NPN DAYS\n\n\nalt in FEN: Tf 120cc/kg/day PE20. Attempting to achieve\nminimal intake with po feeds. Needs 37cc qfeed, has taken\n35, 35, 30cc. Belly benign. Trace stool x2. No spits. \nneed NG tube if she does not make her minimum intake\nrequirement.\n\nAlt in Dev: Temp stable in servo isolette, changed to air\nisolette. Awake and with cares. Waking on her own\nprior to feeding times. Loves her pacifier. Will continue to\nprovide for developmental needs.\n\nAlt in Parenting: Parents up to visit and participating in\ncares, see siblings note.\n\nBili: remains under single phototherapy. To check bili in\nthe am.\n\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850676,\n \"text\": \"Neonatology Attending Admission Note\\n\\nBaby is a 34 week female admitted to the NICU because of prematurity.\\n\\nPediatrician - Dr. .\\n\\nMother is 32 old G2 P0-2.\\nPNS: HBSAg neg, RPR NR, O pos, Ab neg, RI, GBS - neg.\\n\\nPregnancy achieved with IVF assistance - dichorionic, diamniotic twins. Pregnancy was uncomplicated until when mother developed elevated .\\n\\nShe went into labor today and delivery was by NSVD with epidural anesthesia. No maternal fever. SROM at 1:00 AM almost 16 hours PTD.\\n\\nApgars 8,9. She was treated with bulb suction and blow by O2 briefly.\\n\\nPE - Baby pink breathing comfortably in RA.\\nVS T 99.2 HR 150 RR 50 BP 67/31 44\\nWt. 1840gm(25%) Lt. 43cm(25%) HC 32cm(75%)\\nHEENT - AF soft and flat, prominent molding, sutures mobile, palate intact\\nResp - breath sounds clear and equal.\\nCVS - S1 S2 normal intensity, no murmur, perfusion good, pulses normal.\\nAbd - soft with normal bowel sounds, no organomegaly\\nGU - normal female\\nAnus - slightly small and anteriorly placed, appearst to be patent\\nNeuro - tone excellent, symmetrical movement of upper and lower extremities\\n\\nDS - 84\\ncbc, diff pending\\n\\nAssessment/plan:\\nWell appearing 34 week gestation female infant with stable cardiorespiratory status thus far.\\nWill observe/monitor for possible apnea of prematurity, temp control.\\nFeedings to be initiated this evening.\\nAt slightly increased risk for sepsis with preterm labor and twin gestation. Will check cbc diff and blood culture. Will hold on antibiotic therapy unless cbc is abnormal, culture is positive or clinical signs of sepsis develop.\\nFather updated at bedside.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850697,\n \"text\": \"coworker 1900-0700\\n\\n\\n#1FEN: wt. 1835 up25g. tf remains at min120cc's/kg/d of\\nPE20. infant is taking 40-50cc's thus far. infant will\\nbottle again at next care. abd benign, belly is soft and\\nround, +bowel sounds, no loops, no spits thus far this\\nshift, voiding and stooling; heme neg. A:tol feeds well\\nP:cont to monitor infant\\n\\n#2DEVE: temp stable. infant is swaddled in the off isolette.\\ninfant is waking for feeds and is and active with\\ncares. font are soft and flat. mae. infant sleeps well in\\nbetween cares. A:AGA P:cont to support g/d of infant\\n\\n#3PARENTING: no contact thus far this shift. A/P:cont to\\nsupport family\\n\\n#4BILI: infant remains off phototherapy. infant is slightly\\njaundice. will get rebound in a.m. A:hyperbilirubinemia\\nP:cont to monitor infant\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850698,\n \"text\": \"npn 7p7a\\n\\n\\nAgree with the above note written by co-worker.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850699,\n \"text\": \"Neonatology Attending Progress Note\\n\\nNow day of life 5 for this 34 week gestation infant.\\n\\nCardiorespiratory status stable in RA.\\nNo apnea and bradc\\n140-170s 61/34 43\\n\\nWt. 1835 up 25gm on ad lib volumes of feedings - took in 173cc/kg/d of PE\\nFeedings are very well tolerated.\\nNormal urine and stool output.\\n\\nBili 7.8 - off phototherapy\\n\\nAssessment/plan:\\nPreterm female with excellent progress.\\nWill plan on discharge to home tomorrow if continues to do well.\\nDischarge screening - car seat testing and hearing to be done.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850700,\n \"text\": \"Co-worker Progress Note-DAYS\\n\\n\\nFEN: TF min 120cc/kg/day (34cc q 4) of PE 20. Botlled 44cc\\nand 50cc at 8am and 12pm. Had large spit at 12pm feeding.\\nVoiding and stooling X2 thus far, hem -. Baby tolerating\\nfeeds well. Continue with current feeding plan.\\n\\nDEV: Baby moved to OAC from off isolette at 12pm.\\nTolerating well. Will continue to monitor temp. Wakes for\\nfeeds and enjoys sucking on hands and pacifier. Continue to\\nmonitor and support developmental needs.\\n\\nParenting: Mother called this am, stating she would not be\\nable to visit this morning but that would be in at 2pm\\nand stay for following cares. Continue to provide support\\nand provide encouragement to .\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850701,\n \"text\": \"NPN 0700-\\nThis RN assessed infant and agrees with the above note by ; co-worker.\\nFormula changed to E20. Passed hearing screen. aware of possible D/C home tomorrow. Mom got readmitted to hospital for 24hr of IV abx. Bath done and D/C teaching begun; see NICU d/c instruction form. Cont to prepare for possible D/C home tomorrow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850702,\n \"text\": \"NICU NPN\\n\\n1. Infant PO feeding Q4 hours, waking on own. Taking 38-50cc\\ntoday of E20cal without problem. feeds well. No spit,\\nvoiding and stooling. Weight 1875g, up 40g today. A: Gaining\\nweight.PO feding well. P: Continue to monitor weight, PO\\nfeed ad lib amts w/ min 120cc/k/d.\\n\\n2. O: Swaddled, in open crib, with side rolls. Passed car\\nseat test. Awake before feeding time, vigorous. Po fed well.\\nA: AGA. P: Support developmental needs.\\n\\n3. O: No contact from as of this time. A/P: Support\\nand keep informed with contact.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850691,\n \"text\": \"npn 1900-0700\\n\\n\\n#1 fen\\ntf min 120cc/kg of pe20 po . wt. 1.810kg 9+20gms). abd\\nbenign. voiding and stooling transitional guiac neg stools.\\nno spits. dstic 78. a: good coordination with bottling.\\ntolerating feedings well.\\n#2 g&d\\npt in air control isolette with stable temps. set temp\\nweaned x2. and awake, irritable with cares. waking on\\nown for feedings. suckin on binki and hands. maew.\\nfontanelles soft and flat. a: stable\\n#3 parenting\\nno contact with thus far this shift.\\n#4 hyperbil\\npt remains under single phototherapy with eye in\\nplace. repeat bili pending. skin slightly jaundice. voiding\\nand stooling qdiaper change.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850692,\n \"text\": \"Social Work\\n\\n\\nFamily meeting yesterday, mother remains in house due to infection.\\nMedical issues reviewed, coping well, with good questions. Delighted with how well babies are doing, planning to bottle feed and be involved in cares.\\nParent packet given with parking information. adjsuting well, will plan to follow as needed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850693,\n \"text\": \"Neonatology Attending Progress Note\\n\\nNow day of life 4.\\nCardiorespiratory status remains stable in RA.\\nNo apnea and bradycardia.\\nRR - 30-60s.\\nHR 150-180s\\nBP 62/39 46\\n\\nWt. 1810gm up 20gm on 120cc/kg/d of PE\\nTook in 123cc/kg/d in past 24 hours - all po.\\nNormal urine and stool output.\\nDS 78\\n\\nBili - 7.9/0.2 on single phototherapy\\n\\nAssessment/plan:\\nVery nice progress continues.\\nWill continue with current feedings.\\nPhototherapy dc'ed today - rebound tomorrow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850694,\n \"text\": \"Co-Worker Note 0700-1900\\n\\n\\n1. FEN\\nO: TFmin 120cc/kg/d of PE20 po. Bottling 25-30cc q3h this\\nshift. Abd exam benign, +BS, no loops. No spits. Voiding and\\nstooling (heme-). Cont to gain wgt. A: Tolerating feeds. P:\\nCont to monitor nutritional status, wgt gain, po intake.\\n\\n2. DEV\\nO: is /active with cares. Waking q3-4h for feeds.\\nTemps stable in off isolette. Sleeping well b/w care times.\\nBrings hands to face. A: AGA. P: Cont to provide dev\\nappropriate care.\\n\\n3. \\nO: Mom in throughout shift to bottle . Mom D/C'ed home\\ntoday. In w/grandmother and @ 1600. Asking appropriate\\nquestions. Mom expressed concern about leaving today w/o her\\nbabies. Updated by RN. A: Attentive, loving family. P: Cont\\nto educate and support family.\\n\\n4. BILI\\nO: Received infant under single phototherapy. Bili this am =\\n7.9/0.2. Phototherapy D/C'ed @ 1200 as ordered. Remains sl.\\njaundiced. A: Resolving hyperbilirubinemia. P: Cont to\\nmonitor, check rebound bili in am.\\n\\nSee flowsheet for details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850695,\n \"text\": \"NPN DAYS\\nI have examined and agree with above note by , co-worker.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850696,\n \"text\": \"NNP Physical Exam\\nPE: pink, jaundiced, AFOF, breath sounds clear/equal with easy WOB, no murmur, abd soft, non distended, + bowel sounds, active with good tone.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850677,\n \"text\": \"Admission Note\\nBaby Girl #1 () was admitted to NICU at 1740 from L&D after spont vaginal delivery. Infant is 34 5/7 weeks gestation. Baby was dried and bulb sxn'd, min BBO2. Arrived to NICU pink and perfused with stable vital signs. No resp distress. Infant cried and was and active. Baby cares were given and blood was drawn for CBC and blood cx. DS=84. Dad stopped by to see infant. Infant voided and bottled 20cc of PE20.\\nSee flowsheet for further details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850678,\n \"text\": \"NPN 7p-7a\\n\\n\\n#1 TF's 40cc/k=12cc q 4hrs. Has po fed volumes of 10cc of\\nPE20 then 16cc overnight thus far. Bottling ability is\\nslowly improving. Abdominal exam unremarkable. DS 53 + 58.\\nHas not voided yet this shift. Is passing meconium. A: all\\npo's for now P: need ngt placed, follow weight and\\ntolerance to feeds\\n\\n#2 Temps stable on warmer-weaned x 1. Likes pacifier.\\nNudgey at times. Nested on sheepskin with boundaries in\\nplace. A: AGA P: support developmental needs\\n\\n#3 Mom and Dad in x 1 with multiple family members to visit.\\nUpdate provided. Very excited their daughters have arrived.\\nA: loving folks P: cont to orient to the NICU environment\\nand offer support\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850679,\n \"text\": \"NICU Attending Note\\n\\nDOL # 1 34 5/7 weeks with apparently mature lungs, learning to PO feed.\\n\\nFull NNP Rivers\\n\\nCVR/RESP: No murmur, BS clear/=, in RA, NO A/B. Will continue to monitor.\\n\\nFEN: Birth weight 1840 gm, abd benign, on minimum of 40 cc/kg/d PE 20, slightly exceeding minimum D sticks in 50's. Will increase minimum to 60 cc/kg/d.\\n\\nID: WBC benign, blood cx NGSF, not on antibiotics. Will continue to follow blood cx results off antibiotics.\\n\\nENV'T: Stable temp wrapped with warmer off. Will continue to monitor temp.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850680,\n \"text\": \"Nursing Progress Note\\n\\n\\n#1-O/A- TF=60cc/kg/d min of PE20. Infant meeting min fluid\\nreq by bottle. Abd exam benign. Voiding and stooling. P-\\nCont to assess for FEN needs.\\n#2-O/A- cont to be awake and active with cluster\\ncares. Wakes for feeds q2-4hrs. Sleeps well between cares.\\n Temp stable on off warmer. Swaddled. Sucks on pacifier.\\nP- Cont to assess for G&D needs.\\n#3-O/A- Parents in to visit with updates given. Parents\\nheld infant. Loving interaction. P- Cont to enc parental\\ncalls and visits.\\nSee flowsheet for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850681,\n \"text\": \"Neonatology - NNP Progress Note\\n\\n is active with good tone. AFOf. She is pink, well perfused, no murmur auscultated. She is comfortable in room air. Breath sounds clear and equal. No spells. She is tolerating enteral feeds @ ad-lib amts. Abd soft, active bowel sounds, no loops. Voiding and stooling. Stable temp on off warmer. Please refer to neonatology attending note for detailed plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850682,\n \"text\": \"NPN 7p-7a\\n\\n\\n#1 TF's min 60cc/k=18cc q 4hrs. Took in 66cc/k yest. Weight\\ndown 40g from BW. Bottle feeding almost Q 2-4hrs overnoc for\\nvolumes of 15-16cc q feed. Needs to burp frequently. DS 71.\\nAbdominal exam unremarkable overnoc. Voiding and passing lg\\namts mec stool. A: feeding fairly well P: Follow weight and\\noffer po's as tol\\n\\n#2 Temps slightly elevated in crib. Hat and sheepskin\\nremoved. Frequently fussy. A: AGA P: Support developmental\\nneeds\\n\\n#3 No parental contact thus far overnight.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850703,\n \"text\": \"Neonatology Attending Progress Note\\n\\nNow day of life 6.\\nCA 4/7 weeks.\\n\\nCardiorespiratory status stable in RA.\\nNo apnea and bradycardia\\nHR 140-170s\\n\\nWt. 1875gm up 40gm - taking 145cc/kg/d of E20\\nFeedings going well by bottle.\\nNormal urine and stool output.\\n\\nBili - 7.8 yesterday - rebound\\n\\nDischarge teaching and screening in progress.\\nPassed car seat and hearing screens.\\n\\nAssessment/plan:\\nVery nice progress continues.\\nWill plan on discharge to home today or tomorrow.\\nAwaiting further word on mother's status.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850704,\n \"text\": \"NPN 0700-\\n\\n\\n1. Min. TF 120cc/k/d of E20= 38cc Q4hr. Infant waking Q4hr\\nand taking 44-47cc well. Abd benign. Voiding and no stool\\nthus far. Taking good PO's without spits. Cont to monitor\\nFEN in newborn nursery.\\n\\n2. Temp stable swaddled in OC. Waking for feeds Q4hr,\\n and active. Resting well inbetween cares. MAE,\\nbrings hands to face. Cont to promote development in\\nnewborn nursery.\\n\\n3. in to visit and updated on plan of care. Mother\\nremains and will be transferred to 5 later\\ntoday. aware that both girls will be transferred to\\nnewborn nursery on this afternoon. \\nindependent with infant cares. Cont to support, update, and\\neducate .\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850705,\n \"text\": \"NNP Physical Exam\\n\\nPE: pink, mild jaundice, AFOF, breath sounds clear/equal with easy WoB, no murmur, abd soft, non distended, active with good tone.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850683,\n \"text\": \"Neonatology\\nDoing well. RA. No spells. Comfortable appearing.\\n\\nWt 1800 down 40. ABdomen bneign. Tolerating feeds. Took in 66 cc/k/d yesterday. Will increase min to 80 cc/k/d.\\n\\nJaundiced this am. Will check bili.\\n\\nWill continue to assess ability to take in adeuqate pos.\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850684,\n \"text\": \"NPN DAYS\\n\\n\\nAlt in FEN: TF increased to 100cc/kg/day PE20. Baby\\ncurrently taking all feeds po. Belly benign. No spits. Stool\\nx2. Will continue to encourage po feeds and place NG if baby\\ntires.\\n\\nAlt in Dev: Recieved baby in open crib with temp stable.\\nPlaced in isolette at 4pm r/t need for bili lights. Nested.\\nIn servo isolette. Wakes q2.5-3hrs for feeds. Awake and\\nactive with cares. Sleeps well between cares. Will continue\\nto provide for developmental needs.\\n\\nAlt in Parenting: Mom and dad in to visit. Dad fed baby x1.\\nExplained phototherapy to the parents and what the girls\\nneed to be doing before they are dc'd home. Mom . She\\nwill be dc'd home tomorrow and would like a family meeting\\nat 3pm. Will continue to encourage parents participation in\\nthe babies cares.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850685,\n \"text\": \"4 Bili\\n\\nREVISIONS TO PATHWAY:\\n\\n 4 Bili; added\\n Start date: \\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850686,\n \"text\": \"NPN\\n\\n\\n#1 cont on 100cc/k/d PE20. Waking q3-4hrs, she has\\nbottled 2 feeds taking 35cc each feed. Abd benign, veg/stlg\\nqs. A: PO's well. P: no change at present\\n#2 stable in servo heat isolette due to need for\\nphototherapy. Waking for feeds, fairly calm with cares.\\nsucks well on pacifier. A: AGA P: cont to support\\ndevelopment\\n#3 No contact with family thusfar in shift.\\n#4 cont under single phototherapy, eyes covered, sl\\njaundice. A: elevated bili P: repeat bili in am.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850687,\n \"text\": \"Neonatology Attending Progress Note\\n\\nNow day of life 3.\\nBaby's respiratory status stable in RA.\\nRR 20-60, no apnea and bradycardia.\\nO2 sat >96 HR 130-160s\\n\\nWt. 1790gm down 10gm on PE20 - ad lib volumes - took in >100cc/kg/day\\nNormal urine and stool output.\\n\\nBili 8.9 on phototherapy.\\n\\nAssessment/plan:\\nVery nice progress continues.\\nWill continue to encourage feedings as tolerated.\\nFU bili planned in 2 days.\\nFamily meeting planned for this afternoon.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850688,\n \"text\": \"Neonatology-NNP Progress Note\\nPE: remains in her isolette, under single pt, eye covering on, in room air, bbs cl=, rrr s1s 2no murmur, abd soft, nontender, cord drying V&S, afso, active with care\\n\\nSee attending note for plan\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850689,\n \"text\": \"Family Meeting\\n\\nMet with both parents and , Social Work.\\nReviewed baby's course thus far and goals for discharge.\\n\\nMet with parents for approximately 35 minutes.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-07-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1850690,\n \"text\": \"NPN DAYS\\n\\n\\nalt in FEN: Tf 120cc/kg/day PE20. Attempting to achieve\\nminimal intake with po feeds. Needs 37cc qfeed, has taken\\n35, 35, 30cc. Belly benign. Trace stool x2. No spits. \\nneed NG tube if she does not make her minimum intake\\nrequirement.\\n\\nAlt in Dev: Temp stable in servo isolette, changed to air\\nisolette. Awake and with cares. Waking on her own\\nprior to feeding times. Loves her pacifier. Will continue to\\nprovide for developmental needs.\\n\\nAlt in Parenting: Parents up to visit and participating in\\ncares, see siblings note.\\n\\nBili: remains under single phototherapy. To check bili in\\nthe am.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":24653,"cells":{"subject_id":{"kind":"number","value":23014,"string":"23,014"},"hadm_id":{"kind":"number","value":180505,"string":"180,505"},"target_text":{"kind":"string","value":"The patient was admitted to the Neurosurgery Service under Dr. service. Blood pressure was to be kept at less then 130. He was started on Dilantin 100 mg q 8 and head of bed was kept greater then 30 degrees. Neuro checks were done q one hour and placed on strict I and O. A CTA was performed, which showed a vertebral artery aneurysm. On at 11:30 in the morning Mr. went to the neuro interventional angio suite where he underwent a cerebral angiogram. He was found to have wide neck aneurysm of a heavily calcified left intracranial vertebral artery proximal to the vertebral basilar junction. He found that there was no right vertebral flow and his bilaterally ICAs did not have an aneurysm. He is brought back to the Intensive Care Unit. His blood pressures kept less then 130 and Dr. discussed possible coiling options with the family at that time. Postoperatively after his diagnostic angio Mr. was found not to open his eyes to sternal rub or following commands. His pupils were 4 mm, sluggish, reactive. He had a positive corneal and gag reflex. No blink to visual threat. He had increased tone in his lower extremities. He localized to pain in all four extremities moving his legs spontaneously. At 8:30 p.m. on he was brought back to the interventional neuro angio suite where he had a stent deployment times two and coil-through- stent embolization of his left vertebral artery aneurysm. Before the procedure he had a ventriculostomy drain placed without any complications. Postoperatively, his blood pressure is kept in the less then 120 range. His drain is open at 15. He is started on Plavix 75 mg q day and aspirin 325 mg po q day. On his intracranial pressures were ranging from 9 to 11. He had been sedated at that point. His pupils were bilateral at 2 with a conjugate gaze, moving spontaneously on the right, following commands in his upper and his lower extremities. He continued to receive intravenous Dilantin. His Dilantin was 8.3 that day. His drain was kept at 15 cm. Later in the day on he had his AICD interrogated and it was found to be functioning normally. It is a single lead ICD. After his coiling procedure Mr. was placed on heparin. On Mr. was weaned from the ventilator and extubated. He tolerated his extubation without difficulty. CAT scan on showed a large amount of subarachnoid hemorrhage within the basilar cistern and third and fourth ventricles as well as the posterior . It appeared stable from previous CAT scans. There was a small amount of subarachnoid hemorrhage overlying the sulci bilaterally. The ventricular size appeared decreased compared with previous studies. Also on Mr. had periods of congestive heart failure. Chest x-ray showed failure. He was given Lasix and pan cultured and did better post receiving Lasix. He was started on tube feeds. He continued to have Nipride to keep his blood pressure in the below 130 range and he continued to receive heparin at 700 units an hour. At this point he had no positive cultures. On Mr. eyes would open spontaneously to stimulation. He showed his thumbs bilaterally, wiggled his toes bilaterally. He was receiving Lasix prn. He received Dilantin to have his Dilantin level greater then 10. He continued to have a drain in at 15 mm. Cerebral spinal fluid showed no microorganisms. He had been ruled out for an myocardial infarction. On his heparin drip was stopped and his femoral sheath was discontinued per Dr. . Cardiology also saw Mr. for his continuing problems with congestive heart failure and they felt that he was volume overloaded and they agreed to keep his volume status balanced and to aim for negative fluid balance. The patient had an echocardiogram and it showed his ejection fraction was 30 percent. At this point his cardiac medications included Coreg, Lipitor, Lisinopril, Nimodipine, Lopressor, Hydralazine, Lisinopril and Carvedilol. He was on a Nipride drip. During the evening of Mr. became more tachypneic and was reintubated at that time. His failure was unable to be controlled with Lasix and his CO2 was becoming very low and he ended up being reintubated without any problems. A head CT on showed stable appearance of his brain since his previous study. His examination on his left pupil was 2.5 to 2. His right pupil was the same. His ICTs were 8 to 11. He was wiggling his toes, would stick out his tongue, grasps were 4 to 6. His sodium was up from 145 to 148, which was felt to be due to his strict fluid balance. His cultures from showed a sputum with gram positive cocci in pairs. The only antibiotics he had been on at that point were Kefzol for his drain prophylaxis. On Mr. went back to the diagnostic angio suite and had a diagnostic cerebral angiogram, which showed no evidence of aneurysm, that his stent was patent and his coils were intact. On Levaquin was started due to continued fevers that Mr. has had since . On he was started and Levaquin due to gram positive cocci in his sputum. On his blood cultures showed 1 out of 2 gram positive cocci. He continued to have a fever without definitive cause. He had bilateral lower extremity ultrasounds, which were negative. Chest x-ray showed bilateral small effusion. His antibiotics were changed from Kefzol to Vancomycin to cover positive blood culture that he had. His Dilantin was changed to Depakote also trying to see if the source of the fever could be from Dilantin. He was started on Depakote 750 mg t.i.d. On the Mr. continued to spike fevers up as high as 101.7. At this point he would show his thumbs bilaterally. He would localize his right upper extremity, localized to 50 percent in his left upper extremity, withdrew both of his lower extremities. He seemed to be intermittently following commands somewhat more unresponsive. His drain was lowered to 8 to see if that would help with his alertness. An ID consult was obtained to see if the source of the fever could be obtained, which they recommended a chest CT and possible change of lines. They also added Ceftazidine and Flagyl to cover possible C-diff. He had an abdominal CT, which was negative and he had a chest CT on which showed a left sided pulmonary embolism and small to moderate bilateral pleural effusion. Also at this point on the 9th his mental status was slightly worsened. A pulmonary consult was obtained and it was recommended to start Mr. on a heparin drip with goal PTT of 50 to 60. We felt that the possible mortality of this pulmonary embolism was higher then the risks of intracranial bleeding so he was started on a drip at that point. On Mr. was only intermittently following commands. He squeezed weakly on the right. Attempt to squeeze on the left localized in his bilateral lower extremities. He continued to have the ventriculostomy drain at 15. We wanted to obtain an MRI of his head and C spine just to rule out a stroke or any problems with his cord that could be causing his decreased weakness and changes in mental status, however, given his AICD placement he was never able to have an MRI. Later it was felt to be more toxometabolic given his fevers and his pulmonary embolism and the severity of his subarachnoid hemorrhage all added together to cause him to have more of a decreased mental status later in his hospital course. He had periods of low sodiums. He had been placed on a sodium drip during the week of through intermittently. He had periods of CPAP and pressure support in attempt to wean his ventilator during this week also. He continued on empiric antibiotics of the Vancomycin, Ceftazidine and Flagyl. The Vanco was for his ventriculostomy drain for prophylaxis. His cultures from the week of through showed no growth. His C-diff was negative. Also during the week of he had periods of recurrent tachycardia and bigeminy and trigeminy at different points. On he had a percutaneous tracheostomy placed without any difficulty. At this point his fevers, temperature maximum was 99.4. He was withdrawing to pain. He would stick out his tongue. He had a weak grip on the right. Cardiology saw him regarding the tachycardia which they felt was related to high catecholamine state and to treat with beta blocker doses as tolerated. He continued to be on aspirin and beta blockers. CAT scan from showed interval decrease in the intraventricular and subarachnoid blood. He was continued to be attempted to wean from his ventilator. His heparin drip continued at a rate of 1800 units an hour for a goal PTT of 60 to 80. On Mr. was found not to really respond to noxious stimuli. He did not follow commands. His pupils were reactive. He did withdraw his right upper extremity. He did not withdraw his left upper extremity. He did withdraw both lower extremities. We got a stat head CT and we opened up his drain at 12 mm above the tragus and his head CT showed that it was stable, no new bleeding. Again we felt that his mental status changes are related to toxometabolic issues from his pulmonary embolisms, his fevers, which have now resolved and an electroencephalogram showed encephalopathy. On his intravenous antibiotics were discontinued and later in the day a lumbar puncture was performed. In order to check an opening pressure we felt that this current ICD monitor did not show an accurate reflection of his ICD given the amount of hydrocephalus that appeared on his CAT scan. However, his opening pressure was 12 and he was found to have normal pressure. On Mr. eyes opened to voice. He grimaced to noxious stimulus. He did not follow command localized in his right upper extremity, slight movement in his left upper extremity. He had slight withdraw with his left leg and was felt to have a left hemiparesis. On Mr. had a PEG tube placed without any difficulty. He had a normal gastric mucosa. No abnormalities were identified. On he had a head CT. There was persistent ventricular dilation not significantly changed from his prior studies. The week of Mr. was successfully weaned from the ventilator and tolerating a trach mask without any difficulty. On a repeat head CT showed stable appearance of his ventricular dilation. No change. On a repeat lumbar puncture was performed with an opening pressure of 10. Neurologically Mr. would open his eyes to stimulation. He would move his right side spontaneously. His toes were upgoing. He was not really following commands. DISCHARGE INSTRUCTIONS: Mr. receives the following care, he has a trach collar at 70 percent, which most likely can be weaned as tolerated. He receives Impact with fiber at 80 cc an hour. He has tolerated that without difficulty. He does have a central line in place. We will leave that in place upon discharge. He has been afebrile. His last fever was on . He is not currently on any antibiotics. His current medications include a heparin drip at a rate of 1250 units per hour. That may change prior to his discharge. His goal PTT is 40 to 50 that was lowered due to some increased hematuria. He is receiving Epoietin 4000 units sq two times a week on Tuesday and Saturday. Panadol 40 mg intravenous q 24, Indocin 2.5 mg po t.i.d., Metoprolol 25 mg po b.i.d., Valproic acid 100 mg po t.i.d. He should be weaned off the valporic acid over the next two weeks to off unless he shows any signs of seizure activity. Nystatin oral solution 5 ml po q.i.d., aspirin 325 mg po q day, Plavix 75 mg po q day. He should follow up with Dr. office in two weeks. He will call if you have any questions. He will be provided an appointment prior to his discharge. Under no circumstances should his heparin be stopped. He needs to continue on heparin, Plavix and aspirin until follow up with Dr. . He needs acute neuro rehab and physical therapy and occupational therapy. Mr. was discharged neurologically in stable condition, mentally responsive upon discharge. Mr. is positive VRE from one rectal swab so he has been on VRE precautions. , Dictated By: MEDQUIST36 D: 12:39:26 T: 14:56:18 Job#: "},"extractive_notes_summ":{"kind":"string","value":"PT NOTED TO HAVE BRIEF EPISODE OF APNEA AND STOKING RESPIRATIONS, ABG DRAWN-UNREMARKABLE, DR. AND NSURG INFORMED, CONT TO MONITOR.GI: ABD SOFT NT/ND, +BOWEL SOUNDS, TOLERATING TF AT GOAL AT 80CC/HR W/ MINIMAL RESIDUALS.GU: FOLEY DRAINING ADEQ U/O CLEAR PINK TINGED W/ SEDIMENTS.ID: TMAX 98.5PLAN: MONITOR VS, LABS, RESP STATUS, NEURO STATUS. 0500 cont pt resp status borderline wbc 16 rales sob i>o md made aware lasix and pan culture done well u/o ^^^ see notes less sob HEAD CT DONE THIS AMCV: AFEBRILE. VENT DRAINING SMALL AMT CLEAR FLUID THEN CLAMPED PER NSURG-LEVELLED AT 0CM ABOVE TRAGUS, ICP 0-9.CV: HR 70-80'S, NSR W/ FREQUENT PVC'S. ALBUTEROL NEB TX X2.GI: NPO, NGT TO LCWS WITH MOD AMT BILIOUS DRAINAGE. BS now with upper airway congestion on occassion. CONDITION UPDATE:D/A: T MAX 99.0NEURO: AROUSABLE TO VOICE, FOLLOWS COMMANDS, . Neo drip titrate to maintain SBP >120 - slowly weaning to off. FEBRILE TO 100.1 MAX.TOLERATING TUBE FEEDS AT GOAL RATE WITH MINIMAL RESIDUALS. WITHDRAWING W/ ALL 4 EXTREMETIES SLIGHTLY AND GRIMACES WHEN NOXIOUS STIMULI APPLIED TO NAILBED.CV: HR 76-92, NSR W/ PVC'S, SBP PARAMETERS >120, NEO GTT TITRATED ACCORDINGLY AND MIDODRINE 2.5MG PGT TID STARTED.CVP 6-12. DR. NOTIFIED.LUNGS COARSE BILAT. Patent blood-tinged drainage.CV: Remains Vpaced w/frequent PVCs/bigemeny noted as per pt's baseline. BS auscultated reveal bilateral coarse sounds which improve after suctioning. afebrile.resp; Clear/coarse lung sound. C-DIFF CULTURE WITH NEXT STOOL. Tmax 100, Tylenol w/effect. INITIALLY NSR WITH FREQUENT ECTOPI. CONTINUE ESMOLOL AT 100MCG TO MAINTAIN SR. MONITOR ECTOPI REPLETE LYTES AS INDICATED. extremities cool (baseline) and pink.IV'S: pt has 2 L PIV's perfusing well, triple lumen CVL with CVP attached- good wave forms + dressing CDI, A-Line CDI w/sharp wave forms, A-line sheath CDI with sharp wave forms.GI: pt's abdomen soft +hypo active BS x4. Cont on Neo to keep SBP 160-170.RESP: lungs coarse through out. CPT done x2.GI/GU: Med loose bm gauaic neg. Stool sent for c-diff. pt sedated and sbp down to 160's. pt remains on cmv at present time due to tachypnea.gi: abd ct neg per dr. . Received albumin x1 as albumin 2.9 and cont with 2-3+ pit edema.RESP: No changes. Ventriculostomy draining burgandydrainage. condition updateD;neuro: pt opens eyes to name. VENT REOPENED PER NEUROSURG TEAM AT 0 TRAGUS, ? titrate neo for sbp 160-170. titrate tf up to 70cc/hr.r: neuro is unchanged. AMBU/SYRINGE @ HOB. GROSS HEMATURIA SHOWN TO TEAM, DR. . TO 19/07 PT STATUS REMAINS AROSABLE TRIES TO TALK AT TIMES OPENS EYES TO COMAND WEAKNESS ALL EXTEMITIES PERIOD OF AGITATION RR 28 TO 30 PTPLACED BACK ON SIMV WITH RELIEF HEART S1S2 NSR WITH 2 TO DEPRESSION IN LEAD 2 PULSES POS 2 THRU OUT NEG NVD VSS ALINE CVP ICP WAVE FORMS WNL SEE FLOW SHEET RESP RONCHI THRU OUT CLEARD AFTER SUCTION SIMV FIO2 35% GOOD AIRATION GI POS BS T/F WELL SMALL RESIDUAL SMALL STOOL U/O QS NO ISSUES NEO 1.5 MCG/KILO/MIN BP 150 TO 170 PER ORDER HEPARIN TO TITRATE SKIN NOTE BUTT SL RED WITH SKIN OPEN AREA SUPPORTIVE CARE ROM TURN SIDE TO SIDE PUL TOILETING PT ON HEPARIN AT 1700U/HR.GI: PT TOLERATING TUBE FEEDINGS, MINIMAL RESIDUALS NOTED.GU: U/O 80-160CC/HR.F/E. Trach continues to ooze, swivel changed X2.ABG:metabolic alkalosis with hyperoxiaPlan: PSV during day as tolerated. AM ABG's 7.48/37/127/28, improvement noted. Tolerating well spont. VT decreased, periods of apnea, placed on a/c noc. LOOSE STOOL A FEW TIMES AND SENT FOR CULTURE.GU- UOP RANGING FROM 80-100CC/HR.ID- AFEBRILE BS ausucltated reveal bilateral aeration in apecies with diminished bases. STATUSD: MORE AWAKE WILL FOLLOW SOME SIMPLE COMMANDS..MOVES ALL EXTREM'S LF LEG MUCH WEAKER THAN RT MOVES BOTH ARMS EQUALLY..FEBRILEA: PERIP/CENTRAL LINE/URINE/VENT CULTURES SENT..MP ? secreations minimal bloody thick. Resp CarePt. HR 70'S-80'S WITH OCCASIONAL PVCS, NSR.RESP- LUNGS COARSE AT TIMES, RELIEVED BY SUCTIONING FOR THICK BLOODY SPUTUM. Ambu/syringe @ hob. 19/07 STATUS PT OPENS EYES TO COMANDS MAE LIMITED ON NO SEDATION PROGRESSIVE IMPROVMENT RESTS LONG PERIODS VSS CVP ICP WNL GOOD WAVE FORMS U/O QS RESP ON CPAP WITH PS VERY WELL RESP 12 TO 14 OCC RHOCHI CLEARS AFTER SUCTIONING .40% FIO2 SAT 99 HEART S1S2 FREQ PVC PNC PULSES +2 THRU OUT W/D NEG NVD NEG HJR NSR MILD ST DEPRESSION 2/3 MM GI POS BS STOOLING T/F WELL NO RESIDUALS T/P SKIN CARE WITH ROM THIS PM SPUTUM BLOOD SENT FOR CULTURES pt.remains on simv+ps ventilation,abg alkalotic, will wean as , has periods of increased rr. AT THIS TIME WAS FEBRILE TO 101.7. Trach care completed x4 d/t amount of secretions. STATUSD: NEURO ESSENTIALLY UNCHANGED..MORE LETHARGIC IN AFTERNOON..REMAINS ON NEO/HEPARIN GTT'SA: AFEBRILE..WEANED ON VENT TO IPS 5 C-PAP 5 SHORT TIME THAN TACHYPNEIC 30'S..PLACED ON IPS 8>> WELL..SUCTIONED THICK WHITE GOOD ABG'S..NEO UP & DOWN TO KEEP SBP 160/-170/'S GTT @ 1.0MCG AT PRESENT HEPARIN REMAINS @ 1700U WITH PTT 70'S..GOOD HUO'S..INCT SOFT BROWN STOOL..TF'S REMAIN OFFR: ESSENTIALLY UNCHANGEDP: CONTINUE TO MONITOR PTT/NA'S Q6H..NEURO SIGNS Q2H..? FEBRILE TO 101.5. CONTINUE TO MONITER NEURO AND RESPIRATORY STATUS. Remains on Flagyl, Vanco and Cefepime with Vanco and Cefepime in NS.GU: U/O qs via foley. RESTART TF'S K+ dropped to 3.6 -> rechecked and will replete per scale. ESMOLOL WEANED OFF SUCCESSFULLY AND IV LOPRESSOR STARTED. PT STILL NOT FOLLOWING COMMANDS.CV: HR 70-90'S, NSR W/ PVC'S, SBP>120 PER PARAMETERS-GOOD RESPONSE ON MIDODRINE 2.5MG TIS. HR 70'S WITH FREQUENT PVCS, NSR.RESP- LUNGS CLEAR WITH DIMINISHED BASES. NEED FOR LASIX..MAINTAIN SBP 120-150.R.STABLE AT THIS TIME WITH POSSIBLE EARLY SIGNS OF FAILURE. RESTARTED AND LP SITE MONITORED, NO OR DRAINAGECV- BP 120-140'S. REHAB TODAY. EKG done. O2 sats adequate on trach collar.Duoderm on coocyx changed. DOES BECOME HYPERTENSIVE WITH TEMP ELEVATION. NOTIFIED AND IVF DECREASED TO KVO. BS auscultated reveal bilateral clear apecies with diminished LS. BP PARAMETERS OF SBP 120-150 TO BE CONTINUED.. TEMP UP TO 100.8 FOR WHICH PT WAS CULTURED AND TYLENOL GIVEN. Patient was then started on nipride gtt to keep sbp<160. AM ABG's 7.48/36/151/28. Ambu/syringe @ hob. TMAX 99.0. STATUSD: NEURO ..REMAINS ON GTT @ 1250UA: VSS..GOOD HUO NO STOOL..PTT Q8H.. TRACH @ 70% SUCTIONED FOR MOD AMT THICK PINK TINGED/TAN SECREATIONSR: ESSENTIALLY P: TO GO TO REHAB TOMORROW..FAMILY AWARE To that end examination of the proximal portion of the stent with three-dimentional rotational angiography revealed that the proximal portion of the stent had been crimped on itself probably as a result of the highly calcific left vertebral artery. POSTOPERATIVE DIAGNOSIS: Same status post stent angioplasty of the intracranial vertebral artery and left segment followed by coiling of the wide-necked aneurysm with preservation of the flow in the left vertebral artery in the posterior circulation and obliteration of the aneurysm using endovascular coiling. Pulmonary artery systolichypertension.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a moderate risk (prophylaxis recommended). The left vertebral artery appears to be dominant and the basilar trunk is somewhat diffusely narrowed possibly as a result of the proximal atherosclerotic stenosis. There is moderateregional left ventricular systolic dysfunction with near akinesis of theinferior and inferolateral walls. There is mildpulmonary artery systolic hypertension."},"n_notes":{"kind":"number","value":127,"string":"127"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2165-06-25 00:00:00.000","description":"Report","row_id":1563068,"text":"CONDITION UPDATE\nD. THIS AM DESPITE ACCEPTABLE ABG'S ON BIPAP MASK,RR=36-44.DECISION TO INTUBATE MADE AND WAS PERFORMED BY ANESTHESIA AFTER PRE- SEDATION .ETT CONFIRMED BY CXR AND PT WAS STARTED ON PROPOFOL DRIP.ABG ACCEPTABLE POST INTUBATION(SEE FLOW SHEET FOR SETTINGS AND CHANGES).\n TEMP UP TO 100.9 OCCASSIONAL SHIVERING WITH SKIN SURFACE COOL.SR 70-90 WITH ECTOPY AT TIMES.RR= 14-22 ON VENT WITH O2 SATS=98 ON 40% FIO2. SBP 120-150.CVP MOST OF DAY .\n ONCE CARDIOLOGY EVALUATED PT ALONG WITH CURRENT DATA FROM CARDIAC ECHO,DECISION WAS MADE BY SICU TEAM AND CONFIRMING WITH CARDIOLOGY AND NEUROSURG TEAMS,PT WAS GIVEN LASIX WITH GREAT DIURETIC RESPONSE. CVP DECREASED TO 10.SBP PARAMETER WAS CHANGED THIS AM TO 140-150 PER DR. ALLOWING NIPRIDE TO BE WEANED OFF SINCE INTUBATION AND SEDATION ON BOARD.\n DESPITE PT BEING ON PROPOFOL 25MCQ,PT DOES RESPOND TO PAIN,MOVING ALL EXTREMITIES BUT NOT FOLLOWING COMMANDS.AFTER SCHEDULED HEAD CT SCAN THIS PM,NEURO CHECK WAS PERFORMED OFF OF PROPOFOL. PT FOLLOWED ALL COMMANDS,MOVING ALL EXTREMITIES. PT TO ATTEMPT TO EXTUBATE HIMSELF BUT PROTECTIVE WRIST RESTRAINTS PREVENTED THIS FROM OCCURING.ICP- AND DRAINING VARYING DEGREES OF RED COLOR.\n A.CHECK COMPLETE NEURO EXAMS Q 4-6 HRS PRN.MAINTAIN SBP 120-150.ICP TO REMAIN AT 15CM ABOVE TRAGUS AND OPEN .\nR.CONDITION REMAINS GUARDED.\n"},{"category":"Nursing/other","chartdate":"2165-06-26 00:00:00.000","description":"Report","row_id":1563069,"text":"RESPIRATORY CARE:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. Patient changed over to IMV this shift for a paco2 if 29.(goal range 35-40.) Current settings IMV/PS 700*12 40%fio2 with 5 peep and 5ps. Breathsounds are coarse. Please see respiratory section of carevue for further data. RSBI this am 62.2 Patients respiratory rate started to climb while doing RSBI.\nPlan: Continue mechanical ventilation. Wean as tolerated.\n"},{"category":"Nursing/other","chartdate":"2165-06-26 00:00:00.000","description":"Report","row_id":1563070,"text":"CONDITION UPDATE\n\nPROPOFOL STOPPED Q 4 HR FOR NEURO CHECKS PT FOLLOWS COMMANDS WITH APPROPRIATE MOVEMENT. NIPRIDE NOT NEEDED SBP < 150 MOST OF NOC.\n\n"},{"category":"Nursing/other","chartdate":"2165-06-26 00:00:00.000","description":"Report","row_id":1563071,"text":"CONDITION UPDATE\nD.TEMP SPIKE THIS AM TO 102 FOR WHICH LINE BC DRAWN AND TYLENOL WAS GIVEN.WITHIN 1 HR,SBP DROPPED TO 80,CVP=9(SCHEDULED ANTIHYPERTENSIVES WERE GIVEN DURING THIS HOUR). PT WAS DIAPHORETIC AT THIS TIME.SICU TEAM WAS NOTIFIED AND LR BOLUS OF 500ML WAS GIVEN ALONG WITH TURNING PROPOFOL OFF UNTIL BP RETURNED.SBP SLOWLY ROSE AND REMAINED 119-130/70.HYDRALAZINE WAS D/C'D.\n PT AWOKE TO GENTLY ATTEMPT TO REACH HIS ET TUBE AND PROPOFOL WAS RESTARTED.\n PT HAS BEEN ABLE TO FOLLOW ALL COMMANDS,MOVING ALL EXTREMITIES AND ATTEMPTING TO FORM WORDS WITH MOUTH WHEN OFF OF PROPOFOL.ON PROPOFOL TO WITHDRAWS EACH EXTREMITY TO PAIN.ICP 4-10 AND LESS BLOODY CSF.\n NO VENT CHANGES MADE.PT FOR MINIMAL SECRETIONS.\n WIFE AND SON IN TODAY AND UPDATE WAS GIVEN BY MYSELF AND THEN DR. .\nA.CONTINUE TOMAINTAIN SBP 120-150.TO ANGIO TOMORROW PM PER DR. FOR FOLLOW-UP.\nR.STABLE AT THIS TIME.\n"},{"category":"Nursing/other","chartdate":"2165-07-15 00:00:00.000","description":"Report","row_id":1563141,"text":"NEURO: PT OPENED EYES TO PAINFUL STIMULI X1, . NOT FOLLOWING COMMANDS, NO SPONT MVMT NOTED, WITHDRAWS ALL 4 EXTREMETIES TO NOXIOUS STIMULI APPLIED TO NAILBED. VENT DRAINING SMALL AMT CLEAR FLUID THEN CLAMPED PER NSURG-LEVELLED AT 0CM ABOVE TRAGUS, ICP 0-9.\n\nCV: HR 70-80'S, NSR W/ FREQUENT PVC'S. SBP PARAMETERS 160-180, REMAINS ON NEO GTT AND TITRATED ACCORDINGLY. HEP GTT REMAINS ON, PTT GOAL 40-50.\n\nRESP: LUNG SOUNDS DIMINISHED, O2 SAT >95% ON TRACH COLLAR AT 50%. SXN PRN FOR THICK BLOOD CLOTS AND TAN SECRETIONS. PT NOTED TO HAVE BRIEF EPISODE OF APNEA AND STOKING RESPIRATIONS, ABG DRAWN-UNREMARKABLE, DR. AND NSURG INFORMED, CONT TO MONITOR.\n\nGI: ABD SOFT NT/ND, +BOWEL SOUNDS, TOLERATING TF AT GOAL AT 80CC/HR W/ MINIMAL RESIDUALS.\n\nGU: FOLEY DRAINING ADEQ U/O CLEAR PINK TINGED W/ SEDIMENTS.\n\nID: TMAX 98.5\n\nPLAN: MONITOR VS, LABS, RESP STATUS, NEURO STATUS. AWAITING PEG PLACEMENT. CONT CURRENT MGMT.\n\n\n"},{"category":"Nursing/other","chartdate":"2165-07-16 00:00:00.000","description":"Report","row_id":1563142,"text":"Resp Care\nPt. remains on 50% cool aerosol mask tolerating well. ABG: adequately oxygenated with a metabolic alkalosis.\nBs: equal bilat. coarse secreations minimal, pt. has strong cough. Inner cannula patent with ess. equipment at bedside.\n"},{"category":"Nursing/other","chartdate":"2165-07-16 00:00:00.000","description":"Report","row_id":1563143,"text":" \"N\" Nsg Progress Note:\n\nCVS: Pulses present. Skin cool and dry. Afebrile. HR=79-89 NSR with quadrigeminy. SBP=165-177 with IV Neo drip titrate to keep SBP between 160 and 180. Currently at 3mcg/kg/min. IV drip at 1200u/h goal to keep PTT=40-60. CVP=. ICP=.\n\nNeuro: Pt is minimally responsive. Opens eyes slightly with stimulation. No movements of extremities. No grimacing. No seizure activity.\n\nResp: Trach collar with 50% O2 tolerated well. Bloody secretions noted. Sats=99-100%. RR=30's mostly. Lung sounds clear but diminished at bases.\n\nSkin: Small ecchymotic areas on torso and rt arm. Peri area slightly reddened-aloe ointment applied. Coccyx area shows small purple area but no breakdown as yet, on air mattress.\n\nGI: +bowel sounds. Incontinent soft brown stool, guaiac -. TF at goal of 80cc/h of Impact with fiber.\n\nGU: U/O=90-140cc/h.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2165-07-16 00:00:00.000","description":"Report","row_id":1563144,"text":"NEURO: PT UNABLE TO OPEN EYES, NOT FOLLOWING COMMANDS, NO SPONT/PURP MVMTS OBSERVED. PT WITHDRAWING TO NOXIOUS STIMULI APPLIED TO NAILBED. VENT REMAINS AT 0CM ABOVE TRAGUS, DRAINING CLEAR FLUID, ICP 1-7. HEAD CT DONE TODAY AND LP DONE W/ OPENING PRESSURE 12.\n\nCV: HR 70-80'S, NSR W/ PVC'S, SBP 160-170'S-NEO TITRATED TO KEEP SBP160-180, CVP 2-9. HEP GTT STOPPED FOR LP.\n\nRESP: REMAINS ON 50% O2 ON TRACH COLLAR W/ SATS 98-100%. LUNG SOUNDS COARSE. SXN PRN FOR THICK SPUTUM. IRREGUALR RESP PATTERN.\n\nGI: ABD SOFT/NT/ND, +BOWEL SOUNDS, TOLERATING TF IMPACT W/ FIBER AT 80CC/HR AT GOAL W/ MINIMAL RESIDUALS.\n\nGU: FOLEY DRAINING ADEQ U/O, CLEAR YELLOW URINE.\n\nID: TMAX 97.9\n\nPLAN: MONITOR VS, LABS, RESP STATUS, NEURO STATUS. PT CONSULT DONE TODAY, CASE MGMT CONSULT PENDING. AWAITING PEG PLACEMENT\n\n"},{"category":"Nursing/other","chartdate":"2165-07-17 00:00:00.000","description":"Report","row_id":1563145,"text":"Resp Care\nPt. on 40% cool aerosol tolerating well with spo2 99%. RR 20-30.\nBs: coarse with occ. rhonchi sxn'd for copious bloody thick plugs. Also pt. has strong cough and occ. expectorates independantly. Inner cannula changed and patent. Will follow.\n"},{"category":"Nursing/other","chartdate":"2165-06-23 00:00:00.000","description":"Report","row_id":1563061,"text":"CONDITION UPDATE\nNEURO: PROPOFOL OFF AT 0800. PT OPENS EYES TO COMMAND, MAE ON BED TO COMMAND. ICP 4-14. VENT DRAIN AT 15 ABOVE TRAGUS WITH MOD AMT BLOOD TINGED DRAINAGE. SPEECH DIFFICULT TO UNDERSTAND POST-EXTUBATION. ORIENTED TO PERSON, STATES HE IS AT . HEAD CT DONE THIS AM\nCV: AFEBRILE. SNP TITRATED TO MAINTAIN SBP 100-130 PRESENTLY ON 0.75 MCQ/KG/MON. PT GIVEN EXTRA DOSE OF HYDRALAZINE IV AT 1600. SEE CAREVUE FOR SPECIFICS\nRESP: PT WEANED AND EXTUBATED BY 1400. OPEN FACE TENT WITH GOOD ABG AND SATS. BS COARSE. CPT DONE X 1. COUGHING BUT NOT RAISING\nGI: TF HELD PRIOR TO EXTUBATION. ABD SOFT AND NON-TENDER, +BS\nGU: CLEAR YELLOW VIA FOLEY IN ADEQUATE AMTS\nENDO: NO ISSUES\nA: NEURO STATUS MONITORED, NIPRIDE TITRATED AS ORDERED, HEAD CT DONE, EXTUBATED\nR: EXTUBATION, IMPROVING NEURO STATUS- CONTINUE TO MONITOR CLOSELY\n"},{"category":"Nursing/other","chartdate":"2165-06-23 00:00:00.000","description":"Report","row_id":1563062,"text":"Respiratory Care Note:\n Patient weaned and extubated after repeat head CT was cleared. He coughs and follows basic commands but still appears sleepy. Propofol off since app 8am. BS now with upper airway congestion on occassion. No wheezing noted. He is on a continuous cool aerosol at 40% via face tent with good abg results. See Carevue flowsheet. Plan to help with pulmonary hygiene as needed.\n"},{"category":"Nursing/other","chartdate":"2165-06-24 00:00:00.000","description":"Report","row_id":1563063,"text":" cont of previous note 0010 pt increase agitation remains alert denies pain resp rapid rate 28 to 32 chest clear vss icp wnl moving hands around picking md brought to bedside to help with eval abg done wnl for pt chest xray mso4 given far response supportive care gradual improvment\n plan wean nipride pt/ot\n\n\n"},{"category":"Nursing/other","chartdate":"2165-06-24 00:00:00.000","description":"Report","row_id":1563064,"text":" 0500 cont pt resp status borderline wbc 16 rales sob i>o md made aware lasix and pan culture done well u/o ^^^ see notes less sob\n"},{"category":"Nursing/other","chartdate":"2165-06-24 00:00:00.000","description":"Report","row_id":1563065,"text":"CONDITION UPDATE:\nD/A: T MAX 99.0\n\nNEURO: AROUSABLE TO VOICE, FOLLOWS COMMANDS, . AWARE OF PERSON AND PLACE, NOT TIME. PAIN X1 TREATED WITH MORPHINE WITH GOOD EFFECT. MAE'S, STRENGTHS EQUAL, STRONG. SPEAKING APPROPRIATELY WITH WIFE. VENTRICULOSTOMY REMAINS @ 15 CM ^ TRAGUS WITH ICPS . CPP AT ~ 55-70 WITH THE TIGHT BLOOD PRESSURE PARAMETERS, PA CHIP AWARE.\n\nCV: HR 70'S-104 LOPRESSOR X2 WITH + EFFECT. PT WITH RESP DISTRESS/CHF PER CHEST XRAY. LASIX X1 IN AM WITH EXCELLENT EFFECT (1 LITER OUT IN FIRST HOUR). IN AFTERNOON LASIX X1 AGAIN, NOT AS EFFECTIVE, ~ 280 CC'S OUT WITH RESP DISTRESS CONTINUING. GOAL ABP 100-120 MET WITH TITRATION OF NIPRIDE ALONG WITH ATC ANTIHYPERTENSIVE MEDS. NIMDIPINE TRANSIENTLY DROPS PT'S PRESSURE TO 80'S AND THEN RETURNS TO PREVIOUS LEVEL. MN-1700 FLUID BALAND -1000 CC'S. HEPARIN GTT D/C'D THIS AM, RIGHT FEMORAL SHEATH D/C'D ~ 1200. PT BE SITTING MORE UPRIGHT @ 1800.\n\nRESP: LS COARSE/DIFFICULT TO AUSCULTATE AS PT MAKES UPPER AIRWAY NOISE THAT REVERBERATES THROUGHOUT LUNGS. ? STRIDOROUS? ABG 0800: 7.42, 33, 98, 22, -1. IN AM PT'S RESP DISTRESS PICTURE IMPROVED WITH LOPRESSOR AND LASIX. IN AFTERNOON PT PRESENTED AGAIN WITH INCREASE RR TO 40'S, O2 SATS TO ~ 90%, LOPRESSOR AND LASIX GIVEN WITH POOR EFFECT, PT WITH COOL NEB FACE TENT, ABG: 7.46, 31, 76, 23, 0, 97. HIGH FLOW HUMIDIFIED SYSTEM APPLIED WITH O2 SATS IMPROVING TO ~ 96%, HOWEVER RESP RATE CONTINUES TO BE ~ 40. REPEAT ABG PENDING.\n\nGI: TUBE FEEDS STOPPED PER DR. DUE TO POOR RESP PICTURE. + BS, NO BM. ~ 100 CC'S OUT OF NGT.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\n\nSX: WIFE AND SON VISITING AND UPDATED BY DOCTORS.\n\nR: LOW GRADE TEMP, WITH POOR RESP STATUS AND CHF. IMPROVED NEUROLOGICAL STATUS.\n\nP: CONTINUE CLOSE MONITORING AND MANAGEMENT. ? INTUBATION IF RESP EFFORT REMAINS LABORED. ECHO ORDERED, UNABLE TO OBTAIN TODAY ( DAY). ? PLACE PA CATHETER TO ADRESS FLUID STATUS MORE CLOSELY IF RESP/CV PICTURE DOES NOT IMPROVE. CONTINUE TO TITRATE NIPRIDE GTT FOR GOAL SBP 100-120. LAST SET OF CARDIAC ENZYMED DUE @ MN. PT AND FAMILY SUPPORT.\n"},{"category":"Nursing/other","chartdate":"2165-06-25 00:00:00.000","description":"Report","row_id":1563066,"text":"CONDITION UPDATE\nNEURO: OPENS EYES TO NAME, ORIENTED TO SELF ONLY, ASKING WHY HE IS IN THE HOSPITAL, FOLLOWS COMMANDS- MAE WITH EQUAL STRENGTH, ICP 4-14, VENT AT 15CM ABOVE TRAGUS WITH MOD AMT BLOOD TINGED DRAINAGE. SPEECH CLEARER THAN YESTERDAY. SNP GTT TITRATED TO MAINTAIN SBP 100-120.\nCV: T MAX 99.8, HR ELEVATED TO 104- LOPRESSOR 10MG IV GIVEN WITH SUBSEQUENT DROP TO 70-80'S, PT HAVING FREQUENT PVC'S.\nRESP: PT ON HIGH FLOW MASK AT BEGINNING OF SHIFT. RESP LABORED WITH SATS 93-95%, PT CHANGED TO CPAP MASK WITH 15 IPS WITH IMPROVEMENT IN SATS BUT RESP RATE STILL REMAINS ELEVATED IN HIGH 20'S-35. ALBUTEROL NEB TX X2.\nGI: NPO, NGT TO LCWS WITH MOD AMT BILIOUS DRAINAGE. ABD SOFT AND NON-TENDER WITH +BS\nGU: NO LASIX THIS SHIFT, HUO 28-60\nA: NEURO STATUS AND RESP STATUS MONITORED, NT SX X 1 FOR SM AMTS THICK TAN SECRETIONS.\nR: RESP STATUS REMAINS GUARDED- CONTINUE TO MONITOR SATS AND ABGS_ ? INTUBATE\n"},{"category":"Nursing/other","chartdate":"2165-06-25 00:00:00.000","description":"Report","row_id":1563067,"text":"resp care\npt re-intubated this shift d/t imp resp fail. oett #7.5 secured 23cm @lip. oett plcmnt confirmed via +etco2, cxr. pt placed on vent, see carevue for settings/changes. pt tx w/o incident to /from ct scan. b/s coarse sxn thk tan, spec sent to lab. plan: cont w/mech support.\n"},{"category":"Nursing/other","chartdate":"2165-07-17 00:00:00.000","description":"Report","row_id":1563146,"text":"7a-3p\nneuro: , withdraws to pain, no response to command, vent dc'd @ 1145, no change in nuero status post removal, to have head ct tomorrow\n\ncv: hr nsr, occasional pvc's, sbp 148-164, continues on neo gtt, goal sbp 150-170, continues on po lopressor\n\nresp: on 50% trach collar, rr 20-38, sat 100, sux mod amt thick bld tinged tan sputum, pt coughing productively, no resp distress noted\n\ngi: goal tf well, no stool, po prevacid, tf off for bedside PEG @ 1600\n\ngu: foley patent, clear yellow urine, good uo\n\nother: gtt continues @ 1200u/hr, to be dc'd @ 1500 for PEG insertion, family in & updated on pt's condition,\n\nplan: continue to monitor respiratory/neuro status, head ct in am, possible vp shunt\n\n\n"},{"category":"Nursing/other","chartdate":"2165-07-18 00:00:00.000","description":"Report","row_id":1563147,"text":"NPN 0700-1500;\nNEURO; OPENS EYES OCCASSIONALLY TO NOXIOUS STIMULI PERLA 3MMREACTS BKS.WITH DRAWS TO PAIN LT MORE THAN RT.GRIMACES OCCASSIONALLY WITH PAIN BUT NOT CONSISTENTLY.TRAVELLED FOR CT THIS AM AWAITING RESULTS.\n\nRESP;LUNGS COARSE, IRREG BREATHING AT TIMES SUCTIONED FOR PROFUSSE AMIUNTS THICK BEIGE SECRETIONS Q3. STRONG PRODUCTIVE COUGH POS GAG.SATS 97%-\n\nCVS; 96.5 PO NSR WITH OCCASIONAL PVC. PT WITH . WEANING NEO FOR SYS BP GREATER THAN 120 SLOWLY,\n\nGU ; MOD DIURESIS THROUGH FOLEY.\n\nGI POS BS NO FLATUS NO STOOL. STARTED T/F VIA PEG,IMPACT WITH FIBRE AT 10 MLS TO ADVANCE 10 CC /HR Q4 TO GOAL OF80 MLS/HR. BS ON RISS NPH 2UNITS THIS AM AS BS 80S BS AT 12 93.\n\nINTEGRUM UNCHANGED DUODERM INTACT OVER COCCYX.\n\nSOC; WIFE INTO VISIT AND UPDATED WITH CURRENT CONDITION SPOKE WITH CASEMANAGER ABOUT BEING SCREENED BY \n\n"},{"category":"Nursing/other","chartdate":"2165-07-18 00:00:00.000","description":"Report","row_id":1563148,"text":"RESPIRATORY CARE\nPt remains on 40% Trach Mask, transported to and from CT. Aerosol maintained.\n"},{"category":"Nursing/other","chartdate":"2165-07-19 00:00:00.000","description":"Report","row_id":1563149,"text":"7p-7a; Full assessment in flow sheet.\n\nneuro; Only respond to painful stimuli - stronger withdrawal to pain on the right versus left side. Slight movement of ext - inconsistent movement. Do not open eyes. do not follow commands. Do not track. - 3 mm brisk. Good gag and cough reflex. head dressing site d/c/i.\n\ncv; NSR with PVC. Neo drip titrate to maintain SBP >120 - slowly weaning to off. warm, dry, no edema. afebrile.\n\nresp; Clear/coarse lung sound. Trach collar - 40% - SaO2 >100%. Trach care done. Productive cough - moderate thick/tan sputum.\n\ngu/gi; soft abd. +BSX4. no bm. G-tube - site d/c/i, +placement, minimal residual - working to goal of TF at 80 cc/hr.\n\nPlan; Continue to monitor.\n"},{"category":"Nursing/other","chartdate":"2165-07-19 00:00:00.000","description":"Report","row_id":1563150,"text":"NEURO: NOTICED PT OPEN EYES VERY SLIGHTLY X1 ONLY HOWEVER UNABLE TO FOLLOW COMMANDS NOR MOVE EXTREMETIES SPONT/PURP. WITHDRAWING W/ ALL 4 EXTREMETIES SLIGHTLY AND GRIMACES WHEN NOXIOUS STIMULI APPLIED TO NAILBED.\n\nCV: HR 76-92, NSR W/ PVC'S, SBP PARAMETERS >120, NEO GTT TITRATED ACCORDINGLY AND MIDODRINE 2.5MG PGT TID STARTED.CVP 6-12. HCT 28.7, VERIFIED. TRANSFUSED 1U PRBC'S.\n\nRESP: LUNG SOUNDS COARSE, O2 SAT 98-100% ON 50% VIA TRACH COLLAR. SXN PRN FOR THICK GREEN TINGED SPUTUM, PT ALSO ABLE TO EXPECTORATE AT TIMES.\n\nGI: ABD SOFT NT/ND, +BOWEL SOUNDS, TF IMPACT W/ FIBER INFUSING VIA PEG-GOAL 80CC/HR PRESENTLY AT 60CC/HR W/ MINIMAL RESIDUALS.\n\nGU: U/O BORDERLINE, CLEAR CONCENTRATED URINE. DR. INFORMED, CONT TO MONITOR.\n\nID: TMAX 97.9.\n\nPLAN: MONITOR VS, LABS, RESP STATUS, NEURO STATUS. CONT CURRENT MGMT.\n"},{"category":"Nursing/other","chartdate":"2165-07-02 00:00:00.000","description":"Report","row_id":1563091,"text":"Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. Patient vent mode changed over to A/C in CT as they were having trouble with synchrony and hypertension. Patient transported to CT with vent without incident. Unable to change patient back over to imv as his respiratory rate increased into the 40's. RSBI this am was 150. Breathsounds are decreased. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation. Wean as tolerated.\n"},{"category":"Nursing/other","chartdate":"2165-07-07 00:00:00.000","description":"Report","row_id":1563109,"text":"RESP CARE NOTE:\n\nPT CONTINUING ON A/C VENT 15, 35%, 400,5 PEEP. TRIED RSBI BUT RR QUICKLY ROSE TO HIGH 40'S AND B/P INCR. CURRENT PLAN IS TO CONTINUE SETTINGS AND PT TO REST. SUCTIONED THIS SHIFT FOR MOD AMT OF VERY THICK WHITE SPUTUM. PT OFTEN BITES ETT MAKING SUCTIONING DIFFICULT .\n"},{"category":"Nursing/other","chartdate":"2165-07-08 00:00:00.000","description":"Report","row_id":1563114,"text":"NPN\n PT NOT OPENING EYES TODAY HOWEVER IS OCCASIONALLY FOLLOWING COMMANDS TO WIGGLE TOES, SQUEEZE HAND. RIGHT HAND SPONTANEOUSLY MOVING, FEET ALSO SPONTANEOUSLY MOVING ON BED. PERRL, 3-4MM. ICP 2-13 DEPENDING ON STIMULI, CLAMPING TO REPOSITION, ETC. VENT DRAINING DARK RED, ABOUT 20-30CC FOR THE SHIFT.\nCV- BP STAYING BETWEEN 160-180'S WITH LOW DOSE OF NEO. HR 70-80'S WITH MULTIPLE PVCS. SODIUM GTT INCREASED TO 20CC WITH NA CHECKED Q2HRS WITH MOST RECENT BEING 131. DR. UPDATED.\nRESP- VENT CHANGED BACK TO SIMV THIS AM DUE TO LONG PERIODS OF APNEA ON CPAP SETTING. ABGS CHECKED AND PT CONTINUES TO BE SLIGHTLY ALKALOTIC, WILL CONTINUE TO MONITOR. LUNGS CLEAR, SUCTIONED INFREQUENTLY FOR THICK CLEAR SPUTUM. MD SPEAKING TO FAMILY ABOUT POSSIBLE TRACH TOMMORROW.\nGI/GU- ABD SOFT, TF AT GOAL WITH MINIMAL RESIDUALS. FOLEY DRAINING LARGE AMOUNTS OF CLEAR URINE, 100-300CC/HR\nID- LOW GRADE TEMP THIS AM. CONTINUES ABT.\nSOCIAL- FAMILY IN TO VISIT, SPOKE WITH MD\n"},{"category":"Nursing/other","chartdate":"2165-07-09 00:00:00.000","description":"Report","row_id":1563115,"text":"D PT MINIMALLY RESPONSIVE. OPEN EYES ONLY ONCE FOLLOWED COMMANDS INCONSISTANT5LY MOVES ARMS UP AND DOWN LIFTING OFF BED AT TIMES MOVES LEGS ONLY SLIGHTLY ON BED. . NS 3% AT 20CC OFF AT 5AM.NA 135. ICP 2-5.\nCV: PT. INITIALLY NSR WITH FREQUENT ECTOPI. BIGEMINI AND TRIGEMINEY. NEO AT 1.25-1.20 MCG/KG/MIN. AT ABOUT 2300 PT IN POSSIBLE SVT ECG DONE HR >130 AND MAINTAINED FOR > 30MIN . ATTEMPTED TO VALSALVA BY SUCTIONING ET AND ORAL WITH OUT EFFECT. HO AT BED SIDE DILTAZIEM 10MG GIVEN . SBP DROPPED . RESIDENT/INTERNAL AT BED SIDE. LOPRESSOR 5MG GIVEN 5-10MIN APART. WITH SOME EFFECT. HR DOWN TO TEENS THEN 90 FOR SHORT TIME THEN BACK UP ESMOLOL BOLUSED AND STARTED AT 100MCG/KG/MIN SVT CONVERTED TO NSR WITH FREQUENT ECTOPI. BOLUS 500CC NS.TEMP MAX 101.8 RECTAL PAN CULTURED INCLUDING OBTAINED BY NEURO.\nLUNGS: COARSE THROUGHOUT,SUCTION FOR SMALL TO MOD WHITE THICK SPUTUM.\nGI: ABD SOFT BS PRESENT TF STOPPED AT MN RESIDUALS < 20.\nGU: FOLEY TO C/D OUTPUT > 100 AN HOUR.\nSKIN: COCCYX WITH DUODERM NO OTHER SKIN REDDNESS OR BREAKDOWN NOTED.\nA PT SVT RESOLVED NSR ON ESMOLOL AND NEO .\nP CONTINUE TO MONITOR NA Q2H.X4 . 3% NA OFF IF NA DROPPES TO 130 AGAIN RESTART 3%. CONTINUE SODIUM TABS. CONTINUE NEO TO MAINTAIN SBP 160-180. CONTINUE ESMOLOL AT 100MCG TO MAINTAIN SR. MONITOR ECTOPI REPLETE LYTES AS INDICATED. POSSIBLE TRACH TODAY HAS REMAINED NPO. SEE CARE VIEW FOR SPECIFICS\n\n"},{"category":"Nursing/other","chartdate":"2165-07-02 00:00:00.000","description":"Report","row_id":1563092,"text":"FOCUS: STATUS UPDATE\nDATA:\nPATIENT VERY EASILY AROUSABLE TO VOICE THIS AFTERNOON. PUPILS EQUAL AND REACTIVE TO LIGHT. LIFTING AND HOLDING BILAT ARMS PURPOSEFULLY AND TO COMMAND. MOVING FEET TO COMMAND. AT TIMES NODDING OR SHAKING HEAD TO QUESTIONS. VENTRICULAR ELEVATED TO 15CM ABOVE TRAGUS. ICP <10 WITH DARK BLOOD TINGED DRAINAGE.\n\nNEOSYNEPHRINE IV DRIP ON AND OFF FOR BLOOD PRESSURE LESS THAN 150. OK PER DR. TO TOLERATE BP MIN 150SYSTOLIC AS LONG AS NEURO EXAM UNCHANGED. PATIENT REQUIRED NICARDIPINE WHILE DOWN AT CAT SCAN DUE TO HYPERTENSION TO 190'S. MULTIPLE PVC'S AND CONSISTENT BIGEMINY WHILE IN CT SCAN. DR. NOTIFIED.\n\nLUNGS COARSE BILAT. CONTINUES ON AC VENT--NO CHANGES TODAY. SATS 99-100%. CHEST CT DONE WITH PRELIMINARY RESULTS CONSISTENT WITH L PE.\nSUCTIONED FOR MINIMAL AMOUNTS WHITE SECRETIONS. FEBRILE TO 100.1 MAX.\n\nTOLERATING TUBE FEEDS AT GOAL RATE WITH MINIMAL RESIDUALS. NO BM.\n\nPLAN:\nSTART HEPARIN DRIP FOR PE PER DR. . C-DIFF CULTURE WITH NEXT STOOL. SPUTUM CULTURE. MAINTAIN BP 150-170 WITH ACCEPTABLE NEURO EXAM.\n\n\n"},{"category":"Nursing/other","chartdate":"2165-07-03 00:00:00.000","description":"Report","row_id":1563093,"text":"Nursing note:\nNEURO: Opens eyes to voice, nodding yes/no to questions. Following simple commands. PERRLA 4-5mm and brisk. Moves all extremities purposefully. Lifts/falls w/upper extremities, wiggles bilateral feet on bed. Grasps equal. Ventricular @15cm above tragus, ICP 8-11. Patent blood-tinged drainage.\nCV: Remains Vpaced w/frequent PVCs/bigemeny noted as per pt's baseline. SBP kept 150 or > w/acceptable neuro exam w/aid of Neo gtt. Titrated up to 3.5mcg/kg/min, nsurg PA aware. SBP does drop w/Nimodopine. Neuro status remains unchanged w/drops below 150 systolic. Sodium 129 from 135, NACL 3% gtt begun w/Sodium levels to be checked q2 hours. Begun on salt tabs as well. Palpable pulses. Skin warm and diaphoretic at times. Tmax 100, Tylenol w/effect. Heparin gtt increased for sub-therapeutic PTT per Nsurg. Vanco levels sent.\nRESP: No vent changes overnight, ABGs acceptable. Suctioned for small amounts thick yellow sputum, specimen sent to cx.\nGI: Abdomen softly distended, +bowel sounds and flatus. Minimal stool via FIB. Tolerating tube feeds via NGT w/minimal residuals.\nGU: Foley patent large amounts light yellow urine.\nENDO: Glucose levels stable, insulin per sliding scale PRN.\nSOCIAL: Wife called and updated.\n\nA/P: Neuro stable. SBP labile, frequent drops in pressure requiring increases in Neo, Nsurg aware. Hyponatremic, begun on 3% sodium gtt. Cont. on Heparin gtt for presumed PE. Cont. current plan of care, follow lytes, coags, maintain SBP 150-170.\n"},{"category":"Nursing/other","chartdate":"2165-07-07 00:00:00.000","description":"Report","row_id":1563110,"text":"nuero: at 1200 pt did open his eyes when you called his name, pt did follow commands pt did squeeze my hands on right and left hand, pt did stick out his tongue. no spontanoues movement noted from legs. at other times pt not following commands or opening eyes(please see nuero flow sheet for nuero assessment). pt does withdraw all four extremties to painful stimuli. vent. raised to 15cm above tragus, draining blood tinged csf. pupils remain equal and reactive to light.\n\nlungs: lungs coarse at bases. pt on cpap with ps. suctioning pt for yellowish secretions.\n\ncards: pt remians in sr, with frequent pvcs. pt diaphrotic at 1200, dr. called and aware, ekg done, dr. assessed ekg. iv neo remians on to keep sbp b/w 170-180.\n\ngi: tube feeding at goal, minimal residuals.\n\ngu: u/o has been over last couple of hours 300cc/hr, dr. aware.\n\nf/e na 130, na rechecked result pending, if less than 130 to start 3% na gtt. blood sugar 148 recieved 8nph and 6u of regular insulin per sliding scale.\n\nplan: continue to monitor nuero status, pulm status, blood sugars, check na. possibe trach on tuesday.\n"},{"category":"Nursing/other","chartdate":"2165-07-07 00:00:00.000","description":"Report","row_id":1563111,"text":"Respiratory Care\nPt remains mechaniclly ventilated, placed on CPAP/PSV this morning. Suction for small amounts of pale white secreations. Breath sounds equal. Pt maintaining consistant spontaneous RR/Vt.\n"},{"category":"Nursing/other","chartdate":"2165-07-07 00:00:00.000","description":"Report","row_id":1563112,"text":" 19 to 07\n\n status unchanged random motion of extemites with pain or loud stimulus only basicly deeply letargic on cpap well icp 4 to 5 good wave form at 15 cm dark red csf\n\n resp wnl thick yellow sputum on cpap .35 fio2 clear after suctioning no issues\n\n heart s1s2 murmur sys nsr pvc st depression 2to 3 mm noted in in lead 2 pulses pos 2 thruout\n\n gi pos bs neg hem tf well no residual\n\n supportive care t/p butt care duo in place side to side only all lines wnl good waves passive rom done\n"},{"category":"Nursing/other","chartdate":"2165-07-08 00:00:00.000","description":"Report","row_id":1563113,"text":"Resp care Note:\n\nPt has been on Cpap/PSV all night and contiues on this at present. RSBI was done this am and was 141 afte full minute on\n"},{"category":"Nursing/other","chartdate":"2165-06-22 00:00:00.000","description":"Report","row_id":1563056,"text":"condition update\nSee ICU flowsheet for specifics\nNeuro: pt's pupils are equal and reactive to light stimuli, able to follow simple commands (to move hands/feet) at times after relaxed- pt has trouble following commands after movement. Pt has good grip strength in hands, can push with feet. Pt sedated per team with propofol. Vent drain at 15cms above tragus- draining small amounts of blood tinges fluid.\nCV: Team would like bp b/t 100-120 systolically- pt is on nitroprussin @ 2.50mcg/kg/hr to maintain bp below 120; bp will increase post suctioning and with turning. Hydralazine 10g was given x 1 with adequate effect- pt will now receive OTC doses. HR70's-80's NSR with random PVC's throughout the day. Oral beta blockers/anti hypertensives admin in the am a/o. +d/p pulses with dopplar- q2 hours. +radial r/l pulses. extremities cool (baseline) and pink.\nIV'S: pt has 2 L PIV's perfusing well, triple lumen CVL with CVP attached- good wave forms + dressing CDI, A-Line CDI w/sharp wave forms, A-line sheath CDI with sharp wave forms.\nGI: pt's abdomen soft +hypo active BS x4. NG tube was to LWS during day draining lg amts of Bilious drainage. Started TF-impact with fiber @10cc/hr at 1500- pt appears to be tolerating well; will increase rate 10cc q 4hrs until a goal of 70.\nSkin: occlusive dsg on scalp cdi with small amounts sersang staining.\nFamily : very supportive and at bedside most of afternoon- very appropriate.\n"},{"category":"Nursing/other","chartdate":"2165-06-22 00:00:00.000","description":"Report","row_id":1563057,"text":"Respiratory Care Note\n Patient remains intubated and sedated on propofol on full ventilatory support. FIO2 weaned to 40%. See Carevue flowsheet for specifics. BS bilat, coarse over RUL. Suctioned for med amounts of tannish sputum. Plan to maintain on A/C overnight.\n"},{"category":"Nursing/other","chartdate":"2165-06-22 00:00:00.000","description":"Report","row_id":1563058,"text":" to to 07\n nuro status improving opens eyes to comands helps to turn self in bed mae tries to talk around ettnote pt becomes agitated wants tube out very clearly during bp becomes elevated md made aware for tonight may increase propofol to sedate nipride for bp sys 110\n heart s1s2 mumur sys pules +2 neg nvd nsr pvcs at times\ncvp fem and arterial a line wnl note icp 8to 15 depending on agitation good wave pattern se notes\n resp ett scant secreations light yellow .40% fio2 rate 12\n gi tube feeding well small residual\n supportive care\n\n"},{"category":"Nursing/other","chartdate":"2165-06-22 00:00:00.000","description":"Report","row_id":1563059,"text":" note pt hard to manage bp elevated agitation remains u/o down i>o md made aware mane morphine and bp meds to be changed see orders\n\n\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2165-06-23 00:00:00.000","description":"Report","row_id":1563060,"text":"RESP CARE\nPT remains intubated and ventilated. Curent settings are A/C 750x12 35% 5peep with peak/plat 24/18. Bs coarse but clear. Suct for a small amt of thick white sput. in fio2 to 35% with good sats. RSBI done=53. Will follow as needed.\n"},{"category":"Nursing/other","chartdate":"2165-07-14 00:00:00.000","description":"Report","row_id":1563135,"text":"Resp: pt on psv 5/5/40%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral coarse sounds which improve after suctioning. Suctioned moderate amounts of bloody thick secretions. Changed out heated wire vent circuits. AM ABG's 7.45/35/197/25. Placing pt on T/C this am. No further changes noted.\n"},{"category":"Nursing/other","chartdate":"2165-06-21 00:00:00.000","description":"Report","row_id":1563051,"text":"NEURO; PT ON AT 25 MCG/KG/MIN, GTT OFF PER SICU AND NEURO TEAM, PT UNRESPONSIVE, WITHDRAWS ONLY RT FOOT TO NAILBED PRESSURE, DOES NOT OPEN EYES OR FOLLOW COMMANDS, RARELY MOVES BOTH FEET SLIGHTLY ON BED, NIPRI8DE TITRATED UP TO KEEP SYS 100-130, PRESENTLY AT 0,8 MCG/KG/MIN, GIVEN HYDRALAZINE 10 MGM X 1 FOR PERSISTENT ELEV BP IN 140'S, DESPITE INCREASE IN NIPRIDE, PT HAS POSITIVE GAG REFLEX, VOMITED SMALL AMT UNDIGES FOOD, NG SUCTION INCREASED, SICU TEAM INFORMED, PUPILS ARE VERY SLUGGISH #2, NEURO RESIDENT IN AND STATED PT DID LOCALIZE UPPER EXTREMITIES TO PRESSURE\nPT TAKEN TO ANGIO FOR FURTHER DIAGNOSTICS\n\nCARDIOVASCULAR; HR 70'S PACED, EXTREMITIES WARM AND DRY,\n\nRESPIR; SUCTIONED FOR SMALL AMTS THICK YELLOW SECRETIONS, SIMV RATE DECRESED FROM 20-18 AND FI02 DECREASED TO 60%, WILL REPEAT ABG WHEN PT RETURNS, WILL HAVE RPT CHEST X-RAY UPON RETURN\n"},{"category":"Nursing/other","chartdate":"2165-06-21 00:00:00.000","description":"Report","row_id":1563052,"text":"resp care\npt remains intubated and mech ventilated. see carevue for settings/changes. b/s coarse, sxn thk yel secretions. pt tx to/from neuro-angio w/o incident. plan: cont w/mech suport.\n"},{"category":"Nursing/other","chartdate":"2165-06-21 00:00:00.000","description":"Report","row_id":1563053,"text":"UPDATE NOTE\n\nNEURO; PT RETURNED FROM ANGIO, OCCLUDED VERTEBRAL ARTERIES, TO RETURN TO ANGIO FOR POSSIBLE STENT AND/OR COILING, PROPOFOL ON AT 35 MCG/KG/MIN AND OFF Q 1HR FOR NEURO CHECKS, DOES NOT OPEN EYES OR FOLLOW COMMANDS, WITHDRAWS ALL EXTREMITIES TO NAILBED PRESSURE, NIPRIDE AT 0.8 MCG/KG/MIN TO KEEP SYS 110-130'S PER DR. , PUPILS REMAIN SLUGGISH, EVALUATED FREQUENTLY BY NEURO RESIDENT,\n\nCARDIOVASCULAR; HR 60'S-70'S SR, SYS 120'S, NIPRIDE OFF PRIOR TO RETURN TRIP TO ANGIO DUE TO SYS 90'S AND AFTER MEDIC BY ANESTHESIA, GIVEN PLAVIX 150 MGM AND ASA 81 MGM VIA NG TUBE THIS PM, RT FEMORAL SHEATH TRANSDUCED, BP LOWER THAN RADIAL A LINE, NEURO AND SICU HO INFORMED, PEDAL AND PT PULSES EASILY PALPABLE, NO HEMATOMA OF RT GROIN\nRT SUBCLAVIAN TRIPLE LUMEN LINE INSERTED, CONFIRMED VIA X-RAY\n\nRESPIR SUCTIONED FOR SMALL THICK LIGHT YELLOW SECRETIONS, ABGS THIS PM-PC02 34, COARSE BREATH SOUNDS THROUGHOUT\n\nSOCIAL FAMILY AT BEDSIDE, WIFE UPDATED BY NEURO TEAM\n\nPLAN PT TAKEN BACK TO ANGIO FOR POSSIBLE STENT/COILING\n"},{"category":"Nursing/other","chartdate":"2165-07-14 00:00:00.000","description":"Report","row_id":1563136,"text":"\nPT MAINTAINED ON TM VENTILATION AND DOING WELL. VITALS STABLE, BLOOD STILL OOZING FROM TRACHEOSTOMY BUT MUCH BETTER THAN YESTERDAY. TM ABG SHOWED VERY GOOD OXYGENATION WITH A MILD ALKALOSIS. MENTAL STATUS UNCHANGED. PLAN IS TO CONT ON TM VENTILATION.\n"},{"category":"Nursing/other","chartdate":"2165-07-14 00:00:00.000","description":"Report","row_id":1563137,"text":"NPN (SEE CAREVUE FOR SPECIFICS)\n PT ONLY RESPONDING TO PAINFUL STIMULI. MAE BUT VERY MINIMALLY. . VENT REOPENED PER NEUROSURG TEAM AT 0 TRAGUS, ? INCREASED HYDROCEPHALUS SINCE CLAMPED TWO DAYS AGO. CHIP MACINTOSH IN TO CHANGE VENT TUBING (DOUBTS ACCURACY OF ICP, 0-3) IN THE PROCESS OF DECREASING , CSF DRAINED 70CC AND IS NOW CLAMPED UNTIL FURTHER NOTICE FROM NEUROSURG. ICP REGISTERING NEGATIVE NUMBERS.\nCV- BP 160'S ON 2.5MCGS OF NEO. I UNIT PRBCS GIVEN AND REPEAT HCT PENDING. HR 70-90 WITH OCCASIONAL PVCS. GROSS HEMATURIA SHOWN TO TEAM, DR. . GTT DECREASED TO 800U/HR WITH NEW PTT GOAL OF 40-50 TO PREVENT FURTHER ACTIVE BLEEDING.\nRESP- NO FURTHER BLEEDING FROM TRACH SITE BUT SPUTUM REMAINS BLOOD TINGED. VERY STRONG COUGH, ABLE TO RAISE. REQUIRED DEEP SUCTIONING ONLY A FEW TIMES. AFTERNOON ABGS ALL WNL ON TRACH COLLAR.\nGI/GU- LOOSE STOOL, DARK, C-DIFF PENDING. TF RESIDUAL 125 THIS AM, TF HELD FOR TWO HOURS AND FOLLOW UP RESIDUAL ONLY 10CC, THEREFOR TF RESTARTED. BLOOD TINGED URINE AVERAGING 100-260CC/HR.\nID- AFEBRILE\n"},{"category":"Nursing/other","chartdate":"2165-07-14 00:00:00.000","description":"Report","row_id":1563138,"text":" 19/07\n\n STATUS APPEARS LIGHTER JUST TOUCHING HIS SKIN CAUSES MOVEMENT PAINFUL STIMULUS YEILDS ORGANIZED MOTION ALL EXT SAME RESPONDS AT O LEVEL AND CLAMPED ICP NEGATIVE NUMBERS UNREALIABLE\n\n RESP T COLLAR .50 FIO2 WITH 100% SAO2 SECREATIONS LESS YELLOW IN WITH FOUL SMELL CLEAR AFTER SUCTION / COUGHING\n\n HEART S1S2 NSR WITH PVCS PULSES FAIR VSS ON NEO MAINTAIN BP 160 THRU SHIFT WELL A LINE CVP FAIR WAVES U/O QS\n\n SUPPORTIVE CARE P/T CONSULT NEEDED OOB TO WITH LIFT FREQ ROM\nOSMOTIC DIURETICS FOR LONG TERM USE FAMILY SUPPORT\n"},{"category":"Nursing/other","chartdate":"2165-07-15 00:00:00.000","description":"Report","row_id":1563139,"text":"NURSING UPDATE\n STATUS UNCHANGED UNTIL 0500, SBP DIMINISHED TO LOW 80'S AND MAP TO 40'S, DR INFORMED, ALBUMIN 25% IV X1 WITHOUT EFFECT, IV BOLUS N/SALINE 500CC INFUSING AT THIS TIME PER DR WITH GOOD EFFECT SO FAR. BP UP TO 105/45(62). SEE CAREVIEW FLOWSHEETS FOR DETAILED DATA.\n WILL CONTINUE TO MONITOR.\n"},{"category":"Nursing/other","chartdate":"2165-07-15 00:00:00.000","description":"Report","row_id":1563140,"text":"ADDENDUM\n****PLEASE DISREGARD ABOVE NOTE - ENTERED ON WRONG PATIENT****\n"},{"category":"Nursing/other","chartdate":"2165-07-01 00:00:00.000","description":"Report","row_id":1563089,"text":"Condition Update A:\nPlease refer to careview and remarks for specifics.\nNEURO: Became less responsive as SBP decreased to 120's. Dr. up to see pt. Pt arousable and following commands, MAE with SBP 160-170's. No indications of pain. Head CT done this afternoon report pending. Ventriculostomy draining burgandydrainage. increased to 12 at tragus by NSURG this afternoon.\nCV: Nicardipine gtt stopped this morning for maintaining SBP <170. Neo gtt started to keep SBP initially 150-165, and parameters increased per Dr. to 160-170. HR NSR with frequent bigeminy. Cycled cardiac enzymes completed, 1800 levels pending, and appears to be ruling out for MI. Received albumin x1 as albumin 2.9 and cont with 2-3+ pit edema.\nRESP: No changes. Minimal secretions. CPT done x2.\nGI/GU: Med loose bm gauaic neg. Stool sent for c-diff. Minimal TF residuals. Glucose in the 140's, no treatment per RISS. TF stopped to admin baricate for abd CT to be done this evening. Foley patent draining adequete urine, occ cloudy.\nSKIN: W/D/I.\nSOCIAL: Dr. and Dr. in to speak with Mrs. and provide updates.\n\nPLAN: Titrate Neo gtt to keep SBP 160-170. Monitor neuro status, ICP. Abd CT once baricat completeed and CT available. Cont with ICU care and monitoring.\n"},{"category":"Nursing/other","chartdate":"2165-07-02 00:00:00.000","description":"Report","row_id":1563090,"text":"condition update\nD;neuro: pt opens eyes to name. follows commands. pupils are equal and reactive to light. moves all extremities to command. lifts and falls both extremities. vent is at 12 cm above the tragus. icp is . draining tea colored drainage.\ncardiac: nsr with bigemeny and frequent pac's. at ct scan pt became very hypertensive to 200 and started on nicapdipne titrated up to 1mcg/kg/min. still hypertensive up to 180. resp rate up to 40 in ct and pt started on propofol at 40mcg/kg/min for sedation. pt sedated and sbp down to 160's. propofol off after ct scan. pt. awake and following commands. neuro exam back to baseline. sbp down to 140 after nimodipine and pt restarted on neo and titrated up to 1mg/kg/min. cvp is 11.\nresp: bs are clear and diminished in the bases. suctioned for thick white. pt remains on cmv at present time due to tachypnea.\ngi: abd ct neg per dr. . positive bowel sounds large amt of loose liquid brown stool. tf restarted and no residuals.\ngu: urine output is adequate and greater than 100cc/hr. iv fluid at kvo.\nskin: transparent head dsg is dry and intact. no areas of breakdown is noted. heels slightly red but no breakdown. placed on pillow.\nid: temp max is 101.3. wbc down to 16.\na: continue with neuro checks. titrate neo for sbp 160-170. titrate tf up to 70cc/hr.\nr: neuro is unchanged. pt follows commands and moves all extremities. temp down to 100.7. neo down to .8mcg/kg/min. abg is less alkalotic.\n"},{"category":"Nursing/other","chartdate":"2165-06-22 00:00:00.000","description":"Report","row_id":1563054,"text":" to 19 to 07\n nuro pt sedated with propofol on vent limit stimulation until am because of new stent and coil inserted this pm intracerebral deep tendon not assessed md 2mm corneal reflex negative mild gag noted icp 7 to 11 good wave scant drainage\n heart s1s2 2+ SYS MURMOR VSS NIPRIDE MAINTAIN BP SYS 110 TO 120 NSR OCC PVC NOTE FREQ PVC PRIOR TO K AND MAG REPLACMENT PULES +2 TO +3 AT TIMES CVP GOOD WAVE 3 to 5\n resp vent rate 12 fio2 .50 scant sputum clear fields ett at 21 lip no spont resp sat 99 to 100 persent\n gi hypoative bowel sounds ng to suction soft nondistended\n all lines wnl alarms on\n"},{"category":"Nursing/other","chartdate":"2165-06-22 00:00:00.000","description":"Report","row_id":1563055,"text":" cont note attempt to wake pt 15 minutes bp elevated pa at bedside test ended nuro no corneal reflex impaired gag ridgid legs\n\n"},{"category":"Nursing/other","chartdate":"2165-07-12 00:00:00.000","description":"Report","row_id":1563129,"text":" TO 19 TIME 19/07\n REMAINS DEEPLY LETHARGIC OPENS EYES MAE LOCALIZES ONLY TO PAIN ONLY OCC BRIEF PERIOD OF SPONT EYE OPENING TO COMMAND ICP 1 TO 4 GOOD WAVE NOTED CLAMPED PER ORDER\n\n RESP ON .40 FIO2 CPAP 5/5 WELL RESP RATE 12 TO 20 SPUTUM SCANT TRACH STOMA BLOODY LARGE AMOUNT AIRWAY CLEAR GELFOME IN PLACE DRESSING AROUND SITE FOR COLLECTION\n\n ABD SOFT LAG BM PASTY DARK MANY T/F WELL SCANT RESIDUAL\n\n HEART S1S2 NSR OCC PAC PVC PNC WAP THRU SHIFT BP 160 TO 170 SYS ON NEO TO REDUCE VASOSPASM NEG NVD PULSES FAINT IN NATURE U/O QS CVP5 TO 6 ALINE IN PLACE GOOD WAVE FORM\n\n SUPPORTIVE CARE FREQ ROM T/P\n"},{"category":"Nursing/other","chartdate":"2165-07-13 00:00:00.000","description":"Report","row_id":1563130,"text":"RESP: PT ON PSV 5/5/40%. ALARMS ON AND FUNCTIONING. AMBU/SYRINGE @ HOB. BS AUSCULTATED REVEAL BILATERAL COARSE SOUNDS. SUCTIONED MODERATE AMOUNTS OF THICK BLOODY TINGED SECRETIONS AND YELLOW. TRACH SITE STILL OZZING. AM ABG'S: 7.37/42/168/25. RSBI=107. POSSIBLE CT SCAN THIS AFTERNOON FOR FOLLOW-UP. NO FURTHER CHANGES NOTED.\n"},{"category":"Nursing/other","chartdate":"2165-07-13 00:00:00.000","description":"Report","row_id":1563131,"text":" O500 NOTE BLEEDING AROUND TRACH SITE REMAINS MD AWARE SEVERAL\n\n JELFORM USED TOLWELL\n\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2165-07-13 00:00:00.000","description":"Report","row_id":1563132,"text":"\nPT MAINTAINED ON PSV VENTILATION AT 40% WITH GOOD OXYGENATION. TRACHEOSTOMY HAS BEEN A PROBLE WITH CONSTANT BLEEDING. M.D. UP TO SUTURE WHICH HAS MADE IT SOMEWHAT BETTER. CT SCAN TODAY TO ASSESS REMOVAL OF VENTRICULOSTOMY. SX FOR BLOODY SECRETIONS. PLAN IS TO TRY PT ON TM VENTILATION AT SOME PT TODAY.\n"},{"category":"Nursing/other","chartdate":"2165-07-05 00:00:00.000","description":"Report","row_id":1563104,"text":" TO 19/07\n\n PT STATUS REMAINS AROSABLE TRIES TO TALK AT TIMES OPENS EYES TO COMAND WEAKNESS ALL EXTEMITIES PERIOD OF AGITATION RR 28 TO 30 PTPLACED BACK ON SIMV WITH RELIEF\n\n HEART S1S2 NSR WITH 2 TO DEPRESSION IN LEAD 2 PULSES POS 2 THRU OUT NEG NVD VSS ALINE CVP ICP WAVE FORMS WNL SEE FLOW SHEET\n\n RESP RONCHI THRU OUT CLEARD AFTER SUCTION SIMV FIO2 35% GOOD AIRATION\n GI POS BS T/F WELL SMALL RESIDUAL SMALL STOOL\n U/O QS NO ISSUES\n\n NEO 1.5 MCG/KILO/MIN BP 150 TO 170 PER ORDER HEPARIN TO TITRATE\n\n SKIN NOTE BUTT SL RED WITH SKIN OPEN AREA\n\n SUPPORTIVE CARE ROM TURN SIDE TO SIDE PUL TOILETING\n\n"},{"category":"Nursing/other","chartdate":"2165-07-06 00:00:00.000","description":"Report","row_id":1563105,"text":"Respiratory Care\nPt remains mechaniclly ventilated, switching from SIMV to CPAP. Changing PSV to accommidate adequate/comfortable spontaneous VT/RR. Suction for scant amounts thick white secreations. Breath sounds diminished.\n"},{"category":"Nursing/other","chartdate":"2165-07-11 00:00:00.000","description":"Report","row_id":1563124,"text":"Neuro: pt remains very lethargic. Pupils 3mm brisk. Having no spontaneous movement. Withdraws to nailbed pressure. ICP 4-6, Vent remains at 15cm above tragus.\nCV: afebrile HR 80's NSR with frequent PVC's. Exremities warm with +PP. Cont on Neo to keep SBP 160-170.\nRESP: lungs coarse through out. No vent changeds overnight. Requring occasional suctioning of thick bloody sputum. Trach care done several times. Pt having lrg amount of blood drg from trach site.\nGI tube feed at goal.\nGU: foley draining adequate amounts of amber urine.\n"},{"category":"Nursing/other","chartdate":"2165-07-11 00:00:00.000","description":"Report","row_id":1563125,"text":"7a-3p\nneuro: neuro in this am & vent increased to 20 above tragus, no response to verbal command, responds to painful stimuli with facial grimacing, withdraws to nail bed pressure, mouthed \"\" to niple pressure, slight movement of R arm, no other movement of extremities noted, vent draining sm amt bld tinged clear drainage, \n\ncv: hr nsr with occasional to frequent pvc's, sbp 160-179, continues on neo gtt to keep sbp 160-170, continues on iv lopressor q 6 hrs\n\nresp: bs+ all lobes & course, sux mod amt thick bld tinged sputum, continues on 40% fio2, imv 20, 5 peep, 8 ips, RSBI 140 this am, lg amt bleeding around trach, ho aware, surgigel applied, hct drawn @ 1400 & pending, rr 20-30, sat 100, no resp distress noted\n\ngi: goal TF well, incont lg amt loose semi-formed brown stool, FIB applied, po prevacid qd\n\ngu: foley patent, clear yellow urine, good uo\n\nother: family in & updated on pt's condition, heparin continues @ 1800u/hr, bs 133 & covered with rssi\n\nplan: continue to monitor neuro/respiratory status, check PM hct\n"},{"category":"Nursing/other","chartdate":"2165-07-11 00:00:00.000","description":"Report","row_id":1563126,"text":"Resp care\nPt reamins on full vent support. No recent ABG\"S as of yet. No vent changes made. Coarse BS, sx mod thick blood tinged secretions. Continues with bleeding around trach. Will follow.\n"},{"category":"Nursing/other","chartdate":"2165-07-12 00:00:00.000","description":"Report","row_id":1563127,"text":"Resp Care\nPt. remains on SIMN mode with no changes made t/o shift. Tolerating well spont. breathing over set rate with shallow pattern and VT's 200-300cc range.\nBs: coarse bilat. secreations minimal bloody thick. Trach continues to ooze, swivel changed X2.\nABG:metabolic alkalosis with hyperoxia\nPlan: PSV during day as tolerated.\n"},{"category":"Nursing/other","chartdate":"2165-07-13 00:00:00.000","description":"Report","row_id":1563133,"text":"NPN\n PT NOT OPENING EYES TODAY, MOVING EXTREMETIES IN RESPONSE TO PAINFUL STIMULI ONLY. CT TODAY SHOWING NO CHANGE SINCE VENT CLAMPED. .\nCV- BP DROPPING TO 100'S BEFORE LEAVING THE FLOOR TO CT, REQUIRING LARGE INCREASE IN NEO GTT. FLUID BOLUS GIVEN WITH GOOD EFFECT AND BP IS NOW 170'S FOLLOWING TWO UNITS OF BLOOD. AFTERNOON HCT DROPPED TO 24, WILL FOLLOW UP WITH REPEAT FOLLOWING SECOND UNIT. TRACH SITE OOZING NON STOP TODAY. SHOWN TO DR. AND DR. PAGED TO . SEVERAL STITCHES PLACED AND BLEEDING HAS NOW STOPPED. WILL CONTINUE TO MONITOR.\nRESP- LUNG SOUNDS COARSE AT TIMES, SUCTIONED FOR THICK BLOOD SPUTUM EVERY FEW HOURS. PT ABLE TO RAISE, VERY STRONG COUGH. O2 SAT 100% ON CPAP.\nGI- ABD SOFT, TF AT GOAL. LOOSE STOOL A FEW TIMES AND SENT FOR CULTURE.\nGU- UOP RANGING FROM 80-100CC/HR.\nID- AFEBRILE\n"},{"category":"Nursing/other","chartdate":"2165-07-14 00:00:00.000","description":"Report","row_id":1563134,"text":" 19/07\n\n status stable mae only to painful stimuli and only on occ no other new trends strong gag\n\n trach in place scant bleeding around stoma only cpap .40 fio2 note bloody sputum only rhonchi thru out possible trach mask\n\n heart s1s2 pulses poss multifocal pvcs noted bp to be maintained greater than 160 sys with neo u/o qs icp 1to 2 cvp 4\na line good wave\n\n gi wnl pos bs tube feeding well note hematuria started this am md decrease\n"},{"category":"Nursing/other","chartdate":"2165-07-06 00:00:00.000","description":"Report","row_id":1563106,"text":"Respiratory Care\nPt becoming more short of breath with spontaneous RR in upper 30's to low 40's. Decreasing Vt to 200 cc. Placed back on SIMV and increase of PSV to 15cm. Decreasing work of breathing as a result of adjustment.\n"},{"category":"Nursing/other","chartdate":"2165-07-06 00:00:00.000","description":"Report","row_id":1563107,"text":"NUERO: PT DOES NOT OPEN HIS EYES WHEN YOU CALL HIS NAME. PUPILS REMIANS EQUAL AND REACTIVE TO LIGHT. PT DOES WITHDRAW ALL FOUR EXTREMTIES TO PAINFUL STIMULI. AT TIMES SPONTANOUES MOVEMENT NOTED FROM RIGHT ARM AND LEFT ARM, NO SPONTANOUES MOVEMENT NOTED FROM RIGHT AND LEFT LEGS. DR. AWARE. (NUEROSURGICAL PA) CALLED AND AWARE AND UP TO ASSESS PATIENT. AT TIMES PT WILL SQUEEZE RIGHT HAND TO COMMANDS. ICP REMIANS , VENTRICULAR DRIAN REMAINS 10CM ABOVE TRAGUS DRIANING BLOOD TINGED DRAINAGE.\n\n\nLUNGS: LUNGS COARSE SUCTIONING PT FOR SCANT AMT OF YELLOW SECRETIONS. PLEASE SEE FLOW SHEET FOR VENT SETTINGS AND ABGS.\n\nCARDS: PT IN SR WITH FREQUENT PVC'S. NEO TITRATED TO KEEP SBP B/W 170-180'S. PT ON HEPARIN AT 1700U/HR.\n\nGI: PT TOLERATING TUBE FEEDINGS, MINIMAL RESIDUALS NOTED.\n\nGU: U/O 80-160CC/HR.\n\nF/E. BLOOD SUGAR THIS MORNING 169 RECIEVED 5U NPH AND 10U REGULAR INSULIN , REPEAT BLOOD SUGAR AT 1645 143 RECIEVED 6U OF REGULAR INSULIN PER SLIDING SCALE. NA 130 REPEAT NA 132, DR. AWARE.\n\nSKIN: BROKEN AREA NOTED ON BUTTUCKS DRAINING SMALL AMT OF BLOODY DRAINAGE DUEODERM APPLIED.\n\nPLAN: CONTINUE TO MONITOR NUERO STATUS, KEEP SBP B/W 170-180, MONITOR BLOODSUGARS, NA,\n"},{"category":"Nursing/other","chartdate":"2165-07-06 00:00:00.000","description":"Report","row_id":1563108,"text":" TO 19/07\n\n PT STATUS LABILE RESPONDSIVENESS OPEN EYES MAE MOUTHS WORDS ON OCC FOR SHORT PERIODS OF TIME BECOMES TIRED THAN FALLS INTO DEEP LETHARGIC STATE SUPPORTIVE CARE\n\n HEART S1S2 ST DEPRESSION REMAINS BP TO BE MAINTAINED SYS 170 TO 180 WITH NEO PVC TRIPLETS PULES POS 2 THRU OUT LOW GRADE TEMP ICP CVP A LINE WNL GOOD WAVE U/O QS\n\n ABD POS BS NOTED T/F WELL NO RESIDUALS F/S AT 8O CC PER HOUR\n\n RESP VENT ASSIST/CONT .35 FIO2 STABLE DECREASE SPUTUM\n\n SKIN FREQ TURNS BUTT CARE BECAUSE OF SMALL WOUND\n"},{"category":"Nursing/other","chartdate":"2165-07-12 00:00:00.000","description":"Report","row_id":1563128,"text":"NPN (SEE CAREVUE FOR SPECIFICS)\n PT NOT OPENING HIS EYES TO STIMULUS BUT GRIMACING TO PAIN. MOVING ONLY IN RESPONSE TO PAIN, LOCALIZING. . VENT INCREASED TO 25 ABOVE TRAGUS BY NSURG. NA MONITORED AND DECREASED THIS AFTERNOON TO 134, WILL UPDATE MD.\nCV- BP WELL MAINTAINED IN 160-170 RANGE WITH NEO AT 2.4 MCGS. HR 70'S-80'S WITH OCCASIONAL PVCS, NSR.\nRESP- LUNGS COARSE AT TIMES, RELIEVED BY SUCTIONING FOR THICK BLOODY SPUTUM. TRACH CARE DONE AND ABOUT TWO HOURS AFTER PT BEGAN OOZING BLOOD FROM SITE. DRESSING REINFORCED, AFTERNOON HCT 29.\nGI- TF AT GOAL. NOTICED SMALL CLOTS AND BLOOD TINGED RESIDUAL FROM STOMACH THIS AM, DR. NOTIFIED, CONTINUE TO MONITOR.\nGU- UOP 200-300CC/HR. DIAMOX GIVEN X 2 FOR SLIGHT ALKALOSIS. ABGS THIS AFTERNOON SLIGHTLY IMPROVED.\nID- AFEBRILE. +VRE IN STOOL.\n"},{"category":"Nursing/other","chartdate":"2165-06-30 00:00:00.000","description":"Report","row_id":1563083,"text":"PT.PRESENTLY ON CPAP+PS VENTILATION, HAD INCREASED RR ON SIMV AND APPEARED TO BREATHE WITH MORE COMFORT ON CPAP WITH INCREASED PRES.SUPPORT, ABG ALKOLOTIC, BS CLEAR BILAT.,WILL WEAN AS ., RSBI-120.7\n"},{"category":"Nursing/other","chartdate":"2165-06-30 00:00:00.000","description":"Report","row_id":1563084,"text":" CONT THIS AM PT MORE ALERT RESP 40 FAIR T.V. TRIAL CPAP WELL MD AWARE\n"},{"category":"Nursing/other","chartdate":"2165-06-30 00:00:00.000","description":"Report","row_id":1563085,"text":"NEURO; OPENS EYES SLIGHTLY TO VOICE ON OCCASION AND FOLLOWS COMMANDS SUCH AS MOVING TOES AND GIVING WEAK HANGRASP INCONSISTENTLY, LOCALIZES TO TACTILE STIMULATION AND WITHDRAWS EXTREMITIES TO NAILBED PRESSURE,VENT LOWERED TO 8 CM AT TRAGUS TODAY PER ORDER NEURO TEAM, PT HAD BEEN MORE LETHARGIC BUT MORE EASILY AROUSEABLE AT PRESENT, MODER THICK BLOODY DGE IN CHAMBER-UNCHANGED FROM YESTERDAY, C&S TAKEN FROM NEURO BY NEURO TEAM\nICP 3-6\nEEG DONE TODAY\n\nCARDIOVASCULAR; HR 70'S SR, FREQUENT PVC ON OCCASION, UNIFOCAL, CVP 9-12, NICARDIPINE GTT OFF FOR SEVERAL HRS BUT RESTARTED AFTER LOPRESSOR GIVEN AND NOT EFFECTIVE IN DECREASING SYS < 170 PER GOAL OF DR ,\nTEMP SPIKE 102.4-TYLEONL AND ALCOHOL SPONGE BATH, SEEN BY INFECTIOUS DISEASE\nAND WILL HAVE VANCOMYCIN RESTARTED\nRESPIR; SUCTIONED FOR SMALL AMTS THICK LIGHT YELLOW-WHITE SECRETIONS, LAST ABG REFLECTS METAB ALKALOSIS ,REMAINS ON C-PAP AND PS PRESENTLY AT 15, ATTEMPTED DECREASNG TO 10 BUT PT BECAME TACHYPNEIC, COARSE BREATH SOUNDS, CXR TODAY,\n\nENDOCRINE; BS 151-COVERED WITH 2 UNITS VIA SLIDING SCALE, TUBE FEEDINGS DECREASED TO 70CC/HR PER SICU TEAM, NEUTRA PHOS GIVEN DOWN TUBE,\n\nGI; INCON ON SEMI-LIQUID STOOL, TRACE HEME POSITIVE\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2165-07-01 00:00:00.000","description":"Report","row_id":1563086,"text":" 19/07\n\n STATUS PT OPENS EYES TO COMANDS MAE LIMITED ON NO SEDATION PROGRESSIVE IMPROVMENT RESTS LONG PERIODS VSS CVP ICP WNL GOOD WAVE FORMS U/O QS\n\n RESP ON CPAP WITH PS VERY WELL RESP 12 TO 14 OCC RHOCHI CLEARS AFTER SUCTIONING .40% FIO2 SAT 99\n\n HEART S1S2 FREQ PVC PNC PULSES +2 THRU OUT W/D NEG NVD NEG HJR NSR MILD ST DEPRESSION 2/3 MM\n\n GI POS BS STOOLING T/F WELL NO RESIDUALS\n\n T/P SKIN CARE WITH ROM\n\n THIS PM SPUTUM BLOOD SENT FOR CULTURES\n"},{"category":"Nursing/other","chartdate":"2165-07-01 00:00:00.000","description":"Report","row_id":1563087,"text":" 0345\n\n note pt period of vent bigemity also resp rate increase 23 to 30 abg done resp alkalosis result placed on simv with low dose mso4 result less ectopics beats ekg no changes labs ok md aware\n"},{"category":"Nursing/other","chartdate":"2165-07-01 00:00:00.000","description":"Report","row_id":1563088,"text":"PT.INITIALLY ON CPAP+PS, CHANGED IN A.M. FOR COMFORT, HAD BEEN RESTLESS AND AGITATED, WEANING DOWN SEDATION,INCR.WOB, ABG ALKALOTIC, BS COARSE ON OCCAISON, SX FOR WHITE SECRETION, WILL ATTEMPT TO WEAN IF .\n"},{"category":"Nursing/other","chartdate":"2165-07-25 00:00:00.000","description":"Report","row_id":1563164,"text":"focus update\nafebrile VSS aline d/ced no neurological changes awaiting bed at , continues on gtt at 1150u/hr goal PTT 40-50 PTT check q 6 hours. expectorating yellow thick sputum q 1/2 hour, lsc\n"},{"category":"Nursing/other","chartdate":"2165-07-26 00:00:00.000","description":"Report","row_id":1563165,"text":"NSG NOTE\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-. SQUINTS AND FLUTTERS EYELIDS TO PAIN AND ? SL OPENS EYES. . NO SPONT MOVEMENT. DOES NOT FOLLOW COMMANDS. FLEXES ALL EXTREMITIES TO PAIN.\n\nCV-AFEB. HR/BP STABLE. SKIN W+D. +PP. PBOOTS ON. CON'T ON GTT. PTT MONITORED, THERAPEUTIC.\n\nRESP-REMAINS ON TRACH COLLAR, 70%. WELL. O2 SAT 100%. LS COARSE, DECREASED AT BASES. PT EXPECTORATING LARGE AMT THICK YELLOW SPUTUM.\n\nGI-ABD SOFT. +BS. TF AT GOAL. INC OF SEMIFORMED STOOL X 1.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nENDO-SSRI AND NPH.\n\nPLAN-CON'T WITH CURRENT PLAN. AWAIT REHAB BED.\n"},{"category":"Nursing/other","chartdate":"2165-07-04 00:00:00.000","description":"Report","row_id":1563098,"text":"Resp: pt on psv 15/+5/40%. Alarms on and functioning. Ambu/syringe @ hob. BS ausucltated reveal bilateral aeration in apecies with diminished bases. Suctioned for small amount of yellow secretions. VT decreased, periods of apnea, placed on a/c noc. AM ABG's 7.48/37/127/28, improvement noted. RSBI=94. Placed back on psv 15/5/34%, continue to wean as tolerated.\n"},{"category":"Nursing/other","chartdate":"2165-07-04 00:00:00.000","description":"Report","row_id":1563099,"text":"Respiratory Care\nPt remains mechaniclly ventilated, on CPAP mode. No changes made this shift to ventilator settings. Breath sounds equal.\n"},{"category":"Nursing/other","chartdate":"2165-07-04 00:00:00.000","description":"Report","row_id":1563100,"text":"STATUS\nD: MORE AWAKE WILL FOLLOW SOME SIMPLE COMMANDS..MOVES ALL EXTREM'S LF LEG MUCH WEAKER THAN RT MOVES BOTH ARMS EQUALLY..FEBRILE\nA: PERIP/CENTRAL LINE/URINE/VENT CULTURES SENT..MP ? V PACED WITH FREQ PVC'S..LEVO INITIALLY INCREASED TO 1.3MCG FOR SBP 150/'S..NOW BACK DOWN TO 1.2MCG TO KEEP SBP >160/..NA'S DRAWN Q2H..NA GTT TO 15 FOR NA 131..VENT TO C-PAP IPS 10 WITH GOOD SAT'S..SUCTIONED FOR MOD AMT THICK WHITE..INCT SOFT BROWN STOOL..FIB DC'D DIAPER ON STOOL FOR C-DIFF SENT\nR: IMPROVED MENTAL STATUS\nP: MONITOR NA'S Q2H AJUST GTT PER HO..PTT Q6H..NEURO Q2H..WEAN LEVO AS \n"},{"category":"Nursing/other","chartdate":"2165-07-09 00:00:00.000","description":"Report","row_id":1563116,"text":"Respiratory Care Note:\n\nPt remain orally intubated on SIMV mosly. We had to change mode of ventilation for most part of the night due to hemodianamic unstability ST & HR rhythm back to< 100/min, back to SIMV this AM. ABG acceptable. Sxtn for thick white sputum Q2-4hr & PRN. He seems to respond this morning. Plan; ?MRI/ talks of trach\n"},{"category":"Nursing/other","chartdate":"2165-07-09 00:00:00.000","description":"Report","row_id":1563117,"text":"RESPIRATORY CARE\nPT S/P TRACH TODAY, REMAINS ON VENTILATORY SUPPORT. SIMV 400/20/40%/+5 PEEP, RATE WAS INCREASED D/T SEDATION FOR THE PROCEDURE. SLIGHT INCREASE IN FIO2 D/T PAO2 OF 76. EARLIER IN THE SHIFT, PT WAS NOTED TO BE TACHYPNEIC/PANTING, FELT TO BE CENTRAL HYPERVENTILATION. NO SIGNS OF DISTRESS. BS RHONCHI T/O. NO WEANING PLANS AT THIS TIME.\n"},{"category":"Nursing/other","chartdate":"2165-07-09 00:00:00.000","description":"Report","row_id":1563118,"text":"NPN (SEE CAREVUE FOR SPECIFICS)\n PT MORE RESPONSIVE TODAY. OPENING EYES TO VOICE THIS AFTERNOON, FOLLOWING SIMPLE COMMANDS. , HOWEVER MINIMAL SPONTANEOUS MOVEMENT FROM LOWER EXT. VENT REMAINS AT 15 ABOVE TRAGUS, ICP 1-6.\nCV- BP PARAMETERS LOWERED TO 160-170 PER DR. AND PT ABLE TO START WEANING OFF NEO. HR IN 70-80'S WITH MULTIPLE PVCS. ESMOLOL WEANED OFF SUCCESSFULLY AND IV LOPRESSOR STARTED. NO FURTHER SPISODES OF SVT TODAY.\nRESP- TRACH'D TODAY WITHOUT COMPLICATION. BREATHING APPEARS TO BE MORE COMFORTABLE AND REMAINS ON SIMV FOR NOW. ABGS FREQUENTLY CHECKED. LUNGS COARSE AT TIMES, RELIEVED BY SUCTIONING FOR SMALL AMOUNTS OF CLEAR WHITE SPUTUM.\nGI/GU- ABD SOFT, TF RESUMED AFTER TRACH. NPH HELD THIS AM DUE TO NPO STATUS. FOLEY PATENT DRAINING CLEAR YELLOW URINE, 100-200CC/HR\nID- TMAX 99.4.\n WIFE IN TO VISIT AND ABLE TO COMMUNICATE WITH PT. SPOKE WITH DR. .\n\n"},{"category":"Nursing/other","chartdate":"2165-07-10 00:00:00.000","description":"Report","row_id":1563119,"text":"Respiratory Care Note:\n\nPt remain on vent support via new trach #8 Shiley done yesterday. No vent changes o/n. We are suctioning blood tinged thick secretions ~q4h. AM abg acceptable. Plan: Continue ICU monitoring; will follow.\n"},{"category":"Nursing/other","chartdate":"2165-07-05 00:00:00.000","description":"Report","row_id":1563101,"text":"CONDITION UPDATE\n 8 PM WAS UNRESPONSIVE, WOULD NOT FOLLOW ANY COMMANDS, PUPILS UNCHANGED. NEURO- NOTIFIED. AT THIS TIME WAS FEBRILE TO 101.7. ONCE FEVER BEGAN TO DROP NEURO STATUS RETURNED TO HAS BEEN HIS BASELINE- FOLLOWING COMMANDS, MOUTHING WORDS, ABLE TO MOVE ALL EXTREMITIES WITH PUPILS EQUAL AND REACTIVE TO LIGHT. REMAINED AFEBRILE THE REST OF THE NIGHT WITH TYLENOL GIVEN Q4 HRS. VENTRICULAR REMAINS AT 15 ABOVE THE TRAGUS WITH SEROSANGUINES DRAINAGE. ICP'S RANGE 1-7.\n SBP MAINTAINED 160 TO 170 RANGE WITH NEO INCREASED AS HIGH AS 3 TO MAINTAIN BP'S WHILE FEBRILE. NEO CURRENTLY AT 1.5. NSR-V PACED WITH FREQUENT PVC'S.\n TUBE FEEDS OFF AT 0400 FOR POTENTIAL EXTUBATION.\n CONTINUE TO MONITER NEURO AND RESPIRATORY STATUS.\n"},{"category":"Nursing/other","chartdate":"2165-07-05 00:00:00.000","description":"Report","row_id":1563102,"text":"Respiratory Care\nPt remains mechaniclly ventilated, attempting 5cm PSV, becoming more short of breath. Spontnaeous Respiratory Rate mid 30's to 40, decreasing spontaneous Vt to 300cc. Increase PSV to 8cm with decreasing Work of Breathing.\n"},{"category":"Nursing/other","chartdate":"2165-07-05 00:00:00.000","description":"Report","row_id":1563103,"text":"STATUS\nD: NEURO ESSENTIALLY UNCHANGED..MORE LETHARGIC IN AFTERNOON..REMAINS ON NEO/HEPARIN GTT'S\nA: AFEBRILE..WEANED ON VENT TO IPS 5 C-PAP 5 SHORT TIME THAN TACHYPNEIC 30'S..PLACED ON IPS 8>> WELL..SUCTIONED THICK WHITE GOOD ABG'S..NEO UP & DOWN TO KEEP SBP 160/-170/'S GTT @ 1.0MCG AT PRESENT HEPARIN REMAINS @ 1700U WITH PTT 70'S..GOOD HUO'S..INCT SOFT BROWN STOOL..TF'S REMAIN OFF\nR: ESSENTIALLY UNCHANGED\nP: CONTINUE TO MONITOR PTT/NA'S Q6H..NEURO SIGNS Q2H..? RESTART TF'S\n"},{"category":"Nursing/other","chartdate":"2165-07-10 00:00:00.000","description":"Report","row_id":1563120,"text":"Neuro: Pt remains very somulant. Withdraws and grimace to nailbed pressure. pupils 3mm brisk. no spontaneous movement noted. Vent 15cm above tragus ICP 3-7, draining small amounts of blood tinged CSF\nCV: afebrile, HR 70's NSR with frequent PVC's. SBP 150-170's, continues on neo to for goal 160-170. Titrated overnight, presently at 2.3mcg/kg/min. Heparin gtt increased to 1800u/hr to keep Ptt 60-80. extremities warm with +PP.\nRESP: lungs coarse. O2 sats >98%. No vent changes occasional suctioning of thick blood tinged sputum. ABG acceptable.\nGI: tube feed at goal. Small BM\nGU: foley draining adequate amounts of clear yellow urine.\nEndocrine: blood sugars slightly elevated requiring coverage Per RISS.\n"},{"category":"Nursing/other","chartdate":"2165-07-10 00:00:00.000","description":"Report","row_id":1563121,"text":"Resp care note\nPt remains on full vent support. ABG's show alkalosis, well oxygenated. No vent changes made as of yet. Sx mod thin bloody secretions. Head CT today, results pending. Will follow.\n"},{"category":"Nursing/other","chartdate":"2165-07-10 00:00:00.000","description":"Report","row_id":1563122,"text":"Nursing Progress Note\n 07:30->19:30\n\nS/O\n\nNEURO: Minimally responsive = withdraws right hand from stim during a-line re-wiring and flushing, grimaces with trach and line care, clamps mouth closed during mouth care. PERRLA , brisk; corneals intact; cough strong. Doesn't follow commands or move spontaneously; no eye opening; did not respond to wife's voice.\nHead CT to evaluate ventricular size -> per Neuro , no changes.\nVentricular tracing dampened and loss of respiratory variation in ventriculostomy tubing -> Neuro up to evaluate, re-established variabilkity and flow when lowered to 12, and returned to 15 at the tragus; transducer changed, and tracing improved with restoration of notch.\n\nCV: Continues on Neo to maintain SBP 160-170, varies between 2.3-3.0mcg/kg-min. HR 80's-70's with bigeminy which responds to Lopressor, and frequent PVC's. Hands and feet cool and clammy.\nA-line tracing lost -> a-line re-wired by Dr. (SICU) with return of tracing.\n\nRESP: LS coarse, occ clear. Sxn'd q2-4 horus for copious amounts of thick bloody secretions. Trach care completed x4 d/t amount of secretions. No innner cannula of trach in place. No changes in vent settings (SIMV 20X Vt 400 x FiO2 .40 with PSV 8 and PEEP5).\n\nGI: Remains on tube feeds. Extremely large stool passed, guaiac negative. Abd soft, bowel sounds +.\n\nFEN: Na+ dropped from 133 -> 129 => all meds and gtts placed in NS; 3% NS gtt started at 15mL with increase in Na+ to 135 after about 2 hours, and gtt stopped. Na+ remains at 134. K+ dropped to 3.6 -> rechecked and will replete per scale. BS per RISS and scheduled coverage. Phos running low.\n\nHAEM: COntinues on heparin at 1800 units/ hour with PTT in therapeutic range of 60's. Tracheal bleeding as noted. No other bleeding noted.\n\nID: Tmax 99.2 rectally. No new ID issues. Remains on Flagyl, Vanco and Cefepime with Vanco and Cefepime in NS.\n\nGU: U/O qs via foley. No GU issues.\n\nSKIN: Duiderm over coccyx intact. Irritation in peri-anal fold between gluteal cheeks -> Aquaphor applied. Continues with multipodux boots, off q 4hours for skin checks -. skin intact.\n\nA/P\n\nContinue current care, including heparin gtt and coag monitoring, Na+ monitoring and repletion, neuro checks, fluid and electrolyte management, and pulmonary support.\nFollow up on phos level as appropriate.\n"},{"category":"Nursing/other","chartdate":"2165-07-11 00:00:00.000","description":"Report","row_id":1563123,"text":"Respiratory Care Note:\n\nPt remain on ventilatory support via new trach Day2 on SIMV & PS. No vent changes maded during shift. We are sxtn mod-cop bld tinged thick seccretions and fair amt of blood around trach site. Plan: No changes just continue ICU monitoring.\n"},{"category":"Nursing/other","chartdate":"2165-06-28 00:00:00.000","description":"Report","row_id":1563078,"text":"FOCUS: STATUS UPDATE\nDATA:\nPATIENT SEDATED ON PROPOFOL DRIP. WOKEN UP EVERY FOUR HOURS FOR NEURO EXAM. WHEN AWAKE PATIENT OPENS EYES TO VOICE AND FOLLOWS ALL COMMNADS. MOVING ALL EXTREMITIES IN BED. PUPILS EQUAL AND REACTIVE TO LIGHT. VENTRICULOSTOMY OPEN AND PATENT AT 15CM ABOVE TRAGUS WITH DARK BLOOD TINGED DRAINAGE. ICP<10. R FEM SHEATH PULLED OUT PER NEUROSURGICAL RESIDENT AND TIP SENT FOR CULTURE.\n\nCONTINUES TO REQUIRE NIPRIDE DRIP TO MAINTAIN BLOOD PRESSURE LESS THAN 160 SYSTOLIC.\n\nLUNGS COARSE WITH MINIMAL SECRETIONS. NO VENT CHANGES TO DAY WITH PERIODS OF RR TO 40. VENT SYSTEM HUMIDIFIED AND LASIX GIVEN X 5MG. FEBRILE TO 101.5. TYLENOL GIVEN. BLOOD CULTURE AND URINE CULTURE SENT.\n\nTUBE FEEDS AT GOAL WITH MINIMAL RESIDUALS.\n\nPLAN:\nMONITOR RESP STATUS CLOSELY. WEAN OFF NIPRIDE AS ABLE.\n"},{"category":"Nursing/other","chartdate":"2165-06-29 00:00:00.000","description":"Report","row_id":1563079,"text":" 19/07\n\n NEURO PT REMAINS ON PROPOFOL DRIP FOR LIGHT SEDATION NOTE PT NEEDED HIGHER DOSE FROM 40 TO 70 MCG/KILO/MIN BECAUSE OF RAPID RESP MD MADE AWARE UNABLE TO FULLY AWAKE PT FOR Q4 HOUR CHECKS AGITATION STARTED THAN UNABLE TO CONTROL BP DESPITE NIPRIDE SEMI CHECKS DONE MD MAE WHEN PROPOFOL STOPPED ICP 5 TO 9 BLOODY IN COLOR\n RESP ETT .40% FIO2 RHONCHI THRU OUT CLEARS AFTER SUCTIONING\n HEART S1S2 NSR OCC PVC 12 BEAT RUN SVT K AT THAT TIME 3.8 REPLACED VSS PULSES POOR NIPRIDE NICARDIPINE STARTED FLUIDS RESTRICTED FREE WATER SUPP VIA N/G A LINE CVP WNL U/O WNL SEE FLOW SHEETS\n GI POS BS TUBE FEEDS WELL\n SUPPORTIVE CARE\n\n"},{"category":"Nursing/other","chartdate":"2165-06-29 00:00:00.000","description":"Report","row_id":1563080,"text":"pt.remains on simv+ps ventilation,abg alkalotic, will wean as , has periods of increased rr.\n"},{"category":"Nursing/other","chartdate":"2165-06-27 00:00:00.000","description":"Report","row_id":1563072,"text":"RESP: PT ON SIMV 12/700/5/+5/40%. ALARMS ON AND FUNCTIONING. AMBU/SYRINGE @ HOB. BS AUSCULTATED REVEAL BILATERAL COARSE SOUNDS. SUCTIONED FOR SMALL AMOUNTS OF THICK TANNISH SECRETIONS. VENT CHANGES PER ABG'S; DECREASED RATE TO 10/DECREASE VT TO 650/FIO2 TO 35%. AM ABG'S 7.47/36/107/27. 02 SATS @ 99%. RSBI=111. NO FURTHER CHANGES NOTED.\n"},{"category":"Nursing/other","chartdate":"2165-06-29 00:00:00.000","description":"Report","row_id":1563081,"text":"SHIFT REPORT\nNEURO: DIFFICULT TO AROUSE DESPITE OFF PROPOFOL. BECOMING MORE ALERT AS SHIFT PROGRESSES. INCONSISTENTLY FOLLOWING SIMPLE COMMANDS. OPENS EYES OCCASSIONALLY. NEUROSURG TEAM UPDATE FREQUENTLY, NEURO NP IN TO PT. KEEP SBP UNDER 170 PER DR. ORDERS. ICP 5 TO 7. SM AMT THICK BLOODY DRAINAGE OUT V. . CONT ON NICARDIPINE DRIP.\nCV: CENTRAL LINE CHANGED O/W TODAY. TIP SENT FOR CULT. TMAX 101.7 - PAN CULTURED PER SICU TEAM'S ORDERS. TYLENOL X1 W/ EFFECT.\nRESP: NO VENT CHANGES. SXN FOR SMALL AMT THICK, YELLOW/WHITE SPUTUM.\nENDOCRINE: BSUGARS 189 TO 159 COVERED VIA SSRI. TFEEDS DECREASED TO 80CC/HR. FREE WATER BOLUSES D/ MD.\nPLAN: WEAN NICARDIPINE TO MAINTAIN ORDERED PARAMETERS. PPF OFF WHILE LETHARGY RESOLVING.\n\n"},{"category":"Nursing/other","chartdate":"2165-06-29 00:00:00.000","description":"Report","row_id":1563082,"text":" ,04 19 TO 07\n PT STATUS MAE ON COMAND TRIES TO OPEN EYES WEAKNESS THRU OUT ON NO SEDATION PROGRESSIVE AWAKENING ALSO TRIES TO TALK AROUND TUBE NO PAIN WHEN ASKED\n\n HEART S1S1 OCC PVC NOTED PULSES POSITIVE 2 WITH 3+ PIT EDEMA TONES WNL VSS BP 150/90 MD PARAMETERS ON NICARIPINE 1.5 MCG/KILO/MIN CVP WNL ICP WNL ALL GOOD WAVE FORMS\n\n RESP CLEAR OCC RHONCHI CLEARS AFTER COUGHING CPT T&P Q2 HOURS ON .40 FIO2 SAT WNL\n\n ABD SOFT POS BS STOOLING T/F WELL NO RESIDUAL\n\n SUPPORTIVE CARE FAMILY SUPPORT\n"},{"category":"Nursing/other","chartdate":"2165-07-22 00:00:00.000","description":"Report","row_id":1563157,"text":"Respiratory Care\nPt dropping SAO2 to upper 80's, requiring vigorious ambu bagging and suctioning. FiO2 increased to 100%, decreasing to 50%. Suction and strong productive cough of copious amounts thick tan/blood tinged secreations.\n"},{"category":"Nursing/other","chartdate":"2165-07-22 00:00:00.000","description":"Report","row_id":1563158,"text":"NPN\n PT . OPENS EYES OCCASIONALLY WHEN TURNING, SUCTIONING, NOT ON COMMANDS. MINIMAL SPONTANEOUS MOVEMENT NOTED. . WILL GO TO CT THIS AFTERNOON\nCV- BP IN 120-130 RANGE. DROPPED TO 110'S FOR A BRIEF PERIOD, SPOKE TO NSURG AND MONITORED, NO MEDS GIVEN.\nRESP- CONTINUES TO HAVE BLOODY SECRETIONS, ABLE TO RAISE. O2 SAT DROPPED TO HIGH 80'S THIS AM, SUCTIONED FOR A PLUG. CHEST X-RAY DONE AND PT IS NOW 100% ON 50% TRACH COLLAR. NO FURTHER EPISODES.\nGI- BM TODAY, TF AT GOAL, WITH MINIMAL RESIDUAL.\nGU- FOLEY DRAINING 80-120CC/HR CLOUDY YELLOW URINE.\nID- AFEBRILE.\n"},{"category":"Nursing/other","chartdate":"2165-07-23 00:00:00.000","description":"Report","row_id":1563159,"text":"update\nneuro: ? moved rt thumb to command during am neuro rounds. otherwize .\ncv: 4 beat run v tach, resolved spontaneously.\ngi: tube feeds at 80/hr, well with min residuals. large BM x 1, hem neg.\ngu: u/o qs.\n? lp today. Need to turn off 4 hrs prior to tap.\n\n"},{"category":"Nursing/other","chartdate":"2165-07-23 00:00:00.000","description":"Report","row_id":1563160,"text":"See Carevue for objective data.\n\nNeuro exam . dc'd at 0900 in preparation for LP which was completed at 1600. Opening pressures: 10. No specimens were obtained. to be restarted at 2200.\n7 beat run of VT/hemodynamically stable and resolved spontaneously.\nBP 100-140 systolic.\nSuctioned and also expectorated on own blood tinged tan thick secretions. O2 sats adequate on trach collar.\nDuoderm on coocyx changed. Small stage 2 ulcer dime size cleansed and new duoderm applied.\nAdequate urine output. Tolerating TF with low residuals. FSBS per SS.\nWife in and updated on day's events.\n"},{"category":"Nursing/other","chartdate":"2165-06-27 00:00:00.000","description":"Report","row_id":1563073,"text":"condition update\nTEMP SPIKES TREATED WITH TYLENOL. DOES BECOME HYPERTENSIVE WITH TEMP ELEVATION. CULTURES PENDING\nONE EPISODE OF PERSISTENT HBP WHICH RESPONDED TO EXTRA PROPOFOL.\nLOPRESSOR @ BEDSIDE IN ANTICIPATION FOR WAKEUPS.\n\n"},{"category":"Nursing/other","chartdate":"2165-06-27 00:00:00.000","description":"Report","row_id":1563074,"text":"Respiratory Care Note:\n He remains sedated and intubated. Taken to anio this am without incident. BS bilat, coarse RUL. Suctioned for small-med amount of thick yellow tinged secretions. RR>20 with VE of >11lpm. Positive for fever this afternoon. Cultures pending. Plan to maintain overnight on SIMV. No vent changes made today. RSBI of 111 noted.\n"},{"category":"Nursing/other","chartdate":"2165-06-27 00:00:00.000","description":"Report","row_id":1563075,"text":"CONDITION UPDATE\nD. PT TO ANGIO TODAY=NO SPASMS AS PER DR. . BP PARAMETERS OF SBP 120-150 TO BE CONTINUED..\n TEMP UP TO 100.8 FOR WHICH PT WAS CULTURED AND TYLENOL GIVEN. POST ANGIO PT WAS ORDERED FOR IVF AT 100ML/HR FOR 1 LITER AND TF RESUMED..BY THIS PM AND AFTER 500ML OF IVF..O2 SAT DROPPED TO 94,RR=33,AND CVP CLIMBED TO 16..DR. NOTIFIED AND IVF DECREASED TO KVO. WITH NEED FOR KCL AND CAGLUC BOLI,CVP CONTINUED TO CLIMB AND DR. WAS NOTIFIED. HUO DOWN TO 60ML.\n NO VENT CHANGES TODAY.ABG ACCEPTABLE WHEN O2 SAT=98. FOR SCANT SECRETIONS..BS DECREASED IN BASES WITH SL RALES.\n PT REMAINS ON PROPOFOL AND NEURO EXAM REMAINS THE SAME..OFF PROPOFOL,PT FOLLOWS COMMANDS.ON PROPOFOL PT MOVES EXTREMITIES TO PAIN.ICP=.COLOR REMAINS DARK RED.\nA.? NEED FOR LASIX..MAINTAIN SBP 120-150.\nR.STABLE AT THIS TIME WITH POSSIBLE EARLY SIGNS OF FAILURE.\n"},{"category":"Nursing/other","chartdate":"2165-06-28 00:00:00.000","description":"Report","row_id":1563076,"text":"Condition Update\nD: See carevue flowsheet for specifics\n TMAX 101.1-tylenol given (patient cultured on day shift). SBP at beginning shift up to 175-lopressor 10mg given with no effect. Patient was then started on nipride gtt to keep sbp<160. Nipride currently infusing at 1mcg/kg/min. CVP ~9 and making 60-80cc/hr of urine. Slowly sats dropped to 94-95% with RR 26-29. SICU resident notified abg drawn and lasix 5mg given with mod amt of diuresis and sats rose to 96-97% paO2 slightly improved RR unchanged.\n Lungs remain coarse but only suctioning for small amt tan colored secretions. No vent changes made overnight.\n Propofol gtt turned off Q4hrs for neuro exam. When off sedation patient follows commands and moves all extremeties. ICP was running ~10 and then went down to 1-2. Vent @ 15 above the tragus and draining old colored blood. Right fem angio sheath in place and transduced.\nPLAN:\n Pulmonary toilet\n Monitor for si/sx of CHF\n Q4hrs neuro exam off sedation\n vent @15 open\n Keep sbp<160\n Notify H.O. with any changes.\n"},{"category":"Nursing/other","chartdate":"2165-06-28 00:00:00.000","description":"Report","row_id":1563077,"text":"Respiratory Care:\nPt remains on Mech Vent as per CareVue. No changes today, and he remains W/Met.Alk ?? Added a heated circut at about 18:30 today for added humidification...\n"},{"category":"Nursing/other","chartdate":"2165-07-24 00:00:00.000","description":"Report","row_id":1563161,"text":"NPN ( SEE CAREVUE FOR ALL SPECIFICS)\nNEURO- NEURO STATUS . NO SPONTANEOUS MOVEMENT. OCCASIONALLY OPENS EYES TO PAIN, NO TRACKING. . RESPONDS TO PAINFUL STIMULI BY SLIGHT MOVEMENT IN EXT. HEP. RESTARTED AND LP SITE MONITORED, NO OR DRAINAGE\nCV- BP 120-140'S. HR 70'S WITH FREQUENT PVCS, NSR.\nRESP- LUNGS CLEAR WITH DIMINISHED BASES. O2 SAT 100%. REQUIRES OCCASIONAL SUCTIONING DESPITE STRONG COUGH FOR THICK BLOOD TINGED SPUTUM. PT ABLE TO RAISE MAJORITY OF SECRETIONS.\nGI- ABD SOFT, NO BM. TF AT GOAL WITH NO RESIDUAL.\nGU- FOLEY DRAINING CLEAR YELLOW URINE, 100-300CC/HR.\nID- AFEBRILE.\n"},{"category":"Nursing/other","chartdate":"2165-07-24 00:00:00.000","description":"Report","row_id":1563162,"text":"STATUS\nD: NEURO ..REMAINS ON GTT @ 1250U\nA: VSS..GOOD HUO NO STOOL..PTT Q8H.. TRACH @ 70% SUCTIONED FOR MOD AMT THICK PINK TINGED/TAN SECREATIONS\nR: ESSENTIALLY \nP: TO GO TO REHAB TOMORROW..FAMILY AWARE\n"},{"category":"Nursing/other","chartdate":"2165-07-25 00:00:00.000","description":"Report","row_id":1563163,"text":"NPN (SEE CAREVUE FOR SPECIFICS)\nPT NEUROLOGICALLY. NO SPONTANEOUS MOVEMENT NOTED, MAE TO PAINFUL STIMULI, NOT LOCALIZING. . SUCTIONED FREQUENTLY FOR MODERATE AMOUNTS OF SPUTUM. HAD ONE EPISODE AT BEGINNING OF SHIFT WITH LARGE AMOUNT OF BLOODY SPUTUM RAISED FROM TRACH. DR. IN TO . NO INTERVENTION AND SPUTUM IS NOW PINK. COAGS FROM THIS AM PENDING. BP 100-140'S, HR 70'S WITH FREQUENT PVCS. TMAX 99.0. REHAB TODAY.\n"},{"category":"Nursing/other","chartdate":"2165-07-20 00:00:00.000","description":"Report","row_id":1563151,"text":" 19/07\n\n STATUS NO CHANGE MAE L>R COUGHING AND PAIN CREATES A RESPONDS OF WITHDRAWAL VSS NO TEMP ALINE GOOD WAVE\n\n HEART S1S2 ST DEPRESSION NOTED CHRONIC IN NATURE PULES WEAK EDENA RESOLVING MULTIFOCAL PVC NEG NVD\n\n RESP RHONCHI RALES CLEARS AFTER SUCTIONING .50 02 sat 99\n\n GI POS BS SMALL HEM POS STOOLS NOTED U/O QS CLEAR\n\n NOTE NEO TO MAINTAINE BP greater than 120 t/f wnl\n\n bp 140/78 98 temp 97 oral t/p well no pain\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2165-07-20 00:00:00.000","description":"Report","row_id":1563152,"text":"NEURO: NOTICED PT OPENING EYES X2 BUT NOT FOCUSSING AND NOT TRACKING, . RESPONDS TO NOXIOUS STIMULI BY WITHDRAWING ALL EXTREMETIES SLIGHTLY. PT STILL NOT FOLLOWING COMMANDS.\n\nCV: HR 70-90'S, NSR W/ PVC'S, SBP>120 PER PARAMETERS-GOOD RESPONSE ON MIDODRINE 2.5MG TIS. CVP 3-13.\n\nRESP: LUNG SOUNDS COARSE, LRG AMT SPUTUM SXN AND ALSO PT EXPECTORATING. SPUTUM YELLOW TO TAN AND INCREASINGLY BLOODY THIS AFTERNOON, SPUTUM CX SENT. O2 SAT >95% ON TRACH COLLAR 50%.\n\nGI: ABD SOFT NT ND,+BOWEL SOUNDS, TF IMPACT W/ FIBER AT GOAL 80CC/HR VIA PEG, SITE C/D/I. BM X1 GUAIAC NEG.\n\nGU: FOLEY DRAINING ADEQ U/O, CLEAR CONCENTRATED YELLOW.\n\nID: TMAX 97.4\n\nPLAN: CONT CURRENT MGMT\n"},{"category":"Nursing/other","chartdate":"2165-07-20 00:00:00.000","description":"Report","row_id":1563153,"text":" 19/07\n\n PT STATUS SLIGHTLY LIGHTER THIS PM OCC OPENS EYES SEEMS TO RESIST COMMUNICATION BY TIGHTLY SHUTTING EYES WHEN TALKED TO EXPLORES SELF WITH RIGHT HAND\n\n RESP BLOOD TINGED SPUTUM CLEARS HIMSELF VERY STRONG COUGH RHONCHI THRU OUT\n\n S1S2 PULES POS 2 PEDAL EDEMA REMAINS NSR WITH PVCS\n\n GI TF WELL F/S STOOL NEG HEM\n TALKED WITH WIFE AT REMAINS HOPEFUL LOOKING FOWARD TOWARDS REHAB\n\n"},{"category":"Nursing/other","chartdate":"2165-07-21 00:00:00.000","description":"Report","row_id":1563154,"text":"NEURO: PT OPENED EYES X2 HOWEVER NOT TRACKING, PUPILS UNEQUAL BUT BRISKLY REACT TO LIGHT, NSURG INFORMED. PT NOT FOLLOWING COMMANDS, NO SPONT/PURP MVMTS NOTED. GRIMACING AND WITHDRAWING SLIGHTLY TO PAIN W/ ALL 4 EXTREMETIES WHEN NOXIOUS STIMULI APPLIED TO NAILBED.\n\nCV: HR 70-80'S, NSR W/ PVC'S, SBP 120-150'S. CVP 8-11. +2 EDEMA.\n\nRESP: RR 20-30'S, O2 SAT 97-100% VIA TRACH COLLAR 50%. SXN PRN FOR THICK TAN SPUTUM AND CX SENT.\n\nGI: ABD SOFT NT/ND, +BOWEL SOUNDS, TOLERATING TF IMPACT W/ FIBER VIA PEG AT 80CC/HR AT GOAL, MINIMAL RESIDUALS.\n\nGU: FOLEY DRAINING ADEQ U/O, CLEAR TO CLOUDY URINE. DR. INFORMED, FOLEY TO BE CHANGED AND U/A TO BE SENT.\n\nID: TMAX 97.8\n\nPLAN: MONITOR VS, LABS, NEURO STATUS. ?LP THIS WEEK, ? CT HEAD TOMORROW.\n"},{"category":"Nursing/other","chartdate":"2165-07-21 00:00:00.000","description":"Report","row_id":1563155,"text":" 19/07\n\n pt status opens eyes on occ to verbal command in general lethargic moves with pain stimulus \n\n resp blood tinged sputum noted clears after coughing on .50 fio2 well sao2 100% CPT Q2 HOURS\n\n HEART S1S2 WNL OCC PVCS PULSES POS 2 THRU OUT U/O QS TUBE FEEDING WELL POS BS SMALL HEM NEG STOOL\n\n SUPPORTIVE CARE ROM CPT SKIN CARE PT CONSULT\n\n NOTE FRANK BLOOD AROUND STOMA OF PEG TUBE MOD AMOUNT NO EVENT PRIOR MD SITUATION T/F DC CLEAR RETURNS\n\n"},{"category":"Nursing/other","chartdate":"2165-07-21 00:00:00.000","description":"Report","row_id":1563156,"text":" CONT OF ABOVE NOTE AT 2100 PT BY MD AROUND PEG TUBE SITE ORDER TO KEEP DRESSING ON AND MONITOR PT\n"},{"category":"Nursing/other","chartdate":"2165-07-03 00:00:00.000","description":"Report","row_id":1563094,"text":"Resp: pt on a/c 10/600/+5/40%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral clear apecies with diminished LS. Suctioned for small to moderate amounts of thick yellow secretions. Sputum sample obtained and sent. 02 sats @100%. RSBI=113.5. AM ABG's 7.48/36/151/28. No further changes noted.\n"},{"category":"Nursing/other","chartdate":"2165-07-03 00:00:00.000","description":"Report","row_id":1563095,"text":"focus: status update\nDATA:\nDECREASED MENTAL STATUS THIS AM--NOT FOLLOWING COMMNADS CONSISTENTLY, NOT OPENING EYES TO VOICE, L SIDE APPEARED WEAKER THAN RIGHT. DR. NOTIFIED AND EVALUATED PATIENT. STAT HEAD CAT SCAN ORDERED AND DONE. NO BLEEDING PRESENT AND PRELIMINARY RESULTS STATE SLIHT VENTRICLE ENLARGEMENT. VENTRICULOSTOMY WAS DECREASED TO 10CM ABOVE TRAGUS. IT CONTINUES TO HAVE DARK BLOOD TINGED DRAINAGE. INTRACRANIAL PRESSURES SLIGHTLY LOWER THAN IN AM WHEN VENTRICULOSTOMY WAS AT 15CM. MENTAL STATUS HAS IMPROVED THROUGHOUT THE DAY AND PATIENT IS NOW LIFTING ARMS SLIGHTLY AND MOVING IN BED. OPENED EYES FOR WIFE VISITING. EEG DONE AT BEDSIDE. PUPILS EQUAL AND REACTIVE TO LIGHT. 3%NS STARTED FOR SODIUM LEVEL 129.\n\nCONTINUES ON NEOSYNEPHRINE IV DRIP TO MAINTAIN BLOOD PRESSURE AROUND 160-170 FOR CEREBRAL PERFUSION.\n\nHEPARIN DRIP STOPPED WHILE AT CAT SCAN NOW RESUMED AND INCREASED DUE TO LOWER PTT. NIVS ORDERED TO F/U. TOLERATING CPAP WITH 10 PRESSURE SUPPORT.\n\nTOLERATING TUBE FEEDS AT GOAL WITH MINIMAL RESIDUALS.\n\nCONTINUES TO DIURESE WELL.\n\nPLAN:\nSODIUM CHECKS Q2HRS WITH GOAL OF 135. PTT CHECKS Q6HRS. AND F/U WITH DR. FOR HEPARIN ORDERS. NIVS TODAY.\n\n"},{"category":"Nursing/other","chartdate":"2165-07-03 00:00:00.000","description":"Report","row_id":1563096,"text":"nursing update\nRun OF VT-11 beats. No spont kick in of pacer. MD aware. EKG done. cards to see.\n"},{"category":"Nursing/other","chartdate":"2165-07-04 00:00:00.000","description":"Report","row_id":1563097,"text":"Nursing note:\nNEURO: Lethargic in beginning of shift, difficult to arouse except to sternal rub. Following simple commands inconsistently. PERRLA. More wakeful later in night, opening eyes spontaneously and consistently following commands. Moving lower extremities on bed and wiggling toes, lifting/holding w/upper extremities. Hand grasps equal bilaterally. ICP 4-8. Ventricular 10cm above tragus, blood -tinged drainage.\nCV: Tmax 100.4, Tylenol given w/good effect. More easily arousable after temp normalized. Vpaced w/frequent PVCs, bigeminy at times. Palpable pulses. SBP kept 170 or > w/Neo gtt, frequently titrated. Nimodopine d/c'd per Dr. for better control of BP. Potassium repleted. NA levels checked q2hours, 3% NACl gtt infusing, decreased to 10cc/hr. Cont. on salt tabs. Heparin gtt increased to 1500u/hr d/t sub-therapeutic levels, bolused w/1000u as well.\nRESP: Returned to A/C rate d/t periods of apnea, low tidal volumes and tachypnea. ABGs less alkalotic after change. Suctioned for thick yellow sputum.\nGI: Abdomen softly distended. +Bowel sounds, +liquid brown stool. FIB changed. Cx. sent for cdiff. Tube feeds @ goal of 80cc/hr, minimal residuals.\nGU: Foley patent large amount pale yellow urine.\nENDO: SSRI PRN.\nSKIN: Intact. Small skin tear to coccyx, open to air.\n\nA/P: More alert overnight, following commands. SBP kept 170 or > w/Neo gtt. Cont. on 3% Sodium gtt and Heparin gtt. Monitor neuro status closely and q2hour labs, reattempt vent wean in am.\n\n"},{"category":"Echo","chartdate":"2165-06-25 00:00:00.000","description":"Report","row_id":93587,"text":"PATIENT/TEST INFORMATION:\nIndication: Chest pain. H/O cardiac surgery. Left ventricular function.\nHeight: (in) 71\nWeight (lb): 201\nBSA (m2): 2.12 m2\nBP (mm Hg): 124/57\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 12:05\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Left ventricular wall thicknesses are normal. The left ventricular\ncavity is mildly dilated. There is moderate regional left ventricular systolic\ndysfunction. There is no resting left ventricular outflow tract obstruction.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal anterior - hypokinetic; mid anterior -\nhypokinetic; basal inferior - akinetic; mid inferior - akinetic; basal\ninferolateral - akinetic; mid inferolateral - akinetic; anterior apex -\nhypokinetic; inferior apex - hypokinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is mildly dilated. There are focal calcifications in\nthe aortic root.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic. Mild (1+) aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is\nmoderate mitral annular calcification. There is mild thickening of the mitral\nvalve chordae. Mild to moderate (+) mitral regurgitation is seen. [Due to\nacoustic shadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. There is mild pulmonary artery systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Based on \nAHA endocarditis prophylaxis recommendations, the echo findings indicate a\nmoderate risk (prophylaxis recommended). Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data. The\nresults were reviewed with the Cardiology Fellow involved with the patient's\ncare.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is mildly dilated. There is moderate\nregional left ventricular systolic dysfunction with near akinesis of the\ninferior and inferolateral walls. The anterolateral wall is severely\nhypokinetic. The remaining walls contract well. Right ventricular cavity size\nand free wall motion are normal. The aortic root is mildly dilated. The aortic\nvalve leaflets (3) are mildly thickened but not stenotic. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets and supporting structures are\nthickened. Mild to moderate (+) mitral regurgitation is seen. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Mild left ventricular cavity enlargement wit extensive regional\nleft ventricular systolic dysfunction c/w multivessel CAD. Mild-moderate\nmitral regurgitation. Mild aortic regurgitation. Pulmonary artery systolic\nhypertension.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"},{"category":"Radiology","chartdate":"2165-06-27 00:00:00.000","description":"CAROTID/CEREBRAL BILAT","row_id":827965,"text":" 8:49 AM\n CAROT/CEREB Clip # \n Reason: S/P COILING\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 104\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT *\n * CAROTID/CEREBRAL BILAT VERT/CAROTID A-GRAM *\n * EXT UNILAT A-GRAM -52 REDUCED SERVICES *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Previously stent and coil intracranial wide neck left\n vertebral artery aneurysm. Rule out vasospasm.\n\n POSTOPERATIVE DIAGNOSIS: Stable appearance of the previously coiled aneurysm\n with patent left vertebral artery with small remnant at the neck of the\n aneurysm but stable appearance of the coil dome and no evidence of significant\n intracranial vasospasm.\n\n INDICATION: Mr. is a patient is patient who presented with subarachnoid\n hemorrhage from a ruptured wide neck aneursym. He underwent successful stent\n angioplasty with coiling of the aneurysm and is undergoing a cerebral artery\n to rule out the presence of intracranial vasospasm.\n\n CONSENT: The patient and her son were given a full and complete explanation\n of the procedure. Specifically, the indications, risks, and benefits and\n alternatives to the procedure were explained in detail. In addition, the\n possible complications such as the risk of bleeding, infection, stroke,\n neurological deficit or deterioration, groin hematoma, and other unforeseen\n complications including the risk of coma and even death were outlined. The\n patient and her son understood and wished to proceed with the operation.\n\n PROCEDURE IN DETAIL: The patient was brought in the endovascular suite and\n placed on the table in supine position. The right groin area was prepped and\n draped in the usual sterile fashion. A 19 gauge single wall needle was then\n used to puncture the right femoral artery and upon the return of brisk\n arterial blood a 4 FR vascular sheath was inserted over a guidewire and kept\n on a heparinized saline drip. Next a diagnostic catheter was used to\n selectively catheterize the following vessels over a guidewire in succession:\n Left subclavian artery, left vertebral artery, left common carotid artery,\n left internal carotid artery, right common carotid artery, right internal\n carotid artery.\n\n RESULTS: Injection of the left subclavian artery shows no atherosclerotic\n disease at the origin of the left vertebral artery and shows a small raised\n plaque distal to the origin of the left vertebral artery. The proximal left\n cervical segment of the vertebral artery shows antegrade flow with no anomaly.\n Intracranially with injection on the left vertebral artery with three\n dimensional rotational angiography showed that the previously deployed tandem\n stents are patent with no evidence of atherosclerotic involvement or intimal\n (Over)\n\n 8:49 AM\n CAROT/CEREB Clip # \n Reason: S/P COILING\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 104\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hyperplasia. The previously coiled aneurysm is stable in appearance with well\n treated dome and a small residual filling at the neck of the aneurysm.\n Injection of both common carotid arteries in the cervical region showed no\n significant atherosclerotic disease or dissection and they are not changed\n compared to the prior study. Injection of both internal carotid arteries on\n the right and the left with three dimensional rotational angiography showed no\n evidence of branch occlusion or significant vasospasm. There is presence of\n bilaterally mild vasospasm which is diffuse.\n\n IMPRESSION: Stable appearance of the previously coiled aneurysm with patent\n stent and presence of mild vasospasm which does not currently require any\n endovascular therapy.\n\n\n"},{"category":"Radiology","chartdate":"2165-06-21 00:00:00.000","description":"MULTI-PROCEDURE SAME DAY","row_id":827384,"text":" 3:26 PM\n CAROT/CEREB Clip # \n Reason: SAH\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 555\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL -51 MULTI-PROCEDURE SAME DAY *\n * PTA BRACHIOCEPHAL EA VESSEL -51 MULTI-PROCEDURE SAME DAY *\n * TRANSCATH PLCT STENTS, INITIAL -51 MULTI-PROCEDURE SAME DAY *\n * SEL CATH 3RD ORDER -59 DISTINCT PROCEDURAL SERVICE *\n * ADD'L 2ND/3RD ORDER TRANSCATH EMBO THERAPY *\n * F/U TRANS CATH THERAPY ANGIOPLASTY PERIPHERAL *\n * TRANSCATH INTRO STENT C1769 GUID WIRES INFU/PERF *\n * C1769 GUID WIRES INFU/PERF C1769 GUID WIRES INFU/PERF *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Subarachnoid hemorrhage from ruptured left\n intracranial wide-necked vertebrobasilar aneurysm in an isolated left\n vertebral artery posterior circulation with no presence of posterior\n communicating flow and a diminutive right vertebral artery providing only\n posterior-inferior cerebellar artery perfusion.\n\n POSTOPERATIVE DIAGNOSIS: Same status post stent angioplasty of the\n intracranial vertebral artery and left segment followed by coiling of the\n wide-necked aneurysm with preservation of the flow in the left vertebral\n artery in the posterior circulation and obliteration of the aneurysm using\n endovascular coiling.\n\n INDICATION: Mr. is a patient who presented with subarachnoid hemorrhage\n from a ruptured wide-necked fusiform aneurysm of the intracranial left\n vertebral artery which was found proximal to the critical stenosis of the\n vertebral artery. This aneurysm because of its appearance currently is not\n amenable to surgical therapy. At this location as well as the inability of the\n patient to tolerate temporary occlusion renders bypass procedure unacceptably\n high risk. In addition aneurysm, because of its size cannot be treated using\n coiling without some means of protecting the neck of the aneurysm. Imaging of\n the posterior circulation with CT angiography and CT scan had revealed a\n highly calcified left vertebral artery and the right vertebral artery does not\n provide any perfusion to the vertebrobasilar junction. These findings were all\n explained to the family and accordingly they gave approval for use of stent\n angioplasty as a means of treating the atherosclerotic stenosis followed by\n coiling of the aneurysm. Accordingly the patient was administered oral Plavix\n and aspirin prior to the beginning of the procedure and taken down to the\n angiography suite for this procedure.\n\n CONSENT: The patient's wife and son were given a full and complete explanation\n of the procedure. Specifically, the indications, risks, benefits, and\n alternatives to the procedure were explained in detail. In addition, the\n possible complications, such as the risk of bleeding, infection, stroke,\n neurological deficit or deterioration, groin hematoma, and other unforeseen\n complications, including the risk of coma and even death, were outlined. The\n patient's wife and son understood and wished to proceed with the operation.\n (Over)\n\n 3:26 PM\n CAROT/CEREB Clip # \n Reason: SAH\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 555\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\n placed on the table in supine position. The right groin area was prepped and\n draped in the usual sterile fashion. A 19-gauge single-wall needle was then\n used to puncture the right common femoral artery, and upon the return of brisk\n arterial blood, a 5 Fr vascular sheath was inserted over a guidewire and kept\n on a heparinized saline drip. Next, a diagnostic catheter was used to\n selectively catheterize the following vessels: left subclavian artery, left\n vertebral artery, left intracranial vertebral artery and posterior cerebral\n artery, and left intracranial aneurysm of the left vertebral artery. At this\n point a 5 Fr guidecatheter was placed into the left vertebral artery. Through\n that guidecatheter a series of angiographic runs with three-dimensional\n rotational angiography enabled us to define the lesion both aneurym and\n stenosis which needed treatment. At this point after inducing heparinization a\n SL-10 microcatheter was used over an Agility microwire to selectively\n catheterize the left posterior cerebral artery P2 segment. This was done by\n crossing the critical stenosis and bypassing the aneurysm. With the\n microcatheter in this position an Exelerator 0.014 inch 300cm exchange wire\n was placed into the distal posterior cerebral artery and this enabled us then\n to withdraw the SL-10 microcatheter. To that 2.5 x 15 mm long stent\n was navigated over the exchange wire and deployed across the stenosis distal\n to the aneurysm with coverage of the neck of the aneurysm. With the stent in\n this position an angiographic run was performed and the stent was deployed at\n 2-4atm above its nomimal pressure which enabled us to obtain a good position\n of the stent. The balloon was then deflated and the balloon was then\n withdrawn. An angiographic run at this point showed successful treatment of\n the distal stenosis distal to the aneurysm with good flow through the left\n vertebral artery and its basilar artery. Leaving the 300 cm exchange wire\n across the stent and in the distal P2 segment of the posterior cerebral artery\n an angiographic run was performed five minutes following deployment of the\n stent which revealed that the flow through the left vertebral artery had\n closed off completely distal to the proximal portion of the stent. At this\n point there was no longer flow in the basilar segment. To that end examination\n of the proximal portion of the stent with three-dimentional rotational\n angiography revealed that the proximal portion of the stent had been crimped\n on itself probably as a result of the highly calcific left vertebral artery.\n To that end an additional 2.5 mm x 9 mm stent was advanced over the exchange\n wire and with its distal portion abutting the proximal struts of the\n previously deployed stent with the stent in this position it was inflated to\n its nominal size and at this point the balloon was withdrawn. Angiography of\n the left vertebral artery at this point showed resumption of flow through the\n basilar artery with no evidence of branch occlusion and excellent\n reconstitution of the stenotic left vertebral artery. Further surveillance\n revealed that the segment in between the stents where the two stents\n overlapped again showed progressive restenosis and loss of flow to the distal\n (Over)\n\n 3:26 PM\n CAROT/CEREB Clip # \n Reason: SAH\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 555\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n basilar artery. At this point a noncompliant 2.75 mm Charger balloon was\n deployed over the exchange wire and positioned across the portion of the left\n vertebral artery between the two stents. This was then inflated to 2.5 x 2.75\n mm and the balloon was then withdrawn. At this point angiography revealed that\n the previously calcific stenosis had in fact had been successfully treated\n with a noncompliant balloon with resumption of distal flow in the basilar\n artery and reconstitution of flow in the left vertebral artery. Three-\n dimensional rotational angiography now revealed that the stenotic segment of\n the left vertebral artery had now been successfully treated with stent\n angioplasty and deployment of both stents. Our attention was then turned to\n the aneurysm. To that end a microcatheter was then positioned of type SL-10\n into the aneurysm through the struts of the 1st depolyed ABE stent. With the\n microcatheter in this position a GDC coil three-dimensional coil was deployed\n following a series of smaller ultrasoft GDC coils. This resulted in complete\n embolization of the dome of the aneurysm with a small .5 mm to 1 mm remnant\n neare the neck of the aneurysm. Additional attempts at treating that small\n remnant resulted in coil herniation into the parent vessel through the struts\n and as such were abandoned. At the end of the procedure three-dimensional\n rotational angiography showed excellent treatment of the aneurysm with no\n further opacification of the dome and patent left vertebral artery with no\n further stenosis and improved distal flow particularly of the left posterior\n cerebral artery which now fills from the left vertebral artery injection.\n\n IMPRESSION: Successful intracranial stent angioplasty of the highly stenotic\n and calcified left vertebral artery with coil through stent embolization of\n the wide-necked aneurysm without iatrogenic branch occlusions.\n\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2165-06-21 00:00:00.000","description":"ADD'L 2ND/3RD ORDER","row_id":827340,"text":" 9:17 AM\n CAROT/CEREB Clip # \n Reason: SAH\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 240\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT *\n * VERT/CAROTID A-GRAM VERT/CAROTID A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE EXT BILAT A-GRAM *\n * -52 REDUCED SERVICES C1760 CLOSURE DEVICE VASC IMP/INS *\n * C1894 INT/SHTH NOT/GUID EP NON-LASER *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Subarachnoid hemorrhage.\n\n POSTOPERATIVE DIAGNOSIS: Fusiform aneurysm of the left vertebral artery with\n severe distal intracranial and proximal intracranial left vertebral artery\n atherosclerosis, no evidence of posterior communicating artery connecting the\n anterior to the posterior circulation and a diminutive right vertebral artery\n ending in a distribution of the right posterior-inferior cerebellar artery.\n\n ANESTHESIA: General endotracheal anesthesia.\n\n INDICATION: Mr. presented with a subarachnoid hemorrhage and was\n transferred to the . He is currently\n undergoing this cerebral angiogram to determine the site of his intracranial\n aneurysm and subsequently to determine optimal therapy.\n\n CONSENT: The patient's wife and her son were given a full and complete\n explanation of the procedure. Specifically, the indications, risks, benefits,\n and alternatives to the procedure were explained in detail. In addition, the\n possible complications, such as the risk of bleeding, infection, stroke,\n neurological deficit or deterioration, groin hematoma, and other unforeseen\n complications, including the risk of coma and even death, were outlined. The\n patient's wife and her son understood and wished to proceed with the\n operation.\n\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\n placed on the table in supine position. The right groin area was prepped and\n draped in the usual sterile fashion. A 19-gauge single-wall needle was then\n used to puncture the right common femoral artery, and upon the return of brisk\n arterial blood, a 4 Fr vascular sheath was inserted over a guidewire and kept\n on a heparinized saline drip. Next, a diagnostic catheter was used to\n selectively catheterize the following vessels: right common carotid artery,\n right internal artery, left common carotid artery, left internal carotid\n artery, left subclavian artery, left vertebral artery, right subclavian\n artery, right vertebral artery.\n\n RESULTS: Injection of the left subclavian artery showed minimal\n (Over)\n\n 9:17 AM\n CAROT/CEREB Clip # \n Reason: SAH\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 240\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n atherosclerotic change and a small raised plaque accounting for approximately\n 20% stenosis at the proximal left vertebral artery distal to its origin. The\n left vertebral artery is otherwise without significant atherosclerosis in the\n cervical segment. Intracranially, the left vertebral artery appears to \n a fusiform wide-necked aneurysm in the intracranial portion just proximal to\n the severe greater than 70% atherosclerotic stenosis. Proximal to this\n fusiform aneurysm is also present an atherosclerotic lesion which is more\n diffuse and less severe than the distal one. The left vertebral artery appears\n to be dominant and the basilar trunk is somewhat diffusely narrowed possibly\n as a result of the proximal atherosclerotic stenosis. The posterior cerebral\n artery is otherwise within normal limits and it appears that the left\n posterior cerebral artery territory is mostly fed by a left posterior\n communicating artery. The left posterior-inferior cerebellar artery origin is\n normal. Injection of the right subclavian artery showed no significant\n atherosclerotic disease at the origin of the right vertebral artery. Injection\n of the right vertebral artery showed it to be small in caliber and in the\n cervical segment it appeared to mostly end in a partial distribution of the\n right posterior-inferior cerebellar artery. The posterior-inferior cerebellar\n artery has a segmental region of mild atherosclerosis distal to its origin off\n of the right vertebral artery. Injection of the right common carotid artery\n shows no significant atherosclerotic disease in the cervical region and\n intracranially shows no evidence of intracranial aneurym shows no vascular\n malformation. The right external carotid artery injection was within normal\n limits with no abnormal arteriovenous shunting. Injection of the left internal\n carotid artery with three-dimensional rotational angiography failed to show\n any evidence of atherosclerosis intracranially or aneurysmal dilatation. The\n left external carotid artery injection revealed no evidence of abnormal\n arteriovenous shunting or dural fistula to account for the patient's\n subarachnoid hemorrhage.\n\n IMPRESSION: Fusiform wide-based aneurysm of the intracranial portion of the\n left vertebral artery measuring approximately 5.5 mm with a neck of\n approximately 6 to 7 mm. This is present just proximal to a critical high-\n grade stenosis and is not amenable to unassisted coil embolization. These\n findings will be discussed with the patient's family in order to determine\n optimal therapy given the high-risk nature of the lesion.\n\n\n\n\n"},{"category":"ECG","chartdate":"2165-07-19 00:00:00.000","description":"Report","row_id":243887,"text":"Sinus rhythm\nST-T changes may be nonspecific\nSince previous tracing of , the rhythm has reverted from flutter to\nsinus rhythm\n\n"},{"category":"ECG","chartdate":"2165-07-08 00:00:00.000","description":"Report","row_id":243888,"text":"Atrial flutter with rapid ventricular response\n2:1 A-V block atrial tachycardia 1:1\nPossible inferior infarct - age undetermined\nLVH with secondary ST-T changes\nSince previous tracing, new supraventricular tachycardia\nClinical correlation is suggested\n\n"},{"category":"ECG","chartdate":"2165-07-07 00:00:00.000","description":"Report","row_id":243889,"text":"Sinus rhythm\nVentricular premature complex es and ventricular couplets\nProbable left ventricular hypertrophy\nSince previous tracing, no significant change\n\n"},{"category":"ECG","chartdate":"2165-07-08 00:00:00.000","description":"Report","row_id":243890,"text":"Sinus rhythm with atrial premature complexes\nInferior/lateral ST-T changes\nSince previous tracing, ventricular ectopic activity no longer present. ST-T\nwave abnormalities more marked\n\n"},{"category":"ECG","chartdate":"2165-07-03 00:00:00.000","description":"Report","row_id":243891,"text":"Sinus rhythm. Left atrial abnormality. Low amplitude P wave. P-R interval 0.18.\nFrequent ventricular and occasional atrial ectopy. Precordial voltage for left\nventricular hypertrophy. Compared to the previous tracing of no\ndiagnostic interim change.\n\n"},{"category":"ECG","chartdate":"2165-07-01 00:00:00.000","description":"Report","row_id":243892,"text":"Sinus rhythm\nBigeminal PVCs\nLateral ST-T changes\nSince previous tracing, ventricular premature complex are new\n\n"},{"category":"ECG","chartdate":"2165-06-24 00:00:00.000","description":"Report","row_id":243893,"text":"Sinus rhythm\nLateral ST-T changes\nSince last ECG, no significant change\n\n"},{"category":"ECG","chartdate":"2165-06-21 00:00:00.000","description":"Report","row_id":243894,"text":"Sinus rhythm with frequent PVCs\nIV conduction defect\nSince previous tracing, ventricular premature complexes noted\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563068,\n \"text\": \"CONDITION UPDATE\\nD. THIS AM DESPITE ACCEPTABLE ABG'S ON BIPAP MASK,RR=36-44.DECISION TO INTUBATE MADE AND WAS PERFORMED BY ANESTHESIA AFTER PRE- SEDATION .ETT CONFIRMED BY CXR AND PT WAS STARTED ON PROPOFOL DRIP.ABG ACCEPTABLE POST INTUBATION(SEE FLOW SHEET FOR SETTINGS AND CHANGES).\\n TEMP UP TO 100.9 OCCASSIONAL SHIVERING WITH SKIN SURFACE COOL.SR 70-90 WITH ECTOPY AT TIMES.RR= 14-22 ON VENT WITH O2 SATS=98 ON 40% FIO2. SBP 120-150.CVP MOST OF DAY .\\n ONCE CARDIOLOGY EVALUATED PT ALONG WITH CURRENT DATA FROM CARDIAC ECHO,DECISION WAS MADE BY SICU TEAM AND CONFIRMING WITH CARDIOLOGY AND NEUROSURG TEAMS,PT WAS GIVEN LASIX WITH GREAT DIURETIC RESPONSE. CVP DECREASED TO 10.SBP PARAMETER WAS CHANGED THIS AM TO 140-150 PER DR. ALLOWING NIPRIDE TO BE WEANED OFF SINCE INTUBATION AND SEDATION ON BOARD.\\n DESPITE PT BEING ON PROPOFOL 25MCQ,PT DOES RESPOND TO PAIN,MOVING ALL EXTREMITIES BUT NOT FOLLOWING COMMANDS.AFTER SCHEDULED HEAD CT SCAN THIS PM,NEURO CHECK WAS PERFORMED OFF OF PROPOFOL. PT FOLLOWED ALL COMMANDS,MOVING ALL EXTREMITIES. PT TO ATTEMPT TO EXTUBATE HIMSELF BUT PROTECTIVE WRIST RESTRAINTS PREVENTED THIS FROM OCCURING.ICP- AND DRAINING VARYING DEGREES OF RED COLOR.\\n A.CHECK COMPLETE NEURO EXAMS Q 4-6 HRS PRN.MAINTAIN SBP 120-150.ICP TO REMAIN AT 15CM ABOVE TRAGUS AND OPEN .\\nR.CONDITION REMAINS GUARDED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563069,\n \"text\": \"RESPIRATORY CARE:\\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. Patient changed over to IMV this shift for a paco2 if 29.(goal range 35-40.) Current settings IMV/PS 700*12 40%fio2 with 5 peep and 5ps. Breathsounds are coarse. Please see respiratory section of carevue for further data. RSBI this am 62.2 Patients respiratory rate started to climb while doing RSBI.\\nPlan: Continue mechanical ventilation. Wean as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563070,\n \"text\": \"CONDITION UPDATE\\n\\nPROPOFOL STOPPED Q 4 HR FOR NEURO CHECKS PT FOLLOWS COMMANDS WITH APPROPRIATE MOVEMENT. NIPRIDE NOT NEEDED SBP < 150 MOST OF NOC.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563071,\n \"text\": \"CONDITION UPDATE\\nD.TEMP SPIKE THIS AM TO 102 FOR WHICH LINE BC DRAWN AND TYLENOL WAS GIVEN.WITHIN 1 HR,SBP DROPPED TO 80,CVP=9(SCHEDULED ANTIHYPERTENSIVES WERE GIVEN DURING THIS HOUR). PT WAS DIAPHORETIC AT THIS TIME.SICU TEAM WAS NOTIFIED AND LR BOLUS OF 500ML WAS GIVEN ALONG WITH TURNING PROPOFOL OFF UNTIL BP RETURNED.SBP SLOWLY ROSE AND REMAINED 119-130/70.HYDRALAZINE WAS D/C'D.\\n PT AWOKE TO GENTLY ATTEMPT TO REACH HIS ET TUBE AND PROPOFOL WAS RESTARTED.\\n PT HAS BEEN ABLE TO FOLLOW ALL COMMANDS,MOVING ALL EXTREMITIES AND ATTEMPTING TO FORM WORDS WITH MOUTH WHEN OFF OF PROPOFOL.ON PROPOFOL TO WITHDRAWS EACH EXTREMITY TO PAIN.ICP 4-10 AND LESS BLOODY CSF.\\n NO VENT CHANGES MADE.PT FOR MINIMAL SECRETIONS.\\n WIFE AND SON IN TODAY AND UPDATE WAS GIVEN BY MYSELF AND THEN DR. .\\nA.CONTINUE TOMAINTAIN SBP 120-150.TO ANGIO TOMORROW PM PER DR. FOR FOLLOW-UP.\\nR.STABLE AT THIS TIME.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563141,\n \"text\": \"NEURO: PT OPENED EYES TO PAINFUL STIMULI X1, . NOT FOLLOWING COMMANDS, NO SPONT MVMT NOTED, WITHDRAWS ALL 4 EXTREMETIES TO NOXIOUS STIMULI APPLIED TO NAILBED. VENT DRAINING SMALL AMT CLEAR FLUID THEN CLAMPED PER NSURG-LEVELLED AT 0CM ABOVE TRAGUS, ICP 0-9.\\n\\nCV: HR 70-80'S, NSR W/ FREQUENT PVC'S. SBP PARAMETERS 160-180, REMAINS ON NEO GTT AND TITRATED ACCORDINGLY. HEP GTT REMAINS ON, PTT GOAL 40-50.\\n\\nRESP: LUNG SOUNDS DIMINISHED, O2 SAT >95% ON TRACH COLLAR AT 50%. SXN PRN FOR THICK BLOOD CLOTS AND TAN SECRETIONS. PT NOTED TO HAVE BRIEF EPISODE OF APNEA AND STOKING RESPIRATIONS, ABG DRAWN-UNREMARKABLE, DR. AND NSURG INFORMED, CONT TO MONITOR.\\n\\nGI: ABD SOFT NT/ND, +BOWEL SOUNDS, TOLERATING TF AT GOAL AT 80CC/HR W/ MINIMAL RESIDUALS.\\n\\nGU: FOLEY DRAINING ADEQ U/O CLEAR PINK TINGED W/ SEDIMENTS.\\n\\nID: TMAX 98.5\\n\\nPLAN: MONITOR VS, LABS, RESP STATUS, NEURO STATUS. AWAITING PEG PLACEMENT. CONT CURRENT MGMT.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563142,\n \"text\": \"Resp Care\\nPt. remains on 50% cool aerosol mask tolerating well. ABG: adequately oxygenated with a metabolic alkalosis.\\nBs: equal bilat. coarse secreations minimal, pt. has strong cough. Inner cannula patent with ess. equipment at bedside.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563143,\n \"text\": \" \\\"N\\\" Nsg Progress Note:\\n\\nCVS: Pulses present. Skin cool and dry. Afebrile. HR=79-89 NSR with quadrigeminy. SBP=165-177 with IV Neo drip titrate to keep SBP between 160 and 180. Currently at 3mcg/kg/min. IV drip at 1200u/h goal to keep PTT=40-60. CVP=. ICP=.\\n\\nNeuro: Pt is minimally responsive. Opens eyes slightly with stimulation. No movements of extremities. No grimacing. No seizure activity.\\n\\nResp: Trach collar with 50% O2 tolerated well. Bloody secretions noted. Sats=99-100%. RR=30's mostly. Lung sounds clear but diminished at bases.\\n\\nSkin: Small ecchymotic areas on torso and rt arm. Peri area slightly reddened-aloe ointment applied. Coccyx area shows small purple area but no breakdown as yet, on air mattress.\\n\\nGI: +bowel sounds. Incontinent soft brown stool, guaiac -. TF at goal of 80cc/h of Impact with fiber.\\n\\nGU: U/O=90-140cc/h.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563144,\n \"text\": \"NEURO: PT UNABLE TO OPEN EYES, NOT FOLLOWING COMMANDS, NO SPONT/PURP MVMTS OBSERVED. PT WITHDRAWING TO NOXIOUS STIMULI APPLIED TO NAILBED. VENT REMAINS AT 0CM ABOVE TRAGUS, DRAINING CLEAR FLUID, ICP 1-7. HEAD CT DONE TODAY AND LP DONE W/ OPENING PRESSURE 12.\\n\\nCV: HR 70-80'S, NSR W/ PVC'S, SBP 160-170'S-NEO TITRATED TO KEEP SBP160-180, CVP 2-9. HEP GTT STOPPED FOR LP.\\n\\nRESP: REMAINS ON 50% O2 ON TRACH COLLAR W/ SATS 98-100%. LUNG SOUNDS COARSE. SXN PRN FOR THICK SPUTUM. IRREGUALR RESP PATTERN.\\n\\nGI: ABD SOFT/NT/ND, +BOWEL SOUNDS, TOLERATING TF IMPACT W/ FIBER AT 80CC/HR AT GOAL W/ MINIMAL RESIDUALS.\\n\\nGU: FOLEY DRAINING ADEQ U/O, CLEAR YELLOW URINE.\\n\\nID: TMAX 97.9\\n\\nPLAN: MONITOR VS, LABS, RESP STATUS, NEURO STATUS. PT CONSULT DONE TODAY, CASE MGMT CONSULT PENDING. AWAITING PEG PLACEMENT\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563145,\n \"text\": \"Resp Care\\nPt. on 40% cool aerosol tolerating well with spo2 99%. RR 20-30.\\nBs: coarse with occ. rhonchi sxn'd for copious bloody thick plugs. Also pt. has strong cough and occ. expectorates independantly. Inner cannula changed and patent. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563061,\n \"text\": \"CONDITION UPDATE\\nNEURO: PROPOFOL OFF AT 0800. PT OPENS EYES TO COMMAND, MAE ON BED TO COMMAND. ICP 4-14. VENT DRAIN AT 15 ABOVE TRAGUS WITH MOD AMT BLOOD TINGED DRAINAGE. SPEECH DIFFICULT TO UNDERSTAND POST-EXTUBATION. ORIENTED TO PERSON, STATES HE IS AT . HEAD CT DONE THIS AM\\nCV: AFEBRILE. SNP TITRATED TO MAINTAIN SBP 100-130 PRESENTLY ON 0.75 MCQ/KG/MON. PT GIVEN EXTRA DOSE OF HYDRALAZINE IV AT 1600. SEE CAREVUE FOR SPECIFICS\\nRESP: PT WEANED AND EXTUBATED BY 1400. OPEN FACE TENT WITH GOOD ABG AND SATS. BS COARSE. CPT DONE X 1. COUGHING BUT NOT RAISING\\nGI: TF HELD PRIOR TO EXTUBATION. ABD SOFT AND NON-TENDER, +BS\\nGU: CLEAR YELLOW VIA FOLEY IN ADEQUATE AMTS\\nENDO: NO ISSUES\\nA: NEURO STATUS MONITORED, NIPRIDE TITRATED AS ORDERED, HEAD CT DONE, EXTUBATED\\nR: EXTUBATION, IMPROVING NEURO STATUS- CONTINUE TO MONITOR CLOSELY\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563062,\n \"text\": \"Respiratory Care Note:\\n Patient weaned and extubated after repeat head CT was cleared. He coughs and follows basic commands but still appears sleepy. Propofol off since app 8am. BS now with upper airway congestion on occassion. No wheezing noted. He is on a continuous cool aerosol at 40% via face tent with good abg results. See Carevue flowsheet. Plan to help with pulmonary hygiene as needed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563063,\n \"text\": \" cont of previous note 0010 pt increase agitation remains alert denies pain resp rapid rate 28 to 32 chest clear vss icp wnl moving hands around picking md brought to bedside to help with eval abg done wnl for pt chest xray mso4 given far response supportive care gradual improvment\\n plan wean nipride pt/ot\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563064,\n \"text\": \" 0500 cont pt resp status borderline wbc 16 rales sob i>o md made aware lasix and pan culture done well u/o ^^^ see notes less sob\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563065,\n \"text\": \"CONDITION UPDATE:\\nD/A: T MAX 99.0\\n\\nNEURO: AROUSABLE TO VOICE, FOLLOWS COMMANDS, . AWARE OF PERSON AND PLACE, NOT TIME. PAIN X1 TREATED WITH MORPHINE WITH GOOD EFFECT. MAE'S, STRENGTHS EQUAL, STRONG. SPEAKING APPROPRIATELY WITH WIFE. VENTRICULOSTOMY REMAINS @ 15 CM ^ TRAGUS WITH ICPS . CPP AT ~ 55-70 WITH THE TIGHT BLOOD PRESSURE PARAMETERS, PA CHIP AWARE.\\n\\nCV: HR 70'S-104 LOPRESSOR X2 WITH + EFFECT. PT WITH RESP DISTRESS/CHF PER CHEST XRAY. LASIX X1 IN AM WITH EXCELLENT EFFECT (1 LITER OUT IN FIRST HOUR). IN AFTERNOON LASIX X1 AGAIN, NOT AS EFFECTIVE, ~ 280 CC'S OUT WITH RESP DISTRESS CONTINUING. GOAL ABP 100-120 MET WITH TITRATION OF NIPRIDE ALONG WITH ATC ANTIHYPERTENSIVE MEDS. NIMDIPINE TRANSIENTLY DROPS PT'S PRESSURE TO 80'S AND THEN RETURNS TO PREVIOUS LEVEL. MN-1700 FLUID BALAND -1000 CC'S. HEPARIN GTT D/C'D THIS AM, RIGHT FEMORAL SHEATH D/C'D ~ 1200. PT BE SITTING MORE UPRIGHT @ 1800.\\n\\nRESP: LS COARSE/DIFFICULT TO AUSCULTATE AS PT MAKES UPPER AIRWAY NOISE THAT REVERBERATES THROUGHOUT LUNGS. ? STRIDOROUS? ABG 0800: 7.42, 33, 98, 22, -1. IN AM PT'S RESP DISTRESS PICTURE IMPROVED WITH LOPRESSOR AND LASIX. IN AFTERNOON PT PRESENTED AGAIN WITH INCREASE RR TO 40'S, O2 SATS TO ~ 90%, LOPRESSOR AND LASIX GIVEN WITH POOR EFFECT, PT WITH COOL NEB FACE TENT, ABG: 7.46, 31, 76, 23, 0, 97. HIGH FLOW HUMIDIFIED SYSTEM APPLIED WITH O2 SATS IMPROVING TO ~ 96%, HOWEVER RESP RATE CONTINUES TO BE ~ 40. REPEAT ABG PENDING.\\n\\nGI: TUBE FEEDS STOPPED PER DR. DUE TO POOR RESP PICTURE. + BS, NO BM. ~ 100 CC'S OUT OF NGT.\\n\\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\\n\\nSX: WIFE AND SON VISITING AND UPDATED BY DOCTORS.\\n\\nR: LOW GRADE TEMP, WITH POOR RESP STATUS AND CHF. IMPROVED NEUROLOGICAL STATUS.\\n\\nP: CONTINUE CLOSE MONITORING AND MANAGEMENT. ? INTUBATION IF RESP EFFORT REMAINS LABORED. ECHO ORDERED, UNABLE TO OBTAIN TODAY ( DAY). ? PLACE PA CATHETER TO ADRESS FLUID STATUS MORE CLOSELY IF RESP/CV PICTURE DOES NOT IMPROVE. CONTINUE TO TITRATE NIPRIDE GTT FOR GOAL SBP 100-120. LAST SET OF CARDIAC ENZYMED DUE @ MN. PT AND FAMILY SUPPORT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563066,\n \"text\": \"CONDITION UPDATE\\nNEURO: OPENS EYES TO NAME, ORIENTED TO SELF ONLY, ASKING WHY HE IS IN THE HOSPITAL, FOLLOWS COMMANDS- MAE WITH EQUAL STRENGTH, ICP 4-14, VENT AT 15CM ABOVE TRAGUS WITH MOD AMT BLOOD TINGED DRAINAGE. SPEECH CLEARER THAN YESTERDAY. SNP GTT TITRATED TO MAINTAIN SBP 100-120.\\nCV: T MAX 99.8, HR ELEVATED TO 104- LOPRESSOR 10MG IV GIVEN WITH SUBSEQUENT DROP TO 70-80'S, PT HAVING FREQUENT PVC'S.\\nRESP: PT ON HIGH FLOW MASK AT BEGINNING OF SHIFT. RESP LABORED WITH SATS 93-95%, PT CHANGED TO CPAP MASK WITH 15 IPS WITH IMPROVEMENT IN SATS BUT RESP RATE STILL REMAINS ELEVATED IN HIGH 20'S-35. ALBUTEROL NEB TX X2.\\nGI: NPO, NGT TO LCWS WITH MOD AMT BILIOUS DRAINAGE. ABD SOFT AND NON-TENDER WITH +BS\\nGU: NO LASIX THIS SHIFT, HUO 28-60\\nA: NEURO STATUS AND RESP STATUS MONITORED, NT SX X 1 FOR SM AMTS THICK TAN SECRETIONS.\\nR: RESP STATUS REMAINS GUARDED- CONTINUE TO MONITOR SATS AND ABGS_ ? INTUBATE\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563067,\n \"text\": \"resp care\\npt re-intubated this shift d/t imp resp fail. oett #7.5 secured 23cm @lip. oett plcmnt confirmed via +etco2, cxr. pt placed on vent, see carevue for settings/changes. pt tx w/o incident to /from ct scan. b/s coarse sxn thk tan, spec sent to lab. plan: cont w/mech support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563146,\n \"text\": \"7a-3p\\nneuro: , withdraws to pain, no response to command, vent dc'd @ 1145, no change in nuero status post removal, to have head ct tomorrow\\n\\ncv: hr nsr, occasional pvc's, sbp 148-164, continues on neo gtt, goal sbp 150-170, continues on po lopressor\\n\\nresp: on 50% trach collar, rr 20-38, sat 100, sux mod amt thick bld tinged tan sputum, pt coughing productively, no resp distress noted\\n\\ngi: goal tf well, no stool, po prevacid, tf off for bedside PEG @ 1600\\n\\ngu: foley patent, clear yellow urine, good uo\\n\\nother: gtt continues @ 1200u/hr, to be dc'd @ 1500 for PEG insertion, family in & updated on pt's condition,\\n\\nplan: continue to monitor respiratory/neuro status, head ct in am, possible vp shunt\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563147,\n \"text\": \"NPN 0700-1500;\\nNEURO; OPENS EYES OCCASSIONALLY TO NOXIOUS STIMULI PERLA 3MMREACTS BKS.WITH DRAWS TO PAIN LT MORE THAN RT.GRIMACES OCCASSIONALLY WITH PAIN BUT NOT CONSISTENTLY.TRAVELLED FOR CT THIS AM AWAITING RESULTS.\\n\\nRESP;LUNGS COARSE, IRREG BREATHING AT TIMES SUCTIONED FOR PROFUSSE AMIUNTS THICK BEIGE SECRETIONS Q3. STRONG PRODUCTIVE COUGH POS GAG.SATS 97%-\\n\\nCVS; 96.5 PO NSR WITH OCCASIONAL PVC. PT WITH . WEANING NEO FOR SYS BP GREATER THAN 120 SLOWLY,\\n\\nGU ; MOD DIURESIS THROUGH FOLEY.\\n\\nGI POS BS NO FLATUS NO STOOL. STARTED T/F VIA PEG,IMPACT WITH FIBRE AT 10 MLS TO ADVANCE 10 CC /HR Q4 TO GOAL OF80 MLS/HR. BS ON RISS NPH 2UNITS THIS AM AS BS 80S BS AT 12 93.\\n\\nINTEGRUM UNCHANGED DUODERM INTACT OVER COCCYX.\\n\\nSOC; WIFE INTO VISIT AND UPDATED WITH CURRENT CONDITION SPOKE WITH CASEMANAGER ABOUT BEING SCREENED BY \\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563148,\n \"text\": \"RESPIRATORY CARE\\nPt remains on 40% Trach Mask, transported to and from CT. Aerosol maintained.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563149,\n \"text\": \"7p-7a; Full assessment in flow sheet.\\n\\nneuro; Only respond to painful stimuli - stronger withdrawal to pain on the right versus left side. Slight movement of ext - inconsistent movement. Do not open eyes. do not follow commands. Do not track. - 3 mm brisk. Good gag and cough reflex. head dressing site d/c/i.\\n\\ncv; NSR with PVC. Neo drip titrate to maintain SBP >120 - slowly weaning to off. warm, dry, no edema. afebrile.\\n\\nresp; Clear/coarse lung sound. Trach collar - 40% - SaO2 >100%. Trach care done. Productive cough - moderate thick/tan sputum.\\n\\ngu/gi; soft abd. +BSX4. no bm. G-tube - site d/c/i, +placement, minimal residual - working to goal of TF at 80 cc/hr.\\n\\nPlan; Continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563150,\n \"text\": \"NEURO: NOTICED PT OPEN EYES VERY SLIGHTLY X1 ONLY HOWEVER UNABLE TO FOLLOW COMMANDS NOR MOVE EXTREMETIES SPONT/PURP. WITHDRAWING W/ ALL 4 EXTREMETIES SLIGHTLY AND GRIMACES WHEN NOXIOUS STIMULI APPLIED TO NAILBED.\\n\\nCV: HR 76-92, NSR W/ PVC'S, SBP PARAMETERS >120, NEO GTT TITRATED ACCORDINGLY AND MIDODRINE 2.5MG PGT TID STARTED.CVP 6-12. HCT 28.7, VERIFIED. TRANSFUSED 1U PRBC'S.\\n\\nRESP: LUNG SOUNDS COARSE, O2 SAT 98-100% ON 50% VIA TRACH COLLAR. SXN PRN FOR THICK GREEN TINGED SPUTUM, PT ALSO ABLE TO EXPECTORATE AT TIMES.\\n\\nGI: ABD SOFT NT/ND, +BOWEL SOUNDS, TF IMPACT W/ FIBER INFUSING VIA PEG-GOAL 80CC/HR PRESENTLY AT 60CC/HR W/ MINIMAL RESIDUALS.\\n\\nGU: U/O BORDERLINE, CLEAR CONCENTRATED URINE. DR. INFORMED, CONT TO MONITOR.\\n\\nID: TMAX 97.9.\\n\\nPLAN: MONITOR VS, LABS, RESP STATUS, NEURO STATUS. CONT CURRENT MGMT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563091,\n \"text\": \"Respiratory care:\\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. Patient vent mode changed over to A/C in CT as they were having trouble with synchrony and hypertension. Patient transported to CT with vent without incident. Unable to change patient back over to imv as his respiratory rate increased into the 40's. RSBI this am was 150. Breathsounds are decreased. Please see respiratory section of carevue for further data.\\nPlan: Continue mechanical ventilation. Wean as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563109,\n \"text\": \"RESP CARE NOTE:\\n\\nPT CONTINUING ON A/C VENT 15, 35%, 400,5 PEEP. TRIED RSBI BUT RR QUICKLY ROSE TO HIGH 40'S AND B/P INCR. CURRENT PLAN IS TO CONTINUE SETTINGS AND PT TO REST. SUCTIONED THIS SHIFT FOR MOD AMT OF VERY THICK WHITE SPUTUM. PT OFTEN BITES ETT MAKING SUCTIONING DIFFICULT .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563114,\n \"text\": \"NPN\\n PT NOT OPENING EYES TODAY HOWEVER IS OCCASIONALLY FOLLOWING COMMANDS TO WIGGLE TOES, SQUEEZE HAND. RIGHT HAND SPONTANEOUSLY MOVING, FEET ALSO SPONTANEOUSLY MOVING ON BED. PERRL, 3-4MM. ICP 2-13 DEPENDING ON STIMULI, CLAMPING TO REPOSITION, ETC. VENT DRAINING DARK RED, ABOUT 20-30CC FOR THE SHIFT.\\nCV- BP STAYING BETWEEN 160-180'S WITH LOW DOSE OF NEO. HR 70-80'S WITH MULTIPLE PVCS. SODIUM GTT INCREASED TO 20CC WITH NA CHECKED Q2HRS WITH MOST RECENT BEING 131. DR. UPDATED.\\nRESP- VENT CHANGED BACK TO SIMV THIS AM DUE TO LONG PERIODS OF APNEA ON CPAP SETTING. ABGS CHECKED AND PT CONTINUES TO BE SLIGHTLY ALKALOTIC, WILL CONTINUE TO MONITOR. LUNGS CLEAR, SUCTIONED INFREQUENTLY FOR THICK CLEAR SPUTUM. MD SPEAKING TO FAMILY ABOUT POSSIBLE TRACH TOMMORROW.\\nGI/GU- ABD SOFT, TF AT GOAL WITH MINIMAL RESIDUALS. FOLEY DRAINING LARGE AMOUNTS OF CLEAR URINE, 100-300CC/HR\\nID- LOW GRADE TEMP THIS AM. CONTINUES ABT.\\nSOCIAL- FAMILY IN TO VISIT, SPOKE WITH MD\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563115,\n \"text\": \"D PT MINIMALLY RESPONSIVE. OPEN EYES ONLY ONCE FOLLOWED COMMANDS INCONSISTANT5LY MOVES ARMS UP AND DOWN LIFTING OFF BED AT TIMES MOVES LEGS ONLY SLIGHTLY ON BED. . NS 3% AT 20CC OFF AT 5AM.NA 135. ICP 2-5.\\nCV: PT. INITIALLY NSR WITH FREQUENT ECTOPI. BIGEMINI AND TRIGEMINEY. NEO AT 1.25-1.20 MCG/KG/MIN. AT ABOUT 2300 PT IN POSSIBLE SVT ECG DONE HR >130 AND MAINTAINED FOR > 30MIN . ATTEMPTED TO VALSALVA BY SUCTIONING ET AND ORAL WITH OUT EFFECT. HO AT BED SIDE DILTAZIEM 10MG GIVEN . SBP DROPPED . RESIDENT/INTERNAL AT BED SIDE. LOPRESSOR 5MG GIVEN 5-10MIN APART. WITH SOME EFFECT. HR DOWN TO TEENS THEN 90 FOR SHORT TIME THEN BACK UP ESMOLOL BOLUSED AND STARTED AT 100MCG/KG/MIN SVT CONVERTED TO NSR WITH FREQUENT ECTOPI. BOLUS 500CC NS.TEMP MAX 101.8 RECTAL PAN CULTURED INCLUDING OBTAINED BY NEURO.\\nLUNGS: COARSE THROUGHOUT,SUCTION FOR SMALL TO MOD WHITE THICK SPUTUM.\\nGI: ABD SOFT BS PRESENT TF STOPPED AT MN RESIDUALS < 20.\\nGU: FOLEY TO C/D OUTPUT > 100 AN HOUR.\\nSKIN: COCCYX WITH DUODERM NO OTHER SKIN REDDNESS OR BREAKDOWN NOTED.\\nA PT SVT RESOLVED NSR ON ESMOLOL AND NEO .\\nP CONTINUE TO MONITOR NA Q2H.X4 . 3% NA OFF IF NA DROPPES TO 130 AGAIN RESTART 3%. CONTINUE SODIUM TABS. CONTINUE NEO TO MAINTAIN SBP 160-180. CONTINUE ESMOLOL AT 100MCG TO MAINTAIN SR. MONITOR ECTOPI REPLETE LYTES AS INDICATED. POSSIBLE TRACH TODAY HAS REMAINED NPO. SEE CARE VIEW FOR SPECIFICS\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563092,\n \"text\": \"FOCUS: STATUS UPDATE\\nDATA:\\nPATIENT VERY EASILY AROUSABLE TO VOICE THIS AFTERNOON. PUPILS EQUAL AND REACTIVE TO LIGHT. LIFTING AND HOLDING BILAT ARMS PURPOSEFULLY AND TO COMMAND. MOVING FEET TO COMMAND. AT TIMES NODDING OR SHAKING HEAD TO QUESTIONS. VENTRICULAR ELEVATED TO 15CM ABOVE TRAGUS. ICP <10 WITH DARK BLOOD TINGED DRAINAGE.\\n\\nNEOSYNEPHRINE IV DRIP ON AND OFF FOR BLOOD PRESSURE LESS THAN 150. OK PER DR. TO TOLERATE BP MIN 150SYSTOLIC AS LONG AS NEURO EXAM UNCHANGED. PATIENT REQUIRED NICARDIPINE WHILE DOWN AT CAT SCAN DUE TO HYPERTENSION TO 190'S. MULTIPLE PVC'S AND CONSISTENT BIGEMINY WHILE IN CT SCAN. DR. NOTIFIED.\\n\\nLUNGS COARSE BILAT. CONTINUES ON AC VENT--NO CHANGES TODAY. SATS 99-100%. CHEST CT DONE WITH PRELIMINARY RESULTS CONSISTENT WITH L PE.\\nSUCTIONED FOR MINIMAL AMOUNTS WHITE SECRETIONS. FEBRILE TO 100.1 MAX.\\n\\nTOLERATING TUBE FEEDS AT GOAL RATE WITH MINIMAL RESIDUALS. NO BM.\\n\\nPLAN:\\nSTART HEPARIN DRIP FOR PE PER DR. . C-DIFF CULTURE WITH NEXT STOOL. SPUTUM CULTURE. MAINTAIN BP 150-170 WITH ACCEPTABLE NEURO EXAM.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563093,\n \"text\": \"Nursing note:\\nNEURO: Opens eyes to voice, nodding yes/no to questions. Following simple commands. PERRLA 4-5mm and brisk. Moves all extremities purposefully. Lifts/falls w/upper extremities, wiggles bilateral feet on bed. Grasps equal. Ventricular @15cm above tragus, ICP 8-11. Patent blood-tinged drainage.\\nCV: Remains Vpaced w/frequent PVCs/bigemeny noted as per pt's baseline. SBP kept 150 or > w/acceptable neuro exam w/aid of Neo gtt. Titrated up to 3.5mcg/kg/min, nsurg PA aware. SBP does drop w/Nimodopine. Neuro status remains unchanged w/drops below 150 systolic. Sodium 129 from 135, NACL 3% gtt begun w/Sodium levels to be checked q2 hours. Begun on salt tabs as well. Palpable pulses. Skin warm and diaphoretic at times. Tmax 100, Tylenol w/effect. Heparin gtt increased for sub-therapeutic PTT per Nsurg. Vanco levels sent.\\nRESP: No vent changes overnight, ABGs acceptable. Suctioned for small amounts thick yellow sputum, specimen sent to cx.\\nGI: Abdomen softly distended, +bowel sounds and flatus. Minimal stool via FIB. Tolerating tube feeds via NGT w/minimal residuals.\\nGU: Foley patent large amounts light yellow urine.\\nENDO: Glucose levels stable, insulin per sliding scale PRN.\\nSOCIAL: Wife called and updated.\\n\\nA/P: Neuro stable. SBP labile, frequent drops in pressure requiring increases in Neo, Nsurg aware. Hyponatremic, begun on 3% sodium gtt. Cont. on Heparin gtt for presumed PE. Cont. current plan of care, follow lytes, coags, maintain SBP 150-170.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563110,\n \"text\": \"nuero: at 1200 pt did open his eyes when you called his name, pt did follow commands pt did squeeze my hands on right and left hand, pt did stick out his tongue. no spontanoues movement noted from legs. at other times pt not following commands or opening eyes(please see nuero flow sheet for nuero assessment). pt does withdraw all four extremties to painful stimuli. vent. raised to 15cm above tragus, draining blood tinged csf. pupils remain equal and reactive to light.\\n\\nlungs: lungs coarse at bases. pt on cpap with ps. suctioning pt for yellowish secretions.\\n\\ncards: pt remians in sr, with frequent pvcs. pt diaphrotic at 1200, dr. called and aware, ekg done, dr. assessed ekg. iv neo remians on to keep sbp b/w 170-180.\\n\\ngi: tube feeding at goal, minimal residuals.\\n\\ngu: u/o has been over last couple of hours 300cc/hr, dr. aware.\\n\\nf/e na 130, na rechecked result pending, if less than 130 to start 3% na gtt. blood sugar 148 recieved 8nph and 6u of regular insulin per sliding scale.\\n\\nplan: continue to monitor nuero status, pulm status, blood sugars, check na. possibe trach on tuesday.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563111,\n \"text\": \"Respiratory Care\\nPt remains mechaniclly ventilated, placed on CPAP/PSV this morning. Suction for small amounts of pale white secreations. Breath sounds equal. Pt maintaining consistant spontaneous RR/Vt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563112,\n \"text\": \" 19 to 07\\n\\n status unchanged random motion of extemites with pain or loud stimulus only basicly deeply letargic on cpap well icp 4 to 5 good wave form at 15 cm dark red csf\\n\\n resp wnl thick yellow sputum on cpap .35 fio2 clear after suctioning no issues\\n\\n heart s1s2 murmur sys nsr pvc st depression 2to 3 mm noted in in lead 2 pulses pos 2 thruout\\n\\n gi pos bs neg hem tf well no residual\\n\\n supportive care t/p butt care duo in place side to side only all lines wnl good waves passive rom done\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563113,\n \"text\": \"Resp care Note:\\n\\nPt has been on Cpap/PSV all night and contiues on this at present. RSBI was done this am and was 141 afte full minute on\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563056,\n \"text\": \"condition update\\nSee ICU flowsheet for specifics\\nNeuro: pt's pupils are equal and reactive to light stimuli, able to follow simple commands (to move hands/feet) at times after relaxed- pt has trouble following commands after movement. Pt has good grip strength in hands, can push with feet. Pt sedated per team with propofol. Vent drain at 15cms above tragus- draining small amounts of blood tinges fluid.\\nCV: Team would like bp b/t 100-120 systolically- pt is on nitroprussin @ 2.50mcg/kg/hr to maintain bp below 120; bp will increase post suctioning and with turning. Hydralazine 10g was given x 1 with adequate effect- pt will now receive OTC doses. HR70's-80's NSR with random PVC's throughout the day. Oral beta blockers/anti hypertensives admin in the am a/o. +d/p pulses with dopplar- q2 hours. +radial r/l pulses. extremities cool (baseline) and pink.\\nIV'S: pt has 2 L PIV's perfusing well, triple lumen CVL with CVP attached- good wave forms + dressing CDI, A-Line CDI w/sharp wave forms, A-line sheath CDI with sharp wave forms.\\nGI: pt's abdomen soft +hypo active BS x4. NG tube was to LWS during day draining lg amts of Bilious drainage. Started TF-impact with fiber @10cc/hr at 1500- pt appears to be tolerating well; will increase rate 10cc q 4hrs until a goal of 70.\\nSkin: occlusive dsg on scalp cdi with small amounts sersang staining.\\nFamily : very supportive and at bedside most of afternoon- very appropriate.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563057,\n \"text\": \"Respiratory Care Note\\n Patient remains intubated and sedated on propofol on full ventilatory support. FIO2 weaned to 40%. See Carevue flowsheet for specifics. BS bilat, coarse over RUL. Suctioned for med amounts of tannish sputum. Plan to maintain on A/C overnight.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563058,\n \"text\": \" to to 07\\n nuro status improving opens eyes to comands helps to turn self in bed mae tries to talk around ettnote pt becomes agitated wants tube out very clearly during bp becomes elevated md made aware for tonight may increase propofol to sedate nipride for bp sys 110\\n heart s1s2 mumur sys pules +2 neg nvd nsr pvcs at times\\ncvp fem and arterial a line wnl note icp 8to 15 depending on agitation good wave pattern se notes\\n resp ett scant secreations light yellow .40% fio2 rate 12\\n gi tube feeding well small residual\\n supportive care\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563059,\n \"text\": \" note pt hard to manage bp elevated agitation remains u/o down i>o md made aware mane morphine and bp meds to be changed see orders\\n\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563060,\n \"text\": \"RESP CARE\\nPT remains intubated and ventilated. Curent settings are A/C 750x12 35% 5peep with peak/plat 24/18. Bs coarse but clear. Suct for a small amt of thick white sput. in fio2 to 35% with good sats. RSBI done=53. Will follow as needed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563135,\n \"text\": \"Resp: pt on psv 5/5/40%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral coarse sounds which improve after suctioning. Suctioned moderate amounts of bloody thick secretions. Changed out heated wire vent circuits. AM ABG's 7.45/35/197/25. Placing pt on T/C this am. No further changes noted.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563051,\n \"text\": \"NEURO; PT ON AT 25 MCG/KG/MIN, GTT OFF PER SICU AND NEURO TEAM, PT UNRESPONSIVE, WITHDRAWS ONLY RT FOOT TO NAILBED PRESSURE, DOES NOT OPEN EYES OR FOLLOW COMMANDS, RARELY MOVES BOTH FEET SLIGHTLY ON BED, NIPRI8DE TITRATED UP TO KEEP SYS 100-130, PRESENTLY AT 0,8 MCG/KG/MIN, GIVEN HYDRALAZINE 10 MGM X 1 FOR PERSISTENT ELEV BP IN 140'S, DESPITE INCREASE IN NIPRIDE, PT HAS POSITIVE GAG REFLEX, VOMITED SMALL AMT UNDIGES FOOD, NG SUCTION INCREASED, SICU TEAM INFORMED, PUPILS ARE VERY SLUGGISH #2, NEURO RESIDENT IN AND STATED PT DID LOCALIZE UPPER EXTREMITIES TO PRESSURE\\nPT TAKEN TO ANGIO FOR FURTHER DIAGNOSTICS\\n\\nCARDIOVASCULAR; HR 70'S PACED, EXTREMITIES WARM AND DRY,\\n\\nRESPIR; SUCTIONED FOR SMALL AMTS THICK YELLOW SECRETIONS, SIMV RATE DECRESED FROM 20-18 AND FI02 DECREASED TO 60%, WILL REPEAT ABG WHEN PT RETURNS, WILL HAVE RPT CHEST X-RAY UPON RETURN\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563052,\n \"text\": \"resp care\\npt remains intubated and mech ventilated. see carevue for settings/changes. b/s coarse, sxn thk yel secretions. pt tx to/from neuro-angio w/o incident. plan: cont w/mech suport.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563053,\n \"text\": \"UPDATE NOTE\\n\\nNEURO; PT RETURNED FROM ANGIO, OCCLUDED VERTEBRAL ARTERIES, TO RETURN TO ANGIO FOR POSSIBLE STENT AND/OR COILING, PROPOFOL ON AT 35 MCG/KG/MIN AND OFF Q 1HR FOR NEURO CHECKS, DOES NOT OPEN EYES OR FOLLOW COMMANDS, WITHDRAWS ALL EXTREMITIES TO NAILBED PRESSURE, NIPRIDE AT 0.8 MCG/KG/MIN TO KEEP SYS 110-130'S PER DR. , PUPILS REMAIN SLUGGISH, EVALUATED FREQUENTLY BY NEURO RESIDENT,\\n\\nCARDIOVASCULAR; HR 60'S-70'S SR, SYS 120'S, NIPRIDE OFF PRIOR TO RETURN TRIP TO ANGIO DUE TO SYS 90'S AND AFTER MEDIC BY ANESTHESIA, GIVEN PLAVIX 150 MGM AND ASA 81 MGM VIA NG TUBE THIS PM, RT FEMORAL SHEATH TRANSDUCED, BP LOWER THAN RADIAL A LINE, NEURO AND SICU HO INFORMED, PEDAL AND PT PULSES EASILY PALPABLE, NO HEMATOMA OF RT GROIN\\nRT SUBCLAVIAN TRIPLE LUMEN LINE INSERTED, CONFIRMED VIA X-RAY\\n\\nRESPIR SUCTIONED FOR SMALL THICK LIGHT YELLOW SECRETIONS, ABGS THIS PM-PC02 34, COARSE BREATH SOUNDS THROUGHOUT\\n\\nSOCIAL FAMILY AT BEDSIDE, WIFE UPDATED BY NEURO TEAM\\n\\nPLAN PT TAKEN BACK TO ANGIO FOR POSSIBLE STENT/COILING\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563136,\n \"text\": \"\\nPT MAINTAINED ON TM VENTILATION AND DOING WELL. VITALS STABLE, BLOOD STILL OOZING FROM TRACHEOSTOMY BUT MUCH BETTER THAN YESTERDAY. TM ABG SHOWED VERY GOOD OXYGENATION WITH A MILD ALKALOSIS. MENTAL STATUS UNCHANGED. PLAN IS TO CONT ON TM VENTILATION.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563137,\n \"text\": \"NPN (SEE CAREVUE FOR SPECIFICS)\\n PT ONLY RESPONDING TO PAINFUL STIMULI. MAE BUT VERY MINIMALLY. . VENT REOPENED PER NEUROSURG TEAM AT 0 TRAGUS, ? INCREASED HYDROCEPHALUS SINCE CLAMPED TWO DAYS AGO. CHIP MACINTOSH IN TO CHANGE VENT TUBING (DOUBTS ACCURACY OF ICP, 0-3) IN THE PROCESS OF DECREASING , CSF DRAINED 70CC AND IS NOW CLAMPED UNTIL FURTHER NOTICE FROM NEUROSURG. ICP REGISTERING NEGATIVE NUMBERS.\\nCV- BP 160'S ON 2.5MCGS OF NEO. I UNIT PRBCS GIVEN AND REPEAT HCT PENDING. HR 70-90 WITH OCCASIONAL PVCS. GROSS HEMATURIA SHOWN TO TEAM, DR. . GTT DECREASED TO 800U/HR WITH NEW PTT GOAL OF 40-50 TO PREVENT FURTHER ACTIVE BLEEDING.\\nRESP- NO FURTHER BLEEDING FROM TRACH SITE BUT SPUTUM REMAINS BLOOD TINGED. VERY STRONG COUGH, ABLE TO RAISE. REQUIRED DEEP SUCTIONING ONLY A FEW TIMES. AFTERNOON ABGS ALL WNL ON TRACH COLLAR.\\nGI/GU- LOOSE STOOL, DARK, C-DIFF PENDING. TF RESIDUAL 125 THIS AM, TF HELD FOR TWO HOURS AND FOLLOW UP RESIDUAL ONLY 10CC, THEREFOR TF RESTARTED. BLOOD TINGED URINE AVERAGING 100-260CC/HR.\\nID- AFEBRILE\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563138,\n \"text\": \" 19/07\\n\\n STATUS APPEARS LIGHTER JUST TOUCHING HIS SKIN CAUSES MOVEMENT PAINFUL STIMULUS YEILDS ORGANIZED MOTION ALL EXT SAME RESPONDS AT O LEVEL AND CLAMPED ICP NEGATIVE NUMBERS UNREALIABLE\\n\\n RESP T COLLAR .50 FIO2 WITH 100% SAO2 SECREATIONS LESS YELLOW IN WITH FOUL SMELL CLEAR AFTER SUCTION / COUGHING\\n\\n HEART S1S2 NSR WITH PVCS PULSES FAIR VSS ON NEO MAINTAIN BP 160 THRU SHIFT WELL A LINE CVP FAIR WAVES U/O QS\\n\\n SUPPORTIVE CARE P/T CONSULT NEEDED OOB TO WITH LIFT FREQ ROM\\nOSMOTIC DIURETICS FOR LONG TERM USE FAMILY SUPPORT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563139,\n \"text\": \"NURSING UPDATE\\n STATUS UNCHANGED UNTIL 0500, SBP DIMINISHED TO LOW 80'S AND MAP TO 40'S, DR INFORMED, ALBUMIN 25% IV X1 WITHOUT EFFECT, IV BOLUS N/SALINE 500CC INFUSING AT THIS TIME PER DR WITH GOOD EFFECT SO FAR. BP UP TO 105/45(62). SEE CAREVIEW FLOWSHEETS FOR DETAILED DATA.\\n WILL CONTINUE TO MONITOR.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563140,\n \"text\": \"ADDENDUM\\n****PLEASE DISREGARD ABOVE NOTE - ENTERED ON WRONG PATIENT****\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563089,\n \"text\": \"Condition Update A:\\nPlease refer to careview and remarks for specifics.\\nNEURO: Became less responsive as SBP decreased to 120's. Dr. up to see pt. Pt arousable and following commands, MAE with SBP 160-170's. No indications of pain. Head CT done this afternoon report pending. Ventriculostomy draining burgandydrainage. increased to 12 at tragus by NSURG this afternoon.\\nCV: Nicardipine gtt stopped this morning for maintaining SBP <170. Neo gtt started to keep SBP initially 150-165, and parameters increased per Dr. to 160-170. HR NSR with frequent bigeminy. Cycled cardiac enzymes completed, 1800 levels pending, and appears to be ruling out for MI. Received albumin x1 as albumin 2.9 and cont with 2-3+ pit edema.\\nRESP: No changes. Minimal secretions. CPT done x2.\\nGI/GU: Med loose bm gauaic neg. Stool sent for c-diff. Minimal TF residuals. Glucose in the 140's, no treatment per RISS. TF stopped to admin baricate for abd CT to be done this evening. Foley patent draining adequete urine, occ cloudy.\\nSKIN: W/D/I.\\nSOCIAL: Dr. and Dr. in to speak with Mrs. and provide updates.\\n\\nPLAN: Titrate Neo gtt to keep SBP 160-170. Monitor neuro status, ICP. Abd CT once baricat completeed and CT available. Cont with ICU care and monitoring.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563090,\n \"text\": \"condition update\\nD;neuro: pt opens eyes to name. follows commands. pupils are equal and reactive to light. moves all extremities to command. lifts and falls both extremities. vent is at 12 cm above the tragus. icp is . draining tea colored drainage.\\ncardiac: nsr with bigemeny and frequent pac's. at ct scan pt became very hypertensive to 200 and started on nicapdipne titrated up to 1mcg/kg/min. still hypertensive up to 180. resp rate up to 40 in ct and pt started on propofol at 40mcg/kg/min for sedation. pt sedated and sbp down to 160's. propofol off after ct scan. pt. awake and following commands. neuro exam back to baseline. sbp down to 140 after nimodipine and pt restarted on neo and titrated up to 1mg/kg/min. cvp is 11.\\nresp: bs are clear and diminished in the bases. suctioned for thick white. pt remains on cmv at present time due to tachypnea.\\ngi: abd ct neg per dr. . positive bowel sounds large amt of loose liquid brown stool. tf restarted and no residuals.\\ngu: urine output is adequate and greater than 100cc/hr. iv fluid at kvo.\\nskin: transparent head dsg is dry and intact. no areas of breakdown is noted. heels slightly red but no breakdown. placed on pillow.\\nid: temp max is 101.3. wbc down to 16.\\na: continue with neuro checks. titrate neo for sbp 160-170. titrate tf up to 70cc/hr.\\nr: neuro is unchanged. pt follows commands and moves all extremities. temp down to 100.7. neo down to .8mcg/kg/min. abg is less alkalotic.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563054,\n \"text\": \" to 19 to 07\\n nuro pt sedated with propofol on vent limit stimulation until am because of new stent and coil inserted this pm intracerebral deep tendon not assessed md 2mm corneal reflex negative mild gag noted icp 7 to 11 good wave scant drainage\\n heart s1s2 2+ SYS MURMOR VSS NIPRIDE MAINTAIN BP SYS 110 TO 120 NSR OCC PVC NOTE FREQ PVC PRIOR TO K AND MAG REPLACMENT PULES +2 TO +3 AT TIMES CVP GOOD WAVE 3 to 5\\n resp vent rate 12 fio2 .50 scant sputum clear fields ett at 21 lip no spont resp sat 99 to 100 persent\\n gi hypoative bowel sounds ng to suction soft nondistended\\n all lines wnl alarms on\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563055,\n \"text\": \" cont note attempt to wake pt 15 minutes bp elevated pa at bedside test ended nuro no corneal reflex impaired gag ridgid legs\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563129,\n \"text\": \" TO 19 TIME 19/07\\n REMAINS DEEPLY LETHARGIC OPENS EYES MAE LOCALIZES ONLY TO PAIN ONLY OCC BRIEF PERIOD OF SPONT EYE OPENING TO COMMAND ICP 1 TO 4 GOOD WAVE NOTED CLAMPED PER ORDER\\n\\n RESP ON .40 FIO2 CPAP 5/5 WELL RESP RATE 12 TO 20 SPUTUM SCANT TRACH STOMA BLOODY LARGE AMOUNT AIRWAY CLEAR GELFOME IN PLACE DRESSING AROUND SITE FOR COLLECTION\\n\\n ABD SOFT LAG BM PASTY DARK MANY T/F WELL SCANT RESIDUAL\\n\\n HEART S1S2 NSR OCC PAC PVC PNC WAP THRU SHIFT BP 160 TO 170 SYS ON NEO TO REDUCE VASOSPASM NEG NVD PULSES FAINT IN NATURE U/O QS CVP5 TO 6 ALINE IN PLACE GOOD WAVE FORM\\n\\n SUPPORTIVE CARE FREQ ROM T/P\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563130,\n \"text\": \"RESP: PT ON PSV 5/5/40%. ALARMS ON AND FUNCTIONING. AMBU/SYRINGE @ HOB. BS AUSCULTATED REVEAL BILATERAL COARSE SOUNDS. SUCTIONED MODERATE AMOUNTS OF THICK BLOODY TINGED SECRETIONS AND YELLOW. TRACH SITE STILL OZZING. AM ABG'S: 7.37/42/168/25. RSBI=107. POSSIBLE CT SCAN THIS AFTERNOON FOR FOLLOW-UP. NO FURTHER CHANGES NOTED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563131,\n \"text\": \" O500 NOTE BLEEDING AROUND TRACH SITE REMAINS MD AWARE SEVERAL\\n\\n JELFORM USED TOLWELL\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563132,\n \"text\": \"\\nPT MAINTAINED ON PSV VENTILATION AT 40% WITH GOOD OXYGENATION. TRACHEOSTOMY HAS BEEN A PROBLE WITH CONSTANT BLEEDING. M.D. UP TO SUTURE WHICH HAS MADE IT SOMEWHAT BETTER. CT SCAN TODAY TO ASSESS REMOVAL OF VENTRICULOSTOMY. SX FOR BLOODY SECRETIONS. PLAN IS TO TRY PT ON TM VENTILATION AT SOME PT TODAY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563104,\n \"text\": \" TO 19/07\\n\\n PT STATUS REMAINS AROSABLE TRIES TO TALK AT TIMES OPENS EYES TO COMAND WEAKNESS ALL EXTEMITIES PERIOD OF AGITATION RR 28 TO 30 PTPLACED BACK ON SIMV WITH RELIEF\\n\\n HEART S1S2 NSR WITH 2 TO DEPRESSION IN LEAD 2 PULSES POS 2 THRU OUT NEG NVD VSS ALINE CVP ICP WAVE FORMS WNL SEE FLOW SHEET\\n\\n RESP RONCHI THRU OUT CLEARD AFTER SUCTION SIMV FIO2 35% GOOD AIRATION\\n GI POS BS T/F WELL SMALL RESIDUAL SMALL STOOL\\n U/O QS NO ISSUES\\n\\n NEO 1.5 MCG/KILO/MIN BP 150 TO 170 PER ORDER HEPARIN TO TITRATE\\n\\n SKIN NOTE BUTT SL RED WITH SKIN OPEN AREA\\n\\n SUPPORTIVE CARE ROM TURN SIDE TO SIDE PUL TOILETING\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563105,\n \"text\": \"Respiratory Care\\nPt remains mechaniclly ventilated, switching from SIMV to CPAP. Changing PSV to accommidate adequate/comfortable spontaneous VT/RR. Suction for scant amounts thick white secreations. Breath sounds diminished.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563124,\n \"text\": \"Neuro: pt remains very lethargic. Pupils 3mm brisk. Having no spontaneous movement. Withdraws to nailbed pressure. ICP 4-6, Vent remains at 15cm above tragus.\\nCV: afebrile HR 80's NSR with frequent PVC's. Exremities warm with +PP. Cont on Neo to keep SBP 160-170.\\nRESP: lungs coarse through out. No vent changeds overnight. Requring occasional suctioning of thick bloody sputum. Trach care done several times. Pt having lrg amount of blood drg from trach site.\\nGI tube feed at goal.\\nGU: foley draining adequate amounts of amber urine.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563125,\n \"text\": \"7a-3p\\nneuro: neuro in this am & vent increased to 20 above tragus, no response to verbal command, responds to painful stimuli with facial grimacing, withdraws to nail bed pressure, mouthed \\\"\\\" to niple pressure, slight movement of R arm, no other movement of extremities noted, vent draining sm amt bld tinged clear drainage, \\n\\ncv: hr nsr with occasional to frequent pvc's, sbp 160-179, continues on neo gtt to keep sbp 160-170, continues on iv lopressor q 6 hrs\\n\\nresp: bs+ all lobes & course, sux mod amt thick bld tinged sputum, continues on 40% fio2, imv 20, 5 peep, 8 ips, RSBI 140 this am, lg amt bleeding around trach, ho aware, surgigel applied, hct drawn @ 1400 & pending, rr 20-30, sat 100, no resp distress noted\\n\\ngi: goal TF well, incont lg amt loose semi-formed brown stool, FIB applied, po prevacid qd\\n\\ngu: foley patent, clear yellow urine, good uo\\n\\nother: family in & updated on pt's condition, heparin continues @ 1800u/hr, bs 133 & covered with rssi\\n\\nplan: continue to monitor neuro/respiratory status, check PM hct\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563126,\n \"text\": \"Resp care\\nPt reamins on full vent support. No recent ABG\\\"S as of yet. No vent changes made. Coarse BS, sx mod thick blood tinged secretions. Continues with bleeding around trach. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563127,\n \"text\": \"Resp Care\\nPt. remains on SIMN mode with no changes made t/o shift. Tolerating well spont. breathing over set rate with shallow pattern and VT's 200-300cc range.\\nBs: coarse bilat. secreations minimal bloody thick. Trach continues to ooze, swivel changed X2.\\nABG:metabolic alkalosis with hyperoxia\\nPlan: PSV during day as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563133,\n \"text\": \"NPN\\n PT NOT OPENING EYES TODAY, MOVING EXTREMETIES IN RESPONSE TO PAINFUL STIMULI ONLY. CT TODAY SHOWING NO CHANGE SINCE VENT CLAMPED. .\\nCV- BP DROPPING TO 100'S BEFORE LEAVING THE FLOOR TO CT, REQUIRING LARGE INCREASE IN NEO GTT. FLUID BOLUS GIVEN WITH GOOD EFFECT AND BP IS NOW 170'S FOLLOWING TWO UNITS OF BLOOD. AFTERNOON HCT DROPPED TO 24, WILL FOLLOW UP WITH REPEAT FOLLOWING SECOND UNIT. TRACH SITE OOZING NON STOP TODAY. SHOWN TO DR. AND DR. PAGED TO . SEVERAL STITCHES PLACED AND BLEEDING HAS NOW STOPPED. WILL CONTINUE TO MONITOR.\\nRESP- LUNG SOUNDS COARSE AT TIMES, SUCTIONED FOR THICK BLOOD SPUTUM EVERY FEW HOURS. PT ABLE TO RAISE, VERY STRONG COUGH. O2 SAT 100% ON CPAP.\\nGI- ABD SOFT, TF AT GOAL. LOOSE STOOL A FEW TIMES AND SENT FOR CULTURE.\\nGU- UOP RANGING FROM 80-100CC/HR.\\nID- AFEBRILE\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563134,\n \"text\": \" 19/07\\n\\n status stable mae only to painful stimuli and only on occ no other new trends strong gag\\n\\n trach in place scant bleeding around stoma only cpap .40 fio2 note bloody sputum only rhonchi thru out possible trach mask\\n\\n heart s1s2 pulses poss multifocal pvcs noted bp to be maintained greater than 160 sys with neo u/o qs icp 1to 2 cvp 4\\na line good wave\\n\\n gi wnl pos bs tube feeding well note hematuria started this am md decrease\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563106,\n \"text\": \"Respiratory Care\\nPt becoming more short of breath with spontaneous RR in upper 30's to low 40's. Decreasing Vt to 200 cc. Placed back on SIMV and increase of PSV to 15cm. Decreasing work of breathing as a result of adjustment.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563107,\n \"text\": \"NUERO: PT DOES NOT OPEN HIS EYES WHEN YOU CALL HIS NAME. PUPILS REMIANS EQUAL AND REACTIVE TO LIGHT. PT DOES WITHDRAW ALL FOUR EXTREMTIES TO PAINFUL STIMULI. AT TIMES SPONTANOUES MOVEMENT NOTED FROM RIGHT ARM AND LEFT ARM, NO SPONTANOUES MOVEMENT NOTED FROM RIGHT AND LEFT LEGS. DR. AWARE. (NUEROSURGICAL PA) CALLED AND AWARE AND UP TO ASSESS PATIENT. AT TIMES PT WILL SQUEEZE RIGHT HAND TO COMMANDS. ICP REMIANS , VENTRICULAR DRIAN REMAINS 10CM ABOVE TRAGUS DRIANING BLOOD TINGED DRAINAGE.\\n\\n\\nLUNGS: LUNGS COARSE SUCTIONING PT FOR SCANT AMT OF YELLOW SECRETIONS. PLEASE SEE FLOW SHEET FOR VENT SETTINGS AND ABGS.\\n\\nCARDS: PT IN SR WITH FREQUENT PVC'S. NEO TITRATED TO KEEP SBP B/W 170-180'S. PT ON HEPARIN AT 1700U/HR.\\n\\nGI: PT TOLERATING TUBE FEEDINGS, MINIMAL RESIDUALS NOTED.\\n\\nGU: U/O 80-160CC/HR.\\n\\nF/E. BLOOD SUGAR THIS MORNING 169 RECIEVED 5U NPH AND 10U REGULAR INSULIN , REPEAT BLOOD SUGAR AT 1645 143 RECIEVED 6U OF REGULAR INSULIN PER SLIDING SCALE. NA 130 REPEAT NA 132, DR. AWARE.\\n\\nSKIN: BROKEN AREA NOTED ON BUTTUCKS DRAINING SMALL AMT OF BLOODY DRAINAGE DUEODERM APPLIED.\\n\\nPLAN: CONTINUE TO MONITOR NUERO STATUS, KEEP SBP B/W 170-180, MONITOR BLOODSUGARS, NA,\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563108,\n \"text\": \" TO 19/07\\n\\n PT STATUS LABILE RESPONDSIVENESS OPEN EYES MAE MOUTHS WORDS ON OCC FOR SHORT PERIODS OF TIME BECOMES TIRED THAN FALLS INTO DEEP LETHARGIC STATE SUPPORTIVE CARE\\n\\n HEART S1S2 ST DEPRESSION REMAINS BP TO BE MAINTAINED SYS 170 TO 180 WITH NEO PVC TRIPLETS PULES POS 2 THRU OUT LOW GRADE TEMP ICP CVP A LINE WNL GOOD WAVE U/O QS\\n\\n ABD POS BS NOTED T/F WELL NO RESIDUALS F/S AT 8O CC PER HOUR\\n\\n RESP VENT ASSIST/CONT .35 FIO2 STABLE DECREASE SPUTUM\\n\\n SKIN FREQ TURNS BUTT CARE BECAUSE OF SMALL WOUND\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563128,\n \"text\": \"NPN (SEE CAREVUE FOR SPECIFICS)\\n PT NOT OPENING HIS EYES TO STIMULUS BUT GRIMACING TO PAIN. MOVING ONLY IN RESPONSE TO PAIN, LOCALIZING. . VENT INCREASED TO 25 ABOVE TRAGUS BY NSURG. NA MONITORED AND DECREASED THIS AFTERNOON TO 134, WILL UPDATE MD.\\nCV- BP WELL MAINTAINED IN 160-170 RANGE WITH NEO AT 2.4 MCGS. HR 70'S-80'S WITH OCCASIONAL PVCS, NSR.\\nRESP- LUNGS COARSE AT TIMES, RELIEVED BY SUCTIONING FOR THICK BLOODY SPUTUM. TRACH CARE DONE AND ABOUT TWO HOURS AFTER PT BEGAN OOZING BLOOD FROM SITE. DRESSING REINFORCED, AFTERNOON HCT 29.\\nGI- TF AT GOAL. NOTICED SMALL CLOTS AND BLOOD TINGED RESIDUAL FROM STOMACH THIS AM, DR. NOTIFIED, CONTINUE TO MONITOR.\\nGU- UOP 200-300CC/HR. DIAMOX GIVEN X 2 FOR SLIGHT ALKALOSIS. ABGS THIS AFTERNOON SLIGHTLY IMPROVED.\\nID- AFEBRILE. +VRE IN STOOL.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563083,\n \"text\": \"PT.PRESENTLY ON CPAP+PS VENTILATION, HAD INCREASED RR ON SIMV AND APPEARED TO BREATHE WITH MORE COMFORT ON CPAP WITH INCREASED PRES.SUPPORT, ABG ALKOLOTIC, BS CLEAR BILAT.,WILL WEAN AS ., RSBI-120.7\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563084,\n \"text\": \" CONT THIS AM PT MORE ALERT RESP 40 FAIR T.V. TRIAL CPAP WELL MD AWARE\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563085,\n \"text\": \"NEURO; OPENS EYES SLIGHTLY TO VOICE ON OCCASION AND FOLLOWS COMMANDS SUCH AS MOVING TOES AND GIVING WEAK HANGRASP INCONSISTENTLY, LOCALIZES TO TACTILE STIMULATION AND WITHDRAWS EXTREMITIES TO NAILBED PRESSURE,VENT LOWERED TO 8 CM AT TRAGUS TODAY PER ORDER NEURO TEAM, PT HAD BEEN MORE LETHARGIC BUT MORE EASILY AROUSEABLE AT PRESENT, MODER THICK BLOODY DGE IN CHAMBER-UNCHANGED FROM YESTERDAY, C&S TAKEN FROM NEURO BY NEURO TEAM\\nICP 3-6\\nEEG DONE TODAY\\n\\nCARDIOVASCULAR; HR 70'S SR, FREQUENT PVC ON OCCASION, UNIFOCAL, CVP 9-12, NICARDIPINE GTT OFF FOR SEVERAL HRS BUT RESTARTED AFTER LOPRESSOR GIVEN AND NOT EFFECTIVE IN DECREASING SYS < 170 PER GOAL OF DR ,\\nTEMP SPIKE 102.4-TYLEONL AND ALCOHOL SPONGE BATH, SEEN BY INFECTIOUS DISEASE\\nAND WILL HAVE VANCOMYCIN RESTARTED\\nRESPIR; SUCTIONED FOR SMALL AMTS THICK LIGHT YELLOW-WHITE SECRETIONS, LAST ABG REFLECTS METAB ALKALOSIS ,REMAINS ON C-PAP AND PS PRESENTLY AT 15, ATTEMPTED DECREASNG TO 10 BUT PT BECAME TACHYPNEIC, COARSE BREATH SOUNDS, CXR TODAY,\\n\\nENDOCRINE; BS 151-COVERED WITH 2 UNITS VIA SLIDING SCALE, TUBE FEEDINGS DECREASED TO 70CC/HR PER SICU TEAM, NEUTRA PHOS GIVEN DOWN TUBE,\\n\\nGI; INCON ON SEMI-LIQUID STOOL, TRACE HEME POSITIVE\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563086,\n \"text\": \" 19/07\\n\\n STATUS PT OPENS EYES TO COMANDS MAE LIMITED ON NO SEDATION PROGRESSIVE IMPROVMENT RESTS LONG PERIODS VSS CVP ICP WNL GOOD WAVE FORMS U/O QS\\n\\n RESP ON CPAP WITH PS VERY WELL RESP 12 TO 14 OCC RHOCHI CLEARS AFTER SUCTIONING .40% FIO2 SAT 99\\n\\n HEART S1S2 FREQ PVC PNC PULSES +2 THRU OUT W/D NEG NVD NEG HJR NSR MILD ST DEPRESSION 2/3 MM\\n\\n GI POS BS STOOLING T/F WELL NO RESIDUALS\\n\\n T/P SKIN CARE WITH ROM\\n\\n THIS PM SPUTUM BLOOD SENT FOR CULTURES\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563087,\n \"text\": \" 0345\\n\\n note pt period of vent bigemity also resp rate increase 23 to 30 abg done resp alkalosis result placed on simv with low dose mso4 result less ectopics beats ekg no changes labs ok md aware\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563088,\n \"text\": \"PT.INITIALLY ON CPAP+PS, CHANGED IN A.M. FOR COMFORT, HAD BEEN RESTLESS AND AGITATED, WEANING DOWN SEDATION,INCR.WOB, ABG ALKALOTIC, BS COARSE ON OCCAISON, SX FOR WHITE SECRETION, WILL ATTEMPT TO WEAN IF .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563164,\n \"text\": \"focus update\\nafebrile VSS aline d/ced no neurological changes awaiting bed at , continues on gtt at 1150u/hr goal PTT 40-50 PTT check q 6 hours. expectorating yellow thick sputum q 1/2 hour, lsc\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563165,\n \"text\": \"NSG NOTE\\nSEE FLOWSHEET FOR SPECIFICS.\\n\\nNEURO-. SQUINTS AND FLUTTERS EYELIDS TO PAIN AND ? SL OPENS EYES. . NO SPONT MOVEMENT. DOES NOT FOLLOW COMMANDS. FLEXES ALL EXTREMITIES TO PAIN.\\n\\nCV-AFEB. HR/BP STABLE. SKIN W+D. +PP. PBOOTS ON. CON'T ON GTT. PTT MONITORED, THERAPEUTIC.\\n\\nRESP-REMAINS ON TRACH COLLAR, 70%. WELL. O2 SAT 100%. LS COARSE, DECREASED AT BASES. PT EXPECTORATING LARGE AMT THICK YELLOW SPUTUM.\\n\\nGI-ABD SOFT. +BS. TF AT GOAL. INC OF SEMIFORMED STOOL X 1.\\n\\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\\n\\nENDO-SSRI AND NPH.\\n\\nPLAN-CON'T WITH CURRENT PLAN. AWAIT REHAB BED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563098,\n \"text\": \"Resp: pt on psv 15/+5/40%. Alarms on and functioning. Ambu/syringe @ hob. BS ausucltated reveal bilateral aeration in apecies with diminished bases. Suctioned for small amount of yellow secretions. VT decreased, periods of apnea, placed on a/c noc. AM ABG's 7.48/37/127/28, improvement noted. RSBI=94. Placed back on psv 15/5/34%, continue to wean as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563099,\n \"text\": \"Respiratory Care\\nPt remains mechaniclly ventilated, on CPAP mode. No changes made this shift to ventilator settings. Breath sounds equal.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563100,\n \"text\": \"STATUS\\nD: MORE AWAKE WILL FOLLOW SOME SIMPLE COMMANDS..MOVES ALL EXTREM'S LF LEG MUCH WEAKER THAN RT MOVES BOTH ARMS EQUALLY..FEBRILE\\nA: PERIP/CENTRAL LINE/URINE/VENT CULTURES SENT..MP ? V PACED WITH FREQ PVC'S..LEVO INITIALLY INCREASED TO 1.3MCG FOR SBP 150/'S..NOW BACK DOWN TO 1.2MCG TO KEEP SBP >160/..NA'S DRAWN Q2H..NA GTT TO 15 FOR NA 131..VENT TO C-PAP IPS 10 WITH GOOD SAT'S..SUCTIONED FOR MOD AMT THICK WHITE..INCT SOFT BROWN STOOL..FIB DC'D DIAPER ON STOOL FOR C-DIFF SENT\\nR: IMPROVED MENTAL STATUS\\nP: MONITOR NA'S Q2H AJUST GTT PER HO..PTT Q6H..NEURO Q2H..WEAN LEVO AS \\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563116,\n \"text\": \"Respiratory Care Note:\\n\\nPt remain orally intubated on SIMV mosly. We had to change mode of ventilation for most part of the night due to hemodianamic unstability ST & HR rhythm back to< 100/min, back to SIMV this AM. ABG acceptable. Sxtn for thick white sputum Q2-4hr & PRN. He seems to respond this morning. Plan; ?MRI/ talks of trach\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563117,\n \"text\": \"RESPIRATORY CARE\\nPT S/P TRACH TODAY, REMAINS ON VENTILATORY SUPPORT. SIMV 400/20/40%/+5 PEEP, RATE WAS INCREASED D/T SEDATION FOR THE PROCEDURE. SLIGHT INCREASE IN FIO2 D/T PAO2 OF 76. EARLIER IN THE SHIFT, PT WAS NOTED TO BE TACHYPNEIC/PANTING, FELT TO BE CENTRAL HYPERVENTILATION. NO SIGNS OF DISTRESS. BS RHONCHI T/O. NO WEANING PLANS AT THIS TIME.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563118,\n \"text\": \"NPN (SEE CAREVUE FOR SPECIFICS)\\n PT MORE RESPONSIVE TODAY. OPENING EYES TO VOICE THIS AFTERNOON, FOLLOWING SIMPLE COMMANDS. , HOWEVER MINIMAL SPONTANEOUS MOVEMENT FROM LOWER EXT. VENT REMAINS AT 15 ABOVE TRAGUS, ICP 1-6.\\nCV- BP PARAMETERS LOWERED TO 160-170 PER DR. AND PT ABLE TO START WEANING OFF NEO. HR IN 70-80'S WITH MULTIPLE PVCS. ESMOLOL WEANED OFF SUCCESSFULLY AND IV LOPRESSOR STARTED. NO FURTHER SPISODES OF SVT TODAY.\\nRESP- TRACH'D TODAY WITHOUT COMPLICATION. BREATHING APPEARS TO BE MORE COMFORTABLE AND REMAINS ON SIMV FOR NOW. ABGS FREQUENTLY CHECKED. LUNGS COARSE AT TIMES, RELIEVED BY SUCTIONING FOR SMALL AMOUNTS OF CLEAR WHITE SPUTUM.\\nGI/GU- ABD SOFT, TF RESUMED AFTER TRACH. NPH HELD THIS AM DUE TO NPO STATUS. FOLEY PATENT DRAINING CLEAR YELLOW URINE, 100-200CC/HR\\nID- TMAX 99.4.\\n WIFE IN TO VISIT AND ABLE TO COMMUNICATE WITH PT. SPOKE WITH DR. .\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563119,\n \"text\": \"Respiratory Care Note:\\n\\nPt remain on vent support via new trach #8 Shiley done yesterday. No vent changes o/n. We are suctioning blood tinged thick secretions ~q4h. AM abg acceptable. Plan: Continue ICU monitoring; will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563101,\n \"text\": \"CONDITION UPDATE\\n 8 PM WAS UNRESPONSIVE, WOULD NOT FOLLOW ANY COMMANDS, PUPILS UNCHANGED. NEURO- NOTIFIED. AT THIS TIME WAS FEBRILE TO 101.7. ONCE FEVER BEGAN TO DROP NEURO STATUS RETURNED TO HAS BEEN HIS BASELINE- FOLLOWING COMMANDS, MOUTHING WORDS, ABLE TO MOVE ALL EXTREMITIES WITH PUPILS EQUAL AND REACTIVE TO LIGHT. REMAINED AFEBRILE THE REST OF THE NIGHT WITH TYLENOL GIVEN Q4 HRS. VENTRICULAR REMAINS AT 15 ABOVE THE TRAGUS WITH SEROSANGUINES DRAINAGE. ICP'S RANGE 1-7.\\n SBP MAINTAINED 160 TO 170 RANGE WITH NEO INCREASED AS HIGH AS 3 TO MAINTAIN BP'S WHILE FEBRILE. NEO CURRENTLY AT 1.5. NSR-V PACED WITH FREQUENT PVC'S.\\n TUBE FEEDS OFF AT 0400 FOR POTENTIAL EXTUBATION.\\n CONTINUE TO MONITER NEURO AND RESPIRATORY STATUS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563102,\n \"text\": \"Respiratory Care\\nPt remains mechaniclly ventilated, attempting 5cm PSV, becoming more short of breath. Spontnaeous Respiratory Rate mid 30's to 40, decreasing spontaneous Vt to 300cc. Increase PSV to 8cm with decreasing Work of Breathing.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563103,\n \"text\": \"STATUS\\nD: NEURO ESSENTIALLY UNCHANGED..MORE LETHARGIC IN AFTERNOON..REMAINS ON NEO/HEPARIN GTT'S\\nA: AFEBRILE..WEANED ON VENT TO IPS 5 C-PAP 5 SHORT TIME THAN TACHYPNEIC 30'S..PLACED ON IPS 8>> WELL..SUCTIONED THICK WHITE GOOD ABG'S..NEO UP & DOWN TO KEEP SBP 160/-170/'S GTT @ 1.0MCG AT PRESENT HEPARIN REMAINS @ 1700U WITH PTT 70'S..GOOD HUO'S..INCT SOFT BROWN STOOL..TF'S REMAIN OFF\\nR: ESSENTIALLY UNCHANGED\\nP: CONTINUE TO MONITOR PTT/NA'S Q6H..NEURO SIGNS Q2H..? RESTART TF'S\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563120,\n \"text\": \"Neuro: Pt remains very somulant. Withdraws and grimace to nailbed pressure. pupils 3mm brisk. no spontaneous movement noted. Vent 15cm above tragus ICP 3-7, draining small amounts of blood tinged CSF\\nCV: afebrile, HR 70's NSR with frequent PVC's. SBP 150-170's, continues on neo to for goal 160-170. Titrated overnight, presently at 2.3mcg/kg/min. Heparin gtt increased to 1800u/hr to keep Ptt 60-80. extremities warm with +PP.\\nRESP: lungs coarse. O2 sats >98%. No vent changes occasional suctioning of thick blood tinged sputum. ABG acceptable.\\nGI: tube feed at goal. Small BM\\nGU: foley draining adequate amounts of clear yellow urine.\\nEndocrine: blood sugars slightly elevated requiring coverage Per RISS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563121,\n \"text\": \"Resp care note\\nPt remains on full vent support. ABG's show alkalosis, well oxygenated. No vent changes made as of yet. Sx mod thin bloody secretions. Head CT today, results pending. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563122,\n \"text\": \"Nursing Progress Note\\n 07:30->19:30\\n\\nS/O\\n\\nNEURO: Minimally responsive = withdraws right hand from stim during a-line re-wiring and flushing, grimaces with trach and line care, clamps mouth closed during mouth care. PERRLA , brisk; corneals intact; cough strong. Doesn't follow commands or move spontaneously; no eye opening; did not respond to wife's voice.\\nHead CT to evaluate ventricular size -> per Neuro , no changes.\\nVentricular tracing dampened and loss of respiratory variation in ventriculostomy tubing -> Neuro up to evaluate, re-established variabilkity and flow when lowered to 12, and returned to 15 at the tragus; transducer changed, and tracing improved with restoration of notch.\\n\\nCV: Continues on Neo to maintain SBP 160-170, varies between 2.3-3.0mcg/kg-min. HR 80's-70's with bigeminy which responds to Lopressor, and frequent PVC's. Hands and feet cool and clammy.\\nA-line tracing lost -> a-line re-wired by Dr. (SICU) with return of tracing.\\n\\nRESP: LS coarse, occ clear. Sxn'd q2-4 horus for copious amounts of thick bloody secretions. Trach care completed x4 d/t amount of secretions. No innner cannula of trach in place. No changes in vent settings (SIMV 20X Vt 400 x FiO2 .40 with PSV 8 and PEEP5).\\n\\nGI: Remains on tube feeds. Extremely large stool passed, guaiac negative. Abd soft, bowel sounds +.\\n\\nFEN: Na+ dropped from 133 -> 129 => all meds and gtts placed in NS; 3% NS gtt started at 15mL with increase in Na+ to 135 after about 2 hours, and gtt stopped. Na+ remains at 134. K+ dropped to 3.6 -> rechecked and will replete per scale. BS per RISS and scheduled coverage. Phos running low.\\n\\nHAEM: COntinues on heparin at 1800 units/ hour with PTT in therapeutic range of 60's. Tracheal bleeding as noted. No other bleeding noted.\\n\\nID: Tmax 99.2 rectally. No new ID issues. Remains on Flagyl, Vanco and Cefepime with Vanco and Cefepime in NS.\\n\\nGU: U/O qs via foley. No GU issues.\\n\\nSKIN: Duiderm over coccyx intact. Irritation in peri-anal fold between gluteal cheeks -> Aquaphor applied. Continues with multipodux boots, off q 4hours for skin checks -. skin intact.\\n\\nA/P\\n\\nContinue current care, including heparin gtt and coag monitoring, Na+ monitoring and repletion, neuro checks, fluid and electrolyte management, and pulmonary support.\\nFollow up on phos level as appropriate.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563123,\n \"text\": \"Respiratory Care Note:\\n\\nPt remain on ventilatory support via new trach Day2 on SIMV & PS. No vent changes maded during shift. We are sxtn mod-cop bld tinged thick seccretions and fair amt of blood around trach site. Plan: No changes just continue ICU monitoring.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563078,\n \"text\": \"FOCUS: STATUS UPDATE\\nDATA:\\nPATIENT SEDATED ON PROPOFOL DRIP. WOKEN UP EVERY FOUR HOURS FOR NEURO EXAM. WHEN AWAKE PATIENT OPENS EYES TO VOICE AND FOLLOWS ALL COMMNADS. MOVING ALL EXTREMITIES IN BED. PUPILS EQUAL AND REACTIVE TO LIGHT. VENTRICULOSTOMY OPEN AND PATENT AT 15CM ABOVE TRAGUS WITH DARK BLOOD TINGED DRAINAGE. ICP<10. R FEM SHEATH PULLED OUT PER NEUROSURGICAL RESIDENT AND TIP SENT FOR CULTURE.\\n\\nCONTINUES TO REQUIRE NIPRIDE DRIP TO MAINTAIN BLOOD PRESSURE LESS THAN 160 SYSTOLIC.\\n\\nLUNGS COARSE WITH MINIMAL SECRETIONS. NO VENT CHANGES TO DAY WITH PERIODS OF RR TO 40. VENT SYSTEM HUMIDIFIED AND LASIX GIVEN X 5MG. FEBRILE TO 101.5. TYLENOL GIVEN. BLOOD CULTURE AND URINE CULTURE SENT.\\n\\nTUBE FEEDS AT GOAL WITH MINIMAL RESIDUALS.\\n\\nPLAN:\\nMONITOR RESP STATUS CLOSELY. WEAN OFF NIPRIDE AS ABLE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563079,\n \"text\": \" 19/07\\n\\n NEURO PT REMAINS ON PROPOFOL DRIP FOR LIGHT SEDATION NOTE PT NEEDED HIGHER DOSE FROM 40 TO 70 MCG/KILO/MIN BECAUSE OF RAPID RESP MD MADE AWARE UNABLE TO FULLY AWAKE PT FOR Q4 HOUR CHECKS AGITATION STARTED THAN UNABLE TO CONTROL BP DESPITE NIPRIDE SEMI CHECKS DONE MD MAE WHEN PROPOFOL STOPPED ICP 5 TO 9 BLOODY IN COLOR\\n RESP ETT .40% FIO2 RHONCHI THRU OUT CLEARS AFTER SUCTIONING\\n HEART S1S2 NSR OCC PVC 12 BEAT RUN SVT K AT THAT TIME 3.8 REPLACED VSS PULSES POOR NIPRIDE NICARDIPINE STARTED FLUIDS RESTRICTED FREE WATER SUPP VIA N/G A LINE CVP WNL U/O WNL SEE FLOW SHEETS\\n GI POS BS TUBE FEEDS WELL\\n SUPPORTIVE CARE\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563080,\n \"text\": \"pt.remains on simv+ps ventilation,abg alkalotic, will wean as , has periods of increased rr.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563072,\n \"text\": \"RESP: PT ON SIMV 12/700/5/+5/40%. ALARMS ON AND FUNCTIONING. AMBU/SYRINGE @ HOB. BS AUSCULTATED REVEAL BILATERAL COARSE SOUNDS. SUCTIONED FOR SMALL AMOUNTS OF THICK TANNISH SECRETIONS. VENT CHANGES PER ABG'S; DECREASED RATE TO 10/DECREASE VT TO 650/FIO2 TO 35%. AM ABG'S 7.47/36/107/27. 02 SATS @ 99%. RSBI=111. NO FURTHER CHANGES NOTED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563081,\n \"text\": \"SHIFT REPORT\\nNEURO: DIFFICULT TO AROUSE DESPITE OFF PROPOFOL. BECOMING MORE ALERT AS SHIFT PROGRESSES. INCONSISTENTLY FOLLOWING SIMPLE COMMANDS. OPENS EYES OCCASSIONALLY. NEUROSURG TEAM UPDATE FREQUENTLY, NEURO NP IN TO PT. KEEP SBP UNDER 170 PER DR. ORDERS. ICP 5 TO 7. SM AMT THICK BLOODY DRAINAGE OUT V. . CONT ON NICARDIPINE DRIP.\\nCV: CENTRAL LINE CHANGED O/W TODAY. TIP SENT FOR CULT. TMAX 101.7 - PAN CULTURED PER SICU TEAM'S ORDERS. TYLENOL X1 W/ EFFECT.\\nRESP: NO VENT CHANGES. SXN FOR SMALL AMT THICK, YELLOW/WHITE SPUTUM.\\nENDOCRINE: BSUGARS 189 TO 159 COVERED VIA SSRI. TFEEDS DECREASED TO 80CC/HR. FREE WATER BOLUSES D/ MD.\\nPLAN: WEAN NICARDIPINE TO MAINTAIN ORDERED PARAMETERS. PPF OFF WHILE LETHARGY RESOLVING.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563082,\n \"text\": \" ,04 19 TO 07\\n PT STATUS MAE ON COMAND TRIES TO OPEN EYES WEAKNESS THRU OUT ON NO SEDATION PROGRESSIVE AWAKENING ALSO TRIES TO TALK AROUND TUBE NO PAIN WHEN ASKED\\n\\n HEART S1S1 OCC PVC NOTED PULSES POSITIVE 2 WITH 3+ PIT EDEMA TONES WNL VSS BP 150/90 MD PARAMETERS ON NICARIPINE 1.5 MCG/KILO/MIN CVP WNL ICP WNL ALL GOOD WAVE FORMS\\n\\n RESP CLEAR OCC RHONCHI CLEARS AFTER COUGHING CPT T&P Q2 HOURS ON .40 FIO2 SAT WNL\\n\\n ABD SOFT POS BS STOOLING T/F WELL NO RESIDUAL\\n\\n SUPPORTIVE CARE FAMILY SUPPORT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563157,\n \"text\": \"Respiratory Care\\nPt dropping SAO2 to upper 80's, requiring vigorious ambu bagging and suctioning. FiO2 increased to 100%, decreasing to 50%. Suction and strong productive cough of copious amounts thick tan/blood tinged secreations.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563158,\n \"text\": \"NPN\\n PT . OPENS EYES OCCASIONALLY WHEN TURNING, SUCTIONING, NOT ON COMMANDS. MINIMAL SPONTANEOUS MOVEMENT NOTED. . WILL GO TO CT THIS AFTERNOON\\nCV- BP IN 120-130 RANGE. DROPPED TO 110'S FOR A BRIEF PERIOD, SPOKE TO NSURG AND MONITORED, NO MEDS GIVEN.\\nRESP- CONTINUES TO HAVE BLOODY SECRETIONS, ABLE TO RAISE. O2 SAT DROPPED TO HIGH 80'S THIS AM, SUCTIONED FOR A PLUG. CHEST X-RAY DONE AND PT IS NOW 100% ON 50% TRACH COLLAR. NO FURTHER EPISODES.\\nGI- BM TODAY, TF AT GOAL, WITH MINIMAL RESIDUAL.\\nGU- FOLEY DRAINING 80-120CC/HR CLOUDY YELLOW URINE.\\nID- AFEBRILE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563159,\n \"text\": \"update\\nneuro: ? moved rt thumb to command during am neuro rounds. otherwize .\\ncv: 4 beat run v tach, resolved spontaneously.\\ngi: tube feeds at 80/hr, well with min residuals. large BM x 1, hem neg.\\ngu: u/o qs.\\n? lp today. Need to turn off 4 hrs prior to tap.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563160,\n \"text\": \"See Carevue for objective data.\\n\\nNeuro exam . dc'd at 0900 in preparation for LP which was completed at 1600. Opening pressures: 10. No specimens were obtained. to be restarted at 2200.\\n7 beat run of VT/hemodynamically stable and resolved spontaneously.\\nBP 100-140 systolic.\\nSuctioned and also expectorated on own blood tinged tan thick secretions. O2 sats adequate on trach collar.\\nDuoderm on coocyx changed. Small stage 2 ulcer dime size cleansed and new duoderm applied.\\nAdequate urine output. Tolerating TF with low residuals. FSBS per SS.\\nWife in and updated on day's events.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563073,\n \"text\": \"condition update\\nTEMP SPIKES TREATED WITH TYLENOL. DOES BECOME HYPERTENSIVE WITH TEMP ELEVATION. CULTURES PENDING\\nONE EPISODE OF PERSISTENT HBP WHICH RESPONDED TO EXTRA PROPOFOL.\\nLOPRESSOR @ BEDSIDE IN ANTICIPATION FOR WAKEUPS.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563074,\n \"text\": \"Respiratory Care Note:\\n He remains sedated and intubated. Taken to anio this am without incident. BS bilat, coarse RUL. Suctioned for small-med amount of thick yellow tinged secretions. RR>20 with VE of >11lpm. Positive for fever this afternoon. Cultures pending. Plan to maintain overnight on SIMV. No vent changes made today. RSBI of 111 noted.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563075,\n \"text\": \"CONDITION UPDATE\\nD. PT TO ANGIO TODAY=NO SPASMS AS PER DR. . BP PARAMETERS OF SBP 120-150 TO BE CONTINUED..\\n TEMP UP TO 100.8 FOR WHICH PT WAS CULTURED AND TYLENOL GIVEN. POST ANGIO PT WAS ORDERED FOR IVF AT 100ML/HR FOR 1 LITER AND TF RESUMED..BY THIS PM AND AFTER 500ML OF IVF..O2 SAT DROPPED TO 94,RR=33,AND CVP CLIMBED TO 16..DR. NOTIFIED AND IVF DECREASED TO KVO. WITH NEED FOR KCL AND CAGLUC BOLI,CVP CONTINUED TO CLIMB AND DR. WAS NOTIFIED. HUO DOWN TO 60ML.\\n NO VENT CHANGES TODAY.ABG ACCEPTABLE WHEN O2 SAT=98. FOR SCANT SECRETIONS..BS DECREASED IN BASES WITH SL RALES.\\n PT REMAINS ON PROPOFOL AND NEURO EXAM REMAINS THE SAME..OFF PROPOFOL,PT FOLLOWS COMMANDS.ON PROPOFOL PT MOVES EXTREMITIES TO PAIN.ICP=.COLOR REMAINS DARK RED.\\nA.? NEED FOR LASIX..MAINTAIN SBP 120-150.\\nR.STABLE AT THIS TIME WITH POSSIBLE EARLY SIGNS OF FAILURE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563076,\n \"text\": \"Condition Update\\nD: See carevue flowsheet for specifics\\n TMAX 101.1-tylenol given (patient cultured on day shift). SBP at beginning shift up to 175-lopressor 10mg given with no effect. Patient was then started on nipride gtt to keep sbp<160. Nipride currently infusing at 1mcg/kg/min. CVP ~9 and making 60-80cc/hr of urine. Slowly sats dropped to 94-95% with RR 26-29. SICU resident notified abg drawn and lasix 5mg given with mod amt of diuresis and sats rose to 96-97% paO2 slightly improved RR unchanged.\\n Lungs remain coarse but only suctioning for small amt tan colored secretions. No vent changes made overnight.\\n Propofol gtt turned off Q4hrs for neuro exam. When off sedation patient follows commands and moves all extremeties. ICP was running ~10 and then went down to 1-2. Vent @ 15 above the tragus and draining old colored blood. Right fem angio sheath in place and transduced.\\nPLAN:\\n Pulmonary toilet\\n Monitor for si/sx of CHF\\n Q4hrs neuro exam off sedation\\n vent @15 open\\n Keep sbp<160\\n Notify H.O. with any changes.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-06-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563077,\n \"text\": \"Respiratory Care:\\nPt remains on Mech Vent as per CareVue. No changes today, and he remains W/Met.Alk ?? Added a heated circut at about 18:30 today for added humidification...\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563161,\n \"text\": \"NPN ( SEE CAREVUE FOR ALL SPECIFICS)\\nNEURO- NEURO STATUS . NO SPONTANEOUS MOVEMENT. OCCASIONALLY OPENS EYES TO PAIN, NO TRACKING. . RESPONDS TO PAINFUL STIMULI BY SLIGHT MOVEMENT IN EXT. HEP. RESTARTED AND LP SITE MONITORED, NO OR DRAINAGE\\nCV- BP 120-140'S. HR 70'S WITH FREQUENT PVCS, NSR.\\nRESP- LUNGS CLEAR WITH DIMINISHED BASES. O2 SAT 100%. REQUIRES OCCASIONAL SUCTIONING DESPITE STRONG COUGH FOR THICK BLOOD TINGED SPUTUM. PT ABLE TO RAISE MAJORITY OF SECRETIONS.\\nGI- ABD SOFT, NO BM. TF AT GOAL WITH NO RESIDUAL.\\nGU- FOLEY DRAINING CLEAR YELLOW URINE, 100-300CC/HR.\\nID- AFEBRILE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563162,\n \"text\": \"STATUS\\nD: NEURO ..REMAINS ON GTT @ 1250U\\nA: VSS..GOOD HUO NO STOOL..PTT Q8H.. TRACH @ 70% SUCTIONED FOR MOD AMT THICK PINK TINGED/TAN SECREATIONS\\nR: ESSENTIALLY \\nP: TO GO TO REHAB TOMORROW..FAMILY AWARE\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563163,\n \"text\": \"NPN (SEE CAREVUE FOR SPECIFICS)\\nPT NEUROLOGICALLY. NO SPONTANEOUS MOVEMENT NOTED, MAE TO PAINFUL STIMULI, NOT LOCALIZING. . SUCTIONED FREQUENTLY FOR MODERATE AMOUNTS OF SPUTUM. HAD ONE EPISODE AT BEGINNING OF SHIFT WITH LARGE AMOUNT OF BLOODY SPUTUM RAISED FROM TRACH. DR. IN TO . NO INTERVENTION AND SPUTUM IS NOW PINK. COAGS FROM THIS AM PENDING. BP 100-140'S, HR 70'S WITH FREQUENT PVCS. TMAX 99.0. REHAB TODAY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563151,\n \"text\": \" 19/07\\n\\n STATUS NO CHANGE MAE L>R COUGHING AND PAIN CREATES A RESPONDS OF WITHDRAWAL VSS NO TEMP ALINE GOOD WAVE\\n\\n HEART S1S2 ST DEPRESSION NOTED CHRONIC IN NATURE PULES WEAK EDENA RESOLVING MULTIFOCAL PVC NEG NVD\\n\\n RESP RHONCHI RALES CLEARS AFTER SUCTIONING .50 02 sat 99\\n\\n GI POS BS SMALL HEM POS STOOLS NOTED U/O QS CLEAR\\n\\n NOTE NEO TO MAINTAINE BP greater than 120 t/f wnl\\n\\n bp 140/78 98 temp 97 oral t/p well no pain\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563152,\n \"text\": \"NEURO: NOTICED PT OPENING EYES X2 BUT NOT FOCUSSING AND NOT TRACKING, . RESPONDS TO NOXIOUS STIMULI BY WITHDRAWING ALL EXTREMETIES SLIGHTLY. PT STILL NOT FOLLOWING COMMANDS.\\n\\nCV: HR 70-90'S, NSR W/ PVC'S, SBP>120 PER PARAMETERS-GOOD RESPONSE ON MIDODRINE 2.5MG TIS. CVP 3-13.\\n\\nRESP: LUNG SOUNDS COARSE, LRG AMT SPUTUM SXN AND ALSO PT EXPECTORATING. SPUTUM YELLOW TO TAN AND INCREASINGLY BLOODY THIS AFTERNOON, SPUTUM CX SENT. O2 SAT >95% ON TRACH COLLAR 50%.\\n\\nGI: ABD SOFT NT ND,+BOWEL SOUNDS, TF IMPACT W/ FIBER AT GOAL 80CC/HR VIA PEG, SITE C/D/I. BM X1 GUAIAC NEG.\\n\\nGU: FOLEY DRAINING ADEQ U/O, CLEAR CONCENTRATED YELLOW.\\n\\nID: TMAX 97.4\\n\\nPLAN: CONT CURRENT MGMT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563153,\n \"text\": \" 19/07\\n\\n PT STATUS SLIGHTLY LIGHTER THIS PM OCC OPENS EYES SEEMS TO RESIST COMMUNICATION BY TIGHTLY SHUTTING EYES WHEN TALKED TO EXPLORES SELF WITH RIGHT HAND\\n\\n RESP BLOOD TINGED SPUTUM CLEARS HIMSELF VERY STRONG COUGH RHONCHI THRU OUT\\n\\n S1S2 PULES POS 2 PEDAL EDEMA REMAINS NSR WITH PVCS\\n\\n GI TF WELL F/S STOOL NEG HEM\\n TALKED WITH WIFE AT REMAINS HOPEFUL LOOKING FOWARD TOWARDS REHAB\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563154,\n \"text\": \"NEURO: PT OPENED EYES X2 HOWEVER NOT TRACKING, PUPILS UNEQUAL BUT BRISKLY REACT TO LIGHT, NSURG INFORMED. PT NOT FOLLOWING COMMANDS, NO SPONT/PURP MVMTS NOTED. GRIMACING AND WITHDRAWING SLIGHTLY TO PAIN W/ ALL 4 EXTREMETIES WHEN NOXIOUS STIMULI APPLIED TO NAILBED.\\n\\nCV: HR 70-80'S, NSR W/ PVC'S, SBP 120-150'S. CVP 8-11. +2 EDEMA.\\n\\nRESP: RR 20-30'S, O2 SAT 97-100% VIA TRACH COLLAR 50%. SXN PRN FOR THICK TAN SPUTUM AND CX SENT.\\n\\nGI: ABD SOFT NT/ND, +BOWEL SOUNDS, TOLERATING TF IMPACT W/ FIBER VIA PEG AT 80CC/HR AT GOAL, MINIMAL RESIDUALS.\\n\\nGU: FOLEY DRAINING ADEQ U/O, CLEAR TO CLOUDY URINE. DR. INFORMED, FOLEY TO BE CHANGED AND U/A TO BE SENT.\\n\\nID: TMAX 97.8\\n\\nPLAN: MONITOR VS, LABS, NEURO STATUS. ?LP THIS WEEK, ? CT HEAD TOMORROW.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563155,\n \"text\": \" 19/07\\n\\n pt status opens eyes on occ to verbal command in general lethargic moves with pain stimulus \\n\\n resp blood tinged sputum noted clears after coughing on .50 fio2 well sao2 100% CPT Q2 HOURS\\n\\n HEART S1S2 WNL OCC PVCS PULSES POS 2 THRU OUT U/O QS TUBE FEEDING WELL POS BS SMALL HEM NEG STOOL\\n\\n SUPPORTIVE CARE ROM CPT SKIN CARE PT CONSULT\\n\\n NOTE FRANK BLOOD AROUND STOMA OF PEG TUBE MOD AMOUNT NO EVENT PRIOR MD SITUATION T/F DC CLEAR RETURNS\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563156,\n \"text\": \" CONT OF ABOVE NOTE AT 2100 PT BY MD AROUND PEG TUBE SITE ORDER TO KEEP DRESSING ON AND MONITOR PT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563094,\n \"text\": \"Resp: pt on a/c 10/600/+5/40%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral clear apecies with diminished LS. Suctioned for small to moderate amounts of thick yellow secretions. Sputum sample obtained and sent. 02 sats @100%. RSBI=113.5. AM ABG's 7.48/36/151/28. No further changes noted.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563095,\n \"text\": \"focus: status update\\nDATA:\\nDECREASED MENTAL STATUS THIS AM--NOT FOLLOWING COMMNADS CONSISTENTLY, NOT OPENING EYES TO VOICE, L SIDE APPEARED WEAKER THAN RIGHT. DR. NOTIFIED AND EVALUATED PATIENT. STAT HEAD CAT SCAN ORDERED AND DONE. NO BLEEDING PRESENT AND PRELIMINARY RESULTS STATE SLIHT VENTRICLE ENLARGEMENT. VENTRICULOSTOMY WAS DECREASED TO 10CM ABOVE TRAGUS. IT CONTINUES TO HAVE DARK BLOOD TINGED DRAINAGE. INTRACRANIAL PRESSURES SLIGHTLY LOWER THAN IN AM WHEN VENTRICULOSTOMY WAS AT 15CM. MENTAL STATUS HAS IMPROVED THROUGHOUT THE DAY AND PATIENT IS NOW LIFTING ARMS SLIGHTLY AND MOVING IN BED. OPENED EYES FOR WIFE VISITING. EEG DONE AT BEDSIDE. PUPILS EQUAL AND REACTIVE TO LIGHT. 3%NS STARTED FOR SODIUM LEVEL 129.\\n\\nCONTINUES ON NEOSYNEPHRINE IV DRIP TO MAINTAIN BLOOD PRESSURE AROUND 160-170 FOR CEREBRAL PERFUSION.\\n\\nHEPARIN DRIP STOPPED WHILE AT CAT SCAN NOW RESUMED AND INCREASED DUE TO LOWER PTT. NIVS ORDERED TO F/U. TOLERATING CPAP WITH 10 PRESSURE SUPPORT.\\n\\nTOLERATING TUBE FEEDS AT GOAL WITH MINIMAL RESIDUALS.\\n\\nCONTINUES TO DIURESE WELL.\\n\\nPLAN:\\nSODIUM CHECKS Q2HRS WITH GOAL OF 135. PTT CHECKS Q6HRS. AND F/U WITH DR. FOR HEPARIN ORDERS. NIVS TODAY.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563096,\n \"text\": \"nursing update\\nRun OF VT-11 beats. No spont kick in of pacer. MD aware. EKG done. cards to see.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2165-07-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563097,\n \"text\": \"Nursing note:\\nNEURO: Lethargic in beginning of shift, difficult to arouse except to sternal rub. Following simple commands inconsistently. PERRLA. More wakeful later in night, opening eyes spontaneously and consistently following commands. Moving lower extremities on bed and wiggling toes, lifting/holding w/upper extremities. Hand grasps equal bilaterally. ICP 4-8. Ventricular 10cm above tragus, blood -tinged drainage.\\nCV: Tmax 100.4, Tylenol given w/good effect. More easily arousable after temp normalized. Vpaced w/frequent PVCs, bigeminy at times. Palpable pulses. SBP kept 170 or > w/Neo gtt, frequently titrated. Nimodopine d/c'd per Dr. for better control of BP. Potassium repleted. NA levels checked q2hours, 3% NACl gtt infusing, decreased to 10cc/hr. Cont. on salt tabs. Heparin gtt increased to 1500u/hr d/t sub-therapeutic levels, bolused w/1000u as well.\\nRESP: Returned to A/C rate d/t periods of apnea, low tidal volumes and tachypnea. ABGs less alkalotic after change. Suctioned for thick yellow sputum.\\nGI: Abdomen softly distended. +Bowel sounds, +liquid brown stool. FIB changed. Cx. sent for cdiff. Tube feeds @ goal of 80cc/hr, minimal residuals.\\nGU: Foley patent large amount pale yellow urine.\\nENDO: SSRI PRN.\\nSKIN: Intact. Small skin tear to coccyx, open to air.\\n\\nA/P: More alert overnight, following commands. SBP kept 170 or > w/Neo gtt. Cont. on 3% Sodium gtt and Heparin gtt. Monitor neuro status closely and q2hour labs, reattempt vent wean in am.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2165-06-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 93587,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Chest pain. H/O cardiac surgery. Left ventricular function.\\nHeight: (in) 71\\nWeight (lb): 201\\nBSA (m2): 2.12 m2\\nBP (mm Hg): 124/57\\nHR (bpm): 73\\nStatus: Inpatient\\nDate/Time: at 12:05\\nTest: Portable TTE (Complete)\\nDoppler: Complete pulse and color flow\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: The left atrium is moderately dilated.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. A\\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\\n\\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\\nimages. Left ventricular wall thicknesses are normal. The left ventricular\\ncavity is mildly dilated. There is moderate regional left ventricular systolic\\ndysfunction. There is no resting left ventricular outflow tract obstruction.\\n\\nLV WALL MOTION: The following resting regional left ventricular wall motion\\nabnormalities are seen: basal anterior - hypokinetic; mid anterior -\\nhypokinetic; basal inferior - akinetic; mid inferior - akinetic; basal\\ninferolateral - akinetic; mid inferolateral - akinetic; anterior apex -\\nhypokinetic; inferior apex - hypokinetic;\\n\\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\\nnormal.\\n\\nAORTA: The aortic root is mildly dilated. There are focal calcifications in\\nthe aortic root.\\n\\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\\nstenotic. Mild (1+) aortic regurgitation is seen.\\n\\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is\\nmoderate mitral annular calcification. There is mild thickening of the mitral\\nvalve chordae. Mild to moderate (+) mitral regurgitation is seen. [Due to\\nacoustic shadowing, the severity of mitral regurgitation may be significantly\\nUNDERestimated.]\\n\\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\\ntricuspid regurgitation. There is mild pulmonary artery systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\\n\\nPERICARDIUM: There is no pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Based on \\nAHA endocarditis prophylaxis recommendations, the echo findings indicate a\\nmoderate risk (prophylaxis recommended). Clinical decisions regarding the need\\nfor prophylaxis should be based on clinical and echocardiographic data. The\\nresults were reviewed with the Cardiology Fellow involved with the patient's\\ncare.\\n\\nConclusions:\\nThe left atrium is moderately dilated. Left ventricular wall thicknesses are\\nnormal. The left ventricular cavity is mildly dilated. There is moderate\\nregional left ventricular systolic dysfunction with near akinesis of the\\ninferior and inferolateral walls. The anterolateral wall is severely\\nhypokinetic. The remaining walls contract well. Right ventricular cavity size\\nand free wall motion are normal. The aortic root is mildly dilated. The aortic\\nvalve leaflets (3) are mildly thickened but not stenotic. Mild (1+) aortic\\nregurgitation is seen. The mitral valve leaflets and supporting structures are\\nthickened. Mild to moderate (+) mitral regurgitation is seen. There is mild\\npulmonary artery systolic hypertension. There is no pericardial effusion.\\n\\nIMPRESSION: Mild left ventricular cavity enlargement wit extensive regional\\nleft ventricular systolic dysfunction c/w multivessel CAD. Mild-moderate\\nmitral regurgitation. Mild aortic regurgitation. Pulmonary artery systolic\\nhypertension.\\n\\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\\nregarding the need for prophylaxis should be based on clinical and\\nechocardiographic data.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2165-06-27 00:00:00.000\",\n \"description\": \"CAROTID/CEREBRAL BILAT\",\n \"row_id\": 827965,\n \"text\": \" 8:49 AM\\n CAROT/CEREB Clip # \\n Reason: S/P COILING\\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\\n Contrast: OPTIRAY Amt: 104\\n ********************************* CPT Codes ********************************\\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT *\\n * CAROTID/CEREBRAL BILAT VERT/CAROTID A-GRAM *\\n * EXT UNILAT A-GRAM -52 REDUCED SERVICES *\\n ****************************************************************************\\n ______________________________________________________________________________\\n FINAL REPORT\\n PREOPERATIVE DIAGNOSIS: Previously stent and coil intracranial wide neck left\\n vertebral artery aneurysm. Rule out vasospasm.\\n\\n POSTOPERATIVE DIAGNOSIS: Stable appearance of the previously coiled aneurysm\\n with patent left vertebral artery with small remnant at the neck of the\\n aneurysm but stable appearance of the coil dome and no evidence of significant\\n intracranial vasospasm.\\n\\n INDICATION: Mr. is a patient is patient who presented with subarachnoid\\n hemorrhage from a ruptured wide neck aneursym. He underwent successful stent\\n angioplasty with coiling of the aneurysm and is undergoing a cerebral artery\\n to rule out the presence of intracranial vasospasm.\\n\\n CONSENT: The patient and her son were given a full and complete explanation\\n of the procedure. Specifically, the indications, risks, and benefits and\\n alternatives to the procedure were explained in detail. In addition, the\\n possible complications such as the risk of bleeding, infection, stroke,\\n neurological deficit or deterioration, groin hematoma, and other unforeseen\\n complications including the risk of coma and even death were outlined. The\\n patient and her son understood and wished to proceed with the operation.\\n\\n PROCEDURE IN DETAIL: The patient was brought in the endovascular suite and\\n placed on the table in supine position. The right groin area was prepped and\\n draped in the usual sterile fashion. A 19 gauge single wall needle was then\\n used to puncture the right femoral artery and upon the return of brisk\\n arterial blood a 4 FR vascular sheath was inserted over a guidewire and kept\\n on a heparinized saline drip. Next a diagnostic catheter was used to\\n selectively catheterize the following vessels over a guidewire in succession:\\n Left subclavian artery, left vertebral artery, left common carotid artery,\\n left internal carotid artery, right common carotid artery, right internal\\n carotid artery.\\n\\n RESULTS: Injection of the left subclavian artery shows no atherosclerotic\\n disease at the origin of the left vertebral artery and shows a small raised\\n plaque distal to the origin of the left vertebral artery. The proximal left\\n cervical segment of the vertebral artery shows antegrade flow with no anomaly.\\n Intracranially with injection on the left vertebral artery with three\\n dimensional rotational angiography showed that the previously deployed tandem\\n stents are patent with no evidence of atherosclerotic involvement or intimal\\n (Over)\\n\\n 8:49 AM\\n CAROT/CEREB Clip # \\n Reason: S/P COILING\\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\\n Contrast: OPTIRAY Amt: 104\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n hyperplasia. The previously coiled aneurysm is stable in appearance with well\\n treated dome and a small residual filling at the neck of the aneurysm.\\n Injection of both common carotid arteries in the cervical region showed no\\n significant atherosclerotic disease or dissection and they are not changed\\n compared to the prior study. Injection of both internal carotid arteries on\\n the right and the left with three dimensional rotational angiography showed no\\n evidence of branch occlusion or significant vasospasm. There is presence of\\n bilaterally mild vasospasm which is diffuse.\\n\\n IMPRESSION: Stable appearance of the previously coiled aneurysm with patent\\n stent and presence of mild vasospasm which does not currently require any\\n endovascular therapy.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2165-06-21 00:00:00.000\",\n \"description\": \"MULTI-PROCEDURE SAME DAY\",\n \"row_id\": 827384,\n \"text\": \" 3:26 PM\\n CAROT/CEREB Clip # \\n Reason: SAH\\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\\n Contrast: OPTIRAY Amt: 555\\n ********************************* CPT Codes ********************************\\n * EMBO TRANSCRANIAL -51 MULTI-PROCEDURE SAME DAY *\\n * PTA BRACHIOCEPHAL EA VESSEL -51 MULTI-PROCEDURE SAME DAY *\\n * TRANSCATH PLCT STENTS, INITIAL -51 MULTI-PROCEDURE SAME DAY *\\n * SEL CATH 3RD ORDER -59 DISTINCT PROCEDURAL SERVICE *\\n * ADD'L 2ND/3RD ORDER TRANSCATH EMBO THERAPY *\\n * F/U TRANS CATH THERAPY ANGIOPLASTY PERIPHERAL *\\n * TRANSCATH INTRO STENT C1769 GUID WIRES INFU/PERF *\\n * C1769 GUID WIRES INFU/PERF C1769 GUID WIRES INFU/PERF *\\n ****************************************************************************\\n ______________________________________________________________________________\\n FINAL REPORT\\n PREOPERATIVE DIAGNOSIS: Subarachnoid hemorrhage from ruptured left\\n intracranial wide-necked vertebrobasilar aneurysm in an isolated left\\n vertebral artery posterior circulation with no presence of posterior\\n communicating flow and a diminutive right vertebral artery providing only\\n posterior-inferior cerebellar artery perfusion.\\n\\n POSTOPERATIVE DIAGNOSIS: Same status post stent angioplasty of the\\n intracranial vertebral artery and left segment followed by coiling of the\\n wide-necked aneurysm with preservation of the flow in the left vertebral\\n artery in the posterior circulation and obliteration of the aneurysm using\\n endovascular coiling.\\n\\n INDICATION: Mr. is a patient who presented with subarachnoid hemorrhage\\n from a ruptured wide-necked fusiform aneurysm of the intracranial left\\n vertebral artery which was found proximal to the critical stenosis of the\\n vertebral artery. This aneurysm because of its appearance currently is not\\n amenable to surgical therapy. At this location as well as the inability of the\\n patient to tolerate temporary occlusion renders bypass procedure unacceptably\\n high risk. In addition aneurysm, because of its size cannot be treated using\\n coiling without some means of protecting the neck of the aneurysm. Imaging of\\n the posterior circulation with CT angiography and CT scan had revealed a\\n highly calcified left vertebral artery and the right vertebral artery does not\\n provide any perfusion to the vertebrobasilar junction. These findings were all\\n explained to the family and accordingly they gave approval for use of stent\\n angioplasty as a means of treating the atherosclerotic stenosis followed by\\n coiling of the aneurysm. Accordingly the patient was administered oral Plavix\\n and aspirin prior to the beginning of the procedure and taken down to the\\n angiography suite for this procedure.\\n\\n CONSENT: The patient's wife and son were given a full and complete explanation\\n of the procedure. Specifically, the indications, risks, benefits, and\\n alternatives to the procedure were explained in detail. In addition, the\\n possible complications, such as the risk of bleeding, infection, stroke,\\n neurological deficit or deterioration, groin hematoma, and other unforeseen\\n complications, including the risk of coma and even death, were outlined. The\\n patient's wife and son understood and wished to proceed with the operation.\\n (Over)\\n\\n 3:26 PM\\n CAROT/CEREB Clip # \\n Reason: SAH\\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\\n Contrast: OPTIRAY Amt: 555\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\\n placed on the table in supine position. The right groin area was prepped and\\n draped in the usual sterile fashion. A 19-gauge single-wall needle was then\\n used to puncture the right common femoral artery, and upon the return of brisk\\n arterial blood, a 5 Fr vascular sheath was inserted over a guidewire and kept\\n on a heparinized saline drip. Next, a diagnostic catheter was used to\\n selectively catheterize the following vessels: left subclavian artery, left\\n vertebral artery, left intracranial vertebral artery and posterior cerebral\\n artery, and left intracranial aneurysm of the left vertebral artery. At this\\n point a 5 Fr guidecatheter was placed into the left vertebral artery. Through\\n that guidecatheter a series of angiographic runs with three-dimensional\\n rotational angiography enabled us to define the lesion both aneurym and\\n stenosis which needed treatment. At this point after inducing heparinization a\\n SL-10 microcatheter was used over an Agility microwire to selectively\\n catheterize the left posterior cerebral artery P2 segment. This was done by\\n crossing the critical stenosis and bypassing the aneurysm. With the\\n microcatheter in this position an Exelerator 0.014 inch 300cm exchange wire\\n was placed into the distal posterior cerebral artery and this enabled us then\\n to withdraw the SL-10 microcatheter. To that 2.5 x 15 mm long stent\\n was navigated over the exchange wire and deployed across the stenosis distal\\n to the aneurysm with coverage of the neck of the aneurysm. With the stent in\\n this position an angiographic run was performed and the stent was deployed at\\n 2-4atm above its nomimal pressure which enabled us to obtain a good position\\n of the stent. The balloon was then deflated and the balloon was then\\n withdrawn. An angiographic run at this point showed successful treatment of\\n the distal stenosis distal to the aneurysm with good flow through the left\\n vertebral artery and its basilar artery. Leaving the 300 cm exchange wire\\n across the stent and in the distal P2 segment of the posterior cerebral artery\\n an angiographic run was performed five minutes following deployment of the\\n stent which revealed that the flow through the left vertebral artery had\\n closed off completely distal to the proximal portion of the stent. At this\\n point there was no longer flow in the basilar segment. To that end examination\\n of the proximal portion of the stent with three-dimentional rotational\\n angiography revealed that the proximal portion of the stent had been crimped\\n on itself probably as a result of the highly calcific left vertebral artery.\\n To that end an additional 2.5 mm x 9 mm stent was advanced over the exchange\\n wire and with its distal portion abutting the proximal struts of the\\n previously deployed stent with the stent in this position it was inflated to\\n its nominal size and at this point the balloon was withdrawn. Angiography of\\n the left vertebral artery at this point showed resumption of flow through the\\n basilar artery with no evidence of branch occlusion and excellent\\n reconstitution of the stenotic left vertebral artery. Further surveillance\\n revealed that the segment in between the stents where the two stents\\n overlapped again showed progressive restenosis and loss of flow to the distal\\n (Over)\\n\\n 3:26 PM\\n CAROT/CEREB Clip # \\n Reason: SAH\\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\\n Contrast: OPTIRAY Amt: 555\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n basilar artery. At this point a noncompliant 2.75 mm Charger balloon was\\n deployed over the exchange wire and positioned across the portion of the left\\n vertebral artery between the two stents. This was then inflated to 2.5 x 2.75\\n mm and the balloon was then withdrawn. At this point angiography revealed that\\n the previously calcific stenosis had in fact had been successfully treated\\n with a noncompliant balloon with resumption of distal flow in the basilar\\n artery and reconstitution of flow in the left vertebral artery. Three-\\n dimensional rotational angiography now revealed that the stenotic segment of\\n the left vertebral artery had now been successfully treated with stent\\n angioplasty and deployment of both stents. Our attention was then turned to\\n the aneurysm. To that end a microcatheter was then positioned of type SL-10\\n into the aneurysm through the struts of the 1st depolyed ABE stent. With the\\n microcatheter in this position a GDC coil three-dimensional coil was deployed\\n following a series of smaller ultrasoft GDC coils. This resulted in complete\\n embolization of the dome of the aneurysm with a small .5 mm to 1 mm remnant\\n neare the neck of the aneurysm. Additional attempts at treating that small\\n remnant resulted in coil herniation into the parent vessel through the struts\\n and as such were abandoned. At the end of the procedure three-dimensional\\n rotational angiography showed excellent treatment of the aneurysm with no\\n further opacification of the dome and patent left vertebral artery with no\\n further stenosis and improved distal flow particularly of the left posterior\\n cerebral artery which now fills from the left vertebral artery injection.\\n\\n IMPRESSION: Successful intracranial stent angioplasty of the highly stenotic\\n and calcified left vertebral artery with coil through stent embolization of\\n the wide-necked aneurysm without iatrogenic branch occlusions.\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2165-06-21 00:00:00.000\",\n \"description\": \"ADD'L 2ND/3RD ORDER\",\n \"row_id\": 827340,\n \"text\": \" 9:17 AM\\n CAROT/CEREB Clip # \\n Reason: SAH\\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\\n Contrast: OPTIRAY Amt: 240\\n ********************************* CPT Codes ********************************\\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\\n * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT *\\n * VERT/CAROTID A-GRAM VERT/CAROTID A-GRAM *\\n * -59 DISTINCT PROCEDURAL SERVICE EXT BILAT A-GRAM *\\n * -52 REDUCED SERVICES C1760 CLOSURE DEVICE VASC IMP/INS *\\n * C1894 INT/SHTH NOT/GUID EP NON-LASER *\\n ****************************************************************************\\n ______________________________________________________________________________\\n FINAL REPORT\\n PREOPERATIVE DIAGNOSIS: Subarachnoid hemorrhage.\\n\\n POSTOPERATIVE DIAGNOSIS: Fusiform aneurysm of the left vertebral artery with\\n severe distal intracranial and proximal intracranial left vertebral artery\\n atherosclerosis, no evidence of posterior communicating artery connecting the\\n anterior to the posterior circulation and a diminutive right vertebral artery\\n ending in a distribution of the right posterior-inferior cerebellar artery.\\n\\n ANESTHESIA: General endotracheal anesthesia.\\n\\n INDICATION: Mr. presented with a subarachnoid hemorrhage and was\\n transferred to the . He is currently\\n undergoing this cerebral angiogram to determine the site of his intracranial\\n aneurysm and subsequently to determine optimal therapy.\\n\\n CONSENT: The patient's wife and her son were given a full and complete\\n explanation of the procedure. Specifically, the indications, risks, benefits,\\n and alternatives to the procedure were explained in detail. In addition, the\\n possible complications, such as the risk of bleeding, infection, stroke,\\n neurological deficit or deterioration, groin hematoma, and other unforeseen\\n complications, including the risk of coma and even death, were outlined. The\\n patient's wife and her son understood and wished to proceed with the\\n operation.\\n\\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\\n placed on the table in supine position. The right groin area was prepped and\\n draped in the usual sterile fashion. A 19-gauge single-wall needle was then\\n used to puncture the right common femoral artery, and upon the return of brisk\\n arterial blood, a 4 Fr vascular sheath was inserted over a guidewire and kept\\n on a heparinized saline drip. Next, a diagnostic catheter was used to\\n selectively catheterize the following vessels: right common carotid artery,\\n right internal artery, left common carotid artery, left internal carotid\\n artery, left subclavian artery, left vertebral artery, right subclavian\\n artery, right vertebral artery.\\n\\n RESULTS: Injection of the left subclavian artery showed minimal\\n (Over)\\n\\n 9:17 AM\\n CAROT/CEREB Clip # \\n Reason: SAH\\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\\n Contrast: OPTIRAY Amt: 240\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n atherosclerotic change and a small raised plaque accounting for approximately\\n 20% stenosis at the proximal left vertebral artery distal to its origin. The\\n left vertebral artery is otherwise without significant atherosclerosis in the\\n cervical segment. Intracranially, the left vertebral artery appears to \\n a fusiform wide-necked aneurysm in the intracranial portion just proximal to\\n the severe greater than 70% atherosclerotic stenosis. Proximal to this\\n fusiform aneurysm is also present an atherosclerotic lesion which is more\\n diffuse and less severe than the distal one. The left vertebral artery appears\\n to be dominant and the basilar trunk is somewhat diffusely narrowed possibly\\n as a result of the proximal atherosclerotic stenosis. The posterior cerebral\\n artery is otherwise within normal limits and it appears that the left\\n posterior cerebral artery territory is mostly fed by a left posterior\\n communicating artery. The left posterior-inferior cerebellar artery origin is\\n normal. Injection of the right subclavian artery showed no significant\\n atherosclerotic disease at the origin of the right vertebral artery. Injection\\n of the right vertebral artery showed it to be small in caliber and in the\\n cervical segment it appeared to mostly end in a partial distribution of the\\n right posterior-inferior cerebellar artery. The posterior-inferior cerebellar\\n artery has a segmental region of mild atherosclerosis distal to its origin off\\n of the right vertebral artery. Injection of the right common carotid artery\\n shows no significant atherosclerotic disease in the cervical region and\\n intracranially shows no evidence of intracranial aneurym shows no vascular\\n malformation. The right external carotid artery injection was within normal\\n limits with no abnormal arteriovenous shunting. Injection of the left internal\\n carotid artery with three-dimensional rotational angiography failed to show\\n any evidence of atherosclerosis intracranially or aneurysmal dilatation. The\\n left external carotid artery injection revealed no evidence of abnormal\\n arteriovenous shunting or dural fistula to account for the patient's\\n subarachnoid hemorrhage.\\n\\n IMPRESSION: Fusiform wide-based aneurysm of the intracranial portion of the\\n left vertebral artery measuring approximately 5.5 mm with a neck of\\n approximately 6 to 7 mm. This is present just proximal to a critical high-\\n grade stenosis and is not amenable to unassisted coil embolization. These\\n findings will be discussed with the patient's family in order to determine\\n optimal therapy given the high-risk nature of the lesion.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2165-07-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 243887,\n \"text\": \"Sinus rhythm\\nST-T changes may be nonspecific\\nSince previous tracing of , the rhythm has reverted from flutter to\\nsinus rhythm\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2165-07-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 243888,\n \"text\": \"Atrial flutter with rapid ventricular response\\n2:1 A-V block atrial tachycardia 1:1\\nPossible inferior infarct - age undetermined\\nLVH with secondary ST-T changes\\nSince previous tracing, new supraventricular tachycardia\\nClinical correlation is suggested\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2165-07-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 243889,\n \"text\": \"Sinus rhythm\\nVentricular premature complex es and ventricular couplets\\nProbable left ventricular hypertrophy\\nSince previous tracing, no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2165-07-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 243890,\n \"text\": \"Sinus rhythm with atrial premature complexes\\nInferior/lateral ST-T changes\\nSince previous tracing, ventricular ectopic activity no longer present. ST-T\\nwave abnormalities more marked\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2165-07-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 243891,\n \"text\": \"Sinus rhythm. Left atrial abnormality. Low amplitude P wave. P-R interval 0.18.\\nFrequent ventricular and occasional atrial ectopy. Precordial voltage for left\\nventricular hypertrophy. Compared to the previous tracing of no\\ndiagnostic interim change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2165-07-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 243892,\n \"text\": \"Sinus rhythm\\nBigeminal PVCs\\nLateral ST-T changes\\nSince previous tracing, ventricular premature complex are new\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2165-06-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 243893,\n \"text\": \"Sinus rhythm\\nLateral ST-T changes\\nSince last ECG, no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2165-06-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 243894,\n \"text\": \"Sinus rhythm with frequent PVCs\\nIV conduction defect\\nSince previous tracing, ventricular premature complexes noted\\n\\n\"\n }\n]"}}},{"rowIdx":24654,"cells":{"subject_id":{"kind":"number","value":12888,"string":"12,888"},"hadm_id":{"kind":"number","value":117735,"string":"117,735"},"target_text":{"kind":"string","value":"1. COPD flare secondary to UTI: At admission she had a saturation of 83% on RA (improved to 94% on 4L) with a peak flow of 100 L/minute. She was given solumedrol, continued on nebs/MDI/antibiotics. She was stable on the floor for approximately 48 hours. She was transferred to the on for hypercarbic respiratory failure (ABG on 2L 7.28/78/53) and was maintained on non-invasive positive pressure ventilation and monitored overnight. She did well, and was transferred back to the floor the following day, satting adequately on 6L NC. She remained on IV steroids at time of transfer back to the floor. She was relatively comfortable, able to speak short sentences. She was continued on IV steroids for two days due to continued wheezing. The day prior to discharge she was transitioned to PO Prednisone as she was no longer having wheezes. She tolerated the PO prednisone and was felt ready for discharge home on a slow steroid taper. She was s/p a 5 day course of azithromycin and it was felt there was no additional need for antibiotics. She was afebrile for the course of her admission on the hospital floor. She was continued on nebulizers. Her albuterol was titrated down secondary to tachycardia. She was continued on inhalers and theophylline. She was discharged on inhalers, home nebulizers, her home medications, and home O2. 2. Tachycardia: She was tachycardic to the 130s it was felt to be likely due to frequent albuterol with a possible component of anxiety. She was monitored on telemetry and the tachycardia was sinus. Her albuterol nebulizers were titrated down to decrease her tachycardia. 3. Osteoporosis - She was continued on fosamax, calcium supplements/vit D. 4. Cataracts - She used her own steroid drops while she was in the hospital."},"extractive_notes_summ":{"kind":"string","value":"Completed course of azithro.CV: HR 130's ST. No VEA. 4 ICU NPN 0700-190062 YO with end-stage COPD admitted to 11R admitted with COPD flare. FINAL REPORT CHEST SINGLE AP FILM: HISTORY: COPD exacerbation with shortness of breath. LAST ABG SHOWING A RESP ACIDOSIS. PROD COUGH MOD. DECREASED WITH SOME SCAT RONCHI. Developed increased SOB, resp distress this AM with sats 80's, ABG 5378/7.28/38/6 on 2L NP. UO has dropped off sig. 12:25 PM CHEST (PORTABLE AP) Clip # Reason: PNA? Sinus tachycardiaRightward axis - is nonspecificConsider right atrial abnormalityModest nonspecific inferior ST-T wave changesSince previous tracing of , sinus tachycardia present and moresuggestive of right atrial abnormality SVN RX GIVEN WITH ALB/ATR Q4. ABG on 2L NP & 40% face tent 85/80/7.29/40/7. Cardiac: HR 100-130ST rare PVC's BP 110-150/60-70's ID: afebrile, Plan: cont frequent nemb treatment, follow sats, BS closely, mask ventilation Attempted bipap. Abd soft No stool.NEURO: A&OX3. BS this morning slightly better, able to hear expiratory phase. BS with bibasilar crackles, scattered wheezed throughout, prolonged exp phase. UO initially 30cc hr. ?if pt would tol NTS. solumedrol 100mg given, to be stopped at 12pm today. SBP 130'sGU: foley catheter inserted. There is COPD as previously demonstrated. past 2 hrs.GI: NPO except meds due to resp status. He has been updated throughout the day on pt's status, plan of careA/P:Resp status tenueous, boarderline, without reserve due to COPD flare. Sputum for culture when availableBipap trial again this eve.Nebs, steroids.Discuss with HO oliguriaNPO except meds until resp status improves. RR 18-26 min. B.S. AMTS. Nemb tx interval increased to Q1hr, placed on mask ventilation with PS 18cm , eventually able to get comfortable and ABG showed 7.31/70/90 (pCO2 had been 88) kept her on mask ventilation, nembs Q3hr during the night, along with CPT, hydrated with NS at 125 cc/hr. PLAN IS TO CONT OFFERING THE BIPAP WITH SVN RX. CXR without evidence of infiltrate.ID: afeb. This morning able to cough productively. Doing OK on 11R. PT MAINTAINED ON INTERMITTENT BIPAP BUT WILL NOT WEAR CONT. Unproductive cough. Feels jittery ( given IV steroids). She was productive X1 of green sputum after brief trial of bipap.Receiving steroids, nebs. Admitting Diagnosis: COPD FLARE MEDICAL CONDITION: 62 year old woman with COPD exacerbation, worsening REASON FOR THIS EXAMINATION: PNA? Sats mid to high 90's. Transferred for further management.RESP: Presently on 35% face tent. Given tylenol for HAACCESS: #22 PIV X1.SOCIAL: Husband at bedside. HAS AGREED TO WEAR Q3- TO Q4 FOR 10 TO 15MIN IF SHE CAN HOLD IT AND NOT BE STRAPPED IN. No definite pulmonary consolidation. Vague haziness in the left lower zone is likely soft tissue shadowing but if symptoms persist, follow up films may be obtained to rule out evolving consolidation in this location. S/MICU Nursing Progress Note Respiratory: Pt on 40% face tent nemb with RR 20's labored, using accessory muscles, BS poor air movement only able to hear a fine insp wheeze, while trying to take her pills,pt felt like she was drowning and unable to catch her breath. Pt feels she has secretions but is unable to raise them. Pt did not tol due to coughing jags when mask mask applied."},"n_notes":{"kind":"number","value":5,"string":"5"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2171-12-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":850161,"text":" 12:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA?\n Admitting Diagnosis: COPD FLARE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with COPD exacerbation, worsening\n REASON FOR THIS EXAMINATION:\n PNA?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: COPD exacerbation with shortness of breath.\n\n Heart size is normal. There is COPD as previously demonstrated. No definite\n pulmonary consolidation. Vague haziness in the left lower zone is likely soft\n tissue shadowing but if symptoms persist, follow up films may be obtained to\n rule out evolving consolidation in this location.\n\n"},{"category":"ECG","chartdate":"2171-12-12 00:00:00.000","description":"Report","row_id":139515,"text":"Sinus tachycardia\nRightward axis - is nonspecific\nConsider right atrial abnormality\nModest nonspecific inferior ST-T wave changes\nSince previous tracing of , sinus tachycardia present and more\nsuggestive of right atrial abnormality\n\n"},{"category":"Nursing/other","chartdate":"2171-12-10 00:00:00.000","description":"Report","row_id":1431418,"text":" 4 ICU NPN 0700-1900\n62 YO with end-stage COPD admitted to 11R admitted with COPD flare. Doing OK on 11R. Developed increased SOB, resp distress this AM with sats 80's, ABG 5378/7.28/38/6 on 2L NP. Transferred for further management.\nRESP: Presently on 35% face tent. RR 18-26 min. BS with bibasilar crackles, scattered wheezed throughout, prolonged exp phase. ABG on 2L NP & 40% face tent 85/80/7.29/40/7. Sats mid to high 90's. Unproductive cough. Pt feels she has secretions but is unable to raise them. Attempted bipap. Pt did not tol due to coughing jags when mask mask applied. She was productive X1 of green sputum after brief trial of bipap.Receiving steroids, nebs. CXR without evidence of infiltrate.\n\nID: afeb. Completed course of azithro.\n\nCV: HR 130's ST. No VEA. SBP 130's\n\nGU: foley catheter inserted. UO initially 30cc hr. UO has dropped off sig. past 2 hrs.\n\nGI: NPO except meds due to resp status. Abd soft No stool.\n\nNEURO: A&OX3. Feels jittery ( given IV steroids). Given tylenol for HA\n\nACCESS: #22 PIV X1.\n\nSOCIAL: Husband at bedside. He has been updated throughout the day on pt's status, plan of care\n\nA/P:\nResp status tenueous, boarderline, without reserve due to COPD flare. ?if pt would tol NTS. Sputum for culture when available\nBipap trial again this eve.\nNebs, steroids.\n\nDiscuss with HO oliguria\n\nNPO except meds until resp status improves.\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2171-12-10 00:00:00.000","description":"Report","row_id":1431419,"text":"\nPT MAINTAINED ON INTERMITTENT BIPAP BUT WILL NOT WEAR CONT. HAS AGREED TO WEAR Q3- TO Q4 FOR 10 TO 15MIN IF SHE CAN HOLD IT AND NOT BE STRAPPED IN. SVN RX GIVEN WITH ALB/ATR Q4. B.S. DECREASED WITH SOME SCAT RONCHI. PROD COUGH MOD. AMTS. LAST ABG SHOWING A RESP ACIDOSIS. PLAN IS TO CONT OFFERING THE BIPAP WITH SVN RX.\n"},{"category":"Nursing/other","chartdate":"2171-12-11 00:00:00.000","description":"Report","row_id":1431420,"text":"S/MICU Nursing Progress Note\n Respiratory: Pt on 40% face tent nemb with RR 20's labored, using accessory muscles, BS poor air movement only able to hear a fine insp wheeze, while trying to take her pills,pt felt like she was drowning and unable to catch her breath. Nemb tx interval increased to Q1hr, placed on mask ventilation with PS 18cm , eventually able to get comfortable and ABG showed 7.31/70/90 (pCO2 had been 88) kept her on mask ventilation, nembs Q3hr during the night, along with CPT, hydrated with NS at 125 cc/hr. This morning able to cough productively. solumedrol 100mg given, to be stopped at 12pm today. BS this morning slightly better, able to hear expiratory phase.\n Cardiac: HR 100-130ST rare PVC's BP 110-150/60-70's\n ID: afebrile,\n Plan: cont frequent nemb treatment, follow sats, BS closely, mask ventilation\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-12-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 850161,\n \"text\": \" 12:25 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: PNA?\\n Admitting Diagnosis: COPD FLARE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old woman with COPD exacerbation, worsening\\n REASON FOR THIS EXAMINATION:\\n PNA?\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST SINGLE AP FILM:\\n\\n HISTORY: COPD exacerbation with shortness of breath.\\n\\n Heart size is normal. There is COPD as previously demonstrated. No definite\\n pulmonary consolidation. Vague haziness in the left lower zone is likely soft\\n tissue shadowing but if symptoms persist, follow up films may be obtained to\\n rule out evolving consolidation in this location.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2171-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 139515,\n \"text\": \"Sinus tachycardia\\nRightward axis - is nonspecific\\nConsider right atrial abnormality\\nModest nonspecific inferior ST-T wave changes\\nSince previous tracing of , sinus tachycardia present and more\\nsuggestive of right atrial abnormality\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1431418,\n \"text\": \" 4 ICU NPN 0700-1900\\n62 YO with end-stage COPD admitted to 11R admitted with COPD flare. Doing OK on 11R. Developed increased SOB, resp distress this AM with sats 80's, ABG 5378/7.28/38/6 on 2L NP. Transferred for further management.\\nRESP: Presently on 35% face tent. RR 18-26 min. BS with bibasilar crackles, scattered wheezed throughout, prolonged exp phase. ABG on 2L NP & 40% face tent 85/80/7.29/40/7. Sats mid to high 90's. Unproductive cough. Pt feels she has secretions but is unable to raise them. Attempted bipap. Pt did not tol due to coughing jags when mask mask applied. She was productive X1 of green sputum after brief trial of bipap.Receiving steroids, nebs. CXR without evidence of infiltrate.\\n\\nID: afeb. Completed course of azithro.\\n\\nCV: HR 130's ST. No VEA. SBP 130's\\n\\nGU: foley catheter inserted. UO initially 30cc hr. UO has dropped off sig. past 2 hrs.\\n\\nGI: NPO except meds due to resp status. Abd soft No stool.\\n\\nNEURO: A&OX3. Feels jittery ( given IV steroids). Given tylenol for HA\\n\\nACCESS: #22 PIV X1.\\n\\nSOCIAL: Husband at bedside. He has been updated throughout the day on pt's status, plan of care\\n\\nA/P:\\nResp status tenueous, boarderline, without reserve due to COPD flare. ?if pt would tol NTS. Sputum for culture when available\\nBipap trial again this eve.\\nNebs, steroids.\\n\\nDiscuss with HO oliguria\\n\\nNPO except meds until resp status improves.\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1431419,\n \"text\": \"\\nPT MAINTAINED ON INTERMITTENT BIPAP BUT WILL NOT WEAR CONT. HAS AGREED TO WEAR Q3- TO Q4 FOR 10 TO 15MIN IF SHE CAN HOLD IT AND NOT BE STRAPPED IN. SVN RX GIVEN WITH ALB/ATR Q4. B.S. DECREASED WITH SOME SCAT RONCHI. PROD COUGH MOD. AMTS. LAST ABG SHOWING A RESP ACIDOSIS. PLAN IS TO CONT OFFERING THE BIPAP WITH SVN RX.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-12-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1431420,\n \"text\": \"S/MICU Nursing Progress Note\\n Respiratory: Pt on 40% face tent nemb with RR 20's labored, using accessory muscles, BS poor air movement only able to hear a fine insp wheeze, while trying to take her pills,pt felt like she was drowning and unable to catch her breath. Nemb tx interval increased to Q1hr, placed on mask ventilation with PS 18cm , eventually able to get comfortable and ABG showed 7.31/70/90 (pCO2 had been 88) kept her on mask ventilation, nembs Q3hr during the night, along with CPT, hydrated with NS at 125 cc/hr. This morning able to cough productively. solumedrol 100mg given, to be stopped at 12pm today. BS this morning slightly better, able to hear expiratory phase.\\n Cardiac: HR 100-130ST rare PVC's BP 110-150/60-70's\\n ID: afebrile,\\n Plan: cont frequent nemb treatment, follow sats, BS closely, mask ventilation\\n\"\n }\n]"}}},{"rowIdx":24655,"cells":{"subject_id":{"kind":"number","value":19911,"string":"19,911"},"hadm_id":{"kind":"number","value":171106,"string":"171,106"},"target_text":{"kind":"string","value":"66F with chronic trach and PEG, s/p CVA in with residual weakness who presents from home with lethargy and hypotension. . # Sepsis: On admission, WBC elevated to 23 with 8% bands and lactate of 4.4. Patient with hx of c diff, serratia and MRSA bacteremia in the past. During a previous admission, pt had MRSA bacteremia but no source was identified. No hx of diarrhea. Blood, sputum cultures sent. Pt is anuric so no urine culture. Patient however with multiple sources of infection, including sacral decub ulcers, dry gangrene in both feet, tracheostomy and G-tube insertion sites. Pt sx's initially improved dramatically with supportive therapy. cultures returned pseudomonas from sputum and begun on meropenem on . CT + MRI of sacral and posterior-tibial decubs showed no evidence of Osteomyelitis. Patient initially failed -stim test and completed a five day course of stress dose steroids. Regarding sacral decub ulcers, plastics was consulted and did not feel there was any role for surgical intervention. During admission, patient with multiple positive cultures including the following: sputum on growing pseudomonas and GNR; sputum on , , growing pseudomonas and GNR; sacral decubitus ulcer swab on growing GNR, Pseudomonas, coag positive staph aureus, and klebsiella; sputum culture on and growing Klebsiella, Pseudomonas; blood culture on growing enterococcus faecium (VRE but sensitive to linezolid). Patient has been treated with tobramycin and zosyn for double coverage of pseudomonas in sacral decubitus ulcers, linezolid for MRSA and VRE, and levofloxacin for chronic aortic abscess with serratia. Patient's HD catheter was removed when patient was found to have VRE. . Patient also with hx of aortic annular abscess with serratia and ? of endocarditis at and is chronically treated with levoquin. Vasc performed a partial amp/debridement of the L great toe in the setting of dry gangrene. wound cultures from the tissue returned pseudomonas as well which showed resistance to meropenem. Vasc surgery recommended amputation with BKA due to gangrneous toes bilaterally. Family refused intervention. . Pt had a recurrent episode of VRE in her blood and a PNA with psuedomonas and klesiella. This was again treated with Meropenem and Amikacin for a 14 day course. She was also started on Daptomycin for recurrent VRE in her blood for a 14 day course. . # Lethargy: Patient with lethargy throughout her course, likely secondary to patient's sepsis. Head CT was negative for any intracranial hemorrhage or mass. This improved and pt was at her baseline at time of discharge. . # Resp: s/p trach, on vent at home with settings of assist control 450x22xPEEP of 5x60%. Pt. remained mostly on home vent settings throughout hospital stay. Oxygenating well on FiO2 of 60%. She had her PEEP increased to 8 increased pleural effusions due to volume resuscitation during bouts of sepsis/GI bleed. Also, during her acute GI bleed, her rate was increased to help offset a lactic acidosis that occured the large amounts of blood products she received. Other than this her vent settings have remained stable. Will likely be able to decrease her FiO2 over time after her pneumonia completely resolves. Trach is 7.0 extra long shiley. . # CV: ** Ischemia: EKG nml ** Rhythm: PAF; on dilt for rate control. continue amio and digoxin. Pt was taken off all anticoagulation due to recurrent GI bleeding. Cardiology consulted for risk of no anticoag with mechanical valve. Risk of thrombus is approx 10% per year, however pt had large GI bleed on any anticoagulation. Due to liver failure, pts INR has remained elevated to 2.0 throughout admission. ** Pump: EF 55% on echo, diastolic dysfxn. . # ESRD on HD: During this admission, patient was initially on hemodialysis and was converted for a short time to CVVHD. However, once patient's renal function and hemodynamics became more stable, patient should be continued on hemodialysis per home regimen. . # Anemia: baseline hct of 29-30. During this admission, patient became supratherapeutic on coumadin and heparin and developed increased bleeding, including vaginal bleeding, skin tears, and sacral ulcers. Pelvic US demonstrated thickened endometrial stripe. OB-gyn was consulted and did not suggest further work-up given that patient was unlikely to receive any further treatment. Patient's coumadin and heparin drip have been held while concern for active bleeding. Pt then had active GI bleeding and all anticoag has been held for recurrent GIB while on anticoagulation. . # GIB: Pt had bright red blood per ostomy and GI service was consulted. Pt found to have petecial lesion in residual colon, no active bleeding. EGD was negative. Attempted to restart anticoagulation however pt continued to have GIB when on heparin. On one occasion, a bleeding vessel was found at the stomal site and a stitch was placed by Surgery, with no recurrent bleeding from that vessel. Decision made with GI and cardiology to hold anticoagulation. . # Lactic acidosis: Pt was found to be hypotensive to the 50s-60s several times during her hospital course. An arterial line was placed for better monitoring and revealed a difference in cuff pressure of 30 points. Lactate was elevated to 10, which was attributed to Linezolid. This was discontinued and she was started on Daptomycin for VRE bacteremia. She should not receive Linezolid again and it was added to her allergy list. . # DM: Patient with very poorly controlled blood glucose at home. Patient's blood glucose was managed during this hospitalization with the help of . She was placed on an insulin drip during her intermittent sepsis, as her sugars were difficult to control. Prior to discharge, her insulin regimen was transitioned to glargine at 7 untis qam and an agressive insulin sliding scale. . # Thrombocytopenia: Pt had progressive thrombocytopenia throughout admission. Hep ab neg. Felt to be 2/2 pts extensive medical illnesses and broad spectrum abx. No furhter intervention at this time. DIC labs normal. Pt did not require plt transfusion. Team was notified after patient was discharged that heparin dependent antibody sent on had come back as positive. Case management was notified to let the patient's dialysis service and home nursing agency know that the patient should not receive heparin in any form. . # Wound care: Pt has large sacral decub and multiple skin tears skin breakdown. Wound care followed throughout admission. . # Social: Multiple family meetings were held with medical, nursing, social work, case management, GI and renal consultants throughout this admission where the medical staff made it clear to the family that the patient is dying and that we would recommend comfort measures at this point. The health care proxy refused to convert care to comfort and wanted to continue with aggressive measures. Ethics and palliative care consulted during this admission and fmaily refused to talk to them. . # Code: already intubated, NO SHOCKS, no compressions. DNR. ."},"extractive_notes_summ":{"kind":"string","value":"Condition UpdatePlease see carevue for specifics.Neuro unchanged. RESP CARE: Pt remains trached/on vent settings per carevue. resp careremains trached and vent dependant. NPNPlease see CareVue for full assessmentsNEURO: Unchanged. RESP CARERemains on vent. trach care done/inner cannula cleaned. Incosistent with following commands.CV: Cont. see chart for recommendations.ID: Cont on mult abx. Drsgs d &i.allevyn drsgs in place.A/P:Cont crrt, sliding scale ca+ k+. Lopressor po as bp tolerates. MDI's given a/o. trached onventilatory support. Resp.CarePt. HD to be done . Condition UpdatePlease see carevue for specifics.Neuro unchanged. Care: Pt. HD today, p tis anuric. Ativan per schedule.CV: Cont. F/U Amikacin levels post-HD today. Tol tf at goal thru J tube.CVVH: Kept euvolemic,-no issues.INTEG: Skin extremely compromised. decub.RESP: lungs rhonchi through out. ALTERNATING FROM NSR TO A-FIB. Tube feedings infusing at goal w/ no residuals. Diltiazem on hold until NEO gtt is off.GI: Abd large soft +BS. SM AMT CLEAR, MUCOID RECTAL DRNG NOTED.ID: AMIKACIN GIVEN POST-HD, MEROPENEMENDO: BS COVERED VIA RISS, LANTUS GIVEN THIS AMINTEG: MULTI DSG DONE, REINFORCED/RE-PACKED PRN. Pressor weaned off in am, though resumed for HD tolerance. Suctioned for sm.->moderate amts. Dtr found suctioning pt. Levaquin per Jtube.GI/METABOLIC: NPO maintained. DIC panel pending.Doppler pulses absent left PT and right DP, MD aware. requesting VBG again while hr elevated and it was drawn per micu team; resulting values ok per respiratory. RUE PICC and left dialysis remain in place- Left dialysis catheter with erythema.GI/METABOLIC: NPO maintained, Jtube clamped. Transfused pt with 1UPRBC and 1U Md orders- Post-transfusion HCT 26.1, am 25.4. CONTINUES IN A-FIB, ON COUMADIN. Follow abg's, respitory effort, 02 sats. HCP, HAS PHONED AND HAS BEEN UPDATED.A--FEBRILE. .5 DILAUDID GIVEN AGAIN.ID--FEBRILE TO 101.5. Suctioned for minimal amounts clear secretions.CV: Afebrile. iv phenylephrine weaned to off. MIDODRINE GIVEN AS ORDERED. condition updated: pt arrived from er with ? PEG/ site intact but draining.GU: CVVH to start this p.m.ID: Afebrile. condition updateplease see carevue for specifics.Neuro unchanged. Metwabolic acidosis unchanged, Bicitra as ordered.ID: Tmax 100.5 with rigors and tachycardia/tachypnea/BP increase- pressors off for short while. BS essentially clear anteriorly sxing for minimal secretions. Resp Care,Pt. wean neo as tolerated.r: tolerating slow pitressin wean. Zosyn, Levaquin, Tobramycin as ordered. Lopressor po per schedule.RESP: Trach. Resp Care Note, Pt remains on current vent settings. Pt is currently being followed by .B/L multi podis splints placed this am. Turn and repositioned Q2hrs and prn. NPNPlease see CareVue for full assessmentsNEURO: Unchanged. Ativan per schedule.CV: Afib occas. Lopressor dose now TID. transfuse with hemo today. Midodrine per schedule. Allevyn dsgs on hips from intact. LEFT A/C PICC D/C'D, RIGHT TLCL DRNG SEROSANG. Dr. aware and lopressor dose given. Lopressor 12.5PO administered. Cortisol stimulation test completed.RESP: Trach. Another amp D50 administered.GI: Abd distended. NPNPlease see CareVue for full assessmentsNEURO: Unchanged. TRACH CARE DONE.GI-ABD SOFT, NT/ND. +granulation, small amount of sero/sang drainage. trached and chronically ventilated. +PP VIA DOPPLER.RESP-NO VENT CHANGES. TOL TF VIA J-TUBE.GU-ANURIC. HAD US OF RUQ.GU-ANURIC ON . MDIs given as ordered. Skin care per orders. Tmax 100.7 remains on tobra and zosyn. trached/vent dependant. Bil hip dressings changed, +granulation, draining small amounts of sero/sang. RSC quinton.lungs: clear to coarse . EKG done per MICU request. continue lantus at present dose . HR A fib with rare pvc's, rate controlled. Albuterol/Atrovent MDI's given Q4hr and Flovent . Albuterol/Atrovent MDI's given Q4hr and Flovent given . Nursing Progress NotePlease see for detailsNeuro: unchanged.CV: afebrile, bair hugger off with temp maintained. Generalized edema.Respir: Remains on CMV. hypothermic-bairhugger on.CV: NSR wtih rate controlled on dilt. Neo weaned off. R-HD CATH SITE WNL,DRESSING INTACT.ID: AFEBRILE. LYTES WNL.ENDO: FS QID. UpdateSee Carevue for specificsNeuro: pt. CSL ON.PULM: TRACHED. Wean neo and diltiazem as tol. TOLERATING TF. nursing noteNeuro:Pt alert, nodding approp at times. REPEAT HCT, ?BLD CULTURES IF PT REMAINS FEBRILE. W/LGE GEN SEROUS DRNG, GEN ANASARCA. pt has slightly course/wheezy BS, suctioned for sm-mod amt of thick secretions MDIs given as ordered. vanco and tobra given, levels drawn. Stool (P) for c-diff. REQUIRED FLUID BOLUSES DURING DIALYSIS THIS AM. Colostomy drainage liquid. Resp Care,Pt. COCCYX DRSG - LG AMT OF PURULENT/S/S DRAINAGE OUT. REMAINS IN AFIB - RATE CONTROLLED ON DILTIAZEM DRIP. K AND DRIPS TITRATED ACCORDING TO ORDERS. DRSG TO /LBUTTOCK - MOD AMT S/S DRAINAGE OUT. HYPOTHERMIC - BAIR HUGGER ON. MDI's given. if firm distended, +bs, colsotomy draining brb this am, endosopy done at bedside per gi, clips applied. Patient remains tachycardic, and the albuterol mdi inline was witheld. atrovent given q6h, albuterol held until tachycardic,given in pm with HR 106. c/w full vent support. Diltiazem/Digoxin/Amiodarone/Midodrine given as ordered. Albuterol/atrovent and flovent given. resp careremains trached/vent dependant. TRACH CARE DONE, IN-LINE SXN CATH CHANGED. Respiratory CarePt remains trached with 7.0 Shiley. Resp Care,Pt. HCP notified.plan: hd as tolerated. tube fdgs as ordered. MDI'S given. Condition UpdatePlease see carevue for specifics.T/max 99.7; Cx's pending from . \"Condition updatePlease see carevue for specifics.neuro unchanged. PERRL.CV/GU: Afib. lg amt of serous drainage . Resp Care Note, Pt remains on current vent settings. Resp Care Note, Pt remains on current vent settings. Condition UpdatePlease see carevue for specifics.Tmax 99.7, AFIB. MDI'S given.Will cont to monitor resp status. Continued resp care planned. Continued resp care planned. Focus Condition UpdateSee flowsheet for specific info.Neuro: Status unchanged. Still awaiting vaginal us. Lung sounds were course with rhonchi that cleared after suction. Amiodorone load IVPB given. Right paramedian hernia. Following gadolinium, T1 sagittal, and axial images were obtained. Clinical correlation issuggested. Note is made of some calcifications in relation to the uterus, consistent with fibroid uterus. Probable multifocal atrial tachycardiaLeft bundle branch blockSince previous tracing of , atrial ectopy present IMPRESSION: Gastrojejunostomy tube in proper position terminating in the jejunum. There has been interval redistribution of the right pleural effusion with mild superimposed hydrostatic edema. CONCLUSION: Trach in situ, bilateral pleural effusions. Tracheostomy tube in standard placement. Status post cholecystectomy. Status post removal of tunneled right internal jugular approach hemodialysis catheter. Tracheostomy tube in standard placements. A 0.035 guidewire was advanced into the superior vena cava and the introducer sheath was removed. COMPARISON: AP supine portable chest x-ray dated . Admitting Diagnosis: SEPSIS FINAL REPORT (Cont) gt/jt seems to be slightly out and Dr. aware and up to pt. CONTINUES IN A-FIB, AS PREVIOUSLY. Condition updatePlease see carevue for secifics.Neuro unchanged. with periodic leaks and adjusted by RT.GI:Abd large, soft,nt. condition updatedS/P sepsis;for complete info please refer to carevue.condition status quo."},"n_notes":{"kind":"number","value":420,"string":"420"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2132-08-14 00:00:00.000","description":"Report","row_id":1524159,"text":"NPN\nPlease see CareVue for full assessments\nNEURO: No change. PERRL. +tracking. Pt. does not follow commands and is inconsistent with communication. Nodding and mouthing words at times. Minimal mvmt with nailbed stimuli in all extremities. LUE tremor in hand, wiggling fingers.\n\nCV: Remains in AF with rare PVC's. HR90's-100's throughout day. Goal MAP >50. SBP dropped into 80's after HD. MICU HO paged with no response. BP came up without intervention. Amiodorone, Digoxin, and lopressor per schedule. Coumadin to be held tonoc. INR3.9.\n\nRESP: No vent changes. Sxn x3 small amts thick yellow secretions. LS rhonci/coarse. Clearer with sxn. Cuff leak treated by RT. MDI by RT. Plan for Passy Muir trial in am prior to discharge per family request.\nDtr. updated by attending on this matter.\n\nRENAL: HD this am. Pt. tol. removal of 2.2L. Albumin admin. during HD.\n\nENDO: BG still 200-300' in to . Glargine dose increased. recommends injections into stomach for optimal effect. RISS coverage.\n\nID: Tmax 99.8po this shift. IV ABX dc'd this am. Levofloxacin restarted for aortic abcess. VRE+ !!!!\n\nGI: TF @goal via PEJ. Small amt mucus drainage around insertion site with small ulcerated area noted at the 3 o'clock position. Wound care RN in and discussed proper care for excoriated skin around PEJ. Aquacel trach sponge ordered for area-until then use aloe vesta on excoriated part and duoderm gel on uclerated area covered with DSD. RN stated OK to use Aloe Vesta under Aquacel too. Liquid stool from colostomy. Lactulose held.\n\nWOUND: Wound management unchanged. Reviewed with wound RN. Right ischial dsg done this shift due to increased drainage at site. All other dsgs intact. Kinair bed &BLE MPS in place.\n\nPSYCHOSICIAL: Husband and son at bedside for most of morning & present during rounds. Informed of possible dc by Attending. Dtr. called and also updated by Attending.\n\nPLAN: Monitor CV, if low BP, sxn prn, assess for cuff leaks, trial in AM of Passy Muir, wound management, diabetic management, turn Q2H to maintain skin integrity, initiate discharge paperwork, provide emotional support to patient and family concering pending discharge.\n"},{"category":"Nursing/other","chartdate":"2132-08-15 00:00:00.000","description":"Report","row_id":1524160,"text":"resp care note\n\n\nPt remains trached and on AC vent , No ABG drawn this shift. Sx for increased yellow-green sputum. sample sent for C&S. # 8 in place.\n"},{"category":"Nursing/other","chartdate":"2132-09-23 00:00:00.000","description":"Report","row_id":1524319,"text":"Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Pt alert mouthing words and weepy at times. Still does not follow commands and is only moving LUE. Cont on standing ativan.\nCV: Pt becoming increasingly hypotensive today. Down to low 70's with MAP's in the 30's. Pt at one point on max triple concentrated Neo and Vasopressin. Remaining with normal HR over coarse of day. CVVH cont and placed to 0. Pt currently off vasopressin and is on 2.0mcgs/kg of neo. currently running even. Pt remaining hypothermic. Unsuccessful line placement today. Pt will need to go to IR for Central access in am.\nResp: No vent changes. Sxn for thick yellow sputum. Lungs coarse throughout. Sats 98-1005.\nGi/GU: Cont on TF at goal 65cc/hr via J-tube. G-tube remains to gravity. Small blood clots aspirated from MD aware. Cont with guiac + stools and some noted vaginal bleeding.\nEndo: insulin gtt stopped FS dropped to 51.\nSkin: Coccyx Hip changed with wound RN. see chart for recommendations.\nID: Cont on mult abx. Hypothermic\nSoc: Family requesting trnf to . Social Services in contact with family and primary team RE: Family meeting tomorrow.\nPlan: Cont with current plan of care IR tomorrow for Central access.\n"},{"category":"Nursing/other","chartdate":"2132-09-24 00:00:00.000","description":"Report","row_id":1524320,"text":"RESP CARE: Pt remains trached/on vent settings per carevue. No changes in settings this shift. pressure 30cmH20. trach care done/inner cannula cleaned. Lungs coarse bilat with no wheezes. MDIs given as ordered. Sxd small amts thick yellow sputum. ABGs consistent with met acidosis. RSBI deferred due to hemodynamic instability. Continue full support.\n"},{"category":"Nursing/other","chartdate":"2132-10-12 00:00:00.000","description":"Report","row_id":1524395,"text":"Respiratory Care\nPt. trached on ventilatory support. Sx for copious amounts thick tan and blood tinged secretions. No vent setting changes made this shift.\n"},{"category":"Nursing/other","chartdate":"2132-10-12 00:00:00.000","description":"Report","row_id":1524396,"text":"Nursing progress note\nPlease see for details\n\nNeuro: unchanged, nodding to questions, mouthing words at times. does not move extremities.\n\ncv: neo remains off, bp on leg in order to achieve . HR decreases to low 60's after diltiazem. Pt's daughter is requesting that dilt be changed back to TID when dialysis resumes. Rate is now controlled at < 90.\n\nPulm: no vent changes. pt sx q 2-3 hrs for thick tan to brown sputum. see vbg's.\n\ngu: anuric\n\ngi: tol tube feeds at 40/hr. pt turned at 0600 for bed change, turned to left side (g port gravity bag is hung on left side.) no tension on tube noted, when pt returned to back, balloon of ft noted to be external on abdomen. Dr notified. Feeding off.\nColostomy draining loose golden stool, guaiac pos. Hct stable tonight at 25.\n\nEndo: insulin drip remains off, blood sugar down to 115. now with TF off, will monitor blood sugar closely.\n\nskin: pt continuously leaks from pinpoint areas over arms and back of legs. quilted pink pads changed frequently for pt comfort.\n\n\n"},{"category":"Nursing/other","chartdate":"2132-08-15 00:00:00.000","description":"Report","row_id":1524161,"text":"Condition Update\nPlease see carevue for specifics.\n\nNeuro unchanged. Tmax 100.1 AFIB rare pvc's. spb 73-109. No vent changes. Pt sxn'd several times for yellow and green sputum. sputum sample sent. w/ beneprotein unfusing at goal. clear oozing in large amts noted at j tube insertion site. DSD applied. blood sugars continue in the 300's. Pt is followed by .\n\nPlan: continue with current plan of care per micu team. discharge planning. speech and swallow consult today for passy mauir placement. Po abx.\n"},{"category":"Nursing/other","chartdate":"2132-08-15 00:00:00.000","description":"Report","row_id":1524162,"text":"Respiratory Care Note\nPt remains on AC home settings as noted. BS diminished throughout. Pt suctioned for small to moderate amts thick, brown secretions. Speech evaluated pt for - pt placed on for 15min x 2 this shift. Pt tolerated well with sats 100%. Pt did not vocalize during either trial. Plan to continue on current settings. Spoke with daughter about her concerns with new trach and referred her to attending physician.\n"},{"category":"Nursing/other","chartdate":"2132-08-15 00:00:00.000","description":"Report","row_id":1524163,"text":"NPN\nPlease see CareVue for full assessments\nNEURO: No changes. Incosistent with following commands.\n\nCV: Cont. in AF with rare PVC's. HR 90's-110's. Episodes of hypotension-not new. MICU team aware. HCT 24. T&S drawn. To receive 2Units PRBC's tonoc.\n\nRESP: Trach. No vent changes. Tolerated Passey-Muir valve trial. Teaching to dtr. by Speech and RT for in line use of . Dtr still has concerns about new trach and care after discharged home. Team aware and to meet with dtr.\n\nENDO: BG remain 200's-300's. Glargine increased again. RISS .\n\nGI: TF@goal. PEJ draining copious amts brown/green liquid this eve. Noted to increaase when pt. turned to left side-family states this is not new. Skin around insertion site excoriated and beginning to break down. Ostomy appliance placed around site. Family had been using appliane at home due to large amts drainage. Colostomy appliance changed. Loose golden guaiac - stool in bag. Colace and Lactulose held due to liquid stools x2days.\n\nWOUNDS: No changes in wound care. Dsgs intact. MPS to BLE.\n\nPLAN: Monitor CV, pulmonary toilet, diabetic management, wound management, discharge planning, provide emotional support to patient and family.\n\n"},{"category":"Nursing/other","chartdate":"2132-08-16 00:00:00.000","description":"Report","row_id":1524164,"text":"resp Care note\n\nPt was placed on via in-line vent circuit with cuff down but did not tolerate trial well. She has significant amt of thck yellow-green secretions, Sputum culture pending. At this time she remains on AC vent 16 x 450, + 5 , 40% . No ABG this shift. Pt is alert but not prone to communicate readily\n"},{"category":"Nursing/other","chartdate":"2132-10-12 00:00:00.000","description":"Report","row_id":1524397,"text":"NURSING NOTE 7A-7P REVIEW OF SYSTEMS:\nNEURO: DROWSY AWAKE AT TIMES, MORE AWAKE WHILE FAMILY VISITING. PERRLA, NO MOVEMENT OF EXTREMITIES. INCONSISTENTLY FOLLOWS SIMPLE COMMANDS. NO PAIN MEDICATIONS GIVEN.\nC/V: CONTINUES IN AFIB RATE 67-94 OCCASSIONAL PVC'S. = 80-110/35-55. NEO REMAINS OFF. PO MEDS THRU PEG TUBE RESTARTED THIS AFTERNOON.\nRESP: VENT SETTINGS UNCHANGED. REMAINS ON AC AT 450X 22X 50%X 5 PEEP.\nTRACH CARE DONE INNER CANNULA CHANGED AND CLEANED. SUCTIONED SEVERAL TIMES FOR SM TO MODERATE AMOUNTS THICK TAN SECRETIONS.\nGU: ANURIC, DUE FOR HD TOMMORROW AM.\nGI: ABD OBESE, POSITIVE BOWEL SOUNDS, COLOSTOMY DRAINING LOOSE GOLDEN COLORED STOOL (GUIAC NEGATIVE). TRANSFER TO XRAY TO CHECK PEG TUBE PLACMENT UNDER FLUOROSCOPY. PLACEMENT CONFIRMED AND TUBE FEEDINGS OF RESTARTED AT 40CC/HR TOLERATED WELL.\nHEME: REPEAT HCT THIS AFTERNOON= 24.7.\nSOCIAL: PATIENTS HUSBAND AND SON INTO VISIT THIS MORNING, QUESTIONS ANSWERED BY RN AND MD, UPDATED ON PLAN OF CARE.\nENDO: WHILE PATIENT NPO FS CONSISTENTLY WERE 57-81. ONCE TUBE FEEDINGS RESUMED FS INCREASED. REMAINS OFF INSULIN DRIP TODAY.\nACCESS: CONTINUES WITH MULTILUMEN LINE RIGHT SC, RIGHT SIDED PICC LINE AND DIALYSIS LINE SHILEY INTACT LEFT SIDE.\nPLAN: DIALYSIS TREATMENT TOMORRW, IF PATIENT STABLE POSSIBLE TRANSFER TO HOME ON TUESDAY.\n"},{"category":"Nursing/other","chartdate":"2132-10-12 00:00:00.000","description":"Report","row_id":1524398,"text":"BS fine crackles, occ wheeze clearing with suction. No significant change with MDI's. To CT to check PEG - in position and functioning. No vent changes or ABG's.\n"},{"category":"Nursing/other","chartdate":"2132-09-05 00:00:00.000","description":"Report","row_id":1524247,"text":"NPN\nPlease see CareVue for full assessments\nNEURO: Unchanged. Nods to questions at times. More interactive during eves. Attempted to mouth words x1. Inconsistently follows commands. Moving upper extremities on bed. No movement noted in BLE. Nodded yes to pain x1. administered. Pt. did not respond when asked if pain relieved.\n\nCV: Afib. HR consistently 120's-130's. Episodes of HR 150's. 1x dose 2.5mg Lopressor IVP with no decrease in HR. MICU HO notified. PO 2200dose lopressor held due to hypotension during eves and given later in shift when BP more stable.\n\nRESP: Trach. No vent changes. Sxn mod amts tan thick secretions.\n\nGI: TF @goal. Ostomy bag placed @ due to drainage from around insertion site. Colostomy bag changed. G- stool.\n\nScant amts vaginal bleeding noted.\nPLAN: Monitor CV, diabetic management, pain management, wound care, HD today, reposition per protocol.\n"},{"category":"Nursing/other","chartdate":"2132-09-05 00:00:00.000","description":"Report","row_id":1524248,"text":"nuero: pt does open her eyes when you call her name. pt nodds yes and no to questions when asked. pt intermittently will follow commands.\n\npain: pt nods head no when you asked if he having pain.\n\npulm: pt remains on trached, pt on cmv. suctioning pt for scant amt of yellowish secretions.\n\ncards: pt in afib hr 120-140's, sbp 80-90 dr. aware, pt recieved 250cc this morning with little effect. hr continued to be 130-140's, dr. aware, pt recieved 2.5gm of iv lopressor with some effect. please see flow sheet\n\ngi: pt continue on tubefeedings at goal which she is tolerating thus far. stoma pink and protruding draining golden brown colored drainage.\n\ngu: pt does not viod. pt to recieve hemodialyisis tomorrow. pt with scant amt of vaginal bleeding noted.\n\nf/e k 3.3 pt treated with 20meq kcl. blood sugar 136 this morning receieved 86 units of glargine as ordered.\n\nsocial: pt husband into visit this morning.\n\nplan: continue to monitor, monitor hr, bp, pain ,\n"},{"category":"Nursing/other","chartdate":"2132-09-05 00:00:00.000","description":"Report","row_id":1524249,"text":"resp care\nremains trached and vent dependant. remains on ac mode, no changes made this shift. sxning thick yellowish/green sputum. mdi's given q4h. refer to flow sheet for data.\n"},{"category":"Nursing/other","chartdate":"2132-09-06 00:00:00.000","description":"Report","row_id":1524250,"text":"Respiratory Care Note:\n\nPt remain on ventilatory/assisted support ventilation via tracheotomy tube. No vent changes done. We are sxtn small amt of yel thick secretions, small cough efforts. MDI's adm with No noticeable changes, albuterol held as Hr 120's. Plan: Continue present ICU monitoring. Will follow.\n"},{"category":"Nursing/other","chartdate":"2132-09-21 00:00:00.000","description":"Report","row_id":1524310,"text":"RESP CARE\nRemains on vent. no changes made. Suctioned mod amt of thick green secretions. Mdis given. WIll continue to monitor.\n"},{"category":"Nursing/other","chartdate":"2132-09-21 00:00:00.000","description":"Report","row_id":1524311,"text":"Respiratory Therapy\nPt remains trached w/ #7.0 Shiley trach on full mechanical support. No vent changes made this shift. BS coarse, suctioned for small amounts of thick tan secretions. SpO2 90s. MDIs given as ordered. Continues on A/C ventilation w/ PIP = 20. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support\n"},{"category":"Nursing/other","chartdate":"2132-08-13 00:00:00.000","description":"Report","row_id":1524154,"text":"Resp Care\nPt remains vented on AC 450x16 at 5 PEEP. Pt was bronched today and a new adjustable flange cuffed Trach tube was placed via Bronch. Cuff pressure was set to 20. MDIs given as ordered. BS scat wheeze and rhonchi. Sxn'd for thin white secretions. No ABGs done today.\n"},{"category":"Nursing/other","chartdate":"2132-09-21 00:00:00.000","description":"Report","row_id":1524312,"text":"focus update note\nhypothermic most of day, MICU team aware, 95-98, bair hugger on, internal bed warmer on most of day, NSR 70-80s no ectopy, kcl and ca continuous repleation, sodium phosphate repleated. goal map > 55 neo .2-1.5 mcq/kg/min neo requirments increasing to maintain map > 55. HCT 24, no active sign/sx bleeding witnessed.\n\nCRRT: machine malfunction at 1500, new machine ordered and restarted at 1700, goal per renal fellow keep pt even to 1 liter negative, pt 100-150cc/hr today.\n\nskin: leg/thigh/ dressings performed please see flowsheet for details, left inner thigh cellulitis unchanged- pt on vancomycin, pt edema increasing in thighs.\n\nsocial: (daughter) spoke with micu resident in length regarding mothers care, daughter continues has many concerns/questions and would like to speak with social work this week\n\nplan: keep MAP > 55 with neo gtt, monitor for afib, continue with CRRT goal even to 1 liter negative, monitor/treat hypothermia, family meeting for next week?, social work consult\n"},{"category":"Nursing/other","chartdate":"2132-09-22 00:00:00.000","description":"Report","row_id":1524313,"text":"Respiratory Care Note:\n patient remains trached with a #7 x-long Shiley trach, secured and patent. remains on full vent support with no changes being made this shift. BS are coarse throughout. SX for small to moderate amounts of thick yellow secretions via trach, MDI's administered as ordered. No RSBI this am due to patient being vent dependent. Tmax this shift was 99.6. SPO2 remains 100%. No ABG's. Plan is to continue with current treatment plan.\n"},{"category":"Nursing/other","chartdate":"2132-09-22 00:00:00.000","description":"Report","row_id":1524314,"text":"Respiratory Care\nPt remains on full ventilatory support as note on Carevue. MDI's given as ordered. Breath sounds diminished with scattered expiratory wheezes. Improving with suctioning. Small amounts of thick yellow secreations removed from airways.\n"},{"category":"Nursing/other","chartdate":"2132-09-22 00:00:00.000","description":"Report","row_id":1524315,"text":"nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT AWAKE, OPENS EYES TO VOICE. OCC MOUTHS WORDS.\n\nCV-HR 80'S, NSR. REMAINS ON NEO GTT TO KEEP >80'S. SKIN WARM.\n\nRESP-REMAINS TRACHED AND VENTED. NO VENT CHANGES MADE TODAY. O2 SAT 100%. LS COARSE WITH OCC WHEEZES. INHALERS AS ORDERED. SXN PRN FOR THICK YELLOW SPUTUM. ABG ACCEPTABLE.\n\nGI-ABD OBESE. +BS. TOL TF VIA . G-TUBE TO GRAVITY WITH YELLOW/WHITE DRG. STOMA PINK. NOTED TO HAVE BLOODY LOOSE STOOL VIA OSTOMY. TEAM AWARE.\n\nGU-ANURIC. ON CHHHDF. TOL WELL. GOAL 1 LITER NEG TODAY. ABLE TO TOL SOME FLUID REMOVAL. CA AND KCL GTTS INFUSING AS ORDERED.\n\nCOMFORT-APPEARS COMFORTABLE. ATIVAN ATC.\n\nENDO-REMAINS ON INSULIN GTT.\n\nACT-REPOSITIONED FREQ. ON AIR MATTRESS.\n\nID-HYPOTHERMIC. BAIR HUGGER ON. ON MULTI ABX.\n\nSKIN-CON'T WITH MULTI SKIN ISSUES. DRESSINGS ALL CHANGED AS ORDERED. SEE FLOWSHEET.\n\nPLAN-CON'T WITH CURRENT PLAN. MONITOR FOR CHAGNES. FOLLOW LABS. . GOAL 1 LITER NEGATIVE. ASSESS PAIN. SKIN CARE. SUPPORT. WEAN PRESSOR AS TOL.\n"},{"category":"Nursing/other","chartdate":"2132-10-10 00:00:00.000","description":"Report","row_id":1524390,"text":"nursing addendum\n MD , amikacin dose to be given with level of 11.8 per pharm. Level trough to be sent at 1730.\n\n"},{"category":"Nursing/other","chartdate":"2132-10-11 00:00:00.000","description":"Report","row_id":1524391,"text":"Respiratory Care\nPT. trached onventilatory support. Suctioned for copious amounts of thick yellow green secretions. No vent setting changes made, not plans for weaning vent settings at this time.\n\n"},{"category":"Nursing/other","chartdate":"2132-08-13 00:00:00.000","description":"Report","row_id":1524155,"text":"Condition Update\nPlease see carevue for specifics.\n\nNeuro unchanged. Pt opening her eyes spontaeously, but not moving extremities or following commads. Low grade temps. TMAX 99.7 AFIB HR 90's-108. No ectopy noted. SBP 70's-90's. 500cc NS boluses x 2 given w/ no effect per micu team. Cortisol test done, 1x dose of cosyntropin given. BP's up since dose given. Results still pending. No vent changes this shift. Trach changed over to a new adjustable flange cuffed trach via bronch at the bedside d/t leakage. Pt sxn'd for scant amts of white, thick sputum. Sats 100% LS clear. w/ beneprotein tube feedings infusing via j tube restarted after trach placed an is at goal. Colostomy draining guiac NEGATIVE liquid stool. spec sent. Lactulose dose held. Pt's blood sugars while NPO as low as 44. amp dextrose given. Since tube feedings restarted, bs have been on the rise and currently 163. B/L hip dressings changed this am. Both hips w/ stage 3 ulcers that drain serous, foul smelling fluid. reddened bases of the wounds. All wounds cleansed w/ NS, duoderm gel placed then covered w/ allevyn dressings.\n\nPlan: continue with current plan of care per micu team. IV F/U on results of cortisol test, bld cx's taken , and spec sent . Discharge planning. Dressing changes. HD to be done . Speech and swallow to speak w/ daughter concerning future use of passy mauir valve.\n"},{"category":"Nursing/other","chartdate":"2132-08-14 00:00:00.000","description":"Report","row_id":1524156,"text":"Resp. Care:\n Pt. continues on mech. ventilation-same settings as at home with chronic vent. New trach. placed yesterday. Tol. well without leak. Inhalers given as ordered. Please see flow sheet for more information.\n"},{"category":"Nursing/other","chartdate":"2132-08-14 00:00:00.000","description":"Report","row_id":1524157,"text":"Nursing NOte 7p-7a:\nNursing Assessment:\n\nTmax 100.6 has started to come down without intervention other than blankets off for a few hours and room temp decreased. No commands other than opens mouth for temperature. Tracks but no nodding yes and no or spontaneous movement other than wiggles left fingers occasionally when awake. No boluses tonight, goal map >50, very inconsistent blood pressures continue and team is aware, not new. Afibb and tachycardic also not new. Lopressor po as bp tolerates. Amiodorone and digoxin po qd. Abdomen softly distended, colostomy with liquid stool and tube feeds continue. Lungs clear and diminished. Inhalers given by respiratory therapist. Dressings to bilat lower extremities and coccyx per wound nurse recommendations. Blood glucoses elevated again despite 75 glargine and reg insulin sliding scale. Will continue to monitor. HD today, p tis anuric. ?Discharge home today on vent following dialysis. Pt has 8 children who participate in managing her home care. Please refer to carevue for details.\n\n"},{"category":"Nursing/other","chartdate":"2132-08-14 00:00:00.000","description":"Report","row_id":1524158,"text":"Respiratory Care Note\nPt remains on AC home settings with no changes. BS diminished, but clear. Pt has a slight cuff leak with air placed in cuff to achieve minimal leak. MDI's given a/o. Plan to continue on current settings at this time.\n"},{"category":"Nursing/other","chartdate":"2132-09-04 00:00:00.000","description":"Report","row_id":1524241,"text":"Resp.Care\nPt. remains on A/C vent with a 7.0 Shiley secured and patent. Sx mod amts yellow with coarse b/s. MDIs given on time with good effect.Plan is to cont to monitor and wean as tol.\n"},{"category":"Nursing/other","chartdate":"2132-10-11 00:00:00.000","description":"Report","row_id":1524392,"text":"Rapid afib\nD:Pt had afib 120-150 not controlled with diltiazem 30mg TB so dose increased per Dr to 60mg QID. Afib now 110.\nPICC line looked like it had slipped out some due to impaired skin integrity and weeping skin difficult to keep DSD on. IV RN in to see pt and said line out 5cm. CXR done but radiologist unable to visulize PICC tip so need another CXR.\nPt responsive always opened mouth when asked, pupils large brisk. Otherwise no neuro change.\nAll DSD changed per plan in pt's room.\nNo vent changes overnight.\nColostomy yellowish soft stool. gastric drainage blood tinged and watery consistency, irrigated x 1 with NS because it had stopped drg.\nPlan today:\nNeed repeat CXR to check PICC position\n effectiveness of increased Dilt dose in rate.\nContinue plan of care.\n"},{"category":"Nursing/other","chartdate":"2132-10-11 00:00:00.000","description":"Report","row_id":1524393,"text":"SICU NPN\nS-Trached.\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\n\nO-Alert. Shaking head in no and yes direction at times to family questioning. Denying pain. Not grimacing to pain or nursing care. Responding inconsistently to questioning when nodding. Attempting to wean off Neo. Neo off for 1hr. BPs into the 60s with a MAP of 30. Restarted and at .5mcg/kg/min. Attempting to keep MAPs > 50. Continues PO Midodrine with no increase in dose. PO Diltiazem dose increased, remains in Afib, HR better controlled, 60-80s from 100-110s. Breath sounds coarse anteriorly. Remains on AC. Suctioning for thick yellow-tan secretions in moderate amounts. Suctioning more frequently than previous. Still unable to obtain O2Sats peripherally or centrally. Remains anuric. CRRT off since yesterday. Goal is to wean off Neo with hopes of pt tolerating conventional dialysis to go home. TFs at GR. Ostomy putting out golden formed soft stool. G-tube to gravity and J-tube to feed. Insulin drip stopped this morning and attempting to treat with aggresive sliding scale coverage and standing Insulin dose. All dressing changed and intact. PICC noted to be out 5cms on previous shift, CXR confirming PICC in place per MICU resident. IV team made aware. Afebrile. Continues antibiotic regimen. Husband and son into visit this morning and expressing feelings of mother to \"come home.\" In addition son and -in-law into visit this afternoon and wanting pt \"home.\" Son, just waiting for sister() to make deciscion.\nA/P:Sepsis c/b failure to wean\nContinue to wean Neo as tolerated\nTreat BS aggressively with sliding scale in effort no to resume gtt.\nEmotionally support pt/family as needed\n"},{"category":"Nursing/other","chartdate":"2132-10-11 00:00:00.000","description":"Report","row_id":1524394,"text":"BS coarse crackles; no change with MDI's. Sx'd for mod amounts thick yellow sputum. Still requiring pressors and now off CVVH per family. Will continue to wean ventilator as appropriate, No ABG's or vent changes this shift.\n"},{"category":"Nursing/other","chartdate":"2132-09-04 00:00:00.000","description":"Report","row_id":1524242,"text":"NPN\nPlease see CareVue for full assessments.\nNeuros unchanged. Ativan per schedule.\nCV: Cont. Afib w/HR 90's up to 120's.\nRESP: Trach. No vent changes. BS coarse throughout. Sxn for scant amt thick tan secretions.\nGI: TF at goal via . Cont. w/copious amts bilious drainage around insertion site. Dsg chgd multiple times. BS+. Abd distended. Golden liquid stool guaiac - from colostomy.\nGU: Anuric. Scant amt blood noted.\nWOUND CARE: All dressings by wound care RN C/D/I.\nPLAN: Monitor CV, diabetic management, wound management-change dsgs per orders/PRN, maintain skin integrity, provide emotional support\n"},{"category":"Nursing/other","chartdate":"2132-09-04 00:00:00.000","description":"Report","row_id":1524243,"text":"SICU NURSING PROGRESS NOTE 0700-1500\nNEURO--INCONSISTENTLY NODS HEAD TO SIMPLE QUESTIONS REGARDING PAIN, COMFORT, HOT/COLD. MOVES BUE BUT NO SPONT. MOVEMENT OBSERVED IN BLE. PEARL AT 4MM. OPENS EYES SPONT. WILL TRACK WITH EYES OCCASIONALLY.\n\nCARDIAC--REMAINS IN AFIB 110-130. SBP 70-110/40'S.\n\nRESP--NO VENT CHANGES MADE. SX Q2 HRS FOR MODERATE AMTS OF THICK TAN SPUTUM. BILATERAL LUNGS ARE COARSE IN ALL FIELDS. SAO2 >97%.\n\nGI--TOL. TUBE FEEDS AT GOAL. COLOSTOMY DRAINING ~200 CC HR GOLDEN LOOSE DRAINAGE. SMALL AMTS OF DRAINAGE AROUND FEEDING TUBE.\n\nGU--ANURIC. NO FOLEY.\n\nID--TEMP MAX 99.9 ORAL. REMAINS ON SEVERAL ABX.\n\nPAIN--PT NODDED YES SEVERAL TIMES WHEN ASKED IF SHE WAS HAVING PAIN. MEDICATED WITH 12.5 DEMEROL FOR RELIEF. 25 MG GIVEN WITH DRESSING CHANGES.\n\nSKIN--SACRAL ,R HIP AND BILATERAL FEET DRESSINGS CHANGED PER PROTOCOL. SACRAL WOUND IS DEEP AND CLEAN AS IS HIP. NO FOUL SMELL NOTED. SEVERAL SKIN TEARS ACROSS BUTTOCKS. TOES ARE NECROTIC DSD APPLIED. REMIANS ON KCL BED.\n\n AND HUSBAND IN THIS AM. THEY HAVE BEEN UPDATED REGARDING PT'S CONDITION. \"NURSES ARE US\" IN TO VISIT AND REVIEW CHART FOR WHEN PT GOES HOME AND NEEDS SERVICES.\n\nA--UNCHANGED NEURO, CARDIAC OR RESP STATUS. J-G TUBE IS LEAKING SMALLER AMTS AROUND TUBE.\n\nP--CON'T TO MONITOR. MEDICATE FOR PAIN, ASSESS RELIEF. OFFER SUPPORT TO PT AND FAMILY.\n"},{"category":"Nursing/other","chartdate":"2132-09-04 00:00:00.000","description":"Report","row_id":1524244,"text":"Respiratory Care\n\n Pt continues on A/C in NARD No changes made today. MDI's as ordered. B/S sl coarse sx'd for moderate amount of thick tan secretions. Will continue to follow closlely.\n"},{"category":"Nursing/other","chartdate":"2132-09-04 00:00:00.000","description":"Report","row_id":1524245,"text":"condition update\n3-7p\nSee carevue for specifics. Tachycardic 120's-130's more consistently this evening, bp stable. Dr. was notified, no new orders, will continue to monitor.\n"},{"category":"Nursing/other","chartdate":"2132-09-05 00:00:00.000","description":"Report","row_id":1524246,"text":"RESPIRATORY CARE NOTE\n\nPatient remains trached with Shiley 7.0 ex. long trach tube. No vent changes made during the night. Inner cannula changed. Sxn for tan thick secretions. RSBI completed on PS 5=105.\n\n , RRT\n\n"},{"category":"Nursing/other","chartdate":"2132-09-20 00:00:00.000","description":"Report","row_id":1524305,"text":"Update\nO: See carevue flowsheet for specifics.\nNeuro: awake,alert, mouthing words&tearful at times altho unable to discern what pt saying. Nods no to pain. Moves lt arm only w purposefl spont mvmnt.\n\nCv: remains in afib on neo. Hr controlled w pgt diltiazem.Distal pulses by doppler.Extrems cool, bair hugger on and off thru .\n\nResp: Trached on cmv mode vent tv 450 rr 16 peep 5 .bbs coarse throughout. lavage and suct for thick yellow secretions.Remains on cmv mode w adeq abg.Trach care done\n\nGi:Abd obese w + bowel snds.Colostomy pink. gjtube w fdg at goal 65cc/hr probalance str w beneprotein. Glucoses managed per riss.Colosstomy w golden to bld tinge serous dnrg.\n\n\nGu: makes no urine.Cont on crrt keeping pt even & tol well.\n\nHeme/Id: hct 25. Tmax 99.4 while off crrt, temp now trending dwn.Cont on meropenem tobra levoflox.\n\nWound & skin: multiple decub buttocks hip and ble. Drsgs d &i.allevyn drsgs in place.\n\nA/P:Cont crrt, sliding scale ca+ k+. Cont titrate insulin gtt per prtocol. Wound and skin care. Pulm toilet.\n"},{"category":"Nursing/other","chartdate":"2132-09-20 00:00:00.000","description":"Report","row_id":1524306,"text":"Resp CAre\nPt remains on vent. Trached with #7 shiley. Suctioned mod amt of thick yellow secretions. mdis given. No changes made. Will continue to monitor.\n"},{"category":"Nursing/other","chartdate":"2132-09-20 00:00:00.000","description":"Report","row_id":1524307,"text":"Respiratory Therapy\n\nPt remains trached w/ #7.0 Shiley on full mechanical support. No vent changes made this shift. Continues on A/C w/ PIP = 22. Anterior BLBS coarse, suctioned for small amounts of thick yellow sputum. MDIs given as ordered. SpO2 90s. See resp flowsheet for specifics.\n\nPlan: maintain support\n"},{"category":"Nursing/other","chartdate":"2132-09-20 00:00:00.000","description":"Report","row_id":1524308,"text":"focus update note\nhypothermic 95-96, required bair hugger most of day, afib continues 70s-130, unable to wean neo gtt, at .5 mcq/kg/min, pt MAP 55-60 80-108\n\nCRRT continues, goal to keep pt even per renal, may take off 10-20 cc/hr if tolerated by pt. CVP 9-11, calcium and potassium gtt continue with labs q 6 hours.\n\nresp: no vent changes, thick yellow sputum suctioned q 2 hours, ls clear to coarse with bases dim.\n\nskin: and leg performed at 0900, wounds appear to be stable ? minimal healing in coccyx decubitus, bilateral toes are black. left upper medial thigh cellulitis found on morning assessment- ? if nec fasicitis- surgical consult performed- will moniotor closely.\n\nplease see flowsheet for details\n\nplan: continue with CRRT as tolerated- goal keep pt even, keep MAP> 55, > 80, labs q 6 hours, Fs q 1 hour, repleat lytes, wean neo gtt as tolerated.\n"},{"category":"Nursing/other","chartdate":"2132-09-21 00:00:00.000","description":"Report","row_id":1524309,"text":"NURSING 7P-7A\n VSS OVERNIGHT. ALTERNATING FROM NSR TO A-FIB. ALTERNATING BETWEEN HYPOTHERMIA AND NORMOTHERMIA. BAIR HUGGER ON AND OFF ACCORDING TO TEMPERATURE. CONTINES ON NEO GTT, ATTEMPTING TO WEAN NEO SLOWLY.\n CONTINUES, ATTEMPTING TO RUN EVEN AS ORDERED. FILTER CLOTTED AND REPLACED AT 2300. POSITIVE AT 2400 BY 450 ML DUE TO FILTER CLOTTING. SEE CARE VUE FOR FULL SPECIFICS.\n DRESSINGS REMAIN INTACT ON MULTIPLE DECUBITUS. REMAINS ON KINAIR BED FOR SKIN INTEGRITY.\n NO VENT CHANGES OVERNIGHT. SUCTIONED Q 2-3 HRS FOR GREEN TINGED SPUTUM IN MODERATE TO COPIUS AMOUNTS. LUNGS COARSE THROUGHOUT.\n INSULIN GTT CONTINUES, INFUSING CURRENTLY AT 7 UNITS/HR. BLOOD SUGARS IN THE 120-160 RANGE. TUBE FEEDS CONTINUE AT 65/HR.\n CONTINUE LABS Q 6/HRS PER PROTOCOL. BLOOD SUGARS Q 2/HRS WHILE GLUCOSE LEVELS STABLE. KEEP >80, MAP>50, WEAN NEO AS TOLERATED.\n"},{"category":"Nursing/other","chartdate":"2132-10-09 00:00:00.000","description":"Report","row_id":1524385,"text":"Nursing Note--A Shift\nPlease see Carevue for complete assessment and specifics:\n\nNEURO: PERRLA 3 and brisk. Alert. Does not follow commands. Nods head continuously at times, but not approprately to questions asked. Intermittently tracks people walking around her bed. (-) gag, weak cough. Minimal movement on bed with all 4 ext.\n\nRESP: LS coarse and diminished. Deep sxn for small to moderate amts of thick yellowish greenish secretions. Tol vent settings.\n\nCARDIAC: On bairhugger 1700 for temp 95.6. HR 95-120 afib. Maintaining MAP >55 able wean NEO gtt slowly. Diltiazem on hold until NEO gtt is off.\n\nGI: Abd large soft +BS. Brownish red tinged stool from ostomy, @200cc q 6hours. G tube to gravity draining scant amts of sanguinous fluid. Tol tf at goal thru J tube.\n\nCVVH: Kept euvolemic,-no issues.\n\nINTEG: Skin extremely compromised. Numerous skin issues-See Carevue Dressing changed consistently throughout shift-Skin oozing copious amts of foul smelling serous liquid. On airbed.\n\nPSYCH/SOCIAL: Husband and son visited in the am given updates and plan of care. Daughter called in the am given updates with meds, vs, and plan of care.\n\nPLAN: Wean NEO gtt off-then CVVH can be terminated, Amikacin level to be drawn at 6am tomorrow, Continue with diligent skin care, Maintain MAP >55. Provide extra comfort to patient.\n"},{"category":"Nursing/other","chartdate":"2132-10-10 00:00:00.000","description":"Report","row_id":1524386,"text":"Respiratory Care\nPt. trached on chronic ventilatory support. Has positional leak. ABG's with good oxygenation, FiO2 decreased accordingly. No other vent setting changes made this shift.\n"},{"category":"Nursing/other","chartdate":"2132-10-10 00:00:00.000","description":"Report","row_id":1524387,"text":"condition update\nS/P SEPSIS, BLEED\nSEE CAREVUE FOR DETAIL INFO.\nUNEVENTFUL NIGHT CRRT FLOWING WELL UNTIL THIS AM. ABLE TO KEEP PT EVEN TO SLIGHTLY NEGATIVE BASED ON BP .\nNEO @ SAME DOSE (1MCG) KEEPING BP MEAN 55. DISCUSSED W/DR.\nPT VERY CALM AND APPARENTLY RESTING ATIVAN NOT NECESSARY AT THIS TIME.\nGENERAL ANASARCA WITH LOTS OF WEEPING AREAS.\nSPOKE W/ AND DISCUSSED PLAN FOR NIGHT\n"},{"category":"Nursing/other","chartdate":"2132-10-10 00:00:00.000","description":"Report","row_id":1524388,"text":"BS coarse crackles; no change with MDI's. Sx'd for mod amount thick yellow mucus. Received CVVH today and will continue until off pressors. PEEP decreased to 5 without incident. WIll continue to wean FiO2 as tolerated.\n"},{"category":"Nursing/other","chartdate":"2132-10-10 00:00:00.000","description":"Report","row_id":1524389,"text":"nursing note\nNeuro:Alert today, nodding side to side and up and down, but not in correct response to questions.\nCV:afib, dilt restarted per micu despite neo requirements. Neo weaned to keep >55, sys at times 70's with MAP still >55.\nResp: Ls coarse, thick yellow secretions. Peep dropped to 5 with acceptable ABG.\nGI:tol tube feeds at 40cc via JT, no residual. GT with minimal output, pink tinged. ostomy with golden brown sotol-no visible bleeding.\nGU: anuric. stopped per micu team.\nsocial: spoke iwth daughter who states her wishes to take her mother home to spend the remainder of her days. States that if while her mother is home- she startes to bleed again or has an acute event, she will not bring her back to hospital. States she wants her home on vent and antibitoics and dilaysis and treated as necessary at . Social work and team aware.\n\nplan:? HD in few days when neo off. wean neo to off to keep MAP >55. follow labs. plan to home if possible. dressing care.\n"},{"category":"Nursing/other","chartdate":"2132-08-26 00:00:00.000","description":"Report","row_id":1524207,"text":"Resp Care Note:\n\nPt cont trached and on mech vent as per Carevue. Lung spounds coarse; suct sm=>mod tan sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required . Air leak around trach cont to be positional though ventilation maintained. Cont mech vent support.\n"},{"category":"Nursing/other","chartdate":"2132-08-26 00:00:00.000","description":"Report","row_id":1524208,"text":"Neuro: Pt alert and nodding and making needs known.\nCV: tmax 101.2. HR 110-130's Afib, with no noted ectopy. pulses. HCT drop from 25-22 this am. Continues to have large amounts of bloody drg from ? R hip skin tear, ? Vagina, ? decub.\nRESP: lungs rhonchi through out. No vent changes overnight. O2 sats >97%. Occasional suctioning of thick blood tinged secretions.\nGI: tol tube feed at goal, Colostomy draining golden liquid stool.\nGU: ANeuric.\nENDO: blood sugars WNL.\n PLAN: ? trach changed, ? trans vaginal ultra sound.\n\n\n"},{"category":"Nursing/other","chartdate":"2132-08-26 00:00:00.000","description":"Report","row_id":1524209,"text":"Respiratory Care\nPt continues to be trached/ventilated. BS: diminished bilaterally. Suctioned for moderate amounts of thick tan secretions. MDI's administered as ordered. Pt currently resting on A/C 450/16/5/.40--overbreathes rate at times. # 8.0 adjustable length /air clean and intact. Plan for Interventional Pumlonary to change to special order trach (7.0 X-tra Long Shiley). Will continue to closely monitor at this time.\n"},{"category":"Nursing/other","chartdate":"2132-08-26 00:00:00.000","description":"Report","row_id":1524210,"text":"Condition Update\nPlease see carevue for specifics.]\n\nNeuro unchanged. TMAX 101; Pan cx'd again except for urine since pt is anuric. Mean BP 30's-40's this afternoon. 250cc NS given x 1 per micu team w/ + effect. No vent changes made. Resp tx giving pt as ordered. Pt sxn'd several times for small amts of thick, tan secretions. + leak from trach. Tube feedings infusing at goal w/ no residuals. Shiley trach that family is requesting is on back order w/ no estimated ship date. Moderate amts of bleeding noted to be coming from pt's skin tears on her hips. All areas cleansed, aquacel placed, then dsd's.\n\nPlan: continue with current plan of care per micu team. continue to monitor hemodynamics. HD tues/th/sat. IV abx, wound care.\n\n\n"},{"category":"Nursing/other","chartdate":"2132-08-27 00:00:00.000","description":"Report","row_id":1524211,"text":"Resp Care Note:\n\nPt cont trached and on mech vent as per Carevue. Lung sounds coarse suct mod th yellow sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required .. Cont mech vent support\n"},{"category":"Nursing/other","chartdate":"2132-08-27 00:00:00.000","description":"Report","row_id":1524212,"text":"nursing note\npt stable , BP transiently dips to 80 sys, no intervetnions. BP up with stimulation. Son in to visit, minimal interaction. Suctioned for thick tan secretions. BS 300, md aware to change official order off q1 hr.\n\nplan:cont family support. increase bs regimen.\n"},{"category":"Nursing/other","chartdate":"2132-09-16 00:00:00.000","description":"Report","row_id":1524289,"text":"Respiratory Care Note:\n patient remains trached and on full vent support at this time. No changes have been made. For specifics please refer to carevue. BS are coarse to diminished at the bases. SX for small amounts of thick yellow secretions Q3-4 hours. No RSBI this am due to patient status and vent dependency. Patient remains afebrile. MDI's administered as ordered. SPO2 remains 100%. Patient overbreathes vent set rate by 6-10 breaths per minute. Will continue with full support.\n"},{"category":"Nursing/other","chartdate":"2132-10-05 00:00:00.000","description":"Report","row_id":1524365,"text":"Resp Care\nPt remains on vent. No changes made. Sucitoned mod amt of htick yellow secretions. Mdis given. Will continue to monitor.\n"},{"category":"Nursing/other","chartdate":"2132-10-05 00:00:00.000","description":"Report","row_id":1524366,"text":"Focused Nursing Note\nPlease see carevue flowsheet for further details\n\nNEURO: Pt awake state waxes and wanes, daughter at bedside and states pt is least responsive that she has witnessed. Does not follow commands as baseline. PERRL 4-5mm. ativan x 2 for incr RR and HR with therapeutic effect.\n\nHEMODYNAMCIS: NSR with occassional PACs vs Afib, controlled rate 80-90s on Diltiazem gtt titrated down to 5mg/hr. 85-102 on Neo 0.5-0.6mcg/kg/min, attempting to titrate. Anasarca, abdominal ascites, serous weepage from multiple skin tears/blistering. Hct stable at 26.1, plt 132, INR 1.6. No active bleeding noted. Jtube drainage 900ml dark maroon/bilious fluid.\n\nRESP: Trach patent, chronic airleak. Ventilator settings unchanged. ABG Ph 7.36/40/24/153 on CMV 0.50/450/20/8. Suctioned for small amts thick yellow drainage. Brown exudate from trach stoma.\n\nGI/METABOLIC: Colostomy stoma grossly edematous, opaque pink, no ischemia- appliance changed. Soft, formed black stool in small amts. Jtube suctioned output 900ml dark maroon/bilious output, Gtube to gravity drainage scant output of same character. Drainage around G/J tube site minimal this shift. No emesis. TPN infusing at 77ml/hr. Glucoses stable 125-137 on insulin gtt protocol.\n\nID: Tmax 99.6, surveillance BC pending. Amikacin level 14.7, dose held. Coccyx wounds with foul odor, rectal/vaginal drainage in small amounts varies from dark red to thin brown to mucosal.\n\nCOMFORT/SKIN INTEGRITY: Responsiveness waxes and wanes- medicated with Ativan in response to elevated RR/HR- therapeutic effect. Turned and repositioned q2hr, heels elevated off bed at all times. Aggressive skin care. dressing changes done to coccyx, right ischial and bilateral trochanter ulcers. Noted generalized erythema, boggy/macerated skin to posterior buttocks and extending as borders to trochanter wounds- scattered areas of small Stage II ulcers/skin tears secondary to edema, moist skin. Aloevesta to all unopened compromised areas- reccomend drressing changes TID to attempt to keep skin dry.\n\nPSYCHOSOCIAL: HCP/Daughter at bedside in evening- assisted RN with stoma appliance changes and was comforted to see no skin breakdown in these areas. Discussed at length with the physiology of SBO and clarified for her the difference between J/G ostomy tube vs very small J-feeding tube she had at home to explore belief that current GI complications are caused by \"too large of a J/G tube placed\". adds that her mother has a chronic hx of n/v and receives compazine/zofran regularly on HD days as prevention.\n\nPLAN OF CARE: Continue to monitor hemodynamics closely, attempt to wean pressor. Monitor GI status, antiemetics per MICU team plan. F/U Amikacin levels post-HD today. Aggressive skin care, dressing changes TID prn, pulmonary hygiene, keep pt comfortable per changes in VS and non-verbal cues. Emotional support and education to pt and family ongoing. Recommend family/multidisciplinary meeting Monday to discuss d/c home\n"},{"category":"Nursing/other","chartdate":"2132-10-05 00:00:00.000","description":"Report","row_id":1524367,"text":"Focused Nursing Note\n(Continued)\n.\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2132-10-05 00:00:00.000","description":"Report","row_id":1524368,"text":"Respiratory Care\nPt remains trached and on vent support. No vent changes were made during shift. Lung sounds were course and diminished throughout. Pt was suctioned for copious amounts of thick yellow secretions. Pt received MDI's. Atrovent was not given, extra dose was requested and was given at 1600. No ABG were drawn during shift. Care plan is to continue current settings and a family meeting is planned for Monday. Will continue to follow pt.\n"},{"category":"Nursing/other","chartdate":"2132-10-24 00:00:00.000","description":"Report","row_id":1524442,"text":"Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. No morning abg results.\n\n deferred due to hemodynamic instability.\n"},{"category":"Nursing/other","chartdate":"2132-10-24 00:00:00.000","description":"Report","row_id":1524443,"text":"Respiratory Care\nPt remains trached and on vent support. No vent changes were made during shift. Lung sounds were course with periods of rhonchi that cleared after suction. Pt received MDI's as ordered. No ABG's were drawn during shift. Pt was suctioned for scant amoutns of thick yellow secretions. Care plan is to continue current therapy and a discharge is planned for Monday. Case Manager requested to have me speak w/ Home Care about vent status. After speaking with H.C company, will place pt on home vent Sunday around midnight. Will continue to follow pt.\n"},{"category":"Nursing/other","chartdate":"2132-10-24 00:00:00.000","description":"Report","row_id":1524444,"text":"NURSING NOTE\nPLEASE SEE CAREVUE FOE DETAILS\nNEURO: NO MENTAL STATUS CHANGES, EASILY AROUSABLE TO VOICE/MIN STIM, NODDING INTERMITTENTLY TO QUESTIONS. TRACKING VOICE W/EYES, PERRL, 4MM, BRISK. ATIVAN GIVEN FOR TACHYPNEA, DISCOMFORT DURING HD. PRE-MEDICATED W/DEMEROL FOR EXTENSIVE DSG CHANGES.\n\nCVS: HR 90S-100S, NSR/ST, 70S-130S, MAP MAINTAINED>60. T-MAX 99.2, HCT 24 MD AWARE, WILL F/U, ?TRANSFUSION. RIGHT CENTRAL LINE D/C'D BY MICU, TIP SENT FOR CULTURE. NO BLOOD FROM COLOSTOMY NOTED. HD FOR 2.6L.\n\nRESP: REMAINS ON CMV, NO VENT CHANGES MADE, NO VBG DONE. PT SUCTIONED FOR SM AMT THICK, TAN/YELLOW, O2 SATS 98-100%, TACHYPNEIC TO 30S THIS AM W/HD-ATIVAN GIVEN W/RELIEF.\n\nGI/GU: COLOSTOMY W/MIN AMT DK BRWN LOOSE STOOL, NO BLEEDING NOTED. SM AMT DRNG AROUND G/JT PINK, VISCOUS, JT PATENT TO FLUSH. GT W/MOD AMT YELLOW SEROUS FLUID DRNG TO GRAVITY. SM AMT CLEAR, MUCOID RECTAL DRNG NOTED.\n\nID: AMIKACIN GIVEN POST-HD, MEROPENEM\n\nENDO: BS COVERED VIA RISS, LANTUS GIVEN THIS AM\n\nINTEG: MULTI DSG DONE, REINFORCED/RE-PACKED PRN. PT SKIN WEEPING COPIOUS AMTS GEN SEROUS DRNG, GEN ANASARCA. PT TURNED FREQUENTLY FOR SKIN CARE, NO NEW AREAS OF BREAKDOWN NOTED.\n\nPLAN: SICU , PLAN D/C TO HOME MON. AGGRESSIVE SKIN CARE, PAIN MGMT, RESP SUPPORT. MONITOR FOR S/S BLEEDING, SERIAL HCTS, ?TRANSFUSION FOR PM HCT 24.\n"},{"category":"Nursing/other","chartdate":"2132-10-25 00:00:00.000","description":"Report","row_id":1524445,"text":"Resp Care,\nPt. remains on A/C . No vent changes this shift. BS coarse, suctioned for thick yellow sputum. MDI's as ordered. See careve.\n"},{"category":"Nursing/other","chartdate":"2132-10-25 00:00:00.000","description":"Report","row_id":1524446,"text":"FOCUSED NURSING NOTE\nPlease see carevue for further details\n\nNEURO: Pt's alertness waxes and wanes, this cycle unrelated to pain meds and sedative. PERRL, 3-4mm. Not making eye contact this shift, nods head \"yes\" to questions inconsistently- attempted to mouth words and became tearful when I asked her to repeat it so I could interpret, nodded head \"yes\" to pain at this time. Medicated with Ativan x 2 for sleep and incr RR, medicated with Demerol x3 as premedication for x2 and spotaneous cues of discomfort at rest.\n\nHEMODYNAMICS: s/p 2UPRBCs for Hct 24, post-transfusion HCT 31.0. Plt low at 40K, no sx acute bleeding. ranges 62-130s, HR NSR 90-102.\nAnasarca persists, purple discoloration and evidence of mottling to buttocks, posterior iliac crest skin breakdown area and BLE.\n\nRESP: Trach patent, yellow exudate. SPO2 98-100% on CMV 0.50. Suctioned frequently for thick/yellow sputum. Lungs are coarse bilaterally.\n\nID: Afebrile. Meropenem as ordered. Levaquin per Jtube.\n\nGI/METABOLIC: NPO maintained. Colostomy with total 100ml black/dark brown liquid drainage. Glucoses stable off nutrition (100/82)\n\nSKIN INTEGRITY: Pressure ulcers as previously documented that pt entered hospital with are uncahnged, no foul odor noted. Pts posterior waist area, buttocks, and posterior thighs are covered with moist erythema and multiple skin blisters, tears weeping serous fluid. Areas are purplish in color and extremely fragile to touch- Dressing changes to all sites completed x3, pt turned and repositioned q2hr with full linen change and application of aloevesta to attempt a clean/dry surface for skin, though no improvement is evident.\n\nPLAN OF CARE: Monitor hemodynamics, sx bleeding. Resp support, . Assess comfort frequently, sedative and pain med prn. Aggressive skin care. Emotional support to pt and family ongoing. D/C home plan discussion per MICU Attending and HCP .\n\n"},{"category":"Nursing/other","chartdate":"2132-09-28 00:00:00.000","description":"Report","row_id":1524337,"text":"Respiratory Care\nBreath sounds bilaterally diminished, bilateral crackles, suctioned for moderate thick yellowish secretions, patient was afebrile, stayed into chronic A-Fib, patient is on Neosynephrin, Hemoglobin on 9.1 consistent with anemia, patient was treated with Albuterol, Atrovent and Flovent during the shift, Oxygen saturation ranged 97 to 100, no ABGs nor vent changes done up to this point. Patient will continue to be on ventilatory support and close monitoring.\n"},{"category":"Nursing/other","chartdate":"2132-09-28 00:00:00.000","description":"Report","row_id":1524338,"text":"condition update\nD: pt opens eyes spontaneously. moves left arm spontaneously. she does not follow commands.\ncardiac: pt remains in afib with rate of 90-102. map greater than 55 on .7 of neo. unable to titrate any lower due to drop in bp to map less than 55.\nresp: pt suctioned for thick yellow sputum. breath sounds are clear and diminished in the bases. 02 sat 95-97%.\ngi: tube feeds remain off and g tube to suction. continues to drain large amts of bilious drainage. abd remains distended. stoma is pink and small amt of brown stool present. small amt of bleeding from the rectum and dr. is aware. hct remains stable a 26.\nskin: pt with genralized edema in all extremities. pressure wound dressing are dry and intact.\na: continue to monitor labs. wean neo as tolerated. ? dialysis today. monitor abd and gastric drainage.\nr: no change in status. still with large amts of gastric drainage. neo remains at .7.\n\n"},{"category":"Nursing/other","chartdate":"2132-10-18 00:00:00.000","description":"Report","row_id":1524418,"text":"NPN 1900-0700\nPlease see carevue for specifics.\nROS:\nNeuro: Arousable to voice, moving LUE only on bed. Pupils equal and reactive. Follows some simple commands inconsistently. Able to nod/shake head when asked if having pain. Medicated with 25mg demerol x1 with effect.\nCV: HR 70-80'SR, BP 69-100/50-70's. Diltiazem held, HO aware. Skin cool, conts. large amts. weeping/drainage, +jaundice. Pedal pulses weakly present by doppler.\nHeme: hct 25.3 (27.6), Dr. aware. Repeat PTT 35 (150).\nAccess: LSC dialysis cath. with old, dry, bloody drainage, no new drainage. R ac PICC + blood return, wnl. RIJ TLCL wnl, unable to draw back blood, HO aware, sm. amt. old dry bloody drainage under dsg.\nResp: LS coarse->clear, diminished at bases. Suctioned for sm.->moderate amts. thick, yellow sputum. No vent changes made .\nGI: abd obese, BS hypoactive, no stool. Stoma , pink. Colostomy appliance intact with sm. amts. liquid green stool. TF started via J tube port with G port to gravity, sm. amt. green drainage. Protonix for GI prophylaxis.\nGU: dialysis yesterday, anuric.\nEndo: BS wnl, no coverage per ss.\nID: afebrile temp. 96 Conts. meropenem/levofloxacin/amikacin.\nSkin: multiple ongoing skin issues, please see flow sheet. Updated recs. from skin care nurse . Conts. to require frequent changing/reinforcement.\nPsych/social: pt's son in last eve; affect/questions appropriate. Stating he would like to see his mother brought home and made \"comfortable\". Emotional support provided. No other contact .\nA/P: Monitor VS, I/O, labs. . ongoing aggressive skin care, pulmonary hygiene. . ongoing open communication, comfort and support to pt and family.\n"},{"category":"Nursing/other","chartdate":"2132-09-16 00:00:00.000","description":"Report","row_id":1524290,"text":"Update\nO: See carevue flowsheet for specifics.\nNeuro: somnolent, arousable to voice. Ativan held overnight. Perl at 4mm brisk. Spont purposeflu mvmnt of lt arm.\n\nCv: st w occ pvc occ burst afib/freq pac. Labile 78-100 syst. improved w stim and repositioning.Distal pulses by doppler.Skin and moist w multiple skin brkdwn issues.\n\nResp: remains trached on cmv mode.Lavage and suct q2-3h for thick pale yellow secretions.Bbs coarse bilat upper lobes, diminished lower lobes bilat.Occ dip in sats to low 90's responsive to lavage and suctioning.\n\nGi: gj tube w tf at goal 40cc/hr. Colostomy w loose golden to bilious grn stool. Bl glucoses managed w insulin gtt.\n\nGu/Renal: crrt dc'd per micu team for frank seropurulent drng around quinton cath line. Drsg under technique and line dc to be done by team in a.m.(*quinton placed in IR previously). Bl cultures sent via line and ports flushed per protocol.\n\nHeme/Id: hct 23.7 this am. No active signs of bldg. Tmax 99.7. Cont on meropenem, tobra, daptomycin, levoflox. Mult decubs , hips and coccyx as well as bilat leg wounds. Coccyx and decubs changed w wound cleanser to sites and aquacell drsg applied.\n\nA/P: Quinton line w purulent drng, crrt on hold per team. ? IR for new line placemnt today. Line tip cult on removal of line.? restart neo for if consistently < 80. Cont tf as ordered, titrate insulin gtt to goal bl sugar.Pulm toilet.Updates to hcp by micu attending last pm. Cont to provide emot support to family.\n"},{"category":"Nursing/other","chartdate":"2132-10-01 00:00:00.000","description":"Report","row_id":1524352,"text":"FOCUSED NURSING NOTE\nPlease see carevue flowsheet for further details\n\nNEURO: Pt awake most of shift, does not follow commands, no spontaneous movements noted- inconsistently tracks with eyes. PERRL, 4-5mm.\n\nRESP: s/p Bronch. No vent changes this shift. trach care done. labored breathing improved slightly after HD. SPO2 99-100%, RR 17-24. ABGs acceptable this am, MICU team aware of results and labored breathing.\n\nHEMODYNAMICS: S/P HD fluid removal 1.5L, tolerated with support of Albumin and neo gtt at 0.5mcg/kg/min. Tachycardic 120s/130 during HD. Diltiazem gtt initiated after HD complete, good rate control 90-110 on 5.0mg/hr. BP parameters of MAP>50, >80 maintained on neo gtt. Pressor weaned off in am, though resumed for HD tolerance. Anasarca increasing, moderate serous fluid losses from several skin openings.\nVaginal bleed in small amounts, intermittent in nature. Guiac positive stool via colostomy, small blood clots noted.\n\nGI/METABOLIC: Current SBO, abdomen obese and ?ascites- G/J tube clamped, no Gtube residuals. Colostomy with maroon loose stool, severe ammonia-like odor. TPN infusing as ordered. Insulin gtt titrated protocol, BG 98-132.\n\nPSYCHOSOCIAL/COMOFORT: Pt visited by husband in am, inquires about HD and urges fluid to be removed. called x 2 today for updates. Son visiting this evening. Pts HR increased during HD and appeared distressed by facial cues, medicated with Ativan. Again appeared uncomfortable after HD complete with incr R and HR, medicated with Demerol IVP with good response in VS and mild sedation. Aggressive skin care, turn and reposition q2hr, oral care frequent.\n\nPLAN: Continue to monitor hemodynamic stability, titrate pressor and cardizem for goal > 80 and HR< 110. Monitor for sx resolution of SBO. Keep pt comfortable, Ativan/Demerol prn. Monitor metabolic status, insulin gtt titrated protocol. Pulmonary hygiene/skin care/ emotional support and education to pts family ongoing.\n\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2132-10-02 00:00:00.000","description":"Report","row_id":1524353,"text":"Respiratory Care\nPt. trached and vented for chronic respiratory failure. Uneventful shift, no setting changes. Suction for small amount thick yellow secretions.\n"},{"category":"Nursing/other","chartdate":"2132-10-02 00:00:00.000","description":"Report","row_id":1524354,"text":"Please See Carevue for Specifics.\n\nNo change over night. Pt was kept comfortable and repositioned. Family was in at start of shift. Neo remains at 0.5mcg/kg/min, insulin gtt off and Lantus started. G-tube residual minimal 0-3cc.\n\n: HD, family meeting, skin care, hemodynamic monitoring, amikacin as ordered.\n"},{"category":"Nursing/other","chartdate":"2132-10-02 00:00:00.000","description":"Report","row_id":1524355,"text":"pt remains on full vent support with minimal secretions sx'd. pressure was effective at 23. ABGs normalized during shift with minor changes.\n"},{"category":"Nursing/other","chartdate":"2132-10-02 00:00:00.000","description":"Report","row_id":1524356,"text":"Focused Nursing Note\nPlease see carevue flowsheet for further details\n\nNEURO: Pt somnolent, no acute changes in neuro assessment. PERRL, 4-5mm. Ativan IV x 2 for incr WOB and facial cues of distress, mild sedation therapeutic.\n\nRESP: Trach patent, ventilatory support titrated for hypercarbia mild hypoxia. current vent settings CMV 0.40/450/R 20/ PEEP 8\nLatest ABG in normal range. Frequent suctioning for thick yellow secretions earlier in shift, now decreasing. Incr WOB continues.\n\nHEMODYNAMICS: Current fluid balance +900ml, grossly anasarcous. Off pressor support, 80-90, MAP 52-60. HR 90-113 on Diltiazem gtt 5mg/hr. Melena stool/clots from colostomy approx 250ml total, vaginal bleeding minor today. No further signs of bleeding.\n\nGI/METABOLIC: G/J tube remain clamped for SBO, abdomen obese, severe anasarca. Gtube residuals 0-5ml. TPN infusing as ordered. Insulin gtt titrated protocol, glucoses stabilizing to low 100s.\n\nSKIN INTEGRITY/COMFORT: Multiple areas of pressure ulcers, venous stasis ulcers and edema/pressure related breakdown in skin folds present as previously documented. All wound care completed and pt turned and repsositioned q2hr ATC, heels elevated off bed at all times. Ativan given for mild sedation in light of incr WOB and facial cues of distress.\n\nSOCIAL: Pts husband at bedside this am briefly. No further family contact by this RN. Multidisciplinary meeting held today re: current and future goals of care for pt. Present at meeting are Dr , SW, Ethics representative, case management, Nurse , Resource RN , and myself. Considered HCP statement to have her mother die at home versus hopsital environment. Obstacles to d/c home include SBO and GIB. Dr to discuss with HCP family goals of home care of full supportive management vs curtailing therapies and managing end-of-life at home. In addition, SBO and GIB to be monitored over next few days to determine resolution vs worsening, plan on Monday for d/c home potential tuesday.\nDr to contact per above discussion.\n\nPLAN: Monitor hemodynamic status, GIB, SBO, resp status. Anticiapte KUB tomorrow. Titrate Cardizem and for goal HR<110. Keep pt comfortable, aggressive skin care, turn and reposition q2hr, heels elevated. titrate insulin gtt protocol. Pulmonary hygiene. as ordered, f/u Amikacin level. Emotional support to pt and family ongoing. Further plan of care per MICU team.\n\n\n"},{"category":"Nursing/other","chartdate":"2132-10-03 00:00:00.000","description":"Report","row_id":1524357,"text":"Respiratory Care Note:\n\nPt remain on full ventilatory support via tracheotomy tube. No vent changes done. ABG drawn last evening, acceptable. We are sxtn routinely for mod amt of thick yel secretions from trach, none orally. IC changed early this morning. Plan: Continue present ICU monitoring & keep comfortable.. Will follow.\n"},{"category":"Nursing/other","chartdate":"2132-10-03 00:00:00.000","description":"Report","row_id":1524358,"text":"NURSING PROGRESS NOTE:\nNeuro: Pt very withdrawn, not responding to verbal or tactile stimuli. Pupils 4mm brisk. + gag +cough reflex.\nCV: afebrile, HR 80's Afib with no noted ectopy. 80-90's MAP>50. Cont on dilt gtt for rate control. pulses.\nRESP: No vent changes. Occasional suctioning of of thick yellow secretions.\nGI: NPO, Colostomy cont to drain dark red stool.+ guaiac.\nGU: Aneuric.\nENDO: Cont on insulin gtt.\nPLAN: Cont to monitor neuro status. Monitor blood sugars.\n"},{"category":"Nursing/other","chartdate":"2132-10-25 00:00:00.000","description":"Report","row_id":1524447,"text":"Respiratory Care\nPt remains trached and on vent support. No vent changes were made during shift. No ABG's were drawn during shift. Lung sounds were course and diminished in the bases with a period of faint exp wheezes that cleared after MDI. Pt received MDI's. Pt was suctioned for scant to small amounts of thick yellow secretions. Care plan is to continue therapy on our vent until Sunday night and then place pt on home care vent. Will continue to follow pt.\n"},{"category":"Nursing/other","chartdate":"2132-07-31 00:00:00.000","description":"Report","row_id":1524099,"text":"Focus Condition Update\nSee careview flowsheet for specific info.\n\nNeuro: Pt mildly responsive. Opens eyes spontaneously, follows commands rather inconsistently, no communication noted from pt. Not moving extremities, except for LUE.\nCV: A-fib with occassional PVC. Hypotensive, SBP 85-110, HR 95-120. 12.5 lopressor given with effect. Afebrile. Crit stable, white count decreasing, K+ 3.8.\nResp: No vent changes overnight, sating 100% on CMV, PEEP 5, 40% O2. LCTA bilaterally, sux'd for small amount of thick white sputum.\nGI: Colostomy patent, draining small amount of loose brown stool. Abdomen soft, BS+.\nEndo: Insulin gtt off for low BG, will recheck in 1 hour. Titrating insulin for BG of 100-120, using protocol.\nInteg: Multiple ulcerations on body. Wet to dry dressings changed over right ischial spine, and left heel per wound care nurse.\nSocial: Dtr and son in to visit. Dtr found suctioning pt. Politely asked her not to do this in the future, but to ask RN or RRT if her mom needs this in the future. Dtr states she understands.\nPlan: To MRI tomorrow.\n Continue with wound care, and skin care mgt.\n Titrate Insulin to keep BG 100-120.\n Continue with current POC.\n\n"},{"category":"Nursing/other","chartdate":"2132-07-31 00:00:00.000","description":"Report","row_id":1524100,"text":"Respiratory Care: Pt remains trach and vented on AC settings. No vent changes made this shift. Pt's breath sounds coarse/diminished. Suctioned for small thick yellow/brown secretions. MDIs given as ordered.will continue to follow.\n"},{"category":"Nursing/other","chartdate":"2132-10-18 00:00:00.000","description":"Report","row_id":1524419,"text":"RESP CARE: Pt remains trached/on vent on AC SEE CAREVUE. No changes in settings. Lungs coarse/sxd thick yellow/MDIs given as ordered. Trach care done/inner cannula changed, pressure 25cmH20. No RSBI due to hemodynamic instability. Pt is vent dependent at this time.\n"},{"category":"Nursing/other","chartdate":"2132-10-18 00:00:00.000","description":"Report","row_id":1524420,"text":"FOCUSED NURSING NOTE\nPlease see carevue flowsheet for further details\n\nNEURO: Alert to lethargic, able to arouse to voice. Spontaneous movement weakly LUE only- only command she follows is to open her mouth, will not blink or nod head on command. Nodding head mainly \"yes\" inconsistently to questions- spontaneously nod head \"yes\" at times as well without questioning. Tracking with eyes. Ativan x 1, Demerol premedication before dressing change with fair effect.\n\nRESP: s/p CXR, results pending. Trach patent, vent settings unchanged. SPO2 99-100%. Frequent suctioning for thick/yellow secretions, no spontaneous cough. Positional air leak continues. Amikacin and Meropenem for gram negative rods sputum.\n\nHEMODYNAMICS: s/p 1UPRBCs this am, post Hct 29.8. No sx active bleeding today. Multiple areas of skin tears and ulcers bleed, frequent . HR 80-90s, NSR, rare PVCs. Erractic swings in BP today, range 71-163/30-114- variable minute to minute this afternoon, no change in neuro status. General anasarca and severe weeping of all dependent skin areas.\n\nID: Maintains temp 96-97 without bair hugger today. Meropenem administered as ordered. Amikacin orders clarified to be given on hemodialysis days only, level to be checked as trough with next dose.\n\nGI/METABOLIC: NPO. TF advanced to 40ml/hr, tolerating well thus far. Colostomy output green/brown liquid stool, no sx GIB today. Receiving Lantus 5U qAM, glucoses 168/164 covered with RISS.\n\nSKIN INTEGRITY: Severely impaired epidermis to buttocks, thighs, skin folds, BLE and feet as previously documented. No acute changes in wounds- all dressing chages done twice today secondary to moderate drainage and weeping of surrounding skin. Aggressive skin care ongoing, heels elevated off bed at all times.\n\nPSYCHOSOCIAL: Family members visit in groups due to discord between HCP and the rest of her siblings- Sons and both claim that pt has expressed to family in past that she did not want to live in her critical condition, she has asked family to keep her home and stop hemodialysis. Sons communicate to me that as HCP is the only child insisting on aggressive care and will not consider a family decision collectively. Sons remain hopeful that pt may be discharged to home this week, however ths unfortunate situation has created much strife between the siblings and communication has broken down.\n\nPLAN OF CARE: Continue to monitor for sx bleeding, f/u HCt tonight. F/U CXR results. Monitor GI status, maintain TF at goal. Monitor glucoses, discuss with MICU increasing glycemic control. Aggressive skin care, comfort care, emotional suuport to pt and family. Discuss with MICU team d/c plan for Monday.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2132-10-19 00:00:00.000","description":"Report","row_id":1524421,"text":"RESP CARE: Pt remains trached/on vent. pressure 25cmH20.No changes in vent settings this shift.SEE CAREVUE FOR SPECIFICS. Lungs coarse bilat. MDIs given as ordered. Sxd small amts thick yellow sputum. Trach care done. Inner cannula changed/trach tie changed. No RSBI this am due to hemodynamic instability, Pt remains vent dependent at this time. Plan is to place pt on home vent 48hrs prior to discharge home.\n"},{"category":"Nursing/other","chartdate":"2132-10-03 00:00:00.000","description":"Report","row_id":1524359,"text":"Resp Care\nPt remains trached on A/C. Suctioned for mod amt of thick tan sputum. MDI's given, no other changes noted.\n"},{"category":"Nursing/other","chartdate":"2132-10-03 00:00:00.000","description":"Report","row_id":1524360,"text":"Update\nSee Carevue for specifics\n\nNeuro: unable to assess pt's mental status though appears alert, opens eyes spontaneously and was observed to respond to family member by tracking, ?opening mouth to command. Does not move any extremities. PERRL. Afebrile.\nCV: controlled afib. Diltiazem gtt. rate in 90s-110s. BP > MAP 55 most of shift. Dropped to 50 late in day and neo gtt started with positive effect. HD, 2.4L off, prbc x 1 given.\nResp: LS coarse/diminished. Sat 94-98% on AC. No vent changes. Sxn'd for thick yellow sputum.\nGI: TPN. Gastrograf study performed at bedside. Contrast given through G tube and J tube. Post procedure pt put out 2L maroon/bilious liquid through G tube. Team notified and hct drawn. G tube continues to ooze sanginous liquid.\nGU: anuric\nSkin: Grossly impaired with numerous site of breakdown. See Carevue and chart for details.\nSocial: family in to visit and talked with MD.\n\nPlan: Monitor Gtube output closely and assess for bleeding. Monitor respiratory status and sxn as needed. Keep family UTD on .\n"},{"category":"Nursing/other","chartdate":"2132-10-04 00:00:00.000","description":"Report","row_id":1524361,"text":"Respiratory Care Note:\n\nPt remain on ventilatory support via trach tube. We increased FIO2 from 40 to 50%. We are sxtn for small amt of thick yel secretions from trach. IC changed early this morning. Plan: Continue present ICu monitoring, follow VS, WOB & Sats. Will follow.\n"},{"category":"Nursing/other","chartdate":"2132-10-04 00:00:00.000","description":"Report","row_id":1524362,"text":"FOCUSED NURSING ASSESSMENT\nPlease see carevue flowsheet for further details\n\nNEURO: No acute changes- moves LUE only- does not follow commands- questionable tracking with eyes- PERRL 4-5mm. Ativan x 2 IV for tachypnea and tachycardia with minimal effect- demerol therapeutic for incr RR/HR.\n\nHEMODYNAMICS: tachycardic 115-120 just prior to emesis and increased G-tube site leakage, now NSR 90s after transfusion and dilt gtt incr to 7.5mg/hr. 84-90s on Neo gtt 0.4mcg/kg/min- falls to 75 without Neo. Noted bloody emesis x 1 and continued dark red/bilious drainage from Gtube exit site (500ml/shift). MD notified. Hct 22.9, plt 89. Transfused pt with 1UPRBC and 1U Md orders- Post-transfusion HCT 26.1, am 25.4. Desmopressin given as well. Gross anasarca.\n\nRESP: Trach patent, ventilated A/C 450/0.50/20/PEEP 8. tachypneic (28-32) during blood transfusion with airway pressure 33, suctioned for minimal tan secretions. tachypnea improved with Ativan/Demerol sedation, RR now 24, pressure 25. Lungs clear R lobe, greatly diminished L lobe.\n\nGI: Emesis dark red mixed with bright red fluid approx 100ml. Dark red/bilious outputs continue from around G/J tube site collected in gravity drainage bag. G-port irrigated with 60ml NS, aspirated 15ml return. J-port irrigated with 60ml NS and aspirated equal return plus 30ml additional, also dark red/bilious outputs. Gtube connected to LCWS with small outputs (200ml over 8 hrs) Larger output is around Gtube exit site. MICU intern and GI Surgery aware of events. Colostomy very small output maroon liquid mixed with soft maroon stool- no new outputs during shift.\n\nID: Tmax 99.9. BC sent with am labs as ordered. Vancomycin as ordered.\n\nMETABOLIC: TPN infusing at 77ml/hr. Blood glucoses stable <150 on insulin gtt protocol.\n\nCOMFORT: Pt turned and repositioned q2hr, heels elevated off bed at all times. Demerol x 2 for tachypnea and premedication for dressing changes with good effect.\n\nPLAN: Continue to monitor GI outputs and follow hemodynamics closely. Pulmonary hygiene, pain control, aggressive skin care. Monitor temperature, new sx infection. Further plan of care per MICU team, ?GI studies today.\n"},{"category":"Nursing/other","chartdate":"2132-10-22 00:00:00.000","description":"Report","row_id":1524435,"text":"Nursing Note 7a-7p:\nNursing Assessment:\n\nAfebrile this shift. Shakes head yes and no. Often shakes head no during care (dressing changes, repositioning, suctioning). Unable to determine appropriateness of yes and no nods to situations.\nCV: NSR to ST 90s-110; 70s-120s. HD today 2.7 off. This afternoon Bright red blood from ostomy stoma. HCT 23.6 (following 1.5 liters out) previously 30.1 on am labs. 2 units prbc's given with resulting Hct 28.3 and bleeding stopped. (total over 3 liters of blood mixed with golytely and stool out). HCT and platelets to be rechecked tonight (last plt count 50s and MD , aware).\nTube feeds on hold d/t NPO for scope and golytely given as prep. Scope now on hold possibly until tommorrow unless bleeding restarts.\nPositive blood cultures gram +cocci in pairs and chains from yesterday and MD , notified. Amikacin level back from before dialysis 11, dose given post-dialysis and level will be rechecked in the am.\nA meeting took place this afternoon regarding hospital policies in relation to the family's wishes. Ethics, social work, casemanagment, resource RN, and Micu attending all present; working towards discharge planning and keeping the patient's best interests in mind. Please refer to carevue for all further details.\n"},{"category":"Nursing/other","chartdate":"2132-10-22 00:00:00.000","description":"Report","row_id":1524436,"text":"Resp. Care Note\nPt remains trached with #7 extra long shiley and vented on AC settings as charted on resp. flowsheet. No vent changes were made this shift. BS slight decreased and coarse. Receiving Albuterol/ Atrovent and Flovent MDI's, see flowsheet for Rx times. Sxn for yellow sputum. current vent support.\n"},{"category":"Nursing/other","chartdate":"2132-07-30 00:00:00.000","description":"Report","row_id":1524094,"text":"Focus Condition Update\nSee flowsheet for specific information.\n\nNeuro: Pt opens eyes and tracks osccassionally, but not following any commands. Movement of extremities noted in all but RUE. No pain noted except when dressing changes done. PO ativan given with good effect.\nCV: Pt afebrile, hypotensive at times, particularly during HD. Remains in A-fib with occassional PVC's. SBP stable 95-115, HR tachy 95-110. K+ and Magnesium repleted, Vit K given for INR of 6.1.\nResp: CMV, PEEP 5, 40% O2. Lungs mildly coarse bilaterally, dim in bases. Sux'd for small to mod amount of thick white sputum.\nGI: TF's started, full strength at 40cc/hr, with no residuals. Abdomen obese, BS hypoactive. G tube site is leaky, but bag is in place to catch drainage. Colostomy patent, draining moderate amount of green liquid stool.\nGU: No UO noted.\nSkin: Multiple necrotic skin ulcers, most notably, a decub on coccyx that is 7cm x 7cm and to the bone. Dressings changed on coccyx, and right hip, wet to dry. Skin care RN to see pt in a.m. See flowsheet for specifics on other wound sites.\nPlan: Monitor and replete lytes\n Continue with dressing changes as needed\n Monitor for changes in neuro status\n Continue to monitor hemodynamic status\n MICU Intern aware of above, contact HO with\n changes\n"},{"category":"Nursing/other","chartdate":"2132-07-30 00:00:00.000","description":"Report","row_id":1524095,"text":"Respiratory Care\nPt. remains trached and ventilated. PT chronically vented at home on A/C settings. This a.m. pt did well with RSBI trial = 46, and appears to tol PS/CPAP well, pt. may be able to tol wean of vent settings to PSV when medical status more stable. Suctioned for thick yellow/tan secretions.\n"},{"category":"Nursing/other","chartdate":"2132-07-30 00:00:00.000","description":"Report","row_id":1524096,"text":"NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT, OCCASIONALLY FOLLOWING COMMANDS. MOVING ALL EXT. EXCEPT FOR RIGHT ARM. PERRL. C/O PAIN WITH DRESSING CHANGE, RESIDENT WILL ORDER PAIN MED FOR DRESSING CHANGES. ATIVAN AROUND THE CLOCK APPEARS TO BE HELPFUL FOR PERCEIVED ANXIETY.\nCV- BP STABLE TODAY, 90'S-LOW 100'S. HR A-FIB, TACHY TO 140'S THIS AM, LOPRESSOR 12.5MG RESTARTED THIS AM WITH GOOD EFFECT. 6 BEAT RUN OF V-TACH THIS AFTERNOON, LYTES AND HCT SENT AND WNL, EKG DONE, RESIDENT NOTIFIED.\nRESP- LUNGS COARSE AT TIMES, SUCTIONED A FEW TIMES FOR SMALL AMOUNTS OF THICK YELLOW SPUTUM. O2 100%, NO VENT CHANGES, REMAINS ON AC.\nGI/GU- ABD SOFT, HYPO BS. COLOSTOMY APPLIANCE CHANGED, STOMA BEEFY RED AND APPEARS HEALTHY. CONTINUES TO HAVE LARGE AMOUNT OF LOOSE BROWNISH STOOL. PT DOES NOT VOID, NO DIALYSIS AT THIS TIME FOR TODAY.\nID- TMAX 100.8\n"},{"category":"Nursing/other","chartdate":"2132-07-30 00:00:00.000","description":"Report","row_id":1524097,"text":"Respiratory Care: Pt remains trach and vented on AC settings. Pt's breath sounds coarse at times that clear with suctioning. Sx for small thick yellow secretions. MDIs given as ordered. Respiratory dicussed with team concern about high cuff pressures, they will evaluate to see if pt needs a larger trach or a new one.\n"},{"category":"Nursing/other","chartdate":"2132-07-31 00:00:00.000","description":"Report","row_id":1524098,"text":"Respiratory Care\nPt. trached on ventilatory support. No vent changes made this shift. Good RSBI = 63. Sx for small amounts thick yellow secretions. Vent dependent not plams to wean from vent at this time,\n"},{"category":"Nursing/other","chartdate":"2132-07-31 00:00:00.000","description":"Report","row_id":1524101,"text":"NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT, OCCASIONALLY FOLLOWING COMMANDS. MOVING ALL EXT. ONLY SLIGHTLY ON THE BED, WITH THE EXCEPTION OF THE RIGHT ARM. PERRL. PT COMFORTABLE MOST OF THE SHIFT, OCCASIONAL DISCOMFORT WITH DRESSING CHANGES, RELIEVED WITH REPOSITIONING.\nCV- BP IN 90-110'S RANGE, NO FLUID BOLUSES NEEDED. DIALYSED THIS AM, UNABLE TO REMOVE MORE THAN 300CC DUE TO HYPOTENSION. A FEW DOSES OF ALBUMIN GIVEN DURING DIALYSIS FOR HYPOTENSION WITH FAIR EFFECT. HR AT TIMES TO 140'S, TEAM NOTIFIED DURING DIALYSIS WHEN PT WAS AND HAVING INCREASED ECTOPY. NO INTERVENTION PER TEAM, SCHEDULED DOSE OF LOPRESSOR EFFECTIVE AND CALCIUM REPLETED REDUCING AMOUNT OF ECTOPY. HEPARIN GTT STARTED THIS AM FOLLOWING . FIRST PTT 150+ DRAWN 5 HOURS AFTER START OF GTT. TEAM NOTIFIED. ORIGINALLY ORDERED TO STOP HEPARIN FOR ONE HOUR THEN RESTART AT HALF THE DOSE, HOWEVER REPEAT PTT REMAINING THE SAME AFTER AN HOUR WITH OBVIOUS SIGNS OF BLEEDING. HEPARIN TO REMAIN OFF AT THIS TIME PER DR. UNTIL FURTHER NOTICE. HCT PENDING.\nRESP- LUNGS CLEAR, SUCTIONED FOR SMALL AMOUNTS OF THICK YELLOW SPUTUM. O2 SAT 100%, NO VENT CHANGES.\nGI/GU- ABD SOFT, HYPO SOUNDS. BRB IN COLOSTOMY THIS AFTERNOON, DR. NOTIFIED AND HCT SENT. FLEETS PHOSPHO SODA HELD TODAY DUE TO LARGE AMOUNTS OF LOOSE STOOL. NO VOID, DIALYSIS DEPENDANT\nID- AFEBRILE. MEROPENUM GIVEN X 1 DOSE AFTER DIALYSIS\nSKIN- VASCULAR IN TO RIGHT TOES AND LOWER EXT. DECUBS. RIGHT GREAT TOES DEBRIDED AND AND POCKET OF INFECTION RELEASED DRAINING PURULENT DRAINAGE. WET TO DRY .\n"},{"category":"Nursing/other","chartdate":"2132-08-19 00:00:00.000","description":"Report","row_id":1524181,"text":"NEURO; OPENS EYES SPONT, DOES NOT FOLLOW COMMANDS, STARES AT SPEAKER BUT ? PT TRACKING SPEAKER, DOES NOT MOVE SPONTANEOUSLY\n\nCARDIOVASCULAR; HR 120'S-140'S A FIB, TEMP UP TO 103, PT MEDIC X 3 WITH TYLENOL, MICU TEAM INFORMED, BLOOD CULTURES PERIPHERALLY AND ONE SET FROM DIALYSIS LINE OBTAINED, COOLING BLANKET ON, TEMP PRESENTLY 102.2, SEVERAL PERIODS OF HYPOTENSION TODAY WHCH REQUIRED FLUID BOLUSES, PT RESPONDED TO FLUID BOLUSES BUT STILL FLUCTUATES, MICU TEAM OKAY WITH MAP OF 50 OR >,\n\nRESPIR; SUCTIONED FREQUENTLY FOR THICK YELLOW SECRETIONS, SPUTUM CULTURE SHOWS PSEUDOMONAS, STARTED ON ZOSYN, COARSE BREATH SOUNDS, REMAINS ON SAME VENT SETTINGS,\n\nENDONCRINE; BS 200'S, COVERED VIA SLIDING SCALE, PLAN WAS TO START INSULIN GTT BUT PT BS NOW 130'S, WILL GO BACK TO INSULIN COVERAGE VIA SLIDING SCALE AND GTT IS DC'D (TUBE FEEDING OFF FOR 2 HRS FOR ? REPLACEMENT OF J TUBE, BUT PLAN DEFERRED DUE TO PT BEING UNSTABLE\n\nWOUND; LARGE OPEN AREAS ON SACRUM, MUCOPURULENT MATERIAL INSIDE LARGER WOUND, MICU MD IN TO EVALUATE, REPACKED WITH AQUACELL ROPE, DSGS TO LEGS-NECROTIC AREA LEFT HEEL ADAPTIC AND DSD,\n\nRENAL; DIALYSIS ATTEMPTED BUT NO FLUID TAKEN OFF DUE TO HYPOTENSION, DIALYSIS STOPPED AFER APPROX 30 MINUTES, MICU TEAM AWARE\n\nPLAN; MAINTAIN MAP > 50 OR >, WOUND CARE, COOLING BLANKET UNTIL TEMP STABLIZES, CHECK BS Q 4 HRS, FAMILY UPDATED SEVERAL X WITH TEAM TODAY\n"},{"category":"Nursing/other","chartdate":"2132-08-20 00:00:00.000","description":"Report","row_id":1524182,"text":"Respiratory Care\nPt continues full vent support and appears comfortable. #8 adjustable trach remains locked at 10 cm. BS coarse and diminished bilaterally. Suctioning for moderate amounts of thick yellow sputum. Fever seems to have resolved with current temp 98.8F. MDIs given as ordered. See Careview for a.m. RSBI and specifics.\nPlan: Maintain support, suction prn\n"},{"category":"Nursing/other","chartdate":"2132-10-23 00:00:00.000","description":"Report","row_id":1524437,"text":"Update\nSee Carevue for specifics\n\nNeuro: Alert but unable to assess level of orientation. Nods appropriately to questions. Attempts to mouth words. Does not move any extremeties. PERRL. Was awake all night.\nCV: ST or ?SA most of shift 90s to 140s. MD aware. No tx at this time. 70s-110s. Pressors remain off. Last 3 hcts 28. Coratid US ordered.\nResp: LS coarse. Sats 98-100%. No vent changes. Sxn'd for tenacious tan sputum.\nID: Afebrile. Gram+ rods in blood. Vancomycin dose x 1 given.\nGI: TF off pending possible scope today. GI bleed study also scheduled for day shift a.m. Colostomy draining clear, golden liquid.\nSkin: Grossly impaired. See flowchart for details.\nPsychosocial: Son at in evening. Daughter called and was updated on by this RN.\n\nPlan: Monitor for further hemorrhaging. Keep family UTD on .\n"},{"category":"Nursing/other","chartdate":"2132-10-23 00:00:00.000","description":"Report","row_id":1524438,"text":"Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. No morning abg results at this time and no measured due to hemodynamic instability. SX'd for small to moderate amounts of thick, tan sputum.\n"},{"category":"Nursing/other","chartdate":"2132-10-23 00:00:00.000","description":"Report","row_id":1524439,"text":"FOCUSED NURSING NOTE\nPlease see carevue flowsheet for further details\n\nNEURO: PERRL, 4-5mm. Dozing intermittently. Will nod head \"yes\" to questions at times, useful for pain assessments. Obvious response to painful stimulus during skin care and dressings changes, general flitches in response to pain and non-sedated state noted during these procedures despite Demerol premedication.\n\nRESP: Trach, CMV ventilation. No changes made in therapy. SPO2 96-100%. Lungs coarse, diminished, exp wheeze LUL- suctioned frequently for thick/yellow sputum. Meropenem/Amikacin current therapy.\n\nHEMODYNAMICS: Labile changes in reported to MD- measures 40-50s for a few minutes without change in HR or LOC, will increase to 90-120s without intervention, confirmed by manual doppler method. HR controlled 90-102, rare PVCs. No sx acute GIB- HCT stable at 26.8, next level to be drawn at 8pm. Active bleeding from pressure ulcers coccyx and right ischial, slow vaginal bleed. DIC panel pending.\nDoppler pulses absent left PT and right DP, MD aware. Gross anasarca present, large amount weeping of multiple skin tears, blisters.\n\nID: Normothermic. Plan to d/c right CVL to culture tip. RUE PICC and left dialysis remain in place- Left dialysis catheter with erythema.\n\nGI/METABOLIC: NPO maintained, Jtube clamped. to gravity drainge with viscous light brown/tan drainage. Colostomy with total 50ml maroon/brown liquid. No GI studies completed thus far today. Glucoses stable on Glargine QD (140/133).\n\nCOMFORT/PSYCHOSOCIAL: Premedicated with Demerol for complete turns and skin care, pt remains awake after Demerol and flinches in pain. Per family, Demerol was administered frequently as premedication in dose of 50mg as well as Ativan 2-3x day. Family (Daughter , granddaughter) at visiting, asking general questions re: status of skin wounds and BP measurements. Family providing comfort care to pt, emotional support and education provided.\n\nPLAN; D/C right CVL, culture tip. Monitor for sx GIB, hemodynamic changes. HCT q8hr as ordered, next due at . as ordered, collect Vanco level. Aggressive skin care, comfort care. Consult with MICU team re: increase pain control. All contact from HCP to be forwarded to Dr only as physician team leader and director of ultimate plan of care. Emotional support and education to pt and family ongoing.\n\n"},{"category":"Nursing/other","chartdate":"2132-10-23 00:00:00.000","description":"Report","row_id":1524440,"text":"Respiratory Care: Pt remains on current vent settings, no changes made this shift.Receiving MDI's. Suctioning mod amt secretions.\n"},{"category":"Nursing/other","chartdate":"2132-10-24 00:00:00.000","description":"Report","row_id":1524441,"text":"Nursing Assessment 7p-7a:\nNursing Note :\n\nTmax 99.0 oral. Family meeting prior to shift and family in room afterwards upset regarding discussions in meeting. When family arrived back in room pt went into Afibb 130-150 and 50-60. MICU resident notified and 500cc ns given/ labs sent for HCT, vanco. BP came back up but remained in afibb and given ativan ivp. Pt converted back to nsr-st after most of family left for the night. Pt's dtr and son remained in room. requesting VBG again while hr elevated and it was drawn per micu team; resulting values ok per respiratory. Frequently asking for pt to be suctioned, concerned that pt not suctioned enough and was assurred that pt was just suctioned prior to her entering the room. Sats are 98-100%, good tidal volumes, and pt appears comfortable on vent. Suctioned occasionally for thick yellow sputum, which is not new. Wound care done per recommendations. PT's dtr also concerned about drg from around G/J Tube site which is pink tinged at times. Family was feeding ice chips with red beverage to patient and believe that the drg is from that and that the tube is the source of all her bleeding from the ostomy. These issues have been discussed with pt's dtr already in meetings and discussions with the micu mds. All discussions regarding pt to be done through the MICU attending only and dtr instructed to speak with them regarding any futher questions or concerns. Early this morning, pt in afibb again and given ativan with no effect. Pt wideeyed, shakey left hand, and nodded yes to pain. Given demerol with good effect, HR sinus 106. Lytes ok on am labs. Glucose wnl. Plan: continue towards discharge planning for home. Family's wishes are to get pt home and are unhappy with care here. Hospice care to be readdressed? Family is aware and still willing to take pt home despite her acute medical issues and risks for rebleeding, ventilator dependency, hypotension, afibb and tachycardia, and periods of hyperglycemia. Case management and social work are continuing to arrange for the home care of this patient. Pts dtr will take pt home but has requests; case management is working towards these as able and GI/Vascular have met with family to discuss risks and why some may not be met at this time d/t not in pt's best interest (changing G/J tube, toe amps). Please refer to GI and vascular notes in chart. Also please refer to carevue for all futher details in nursing assessments.\n"},{"category":"Nursing/other","chartdate":"2132-07-29 00:00:00.000","description":"Report","row_id":1524091,"text":"condition update\nd: pt arrived from er with ? of sepsis. hr afib in the 100-115. sbp 90-120/60. blood cultures sent from pic line. pt. given 1 liter ns fluid given after fluid sbp up to 120 and pt more awake. opening eyes spontaneously and looking around the room. spontaneously lifting left arm off the bed.\nresp: pt trached. on a/c 40% with rate of 16 pt is overbreathing the vent.\ngi: gt clamped.\ngu: pt on hd left subclavian quinton patent. pt due to have hd today.\nskin: see assessment for skin . coccyx wound is open with blackend center. per son it was improving but recently has started to look worse. pt was on kinair bed at home. bilateral calfs are open and through fascia. wound is pink. right hip is open and reddened base through the fascia. left hip is open tthrough the dermis. aqualcel dressing applied. left heal with black center and ns packing applied.\nrigth toes are dry and necrotic.\na: skin rn to come see pt today. ? kinair bed. check blood culture results. hd today. head ct today.\nr: pt more awake this am. sbp greater than 100.\n"},{"category":"Nursing/other","chartdate":"2132-07-29 00:00:00.000","description":"Report","row_id":1524092,"text":"Resp Care\nPt remains intubated on AC, no vent changes, stable shift. Pt went for ct without incident. Plan to continue with current tx, sx for mod yellow thick.\n"},{"category":"Nursing/other","chartdate":"2132-07-29 00:00:00.000","description":"Report","row_id":1524093,"text":"NPN (SEE CAREVUE FOR SPECIFICS)\n PT LETHARGIC THIS AM, NOT FOLLOWING COMMANDS. IMPROVED THROUGHOUT THE DAY, BECOMING MORE ALERT AND OCCASIOANLLY FOLLOWING COMMANDS. ATIVAN HELD THROUGHOUT THE DAY DUE TO LETHARGY AND HYPOTENSION. SPONTANEOUS MOVEMENT NOTED IN ALL EXT. EXCEPT FOR THE RIGHT UPPER. HEAD CT DONE THIS AM, RESULTS UNKNOWN. PERRL. NODDING HEAD APPROPRIATELY IN RESPONSE TO SIMPLE QUESTIONS. C/O PAIN IN COCCYX AREA, FREQUENTLY REPOSITIONED, NOW ON KINAIR BED.\nCV- HYPOTENSIVE THIS AFTERNOON IN LOW 80'S. DIALYSIS ON HOLD FOR NOW. NS BOLUSES GIVEN WITH GOOD EFFECT, PRBCS TO BE GIVEN, AWAITING CONSENT. REMAINS IN A-FIB, HR 110-120'S THIS AM, RESPONDED WELL TO LOPRESSOR 12.5MG HOWEVER, BP NOT TOLERATE FURTHER DOSES.\nRESP- LUNGS CLEAR, COARSE AT TIMES. SUCTIONED EVERY FEW HOURS FOR THICK YELLOW SPUTUM. 02 SAT 100% ON AC, NO VENT CHANGES MADE THROUGHOUT THE DAY.\nGI/GU- ABD SOFT, DISTENDED. COLOSTOMY DRAINAGE GREENISH BROWN, LOOSE STOOL. PT RECEIVING LACTULOSE AND FLEETS PHOSPHOSODA, SPOKE TO INTERN REGARDING OUTPUT OF ABOUT 800CC, WILL CONTINUE FOR NOW. HYPOACTIVE BS, REMAINS NPO. PT DOES NOT VOID, WILL BE DIALYSED TONIGHT IF BP INCREASES.\n PT HAS SEVERAL LARGE DECUBS, ALL DRESSINGS CHANGED. SPOKE WITH WOUND CARE RN, HOWEVER SHE COULD NOT SEE PT TODAY, WILL FOLLOW UP TOMORROW. COCCYX DECUB IS TO BONE, 7CM X 7CM, PELVIC CT DONE THIS AM, RESULTS PENDING. PLACED ON KINAIR BED.\nID- AFEBRILE\n"},{"category":"Nursing/other","chartdate":"2132-08-18 00:00:00.000","description":"Report","row_id":1524173,"text":"RESPIRATORY CARE NOTE\n\nPatient remains trached with 8.0 air cuff adjustable length locked at 10mm. No vent changes made during the . RSBI completed on PS 5=96. Sxn for small thick yellow secretions.\n\n , RRT\n"},{"category":"Nursing/other","chartdate":"2132-08-18 00:00:00.000","description":"Report","row_id":1524174,"text":"Respiratory Therapy\n\nPt remains trached w/ TTS on full mechanical support. No vent changes made this shift. Currently on A/C ventilation w/ PIP/Pplat = 23/20. SpO2 90s-100%. BS slightly coarse bilaterally, suctioned for small amounts of thick whitish sputum. Cuff pressure = 25cmH2O. MDIs given as ordered. See resp flowsheet for specifics.\n\nPlan: maintain support\n"},{"category":"Nursing/other","chartdate":"2132-08-18 00:00:00.000","description":"Report","row_id":1524175,"text":"SICU NURSING PROGRESS NOTE 0700-1900\nNEURO--ASLEEP MOST OF SHIFT. AT TIMES WILL NOD HEAD TO SIMPLE QUESTIONS REGARDING COMFORT, PAIN,HOT/COLD. DOES NOT FOLLOW COMMANDS. NO SPONTANEOUS MOVEMENT OBSERVED. EYES OPEN SPONT. NO ATIVAN GIVEN TODAY AS PT IS .\n\nRESP--NO VENT CHANGES DONE. SAO2 >96%. SX Q2HRS FOR SMALL AMTS OF YELLOW/WHITE SPUTUM . LUNGS COARSE IN ALL FIELDS. PLAN IS FOR IP TO BRONCH PT TO SEE WHERE END OF TRACH TUBE IS PLACED. THEN TO REPLACE OLD TRACH WITH NEW PORTEX TRACH WHERE PT CAN BE VENTED AND SPEAK. IP WAS BY BUT PROCEDURE NOT DONE AS OF THIS TIME.\n\nGI--TOL TUBE FEEDS AT F/S. OSTOMY DRAINING GOLDEN LOOSE STOOL.\n\nGU--ANURIC. NO HD TODAY. NO STR. CATH.\n\nCARDIAC--MAP>55. HR A FIB WITH NO OBSERVED VEA. MIDODRINE GIVEN AS ORDERED. PICC DRESSING/CAP CHANGED.\n\nPAIN--GRIMACES AND NODDING HEAD WHEN SACRAL DECUB DRESSING CHANGED. MEDICATED WITH 1MG IV DILAUDID WITH GOOD RELIEF. NODDED HEAD YES WHEN ASKED IF IN PAIN AT 1630. WHEN ASKED IF FEET HURT SHE RESPONDED YES. .5 DILAUDID GIVEN AGAIN.\n\nID--FEBRILE TO 101.5. 650 MG PO TYLENOL GIVEN WITH DECREASE IN TEMP TO 99.6. REMAINS ON LEVO.\n\nSKIN--ALL WOUNDS DRESSED BY WOUND/SKIN CARE RN. NO FOUL ODOR FROM ANY WOUND. SACRAL WOUND IS THE SIZE OF A SOFTBALL AND ~1.5INCHES DEEP. WOUND CARE/DRESSING CHANGE INSTRUCTIONS ARE IN CHART AND ON PT'S WALL IN ROOM. R ISCHEIAL TUBEROSITY IS DRAINING SMALL AMTS OF SERO-SANGINOUS DRAINAGE. SMALL AMT OF ESCHAR ON WOUND. R CALF WOUND IS CLEAN WITH GOOD GRANULATION TISSUE FORMING. L TOES 4 ARE NECROTIC WITH OPEN SORE ON JOINT CAPSULE OF GREAT TOE. R FINGERS ARE EDEMATOUS AND SMALL BLISTERS ARE FORMING ON 4 FINGERS. RUE IS >L. ORAL MEMBRANE DRY. ORAL CARE GIVEN. BACK IS CLEAN DRY AND INTACT.\n\nCOPING--DAUGHTER , , AND HUSBAND IN TO VISIT. ASKING REPETATIVE QUESTIONS REGARDING PLAN FOR TRACH. QUESTIONS HAVE BEEN ANSWERED. THE FAMILY IS REQUESTING THAT ID BE CONSULTED, PT'S TRACH IS CHANGED, WHERE FEVER IS COMING FROM. HCP, HAS PHONED AND HAS BEEN UPDATED.\n\nA--FEBRILE. REMAINS IN A-FIB. TOL. TUBE FEEDS. PLAN FOR BRONCH. PAIN WITH DRESSING CHANGES.\n\nP--GIVEN TYLENOL AS NEEDED. PLAN FOR BRONCH AND ? TRACH TUBE REPLACEMENT. IR TO COME BY AND ASSESS PEG SITE. OFFER SUPPORT TO PT AND FAMILY.\n"},{"category":"Nursing/other","chartdate":"2132-08-18 00:00:00.000","description":"Report","row_id":1524176,"text":"SICU NURSING PROGRESS NOTE 0700-1900\nBLOOD CX X2 OBTAINED, 1 FROM DIALYSIS CATH AND 1 PERIPHERALLENDO--BLOOD SUGARS REMAIN >290. PLS CHECK BS Q4HRS AND PROVIDE HUMALOG IF NEEDED. NO LABS DRAWN TODAY.Y. NO URINE OBTAINED AS PT IS ANURIC AND HAS NO CATHETER.\n\nHCP PHONED AND WAS VERY UPSET ABOUT PT GETTING DILAUDID FOR PAIN. SHE IS INSISTENT ABOUT HER MOTHER \"ONLY GETTING DEMEROL, NOTHING ELSE FOR PAIN.\"\n"},{"category":"Nursing/other","chartdate":"2132-08-18 00:00:00.000","description":"Report","row_id":1524177,"text":"SICU NURSING PROGRESS NOTE 0700-1900\nBLOOD CX X2 OBTAINED, 1 FROM DIALYSIS CATH AND 1 PERIPHERALLENDO--BLOOD SUGARS REMAIN >290. PLS CHECK BS Q4HRS AND PROVIDE HUMALOG IF NEEDED. NO LABS DRAWN TODAY.Y. NO URINE OBTAINED AS PT IS ANURIC AND HAS NO CATHETER.\n\nHCP PHONED AND WAS VERY UPSET ABOUT PT GETTING DILAUDID FOR PAIN. SHE IS INSISTENT ABOUT HER MOTHER \"ONLY GETTING DEMEROL, NOTHING ELSE FOR PAIN.\"\n"},{"category":"Nursing/other","chartdate":"2132-08-19 00:00:00.000","description":"Report","row_id":1524178,"text":"NURSING\n VSS, TMAX 99 OVERNIGHT. CONTINUES IN A-FIB, ON COUMADIN. TUBE FEEDS CONTINUE AT 40/HR. ANURIC. ALL DRESSINGS CHANGED BY SKINCARE NURSES TODAY. ONLY VENT CHANGE WAS TO DECREASE FIO2 FROM 50 TO 40. SEE VUE FOR FULL ASSESSMENT.\n TODAY ID CONSULT, BRONCH BY INTERVENTIOAL PULMONOLOGY, IR TO COME BY TO ASSESS PEJ TUBE TOMORROW. CULTURE SACRAL DECUB WITH NEXT DRESSING CHANGE.\n"},{"category":"Nursing/other","chartdate":"2132-08-19 00:00:00.000","description":"Report","row_id":1524179,"text":"Respiratory Care\nPt remains intubated on full vent support. #8 trach with adjustable flange is set at 10cm. No vent changes made this shift. BS coarse bilaterally and diminished at bases. Sxn'd for small amount of thick yellow secretions. MDIs given as ordered. See Careview for a.m. RSBI results.\nPlan: Maintain ventilator suppport\n"},{"category":"Nursing/other","chartdate":"2132-08-19 00:00:00.000","description":"Report","row_id":1524180,"text":"Respiratory Therapy\n\nPt remains trached w/ #8.0 TTS adjustable trach set @ 10cm. Became more dis-coordinate w/ the ventilator this shift w/ RR ^high 30s, PIPs ^40s, tachycardic w/ HR 140s, hypotensive requiring fluid . Also had a noticeable increase in secretions...suctioning copious amounts of thick yellowish green sputum. SpO2 90s-100% and ABG acceptable. MICU team aware, sputum spec sent for culture. Pt febrile to 102.7. No vent changes made this shift. ABG drawn from R radial artery w/ no complications. See resp flowsheet for specifics.\n\nPlan: maintain support; aggressive pulmonary toilet...\n"},{"category":"Nursing/other","chartdate":"2132-09-10 00:00:00.000","description":"Report","row_id":1524267,"text":"See data, MD notes/orders. Neuro: Opening eyes spontaneously and intermitently nodding head to questions at begining of shift, more lethargic and less reponsive in pm. CV: Afib with occ pvc's, rapid bursts to 130 during dialysis that are self limiting. Continues on phenylephrine gtt to maintain blood pressure, currently 94/45 with gtt rate at 1.2mcg/kg/min. Hypotensive to 69/30's during HD - see notes. Pulm: Trached, dependent on ventilator support, minimal secretions suctioned, lungs clear, decreased at bases. GU: Anuric, HD for 1.5hrs with 1Liter fluid removal. GI: Abd obese, bs present, colostomy patent with output per flow sheet. Gtube to gravity with return of 100cc fluid. TF at goal rate 40cc/hr. Endo: by NP from clinic with ssc adjusted and HS insulin dc'd. Skin: Afebrile see wound care nurses notes for description of decubitus ulcers present at coccyx, bilateral trochanters and right ishcium as well as left heel and bilateral calfs. Mutiple areas of echcymosis, excoration and skin tears along thighs, under on right upper chest. General 3+ pitting edema noted. F/E: Grossly + fluid balance, lactate this am 10.4,LFT's elevated, hct 24.9. Soc: Husband and one son in this morning, daughter phoned in this pm and updated on pt condition. P: Monitor LOC, reorient prn, ativan as ordered, hold for sedation. Titrate neo gtt as above to keep map >50, notify team of refractory hypotension/tachycardia. Follow abg's, respitory effort, 02 sats. ?HD for further fluid removal tomorrow. To utilize pedi tubes for blood draws as able, note daily hct, observe for bleeding. Npo after mn for am RUQ ultrasound, q6hr finger stick with new coverage as ordered. Meticulous skin care, air matress and turn q1-2hrs, dressings per wound care nurse . Keep family up to date on , offer support, facilitate communications with MICU team as needed.\n"},{"category":"Nursing/other","chartdate":"2132-08-20 00:00:00.000","description":"Report","row_id":1524183,"text":"NURSING\n VSS, TEMPERATURE SLOWLY DECREASED TO NORMAL. COOLING BLANKET OFF.\nTUBE FEEDS CONTINUE AT 40/HR. STARTED ON VANCOMYCIN AND ZOSYN YESTERDAY FOR FEVERS. ALL CULTURES STILL PENDING. NO ISSUES OVERNIGHT, SEE CARE VUE FOR FULL SPECIFICS.\n NO VENT CHANGES OVERNIGHT. LARGE AMOUNTS OF SPUTUM, THICK, GREEN.\n DAUGHTER IN LAST EVENING. MULTIPLE QUESTIONS ASKED AND ANSWERED REGARDING ANTIBIOTICS, LABS, WHEN BRONCH WOULD TAKE PLACE, WHEN J TUBE WOULD BE CHANGED.\n CONTINUE TO MONITER HEMODYNAMICS, FEVERS. FOLLOW LABS. CULTURES PENDING. BRONCH WHEN STABLE. J TUBE CHANGE WHEN STABLE.\n"},{"category":"Nursing/other","chartdate":"2132-09-12 00:00:00.000","description":"Report","row_id":1524273,"text":"nursing note\nNeuro:pt remains minimally responsive, nods approp at times but inconsistently. hypethermic and bairhugger on.\nCV: afib, rate to 140-150's at times, resting in 130's most of night. MD aware and no interventions made since not more hypotensive with increased rate. Rate seems unrelated to pitressin increase earlier in evening or neo titration. MD aware of plt 39 on pre labs, coags sent and PTT >150 with INR 2.7. HCT sent at this time stable and plt up to 49. No bleeding noted. Later in , bleeding from ostomy site noted, 2u given. labs repeated. neo titrated to keep sys 80's, pitressin increase to 2.4 MD . Immediately on initiation of , down to 60's, neo titrated up and MD aware. Decision made at this time to increase pit.\nRESP:no vent changes, minimal secretions.\nGI:tol tube feeds at goal. GT/JT ostomy site changed per daughter request. small at 4 o'clock, covered wtih duoderm on ostomy appliance. Ostomy bleeding as above, bleeding noted from ostomy site itself, not bloody stool.\nGU:anuric. to take on fluid as tolerated.\nSKIN: no dressing changes this shift, all done on day shift. Multiple raw areas under L breast, in groin area, nystatin applied.\nSOCIAL: daughter -HCP in to visit last night and spoke with MD regarding many issues: i.e:no dilaudid use, , liver failure, hypotension, dialysis. Daughter would possibly want patient transferred to if we are unable to get fluid off during .\n\nPLAN:follow sepsis picture including possible DIC. monitor for bleeding and treat labs PRN. a/o as awaiting sensitivities. supportive family care.\n"},{"category":"Nursing/other","chartdate":"2132-09-12 00:00:00.000","description":"Report","row_id":1524274,"text":"RESP CARE - Pt remains intubated w/#7 XL trach on a/c 450/16/5 40%. No changes were made this shift. ABG is within normal range. BS coarse in upper lobes, which cleared on sx of small to moderate amounts of thick yellow secretions. BS were dim in bases. Flovent given as ordered, Atrovent given Q6, Albuterol given at 0800, but not at 1400, due to HR>120. Email sent to Pulm for ordering info for IC. Continued resp care planned.\n"},{"category":"Nursing/other","chartdate":"2132-09-12 00:00:00.000","description":"Report","row_id":1524275,"text":"nuero: pt at times opens her eyes when you call her name. pupils equal and reactive to light. pt does not follow commands. pt does move left hand on bed. no spontanous movement noted from right arm and right leg and right arm. ativan held at 0800 and 1400.\n\npain: no pain noted.\n\npulm: pt remains on ac, please see flow sheet for vent settings. lungs diminished at bases. most recent abg 7.37/35/118/21, dr. aware. suctioning pt for thick yellow sputum.\n\ncards: pt remain in afib hr 120-130's. iv phenylephrine weaned to off. pt continues on pitressin at 2.4u/hr. pt continues on , initally this morning taken off no fluid, but gradually increased pfr to 100cc/hr per dr. , pt becoming increasing tachycaric up to 138-140's, dr. called and aware. patient fluid removal decreased back to 50cc/hr.\n\ngi: pt continue on tube feeding at goal via j-tube. this morning colostomy emptied for 300cc of bloody drainage, mixed with a small amt of stool, dr. into assess colostomy output. no further bloody drainage noted from colostomy site, pt has had golden brown stool, which is guaic postive.\n\nheme. repeat hct 26.5, plt 29, dr. aware, no treatment ordered.\n\ngu: pt continues on .\n\nf/e: blood sugar 253 insulin gtt started, insulin gtt presently at 4u/hr. k 3.4 kcl gtt adjusted per k sliding scale, ionized calicm 1.20 calicum gtt adjusted per sliding scale\n\nid: pt started on meropenum. tobramycin trough to be checked.\n\nsocial: pt husband into visit this morning. update daughter x2 on pt condition.\n\nplan: continue to monitor, monitor for any sign of bleeding. check labs as ordered. adjust k and calicum gtt per sliding scale. monitor .\n\n"},{"category":"Nursing/other","chartdate":"2132-09-12 00:00:00.000","description":"Report","row_id":1524276,"text":"pt with an eposide of hr up to 150-160 and up to 160's (please see flow sheet), vasopressin initally shut off, dr. called and into assess patient, resp. therapy called and into assess patient. abg done which was similar to earlier abg, pt recieved 2.5mg of iv lopressor, dropped down to 90, vasopressin restarted back at 2.4u/hr. dr. aware. hr down to 120-130 after lopressor\n"},{"category":"Nursing/other","chartdate":"2132-08-03 00:00:00.000","description":"Report","row_id":1524112,"text":"Neuro:Pt sleeping most of night. Appears comfortable. Pupils 3mm brisk. Making no effort to communicate.\nCV: afebrile, HR 90-110's Afib with no noted ectopy. SBP90-120's. extremities cool with poor pulses. Heparin gtt titrated, R great toe continues to bleed. L buttocks slight bleeding,\nRESP: lungs clear through-out, No vent changes over night.\nGI: tol tube feed. draining brown stool via ostomy.\nGU: aneuric.\nENDO: Remains on insulin gtt blood sugars stable over night\nPLAN: awaiting MRI results.\n"},{"category":"Nursing/other","chartdate":"2132-08-05 00:00:00.000","description":"Report","row_id":1524119,"text":"Resp. Care:\n Pt. remains trach'd and on vent.support. BS-occas. coarse. sx- sm amounts thick yellow secretions. MDI's given as ordered. Cuff press. @ 25cm to seal. Occas. positional leak, but without volume loss. 40 second RSBI test with low volumes and rr ^^ 40's. Cont. present vent. management/MDI's.\n"},{"category":"Nursing/other","chartdate":"2132-08-05 00:00:00.000","description":"Report","row_id":1524120,"text":"Nursing note:\nNEURO: Alert, does not follow commands or communicate. Moving L. side on bed minimally. PERRLA. Appears comforable.\nRESP: Lung sounds clear, no vent changes. Suctioned for minimal amounts clear secretions.\nCV: Afebrile. Afib w/occ PVCs. MAP >60, SBP dipping when pt. sleeping though MAP remains 60-65. Pt. off Heparin gtt, therapeutic on Coumadin.\nGI: Abdomen soft, +Hypo BS. New J-tube intact, used for meds only overnight. To begin TFs in am. IVF running overnight until given TFs. Colostomy patent small amount brown semi-formed stool.\nGU: Anuric, HD pt.\nSKIN: Mult. skin and wound issues, all dressings (except R. great toe) changed per skin care RN's recs. See Carevue for details.\nENDO: Glucose levels labile, 1.5 amps D50 given for low blood glucoses in 30-70s, currently stable in high 70s. MICU team aware.\nSOCIAL: Family visiting during evening, updated.\n\nA/P: Stable with mult. wound issues. Continue skin and wound care, restart TFs, follow glucose levels, continue current plan of care.\n"},{"category":"Nursing/other","chartdate":"2132-08-05 00:00:00.000","description":"Report","row_id":1524121,"text":"Focus Condition Update\nSee flowsheet for specific info.\n\nNeuro: Pt opens eyes to voice, tracks, follows some commands, and MAE's with the exception of her RUE, on the bed. PERRL.\nCV: Pt dialyzed today, 1700cc of fluid removed. Hypotensive at times today, albumin given during HD to keep MAP >60. Chronic a-fib with the occassional PVC.\nResp: Pt trached, CMV, 40%O2, PEEP 5, sating 98-100%. No vent changes made, no blood gas sent. LCTA, dim in bases, minimal suctioning.\nGI: TF's restarted, FS at 40cc/hr. J-tube patent, site is clean dry, and covered with DSD. Abd soft, BS+, colostomy draining loose green stool.\nEndo: Blood sugar stable this shift 85-126, awaiting consult from .\nPlan: Continue to monitor BP\n Continue with current POC\n Discharge to home\n"},{"category":"Nursing/other","chartdate":"2132-08-05 00:00:00.000","description":"Report","row_id":1524122,"text":"Resp Care\n\nPt remains trached with #6 shiley with positional leak noted. Cuff pressure pressured at 24cmh20. Pt currently vented on a/c with no changes made this shift to parameter settings. BS clear to course sxing for small to mod amts of thick white to yellow secretions. Trach patent/secured with adequate humidification noted. Will cont with vent support as needed.\n"},{"category":"Nursing/other","chartdate":"2132-08-06 00:00:00.000","description":"Report","row_id":1524123,"text":"Nursing note:\n Afebrile. SBP in 80s-90s, MAP 60-65. Remains on A/C, no ABGs done. Sats 100% and pt. appearing comfortable and compliant w/vent. Tolerating TFs w/minimal residuals. +BS, hypo. Colostomy intact w/green liquid stool. Glucose level normalizing, SSRI PRN. Anuric. Coccyx dressing changed x1 along with L. trochanter site according to skin care RN's recs. See Carevue for details. All other dressings intact. Family visiting.\nA/P: Stable overnight. Continue wound care, cont. current plan of care and ready for d/c to rehab.\n"},{"category":"Nursing/other","chartdate":"2132-08-17 00:00:00.000","description":"Report","row_id":1524169,"text":"Resp care note\n\nNo ABG this shift but RSBI was done which shows much better result today, ~ 85. Pt presently remains on AC 16 x 450 but RSBI suggests that may be able to change to more spont mode. Pt has consistently had small to mod amts of thk tan secretions and one time what appeared to be bloody clots. Humidifyer system is functioning well, Spo2 is high and PiPs have been in low 20's. Adjustable T-tube monitored and adjusted x 2 to maintain @ 10 cm marker. Family member expressed concern that catheter is not getting down far enough but total length of Trach tube is 15 cm while in-line sx catrheter hax length of 30 cm. Continued use of longer catheter is not advisable as repeated usge could cause some trauma in smaller airways beyond trachea. Also recomment attempting cautious wean.\n"},{"category":"Nursing/other","chartdate":"2132-08-17 00:00:00.000","description":"Report","row_id":1524170,"text":"Resp Care: Pt remains intubated via #8 air filled cuff trach tube. Positional cuff leak. Team aware. BS coarse bilat I+E wheezes. MDI's given w/ gd effect. SX'd for small amts thick yellow sputum. No vent changes made this shift. No recent ABG. Most recent cxray from reveals \"^'d effusions, suggestive of failure rather than infection\". Plan: cont vent support. Please see carevue for further vent inquiries.\n"},{"category":"Nursing/other","chartdate":"2132-08-17 00:00:00.000","description":"Report","row_id":1524171,"text":"nursing note\nNeuro: opens eyes spont, not following commands. Per family- open eys are anxiety and pt medicated with ativan a/o. no spont movement.\nCV:SR, no ectopy. SBP >90 sys on midodrine. Lytes repleted per micu. Micu resident questioned regarding lytes with renal status and this RN instructed to give. Later in day-lytes and MD aware that lytes had already been given. Remaining Kphos discotinued.\nRESP:LS coarse,thick yellow secretions.\nGI:Tol JT feeds at goal.Colostomy with golden liquid brown.\nGU:anuric.\nSKIN:per skin care recs.\nSocial:son in to visit-asking approp questions. Husband in this AM.\n\nPLAN:await IR consult at bedside in AM re:JT site and leakage. Await decision re:pulm re trach and home status with . HD tues. Home planning.\n"},{"category":"Nursing/other","chartdate":"2132-08-18 00:00:00.000","description":"Report","row_id":1524172,"text":"condition update\nplease see carevue for specifics.\n\nNeuro unchanged. pt still not moving or following commands. Pt's daughter felt she was less responsive than usual however. MICU team up to go over and explain that the only changes to her meds was the increase in the glargine dose. All doses of ativan held during the . Tmax 101. AFIB. HR 90's-130. SBP 80's-120. Pm lopressor dose held. No vent changes made. Pt continues on AC/ 50%/5 peep. LS are coarse. Pt sxn'd several times for small amts of thick yellow secretions. TF infusing at goal via J tube. J tube drainage at start of shift was bilious and by 0400am yellow pus like. Colostomy w/ golden loose, guiac negative stool. Coccyx dressing changed as per wound care orders.\n\nPlan: continue with current plan of care per micu team. IR to j tube for continued leakage. Md. to perform test w/ resp tx at bedside on pt's home vent and new boniva trach. continue wound care.\n"},{"category":"Nursing/other","chartdate":"2132-09-10 00:00:00.000","description":"Report","row_id":1524268,"text":"Resp Care\n\nPt remains trached with #7XL Shiley and currently vented on a/c with no changes made to parameter settings. Inner cannula changed this shift and is clean/patent. BS essentially clear anteriorly sxing for minimal secretions. MDIS given x3 this shift with improved aeration noted. Will cont with vent support as needed.\n"},{"category":"Nursing/other","chartdate":"2132-09-11 00:00:00.000","description":"Report","row_id":1524269,"text":"RESPIRATORY CARE\nPT REMAINS ON A/C WITH NO CHANGES MADE THIS SHIFT.SUCTIONED FOR SAMLL AMT OF YELLOW THK SECRETIONS.BS CLEAR B/L.MDI'S GIVEN AS ORDERED.PLAN TO CONT. VENT SUPPORT.\n"},{"category":"Nursing/other","chartdate":"2132-09-11 00:00:00.000","description":"Report","row_id":1524270,"text":"FOCUSED NURSING NOTE\nPlease see carevue flowsheet for further details\n\nNEURO: Pt more alert at times alternating with lethargy- nodding head \"yes\" and \"no\" inconsistently. PERRL, 5-6mm. Demerol given x 1 for rigors/tachypnea with temp spike- therapeutic.\n\nRESP: Trach patent, collar changed and care done. Ventilated via CMV per pre-admission settings- no vent changes this shift. Tachypneic during fever, otherwise RR 19-22, SPO2 100%. CXR done. ABGs show metabolic acidosis, compensated Ph 7.36. Secretions thick/yellow, occassional suctioning required.\n\nHEMODYNAMICS: s/p HD, Septic shock supported by pressors needing increase titrations o/n. Neo gtt at 4.0mcg/kg/min to maintain >80- now 90, titrating Neo down as able. Sharp increase in Afib rate just before midnight correlating with temp spike to 100.5 max. Afib 130s-140s with occassional bursts 150s- PVCs infrequent. Anasarca worsening, especially abdominal. CVP 10-12 recently. Hct decreasing, 22.4 as well as plt ct 51K- confirmed by repeat analysis. Dark, red blood slow ooze from vagina, loose stool by colostomy guiac pos.\n\nGI/METABOLIC: Sclera jaundiced- TF suspended at 2400 for Abd US this am. Colostomy loose/liquid stool, sample sent for . Rectal drainage small amounts, tan mucosal to serosanguinous. Glucoses 192/126 on RISS. D5W line changed to NS. Metwabolic acidosis unchanged, Bicitra as ordered.\n\nID: Tmax 100.5 with rigors and tachycardia/tachypnea/BP increase- pressors off for short while. BC (2) pending, BC x 1 sent this am. CBC showing pancytopenia.\nSKIN INTEGRITY: All dressings intact, change daily. Right hip Allevyne drsg , pressure with pink/granulating wound bed, clean- 10% scattered yellow base. New skin tear adjacent to Dialysis catheter continues to bleed despite adaptic tx- covered with aquacel and light gauze pressure drsg- cont to monitor.\n\nPSYCHOSOCIAL: Son at bedside most of evening- sharing stories and pictures of Mrs over last 2 years- his goal is for her to make it home- supportive and appears to be coping appropriately. No additional family contact this shift.\n\nPLAN: Monitor hemodynamics on pressors. goal > 80. Consult with MICU team re: tachycardia ?fluid vs blood transfusion. HD/ plan per MICU/Renal team. Monitor for bleeding, new signs of infection. . Pulmonary hygiene, aggressive skin care as documented. Emotional support and education to pt/family ongoing.\n"},{"category":"Nursing/other","chartdate":"2132-09-11 00:00:00.000","description":"Report","row_id":1524271,"text":"Update\nSee Carevue for specifics\n\nNeuro: Mostly alert but unable to assess level of orientation. Will nod appropriately to some questions but does not follow commands. Withdraws to pain. PERRL.\nCV: Afib 110s-130s with rare PVCs. Neo gtt being weaned down as tolerated for >90 and MAP >50. Vasopressin gtt started at 1.2 u/hr. 1 unit prbc for falling hct. HIT panel sent. Anticoag. products d/c'd.\nResp: LS clear/coarse. No vent changes.\nGI: Abd U/S done r/t elevated bili. TF restarted at goal. Loose golden stool from colostomy. PEG/ site intact but draining.\nGU: CVVH to start this p.m.\nID: Afebrile. Blood positive for gram neg rods.\nSkin: Skin grossly impaired. See carevue for specifics on wounds & treatments.\nSocial: Husband visited in a.m. Daughter called and recieved update from RN & MD .\n\nPlan: Monitor hemodynamic status & wean neo as tolerated. Do not use heparin products. Start CVVH this p.m. Continue with agressive turning and skin care regimen. Keep family up to date on .\n\n\n"},{"category":"Nursing/other","chartdate":"2132-09-11 00:00:00.000","description":"Report","row_id":1524272,"text":"Resp CAre\n\nPt remains trached on a/c with no changes made to parameter settings. BS clear to course sxing for small amts of thick yellow secretions. Inner cannula changed this shift. Will cont with vent support as needed.\n"},{"category":"Nursing/other","chartdate":"2132-09-26 00:00:00.000","description":"Report","row_id":1524332,"text":"nuero: at times pt open her eyes when you call her name. at other times will open her eyes to painful stimuli. pt does not follow commands. pt her head no at times. spontanous movement noted from left hand, no further spontanous movement noted. pt does withdraw all four extremties to painful stimuli.\n\npulm: pt remain trached and vented. please see flow sheet for vent settings. lung diminished at bases. suctioning pt for scant amt of yellow sputum.\n\ncards: pt remains in afib. iv neo weaned down to 1.05 mcg/kg/min. vasopressin remains at 2.4u/hr. keep map greater than 55 and greater than 90.\n\ngi: abd soft, but distended. colostomy only put out 10cc of stool. increased drainage noted from g-tube dr. aware. tube feedings remain at goal. 50cc of bloody drainage noted around g-tube site, dr aware and into assess site.\ngu: remains off.\n\niv access: pt went to ir today. pt had two double lumen picc line placed in ir.\nskin: wound dsg changed as ordered.\n\nheme: inr 1.9 pt recieved 2 , plt 52 pt recieved one bag of plts.\n\nf/e: insulin gtt presently at 7u/hr. last blood sugar 269.\n\nsocial: pt husband and son into visit this morning. spoke with pt daughter after picc line placed.\n\nplan: continue to monitor, to d/c central line once plt infused and sent central line tip for culture. recheck plt count when plts finished. continue to monitor.\n"},{"category":"Nursing/other","chartdate":"2132-09-27 00:00:00.000","description":"Report","row_id":1524333,"text":"condition update\nd: pt opens eyes and intermittantly nods to questions. pupils are equal and reactive to light.\nCardiac: pt in afib rate controlled in the 90's. greater than 100 and map 68-71. neo weaned to 1.02 and pitressin weaned to .08units/hr pitressin weaned first per Dr. . pt with generalized edema.\nresp: pt remains on cmv with rate on 16. abg good see flowsheet. lactate down to 6 last night. pt suctioned for thick yellow sputum. no vent changes. pt appears comfortable on current settings.\ngi: tube feeds continue to infuse. abd distented and obese. evaluated by dr. and abd kub done and lactate checked and down to 6. pt difficult to assess for pain.\ngu: pt makes no urine. skin: dressings are dry and intact. pt remains on air bed and turned frequently.\ntubes: right groin central line dc'd and tip culture. site checked frequently and no bleeding or hematoma present.\na: continue with frequent turning. wean neo as tolerated.\nr: tolerating slow pitressin wean. dr. spoke with daughter \n and daughter given update.\n"},{"category":"Nursing/other","chartdate":"2132-10-15 00:00:00.000","description":"Report","row_id":1524410,"text":"STATUS\nD: APPEARS MORE AWAKE WILL FOLLOW SOME SIMPLE COMMANDS(OPEN YOUR MOUTH ETC)\nA: HD DONE REMOVED 1800CC WITH MIN DROP IN BP..GOLYTELY GIVEN AS PREP FOR COLONOSTOMY..PT BLEEDING FROM COLONOSTOMY HO AWARE WILL CONTINUE WITH BOWEL PREP & GIVE 2U PC'S(#1 IN AWAITING #2)COLONOSTOMY DONE NO SIGNS OF FURTHER BLEEDING..STOMA BAG CHANGED..ALL DSG'S CHANGED\nR: LABILE BP\nP: AWAITING PC #2..WILL CHECK HCT AFTER TRANSFUSION..MONITOR FOR ANY FURTHER BLEEDING\n"},{"category":"Nursing/other","chartdate":"2132-10-16 00:00:00.000","description":"Report","row_id":1524411,"text":"Resp Care,\nPt. remains on A/C , No vent changes this shift. MDI's as ordered, suctioned for thick tan sputum. ? transition to home vent soon. See carevue.\n"},{"category":"Nursing/other","chartdate":"2132-08-03 00:00:00.000","description":"Report","row_id":1524113,"text":"NPN (SEE CAREVUE FOR SPECIFICS)\n PT MORE ALERT TODAY, NODDING AND OCCASIONALLY MOUTHING WORDS. MOVEMENT NOTED FROM ALL EXT. EXCEPT RIGHT ARM. PERRL. PAIN MED GIVEN FOR DRESSING CHANGE ONLY WITH GOOD EFFECT.\n PT REMAINS HYPOTENSIVE IN HIGH 80'S-100 SYSTOLIC, HOWEVER PT NOT NEEDING ANY FLUID BOLUSES. HR 80'S-90'S, A-FIB WITH OCCASIONAL ECTOPY. PTT 40 THIS AM, GTT INCREASED TO 600U/HR AND NEXT PTT TO BE DRAWN AT 1700.\nRESP- LUNGS CLEAR, SUCTIONED A FEW TIMES FOR SMALL AMOUNT OF THICK YELLOW SPUTUM. NO VENT CHANGES MADE.\nGI/GU- ABD SOFT AND DISTENDED. G-TUBE CONTINUES TO LEAK AROUND SITE AND DRAINING INTO OSTOMY BAG. PT WILL GO TO IR TOMORROW TO CHANGE G-TUBE TO LARGER. COLOSTOMY INTACT, STOMA BEEFY RED AND DRAINING LOOSE BROWN STOOL. PT DOES NOT VOID, NO DIALYSIS TODAY.\nSKIN- COCCYX WOUND DRESSING CHANGED TODAY. PACKED WITH AQUACEL AND COVERED WITH DSD. AREA APPEARS TO BE IMPROVED, PERIPHERY EXCORIATED AND COVERED WITH BARRIER CREAM. DECUB GREYISH, OOZING BRB INSIDE. NEED TO BE REEVALUATED ON MONDAY.\nID- AFEBRILE. MEROPENUM TO CONTINUE, VANCO LEVEL PENDING.\n"},{"category":"Nursing/other","chartdate":"2132-08-03 00:00:00.000","description":"Report","row_id":1524114,"text":"Resp Care\npt remains trached and stable on A/C no vent changes made. BS course suctioned for sm amt of thick white-yellow secretions, MDIs given as ordered. will continue to follow.\n"},{"category":"Nursing/other","chartdate":"2132-08-04 00:00:00.000","description":"Report","row_id":1524115,"text":"Resp Care\nPt remains on CMV, no vent changes, stable shift. Plan to continue with current tx.\n"},{"category":"Nursing/other","chartdate":"2132-08-04 00:00:00.000","description":"Report","row_id":1524116,"text":"data: vss. hr 96-113 afib. sb/p 88-112.\nt. fdg off @ 12mn for proceedure today. bs-dropped to 44 @ 0500 insulin gtt stopped(rate was on 1u/hr) and 1/2amp d50 ivp given w/ bs^64. will cont to check freq.\nall dsgs intact except rt lower -n/s pkg replaced-oozing from same area from skin tears.\n"},{"category":"Nursing/other","chartdate":"2132-08-04 00:00:00.000","description":"Report","row_id":1524117,"text":"Resp Care\n\nPt remains trached and vented on a/c with no changes made to parameter settings. BS slightly course sxing for small to mod amts of thick yellow secretions. MDIs given as ordered. Transported to and from IR without any incident. Will cont with vent support as needed.\n"},{"category":"Nursing/other","chartdate":"2132-08-04 00:00:00.000","description":"Report","row_id":1524118,"text":"Nursing update\nSee flowsheet for specific info\n\nVSS, A-fib with rare PVC, SBP low but MAP kept >65. Neuro status unchanged. Pt to IR today for replacement of leaky J-tube, no problems. ischial dressing changed today, all other dressings intact. Insulin gtt off this a.m. per MICU, 70 units lantis given. noon sugar was 28, MD notified, amp D50 given. A couple of hours later, sugar was 27, another amp d50 given. Will restart insulin gtt when sugar reaches 200 per MICU.\n"},{"category":"Nursing/other","chartdate":"2132-08-24 00:00:00.000","description":"Report","row_id":1524202,"text":"FOCUSED NURSING ASSESSMENT\nPlease see carevue flowsheet for further details\n\nNeuro: No changes in neuro status- opens eyes spontaneously, follows comands inconsistently. Nodding head to answer simple questions for assessment of pts basic needs.\n\nResp: Biovina trach patent, positive positional cuff leaks, cuff pressure monitoring by RT. No resp distress on A/C 0.40, 450, 16, 5. SPO2 >95%. Frequent suctioning of moderate thick yellow sputum.\n\nHemodynamics: HR afib, controlled rate, no ectopy. Noted possible ST depression in lead II- 12lead EKG completed and reviewed by MD properly- MD, no changes in EKG. transient low SBP 73-89, NINV cuff BP not registering on thigh, now measuring NINV BP left radial. Pt is anuric secondary to renal failure, plan HD tomorrow if BP tolerates. INR 3.7, no sx bleeding.\n\nNutrition/metabolic: TF via J/G tube at goal rate- Glucoses 169/148 on Lantus 90U and RISS available. Na 132, K 4.9, discussed by MICU team, no action needed.\n\nID: Afebrile. Zosyn, Levaquin, Tobramycin as ordered. Blood cx neg, c-diff neg.\n\nPSYCHOSOCIAL: Mrs visited by her husband in am and followed by son in afternoon- Son asking appropriate questions and shares with medical team that majority of children would like to see their mother come home with hospice care \"We are doing our best to convince my sisters\" SW following, f/u family conference this week.\n\n POC: Cont to monitor hemodynamics, resp status. Monitor fever curve. Plan HD tomorrow if BP stable- please draw Tobramycin peak/trough with HD tx dose. Monitor glucose levels, RISS and Lantus as ordered. Aggressive skin care, turn and reposition with mouth care q2hr. Emotional support and education to family- f/u from SW appreciated.\n\n"},{"category":"Nursing/other","chartdate":"2132-08-25 00:00:00.000","description":"Report","row_id":1524203,"text":"Resp Care Note:\n\nPt cont trached and on mech vent as per carevue. Lung sounds coarse suct mod th yellow sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required . Cont mech vent support.\n"},{"category":"Nursing/other","chartdate":"2132-08-25 00:00:00.000","description":"Report","row_id":1524204,"text":"Nursing progress note\nneuro: unchanged\ncv: pt has episodes of low bp which resolve with turning and stimulation of patient. Metoprolol given at 2200 as per parameters on med sheet.\npulm: trach leak continues. sx q 2-3 hrs for thick yellow. bs coarse\ngu: anuric, for hemodialysis today\ngi: tol tube feeds well. colostomy draining loose brown stool guaiac negative.\nendo: blood sugars in good control tonight, < 150. glargine 90 u sc q 12 hrs. no reg ins coverage needed.\nwounds: appear unchanged, leg dsgs changed, dacral dsgs changed.\n\nsocial: daughter and husband in to visit. She wanted to help turn pt, and participate in her care. It was explained to her that hospital policy will not allow her to do this. Shortly after, pt began coughing, and proceeded to suction her mother. I spoke to her about this: we realize that she cares for her mother at home, but that while she is hospitalized her technical care is our responsibility, and I reiterated hospital policy. This issue needs to be addressed by MD's and ethics Committee, as it causes conflict between the family and Mrs. caregivers.\n\n"},{"category":"Nursing/other","chartdate":"2132-08-09 00:00:00.000","description":"Report","row_id":1524137,"text":"Resp Care Note, Pt remains on current vent settings.See vent flow sheet for weaning. Unable to tol RSBI.RR into the 50's. Will cont to monitor resp status. Suctioned mod amts thick yellow secretions. Temp 99.HR A-Fib.\n"},{"category":"Nursing/other","chartdate":"2132-09-02 00:00:00.000","description":"Report","row_id":1524236,"text":"See carevue for objective data.\n\nAssessment remains unchanged. No vent changes made. Suctioned Q3H for thick yellow secretions. Trach care done.\nRemains in AFIB with adequate BP per parameters of team. Tolerated lopressor and amiodarone.\nFoley with frank blood-approximately 40cc's this shift. Also, oozing noted around foley. Team aware.\nAll dressings changed. Coccyx with large amt of serosangious/green drainage and hips with serosangious drainage. Avelyn placed on hips cleaned with wound cleanser and no sting barrier applied. Wound care nurse wounds in AM. Lower extremities remain with black areas.\nTF as ordered. Colostomy care done. Mouth care per protocol.\nCase management/SW involved in pt's care.\nFamily called and updated on POC.\n\nAwaiting to go to IR for tunnel dialysis catheter-on call.\n\nContinue current POC.\n\n"},{"category":"Nursing/other","chartdate":"2132-09-02 00:00:00.000","description":"Report","row_id":1524237,"text":"Respiratory Therapist\nBreath sounds bilaterally diminished, suctioned for small thick amount of yellowish secretions, WBC 12.8 ongoing bacterial infection, hemoglobin only 8, sign of anemia, patient got treated with Albuterol, Atrovent and Flovent inhalers, went to Angioplasty for line replacement, no ABGs drawn, nor vent changes done today, patient will continue to receive ventilatory support and close monitoring.\n"},{"category":"Nursing/other","chartdate":"2132-09-03 00:00:00.000","description":"Report","row_id":1524238,"text":"Resp.Care\nPt. remains on A/C vent. via a 7.0 Shiley trach which is patent and secure. She is being sx for mod amts of yellow with scat rhonchi t/o. Pt, nebs were tol. well with good results and better aeration post rx.Plan is to monitor and wean as tol.\n"},{"category":"Nursing/other","chartdate":"2132-09-03 00:00:00.000","description":"Report","row_id":1524239,"text":"NPN\nPlease see CareVue for full assessments\nNEURO: Unchanged. Nods to questions at times. Inconsistent with following commands and communicating. Ativan po per schedule for anxiety.\n\nCV: Afib. HR 90's-120's. NBP stable. Lopressor po per schedule.\n\nRESP: Trach. No vent changes or issues. Sxn for sm amt tan secretions.\n\nGI: TF via off @0200 2T episode vomiting x1 green bilious liquid. MICU HO notified and in to . No further action or episodes. Copious amts green gelatinous bilious liquid draining from around . Noted to drain more when pt. positioned on left side. MICU HO aware.\nBS+. Colostomy with 125cc brown liquid stool, guaiac-.\n\nGU: Patent foley draining dk. red blood. Flushed x2.\n\nWOUND/SKIN INTEGRITY: Dsgs intact. MPS in place, repositioned Q2H.\n\nPLAN: CV monitoring, diabetic management, monitor for increased pain/anxiety, monitor for nausea/vomiting, monitor resp status, wound management, reposition to maintain skin integrity, monitor foley for increased bleeding.\n"},{"category":"Nursing/other","chartdate":"2132-09-03 00:00:00.000","description":"Report","row_id":1524240,"text":"See carevue for objective data.\n\nAssessment remains unchanged.\nOpens eyes/tracks occasional only nods yes to questions/other times does not respond.\nTF re-initiated at 0700AM with no further vomiting. G-tube placed to gravity as well.\nFoley dc'd-no further bleeding noted. Pt anuric otherwise.\nTolerated HD/received albumin during HD.\nSkin care nurse evaluated and dressed all wounds. Please see progress note for details.\nNo vent changes. Suctioned Q2-3H for yellow thick secretions. Trach care done.\nAFIB. Non-labile BP.\n\nContinue current POC.\n"},{"category":"Nursing/other","chartdate":"2132-08-11 00:00:00.000","description":"Report","row_id":1524147,"text":"NPN\nPlease see CareVue for full assessments\nNEURO: Pt. inconsistently nods to questions and follows commands. MAE. Noted to have LUE tremor and left gaze @1200. Pupils 4-5mm and briskly reactive. MICU team notified. No action. On recheck pt able to look towards right, pupils remain 4-5mm. No c/o pain. Ativan per schedule.\nCV: Afib occas. PVC's. HR100-130's. Team aware-no action at this time.\nSBP 80-100's. Goal MAP grtr than 60.\nRESP: Trach. No vent changes. Cuff leak noted x2. Resp notified&at bedside. LS clear. Sxn x1 scant secretions.\nGI: TF @goal via PEJ. Free H20 Boluses on hold per MICU team. (Na 140). Moderate drainage around PEJ insertion site. Colostomy draining golden brown guaiac neg. stool.\nENDO: BG 300's this shift. Seen by . Fixed dose increased.\nWOUND: Dsgs intact. BLE dsgs changed per wound care recommendations.\nPLAN: Neuro checks, monitor CV and HR,diabetic management, wound management, call speech and swallow @passe muir valve, follow-up with team concerning upcoming discharge home, emotional support to pt/family.\n\n"},{"category":"Nursing/other","chartdate":"2132-08-12 00:00:00.000","description":"Report","row_id":1524148,"text":"Resp.Care\nPt. remains trached on A/C mode. No changes during the night. Cuff pressure was measured at 30 with a posistional leak. MDIs were given with good effect and pt. was sx for mod amts of white thick secr.\nPlan pt. is a chronic vent and possibly D/C to home .\n"},{"category":"Nursing/other","chartdate":"2132-08-12 00:00:00.000","description":"Report","row_id":1524149,"text":"Nursing Progress Note\nPlease see carvue for specifics:\nUneventful night. Status unchanged. Turn and repositioned Q2hrs and prn. Plan: Cont plans to d/c home\n"},{"category":"Nursing/other","chartdate":"2132-08-12 00:00:00.000","description":"Report","row_id":1524150,"text":"resp care - Pt remains intubated on ac 450/16/5 40%. Pt cuff pressure was not able to be assessed due to possible pinhole in pilot balloon. Balloon is remaining inflated and pt is receiving appropriate tidal volumes. Meds given as prescribed. BS wheezes t/o. Pt went to IR for jpeg change. Plan is to d/c to home soon.\n"},{"category":"Nursing/other","chartdate":"2132-08-12 00:00:00.000","description":"Report","row_id":1524151,"text":"Condition Update\nPlease see carevue for specifics.\n\nPt opening eyes spontaneously. Follows commands inconsistently. No moving extremities. TMAX 101.2; Bld cx's x 2 sent. Pending sputum from . Pt had HD today. 2200 out. AFIB continues. HR 90's-160's. occasional to rare PVC's noted. HR in the 130's-160's approx 30min into start of HD. MICU team notified. SBP only 70's-80's.\n\nNo vent changes made this shift. Pt sxn'd several times for thick, white sputum in scant amts. LS clear, but diminished at b/l bases. Pt an ad on for the OR for trach replacement d/t constant leakage. Pt maintaining volumes as was explained to pt's family, but they were still unhappy and demanding a new trach. Speech and swallow also consulted again for in line passy mauir.\n\nPt is anuric d/t renal status. colostomy draining liquid stool. spec #2 to be collected. Colace and lactulose doses held this am. stoma is pink. PEJ tube noted this am to have copious amts of clear drainage draining. Wound care RN in to inspect pej insertion site. Pt down to IR for replacement. .5 mg ativan given during the procedure. Since replacement, no further drainage noted. Pt's and beneprotein tube feedings held this afternoon for pej placement and eventual OR for trach placement.\n\nPt has a riss and glargine ordered for bs control. Pt is currently being followed by .\n\nB/L multi podis splints placed this am. foot and leg dressings changed this eve. Toes, heels, and achilles tendon necrotic. Duoderm gel adaptic and dsd's placed. Back of b/l calfs also w/ open areas. All areas cleansed w/ wound gel. Duoderm gel, adaptic and dsd's placed. Pt's coccyx and hips w/ intact dressings.\n\nPlan: continue with current plan of care per MICU team. speech and swallow consult for in line passy mauir placement. O.R. for trach replacement. Digoxin, lopressor and amiodarone for rate ctrl. Hold coumadin for inr 4.0 f/u on results of bld cx x 2 taken . Dressing changes.\n\n\n"},{"category":"Nursing/other","chartdate":"2132-08-13 00:00:00.000","description":"Report","row_id":1524152,"text":"Resp. Care\nThere was a question of Pt. going to the OR for trach replacement at the request of the family. She was added to list , but did not go.She continues to have a posistional leak . 4ccs was added to reach pressure of 30. Pt. 8.0portex trach remains secured and patent and is being sx for sm. to mod amts of thin white secr. B/S are scat wheezes and rhonchi, MDIs were given with good effect.Pt. remains on A/C 450by 1640% and 5of peep.ABGs and RSBI not done due to being vent dependent.\n"},{"category":"Nursing/other","chartdate":"2132-08-13 00:00:00.000","description":"Report","row_id":1524153,"text":"nursing note 7p-7a:\nNursing ASsessment:\n\nTmax 100.3 oral. HR afibb 90s-130s briefly, pvc's at times. BP goal map >50, no boluses needed overnight. lungs clear and diminished in the bases, infreq suctioned, sat 100%. NS at KVO switched to 5% dextrose while tube feeds off for OR trach replacement (pt is an add-on, still waiting). PM glargine held and sugars monitored closely while tube feeds off. Coccyx dressing changed per wound care recommendations, pt tolerated well. Please refer to carevue for all further details.\nPLan: wound care. TRach to be changed in OR. Speech and swallow for passe-muir valve? Discharge planning for home, children will care for patient there. EMotional support for family.\n"},{"category":"Nursing/other","chartdate":"2132-09-08 00:00:00.000","description":"Report","row_id":1524257,"text":"Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick yellow secretions. MDI'S given.HR-A-Fib with few PVC'S.BP labile requiring fluid . RR 20'S-30.Hasn't had dialysis for 5 days due to drop in BP.ABG metabolic acidosis. Will cont to monitor resp status.\n"},{"category":"Nursing/other","chartdate":"2132-09-08 00:00:00.000","description":"Report","row_id":1524258,"text":"Nursing Progress Note\nPlease see careview for details.\n\nNeuro: unchanged, lethargic to alert. nodding \"Yes\" to all questions.\nCV: afebrile. afib rate 110-145, but not sustained at the higher rate. Low bp by , at times unable to obtain , but as low as 45 systolic. abg's sent, lactate of 10, aline and multi lumen central line inserted rt femoral. given 1000cc ns, levophed started at .02mcg/kg/min. and a line not always correlating. levophed off by 0600. occasional pvc's. k 2.9, repleted with 20meq/50cc.\nPulm: sx for thick yellow, small amts. bs clear to coarse. RR up to 30, but not labored.\nGI: tube feeds at goal of 40/hr tol well, via j tube portion of gastric tube.. colostomy pink, draining golden loose stool guaiac neg. gastric tube to gravity, draining clear light yellow. frequent mouth care with water and mouthwash, pt swallows without difficulty.\ngu: anuric, possibly hemodialysis today if bp tolerates.\nendo: insulin to sliding scale as well as fixed dose of Lantis 2 x day.\nfamily notified of treatments by resident.\n"},{"category":"Nursing/other","chartdate":"2132-09-08 00:00:00.000","description":"Report","row_id":1524259,"text":"Respiratory Care\nBreath sounds slight bilateral rhonchi, suctioned intermittently for small thick yellowish secretions, WBC 22.6, ongoing bacterial infection for which patient is on tobramycin, patient is anemic since hemoglobin is only 8.8, patient was afebrile whole day and stayed into A-fib, has had few PVCs, had hemodialysis started at 1000 am to stop two hours later at noon due to adverse effects like hypotension and tachycardia (HR 150 to 160), patient has been treated with Albuterol, Atrovent and Flovent inhalers, no vent change done during the shift, post hemodialysis ABGs on AC 450 x 16 40% +5 revealed a fully compensated metabolic acidosis with hyperoxemia, we will continue with mechanical ventilation and close monitoring of patient.\n"},{"category":"Nursing/other","chartdate":"2132-09-08 00:00:00.000","description":"Report","row_id":1524260,"text":"NPN\nPlease see CareVue for full assessments\nNEURO: Unchanged. Nods head to all simple questions. Did not attempt to mouth words to this RN. +tracking. Observed moving LUE and RLE on bed. No movement witnessed from RUE or LLE.\n\nCV: Restarted Levophed after HD initiation due to hypotension. Titrated for BP grtr than 90. Mean grtr than 60 per MICU team. Right femoral Aline consistently 20-30pts higher than NBP. Remains in Afib. HR110's-120's prior to HD this AM.Episodes of HR to 140's. Lopressor 12.5PO administered. HR returned to 120's. CVP 14. Lopressor dose now TID. Midodrine per schedule. Potassium 3.0 after HD. To receive repletion.\n\nRENAL: Pt. did not tolerate fluid removal today. HD only 2hrs per Renal Fellow due to hypotension and tachycardia. Received 600cc NS fluid and Albumin during HD. Will attempt HD with fluid removal again tomorrow MD .\n\nRESP: Trach. No vent changes this shift. Remains acidotic. LS coarse to rhonci, right greater than left. Sxn for small amts thick light tan secretions. In line sxn changed by RT.\n\nID: ID consulted and in to /assessed coccyx wound. ?Linezolid induced lactic acidosis per MICU attending. L. acid now trending down(9.6). ABX changed per ID recommendations. Tobramycin level drawn at HD(0.2) but no dose administered. To be administered tonight per MICU HO. ID attending updated dtr.\n\nENDO: Hypoglycemic this afternoon. Received fixed dose of 87Units Glargine this AM. BG to 43. MD aware. amp D50 administered with repeat BG 43. Another amp D50 administered.\n\nGI: Abd distended. Golden loose guaiac- stool in colostomy. Bag emptied multiple times for flatus. Tol. TF at goal. Cont. to leak light yellow gelationous drainage around insertion site. Ostomy bag changed at site to collect drainage. Gastric tube to gravity with similar drainage as well as small amts of it oozing from rectum.\n\nScant smearing of vaginal bleeding noted with peri care.\nWOUND: All dressings changed per wound care recommendations. Dtr. viewed wounds with this RN.\n\nPsychosocial: HCP Dtr in-spoke with attending at length regarding , HD, and pending DC home.\n\nPLAN: Monitor CV status, wean levo as pt. tolerates, diabetic management, frequent BG checks due to hypoglycemia, administer ABX, wound management, reposition per protocol, provide emotional support to pt/family.\n"},{"category":"Nursing/other","chartdate":"2132-09-09 00:00:00.000","description":"Report","row_id":1524261,"text":"condition update\nd: pt opens eyes to name and nods yes. moves left arm spontaneously.\ncardiac: pt remains in afib with rate 90-130 with occasional pvc's. Dr. aware and lopressor dose given. pt on lopressor and given dose with minimal effect on bp and hr down to 100. pt remains on levophed and .04mcg/kg/min. rate titrated for 90. rate increased from .02-.04mcg/kg/min. pt remains on .04mcgs.\ngi: pt remains on tube feeds at 40cc/hr. no residual from j tube. no tube feeds draining from gtube. continues to leak yellow thick drainage from around feeding tubed. drainage bag is intact. abd obese and soft. hypoactive bowel sounds. colostomy pink and draining golden loose stools.\ngu: no urine. to attempt hemodialysis today with fluid removal. pt remains edematous in all extremities.\nlabs: blood sugars in the 40's. pt treated with d 50. Dr. aware and up to see pt. bedtime Glargine dose cut in half and pt started on d51/2ns at 100cc/hr for 5 hrs. see flowsheet for blood sugars. Spoke with Dr. re: insulin with blood sugar in the 60's. iv fluid changed to d5w at 100cc/hr and she wants pt to get glargine dose. blood sugar down to 57 at 3am and pt treated with 1 amp of d 50. Dr. aware. continue to monitor blood sugars. no further fluid at this time. hct down to 24 this am and Dr. aware. k 3.0 and repleted. repeat k this am 3.1\nskin: dressing are intact and pt remains on air mattress.\na: continue with q1hr blood sugars. attempt hemodialysis today. continue to support the family.\nr: 4am blood sugar is 118. tube feeds remain at 40cc. iv fluid at 10cc/hr. greater than 90 on current levophed dose. ? if she will be able to tolerate dialysis today. and aline approximately 20 pts difference. ? transfuse with hemo today. check with team and renal md. pt more edematous than over the weekend.\n"},{"category":"Nursing/other","chartdate":"2132-09-09 00:00:00.000","description":"Report","row_id":1524262,"text":"Respiratory Care Note:\n\nPt remain on ventilatory/assist support via trachetomy tube. No vent changes done. BS are clear/BBS. We are sxtn small amt of clear to blood tinged secretions from trach, none orally, IC changed and cleaned, spare unopened untop of ventilator. Plan: Continue present ICU minitoring, anuric ?dialysis as tol. Will follow.\n"},{"category":"Nursing/other","chartdate":"2132-09-09 00:00:00.000","description":"Report","row_id":1524263,"text":"NPN\nPlease See CareVue for full assessments.\nNEURO: Pt. lethargic. Pupils 4mm. Equally reactive. Does not follow any commands. No nodding of head or attempting to mouth words.\n\nCV: BP labile. Aline does not correlate with pressure. NBP cont to read 20-30pts lower than Aline. Cont. to titrate Levophed gtt to goal of grtr 80 MAP grtr 50 MICU MD . Levo changed to Neo gtt @1700. Titrated to grtr 80. Presently 1.5mcg/kg/min. HR 110's-120's with episodes of tachycardia to 150's. MICU team aware. Lopressor IVP with no effect. Change of CV meds today. please see MARs for changes. CVP 16-19. Cortisol stimulation test completed.\n\nRESP: Trach. No vent changes. No issues. Weak cough. Minimal sxn.\n\nRENAL: Unable to tolerate fluid removal with HD. Pt. hypotensive with to 70's. Levo titrated. to 150's. No result from Lopressor IVP. Renal and MICU teams aware and at bedside to .\n\nENDO: Hypoglycemic throughout day requiring amp D50 x3. BG ranging 30-83. See Flowsheet. No fixed dose this AM. No Lantus tonight per MICU team. consulted. Insulin Lantus dose changed to QD starting tomorrow.\n\nGI: Distended abd. Golden, guaiac+ stools x3. Colostomy bag intact. Minimal flatus. TF remains at goal via . Cont. leakage around site. G-tube to gravity with similar gelatinous yellow drainage. Also noted to be oozing from rectum. MICU team notified.\n\nGYN: No bleeding noted from vagina.\n\nWOUND: Assessed by wound care RN this AM. All QD dsgs changed. Allevyn dsgs on hips from intact. Please see wound care RN note for specifics. Wound care RN called and updated dtr. on recommendations at dtr's request.\n\nPSYCHOSOCIAL: Family updated by MICU team of HD, CV, and Hypoglycemic issues. Dtr updated by attending .\n\nPLAN: Assess MS, Monitor CV, titrate Neo gtt to goal grtr 80, diabetic management-hold Lantus tonight, D50 for hypoglycemia, administer ABX per schedule, Wound management, monitor labs,\nreposition frequently to maintain skin integrity.\n\n"},{"category":"Nursing/other","chartdate":"2132-09-09 00:00:00.000","description":"Report","row_id":1524264,"text":"BS few coarse crackles; no change with MDI's. Sx'd for mod amount pale yellow secretions. No ABG's or vent changes. COntinue with current care plan.\n"},{"category":"Nursing/other","chartdate":"2132-09-10 00:00:00.000","description":"Report","row_id":1524265,"text":"RESP CARE: Pt remains trached/on vent with settings per carevue. No changes in vent this shift. pressure of 25cmH20. Lungs coarse rhonchi with scattered insp wheezes bilat. Sxd thick yellow sputum at start of shift and white sputum by end of shift. ABGs consistent with comp met acidosis.No RSBI this am due to hemodynamic instability. Continue full support.\n"},{"category":"Nursing/other","chartdate":"2132-09-10 00:00:00.000","description":"Report","row_id":1524266,"text":"FOCUSED NURSING NOTE\nPlease see carevue flowsheet for further details\n\nNeuro: Decrease in LOC continues, alertness waxes and wanes- PEERL, 5mm. Glucoses stabilizing in 80s.\n\nResp: trach patent, ventilated via CMV 0.40/450/16/5. RR 18-24, SPO2 100%. ABG shows metabolic acidosis, attempting compensation. Suctioned infrequently for small thin tan secretions. Lungs coarse to rhonchi left lobe.\n\nHemodynamics: Unable to titrate Neosynpehrine gtt, maintained arterial 85-90s on Neo 1.00-1.25mcg/kg/min. Afib, rate 104-116, occassional PVcs. Anasarca increasing, CVP 12-14. Hct trending down, now 24.9. Small amt vaginal bleed, serosanguinous from rectal. Colostomy stool strong guiac positive.\n\nGI/Metabolic: TF at goal 40ml/hr. Colostomy golden/yellow loose stool, guiac positive. Hypoglycemic earlier in shift, treated with 1amp D50 and maintenance line D5W at 10ml/hr initiated. Glucose now stabilizing in 80s. Potassium 3.0 repleted with 20meq KCL. Metabolic acidosis, Bicitra administered as ordered.\n\nID: Tmax 99.2. Tobramycin/Zosyn/Levaquin/Daptomycin active. WBC decreasing along with Hct. Central line sites benign.\n\nSkin Integrity/Comfort: Please refer to wound care RN progress note- all dressings left intact, plan change daily. Turn and repositioned q2-3hr. Pt shows facial grimace at times, relaxation of face evident after stimulation of nursing care ends and pt allowed to rest in longer periods.\n\nPsychosocial: \"My mom lets us know what she wants, she wants to live\" Pts son at bedside until midnight- Daughter calls for updates. Emotional support and education provided re: disease processes, plan of care, hypoglycemia management, .\n\nPLAN: Monitor hemodynamics on pressors, goal > 80, MAP > 50. Consult with MICU team re: Hemodialysis repeat attempt vs . Monitor for bleeding, anemia management per MICU team. Pulmonary hygiene, aggressive skin care. Monitor hypoglycemia, hold Lantus. Monitor neurological status closely, report changes to MICU team. Administer . Close Social Work follow-up appreciated.\n\n"},{"category":"Nursing/other","chartdate":"2132-09-25 00:00:00.000","description":"Report","row_id":1524327,"text":"FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITALS/LABS/ASSESSMENTS.\nPATIENT CLEARLY GETTING MORE SEPTIC WITH INCREASING LACTATE AND WORSENING LABS.\nRECEIVED 2 U PB FOR HCT OF 20 AND 4U FOR INR 2.8\nUNABLE TO WEAN GTT--GOAL TO KEEP MAP>55.\nWOUNDS CHANGED AS ORDERED, UNCHANGED IN APPEARANCE.\nFAMILY MEETING HELD TODAY WITH DR. / RN/ / /DR. AND SON/DAUGHTER AND HUSBAND. FAMILY VERY ANGRY AND CONTENTIOUS THROUGHTOUT MEETING. LOTS OF YELLING BY SON, MOSTLY DIRECTED AT PERCEIVED POOR CARE GIVEN BY NURSING AND MEDICAL STAFF.\nWHEN ISSUES FINALLY DISCUSSED, IT WAS AGREED TO THE FOLLOWING 5 THINGS:\n1. STOP DIALYSIS FOR 24-48 HRS. AS FAMILY FEELS IT WEARS OUT THEIR MOTHER.\n2. DILTIZEM DOSE WILL BE DECREASED.\n3. FAMILY VERY MUCH WANTS LINE TO BE RESITED IN IR, BUT WERE TOLD IT WAS CURRENTLY TOO UNSAFE TO TRAVEL WITH PATIENT.\nIT WAS AGREED TO TRY TO WEAN NEO TO OF CURRENT DOSE, AND TO KNOW THAT PATIENT'S BLOOD PRESSURE WOULDN'T DROP LOWER THAN 60/S IF PATIENT WAS OFF NEO FOR PROLONGED PERIOD OF TIME (IE/DIFFICULTY PLACING LINE/LOST LINE FOR ANY PERIOD OF TIME).\n4. ID ISSUES --SPECIFICALLY IF AMIAKACIN WOULD BE APPROPRIATE DRUG AT THIS TIME WILL BE ADDRESSED.\n5. HOB WILL BE UP AT 30 DEGREES MOST OF THE TIME IF TOLERATED.\nA/P---AS OUTLINED ABOVE.\n\nMEDICAL TEAM AWARE, WILL CALL WITH ANY CHANGES.\n\n"},{"category":"Nursing/other","chartdate":"2132-09-26 00:00:00.000","description":"Report","row_id":1524328,"text":"Respiratory Care\nMinute ventilation in Fact is consistent with her usual values and not increased as previously report by this therapist\n"},{"category":"Nursing/other","chartdate":"2132-09-26 00:00:00.000","description":"Report","row_id":1524329,"text":"Respiratory Care\nPt. trach and on ventilatory support. No vent setting changes this shift. Pt. sx for abundent thick yellow secretions. ABG's with in normal values. Increasing minute volume noted to occur over duration of shift, may be attributable to increased Lactic acid.\n"},{"category":"Nursing/other","chartdate":"2132-09-26 00:00:00.000","description":"Report","row_id":1524330,"text":"Nursing Progress note:\nNeuro: Pt arouses to voice, withdraws to nailbed pressure but making no attempt to communicate. Appears comfortable.\nCV: Tmax 101.1 presently 99.8. HR 100-110's Afib with no ectopy. 95-101 MAP 59-61. Able to wean NEO to 1.5 mcg/kg/min. Pitressin unchanged at 2.4 u/hr. Extremities cool with pulses. HCT 24 this am.\nRESP: lungs clear to dim at bases. No vent changes overnight. Occasional suctioning of thick yellow secretions.\nGI: tube feed at goal. colostomy draining moderate amounts of maroon guaiac + stool.\nGU: aneuric.\nENDO: Cont on insulin gtt at 5u/hr for blood sugars 109-125.\nSKIN: all dressings dry and intact.\nPLAN: Cont to wean pressors. Cont to monitor HCT,PLT and INR\n"},{"category":"Nursing/other","chartdate":"2132-09-26 00:00:00.000","description":"Report","row_id":1524331,"text":"BS fine crackles; no change with MDI's. Sx'd for mod amount thick yellow secretions; inner cannula changed. To IR today for central line placement. No vent changes.\n"},{"category":"Nursing/other","chartdate":"2132-10-14 00:00:00.000","description":"Report","row_id":1524404,"text":"Respiratory Care\nPt. trached and on chronic ventilator management. Remains congested, suction for thick green secretions. Vent settings unchanged due to pt, chronic needs. Oxygenating well, MDIs administered as ordered.\n"},{"category":"Nursing/other","chartdate":"2132-10-16 00:00:00.000","description":"Report","row_id":1524412,"text":"NURSING NOTE\nPT ALERT/EASILY AROUSABLE, NOT FOLLOWING COMMANDS, NODS INTERMITTENTLY. PERRL, 4MM, BRISK, INTERMITTENLY TRACKING FAMILY MEMBERS. SPONTANEOUSLY TO LUE ONLY. HR 70S-80S, >80/MAP>55 MAINTAINED PER MICU, AFEBRILE. RECEIVED #2 PRBCS THIS EVE, POST-HCT 29, K 3.6, MAG 2.0, INR 1.6. LEFT A/C PICC D/C'D, RIGHT TLCL DRNG SEROSANG. NO VENT CHANGES, O2 SATS 98-100%, SUCTIONED FOR LGE AMTS BRN, THK SECRETIONS. COLOSTOMY W/MOD AMTS REDDISH-BROWN LIQUID DRNG, CLEARING THIS AM. GT TO GRAVITY W/MIN BRWN LIQUID DRNG, JT PATENT, CLAMPED. BS 120S-160S, PM LANTUS HELD, COVERED PER RISS. PT TURNED FREQUENTLY, MULTI DSGS REINFORCED, NO NEW AREAS OF BREAKDOWN NOTED.\n\n TO MONITOR HD, LOC, PULM TOILETING, AGGRESSIVE SKIN CARE, BS CHECKS, FAMILY SUPPORT. SICU , PLAN TO D/C HOME MON.\n"},{"category":"Nursing/other","chartdate":"2132-10-16 00:00:00.000","description":"Report","row_id":1524413,"text":"Resp Care\nPt remains trached on full vent support. no vent changes made this shift. Pt went to IR this afternoon for line placement without incident. Suctioned for mod-copious blood tinged to tan secretions. MDIs given. Please refer to for all vent settings.\n\n"},{"category":"Nursing/other","chartdate":"2132-10-16 00:00:00.000","description":"Report","row_id":1524414,"text":"STATUS\nD: AWAKE FOLLOWS SOME SIMPLE COMMANDS..NO SIGNS OF BLEEDING\nA: WD'S UNCHANGED..TO IR FOR PICC PLACEMENT & QUINTON CHANGED OVER WIRE TO TUNNELED DIALYSIS CATH..TOL PROCEDURE FAIRLY WELL..BP REMAINS LABILE..MP TO SR WITH FREQ PAC'S & OCC PVC'S..NO VENT CHANGES SUCTIONED FOR SM AMT THICK TAN/BLD TINGED..COLOSTOMY DRAINING LOOSE BLACK STOOL SM AMT\nR: ESSENTIALLY UNCHANGED\nP: ? TRANSFER HOME ON MONDAY..CONTINUE WITH PLAN OF CARE\n"},{"category":"Nursing/other","chartdate":"2132-10-17 00:00:00.000","description":"Report","row_id":1524415,"text":"RESP CARE: Pt remains trached/on vent on settings per carevue. pressure 25cmH20. Lungs coarse bilat, sxd thick yellow sputum. No RSBI due to hemodynamic instability. Hypotension. Waiting for MD order to place pt on home vent.\n"},{"category":"Nursing/other","chartdate":"2132-10-17 00:00:00.000","description":"Report","row_id":1524416,"text":"Nursing Progress Note\nPlease see for details.\n\nNeuro: unchanged\n\nCV: bair hugger for low temp, now normothermic. bp varies but continues to be low. Diltiazen held this am.\n\nPulm: sput sent for c+s, gm stain. sx thick yellow. sats>97.\n\ngi: tube feeds remain on hold, black stool from colostomy. hct 27.\nBS 44 at 0400, D50 amp ivp, rpt 80.\n\ngu: anuric, for hemodialysis this am.\n\ncontinues to seep large amts serous fluid from all skin breaks.\n\n\n"},{"category":"Nursing/other","chartdate":"2132-10-17 00:00:00.000","description":"Report","row_id":1524417,"text":"resp care\nremains on vent settings as charted, no changes made. discussed home vent with team..decided not necessary to place on pt until closer to discharge (approx 24hrs prior). admin mdi's per orders. pressure maintained between 25-30 with positional leak only.\n"},{"category":"Nursing/other","chartdate":"2132-08-23 00:00:00.000","description":"Report","row_id":1524197,"text":"Update\nO: see carevue flowsheet for specifics...\nNeuro: neuro status unchanged, eyes open spont perl at 4mm and tracking w eyes, does not follow any commands.\n\nCV: afib no ectopy.Lopressor held for sys bp <90. Sbp trending up to wnl range.doppler pt's bilat. Multiple skin issues and bilat lower extrms dsd.\n\nResp: remains on cmv tv 450 fio2 40% rr 16 peep 5. trach in place, trach care done. Adeq sats.Sux for thck tan.\n\nGi: g-j tube w tf at goal as ordered.Glucoses rx per ss, no reg insulin req. Rec'd pm lantus dose.\n\nGu: renal failure pt on sched for hemodylasis for Monday.\n\nSkin: multiple skin issues. Ble kerlex drsg.. Decub on coccyx , area w light yellow drngs->wound skin cleanser to area and aquacell dsg to be applied.\n\nHeme/ID: am labs pending. Tmax 100.7 remains on tobra and zosyn. tobra peak tobra level.\n\nA/P: hemodialysis on mnday.pulm toilet.wound and skin drsgas done per schedule.\n"},{"category":"Nursing/other","chartdate":"2132-08-23 00:00:00.000","description":"Report","row_id":1524198,"text":"nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT OPENS EYES SPONT. MOVES LEFT ARM. DOES NOT FOLLOW ANY COMMANDS.\n\nCV-REMAINS IN AFIB. SBP STABLE. SKIN WARM. +PP VIA DOPPLER.\n\nRESP-NO VENT CHANGES. O2 SAT 100%. LS COARSE. SXN PRN FOR THICK YELLOW SPUTUM. TRACH CARE DONE.\n\nGI-ABD SOFT, NT/ND. +BS. COLOSTOMY PINK WITH LOOSE GOLDEN STOOL. TOL TF VIA J-TUBE.\n\nGU-ANURIC. TO HAVE HD ON MONDAY.\n\nCOMFORT-APPEARS COMFORTABLE.\n\nENDO-GALRGINE GIVEN. NO SSRI NEEDED.\n\nID-AFEB. REMAINS ON ABX.\n\nSKIN-CON'T WITH MULTI SKIN TEARS AND BREAKDOWN. SEE FLOWSHEET. WOUND CARE AND DSGS CHANGED AS ORDERED.\n\nP-CON'T WITH CURRENT PLAN.\n"},{"category":"Nursing/other","chartdate":"2132-08-24 00:00:00.000","description":"Report","row_id":1524199,"text":"Resp Care Note:\n\nPt cont trached on mech vent as per Carevue. Lung sounds coarse after suct mod th pale yellow sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required . Positional air leak persists however adequate ventilation is maintained. Cont mech vent support.\n"},{"category":"Nursing/other","chartdate":"2132-08-24 00:00:00.000","description":"Report","row_id":1524200,"text":"nursing progress note\nblood sugars are elevated to >200. glargine 90 units q 12 hrs. HO notified, there is no sliding scale.\n"},{"category":"Nursing/other","chartdate":"2132-08-24 00:00:00.000","description":"Report","row_id":1524201,"text":"Resp Care\n\nPt remains on full vent support maintaining mv's in the 9-11L range. BS are diminished to coarse and suctioning thick yellow sputum in small to moderate amts. Cuff pressure at 18 cmH2O\n"},{"category":"Nursing/other","chartdate":"2132-09-15 00:00:00.000","description":"Report","row_id":1524286,"text":"Skin Assessment.\n\n->Bil underarms pink, no breakdown noted. Skin cleansed and dried well. Miconazole powder applied to both under arms.\n\n->Bil breast folds are pink with small pinpoint open area. Areas also have small amounts of thick whitish/yellow discharge. Areas cleansed and dried well. Miconazole powder applied to areas, dry gauze to cover.\n\n->Bil groin folds are pink/red with open areas. Areas are draining moderate amounts of sero/sang. Areas cleansed with wound cleanser and dried. Gauze placed inbetween folds and have been changed frequently.\n\n->Right posterior lower arm with two small pinpoint open areas draining copious amounts of sero fluid. Area cleansed with wound cleanser and drainage bag applied to area.\n\n->Right lower quad with skin breakdown from tape. Area again cleansed with wound cleanser, dried and drainage bag applied to help protect drainage from leaking into CVL and Aline.\n\n->Left lower posterior leg with open area. +granulation, small amount of sero/sang drainage. Wound is about 12cm long, 2cm wide and 0.5-1cm deep. Wound cleansed with wound cleanser and dried. Adaptic with DSD covering area.\n\n->Left great toe and other toes are dark brown, dry, and brittle. Left great toe with a scant amount of thick tan drainage at large knuckle. Area covered with DSD. Left heel is pink with escar. Area cleansed with wound cleanser and DSD applied.\n\n->Right lower posterior leg with open area. Area is pink with +granulation. Area cleansed well with wound cleanser, adaptic and DSD to the area. Right heel is pink, +eschar, no drainage. DSD applied.\n\n->Right toes with small black non-draining areas. DSD covering for padding.\n"},{"category":"Nursing/other","chartdate":"2132-09-15 00:00:00.000","description":"Report","row_id":1524287,"text":"Respiratory Therapy\n\nPt remains trached w/ #7.0 Shiley trach on full mechanical support. No vent changes made this shift. Continues on A/C ventilation w/ PIP/Pplat = 24/20. BLBS coarse, suctioned for small amounts of thick tannish/yellow sputum. MDIs given as ordered. SpO2 90s. ABG good. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support\n"},{"category":"Nursing/other","chartdate":"2132-09-15 00:00:00.000","description":"Report","row_id":1524288,"text":"Please See Carevue for Specifics.\n\nArousable to voice, does not follow commands, only moves LUE to nailbed pressure. Afternoon dose of 0.5mg Ativan held this afternoon for ?sedation. NSR, frequent PVC's, ?borderline first degree AV block and left BBB. +generalized edema, fluid balance goal is to be even/24hours. Remains on CMV. Suctioned for thick yellow secretions. Lungs are coarse-clear and diminshed at bases. ABd is obese with +BSx4, G-tube to gravity with clear/yellow mucous, J-tube with TF at goal. Pt does not void.\n\nSKIN: See previous assess entered. Bil hip dressings changed, +granulation, draining small amounts of sero/sang. Aquacel AG applied after cleansed with wound cleanser, alleyvn covering. Iliac Crest draining small amount of thick yellow discharge. Area cleansed well with wound cleanser, Aquacel AG applied to area, followed by DSD, and super-sorb pad.\n\n: Monitor MS, monitor skin integrity, dressing changes as ordered. Ativan when not sedated. Continue to offer emotional support to pt and family.\n"},{"category":"Nursing/other","chartdate":"2132-08-09 00:00:00.000","description":"Report","row_id":1524138,"text":"Condition Update A:\nPlease refer to careview and remarks for details.\n\nPt alert, when dozing pt is easily arousable, inconsistently follows commands. Moves LUE only. PERL 3-4mm bilat. Indications of pain during repositioning.\n\nTmax 100.1, low 98.7. Cont in afib 90-116 with rare PVC's.. SBP >90 tol MAP's >50 as discussed with Dr. . Potassium repleted per Jtube. During HD BP ranged 80-100's. 2L removed.\n\nLS CTA dim bases. Suctioned scant secretions. Trach care done.\n\nLE dsgs changed as in careview. Jtube dsg changed x2 as copious mucous drainage bursts dsg. Under flange of jtube are two open areas. The first is at the 1000 position with a yellow slough wound bed. The second is at the 0500 position with small amount of bleeding. Dr. from IR up to see pt and made aware of drainage from insertion site and the two open areas under flange.\n\nLantis dose increased as glucose levels remain greater then 250.\n\nHCP, , discussed her concerns. Support provided. Dr. and Dr. notified.\n\nPLAN: Neuro exam every four hours. Skin care per orders. Labs per orders. Monitor glucose levels and effect of lantis increase. Reposition every two hours. Monitor hemodynamics, SBP>90 and MAP>50. Facilitate discharge. Call H.O. with changes.\n"},{"category":"Nursing/other","chartdate":"2132-08-09 00:00:00.000","description":"Report","row_id":1524139,"text":"Respiratory Therapist\nBreath sounds bilaterally diminished, few wheezes, suctioned for small thick yellowish, WBC 11.5 consistent with bacterial infection, Hemoglobin 9.1 consistent with anemia, creatine 2.3 suggesting renal insufficiency for which patient had hemodialysis this morning, patient was afebrile whole day and stayed into chronic A-fib,no ABGs today, patient will continue to receive ventilatory support and close monitoring.\n"},{"category":"Nursing/other","chartdate":"2132-08-10 00:00:00.000","description":"Report","row_id":1524140,"text":"Focus-Condition Update\nData-Low grade temp during the night. No vent changes-pt suctioned for sm ams clear white secretions. Dressings changed as scheduled.\nBlood sugars better controlled with increased Insulin dose. Continues to have mod amt clear mucousy drainage from around PEJ site.\nAction-Continue to monitor. AM labs drawn as ordered.\nResponse-Ongoing evaluation.\nPlan-Continue to monitor Blood sugars closely. Ongoing discharge planning for discharge to home.\n"},{"category":"Nursing/other","chartdate":"2132-08-10 00:00:00.000","description":"Report","row_id":1524141,"text":"Resp Care: pt continues trached and on ventilatory support with a/c, no vent changes maintaining spo2 100%, persistent minimal cuff leak but attaining volume; BS coarse, sxn thick white secretions, rx with mdi albuterol/atrovent/flovent, rsbi 93, consider short trach collar trials\n"},{"category":"Nursing/other","chartdate":"2132-08-30 00:00:00.000","description":"Report","row_id":1524226,"text":"Respiratory Therapist\nBreath sounds revealed clear right lung and diminished left lung, suctioned for small thick yellowish, still on droplet precautions for MRSA, afebrile and stayed whole day into chronic A-fib, Oxygen saturation stayed around 100, patient was treated with Albuterol, Atrovent, Flovent inhalers, WBC 20.9 consistent with bacterial infection, Hemoglobin only 9.1, signs of anemia, no ABG drawn nor vent changes done during the shift, patient will remain vented, most likely on same settings and will continue to be closely monitored.\n"},{"category":"Nursing/other","chartdate":"2132-09-24 00:00:00.000","description":"Report","row_id":1524321,"text":"condition update\nno significant change in status; still requires pressor support. given replacements as ordered. crrt on/off= fluid removal dependant on bp, acidosis worsening . discussed with resident and will attempt to support bp to allow for optimal fluid removal.\n"},{"category":"Nursing/other","chartdate":"2132-09-24 00:00:00.000","description":"Report","row_id":1524322,"text":"Respiratory Care\nBreath sounds bilaterally coarse, suctioned for moderate thick green, oral temp ranged 96.5 to 98.1 using warming blanket since she stay on CCVHD whole day, WBC 9.8 ruling out the presence of bacterial infection, hemoglobin only 8.5 which is indicative of anemia, lactic acid 3.4, pressure 15cmH2O, patient has been treated with Albuterol, Atrovent and Flovent inhalers. Projected family meeting did not happen today, is postponed for tommorrow. No vent changes ordered nor made today, settings are the same.\n"},{"category":"Nursing/other","chartdate":"2132-09-24 00:00:00.000","description":"Report","row_id":1524323,"text":"nsg note\nsee flowsheet for specifics.\n\nNEURO-OPENS EYES SPONT. MOVES LEFT ARM ON BED. DOES NOT MOVE OTHER EXTREMITIES.\n\nCV-BACK IN AFIB. RATE 70-100'S. DOWN TO 70'S. ON MAX DOSE OF NEO. TO START VASOPRESSIN. SKIN WARM. JAUNDICE.\n\nRESP-REMAINS TRACHED AND VENTED. NO VENT CHAGNES MADE TODAY. PT ACIDOSIS IMPROVING. SXN PRN FOR THICK YELLOW SPUTUM. LS COARSE WITH SOME WHEEZES AND RHONCHI. INHALERS GIVEN. O2 SAT 98%.\n\nGI-ABD OBESE, +BS. TOL TF VIA . PEG TO GRAVITY WITH BROWN TO YELLOW DRG. STOMA PINK WITH LOOSE GOLDEN STOOL. + MUCOUS DRG FROM ANUS. HAD US OF RUQ.\n\nGU-ANURIC ON . UNABLE TO TOL ANY FLUID REMOVAL D/T HYPOTENSION.\n\nENDO-ON INSULIN GTT.\n\nACT-REPOSTIONED FREQ. ON AIRBED.\n\nSKIN-CON'T WITH MULTI SKIN ISSUES. SEE FLOWHSEET. DSGS CLEANED AS ORDERED. SKIN UNCHANGED.\n\nID-HYPOTHERMIC WITH BAIR HUGGER ON.\n\nP-CON'T WITH CURRENT PLAN. NEO AND VASOPRESSIN GTTS. SKIN CARE. INSULIN GTT. FAMILY MEETING PLANNED FOR TORROW AT 3PM.\n"},{"category":"Nursing/other","chartdate":"2132-09-25 00:00:00.000","description":"Report","row_id":1524324,"text":"Respiratory CAre\nPt. trached and chronically ventilated. Sx for thick secretions. No vent setting changes made this shift.\n"},{"category":"Nursing/other","chartdate":"2132-09-25 00:00:00.000","description":"Report","row_id":1524325,"text":"condition update\ncondition continues to remain guarded with bp 80-90 systolic on 5mcg neo and 2.4 pitressin. crrt keeping even to 50ml removal but pt still very much compromised with decreased pressure\ninsulin titrated for bs no real issues. team aware of am labs and will discuss treatment during rounds. pt has no visible evidence of bleeding. will continue to monitor\n\n"},{"category":"Nursing/other","chartdate":"2132-09-25 00:00:00.000","description":"Report","row_id":1524326,"text":"Respiratory Care\nPt remains trached and on vent support. No vent changes were made during shift. Lung sounds were course throughout. Pt was suctioned for moderate amounts of thick yellow secretions. Pt received MDI's as ordered. Last ABG 7.39/34/84/21/-3. Care plan is for a family today. No vent changes to be made. Will continue to follow.\n"},{"category":"Nursing/other","chartdate":"2132-10-14 00:00:00.000","description":"Report","row_id":1524405,"text":"resp care\nremains on ac mode. no changes made this shift. mdi's given q4h. sxned yellowish sputum. trached/vent dependant. positional leak with pressure kept at <30 cmh20. tolerating well. minimal to no spont efforts.\n"},{"category":"Nursing/other","chartdate":"2132-10-14 00:00:00.000","description":"Report","row_id":1524406,"text":"Nursing Update\nSee flowsheet for specific info\n\nNeuro: Pt nodding and tracking occasionally, not following commands, no movement of extremities noted. Afebrile.\n\nCV: NSR with occasional PVC's, kept above 80, Neo gtt remains off. Crit stable despite vag bleeding and blood in stool. PICC line dressing very leaky, line is out about 7cm, MICU aware.\n\nResp: Remains vented, CMV, PEEP 5, 50%. No vent changes made today. Sux'd for small amount of thick yellow sputum, lungs coarse throughout, sating 90-100%.\n\nGI: Bloody stool in colostomy, MICU aware, crit stable 26-27. GI consulted this morning, pt to have colostomy in a.m., TF's off, Go-lytly started for bowel prep.\n\nGU: Pt anuric, scheduled to be dialyzed tomorrow.\n\nEndo: Insulin gtt off. Blood sugar low today (20's) 1 amp D50 given, MICU HO aware, Glargine to be held this evening.\n\nSkin: All dressings changed today.\n\nPlan: Coloilioscopy to be done tomorrow.\n Closely monitor blood sugar.\n Dialysis tomorrow.\n Home by end of week.\n"},{"category":"Nursing/other","chartdate":"2132-10-15 00:00:00.000","description":"Report","row_id":1524407,"text":"NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\n\nNO MENTAL STATUS CHANGES, NODDING INTERMITTENTLY, MOVES ONLY LUE, NOT FOLLOWING COMMANDS. PERRL, 4MM, BRISK, OPENS EYES SPONTANEOUSLY. HR 60S-70S, >80/MAP>55, REMAINS OFF DRIPS, AFEBRILE. HCT 26.6, K 3.6, MAG 1.8, HO AWARE. NO VENT CHANGES MADE, LUNGS COARSE THROUGHOUT. PT SUCTIONED FOR MOD AMTS YELLOW, THICK SECRETIONS. TF OFF SINCE MN, COLOSTOMY W/SM AMT MAROON, LOOSE STOOL, GT W/MIN OUTPUT. BS DOWN TO 20S THIS EVE, 1/2AMP D50 GIVEN X3, PRESENTLY 50S-HO AWARE, TO MONITOR. PT TURNED FREQUENTLY, NO NEW AREAS OF BREAKDOWN NOTED, SEEPING MOD AMTS SEROUS FLUID TO MULTI SPOTS.\n\nPLAN: HEMODYNAMIC MONITORING, FREQUENT BS CHECKS, DEXTROSE AS NEEDED, SERIAL HCTS. AGGRESSIVE SKIN CARE, HD PLANNED FOR TODAY, POTENTIAL D/C HOME THURS.\n"},{"category":"Nursing/other","chartdate":"2132-10-15 00:00:00.000","description":"Report","row_id":1524408,"text":"Resp Care\nPt. remains trached on AC mode w/o change overnight. BS: coarse t/o sxn'd q4 for mod. thick greenish yellow. Mdis given q6 as ordered.\nPlaN:HD today and possible d/c home later this week. Pt. needs to be transitioned to home vent at some point today.\n"},{"category":"Nursing/other","chartdate":"2132-10-15 00:00:00.000","description":"Report","row_id":1524409,"text":"BS coarse crackles; no change with MDI's. Pt had HD today and is now awaiting colonoscopy. After procedure will attempt to transition to home ventilator (). If she tolerates vent successfully for about 2 days, she will be discharged home.\n"},{"category":"Nursing/other","chartdate":"2132-09-14 00:00:00.000","description":"Report","row_id":1524284,"text":"focus update note\nhypothermic 95-96 with bair hugger on pt 97-98 consistently most of day, currently bair hugger off last temp 98.7, initially heart rate 130-150 afib- 78-high 80s, pt given one unit PRBC and heart rate improved to 102, increased high 90s to 120. diltiazem gtt started at 5mg/hr. goal map >55, goal CVP = 10, initially cvp 17 now 10.\n\nresp: minimal suctioning secondary to platelet count 22-30, suctioning for small amount yellow thick sputum, no vent changes today, o2 sat consistently 100%, lsc dim at bases\n\ngu/gi: ileostomy draining yellow liquid stool, anuric, TF continue- no residual, bs hypoactive\n\nskin: changed decub and hip dressings at 1600, skin red with good granulation, scant bloody drainage, yellow slough, toes black on bilateral feet, skin under pannus ulcerated open drainag yellow draiange- resident notified and aware- area cleaned with wound spray and dressed with dsd.\n\nCRRT clotted at 1700 and restarted at 1800, please see dialysis flowsheet for details\n\ngoals: map > 55, cvp 10, run CRRT to keep pt 1 liter positive over 24 hours, continue with wound care as ordered collaborate with skin RN as needed, continue with lab monitoring q 6 hours, transfuse platlets for less than20, moniotr for signs symptoms bleeding, control blood sugars with insulin gtt and monitor finger stick q 1 hour.\n"},{"category":"Nursing/other","chartdate":"2132-09-15 00:00:00.000","description":"Report","row_id":1524285,"text":"Update\nO: See carevue for specifics...\nNeuro: awake,alert,perl @ 4mm brisk.moving lue otherwise no mvmnt.\n\nCV: sr to on diltiazem gtt. 90-110 range Cvp 12-15 range.Cont on crrt w goal overnight 1 liter positive achieved. Vss overnight.Doppler dp's bilat, necrotic toes. Ble drsg d&i.\n\n\nResp: trached on cmv mode tv 450 rr 16 fio2 40% w peep 5cm w adeq abg on same.Lungs lcear diminished, lavaged and suct for thick yellow.\n\nGi: g-j tube w tf at goal 40cc/hr via jtube, gt to gravity.Abd obese soft, colostomy w loose golden brn stool. glucoses managed per riss.\n\nGu/Renal; on crrt and tol well w current goals 1liter + .Cont on K+ Ca+ gtts per ss.\n\nHeme/Id: hct 27, plt ct holding at 33K pt 18.4 inr 1.7. wbc flat. temp subnl at times req bair hugger blanket.HO aware plt ct's <50 and no rx ordered.\n\nskin/wounds: coccyx decub drsg , purulence non healing site. Wound cleanser and aquacell packing and sofsorb drsg .Bilat lower leg dsg intact.Excoriated area under -> miconazole to site.\nA/P: Cont crrt w lyte repletion per ss. Confirm crrt goals for today w renal fellow. Pulm toilet. Wound and skin care.Q!h glucoses and titrate insulin gtt.Empty and record colostomy q shift.\n"},{"category":"Nursing/other","chartdate":"2132-09-30 00:00:00.000","description":"Report","row_id":1524346,"text":"Respiratory Care:\n\nPatient trached with 7.0 shiley. Vent dependent. Vent settings unchanged. Vt 450, A/c 16, Fio2 40% and Peep 5. 02 sats 99%. Bs clear bilaterally. Sx'd for sm amount of thick yellow secretions. Albuterol/Atrovent MDI's given Q4hr and Flovent given . CXR Worsening pleural effusions. Sputum + for Pseudomonas. No further changes made. Continue with mechanical support.\n"},{"category":"Nursing/other","chartdate":"2132-09-30 00:00:00.000","description":"Report","row_id":1524347,"text":"Focus Condiiton Update\nSee flowsheet for specific info.\n\nNeuro: Pt dozing off and on throughout the day, will occassionally nod to simple questions. Not following commands.\nCV: A-fib 100-120's. Neo on this a.m., weaned off this afternoon. Pt had one episode of wide complex tachycardia to 140's, MICU team at bedside, EKG obtained, 2gm Calcium Gluc given, 20mg Diltiazem given. Pt's HR returned to 90's while pushing Dilt. K+ of 3.3 repleted.\nResp: Pt remains on CMV, no vent changes made today. Sux'd for small amount of thick white sputum.\nGI: Abdomen is obese, +BS. G-tube to LCS draining brownish stool. Colostomy intact, also draining small amount of brownish loose stool.\nGU: Pt continues to have a small amount vaginal bleeding, OB has not yet consulted at time of note.\nSkin: Wound care RN in this a.m. to change all dressings. Xeroform in skin folds replaced.\nEndo: BS's running high, MD aware, Insulin gtt restarted, sugar checked qhr.\nSocial: Husband and son in briefly this morning to see pt.\nPlan: Titrate Insulin to keep BS 100-150\n Continue to monitor hemodynamics\n Change wound dressings as needed\n Family support.\n Cont. with MICU , contact HO with changes\n"},{"category":"Nursing/other","chartdate":"2132-09-30 00:00:00.000","description":"Report","row_id":1524348,"text":"Resp Care\nPt reamins trached on full vent support. no vent changes made this shift. Pt continues to have mod amt of thick yellow sputum. MDIs given. will continue to follow\n"},{"category":"Nursing/other","chartdate":"2132-10-01 00:00:00.000","description":"Report","row_id":1524349,"text":"Please See Carevue for Specifics.\n\nPt has had no change over night. Pt kept comfortable and with skin care, back rub, repositioning, and reassuring of care.\n\nSOC: Pt son was escorted out of building by security this evening for his continuous demanding and swearing behaviors to all staff. MICU resident, MICU attending, Nursing Supervisors aware of plan. Son is allowed supervised visits with security for 30 minutes/day. Security has explained the restrictions to the son. Pt HCP also aware of plan.\n\n: Continue to keep pt comfortable, pain meds as needed, HD this morning, skin care as ordered, surgical team to follow, family aware of plan.\n"},{"category":"Nursing/other","chartdate":"2132-10-01 00:00:00.000","description":"Report","row_id":1524350,"text":"Respiratory Care:\n\nPatient trached with 7.0 Shiley. Bs coarse bilaterally with crackles R base. Some increased WOB noted at beginning of shift. Secretions unchanged. Sx'd for sm amounts of thick yellow secretions. Albuterol/Atrovent MDI's given Q4hr and Flovent . CXR repeated. Peep increased to 8cm for increased fluid. Repeat ABG's revealed PaCO2 slightly elevated. Current vent settings Vt 450, A/c 16, Fio2 40% and Peep 8. No further changes made.\nPlan: Continue with mechanical support.\n"},{"category":"Nursing/other","chartdate":"2132-10-01 00:00:00.000","description":"Report","row_id":1524351,"text":"pt remained on full vent support throughout shift, Bronch done around 1PM looking for any abnormalities but was negative. Different settings attempted in order to make pt look more comfortable, but unsuccessful. Sx'd for minimal secretions. ABG within normal limits.\n"},{"category":"Nursing/other","chartdate":"2132-08-31 00:00:00.000","description":"Report","row_id":1524227,"text":"Respiratory Care\nPt remains trached on ventilator. No vent changes made. BS clearer today, still diminished at bases. Suctioned for small amount of thick tan secretions. No ABGs drawn this shift. Pt oxygenating well with SpO2 100%. MDIs given as ordered. RSBI attempted but pt showed no spontaneous effort.\nPlan: continue ventilator support.\n"},{"category":"Nursing/other","chartdate":"2132-08-31 00:00:00.000","description":"Report","row_id":1524228,"text":"Neuro:pt is alert . response to question by nodding appears appropriate.\nPain: pt had some discomfort when changing leg dsgs demerol given.\nCV: chronic AF SBP >85 today. R single lumen picc patent. RSC quinton.\nlungs: clear to coarse . more secreation today then yesterday. thick yellow sputum. BS more coarse.\nGI: ABD soft BS present. TF at goal tolerating well. colostomy pink draining brown liquid.\nGU: foley in place . still with small amt of blood.\nGYN: still having vaginal spotting of blood.\nEndo: FS 70-113 on lantus @ 86 q12.\nSkin: see care view and wound care nurses note. turned q3-4 hours.\nA/P continue scan care as indicated. monitor as indicated. HD tomorrow. continue lantus at present dose . continue monitoring bleeding. given Vita K as ordered.\n"},{"category":"Nursing/other","chartdate":"2132-08-31 00:00:00.000","description":"Report","row_id":1524229,"text":"Respiratory Therapist\nBreath sounds clear, few crackles, suctioned for copious thick yellowish secretions, WBC 20.1, ongoing bacterial infection, hemoglobin only 8.6 patient is anemic, patient was afebrile and stayed into chronic A-fib treated with Albuterol, Atrovent and Flovent inhalers, no vent changes nor Arterial Blood Gas done today, patient still under close monitoring.\n"},{"category":"Nursing/other","chartdate":"2132-09-01 00:00:00.000","description":"Report","row_id":1524230,"text":"Respiratory Care\nPt remains trached on full vent support, breathing slightly over the ventilator. BS coarse & diminished bilaterally. Suctioned for small-mod amounts of thick white sputum. MDIs given as ordered. SpO2 100%.\nPlan:Continue vent support\n"},{"category":"Nursing/other","chartdate":"2132-09-01 00:00:00.000","description":"Report","row_id":1524231,"text":"NURSING\n VSS, AFEBRILE. CONTINUES IN AFIB. HCT STABLE. MINIMAL BLEEDING EITHER VAGINALLY OR FROM FOLEY. NO ISSUES OVERNIGHT. SEE CARE VUE FOR FULL SPECIFICS.\n CONTINUE TO MONITER HEMODYNAMICS. REPEAT HCT THIS AFTERNOON AFTER HEMO. HEMODIALYSIS TODAY. CONTINUE TO MONITER FOR VAGINAL OR BLEEDING FROM FOLEY.\n"},{"category":"Nursing/other","chartdate":"2132-09-17 00:00:00.000","description":"Report","row_id":1524295,"text":"Nursing note:\n Alert, no neuro change. Not following commands or communicating. Does not appear to be in any pain. PERRLA. No neuro changes. No vent changes, remains trached on A/C. Appears comfortable. Slightly hypothermic this am, Bair Hugger on low to keep temps in 97s. SR, occ PVCs. Dilt gtt titrated down to 5/hr, well tolerated. WBCs elevated today, team aware. Cultured overnight. ID following, on mult. IV abx. EKG done per MICU request. >80 w/MAP >50 on Neo gtt, unable to titrate down. +BS, tolerating TFs via jtube, gtube to GD. Colostomy intact, liquid golden stool. Glucose stable on insulin gtt. Anuric, running to keep pt. even. K+ and Calcium gtts running per sliding scale.\nImpressive wounds to hips/coccyx and LEs, dressings done per skin care RN recs. See Flowsheet for details.\n\nA/P: Remains on and pressors for sepsis as well as multiple medical issues. Continue to monitor closely.\n"},{"category":"Nursing/other","chartdate":"2132-09-17 00:00:00.000","description":"Report","row_id":1524296,"text":"Respiratory Care Note:\n Patient remains on full vent support. #7 extra long Shiley trach is secure. BS=bilat, coarse with rales and rhonchi. Suctioned for moderate amounts of thick yellow secretions. Plan to maintain supportive care.\n"},{"category":"Nursing/other","chartdate":"2132-10-13 00:00:00.000","description":"Report","row_id":1524399,"text":"Nursing Progress Note\nPlease see for details\n\nNeuro: unchanged.\n\nCV: afebrile, bair hugger off with temp maintained. HR A fib with rare pvc's, rate controlled. BP difficult to obtain at times, but remains adequate. Neo drip remains off.\n\nPulm: bs coarse, sx for tan thick secretions, but less brown and fewer than yesterday. O2 sats 96-100 when obtainable.\n\ngi: tube feeds via j tube at 40/hr tol well. gt to gravity. golden stool from colostomy.\n\ngu: anuric, for hemodialysis today.\n\nblood transfusion completed, Hct pending with am labs.\nBlood glucose under control, see flow sheet and labs for FS sugars.\nInsulin drip remains off.\n\n\n"},{"category":"Nursing/other","chartdate":"2132-10-13 00:00:00.000","description":"Report","row_id":1524400,"text":"Respiratory Care\nPt. trached on ventilatory support. Congested, frequently suctioned for thick tan-green secretions. Trach appears to have positional leak even with adequate . No vent setting changes made this shift. Chronically vented with no plans for weaning, no RSBI performed.\n"},{"category":"Nursing/other","chartdate":"2132-10-13 00:00:00.000","description":"Report","row_id":1524401,"text":"Respiratory Care:\n No change in vent status. Patient receiving dialysis. BS=bilat with occassional rhonchi. Suctioned for thick green tinged sputum and receiving MDIs. See Carevue flowsheet for specifics.\n Spare #7 X-Long Shiley trach ordered for possible patient discharge to have as spare. Notes written for possible DC .\n"},{"category":"Nursing/other","chartdate":"2132-10-13 00:00:00.000","description":"Report","row_id":1524402,"text":"NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\nNEURO: PT OPENING EYES SPONTANEOUSLY, PERRL 4-5MM, BRISK, INTERMITTENTLY TRACKING. NOT FOLLOWING COMMANDS, MIN SPONTANEOUS MVMT, LUE OBSERVED ONLY. NO ATIVAN GIVEN.\n\nCVS: REMAINS OFF PRESSORS, MAP MAINTAINED>55, VIA 70S-110S, UP TO 150S W/HD, HO AWARE, ?ACCURACY. PT HEMODIALYSED FOR 1.5L, ALBUMIN GIVEN CONCURRENTLY FOR >50 PER MICU TEAM DURING HD. PM HCT 26.7, AFEBRILE.\n\nRESP: NO VENT CHANGES, SET RATE 22, PT BREATHING 2-6 BPM OVER. SUCTIONED Q2-3 HRS FOR SM AMTS THICK, YELLOW-BROWNISH SECRETIONS. LUNGS COARSE THROUGHOUT, RHONCHOROUS AT TIMES. O2 SATS 96-100%.\n\nGI/GU: REMAINS ANUERIC. COLOSTOMY PATENT W/MOD AMTS GOLDEN, SEMI0FORMED STOOL. GT TO GRAVITY W/SM AMT VISCOUS YELLOWISH DRNG. JT PATENT, TF AT GOAL, MIN RESIDUALS.\n\nENDO: REMAINS OFF INSULIN DRIP, BS 102-138--NO COVERAGE REQUIRED. LANTUS 50 UNITS GIVEN THIS AM.\n\nINTEG: MULTIPLE DSG CHANGES PERFORMED PER WND CARE PROTOCOL, PT TURNED FREQUENTLY, NO NEW AREAS OF BREAKDOWN NOTED.\n\nPLAN: HEMODYNAMIC MONITORING, AGGRESSIVE SKIN CARE, PULM TOILETING/RESP SUPPORT, FAMILY SUPPORT. PROBABLE D/C TO HOME THURS, REMAIN IN SICU FOR HD ON WEDS, SICU .\n\n\n"},{"category":"Nursing/other","chartdate":"2132-10-14 00:00:00.000","description":"Report","row_id":1524403,"text":"CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: OPENS EYES SPONT. INTERMITTENTLY TRACKING. PERRL. NO SPONT. MOVEMENT SEEN IN EXTREMITES. PT DOES APPEAR TO GRIMACE WHEN ABD LIFTED TO PERFORM SKIN CARE ON FOLDS.\nCV: AFEBRILE. REMAINS IN AFIB WITH RARE PVC'S. 80-95.\nRESP: NO VENT CHANGES. SX FOR SM AMTS THICK YELLOW SECRETIONS. BS COARSE.\nGI: TOL TF AT GOAL. PEG TO GRAVITY DRAINING LIGHT TANNISH-BROWN. OSTOMY PATENT WITH LOOSE REDDISH BROWN STOOL. HO AWARE. HCT STABLE AT 27.\nGU: DIALYSIS SCHEDULED FOR WEDNESDAY\nENDO: OFF INSULIN GTT. BS 72-90.\nA/P: . TO MONITOR HEMODYNAMICS, SERIAL HCTS AS ORDERED, . DRESSING CHANGES AS PER WOUND CARE NURSE., ASSIST FAMILY IN GOAL OF GETTING PT HOME LATER THIS WEEK.\n"},{"category":"Nursing/other","chartdate":"2132-09-29 00:00:00.000","description":"Report","row_id":1524343,"text":"CONDITION UPDATE\nASSESSMENT:\n PATIENT OPENS EYES SPONTANEOUSLY, DOES NOT FOLLOW COMMANDS. ONLY MOVES LEFT UPPER EXTREMITY. PATIENT DOES NOT APPEAR IN ANY PAIN WITH MOVEMENT OR DRESSING CHANGES, NO NEED FOR PAIN MED.\n HEART RATE 100-110 AFIB AND MAP > 55 ON LOW DOSE NEO GTT THIS AM. PATIENT STARTED ON HD THIS AM, PATIENT WITH HR INCREASING TO 130'S-140'S BUT BP STABLE. HD RN UNABLE TO REMOVE ANY FLUID, FILTRATED FOR 2 HOURS AND TREATMENT STOPPED. AFEBRILE, WBC COUNT NORMAL. INR 2 THIS AM & PATIENT HAVING MODERATE AMOUNTS ? VAGINAL BLEEDING. 2 UNITS GIVEN, AWAITING REPEAT LABS.\n LUNG SOUNDS OCCASIONALLY COARSE, SUCTIONED FOR MODERATE THICK YELLOW SPUTUM. REMAINS ON ASSIST CONTROL. ABDOMEN SOFTLY DISTENDED, J-TUBE CLAMPED AND G-TUBE TO LOW CONT SUCTION WITH MODERATE AMOUNT BROWN DRAINAGE. COLOSTOMY STILL WITH MINIMAL LOOSE BROWN STOOL. ? BOWEL OBSTRUCTION RESOLVING. PATIENT TO BE STARTED ON TPN TOMORROW. SEE FLOWSHEET FOR MULTIPLE SKIN AREAS AND TREATMENT.\nPLAN:\n WEAN NEO TO OFF. REPEAT KUB TOMORROW TO SEE IF BOWEL OBSTRUCTION RESOLVING. CASE MANAGER AWARE OF PATIENT. CONTINUE WITH SKIN CARE.\n\n"},{"category":"Nursing/other","chartdate":"2132-09-29 00:00:00.000","description":"Report","row_id":1524344,"text":"Resp Care\nPt reamins trached on full vent support. No vent changes made this shift. innner cannula changed this afternoon. Pt suctioned for sm amt of thick pale yellow secretions. plan at this time is to continue vent support, please see carevue for current settings.\n"},{"category":"Nursing/other","chartdate":"2132-09-30 00:00:00.000","description":"Report","row_id":1524345,"text":"Please See Carevue for Specifics.\n\nNeuro: Alert, orientation unknown, does not follow commands, evening dose of 0.5mg Ativan adm and early morning dose held.\n\nCV: Afib 100-130's. Neo weaned off. Generalized edema.\n\nRespir: Remains on CMV. Suctioned for scant amount of thick yellow secretions.\n\nGI: Abd is softly distended, +bsx4, Gtube to LWCS with thick brown/ stool draining, aware of findings. Stoma pink and draining scant amounts of loose stool. Clear/yellow mucous draining from rectum.\n\nGU: Vaginal bleeding, aware, GYNO/OB to .\n\nSKIN: per family request: Xeroform applied to all folds: Underarms, under breast, groin area. Sacral area with thick yellow/green foul drainage. Area cleansed well with soap and water followed by wound cleanser and Aquacel Ag, softsorg to cover. Right trocanter site with thick yellow foul drainage. Site also cleansed with soap and water followed by wound cleanser and Aquacel Ag. aware of findings, no intervention at this time.\n\n: Wound RN to follow . Gyno/OB consult . HD scheduled . Continue to monitor skin integrity, hemodynamics, family meetings as needed. ID to follow regarding antibiotic treatment. KUB scheduled to see if bowel obstruction is resolving.\n"},{"category":"Nursing/other","chartdate":"2132-10-21 00:00:00.000","description":"Report","row_id":1524431,"text":"Respiratory Care\nBreath sounds bilaterally coarse, suctioned intermittently for moderate thick yellowish secretions, pressure 20cmh2o, patient was afebrile whole day, stayed mostly into normal sinus rhythm, and was mostly hypotensive. Patient was treated with Albuterol and Atrovent inhalers, was swithched at 1015 am on her own home ventilator HT 50 with the help of respiratory supervisor,4L O2 bleeded in instead of dialing an FiO2, settings are about the same they were on , 450 x 22 5PEEP, patient might get discharged with next two days, should be put back on vent overnight since she has tracheostomy and the home vent only has HME. No ABGs drawn nor vent settings changes done up to this point.\n"},{"category":"Nursing/other","chartdate":"2132-10-21 00:00:00.000","description":"Report","row_id":1524432,"text":"Nursing Note 7a-7p:\nNursing Assessment:\n\nPt afebrile all day, white count coming down. Tentative plan to d/c home tommorrow but pt may have to stay d/t issues with supplies being covered by medicaid, which social work and casemanagement have been working on. Wound care nurse needs to contact medicaid and explain dressings/wounds and amounts of supplies needed. Wound care also to arrange a time with pt's family to go over the dressings for home . Other issues include GI to discuss with pt's dtr reasons for not changing over site again (including risk for bleeding/fistula formation). Vascular to be in touch with pt's dtr regarding toes and if they want to remove the toes or not. Dtr does not want BKA, but may be willing to remove just toes per case . Pt's dtr also requested that the pt be placed on home vent for trial prior to d/c home and has tolerated the home vent well all day today. Will go back on hospital ventilator tonight for humidification on trach. Home vent will be able to do this once set up at home, but we do not have the supplies here. CV: HR NSR to sinus <110 relieved with ativan and demerol and no ectopy. Mag repleted this morning. Continues on amiodorone, digoxin, midarone po, diltazem po d/c'd d/t continued low bps. HCT now stable at 31 and no further products necessary at this time. Endo: RISS and am glargine sugars 200s adn team aware. REsp: lungs coarse at times, cleared with suctioning, and diminished throughout. Placed on home vent this morning and tolerated well all day.\nPlan: Discharge planning continues, working towards getting patient home this week. Social work and case management. Vascular/GI to discuss plans with dtr regarding /amp of toes. Dialysis tommorrow. Wound supplies needed for home. to monitor hct and glucose levels, if remain stable ok to d/c home and when all other previously mentioned issues are resolved. MICU team has been updated with all concerns/issues mentioned above. Please refer to carevue for details.\n"},{"category":"Nursing/other","chartdate":"2132-10-22 00:00:00.000","description":"Report","row_id":1524433,"text":"Update\nSee Carevue for specifics\n\nNeuro: Alertness waxes and wanes but unable to assess orientation. Will nod appropriately to questions. Follows commands inconsistently. Localizes pain. Purposeful movements at times. Lifted and held LUE. No movement in other extremeties. PERRL.\n\nCV: ST early in shift correlating with tmax of 100.7. Blood cx'd. Currently afebrile and NSR. 70s-110s. Hct pending.\n\nResp: Switched from home vent back to . LS coarse/diminished. Sats 98-100%. Sxn'd for moderate thick yellow secretions.\n\nGI: TF to goal, no residuals. Colostomy draining golden liquid stool. G tube draining clear fluid. Drainage bag around G-J tube collecting serosang drainage. Chem 7 pending.\n\nGU: HD scheduled for next shift.\n\nSkin: Grossly impaired. See Carevue for details.\n\nPsychosocial: son in to visit early evening.\n\nPlan: Wound care RN to contact Medicaid & meet with daughter for wound care education. Continue planning discharge.\n"},{"category":"Nursing/other","chartdate":"2132-10-22 00:00:00.000","description":"Report","row_id":1524434,"text":"Respiratory Care:\nPatient switched from home ventilator to , as noted in CareVue. SX'd for small to moderate amounts of thick, yellow sputum. No abg results this am.\n\nNo due to hemodynamic instability.\n"},{"category":"Nursing/other","chartdate":"2132-09-18 00:00:00.000","description":"Report","row_id":1524297,"text":"nursing note\nNeuro:Pt alert, nodding approp at times. Daughter in to viisit and upset with head motion side to side, as in nodding \"no\". MD aware and spoke with daughter regarding this. hypothermic-bairhugger on.\nCV: NSR wtih rate controlled on dilt. Neo weaned slightly to .3. cont to keep even.\nRESP:ls coarse, thick white sputum. ambu'd and lavaged by RT and valve tried but pt unable to talk. Done per fmaily request.\nGI:loose brown stool via ostomy. GT/JT site with small pink drainage with air into bag into pouch.\n\nPLAN: cont to keep even. dilt/neo/insulin. awaiting plan from family.\n\n"},{"category":"Nursing/other","chartdate":"2132-09-18 00:00:00.000","description":"Report","row_id":1524298,"text":"Respiratory Care Note:\n patient remains trached with a #7 x-long Shiley trach in place and secure. Trach collar changed this shift. BS are coarse throughout. MDI's administered as ordered. Patient ambued and lavaged x 1 for a scant amount of thick white secretions. attempt made post ambu and patient too tired and unable to speak. Patient then placed back on full vent settings with inflated. SX for small amounts of white thick secretions via trach. patient remained afebrile this shift, bair hugger on. SPO2 remains 100%. patient often overbreathes vent by 10-13 breaths. Latest ABG acceptable. No RSBI this am as patient is vent dependent. CXR showed moderate bilateral pleural effusions, increasing on the left. Will continue with full support.\n"},{"category":"Nursing/other","chartdate":"2132-10-06 00:00:00.000","description":"Report","row_id":1524371,"text":"Update\nO: See carevue flowsheet for specifics.\nNeuro: Eyes open spontaneously perl at 3mm sluggish, does not track w eyes or follow any commands.Med x 1 for ? discomfort, family states pt uncomfortable and appearing more distressed, desires pt to have something for pain. Pt med w dilaudid 12.5mg w no appreciable change in pt status.Distress seems most likely to be respiratory in nature.See resp on carevue flowsheet.\n\nCV:sr w occ to freq pac's. Remains on dilt and low dose neo for bp/hr control.Distal pulses by doppler.Mult skin and circ issues w necrotic toes/ lt heel\n\nResp: Abg's bdline pao2 - metab acidosis worsening, vent adjustmnts made for same w slow imprvmnt in abg.Bbs coarse, lavage and suction for thick pale yellow secretions.\n\nGi: npo. gjtube-to gravity w no drng thru gj tube, 200cc serous around the tube.Abd distended, obese, + hypoactive bowel snds. Colostomy pink, edematous w sm amts of black loose stool.\n\nGu/Renal: crf makes no urine.HD 3x week,? to be dialyzed today.\n\nHeme/ID: hct 24-25 range, no treatment for now per micu team.Tmax 99.6 continues on meropenem and amikacin.\n\nSkin: Multiple non healing decubiti buttocks, rt hip and ble's. Wound care done to all sites.\n\n\nA/P: w supportive icu care. Wean neo and diltiazem as tol. Wound and skin care per wound care nurses plan. Aggressive pulm toilet.Multidisciplinary team family meeting today to discuss pt care plans, update.\n"},{"category":"Nursing/other","chartdate":"2132-10-20 00:00:00.000","description":"Report","row_id":1524427,"text":"Respiratory Care\nBreath sounds bilaterally coarse and diminished at bases, suctioned intermittently for moderate thick yellowish secretions, was afebrile, stayed mostly into normal sinus rhythm, WBC 13.6, ongoing bacterial infection, hemoglobin only 10, sign of anemia, creatine 1.7, sign of renal insufficiency for which patient had hemodialysis from 0900 am to 1100 am, patient has been treated with Albuterol, Atrovent and Flovent inhalers, no ABGs drawn, no vent changes made during the shift, patient will continue to receive mechanical ventilation and close monitoring.\n"},{"category":"Nursing/other","chartdate":"2132-10-20 00:00:00.000","description":"Report","row_id":1524428,"text":"Update\nSee Carevue for specifics\n\nNeuro: pt. alert but unable to assess level of orientation d/t trache. Pt. nods appropriately to questions, mouths words and actively tracks activity in the room. Inconsistently follows commands. Moved RLE on bed once, no movement from other extremeties but localizes pain.\n\nCV: NSR. 60s-105. Rare PVC's.\n\nResp: LS clear/coarse. Sats 95-100%. No vent changes. Sxn'd for very thick yellow sputum.\n\nGI: TF to goal. Colostomy putting out gold/green liquid stool. G-J tube re-pouched by enterostomal RN and stoma site draining small serosang fluid. G tube draining clear, slightly bilious fluid.\n\nGU: Dialysed in a.m. 2.3L removed. Pt. tolerated well with no hypotension.\n\nSkin: Grossly impaired with numerous areas of breakdown. Please see Carevue for details.\n\nID: Afebrile. Amikacin held d/t high level. New one drawn s/p HD.\n\nPsychosocial: husband and son visited in a.m. Daughter talked to RN and MD on the phone.\n\nPlan: Continue to monitor hemodynamic status. Continue to treat wounds agressively. Enterostomal nurse to call daughter with update on re: stomas/colostomies. ?trial home vent tomorrow. ?transfer to home on Wed.\n"},{"category":"Nursing/other","chartdate":"2132-10-21 00:00:00.000","description":"Report","row_id":1524429,"text":"NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT MOST OF THE NIGHT, MOUTHING WORDS, FOLLOWING SOME COMMANDS. ONLY MOVING LEFT UPPER ARM OCCASIONALLY ON THE BED. PERRL. PT NOT COMPLAINING OF PAIN, APPEARING COMFORTABLE, REPOSITIONED FREQUENTLY.\nCV- BP RANGING FROM 70'S SYSTOLIC TO 110, MAP 40'S-50'S. DR. NOTIFIED WHEN BP CONSISTENTLY BELOW 80'S SYSTOLIC. I UNIT OF PRBCS GIVEN FOR HCT 26, BP IMPROVED, AM HCT PENDING. HR 90'S, APPEARING TO BE IN A-FIB EARLY IN THE SHIFT, DR. NOTIFIED. KCL REPLETED IN THE LATE EVENING, PT IN NSR AT THIS TIME WITH OCCASIONAL PVCS AND PACS.\nRESP- LUNGS SOUND DIMINISHED, O2 SAT 99-100%. SUCTIONED OCCASIONALLY FOR SMALL AMOUNTS OF THICK YELLOW SPUTUM.\nSKIN- OOZING FROM SEVERAL AREAS OF SKIN TEARS, SMALL PIN POINT AREAS, AND VARIOUS DECUBS. MOST DRESSINGS INTACT, OUTER LAYERS OF DRESSINGS CHANGED AND REINFORCED WHEN APPEARING TO BE SOILED.\nGI/GU- ABD SOFT, HYPO SOUNDS. TOLERATING TF. PT DOES NOT VOID.\nID- AFEBRILE\n"},{"category":"Nursing/other","chartdate":"2132-10-21 00:00:00.000","description":"Report","row_id":1524430,"text":"RESPIRATORY CARE NOTE\n\nPatient remains trached with Shiley ex. long trach tube. No vent changes made during the . No MD order.\n\n , RRT\n"},{"category":"Nursing/other","chartdate":"2132-08-08 00:00:00.000","description":"Report","row_id":1524135,"text":"Nursing Progress Note\n Please see carevue for details of care. Alert, eyes open,follows simple commands and randomly nods yes or no but inconsistently. Spont movement in LUE only. PERL @ 4mm. Restless at times, settles down w/repositioning. BS cl/dim, suctions via trach for scant-small thick yellow secretions. Vent AC 450x16x40%+5PEEP.\n To IR this am for Peg tube change, tol well. No drainage around PEG post insertion this pm. TF and meds resumed after ok w/MICU resident on unit, minimal TF residual noted. BOS +, colos draining brown liquid BM.\n Multiple wounds persist, leg wounds dressing changed per wound care directions tol well. See carevue for specifics. Legs wounds draining pink serous drainage, no purulent or fkoul smelling drainage noted. Coccyx/ischial dressings to be changed on B shift.\n Insulin gtt remains off this shift, BS elvated to 300's, covered w/RISS. Glargine changed to dosing and SS tightened by team. team in this pm, aware of adjustments pending.\n Dgt/husband in this pm. Insist on feeding patiernt ice chips in spite of direction of staff not to d/t cuff leak and chance for aspiration. Daughter upset that PEG was changed and placed in Jejunum. Attempted to obtain records from admit but unable d/t time of day (after 5p). Will attempt record retrieval on Monday.\n PLAN: Continue to monitor glucose needs/demands, dressing changes, monitor VS, family support and education.\n"},{"category":"Nursing/other","chartdate":"2132-08-09 00:00:00.000","description":"Report","row_id":1524136,"text":"NURSING PROGRESS NOTE: SEE CAREVUE FOR OBJECTIVE DATA AND TRENDS\n\nNEURO: ALERT. OCC MOUTHING WORDS TO MAKE NEEDS KNOWN. APPEARS TO NOD APPROP TO YES/NO QUESTIONS. INCONSISTENTLY FOLLOWS COMMANDS. PERRLA, 4MM/4MM,BRISK. OCC SPONTANEOUS MOVEMENT OF LUE. +WEAK COUGH. MEDICATED WITH 12.5MG DEMEROL X1 FOR TROCANTER/COCCYX DRESSING CHANGE. PT TOLERATED DRESSING CHANGE WELL.\n\nCARDIAC: HCT: 28. A-FIB. HR-90'S-110'S. NIBP: 93-110/39-67. 12.5MG LOPRESSOR GIVEN WITH EFFECT. COUMADIN 2.5MG GIVEN. INR: 2.6. +RADIAL/FEMORAL/POPITEAL/PT/DP X2. CSL ON.\n\nPULM: TRACHED. CMV/40%/450/5 PEEP. POX: 98-100%. LS: R+LUL CLEAR,DIMINISHED BIBASILAR. SX FOR SM AMTS OF THICK YELLOW SPUTUM.\nVENOUS GAS SENT AT 1800 ON WNL.\n\nGI: REMAINS NPO. G-TUBE SITE WITH SM AMT OF CLEAR DRAINAGE. DRESSING CHANGED. TOLERATING TF AT GOAL WITH NO RESIDUALS. ABD: OBESE,+HYPOACTIVE BS,S,NT. OSTOMY STOMA MOIST PINK WITH BROWN LIQUID STOOL.\n\nGU: ANURIC. LYTES WNL.\n\nENDO: FS QID. FS: 258-277. COVERAGE PER RISS. LANTUS INCREASED TO .\n\nINVL: R-AC SINGLE LUMEN PICC. SITE WNL,DRESSING INTACT. R-HD CATH SITE WNL,DRESSING INTACT.\n\nID: AFEBRILE. CONTINUES ON MEROPENEM.\n\nSOCIAL: DAUGHTER AND HUSBAND IN TO VISIT. CRITICAL QUESTIONS REGARDING G-TUBE PLACEMENT/DRAINAGE AROUND SITE ADDRESS. FAMILY CONCERNED ABOUT DISCHARGE TO HOME D/T MEDICAL NEEDS.\n\nPLAN: Q 4 HOUR NEURO CHECKS. MONITOR HEMODYNAMICS. FOLLOW FS Q4-6 HOURS. LANTUS INCREASED TO . CONSULTED ON . MEDICATE PRN FOR PAIN. DRESSING CHANGES TO TROCANTER/COCCYX AND LOWER EXTREMITES QD. WOUND CARE CONSULT TO ADDRESS DRAINAGE AT G-TUBE SITE. REPOSITION Q 2. SURVAILLENCE LABS PRN. MONITOR INR'S. PROVIDE EMOTIONAL SUPPORT TO PT AND FAMILY. SOCIALWORK CONSULTED AND TO FOLLOW.\n\n"},{"category":"Nursing/other","chartdate":"2132-10-06 00:00:00.000","description":"Report","row_id":1524372,"text":"Nursing Progress Note\n Please see carevue for details of care. HD tol well this am, BP remains stable on 0.2mcg of neo. Dressing changew post HD today for mod-lg amt drainage and multiple areas of skin tears persist around wounds. Nuero satatus unchanged this shift, does not track movements in room.\n Blleding from colostomy site w/large amt dark black clots in colostomy appliance followed by bright red blood. Labs drawn, HCT 21.9. Total 6 units PRBC's, 1 unit and 1 dose of DDAVP hung. 1L LR infusing wide open, EJ line attempted unsuccessfully by MICU attending. TO angio this pm.\n"},{"category":"Nursing/other","chartdate":"2132-10-07 00:00:00.000","description":"Report","row_id":1524373,"text":"Respiratory Care:\nPatient remains on A/C ventilatory support, returning from IR. No parametr settings changed throughout the night. Latest abg results determined a mild metabolic acidemia with very good oxygenation on the current settings. MDI albuterol and atrovent administerd in-line with each vent check. Sx'd for a moderate amount of thick, yellow secretions at the last vent check.\n\nNo RSBI measured at this time due to the patient's high FIO2 and unstable cardiodynamics.\n"},{"category":"Nursing/other","chartdate":"2132-10-07 00:00:00.000","description":"Report","row_id":1524374,"text":"Update\nO: See carevue flowsheet and IR flowsheet for specifics.\nPt in IR until 2330.Relatively stable on neo 0.5 to 1.25 mcg/kg/min and ppfl at 20mcg/kg/m for sedation.Attempts by IR MD unsuccessful d.t inabilty to locate any bleeders. Hct stable at 34 x 2 in IR suite. Tlc line placed in IR and pt returned to sicu. Overnight pt req relatively more neo and flds to maintain ~80 and mbp 55. Per micu team pt to have endoscopy today-> golytely initiated and pt putting out initially lg dk clotty drng via colostomy-> to brb w hct drop. Fld x 2 liters and colloid resusc w x4 units and 5 prbc overnght. Despite aggressive volume resusc pt still having difficulty maintaining bp, neo gtt max dose at 5mc/kg and vasopresssin added w some improvemnt until 630am w incr via colostomy pt req more bld products and levophed ordered to support bp. Dr here and aware of changes, Endoscopy called by Dr to notify of urgent need for scope early am.\nCv- remains in afib, rate fairly controlled;unable to receive diltiazem overnight d/t low bp. Doppler pulses present and groin sites check per protocol orders. Sm hematoma rt groin, intermitt sm ss ooze rt groin only.\n\nResP: remains vented on cmv mode-see resp sheet/ w metab acidosis. HO aware. Bbs coarse suct for mod amts of thick yellow sputum.\n\nGi: gj tube to drng bag w sm to mod coffee grnd around gjtube, nothing draining through it. Abd obese slt firm distended. Colostomy as noted above w overnight.Glucoses managed w insulin gtt. Nutrition overnght receiving tpn.\n\nGu/Renal: hd yesterday tol well w 3liters removed.\n\nSKin: mult decubs buttocks, bilat lower legs and anasarca. Drsgs changed per skin care nurse.\n\nPsych/Soc/ Family: extensive support and allowance for time for questions to be answered given by Dr ; nursing and resp staff as well addressed some of family's questions and concerns. Pt family daughter & son escorted by security for visit. Daughter hostile and voicing discontent of her mothers care to medical and nsg staff, spoke w Nsg supervisor as well.\n\nA/P: titrate neo, levo, pitressin for goal 80 mbp 55. check results of hct & check w HO re: # of prbc transfused. Glucoses q1 and titrate gtt. per protocol.Keep case managemnt up to date and involved w team to maintain clear communication w family.\n"},{"category":"Nursing/other","chartdate":"2132-10-26 00:00:00.000","description":"Report","row_id":1524451,"text":"Respiratory Care\nPt remains trached and on vent support. No vent changes were made during shift. No ABG's were drawn during shift. Lung sounds clear at start of shift and became course and diminished in the bases. Pt was suctioned for scant to moderate amounts of thick yellow secretions. Pt received MDI's. Albuterol was NOT given at 1200 and 1600 due to HR >110. Pt received Flovent at 1200 as MDI was empty and replacement not available at 0800. Care plan is to place pt on home vent tonight at midnight and leave on vent until D/C for home. Will continue to follow pt.\n"},{"category":"Nursing/other","chartdate":"2132-08-02 00:00:00.000","description":"Report","row_id":1524106,"text":"nursing progress note\nPlease see careview for details\n\nNeuro: perl, nods to some questions, not moving extrmities on bed. nailbed pressure not applied due to discoloration and eschar of extremities.\n\nCV: afib, heparin drip at 750 u/hr with ptt 77. bp stable. bilat pedal pulsses palp, rt foot toes black, bleeding from debrided area with dsd changed x 2. hct stable.\n\npulm: vented at 40 %. A/C. sats 100%, sx sm-mod amts thick tan. bs clear to diminished in bases.\n\ngi: tol tube feeds well, colostomy drainage 200 cc guaiac trace pos.\n\ngu: anuric, for hemodialysis today.\n\nskin: rt foot wound is black with eschar. dsd changed x 2 for mod amts bleeding. all other dsgs clean and dry, changed x 1 /day.\n"},{"category":"Nursing/other","chartdate":"2132-08-02 00:00:00.000","description":"Report","row_id":1524107,"text":"nursing progress note\ninsulin drip at 20-3 u/hr to regulate high blood sugars. glargine 80 u sc given at 2200.\n"},{"category":"Nursing/other","chartdate":"2132-08-02 00:00:00.000","description":"Report","row_id":1524108,"text":"Respiratory Therapy\nPt remainstrached #6 Shiley cuff pressure 38cm. BS coarse rhonchi bilaterally W diffuse I&e wheezes which clear after Sx and MDI's.Sx for sml to mod thick yellow/tan secretions. Please see nsg note and carevue for specifics.\n"},{"category":"Nursing/other","chartdate":"2132-08-02 00:00:00.000","description":"Report","row_id":1524109,"text":"Resp Care\npt remains trach on mech vent. no vent changes this shift. pt taken to MRI today for scan of lower back bed sore, trip uneventful. pt has slightly course/wheezy BS, suctioned for sm-mod amt of thick secretions MDIs given as ordered. will continue to follow.\n"},{"category":"Nursing/other","chartdate":"2132-08-02 00:00:00.000","description":"Report","row_id":1524110,"text":"NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT, NODDING HEAD TO SOME QUESTIONS. DENIES PAIN WHEN AT REST. ONLY LOWER EXT. AND LEFT UPPER ARM MOVING SPONTANEOUSLY AND ONLY SLIGHTLY ON THE BED. PERRL.\nCV- BP RANGING FROM 80'S- 115. REQUIRED FLUID BOLUSES DURING DIALYSIS THIS AM. I UNIT OF PRBCS GIVEN AND 25 G OF ALBUMIN TO KEEP BP ABOVE 85 SYSTOLICALLY DURING DIALYSIS. PT COULD ONLY TOLERATE REMOVAL OF ABOUT 700CC. HR TO 150'S THIS AM, A-FIB. SHOWN TO MICU TEAM ON ROUNDS, LOPRESSOR PO GIVEN AS SCHEDULED AND 2.5 MG LOPRESSOR IV ALSO GIVEN WITH GOOD EFFECT. HR REMAINS 90'S-110 FOR THE REMAINDER OF THE SHIFT, OCCASIONAL PVCS, POST DIALYSIS LABS, INCLUDING A HCT SENT. PTT GREATER THAN 150 THIS AM, HEPARIN GTT STOPPED FOR TWO HOURS AND RESTARTED AT 600U. NEXT PTT DUE AT .\nRESP- LUNGS CLEAR, VENT SETTINGS REMAIN THE SAME. NO DIFFICULTY BREATHING NOTED.\nGI/GU- ABD SOFT AND DISTENDED. COLOSTOMY DRAINING SEMI FORMED LOOSE BROWN STOOL, STOMA APPEARS TO BE BEEFY RED. TOLERATING TF AT GOAL, INSULIN GTT REMAINS ON AND BS RANGING FROM 90'S- 150'S. PT DOES NOT VOID.\nSKIN- SKIN REMAINS WEEPY IN SOME AREAS. ALL DRESSINGS TAKEN DOWN AND CHANGED TODAY. SACRAL DECUB GREYISH ON INSIDE WITH RED EXCORIATED SKIN AROUND WOUND. PACKED WITH AQUACEL AND COVERED WITH DSD. ALL AREA OF INTACT SKIN COVERED WITH ALOE VESTA BARRIER CREAM. RIGHT GREAT TOE CONTINUES TO OOZE BRB, DRESSING CHANGED SEVERAL TIMES, HCT MONITORED. MRI TODAY FOR SACRAL DECUB TO CHECK FOR OSTEO, RESULTS PENDING, PT TOLERATED WELL.\n"},{"category":"Nursing/other","chartdate":"2132-08-03 00:00:00.000","description":"Report","row_id":1524111,"text":"Resp Care\nPt remains on CMV stable no vent changes. Plan to continue with current tx.\n"},{"category":"Nursing/other","chartdate":"2132-08-29 00:00:00.000","description":"Report","row_id":1524221,"text":"Admitted via ER with fever,fatigue and hyperglycemia,?sepsis.Patient on mechanical ventilation At home. More alert today,suctioned for moderate amount of thick yellow secretion.Being treated with Floventterol and Atrovent. Has periods of hypotension and bradycardia.meeting with family to discuss disposition of patient on hold as daughter does not want to discuss it untill patient home services are specifically arranged :dialysis done today.\n"},{"category":"Nursing/other","chartdate":"2132-08-29 00:00:00.000","description":"Report","row_id":1524222,"text":"condition update\nplease see carevue for specifics.\n\nafebrile. pt nodding yes/no appropriately. afib. hd today. vanco and tobra given, levels drawn. bld cx's taken from hd catheter. vag ultrasound done d/t bleeding. foley instilled w/ 400cc ns. when ns drained bright red blood draining. micu aware. foley kept in and being irrigated. red blood continues. hct 23.\n\nsxn'd for thick, yellow sputum. no vent changes made. w/ propass infusing via peg. maroon colored blood noted in peg. micu team notified.\n\nplan: monitor hcts/ hemodynamics. dressing changes as ordered. iv abx.\n"},{"category":"Nursing/other","chartdate":"2132-08-30 00:00:00.000","description":"Report","row_id":1524223,"text":"Respiratory Care\nPt remains trached on full vent support. No ventilator changes made this shift. BS coarse and diminished @ bases. Suctioned for moderate amounts of thick yellow/tan secretions. Pt awake & alert and breathing over the vent at this time. No recent ABG. Morning RSBI not completed due to decreased BP.\nPlan: Continue current vent support, ? trial\n"},{"category":"Nursing/other","chartdate":"2132-08-30 00:00:00.000","description":"Report","row_id":1524224,"text":"NURSING\n VSS, AFEBRILE. CONTINUES IN AFIB. NO ECTOPY. HCT DECREASED TO 23, TRANSFUSED WITH 1 UNIT RBC'S. REPEAT HCT 26.\n CONTINUES TO HAVE VAGINAL BLEEDING AND BLEEDING FROM FOLEY, ALTHOUGH BLEEDING FROM FOLEY APPEARS TO BE DECREASED. NOW IRRIGATION APPEARS TO JUST BE BLOOD TINGED FROM TUBING OR PERHAPS A CLOT IN BLADDER. IRRIGATED Q 2 HRS OVERNIGHT WITH 120 CC EACH TIME. OLD LOOKING BLOOD PRESENT IN GT CHANNEL OF TUBE, MD'S AWARE AND HAVE EXAMINED PATIENT. HEMATOLOGY CONSULT PUT IN BY MICU TEAM.\n CONTINUES TO HAVE MODERATE AMOUNTS OF SPUTUM TAN TO GREEN TINGED FROM TRACH. SUCTIONED Q 2-3 OVERNIGHT.\n CONTINUE TO MONITER HEMODYNAMICS, BLEEDING. REPEAT HCT EARLY AFTERNOON.\n"},{"category":"Nursing/other","chartdate":"2132-08-30 00:00:00.000","description":"Report","row_id":1524225,"text":"Neuro: pt alert. responds to question by nodding. Minimal movement of limbs very slight movement of feet and rt arm . noted to move left arm slightly on bed.\nPain: complained of pain x1. Given tylenol 650mg x1.\nCV: AF 100's currently early Hr has high as 130's improved after am amniodarone and Digoxin. ABP dropped to 80's a few times but improved without tx. DP/PT.\nLungs: Coarse throughout. suction for thick yellow sputum. trach care given green drainage around trach.\nGI: ABD soft BS present. G/J tube TF at goal tolerated well. J tube with no further bleeding noted. Colostomy drainage liquid. stoma pinkish red.\nGU: Foley to gravity. minimal bloody drainage when irrigated obtain small clots.\nSkin: necrotic toes left heel necrotic. pressure sores on coccyx and hips. see care view and wound care note. DSG changed at 11am.\nA/P DSG changes per wound nurses . frequent turns. serial hct.. monitor bleeding hct notify ho of changes.\n"},{"category":"Nursing/other","chartdate":"2132-10-26 00:00:00.000","description":"Report","row_id":1524452,"text":"NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\nNEURO: NEUROS UNCHANGED, MORE ALERT TODAY, MIN NODDING TO QUESTIONS, NOT TRACKING TO VOICE. PERRL, 4-5MM, BRISK. ATIVAN GIVEN X2 R/T TACHYPNEA, DISCOMFORT. DEMEROL GIVEN X2 R/T FREQUENT TURNING & REPOSITIONING, PRIOR TO DSG CHANGES.\n\nCVS: HR 90S-100S, UP TO 120S THIS PM W/MILD(99.8)FEVER AND TACHYPNEA-MD AWARE, NO CULTURES AT THIS TIME, TO FOLLOW. MAP MAINTAINED>60 PER GOAL, 70S-100S. PICC DSG CHANGED, ?PLACEMENT R/T FREQUENT TURNING, MICU RESIDENT AWARE. PM HCT 32.9, NO NEW BLEEDING NOTED. MAG OXIDE GIVEN FOR AM MAG 1.9, AM SODIUM 148.\n\nRESP: NO VENT CHANGES MADE, REMAINS ON A/C, NO VBG DONE. PT TACHYPNEIC UP TO 30S, ATIVAN GIVEN X2 W/MIN RELIEF. LUNGS COARSE, DIMINISHED AT BASES. PT SUCTIONED FOR MOD/LGE AMTS THICK, YELLOW SECRETIONS. PT TO BE PUT ON \"HOME VENT\" AT MN PER RESP.\n\nGI/GU: TF AT 40CC/HR, NO RESIDUAL, FLUSHED W/200CC Q4. GT TO GRAVITY W/SM AMT YELLOW, VISCOUS FLUID. OSTOMY BAG AROUND G-JT W/SM AMT STRAW-COLORED FLUID. COLOSTOMY W/MOD AMT GREENISH-BROWN LOOSE STOOL, NO BLOOD NOTED. CLEAR-BROWN MUCOID RECTAL DRNG NOTED, VAGINAL BLEEDINAL.\n\nENDO: BS COVERED PER RISS, AM LANTUS GIVEN\nID: PLAN TO AT HOME. RECIEVING AMIKACIN, MEROPENEM, DAPTOMYCIN.\n\nINTEG: MULTI SKIN TEARS, AREAS OF LGE AMTS SEROUS DRNG COVERED W/DSD. BLE/TOE DSGS CHANGED, SACRAL/R-HIP DECUB ULCERS PACKED W/AQUACEL, COVERED W/DSD, RE-DRESSED PRN. W/LGE GEN SEROUS DRNG, GEN ANASARCA. SARNA LOTION APPLIED TO RIGHT LATERAL RASH. MULTIPLE AREAS OF ABRASIONS/BREAKDOWN COVERED W/ADAPTIC AS ORDERED. PT TURNED, REPOSITIONED FREQUENTLY.\n\nPLAN: SICU , ATIVAN & DEMEROL FOR PT COMFORT, PLAN FOR D/C TO HOME , AFTER AM HD. HEMODYNAMIC MONITORING, RESP SUPPORT. REPEAT HCT, ?BLD CULTURES IF PT REMAINS FEBRILE. AGGRESSIVE SKIN CARE.\n\n\n"},{"category":"Nursing/other","chartdate":"2132-08-10 00:00:00.000","description":"Report","row_id":1524142,"text":"Condition Update A:\nPlease refer to careview and remarks for details.\n\nPt calmly alert and dozing periodically. Ativan held as no indications of anxiety and continued hypotension as discussed with MICU team ( Dr. ). Tmax 100.1. cont in afib with rare PVC's. Pt received 1.25L in LR boluses for hypotension 70-80's with MAP's<50. H20 boluses started and increased to 250cc every four hours for low Na level and hypotension. Pt's SBP improving during the late afternoon, up to 120-130.\n\nJ-tube leaking small amount of thick clear mucous. Dsg changed at 0800 and remains C/D/I. The two areas of breakdown ( at the 1000 and 0500 position unchanged from ). BLE dsgs changed at 0800, please refer to careview for specifics.\n\nWBC 17. K 3.8 Ph 1.2. Stool (P) for c-diff. Glucose levels improved from with increased Lantis dose and RISS.\n\nPLAN: Vanco 1g IV every 48 hours. KPhos infusing. Obtain blood cultures, RT to obtain sputum. Monitor glucose levels. Cont discharge planning. Call H.O. for changes.\n"},{"category":"Nursing/other","chartdate":"2132-08-10 00:00:00.000","description":"Report","row_id":1524143,"text":"Resp Care: Pt remains intubated via #6 Shiley trach, cuff leak noted. Team is aware. Achieving gd Vt's. Sx'd for mod amts thick tan sputum. MDI's given as ordered. No vent changes made this shift. No recent ABG. Cxray pending. Cxray \"small R pl. eff. L lung clear\". Plan: cont vent support. Please see carevue for further vent inquiries.\n"},{"category":"Nursing/other","chartdate":"2132-08-11 00:00:00.000","description":"Report","row_id":1524144,"text":"Update\nSee careview for details....\n\nNeuro: Pt alert and awake, follows simple commands, moves extrems in bed\n\nCV: A fib, 90-110's, afebrile, BP 80's-110's\n\nResp: Lungs clear, sx scant white sputum and sent for cx, vent unchanged, trach care done\n\nGI: tol TF's, + BS, colostomy dng liquid brown stool\n\nGU: pt does not void\n\nSkin: Pt turned Q2hrs, on air matress, waffle boots on, dsd to LE's D/I, sacral dsg changed, pink tissue with areas of yellow/green slough, sm amt bleeding, dsgs to hips intact, J tube site dng amts thick clear dng, dsg changed x2, pt med with demerol prior to dsg change\n\nPlan: Wound care, emotional support for family\n"},{"category":"Nursing/other","chartdate":"2132-08-11 00:00:00.000","description":"Report","row_id":1524145,"text":"Resp Care\nPt. remains trached, chronic vent, no changes overnight, no rsbi.\nBs: clear equal bilat. secreations minimal, spec sent. Mdis as ordered.\nPlan: cont. current support.\n"},{"category":"Nursing/other","chartdate":"2132-08-11 00:00:00.000","description":"Report","row_id":1524146,"text":"BS generally CTAB, occ rhonchi clearing with suction. CUff pressure measured and maintained at 16-18cm. ? discharge to home tomorrow. Instruct daughter how to measure cuff pressures. Tolerate small leaks if necessary per Dr. .\n"},{"category":"Nursing/other","chartdate":"2132-09-01 00:00:00.000","description":"Report","row_id":1524232,"text":"DNR Contact Precautions - MRSA/VRE\nAllergies: Morphine, Erthromycin, Fent, Keflex\n\n\nNeuro: Opens eyes spont and occ tracks - pupils 5mm/brisk. No movement in extrems - occ L hand moves - no movement on command. She nods approp.\n\nCV: HR=90-100s, afib, no ectopy. BP=78-110/40-50s. +edema, extrems warm.\n\nResp: 450x16, 40%, P=5 - 02sat 98-96%. Suction small amt thick tan secretions - lungs fairly clear, diminished in bases bilat. RR=14-22.\n\nGI/GU: abd obese, g-jtube intact - tube feeds at 40cc/hr. Colostomy fx- liq golden brown stool - 400cc/shift. Foley cath - no urine. Output has been BRB - irrigated this am - no clots, bloody returns, but no additional output for the day. Dialyzed for 2liters.\n\nSkin: Ostomy appliance changed for leaking. g-jtube leaks at site - dressing changed. Coccyx, ischeal, and leg dressings changes. Bilat hip dressing w/ allevyn changed yesterday - due to be changed on .\n\nAccess: Rsubcl dialysis cath, R antecub single lumen PICC. Ordered placed for tunneled dialysis cath.\n\nPain: Med w/ demerol 12.5mg IVP for dressing change. Ativan .5mg po ATC.\n\nSocial: Son in this evening - updated.\n\nPlan: Continue w/ current plan. Ethics reviewing the case and legal consult in as well. Case management continues to review possiblilities when pt is ready to be d/c'd.\n"},{"category":"Nursing/other","chartdate":"2132-09-01 00:00:00.000","description":"Report","row_id":1524233,"text":"Respiratory Therapist\nBreath sounds bilaterally clear and diminished, suctioned for small amount of thick green secretions WBC 18.8 consistent with bacterial infection, hemoglobin only 9 suggests anemia, creatine 2.4 suggest renal insufficiency for which patient had dialysis today started at 1000 am, patient was treated with Albuterol, Atrovent and Flovent inhalers, no ABGs nor vent changes made up to this moment.\n"},{"category":"Nursing/other","chartdate":"2132-09-02 00:00:00.000","description":"Report","row_id":1524234,"text":"Nursing Assessment Note 1900-0700\nNEURO: Pt neuro status remains unchanged, pt will open eyes to voice and will follow simple commands, but does not try to mouth words\n\nCV: Pt's vss, afebrile, pt has right A/C picc line with NS @ , pt in AFIB, skin is pale, warm, and dry, pp + & =, with +2 generalized edema, Pt given dose of Desmopressin for her bleeding, the hope is to stop bleeding so pt can be started on heparin gtt\n\nRESP: Pt's has 7.0 extra long shiley on CMV Rate-16, TV-450, PEEP-5, Fio2-40%, with sats 97-100%, pt suctioned for scant amount thick yellow sputum, Lung sounds are coarse throughout\n\nGI: Pt has peg G/J tube with tube feeding infusing at goal rate of 40 cc/hour, placement confirmed via air , pt's colostomy draining brown liquid stool, stoma is pink and beefy\n\nGU: pt's foley has very small amount bloody drainage, pt is dialysis pt and does not make urine\n\nPLAN:\n-Continue to monitor bleeding, once bleeding stops, pt to be started on heparin drip\n-? home placement vs. , family would prefer home, but issue's still need to be worked out\n"},{"category":"Nursing/other","chartdate":"2132-09-02 00:00:00.000","description":"Report","row_id":1524235,"text":"Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. No morning abg results at this time.\n\nRSBI = 93 on 0-PEEP and 5 cm PSV.\n"},{"category":"Nursing/other","chartdate":"2132-10-07 00:00:00.000","description":"Report","row_id":1524375,"text":"condition update\nplease see carevue for all specifics.\nneuro: does not follow commands, rare spont. movements noted on left arm this am, but not this afternoon. Does not attempt to communicate, does not track in room. Pupils are 4mm and sluggishly reactive. Pt received 1mg midaz. this am for endoscopy, midaz gtt started this afternoon for comfort, d/c'd this pm as per Dr. instructions, will as necessary.\ncv: afib 100's. vasopression, levo titrated off, with goal map >60. Pt received total of 6 units prbc's, 2 platelets, and 3 this shift. for hct 19, and inr as high as 2.1 Also received 2 liters ns for hypotension. hct currently stable at ~34. Ostomy draining copoius amts. bright red blood this am, which has slowed significantly.\nresp: see resp. note for specifics, suctioned for small amts. thick yellow sputum. trach. care done. Rate increased for acidosis, fi02 weaned down to 50%. Ls coarse and diminished.\ngi: abd. if firm distended, +bs, colsotomy draining brb this am, endosopy done at bedside per gi, clips applied. tolerated well. GI bleeding decreased significantly.\ngu/renal: cvvh started this afternoon by a 2nd RN.\nendo: insulin gtt titrated, off this afternoon for bs 53 - received 1/3 amp d50.\nsocial: Daughter called and was updated by this rn and Dr. . Husband and son at bedside this am.\nplan: continue to titrate neo to keep map >60, monitor hct, monitor colostomy output, continue ddavp and decadron, . cvvh.\n\n"},{"category":"Nursing/other","chartdate":"2132-10-07 00:00:00.000","description":"Report","row_id":1524376,"text":"addendum\nbilat. leg, and groin dsg changed today as per wound care rn instructions. Sacral and hip dsgs deferred as pt may not tolerate extended turning d/t pt's unstable hemodynamic status.\n"},{"category":"Nursing/other","chartdate":"2132-10-08 00:00:00.000","description":"Report","row_id":1524377,"text":"nursing note\nPt opening at eyes at times, not following commands or acknowedging request s by nodding or moving. No movement of extremeties. Afib with bursts to 120's. Neo weaned down to keep MAP >55, sys >90. to keep even. MD , keep pt. even and go up on pressors if needed. LS coarse,thick yellow secretions. NPO. Osotmy with melena output, minimal amounts. HCT/plt/INR stable. . on DDAVP and decadron. Son and in to visit and calm and appropriate with care and questions. Son escorted by security and non aggressive with this RN.\n\nPLAN: CVHHDF to keep even and go up on pressors as needed. insulin gtt. DDAVP and decadron. labs q6. family support and guidelines as in place.\n\n"},{"category":"Nursing/other","chartdate":"2132-10-08 00:00:00.000","description":"Report","row_id":1524378,"text":"Resp Care Note, Pt remains on current vent settings.See vent flow sheet for details. Suctioned mod amts thick yellow secrtions.MDI'S given, HR-A-Fib. Getting neosynephrine and insulin. . Will to monitor resp status.\n"},{"category":"Nursing/other","chartdate":"2132-10-08 00:00:00.000","description":"Report","row_id":1524379,"text":"Resp Care\nPt remains trached on A/C. FIO2 increased from 40 to 60 due to ABG results. MDI's given. No other changes noted.\n"},{"category":"Nursing/other","chartdate":"2132-10-27 00:00:00.000","description":"Report","row_id":1524453,"text":"Resp Care,\nPt. remains on A/C . Suctioned for copious amount thick yellow sputum. Planned to put on home vent MN, but developed tachycardia and RR high 30's with MV 21L. MICU team aware pt. not placed on home vent.Will attempt this am. See carevue.\n"},{"category":"Nursing/other","chartdate":"2132-08-22 00:00:00.000","description":"Report","row_id":1524191,"text":"Neuro: Pt alert and awake all night. Able to talk around trach, ? leak. Able to make needs known. Med for pain X2 per pt request with good effect.\n\nCV: Hypothermic 92.0, Bare hugger inplace T=95.2. Pt refusing oral temp and requiring coaxing to obtain axillary temp. HR 80-100's Afib with no noted ectopy, SBP 80-130's. CVVH continues pt remains even.\n pulses bilat dorsal. Extremities cool and pale.\n\nRESP: lung clear to dim at bases. Requiring occasional suctioning of thick tan secretions with plugs.\n\nGI: tol tube feed. Colostomy draining small amounts of golden liquid stool.\n\nGU: Remains aneuric\n\nENDO: blood sugars WNL overnight. Recieved lantus per order.\n\nPLAN: Family would like to speak to renal team today concerning CVVH, Family cont to request Shiley trach reinserted as soon as possible.\n"},{"category":"Nursing/other","chartdate":"2132-08-22 00:00:00.000","description":"Report","row_id":1524192,"text":"Events:\n\n clotted and D/C per Renal team, plan for HD Monday\nPulmonary into see patient plan for Bronch and trach change Monday\n\nNeuro-PERL, moves upper extrem purposefully, mouths words, and shakes head to yes/no questions, denies pain\nCV-MP Afib irreg S1 S2, continues on amio/lopressor, amio dose decreased r/t elevated INR, coumadin held, doppler pulses LE bilaterally, necrotic toes bilaterally\nResp-Remains on AC LS coarse upper lobes dim at bases, sx for thick tan secretions\nGI-TF at 40cc/hr, glucose well controlled with glargine 90u SQ , colostomy with liquid stool out, pending\nGU-anuric, d/c acid base balance and lytes monitored\nskin-see carvue\n\nFamily-daughter phoned in update given, daughter gives recomendations for patient care regarding HD and albumin, renal nephrologist attempt to contact daughter to give update. Daughter into see patient. states \"my mother should get what she wants, not what wants, my mother has been through enough. states \"my mother never wanted hemodialysis and my mother is aware that if she does not get hemodialysis she would die\". states we just wanted my mother to be home and be comfortable, not going in and out of the hospital\". states the HCP form is the patient first, her mother. Stating her family should listen to her mother first, also second to make decisions is the patient husband. states her father is old almost 70yrs old and has taken over. request to speak with social work, social worker updated , MICU MD notified, question need for ethics consult, also chart need to to be reviewed for HCP proxy form. Emotional support provided. Awaiting social work and MICU review of legal documents\n\nPlan-pulmonary toilet, skin care, maintain pts comfort, monitor fluid balance, HD on Monday, cont ABX\n"},{"category":"Nursing/other","chartdate":"2132-08-22 00:00:00.000","description":"Report","row_id":1524193,"text":"Respiratory care\n\n Pt continues on A/C as per home regime. B/S coarse sx'd for thick tan secretions. Adjustable flange on trach found open. Trach at #7 replaced to the #11 flange closed CXR pending. Pt ventilating in NARD. Will continue to follow closely.\n"},{"category":"Nursing/other","chartdate":"2132-08-22 00:00:00.000","description":"Report","row_id":1524194,"text":"Addendum:\n\nSocial work and MICU resident updated on daughter concerns of whether the patient is getting what she wants. stated that 6 out ot the 8 children agree that her mother would not want to live like this and would not want hemodialysis.\n\nEthics consult: Dr. into evaluate chart. Plan for family meeting to address current plan of care and evaluate evidence of \"what the patient would want\", message left with daughter to call Dr at \n\nSocial work and ethics to follow up with family on Monday\n\n"},{"category":"Nursing/other","chartdate":"2132-08-22 00:00:00.000","description":"Report","row_id":1524195,"text":"Addendum: Family\n\nSon into see patient, states \"we are not all crazy\", I aksed what he met. He said my family is working hard to take care of my mother, maybe \"she has to go through the fires of hell to get to heaven\", we did get told at that if the hemodialysis was stopped our mother would die in five days. states \"that I hope god takes her in the middle of the night. states he does not want to go against the family but has already spoken to his Dad and realizes this maybe torture to his mother especially since we have all the machines going. We are trying to get my other siblings to see that Mom is saying \"No\"\n\n given Dr. phone number to discuss feeling fo what his mother wants. again states that he does not want to go against his family. emotional support provided\n"},{"category":"Nursing/other","chartdate":"2132-08-23 00:00:00.000","description":"Report","row_id":1524196,"text":"Resp Care Note:\n\nPt cont trached and on mech vent as per Carevue. Lung sounds coarse improve with suct mod th tan sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required . Cont mech vent support.\n"},{"category":"Nursing/other","chartdate":"2132-09-17 00:00:00.000","description":"Report","row_id":1524293,"text":"Resp Care: Pt continues trached and on ventilatory support with a/c, no vent changes maintaining good abg; bs coarse rhonchi, sxn thick yell secretions, rx with mdi albuterol/atrovent/flovent mdi, rsbi held d/t vent dependence, will cont full support.\n"},{"category":"Nursing/other","chartdate":"2132-09-17 00:00:00.000","description":"Report","row_id":1524294,"text":"CONDITION UPDATE\nVSS. REMAINS ON NEO TO MAINTAIN PER ORDERED PARAMETERS. REMAINS IN AFIB - RATE CONTROLLED ON DILTIAZEM DRIP. HYPOTHERMIC - BAIR HUGGER ON. ALERT. PUPILS EQUAL AND REACTIVE. DOES NOT FOLLOW COMMANDS. NODS YES/NO. MOUTHING INCOHERENT WORDS. NO MOVEMENT NOTED RSIDE OR LLE. MOVES LUE SPONTANEOUSLY AND TO PAINFUL STIMULI. LUNGS COARSE TO DIMINISHED AT BASES. OCC. SUCTIONING FOR THICK, YELLOW SPUTUM. NO VENT CHANGES MADE THIS SHIFT. ABG THIS AM ACCEPTABLE. ABD OBESE. POSITIVE BOWEL SOUNDS. MOD AMT OF LOOSE, GOLDEN STOOL OUT COLOSTOMY. GTUBE TO DRAINAGE, SEROUS, MUCOUS DRAINAGE OUT. JTUBE TO TFEEDING W/O INCIDENT. AREA UNDER BOTH BREASTS EXCORIATED. SKIN UNDER PANNUS W/ MULT BREAKDOWNS - AREA CLEANSED W/ WOUND CLEANSER, MYCOSTATIN APPLIED ALONG W/ DSD. LOWER EXTREMITY DRESSINGS REMAIN INTACT. COCCYX DRSG - LG AMT OF PURULENT/S/S DRAINAGE OUT. TISSUE PINK. DRSG TO /LBUTTOCK - MOD AMT S/S DRAINAGE OUT. PERI AREA PINK AND EXCORIATED - AREA CLEANSED W/ SOAP AND WATER - MYCOSTATIN POWDER APPLIED. RARM W/ MULT SKIN TEARS - WEEPING COPIOUS AMTS OF SEROUS DRAINAGE. REMAINS ON . GOAL TO KEEP EVEN. SEE FLOWSHEETS FOR DETAILS. K AND DRIPS TITRATED ACCORDING TO ORDERS. REMAINS ON INSULIN DRIP. BSUGARS LABILE. SON IN FROM 7PM TO ALMOST 11PM VISITING W/ PT.\nCONT TO MONITOR FOR S/S OF WORSENING INFECTION. PAIN MANAGEMENT. MAINTAIN SKIN INTEGRITY. DIABETIC MANAGEMENT. PT/FAMILY TEACHING AND SUPPORT. CONT CURRENT ICU CARE AND ASSESSMENTS.\n\n"},{"category":"Nursing/other","chartdate":"2132-09-18 00:00:00.000","description":"Report","row_id":1524299,"text":"Nursing note:\n Alert, attempting to mouth words at times, this RN unable to understand. Moving LUE only. PERRLA. Does not appear to be in pain. Remains trached, no vent changes. Sats 100%, suctioned occ. per flow sheet. SR in 70s, no ectopy. Dilt gtt @ 5mg/hr. Weaned down Neo gtt to off for >80/MAP >50 this afternoon. Slightly hypothermic w/o Bair Hugger so remained on low/radient for the day w/temps in 97s. +BS, abdomen large, obese. Gtube to GD for bilious drainage. JTube for feeds, no residuals. Awaiting new TFs from kitchen. Small amount of serous drainage around sites into ostomy appliance. Colostomy w/red stoma, loose golden stool, appliance intact. Anuric, CRRT running to keep pt. negative by approximately 50cc/hr (24 hour goal 1L negative). CVP 6-12. Pt. tolerating fluid removal off pressors. Calcium/K+ gtts running per Sliding scale. Insulin gtt @5u/hr for stable glucose levels 100-120s. Wounds impressive, all dressings changed - see flow sheets for details. Bilat. heels and toes black. Deep cavernous wound to R. hip and large sacral decub as well. Mycostatin powder to reddened and excoriated groin folds.\n\nA/P: Tolerating fluid removal via off pressors. Hct stable @28, WBCs trending down.\nSlightly more alert today. Continues w/impressive non-healing wounds.\nContinue skin care, monitor hemodynamics, , update family spokesperson PRN.\n"},{"category":"Nursing/other","chartdate":"2132-09-18 00:00:00.000","description":"Report","row_id":1524300,"text":"Respiratory Care:\n Patient continues on full vent support. Suctioned app Q4 for thick yellowish secretions. BS with scattered rales and occassional rhonchi. She continues on . Plan to continue with supportive care and monitoring.\n"},{"category":"Nursing/other","chartdate":"2132-09-19 00:00:00.000","description":"Report","row_id":1524301,"text":"Resp Care\nPt remains on vent. Trached with 7.0 shiley. Suctioned for mod amt of thick green secretions. Mdis given. No changes made. Rsbi 104. Will continue to monitor.\n"},{"category":"Nursing/other","chartdate":"2132-09-19 00:00:00.000","description":"Report","row_id":1524302,"text":"NURSING 7P-7A\n VS LABILE OVERNIGHT. DECREASED TO THE 70'S WITH MAP<50. LEVO RESUMED TO MAINTAIN BP WITHIN DESIRED RANGE, ALSO CONTINUES ON DILTIAZEM AT 5 MG. ORDERS IN TO RESUME PO DILT AND DC GTT AFTER PO DOSE GIVEN. HYPOTHERMIC MOST OF THE SHIFT WITH TEMPERATURE NORMALIZING AT 0400. BAIR HUGGER ON UNTIL 0400.\n CONTINUES ON . AT 2400 LAST NIGHT NEGATIVE FOR 1100 ML. GOAL REMAINS AT 1000 ML/24 HRS. POTASSIUM GTT AND CALCIUM GTT SLIDING SCALES CONTINUE AS ORDERED. FILTER CLOTTED THIS AM AT 0500, RESTARTED AT 0615. SEE CARE VUE FOR FULL SPECIFICS.\n INSULIN GTT CONTINUES. BLOOD SUGARS HIGH LAST NIGHT FOR A PERIOD OF TIME, 4 HRS. INSULIN GTT HAD BECOME DISCONNECTED FOR APPROXIMATELY 2 HRS. DISCONNECTION WAS NOT IMMEDIATELY VISIBLE AS TUBING WAS STILL LODGED UNDER PANNUS AND APPEARED TO BE CONNECTED. GTT INCREASED TO 10 UNITS/HR, THIS AM LEVELS BECOMING MORE NORMALIZED, IN THE 150 RANGE THIS MORNING. SEE CARE VUE FOR FULL SPECIFICS.\n DOES NOT APPEAR TO BE IN PAIN. WHEN QUESTIONED SHAKES HEAD \"NO\". ANY ATTEMPTS TO DO ANYTHING TO HER ARE MET WITH A NEGATIVE SHAKING OF HER HEAD. ATTEMPTS TO MOUTH WORDS, UNABLE TO DETERMINE WHAT SHE IS TRYING TO SAY.\n CONTINUE . LABS Q 6/HRS, NEXT AT 0900. CONTINUE INSULIN GTT, MONITER SUGARS Q /HRS. GIVE DILTIAZEM PO AND STOP GTT A FEW HRS AFTER AS ORDERED.\n"},{"category":"Nursing/other","chartdate":"2132-10-27 00:00:00.000","description":"Report","row_id":1524454,"text":"NURSING PROGRESS NOTE;\nNeuro: Pt remains lethargic. opens eyes to voice, pupils 4mm brisk. Moving LUE slightly. Nodding yes when asked if having pain. Med with demerol X2 with some noted effect.\nCV: Afebrile, HR very labile, 100-140's Afib with occasional PVC's. labile 70-200/30-100's. tachypneic 30-40's MICU team aware of vital signs. extremities cool with pulses.\nRESP: lungs coarse to dim at bases. Occasional suctioning of thick yellow secretions. O2 sats >95%. Unable to place pt on home ventilator due to very labile VS. Family giving pt ice chips. Nurse asked family to not give pt ice due to aspiration. Pt's grand daughter found giving pt her slurpee, now having pink drg on trach drain sponge around trach, appears to be same color as slurpee.\nGI: tol tube feed at goal. draining adequate amount of brown loose stool.\nENDO: blood sugars elevated requiring mod coverage per RISS.\nPLAN: Awaiting ? transfer to floor.\n"},{"category":"Nursing/other","chartdate":"2132-10-27 00:00:00.000","description":"Report","row_id":1524455,"text":"Respiratory Care\nPt remains trached and on vent support. Pt was placed onto home vent and 2 hrs. Pt removed and placed back onto for increased RR. RR 28-35 on home vent and remained 28-35 on , pt was placed back to see if home vent was not tol. Pt tol. home vent. Lung sounds course and diminished in the bases. Pt was suctioned for scant to moderate amounts of thick yellow secretions. No ABG's were drawn and VBG was 7.36/38/32/22. Pt received MDI's albuterol was not given due to HR >110. Care plan is to place pt on home vent and remain on vent overnight. Pt is planned for a d/c tomorrow. Will continue to follow pt.\n"},{"category":"Nursing/other","chartdate":"2132-10-28 00:00:00.000","description":"Report","row_id":1524456,"text":"Respiratory Care\nPt remains trached with 7.0 Shiley. Pt stayed on ventilator on full support throughout the night. BS coarse bilaterally and diminished at lung bases. Suctioned for small amounts of thick tan secretions. MDI's given as ordered with increases aeration throughout lung fields. Pt remained hypertensive throughout the majority of the shift. No morning completed due to increased BP. See CareVue for details and specifics.\nPlan: ? placing pt on home vent.\n"},{"category":"Nursing/other","chartdate":"2132-09-14 00:00:00.000","description":"Report","row_id":1524281,"text":"NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT MOST OF THE NIGHT, OCCASIONALLY SLEEPING FOR BRIEF PERIODS. MOUTHING WORDS OCCASIONALLY, FOLLOWING SOME SIMPLE COMMANDS. MOVING LEFT HAND OFF THE BED, SLIGHT MOVEMENT NOTED FROM RIGHT FOOT, HOWEVER NO OTHER SPONTANEOUS MOVEMENT NOTED. PERRL. NODDING YES TO PAIN, RELIEVED BY REPOSITIONING.\nCV- BP STABLE IN 90-100 RANGE SYSTOLIC. NO PRESSORS OVERNIGHT. REMAINS IN 120-140'S, A-FIB WITH OCCASIONAL PVCS. LYTES CHECKED Q 6 HOURS PER CRRT PROTOCOL. DR. UPDATED ABOUT INCREASING HR A FEW TIMES OVERNIGHT, DILT 5MG GIVEN X 1 WITH MINIMAL EFFECT ON RATE. DR. WILL FOLLOW UP WITH TEAM ABOUT TREATMENT THIS AM. CONTINUES, PT WAS ABOUT A LITER POSITIVE AT MIDNIGHT WITH REMOVAL RATE OF 0. AFTER MIDNIGHT, REMOVAL RATE SET TO KEEP PT EVEN, HOWEVER BP DROPPING THIS AM TO 80'S, RATE DECREASED BACK TO 0 FOR NOW. PLATELETS 22 THIS AM, DR. NOTIFIED, WILL TREAT FOR LESS THAN 20 ONLY. PHOSPHOROUS LOW, .8, 2 PACKETS OF NEUTRAPHOS GIVEN X 1, WILL FOLLOW UP.\nRESP- LUNGS COARSE, SUCTIONED A FEW TIMES FOR THICK WHITISH SPUTUM. O2 SAT 100%, ABGS SLIGHTLY ALKALOTIC WITH PCO2 33-34. NO VENT CHANGES MADE.\nGI/GU- ABD SOFT, + BS. TOLERATING TF AT GOAL. COLOSTOMY DRAINING MODERATE AMOUNT OF LOOSE GOLDEN STOOL. APPLIANCE CHANGED, STOMA PINK. PT DOES NOT VOID.\nID- TEMP DECREASING TO 95 THIS AM, BAIR HUGGER PLACED. BLOOD CULTURES DRAWN WITH AM LABS.\n"},{"category":"Nursing/other","chartdate":"2132-09-14 00:00:00.000","description":"Report","row_id":1524282,"text":"Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the shift. Latest abg results determined a respiratory alkalemia with excellent oxygenation on the current settings. Patient remains tachycardic, and the albuterol mdi inline was witheld. Atrovent given with each vent check.\n\nNo RSBI measured due to the cardiac status and the general instability of the patient.\n"},{"category":"Nursing/other","chartdate":"2132-09-14 00:00:00.000","description":"Report","row_id":1524283,"text":"resp care\nremains trached/vent dependant. no changes on vent settings this shift. sxned for small amt yellow thick secretions. nard. consistently breathes over set rate. abg acceptable. atrovent given q6h, albuterol held until tachycardic,given in pm with HR 106. c/w full vent support.\n"},{"category":"Nursing/other","chartdate":"2132-09-28 00:00:00.000","description":"Report","row_id":1524339,"text":"CONDITION UPDATE\nASSESSMENT:\n NEURO EXAM UNCHANGED. PATIENT OPENS EYES SPONTANEOUSLY BUT DOES NOT FOLLOW COMMANDS. DOES NOT APPEAR TO BE IN PAIN. HEART RATE ~ 100 AFIB, REMAINS ON DILTIAZEM. PATIENT CURRENTLY ON 0.5 MGS NEO, WEANING EXTREMELY SLOW KEEPING MAP>55. CREAT 1.2, ELECTROLYTES NORMAL. NO DIALYSIS TODAY. AFEBRILE.\n LUNG SOUNDS COARSE, SUCTIONED OCCASIONALLY FOR THICK YELLOW SPUTUM. TOLERATING ASSIST CONTROL. ABDOMEN DISTENDED BUT IMPROVED SINCE . TUBE FEEDS REMAIN OFF (J-TUBE CLAMPED) AND G-TUBE TO WALL SUCTION WITH MODERATE AMOUNT BROWN/YELLOW OUTPUT. G-J SITE CONTINUES TO OOZE, APPLIANCE INTACT. COLOSTOMY WITH SCANT LOOSE BROWN STOOL. SEE CAREVUE FLOWSHEET FOR SKIN ASSESSMENT & TREATMENT.\nPLAN:\n? ATTEMPT TO RESTART TUBE FEEDS TOMMORROW. PROVIDE SUPPORT. WEAN NEO AS PATIENT TOLERATES.\n"},{"category":"Nursing/other","chartdate":"2132-09-28 00:00:00.000","description":"Report","row_id":1524340,"text":"BS rare fine crackles; no change with MDI's. No vent changes. Dialysis still on hold. Pressors weaned. Will wean vent as tolerated. Inner cannula changed.\n"},{"category":"Nursing/other","chartdate":"2132-10-05 00:00:00.000","description":"Report","row_id":1524369,"text":"NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\nNEURO: PT NOT RESPONSIVE TO ANY STIMULI, EVEN FROM FAMILY MEMBERS, NOT FOLLOWING COMMANDS. OPENS EYES SPONTANEOUSLY, PERRL 5MM, BRISK, NOT TRACKING. VERY MIN MVMT OF LUE ONLY, NO MVMT TO ALL OTHER EXTREMS. DEMEROL 12.5MG GIVEN PRIOR TO DSG CHANGES.\n\nCVS: HR 70S-90S, NSR, DILTIAZEM DRIP AT 5MG/HR. 80S-90S, MAP>55 W/NEO DRIP 0.2-0.4 MCG/KG/MIN. T-MAX 99.4, HCT 24.4 THIS PM-HO AWARE-NO INTVN TAKEN AT THIS TIME, REPEAT HCT AT 2100, NO S/S ACUTE BLEEDING NOTED. PP VIA DOPPLER, ?HD .\n\nRESP: NO VENT CHANGES, LUNGS COARSE TO APICES, DIMINISHED AT BASES BILAT. PT SUCTIONED FOR MOD AMTS THICK, YELLOW SECRETIONS. O2 SATS 97-100%, PT ACUTELY TACHYPNEIC DURING DSG CHANGES, UP TO 30S. TRACH CARE DONE, IN-LINE SXN CATH CHANGED. PT W/2-8 BPM OVER SET RATE, ATIVAN 1MG GIVEN X1 FOR PT COMFORT.\n\nGI/GU: COLOSTOMY STOMA PINK, EDEMATOUS, PATENT DRNG SM AMT BLK, TARRY SOFT STOOL, HYPO+BS. JT PATENT TO FLUSH/RETURNS>AMT FLUSHED, GT PATENT, MIN DRAW BACK. MIN BRWN DRNG FROM AROUND J/GT INSERTION SITE.\nTPN AT 77CC/HR, ?RE-START TF .\n\nENDO: BS BET 111-128, INSULIN DRIP AT 8.5MG/HR\n\nINTEG: PT W/MULTI AREAS SKIN BREAKDOWN-DSG CHANGES DONE TO SACRAL, RIGHT , BILAT TROCHANTER DECUBITUS ULCERS, REINFORCED PRN. MUTLI AREAS OF SKIN TEARS DRNG MOD AMTS SEROUS FLUID, REINFORCED PRN.\nBILAT HEEL ULCERS COVERED W/ADAPTIC, WRAPPED W/KERLIX. PT Q2-3HRS, HEELS OFF BED.\n\nID: AMIKACIN HELD FOR LEVEL 12.8, MEROPENEM RE-STARTED PER DR.\n\nPLAN: HEMODYNAMIC MONITORING, PAIN MGMT/PT COMFORT, GI OUTPUT FOR S/S ACUTE BLEEDING, RESP SUPPORT, SERIAL HCTS, PROBABLE HD , , NEURO ASSESSMENT, AGGRESSIVE SKIN CARE, FAMILY SUPPORT.\n"},{"category":"Nursing/other","chartdate":"2132-10-06 00:00:00.000","description":"Report","row_id":1524370,"text":"Respiratory care:\nPatient remains trached and mechanically vented. Vent checked and alarms functioning. Current settings: A/C 450*22 50% 8 peep. ABG this am with improvement in acidosis and oxygenation. (7.33/43/101 24 -3).\nBreathsounds are coarse. Albuterol/atrovent and flovent given. Continues with a #7 portex extra long trach, Inner cannula replaced. Trach patent and site looks good. Suctioned for small amounts of clear to yellow secretions. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation. Continue aggressive bronchodilators and pulmonary toilet.\n"},{"category":"Nursing/other","chartdate":"2132-08-01 00:00:00.000","description":"Report","row_id":1524102,"text":"Focus Condition Update\nSee flowsheet for specific information\n\nNeuro: No change in neuro status. Pt follows commands inconsistently, MAE's on bed except for RUE. Opens eyes spontaneously, PERRL.\nCV: Pt afebrile, in a-fib, hypotensive and most of shift. 500cc NS given, 12.5 lopressor given with effect. PTT >150, heparin gtt off until 0200, restarted at 700 units/hr MD, PTT currently 31, will recheck at 0500. Crit down to 27.9, MD aware.\nResp: Remains on CMV, no vent changes made this shift. LCTA bilaterally, sux'd for small amount of thick white sputum.\nGI: Colostomy patent, draining moderate amount of brown loose stool. Abdomen soft. Getting FS at 40cc/hr.\nEndo: Insulin gtt on at start of shift, shut off at midnight per order, switched to s/s. 70 units of glargine given hs.\nInteg: Right toe wound draining moderate amount of sang fluid, cleansed with wound cleanser, wet to dry dressing changed x3, cx sent. Wet to dry dressing over right ischial ulcer, cleansed and changed.\nPlan: L-spine MRI today.\n Change wound dressings as needed.\n Continue to monitor hemodynamic status.\n Monitor PTT to achieve therapeutic heparin dose.\n Contact MICU with changes.\n"},{"category":"Nursing/other","chartdate":"2132-08-01 00:00:00.000","description":"Report","row_id":1524103,"text":"\nPt presents trached On A/C 450X16 /5 .4. BS sligt coarse diminished bases. Sx for a sml amt thick tan secretions. No ABG this AM. Sats 100%. Plan: wean as tol.\n"},{"category":"Nursing/other","chartdate":"2132-09-29 00:00:00.000","description":"Report","row_id":1524341,"text":"Neuro: Pt. opens eyes especially when family present. Nods head at times but inconsistent with verbal commands. Noted to move LUE only.\nCV: continues to be in afib. Neo @.4mcq/kg/min. to keep MAP >55.\nSkin warm and color pink.\nPulm: yellow secretions per tracheal sx. Inhalers per vent circuit adm. by resp. therapist. Noted leak but no TV losses. pressure checked by RT and adjusted to try to correct for leak.\nGI: GJ tube in position. Gtube to CLWS with brown/green drng. J tube clamped except for meds. + bowel sounds. ABD. non-tender to palp. as no noted facial grimacing per pt. Colostomy with scant amount liquid brown stool. pink stoma.\nGU: None as pt. is anuric and s/p HD/CRRT.\nSKin: see AFS for dsg management. Left upper thigh pink as reported by previous RN as being a known cellulitis. Lower extr. DSG's intact(QD).\nPt. has two collection bags on right arm for serous drng. Collection bag aroung GJ tube site for similar drng. Skin tears in all skin folds. Mycostatin powder applied.\nEndo: SSRI as per Q6 BS's.\nID. Amikacin dose IV given for new BC growth of gram neg rods. ID to follow dosing.\nPlan: monitor GI status due to partial small bowel obstr. Surgery following. Monitor temps, lactic acid, WBC. Continue to assess need for CRRT in the future-vs-HD.\nam labs pending: see flowsheet.\n"},{"category":"Nursing/other","chartdate":"2132-09-29 00:00:00.000","description":"Report","row_id":1524342,"text":"pt remained on full vent support through PM. ABG was within acceptable limits and secretions sx'd were minimal, pressure measured was 22 with a very slight leak.\n"},{"category":"Nursing/other","chartdate":"2132-10-19 00:00:00.000","description":"Report","row_id":1524422,"text":"focus hemodynmics\ndata: neuro: awake and eyes open when spoken to. at times mouthing words but very difficult to undersand. pt will nod head. does not move extremites on the bed. very rigid when turning in the bed. passive range of motion done. pupils react briskly to light.\n\nresp: breath sounds course. suctioned for thick yellow sputum. trach care done. no vent changes done. on a/c of 50%.\n\ncardiac: remains in nsr. no ectopy seen. mag level 1.8. inr 1.5 and hct 28.6. k 3.5. to have dialysis on monday.\n\ngI abd soft. colostomy patent and draining brown stool. colostomy site pink. tube fdg site oozing some bloody drainage.\n\ngu: foley patent and draining yellow urine. creat 1.7 bun32.\n\nskin: multiple skin tears with lg amt of serous ddrainage . buttocks excoriated.\n\naction:: skin care done. suctioned prn. tube fgs tol well. colostomy patent. update to family. respiratory therapist spoke with daughter in length regarding discharge to home. continues on iv merepenum and levofloxacin. triple lumen patent. dialysis catheter intact with visable oozing of blood at the insertion site. ho notified.\n\nresponse: monitor closely.\n"},{"category":"Nursing/other","chartdate":"2132-10-19 00:00:00.000","description":"Report","row_id":1524423,"text":"FOCUSED NURSING ASSESSMENT\nPlease see carevue flowsheet for further details\n\nNeuro: No changes from prior assessments, dozing intermittently. Unable to determine appropriateness of head nodding- inconsistent answers with simple questions- opens her mouth spontaneously to any motion near her mouth- seems to most enjoy ice chips, cold swabs repetitively. Demerol x 1 premedication for dressing changes, exhibited facial grimace and incr RR during procedure.\n\nResp: Trached on CMV. Sputum suctioned thick/yellow alternating with white/thin. Copious amts yellow/tan exudate from trach stoma. SPO2 95-100%, RR 19-28.\n\nHEMODYNAMICS: No sx active bleeding aside from baseline slow vaginal bleed. range 72-135/28-76, BP changes from systolic of 72 to 135 in a matter of 15 minutes without intervention. MICU resident aware, qwil lbegin CVP monitoring. HR 80-90s NSR, occassional PVCs. Diltiazem/Digoxin/Amiodarone/Midodrine given as ordered. Anasarcous, serous fluid weeping from new and old skin tears/blisters. Hct from 1800 pndig.\n\nGI/METABOLIC: TF at 40ml/hr vai J-port, no emesis, colostomy with 300ml liquid brown stool, guiac positive. New onset today of copious amts of viscous/clear to at times bilious drainage from G/J stoma site- Gtube is to gravity drainage with small outputs (80ml).\nGlucoses elevated today 164/191, covered with RISS as ordered- Lantus 5U in am daily dose.\n\nPSYCHOSOCIAL: Husband visit in am for 30 minutes- no further family contact this shift. Pt attempted to mouth words today, unable to interpret- pt became tearful then closed eyes and would not respond to verbal stimuli.\n\nPLAN OF CARE: Continue to monitor hemodynamcis, sx bleeding closely. Monitor CVPs, notify MICU resident of results. Aggressive skin care, nursing measures to ensure pts comfort, emotional support to pt and family ongoing. Reccomend family and interdisciplinary team conference in am to determine disposition plan and revisit pts comfort and \"big picture\" of disease states and inability to recover/heal and intolerance to medical interventions. This was requested by RN on MICU rounds today.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2132-10-19 00:00:00.000","description":"Report","row_id":1524424,"text":"Resp Care\nPt remains on CMV, no vent changes. Plan to prepare for home discharge and transition to home vent.\n"},{"category":"Nursing/other","chartdate":"2132-10-20 00:00:00.000","description":"Report","row_id":1524425,"text":"RESP CARE: pt remains trached/on vent No changes in vent settings. Lungs coarse bilat. Sxd mod amts thick yellow sputum. pressure in trach at 25cmH20. No RSBI due to henodynamic instability. Plan is to place pt on home vent today in anticipation of DC home Wed.\n"},{"category":"Nursing/other","chartdate":"2132-08-07 00:00:00.000","description":"Report","row_id":1524131,"text":"Status A\nSee Carevue for specifics\n\nNeuro: Alert but unable to assess orientation. Follows commands inconsistently. PERRL.\nCV/GU: Afib. Hypotensive but maintained parameter of MAP >50. 1 unit of PRBC given during dialysis.\nResp: LS clear. No vent changes.\nGI: BS present. TF to goal. Drainage around PEG, dsg changed. Colostomy putting out brown liquid stool.\nSkin: Multiple wounds and areas of skin breakdown. See Carevue for specifics.\nEndo: glucose fairly stable in 110s-120s with insulin gtt with drop later in afternoon to 70s.\nSocial: children at bedside.\nPlan: continue with skin care regimen. Educate family on homecare needs.\n"},{"category":"Nursing/other","chartdate":"2132-08-08 00:00:00.000","description":"Report","row_id":1524132,"text":"NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT, FOLLOWS COMMANDS TO OPEN MOUTH, OPEN EYES. ONLY SPONTANEOUS MOVEMENT NOTED IS FROM UPPER LEFT EXT. PERRL. C/O PAIN THAT SEEMS TO BE RELIEVED WITH REPOSITIONING.\nCV- REMAINS HYPOTENSIVE, 80-100 SYSTOLIC, CAN HAVE FLUID IF SYSTOLIC BELOW 80. HR 90-100'S, A-FIB WITH OCCASIONAL PVCS, AM LABS PENDING.\nRESP- LUNGS CLEAR, SUCTIONED A FEW TIMES FOR SMALL AMOUNT OF THICK YELLOW SPUTUM. O2 SAT 100% ON CURRENT VENT SETTINGS, NO CHANGES MADE, BREATHING COMFORTABLY.\nGI/GU- ABD SOFT, HYPO SOUNDS. TUBE FEED CONTINUES AT GOAL, SMALL AMOUNT OF DRAINAGE NOTED FROM AROUND PEJ SITE, CLEANED AND DRY DRESSING PLACED. CHANGE OVER TO LARGER TUBE TODAY IN IR. PT DOES NOT VOID.\nID- AFEBRILE\n"},{"category":"Nursing/other","chartdate":"2132-08-08 00:00:00.000","description":"Report","row_id":1524133,"text":"Respiratory Care Note:\n\nPt remain on full ventilatory support via tracheotomy tube. No vent changes maded. RSBI done ~77. We are sxtn routinely for smalla mt of thick yellow secretions from trach. Plan: Continue present iCu moniotoring. Will follow.\n"},{"category":"Nursing/other","chartdate":"2132-08-08 00:00:00.000","description":"Report","row_id":1524134,"text":"Respiratory Care\n\n Pt continues on full ventilatory support. No changes made today. Cuff pressure 25cm H20. Pt traveled to I.R. without complication. B/S sl coarse sx'd for scant thick yellow. Will continue to follow closely.\n"},{"category":"Nursing/other","chartdate":"2132-08-27 00:00:00.000","description":"Report","row_id":1524213,"text":"Repiratory care\nPt remains on a/c vent without changes, Suctioned for large amts of thick yellow sample sent to lab. Pt had trach change to Shiley #7 long\nvia bronchoscopy without incident. MDI's as ordered.\n"},{"category":"Nursing/other","chartdate":"2132-08-27 00:00:00.000","description":"Report","row_id":1524214,"text":"\"Condition update\nPlease see carevue for specifics.\n\nneuro unchanged. tmax 100.9; wbc ct up to 25. plt re pan cx'd today. afib continues. HR 120's - 150. MICU team aware. 12 lead EKG done. HD today. 2300 off. hct down to 17.8; 2 units prbc given. post transfusion hct only 21. no further blood given. pt noted to have dark red bleeding in moderate amts from her vagina. MICU team notified. bs's 200's-300's. insulin gtt ordered. wounds cx'd. trach changed over to 7 long shiley. HCP notified.\n\nplan: hd as tolerated. iv abx. wound care. monitor hemodynamics. family meeting to discuss plan of care.\n"},{"category":"Nursing/other","chartdate":"2132-08-28 00:00:00.000","description":"Report","row_id":1524215,"text":"Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick tan secretions. MDI'S given. Temp 101.2. HR-A-Fib.No weaning done.Will cont to monitor resp status.\n"},{"category":"Nursing/other","chartdate":"2132-08-28 00:00:00.000","description":"Report","row_id":1524216,"text":"nursing note\nAlert with open eyes. nods at times but question if she understands. All dressing done and documented. Tmax 101.8- given as pan cx'd on days.\nplan:await culture results. if temp. skin care. family meeting to discuss dispo.\n"},{"category":"Nursing/other","chartdate":"2132-10-25 00:00:00.000","description":"Report","row_id":1524448,"text":"NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\nNEURO: ALERT, DOZING INTERMITTENTLY, EASLIY AROUSABLE. NOT FOLLOWING COMMANDS, INCONSISTENLY NODDING HEAD TO QUESTIONS. PERRL 4-5MM, BRISK, NOT TRACKING W/EYES. DEMEROL GIVEN FOR PAIN PRIOR TO DSG CHANGES X2.\n\nCVS: HR 80S-90S, NSR, NO ECTOPY NOTED. 70S-140S, MAP MAINTAINED>60 PER MICU, AFEBRILE. PM HCT 31.1, INR 1.9, PLT CT 37, K REPLETED FOR 3.9, REPEAT LABS AT 2100.\n\nRESP: REMAINS ON CMV, RATE 22/VT 450, NO VENT CHANGES MADE. PT SUCTIONED FOR SM AMTS THICK, YELLOW SECRETIONS. LUNGS COARSE TO APICES, DIMINISHED AT BASES, SLIGHT EXP WHEEZE NOTED TO RUL AT TIMES, MDI TREATMENTS GIVEN.\n\nGI/GU: RE-START TF AFTER MN PER MICU TEAM. COLOSTOMY PINK W/MIN GRN/BRWN DRNG, NO BLOOD NOTED. GT TO GRAVITY W/MOD AMT YELLOW, SEROUS DRNG, JT PATENT TO FLUSH, AREA AROUND INSERTION SITE DRNG SM AMTS STRAW COLORED FLUID. SM AMT CLEAR MUCOID RECTAL DRNG NOTED, AS WELL AS SM AMT VAGINAL BLEEDING NOTED-DR. AWARE.\n\nENDO: BS REQUIRED NO COVERAGE, AM LANTUS HELD PER MICU FOR AM BS 89\n\nINTEG: EXTENSIVE WND CARE DONE, INCL MULTI DSG CHANGES, FREQUENT TURNING & RE-POSITIONING. SARNA LOTION APPLIED TO MULTI AREAS RED RASH, MICONAZOLE/ANTI-FUNGAL POWDER APPLIED TO PERINEAL AREA. REDDENED, EXCORIATED AREA TO NECK UNDER TRACH COLLAR NOTED. PT W/GENERALIZED LEAKING COPIOUS AMTS SEROUS FLUID.\n\nPSYCHOSOCIAL: PT HUSBAND IN TO VISIT FOR SHORT TIME THIS AM. DAUGHTER CALLED INQUIRING ABOUT PT CONDITION, REQUESTED COPY OF PT , UPDATE FROM ATTENDING MD, MSG PASSED ALONG.\n\nPLAN: AGGRESSIVE SKIN CARE, PT COMFORT, RESP SUPPORT. SICU , PLAN FOR D/C HOME MON IN ACCORDANCE W/FAMILY WISHES.\n"},{"category":"Nursing/other","chartdate":"2132-10-26 00:00:00.000","description":"Report","row_id":1524449,"text":"Resp Care,\nPt. remains on A/C . No vent changes this shift. BS coarse, suctioned yellow sputum. MDI's as ordered. 65 this am. Plan home vent Sun. Plan D/C to home Mon. See carevue.\n"},{"category":"Nursing/other","chartdate":"2132-10-26 00:00:00.000","description":"Report","row_id":1524450,"text":"Narrative Note\nB-Shift:\nNeuro: Unchanged. Con't w/ rightward gaze. Does not respond to threat or startle. Daughter () appeared to be conversing w/ pt. early in shift, but no such communication could be elicited later. Does appear to sleep at times, and wakeful at others.\nCV: NSR-ST w/ rare ectopic. BP low, but within normal limits for pt.\nPulmonary: Vent settings unchanged, refer to CareVue for specific interventions.\nGI: TF's () started this shift @ 40cc/hr through gastric port on G/J tube.\nGU: Con't to pass blood/clots through vagina. No change in amount or quality of drainage.\nSkin: Breakdown in virtually all areas. BUE's w/ tears and ecchymosis, dsg's applied in areas of most significant breakdown (mostly RUE). BLE's w/ many areas of breakdown, DSD's not changed on feet/anlkes. Posterior thigh dsg's changed, areas reddened, not blanching. Dressing on rear-end changed, both tunneled decubitii packed w/ aquacel as ordered, Adaptic placed on open areas. SoftSorbs taped in place with Mefix.\nSocial/Plan: Son and daughter in to visit from beginning of shift until 11pm. Were concerned w/ G/J tube site and its ostomy appliance. Update given by Dr. who spoke with them for some time. Plan remains to send pt. home on Monday.\n\n"},{"category":"Nursing/other","chartdate":"2132-08-01 00:00:00.000","description":"Report","row_id":1524104,"text":"Respiratory Therapy\n\nPt remains trached w/ #6.0 on full mechanical support. No vent changes made this shift. Currently on A/C ventilation w/ PIP = 14. BLBS slightly coarse, suctioned for moderate amounts of thick tannish sputum. SpO2 90s. MDIs given as ordered. See resp flowsheet for specifics.\n\nPlan: maintain support\n"},{"category":"Nursing/other","chartdate":"2132-08-01 00:00:00.000","description":"Report","row_id":1524105,"text":"7a-7p\nneuro: lethargic, easily aroused, follows commands @ times, perl, pt on atc po ativan q 6 hrs, pm dose held due to oversedation, pt more awake & responsive after dose held\n\ncv: hr a-fib(102-120), occasional pvc's, sbp 87-115, po lopressor, po amiodarone\n\nresp: continues on 40% fio2/AC 16/5 peep, no vent changes, bs+ all lobes & clear, sux scant amt sputum, inhalers by R.T., sat 100, rr 20-24, no resp dsitress noted\n\ngi: goal tf tol well, mod amt loose brown stool via colostomy, iv protonix, po reglan, colace & lactulose\n\ngu: anuric, hemo 3 x's per weak, no hemo today, done yesterday, due tomorrow, albumin(12.5 gm) x 1 ordered for hemo tomorrow, see stat med sheet\n\nother: wound care done as ordered, R foot with lg amt bleeding, ho aware, hct done @ 1300(26.9), no tx, pt to have blood tx with hemo tomorrow, daughter in & updated on pt by nurse & medical team, bs 424, insulin gtt resumed, ptt 99.5, heparin gtt off x 1&1/2 hrs then resumed @ 750 u/hr, PTT due @ 2330, no c/o pain\n\nplan: continue to monitor blood pressure/sepsis in ICU, fluid boluses for sbp < 80, MRI to r/o osteo from sacral decub, hemo tomorrow, antibiotics as ordered\n"},{"category":"Nursing/other","chartdate":"2132-08-20 00:00:00.000","description":"Report","row_id":1524184,"text":"Condition Update\nPlease see carevue for specifics.\n\nT/max 99.7; Cx's pending from . AFib. HR 90's-130's. Lopressor dose held d/t sbp 80's. Rare PVC's noted. 12.5 mg Demerol given for pain prior to dressing changes. Pt sxn'd for large amts of thick, yellow sputum. A sputum cx and gram stain sent. No vent changes made this shift. Pt continues on AC 40%/5 peep. Resp tx giving pt . Pt went down to I.R. for new G/J tube. w/ beneprotein infusing at goal. Colostomy draining golden loose stool. Stoma is pink. Regular insulin gtt started this afternoon d/t continued high blood sugars. Pt still receiving 90 units glargine q 12 hours. Plastics team up this eve to pt's wounds. Feedback pending. Pt to be started on CRRT this eve since she was unable to tolerate HD .\n\nPlan: continue with current plan of care per MICU team. CRRT. Q 6 hour labs. MICU team to evaluate for arterial line. Hourly blood sugars d/t insulin gtt. Pain mgmt. Daily dressing changes. F/U on plastics consult. IV ABX.\n"},{"category":"Nursing/other","chartdate":"2132-08-20 00:00:00.000","description":"Report","row_id":1524185,"text":"Respiratory Therapy\n\nPt remains trached w/ #8 TTS adjustable trach locked @ 10cm. Currently on A/C ventilation, no changes made this shift. SpO2 90s. Travelled to and from IR for G/J tube placement w/out incident. MDIs given as ordered. BS coarse bilaterally, suctioned for moderate amounts of thick tan sputum. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support; still to be evaluated by IP for ?trach change\n"},{"category":"Nursing/other","chartdate":"2132-10-20 00:00:00.000","description":"Report","row_id":1524426,"text":"focus hemodynmics\ndata: neuro: awake and opens eyes to verbal stimuli. mouths words but difficult to understand. does not move extremities due to fluid in extremites. nods to daughter and son in law. nods to some questions.\n\nresp: breath sounds course. suctioned for thick yellow sputum. trach care done. skin near trach reddened and excoriated.\n\ncardiac: remains in nsr. occ pvc. k 3.0 and ho notified. k being repleted with 20meq iv. diltazem held due to bp < 90.\n\ngi abd soft. tube fdgs infusing at goal rate of 40cc/hr. colostomy bag intact and draining brown/green drainage.\n\ngu creat 1.7. due to be dialysized today.\n\naction: labs as ordered. suctioned prn. tube fdgs as ordered. k repleted with 20meq kcl. skin care done q1-2 hrs. buttocks excoriated. lg amt of serous drainage . lg decubitus on buttocks and dsg changed x3. leg dsg intact with feet dsg changed x2. daughter in to see pt tonite and very upset with the g j tube insertion site. daughter spoke with ho and verbalized her concerns of tube and skin condition. daughter upset with overall skin condition. dsughter would like to talk with the attending md. ho aware of this and will discuss in rounds today.\n\nresponse: monitor closely.\n"},{"category":"Nursing/other","chartdate":"2132-08-06 00:00:00.000","description":"Report","row_id":1524124,"text":"RESPIRATORY CARE NOTE\n\nPatient remains trached with Shiley trach tube 6.0 SCT. No vent changes made during the . BLBS are coarse. Sxn for moderate thick yellow secretions. RSBI completed on PS 5=99.\n\n , RRT\n"},{"category":"Nursing/other","chartdate":"2132-08-06 00:00:00.000","description":"Report","row_id":1524125,"text":"Addendum: Progressively lower diastolics to 30s-40s with MAPs <60. HR stable, pt. alert and appears neurologically unchanged, though does not follow commands at baseline. MICU team in to assess and given 500cc NS and lytes repleted. SBP to 90s after begun.\n"},{"category":"Nursing/other","chartdate":"2132-08-28 00:00:00.000","description":"Report","row_id":1524217,"text":"Patient uses portable vent @ home,trach is changed to # 7 extra long. Inner canulae on top on vent for daily usage.BS rhochious with L>R,suctioned for thick yellow secretion;sputum cultured gram(-) rod.Patient on tobramycin.CXR (l) pleural effusion and lingula atelectasi.Plan to meet with family to discuss disposition.\n"},{"category":"Nursing/other","chartdate":"2132-08-28 00:00:00.000","description":"Report","row_id":1524218,"text":"Condition Update\nPlease see carevue for specifics.\n\nTmax 99.7, AFIB. HCT stable at 25.2, but vaginal bleeding continues. Transvaginal Pelvic ultrasound ordered. Pt sxn'd several times for thick, yellow/green secretions in moderate amts. TF's infusing at goal. BS 91-127. RISS ordered, glargine dose increased to 92 units. toxin B assay sent, and Po flagyl ordered despite all previous specs being negative.\n\nPlan: continue with current plan of care per micu team. continue to closely follow blood sugars, hemodynamics. HD to be . Vanco and tobramycin peak and trough to be drawn. Still awaiting vaginal us. Dressing changes. Family meeting to be scheduled by social services to include family, nursing, social srvs, case mgmt, ethics, micu team + the attending. Blood cx to be drawn from the HD catheter by the HD RN.\n"},{"category":"Nursing/other","chartdate":"2132-08-29 00:00:00.000","description":"Report","row_id":1524219,"text":"Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned mod amts thick green/tan secretions. MDI'S given.Will cont to monitor resp status.\n"},{"category":"Nursing/other","chartdate":"2132-08-29 00:00:00.000","description":"Report","row_id":1524220,"text":"nursing update\nno events. MD spoke with daughter regarding family meeting. Duaghter at this time does not want family meeting. She states she will have one when home services are set up and mom is ready to go home.\n\n\n"},{"category":"Nursing/other","chartdate":"2132-09-16 00:00:00.000","description":"Report","row_id":1524291,"text":"Resp Care\nPt remains trach on full vent support. No vent changes this shift. Pt continues to be suctioned for mod amt of thick yellow sputum, MDIs given per order. Pt brought to IR this afternoon. plan to continue vent support.\n"},{"category":"Nursing/other","chartdate":"2132-08-21 00:00:00.000","description":"Report","row_id":1524186,"text":"nursing note\nNeuro:Mouthing words at times, not sure what she is saying. some movement noted with L hand. afebrile.\nCV: Cont in afib, lopressor held secodnary to low BP.\nRESP:thick tan secretions, copius at times.\nGI: at goal. loose stool via ostomy- sent\nGU:anuric. started with goal even. ultrafltrate titrated frequently secondary to BP.\nSocial: MD wspoke with daughter re: and 2 sons. spoke with 2 sons and answered many questions re:, labs, antibiotics, cultures and wound care.\n\nplan:cont to await culture data, resp toilet, to keep even. social support\n"},{"category":"Nursing/other","chartdate":"2132-08-21 00:00:00.000","description":"Report","row_id":1524187,"text":"Respiratory Care\nPt continues full vent support with #8 adjustable protex trach locked at 10cm. BS coarse and diminished bilaterally. Suctioned for moderate amounts of thick tan sputum. No vent changes made this shift. MDIs given as ordered. See Careview for morning RBSI results.\nPlan: maintain suppport\n\n"},{"category":"Nursing/other","chartdate":"2132-08-21 00:00:00.000","description":"Report","row_id":1524188,"text":"Events:\n\nSacral wound cultured\n running even and transiently positive for hypotension with effect\nKPhos repleted\n\nNeuro-shakes head to yes/no questions, moves upper extrem >LE, withdraws LE weakly, PERRLA, ativan ATC for comfort\nCV-HS S1S2 irreg with click, doppler DP bilaterally cool extrem x4, cont on amiodarone/lopressor remains in AFib, coumadin dose to be held tonight INR 4.3\nResp-ML trach site red, remains on AC, sx for scant thick plugs, LS coarse upper lobes dim at bases\nGI-TF at 40cc/hr, GJtube leaking serous at site, DSD and skin barrier cream at site, glucose covered with glargin 90u SQ and insulin drip, colostomy loose liquid stool out\nGU- running even RF/Dialysate prismasate, K and calcium repleted with SS, acid base balance and lytes monitored q6 hours\nskin-sacral decubitis to bone foul odor out, packed and DSD to area, r/l hip stage II aquacel/allevyn dressings, necrotic toes bilaterally and calf stage II-III dressing changed per wound care recomendations\n\n HCP updated via phone, daughter many questions and felt the patient needed albumin with dialysis to remove fluid, daughter requested antibiotic changes. update given and teaching done regarding and albumin, and blood pressure.Update given current cultures and sensitivity to current ABX, daughter aware infectious disease following. MICU team aware of daughters concerns. Daughter stated \" failed to identify infection, she was the one to tell the doctors to , she was the one to identify nutrition needs\" stated that she was the primary person managing her at home and albumin \"worked\", extensive teaching done and update on current plan of care, daughter continues to state negative comments regarding the care and doctor \" stating she was able to manage this at home. Risk /patient care services notified. Daughter made aware she can voice her concerns to case management.Reassurance given to that her mother is getting aggressive care and the best care. Emotional support provided, at this time the MICU team is in agreement to only give information and daily updates to primary HCP in order to avoid confusion among family members. SICU staff will attempt to provide info to HCP . Social work notified\n\nPlan-cont running even, cont TF, continue skin care, monitor lytes and acid base balance, cont emotional support to family, information to HCP only to avoid confusion among family members, updated on this\n"},{"category":"Nursing/other","chartdate":"2132-08-21 00:00:00.000","description":"Report","row_id":1524189,"text":"Respiratory Care\n\n Pt continues on full ventilatory support. No changes made today. B/S sl coarse and diminished. MDI's as ordered. Sx'd for sm/mod amount thinish yellow secretions. Will continue to follow closely.\n"},{"category":"Nursing/other","chartdate":"2132-08-22 00:00:00.000","description":"Report","row_id":1524190,"text":"Resp Care Note:\n\nPt cont trached and on mech vent as per Carevue. Lung sounds coarse suct mod th off white/tan sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required . Had difficulty asp secretions from trach; repositioned tube problem resolved. Cont mech vent support.\n"},{"category":"Nursing/other","chartdate":"2132-09-13 00:00:00.000","description":"Report","row_id":1524277,"text":"NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT, MOUTHING WORDS, OCCASIONALLY NODDING IN RESPONSE TO SOME QUESTIONS. MOVING ONLY LEFT HAND ON THE BED. PERRL. PT APPEARING TO BE CRYING AT TIMES, UNABLE TO UNDERSTAND THE WORDS THAT SHE IS MOUTHING, OFFERED EMOTIONAL SUPPORT.\nCV- BP STABLE IN 90-115 RANGE SYSTOLIC. NEO REMAINS OFF FOR NOW, PITRESSIN CONTINUES AT 2.4 U/HR. A-FIB, TACHYCARDIC 110-150'S AT TIMES, HOWEVER NOT SUSTAINED. AT BEGINNING OF THE SHIFT, PT APPEARED TO BE INCREASINGLY TO 150'S, 2L NEG FLUID BALANCE, BP STABLE, DR. NOTIFIED. NO NEW ORDERS AT THE TIME. DECISION MADE TO TAKE OFF LESS FLUID, TRYING TO KEEP EVEN FLUID BALANCE. CVP 13-16.\nRESP- LUNGS COARSE AT TIMES, SUCTIONED OCCASIONALLY FOR THICK WHITE SPUTUM. ABGS WNL THIS AM.\nGI/GU- ABD SOFT, HYPO SOUNDS. COLOSTOMY DRAINAGE IS GOLDEN BROWN LOOSE. TOLERATING TF AT GOAL. PT DOES NOT VOID.\nID- TEMP 95 AT MIDNIGHT FOLLOWING BATH, VERIFIED BY AXILLARY. WARM BLANKETS PLACED, HEAT TURNED UP IN ROOM.\n"},{"category":"Nursing/other","chartdate":"2132-09-13 00:00:00.000","description":"Report","row_id":1524278,"text":"Respiratory Care Note:\n\nPt remain on ventilatory support/assist via tracheotomy tube. No vent changes done. Lung sound clear to coarse, BBS. We are sxtn for small amt of thick white secretions from trach. none orally. MDI adm as ordered with no noticeable changes, Albuterol held t/o shift as HR> remain above 120 bpm. Plan: Continue present ICU monitoring. Will follow.\n"},{"category":"Nursing/other","chartdate":"2132-08-06 00:00:00.000","description":"Report","row_id":1524126,"text":"Focus Condition Update\nSee flowsheet for specific info.\n\nNeuro: Status unchanged. Pt mouthing words, following some commands, MAE's except for RUE. Fentanyl given for pain with dressing changes. Demerol written PRN for future dressing changes.\nCV: Hypotensive at times, , team aware. Afebrile. Lopressor and midodrine given.\nResp: No vent changes made this shift. LCTA, dim in bases. trach care done.\nGI: J-tube leaky, MD aware, surgery called by resident, but they have not come by to see pt. at 40cc/hr. Colostomy draining moderate amount of brown liquid stool.\nSkin: All wound dressings changed today with skin care RN. See updated note for dressing instructions.\nEndo: Sugars running high today, covered with new s/s. consulted this a.m.\nSocial: Dtr in to visit, many questions and needs.\nPlan: Discharge to home on Monday\n Continue with current POC\n\n"},{"category":"Nursing/other","chartdate":"2132-08-06 00:00:00.000","description":"Report","row_id":1524127,"text":"resp care - pt remains intubated with #6 shiley trach. Settings are a/c 450/16/5 40%. No changes were made during the day. Breath sounds were course bilaterally in the upper lobes, clearing slightly on sx of small amounts of thick yellow secretions. BS were dim in RML and LLL.\nPt's cuff leak was resolved with a pressure of 25 cmH2O. Continued resp care planned.\n"},{"category":"Nursing/other","chartdate":"2132-08-07 00:00:00.000","description":"Report","row_id":1524128,"text":"NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT MOST OF THE NIGHT. ABLE TO MOUTH SOME WORDS AND NOD IN RESPONSE TO SOME QUESTIONS. NO SPONTANEOUS MOVEMENT NOTED OVERNIGHT.\nCV- BP DECREASING TO 70'S SYSTOLIC THIS AM, DR. NOTIFIED AND 500CC NS GIVEN WITH GOOD EFFECT. HR 90'S-100, A-FIB WITH OCCASIONAL PVCS.\nRESP- LUNGS CLEAR, SUCTIONED A FEW TIMES FOR SMALL AMOUNTS OF THICK YELLOWISH. O2 SAT 100%, NO VENT CHANGES.\nGI/GU- ABD SOFT. COLOSTOMY DRAINING BROWN LOOSE STOOL, STOMA BEEFY RED AND APPEARS HEALTHY. INSULIN GTT RESTARTED FOR BS 309, BS DECREASING BY AM, LANTIS GIVEN AS ORDERED.\nID- TMAX 99.3\n"},{"category":"Nursing/other","chartdate":"2132-08-07 00:00:00.000","description":"Report","row_id":1524129,"text":"Respiratory Care Note:\n\nPt remain on ventilatory support via traheotomy tube, No vent changes maded. We are sxtn for small amt of thick yellow sputm thru trach. MDI adm as ordered with No noticesable cgaanges in BS. Plan: Continue present ICU monitoring. Will follow.\n"},{"category":"Nursing/other","chartdate":"2132-08-07 00:00:00.000","description":"Report","row_id":1524130,"text":"resp care - pt remains intubated with #6 Shiley trach on a/c 450,16,5,.40. No changes made. Rhonchi t/o cleared on sx of sm amt of thick white sputum. Meds given as ordered. Dim BS in LLL. Positional leak persists. MD wants no more than 25cmH2O cuff pressure. Continued resp care planned.\n"},{"category":"Nursing/other","chartdate":"2132-08-25 00:00:00.000","description":"Report","row_id":1524205,"text":"BS rhonchi; no change with MDI's. Pt continues to have variable trach leak and we are looking into ordering a non- (to accomodate family), that is extra length, ideally >100mm. Current cuff pressures < 20 cm but adding air frequently. HD today. Pt will be discharged to family when sepsis and trach issues are resolved.\n"},{"category":"Nursing/other","chartdate":"2132-08-25 00:00:00.000","description":"Report","row_id":1524206,"text":"FOCUSED NURSING ASSESSMENT\nPlease see carevue for further details\nNeuro: No acute changes in mental status, pt lethargic. alertness and responding to commands fluctuates- nods to communicate basic needs. PERRL, 3mm. Medicated with Demerol 12.5mg IV for drsg .\n\nResp: Trach patent, leak persistent though not interfering with oxygenation or ventilation. No vent changes made. Family goals of opportunity to place passy muir valve so pt can communicate her POC/medical wishes made known to MD. acceptable after inflation. Scattered rhonchi bilaterally- SPO2> 98% on A/C 0.40 PEEP 5. Frequent suctioning required, sputum change to copious blood-tinged, rusty and MD notified.\n\nHemodynamics: s/p HD removal of 1.75ml. Unable to remove goal of 3liters secondary to BP drops- tx by HD RN with NS and Albumin. Average SBP s/p HD is 88-96, DBP decreasing 30-45. Afib controlled rate 95-118. New onset vaginal bleeding, slow ooze, dark red MD notified, plan tranvaginal US. INR 3.0, coumadin held secondary to sx bleeding. HCT 27.5 stable this am.\n\nMetabolic: TF at goal rate 40ml/hr. Improved glycemic control, BS 111/87.\n\nID: Tmax 99.8. Tachycardic since HD. Tobramycin random 0.5, peak pending. Zosyn, Levaquin as ordered.\n\nSKIN INTEGRITY: Multiple pressure ulcers/wounds. Full re-evaluation and drsg with Skin care RN, please see her full note. Turn and repositioned q2-3hr. Pt requires premedication with demerol for drsg procedure.\n\nPSYCHOSOCIAL: Pt visited by husband and son in am during HD. Followed by daughter in afternoon who is very knowledgeable of her mother's medical care, specifically nursing focuses, and supportive. Emotional support and education to family members ongoing. SW following as well. POC per HCP daughter.\n\n PLAN: Monitor vag bleeding, hemostasis. F/U transvag US results. Hold coumadin today. Monitor labs/fevers. Skin care, resp care, comfort measures as appropriate per aggressive POC. Family support, d/c planning needs for home ventilation/HD/ and IV abx course.\n"},{"category":"Nursing/other","chartdate":"2132-09-16 00:00:00.000","description":"Report","row_id":1524292,"text":"Please See Carevue for Specifics.\n\nNeuro: Arousable to voice does not follow commands only moves LUE to nailbed pressure. Ativan held this shift for sedation.\n\nCardio: SR-ST till 1755 this evening when pt coverted to afib 140-150's. MICU team aware, pt started on Diltiazem IV. this morning 70 and was started on Neo at 0.5mg/kg/hr. Generalized edema. Received two units , three units platelets, and one unit pRBC's prior and during new quinton placement and old quinton removal in IR. Blood cultures from old quinton cath, and right CVL. Line tip cultures sent from old quinton and PICC line. CVP 13-20. restarted at 1800.\n\nRespir: Remains on CMV. Suctioned for small amounts of thick tan-yellow secretions.\n\nGI: TF stopped at 1130 for procedure scheduled in IR and restarted at 1800. G-tube to gravity with clear/yellow mucous discharge. Stoma beefy and pink with guaiac negative loose golden stool.\n\nCVVH: Restarted at 1800. Fluid balance goal 0.\n\nSKIN: Skin remains impaired. Yeast under both breast, both underarms, both groin folds. All folds cleansed with soap and water, dried, and miconazole powder applied. Right great toe brown and hard. Thick foul yellow/green discharge from larger knuckle. Discharge obtained for culture. Bil posterior lower ext with pink +granulating tissue. Areas cleansed with wound cleanser and adaptic with DSD covering. Heels pink, cleansed, adaptic and DSD re-covered.\n\n: Monitor hemodynamics, monitor MS, pain, respir status, family aware of . HCP spoke with MICU attending this afternoon regarding limited line access.\n"},{"category":"Nursing/other","chartdate":"2132-10-04 00:00:00.000","description":"Report","row_id":1524363,"text":"Respiratory Care\nPt remains trached and on vent support. No vent changes were made during shift. Lung sounds were course with rhonchi that cleared after suction. LLL and RLL were dim. Pt was suctioned for small to moderate amounts of thick yellow secretions. Pt received MDI's with improvement. Care plan is to continue current therapy with no changes to be made. Will continue to follow pt.\n"},{"category":"Nursing/other","chartdate":"2132-10-04 00:00:00.000","description":"Report","row_id":1524364,"text":"NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\nNEURO: PT CONT UNRESPONSIVE EVEN TO NAILBED PRESSURE, OPENS EYES SPOENTANEOUSLY, NOT FOLLOWING COMMANDS. PERRL 5MM, BRISK, DOES NOT TRACK W/EYES. NOT MOVING ANY EXTREMS.\n\nCVS: HR 70S-90S, DILTIAZEM DRIP CONT AT 7.5MG/HR, NSR, NO ECTOPY. 70S-100S, MAP MAINTAINED >55, NEO DRIP AT 0.3-0.4MCG/KG/MIN. T-MAX 99.4, TRANSFUSED 1 UNIT PRBCS, POST HCT PENDING, NO DIALYSIS TODAY PER RENAL, ?. PP , CONT W/ GEN ANASARCA, WEEPING SM AMTS SEROUS FLUID VIA MULTI SKIN TEARS.\n\nRESP: A/C-VT 450/PEEP 8/50%, RATE 20S-30S, DEMEROL GIVEN X1 FOR TACHYPNEA PRIOR TO DSG CHANGES. LUNGS SNDS DIMINISHED THROUGHOUT, SOMEWHAT CLEARER TO RUL, DIFFUSE RHONCI AT TIMES. PT FOR MOD AMTS THICK, YELLOW SECRETIONS, TRACH CARE DONE. NEBS GIVEN.\n\nGI/GU: COLOSTOMY PATENT, DRNG MIN AMTS DK RED STOOL. J/G TUBE CONT LEAKING MOD AMTS BROWN LIQUID DRNG AROUND INSERTION SITE, NO FRANK BLOOD NOTED. JT PATENT TO FLUSH, EASILY DRAWING BACK DK RED FLUID>FLUSH AMT, GT PATENT TO FLUSH, NO DRAW BACK>5-10CC-HO AWARE. HYPO +BS.\n\nENDO: BS 120S-170S, INSULIN DRIP 8-9MG/HR\nID: AMIKACIN LEVELS PENDING, HOLD MED IF>4 PER MICU, BLD CX PENDING.\n\nPLAN: CONT HEMODYNAMIC MONITORING, AGGRESSIVE SKIN CARE, PAIN MGMT, RESP SUPPORT, ?HD , NEURO CHECKS, ANTIBIOTIC THERAPY, GI OUTPUT MONITORING FOR GI BLEEDING, SERIAL LABS.\n"},{"category":"Nursing/other","chartdate":"2132-09-13 00:00:00.000","description":"Report","row_id":1524279,"text":"SICU NPN\nS-Trached\n\nO-Alert. Opens eyes spontaneously. Following commands inconsistently. Beginning to mouth words. PERL. Denies pain. Demerol IVP for dressing changes. HR 140-160s, RAF with stable BPs. SBPs 100-110s. Pitressin off at 0800. Since stable. Amiodorone load IVPB given. No gtt started. HR 110-130s post and no continious gtt started. SBPs post 80-90s. Dr. aware. Verbal orders to not to start Pitressin. Keeping MAPs > 55. Breath sounds clear. Remains on AC. Repeat ABG with respiratory alkalosis. MICU team aware during rounds. Bicitra discontinued. No vent changes made. CRRT continues. Fluid balance discussed with MICU team during rounds. Deciscion made to keep even. Now currently deciscion made to keep 1L ahead at 4PM. I/O currently even. CRRT labs pending for 4PM with ABG. Potassium scale increased for K of 3.3 this AM. ICa left the same. Abd obese and soft, bowels sounds active. TFs at GR. Ostomy and J-G tube intact. Hypothermic this morning, currently normothermic but remains on bair hugger at ambience setting. Tc 97.0, PO. Continues quadruple Abx for bacteremia. Family in and out most of day.\nA/P:Sepsis, improving off pressors. Goal now is to keep 1L ahead for daily I/O\nFollow ABGs and lytes while on CRRT Q6H.\nMonitor BPs closely, keeping MAP > 55.\nContinue to monitor\n"},{"category":"Nursing/other","chartdate":"2132-09-13 00:00:00.000","description":"Report","row_id":1524280,"text":"Resp Care\nPt remains on AC 450 x 16. ABGs do show some Resp Alkalosis, Bicitrate was discontinued. BS clear to coarse. Sxn' d clear to thick yellow secretions at times. RR breathing over vent by around 9 breaths per min.\n"},{"category":"Nursing/other","chartdate":"2132-09-27 00:00:00.000","description":"Report","row_id":1524334,"text":"Respiratory Care\nPt trached on ventilatory support. Sx copious amounts thick green secretions. Minute ventilation markedly decreased over last 24 hours. ABGs within normal values with good oxygention.\n"},{"category":"Nursing/other","chartdate":"2132-09-27 00:00:00.000","description":"Report","row_id":1524335,"text":"CONDITION UPDATE\nASSESSMENT:\n NEURO UNCHANGED. PATIENT DOES NOT APPEAR IN PAIN, NO PAIN MED NECESSARY. HEART RATE ~ 100 AFIB. MAP > 55 ON 0.8 MCGS NEO, UNABLE TO WEAN FURTHER. RECEIVED 1 UNIT PRBCS FOR HCT 21 THIS AM, REPEAT HCT UP TO 25. AFEBRILE. PATIENT REMAINS EXTREMELY FLUID OVERLOADED. CREAT 1.0 AND ELECTROLYTES NORMAL, NO DIALYSIS TODAY.\n ABDOMEN SOFTLY DISTENDED, PATIENT HAD FEEDINGS THRU J-TUBE THIS AM AND LARGE G-TUBE OUTPUT. KUB DONE IN AM. PATIENT ALSO VOMITED BILIOUS APPEARING FLUID & MODERATE AMOUNT OOZING FROM TRACH SITE. MICU TEAM AWARE, G-TUBE TO SUCTION & IMMEDIATELY DRAINED 750 CC. TUBE FEEDS OFF AND AWAITING ABDOMINAL CT SCAN FOR ? OBSTRUCTION. COLOSTOMY WITH ONLY 50 CC LIQUID BROWN STOOL THIS SHIFT. PATIENT ON INSULIN GTT, STOPPED IN AFTERNOON WHEN TF OFF.\n TRACH CARE DONE SEVERAL TIMES. SUCTIONED FREQUENTLY FOR THICK YELLOW SPUTUM. REMAINS ON ASSIST CONTROL & TOLERATING WELL. LUNG SOUNDS COARSE. SEE FLOWSHEET FOR SKIN/WOUND CARE.\nPLAN:\n CT SCAN AND AWAIT RESULTS. KEEP G-TUBE TO SUCTION. CONTINUE WITH SKIN CARE.\n\n"},{"category":"Nursing/other","chartdate":"2132-09-27 00:00:00.000","description":"Report","row_id":1524336,"text":"BS fine crackles but less so than yesterday; no change with MDI's. Vomited up bile with some seen around trach site, ? aspiration. CT of abdomen and chest today - results pending. No vent changes or ABG's this shift.\n"},{"category":"ECG","chartdate":"2132-10-21 00:00:00.000","description":"Report","row_id":184247,"text":"Baseline artifact. Probable sinus tachycardia with atrial premature beat, but\nbaseline artifact and generalized low voltage make assessment difficult. Left\nbundle-branch block. Generalized low voltage. Clinical correlation is\nsuggested. Since the previous tracing of rhythm is more suggestive of\nsinus tachycardia.\n\n"},{"category":"ECG","chartdate":"2132-09-30 00:00:00.000","description":"Report","row_id":184248,"text":"Regular wide complex tachycardia - mechanism uncertain - probably\nsupraventricular with intraventricular conduction delay\nGeneralized low voltage\nClinical correlation is suggested\nSince previous tracing of , tachycardia present - in retrospect the\nrhythm on previous tracing of , may be atrial flutter rather than sinus\n\n"},{"category":"ECG","chartdate":"2132-09-17 00:00:00.000","description":"Report","row_id":184249,"text":"Baseline artifact. Rhythm is uncertain - is probably sinus with first degree\nA-V delay and left atrial abnormality but baseline artifact makes assessment\ndifficult. Left bundle-branch block. Since the previous tracing of axis\nis less rightward.\n\n"},{"category":"ECG","chartdate":"2132-09-14 00:00:00.000","description":"Report","row_id":184250,"text":"Sinus tachycardia\nIndeterminate axis\nFirst degree AV block\nLeft atrial abnormality\nIntraventricular conduction delay\nPossible anteroseptal myocardial infarction\nInferior T wave changes are nonspecific\nLow QRS voltages in limb leads\nSince previous tracing of , no significant change\n\n"},{"category":"ECG","chartdate":"2132-08-27 00:00:00.000","description":"Report","row_id":184251,"text":"Atrial fibrillation with rapid ventricular response\nMarked right axis deviation\nLeft bundle branch block\nGeneralized low QRS voltages in limb leads\nSince previous tracing, rate faster\n\n"},{"category":"ECG","chartdate":"2132-08-24 00:00:00.000","description":"Report","row_id":184252,"text":"Atrial fibrillation\nLeft bundle branch block\nGeneralized low QRS voltages in limb leads\nSince previous tracing, atrial fibrillation present\n\n"},{"category":"ECG","chartdate":"2132-07-29 00:00:00.000","description":"Report","row_id":184253,"text":"Probable multifocal atrial tachycardia\nLeft bundle branch block\nSince previous tracing of , atrial ectopy present\n\n"},{"category":"Radiology","chartdate":"2132-08-29 00:00:00.000","description":"PELVIS, NON-OBSTETRIC","row_id":923655,"text":" 10:22 AM\n PELVIS, NON-OBSTETRIC Clip # \n Reason: Endometrial lesion?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with multiple medical problems including respiratory failure\n s/p trach, multiple infections, including pseudomonas pneumonia/sacral\n decubitus ulcers, chronic renal failure on CVVH in the hospitals presents\n withnew onset of vaginal bleeding and . Hct.\n REASON FOR THIS EXAMINATION:\n Endometrial lesion?\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Portable pelvic ultrasound.\n\n INDICATION: Query vaginal bleeding.\n\n FINDINGS:\n\n The uterus is visualized and measures 9.7 x 4.3 x 6 cm. The endometrial\n stripe is slightly thickened for the patient's age at 0.5 cm. In the presence\n of vaginal bleeding, it is not possible to distinguish blood from endometrial\n thickness. The note is made of some areas of high echogenicity within the\n uterus anteriorly. This may represent focal areas of calcification or may be\n contained within fibroid. The right ovary is not visualized. The left ovary\n measures 2.8 x 2 x 2.6 cm and is unremarkable. There is an impression of some\n minimal fluid in the pouch of .\n\n CONCLUSION:\n\n Technically difficult examination. Prominent endometrial stripe. Right ovary\n not visualized. Impression of some fluid in the pouch of .\n\n\n"},{"category":"Radiology","chartdate":"2132-09-02 00:00:00.000","description":"CENTRAL TUNNELED W/O PORT","row_id":924060,"text":" 7:24 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: New HD cath needed for enterococcus cultured from tip\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * CENTRAL TUNNELED W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1750 CATH,HEMO/PERTI DIALYSIS LONG C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 y/o F s/p CVA, now with Enterococcus from HD cath, needs new one. Thank\n you.\n REASON FOR THIS EXAMINATION:\n New HD cath needed for enterococcus cultured from tip\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Over the wire exchange of right internal jugular approach tunneled\n hemodialysis catheter.\n\n CLINICAL HISTORY: 66-year-old female status post CVA, now with enterococcus\n identified on blood culture from hemodialysis catheter. Suspected catheter\n infection.\n\n OPERATORS: , M.D. (fellow).\n , M.D. (supervising staff).\n\n INFORMED CONSENT: Procedural informed consent was obtained from the patient's\n husband who was present upon assessment of the patient. Signed witnessed\n informed consent was then placed in the medical record.\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, the site of the procedure, and appropriate\n requisition, and consent. Once the above were verified, the patient was\n positioned in supine fashion on a special procedures table. The right upper\n anterior chest wall and exiting tunneled dialysis catheter were prepped and\n draped in the usual sterile fashion. Both lumens of the catheter were\n aspirated free of heparin solution. Both ports were accessed using 2, stiff\n Glidewires, which were advanced, under fluoroscopic visualization through the\n superior vena cava, right atrium, and into the inferior vena The retention\n sutures of the catheter were then released. The catheter was then delivered,\n over the guidewire, with digital compression applied at the lower right\n internal jugular vein for hemostasis. Subsequently, a new 19 cm tip-to-cuff\n length hemodialysis catheter was placed over the paired guidewires. The tip\n of the catheter was placed in the cephaldad right atrium. The retention cuff\n was approximately 2 cm deep to the exit wound. The catheter hub was then\n sutured in place using two, 2-0, interrupted, silk retention sutures. Both\n lumens of the catheter were flushed and heparin locked per protocol. The\n puncture site was then overlaid with a Tegaderm occlusive patch. The patient\n tolerated procedure well without incident.\n\n ESTIMATED BLOOD LOSS: Minimal.\n\n (Over)\n\n 7:24 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: New HD cath needed for enterococcus cultured from tip\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n MEDICATIONS: Xylocaine 1%, 10 cc total.\n\n IMPRESSION:\n\n 1. Status post successful over the wire exchange of tunneled hemodialysis\n catheter. A new, 19cm long (tip-to-cuff) hemodialysis catheter was placed\n uneventfully. The catheter is ready to employ.\n\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2132-08-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":922829,"text":" 4:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess trach placement. Thanks.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with chronic trach/peg, lethargy, hypotension, now with\n persistent fevers and increased respiratory rate.\n REASON FOR THIS EXAMINATION:\n please assess trach placement. Thanks.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess tracheal tube, patient with persistent fever and\n increased respiratory rate.\n\n Comparison is made with prior study dated .\n\n FINDINGS:\n Mild right pleural effusion is stable. Interval mild increase in size in the\n small left pleural effusion. New atelectasis in the lingula. Worsening of\n right lower lobe consolidation. Tracheal tube with tip in standar position.\n Right PIC line and right internal jugular vein catheter with tips in standar\n position in the SVC, unchanged. There is no pneumothorax. The left border of\n the heart is obscured by the atelectasis and pleural effusion. New mild\n asymmetric pulmonary edema greater in the left\n\n\n IMPRESSION:\n New left pleural effusion and lingular atelectasis.\n Worsening of right lower lobe consolidation.\n New asymmetric mild pulmonary edema greater in the left side.\n\n\n\n"},{"category":"Radiology","chartdate":"2132-08-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":921134,"text":" 10:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for infiltrate/consolidation\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with chronic trach/peg, lethargy, hypotension, now with\n fever\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate/consolidation\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Lethargy, hypertension, fever.\n\n CHEST: Compared with the prior film, there is an increase in the effusions.\n No definite infiltrates are present. The appearances suggest some failure\n rather than infection.\n\n IMPRESSION: Evidence of failure.\n\n\n"},{"category":"Radiology","chartdate":"2132-08-02 00:00:00.000","description":"MR CONTRAST GADOLIN","row_id":920166,"text":" 2:02 PM\n MR W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: ?osteo of sacrum\n Admitting Diagnosis: SEPSIS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with ?osteomyelitis from sacral decub\n REASON FOR THIS EXAMINATION:\n ?osteo of sacrum\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the lumbar and sacral spine.\n\n CLINICAL INFORMATION: Patient with large sacral decubitus ulcer, rule out\n bone involvement of osteomyelitis.\n\n TECHNIQUE: T1, T2, and inversion recovery sagittal, and T1 and T2 axial\n images of the lumbar and sacral spine were obtained before gadolinium.\n Inversion recovery sagittal images were also acquired. Following gadolinium,\n T1 sagittal, and axial images were obtained. Post-gadolinium images are\n somewhat limited for evaluation secondary to lack of fat suppression.\n\n FINDINGS: In the lumbar region mild multilevel degenerative changes are\n identified within the spine from T11-12 to L5-S1 level. At L4-5, there are\n disc degenerative changes with facet degenerative changes and bulging of the\n disc resulting in moderate spinal stenosis. At L5-S1 level facet degenerative\n changes are identified.\n\n There is a rudimentary disc between S1 and S2 visualized.\n\n There is a soft tissue defect indicative of decubitus ulcer identified in the\n region of S4 and S5 segment with T1 low signal in this region. The adjacent\n sacral segments demonstrate no significant signal changes to indicate\n osteomyelitis. No definite enhancement is identified. There is no evidence\n of presacral edema. There is subtle increased signal seen within the coccyx\n on sagittal inversion recovery images, which could be secondary to partial\n volume averaging.\n\n IMPRESSION: No definite evidence of osteomyelitis of the sacrum. Subtle\n increased signal within the coccyx could be secondary to partial volume\n averaging from the adjacent decubitus ulcer. Moderate spinal stenosis at L4-5\n level.\n\n"},{"category":"Radiology","chartdate":"2132-08-04 00:00:00.000","description":"J TUBE CHANGE","row_id":920327,"text":" 7:24 AM\n PERC G/G-J TUBE PLMT Clip # \n Reason: replace J tube with larger tube\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 10\n ********************************* CPT Codes ********************************\n * J TUBE CHANGE CHANGE PERC TUBE OR CATH W/CON *\n * CATHETER, DRAINAGE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with J tube - needs to be replaced\n REASON FOR THIS EXAMINATION:\n replace J tube with larger tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR THE EXAM: 66-year-old woman with leakage around J tube.\n\n RADIOLOGISTS: Dr. and Dr. , the attending radiologist, who\n was present throughout the procedure. Informed consent was obtained from the\n patient's daughter over the telephone.\n\n PROCEDURE AND FINDINGS: The patient was positioned on the angiographic table\n in supine position, was prepped and draped in the sterile fashion. An\n abdominal scout was obtained to demonstrate the location of the J tube.\n Injection of diluted contrast was performed through the tube under\n fluoroscopic guidance, documenting position of the tube in the jejunum. A\n wire was advanced through the tube and the tube was pulled back over\n the wire. A new 16 French J tube was then advanced under fluoroscopic guidance\n and the position was confirmed after injection of contrast under fluoroscopic\n guidance. The J tube was secured with sutures at the enter site.\n\n COMPLICATONS: No immediate complications.\n\n IMPRESSION: Successful exchange and upsize of jejunostomy catheter.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2132-07-29 00:00:00.000","description":"CT PELVIS W/CONTRAST","row_id":919547,"text":" 10:36 AM\n CT PELVIS W/CONTRAST Clip # \n Reason: R/o bone involvement of sacral decub\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with large sacral decubitus ulcer\n REASON FOR THIS EXAMINATION:\n R/o bone involvement of sacral decub\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: CT pelvis.\n\n INDICATION: Large sacral decubitus ulcer.\n\n FINDINGS:\n\n TECHNIQUE:\n\n Axial images were taken of the lower abdomen and pelvis after administration\n of IV contrast. Multiplanar reformation was performed. In relation to the\n lower abdomen, note is made of a hernia in the right paramedian line. The\n small and large bowel visualized is unremarkable. Note is made of some\n calcifications in relation to the uterus, consistent with fibroid uterus.\n\n There is a defect in the skin posteroinferior to the sacrum. This is\n extending right down to the level of the sacrum, but there is no definite\n destruction of the sacrum.\n\n IMPRESSION:\n\n Large decubitus ulcer posteroinferior to the sacrum. This is abutting the\n sacrum but no definite destruction of sacrum identified.\n\n Right paramedian hernia. Fibroid uterus.\n\n\n"},{"category":"Radiology","chartdate":"2132-07-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":919465,"text":" 7:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate, effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with chronic trach/peg, lethargy, hypotension\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old female with tracheostomy and gastrostomy, now with\n lethargy and hypotension.\n\n COMPARISON: .\n\n AP SEMI-UPRIGHT PORTABLE CHEST:\n\n A right-sided PICC line and right subclavian dual lumen central catheter both\n terminate near the cavoatrial junction. The patient is status post sternotomy\n and valve replacement. The heart size is top normal. The cardiomediastinal\n contours are stable. There is a tracheostomy in appropriate position. There\n is a small amount of pleural fluid on the right, tracking into the minor\n fissure. The left lung is grossly clear. No focal consolidation or\n pneumothorax is identified. There is no free air under the diaphragm.\n\n IMPRESSION: Small right pleural effusion. No pneumonia identified.\n\n"},{"category":"Radiology","chartdate":"2132-07-29 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":919546,"text":" 10:36 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: rule out new bleed\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with hx of left parietal hemorrhage, PEA arrest now admitted\n with fever and lethargy, supratherapeutic INR\n REASON FOR THIS EXAMINATION:\n rule out new bleed\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old with history of prior left parietal hemorrhage, now\n post-cardiac arrest with fever and lethargy.\n\n TECHNIQUE: CT of the brain without IV contrast.\n\n COMPARISON: .\n\n FINDINGS: There is no acute intracranial hemorrhage, shift of normally\n midline structures, or hydrocephalus. -white matter differentiation is\n preserved. Areas of decreased attenuation in the frontal lobe white matter\n and periventricular white matter are unchanged. Bilateral basal ganglial\n calcification, and high density in the right occipital lobe are also stable in\n appearance. There has been prior surgical intervention along the posterior\n wall of the right maxillary sinus with clips seen adjacent to the\n pterygopalatine fossa. A mucus retention cyst or polyp is seen in the right\n ethmoidal air cells. The remaining visualized paranasal sinuses and mastoid\n air cells are clear. Soft tissues are normal.\n\n IMPRESSION:\n\n No acute intracranial hemorrhage or change from the prior examination.\n\n\n"},{"category":"Radiology","chartdate":"2132-08-12 00:00:00.000","description":"CHANGE GASTROSTOMY TUBE","row_id":921423,"text":" 1:16 PM\n PERC G/G-J TUBE PLMT Clip # \n Reason: please change j-tube\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 50\n ********************************* CPT Codes ********************************\n * CHANGE GASTROSTOMY TUBE CHANGE PERC TUBE OR CATH W/CON *\n * CATHETER, DRAINAGE C1769 GUID WIRES INCL INF *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with 18F J tube - needs to be replaced per IR due to\n continued leaking around current tube.\n REASON FOR THIS EXAMINATION:\n please change j-tube\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Gastrojejunostomy tube exchange.\n\n CLINICAL HISTORY: 66-year-old female with history of 18 French J-tube with\n peri-catheteral leak.\n\n OPERATORS: , M.D. (Fellow).\n\n , M.D. (Staff).\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, and the site of the procedure. The epigastric\n region and the external course of the gastrojejunostomy tube were prepped and\n draped in the usual sterile fashion. A guidewire was used to cannulate the\n gastrojejunostomy tube. Once the distal segment wire was noted to extend\n distal to the gastrojejunostomy under fluoroscopy, the gastrojejunostomy tube\n was removed over the guidewire leaving the guidewire in situ. A 6Fr sheath\n was then inserted and a pull-out contrast injection was performed to\n determine the catheter track, since this was not clear to us, because the\n catheter was placed at OSH. The contrast injection showed that the catheter\n appears to be entering the very distal gastric antrum, very close to the\n pylorus. Subsequently, a 14 French gastrojejunostomy tube was delivered\n over the guidewire with the retention pigtail formed in the D-2 segment of the\n duodenum. The distal segment is seen in the mid jejunum. The catheter was\n secured with formation of the retention suture. A small purse-string suture\n was applied at the skin exit wound. The wound was dressed with drain sponges\n overlaid with Tegaderm patches and paper tape. The patient tolerated the\n procedure well.\n\n ANESTHESIA: 1% Xylocaine locally infiltrated, 8 cc total.\n\n ESTIMATED BLOOD LOSS: Minimal.\n\n COMPLICATIONS: None immediately.\n\n IMPRESSION: Status post exchange of gastrojejunostomy tube as described\n (Over)\n\n 1:16 PM\n PERC G/G-J TUBE PLMT Clip # \n Reason: please change j-tube\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n above. Tube is ready to employ.\n\n\n"},{"category":"Radiology","chartdate":"2132-07-30 00:00:00.000","description":"G/GJ TUBE CHECK","row_id":919735,"text":" 1:20 PM\n G/GJ TUBE CHECK Clip # \n Reason: KUB with contrast through J-tube to evaluate placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with J tube\n REASON FOR THIS EXAMINATION:\n KUB with contrast through J-tube to evaluate placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Jejunostomy tube, query placement.\n\n ABDOMEN, TWO VIEWS: Single abdominal radiograph after hand injection of\n contrast through the jejunostomy tube by the surgical housestaff shows\n opacification of the tube and a jejunal loop in the left mid abdomen. No\n other bowel loops are visible. There are midline sternotomy wires and a\n prosthetic valve. Vascular calcifications are seen in the aorta and common\n iliacs. There are degenerative changes of the spine.\n\n"},{"category":"Radiology","chartdate":"2132-08-08 00:00:00.000","description":"CHANGE GASTROSTOMY TUBE","row_id":920921,"text":" 10:32 AM\n PERC G/G-J TUBE PLMT Clip # \n Reason: Please place 18F J-tube if possible\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 10\n ********************************* CPT Codes ********************************\n * CHANGE GASTROSTOMY TUBE CHANGE PERC TUBE OR CATH W/CON *\n * CATHETER, DRAINAGE C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF C1892 INT/SHTH,EP,FXD CURVE/ AWY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with 16F J tube - needs to be replaced with 18F J tube per\n IR due to continued leaking around current tube.\n REASON FOR THIS EXAMINATION:\n Please place 18F J-tube if possible\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Exchange of gastrojejunostomy tube.\n\n CLINICAL HISTORY: 66-year-old female with perigastric catheter leak around\n pre-existent 16 French percutaneous gastrojejunostomy tube.\n\n OPERATORS:\n 1. , M.D. (fellow)\n 2. , M.D. (supervising staff)\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, the site of the procedure, appropriate requisition\n material, and appropriate informed consent. Once verified, the patient was\n positioned in supine fashion. The epigastric region was prepped and draped\n along with the external course of the previous gastrojejunostomy tube. A\n stiff guidewire was advanced through the prior gastrojejunostomy tube. Once\n satisfactory positioning of the tip of the guidewire was confirmed using\n fluoroscopic visualization, the retention sutures for the catheter were\n released and the catheter removed over the guidewire, leaving the guidewire in\n situ. Subsequently, a new 18 French MIC jejunostomy tube was delivered over\n the guidewire with the distal segment within the mid jejunum. Test injection\n of contrast demonstrates satisfactory positioning. The retention balloon was\n inflated with 20 cc of saline solution. Two retention sutures were placed\n securing the catheter to the anterior abdominal wall. The patient tolerated\n the procedure well without incident.\n\n IMPRESSION:\n 1. Status post successful exchange of percutaneous gastrojejunostomy tube as\n described above. The catheter is ready to employ.\n\n\n (Over)\n\n 10:32 AM\n PERC G/G-J TUBE PLMT Clip # \n Reason: Please place 18F J-tube if possible\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 10\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2132-09-27 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":927267,"text":" 3:57 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? obstruction\n Admitting Diagnosis: SEPSIS\n Field of view: 48\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with n/v, evidence of obstruction on plain film\n REASON FOR THIS EXAMINATION:\n ? obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 66-year-old woman with nausea, vomiting, evidence of\n obstruction on plain film.\n\n TECHNIQUE: Multiple axial images of the abdomen and pelvis were obtained\n after the administration of oral contrast through the patient's gastrostomy\n tube. No intravenous contrast was administered.\n\n Findings are compared with patient's prior examination dated .\n\n FINDINGS: Evaluation of the lung bases demonstrates the patient to be status\n post median sternotomy. There is dense calcification of the mitral annulus\n and dense coronary artery calcification. There are bilateral pleural\n effusions, right greater than left with underlying atelectasis.\n\n Images of the upper abdomen demonstrate a gastrostomy tube with the distal tip\n terminating in the proximal jejunum. Contrast is seen progressing to the\n proximal jejunum. There is fecalization of the small bowel proximal to a\n transition point in the right upper quadrant, where there is marked collapse\n of the distal small bowel. These findings are compatible with a small bowel\n obstruction. No obstructing mass is seen and the obstruction is remote from\n the ostomy site. Two limbs enter and exit the ostomy site in the right lower\n quadrant; the proximal limb is presumably distal ileum, and the exiting limb\n is presumably transverse colon. The distal transverse, descending and sigmoid\n colon are collapsed.\n\n Non-contrast evaluation of the liver is unremarkable. Clips are visualized in\n the gallbladder fossa. There is dense calcification of the splenic and\n hepatic arteries. There is a moderate amount of intraabdominal ascites. The\n kidneys are noted to be atrophic bilaterally with linear calcification of the\n parenchyma. The right adrenal gland, pancreas, and spleen are unremarkable.\n There is a left adrenal adenoma. Evaluation of the uterus demonstrates dense\n calcification of the uterine arteries. The osseous structures demonstrate\n degenerative changes without evidence for acute fracture or dislocation.\n\n The overlying soft tissues are markedly edematous compatible with anasarca.\n\n IMPRESSION: Small bowel obstruction with transition point in the right upper\n quadrant, remote from the more distal ostomy.\n\n\n (Over)\n\n 3:57 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? obstruction\n Admitting Diagnosis: SEPSIS\n Field of view: 48\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2132-10-27 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":930861,"text":" 11:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate, pulm edema\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with sepsis, ESRD, respiratory failure w/ trach with\n increased resp rate, tachycardia\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate, pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST 12:09\n\n INDICATION: Respiratory failure with increased respiratory rate.\n\n COMPARISON: at 8:26.\n\n FINDINGS: Right PICC line, left dialysis catheter and tracheostomy tube\n remain in place. Compared to the prior study, there is new increased density\n in the left upper lung zone, which could be a developing pneumonia. Extremely\n subtle increase in density is seen adjacent to the right hilar region, which\n could relate to early pulmonary edema. However, the pulmonary vascular\n markings are not significantly distended. Right effusion is again\n demonstrated.\n\n IMPRESSION:\n\n New airspace finding in the left upper lung zone, possibly in the right mid\n lung zone. Continued followup is recommended.\n\n\n"},{"category":"Radiology","chartdate":"2132-10-23 00:00:00.000","description":"PR ART DUP EXT UP UNI LMTD PORT RIGHT","row_id":930400,"text":" 10:02 AM\n ART DUP EXT UP UNI LMTD PORT RIGHT Clip # \n Reason: please eval for R A-V fistula (IJ-carotid??)\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with MMP, now R IJ with venous blood gas appearing arterial,\n appropriately placed per CXR\n REASON FOR THIS EXAMINATION:\n please eval for R A-V fistula (IJ-carotid??)\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Carotid series complete.\n\n REASON: Question AV fistula.\n\n FINDINGS: Duplex evaluation was performed of the right neck region. Common\n carotid artery and internal jugular veins are patent. There is no evidence of\n thrombus or normal appearing waveforms. There is no evidence of fistula.\n\n IMPRESSION: No evidence of right neck carotid artery or jugular vein fistula\n or overt disease.\n\n\n"},{"category":"Radiology","chartdate":"2132-09-16 00:00:00.000","description":"NON-TUNNELED","row_id":925833,"text":" 11:24 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please remove current R central dialysis catheter and replac\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1752 CATH,HEM/PERTI DIALYSIS SHORT *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with pus at site of R central dialysis catheter\n REASON FOR THIS EXAMINATION:\n Please remove current R central dialysis catheter and replace with L central\n dialysis catheter\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE:\n\n 1. Left internal jugular approach temporary hemodialysis catheter placement.\n 2. Removal of tunneled right internal jugular approach tunneled hemodialysis\n catheter.\n 3. Ultrasound-guided venipuncture.\n 4. Removal of right arm PICC\n CLINICAL HISTORY: 66-year-old female with infected tunneled right internal\n jugular approach tunneled dialysis catheter requires IV access for dialysis.\n Suspected PICC line infection.\n\n INFORMED CONSENT: Procedural informed consent was obtained prior to the study\n and placed in the medical record.\n\n OPERATORS: , M.D. (fellow).\n , M.D. (supervising staff).\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedures to be performed, the sites of the procedures, appropriate\n requisition, and appropriate informed consent. Once the above were verified,\n the patient was positioned in supine fashion on a special procedures table.\n The lower left side of the neck and left upper anterior chest wall were\n prepped and draped in usual sterile fashion. Ultrasound was employed to\n visualize the low left internal jugular vein, which was widely patent and\n compressible. This site was selected for venipuncture. The skin and\n subcutaneous tissues were infiltrated with approximately 5 cc of 1% Xylocaine\n for local anesthesia. Uneventful one-wall venipuncture was achieved in the\n low left internal jugular vein using micropuncture access technique. A 1.5 mm\n J, 0.035 inch wire was advanced by way of the 4 French catheter of the\n micropuncture set, under fluoroscopic visualization to the level of the\n inferior vena cava. Subsequently, the tract was then serially dilated. A\n angiodynamics, 24 cm length, hemodialysis catheter was then delivered\n over the guidewire with the tip positioned in the cephalad right atrium. Both\n lumens were flushed and heparin-locked. The catheter was secured in place\n with two, 0 silk retention sutures. The puncture site was overlaid with a\n Tegaderm occlusive patch. Hemostasis was achieved promptly. No residual\n (Over)\n\n 11:24 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please remove current R central dialysis catheter and replac\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n bleeding or hematoma was encountered. Postprocedural chest x-ray demonstrates\n good positioning of the catheter.\n\n (Hard copy ultrasound images were obtained both prior to and subsequent to the\n venipuncture for documentation.)\n\n Subsequent to the procedure, the patient was transferred to the guerney, in\n semi-upright positioning. The tunneled right internal jugular approach\n hemodialysis catheter was prepped and draped. The retention cuff was freed\n and the catheter was removed uneventfully. Hemostasis was achieved promptly\n using digital compression for a total of 10 minutes. No residual bleeding was\n encountered. Frank pus was expressed from the tunnel tract and cultured, along\n with the catheter. The wound was then dressed with guaze and tape.\n The patient tolerated the procedure well.\n\n The 5 Fr dual luimen PICC line in the right are was prepped, draped, and\n removed uneventfully. This catheter too was ent for culture.\n\n IMPRESSION:\n\n 1. Status post placement of left internal jugular approach temporary\n hemodialysis catheter. See above description.\n\n 2. Status post removal of tunneled right internal jugular approach\n hemodialysis catheter. See above description.\n\n 3. Status post removal of right PICC line\n\n 4. The newly placed left internal jugular approach temporary hemodialysis\n catheter is ready to employ. Post-procedural orders were written.\n\n\n"},{"category":"Radiology","chartdate":"2132-10-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":928935,"text":" 4:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess PICC line for position.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with sepsis, ESRD, vented with pulmonary effusions, check\n PICC line for position.\n REASON FOR THIS EXAMINATION:\n Assess PICC line for position.\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST AT 05:27 HOURS\n\n HISTORY: Multiple medical problems. Assess PICC line for positioning.\n\n COMPARISON: .\n\n FINDINGS: The patient is rotated. There is near-complete opacification of\n the left hemithorax with only a small residual left upper lung noted. There\n has been interval placement of a right internal jugular approach central line\n with the distal tip projecting over the superior vena cava. There has been\n interval decrease in the right pleural effusion. There is fluid tracking\n within the major fissure. Mild hydrostatic edema is evident in the aerated\n right lung.\n\n IMPRESSION: Near-complete opacification of the left lung. Evaluation limited\n secondary to rotation, however, atelectasis and effusion are considered\n leading diagnostic considerations. There has been interval redistribution of\n the right pleural effusion with mild superimposed hydrostatic edema.\n\n\n DR. \n"},{"category":"Radiology","chartdate":"2132-10-12 00:00:00.000","description":"G/GJ TUBE CHECK","row_id":929039,"text":" 12:19 PM\n G/GJ TUBE CHECK Clip # \n Reason: please confirm placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with G-J tube\n\n REASON FOR THIS EXAMINATION:\n please confirm placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old woman with gastrojejunostomy tube dislodged this\n morning.\n\n GJ TUBE CHECK: The patient was brought to the Fluoroscopic Suite where\n approximately 20 cc of Gastrografin was administered through the\n gastrojejunostomy tube. The tube demonstrated patentcy and terminates in the\n jejunum. There is no evidence of extraluminal contrast. The caliber and\n appearance of the visualized jejunum is normal. Please note that there is\n approximately 15 cm of tubing within the patient which terminates in the\n jejunum.\n\n IMPRESSION: Gastrojejunostomy tube in proper position terminating in the\n jejunum. No evidence for extraluminal contrast.\n\n"},{"category":"Radiology","chartdate":"2132-09-27 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":927245,"text":" 10:39 AM\n PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # \n Reason: r/o obstruction around j-tube with gastrograffin injection\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman s/p g tube and colostomy now with new abd mass and increase\n output from g-tube\n REASON FOR THIS EXAMINATION:\n r/o obstruction around j-tube with gastrograffin injection\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Question obstruction around J-tube site after Gastrografin\n injection.\n\n FINDINGS: This film was taken after injection of Gastrografin. Contrast is\n seen entering a loop of bowel in the left mid abdomen compatible with jejunum.\n Just after the J-tube this loop of bowel dilates to 6 cm. Otherwise there is\n paucity of small bowel gas seen in the abdomen. This could represent a small\n bowel obstruction. A CT is recommended for further evaluation.\n\n\n"},{"category":"Radiology","chartdate":"2132-09-23 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":926736,"text":" 5:13 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: right sc line placement attempt and failed r/o ptx\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with ESRD on CVVH, resp. failure with increased secretions\n and increasing WBC count\n REASON FOR THIS EXAMINATION:\n right sc line placement attempt and failed r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right subclavian line placement attempt, failed.\n\n PORTABLE CHEST: Comparison with . No pneumothorax seen.\n Bilateral pleural effusions, slightly improved. Left lower lobe\n atelectasis/consolidation is increased slightly. This study is somewhat\n limited by respiratory motion. Aortic mural calcifications, tracheostomy,\n midline sternotomy wires, valvular replacement, and left dialysis line are\n unchanged.\n\n IMPRESSION: No pneumothorax.\n\n"},{"category":"Radiology","chartdate":"2132-09-24 00:00:00.000","description":"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT","row_id":926846,"text":" 2:41 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: RISING T.BILI AND ELEVATED ALK PHOS\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with MMP, now with hypotension, rising t.bili and elevated\n alk phos.\n REASON FOR THIS EXAMINATION:\n Evaluate gallbladder and biliary system.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old female with multiple medical problems, now with\n hypertension and elevated bilirubin and alkaline phosphatase.\n\n COMPARISON: .\n\n RIGHT UPPER QUADRANT ULTRASOUND: Again demonstrated is slightly coarsened\n echotexture of the liver without focal hepatic lesion identified. There is a\n trace amount of perihepatic ascites, which is decreased compared to . There is no intra- or extra-hepatic biliary ductal dilatation. There\n is appropriate hepatopetal blood flow in the main portal vein. The common\n duct measures normal maximal caliber of 3 mm. The patient is status post\n cholecystectomy. There is no evidence of choledocholithiasis in the\n visualized common bile duct. A small right pleural effusion remains.\n\n IMPRESSION:\n 1. Status post cholecystectomy. No biliary ductal dilatation or evidence of\n cholecocholithiasis in the visualized common bile duct.\n 2. Trace perihepatic ascites is decreased compared to .\n 3. Persistent small right pleural effusion.\n\n\n"},{"category":"Radiology","chartdate":"2132-09-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":925785,"text":" 4:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for clinical change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with ESRD on CVVH, resp. failure.\n REASON FOR THIS EXAMINATION:\n Please assess for clinical change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:38 A.M. ON .\n\n HISTORY: On dialysis. Respiratory failure.\n\n IMPRESSION: AP chest compared to and 24:\n\n Moderate right pleural effusion has increased since , partially\n obscuring anatomic detail in the right lung but mild interstitial edema is\n probably present. Leftward mediastinal shift _____ a function of right\n pleural effusion and substantial left lower lobe collapse, even though the\n latter appears to have improved since . Cardiac silhouette is top\n normal size. No pneumothorax.\n\n Tracheostomy tube and a dual channel right internal jugular dialysis line are\n in standard placements. No pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2132-09-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":926341,"text":" 7:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o worsening infiltrate/effusion\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with ESRD on CVVH, resp. failure with increased secretions\n and increasing WBC count\n REASON FOR THIS EXAMINATION:\n r/o worsening infiltrate/effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n INDICATION: End-stage renal disease.\n\n FINDINGS:\n Comparison was made with the recent x-ray from . The patient is\n status post sternotomy. Note is made of aortic valve replacement.\n Tracheostomy is in situ. Central venous line is seen, the tip of which is in\n the SVC. There are bilateral pleural effusions.\n\n No significant interval change when compared to the previous x-ray.\n\n CONCLUSION:\n Trach in situ, bilateral pleural effusions. No significant interval change.\n\n\n"},{"category":"Radiology","chartdate":"2132-09-11 00:00:00.000","description":"P ABDOMEN U.S. (COMPLETE STUDY) PORT","row_id":925186,"text":" 7:46 AM\n ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # \n Reason: ELAVATED BIL,ALK PHOSPHATASE ,EVAL FOR CHOLANGITIS\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with MMP, now with hypotension, rising t.bili and elevated\n alk phos.\n REASON FOR THIS EXAMINATION:\n please eval for cholangitis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old woman with multiple medical problems now with\n hypotension and rising bilirubin and elevated LFTs.\n\n ABDOMINAL ULTRASOUND STUDY: Slightly coarsened echotexture of the liver\n without focal liver lesions. There is small amount of ascites and small right\n pleural effusion is seen. There is no intrahepatic or extrahepatic biliary\n ductal dilatation. The common bile duct measures 4 mm in diameter. Patient\n is status post cholecystectomy. The main portal vein is patent and its flow\n is hepatopetal.\n\n The pancreatic tail is not well visualized. In the pancreatic head, there is\n a 1.6 x 1.4 cm cystic lesion. The spleen is enlarged. The kidneys appear to\n be slightly atrophic and echogenic and are not well imaged. This could be in\n part due to the patient's body habitus, however, renal parenchymal disease\n cannot be entirely excluded.\n\n IMPRESSION:\n 1. No intrahepatic or extrahepatic biliary ductal dilatation.\n 2. Small right pleural effusion and ascites.\n 3. Splenomegaly.\n 4. Small cystic lesion in the head of the pancreas, further evaluation with\n dedicated CT angiography or MRCP study could be considered.\n 5. Possible renal parenchymal disease.\n\n\n"},{"category":"Radiology","chartdate":"2132-09-27 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":927252,"text":" 12:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with ESRD on CVVH, resp. failure with increased\n secretions and ? aspiration event\n REASON FOR THIS EXAMINATION:\n please evaluate interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON .\n\n HISTORY: End-stage renal disease with respiratory failure. Question\n aspiration.\n\n REFERENCE EXAM: .\n\n FINDINGS: Again seen is a tracheostomy tube. There is hazy increased opacity\n projecting over both lungs consistent with layering effusions bilaterally.\n These are increased in size compared to the prior film. There is dense\n retrocardiac opacity and it is unclear if this is due to volume loss or a\n retrocardiac infiltrate. A lateral film would be helpful if the patient is\n able. The heart is shifted to the left on this film but it is unclear how\n much of this is due to rotation. Contrast is seen in the left upper quadrant,\n presumably in the stomach, which is slightly distended.\n\n\n"},{"category":"Radiology","chartdate":"2132-09-16 00:00:00.000","description":"TUNNELED CENTRAL W/O PORT","row_id":925854,"text":" 2:43 PM\n DIALYSIS REMOVE Clip # \n Reason: Please remove right subclavian dialysis catheter.\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * TUNNELED CENTRAL W/O PORT -51 MULTI-PROCEDURE SAME DAY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 y/o F s/p CVA, now with pus draining from site of right subclavian dialysis\n catheter. Needs removal.\n REASON FOR THIS EXAMINATION:\n Please remove right subclavian dialysis catheter.\n ______________________________________________________________________________\n FINAL REPORT\n Please see clip for the complete report.\n\n"},{"category":"Radiology","chartdate":"2132-09-17 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":925920,"text":" 4:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o worsening effusion\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with ESRD on CVVH, resp. failure.\n\n REASON FOR THIS EXAMINATION:\n r/o worsening effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:13 A.M. on :\n\n HISTORY: End stage renal disease. Respiratory failure.\n\n IMPRESSION: AP chest compared to through :\n\n Moderate volume bilateral pleural effusion, stable on the right and increased\n on the left relative to . Mild enlargement of the cardiomediastinal\n silhouette is stable. Left lower lobe atelectasis has worsened. Tracheostomy\n tube in standard placement. Dual channel left supraclavicular central venous\n line tip projects over the superior cavoatrial junction.\n\n\n"},{"category":"Radiology","chartdate":"2132-09-26 00:00:00.000","description":"PICC W/O PORT","row_id":927152,"text":" 3:01 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: bilateral piccs for access-thank you\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * PICC W/O PORT 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * FLUOR GUID PLCT/REPLCT/REMOVE US GUID FOR VAS. ACCESS *\n * C1751 CATH ,/CENT/MID(NOT D C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 y/o F s/p CVA, multiple infections, hypotensive, CRF and femoral line that\n needs removal infection. Needs second line for chronic Abx.\n REASON FOR THIS EXAMINATION:\n bilateral piccs for access-thank you\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: 5 French dual-lumen PICC catheter placement via right\n brachial vein approach; ultrasound-guided venipuncture.\n\n CLINICAL HISTORY: 66-year-old female status post cerebrovascular accident,\n multiple infections, hypotensive episodes, chronic renal failure, requires IV\n access for antibiotics, blood draws, and blood products.\n\n OPERATORS: , M.D. (fellow).\n , M.D. (supervising staff).\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, the site of the procedure, and appropriate informed\n consent. Once the above were verified, the patient was positioned in supine\n fashion on a special procedures table. This examination was originally\n requested as a central venous catheter, however, the order was changed by the\n requesting physician to that of a peripherally inserted central venous\n catheter.\n\n (Hard copy son images of the venipuncture, both prior to and after\n access were achieved and are placed in the patient's record.)\n\n The right arm was prepped and draped in usual sterile fashion. Ultrasound was\n employed to assess the venous anatomy of the right upper extremity. The\n venous anatomy was very diminutive. However, right brachial vein was\n punctured under ultrasonographic guidance in retrograde fashion using one wall\n technique and a 5 French dual-lumen catheter delivered by modified\n Seldinger technique to the level of the caudal superior vena cava using\n flouroscopic guidance. The catheter was advanced to the level of the 39 cm\n mark at the skin. The remainder of the catheter was externalized and secured\n with a StatLock device and then overlaid with Tegaderm occlusive dressing\n patches. Both lumens were flushed with saline. The patient tolerated the\n procedure well. Estimated blood loss was minimal.\n\n ANESTHESIA:\n 1% Xylocaine, 10 cc total.\n\n (Over)\n\n 3:01 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: bilateral piccs for access-thank you\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: Status post successful 5 French dual-lumen PICC line via\n right brachial vein approach. The patient tolerated the procedure well. The\n line is ready to employ. See above description.\n\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2132-09-26 00:00:00.000","description":"PICC W/O PORT","row_id":927153,"text":" 3:01 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: picc for access\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 5\n ********************************* CPT Codes ********************************\n * PICC W/O PORT 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * -51 MULTI-PROCEDURE SAME DAY FLUOR GUID PLCT/REPLCT/REMOVE *\n * -59 DISTINCT PROCEDURAL SERVICE US GUID FOR VAS. ACCESS *\n * -59 DISTINCT PROCEDURAL SERVICE C1751 CATH ,/CENT/MID(NOT D *\n * C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 y/o F s/p CVA, multiple infections, hypotensive, CRF and femoral line\n that needs removal infection. Needs second line for chronic Abx.\n REASON FOR THIS EXAMINATION:\n picc for access\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: 5 French dual-lumen PICC line placement via left cephalic\n vein approach; ultrasound-guided venipuncture.\n\n CLINICAL INDICATION: IV access.\n\n OPERATORS: , M.D. (fellow).\n , M.D. (supervising staff).\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, the site of the procedure, and appropriate\n requisition. Once the above were verified, the patient was positioned in\n supine fashion on a special procedures table. Left arm was abducted,\n externally rotated, and then prepped from the axilla to the antecubital fossa.\n A tourniquet was applied to the upper arm. Uneventful venipuncture was\n achieved using ultrasound guidance at the left cephalic vein. Hard copy\n ultrasound images were obtained before and after venous access documenting\n vessel patency. A guide wire was advanced by way of the cephalic vein to the\n central circulation. A 5 French dual-lumen PICC line was then\n delivered with the aid of the stiffening inner stylet, using modified\n Seldinger technique under fluoroscopic visualization. Tip position is in the\n caudal superior vena cava. Both lumens of the catheter were flushed\n and heparin locked. Specific attention was made to remove the inner stylet.\n The catheter was secured using a statlock device and then overlaid with a\n Tegaderm patch.\n\n ESTIMATED BLOOD LOSS: Minimal.\n\n ANESTHESIA: 1% Xylocaine, 10 cc local infiltration.\n\n IMPRESSION: Status post successful placement of 5 French dual-lumen \n PICC catheter via left cephalic vein approach. Tip position is in the caudal\n superior vena cava. The catheter is at the 42 cm mark at the skin. The\n catheter is ready to employ. Post-procedural orders are written.\n (Over)\n\n 3:01 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: picc for access\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 5\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n\n\n\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2132-09-27 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":927199,"text":" 12:49 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval for obstruction\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman s/p g tube and colostomy now with new abd mass and increase\n output from g-tube\n REASON FOR THIS EXAMINATION:\n eval for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Evaluate for obstruction, patient with G-tube, J-tube\n and ostomy.\n\n TECHNIQUE: AP examination of the abdomen is submitted for interpretation.\n Findings are compared with prior examination dated .\n\n FINDINGS: Limited evaluation of the lower abdomen and pelvis demonstrates\n three dilated loops of small bowel that appear to surround the patient's\n jejunostomy tube. These measure up to 6.1 cm in maximal diameter. Findings\n are concerning for a small-bowel obstruction.\n\n Degenerative changes are noted in the spine and pelvis.\n\n IMPRESSION: Limited evaluation of the abdomen with 3 dilated small bowel\n loops, concerning for small- bowel obstruction. Correlate clinically.\n Findings were communicated with Dr. at the time of dictation.\n\n"},{"category":"Radiology","chartdate":"2132-09-29 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":927383,"text":" 4:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for interval change.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with ESRD on CVVH, resp. failure with P. aeruginosa in\n sputum.\n REASON FOR THIS EXAMINATION:\n Assess for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage renal disease, respiratory failure and Pseudomonas\n aeruginosa in sputum. Assess for interval change.\n\n Comparison is made to .\n\n SUPINE PORTABLE RADIOGRAPH OF THE CHEST: The tracheostomy is in unchanged\n position. The left subclavian central venous line is located with the tip in\n the distal SVC. There are significantly increased bilateral hazy opacities,\n most likely representing layering pleural effusions. The left retrocardiac\n opacity may represent effusion and/or atelectasis, but a consolidation in this\n region cannot be excluded. The patient is status post median sternotomy and\n aortic valve replacement.\n\n IMPRESSION: Worsening bilateral pleural effusions. Increased left\n retrocardiac opacity may represent effusion and/or atelectasis, consolidation\n cannot be excluded.\n\n\n"},{"category":"Radiology","chartdate":"2132-09-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":925164,"text":" 12:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?acute change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with chronic trach/peg, lethargy, hypotension, now with\n persistent fevers and increased respiratory rate.\n REASON FOR THIS EXAMINATION:\n ?acute change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM\n\n History of fever and tachypnea in patient with tracheostomy and a J tube.\n\n SINGLE SUPINE AP FILMS\n\n Status post AVR. The dialysis catheter is in the region of the cavoatrial\n junction. Tracheostomy tube is 4 cm above the carina. The PICC line is in\n distal SVC allowing for low lung volumes. There are persistent bilateral\n pleural effusions and associated atelectases in the lower zones. No definite\n new pulmonary consolidation or pulmonary edema since the prior film of , . No pneumothorax.\n\n"},{"category":"Radiology","chartdate":"2132-09-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":927643,"text":" 8:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for fluid status and interval changes in effusions\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with sepsis, ESRD, vented with pulmonary effusions\n REASON FOR THIS EXAMINATION:\n evaluate for fluid status and interval changes in effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old female with sepsis, end-stage renal disease, and\n ventilated. Evaluate.\n\n COMPARISON: AP supine portable chest x-ray dated .\n\n AP UPRIGHT PORTABLE CHEST X-RAY: A right-sided PICC catheter terminates\n within the right mid SVC. A tracheostomy tube is in place. A left subclavian\n hemodialysis catheter terminates within the right atrium. The cardiac\n silhouette, mediastinal and hilar contours are stable in this patient status\n post median sternotomy, and valve replacement. Allowing for differences in\n position, moderate layering pleural effusions are not significantly changed.\n The surrounding soft tissues are stable.\n\n IMPRESSION: No interval change.\n\n\n"},{"category":"Radiology","chartdate":"2132-08-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":922366,"text":" 3:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pneumonia\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with chronic trach/peg, lethargy, hypotension, now with\n fever\n REASON FOR THIS EXAMINATION:\n eval pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: 66-year-old woman with chronic tracheostomy, lethargic,\n hypotensive with fever question pneumonia.\n\n Comparison is made with prior study with the most recent one performed , .\n\n FINDINGS: Stable mild right pleural effusion. Persistent right lower lobe\n consolidation, mild interval decrease in left retrocardiac\n consolidation/atelectasis. There is no pneumothorax. Stable top size heart,\n patient is S/P median sternotomy and valve replacement. There is a\n tracheostomy in appropriate position. Right PICC line and right internal\n jugular vein double-lumen catheter unchanged in position.\n\n There is no pneumothorax.\n\n IMPRESSION: Persistent right lower lobe consolidation.\n\n\n"},{"category":"Radiology","chartdate":"2132-10-06 00:00:00.000","description":"NON-TUNNELED","row_id":928363,"text":" 7:15 PM\n CENTRAL LINE PLCT Clip # \n Reason: needs access for blood\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n * C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman needs 3-port CV access for abx, pressors, and CVVH\n\n REASON FOR THIS EXAMINATION:\n needs access for blood\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old female requiring central venous access for\n antibiotics, pressors and CVVH.\n\n RADIOLOGISTS: Drs. and performed this procedure, with Dr.\n , the attending radiologist, present and supervising throughout.\n\n PROCEDURE: Written and informed consent were obtained from the patient's\n daughter. The patient was placed supine on the angiographic table. The right\n lower neck and upper chest were prepped and draped sterilely. Ultrasound\n imaging was performed confirming the patency of the right internal jugular\n vein. 5 cc of 1% lidocaine were applied for local anesthesia. Under\n ultrasonic guidance, a 21-gauge needle was used to access the right internal\n jugular vein. Hard copy ultrasound images were obtained before and after\n venous access documenting vessel patency. A 0.018 guidewire was placed through\n the needle under fluoroscopic guidance with its tip in the superior vena cava.\n The needle was then exchanged for a 4.5- French introducer sheath and the\n inner dilator and 0.018 guidewire were removed. A 0.035 guidewire was\n advanced into the superior vena cava and the introducer sheath was removed. A\n 16 cm long triple lumen central line was placed over the wire under\n fluoroscopic guidance with the tip in the superior vena cava. The wire was\n removed. Three lumens of the catheter were flushed with heparinized saline\n and demonstrated excellent blood flow. The catheter was secured to the skin\n with 0 silk and a sterile dressing was applied.\n\n IMPRESSION: Successful placement of a triple lumen central venous catheter\n via the right internal jugular vein with tip in the SVC. The catheter is\n ready for immediate use.\n\n"},{"category":"Radiology","chartdate":"2132-10-06 00:00:00.000","description":"ABDOMINAL A-GRAM","row_id":928364,"text":" 7:17 PM\n ABDOMINAL A-GRAM Clip # \n Reason: please evaluate for bleed and embolization if necessary\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 250\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with GI bleed\n\n REASON FOR THIS EXAMINATION:\n please evaluate for bleed and embolization if necessary\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old female with likely lower GI bleed.\n\n RADIOLOGISTS: The procedure was performed by Doctors and .\n Dr. , the attending radiologist was present and supervising throughout\n the procedure.\n\n PROCEDURE/FINDINGS: After explaining the risks and benefits of the procedure,\n written informed consent was obtained from the patient's daughter. Timeout\n was performed to identify the procedure to be performed, the site and\n requisition. The patient was then placed in a supine position on the\n angiographic table. The right groin was prepped and draped in the standard\n sterile fashion. The skin of the anticipated puncture site was then\n infiltrated intradermally with 5 cc of 1% lidocaine. One wall retrograde\n arterial puncture was achieved of the right common femoral artery. A\n guidewire was advanced to the infra-renal abdominal aorta. A 5 French\n vascular sheath was placed in the right common femoral artery. A Omni Flush\n catheter was then advanced over the guidewire into the infrarenal abdominal\n aorta and a nonselective aortic angiogram was performed demonstrating filling\n of the inferior mesenteric artery, common iliacs and several lumbar branches.\n No evidence of active extravasation was noted. Numerous attempts were made to\n access the inferior mesenteric artery using several angiographic catheters\n (Sos, Cobra, , Mikaelson) without success. A Sos catheter was then used\n to catheterize the superior mesenteric artery, and a selective arteriogram was\n performed. A normal pattern of blood flow was identified within the branches\n of the superior mesenteric artery territory with no evidence of obstruction,\n stenosis,abnormal blush or contrast extravasation. Extensive atherosclerosis\n was noted within the abdominal aorta and throughout its branches. Finally, the\n catheter and 5 French vascular sheath were removed. Hemostasis was achieved at\n the right puncture site using digital compression for a total time of 20\n minutes. No hematoma was encountered. The patient tolerated the procedure\n well without immediate complications.\n\n IMPRESSION:\n 1. Nonselective aortography and selective superior mesenteric artery\n arteriogram demonstrate no evidence of active gastrointestinal bleeding.\n Diffuse atheromatous disease was noted.\n\n 2. Selective catheterization of the inferior mesenteric artery was\n unsuccessful, likely due to severe atherosclerotic disease at its origin as\n shown on a previous CT scan.\n (Over)\n\n 7:17 PM\n ABDOMINAL A-GRAM Clip # \n Reason: please evaluate for bleed and embolization if necessary\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 250\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. Endoscopy recommended to better clarify origin of bleeding.\n\n"},{"category":"Radiology","chartdate":"2132-10-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":928948,"text":" 8:19 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Assess PICC line for position.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with sepsis, ESRD, vented with pulmonary effusions, check\n PICC line for position.\n REASON FOR THIS EXAMINATION:\n Assess PICC line for position.\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 8:22 A.M.\n\n HISTORY: Sepsis, endstage renal disease with recent PICC line placement.\n\n COMPARISON: Multiple priors, the most recent dated earlier same day.\n\n FINDINGS: The patient is significantly rotated limiting the evaluation.\n Support tubes and lines remain stable including the right upper extremity\n approach PICC line. The left lung is not adequately evaluated secondary to\n rotation with only a small amount of area of lung noted in the left upper\n chest. Overall no significant interval change.\n\n IMPRESSION: As best can be determined, no significant interval change\n relative to study obtained earlier same day. The study is nondiagnostic for\n evaluation of the left lung. Despite the given history, support tubes and\n lines remain stable with no new line noted.\n\n DR. \n"},{"category":"Radiology","chartdate":"2132-08-20 00:00:00.000","description":"CHANGE GASTROSTOMY TUBE","row_id":922445,"text":" 7:35 AM\n PERC G/J TUBE CHECK Clip # \n Reason: change GJ tube. thank you.\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 40\n ********************************* CPT Codes ********************************\n * CHANGE GASTROSTOMY TUBE INJ SINUS TRACT, THERAPUTIC *\n * -51 MULTI-PROCEDURE SAME DAY CHANGE PERC TUBE OR CATH W/CON *\n * FISTULOGRAM/SINOGRAM CATHETER, DRAINAGE *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with G-J tube\n REASON FOR THIS EXAMINATION:\n change GJ tube. thank you.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old woman with long-term gastrojejunostomy which is leaking\n at the skin site.\n\n PROCEDURE AND FINDINGS: The procedure was performed by Drs. and ,\n the attending physician, was present and supervising. Informed consent\n was obtained, and preprocedure timeout was performed. The patient's abdomen\n was prepped and draped in standard sterile fashion. Lidocaine jelly was\n infused at the skin site. The existing catheter was cut and removed over an\n 0.035 wire. A 7 French bright-tipped sheath was subsequently advanced and a\n pullback sinogram was performed. This demonstrated the gastric entry site of\n the tract to be within the mid body of the stomach. The tract was then\n sclerosed with silver nitrate sticks. A new 22 French MIC gastrojejunostomy\n tube was subsequently advanced over the wire after cutting off the superficial\n plastic disk. The wire was removed. 10 cc of saline were insufflated into\n the balloon. Injection of contrast through the gastric and jejunal ports\n demonstrated appropriate positioning of the tube with the proximal sideholes\n within the stomach and the distal tip within the jejunum. The catheter was\n secured with a Flexi-Trak, and the site was dressed. The patient tolerated\n the procedure well, and there were no immediate post-procedure complications.\n\n IMPRESSION:\n 1. Successful exchange for 22 French MIC gastrojejunostomy tube. The balloon\n was inflated with 10 cc of saline. The catheter is positioned with the marker\n above the #2 at the skin exit site. In the case of leaking around the skin,\n the gastric port can be open to continuous bag gravity drainage or be\n aspirated several times a day.\n 2. The tract was sclerosed with silver nitrate.\n\n"},{"category":"Radiology","chartdate":"2132-10-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":930243,"text":" 8:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: question of infectious process\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with sepsis, ESRD, respiratory failure, SBO, GIB now with\n fever\n REASON FOR THIS EXAMINATION:\n question of infectious process\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:26 A.M., .\n\n HISTORY: Sepsis. End-stage renal disease. GI bleed.\n\n IMPRESSION: AP chest compared to through 30.\n\n Left lower lobe atelectasis has improved substantially since \n though there is still sufficient atelectasis to produce leftward mediastinal\n shift. Small-to-moderate right and small left pleural effusion are unchanged.\n The heart is probably enlarged, but partially obscured by adjacent\n atelectasis. Right PICC and supraclavicular venous lines end at the junction\n of the brachiocephalic veins and a large-bore dual-channel left\n supraclavicular catheter ends in the SVC and at the superior cavoatrial\n junction. Tracheostomy tube in standard placements.\n\n\n"},{"category":"Radiology","chartdate":"2132-10-03 00:00:00.000","description":"P SMALL BOWEL ONLY (GASTROGRAF) PORT","row_id":927966,"text":" 9:35 AM\n SMALL BOWEL ONLY (GASTROGRAF) PORT Clip # \n Reason: eval for SBO\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with resolving SBO\n REASON FOR THIS EXAMINATION:\n eval for SBO\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Resolving SBO.\n\n , CT scan.\n\n FINDINGS: Eight very limited quality abdominal radiographs were provided for\n interpretation. Due to the poor quality of films, evaluation is significantly\n limited. There is evidence for dilated bowel loops consistent with\n obstruction. Overlying contrast may be external to the patient. No\n radiologist was present during this procedure.\n\n IMPRESSION: Limited evaluation secondary to technical difficulties. If there\n is high clinical concern for pathology, further imaging is recommended.\n\n"},{"category":"Radiology","chartdate":"2132-10-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":929800,"text":" 4:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pls evaluated for PNA.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with sepsis, ESRD, respiratory failure, SBO, GIB now with\n Bandemia and hypothermia.\n REASON FOR THIS EXAMINATION:\n Pls evaluated for PNA.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST.\n\n INDICATION: Respiratory failure.\n\n A single AP view of the chest is obtained and compared with the most\n recent study performed on . The patient is significantly rotated to\n the left side. There is no significant change between the two studies\n allowing for technique. Tubes and lines appear unchanged. The left lung is\n poorly evaluated due to the degree of rotation. There is loss of the left\n hemidiaphragm shadow, which may represent atelectasis/infiltrate in the left\n lower lobe. Right pleural effusion appears unchanged.\n\n IMPRESSION:\n\n Allowing for differences in technique, likely no significant change since the\n study of with opacification in the left hemithorax with obscuration of\n the left hemidiaphragm likely representing atelectasis. Right pleural\n effusion unchanged. Tubes and lines unchanged.\n\n"},{"category":"Radiology","chartdate":"2132-10-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":927672,"text":" 5:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for changes in pulmonary edema/consolidation\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with sepsis, vented with pulmonary effusions\n REASON FOR THIS EXAMINATION:\n please evaluate for changes in pulmonary edema/consolidation\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:18 A.M., .\n\n HISTORY: Sepsis. Pleural effusions. Pulmonary edema.\n\n IMPRESSION: AP chest compared to through 12. Moderate bilateral\n pleural effusion, left greater than right, and mild interstitial pulmonary\n edema are stable since . Cardiac silhouette is moderately\n enlarged. Tracheostomy tube is in standard placement. A dual channel left\n supraclavicular central venous line ends in the SVC. No pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2132-10-16 00:00:00.000","description":"TUNNELED W/O PORT","row_id":929481,"text":" 7:31 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: Please place left tunneled HD catheter for long term HD.\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * TUNNELED W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1750 CATH,HEMO/PERTI DIALYSIS LONG C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with MMP incl CRF on HD.\n REASON FOR THIS EXAMINATION:\n Please place left tunneled HD catheter for long term HD. Please place three\n access lines (two for HD, one VIP line).\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old female with chronic renal failure requiring tunneled\n hemodialysis catheter for long-term hemodialysis.\n\n RADIOLOGISTS: Drs. and . Dr. , the\n attending radiologist was present and supervising throughout the procedure.\n\n PROCEDURE/FINDINGS: The risks and benefits were explained to the patient's\n family, and verbal consent was obtained. The patient was placed supine on the\n angiographic table. The left neck, left upper chest and right upper chest\n were prepped and draped in the standard sterile fashion. A preprocedure\n timeout was performed to confirm the patient's name, procedure and the site.\n 10 cc of 1% lidocaine was then applied at the upper left chest for local\n anesthesia. A small incision was made approximately 8 cm laterally from the\n left IJ access site. The tunnel was then created with the tunneling device. A\n 23 cm tip to cuff hemodialysis catheter was then advanced through the tunnel.\n A 0.035 Bentson guidewire was then placed through the in situ temporary\n dialysis catheter under fluoroscopic guidance. The catheter was removed. A\n 14 French peel-away sheath was then placed over the wire. After the inner\n dilator and wire were removed, the new hemodialysis catheter was then placed\n through the sheath as the sheath was peeled away. A fluoroscopic spot image\n confirmed the tip of the hemodialysis catheter within the right atrium. The\n catheter was secured to the chest with a 0 Prolene stitch. Dermabond was used\n to close the lower neck incision site. The catheter ports were flushed,\n capped and heplocked. A sterile dressing was applied.\n\n The patient tolerated the procedure well and there were no immediate\n complications.\n\n IMPRESSION: Successful removal of a preexisting hemodialysis catheter and\n replacement with a new 23 cm cuff to tip 14.5 French double lumen tunneled\n hemodialysis catheter by way of the left internal jugular vein. The catheter\n tip is located in the right atrium. The catheter can be used immediately.\n (Over)\n\n 7:31 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: Please place left tunneled HD catheter for long term HD.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2132-10-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":927959,"text":" 9:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval changes\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with sepsis, ESRD, vented with pulmonary effusions,\n decreased BS on left\n REASON FOR THIS EXAMINATION:\n evaluate for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, , AT 9:11 A.M.\n\n HISTORY: Sepsis, end-stage renal disease, on ventilator. There are decreased\n breath sounds on the left. Assess for interval change.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: The extreme left costophrenic angle has been excluded from view.\n There has been minimal relative improvement in the previously noted diffuse\n hydrostatic edema. Pleural effusions have redistributed with small bilateral\n effusions persisting, right slightly worse than left. The various support\n tubes and lines as well as the post surgical changes consistent with prior\n aortic valve replacement stable.\n\n IMPRESSION: Mild interval improvement in fluid balance with relatively stable\n bilateral effusions as above.\n\n DR. \n"},{"category":"Radiology","chartdate":"2132-10-16 00:00:00.000","description":"PICC W/O PORT","row_id":929532,"text":" 1:37 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC line\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * PICC W/O PORT -51 MULTI-PROCEDURE SAME DAY *\n * FLUOR GUID PLCT/REPLCT/REMOVE -59 DISTINCT PROCEDURAL SERVICE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n * C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 y/o F s/p CVA, multiple infections, hypotensive, CRF and femoral line\n that needs removal infection. Needs second line for chronic Abx.\n REASON FOR THIS EXAMINATION:\n Please place PICC line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old female with numerous infections requiring chronic\n antibiotics.\n\n RADIOLOGISTS: Drs. and . Dr. , the\n attending radiologist was present and supervising throughout the procedure.\n\n PROCEDURE/FINDINGS: The patient was brought to the radiology suite and placed\n supine on the angiography table. Following a preprocedure timeout including\n the patient's name and two patient identifiers, the right arm was sterilely\n prepped and draped. As no suitable veins were visible, ultrasound was used to\n identify the right brachial vein which was patent and compressible.\n Approximately 5 cc of 1% lidocaine was administered for local anesthesia. A\n 21-gauge needle was used to access the right brachial vein. Hard copy\n ultrasound images were obtained before and after venipuncture. A 0.018-inch\n guide wire was threaded through the needle into the vein. Then the needle was\n exchanged for a 4 French micropuncture sheath. The guide wire was advanced\n into the SVC and based on the markings on the wire, a PICC line was trimmed to\n a length of 40 cm. The PICC was then advanced over the wire and into the SVC\n under fluoroscopic guidance. The wire and peel-away sheath were removed. The\n catheter was flushed, capped, and heplocked. Finally, the catheter was\n statlocked into place and a sterile transparent dressing was applied. A final\n fluoroscopic image was taken demonstrating the tip of the PICC in the distal\n SVC.\n\n IMPRESSION: Successful placement of a 4 French single-lumen 40-cm PICC by way\n of the right brachial vein with the tip in the distal SVC. The line is ready\n for use.\n\n"},{"category":"Nursing/other","chartdate":"2132-09-19 00:00:00.000","description":"Report","row_id":1524303,"text":"Respiratory Therapy\n\nPt remains trached w/ #7.0 Shiley trach on full mechanical support. No vent changes made this shift. Currently on A/C ventilation w/ PIP = 23. BS w/ rhonchi bilaterally, suctioned for moderate to copious amounts of yellowish/tan sputum. SpO2 90s. ABG acceptable. MDIs given as ordered. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support; pulmonary toilet\n"},{"category":"Nursing/other","chartdate":"2132-09-19 00:00:00.000","description":"Report","row_id":1524304,"text":"SICU NPN\nT-Trached.\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\n\nO-Alert. Following commands inconsistently. Noted shaking head in \"no\" directions when approached or asked question and then crying. Pt doing this consistently. Not grimacing to pain. MICU team witnessing when rounding on pt. Ethics consult discussed in rounds this morning but unclear on efficacy of consult due to nature of family dynamics. HR 60-100s, NSR with frequent PACs then later returning to Afib with rate control. Diltiazem drip discontinued 1hr after PO dose of Diltiazem begun. SBPs 80-100s. Attempted to wean Neo but unsuccesful. Neo as high as 0.75mcg/kg/min and currently at 0.3mcg/kg/min. Attempting to keep SBPs 80 and MAPs > 50. Breath sounds coarse throughout. Remains on AC. ABG with metabolic akalosis, no vent changes made. Suctioning for thick yellow sputum. Anuric. Continues CRRT. Goal is keep even in efforts to wean pressors first. Midordrine restarted. Abd obese but soft. (+) bowel sounds. Colostomy, G-J, and vaginal with small dark red bloody ooze. Colostomy at stoma site and G-J at insertion site. Dr. aware. HCT and coags pending. Colostomy prior with goldens soft stool, G-tube with bilious output prior and currently. J-tube to TFs. Hypothermic placed back on bair hugger. (+)BCx from with GNRs in aerobic and anaerobic bottles. Dr. aware. No change in Abx regimen. Husband visiting this morning briefly and no further visitors for day into evening. Continue Insulin gtt, goal BSs 80-120s.\n\nA/P: Sepsis\nContinue to montior\nCRRT to run even\nWean Neo as tolerated, > 80/MAP > 50\nFollow K and ICa Q6H\n"},{"category":"Nursing/other","chartdate":"2132-10-08 00:00:00.000","description":"Report","row_id":1524380,"text":"nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-OPENS EYES SPONT. MOVES HEAD SPONT ON BED. PUPILS EQUAL AND SLUGGISHLY REACTIVE. NO SPONT MOVEMENT OF EXTREMITIES.\n\nCV-HR 80-100'S. AFIB, NO ECTOPY. REMAINS ON NEO GTT BUT SLOWLY WEANING. MAP>50. SKIN WARM. HCT STABLE.\n\nRESP-REMAINS TRACHED AND VENTED. RR DOWN TO 26. FIO2 UP0 TO 60%. NO OTHER VENT CHANGES MADE. ABG CHECKED FREQ. LS COARSE, DECREASED AT BASES. SXN FOR THICK YELLOW SPUTUM. UNABLE TO GET O2 SAT TRACING.\n\nGI-ABD FIRM AND DISTENDED. OBESE. +BS. TF STARTED VIA . TPN TO FINISH, NEW TPN NOT ORDERED. G-TUBE TO GRAVITY WITH BROWN/MAROON DRG. STOMA RED WITH OLD MELENA STOOL.\n\nGU-ANURIC. REMAINS ON WITH GOAL \"EVEN\". CA+ AND K+ GTTS INFUSING PER PROTOCOL.\n\nENDO-ON INSULIN GTT.\n\nACT-REPOSITIONED FREQ.\n\nCOMFORT-DOES NOT APPEAR TO BE IN PAIN.\n\nID-TEMP 96. BAIR HUGGER ON. ON MULTI ABX. SURVEILLENCE BLOOD CX SENT.\n\nSKIN-CON'T WITH MULTI SKIN ISSUES. MULTI AREAS OF WEEPY SKIN, SKIN TEARS AND ECCHYMOSIS. ALL DSGS INTACT OR CHANGED AS ORDERED. TOES REMAIN NECROTIC. ERYTHEMIC AREA ON LEFT THIGH UNCHANGED.\n\nSOCIAL-HUSBAND IN TO VISIT TODAY. PT'S DAUGHTER, , CALLED AND UPDATED ON PT'S CONDITION.\n\nP-CON'T WITH CURRENT PLAN. WEAN NEO AS TOL. ASSESS PAIN. SKIN CARE. ADVANCE TF AS TOL. SUPPORT.\n"},{"category":"Nursing/other","chartdate":"2132-10-09 00:00:00.000","description":"Report","row_id":1524381,"text":"condition updated\nS/P sepsis;\nfor complete info please refer to carevue.\ncondition status quo. neo remains at 2mcg with no attempts to wean, CRRT keeping even to perserve bp. labs adjusted as needed. general anasarca continues. family present at bedside during early pm. no issues at this time\n\n"},{"category":"Nursing/other","chartdate":"2132-10-09 00:00:00.000","description":"Report","row_id":1524382,"text":"Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. SX'd for small to moderate amounts of thick yellow-green secretions. Received MDI albuterol and atrovent with each vent check and flovent as noted in CareVue. Latest abg results determined a compensated respiratory alkalemia with very good oxygenation on the current settings.\n\nNo RSBI measured due to the FIO2 required at this time.\n"},{"category":"Nursing/other","chartdate":"2132-10-09 00:00:00.000","description":"Report","row_id":1524383,"text":"Respiratory Care:\nPlease note that the respiratory rate was decreased from 26 to 22 due to hypocarbia (PCO2 was 27).\n"},{"category":"Nursing/other","chartdate":"2132-10-09 00:00:00.000","description":"Report","row_id":1524384,"text":"respiratory care\npt on the vent tol well no changes made. see respiratory page of carevue for more information.\n"},{"category":"Nursing/other","chartdate":"2132-10-28 00:00:00.000","description":"Report","row_id":1524457,"text":"Condition Update\nPlease see carevue for specifics.\n\nPt has been unarousable throughout the . There were only slight up and down movements w/ her left arm noted. PERRL. she was afebrile. In AFIB. Pt hypertensive to the 200's and 130's-140's 2 the beginning of the shift. 5 mg IV diltiazem given @ 20:00 w/ no effect, then 5mg IV labetolol given @ 2100 & 2300 w/ + effect. No vent changes made over . Pt sxn'd several times for sml amts of thick, tan secretions. LS coarse w/ rhonchi. w/ beneprotein TF's infusing via pt's j tube. Her G tube is to gravity and drained yellow mucus material. Pt's stoma is pink. Pt w/ multiple skin tears that are covered w/ adaptic and dsd. Coccyx stage 3 ulcers cleansed all NS, packed w/ aquacel, dsd's placed then softsorbs to cover.\n\nPlan: continue w/ current plan of care per micu team. PRN electrolyte repletion. Multiple dressing changes as needed. TF's for nutrition. IV/po abx. ? d/c home w/ services when bp/hr stable.\n"},{"category":"Nursing/other","chartdate":"2132-07-29 00:00:00.000","description":"Report","row_id":1524090,"text":"Respirtory Care\nVent dependent pt admitted from home for increasing lethargy and question infection. Has size 6 Shiley trach which requires 40 cm pressure in cuff to obtain seal. Sx for minimal amount thick yellow secretions. ABG reveals metabolic acidosis with beginning respiratory compensation, well oxygenated. BS appear clear.\n"},{"category":"Nursing/other","chartdate":"2132-08-16 00:00:00.000","description":"Report","row_id":1524165,"text":"NURSING\n VSS, AFEBRILE OVERNIGHT. CONTINUES IN A-FIB, AS PREVIOUSLY. OCCASIONAL PVC'S.RECIEVED 2 UNITS RBC'S. NO ISSUES OVERNIGHT. SEE CARE VUE FOR SPECIFICS.\n TUBE FEEDS CONTINUE AT 40/HR. GLUCOSE LEVELS CONTINUE TO BE ELEVATED. TREATED WITH SLIDING SCALE AND 90 UNITS OF LANTIS .\n ALL DRESSINGS CHANGED AT MIDNIGHT. REMAINS ON KINAIR BED, TURNED SIDE TO SIDE Q2/HRS. NO INDICATIONS OF ANY PAIN.\n CONTINUE SKIN CARE REGIMEN. DIALYSIS TODAY. CONTINUE DISCHARGE CARE PLANNING.\n\n\n"},{"category":"Nursing/other","chartdate":"2132-08-16 00:00:00.000","description":"Report","row_id":1524166,"text":"Respiratory Care:\n Patient continues on full vent support with secretions changing from yellow to yellow-green sputum. BS=bilat, diminished t/o. Trach secure. No changes made in vent settings. See Carevue flowsheet. Plan to continue with supportive care and monitoring.\n"},{"category":"Nursing/other","chartdate":"2132-08-16 00:00:00.000","description":"Report","row_id":1524167,"text":"nursing note\nNeuro:Opens eyes spont, not following commands or mouthing words. Some spont mvmt noted with LUE. Afebrile.\nCV:Remians in afib-rate controlled with lorpssor/dig/amio. Rate <120- SBP WNL. HD done with total 1400 ultrafiltrate. transient drops in BP during HD.\nRESP:LS coarse, thick yellow to green copius at times sputum. with periodic leaks and adjusted by RT.\nGI:Abd large, soft,nt. PEJ with ostomy appliance surrounding area- draining bilious and air into bag. MD aware and IR MD to come and check tube. MD- pylorus open and therefore not surprised by bilious draining. Ostomy with golden brown liquid stool.\nGU:anuric.\nSKIN: per skin rec's- leg dressing remain necrotic with exception of L calf- reddened.\nSOCIAL:husband and son in this AM and aware of check on PEJ in progress. Per medicine team- pt to go home with family care.\n\nPLAN:Check PEJ, passy muir per family requests, cont plan to go home.\n"},{"category":"Nursing/other","chartdate":"2132-08-17 00:00:00.000","description":"Report","row_id":1524168,"text":"Condition update\nPlease see carevue for secifics.\n\nNeuro unchanged. Tmax 99.8 Afib. PM dose of lopressor held d/t sbp 70's-80' MD notified. No vent changes made this shift. Sats 100%. LS coarse throughout. Pt sxn'd several times for sml to moderate amts of thick, tan secretions. RSBI this am 94. Neb tx's done during the by resp tx. w/ beneprotein tubefeedings infusing at goal via j tube. J tube insertion site w/ large amts of bilious drainage. Colostomy draining golden colored, guiac negative, liquid stool. The stoma is pink. Hip dressings and coccyx wound dressings changed . Pt w/ many skin tears noted from removal of the allevyn dressings.\n\n son in to visit this eve. Son very concerned that current trach in line sxn not going down far enough to sxn all of secretions and spoke at great lengths to 3 RN's and resp tx regarding. Son also wants current trach to be replaced by a shorter one to ensure pt is sxn'd adequately. Son still not satified w/ any answers given, and will have primary team discuss w/ him in the am.\n\nPlan: continue with current plan of care per micu team. Continue planned dressing changes. D/C planning. HD Tues/Thurs/Sat.\n"},{"category":"Nursing/other","chartdate":"2132-09-06 00:00:00.000","description":"Report","row_id":1524251,"text":"condition update\nD: pt opens eyes spontaneously. moves upper extremities. inconsistently follows commands.\ncardiac: afib rate of 100-130's. due for lopressor at 4am. when asleep sbp dip to 70's and up to 90's with stimulation. Dr. aware and wants pt to get 12.5mg of po lopressor. Hr down to 102 and sbp 85/47 after lopressor. sbp dip down to 70's with sleeping and up to 80's-90's with stimulation. Dr. aware and 250cc of ns fluid given.\nresp: pt remains on cmv with fio2 of 40%. breath sounds remain clear and diminished in the bases. pt suctioned for yellow sputum.\ngi: pt tolerating tube feeds through j tube at 40cc/hr. gt/jt seems to be slightly out and Dr. aware and up to pt. surgery to be called in am to tube. tube to continue. gtube draining bilious drainage. yellow drainage still draining around tube with ostomy bag intact.\ngu: pt remains anuric and to have hemodialysis today. small amt of vaginal bleeding noted. Dr. aware. hct remains stable.\nskin: pt turned every 2 hours and pt remains on air bed. dressing are\n dry and intact.\nsocial: son in to visit.\na: surgery to see pt today re: feeding tube. hemodialysis today. continue to monitor for hypotension.\nr: hr and sbp responded to fluid. no change in feeding tube position. no tube feeds draining around tube. drainage remains yellow. minimal vaginal drainage at this time.\n"},{"category":"Nursing/other","chartdate":"2132-09-06 00:00:00.000","description":"Report","row_id":1524252,"text":"Resp. care note - Pt. remaines trached and vented, no vent changes made at this time.\n"},{"category":"Nursing/other","chartdate":"2132-09-06 00:00:00.000","description":"Report","row_id":1524253,"text":"FOCUSED NURSING NOTE\nPlease see carevue flowsheet for further details\n\nNeuro: Alert, not following commands, nodding head \"yes\" \"no\" to basic needs/questions. PEERL, 3-4mm. Ativan held x 1 today.\n\nResp: No vent changes this shift. Trach patent, on CMV 0.40. Suctioned q3-4hr for thick/yellow sputum. SPO2 100% at all times.\n\nHemodynamics: Remains in Afib rate 102-120s. No sustained rapid V-rate today. BP labile minute to minute, lowest 52 after Demerol 12.5mg for pain, no LOC, responded to fluid with transient drops in BP throughout afternoon recovering quickly without intervention- Dr aware and in to assess pt. Lopressor dc'd per MICU team, Midrodine dose increased. Hemodialysis held today. No sx bleeding. Anasarca appears to be increasing- fluid losses via Gtube, multiple wounds, stools, J/G tube exit site.\n\nGI/Metabolic: TF Neopro FS at goal rate 40ml/hr. Copious amts clear/pale yellow gelatinous/viscous ?mucosal drainage from PEG tube site, MICU team aware. Small amt of same drainage character noted from rectum. Glycemic control acceptable on Lantus 86U . Colsotomy with frequent outputs, loose and trace guiac pos. Electrolytes stable without HD.\n\nID: Afebrile. Zosyn/Zyvox/Levaquin administered as ordered. Tobramycin not given secondary to HD suspended. No obvious source of worsening infection in wounds, slight odor waxes and wanes.\n\nSKIN INTEGRITY/COMFORT: Please see carevue flowsheet- multiple pressure/venous stasis ulcers. Drsg Wound RN consult instructions. Turn and repositioned q2-3hr. Oral care q2-4hr.\nDemerol IV x 1 for affirmation of pain on assessment, therapeutic effect of Demerol though significant drop in BP as noted.\n\nPSYCHOSOCIAL: Attentive visits today by husband, daughter , and Son . children are habitated to providing hygiene and nursing care- asking questions respectively to what each child's healthcare interest is ie : Diabetes vs wound care vs BP. Emotional support provided and edcuation ongoing re: greater picture of chronic illness, organ failure, sepsis and realistic goals of recovery vs plan of care for comfort only.\n\nPLAN: Monitor BP, notify MD <80 persists when HOB flat and stimulation provided. Monitor fluid balance closely, plan CVVH tomorrow per MICU team evaluation in am. Aggressive skin care. Monitor labs/sx bleeding/sx worsening sepsis. Plan D/C home with services this week per family/MD discussions.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2132-09-07 00:00:00.000","description":"Report","row_id":1524254,"text":"condition update\nd: pt remains awake and inconsistently follows commands.\ncardiac: afib rate of 110-138. bs still less labile. one episode of bp down to 70's. Dr. aware and up to 80-90's with no treatment. Dr. aware of hr 120-130's and continue to monitor with no treatment.\nresp: pt remains on cmv fio2 of 40%. pt appears comfortable. suctioned for thick yellow sputum.\ngi: tube feeds at goal at 40cc/hr. abd soft and slightly distended. colostomy stoma is pink and stool loose brown trace guaiac positve. feeding tube continues to leak around the insertion site thick yellow drainage.\ngu: pt anuric and on hemodialysis.\nskin: pt on airbed and turned frequently. left foot dressing changed and toes remain necrotic and black.\nsocial: son visiting during the evening. asking questions about possible cvvh tomorrow.\na: continue to monitor hemodynamics.\nr: less labile tonight. no fluid boluses during the night. hr more tachycardic. pt remains afebrile.\n"},{"category":"Nursing/other","chartdate":"2132-09-07 00:00:00.000","description":"Report","row_id":1524255,"text":"RESP CARE: Pt remains trached/on vent per carevue. No changes in vent settings this shift. Lungs coarse with rhonchi/sxd thick yellow. No RSBI due to hemodynamic instability.\n"},{"category":"Nursing/other","chartdate":"2132-09-07 00:00:00.000","description":"Report","row_id":1524256,"text":"FOCUSED NURSING NOTE\nPlease see carevue flowsheet for further details\n\nNEURO: Pt alert throughout the day, PERRL 3-4MM. Ativan doses held secondary to labile BP and pt does not exhibit signs of agitation. Does not follow commands per baseline, nodding head \"yes\" to all questions asked- it is this RN's opinion that pt does not have cognitive understanding of questions- nodding \"yes\" to nearly all speech addressed to her.\nRESP: Ventilated on CMV 0.40 via trach, no vent changes this shift. SPO2 100%, decreases to 88-92% when side-lying for dressing changes, skin care. Lungs clear to diminished. Thick/yellow sputum suctioned prn.\nHEMODYNAMICS: Afib persists with rapid Vresponse, occassional PVCs, average rate 120s. BP remains labile, range 70-96/30-58- NINV alternated to LLE and RUE with subtle variances. MICU team aware of HR and BP measurements, no change in LOC, no fluid boluses this shift. Worsening anasarca- no resp distress on CMV. Anuric, HD dependent pt with HD/CVVH on hold per MICU team.\nMETABOLIC/GI: TF via Jtube at goal rate 40ml/hr. Hyperglycemia increasing (181/195), treated per Lantus order and RISS. Moderate clear gelatinous secretions from G/J tube exit site continues, MD aware. Loose stool in adequate amounts via colostomy- stoma. pink/edematous.\nSKIN INTEGRITY: No change in pressure ulcers, venous stasis ulcers as previosuly documented, all dressings changes done as ordered. Noted increase exudate and ?exposed bone to right metatarsal area (base of great toe which is completely necrosed/gangrinous)- wound base yellow/red with yellow exudate and erythema borders. Site cleansed, covered with adaptic and covered with DSD. MD notified of assessment.\nPSYCHOSOCIAL: Husband visited briefly in am, discussed with him inability to offer HD without harming her. Daughter (HCP) called to speak with Renal MD and spoke with Dr . She declined speaking with MICU attending Dr though I expressed his desire to speak with her re: Mrs of further aggressive measures vs goal of d/c home.\n\n PLAN: Continue to monitor pts hemodynamics off HD, monitor for sx worsening sepsis. Administer , aggressive wound care. Turn and reposition q2-3hr, pulmonary hygiene prn. Discuss with Pharmacy alternative to D5W diluent for Linezolid to decrease hyperglycemia. Lantus increased as ordered, RISS as ordered. Emotional support to pt and family- Dr and MICU team to f/u with for further .\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2132-09-23 00:00:00.000","description":"Report","row_id":1524316,"text":"NURSING 7P-7A\n VSS, KEPT WITHIN PARAMETERS OF >80 WITH MAP >50. NEO GTT CONTINUES AT 1.5. REMAINS HYPOTHERMIC WITH TEMPS IN THE 97 RANGE, BAIR HUGGER REMAINS ON LOW.\n CONTINUES, RUNNING EVEN TO 1 LITER NEGATIVE/DAY. AT 2400 NEGATIVE 1050 FOR 24/HRS. CONTINUES ON CA AND K GTTS PER CVVH PROTOCOL.\n COLOSTOMY WITH BLOOD TINGED STOOL IN THE EVENING, AFTER MIDNIGHT STOOL RETURNED TO GREEN COLOR. HCT DECREASED TO 22.9 FROM 24.1. MD NOTIFIED, I UNIT RBC'S TO BE GIVEN.\n CONTINUES ON INSULIN GTT, BLOOD SUGARS RANGE FROM 104-160. TUBE FEEDS CONTINIE AT 65/HR.\n SEE CARE VUE FOR FULL ASSESSMENT.CONINUE CVVH, RUN EVEN TO 1 LITER NEGATIVE.. TO INTERVENTIONAL RADIOLOGY TODAY FOR PICC LINE. CONTINUE TO MAINTAIN >80, MAP>50. WILL RECIEVE I UNIT RBC'S.\n"},{"category":"Nursing/other","chartdate":"2132-09-23 00:00:00.000","description":"Report","row_id":1524317,"text":"Resp Care: Pt continues trached and on ventilatory support with a/c, no vent changes maintaining spo2 99%; bs rhonchorous, sxn thick yell secretions, rx with mdi albuterol/atrovent/flovent mdi, rsbi n/a d/t vent dependence, will cont full support.\n"},{"category":"Nursing/other","chartdate":"2132-09-23 00:00:00.000","description":"Report","row_id":1524318,"text":"Respiratory Care\nPt continues to be trached/ventilated. #7.0 Extra-Long Shiley DIC clean and intact. B/S coarse bilterally. Suctioned for moderate amounts of thick yellow secretions. MDI's administered per orders. Pt continues on /NEO. Current resting on A/C 450/16/5/.40 with PIP/Plat 25/22. Plan to continue current support at this time. No ventilatory changes made this shift. Will closely monitor.\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524159,\n \"text\": \"NPN\\nPlease see CareVue for full assessments\\nNEURO: No change. PERRL. +tracking. Pt. does not follow commands and is inconsistent with communication. Nodding and mouthing words at times. Minimal mvmt with nailbed stimuli in all extremities. LUE tremor in hand, wiggling fingers.\\n\\nCV: Remains in AF with rare PVC's. HR90's-100's throughout day. Goal MAP >50. SBP dropped into 80's after HD. MICU HO paged with no response. BP came up without intervention. Amiodorone, Digoxin, and lopressor per schedule. Coumadin to be held tonoc. INR3.9.\\n\\nRESP: No vent changes. Sxn x3 small amts thick yellow secretions. LS rhonci/coarse. Clearer with sxn. Cuff leak treated by RT. MDI by RT. Plan for Passy Muir trial in am prior to discharge per family request.\\nDtr. updated by attending on this matter.\\n\\nRENAL: HD this am. Pt. tol. removal of 2.2L. Albumin admin. during HD.\\n\\nENDO: BG still 200-300' in to . Glargine dose increased. recommends injections into stomach for optimal effect. RISS coverage.\\n\\nID: Tmax 99.8po this shift. IV ABX dc'd this am. Levofloxacin restarted for aortic abcess. VRE+ !!!!\\n\\nGI: TF @goal via PEJ. Small amt mucus drainage around insertion site with small ulcerated area noted at the 3 o'clock position. Wound care RN in and discussed proper care for excoriated skin around PEJ. Aquacel trach sponge ordered for area-until then use aloe vesta on excoriated part and duoderm gel on uclerated area covered with DSD. RN stated OK to use Aloe Vesta under Aquacel too. Liquid stool from colostomy. Lactulose held.\\n\\nWOUND: Wound management unchanged. Reviewed with wound RN. Right ischial dsg done this shift due to increased drainage at site. All other dsgs intact. Kinair bed &BLE MPS in place.\\n\\nPSYCHOSICIAL: Husband and son at bedside for most of morning & present during rounds. Informed of possible dc by Attending. Dtr. called and also updated by Attending.\\n\\nPLAN: Monitor CV, if low BP, sxn prn, assess for cuff leaks, trial in AM of Passy Muir, wound management, diabetic management, turn Q2H to maintain skin integrity, initiate discharge paperwork, provide emotional support to patient and family concering pending discharge.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524160,\n \"text\": \"resp care note\\n\\n\\nPt remains trached and on AC vent , No ABG drawn this shift. Sx for increased yellow-green sputum. sample sent for C&S. # 8 in place.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524319,\n \"text\": \"Nursing Progress Note\\nPlease see carvue for specifics:\\nNeuro: Pt alert mouthing words and weepy at times. Still does not follow commands and is only moving LUE. Cont on standing ativan.\\nCV: Pt becoming increasingly hypotensive today. Down to low 70's with MAP's in the 30's. Pt at one point on max triple concentrated Neo and Vasopressin. Remaining with normal HR over coarse of day. CVVH cont and placed to 0. Pt currently off vasopressin and is on 2.0mcgs/kg of neo. currently running even. Pt remaining hypothermic. Unsuccessful line placement today. Pt will need to go to IR for Central access in am.\\nResp: No vent changes. Sxn for thick yellow sputum. Lungs coarse throughout. Sats 98-1005.\\nGi/GU: Cont on TF at goal 65cc/hr via J-tube. G-tube remains to gravity. Small blood clots aspirated from MD aware. Cont with guiac + stools and some noted vaginal bleeding.\\nEndo: insulin gtt stopped FS dropped to 51.\\nSkin: Coccyx Hip changed with wound RN. see chart for recommendations.\\nID: Cont on mult abx. Hypothermic\\nSoc: Family requesting trnf to . Social Services in contact with family and primary team RE: Family meeting tomorrow.\\nPlan: Cont with current plan of care IR tomorrow for Central access.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524320,\n \"text\": \"RESP CARE: Pt remains trached/on vent settings per carevue. No changes in settings this shift. pressure 30cmH20. trach care done/inner cannula cleaned. Lungs coarse bilat with no wheezes. MDIs given as ordered. Sxd small amts thick yellow sputum. ABGs consistent with met acidosis. RSBI deferred due to hemodynamic instability. Continue full support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524395,\n \"text\": \"Respiratory Care\\nPt. trached on ventilatory support. Sx for copious amounts thick tan and blood tinged secretions. No vent setting changes made this shift.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524396,\n \"text\": \"Nursing progress note\\nPlease see for details\\n\\nNeuro: unchanged, nodding to questions, mouthing words at times. does not move extremities.\\n\\ncv: neo remains off, bp on leg in order to achieve . HR decreases to low 60's after diltiazem. Pt's daughter is requesting that dilt be changed back to TID when dialysis resumes. Rate is now controlled at < 90.\\n\\nPulm: no vent changes. pt sx q 2-3 hrs for thick tan to brown sputum. see vbg's.\\n\\ngu: anuric\\n\\ngi: tol tube feeds at 40/hr. pt turned at 0600 for bed change, turned to left side (g port gravity bag is hung on left side.) no tension on tube noted, when pt returned to back, balloon of ft noted to be external on abdomen. Dr notified. Feeding off.\\nColostomy draining loose golden stool, guaiac pos. Hct stable tonight at 25.\\n\\nEndo: insulin drip remains off, blood sugar down to 115. now with TF off, will monitor blood sugar closely.\\n\\nskin: pt continuously leaks from pinpoint areas over arms and back of legs. quilted pink pads changed frequently for pt comfort.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524161,\n \"text\": \"Condition Update\\nPlease see carevue for specifics.\\n\\nNeuro unchanged. Tmax 100.1 AFIB rare pvc's. spb 73-109. No vent changes. Pt sxn'd several times for yellow and green sputum. sputum sample sent. w/ beneprotein unfusing at goal. clear oozing in large amts noted at j tube insertion site. DSD applied. blood sugars continue in the 300's. Pt is followed by .\\n\\nPlan: continue with current plan of care per micu team. discharge planning. speech and swallow consult today for passy mauir placement. Po abx.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524162,\n \"text\": \"Respiratory Care Note\\nPt remains on AC home settings as noted. BS diminished throughout. Pt suctioned for small to moderate amts thick, brown secretions. Speech evaluated pt for - pt placed on for 15min x 2 this shift. Pt tolerated well with sats 100%. Pt did not vocalize during either trial. Plan to continue on current settings. Spoke with daughter about her concerns with new trach and referred her to attending physician.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524163,\n \"text\": \"NPN\\nPlease see CareVue for full assessments\\nNEURO: No changes. Incosistent with following commands.\\n\\nCV: Cont. in AF with rare PVC's. HR 90's-110's. Episodes of hypotension-not new. MICU team aware. HCT 24. T&S drawn. To receive 2Units PRBC's tonoc.\\n\\nRESP: Trach. No vent changes. Tolerated Passey-Muir valve trial. Teaching to dtr. by Speech and RT for in line use of . Dtr still has concerns about new trach and care after discharged home. Team aware and to meet with dtr.\\n\\nENDO: BG remain 200's-300's. Glargine increased again. RISS .\\n\\nGI: TF@goal. PEJ draining copious amts brown/green liquid this eve. Noted to increaase when pt. turned to left side-family states this is not new. Skin around insertion site excoriated and beginning to break down. Ostomy appliance placed around site. Family had been using appliane at home due to large amts drainage. Colostomy appliance changed. Loose golden guaiac - stool in bag. Colace and Lactulose held due to liquid stools x2days.\\n\\nWOUNDS: No changes in wound care. Dsgs intact. MPS to BLE.\\n\\nPLAN: Monitor CV, pulmonary toilet, diabetic management, wound management, discharge planning, provide emotional support to patient and family.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524164,\n \"text\": \"resp Care note\\n\\nPt was placed on via in-line vent circuit with cuff down but did not tolerate trial well. She has significant amt of thck yellow-green secretions, Sputum culture pending. At this time she remains on AC vent 16 x 450, + 5 , 40% . No ABG this shift. Pt is alert but not prone to communicate readily\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524397,\n \"text\": \"NURSING NOTE 7A-7P REVIEW OF SYSTEMS:\\nNEURO: DROWSY AWAKE AT TIMES, MORE AWAKE WHILE FAMILY VISITING. PERRLA, NO MOVEMENT OF EXTREMITIES. INCONSISTENTLY FOLLOWS SIMPLE COMMANDS. NO PAIN MEDICATIONS GIVEN.\\nC/V: CONTINUES IN AFIB RATE 67-94 OCCASSIONAL PVC'S. = 80-110/35-55. NEO REMAINS OFF. PO MEDS THRU PEG TUBE RESTARTED THIS AFTERNOON.\\nRESP: VENT SETTINGS UNCHANGED. REMAINS ON AC AT 450X 22X 50%X 5 PEEP.\\nTRACH CARE DONE INNER CANNULA CHANGED AND CLEANED. SUCTIONED SEVERAL TIMES FOR SM TO MODERATE AMOUNTS THICK TAN SECRETIONS.\\nGU: ANURIC, DUE FOR HD TOMMORROW AM.\\nGI: ABD OBESE, POSITIVE BOWEL SOUNDS, COLOSTOMY DRAINING LOOSE GOLDEN COLORED STOOL (GUIAC NEGATIVE). TRANSFER TO XRAY TO CHECK PEG TUBE PLACMENT UNDER FLUOROSCOPY. PLACEMENT CONFIRMED AND TUBE FEEDINGS OF RESTARTED AT 40CC/HR TOLERATED WELL.\\nHEME: REPEAT HCT THIS AFTERNOON= 24.7.\\nSOCIAL: PATIENTS HUSBAND AND SON INTO VISIT THIS MORNING, QUESTIONS ANSWERED BY RN AND MD, UPDATED ON PLAN OF CARE.\\nENDO: WHILE PATIENT NPO FS CONSISTENTLY WERE 57-81. ONCE TUBE FEEDINGS RESUMED FS INCREASED. REMAINS OFF INSULIN DRIP TODAY.\\nACCESS: CONTINUES WITH MULTILUMEN LINE RIGHT SC, RIGHT SIDED PICC LINE AND DIALYSIS LINE SHILEY INTACT LEFT SIDE.\\nPLAN: DIALYSIS TREATMENT TOMORRW, IF PATIENT STABLE POSSIBLE TRANSFER TO HOME ON TUESDAY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524398,\n \"text\": \"BS fine crackles, occ wheeze clearing with suction. No significant change with MDI's. To CT to check PEG - in position and functioning. No vent changes or ABG's.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524247,\n \"text\": \"NPN\\nPlease see CareVue for full assessments\\nNEURO: Unchanged. Nods to questions at times. More interactive during eves. Attempted to mouth words x1. Inconsistently follows commands. Moving upper extremities on bed. No movement noted in BLE. Nodded yes to pain x1. administered. Pt. did not respond when asked if pain relieved.\\n\\nCV: Afib. HR consistently 120's-130's. Episodes of HR 150's. 1x dose 2.5mg Lopressor IVP with no decrease in HR. MICU HO notified. PO 2200dose lopressor held due to hypotension during eves and given later in shift when BP more stable.\\n\\nRESP: Trach. No vent changes. Sxn mod amts tan thick secretions.\\n\\nGI: TF @goal. Ostomy bag placed @ due to drainage from around insertion site. Colostomy bag changed. G- stool.\\n\\nScant amts vaginal bleeding noted.\\nPLAN: Monitor CV, diabetic management, pain management, wound care, HD today, reposition per protocol.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524248,\n \"text\": \"nuero: pt does open her eyes when you call her name. pt nodds yes and no to questions when asked. pt intermittently will follow commands.\\n\\npain: pt nods head no when you asked if he having pain.\\n\\npulm: pt remains on trached, pt on cmv. suctioning pt for scant amt of yellowish secretions.\\n\\ncards: pt in afib hr 120-140's, sbp 80-90 dr. aware, pt recieved 250cc this morning with little effect. hr continued to be 130-140's, dr. aware, pt recieved 2.5gm of iv lopressor with some effect. please see flow sheet\\n\\ngi: pt continue on tubefeedings at goal which she is tolerating thus far. stoma pink and protruding draining golden brown colored drainage.\\n\\ngu: pt does not viod. pt to recieve hemodialyisis tomorrow. pt with scant amt of vaginal bleeding noted.\\n\\nf/e k 3.3 pt treated with 20meq kcl. blood sugar 136 this morning receieved 86 units of glargine as ordered.\\n\\nsocial: pt husband into visit this morning.\\n\\nplan: continue to monitor, monitor hr, bp, pain ,\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524249,\n \"text\": \"resp care\\nremains trached and vent dependant. remains on ac mode, no changes made this shift. sxning thick yellowish/green sputum. mdi's given q4h. refer to flow sheet for data.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524250,\n \"text\": \"Respiratory Care Note:\\n\\nPt remain on ventilatory/assisted support ventilation via tracheotomy tube. No vent changes done. We are sxtn small amt of yel thick secretions, small cough efforts. MDI's adm with No noticeable changes, albuterol held as Hr 120's. Plan: Continue present ICU monitoring. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524310,\n \"text\": \"RESP CARE\\nRemains on vent. no changes made. Suctioned mod amt of thick green secretions. Mdis given. WIll continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524311,\n \"text\": \"Respiratory Therapy\\nPt remains trached w/ #7.0 Shiley trach on full mechanical support. No vent changes made this shift. BS coarse, suctioned for small amounts of thick tan secretions. SpO2 90s. MDIs given as ordered. Continues on A/C ventilation w/ PIP = 20. See resp flowsheet for specific vent settings/data.\\n\\nPlan: maintain support\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524154,\n \"text\": \"Resp Care\\nPt remains vented on AC 450x16 at 5 PEEP. Pt was bronched today and a new adjustable flange cuffed Trach tube was placed via Bronch. Cuff pressure was set to 20. MDIs given as ordered. BS scat wheeze and rhonchi. Sxn'd for thin white secretions. No ABGs done today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524312,\n \"text\": \"focus update note\\nhypothermic most of day, MICU team aware, 95-98, bair hugger on, internal bed warmer on most of day, NSR 70-80s no ectopy, kcl and ca continuous repleation, sodium phosphate repleated. goal map > 55 neo .2-1.5 mcq/kg/min neo requirments increasing to maintain map > 55. HCT 24, no active sign/sx bleeding witnessed.\\n\\nCRRT: machine malfunction at 1500, new machine ordered and restarted at 1700, goal per renal fellow keep pt even to 1 liter negative, pt 100-150cc/hr today.\\n\\nskin: leg/thigh/ dressings performed please see flowsheet for details, left inner thigh cellulitis unchanged- pt on vancomycin, pt edema increasing in thighs.\\n\\nsocial: (daughter) spoke with micu resident in length regarding mothers care, daughter continues has many concerns/questions and would like to speak with social work this week\\n\\nplan: keep MAP > 55 with neo gtt, monitor for afib, continue with CRRT goal even to 1 liter negative, monitor/treat hypothermia, family meeting for next week?, social work consult\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524313,\n \"text\": \"Respiratory Care Note:\\n patient remains trached with a #7 x-long Shiley trach, secured and patent. remains on full vent support with no changes being made this shift. BS are coarse throughout. SX for small to moderate amounts of thick yellow secretions via trach, MDI's administered as ordered. No RSBI this am due to patient being vent dependent. Tmax this shift was 99.6. SPO2 remains 100%. No ABG's. Plan is to continue with current treatment plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524314,\n \"text\": \"Respiratory Care\\nPt remains on full ventilatory support as note on Carevue. MDI's given as ordered. Breath sounds diminished with scattered expiratory wheezes. Improving with suctioning. Small amounts of thick yellow secreations removed from airways.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524315,\n \"text\": \"nsg note\\nSEE FLOWSHEET FOR SPECIFICS.\\n\\nNEURO-PT AWAKE, OPENS EYES TO VOICE. OCC MOUTHS WORDS.\\n\\nCV-HR 80'S, NSR. REMAINS ON NEO GTT TO KEEP >80'S. SKIN WARM.\\n\\nRESP-REMAINS TRACHED AND VENTED. NO VENT CHANGES MADE TODAY. O2 SAT 100%. LS COARSE WITH OCC WHEEZES. INHALERS AS ORDERED. SXN PRN FOR THICK YELLOW SPUTUM. ABG ACCEPTABLE.\\n\\nGI-ABD OBESE. +BS. TOL TF VIA . G-TUBE TO GRAVITY WITH YELLOW/WHITE DRG. STOMA PINK. NOTED TO HAVE BLOODY LOOSE STOOL VIA OSTOMY. TEAM AWARE.\\n\\nGU-ANURIC. ON CHHHDF. TOL WELL. GOAL 1 LITER NEG TODAY. ABLE TO TOL SOME FLUID REMOVAL. CA AND KCL GTTS INFUSING AS ORDERED.\\n\\nCOMFORT-APPEARS COMFORTABLE. ATIVAN ATC.\\n\\nENDO-REMAINS ON INSULIN GTT.\\n\\nACT-REPOSITIONED FREQ. ON AIR MATTRESS.\\n\\nID-HYPOTHERMIC. BAIR HUGGER ON. ON MULTI ABX.\\n\\nSKIN-CON'T WITH MULTI SKIN ISSUES. DRESSINGS ALL CHANGED AS ORDERED. SEE FLOWSHEET.\\n\\nPLAN-CON'T WITH CURRENT PLAN. MONITOR FOR CHAGNES. FOLLOW LABS. . GOAL 1 LITER NEGATIVE. ASSESS PAIN. SKIN CARE. SUPPORT. WEAN PRESSOR AS TOL.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524390,\n \"text\": \"nursing addendum\\n MD , amikacin dose to be given with level of 11.8 per pharm. Level trough to be sent at 1730.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524391,\n \"text\": \"Respiratory Care\\nPT. trached onventilatory support. Suctioned for copious amounts of thick yellow green secretions. No vent setting changes made, not plans for weaning vent settings at this time.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524155,\n \"text\": \"Condition Update\\nPlease see carevue for specifics.\\n\\nNeuro unchanged. Pt opening her eyes spontaeously, but not moving extremities or following commads. Low grade temps. TMAX 99.7 AFIB HR 90's-108. No ectopy noted. SBP 70's-90's. 500cc NS boluses x 2 given w/ no effect per micu team. Cortisol test done, 1x dose of cosyntropin given. BP's up since dose given. Results still pending. No vent changes this shift. Trach changed over to a new adjustable flange cuffed trach via bronch at the bedside d/t leakage. Pt sxn'd for scant amts of white, thick sputum. Sats 100% LS clear. w/ beneprotein tube feedings infusing via j tube restarted after trach placed an is at goal. Colostomy draining guiac NEGATIVE liquid stool. spec sent. Lactulose dose held. Pt's blood sugars while NPO as low as 44. amp dextrose given. Since tube feedings restarted, bs have been on the rise and currently 163. B/L hip dressings changed this am. Both hips w/ stage 3 ulcers that drain serous, foul smelling fluid. reddened bases of the wounds. All wounds cleansed w/ NS, duoderm gel placed then covered w/ allevyn dressings.\\n\\nPlan: continue with current plan of care per micu team. IV F/U on results of cortisol test, bld cx's taken , and spec sent . Discharge planning. Dressing changes. HD to be done . Speech and swallow to speak w/ daughter concerning future use of passy mauir valve.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524156,\n \"text\": \"Resp. Care:\\n Pt. continues on mech. ventilation-same settings as at home with chronic vent. New trach. placed yesterday. Tol. well without leak. Inhalers given as ordered. Please see flow sheet for more information.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524157,\n \"text\": \"Nursing NOte 7p-7a:\\nNursing Assessment:\\n\\nTmax 100.6 has started to come down without intervention other than blankets off for a few hours and room temp decreased. No commands other than opens mouth for temperature. Tracks but no nodding yes and no or spontaneous movement other than wiggles left fingers occasionally when awake. No boluses tonight, goal map >50, very inconsistent blood pressures continue and team is aware, not new. Afibb and tachycardic also not new. Lopressor po as bp tolerates. Amiodorone and digoxin po qd. Abdomen softly distended, colostomy with liquid stool and tube feeds continue. Lungs clear and diminished. Inhalers given by respiratory therapist. Dressings to bilat lower extremities and coccyx per wound nurse recommendations. Blood glucoses elevated again despite 75 glargine and reg insulin sliding scale. Will continue to monitor. HD today, p tis anuric. ?Discharge home today on vent following dialysis. Pt has 8 children who participate in managing her home care. Please refer to carevue for details.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524158,\n \"text\": \"Respiratory Care Note\\nPt remains on AC home settings with no changes. BS diminished, but clear. Pt has a slight cuff leak with air placed in cuff to achieve minimal leak. MDI's given a/o. Plan to continue on current settings at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524241,\n \"text\": \"Resp.Care\\nPt. remains on A/C vent with a 7.0 Shiley secured and patent. Sx mod amts yellow with coarse b/s. MDIs given on time with good effect.Plan is to cont to monitor and wean as tol.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524392,\n \"text\": \"Rapid afib\\nD:Pt had afib 120-150 not controlled with diltiazem 30mg TB so dose increased per Dr to 60mg QID. Afib now 110.\\nPICC line looked like it had slipped out some due to impaired skin integrity and weeping skin difficult to keep DSD on. IV RN in to see pt and said line out 5cm. CXR done but radiologist unable to visulize PICC tip so need another CXR.\\nPt responsive always opened mouth when asked, pupils large brisk. Otherwise no neuro change.\\nAll DSD changed per plan in pt's room.\\nNo vent changes overnight.\\nColostomy yellowish soft stool. gastric drainage blood tinged and watery consistency, irrigated x 1 with NS because it had stopped drg.\\nPlan today:\\nNeed repeat CXR to check PICC position\\n effectiveness of increased Dilt dose in rate.\\nContinue plan of care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524393,\n \"text\": \"SICU NPN\\nS-Trached.\\n\\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\\n\\nO-Alert. Shaking head in no and yes direction at times to family questioning. Denying pain. Not grimacing to pain or nursing care. Responding inconsistently to questioning when nodding. Attempting to wean off Neo. Neo off for 1hr. BPs into the 60s with a MAP of 30. Restarted and at .5mcg/kg/min. Attempting to keep MAPs > 50. Continues PO Midodrine with no increase in dose. PO Diltiazem dose increased, remains in Afib, HR better controlled, 60-80s from 100-110s. Breath sounds coarse anteriorly. Remains on AC. Suctioning for thick yellow-tan secretions in moderate amounts. Suctioning more frequently than previous. Still unable to obtain O2Sats peripherally or centrally. Remains anuric. CRRT off since yesterday. Goal is to wean off Neo with hopes of pt tolerating conventional dialysis to go home. TFs at GR. Ostomy putting out golden formed soft stool. G-tube to gravity and J-tube to feed. Insulin drip stopped this morning and attempting to treat with aggresive sliding scale coverage and standing Insulin dose. All dressing changed and intact. PICC noted to be out 5cms on previous shift, CXR confirming PICC in place per MICU resident. IV team made aware. Afebrile. Continues antibiotic regimen. Husband and son into visit this morning and expressing feelings of mother to \\\"come home.\\\" In addition son and -in-law into visit this afternoon and wanting pt \\\"home.\\\" Son, just waiting for sister() to make deciscion.\\nA/P:Sepsis c/b failure to wean\\nContinue to wean Neo as tolerated\\nTreat BS aggressively with sliding scale in effort no to resume gtt.\\nEmotionally support pt/family as needed\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524394,\n \"text\": \"BS coarse crackles; no change with MDI's. Sx'd for mod amounts thick yellow sputum. Still requiring pressors and now off CVVH per family. Will continue to wean ventilator as appropriate, No ABG's or vent changes this shift.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524242,\n \"text\": \"NPN\\nPlease see CareVue for full assessments.\\nNeuros unchanged. Ativan per schedule.\\nCV: Cont. Afib w/HR 90's up to 120's.\\nRESP: Trach. No vent changes. BS coarse throughout. Sxn for scant amt thick tan secretions.\\nGI: TF at goal via . Cont. w/copious amts bilious drainage around insertion site. Dsg chgd multiple times. BS+. Abd distended. Golden liquid stool guaiac - from colostomy.\\nGU: Anuric. Scant amt blood noted.\\nWOUND CARE: All dressings by wound care RN C/D/I.\\nPLAN: Monitor CV, diabetic management, wound management-change dsgs per orders/PRN, maintain skin integrity, provide emotional support\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524243,\n \"text\": \"SICU NURSING PROGRESS NOTE 0700-1500\\nNEURO--INCONSISTENTLY NODS HEAD TO SIMPLE QUESTIONS REGARDING PAIN, COMFORT, HOT/COLD. MOVES BUE BUT NO SPONT. MOVEMENT OBSERVED IN BLE. PEARL AT 4MM. OPENS EYES SPONT. WILL TRACK WITH EYES OCCASIONALLY.\\n\\nCARDIAC--REMAINS IN AFIB 110-130. SBP 70-110/40'S.\\n\\nRESP--NO VENT CHANGES MADE. SX Q2 HRS FOR MODERATE AMTS OF THICK TAN SPUTUM. BILATERAL LUNGS ARE COARSE IN ALL FIELDS. SAO2 >97%.\\n\\nGI--TOL. TUBE FEEDS AT GOAL. COLOSTOMY DRAINING ~200 CC HR GOLDEN LOOSE DRAINAGE. SMALL AMTS OF DRAINAGE AROUND FEEDING TUBE.\\n\\nGU--ANURIC. NO FOLEY.\\n\\nID--TEMP MAX 99.9 ORAL. REMAINS ON SEVERAL ABX.\\n\\nPAIN--PT NODDED YES SEVERAL TIMES WHEN ASKED IF SHE WAS HAVING PAIN. MEDICATED WITH 12.5 DEMEROL FOR RELIEF. 25 MG GIVEN WITH DRESSING CHANGES.\\n\\nSKIN--SACRAL ,R HIP AND BILATERAL FEET DRESSINGS CHANGED PER PROTOCOL. SACRAL WOUND IS DEEP AND CLEAN AS IS HIP. NO FOUL SMELL NOTED. SEVERAL SKIN TEARS ACROSS BUTTOCKS. TOES ARE NECROTIC DSD APPLIED. REMIANS ON KCL BED.\\n\\n AND HUSBAND IN THIS AM. THEY HAVE BEEN UPDATED REGARDING PT'S CONDITION. \\\"NURSES ARE US\\\" IN TO VISIT AND REVIEW CHART FOR WHEN PT GOES HOME AND NEEDS SERVICES.\\n\\nA--UNCHANGED NEURO, CARDIAC OR RESP STATUS. J-G TUBE IS LEAKING SMALLER AMTS AROUND TUBE.\\n\\nP--CON'T TO MONITOR. MEDICATE FOR PAIN, ASSESS RELIEF. OFFER SUPPORT TO PT AND FAMILY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524244,\n \"text\": \"Respiratory Care\\n\\n Pt continues on A/C in NARD No changes made today. MDI's as ordered. B/S sl coarse sx'd for moderate amount of thick tan secretions. Will continue to follow closlely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524245,\n \"text\": \"condition update\\n3-7p\\nSee carevue for specifics. Tachycardic 120's-130's more consistently this evening, bp stable. Dr. was notified, no new orders, will continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524246,\n \"text\": \"RESPIRATORY CARE NOTE\\n\\nPatient remains trached with Shiley 7.0 ex. long trach tube. No vent changes made during the night. Inner cannula changed. Sxn for tan thick secretions. RSBI completed on PS 5=105.\\n\\n , RRT\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524305,\n \"text\": \"Update\\nO: See carevue flowsheet for specifics.\\nNeuro: awake,alert, mouthing words&tearful at times altho unable to discern what pt saying. Nods no to pain. Moves lt arm only w purposefl spont mvmnt.\\n\\nCv: remains in afib on neo. Hr controlled w pgt diltiazem.Distal pulses by doppler.Extrems cool, bair hugger on and off thru .\\n\\nResp: Trached on cmv mode vent tv 450 rr 16 peep 5 .bbs coarse throughout. lavage and suct for thick yellow secretions.Remains on cmv mode w adeq abg.Trach care done\\n\\nGi:Abd obese w + bowel snds.Colostomy pink. gjtube w fdg at goal 65cc/hr probalance str w beneprotein. Glucoses managed per riss.Colosstomy w golden to bld tinge serous dnrg.\\n\\n\\nGu: makes no urine.Cont on crrt keeping pt even & tol well.\\n\\nHeme/Id: hct 25. Tmax 99.4 while off crrt, temp now trending dwn.Cont on meropenem tobra levoflox.\\n\\nWound & skin: multiple decub buttocks hip and ble. Drsgs d &i.allevyn drsgs in place.\\n\\nA/P:Cont crrt, sliding scale ca+ k+. Cont titrate insulin gtt per prtocol. Wound and skin care. Pulm toilet.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524306,\n \"text\": \"Resp CAre\\nPt remains on vent. Trached with #7 shiley. Suctioned mod amt of thick yellow secretions. mdis given. No changes made. Will continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524307,\n \"text\": \"Respiratory Therapy\\n\\nPt remains trached w/ #7.0 Shiley on full mechanical support. No vent changes made this shift. Continues on A/C w/ PIP = 22. Anterior BLBS coarse, suctioned for small amounts of thick yellow sputum. MDIs given as ordered. SpO2 90s. See resp flowsheet for specifics.\\n\\nPlan: maintain support\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524308,\n \"text\": \"focus update note\\nhypothermic 95-96, required bair hugger most of day, afib continues 70s-130, unable to wean neo gtt, at .5 mcq/kg/min, pt MAP 55-60 80-108\\n\\nCRRT continues, goal to keep pt even per renal, may take off 10-20 cc/hr if tolerated by pt. CVP 9-11, calcium and potassium gtt continue with labs q 6 hours.\\n\\nresp: no vent changes, thick yellow sputum suctioned q 2 hours, ls clear to coarse with bases dim.\\n\\nskin: and leg performed at 0900, wounds appear to be stable ? minimal healing in coccyx decubitus, bilateral toes are black. left upper medial thigh cellulitis found on morning assessment- ? if nec fasicitis- surgical consult performed- will moniotor closely.\\n\\nplease see flowsheet for details\\n\\nplan: continue with CRRT as tolerated- goal keep pt even, keep MAP> 55, > 80, labs q 6 hours, Fs q 1 hour, repleat lytes, wean neo gtt as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524309,\n \"text\": \"NURSING 7P-7A\\n VSS OVERNIGHT. ALTERNATING FROM NSR TO A-FIB. ALTERNATING BETWEEN HYPOTHERMIA AND NORMOTHERMIA. BAIR HUGGER ON AND OFF ACCORDING TO TEMPERATURE. CONTINES ON NEO GTT, ATTEMPTING TO WEAN NEO SLOWLY.\\n CONTINUES, ATTEMPTING TO RUN EVEN AS ORDERED. FILTER CLOTTED AND REPLACED AT 2300. POSITIVE AT 2400 BY 450 ML DUE TO FILTER CLOTTING. SEE CARE VUE FOR FULL SPECIFICS.\\n DRESSINGS REMAIN INTACT ON MULTIPLE DECUBITUS. REMAINS ON KINAIR BED FOR SKIN INTEGRITY.\\n NO VENT CHANGES OVERNIGHT. SUCTIONED Q 2-3 HRS FOR GREEN TINGED SPUTUM IN MODERATE TO COPIUS AMOUNTS. LUNGS COARSE THROUGHOUT.\\n INSULIN GTT CONTINUES, INFUSING CURRENTLY AT 7 UNITS/HR. BLOOD SUGARS IN THE 120-160 RANGE. TUBE FEEDS CONTINUE AT 65/HR.\\n CONTINUE LABS Q 6/HRS PER PROTOCOL. BLOOD SUGARS Q 2/HRS WHILE GLUCOSE LEVELS STABLE. KEEP >80, MAP>50, WEAN NEO AS TOLERATED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524385,\n \"text\": \"Nursing Note--A Shift\\nPlease see Carevue for complete assessment and specifics:\\n\\nNEURO: PERRLA 3 and brisk. Alert. Does not follow commands. Nods head continuously at times, but not approprately to questions asked. Intermittently tracks people walking around her bed. (-) gag, weak cough. Minimal movement on bed with all 4 ext.\\n\\nRESP: LS coarse and diminished. Deep sxn for small to moderate amts of thick yellowish greenish secretions. Tol vent settings.\\n\\nCARDIAC: On bairhugger 1700 for temp 95.6. HR 95-120 afib. Maintaining MAP >55 able wean NEO gtt slowly. Diltiazem on hold until NEO gtt is off.\\n\\nGI: Abd large soft +BS. Brownish red tinged stool from ostomy, @200cc q 6hours. G tube to gravity draining scant amts of sanguinous fluid. Tol tf at goal thru J tube.\\n\\nCVVH: Kept euvolemic,-no issues.\\n\\nINTEG: Skin extremely compromised. Numerous skin issues-See Carevue Dressing changed consistently throughout shift-Skin oozing copious amts of foul smelling serous liquid. On airbed.\\n\\nPSYCH/SOCIAL: Husband and son visited in the am given updates and plan of care. Daughter called in the am given updates with meds, vs, and plan of care.\\n\\nPLAN: Wean NEO gtt off-then CVVH can be terminated, Amikacin level to be drawn at 6am tomorrow, Continue with diligent skin care, Maintain MAP >55. Provide extra comfort to patient.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524386,\n \"text\": \"Respiratory Care\\nPt. trached on chronic ventilatory support. Has positional leak. ABG's with good oxygenation, FiO2 decreased accordingly. No other vent setting changes made this shift.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524387,\n \"text\": \"condition update\\nS/P SEPSIS, BLEED\\nSEE CAREVUE FOR DETAIL INFO.\\nUNEVENTFUL NIGHT CRRT FLOWING WELL UNTIL THIS AM. ABLE TO KEEP PT EVEN TO SLIGHTLY NEGATIVE BASED ON BP .\\nNEO @ SAME DOSE (1MCG) KEEPING BP MEAN 55. DISCUSSED W/DR.\\nPT VERY CALM AND APPARENTLY RESTING ATIVAN NOT NECESSARY AT THIS TIME.\\nGENERAL ANASARCA WITH LOTS OF WEEPING AREAS.\\nSPOKE W/ AND DISCUSSED PLAN FOR NIGHT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524388,\n \"text\": \"BS coarse crackles; no change with MDI's. Sx'd for mod amount thick yellow mucus. Received CVVH today and will continue until off pressors. PEEP decreased to 5 without incident. WIll continue to wean FiO2 as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524389,\n \"text\": \"nursing note\\nNeuro:Alert today, nodding side to side and up and down, but not in correct response to questions.\\nCV:afib, dilt restarted per micu despite neo requirements. Neo weaned to keep >55, sys at times 70's with MAP still >55.\\nResp: Ls coarse, thick yellow secretions. Peep dropped to 5 with acceptable ABG.\\nGI:tol tube feeds at 40cc via JT, no residual. GT with minimal output, pink tinged. ostomy with golden brown sotol-no visible bleeding.\\nGU: anuric. stopped per micu team.\\nsocial: spoke iwth daughter who states her wishes to take her mother home to spend the remainder of her days. States that if while her mother is home- she startes to bleed again or has an acute event, she will not bring her back to hospital. States she wants her home on vent and antibitoics and dilaysis and treated as necessary at . Social work and team aware.\\n\\nplan:? HD in few days when neo off. wean neo to off to keep MAP >55. follow labs. plan to home if possible. dressing care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524207,\n \"text\": \"Resp Care Note:\\n\\nPt cont trached and on mech vent as per Carevue. Lung spounds coarse; suct sm=>mod tan sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required . Air leak around trach cont to be positional though ventilation maintained. Cont mech vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524208,\n \"text\": \"Neuro: Pt alert and nodding and making needs known.\\nCV: tmax 101.2. HR 110-130's Afib, with no noted ectopy. pulses. HCT drop from 25-22 this am. Continues to have large amounts of bloody drg from ? R hip skin tear, ? Vagina, ? decub.\\nRESP: lungs rhonchi through out. No vent changes overnight. O2 sats >97%. Occasional suctioning of thick blood tinged secretions.\\nGI: tol tube feed at goal, Colostomy draining golden liquid stool.\\nGU: ANeuric.\\nENDO: blood sugars WNL.\\n PLAN: ? trach changed, ? trans vaginal ultra sound.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524209,\n \"text\": \"Respiratory Care\\nPt continues to be trached/ventilated. BS: diminished bilaterally. Suctioned for moderate amounts of thick tan secretions. MDI's administered as ordered. Pt currently resting on A/C 450/16/5/.40--overbreathes rate at times. # 8.0 adjustable length /air clean and intact. Plan for Interventional Pumlonary to change to special order trach (7.0 X-tra Long Shiley). Will continue to closely monitor at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524210,\n \"text\": \"Condition Update\\nPlease see carevue for specifics.]\\n\\nNeuro unchanged. TMAX 101; Pan cx'd again except for urine since pt is anuric. Mean BP 30's-40's this afternoon. 250cc NS given x 1 per micu team w/ + effect. No vent changes made. Resp tx giving pt as ordered. Pt sxn'd several times for small amts of thick, tan secretions. + leak from trach. Tube feedings infusing at goal w/ no residuals. Shiley trach that family is requesting is on back order w/ no estimated ship date. Moderate amts of bleeding noted to be coming from pt's skin tears on her hips. All areas cleansed, aquacel placed, then dsd's.\\n\\nPlan: continue with current plan of care per micu team. continue to monitor hemodynamics. HD tues/th/sat. IV abx, wound care.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524211,\n \"text\": \"Resp Care Note:\\n\\nPt cont trached and on mech vent as per Carevue. Lung sounds coarse suct mod th yellow sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required .. Cont mech vent support\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524212,\n \"text\": \"nursing note\\npt stable , BP transiently dips to 80 sys, no intervetnions. BP up with stimulation. Son in to visit, minimal interaction. Suctioned for thick tan secretions. BS 300, md aware to change official order off q1 hr.\\n\\nplan:cont family support. increase bs regimen.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524289,\n \"text\": \"Respiratory Care Note:\\n patient remains trached and on full vent support at this time. No changes have been made. For specifics please refer to carevue. BS are coarse to diminished at the bases. SX for small amounts of thick yellow secretions Q3-4 hours. No RSBI this am due to patient status and vent dependency. Patient remains afebrile. MDI's administered as ordered. SPO2 remains 100%. Patient overbreathes vent set rate by 6-10 breaths per minute. Will continue with full support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524365,\n \"text\": \"Resp Care\\nPt remains on vent. No changes made. Sucitoned mod amt of htick yellow secretions. Mdis given. Will continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524366,\n \"text\": \"Focused Nursing Note\\nPlease see carevue flowsheet for further details\\n\\nNEURO: Pt awake state waxes and wanes, daughter at bedside and states pt is least responsive that she has witnessed. Does not follow commands as baseline. PERRL 4-5mm. ativan x 2 for incr RR and HR with therapeutic effect.\\n\\nHEMODYNAMCIS: NSR with occassional PACs vs Afib, controlled rate 80-90s on Diltiazem gtt titrated down to 5mg/hr. 85-102 on Neo 0.5-0.6mcg/kg/min, attempting to titrate. Anasarca, abdominal ascites, serous weepage from multiple skin tears/blistering. Hct stable at 26.1, plt 132, INR 1.6. No active bleeding noted. Jtube drainage 900ml dark maroon/bilious fluid.\\n\\nRESP: Trach patent, chronic airleak. Ventilator settings unchanged. ABG Ph 7.36/40/24/153 on CMV 0.50/450/20/8. Suctioned for small amts thick yellow drainage. Brown exudate from trach stoma.\\n\\nGI/METABOLIC: Colostomy stoma grossly edematous, opaque pink, no ischemia- appliance changed. Soft, formed black stool in small amts. Jtube suctioned output 900ml dark maroon/bilious output, Gtube to gravity drainage scant output of same character. Drainage around G/J tube site minimal this shift. No emesis. TPN infusing at 77ml/hr. Glucoses stable 125-137 on insulin gtt protocol.\\n\\nID: Tmax 99.6, surveillance BC pending. Amikacin level 14.7, dose held. Coccyx wounds with foul odor, rectal/vaginal drainage in small amounts varies from dark red to thin brown to mucosal.\\n\\nCOMFORT/SKIN INTEGRITY: Responsiveness waxes and wanes- medicated with Ativan in response to elevated RR/HR- therapeutic effect. Turned and repositioned q2hr, heels elevated off bed at all times. Aggressive skin care. dressing changes done to coccyx, right ischial and bilateral trochanter ulcers. Noted generalized erythema, boggy/macerated skin to posterior buttocks and extending as borders to trochanter wounds- scattered areas of small Stage II ulcers/skin tears secondary to edema, moist skin. Aloevesta to all unopened compromised areas- reccomend drressing changes TID to attempt to keep skin dry.\\n\\nPSYCHOSOCIAL: HCP/Daughter at bedside in evening- assisted RN with stoma appliance changes and was comforted to see no skin breakdown in these areas. Discussed at length with the physiology of SBO and clarified for her the difference between J/G ostomy tube vs very small J-feeding tube she had at home to explore belief that current GI complications are caused by \\\"too large of a J/G tube placed\\\". adds that her mother has a chronic hx of n/v and receives compazine/zofran regularly on HD days as prevention.\\n\\nPLAN OF CARE: Continue to monitor hemodynamics closely, attempt to wean pressor. Monitor GI status, antiemetics per MICU team plan. F/U Amikacin levels post-HD today. Aggressive skin care, dressing changes TID prn, pulmonary hygiene, keep pt comfortable per changes in VS and non-verbal cues. Emotional support and education to pt and family ongoing. Recommend family/multidisciplinary meeting Monday to discuss d/c home\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524367,\n \"text\": \"Focused Nursing Note\\n(Continued)\\n.\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524368,\n \"text\": \"Respiratory Care\\nPt remains trached and on vent support. No vent changes were made during shift. Lung sounds were course and diminished throughout. Pt was suctioned for copious amounts of thick yellow secretions. Pt received MDI's. Atrovent was not given, extra dose was requested and was given at 1600. No ABG were drawn during shift. Care plan is to continue current settings and a family meeting is planned for Monday. Will continue to follow pt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524442,\n \"text\": \"Respiratory Care:\\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. No morning abg results.\\n\\n deferred due to hemodynamic instability.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524443,\n \"text\": \"Respiratory Care\\nPt remains trached and on vent support. No vent changes were made during shift. Lung sounds were course with periods of rhonchi that cleared after suction. Pt received MDI's as ordered. No ABG's were drawn during shift. Pt was suctioned for scant amoutns of thick yellow secretions. Care plan is to continue current therapy and a discharge is planned for Monday. Case Manager requested to have me speak w/ Home Care about vent status. After speaking with H.C company, will place pt on home vent Sunday around midnight. Will continue to follow pt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524444,\n \"text\": \"NURSING NOTE\\nPLEASE SEE CAREVUE FOE DETAILS\\nNEURO: NO MENTAL STATUS CHANGES, EASILY AROUSABLE TO VOICE/MIN STIM, NODDING INTERMITTENTLY TO QUESTIONS. TRACKING VOICE W/EYES, PERRL, 4MM, BRISK. ATIVAN GIVEN FOR TACHYPNEA, DISCOMFORT DURING HD. PRE-MEDICATED W/DEMEROL FOR EXTENSIVE DSG CHANGES.\\n\\nCVS: HR 90S-100S, NSR/ST, 70S-130S, MAP MAINTAINED>60. T-MAX 99.2, HCT 24 MD AWARE, WILL F/U, ?TRANSFUSION. RIGHT CENTRAL LINE D/C'D BY MICU, TIP SENT FOR CULTURE. NO BLOOD FROM COLOSTOMY NOTED. HD FOR 2.6L.\\n\\nRESP: REMAINS ON CMV, NO VENT CHANGES MADE, NO VBG DONE. PT SUCTIONED FOR SM AMT THICK, TAN/YELLOW, O2 SATS 98-100%, TACHYPNEIC TO 30S THIS AM W/HD-ATIVAN GIVEN W/RELIEF.\\n\\nGI/GU: COLOSTOMY W/MIN AMT DK BRWN LOOSE STOOL, NO BLEEDING NOTED. SM AMT DRNG AROUND G/JT PINK, VISCOUS, JT PATENT TO FLUSH. GT W/MOD AMT YELLOW SEROUS FLUID DRNG TO GRAVITY. SM AMT CLEAR, MUCOID RECTAL DRNG NOTED.\\n\\nID: AMIKACIN GIVEN POST-HD, MEROPENEM\\n\\nENDO: BS COVERED VIA RISS, LANTUS GIVEN THIS AM\\n\\nINTEG: MULTI DSG DONE, REINFORCED/RE-PACKED PRN. PT SKIN WEEPING COPIOUS AMTS GEN SEROUS DRNG, GEN ANASARCA. PT TURNED FREQUENTLY FOR SKIN CARE, NO NEW AREAS OF BREAKDOWN NOTED.\\n\\nPLAN: SICU , PLAN D/C TO HOME MON. AGGRESSIVE SKIN CARE, PAIN MGMT, RESP SUPPORT. MONITOR FOR S/S BLEEDING, SERIAL HCTS, ?TRANSFUSION FOR PM HCT 24.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524445,\n \"text\": \"Resp Care,\\nPt. remains on A/C . No vent changes this shift. BS coarse, suctioned for thick yellow sputum. MDI's as ordered. See careve.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524446,\n \"text\": \"FOCUSED NURSING NOTE\\nPlease see carevue for further details\\n\\nNEURO: Pt's alertness waxes and wanes, this cycle unrelated to pain meds and sedative. PERRL, 3-4mm. Not making eye contact this shift, nods head \\\"yes\\\" to questions inconsistently- attempted to mouth words and became tearful when I asked her to repeat it so I could interpret, nodded head \\\"yes\\\" to pain at this time. Medicated with Ativan x 2 for sleep and incr RR, medicated with Demerol x3 as premedication for x2 and spotaneous cues of discomfort at rest.\\n\\nHEMODYNAMICS: s/p 2UPRBCs for Hct 24, post-transfusion HCT 31.0. Plt low at 40K, no sx acute bleeding. ranges 62-130s, HR NSR 90-102.\\nAnasarca persists, purple discoloration and evidence of mottling to buttocks, posterior iliac crest skin breakdown area and BLE.\\n\\nRESP: Trach patent, yellow exudate. SPO2 98-100% on CMV 0.50. Suctioned frequently for thick/yellow sputum. Lungs are coarse bilaterally.\\n\\nID: Afebrile. Meropenem as ordered. Levaquin per Jtube.\\n\\nGI/METABOLIC: NPO maintained. Colostomy with total 100ml black/dark brown liquid drainage. Glucoses stable off nutrition (100/82)\\n\\nSKIN INTEGRITY: Pressure ulcers as previously documented that pt entered hospital with are uncahnged, no foul odor noted. Pts posterior waist area, buttocks, and posterior thighs are covered with moist erythema and multiple skin blisters, tears weeping serous fluid. Areas are purplish in color and extremely fragile to touch- Dressing changes to all sites completed x3, pt turned and repositioned q2hr with full linen change and application of aloevesta to attempt a clean/dry surface for skin, though no improvement is evident.\\n\\nPLAN OF CARE: Monitor hemodynamics, sx bleeding. Resp support, . Assess comfort frequently, sedative and pain med prn. Aggressive skin care. Emotional support to pt and family ongoing. D/C home plan discussion per MICU Attending and HCP .\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524337,\n \"text\": \"Respiratory Care\\nBreath sounds bilaterally diminished, bilateral crackles, suctioned for moderate thick yellowish secretions, patient was afebrile, stayed into chronic A-Fib, patient is on Neosynephrin, Hemoglobin on 9.1 consistent with anemia, patient was treated with Albuterol, Atrovent and Flovent during the shift, Oxygen saturation ranged 97 to 100, no ABGs nor vent changes done up to this point. Patient will continue to be on ventilatory support and close monitoring.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524338,\n \"text\": \"condition update\\nD: pt opens eyes spontaneously. moves left arm spontaneously. she does not follow commands.\\ncardiac: pt remains in afib with rate of 90-102. map greater than 55 on .7 of neo. unable to titrate any lower due to drop in bp to map less than 55.\\nresp: pt suctioned for thick yellow sputum. breath sounds are clear and diminished in the bases. 02 sat 95-97%.\\ngi: tube feeds remain off and g tube to suction. continues to drain large amts of bilious drainage. abd remains distended. stoma is pink and small amt of brown stool present. small amt of bleeding from the rectum and dr. is aware. hct remains stable a 26.\\nskin: pt with genralized edema in all extremities. pressure wound dressing are dry and intact.\\na: continue to monitor labs. wean neo as tolerated. ? dialysis today. monitor abd and gastric drainage.\\nr: no change in status. still with large amts of gastric drainage. neo remains at .7.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524418,\n \"text\": \"NPN 1900-0700\\nPlease see carevue for specifics.\\nROS:\\nNeuro: Arousable to voice, moving LUE only on bed. Pupils equal and reactive. Follows some simple commands inconsistently. Able to nod/shake head when asked if having pain. Medicated with 25mg demerol x1 with effect.\\nCV: HR 70-80'SR, BP 69-100/50-70's. Diltiazem held, HO aware. Skin cool, conts. large amts. weeping/drainage, +jaundice. Pedal pulses weakly present by doppler.\\nHeme: hct 25.3 (27.6), Dr. aware. Repeat PTT 35 (150).\\nAccess: LSC dialysis cath. with old, dry, bloody drainage, no new drainage. R ac PICC + blood return, wnl. RIJ TLCL wnl, unable to draw back blood, HO aware, sm. amt. old dry bloody drainage under dsg.\\nResp: LS coarse->clear, diminished at bases. Suctioned for sm.->moderate amts. thick, yellow sputum. No vent changes made .\\nGI: abd obese, BS hypoactive, no stool. Stoma , pink. Colostomy appliance intact with sm. amts. liquid green stool. TF started via J tube port with G port to gravity, sm. amt. green drainage. Protonix for GI prophylaxis.\\nGU: dialysis yesterday, anuric.\\nEndo: BS wnl, no coverage per ss.\\nID: afebrile temp. 96 Conts. meropenem/levofloxacin/amikacin.\\nSkin: multiple ongoing skin issues, please see flow sheet. Updated recs. from skin care nurse . Conts. to require frequent changing/reinforcement.\\nPsych/social: pt's son in last eve; affect/questions appropriate. Stating he would like to see his mother brought home and made \\\"comfortable\\\". Emotional support provided. No other contact .\\nA/P: Monitor VS, I/O, labs. . ongoing aggressive skin care, pulmonary hygiene. . ongoing open communication, comfort and support to pt and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524290,\n \"text\": \"Update\\nO: See carevue flowsheet for specifics.\\nNeuro: somnolent, arousable to voice. Ativan held overnight. Perl at 4mm brisk. Spont purposeflu mvmnt of lt arm.\\n\\nCv: st w occ pvc occ burst afib/freq pac. Labile 78-100 syst. improved w stim and repositioning.Distal pulses by doppler.Skin and moist w multiple skin brkdwn issues.\\n\\nResp: remains trached on cmv mode.Lavage and suct q2-3h for thick pale yellow secretions.Bbs coarse bilat upper lobes, diminished lower lobes bilat.Occ dip in sats to low 90's responsive to lavage and suctioning.\\n\\nGi: gj tube w tf at goal 40cc/hr. Colostomy w loose golden to bilious grn stool. Bl glucoses managed w insulin gtt.\\n\\nGu/Renal: crrt dc'd per micu team for frank seropurulent drng around quinton cath line. Drsg under technique and line dc to be done by team in a.m.(*quinton placed in IR previously). Bl cultures sent via line and ports flushed per protocol.\\n\\nHeme/Id: hct 23.7 this am. No active signs of bldg. Tmax 99.7. Cont on meropenem, tobra, daptomycin, levoflox. Mult decubs , hips and coccyx as well as bilat leg wounds. Coccyx and decubs changed w wound cleanser to sites and aquacell drsg applied.\\n\\nA/P: Quinton line w purulent drng, crrt on hold per team. ? IR for new line placemnt today. Line tip cult on removal of line.? restart neo for if consistently < 80. Cont tf as ordered, titrate insulin gtt to goal bl sugar.Pulm toilet.Updates to hcp by micu attending last pm. Cont to provide emot support to family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524352,\n \"text\": \"FOCUSED NURSING NOTE\\nPlease see carevue flowsheet for further details\\n\\nNEURO: Pt awake most of shift, does not follow commands, no spontaneous movements noted- inconsistently tracks with eyes. PERRL, 4-5mm.\\n\\nRESP: s/p Bronch. No vent changes this shift. trach care done. labored breathing improved slightly after HD. SPO2 99-100%, RR 17-24. ABGs acceptable this am, MICU team aware of results and labored breathing.\\n\\nHEMODYNAMICS: S/P HD fluid removal 1.5L, tolerated with support of Albumin and neo gtt at 0.5mcg/kg/min. Tachycardic 120s/130 during HD. Diltiazem gtt initiated after HD complete, good rate control 90-110 on 5.0mg/hr. BP parameters of MAP>50, >80 maintained on neo gtt. Pressor weaned off in am, though resumed for HD tolerance. Anasarca increasing, moderate serous fluid losses from several skin openings.\\nVaginal bleed in small amounts, intermittent in nature. Guiac positive stool via colostomy, small blood clots noted.\\n\\nGI/METABOLIC: Current SBO, abdomen obese and ?ascites- G/J tube clamped, no Gtube residuals. Colostomy with maroon loose stool, severe ammonia-like odor. TPN infusing as ordered. Insulin gtt titrated protocol, BG 98-132.\\n\\nPSYCHOSOCIAL/COMOFORT: Pt visited by husband in am, inquires about HD and urges fluid to be removed. called x 2 today for updates. Son visiting this evening. Pts HR increased during HD and appeared distressed by facial cues, medicated with Ativan. Again appeared uncomfortable after HD complete with incr R and HR, medicated with Demerol IVP with good response in VS and mild sedation. Aggressive skin care, turn and reposition q2hr, oral care frequent.\\n\\nPLAN: Continue to monitor hemodynamic stability, titrate pressor and cardizem for goal > 80 and HR< 110. Monitor for sx resolution of SBO. Keep pt comfortable, Ativan/Demerol prn. Monitor metabolic status, insulin gtt titrated protocol. Pulmonary hygiene/skin care/ emotional support and education to pts family ongoing.\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524353,\n \"text\": \"Respiratory Care\\nPt. trached and vented for chronic respiratory failure. Uneventful shift, no setting changes. Suction for small amount thick yellow secretions.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524354,\n \"text\": \"Please See Carevue for Specifics.\\n\\nNo change over night. Pt was kept comfortable and repositioned. Family was in at start of shift. Neo remains at 0.5mcg/kg/min, insulin gtt off and Lantus started. G-tube residual minimal 0-3cc.\\n\\n: HD, family meeting, skin care, hemodynamic monitoring, amikacin as ordered.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524355,\n \"text\": \"pt remains on full vent support with minimal secretions sx'd. pressure was effective at 23. ABGs normalized during shift with minor changes.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524356,\n \"text\": \"Focused Nursing Note\\nPlease see carevue flowsheet for further details\\n\\nNEURO: Pt somnolent, no acute changes in neuro assessment. PERRL, 4-5mm. Ativan IV x 2 for incr WOB and facial cues of distress, mild sedation therapeutic.\\n\\nRESP: Trach patent, ventilatory support titrated for hypercarbia mild hypoxia. current vent settings CMV 0.40/450/R 20/ PEEP 8\\nLatest ABG in normal range. Frequent suctioning for thick yellow secretions earlier in shift, now decreasing. Incr WOB continues.\\n\\nHEMODYNAMICS: Current fluid balance +900ml, grossly anasarcous. Off pressor support, 80-90, MAP 52-60. HR 90-113 on Diltiazem gtt 5mg/hr. Melena stool/clots from colostomy approx 250ml total, vaginal bleeding minor today. No further signs of bleeding.\\n\\nGI/METABOLIC: G/J tube remain clamped for SBO, abdomen obese, severe anasarca. Gtube residuals 0-5ml. TPN infusing as ordered. Insulin gtt titrated protocol, glucoses stabilizing to low 100s.\\n\\nSKIN INTEGRITY/COMFORT: Multiple areas of pressure ulcers, venous stasis ulcers and edema/pressure related breakdown in skin folds present as previously documented. All wound care completed and pt turned and repsositioned q2hr ATC, heels elevated off bed at all times. Ativan given for mild sedation in light of incr WOB and facial cues of distress.\\n\\nSOCIAL: Pts husband at bedside this am briefly. No further family contact by this RN. Multidisciplinary meeting held today re: current and future goals of care for pt. Present at meeting are Dr , SW, Ethics representative, case management, Nurse , Resource RN , and myself. Considered HCP statement to have her mother die at home versus hopsital environment. Obstacles to d/c home include SBO and GIB. Dr to discuss with HCP family goals of home care of full supportive management vs curtailing therapies and managing end-of-life at home. In addition, SBO and GIB to be monitored over next few days to determine resolution vs worsening, plan on Monday for d/c home potential tuesday.\\nDr to contact per above discussion.\\n\\nPLAN: Monitor hemodynamic status, GIB, SBO, resp status. Anticiapte KUB tomorrow. Titrate Cardizem and for goal HR<110. Keep pt comfortable, aggressive skin care, turn and reposition q2hr, heels elevated. titrate insulin gtt protocol. Pulmonary hygiene. as ordered, f/u Amikacin level. Emotional support to pt and family ongoing. Further plan of care per MICU team.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524357,\n \"text\": \"Respiratory Care Note:\\n\\nPt remain on full ventilatory support via tracheotomy tube. No vent changes done. ABG drawn last evening, acceptable. We are sxtn routinely for mod amt of thick yel secretions from trach, none orally. IC changed early this morning. Plan: Continue present ICU monitoring & keep comfortable.. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524358,\n \"text\": \"NURSING PROGRESS NOTE:\\nNeuro: Pt very withdrawn, not responding to verbal or tactile stimuli. Pupils 4mm brisk. + gag +cough reflex.\\nCV: afebrile, HR 80's Afib with no noted ectopy. 80-90's MAP>50. Cont on dilt gtt for rate control. pulses.\\nRESP: No vent changes. Occasional suctioning of of thick yellow secretions.\\nGI: NPO, Colostomy cont to drain dark red stool.+ guaiac.\\nGU: Aneuric.\\nENDO: Cont on insulin gtt.\\nPLAN: Cont to monitor neuro status. Monitor blood sugars.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524447,\n \"text\": \"Respiratory Care\\nPt remains trached and on vent support. No vent changes were made during shift. No ABG's were drawn during shift. Lung sounds were course and diminished in the bases with a period of faint exp wheezes that cleared after MDI. Pt received MDI's. Pt was suctioned for scant to small amounts of thick yellow secretions. Care plan is to continue therapy on our vent until Sunday night and then place pt on home care vent. Will continue to follow pt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-07-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524099,\n \"text\": \"Focus Condition Update\\nSee careview flowsheet for specific info.\\n\\nNeuro: Pt mildly responsive. Opens eyes spontaneously, follows commands rather inconsistently, no communication noted from pt. Not moving extremities, except for LUE.\\nCV: A-fib with occassional PVC. Hypotensive, SBP 85-110, HR 95-120. 12.5 lopressor given with effect. Afebrile. Crit stable, white count decreasing, K+ 3.8.\\nResp: No vent changes overnight, sating 100% on CMV, PEEP 5, 40% O2. LCTA bilaterally, sux'd for small amount of thick white sputum.\\nGI: Colostomy patent, draining small amount of loose brown stool. Abdomen soft, BS+.\\nEndo: Insulin gtt off for low BG, will recheck in 1 hour. Titrating insulin for BG of 100-120, using protocol.\\nInteg: Multiple ulcerations on body. Wet to dry dressings changed over right ischial spine, and left heel per wound care nurse.\\nSocial: Dtr and son in to visit. Dtr found suctioning pt. Politely asked her not to do this in the future, but to ask RN or RRT if her mom needs this in the future. Dtr states she understands.\\nPlan: To MRI tomorrow.\\n Continue with wound care, and skin care mgt.\\n Titrate Insulin to keep BG 100-120.\\n Continue with current POC.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-07-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524100,\n \"text\": \"Respiratory Care: Pt remains trach and vented on AC settings. No vent changes made this shift. Pt's breath sounds coarse/diminished. Suctioned for small thick yellow/brown secretions. MDIs given as ordered.will continue to follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524419,\n \"text\": \"RESP CARE: Pt remains trached/on vent on AC SEE CAREVUE. No changes in settings. Lungs coarse/sxd thick yellow/MDIs given as ordered. Trach care done/inner cannula changed, pressure 25cmH20. No RSBI due to hemodynamic instability. Pt is vent dependent at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524420,\n \"text\": \"FOCUSED NURSING NOTE\\nPlease see carevue flowsheet for further details\\n\\nNEURO: Alert to lethargic, able to arouse to voice. Spontaneous movement weakly LUE only- only command she follows is to open her mouth, will not blink or nod head on command. Nodding head mainly \\\"yes\\\" inconsistently to questions- spontaneously nod head \\\"yes\\\" at times as well without questioning. Tracking with eyes. Ativan x 1, Demerol premedication before dressing change with fair effect.\\n\\nRESP: s/p CXR, results pending. Trach patent, vent settings unchanged. SPO2 99-100%. Frequent suctioning for thick/yellow secretions, no spontaneous cough. Positional air leak continues. Amikacin and Meropenem for gram negative rods sputum.\\n\\nHEMODYNAMICS: s/p 1UPRBCs this am, post Hct 29.8. No sx active bleeding today. Multiple areas of skin tears and ulcers bleed, frequent . HR 80-90s, NSR, rare PVCs. Erractic swings in BP today, range 71-163/30-114- variable minute to minute this afternoon, no change in neuro status. General anasarca and severe weeping of all dependent skin areas.\\n\\nID: Maintains temp 96-97 without bair hugger today. Meropenem administered as ordered. Amikacin orders clarified to be given on hemodialysis days only, level to be checked as trough with next dose.\\n\\nGI/METABOLIC: NPO. TF advanced to 40ml/hr, tolerating well thus far. Colostomy output green/brown liquid stool, no sx GIB today. Receiving Lantus 5U qAM, glucoses 168/164 covered with RISS.\\n\\nSKIN INTEGRITY: Severely impaired epidermis to buttocks, thighs, skin folds, BLE and feet as previously documented. No acute changes in wounds- all dressing chages done twice today secondary to moderate drainage and weeping of surrounding skin. Aggressive skin care ongoing, heels elevated off bed at all times.\\n\\nPSYCHOSOCIAL: Family members visit in groups due to discord between HCP and the rest of her siblings- Sons and both claim that pt has expressed to family in past that she did not want to live in her critical condition, she has asked family to keep her home and stop hemodialysis. Sons communicate to me that as HCP is the only child insisting on aggressive care and will not consider a family decision collectively. Sons remain hopeful that pt may be discharged to home this week, however ths unfortunate situation has created much strife between the siblings and communication has broken down.\\n\\nPLAN OF CARE: Continue to monitor for sx bleeding, f/u HCt tonight. F/U CXR results. Monitor GI status, maintain TF at goal. Monitor glucoses, discuss with MICU increasing glycemic control. Aggressive skin care, comfort care, emotional suuport to pt and family. Discuss with MICU team d/c plan for Monday.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524421,\n \"text\": \"RESP CARE: Pt remains trached/on vent. pressure 25cmH20.No changes in vent settings this shift.SEE CAREVUE FOR SPECIFICS. Lungs coarse bilat. MDIs given as ordered. Sxd small amts thick yellow sputum. Trach care done. Inner cannula changed/trach tie changed. No RSBI this am due to hemodynamic instability, Pt remains vent dependent at this time. Plan is to place pt on home vent 48hrs prior to discharge home.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524359,\n \"text\": \"Resp Care\\nPt remains trached on A/C. Suctioned for mod amt of thick tan sputum. MDI's given, no other changes noted.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524360,\n \"text\": \"Update\\nSee Carevue for specifics\\n\\nNeuro: unable to assess pt's mental status though appears alert, opens eyes spontaneously and was observed to respond to family member by tracking, ?opening mouth to command. Does not move any extremities. PERRL. Afebrile.\\nCV: controlled afib. Diltiazem gtt. rate in 90s-110s. BP > MAP 55 most of shift. Dropped to 50 late in day and neo gtt started with positive effect. HD, 2.4L off, prbc x 1 given.\\nResp: LS coarse/diminished. Sat 94-98% on AC. No vent changes. Sxn'd for thick yellow sputum.\\nGI: TPN. Gastrograf study performed at bedside. Contrast given through G tube and J tube. Post procedure pt put out 2L maroon/bilious liquid through G tube. Team notified and hct drawn. G tube continues to ooze sanginous liquid.\\nGU: anuric\\nSkin: Grossly impaired with numerous site of breakdown. See Carevue and chart for details.\\nSocial: family in to visit and talked with MD.\\n\\nPlan: Monitor Gtube output closely and assess for bleeding. Monitor respiratory status and sxn as needed. Keep family UTD on .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524361,\n \"text\": \"Respiratory Care Note:\\n\\nPt remain on ventilatory support via trach tube. We increased FIO2 from 40 to 50%. We are sxtn for small amt of thick yel secretions from trach. IC changed early this morning. Plan: Continue present ICu monitoring, follow VS, WOB & Sats. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524362,\n \"text\": \"FOCUSED NURSING ASSESSMENT\\nPlease see carevue flowsheet for further details\\n\\nNEURO: No acute changes- moves LUE only- does not follow commands- questionable tracking with eyes- PERRL 4-5mm. Ativan x 2 IV for tachypnea and tachycardia with minimal effect- demerol therapeutic for incr RR/HR.\\n\\nHEMODYNAMICS: tachycardic 115-120 just prior to emesis and increased G-tube site leakage, now NSR 90s after transfusion and dilt gtt incr to 7.5mg/hr. 84-90s on Neo gtt 0.4mcg/kg/min- falls to 75 without Neo. Noted bloody emesis x 1 and continued dark red/bilious drainage from Gtube exit site (500ml/shift). MD notified. Hct 22.9, plt 89. Transfused pt with 1UPRBC and 1U Md orders- Post-transfusion HCT 26.1, am 25.4. Desmopressin given as well. Gross anasarca.\\n\\nRESP: Trach patent, ventilated A/C 450/0.50/20/PEEP 8. tachypneic (28-32) during blood transfusion with airway pressure 33, suctioned for minimal tan secretions. tachypnea improved with Ativan/Demerol sedation, RR now 24, pressure 25. Lungs clear R lobe, greatly diminished L lobe.\\n\\nGI: Emesis dark red mixed with bright red fluid approx 100ml. Dark red/bilious outputs continue from around G/J tube site collected in gravity drainage bag. G-port irrigated with 60ml NS, aspirated 15ml return. J-port irrigated with 60ml NS and aspirated equal return plus 30ml additional, also dark red/bilious outputs. Gtube connected to LCWS with small outputs (200ml over 8 hrs) Larger output is around Gtube exit site. MICU intern and GI Surgery aware of events. Colostomy very small output maroon liquid mixed with soft maroon stool- no new outputs during shift.\\n\\nID: Tmax 99.9. BC sent with am labs as ordered. Vancomycin as ordered.\\n\\nMETABOLIC: TPN infusing at 77ml/hr. Blood glucoses stable <150 on insulin gtt protocol.\\n\\nCOMFORT: Pt turned and repositioned q2hr, heels elevated off bed at all times. Demerol x 2 for tachypnea and premedication for dressing changes with good effect.\\n\\nPLAN: Continue to monitor GI outputs and follow hemodynamics closely. Pulmonary hygiene, pain control, aggressive skin care. Monitor temperature, new sx infection. Further plan of care per MICU team, ?GI studies today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524435,\n \"text\": \"Nursing Note 7a-7p:\\nNursing Assessment:\\n\\nAfebrile this shift. Shakes head yes and no. Often shakes head no during care (dressing changes, repositioning, suctioning). Unable to determine appropriateness of yes and no nods to situations.\\nCV: NSR to ST 90s-110; 70s-120s. HD today 2.7 off. This afternoon Bright red blood from ostomy stoma. HCT 23.6 (following 1.5 liters out) previously 30.1 on am labs. 2 units prbc's given with resulting Hct 28.3 and bleeding stopped. (total over 3 liters of blood mixed with golytely and stool out). HCT and platelets to be rechecked tonight (last plt count 50s and MD , aware).\\nTube feeds on hold d/t NPO for scope and golytely given as prep. Scope now on hold possibly until tommorrow unless bleeding restarts.\\nPositive blood cultures gram +cocci in pairs and chains from yesterday and MD , notified. Amikacin level back from before dialysis 11, dose given post-dialysis and level will be rechecked in the am.\\nA meeting took place this afternoon regarding hospital policies in relation to the family's wishes. Ethics, social work, casemanagment, resource RN, and Micu attending all present; working towards discharge planning and keeping the patient's best interests in mind. Please refer to carevue for all further details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524436,\n \"text\": \"Resp. Care Note\\nPt remains trached with #7 extra long shiley and vented on AC settings as charted on resp. flowsheet. No vent changes were made this shift. BS slight decreased and coarse. Receiving Albuterol/ Atrovent and Flovent MDI's, see flowsheet for Rx times. Sxn for yellow sputum. current vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-07-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524094,\n \"text\": \"Focus Condition Update\\nSee flowsheet for specific information.\\n\\nNeuro: Pt opens eyes and tracks osccassionally, but not following any commands. Movement of extremities noted in all but RUE. No pain noted except when dressing changes done. PO ativan given with good effect.\\nCV: Pt afebrile, hypotensive at times, particularly during HD. Remains in A-fib with occassional PVC's. SBP stable 95-115, HR tachy 95-110. K+ and Magnesium repleted, Vit K given for INR of 6.1.\\nResp: CMV, PEEP 5, 40% O2. Lungs mildly coarse bilaterally, dim in bases. Sux'd for small to mod amount of thick white sputum.\\nGI: TF's started, full strength at 40cc/hr, with no residuals. Abdomen obese, BS hypoactive. G tube site is leaky, but bag is in place to catch drainage. Colostomy patent, draining moderate amount of green liquid stool.\\nGU: No UO noted.\\nSkin: Multiple necrotic skin ulcers, most notably, a decub on coccyx that is 7cm x 7cm and to the bone. Dressings changed on coccyx, and right hip, wet to dry. Skin care RN to see pt in a.m. See flowsheet for specifics on other wound sites.\\nPlan: Monitor and replete lytes\\n Continue with dressing changes as needed\\n Monitor for changes in neuro status\\n Continue to monitor hemodynamic status\\n MICU Intern aware of above, contact HO with\\n changes\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-07-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524095,\n \"text\": \"Respiratory Care\\nPt. remains trached and ventilated. PT chronically vented at home on A/C settings. This a.m. pt did well with RSBI trial = 46, and appears to tol PS/CPAP well, pt. may be able to tol wean of vent settings to PSV when medical status more stable. Suctioned for thick yellow/tan secretions.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-07-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524096,\n \"text\": \"NPN (SEE CAREVUE FOR SPECIFICS)\\n PT ALERT, OCCASIONALLY FOLLOWING COMMANDS. MOVING ALL EXT. EXCEPT FOR RIGHT ARM. PERRL. C/O PAIN WITH DRESSING CHANGE, RESIDENT WILL ORDER PAIN MED FOR DRESSING CHANGES. ATIVAN AROUND THE CLOCK APPEARS TO BE HELPFUL FOR PERCEIVED ANXIETY.\\nCV- BP STABLE TODAY, 90'S-LOW 100'S. HR A-FIB, TACHY TO 140'S THIS AM, LOPRESSOR 12.5MG RESTARTED THIS AM WITH GOOD EFFECT. 6 BEAT RUN OF V-TACH THIS AFTERNOON, LYTES AND HCT SENT AND WNL, EKG DONE, RESIDENT NOTIFIED.\\nRESP- LUNGS COARSE AT TIMES, SUCTIONED A FEW TIMES FOR SMALL AMOUNTS OF THICK YELLOW SPUTUM. O2 100%, NO VENT CHANGES, REMAINS ON AC.\\nGI/GU- ABD SOFT, HYPO BS. COLOSTOMY APPLIANCE CHANGED, STOMA BEEFY RED AND APPEARS HEALTHY. CONTINUES TO HAVE LARGE AMOUNT OF LOOSE BROWNISH STOOL. PT DOES NOT VOID, NO DIALYSIS AT THIS TIME FOR TODAY.\\nID- TMAX 100.8\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-07-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524097,\n \"text\": \"Respiratory Care: Pt remains trach and vented on AC settings. Pt's breath sounds coarse at times that clear with suctioning. Sx for small thick yellow secretions. MDIs given as ordered. Respiratory dicussed with team concern about high cuff pressures, they will evaluate to see if pt needs a larger trach or a new one.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-07-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524098,\n \"text\": \"Respiratory Care\\nPt. trached on ventilatory support. No vent changes made this shift. Good RSBI = 63. Sx for small amounts thick yellow secretions. Vent dependent not plams to wean from vent at this time,\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-07-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524101,\n \"text\": \"NPN (SEE CAREVUE FOR SPECIFICS)\\n PT ALERT, OCCASIONALLY FOLLOWING COMMANDS. MOVING ALL EXT. ONLY SLIGHTLY ON THE BED, WITH THE EXCEPTION OF THE RIGHT ARM. PERRL. PT COMFORTABLE MOST OF THE SHIFT, OCCASIONAL DISCOMFORT WITH DRESSING CHANGES, RELIEVED WITH REPOSITIONING.\\nCV- BP IN 90-110'S RANGE, NO FLUID BOLUSES NEEDED. DIALYSED THIS AM, UNABLE TO REMOVE MORE THAN 300CC DUE TO HYPOTENSION. A FEW DOSES OF ALBUMIN GIVEN DURING DIALYSIS FOR HYPOTENSION WITH FAIR EFFECT. HR AT TIMES TO 140'S, TEAM NOTIFIED DURING DIALYSIS WHEN PT WAS AND HAVING INCREASED ECTOPY. NO INTERVENTION PER TEAM, SCHEDULED DOSE OF LOPRESSOR EFFECTIVE AND CALCIUM REPLETED REDUCING AMOUNT OF ECTOPY. HEPARIN GTT STARTED THIS AM FOLLOWING . FIRST PTT 150+ DRAWN 5 HOURS AFTER START OF GTT. TEAM NOTIFIED. ORIGINALLY ORDERED TO STOP HEPARIN FOR ONE HOUR THEN RESTART AT HALF THE DOSE, HOWEVER REPEAT PTT REMAINING THE SAME AFTER AN HOUR WITH OBVIOUS SIGNS OF BLEEDING. HEPARIN TO REMAIN OFF AT THIS TIME PER DR. UNTIL FURTHER NOTICE. HCT PENDING.\\nRESP- LUNGS CLEAR, SUCTIONED FOR SMALL AMOUNTS OF THICK YELLOW SPUTUM. O2 SAT 100%, NO VENT CHANGES.\\nGI/GU- ABD SOFT, HYPO SOUNDS. BRB IN COLOSTOMY THIS AFTERNOON, DR. NOTIFIED AND HCT SENT. FLEETS PHOSPHO SODA HELD TODAY DUE TO LARGE AMOUNTS OF LOOSE STOOL. NO VOID, DIALYSIS DEPENDANT\\nID- AFEBRILE. MEROPENUM GIVEN X 1 DOSE AFTER DIALYSIS\\nSKIN- VASCULAR IN TO RIGHT TOES AND LOWER EXT. DECUBS. RIGHT GREAT TOES DEBRIDED AND AND POCKET OF INFECTION RELEASED DRAINING PURULENT DRAINAGE. WET TO DRY .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524181,\n \"text\": \"NEURO; OPENS EYES SPONT, DOES NOT FOLLOW COMMANDS, STARES AT SPEAKER BUT ? PT TRACKING SPEAKER, DOES NOT MOVE SPONTANEOUSLY\\n\\nCARDIOVASCULAR; HR 120'S-140'S A FIB, TEMP UP TO 103, PT MEDIC X 3 WITH TYLENOL, MICU TEAM INFORMED, BLOOD CULTURES PERIPHERALLY AND ONE SET FROM DIALYSIS LINE OBTAINED, COOLING BLANKET ON, TEMP PRESENTLY 102.2, SEVERAL PERIODS OF HYPOTENSION TODAY WHCH REQUIRED FLUID BOLUSES, PT RESPONDED TO FLUID BOLUSES BUT STILL FLUCTUATES, MICU TEAM OKAY WITH MAP OF 50 OR >,\\n\\nRESPIR; SUCTIONED FREQUENTLY FOR THICK YELLOW SECRETIONS, SPUTUM CULTURE SHOWS PSEUDOMONAS, STARTED ON ZOSYN, COARSE BREATH SOUNDS, REMAINS ON SAME VENT SETTINGS,\\n\\nENDONCRINE; BS 200'S, COVERED VIA SLIDING SCALE, PLAN WAS TO START INSULIN GTT BUT PT BS NOW 130'S, WILL GO BACK TO INSULIN COVERAGE VIA SLIDING SCALE AND GTT IS DC'D (TUBE FEEDING OFF FOR 2 HRS FOR ? REPLACEMENT OF J TUBE, BUT PLAN DEFERRED DUE TO PT BEING UNSTABLE\\n\\nWOUND; LARGE OPEN AREAS ON SACRUM, MUCOPURULENT MATERIAL INSIDE LARGER WOUND, MICU MD IN TO EVALUATE, REPACKED WITH AQUACELL ROPE, DSGS TO LEGS-NECROTIC AREA LEFT HEEL ADAPTIC AND DSD,\\n\\nRENAL; DIALYSIS ATTEMPTED BUT NO FLUID TAKEN OFF DUE TO HYPOTENSION, DIALYSIS STOPPED AFER APPROX 30 MINUTES, MICU TEAM AWARE\\n\\nPLAN; MAINTAIN MAP > 50 OR >, WOUND CARE, COOLING BLANKET UNTIL TEMP STABLIZES, CHECK BS Q 4 HRS, FAMILY UPDATED SEVERAL X WITH TEAM TODAY\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524182,\n \"text\": \"Respiratory Care\\nPt continues full vent support and appears comfortable. #8 adjustable trach remains locked at 10 cm. BS coarse and diminished bilaterally. Suctioning for moderate amounts of thick yellow sputum. Fever seems to have resolved with current temp 98.8F. MDIs given as ordered. See Careview for a.m. RSBI and specifics.\\nPlan: Maintain support, suction prn\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524437,\n \"text\": \"Update\\nSee Carevue for specifics\\n\\nNeuro: Alert but unable to assess level of orientation. Nods appropriately to questions. Attempts to mouth words. Does not move any extremeties. PERRL. Was awake all night.\\nCV: ST or ?SA most of shift 90s to 140s. MD aware. No tx at this time. 70s-110s. Pressors remain off. Last 3 hcts 28. Coratid US ordered.\\nResp: LS coarse. Sats 98-100%. No vent changes. Sxn'd for tenacious tan sputum.\\nID: Afebrile. Gram+ rods in blood. Vancomycin dose x 1 given.\\nGI: TF off pending possible scope today. GI bleed study also scheduled for day shift a.m. Colostomy draining clear, golden liquid.\\nSkin: Grossly impaired. See flowchart for details.\\nPsychosocial: Son at in evening. Daughter called and was updated on by this RN.\\n\\nPlan: Monitor for further hemorrhaging. Keep family UTD on .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524438,\n \"text\": \"Respiratory Care:\\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. No morning abg results at this time and no measured due to hemodynamic instability. SX'd for small to moderate amounts of thick, tan sputum.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524439,\n \"text\": \"FOCUSED NURSING NOTE\\nPlease see carevue flowsheet for further details\\n\\nNEURO: PERRL, 4-5mm. Dozing intermittently. Will nod head \\\"yes\\\" to questions at times, useful for pain assessments. Obvious response to painful stimulus during skin care and dressings changes, general flitches in response to pain and non-sedated state noted during these procedures despite Demerol premedication.\\n\\nRESP: Trach, CMV ventilation. No changes made in therapy. SPO2 96-100%. Lungs coarse, diminished, exp wheeze LUL- suctioned frequently for thick/yellow sputum. Meropenem/Amikacin current therapy.\\n\\nHEMODYNAMICS: Labile changes in reported to MD- measures 40-50s for a few minutes without change in HR or LOC, will increase to 90-120s without intervention, confirmed by manual doppler method. HR controlled 90-102, rare PVCs. No sx acute GIB- HCT stable at 26.8, next level to be drawn at 8pm. Active bleeding from pressure ulcers coccyx and right ischial, slow vaginal bleed. DIC panel pending.\\nDoppler pulses absent left PT and right DP, MD aware. Gross anasarca present, large amount weeping of multiple skin tears, blisters.\\n\\nID: Normothermic. Plan to d/c right CVL to culture tip. RUE PICC and left dialysis remain in place- Left dialysis catheter with erythema.\\n\\nGI/METABOLIC: NPO maintained, Jtube clamped. to gravity drainge with viscous light brown/tan drainage. Colostomy with total 50ml maroon/brown liquid. No GI studies completed thus far today. Glucoses stable on Glargine QD (140/133).\\n\\nCOMFORT/PSYCHOSOCIAL: Premedicated with Demerol for complete turns and skin care, pt remains awake after Demerol and flinches in pain. Per family, Demerol was administered frequently as premedication in dose of 50mg as well as Ativan 2-3x day. Family (Daughter , granddaughter) at visiting, asking general questions re: status of skin wounds and BP measurements. Family providing comfort care to pt, emotional support and education provided.\\n\\nPLAN; D/C right CVL, culture tip. Monitor for sx GIB, hemodynamic changes. HCT q8hr as ordered, next due at . as ordered, collect Vanco level. Aggressive skin care, comfort care. Consult with MICU team re: increase pain control. All contact from HCP to be forwarded to Dr only as physician team leader and director of ultimate plan of care. Emotional support and education to pt and family ongoing.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524440,\n \"text\": \"Respiratory Care: Pt remains on current vent settings, no changes made this shift.Receiving MDI's. Suctioning mod amt secretions.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524441,\n \"text\": \"Nursing Assessment 7p-7a:\\nNursing Note :\\n\\nTmax 99.0 oral. Family meeting prior to shift and family in room afterwards upset regarding discussions in meeting. When family arrived back in room pt went into Afibb 130-150 and 50-60. MICU resident notified and 500cc ns given/ labs sent for HCT, vanco. BP came back up but remained in afibb and given ativan ivp. Pt converted back to nsr-st after most of family left for the night. Pt's dtr and son remained in room. requesting VBG again while hr elevated and it was drawn per micu team; resulting values ok per respiratory. Frequently asking for pt to be suctioned, concerned that pt not suctioned enough and was assurred that pt was just suctioned prior to her entering the room. Sats are 98-100%, good tidal volumes, and pt appears comfortable on vent. Suctioned occasionally for thick yellow sputum, which is not new. Wound care done per recommendations. PT's dtr also concerned about drg from around G/J Tube site which is pink tinged at times. Family was feeding ice chips with red beverage to patient and believe that the drg is from that and that the tube is the source of all her bleeding from the ostomy. These issues have been discussed with pt's dtr already in meetings and discussions with the micu mds. All discussions regarding pt to be done through the MICU attending only and dtr instructed to speak with them regarding any futher questions or concerns. Early this morning, pt in afibb again and given ativan with no effect. Pt wideeyed, shakey left hand, and nodded yes to pain. Given demerol with good effect, HR sinus 106. Lytes ok on am labs. Glucose wnl. Plan: continue towards discharge planning for home. Family's wishes are to get pt home and are unhappy with care here. Hospice care to be readdressed? Family is aware and still willing to take pt home despite her acute medical issues and risks for rebleeding, ventilator dependency, hypotension, afibb and tachycardia, and periods of hyperglycemia. Case management and social work are continuing to arrange for the home care of this patient. Pts dtr will take pt home but has requests; case management is working towards these as able and GI/Vascular have met with family to discuss risks and why some may not be met at this time d/t not in pt's best interest (changing G/J tube, toe amps). Please refer to GI and vascular notes in chart. Also please refer to carevue for all futher details in nursing assessments.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-07-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524091,\n \"text\": \"condition update\\nd: pt arrived from er with ? of sepsis. hr afib in the 100-115. sbp 90-120/60. blood cultures sent from pic line. pt. given 1 liter ns fluid given after fluid sbp up to 120 and pt more awake. opening eyes spontaneously and looking around the room. spontaneously lifting left arm off the bed.\\nresp: pt trached. on a/c 40% with rate of 16 pt is overbreathing the vent.\\ngi: gt clamped.\\ngu: pt on hd left subclavian quinton patent. pt due to have hd today.\\nskin: see assessment for skin . coccyx wound is open with blackend center. per son it was improving but recently has started to look worse. pt was on kinair bed at home. bilateral calfs are open and through fascia. wound is pink. right hip is open and reddened base through the fascia. left hip is open tthrough the dermis. aqualcel dressing applied. left heal with black center and ns packing applied.\\nrigth toes are dry and necrotic.\\na: skin rn to come see pt today. ? kinair bed. check blood culture results. hd today. head ct today.\\nr: pt more awake this am. sbp greater than 100.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-07-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524092,\n \"text\": \"Resp Care\\nPt remains intubated on AC, no vent changes, stable shift. Pt went for ct without incident. Plan to continue with current tx, sx for mod yellow thick.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-07-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524093,\n \"text\": \"NPN (SEE CAREVUE FOR SPECIFICS)\\n PT LETHARGIC THIS AM, NOT FOLLOWING COMMANDS. IMPROVED THROUGHOUT THE DAY, BECOMING MORE ALERT AND OCCASIOANLLY FOLLOWING COMMANDS. ATIVAN HELD THROUGHOUT THE DAY DUE TO LETHARGY AND HYPOTENSION. SPONTANEOUS MOVEMENT NOTED IN ALL EXT. EXCEPT FOR THE RIGHT UPPER. HEAD CT DONE THIS AM, RESULTS UNKNOWN. PERRL. NODDING HEAD APPROPRIATELY IN RESPONSE TO SIMPLE QUESTIONS. C/O PAIN IN COCCYX AREA, FREQUENTLY REPOSITIONED, NOW ON KINAIR BED.\\nCV- HYPOTENSIVE THIS AFTERNOON IN LOW 80'S. DIALYSIS ON HOLD FOR NOW. NS BOLUSES GIVEN WITH GOOD EFFECT, PRBCS TO BE GIVEN, AWAITING CONSENT. REMAINS IN A-FIB, HR 110-120'S THIS AM, RESPONDED WELL TO LOPRESSOR 12.5MG HOWEVER, BP NOT TOLERATE FURTHER DOSES.\\nRESP- LUNGS CLEAR, COARSE AT TIMES. SUCTIONED EVERY FEW HOURS FOR THICK YELLOW SPUTUM. 02 SAT 100% ON AC, NO VENT CHANGES MADE THROUGHOUT THE DAY.\\nGI/GU- ABD SOFT, DISTENDED. COLOSTOMY DRAINAGE GREENISH BROWN, LOOSE STOOL. PT RECEIVING LACTULOSE AND FLEETS PHOSPHOSODA, SPOKE TO INTERN REGARDING OUTPUT OF ABOUT 800CC, WILL CONTINUE FOR NOW. HYPOACTIVE BS, REMAINS NPO. PT DOES NOT VOID, WILL BE DIALYSED TONIGHT IF BP INCREASES.\\n PT HAS SEVERAL LARGE DECUBS, ALL DRESSINGS CHANGED. SPOKE WITH WOUND CARE RN, HOWEVER SHE COULD NOT SEE PT TODAY, WILL FOLLOW UP TOMORROW. COCCYX DECUB IS TO BONE, 7CM X 7CM, PELVIC CT DONE THIS AM, RESULTS PENDING. PLACED ON KINAIR BED.\\nID- AFEBRILE\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524173,\n \"text\": \"RESPIRATORY CARE NOTE\\n\\nPatient remains trached with 8.0 air cuff adjustable length locked at 10mm. No vent changes made during the . RSBI completed on PS 5=96. Sxn for small thick yellow secretions.\\n\\n , RRT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524174,\n \"text\": \"Respiratory Therapy\\n\\nPt remains trached w/ TTS on full mechanical support. No vent changes made this shift. Currently on A/C ventilation w/ PIP/Pplat = 23/20. SpO2 90s-100%. BS slightly coarse bilaterally, suctioned for small amounts of thick whitish sputum. Cuff pressure = 25cmH2O. MDIs given as ordered. See resp flowsheet for specifics.\\n\\nPlan: maintain support\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524175,\n \"text\": \"SICU NURSING PROGRESS NOTE 0700-1900\\nNEURO--ASLEEP MOST OF SHIFT. AT TIMES WILL NOD HEAD TO SIMPLE QUESTIONS REGARDING COMFORT, PAIN,HOT/COLD. DOES NOT FOLLOW COMMANDS. NO SPONTANEOUS MOVEMENT OBSERVED. EYES OPEN SPONT. NO ATIVAN GIVEN TODAY AS PT IS .\\n\\nRESP--NO VENT CHANGES DONE. SAO2 >96%. SX Q2HRS FOR SMALL AMTS OF YELLOW/WHITE SPUTUM . LUNGS COARSE IN ALL FIELDS. PLAN IS FOR IP TO BRONCH PT TO SEE WHERE END OF TRACH TUBE IS PLACED. THEN TO REPLACE OLD TRACH WITH NEW PORTEX TRACH WHERE PT CAN BE VENTED AND SPEAK. IP WAS BY BUT PROCEDURE NOT DONE AS OF THIS TIME.\\n\\nGI--TOL TUBE FEEDS AT F/S. OSTOMY DRAINING GOLDEN LOOSE STOOL.\\n\\nGU--ANURIC. NO HD TODAY. NO STR. CATH.\\n\\nCARDIAC--MAP>55. HR A FIB WITH NO OBSERVED VEA. MIDODRINE GIVEN AS ORDERED. PICC DRESSING/CAP CHANGED.\\n\\nPAIN--GRIMACES AND NODDING HEAD WHEN SACRAL DECUB DRESSING CHANGED. MEDICATED WITH 1MG IV DILAUDID WITH GOOD RELIEF. NODDED HEAD YES WHEN ASKED IF IN PAIN AT 1630. WHEN ASKED IF FEET HURT SHE RESPONDED YES. .5 DILAUDID GIVEN AGAIN.\\n\\nID--FEBRILE TO 101.5. 650 MG PO TYLENOL GIVEN WITH DECREASE IN TEMP TO 99.6. REMAINS ON LEVO.\\n\\nSKIN--ALL WOUNDS DRESSED BY WOUND/SKIN CARE RN. NO FOUL ODOR FROM ANY WOUND. SACRAL WOUND IS THE SIZE OF A SOFTBALL AND ~1.5INCHES DEEP. WOUND CARE/DRESSING CHANGE INSTRUCTIONS ARE IN CHART AND ON PT'S WALL IN ROOM. R ISCHEIAL TUBEROSITY IS DRAINING SMALL AMTS OF SERO-SANGINOUS DRAINAGE. SMALL AMT OF ESCHAR ON WOUND. R CALF WOUND IS CLEAN WITH GOOD GRANULATION TISSUE FORMING. L TOES 4 ARE NECROTIC WITH OPEN SORE ON JOINT CAPSULE OF GREAT TOE. R FINGERS ARE EDEMATOUS AND SMALL BLISTERS ARE FORMING ON 4 FINGERS. RUE IS >L. ORAL MEMBRANE DRY. ORAL CARE GIVEN. BACK IS CLEAN DRY AND INTACT.\\n\\nCOPING--DAUGHTER , , AND HUSBAND IN TO VISIT. ASKING REPETATIVE QUESTIONS REGARDING PLAN FOR TRACH. QUESTIONS HAVE BEEN ANSWERED. THE FAMILY IS REQUESTING THAT ID BE CONSULTED, PT'S TRACH IS CHANGED, WHERE FEVER IS COMING FROM. HCP, HAS PHONED AND HAS BEEN UPDATED.\\n\\nA--FEBRILE. REMAINS IN A-FIB. TOL. TUBE FEEDS. PLAN FOR BRONCH. PAIN WITH DRESSING CHANGES.\\n\\nP--GIVEN TYLENOL AS NEEDED. PLAN FOR BRONCH AND ? TRACH TUBE REPLACEMENT. IR TO COME BY AND ASSESS PEG SITE. OFFER SUPPORT TO PT AND FAMILY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524176,\n \"text\": \"SICU NURSING PROGRESS NOTE 0700-1900\\nBLOOD CX X2 OBTAINED, 1 FROM DIALYSIS CATH AND 1 PERIPHERALLENDO--BLOOD SUGARS REMAIN >290. PLS CHECK BS Q4HRS AND PROVIDE HUMALOG IF NEEDED. NO LABS DRAWN TODAY.Y. NO URINE OBTAINED AS PT IS ANURIC AND HAS NO CATHETER.\\n\\nHCP PHONED AND WAS VERY UPSET ABOUT PT GETTING DILAUDID FOR PAIN. SHE IS INSISTENT ABOUT HER MOTHER \\\"ONLY GETTING DEMEROL, NOTHING ELSE FOR PAIN.\\\"\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524177,\n \"text\": \"SICU NURSING PROGRESS NOTE 0700-1900\\nBLOOD CX X2 OBTAINED, 1 FROM DIALYSIS CATH AND 1 PERIPHERALLENDO--BLOOD SUGARS REMAIN >290. PLS CHECK BS Q4HRS AND PROVIDE HUMALOG IF NEEDED. NO LABS DRAWN TODAY.Y. NO URINE OBTAINED AS PT IS ANURIC AND HAS NO CATHETER.\\n\\nHCP PHONED AND WAS VERY UPSET ABOUT PT GETTING DILAUDID FOR PAIN. SHE IS INSISTENT ABOUT HER MOTHER \\\"ONLY GETTING DEMEROL, NOTHING ELSE FOR PAIN.\\\"\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524178,\n \"text\": \"NURSING\\n VSS, TMAX 99 OVERNIGHT. CONTINUES IN A-FIB, ON COUMADIN. TUBE FEEDS CONTINUE AT 40/HR. ANURIC. ALL DRESSINGS CHANGED BY SKINCARE NURSES TODAY. ONLY VENT CHANGE WAS TO DECREASE FIO2 FROM 50 TO 40. SEE VUE FOR FULL ASSESSMENT.\\n TODAY ID CONSULT, BRONCH BY INTERVENTIOAL PULMONOLOGY, IR TO COME BY TO ASSESS PEJ TUBE TOMORROW. CULTURE SACRAL DECUB WITH NEXT DRESSING CHANGE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524179,\n \"text\": \"Respiratory Care\\nPt remains intubated on full vent support. #8 trach with adjustable flange is set at 10cm. No vent changes made this shift. BS coarse bilaterally and diminished at bases. Sxn'd for small amount of thick yellow secretions. MDIs given as ordered. See Careview for a.m. RSBI results.\\nPlan: Maintain ventilator suppport\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524180,\n \"text\": \"Respiratory Therapy\\n\\nPt remains trached w/ #8.0 TTS adjustable trach set @ 10cm. Became more dis-coordinate w/ the ventilator this shift w/ RR ^high 30s, PIPs ^40s, tachycardic w/ HR 140s, hypotensive requiring fluid . Also had a noticeable increase in secretions...suctioning copious amounts of thick yellowish green sputum. SpO2 90s-100% and ABG acceptable. MICU team aware, sputum spec sent for culture. Pt febrile to 102.7. No vent changes made this shift. ABG drawn from R radial artery w/ no complications. See resp flowsheet for specifics.\\n\\nPlan: maintain support; aggressive pulmonary toilet...\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524267,\n \"text\": \"See data, MD notes/orders. Neuro: Opening eyes spontaneously and intermitently nodding head to questions at begining of shift, more lethargic and less reponsive in pm. CV: Afib with occ pvc's, rapid bursts to 130 during dialysis that are self limiting. Continues on phenylephrine gtt to maintain blood pressure, currently 94/45 with gtt rate at 1.2mcg/kg/min. Hypotensive to 69/30's during HD - see notes. Pulm: Trached, dependent on ventilator support, minimal secretions suctioned, lungs clear, decreased at bases. GU: Anuric, HD for 1.5hrs with 1Liter fluid removal. GI: Abd obese, bs present, colostomy patent with output per flow sheet. Gtube to gravity with return of 100cc fluid. TF at goal rate 40cc/hr. Endo: by NP from clinic with ssc adjusted and HS insulin dc'd. Skin: Afebrile see wound care nurses notes for description of decubitus ulcers present at coccyx, bilateral trochanters and right ishcium as well as left heel and bilateral calfs. Mutiple areas of echcymosis, excoration and skin tears along thighs, under on right upper chest. General 3+ pitting edema noted. F/E: Grossly + fluid balance, lactate this am 10.4,LFT's elevated, hct 24.9. Soc: Husband and one son in this morning, daughter phoned in this pm and updated on pt condition. P: Monitor LOC, reorient prn, ativan as ordered, hold for sedation. Titrate neo gtt as above to keep map >50, notify team of refractory hypotension/tachycardia. Follow abg's, respitory effort, 02 sats. ?HD for further fluid removal tomorrow. To utilize pedi tubes for blood draws as able, note daily hct, observe for bleeding. Npo after mn for am RUQ ultrasound, q6hr finger stick with new coverage as ordered. Meticulous skin care, air matress and turn q1-2hrs, dressings per wound care nurse . Keep family up to date on , offer support, facilitate communications with MICU team as needed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524183,\n \"text\": \"NURSING\\n VSS, TEMPERATURE SLOWLY DECREASED TO NORMAL. COOLING BLANKET OFF.\\nTUBE FEEDS CONTINUE AT 40/HR. STARTED ON VANCOMYCIN AND ZOSYN YESTERDAY FOR FEVERS. ALL CULTURES STILL PENDING. NO ISSUES OVERNIGHT, SEE CARE VUE FOR FULL SPECIFICS.\\n NO VENT CHANGES OVERNIGHT. LARGE AMOUNTS OF SPUTUM, THICK, GREEN.\\n DAUGHTER IN LAST EVENING. MULTIPLE QUESTIONS ASKED AND ANSWERED REGARDING ANTIBIOTICS, LABS, WHEN BRONCH WOULD TAKE PLACE, WHEN J TUBE WOULD BE CHANGED.\\n CONTINUE TO MONITER HEMODYNAMICS, FEVERS. FOLLOW LABS. CULTURES PENDING. BRONCH WHEN STABLE. J TUBE CHANGE WHEN STABLE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524273,\n \"text\": \"nursing note\\nNeuro:pt remains minimally responsive, nods approp at times but inconsistently. hypethermic and bairhugger on.\\nCV: afib, rate to 140-150's at times, resting in 130's most of night. MD aware and no interventions made since not more hypotensive with increased rate. Rate seems unrelated to pitressin increase earlier in evening or neo titration. MD aware of plt 39 on pre labs, coags sent and PTT >150 with INR 2.7. HCT sent at this time stable and plt up to 49. No bleeding noted. Later in , bleeding from ostomy site noted, 2u given. labs repeated. neo titrated to keep sys 80's, pitressin increase to 2.4 MD . Immediately on initiation of , down to 60's, neo titrated up and MD aware. Decision made at this time to increase pit.\\nRESP:no vent changes, minimal secretions.\\nGI:tol tube feeds at goal. GT/JT ostomy site changed per daughter request. small at 4 o'clock, covered wtih duoderm on ostomy appliance. Ostomy bleeding as above, bleeding noted from ostomy site itself, not bloody stool.\\nGU:anuric. to take on fluid as tolerated.\\nSKIN: no dressing changes this shift, all done on day shift. Multiple raw areas under L breast, in groin area, nystatin applied.\\nSOCIAL: daughter -HCP in to visit last night and spoke with MD regarding many issues: i.e:no dilaudid use, , liver failure, hypotension, dialysis. Daughter would possibly want patient transferred to if we are unable to get fluid off during .\\n\\nPLAN:follow sepsis picture including possible DIC. monitor for bleeding and treat labs PRN. a/o as awaiting sensitivities. supportive family care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524274,\n \"text\": \"RESP CARE - Pt remains intubated w/#7 XL trach on a/c 450/16/5 40%. No changes were made this shift. ABG is within normal range. BS coarse in upper lobes, which cleared on sx of small to moderate amounts of thick yellow secretions. BS were dim in bases. Flovent given as ordered, Atrovent given Q6, Albuterol given at 0800, but not at 1400, due to HR>120. Email sent to Pulm for ordering info for IC. Continued resp care planned.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524275,\n \"text\": \"nuero: pt at times opens her eyes when you call her name. pupils equal and reactive to light. pt does not follow commands. pt does move left hand on bed. no spontanous movement noted from right arm and right leg and right arm. ativan held at 0800 and 1400.\\n\\npain: no pain noted.\\n\\npulm: pt remains on ac, please see flow sheet for vent settings. lungs diminished at bases. most recent abg 7.37/35/118/21, dr. aware. suctioning pt for thick yellow sputum.\\n\\ncards: pt remain in afib hr 120-130's. iv phenylephrine weaned to off. pt continues on pitressin at 2.4u/hr. pt continues on , initally this morning taken off no fluid, but gradually increased pfr to 100cc/hr per dr. , pt becoming increasing tachycaric up to 138-140's, dr. called and aware. patient fluid removal decreased back to 50cc/hr.\\n\\ngi: pt continue on tube feeding at goal via j-tube. this morning colostomy emptied for 300cc of bloody drainage, mixed with a small amt of stool, dr. into assess colostomy output. no further bloody drainage noted from colostomy site, pt has had golden brown stool, which is guaic postive.\\n\\nheme. repeat hct 26.5, plt 29, dr. aware, no treatment ordered.\\n\\ngu: pt continues on .\\n\\nf/e: blood sugar 253 insulin gtt started, insulin gtt presently at 4u/hr. k 3.4 kcl gtt adjusted per k sliding scale, ionized calicm 1.20 calicum gtt adjusted per sliding scale\\n\\nid: pt started on meropenum. tobramycin trough to be checked.\\n\\nsocial: pt husband into visit this morning. update daughter x2 on pt condition.\\n\\nplan: continue to monitor, monitor for any sign of bleeding. check labs as ordered. adjust k and calicum gtt per sliding scale. monitor .\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524276,\n \"text\": \"pt with an eposide of hr up to 150-160 and up to 160's (please see flow sheet), vasopressin initally shut off, dr. called and into assess patient, resp. therapy called and into assess patient. abg done which was similar to earlier abg, pt recieved 2.5mg of iv lopressor, dropped down to 90, vasopressin restarted back at 2.4u/hr. dr. aware. hr down to 120-130 after lopressor\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524112,\n \"text\": \"Neuro:Pt sleeping most of night. Appears comfortable. Pupils 3mm brisk. Making no effort to communicate.\\nCV: afebrile, HR 90-110's Afib with no noted ectopy. SBP90-120's. extremities cool with poor pulses. Heparin gtt titrated, R great toe continues to bleed. L buttocks slight bleeding,\\nRESP: lungs clear through-out, No vent changes over night.\\nGI: tol tube feed. draining brown stool via ostomy.\\nGU: aneuric.\\nENDO: Remains on insulin gtt blood sugars stable over night\\nPLAN: awaiting MRI results.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524119,\n \"text\": \"Resp. Care:\\n Pt. remains trach'd and on vent.support. BS-occas. coarse. sx- sm amounts thick yellow secretions. MDI's given as ordered. Cuff press. @ 25cm to seal. Occas. positional leak, but without volume loss. 40 second RSBI test with low volumes and rr ^^ 40's. Cont. present vent. management/MDI's.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524120,\n \"text\": \"Nursing note:\\nNEURO: Alert, does not follow commands or communicate. Moving L. side on bed minimally. PERRLA. Appears comforable.\\nRESP: Lung sounds clear, no vent changes. Suctioned for minimal amounts clear secretions.\\nCV: Afebrile. Afib w/occ PVCs. MAP >60, SBP dipping when pt. sleeping though MAP remains 60-65. Pt. off Heparin gtt, therapeutic on Coumadin.\\nGI: Abdomen soft, +Hypo BS. New J-tube intact, used for meds only overnight. To begin TFs in am. IVF running overnight until given TFs. Colostomy patent small amount brown semi-formed stool.\\nGU: Anuric, HD pt.\\nSKIN: Mult. skin and wound issues, all dressings (except R. great toe) changed per skin care RN's recs. See Carevue for details.\\nENDO: Glucose levels labile, 1.5 amps D50 given for low blood glucoses in 30-70s, currently stable in high 70s. MICU team aware.\\nSOCIAL: Family visiting during evening, updated.\\n\\nA/P: Stable with mult. wound issues. Continue skin and wound care, restart TFs, follow glucose levels, continue current plan of care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524121,\n \"text\": \"Focus Condition Update\\nSee flowsheet for specific info.\\n\\nNeuro: Pt opens eyes to voice, tracks, follows some commands, and MAE's with the exception of her RUE, on the bed. PERRL.\\nCV: Pt dialyzed today, 1700cc of fluid removed. Hypotensive at times today, albumin given during HD to keep MAP >60. Chronic a-fib with the occassional PVC.\\nResp: Pt trached, CMV, 40%O2, PEEP 5, sating 98-100%. No vent changes made, no blood gas sent. LCTA, dim in bases, minimal suctioning.\\nGI: TF's restarted, FS at 40cc/hr. J-tube patent, site is clean dry, and covered with DSD. Abd soft, BS+, colostomy draining loose green stool.\\nEndo: Blood sugar stable this shift 85-126, awaiting consult from .\\nPlan: Continue to monitor BP\\n Continue with current POC\\n Discharge to home\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524122,\n \"text\": \"Resp Care\\n\\nPt remains trached with #6 shiley with positional leak noted. Cuff pressure pressured at 24cmh20. Pt currently vented on a/c with no changes made this shift to parameter settings. BS clear to course sxing for small to mod amts of thick white to yellow secretions. Trach patent/secured with adequate humidification noted. Will cont with vent support as needed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524123,\n \"text\": \"Nursing note:\\n Afebrile. SBP in 80s-90s, MAP 60-65. Remains on A/C, no ABGs done. Sats 100% and pt. appearing comfortable and compliant w/vent. Tolerating TFs w/minimal residuals. +BS, hypo. Colostomy intact w/green liquid stool. Glucose level normalizing, SSRI PRN. Anuric. Coccyx dressing changed x1 along with L. trochanter site according to skin care RN's recs. See Carevue for details. All other dressings intact. Family visiting.\\nA/P: Stable overnight. Continue wound care, cont. current plan of care and ready for d/c to rehab.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524169,\n \"text\": \"Resp care note\\n\\nNo ABG this shift but RSBI was done which shows much better result today, ~ 85. Pt presently remains on AC 16 x 450 but RSBI suggests that may be able to change to more spont mode. Pt has consistently had small to mod amts of thk tan secretions and one time what appeared to be bloody clots. Humidifyer system is functioning well, Spo2 is high and PiPs have been in low 20's. Adjustable T-tube monitored and adjusted x 2 to maintain @ 10 cm marker. Family member expressed concern that catheter is not getting down far enough but total length of Trach tube is 15 cm while in-line sx catrheter hax length of 30 cm. Continued use of longer catheter is not advisable as repeated usge could cause some trauma in smaller airways beyond trachea. Also recomment attempting cautious wean.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524170,\n \"text\": \"Resp Care: Pt remains intubated via #8 air filled cuff trach tube. Positional cuff leak. Team aware. BS coarse bilat I+E wheezes. MDI's given w/ gd effect. SX'd for small amts thick yellow sputum. No vent changes made this shift. No recent ABG. Most recent cxray from reveals \\\"^'d effusions, suggestive of failure rather than infection\\\". Plan: cont vent support. Please see carevue for further vent inquiries.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524171,\n \"text\": \"nursing note\\nNeuro: opens eyes spont, not following commands. Per family- open eys are anxiety and pt medicated with ativan a/o. no spont movement.\\nCV:SR, no ectopy. SBP >90 sys on midodrine. Lytes repleted per micu. Micu resident questioned regarding lytes with renal status and this RN instructed to give. Later in day-lytes and MD aware that lytes had already been given. Remaining Kphos discotinued.\\nRESP:LS coarse,thick yellow secretions.\\nGI:Tol JT feeds at goal.Colostomy with golden liquid brown.\\nGU:anuric.\\nSKIN:per skin care recs.\\nSocial:son in to visit-asking approp questions. Husband in this AM.\\n\\nPLAN:await IR consult at bedside in AM re:JT site and leakage. Await decision re:pulm re trach and home status with . HD tues. Home planning.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524172,\n \"text\": \"condition update\\nplease see carevue for specifics.\\n\\nNeuro unchanged. pt still not moving or following commands. Pt's daughter felt she was less responsive than usual however. MICU team up to go over and explain that the only changes to her meds was the increase in the glargine dose. All doses of ativan held during the . Tmax 101. AFIB. HR 90's-130. SBP 80's-120. Pm lopressor dose held. No vent changes made. Pt continues on AC/ 50%/5 peep. LS are coarse. Pt sxn'd several times for small amts of thick yellow secretions. TF infusing at goal via J tube. J tube drainage at start of shift was bilious and by 0400am yellow pus like. Colostomy w/ golden loose, guiac negative stool. Coccyx dressing changed as per wound care orders.\\n\\nPlan: continue with current plan of care per micu team. IR to j tube for continued leakage. Md. to perform test w/ resp tx at bedside on pt's home vent and new boniva trach. continue wound care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524268,\n \"text\": \"Resp Care\\n\\nPt remains trached with #7XL Shiley and currently vented on a/c with no changes made to parameter settings. Inner cannula changed this shift and is clean/patent. BS essentially clear anteriorly sxing for minimal secretions. MDIS given x3 this shift with improved aeration noted. Will cont with vent support as needed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524269,\n \"text\": \"RESPIRATORY CARE\\nPT REMAINS ON A/C WITH NO CHANGES MADE THIS SHIFT.SUCTIONED FOR SAMLL AMT OF YELLOW THK SECRETIONS.BS CLEAR B/L.MDI'S GIVEN AS ORDERED.PLAN TO CONT. VENT SUPPORT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524270,\n \"text\": \"FOCUSED NURSING NOTE\\nPlease see carevue flowsheet for further details\\n\\nNEURO: Pt more alert at times alternating with lethargy- nodding head \\\"yes\\\" and \\\"no\\\" inconsistently. PERRL, 5-6mm. Demerol given x 1 for rigors/tachypnea with temp spike- therapeutic.\\n\\nRESP: Trach patent, collar changed and care done. Ventilated via CMV per pre-admission settings- no vent changes this shift. Tachypneic during fever, otherwise RR 19-22, SPO2 100%. CXR done. ABGs show metabolic acidosis, compensated Ph 7.36. Secretions thick/yellow, occassional suctioning required.\\n\\nHEMODYNAMICS: s/p HD, Septic shock supported by pressors needing increase titrations o/n. Neo gtt at 4.0mcg/kg/min to maintain >80- now 90, titrating Neo down as able. Sharp increase in Afib rate just before midnight correlating with temp spike to 100.5 max. Afib 130s-140s with occassional bursts 150s- PVCs infrequent. Anasarca worsening, especially abdominal. CVP 10-12 recently. Hct decreasing, 22.4 as well as plt ct 51K- confirmed by repeat analysis. Dark, red blood slow ooze from vagina, loose stool by colostomy guiac pos.\\n\\nGI/METABOLIC: Sclera jaundiced- TF suspended at 2400 for Abd US this am. Colostomy loose/liquid stool, sample sent for . Rectal drainage small amounts, tan mucosal to serosanguinous. Glucoses 192/126 on RISS. D5W line changed to NS. Metwabolic acidosis unchanged, Bicitra as ordered.\\n\\nID: Tmax 100.5 with rigors and tachycardia/tachypnea/BP increase- pressors off for short while. BC (2) pending, BC x 1 sent this am. CBC showing pancytopenia.\\nSKIN INTEGRITY: All dressings intact, change daily. Right hip Allevyne drsg , pressure with pink/granulating wound bed, clean- 10% scattered yellow base. New skin tear adjacent to Dialysis catheter continues to bleed despite adaptic tx- covered with aquacel and light gauze pressure drsg- cont to monitor.\\n\\nPSYCHOSOCIAL: Son at bedside most of evening- sharing stories and pictures of Mrs over last 2 years- his goal is for her to make it home- supportive and appears to be coping appropriately. No additional family contact this shift.\\n\\nPLAN: Monitor hemodynamics on pressors. goal > 80. Consult with MICU team re: tachycardia ?fluid vs blood transfusion. HD/ plan per MICU/Renal team. Monitor for bleeding, new signs of infection. . Pulmonary hygiene, aggressive skin care as documented. Emotional support and education to pt/family ongoing.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524271,\n \"text\": \"Update\\nSee Carevue for specifics\\n\\nNeuro: Mostly alert but unable to assess level of orientation. Will nod appropriately to some questions but does not follow commands. Withdraws to pain. PERRL.\\nCV: Afib 110s-130s with rare PVCs. Neo gtt being weaned down as tolerated for >90 and MAP >50. Vasopressin gtt started at 1.2 u/hr. 1 unit prbc for falling hct. HIT panel sent. Anticoag. products d/c'd.\\nResp: LS clear/coarse. No vent changes.\\nGI: Abd U/S done r/t elevated bili. TF restarted at goal. Loose golden stool from colostomy. PEG/ site intact but draining.\\nGU: CVVH to start this p.m.\\nID: Afebrile. Blood positive for gram neg rods.\\nSkin: Skin grossly impaired. See carevue for specifics on wounds & treatments.\\nSocial: Husband visited in a.m. Daughter called and recieved update from RN & MD .\\n\\nPlan: Monitor hemodynamic status & wean neo as tolerated. Do not use heparin products. Start CVVH this p.m. Continue with agressive turning and skin care regimen. Keep family up to date on .\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524272,\n \"text\": \"Resp CAre\\n\\nPt remains trached on a/c with no changes made to parameter settings. BS clear to course sxing for small amts of thick yellow secretions. Inner cannula changed this shift. Will cont with vent support as needed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524332,\n \"text\": \"nuero: at times pt open her eyes when you call her name. at other times will open her eyes to painful stimuli. pt does not follow commands. pt her head no at times. spontanous movement noted from left hand, no further spontanous movement noted. pt does withdraw all four extremties to painful stimuli.\\n\\npulm: pt remain trached and vented. please see flow sheet for vent settings. lung diminished at bases. suctioning pt for scant amt of yellow sputum.\\n\\ncards: pt remains in afib. iv neo weaned down to 1.05 mcg/kg/min. vasopressin remains at 2.4u/hr. keep map greater than 55 and greater than 90.\\n\\ngi: abd soft, but distended. colostomy only put out 10cc of stool. increased drainage noted from g-tube dr. aware. tube feedings remain at goal. 50cc of bloody drainage noted around g-tube site, dr aware and into assess site.\\ngu: remains off.\\n\\niv access: pt went to ir today. pt had two double lumen picc line placed in ir.\\nskin: wound dsg changed as ordered.\\n\\nheme: inr 1.9 pt recieved 2 , plt 52 pt recieved one bag of plts.\\n\\nf/e: insulin gtt presently at 7u/hr. last blood sugar 269.\\n\\nsocial: pt husband and son into visit this morning. spoke with pt daughter after picc line placed.\\n\\nplan: continue to monitor, to d/c central line once plt infused and sent central line tip for culture. recheck plt count when plts finished. continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524333,\n \"text\": \"condition update\\nd: pt opens eyes and intermittantly nods to questions. pupils are equal and reactive to light.\\nCardiac: pt in afib rate controlled in the 90's. greater than 100 and map 68-71. neo weaned to 1.02 and pitressin weaned to .08units/hr pitressin weaned first per Dr. . pt with generalized edema.\\nresp: pt remains on cmv with rate on 16. abg good see flowsheet. lactate down to 6 last night. pt suctioned for thick yellow sputum. no vent changes. pt appears comfortable on current settings.\\ngi: tube feeds continue to infuse. abd distented and obese. evaluated by dr. and abd kub done and lactate checked and down to 6. pt difficult to assess for pain.\\ngu: pt makes no urine. skin: dressings are dry and intact. pt remains on air bed and turned frequently.\\ntubes: right groin central line dc'd and tip culture. site checked frequently and no bleeding or hematoma present.\\na: continue with frequent turning. wean neo as tolerated.\\nr: tolerating slow pitressin wean. dr. spoke with daughter \\n and daughter given update.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524410,\n \"text\": \"STATUS\\nD: APPEARS MORE AWAKE WILL FOLLOW SOME SIMPLE COMMANDS(OPEN YOUR MOUTH ETC)\\nA: HD DONE REMOVED 1800CC WITH MIN DROP IN BP..GOLYTELY GIVEN AS PREP FOR COLONOSTOMY..PT BLEEDING FROM COLONOSTOMY HO AWARE WILL CONTINUE WITH BOWEL PREP & GIVE 2U PC'S(#1 IN AWAITING #2)COLONOSTOMY DONE NO SIGNS OF FURTHER BLEEDING..STOMA BAG CHANGED..ALL DSG'S CHANGED\\nR: LABILE BP\\nP: AWAITING PC #2..WILL CHECK HCT AFTER TRANSFUSION..MONITOR FOR ANY FURTHER BLEEDING\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524411,\n \"text\": \"Resp Care,\\nPt. remains on A/C , No vent changes this shift. MDI's as ordered, suctioned for thick tan sputum. ? transition to home vent soon. See carevue.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524113,\n \"text\": \"NPN (SEE CAREVUE FOR SPECIFICS)\\n PT MORE ALERT TODAY, NODDING AND OCCASIONALLY MOUTHING WORDS. MOVEMENT NOTED FROM ALL EXT. EXCEPT RIGHT ARM. PERRL. PAIN MED GIVEN FOR DRESSING CHANGE ONLY WITH GOOD EFFECT.\\n PT REMAINS HYPOTENSIVE IN HIGH 80'S-100 SYSTOLIC, HOWEVER PT NOT NEEDING ANY FLUID BOLUSES. HR 80'S-90'S, A-FIB WITH OCCASIONAL ECTOPY. PTT 40 THIS AM, GTT INCREASED TO 600U/HR AND NEXT PTT TO BE DRAWN AT 1700.\\nRESP- LUNGS CLEAR, SUCTIONED A FEW TIMES FOR SMALL AMOUNT OF THICK YELLOW SPUTUM. NO VENT CHANGES MADE.\\nGI/GU- ABD SOFT AND DISTENDED. G-TUBE CONTINUES TO LEAK AROUND SITE AND DRAINING INTO OSTOMY BAG. PT WILL GO TO IR TOMORROW TO CHANGE G-TUBE TO LARGER. COLOSTOMY INTACT, STOMA BEEFY RED AND DRAINING LOOSE BROWN STOOL. PT DOES NOT VOID, NO DIALYSIS TODAY.\\nSKIN- COCCYX WOUND DRESSING CHANGED TODAY. PACKED WITH AQUACEL AND COVERED WITH DSD. AREA APPEARS TO BE IMPROVED, PERIPHERY EXCORIATED AND COVERED WITH BARRIER CREAM. DECUB GREYISH, OOZING BRB INSIDE. NEED TO BE REEVALUATED ON MONDAY.\\nID- AFEBRILE. MEROPENUM TO CONTINUE, VANCO LEVEL PENDING.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524114,\n \"text\": \"Resp Care\\npt remains trached and stable on A/C no vent changes made. BS course suctioned for sm amt of thick white-yellow secretions, MDIs given as ordered. will continue to follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524115,\n \"text\": \"Resp Care\\nPt remains on CMV, no vent changes, stable shift. Plan to continue with current tx.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524116,\n \"text\": \"data: vss. hr 96-113 afib. sb/p 88-112.\\nt. fdg off @ 12mn for proceedure today. bs-dropped to 44 @ 0500 insulin gtt stopped(rate was on 1u/hr) and 1/2amp d50 ivp given w/ bs^64. will cont to check freq.\\nall dsgs intact except rt lower -n/s pkg replaced-oozing from same area from skin tears.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524117,\n \"text\": \"Resp Care\\n\\nPt remains trached and vented on a/c with no changes made to parameter settings. BS slightly course sxing for small to mod amts of thick yellow secretions. MDIs given as ordered. Transported to and from IR without any incident. Will cont with vent support as needed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524118,\n \"text\": \"Nursing update\\nSee flowsheet for specific info\\n\\nVSS, A-fib with rare PVC, SBP low but MAP kept >65. Neuro status unchanged. Pt to IR today for replacement of leaky J-tube, no problems. ischial dressing changed today, all other dressings intact. Insulin gtt off this a.m. per MICU, 70 units lantis given. noon sugar was 28, MD notified, amp D50 given. A couple of hours later, sugar was 27, another amp d50 given. Will restart insulin gtt when sugar reaches 200 per MICU.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524202,\n \"text\": \"FOCUSED NURSING ASSESSMENT\\nPlease see carevue flowsheet for further details\\n\\nNeuro: No changes in neuro status- opens eyes spontaneously, follows comands inconsistently. Nodding head to answer simple questions for assessment of pts basic needs.\\n\\nResp: Biovina trach patent, positive positional cuff leaks, cuff pressure monitoring by RT. No resp distress on A/C 0.40, 450, 16, 5. SPO2 >95%. Frequent suctioning of moderate thick yellow sputum.\\n\\nHemodynamics: HR afib, controlled rate, no ectopy. Noted possible ST depression in lead II- 12lead EKG completed and reviewed by MD properly- MD, no changes in EKG. transient low SBP 73-89, NINV cuff BP not registering on thigh, now measuring NINV BP left radial. Pt is anuric secondary to renal failure, plan HD tomorrow if BP tolerates. INR 3.7, no sx bleeding.\\n\\nNutrition/metabolic: TF via J/G tube at goal rate- Glucoses 169/148 on Lantus 90U and RISS available. Na 132, K 4.9, discussed by MICU team, no action needed.\\n\\nID: Afebrile. Zosyn, Levaquin, Tobramycin as ordered. Blood cx neg, c-diff neg.\\n\\nPSYCHOSOCIAL: Mrs visited by her husband in am and followed by son in afternoon- Son asking appropriate questions and shares with medical team that majority of children would like to see their mother come home with hospice care \\\"We are doing our best to convince my sisters\\\" SW following, f/u family conference this week.\\n\\n POC: Cont to monitor hemodynamics, resp status. Monitor fever curve. Plan HD tomorrow if BP stable- please draw Tobramycin peak/trough with HD tx dose. Monitor glucose levels, RISS and Lantus as ordered. Aggressive skin care, turn and reposition with mouth care q2hr. Emotional support and education to family- f/u from SW appreciated.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524203,\n \"text\": \"Resp Care Note:\\n\\nPt cont trached and on mech vent as per carevue. Lung sounds coarse suct mod th yellow sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required . Cont mech vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524204,\n \"text\": \"Nursing progress note\\nneuro: unchanged\\ncv: pt has episodes of low bp which resolve with turning and stimulation of patient. Metoprolol given at 2200 as per parameters on med sheet.\\npulm: trach leak continues. sx q 2-3 hrs for thick yellow. bs coarse\\ngu: anuric, for hemodialysis today\\ngi: tol tube feeds well. colostomy draining loose brown stool guaiac negative.\\nendo: blood sugars in good control tonight, < 150. glargine 90 u sc q 12 hrs. no reg ins coverage needed.\\nwounds: appear unchanged, leg dsgs changed, dacral dsgs changed.\\n\\nsocial: daughter and husband in to visit. She wanted to help turn pt, and participate in her care. It was explained to her that hospital policy will not allow her to do this. Shortly after, pt began coughing, and proceeded to suction her mother. I spoke to her about this: we realize that she cares for her mother at home, but that while she is hospitalized her technical care is our responsibility, and I reiterated hospital policy. This issue needs to be addressed by MD's and ethics Committee, as it causes conflict between the family and Mrs. caregivers.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524137,\n \"text\": \"Resp Care Note, Pt remains on current vent settings.See vent flow sheet for weaning. Unable to tol RSBI.RR into the 50's. Will cont to monitor resp status. Suctioned mod amts thick yellow secretions. Temp 99.HR A-Fib.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524236,\n \"text\": \"See carevue for objective data.\\n\\nAssessment remains unchanged. No vent changes made. Suctioned Q3H for thick yellow secretions. Trach care done.\\nRemains in AFIB with adequate BP per parameters of team. Tolerated lopressor and amiodarone.\\nFoley with frank blood-approximately 40cc's this shift. Also, oozing noted around foley. Team aware.\\nAll dressings changed. Coccyx with large amt of serosangious/green drainage and hips with serosangious drainage. Avelyn placed on hips cleaned with wound cleanser and no sting barrier applied. Wound care nurse wounds in AM. Lower extremities remain with black areas.\\nTF as ordered. Colostomy care done. Mouth care per protocol.\\nCase management/SW involved in pt's care.\\nFamily called and updated on POC.\\n\\nAwaiting to go to IR for tunnel dialysis catheter-on call.\\n\\nContinue current POC.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524237,\n \"text\": \"Respiratory Therapist\\nBreath sounds bilaterally diminished, suctioned for small thick amount of yellowish secretions, WBC 12.8 ongoing bacterial infection, hemoglobin only 8, sign of anemia, patient got treated with Albuterol, Atrovent and Flovent inhalers, went to Angioplasty for line replacement, no ABGs drawn, nor vent changes done today, patient will continue to receive ventilatory support and close monitoring.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524238,\n \"text\": \"Resp.Care\\nPt. remains on A/C vent. via a 7.0 Shiley trach which is patent and secure. She is being sx for mod amts of yellow with scat rhonchi t/o. Pt, nebs were tol. well with good results and better aeration post rx.Plan is to monitor and wean as tol.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524239,\n \"text\": \"NPN\\nPlease see CareVue for full assessments\\nNEURO: Unchanged. Nods to questions at times. Inconsistent with following commands and communicating. Ativan po per schedule for anxiety.\\n\\nCV: Afib. HR 90's-120's. NBP stable. Lopressor po per schedule.\\n\\nRESP: Trach. No vent changes or issues. Sxn for sm amt tan secretions.\\n\\nGI: TF via off @0200 2T episode vomiting x1 green bilious liquid. MICU HO notified and in to . No further action or episodes. Copious amts green gelatinous bilious liquid draining from around . Noted to drain more when pt. positioned on left side. MICU HO aware.\\nBS+. Colostomy with 125cc brown liquid stool, guaiac-.\\n\\nGU: Patent foley draining dk. red blood. Flushed x2.\\n\\nWOUND/SKIN INTEGRITY: Dsgs intact. MPS in place, repositioned Q2H.\\n\\nPLAN: CV monitoring, diabetic management, monitor for increased pain/anxiety, monitor for nausea/vomiting, monitor resp status, wound management, reposition to maintain skin integrity, monitor foley for increased bleeding.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524240,\n \"text\": \"See carevue for objective data.\\n\\nAssessment remains unchanged.\\nOpens eyes/tracks occasional only nods yes to questions/other times does not respond.\\nTF re-initiated at 0700AM with no further vomiting. G-tube placed to gravity as well.\\nFoley dc'd-no further bleeding noted. Pt anuric otherwise.\\nTolerated HD/received albumin during HD.\\nSkin care nurse evaluated and dressed all wounds. Please see progress note for details.\\nNo vent changes. Suctioned Q2-3H for yellow thick secretions. Trach care done.\\nAFIB. Non-labile BP.\\n\\nContinue current POC.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524147,\n \"text\": \"NPN\\nPlease see CareVue for full assessments\\nNEURO: Pt. inconsistently nods to questions and follows commands. MAE. Noted to have LUE tremor and left gaze @1200. Pupils 4-5mm and briskly reactive. MICU team notified. No action. On recheck pt able to look towards right, pupils remain 4-5mm. No c/o pain. Ativan per schedule.\\nCV: Afib occas. PVC's. HR100-130's. Team aware-no action at this time.\\nSBP 80-100's. Goal MAP grtr than 60.\\nRESP: Trach. No vent changes. Cuff leak noted x2. Resp notified&at bedside. LS clear. Sxn x1 scant secretions.\\nGI: TF @goal via PEJ. Free H20 Boluses on hold per MICU team. (Na 140). Moderate drainage around PEJ insertion site. Colostomy draining golden brown guaiac neg. stool.\\nENDO: BG 300's this shift. Seen by . Fixed dose increased.\\nWOUND: Dsgs intact. BLE dsgs changed per wound care recommendations.\\nPLAN: Neuro checks, monitor CV and HR,diabetic management, wound management, call speech and swallow @passe muir valve, follow-up with team concerning upcoming discharge home, emotional support to pt/family.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524148,\n \"text\": \"Resp.Care\\nPt. remains trached on A/C mode. No changes during the night. Cuff pressure was measured at 30 with a posistional leak. MDIs were given with good effect and pt. was sx for mod amts of white thick secr.\\nPlan pt. is a chronic vent and possibly D/C to home .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524149,\n \"text\": \"Nursing Progress Note\\nPlease see carvue for specifics:\\nUneventful night. Status unchanged. Turn and repositioned Q2hrs and prn. Plan: Cont plans to d/c home\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524150,\n \"text\": \"resp care - Pt remains intubated on ac 450/16/5 40%. Pt cuff pressure was not able to be assessed due to possible pinhole in pilot balloon. Balloon is remaining inflated and pt is receiving appropriate tidal volumes. Meds given as prescribed. BS wheezes t/o. Pt went to IR for jpeg change. Plan is to d/c to home soon.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524151,\n \"text\": \"Condition Update\\nPlease see carevue for specifics.\\n\\nPt opening eyes spontaneously. Follows commands inconsistently. No moving extremities. TMAX 101.2; Bld cx's x 2 sent. Pending sputum from . Pt had HD today. 2200 out. AFIB continues. HR 90's-160's. occasional to rare PVC's noted. HR in the 130's-160's approx 30min into start of HD. MICU team notified. SBP only 70's-80's.\\n\\nNo vent changes made this shift. Pt sxn'd several times for thick, white sputum in scant amts. LS clear, but diminished at b/l bases. Pt an ad on for the OR for trach replacement d/t constant leakage. Pt maintaining volumes as was explained to pt's family, but they were still unhappy and demanding a new trach. Speech and swallow also consulted again for in line passy mauir.\\n\\nPt is anuric d/t renal status. colostomy draining liquid stool. spec #2 to be collected. Colace and lactulose doses held this am. stoma is pink. PEJ tube noted this am to have copious amts of clear drainage draining. Wound care RN in to inspect pej insertion site. Pt down to IR for replacement. .5 mg ativan given during the procedure. Since replacement, no further drainage noted. Pt's and beneprotein tube feedings held this afternoon for pej placement and eventual OR for trach placement.\\n\\nPt has a riss and glargine ordered for bs control. Pt is currently being followed by .\\n\\nB/L multi podis splints placed this am. foot and leg dressings changed this eve. Toes, heels, and achilles tendon necrotic. Duoderm gel adaptic and dsd's placed. Back of b/l calfs also w/ open areas. All areas cleansed w/ wound gel. Duoderm gel, adaptic and dsd's placed. Pt's coccyx and hips w/ intact dressings.\\n\\nPlan: continue with current plan of care per MICU team. speech and swallow consult for in line passy mauir placement. O.R. for trach replacement. Digoxin, lopressor and amiodarone for rate ctrl. Hold coumadin for inr 4.0 f/u on results of bld cx x 2 taken . Dressing changes.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524152,\n \"text\": \"Resp. Care\\nThere was a question of Pt. going to the OR for trach replacement at the request of the family. She was added to list , but did not go.She continues to have a posistional leak . 4ccs was added to reach pressure of 30. Pt. 8.0portex trach remains secured and patent and is being sx for sm. to mod amts of thin white secr. B/S are scat wheezes and rhonchi, MDIs were given with good effect.Pt. remains on A/C 450by 1640% and 5of peep.ABGs and RSBI not done due to being vent dependent.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524153,\n \"text\": \"nursing note 7p-7a:\\nNursing ASsessment:\\n\\nTmax 100.3 oral. HR afibb 90s-130s briefly, pvc's at times. BP goal map >50, no boluses needed overnight. lungs clear and diminished in the bases, infreq suctioned, sat 100%. NS at KVO switched to 5% dextrose while tube feeds off for OR trach replacement (pt is an add-on, still waiting). PM glargine held and sugars monitored closely while tube feeds off. Coccyx dressing changed per wound care recommendations, pt tolerated well. Please refer to carevue for all further details.\\nPLan: wound care. TRach to be changed in OR. Speech and swallow for passe-muir valve? Discharge planning for home, children will care for patient there. EMotional support for family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524257,\n \"text\": \"Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick yellow secretions. MDI'S given.HR-A-Fib with few PVC'S.BP labile requiring fluid . RR 20'S-30.Hasn't had dialysis for 5 days due to drop in BP.ABG metabolic acidosis. Will cont to monitor resp status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524258,\n \"text\": \"Nursing Progress Note\\nPlease see careview for details.\\n\\nNeuro: unchanged, lethargic to alert. nodding \\\"Yes\\\" to all questions.\\nCV: afebrile. afib rate 110-145, but not sustained at the higher rate. Low bp by , at times unable to obtain , but as low as 45 systolic. abg's sent, lactate of 10, aline and multi lumen central line inserted rt femoral. given 1000cc ns, levophed started at .02mcg/kg/min. and a line not always correlating. levophed off by 0600. occasional pvc's. k 2.9, repleted with 20meq/50cc.\\nPulm: sx for thick yellow, small amts. bs clear to coarse. RR up to 30, but not labored.\\nGI: tube feeds at goal of 40/hr tol well, via j tube portion of gastric tube.. colostomy pink, draining golden loose stool guaiac neg. gastric tube to gravity, draining clear light yellow. frequent mouth care with water and mouthwash, pt swallows without difficulty.\\ngu: anuric, possibly hemodialysis today if bp tolerates.\\nendo: insulin to sliding scale as well as fixed dose of Lantis 2 x day.\\nfamily notified of treatments by resident.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524259,\n \"text\": \"Respiratory Care\\nBreath sounds slight bilateral rhonchi, suctioned intermittently for small thick yellowish secretions, WBC 22.6, ongoing bacterial infection for which patient is on tobramycin, patient is anemic since hemoglobin is only 8.8, patient was afebrile whole day and stayed into A-fib, has had few PVCs, had hemodialysis started at 1000 am to stop two hours later at noon due to adverse effects like hypotension and tachycardia (HR 150 to 160), patient has been treated with Albuterol, Atrovent and Flovent inhalers, no vent change done during the shift, post hemodialysis ABGs on AC 450 x 16 40% +5 revealed a fully compensated metabolic acidosis with hyperoxemia, we will continue with mechanical ventilation and close monitoring of patient.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524260,\n \"text\": \"NPN\\nPlease see CareVue for full assessments\\nNEURO: Unchanged. Nods head to all simple questions. Did not attempt to mouth words to this RN. +tracking. Observed moving LUE and RLE on bed. No movement witnessed from RUE or LLE.\\n\\nCV: Restarted Levophed after HD initiation due to hypotension. Titrated for BP grtr than 90. Mean grtr than 60 per MICU team. Right femoral Aline consistently 20-30pts higher than NBP. Remains in Afib. HR110's-120's prior to HD this AM.Episodes of HR to 140's. Lopressor 12.5PO administered. HR returned to 120's. CVP 14. Lopressor dose now TID. Midodrine per schedule. Potassium 3.0 after HD. To receive repletion.\\n\\nRENAL: Pt. did not tolerate fluid removal today. HD only 2hrs per Renal Fellow due to hypotension and tachycardia. Received 600cc NS fluid and Albumin during HD. Will attempt HD with fluid removal again tomorrow MD .\\n\\nRESP: Trach. No vent changes this shift. Remains acidotic. LS coarse to rhonci, right greater than left. Sxn for small amts thick light tan secretions. In line sxn changed by RT.\\n\\nID: ID consulted and in to /assessed coccyx wound. ?Linezolid induced lactic acidosis per MICU attending. L. acid now trending down(9.6). ABX changed per ID recommendations. Tobramycin level drawn at HD(0.2) but no dose administered. To be administered tonight per MICU HO. ID attending updated dtr.\\n\\nENDO: Hypoglycemic this afternoon. Received fixed dose of 87Units Glargine this AM. BG to 43. MD aware. amp D50 administered with repeat BG 43. Another amp D50 administered.\\n\\nGI: Abd distended. Golden loose guaiac- stool in colostomy. Bag emptied multiple times for flatus. Tol. TF at goal. Cont. to leak light yellow gelationous drainage around insertion site. Ostomy bag changed at site to collect drainage. Gastric tube to gravity with similar drainage as well as small amts of it oozing from rectum.\\n\\nScant smearing of vaginal bleeding noted with peri care.\\nWOUND: All dressings changed per wound care recommendations. Dtr. viewed wounds with this RN.\\n\\nPsychosocial: HCP Dtr in-spoke with attending at length regarding , HD, and pending DC home.\\n\\nPLAN: Monitor CV status, wean levo as pt. tolerates, diabetic management, frequent BG checks due to hypoglycemia, administer ABX, wound management, reposition per protocol, provide emotional support to pt/family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524261,\n \"text\": \"condition update\\nd: pt opens eyes to name and nods yes. moves left arm spontaneously.\\ncardiac: pt remains in afib with rate 90-130 with occasional pvc's. Dr. aware and lopressor dose given. pt on lopressor and given dose with minimal effect on bp and hr down to 100. pt remains on levophed and .04mcg/kg/min. rate titrated for 90. rate increased from .02-.04mcg/kg/min. pt remains on .04mcgs.\\ngi: pt remains on tube feeds at 40cc/hr. no residual from j tube. no tube feeds draining from gtube. continues to leak yellow thick drainage from around feeding tubed. drainage bag is intact. abd obese and soft. hypoactive bowel sounds. colostomy pink and draining golden loose stools.\\ngu: no urine. to attempt hemodialysis today with fluid removal. pt remains edematous in all extremities.\\nlabs: blood sugars in the 40's. pt treated with d 50. Dr. aware and up to see pt. bedtime Glargine dose cut in half and pt started on d51/2ns at 100cc/hr for 5 hrs. see flowsheet for blood sugars. Spoke with Dr. re: insulin with blood sugar in the 60's. iv fluid changed to d5w at 100cc/hr and she wants pt to get glargine dose. blood sugar down to 57 at 3am and pt treated with 1 amp of d 50. Dr. aware. continue to monitor blood sugars. no further fluid at this time. hct down to 24 this am and Dr. aware. k 3.0 and repleted. repeat k this am 3.1\\nskin: dressing are intact and pt remains on air mattress.\\na: continue with q1hr blood sugars. attempt hemodialysis today. continue to support the family.\\nr: 4am blood sugar is 118. tube feeds remain at 40cc. iv fluid at 10cc/hr. greater than 90 on current levophed dose. ? if she will be able to tolerate dialysis today. and aline approximately 20 pts difference. ? transfuse with hemo today. check with team and renal md. pt more edematous than over the weekend.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524262,\n \"text\": \"Respiratory Care Note:\\n\\nPt remain on ventilatory/assist support via trachetomy tube. No vent changes done. BS are clear/BBS. We are sxtn small amt of clear to blood tinged secretions from trach, none orally, IC changed and cleaned, spare unopened untop of ventilator. Plan: Continue present ICU minitoring, anuric ?dialysis as tol. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524263,\n \"text\": \"NPN\\nPlease See CareVue for full assessments.\\nNEURO: Pt. lethargic. Pupils 4mm. Equally reactive. Does not follow any commands. No nodding of head or attempting to mouth words.\\n\\nCV: BP labile. Aline does not correlate with pressure. NBP cont to read 20-30pts lower than Aline. Cont. to titrate Levophed gtt to goal of grtr 80 MAP grtr 50 MICU MD . Levo changed to Neo gtt @1700. Titrated to grtr 80. Presently 1.5mcg/kg/min. HR 110's-120's with episodes of tachycardia to 150's. MICU team aware. Lopressor IVP with no effect. Change of CV meds today. please see MARs for changes. CVP 16-19. Cortisol stimulation test completed.\\n\\nRESP: Trach. No vent changes. No issues. Weak cough. Minimal sxn.\\n\\nRENAL: Unable to tolerate fluid removal with HD. Pt. hypotensive with to 70's. Levo titrated. to 150's. No result from Lopressor IVP. Renal and MICU teams aware and at bedside to .\\n\\nENDO: Hypoglycemic throughout day requiring amp D50 x3. BG ranging 30-83. See Flowsheet. No fixed dose this AM. No Lantus tonight per MICU team. consulted. Insulin Lantus dose changed to QD starting tomorrow.\\n\\nGI: Distended abd. Golden, guaiac+ stools x3. Colostomy bag intact. Minimal flatus. TF remains at goal via . Cont. leakage around site. G-tube to gravity with similar gelatinous yellow drainage. Also noted to be oozing from rectum. MICU team notified.\\n\\nGYN: No bleeding noted from vagina.\\n\\nWOUND: Assessed by wound care RN this AM. All QD dsgs changed. Allevyn dsgs on hips from intact. Please see wound care RN note for specifics. Wound care RN called and updated dtr. on recommendations at dtr's request.\\n\\nPSYCHOSOCIAL: Family updated by MICU team of HD, CV, and Hypoglycemic issues. Dtr updated by attending .\\n\\nPLAN: Assess MS, Monitor CV, titrate Neo gtt to goal grtr 80, diabetic management-hold Lantus tonight, D50 for hypoglycemia, administer ABX per schedule, Wound management, monitor labs,\\nreposition frequently to maintain skin integrity.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524264,\n \"text\": \"BS few coarse crackles; no change with MDI's. Sx'd for mod amount pale yellow secretions. No ABG's or vent changes. COntinue with current care plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524265,\n \"text\": \"RESP CARE: Pt remains trached/on vent with settings per carevue. No changes in vent this shift. pressure of 25cmH20. Lungs coarse rhonchi with scattered insp wheezes bilat. Sxd thick yellow sputum at start of shift and white sputum by end of shift. ABGs consistent with comp met acidosis.No RSBI this am due to hemodynamic instability. Continue full support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524266,\n \"text\": \"FOCUSED NURSING NOTE\\nPlease see carevue flowsheet for further details\\n\\nNeuro: Decrease in LOC continues, alertness waxes and wanes- PEERL, 5mm. Glucoses stabilizing in 80s.\\n\\nResp: trach patent, ventilated via CMV 0.40/450/16/5. RR 18-24, SPO2 100%. ABG shows metabolic acidosis, attempting compensation. Suctioned infrequently for small thin tan secretions. Lungs coarse to rhonchi left lobe.\\n\\nHemodynamics: Unable to titrate Neosynpehrine gtt, maintained arterial 85-90s on Neo 1.00-1.25mcg/kg/min. Afib, rate 104-116, occassional PVcs. Anasarca increasing, CVP 12-14. Hct trending down, now 24.9. Small amt vaginal bleed, serosanguinous from rectal. Colostomy stool strong guiac positive.\\n\\nGI/Metabolic: TF at goal 40ml/hr. Colostomy golden/yellow loose stool, guiac positive. Hypoglycemic earlier in shift, treated with 1amp D50 and maintenance line D5W at 10ml/hr initiated. Glucose now stabilizing in 80s. Potassium 3.0 repleted with 20meq KCL. Metabolic acidosis, Bicitra administered as ordered.\\n\\nID: Tmax 99.2. Tobramycin/Zosyn/Levaquin/Daptomycin active. WBC decreasing along with Hct. Central line sites benign.\\n\\nSkin Integrity/Comfort: Please refer to wound care RN progress note- all dressings left intact, plan change daily. Turn and repositioned q2-3hr. Pt shows facial grimace at times, relaxation of face evident after stimulation of nursing care ends and pt allowed to rest in longer periods.\\n\\nPsychosocial: \\\"My mom lets us know what she wants, she wants to live\\\" Pts son at bedside until midnight- Daughter calls for updates. Emotional support and education provided re: disease processes, plan of care, hypoglycemia management, .\\n\\nPLAN: Monitor hemodynamics on pressors, goal > 80, MAP > 50. Consult with MICU team re: Hemodialysis repeat attempt vs . Monitor for bleeding, anemia management per MICU team. Pulmonary hygiene, aggressive skin care. Monitor hypoglycemia, hold Lantus. Monitor neurological status closely, report changes to MICU team. Administer . Close Social Work follow-up appreciated.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524327,\n \"text\": \"FOCUS: CONDITION UPDATE\\nD: SEE CAREVUE FOR SPECIFIC VITALS/LABS/ASSESSMENTS.\\nPATIENT CLEARLY GETTING MORE SEPTIC WITH INCREASING LACTATE AND WORSENING LABS.\\nRECEIVED 2 U PB FOR HCT OF 20 AND 4U FOR INR 2.8\\nUNABLE TO WEAN GTT--GOAL TO KEEP MAP>55.\\nWOUNDS CHANGED AS ORDERED, UNCHANGED IN APPEARANCE.\\nFAMILY MEETING HELD TODAY WITH DR. / RN/ / /DR. AND SON/DAUGHTER AND HUSBAND. FAMILY VERY ANGRY AND CONTENTIOUS THROUGHTOUT MEETING. LOTS OF YELLING BY SON, MOSTLY DIRECTED AT PERCEIVED POOR CARE GIVEN BY NURSING AND MEDICAL STAFF.\\nWHEN ISSUES FINALLY DISCUSSED, IT WAS AGREED TO THE FOLLOWING 5 THINGS:\\n1. STOP DIALYSIS FOR 24-48 HRS. AS FAMILY FEELS IT WEARS OUT THEIR MOTHER.\\n2. DILTIZEM DOSE WILL BE DECREASED.\\n3. FAMILY VERY MUCH WANTS LINE TO BE RESITED IN IR, BUT WERE TOLD IT WAS CURRENTLY TOO UNSAFE TO TRAVEL WITH PATIENT.\\nIT WAS AGREED TO TRY TO WEAN NEO TO OF CURRENT DOSE, AND TO KNOW THAT PATIENT'S BLOOD PRESSURE WOULDN'T DROP LOWER THAN 60/S IF PATIENT WAS OFF NEO FOR PROLONGED PERIOD OF TIME (IE/DIFFICULTY PLACING LINE/LOST LINE FOR ANY PERIOD OF TIME).\\n4. ID ISSUES --SPECIFICALLY IF AMIAKACIN WOULD BE APPROPRIATE DRUG AT THIS TIME WILL BE ADDRESSED.\\n5. HOB WILL BE UP AT 30 DEGREES MOST OF THE TIME IF TOLERATED.\\nA/P---AS OUTLINED ABOVE.\\n\\nMEDICAL TEAM AWARE, WILL CALL WITH ANY CHANGES.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524328,\n \"text\": \"Respiratory Care\\nMinute ventilation in Fact is consistent with her usual values and not increased as previously report by this therapist\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524329,\n \"text\": \"Respiratory Care\\nPt. trach and on ventilatory support. No vent setting changes this shift. Pt. sx for abundent thick yellow secretions. ABG's with in normal values. Increasing minute volume noted to occur over duration of shift, may be attributable to increased Lactic acid.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524330,\n \"text\": \"Nursing Progress note:\\nNeuro: Pt arouses to voice, withdraws to nailbed pressure but making no attempt to communicate. Appears comfortable.\\nCV: Tmax 101.1 presently 99.8. HR 100-110's Afib with no ectopy. 95-101 MAP 59-61. Able to wean NEO to 1.5 mcg/kg/min. Pitressin unchanged at 2.4 u/hr. Extremities cool with pulses. HCT 24 this am.\\nRESP: lungs clear to dim at bases. No vent changes overnight. Occasional suctioning of thick yellow secretions.\\nGI: tube feed at goal. colostomy draining moderate amounts of maroon guaiac + stool.\\nGU: aneuric.\\nENDO: Cont on insulin gtt at 5u/hr for blood sugars 109-125.\\nSKIN: all dressings dry and intact.\\nPLAN: Cont to wean pressors. Cont to monitor HCT,PLT and INR\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524331,\n \"text\": \"BS fine crackles; no change with MDI's. Sx'd for mod amount thick yellow secretions; inner cannula changed. To IR today for central line placement. No vent changes.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524404,\n \"text\": \"Respiratory Care\\nPt. trached and on chronic ventilator management. Remains congested, suction for thick green secretions. Vent settings unchanged due to pt, chronic needs. Oxygenating well, MDIs administered as ordered.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524412,\n \"text\": \"NURSING NOTE\\nPT ALERT/EASILY AROUSABLE, NOT FOLLOWING COMMANDS, NODS INTERMITTENTLY. PERRL, 4MM, BRISK, INTERMITTENLY TRACKING FAMILY MEMBERS. SPONTANEOUSLY TO LUE ONLY. HR 70S-80S, >80/MAP>55 MAINTAINED PER MICU, AFEBRILE. RECEIVED #2 PRBCS THIS EVE, POST-HCT 29, K 3.6, MAG 2.0, INR 1.6. LEFT A/C PICC D/C'D, RIGHT TLCL DRNG SEROSANG. NO VENT CHANGES, O2 SATS 98-100%, SUCTIONED FOR LGE AMTS BRN, THK SECRETIONS. COLOSTOMY W/MOD AMTS REDDISH-BROWN LIQUID DRNG, CLEARING THIS AM. GT TO GRAVITY W/MIN BRWN LIQUID DRNG, JT PATENT, CLAMPED. BS 120S-160S, PM LANTUS HELD, COVERED PER RISS. PT TURNED FREQUENTLY, MULTI DSGS REINFORCED, NO NEW AREAS OF BREAKDOWN NOTED.\\n\\n TO MONITOR HD, LOC, PULM TOILETING, AGGRESSIVE SKIN CARE, BS CHECKS, FAMILY SUPPORT. SICU , PLAN TO D/C HOME MON.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524413,\n \"text\": \"Resp Care\\nPt remains trached on full vent support. no vent changes made this shift. Pt went to IR this afternoon for line placement without incident. Suctioned for mod-copious blood tinged to tan secretions. MDIs given. Please refer to for all vent settings.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524414,\n \"text\": \"STATUS\\nD: AWAKE FOLLOWS SOME SIMPLE COMMANDS..NO SIGNS OF BLEEDING\\nA: WD'S UNCHANGED..TO IR FOR PICC PLACEMENT & QUINTON CHANGED OVER WIRE TO TUNNELED DIALYSIS CATH..TOL PROCEDURE FAIRLY WELL..BP REMAINS LABILE..MP TO SR WITH FREQ PAC'S & OCC PVC'S..NO VENT CHANGES SUCTIONED FOR SM AMT THICK TAN/BLD TINGED..COLOSTOMY DRAINING LOOSE BLACK STOOL SM AMT\\nR: ESSENTIALLY UNCHANGED\\nP: ? TRANSFER HOME ON MONDAY..CONTINUE WITH PLAN OF CARE\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524415,\n \"text\": \"RESP CARE: Pt remains trached/on vent on settings per carevue. pressure 25cmH20. Lungs coarse bilat, sxd thick yellow sputum. No RSBI due to hemodynamic instability. Hypotension. Waiting for MD order to place pt on home vent.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524416,\n \"text\": \"Nursing Progress Note\\nPlease see for details.\\n\\nNeuro: unchanged\\n\\nCV: bair hugger for low temp, now normothermic. bp varies but continues to be low. Diltiazen held this am.\\n\\nPulm: sput sent for c+s, gm stain. sx thick yellow. sats>97.\\n\\ngi: tube feeds remain on hold, black stool from colostomy. hct 27.\\nBS 44 at 0400, D50 amp ivp, rpt 80.\\n\\ngu: anuric, for hemodialysis this am.\\n\\ncontinues to seep large amts serous fluid from all skin breaks.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524417,\n \"text\": \"resp care\\nremains on vent settings as charted, no changes made. discussed home vent with team..decided not necessary to place on pt until closer to discharge (approx 24hrs prior). admin mdi's per orders. pressure maintained between 25-30 with positional leak only.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524197,\n \"text\": \"Update\\nO: see carevue flowsheet for specifics...\\nNeuro: neuro status unchanged, eyes open spont perl at 4mm and tracking w eyes, does not follow any commands.\\n\\nCV: afib no ectopy.Lopressor held for sys bp <90. Sbp trending up to wnl range.doppler pt's bilat. Multiple skin issues and bilat lower extrms dsd.\\n\\nResp: remains on cmv tv 450 fio2 40% rr 16 peep 5. trach in place, trach care done. Adeq sats.Sux for thck tan.\\n\\nGi: g-j tube w tf at goal as ordered.Glucoses rx per ss, no reg insulin req. Rec'd pm lantus dose.\\n\\nGu: renal failure pt on sched for hemodylasis for Monday.\\n\\nSkin: multiple skin issues. Ble kerlex drsg.. Decub on coccyx , area w light yellow drngs->wound skin cleanser to area and aquacell dsg to be applied.\\n\\nHeme/ID: am labs pending. Tmax 100.7 remains on tobra and zosyn. tobra peak tobra level.\\n\\nA/P: hemodialysis on mnday.pulm toilet.wound and skin drsgas done per schedule.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524198,\n \"text\": \"nsg note\\nSEE FLOWSHEET FOR SPECIFICS.\\n\\nNEURO-PT OPENS EYES SPONT. MOVES LEFT ARM. DOES NOT FOLLOW ANY COMMANDS.\\n\\nCV-REMAINS IN AFIB. SBP STABLE. SKIN WARM. +PP VIA DOPPLER.\\n\\nRESP-NO VENT CHANGES. O2 SAT 100%. LS COARSE. SXN PRN FOR THICK YELLOW SPUTUM. TRACH CARE DONE.\\n\\nGI-ABD SOFT, NT/ND. +BS. COLOSTOMY PINK WITH LOOSE GOLDEN STOOL. TOL TF VIA J-TUBE.\\n\\nGU-ANURIC. TO HAVE HD ON MONDAY.\\n\\nCOMFORT-APPEARS COMFORTABLE.\\n\\nENDO-GALRGINE GIVEN. NO SSRI NEEDED.\\n\\nID-AFEB. REMAINS ON ABX.\\n\\nSKIN-CON'T WITH MULTI SKIN TEARS AND BREAKDOWN. SEE FLOWSHEET. WOUND CARE AND DSGS CHANGED AS ORDERED.\\n\\nP-CON'T WITH CURRENT PLAN.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524199,\n \"text\": \"Resp Care Note:\\n\\nPt cont trached on mech vent as per Carevue. Lung sounds coarse after suct mod th pale yellow sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required . Positional air leak persists however adequate ventilation is maintained. Cont mech vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524200,\n \"text\": \"nursing progress note\\nblood sugars are elevated to >200. glargine 90 units q 12 hrs. HO notified, there is no sliding scale.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524201,\n \"text\": \"Resp Care\\n\\nPt remains on full vent support maintaining mv's in the 9-11L range. BS are diminished to coarse and suctioning thick yellow sputum in small to moderate amts. Cuff pressure at 18 cmH2O\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524286,\n \"text\": \"Skin Assessment.\\n\\n->Bil underarms pink, no breakdown noted. Skin cleansed and dried well. Miconazole powder applied to both under arms.\\n\\n->Bil breast folds are pink with small pinpoint open area. Areas also have small amounts of thick whitish/yellow discharge. Areas cleansed and dried well. Miconazole powder applied to areas, dry gauze to cover.\\n\\n->Bil groin folds are pink/red with open areas. Areas are draining moderate amounts of sero/sang. Areas cleansed with wound cleanser and dried. Gauze placed inbetween folds and have been changed frequently.\\n\\n->Right posterior lower arm with two small pinpoint open areas draining copious amounts of sero fluid. Area cleansed with wound cleanser and drainage bag applied to area.\\n\\n->Right lower quad with skin breakdown from tape. Area again cleansed with wound cleanser, dried and drainage bag applied to help protect drainage from leaking into CVL and Aline.\\n\\n->Left lower posterior leg with open area. +granulation, small amount of sero/sang drainage. Wound is about 12cm long, 2cm wide and 0.5-1cm deep. Wound cleansed with wound cleanser and dried. Adaptic with DSD covering area.\\n\\n->Left great toe and other toes are dark brown, dry, and brittle. Left great toe with a scant amount of thick tan drainage at large knuckle. Area covered with DSD. Left heel is pink with escar. Area cleansed with wound cleanser and DSD applied.\\n\\n->Right lower posterior leg with open area. Area is pink with +granulation. Area cleansed well with wound cleanser, adaptic and DSD to the area. Right heel is pink, +eschar, no drainage. DSD applied.\\n\\n->Right toes with small black non-draining areas. DSD covering for padding.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524287,\n \"text\": \"Respiratory Therapy\\n\\nPt remains trached w/ #7.0 Shiley trach on full mechanical support. No vent changes made this shift. Continues on A/C ventilation w/ PIP/Pplat = 24/20. BLBS coarse, suctioned for small amounts of thick tannish/yellow sputum. MDIs given as ordered. SpO2 90s. ABG good. See resp flowsheet for specific vent settings/data.\\n\\nPlan: maintain support\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524288,\n \"text\": \"Please See Carevue for Specifics.\\n\\nArousable to voice, does not follow commands, only moves LUE to nailbed pressure. Afternoon dose of 0.5mg Ativan held this afternoon for ?sedation. NSR, frequent PVC's, ?borderline first degree AV block and left BBB. +generalized edema, fluid balance goal is to be even/24hours. Remains on CMV. Suctioned for thick yellow secretions. Lungs are coarse-clear and diminshed at bases. ABd is obese with +BSx4, G-tube to gravity with clear/yellow mucous, J-tube with TF at goal. Pt does not void.\\n\\nSKIN: See previous assess entered. Bil hip dressings changed, +granulation, draining small amounts of sero/sang. Aquacel AG applied after cleansed with wound cleanser, alleyvn covering. Iliac Crest draining small amount of thick yellow discharge. Area cleansed well with wound cleanser, Aquacel AG applied to area, followed by DSD, and super-sorb pad.\\n\\n: Monitor MS, monitor skin integrity, dressing changes as ordered. Ativan when not sedated. Continue to offer emotional support to pt and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524138,\n \"text\": \"Condition Update A:\\nPlease refer to careview and remarks for details.\\n\\nPt alert, when dozing pt is easily arousable, inconsistently follows commands. Moves LUE only. PERL 3-4mm bilat. Indications of pain during repositioning.\\n\\nTmax 100.1, low 98.7. Cont in afib 90-116 with rare PVC's.. SBP >90 tol MAP's >50 as discussed with Dr. . Potassium repleted per Jtube. During HD BP ranged 80-100's. 2L removed.\\n\\nLS CTA dim bases. Suctioned scant secretions. Trach care done.\\n\\nLE dsgs changed as in careview. Jtube dsg changed x2 as copious mucous drainage bursts dsg. Under flange of jtube are two open areas. The first is at the 1000 position with a yellow slough wound bed. The second is at the 0500 position with small amount of bleeding. Dr. from IR up to see pt and made aware of drainage from insertion site and the two open areas under flange.\\n\\nLantis dose increased as glucose levels remain greater then 250.\\n\\nHCP, , discussed her concerns. Support provided. Dr. and Dr. notified.\\n\\nPLAN: Neuro exam every four hours. Skin care per orders. Labs per orders. Monitor glucose levels and effect of lantis increase. Reposition every two hours. Monitor hemodynamics, SBP>90 and MAP>50. Facilitate discharge. Call H.O. with changes.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524139,\n \"text\": \"Respiratory Therapist\\nBreath sounds bilaterally diminished, few wheezes, suctioned for small thick yellowish, WBC 11.5 consistent with bacterial infection, Hemoglobin 9.1 consistent with anemia, creatine 2.3 suggesting renal insufficiency for which patient had hemodialysis this morning, patient was afebrile whole day and stayed into chronic A-fib,no ABGs today, patient will continue to receive ventilatory support and close monitoring.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524140,\n \"text\": \"Focus-Condition Update\\nData-Low grade temp during the night. No vent changes-pt suctioned for sm ams clear white secretions. Dressings changed as scheduled.\\nBlood sugars better controlled with increased Insulin dose. Continues to have mod amt clear mucousy drainage from around PEJ site.\\nAction-Continue to monitor. AM labs drawn as ordered.\\nResponse-Ongoing evaluation.\\nPlan-Continue to monitor Blood sugars closely. Ongoing discharge planning for discharge to home.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524141,\n \"text\": \"Resp Care: pt continues trached and on ventilatory support with a/c, no vent changes maintaining spo2 100%, persistent minimal cuff leak but attaining volume; BS coarse, sxn thick white secretions, rx with mdi albuterol/atrovent/flovent, rsbi 93, consider short trach collar trials\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524226,\n \"text\": \"Respiratory Therapist\\nBreath sounds revealed clear right lung and diminished left lung, suctioned for small thick yellowish, still on droplet precautions for MRSA, afebrile and stayed whole day into chronic A-fib, Oxygen saturation stayed around 100, patient was treated with Albuterol, Atrovent, Flovent inhalers, WBC 20.9 consistent with bacterial infection, Hemoglobin only 9.1, signs of anemia, no ABG drawn nor vent changes done during the shift, patient will remain vented, most likely on same settings and will continue to be closely monitored.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524321,\n \"text\": \"condition update\\nno significant change in status; still requires pressor support. given replacements as ordered. crrt on/off= fluid removal dependant on bp, acidosis worsening . discussed with resident and will attempt to support bp to allow for optimal fluid removal.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524322,\n \"text\": \"Respiratory Care\\nBreath sounds bilaterally coarse, suctioned for moderate thick green, oral temp ranged 96.5 to 98.1 using warming blanket since she stay on CCVHD whole day, WBC 9.8 ruling out the presence of bacterial infection, hemoglobin only 8.5 which is indicative of anemia, lactic acid 3.4, pressure 15cmH2O, patient has been treated with Albuterol, Atrovent and Flovent inhalers. Projected family meeting did not happen today, is postponed for tommorrow. No vent changes ordered nor made today, settings are the same.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524323,\n \"text\": \"nsg note\\nsee flowsheet for specifics.\\n\\nNEURO-OPENS EYES SPONT. MOVES LEFT ARM ON BED. DOES NOT MOVE OTHER EXTREMITIES.\\n\\nCV-BACK IN AFIB. RATE 70-100'S. DOWN TO 70'S. ON MAX DOSE OF NEO. TO START VASOPRESSIN. SKIN WARM. JAUNDICE.\\n\\nRESP-REMAINS TRACHED AND VENTED. NO VENT CHAGNES MADE TODAY. PT ACIDOSIS IMPROVING. SXN PRN FOR THICK YELLOW SPUTUM. LS COARSE WITH SOME WHEEZES AND RHONCHI. INHALERS GIVEN. O2 SAT 98%.\\n\\nGI-ABD OBESE, +BS. TOL TF VIA . PEG TO GRAVITY WITH BROWN TO YELLOW DRG. STOMA PINK WITH LOOSE GOLDEN STOOL. + MUCOUS DRG FROM ANUS. HAD US OF RUQ.\\n\\nGU-ANURIC ON . UNABLE TO TOL ANY FLUID REMOVAL D/T HYPOTENSION.\\n\\nENDO-ON INSULIN GTT.\\n\\nACT-REPOSTIONED FREQ. ON AIRBED.\\n\\nSKIN-CON'T WITH MULTI SKIN ISSUES. SEE FLOWHSEET. DSGS CLEANED AS ORDERED. SKIN UNCHANGED.\\n\\nID-HYPOTHERMIC WITH BAIR HUGGER ON.\\n\\nP-CON'T WITH CURRENT PLAN. NEO AND VASOPRESSIN GTTS. SKIN CARE. INSULIN GTT. FAMILY MEETING PLANNED FOR TORROW AT 3PM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524324,\n \"text\": \"Respiratory CAre\\nPt. trached and chronically ventilated. Sx for thick secretions. No vent setting changes made this shift.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524325,\n \"text\": \"condition update\\ncondition continues to remain guarded with bp 80-90 systolic on 5mcg neo and 2.4 pitressin. crrt keeping even to 50ml removal but pt still very much compromised with decreased pressure\\ninsulin titrated for bs no real issues. team aware of am labs and will discuss treatment during rounds. pt has no visible evidence of bleeding. will continue to monitor\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524326,\n \"text\": \"Respiratory Care\\nPt remains trached and on vent support. No vent changes were made during shift. Lung sounds were course throughout. Pt was suctioned for moderate amounts of thick yellow secretions. Pt received MDI's as ordered. Last ABG 7.39/34/84/21/-3. Care plan is for a family today. No vent changes to be made. Will continue to follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524405,\n \"text\": \"resp care\\nremains on ac mode. no changes made this shift. mdi's given q4h. sxned yellowish sputum. trached/vent dependant. positional leak with pressure kept at <30 cmh20. tolerating well. minimal to no spont efforts.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524406,\n \"text\": \"Nursing Update\\nSee flowsheet for specific info\\n\\nNeuro: Pt nodding and tracking occasionally, not following commands, no movement of extremities noted. Afebrile.\\n\\nCV: NSR with occasional PVC's, kept above 80, Neo gtt remains off. Crit stable despite vag bleeding and blood in stool. PICC line dressing very leaky, line is out about 7cm, MICU aware.\\n\\nResp: Remains vented, CMV, PEEP 5, 50%. No vent changes made today. Sux'd for small amount of thick yellow sputum, lungs coarse throughout, sating 90-100%.\\n\\nGI: Bloody stool in colostomy, MICU aware, crit stable 26-27. GI consulted this morning, pt to have colostomy in a.m., TF's off, Go-lytly started for bowel prep.\\n\\nGU: Pt anuric, scheduled to be dialyzed tomorrow.\\n\\nEndo: Insulin gtt off. Blood sugar low today (20's) 1 amp D50 given, MICU HO aware, Glargine to be held this evening.\\n\\nSkin: All dressings changed today.\\n\\nPlan: Coloilioscopy to be done tomorrow.\\n Closely monitor blood sugar.\\n Dialysis tomorrow.\\n Home by end of week.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524407,\n \"text\": \"NURSING NOTE\\nPLEASE SEE CAREVUE FOR DETAILS\\n\\nNO MENTAL STATUS CHANGES, NODDING INTERMITTENTLY, MOVES ONLY LUE, NOT FOLLOWING COMMANDS. PERRL, 4MM, BRISK, OPENS EYES SPONTANEOUSLY. HR 60S-70S, >80/MAP>55, REMAINS OFF DRIPS, AFEBRILE. HCT 26.6, K 3.6, MAG 1.8, HO AWARE. NO VENT CHANGES MADE, LUNGS COARSE THROUGHOUT. PT SUCTIONED FOR MOD AMTS YELLOW, THICK SECRETIONS. TF OFF SINCE MN, COLOSTOMY W/SM AMT MAROON, LOOSE STOOL, GT W/MIN OUTPUT. BS DOWN TO 20S THIS EVE, 1/2AMP D50 GIVEN X3, PRESENTLY 50S-HO AWARE, TO MONITOR. PT TURNED FREQUENTLY, NO NEW AREAS OF BREAKDOWN NOTED, SEEPING MOD AMTS SEROUS FLUID TO MULTI SPOTS.\\n\\nPLAN: HEMODYNAMIC MONITORING, FREQUENT BS CHECKS, DEXTROSE AS NEEDED, SERIAL HCTS. AGGRESSIVE SKIN CARE, HD PLANNED FOR TODAY, POTENTIAL D/C HOME THURS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524408,\n \"text\": \"Resp Care\\nPt. remains trached on AC mode w/o change overnight. BS: coarse t/o sxn'd q4 for mod. thick greenish yellow. Mdis given q6 as ordered.\\nPlaN:HD today and possible d/c home later this week. Pt. needs to be transitioned to home vent at some point today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524409,\n \"text\": \"BS coarse crackles; no change with MDI's. Pt had HD today and is now awaiting colonoscopy. After procedure will attempt to transition to home ventilator (). If she tolerates vent successfully for about 2 days, she will be discharged home.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524284,\n \"text\": \"focus update note\\nhypothermic 95-96 with bair hugger on pt 97-98 consistently most of day, currently bair hugger off last temp 98.7, initially heart rate 130-150 afib- 78-high 80s, pt given one unit PRBC and heart rate improved to 102, increased high 90s to 120. diltiazem gtt started at 5mg/hr. goal map >55, goal CVP = 10, initially cvp 17 now 10.\\n\\nresp: minimal suctioning secondary to platelet count 22-30, suctioning for small amount yellow thick sputum, no vent changes today, o2 sat consistently 100%, lsc dim at bases\\n\\ngu/gi: ileostomy draining yellow liquid stool, anuric, TF continue- no residual, bs hypoactive\\n\\nskin: changed decub and hip dressings at 1600, skin red with good granulation, scant bloody drainage, yellow slough, toes black on bilateral feet, skin under pannus ulcerated open drainag yellow draiange- resident notified and aware- area cleaned with wound spray and dressed with dsd.\\n\\nCRRT clotted at 1700 and restarted at 1800, please see dialysis flowsheet for details\\n\\ngoals: map > 55, cvp 10, run CRRT to keep pt 1 liter positive over 24 hours, continue with wound care as ordered collaborate with skin RN as needed, continue with lab monitoring q 6 hours, transfuse platlets for less than20, moniotr for signs symptoms bleeding, control blood sugars with insulin gtt and monitor finger stick q 1 hour.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524285,\n \"text\": \"Update\\nO: See carevue for specifics...\\nNeuro: awake,alert,perl @ 4mm brisk.moving lue otherwise no mvmnt.\\n\\nCV: sr to on diltiazem gtt. 90-110 range Cvp 12-15 range.Cont on crrt w goal overnight 1 liter positive achieved. Vss overnight.Doppler dp's bilat, necrotic toes. Ble drsg d&i.\\n\\n\\nResp: trached on cmv mode tv 450 rr 16 fio2 40% w peep 5cm w adeq abg on same.Lungs lcear diminished, lavaged and suct for thick yellow.\\n\\nGi: g-j tube w tf at goal 40cc/hr via jtube, gt to gravity.Abd obese soft, colostomy w loose golden brn stool. glucoses managed per riss.\\n\\nGu/Renal; on crrt and tol well w current goals 1liter + .Cont on K+ Ca+ gtts per ss.\\n\\nHeme/Id: hct 27, plt ct holding at 33K pt 18.4 inr 1.7. wbc flat. temp subnl at times req bair hugger blanket.HO aware plt ct's <50 and no rx ordered.\\n\\nskin/wounds: coccyx decub drsg , purulence non healing site. Wound cleanser and aquacell packing and sofsorb drsg .Bilat lower leg dsg intact.Excoriated area under -> miconazole to site.\\nA/P: Cont crrt w lyte repletion per ss. Confirm crrt goals for today w renal fellow. Pulm toilet. Wound and skin care.Q!h glucoses and titrate insulin gtt.Empty and record colostomy q shift.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524346,\n \"text\": \"Respiratory Care:\\n\\nPatient trached with 7.0 shiley. Vent dependent. Vent settings unchanged. Vt 450, A/c 16, Fio2 40% and Peep 5. 02 sats 99%. Bs clear bilaterally. Sx'd for sm amount of thick yellow secretions. Albuterol/Atrovent MDI's given Q4hr and Flovent given . CXR Worsening pleural effusions. Sputum + for Pseudomonas. No further changes made. Continue with mechanical support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524347,\n \"text\": \"Focus Condiiton Update\\nSee flowsheet for specific info.\\n\\nNeuro: Pt dozing off and on throughout the day, will occassionally nod to simple questions. Not following commands.\\nCV: A-fib 100-120's. Neo on this a.m., weaned off this afternoon. Pt had one episode of wide complex tachycardia to 140's, MICU team at bedside, EKG obtained, 2gm Calcium Gluc given, 20mg Diltiazem given. Pt's HR returned to 90's while pushing Dilt. K+ of 3.3 repleted.\\nResp: Pt remains on CMV, no vent changes made today. Sux'd for small amount of thick white sputum.\\nGI: Abdomen is obese, +BS. G-tube to LCS draining brownish stool. Colostomy intact, also draining small amount of brownish loose stool.\\nGU: Pt continues to have a small amount vaginal bleeding, OB has not yet consulted at time of note.\\nSkin: Wound care RN in this a.m. to change all dressings. Xeroform in skin folds replaced.\\nEndo: BS's running high, MD aware, Insulin gtt restarted, sugar checked qhr.\\nSocial: Husband and son in briefly this morning to see pt.\\nPlan: Titrate Insulin to keep BS 100-150\\n Continue to monitor hemodynamics\\n Change wound dressings as needed\\n Family support.\\n Cont. with MICU , contact HO with changes\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524348,\n \"text\": \"Resp Care\\nPt reamins trached on full vent support. no vent changes made this shift. Pt continues to have mod amt of thick yellow sputum. MDIs given. will continue to follow\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524349,\n \"text\": \"Please See Carevue for Specifics.\\n\\nPt has had no change over night. Pt kept comfortable and with skin care, back rub, repositioning, and reassuring of care.\\n\\nSOC: Pt son was escorted out of building by security this evening for his continuous demanding and swearing behaviors to all staff. MICU resident, MICU attending, Nursing Supervisors aware of plan. Son is allowed supervised visits with security for 30 minutes/day. Security has explained the restrictions to the son. Pt HCP also aware of plan.\\n\\n: Continue to keep pt comfortable, pain meds as needed, HD this morning, skin care as ordered, surgical team to follow, family aware of plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524350,\n \"text\": \"Respiratory Care:\\n\\nPatient trached with 7.0 Shiley. Bs coarse bilaterally with crackles R base. Some increased WOB noted at beginning of shift. Secretions unchanged. Sx'd for sm amounts of thick yellow secretions. Albuterol/Atrovent MDI's given Q4hr and Flovent . CXR repeated. Peep increased to 8cm for increased fluid. Repeat ABG's revealed PaCO2 slightly elevated. Current vent settings Vt 450, A/c 16, Fio2 40% and Peep 8. No further changes made.\\nPlan: Continue with mechanical support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524351,\n \"text\": \"pt remained on full vent support throughout shift, Bronch done around 1PM looking for any abnormalities but was negative. Different settings attempted in order to make pt look more comfortable, but unsuccessful. Sx'd for minimal secretions. ABG within normal limits.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524227,\n \"text\": \"Respiratory Care\\nPt remains trached on ventilator. No vent changes made. BS clearer today, still diminished at bases. Suctioned for small amount of thick tan secretions. No ABGs drawn this shift. Pt oxygenating well with SpO2 100%. MDIs given as ordered. RSBI attempted but pt showed no spontaneous effort.\\nPlan: continue ventilator support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524228,\n \"text\": \"Neuro:pt is alert . response to question by nodding appears appropriate.\\nPain: pt had some discomfort when changing leg dsgs demerol given.\\nCV: chronic AF SBP >85 today. R single lumen picc patent. RSC quinton.\\nlungs: clear to coarse . more secreation today then yesterday. thick yellow sputum. BS more coarse.\\nGI: ABD soft BS present. TF at goal tolerating well. colostomy pink draining brown liquid.\\nGU: foley in place . still with small amt of blood.\\nGYN: still having vaginal spotting of blood.\\nEndo: FS 70-113 on lantus @ 86 q12.\\nSkin: see care view and wound care nurses note. turned q3-4 hours.\\nA/P continue scan care as indicated. monitor as indicated. HD tomorrow. continue lantus at present dose . continue monitoring bleeding. given Vita K as ordered.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524229,\n \"text\": \"Respiratory Therapist\\nBreath sounds clear, few crackles, suctioned for copious thick yellowish secretions, WBC 20.1, ongoing bacterial infection, hemoglobin only 8.6 patient is anemic, patient was afebrile and stayed into chronic A-fib treated with Albuterol, Atrovent and Flovent inhalers, no vent changes nor Arterial Blood Gas done today, patient still under close monitoring.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524230,\n \"text\": \"Respiratory Care\\nPt remains trached on full vent support, breathing slightly over the ventilator. BS coarse & diminished bilaterally. Suctioned for small-mod amounts of thick white sputum. MDIs given as ordered. SpO2 100%.\\nPlan:Continue vent support\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524231,\n \"text\": \"NURSING\\n VSS, AFEBRILE. CONTINUES IN AFIB. HCT STABLE. MINIMAL BLEEDING EITHER VAGINALLY OR FROM FOLEY. NO ISSUES OVERNIGHT. SEE CARE VUE FOR FULL SPECIFICS.\\n CONTINUE TO MONITER HEMODYNAMICS. REPEAT HCT THIS AFTERNOON AFTER HEMO. HEMODIALYSIS TODAY. CONTINUE TO MONITER FOR VAGINAL OR BLEEDING FROM FOLEY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524295,\n \"text\": \"Nursing note:\\n Alert, no neuro change. Not following commands or communicating. Does not appear to be in any pain. PERRLA. No neuro changes. No vent changes, remains trached on A/C. Appears comfortable. Slightly hypothermic this am, Bair Hugger on low to keep temps in 97s. SR, occ PVCs. Dilt gtt titrated down to 5/hr, well tolerated. WBCs elevated today, team aware. Cultured overnight. ID following, on mult. IV abx. EKG done per MICU request. >80 w/MAP >50 on Neo gtt, unable to titrate down. +BS, tolerating TFs via jtube, gtube to GD. Colostomy intact, liquid golden stool. Glucose stable on insulin gtt. Anuric, running to keep pt. even. K+ and Calcium gtts running per sliding scale.\\nImpressive wounds to hips/coccyx and LEs, dressings done per skin care RN recs. See Flowsheet for details.\\n\\nA/P: Remains on and pressors for sepsis as well as multiple medical issues. Continue to monitor closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524296,\n \"text\": \"Respiratory Care Note:\\n Patient remains on full vent support. #7 extra long Shiley trach is secure. BS=bilat, coarse with rales and rhonchi. Suctioned for moderate amounts of thick yellow secretions. Plan to maintain supportive care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524399,\n \"text\": \"Nursing Progress Note\\nPlease see for details\\n\\nNeuro: unchanged.\\n\\nCV: afebrile, bair hugger off with temp maintained. HR A fib with rare pvc's, rate controlled. BP difficult to obtain at times, but remains adequate. Neo drip remains off.\\n\\nPulm: bs coarse, sx for tan thick secretions, but less brown and fewer than yesterday. O2 sats 96-100 when obtainable.\\n\\ngi: tube feeds via j tube at 40/hr tol well. gt to gravity. golden stool from colostomy.\\n\\ngu: anuric, for hemodialysis today.\\n\\nblood transfusion completed, Hct pending with am labs.\\nBlood glucose under control, see flow sheet and labs for FS sugars.\\nInsulin drip remains off.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524400,\n \"text\": \"Respiratory Care\\nPt. trached on ventilatory support. Congested, frequently suctioned for thick tan-green secretions. Trach appears to have positional leak even with adequate . No vent setting changes made this shift. Chronically vented with no plans for weaning, no RSBI performed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524401,\n \"text\": \"Respiratory Care:\\n No change in vent status. Patient receiving dialysis. BS=bilat with occassional rhonchi. Suctioned for thick green tinged sputum and receiving MDIs. See Carevue flowsheet for specifics.\\n Spare #7 X-Long Shiley trach ordered for possible patient discharge to have as spare. Notes written for possible DC .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524402,\n \"text\": \"NURSING NOTE\\nPLEASE SEE CAREVUE FOR DETAILS\\nNEURO: PT OPENING EYES SPONTANEOUSLY, PERRL 4-5MM, BRISK, INTERMITTENTLY TRACKING. NOT FOLLOWING COMMANDS, MIN SPONTANEOUS MVMT, LUE OBSERVED ONLY. NO ATIVAN GIVEN.\\n\\nCVS: REMAINS OFF PRESSORS, MAP MAINTAINED>55, VIA 70S-110S, UP TO 150S W/HD, HO AWARE, ?ACCURACY. PT HEMODIALYSED FOR 1.5L, ALBUMIN GIVEN CONCURRENTLY FOR >50 PER MICU TEAM DURING HD. PM HCT 26.7, AFEBRILE.\\n\\nRESP: NO VENT CHANGES, SET RATE 22, PT BREATHING 2-6 BPM OVER. SUCTIONED Q2-3 HRS FOR SM AMTS THICK, YELLOW-BROWNISH SECRETIONS. LUNGS COARSE THROUGHOUT, RHONCHOROUS AT TIMES. O2 SATS 96-100%.\\n\\nGI/GU: REMAINS ANUERIC. COLOSTOMY PATENT W/MOD AMTS GOLDEN, SEMI0FORMED STOOL. GT TO GRAVITY W/SM AMT VISCOUS YELLOWISH DRNG. JT PATENT, TF AT GOAL, MIN RESIDUALS.\\n\\nENDO: REMAINS OFF INSULIN DRIP, BS 102-138--NO COVERAGE REQUIRED. LANTUS 50 UNITS GIVEN THIS AM.\\n\\nINTEG: MULTIPLE DSG CHANGES PERFORMED PER WND CARE PROTOCOL, PT TURNED FREQUENTLY, NO NEW AREAS OF BREAKDOWN NOTED.\\n\\nPLAN: HEMODYNAMIC MONITORING, AGGRESSIVE SKIN CARE, PULM TOILETING/RESP SUPPORT, FAMILY SUPPORT. PROBABLE D/C TO HOME THURS, REMAIN IN SICU FOR HD ON WEDS, SICU .\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524403,\n \"text\": \"CONDITION UPDATE\\nD: PLEASE SEE CAREVUE FOR SPECIFICS\\nNEURO: OPENS EYES SPONT. INTERMITTENTLY TRACKING. PERRL. NO SPONT. MOVEMENT SEEN IN EXTREMITES. PT DOES APPEAR TO GRIMACE WHEN ABD LIFTED TO PERFORM SKIN CARE ON FOLDS.\\nCV: AFEBRILE. REMAINS IN AFIB WITH RARE PVC'S. 80-95.\\nRESP: NO VENT CHANGES. SX FOR SM AMTS THICK YELLOW SECRETIONS. BS COARSE.\\nGI: TOL TF AT GOAL. PEG TO GRAVITY DRAINING LIGHT TANNISH-BROWN. OSTOMY PATENT WITH LOOSE REDDISH BROWN STOOL. HO AWARE. HCT STABLE AT 27.\\nGU: DIALYSIS SCHEDULED FOR WEDNESDAY\\nENDO: OFF INSULIN GTT. BS 72-90.\\nA/P: . TO MONITOR HEMODYNAMICS, SERIAL HCTS AS ORDERED, . DRESSING CHANGES AS PER WOUND CARE NURSE., ASSIST FAMILY IN GOAL OF GETTING PT HOME LATER THIS WEEK.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524343,\n \"text\": \"CONDITION UPDATE\\nASSESSMENT:\\n PATIENT OPENS EYES SPONTANEOUSLY, DOES NOT FOLLOW COMMANDS. ONLY MOVES LEFT UPPER EXTREMITY. PATIENT DOES NOT APPEAR IN ANY PAIN WITH MOVEMENT OR DRESSING CHANGES, NO NEED FOR PAIN MED.\\n HEART RATE 100-110 AFIB AND MAP > 55 ON LOW DOSE NEO GTT THIS AM. PATIENT STARTED ON HD THIS AM, PATIENT WITH HR INCREASING TO 130'S-140'S BUT BP STABLE. HD RN UNABLE TO REMOVE ANY FLUID, FILTRATED FOR 2 HOURS AND TREATMENT STOPPED. AFEBRILE, WBC COUNT NORMAL. INR 2 THIS AM & PATIENT HAVING MODERATE AMOUNTS ? VAGINAL BLEEDING. 2 UNITS GIVEN, AWAITING REPEAT LABS.\\n LUNG SOUNDS OCCASIONALLY COARSE, SUCTIONED FOR MODERATE THICK YELLOW SPUTUM. REMAINS ON ASSIST CONTROL. ABDOMEN SOFTLY DISTENDED, J-TUBE CLAMPED AND G-TUBE TO LOW CONT SUCTION WITH MODERATE AMOUNT BROWN DRAINAGE. COLOSTOMY STILL WITH MINIMAL LOOSE BROWN STOOL. ? BOWEL OBSTRUCTION RESOLVING. PATIENT TO BE STARTED ON TPN TOMORROW. SEE FLOWSHEET FOR MULTIPLE SKIN AREAS AND TREATMENT.\\nPLAN:\\n WEAN NEO TO OFF. REPEAT KUB TOMORROW TO SEE IF BOWEL OBSTRUCTION RESOLVING. CASE MANAGER AWARE OF PATIENT. CONTINUE WITH SKIN CARE.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524344,\n \"text\": \"Resp Care\\nPt reamins trached on full vent support. No vent changes made this shift. innner cannula changed this afternoon. Pt suctioned for sm amt of thick pale yellow secretions. plan at this time is to continue vent support, please see carevue for current settings.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524345,\n \"text\": \"Please See Carevue for Specifics.\\n\\nNeuro: Alert, orientation unknown, does not follow commands, evening dose of 0.5mg Ativan adm and early morning dose held.\\n\\nCV: Afib 100-130's. Neo weaned off. Generalized edema.\\n\\nRespir: Remains on CMV. Suctioned for scant amount of thick yellow secretions.\\n\\nGI: Abd is softly distended, +bsx4, Gtube to LWCS with thick brown/ stool draining, aware of findings. Stoma pink and draining scant amounts of loose stool. Clear/yellow mucous draining from rectum.\\n\\nGU: Vaginal bleeding, aware, GYNO/OB to .\\n\\nSKIN: per family request: Xeroform applied to all folds: Underarms, under breast, groin area. Sacral area with thick yellow/green foul drainage. Area cleansed well with soap and water followed by wound cleanser and Aquacel Ag, softsorg to cover. Right trocanter site with thick yellow foul drainage. Site also cleansed with soap and water followed by wound cleanser and Aquacel Ag. aware of findings, no intervention at this time.\\n\\n: Wound RN to follow . Gyno/OB consult . HD scheduled . Continue to monitor skin integrity, hemodynamics, family meetings as needed. ID to follow regarding antibiotic treatment. KUB scheduled to see if bowel obstruction is resolving.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524431,\n \"text\": \"Respiratory Care\\nBreath sounds bilaterally coarse, suctioned intermittently for moderate thick yellowish secretions, pressure 20cmh2o, patient was afebrile whole day, stayed mostly into normal sinus rhythm, and was mostly hypotensive. Patient was treated with Albuterol and Atrovent inhalers, was swithched at 1015 am on her own home ventilator HT 50 with the help of respiratory supervisor,4L O2 bleeded in instead of dialing an FiO2, settings are about the same they were on , 450 x 22 5PEEP, patient might get discharged with next two days, should be put back on vent overnight since she has tracheostomy and the home vent only has HME. No ABGs drawn nor vent settings changes done up to this point.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524432,\n \"text\": \"Nursing Note 7a-7p:\\nNursing Assessment:\\n\\nPt afebrile all day, white count coming down. Tentative plan to d/c home tommorrow but pt may have to stay d/t issues with supplies being covered by medicaid, which social work and casemanagement have been working on. Wound care nurse needs to contact medicaid and explain dressings/wounds and amounts of supplies needed. Wound care also to arrange a time with pt's family to go over the dressings for home . Other issues include GI to discuss with pt's dtr reasons for not changing over site again (including risk for bleeding/fistula formation). Vascular to be in touch with pt's dtr regarding toes and if they want to remove the toes or not. Dtr does not want BKA, but may be willing to remove just toes per case . Pt's dtr also requested that the pt be placed on home vent for trial prior to d/c home and has tolerated the home vent well all day today. Will go back on hospital ventilator tonight for humidification on trach. Home vent will be able to do this once set up at home, but we do not have the supplies here. CV: HR NSR to sinus <110 relieved with ativan and demerol and no ectopy. Mag repleted this morning. Continues on amiodorone, digoxin, midarone po, diltazem po d/c'd d/t continued low bps. HCT now stable at 31 and no further products necessary at this time. Endo: RISS and am glargine sugars 200s adn team aware. REsp: lungs coarse at times, cleared with suctioning, and diminished throughout. Placed on home vent this morning and tolerated well all day.\\nPlan: Discharge planning continues, working towards getting patient home this week. Social work and case management. Vascular/GI to discuss plans with dtr regarding /amp of toes. Dialysis tommorrow. Wound supplies needed for home. to monitor hct and glucose levels, if remain stable ok to d/c home and when all other previously mentioned issues are resolved. MICU team has been updated with all concerns/issues mentioned above. Please refer to carevue for details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524433,\n \"text\": \"Update\\nSee Carevue for specifics\\n\\nNeuro: Alertness waxes and wanes but unable to assess orientation. Will nod appropriately to questions. Follows commands inconsistently. Localizes pain. Purposeful movements at times. Lifted and held LUE. No movement in other extremeties. PERRL.\\n\\nCV: ST early in shift correlating with tmax of 100.7. Blood cx'd. Currently afebrile and NSR. 70s-110s. Hct pending.\\n\\nResp: Switched from home vent back to . LS coarse/diminished. Sats 98-100%. Sxn'd for moderate thick yellow secretions.\\n\\nGI: TF to goal, no residuals. Colostomy draining golden liquid stool. G tube draining clear fluid. Drainage bag around G-J tube collecting serosang drainage. Chem 7 pending.\\n\\nGU: HD scheduled for next shift.\\n\\nSkin: Grossly impaired. See Carevue for details.\\n\\nPsychosocial: son in to visit early evening.\\n\\nPlan: Wound care RN to contact Medicaid & meet with daughter for wound care education. Continue planning discharge.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524434,\n \"text\": \"Respiratory Care:\\nPatient switched from home ventilator to , as noted in CareVue. SX'd for small to moderate amounts of thick, yellow sputum. No abg results this am.\\n\\nNo due to hemodynamic instability.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524297,\n \"text\": \"nursing note\\nNeuro:Pt alert, nodding approp at times. Daughter in to viisit and upset with head motion side to side, as in nodding \\\"no\\\". MD aware and spoke with daughter regarding this. hypothermic-bairhugger on.\\nCV: NSR wtih rate controlled on dilt. Neo weaned slightly to .3. cont to keep even.\\nRESP:ls coarse, thick white sputum. ambu'd and lavaged by RT and valve tried but pt unable to talk. Done per fmaily request.\\nGI:loose brown stool via ostomy. GT/JT site with small pink drainage with air into bag into pouch.\\n\\nPLAN: cont to keep even. dilt/neo/insulin. awaiting plan from family.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524298,\n \"text\": \"Respiratory Care Note:\\n patient remains trached with a #7 x-long Shiley trach in place and secure. Trach collar changed this shift. BS are coarse throughout. MDI's administered as ordered. Patient ambued and lavaged x 1 for a scant amount of thick white secretions. attempt made post ambu and patient too tired and unable to speak. Patient then placed back on full vent settings with inflated. SX for small amounts of white thick secretions via trach. patient remained afebrile this shift, bair hugger on. SPO2 remains 100%. patient often overbreathes vent by 10-13 breaths. Latest ABG acceptable. No RSBI this am as patient is vent dependent. CXR showed moderate bilateral pleural effusions, increasing on the left. Will continue with full support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524371,\n \"text\": \"Update\\nO: See carevue flowsheet for specifics.\\nNeuro: Eyes open spontaneously perl at 3mm sluggish, does not track w eyes or follow any commands.Med x 1 for ? discomfort, family states pt uncomfortable and appearing more distressed, desires pt to have something for pain. Pt med w dilaudid 12.5mg w no appreciable change in pt status.Distress seems most likely to be respiratory in nature.See resp on carevue flowsheet.\\n\\nCV:sr w occ to freq pac's. Remains on dilt and low dose neo for bp/hr control.Distal pulses by doppler.Mult skin and circ issues w necrotic toes/ lt heel\\n\\nResp: Abg's bdline pao2 - metab acidosis worsening, vent adjustmnts made for same w slow imprvmnt in abg.Bbs coarse, lavage and suction for thick pale yellow secretions.\\n\\nGi: npo. gjtube-to gravity w no drng thru gj tube, 200cc serous around the tube.Abd distended, obese, + hypoactive bowel snds. Colostomy pink, edematous w sm amts of black loose stool.\\n\\nGu/Renal: crf makes no urine.HD 3x week,? to be dialyzed today.\\n\\nHeme/ID: hct 24-25 range, no treatment for now per micu team.Tmax 99.6 continues on meropenem and amikacin.\\n\\nSkin: Multiple non healing decubiti buttocks, rt hip and ble's. Wound care done to all sites.\\n\\n\\nA/P: w supportive icu care. Wean neo and diltiazem as tol. Wound and skin care per wound care nurses plan. Aggressive pulm toilet.Multidisciplinary team family meeting today to discuss pt care plans, update.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524427,\n \"text\": \"Respiratory Care\\nBreath sounds bilaterally coarse and diminished at bases, suctioned intermittently for moderate thick yellowish secretions, was afebrile, stayed mostly into normal sinus rhythm, WBC 13.6, ongoing bacterial infection, hemoglobin only 10, sign of anemia, creatine 1.7, sign of renal insufficiency for which patient had hemodialysis from 0900 am to 1100 am, patient has been treated with Albuterol, Atrovent and Flovent inhalers, no ABGs drawn, no vent changes made during the shift, patient will continue to receive mechanical ventilation and close monitoring.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524428,\n \"text\": \"Update\\nSee Carevue for specifics\\n\\nNeuro: pt. alert but unable to assess level of orientation d/t trache. Pt. nods appropriately to questions, mouths words and actively tracks activity in the room. Inconsistently follows commands. Moved RLE on bed once, no movement from other extremeties but localizes pain.\\n\\nCV: NSR. 60s-105. Rare PVC's.\\n\\nResp: LS clear/coarse. Sats 95-100%. No vent changes. Sxn'd for very thick yellow sputum.\\n\\nGI: TF to goal. Colostomy putting out gold/green liquid stool. G-J tube re-pouched by enterostomal RN and stoma site draining small serosang fluid. G tube draining clear, slightly bilious fluid.\\n\\nGU: Dialysed in a.m. 2.3L removed. Pt. tolerated well with no hypotension.\\n\\nSkin: Grossly impaired with numerous areas of breakdown. Please see Carevue for details.\\n\\nID: Afebrile. Amikacin held d/t high level. New one drawn s/p HD.\\n\\nPsychosocial: husband and son visited in a.m. Daughter talked to RN and MD on the phone.\\n\\nPlan: Continue to monitor hemodynamic status. Continue to treat wounds agressively. Enterostomal nurse to call daughter with update on re: stomas/colostomies. ?trial home vent tomorrow. ?transfer to home on Wed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524429,\n \"text\": \"NPN (SEE CAREVUE FOR SPECIFICS)\\n PT ALERT MOST OF THE NIGHT, MOUTHING WORDS, FOLLOWING SOME COMMANDS. ONLY MOVING LEFT UPPER ARM OCCASIONALLY ON THE BED. PERRL. PT NOT COMPLAINING OF PAIN, APPEARING COMFORTABLE, REPOSITIONED FREQUENTLY.\\nCV- BP RANGING FROM 70'S SYSTOLIC TO 110, MAP 40'S-50'S. DR. NOTIFIED WHEN BP CONSISTENTLY BELOW 80'S SYSTOLIC. I UNIT OF PRBCS GIVEN FOR HCT 26, BP IMPROVED, AM HCT PENDING. HR 90'S, APPEARING TO BE IN A-FIB EARLY IN THE SHIFT, DR. NOTIFIED. KCL REPLETED IN THE LATE EVENING, PT IN NSR AT THIS TIME WITH OCCASIONAL PVCS AND PACS.\\nRESP- LUNGS SOUND DIMINISHED, O2 SAT 99-100%. SUCTIONED OCCASIONALLY FOR SMALL AMOUNTS OF THICK YELLOW SPUTUM.\\nSKIN- OOZING FROM SEVERAL AREAS OF SKIN TEARS, SMALL PIN POINT AREAS, AND VARIOUS DECUBS. MOST DRESSINGS INTACT, OUTER LAYERS OF DRESSINGS CHANGED AND REINFORCED WHEN APPEARING TO BE SOILED.\\nGI/GU- ABD SOFT, HYPO SOUNDS. TOLERATING TF. PT DOES NOT VOID.\\nID- AFEBRILE\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524430,\n \"text\": \"RESPIRATORY CARE NOTE\\n\\nPatient remains trached with Shiley ex. long trach tube. No vent changes made during the . No MD order.\\n\\n , RRT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524135,\n \"text\": \"Nursing Progress Note\\n Please see carevue for details of care. Alert, eyes open,follows simple commands and randomly nods yes or no but inconsistently. Spont movement in LUE only. PERL @ 4mm. Restless at times, settles down w/repositioning. BS cl/dim, suctions via trach for scant-small thick yellow secretions. Vent AC 450x16x40%+5PEEP.\\n To IR this am for Peg tube change, tol well. No drainage around PEG post insertion this pm. TF and meds resumed after ok w/MICU resident on unit, minimal TF residual noted. BOS +, colos draining brown liquid BM.\\n Multiple wounds persist, leg wounds dressing changed per wound care directions tol well. See carevue for specifics. Legs wounds draining pink serous drainage, no purulent or fkoul smelling drainage noted. Coccyx/ischial dressings to be changed on B shift.\\n Insulin gtt remains off this shift, BS elvated to 300's, covered w/RISS. Glargine changed to dosing and SS tightened by team. team in this pm, aware of adjustments pending.\\n Dgt/husband in this pm. Insist on feeding patiernt ice chips in spite of direction of staff not to d/t cuff leak and chance for aspiration. Daughter upset that PEG was changed and placed in Jejunum. Attempted to obtain records from admit but unable d/t time of day (after 5p). Will attempt record retrieval on Monday.\\n PLAN: Continue to monitor glucose needs/demands, dressing changes, monitor VS, family support and education.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524136,\n \"text\": \"NURSING PROGRESS NOTE: SEE CAREVUE FOR OBJECTIVE DATA AND TRENDS\\n\\nNEURO: ALERT. OCC MOUTHING WORDS TO MAKE NEEDS KNOWN. APPEARS TO NOD APPROP TO YES/NO QUESTIONS. INCONSISTENTLY FOLLOWS COMMANDS. PERRLA, 4MM/4MM,BRISK. OCC SPONTANEOUS MOVEMENT OF LUE. +WEAK COUGH. MEDICATED WITH 12.5MG DEMEROL X1 FOR TROCANTER/COCCYX DRESSING CHANGE. PT TOLERATED DRESSING CHANGE WELL.\\n\\nCARDIAC: HCT: 28. A-FIB. HR-90'S-110'S. NIBP: 93-110/39-67. 12.5MG LOPRESSOR GIVEN WITH EFFECT. COUMADIN 2.5MG GIVEN. INR: 2.6. +RADIAL/FEMORAL/POPITEAL/PT/DP X2. CSL ON.\\n\\nPULM: TRACHED. CMV/40%/450/5 PEEP. POX: 98-100%. LS: R+LUL CLEAR,DIMINISHED BIBASILAR. SX FOR SM AMTS OF THICK YELLOW SPUTUM.\\nVENOUS GAS SENT AT 1800 ON WNL.\\n\\nGI: REMAINS NPO. G-TUBE SITE WITH SM AMT OF CLEAR DRAINAGE. DRESSING CHANGED. TOLERATING TF AT GOAL WITH NO RESIDUALS. ABD: OBESE,+HYPOACTIVE BS,S,NT. OSTOMY STOMA MOIST PINK WITH BROWN LIQUID STOOL.\\n\\nGU: ANURIC. LYTES WNL.\\n\\nENDO: FS QID. FS: 258-277. COVERAGE PER RISS. LANTUS INCREASED TO .\\n\\nINVL: R-AC SINGLE LUMEN PICC. SITE WNL,DRESSING INTACT. R-HD CATH SITE WNL,DRESSING INTACT.\\n\\nID: AFEBRILE. CONTINUES ON MEROPENEM.\\n\\nSOCIAL: DAUGHTER AND HUSBAND IN TO VISIT. CRITICAL QUESTIONS REGARDING G-TUBE PLACEMENT/DRAINAGE AROUND SITE ADDRESS. FAMILY CONCERNED ABOUT DISCHARGE TO HOME D/T MEDICAL NEEDS.\\n\\nPLAN: Q 4 HOUR NEURO CHECKS. MONITOR HEMODYNAMICS. FOLLOW FS Q4-6 HOURS. LANTUS INCREASED TO . CONSULTED ON . MEDICATE PRN FOR PAIN. DRESSING CHANGES TO TROCANTER/COCCYX AND LOWER EXTREMITES QD. WOUND CARE CONSULT TO ADDRESS DRAINAGE AT G-TUBE SITE. REPOSITION Q 2. SURVAILLENCE LABS PRN. MONITOR INR'S. PROVIDE EMOTIONAL SUPPORT TO PT AND FAMILY. SOCIALWORK CONSULTED AND TO FOLLOW.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524372,\n \"text\": \"Nursing Progress Note\\n Please see carevue for details of care. HD tol well this am, BP remains stable on 0.2mcg of neo. Dressing changew post HD today for mod-lg amt drainage and multiple areas of skin tears persist around wounds. Nuero satatus unchanged this shift, does not track movements in room.\\n Blleding from colostomy site w/large amt dark black clots in colostomy appliance followed by bright red blood. Labs drawn, HCT 21.9. Total 6 units PRBC's, 1 unit and 1 dose of DDAVP hung. 1L LR infusing wide open, EJ line attempted unsuccessfully by MICU attending. TO angio this pm.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524373,\n \"text\": \"Respiratory Care:\\nPatient remains on A/C ventilatory support, returning from IR. No parametr settings changed throughout the night. Latest abg results determined a mild metabolic acidemia with very good oxygenation on the current settings. MDI albuterol and atrovent administerd in-line with each vent check. Sx'd for a moderate amount of thick, yellow secretions at the last vent check.\\n\\nNo RSBI measured at this time due to the patient's high FIO2 and unstable cardiodynamics.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524374,\n \"text\": \"Update\\nO: See carevue flowsheet and IR flowsheet for specifics.\\nPt in IR until 2330.Relatively stable on neo 0.5 to 1.25 mcg/kg/min and ppfl at 20mcg/kg/m for sedation.Attempts by IR MD unsuccessful d.t inabilty to locate any bleeders. Hct stable at 34 x 2 in IR suite. Tlc line placed in IR and pt returned to sicu. Overnight pt req relatively more neo and flds to maintain ~80 and mbp 55. Per micu team pt to have endoscopy today-> golytely initiated and pt putting out initially lg dk clotty drng via colostomy-> to brb w hct drop. Fld x 2 liters and colloid resusc w x4 units and 5 prbc overnght. Despite aggressive volume resusc pt still having difficulty maintaining bp, neo gtt max dose at 5mc/kg and vasopresssin added w some improvemnt until 630am w incr via colostomy pt req more bld products and levophed ordered to support bp. Dr here and aware of changes, Endoscopy called by Dr to notify of urgent need for scope early am.\\nCv- remains in afib, rate fairly controlled;unable to receive diltiazem overnight d/t low bp. Doppler pulses present and groin sites check per protocol orders. Sm hematoma rt groin, intermitt sm ss ooze rt groin only.\\n\\nResP: remains vented on cmv mode-see resp sheet/ w metab acidosis. HO aware. Bbs coarse suct for mod amts of thick yellow sputum.\\n\\nGi: gj tube to drng bag w sm to mod coffee grnd around gjtube, nothing draining through it. Abd obese slt firm distended. Colostomy as noted above w overnight.Glucoses managed w insulin gtt. Nutrition overnght receiving tpn.\\n\\nGu/Renal: hd yesterday tol well w 3liters removed.\\n\\nSKin: mult decubs buttocks, bilat lower legs and anasarca. Drsgs changed per skin care nurse.\\n\\nPsych/Soc/ Family: extensive support and allowance for time for questions to be answered given by Dr ; nursing and resp staff as well addressed some of family's questions and concerns. Pt family daughter & son escorted by security for visit. Daughter hostile and voicing discontent of her mothers care to medical and nsg staff, spoke w Nsg supervisor as well.\\n\\nA/P: titrate neo, levo, pitressin for goal 80 mbp 55. check results of hct & check w HO re: # of prbc transfused. Glucoses q1 and titrate gtt. per protocol.Keep case managemnt up to date and involved w team to maintain clear communication w family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524451,\n \"text\": \"Respiratory Care\\nPt remains trached and on vent support. No vent changes were made during shift. No ABG's were drawn during shift. Lung sounds clear at start of shift and became course and diminished in the bases. Pt was suctioned for scant to moderate amounts of thick yellow secretions. Pt received MDI's. Albuterol was NOT given at 1200 and 1600 due to HR >110. Pt received Flovent at 1200 as MDI was empty and replacement not available at 0800. Care plan is to place pt on home vent tonight at midnight and leave on vent until D/C for home. Will continue to follow pt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524106,\n \"text\": \"nursing progress note\\nPlease see careview for details\\n\\nNeuro: perl, nods to some questions, not moving extrmities on bed. nailbed pressure not applied due to discoloration and eschar of extremities.\\n\\nCV: afib, heparin drip at 750 u/hr with ptt 77. bp stable. bilat pedal pulsses palp, rt foot toes black, bleeding from debrided area with dsd changed x 2. hct stable.\\n\\npulm: vented at 40 %. A/C. sats 100%, sx sm-mod amts thick tan. bs clear to diminished in bases.\\n\\ngi: tol tube feeds well, colostomy drainage 200 cc guaiac trace pos.\\n\\ngu: anuric, for hemodialysis today.\\n\\nskin: rt foot wound is black with eschar. dsd changed x 2 for mod amts bleeding. all other dsgs clean and dry, changed x 1 /day.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524107,\n \"text\": \"nursing progress note\\ninsulin drip at 20-3 u/hr to regulate high blood sugars. glargine 80 u sc given at 2200.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524108,\n \"text\": \"Respiratory Therapy\\nPt remainstrached #6 Shiley cuff pressure 38cm. BS coarse rhonchi bilaterally W diffuse I&e wheezes which clear after Sx and MDI's.Sx for sml to mod thick yellow/tan secretions. Please see nsg note and carevue for specifics.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524109,\n \"text\": \"Resp Care\\npt remains trach on mech vent. no vent changes this shift. pt taken to MRI today for scan of lower back bed sore, trip uneventful. pt has slightly course/wheezy BS, suctioned for sm-mod amt of thick secretions MDIs given as ordered. will continue to follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524110,\n \"text\": \"NPN (SEE CAREVUE FOR SPECIFICS)\\n PT ALERT, NODDING HEAD TO SOME QUESTIONS. DENIES PAIN WHEN AT REST. ONLY LOWER EXT. AND LEFT UPPER ARM MOVING SPONTANEOUSLY AND ONLY SLIGHTLY ON THE BED. PERRL.\\nCV- BP RANGING FROM 80'S- 115. REQUIRED FLUID BOLUSES DURING DIALYSIS THIS AM. I UNIT OF PRBCS GIVEN AND 25 G OF ALBUMIN TO KEEP BP ABOVE 85 SYSTOLICALLY DURING DIALYSIS. PT COULD ONLY TOLERATE REMOVAL OF ABOUT 700CC. HR TO 150'S THIS AM, A-FIB. SHOWN TO MICU TEAM ON ROUNDS, LOPRESSOR PO GIVEN AS SCHEDULED AND 2.5 MG LOPRESSOR IV ALSO GIVEN WITH GOOD EFFECT. HR REMAINS 90'S-110 FOR THE REMAINDER OF THE SHIFT, OCCASIONAL PVCS, POST DIALYSIS LABS, INCLUDING A HCT SENT. PTT GREATER THAN 150 THIS AM, HEPARIN GTT STOPPED FOR TWO HOURS AND RESTARTED AT 600U. NEXT PTT DUE AT .\\nRESP- LUNGS CLEAR, VENT SETTINGS REMAIN THE SAME. NO DIFFICULTY BREATHING NOTED.\\nGI/GU- ABD SOFT AND DISTENDED. COLOSTOMY DRAINING SEMI FORMED LOOSE BROWN STOOL, STOMA APPEARS TO BE BEEFY RED. TOLERATING TF AT GOAL, INSULIN GTT REMAINS ON AND BS RANGING FROM 90'S- 150'S. PT DOES NOT VOID.\\nSKIN- SKIN REMAINS WEEPY IN SOME AREAS. ALL DRESSINGS TAKEN DOWN AND CHANGED TODAY. SACRAL DECUB GREYISH ON INSIDE WITH RED EXCORIATED SKIN AROUND WOUND. PACKED WITH AQUACEL AND COVERED WITH DSD. ALL AREA OF INTACT SKIN COVERED WITH ALOE VESTA BARRIER CREAM. RIGHT GREAT TOE CONTINUES TO OOZE BRB, DRESSING CHANGED SEVERAL TIMES, HCT MONITORED. MRI TODAY FOR SACRAL DECUB TO CHECK FOR OSTEO, RESULTS PENDING, PT TOLERATED WELL.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524111,\n \"text\": \"Resp Care\\nPt remains on CMV stable no vent changes. Plan to continue with current tx.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524221,\n \"text\": \"Admitted via ER with fever,fatigue and hyperglycemia,?sepsis.Patient on mechanical ventilation At home. More alert today,suctioned for moderate amount of thick yellow secretion.Being treated with Floventterol and Atrovent. Has periods of hypotension and bradycardia.meeting with family to discuss disposition of patient on hold as daughter does not want to discuss it untill patient home services are specifically arranged :dialysis done today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524222,\n \"text\": \"condition update\\nplease see carevue for specifics.\\n\\nafebrile. pt nodding yes/no appropriately. afib. hd today. vanco and tobra given, levels drawn. bld cx's taken from hd catheter. vag ultrasound done d/t bleeding. foley instilled w/ 400cc ns. when ns drained bright red blood draining. micu aware. foley kept in and being irrigated. red blood continues. hct 23.\\n\\nsxn'd for thick, yellow sputum. no vent changes made. w/ propass infusing via peg. maroon colored blood noted in peg. micu team notified.\\n\\nplan: monitor hcts/ hemodynamics. dressing changes as ordered. iv abx.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524223,\n \"text\": \"Respiratory Care\\nPt remains trached on full vent support. No ventilator changes made this shift. BS coarse and diminished @ bases. Suctioned for moderate amounts of thick yellow/tan secretions. Pt awake & alert and breathing over the vent at this time. No recent ABG. Morning RSBI not completed due to decreased BP.\\nPlan: Continue current vent support, ? trial\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524224,\n \"text\": \"NURSING\\n VSS, AFEBRILE. CONTINUES IN AFIB. NO ECTOPY. HCT DECREASED TO 23, TRANSFUSED WITH 1 UNIT RBC'S. REPEAT HCT 26.\\n CONTINUES TO HAVE VAGINAL BLEEDING AND BLEEDING FROM FOLEY, ALTHOUGH BLEEDING FROM FOLEY APPEARS TO BE DECREASED. NOW IRRIGATION APPEARS TO JUST BE BLOOD TINGED FROM TUBING OR PERHAPS A CLOT IN BLADDER. IRRIGATED Q 2 HRS OVERNIGHT WITH 120 CC EACH TIME. OLD LOOKING BLOOD PRESENT IN GT CHANNEL OF TUBE, MD'S AWARE AND HAVE EXAMINED PATIENT. HEMATOLOGY CONSULT PUT IN BY MICU TEAM.\\n CONTINUES TO HAVE MODERATE AMOUNTS OF SPUTUM TAN TO GREEN TINGED FROM TRACH. SUCTIONED Q 2-3 OVERNIGHT.\\n CONTINUE TO MONITER HEMODYNAMICS, BLEEDING. REPEAT HCT EARLY AFTERNOON.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524225,\n \"text\": \"Neuro: pt alert. responds to question by nodding. Minimal movement of limbs very slight movement of feet and rt arm . noted to move left arm slightly on bed.\\nPain: complained of pain x1. Given tylenol 650mg x1.\\nCV: AF 100's currently early Hr has high as 130's improved after am amniodarone and Digoxin. ABP dropped to 80's a few times but improved without tx. DP/PT.\\nLungs: Coarse throughout. suction for thick yellow sputum. trach care given green drainage around trach.\\nGI: ABD soft BS present. G/J tube TF at goal tolerated well. J tube with no further bleeding noted. Colostomy drainage liquid. stoma pinkish red.\\nGU: Foley to gravity. minimal bloody drainage when irrigated obtain small clots.\\nSkin: necrotic toes left heel necrotic. pressure sores on coccyx and hips. see care view and wound care note. DSG changed at 11am.\\nA/P DSG changes per wound nurses . frequent turns. serial hct.. monitor bleeding hct notify ho of changes.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524452,\n \"text\": \"NURSING NOTE\\nPLEASE SEE CAREVUE FOR DETAILS\\nNEURO: NEUROS UNCHANGED, MORE ALERT TODAY, MIN NODDING TO QUESTIONS, NOT TRACKING TO VOICE. PERRL, 4-5MM, BRISK. ATIVAN GIVEN X2 R/T TACHYPNEA, DISCOMFORT. DEMEROL GIVEN X2 R/T FREQUENT TURNING & REPOSITIONING, PRIOR TO DSG CHANGES.\\n\\nCVS: HR 90S-100S, UP TO 120S THIS PM W/MILD(99.8)FEVER AND TACHYPNEA-MD AWARE, NO CULTURES AT THIS TIME, TO FOLLOW. MAP MAINTAINED>60 PER GOAL, 70S-100S. PICC DSG CHANGED, ?PLACEMENT R/T FREQUENT TURNING, MICU RESIDENT AWARE. PM HCT 32.9, NO NEW BLEEDING NOTED. MAG OXIDE GIVEN FOR AM MAG 1.9, AM SODIUM 148.\\n\\nRESP: NO VENT CHANGES MADE, REMAINS ON A/C, NO VBG DONE. PT TACHYPNEIC UP TO 30S, ATIVAN GIVEN X2 W/MIN RELIEF. LUNGS COARSE, DIMINISHED AT BASES. PT SUCTIONED FOR MOD/LGE AMTS THICK, YELLOW SECRETIONS. PT TO BE PUT ON \\\"HOME VENT\\\" AT MN PER RESP.\\n\\nGI/GU: TF AT 40CC/HR, NO RESIDUAL, FLUSHED W/200CC Q4. GT TO GRAVITY W/SM AMT YELLOW, VISCOUS FLUID. OSTOMY BAG AROUND G-JT W/SM AMT STRAW-COLORED FLUID. COLOSTOMY W/MOD AMT GREENISH-BROWN LOOSE STOOL, NO BLOOD NOTED. CLEAR-BROWN MUCOID RECTAL DRNG NOTED, VAGINAL BLEEDINAL.\\n\\nENDO: BS COVERED PER RISS, AM LANTUS GIVEN\\nID: PLAN TO AT HOME. RECIEVING AMIKACIN, MEROPENEM, DAPTOMYCIN.\\n\\nINTEG: MULTI SKIN TEARS, AREAS OF LGE AMTS SEROUS DRNG COVERED W/DSD. BLE/TOE DSGS CHANGED, SACRAL/R-HIP DECUB ULCERS PACKED W/AQUACEL, COVERED W/DSD, RE-DRESSED PRN. W/LGE GEN SEROUS DRNG, GEN ANASARCA. SARNA LOTION APPLIED TO RIGHT LATERAL RASH. MULTIPLE AREAS OF ABRASIONS/BREAKDOWN COVERED W/ADAPTIC AS ORDERED. PT TURNED, REPOSITIONED FREQUENTLY.\\n\\nPLAN: SICU , ATIVAN & DEMEROL FOR PT COMFORT, PLAN FOR D/C TO HOME , AFTER AM HD. HEMODYNAMIC MONITORING, RESP SUPPORT. REPEAT HCT, ?BLD CULTURES IF PT REMAINS FEBRILE. AGGRESSIVE SKIN CARE.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524142,\n \"text\": \"Condition Update A:\\nPlease refer to careview and remarks for details.\\n\\nPt calmly alert and dozing periodically. Ativan held as no indications of anxiety and continued hypotension as discussed with MICU team ( Dr. ). Tmax 100.1. cont in afib with rare PVC's. Pt received 1.25L in LR boluses for hypotension 70-80's with MAP's<50. H20 boluses started and increased to 250cc every four hours for low Na level and hypotension. Pt's SBP improving during the late afternoon, up to 120-130.\\n\\nJ-tube leaking small amount of thick clear mucous. Dsg changed at 0800 and remains C/D/I. The two areas of breakdown ( at the 1000 and 0500 position unchanged from ). BLE dsgs changed at 0800, please refer to careview for specifics.\\n\\nWBC 17. K 3.8 Ph 1.2. Stool (P) for c-diff. Glucose levels improved from with increased Lantis dose and RISS.\\n\\nPLAN: Vanco 1g IV every 48 hours. KPhos infusing. Obtain blood cultures, RT to obtain sputum. Monitor glucose levels. Cont discharge planning. Call H.O. for changes.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524143,\n \"text\": \"Resp Care: Pt remains intubated via #6 Shiley trach, cuff leak noted. Team is aware. Achieving gd Vt's. Sx'd for mod amts thick tan sputum. MDI's given as ordered. No vent changes made this shift. No recent ABG. Cxray pending. Cxray \\\"small R pl. eff. L lung clear\\\". Plan: cont vent support. Please see carevue for further vent inquiries.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524144,\n \"text\": \"Update\\nSee careview for details....\\n\\nNeuro: Pt alert and awake, follows simple commands, moves extrems in bed\\n\\nCV: A fib, 90-110's, afebrile, BP 80's-110's\\n\\nResp: Lungs clear, sx scant white sputum and sent for cx, vent unchanged, trach care done\\n\\nGI: tol TF's, + BS, colostomy dng liquid brown stool\\n\\nGU: pt does not void\\n\\nSkin: Pt turned Q2hrs, on air matress, waffle boots on, dsd to LE's D/I, sacral dsg changed, pink tissue with areas of yellow/green slough, sm amt bleeding, dsgs to hips intact, J tube site dng amts thick clear dng, dsg changed x2, pt med with demerol prior to dsg change\\n\\nPlan: Wound care, emotional support for family\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524145,\n \"text\": \"Resp Care\\nPt. remains trached, chronic vent, no changes overnight, no rsbi.\\nBs: clear equal bilat. secreations minimal, spec sent. Mdis as ordered.\\nPlan: cont. current support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524146,\n \"text\": \"BS generally CTAB, occ rhonchi clearing with suction. CUff pressure measured and maintained at 16-18cm. ? discharge to home tomorrow. Instruct daughter how to measure cuff pressures. Tolerate small leaks if necessary per Dr. .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524232,\n \"text\": \"DNR Contact Precautions - MRSA/VRE\\nAllergies: Morphine, Erthromycin, Fent, Keflex\\n\\n\\nNeuro: Opens eyes spont and occ tracks - pupils 5mm/brisk. No movement in extrems - occ L hand moves - no movement on command. She nods approp.\\n\\nCV: HR=90-100s, afib, no ectopy. BP=78-110/40-50s. +edema, extrems warm.\\n\\nResp: 450x16, 40%, P=5 - 02sat 98-96%. Suction small amt thick tan secretions - lungs fairly clear, diminished in bases bilat. RR=14-22.\\n\\nGI/GU: abd obese, g-jtube intact - tube feeds at 40cc/hr. Colostomy fx- liq golden brown stool - 400cc/shift. Foley cath - no urine. Output has been BRB - irrigated this am - no clots, bloody returns, but no additional output for the day. Dialyzed for 2liters.\\n\\nSkin: Ostomy appliance changed for leaking. g-jtube leaks at site - dressing changed. Coccyx, ischeal, and leg dressings changes. Bilat hip dressing w/ allevyn changed yesterday - due to be changed on .\\n\\nAccess: Rsubcl dialysis cath, R antecub single lumen PICC. Ordered placed for tunneled dialysis cath.\\n\\nPain: Med w/ demerol 12.5mg IVP for dressing change. Ativan .5mg po ATC.\\n\\nSocial: Son in this evening - updated.\\n\\nPlan: Continue w/ current plan. Ethics reviewing the case and legal consult in as well. Case management continues to review possiblilities when pt is ready to be d/c'd.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524233,\n \"text\": \"Respiratory Therapist\\nBreath sounds bilaterally clear and diminished, suctioned for small amount of thick green secretions WBC 18.8 consistent with bacterial infection, hemoglobin only 9 suggests anemia, creatine 2.4 suggest renal insufficiency for which patient had dialysis today started at 1000 am, patient was treated with Albuterol, Atrovent and Flovent inhalers, no ABGs nor vent changes made up to this moment.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524234,\n \"text\": \"Nursing Assessment Note 1900-0700\\nNEURO: Pt neuro status remains unchanged, pt will open eyes to voice and will follow simple commands, but does not try to mouth words\\n\\nCV: Pt's vss, afebrile, pt has right A/C picc line with NS @ , pt in AFIB, skin is pale, warm, and dry, pp + & =, with +2 generalized edema, Pt given dose of Desmopressin for her bleeding, the hope is to stop bleeding so pt can be started on heparin gtt\\n\\nRESP: Pt's has 7.0 extra long shiley on CMV Rate-16, TV-450, PEEP-5, Fio2-40%, with sats 97-100%, pt suctioned for scant amount thick yellow sputum, Lung sounds are coarse throughout\\n\\nGI: Pt has peg G/J tube with tube feeding infusing at goal rate of 40 cc/hour, placement confirmed via air , pt's colostomy draining brown liquid stool, stoma is pink and beefy\\n\\nGU: pt's foley has very small amount bloody drainage, pt is dialysis pt and does not make urine\\n\\nPLAN:\\n-Continue to monitor bleeding, once bleeding stops, pt to be started on heparin drip\\n-? home placement vs. , family would prefer home, but issue's still need to be worked out\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524235,\n \"text\": \"Respiratory Care:\\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. No morning abg results at this time.\\n\\nRSBI = 93 on 0-PEEP and 5 cm PSV.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524375,\n \"text\": \"condition update\\nplease see carevue for all specifics.\\nneuro: does not follow commands, rare spont. movements noted on left arm this am, but not this afternoon. Does not attempt to communicate, does not track in room. Pupils are 4mm and sluggishly reactive. Pt received 1mg midaz. this am for endoscopy, midaz gtt started this afternoon for comfort, d/c'd this pm as per Dr. instructions, will as necessary.\\ncv: afib 100's. vasopression, levo titrated off, with goal map >60. Pt received total of 6 units prbc's, 2 platelets, and 3 this shift. for hct 19, and inr as high as 2.1 Also received 2 liters ns for hypotension. hct currently stable at ~34. Ostomy draining copoius amts. bright red blood this am, which has slowed significantly.\\nresp: see resp. note for specifics, suctioned for small amts. thick yellow sputum. trach. care done. Rate increased for acidosis, fi02 weaned down to 50%. Ls coarse and diminished.\\ngi: abd. if firm distended, +bs, colsotomy draining brb this am, endosopy done at bedside per gi, clips applied. tolerated well. GI bleeding decreased significantly.\\ngu/renal: cvvh started this afternoon by a 2nd RN.\\nendo: insulin gtt titrated, off this afternoon for bs 53 - received 1/3 amp d50.\\nsocial: Daughter called and was updated by this rn and Dr. . Husband and son at bedside this am.\\nplan: continue to titrate neo to keep map >60, monitor hct, monitor colostomy output, continue ddavp and decadron, . cvvh.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524376,\n \"text\": \"addendum\\nbilat. leg, and groin dsg changed today as per wound care rn instructions. Sacral and hip dsgs deferred as pt may not tolerate extended turning d/t pt's unstable hemodynamic status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524377,\n \"text\": \"nursing note\\nPt opening at eyes at times, not following commands or acknowedging request s by nodding or moving. No movement of extremeties. Afib with bursts to 120's. Neo weaned down to keep MAP >55, sys >90. to keep even. MD , keep pt. even and go up on pressors if needed. LS coarse,thick yellow secretions. NPO. Osotmy with melena output, minimal amounts. HCT/plt/INR stable. . on DDAVP and decadron. Son and in to visit and calm and appropriate with care and questions. Son escorted by security and non aggressive with this RN.\\n\\nPLAN: CVHHDF to keep even and go up on pressors as needed. insulin gtt. DDAVP and decadron. labs q6. family support and guidelines as in place.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524378,\n \"text\": \"Resp Care Note, Pt remains on current vent settings.See vent flow sheet for details. Suctioned mod amts thick yellow secrtions.MDI'S given, HR-A-Fib. Getting neosynephrine and insulin. . Will to monitor resp status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524379,\n \"text\": \"Resp Care\\nPt remains trached on A/C. FIO2 increased from 40 to 60 due to ABG results. MDI's given. No other changes noted.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524453,\n \"text\": \"Resp Care,\\nPt. remains on A/C . Suctioned for copious amount thick yellow sputum. Planned to put on home vent MN, but developed tachycardia and RR high 30's with MV 21L. MICU team aware pt. not placed on home vent.Will attempt this am. See carevue.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524191,\n \"text\": \"Neuro: Pt alert and awake all night. Able to talk around trach, ? leak. Able to make needs known. Med for pain X2 per pt request with good effect.\\n\\nCV: Hypothermic 92.0, Bare hugger inplace T=95.2. Pt refusing oral temp and requiring coaxing to obtain axillary temp. HR 80-100's Afib with no noted ectopy, SBP 80-130's. CVVH continues pt remains even.\\n pulses bilat dorsal. Extremities cool and pale.\\n\\nRESP: lung clear to dim at bases. Requiring occasional suctioning of thick tan secretions with plugs.\\n\\nGI: tol tube feed. Colostomy draining small amounts of golden liquid stool.\\n\\nGU: Remains aneuric\\n\\nENDO: blood sugars WNL overnight. Recieved lantus per order.\\n\\nPLAN: Family would like to speak to renal team today concerning CVVH, Family cont to request Shiley trach reinserted as soon as possible.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524192,\n \"text\": \"Events:\\n\\n clotted and D/C per Renal team, plan for HD Monday\\nPulmonary into see patient plan for Bronch and trach change Monday\\n\\nNeuro-PERL, moves upper extrem purposefully, mouths words, and shakes head to yes/no questions, denies pain\\nCV-MP Afib irreg S1 S2, continues on amio/lopressor, amio dose decreased r/t elevated INR, coumadin held, doppler pulses LE bilaterally, necrotic toes bilaterally\\nResp-Remains on AC LS coarse upper lobes dim at bases, sx for thick tan secretions\\nGI-TF at 40cc/hr, glucose well controlled with glargine 90u SQ , colostomy with liquid stool out, pending\\nGU-anuric, d/c acid base balance and lytes monitored\\nskin-see carvue\\n\\nFamily-daughter phoned in update given, daughter gives recomendations for patient care regarding HD and albumin, renal nephrologist attempt to contact daughter to give update. Daughter into see patient. states \\\"my mother should get what she wants, not what wants, my mother has been through enough. states \\\"my mother never wanted hemodialysis and my mother is aware that if she does not get hemodialysis she would die\\\". states we just wanted my mother to be home and be comfortable, not going in and out of the hospital\\\". states the HCP form is the patient first, her mother. Stating her family should listen to her mother first, also second to make decisions is the patient husband. states her father is old almost 70yrs old and has taken over. request to speak with social work, social worker updated , MICU MD notified, question need for ethics consult, also chart need to to be reviewed for HCP proxy form. Emotional support provided. Awaiting social work and MICU review of legal documents\\n\\nPlan-pulmonary toilet, skin care, maintain pts comfort, monitor fluid balance, HD on Monday, cont ABX\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524193,\n \"text\": \"Respiratory care\\n\\n Pt continues on A/C as per home regime. B/S coarse sx'd for thick tan secretions. Adjustable flange on trach found open. Trach at #7 replaced to the #11 flange closed CXR pending. Pt ventilating in NARD. Will continue to follow closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524194,\n \"text\": \"Addendum:\\n\\nSocial work and MICU resident updated on daughter concerns of whether the patient is getting what she wants. stated that 6 out ot the 8 children agree that her mother would not want to live like this and would not want hemodialysis.\\n\\nEthics consult: Dr. into evaluate chart. Plan for family meeting to address current plan of care and evaluate evidence of \\\"what the patient would want\\\", message left with daughter to call Dr at \\n\\nSocial work and ethics to follow up with family on Monday\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524195,\n \"text\": \"Addendum: Family\\n\\nSon into see patient, states \\\"we are not all crazy\\\", I aksed what he met. He said my family is working hard to take care of my mother, maybe \\\"she has to go through the fires of hell to get to heaven\\\", we did get told at that if the hemodialysis was stopped our mother would die in five days. states \\\"that I hope god takes her in the middle of the night. states he does not want to go against the family but has already spoken to his Dad and realizes this maybe torture to his mother especially since we have all the machines going. We are trying to get my other siblings to see that Mom is saying \\\"No\\\"\\n\\n given Dr. phone number to discuss feeling fo what his mother wants. again states that he does not want to go against his family. emotional support provided\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524196,\n \"text\": \"Resp Care Note:\\n\\nPt cont trached and on mech vent as per Carevue. Lung sounds coarse improve with suct mod th tan sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required . Cont mech vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524293,\n \"text\": \"Resp Care: Pt continues trached and on ventilatory support with a/c, no vent changes maintaining good abg; bs coarse rhonchi, sxn thick yell secretions, rx with mdi albuterol/atrovent/flovent mdi, rsbi held d/t vent dependence, will cont full support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524294,\n \"text\": \"CONDITION UPDATE\\nVSS. REMAINS ON NEO TO MAINTAIN PER ORDERED PARAMETERS. REMAINS IN AFIB - RATE CONTROLLED ON DILTIAZEM DRIP. HYPOTHERMIC - BAIR HUGGER ON. ALERT. PUPILS EQUAL AND REACTIVE. DOES NOT FOLLOW COMMANDS. NODS YES/NO. MOUTHING INCOHERENT WORDS. NO MOVEMENT NOTED RSIDE OR LLE. MOVES LUE SPONTANEOUSLY AND TO PAINFUL STIMULI. LUNGS COARSE TO DIMINISHED AT BASES. OCC. SUCTIONING FOR THICK, YELLOW SPUTUM. NO VENT CHANGES MADE THIS SHIFT. ABG THIS AM ACCEPTABLE. ABD OBESE. POSITIVE BOWEL SOUNDS. MOD AMT OF LOOSE, GOLDEN STOOL OUT COLOSTOMY. GTUBE TO DRAINAGE, SEROUS, MUCOUS DRAINAGE OUT. JTUBE TO TFEEDING W/O INCIDENT. AREA UNDER BOTH BREASTS EXCORIATED. SKIN UNDER PANNUS W/ MULT BREAKDOWNS - AREA CLEANSED W/ WOUND CLEANSER, MYCOSTATIN APPLIED ALONG W/ DSD. LOWER EXTREMITY DRESSINGS REMAIN INTACT. COCCYX DRSG - LG AMT OF PURULENT/S/S DRAINAGE OUT. TISSUE PINK. DRSG TO /LBUTTOCK - MOD AMT S/S DRAINAGE OUT. PERI AREA PINK AND EXCORIATED - AREA CLEANSED W/ SOAP AND WATER - MYCOSTATIN POWDER APPLIED. RARM W/ MULT SKIN TEARS - WEEPING COPIOUS AMTS OF SEROUS DRAINAGE. REMAINS ON . GOAL TO KEEP EVEN. SEE FLOWSHEETS FOR DETAILS. K AND DRIPS TITRATED ACCORDING TO ORDERS. REMAINS ON INSULIN DRIP. BSUGARS LABILE. SON IN FROM 7PM TO ALMOST 11PM VISITING W/ PT.\\nCONT TO MONITOR FOR S/S OF WORSENING INFECTION. PAIN MANAGEMENT. MAINTAIN SKIN INTEGRITY. DIABETIC MANAGEMENT. PT/FAMILY TEACHING AND SUPPORT. CONT CURRENT ICU CARE AND ASSESSMENTS.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524299,\n \"text\": \"Nursing note:\\n Alert, attempting to mouth words at times, this RN unable to understand. Moving LUE only. PERRLA. Does not appear to be in pain. Remains trached, no vent changes. Sats 100%, suctioned occ. per flow sheet. SR in 70s, no ectopy. Dilt gtt @ 5mg/hr. Weaned down Neo gtt to off for >80/MAP >50 this afternoon. Slightly hypothermic w/o Bair Hugger so remained on low/radient for the day w/temps in 97s. +BS, abdomen large, obese. Gtube to GD for bilious drainage. JTube for feeds, no residuals. Awaiting new TFs from kitchen. Small amount of serous drainage around sites into ostomy appliance. Colostomy w/red stoma, loose golden stool, appliance intact. Anuric, CRRT running to keep pt. negative by approximately 50cc/hr (24 hour goal 1L negative). CVP 6-12. Pt. tolerating fluid removal off pressors. Calcium/K+ gtts running per Sliding scale. Insulin gtt @5u/hr for stable glucose levels 100-120s. Wounds impressive, all dressings changed - see flow sheets for details. Bilat. heels and toes black. Deep cavernous wound to R. hip and large sacral decub as well. Mycostatin powder to reddened and excoriated groin folds.\\n\\nA/P: Tolerating fluid removal via off pressors. Hct stable @28, WBCs trending down.\\nSlightly more alert today. Continues w/impressive non-healing wounds.\\nContinue skin care, monitor hemodynamics, , update family spokesperson PRN.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524300,\n \"text\": \"Respiratory Care:\\n Patient continues on full vent support. Suctioned app Q4 for thick yellowish secretions. BS with scattered rales and occassional rhonchi. She continues on . Plan to continue with supportive care and monitoring.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524301,\n \"text\": \"Resp Care\\nPt remains on vent. Trached with 7.0 shiley. Suctioned for mod amt of thick green secretions. Mdis given. No changes made. Rsbi 104. Will continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524302,\n \"text\": \"NURSING 7P-7A\\n VS LABILE OVERNIGHT. DECREASED TO THE 70'S WITH MAP<50. LEVO RESUMED TO MAINTAIN BP WITHIN DESIRED RANGE, ALSO CONTINUES ON DILTIAZEM AT 5 MG. ORDERS IN TO RESUME PO DILT AND DC GTT AFTER PO DOSE GIVEN. HYPOTHERMIC MOST OF THE SHIFT WITH TEMPERATURE NORMALIZING AT 0400. BAIR HUGGER ON UNTIL 0400.\\n CONTINUES ON . AT 2400 LAST NIGHT NEGATIVE FOR 1100 ML. GOAL REMAINS AT 1000 ML/24 HRS. POTASSIUM GTT AND CALCIUM GTT SLIDING SCALES CONTINUE AS ORDERED. FILTER CLOTTED THIS AM AT 0500, RESTARTED AT 0615. SEE CARE VUE FOR FULL SPECIFICS.\\n INSULIN GTT CONTINUES. BLOOD SUGARS HIGH LAST NIGHT FOR A PERIOD OF TIME, 4 HRS. INSULIN GTT HAD BECOME DISCONNECTED FOR APPROXIMATELY 2 HRS. DISCONNECTION WAS NOT IMMEDIATELY VISIBLE AS TUBING WAS STILL LODGED UNDER PANNUS AND APPEARED TO BE CONNECTED. GTT INCREASED TO 10 UNITS/HR, THIS AM LEVELS BECOMING MORE NORMALIZED, IN THE 150 RANGE THIS MORNING. SEE CARE VUE FOR FULL SPECIFICS.\\n DOES NOT APPEAR TO BE IN PAIN. WHEN QUESTIONED SHAKES HEAD \\\"NO\\\". ANY ATTEMPTS TO DO ANYTHING TO HER ARE MET WITH A NEGATIVE SHAKING OF HER HEAD. ATTEMPTS TO MOUTH WORDS, UNABLE TO DETERMINE WHAT SHE IS TRYING TO SAY.\\n CONTINUE . LABS Q 6/HRS, NEXT AT 0900. CONTINUE INSULIN GTT, MONITER SUGARS Q /HRS. GIVE DILTIAZEM PO AND STOP GTT A FEW HRS AFTER AS ORDERED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524454,\n \"text\": \"NURSING PROGRESS NOTE;\\nNeuro: Pt remains lethargic. opens eyes to voice, pupils 4mm brisk. Moving LUE slightly. Nodding yes when asked if having pain. Med with demerol X2 with some noted effect.\\nCV: Afebrile, HR very labile, 100-140's Afib with occasional PVC's. labile 70-200/30-100's. tachypneic 30-40's MICU team aware of vital signs. extremities cool with pulses.\\nRESP: lungs coarse to dim at bases. Occasional suctioning of thick yellow secretions. O2 sats >95%. Unable to place pt on home ventilator due to very labile VS. Family giving pt ice chips. Nurse asked family to not give pt ice due to aspiration. Pt's grand daughter found giving pt her slurpee, now having pink drg on trach drain sponge around trach, appears to be same color as slurpee.\\nGI: tol tube feed at goal. draining adequate amount of brown loose stool.\\nENDO: blood sugars elevated requiring mod coverage per RISS.\\nPLAN: Awaiting ? transfer to floor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524455,\n \"text\": \"Respiratory Care\\nPt remains trached and on vent support. Pt was placed onto home vent and 2 hrs. Pt removed and placed back onto for increased RR. RR 28-35 on home vent and remained 28-35 on , pt was placed back to see if home vent was not tol. Pt tol. home vent. Lung sounds course and diminished in the bases. Pt was suctioned for scant to moderate amounts of thick yellow secretions. No ABG's were drawn and VBG was 7.36/38/32/22. Pt received MDI's albuterol was not given due to HR >110. Care plan is to place pt on home vent and remain on vent overnight. Pt is planned for a d/c tomorrow. Will continue to follow pt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524456,\n \"text\": \"Respiratory Care\\nPt remains trached with 7.0 Shiley. Pt stayed on ventilator on full support throughout the night. BS coarse bilaterally and diminished at lung bases. Suctioned for small amounts of thick tan secretions. MDI's given as ordered with increases aeration throughout lung fields. Pt remained hypertensive throughout the majority of the shift. No morning completed due to increased BP. See CareVue for details and specifics.\\nPlan: ? placing pt on home vent.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524281,\n \"text\": \"NPN (SEE CAREVUE FOR SPECIFICS)\\n PT ALERT MOST OF THE NIGHT, OCCASIONALLY SLEEPING FOR BRIEF PERIODS. MOUTHING WORDS OCCASIONALLY, FOLLOWING SOME SIMPLE COMMANDS. MOVING LEFT HAND OFF THE BED, SLIGHT MOVEMENT NOTED FROM RIGHT FOOT, HOWEVER NO OTHER SPONTANEOUS MOVEMENT NOTED. PERRL. NODDING YES TO PAIN, RELIEVED BY REPOSITIONING.\\nCV- BP STABLE IN 90-100 RANGE SYSTOLIC. NO PRESSORS OVERNIGHT. REMAINS IN 120-140'S, A-FIB WITH OCCASIONAL PVCS. LYTES CHECKED Q 6 HOURS PER CRRT PROTOCOL. DR. UPDATED ABOUT INCREASING HR A FEW TIMES OVERNIGHT, DILT 5MG GIVEN X 1 WITH MINIMAL EFFECT ON RATE. DR. WILL FOLLOW UP WITH TEAM ABOUT TREATMENT THIS AM. CONTINUES, PT WAS ABOUT A LITER POSITIVE AT MIDNIGHT WITH REMOVAL RATE OF 0. AFTER MIDNIGHT, REMOVAL RATE SET TO KEEP PT EVEN, HOWEVER BP DROPPING THIS AM TO 80'S, RATE DECREASED BACK TO 0 FOR NOW. PLATELETS 22 THIS AM, DR. NOTIFIED, WILL TREAT FOR LESS THAN 20 ONLY. PHOSPHOROUS LOW, .8, 2 PACKETS OF NEUTRAPHOS GIVEN X 1, WILL FOLLOW UP.\\nRESP- LUNGS COARSE, SUCTIONED A FEW TIMES FOR THICK WHITISH SPUTUM. O2 SAT 100%, ABGS SLIGHTLY ALKALOTIC WITH PCO2 33-34. NO VENT CHANGES MADE.\\nGI/GU- ABD SOFT, + BS. TOLERATING TF AT GOAL. COLOSTOMY DRAINING MODERATE AMOUNT OF LOOSE GOLDEN STOOL. APPLIANCE CHANGED, STOMA PINK. PT DOES NOT VOID.\\nID- TEMP DECREASING TO 95 THIS AM, BAIR HUGGER PLACED. BLOOD CULTURES DRAWN WITH AM LABS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524282,\n \"text\": \"Respiratory Care:\\nPatient remains on A/C ventilatory support with no parameter changes made throughout the shift. Latest abg results determined a respiratory alkalemia with excellent oxygenation on the current settings. Patient remains tachycardic, and the albuterol mdi inline was witheld. Atrovent given with each vent check.\\n\\nNo RSBI measured due to the cardiac status and the general instability of the patient.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524283,\n \"text\": \"resp care\\nremains trached/vent dependant. no changes on vent settings this shift. sxned for small amt yellow thick secretions. nard. consistently breathes over set rate. abg acceptable. atrovent given q6h, albuterol held until tachycardic,given in pm with HR 106. c/w full vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524339,\n \"text\": \"CONDITION UPDATE\\nASSESSMENT:\\n NEURO EXAM UNCHANGED. PATIENT OPENS EYES SPONTANEOUSLY BUT DOES NOT FOLLOW COMMANDS. DOES NOT APPEAR TO BE IN PAIN. HEART RATE ~ 100 AFIB, REMAINS ON DILTIAZEM. PATIENT CURRENTLY ON 0.5 MGS NEO, WEANING EXTREMELY SLOW KEEPING MAP>55. CREAT 1.2, ELECTROLYTES NORMAL. NO DIALYSIS TODAY. AFEBRILE.\\n LUNG SOUNDS COARSE, SUCTIONED OCCASIONALLY FOR THICK YELLOW SPUTUM. TOLERATING ASSIST CONTROL. ABDOMEN DISTENDED BUT IMPROVED SINCE . TUBE FEEDS REMAIN OFF (J-TUBE CLAMPED) AND G-TUBE TO WALL SUCTION WITH MODERATE AMOUNT BROWN/YELLOW OUTPUT. G-J SITE CONTINUES TO OOZE, APPLIANCE INTACT. COLOSTOMY WITH SCANT LOOSE BROWN STOOL. SEE CAREVUE FLOWSHEET FOR SKIN ASSESSMENT & TREATMENT.\\nPLAN:\\n? ATTEMPT TO RESTART TUBE FEEDS TOMMORROW. PROVIDE SUPPORT. WEAN NEO AS PATIENT TOLERATES.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524340,\n \"text\": \"BS rare fine crackles; no change with MDI's. No vent changes. Dialysis still on hold. Pressors weaned. Will wean vent as tolerated. Inner cannula changed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524369,\n \"text\": \"NURSING NOTE\\nPLEASE SEE CAREVUE FOR DETAILS\\nNEURO: PT NOT RESPONSIVE TO ANY STIMULI, EVEN FROM FAMILY MEMBERS, NOT FOLLOWING COMMANDS. OPENS EYES SPONTANEOUSLY, PERRL 5MM, BRISK, NOT TRACKING. VERY MIN MVMT OF LUE ONLY, NO MVMT TO ALL OTHER EXTREMS. DEMEROL 12.5MG GIVEN PRIOR TO DSG CHANGES.\\n\\nCVS: HR 70S-90S, NSR, DILTIAZEM DRIP AT 5MG/HR. 80S-90S, MAP>55 W/NEO DRIP 0.2-0.4 MCG/KG/MIN. T-MAX 99.4, HCT 24.4 THIS PM-HO AWARE-NO INTVN TAKEN AT THIS TIME, REPEAT HCT AT 2100, NO S/S ACUTE BLEEDING NOTED. PP VIA DOPPLER, ?HD .\\n\\nRESP: NO VENT CHANGES, LUNGS COARSE TO APICES, DIMINISHED AT BASES BILAT. PT SUCTIONED FOR MOD AMTS THICK, YELLOW SECRETIONS. O2 SATS 97-100%, PT ACUTELY TACHYPNEIC DURING DSG CHANGES, UP TO 30S. TRACH CARE DONE, IN-LINE SXN CATH CHANGED. PT W/2-8 BPM OVER SET RATE, ATIVAN 1MG GIVEN X1 FOR PT COMFORT.\\n\\nGI/GU: COLOSTOMY STOMA PINK, EDEMATOUS, PATENT DRNG SM AMT BLK, TARRY SOFT STOOL, HYPO+BS. JT PATENT TO FLUSH/RETURNS>AMT FLUSHED, GT PATENT, MIN DRAW BACK. MIN BRWN DRNG FROM AROUND J/GT INSERTION SITE.\\nTPN AT 77CC/HR, ?RE-START TF .\\n\\nENDO: BS BET 111-128, INSULIN DRIP AT 8.5MG/HR\\n\\nINTEG: PT W/MULTI AREAS SKIN BREAKDOWN-DSG CHANGES DONE TO SACRAL, RIGHT , BILAT TROCHANTER DECUBITUS ULCERS, REINFORCED PRN. MUTLI AREAS OF SKIN TEARS DRNG MOD AMTS SEROUS FLUID, REINFORCED PRN.\\nBILAT HEEL ULCERS COVERED W/ADAPTIC, WRAPPED W/KERLIX. PT Q2-3HRS, HEELS OFF BED.\\n\\nID: AMIKACIN HELD FOR LEVEL 12.8, MEROPENEM RE-STARTED PER DR.\\n\\nPLAN: HEMODYNAMIC MONITORING, PAIN MGMT/PT COMFORT, GI OUTPUT FOR S/S ACUTE BLEEDING, RESP SUPPORT, SERIAL HCTS, PROBABLE HD , , NEURO ASSESSMENT, AGGRESSIVE SKIN CARE, FAMILY SUPPORT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524370,\n \"text\": \"Respiratory care:\\nPatient remains trached and mechanically vented. Vent checked and alarms functioning. Current settings: A/C 450*22 50% 8 peep. ABG this am with improvement in acidosis and oxygenation. (7.33/43/101 24 -3).\\nBreathsounds are coarse. Albuterol/atrovent and flovent given. Continues with a #7 portex extra long trach, Inner cannula replaced. Trach patent and site looks good. Suctioned for small amounts of clear to yellow secretions. Please see respiratory section of carevue for further data.\\nPlan: Continue mechanical ventilation. Continue aggressive bronchodilators and pulmonary toilet.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524102,\n \"text\": \"Focus Condition Update\\nSee flowsheet for specific information\\n\\nNeuro: No change in neuro status. Pt follows commands inconsistently, MAE's on bed except for RUE. Opens eyes spontaneously, PERRL.\\nCV: Pt afebrile, in a-fib, hypotensive and most of shift. 500cc NS given, 12.5 lopressor given with effect. PTT >150, heparin gtt off until 0200, restarted at 700 units/hr MD, PTT currently 31, will recheck at 0500. Crit down to 27.9, MD aware.\\nResp: Remains on CMV, no vent changes made this shift. LCTA bilaterally, sux'd for small amount of thick white sputum.\\nGI: Colostomy patent, draining moderate amount of brown loose stool. Abdomen soft. Getting FS at 40cc/hr.\\nEndo: Insulin gtt on at start of shift, shut off at midnight per order, switched to s/s. 70 units of glargine given hs.\\nInteg: Right toe wound draining moderate amount of sang fluid, cleansed with wound cleanser, wet to dry dressing changed x3, cx sent. Wet to dry dressing over right ischial ulcer, cleansed and changed.\\nPlan: L-spine MRI today.\\n Change wound dressings as needed.\\n Continue to monitor hemodynamic status.\\n Monitor PTT to achieve therapeutic heparin dose.\\n Contact MICU with changes.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524103,\n \"text\": \"\\nPt presents trached On A/C 450X16 /5 .4. BS sligt coarse diminished bases. Sx for a sml amt thick tan secretions. No ABG this AM. Sats 100%. Plan: wean as tol.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524341,\n \"text\": \"Neuro: Pt. opens eyes especially when family present. Nods head at times but inconsistent with verbal commands. Noted to move LUE only.\\nCV: continues to be in afib. Neo @.4mcq/kg/min. to keep MAP >55.\\nSkin warm and color pink.\\nPulm: yellow secretions per tracheal sx. Inhalers per vent circuit adm. by resp. therapist. Noted leak but no TV losses. pressure checked by RT and adjusted to try to correct for leak.\\nGI: GJ tube in position. Gtube to CLWS with brown/green drng. J tube clamped except for meds. + bowel sounds. ABD. non-tender to palp. as no noted facial grimacing per pt. Colostomy with scant amount liquid brown stool. pink stoma.\\nGU: None as pt. is anuric and s/p HD/CRRT.\\nSKin: see AFS for dsg management. Left upper thigh pink as reported by previous RN as being a known cellulitis. Lower extr. DSG's intact(QD).\\nPt. has two collection bags on right arm for serous drng. Collection bag aroung GJ tube site for similar drng. Skin tears in all skin folds. Mycostatin powder applied.\\nEndo: SSRI as per Q6 BS's.\\nID. Amikacin dose IV given for new BC growth of gram neg rods. ID to follow dosing.\\nPlan: monitor GI status due to partial small bowel obstr. Surgery following. Monitor temps, lactic acid, WBC. Continue to assess need for CRRT in the future-vs-HD.\\nam labs pending: see flowsheet.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524342,\n \"text\": \"pt remained on full vent support through PM. ABG was within acceptable limits and secretions sx'd were minimal, pressure measured was 22 with a very slight leak.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524422,\n \"text\": \"focus hemodynmics\\ndata: neuro: awake and eyes open when spoken to. at times mouthing words but very difficult to undersand. pt will nod head. does not move extremites on the bed. very rigid when turning in the bed. passive range of motion done. pupils react briskly to light.\\n\\nresp: breath sounds course. suctioned for thick yellow sputum. trach care done. no vent changes done. on a/c of 50%.\\n\\ncardiac: remains in nsr. no ectopy seen. mag level 1.8. inr 1.5 and hct 28.6. k 3.5. to have dialysis on monday.\\n\\ngI abd soft. colostomy patent and draining brown stool. colostomy site pink. tube fdg site oozing some bloody drainage.\\n\\ngu: foley patent and draining yellow urine. creat 1.7 bun32.\\n\\nskin: multiple skin tears with lg amt of serous ddrainage . buttocks excoriated.\\n\\naction:: skin care done. suctioned prn. tube fgs tol well. colostomy patent. update to family. respiratory therapist spoke with daughter in length regarding discharge to home. continues on iv merepenum and levofloxacin. triple lumen patent. dialysis catheter intact with visable oozing of blood at the insertion site. ho notified.\\n\\nresponse: monitor closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524423,\n \"text\": \"FOCUSED NURSING ASSESSMENT\\nPlease see carevue flowsheet for further details\\n\\nNeuro: No changes from prior assessments, dozing intermittently. Unable to determine appropriateness of head nodding- inconsistent answers with simple questions- opens her mouth spontaneously to any motion near her mouth- seems to most enjoy ice chips, cold swabs repetitively. Demerol x 1 premedication for dressing changes, exhibited facial grimace and incr RR during procedure.\\n\\nResp: Trached on CMV. Sputum suctioned thick/yellow alternating with white/thin. Copious amts yellow/tan exudate from trach stoma. SPO2 95-100%, RR 19-28.\\n\\nHEMODYNAMICS: No sx active bleeding aside from baseline slow vaginal bleed. range 72-135/28-76, BP changes from systolic of 72 to 135 in a matter of 15 minutes without intervention. MICU resident aware, qwil lbegin CVP monitoring. HR 80-90s NSR, occassional PVCs. Diltiazem/Digoxin/Amiodarone/Midodrine given as ordered. Anasarcous, serous fluid weeping from new and old skin tears/blisters. Hct from 1800 pndig.\\n\\nGI/METABOLIC: TF at 40ml/hr vai J-port, no emesis, colostomy with 300ml liquid brown stool, guiac positive. New onset today of copious amts of viscous/clear to at times bilious drainage from G/J stoma site- Gtube is to gravity drainage with small outputs (80ml).\\nGlucoses elevated today 164/191, covered with RISS as ordered- Lantus 5U in am daily dose.\\n\\nPSYCHOSOCIAL: Husband visit in am for 30 minutes- no further family contact this shift. Pt attempted to mouth words today, unable to interpret- pt became tearful then closed eyes and would not respond to verbal stimuli.\\n\\nPLAN OF CARE: Continue to monitor hemodynamcis, sx bleeding closely. Monitor CVPs, notify MICU resident of results. Aggressive skin care, nursing measures to ensure pts comfort, emotional support to pt and family ongoing. Reccomend family and interdisciplinary team conference in am to determine disposition plan and revisit pts comfort and \\\"big picture\\\" of disease states and inability to recover/heal and intolerance to medical interventions. This was requested by RN on MICU rounds today.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524424,\n \"text\": \"Resp Care\\nPt remains on CMV, no vent changes. Plan to prepare for home discharge and transition to home vent.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524425,\n \"text\": \"RESP CARE: pt remains trached/on vent No changes in vent settings. Lungs coarse bilat. Sxd mod amts thick yellow sputum. pressure in trach at 25cmH20. No RSBI due to henodynamic instability. Plan is to place pt on home vent today in anticipation of DC home Wed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524131,\n \"text\": \"Status A\\nSee Carevue for specifics\\n\\nNeuro: Alert but unable to assess orientation. Follows commands inconsistently. PERRL.\\nCV/GU: Afib. Hypotensive but maintained parameter of MAP >50. 1 unit of PRBC given during dialysis.\\nResp: LS clear. No vent changes.\\nGI: BS present. TF to goal. Drainage around PEG, dsg changed. Colostomy putting out brown liquid stool.\\nSkin: Multiple wounds and areas of skin breakdown. See Carevue for specifics.\\nEndo: glucose fairly stable in 110s-120s with insulin gtt with drop later in afternoon to 70s.\\nSocial: children at bedside.\\nPlan: continue with skin care regimen. Educate family on homecare needs.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524132,\n \"text\": \"NPN (SEE CAREVUE FOR SPECIFICS)\\n PT ALERT, FOLLOWS COMMANDS TO OPEN MOUTH, OPEN EYES. ONLY SPONTANEOUS MOVEMENT NOTED IS FROM UPPER LEFT EXT. PERRL. C/O PAIN THAT SEEMS TO BE RELIEVED WITH REPOSITIONING.\\nCV- REMAINS HYPOTENSIVE, 80-100 SYSTOLIC, CAN HAVE FLUID IF SYSTOLIC BELOW 80. HR 90-100'S, A-FIB WITH OCCASIONAL PVCS, AM LABS PENDING.\\nRESP- LUNGS CLEAR, SUCTIONED A FEW TIMES FOR SMALL AMOUNT OF THICK YELLOW SPUTUM. O2 SAT 100% ON CURRENT VENT SETTINGS, NO CHANGES MADE, BREATHING COMFORTABLY.\\nGI/GU- ABD SOFT, HYPO SOUNDS. TUBE FEED CONTINUES AT GOAL, SMALL AMOUNT OF DRAINAGE NOTED FROM AROUND PEJ SITE, CLEANED AND DRY DRESSING PLACED. CHANGE OVER TO LARGER TUBE TODAY IN IR. PT DOES NOT VOID.\\nID- AFEBRILE\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524133,\n \"text\": \"Respiratory Care Note:\\n\\nPt remain on full ventilatory support via tracheotomy tube. No vent changes maded. RSBI done ~77. We are sxtn routinely for smalla mt of thick yellow secretions from trach. Plan: Continue present iCu moniotoring. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524134,\n \"text\": \"Respiratory Care\\n\\n Pt continues on full ventilatory support. No changes made today. Cuff pressure 25cm H20. Pt traveled to I.R. without complication. B/S sl coarse sx'd for scant thick yellow. Will continue to follow closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524213,\n \"text\": \"Repiratory care\\nPt remains on a/c vent without changes, Suctioned for large amts of thick yellow sample sent to lab. Pt had trach change to Shiley #7 long\\nvia bronchoscopy without incident. MDI's as ordered.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524214,\n \"text\": \"\\\"Condition update\\nPlease see carevue for specifics.\\n\\nneuro unchanged. tmax 100.9; wbc ct up to 25. plt re pan cx'd today. afib continues. HR 120's - 150. MICU team aware. 12 lead EKG done. HD today. 2300 off. hct down to 17.8; 2 units prbc given. post transfusion hct only 21. no further blood given. pt noted to have dark red bleeding in moderate amts from her vagina. MICU team notified. bs's 200's-300's. insulin gtt ordered. wounds cx'd. trach changed over to 7 long shiley. HCP notified.\\n\\nplan: hd as tolerated. iv abx. wound care. monitor hemodynamics. family meeting to discuss plan of care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524215,\n \"text\": \"Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick tan secretions. MDI'S given. Temp 101.2. HR-A-Fib.No weaning done.Will cont to monitor resp status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524216,\n \"text\": \"nursing note\\nAlert with open eyes. nods at times but question if she understands. All dressing done and documented. Tmax 101.8- given as pan cx'd on days.\\nplan:await culture results. if temp. skin care. family meeting to discuss dispo.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524448,\n \"text\": \"NURSING NOTE\\nPLEASE SEE CAREVUE FOR DETAILS\\nNEURO: ALERT, DOZING INTERMITTENTLY, EASLIY AROUSABLE. NOT FOLLOWING COMMANDS, INCONSISTENLY NODDING HEAD TO QUESTIONS. PERRL 4-5MM, BRISK, NOT TRACKING W/EYES. DEMEROL GIVEN FOR PAIN PRIOR TO DSG CHANGES X2.\\n\\nCVS: HR 80S-90S, NSR, NO ECTOPY NOTED. 70S-140S, MAP MAINTAINED>60 PER MICU, AFEBRILE. PM HCT 31.1, INR 1.9, PLT CT 37, K REPLETED FOR 3.9, REPEAT LABS AT 2100.\\n\\nRESP: REMAINS ON CMV, RATE 22/VT 450, NO VENT CHANGES MADE. PT SUCTIONED FOR SM AMTS THICK, YELLOW SECRETIONS. LUNGS COARSE TO APICES, DIMINISHED AT BASES, SLIGHT EXP WHEEZE NOTED TO RUL AT TIMES, MDI TREATMENTS GIVEN.\\n\\nGI/GU: RE-START TF AFTER MN PER MICU TEAM. COLOSTOMY PINK W/MIN GRN/BRWN DRNG, NO BLOOD NOTED. GT TO GRAVITY W/MOD AMT YELLOW, SEROUS DRNG, JT PATENT TO FLUSH, AREA AROUND INSERTION SITE DRNG SM AMTS STRAW COLORED FLUID. SM AMT CLEAR MUCOID RECTAL DRNG NOTED, AS WELL AS SM AMT VAGINAL BLEEDING NOTED-DR. AWARE.\\n\\nENDO: BS REQUIRED NO COVERAGE, AM LANTUS HELD PER MICU FOR AM BS 89\\n\\nINTEG: EXTENSIVE WND CARE DONE, INCL MULTI DSG CHANGES, FREQUENT TURNING & RE-POSITIONING. SARNA LOTION APPLIED TO MULTI AREAS RED RASH, MICONAZOLE/ANTI-FUNGAL POWDER APPLIED TO PERINEAL AREA. REDDENED, EXCORIATED AREA TO NECK UNDER TRACH COLLAR NOTED. PT W/GENERALIZED LEAKING COPIOUS AMTS SEROUS FLUID.\\n\\nPSYCHOSOCIAL: PT HUSBAND IN TO VISIT FOR SHORT TIME THIS AM. DAUGHTER CALLED INQUIRING ABOUT PT CONDITION, REQUESTED COPY OF PT , UPDATE FROM ATTENDING MD, MSG PASSED ALONG.\\n\\nPLAN: AGGRESSIVE SKIN CARE, PT COMFORT, RESP SUPPORT. SICU , PLAN FOR D/C HOME MON IN ACCORDANCE W/FAMILY WISHES.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524449,\n \"text\": \"Resp Care,\\nPt. remains on A/C . No vent changes this shift. BS coarse, suctioned yellow sputum. MDI's as ordered. 65 this am. Plan home vent Sun. Plan D/C to home Mon. See carevue.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524450,\n \"text\": \"Narrative Note\\nB-Shift:\\nNeuro: Unchanged. Con't w/ rightward gaze. Does not respond to threat or startle. Daughter () appeared to be conversing w/ pt. early in shift, but no such communication could be elicited later. Does appear to sleep at times, and wakeful at others.\\nCV: NSR-ST w/ rare ectopic. BP low, but within normal limits for pt.\\nPulmonary: Vent settings unchanged, refer to CareVue for specific interventions.\\nGI: TF's () started this shift @ 40cc/hr through gastric port on G/J tube.\\nGU: Con't to pass blood/clots through vagina. No change in amount or quality of drainage.\\nSkin: Breakdown in virtually all areas. BUE's w/ tears and ecchymosis, dsg's applied in areas of most significant breakdown (mostly RUE). BLE's w/ many areas of breakdown, DSD's not changed on feet/anlkes. Posterior thigh dsg's changed, areas reddened, not blanching. Dressing on rear-end changed, both tunneled decubitii packed w/ aquacel as ordered, Adaptic placed on open areas. SoftSorbs taped in place with Mefix.\\nSocial/Plan: Son and daughter in to visit from beginning of shift until 11pm. Were concerned w/ G/J tube site and its ostomy appliance. Update given by Dr. who spoke with them for some time. Plan remains to send pt. home on Monday.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524104,\n \"text\": \"Respiratory Therapy\\n\\nPt remains trached w/ #6.0 on full mechanical support. No vent changes made this shift. Currently on A/C ventilation w/ PIP = 14. BLBS slightly coarse, suctioned for moderate amounts of thick tannish sputum. SpO2 90s. MDIs given as ordered. See resp flowsheet for specifics.\\n\\nPlan: maintain support\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524105,\n \"text\": \"7a-7p\\nneuro: lethargic, easily aroused, follows commands @ times, perl, pt on atc po ativan q 6 hrs, pm dose held due to oversedation, pt more awake & responsive after dose held\\n\\ncv: hr a-fib(102-120), occasional pvc's, sbp 87-115, po lopressor, po amiodarone\\n\\nresp: continues on 40% fio2/AC 16/5 peep, no vent changes, bs+ all lobes & clear, sux scant amt sputum, inhalers by R.T., sat 100, rr 20-24, no resp dsitress noted\\n\\ngi: goal tf tol well, mod amt loose brown stool via colostomy, iv protonix, po reglan, colace & lactulose\\n\\ngu: anuric, hemo 3 x's per weak, no hemo today, done yesterday, due tomorrow, albumin(12.5 gm) x 1 ordered for hemo tomorrow, see stat med sheet\\n\\nother: wound care done as ordered, R foot with lg amt bleeding, ho aware, hct done @ 1300(26.9), no tx, pt to have blood tx with hemo tomorrow, daughter in & updated on pt by nurse & medical team, bs 424, insulin gtt resumed, ptt 99.5, heparin gtt off x 1&1/2 hrs then resumed @ 750 u/hr, PTT due @ 2330, no c/o pain\\n\\nplan: continue to monitor blood pressure/sepsis in ICU, fluid boluses for sbp < 80, MRI to r/o osteo from sacral decub, hemo tomorrow, antibiotics as ordered\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524184,\n \"text\": \"Condition Update\\nPlease see carevue for specifics.\\n\\nT/max 99.7; Cx's pending from . AFib. HR 90's-130's. Lopressor dose held d/t sbp 80's. Rare PVC's noted. 12.5 mg Demerol given for pain prior to dressing changes. Pt sxn'd for large amts of thick, yellow sputum. A sputum cx and gram stain sent. No vent changes made this shift. Pt continues on AC 40%/5 peep. Resp tx giving pt . Pt went down to I.R. for new G/J tube. w/ beneprotein infusing at goal. Colostomy draining golden loose stool. Stoma is pink. Regular insulin gtt started this afternoon d/t continued high blood sugars. Pt still receiving 90 units glargine q 12 hours. Plastics team up this eve to pt's wounds. Feedback pending. Pt to be started on CRRT this eve since she was unable to tolerate HD .\\n\\nPlan: continue with current plan of care per MICU team. CRRT. Q 6 hour labs. MICU team to evaluate for arterial line. Hourly blood sugars d/t insulin gtt. Pain mgmt. Daily dressing changes. F/U on plastics consult. IV ABX.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524185,\n \"text\": \"Respiratory Therapy\\n\\nPt remains trached w/ #8 TTS adjustable trach locked @ 10cm. Currently on A/C ventilation, no changes made this shift. SpO2 90s. Travelled to and from IR for G/J tube placement w/out incident. MDIs given as ordered. BS coarse bilaterally, suctioned for moderate amounts of thick tan sputum. See resp flowsheet for specific vent settings/data.\\n\\nPlan: maintain support; still to be evaluated by IP for ?trach change\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524426,\n \"text\": \"focus hemodynmics\\ndata: neuro: awake and opens eyes to verbal stimuli. mouths words but difficult to understand. does not move extremities due to fluid in extremites. nods to daughter and son in law. nods to some questions.\\n\\nresp: breath sounds course. suctioned for thick yellow sputum. trach care done. skin near trach reddened and excoriated.\\n\\ncardiac: remains in nsr. occ pvc. k 3.0 and ho notified. k being repleted with 20meq iv. diltazem held due to bp < 90.\\n\\ngi abd soft. tube fdgs infusing at goal rate of 40cc/hr. colostomy bag intact and draining brown/green drainage.\\n\\ngu creat 1.7. due to be dialysized today.\\n\\naction: labs as ordered. suctioned prn. tube fdgs as ordered. k repleted with 20meq kcl. skin care done q1-2 hrs. buttocks excoriated. lg amt of serous drainage . lg decubitus on buttocks and dsg changed x3. leg dsg intact with feet dsg changed x2. daughter in to see pt tonite and very upset with the g j tube insertion site. daughter spoke with ho and verbalized her concerns of tube and skin condition. daughter upset with overall skin condition. dsughter would like to talk with the attending md. ho aware of this and will discuss in rounds today.\\n\\nresponse: monitor closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524124,\n \"text\": \"RESPIRATORY CARE NOTE\\n\\nPatient remains trached with Shiley trach tube 6.0 SCT. No vent changes made during the . BLBS are coarse. Sxn for moderate thick yellow secretions. RSBI completed on PS 5=99.\\n\\n , RRT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524125,\n \"text\": \"Addendum: Progressively lower diastolics to 30s-40s with MAPs <60. HR stable, pt. alert and appears neurologically unchanged, though does not follow commands at baseline. MICU team in to assess and given 500cc NS and lytes repleted. SBP to 90s after begun.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524217,\n \"text\": \"Patient uses portable vent @ home,trach is changed to # 7 extra long. Inner canulae on top on vent for daily usage.BS rhochious with L>R,suctioned for thick yellow secretion;sputum cultured gram(-) rod.Patient on tobramycin.CXR (l) pleural effusion and lingula atelectasi.Plan to meet with family to discuss disposition.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524218,\n \"text\": \"Condition Update\\nPlease see carevue for specifics.\\n\\nTmax 99.7, AFIB. HCT stable at 25.2, but vaginal bleeding continues. Transvaginal Pelvic ultrasound ordered. Pt sxn'd several times for thick, yellow/green secretions in moderate amts. TF's infusing at goal. BS 91-127. RISS ordered, glargine dose increased to 92 units. toxin B assay sent, and Po flagyl ordered despite all previous specs being negative.\\n\\nPlan: continue with current plan of care per micu team. continue to closely follow blood sugars, hemodynamics. HD to be . Vanco and tobramycin peak and trough to be drawn. Still awaiting vaginal us. Dressing changes. Family meeting to be scheduled by social services to include family, nursing, social srvs, case mgmt, ethics, micu team + the attending. Blood cx to be drawn from the HD catheter by the HD RN.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524219,\n \"text\": \"Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned mod amts thick green/tan secretions. MDI'S given.Will cont to monitor resp status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524220,\n \"text\": \"nursing update\\nno events. MD spoke with daughter regarding family meeting. Duaghter at this time does not want family meeting. She states she will have one when home services are set up and mom is ready to go home.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524291,\n \"text\": \"Resp Care\\nPt remains trach on full vent support. No vent changes this shift. Pt continues to be suctioned for mod amt of thick yellow sputum, MDIs given per order. Pt brought to IR this afternoon. plan to continue vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524186,\n \"text\": \"nursing note\\nNeuro:Mouthing words at times, not sure what she is saying. some movement noted with L hand. afebrile.\\nCV: Cont in afib, lopressor held secodnary to low BP.\\nRESP:thick tan secretions, copius at times.\\nGI: at goal. loose stool via ostomy- sent\\nGU:anuric. started with goal even. ultrafltrate titrated frequently secondary to BP.\\nSocial: MD wspoke with daughter re: and 2 sons. spoke with 2 sons and answered many questions re:, labs, antibiotics, cultures and wound care.\\n\\nplan:cont to await culture data, resp toilet, to keep even. social support\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524187,\n \"text\": \"Respiratory Care\\nPt continues full vent support with #8 adjustable protex trach locked at 10cm. BS coarse and diminished bilaterally. Suctioned for moderate amounts of thick tan sputum. No vent changes made this shift. MDIs given as ordered. See Careview for morning RBSI results.\\nPlan: maintain suppport\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524188,\n \"text\": \"Events:\\n\\nSacral wound cultured\\n running even and transiently positive for hypotension with effect\\nKPhos repleted\\n\\nNeuro-shakes head to yes/no questions, moves upper extrem >LE, withdraws LE weakly, PERRLA, ativan ATC for comfort\\nCV-HS S1S2 irreg with click, doppler DP bilaterally cool extrem x4, cont on amiodarone/lopressor remains in AFib, coumadin dose to be held tonight INR 4.3\\nResp-ML trach site red, remains on AC, sx for scant thick plugs, LS coarse upper lobes dim at bases\\nGI-TF at 40cc/hr, GJtube leaking serous at site, DSD and skin barrier cream at site, glucose covered with glargin 90u SQ and insulin drip, colostomy loose liquid stool out\\nGU- running even RF/Dialysate prismasate, K and calcium repleted with SS, acid base balance and lytes monitored q6 hours\\nskin-sacral decubitis to bone foul odor out, packed and DSD to area, r/l hip stage II aquacel/allevyn dressings, necrotic toes bilaterally and calf stage II-III dressing changed per wound care recomendations\\n\\n HCP updated via phone, daughter many questions and felt the patient needed albumin with dialysis to remove fluid, daughter requested antibiotic changes. update given and teaching done regarding and albumin, and blood pressure.Update given current cultures and sensitivity to current ABX, daughter aware infectious disease following. MICU team aware of daughters concerns. Daughter stated \\\" failed to identify infection, she was the one to tell the doctors to , she was the one to identify nutrition needs\\\" stated that she was the primary person managing her at home and albumin \\\"worked\\\", extensive teaching done and update on current plan of care, daughter continues to state negative comments regarding the care and doctor \\\" stating she was able to manage this at home. Risk /patient care services notified. Daughter made aware she can voice her concerns to case management.Reassurance given to that her mother is getting aggressive care and the best care. Emotional support provided, at this time the MICU team is in agreement to only give information and daily updates to primary HCP in order to avoid confusion among family members. SICU staff will attempt to provide info to HCP . Social work notified\\n\\nPlan-cont running even, cont TF, continue skin care, monitor lytes and acid base balance, cont emotional support to family, information to HCP only to avoid confusion among family members, updated on this\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524189,\n \"text\": \"Respiratory Care\\n\\n Pt continues on full ventilatory support. No changes made today. B/S sl coarse and diminished. MDI's as ordered. Sx'd for sm/mod amount thinish yellow secretions. Will continue to follow closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524190,\n \"text\": \"Resp Care Note:\\n\\nPt cont trached and on mech vent as per Carevue. Lung sounds coarse suct mod th off white/tan sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required . Had difficulty asp secretions from trach; repositioned tube problem resolved. Cont mech vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524277,\n \"text\": \"NPN (SEE CAREVUE FOR SPECIFICS)\\n PT ALERT, MOUTHING WORDS, OCCASIONALLY NODDING IN RESPONSE TO SOME QUESTIONS. MOVING ONLY LEFT HAND ON THE BED. PERRL. PT APPEARING TO BE CRYING AT TIMES, UNABLE TO UNDERSTAND THE WORDS THAT SHE IS MOUTHING, OFFERED EMOTIONAL SUPPORT.\\nCV- BP STABLE IN 90-115 RANGE SYSTOLIC. NEO REMAINS OFF FOR NOW, PITRESSIN CONTINUES AT 2.4 U/HR. A-FIB, TACHYCARDIC 110-150'S AT TIMES, HOWEVER NOT SUSTAINED. AT BEGINNING OF THE SHIFT, PT APPEARED TO BE INCREASINGLY TO 150'S, 2L NEG FLUID BALANCE, BP STABLE, DR. NOTIFIED. NO NEW ORDERS AT THE TIME. DECISION MADE TO TAKE OFF LESS FLUID, TRYING TO KEEP EVEN FLUID BALANCE. CVP 13-16.\\nRESP- LUNGS COARSE AT TIMES, SUCTIONED OCCASIONALLY FOR THICK WHITE SPUTUM. ABGS WNL THIS AM.\\nGI/GU- ABD SOFT, HYPO SOUNDS. COLOSTOMY DRAINAGE IS GOLDEN BROWN LOOSE. TOLERATING TF AT GOAL. PT DOES NOT VOID.\\nID- TEMP 95 AT MIDNIGHT FOLLOWING BATH, VERIFIED BY AXILLARY. WARM BLANKETS PLACED, HEAT TURNED UP IN ROOM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524278,\n \"text\": \"Respiratory Care Note:\\n\\nPt remain on ventilatory support/assist via tracheotomy tube. No vent changes done. Lung sound clear to coarse, BBS. We are sxtn for small amt of thick white secretions from trach. none orally. MDI adm as ordered with no noticeable changes, Albuterol held t/o shift as HR> remain above 120 bpm. Plan: Continue present ICU monitoring. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524126,\n \"text\": \"Focus Condition Update\\nSee flowsheet for specific info.\\n\\nNeuro: Status unchanged. Pt mouthing words, following some commands, MAE's except for RUE. Fentanyl given for pain with dressing changes. Demerol written PRN for future dressing changes.\\nCV: Hypotensive at times, , team aware. Afebrile. Lopressor and midodrine given.\\nResp: No vent changes made this shift. LCTA, dim in bases. trach care done.\\nGI: J-tube leaky, MD aware, surgery called by resident, but they have not come by to see pt. at 40cc/hr. Colostomy draining moderate amount of brown liquid stool.\\nSkin: All wound dressings changed today with skin care RN. See updated note for dressing instructions.\\nEndo: Sugars running high today, covered with new s/s. consulted this a.m.\\nSocial: Dtr in to visit, many questions and needs.\\nPlan: Discharge to home on Monday\\n Continue with current POC\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524127,\n \"text\": \"resp care - pt remains intubated with #6 shiley trach. Settings are a/c 450/16/5 40%. No changes were made during the day. Breath sounds were course bilaterally in the upper lobes, clearing slightly on sx of small amounts of thick yellow secretions. BS were dim in RML and LLL.\\nPt's cuff leak was resolved with a pressure of 25 cmH2O. Continued resp care planned.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524128,\n \"text\": \"NPN (SEE CAREVUE FOR SPECIFICS)\\n PT ALERT MOST OF THE NIGHT. ABLE TO MOUTH SOME WORDS AND NOD IN RESPONSE TO SOME QUESTIONS. NO SPONTANEOUS MOVEMENT NOTED OVERNIGHT.\\nCV- BP DECREASING TO 70'S SYSTOLIC THIS AM, DR. NOTIFIED AND 500CC NS GIVEN WITH GOOD EFFECT. HR 90'S-100, A-FIB WITH OCCASIONAL PVCS.\\nRESP- LUNGS CLEAR, SUCTIONED A FEW TIMES FOR SMALL AMOUNTS OF THICK YELLOWISH. O2 SAT 100%, NO VENT CHANGES.\\nGI/GU- ABD SOFT. COLOSTOMY DRAINING BROWN LOOSE STOOL, STOMA BEEFY RED AND APPEARS HEALTHY. INSULIN GTT RESTARTED FOR BS 309, BS DECREASING BY AM, LANTIS GIVEN AS ORDERED.\\nID- TMAX 99.3\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524129,\n \"text\": \"Respiratory Care Note:\\n\\nPt remain on ventilatory support via traheotomy tube, No vent changes maded. We are sxtn for small amt of thick yellow sputm thru trach. MDI adm as ordered with No noticesable cgaanges in BS. Plan: Continue present ICU monitoring. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524130,\n \"text\": \"resp care - pt remains intubated with #6 Shiley trach on a/c 450,16,5,.40. No changes made. Rhonchi t/o cleared on sx of sm amt of thick white sputum. Meds given as ordered. Dim BS in LLL. Positional leak persists. MD wants no more than 25cmH2O cuff pressure. Continued resp care planned.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524205,\n \"text\": \"BS rhonchi; no change with MDI's. Pt continues to have variable trach leak and we are looking into ordering a non- (to accomodate family), that is extra length, ideally >100mm. Current cuff pressures < 20 cm but adding air frequently. HD today. Pt will be discharged to family when sepsis and trach issues are resolved.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524206,\n \"text\": \"FOCUSED NURSING ASSESSMENT\\nPlease see carevue for further details\\nNeuro: No acute changes in mental status, pt lethargic. alertness and responding to commands fluctuates- nods to communicate basic needs. PERRL, 3mm. Medicated with Demerol 12.5mg IV for drsg .\\n\\nResp: Trach patent, leak persistent though not interfering with oxygenation or ventilation. No vent changes made. Family goals of opportunity to place passy muir valve so pt can communicate her POC/medical wishes made known to MD. acceptable after inflation. Scattered rhonchi bilaterally- SPO2> 98% on A/C 0.40 PEEP 5. Frequent suctioning required, sputum change to copious blood-tinged, rusty and MD notified.\\n\\nHemodynamics: s/p HD removal of 1.75ml. Unable to remove goal of 3liters secondary to BP drops- tx by HD RN with NS and Albumin. Average SBP s/p HD is 88-96, DBP decreasing 30-45. Afib controlled rate 95-118. New onset vaginal bleeding, slow ooze, dark red MD notified, plan tranvaginal US. INR 3.0, coumadin held secondary to sx bleeding. HCT 27.5 stable this am.\\n\\nMetabolic: TF at goal rate 40ml/hr. Improved glycemic control, BS 111/87.\\n\\nID: Tmax 99.8. Tachycardic since HD. Tobramycin random 0.5, peak pending. Zosyn, Levaquin as ordered.\\n\\nSKIN INTEGRITY: Multiple pressure ulcers/wounds. Full re-evaluation and drsg with Skin care RN, please see her full note. Turn and repositioned q2-3hr. Pt requires premedication with demerol for drsg procedure.\\n\\nPSYCHOSOCIAL: Pt visited by husband and son in am during HD. Followed by daughter in afternoon who is very knowledgeable of her mother's medical care, specifically nursing focuses, and supportive. Emotional support and education to family members ongoing. SW following as well. POC per HCP daughter.\\n\\n PLAN: Monitor vag bleeding, hemostasis. F/U transvag US results. Hold coumadin today. Monitor labs/fevers. Skin care, resp care, comfort measures as appropriate per aggressive POC. Family support, d/c planning needs for home ventilation/HD/ and IV abx course.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524292,\n \"text\": \"Please See Carevue for Specifics.\\n\\nNeuro: Arousable to voice does not follow commands only moves LUE to nailbed pressure. Ativan held this shift for sedation.\\n\\nCardio: SR-ST till 1755 this evening when pt coverted to afib 140-150's. MICU team aware, pt started on Diltiazem IV. this morning 70 and was started on Neo at 0.5mg/kg/hr. Generalized edema. Received two units , three units platelets, and one unit pRBC's prior and during new quinton placement and old quinton removal in IR. Blood cultures from old quinton cath, and right CVL. Line tip cultures sent from old quinton and PICC line. CVP 13-20. restarted at 1800.\\n\\nRespir: Remains on CMV. Suctioned for small amounts of thick tan-yellow secretions.\\n\\nGI: TF stopped at 1130 for procedure scheduled in IR and restarted at 1800. G-tube to gravity with clear/yellow mucous discharge. Stoma beefy and pink with guaiac negative loose golden stool.\\n\\nCVVH: Restarted at 1800. Fluid balance goal 0.\\n\\nSKIN: Skin remains impaired. Yeast under both breast, both underarms, both groin folds. All folds cleansed with soap and water, dried, and miconazole powder applied. Right great toe brown and hard. Thick foul yellow/green discharge from larger knuckle. Discharge obtained for culture. Bil posterior lower ext with pink +granulating tissue. Areas cleansed with wound cleanser and adaptic with DSD covering. Heels pink, cleansed, adaptic and DSD re-covered.\\n\\n: Monitor hemodynamics, monitor MS, pain, respir status, family aware of . HCP spoke with MICU attending this afternoon regarding limited line access.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524363,\n \"text\": \"Respiratory Care\\nPt remains trached and on vent support. No vent changes were made during shift. Lung sounds were course with rhonchi that cleared after suction. LLL and RLL were dim. Pt was suctioned for small to moderate amounts of thick yellow secretions. Pt received MDI's with improvement. Care plan is to continue current therapy with no changes to be made. Will continue to follow pt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524364,\n \"text\": \"NURSING NOTE\\nPLEASE SEE CAREVUE FOR DETAILS\\nNEURO: PT CONT UNRESPONSIVE EVEN TO NAILBED PRESSURE, OPENS EYES SPOENTANEOUSLY, NOT FOLLOWING COMMANDS. PERRL 5MM, BRISK, DOES NOT TRACK W/EYES. NOT MOVING ANY EXTREMS.\\n\\nCVS: HR 70S-90S, DILTIAZEM DRIP CONT AT 7.5MG/HR, NSR, NO ECTOPY. 70S-100S, MAP MAINTAINED >55, NEO DRIP AT 0.3-0.4MCG/KG/MIN. T-MAX 99.4, TRANSFUSED 1 UNIT PRBCS, POST HCT PENDING, NO DIALYSIS TODAY PER RENAL, ?. PP , CONT W/ GEN ANASARCA, WEEPING SM AMTS SEROUS FLUID VIA MULTI SKIN TEARS.\\n\\nRESP: A/C-VT 450/PEEP 8/50%, RATE 20S-30S, DEMEROL GIVEN X1 FOR TACHYPNEA PRIOR TO DSG CHANGES. LUNGS SNDS DIMINISHED THROUGHOUT, SOMEWHAT CLEARER TO RUL, DIFFUSE RHONCI AT TIMES. PT FOR MOD AMTS THICK, YELLOW SECRETIONS, TRACH CARE DONE. NEBS GIVEN.\\n\\nGI/GU: COLOSTOMY PATENT, DRNG MIN AMTS DK RED STOOL. J/G TUBE CONT LEAKING MOD AMTS BROWN LIQUID DRNG AROUND INSERTION SITE, NO FRANK BLOOD NOTED. JT PATENT TO FLUSH, EASILY DRAWING BACK DK RED FLUID>FLUSH AMT, GT PATENT TO FLUSH, NO DRAW BACK>5-10CC-HO AWARE. HYPO +BS.\\n\\nENDO: BS 120S-170S, INSULIN DRIP 8-9MG/HR\\nID: AMIKACIN LEVELS PENDING, HOLD MED IF>4 PER MICU, BLD CX PENDING.\\n\\nPLAN: CONT HEMODYNAMIC MONITORING, AGGRESSIVE SKIN CARE, PAIN MGMT, RESP SUPPORT, ?HD , NEURO CHECKS, ANTIBIOTIC THERAPY, GI OUTPUT MONITORING FOR GI BLEEDING, SERIAL LABS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524279,\n \"text\": \"SICU NPN\\nS-Trached\\n\\nO-Alert. Opens eyes spontaneously. Following commands inconsistently. Beginning to mouth words. PERL. Denies pain. Demerol IVP for dressing changes. HR 140-160s, RAF with stable BPs. SBPs 100-110s. Pitressin off at 0800. Since stable. Amiodorone load IVPB given. No gtt started. HR 110-130s post and no continious gtt started. SBPs post 80-90s. Dr. aware. Verbal orders to not to start Pitressin. Keeping MAPs > 55. Breath sounds clear. Remains on AC. Repeat ABG with respiratory alkalosis. MICU team aware during rounds. Bicitra discontinued. No vent changes made. CRRT continues. Fluid balance discussed with MICU team during rounds. Deciscion made to keep even. Now currently deciscion made to keep 1L ahead at 4PM. I/O currently even. CRRT labs pending for 4PM with ABG. Potassium scale increased for K of 3.3 this AM. ICa left the same. Abd obese and soft, bowels sounds active. TFs at GR. Ostomy and J-G tube intact. Hypothermic this morning, currently normothermic but remains on bair hugger at ambience setting. Tc 97.0, PO. Continues quadruple Abx for bacteremia. Family in and out most of day.\\nA/P:Sepsis, improving off pressors. Goal now is to keep 1L ahead for daily I/O\\nFollow ABGs and lytes while on CRRT Q6H.\\nMonitor BPs closely, keeping MAP > 55.\\nContinue to monitor\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524280,\n \"text\": \"Resp Care\\nPt remains on AC 450 x 16. ABGs do show some Resp Alkalosis, Bicitrate was discontinued. BS clear to coarse. Sxn' d clear to thick yellow secretions at times. RR breathing over vent by around 9 breaths per min.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524334,\n \"text\": \"Respiratory Care\\nPt trached on ventilatory support. Sx copious amounts thick green secretions. Minute ventilation markedly decreased over last 24 hours. ABGs within normal values with good oxygention.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524335,\n \"text\": \"CONDITION UPDATE\\nASSESSMENT:\\n NEURO UNCHANGED. PATIENT DOES NOT APPEAR IN PAIN, NO PAIN MED NECESSARY. HEART RATE ~ 100 AFIB. MAP > 55 ON 0.8 MCGS NEO, UNABLE TO WEAN FURTHER. RECEIVED 1 UNIT PRBCS FOR HCT 21 THIS AM, REPEAT HCT UP TO 25. AFEBRILE. PATIENT REMAINS EXTREMELY FLUID OVERLOADED. CREAT 1.0 AND ELECTROLYTES NORMAL, NO DIALYSIS TODAY.\\n ABDOMEN SOFTLY DISTENDED, PATIENT HAD FEEDINGS THRU J-TUBE THIS AM AND LARGE G-TUBE OUTPUT. KUB DONE IN AM. PATIENT ALSO VOMITED BILIOUS APPEARING FLUID & MODERATE AMOUNT OOZING FROM TRACH SITE. MICU TEAM AWARE, G-TUBE TO SUCTION & IMMEDIATELY DRAINED 750 CC. TUBE FEEDS OFF AND AWAITING ABDOMINAL CT SCAN FOR ? OBSTRUCTION. COLOSTOMY WITH ONLY 50 CC LIQUID BROWN STOOL THIS SHIFT. PATIENT ON INSULIN GTT, STOPPED IN AFTERNOON WHEN TF OFF.\\n TRACH CARE DONE SEVERAL TIMES. SUCTIONED FREQUENTLY FOR THICK YELLOW SPUTUM. REMAINS ON ASSIST CONTROL & TOLERATING WELL. LUNG SOUNDS COARSE. SEE FLOWSHEET FOR SKIN/WOUND CARE.\\nPLAN:\\n CT SCAN AND AWAIT RESULTS. KEEP G-TUBE TO SUCTION. CONTINUE WITH SKIN CARE.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524336,\n \"text\": \"BS fine crackles but less so than yesterday; no change with MDI's. Vomited up bile with some seen around trach site, ? aspiration. CT of abdomen and chest today - results pending. No vent changes or ABG's this shift.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2132-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 184247,\n \"text\": \"Baseline artifact. Probable sinus tachycardia with atrial premature beat, but\\nbaseline artifact and generalized low voltage make assessment difficult. Left\\nbundle-branch block. Generalized low voltage. Clinical correlation is\\nsuggested. Since the previous tracing of rhythm is more suggestive of\\nsinus tachycardia.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2132-09-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 184248,\n \"text\": \"Regular wide complex tachycardia - mechanism uncertain - probably\\nsupraventricular with intraventricular conduction delay\\nGeneralized low voltage\\nClinical correlation is suggested\\nSince previous tracing of , tachycardia present - in retrospect the\\nrhythm on previous tracing of , may be atrial flutter rather than sinus\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2132-09-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 184249,\n \"text\": \"Baseline artifact. Rhythm is uncertain - is probably sinus with first degree\\nA-V delay and left atrial abnormality but baseline artifact makes assessment\\ndifficult. Left bundle-branch block. Since the previous tracing of axis\\nis less rightward.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2132-09-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 184250,\n \"text\": \"Sinus tachycardia\\nIndeterminate axis\\nFirst degree AV block\\nLeft atrial abnormality\\nIntraventricular conduction delay\\nPossible anteroseptal myocardial infarction\\nInferior T wave changes are nonspecific\\nLow QRS voltages in limb leads\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2132-08-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 184251,\n \"text\": \"Atrial fibrillation with rapid ventricular response\\nMarked right axis deviation\\nLeft bundle branch block\\nGeneralized low QRS voltages in limb leads\\nSince previous tracing, rate faster\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2132-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 184252,\n \"text\": \"Atrial fibrillation\\nLeft bundle branch block\\nGeneralized low QRS voltages in limb leads\\nSince previous tracing, atrial fibrillation present\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2132-07-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 184253,\n \"text\": \"Probable multifocal atrial tachycardia\\nLeft bundle branch block\\nSince previous tracing of , atrial ectopy present\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-08-29 00:00:00.000\",\n \"description\": \"PELVIS, NON-OBSTETRIC\",\n \"row_id\": 923655,\n \"text\": \" 10:22 AM\\n PELVIS, NON-OBSTETRIC Clip # \\n Reason: Endometrial lesion?\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with multiple medical problems including respiratory failure\\n s/p trach, multiple infections, including pseudomonas pneumonia/sacral\\n decubitus ulcers, chronic renal failure on CVVH in the hospitals presents\\n withnew onset of vaginal bleeding and . Hct.\\n REASON FOR THIS EXAMINATION:\\n Endometrial lesion?\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION: Portable pelvic ultrasound.\\n\\n INDICATION: Query vaginal bleeding.\\n\\n FINDINGS:\\n\\n The uterus is visualized and measures 9.7 x 4.3 x 6 cm. The endometrial\\n stripe is slightly thickened for the patient's age at 0.5 cm. In the presence\\n of vaginal bleeding, it is not possible to distinguish blood from endometrial\\n thickness. The note is made of some areas of high echogenicity within the\\n uterus anteriorly. This may represent focal areas of calcification or may be\\n contained within fibroid. The right ovary is not visualized. The left ovary\\n measures 2.8 x 2 x 2.6 cm and is unremarkable. There is an impression of some\\n minimal fluid in the pouch of .\\n\\n CONCLUSION:\\n\\n Technically difficult examination. Prominent endometrial stripe. Right ovary\\n not visualized. Impression of some fluid in the pouch of .\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-09-02 00:00:00.000\",\n \"description\": \"CENTRAL TUNNELED W/O PORT\",\n \"row_id\": 924060,\n \"text\": \" 7:24 AM\\n TUNNELLED CATH PLACE SCH Clip # \\n Reason: New HD cath needed for enterococcus cultured from tip\\n Admitting Diagnosis: SEPSIS\\n ********************************* CPT Codes ********************************\\n * CENTRAL TUNNELED W/O FLUOR GUID PLCT/REPLCT/REMOVE *\\n * C1750 CATH,HEMO/PERTI DIALYSIS LONG C1769 GUID WIRES INCL INF *\\n * C1769 GUID WIRES INCL INF *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 y/o F s/p CVA, now with Enterococcus from HD cath, needs new one. Thank\\n you.\\n REASON FOR THIS EXAMINATION:\\n New HD cath needed for enterococcus cultured from tip\\n ______________________________________________________________________________\\n FINAL REPORT\\n PROCEDURE: Over the wire exchange of right internal jugular approach tunneled\\n hemodialysis catheter.\\n\\n CLINICAL HISTORY: 66-year-old female status post CVA, now with enterococcus\\n identified on blood culture from hemodialysis catheter. Suspected catheter\\n infection.\\n\\n OPERATORS: , M.D. (fellow).\\n , M.D. (supervising staff).\\n\\n INFORMED CONSENT: Procedural informed consent was obtained from the patient's\\n husband who was present upon assessment of the patient. Signed witnessed\\n informed consent was then placed in the medical record.\\n\\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\\n procedure to be performed, the site of the procedure, and appropriate\\n requisition, and consent. Once the above were verified, the patient was\\n positioned in supine fashion on a special procedures table. The right upper\\n anterior chest wall and exiting tunneled dialysis catheter were prepped and\\n draped in the usual sterile fashion. Both lumens of the catheter were\\n aspirated free of heparin solution. Both ports were accessed using 2, stiff\\n Glidewires, which were advanced, under fluoroscopic visualization through the\\n superior vena cava, right atrium, and into the inferior vena The retention\\n sutures of the catheter were then released. The catheter was then delivered,\\n over the guidewire, with digital compression applied at the lower right\\n internal jugular vein for hemostasis. Subsequently, a new 19 cm tip-to-cuff\\n length hemodialysis catheter was placed over the paired guidewires. The tip\\n of the catheter was placed in the cephaldad right atrium. The retention cuff\\n was approximately 2 cm deep to the exit wound. The catheter hub was then\\n sutured in place using two, 2-0, interrupted, silk retention sutures. Both\\n lumens of the catheter were flushed and heparin locked per protocol. The\\n puncture site was then overlaid with a Tegaderm occlusive patch. The patient\\n tolerated procedure well without incident.\\n\\n ESTIMATED BLOOD LOSS: Minimal.\\n\\n (Over)\\n\\n 7:24 AM\\n TUNNELLED CATH PLACE SCH Clip # \\n Reason: New HD cath needed for enterococcus cultured from tip\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n MEDICATIONS: Xylocaine 1%, 10 cc total.\\n\\n IMPRESSION:\\n\\n 1. Status post successful over the wire exchange of tunneled hemodialysis\\n catheter. A new, 19cm long (tip-to-cuff) hemodialysis catheter was placed\\n uneventfully. The catheter is ready to employ.\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-08-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 922829,\n \"text\": \" 4:35 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please assess trach placement. Thanks.\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with chronic trach/peg, lethargy, hypotension, now with\\n persistent fevers and increased respiratory rate.\\n REASON FOR THIS EXAMINATION:\\n please assess trach placement. Thanks.\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Assess tracheal tube, patient with persistent fever and\\n increased respiratory rate.\\n\\n Comparison is made with prior study dated .\\n\\n FINDINGS:\\n Mild right pleural effusion is stable. Interval mild increase in size in the\\n small left pleural effusion. New atelectasis in the lingula. Worsening of\\n right lower lobe consolidation. Tracheal tube with tip in standar position.\\n Right PIC line and right internal jugular vein catheter with tips in standar\\n position in the SVC, unchanged. There is no pneumothorax. The left border of\\n the heart is obscured by the atelectasis and pleural effusion. New mild\\n asymmetric pulmonary edema greater in the left\\n\\n\\n IMPRESSION:\\n New left pleural effusion and lingular atelectasis.\\n Worsening of right lower lobe consolidation.\\n New asymmetric mild pulmonary edema greater in the left side.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-08-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 921134,\n \"text\": \" 10:00 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval for infiltrate/consolidation\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with chronic trach/peg, lethargy, hypotension, now with\\n fever\\n REASON FOR THIS EXAMINATION:\\n please eval for infiltrate/consolidation\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Lethargy, hypertension, fever.\\n\\n CHEST: Compared with the prior film, there is an increase in the effusions.\\n No definite infiltrates are present. The appearances suggest some failure\\n rather than infection.\\n\\n IMPRESSION: Evidence of failure.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-08-02 00:00:00.000\",\n \"description\": \"MR CONTRAST GADOLIN\",\n \"row_id\": 920166,\n \"text\": \" 2:02 PM\\n MR W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \\n Reason: ?osteo of sacrum\\n Admitting Diagnosis: SEPSIS\\n Contrast: MAGNEVIST Amt: 15\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with ?osteomyelitis from sacral decub\\n REASON FOR THIS EXAMINATION:\\n ?osteo of sacrum\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAM: MRI of the lumbar and sacral spine.\\n\\n CLINICAL INFORMATION: Patient with large sacral decubitus ulcer, rule out\\n bone involvement of osteomyelitis.\\n\\n TECHNIQUE: T1, T2, and inversion recovery sagittal, and T1 and T2 axial\\n images of the lumbar and sacral spine were obtained before gadolinium.\\n Inversion recovery sagittal images were also acquired. Following gadolinium,\\n T1 sagittal, and axial images were obtained. Post-gadolinium images are\\n somewhat limited for evaluation secondary to lack of fat suppression.\\n\\n FINDINGS: In the lumbar region mild multilevel degenerative changes are\\n identified within the spine from T11-12 to L5-S1 level. At L4-5, there are\\n disc degenerative changes with facet degenerative changes and bulging of the\\n disc resulting in moderate spinal stenosis. At L5-S1 level facet degenerative\\n changes are identified.\\n\\n There is a rudimentary disc between S1 and S2 visualized.\\n\\n There is a soft tissue defect indicative of decubitus ulcer identified in the\\n region of S4 and S5 segment with T1 low signal in this region. The adjacent\\n sacral segments demonstrate no significant signal changes to indicate\\n osteomyelitis. No definite enhancement is identified. There is no evidence\\n of presacral edema. There is subtle increased signal seen within the coccyx\\n on sagittal inversion recovery images, which could be secondary to partial\\n volume averaging.\\n\\n IMPRESSION: No definite evidence of osteomyelitis of the sacrum. Subtle\\n increased signal within the coccyx could be secondary to partial volume\\n averaging from the adjacent decubitus ulcer. Moderate spinal stenosis at L4-5\\n level.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-08-04 00:00:00.000\",\n \"description\": \"J TUBE CHANGE\",\n \"row_id\": 920327,\n \"text\": \" 7:24 AM\\n PERC G/G-J TUBE PLMT Clip # \\n Reason: replace J tube with larger tube\\n Admitting Diagnosis: SEPSIS\\n Contrast: OPTIRAY Amt: 10\\n ********************************* CPT Codes ********************************\\n * J TUBE CHANGE CHANGE PERC TUBE OR CATH W/CON *\\n * CATHETER, DRAINAGE *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with J tube - needs to be replaced\\n REASON FOR THIS EXAMINATION:\\n replace J tube with larger tube\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION FOR THE EXAM: 66-year-old woman with leakage around J tube.\\n\\n RADIOLOGISTS: Dr. and Dr. , the attending radiologist, who\\n was present throughout the procedure. Informed consent was obtained from the\\n patient's daughter over the telephone.\\n\\n PROCEDURE AND FINDINGS: The patient was positioned on the angiographic table\\n in supine position, was prepped and draped in the sterile fashion. An\\n abdominal scout was obtained to demonstrate the location of the J tube.\\n Injection of diluted contrast was performed through the tube under\\n fluoroscopic guidance, documenting position of the tube in the jejunum. A\\n wire was advanced through the tube and the tube was pulled back over\\n the wire. A new 16 French J tube was then advanced under fluoroscopic guidance\\n and the position was confirmed after injection of contrast under fluoroscopic\\n guidance. The J tube was secured with sutures at the enter site.\\n\\n COMPLICATONS: No immediate complications.\\n\\n IMPRESSION: Successful exchange and upsize of jejunostomy catheter.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-07-29 00:00:00.000\",\n \"description\": \"CT PELVIS W/CONTRAST\",\n \"row_id\": 919547,\n \"text\": \" 10:36 AM\\n CT PELVIS W/CONTRAST Clip # \\n Reason: R/o bone involvement of sacral decub\\n Admitting Diagnosis: SEPSIS\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with large sacral decubitus ulcer\\n REASON FOR THIS EXAMINATION:\\n R/o bone involvement of sacral decub\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION: CT pelvis.\\n\\n INDICATION: Large sacral decubitus ulcer.\\n\\n FINDINGS:\\n\\n TECHNIQUE:\\n\\n Axial images were taken of the lower abdomen and pelvis after administration\\n of IV contrast. Multiplanar reformation was performed. In relation to the\\n lower abdomen, note is made of a hernia in the right paramedian line. The\\n small and large bowel visualized is unremarkable. Note is made of some\\n calcifications in relation to the uterus, consistent with fibroid uterus.\\n\\n There is a defect in the skin posteroinferior to the sacrum. This is\\n extending right down to the level of the sacrum, but there is no definite\\n destruction of the sacrum.\\n\\n IMPRESSION:\\n\\n Large decubitus ulcer posteroinferior to the sacrum. This is abutting the\\n sacrum but no definite destruction of sacrum identified.\\n\\n Right paramedian hernia. Fibroid uterus.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-07-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 919465,\n \"text\": \" 7:50 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o infiltrate, effusion\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with chronic trach/peg, lethargy, hypotension\\n REASON FOR THIS EXAMINATION:\\n r/o infiltrate, effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 66-year-old female with tracheostomy and gastrostomy, now with\\n lethargy and hypotension.\\n\\n COMPARISON: .\\n\\n AP SEMI-UPRIGHT PORTABLE CHEST:\\n\\n A right-sided PICC line and right subclavian dual lumen central catheter both\\n terminate near the cavoatrial junction. The patient is status post sternotomy\\n and valve replacement. The heart size is top normal. The cardiomediastinal\\n contours are stable. There is a tracheostomy in appropriate position. There\\n is a small amount of pleural fluid on the right, tracking into the minor\\n fissure. The left lung is grossly clear. No focal consolidation or\\n pneumothorax is identified. There is no free air under the diaphragm.\\n\\n IMPRESSION: Small right pleural effusion. No pneumonia identified.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-07-29 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 919546,\n \"text\": \" 10:36 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: rule out new bleed\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with hx of left parietal hemorrhage, PEA arrest now admitted\\n with fever and lethargy, supratherapeutic INR\\n REASON FOR THIS EXAMINATION:\\n rule out new bleed\\n CONTRAINDICATIONS for IV CONTRAST:\\n renal failure\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 66-year-old with history of prior left parietal hemorrhage, now\\n post-cardiac arrest with fever and lethargy.\\n\\n TECHNIQUE: CT of the brain without IV contrast.\\n\\n COMPARISON: .\\n\\n FINDINGS: There is no acute intracranial hemorrhage, shift of normally\\n midline structures, or hydrocephalus. -white matter differentiation is\\n preserved. Areas of decreased attenuation in the frontal lobe white matter\\n and periventricular white matter are unchanged. Bilateral basal ganglial\\n calcification, and high density in the right occipital lobe are also stable in\\n appearance. There has been prior surgical intervention along the posterior\\n wall of the right maxillary sinus with clips seen adjacent to the\\n pterygopalatine fossa. A mucus retention cyst or polyp is seen in the right\\n ethmoidal air cells. The remaining visualized paranasal sinuses and mastoid\\n air cells are clear. Soft tissues are normal.\\n\\n IMPRESSION:\\n\\n No acute intracranial hemorrhage or change from the prior examination.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-08-12 00:00:00.000\",\n \"description\": \"CHANGE GASTROSTOMY TUBE\",\n \"row_id\": 921423,\n \"text\": \" 1:16 PM\\n PERC G/G-J TUBE PLMT Clip # \\n Reason: please change j-tube\\n Admitting Diagnosis: SEPSIS\\n Contrast: OPTIRAY Amt: 50\\n ********************************* CPT Codes ********************************\\n * CHANGE GASTROSTOMY TUBE CHANGE PERC TUBE OR CATH W/CON *\\n * CATHETER, DRAINAGE C1769 GUID WIRES INCL INF *\\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with 18F J tube - needs to be replaced per IR due to\\n continued leaking around current tube.\\n REASON FOR THIS EXAMINATION:\\n please change j-tube\\n ______________________________________________________________________________\\n FINAL REPORT\\n PROCEDURE: Gastrojejunostomy tube exchange.\\n\\n CLINICAL HISTORY: 66-year-old female with history of 18 French J-tube with\\n peri-catheteral leak.\\n\\n OPERATORS: , M.D. (Fellow).\\n\\n , M.D. (Staff).\\n\\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\\n procedure to be performed, and the site of the procedure. The epigastric\\n region and the external course of the gastrojejunostomy tube were prepped and\\n draped in the usual sterile fashion. A guidewire was used to cannulate the\\n gastrojejunostomy tube. Once the distal segment wire was noted to extend\\n distal to the gastrojejunostomy under fluoroscopy, the gastrojejunostomy tube\\n was removed over the guidewire leaving the guidewire in situ. A 6Fr sheath\\n was then inserted and a pull-out contrast injection was performed to\\n determine the catheter track, since this was not clear to us, because the\\n catheter was placed at OSH. The contrast injection showed that the catheter\\n appears to be entering the very distal gastric antrum, very close to the\\n pylorus. Subsequently, a 14 French gastrojejunostomy tube was delivered\\n over the guidewire with the retention pigtail formed in the D-2 segment of the\\n duodenum. The distal segment is seen in the mid jejunum. The catheter was\\n secured with formation of the retention suture. A small purse-string suture\\n was applied at the skin exit wound. The wound was dressed with drain sponges\\n overlaid with Tegaderm patches and paper tape. The patient tolerated the\\n procedure well.\\n\\n ANESTHESIA: 1% Xylocaine locally infiltrated, 8 cc total.\\n\\n ESTIMATED BLOOD LOSS: Minimal.\\n\\n COMPLICATIONS: None immediately.\\n\\n IMPRESSION: Status post exchange of gastrojejunostomy tube as described\\n (Over)\\n\\n 1:16 PM\\n PERC G/G-J TUBE PLMT Clip # \\n Reason: please change j-tube\\n Admitting Diagnosis: SEPSIS\\n Contrast: OPTIRAY Amt: 50\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n above. Tube is ready to employ.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-07-30 00:00:00.000\",\n \"description\": \"G/GJ TUBE CHECK\",\n \"row_id\": 919735,\n \"text\": \" 1:20 PM\\n G/GJ TUBE CHECK Clip # \\n Reason: KUB with contrast through J-tube to evaluate placement\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with J tube\\n REASON FOR THIS EXAMINATION:\\n KUB with contrast through J-tube to evaluate placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Jejunostomy tube, query placement.\\n\\n ABDOMEN, TWO VIEWS: Single abdominal radiograph after hand injection of\\n contrast through the jejunostomy tube by the surgical housestaff shows\\n opacification of the tube and a jejunal loop in the left mid abdomen. No\\n other bowel loops are visible. There are midline sternotomy wires and a\\n prosthetic valve. Vascular calcifications are seen in the aorta and common\\n iliacs. There are degenerative changes of the spine.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-08-08 00:00:00.000\",\n \"description\": \"CHANGE GASTROSTOMY TUBE\",\n \"row_id\": 920921,\n \"text\": \" 10:32 AM\\n PERC G/G-J TUBE PLMT Clip # \\n Reason: Please place 18F J-tube if possible\\n Admitting Diagnosis: SEPSIS\\n Contrast: OPTIRAY Amt: 10\\n ********************************* CPT Codes ********************************\\n * CHANGE GASTROSTOMY TUBE CHANGE PERC TUBE OR CATH W/CON *\\n * CATHETER, DRAINAGE C1769 GUID WIRES INCL INF *\\n * C1769 GUID WIRES INCL INF C1892 INT/SHTH,EP,FXD CURVE/ AWY *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with 16F J tube - needs to be replaced with 18F J tube per\\n IR due to continued leaking around current tube.\\n REASON FOR THIS EXAMINATION:\\n Please place 18F J-tube if possible\\n ______________________________________________________________________________\\n FINAL REPORT\\n PROCEDURE: Exchange of gastrojejunostomy tube.\\n\\n CLINICAL HISTORY: 66-year-old female with perigastric catheter leak around\\n pre-existent 16 French percutaneous gastrojejunostomy tube.\\n\\n OPERATORS:\\n 1. , M.D. (fellow)\\n 2. , M.D. (supervising staff)\\n\\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\\n procedure to be performed, the site of the procedure, appropriate requisition\\n material, and appropriate informed consent. Once verified, the patient was\\n positioned in supine fashion. The epigastric region was prepped and draped\\n along with the external course of the previous gastrojejunostomy tube. A\\n stiff guidewire was advanced through the prior gastrojejunostomy tube. Once\\n satisfactory positioning of the tip of the guidewire was confirmed using\\n fluoroscopic visualization, the retention sutures for the catheter were\\n released and the catheter removed over the guidewire, leaving the guidewire in\\n situ. Subsequently, a new 18 French MIC jejunostomy tube was delivered over\\n the guidewire with the distal segment within the mid jejunum. Test injection\\n of contrast demonstrates satisfactory positioning. The retention balloon was\\n inflated with 20 cc of saline solution. Two retention sutures were placed\\n securing the catheter to the anterior abdominal wall. The patient tolerated\\n the procedure well without incident.\\n\\n IMPRESSION:\\n 1. Status post successful exchange of percutaneous gastrojejunostomy tube as\\n described above. The catheter is ready to employ.\\n\\n\\n (Over)\\n\\n 10:32 AM\\n PERC G/G-J TUBE PLMT Clip # \\n Reason: Please place 18F J-tube if possible\\n Admitting Diagnosis: SEPSIS\\n Contrast: OPTIRAY Amt: 10\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-09-27 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 927267,\n \"text\": \" 3:57 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: ? obstruction\\n Admitting Diagnosis: SEPSIS\\n Field of view: 48\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with n/v, evidence of obstruction on plain film\\n REASON FOR THIS EXAMINATION:\\n ? obstruction\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INDICATION: 66-year-old woman with nausea, vomiting, evidence of\\n obstruction on plain film.\\n\\n TECHNIQUE: Multiple axial images of the abdomen and pelvis were obtained\\n after the administration of oral contrast through the patient's gastrostomy\\n tube. No intravenous contrast was administered.\\n\\n Findings are compared with patient's prior examination dated .\\n\\n FINDINGS: Evaluation of the lung bases demonstrates the patient to be status\\n post median sternotomy. There is dense calcification of the mitral annulus\\n and dense coronary artery calcification. There are bilateral pleural\\n effusions, right greater than left with underlying atelectasis.\\n\\n Images of the upper abdomen demonstrate a gastrostomy tube with the distal tip\\n terminating in the proximal jejunum. Contrast is seen progressing to the\\n proximal jejunum. There is fecalization of the small bowel proximal to a\\n transition point in the right upper quadrant, where there is marked collapse\\n of the distal small bowel. These findings are compatible with a small bowel\\n obstruction. No obstructing mass is seen and the obstruction is remote from\\n the ostomy site. Two limbs enter and exit the ostomy site in the right lower\\n quadrant; the proximal limb is presumably distal ileum, and the exiting limb\\n is presumably transverse colon. The distal transverse, descending and sigmoid\\n colon are collapsed.\\n\\n Non-contrast evaluation of the liver is unremarkable. Clips are visualized in\\n the gallbladder fossa. There is dense calcification of the splenic and\\n hepatic arteries. There is a moderate amount of intraabdominal ascites. The\\n kidneys are noted to be atrophic bilaterally with linear calcification of the\\n parenchyma. The right adrenal gland, pancreas, and spleen are unremarkable.\\n There is a left adrenal adenoma. Evaluation of the uterus demonstrates dense\\n calcification of the uterine arteries. The osseous structures demonstrate\\n degenerative changes without evidence for acute fracture or dislocation.\\n\\n The overlying soft tissues are markedly edematous compatible with anasarca.\\n\\n IMPRESSION: Small bowel obstruction with transition point in the right upper\\n quadrant, remote from the more distal ostomy.\\n\\n\\n (Over)\\n\\n 3:57 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: ? obstruction\\n Admitting Diagnosis: SEPSIS\\n Field of view: 48\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-10-27 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 930861,\n \"text\": \" 11:53 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for infiltrate, pulm edema\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with sepsis, ESRD, respiratory failure w/ trach with\\n increased resp rate, tachycardia\\n REASON FOR THIS EXAMINATION:\\n evaluate for infiltrate, pulm edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST 12:09\\n\\n INDICATION: Respiratory failure with increased respiratory rate.\\n\\n COMPARISON: at 8:26.\\n\\n FINDINGS: Right PICC line, left dialysis catheter and tracheostomy tube\\n remain in place. Compared to the prior study, there is new increased density\\n in the left upper lung zone, which could be a developing pneumonia. Extremely\\n subtle increase in density is seen adjacent to the right hilar region, which\\n could relate to early pulmonary edema. However, the pulmonary vascular\\n markings are not significantly distended. Right effusion is again\\n demonstrated.\\n\\n IMPRESSION:\\n\\n New airspace finding in the left upper lung zone, possibly in the right mid\\n lung zone. Continued followup is recommended.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-10-23 00:00:00.000\",\n \"description\": \"PR ART DUP EXT UP UNI LMTD PORT RIGHT\",\n \"row_id\": 930400,\n \"text\": \" 10:02 AM\\n ART DUP EXT UP UNI LMTD PORT RIGHT Clip # \\n Reason: please eval for R A-V fistula (IJ-carotid??)\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with MMP, now R IJ with venous blood gas appearing arterial,\\n appropriately placed per CXR\\n REASON FOR THIS EXAMINATION:\\n please eval for R A-V fistula (IJ-carotid??)\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Carotid series complete.\\n\\n REASON: Question AV fistula.\\n\\n FINDINGS: Duplex evaluation was performed of the right neck region. Common\\n carotid artery and internal jugular veins are patent. There is no evidence of\\n thrombus or normal appearing waveforms. There is no evidence of fistula.\\n\\n IMPRESSION: No evidence of right neck carotid artery or jugular vein fistula\\n or overt disease.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-09-16 00:00:00.000\",\n \"description\": \"NON-TUNNELED\",\n \"row_id\": 925833,\n \"text\": \" 11:24 AM\\n TEMP DIALYSIS LINE PLCT Clip # \\n Reason: Please remove current R central dialysis catheter and replac\\n Admitting Diagnosis: SEPSIS\\n ********************************* CPT Codes ********************************\\n * NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\\n * US GUID FOR VAS. ACCESS C1752 CATH,HEM/PERTI DIALYSIS SHORT *\\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with pus at site of R central dialysis catheter\\n REASON FOR THIS EXAMINATION:\\n Please remove current R central dialysis catheter and replace with L central\\n dialysis catheter\\n ______________________________________________________________________________\\n FINAL REPORT\\n PROCEDURE:\\n\\n 1. Left internal jugular approach temporary hemodialysis catheter placement.\\n 2. Removal of tunneled right internal jugular approach tunneled hemodialysis\\n catheter.\\n 3. Ultrasound-guided venipuncture.\\n 4. Removal of right arm PICC\\n CLINICAL HISTORY: 66-year-old female with infected tunneled right internal\\n jugular approach tunneled dialysis catheter requires IV access for dialysis.\\n Suspected PICC line infection.\\n\\n INFORMED CONSENT: Procedural informed consent was obtained prior to the study\\n and placed in the medical record.\\n\\n OPERATORS: , M.D. (fellow).\\n , M.D. (supervising staff).\\n\\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\\n procedures to be performed, the sites of the procedures, appropriate\\n requisition, and appropriate informed consent. Once the above were verified,\\n the patient was positioned in supine fashion on a special procedures table.\\n The lower left side of the neck and left upper anterior chest wall were\\n prepped and draped in usual sterile fashion. Ultrasound was employed to\\n visualize the low left internal jugular vein, which was widely patent and\\n compressible. This site was selected for venipuncture. The skin and\\n subcutaneous tissues were infiltrated with approximately 5 cc of 1% Xylocaine\\n for local anesthesia. Uneventful one-wall venipuncture was achieved in the\\n low left internal jugular vein using micropuncture access technique. A 1.5 mm\\n J, 0.035 inch wire was advanced by way of the 4 French catheter of the\\n micropuncture set, under fluoroscopic visualization to the level of the\\n inferior vena cava. Subsequently, the tract was then serially dilated. A\\n angiodynamics, 24 cm length, hemodialysis catheter was then delivered\\n over the guidewire with the tip positioned in the cephalad right atrium. Both\\n lumens were flushed and heparin-locked. The catheter was secured in place\\n with two, 0 silk retention sutures. The puncture site was overlaid with a\\n Tegaderm occlusive patch. Hemostasis was achieved promptly. No residual\\n (Over)\\n\\n 11:24 AM\\n TEMP DIALYSIS LINE PLCT Clip # \\n Reason: Please remove current R central dialysis catheter and replac\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n bleeding or hematoma was encountered. Postprocedural chest x-ray demonstrates\\n good positioning of the catheter.\\n\\n (Hard copy ultrasound images were obtained both prior to and subsequent to the\\n venipuncture for documentation.)\\n\\n Subsequent to the procedure, the patient was transferred to the guerney, in\\n semi-upright positioning. The tunneled right internal jugular approach\\n hemodialysis catheter was prepped and draped. The retention cuff was freed\\n and the catheter was removed uneventfully. Hemostasis was achieved promptly\\n using digital compression for a total of 10 minutes. No residual bleeding was\\n encountered. Frank pus was expressed from the tunnel tract and cultured, along\\n with the catheter. The wound was then dressed with guaze and tape.\\n The patient tolerated the procedure well.\\n\\n The 5 Fr dual luimen PICC line in the right are was prepped, draped, and\\n removed uneventfully. This catheter too was ent for culture.\\n\\n IMPRESSION:\\n\\n 1. Status post placement of left internal jugular approach temporary\\n hemodialysis catheter. See above description.\\n\\n 2. Status post removal of tunneled right internal jugular approach\\n hemodialysis catheter. See above description.\\n\\n 3. Status post removal of right PICC line\\n\\n 4. The newly placed left internal jugular approach temporary hemodialysis\\n catheter is ready to employ. Post-procedural orders were written.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-10-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 928935,\n \"text\": \" 4:58 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Assess PICC line for position.\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with sepsis, ESRD, vented with pulmonary effusions, check\\n PICC line for position.\\n REASON FOR THIS EXAMINATION:\\n Assess PICC line for position.\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP PORTABLE CHEST AT 05:27 HOURS\\n\\n HISTORY: Multiple medical problems. Assess PICC line for positioning.\\n\\n COMPARISON: .\\n\\n FINDINGS: The patient is rotated. There is near-complete opacification of\\n the left hemithorax with only a small residual left upper lung noted. There\\n has been interval placement of a right internal jugular approach central line\\n with the distal tip projecting over the superior vena cava. There has been\\n interval decrease in the right pleural effusion. There is fluid tracking\\n within the major fissure. Mild hydrostatic edema is evident in the aerated\\n right lung.\\n\\n IMPRESSION: Near-complete opacification of the left lung. Evaluation limited\\n secondary to rotation, however, atelectasis and effusion are considered\\n leading diagnostic considerations. There has been interval redistribution of\\n the right pleural effusion with mild superimposed hydrostatic edema.\\n\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-10-12 00:00:00.000\",\n \"description\": \"G/GJ TUBE CHECK\",\n \"row_id\": 929039,\n \"text\": \" 12:19 PM\\n G/GJ TUBE CHECK Clip # \\n Reason: please confirm placement\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with G-J tube\\n\\n REASON FOR THIS EXAMINATION:\\n please confirm placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 66-year-old woman with gastrojejunostomy tube dislodged this\\n morning.\\n\\n GJ TUBE CHECK: The patient was brought to the Fluoroscopic Suite where\\n approximately 20 cc of Gastrografin was administered through the\\n gastrojejunostomy tube. The tube demonstrated patentcy and terminates in the\\n jejunum. There is no evidence of extraluminal contrast. The caliber and\\n appearance of the visualized jejunum is normal. Please note that there is\\n approximately 15 cm of tubing within the patient which terminates in the\\n jejunum.\\n\\n IMPRESSION: Gastrojejunostomy tube in proper position terminating in the\\n jejunum. No evidence for extraluminal contrast.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-09-27 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 927245,\n \"text\": \" 10:39 AM\\n PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # \\n Reason: r/o obstruction around j-tube with gastrograffin injection\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman s/p g tube and colostomy now with new abd mass and increase\\n output from g-tube\\n REASON FOR THIS EXAMINATION:\\n r/o obstruction around j-tube with gastrograffin injection\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Question obstruction around J-tube site after Gastrografin\\n injection.\\n\\n FINDINGS: This film was taken after injection of Gastrografin. Contrast is\\n seen entering a loop of bowel in the left mid abdomen compatible with jejunum.\\n Just after the J-tube this loop of bowel dilates to 6 cm. Otherwise there is\\n paucity of small bowel gas seen in the abdomen. This could represent a small\\n bowel obstruction. A CT is recommended for further evaluation.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-09-23 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 926736,\n \"text\": \" 5:13 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: right sc line placement attempt and failed r/o ptx\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with ESRD on CVVH, resp. failure with increased secretions\\n and increasing WBC count\\n REASON FOR THIS EXAMINATION:\\n right sc line placement attempt and failed r/o ptx\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Right subclavian line placement attempt, failed.\\n\\n PORTABLE CHEST: Comparison with . No pneumothorax seen.\\n Bilateral pleural effusions, slightly improved. Left lower lobe\\n atelectasis/consolidation is increased slightly. This study is somewhat\\n limited by respiratory motion. Aortic mural calcifications, tracheostomy,\\n midline sternotomy wires, valvular replacement, and left dialysis line are\\n unchanged.\\n\\n IMPRESSION: No pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-09-24 00:00:00.000\",\n \"description\": \"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT\",\n \"row_id\": 926846,\n \"text\": \" 2:41 PM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \\n Reason: RISING T.BILI AND ELEVATED ALK PHOS\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with MMP, now with hypotension, rising t.bili and elevated\\n alk phos.\\n REASON FOR THIS EXAMINATION:\\n Evaluate gallbladder and biliary system.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 66-year-old female with multiple medical problems, now with\\n hypertension and elevated bilirubin and alkaline phosphatase.\\n\\n COMPARISON: .\\n\\n RIGHT UPPER QUADRANT ULTRASOUND: Again demonstrated is slightly coarsened\\n echotexture of the liver without focal hepatic lesion identified. There is a\\n trace amount of perihepatic ascites, which is decreased compared to . There is no intra- or extra-hepatic biliary ductal dilatation. There\\n is appropriate hepatopetal blood flow in the main portal vein. The common\\n duct measures normal maximal caliber of 3 mm. The patient is status post\\n cholecystectomy. There is no evidence of choledocholithiasis in the\\n visualized common bile duct. A small right pleural effusion remains.\\n\\n IMPRESSION:\\n 1. Status post cholecystectomy. No biliary ductal dilatation or evidence of\\n cholecocholithiasis in the visualized common bile duct.\\n 2. Trace perihepatic ascites is decreased compared to .\\n 3. Persistent small right pleural effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-09-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 925785,\n \"text\": \" 4:20 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please assess for clinical change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with ESRD on CVVH, resp. failure.\\n REASON FOR THIS EXAMINATION:\\n Please assess for clinical change\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST 4:38 A.M. ON .\\n\\n HISTORY: On dialysis. Respiratory failure.\\n\\n IMPRESSION: AP chest compared to and 24:\\n\\n Moderate right pleural effusion has increased since , partially\\n obscuring anatomic detail in the right lung but mild interstitial edema is\\n probably present. Leftward mediastinal shift _____ a function of right\\n pleural effusion and substantial left lower lobe collapse, even though the\\n latter appears to have improved since . Cardiac silhouette is top\\n normal size. No pneumothorax.\\n\\n Tracheostomy tube and a dual channel right internal jugular dialysis line are\\n in standard placements. No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-09-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 926341,\n \"text\": \" 7:32 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o worsening infiltrate/effusion\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with ESRD on CVVH, resp. failure with increased secretions\\n and increasing WBC count\\n REASON FOR THIS EXAMINATION:\\n r/o worsening infiltrate/effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST X-RAY\\n\\n INDICATION: End-stage renal disease.\\n\\n FINDINGS:\\n Comparison was made with the recent x-ray from . The patient is\\n status post sternotomy. Note is made of aortic valve replacement.\\n Tracheostomy is in situ. Central venous line is seen, the tip of which is in\\n the SVC. There are bilateral pleural effusions.\\n\\n No significant interval change when compared to the previous x-ray.\\n\\n CONCLUSION:\\n Trach in situ, bilateral pleural effusions. No significant interval change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-09-11 00:00:00.000\",\n \"description\": \"P ABDOMEN U.S. (COMPLETE STUDY) PORT\",\n \"row_id\": 925186,\n \"text\": \" 7:46 AM\\n ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # \\n Reason: ELAVATED BIL,ALK PHOSPHATASE ,EVAL FOR CHOLANGITIS\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with MMP, now with hypotension, rising t.bili and elevated\\n alk phos.\\n REASON FOR THIS EXAMINATION:\\n please eval for cholangitis\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 66-year-old woman with multiple medical problems now with\\n hypotension and rising bilirubin and elevated LFTs.\\n\\n ABDOMINAL ULTRASOUND STUDY: Slightly coarsened echotexture of the liver\\n without focal liver lesions. There is small amount of ascites and small right\\n pleural effusion is seen. There is no intrahepatic or extrahepatic biliary\\n ductal dilatation. The common bile duct measures 4 mm in diameter. Patient\\n is status post cholecystectomy. The main portal vein is patent and its flow\\n is hepatopetal.\\n\\n The pancreatic tail is not well visualized. In the pancreatic head, there is\\n a 1.6 x 1.4 cm cystic lesion. The spleen is enlarged. The kidneys appear to\\n be slightly atrophic and echogenic and are not well imaged. This could be in\\n part due to the patient's body habitus, however, renal parenchymal disease\\n cannot be entirely excluded.\\n\\n IMPRESSION:\\n 1. No intrahepatic or extrahepatic biliary ductal dilatation.\\n 2. Small right pleural effusion and ascites.\\n 3. Splenomegaly.\\n 4. Small cystic lesion in the head of the pancreas, further evaluation with\\n dedicated CT angiography or MRCP study could be considered.\\n 5. Possible renal parenchymal disease.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-09-27 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 927252,\n \"text\": \" 12:23 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with ESRD on CVVH, resp. failure with increased\\n secretions and ? aspiration event\\n REASON FOR THIS EXAMINATION:\\n please evaluate interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST SINGLE VIEW ON .\\n\\n HISTORY: End-stage renal disease with respiratory failure. Question\\n aspiration.\\n\\n REFERENCE EXAM: .\\n\\n FINDINGS: Again seen is a tracheostomy tube. There is hazy increased opacity\\n projecting over both lungs consistent with layering effusions bilaterally.\\n These are increased in size compared to the prior film. There is dense\\n retrocardiac opacity and it is unclear if this is due to volume loss or a\\n retrocardiac infiltrate. A lateral film would be helpful if the patient is\\n able. The heart is shifted to the left on this film but it is unclear how\\n much of this is due to rotation. Contrast is seen in the left upper quadrant,\\n presumably in the stomach, which is slightly distended.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-09-16 00:00:00.000\",\n \"description\": \"TUNNELED CENTRAL W/O PORT\",\n \"row_id\": 925854,\n \"text\": \" 2:43 PM\\n DIALYSIS REMOVE Clip # \\n Reason: Please remove right subclavian dialysis catheter.\\n Admitting Diagnosis: SEPSIS\\n ********************************* CPT Codes ********************************\\n * TUNNELED CENTRAL W/O PORT -51 MULTI-PROCEDURE SAME DAY *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 y/o F s/p CVA, now with pus draining from site of right subclavian dialysis\\n catheter. Needs removal.\\n REASON FOR THIS EXAMINATION:\\n Please remove right subclavian dialysis catheter.\\n ______________________________________________________________________________\\n FINAL REPORT\\n Please see clip for the complete report.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-09-17 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 925920,\n \"text\": \" 4:56 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o worsening effusion\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with ESRD on CVVH, resp. failure.\\n\\n REASON FOR THIS EXAMINATION:\\n r/o worsening effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST 5:13 A.M. on :\\n\\n HISTORY: End stage renal disease. Respiratory failure.\\n\\n IMPRESSION: AP chest compared to through :\\n\\n Moderate volume bilateral pleural effusion, stable on the right and increased\\n on the left relative to . Mild enlargement of the cardiomediastinal\\n silhouette is stable. Left lower lobe atelectasis has worsened. Tracheostomy\\n tube in standard placement. Dual channel left supraclavicular central venous\\n line tip projects over the superior cavoatrial junction.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-09-26 00:00:00.000\",\n \"description\": \"PICC W/O PORT\",\n \"row_id\": 927152,\n \"text\": \" 3:01 PM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: bilateral piccs for access-thank you\\n Admitting Diagnosis: SEPSIS\\n ********************************* CPT Codes ********************************\\n * PICC W/O PORT 79 UNRELATED PROCEDURE/SERVICE DURIN *\\n * FLUOR GUID PLCT/REPLCT/REMOVE US GUID FOR VAS. ACCESS *\\n * C1751 CATH ,/CENT/MID(NOT D C1769 GUID WIRES INCL INF *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 y/o F s/p CVA, multiple infections, hypotensive, CRF and femoral line that\\n needs removal infection. Needs second line for chronic Abx.\\n REASON FOR THIS EXAMINATION:\\n bilateral piccs for access-thank you\\n ______________________________________________________________________________\\n FINAL REPORT\\n PROCEDURE: 5 French dual-lumen PICC catheter placement via right\\n brachial vein approach; ultrasound-guided venipuncture.\\n\\n CLINICAL HISTORY: 66-year-old female status post cerebrovascular accident,\\n multiple infections, hypotensive episodes, chronic renal failure, requires IV\\n access for antibiotics, blood draws, and blood products.\\n\\n OPERATORS: , M.D. (fellow).\\n , M.D. (supervising staff).\\n\\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\\n procedure to be performed, the site of the procedure, and appropriate informed\\n consent. Once the above were verified, the patient was positioned in supine\\n fashion on a special procedures table. This examination was originally\\n requested as a central venous catheter, however, the order was changed by the\\n requesting physician to that of a peripherally inserted central venous\\n catheter.\\n\\n (Hard copy son images of the venipuncture, both prior to and after\\n access were achieved and are placed in the patient's record.)\\n\\n The right arm was prepped and draped in usual sterile fashion. Ultrasound was\\n employed to assess the venous anatomy of the right upper extremity. The\\n venous anatomy was very diminutive. However, right brachial vein was\\n punctured under ultrasonographic guidance in retrograde fashion using one wall\\n technique and a 5 French dual-lumen catheter delivered by modified\\n Seldinger technique to the level of the caudal superior vena cava using\\n flouroscopic guidance. The catheter was advanced to the level of the 39 cm\\n mark at the skin. The remainder of the catheter was externalized and secured\\n with a StatLock device and then overlaid with Tegaderm occlusive dressing\\n patches. Both lumens were flushed with saline. The patient tolerated the\\n procedure well. Estimated blood loss was minimal.\\n\\n ANESTHESIA:\\n 1% Xylocaine, 10 cc total.\\n\\n (Over)\\n\\n 3:01 PM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: bilateral piccs for access-thank you\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n IMPRESSION: Status post successful 5 French dual-lumen PICC line via\\n right brachial vein approach. The patient tolerated the procedure well. The\\n line is ready to employ. See above description.\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-09-26 00:00:00.000\",\n \"description\": \"PICC W/O PORT\",\n \"row_id\": 927153,\n \"text\": \" 3:01 PM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: picc for access\\n Admitting Diagnosis: SEPSIS\\n Contrast: OPTIRAY Amt: 5\\n ********************************* CPT Codes ********************************\\n * PICC W/O PORT 79 UNRELATED PROCEDURE/SERVICE DURIN *\\n * -51 MULTI-PROCEDURE SAME DAY FLUOR GUID PLCT/REPLCT/REMOVE *\\n * -59 DISTINCT PROCEDURAL SERVICE US GUID FOR VAS. ACCESS *\\n * -59 DISTINCT PROCEDURAL SERVICE C1751 CATH ,/CENT/MID(NOT D *\\n * C1769 GUID WIRES INCL INF *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 y/o F s/p CVA, multiple infections, hypotensive, CRF and femoral line\\n that needs removal infection. Needs second line for chronic Abx.\\n REASON FOR THIS EXAMINATION:\\n picc for access\\n ______________________________________________________________________________\\n FINAL REPORT\\n PROCEDURE: 5 French dual-lumen PICC line placement via left cephalic\\n vein approach; ultrasound-guided venipuncture.\\n\\n CLINICAL INDICATION: IV access.\\n\\n OPERATORS: , M.D. (fellow).\\n , M.D. (supervising staff).\\n\\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\\n procedure to be performed, the site of the procedure, and appropriate\\n requisition. Once the above were verified, the patient was positioned in\\n supine fashion on a special procedures table. Left arm was abducted,\\n externally rotated, and then prepped from the axilla to the antecubital fossa.\\n A tourniquet was applied to the upper arm. Uneventful venipuncture was\\n achieved using ultrasound guidance at the left cephalic vein. Hard copy\\n ultrasound images were obtained before and after venous access documenting\\n vessel patency. A guide wire was advanced by way of the cephalic vein to the\\n central circulation. A 5 French dual-lumen PICC line was then\\n delivered with the aid of the stiffening inner stylet, using modified\\n Seldinger technique under fluoroscopic visualization. Tip position is in the\\n caudal superior vena cava. Both lumens of the catheter were flushed\\n and heparin locked. Specific attention was made to remove the inner stylet.\\n The catheter was secured using a statlock device and then overlaid with a\\n Tegaderm patch.\\n\\n ESTIMATED BLOOD LOSS: Minimal.\\n\\n ANESTHESIA: 1% Xylocaine, 10 cc local infiltration.\\n\\n IMPRESSION: Status post successful placement of 5 French dual-lumen \\n PICC catheter via left cephalic vein approach. Tip position is in the caudal\\n superior vena cava. The catheter is at the 42 cm mark at the skin. The\\n catheter is ready to employ. Post-procedural orders are written.\\n (Over)\\n\\n 3:01 PM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: picc for access\\n Admitting Diagnosis: SEPSIS\\n Contrast: OPTIRAY Amt: 5\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-09-27 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 927199,\n \"text\": \" 12:49 AM\\n PORTABLE ABDOMEN Clip # \\n Reason: eval for obstruction\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman s/p g tube and colostomy now with new abd mass and increase\\n output from g-tube\\n REASON FOR THIS EXAMINATION:\\n eval for obstruction\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INDICATION: Evaluate for obstruction, patient with G-tube, J-tube\\n and ostomy.\\n\\n TECHNIQUE: AP examination of the abdomen is submitted for interpretation.\\n Findings are compared with prior examination dated .\\n\\n FINDINGS: Limited evaluation of the lower abdomen and pelvis demonstrates\\n three dilated loops of small bowel that appear to surround the patient's\\n jejunostomy tube. These measure up to 6.1 cm in maximal diameter. Findings\\n are concerning for a small-bowel obstruction.\\n\\n Degenerative changes are noted in the spine and pelvis.\\n\\n IMPRESSION: Limited evaluation of the abdomen with 3 dilated small bowel\\n loops, concerning for small- bowel obstruction. Correlate clinically.\\n Findings were communicated with Dr. at the time of dictation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-09-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 927383,\n \"text\": \" 4:38 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Assess for interval change.\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with ESRD on CVVH, resp. failure with P. aeruginosa in\\n sputum.\\n REASON FOR THIS EXAMINATION:\\n Assess for interval change.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: End-stage renal disease, respiratory failure and Pseudomonas\\n aeruginosa in sputum. Assess for interval change.\\n\\n Comparison is made to .\\n\\n SUPINE PORTABLE RADIOGRAPH OF THE CHEST: The tracheostomy is in unchanged\\n position. The left subclavian central venous line is located with the tip in\\n the distal SVC. There are significantly increased bilateral hazy opacities,\\n most likely representing layering pleural effusions. The left retrocardiac\\n opacity may represent effusion and/or atelectasis, but a consolidation in this\\n region cannot be excluded. The patient is status post median sternotomy and\\n aortic valve replacement.\\n\\n IMPRESSION: Worsening bilateral pleural effusions. Increased left\\n retrocardiac opacity may represent effusion and/or atelectasis, consolidation\\n cannot be excluded.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-09-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 925164,\n \"text\": \" 12:33 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?acute change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with chronic trach/peg, lethargy, hypotension, now with\\n persistent fevers and increased respiratory rate.\\n REASON FOR THIS EXAMINATION:\\n ?acute change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST SINGLE AP FILM\\n\\n History of fever and tachypnea in patient with tracheostomy and a J tube.\\n\\n SINGLE SUPINE AP FILMS\\n\\n Status post AVR. The dialysis catheter is in the region of the cavoatrial\\n junction. Tracheostomy tube is 4 cm above the carina. The PICC line is in\\n distal SVC allowing for low lung volumes. There are persistent bilateral\\n pleural effusions and associated atelectases in the lower zones. No definite\\n new pulmonary consolidation or pulmonary edema since the prior film of , . No pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-09-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 927643,\n \"text\": \" 8:40 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for fluid status and interval changes in effusions\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with sepsis, ESRD, vented with pulmonary effusions\\n REASON FOR THIS EXAMINATION:\\n evaluate for fluid status and interval changes in effusions\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 66-year-old female with sepsis, end-stage renal disease, and\\n ventilated. Evaluate.\\n\\n COMPARISON: AP supine portable chest x-ray dated .\\n\\n AP UPRIGHT PORTABLE CHEST X-RAY: A right-sided PICC catheter terminates\\n within the right mid SVC. A tracheostomy tube is in place. A left subclavian\\n hemodialysis catheter terminates within the right atrium. The cardiac\\n silhouette, mediastinal and hilar contours are stable in this patient status\\n post median sternotomy, and valve replacement. Allowing for differences in\\n position, moderate layering pleural effusions are not significantly changed.\\n The surrounding soft tissues are stable.\\n\\n IMPRESSION: No interval change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-08-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 922366,\n \"text\": \" 3:34 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval pneumonia\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with chronic trach/peg, lethargy, hypotension, now with\\n fever\\n REASON FOR THIS EXAMINATION:\\n eval pneumonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: 66-year-old woman with chronic tracheostomy, lethargic,\\n hypotensive with fever question pneumonia.\\n\\n Comparison is made with prior study with the most recent one performed , .\\n\\n FINDINGS: Stable mild right pleural effusion. Persistent right lower lobe\\n consolidation, mild interval decrease in left retrocardiac\\n consolidation/atelectasis. There is no pneumothorax. Stable top size heart,\\n patient is S/P median sternotomy and valve replacement. There is a\\n tracheostomy in appropriate position. Right PICC line and right internal\\n jugular vein double-lumen catheter unchanged in position.\\n\\n There is no pneumothorax.\\n\\n IMPRESSION: Persistent right lower lobe consolidation.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-10-06 00:00:00.000\",\n \"description\": \"NON-TUNNELED\",\n \"row_id\": 928363,\n \"text\": \" 7:15 PM\\n CENTRAL LINE PLCT Clip # \\n Reason: needs access for blood\\n Admitting Diagnosis: SEPSIS\\n ********************************* CPT Codes ********************************\\n * NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\\n * C1769 GUID WIRES INCL INF *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman needs 3-port CV access for abx, pressors, and CVVH\\n\\n REASON FOR THIS EXAMINATION:\\n needs access for blood\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 66-year-old female requiring central venous access for\\n antibiotics, pressors and CVVH.\\n\\n RADIOLOGISTS: Drs. and performed this procedure, with Dr.\\n , the attending radiologist, present and supervising throughout.\\n\\n PROCEDURE: Written and informed consent were obtained from the patient's\\n daughter. The patient was placed supine on the angiographic table. The right\\n lower neck and upper chest were prepped and draped sterilely. Ultrasound\\n imaging was performed confirming the patency of the right internal jugular\\n vein. 5 cc of 1% lidocaine were applied for local anesthesia. Under\\n ultrasonic guidance, a 21-gauge needle was used to access the right internal\\n jugular vein. Hard copy ultrasound images were obtained before and after\\n venous access documenting vessel patency. A 0.018 guidewire was placed through\\n the needle under fluoroscopic guidance with its tip in the superior vena cava.\\n The needle was then exchanged for a 4.5- French introducer sheath and the\\n inner dilator and 0.018 guidewire were removed. A 0.035 guidewire was\\n advanced into the superior vena cava and the introducer sheath was removed. A\\n 16 cm long triple lumen central line was placed over the wire under\\n fluoroscopic guidance with the tip in the superior vena cava. The wire was\\n removed. Three lumens of the catheter were flushed with heparinized saline\\n and demonstrated excellent blood flow. The catheter was secured to the skin\\n with 0 silk and a sterile dressing was applied.\\n\\n IMPRESSION: Successful placement of a triple lumen central venous catheter\\n via the right internal jugular vein with tip in the SVC. The catheter is\\n ready for immediate use.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-10-06 00:00:00.000\",\n \"description\": \"ABDOMINAL A-GRAM\",\n \"row_id\": 928364,\n \"text\": \" 7:17 PM\\n ABDOMINAL A-GRAM Clip # \\n Reason: please evaluate for bleed and embolization if necessary\\n Admitting Diagnosis: SEPSIS\\n Contrast: OPTIRAY Amt: 250\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with GI bleed\\n\\n REASON FOR THIS EXAMINATION:\\n please evaluate for bleed and embolization if necessary\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 66-year-old female with likely lower GI bleed.\\n\\n RADIOLOGISTS: The procedure was performed by Doctors and .\\n Dr. , the attending radiologist was present and supervising throughout\\n the procedure.\\n\\n PROCEDURE/FINDINGS: After explaining the risks and benefits of the procedure,\\n written informed consent was obtained from the patient's daughter. Timeout\\n was performed to identify the procedure to be performed, the site and\\n requisition. The patient was then placed in a supine position on the\\n angiographic table. The right groin was prepped and draped in the standard\\n sterile fashion. The skin of the anticipated puncture site was then\\n infiltrated intradermally with 5 cc of 1% lidocaine. One wall retrograde\\n arterial puncture was achieved of the right common femoral artery. A\\n guidewire was advanced to the infra-renal abdominal aorta. A 5 French\\n vascular sheath was placed in the right common femoral artery. A Omni Flush\\n catheter was then advanced over the guidewire into the infrarenal abdominal\\n aorta and a nonselective aortic angiogram was performed demonstrating filling\\n of the inferior mesenteric artery, common iliacs and several lumbar branches.\\n No evidence of active extravasation was noted. Numerous attempts were made to\\n access the inferior mesenteric artery using several angiographic catheters\\n (Sos, Cobra, , Mikaelson) without success. A Sos catheter was then used\\n to catheterize the superior mesenteric artery, and a selective arteriogram was\\n performed. A normal pattern of blood flow was identified within the branches\\n of the superior mesenteric artery territory with no evidence of obstruction,\\n stenosis,abnormal blush or contrast extravasation. Extensive atherosclerosis\\n was noted within the abdominal aorta and throughout its branches. Finally, the\\n catheter and 5 French vascular sheath were removed. Hemostasis was achieved at\\n the right puncture site using digital compression for a total time of 20\\n minutes. No hematoma was encountered. The patient tolerated the procedure\\n well without immediate complications.\\n\\n IMPRESSION:\\n 1. Nonselective aortography and selective superior mesenteric artery\\n arteriogram demonstrate no evidence of active gastrointestinal bleeding.\\n Diffuse atheromatous disease was noted.\\n\\n 2. Selective catheterization of the inferior mesenteric artery was\\n unsuccessful, likely due to severe atherosclerotic disease at its origin as\\n shown on a previous CT scan.\\n (Over)\\n\\n 7:17 PM\\n ABDOMINAL A-GRAM Clip # \\n Reason: please evaluate for bleed and embolization if necessary\\n Admitting Diagnosis: SEPSIS\\n Contrast: OPTIRAY Amt: 250\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n 3. Endoscopy recommended to better clarify origin of bleeding.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-10-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 928948,\n \"text\": \" 8:19 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: Assess PICC line for position.\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with sepsis, ESRD, vented with pulmonary effusions, check\\n PICC line for position.\\n REASON FOR THIS EXAMINATION:\\n Assess PICC line for position.\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP PORTABLE CHEST, AT 8:22 A.M.\\n\\n HISTORY: Sepsis, endstage renal disease with recent PICC line placement.\\n\\n COMPARISON: Multiple priors, the most recent dated earlier same day.\\n\\n FINDINGS: The patient is significantly rotated limiting the evaluation.\\n Support tubes and lines remain stable including the right upper extremity\\n approach PICC line. The left lung is not adequately evaluated secondary to\\n rotation with only a small amount of area of lung noted in the left upper\\n chest. Overall no significant interval change.\\n\\n IMPRESSION: As best can be determined, no significant interval change\\n relative to study obtained earlier same day. The study is nondiagnostic for\\n evaluation of the left lung. Despite the given history, support tubes and\\n lines remain stable with no new line noted.\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-08-20 00:00:00.000\",\n \"description\": \"CHANGE GASTROSTOMY TUBE\",\n \"row_id\": 922445,\n \"text\": \" 7:35 AM\\n PERC G/J TUBE CHECK Clip # \\n Reason: change GJ tube. thank you.\\n Admitting Diagnosis: SEPSIS\\n Contrast: OPTIRAY Amt: 40\\n ********************************* CPT Codes ********************************\\n * CHANGE GASTROSTOMY TUBE INJ SINUS TRACT, THERAPUTIC *\\n * -51 MULTI-PROCEDURE SAME DAY CHANGE PERC TUBE OR CATH W/CON *\\n * FISTULOGRAM/SINOGRAM CATHETER, DRAINAGE *\\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with G-J tube\\n REASON FOR THIS EXAMINATION:\\n change GJ tube. thank you.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 66-year-old woman with long-term gastrojejunostomy which is leaking\\n at the skin site.\\n\\n PROCEDURE AND FINDINGS: The procedure was performed by Drs. and ,\\n the attending physician, was present and supervising. Informed consent\\n was obtained, and preprocedure timeout was performed. The patient's abdomen\\n was prepped and draped in standard sterile fashion. Lidocaine jelly was\\n infused at the skin site. The existing catheter was cut and removed over an\\n 0.035 wire. A 7 French bright-tipped sheath was subsequently advanced and a\\n pullback sinogram was performed. This demonstrated the gastric entry site of\\n the tract to be within the mid body of the stomach. The tract was then\\n sclerosed with silver nitrate sticks. A new 22 French MIC gastrojejunostomy\\n tube was subsequently advanced over the wire after cutting off the superficial\\n plastic disk. The wire was removed. 10 cc of saline were insufflated into\\n the balloon. Injection of contrast through the gastric and jejunal ports\\n demonstrated appropriate positioning of the tube with the proximal sideholes\\n within the stomach and the distal tip within the jejunum. The catheter was\\n secured with a Flexi-Trak, and the site was dressed. The patient tolerated\\n the procedure well, and there were no immediate post-procedure complications.\\n\\n IMPRESSION:\\n 1. Successful exchange for 22 French MIC gastrojejunostomy tube. The balloon\\n was inflated with 10 cc of saline. The catheter is positioned with the marker\\n above the #2 at the skin exit site. In the case of leaking around the skin,\\n the gastric port can be open to continuous bag gravity drainage or be\\n aspirated several times a day.\\n 2. The tract was sclerosed with silver nitrate.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-10-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 930243,\n \"text\": \" 8:31 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: question of infectious process\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with sepsis, ESRD, respiratory failure, SBO, GIB now with\\n fever\\n REASON FOR THIS EXAMINATION:\\n question of infectious process\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 8:26 A.M., .\\n\\n HISTORY: Sepsis. End-stage renal disease. GI bleed.\\n\\n IMPRESSION: AP chest compared to through 30.\\n\\n Left lower lobe atelectasis has improved substantially since \\n though there is still sufficient atelectasis to produce leftward mediastinal\\n shift. Small-to-moderate right and small left pleural effusion are unchanged.\\n The heart is probably enlarged, but partially obscured by adjacent\\n atelectasis. Right PICC and supraclavicular venous lines end at the junction\\n of the brachiocephalic veins and a large-bore dual-channel left\\n supraclavicular catheter ends in the SVC and at the superior cavoatrial\\n junction. Tracheostomy tube in standard placements.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-10-03 00:00:00.000\",\n \"description\": \"P SMALL BOWEL ONLY (GASTROGRAF) PORT\",\n \"row_id\": 927966,\n \"text\": \" 9:35 AM\\n SMALL BOWEL ONLY (GASTROGRAF) PORT Clip # \\n Reason: eval for SBO\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with resolving SBO\\n REASON FOR THIS EXAMINATION:\\n eval for SBO\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Resolving SBO.\\n\\n , CT scan.\\n\\n FINDINGS: Eight very limited quality abdominal radiographs were provided for\\n interpretation. Due to the poor quality of films, evaluation is significantly\\n limited. There is evidence for dilated bowel loops consistent with\\n obstruction. Overlying contrast may be external to the patient. No\\n radiologist was present during this procedure.\\n\\n IMPRESSION: Limited evaluation secondary to technical difficulties. If there\\n is high clinical concern for pathology, further imaging is recommended.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-10-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 929800,\n \"text\": \" 4:20 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Pls evaluated for PNA.\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with sepsis, ESRD, respiratory failure, SBO, GIB now with\\n Bandemia and hypothermia.\\n REASON FOR THIS EXAMINATION:\\n Pls evaluated for PNA.\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST.\\n\\n INDICATION: Respiratory failure.\\n\\n A single AP view of the chest is obtained and compared with the most\\n recent study performed on . The patient is significantly rotated to\\n the left side. There is no significant change between the two studies\\n allowing for technique. Tubes and lines appear unchanged. The left lung is\\n poorly evaluated due to the degree of rotation. There is loss of the left\\n hemidiaphragm shadow, which may represent atelectasis/infiltrate in the left\\n lower lobe. Right pleural effusion appears unchanged.\\n\\n IMPRESSION:\\n\\n Allowing for differences in technique, likely no significant change since the\\n study of with opacification in the left hemithorax with obscuration of\\n the left hemidiaphragm likely representing atelectasis. Right pleural\\n effusion unchanged. Tubes and lines unchanged.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-10-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 927672,\n \"text\": \" 5:53 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate for changes in pulmonary edema/consolidation\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with sepsis, vented with pulmonary effusions\\n REASON FOR THIS EXAMINATION:\\n please evaluate for changes in pulmonary edema/consolidation\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 6:18 A.M., .\\n\\n HISTORY: Sepsis. Pleural effusions. Pulmonary edema.\\n\\n IMPRESSION: AP chest compared to through 12. Moderate bilateral\\n pleural effusion, left greater than right, and mild interstitial pulmonary\\n edema are stable since . Cardiac silhouette is moderately\\n enlarged. Tracheostomy tube is in standard placement. A dual channel left\\n supraclavicular central venous line ends in the SVC. No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-10-16 00:00:00.000\",\n \"description\": \"TUNNELED W/O PORT\",\n \"row_id\": 929481,\n \"text\": \" 7:31 AM\\n TUNNELLED CATH PLACE SCH Clip # \\n Reason: Please place left tunneled HD catheter for long term HD.\\n Admitting Diagnosis: SEPSIS\\n ********************************* CPT Codes ********************************\\n * TUNNELED W/O FLUOR GUID PLCT/REPLCT/REMOVE *\\n * C1750 CATH,HEMO/PERTI DIALYSIS LONG C1769 GUID WIRES INCL INF *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with MMP incl CRF on HD.\\n REASON FOR THIS EXAMINATION:\\n Please place left tunneled HD catheter for long term HD. Please place three\\n access lines (two for HD, one VIP line).\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 66-year-old female with chronic renal failure requiring tunneled\\n hemodialysis catheter for long-term hemodialysis.\\n\\n RADIOLOGISTS: Drs. and . Dr. , the\\n attending radiologist was present and supervising throughout the procedure.\\n\\n PROCEDURE/FINDINGS: The risks and benefits were explained to the patient's\\n family, and verbal consent was obtained. The patient was placed supine on the\\n angiographic table. The left neck, left upper chest and right upper chest\\n were prepped and draped in the standard sterile fashion. A preprocedure\\n timeout was performed to confirm the patient's name, procedure and the site.\\n 10 cc of 1% lidocaine was then applied at the upper left chest for local\\n anesthesia. A small incision was made approximately 8 cm laterally from the\\n left IJ access site. The tunnel was then created with the tunneling device. A\\n 23 cm tip to cuff hemodialysis catheter was then advanced through the tunnel.\\n A 0.035 Bentson guidewire was then placed through the in situ temporary\\n dialysis catheter under fluoroscopic guidance. The catheter was removed. A\\n 14 French peel-away sheath was then placed over the wire. After the inner\\n dilator and wire were removed, the new hemodialysis catheter was then placed\\n through the sheath as the sheath was peeled away. A fluoroscopic spot image\\n confirmed the tip of the hemodialysis catheter within the right atrium. The\\n catheter was secured to the chest with a 0 Prolene stitch. Dermabond was used\\n to close the lower neck incision site. The catheter ports were flushed,\\n capped and heplocked. A sterile dressing was applied.\\n\\n The patient tolerated the procedure well and there were no immediate\\n complications.\\n\\n IMPRESSION: Successful removal of a preexisting hemodialysis catheter and\\n replacement with a new 23 cm cuff to tip 14.5 French double lumen tunneled\\n hemodialysis catheter by way of the left internal jugular vein. The catheter\\n tip is located in the right atrium. The catheter can be used immediately.\\n (Over)\\n\\n 7:31 AM\\n TUNNELLED CATH PLACE SCH Clip # \\n Reason: Please place left tunneled HD catheter for long term HD.\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-10-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 927959,\n \"text\": \" 9:00 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for interval changes\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with sepsis, ESRD, vented with pulmonary effusions,\\n decreased BS on left\\n REASON FOR THIS EXAMINATION:\\n evaluate for interval changes\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP PORTABLE CHEST, , AT 9:11 A.M.\\n\\n HISTORY: Sepsis, end-stage renal disease, on ventilator. There are decreased\\n breath sounds on the left. Assess for interval change.\\n\\n COMPARISON: Multiple priors, the most recent dated .\\n\\n FINDINGS: The extreme left costophrenic angle has been excluded from view.\\n There has been minimal relative improvement in the previously noted diffuse\\n hydrostatic edema. Pleural effusions have redistributed with small bilateral\\n effusions persisting, right slightly worse than left. The various support\\n tubes and lines as well as the post surgical changes consistent with prior\\n aortic valve replacement stable.\\n\\n IMPRESSION: Mild interval improvement in fluid balance with relatively stable\\n bilateral effusions as above.\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-10-16 00:00:00.000\",\n \"description\": \"PICC W/O PORT\",\n \"row_id\": 929532,\n \"text\": \" 1:37 PM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: Please place PICC line\\n Admitting Diagnosis: SEPSIS\\n ********************************* CPT Codes ********************************\\n * PICC W/O PORT -51 MULTI-PROCEDURE SAME DAY *\\n * FLUOR GUID PLCT/REPLCT/REMOVE -59 DISTINCT PROCEDURAL SERVICE *\\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\\n * C1769 GUID WIRES INCL INF *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 y/o F s/p CVA, multiple infections, hypotensive, CRF and femoral line\\n that needs removal infection. Needs second line for chronic Abx.\\n REASON FOR THIS EXAMINATION:\\n Please place PICC line\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 66-year-old female with numerous infections requiring chronic\\n antibiotics.\\n\\n RADIOLOGISTS: Drs. and . Dr. , the\\n attending radiologist was present and supervising throughout the procedure.\\n\\n PROCEDURE/FINDINGS: The patient was brought to the radiology suite and placed\\n supine on the angiography table. Following a preprocedure timeout including\\n the patient's name and two patient identifiers, the right arm was sterilely\\n prepped and draped. As no suitable veins were visible, ultrasound was used to\\n identify the right brachial vein which was patent and compressible.\\n Approximately 5 cc of 1% lidocaine was administered for local anesthesia. A\\n 21-gauge needle was used to access the right brachial vein. Hard copy\\n ultrasound images were obtained before and after venipuncture. A 0.018-inch\\n guide wire was threaded through the needle into the vein. Then the needle was\\n exchanged for a 4 French micropuncture sheath. The guide wire was advanced\\n into the SVC and based on the markings on the wire, a PICC line was trimmed to\\n a length of 40 cm. The PICC was then advanced over the wire and into the SVC\\n under fluoroscopic guidance. The wire and peel-away sheath were removed. The\\n catheter was flushed, capped, and heplocked. Finally, the catheter was\\n statlocked into place and a sterile transparent dressing was applied. A final\\n fluoroscopic image was taken demonstrating the tip of the PICC in the distal\\n SVC.\\n\\n IMPRESSION: Successful placement of a 4 French single-lumen 40-cm PICC by way\\n of the right brachial vein with the tip in the distal SVC. The line is ready\\n for use.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524303,\n \"text\": \"Respiratory Therapy\\n\\nPt remains trached w/ #7.0 Shiley trach on full mechanical support. No vent changes made this shift. Currently on A/C ventilation w/ PIP = 23. BS w/ rhonchi bilaterally, suctioned for moderate to copious amounts of yellowish/tan sputum. SpO2 90s. ABG acceptable. MDIs given as ordered. See resp flowsheet for specific vent settings/data.\\n\\nPlan: maintain support; pulmonary toilet\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524304,\n \"text\": \"SICU NPN\\nT-Trached.\\n\\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\\n\\nO-Alert. Following commands inconsistently. Noted shaking head in \\\"no\\\" directions when approached or asked question and then crying. Pt doing this consistently. Not grimacing to pain. MICU team witnessing when rounding on pt. Ethics consult discussed in rounds this morning but unclear on efficacy of consult due to nature of family dynamics. HR 60-100s, NSR with frequent PACs then later returning to Afib with rate control. Diltiazem drip discontinued 1hr after PO dose of Diltiazem begun. SBPs 80-100s. Attempted to wean Neo but unsuccesful. Neo as high as 0.75mcg/kg/min and currently at 0.3mcg/kg/min. Attempting to keep SBPs 80 and MAPs > 50. Breath sounds coarse throughout. Remains on AC. ABG with metabolic akalosis, no vent changes made. Suctioning for thick yellow sputum. Anuric. Continues CRRT. Goal is keep even in efforts to wean pressors first. Midordrine restarted. Abd obese but soft. (+) bowel sounds. Colostomy, G-J, and vaginal with small dark red bloody ooze. Colostomy at stoma site and G-J at insertion site. Dr. aware. HCT and coags pending. Colostomy prior with goldens soft stool, G-tube with bilious output prior and currently. J-tube to TFs. Hypothermic placed back on bair hugger. (+)BCx from with GNRs in aerobic and anaerobic bottles. Dr. aware. No change in Abx regimen. Husband visiting this morning briefly and no further visitors for day into evening. Continue Insulin gtt, goal BSs 80-120s.\\n\\nA/P: Sepsis\\nContinue to montior\\nCRRT to run even\\nWean Neo as tolerated, > 80/MAP > 50\\nFollow K and ICa Q6H\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524380,\n \"text\": \"nsg note\\nSEE FLOWSHEET FOR SPECIFICS.\\n\\nNEURO-OPENS EYES SPONT. MOVES HEAD SPONT ON BED. PUPILS EQUAL AND SLUGGISHLY REACTIVE. NO SPONT MOVEMENT OF EXTREMITIES.\\n\\nCV-HR 80-100'S. AFIB, NO ECTOPY. REMAINS ON NEO GTT BUT SLOWLY WEANING. MAP>50. SKIN WARM. HCT STABLE.\\n\\nRESP-REMAINS TRACHED AND VENTED. RR DOWN TO 26. FIO2 UP0 TO 60%. NO OTHER VENT CHANGES MADE. ABG CHECKED FREQ. LS COARSE, DECREASED AT BASES. SXN FOR THICK YELLOW SPUTUM. UNABLE TO GET O2 SAT TRACING.\\n\\nGI-ABD FIRM AND DISTENDED. OBESE. +BS. TF STARTED VIA . TPN TO FINISH, NEW TPN NOT ORDERED. G-TUBE TO GRAVITY WITH BROWN/MAROON DRG. STOMA RED WITH OLD MELENA STOOL.\\n\\nGU-ANURIC. REMAINS ON WITH GOAL \\\"EVEN\\\". CA+ AND K+ GTTS INFUSING PER PROTOCOL.\\n\\nENDO-ON INSULIN GTT.\\n\\nACT-REPOSITIONED FREQ.\\n\\nCOMFORT-DOES NOT APPEAR TO BE IN PAIN.\\n\\nID-TEMP 96. BAIR HUGGER ON. ON MULTI ABX. SURVEILLENCE BLOOD CX SENT.\\n\\nSKIN-CON'T WITH MULTI SKIN ISSUES. MULTI AREAS OF WEEPY SKIN, SKIN TEARS AND ECCHYMOSIS. ALL DSGS INTACT OR CHANGED AS ORDERED. TOES REMAIN NECROTIC. ERYTHEMIC AREA ON LEFT THIGH UNCHANGED.\\n\\nSOCIAL-HUSBAND IN TO VISIT TODAY. PT'S DAUGHTER, , CALLED AND UPDATED ON PT'S CONDITION.\\n\\nP-CON'T WITH CURRENT PLAN. WEAN NEO AS TOL. ASSESS PAIN. SKIN CARE. ADVANCE TF AS TOL. SUPPORT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524381,\n \"text\": \"condition updated\\nS/P sepsis;\\nfor complete info please refer to carevue.\\ncondition status quo. neo remains at 2mcg with no attempts to wean, CRRT keeping even to perserve bp. labs adjusted as needed. general anasarca continues. family present at bedside during early pm. no issues at this time\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524382,\n \"text\": \"Respiratory Care:\\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. SX'd for small to moderate amounts of thick yellow-green secretions. Received MDI albuterol and atrovent with each vent check and flovent as noted in CareVue. Latest abg results determined a compensated respiratory alkalemia with very good oxygenation on the current settings.\\n\\nNo RSBI measured due to the FIO2 required at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524383,\n \"text\": \"Respiratory Care:\\nPlease note that the respiratory rate was decreased from 26 to 22 due to hypocarbia (PCO2 was 27).\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524384,\n \"text\": \"respiratory care\\npt on the vent tol well no changes made. see respiratory page of carevue for more information.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-10-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524457,\n \"text\": \"Condition Update\\nPlease see carevue for specifics.\\n\\nPt has been unarousable throughout the . There were only slight up and down movements w/ her left arm noted. PERRL. she was afebrile. In AFIB. Pt hypertensive to the 200's and 130's-140's 2 the beginning of the shift. 5 mg IV diltiazem given @ 20:00 w/ no effect, then 5mg IV labetolol given @ 2100 & 2300 w/ + effect. No vent changes made over . Pt sxn'd several times for sml amts of thick, tan secretions. LS coarse w/ rhonchi. w/ beneprotein TF's infusing via pt's j tube. Her G tube is to gravity and drained yellow mucus material. Pt's stoma is pink. Pt w/ multiple skin tears that are covered w/ adaptic and dsd. Coccyx stage 3 ulcers cleansed all NS, packed w/ aquacel, dsd's placed then softsorbs to cover.\\n\\nPlan: continue w/ current plan of care per micu team. PRN electrolyte repletion. Multiple dressing changes as needed. TF's for nutrition. IV/po abx. ? d/c home w/ services when bp/hr stable.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-07-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524090,\n \"text\": \"Respirtory Care\\nVent dependent pt admitted from home for increasing lethargy and question infection. Has size 6 Shiley trach which requires 40 cm pressure in cuff to obtain seal. Sx for minimal amount thick yellow secretions. ABG reveals metabolic acidosis with beginning respiratory compensation, well oxygenated. BS appear clear.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524165,\n \"text\": \"NURSING\\n VSS, AFEBRILE OVERNIGHT. CONTINUES IN A-FIB, AS PREVIOUSLY. OCCASIONAL PVC'S.RECIEVED 2 UNITS RBC'S. NO ISSUES OVERNIGHT. SEE CARE VUE FOR SPECIFICS.\\n TUBE FEEDS CONTINUE AT 40/HR. GLUCOSE LEVELS CONTINUE TO BE ELEVATED. TREATED WITH SLIDING SCALE AND 90 UNITS OF LANTIS .\\n ALL DRESSINGS CHANGED AT MIDNIGHT. REMAINS ON KINAIR BED, TURNED SIDE TO SIDE Q2/HRS. NO INDICATIONS OF ANY PAIN.\\n CONTINUE SKIN CARE REGIMEN. DIALYSIS TODAY. CONTINUE DISCHARGE CARE PLANNING.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524166,\n \"text\": \"Respiratory Care:\\n Patient continues on full vent support with secretions changing from yellow to yellow-green sputum. BS=bilat, diminished t/o. Trach secure. No changes made in vent settings. See Carevue flowsheet. Plan to continue with supportive care and monitoring.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524167,\n \"text\": \"nursing note\\nNeuro:Opens eyes spont, not following commands or mouthing words. Some spont mvmt noted with LUE. Afebrile.\\nCV:Remians in afib-rate controlled with lorpssor/dig/amio. Rate <120- SBP WNL. HD done with total 1400 ultrafiltrate. transient drops in BP during HD.\\nRESP:LS coarse, thick yellow to green copius at times sputum. with periodic leaks and adjusted by RT.\\nGI:Abd large, soft,nt. PEJ with ostomy appliance surrounding area- draining bilious and air into bag. MD aware and IR MD to come and check tube. MD- pylorus open and therefore not surprised by bilious draining. Ostomy with golden brown liquid stool.\\nGU:anuric.\\nSKIN: per skin rec's- leg dressing remain necrotic with exception of L calf- reddened.\\nSOCIAL:husband and son in this AM and aware of check on PEJ in progress. Per medicine team- pt to go home with family care.\\n\\nPLAN:Check PEJ, passy muir per family requests, cont plan to go home.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-08-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524168,\n \"text\": \"Condition update\\nPlease see carevue for secifics.\\n\\nNeuro unchanged. Tmax 99.8 Afib. PM dose of lopressor held d/t sbp 70's-80' MD notified. No vent changes made this shift. Sats 100%. LS coarse throughout. Pt sxn'd several times for sml to moderate amts of thick, tan secretions. RSBI this am 94. Neb tx's done during the by resp tx. w/ beneprotein tubefeedings infusing at goal via j tube. J tube insertion site w/ large amts of bilious drainage. Colostomy draining golden colored, guiac negative, liquid stool. The stoma is pink. Hip dressings and coccyx wound dressings changed . Pt w/ many skin tears noted from removal of the allevyn dressings.\\n\\n son in to visit this eve. Son very concerned that current trach in line sxn not going down far enough to sxn all of secretions and spoke at great lengths to 3 RN's and resp tx regarding. Son also wants current trach to be replaced by a shorter one to ensure pt is sxn'd adequately. Son still not satified w/ any answers given, and will have primary team discuss w/ him in the am.\\n\\nPlan: continue with current plan of care per micu team. Continue planned dressing changes. D/C planning. HD Tues/Thurs/Sat.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524251,\n \"text\": \"condition update\\nD: pt opens eyes spontaneously. moves upper extremities. inconsistently follows commands.\\ncardiac: afib rate of 100-130's. due for lopressor at 4am. when asleep sbp dip to 70's and up to 90's with stimulation. Dr. aware and wants pt to get 12.5mg of po lopressor. Hr down to 102 and sbp 85/47 after lopressor. sbp dip down to 70's with sleeping and up to 80's-90's with stimulation. Dr. aware and 250cc of ns fluid given.\\nresp: pt remains on cmv with fio2 of 40%. breath sounds remain clear and diminished in the bases. pt suctioned for yellow sputum.\\ngi: pt tolerating tube feeds through j tube at 40cc/hr. gt/jt seems to be slightly out and Dr. aware and up to pt. surgery to be called in am to tube. tube to continue. gtube draining bilious drainage. yellow drainage still draining around tube with ostomy bag intact.\\ngu: pt remains anuric and to have hemodialysis today. small amt of vaginal bleeding noted. Dr. aware. hct remains stable.\\nskin: pt turned every 2 hours and pt remains on air bed. dressing are\\n dry and intact.\\nsocial: son in to visit.\\na: surgery to see pt today re: feeding tube. hemodialysis today. continue to monitor for hypotension.\\nr: hr and sbp responded to fluid. no change in feeding tube position. no tube feeds draining around tube. drainage remains yellow. minimal vaginal drainage at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524252,\n \"text\": \"Resp. care note - Pt. remaines trached and vented, no vent changes made at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524253,\n \"text\": \"FOCUSED NURSING NOTE\\nPlease see carevue flowsheet for further details\\n\\nNeuro: Alert, not following commands, nodding head \\\"yes\\\" \\\"no\\\" to basic needs/questions. PEERL, 3-4mm. Ativan held x 1 today.\\n\\nResp: No vent changes this shift. Trach patent, on CMV 0.40. Suctioned q3-4hr for thick/yellow sputum. SPO2 100% at all times.\\n\\nHemodynamics: Remains in Afib rate 102-120s. No sustained rapid V-rate today. BP labile minute to minute, lowest 52 after Demerol 12.5mg for pain, no LOC, responded to fluid with transient drops in BP throughout afternoon recovering quickly without intervention- Dr aware and in to assess pt. Lopressor dc'd per MICU team, Midrodine dose increased. Hemodialysis held today. No sx bleeding. Anasarca appears to be increasing- fluid losses via Gtube, multiple wounds, stools, J/G tube exit site.\\n\\nGI/Metabolic: TF Neopro FS at goal rate 40ml/hr. Copious amts clear/pale yellow gelatinous/viscous ?mucosal drainage from PEG tube site, MICU team aware. Small amt of same drainage character noted from rectum. Glycemic control acceptable on Lantus 86U . Colsotomy with frequent outputs, loose and trace guiac pos. Electrolytes stable without HD.\\n\\nID: Afebrile. Zosyn/Zyvox/Levaquin administered as ordered. Tobramycin not given secondary to HD suspended. No obvious source of worsening infection in wounds, slight odor waxes and wanes.\\n\\nSKIN INTEGRITY/COMFORT: Please see carevue flowsheet- multiple pressure/venous stasis ulcers. Drsg Wound RN consult instructions. Turn and repositioned q2-3hr. Oral care q2-4hr.\\nDemerol IV x 1 for affirmation of pain on assessment, therapeutic effect of Demerol though significant drop in BP as noted.\\n\\nPSYCHOSOCIAL: Attentive visits today by husband, daughter , and Son . children are habitated to providing hygiene and nursing care- asking questions respectively to what each child's healthcare interest is ie : Diabetes vs wound care vs BP. Emotional support provided and edcuation ongoing re: greater picture of chronic illness, organ failure, sepsis and realistic goals of recovery vs plan of care for comfort only.\\n\\nPLAN: Monitor BP, notify MD <80 persists when HOB flat and stimulation provided. Monitor fluid balance closely, plan CVVH tomorrow per MICU team evaluation in am. Aggressive skin care. Monitor labs/sx bleeding/sx worsening sepsis. Plan D/C home with services this week per family/MD discussions.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524254,\n \"text\": \"condition update\\nd: pt remains awake and inconsistently follows commands.\\ncardiac: afib rate of 110-138. bs still less labile. one episode of bp down to 70's. Dr. aware and up to 80-90's with no treatment. Dr. aware of hr 120-130's and continue to monitor with no treatment.\\nresp: pt remains on cmv fio2 of 40%. pt appears comfortable. suctioned for thick yellow sputum.\\ngi: tube feeds at goal at 40cc/hr. abd soft and slightly distended. colostomy stoma is pink and stool loose brown trace guaiac positve. feeding tube continues to leak around the insertion site thick yellow drainage.\\ngu: pt anuric and on hemodialysis.\\nskin: pt on airbed and turned frequently. left foot dressing changed and toes remain necrotic and black.\\nsocial: son visiting during the evening. asking questions about possible cvvh tomorrow.\\na: continue to monitor hemodynamics.\\nr: less labile tonight. no fluid boluses during the night. hr more tachycardic. pt remains afebrile.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524255,\n \"text\": \"RESP CARE: Pt remains trached/on vent per carevue. No changes in vent settings this shift. Lungs coarse with rhonchi/sxd thick yellow. No RSBI due to hemodynamic instability.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524256,\n \"text\": \"FOCUSED NURSING NOTE\\nPlease see carevue flowsheet for further details\\n\\nNEURO: Pt alert throughout the day, PERRL 3-4MM. Ativan doses held secondary to labile BP and pt does not exhibit signs of agitation. Does not follow commands per baseline, nodding head \\\"yes\\\" to all questions asked- it is this RN's opinion that pt does not have cognitive understanding of questions- nodding \\\"yes\\\" to nearly all speech addressed to her.\\nRESP: Ventilated on CMV 0.40 via trach, no vent changes this shift. SPO2 100%, decreases to 88-92% when side-lying for dressing changes, skin care. Lungs clear to diminished. Thick/yellow sputum suctioned prn.\\nHEMODYNAMICS: Afib persists with rapid Vresponse, occassional PVCs, average rate 120s. BP remains labile, range 70-96/30-58- NINV alternated to LLE and RUE with subtle variances. MICU team aware of HR and BP measurements, no change in LOC, no fluid boluses this shift. Worsening anasarca- no resp distress on CMV. Anuric, HD dependent pt with HD/CVVH on hold per MICU team.\\nMETABOLIC/GI: TF via Jtube at goal rate 40ml/hr. Hyperglycemia increasing (181/195), treated per Lantus order and RISS. Moderate clear gelatinous secretions from G/J tube exit site continues, MD aware. Loose stool in adequate amounts via colostomy- stoma. pink/edematous.\\nSKIN INTEGRITY: No change in pressure ulcers, venous stasis ulcers as previosuly documented, all dressings changes done as ordered. Noted increase exudate and ?exposed bone to right metatarsal area (base of great toe which is completely necrosed/gangrinous)- wound base yellow/red with yellow exudate and erythema borders. Site cleansed, covered with adaptic and covered with DSD. MD notified of assessment.\\nPSYCHOSOCIAL: Husband visited briefly in am, discussed with him inability to offer HD without harming her. Daughter (HCP) called to speak with Renal MD and spoke with Dr . She declined speaking with MICU attending Dr though I expressed his desire to speak with her re: Mrs of further aggressive measures vs goal of d/c home.\\n\\n PLAN: Continue to monitor pts hemodynamics off HD, monitor for sx worsening sepsis. Administer , aggressive wound care. Turn and reposition q2-3hr, pulmonary hygiene prn. Discuss with Pharmacy alternative to D5W diluent for Linezolid to decrease hyperglycemia. Lantus increased as ordered, RISS as ordered. Emotional support to pt and family- Dr and MICU team to f/u with for further .\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524316,\n \"text\": \"NURSING 7P-7A\\n VSS, KEPT WITHIN PARAMETERS OF >80 WITH MAP >50. NEO GTT CONTINUES AT 1.5. REMAINS HYPOTHERMIC WITH TEMPS IN THE 97 RANGE, BAIR HUGGER REMAINS ON LOW.\\n CONTINUES, RUNNING EVEN TO 1 LITER NEGATIVE/DAY. AT 2400 NEGATIVE 1050 FOR 24/HRS. CONTINUES ON CA AND K GTTS PER CVVH PROTOCOL.\\n COLOSTOMY WITH BLOOD TINGED STOOL IN THE EVENING, AFTER MIDNIGHT STOOL RETURNED TO GREEN COLOR. HCT DECREASED TO 22.9 FROM 24.1. MD NOTIFIED, I UNIT RBC'S TO BE GIVEN.\\n CONTINUES ON INSULIN GTT, BLOOD SUGARS RANGE FROM 104-160. TUBE FEEDS CONTINIE AT 65/HR.\\n SEE CARE VUE FOR FULL ASSESSMENT.CONINUE CVVH, RUN EVEN TO 1 LITER NEGATIVE.. TO INTERVENTIONAL RADIOLOGY TODAY FOR PICC LINE. CONTINUE TO MAINTAIN >80, MAP>50. WILL RECIEVE I UNIT RBC'S.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524317,\n \"text\": \"Resp Care: Pt continues trached and on ventilatory support with a/c, no vent changes maintaining spo2 99%; bs rhonchorous, sxn thick yell secretions, rx with mdi albuterol/atrovent/flovent mdi, rsbi n/a d/t vent dependence, will cont full support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2132-09-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1524318,\n \"text\": \"Respiratory Care\\nPt continues to be trached/ventilated. #7.0 Extra-Long Shiley DIC clean and intact. B/S coarse bilterally. Suctioned for moderate amounts of thick yellow secretions. MDI's administered per orders. Pt continues on /NEO. Current resting on A/C 450/16/5/.40 with PIP/Plat 25/22. Plan to continue current support at this time. No ventilatory changes made this shift. Will closely monitor.\\n\"\n }\n]"}}},{"rowIdx":24656,"cells":{"subject_id":{"kind":"number","value":5364,"string":"5,364"},"hadm_id":{"kind":"number","value":190730,"string":"190,730"},"target_text":{"kind":"string","value":"The patient was intensely monitored in the Intensive Care Unit and repeat imaging showed petechial hemorrhages in the area of the left middle cerebral artery distribution but no uncontrolled hemorrhage. It was thought that the patient's stroke was due to embolic phenomena that resulted from hypercoagulable state from a genetic abnormality exacerbated by oral contraceptive use as an outpatient which when combined with the patient's heavy smoking put her at risk for cerebrovascular accident. When the patient was deemed stable with no advancing hemorrhage, the patient was transferred to the general medical floor on the Neurology service for further work up. As noted above, an abdominal CT scan revealed right DVT in the iliac vein, which required the placement of a DVT filter in the inferior vena cava by Interventional Radiology. The type of filter that was placed can be removed at any time if and when the decision is made to anticoagulate the patient for stroke prevention. The patient's neurologic examination throughout her admission improved with her aphasia improving from a dense mixed aphasia to a transcortical mixed aphasia at the time of discharge. The patient's power in the right upper and lower extremities also improved with time and physical therapy intervention, increasing to a in the upper extremity and a 4-/5 in the lower extremity at the time of discharge. The patient was placed on Plavix and subcutaneous Heparin for CVA and DVT prophylaxis during this admission. Great care was taken to prevent any extension of the hemorrhage and the decision was made not to anticoagulate the patient with either Coumadin or Lovenox at the time of discharge. However, repeat head CT scan will be needed and has been scheduled for four to five days after discharge to evaluate the size of hemorrhagic transformation and after evaluation, anticoagulation will likely be started and as indicated in this young female with large middle cerebral artery stroke. The stroke work up including carotid ultrasounds, which showed no stenosis of either carotid artery and a transesophageal echocardiogram performed on , which showed no echocardiographic evidence of cardiac source of embolus. This study included a bubble study search for patent foramen ovale. Therefore, it was thought that the patient's source for embolus was hypercoagulable state due to genetic defect, most likely to be factor V Leiden as per the prevalence in the general population, although prothrombin mutation can not be ruled out as these laboratory results are not available at this time. After coordinating follow-up care with Interventional Radiology, which will contact the patient to remove new DVT filter, the patient was sent to acute rehabilitation facility where she could regain her strength and resume her abilities to carry out her activities of daily living. The patient will have close follow-up after discharge as a repeat CT scan will be scheduled on , at 9:15 a.m. The results of this CT scan will be followed up by Dr. of the Stroke Department, at which time, a decision regarding anticoagulation will be communicated to the rehabilitation facility. The patient's primary care physician, . will also be informed about this decision. Interventional Radiology Department will also contact the patient regarding the date on which they can retrieve the deep venous thrombosis filter placed in her inferior vena cava as the retrieval equipment is not available at this time and they can not set a specific date."},"extractive_notes_summ":{"kind":"string","value":"There is mildly progressive edema and associated mass effect, with further flattening of the left lateral ventricle and displacement to the right. REASON FOR THIS EXAMINATION: r/o DVT FINAL REPORT INDICATION: Right upper extremity swelling, hypercoagulable state. No contraindications for IV contrast FINAL REPORT INDICATION: Recent left middle cerebral arterial stroke, hemorrhage and basal ganglia suspected, but previous CT was done after abdominal contrast-enhanced CT. ? This filling defect terminates just below the level where there is infiltration and subcutaneous air within the right groin consisten with the given history of a prior central line in this location. PLEASE DO now for r/o hemorrhagic transformation No contraindications for IV contrast FINAL REPORT NONCONTRAST CT OF THE BRAIN. An inferior vena cavagram was then performed. No contraindications for IV contrast FINAL REPORT INDICATION: Embolic stroke without clear etiology. FINDINGS: Duplex evaluation was performed of both carotid arteries. There is surrounding hypoattenuation and mass effect with partial effacement of the anterior of the left lateral ventricle. The distal vertebral arteries, the basilar artery and the right internal carotid artery appear normal. This finding is consistent with an evolving left middle cerebral artery distribution infarction. Right iliac vein deep venous thrombosis. This was performed secondary to concern of a duplicated IVC. It appeared to hang up in the region of the left iliac vein. The sheath was left in the left iliac vein and a pelvic venogram was performed through the inner dilator which contained multiple sideholes. These findings are consistent with the patient's known history of occlusion of the left middle cerebral artery and evolving left middle cerebral artery distribution infarction. No contraindications for IV contrast FINAL REPORT NONCONTRAST CT OF THE BRAIN. There is air within the bladder noting the presence of a foley catheter with the bladder otherwise appearing normal. Pelvic venogram demostrated a widely patent left iliac venous system. The angiographic sheath was then withdrawn down into the distal inferior vena cava and a post-procedure inferior vena cavagram was performed. REMAINS IN SR 50-70'S WITHOUT ECTOPY.GI--PEDI NGT PLACED AND CONFIRMED BY CXR. The ascending, transverse and descending thoracic aorta arenormal in diameter and free of atherosclerotic plaque. Thepatient appears to be in sinus rhythm.Conclusions:The left atrium is normal in size. nursing note - 1900hrs - 04.30hrsneuro - slight improvement with right sided deficit - weak grasp now evident with right hand, can move on bed - right leg some power evident can push against some resistance - speech little improvement although can now answer yes/no to simple questions - repeat CT performed as requested at approx 0100hrs this am - await official resultscvs - aim to keep b/p @ 160 for perfussion - b/p 120-160 overnight - dopamine weaned as requested - levo titrated to obtain systolic pressure - levo presently @ 0.2 mcg/kg - h/r stable 50-80 sinus - no further episodes of tachy/ brady /heart block as previousborderline temp - observe @ 100blood sugras covered as per sliding scaleresp - chest clear sats R/A @ 98g/i - x2 bouts of nausea - ondanstron with effect - no bowel motiong/u - urine output 60-80cc per hour much less than previous crstalloids in progress @ 150ccper hour - urine output dropped to 30cc then 20cc per/hr - foley checked for patency. Radial aline placed without incident.Neuro: Alert but lethargic secondary to fentanyl and versed. speech /swallow assessment todaycvs - b/p remined@ parameters ordered 125-130 systolic -- slowly weaning levophed - h/r remians stable 60-70bpm - afebrile - blood sugars stableresp - no issues with asthma - able to use inhaler if required by self - sats 98% - occassional cough evidentg/i - no bowel motion since admission - feed @ goal appears to be tollerating unable to check residuals as pedi tube insitu - remains npo until gag assessedg/u - urine output satisfactory 60-80cc clewar urine per hr via foleyskin - numerous bruises on legs ? PATIENT/TEST INFORMATION:Indication: Cerebrovascular event/TIA.BP (mm Hg): 130/80HR (bpm): 90Status: InpatientDate/Time: at 15:40Test: Portable TEE (Complete)Doppler: Complete pulse and color flowContrast: SalineTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size. MRI OF NECK DONE TODAY.CV--REMAINS ON LEVOPHED GTT WITH LABILE BP. GI: TF at goal, min residual, abd benign. Denies any SOB.GI: Abd soft, non-tender, +bs, -bm. The aortic valveleaflets (3) appear structurally normal with good leaflet excursion and noaortic regurgitation. +Expressive aphasia, but when patient with self is able to find appropriate word. UO>80cc/hr.Access: R Radial aline in place. SBP parameter reduced with levo gtt to keep sbp >130. Pulm: Clear/decr, ra sat 100%. Right ventricular chamber size and free wallmotion are normal. HR 60-70 nsr- no ectopy noted. Good amounts of UO.Access: Right femoral quad lumen. Right Femoral line in place. TF stopped and NGT removed today by Neuro med.GU: Foley cath intact with clear yellow urine. ABD SOFT NONTENDER.GU--NS WITH 20MEQ KCL/1L AT 125/HR TILL TF AT GOAL. NS w/ 20KCL @ 150cc/hr x 4liters.Resp: LS clear bilaterally. CV: SR/no ectopy, sbp 127-133."},"n_notes":{"kind":"number","value":25,"string":"25"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2196-12-26 00:00:00.000","description":"P CAROTID SERIES COMPLETE PORT","row_id":813115,"text":" 2:37 PM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: Carotid source for embolization, carotid stenosis\n Admitting Diagnosis: MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with stroke.\n REASON FOR THIS EXAMINATION:\n Carotid source for embolization, carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Stroke.\n\n FINDINGS: Duplex evaluation was performed of both carotid arteries. Minimal\n plaque was identified.\n\n On the right, peak systolic velocities are 71, 86, 105 in the ICA, CCA, ECA\n respectively. The ICA to CCA ratio is 0.8. This is consistent with no\n stenosis.\n\n On the left, peak systolic velocities are 75, 72, 90 in the ICA, CCA, ECA\n respectively. ICA to CCA ratio is 1. This is consistent with no stenosis.\n\n There is antegrade flow in both vertebral arteries.\n\n IMPRESSION: No evidence of stenosis in either carotid artery.\n\n"},{"category":"Radiology","chartdate":"2196-12-27 00:00:00.000","description":"CT ABD W&W/O C","row_id":813261,"text":" 5:29 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: evaluate for embolic damage to liver, spleen, kidneys in pt\n Admitting Diagnosis: MCA STROKE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with\n REASON FOR THIS EXAMINATION:\n evaluate for embolic damage to liver, spleen, kidneys in pt who has suffered\n embolic stroke with no clear etiology.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Embolic stroke without clear etiology.\n\n TECHNIQUE: Axial pre and post contrast CT abdomen and pelvis.\n\n FINDINGS: The lung bases are clear. The liver, spleen, pancreas, adrenals,\n and kidneys have a normal appearance. No hydronephrosis bilaterally. The\n gallbladder is present. No abnormally thickened or dilated abdominal bowel\n loops. No abdominal ascites, lymphadenopathy, or pneumoperitoneum.\n\n Specifically, there is no CT evidence of infarction of the abovementioned\n organs.\n\n PRE AND POST CONTRAST CT PELVIS: No pelvic ascites or lymphadenopathy. No\n abnormally dilated or thickened pelvic bowel loops. There is air within the\n bladder noting the presence of a foley catheter with the bladder otherwise\n appearing normal.\n\n There is a filling defect which contains air within the right external iliac\n vein extending proximally to the peripheral portion of the common iliac artery\n vein as well as into the central aspect of the internal iliac vein. This\n filling defect terminates just below the level where there is infiltration and\n subcutaneous air within the right groin consisten with the given history of a\n prior central line in this location. Overall the findings are consistent with\n a deep venous thrombosis on the right.\n\n No lytic or blastic destructive osseous lesions.\n\n IMPRESSION:\n\n 1. Right iliac vein deep venous thrombosis.\n\n 2. No evidence of infarction of the liver, spleen, or kidneys as clinically\n questioned.\n\n 3. The findings were directly discussed with Dr. from the neurology\n service at approximately 6PM on .\n\n (Over)\n\n 5:29 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: evaluate for embolic damage to liver, spleen, kidneys in pt\n Admitting Diagnosis: MCA STROKE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2196-12-28 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":813351,"text":" 1:34 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Does this patient truly have hemorrage after IV contrast fro\n Admitting Diagnosis: MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with L MCA stroke found to have hemorrhage in basal ganglia\n yesterday shortly after Abd CT with contrast.\n REASON FOR THIS EXAMINATION:\n Does this patient truly have hemorrage after IV contrast from yesterday's Abd\n CT scan has had time to clear?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent left middle cerebral arterial stroke, hemorrhage and basal\n ganglia suspected, but previous CT was done after abdominal contrast-enhanced\n CT. ? degree of hemorrhage.\n\n TECHNIQUE: Axial non-contrast CT scans of the brain were obtained.\n\n Comparison is made to the previous CT of .\n\n FINDINGS:\n\n At the time of interpretation of the previous study, it was unclear that there\n had been recent contrast administration. Areas of increased density noted in\n the left middle cerebral arterial territory infarction was predominantly\n delayed contrast enhancement. However, on the non-contrast study obtained\n today, there are persistent foci of increased density in the left middle\n cerebral infarction, particularly involving the putamen and caudate. This is\n indicative of petecchial hemorrhage in the infarction.\n\n There is mildly progressive edema and associated mass effect, with further\n flattening of the left lateral ventricle and displacement to the right. The\n basal cisternal spaces remain well visualized. No new areas of abnormal\n attenuation are identified.\n\n IMPRESSION: Petecchial hemorrhage within the left middle cerebral arterial\n territory infarction. Slightly more edema than on the previous studies.\n\n\n"},{"category":"Radiology","chartdate":"2196-12-27 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":813272,"text":" 7:32 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for petechial hemorrhages/infarcts in pt with new D\n Admitting Diagnosis: MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with NEW MCA STROKE\n\n REASON FOR THIS EXAMINATION:\n evaluate for petechial hemorrhages/infarcts in pt with new DVT.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NONCONTRAST CT OF THE BRAIN.\n\n INDICATION: 40 year old female with left middle cerebral artery distribution\n infarct and new DVT.\n\n TECHNIQUE: Axial noncontrast CT imaging of the brain. Comparison is made to\n prior studies from and .\n\n FINDINGS: Compared to prior exams, there is greater hyperattenuation within\n the left basal ganglia, the left frontal lobe as well as the left temporal\n lobe in the distribution of the patient's known left middle cerebral\n infarction. There is surrounding hypoattenuation and mass effect with partial\n effacement of the anterior of the left lateral ventricle. There is no\n evidence of uncal herniation or hydrocephalus. There is no evidence of\n definite extra- axial hemorrhage. Bone windows show no evidence of fracture\n and opacification of the ethmoid air cells.\n\n IMPRESSION:\n Evolving infarction in the distribution of the left middle cerebral artery.\n The areas of hyperattenuation indicative of hemorrhagic transformation.\n\n These findings were discussed with Dr. the night of .\n\n\n"},{"category":"Radiology","chartdate":"2196-12-22 00:00:00.000","description":"MR HEAD W/O CONTRAST","row_id":812703,"text":" 8:27 PM\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \n Reason: acute ischemic stroke with right hemiparesis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with asthma\n REASON FOR THIS EXAMINATION:\n acute ischemic stroke with right hemiparesis\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Right hemiparesis.\n\n TECHNIQUE: Sagittal T1-weighted images, axial T2-weighted, susceptibility and\n FLAIR images were obtained.\n\n FINDINGS:\n\n There is subtle increased signal intensity on the diffusion-weighted images,\n involving the left insula and corona radiata most consistent with a very early\n infarct. No abnormalities yet visible on the FLAIR images. The ventricles,\n cisterns and sulci are normal, without mass effect. The craniovertebral\n junction is normal. Note is made of opacification of the mastoid air cells\n bilaterally. There is trace of fluid in both maxillary sinuses.\n\n IMPRESSION: There is an early infarct within the left MCA territory with\n areas of early restricted diffusion visible in the left insula and corona\n radiata.\n\n MRA HEAD:\n\n CLINICAL HISTORY: Infarct.\n\n TECHNIQUE: A 3D time-of-flight study was derived from an axial slab through\n the inferior cranium.\n\n FINDINGS:\n\n There is good flow in the distal left internal carotid artery. The left MCA\n is truncated at the level of the mid-left M1 segment and no flow is seen\n lateral to the point. The distal vertebral arteries, the basilar artery and\n the right internal carotid artery appear normal. The other cerebral arteries\n are normal.\n\n IMPRESSION: The left MCA is occluded at the level of the mid-left M1 segment.\n The results were called to the emergency room physician at approximately 9:30\n p.m. on . The EU was aware of the findings and TPA had already been\n administered.\n\n"},{"category":"Radiology","chartdate":"2196-12-24 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":812843,"text":" 12:46 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please compare to previous CT\n Admitting Diagnosis: MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with NEW MCA STROKE\n\n REASON FOR THIS EXAMINATION:\n please compare to previous CT\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40 year old female with new MCA stroke.\n\n TECHNIQUE: CT imaging of the brain without contrast.\n\n COMPARISON: .\n\n FINDINGS: There is continued evidence of an evolving left middle cerebral\n artery distribution infarction with hypodensity within the left basal ganglia,\n insular cortex, temporal lobe and frontal lobe. There are multiple\n hyperdensities within the region of the left insular cortex which could\n represent thrombosed vessels in the distribution of the left middle cerebral\n artery. Alternatively these foci of hyperdensity could represent petechial\n hemorrhage. There is evidence of increased mass effect in this region with\n worsening effacement of the left lateral ventricle. There is no evidence of\n hydrocephalus. There is opacification within the ethmoid air cells. Bone\n windows show no evidence of fracture.\n\n IMPRESSION:\n\n 1) Evolving left middle cerebral artery distribution infarct effecting the\n left basal ganglia, left temporal lobe, and left frontal lobe. There is\n evidence of increased mass effect when compared with the prior examination\n with multiple foci of hyperdensity in the region of the left insular cortex\n which likely represents thrombosed vessels or less likely petechial hemorrhage\n in this region .\n\n"},{"category":"Radiology","chartdate":"2196-12-24 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":812881,"text":" 1:55 PM\n PORTABLE ABDOMEN Clip # \n Reason: check feeding tube placement\n Admitting Diagnosis: MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with s/p cva\n REASON FOR THIS EXAMINATION:\n check feeding tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40 year old woman status post CVA. Please check feeding tube\n placement.\n\n FINDINGS: There is a feeding tube, which is curled upon itself, in the\n stomach. The lung fields are clear.\n\n\n"},{"category":"Radiology","chartdate":"2196-12-24 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":812876,"text":" 12:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?infiltrate, and ngt placement\n Admitting Diagnosis: MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with stroke and elevated wbc and new ngt placement\n\n REASON FOR THIS EXAMINATION:\n ?infiltrate, and ngt placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 40-year-old woman with stroke and elevated white count with new NG\n tube placement.\n\n CHEST AP PORTABLE:\n\n FINDINGS: It would appear that this film is mislabeled with the left marker\n over the right shoulder. Since prior study of , there has been\n placement of a nasogastric tube with its tip in the stomach. There is no\n acute cardiopulmonary disease is seen.\n\n"},{"category":"Radiology","chartdate":"2196-12-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":812711,"text":" 10:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?aspiration\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with stroke\n REASON FOR THIS EXAMINATION:\n ?aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40 y/o female with stroke. Evaluate for aspiration.\n\n FINDINGS: The heart size and mediastinal contours are within normal limits\n allowing for the supine nature of this film. The lungs are clear with no\n parenchymal consolidation or pulmonary nodules. No evidence of pneumothorax or\n pleural effusion. The osseous structures are unremarkable.\n\n IMPRESSION: No evidence of aspiration pneumonia.\n\n"},{"category":"Radiology","chartdate":"2196-12-23 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":812721,"text":" 12:56 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: POST TPA. PLEASE DO now for r/o hemorrhagic transformation\n Admitting Diagnosis: MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with NEW MCA STROKE\n REASON FOR THIS EXAMINATION:\n POST TPA. PLEASE DO now for r/o hemorrhagic transformation\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NONCONTRAST CT OF THE BRAIN.\n\n INDICATION: 40 year old female with new left middle cerebral artery CVA.\n Patient with recent TPA administration. Evaluate for hemorrhagic\n transformation.\n\n TECHNIQUE: Axial noncontrast CT imaging of the brain. Comparison is made to\n a prior MRI performed on .\n\n FINDINGS: There is no evidence of acute intracranial hemorrhage. There is no\n evidence of shift of normally midline structures. Increased density is noted\n within the proximal left middle cerebral artery that is consistent with the\n patient's known occlusion of the left middle cerebral artery. Hypodensity is\n present within the left basal ganglia and insular cortex in the distribution\n of the left middle cerebral artery. This finding is consistent with an\n evolving left middle cerebral artery distribution infarction. The ventricles\n and sulci are normal in size. Bone windows show opacification of the right\n ethmoid air cells and no evidence of fracture.\n\n IMPRESSION:\n 1. No evidence of acute intracranial hemorrhage.\n\n 2. Hyperdensity within the left middle cerebral artery and hypoattenuation\n within the left basal ganglia/insular cortex with edema. These findings are\n consistent with the patient's known history of occlusion of the left middle\n cerebral artery and evolving left middle cerebral artery distribution\n infarction.\n\n\n"},{"category":"Radiology","chartdate":"2196-12-28 00:00:00.000","description":"INTERUP IVC","row_id":813375,"text":" 3:41 PM\n IVC GRAM/ Clip # \n Reason: please place , with any questions\n Admitting Diagnosis: MCA STROKE\n Contrast: OPTIRAY Amt: 95CC\n ********************************* CPT Codes ********************************\n * INTERUP IVC INTRO CATH SVC/IVC *\n * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT IVC *\n * IVC GRAM EXTREM UNILAT VENOGRAPHY *\n * -52 REDUCED SERVICES C1880 VENA CAVA *\n * NON-IONIC 50 CC *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with hemorrhage left mca stroke and right common iliac vein\n dvt\n REASON FOR THIS EXAMINATION:\n please place , with any questions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40 year old woman with hemorrhagic left MCA stroke and right\n common iliac DVT.\n\n RADIOLOGISTS PERFORMING PROCEDURE: Dr. ; Dr. ,\n the staff radiologist, present throughout the entire procedure.\n\n PROCEDURE/TECHNIQUE: Informed, written consent was obtained. The left groin\n was prepped and draped in the usual sterile fashion. Through an anesthetized\n skin approach and utilizing a 19 gauge needle access was obtained into the\n left common femoral vein. wire was then advanced through the\n puncture needle. It appeared to hang up in the region of the left iliac vein.\n This raised concern for a duplicated IVC even though the CT scan did not\n demonstrate such a vascular anomaly. The puncture needle was then exchanged\n for a 7 French angiographic sheath. The sheath was left in the left iliac\n vein and a pelvic venogram was performed through the inner dilator which\n contained multiple sideholes. This was performed secondary to concern of a\n duplicated IVC.\n\n Pelvic venogram demostrated a widely patent left iliac venous system. No\n duplicated IVC was seen. The distal inferior vena cava was also widely\n patent.\n\n An inferior vena cavagram was then performed. This demonstrated the level of\n the left and right renal vein confluence. There were single bilateral renal\n veins. No vascular anomaly was detected. There was no IVC thrombus.\n\n wire was then advanced into the angiographic sheath and used to\n reposition the sheath at the level of the lowest renal vein which was the\n left. The Bard removal was then advanced through the 7 French\n angiographic sheath after removing the inner dilator and wire. The removable\n was then deployed. The angiographic sheath was then withdrawn down\n into the distal inferior vena cava and a post-procedure inferior vena cavagram\n was performed. This demonstrated the to be in optimal location with\n (Over)\n\n 3:41 PM\n IVC GRAM/ Clip # \n Reason: please place , with any questions\n Admitting Diagnosis: MCA STROKE\n Contrast: OPTIRAY Amt: 95CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the tip at the level of the left renal vein (the lowest). There was no tilt\n to the .\n\n The angiographic sheath was removed and pressure was applied until hemostasis\n was achieved.\n\n COMPLICATIONS: None.\n\n CONTRAST/MEDICATIONS: IV conscious sedation consisting of incremental doses\n of Versed and Fentanyl. 4 cc 1% Lidocaine. 60 cc of dilute Optiray 320.\n\n IMPRESSION: Successful placement of a Bard Recovery in the IVC. There\n is no inferior vena cava thrombus.\n\n\n"},{"category":"Radiology","chartdate":"2196-12-29 00:00:00.000","description":"R UNILAT UP EXT VEINS US RIGHT","row_id":813499,"text":" 3:00 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: SWELLING\n Admitting Diagnosis: MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman who p/w L MCA CVA, s/p thrombolytics, concerning for\n hypercoagulable state w/u pending, today with RUE swelling.\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right upper extremity swelling, hypercoagulable state.\n\n RIGHT UPPER EXTREMITY DOPPLER ULTRASOUND: scale and Doppler son of\n the right internal jugular, subclavian, axillary, cephalic, basilic and\n brachial veins were performed. Normal flow, compressibility, augmentation and\n wave forms are demonstrated. Intraluminal thrombus is not identified.\n\n IMPRESSION: No evidence of DVT.\n\n"},{"category":"Radiology","chartdate":"2196-12-24 00:00:00.000","description":"MR-ANGIO NECK WITHOUT CONTRAST","row_id":812884,"text":" 2:35 PM\n MR-ANGIO NECK WITHOUT CONTRAST Clip # \n Reason: please do fat sat; ?dissection\n Admitting Diagnosis: MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with large left mca stroke, ?dissection as etiology\n REASON FOR THIS EXAMINATION:\n please do fat sat; ?dissection\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY:\n 40 year old female with large left MCA stroke. Rule out dissection.\n\n MR angiography of the neck was performed without the administration of\n contrast. 2D and 3D images were also performed.\n\n FINDINGS:\n The study is minimally limited secondary to motion, especially the 3D images.\n There is good flow noted in the common carotid arteries, internal carotid\n arteries and vertebral arteries bilaterally.\n\n There is a suggestion of large focal eccentric plaque in the proximal left\n internal carotid artery causing moderately severe stenosis in the proximal\n left internal carotid artery. This is only well seen on the axial images.\n This cannot be confirmed on the reformats secondary to motion. An ultrasound\n examination is recommended for further evaluation. No evidence of dissection\n noted.\n\n IMPRESSION:\n 1) No definite evidence of dissection noted.\n\n 2) Suggestion of large focal eccentric plaque in the proximal left internal\n carotid artery thereby causing moderately severe focal stenosis in the\n proximal left internal carotid artery. This is well seen on the axial images\n but cannot be confirmed on the reformatted images. This should be further\n evaluated with ultrasound examination.\n\n\n"},{"category":"Radiology","chartdate":"2196-12-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":812933,"text":" 5:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval\n Admitting Diagnosis: MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with stroke and elevated wbc and new ngt placement\n\n REASON FOR THIS EXAMINATION:\n eval\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY:40 year old woman with stroke and elevated white count with new NG\n tube placement.\n\n AP semiupright portable chest at 5:30 AM.\n\n The tip of the feeding tube now appears to be in the distal antrum of the\n stomach. No acute cardiopulmonary disease.\n\n\n"},{"category":"Nursing/other","chartdate":"2196-12-24 00:00:00.000","description":"Report","row_id":1332933,"text":"MICU A NSG 7A-7P\nNEURO--PT SLOWLY IMPROVING OVER COURSE OF SHIFT. SPEAKING IN SIMPLE ONE WORD ANSWERS THAT ARE AT TIMES GARBLED. GAG AND COUGH IMPAIRED TO ABSENT. ABLE TO LIFT AND HOLD RIGHT ARM AND RIGHT LEG, BUT STRENGTH REMAINS WEAK. MOVING LEFT ARM WITH NORMAL STRENGTH, AND ABLE TO LIFT AND HOLD LEFT LEG. RIGHT SIDED FACIAL DROOP NOTED, PERRL AT 3-4MM BILAT. MRI OF NECK DONE TODAY.\nCV--REMAINS ON LEVOPHED GTT WITH LABILE BP. GOAL REMAINS SBP 160-180, PLEASE SEE CAREVIEW. K AND MAG REPLETED THIS SHIFT. REMAINS IN SR 50-70'S WITHOUT ECTOPY.\nGI--PEDI NGT PLACED AND CONFIRMED BY CXR. TF PROMOTE WITH FIBER STARTED AT 10CC/HR PLAN IS TO INC Q6 BY 20CC FOR GOAL OF 80CC/HR. ABD SOFT NONTENDER.\nGU--NS WITH 20MEQ KCL/1L AT 125/HR TILL TF AT GOAL. U/O BRISK 100-500CC/HR DILUTE URINE. URINE LYTES AND OSMOLALITY AND SERUM CHEM 7 AND OSMOLALITY TO BE SNET AT 6PM.\nSOCIAL--SIG OTHER AND MOTHER IN TO VISIT TODAY. UPDATED ON PT'S CONDITION BY RN.\n"},{"category":"Nursing/other","chartdate":"2196-12-25 00:00:00.000","description":"Report","row_id":1332934,"text":"nursing note 1900hrs - 0500hrs\n\n\nneuro - status syable overnight - continues to be able to lift and move rt arm periodically with some grasp evident - moves rt leg on bed - follows commands and attempts to communicate - is able to respond yes/no and seems appropriate with response - rt facial droop evident\n\ncvs - systloic maintained 150-180 with levo in progress - attempted to decrease but b/p dips to 140 whilst sleeping - h/r stable 50-70bpm - afebrile - blood sugars stable\ncheck chem 7 last pm - k replaced - results reported to team\n\nresp - lungs wheezy last pm - known asthmatic normally regularly on albuterol @ home - nebulised with good effect - lungs clear sats @98% on R/A RR stable\n\ng/i - no bowel motion - feed increased as perscribed but unable to check for residuals due to size of tube - presently @ 50cc per hour - aim of 80\n\ng/u - urine output 80-240 cc per hour - samples sent this am as requested - team aware of serum amd urine osmolarity - no repeat ordered\n\nskin - able to turn self - presure areas intact\n\nlines - remain patent/insitu\n\nsocial - boyfriend stayed overnight\n\ng/u\n"},{"category":"Nursing/other","chartdate":"2196-12-24 00:00:00.000","description":"Report","row_id":1332932,"text":"nursing note - 1900hrs - 04.30hrs\n\n\nneuro - slight improvement with right sided deficit - weak grasp now evident with right hand, can move on bed - right leg some power evident can push against some resistance - speech little improvement although can now answer yes/no to simple questions - repeat CT performed as requested at approx 0100hrs this am - await official results\n\n\ncvs - aim to keep b/p @ 160 for perfussion - b/p 120-160 overnight - dopamine weaned as requested - levo titrated to obtain systolic pressure - levo presently @ 0.2 mcg/kg - h/r stable 50-80 sinus - no further episodes of tachy/ brady /heart block as previous\nborderline temp - observe @ 100\nblood sugras covered as per sliding scale\n\nresp - chest clear sats R/A @ 98\n\ng/i - x2 bouts of nausea - ondanstron with effect - no bowel motion\n\ng/u - urine output 60-80cc per hour much less than previous crstalloids in progress @ 150ccper hour - urine output dropped to 30cc then 20cc per/hr - foley checked for patency. team informed bolus of fluid - some response to observe - presently 600cc pos for today - team aware\n\n\nskin - intact\n\nlines - patent fem central line - rt art line\n\nsocial - partner stayed overnight\n"},{"category":"Nursing/other","chartdate":"2196-12-25 00:00:00.000","description":"Report","row_id":1332935,"text":"D: See data, MD notes/orders. Neuro: Alert, perrl. Speech is clear, pt is able to string several words together at times, unable to articulate at others. Right sided weakness remains, she is able to lift/hold right arm, right leg lifts/falls. Left appears strong. Neuro checks now q6hrs per neuromed. SBP parameter reduced with levo gtt to keep sbp >130. CV: SR/no ectopy, sbp 127-133. Pulm: Clear/decr, ra sat 100%. GU: Foley draining 100-200cc/hr clear yellow urine. GI: TF at goal, min residual, abd benign. Skin: Surfaces intact, scattered bruises on legs/upper arms. Soc: Family at bedside most of day. P: Wean levo gtt off as tolerated and transfer to neuro floor. Keep family/pt up to date, validate emotions, reinforce + aspects of situation. R: Levo at 0.12mcg/kg/min, sbp dips to <125 when titrated lower. Family/pt updated by team on rounds with questions/concerns addressed.\n"},{"category":"Nursing/other","chartdate":"2196-12-26 00:00:00.000","description":"Report","row_id":1332936,"text":"nursing note 1900hrs 0400hrs\n\n\nneuro - remains stable - able to lift right arm and hold and grip, lift right leg/ move on bed push against pressure - right sided facial droop remains - speech slowly improving - words clearer managing to slowly string words together, occassionally becoming frustrated - able to turn self well in bed - left side remains full power - neuro team satisfied with q6hrly checks - PT involved with rehab ? speech /swallow assessment today\n\n\ncvs - b/p remined@ parameters ordered 125-130 systolic -- slowly weaning levophed - h/r remians stable 60-70bpm - afebrile - blood sugars stable\n\n\nresp - no issues with asthma - able to use inhaler if required by self - sats 98% - occassional cough evident\n\ng/i - no bowel motion since admission - feed @ goal appears to be tollerating unable to check residuals as pedi tube insitu - remains npo until gag assessed\n\ng/u - urine output satisfactory 60-80cc clewar urine per hr via foley\n\n\nskin - numerous bruises on legs ? from initial fall - otherwise intact\n\nlines - central access rt groin satisfactory - art line rt radial satisfactory - x2 peripheral lines removed\n\nsocail - boyfriend stayed overnight - children being taken care of by family - declined any social work input\n\nplan - continue to wean levo - P/T input/rehab ? swallow eval ? call out today\n\n\n\n"},{"category":"Nursing/other","chartdate":"2196-12-23 00:00:00.000","description":"Report","row_id":1332930,"text":"nursing note 0300hrs - 0600hrs\n\n\nadmit from ER with left MCA occlussion - for dopamine to maintain b/p 160-180 systolic - to monitor neuro status hourly, cycle cardiac enzymes\n\nneuro - amitted with aphasia and no movement on the right side with right sisded facial drooping - continues in the same condition, tpa received in ER @ 2100hrs - full power in left side obeys commands attempting to communicate but unable to verbalise - for repeat CT scan today\n\ncvs - dopamine on admission @ 10mcgs/kg/min - had to increase to 14mcgs /kg [team aware]to try to obtain b/p to set limits - x2 episodes dropping b/p to 100 systolic when feeling nauseated and has vomited x1, zofran as perscibed - hr also dropping when naseated ? had x2 short of episode second degree heart block - self terminated - ekg taken and reviewed by team - second set of cardiac enzymes @ 0400hrs await result first set negative - afebrile - received insulin as per order\nall bloods for clotting sent as requested at 4am\n\nresp - chest clear sats at 98% on 2l\n\ng/i - soft no bowel motion NPO\n\ngu / cryastalloids as persribed - urine output satisfactory\n\nskin - intact\n\nlines - x3 peripheral lines - have repeatadly asked team to review for central line\n\nsocial - boyfriend in attendance\n"},{"category":"Nursing/other","chartdate":"2196-12-23 00:00:00.000","description":"Report","row_id":1332931,"text":"Nursing Progress Note MICU A\n\nEvents: Femoral line placed this am secondary to needing central access for pressors. TEE done at bedside, medicated with Fentanyl and Versed. BP done to 110's start 2nd pressors to maintaing bp >160's. Radial aline placed without incident.\n\nNeuro: Alert but lethargic secondary to fentanyl and versed. PEARL, 3mm/bsk. Moving left upper and lower extremities. Is able to squeeze with right and and move right leg on bed. Become very frustrated when asked to move right upper and lower extremities and become tearful.\n\nCV: HR 50-140's, SBP 120-150's. Goal for BP to be greater than 150-160. Dopa @ 12mcg/kg/min. Started on second pressor and then stopped after TEE completed. +palp pedal pulses on bilateral lower extremities. NS w/ 20KCL @ 150cc/hr x 4liters.\n\nResp: LS clear bilaterally. O2 sats 98-100% on 2l. O2 taken off and now 98% on RA.\n\nGI: Abd soft, +bs, -bm.\n\nGU: Foley cath in place with clear yellow urine. UO>80cc/hr.\n\nAccess: R Radial aline in place. Right Femoral line in place. 3 PIV's.\n\nSocial: Boyfriend at bedside, updated on pt's progress by RN and MD.\n\n\n"},{"category":"Nursing/other","chartdate":"2196-12-26 00:00:00.000","description":"Report","row_id":1332937,"text":"Nursing Progress Note MICU A\n\nNeuro: Alert and oriented. PEARL, 3mm/bsk. Moving left upper and lower extremities with normal strength. Able to Move both right upper and lower on bed. Right sided facial droop, but is improved since admit. Pt very frustrated about not being able to communicate. Pt word searching and becomes tearful when she commincate her needs.\n\nCV: NSR with no ectopy. HR 68-89. ABP 108-138/56-81. Recieved pt on Levophed and weaned to off this afternoon. Goal to keep BP >110 per neuro med team. IVF NS w/ 20KCL @ 45cc/hr. 500NS bolus given x 2 to increase BP while weaning Levo. +palp pedal pulses bilat. No edema. Remains afebrile. US of Bilat carotids done this afternoon, neg.\n\nResp: LS CTA, O2 sats 95-99% on RA. Denies any SOB.\n\nGI: Abd soft, non-tender, +bs, -bm. Denies any Nausea. Swallow eval. done by speech and swallow. Ordered for soft diet. Pt does pocket small amount of food on right side of mouth. TF stopped and NGT removed today by Neuro med.\n\nGU: Foley cath intact with clear yellow urine. Good amounts of UO.\n\nAccess: Right femoral quad lumen. Right radial aline.\n\nSocial: Boyfriend at bedside most of day, will return later this evening. Updated on pts progress by RN and MD.\n"},{"category":"Nursing/other","chartdate":"2196-12-27 00:00:00.000","description":"Report","row_id":1332938,"text":"Micu Nursing Progress Note:\n\nNeuro: alert and oriented x 3. Mildly garbled speech. +Expressive aphasia, but when patient with self is able to find appropriate word. MAE with R55%). No masses or thrombi are seen in the left ventricle.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The ascending, transverse and descending thoracic aorta are normal in\ndiameter and free of atherosclerotic plaque.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation. No masses or vegetations\nare seen on the aortic valve.\n\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\nregurgitation. No mass or vegetation is seen on the mitral valve.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: A transesophageal echocardiogram was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was sedated for the TEE. Medications and dosages are\nlisted above (see Test Information section). Local anesthesia was provided by\nlidocaine spray. There were no TEE related complications. 0.2 mg of IV\nglycopyrrolate was given as an antisialogogue prior to TEE probe insertion.\nContrast study was performed with one iv injection of 8 ccs of agitated normal\nsaline at rest. The patient was unable to cooperate with maneuvers. The\npatient appears to be in sinus rhythm.\n\nConclusions:\nThe left atrium is normal in size. No spontaneous echo contrast or thrombus is\nseen in the body of the left atrium/left atrial appendage or the body of the\nright atrium/right atrial appendage. No atrial septal defect or patent foramen\novale is seen by 2D, color Doppler or saline contrast with maneuvers. Overall\nleft ventricular systolic function is normal (LVEF>55%). No masses or thrombi\nare seen in the left ventricle. Right ventricular chamber size and free wall\nmotion are normal. The ascending, transverse and descending thoracic aorta are\nnormal in diameter and free of atherosclerotic plaque. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. No masses or vegetations are seen on the aortic valve.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. No mass or vegetation is seen on the mitral valve. There is no\npericardial effusion.\n\nIMPRESSION: No echocardiographic evidence of cardiac source of embolus.\n\n\n"},{"category":"ECG","chartdate":"2196-12-22 00:00:00.000","description":"Report","row_id":196361,"text":"Sinus rhythm\nST junctional depression is nonspecific\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-12-26 00:00:00.000\",\n \"description\": \"P CAROTID SERIES COMPLETE PORT\",\n \"row_id\": 813115,\n \"text\": \" 2:37 PM\\n CAROTID SERIES COMPLETE PORT Clip # \\n Reason: Carotid source for embolization, carotid stenosis\\n Admitting Diagnosis: MCA STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman with stroke.\\n REASON FOR THIS EXAMINATION:\\n Carotid source for embolization, carotid stenosis\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Stroke.\\n\\n FINDINGS: Duplex evaluation was performed of both carotid arteries. Minimal\\n plaque was identified.\\n\\n On the right, peak systolic velocities are 71, 86, 105 in the ICA, CCA, ECA\\n respectively. The ICA to CCA ratio is 0.8. This is consistent with no\\n stenosis.\\n\\n On the left, peak systolic velocities are 75, 72, 90 in the ICA, CCA, ECA\\n respectively. ICA to CCA ratio is 1. This is consistent with no stenosis.\\n\\n There is antegrade flow in both vertebral arteries.\\n\\n IMPRESSION: No evidence of stenosis in either carotid artery.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-12-27 00:00:00.000\",\n \"description\": \"CT ABD W&W/O C\",\n \"row_id\": 813261,\n \"text\": \" 5:29 PM\\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \\n CT 150CC NONIONIC CONTRAST\\n Reason: evaluate for embolic damage to liver, spleen, kidneys in pt\\n Admitting Diagnosis: MCA STROKE\\n Field of view: 36 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman with\\n REASON FOR THIS EXAMINATION:\\n evaluate for embolic damage to liver, spleen, kidneys in pt who has suffered\\n embolic stroke with no clear etiology.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Embolic stroke without clear etiology.\\n\\n TECHNIQUE: Axial pre and post contrast CT abdomen and pelvis.\\n\\n FINDINGS: The lung bases are clear. The liver, spleen, pancreas, adrenals,\\n and kidneys have a normal appearance. No hydronephrosis bilaterally. The\\n gallbladder is present. No abnormally thickened or dilated abdominal bowel\\n loops. No abdominal ascites, lymphadenopathy, or pneumoperitoneum.\\n\\n Specifically, there is no CT evidence of infarction of the abovementioned\\n organs.\\n\\n PRE AND POST CONTRAST CT PELVIS: No pelvic ascites or lymphadenopathy. No\\n abnormally dilated or thickened pelvic bowel loops. There is air within the\\n bladder noting the presence of a foley catheter with the bladder otherwise\\n appearing normal.\\n\\n There is a filling defect which contains air within the right external iliac\\n vein extending proximally to the peripheral portion of the common iliac artery\\n vein as well as into the central aspect of the internal iliac vein. This\\n filling defect terminates just below the level where there is infiltration and\\n subcutaneous air within the right groin consisten with the given history of a\\n prior central line in this location. Overall the findings are consistent with\\n a deep venous thrombosis on the right.\\n\\n No lytic or blastic destructive osseous lesions.\\n\\n IMPRESSION:\\n\\n 1. Right iliac vein deep venous thrombosis.\\n\\n 2. No evidence of infarction of the liver, spleen, or kidneys as clinically\\n questioned.\\n\\n 3. The findings were directly discussed with Dr. from the neurology\\n service at approximately 6PM on .\\n\\n (Over)\\n\\n 5:29 PM\\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \\n CT 150CC NONIONIC CONTRAST\\n Reason: evaluate for embolic damage to liver, spleen, kidneys in pt\\n Admitting Diagnosis: MCA STROKE\\n Field of view: 36 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-12-28 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 813351,\n \"text\": \" 1:34 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: Does this patient truly have hemorrage after IV contrast fro\\n Admitting Diagnosis: MCA STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman with L MCA stroke found to have hemorrhage in basal ganglia\\n yesterday shortly after Abd CT with contrast.\\n REASON FOR THIS EXAMINATION:\\n Does this patient truly have hemorrage after IV contrast from yesterday's Abd\\n CT scan has had time to clear?\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Recent left middle cerebral arterial stroke, hemorrhage and basal\\n ganglia suspected, but previous CT was done after abdominal contrast-enhanced\\n CT. ? degree of hemorrhage.\\n\\n TECHNIQUE: Axial non-contrast CT scans of the brain were obtained.\\n\\n Comparison is made to the previous CT of .\\n\\n FINDINGS:\\n\\n At the time of interpretation of the previous study, it was unclear that there\\n had been recent contrast administration. Areas of increased density noted in\\n the left middle cerebral arterial territory infarction was predominantly\\n delayed contrast enhancement. However, on the non-contrast study obtained\\n today, there are persistent foci of increased density in the left middle\\n cerebral infarction, particularly involving the putamen and caudate. This is\\n indicative of petecchial hemorrhage in the infarction.\\n\\n There is mildly progressive edema and associated mass effect, with further\\n flattening of the left lateral ventricle and displacement to the right. The\\n basal cisternal spaces remain well visualized. No new areas of abnormal\\n attenuation are identified.\\n\\n IMPRESSION: Petecchial hemorrhage within the left middle cerebral arterial\\n territory infarction. Slightly more edema than on the previous studies.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-12-27 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 813272,\n \"text\": \" 7:32 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: evaluate for petechial hemorrhages/infarcts in pt with new D\\n Admitting Diagnosis: MCA STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman with NEW MCA STROKE\\n\\n REASON FOR THIS EXAMINATION:\\n evaluate for petechial hemorrhages/infarcts in pt with new DVT.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n NONCONTRAST CT OF THE BRAIN.\\n\\n INDICATION: 40 year old female with left middle cerebral artery distribution\\n infarct and new DVT.\\n\\n TECHNIQUE: Axial noncontrast CT imaging of the brain. Comparison is made to\\n prior studies from and .\\n\\n FINDINGS: Compared to prior exams, there is greater hyperattenuation within\\n the left basal ganglia, the left frontal lobe as well as the left temporal\\n lobe in the distribution of the patient's known left middle cerebral\\n infarction. There is surrounding hypoattenuation and mass effect with partial\\n effacement of the anterior of the left lateral ventricle. There is no\\n evidence of uncal herniation or hydrocephalus. There is no evidence of\\n definite extra- axial hemorrhage. Bone windows show no evidence of fracture\\n and opacification of the ethmoid air cells.\\n\\n IMPRESSION:\\n Evolving infarction in the distribution of the left middle cerebral artery.\\n The areas of hyperattenuation indicative of hemorrhagic transformation.\\n\\n These findings were discussed with Dr. the night of .\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-12-22 00:00:00.000\",\n \"description\": \"MR HEAD W/O CONTRAST\",\n \"row_id\": 812703,\n \"text\": \" 8:27 PM\\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \\n Reason: acute ischemic stroke with right hemiparesis\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman with asthma\\n REASON FOR THIS EXAMINATION:\\n acute ischemic stroke with right hemiparesis\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Right hemiparesis.\\n\\n TECHNIQUE: Sagittal T1-weighted images, axial T2-weighted, susceptibility and\\n FLAIR images were obtained.\\n\\n FINDINGS:\\n\\n There is subtle increased signal intensity on the diffusion-weighted images,\\n involving the left insula and corona radiata most consistent with a very early\\n infarct. No abnormalities yet visible on the FLAIR images. The ventricles,\\n cisterns and sulci are normal, without mass effect. The craniovertebral\\n junction is normal. Note is made of opacification of the mastoid air cells\\n bilaterally. There is trace of fluid in both maxillary sinuses.\\n\\n IMPRESSION: There is an early infarct within the left MCA territory with\\n areas of early restricted diffusion visible in the left insula and corona\\n radiata.\\n\\n MRA HEAD:\\n\\n CLINICAL HISTORY: Infarct.\\n\\n TECHNIQUE: A 3D time-of-flight study was derived from an axial slab through\\n the inferior cranium.\\n\\n FINDINGS:\\n\\n There is good flow in the distal left internal carotid artery. The left MCA\\n is truncated at the level of the mid-left M1 segment and no flow is seen\\n lateral to the point. The distal vertebral arteries, the basilar artery and\\n the right internal carotid artery appear normal. The other cerebral arteries\\n are normal.\\n\\n IMPRESSION: The left MCA is occluded at the level of the mid-left M1 segment.\\n The results were called to the emergency room physician at approximately 9:30\\n p.m. on . The EU was aware of the findings and TPA had already been\\n administered.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-12-24 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 812843,\n \"text\": \" 12:46 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: please compare to previous CT\\n Admitting Diagnosis: MCA STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman with NEW MCA STROKE\\n\\n REASON FOR THIS EXAMINATION:\\n please compare to previous CT\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 40 year old female with new MCA stroke.\\n\\n TECHNIQUE: CT imaging of the brain without contrast.\\n\\n COMPARISON: .\\n\\n FINDINGS: There is continued evidence of an evolving left middle cerebral\\n artery distribution infarction with hypodensity within the left basal ganglia,\\n insular cortex, temporal lobe and frontal lobe. There are multiple\\n hyperdensities within the region of the left insular cortex which could\\n represent thrombosed vessels in the distribution of the left middle cerebral\\n artery. Alternatively these foci of hyperdensity could represent petechial\\n hemorrhage. There is evidence of increased mass effect in this region with\\n worsening effacement of the left lateral ventricle. There is no evidence of\\n hydrocephalus. There is opacification within the ethmoid air cells. Bone\\n windows show no evidence of fracture.\\n\\n IMPRESSION:\\n\\n 1) Evolving left middle cerebral artery distribution infarct effecting the\\n left basal ganglia, left temporal lobe, and left frontal lobe. There is\\n evidence of increased mass effect when compared with the prior examination\\n with multiple foci of hyperdensity in the region of the left insular cortex\\n which likely represents thrombosed vessels or less likely petechial hemorrhage\\n in this region .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-12-24 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 812881,\n \"text\": \" 1:55 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: check feeding tube placement\\n Admitting Diagnosis: MCA STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman with s/p cva\\n REASON FOR THIS EXAMINATION:\\n check feeding tube placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 40 year old woman status post CVA. Please check feeding tube\\n placement.\\n\\n FINDINGS: There is a feeding tube, which is curled upon itself, in the\\n stomach. The lung fields are clear.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-12-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 812876,\n \"text\": \" 12:02 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?infiltrate, and ngt placement\\n Admitting Diagnosis: MCA STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman with stroke and elevated wbc and new ngt placement\\n\\n REASON FOR THIS EXAMINATION:\\n ?infiltrate, and ngt placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 40-year-old woman with stroke and elevated white count with new NG\\n tube placement.\\n\\n CHEST AP PORTABLE:\\n\\n FINDINGS: It would appear that this film is mislabeled with the left marker\\n over the right shoulder. Since prior study of , there has been\\n placement of a nasogastric tube with its tip in the stomach. There is no\\n acute cardiopulmonary disease is seen.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-12-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 812711,\n \"text\": \" 10:12 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?aspiration\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman with stroke\\n REASON FOR THIS EXAMINATION:\\n ?aspiration\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 40 y/o female with stroke. Evaluate for aspiration.\\n\\n FINDINGS: The heart size and mediastinal contours are within normal limits\\n allowing for the supine nature of this film. The lungs are clear with no\\n parenchymal consolidation or pulmonary nodules. No evidence of pneumothorax or\\n pleural effusion. The osseous structures are unremarkable.\\n\\n IMPRESSION: No evidence of aspiration pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-12-23 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 812721,\n \"text\": \" 12:56 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: POST TPA. PLEASE DO now for r/o hemorrhagic transformation\\n Admitting Diagnosis: MCA STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman with NEW MCA STROKE\\n REASON FOR THIS EXAMINATION:\\n POST TPA. PLEASE DO now for r/o hemorrhagic transformation\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n NONCONTRAST CT OF THE BRAIN.\\n\\n INDICATION: 40 year old female with new left middle cerebral artery CVA.\\n Patient with recent TPA administration. Evaluate for hemorrhagic\\n transformation.\\n\\n TECHNIQUE: Axial noncontrast CT imaging of the brain. Comparison is made to\\n a prior MRI performed on .\\n\\n FINDINGS: There is no evidence of acute intracranial hemorrhage. There is no\\n evidence of shift of normally midline structures. Increased density is noted\\n within the proximal left middle cerebral artery that is consistent with the\\n patient's known occlusion of the left middle cerebral artery. Hypodensity is\\n present within the left basal ganglia and insular cortex in the distribution\\n of the left middle cerebral artery. This finding is consistent with an\\n evolving left middle cerebral artery distribution infarction. The ventricles\\n and sulci are normal in size. Bone windows show opacification of the right\\n ethmoid air cells and no evidence of fracture.\\n\\n IMPRESSION:\\n 1. No evidence of acute intracranial hemorrhage.\\n\\n 2. Hyperdensity within the left middle cerebral artery and hypoattenuation\\n within the left basal ganglia/insular cortex with edema. These findings are\\n consistent with the patient's known history of occlusion of the left middle\\n cerebral artery and evolving left middle cerebral artery distribution\\n infarction.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-12-28 00:00:00.000\",\n \"description\": \"INTERUP IVC\",\n \"row_id\": 813375,\n \"text\": \" 3:41 PM\\n IVC GRAM/ Clip # \\n Reason: please place , with any questions\\n Admitting Diagnosis: MCA STROKE\\n Contrast: OPTIRAY Amt: 95CC\\n ********************************* CPT Codes ********************************\\n * INTERUP IVC INTRO CATH SVC/IVC *\\n * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT IVC *\\n * IVC GRAM EXTREM UNILAT VENOGRAPHY *\\n * -52 REDUCED SERVICES C1880 VENA CAVA *\\n * NON-IONIC 50 CC *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman with hemorrhage left mca stroke and right common iliac vein\\n dvt\\n REASON FOR THIS EXAMINATION:\\n please place , with any questions\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 40 year old woman with hemorrhagic left MCA stroke and right\\n common iliac DVT.\\n\\n RADIOLOGISTS PERFORMING PROCEDURE: Dr. ; Dr. ,\\n the staff radiologist, present throughout the entire procedure.\\n\\n PROCEDURE/TECHNIQUE: Informed, written consent was obtained. The left groin\\n was prepped and draped in the usual sterile fashion. Through an anesthetized\\n skin approach and utilizing a 19 gauge needle access was obtained into the\\n left common femoral vein. wire was then advanced through the\\n puncture needle. It appeared to hang up in the region of the left iliac vein.\\n This raised concern for a duplicated IVC even though the CT scan did not\\n demonstrate such a vascular anomaly. The puncture needle was then exchanged\\n for a 7 French angiographic sheath. The sheath was left in the left iliac\\n vein and a pelvic venogram was performed through the inner dilator which\\n contained multiple sideholes. This was performed secondary to concern of a\\n duplicated IVC.\\n\\n Pelvic venogram demostrated a widely patent left iliac venous system. No\\n duplicated IVC was seen. The distal inferior vena cava was also widely\\n patent.\\n\\n An inferior vena cavagram was then performed. This demonstrated the level of\\n the left and right renal vein confluence. There were single bilateral renal\\n veins. No vascular anomaly was detected. There was no IVC thrombus.\\n\\n wire was then advanced into the angiographic sheath and used to\\n reposition the sheath at the level of the lowest renal vein which was the\\n left. The Bard removal was then advanced through the 7 French\\n angiographic sheath after removing the inner dilator and wire. The removable\\n was then deployed. The angiographic sheath was then withdrawn down\\n into the distal inferior vena cava and a post-procedure inferior vena cavagram\\n was performed. This demonstrated the to be in optimal location with\\n (Over)\\n\\n 3:41 PM\\n IVC GRAM/ Clip # \\n Reason: please place , with any questions\\n Admitting Diagnosis: MCA STROKE\\n Contrast: OPTIRAY Amt: 95CC\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n the tip at the level of the left renal vein (the lowest). There was no tilt\\n to the .\\n\\n The angiographic sheath was removed and pressure was applied until hemostasis\\n was achieved.\\n\\n COMPLICATIONS: None.\\n\\n CONTRAST/MEDICATIONS: IV conscious sedation consisting of incremental doses\\n of Versed and Fentanyl. 4 cc 1% Lidocaine. 60 cc of dilute Optiray 320.\\n\\n IMPRESSION: Successful placement of a Bard Recovery in the IVC. There\\n is no inferior vena cava thrombus.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-12-29 00:00:00.000\",\n \"description\": \"R UNILAT UP EXT VEINS US RIGHT\",\n \"row_id\": 813499,\n \"text\": \" 3:00 PM\\n UNILAT UP EXT VEINS US RIGHT Clip # \\n Reason: SWELLING\\n Admitting Diagnosis: MCA STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman who p/w L MCA CVA, s/p thrombolytics, concerning for\\n hypercoagulable state w/u pending, today with RUE swelling.\\n REASON FOR THIS EXAMINATION:\\n r/o DVT\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Right upper extremity swelling, hypercoagulable state.\\n\\n RIGHT UPPER EXTREMITY DOPPLER ULTRASOUND: scale and Doppler son of\\n the right internal jugular, subclavian, axillary, cephalic, basilic and\\n brachial veins were performed. Normal flow, compressibility, augmentation and\\n wave forms are demonstrated. Intraluminal thrombus is not identified.\\n\\n IMPRESSION: No evidence of DVT.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-12-24 00:00:00.000\",\n \"description\": \"MR-ANGIO NECK WITHOUT CONTRAST\",\n \"row_id\": 812884,\n \"text\": \" 2:35 PM\\n MR-ANGIO NECK WITHOUT CONTRAST Clip # \\n Reason: please do fat sat; ?dissection\\n Admitting Diagnosis: MCA STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman with large left mca stroke, ?dissection as etiology\\n REASON FOR THIS EXAMINATION:\\n please do fat sat; ?dissection\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY:\\n 40 year old female with large left MCA stroke. Rule out dissection.\\n\\n MR angiography of the neck was performed without the administration of\\n contrast. 2D and 3D images were also performed.\\n\\n FINDINGS:\\n The study is minimally limited secondary to motion, especially the 3D images.\\n There is good flow noted in the common carotid arteries, internal carotid\\n arteries and vertebral arteries bilaterally.\\n\\n There is a suggestion of large focal eccentric plaque in the proximal left\\n internal carotid artery causing moderately severe stenosis in the proximal\\n left internal carotid artery. This is only well seen on the axial images.\\n This cannot be confirmed on the reformats secondary to motion. An ultrasound\\n examination is recommended for further evaluation. No evidence of dissection\\n noted.\\n\\n IMPRESSION:\\n 1) No definite evidence of dissection noted.\\n\\n 2) Suggestion of large focal eccentric plaque in the proximal left internal\\n carotid artery thereby causing moderately severe focal stenosis in the\\n proximal left internal carotid artery. This is well seen on the axial images\\n but cannot be confirmed on the reformatted images. This should be further\\n evaluated with ultrasound examination.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-12-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 812933,\n \"text\": \" 5:19 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval\\n Admitting Diagnosis: MCA STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman with stroke and elevated wbc and new ngt placement\\n\\n REASON FOR THIS EXAMINATION:\\n eval\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY:40 year old woman with stroke and elevated white count with new NG\\n tube placement.\\n\\n AP semiupright portable chest at 5:30 AM.\\n\\n The tip of the feeding tube now appears to be in the distal antrum of the\\n stomach. No acute cardiopulmonary disease.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2196-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332933,\n \"text\": \"MICU A NSG 7A-7P\\nNEURO--PT SLOWLY IMPROVING OVER COURSE OF SHIFT. SPEAKING IN SIMPLE ONE WORD ANSWERS THAT ARE AT TIMES GARBLED. GAG AND COUGH IMPAIRED TO ABSENT. ABLE TO LIFT AND HOLD RIGHT ARM AND RIGHT LEG, BUT STRENGTH REMAINS WEAK. MOVING LEFT ARM WITH NORMAL STRENGTH, AND ABLE TO LIFT AND HOLD LEFT LEG. RIGHT SIDED FACIAL DROOP NOTED, PERRL AT 3-4MM BILAT. MRI OF NECK DONE TODAY.\\nCV--REMAINS ON LEVOPHED GTT WITH LABILE BP. GOAL REMAINS SBP 160-180, PLEASE SEE CAREVIEW. K AND MAG REPLETED THIS SHIFT. REMAINS IN SR 50-70'S WITHOUT ECTOPY.\\nGI--PEDI NGT PLACED AND CONFIRMED BY CXR. TF PROMOTE WITH FIBER STARTED AT 10CC/HR PLAN IS TO INC Q6 BY 20CC FOR GOAL OF 80CC/HR. ABD SOFT NONTENDER.\\nGU--NS WITH 20MEQ KCL/1L AT 125/HR TILL TF AT GOAL. U/O BRISK 100-500CC/HR DILUTE URINE. URINE LYTES AND OSMOLALITY AND SERUM CHEM 7 AND OSMOLALITY TO BE SNET AT 6PM.\\nSOCIAL--SIG OTHER AND MOTHER IN TO VISIT TODAY. UPDATED ON PT'S CONDITION BY RN.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2196-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332934,\n \"text\": \"nursing note 1900hrs - 0500hrs\\n\\n\\nneuro - status syable overnight - continues to be able to lift and move rt arm periodically with some grasp evident - moves rt leg on bed - follows commands and attempts to communicate - is able to respond yes/no and seems appropriate with response - rt facial droop evident\\n\\ncvs - systloic maintained 150-180 with levo in progress - attempted to decrease but b/p dips to 140 whilst sleeping - h/r stable 50-70bpm - afebrile - blood sugars stable\\ncheck chem 7 last pm - k replaced - results reported to team\\n\\nresp - lungs wheezy last pm - known asthmatic normally regularly on albuterol @ home - nebulised with good effect - lungs clear sats @98% on R/A RR stable\\n\\ng/i - no bowel motion - feed increased as perscribed but unable to check for residuals due to size of tube - presently @ 50cc per hour - aim of 80\\n\\ng/u - urine output 80-240 cc per hour - samples sent this am as requested - team aware of serum amd urine osmolarity - no repeat ordered\\n\\nskin - able to turn self - presure areas intact\\n\\nlines - remain patent/insitu\\n\\nsocial - boyfriend stayed overnight\\n\\ng/u\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2196-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332932,\n \"text\": \"nursing note - 1900hrs - 04.30hrs\\n\\n\\nneuro - slight improvement with right sided deficit - weak grasp now evident with right hand, can move on bed - right leg some power evident can push against some resistance - speech little improvement although can now answer yes/no to simple questions - repeat CT performed as requested at approx 0100hrs this am - await official results\\n\\n\\ncvs - aim to keep b/p @ 160 for perfussion - b/p 120-160 overnight - dopamine weaned as requested - levo titrated to obtain systolic pressure - levo presently @ 0.2 mcg/kg - h/r stable 50-80 sinus - no further episodes of tachy/ brady /heart block as previous\\nborderline temp - observe @ 100\\nblood sugras covered as per sliding scale\\n\\nresp - chest clear sats R/A @ 98\\n\\ng/i - x2 bouts of nausea - ondanstron with effect - no bowel motion\\n\\ng/u - urine output 60-80cc per hour much less than previous crstalloids in progress @ 150ccper hour - urine output dropped to 30cc then 20cc per/hr - foley checked for patency. team informed bolus of fluid - some response to observe - presently 600cc pos for today - team aware\\n\\n\\nskin - intact\\n\\nlines - patent fem central line - rt art line\\n\\nsocial - partner stayed overnight\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2196-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332935,\n \"text\": \"D: See data, MD notes/orders. Neuro: Alert, perrl. Speech is clear, pt is able to string several words together at times, unable to articulate at others. Right sided weakness remains, she is able to lift/hold right arm, right leg lifts/falls. Left appears strong. Neuro checks now q6hrs per neuromed. SBP parameter reduced with levo gtt to keep sbp >130. CV: SR/no ectopy, sbp 127-133. Pulm: Clear/decr, ra sat 100%. GU: Foley draining 100-200cc/hr clear yellow urine. GI: TF at goal, min residual, abd benign. Skin: Surfaces intact, scattered bruises on legs/upper arms. Soc: Family at bedside most of day. P: Wean levo gtt off as tolerated and transfer to neuro floor. Keep family/pt up to date, validate emotions, reinforce + aspects of situation. R: Levo at 0.12mcg/kg/min, sbp dips to <125 when titrated lower. Family/pt updated by team on rounds with questions/concerns addressed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2196-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332936,\n \"text\": \"nursing note 1900hrs 0400hrs\\n\\n\\nneuro - remains stable - able to lift right arm and hold and grip, lift right leg/ move on bed push against pressure - right sided facial droop remains - speech slowly improving - words clearer managing to slowly string words together, occassionally becoming frustrated - able to turn self well in bed - left side remains full power - neuro team satisfied with q6hrly checks - PT involved with rehab ? speech /swallow assessment today\\n\\n\\ncvs - b/p remined@ parameters ordered 125-130 systolic -- slowly weaning levophed - h/r remians stable 60-70bpm - afebrile - blood sugars stable\\n\\n\\nresp - no issues with asthma - able to use inhaler if required by self - sats 98% - occassional cough evident\\n\\ng/i - no bowel motion since admission - feed @ goal appears to be tollerating unable to check residuals as pedi tube insitu - remains npo until gag assessed\\n\\ng/u - urine output satisfactory 60-80cc clewar urine per hr via foley\\n\\n\\nskin - numerous bruises on legs ? from initial fall - otherwise intact\\n\\nlines - central access rt groin satisfactory - art line rt radial satisfactory - x2 peripheral lines removed\\n\\nsocail - boyfriend stayed overnight - children being taken care of by family - declined any social work input\\n\\nplan - continue to wean levo - P/T input/rehab ? swallow eval ? call out today\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2196-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332930,\n \"text\": \"nursing note 0300hrs - 0600hrs\\n\\n\\nadmit from ER with left MCA occlussion - for dopamine to maintain b/p 160-180 systolic - to monitor neuro status hourly, cycle cardiac enzymes\\n\\nneuro - amitted with aphasia and no movement on the right side with right sisded facial drooping - continues in the same condition, tpa received in ER @ 2100hrs - full power in left side obeys commands attempting to communicate but unable to verbalise - for repeat CT scan today\\n\\ncvs - dopamine on admission @ 10mcgs/kg/min - had to increase to 14mcgs /kg [team aware]to try to obtain b/p to set limits - x2 episodes dropping b/p to 100 systolic when feeling nauseated and has vomited x1, zofran as perscibed - hr also dropping when naseated ? had x2 short of episode second degree heart block - self terminated - ekg taken and reviewed by team - second set of cardiac enzymes @ 0400hrs await result first set negative - afebrile - received insulin as per order\\nall bloods for clotting sent as requested at 4am\\n\\nresp - chest clear sats at 98% on 2l\\n\\ng/i - soft no bowel motion NPO\\n\\ngu / cryastalloids as persribed - urine output satisfactory\\n\\nskin - intact\\n\\nlines - x3 peripheral lines - have repeatadly asked team to review for central line\\n\\nsocial - boyfriend in attendance\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2196-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332931,\n \"text\": \"Nursing Progress Note MICU A\\n\\nEvents: Femoral line placed this am secondary to needing central access for pressors. TEE done at bedside, medicated with Fentanyl and Versed. BP done to 110's start 2nd pressors to maintaing bp >160's. Radial aline placed without incident.\\n\\nNeuro: Alert but lethargic secondary to fentanyl and versed. PEARL, 3mm/bsk. Moving left upper and lower extremities. Is able to squeeze with right and and move right leg on bed. Become very frustrated when asked to move right upper and lower extremities and become tearful.\\n\\nCV: HR 50-140's, SBP 120-150's. Goal for BP to be greater than 150-160. Dopa @ 12mcg/kg/min. Started on second pressor and then stopped after TEE completed. +palp pedal pulses on bilateral lower extremities. NS w/ 20KCL @ 150cc/hr x 4liters.\\n\\nResp: LS clear bilaterally. O2 sats 98-100% on 2l. O2 taken off and now 98% on RA.\\n\\nGI: Abd soft, +bs, -bm.\\n\\nGU: Foley cath in place with clear yellow urine. UO>80cc/hr.\\n\\nAccess: R Radial aline in place. Right Femoral line in place. 3 PIV's.\\n\\nSocial: Boyfriend at bedside, updated on pt's progress by RN and MD.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2196-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332937,\n \"text\": \"Nursing Progress Note MICU A\\n\\nNeuro: Alert and oriented. PEARL, 3mm/bsk. Moving left upper and lower extremities with normal strength. Able to Move both right upper and lower on bed. Right sided facial droop, but is improved since admit. Pt very frustrated about not being able to communicate. Pt word searching and becomes tearful when she commincate her needs.\\n\\nCV: NSR with no ectopy. HR 68-89. ABP 108-138/56-81. Recieved pt on Levophed and weaned to off this afternoon. Goal to keep BP >110 per neuro med team. IVF NS w/ 20KCL @ 45cc/hr. 500NS bolus given x 2 to increase BP while weaning Levo. +palp pedal pulses bilat. No edema. Remains afebrile. US of Bilat carotids done this afternoon, neg.\\n\\nResp: LS CTA, O2 sats 95-99% on RA. Denies any SOB.\\n\\nGI: Abd soft, non-tender, +bs, -bm. Denies any Nausea. Swallow eval. done by speech and swallow. Ordered for soft diet. Pt does pocket small amount of food on right side of mouth. TF stopped and NGT removed today by Neuro med.\\n\\nGU: Foley cath intact with clear yellow urine. Good amounts of UO.\\n\\nAccess: Right femoral quad lumen. Right radial aline.\\n\\nSocial: Boyfriend at bedside most of day, will return later this evening. Updated on pts progress by RN and MD.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2196-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1332938,\n \"text\": \"Micu Nursing Progress Note:\\n\\nNeuro: alert and oriented x 3. Mildly garbled speech. +Expressive aphasia, but when patient with self is able to find appropriate word. MAE with R55%). No masses or thrombi are seen in the left ventricle.\\n\\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\\nnormal.\\n\\nAORTA: The ascending, transverse and descending thoracic aorta are normal in\\ndiameter and free of atherosclerotic plaque.\\n\\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\\ngood leaflet excursion and no aortic regurgitation. No masses or vegetations\\nare seen on the aortic valve.\\n\\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\\nregurgitation. No mass or vegetation is seen on the mitral valve.\\n\\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\\ntricuspid regurgitation.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\\nstructurally normal with physiologic pulmonic regurgitation.\\n\\nPERICARDIUM: There is no pericardial effusion.\\n\\nGENERAL COMMENTS: A transesophageal echocardiogram was performed in the\\nlocation listed above. I certify I was present in compliance with HCFA\\nregulations. The patient was monitored by a nurse throughout the\\nprocedure. The patient was sedated for the TEE. Medications and dosages are\\nlisted above (see Test Information section). Local anesthesia was provided by\\nlidocaine spray. There were no TEE related complications. 0.2 mg of IV\\nglycopyrrolate was given as an antisialogogue prior to TEE probe insertion.\\nContrast study was performed with one iv injection of 8 ccs of agitated normal\\nsaline at rest. The patient was unable to cooperate with maneuvers. The\\npatient appears to be in sinus rhythm.\\n\\nConclusions:\\nThe left atrium is normal in size. No spontaneous echo contrast or thrombus is\\nseen in the body of the left atrium/left atrial appendage or the body of the\\nright atrium/right atrial appendage. No atrial septal defect or patent foramen\\novale is seen by 2D, color Doppler or saline contrast with maneuvers. Overall\\nleft ventricular systolic function is normal (LVEF>55%). No masses or thrombi\\nare seen in the left ventricle. Right ventricular chamber size and free wall\\nmotion are normal. The ascending, transverse and descending thoracic aorta are\\nnormal in diameter and free of atherosclerotic plaque. The aortic valve\\nleaflets (3) appear structurally normal with good leaflet excursion and no\\naortic regurgitation. No masses or vegetations are seen on the aortic valve.\\nThe mitral valve appears structurally normal with trivial mitral\\nregurgitation. No mass or vegetation is seen on the mitral valve. There is no\\npericardial effusion.\\n\\nIMPRESSION: No echocardiographic evidence of cardiac source of embolus.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2196-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 196361,\n \"text\": \"Sinus rhythm\\nST junctional depression is nonspecific\\n\\n\"\n }\n]"}}},{"rowIdx":24657,"cells":{"subject_id":{"kind":"number","value":20064,"string":"20,064"},"hadm_id":{"kind":"number","value":180633,"string":"180,633"},"target_text":{"kind":"string","value":"Pt. was scheduled to be a same day admit following his surgery but was found to have an elevated INR and had to be admitted and delayed until a lower INR. On pt. was given one dose of Vitamin K and scheduled for the OR the next day. On pt. had a stable INR and was brought to the operating room where he underwent a Redo Ascending Ao replacement (and Bentall procedure) w/ a #28 Gel weave graft. Along with an AVR w/ a #23 . Please see surgical note for full details. Pt. tolerated the procedure well. Total CPB time was 210 minutes with a XCT of 142 minutes. Pt. was brought to the CSRU in stable condition with a MAP 80, CVP 12, PAD 15, 22, and a HR of 80 NSR. He was being titrated on Nitro, Epi, and propofol when transferred. On Post-Op day #1, propofol was weaned. NMB reversed and pt. was weaned off ventilation. After extubation, pt was awake, alert and oriented and had no new deficits(r-sided hemiparesis pre-op). Pt. was now on Nipride and that was planned to be weaned. POD #2 pt. had no new events but was still being titrated on Nipride. Anticoagulation started today. POD #3, pt. was transfused 1 unit of PRBC due to low HCT (25). Still in CSRU secondary to not being able to titrate off Nipride. Chest tubes were removed and Foley replaced. POD #4, HCT increased to 29.1. Pt. had increased DOE though the day with a transient drop in SBP after Lopressor (80's). Neo was started. An echo was performed which showed a small pericardial effusion. CXR showed L. pleural effusion. Suture over CT site due to bleeding. POD #5 Neo was weaned. POD # 6 pt. had PO2 in 90's and was receiving O2 via open face tent. POD #7, repeat CXR performed yesterday revealed increased L pleural effusion. A pigtail catheter was placed over guidewire into left chest which immediately drained 550 cc. Weaned mask to nasal cannula since oxygenation improved. POD #8, CT d/c'd. Later that night pt. was oozing from l. chest tube sight with resolution after stitch placement. Pt. was transferred to telemetry floor. POD #9 & 10: Hemodynamically stable. Pt. is now awaiting INR to increase and still needs an increase and strength and activity before being discharged home. Cont. to receive Coumadin. POD #11, pt doing well and was d/c'd home with VNA services and INR will be checked on and with results sent to Dr. . D/C PE: VS: 99.5 75 SR 120/60 22 Neuro: alert, oriented with r-side hemiparesis Pulm: CTAB Cardiac: RRR Sternum: + Bledding from pacer site, -Erythema Abd: soft, NT/ND +BS Ext: warm, -c/c/e"},"extractive_notes_summ":{"kind":"string","value":"dp's palpable and pt's by doppler. CONSISTENTLY >2.0; SWAN PULLED BACK TO CVP POSITION. CT dc'd.gi/gu: pt with + bs. : OGT D/C'D W/ETT. Pt presently on 0.75mcg nipride.Good hemodynamics epi weaned off with Svo2 of 68-71% and CO of 6.1-6.9. GU: GOOD UO ENDO: SSI X2. care note - Pt. Resp. RESP. CONT TO ENC I.S., C&DB. K +CA REPLACED. cpt done. COUDE CATH INSERTED. CARE: PT. PTT checks, refer heparin adjustments. BS DIMINISHED BIBASILAR. PALP.PULSES.RESP- 3LNC=98%.LS CLEAR. RR 18-32.BS DIMINISHED BIBASILAR. NIPRIDE @ 1 MCGKGMIN SBP < 120. TRANSFUSED W/ 2 UNITS PRBC'S FOR HCT~24.9. TITRATING TO MAINTAIN BG LEVEL W/IN CSRU PROTOCOL.A/P~LABILE BP. L FEM A-LINE D/C'D IN A.M, SITE D&I. POS PAL PEDAL PULSES BILAT.GI/GUTOL PO FLUIDS WELL. REPEAT PTT @ . NONPRODUCTIVE COUGH.CARDIAC~60'S-70'S W/ OCC PVC'S. CPT X 2. some oozing from around foley of sang drainage.gu: good uop. POSTTRANSFUSION HCT 29.. ALTERED CARDIAC STATUSS: \"I'M CHILLY\"O: CARDIAC: SR 70'S WITH ISOLATED PAC/PVC NOTED. neuro: perla. + BS. TAKING PO MEDS.GU- ADEQ. dp/pt pulses palp bilat. TO KEEP SBP<130. CT SCANT DRG.GI- ABS SOFT. ADV DIET AND ACTIVITY AS TOL. afebrile. NIPRIDE OFF. HCT 31-28.9. PAIN: PERCOCET 2 TABS X 2 WITH GOOD EFFECT ID: TEMP 99.6 AX NOT REGISTERING ORALLY ABOVE 96. NEURO: UNCHANGED PLEASE SEE FLOW. ABG ->PO2 102.neuro: moves left side with normal strength, right sided body weakness, right hand appears contracted. TRANSIENT NEOP: MONITOR COMFORT, HR AND RYTHYM, SBP-WEAN NEO AS TOLERATED, DSGS, PP, RESP STATUS-PO2/SATS-PULM TOILET, NEURO STATUS, I+O, LABS HCT Q6HR. HYPERTENSIVE. REHAB PLACEMENT. BS- CLEAR AND = BILAT. palpable pedal pulsesresp: advised coughing and dbe's, nothing expectorated. GD OXYGENATION. NOW BEGINNING TO BREATH OVER SET RR. P02 60'S. CURRENTLY CONTROLLED W/ ANTI HYPERTENSIVE REGIMEN.AGGRESSIVE REHAB. HYDRALIZINE/LOPRESSOR FOR HTN. remained on 6LO2/NC sao2 97%. RSBI=63, DESPITE STILL BEING ON PROPAFOL. epicardial wires dc'd. DC CT. percocet x2 given with effect though mild pain still remains.plan: ?thoracotomy. Pt in sinus rhythm with occasional pvc's. C.I. IV MSO4 GIVEN PRIOR TO ACTIVITY W/ MOD RELIEF. both pedal pulses palpable.resp: pleural effusion. Nipride gtt titrated to keep SBP 90-120. pt started on vasotec this am. INCISIONS C+D DSGS CHANGED. + BS.ENDO~INSULIN GTT. csru updatecvs: remained on NSR. slept well.resp: o2 weaned to 4 l nc. pain well-controlled with percocet x2. good oral fluid intakegu: adequate uo. ptt therapeutic.chest/med incision with scant serosang drainage. good bowel sounds. EXTUBATED 0930, NOW ON 4L NC O2 W/ SPO2 99%. lung sounds dim at the basesneuro: right sided body weakness. DOES I.S. NEED TO CHECK K/PTT AT .. LYTES REPLETED PRN.SKIN: INTACT. WEAN TO EXTUBATE WHEN AWAKENED. QUIET PERSONALITY.ASSISTS WITH TURNING.RT ARM FLEXED/RIGID.FOLLOWS COMMANDS.CV- NSR.OCC.PVC. PERICARDIAL EFFUSION, TO MONITOR SERIAL HCTS. lungs coarse and diminished lll. 40 MEQ PO K X 1. CUFF SIG LOWER. SBP GOAL <110. COUMADIN 5 MG PO. continue pulmonary toilet. GI: GOOD APPETITE, BOOST X 2. pearl. Neuro: alert and oriented x 3, mae, right sidded weakness, more weak with right upper extremity then right lower, following commands corrrectly, percocets for pain.Cardiac: nsr in the 70-80's with rare pvc's, sbp's wnl's, palpible pedial pulses, skin warm dry and intact, +2 edema in extremities, afebrile, continues heparin gtt.Resp: on 2 liters nc satting at 100%, lungs are clesr, ct to scn draining scant serosang with no air leak in ct system.Skin: chest with steris is cdi, old medial ct site are approximated and cdi, current ct site with transparent dsd that is cdi.Gi/Gu: tolerating po's, abd soft round and nontender with good bowel sounds, is passing gas, on riss, making good u/o.PLan: increase activity as tolerates, encourage to cough and deep breath and use i/s, monitor ptt's. There has been interval removal of the right internal jugular central line. Retrocardiac opacity persists, obscuring the left hemidiaphragm. Some free intraperitoneal air is seen under the right hemidiaphragm. Right internal jugular catheter was removed, though the sheath remains in place. 2) Persistent stable small right pleural effusion. cpt done. There is nopericardial effusion. No change in the left basilar opacity, which most likely is a combination of left pleural effusion and consolidation and/or atelectasis. Opacity at the right cardiophrenic angle is unchanged. Decreased left pleural effusion. The left upper lung and right lung are well-aerated. The right lung and left upper lung are well aerated. A small right pleural effusion is unchanged. Median sternotomy wires and aortic valve replacement are again seen. The right lung is well aerated. Cardiac and mediastinal contours appear slightly widened, but are stable in the postoperative. The right cardiophrenic angle specifically is unchanged. PAIN/RESP MNGMGNT. IMPRESSION: Right IJ line has been removed. Modest diffuseST-T wave changes with ST segment elevation. UPRIGHT AP CHEST: The patient has been extubated. The retrocardiac opacity and blunting of the left costophrenic angle persist. UPRIGHT AP CHEST: The right internal jugular central venous catheter sheath remains in place, though the catheter itself has been removed. The left costophrenic angle remains blunted. A right internal jugular sheath remains in place. Left lower lobe partial atelectasis is unchanged. There is left lower lobe partial atelectasis. Sternotomy wires and aortic valve replacement are again noted. Improvement in the right basilar opacity. Probable sinus rhythm but consider also ectopic atrial rhythm. The right cardiac border appears somewhat prominent in comparison with prior preoperative exam. IMPRESSION: Postoperative changes as described above. The left chest tube has been removed. BASELINE R SIDED WEAKNESS. The right retrocardiac opacity is slightly improved. csru updatecvs: SB/NSR 58-60 rare pvc's noted k+ supp given. Sternotomy wires and an aortic valve replacement are again noted. IMPRESSION: Free intraperitoneal air under the right hemidiaphragm, which may be due to pigtail removal. There is left lower lobe atelectasis. +bsskin: mediastinal wound oozy, redressed. The opacity at the left base has decreased in the interim, consistent with some drainage of pleural fluid. Left lower lobe atelectasis. + BS +FLATUS. The old fracture of the right clavicle is again noted. DIM RT BASE. Small bilateral pleural effusion. IMPRESSION: Status post left chest tube removal, without pneumothorax detected. IMPRESSION: 1) Moderate left pleural effusion, slightly increased in the interval. 2 PERCOCET X2 WITH EFFECT.PLAN- AM CXR, IF PLEURAL EFFUSION LARGER,TO IR TO TAP IT. 1 MED BRN FORMED BM TODAY.SKIN: L CT SITE CDI W/ TRANSPARANT DSD. There are mediastinal and bilateral chest tubes in place. MEDICATED W/ 2 PERCS PRIOR TO. Preop for aortic root and arch replacement. assess and address dysrhythmias. The findings at the left base may represent residual left pleural effusion and/or associated atelectasis, although an infiltrate cannot be excluded. + BS. There are ET tube and NG tube, and the right IJ line in place.the Tip of the right IJ line is most likely in the right atrium.the Tip of the ET tube is 8 cm above the carina."},"n_notes":{"kind":"number","value":29,"string":"29"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2117-01-15 00:00:00.000","description":"Report","row_id":1526192,"text":"PATIENT DOING WELL THIS PM, HCT THIS AM 26 GIVEN 1UPRBC WITHOUT INCIDENT LASIX 40 MG GIVEN AFTERTRANSFUSION. POSTTRANSFUSION HCT 29.. PATIENT OOB TO PT DID WELL, STAYED IN CHAIR FOR APPROX. 3HRS THEN BACK TO BED.. HEPARIN HAD BEEN OFF FOR APPROX. 7HRS, RESTARTED BACK AT 1430 AT 1500U/HR, NO BOLUS GIVEN. PLAN TO GIVE 5MG COUMADIN PO THIS PM.. URINARY MEATUS OOZING LOTS OF CLOTS, TIL THIS PM, CLEANED SMALL AMT. OF BLOOD OOZING. RESP ON 6LNP WITH NONPRODUCTIVE COUGH, USING I/S WITH ENCOURAGEMENT. GU ADEQUATE U/O WITH LASIX, K 4.1 THIS PM TO BE REPLETED.. GI TOLERATING JELLO/CUSTARD /BOOST.. BS ELEVATED ON DRIP UP TO 7U/HR THEN DROPPED OFF, THEN BS AT 1300 130 GIVEN 4UNITS REGULAR SC.. ABD/STERNUM DSG D/I.. CORDIS DCD, ALINE KEPT IN FOR BLOOD DRAW. WIFE INTO VISIT THIS PM..ENCOURAGE ACTIVITY/ADLS...\n"},{"category":"Nursing/other","chartdate":"2117-01-15 00:00:00.000","description":"Report","row_id":1526193,"text":"ADDENUM PATIENT OOB TO CHAIR AT 1800 FOR DINNER ATE REALLY WELL TONIGHT, BS PRIOR TO EATING 152 6UNITS REGULAR SC GIVEN.. NEED TO CHECK K/PTT AT .. IF PATIENT ATTEMPTS TO WALK IN AM NEEDS BRACE/AND SHOES TO WALK\n"},{"category":"Nursing/other","chartdate":"2117-01-16 00:00:00.000","description":"Report","row_id":1526194,"text":"neuro: perla. alert and oriented. follows commands. right sided weakness from old cva.speech thick at times, but able to communicate well when he takes his time. pain well-controlled with percocet x2. slept well.\nresp: o2 weaned to 4 l nc. sats 95-98%. lungs coarse and diminished lll. chest pt really helps him cough, but he swallows secretions. is raises 500-750cc. becomes sob with minimal exertion, but recovers quickly.\ncv: nsr. sbp contolled with po agents, but iv hydralazine given x1 after ambulated back to bed for persistent sbp> 130s. afebrile. dp/pt pulses palp bilat. heparin drip at 1500 units/hour. ptt therapeutic.chest/med incision with scant serosang drainage. some oozing from around foley of sang drainage.\ngu: good uop. some bloody drainage around foley.\ngi: tol po well. good bowel sounds. blood sugars covered per protocol.\nplan: ambulate with pt today with leg brace and shoes. ? transfer to II soon.\n"},{"category":"Nursing/other","chartdate":"2117-01-16 00:00:00.000","description":"Report","row_id":1526195,"text":"Resp. care note - Pt. remaines on 50% tm, tol ok at this time.\n"},{"category":"Nursing/other","chartdate":"2117-01-12 00:00:00.000","description":"Report","row_id":1526184,"text":"RESP. CARE:\n PT. PLACED ON VENT. ON ARRIVAL FROM O.R.--SIMV 650 X 14 100% 5P 5PS. FI02 QUICKLY WEANED TO 50%. BS- CLEAR AND = BILAT. NOW BEGINNING TO BREATH OVER SET RR. RSBI=63, DESPITE STILL BEING ON PROPAFOL. WEAN TO EXTUBATE WHEN AWAKENED.\n"},{"category":"Nursing/other","chartdate":"2117-01-12 00:00:00.000","description":"Report","row_id":1526185,"text":"pt arrived from Or around 2100 s/p ascending aortic repair, Bentall Procedure with #25mm St. Jude valve. Pt arrived on nitro , Epi and Propofol With FFP running.\nNeuro: Pt remained sedated overnight on Propofol Starting to move slightly with stimulation.\nResp: Fio2 weaned down to 50% with good po2. Will plan to wean to extubat this am after rounds. Suctioned for scant amount of white secretions.\nC/V:vss pt switched from nitro to nipride for blod pressure control. Goal is 90-110 SBP. Pt presently on 0.75mcg nipride.\nGood hemodynamics epi weaned off with Svo2 of 68-71% and CO of 6.1-6.9. Pt in sinus rhythm with occasional pvc's. all electrolytes treated as ordered. A wires do not work Vwires sense and capture. Chest tubes patent draining serous sangunious from pleural and dark sangunious from medistinal small amounts. Coags with in normal no treatment needed and hct stable at 28.\nGI: OGT draining small amounts of thin bilious colored fluid.\nEndo: pt started on insulin gtt for blood sugar 126 and titrated per protocol.\nGU: pt diuresis large amounts of urine. He had received lasix in the or.\nSkin: chest icision scant amount of drainage on dsg. left groin dsg intact.\nPain: medicated morphine 2mg iv x3 for perceived pain\nSocial: Wife and sons in to see pt last evening updated on condition.\n"},{"category":"Nursing/other","chartdate":"2117-01-12 00:00:00.000","description":"Report","row_id":1526186,"text":"UPDATE\nCV: NSR, RARE PVC ONLY. C.I. CONSISTENTLY >2.0; SWAN PULLED BACK TO CVP POSITION. PO LOPRESSOR STARTED BUT UNABLE TO WEAN SNP DRIP SIGNIFICANTLY SO LOPRESSOR DOSE INCREASED. SBP GOAL <110. L FEM A-LINE D/C'D IN A.M, SITE D&I. FEET W/ STRONG DISTAL PULSES. CT'S X 5 W/ SM AMTS DK SEROSANG DRNG.\n\nRESP: LUNGS MOSTLY CLEAR(SL COARSE L BASE). EXTUBATED 0930, NOW ON 4L NC O2 W/ SPO2 99%. PT HAS VERY WEAK, INEFFECTIVE AND NONPRODUCTIVE COUGH. STATES HE CAN'T DO ANY BETTER. DOES I.S. W/ VT'S TO 400ML.\n\nNEURO: A&O, COOPERATIVE. SEEMS DISCOURAGED DUE TO WEKNESS AND DISCOMFORT(MOSTLY W/ ACTIVITY). IV MSO4 GIVEN PRIOR TO ACTIVITY W/ MOD RELIEF. OOB TO CHAIR X 2 HRS, ASSIST OF 2. R LEG SL WEAKER THAN L BUT STOOD W/ MIN ASSIST. PT HAS NO CONTROL OVER R ARM WHICH REMAINS PERISTENTLY FLEXED-ABLE TO STRAIGHTEN IT MANUALLY.\n\nG.I.: OGT D/C'D W/ETT. TOL ICE CHIPS AND SIPS H2O.\n\nG.U./RENAL: ADEQ HUO VIA FOLEY. LYTES REPLETED PRN.\n\nSKIN: INTACT. SM AMT OLD SANG DRNG ON STERNAL DRSG.\n\nENDO: CONT ON INSULIN DRIP PER PROTOCOL.\n\nSOCIAL: PT W/ MANY VISITORS TODAY--PT NOW ASKING TO RESTRICT VISITORS TO WIFE AND CHILDREN ONLY. WIFE AWARE AND WILL NOTIFY OTHERS.\n\nA/P: NEEDS BETTER ANTIHYPERTENSIVE CONTROL TO FACILLITATE SNP WEAN. NEXT DOSE LOPRESSOR UP TO 50MG. GD OXYGENATION. CONT TO ENC I.S., C&DB. PAIN MED PRN FOR COMFORT. ADV DIET AND ACTIVITY AS TOL.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2117-01-16 00:00:00.000","description":"Report","row_id":1526196,"text":"ALTERED CARDIAC STATUS\nS: \"I'M CHILLY\"\nO: CARDIAC: SR 70'S WITH ISOLATED PAC/PVC NOTED. SBP TRANSIENT DROP TO 80'S AFTER 0900 LOPRESSOR. SBP 110'S-160'S THROUGHOUT THE DAY. DID NOT RECIEVE ANY HYDRALAZINE TODAY. 1720 NOTED SBP 80'S PT DENIED COMPLAINT NEO STARTED TO KEEP SBP > 90. ? PERICARDIAL EFFUSION, TO MONITOR SERIAL HCTS. EXTREMITIES WARM,PALP PP. HCT 31-28.9. DSGS D+I, NO DRAINAGE FROM CT DSG. 40 MEQ PO K X 1. OOB TO CHAIR AND AMB X 1 TO WITH ASSIST OF TWO.\n RESP: NOTED INCREASED DOE WITH ANY EXERTION, PT DENIED INITIALLY HOWEVER ADMITTED TO DOE AS DAY PROGRESSED. P02 60'S. O2 VIA NP 6L WITH O2 SAT >95%. BS DIMINISHED BIBASILAR. CPT X 1 DID NOT TOLERATE 2ND ROUND OF CPT.+ LEFT PLEURAL EFFUSION. WEAK COUGH WITH STRONG ENCOURAGEMENT. COUGHING AND SWALLOWING. IS 250-500.\n NEURO: UNCHANGED AS PER FLOW, PERL, RIGHT SIDED ARM MOVES ON BED, RIGHT LEG CAN LIFT AND FALL, STRONG LEFT GRASP AND LEG. OX3. THICK SLOW SPEECH AT TIMES.\n GI: GOOD APPETITE, BOOST X 2. ABS SOFT, NONTENDER, + BOWEL SOUNDS, NO STOOL.\n GU: GOOD UO\n ENDO: SSI X2.\n PAIN: PERCOCET 2 TABS X 2 WITH GOOD EFFECT\n ID: TEMP 99.6 AX NOT REGISTERING ORALLY ABOVE 96.\n SOCIAL: WIFE AND FAMILY INTO VISIT AND UPDATED.\nA: REQUIRING NEO @ 1745, ? PERICARDIAL EFFUSION, + PLEURAL EFFUSION, SOBOE,\nP: MONTIOR COMFORT, HR + RYTHYM, SBP -WEAN NEO AS TOLERATED, CT DRAINAGE, SERIAL HCT Q6HR, PP, RESP STATUS- PULM TOILET-MONITOR ABG, NEURO STATUS, I+O, LABS. AS PER ORDERS. TTE AT 1900.\n\n"},{"category":"Nursing/other","chartdate":"2117-01-17 00:00:00.000","description":"Report","row_id":1526197,"text":"csru update\ncvs: remained on NSR. isolated pvc's noted at times. neo continued, sbp 90-130mmhg.hydralazine not given.heparin dose adjusted down to 1400 units/hr, repeat PTT 0800hrs. TTE done, no pericardial effusion found. both pedal pulses palpable.\n\nresp: pleural effusion. remained on 6LO2/NC sao2 97%. dbe's and coughing done, no secretions expectorated. ABG ->PO2 102.\n\nneuro: moves left side with normal strength, right sided body weakness, right hand appears contracted. pearl. oriented. slept for long periods.\n\ngi: on insulin s/s. good oral fluid intake\n\ngu: adequate uo. lasix 40mg ix \n\npain: verbalized pain over left changed, constant, and continues even at rest. percocet x2 given with effect though mild pain still remains.\n\nplan: ?thoracotomy. continue pulmonary toilet. PTT checks, refer heparin adjustments. hemodynamic status monitoring\n"},{"category":"Nursing/other","chartdate":"2117-01-19 00:00:00.000","description":"Report","row_id":1526201,"text":"Neuro: alert and oriented x 3, mae, right sidded weakness, more weak with right upper extremity then right lower, following commands corrrectly, percocets for pain.\n\nCardiac: nsr in the 70-80's with rare pvc's, sbp's wnl's, palpible pedial pulses, skin warm dry and intact, +2 edema in extremities, afebrile, continues heparin gtt.\n\nResp: on 2 liters nc satting at 100%, lungs are clesr, ct to scn draining scant serosang with no air leak in ct system.\n\nSkin: chest with steris is cdi, old medial ct site are approximated and cdi, current ct site with transparent dsd that is cdi.\n\nGi/Gu: tolerating po's, abd soft round and nontender with good bowel sounds, is passing gas, on riss, making good u/o.\n\nPLan: increase activity as tolerates, encourage to cough and deep breath and use i/s, monitor ptt's.\n"},{"category":"Nursing/other","chartdate":"2117-01-13 00:00:00.000","description":"Report","row_id":1526187,"text":"NEURO- PLEASANT,COOPERATIVE WITH CARE. QUIET PERSONALITY.ASSISTS WITH TURNING.RT ARM FLEXED/RIGID.FOLLOWS COMMANDS.\n\nCV- NSR.OCC.PVC. NIPRIDE @ 1 MCGKGMIN SBP < 120. NO DECREASE IN BP/HR AFTER 50MG PO LOPRESSSOR.AFEBRILE. PALP.PULSES.\n\nRESP- 3LNC=98%.LS CLEAR. DIM BASES. CT SCANT DRG.\n\nGI- ABS SOFT. + BS. TAKING PO MEDS.\n\nGU- ADEQ. HOURLY U/O.\n\nLABS- PENDING.\n\nENDO- INSULIN GTT @ 4U/HR WITH TIGHT GLUCOSSE CONTROL. GLUCOSE=105.\n\nPAIN- 1 PERCOCET PO WITH EFFECT.\n\nPLAN- WEAN NIPRIDE. INCREASE DIET/ACTIVITY AS TOL. ? DC CT.\n"},{"category":"Nursing/other","chartdate":"2117-01-13 00:00:00.000","description":"Report","row_id":1526188,"text":"7am-3pm update\nneuro: pt alert and orieanted x3. able to follow commands. R arm contracted (from previous stroke)\n\nCV: pt remains in NSR, no ectopy noted. HR in the 60's. Nipride gtt titrated to keep SBP 90-120. pt started on vasotec this am. hydralazine prn for bp control. dp's palpable and pt's by doppler. epicardial wires dc'd. plan to start heparin gtt at 1500 and start coumadin this evening\n\nresp: LS clear with dim bases bil. pt on 4 LC nc, o2 sats 92-100%. pt using IS to 500. pt with weak cough. CT dc'd.\n\ngi/gu: pt with + bs. poor appetite. foley draining clear yellow urine. creatinine 1.5 this am (same as yesterday)\n\nendo: continues on insulin gtt and titrated per protocol\n\nplan: wean nipride gtt to keep sbp 90-120, pulm toleit, pain control, monitor lytes, start heparin gtt at 1500\n"},{"category":"Nursing/other","chartdate":"2117-01-14 00:00:00.000","description":"Report","row_id":1526189,"text":"csru update\ncvs: nipride titrated to keep sbp 90-120. hydralazine not indicated as sbp mostly at 100-110mmhg, nipride at 0.5- 1. hr on NSR 70's no ectopics noted. slight elevation in temp ^37.8, medic aware, nothing ordered. palpable pedal pulses\n\nresp: advised coughing and dbe's, nothing expectorated. cpt done. managed up to 500 with IS. lung sounds dim at the bases\n\nneuro: right sided body weakness. oriented. slept adequately in the night\n\ngi: on insulin s/s. needs encouragement with diets and fluids. to have boost supp during lunch and dinner\n\ngu: foley dc'd awaiting to void. +bs\n\npain/soc: pain controlled, no analgesics taken. all procedures explained\n\nplan: pulmonary toilet. encourage ^diets. increase activity as tolerated\n"},{"category":"Nursing/other","chartdate":"2117-01-14 00:00:00.000","description":"Report","row_id":1526190,"text":"NEURO~A&OX3. FC. MAE. ABLE TO LIFT AND HOLD RIGHT HAND. MORPHINE AND PERCOCET FOR DISCOMFORT. EFFECTIVE. OOB TO CHAIR, GAIT STEADY. TOL WELL.\n\nRESP~ON 35% OFM, AND 4L NP. MAINTAINING SATS OF 97%. LUNGS COARSE UPPER DIM IN BASES VERY DIM IN RLL. NONPRODUCTIVE COUGH.\n\nCARDIAC~60'S-70'S W/ OCC PVC'S. HYPERTENSIVE. NIPRIDE OFF. HYDRALIZINE/LOPRESSOR FOR HTN. TO KEEP SBP<130. FOLLOW ALINE. CUFF SIG LOWER. HEPARIN @ 1300 UNITS/HR. REPEAT PTT @ . COUMADIN 5 MG PO. TRANSFUSED W/ 2 UNITS PRBC'S FOR HCT~24.9. POST HCT~30. POS PAL PEDAL PULSES BILAT.\n\nGI/GUTOL PO FLUIDS WELL. APPETITE POOR. REFUSING FOOD. UNABLE TO INSERT FOLEY THIS AM. BLOOD CLOT NOTED WHEN FOLEY DC'D. COUDE CATH INSERTED. HUGE BLOOD CLOT PASSED. URINE CLEAR AND CONT TO BE CLEAR. GIVEN 40 MG IV LASIX BETWEEN TRANS AND CONT W/ DOSE. + BS.\n\nENDO~INSULIN GTT. TITRATING TO MAINTAIN BG LEVEL W/IN CSRU PROTOCOL.\n\nA/P~LABILE BP. CURRENTLY CONTROLLED W/ ANTI HYPERTENSIVE REGIMEN.\nAGGRESSIVE REHAB. CONT W/ POST OP TEACHING. ? REHAB PLACEMENT.\n\n"},{"category":"Nursing/other","chartdate":"2117-01-17 00:00:00.000","description":"Report","row_id":1526198,"text":"ALTERED CARDIAC STATUS\nS: \"I'M NOT GETTING UP YET\"\nO: CARDIAC: SR 100-80'S, LOPRESSOR DECREASED TO -12 NOON LOPRESSOR HELD, LASIX DECREASED TO 20 MG , SBP REQUIRED NEO PRESENTLY OFF. INCISIONS C+D DSGS CHANGED. EXTREMITIES WARM , PALP PP. HYDRALAZINE NOT GIVEN DUE TO SBP <100. HCT STABLE AT 29. K +CA REPLACED.\n RESP: OPEN FACE TENT @ 50% WITH PO2 IN THE 90'S, COUGH WITHOUT RAISING-PT STATES RAISED YELLOW -TO SEND FOR C+S IF PRODUCES AGAIN. O2 SAT PRESENTLY 96 ON 6LNP. RR 18-32.BS DIMINISHED BIBASILAR. CPT X 2.\n NEURO: UNCHANGED PLEASE SEE FLOW. CALM PLEASANT, MORE ENGAGING TODAY.\n SKIN: INTACT 2 PURPLE LINES NOTED ON BACK ? DUE TO PADS BEING ROLLED UNDER BACK-NO CHANGE FROM YESTERDAY. OOB TO CHAIR FOR 5 HOURS. AMBULATED TO TOLERATED MUCH BETTER THAN YESTERDAY.\n GI: GOOD APPETITE, ABD SOFT,NONTENDER, + BOWEL SOUNDS, NO STOOL.\n GU: GOOD UO TO RECIEVE LASIX DOSE @ 1815\n ENDO: SSI X2\n PAIN: 2 PERCOCET X2 WITH GOOD EFFECT,\n ID: TEMP MAX AX 99.3 UA + C+S SENT\n SOCIAL: WIFE AND CHILDREN INTO VISIT AND UPDATED\nA: BETTER OXYGENATION WITH OPEN FACE TENT, AWAITING ? IR IN AM TO TAP EFFUSION TO CHECK CXR IN AM. TRANSIENT NEO\nP: MONITOR COMFORT, HR AND RYTHYM, SBP-WEAN NEO AS TOLERATED, DSGS, PP, RESP STATUS-PO2/SATS-PULM TOILET, NEURO STATUS, I+O, LABS HCT Q6HR. AS PER ORDERS.\n"},{"category":"Nursing/other","chartdate":"2117-01-18 00:00:00.000","description":"Report","row_id":1526199,"text":"NEURO-QUIET,COOPERATIVE WITH CARE. BASELINE MOVEMENT OF EXTREMETIES.VOICING NEEDS.\n\nCV-NSR.SBP DECREASAED TO 98 AFTER TAKING HYDRALAZINE/LOPRESSOR .T-MAX=100.7-> 650MG TYLENOL PO.HEPARIN @ 1400U/HR PTT=54.9 HCT=27.9\n\nRESP-MOUTH BREATHER AT NOC. 50%OFM =98%. DIM RT BASE. NON-PRODUCTIVE COUGH.\n\nGI- ABD SOFT. + BS +FLATUS. TAKIING MEDS WITHOUT DIFFICULTY.\n\nGU- ADEQ. HOURLY U/O. RESPONDS WELL TO LASIX IV.\n\nLABS- GLUCOSE- 123,COVERED WITH 2UNITS REG. INS SC.\n\nPAIN-C/O STERNAL PAIN WITH MOVEMENT. 2 PERCOCET X2 WITH EFFECT.\n\nPLAN- AM CXR, IF PLEURAL EFFUSION LARGER,TO IR TO TAP IT. PAIN/RESP MNGMGNT.\n"},{"category":"Nursing/other","chartdate":"2117-01-18 00:00:00.000","description":"Report","row_id":1526200,"text":"NEURO: A+OX3, PLEASANT AND COOPERATIVE. BASELINE R SIDED WEAKNESS. GIVEN 2 PERCOCET TWICE FOR PAIN W/ GOOD EFFECT.\n\nCV: NSR 80'S. NO ECTOPY. STARTED ON ZESTRIL PO TODAY. SBP 88-92. PT ALSO HYDRALZINE AND PO LOPRESSOR.\n\nRESP: PT L PLEURAL CT W/ PIGTAIL DRAIN FROM NP. NO PROBLEMS. MEDICATED W/ 2 PERCS PRIOR TO. PT 590CC SERO SANG DRAINAGE IMMEDIATELY. OXEGENATION IMPROVED. PT WEANED TO 2L NP. MAINTAINING HIGH SPO2'S.\n\nGU: FOLEY PATENT. GOOD CLEAR YELLOW UOP.\n\nGI: SOFT NT ABD. + BS. GOOD APPETITE. 1 MED BRN FORMED BM TODAY.\n\nSKIN: L CT SITE CDI W/ TRANSPARANT DSD. CHEST AND L GROIN INCISION ARE CDI AND OTA W/ STERI STRIPS\n\nSOCIAL: FAMILY IN AT BEDSIDE.\n\nA/P IMPROVED RESP STATUS S/P CT. RECHECK PTT @ , START COUMADIN THISD PM, TO DECREASE HYDRALAZINE DOSE, CONTINUE CARE AS PLANNED. PREPARE FOR TRANSFER TO FLOOR TOMORROW.\n"},{"category":"Nursing/other","chartdate":"2117-01-15 00:00:00.000","description":"Report","row_id":1526191,"text":"csru update\ncvs: SB/NSR 58-60 rare pvc's noted k+ supp given. sbp 100-130 hydralazine,metoprolol. afebrile. palpable pedal pulses.\n\nresp: encouraged dbe's and coughing, nothing expectorated. cpt done. sao2 97-100%. coarse breath sounds on both upper lobes, dim on the bases.\n\nneuro: right sided body weakness. oriented. right hand unable to grasp or hold. right arm lifts and holds.\n\ngi: poor appetite. encouraged to take boost, took approx 80 mls. on insulin s/s\n\ngu: excessive uo. lasix 40 . +bs\n\nskin: mediastinal wound oozy, redressed. penile bleeding. pain controlled\n\nsoc: family visited and updated. all procedures explained to pt.\n\nplan: continue strict pulmonary hygiene. monitor v/s. assess and address dysrhythmias. ^ mobility. encourage ^ food intake\n\n\n\n\n"},{"category":"Echo","chartdate":"2117-01-16 00:00:00.000","description":"Report","row_id":67846,"text":"PATIENT/TEST INFORMATION:\nIndication: Tamponade.\nBP (mm Hg): 121/53\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 20:26\nTest: Portable TTE (Focused views)\nDoppler: No doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%).\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTIC VALVE: BIleaflet aortic valve prosthesis (AVR).\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nLeft ventricular wall thickness, cavity size, and systolic function are normal\n(LVEF>55%). A bileaflet aortic valve prosthesis is present. There is no\npericardial effusion.\n\n\n"},{"category":"Radiology","chartdate":"2117-01-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":856244,"text":" 7:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: CHRONIC PERICARDIAL\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p redo Bentall with bleeding from CT site on\n anticoagulation\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest compared to previous dated one day earlier.\n\n CLINICAL INDICATION: Bleeding from chest tube site.\n\n Cardiac and mediastinal contours appear slightly widened, but are stable in\n the postoperative. A right internal jugular sheath remains in place. No\n chest tube is identified. There is a moderate-sized left pleural effusion,\n which is slightly increased in size in the interval. A small right pleural\n effusion is unchanged. Retrocardiac opacities are slightly worsened in the\n interval.\n\n IMPRESSION:\n\n 1) Moderate left pleural effusion, slightly increased in the interval.\n Hemothorax cannot be excluded given history of anticoagulation and bleeding.\n\n 2) Persistent stable small right pleural effusion.\n\n\n"},{"category":"Radiology","chartdate":"2117-01-17 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":856408,"text":" 8:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change in effusion\n Admitting Diagnosis: CHRONIC PERICARDIAL\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48M s/p redo Bentall with bleeding from CT site on anticoagulation\n\n REASON FOR THIS EXAMINATION:\n interval change in effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 48-year-old man with bleeding from chest tube site, on\n anticoagulation, question interval change in effusion.\n\n AP portable chest at 8:45 a.m.: Compared to prior study one day\n earlier, there is an increase in the left-sided pleural effusion. Opacity at\n the right cardiophrenic angle is unchanged.\n\n\n"},{"category":"Radiology","chartdate":"2117-01-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":855813,"text":" 9:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: postop film\n Admitting Diagnosis: CHRONIC PERICARDIAL\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p redo Bentall\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 48-year-old status post surgery.\n\n AP portable study of the chest on at 21:52 hours.\n\n Comparison is made to prior study of . Since the prior study, there\n has been placement of an aortic valve. There are mediastinal and bilateral\n chest tubes in place. There is left lower lobe atelectasis. There are ET\n tube and NG tube, and the right IJ line in place.the Tip of the right IJ line\n is most likely in the right atrium.the Tip of the ET tube is 8 cm above the\n carina. Except for the atelectasis of the left lower lobe, the remainder of\n the lungs are clear. There is no evidence of pneumothoraces.\n\n IMPRESSION:\n\n Postoperative changes as described above. Left lower lobe atelectasis.\n Multiple lines and tubes in place.\n\n"},{"category":"Radiology","chartdate":"2117-01-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":856484,"text":" 10:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: CHRONIC PERICARDIAL\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48M s/p redo Bentall and pigtail placement\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post Bentall revision and pigtail catheter placement.\n Evaluate for pneumothorax.\n\n COMPARISON: .\n\n UPRIGHT AP CHEST: There has been interval placement of a pigtail catheter\n into the left lateral chest. No pneumothorax is detected. The opacity at the\n left base has decreased in the interim, consistent with some drainage of\n pleural fluid. Some opacity persists at the left base. The cardiac and\n mediastinal contours have not significantly changed compared to one day ago.\n The right cardiophrenic angle specifically is unchanged. The right lung and\n left upper lung are well aerated. Sternotomy wires and an aortic valve\n replacement are again noted.\n\n IMPRESSION:\n\n Interval pigtail catheter placement at the left lateral chest. Decreased left\n pleural effusion. No pneumothorax.\n\n"},{"category":"Radiology","chartdate":"2117-01-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":856113,"text":" 6:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ro pneumo\n Admitting Diagnosis: CHRONIC PERICARDIAL\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p redo Bentall\n\n REASON FOR THIS EXAMINATION:\n ro pneumo\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Status post Bental revision.\n\n COMPARISON: .\n\n UPRIGHT AP CHEST: The right internal jugular central venous catheter sheath\n remains in place, though the catheter itself has been removed. Median\n sternotomy wires and aortic valve replacement are again seen. No pneumothorax\n is detected. The right cardiac border appears somewhat prominent in\n comparison with prior preoperative exam. The finding may be related to\n postoperative change, though pericardial hematoma/effusion could be\n considered. The appearance of the lung fields is unchanged from yesterday.\n There are probably bilateral small pleural effusions layering posteriorly.\n\n IMPRESSION:\n\n 1. Right internal jugular catheter was removed, though the sheath remains in\n place. No pneumothorax detected.\n 2. Prominent right heart border. The finding may represent postoperative\n change, though pericardial hematoma/effusion could be considered.\n 3. Small bilateral pleural effusion.\n\n"},{"category":"Radiology","chartdate":"2117-01-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":856033,"text":" 11:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O PTX S/P CT'S REMOVED\n Admitting Diagnosis: CHRONIC PERICARDIAL\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p redo Bentall\n\n REASON FOR THIS EXAMINATION:\n R/O PTX S/P CT'S REMOVED\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post chest tube removal. Evaluate for pneumothorax.\n\n COMPARISON: .\n\n UPRIGHT AP CHEST: The patient has been extubated. The right internal jugular\n central venous catheter is again seen, with the tip overlying the right\n atrium. The left chest tube has been removed. No pneumothorax is detected.\n There is opacity at the left base, which may be related to a small left\n effusion with associated compressive atelectasis or rather an infiltrate. The\n right lung is well aerated.\n\n The patient is post-median sternotomy and aortic valve replacement. The old\n fracture of the right clavicle is again noted.\n\n IMPRESSION:\n\n Status post left chest tube removal, without pneumothorax detected. The right\n IJ line overlies the right atrium.\n\n\n"},{"category":"Radiology","chartdate":"2117-01-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":856356,"text":" 12:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion/infiltrate\n Admitting Diagnosis: CHRONIC PERICARDIAL\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48M s/p redo Bentall with bleeding from CT site on anticoagulation\n REASON FOR THIS EXAMINATION:\n eval for effusion/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 48-year-old man with bleeding from chest tube site, on\n anticoagulation. Please evaluate for effusion or infiltrate.\n\n AP PORTABLE UPRIGHT CHEST AT 1:00 P.M.: Comparison is made to study\n of one day earlier at 7:30 in the morning. There has been interval removal of\n the right internal jugular central line. The right retrocardiac opacity is\n slightly improved. No change in the left basilar opacity, which most likely\n is a combination of left pleural effusion and consolidation and/or\n atelectasis.\n\n IMPRESSION:\n\n Right IJ line has been removed. No pneumothorax. Improvement in the right\n basilar opacity. No change in the left basilar opacity and pleural effusion.\n\n\n"},{"category":"Radiology","chartdate":"2117-01-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":856600,"text":" 9:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: CHRONIC PERICARDIAL\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48M s/p redo Bentall and pigtail removal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 48-year-old status post pigtail removal. Evaluate for\n pneumothorax.\n\n FINDINGS:\n\n Comparison is made to the prior study of a day earlier. Some free\n intraperitoneal air is seen under the right hemidiaphragm. There is left\n lower lobe partial atelectasis. No evidence of pneumothoraces. The right\n lung is clear. The appearance of the lung fields have not changed since the\n prior study. Cardiomegaly and arteriosclerotic changes involving thoracic\n aorta as well as postoperative changes are again noted.\n\n IMPRESSION:\n\n Free intraperitoneal air under the right hemidiaphragm, which may be due to\n pigtail removal.\n\n Left lower lobe partial atelectasis is unchanged.\n\n No evidence of pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2117-01-21 00:00:00.000","description":"CHEST (PA & LAT)","row_id":856859,"text":" 11:34 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o ptx, eff\n Admitting Diagnosis: CHRONIC PERICARDIAL\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with known type 1 aortic dissection pre-op for aortic root and\n arch replacement.\n REASON FOR THIS EXAMINATION:\n r/o ptx, eff\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Known Type I aortic dissection. Preop for aortic root and arch\n replacement.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST: The appearance of the chest is unchanged compared to\n two days ago. The cardiac silhouette is unchanged from several prior\n postoperative exams. The mediastinal contours are also unchanged. There is\n no vascular congestion present. Retrocardiac opacity persists, obscuring the\n left hemidiaphragm. The left costophrenic angle remains blunted. The left\n upper lung and right lung are well-aerated. The findings at the left base may\n represent residual left pleural effusion and/or associated atelectasis,\n although an infiltrate cannot be excluded. Sternotomy wires and aortic valve\n replacement are again noted. No pneumothorax.\n\n The previously described free air beneath the right hemidiaphragm is not\n appreciated on today's study. Please correlate clinically.\n\n IMPRESSION:\n 1. Unchanged appearance of the chest compared to the last several exams. No\n evidence of failure. The retrocardiac opacity and blunting of the left\n costophrenic angle persist.\n 2. Free air under the right hemidiaphragm is not appreciated on the current\n study.\n\n"},{"category":"ECG","chartdate":"2117-01-12 00:00:00.000","description":"Report","row_id":150087,"text":"Probable sinus rhythm but consider also ectopic atrial rhythm. Modest diffuse\nST-T wave changes with ST segment elevation. Clinical correlation is suggested\nfor possible pericarditis. Since the previous tracing of ectopic atrial\nrhythm is suggested and further ST-T wave changes are present.\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-01-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1526192,\n \"text\": \"PATIENT DOING WELL THIS PM, HCT THIS AM 26 GIVEN 1UPRBC WITHOUT INCIDENT LASIX 40 MG GIVEN AFTERTRANSFUSION. POSTTRANSFUSION HCT 29.. PATIENT OOB TO PT DID WELL, STAYED IN CHAIR FOR APPROX. 3HRS THEN BACK TO BED.. HEPARIN HAD BEEN OFF FOR APPROX. 7HRS, RESTARTED BACK AT 1430 AT 1500U/HR, NO BOLUS GIVEN. PLAN TO GIVE 5MG COUMADIN PO THIS PM.. URINARY MEATUS OOZING LOTS OF CLOTS, TIL THIS PM, CLEANED SMALL AMT. OF BLOOD OOZING. RESP ON 6LNP WITH NONPRODUCTIVE COUGH, USING I/S WITH ENCOURAGEMENT. GU ADEQUATE U/O WITH LASIX, K 4.1 THIS PM TO BE REPLETED.. GI TOLERATING JELLO/CUSTARD /BOOST.. BS ELEVATED ON DRIP UP TO 7U/HR THEN DROPPED OFF, THEN BS AT 1300 130 GIVEN 4UNITS REGULAR SC.. ABD/STERNUM DSG D/I.. CORDIS DCD, ALINE KEPT IN FOR BLOOD DRAW. WIFE INTO VISIT THIS PM..ENCOURAGE ACTIVITY/ADLS...\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-01-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1526193,\n \"text\": \"ADDENUM PATIENT OOB TO CHAIR AT 1800 FOR DINNER ATE REALLY WELL TONIGHT, BS PRIOR TO EATING 152 6UNITS REGULAR SC GIVEN.. NEED TO CHECK K/PTT AT .. IF PATIENT ATTEMPTS TO WALK IN AM NEEDS BRACE/AND SHOES TO WALK\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-01-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1526194,\n \"text\": \"neuro: perla. alert and oriented. follows commands. right sided weakness from old cva.speech thick at times, but able to communicate well when he takes his time. pain well-controlled with percocet x2. slept well.\\nresp: o2 weaned to 4 l nc. sats 95-98%. lungs coarse and diminished lll. chest pt really helps him cough, but he swallows secretions. is raises 500-750cc. becomes sob with minimal exertion, but recovers quickly.\\ncv: nsr. sbp contolled with po agents, but iv hydralazine given x1 after ambulated back to bed for persistent sbp> 130s. afebrile. dp/pt pulses palp bilat. heparin drip at 1500 units/hour. ptt therapeutic.chest/med incision with scant serosang drainage. some oozing from around foley of sang drainage.\\ngu: good uop. some bloody drainage around foley.\\ngi: tol po well. good bowel sounds. blood sugars covered per protocol.\\nplan: ambulate with pt today with leg brace and shoes. ? transfer to II soon.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-01-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1526195,\n \"text\": \"Resp. care note - Pt. remaines on 50% tm, tol ok at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-01-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1526184,\n \"text\": \"RESP. CARE:\\n PT. PLACED ON VENT. ON ARRIVAL FROM O.R.--SIMV 650 X 14 100% 5P 5PS. FI02 QUICKLY WEANED TO 50%. BS- CLEAR AND = BILAT. NOW BEGINNING TO BREATH OVER SET RR. RSBI=63, DESPITE STILL BEING ON PROPAFOL. WEAN TO EXTUBATE WHEN AWAKENED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-01-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1526185,\n \"text\": \"pt arrived from Or around 2100 s/p ascending aortic repair, Bentall Procedure with #25mm St. Jude valve. Pt arrived on nitro , Epi and Propofol With FFP running.\\nNeuro: Pt remained sedated overnight on Propofol Starting to move slightly with stimulation.\\nResp: Fio2 weaned down to 50% with good po2. Will plan to wean to extubat this am after rounds. Suctioned for scant amount of white secretions.\\nC/V:vss pt switched from nitro to nipride for blod pressure control. Goal is 90-110 SBP. Pt presently on 0.75mcg nipride.\\nGood hemodynamics epi weaned off with Svo2 of 68-71% and CO of 6.1-6.9. Pt in sinus rhythm with occasional pvc's. all electrolytes treated as ordered. A wires do not work Vwires sense and capture. Chest tubes patent draining serous sangunious from pleural and dark sangunious from medistinal small amounts. Coags with in normal no treatment needed and hct stable at 28.\\nGI: OGT draining small amounts of thin bilious colored fluid.\\nEndo: pt started on insulin gtt for blood sugar 126 and titrated per protocol.\\nGU: pt diuresis large amounts of urine. He had received lasix in the or.\\nSkin: chest icision scant amount of drainage on dsg. left groin dsg intact.\\nPain: medicated morphine 2mg iv x3 for perceived pain\\nSocial: Wife and sons in to see pt last evening updated on condition.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-01-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1526186,\n \"text\": \"UPDATE\\nCV: NSR, RARE PVC ONLY. C.I. CONSISTENTLY >2.0; SWAN PULLED BACK TO CVP POSITION. PO LOPRESSOR STARTED BUT UNABLE TO WEAN SNP DRIP SIGNIFICANTLY SO LOPRESSOR DOSE INCREASED. SBP GOAL <110. L FEM A-LINE D/C'D IN A.M, SITE D&I. FEET W/ STRONG DISTAL PULSES. CT'S X 5 W/ SM AMTS DK SEROSANG DRNG.\\n\\nRESP: LUNGS MOSTLY CLEAR(SL COARSE L BASE). EXTUBATED 0930, NOW ON 4L NC O2 W/ SPO2 99%. PT HAS VERY WEAK, INEFFECTIVE AND NONPRODUCTIVE COUGH. STATES HE CAN'T DO ANY BETTER. DOES I.S. W/ VT'S TO 400ML.\\n\\nNEURO: A&O, COOPERATIVE. SEEMS DISCOURAGED DUE TO WEKNESS AND DISCOMFORT(MOSTLY W/ ACTIVITY). IV MSO4 GIVEN PRIOR TO ACTIVITY W/ MOD RELIEF. OOB TO CHAIR X 2 HRS, ASSIST OF 2. R LEG SL WEAKER THAN L BUT STOOD W/ MIN ASSIST. PT HAS NO CONTROL OVER R ARM WHICH REMAINS PERISTENTLY FLEXED-ABLE TO STRAIGHTEN IT MANUALLY.\\n\\nG.I.: OGT D/C'D W/ETT. TOL ICE CHIPS AND SIPS H2O.\\n\\nG.U./RENAL: ADEQ HUO VIA FOLEY. LYTES REPLETED PRN.\\n\\nSKIN: INTACT. SM AMT OLD SANG DRNG ON STERNAL DRSG.\\n\\nENDO: CONT ON INSULIN DRIP PER PROTOCOL.\\n\\nSOCIAL: PT W/ MANY VISITORS TODAY--PT NOW ASKING TO RESTRICT VISITORS TO WIFE AND CHILDREN ONLY. WIFE AWARE AND WILL NOTIFY OTHERS.\\n\\nA/P: NEEDS BETTER ANTIHYPERTENSIVE CONTROL TO FACILLITATE SNP WEAN. NEXT DOSE LOPRESSOR UP TO 50MG. GD OXYGENATION. CONT TO ENC I.S., C&DB. PAIN MED PRN FOR COMFORT. ADV DIET AND ACTIVITY AS TOL.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-01-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1526196,\n \"text\": \"ALTERED CARDIAC STATUS\\nS: \\\"I'M CHILLY\\\"\\nO: CARDIAC: SR 70'S WITH ISOLATED PAC/PVC NOTED. SBP TRANSIENT DROP TO 80'S AFTER 0900 LOPRESSOR. SBP 110'S-160'S THROUGHOUT THE DAY. DID NOT RECIEVE ANY HYDRALAZINE TODAY. 1720 NOTED SBP 80'S PT DENIED COMPLAINT NEO STARTED TO KEEP SBP > 90. ? PERICARDIAL EFFUSION, TO MONITOR SERIAL HCTS. EXTREMITIES WARM,PALP PP. HCT 31-28.9. DSGS D+I, NO DRAINAGE FROM CT DSG. 40 MEQ PO K X 1. OOB TO CHAIR AND AMB X 1 TO WITH ASSIST OF TWO.\\n RESP: NOTED INCREASED DOE WITH ANY EXERTION, PT DENIED INITIALLY HOWEVER ADMITTED TO DOE AS DAY PROGRESSED. P02 60'S. O2 VIA NP 6L WITH O2 SAT >95%. BS DIMINISHED BIBASILAR. CPT X 1 DID NOT TOLERATE 2ND ROUND OF CPT.+ LEFT PLEURAL EFFUSION. WEAK COUGH WITH STRONG ENCOURAGEMENT. COUGHING AND SWALLOWING. IS 250-500.\\n NEURO: UNCHANGED AS PER FLOW, PERL, RIGHT SIDED ARM MOVES ON BED, RIGHT LEG CAN LIFT AND FALL, STRONG LEFT GRASP AND LEG. OX3. THICK SLOW SPEECH AT TIMES.\\n GI: GOOD APPETITE, BOOST X 2. ABS SOFT, NONTENDER, + BOWEL SOUNDS, NO STOOL.\\n GU: GOOD UO\\n ENDO: SSI X2.\\n PAIN: PERCOCET 2 TABS X 2 WITH GOOD EFFECT\\n ID: TEMP 99.6 AX NOT REGISTERING ORALLY ABOVE 96.\\n SOCIAL: WIFE AND FAMILY INTO VISIT AND UPDATED.\\nA: REQUIRING NEO @ 1745, ? PERICARDIAL EFFUSION, + PLEURAL EFFUSION, SOBOE,\\nP: MONTIOR COMFORT, HR + RYTHYM, SBP -WEAN NEO AS TOLERATED, CT DRAINAGE, SERIAL HCT Q6HR, PP, RESP STATUS- PULM TOILET-MONITOR ABG, NEURO STATUS, I+O, LABS. AS PER ORDERS. TTE AT 1900.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-01-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1526197,\n \"text\": \"csru update\\ncvs: remained on NSR. isolated pvc's noted at times. neo continued, sbp 90-130mmhg.hydralazine not given.heparin dose adjusted down to 1400 units/hr, repeat PTT 0800hrs. TTE done, no pericardial effusion found. both pedal pulses palpable.\\n\\nresp: pleural effusion. remained on 6LO2/NC sao2 97%. dbe's and coughing done, no secretions expectorated. ABG ->PO2 102.\\n\\nneuro: moves left side with normal strength, right sided body weakness, right hand appears contracted. pearl. oriented. slept for long periods.\\n\\ngi: on insulin s/s. good oral fluid intake\\n\\ngu: adequate uo. lasix 40mg ix \\n\\npain: verbalized pain over left changed, constant, and continues even at rest. percocet x2 given with effect though mild pain still remains.\\n\\nplan: ?thoracotomy. continue pulmonary toilet. PTT checks, refer heparin adjustments. hemodynamic status monitoring\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-01-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1526201,\n \"text\": \"Neuro: alert and oriented x 3, mae, right sidded weakness, more weak with right upper extremity then right lower, following commands corrrectly, percocets for pain.\\n\\nCardiac: nsr in the 70-80's with rare pvc's, sbp's wnl's, palpible pedial pulses, skin warm dry and intact, +2 edema in extremities, afebrile, continues heparin gtt.\\n\\nResp: on 2 liters nc satting at 100%, lungs are clesr, ct to scn draining scant serosang with no air leak in ct system.\\n\\nSkin: chest with steris is cdi, old medial ct site are approximated and cdi, current ct site with transparent dsd that is cdi.\\n\\nGi/Gu: tolerating po's, abd soft round and nontender with good bowel sounds, is passing gas, on riss, making good u/o.\\n\\nPLan: increase activity as tolerates, encourage to cough and deep breath and use i/s, monitor ptt's.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-01-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1526187,\n \"text\": \"NEURO- PLEASANT,COOPERATIVE WITH CARE. QUIET PERSONALITY.ASSISTS WITH TURNING.RT ARM FLEXED/RIGID.FOLLOWS COMMANDS.\\n\\nCV- NSR.OCC.PVC. NIPRIDE @ 1 MCGKGMIN SBP < 120. NO DECREASE IN BP/HR AFTER 50MG PO LOPRESSSOR.AFEBRILE. PALP.PULSES.\\n\\nRESP- 3LNC=98%.LS CLEAR. DIM BASES. CT SCANT DRG.\\n\\nGI- ABS SOFT. + BS. TAKING PO MEDS.\\n\\nGU- ADEQ. HOURLY U/O.\\n\\nLABS- PENDING.\\n\\nENDO- INSULIN GTT @ 4U/HR WITH TIGHT GLUCOSSE CONTROL. GLUCOSE=105.\\n\\nPAIN- 1 PERCOCET PO WITH EFFECT.\\n\\nPLAN- WEAN NIPRIDE. INCREASE DIET/ACTIVITY AS TOL. ? DC CT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-01-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1526188,\n \"text\": \"7am-3pm update\\nneuro: pt alert and orieanted x3. able to follow commands. R arm contracted (from previous stroke)\\n\\nCV: pt remains in NSR, no ectopy noted. HR in the 60's. Nipride gtt titrated to keep SBP 90-120. pt started on vasotec this am. hydralazine prn for bp control. dp's palpable and pt's by doppler. epicardial wires dc'd. plan to start heparin gtt at 1500 and start coumadin this evening\\n\\nresp: LS clear with dim bases bil. pt on 4 LC nc, o2 sats 92-100%. pt using IS to 500. pt with weak cough. CT dc'd.\\n\\ngi/gu: pt with + bs. poor appetite. foley draining clear yellow urine. creatinine 1.5 this am (same as yesterday)\\n\\nendo: continues on insulin gtt and titrated per protocol\\n\\nplan: wean nipride gtt to keep sbp 90-120, pulm toleit, pain control, monitor lytes, start heparin gtt at 1500\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-01-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1526189,\n \"text\": \"csru update\\ncvs: nipride titrated to keep sbp 90-120. hydralazine not indicated as sbp mostly at 100-110mmhg, nipride at 0.5- 1. hr on NSR 70's no ectopics noted. slight elevation in temp ^37.8, medic aware, nothing ordered. palpable pedal pulses\\n\\nresp: advised coughing and dbe's, nothing expectorated. cpt done. managed up to 500 with IS. lung sounds dim at the bases\\n\\nneuro: right sided body weakness. oriented. slept adequately in the night\\n\\ngi: on insulin s/s. needs encouragement with diets and fluids. to have boost supp during lunch and dinner\\n\\ngu: foley dc'd awaiting to void. +bs\\n\\npain/soc: pain controlled, no analgesics taken. all procedures explained\\n\\nplan: pulmonary toilet. encourage ^diets. increase activity as tolerated\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-01-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1526190,\n \"text\": \"NEURO~A&OX3. FC. MAE. ABLE TO LIFT AND HOLD RIGHT HAND. MORPHINE AND PERCOCET FOR DISCOMFORT. EFFECTIVE. OOB TO CHAIR, GAIT STEADY. TOL WELL.\\n\\nRESP~ON 35% OFM, AND 4L NP. MAINTAINING SATS OF 97%. LUNGS COARSE UPPER DIM IN BASES VERY DIM IN RLL. NONPRODUCTIVE COUGH.\\n\\nCARDIAC~60'S-70'S W/ OCC PVC'S. HYPERTENSIVE. NIPRIDE OFF. HYDRALIZINE/LOPRESSOR FOR HTN. TO KEEP SBP<130. FOLLOW ALINE. CUFF SIG LOWER. HEPARIN @ 1300 UNITS/HR. REPEAT PTT @ . COUMADIN 5 MG PO. TRANSFUSED W/ 2 UNITS PRBC'S FOR HCT~24.9. POST HCT~30. POS PAL PEDAL PULSES BILAT.\\n\\nGI/GUTOL PO FLUIDS WELL. APPETITE POOR. REFUSING FOOD. UNABLE TO INSERT FOLEY THIS AM. BLOOD CLOT NOTED WHEN FOLEY DC'D. COUDE CATH INSERTED. HUGE BLOOD CLOT PASSED. URINE CLEAR AND CONT TO BE CLEAR. GIVEN 40 MG IV LASIX BETWEEN TRANS AND CONT W/ DOSE. + BS.\\n\\nENDO~INSULIN GTT. TITRATING TO MAINTAIN BG LEVEL W/IN CSRU PROTOCOL.\\n\\nA/P~LABILE BP. CURRENTLY CONTROLLED W/ ANTI HYPERTENSIVE REGIMEN.\\nAGGRESSIVE REHAB. CONT W/ POST OP TEACHING. ? REHAB PLACEMENT.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-01-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1526198,\n \"text\": \"ALTERED CARDIAC STATUS\\nS: \\\"I'M NOT GETTING UP YET\\\"\\nO: CARDIAC: SR 100-80'S, LOPRESSOR DECREASED TO -12 NOON LOPRESSOR HELD, LASIX DECREASED TO 20 MG , SBP REQUIRED NEO PRESENTLY OFF. INCISIONS C+D DSGS CHANGED. EXTREMITIES WARM , PALP PP. HYDRALAZINE NOT GIVEN DUE TO SBP <100. HCT STABLE AT 29. K +CA REPLACED.\\n RESP: OPEN FACE TENT @ 50% WITH PO2 IN THE 90'S, COUGH WITHOUT RAISING-PT STATES RAISED YELLOW -TO SEND FOR C+S IF PRODUCES AGAIN. O2 SAT PRESENTLY 96 ON 6LNP. RR 18-32.BS DIMINISHED BIBASILAR. CPT X 2.\\n NEURO: UNCHANGED PLEASE SEE FLOW. CALM PLEASANT, MORE ENGAGING TODAY.\\n SKIN: INTACT 2 PURPLE LINES NOTED ON BACK ? DUE TO PADS BEING ROLLED UNDER BACK-NO CHANGE FROM YESTERDAY. OOB TO CHAIR FOR 5 HOURS. AMBULATED TO TOLERATED MUCH BETTER THAN YESTERDAY.\\n GI: GOOD APPETITE, ABD SOFT,NONTENDER, + BOWEL SOUNDS, NO STOOL.\\n GU: GOOD UO TO RECIEVE LASIX DOSE @ 1815\\n ENDO: SSI X2\\n PAIN: 2 PERCOCET X2 WITH GOOD EFFECT,\\n ID: TEMP MAX AX 99.3 UA + C+S SENT\\n SOCIAL: WIFE AND CHILDREN INTO VISIT AND UPDATED\\nA: BETTER OXYGENATION WITH OPEN FACE TENT, AWAITING ? IR IN AM TO TAP EFFUSION TO CHECK CXR IN AM. TRANSIENT NEO\\nP: MONITOR COMFORT, HR AND RYTHYM, SBP-WEAN NEO AS TOLERATED, DSGS, PP, RESP STATUS-PO2/SATS-PULM TOILET, NEURO STATUS, I+O, LABS HCT Q6HR. AS PER ORDERS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-01-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1526199,\n \"text\": \"NEURO-QUIET,COOPERATIVE WITH CARE. BASELINE MOVEMENT OF EXTREMETIES.VOICING NEEDS.\\n\\nCV-NSR.SBP DECREASAED TO 98 AFTER TAKING HYDRALAZINE/LOPRESSOR .T-MAX=100.7-> 650MG TYLENOL PO.HEPARIN @ 1400U/HR PTT=54.9 HCT=27.9\\n\\nRESP-MOUTH BREATHER AT NOC. 50%OFM =98%. DIM RT BASE. NON-PRODUCTIVE COUGH.\\n\\nGI- ABD SOFT. + BS +FLATUS. TAKIING MEDS WITHOUT DIFFICULTY.\\n\\nGU- ADEQ. HOURLY U/O. RESPONDS WELL TO LASIX IV.\\n\\nLABS- GLUCOSE- 123,COVERED WITH 2UNITS REG. INS SC.\\n\\nPAIN-C/O STERNAL PAIN WITH MOVEMENT. 2 PERCOCET X2 WITH EFFECT.\\n\\nPLAN- AM CXR, IF PLEURAL EFFUSION LARGER,TO IR TO TAP IT. PAIN/RESP MNGMGNT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-01-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1526200,\n \"text\": \"NEURO: A+OX3, PLEASANT AND COOPERATIVE. BASELINE R SIDED WEAKNESS. GIVEN 2 PERCOCET TWICE FOR PAIN W/ GOOD EFFECT.\\n\\nCV: NSR 80'S. NO ECTOPY. STARTED ON ZESTRIL PO TODAY. SBP 88-92. PT ALSO HYDRALZINE AND PO LOPRESSOR.\\n\\nRESP: PT L PLEURAL CT W/ PIGTAIL DRAIN FROM NP. NO PROBLEMS. MEDICATED W/ 2 PERCS PRIOR TO. PT 590CC SERO SANG DRAINAGE IMMEDIATELY. OXEGENATION IMPROVED. PT WEANED TO 2L NP. MAINTAINING HIGH SPO2'S.\\n\\nGU: FOLEY PATENT. GOOD CLEAR YELLOW UOP.\\n\\nGI: SOFT NT ABD. + BS. GOOD APPETITE. 1 MED BRN FORMED BM TODAY.\\n\\nSKIN: L CT SITE CDI W/ TRANSPARANT DSD. CHEST AND L GROIN INCISION ARE CDI AND OTA W/ STERI STRIPS\\n\\nSOCIAL: FAMILY IN AT BEDSIDE.\\n\\nA/P IMPROVED RESP STATUS S/P CT. RECHECK PTT @ , START COUMADIN THISD PM, TO DECREASE HYDRALAZINE DOSE, CONTINUE CARE AS PLANNED. PREPARE FOR TRANSFER TO FLOOR TOMORROW.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-01-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1526191,\n \"text\": \"csru update\\ncvs: SB/NSR 58-60 rare pvc's noted k+ supp given. sbp 100-130 hydralazine,metoprolol. afebrile. palpable pedal pulses.\\n\\nresp: encouraged dbe's and coughing, nothing expectorated. cpt done. sao2 97-100%. coarse breath sounds on both upper lobes, dim on the bases.\\n\\nneuro: right sided body weakness. oriented. right hand unable to grasp or hold. right arm lifts and holds.\\n\\ngi: poor appetite. encouraged to take boost, took approx 80 mls. on insulin s/s\\n\\ngu: excessive uo. lasix 40 . +bs\\n\\nskin: mediastinal wound oozy, redressed. penile bleeding. pain controlled\\n\\nsoc: family visited and updated. all procedures explained to pt.\\n\\nplan: continue strict pulmonary hygiene. monitor v/s. assess and address dysrhythmias. ^ mobility. encourage ^ food intake\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2117-01-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 67846,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Tamponade.\\nBP (mm Hg): 121/53\\nHR (bpm): 65\\nStatus: Inpatient\\nDate/Time: at 20:26\\nTest: Portable TTE (Focused views)\\nDoppler: No doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\\n(LVEF>55%).\\n\\nRIGHT VENTRICLE: RV not well seen.\\n\\nAORTIC VALVE: BIleaflet aortic valve prosthesis (AVR).\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Left pleural effusion.\\n\\nConclusions:\\nLeft ventricular wall thickness, cavity size, and systolic function are normal\\n(LVEF>55%). A bileaflet aortic valve prosthesis is present. There is no\\npericardial effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-01-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 856244,\n \"text\": \" 7:39 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for effusion\\n Admitting Diagnosis: CHRONIC PERICARDIAL\\\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year old man s/p redo Bentall with bleeding from CT site on\\n anticoagulation\\n REASON FOR THIS EXAMINATION:\\n eval for effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n Portable chest compared to previous dated one day earlier.\\n\\n CLINICAL INDICATION: Bleeding from chest tube site.\\n\\n Cardiac and mediastinal contours appear slightly widened, but are stable in\\n the postoperative. A right internal jugular sheath remains in place. No\\n chest tube is identified. There is a moderate-sized left pleural effusion,\\n which is slightly increased in size in the interval. A small right pleural\\n effusion is unchanged. Retrocardiac opacities are slightly worsened in the\\n interval.\\n\\n IMPRESSION:\\n\\n 1) Moderate left pleural effusion, slightly increased in the interval.\\n Hemothorax cannot be excluded given history of anticoagulation and bleeding.\\n\\n 2) Persistent stable small right pleural effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-01-17 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 856408,\n \"text\": \" 8:44 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change in effusion\\n Admitting Diagnosis: CHRONIC PERICARDIAL\\\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48M s/p redo Bentall with bleeding from CT site on anticoagulation\\n\\n REASON FOR THIS EXAMINATION:\\n interval change in effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: A 48-year-old man with bleeding from chest tube site, on\\n anticoagulation, question interval change in effusion.\\n\\n AP portable chest at 8:45 a.m.: Compared to prior study one day\\n earlier, there is an increase in the left-sided pleural effusion. Opacity at\\n the right cardiophrenic angle is unchanged.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-01-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 855813,\n \"text\": \" 9:18 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: postop film\\n Admitting Diagnosis: CHRONIC PERICARDIAL\\\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year old man s/p redo Bentall\\n REASON FOR THIS EXAMINATION:\\n postop film\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: A 48-year-old status post surgery.\\n\\n AP portable study of the chest on at 21:52 hours.\\n\\n Comparison is made to prior study of . Since the prior study, there\\n has been placement of an aortic valve. There are mediastinal and bilateral\\n chest tubes in place. There is left lower lobe atelectasis. There are ET\\n tube and NG tube, and the right IJ line in place.the Tip of the right IJ line\\n is most likely in the right atrium.the Tip of the ET tube is 8 cm above the\\n carina. Except for the atelectasis of the left lower lobe, the remainder of\\n the lungs are clear. There is no evidence of pneumothoraces.\\n\\n IMPRESSION:\\n\\n Postoperative changes as described above. Left lower lobe atelectasis.\\n Multiple lines and tubes in place.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-01-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 856484,\n \"text\": \" 10:54 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o ptx\\n Admitting Diagnosis: CHRONIC PERICARDIAL\\\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48M s/p redo Bentall and pigtail placement\\n REASON FOR THIS EXAMINATION:\\n r/o ptx\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post Bentall revision and pigtail catheter placement.\\n Evaluate for pneumothorax.\\n\\n COMPARISON: .\\n\\n UPRIGHT AP CHEST: There has been interval placement of a pigtail catheter\\n into the left lateral chest. No pneumothorax is detected. The opacity at the\\n left base has decreased in the interim, consistent with some drainage of\\n pleural fluid. Some opacity persists at the left base. The cardiac and\\n mediastinal contours have not significantly changed compared to one day ago.\\n The right cardiophrenic angle specifically is unchanged. The right lung and\\n left upper lung are well aerated. Sternotomy wires and an aortic valve\\n replacement are again noted.\\n\\n IMPRESSION:\\n\\n Interval pigtail catheter placement at the left lateral chest. Decreased left\\n pleural effusion. No pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-01-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 856113,\n \"text\": \" 6:17 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ro pneumo\\n Admitting Diagnosis: CHRONIC PERICARDIAL\\\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year old man s/p redo Bentall\\n\\n REASON FOR THIS EXAMINATION:\\n ro pneumo\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n INDICATION: Status post Bental revision.\\n\\n COMPARISON: .\\n\\n UPRIGHT AP CHEST: The right internal jugular central venous catheter sheath\\n remains in place, though the catheter itself has been removed. Median\\n sternotomy wires and aortic valve replacement are again seen. No pneumothorax\\n is detected. The right cardiac border appears somewhat prominent in\\n comparison with prior preoperative exam. The finding may be related to\\n postoperative change, though pericardial hematoma/effusion could be\\n considered. The appearance of the lung fields is unchanged from yesterday.\\n There are probably bilateral small pleural effusions layering posteriorly.\\n\\n IMPRESSION:\\n\\n 1. Right internal jugular catheter was removed, though the sheath remains in\\n place. No pneumothorax detected.\\n 2. Prominent right heart border. The finding may represent postoperative\\n change, though pericardial hematoma/effusion could be considered.\\n 3. Small bilateral pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-01-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 856033,\n \"text\": \" 11:32 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: R/O PTX S/P CT'S REMOVED\\n Admitting Diagnosis: CHRONIC PERICARDIAL\\\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year old man s/p redo Bentall\\n\\n REASON FOR THIS EXAMINATION:\\n R/O PTX S/P CT'S REMOVED\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post chest tube removal. Evaluate for pneumothorax.\\n\\n COMPARISON: .\\n\\n UPRIGHT AP CHEST: The patient has been extubated. The right internal jugular\\n central venous catheter is again seen, with the tip overlying the right\\n atrium. The left chest tube has been removed. No pneumothorax is detected.\\n There is opacity at the left base, which may be related to a small left\\n effusion with associated compressive atelectasis or rather an infiltrate. The\\n right lung is well aerated.\\n\\n The patient is post-median sternotomy and aortic valve replacement. The old\\n fracture of the right clavicle is again noted.\\n\\n IMPRESSION:\\n\\n Status post left chest tube removal, without pneumothorax detected. The right\\n IJ line overlies the right atrium.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-01-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 856356,\n \"text\": \" 12:50 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for effusion/infiltrate\\n Admitting Diagnosis: CHRONIC PERICARDIAL\\\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48M s/p redo Bentall with bleeding from CT site on anticoagulation\\n REASON FOR THIS EXAMINATION:\\n eval for effusion/infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: A 48-year-old man with bleeding from chest tube site, on\\n anticoagulation. Please evaluate for effusion or infiltrate.\\n\\n AP PORTABLE UPRIGHT CHEST AT 1:00 P.M.: Comparison is made to study\\n of one day earlier at 7:30 in the morning. There has been interval removal of\\n the right internal jugular central line. The right retrocardiac opacity is\\n slightly improved. No change in the left basilar opacity, which most likely\\n is a combination of left pleural effusion and consolidation and/or\\n atelectasis.\\n\\n IMPRESSION:\\n\\n Right IJ line has been removed. No pneumothorax. Improvement in the right\\n basilar opacity. No change in the left basilar opacity and pleural effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-01-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 856600,\n \"text\": \" 9:29 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o ptx\\n Admitting Diagnosis: CHRONIC PERICARDIAL\\\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48M s/p redo Bentall and pigtail removal\\n REASON FOR THIS EXAMINATION:\\n r/o ptx\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: A 48-year-old status post pigtail removal. Evaluate for\\n pneumothorax.\\n\\n FINDINGS:\\n\\n Comparison is made to the prior study of a day earlier. Some free\\n intraperitoneal air is seen under the right hemidiaphragm. There is left\\n lower lobe partial atelectasis. No evidence of pneumothoraces. The right\\n lung is clear. The appearance of the lung fields have not changed since the\\n prior study. Cardiomegaly and arteriosclerotic changes involving thoracic\\n aorta as well as postoperative changes are again noted.\\n\\n IMPRESSION:\\n\\n Free intraperitoneal air under the right hemidiaphragm, which may be due to\\n pigtail removal.\\n\\n Left lower lobe partial atelectasis is unchanged.\\n\\n No evidence of pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-01-21 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 856859,\n \"text\": \" 11:34 AM\\n CHEST (PA & LAT) Clip # \\n Reason: r/o ptx, eff\\n Admitting Diagnosis: CHRONIC PERICARDIAL\\\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year old man with known type 1 aortic dissection pre-op for aortic root and\\n arch replacement.\\n REASON FOR THIS EXAMINATION:\\n r/o ptx, eff\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Known Type I aortic dissection. Preop for aortic root and arch\\n replacement.\\n\\n COMPARISON: .\\n\\n PA AND LATERAL CHEST: The appearance of the chest is unchanged compared to\\n two days ago. The cardiac silhouette is unchanged from several prior\\n postoperative exams. The mediastinal contours are also unchanged. There is\\n no vascular congestion present. Retrocardiac opacity persists, obscuring the\\n left hemidiaphragm. The left costophrenic angle remains blunted. The left\\n upper lung and right lung are well-aerated. The findings at the left base may\\n represent residual left pleural effusion and/or associated atelectasis,\\n although an infiltrate cannot be excluded. Sternotomy wires and aortic valve\\n replacement are again noted. No pneumothorax.\\n\\n The previously described free air beneath the right hemidiaphragm is not\\n appreciated on today's study. Please correlate clinically.\\n\\n IMPRESSION:\\n 1. Unchanged appearance of the chest compared to the last several exams. No\\n evidence of failure. The retrocardiac opacity and blunting of the left\\n costophrenic angle persist.\\n 2. Free air under the right hemidiaphragm is not appreciated on the current\\n study.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2117-01-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 150087,\n \"text\": \"Probable sinus rhythm but consider also ectopic atrial rhythm. Modest diffuse\\nST-T wave changes with ST segment elevation. Clinical correlation is suggested\\nfor possible pericarditis. Since the previous tracing of ectopic atrial\\nrhythm is suggested and further ST-T wave changes are present.\\n\\n\"\n }\n]"}}},{"rowIdx":24658,"cells":{"subject_id":{"kind":"number","value":6658,"string":"6,658"},"hadm_id":{"kind":"number","value":137737,"string":"137,737"},"target_text":{"kind":"string","value":"She was admitted to the Trauma Service. She was immediately taken to the operating room for exploratory laparotomy, LOA, splenectomy and small bowel resection. There were no intra-operative complications; she was taken to the Trauma ICU where she was monitored closely. She was eventually weaned and extubated and then transferred to the regular nursing unit. She did receive the appropriate vaccinations with the exception of the meningococcal as this was not available in the hospital pharmacy; she will need to follow up with her primary care physician to receive the final of the three vaccinations that are required post splenectomy. She continued to require supplemental oxygen postoperatively; reportedly she had oxygen requirements in the past from a previous surgery and was discharged to home with this and ultimately was weaned off. She was diuresed with Lasix as well with improvement in her respiratory status. She will be discharged home with oxygen therapy. She also developed a distal abdominal wound cellulitis and is being discharged home on 10 days Keflex. Physical and Occupational therapy worked with her and have recommended home with services."},"extractive_notes_summ":{"kind":"string","value":"No BM.GU - Adequate UOP via foley.Endo - RISS, blood sugars trending down.A - Stable neuro exam. Shortness of breath.Height: (in) 63Weight (lb): 240BSA (m2): 2.09 m2BP (mm Hg): 118/62HR (bpm): 93Status: InpatientDate/Time: at 16:11Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). Pt had clear though slightly diminished BS bilaterally post extubation. LS clear and diminished at bases. Resolved with ambu, lavage and suctioning. Mildlydilated ascending aorta. addendum: pt phosphorou level low.. neutrophos ordered po. MSO4 prn abd pain with effect.RESP: LS CTA and diminished. BP 100s-140s/40s-70s.HEME: Given 2u PRBC's for hct 21.2; post transfusion hct 28.6.GI: Abd obese, bowel sounds hypoactive. Peripheral pulses intact.Resp - Tolerating vent settings on propofol. ID - pt low temps PO, but normal axillary. Inhalers as ordered and prn for intermittent wheezing.GI/GU: Abd. R IJ TLC line intact.OTHER: Possible d/c to floor today. Normal regional LV systolic function. The mitral valve appears structurally normal with trivialmitral regurgitation. Right ventricular chamber size and free wall motion arenormal. Lytes repleted (awaiting order for phos repletion).ID: Afebrile. Pboots on.GI: Abd obese, bowel sounds absent.GU: Low u/o at same time of hypotension which was resolved with 500cc bolus. There is an anteriorspace which most likely represents a fat pad, though a loculated anteriorpericardial effusion cannot be excluded.IMPRESSION: Normal global and regional biventricular systolic function. Abx course completed.ENDO: FS covered per RISS.SKIN: Back/buttocks with no breakdown noted. Clear lung sounds in upper lobes, diminished in bases, coughs and clears, pt using suction to clear mouth. Improved moderately since transfusion.CV: HR 80s-100s SR/ST, no ectopy noted. She alert to lethagic but easily arousable and oriented x3, mae, fc, pupils pinptresp pt with discordiant breathing all shift lungs crackles 3/4 up on right and coarse and diminished lt abg on 4lnp 7.31/55/114/0/29 cxr taken relatively unchanged from earlier in the day. cv: hr to 102 st no ectopy. No abx.ENDO: FS covered per RISS.SKIN: Grossly intact, no breakdown noted.SOCIAL: Multiple family members in today and supportive.ASSESSMENT: Pt s/p MVC with spenelctomy and .Current nsg issues:Fluid volume overload leading to DOE.Pain.Anemia.PLAN: Cont to monitor vs, labs with serial hcts, lasix gtt as ordered, replete lytes, analgesia, encourage moblity, encourage C+DB. BS essentially clear, but decreased in the bases. Generalized + edema. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.Conclusions:The left atrium is normal in size. Reaches for ETT with BUE when unrestrainted. Antibiotics finished peri-op. sbp 92-117/gi: tolerating clear liquids. ABG with slight metabolic acidosis. Repeat abg at 0500 on 2lnp 7.34/54/90/1/30cvs HR 103-114 given lopressor 5mg iv q 6hr bp 124/55-140/55 hct 21.9/22 color white, cpk drawn 650 mb 5 troponin <.01 ekg taken cvp 20gi abd obese bs absent staples in place no drainagegu u/o >30 bun 10 cr .7 on lasix presently at 4mg q hr + > 6liters losendo requiring ss insulinskin ecchymotic lt arm and rt lega. The cardiac silhouette, mediastinal and hilar contours appear unchanged.N o evidence of pneumothorax. There is a mildly tortuous atherosclerotic aorta. AP pelvis with overlying trauma board demonstrates only mild demineralization. Mild degenerative changes are noted, particularly at the C3/4 level without thecal sac compression. There is probable mild cardiomegaly with an unfolded aorta. However, there does appear to be a focus of periosteal reaction and cortical lucency seen along the proximal fibular shaft, incompletely visualized. Right hilar atelectasis. Repeat HCT sent.A - Resp status stable. There is probable diffuse osteopenia. The pleural parenchymal findings are unchanged. Equivocal minimal blunting of the costophrenic angles, doubt gross effusion. Mild degenerative changes throughout. Calcification of the abdominal aorta without evidence of aneurysmal dilatation. Edema difficult to assess.Resp - Lungs essentially clear, occ wheezing, dim in bases. Right IJ central line tip over mid/distal SVC. Persistent bibasilar atelectasis with left-sided small pleural effusion. Occ dyspneic with exertion. Somewhat wide appearance to the mid mediastinum appears to be related to uncoiling of the thoracic aorta and slight rotation of the patient to the right. Persistent bibasilar atelectasis, with possible small left-sided pleural effusion. Mild prominence of right paratracheal soft tissues likely reflects vascular structures in someone of this age. IMPRESSION: Interval placement of ET tube in satisfactory position. Right IJ approach central venous catheter is unchanged with its tip projecting over the SVC. Peripheral pulses palpable. therefore it is solid and not a terminal meningeal cyst). There is mild circumferential maxillary mucosal thickening without air-fluid levels. There is a small fluid levels within the sphenoid sinuses without evidence of displaced fracture, which may relate to intubation and supine positioning. Albuterol nebs PRN. Mild degenerative change of the left hip is seen. FINDINGS: There is normal alignment of the lumbar vertebral bodies without evidence of fracture or traumatic listhesis. MAE.CV - NSR, rate 90s without ectopy. The tip overlies the mid/distal SVC. Tender to palpation at incision. Mild bibasilar atelectasis is worsened. IMPRESSION: Underlying emphysema with no acute pulmonary process. Note is again made of prominent radiodensity of the right hilum. The left costophrenic angle is mildly blunted, may represent small pleural effusions. Endotracheal and nasogastric tubes limit the evaluation of prevertebral soft tissue swelling. Interval removal of the ET and NG tubes. Again seen are the ET and NG tubes. IMPRESSION: 1) No acute fracture or malalignment. IMPRESSION: 1) No acute fracture or malalignment. The mediastinum is within normal limits allowing for technique. TECHNIQUE: Axial MDCT images through the lumbosacral spine without IV contrast with coronal and sagittal reformats. Stable appearance of the right IJ-approach central venous catheter with its tip projecting over the SVC. FINDINGS: Since the prior examination, patient has been extubated and the NG tube has been removed. Persistent bibasilar atelectasis. Heart size top normal. No superimposed edema is appreciated. The soft tissues are within normal limits. CHEST, SINGLE AP VIEW. CHEST, SINGLE AP VIEW. IMPRESSION: No significant interval changes."},"n_notes":{"kind":"number","value":32,"string":"32"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2123-10-19 00:00:00.000","description":"Report","row_id":82620,"text":"PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Shortness of breath.\nHeight: (in) 63\nWeight (lb): 240\nBSA (m2): 2.09 m2\nBP (mm Hg): 118/62\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 16:11\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta. No 2D or\nDoppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%), without regional wall\nmotion abnormalitiesl. Right ventricular chamber size and free wall motion are\nnormal. The ascending aorta is mildly dilated. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion and no aortic\nregurgitation. The mitral valve appears structurally normal with trivial\nmitral regurgitation. There is no mitral valve prolapse. There is an anterior\nspace which most likely represents a fat pad, though a loculated anterior\npericardial effusion cannot be excluded.\n\nIMPRESSION: Normal global and regional biventricular systolic function. Mildly\ndilated ascending aorta.\n\n\n"},{"category":"Nursing/other","chartdate":"2123-10-17 00:00:00.000","description":"Report","row_id":1349963,"text":"TSICU Nursing Progress Note\nNeuro - Pt arouses to voice, nodds to questions, mouthing words at times. PERRL. MAE. C-collar and logroll precautions maintained.\n\nCV - NSR to ST without ectopy. MBP maintained above 65 with fluid boluses when needed. Lactate trending down. Peripheral pulses intact.\n\nResp - Tolerating vent settings on propofol. Not breathing over vent most of shift. ABG WNL. Minimal secretions.\n\nGI - Abdomen soft, tender. Dressing D&I. OR dressing intact. Absent BS. No BM.\n\nGU - Adequate UOP via foley.\n\nEndo - RISS, blood sugars trending down.\n\nA - Stable neuro exam. Metabolic acidosis improving.\n\nP - Awaiting orders for radiology. Clear back when able. Wean vent as tolerated.\n"},{"category":"Nursing/other","chartdate":"2123-10-17 00:00:00.000","description":"Report","row_id":1349964,"text":"Respiratory Care Note\nPt received on AC as noted with no changes this shift. BS essentially clear, but decreased in the bases. Atrovent MDI given with no change in BS. ABG's had been metabolically acidotic earlier this shift, but are now within normal limits. Plan to continue on current settings at this time.\n"},{"category":"Nursing/other","chartdate":"2123-10-18 00:00:00.000","description":"Report","row_id":1349965,"text":"NPN 1900-0700\nNEURO: Pt sedated on propofol. When lightened follows commands and MAE. Communicates via nodding. Pt requring 2-4mg MSO4 for abd pain q 2-3 hrs; dose increased this AM. CT of neck, T and L spine done. Xray of left shoulder and RLE done.\n\nRESP: No vent changes made. Pt had one episode where sats decreased to 88-89% after turning. Resolved with ambu, lavage and suctioning. ABG WNL.\n\nCV: HR 60s-90s NSR no ectopy noted. 500LR bolus x 1 for MAP below 60 and decreasing CVP. Goal is MAP greater than or equal to 65.\n\nHEME: Hct 23 from 25. Sq heparin cont. Pboots on.\n\nGI: Abd obese, bowel sounds absent.\n\nGU: Low u/o at same time of hypotension which was resolved with 500cc bolus. AM lytes WNL.\n\nID: Afebrile. Abx course completed.\n\nENDO: FS covered per RISS.\n\nSKIN: Back/buttocks with no breakdown noted. Ecchymosis to left scapula and right thigh.\n\nSOCIAL: No contacts from family this shift.\n\nASSESSMENT: Pt s/p MVC, splenectomy and .\n\nCurrent nsg issues:\nBP alteration requiring fluid boluses.\nPain.\n\nPLAN: Cont to monitor VS, maintain BP as per orders, monitor labs and hct trends, pain management, ?wean sedation and vent if TLS cleared today.\n\n\n"},{"category":"Nursing/other","chartdate":"2123-10-18 00:00:00.000","description":"Report","row_id":1349966,"text":"Resp: pt on a/c 18/550/+5/40%. Alarms on and functioning. Ambu/syringe @ hob. BS are diminished bilaterally. Suctioned for small amounts of thick secretions. MDI's administered 2P Atr with no adverse reactions. Trip to CT without incident, with results pending. AM ABG 7.40/41/75/26 with no changes noc. RSBI=no resps. Will continue full vent support.\n"},{"category":"Nursing/other","chartdate":"2123-10-18 00:00:00.000","description":"Report","row_id":1349967,"text":"T-SICU Nsg Note\n Events - C-spine cleared, collar off\n TLS spine cleared, pt sitting\n Vent weaned to 5 CPAP and then extubated at 0910\n\nROS - Neuro - pt alert, O x 3 (after she asked what day it was), moving all limbs. Pain all over, but especially L chest (due to rib fx)\n\nNote to continue\n"},{"category":"Nursing/other","chartdate":"2123-10-18 00:00:00.000","description":"Report","row_id":1349968,"text":"Resp Care\nPt extubated this morning to 50% cool aerosol. Pt orally suctioned prior to extubation for mod amt of bloody secretions, no secretions noted down ETT. Pt had audible cuff leak. Pt had clear though slightly diminished BS bilaterally post extubation.\n"},{"category":"Nursing/other","chartdate":"2123-10-21 00:00:00.000","description":"Report","row_id":1349975,"text":"TSICU NPN:\nNEURO: A&Ox3. Pleasant and cooperative. MAE. PERL 3mm and brisk. Complaining of incisional pain and L shoulder pain- given 4mg sq MSO4 with good effect.\nCV: Afeb. HR 80s-100s SR/ST, no ectopy noted. On lopressor IV q6hr. BP stable via NIBP cuff on L forearm. CVP 7-9. Skin warm and dry with palpable pedal pulses bilaterally. Generalized + edema. Lasix gtt d/c'd and continues on acetazolamide po bid.\nRESP: Continues on 3L NC with O2 Sat >95%. LS clear and diminished at bases. Intermittent cough. Pt. +DOE but sats stable. Inhalers as ordered and prn for intermittent wheezing.\nGI/GU: Abd. obese, soft with hypoactive bowel sounds. Tolerating clear liquid diet, no nausea. Foley draining clear light yellow urine >100cc/hr.\nSKIN: Midline abd. incision with staples, clean, dry and intact- open to air. No swelling or drainage. Ecchymosis to L upper arm/shoulder and R upper thigh. Coccyx and backside intact. R IJ TLC line intact.\nOTHER: Possible d/c to floor today.\n"},{"category":"Nursing/other","chartdate":"2123-10-21 00:00:00.000","description":"Report","row_id":1349976,"text":"NURSING NOTE 7AM TO 1PM\nPATIENT STABLE AND TRANSFERED TO 915, TRANSFER NOTE FAXED AND SENT. REPORT GIVEN VERBALLY TO . PATIENT SENT WITH DENTURES NO OTHER PERSONAL ITEMS WITH PATINET AT HOSPITAL.\n"},{"category":"Nursing/other","chartdate":"2123-10-18 00:00:00.000","description":"Report","row_id":1349969,"text":"T-SICU NSg note cont.\n Medicated for pain with 2mg morphine sulfate IVP with some relief and dozing. Pt has grimace on face even while asleep.\n CV - NSR 90's- to sinus tach 125. BP 125-145sys and MAP maintained > 65. On metoprolol 5mg IVP q 6 hrs. Pt on lisinopril at home.\n Resp - resp rate slow, . Clear lung sounds in upper lobes, diminished in bases, coughs and clears, pt using suction to clear mouth. O2 sats on 4 l NC 90-97%, sats drifted down this am to 86%, and face tent with cool neb added at times - pt does not like face tent and has not needed it this eve.\n GU - lasix drip started. K+ repleted, and last level 4.6 Pt is still net positive for today, discuss with HO about increasing lasix drip rate.\n GI - pt has tolerated ice chips and sips of water. Abd obese, hypoactive bowel sounds heard this eve. Abd incision clean Dry & closed with staples.\n Heme - Hct down to 22 this eve despite some diuresis. REcheck Hct at MN. Pt pale.\n ID - pt low temps PO, but normal axillary. Antibiotics finished peri-op.\n Endo - sliding scale insulin for blood glucose 125 to 180.\nA: O2 sats have improved this eve. Pt sore and uncomfortable. Pt's daughters in to visit today. Pt alert and articulating needs.\nP: Check Hct at 00. monitor u/o and lytes. Informational support to pt & family.\n"},{"category":"Nursing/other","chartdate":"2123-10-19 00:00:00.000","description":"Report","row_id":1349970,"text":"c/o of pain especially left upper quadrant and arm. Denies cp, dizziness, sob\no. Neuro medicated morphine 4mg iv x3 with good relief pt needing less pain med as night went on. She alert to lethagic but easily arousable and oriented x3, mae, fc, pupils pinpt\nresp pt with discordiant breathing all shift lungs crackles 3/4 up on right and coarse and diminished lt abg on 4lnp 7.31/55/114/0/29 cxr taken relatively unchanged from earlier in the day. Lasix increased to 4mg IV qhr, pt given albuteral and atrovent nebs wheezing with exertion. Repeat abg at 0500 on 2lnp 7.34/54/90/1/30\ncvs HR 103-114 given lopressor 5mg iv q 6hr bp 124/55-140/55 hct 21.9/22 color white, cpk drawn 650 mb 5 troponin <.01 ekg taken cvp 20\ngi abd obese bs absent staples in place no drainage\ngu u/o >30 bun 10 cr .7 on lasix presently at 4mg q hr + > 6liters los\nendo requiring ss insulin\nskin ecchymotic lt arm and rt leg\na. fluid overload, anemic tachycardic\np. continuing lasix goal neg 500-1liter monitor lytes replete prn, cr bun, ? pt benefit from 1-2uprbc given her age, +obesity, +HTN, monitor hcts, nebs prn, medicate for pain prn, encourage incentive spironmeter, cdb\n\n"},{"category":"Nursing/other","chartdate":"2123-10-17 00:00:00.000","description":"Report","row_id":1349961,"text":"Resp: pt intubated via OR Ett 7.0 retaped and secured 19 @ lip. Place on a/c 18/550/+5/50%. Alarms on and functioning. Ambu/syringe @ hob. Bs are coarse bilaterally. Suctioned for small to moderate amounts of thick tan secretions. MDI's administered as ordered 2P Atr with no adverse reactions. Vent changes to decrease fio2 to 40%. AM ABG 7.28/41/107/20. No further changes noted. Will continue full vent support.\n"},{"category":"Nursing/other","chartdate":"2123-10-17 00:00:00.000","description":"Report","row_id":1349962,"text":"NPN 0100-0700\n77 yo restrained passenger involved in MVC, car T-boned on driver's side. Pt went to hospital in where CT showed free fluid in abd and suspected splenic lac. Trans to and taken to OR for ex lap...resulted in splenectomy and (pt was intubated in OR at ). Pt also has left rib fx's, large area of ecchymosis to right scapula and right thigh. Initial head CT neg.\n\nNEURO: Pt intubated and sedated on propofol. When lightened, pt follows all commands and MAE. Reaches for ETT with BUE when unrestrainted. MSO4 prn abd pain with effect.\n\nRESP: LS CTA and diminished. Vented on assist control 550 x 14 5peep 50%, overbreaths 4-6 breaths. ABG with slight metabolic acidosis. Sats WNL.\n\nCV: HR 80s-100s SR/ST no ectopy noted. Arrived hypotensive with BP 80s/40s, however has responded to blood and IVF. Goal MAP > 60.\n\nHEME: Hct 29.8 from 24.7 after 1u PRBC's. Sq heparin to start this afternoon if hct stable.\n\nGI: Abd obese, OGT to LCS with thick brown output.\n\nGU: Adequate u/o via foley. Lytes repleted (awaiting order for phos repletion).\n\nID: Afebrile. On kefzol/flagyl x 3 doses.\n\nENDO: FS covered per RISS.\n\nSOCIAL: Daughter and son post op and updated on condition.\n\nASSESSMENT: Pt s/p MVC, splenectomy and .\n\nPLAN: Cont to monitor vs, pain management, correct lytes, serial hct's, wean sedation/vent as tol.\n"},{"category":"Nursing/other","chartdate":"2123-10-19 00:00:00.000","description":"Report","row_id":1349971,"text":"NPN 0700-1900\nNEURO: Pt A+Ox3, lethargic at times (possibly d/t anemia). MAE and follows commands. MSO4 for pain with effect. OOB to chair today x 2hrs.\n\nRESP: LS with coarse crackles to right side halfway up. Left side coarse and diminished. Sats 94-98% on 4LNC; desaturates to high 80s without O2. Prior to blood transfusion, breathing was quite discoordinate, and pt appeared to have increased amount of abd breathing. Pt had significant DOE and SOB with talking. Improved moderately since transfusion.\n\nCV: HR 80s-100s SR/ST, no ectopy noted. BP 100s-140s/40s-70s.\n\nHEME: Given 2u PRBC's for hct 21.2; post transfusion hct 28.6.\n\nGI: Abd obese, bowel sounds hypoactive. Tolerating clear liquids without N/V.\n\nGU: Lasix gtt on 4mg/hr for most of day. Pt is currently 1600cc neg; goal is 1-2L neg for 24hr. Gtt decreased to 1mg/hr at 1600. K+ repleted. PM lytes pending.\n\nID: Afebrile. No abx.\n\nENDO: FS covered per RISS.\n\nSKIN: Grossly intact, no breakdown noted.\n\nSOCIAL: Multiple family members in today and supportive.\n\nASSESSMENT: Pt s/p MVC with spenelctomy and .\n\nCurrent nsg issues:\nFluid volume overload leading to DOE.\nPain.\nAnemia.\n\nPLAN: Cont to monitor vs, labs with serial hcts, lasix gtt as ordered, replete lytes, analgesia, encourage moblity, encourage C+DB.\n"},{"category":"Nursing/other","chartdate":"2123-10-20 00:00:00.000","description":"Report","row_id":1349972,"text":"addendum: pt phosphorou level low.. neutrophos ordered po. pt took phosphorous but immediately developed nausea and vomited a small amount. anzimet 12.5 mg given iv with good effect.ho notified that pat unable to tolerated po phosphorous.\n"},{"category":"Nursing/other","chartdate":"2123-10-20 00:00:00.000","description":"Report","row_id":1349973,"text":"cv: hr to 102 st no ectopy. pt on lopressor 10 mg iv Q6 hours. hr decreased to 81 after dose of lopressor iv. sbp 92-117/\n\ngi: tolerating clear liquids. abdomen obese. bowel sounds present but hypoactive. abd incision clean open to air. staples intact.\n\ngu: foley draining clear yellow urine. fluid balance goal attained negative ~ 2 liters. lasix drip infusing at 1 mg/hr..uo dropped off to 20 cc/hr at 0100 so lasix drip increased to 2 mg/hr. uo improved at 50-65 cc/hr.\n\nresp: albuterol nebs given at 2400 and again at 0400. while encourageing pt to do IS pt stated that she always takes a breathing tx at home.pt states she has a nebulizer machine at her home and that she takes a treatment 3-4 times per day and this worked much better for her than the inhalers. At 0400 pt sats decreased to 90 and pt found with expiratory wheezes in bilateral upper lobes and diminished lower lobes. wheezing dissipated after treatment and stas back to baseline 97-100 % on liters nc.\n\nmental status: alert and oriented,calm and cooperative.\n\nendo: blood sugars q 6 hours covered with ss. bs 126 at 0200 treated with 2 reg.\n\npain: pt complaining of generalized pain. pain in l shoulder and arm when turning to that side. Pain in abdomen . morphine given sc 8mg at . pt reported being comfortable. some discomfort at 2300 reported so another 8 mg sc injection given. resp rate decreasing to 6... pt sleeping.when pt awakened by this rn resp rate increased to 8- 12.\n\nlabs: K= 3.9 kcl 20 meq f/u k = 4.1. hct checked serially at and 0200... 25 and 25.6\n\nintegumentary: abdominal incision intact. staples intact. incision clean and open to air. ecchymosis of upper left arm and shoulder. ecchymosis of upper r thigh.\n\nasessment: improved ventilation with albuterol nebs.\n improved pain control with sc morphine.\n\nplan: will give smaller dose of morphine sc next injection. will try 6 mg sc to avoid respiratory depression .\nmonitor urine ouput and notify ho of decrease in urine to adjust lasix drip according ly.\ngive albuterol nebs q 6 hours and encourage IS and coughing and deep breathing.\nmonitor hct. check with ho to regarding frequency of serial hct to be drawn.\nmonitor lytes esp K whil on lasix drip. q 6 hr glucose and ss coverage\n"},{"category":"Nursing/other","chartdate":"2123-10-20 00:00:00.000","description":"Report","row_id":1349974,"text":"TSICU Nursing Progress Note\nNeuro - Pt x3. Conversing appropriately, able to make needs known. MAE.\n\nCV - NSR, rate 90s without ectopy. SBP 110s by cuff on forearm. Peripheral pulses palpable. Edema difficult to assess.\n\nResp - Lungs essentially clear, occ wheezing, dim in bases. Occ dyspneic with exertion. O2 sat >95% on 3 L NC. Albuterol nebs PRN. Strong cough with encouragement.\n\nGI - Abdomen obese, soft, hypoactive BS. Tender to palpation at incision. Tolerating sips of water and ice chips. No BM.\n\nGU - Brisk UOP on furosemide gtt with acetazolamide. Lasix gtt down to 1 mg/hr.\n\nEndo - No RISS coverage needed.\n\nHeme - 1 unit PRBC for HCT 25. Repeat HCT sent.\n\nA - Resp status stable. Tolerating clears.\n\nP - Continue to monitor resp status. Pulm toilet. Advance diet as tolerated. Consider tx to floor in AM.\n"},{"category":"ECG","chartdate":"2123-10-19 00:00:00.000","description":"Report","row_id":199725,"text":"Sinus tachycardia\nNormal ECG except for rate\nSince previous tracing, limb lead voltage increased, and T wave abnormalities\nless\n\n"},{"category":"ECG","chartdate":"2123-10-18 00:00:00.000","description":"Report","row_id":199726,"text":"Sinus tachycardia\nLow limb lead voltage\nT wave abnormalities\nClinical correlation is suggested\n\n"},{"category":"Radiology","chartdate":"2123-10-17 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":928171,"text":" 9:38 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval for Line placement, PTX\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p MVC, s/p splenectomy, s/p SB resection, new Right IJ\n placed\n REASON FOR THIS EXAMINATION:\n eval for Line placement, PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post MVC, splenectomy, small bowel resection, new right IJ\n placed. Evaluate line.\n\n CHEST, SINGLE AP VIEW.\n\n Compared with earlier the same day, a right IJ central line has been placed.\n The tip overlies the mid/distal SVC. No pneumothorax is identified. Again\n seen are the ET and NG tubes. The pleural parenchymal findings are unchanged.\n\n IMPRESSION:\n 1. Right IJ central line tip over mid/distal SVC. No pneumothorax detected.\n 2. NG tube -- side-port lies in region of GE junction. Clinical correlation\n is requested.\n\n"},{"category":"Radiology","chartdate":"2123-10-16 00:00:00.000","description":"TRAUMA #2 (AP CXR & PELVIS PORT)","row_id":928142,"text":" 9:19 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma; no further clinical history provided.\n\n TRAUMA TWO SERIES:\n\n AP chest radiograph with overlying trauma board demonstrates no pneumothorax\n or fracture. The mediastinum is within normal limits allowing for technique.\n Heart size is normal allowing for technique. The aortic arch is sharp. Lungs\n are grossly clear.\n\n AP pelvis with overlying trauma board demonstrates only mild demineralization.\n No acute fracture or dislocation, though its poor image contrast somewhat\n limits sensitivity. The lower lumbosacral spine and sacrum are not well\n visualized.\n\n IMPRESSION: No evidence of traumatic injury. Suboptimal assessment of the\n sacrum and lower lumbosacral spine.\n\n\n"},{"category":"Radiology","chartdate":"2123-10-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":928387,"text":" 3:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pulmonary edema\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p MVC, s/p splenectomy, s/p SB resection placed\n\n REASON FOR THIS EXAMINATION:\n r/o pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 77-year-old woman status post MVC, splenectomy, and small bowel\n resection.\n\n COMPARISON: .\n\n FINDINGS: Since the prior examination, there has been no significant interval\n changes. Persistent bibasilar atelectasis with left-sided small pleural\n effusion. Right IJ approach central venous catheter is unchanged with its tip\n projecting over the SVC. No evidence of pneumothorax.\n\n IMPRESSION: No significant interval changes.\n\n"},{"category":"Radiology","chartdate":"2123-10-17 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":928147,"text":" 1:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p intubation\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p intubation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post intubation.\n\n CHEST, SINGLE AP VIEW.\n No previous chest x-rays on PACS record for comparison. (Trauma film only).\n\n An ET tube has been placed, tip in satisfactory position approximately 3.5 cm\n above the carina. An NG tube is present, tip overlying gastric fundus. The\n sideport lies in the expected region of the GE junction. No CHF or focal\n infiltrate is identified. There is bibasilar atelectasis. Equivocal minimal\n blunting of the costophrenic angles, doubt gross effusion. Mild prominence of\n right paratracheal soft tissues likely reflects vascular structures in someone\n of this age. There is probable mild cardiomegaly with an unfolded aorta.\n Skin staples noted over upper abdomen in the midline.\n\n IMPRESSION: Interval placement of ET tube in satisfactory position. NG tube\n with sideport in region of GE junction. Clinical correlation requested.\n Bibasilar atelectasis.\n\n"},{"category":"Radiology","chartdate":"2123-10-18 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":928218,"text":" 12:01 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for fracture\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p MVC intubated sedated s/p splenectomy\n REASON FOR THIS EXAMINATION:\n eval for fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DJD MON 1:50 AM\n No fracture or malalignment\n Mild . changes\n MD\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old status post MVC, sedated status post splenectomy,\n evaluate for fracture.\n\n COMPARISONS: None.\n\n TECHNIQUE: Axial MDCT images of the cervical spine with coronal and sagittal\n reformats.\n\n FINDINGS: C1 through the superior endplate of T2 are well visualized. There\n is no evidence of acute fracture or traumatic listhesis. Mild degenerative\n changes are noted, particularly at the C3/4 level without thecal sac\n compression. Endotracheal and nasogastric tubes limit the evaluation of\n prevertebral soft tissue swelling. No pneumothorax at the lung apices.\n Visualized portion of the temporal bones show no fracture. Mastoid processes\n are normally pneumatized. There is mild circumferential maxillary mucosal\n thickening without air-fluid levels. There is a small fluid levels within the\n sphenoid sinuses without evidence of displaced fracture, which may relate to\n intubation and supine positioning.\n\n IMPRESSION: No acute fracture or traumatic malalignment.\n\n\n"},{"category":"Radiology","chartdate":"2123-10-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":928555,"text":" 5:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p MVC, s/p splenectomy, s/p SB resection placed\n\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:54 A.M. ON .\n\n HISTORY: Splenectomy.\n\n IMPRESSION: AP chest compared to through 19:\n\n Lungs are lower in volume. Mild bibasilar atelectasis is worsened. Heart\n size top normal. No pleural effusion. Since , the right hilus\n has gotten larger and more radiodense. This can be a sign of acute pulmonary\n embolism. Dr. and I discussed these findings by telephone at the\n time of dictation.\n\n"},{"category":"Radiology","chartdate":"2123-10-24 00:00:00.000","description":"CHEST (PA & LAT)","row_id":929027,"text":" 9:52 AM\n CHEST (PA & LAT) Clip # \n Reason: f/u on diuresing fluid.\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p mva\n REASON FOR THIS EXAMINATION:\n f/u on diuresing fluid.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, AT 0918 HOURS.\n\n HISTORY: Status post motor vehicle collision.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Lungs are hyperexpanded consistent with underlying obstructive lung\n disease. Linear atelectasis is noted in the right middle lobe. There is no\n focal consolidation. No superimposed edema is appreciated. There is a mildly\n tortuous atherosclerotic aorta. The cardiac silhouette is borderline enlarged\n with a prominent left epicardial fat pad. No pleural effusion or pneumothorax\n is evident. The bones are diffusely osteopenic and there is an exaggerated\n kyphosis of the thoracic spine.\n\n IMPRESSION: Underlying emphysema with no acute pulmonary process. Right\n hilar atelectasis.\n\n\n DR. \n"},{"category":"Radiology","chartdate":"2123-10-18 00:00:00.000","description":"R FEMUR (AP & LAT) RIGHT","row_id":928226,"text":" 1:14 AM\n FEMUR (AP & LAT) RIGHT Clip # \n Reason: assess for fracture\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with\n REASON FOR THIS EXAMINATION:\n assess for fracture\n ______________________________________________________________________________\n FINAL REPORT\n LEFT FEMUR, FOUR VIEWS\n\n INDICATION: 77-year-old woman. Evaluate for fracture.\n\n FINDINGS: No comparisons. No definite displaced fracture is seen. Quality\n of the radiographs is limited due to body habitus. No lytic or sclerotic\n lesion is noted. Mild degenerative change of the left hip is seen. The soft\n tissues are within normal limits. However, there does appear to be a focus of\n periosteal reaction and cortical lucency seen along the proximal fibular\n shaft, incompletely visualized. This area is concerning for a stress\n fracture. The soft tissues are otherwise unremarkable.\n\n IMPRESSION:\n 1. No definite evidence of femoral fracture.\n 2. Focal periosteal reaction and eccentric transversely oriented lucency of\n the proximal fibular shaft may represent a stress fracture. Consider\n dedicated imaging of the lower leg to further evaluate this region.\n\n DR. \n"},{"category":"Radiology","chartdate":"2123-10-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":928683,"text":" 6:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p MVC, s/p splenectomy, s/p SB resection placed\n\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST FROM \n\n HISTORY: Status post small bowel resection, splenectomy and status post MVC,\n evaluate for interval change.\n\n FINDINGS: Portable upright chest radiograph appears unchanged compared to\n yesterday's study. Note is again made of prominent radiodensity of the right\n hilum. The lucency of the two hemithoraces appears equal. Somewhat wide\n appearance to the mid mediastinum appears to be related to uncoiling of the\n thoracic aorta and slight rotation of the patient to the right. The lungs are\n clear.\n\n\n"},{"category":"Radiology","chartdate":"2123-10-18 00:00:00.000","description":"L HUMERUS (AP & LAT) LEFT","row_id":928225,"text":" 1:13 AM\n HUMERUS (AP & LAT) LEFT Clip # \n Reason: assess for fracture\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with\n REASON FOR THIS EXAMINATION:\n assess for fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess for fracture.\n\n LEFT HUMERUS, TWO VIEWS.\n\n There is probable diffuse osteopenia. No fracture is detected involving the\n left humerus. If there is clinical concern for an injury to the elbow, then\n dedicated elbow views would be recommended. Note is made of atelectasis at\n left lung base.\n\n Of note, the AC joint appears diastatic on these views measuring 10.8 mm. If\n the patient has symptoms related to the AC joint, then further assessment with\n dedicated views, ideally weightbearing and nonweightbearing views, of the AC\n joint may help for further assessment.\n\n"},{"category":"Radiology","chartdate":"2123-10-18 00:00:00.000","description":"CT T-SPINE W/O CONTRAST","row_id":928219,"text":" 12:02 AM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: eval for fracture\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p MVC intubated sedated s/p splenectomy\n REASON FOR THIS EXAMINATION:\n eval for fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DJD MON 1:52 AM\n No fracture or malalignment\n Hemangioma within the T10 vertebral body\n\n MD\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old status post MVC, sedated status post splenectomy,\n evaluate for fracture.\n\n TECHNIQUE: Axial MDCT images of the thoracic spine with coronal and sagittal\n reformatted images.\n\n FINDINGS: No acute fracture or traumatic malalignment is appreciated within\n the visualized thoracic spine. Mild degenerative changes throughout.\n Endotracheal and feeding tube noted. There is prominent atelectasis and small\n effusions within the visualized lungs. The limited visualized paraspinal soft\n tissues demonstrate an exophytic lesion emanating from the posterolateral\n aspect of the left kidney, not well characterized. Atherosclerotic\n calcification of the aorta and coronary arteries. There are extensive\n dependent pulmonary air space opacities.\n\n IMPRESSION:\n 1) No acute fracture or malalignment.\n 2) Bibasilar atelectasis/consolidation.\n 3) Exophytic lesion, originating off the left kidney, not well characterized\n on this study; correlate with prior abdominal imaging. In the absence of\n this, ultrasound could further evaluate when the patient is stable.\n\n\n"},{"category":"Radiology","chartdate":"2123-10-18 00:00:00.000","description":"CT L-SPINE W/O CONTRAST","row_id":928220,"text":" 12:02 AM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: eval for lumbosacral fracture\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p MVC intubated sedated s/p splenectomy\n REASON FOR THIS EXAMINATION:\n eval for lumbosacral fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DJD MON 1:59 AM\n No fracture or malalignment\n\n HOWEVER: Positive for 6cm x 3cm expansile mass in the sacral canal (measures\n 35-45 H.U. therefore it is solid and not a terminal meningeal cyst). Will need\n evaluation for neoplasm, ie primary bone tumor vs canal/neural tumor vs\n metastasis.\n\n MD\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 77-year-old status post MVC, intubated, status post splenectomy,\n evaluate for fracture.\n\n COMPARISONS: None.\n TECHNIQUE: Axial MDCT images through the lumbosacral spine without IV\n contrast with coronal and sagittal reformats.\n\n FINDINGS: There is normal alignment of the lumbar vertebral bodies without\n evidence of fracture or traumatic listhesis. Lumbar vertebral bodies are\n preserved in height. There is mild degenerative changes, most prominent at\n the L4-5 and L1-L2 levels. Calcification of the abdominal aorta without\n evidence of aneurysmal dilatation. No acute fractures are seen within the\n visualized pelvis. However, there is a large lytic lesion centered in the\n sacrum demonstrating sclerotic margins and central soft tissue density, of\n unclear etiology but requiring further workup. Indeterminate exophytic lesion\n off the left kidney again appreciated.\n\n IMPRESSION:\n 1) No acute fracture or malalignment.\n\n 2) Destructive lytic lesion centered in the sacrum with central soft tissue\n component; in the absence of prior studies, MRI is recommended for further\n characterization.\n\n 3) Exophytic lesion off the left kidney, not well characterized on this study.\n\n Findings discussed with Dr. after the study.\n\n NOTE ADDED AT ATTENDING REVIEW: I agree that the sacral lesion should be\n pursued with MR. However, measurements of soft tissue density within the\n sacrum may not be reliable. This may represent a large dilated nerve root\n (Over)\n\n 12:02 AM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: eval for lumbosacral fracture\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n sheath. There is a similar, but smaller, lesion on the right along the S3\n root. Both lesions appear chronic, with smooth erosion of the bone.\n\n"},{"category":"Radiology","chartdate":"2123-10-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":928261,"text":" 10:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: post-extubation\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p MVC, s/p splenectomy, s/p SB resection placed\n\n REASON FOR THIS EXAMINATION:\n post-extubation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old woman status post MVC, status post splenectomy, SB\n resection, and extubation.\n\n COMPARISON: .\n\n FINDINGS: Since the prior examination, patient has been extubated and the NG\n tube has been removed. Stable appearance of the right IJ-approach central\n venous catheter with its tip projecting over the SVC. Persistent bibasilar\n atelectasis. The left costophrenic angle is mildly blunted, may represent\n small pleural effusions. The cardiac silhouette, mediastinal and hilar\n contours appear unchanged.N o evidence of pneumothorax.\n\n IMPRESSION:\n\n 1. Interval removal of the ET and NG tubes.\n\n 2. Persistent bibasilar atelectasis, with possible small left-sided pleural\n effusion.\n\n 3. No evidence of pneumothorax.\n\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2123-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 82620,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Congestive heart failure. Shortness of breath.\\nHeight: (in) 63\\nWeight (lb): 240\\nBSA (m2): 2.09 m2\\nBP (mm Hg): 118/62\\nHR (bpm): 93\\nStatus: Inpatient\\nDate/Time: at 16:11\\nTest: TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\\n(LVEF>55%). Normal regional LV systolic function. No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta. No 2D or\\nDoppler evidence of distal arch coarctation.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\\nphysiologic PR.\\n\\nPERICARDIUM: There is an anterior space which most likely represents a fat\\npad, though a loculated anterior pericardial effusion cannot be excluded.\\n\\nConclusions:\\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\\nsize, and systolic function are normal (LVEF>55%), without regional wall\\nmotion abnormalitiesl. Right ventricular chamber size and free wall motion are\\nnormal. The ascending aorta is mildly dilated. The aortic valve leaflets (3)\\nappear structurally normal with good leaflet excursion and no aortic\\nregurgitation. The mitral valve appears structurally normal with trivial\\nmitral regurgitation. There is no mitral valve prolapse. There is an anterior\\nspace which most likely represents a fat pad, though a loculated anterior\\npericardial effusion cannot be excluded.\\n\\nIMPRESSION: Normal global and regional biventricular systolic function. Mildly\\ndilated ascending aorta.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-10-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1349963,\n \"text\": \"TSICU Nursing Progress Note\\nNeuro - Pt arouses to voice, nodds to questions, mouthing words at times. PERRL. MAE. C-collar and logroll precautions maintained.\\n\\nCV - NSR to ST without ectopy. MBP maintained above 65 with fluid boluses when needed. Lactate trending down. Peripheral pulses intact.\\n\\nResp - Tolerating vent settings on propofol. Not breathing over vent most of shift. ABG WNL. Minimal secretions.\\n\\nGI - Abdomen soft, tender. Dressing D&I. OR dressing intact. Absent BS. No BM.\\n\\nGU - Adequate UOP via foley.\\n\\nEndo - RISS, blood sugars trending down.\\n\\nA - Stable neuro exam. Metabolic acidosis improving.\\n\\nP - Awaiting orders for radiology. Clear back when able. Wean vent as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-10-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1349964,\n \"text\": \"Respiratory Care Note\\nPt received on AC as noted with no changes this shift. BS essentially clear, but decreased in the bases. Atrovent MDI given with no change in BS. ABG's had been metabolically acidotic earlier this shift, but are now within normal limits. Plan to continue on current settings at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1349965,\n \"text\": \"NPN 1900-0700\\nNEURO: Pt sedated on propofol. When lightened follows commands and MAE. Communicates via nodding. Pt requring 2-4mg MSO4 for abd pain q 2-3 hrs; dose increased this AM. CT of neck, T and L spine done. Xray of left shoulder and RLE done.\\n\\nRESP: No vent changes made. Pt had one episode where sats decreased to 88-89% after turning. Resolved with ambu, lavage and suctioning. ABG WNL.\\n\\nCV: HR 60s-90s NSR no ectopy noted. 500LR bolus x 1 for MAP below 60 and decreasing CVP. Goal is MAP greater than or equal to 65.\\n\\nHEME: Hct 23 from 25. Sq heparin cont. Pboots on.\\n\\nGI: Abd obese, bowel sounds absent.\\n\\nGU: Low u/o at same time of hypotension which was resolved with 500cc bolus. AM lytes WNL.\\n\\nID: Afebrile. Abx course completed.\\n\\nENDO: FS covered per RISS.\\n\\nSKIN: Back/buttocks with no breakdown noted. Ecchymosis to left scapula and right thigh.\\n\\nSOCIAL: No contacts from family this shift.\\n\\nASSESSMENT: Pt s/p MVC, splenectomy and .\\n\\nCurrent nsg issues:\\nBP alteration requiring fluid boluses.\\nPain.\\n\\nPLAN: Cont to monitor VS, maintain BP as per orders, monitor labs and hct trends, pain management, ?wean sedation and vent if TLS cleared today.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1349966,\n \"text\": \"Resp: pt on a/c 18/550/+5/40%. Alarms on and functioning. Ambu/syringe @ hob. BS are diminished bilaterally. Suctioned for small amounts of thick secretions. MDI's administered 2P Atr with no adverse reactions. Trip to CT without incident, with results pending. AM ABG 7.40/41/75/26 with no changes noc. RSBI=no resps. Will continue full vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1349967,\n \"text\": \"T-SICU Nsg Note\\n Events - C-spine cleared, collar off\\n TLS spine cleared, pt sitting\\n Vent weaned to 5 CPAP and then extubated at 0910\\n\\nROS - Neuro - pt alert, O x 3 (after she asked what day it was), moving all limbs. Pain all over, but especially L chest (due to rib fx)\\n\\nNote to continue\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1349968,\n \"text\": \"Resp Care\\nPt extubated this morning to 50% cool aerosol. Pt orally suctioned prior to extubation for mod amt of bloody secretions, no secretions noted down ETT. Pt had audible cuff leak. Pt had clear though slightly diminished BS bilaterally post extubation.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1349975,\n \"text\": \"TSICU NPN:\\nNEURO: A&Ox3. Pleasant and cooperative. MAE. PERL 3mm and brisk. Complaining of incisional pain and L shoulder pain- given 4mg sq MSO4 with good effect.\\nCV: Afeb. HR 80s-100s SR/ST, no ectopy noted. On lopressor IV q6hr. BP stable via NIBP cuff on L forearm. CVP 7-9. Skin warm and dry with palpable pedal pulses bilaterally. Generalized + edema. Lasix gtt d/c'd and continues on acetazolamide po bid.\\nRESP: Continues on 3L NC with O2 Sat >95%. LS clear and diminished at bases. Intermittent cough. Pt. +DOE but sats stable. Inhalers as ordered and prn for intermittent wheezing.\\nGI/GU: Abd. obese, soft with hypoactive bowel sounds. Tolerating clear liquid diet, no nausea. Foley draining clear light yellow urine >100cc/hr.\\nSKIN: Midline abd. incision with staples, clean, dry and intact- open to air. No swelling or drainage. Ecchymosis to L upper arm/shoulder and R upper thigh. Coccyx and backside intact. R IJ TLC line intact.\\nOTHER: Possible d/c to floor today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1349976,\n \"text\": \"NURSING NOTE 7AM TO 1PM\\nPATIENT STABLE AND TRANSFERED TO 915, TRANSFER NOTE FAXED AND SENT. REPORT GIVEN VERBALLY TO . PATIENT SENT WITH DENTURES NO OTHER PERSONAL ITEMS WITH PATINET AT HOSPITAL.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1349969,\n \"text\": \"T-SICU NSg note cont.\\n Medicated for pain with 2mg morphine sulfate IVP with some relief and dozing. Pt has grimace on face even while asleep.\\n CV - NSR 90's- to sinus tach 125. BP 125-145sys and MAP maintained > 65. On metoprolol 5mg IVP q 6 hrs. Pt on lisinopril at home.\\n Resp - resp rate slow, . Clear lung sounds in upper lobes, diminished in bases, coughs and clears, pt using suction to clear mouth. O2 sats on 4 l NC 90-97%, sats drifted down this am to 86%, and face tent with cool neb added at times - pt does not like face tent and has not needed it this eve.\\n GU - lasix drip started. K+ repleted, and last level 4.6 Pt is still net positive for today, discuss with HO about increasing lasix drip rate.\\n GI - pt has tolerated ice chips and sips of water. Abd obese, hypoactive bowel sounds heard this eve. Abd incision clean Dry & closed with staples.\\n Heme - Hct down to 22 this eve despite some diuresis. REcheck Hct at MN. Pt pale.\\n ID - pt low temps PO, but normal axillary. Antibiotics finished peri-op.\\n Endo - sliding scale insulin for blood glucose 125 to 180.\\nA: O2 sats have improved this eve. Pt sore and uncomfortable. Pt's daughters in to visit today. Pt alert and articulating needs.\\nP: Check Hct at 00. monitor u/o and lytes. Informational support to pt & family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1349970,\n \"text\": \"c/o of pain especially left upper quadrant and arm. Denies cp, dizziness, sob\\no. Neuro medicated morphine 4mg iv x3 with good relief pt needing less pain med as night went on. She alert to lethagic but easily arousable and oriented x3, mae, fc, pupils pinpt\\nresp pt with discordiant breathing all shift lungs crackles 3/4 up on right and coarse and diminished lt abg on 4lnp 7.31/55/114/0/29 cxr taken relatively unchanged from earlier in the day. Lasix increased to 4mg IV qhr, pt given albuteral and atrovent nebs wheezing with exertion. Repeat abg at 0500 on 2lnp 7.34/54/90/1/30\\ncvs HR 103-114 given lopressor 5mg iv q 6hr bp 124/55-140/55 hct 21.9/22 color white, cpk drawn 650 mb 5 troponin <.01 ekg taken cvp 20\\ngi abd obese bs absent staples in place no drainage\\ngu u/o >30 bun 10 cr .7 on lasix presently at 4mg q hr + > 6liters los\\nendo requiring ss insulin\\nskin ecchymotic lt arm and rt leg\\na. fluid overload, anemic tachycardic\\np. continuing lasix goal neg 500-1liter monitor lytes replete prn, cr bun, ? pt benefit from 1-2uprbc given her age, +obesity, +HTN, monitor hcts, nebs prn, medicate for pain prn, encourage incentive spironmeter, cdb\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-10-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1349961,\n \"text\": \"Resp: pt intubated via OR Ett 7.0 retaped and secured 19 @ lip. Place on a/c 18/550/+5/50%. Alarms on and functioning. Ambu/syringe @ hob. Bs are coarse bilaterally. Suctioned for small to moderate amounts of thick tan secretions. MDI's administered as ordered 2P Atr with no adverse reactions. Vent changes to decrease fio2 to 40%. AM ABG 7.28/41/107/20. No further changes noted. Will continue full vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-10-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1349962,\n \"text\": \"NPN 0100-0700\\n77 yo restrained passenger involved in MVC, car T-boned on driver's side. Pt went to hospital in where CT showed free fluid in abd and suspected splenic lac. Trans to and taken to OR for ex lap...resulted in splenectomy and (pt was intubated in OR at ). Pt also has left rib fx's, large area of ecchymosis to right scapula and right thigh. Initial head CT neg.\\n\\nNEURO: Pt intubated and sedated on propofol. When lightened, pt follows all commands and MAE. Reaches for ETT with BUE when unrestrainted. MSO4 prn abd pain with effect.\\n\\nRESP: LS CTA and diminished. Vented on assist control 550 x 14 5peep 50%, overbreaths 4-6 breaths. ABG with slight metabolic acidosis. Sats WNL.\\n\\nCV: HR 80s-100s SR/ST no ectopy noted. Arrived hypotensive with BP 80s/40s, however has responded to blood and IVF. Goal MAP > 60.\\n\\nHEME: Hct 29.8 from 24.7 after 1u PRBC's. Sq heparin to start this afternoon if hct stable.\\n\\nGI: Abd obese, OGT to LCS with thick brown output.\\n\\nGU: Adequate u/o via foley. Lytes repleted (awaiting order for phos repletion).\\n\\nID: Afebrile. On kefzol/flagyl x 3 doses.\\n\\nENDO: FS covered per RISS.\\n\\nSOCIAL: Daughter and son post op and updated on condition.\\n\\nASSESSMENT: Pt s/p MVC, splenectomy and .\\n\\nPLAN: Cont to monitor vs, pain management, correct lytes, serial hct's, wean sedation/vent as tol.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1349971,\n \"text\": \"NPN 0700-1900\\nNEURO: Pt A+Ox3, lethargic at times (possibly d/t anemia). MAE and follows commands. MSO4 for pain with effect. OOB to chair today x 2hrs.\\n\\nRESP: LS with coarse crackles to right side halfway up. Left side coarse and diminished. Sats 94-98% on 4LNC; desaturates to high 80s without O2. Prior to blood transfusion, breathing was quite discoordinate, and pt appeared to have increased amount of abd breathing. Pt had significant DOE and SOB with talking. Improved moderately since transfusion.\\n\\nCV: HR 80s-100s SR/ST, no ectopy noted. BP 100s-140s/40s-70s.\\n\\nHEME: Given 2u PRBC's for hct 21.2; post transfusion hct 28.6.\\n\\nGI: Abd obese, bowel sounds hypoactive. Tolerating clear liquids without N/V.\\n\\nGU: Lasix gtt on 4mg/hr for most of day. Pt is currently 1600cc neg; goal is 1-2L neg for 24hr. Gtt decreased to 1mg/hr at 1600. K+ repleted. PM lytes pending.\\n\\nID: Afebrile. No abx.\\n\\nENDO: FS covered per RISS.\\n\\nSKIN: Grossly intact, no breakdown noted.\\n\\nSOCIAL: Multiple family members in today and supportive.\\n\\nASSESSMENT: Pt s/p MVC with spenelctomy and .\\n\\nCurrent nsg issues:\\nFluid volume overload leading to DOE.\\nPain.\\nAnemia.\\n\\nPLAN: Cont to monitor vs, labs with serial hcts, lasix gtt as ordered, replete lytes, analgesia, encourage moblity, encourage C+DB.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1349972,\n \"text\": \"addendum: pt phosphorou level low.. neutrophos ordered po. pt took phosphorous but immediately developed nausea and vomited a small amount. anzimet 12.5 mg given iv with good effect.ho notified that pat unable to tolerated po phosphorous.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1349973,\n \"text\": \"cv: hr to 102 st no ectopy. pt on lopressor 10 mg iv Q6 hours. hr decreased to 81 after dose of lopressor iv. sbp 92-117/\\n\\ngi: tolerating clear liquids. abdomen obese. bowel sounds present but hypoactive. abd incision clean open to air. staples intact.\\n\\ngu: foley draining clear yellow urine. fluid balance goal attained negative ~ 2 liters. lasix drip infusing at 1 mg/hr..uo dropped off to 20 cc/hr at 0100 so lasix drip increased to 2 mg/hr. uo improved at 50-65 cc/hr.\\n\\nresp: albuterol nebs given at 2400 and again at 0400. while encourageing pt to do IS pt stated that she always takes a breathing tx at home.pt states she has a nebulizer machine at her home and that she takes a treatment 3-4 times per day and this worked much better for her than the inhalers. At 0400 pt sats decreased to 90 and pt found with expiratory wheezes in bilateral upper lobes and diminished lower lobes. wheezing dissipated after treatment and stas back to baseline 97-100 % on liters nc.\\n\\nmental status: alert and oriented,calm and cooperative.\\n\\nendo: blood sugars q 6 hours covered with ss. bs 126 at 0200 treated with 2 reg.\\n\\npain: pt complaining of generalized pain. pain in l shoulder and arm when turning to that side. Pain in abdomen . morphine given sc 8mg at . pt reported being comfortable. some discomfort at 2300 reported so another 8 mg sc injection given. resp rate decreasing to 6... pt sleeping.when pt awakened by this rn resp rate increased to 8- 12.\\n\\nlabs: K= 3.9 kcl 20 meq f/u k = 4.1. hct checked serially at and 0200... 25 and 25.6\\n\\nintegumentary: abdominal incision intact. staples intact. incision clean and open to air. ecchymosis of upper left arm and shoulder. ecchymosis of upper r thigh.\\n\\nasessment: improved ventilation with albuterol nebs.\\n improved pain control with sc morphine.\\n\\nplan: will give smaller dose of morphine sc next injection. will try 6 mg sc to avoid respiratory depression .\\nmonitor urine ouput and notify ho of decrease in urine to adjust lasix drip according ly.\\ngive albuterol nebs q 6 hours and encourage IS and coughing and deep breathing.\\nmonitor hct. check with ho to regarding frequency of serial hct to be drawn.\\nmonitor lytes esp K whil on lasix drip. q 6 hr glucose and ss coverage\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1349974,\n \"text\": \"TSICU Nursing Progress Note\\nNeuro - Pt x3. Conversing appropriately, able to make needs known. MAE.\\n\\nCV - NSR, rate 90s without ectopy. SBP 110s by cuff on forearm. Peripheral pulses palpable. Edema difficult to assess.\\n\\nResp - Lungs essentially clear, occ wheezing, dim in bases. Occ dyspneic with exertion. O2 sat >95% on 3 L NC. Albuterol nebs PRN. Strong cough with encouragement.\\n\\nGI - Abdomen obese, soft, hypoactive BS. Tender to palpation at incision. Tolerating sips of water and ice chips. No BM.\\n\\nGU - Brisk UOP on furosemide gtt with acetazolamide. Lasix gtt down to 1 mg/hr.\\n\\nEndo - No RISS coverage needed.\\n\\nHeme - 1 unit PRBC for HCT 25. Repeat HCT sent.\\n\\nA - Resp status stable. Tolerating clears.\\n\\nP - Continue to monitor resp status. Pulm toilet. Advance diet as tolerated. Consider tx to floor in AM.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2123-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 199725,\n \"text\": \"Sinus tachycardia\\nNormal ECG except for rate\\nSince previous tracing, limb lead voltage increased, and T wave abnormalities\\nless\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2123-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 199726,\n \"text\": \"Sinus tachycardia\\nLow limb lead voltage\\nT wave abnormalities\\nClinical correlation is suggested\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-17 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 928171,\n \"text\": \" 9:38 AM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: eval for Line placement, PTX\\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old woman s/p MVC, s/p splenectomy, s/p SB resection, new Right IJ\\n placed\\n REASON FOR THIS EXAMINATION:\\n eval for Line placement, PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post MVC, splenectomy, small bowel resection, new right IJ\\n placed. Evaluate line.\\n\\n CHEST, SINGLE AP VIEW.\\n\\n Compared with earlier the same day, a right IJ central line has been placed.\\n The tip overlies the mid/distal SVC. No pneumothorax is identified. Again\\n seen are the ET and NG tubes. The pleural parenchymal findings are unchanged.\\n\\n IMPRESSION:\\n 1. Right IJ central line tip over mid/distal SVC. No pneumothorax detected.\\n 2. NG tube -- side-port lies in region of GE junction. Clinical correlation\\n is requested.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-16 00:00:00.000\",\n \"description\": \"TRAUMA #2 (AP CXR & PELVIS PORT)\",\n \"row_id\": 928142,\n \"text\": \" 9:19 PM\\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \\n Reason: TRAUMA\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Trauma; no further clinical history provided.\\n\\n TRAUMA TWO SERIES:\\n\\n AP chest radiograph with overlying trauma board demonstrates no pneumothorax\\n or fracture. The mediastinum is within normal limits allowing for technique.\\n Heart size is normal allowing for technique. The aortic arch is sharp. Lungs\\n are grossly clear.\\n\\n AP pelvis with overlying trauma board demonstrates only mild demineralization.\\n No acute fracture or dislocation, though its poor image contrast somewhat\\n limits sensitivity. The lower lumbosacral spine and sacrum are not well\\n visualized.\\n\\n IMPRESSION: No evidence of traumatic injury. Suboptimal assessment of the\\n sacrum and lower lumbosacral spine.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 928387,\n \"text\": \" 3:11 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o pulmonary edema\\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old woman s/p MVC, s/p splenectomy, s/p SB resection placed\\n\\n REASON FOR THIS EXAMINATION:\\n r/o pulmonary edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: A 77-year-old woman status post MVC, splenectomy, and small bowel\\n resection.\\n\\n COMPARISON: .\\n\\n FINDINGS: Since the prior examination, there has been no significant interval\\n changes. Persistent bibasilar atelectasis with left-sided small pleural\\n effusion. Right IJ approach central venous catheter is unchanged with its tip\\n projecting over the SVC. No evidence of pneumothorax.\\n\\n IMPRESSION: No significant interval changes.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-17 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 928147,\n \"text\": \" 1:13 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p intubation\\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old woman with\\n REASON FOR THIS EXAMINATION:\\n s/p intubation\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post intubation.\\n\\n CHEST, SINGLE AP VIEW.\\n No previous chest x-rays on PACS record for comparison. (Trauma film only).\\n\\n An ET tube has been placed, tip in satisfactory position approximately 3.5 cm\\n above the carina. An NG tube is present, tip overlying gastric fundus. The\\n sideport lies in the expected region of the GE junction. No CHF or focal\\n infiltrate is identified. There is bibasilar atelectasis. Equivocal minimal\\n blunting of the costophrenic angles, doubt gross effusion. Mild prominence of\\n right paratracheal soft tissues likely reflects vascular structures in someone\\n of this age. There is probable mild cardiomegaly with an unfolded aorta.\\n Skin staples noted over upper abdomen in the midline.\\n\\n IMPRESSION: Interval placement of ET tube in satisfactory position. NG tube\\n with sideport in region of GE junction. Clinical correlation requested.\\n Bibasilar atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-18 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 928218,\n \"text\": \" 12:01 AM\\n CT C-SPINE W/O CONTRAST Clip # \\n Reason: eval for fracture\\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old woman s/p MVC intubated sedated s/p splenectomy\\n REASON FOR THIS EXAMINATION:\\n eval for fracture\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: DJD MON 1:50 AM\\n No fracture or malalignment\\n Mild . changes\\n MD\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 77-year-old status post MVC, sedated status post splenectomy,\\n evaluate for fracture.\\n\\n COMPARISONS: None.\\n\\n TECHNIQUE: Axial MDCT images of the cervical spine with coronal and sagittal\\n reformats.\\n\\n FINDINGS: C1 through the superior endplate of T2 are well visualized. There\\n is no evidence of acute fracture or traumatic listhesis. Mild degenerative\\n changes are noted, particularly at the C3/4 level without thecal sac\\n compression. Endotracheal and nasogastric tubes limit the evaluation of\\n prevertebral soft tissue swelling. No pneumothorax at the lung apices.\\n Visualized portion of the temporal bones show no fracture. Mastoid processes\\n are normally pneumatized. There is mild circumferential maxillary mucosal\\n thickening without air-fluid levels. There is a small fluid levels within the\\n sphenoid sinuses without evidence of displaced fracture, which may relate to\\n intubation and supine positioning.\\n\\n IMPRESSION: No acute fracture or traumatic malalignment.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 928555,\n \"text\": \" 5:53 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for interval change\\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old woman s/p MVC, s/p splenectomy, s/p SB resection placed\\n\\n REASON FOR THIS EXAMINATION:\\n eval for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 5:54 A.M. ON .\\n\\n HISTORY: Splenectomy.\\n\\n IMPRESSION: AP chest compared to through 19:\\n\\n Lungs are lower in volume. Mild bibasilar atelectasis is worsened. Heart\\n size top normal. No pleural effusion. Since , the right hilus\\n has gotten larger and more radiodense. This can be a sign of acute pulmonary\\n embolism. Dr. and I discussed these findings by telephone at the\\n time of dictation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-24 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 929027,\n \"text\": \" 9:52 AM\\n CHEST (PA & LAT) Clip # \\n Reason: f/u on diuresing fluid.\\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old woman s/p mva\\n REASON FOR THIS EXAMINATION:\\n f/u on diuresing fluid.\\n ______________________________________________________________________________\\n FINAL REPORT\\n PA AND LATERAL CHEST, AT 0918 HOURS.\\n\\n HISTORY: Status post motor vehicle collision.\\n\\n COMPARISON: Multiple priors, the most recent dated .\\n\\n FINDINGS: Lungs are hyperexpanded consistent with underlying obstructive lung\\n disease. Linear atelectasis is noted in the right middle lobe. There is no\\n focal consolidation. No superimposed edema is appreciated. There is a mildly\\n tortuous atherosclerotic aorta. The cardiac silhouette is borderline enlarged\\n with a prominent left epicardial fat pad. No pleural effusion or pneumothorax\\n is evident. The bones are diffusely osteopenic and there is an exaggerated\\n kyphosis of the thoracic spine.\\n\\n IMPRESSION: Underlying emphysema with no acute pulmonary process. Right\\n hilar atelectasis.\\n\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-18 00:00:00.000\",\n \"description\": \"R FEMUR (AP & LAT) RIGHT\",\n \"row_id\": 928226,\n \"text\": \" 1:14 AM\\n FEMUR (AP & LAT) RIGHT Clip # \\n Reason: assess for fracture\\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old woman with\\n REASON FOR THIS EXAMINATION:\\n assess for fracture\\n ______________________________________________________________________________\\n FINAL REPORT\\n LEFT FEMUR, FOUR VIEWS\\n\\n INDICATION: 77-year-old woman. Evaluate for fracture.\\n\\n FINDINGS: No comparisons. No definite displaced fracture is seen. Quality\\n of the radiographs is limited due to body habitus. No lytic or sclerotic\\n lesion is noted. Mild degenerative change of the left hip is seen. The soft\\n tissues are within normal limits. However, there does appear to be a focus of\\n periosteal reaction and cortical lucency seen along the proximal fibular\\n shaft, incompletely visualized. This area is concerning for a stress\\n fracture. The soft tissues are otherwise unremarkable.\\n\\n IMPRESSION:\\n 1. No definite evidence of femoral fracture.\\n 2. Focal periosteal reaction and eccentric transversely oriented lucency of\\n the proximal fibular shaft may represent a stress fracture. Consider\\n dedicated imaging of the lower leg to further evaluate this region.\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 928683,\n \"text\": \" 6:00 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for interval change\\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old woman s/p MVC, s/p splenectomy, s/p SB resection placed\\n\\n REASON FOR THIS EXAMINATION:\\n eval for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST FROM \\n\\n HISTORY: Status post small bowel resection, splenectomy and status post MVC,\\n evaluate for interval change.\\n\\n FINDINGS: Portable upright chest radiograph appears unchanged compared to\\n yesterday's study. Note is again made of prominent radiodensity of the right\\n hilum. The lucency of the two hemithoraces appears equal. Somewhat wide\\n appearance to the mid mediastinum appears to be related to uncoiling of the\\n thoracic aorta and slight rotation of the patient to the right. The lungs are\\n clear.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-18 00:00:00.000\",\n \"description\": \"L HUMERUS (AP & LAT) LEFT\",\n \"row_id\": 928225,\n \"text\": \" 1:13 AM\\n HUMERUS (AP & LAT) LEFT Clip # \\n Reason: assess for fracture\\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old woman with\\n REASON FOR THIS EXAMINATION:\\n assess for fracture\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Assess for fracture.\\n\\n LEFT HUMERUS, TWO VIEWS.\\n\\n There is probable diffuse osteopenia. No fracture is detected involving the\\n left humerus. If there is clinical concern for an injury to the elbow, then\\n dedicated elbow views would be recommended. Note is made of atelectasis at\\n left lung base.\\n\\n Of note, the AC joint appears diastatic on these views measuring 10.8 mm. If\\n the patient has symptoms related to the AC joint, then further assessment with\\n dedicated views, ideally weightbearing and nonweightbearing views, of the AC\\n joint may help for further assessment.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-18 00:00:00.000\",\n \"description\": \"CT T-SPINE W/O CONTRAST\",\n \"row_id\": 928219,\n \"text\": \" 12:02 AM\\n CT T-SPINE W/O CONTRAST Clip # \\n Reason: eval for fracture\\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old woman s/p MVC intubated sedated s/p splenectomy\\n REASON FOR THIS EXAMINATION:\\n eval for fracture\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: DJD MON 1:52 AM\\n No fracture or malalignment\\n Hemangioma within the T10 vertebral body\\n\\n MD\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 77-year-old status post MVC, sedated status post splenectomy,\\n evaluate for fracture.\\n\\n TECHNIQUE: Axial MDCT images of the thoracic spine with coronal and sagittal\\n reformatted images.\\n\\n FINDINGS: No acute fracture or traumatic malalignment is appreciated within\\n the visualized thoracic spine. Mild degenerative changes throughout.\\n Endotracheal and feeding tube noted. There is prominent atelectasis and small\\n effusions within the visualized lungs. The limited visualized paraspinal soft\\n tissues demonstrate an exophytic lesion emanating from the posterolateral\\n aspect of the left kidney, not well characterized. Atherosclerotic\\n calcification of the aorta and coronary arteries. There are extensive\\n dependent pulmonary air space opacities.\\n\\n IMPRESSION:\\n 1) No acute fracture or malalignment.\\n 2) Bibasilar atelectasis/consolidation.\\n 3) Exophytic lesion, originating off the left kidney, not well characterized\\n on this study; correlate with prior abdominal imaging. In the absence of\\n this, ultrasound could further evaluate when the patient is stable.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-18 00:00:00.000\",\n \"description\": \"CT L-SPINE W/O CONTRAST\",\n \"row_id\": 928220,\n \"text\": \" 12:02 AM\\n CT L-SPINE W/O CONTRAST Clip # \\n Reason: eval for lumbosacral fracture\\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old woman s/p MVC intubated sedated s/p splenectomy\\n REASON FOR THIS EXAMINATION:\\n eval for lumbosacral fracture\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: DJD MON 1:59 AM\\n No fracture or malalignment\\n\\n HOWEVER: Positive for 6cm x 3cm expansile mass in the sacral canal (measures\\n 35-45 H.U. therefore it is solid and not a terminal meningeal cyst). Will need\\n evaluation for neoplasm, ie primary bone tumor vs canal/neural tumor vs\\n metastasis.\\n\\n MD\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n INDICATION: 77-year-old status post MVC, intubated, status post splenectomy,\\n evaluate for fracture.\\n\\n COMPARISONS: None.\\n TECHNIQUE: Axial MDCT images through the lumbosacral spine without IV\\n contrast with coronal and sagittal reformats.\\n\\n FINDINGS: There is normal alignment of the lumbar vertebral bodies without\\n evidence of fracture or traumatic listhesis. Lumbar vertebral bodies are\\n preserved in height. There is mild degenerative changes, most prominent at\\n the L4-5 and L1-L2 levels. Calcification of the abdominal aorta without\\n evidence of aneurysmal dilatation. No acute fractures are seen within the\\n visualized pelvis. However, there is a large lytic lesion centered in the\\n sacrum demonstrating sclerotic margins and central soft tissue density, of\\n unclear etiology but requiring further workup. Indeterminate exophytic lesion\\n off the left kidney again appreciated.\\n\\n IMPRESSION:\\n 1) No acute fracture or malalignment.\\n\\n 2) Destructive lytic lesion centered in the sacrum with central soft tissue\\n component; in the absence of prior studies, MRI is recommended for further\\n characterization.\\n\\n 3) Exophytic lesion off the left kidney, not well characterized on this study.\\n\\n Findings discussed with Dr. after the study.\\n\\n NOTE ADDED AT ATTENDING REVIEW: I agree that the sacral lesion should be\\n pursued with MR. However, measurements of soft tissue density within the\\n sacrum may not be reliable. This may represent a large dilated nerve root\\n (Over)\\n\\n 12:02 AM\\n CT L-SPINE W/O CONTRAST Clip # \\n Reason: eval for lumbosacral fracture\\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n (Cont)\\n sheath. There is a similar, but smaller, lesion on the right along the S3\\n root. Both lesions appear chronic, with smooth erosion of the bone.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 928261,\n \"text\": \" 10:00 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: post-extubation\\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old woman s/p MVC, s/p splenectomy, s/p SB resection placed\\n\\n REASON FOR THIS EXAMINATION:\\n post-extubation\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 77-year-old woman status post MVC, status post splenectomy, SB\\n resection, and extubation.\\n\\n COMPARISON: .\\n\\n FINDINGS: Since the prior examination, patient has been extubated and the NG\\n tube has been removed. Stable appearance of the right IJ-approach central\\n venous catheter with its tip projecting over the SVC. Persistent bibasilar\\n atelectasis. The left costophrenic angle is mildly blunted, may represent\\n small pleural effusions. The cardiac silhouette, mediastinal and hilar\\n contours appear unchanged.N o evidence of pneumothorax.\\n\\n IMPRESSION:\\n\\n 1. Interval removal of the ET and NG tubes.\\n\\n 2. Persistent bibasilar atelectasis, with possible small left-sided pleural\\n effusion.\\n\\n 3. No evidence of pneumothorax.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":24659,"cells":{"subject_id":{"kind":"number","value":31642,"string":"31,642"},"hadm_id":{"kind":"number","value":150166,"string":"150,166"},"target_text":{"kind":"string","value":"Vascular surgery consulted due to back pain / ? increased size of known thoracic aortic aneurysm. No evidence of leaking or rupture was seen on CT here; slight interval increase in aneurysm since . Prior CT at non-contrast, reviewed by Dr. , who would like Ms. to have a repeat CT scan with contrast in 3 months and follow up with him in clinic."},"extractive_notes_summ":{"kind":"string","value":"The ascending thoracic aorta is ectatic measuring 4.7 cm x 5.0 cm (2:31), unchanged from prior. Additionally, there is ectasia of the infrarenal portion of the abdominal aorta, and above the level of the bifurcation, measuring up to 2.6 cm in AP dimensions, unchanged from . Evaluatoin for dissectrion limited without IV contrast. Stable ectasia of the ascending aorta and infrarenal abdominal aorta. Extensive atherosclerotic calcifications are present throughout the thoracic aorta, with associated streak artifact from the intimal calcifications as well as from adjacent pacer leads slightly limiting evaluation. Non-contrast images of the stomach and small bowel are within normal limits. TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the symphysis pubis without the administration of IV and oral contrast. The lungs reveal patchy areas of atelectasis bilaterally, with left lower lobe chronic compressive atelectasis seen adjacent to the descending thoracic aorta/aneurysm. Otherwise, the airways are patent to the subsegmental level. Diverticulosis without diverticulitis. Additionally, there is a 5 mm pulmonary nodule, abutting the right major fissure (2:25), unchanged from . D/w surgery. CT OF THE CHEST WITHOUT IV CONTRAST: The heart is mildly enlarged in size, with an AICD device present, with leads terminating in the right atrium and right ventricle. This could represent atrial sensing, ventricular pacing with difficultyin discerning atrial activity, although in lead II a candidate P wave canbe seen. A few scattered mediastinal nodes are present, not meeting size criteria for pathologic enlargement. AORTA: Again noted is a thoracic aortic aneurysm which involves the descending thoracic aorta and continues through the level of the diaphragm. Scattered diverticula are present within the colon, with retained contrast present within the transverse and descending colons. Stable 5 mm pulmonary nodule in the right upper lobe. Coronal and sagittal reformations were obtained. A-V paced rhythmSince previous tracing of , no significant change CT OF THE ABDOMEN WITHOUT IV CONTRAST: Non-contrast liver, spleen, pancreas, adrenal glands, and kidneys are unremarkable. Multilevel degenerative changes are present throughout the thoracolumbar spine. There is a grade 1 anterolisthesis of L4 on L5, stable. Large descending thoracic aortic aneurysm, with a slight interval increase in size from as noted above. OSSEOUS STRUCTURES: Sclerotic focus in the T6 vertebral body is stable from , may reflect a bone island. Minimal calcifications of the tracheobronchial tree is seen. Atelectasis at the left lower lobe adjacent to the descending thoracic aorta. (Over) 7:38 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: AAA/Dissection Field of view: 36 FINAL REPORT (Cont) The aneurysm measures approximately 5.9 cm x 6.0 cm (previously 5.7 cm x 5.3 cm) at the level just above the diaphragm. A pacing spike is seen priorto every QRS complex indicating one hundred percent ventricular pacing.Compared to the previous tracing of atrial pacing is no longerseen. A-V paced rhythmSince previous tracing of , paced rhythm now present larger on outpatient CT REASON FOR THIS EXAMINATION: AAA/Dissection No contraindications for IV contrast WET READ: JXKc WED 10:14 PM Thoracic aortic aneurysm, with the ascending aorta similar in size from , but with slight interval increase in size of the descending thoracic aorta (5.8 cm x 6.0 cm) versus (5.7cm x 5.4 cm on prior study). There is no pericardial effusion. IMPRESSION: 1. There is no pleural effusion. Small amount of layering hyperdensity within the gallbladder may reflect a sludge. The atrial activity is difficult to discern. 4. Again noted are extensive atherosclerotic calcifications of the abdominal aorta as well as splenic artery and renal vessels. There is no evidence of aortic rupture. Evaluate. COMPARISON: . SESHa There is no evidence of rupture. There is no definite evidence for displaced intimal calcifications on this study. There is no free air, free fluid or pathologic adenopathy. midnight-7a81 y/o female w/ extensive medical hx admitted to cvicu for monitoring after follow-up ct of previously stable thoracoabdominal aneurysm showed possible growth in size of aneurysm and potential for leak vs dissectionneuro: a+ox3, mae, follows commands, turns self in bed, no c/o pain at this timecv: sr 70s w/ rare pacs, sbp 115-130, afebresp: lungs cta, 02 sats>95% on 2L nc while awake, O2 increased to 4Lnc while pt sleeping to maintain higher 02 satgi: npo, bowel sounds present, tolerating sips of h20 w/ pills without distressgu: voids per urinal clear green urine (pt states green urine colour r/t bladder med taken at home)assess: stableplan: keep npo overnoc for possible tests in am, transfer to floor when able 3. 5. 2. 7:38 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: AAA/Dissection Field of view: 36 MEDICAL CONDITION: 81 year old woman with known AAA, ? Findings posted to the ED dashboard at the time of interpretation. FINAL REPORT HISTORY: 81-year-old female with known abdominal aortic aneurysm, question larger on outpatient CT."},"n_notes":{"kind":"number","value":5,"string":"5"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2147-07-26 00:00:00.000","description":"CT PELVIS W/O CONTRAST","row_id":1028984,"text":" 7:38 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: AAA/Dissection\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with known AAA, ? larger on outpatient CT\n REASON FOR THIS EXAMINATION:\n AAA/Dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc WED 10:14 PM\n Thoracic aortic aneurysm, with the ascending aorta similar in size from ,\n but with slight interval increase in size of the descending thoracic aorta\n (5.8 cm x 6.0 cm) versus (5.7cm x 5.4 cm on prior study). D/w surgery.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81-year-old female with known abdominal aortic aneurysm, question\n larger on outpatient CT. Evaluate.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the\n symphysis pubis without the administration of IV and oral contrast. Coronal\n and sagittal reformations were obtained.\n\n CT OF THE CHEST WITHOUT IV CONTRAST: The heart is mildly enlarged in size,\n with an AICD device present, with leads terminating in the right atrium and\n right ventricle. There is no pericardial effusion. A few scattered mediastinal\n nodes are present, not meeting size criteria for pathologic enlargement. The\n lungs reveal patchy areas of atelectasis bilaterally, with left lower lobe\n chronic compressive atelectasis seen adjacent to the descending thoracic\n aorta/aneurysm. Additionally, there is a 5 mm pulmonary nodule, abutting the\n right major fissure (2:25), unchanged from . Minimal\n calcifications of the tracheobronchial tree is seen. Otherwise, the airways\n are patent to the subsegmental level. There is no pleural effusion.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: Non-contrast liver, spleen, pancreas,\n adrenal glands, and kidneys are unremarkable. Small amount of layering\n hyperdensity within the gallbladder may reflect a sludge. Non-contrast images\n of the stomach and small bowel are within normal limits. Scattered\n diverticula are present within the colon, with retained contrast present\n within the transverse and descending colons. There is no free air, free fluid\n or pathologic adenopathy.\n\n OSSEOUS STRUCTURES: Sclerotic focus in the T6 vertebral body is stable from\n , may reflect a bone island. There is a grade 1\n anterolisthesis of L4 on L5, stable. Multilevel degenerative changes are\n present throughout the thoracolumbar spine.\n\n AORTA: Again noted is a thoracic aortic aneurysm which involves the\n descending thoracic aorta and continues through the level of the diaphragm.\n (Over)\n\n 7:38 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: AAA/Dissection\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The aneurysm measures approximately 5.9 cm x 6.0 cm (previously 5.7 cm x 5.3\n cm) at the level just above the diaphragm. The ascending thoracic aorta is\n ectatic measuring 4.7 cm x 5.0 cm (2:31), unchanged from prior. Extensive\n atherosclerotic calcifications are present throughout the thoracic aorta, with\n associated streak artifact from the intimal calcifications as well as from\n adjacent pacer leads slightly limiting evaluation. There is no definite\n evidence for displaced intimal calcifications on this study. There is no\n evidence of aortic rupture.\n\n Additionally, there is ectasia of the infrarenal portion of the abdominal\n aorta, and above the level of the bifurcation, measuring up to 2.6 cm in AP\n dimensions, unchanged from . Again noted are extensive\n atherosclerotic calcifications of the abdominal aorta as well as splenic\n artery and renal vessels.\n\n IMPRESSION:\n 1. Large descending thoracic aortic aneurysm, with a slight interval increase\n in size from as noted above. There is no evidence of\n rupture. Evaluatoin for dissectrion limited without IV contrast. Patient\n reportedly had a contrast enhanced study at an outside hospital within the\n last 2 days and correlation with the results from that study is recommended.\n 2. Stable ectasia of the ascending aorta and infrarenal abdominal aorta. 3.\n Atelectasis at the left lower lobe adjacent to the descending thoracic aorta.\n 4. Stable 5 mm pulmonary nodule in the right upper lobe.\n 5. Diverticulosis without diverticulitis.\n\n Findings posted to the ED dashboard at the time of interpretation.\n SESHa\n\n"},{"category":"Nursing/other","chartdate":"2147-07-27 00:00:00.000","description":"Report","row_id":1664839,"text":" midnight-7a\n81 y/o female w/ extensive medical hx admitted to cvicu for monitoring after follow-up ct of previously stable thoracoabdominal aneurysm showed possible growth in size of aneurysm and potential for leak vs dissection\n\nneuro: a+ox3, mae, follows commands, turns self in bed, no c/o pain at this time\n\ncv: sr 70s w/ rare pacs, sbp 115-130, afeb\n\nresp: lungs cta, 02 sats>95% on 2L nc while awake, O2 increased to 4Lnc while pt sleeping to maintain higher 02 sat\n\ngi: npo, bowel sounds present, tolerating sips of h20 w/ pills without distress\n\ngu: voids per urinal clear green urine (pt states green urine colour r/t bladder med taken at home)\n\nassess: stable\n\nplan: keep npo overnoc for possible tests in am, transfer to floor when able\n"},{"category":"ECG","chartdate":"2147-07-28 00:00:00.000","description":"Report","row_id":186657,"text":"The atrial activity is difficult to discern. A pacing spike is seen prior\nto every QRS complex indicating one hundred percent ventricular pacing.\nCompared to the previous tracing of atrial pacing is no longer\nseen. This could represent atrial sensing, ventricular pacing with difficulty\nin discerning atrial activity, although in lead II a candidate P wave can\nbe seen.\n\n"},{"category":"ECG","chartdate":"2147-07-27 00:00:00.000","description":"Report","row_id":186913,"text":"A-V paced rhythm\nSince previous tracing of , no significant change\n\n"},{"category":"ECG","chartdate":"2147-07-26 00:00:00.000","description":"Report","row_id":186914,"text":"A-V paced rhythm\nSince previous tracing of , paced rhythm now present\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-07-26 00:00:00.000\",\n \"description\": \"CT PELVIS W/O CONTRAST\",\n \"row_id\": 1028984,\n \"text\": \" 7:38 PM\\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \\n CT PELVIS W/O CONTRAST\\n Reason: AAA/Dissection\\n Field of view: 36\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old woman with known AAA, ? larger on outpatient CT\\n REASON FOR THIS EXAMINATION:\\n AAA/Dissection\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JXKc WED 10:14 PM\\n Thoracic aortic aneurysm, with the ascending aorta similar in size from ,\\n but with slight interval increase in size of the descending thoracic aorta\\n (5.8 cm x 6.0 cm) versus (5.7cm x 5.4 cm on prior study). D/w surgery.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 81-year-old female with known abdominal aortic aneurysm, question\\n larger on outpatient CT. Evaluate.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the\\n symphysis pubis without the administration of IV and oral contrast. Coronal\\n and sagittal reformations were obtained.\\n\\n CT OF THE CHEST WITHOUT IV CONTRAST: The heart is mildly enlarged in size,\\n with an AICD device present, with leads terminating in the right atrium and\\n right ventricle. There is no pericardial effusion. A few scattered mediastinal\\n nodes are present, not meeting size criteria for pathologic enlargement. The\\n lungs reveal patchy areas of atelectasis bilaterally, with left lower lobe\\n chronic compressive atelectasis seen adjacent to the descending thoracic\\n aorta/aneurysm. Additionally, there is a 5 mm pulmonary nodule, abutting the\\n right major fissure (2:25), unchanged from . Minimal\\n calcifications of the tracheobronchial tree is seen. Otherwise, the airways\\n are patent to the subsegmental level. There is no pleural effusion.\\n\\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: Non-contrast liver, spleen, pancreas,\\n adrenal glands, and kidneys are unremarkable. Small amount of layering\\n hyperdensity within the gallbladder may reflect a sludge. Non-contrast images\\n of the stomach and small bowel are within normal limits. Scattered\\n diverticula are present within the colon, with retained contrast present\\n within the transverse and descending colons. There is no free air, free fluid\\n or pathologic adenopathy.\\n\\n OSSEOUS STRUCTURES: Sclerotic focus in the T6 vertebral body is stable from\\n , may reflect a bone island. There is a grade 1\\n anterolisthesis of L4 on L5, stable. Multilevel degenerative changes are\\n present throughout the thoracolumbar spine.\\n\\n AORTA: Again noted is a thoracic aortic aneurysm which involves the\\n descending thoracic aorta and continues through the level of the diaphragm.\\n (Over)\\n\\n 7:38 PM\\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \\n CT PELVIS W/O CONTRAST\\n Reason: AAA/Dissection\\n Field of view: 36\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n The aneurysm measures approximately 5.9 cm x 6.0 cm (previously 5.7 cm x 5.3\\n cm) at the level just above the diaphragm. The ascending thoracic aorta is\\n ectatic measuring 4.7 cm x 5.0 cm (2:31), unchanged from prior. Extensive\\n atherosclerotic calcifications are present throughout the thoracic aorta, with\\n associated streak artifact from the intimal calcifications as well as from\\n adjacent pacer leads slightly limiting evaluation. There is no definite\\n evidence for displaced intimal calcifications on this study. There is no\\n evidence of aortic rupture.\\n\\n Additionally, there is ectasia of the infrarenal portion of the abdominal\\n aorta, and above the level of the bifurcation, measuring up to 2.6 cm in AP\\n dimensions, unchanged from . Again noted are extensive\\n atherosclerotic calcifications of the abdominal aorta as well as splenic\\n artery and renal vessels.\\n\\n IMPRESSION:\\n 1. Large descending thoracic aortic aneurysm, with a slight interval increase\\n in size from as noted above. There is no evidence of\\n rupture. Evaluatoin for dissectrion limited without IV contrast. Patient\\n reportedly had a contrast enhanced study at an outside hospital within the\\n last 2 days and correlation with the results from that study is recommended.\\n 2. Stable ectasia of the ascending aorta and infrarenal abdominal aorta. 3.\\n Atelectasis at the left lower lobe adjacent to the descending thoracic aorta.\\n 4. Stable 5 mm pulmonary nodule in the right upper lobe.\\n 5. Diverticulosis without diverticulitis.\\n\\n Findings posted to the ED dashboard at the time of interpretation.\\n SESHa\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-07-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1664839,\n \"text\": \" midnight-7a\\n81 y/o female w/ extensive medical hx admitted to cvicu for monitoring after follow-up ct of previously stable thoracoabdominal aneurysm showed possible growth in size of aneurysm and potential for leak vs dissection\\n\\nneuro: a+ox3, mae, follows commands, turns self in bed, no c/o pain at this time\\n\\ncv: sr 70s w/ rare pacs, sbp 115-130, afeb\\n\\nresp: lungs cta, 02 sats>95% on 2L nc while awake, O2 increased to 4Lnc while pt sleeping to maintain higher 02 sat\\n\\ngi: npo, bowel sounds present, tolerating sips of h20 w/ pills without distress\\n\\ngu: voids per urinal clear green urine (pt states green urine colour r/t bladder med taken at home)\\n\\nassess: stable\\n\\nplan: keep npo overnoc for possible tests in am, transfer to floor when able\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2147-07-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 186657,\n \"text\": \"The atrial activity is difficult to discern. A pacing spike is seen prior\\nto every QRS complex indicating one hundred percent ventricular pacing.\\nCompared to the previous tracing of atrial pacing is no longer\\nseen. This could represent atrial sensing, ventricular pacing with difficulty\\nin discerning atrial activity, although in lead II a candidate P wave can\\nbe seen.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2147-07-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 186913,\n \"text\": \"A-V paced rhythm\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2147-07-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 186914,\n \"text\": \"A-V paced rhythm\\nSince previous tracing of , paced rhythm now present\\n\\n\"\n }\n]"}}},{"rowIdx":24660,"cells":{"subject_id":{"kind":"number","value":28222,"string":"28,222"},"hadm_id":{"kind":"number","value":177613,"string":"177,613"},"target_text":{"kind":"string","value":"ASSESSMENT AND PLAN: 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM, systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS change and hypotension. Etiology of hypotension and hypercarbia were never clarified during his hospital course. The hypotension was concerning for sepsis given l-shift, indwelling HD line and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/ prior HD line. Also has a pacemaker. Could not get a urine specimen. CXR w/ loss of diaphragm on R but w/o obvious infiltrate. Could also be from cardiogenic shock given baseline depressed EF. Given his presentation w/ altered mental status, he was covered with Vanc, ceftriaxone, ampicillin and acyclovir for possible meningitis. An LP was attempted but not successful given prior lumbar laminectomy surgery and an IR-guided LP was planned. He was initially on NE for blood pressure support but this was weaned off the day after admission. The following morning, when the resident went in to round on Mr. , she noted that he was apneic and without a pulse. A code was called and he was given epi/atropine, insulin, dextrose, bicarb for PEA. He was intubated by anesthesia. His wife was called and she asked that agressive recussitation be stopped (it had not been successful to that point) and he expired. . Hospital course also complicated by the following problems: . #. Acute respiratory acidosis: Unclear precipitant. DDX from percocets vs infection vs hypophosphatemia vs respiratory muscle fatigue. He tolerated bipap the night of admssion with a small decrease in CO2. His mental status improved slightly over the next day. . #. Altered mental status: DDX from hypercarbia vs from percocets vs from infection. CT head w/o acute process. Could possibly be from meningitis but no nucal rigidity or headache. - treatment w/ bipap and antibiotics for meningitis as above . #. Hypoxia: CXR seems consistent w/ pulmonary edema. Likely from worsening valvular disease. Could also be an infiltrate that is hidden by edema. Apparently has been on L NC at rehab w/ unclear diagnosis but getting spiriva and albuterol. No formal dx of COPD. - albuterol and atrovent nebs . #. ESRD on HD: Dialysis MWF at Dialysis. - renal followed him and was planning for dialysis the day he expired . #. Systolic heart failure: Unclear if ischemic in etiology or from valvular disease (mod AS, severe MR). - appeared total body volume overloaded despite hypotension. . #. Afib: INR supratherapeutic at 13.2 on admission but quickly resolved s/p 2 U FFP and 10 mg vit K IV X 1 in the ED. No obvious signs of bleeding. HCT w/ hemoconcentration given baseline of 32. S/p AVN ablation and dual-chamber pacemaker. - held coumadin - trended coags . #. PVD: Known LUE and bilateral LE PVD followed by Dr. . - per , nothing to do for now . #. Macrocytic Anemia: Current hct likely hemoconcentration. No signs of bleeding. B12/folate wnl in . . EMERGENCY CONTACT: (, , wife "},"extractive_notes_summ":{"kind":"string","value":"HEENT: Normocephalic, atraumatic. HEENT: Normocephalic, atraumatic. HEENT: Normocephalic, atraumatic. HEENT: Normocephalic, atraumatic. CXR w/ loss of diaphragm on R but w/o obvious infiltrate. CXR w/ loss of diaphragm on R but w/o obvious infiltrate. CXR w/ loss of diaphragm on R but w/o obvious infiltrate. CXR w/ loss of diaphragm on R but w/o obvious infiltrate. CT head w/o acute process. CT head w/o acute process. CT head w/o acute process. CT head w/o acute process. Has sig vasculopathy. CT head neg. CT head neg. CT head neg. Pt is dialysis dependent. Head CT NEG. Head CT NEG. Head CT NEG. Head CT NEG. - hold coumadin - trend coags . - hold coumadin - trend coags . - hold coumadin - trend coags . - hold coumadin - trend coags . CXR w/ worsening bilat pl. CXR w/ worsening bilat pl. TITLE: Respiratory Pt. Response: Afebrile. Response: Afebrile. Response: Afebrile. Response: Afebrile. Response: Afebrile. - albuterol and atrovent nebs . - albuterol and atrovent nebs . - albuterol and atrovent nebs . - albuterol and atrovent nebs . INR 13.2, received IV vit K and FFP. INR 13.2, received IV vit K and FFP. INR 13.2, received IV vit K and FFP. INR 13.2, received IV vit K and FFP. Hypercarbic resp failure with minimal disturbance of Aa gradient. Altered mental status (not Delirium) Assessment: A&Ox1 w/ constant confused questions and statements; ? Altered mental status (not Delirium) Assessment: A&Ox1 w/ constant confused questions and statements; ? I noted that he was apneic w/o a pulse. PERRLA/EOMI. PERRLA/EOMI. PERRLA/EOMI. PERRLA/EOMI. Macrocytic Anemia: Current hct likely hemoconcentration. Macrocytic Anemia: Current hct likely hemoconcentration. Macrocytic Anemia: Current hct likely hemoconcentration. Macrocytic Anemia: Current hct likely hemoconcentration. LLE pedal pulses dopplarable, RLE dorsal pulses absent but post tib dopplerable. LLE pedal pulses dopplarable, RLE dorsal pulses absent but post tib dopplerable. PVD: Known LUE and bilateral LE PVD followed by Dr. . PVD: Known LUE and bilateral LE PVD followed by Dr. . PVD: Known LUE and bilateral LE PVD followed by Dr. . PVD: Known LUE and bilateral LE PVD followed by Dr. . ABDOMEN: NABS. ABDOMEN: NABS. ABDOMEN: NABS. ABDOMEN: NABS. Levophed started for hypotension resistant to IVF resuscitation. Levophed started for hypotension resistant to IVF resuscitation. Levophed started for hypotension resistant to IVF resuscitation. Levophed started for hypotension resistant to IVF resuscitation. infection vs hypercarbia. infection vs hypercarbia. Lactate 1.2. Lactate 1.2. and CHF. and CHF. ------ Protected Section Addendum Entered By: , MD on: 17:08 ------ Moderate (2+) aortic regurgitation is seen. Moderate (2+) aortic regurgitation is seen. Moderate (2+) aortic regurgitation is seen. Moderate (2+) aortic regurgitation is seen. Apparently has been on L NC at rehab w/ unclear diagnosis but getting spiriva and albuterol. Apparently has been on L NC at rehab w/ unclear diagnosis but getting spiriva and albuterol. Apparently has been on L NC at rehab w/ unclear diagnosis but getting spiriva and albuterol. Apparently has been on L NC at rehab w/ unclear diagnosis but getting spiriva and albuterol. Needed hands restrained otherwise pt was fine.Rxd with atrovent Q6 last 0600. In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22. In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22. In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22. In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22. LUE w/ old fistulas. LUE w/ old fistulas. Afib: INR supratherapeutic at 13.2. Afib: INR supratherapeutic at 13.2. Afib: INR supratherapeutic at 13.2. Afib: INR supratherapeutic at 13.2. Acute respiratory acidosis: Unclear precipitant. Acute respiratory acidosis: Unclear precipitant. Acute respiratory acidosis: Unclear precipitant. Acute respiratory acidosis: Unclear precipitant. Altered mental status: DDX from hypercarbia vs from percocets vs from infection. Altered mental status: DDX from hypercarbia vs from percocets vs from infection. Altered mental status: DDX from hypercarbia vs from percocets vs from infection. Altered mental status: DDX from hypercarbia vs from percocets vs from infection. Let renal know pt has been admitted. Concern for infectious process as patient remains hypotensive requiring Levophed gtt. Concern for infectious process as patient remains hypotensive requiring Levophed gtt. Concern for infectious process as patient remains hypotensive requiring Levophed gtt. EMS activated. eff. eff. - check a MVO2 . Hypotension: Concerning for sepsis given l-shift, indwelling HD line and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/ prior HD line. Hypotension: Concerning for sepsis given l-shift, indwelling HD line and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/ prior HD line. Hypotension: Concerning for sepsis given l-shift, indwelling HD line and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/ prior HD line. Hypotension: Concerning for sepsis given l-shift, indwelling HD line and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/ prior HD line. 24 Hour Events: In ED, noted SBP 70s not responsive to IVF challenges, U/S guided CVL placement Lt femoral. 24 Hour Events: In ED, noted SBP 70s not responsive to IVF challenges, U/S guided CVL placement Lt femoral. 24 Hour Events: In ED, noted SBP 70s not responsive to IVF challenges, U/S guided CVL placement Lt femoral."},"n_notes":{"kind":"number","value":20,"string":"20"},"notes":{"kind":"list like","value":[{"category":"Physician ","chartdate":"2134-04-12 00:00:00.000","description":"Physician Resident Admission Note","row_id":376058,"text":"Chief Complaint: Hypotension, altered mental status\n HPI:\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\n change. His son who accompanies him says that he has noticed an\n increase in his RR over the past few days and a decrease in his energy\n level. When he went to visit him this morning, he was very sleepy and\n not coherent which is a change so they called the ambulance. BP and O2\n sats there noted to be low. He did not eat breakfast this morning\n which is very unusual for him.\n .\n In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22.\n 97% on 5L NC. Arrived hypotensive in 70s, MS A+Ox3 here (but per son,\n not at baseline), BP unresponsive to 2L NS so left femoral central line\n placed under U/S guidance (as INR 13) and levo started. Moving arms\n but legs weaker. 2 U FFP, 10 vit K IV. Cxr w/ increased CHF. Head CT\n NEG. Could not pass foley X 2, now w/ small amt of blood. Given vanco\n 1g IV, levo 750 mg IV, flagyl 500 mg IV. Cool hands/feet, dopplerable\n PT but not DP, vasc called and will see on the floor. Guaiac + brown\n stool.\n .\n On arrival to the ICU, his son states he is more alert now but not back\n to baseline.\n .\n Review of systems: Pt. states he feels short of breath but cannot\n clarify further.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Horse/Equine Product Derivatives\n Unknown;\n Calcium Channel Blocking Agents-Benzothiazepines\n Headache;\n Metoprolol\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.12 mcg/Kg/min\n Other ICU medications:\n Other medications:\n (per med sheets)\n Coumadin 3 mg daily\n Dialysis at dialysis MWF\n Acetaminophen\n ASA 325 mg daily\n calcium acetate 667 mg 2 tabs tid\n dextroamphetamine 2.5 mg daily\n docusate\n folate 1 mg daily\n lotemax 0.5% eye drops\n mucinex 600 mg \n mucomyst nebs \n nephrocaps\n pantoprazole 40 mg daily\n sensipar 30 mg \n spiriva daily\n tobramycin 0.3% eye drops\n Valtrex 500 mg daily\n lactulose\n lorazepam 0.5 mg \n percocet 5/325 \n dexadrine 5 mg daily\n Albuterol\n vit B12 1000 mg daily\n nepro 235 daily\n albumin w/ dialysis\n darbapoetin w/ dialysis\n Past medical history:\n Family history:\n Social History:\n - PVD (Followed by ) w/ chronic LUE and bilateral LE ischemis\n - Chronic renal failure on HD x 4 years (thought to be due to\n obstructive uropathy, kidney stones, BPH)\n - Systolic heart failure w/ EF 25% on ECHO \n - Moderate aortic valve stenosis (area 1.0-1.2cm2). Moderate (2+)\n aortic regurgitation is seen. Moderate to severe (3+) mitral\n regurgitation is seen. There is mild pulmonary artery systolic\n hypertension. ()\n - Hx atrial fibrillation and paroxysmal atrial tachycardia\n - s/p AV nodal ablation and implantation of a dual chamber pacemaker\n - Baseline AV conduction delay\n - Hypertension\n - Coronary artery disease with old posterior MI on EKG and pMIBI\n in with EF44%, global hypokinesis, no reversible defects.\n - Hx Left 4-9th rib fx, Left hemothorax\n - R kidney stone s/p Lithotripsy\n (, complicated by ESBL Klebsiella UTI)\n - s/p stroke (cerebellar), found on MRI, sxs of gait instability\n - hx gait d/o, hand paresthesias, polyneuropathy, C3/C4 spinal\n cord compression cerival spondylosis, L median nerve injury\n - Anemia\n - Benign prostatic hypertrophy\n - Cluster headaches\n - Hx of positive PPD, never treated\n - Hx squamous cell and basal cell ca\n - HSV keratouveitis\n - ventral hernia\n - s/p open cholecystectomy \n - s/p small bowel resection (80-90%) for mesenteric ischemia\n - s/p umbilical hernia repair\n - s/p cystocele repair\n - s/p laminectomy - c/b osteomyelitis\n - s/p TURP \n There is no family history of premature coronary artery disease or\n sudden death.\n Patient has been at a NH and has not gotten home since hospitalization\n in . His wife lives in . He is a retired psychiatrist.\n Social history is significant for the remote tobacco use, 3ppd x 40\n years, quit 20 years ago. He drinks alcohol occasionally, denies\n illicit drug use.\n Review of systems:\n Flowsheet Data as of 02:32 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.5\nC (95.9\n HR: 70 (70 - 76) bpm\n BP: 101/58(68) {89/58(68) - 101/68(73)} mmHg\n RR: 18 (17 - 20) insp/min\n SpO2: 94%\n Heart rhythm: V Paced\n Height: 70 Inch\n Total In:\n 2,116 mL\n PO:\n TF:\n IVF:\n 116 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,116 mL\n Respiratory\n O2 Delivery Device: Bipap mask\n SpO2: 94%\n Physical Examination\n GENERAL: Awake but confused, NAD. Answers do not make sense.\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. dry MM. OP w/ poor dentition. Neck Supple.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or but very distant heart sounds.\n LUNGS: Occasional crackles anteriorly and posteriorly w/ poor\n inspiratory effort.\n ABDOMEN: NABS. Soft, midline scar. No HSM\n EXTREMITIES: anasarca, palp radial pulses, dopperable PT/DP\n bilaterally. L hand w/ purple fingertips on fingers 2, 3 and 4.\n SKIN: Xerosis.\n NEURO: Alert but not oriented. Speaking nonsensical sentences. Able\n to show 2 fingers on the R but not L. Able to wiggle toes. Could not\n follow other commands.\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:1.2 mmol/L\n Imaging: CT Head: wet read - no acute intracranial pathology.\n .\n CXR:\n FINDINGS: Comparison is made to . Right pacemaker and two\n intracardiac leads remain in place. Since prior exam, left IJ\n hemodialysis catheter has been placed, with tip low in position,\n possibly within the IVC. Vascular stens are noted in the left\n subclavian and brachiocephalic vein.\n Cardiomegaly again noted with central congestion, bilateral pleural\n effusions. Lung bases are suboptimally assessed given low lung volumes\n though compared with prior, effusion and CHF is increased.\n IMPRESSION:\n 1. Dialysis catheter tip low, likely in IVC.\n 2. CHF, worse.\n Microbiology: Blood cx w/ NGTD\n ECG: ECG: V-paced (74)\n Assessment and Plan\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\n change and hypotension.\n .\n #. Hypotension: Concerning for sepsis given l-shift, indwelling HD line\n and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/\n prior HD line. Also has a pacemaker. Could not get a urine specimen.\n CXR w/ loss of diaphragm on R but w/o obvious infiltrate. Could also\n be from cardiogenic shock given baseline depressed EF.\n - cover w/ broad-spectrum antibiotics w/ Vanc/ given h/o ESBL and\n narrow as cx return\n - NE w/ goal MAP > 60\n - continue to gently bolus w/ LR given depressed EF, severe valvular\n disease\n - Repeat ECHO to eval for worsening CHF/Valvular disease\n - would ideally like to place an a-line for HD monitoring but I would\n be concerned to precipitate ischemia to R hand and L-hand already\n ischemic. Will follow w/ non-invasive for now.\n - check a MVO2\n .\n #. Acute respiratory acidosis: Unclear precipitant. DDX from percocets\n vs infection vs hypophosphatemia vs respiratory muscle fatigue\n - will try bipap for now to see if he tolerates\n - check phos\n - continue to monitor\n .\n #. Altered mental status: DDX from hypercarbia vs from percocets vs\n from infection. CT head w/o acute process. Could possibly be from\n meningitis but no nucal rigidity or headache.\n - continue to monitor\n .\n #. Hypoxia: CXR seems consistent w/ pulmonary edema. Likely from\n worsening valvular disease. Could also be an infiltrate that is hidden\n by edema. Apparently has been on L NC at rehab w/ unclear\n diagnosis but getting spiriva and albuterol. No formal dx of COPD.\n - albuterol and atrovent nebs\n .\n #. ESRD on HD: Dialysis MWF at Dialysis.\n - contact renal in the am for cvvh vs HD depending on BP\n .\n #. Systolic heart failure: Unclear if ischemic in etiology or from\n valvular disease (mod AS, severe MR).\n - appears total body volume overloaded despite hypotension.\n .\n #. Afib: INR supratherapeutic at 13.2. Now s/p 2 U FFP and 10 mg vit K\n IV X 1 in the ED. No obvious signs of bleeding. HCT w/\n hemoconcentration given baseline of 32. S/p AVN ablation and\n dual-chamber pacemaker.\n - hold coumadin\n - trend coags\n .\n #. PVD: Known LUE and bilateral LE PVD followed by Dr. .\n - appreciate vascular input, nothing to do for now\n .\n #. Macrocytic Anemia: Current hct likely hemoconcentration. Will watch\n for signs of bleeding given supra-therapeutic INR. B12/folate wnl in\n .\n - trend for now.\n - guaiac stools\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 12:30 AM\n Dialysis Catheter - 12:30 AM\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2134-04-12 00:00:00.000","description":"Physician Resident Admission Note","row_id":376059,"text":"Chief Complaint: Hypotension, altered mental status\n HPI:\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\n change. His son who accompanies him says that he has noticed an\n increase in his RR over the past few days and a decrease in his energy\n level. When he went to visit him this morning, he was very sleepy and\n not coherent which is a change so they called the ambulance. BP and O2\n sats there noted to be low. He did not eat breakfast this morning\n which is very unusual for him.\n .\n In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22.\n 97% on 5L NC. Arrived hypotensive in 70s, MS A+Ox3 here (but per son,\n not at baseline), BP unresponsive to 2L NS so left femoral central line\n placed under U/S guidance (as INR 13) and levo started. Moving arms\n but legs weaker. 2 U FFP, 10 vit K IV. Cxr w/ increased CHF. Head CT\n NEG. Could not pass foley X 2, now w/ small amt of blood. Given vanco\n 1g IV, levo 750 mg IV, flagyl 500 mg IV. Cool hands/feet, dopplerable\n PT but not DP, vasc called and will see on the floor. Guaiac + brown\n stool.\n .\n On arrival to the ICU, his son states he is more alert now but not back\n to baseline.\n .\n Review of systems: Pt. states he feels short of breath but cannot\n clarify further.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Horse/Equine Product Derivatives\n Unknown;\n Calcium Channel Blocking Agents-Benzothiazepines\n Headache;\n Metoprolol\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.12 mcg/Kg/min\n Other ICU medications:\n Other medications:\n (per med sheets)\n Coumadin 3 mg daily\n Dialysis at dialysis MWF\n Acetaminophen\n ASA 325 mg daily\n calcium acetate 667 mg 2 tabs tid\n dextroamphetamine 2.5 mg daily\n docusate\n folate 1 mg daily\n lotemax 0.5% eye drops\n mucinex 600 mg \n mucomyst nebs \n nephrocaps\n pantoprazole 40 mg daily\n sensipar 30 mg \n spiriva daily\n tobramycin 0.3% eye drops\n Valtrex 500 mg daily\n lactulose\n lorazepam 0.5 mg \n percocet 5/325 \n dexadrine 5 mg daily\n Albuterol\n vit B12 1000 mg daily\n nepro 235 daily\n albumin w/ dialysis\n darbapoetin w/ dialysis\n Past medical history:\n Family history:\n Social History:\n - PVD (Followed by ) w/ chronic LUE and bilateral LE ischemis\n - Chronic renal failure on HD x 4 years (thought to be due to\n obstructive uropathy, kidney stones, BPH)\n - Systolic heart failure w/ EF 25% on ECHO \n - Moderate aortic valve stenosis (area 1.0-1.2cm2). Moderate (2+)\n aortic regurgitation is seen. Moderate to severe (3+) mitral\n regurgitation is seen. There is mild pulmonary artery systolic\n hypertension. ()\n - Hx atrial fibrillation and paroxysmal atrial tachycardia\n - s/p AV nodal ablation and implantation of a dual chamber pacemaker\n - Baseline AV conduction delay\n - Hypertension\n - Coronary artery disease with old posterior MI on EKG and pMIBI\n in with EF44%, global hypokinesis, no reversible defects.\n - Hx Left 4-9th rib fx, Left hemothorax\n - R kidney stone s/p Lithotripsy\n (, complicated by ESBL Klebsiella UTI)\n - s/p stroke (cerebellar), found on MRI, sxs of gait instability\n - hx gait d/o, hand paresthesias, polyneuropathy, C3/C4 spinal\n cord compression cerival spondylosis, L median nerve injury\n - Anemia\n - Benign prostatic hypertrophy\n - Cluster headaches\n - Hx of positive PPD, never treated\n - Hx squamous cell and basal cell ca\n - HSV keratouveitis\n - ventral hernia\n - s/p open cholecystectomy \n - s/p small bowel resection (80-90%) for mesenteric ischemia\n - s/p umbilical hernia repair\n - s/p cystocele repair\n - s/p laminectomy - c/b osteomyelitis\n - s/p TURP \n There is no family history of premature coronary artery disease or\n sudden death.\n Patient has been at a NH and has not gotten home since hospitalization\n in . His wife lives in . He is a retired psychiatrist.\n Social history is significant for the remote tobacco use, 3ppd x 40\n years, quit 20 years ago. He drinks alcohol occasionally, denies\n illicit drug use.\n Review of systems:\n Flowsheet Data as of 02:32 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.5\nC (95.9\n HR: 70 (70 - 76) bpm\n BP: 101/58(68) {89/58(68) - 101/68(73)} mmHg\n RR: 18 (17 - 20) insp/min\n SpO2: 94%\n Heart rhythm: V Paced\n Height: 70 Inch\n Total In:\n 2,116 mL\n PO:\n TF:\n IVF:\n 116 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,116 mL\n Respiratory\n O2 Delivery Device: Bipap mask\n SpO2: 94%\n Physical Examination\n GENERAL: Awake but confused, NAD. Answers do not make sense.\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. dry MM. OP w/ poor dentition. Neck Supple.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or but very distant heart sounds.\n LUNGS: Occasional crackles anteriorly and posteriorly w/ poor\n inspiratory effort.\n ABDOMEN: NABS. Soft, midline scar. No HSM\n EXTREMITIES: anasarca, palp radial pulses, dopperable PT/DP\n bilaterally. L hand w/ purple fingertips on fingers 2, 3 and 4.\n SKIN: Xerosis.\n NEURO: Alert but not oriented. Speaking nonsensical sentences. Able\n to show 2 fingers on the R but not L. Able to wiggle toes. Could not\n follow other commands.\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:1.2 mmol/L\n Imaging: CT Head: wet read - no acute intracranial pathology.\n .\n CXR:\n FINDINGS: Comparison is made to . Right pacemaker and two\n intracardiac leads remain in place. Since prior exam, left IJ\n hemodialysis catheter has been placed, with tip low in position,\n possibly within the IVC. Vascular stens are noted in the left\n subclavian and brachiocephalic vein.\n Cardiomegaly again noted with central congestion, bilateral pleural\n effusions. Lung bases are suboptimally assessed given low lung volumes\n though compared with prior, effusion and CHF is increased.\n IMPRESSION:\n 1. Dialysis catheter tip low, likely in IVC.\n 2. CHF, worse.\n Microbiology: Blood cx w/ NGTD\n ECG: ECG: V-paced (74)\n Assessment and Plan\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\n change and hypotension.\n .\n #. Hypotension: Concerning for sepsis given l-shift, indwelling HD line\n and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/\n prior HD line. Also has a pacemaker. Could not get a urine specimen.\n CXR w/ loss of diaphragm on R but w/o obvious infiltrate. Could also\n be from cardiogenic shock given baseline depressed EF. Cardiac output\n limited by paced rate.\n - cover w/ broad-spectrum antibiotics w/ Vanc/ given h/o ESBL and\n narrow as cx return\n - NE w/ goal MAP > 60\n - continue to gently bolus w/ LR given depressed EF, severe valvular\n disease\n - Repeat ECHO to eval for worsening CHF/Valvular disease\n - would ideally like to place an a-line for HD monitoring but I would\n be concerned to precipitate ischemia to R hand and L-hand already\n ischemic. Will follow w/ non-invasive for now.\n - check a MVO2\n - will ask EP to turn up rate in am\n .\n #. Acute respiratory acidosis: Unclear precipitant. DDX from percocets\n vs infection vs hypophosphatemia vs respiratory muscle fatigue\n - will try bipap for now to see if he tolerates\n - check phos\n - continue to monitor\n .\n #. Altered mental status: DDX from hypercarbia vs from percocets vs\n from infection. CT head w/o acute process. Could possibly be from\n meningitis but no nucal rigidity or headache.\n - continue to monitor\n .\n #. Hypoxia: CXR seems consistent w/ pulmonary edema. Likely from\n worsening valvular disease. Could also be an infiltrate that is hidden\n by edema. Apparently has been on L NC at rehab w/ unclear\n diagnosis but getting spiriva and albuterol. No formal dx of COPD.\n - albuterol and atrovent nebs\n .\n #. ESRD on HD: Dialysis MWF at Dialysis.\n - contact renal in the am for cvvh vs HD depending on BP\n .\n #. Systolic heart failure: Unclear if ischemic in etiology or from\n valvular disease (mod AS, severe MR).\n - appears total body volume overloaded despite hypotension.\n .\n #. Afib: INR supratherapeutic at 13.2. Now s/p 2 U FFP and 10 mg vit K\n IV X 1 in the ED. No obvious signs of bleeding. HCT w/\n hemoconcentration given baseline of 32. S/p AVN ablation and\n dual-chamber pacemaker.\n - hold coumadin\n - trend coags\n .\n #. PVD: Known LUE and bilateral LE PVD followed by Dr. .\n - appreciate vascular input, nothing to do for now\n .\n #. Macrocytic Anemia: Current hct likely hemoconcentration. Will watch\n for signs of bleeding given supra-therapeutic INR. B12/folate wnl in\n .\n - trend for now.\n - guaiac stools\n ICU Care\n Nutrition:NPO for now\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 12:30 AM\n Dialysis Catheter - 12:30 AM\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2134-04-12 00:00:00.000","description":"MICU Attending Note","row_id":376063,"text":"TITLE:\n Chart reviewed, patient examined. Case discussed in detail with\n resident. I agree with her note and gap outlined above. In addition,\n I would add/emphasize:\n 83M w/ multiple medical problems including ESRD on HD, Afib s/p AVN\n ablation and dual-chamber PM, systolic CHF (EF 25%, 2+AS, 3+MR)\n transferred from nursing home, w/ MS change. Pt has been at NH/rehab\n since last admission for UTI at . Son noted increase in\n pt\ns RR over the past several days as well as decrease in his energy\n level. While visiting pt son noted father to be solmolent and more\n confused. EMS activated. In ED, noted SBP 70s not responsive to IVF\n challenges, U/S guided CVL placement Lt femoral. Vanc/Levo/Flagyl\n started empirically for sepsis. INR 13.2, received IV vit K and FFP.\n Levophed started for hypotension resistant to IVF resuscitation.\n Transferred to MICU for managemend of sepsis, hemodynamics. No\n headache or photophobia.\n On exam:\n 95.9, 101/68, 70v-paced, 91% 5L NC\n Mask vent. Suppine in bed NAD\n Rales b/l\n Distant heart sounds\n Soft ntnd bs+\n 2+ pitting edema, dusky digits UE & LE worst on Lt hand\n No nuchal rigidity\n Data:\n 7.13/79/70 in ED 7.17/79/49 VBG in ICU\n W8.6 91S/1B Hct 48.4 plt 200\n Hco3 26 creat 4.3 .INR 13.2\n CT head\n no bleed, mass\n CXR\n lowish lung volumes, dialysis line goes down into IVC,\n cardiomegally, rotation, CHF increased vs. last\n AP/\n 83M w/ MMP presents with sepsis of unclear etiology given hypothermia,\n left shift, hypotension requiring pressors. Source unclear, several\n potential causes including line infxn from indwelling dialysis line,\n uti possible though makes little urine. BCx sent, ucx when able.\n Meningitis is in differential, esp given new confusion (but also has\n inc CO2, acute illness in elderly which could explain) but doesn\nt have\n neck stiffness, photophobia or headache. INR is too high for LP so\n cover empirically w/ broad spectrum abx.\n Hypercarbic resp failure with minimal disturbance of Aa gradient. A\n bit hard to explain as would expect more disturbance in oxygenation\n rather than acute disturbance in ventilation unless worsening of\n underlying lung disease. If doesn\nt turn around quickly would intubate\n to facilitate care. Appears to be acute respiratory acidosis by abg.\n Pt labs suggest strongly hemoconcentrated though CXR c/w chronic CHF\n (EF25% by last measure) , gentle fluid boluses as likely has small\n euvolemic zone.\n Has sig vasculopathy. Digits dusky at baseline. Carefully monitoring\n but is at risk while requiring pressors esp with alpha activity.\n Vascular consulted.\n Pt is dialysis dependent. Let renal know pt has been admitted.\n Remainder of plan as outlined in resident note above.\n Pt is critically ill.\n Time spent on care: 50\n"},{"category":"Physician ","chartdate":"2134-04-12 00:00:00.000","description":"Physician Resident Admission Note","row_id":376064,"text":"Chief Complaint: Hypotension, altered mental status\n HPI:\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\n change. His son who accompanies him says that he has noticed an\n increase in his RR over the past few days and a decrease in his energy\n level. When he went to visit him this morning, he was very sleepy and\n not coherent which is a change so they called the ambulance. BP and O2\n sats there noted to be low. He did not eat breakfast this morning\n which is very unusual for him.\n .\n In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22.\n 97% on 5L NC. Arrived hypotensive in 70s, MS A+Ox3 here (but per son,\n not at baseline), BP unresponsive to 2L NS so left femoral central line\n placed under U/S guidance (as INR 13) and levo started. Moving arms\n but legs weaker. 2 U FFP, 10 vit K IV. Cxr w/ increased CHF. Head CT\n NEG. Could not pass foley X 2, now w/ small amt of blood. Given vanco\n 1g IV, levo 750 mg IV, flagyl 500 mg IV. Cool hands/feet, dopplerable\n PT but not DP, vasc called and will see on the floor. Guaiac + brown\n stool.\n .\n On arrival to the ICU, his son states he is more alert now but not back\n to baseline.\n .\n Review of systems: Pt. states he feels short of breath but cannot\n clarify further.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Horse/Equine Product Derivatives\n Unknown;\n Calcium Channel Blocking Agents-Benzothiazepines\n Headache;\n Metoprolol\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.12 mcg/Kg/min\n Other ICU medications:\n Other medications:\n (per med sheets)\n Coumadin 3 mg daily\n Dialysis at dialysis MWF\n Acetaminophen\n ASA 325 mg daily\n calcium acetate 667 mg 2 tabs tid\n dextroamphetamine 2.5 mg daily\n docusate\n folate 1 mg daily\n lotemax 0.5% eye drops\n mucinex 600 mg \n mucomyst nebs \n nephrocaps\n pantoprazole 40 mg daily\n sensipar 30 mg \n spiriva daily\n tobramycin 0.3% eye drops\n Valtrex 500 mg daily\n lactulose\n lorazepam 0.5 mg \n percocet 5/325 \n dexadrine 5 mg daily\n Albuterol\n vit B12 1000 mg daily\n nepro 235 daily\n albumin w/ dialysis\n darbapoetin w/ dialysis\n Past medical history:\n Family history:\n Social History:\n - PVD (Followed by ) w/ chronic LUE and bilateral LE ischemis\n - Chronic renal failure on HD x 4 years (thought to be due to\n obstructive uropathy, kidney stones, BPH)\n - Systolic heart failure w/ EF 25% on ECHO \n - Moderate aortic valve stenosis (area 1.0-1.2cm2). Moderate (2+)\n aortic regurgitation is seen. Moderate to severe (3+) mitral\n regurgitation is seen. There is mild pulmonary artery systolic\n hypertension. ()\n - Hx atrial fibrillation and paroxysmal atrial tachycardia\n - s/p AV nodal ablation and implantation of a dual chamber pacemaker\n - Baseline AV conduction delay\n - Hypertension\n - Coronary artery disease with old posterior MI on EKG and pMIBI\n in with EF44%, global hypokinesis, no reversible defects.\n - Hx Left 4-9th rib fx, Left hemothorax\n - R kidney stone s/p Lithotripsy\n (, complicated by ESBL Klebsiella UTI)\n - s/p stroke (cerebellar), found on MRI, sxs of gait instability\n - hx gait d/o, hand paresthesias, polyneuropathy, C3/C4 spinal\n cord compression cerival spondylosis, L median nerve injury\n - Anemia\n - Benign prostatic hypertrophy\n - Cluster headaches\n - Hx of positive PPD, never treated\n - Hx squamous cell and basal cell ca\n - HSV keratouveitis\n - ventral hernia\n - s/p open cholecystectomy \n - s/p small bowel resection (80-90%) for mesenteric ischemia\n - s/p umbilical hernia repair\n - s/p cystocele repair\n - s/p laminectomy - c/b osteomyelitis\n - s/p TURP \n There is no family history of premature coronary artery disease or\n sudden death.\n Patient has been at a NH and has not gotten home since hospitalization\n in . His wife lives in . He is a retired psychiatrist.\n Social history is significant for the remote tobacco use, 3ppd x 40\n years, quit 20 years ago. He drinks alcohol occasionally, denies\n illicit drug use.\n Review of systems:\n Flowsheet Data as of 02:32 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.5\nC (95.9\n HR: 70 (70 - 76) bpm\n BP: 101/58(68) {89/58(68) - 101/68(73)} mmHg\n RR: 18 (17 - 20) insp/min\n SpO2: 94%\n Heart rhythm: V Paced\n Height: 70 Inch\n Total In:\n 2,116 mL\n PO:\n TF:\n IVF:\n 116 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,116 mL\n Respiratory\n O2 Delivery Device: Bipap mask\n SpO2: 94%\n Physical Examination\n GENERAL: Awake but confused, NAD. Answers do not make sense.\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. dry MM. OP w/ poor dentition. Neck Supple.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or but very distant heart sounds.\n LUNGS: Occasional crackles anteriorly and posteriorly w/ poor\n inspiratory effort.\n ABDOMEN: NABS. Soft, midline scar. No HSM\n EXTREMITIES: anasarca, palp radial pulses, dopperable PT/DP\n bilaterally. L hand w/ purple fingertips on fingers 2, 3 and 4.\n SKIN: Xerosis.\n NEURO: Alert but not oriented. Speaking nonsensical sentences. Able\n to show 2 fingers on the R but not L. Able to wiggle toes. Could not\n follow other commands.\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:1.2 mmol/L\n Imaging: CT Head: wet read - no acute intracranial pathology.\n .\n CXR:\n FINDINGS: Comparison is made to . Right pacemaker and two\n intracardiac leads remain in place. Since prior exam, left IJ\n hemodialysis catheter has been placed, with tip low in position,\n possibly within the IVC. Vascular stens are noted in the left\n subclavian and brachiocephalic vein.\n Cardiomegaly again noted with central congestion, bilateral pleural\n effusions. Lung bases are suboptimally assessed given low lung volumes\n though compared with prior, effusion and CHF is increased.\n IMPRESSION:\n 1. Dialysis catheter tip low, likely in IVC.\n 2. CHF, worse.\n Microbiology: Blood cx w/ NGTD\n ECG: ECG: V-paced (74)\n Assessment and Plan\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\n change and hypotension.\n .\n #. Hypotension: Concerning for sepsis given l-shift, indwelling HD line\n and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/\n prior HD line. Also has a pacemaker. Could not get a urine specimen.\n CXR w/ loss of diaphragm on R but w/o obvious infiltrate. Could also\n be from a meningitis given altered mental status. Would be unsafe to\n perform LP in the setting of INR 13.3. Could also be from cardiogenic\n shock given baseline depressed EF. Cardiac output limited by paced\n rate.\n - cover w/ antibiotics to treat meningitis w/ Vanc/CTX, ampicillin\n acyclovir for now\n - NE w/ goal MAP > 60\n - continue to gently bolus w/ LR given depressed EF, severe valvular\n disease\n - Repeat ECHO to eval for worsening CHF/Valvular disease\n - would ideally like to place an a-line for HD monitoring but I would\n be concerned to precipitate ischemia to R hand and L-hand already\n ischemic. Will follow w/ non-invasive for now.\n - check a MVO2\n - will ask EP to turn up rate in am\n .\n #. Acute respiratory acidosis: Unclear precipitant. DDX from percocets\n vs infection vs hypophosphatemia vs respiratory muscle fatigue\n - will try bipap for now to see if he tolerates\n - check phos\n - continue to monitor\n .\n #. Altered mental status: DDX from hypercarbia vs from percocets vs\n from infection. CT head w/o acute process. Could possibly be from\n meningitis but no nucal rigidity or headache.\n - continue to monitor\n - treat empirically for meningitis as cannot safely do an LP given\n coagulopathy\n .\n #. Hypoxia: CXR seems consistent w/ pulmonary edema. Likely from\n worsening valvular disease. Could also be an infiltrate that is hidden\n by edema. Apparently has been on L NC at rehab w/ unclear\n diagnosis but getting spiriva and albuterol. No formal dx of COPD.\n - albuterol and atrovent nebs\n .\n #. ESRD on HD: Dialysis MWF at Dialysis.\n - contact renal in the am for cvvh vs HD depending on BP\n .\n #. Systolic heart failure: Unclear if ischemic in etiology or from\n valvular disease (mod AS, severe MR).\n - appears total body volume overloaded despite hypotension.\n .\n #. Afib: INR supratherapeutic at 13.2. Now s/p 2 U FFP and 10 mg vit K\n IV X 1 in the ED. No obvious signs of bleeding. HCT w/\n hemoconcentration given baseline of 32. S/p AVN ablation and\n dual-chamber pacemaker.\n - hold coumadin\n - trend coags\n .\n #. PVD: Known LUE and bilateral LE PVD followed by Dr. .\n - appreciate vascular input, nothing to do for now\n .\n #. Macrocytic Anemia: Current hct likely hemoconcentration. Will watch\n for signs of bleeding given supra-therapeutic INR. B12/folate wnl in\n .\n - trend for now.\n - guaiac stools\n ICU Care\n Nutrition:NPO for now\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 12:30 AM\n Dialysis Catheter - 12:30 AM\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2134-04-12 00:00:00.000","description":"Physician Resident Admission Note","row_id":376098,"text":"Chief Complaint: Hypotension, altered mental status\n HPI:\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\n change. His son who accompanies him says that he has noticed an\n increase in his RR over the past few days and a decrease in his energy\n level. When he went to visit him this morning, he was very sleepy and\n not coherent which is a change so they called the ambulance. BP and O2\n sats there noted to be low. He did not eat breakfast this morning\n which is very unusual for him.\n .\n In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22.\n 97% on 5L NC. Arrived hypotensive in 70s, MS A+Ox3 here (but per son,\n not at baseline), BP unresponsive to 2L NS so left femoral central line\n placed under U/S guidance (as INR 13) and levo started. Moving arms\n but legs weaker. 2 U FFP, 10 vit K IV. Cxr w/ increased CHF. Head CT\n NEG. Could not pass foley X 2, now w/ small amt of blood. Given vanco\n 1g IV, levo 750 mg IV, flagyl 500 mg IV. Cool hands/feet, dopplerable\n PT but not DP, vasc called and will see on the floor. Guaiac + brown\n stool.\n .\n On arrival to the ICU, his son states he is more alert now but not back\n to baseline.\n .\n Review of systems: Pt. states he feels short of breath but cannot\n clarify further.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Horse/Equine Product Derivatives\n Unknown;\n Calcium Channel Blocking Agents-Benzothiazepines\n Headache;\n Metoprolol\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.12 mcg/Kg/min\n Other ICU medications:\n Other medications:\n (per med sheets)\n Coumadin 3 mg daily\n Dialysis at dialysis MWF\n Acetaminophen\n ASA 325 mg daily\n calcium acetate 667 mg 2 tabs tid\n dextroamphetamine 2.5 mg daily\n docusate\n folate 1 mg daily\n lotemax 0.5% eye drops\n mucinex 600 mg \n mucomyst nebs \n nephrocaps\n pantoprazole 40 mg daily\n sensipar 30 mg \n spiriva daily\n tobramycin 0.3% eye drops\n Valtrex 500 mg daily\n lactulose\n lorazepam 0.5 mg \n percocet 5/325 \n dexadrine 5 mg daily\n Albuterol\n vit B12 1000 mg daily\n nepro 235 daily\n albumin w/ dialysis\n darbapoetin w/ dialysis\n Past medical history:\n Family history:\n Social History:\n - PVD (Followed by ) w/ chronic LUE and bilateral LE ischemis\n - Chronic renal failure on HD x 4 years (thought to be due to\n obstructive uropathy, kidney stones, BPH)\n - Systolic heart failure w/ EF 25% on ECHO \n - Moderate aortic valve stenosis (area 1.0-1.2cm2). Moderate (2+)\n aortic regurgitation is seen. Moderate to severe (3+) mitral\n regurgitation is seen. There is mild pulmonary artery systolic\n hypertension. ()\n - Hx atrial fibrillation and paroxysmal atrial tachycardia\n - s/p AV nodal ablation and implantation of a dual chamber pacemaker\n - Baseline AV conduction delay\n - Hypertension\n - Coronary artery disease with old posterior MI on EKG and pMIBI\n in with EF44%, global hypokinesis, no reversible defects.\n - Hx Left 4-9th rib fx, Left hemothorax\n - R kidney stone s/p Lithotripsy\n (, complicated by ESBL Klebsiella UTI)\n - s/p stroke (cerebellar), found on MRI, sxs of gait instability\n - hx gait d/o, hand paresthesias, polyneuropathy, C3/C4 spinal\n cord compression cerival spondylosis, L median nerve injury\n - Anemia\n - Benign prostatic hypertrophy\n - Cluster headaches\n - Hx of positive PPD, never treated\n - Hx squamous cell and basal cell ca\n - HSV keratouveitis\n - ventral hernia\n - s/p open cholecystectomy \n - s/p small bowel resection (80-90%) for mesenteric ischemia\n - s/p umbilical hernia repair\n - s/p cystocele repair\n - s/p laminectomy - c/b osteomyelitis\n - s/p TURP \n There is no family history of premature coronary artery disease or\n sudden death.\n Patient has been at a NH and has not gotten home since hospitalization\n in . His wife lives in . He is a retired psychiatrist.\n Social history is significant for the remote tobacco use, 3ppd x 40\n years, quit 20 years ago. He drinks alcohol occasionally, denies\n illicit drug use.\n Review of systems:\n Flowsheet Data as of 02:32 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.5\nC (95.9\n HR: 70 (70 - 76) bpm\n BP: 101/58(68) {89/58(68) - 101/68(73)} mmHg\n RR: 18 (17 - 20) insp/min\n SpO2: 94%\n Heart rhythm: V Paced\n Height: 70 Inch\n Total In:\n 2,116 mL\n PO:\n TF:\n IVF:\n 116 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,116 mL\n Respiratory\n O2 Delivery Device: Bipap mask\n SpO2: 94%\n Physical Examination\n GENERAL: Awake but confused, NAD. Answers do not make sense.\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. dry MM. OP w/ poor dentition. Neck Supple.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or but very distant heart sounds.\n LUNGS: Occasional crackles anteriorly and posteriorly w/ poor\n inspiratory effort.\n ABDOMEN: NABS. Soft, midline scar. No HSM\n EXTREMITIES: anasarca, palp radial pulses, dopperable PT/DP\n bilaterally. L hand w/ purple fingertips on fingers 2, 3 and 4.\n SKIN: Xerosis.\n NEURO: Alert but not oriented. Speaking nonsensical sentences. Able\n to show 2 fingers on the R but not L. Able to wiggle toes. Could not\n follow other commands.\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:1.2 mmol/L\n Imaging: CT Head: wet read - no acute intracranial pathology.\n .\n CXR:\n FINDINGS: Comparison is made to . Right pacemaker and two\n intracardiac leads remain in place. Since prior exam, left IJ\n hemodialysis catheter has been placed, with tip low in position,\n possibly within the IVC. Vascular stens are noted in the left\n subclavian and brachiocephalic vein.\n Cardiomegaly again noted with central congestion, bilateral pleural\n effusions. Lung bases are suboptimally assessed given low lung volumes\n though compared with prior, effusion and CHF is increased.\n IMPRESSION:\n 1. Dialysis catheter tip low, likely in IVC.\n 2. CHF, worse.\n Microbiology: Blood cx w/ NGTD\n ECG: ECG: V-paced (74)\n Assessment and Plan\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\n change and hypotension.\n .\n #. Hypotension: Concerning for sepsis given l-shift, indwelling HD line\n and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/\n prior HD line. Also has a pacemaker. Could not get a urine specimen.\n CXR w/ loss of diaphragm on R but w/o obvious infiltrate. Could also\n be from a meningitis given altered mental status. Would be unsafe to\n perform LP in the setting of INR 13.3. Could also be from cardiogenic\n shock given baseline depressed EF. Cardiac output limited by paced\n rate.\n - cover w/ antibiotics to treat meningitis w/ Vanc/CTX, ampicillin\n acyclovir for now\n - NE w/ goal MAP > 60\n - continue to gently bolus w/ LR given depressed EF, severe valvular\n disease\n - Repeat ECHO to eval for worsening CHF/Valvular disease\n - would ideally like to place an a-line for HD monitoring but I would\n be concerned to precipitate ischemia to R hand and L-hand already\n ischemic. Will follow w/ non-invasive for now.\n - check a MVO2\n - will ask EP to turn up rate in am\n .\n #. Acute respiratory acidosis: Unclear precipitant. DDX from percocets\n vs infection vs hypophosphatemia vs respiratory muscle fatigue\n - will try bipap for now to see if he tolerates\n - check phos\n - continue to monitor\n .\n #. Altered mental status: DDX from hypercarbia vs from percocets vs\n from infection. CT head w/o acute process. Could possibly be from\n meningitis but no nucal rigidity or headache.\n - continue to monitor\n - treat empirically for meningitis as cannot safely do an LP given\n coagulopathy\n .\n #. Hypoxia: CXR seems consistent w/ pulmonary edema. Likely from\n worsening valvular disease. Could also be an infiltrate that is hidden\n by edema. Apparently has been on L NC at rehab w/ unclear\n diagnosis but getting spiriva and albuterol. No formal dx of COPD.\n - albuterol and atrovent nebs\n .\n #. ESRD on HD: Dialysis MWF at Dialysis.\n - contact renal in the am for cvvh vs HD depending on BP\n .\n #. Systolic heart failure: Unclear if ischemic in etiology or from\n valvular disease (mod AS, severe MR).\n - appears total body volume overloaded despite hypotension.\n .\n #. Afib: INR supratherapeutic at 13.2. Now s/p 2 U FFP and 10 mg vit K\n IV X 1 in the ED. No obvious signs of bleeding. HCT w/\n hemoconcentration given baseline of 32. S/p AVN ablation and\n dual-chamber pacemaker.\n - hold coumadin\n - trend coags\n .\n #. PVD: Known LUE and bilateral LE PVD followed by Dr. .\n - appreciate vascular input, nothing to do for now\n .\n #. Macrocytic Anemia: Current hct likely hemoconcentration. Will watch\n for signs of bleeding given supra-therapeutic INR. B12/folate wnl in\n .\n - trend for now.\n - guaiac stools\n ICU Care\n Nutrition:NPO for now\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 12:30 AM\n Dialysis Catheter - 12:30 AM\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Will cont vanco, CTX, amp, acyclovir given concern for infection. Will\n cont to trend VBGs. Call renal due to need for HD, f/u vasc recs but\n hold on any A-line given PVD. User BiPAP as tolerated. Discuss with\n family re: goals of care. Will attempt LP today after repeating coags.\n ------ Protected Section Addendum Entered By: , MD\n on: 08:55 ------\n"},{"category":"Physician ","chartdate":"2134-04-12 00:00:00.000","description":"Physician Attending Progress Note","row_id":376099,"text":"Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 83M w/ multiple medical problems including ESRD on HD, Afib s/p AVN\n ablation and dual-chamber PM, systolic CHF (EF 25%, 2+AS, 3+MR)\n transferred from nursing home, w/ tachypnea and decreased\n responsiveness, in presumed septic shock.\n 24 Hour Events:\n In ED, noted SBP 70s not responsive to IVF challenges, U/S guided CVL\n placement Lt femoral. Vanc/Levo/Flagyl started empirically for\n sepsis. INR 13.2, received IV vit K and FFP. Levophed started for\n hypotension resistant to IVF resuscitation. Transferred to MICU for\n managemend of sepsis, hemodynamics.\n PMH:\n On continuous O2 at nursing home for unclear reasons\n CAD\n s/p pacer\n ICM- EF 15-20%\n ESRD on HD via L IJ cath x 4yrs d/t obstructive uropathy\n MR\n Afib\n PVD\n HTN\n SH: remote prior smoker\n Overnight, underwent head CT without focal change. Evaluated by\n Vascular svce. Remained on Levophed overnight. Started on BiPAP\n w/ 5LO2 overnight, now on NC 3L\n Patient unable to provide history: Encephalopathy\n Allergies:\n Horse/Equine Product Derivatives\n Unknown;\n Calcium Channel Blocking Agents-Benzothiazepines\n Headache;\n Metoprolol\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 03:00 AM\n Ceftriaxone - 04:00 AM\n Ampicillin - 05:30 AM\n Acyclovir - 06:00 AM\n Infusions:\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Vanco w/ HD, pantoprazole, tobramycin ou gtt, Atrovent nebs, ampcillin,\n acyclovir,\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 71 (70 - 76) bpm\n BP: 92/58(208) {89/58(68) - 102/68(208)} mmHg\n RR: 22 (17 - 25) insp/min\n SpO2: 94%\n Heart rhythm: V Paced\n Height: 70 Inch\n Total In:\n 2,857 mL\n PO:\n TF:\n IVF:\n 857 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,857 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress, No(t) Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), apical\n murmur\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : ant and post)\n Extremities: LUE fingertips dusky, B toes w/ some duskiness. 2+\n anasarca\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Not assessed, garbled speech, not oriented\n Labs / Radiology\n 12.5 g/dL\n 200 K/uL\n 114 mg/dL\n 3.6 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 43 mg/dL\n 97 mEq/L\n 137 mEq/L\n 39.8 %\n 14.8 K/uL\n [image002.jpg]\n 03:04 AM\n WBC\n 14.8\n Hct\n 39.8\n Plt\n 200\n Cr\n 3.6\n TropT\n 0.34\n Glucose\n 114\n Other labs: PT / PTT / INR:21.9/43.0/2.1, CK / CKMB /\n Troponin-T:33//0.34, Differential-Neuts:91%, Band:1%, Lactic Acid:1.2\n mmol/L, Albumin:4.1, Ca++:7.4 mg/dL, Mg++:1.2 mg/dL, PO4:5.6 mg/dL\n Fluid analysis / Other labs: VBG (admit)- 7.13 / 79 / 70\n fem line central venous sat- 56%\n VBG (0700)- 7.28 / 56 / 32 (on BiPAP)\n anion gap- 17\n Imaging: Head CT ()- nonfocal (per report)\n CXR ()- low lung vols, chr bilat ple effusions, L IJ HD cath in\n IVC, increased interstitial markings compared to film\n Echo ()- LVH, , EF 25-30%, mod AS, 3+ MR, mild PA HTN\n Microbiology: Blood- pending\n Assessment and Plan\n 83M w/ MMP presents with sepsis of unclear etiology currently in shock\n and pressor-dependent. Several potential causes including line infxn\n from indwelling dialysis line, uti possible though makes little urine.\n BCx sent, ucx when able. Meningitis is in differential, esp given new\n confusion (but also has inc CO2, acute illness in elderly which could\n explain) but doesn\nt have neck stiffness, photophobia or headache. INR\n is too high for LP so cover empirically w/ broad spectrum abx.\n SHOCK- Probably multifactorial: cardiogenic given ischemic\n cardiomyopathy and sepsis (poss sources include line infection vs urine\n vs CNS infection)\n -gentle fluid resuscitation given cardiomyopathy\n -could trend fem line venous pressures to follow\n -ABX as below\n PRESUMED unclear source\n -vanco + ampcillin + CTX + acyclovir covering broadly for\n meningoencephalitis (covering viral as well given hx of chronic HSV\n infxn) as well as for possible line infxn\n -f/u pan-culture\n ISCHEMIC CARDIOMYOPATHY w/ MITRAL REGURGITATION- mild troponin leak\n overnight, unclear if represents new ACS given renal failure\n -repeat echo w/ dopplers today to better assess\n AFIB- suprathrerapeutic on coumadin which we are holding\n -holding rate control for hypotension\n -V-paced on telemetry\n PERIPHERAL VASCULAR DISEASE- dusky digits\n -Vascular following, holding off on arterial line access given\n concern for further digital ischemia\n ALTERED MENTAL STATUS- persistent despite lowering of pCO2 w/ BiPAP\n overnight, now considering infection/ shock or primary CNS infxn vs\n primary vascular insult\n -treat shock state as above\n -minimize sedatives\n -will attempt LP to further evaluate once coagulopathy corrected\n -consider MRI brain if not improved w/ treatment of above.\n HYPERCARBIC RESPIRATORY DISTRESS- related to depressed mental status\n last night, tolerated BiPAP well\n -continue hs BiPAP\n ESRD- notify Renal svce\n -will need to notify re: placement of L IJ in IVC\n COAGULOPATHY- related to coumadin\n -getting vitamin K and FFP, following\n ICU Care\n Nutrition:\n Comments: npo\n Glycemic Control:\n Lines:\n Multi Lumen - 12:30 AM\n Dialysis Catheter - 12:30 AM\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 50 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2134-04-12 00:00:00.000","description":"Nursing Progress Note","row_id":376074,"text":"83yo mal w/ hx CHF, PVD, chronic renal failure on dialysis x3 weekly\n presenting to ED from Nursing home w/ altered mental status, A&Ox1,\n hypotensive to 70's and o2sat 80's. Pt place on 4L NC, femoral TLC\n placed, gave 1.5L NS w/ no change in BP, started levophed. Unable to\n place foley after x3 attempts. CT head neg. Given 2U FFP for INR 13,\n also given 10mg Vit K, Vanco, flagyl, and levoquin. To micu for\n further monitoring.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n All limbs cool w/ varying degrees of dusky tissue and some skin tears\n and scabs from previous injuries/tears. Vascular team following. LLE\n pedal pulses dopplarable, RLE dorsal pulses absent but post tib\n dopplerable. RLE popliteal pulse easily palpated. Radial pulses\n thready bilat. LUE w/ old fistulas. Coccyx w/ stage 1 pressure ulcer\n (pink)\n Action:\n Pneumo boots in place, ordered waffle boots but none in distribution,\n warm blankets on pt and socks on feet for warmth. Adaptic dressing on\n RLE skin tear. Aloe vesta cream to coccyx and frequent turns.\n Response:\n No change in skin issues @ this time.\n Plan:\n Vascular team following, waffle boots for bilat LE\ns when available,\n frequent turns and monitor for worsening perfusion.\n Altered mental status (not Delirium)\n Assessment:\n A&Ox1 w/ constant confused questions and statements; ? infection vs\n hypercarbia. No growth in cx\ns to this point (unable to get urine, x3\n attempts in ED to get foley but failed). Venous gas 7.17/79/42/30\n initially in MICU. Pt follows commands, PERRL 4mm/brisk, CT head was\n neg. BP w/ MAP >65 while on levophed from ED. Lactate 1.2. WBC 8.6.\n Got 2L IVF in ED, Vanco, levoquin, and flagyl.\n Action:\n Frequently reorient pt, started meropenem, ceftriaxone, acyclovir,\n ampicillin for ? meningitis and/or HD line infection. Placed on CPAP\n machine. Weaning Levophed as BP tolerates, gave 250cc LR bolus x1.\n Response:\n No change in MS, only small change in Levophed which is now @\n 0.10mcg/kg/min, WBC w/ AM labs was 14.8.\n Plan:\n Monitor MS, cont CPAP (pt to remain NPO @ this time), wean levophed as\n BP tolerates for goal MAP >60. Cont abx, pt will need blood cx\ns from\n HD line if he gets HD today.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Anuric, last HD on Friday . BUN/Creat 45/4.3 from ED\n labs. CXR w/ worsening bilat pl. eff. and CHF.\n Action:\n No intervention overnight\n Response:\n Remains anuric, AM BUN/Creat 43/3.6.\n Plan:\n Scheduled HD on M/W/F but unknown if it will be done today.\n"},{"category":"Nursing","chartdate":"2134-04-13 00:00:00.000","description":"Nursing Progress Note","row_id":376165,"text":"83yo mal w/ hx CHF, PVD, chronic renal failure on dialysis x3 weekly\n presenting to ED from Nursing home w/ altered mental status, A&Ox1,\n hypotensive to 70's and o2sat 80's.To MICU for further monitoring.\n Altered mental status (not Delirium)\n Assessment:\n Alert/oriented X . Speaking nonsensically but cooperative and\n following commands.\n Action:\n ABX coverage. Frequent reorientation.\n Response:\n Afebrile.\n Plan:\n Goal MAPs >60. Monitor patient safety and provide reorientation and\n reassurance of safety.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n HD three times weekly.\n Action:\n Renal following.\n Response:\n Ongoing.\n Plan:\n Possible HD today.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Toes/fingers purple but dopplerable pulses.\n Action:\n Vascular in to assess.\n Response:\n Unchanged vascular status.\n Plan:\n Vascular will continue to follow.\n"},{"category":"Nursing","chartdate":"2134-04-12 00:00:00.000","description":"Nursing Progress Note","row_id":376081,"text":"83yo mal w/ hx CHF, PVD, chronic renal failure on dialysis x3 weekly\n presenting to ED from Nursing home w/ altered mental status, A&Ox1,\n hypotensive to 70's and o2sat 80's. Pt place on 4L NC, femoral TLC\n placed, gave 1.5L NS w/ no change in BP, started levophed. Unable to\n place foley after x3 attempts. CT head neg. Given 2U FFP for INR 13,\n also given 10mg Vit K, Vanco, flagyl, and levoquin. To micu for\n further monitoring.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n All limbs cool w/ varying degrees of dusky tissue and some skin tears\n and scabs from previous injuries/tears. Vascular team following. LLE\n pedal pulses dopplarable, RLE dorsal pulses absent but post tib\n dopplerable. RLE popliteal pulse easily palpated. Radial pulses\n thready bilat. LUE w/ old fistulas. Coccyx w/ stage 1 pressure ulcer\n (pink)\n Action:\n Pneumo boots in place, ordered waffle boots but none in distribution,\n warm blankets on pt and socks on feet for warmth. Adaptic dressing on\n RLE skin tear. Aloe vesta cream to coccyx and frequent turns.\n Response:\n No change in skin issues @ this time.\n Plan:\n Vascular team following, waffle boots for bilat LE\ns when available,\n frequent turns and monitor for worsening perfusion.\n Altered mental status (not Delirium)\n Assessment:\n A&Ox1 w/ constant confused questions and statements; ? infection vs\n hypercarbia. No growth in cx\ns to this point (unable to get urine, x3\n attempts in ED to get foley but failed). Venous gas 7.17/79/42/30\n initially in MICU. Pt follows commands, PERRL 4mm/brisk, CT head was\n neg. BP w/ MAP >65 while on levophed from ED. Lactate 1.2. WBC 8.6.\n Got 2L IVF in ED, Vanco, levoquin, and flagyl.\n Action:\n Frequently reorient pt, started meropenem, ceftriaxone, acyclovir,\n ampicillin for ? meningitis and/or HD line infection. Placed on CPAP\n machine. Weaning Levophed as BP tolerates, gave 250cc LR bolus x1.\n Response:\n No change in MS, only small change in Levophed which is now @\n 0.10mcg/kg/min, WBC w/ AM labs was 14.8.\n Plan:\n Monitor MS, cont CPAP (pt to remain NPO @ this time), wean levophed as\n BP tolerates for goal MAP >60. Cont abx, pt will need blood cx\ns from\n HD line if he gets HD today.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Anuric, last HD on Friday . BUN/Creat 45/4.3 from ED\n labs. CXR w/ worsening bilat pl. eff. and CHF.\n Action:\n No intervention overnight\n Response:\n Remains anuric, AM BUN/Creat 43/3.6.\n Plan:\n Scheduled HD on M/W/F but unknown if it will be done today.\n Plan for ECHO today to reassess cardiac function (MR, EF, etc).\n"},{"category":"Nursing","chartdate":"2134-04-13 00:00:00.000","description":"Nursing Progress Note","row_id":376164,"text":"83yo mal w/ hx CHF, PVD, chronic renal failure on dialysis x3 weekly\n presenting to ED from Nursing home w/ altered mental status, A&Ox1,\n hypotensive to 70's and o2sat 80's.To MICU for further monitoring.\n Altered mental status (not Delirium)\n Assessment:\n Alert/oriented X .\n Speaking nonsensically but cooperative and following commands.\n Wife and son in to visit saying some improvement than yesterday and\n mental status improving as shift advances.\n Concern for infectious process as patient remains hypotensive requiring\n Levophed gtt.\n BP 90s on Levophed; baseline reported to be 100s.\n Action:\n ABX coverage.\n Frequent reorientation.\n Response:\n Afebrile.\n Able to wean Levophed and off at 1700.\n Plan:\n Goal MAPs >60.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n HD three times weekly.\n Action:\n Renal following.\n Response:\n Ongoing.\n Plan:\n Will not require HD today.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Toes/fingers purple but dopplerable pulses.\n Action:\n Vascular in to assess.\n Response:\n Unchanged vascular status.\n Plan:\n Vascular will continue to follow.\n"},{"category":"General","chartdate":"2134-04-12 00:00:00.000","description":"Generic Note","row_id":376073,"text":"TITLE: Respiratory\n Pt. placed on Bipap 8 PS, 5 Peep with 5 LPM O2 per VBG results. Pt\n showing slight improvement.\n"},{"category":"Nursing","chartdate":"2134-04-12 00:00:00.000","description":"Nursing Progress Note","row_id":376135,"text":"83yo mal w/ hx CHF, PVD, chronic renal failure on dialysis x3 weekly\n presenting to ED from Nursing home w/ altered mental status, A&Ox1,\n hypotensive to 70's and o2sat 80's. Pt place on 4L NC, femoral TLC\n placed, gave 1.5L NS w/ no change in BP, started levophed. Unable to\n place foley after x3 attempts. CT head neg. Given 2U FFP for INR 13,\n also given 10mg Vit K, Vanco, flagyl, and levoquin. To micu for\n further monitoring.\n Altered mental status (not Delirium)\n Assessment:\n Alert/oriented X .\n Speaking nonsensically but cooperative and following commands.\n Wife and son in to visit saying some improvement than yesterday and\n mental status improving as shift advances.\n Concern for infectious process as patient remains hypotensive requiring\n Levophed gtt.\n BP 90s on Levophed; baseline reported to be 100s.\n Action:\n ABX coverage.\n Frequent reorientation.\n Response:\n Afebrile.\n Able to wean Levophed and off at 1700.\n Plan:\n Goal MAPs >60.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n HD three times weekly.\n Action:\n Renal following.\n Response:\n Ongoing.\n Plan:\n Will not require HD today.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Toes/fingers purple but dopplerable pulses.\n Action:\n Vascular in to assess.\n Response:\n Unchanged vascular status.\n Plan:\n Vascular will continue to follow.\n"},{"category":"Physician ","chartdate":"2134-04-13 00:00:00.000","description":"ICU Event Note","row_id":376210,"text":"Clinician: Attending\n Went into Mr. room to pre-round this morning at 7:25 am. I\n noted that he was apneic w/o a pulse. A code was called. Recussitation\n was started w/ cpr and manually ventilating him. He was in PEA so\n received 2 amp epi, 2 amps of bicarb, 1 amp atropine, 10 U insulin, amp\n of D50. He was intubated by anesthesia. I called his wife who asked\n that recussitation be stopped. When recussitation stopped, he did not\n have any spontaneous respirations or heart sounds. Pupils fixed and\n dilated. Time of death: 07:30 am. His and and were\n notified and there will not be an autopsy. Dr. and Dr. \n were notified by pager.\n Total time spent: 60 minutes\n"},{"category":"Nursing","chartdate":"2134-04-13 00:00:00.000","description":"Nursing Progress Note","row_id":376216,"text":"EVENT NOTE:\n Report taken from nurse on previous shift at 06:50, saw pt at 07:00 as\n vascular team entered to examine patient.\n At 07:25 I entered to begin examining pt and to administer am\n medications, I was followed in to the room by the MICU resident. We\n noted that the pt was in respiratory arrest and called a code blue.\n Code continued until family contact and advised us to stop, time of\n death called by MICU resident.\n"},{"category":"Nursing","chartdate":"2134-04-13 00:00:00.000","description":"Nursing Progress Note","row_id":376192,"text":"83yo mal w/ hx CHF, PVD, chronic renal failure on dialysis x3 weekly\n presenting to ED from Nursing home w/ altered mental status, A&Ox1,\n hypotensive to 70's and o2sat 80's.To MICU for further monitoring.\n Altered mental status (not Delirium)\n Assessment:\n Alert/oriented X . Speaking nonsensically but cooperative and\n following commands.\n Action:\n ABX coverage. Frequent reorientation.\n Response:\n Afebrile.\n Plan:\n Goal MAPs >60. Monitor patient safety and provide reorientation and\n reassurance of safety.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n HD three times weekly.\n Action:\n Renal following.\n Response:\n Ongoing.\n Plan:\n Possible HD today.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Toes/fingers purple but dopplerable pulses.\n Action:\n Vascular in to assess.\n Response:\n Unchanged vascular status.\n Plan:\n Vascular will continue to follow.\n"},{"category":"Physician ","chartdate":"2134-04-12 00:00:00.000","description":"Physician Attending Progress Note","row_id":376121,"text":"Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 83M w/ multiple medical problems including ESRD on HD, Afib s/p AVN\n ablation and dual-chamber PM, systolic CHF (EF 25%, 2+AS, 3+MR)\n transferred from nursing home, w/ tachypnea and decreased\n responsiveness, in presumed septic shock.\n 24 Hour Events:\n In ED, noted SBP 70s not responsive to IVF challenges, U/S guided CVL\n placement Lt femoral. Vanc/Levo/Flagyl started empirically for\n sepsis. INR 13.2, received IV vit K and FFP. Levophed started for\n hypotension resistant to IVF resuscitation. Transferred to MICU for\n managemend of sepsis, hemodynamics.\n PMH:\n On continuous O2 at nursing home for unclear reasons\n CAD\n s/p pacer\n ICM- EF 15-20%\n ESRD on HD via L IJ cath x 4yrs d/t obstructive uropathy\n MR\n Afib\n PVD\n HTN\n SH: remote prior smoker\n Overnight, underwent head CT without focal change. Evaluated by\n Vascular svce. Remained on Levophed overnight. Started on BiPAP\n w/ 5LO2 overnight, now on NC 3L\n Patient unable to provide history: Encephalopathy\n Allergies:\n Horse/Equine Product Derivatives\n Unknown;\n Calcium Channel Blocking Agents-Benzothiazepines\n Headache;\n Metoprolol\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 03:00 AM\n Ceftriaxone - 04:00 AM\n Ampicillin - 05:30 AM\n Acyclovir - 06:00 AM\n Infusions:\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Vanco w/ HD, pantoprazole, tobramycin ou gtt, Atrovent nebs, ampcillin,\n acyclovir,\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 71 (70 - 76) bpm\n BP: 92/58(208) {89/58(68) - 102/68(208)} mmHg\n RR: 22 (17 - 25) insp/min\n SpO2: 94%\n Heart rhythm: V Paced\n Height: 70 Inch\n Total In:\n 2,857 mL\n PO:\n TF:\n IVF:\n 857 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,857 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress, No(t) Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), apical\n murmur\n Peripheral Vascular: (Right radial pulse:decreased), (Left radial\n pulse:decreased), (Right DP pulse:decreased), (Left DP pulse:decreased)\n Respiratory / Chest: (Breath Sounds: Crackles : ant and post)\n Extremities: LUE fingertips dusky, B toes w/ some duskiness. 2+\n anasarca\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Not assessed, garbled speech, not oriented\n Labs / Radiology\n 12.5 g/dL\n 200 K/uL\n 114 mg/dL\n 3.6 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 43 mg/dL\n 97 mEq/L\n 137 mEq/L\n 39.8 %\n 14.8 K/uL\n [image002.jpg]\n 03:04 AM\n WBC\n 14.8\n Hct\n 39.8\n Plt\n 200\n Cr\n 3.6\n TropT\n 0.34\n Glucose\n 114\n Other labs: PT / PTT / INR:21.9/43.0/2.1, CK / CKMB /\n Troponin-T:33//0.34, Differential-Neuts:91%, Band:1%, Lactic Acid:1.2\n mmol/L, Albumin:4.1, Ca++:7.4 mg/dL, Mg++:1.2 mg/dL, PO4:5.6 mg/dL\n Fluid analysis / Other labs: VBG (admit)- 7.13 / 79 / 70\n fem line central venous sat- 56%\n VBG (0700)- 7.28 / 56 / 32 (on BiPAP)\n anion gap- 17\n Imaging: Head CT ()- nonfocal (per report)\n CXR ()- low lung vols, chr bilat ple effusions, L IJ HD cath in\n IVC, increased interstitial markings compared to film\n Echo ()- LVH, , EF 25-30%, mod AS, 3+ MR, mild PA HTN\n Microbiology: Blood- pending\n Assessment and Plan\n 83M w/ MMP presents with sepsis of unclear etiology currently in shock\n and pressor-dependent. Several potential causes including line infxn\n from indwelling dialysis line, uti possible though makes little urine.\n BCx sent, ucx when able. Meningitis is in differential, esp given new\n confusion (but also has inc CO2, acute illness in elderly which could\n explain) but doesn\nt have neck stiffness, photophobia or headache. INR\n is too high for LP so cover empirically w/ broad spectrum abx.\n SHOCK- Probably multifactorial: cardiogenic given ischemic\n cardiomyopathy and sepsis (poss sources include line infection vs urine\n vs CNS infection)\n -gentle fluid resuscitation given cardiomyopathy\n -could trend fem line venous pressures to follow\n -ABX as below\n PRESUMED unclear source\n -vanco + ampcillin + CTX + acyclovir covering broadly for\n meningoencephalitis (covering viral as well given hx of chronic HSV\n infxn) as well as for possible line infxn\n -f/u pan-culture\n ISCHEMIC CARDIOMYOPATHY w/ MITRAL REGURGITATION- mild troponin leak\n overnight, unclear if represents new ACS given renal failure\n -repeat echo w/ dopplers today to better assess\n AFIB- suprathrerapeutic on coumadin which we are holding\n -holding rate control for hypotension\n -V-paced on telemetry\n PERIPHERAL VASCULAR DISEASE- dusky digits\n -Vascular following, holding off on arterial line access given\n concern for further digital ischemia\n ALTERED MENTAL STATUS- persistent despite lowering of pCO2 w/ BiPAP\n overnight, now considering infection/ shock or primary CNS infxn vs\n primary vascular insult\n -treat shock state as above\n -minimize sedatives\n -will attempt LP to further evaluate once coagulopathy corrected\n -consider MRI brain if not improved w/ treatment of above.\n HYPERCARBIC RESPIRATORY DISTRESS- related to depressed mental status\n last night, tolerated BiPAP well\n -continue hs BiPAP\n ESRD- notify Renal svce\n -will need to notify re: placement of L IJ in IVC\n COAGULOPATHY- related to coumadin\n -getting vitamin K and FFP, following\n ICU Care\n Nutrition:\n Comments: npo\n Glycemic Control:\n Lines:\n Multi Lumen - 12:30 AM\n Dialysis Catheter - 12:30 AM\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2134-04-12 00:00:00.000","description":"Physician Attending Progress Note","row_id":376124,"text":"Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 83M w/ multiple medical problems including ESRD on HD, Afib s/p AVN\n ablation and dual-chamber PM, systolic CHF (EF 25%, 2+AS, 3+MR)\n transferred from nursing home, w/ tachypnea and decreased\n responsiveness, in presumed septic shock.\n 24 Hour Events:\n In ED, noted SBP 70s not responsive to IVF challenges, U/S guided CVL\n placement Lt femoral. Vanc/Levo/Flagyl started empirically for\n sepsis. INR 13.2, received IV vit K and FFP. Levophed started for\n hypotension resistant to IVF resuscitation. Transferred to MICU for\n managemend of sepsis, hemodynamics.\n PMH:\n On continuous O2 at nursing home for unclear reasons\n CAD\n s/p pacer\n ICM- EF 15-20%\n ESRD on HD via L IJ cath x 4yrs d/t obstructive uropathy\n MR\n Afib\n PVD\n HTN\n SH: remote prior smoker\n Overnight, underwent head CT without focal change. Evaluated by\n Vascular svce. Remained on Levophed overnight. Started on BiPAP\n w/ 5LO2 overnight, now on NC 3L\n Patient unable to provide history: Encephalopathy\n Allergies:\n Horse/Equine Product Derivatives\n Unknown;\n Calcium Channel Blocking Agents-Benzothiazepines\n Headache;\n Metoprolol\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 03:00 AM\n Ceftriaxone - 04:00 AM\n Ampicillin - 05:30 AM\n Acyclovir - 06:00 AM\n Infusions:\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Vanco w/ HD, pantoprazole, tobramycin ou gtt, Atrovent nebs, ampcillin,\n acyclovir,\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 71 (70 - 76) bpm\n BP: 92/58(208) {89/58(68) - 102/68(208)} mmHg\n RR: 22 (17 - 25) insp/min\n SpO2: 94%\n Heart rhythm: V Paced\n Height: 70 Inch\n Total In:\n 2,857 mL\n PO:\n TF:\n IVF:\n 857 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,857 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress, No(t) Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), apical\n murmur\n Peripheral Vascular: (Right radial pulse:decreased), (Left radial\n pulse:decreased), (Right DP pulse:decreased), (Left DP pulse:decreased)\n Respiratory / Chest: (Breath Sounds: Crackles : ant and post)\n Extremities: LUE fingertips dusky, B toes w/ some duskiness. 2+\n anasarca\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Not assessed, garbled speech, not oriented\n Labs / Radiology\n 12.5 g/dL\n 200 K/uL\n 114 mg/dL\n 3.6 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 43 mg/dL\n 97 mEq/L\n 137 mEq/L\n 39.8 %\n 14.8 K/uL\n [image002.jpg]\n 03:04 AM\n WBC\n 14.8\n Hct\n 39.8\n Plt\n 200\n Cr\n 3.6\n TropT\n 0.34\n Glucose\n 114\n Other labs: PT / PTT / INR:21.9/43.0/2.1, CK / CKMB /\n Troponin-T:33//0.34, Differential-Neuts:91%, Band:1%, Lactic Acid:1.2\n mmol/L, Albumin:4.1, Ca++:7.4 mg/dL, Mg++:1.2 mg/dL, PO4:5.6 mg/dL\n Fluid analysis / Other labs: VBG (admit)- 7.13 / 79 / 70\n fem line central venous sat- 56%\n VBG (0700)- 7.28 / 56 / 32 (on BiPAP)\n anion gap- 17\n Imaging: Head CT ()- nonfocal (per report)\n CXR ()- low lung vols, chr bilat ple effusions, L IJ HD cath in\n IVC, increased interstitial markings compared to film\n Echo ()- LVH, , EF 25-30%, mod AS, 3+ MR, mild PA HTN\n Microbiology: Blood- pending\n Assessment and Plan\n 83M w/ MMP presents with sepsis of unclear etiology currently in shock\n and pressor-dependent. Several potential causes including line infxn\n from indwelling dialysis line, uti possible though makes little urine.\n BCx sent, ucx when able. Meningitis is in differential, esp given new\n confusion (but also has inc CO2, acute illness in elderly which could\n explain) but doesn\nt have neck stiffness, photophobia or headache. INR\n is too high for LP so cover empirically w/ broad spectrum abx.\n SHOCK- Probably multifactorial: cardiogenic given ischemic\n cardiomyopathy and sepsis (poss sources include line infection vs urine\n vs CNS infection)\n -gentle fluid resuscitation given cardiomyopathy\n -could trend fem line venous pressures to follow\n -ABX as below\n PRESUMED unclear source\n -vanco + ampcillin + CTX + acyclovir covering broadly for\n meningoencephalitis (covering viral as well given hx of chronic HSV\n infxn) as well as for possible line infxn\n -f/u pan-culture\n ISCHEMIC CARDIOMYOPATHY w/ MITRAL REGURGITATION- mild troponin leak\n overnight, unclear if represents new ACS given renal failure\n -repeat echo w/ dopplers today to better assess\n AFIB- suprathrerapeutic on coumadin which we are holding\n -holding rate control for hypotension\n -V-paced on telemetry\n PERIPHERAL VASCULAR DISEASE- dusky digits\n -Vascular following, holding off on arterial line access given\n concern for further digital ischemia\n ALTERED MENTAL STATUS- persistent despite lowering of pCO2 w/ BiPAP\n overnight, now considering infection/ shock or primary CNS infxn vs\n primary vascular insult\n -treat shock state as above\n -minimize sedatives\n -will attempt LP to further evaluate once coagulopathy corrected\n -consider MRI brain if not improved w/ treatment of above.\n HYPERCARBIC RESPIRATORY DISTRESS- related to depressed mental status\n last night, tolerated BiPAP well\n -continue hs BiPAP\n ESRD- notify Renal svce\n -will need to notify re: placement of L IJ in IVC\n COAGULOPATHY- related to coumadin\n -getting vitamin K and FFP, following\n ICU Care\n Nutrition:\n Comments: npo\n Glycemic Control:\n Lines:\n Multi Lumen - 12:30 AM\n Dialysis Catheter - 12:30 AM\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n ------ Protected Section ------\n Attempted to perform LP at bedside. Given prior history of lumbar\n laminectomy and possible fusion we were not able to palpate anatomic\n landmarks to guide procedure. Will contact IR for asistance in AM.\n ------ Protected Section Addendum Entered By: , MD\n on: 17:08 ------\n"},{"category":"Respiratory ","chartdate":"2134-04-13 00:00:00.000","description":"Generic Note","row_id":376179,"text":"TITLE: Resp Care Note, Pt placed on bipap and remained on all night.\n Needed hands restrained otherwise pt was fine.Rx\nd with atrovent Q6\n last 0600. Will cont to follow.\n"},{"category":"Nursing","chartdate":"2134-04-12 00:00:00.000","description":"Nursing Progress Note","row_id":376114,"text":"Altered mental status (not Delirium)\n Assessment:\n Alert/oriented X .\n Speaking nonsensically but cooperative and following commands.\n Wife and son in to visit saying some improvement than yesterday.\n Concern for infectious process as patient remains hypotensive requiring\n Levophed gtt.\n BP 90s on Levophed; baseline reported to be 100s.\n Action:\n ABX coverage.\n Frequent reorientation.\n Response:\n Afebrile.\n Able to wean Levophed.\n Plan:\n Will obtain LP.\n Will wean pressor as tolerated.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n HD three times weekly.\n Action:\n Renal following.\n Response:\n Ongoing.\n Plan:\n Will not require HD today.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Toes/fingers purple but dopplerable pulses.\n Action:\n Vascular in to assess.\n Response:\n Unchanged vascular status.\n Plan:\n Vascular will continue to follow.\n"},{"category":"ECG","chartdate":"2134-04-11 00:00:00.000","description":"Report","row_id":259130,"text":"Ventricular paced rhythm with underlying atrial flutter. Compared to the\nprevious tracing of atrial flutter now manifest.\n\n"}],"string":"[\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2134-04-12 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 376058,\n \"text\": \"Chief Complaint: Hypotension, altered mental status\\n HPI:\\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\\n change. His son who accompanies him says that he has noticed an\\n increase in his RR over the past few days and a decrease in his energy\\n level. When he went to visit him this morning, he was very sleepy and\\n not coherent which is a change so they called the ambulance. BP and O2\\n sats there noted to be low. He did not eat breakfast this morning\\n which is very unusual for him.\\n .\\n In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22.\\n 97% on 5L NC. Arrived hypotensive in 70s, MS A+Ox3 here (but per son,\\n not at baseline), BP unresponsive to 2L NS so left femoral central line\\n placed under U/S guidance (as INR 13) and levo started. Moving arms\\n but legs weaker. 2 U FFP, 10 vit K IV. Cxr w/ increased CHF. Head CT\\n NEG. Could not pass foley X 2, now w/ small amt of blood. Given vanco\\n 1g IV, levo 750 mg IV, flagyl 500 mg IV. Cool hands/feet, dopplerable\\n PT but not DP, vasc called and will see on the floor. Guaiac + brown\\n stool.\\n .\\n On arrival to the ICU, his son states he is more alert now but not back\\n to baseline.\\n .\\n Review of systems: Pt. states he feels short of breath but cannot\\n clarify further.\\n Patient admitted from: ER\\n History obtained from Family / Medical records\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Horse/Equine Product Derivatives\\n Unknown;\\n Calcium Channel Blocking Agents-Benzothiazepines\\n Headache;\\n Metoprolol\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Norepinephrine - 0.12 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n (per med sheets)\\n Coumadin 3 mg daily\\n Dialysis at dialysis MWF\\n Acetaminophen\\n ASA 325 mg daily\\n calcium acetate 667 mg 2 tabs tid\\n dextroamphetamine 2.5 mg daily\\n docusate\\n folate 1 mg daily\\n lotemax 0.5% eye drops\\n mucinex 600 mg \\n mucomyst nebs \\n nephrocaps\\n pantoprazole 40 mg daily\\n sensipar 30 mg \\n spiriva daily\\n tobramycin 0.3% eye drops\\n Valtrex 500 mg daily\\n lactulose\\n lorazepam 0.5 mg \\n percocet 5/325 \\n dexadrine 5 mg daily\\n Albuterol\\n vit B12 1000 mg daily\\n nepro 235 daily\\n albumin w/ dialysis\\n darbapoetin w/ dialysis\\n Past medical history:\\n Family history:\\n Social History:\\n - PVD (Followed by ) w/ chronic LUE and bilateral LE ischemis\\n - Chronic renal failure on HD x 4 years (thought to be due to\\n obstructive uropathy, kidney stones, BPH)\\n - Systolic heart failure w/ EF 25% on ECHO \\n - Moderate aortic valve stenosis (area 1.0-1.2cm2). Moderate (2+)\\n aortic regurgitation is seen. Moderate to severe (3+) mitral\\n regurgitation is seen. There is mild pulmonary artery systolic\\n hypertension. ()\\n - Hx atrial fibrillation and paroxysmal atrial tachycardia\\n - s/p AV nodal ablation and implantation of a dual chamber pacemaker\\n - Baseline AV conduction delay\\n - Hypertension\\n - Coronary artery disease with old posterior MI on EKG and pMIBI\\n in with EF44%, global hypokinesis, no reversible defects.\\n - Hx Left 4-9th rib fx, Left hemothorax\\n - R kidney stone s/p Lithotripsy\\n (, complicated by ESBL Klebsiella UTI)\\n - s/p stroke (cerebellar), found on MRI, sxs of gait instability\\n - hx gait d/o, hand paresthesias, polyneuropathy, C3/C4 spinal\\n cord compression cerival spondylosis, L median nerve injury\\n - Anemia\\n - Benign prostatic hypertrophy\\n - Cluster headaches\\n - Hx of positive PPD, never treated\\n - Hx squamous cell and basal cell ca\\n - HSV keratouveitis\\n - ventral hernia\\n - s/p open cholecystectomy \\n - s/p small bowel resection (80-90%) for mesenteric ischemia\\n - s/p umbilical hernia repair\\n - s/p cystocele repair\\n - s/p laminectomy - c/b osteomyelitis\\n - s/p TURP \\n There is no family history of premature coronary artery disease or\\n sudden death.\\n Patient has been at a NH and has not gotten home since hospitalization\\n in . His wife lives in . He is a retired psychiatrist.\\n Social history is significant for the remote tobacco use, 3ppd x 40\\n years, quit 20 years ago. He drinks alcohol occasionally, denies\\n illicit drug use.\\n Review of systems:\\n Flowsheet Data as of 02:32 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.5\\nC (95.9\\n HR: 70 (70 - 76) bpm\\n BP: 101/58(68) {89/58(68) - 101/68(73)} mmHg\\n RR: 18 (17 - 20) insp/min\\n SpO2: 94%\\n Heart rhythm: V Paced\\n Height: 70 Inch\\n Total In:\\n 2,116 mL\\n PO:\\n TF:\\n IVF:\\n 116 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 2,116 mL\\n Respiratory\\n O2 Delivery Device: Bipap mask\\n SpO2: 94%\\n Physical Examination\\n GENERAL: Awake but confused, NAD. Answers do not make sense.\\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\\n icterus. PERRLA/EOMI. dry MM. OP w/ poor dentition. Neck Supple.\\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\\n or but very distant heart sounds.\\n LUNGS: Occasional crackles anteriorly and posteriorly w/ poor\\n inspiratory effort.\\n ABDOMEN: NABS. Soft, midline scar. No HSM\\n EXTREMITIES: anasarca, palp radial pulses, dopperable PT/DP\\n bilaterally. L hand w/ purple fingertips on fingers 2, 3 and 4.\\n SKIN: Xerosis.\\n NEURO: Alert but not oriented. Speaking nonsensical sentences. Able\\n to show 2 fingers on the R but not L. Able to wiggle toes. Could not\\n follow other commands.\\n Labs / Radiology\\n [image002.jpg]\\n Other labs: Lactic Acid:1.2 mmol/L\\n Imaging: CT Head: wet read - no acute intracranial pathology.\\n .\\n CXR:\\n FINDINGS: Comparison is made to . Right pacemaker and two\\n intracardiac leads remain in place. Since prior exam, left IJ\\n hemodialysis catheter has been placed, with tip low in position,\\n possibly within the IVC. Vascular stens are noted in the left\\n subclavian and brachiocephalic vein.\\n Cardiomegaly again noted with central congestion, bilateral pleural\\n effusions. Lung bases are suboptimally assessed given low lung volumes\\n though compared with prior, effusion and CHF is increased.\\n IMPRESSION:\\n 1. Dialysis catheter tip low, likely in IVC.\\n 2. CHF, worse.\\n Microbiology: Blood cx w/ NGTD\\n ECG: ECG: V-paced (74)\\n Assessment and Plan\\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\\n change and hypotension.\\n .\\n #. Hypotension: Concerning for sepsis given l-shift, indwelling HD line\\n and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/\\n prior HD line. Also has a pacemaker. Could not get a urine specimen.\\n CXR w/ loss of diaphragm on R but w/o obvious infiltrate. Could also\\n be from cardiogenic shock given baseline depressed EF.\\n - cover w/ broad-spectrum antibiotics w/ Vanc/ given h/o ESBL and\\n narrow as cx return\\n - NE w/ goal MAP > 60\\n - continue to gently bolus w/ LR given depressed EF, severe valvular\\n disease\\n - Repeat ECHO to eval for worsening CHF/Valvular disease\\n - would ideally like to place an a-line for HD monitoring but I would\\n be concerned to precipitate ischemia to R hand and L-hand already\\n ischemic. Will follow w/ non-invasive for now.\\n - check a MVO2\\n .\\n #. Acute respiratory acidosis: Unclear precipitant. DDX from percocets\\n vs infection vs hypophosphatemia vs respiratory muscle fatigue\\n - will try bipap for now to see if he tolerates\\n - check phos\\n - continue to monitor\\n .\\n #. Altered mental status: DDX from hypercarbia vs from percocets vs\\n from infection. CT head w/o acute process. Could possibly be from\\n meningitis but no nucal rigidity or headache.\\n - continue to monitor\\n .\\n #. Hypoxia: CXR seems consistent w/ pulmonary edema. Likely from\\n worsening valvular disease. Could also be an infiltrate that is hidden\\n by edema. Apparently has been on L NC at rehab w/ unclear\\n diagnosis but getting spiriva and albuterol. No formal dx of COPD.\\n - albuterol and atrovent nebs\\n .\\n #. ESRD on HD: Dialysis MWF at Dialysis.\\n - contact renal in the am for cvvh vs HD depending on BP\\n .\\n #. Systolic heart failure: Unclear if ischemic in etiology or from\\n valvular disease (mod AS, severe MR).\\n - appears total body volume overloaded despite hypotension.\\n .\\n #. Afib: INR supratherapeutic at 13.2. Now s/p 2 U FFP and 10 mg vit K\\n IV X 1 in the ED. No obvious signs of bleeding. HCT w/\\n hemoconcentration given baseline of 32. S/p AVN ablation and\\n dual-chamber pacemaker.\\n - hold coumadin\\n - trend coags\\n .\\n #. PVD: Known LUE and bilateral LE PVD followed by Dr. .\\n - appreciate vascular input, nothing to do for now\\n .\\n #. Macrocytic Anemia: Current hct likely hemoconcentration. Will watch\\n for signs of bleeding given supra-therapeutic INR. B12/folate wnl in\\n .\\n - trend for now.\\n - guaiac stools\\n ICU Care\\n Nutrition:\\n Glycemic Control: Blood sugar well controlled\\n Lines:\\n Multi Lumen - 12:30 AM\\n Dialysis Catheter - 12:30 AM\\n 18 Gauge - 12:30 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , Family\\n meeting held , ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2134-04-12 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 376059,\n \"text\": \"Chief Complaint: Hypotension, altered mental status\\n HPI:\\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\\n change. His son who accompanies him says that he has noticed an\\n increase in his RR over the past few days and a decrease in his energy\\n level. When he went to visit him this morning, he was very sleepy and\\n not coherent which is a change so they called the ambulance. BP and O2\\n sats there noted to be low. He did not eat breakfast this morning\\n which is very unusual for him.\\n .\\n In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22.\\n 97% on 5L NC. Arrived hypotensive in 70s, MS A+Ox3 here (but per son,\\n not at baseline), BP unresponsive to 2L NS so left femoral central line\\n placed under U/S guidance (as INR 13) and levo started. Moving arms\\n but legs weaker. 2 U FFP, 10 vit K IV. Cxr w/ increased CHF. Head CT\\n NEG. Could not pass foley X 2, now w/ small amt of blood. Given vanco\\n 1g IV, levo 750 mg IV, flagyl 500 mg IV. Cool hands/feet, dopplerable\\n PT but not DP, vasc called and will see on the floor. Guaiac + brown\\n stool.\\n .\\n On arrival to the ICU, his son states he is more alert now but not back\\n to baseline.\\n .\\n Review of systems: Pt. states he feels short of breath but cannot\\n clarify further.\\n Patient admitted from: ER\\n History obtained from Family / Medical records\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Horse/Equine Product Derivatives\\n Unknown;\\n Calcium Channel Blocking Agents-Benzothiazepines\\n Headache;\\n Metoprolol\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Norepinephrine - 0.12 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n (per med sheets)\\n Coumadin 3 mg daily\\n Dialysis at dialysis MWF\\n Acetaminophen\\n ASA 325 mg daily\\n calcium acetate 667 mg 2 tabs tid\\n dextroamphetamine 2.5 mg daily\\n docusate\\n folate 1 mg daily\\n lotemax 0.5% eye drops\\n mucinex 600 mg \\n mucomyst nebs \\n nephrocaps\\n pantoprazole 40 mg daily\\n sensipar 30 mg \\n spiriva daily\\n tobramycin 0.3% eye drops\\n Valtrex 500 mg daily\\n lactulose\\n lorazepam 0.5 mg \\n percocet 5/325 \\n dexadrine 5 mg daily\\n Albuterol\\n vit B12 1000 mg daily\\n nepro 235 daily\\n albumin w/ dialysis\\n darbapoetin w/ dialysis\\n Past medical history:\\n Family history:\\n Social History:\\n - PVD (Followed by ) w/ chronic LUE and bilateral LE ischemis\\n - Chronic renal failure on HD x 4 years (thought to be due to\\n obstructive uropathy, kidney stones, BPH)\\n - Systolic heart failure w/ EF 25% on ECHO \\n - Moderate aortic valve stenosis (area 1.0-1.2cm2). Moderate (2+)\\n aortic regurgitation is seen. Moderate to severe (3+) mitral\\n regurgitation is seen. There is mild pulmonary artery systolic\\n hypertension. ()\\n - Hx atrial fibrillation and paroxysmal atrial tachycardia\\n - s/p AV nodal ablation and implantation of a dual chamber pacemaker\\n - Baseline AV conduction delay\\n - Hypertension\\n - Coronary artery disease with old posterior MI on EKG and pMIBI\\n in with EF44%, global hypokinesis, no reversible defects.\\n - Hx Left 4-9th rib fx, Left hemothorax\\n - R kidney stone s/p Lithotripsy\\n (, complicated by ESBL Klebsiella UTI)\\n - s/p stroke (cerebellar), found on MRI, sxs of gait instability\\n - hx gait d/o, hand paresthesias, polyneuropathy, C3/C4 spinal\\n cord compression cerival spondylosis, L median nerve injury\\n - Anemia\\n - Benign prostatic hypertrophy\\n - Cluster headaches\\n - Hx of positive PPD, never treated\\n - Hx squamous cell and basal cell ca\\n - HSV keratouveitis\\n - ventral hernia\\n - s/p open cholecystectomy \\n - s/p small bowel resection (80-90%) for mesenteric ischemia\\n - s/p umbilical hernia repair\\n - s/p cystocele repair\\n - s/p laminectomy - c/b osteomyelitis\\n - s/p TURP \\n There is no family history of premature coronary artery disease or\\n sudden death.\\n Patient has been at a NH and has not gotten home since hospitalization\\n in . His wife lives in . He is a retired psychiatrist.\\n Social history is significant for the remote tobacco use, 3ppd x 40\\n years, quit 20 years ago. He drinks alcohol occasionally, denies\\n illicit drug use.\\n Review of systems:\\n Flowsheet Data as of 02:32 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.5\\nC (95.9\\n HR: 70 (70 - 76) bpm\\n BP: 101/58(68) {89/58(68) - 101/68(73)} mmHg\\n RR: 18 (17 - 20) insp/min\\n SpO2: 94%\\n Heart rhythm: V Paced\\n Height: 70 Inch\\n Total In:\\n 2,116 mL\\n PO:\\n TF:\\n IVF:\\n 116 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 2,116 mL\\n Respiratory\\n O2 Delivery Device: Bipap mask\\n SpO2: 94%\\n Physical Examination\\n GENERAL: Awake but confused, NAD. Answers do not make sense.\\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\\n icterus. PERRLA/EOMI. dry MM. OP w/ poor dentition. Neck Supple.\\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\\n or but very distant heart sounds.\\n LUNGS: Occasional crackles anteriorly and posteriorly w/ poor\\n inspiratory effort.\\n ABDOMEN: NABS. Soft, midline scar. No HSM\\n EXTREMITIES: anasarca, palp radial pulses, dopperable PT/DP\\n bilaterally. L hand w/ purple fingertips on fingers 2, 3 and 4.\\n SKIN: Xerosis.\\n NEURO: Alert but not oriented. Speaking nonsensical sentences. Able\\n to show 2 fingers on the R but not L. Able to wiggle toes. Could not\\n follow other commands.\\n Labs / Radiology\\n [image002.jpg]\\n Other labs: Lactic Acid:1.2 mmol/L\\n Imaging: CT Head: wet read - no acute intracranial pathology.\\n .\\n CXR:\\n FINDINGS: Comparison is made to . Right pacemaker and two\\n intracardiac leads remain in place. Since prior exam, left IJ\\n hemodialysis catheter has been placed, with tip low in position,\\n possibly within the IVC. Vascular stens are noted in the left\\n subclavian and brachiocephalic vein.\\n Cardiomegaly again noted with central congestion, bilateral pleural\\n effusions. Lung bases are suboptimally assessed given low lung volumes\\n though compared with prior, effusion and CHF is increased.\\n IMPRESSION:\\n 1. Dialysis catheter tip low, likely in IVC.\\n 2. CHF, worse.\\n Microbiology: Blood cx w/ NGTD\\n ECG: ECG: V-paced (74)\\n Assessment and Plan\\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\\n change and hypotension.\\n .\\n #. Hypotension: Concerning for sepsis given l-shift, indwelling HD line\\n and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/\\n prior HD line. Also has a pacemaker. Could not get a urine specimen.\\n CXR w/ loss of diaphragm on R but w/o obvious infiltrate. Could also\\n be from cardiogenic shock given baseline depressed EF. Cardiac output\\n limited by paced rate.\\n - cover w/ broad-spectrum antibiotics w/ Vanc/ given h/o ESBL and\\n narrow as cx return\\n - NE w/ goal MAP > 60\\n - continue to gently bolus w/ LR given depressed EF, severe valvular\\n disease\\n - Repeat ECHO to eval for worsening CHF/Valvular disease\\n - would ideally like to place an a-line for HD monitoring but I would\\n be concerned to precipitate ischemia to R hand and L-hand already\\n ischemic. Will follow w/ non-invasive for now.\\n - check a MVO2\\n - will ask EP to turn up rate in am\\n .\\n #. Acute respiratory acidosis: Unclear precipitant. DDX from percocets\\n vs infection vs hypophosphatemia vs respiratory muscle fatigue\\n - will try bipap for now to see if he tolerates\\n - check phos\\n - continue to monitor\\n .\\n #. Altered mental status: DDX from hypercarbia vs from percocets vs\\n from infection. CT head w/o acute process. Could possibly be from\\n meningitis but no nucal rigidity or headache.\\n - continue to monitor\\n .\\n #. Hypoxia: CXR seems consistent w/ pulmonary edema. Likely from\\n worsening valvular disease. Could also be an infiltrate that is hidden\\n by edema. Apparently has been on L NC at rehab w/ unclear\\n diagnosis but getting spiriva and albuterol. No formal dx of COPD.\\n - albuterol and atrovent nebs\\n .\\n #. ESRD on HD: Dialysis MWF at Dialysis.\\n - contact renal in the am for cvvh vs HD depending on BP\\n .\\n #. Systolic heart failure: Unclear if ischemic in etiology or from\\n valvular disease (mod AS, severe MR).\\n - appears total body volume overloaded despite hypotension.\\n .\\n #. Afib: INR supratherapeutic at 13.2. Now s/p 2 U FFP and 10 mg vit K\\n IV X 1 in the ED. No obvious signs of bleeding. HCT w/\\n hemoconcentration given baseline of 32. S/p AVN ablation and\\n dual-chamber pacemaker.\\n - hold coumadin\\n - trend coags\\n .\\n #. PVD: Known LUE and bilateral LE PVD followed by Dr. .\\n - appreciate vascular input, nothing to do for now\\n .\\n #. Macrocytic Anemia: Current hct likely hemoconcentration. Will watch\\n for signs of bleeding given supra-therapeutic INR. B12/folate wnl in\\n .\\n - trend for now.\\n - guaiac stools\\n ICU Care\\n Nutrition:NPO for now\\n Glycemic Control: Blood sugar well controlled\\n Lines:\\n Multi Lumen - 12:30 AM\\n Dialysis Catheter - 12:30 AM\\n 18 Gauge - 12:30 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , Family\\n meeting held , ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2134-04-12 00:00:00.000\",\n \"description\": \"MICU Attending Note\",\n \"row_id\": 376063,\n \"text\": \"TITLE:\\n Chart reviewed, patient examined. Case discussed in detail with\\n resident. I agree with her note and gap outlined above. In addition,\\n I would add/emphasize:\\n 83M w/ multiple medical problems including ESRD on HD, Afib s/p AVN\\n ablation and dual-chamber PM, systolic CHF (EF 25%, 2+AS, 3+MR)\\n transferred from nursing home, w/ MS change. Pt has been at NH/rehab\\n since last admission for UTI at . Son noted increase in\\n pt\\ns RR over the past several days as well as decrease in his energy\\n level. While visiting pt son noted father to be solmolent and more\\n confused. EMS activated. In ED, noted SBP 70s not responsive to IVF\\n challenges, U/S guided CVL placement Lt femoral. Vanc/Levo/Flagyl\\n started empirically for sepsis. INR 13.2, received IV vit K and FFP.\\n Levophed started for hypotension resistant to IVF resuscitation.\\n Transferred to MICU for managemend of sepsis, hemodynamics. No\\n headache or photophobia.\\n On exam:\\n 95.9, 101/68, 70v-paced, 91% 5L NC\\n Mask vent. Suppine in bed NAD\\n Rales b/l\\n Distant heart sounds\\n Soft ntnd bs+\\n 2+ pitting edema, dusky digits UE & LE worst on Lt hand\\n No nuchal rigidity\\n Data:\\n 7.13/79/70 in ED 7.17/79/49 VBG in ICU\\n W8.6 91S/1B Hct 48.4 plt 200\\n Hco3 26 creat 4.3 .INR 13.2\\n CT head\\n no bleed, mass\\n CXR\\n lowish lung volumes, dialysis line goes down into IVC,\\n cardiomegally, rotation, CHF increased vs. last\\n AP/\\n 83M w/ MMP presents with sepsis of unclear etiology given hypothermia,\\n left shift, hypotension requiring pressors. Source unclear, several\\n potential causes including line infxn from indwelling dialysis line,\\n uti possible though makes little urine. BCx sent, ucx when able.\\n Meningitis is in differential, esp given new confusion (but also has\\n inc CO2, acute illness in elderly which could explain) but doesn\\nt have\\n neck stiffness, photophobia or headache. INR is too high for LP so\\n cover empirically w/ broad spectrum abx.\\n Hypercarbic resp failure with minimal disturbance of Aa gradient. A\\n bit hard to explain as would expect more disturbance in oxygenation\\n rather than acute disturbance in ventilation unless worsening of\\n underlying lung disease. If doesn\\nt turn around quickly would intubate\\n to facilitate care. Appears to be acute respiratory acidosis by abg.\\n Pt labs suggest strongly hemoconcentrated though CXR c/w chronic CHF\\n (EF25% by last measure) , gentle fluid boluses as likely has small\\n euvolemic zone.\\n Has sig vasculopathy. Digits dusky at baseline. Carefully monitoring\\n but is at risk while requiring pressors esp with alpha activity.\\n Vascular consulted.\\n Pt is dialysis dependent. Let renal know pt has been admitted.\\n Remainder of plan as outlined in resident note above.\\n Pt is critically ill.\\n Time spent on care: 50\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2134-04-12 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 376064,\n \"text\": \"Chief Complaint: Hypotension, altered mental status\\n HPI:\\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\\n change. His son who accompanies him says that he has noticed an\\n increase in his RR over the past few days and a decrease in his energy\\n level. When he went to visit him this morning, he was very sleepy and\\n not coherent which is a change so they called the ambulance. BP and O2\\n sats there noted to be low. He did not eat breakfast this morning\\n which is very unusual for him.\\n .\\n In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22.\\n 97% on 5L NC. Arrived hypotensive in 70s, MS A+Ox3 here (but per son,\\n not at baseline), BP unresponsive to 2L NS so left femoral central line\\n placed under U/S guidance (as INR 13) and levo started. Moving arms\\n but legs weaker. 2 U FFP, 10 vit K IV. Cxr w/ increased CHF. Head CT\\n NEG. Could not pass foley X 2, now w/ small amt of blood. Given vanco\\n 1g IV, levo 750 mg IV, flagyl 500 mg IV. Cool hands/feet, dopplerable\\n PT but not DP, vasc called and will see on the floor. Guaiac + brown\\n stool.\\n .\\n On arrival to the ICU, his son states he is more alert now but not back\\n to baseline.\\n .\\n Review of systems: Pt. states he feels short of breath but cannot\\n clarify further.\\n Patient admitted from: ER\\n History obtained from Family / Medical records\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Horse/Equine Product Derivatives\\n Unknown;\\n Calcium Channel Blocking Agents-Benzothiazepines\\n Headache;\\n Metoprolol\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Norepinephrine - 0.12 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n (per med sheets)\\n Coumadin 3 mg daily\\n Dialysis at dialysis MWF\\n Acetaminophen\\n ASA 325 mg daily\\n calcium acetate 667 mg 2 tabs tid\\n dextroamphetamine 2.5 mg daily\\n docusate\\n folate 1 mg daily\\n lotemax 0.5% eye drops\\n mucinex 600 mg \\n mucomyst nebs \\n nephrocaps\\n pantoprazole 40 mg daily\\n sensipar 30 mg \\n spiriva daily\\n tobramycin 0.3% eye drops\\n Valtrex 500 mg daily\\n lactulose\\n lorazepam 0.5 mg \\n percocet 5/325 \\n dexadrine 5 mg daily\\n Albuterol\\n vit B12 1000 mg daily\\n nepro 235 daily\\n albumin w/ dialysis\\n darbapoetin w/ dialysis\\n Past medical history:\\n Family history:\\n Social History:\\n - PVD (Followed by ) w/ chronic LUE and bilateral LE ischemis\\n - Chronic renal failure on HD x 4 years (thought to be due to\\n obstructive uropathy, kidney stones, BPH)\\n - Systolic heart failure w/ EF 25% on ECHO \\n - Moderate aortic valve stenosis (area 1.0-1.2cm2). Moderate (2+)\\n aortic regurgitation is seen. Moderate to severe (3+) mitral\\n regurgitation is seen. There is mild pulmonary artery systolic\\n hypertension. ()\\n - Hx atrial fibrillation and paroxysmal atrial tachycardia\\n - s/p AV nodal ablation and implantation of a dual chamber pacemaker\\n - Baseline AV conduction delay\\n - Hypertension\\n - Coronary artery disease with old posterior MI on EKG and pMIBI\\n in with EF44%, global hypokinesis, no reversible defects.\\n - Hx Left 4-9th rib fx, Left hemothorax\\n - R kidney stone s/p Lithotripsy\\n (, complicated by ESBL Klebsiella UTI)\\n - s/p stroke (cerebellar), found on MRI, sxs of gait instability\\n - hx gait d/o, hand paresthesias, polyneuropathy, C3/C4 spinal\\n cord compression cerival spondylosis, L median nerve injury\\n - Anemia\\n - Benign prostatic hypertrophy\\n - Cluster headaches\\n - Hx of positive PPD, never treated\\n - Hx squamous cell and basal cell ca\\n - HSV keratouveitis\\n - ventral hernia\\n - s/p open cholecystectomy \\n - s/p small bowel resection (80-90%) for mesenteric ischemia\\n - s/p umbilical hernia repair\\n - s/p cystocele repair\\n - s/p laminectomy - c/b osteomyelitis\\n - s/p TURP \\n There is no family history of premature coronary artery disease or\\n sudden death.\\n Patient has been at a NH and has not gotten home since hospitalization\\n in . His wife lives in . He is a retired psychiatrist.\\n Social history is significant for the remote tobacco use, 3ppd x 40\\n years, quit 20 years ago. He drinks alcohol occasionally, denies\\n illicit drug use.\\n Review of systems:\\n Flowsheet Data as of 02:32 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.5\\nC (95.9\\n HR: 70 (70 - 76) bpm\\n BP: 101/58(68) {89/58(68) - 101/68(73)} mmHg\\n RR: 18 (17 - 20) insp/min\\n SpO2: 94%\\n Heart rhythm: V Paced\\n Height: 70 Inch\\n Total In:\\n 2,116 mL\\n PO:\\n TF:\\n IVF:\\n 116 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 2,116 mL\\n Respiratory\\n O2 Delivery Device: Bipap mask\\n SpO2: 94%\\n Physical Examination\\n GENERAL: Awake but confused, NAD. Answers do not make sense.\\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\\n icterus. PERRLA/EOMI. dry MM. OP w/ poor dentition. Neck Supple.\\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\\n or but very distant heart sounds.\\n LUNGS: Occasional crackles anteriorly and posteriorly w/ poor\\n inspiratory effort.\\n ABDOMEN: NABS. Soft, midline scar. No HSM\\n EXTREMITIES: anasarca, palp radial pulses, dopperable PT/DP\\n bilaterally. L hand w/ purple fingertips on fingers 2, 3 and 4.\\n SKIN: Xerosis.\\n NEURO: Alert but not oriented. Speaking nonsensical sentences. Able\\n to show 2 fingers on the R but not L. Able to wiggle toes. Could not\\n follow other commands.\\n Labs / Radiology\\n [image002.jpg]\\n Other labs: Lactic Acid:1.2 mmol/L\\n Imaging: CT Head: wet read - no acute intracranial pathology.\\n .\\n CXR:\\n FINDINGS: Comparison is made to . Right pacemaker and two\\n intracardiac leads remain in place. Since prior exam, left IJ\\n hemodialysis catheter has been placed, with tip low in position,\\n possibly within the IVC. Vascular stens are noted in the left\\n subclavian and brachiocephalic vein.\\n Cardiomegaly again noted with central congestion, bilateral pleural\\n effusions. Lung bases are suboptimally assessed given low lung volumes\\n though compared with prior, effusion and CHF is increased.\\n IMPRESSION:\\n 1. Dialysis catheter tip low, likely in IVC.\\n 2. CHF, worse.\\n Microbiology: Blood cx w/ NGTD\\n ECG: ECG: V-paced (74)\\n Assessment and Plan\\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\\n change and hypotension.\\n .\\n #. Hypotension: Concerning for sepsis given l-shift, indwelling HD line\\n and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/\\n prior HD line. Also has a pacemaker. Could not get a urine specimen.\\n CXR w/ loss of diaphragm on R but w/o obvious infiltrate. Could also\\n be from a meningitis given altered mental status. Would be unsafe to\\n perform LP in the setting of INR 13.3. Could also be from cardiogenic\\n shock given baseline depressed EF. Cardiac output limited by paced\\n rate.\\n - cover w/ antibiotics to treat meningitis w/ Vanc/CTX, ampicillin\\n acyclovir for now\\n - NE w/ goal MAP > 60\\n - continue to gently bolus w/ LR given depressed EF, severe valvular\\n disease\\n - Repeat ECHO to eval for worsening CHF/Valvular disease\\n - would ideally like to place an a-line for HD monitoring but I would\\n be concerned to precipitate ischemia to R hand and L-hand already\\n ischemic. Will follow w/ non-invasive for now.\\n - check a MVO2\\n - will ask EP to turn up rate in am\\n .\\n #. Acute respiratory acidosis: Unclear precipitant. DDX from percocets\\n vs infection vs hypophosphatemia vs respiratory muscle fatigue\\n - will try bipap for now to see if he tolerates\\n - check phos\\n - continue to monitor\\n .\\n #. Altered mental status: DDX from hypercarbia vs from percocets vs\\n from infection. CT head w/o acute process. Could possibly be from\\n meningitis but no nucal rigidity or headache.\\n - continue to monitor\\n - treat empirically for meningitis as cannot safely do an LP given\\n coagulopathy\\n .\\n #. Hypoxia: CXR seems consistent w/ pulmonary edema. Likely from\\n worsening valvular disease. Could also be an infiltrate that is hidden\\n by edema. Apparently has been on L NC at rehab w/ unclear\\n diagnosis but getting spiriva and albuterol. No formal dx of COPD.\\n - albuterol and atrovent nebs\\n .\\n #. ESRD on HD: Dialysis MWF at Dialysis.\\n - contact renal in the am for cvvh vs HD depending on BP\\n .\\n #. Systolic heart failure: Unclear if ischemic in etiology or from\\n valvular disease (mod AS, severe MR).\\n - appears total body volume overloaded despite hypotension.\\n .\\n #. Afib: INR supratherapeutic at 13.2. Now s/p 2 U FFP and 10 mg vit K\\n IV X 1 in the ED. No obvious signs of bleeding. HCT w/\\n hemoconcentration given baseline of 32. S/p AVN ablation and\\n dual-chamber pacemaker.\\n - hold coumadin\\n - trend coags\\n .\\n #. PVD: Known LUE and bilateral LE PVD followed by Dr. .\\n - appreciate vascular input, nothing to do for now\\n .\\n #. Macrocytic Anemia: Current hct likely hemoconcentration. Will watch\\n for signs of bleeding given supra-therapeutic INR. B12/folate wnl in\\n .\\n - trend for now.\\n - guaiac stools\\n ICU Care\\n Nutrition:NPO for now\\n Glycemic Control: Blood sugar well controlled\\n Lines:\\n Multi Lumen - 12:30 AM\\n Dialysis Catheter - 12:30 AM\\n 18 Gauge - 12:30 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , Family\\n meeting held , ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2134-04-12 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 376098,\n \"text\": \"Chief Complaint: Hypotension, altered mental status\\n HPI:\\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\\n change. His son who accompanies him says that he has noticed an\\n increase in his RR over the past few days and a decrease in his energy\\n level. When he went to visit him this morning, he was very sleepy and\\n not coherent which is a change so they called the ambulance. BP and O2\\n sats there noted to be low. He did not eat breakfast this morning\\n which is very unusual for him.\\n .\\n In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22.\\n 97% on 5L NC. Arrived hypotensive in 70s, MS A+Ox3 here (but per son,\\n not at baseline), BP unresponsive to 2L NS so left femoral central line\\n placed under U/S guidance (as INR 13) and levo started. Moving arms\\n but legs weaker. 2 U FFP, 10 vit K IV. Cxr w/ increased CHF. Head CT\\n NEG. Could not pass foley X 2, now w/ small amt of blood. Given vanco\\n 1g IV, levo 750 mg IV, flagyl 500 mg IV. Cool hands/feet, dopplerable\\n PT but not DP, vasc called and will see on the floor. Guaiac + brown\\n stool.\\n .\\n On arrival to the ICU, his son states he is more alert now but not back\\n to baseline.\\n .\\n Review of systems: Pt. states he feels short of breath but cannot\\n clarify further.\\n Patient admitted from: ER\\n History obtained from Family / Medical records\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Horse/Equine Product Derivatives\\n Unknown;\\n Calcium Channel Blocking Agents-Benzothiazepines\\n Headache;\\n Metoprolol\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Norepinephrine - 0.12 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n (per med sheets)\\n Coumadin 3 mg daily\\n Dialysis at dialysis MWF\\n Acetaminophen\\n ASA 325 mg daily\\n calcium acetate 667 mg 2 tabs tid\\n dextroamphetamine 2.5 mg daily\\n docusate\\n folate 1 mg daily\\n lotemax 0.5% eye drops\\n mucinex 600 mg \\n mucomyst nebs \\n nephrocaps\\n pantoprazole 40 mg daily\\n sensipar 30 mg \\n spiriva daily\\n tobramycin 0.3% eye drops\\n Valtrex 500 mg daily\\n lactulose\\n lorazepam 0.5 mg \\n percocet 5/325 \\n dexadrine 5 mg daily\\n Albuterol\\n vit B12 1000 mg daily\\n nepro 235 daily\\n albumin w/ dialysis\\n darbapoetin w/ dialysis\\n Past medical history:\\n Family history:\\n Social History:\\n - PVD (Followed by ) w/ chronic LUE and bilateral LE ischemis\\n - Chronic renal failure on HD x 4 years (thought to be due to\\n obstructive uropathy, kidney stones, BPH)\\n - Systolic heart failure w/ EF 25% on ECHO \\n - Moderate aortic valve stenosis (area 1.0-1.2cm2). Moderate (2+)\\n aortic regurgitation is seen. Moderate to severe (3+) mitral\\n regurgitation is seen. There is mild pulmonary artery systolic\\n hypertension. ()\\n - Hx atrial fibrillation and paroxysmal atrial tachycardia\\n - s/p AV nodal ablation and implantation of a dual chamber pacemaker\\n - Baseline AV conduction delay\\n - Hypertension\\n - Coronary artery disease with old posterior MI on EKG and pMIBI\\n in with EF44%, global hypokinesis, no reversible defects.\\n - Hx Left 4-9th rib fx, Left hemothorax\\n - R kidney stone s/p Lithotripsy\\n (, complicated by ESBL Klebsiella UTI)\\n - s/p stroke (cerebellar), found on MRI, sxs of gait instability\\n - hx gait d/o, hand paresthesias, polyneuropathy, C3/C4 spinal\\n cord compression cerival spondylosis, L median nerve injury\\n - Anemia\\n - Benign prostatic hypertrophy\\n - Cluster headaches\\n - Hx of positive PPD, never treated\\n - Hx squamous cell and basal cell ca\\n - HSV keratouveitis\\n - ventral hernia\\n - s/p open cholecystectomy \\n - s/p small bowel resection (80-90%) for mesenteric ischemia\\n - s/p umbilical hernia repair\\n - s/p cystocele repair\\n - s/p laminectomy - c/b osteomyelitis\\n - s/p TURP \\n There is no family history of premature coronary artery disease or\\n sudden death.\\n Patient has been at a NH and has not gotten home since hospitalization\\n in . His wife lives in . He is a retired psychiatrist.\\n Social history is significant for the remote tobacco use, 3ppd x 40\\n years, quit 20 years ago. He drinks alcohol occasionally, denies\\n illicit drug use.\\n Review of systems:\\n Flowsheet Data as of 02:32 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.5\\nC (95.9\\n HR: 70 (70 - 76) bpm\\n BP: 101/58(68) {89/58(68) - 101/68(73)} mmHg\\n RR: 18 (17 - 20) insp/min\\n SpO2: 94%\\n Heart rhythm: V Paced\\n Height: 70 Inch\\n Total In:\\n 2,116 mL\\n PO:\\n TF:\\n IVF:\\n 116 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 2,116 mL\\n Respiratory\\n O2 Delivery Device: Bipap mask\\n SpO2: 94%\\n Physical Examination\\n GENERAL: Awake but confused, NAD. Answers do not make sense.\\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\\n icterus. PERRLA/EOMI. dry MM. OP w/ poor dentition. Neck Supple.\\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\\n or but very distant heart sounds.\\n LUNGS: Occasional crackles anteriorly and posteriorly w/ poor\\n inspiratory effort.\\n ABDOMEN: NABS. Soft, midline scar. No HSM\\n EXTREMITIES: anasarca, palp radial pulses, dopperable PT/DP\\n bilaterally. L hand w/ purple fingertips on fingers 2, 3 and 4.\\n SKIN: Xerosis.\\n NEURO: Alert but not oriented. Speaking nonsensical sentences. Able\\n to show 2 fingers on the R but not L. Able to wiggle toes. Could not\\n follow other commands.\\n Labs / Radiology\\n [image002.jpg]\\n Other labs: Lactic Acid:1.2 mmol/L\\n Imaging: CT Head: wet read - no acute intracranial pathology.\\n .\\n CXR:\\n FINDINGS: Comparison is made to . Right pacemaker and two\\n intracardiac leads remain in place. Since prior exam, left IJ\\n hemodialysis catheter has been placed, with tip low in position,\\n possibly within the IVC. Vascular stens are noted in the left\\n subclavian and brachiocephalic vein.\\n Cardiomegaly again noted with central congestion, bilateral pleural\\n effusions. Lung bases are suboptimally assessed given low lung volumes\\n though compared with prior, effusion and CHF is increased.\\n IMPRESSION:\\n 1. Dialysis catheter tip low, likely in IVC.\\n 2. CHF, worse.\\n Microbiology: Blood cx w/ NGTD\\n ECG: ECG: V-paced (74)\\n Assessment and Plan\\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\\n change and hypotension.\\n .\\n #. Hypotension: Concerning for sepsis given l-shift, indwelling HD line\\n and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/\\n prior HD line. Also has a pacemaker. Could not get a urine specimen.\\n CXR w/ loss of diaphragm on R but w/o obvious infiltrate. Could also\\n be from a meningitis given altered mental status. Would be unsafe to\\n perform LP in the setting of INR 13.3. Could also be from cardiogenic\\n shock given baseline depressed EF. Cardiac output limited by paced\\n rate.\\n - cover w/ antibiotics to treat meningitis w/ Vanc/CTX, ampicillin\\n acyclovir for now\\n - NE w/ goal MAP > 60\\n - continue to gently bolus w/ LR given depressed EF, severe valvular\\n disease\\n - Repeat ECHO to eval for worsening CHF/Valvular disease\\n - would ideally like to place an a-line for HD monitoring but I would\\n be concerned to precipitate ischemia to R hand and L-hand already\\n ischemic. Will follow w/ non-invasive for now.\\n - check a MVO2\\n - will ask EP to turn up rate in am\\n .\\n #. Acute respiratory acidosis: Unclear precipitant. DDX from percocets\\n vs infection vs hypophosphatemia vs respiratory muscle fatigue\\n - will try bipap for now to see if he tolerates\\n - check phos\\n - continue to monitor\\n .\\n #. Altered mental status: DDX from hypercarbia vs from percocets vs\\n from infection. CT head w/o acute process. Could possibly be from\\n meningitis but no nucal rigidity or headache.\\n - continue to monitor\\n - treat empirically for meningitis as cannot safely do an LP given\\n coagulopathy\\n .\\n #. Hypoxia: CXR seems consistent w/ pulmonary edema. Likely from\\n worsening valvular disease. Could also be an infiltrate that is hidden\\n by edema. Apparently has been on L NC at rehab w/ unclear\\n diagnosis but getting spiriva and albuterol. No formal dx of COPD.\\n - albuterol and atrovent nebs\\n .\\n #. ESRD on HD: Dialysis MWF at Dialysis.\\n - contact renal in the am for cvvh vs HD depending on BP\\n .\\n #. Systolic heart failure: Unclear if ischemic in etiology or from\\n valvular disease (mod AS, severe MR).\\n - appears total body volume overloaded despite hypotension.\\n .\\n #. Afib: INR supratherapeutic at 13.2. Now s/p 2 U FFP and 10 mg vit K\\n IV X 1 in the ED. No obvious signs of bleeding. HCT w/\\n hemoconcentration given baseline of 32. S/p AVN ablation and\\n dual-chamber pacemaker.\\n - hold coumadin\\n - trend coags\\n .\\n #. PVD: Known LUE and bilateral LE PVD followed by Dr. .\\n - appreciate vascular input, nothing to do for now\\n .\\n #. Macrocytic Anemia: Current hct likely hemoconcentration. Will watch\\n for signs of bleeding given supra-therapeutic INR. B12/folate wnl in\\n .\\n - trend for now.\\n - guaiac stools\\n ICU Care\\n Nutrition:NPO for now\\n Glycemic Control: Blood sugar well controlled\\n Lines:\\n Multi Lumen - 12:30 AM\\n Dialysis Catheter - 12:30 AM\\n 18 Gauge - 12:30 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , Family\\n meeting held , ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n ------ Protected Section ------\\n Will cont vanco, CTX, amp, acyclovir given concern for infection. Will\\n cont to trend VBGs. Call renal due to need for HD, f/u vasc recs but\\n hold on any A-line given PVD. User BiPAP as tolerated. Discuss with\\n family re: goals of care. Will attempt LP today after repeating coags.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 08:55 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2134-04-12 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 376099,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 83M w/ multiple medical problems including ESRD on HD, Afib s/p AVN\\n ablation and dual-chamber PM, systolic CHF (EF 25%, 2+AS, 3+MR)\\n transferred from nursing home, w/ tachypnea and decreased\\n responsiveness, in presumed septic shock.\\n 24 Hour Events:\\n In ED, noted SBP 70s not responsive to IVF challenges, U/S guided CVL\\n placement Lt femoral. Vanc/Levo/Flagyl started empirically for\\n sepsis. INR 13.2, received IV vit K and FFP. Levophed started for\\n hypotension resistant to IVF resuscitation. Transferred to MICU for\\n managemend of sepsis, hemodynamics.\\n PMH:\\n On continuous O2 at nursing home for unclear reasons\\n CAD\\n s/p pacer\\n ICM- EF 15-20%\\n ESRD on HD via L IJ cath x 4yrs d/t obstructive uropathy\\n MR\\n Afib\\n PVD\\n HTN\\n SH: remote prior smoker\\n Overnight, underwent head CT without focal change. Evaluated by\\n Vascular svce. Remained on Levophed overnight. Started on BiPAP\\n w/ 5LO2 overnight, now on NC 3L\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Horse/Equine Product Derivatives\\n Unknown;\\n Calcium Channel Blocking Agents-Benzothiazepines\\n Headache;\\n Metoprolol\\n Unknown;\\n Last dose of Antibiotics:\\n Meropenem - 03:00 AM\\n Ceftriaxone - 04:00 AM\\n Ampicillin - 05:30 AM\\n Acyclovir - 06:00 AM\\n Infusions:\\n Norepinephrine - 0.08 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n Vanco w/ HD, pantoprazole, tobramycin ou gtt, Atrovent nebs, ampcillin,\\n acyclovir,\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:55 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 37.1\\nC (98.7\\n HR: 71 (70 - 76) bpm\\n BP: 92/58(208) {89/58(68) - 102/68(208)} mmHg\\n RR: 22 (17 - 25) insp/min\\n SpO2: 94%\\n Heart rhythm: V Paced\\n Height: 70 Inch\\n Total In:\\n 2,857 mL\\n PO:\\n TF:\\n IVF:\\n 857 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 2,857 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ///23/\\n Physical Examination\\n General Appearance: No acute distress, No(t) Overweight / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), apical\\n murmur\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Breath Sounds: Crackles : ant and post)\\n Extremities: LUE fingertips dusky, B toes w/ some duskiness. 2+\\n anasarca\\n Skin: Not assessed\\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\\n Not assessed, garbled speech, not oriented\\n Labs / Radiology\\n 12.5 g/dL\\n 200 K/uL\\n 114 mg/dL\\n 3.6 mg/dL\\n 23 mEq/L\\n 4.4 mEq/L\\n 43 mg/dL\\n 97 mEq/L\\n 137 mEq/L\\n 39.8 %\\n 14.8 K/uL\\n [image002.jpg]\\n 03:04 AM\\n WBC\\n 14.8\\n Hct\\n 39.8\\n Plt\\n 200\\n Cr\\n 3.6\\n TropT\\n 0.34\\n Glucose\\n 114\\n Other labs: PT / PTT / INR:21.9/43.0/2.1, CK / CKMB /\\n Troponin-T:33//0.34, Differential-Neuts:91%, Band:1%, Lactic Acid:1.2\\n mmol/L, Albumin:4.1, Ca++:7.4 mg/dL, Mg++:1.2 mg/dL, PO4:5.6 mg/dL\\n Fluid analysis / Other labs: VBG (admit)- 7.13 / 79 / 70\\n fem line central venous sat- 56%\\n VBG (0700)- 7.28 / 56 / 32 (on BiPAP)\\n anion gap- 17\\n Imaging: Head CT ()- nonfocal (per report)\\n CXR ()- low lung vols, chr bilat ple effusions, L IJ HD cath in\\n IVC, increased interstitial markings compared to film\\n Echo ()- LVH, , EF 25-30%, mod AS, 3+ MR, mild PA HTN\\n Microbiology: Blood- pending\\n Assessment and Plan\\n 83M w/ MMP presents with sepsis of unclear etiology currently in shock\\n and pressor-dependent. Several potential causes including line infxn\\n from indwelling dialysis line, uti possible though makes little urine.\\n BCx sent, ucx when able. Meningitis is in differential, esp given new\\n confusion (but also has inc CO2, acute illness in elderly which could\\n explain) but doesn\\nt have neck stiffness, photophobia or headache. INR\\n is too high for LP so cover empirically w/ broad spectrum abx.\\n SHOCK- Probably multifactorial: cardiogenic given ischemic\\n cardiomyopathy and sepsis (poss sources include line infection vs urine\\n vs CNS infection)\\n -gentle fluid resuscitation given cardiomyopathy\\n -could trend fem line venous pressures to follow\\n -ABX as below\\n PRESUMED unclear source\\n -vanco + ampcillin + CTX + acyclovir covering broadly for\\n meningoencephalitis (covering viral as well given hx of chronic HSV\\n infxn) as well as for possible line infxn\\n -f/u pan-culture\\n ISCHEMIC CARDIOMYOPATHY w/ MITRAL REGURGITATION- mild troponin leak\\n overnight, unclear if represents new ACS given renal failure\\n -repeat echo w/ dopplers today to better assess\\n AFIB- suprathrerapeutic on coumadin which we are holding\\n -holding rate control for hypotension\\n -V-paced on telemetry\\n PERIPHERAL VASCULAR DISEASE- dusky digits\\n -Vascular following, holding off on arterial line access given\\n concern for further digital ischemia\\n ALTERED MENTAL STATUS- persistent despite lowering of pCO2 w/ BiPAP\\n overnight, now considering infection/ shock or primary CNS infxn vs\\n primary vascular insult\\n -treat shock state as above\\n -minimize sedatives\\n -will attempt LP to further evaluate once coagulopathy corrected\\n -consider MRI brain if not improved w/ treatment of above.\\n HYPERCARBIC RESPIRATORY DISTRESS- related to depressed mental status\\n last night, tolerated BiPAP well\\n -continue hs BiPAP\\n ESRD- notify Renal svce\\n -will need to notify re: placement of L IJ in IVC\\n COAGULOPATHY- related to coumadin\\n -getting vitamin K and FFP, following\\n ICU Care\\n Nutrition:\\n Comments: npo\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 12:30 AM\\n Dialysis Catheter - 12:30 AM\\n 18 Gauge - 12:30 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 50 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2134-04-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 376074,\n \"text\": \"83yo mal w/ hx CHF, PVD, chronic renal failure on dialysis x3 weekly\\n presenting to ED from Nursing home w/ altered mental status, A&Ox1,\\n hypotensive to 70's and o2sat 80's. Pt place on 4L NC, femoral TLC\\n placed, gave 1.5L NS w/ no change in BP, started levophed. Unable to\\n place foley after x3 attempts. CT head neg. Given 2U FFP for INR 13,\\n also given 10mg Vit K, Vanco, flagyl, and levoquin. To micu for\\n further monitoring.\\n Peripheral vascular disease (PVD) with critical limb ischemia\\n Assessment:\\n All limbs cool w/ varying degrees of dusky tissue and some skin tears\\n and scabs from previous injuries/tears. Vascular team following. LLE\\n pedal pulses dopplarable, RLE dorsal pulses absent but post tib\\n dopplerable. RLE popliteal pulse easily palpated. Radial pulses\\n thready bilat. LUE w/ old fistulas. Coccyx w/ stage 1 pressure ulcer\\n (pink)\\n Action:\\n Pneumo boots in place, ordered waffle boots but none in distribution,\\n warm blankets on pt and socks on feet for warmth. Adaptic dressing on\\n RLE skin tear. Aloe vesta cream to coccyx and frequent turns.\\n Response:\\n No change in skin issues @ this time.\\n Plan:\\n Vascular team following, waffle boots for bilat LE\\ns when available,\\n frequent turns and monitor for worsening perfusion.\\n Altered mental status (not Delirium)\\n Assessment:\\n A&Ox1 w/ constant confused questions and statements; ? infection vs\\n hypercarbia. No growth in cx\\ns to this point (unable to get urine, x3\\n attempts in ED to get foley but failed). Venous gas 7.17/79/42/30\\n initially in MICU. Pt follows commands, PERRL 4mm/brisk, CT head was\\n neg. BP w/ MAP >65 while on levophed from ED. Lactate 1.2. WBC 8.6.\\n Got 2L IVF in ED, Vanco, levoquin, and flagyl.\\n Action:\\n Frequently reorient pt, started meropenem, ceftriaxone, acyclovir,\\n ampicillin for ? meningitis and/or HD line infection. Placed on CPAP\\n machine. Weaning Levophed as BP tolerates, gave 250cc LR bolus x1.\\n Response:\\n No change in MS, only small change in Levophed which is now @\\n 0.10mcg/kg/min, WBC w/ AM labs was 14.8.\\n Plan:\\n Monitor MS, cont CPAP (pt to remain NPO @ this time), wean levophed as\\n BP tolerates for goal MAP >60. Cont abx, pt will need blood cx\\ns from\\n HD line if he gets HD today.\\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\\n disease)\\n Assessment:\\n Anuric, last HD on Friday . BUN/Creat 45/4.3 from ED\\n labs. CXR w/ worsening bilat pl. eff. and CHF.\\n Action:\\n No intervention overnight\\n Response:\\n Remains anuric, AM BUN/Creat 43/3.6.\\n Plan:\\n Scheduled HD on M/W/F but unknown if it will be done today.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2134-04-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 376165,\n \"text\": \"83yo mal w/ hx CHF, PVD, chronic renal failure on dialysis x3 weekly\\n presenting to ED from Nursing home w/ altered mental status, A&Ox1,\\n hypotensive to 70's and o2sat 80's.To MICU for further monitoring.\\n Altered mental status (not Delirium)\\n Assessment:\\n Alert/oriented X . Speaking nonsensically but cooperative and\\n following commands.\\n Action:\\n ABX coverage. Frequent reorientation.\\n Response:\\n Afebrile.\\n Plan:\\n Goal MAPs >60. Monitor patient safety and provide reorientation and\\n reassurance of safety.\\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\\n disease)\\n Assessment:\\n HD three times weekly.\\n Action:\\n Renal following.\\n Response:\\n Ongoing.\\n Plan:\\n Possible HD today.\\n Peripheral vascular disease (PVD) with critical limb ischemia\\n Assessment:\\n Toes/fingers purple but dopplerable pulses.\\n Action:\\n Vascular in to assess.\\n Response:\\n Unchanged vascular status.\\n Plan:\\n Vascular will continue to follow.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2134-04-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 376081,\n \"text\": \"83yo mal w/ hx CHF, PVD, chronic renal failure on dialysis x3 weekly\\n presenting to ED from Nursing home w/ altered mental status, A&Ox1,\\n hypotensive to 70's and o2sat 80's. Pt place on 4L NC, femoral TLC\\n placed, gave 1.5L NS w/ no change in BP, started levophed. Unable to\\n place foley after x3 attempts. CT head neg. Given 2U FFP for INR 13,\\n also given 10mg Vit K, Vanco, flagyl, and levoquin. To micu for\\n further monitoring.\\n Peripheral vascular disease (PVD) with critical limb ischemia\\n Assessment:\\n All limbs cool w/ varying degrees of dusky tissue and some skin tears\\n and scabs from previous injuries/tears. Vascular team following. LLE\\n pedal pulses dopplarable, RLE dorsal pulses absent but post tib\\n dopplerable. RLE popliteal pulse easily palpated. Radial pulses\\n thready bilat. LUE w/ old fistulas. Coccyx w/ stage 1 pressure ulcer\\n (pink)\\n Action:\\n Pneumo boots in place, ordered waffle boots but none in distribution,\\n warm blankets on pt and socks on feet for warmth. Adaptic dressing on\\n RLE skin tear. Aloe vesta cream to coccyx and frequent turns.\\n Response:\\n No change in skin issues @ this time.\\n Plan:\\n Vascular team following, waffle boots for bilat LE\\ns when available,\\n frequent turns and monitor for worsening perfusion.\\n Altered mental status (not Delirium)\\n Assessment:\\n A&Ox1 w/ constant confused questions and statements; ? infection vs\\n hypercarbia. No growth in cx\\ns to this point (unable to get urine, x3\\n attempts in ED to get foley but failed). Venous gas 7.17/79/42/30\\n initially in MICU. Pt follows commands, PERRL 4mm/brisk, CT head was\\n neg. BP w/ MAP >65 while on levophed from ED. Lactate 1.2. WBC 8.6.\\n Got 2L IVF in ED, Vanco, levoquin, and flagyl.\\n Action:\\n Frequently reorient pt, started meropenem, ceftriaxone, acyclovir,\\n ampicillin for ? meningitis and/or HD line infection. Placed on CPAP\\n machine. Weaning Levophed as BP tolerates, gave 250cc LR bolus x1.\\n Response:\\n No change in MS, only small change in Levophed which is now @\\n 0.10mcg/kg/min, WBC w/ AM labs was 14.8.\\n Plan:\\n Monitor MS, cont CPAP (pt to remain NPO @ this time), wean levophed as\\n BP tolerates for goal MAP >60. Cont abx, pt will need blood cx\\ns from\\n HD line if he gets HD today.\\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\\n disease)\\n Assessment:\\n Anuric, last HD on Friday . BUN/Creat 45/4.3 from ED\\n labs. CXR w/ worsening bilat pl. eff. and CHF.\\n Action:\\n No intervention overnight\\n Response:\\n Remains anuric, AM BUN/Creat 43/3.6.\\n Plan:\\n Scheduled HD on M/W/F but unknown if it will be done today.\\n Plan for ECHO today to reassess cardiac function (MR, EF, etc).\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2134-04-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 376164,\n \"text\": \"83yo mal w/ hx CHF, PVD, chronic renal failure on dialysis x3 weekly\\n presenting to ED from Nursing home w/ altered mental status, A&Ox1,\\n hypotensive to 70's and o2sat 80's.To MICU for further monitoring.\\n Altered mental status (not Delirium)\\n Assessment:\\n Alert/oriented X .\\n Speaking nonsensically but cooperative and following commands.\\n Wife and son in to visit saying some improvement than yesterday and\\n mental status improving as shift advances.\\n Concern for infectious process as patient remains hypotensive requiring\\n Levophed gtt.\\n BP 90s on Levophed; baseline reported to be 100s.\\n Action:\\n ABX coverage.\\n Frequent reorientation.\\n Response:\\n Afebrile.\\n Able to wean Levophed and off at 1700.\\n Plan:\\n Goal MAPs >60.\\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\\n disease)\\n Assessment:\\n HD three times weekly.\\n Action:\\n Renal following.\\n Response:\\n Ongoing.\\n Plan:\\n Will not require HD today.\\n Peripheral vascular disease (PVD) with critical limb ischemia\\n Assessment:\\n Toes/fingers purple but dopplerable pulses.\\n Action:\\n Vascular in to assess.\\n Response:\\n Unchanged vascular status.\\n Plan:\\n Vascular will continue to follow.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2134-04-12 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 376073,\n \"text\": \"TITLE: Respiratory\\n Pt. placed on Bipap 8 PS, 5 Peep with 5 LPM O2 per VBG results. Pt\\n showing slight improvement.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2134-04-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 376135,\n \"text\": \"83yo mal w/ hx CHF, PVD, chronic renal failure on dialysis x3 weekly\\n presenting to ED from Nursing home w/ altered mental status, A&Ox1,\\n hypotensive to 70's and o2sat 80's. Pt place on 4L NC, femoral TLC\\n placed, gave 1.5L NS w/ no change in BP, started levophed. Unable to\\n place foley after x3 attempts. CT head neg. Given 2U FFP for INR 13,\\n also given 10mg Vit K, Vanco, flagyl, and levoquin. To micu for\\n further monitoring.\\n Altered mental status (not Delirium)\\n Assessment:\\n Alert/oriented X .\\n Speaking nonsensically but cooperative and following commands.\\n Wife and son in to visit saying some improvement than yesterday and\\n mental status improving as shift advances.\\n Concern for infectious process as patient remains hypotensive requiring\\n Levophed gtt.\\n BP 90s on Levophed; baseline reported to be 100s.\\n Action:\\n ABX coverage.\\n Frequent reorientation.\\n Response:\\n Afebrile.\\n Able to wean Levophed and off at 1700.\\n Plan:\\n Goal MAPs >60.\\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\\n disease)\\n Assessment:\\n HD three times weekly.\\n Action:\\n Renal following.\\n Response:\\n Ongoing.\\n Plan:\\n Will not require HD today.\\n Peripheral vascular disease (PVD) with critical limb ischemia\\n Assessment:\\n Toes/fingers purple but dopplerable pulses.\\n Action:\\n Vascular in to assess.\\n Response:\\n Unchanged vascular status.\\n Plan:\\n Vascular will continue to follow.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2134-04-13 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 376210,\n \"text\": \"Clinician: Attending\\n Went into Mr. room to pre-round this morning at 7:25 am. I\\n noted that he was apneic w/o a pulse. A code was called. Recussitation\\n was started w/ cpr and manually ventilating him. He was in PEA so\\n received 2 amp epi, 2 amps of bicarb, 1 amp atropine, 10 U insulin, amp\\n of D50. He was intubated by anesthesia. I called his wife who asked\\n that recussitation be stopped. When recussitation stopped, he did not\\n have any spontaneous respirations or heart sounds. Pupils fixed and\\n dilated. Time of death: 07:30 am. His and and were\\n notified and there will not be an autopsy. Dr. and Dr. \\n were notified by pager.\\n Total time spent: 60 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2134-04-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 376216,\n \"text\": \"EVENT NOTE:\\n Report taken from nurse on previous shift at 06:50, saw pt at 07:00 as\\n vascular team entered to examine patient.\\n At 07:25 I entered to begin examining pt and to administer am\\n medications, I was followed in to the room by the MICU resident. We\\n noted that the pt was in respiratory arrest and called a code blue.\\n Code continued until family contact and advised us to stop, time of\\n death called by MICU resident.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2134-04-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 376192,\n \"text\": \"83yo mal w/ hx CHF, PVD, chronic renal failure on dialysis x3 weekly\\n presenting to ED from Nursing home w/ altered mental status, A&Ox1,\\n hypotensive to 70's and o2sat 80's.To MICU for further monitoring.\\n Altered mental status (not Delirium)\\n Assessment:\\n Alert/oriented X . Speaking nonsensically but cooperative and\\n following commands.\\n Action:\\n ABX coverage. Frequent reorientation.\\n Response:\\n Afebrile.\\n Plan:\\n Goal MAPs >60. Monitor patient safety and provide reorientation and\\n reassurance of safety.\\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\\n disease)\\n Assessment:\\n HD three times weekly.\\n Action:\\n Renal following.\\n Response:\\n Ongoing.\\n Plan:\\n Possible HD today.\\n Peripheral vascular disease (PVD) with critical limb ischemia\\n Assessment:\\n Toes/fingers purple but dopplerable pulses.\\n Action:\\n Vascular in to assess.\\n Response:\\n Unchanged vascular status.\\n Plan:\\n Vascular will continue to follow.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2134-04-12 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 376121,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 83M w/ multiple medical problems including ESRD on HD, Afib s/p AVN\\n ablation and dual-chamber PM, systolic CHF (EF 25%, 2+AS, 3+MR)\\n transferred from nursing home, w/ tachypnea and decreased\\n responsiveness, in presumed septic shock.\\n 24 Hour Events:\\n In ED, noted SBP 70s not responsive to IVF challenges, U/S guided CVL\\n placement Lt femoral. Vanc/Levo/Flagyl started empirically for\\n sepsis. INR 13.2, received IV vit K and FFP. Levophed started for\\n hypotension resistant to IVF resuscitation. Transferred to MICU for\\n managemend of sepsis, hemodynamics.\\n PMH:\\n On continuous O2 at nursing home for unclear reasons\\n CAD\\n s/p pacer\\n ICM- EF 15-20%\\n ESRD on HD via L IJ cath x 4yrs d/t obstructive uropathy\\n MR\\n Afib\\n PVD\\n HTN\\n SH: remote prior smoker\\n Overnight, underwent head CT without focal change. Evaluated by\\n Vascular svce. Remained on Levophed overnight. Started on BiPAP\\n w/ 5LO2 overnight, now on NC 3L\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Horse/Equine Product Derivatives\\n Unknown;\\n Calcium Channel Blocking Agents-Benzothiazepines\\n Headache;\\n Metoprolol\\n Unknown;\\n Last dose of Antibiotics:\\n Meropenem - 03:00 AM\\n Ceftriaxone - 04:00 AM\\n Ampicillin - 05:30 AM\\n Acyclovir - 06:00 AM\\n Infusions:\\n Norepinephrine - 0.08 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n Vanco w/ HD, pantoprazole, tobramycin ou gtt, Atrovent nebs, ampcillin,\\n acyclovir,\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:55 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 37.1\\nC (98.7\\n HR: 71 (70 - 76) bpm\\n BP: 92/58(208) {89/58(68) - 102/68(208)} mmHg\\n RR: 22 (17 - 25) insp/min\\n SpO2: 94%\\n Heart rhythm: V Paced\\n Height: 70 Inch\\n Total In:\\n 2,857 mL\\n PO:\\n TF:\\n IVF:\\n 857 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 2,857 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ///23/\\n Physical Examination\\n General Appearance: No acute distress, No(t) Overweight / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), apical\\n murmur\\n Peripheral Vascular: (Right radial pulse:decreased), (Left radial\\n pulse:decreased), (Right DP pulse:decreased), (Left DP pulse:decreased)\\n Respiratory / Chest: (Breath Sounds: Crackles : ant and post)\\n Extremities: LUE fingertips dusky, B toes w/ some duskiness. 2+\\n anasarca\\n Skin: Not assessed\\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\\n Not assessed, garbled speech, not oriented\\n Labs / Radiology\\n 12.5 g/dL\\n 200 K/uL\\n 114 mg/dL\\n 3.6 mg/dL\\n 23 mEq/L\\n 4.4 mEq/L\\n 43 mg/dL\\n 97 mEq/L\\n 137 mEq/L\\n 39.8 %\\n 14.8 K/uL\\n [image002.jpg]\\n 03:04 AM\\n WBC\\n 14.8\\n Hct\\n 39.8\\n Plt\\n 200\\n Cr\\n 3.6\\n TropT\\n 0.34\\n Glucose\\n 114\\n Other labs: PT / PTT / INR:21.9/43.0/2.1, CK / CKMB /\\n Troponin-T:33//0.34, Differential-Neuts:91%, Band:1%, Lactic Acid:1.2\\n mmol/L, Albumin:4.1, Ca++:7.4 mg/dL, Mg++:1.2 mg/dL, PO4:5.6 mg/dL\\n Fluid analysis / Other labs: VBG (admit)- 7.13 / 79 / 70\\n fem line central venous sat- 56%\\n VBG (0700)- 7.28 / 56 / 32 (on BiPAP)\\n anion gap- 17\\n Imaging: Head CT ()- nonfocal (per report)\\n CXR ()- low lung vols, chr bilat ple effusions, L IJ HD cath in\\n IVC, increased interstitial markings compared to film\\n Echo ()- LVH, , EF 25-30%, mod AS, 3+ MR, mild PA HTN\\n Microbiology: Blood- pending\\n Assessment and Plan\\n 83M w/ MMP presents with sepsis of unclear etiology currently in shock\\n and pressor-dependent. Several potential causes including line infxn\\n from indwelling dialysis line, uti possible though makes little urine.\\n BCx sent, ucx when able. Meningitis is in differential, esp given new\\n confusion (but also has inc CO2, acute illness in elderly which could\\n explain) but doesn\\nt have neck stiffness, photophobia or headache. INR\\n is too high for LP so cover empirically w/ broad spectrum abx.\\n SHOCK- Probably multifactorial: cardiogenic given ischemic\\n cardiomyopathy and sepsis (poss sources include line infection vs urine\\n vs CNS infection)\\n -gentle fluid resuscitation given cardiomyopathy\\n -could trend fem line venous pressures to follow\\n -ABX as below\\n PRESUMED unclear source\\n -vanco + ampcillin + CTX + acyclovir covering broadly for\\n meningoencephalitis (covering viral as well given hx of chronic HSV\\n infxn) as well as for possible line infxn\\n -f/u pan-culture\\n ISCHEMIC CARDIOMYOPATHY w/ MITRAL REGURGITATION- mild troponin leak\\n overnight, unclear if represents new ACS given renal failure\\n -repeat echo w/ dopplers today to better assess\\n AFIB- suprathrerapeutic on coumadin which we are holding\\n -holding rate control for hypotension\\n -V-paced on telemetry\\n PERIPHERAL VASCULAR DISEASE- dusky digits\\n -Vascular following, holding off on arterial line access given\\n concern for further digital ischemia\\n ALTERED MENTAL STATUS- persistent despite lowering of pCO2 w/ BiPAP\\n overnight, now considering infection/ shock or primary CNS infxn vs\\n primary vascular insult\\n -treat shock state as above\\n -minimize sedatives\\n -will attempt LP to further evaluate once coagulopathy corrected\\n -consider MRI brain if not improved w/ treatment of above.\\n HYPERCARBIC RESPIRATORY DISTRESS- related to depressed mental status\\n last night, tolerated BiPAP well\\n -continue hs BiPAP\\n ESRD- notify Renal svce\\n -will need to notify re: placement of L IJ in IVC\\n COAGULOPATHY- related to coumadin\\n -getting vitamin K and FFP, following\\n ICU Care\\n Nutrition:\\n Comments: npo\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 12:30 AM\\n Dialysis Catheter - 12:30 AM\\n 18 Gauge - 12:30 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 30 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2134-04-12 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 376124,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 83M w/ multiple medical problems including ESRD on HD, Afib s/p AVN\\n ablation and dual-chamber PM, systolic CHF (EF 25%, 2+AS, 3+MR)\\n transferred from nursing home, w/ tachypnea and decreased\\n responsiveness, in presumed septic shock.\\n 24 Hour Events:\\n In ED, noted SBP 70s not responsive to IVF challenges, U/S guided CVL\\n placement Lt femoral. Vanc/Levo/Flagyl started empirically for\\n sepsis. INR 13.2, received IV vit K and FFP. Levophed started for\\n hypotension resistant to IVF resuscitation. Transferred to MICU for\\n managemend of sepsis, hemodynamics.\\n PMH:\\n On continuous O2 at nursing home for unclear reasons\\n CAD\\n s/p pacer\\n ICM- EF 15-20%\\n ESRD on HD via L IJ cath x 4yrs d/t obstructive uropathy\\n MR\\n Afib\\n PVD\\n HTN\\n SH: remote prior smoker\\n Overnight, underwent head CT without focal change. Evaluated by\\n Vascular svce. Remained on Levophed overnight. Started on BiPAP\\n w/ 5LO2 overnight, now on NC 3L\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Horse/Equine Product Derivatives\\n Unknown;\\n Calcium Channel Blocking Agents-Benzothiazepines\\n Headache;\\n Metoprolol\\n Unknown;\\n Last dose of Antibiotics:\\n Meropenem - 03:00 AM\\n Ceftriaxone - 04:00 AM\\n Ampicillin - 05:30 AM\\n Acyclovir - 06:00 AM\\n Infusions:\\n Norepinephrine - 0.08 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n Vanco w/ HD, pantoprazole, tobramycin ou gtt, Atrovent nebs, ampcillin,\\n acyclovir,\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:55 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 37.1\\nC (98.7\\n HR: 71 (70 - 76) bpm\\n BP: 92/58(208) {89/58(68) - 102/68(208)} mmHg\\n RR: 22 (17 - 25) insp/min\\n SpO2: 94%\\n Heart rhythm: V Paced\\n Height: 70 Inch\\n Total In:\\n 2,857 mL\\n PO:\\n TF:\\n IVF:\\n 857 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 2,857 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ///23/\\n Physical Examination\\n General Appearance: No acute distress, No(t) Overweight / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), apical\\n murmur\\n Peripheral Vascular: (Right radial pulse:decreased), (Left radial\\n pulse:decreased), (Right DP pulse:decreased), (Left DP pulse:decreased)\\n Respiratory / Chest: (Breath Sounds: Crackles : ant and post)\\n Extremities: LUE fingertips dusky, B toes w/ some duskiness. 2+\\n anasarca\\n Skin: Not assessed\\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\\n Not assessed, garbled speech, not oriented\\n Labs / Radiology\\n 12.5 g/dL\\n 200 K/uL\\n 114 mg/dL\\n 3.6 mg/dL\\n 23 mEq/L\\n 4.4 mEq/L\\n 43 mg/dL\\n 97 mEq/L\\n 137 mEq/L\\n 39.8 %\\n 14.8 K/uL\\n [image002.jpg]\\n 03:04 AM\\n WBC\\n 14.8\\n Hct\\n 39.8\\n Plt\\n 200\\n Cr\\n 3.6\\n TropT\\n 0.34\\n Glucose\\n 114\\n Other labs: PT / PTT / INR:21.9/43.0/2.1, CK / CKMB /\\n Troponin-T:33//0.34, Differential-Neuts:91%, Band:1%, Lactic Acid:1.2\\n mmol/L, Albumin:4.1, Ca++:7.4 mg/dL, Mg++:1.2 mg/dL, PO4:5.6 mg/dL\\n Fluid analysis / Other labs: VBG (admit)- 7.13 / 79 / 70\\n fem line central venous sat- 56%\\n VBG (0700)- 7.28 / 56 / 32 (on BiPAP)\\n anion gap- 17\\n Imaging: Head CT ()- nonfocal (per report)\\n CXR ()- low lung vols, chr bilat ple effusions, L IJ HD cath in\\n IVC, increased interstitial markings compared to film\\n Echo ()- LVH, , EF 25-30%, mod AS, 3+ MR, mild PA HTN\\n Microbiology: Blood- pending\\n Assessment and Plan\\n 83M w/ MMP presents with sepsis of unclear etiology currently in shock\\n and pressor-dependent. Several potential causes including line infxn\\n from indwelling dialysis line, uti possible though makes little urine.\\n BCx sent, ucx when able. Meningitis is in differential, esp given new\\n confusion (but also has inc CO2, acute illness in elderly which could\\n explain) but doesn\\nt have neck stiffness, photophobia or headache. INR\\n is too high for LP so cover empirically w/ broad spectrum abx.\\n SHOCK- Probably multifactorial: cardiogenic given ischemic\\n cardiomyopathy and sepsis (poss sources include line infection vs urine\\n vs CNS infection)\\n -gentle fluid resuscitation given cardiomyopathy\\n -could trend fem line venous pressures to follow\\n -ABX as below\\n PRESUMED unclear source\\n -vanco + ampcillin + CTX + acyclovir covering broadly for\\n meningoencephalitis (covering viral as well given hx of chronic HSV\\n infxn) as well as for possible line infxn\\n -f/u pan-culture\\n ISCHEMIC CARDIOMYOPATHY w/ MITRAL REGURGITATION- mild troponin leak\\n overnight, unclear if represents new ACS given renal failure\\n -repeat echo w/ dopplers today to better assess\\n AFIB- suprathrerapeutic on coumadin which we are holding\\n -holding rate control for hypotension\\n -V-paced on telemetry\\n PERIPHERAL VASCULAR DISEASE- dusky digits\\n -Vascular following, holding off on arterial line access given\\n concern for further digital ischemia\\n ALTERED MENTAL STATUS- persistent despite lowering of pCO2 w/ BiPAP\\n overnight, now considering infection/ shock or primary CNS infxn vs\\n primary vascular insult\\n -treat shock state as above\\n -minimize sedatives\\n -will attempt LP to further evaluate once coagulopathy corrected\\n -consider MRI brain if not improved w/ treatment of above.\\n HYPERCARBIC RESPIRATORY DISTRESS- related to depressed mental status\\n last night, tolerated BiPAP well\\n -continue hs BiPAP\\n ESRD- notify Renal svce\\n -will need to notify re: placement of L IJ in IVC\\n COAGULOPATHY- related to coumadin\\n -getting vitamin K and FFP, following\\n ICU Care\\n Nutrition:\\n Comments: npo\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 12:30 AM\\n Dialysis Catheter - 12:30 AM\\n 18 Gauge - 12:30 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 30 minutes\\n Patient is critically ill\\n ------ Protected Section ------\\n Attempted to perform LP at bedside. Given prior history of lumbar\\n laminectomy and possible fusion we were not able to palpate anatomic\\n landmarks to guide procedure. Will contact IR for asistance in AM.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 17:08 ------\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2134-04-13 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 376179,\n \"text\": \"TITLE: Resp Care Note, Pt placed on bipap and remained on all night.\\n Needed hands restrained otherwise pt was fine.Rx\\nd with atrovent Q6\\n last 0600. Will cont to follow.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2134-04-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 376114,\n \"text\": \"Altered mental status (not Delirium)\\n Assessment:\\n Alert/oriented X .\\n Speaking nonsensically but cooperative and following commands.\\n Wife and son in to visit saying some improvement than yesterday.\\n Concern for infectious process as patient remains hypotensive requiring\\n Levophed gtt.\\n BP 90s on Levophed; baseline reported to be 100s.\\n Action:\\n ABX coverage.\\n Frequent reorientation.\\n Response:\\n Afebrile.\\n Able to wean Levophed.\\n Plan:\\n Will obtain LP.\\n Will wean pressor as tolerated.\\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\\n disease)\\n Assessment:\\n HD three times weekly.\\n Action:\\n Renal following.\\n Response:\\n Ongoing.\\n Plan:\\n Will not require HD today.\\n Peripheral vascular disease (PVD) with critical limb ischemia\\n Assessment:\\n Toes/fingers purple but dopplerable pulses.\\n Action:\\n Vascular in to assess.\\n Response:\\n Unchanged vascular status.\\n Plan:\\n Vascular will continue to follow.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2134-04-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 259130,\n \"text\": \"Ventricular paced rhythm with underlying atrial flutter. Compared to the\\nprevious tracing of atrial flutter now manifest.\\n\\n\"\n }\n]"}}},{"rowIdx":24661,"cells":{"subject_id":{"kind":"number","value":15285,"string":"15,285"},"hadm_id":{"kind":"number","value":181964,"string":"181,964"},"target_text":{"kind":"string","value":"hypermagnesemia - With regards to his hypermagnesemia, it appears likely that he experienced dangerously elevated levels of magnesium, with a maximum of 6.5 on admission. The renal service was consulted, and HD was considered, though his electrolytes normalized shortly after admission, and his Cr returned to baseline with rehydration. It is felt that the etiology of his hypermagnesemia was primarily secondary to excessive Milk of Magnesia intake prior to admission and ARF (he had been on oxycontin/oxycodone following toe amputation, and was using laxative to counteract his constipation). Hypotension - shortly after hospital admission, Mr. became hypotensive in setting of hypermagnesemia and lasix diuresis, and was briefly admitted to the MICU. His MICU course was notable for placement of a R subclavian line, volume resuscitation with IV saline, and briefly requiring pressors, with subsequent rapid resolution of his hypotension. Hypoxia - MICU course also notable for an apneic episode, lasting 50 seconds, with O2 desaturation from 100% RA to 90% RA, and requiring emergent intubation. He was successfully extubated the following day. It is felt that his hypoxia was likely secondary to hypermagnesemia. His electrolytes normalized and he was transfered to the medical floor. ARF - His Cr 1.6 on admission, and improved back to his baseline of .5 -.9 with IV hydration. Cr remained stable for remainder of hospital course arrhythmia - Mr. has been maintained on dofetilide, given his history of ventriculra tachycardia (VT). He was noted to have frequent ectopy while on telemetry and on daily ECGs, and given his h/o VT, an EP consult was obtained for further titration of his medication regimen. His dofetilide was discontinued given his ARF, and out of concern for possible future episodes of renal insufficiency (as it is not clear what precipitated his ARF on admission). After an appropriate time, he was initiated on quinidine, and maintained on a dose of 324 mg SR twice daily. His QT interval was monitored with daily ECGs for the first several weeks, and remained stable. He has continued to have frequent ectopy, with frequent episodes of short runs of supraventricular tachycardia. He was monitored on telemetry for 9 days, notable only for frequent ectopy and short runs of SVT. Prior to discharge, he was given of Hearts monitor, for further evalution and titration of his quinidine dosing, and he will follow-up with Dr. , his cardiologist. UTI - Mr. was noted to have a proteus UTI, with a multiply-drug resistant isolate. He was initially treated for 3 days with levofloxacin, though switched to ceftriaxone when the sensitivities returned (fluoroquinolone resistant isolate), with resolution of his leukocytosis. diarrhea - noted to have episodes of diarrhea worrisome for C difficile colitis. Though the toxin assay was negative, given his significant leukocytosis and abx exposure, he was treated with an empiric course of metronidazole via his NG-tube. Altered mental status - On the medical floor, Mr continued to be deleirius for much of the hospitalization. A neurology consult was obtained, and felt that his delerium and lethargy were likely attributable to toxic/metabolic effects of his acute illness, that may persist for weeks after stabilization/resolution of his acute issues. Multiple medication changes were made to remove or reduce non-essential medications. EEG demonstrated encephalopathy (toxic-metabolic pattern), with no evidence of epileptiform activity, and brain MRI did not reveal any evidence of an acute intracranial process. Nutrition - Mr. required NG tube placement for medications and for nutrition, given his altered sensorium, which caused him to fail his first three speech and swallow evaluations. An NG tube was placed on two occasions via IR (he pulled the first out), and he was maintained on tube feeds for much of the hospitalization. A fourth Speech and Swallow evaluation, including videoswallow study, was obtained, and it was determined that Mr. could in fact resume PO intake with pureed solids and thin liquids, with Boost supplementation with all meals, and with strict aspiration precautions. His NG tube was removed. A calorie count was instated for several days, and although Mr. only achieved approximately of his calorie target and of his protein target, his family was quite encouraged by his progress and on multiple occasions clearly stated that they would not want to have a PEG tube placed for enteral nutrition. He also had not met his fluid goals, and required saline rehydration several days prior to discharge. Parkinson's - maintained on carbidopa/levodopa, though Mirapex was discontinued in an effort to simplify his medical regimen, given his ongoing delerium. pulmonary fibrosis - maintained on 5mg/day of prednisone for much of the hospitalizaiton, though dose decreased to 2.5mg/day several days prior to discharge as above (regimen simplification). Gout - Mr. , in the setting of dehydration, was noted to have an erythematous second MCP of the Right hand several days prior to discharge, tender to palpation. Given his h/o gout, it is likely that this represented a gouty arthritis, and was self-limited. I have discussed with his family members that when his delerium clears, it may be appropriate to restart him on allopurinol, which he should discuss with his PCP. s/p toe amputation - vascular surgery was consulted to follow the patient, and twice daily dressing changes were carreid out, with evidence of granulation tissue and overall good wound healing. He is to have once daily dry dressing changes following discharge. tinea - axillary rash with likely fungal involvement, and miconazole was applied."},"extractive_notes_summ":{"kind":"string","value":"There is a small old lacunar infarct within the right inferior cerebellum. An endotracheal tube has been removed. FINDINGS: AP single view of the chest has been obtained with the patient in semi-upright position. FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view. Normal signal flow voids are seen within the intracranial portions of the carotid and basilar arteries. There is scattered nonspecific T2 hyperintensity involving the periventricular white matter and centrum semiovale suggestive of chronic microvascular ischemic or gliotic changes. A single supine portable abdominal radiograph was obtained. A right subclavian line terminates within the lower SVC. AP PORTABLE CHEST X-RAY: The study is seriously limited secondary to patient positioning. FINDINGS: A right subclavian line terminates within the region of the SVC/right atrial junction. 2) Slight interval worsening of bibasilar atelectasis. REASON FOR THIS EXAMINATION: intubated FINAL REPORT INDICATION: Elevated lactate, right subclavian line placement. FINDINGS: An NG tube is in position with its distal tip terminating near the fundus of the stomach. The cardiac, mediastinal, and hilar silhouettes are unchanged. There is mild generalized sulcal dilatation consistent with mild cortical atrophy. FINDINGS: AP single view of the chest with patient in semi-upright position demonstrates the presence of an NG tube reaching far below the diaphragm and being curled in the fundus of the stomach. A right subclavian approach central venous line is identified terminating overlying the SVC just above the expected site of the atrial junction. There is slight interval worsening in the bibasilar atelectasis. IMPRESSION: 1) Interval placement of an ET tube and no evidence of pneumothorax. IMPRESSION: Moderate amount of stool in the rectosigmoid colon. The right costophrenic angle is partially excluded from this examination. A right-sided subclavian approach central venous line remains in unchanged position. Since the previous tracing of ventricular ectopyis absent. FINAL REPORT TYPE OF EXAMINATION: Chest PA and lateral. IMPRESSION: Withdrawal of orogastric tube, which is not visualized beyond the oropharynx region. This position appears unchanged; however, it is noted that some barium contrast medium has now entered the stomach. REASON FOR THIS EXAMINATION: S/P partial D/C OF NGT, replacement. There is discoid atelectasis at the right lung base with adjacent mild elevation of the right hemidiaphragm. CLINICAL INDICATION: Hypoxia. Central venous catheter and orogastric tube remain in place. There exist, however, thin plate atelectasis in the right base, a finding which was already noted on the preceding study. A right subclavian central venous catheter remains in good position within the distal superior vena cava. Ventricular bigeminy amd trigeminy. Cardiac and mediastinal contours are unchanged compared to the prior study. FINDINGS: The right IJ line is unchanged compared to the prior study. 12:19 PM CHEST (PA & LAT) Clip # Reason: pls assess for aspiration. Low lung volumes with bibasilar atelectasis persists. CLINICAL INDICATION: Nasogastric tube assessment. Sinus rhythmInterpolated PVCsLow QRS voltages in limb leadsSince previous tracing, new ventricular premature complexes The cardiac mediastinal, and hilar silhouettes remain unchanged. An NG tube is presently seen to pass the stomach and terminating in the jejunum distal to the duodenum. 4:49 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: S/P partial D/C OF NGT, replacement. Sinus rhythmFrequent ventricular premature complexesLow QRS voltages in limb leads - is nonspecificProbable left atrial abnormalitySince previous tracing of , no significant change Quinidine as ordered, QTC wnl.Resp: LS ess clear, diminshed bases. S+S to re-eval when MS clear.GU- U/O adequate 60-120cc/hr. .Gi/GU: NGT pulled by pt; replaced and placement confirmed by G. . Otherwise, nodiagnostic interim change.TRACING #1 Pt presented to PCP with c/o weakness/lethargy. Moves all extremeties and PERL.Resp: Extubated after succesful wean to PSV and SBT. Cont w/laxatives. Updated on plan of care and met with pulmonologist today.Dispo- C/o to floor with 1:1 observer. hydrating to lower mag level and labs sent at 0420 and pending. Predisone taper to begin tom'row per pulm.ID- Gram + cocci from arterial line on , vanco X 1 given, art line d/c'd and cultures resent from art line and central line this am. NGT placed d/t failed s+s eval. Sinus rhythmFrequent multifocal PVCsBorderline first degree A-V blockLow QRS voltages in limb leadsNondiagnostic T wave flatteningBorderline Q-Tc interval prolongedSince previous tracing, QTc slightly shorter Hypertensive to 170-180's with agitation; 140-160's at rest. no nedema present.endo: glu in acceptable range. Ventriculartrigeminy. Q-T interval prolongation. PT seemed to have more ectopy after extubation. MD notified. Received 1 dose vanco for +BC from aline . MICU Nursing Progress Note 0700-1900Pt weaned off dopamine and propofol. KCL and Calicum gluconate repleted.Endo- QID FS requiring no coverage. CVP running at goal of , IVF stopped. line removed d/t gram + cocci growing out of bottles, 2 more sets of BC sentReview of Systems-Neuro- MS waxing and , short periods of agitation restraints, incoherent at times, lethargic, arousing easily to voice. Need for aggressive bowel regimen vs. slowed bowel motility Speech and swallow in am. NPN 7A-7PEVENTS: Mg down to 2.8 from 3.2, CREAT improving to .9 (baseline .8), MS s+s eval- pt. of NIV for sleep apnea. Full code.Plan: Replete lytes prn. Baseline artifactSinus rhythmVentricular premature complexesLow limb leads voltage - is nonspecificSince previous tracing of , ventricular ectopy present BBS clear in upper lobes, crackles noted in lower lobes."},"n_notes":{"kind":"number","value":42,"string":"42"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2169-01-11 00:00:00.000","description":"NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)","row_id":854355,"text":" 3:45 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please place NG tube via fluoro. Unable to place at bedside\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with parkinsons, delerium, requires NG tube for meds and tube\n feeds\n REASON FOR THIS EXAMINATION:\n please place NG tube via fluoro. Unable to place at bedside.\n ______________________________________________________________________________\n FINAL REPORT\n NAS0-INTESTINAL FEEDING TUBE PLACEMENT\n\n CLINICAL INDICATION: Patient with delirium, needs feeding tube for feeding\n and medications.\n\n FINDINGS: - feeding tube was placed under fluoroscopy into\n the duodenum. Placement was confirmed with 10 cc of Conray. No signs of\n perforation were seen.\n\n IMPRESSION: Successful placement of feeding tube with fluoroscopy.\n\n"},{"category":"Radiology","chartdate":"2169-01-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":853834,"text":" 1:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check proper placement of NGT\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with PD and mental status s/p NGT placement\n REASON FOR THIS EXAMINATION:\n check proper placement of NGT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: An 82-year-old man with new NG tube, please assess placement.\n\n TECHNIQUE: AP supine portable chest at 1:15 a.m.\n\n COMPARISON: Compared to the prior study of yesterday at 8:35 in the morning.\n\n FINDINGS:\n\n The NG tube tip is now at the esophageal gastric junction, it should be\n advanced. Change in the position of the right subclavian line. No\n cardiopulmonary disease.\n\n IMPRESSION:\n\n NG tube tip is at the EG junction, it should be advanced.\n\n\n"},{"category":"Radiology","chartdate":"2169-01-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":853466,"text":" 5:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubated\n Admitting Diagnosis: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with and elevated lactate s/p intubation\n and s/p R subclavian placement.\n REASON FOR THIS EXAMINATION:\n intubated\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Elevated lactate, right subclavian line placement.\n\n FINDINGS: A right subclavian line terminates within the region of the\n SVC/right atrial junction. An endotracheal tube has been removed. The heart\n size and mediastinal contours are unchanged. There are low lung volumes.\n Atelectasis is present at both lung bases with no evidence of pulmonary\n parenchumal consolidation, pneumothorax, or pleural effusion. The right\n costophrenic angle is partially excluded from this examination.\n\n IMPRESSION: Low lung volumes with atelectasis within both lung bases. No\n evidence of pneumothorax or pleural effusion.\n\n"},{"category":"Radiology","chartdate":"2169-01-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":853338,"text":" 6:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval central line placement\n Admitting Diagnosis: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with and elevated lactate s/p intubation\n and s/p R subclavian placement.\n REASON FOR THIS EXAMINATION:\n eval central line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 82-year-old man with and elevated lactate\n status post intubation and status post right subclavian placement. Evaluate\n line placement and rule pneumothorax.\n\n Comparison is made with a prior AP semi-erect portable chest x-ray dated\n at 4:55 a.m.\n\n AP SUPINE PORTABLE CHEST X-RAY: An endotracheal tube is seen terminating\n approximately 2 cm superior to the carina. A right subclavian central venous\n catheter is seen in the distal superior vena cava. There is no evidence of\n pneumothorax. The nasogastric tube is seen terminating below the diaphragm\n with the tip curled within the fundus of the stomach. The cardiac,\n mediastinal, and hilar silhouettes are unchanged. The pulmonary vasculature\n bilaterally appears normal. The left costophrenic angle is not seen. The\n imaged portions of bilateral lungs appear clear without evidence of\n infiltrates, effusions, or consolidations. There is mild atelectasis at the\n left lung base. Surrounding soft tissue and osseous structures reveal\n degenerative changes along the thoracic spine.\n\n IMPRESSION:\n\n 1) Right subclavian central venous catheter in good position in the distal\n superior vena cava.\n 2) No pneumothorax.\n 3) Mild left lower lobe atelectasis.\n 4) No evidence of acute cardiopulmonary process.\n\n\n"},{"category":"Radiology","chartdate":"2169-01-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":853540,"text":" 2:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p NGT adjustment\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with hypermagnesemia and elevated lactate s/p intubation\n and s/p R subclavian placement.\n REASON FOR THIS EXAMINATION:\n s/p NGT adjustment\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: NG tube placement.\n\n FINDINGS:\n\n An NG tube is in position with its distal tip terminating near the fundus of\n the stomach. A right subclavian line terminates within the lower SVC. A\n metallic bar obscures the right chest limiting evaluation of the right\n hemithorax. The heart size and mediastinal contours are unchanged.\n Atelectasis is seen within both lung bases. No osseous abnormalities are\n identified.\n\n IMPRESSION:\n\n An NG tube passes into the stomach with its distal tip near the fundus.\n\n"},{"category":"Radiology","chartdate":"2169-01-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":854482,"text":" 3:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls assess interval change, patient with worsening leukocyto\n Admitting Diagnosis: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 M w/ parkinsons, altered mental status, with elevated temp, worsening\n leukocytosis despite treatment of UTI.\n REASON FOR THIS EXAMINATION:\n pls assess interval change, patient with worsening leukocytosis, ? aspiration.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: History of Parkinson's, altered mental status, elevated\n temperature, worsening leukocytosis despite treatment of urinary tract\n infection, assess for interval changes.\n\n FINDINGS:\n\n AP single view of the chest has been obtained with the patient in semi-upright\n position. Comparison is made with a similar portable chest examination dated\n . A right-sided subclavian approach central venous line remains in\n unchanged position. An NG tube has been placed and reaches well into the\n stomach with an additional curvature indicating its advancement in the\n duodenum and jejunum. The lungs remain clear without evidence of pulmonary\n vascular congestion or acute infiltrates. No pneumothorax is seen. The\n lateral pleural sinuses remain free.\n\n IMPRESSION:\n\n No evidence of new infiltrates including aspiration pneumonia as can be\n identified on a single portable chest examination.\n\n\n"},{"category":"Radiology","chartdate":"2169-01-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":853862,"text":" 10:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: correct placement of NGT\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with PD and mental status s/p NGT advancement\n REASON FOR THIS EXAMINATION:\n correct placement of NGT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: An 82-year-old man status post nasogastric tube advancement, please\n check placement.\n\n Portable AP and chest at 11:41 a.m.: Since prior study on the same\n date, the NG tube has been advanced. The tip now appears to be in the fundus\n of the stomach.\n\n\n"},{"category":"Radiology","chartdate":"2169-01-25 00:00:00.000","description":"MR HEAD W/O CONTRAST","row_id":856088,"text":" 6:25 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: ongoing altered MS, without clear etiology. Had hypoxic/hyp\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with ?Parkinsons, s/p toe amputation, CAD\n REASON FOR THIS EXAMINATION:\n ongoing altered MS, without clear etiology. Had hypoxic/hypotensive episode\n two weeks ago.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status, question Parkinson's.\n\n TECHNIQUE:\n\n Multiplanar T1- and T2-weighted images of the brain along with diffusion-\n weighted images were obtained. Correlation is made to the prior head CT from\n .\n\n FINDINGS:\n\n There are no acute territorial infarcts seen on diffusion images. There is\n mild generalized sulcal dilatation consistent with mild cortical atrophy. No\n midline shift or mass effect is seen. Diffusion-weighted images are within\n normal. Overall exam is partially degraded by repeated motion artifact.\n\n There is scattered nonspecific T2 hyperintensity involving the periventricular\n white matter and centrum semiovale suggestive of chronic microvascular\n ischemic or gliotic changes. Normal signal flow voids are seen within the\n intracranial portions of the carotid and basilar arteries. There is a small\n old lacunar infarct within the right inferior cerebellum.\n\n IMPRESSION:\n\n Chronic periventricular microvascular ischemic changes. No acute territorial\n infarct seen. Old lacune within the right cerebellum.\n\n\n"},{"category":"Radiology","chartdate":"2169-01-03 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":853442,"text":" 7:24 PM\n PORTABLE ABDOMEN Clip # \n Reason: ?reason for 2 weeks constipation, hypoactive bowel sounds\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with s/p intubation and now extubation secondary to\n hypermagnesemia.\n REASON FOR THIS EXAMINATION:\n ?reason for 2 weeks constipation, hypoactive bowel sounds\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Two weeks of constipation and hypo-active bowel sounds.\n\n A single supine portable abdominal radiograph was obtained. There is no\n evidence of bowel obstruction. Air is seen throughout the small and large\n bowel. There is a moderate amount of stool within the sigmoid colon and\n rectum. Changes are present within the spine from a convex left lumbar\n scoliosis with extensive degenerative changes.\n\n IMPRESSION: Moderate amount of stool in the rectosigmoid colon. No evidence\n of bowel obstruction.\n\n\n"},{"category":"Radiology","chartdate":"2169-01-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":853332,"text":" 4:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT placement and CHF?\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with hypermagnesemia and elevated lactate s/p intubation\n\n REASON FOR THIS EXAMINATION:\n eval ETT placement and CHF?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: An 82-year-old with ET tube placement and questionable CHF.\n\n the study was obtained at 0455 hours and comparison is made to the prior study\n of the same day obtained at 0314 hours. Since the prior study, there has been\n placement of an ET tube. The tip is 1.8 cm above the carina. Partial\n atelectasis involving the lower lobes are noted. Unchanged. There is no\n evidence of pneumothorax. There is no evidence of pleural effusion. There is\n no evidence of congestive heart failure.\n\n IMPRESSION:\n\n 1) Interval placement of an ET tube and no evidence of pneumothorax.\n 2) Partial atelectasis involving the lower lobes.\n 3) No evidence of congestive heart failure.\n\n"},{"category":"Radiology","chartdate":"2169-01-03 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":853327,"text":" 3:07 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for stroke or ICH\n Admitting Diagnosis: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with delta MS .\n REASON FOR THIS EXAMINATION:\n eval for stroke or ICH\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82-year-old male with MS . Evaluate for stroke\n or intracranial hemorrhage.\n\n TECHNIQUE: Contiguous 5 mm axial images were obtained from the vertex to the\n base of the skull on bone and soft tissue images. There are no prior studies\n for comparison.\n\n FINDINGS: There is no intracranial hemorrhage. There is no mass effect, shift\n of normally midline structures, hydrocephalus, or large territorial infarct.\n There are mild hypodense areas within the periventricular and deep white\n matter, consistent with chronic small vessel ischemic infarcts. There are a\n few small old lacunar infarcts, one within the right cerebellar hemisphere,\n the other within the left basal ganglia and left frontal lobe.\n\n IMPRESSION: No acute intracranial abnormality visualized.\n\n"},{"category":"Radiology","chartdate":"2169-01-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":853574,"text":" 11:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please confir NGT placement\n Admitting Diagnosis: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with and elevated lactate s/p intubation\n and s/p R subclavian placement.\n REASON FOR THIS EXAMINATION:\n please confir NGT placement\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: An 82-year-old man with hypomagnesemia and elevated lactate\n status post intubation and status post right subclavian placement. Please\n confirm NG tube placement.\n\n Comparison is made with a prior AP portable chest x-ray dated at\n 1526.\n\n AP PORTABLE CHEST X-RAY: The study is seriously limited secondary to patient\n positioning. A nasogastric tube is seen descending to the level of the\n diaphragm with the tip terminating in the region of the gastroesophageal\n junction. Repositioning is recommended. Osseous structures demonstrate\n diffuse degenerative changes along the thoracic and lumbar spine with endplate\n destruction at the L3/L4 interspace. Correlate clinically.\n\n"},{"category":"Radiology","chartdate":"2169-01-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":853725,"text":" 8:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate placement of NGT.\n Admitting Diagnosis: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with and elevated lactate s/p\n intubation and s/p R subclavian line palcement with h/o incorrectly placed NGT.\n REASON FOR THIS EXAMINATION:\n Please evaluate placement of NGT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 82-year-old man with and elevated lactate\n status post intubation and right subclavian line placement and NG tube\n placement. Evaluate for NG tube placement.\n\n Comparison is made with a prior AP portable chest x-ray dated .\n\n FINDINGS:\n\n AP semi-erect portable chest x-ray: A right subclavian central venous\n catheter is seen with the tip terminating in the mid/distal superior vena\n cava. Nasogastric tube descends below the diaphragm and appears with the tip\n in good position in the body of the stomach. The cardiac, mediastinal, and\n hilar silhouettes remain stable. The aorta is tortuous with mural\n calcifications. There is no evidence of pneumothorax. Low lung volumes are\n seen bilaterally. There is slight interval worsening in the bibasilar\n atelectasis. Surrounding soft tissue and osseous structures again reveal\n diffuse degenerative changes along the thoracic spine with wedging of the L4-\n L5 vertebral bodies.\n\n IMPRESSION:\n\n 1) Nasogastric tube in good position with the tip in the body of the stomach.\n\n 2) Slight interval worsening of bibasilar atelectasis.\n\n\n"},{"category":"Radiology","chartdate":"2169-01-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":854055,"text":" 9:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate\n Admitting Diagnosis: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 M with PD and mental status changes with ? infection\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Parkinsons and mental status changes, questionable infection.\n Evaluate for pulmonary infiltrates.\n\n FINDINGS:\n\n AP single view of the chest with patient in semi-upright position demonstrates\n the presence of an NG tube reaching far below the diaphragm and being curled\n in the fundus of the stomach. A right subclavian approach central venous line\n is identified terminating overlying the SVC just above the expected site of\n the atrial junction. There is no pneumothorax. The accessible pulmonary\n vasculature appears normal without evidence of congestion. No acute\n infiltrates can be identified. Relatively high positioned diaphragms are\n related to poor inspirational effort and lordotic position of the patient.\n\n Preceding chest examination of had special over penetration\n exposure to identified tubes. The pulmonary lung fields cannot be compared.\n\n IMPRESSION:\n\n No evidence of CHF or acute infiltrates on portable AP lordotic view.\n\n\n\n"},{"category":"Radiology","chartdate":"2169-01-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":854307,"text":" 10:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p NGT placement, pls assess placement and interval change.\n Admitting Diagnosis: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 M w/ parkinsons, altered mental status, episode of hypoxia .\n\n REASON FOR THIS EXAMINATION:\n s/p NGT placement, pls assess placement and interval change.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 82-year-old man with hypoxia. NG tube placement.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n The comparison is made with a prior chest radiograph dated .\n\n FINDINGS:\n\n The right IJ line is unchanged compared to the prior study. Cardiac and\n mediastinal contours are unchanged compared to the prior study. Bilateral\n lung volumes are low. Bibasilar atelectasis is also noted. No CHF.\n\n Nasogastric tube appears to be terminating in the mid portion of the thorax,\n at the level of carina.\n\n IMPRESSION:\n\n Nasogastric tube terminating in middle thorax, at the level of carina. Without\n lateral view, the precise location of the tube, in terms of whether this is in\n esophagus or trachea, is unclear. Please correlate clinically.\n\n The information is communicated with the referring physician, . \n , by telephone in the morning of .\n\n"},{"category":"Radiology","chartdate":"2169-01-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":853325,"text":" 3:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA or CHF\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with hypermagnesemia and elevated lactate\n REASON FOR THIS EXAMINATION:\n eval for PNA or CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: An 82-year-old male with elevated lactate. Evaluate for\n pneumonia or CHF.\n\n FINDINGS:\n\n Comparisons made to a prior radiograph from .\n\n The heart size and mediastinal contours are unchanged in this patient with low\n lung volumes. Opacity is seen within the left lower lobe laterally that is\n suspicious for pneumonia versus aspiration. No pneumothorax is seen.\n Atelectasis is seen within the right lower lobe. No osseous abnormalities are\n identified.\n\n IMPRESSION:\n\n Opacity within the left lower lobe laterally that is suspicious for pneumonia\n versus aspiration event.\n\n"},{"category":"Radiology","chartdate":"2169-01-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":854141,"text":" 1:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: compare for interval change\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 M w/ hypoxia, ?aspiration event\n REASON FOR THIS EXAMINATION:\n compare for interval change\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest compared to .\n\n CLINICAL INDICATION: Hypoxia.\n\n Central venous catheter and orogastric tube remain in place. Cardiac and\n mediastinal contours are stable. There is discoid atelectasis at the right\n lung base with adjacent mild elevation of the right hemidiaphragm. The lungs\n are otherwise clear. A small amount of fluid is noted in the minor fissure.\n\n IMPRESSION:\n\n No significant change. No new findings to suggest an acute aspiration event.\n\n\n"},{"category":"Radiology","chartdate":"2169-01-10 00:00:00.000","description":"BY SAME PHYSICIAN","row_id":854246,"text":" 4:49 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: S/P partial D/C OF NGT, replacement. Pls assess NGT positio\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 M w/ parkinsons, altered mental status, episode of hypoxia .\n REASON FOR THIS EXAMINATION:\n S/P partial D/C OF NGT, replacement. Pls assess NGT position\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest on compared with previous study of earlier the\n same date.\n\n CLINICAL INDICATION: Nasogastric tube assessment.\n\n The nasogastric tube is no longer visualized within the thoracic esophagus.\n The proximal portion of the tube is seen extending into the oropharynx region,\n but it is not well visualized below this level. There is otherwise no\n significant change since recent study.\n\n IMPRESSION:\n\n Withdrawal of orogastric tube, which is not visualized beyond the oropharynx\n region.\n\n"},{"category":"Radiology","chartdate":"2169-01-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":853513,"text":" 11:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT placement.\n Admitting Diagnosis: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with and elevated lactate s/p intubation\n and s/p R subclavian placement.\n REASON FOR THIS EXAMINATION:\n NGT placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 82-year-old man with right subclavian line placement and NG\n tube placement. Evaluate.\n\n Comparison is made with an AP supine portable chest x-ray dated at\n 5:37.\n\n AP ERECT PORTABLE CHEST X-RAY: There has been interval placement of a\n nasogastric tube with the tip coiled within the body of the stomach. A right\n subclavian central venous catheter remains in good position within the distal\n superior vena cava. The cardiac mediastinal, and hilar silhouettes remain\n unchanged. There is a tortuous aorta with mural calcifications. Bilateral\n lungs are stable in appearance. Low lung volumes with bibasilar atelectasis\n persists. Surrounding soft tissue and osseous structures remain stable.\n\n IMPRESSION:\n\n Interval placement of a nasogastric tube with the tip coiled within the body\n of the stomach. These findings were called to Dr. at 2:00 p.m. on\n .\n\n\n"},{"category":"Radiology","chartdate":"2169-01-20 00:00:00.000","description":"CHEST (PA & LAT)","row_id":855427,"text":" 12:19 PM\n CHEST (PA & LAT) Clip # \n Reason: pls assess for aspiration.\n Admitting Diagnosis: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with h/o hypersensitivity pneumonitis, right first toe\n gangarene, delerium.\n REASON FOR THIS EXAMINATION:\n pls assess for aspiration.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest PA and lateral.\n\n INDICATION: History of hypersensitivity pneumonitis, right-sided first toe\n gangrene, delirium. Assess for possible aspiration pneumonia.\n\n FINDINGS:\n\n AP and lateral views were obtained with the patient in sitting half erected\n position. The frontal view is compared with a similar study dated . An NG tube is presently seen to pass the stomach and terminating in the\n jejunum distal to the duodenum. This position appears unchanged; however, it\n is noted that some barium contrast medium has now entered the stomach. The\n thoracic aorta is moderately widened with some wall calcifications at the\n level of the arch. The heart shadow is mostly concealed by the elevated\n diaphragms, but significant cardiac enlargement is unlikely, as the pulmonary\n vasculature does not demonstrate any evidence of congestion. No acute\n infiltrates can be identified. There exist, however, thin plate atelectasis\n in the right base, a finding which was already noted on the preceding study.\n The lateral pleural sinuses remain free. A lateral view is under exposed and\n suffers from the patient's inability to elevate the arms. Although the image\n quality is clearly suboptimal, one can identify the posterior pleural sinuses\n to be free.\n\n IMPRESSION:\n\n Portable AP and lateral chest examination does not disclose evidence of new\n infiltrates, and there is no evidence of CHF.\n\n\n"},{"category":"Radiology","chartdate":"2169-01-20 00:00:00.000","description":"VIDEO OROPHARYNGEAL SWALLOW","row_id":855420,"text":" 11:29 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: pls assess swallowing.\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with UTI, parkinson's\n REASON FOR THIS EXAMINATION:\n pls assess swallowing.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Assess for aspiration.\n\n VIDEO OROPHARYNGEAL SWALLOW: Fluoroscopic guidance was provided for the\n speech pathologist who administered barium swallow and then liquids of the\n various consistencies to the patient. There is trace aspiration with a single\n cup sip of thin liquids. This was not redemonstrated throughout the\n remainder of the exam. There is delayed oral phase of excessive oral residue\n with all materials. A 13 mm calibrated barium tablet passed freely into the\n stomach.\n\n IMPRESSION:\n Trace aspiration with a single cup sip of thin liquids only. This was not\n redemonstrated throughout the remainder of the exam.\n\n For additional report details, please consult the speech pathologist's report,\n which is available on the online medical record section of CCC.\n\n"},{"category":"ECG","chartdate":"2169-01-16 00:00:00.000","description":"Report","row_id":168187,"text":"Baseline artifact. Sinus rhythm, may be normal ECG, but baseline artifact makes\nassessment difficult. Since the previous tracing of ventricular ectopy\nis absent.\n\n"},{"category":"ECG","chartdate":"2169-01-13 00:00:00.000","description":"Report","row_id":168188,"text":"Sinus rhythm. Ventricular bigeminy amd trigeminy. Low voltage in the limb\nleads, low normal voltage in the precordial leads. Prolonged A-V conduction.\nOtherwise, normally conducted complexes are without diagnostic abnormality.\nCompared to the previous tracing of no significant change.\n\n"},{"category":"ECG","chartdate":"2169-01-12 00:00:00.000","description":"Report","row_id":168189,"text":"Sinus rhythm\nFrequent multifocal PVCs\nLow QRS voltages in limb leads\nSince previous tracing, no significant change\n\n"},{"category":"ECG","chartdate":"2169-01-11 00:00:00.000","description":"Report","row_id":168190,"text":"Sinus rhythm\nFrequent multifocal PVCs\nLow QRS voltages in limb leads\nSince previous tracing, QRS changes in leads V3-V4 - ? lead placement; atrial\npremature complexes absent\n\n"},{"category":"ECG","chartdate":"2169-01-10 00:00:00.000","description":"Report","row_id":168191,"text":"Sinus rhythm\nVentricular couplets\nSupraventricular extrasystoles\nLow QRS voltage limb leads\nPoor R wave progression - ? lead placement\nSince previous tracing, QRS changes in V2-V4 - ? lead placement; atrial\npremature complexes noted\n\n"},{"category":"ECG","chartdate":"2169-01-09 00:00:00.000","description":"Report","row_id":168192,"text":"Sinus rhythm\nFrequent ventricular premature complexes\nLow QRS voltages in limb leads - is nonspecific\nProbable left atrial abnormality\nSince previous tracing of , no significant change\n\n"},{"category":"ECG","chartdate":"2169-01-07 00:00:00.000","description":"Report","row_id":168193,"text":"Sinus rhythm\nInterpolated PVCs\nLow QRS voltages in limb leads\nSince previous tracing, new ventricular premature complexes\n\n"},{"category":"ECG","chartdate":"2169-01-06 00:00:00.000","description":"Report","row_id":168194,"text":"Sinus rhythm. Compared to the previous tracing of ventricular ectopy is\nno longer recorded. There is baseline artifact. No diagnostic interim change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2169-01-06 00:00:00.000","description":"Report","row_id":168195,"text":"Sinus rhythm and frequent ventricular ectopy. Baseline artifact. Compared to\nthe previous tracing of the rate has increased. Otherwise, no\ndiagnostic interim change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2169-01-25 00:00:00.000","description":"Report","row_id":168186,"text":"Baseline artifact\nSinus rhythm\nVentricular premature complexes\nLow limb leads voltage - is nonspecific\nSince previous tracing of , ventricular ectopy present\n\n"},{"category":"ECG","chartdate":"2169-01-05 00:00:00.000","description":"Report","row_id":168196,"text":"Sinus rhythm\nFrequent multifocal PVCs\nBorderline first degree A-V block\nLow QRS voltages in limb leads\nNondiagnostic T wave flattening\nBorderline Q-Tc interval prolonged\nSince previous tracing, QTc slightly shorter\n\n"},{"category":"ECG","chartdate":"2169-01-04 00:00:00.000","description":"Report","row_id":168197,"text":"Sinus rhythm. A-V conduction delay and frequent ventricular ectopy. Ventricular\ntrigeminy. Low limb lead voltage. Q-T interval prolongation. Compared to the\nprevious tracing of no diagnostic interim change.\n\n"},{"category":"ECG","chartdate":"2169-01-03 00:00:00.000","description":"Report","row_id":168198,"text":"Sinus rhythm\nVentricular premature complexes\nFirst degree A-V delay\nLeft atrial abnormality\nLow limb leads voltage - is nonspecific\nModest nonspecific ST-T wave changes\nSince previous tracing of , probably no significant change\n\n"},{"category":"ECG","chartdate":"2169-01-02 00:00:00.000","description":"Report","row_id":168199,"text":"Baseline artifact in V2\nSinus rhythm\nVentricular premature complexes\nFirst degree A-V delay\nLeft atrial abnormality\nLow limb leads voltage - is nonspecific\nNo previous tracing for comparison\n\n"},{"category":"Nursing/other","chartdate":"2169-01-05 00:00:00.000","description":"Report","row_id":1461061,"text":"Nursing Note (1900-0700)\n\nMr. had an uneventful night. He did pass several large formed hardened stools thru the night.\n\nReview of systems:\nNeuro: Confused; reorientated with some effect. Agitated/restless thru most of shift. Requiring bil wrist restraints to maintain NGT in place. Frequently placing feet over siderails; freq monitoring requiried for safety.\n\nCV: Hemodynamically stable; NSR with freq PVC's; repeat K 3.9; repleted with 20KCL. Hypertensive to 170-180's with agitation; 140-160's at rest. Received 1 dose vanco for +BC from aline . Has 2 PIV's and 1 TLCL. Mutiple skin tears/bruising. Buttocks red but intact. Quinidine as ordered, QTC wnl.\n\nResp: LS ess clear, diminshed bases. 3L for 02 sats >96%. .\n\nGi/GU: NGT pulled by pt; replaced and placement confirmed by G. . Tol probalace 30cc/hr, goal 65cc/hr. Several large hard stools thru noc. Receiving laxatives for constipation. Adequate u/o./\n\nEndo: steroid taper; no SSI required.\nSocial: No calls. Full code.\n\nPlan: Replete lytes prn. Cont w/laxatives. Close monitoring for safety; will need 1:1 when bed available. Called out to floor. Advance TF as tol. Decrease FS to . Contact / . Full code.\n"},{"category":"Nursing/other","chartdate":"2169-01-03 00:00:00.000","description":"Report","row_id":1461055,"text":"Shift Note 0200-0700\nPt 82yo male admitted to MICU-A from OSH with dx hypermagnesia and mental status changes. Pt presented to PCP with c/o weakness/lethargy. Lab work sent and PCP called patient with MG 6.9 to go to ER...at this time patient was having mental status changes. In ER repeat Mg 7.3 and patient given 3 amp calcium gluconate and solu-cortef since tapering off long-term steriod use. Transferred to for further work-up.\n\nPMH: hx V-tach, pulmonary fibrosis (on predinsone at home), PVD, parkinson's disease, Shy- syndrome, right big toe amputation.\n\nCV: HR SB 50-60's, with vent bigeminy. BP initially low when presented to OSH EW...given 500cc NS bolus, BP responded well. Upon arrival to MICU, SBP 110-140's. PIVx2 intact.\n\nResp: Pt initially on 3L NC, RR 8-12, sats >96%. BBS clear in upper lobes, crackles noted in lower lobes. Around 0415 pt noted to be having apneic periods lasting 50seconds...NIBP not registering and manual BP 80/50....intern paged to unit. Pt continued to have frequent episodes of apnea...anesthesia called stat and patient intubated. Right radial art line and LSC triple lumen placed. SBP 62/30 manually while art line being placed. 500cc D5NS given and dopamine started at 3mcg and titrated to 10mcg to maintain BP. CXR ordered for line confirmation.\n\nNeuro: Upon arrival, patient very lethargic...oriented to self only and when answering questions mumbling incomprehensible words. Opening eyes to verbal command...when found with apneic periods, patient extremely difficult to arouse and not opening eyes. Pt given fentanyl/versed for intubation and started on propofol gtt for sedation.\n\nGI/GU: Abdomen soft, BS present. OG tube placed, awaiting confirmation. Foley cath draining clear yellow urine. Patient given 20mg IV lasix to assist with excreting Mg...D5NS at 125cc/hr. Given 500cc bolus when BP decreased.\n\nSocial: Intern spoke with patient's children on phone...pt full code.\n\nMg currently 4.8....ICa 1.05, patient to receive 1 amp calcium gluconate.\n"},{"category":"Nursing/other","chartdate":"2169-01-03 00:00:00.000","description":"Report","row_id":1461056,"text":"Respiratory care:\nPatient noted to have several periods of apnea lasting 50 sec. MD notified. Patient intubated with 7.5 Ett taped and secured at 23 cm. Breathsounds equal bilaterally and placement confirmed with easy cap.\nPlease see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation.\n"},{"category":"Nursing/other","chartdate":"2169-01-03 00:00:00.000","description":"Report","row_id":1461057,"text":"MICU Nursing Progress Note 0700-1900\n\nPt weaned off dopamine and propofol. Extubated at 1800 and tolerating well. Head CT this am negative. Mag continues to decrease- lytes sent at 1800- results pending. Currently being followed by cardiology and renal teams.\n\nNote: Pt takes dofetilide at home. Drug is very tightly controlled in this hospital- pharmacy following. Dc'd here due to ? renal function. If prescribed- consult pharmacy before administering. Cardiology following.\n\nNeuro: Pt initially sedated on propofol when intubated. Weaned off at 1600. Now pt is awake and follows commands. Oriented to person, place and month. Speech is very garbled and hard to understand at times. Stares into space at times. Moves all extremeties and PERL.\n\nResp: Extubated after succesful wean to PSV and SBT. No periods of apnea this shift. Sats 99-100% on 5 L NC. Resp in mid to high teens. Lung sounds clear bilat. ? sleep apnea and ? need for non invasive vent.\n\nCV: HR NSR-NSB 50's-70's. Frequent PVC's, runs of vtach at times and vent bigeminy. PT seemed to have more ectopy after extubation. BP tolerates. Stat lytes drawn at 1800- results pending. Weaned off dopamine at 1500. BP now 140's-150's. CVP 8-10.\n\nLytes: Repleted with 40 MEQ of K and 3 grams calcium total this shift.\n\nGI: Pt continues NPO, OG tube pulled with extubation. Will have speech and swallow tomorrow am. Swabs for dry mouth. Hypoactive BS, abd nontender, no BM this shift. Per family last BM was 5 days ago- ? need for aggressive BM. ? ileus.\n\nGU: Foley drg amber yellow urine. Maintenance of NS at 125cc/hr x 1 liter. 2 boluses given earlier this am.\n\nEndo: RISS in place, cvg as needed.\n\nAccess: R TLC, R radial aline.\n\nSocial: 2 daughters and wife here most of day, very supportive and involved. Family updated on status by attending, residents and this rn. Topic of code status touched upon- family will discuss.\n\nPlan: Monitor resp status\n Monitor MS\n Monitor lytes closely and f/u with pm lytes\n ? Need for aggressive bowel regimen vs. slowed bowel motility\n Speech and swallow in am.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2169-01-03 00:00:00.000","description":"Report","row_id":1461058,"text":"Respiratory Care\nPt to cat-scan this am, results pending, Weaned to PSV tolerated well no apnea. Pt extubated 1800 will leave vent on stand by for ? of NIV for sleep apnea.\n"},{"category":"Nursing/other","chartdate":"2169-01-04 00:00:00.000","description":"Report","row_id":1461059,"text":"pt is off vent since 1800 and resp status is good. hydrating to lower mag level and labs sent at 0420 and pending.\n* pt had been taking dofetilide at home but it is tightly controled here in hosp. pt was seen by card and H.O. to start quinadine this am in place as antiarrythmic, If ever to restart dofetilide must consult pharmacy first.\n\nneuro: PERL and pt moves uper extremities purposefully. legs are very stiff? parkinsons involvement. pt able to follow commands with much encouragment. oriented to person and place but speech is garbled. more clear on occasion. cough is intact but gag weak with oral care suction. to have swallow test this am.\n\ncard: rate is 60's most of night with lg amt ectopy. periods of bigemeny. pvcs in pairs and >16 pvcs per min most of shift. hx of v tach but not runs this shift.bp sys 100-150. peripheral pulses weak but feet warm. hands cold with cyanotic nail beds but good peripheral blood return. HX of PVD.\n\nresp: 3l with sat 97-99. coughing and once brought up gerrn thick sputum but unable to send as ws in pt bed.\n\ngi: NPO til swallow test done, good cough but weak gag. able to handle owm secretions all shift. pt had two small stools brown soft and hem neg. ducolax supp this am to improve stool output, bs present\n\ngu: pt is in slight pos balance and is voiding 60-75 cc/hr with iv infusing 150cc/hr to improve mag and urine output. no nedema present.\n\nendo: glu in acceptable range. no coverage required.\n\nlabs: see 0430 labs and mag at 2200 down to 3.7. no electrolytes repleted this shift.\n\nskin: pt has multiple areaas of raised hematomas which some have opened and bled. skin is dry with scaled patches and red rash like appearance. bath given and lotion applied. wet to dry dsg to rt great toe and may need some consult as needs debridment as family states were using a debriding skin tx at home,\n\nsocial: pt was cared for at home by family and issues around d/c will need to be discussed as in past family opted not to sent pt to rehab.\n\naccess: all ports functioning.\n\nplan: monitor MS\n start antiarrythmic per card consult\nfollow labs and promote bm\n\n"},{"category":"Nursing/other","chartdate":"2169-01-04 00:00:00.000","description":"Report","row_id":1461060,"text":"NPN 7A-7P\n\nEVENTS: Mg down to 2.8 from 3.2, CREAT improving to .9 (baseline .8), MS s+s eval- pt. failed- NGT placed for meds and feeds, Art. line removed d/t gram + cocci growing out of bottles, 2 more sets of BC sent\n\nReview of Systems-\n\nNeuro- MS waxing and , short periods of agitation restraints, incoherent at times, lethargic, arousing easily to voice. No pain issues today. OOB to chair via lift X 4 hours.\n\nResp- 3L O2 via NC tolerating well, O2 sats 98%, no significant issues. Concern for aspiration s/t MS, HOB elevated, CDB encouraged.\n\nCV- HR 60-70's frequent ectopy (PVCs), restarted on quinadine today need to check daily EKGs for Qtc prolongation, BP stable reamins off Dopamine with some episodes of hypertension. CVP running at goal of , IVF stopped. E-lytes sent at 1500 significant results as mentioned above.\n\nDerm- considerable skin issues- multiple areas of ecchymosis, skin tears covered with tegaderm, wound on heel covered with duoderm, wet to dry on right great toe amp appears to be red around wound base with yellow drainage and sloughing, other open areas on back and shoulders.\n\nGI- ABD quite distended, soft. Disimpacted for LARGE AMOUNT OF BROWN HARD STOOL... started on lactulose, to be given RTC, would also recommend rechecking rectum for further stool overnoc. TF at 10cc/hr of Probalance, goal rate of 65cc/hr. NGT placed d/t failed s+s eval. S+S to re-eval when MS clear.\n\nGU- U/O adequate 60-120cc/hr. IVF stopped. KCL and Calicum gluconate repleted.\n\nEndo- QID FS requiring no coverage. Predisone taper to begin tom'row per pulm.\n\nID- Gram + cocci from arterial line on , vanco X 1 given, art line d/c'd and cultures resent from art line and central line this am. Team may consider repeating vanco dose.\n\nAccess- Triple lumen in right subclavian , team wanted this to be pulled given 1/4 bottles + for GPC- however, pt. could use this access while staying in the ICU. Has 2 PIV not in use. Art line pulled and tip sent for cx.\n\n Pt. has 5 dtrs, 2 visiting today with wife. Updated on plan of care and met with pulmonologist today.\n\nDispo- C/o to floor with 1:1 observer. Remains full code.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-11 00:00:00.000\",\n \"description\": \"NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)\",\n \"row_id\": 854355,\n \"text\": \" 3:45 PM\\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \\n Reason: please place NG tube via fluoro. Unable to place at bedside\\n Admitting Diagnosis: HYPERMAGNESEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with parkinsons, delerium, requires NG tube for meds and tube\\n feeds\\n REASON FOR THIS EXAMINATION:\\n please place NG tube via fluoro. Unable to place at bedside.\\n ______________________________________________________________________________\\n FINAL REPORT\\n NAS0-INTESTINAL FEEDING TUBE PLACEMENT\\n\\n CLINICAL INDICATION: Patient with delirium, needs feeding tube for feeding\\n and medications.\\n\\n FINDINGS: - feeding tube was placed under fluoroscopy into\\n the duodenum. Placement was confirmed with 10 cc of Conray. No signs of\\n perforation were seen.\\n\\n IMPRESSION: Successful placement of feeding tube with fluoroscopy.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 853834,\n \"text\": \" 1:03 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: check proper placement of NGT\\n Admitting Diagnosis: HYPERMAGNESEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with PD and mental status s/p NGT placement\\n REASON FOR THIS EXAMINATION:\\n check proper placement of NGT\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: An 82-year-old man with new NG tube, please assess placement.\\n\\n TECHNIQUE: AP supine portable chest at 1:15 a.m.\\n\\n COMPARISON: Compared to the prior study of yesterday at 8:35 in the morning.\\n\\n FINDINGS:\\n\\n The NG tube tip is now at the esophageal gastric junction, it should be\\n advanced. Change in the position of the right subclavian line. No\\n cardiopulmonary disease.\\n\\n IMPRESSION:\\n\\n NG tube tip is at the EG junction, it should be advanced.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 853466,\n \"text\": \" 5:07 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: intubated\\n Admitting Diagnosis: \\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with and elevated lactate s/p intubation\\n and s/p R subclavian placement.\\n REASON FOR THIS EXAMINATION:\\n intubated\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Elevated lactate, right subclavian line placement.\\n\\n FINDINGS: A right subclavian line terminates within the region of the\\n SVC/right atrial junction. An endotracheal tube has been removed. The heart\\n size and mediastinal contours are unchanged. There are low lung volumes.\\n Atelectasis is present at both lung bases with no evidence of pulmonary\\n parenchumal consolidation, pneumothorax, or pleural effusion. The right\\n costophrenic angle is partially excluded from this examination.\\n\\n IMPRESSION: Low lung volumes with atelectasis within both lung bases. No\\n evidence of pneumothorax or pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 853338,\n \"text\": \" 6:03 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval central line placement\\n Admitting Diagnosis: \\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with and elevated lactate s/p intubation\\n and s/p R subclavian placement.\\n REASON FOR THIS EXAMINATION:\\n eval central line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: An 82-year-old man with and elevated lactate\\n status post intubation and status post right subclavian placement. Evaluate\\n line placement and rule pneumothorax.\\n\\n Comparison is made with a prior AP semi-erect portable chest x-ray dated\\n at 4:55 a.m.\\n\\n AP SUPINE PORTABLE CHEST X-RAY: An endotracheal tube is seen terminating\\n approximately 2 cm superior to the carina. A right subclavian central venous\\n catheter is seen in the distal superior vena cava. There is no evidence of\\n pneumothorax. The nasogastric tube is seen terminating below the diaphragm\\n with the tip curled within the fundus of the stomach. The cardiac,\\n mediastinal, and hilar silhouettes are unchanged. The pulmonary vasculature\\n bilaterally appears normal. The left costophrenic angle is not seen. The\\n imaged portions of bilateral lungs appear clear without evidence of\\n infiltrates, effusions, or consolidations. There is mild atelectasis at the\\n left lung base. Surrounding soft tissue and osseous structures reveal\\n degenerative changes along the thoracic spine.\\n\\n IMPRESSION:\\n\\n 1) Right subclavian central venous catheter in good position in the distal\\n superior vena cava.\\n 2) No pneumothorax.\\n 3) Mild left lower lobe atelectasis.\\n 4) No evidence of acute cardiopulmonary process.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 853540,\n \"text\": \" 2:39 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p NGT adjustment\\n Admitting Diagnosis: HYPERMAGNESEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with hypermagnesemia and elevated lactate s/p intubation\\n and s/p R subclavian placement.\\n REASON FOR THIS EXAMINATION:\\n s/p NGT adjustment\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: NG tube placement.\\n\\n FINDINGS:\\n\\n An NG tube is in position with its distal tip terminating near the fundus of\\n the stomach. A right subclavian line terminates within the lower SVC. A\\n metallic bar obscures the right chest limiting evaluation of the right\\n hemithorax. The heart size and mediastinal contours are unchanged.\\n Atelectasis is seen within both lung bases. No osseous abnormalities are\\n identified.\\n\\n IMPRESSION:\\n\\n An NG tube passes into the stomach with its distal tip near the fundus.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 854482,\n \"text\": \" 3:24 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pls assess interval change, patient with worsening leukocyto\\n Admitting Diagnosis: \\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 M w/ parkinsons, altered mental status, with elevated temp, worsening\\n leukocytosis despite treatment of UTI.\\n REASON FOR THIS EXAMINATION:\\n pls assess interval change, patient with worsening leukocytosis, ? aspiration.\\n ______________________________________________________________________________\\n FINAL REPORT\\n TYPE OF EXAMINATION: Chest AP portable single view.\\n\\n INDICATION: History of Parkinson's, altered mental status, elevated\\n temperature, worsening leukocytosis despite treatment of urinary tract\\n infection, assess for interval changes.\\n\\n FINDINGS:\\n\\n AP single view of the chest has been obtained with the patient in semi-upright\\n position. Comparison is made with a similar portable chest examination dated\\n . A right-sided subclavian approach central venous line remains in\\n unchanged position. An NG tube has been placed and reaches well into the\\n stomach with an additional curvature indicating its advancement in the\\n duodenum and jejunum. The lungs remain clear without evidence of pulmonary\\n vascular congestion or acute infiltrates. No pneumothorax is seen. The\\n lateral pleural sinuses remain free.\\n\\n IMPRESSION:\\n\\n No evidence of new infiltrates including aspiration pneumonia as can be\\n identified on a single portable chest examination.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 853862,\n \"text\": \" 10:59 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: correct placement of NGT\\n Admitting Diagnosis: HYPERMAGNESEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with PD and mental status s/p NGT advancement\\n REASON FOR THIS EXAMINATION:\\n correct placement of NGT\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: An 82-year-old man status post nasogastric tube advancement, please\\n check placement.\\n\\n Portable AP and chest at 11:41 a.m.: Since prior study on the same\\n date, the NG tube has been advanced. The tip now appears to be in the fundus\\n of the stomach.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-25 00:00:00.000\",\n \"description\": \"MR HEAD W/O CONTRAST\",\n \"row_id\": 856088,\n \"text\": \" 6:25 PM\\n MR HEAD W/O CONTRAST Clip # \\n Reason: ongoing altered MS, without clear etiology. Had hypoxic/hyp\\n Admitting Diagnosis: HYPERMAGNESEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with ?Parkinsons, s/p toe amputation, CAD\\n REASON FOR THIS EXAMINATION:\\n ongoing altered MS, without clear etiology. Had hypoxic/hypotensive episode\\n two weeks ago.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Altered mental status, question Parkinson's.\\n\\n TECHNIQUE:\\n\\n Multiplanar T1- and T2-weighted images of the brain along with diffusion-\\n weighted images were obtained. Correlation is made to the prior head CT from\\n .\\n\\n FINDINGS:\\n\\n There are no acute territorial infarcts seen on diffusion images. There is\\n mild generalized sulcal dilatation consistent with mild cortical atrophy. No\\n midline shift or mass effect is seen. Diffusion-weighted images are within\\n normal. Overall exam is partially degraded by repeated motion artifact.\\n\\n There is scattered nonspecific T2 hyperintensity involving the periventricular\\n white matter and centrum semiovale suggestive of chronic microvascular\\n ischemic or gliotic changes. Normal signal flow voids are seen within the\\n intracranial portions of the carotid and basilar arteries. There is a small\\n old lacunar infarct within the right inferior cerebellum.\\n\\n IMPRESSION:\\n\\n Chronic periventricular microvascular ischemic changes. No acute territorial\\n infarct seen. Old lacune within the right cerebellum.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-03 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 853442,\n \"text\": \" 7:24 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: ?reason for 2 weeks constipation, hypoactive bowel sounds\\n Admitting Diagnosis: HYPERMAGNESEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with s/p intubation and now extubation secondary to\\n hypermagnesemia.\\n REASON FOR THIS EXAMINATION:\\n ?reason for 2 weeks constipation, hypoactive bowel sounds\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Two weeks of constipation and hypo-active bowel sounds.\\n\\n A single supine portable abdominal radiograph was obtained. There is no\\n evidence of bowel obstruction. Air is seen throughout the small and large\\n bowel. There is a moderate amount of stool within the sigmoid colon and\\n rectum. Changes are present within the spine from a convex left lumbar\\n scoliosis with extensive degenerative changes.\\n\\n IMPRESSION: Moderate amount of stool in the rectosigmoid colon. No evidence\\n of bowel obstruction.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 853332,\n \"text\": \" 4:39 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval ETT placement and CHF?\\n Admitting Diagnosis: HYPERMAGNESEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with hypermagnesemia and elevated lactate s/p intubation\\n\\n REASON FOR THIS EXAMINATION:\\n eval ETT placement and CHF?\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: An 82-year-old with ET tube placement and questionable CHF.\\n\\n the study was obtained at 0455 hours and comparison is made to the prior study\\n of the same day obtained at 0314 hours. Since the prior study, there has been\\n placement of an ET tube. The tip is 1.8 cm above the carina. Partial\\n atelectasis involving the lower lobes are noted. Unchanged. There is no\\n evidence of pneumothorax. There is no evidence of pleural effusion. There is\\n no evidence of congestive heart failure.\\n\\n IMPRESSION:\\n\\n 1) Interval placement of an ET tube and no evidence of pneumothorax.\\n 2) Partial atelectasis involving the lower lobes.\\n 3) No evidence of congestive heart failure.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-03 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 853327,\n \"text\": \" 3:07 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval for stroke or ICH\\n Admitting Diagnosis: \\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with delta MS .\\n REASON FOR THIS EXAMINATION:\\n eval for stroke or ICH\\n CONTRAINDICATIONS for IV CONTRAST:\\n ARF\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 82-year-old male with MS . Evaluate for stroke\\n or intracranial hemorrhage.\\n\\n TECHNIQUE: Contiguous 5 mm axial images were obtained from the vertex to the\\n base of the skull on bone and soft tissue images. There are no prior studies\\n for comparison.\\n\\n FINDINGS: There is no intracranial hemorrhage. There is no mass effect, shift\\n of normally midline structures, hydrocephalus, or large territorial infarct.\\n There are mild hypodense areas within the periventricular and deep white\\n matter, consistent with chronic small vessel ischemic infarcts. There are a\\n few small old lacunar infarcts, one within the right cerebellar hemisphere,\\n the other within the left basal ganglia and left frontal lobe.\\n\\n IMPRESSION: No acute intracranial abnormality visualized.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 853574,\n \"text\": \" 11:07 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please confir NGT placement\\n Admitting Diagnosis: \\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with and elevated lactate s/p intubation\\n and s/p R subclavian placement.\\n REASON FOR THIS EXAMINATION:\\n please confir NGT placement\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n INDICATION: An 82-year-old man with hypomagnesemia and elevated lactate\\n status post intubation and status post right subclavian placement. Please\\n confirm NG tube placement.\\n\\n Comparison is made with a prior AP portable chest x-ray dated at\\n 1526.\\n\\n AP PORTABLE CHEST X-RAY: The study is seriously limited secondary to patient\\n positioning. A nasogastric tube is seen descending to the level of the\\n diaphragm with the tip terminating in the region of the gastroesophageal\\n junction. Repositioning is recommended. Osseous structures demonstrate\\n diffuse degenerative changes along the thoracic and lumbar spine with endplate\\n destruction at the L3/L4 interspace. Correlate clinically.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 853725,\n \"text\": \" 8:13 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please evaluate placement of NGT.\\n Admitting Diagnosis: \\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with and elevated lactate s/p\\n intubation and s/p R subclavian line palcement with h/o incorrectly placed NGT.\\n REASON FOR THIS EXAMINATION:\\n Please evaluate placement of NGT.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: An 82-year-old man with and elevated lactate\\n status post intubation and right subclavian line placement and NG tube\\n placement. Evaluate for NG tube placement.\\n\\n Comparison is made with a prior AP portable chest x-ray dated .\\n\\n FINDINGS:\\n\\n AP semi-erect portable chest x-ray: A right subclavian central venous\\n catheter is seen with the tip terminating in the mid/distal superior vena\\n cava. Nasogastric tube descends below the diaphragm and appears with the tip\\n in good position in the body of the stomach. The cardiac, mediastinal, and\\n hilar silhouettes remain stable. The aorta is tortuous with mural\\n calcifications. There is no evidence of pneumothorax. Low lung volumes are\\n seen bilaterally. There is slight interval worsening in the bibasilar\\n atelectasis. Surrounding soft tissue and osseous structures again reveal\\n diffuse degenerative changes along the thoracic spine with wedging of the L4-\\n L5 vertebral bodies.\\n\\n IMPRESSION:\\n\\n 1) Nasogastric tube in good position with the tip in the body of the stomach.\\n\\n 2) Slight interval worsening of bibasilar atelectasis.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 854055,\n \"text\": \" 9:57 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for infiltrate\\n Admitting Diagnosis: \\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 M with PD and mental status changes with ? infection\\n REASON FOR THIS EXAMINATION:\\n evaluate for infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n TYPE OF EXAMINATION: Chest AP portable single view.\\n\\n INDICATION: Parkinsons and mental status changes, questionable infection.\\n Evaluate for pulmonary infiltrates.\\n\\n FINDINGS:\\n\\n AP single view of the chest with patient in semi-upright position demonstrates\\n the presence of an NG tube reaching far below the diaphragm and being curled\\n in the fundus of the stomach. A right subclavian approach central venous line\\n is identified terminating overlying the SVC just above the expected site of\\n the atrial junction. There is no pneumothorax. The accessible pulmonary\\n vasculature appears normal without evidence of congestion. No acute\\n infiltrates can be identified. Relatively high positioned diaphragms are\\n related to poor inspirational effort and lordotic position of the patient.\\n\\n Preceding chest examination of had special over penetration\\n exposure to identified tubes. The pulmonary lung fields cannot be compared.\\n\\n IMPRESSION:\\n\\n No evidence of CHF or acute infiltrates on portable AP lordotic view.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 854307,\n \"text\": \" 10:04 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p NGT placement, pls assess placement and interval change.\\n Admitting Diagnosis: \\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 M w/ parkinsons, altered mental status, episode of hypoxia .\\n\\n REASON FOR THIS EXAMINATION:\\n s/p NGT placement, pls assess placement and interval change.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: An 82-year-old man with hypoxia. NG tube placement.\\n\\n TECHNIQUE: Portable AP chest radiograph.\\n\\n The comparison is made with a prior chest radiograph dated .\\n\\n FINDINGS:\\n\\n The right IJ line is unchanged compared to the prior study. Cardiac and\\n mediastinal contours are unchanged compared to the prior study. Bilateral\\n lung volumes are low. Bibasilar atelectasis is also noted. No CHF.\\n\\n Nasogastric tube appears to be terminating in the mid portion of the thorax,\\n at the level of carina.\\n\\n IMPRESSION:\\n\\n Nasogastric tube terminating in middle thorax, at the level of carina. Without\\n lateral view, the precise location of the tube, in terms of whether this is in\\n esophagus or trachea, is unclear. Please correlate clinically.\\n\\n The information is communicated with the referring physician, . \\n , by telephone in the morning of .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 853325,\n \"text\": \" 3:01 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for PNA or CHF\\n Admitting Diagnosis: HYPERMAGNESEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with hypermagnesemia and elevated lactate\\n REASON FOR THIS EXAMINATION:\\n eval for PNA or CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: An 82-year-old male with elevated lactate. Evaluate for\\n pneumonia or CHF.\\n\\n FINDINGS:\\n\\n Comparisons made to a prior radiograph from .\\n\\n The heart size and mediastinal contours are unchanged in this patient with low\\n lung volumes. Opacity is seen within the left lower lobe laterally that is\\n suspicious for pneumonia versus aspiration. No pneumothorax is seen.\\n Atelectasis is seen within the right lower lobe. No osseous abnormalities are\\n identified.\\n\\n IMPRESSION:\\n\\n Opacity within the left lower lobe laterally that is suspicious for pneumonia\\n versus aspiration event.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 854141,\n \"text\": \" 1:33 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: compare for interval change\\n Admitting Diagnosis: HYPERMAGNESEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 M w/ hypoxia, ?aspiration event\\n REASON FOR THIS EXAMINATION:\\n compare for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n Portable chest compared to .\\n\\n CLINICAL INDICATION: Hypoxia.\\n\\n Central venous catheter and orogastric tube remain in place. Cardiac and\\n mediastinal contours are stable. There is discoid atelectasis at the right\\n lung base with adjacent mild elevation of the right hemidiaphragm. The lungs\\n are otherwise clear. A small amount of fluid is noted in the minor fissure.\\n\\n IMPRESSION:\\n\\n No significant change. No new findings to suggest an acute aspiration event.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-10 00:00:00.000\",\n \"description\": \"BY SAME PHYSICIAN\",\n \"row_id\": 854246,\n \"text\": \" 4:49 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: S/P partial D/C OF NGT, replacement. Pls assess NGT positio\\n Admitting Diagnosis: HYPERMAGNESEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 M w/ parkinsons, altered mental status, episode of hypoxia .\\n REASON FOR THIS EXAMINATION:\\n S/P partial D/C OF NGT, replacement. Pls assess NGT position\\n ______________________________________________________________________________\\n FINAL REPORT\\n Portable chest on compared with previous study of earlier the\\n same date.\\n\\n CLINICAL INDICATION: Nasogastric tube assessment.\\n\\n The nasogastric tube is no longer visualized within the thoracic esophagus.\\n The proximal portion of the tube is seen extending into the oropharynx region,\\n but it is not well visualized below this level. There is otherwise no\\n significant change since recent study.\\n\\n IMPRESSION:\\n\\n Withdrawal of orogastric tube, which is not visualized beyond the oropharynx\\n region.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 853513,\n \"text\": \" 11:59 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: NGT placement.\\n Admitting Diagnosis: \\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with and elevated lactate s/p intubation\\n and s/p R subclavian placement.\\n REASON FOR THIS EXAMINATION:\\n NGT placement.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: An 82-year-old man with right subclavian line placement and NG\\n tube placement. Evaluate.\\n\\n Comparison is made with an AP supine portable chest x-ray dated at\\n 5:37.\\n\\n AP ERECT PORTABLE CHEST X-RAY: There has been interval placement of a\\n nasogastric tube with the tip coiled within the body of the stomach. A right\\n subclavian central venous catheter remains in good position within the distal\\n superior vena cava. The cardiac mediastinal, and hilar silhouettes remain\\n unchanged. There is a tortuous aorta with mural calcifications. Bilateral\\n lungs are stable in appearance. Low lung volumes with bibasilar atelectasis\\n persists. Surrounding soft tissue and osseous structures remain stable.\\n\\n IMPRESSION:\\n\\n Interval placement of a nasogastric tube with the tip coiled within the body\\n of the stomach. These findings were called to Dr. at 2:00 p.m. on\\n .\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-20 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 855427,\n \"text\": \" 12:19 PM\\n CHEST (PA & LAT) Clip # \\n Reason: pls assess for aspiration.\\n Admitting Diagnosis: \\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with h/o hypersensitivity pneumonitis, right first toe\\n gangarene, delerium.\\n REASON FOR THIS EXAMINATION:\\n pls assess for aspiration.\\n ______________________________________________________________________________\\n FINAL REPORT\\n TYPE OF EXAMINATION: Chest PA and lateral.\\n\\n INDICATION: History of hypersensitivity pneumonitis, right-sided first toe\\n gangrene, delirium. Assess for possible aspiration pneumonia.\\n\\n FINDINGS:\\n\\n AP and lateral views were obtained with the patient in sitting half erected\\n position. The frontal view is compared with a similar study dated . An NG tube is presently seen to pass the stomach and terminating in the\\n jejunum distal to the duodenum. This position appears unchanged; however, it\\n is noted that some barium contrast medium has now entered the stomach. The\\n thoracic aorta is moderately widened with some wall calcifications at the\\n level of the arch. The heart shadow is mostly concealed by the elevated\\n diaphragms, but significant cardiac enlargement is unlikely, as the pulmonary\\n vasculature does not demonstrate any evidence of congestion. No acute\\n infiltrates can be identified. There exist, however, thin plate atelectasis\\n in the right base, a finding which was already noted on the preceding study.\\n The lateral pleural sinuses remain free. A lateral view is under exposed and\\n suffers from the patient's inability to elevate the arms. Although the image\\n quality is clearly suboptimal, one can identify the posterior pleural sinuses\\n to be free.\\n\\n IMPRESSION:\\n\\n Portable AP and lateral chest examination does not disclose evidence of new\\n infiltrates, and there is no evidence of CHF.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-01-20 00:00:00.000\",\n \"description\": \"VIDEO OROPHARYNGEAL SWALLOW\",\n \"row_id\": 855420,\n \"text\": \" 11:29 AM\\n VIDEO OROPHARYNGEAL SWALLOW Clip # \\n Reason: pls assess swallowing.\\n Admitting Diagnosis: HYPERMAGNESEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with UTI, parkinson's\\n REASON FOR THIS EXAMINATION:\\n pls assess swallowing.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: Assess for aspiration.\\n\\n VIDEO OROPHARYNGEAL SWALLOW: Fluoroscopic guidance was provided for the\\n speech pathologist who administered barium swallow and then liquids of the\\n various consistencies to the patient. There is trace aspiration with a single\\n cup sip of thin liquids. This was not redemonstrated throughout the\\n remainder of the exam. There is delayed oral phase of excessive oral residue\\n with all materials. A 13 mm calibrated barium tablet passed freely into the\\n stomach.\\n\\n IMPRESSION:\\n Trace aspiration with a single cup sip of thin liquids only. This was not\\n redemonstrated throughout the remainder of the exam.\\n\\n For additional report details, please consult the speech pathologist's report,\\n which is available on the online medical record section of CCC.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-01-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 168187,\n \"text\": \"Baseline artifact. Sinus rhythm, may be normal ECG, but baseline artifact makes\\nassessment difficult. Since the previous tracing of ventricular ectopy\\nis absent.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-01-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 168188,\n \"text\": \"Sinus rhythm. Ventricular bigeminy amd trigeminy. Low voltage in the limb\\nleads, low normal voltage in the precordial leads. Prolonged A-V conduction.\\nOtherwise, normally conducted complexes are without diagnostic abnormality.\\nCompared to the previous tracing of no significant change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-01-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 168189,\n \"text\": \"Sinus rhythm\\nFrequent multifocal PVCs\\nLow QRS voltages in limb leads\\nSince previous tracing, no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-01-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 168190,\n \"text\": \"Sinus rhythm\\nFrequent multifocal PVCs\\nLow QRS voltages in limb leads\\nSince previous tracing, QRS changes in leads V3-V4 - ? lead placement; atrial\\npremature complexes absent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-01-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 168191,\n \"text\": \"Sinus rhythm\\nVentricular couplets\\nSupraventricular extrasystoles\\nLow QRS voltage limb leads\\nPoor R wave progression - ? lead placement\\nSince previous tracing, QRS changes in V2-V4 - ? lead placement; atrial\\npremature complexes noted\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-01-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 168192,\n \"text\": \"Sinus rhythm\\nFrequent ventricular premature complexes\\nLow QRS voltages in limb leads - is nonspecific\\nProbable left atrial abnormality\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-01-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 168193,\n \"text\": \"Sinus rhythm\\nInterpolated PVCs\\nLow QRS voltages in limb leads\\nSince previous tracing, new ventricular premature complexes\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-01-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 168194,\n \"text\": \"Sinus rhythm. Compared to the previous tracing of ventricular ectopy is\\nno longer recorded. There is baseline artifact. No diagnostic interim change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-01-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 168195,\n \"text\": \"Sinus rhythm and frequent ventricular ectopy. Baseline artifact. Compared to\\nthe previous tracing of the rate has increased. Otherwise, no\\ndiagnostic interim change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-01-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 168186,\n \"text\": \"Baseline artifact\\nSinus rhythm\\nVentricular premature complexes\\nLow limb leads voltage - is nonspecific\\nSince previous tracing of , ventricular ectopy present\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-01-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 168196,\n \"text\": \"Sinus rhythm\\nFrequent multifocal PVCs\\nBorderline first degree A-V block\\nLow QRS voltages in limb leads\\nNondiagnostic T wave flattening\\nBorderline Q-Tc interval prolonged\\nSince previous tracing, QTc slightly shorter\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-01-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 168197,\n \"text\": \"Sinus rhythm. A-V conduction delay and frequent ventricular ectopy. Ventricular\\ntrigeminy. Low limb lead voltage. Q-T interval prolongation. Compared to the\\nprevious tracing of no diagnostic interim change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-01-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 168198,\n \"text\": \"Sinus rhythm\\nVentricular premature complexes\\nFirst degree A-V delay\\nLeft atrial abnormality\\nLow limb leads voltage - is nonspecific\\nModest nonspecific ST-T wave changes\\nSince previous tracing of , probably no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-01-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 168199,\n \"text\": \"Baseline artifact in V2\\nSinus rhythm\\nVentricular premature complexes\\nFirst degree A-V delay\\nLeft atrial abnormality\\nLow limb leads voltage - is nonspecific\\nNo previous tracing for comparison\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-01-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1461061,\n \"text\": \"Nursing Note (1900-0700)\\n\\nMr. had an uneventful night. He did pass several large formed hardened stools thru the night.\\n\\nReview of systems:\\nNeuro: Confused; reorientated with some effect. Agitated/restless thru most of shift. Requiring bil wrist restraints to maintain NGT in place. Frequently placing feet over siderails; freq monitoring requiried for safety.\\n\\nCV: Hemodynamically stable; NSR with freq PVC's; repeat K 3.9; repleted with 20KCL. Hypertensive to 170-180's with agitation; 140-160's at rest. Received 1 dose vanco for +BC from aline . Has 2 PIV's and 1 TLCL. Mutiple skin tears/bruising. Buttocks red but intact. Quinidine as ordered, QTC wnl.\\n\\nResp: LS ess clear, diminshed bases. 3L for 02 sats >96%. .\\n\\nGi/GU: NGT pulled by pt; replaced and placement confirmed by G. . Tol probalace 30cc/hr, goal 65cc/hr. Several large hard stools thru noc. Receiving laxatives for constipation. Adequate u/o./\\n\\nEndo: steroid taper; no SSI required.\\nSocial: No calls. Full code.\\n\\nPlan: Replete lytes prn. Cont w/laxatives. Close monitoring for safety; will need 1:1 when bed available. Called out to floor. Advance TF as tol. Decrease FS to . Contact / . Full code.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-01-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1461055,\n \"text\": \"Shift Note 0200-0700\\nPt 82yo male admitted to MICU-A from OSH with dx hypermagnesia and mental status changes. Pt presented to PCP with c/o weakness/lethargy. Lab work sent and PCP called patient with MG 6.9 to go to ER...at this time patient was having mental status changes. In ER repeat Mg 7.3 and patient given 3 amp calcium gluconate and solu-cortef since tapering off long-term steriod use. Transferred to for further work-up.\\n\\nPMH: hx V-tach, pulmonary fibrosis (on predinsone at home), PVD, parkinson's disease, Shy- syndrome, right big toe amputation.\\n\\nCV: HR SB 50-60's, with vent bigeminy. BP initially low when presented to OSH EW...given 500cc NS bolus, BP responded well. Upon arrival to MICU, SBP 110-140's. PIVx2 intact.\\n\\nResp: Pt initially on 3L NC, RR 8-12, sats >96%. BBS clear in upper lobes, crackles noted in lower lobes. Around 0415 pt noted to be having apneic periods lasting 50seconds...NIBP not registering and manual BP 80/50....intern paged to unit. Pt continued to have frequent episodes of apnea...anesthesia called stat and patient intubated. Right radial art line and LSC triple lumen placed. SBP 62/30 manually while art line being placed. 500cc D5NS given and dopamine started at 3mcg and titrated to 10mcg to maintain BP. CXR ordered for line confirmation.\\n\\nNeuro: Upon arrival, patient very lethargic...oriented to self only and when answering questions mumbling incomprehensible words. Opening eyes to verbal command...when found with apneic periods, patient extremely difficult to arouse and not opening eyes. Pt given fentanyl/versed for intubation and started on propofol gtt for sedation.\\n\\nGI/GU: Abdomen soft, BS present. OG tube placed, awaiting confirmation. Foley cath draining clear yellow urine. Patient given 20mg IV lasix to assist with excreting Mg...D5NS at 125cc/hr. Given 500cc bolus when BP decreased.\\n\\nSocial: Intern spoke with patient's children on phone...pt full code.\\n\\nMg currently 4.8....ICa 1.05, patient to receive 1 amp calcium gluconate.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-01-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1461056,\n \"text\": \"Respiratory care:\\nPatient noted to have several periods of apnea lasting 50 sec. MD notified. Patient intubated with 7.5 Ett taped and secured at 23 cm. Breathsounds equal bilaterally and placement confirmed with easy cap.\\nPlease see respiratory section of carevue for further data.\\nPlan: Continue mechanical ventilation.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-01-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1461057,\n \"text\": \"MICU Nursing Progress Note 0700-1900\\n\\nPt weaned off dopamine and propofol. Extubated at 1800 and tolerating well. Head CT this am negative. Mag continues to decrease- lytes sent at 1800- results pending. Currently being followed by cardiology and renal teams.\\n\\nNote: Pt takes dofetilide at home. Drug is very tightly controlled in this hospital- pharmacy following. Dc'd here due to ? renal function. If prescribed- consult pharmacy before administering. Cardiology following.\\n\\nNeuro: Pt initially sedated on propofol when intubated. Weaned off at 1600. Now pt is awake and follows commands. Oriented to person, place and month. Speech is very garbled and hard to understand at times. Stares into space at times. Moves all extremeties and PERL.\\n\\nResp: Extubated after succesful wean to PSV and SBT. No periods of apnea this shift. Sats 99-100% on 5 L NC. Resp in mid to high teens. Lung sounds clear bilat. ? sleep apnea and ? need for non invasive vent.\\n\\nCV: HR NSR-NSB 50's-70's. Frequent PVC's, runs of vtach at times and vent bigeminy. PT seemed to have more ectopy after extubation. BP tolerates. Stat lytes drawn at 1800- results pending. Weaned off dopamine at 1500. BP now 140's-150's. CVP 8-10.\\n\\nLytes: Repleted with 40 MEQ of K and 3 grams calcium total this shift.\\n\\nGI: Pt continues NPO, OG tube pulled with extubation. Will have speech and swallow tomorrow am. Swabs for dry mouth. Hypoactive BS, abd nontender, no BM this shift. Per family last BM was 5 days ago- ? need for aggressive BM. ? ileus.\\n\\nGU: Foley drg amber yellow urine. Maintenance of NS at 125cc/hr x 1 liter. 2 boluses given earlier this am.\\n\\nEndo: RISS in place, cvg as needed.\\n\\nAccess: R TLC, R radial aline.\\n\\nSocial: 2 daughters and wife here most of day, very supportive and involved. Family updated on status by attending, residents and this rn. Topic of code status touched upon- family will discuss.\\n\\nPlan: Monitor resp status\\n Monitor MS\\n Monitor lytes closely and f/u with pm lytes\\n ? Need for aggressive bowel regimen vs. slowed bowel motility\\n Speech and swallow in am.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-01-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1461058,\n \"text\": \"Respiratory Care\\nPt to cat-scan this am, results pending, Weaned to PSV tolerated well no apnea. Pt extubated 1800 will leave vent on stand by for ? of NIV for sleep apnea.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-01-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1461059,\n \"text\": \"pt is off vent since 1800 and resp status is good. hydrating to lower mag level and labs sent at 0420 and pending.\\n* pt had been taking dofetilide at home but it is tightly controled here in hosp. pt was seen by card and H.O. to start quinadine this am in place as antiarrythmic, If ever to restart dofetilide must consult pharmacy first.\\n\\nneuro: PERL and pt moves uper extremities purposefully. legs are very stiff? parkinsons involvement. pt able to follow commands with much encouragment. oriented to person and place but speech is garbled. more clear on occasion. cough is intact but gag weak with oral care suction. to have swallow test this am.\\n\\ncard: rate is 60's most of night with lg amt ectopy. periods of bigemeny. pvcs in pairs and >16 pvcs per min most of shift. hx of v tach but not runs this shift.bp sys 100-150. peripheral pulses weak but feet warm. hands cold with cyanotic nail beds but good peripheral blood return. HX of PVD.\\n\\nresp: 3l with sat 97-99. coughing and once brought up gerrn thick sputum but unable to send as ws in pt bed.\\n\\ngi: NPO til swallow test done, good cough but weak gag. able to handle owm secretions all shift. pt had two small stools brown soft and hem neg. ducolax supp this am to improve stool output, bs present\\n\\ngu: pt is in slight pos balance and is voiding 60-75 cc/hr with iv infusing 150cc/hr to improve mag and urine output. no nedema present.\\n\\nendo: glu in acceptable range. no coverage required.\\n\\nlabs: see 0430 labs and mag at 2200 down to 3.7. no electrolytes repleted this shift.\\n\\nskin: pt has multiple areaas of raised hematomas which some have opened and bled. skin is dry with scaled patches and red rash like appearance. bath given and lotion applied. wet to dry dsg to rt great toe and may need some consult as needs debridment as family states were using a debriding skin tx at home,\\n\\nsocial: pt was cared for at home by family and issues around d/c will need to be discussed as in past family opted not to sent pt to rehab.\\n\\naccess: all ports functioning.\\n\\nplan: monitor MS\\n start antiarrythmic per card consult\\nfollow labs and promote bm\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-01-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1461060,\n \"text\": \"NPN 7A-7P\\n\\nEVENTS: Mg down to 2.8 from 3.2, CREAT improving to .9 (baseline .8), MS s+s eval- pt. failed- NGT placed for meds and feeds, Art. line removed d/t gram + cocci growing out of bottles, 2 more sets of BC sent\\n\\nReview of Systems-\\n\\nNeuro- MS waxing and , short periods of agitation restraints, incoherent at times, lethargic, arousing easily to voice. No pain issues today. OOB to chair via lift X 4 hours.\\n\\nResp- 3L O2 via NC tolerating well, O2 sats 98%, no significant issues. Concern for aspiration s/t MS, HOB elevated, CDB encouraged.\\n\\nCV- HR 60-70's frequent ectopy (PVCs), restarted on quinadine today need to check daily EKGs for Qtc prolongation, BP stable reamins off Dopamine with some episodes of hypertension. CVP running at goal of , IVF stopped. E-lytes sent at 1500 significant results as mentioned above.\\n\\nDerm- considerable skin issues- multiple areas of ecchymosis, skin tears covered with tegaderm, wound on heel covered with duoderm, wet to dry on right great toe amp appears to be red around wound base with yellow drainage and sloughing, other open areas on back and shoulders.\\n\\nGI- ABD quite distended, soft. Disimpacted for LARGE AMOUNT OF BROWN HARD STOOL... started on lactulose, to be given RTC, would also recommend rechecking rectum for further stool overnoc. TF at 10cc/hr of Probalance, goal rate of 65cc/hr. NGT placed d/t failed s+s eval. S+S to re-eval when MS clear.\\n\\nGU- U/O adequate 60-120cc/hr. IVF stopped. KCL and Calicum gluconate repleted.\\n\\nEndo- QID FS requiring no coverage. Predisone taper to begin tom'row per pulm.\\n\\nID- Gram + cocci from arterial line on , vanco X 1 given, art line d/c'd and cultures resent from art line and central line this am. Team may consider repeating vanco dose.\\n\\nAccess- Triple lumen in right subclavian , team wanted this to be pulled given 1/4 bottles + for GPC- however, pt. could use this access while staying in the ICU. Has 2 PIV not in use. Art line pulled and tip sent for cx.\\n\\n Pt. has 5 dtrs, 2 visiting today with wife. Updated on plan of care and met with pulmonologist today.\\n\\nDispo- C/o to floor with 1:1 observer. Remains full code.\\n\\n\"\n }\n]"}}},{"rowIdx":24662,"cells":{"subject_id":{"kind":"number","value":69981,"string":"69,981"},"hadm_id":{"kind":"number","value":162851,"string":"162,851"},"target_text":{"kind":"string","value":"31F admitted electively for a R retromastoid crani for MVD of 5th nerve. Post-operatively, she as admitted to the ICU for monitoring. Her post-operative Head CT was stable with expected post-op changes. On , she was transferred to the floor from the ICU. Her home medications were started per the recommendations of her Rheumotologist. Her activity was increased she ambulated in the hallway and tolerated a regular diet. Her pain was improving on the right side of her face but had intermittent electrical type pain, she felt the pain meds were improving. Neurologically she had no deficits on discharge."},"extractive_notes_summ":{"kind":"string","value":"There is a small amount of extra-axial hypodense fluid collection in the right posterior cranial fossa, without significant mass effect. No intracranial hemorrhage detected. No intracranial hemorrhage detected. No intracranial hemorrhage, edema, masses, or mass effect is seen. TECHNIQUE: MDCT helical images were acquired through the head without intravenous contrast. Small extra-axial fluid collection in the right posterior cranial fossa. FINDINGS: The patient is status post right suboccipital craniotomy, with small-to-moderate amount of pneumocephalus, relating to the recent surgery. The ventricles, sulci, and basal cisterns are normal. Mild mucosal thickening is seen in bilateral ethmoid air cells and frontal sinuses. IMPRESSION: Status post trigeminal decompression surgery, with expected pneumocephalus. The mastoid air cells are clear. 3:57 PM CT HEAD W/O CONTRAST Clip # Reason: post op, within 4 hours Admitting Diagnosis: TRIGEMINAL NEURALGIA/SDA MEDICAL CONDITION: 31 year old woman with trigeminal decompression REASON FOR THIS EXAMINATION: post op, within 4 hours No contraindications for IV contrast WET READ: KKgc FRI 6:29 PM Status post trigeminal decompression surgery, with expected pneumocephalus. COMPARISON: None available."},"n_notes":{"kind":"number","value":1,"string":"1"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2189-05-01 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1190257,"text":" 3:57 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: post op, within 4 hours\n Admitting Diagnosis: TRIGEMINAL NEURALGIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with trigeminal decompression\n REASON FOR THIS EXAMINATION:\n post op, within 4 hours\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc FRI 6:29 PM\n Status post trigeminal decompression surgery, with expected pneumocephalus.\n No intracranial hemorrhage detected.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old woman with trigeminal decompression, status post\n surgery.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT helical images were acquired through the head without\n intravenous contrast.\n\n FINDINGS: The patient is status post right suboccipital craniotomy, with\n small-to-moderate amount of pneumocephalus, relating to the recent surgery.\n There is a small amount of extra-axial hypodense fluid collection in the right\n posterior cranial fossa, without significant mass effect. No intracranial\n hemorrhage, edema, masses, or mass effect is seen. The ventricles, sulci, and\n basal cisterns are normal. Mild mucosal thickening is seen in bilateral\n ethmoid air cells and frontal sinuses. The mastoid air cells are clear.\n\n IMPRESSION: Status post trigeminal decompression surgery, with expected\n pneumocephalus. No intracranial hemorrhage detected. Small extra-axial fluid\n collection in the right posterior cranial fossa.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2189-05-01 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1190257,\n \"text\": \" 3:57 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: post op, within 4 hours\\n Admitting Diagnosis: TRIGEMINAL NEURALGIA/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 31 year old woman with trigeminal decompression\\n REASON FOR THIS EXAMINATION:\\n post op, within 4 hours\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: KKgc FRI 6:29 PM\\n Status post trigeminal decompression surgery, with expected pneumocephalus.\\n No intracranial hemorrhage detected.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 31-year-old woman with trigeminal decompression, status post\\n surgery.\\n\\n COMPARISON: None available.\\n\\n TECHNIQUE: MDCT helical images were acquired through the head without\\n intravenous contrast.\\n\\n FINDINGS: The patient is status post right suboccipital craniotomy, with\\n small-to-moderate amount of pneumocephalus, relating to the recent surgery.\\n There is a small amount of extra-axial hypodense fluid collection in the right\\n posterior cranial fossa, without significant mass effect. No intracranial\\n hemorrhage, edema, masses, or mass effect is seen. The ventricles, sulci, and\\n basal cisterns are normal. Mild mucosal thickening is seen in bilateral\\n ethmoid air cells and frontal sinuses. The mastoid air cells are clear.\\n\\n IMPRESSION: Status post trigeminal decompression surgery, with expected\\n pneumocephalus. No intracranial hemorrhage detected. Small extra-axial fluid\\n collection in the right posterior cranial fossa.\\n\\n\"\n }\n]"}}},{"rowIdx":24663,"cells":{"subject_id":{"kind":"number","value":24981,"string":"24,981"},"hadm_id":{"kind":"number","value":167592,"string":"167,592"},"target_text":{"kind":"string","value":"This is a 71 year old gentleman with T2N0M0 soft palate squamous cell CA, undergoing adjuvant chemoradiation week of low dose /Taxol and daily XRT. He was iniitally admitted on with hypotension, tachycardia, ARF. Felt to be dehydrated at that time. He was hydrated with NS and then developed fevers and was noted to have LLL opacity. He was initially given cefepime, fluconazole (concern for esophagitis), flagyl. This was then switched to Levo and vanco. Later, flagyl was re-started. He had frequent desaturations that were found to be secondary to mucus plugging and which resolved with deep suctioning. His sputum cultures then grew back Coag + staph sensitive to oxacillin and vanco was switched to oxacillin. . On pt respiratory status deteriorated to the point he could only maintain adequate oxygenatin on non-rebreather. By this time he had been getting significant amounts of fluid with a daily fluid balance positive 500-1000ml per day. CXR's have also shown progressive pulmonary edema In , pt. did not require intubation. It was felt his resp distress was secondary to pulm edema/volume overload and we was therefore diuresed with PRN lasix 40 mg. Over LOS in he was roughly -1.2 L. An echocardiogram revealed the patient had deteriorated LV function and new wall motion abnormalities. His resp. status did improve such that he was saturating adequately on 40% FM. He had been afebrile and otherwise hemodynamically stable and was therefore transferred back to the floor. Over the subsequently few days of his hospital course the pt. felt his breathing had improved and he had no fevers, chest pain, or cough. His volume status returned to euvolemic state. He was slowly weaned from oxygen support and by discharge was down to 3L face mask. Repeat CXR revealed stable lower lobe infiltrates but almost complete resolution of pulmonary edema. Aggressive diuresis was no longer pursued. External radiation therapy for his oral squamous cell CA was resumed. On discharge, the patient remained afebrile and hemodynamically stable. He was to continue 5 more days of levo/flagyl, oxacillin was discontinued. He was transferred to a rehabilitation hospital to enable further improvement of his respiratory status and for reconditioning. In summary, this is a 71 year old gentleman with oral squamous cell carcinoma on radiation therapy who was admitted for fever and finding of lower lobe lung infiltrates. He developed respiratory distress from a combination of pneumonia, new CHF seen on echocardiography, and mucus plugging and required a brief stay in intensive care but not intubation. He did well with diuretic therapy for his CHF, antibiotics for his MSSA pneumonia and was transferred to a rehabilitation hospital to enable further improvement of his respiratory status. . Issues and plan arising from this hospitalization: 1) Respiratory Failure/Hypoxia- Now appears resolved. Secondary to combination of PNA, CHF exacerbation, ? mucus plugging. No intubation was required. - albuterol/atrovent nebs q4h. - Chest PT, aggressive suctioning as needed - Aggressive diuresis no longer needed. 2) CHF. now with apparently worsened EF, new wall motion abnormalities - Will need oupatient follow up with Cardiology. - Continue Lasix, Lisinopril, and metoprolol. - Watch for signs of overload (weight gain, edema) . 3) RLL and LLL multilobar PNA: Initially with LLL opacity with sputum cultures growing MSSA. Also satrted on levofloxacin and flagyl for possible aspiration PNA after developing RLL opacity. Currently afebrile with normal, WBC. - continue flagyl and levofloxacin for broad coverage for 5 days . 4) Squamous cell CA of mouth: Chemoradiation. Last dose chemo (taxol/carboplatinum) Per Dr. will not continue chemo. Pt will continue XRT. -Mucositis: Improved during admission. Cont KBL, aspiration precautions, Nystatin, Roxicet. -continue aquaphor 5) Anemia: Hematocrit remains stable. Pt is s/p 2 units PRBC for hct 22.6, likely chemo related. 6) FEN: Tube Feeds at goal.. . 7) Prophylaxis: Aspiration Precautions, Hep SC . 8) Code status remains full. . 10) Disposition: Rehabilitation facility."},"extractive_notes_summ":{"kind":"string","value":"IMPRESSION: 1) Decreased mild pulmonary edema. IMPRESSION: AP chest compared to and : Mild pulmonary edema asymmetrically distributed is clearing. Noaortic regurgitation is seen. Diuresed from lasix ~700mls, breathing more comfortable.Resp: Pt initially on nonrebreather, ABG improved, pao2 98. LS diminished at bases, crackles cont on L.GI: +BS, abd soft, nt. The mitral valve leaflets are mildly thickened.Trivial mitral regurgitation is seen. Sinus rhythmLeft atrial abnormalityPoor R wave progression - probable normal variantLateral T wave changes may be due to myocardial ischemiaSince previous tracing of -o5, poor R wave progression seen HR 84-90s, nsr, occ pacs, esp when BP low. Moderate-to-large bilateral pleural effusions with bibasilar atelectasis. REASON FOR THIS EXAMINATION: r/o new or worsening infiltrate, effusion, pulmonary edema FINAL REPORT STUDY: AP chest, . Mild mitral annularcalcification. They are again most consistent with a prominent pulmonary edema. There is an area of consolidation in the left lingula (image 3:34 and right upper lobe image 3:29). Adm note71 yo ma adm c dehydration, hypotension, tachycardia, diarrhea 2nd to chemoradiation for squamous cell CA of soft palate. The aortic root is moderately dilated. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 71Weight (lb): 175BSA (m2): 1.99 m2BP (mm Hg): 108/51HR (bpm): 73Status: OutpatientDate/Time: at 14:58Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the report of the prior study (images notavailable) of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. FINDINGS: There are bilateral moderate-to-large pleural effusions. Compared to the previous tracing first degreeA-V conduction delay is no longer present. Overall left ventricular systolic function isprobably mildly depressed. Yest, on cxr noted to also have RLL opacity. sbp very low - 70s, on R arm. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Cr 1.1 on adm from dehydration. Mild pulmonary edema has decreased. Pt noted to have LLL opacity, then infiltrate, sputum coag+staph, sensitive to oxacillin. Severe coronary artery calcifications are noted. Pt turned onto back, BP up into low 90s. There is again seen an infiltrate in the left mid lung and left lower lobe, which is more apparent on today's study and slightly more confluent. Basal to mid antero-septal and inferior hypokinesisis suggested, but not confirmed. Trivial MR. LV inflow pattern c/w impaired relaxation.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:Poor echo windows.The left atrium is normal in size. Hct down from 30.2 to 29.2. The left ventricular inflow patternsuggests impaired relaxation. Normal ascending aorta diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). New multifocal parenchymal opacity is seen in the left lung compared to . Now with worsening shortness of breath. Now with worsening shortness of breath. Degenerative changes are noted in the thoracic vertebral bodies. Severe coronary artery calcifications. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. New shortness of breath. Afebrile.GI: TF via G tube. There is calcification of the thoracic aorta. Emphysema. No ASD by 2D or colorDoppler.LEFT VENTRICLE: Mildly depressed LVEF. Has been NPO except occ tiny sip water.GU: Good u/o at 40-60mls/hr. REASON FOR THIS EXAMINATION: please evaluate for interval change, worsening of infiltrates FINAL REPORT STUDY: AP chest, performed on . Calcifications of the thoracic aorta is again seen. AP & LATERAL CHEST: The heart size is within normal limits. Small to moderate bilateral pleural effusions and bibasilar pulmonary opacities are unchanged. Bibasilar atelectasis is noted. These findings appeared to have worsened slightly and are again suspicious for multifocal pneumonia. Cardiac size and mediastinum are within normal limits. 12-13 mm hypodense stable right renal cyst. Left lower lobe pneumonia. Left lower lobe pneumonia with additional focal patchy areas of consolidation in the lingula and right upper lobe. These findings have worsened slightly since the previous study. 2) Unchanged bilateral pleural effusions and bibasilar opacities. Sinus rhythm. Moderate-sized right pleural effusion has enlarged. Resp distress increasing, hypoxic on general unit, nonrebreather applied, lasix 20mg followed by 40mg given, to MICU. REASON FOR THIS EXAMINATION: eval for interval change FINAL REPORT STUDY: AP chest, . LS diminished at bases c crackles, coarse, rhonchorus, bilat wheezes on evenings. Breathsounds are coarse with decreased aeration in lower lobes. component of CHF, altho cardiac disease not documented, except long standing HTN.ROS:Neuro: A&O x3. Evaluate progression of pulmonary edema and pleural effusions. These findings are worrisome for congestive heart failure. There is prominence of the interstitial markings with more focal opacities in the left mid and left lower lung fields. There has been worsening of the increased pulmonary vascular markings and more focal opacities in the left perihilar and right basilar regions. There is severe atherosclerotic aortic calcification extending up to the abdominal aorta and the renal arteries. FINDINGS: There is again seen marked prominence of the pulmonary vasculature bilaterally with more focal airspace opacities forming within the left mid lung field as well as a left retrocardiac opacity. Severe atherosclerotic aortic calcification extending into the renal arteries. The airways are patent up to the segmental bronchi. There is diffuse moderate emphysema more on the right than the left. Patient tolerating nebs will. A hypodense stable cyst is seen in the right kidney."},"n_notes":{"kind":"number","value":15,"string":"15"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2192-12-04 00:00:00.000","description":"Report","row_id":1587969,"text":"NPN\n\nNeuro: Pt alert, not very interactive today, cooperating with care but needed to be encouraged to participate.\n\nCV: He has not received lopressor today due SBP 90-low 100s, HR has been in the 90s. There was talk of an echo today but it has not been today.\n\nResp: LS clear with rales in the bases, 02 SAT mid 90s on 50% face tent. He is coughing up a large amount of thick yellow sputum which is blood tinged at times. Chest CT done today which showed fluid in his lungs.\n\nGI: Conts on TF, he was seen by speach and swallow today, he is not able to swallow anything as he aspirated on everything.\n\nGU: U/O 20-40cc/hr, he may receive lasix later today.\n\nOnc: He had XRT today, onc said that they will hold on further chemo. He has been tired today, says that he does feel exhausted after xrt. Onc said that he should be able to eat in a few months after his mouth and throat heals.\n\n"},{"category":"Nursing/other","chartdate":"2192-12-05 00:00:00.000","description":"Report","row_id":1587970,"text":"Respiratory care:\nPatient followed Q4 for albuterol/atrovent nebs. Breathsounds are coarse with decreased aeration in lower lobes. Patient tolerating nebs will. Please see respiratory section of carevue for treatment times and data.\nPlan: Continue bronchodilator therapy Q4.\n"},{"category":"Nursing/other","chartdate":"2192-12-05 00:00:00.000","description":"Report","row_id":1587971,"text":"NPN 1900-0700\nNeuro: A&O x3. mae well. No c/o pain, some soreness in throat but pain med not required.\n\nCV: Did receive Lopressor last noc at 8pm as sbp was 108. SBP >100 most of noc. At ~ 0300, BP down to 80/36 - 84/50 c freq pac s at the time, pt was sleeping. Pt turned onto back, BP up into low 90s. Currently 96/42. HR 84-90s, nsr, occ pacs, esp when BP low. Afebrile. Cont on abx. Hct down from 30.2 to 29.2. K good at 4.3, Mg 1.9, will ask team re repletion.\n\nResp: Cont on fact tent at 50%. Sats usu 94-99, down to 89 x1. Encouraged C&DB, pt expectorated large clump of mucous as he had done earlier in evening, thick, bld tinged. LS diminished at bases, crackles cont on L.\n\nGI: +BS, abd soft, nt. Tol TF well, at 60mls/hr, goal 80mls. No stool. Has been NPO except occ tiny sip water.\n\nGU: Good u/o at 40-60mls/hr. No lasix given. Negative fld balance at 840mls los.\n\nSocial: Brother called, will be visiting tomorrow.\n\nPlan: Continue positive outcome discussion with pt. Encourage C&DB. Monitor BP and sats. ? Echo today.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2192-12-04 00:00:00.000","description":"Report","row_id":1587968,"text":"Adm note\n71 yo ma adm c dehydration, hypotension, tachycardia, diarrhea 2nd to chemoradiation for squamous cell CA of soft palate. On chemoradiation for ~5weeks caused mucositis with ulcers in mouth, weakness, anemia (hct 22.6, tx c 2units pc). Pt noted to have LLL opacity, then infiltrate, sputum coag+staph, sensitive to oxacillin. Yest, on cxr noted to also have RLL opacity. Resp distress increasing, hypoxic on general unit, nonrebreather applied, lasix 20mg followed by 40mg given, to MICU. ? component of CHF, altho cardiac disease not documented, except long standing HTN.\n\nROS:\n\nNeuro: A&O x3. mae. Communicates needs well. Pt tired, sleeping most of time. C/o slight sore throat, did not want pain med.\n\nCV: HR 80-105, ns/st, no ectopy. sbp very low - 70s, on R arm. Changed BP cuff to L arm ~ 10points higher. Pt mentating well even when SBP in 70s on R arm. Team did not want to give flds. Diuresed from lasix ~700mls, breathing more comfortable.\n\nResp: Pt initially on nonrebreather, ABG improved, pao2 98. Nebs given q2hrs, then q4hrs. Changed to face tent at 50% with sats >96. LS diminished at bases c crackles, coarse, rhonchorus, bilat wheezes on evenings. Expectorated yellow sputum followed by lge amt thick, tan sputum. Spec sent. RR now in high teens to 20s.\n\nID: On Levoflox, metronidazole, oxacillin. Afebrile.\n\nGI: TF via G tube. Advance by 10mls/hr q6hrs til at goal of 80mls/hr. Tol well. No stool.\n\nGU: Light yellow urine from lasix, adequate amts. Cr 1.1 on adm from dehydration. Improving.\n\nSkin: Intact.\n\nSocial: Brother is health care proxy.\n\nPlan: Pt may be called out if remains stable. Monitor u/o. Echo planned for today. Monitor BP, HR, resp status carefully. Titrate TF up to 80 mls. Continue abx.\n"},{"category":"Echo","chartdate":"2192-12-05 00:00:00.000","description":"Report","row_id":98327,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 71\nWeight (lb): 175\nBSA (m2): 1.99 m2\nBP (mm Hg): 108/51\nHR (bpm): 73\nStatus: Outpatient\nDate/Time: at 14:58\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Mildly depressed LVEF. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Trivial MR. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nPoor echo windows.The left atrium is normal in size. No atrial septal defect\nis seen by 2D or color Doppler. Overall left ventricular systolic function is\nprobably mildly depressed. Basal to mid antero-septal and inferior hypokinesis\nis suggested, but not confirmed. Right ventricular chamber size and free wall\nmotion appear normal. The aortic root is moderately dilated. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nTrivial mitral regurgitation is seen. The left ventricular inflow pattern\nsuggests impaired relaxation. The pulmonary artery systolic pressure could not\nbe determined. There is no pericardial effusion.\n\nCompared with the report of the prior study (tape unavailable for review) of\n, regional LV systolic dysfunction is now suggested. If clinically\nindicated, a repeat TTE with contrast (Definity) may better characterize LVEF\nand regional LV function.\n\n\n"},{"category":"Radiology","chartdate":"2192-12-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":895316,"text":" 12:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o new or worsening infiltrate, effusion, pulmonary edema\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with head&neck SCC, with LLL PNA, now with worsening SOB,\n O2sat down to 85% on 50% shovel mask again.\n REASON FOR THIS EXAMINATION:\n r/o new or worsening infiltrate, effusion, pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 71-year-old man with worsening shortness of breath.\n\n FINDINGS: Compared to prior studies dating back to .\n\n There has been worsening of the increased pulmonary vascular markings and more\n focal opacities in the left perihilar and right basilar regions. These\n findings are worrisome for congestive heart failure. The opacities may\n represent underlying pneumonia and these changes have increased. Cardiac size\n and mediastinum are within normal limits.\n\n\n\n"},{"category":"Radiology","chartdate":"2192-12-04 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":895461,"text":" 10:01 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: please assess lung infiltrate and pulmonary edema in attempt\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with pneumonia and apparent CHF, unclear which component is the\n overriding problem\n REASON FOR THIS EXAMINATION:\n please assess lung infiltrate and pulmonary edema in attempt to assess pts\n primary process\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old with CHF and pneumonia. Patient has history of\n cancer of the neck and soft palate.\n\n CT CHEST WITHOUT CONTRAST.\n\n TECHNIQUE: MDCT of the chest was performed from the thoracic inlet through\n the adrenals without injection of intravenous contrast.\n\n Comparison done to serial chest x-rays done between , to\n and a PET/CT of .\n\n FINDINGS: There are bilateral moderate-to-large pleural effusions. Bibasilar\n atelectasis is noted. There is an area of consolidation in the left lingula\n (image 3:34 and right upper lobe image 3:29). The airways are patent up to\n the segmental bronchi. There is diffuse moderate emphysema more on the right\n than the left.\n\n There is no significant mediastinal or hilar lymphadenopathy, though small\n subcentimeter mediastinal lymph nodes are seen which do not meet the CT\n criteria for lymphadenopathy. There is severe atherosclerotic aortic\n calcification extending up to the abdominal aorta and the renal arteries.\n Severe coronary artery calcifications are noted. There is no pericardial\n effusion.\n\n In the imaged portion of the upper abdomen, the liver, spleen, and adrenals\n are unremarkable. A hypodense stable cyst is seen in the right kidney.\n\n Degenerative changes are noted in the thoracic vertebral bodies. There is no\n suspicious lytic or blastic lesion in the bones.\n\n IMPRESSION:\n 1. Left lower lobe pneumonia with additional focal patchy areas of\n consolidation in the lingula and right upper lobe.\n 2. Moderate-to-large bilateral pleural effusions with bibasilar atelectasis.\n 3. Severe atherosclerotic aortic calcification extending into the renal\n arteries.\n 4. Severe coronary artery calcifications.\n 5. Emphysema.\n 6. 12-13 mm hypodense stable right renal cyst.\n (Over)\n\n 10:01 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: please assess lung infiltrate and pulmonary edema in attempt\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n"},{"category":"Radiology","chartdate":"2192-12-02 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":895243,"text":" 2:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change, worsening of infiltrate\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with head&neck SCC, with LLL PNA, now with worsening SOB,\n )2sat down to 85% on RA.\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change, worsening of infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, performed on .\n\n HISTORY: 71-year-old male with head and neck squamous cell cancer and left\n lower lobe pneumonia. Now with worsening shortness of breath.\n\n FINDINGS: Compared to the previous studies from through , .\n\n The cardiac silhouette is within normal limits and is unchanged.\n Calcifications of the thoracic aorta is again seen. There is prominence of\n the interstitial markings with more focal opacities in the left mid and left\n lower lung fields. These findings appeared to have worsened slightly and are\n again suspicious for multifocal pneumonia. The increased interstitial\n markings raises an element of underlying pulmonary edema as well.\n\n\n\n"},{"category":"Radiology","chartdate":"2192-12-06 00:00:00.000","description":"CHEST (PA & LAT)","row_id":895784,"text":" 9:40 AM\n CHEST (PA & LAT) Clip # \n Reason: Please assess for progression of pulmonary edema and pleural\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with history of head and neck cancer, LLL pneumonia, CHF\n exacerbation.\n REASON FOR THIS EXAMINATION:\n Please assess for progression of pulmonary edema and pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70 y/o man with history of head and neck cancer, left lower lobe\n pneumonia and CHF exacerbation. Evaluate progression of pulmonary edema and\n pleural effusions.\n\n COMPARISON: .\n\n AP & LATERAL CHEST: The heart size is within normal limits. Mild pulmonary\n edema has decreased. Small to moderate bilateral pleural effusions and\n bibasilar pulmonary opacities are unchanged.\n\n IMPRESSION:\n 1) Decreased mild pulmonary edema.\n 2) Unchanged bilateral pleural effusions and bibasilar opacities.\n\n"},{"category":"Radiology","chartdate":"2192-11-29 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":894866,"text":" 12:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrates, any CP abnormalities\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with head&neck SCC, admitted for hypotension with temp spike to\n 101.6; productive cough\n REASON FOR THIS EXAMINATION:\n eval for infiltrates, any CP abnormalities\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Squamous cell carcinoma of the neck. Fever.\n\n FINDINGS:\n\n The heart size is normal. No pneumothorax or effusions are seen. No\n pulmonary nodules are identified. New multifocal parenchymal opacity is seen\n in the left lung compared to .\n\n IMPRESSION: Multifocal pneumonia in the left lung.\n\n\n\n"},{"category":"Radiology","chartdate":"2192-12-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":895184,"text":" 10:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change in PNA\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with head&neck SCC, with LLL PNA\n REASON FOR THIS EXAMINATION:\n please eval for interval change in PNA\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 71-year-old man with head and neck squamous cell cancer with left\n lower lobe pneumonia.\n\n FINDINGS: Compared to previous study from .\n\n There is again seen an infiltrate in the left mid lung and left lower lobe,\n which is more apparent on today's study and slightly more confluent.\n Followup to resolution recommended. The right lung remains clear. There is\n calcification of the thoracic aorta.\n Cardiac size is normal.\n\n\n\n"},{"category":"Radiology","chartdate":"2192-12-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":895392,"text":" 5:42 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for interval change\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with head&neck SCC, with LLL PNA, now with worsening SOB,\n O2sat down to 85% on 50% shovel mask again.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 71-year-old man with head and neck cancer and left lower lobe\n pneumonia. Now with worsening shortness of breath.\n\n FINDINGS: There is again seen marked prominence of the pulmonary vasculature\n bilaterally with more focal airspace opacities forming within the left mid\n lung field as well as a left retrocardiac opacity. These findings have\n worsened slightly since the previous study. They are again most consistent\n with a prominent pulmonary edema. Underlying pneumonia especially at the left\n mid lung and left base will be difficult to exclude.\n\n\n"},{"category":"Radiology","chartdate":"2192-12-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":895430,"text":" 6:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for CHF and progression of infiltrate.\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with head&neck SCC, with LLL PNA, now with SOB.\n REASON FOR THIS EXAMINATION:\n Please eval for CHF and progression of infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:03 A.M. .\n\n HISTORY: Head and neck carcinoma. Left lower lobe pneumonia. New shortness\n of breath.\n\n IMPRESSION: AP chest compared to and :\n\n Mild pulmonary edema asymmetrically distributed is clearing. Improvement in\n perihilar consolidation in the left lung probably reflects resolving\n deposition of edema in the region of pneumonia. Moderate-sized right pleural\n effusion has enlarged. The heart is normal size and midline.\n\n\n"},{"category":"ECG","chartdate":"2192-12-03 00:00:00.000","description":"Report","row_id":278807,"text":"Sinus rhythm\nLeft atrial abnormality\nPoor R wave progression - probable normal variant\nLateral T wave changes may be due to myocardial ischemia\nSince previous tracing of -o5, poor R wave progression seen\n\n"},{"category":"ECG","chartdate":"2192-11-28 00:00:00.000","description":"Report","row_id":278808,"text":"Sinus rhythm. Normal ECG. Compared to the previous tracing first degree\nA-V conduction delay is no longer present.\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2192-12-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1587969,\n \"text\": \"NPN\\n\\nNeuro: Pt alert, not very interactive today, cooperating with care but needed to be encouraged to participate.\\n\\nCV: He has not received lopressor today due SBP 90-low 100s, HR has been in the 90s. There was talk of an echo today but it has not been today.\\n\\nResp: LS clear with rales in the bases, 02 SAT mid 90s on 50% face tent. He is coughing up a large amount of thick yellow sputum which is blood tinged at times. Chest CT done today which showed fluid in his lungs.\\n\\nGI: Conts on TF, he was seen by speach and swallow today, he is not able to swallow anything as he aspirated on everything.\\n\\nGU: U/O 20-40cc/hr, he may receive lasix later today.\\n\\nOnc: He had XRT today, onc said that they will hold on further chemo. He has been tired today, says that he does feel exhausted after xrt. Onc said that he should be able to eat in a few months after his mouth and throat heals.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2192-12-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1587970,\n \"text\": \"Respiratory care:\\nPatient followed Q4 for albuterol/atrovent nebs. Breathsounds are coarse with decreased aeration in lower lobes. Patient tolerating nebs will. Please see respiratory section of carevue for treatment times and data.\\nPlan: Continue bronchodilator therapy Q4.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2192-12-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1587971,\n \"text\": \"NPN 1900-0700\\nNeuro: A&O x3. mae well. No c/o pain, some soreness in throat but pain med not required.\\n\\nCV: Did receive Lopressor last noc at 8pm as sbp was 108. SBP >100 most of noc. At ~ 0300, BP down to 80/36 - 84/50 c freq pac s at the time, pt was sleeping. Pt turned onto back, BP up into low 90s. Currently 96/42. HR 84-90s, nsr, occ pacs, esp when BP low. Afebrile. Cont on abx. Hct down from 30.2 to 29.2. K good at 4.3, Mg 1.9, will ask team re repletion.\\n\\nResp: Cont on fact tent at 50%. Sats usu 94-99, down to 89 x1. Encouraged C&DB, pt expectorated large clump of mucous as he had done earlier in evening, thick, bld tinged. LS diminished at bases, crackles cont on L.\\n\\nGI: +BS, abd soft, nt. Tol TF well, at 60mls/hr, goal 80mls. No stool. Has been NPO except occ tiny sip water.\\n\\nGU: Good u/o at 40-60mls/hr. No lasix given. Negative fld balance at 840mls los.\\n\\nSocial: Brother called, will be visiting tomorrow.\\n\\nPlan: Continue positive outcome discussion with pt. Encourage C&DB. Monitor BP and sats. ? Echo today.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2192-12-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1587968,\n \"text\": \"Adm note\\n71 yo ma adm c dehydration, hypotension, tachycardia, diarrhea 2nd to chemoradiation for squamous cell CA of soft palate. On chemoradiation for ~5weeks caused mucositis with ulcers in mouth, weakness, anemia (hct 22.6, tx c 2units pc). Pt noted to have LLL opacity, then infiltrate, sputum coag+staph, sensitive to oxacillin. Yest, on cxr noted to also have RLL opacity. Resp distress increasing, hypoxic on general unit, nonrebreather applied, lasix 20mg followed by 40mg given, to MICU. ? component of CHF, altho cardiac disease not documented, except long standing HTN.\\n\\nROS:\\n\\nNeuro: A&O x3. mae. Communicates needs well. Pt tired, sleeping most of time. C/o slight sore throat, did not want pain med.\\n\\nCV: HR 80-105, ns/st, no ectopy. sbp very low - 70s, on R arm. Changed BP cuff to L arm ~ 10points higher. Pt mentating well even when SBP in 70s on R arm. Team did not want to give flds. Diuresed from lasix ~700mls, breathing more comfortable.\\n\\nResp: Pt initially on nonrebreather, ABG improved, pao2 98. Nebs given q2hrs, then q4hrs. Changed to face tent at 50% with sats >96. LS diminished at bases c crackles, coarse, rhonchorus, bilat wheezes on evenings. Expectorated yellow sputum followed by lge amt thick, tan sputum. Spec sent. RR now in high teens to 20s.\\n\\nID: On Levoflox, metronidazole, oxacillin. Afebrile.\\n\\nGI: TF via G tube. Advance by 10mls/hr q6hrs til at goal of 80mls/hr. Tol well. No stool.\\n\\nGU: Light yellow urine from lasix, adequate amts. Cr 1.1 on adm from dehydration. Improving.\\n\\nSkin: Intact.\\n\\nSocial: Brother is health care proxy.\\n\\nPlan: Pt may be called out if remains stable. Monitor u/o. Echo planned for today. Monitor BP, HR, resp status carefully. Titrate TF up to 80 mls. Continue abx.\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2192-12-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 98327,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function.\\nHeight: (in) 71\\nWeight (lb): 175\\nBSA (m2): 1.99 m2\\nBP (mm Hg): 108/51\\nHR (bpm): 73\\nStatus: Outpatient\\nDate/Time: at 14:58\\nTest: TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the report of the prior study (images not\\navailable) of .\\n\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\\nDoppler.\\n\\nLEFT VENTRICLE: Mildly depressed LVEF. No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Moderately dilated aortic root. Normal ascending aorta diameter.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\\ncalcification. Trivial MR. LV inflow pattern c/w impaired relaxation.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\nIndeterminate PA systolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\\n\\nConclusions:\\nPoor echo windows.The left atrium is normal in size. No atrial septal defect\\nis seen by 2D or color Doppler. Overall left ventricular systolic function is\\nprobably mildly depressed. Basal to mid antero-septal and inferior hypokinesis\\nis suggested, but not confirmed. Right ventricular chamber size and free wall\\nmotion appear normal. The aortic root is moderately dilated. The aortic valve\\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\\nTrivial mitral regurgitation is seen. The left ventricular inflow pattern\\nsuggests impaired relaxation. The pulmonary artery systolic pressure could not\\nbe determined. There is no pericardial effusion.\\n\\nCompared with the report of the prior study (tape unavailable for review) of\\n, regional LV systolic dysfunction is now suggested. If clinically\\nindicated, a repeat TTE with contrast (Definity) may better characterize LVEF\\nand regional LV function.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2192-12-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 895316,\n \"text\": \" 12:21 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o new or worsening infiltrate, effusion, pulmonary edema\\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with head&neck SCC, with LLL PNA, now with worsening SOB,\\n O2sat down to 85% on 50% shovel mask again.\\n REASON FOR THIS EXAMINATION:\\n r/o new or worsening infiltrate, effusion, pulmonary edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: AP chest, .\\n\\n HISTORY: 71-year-old man with worsening shortness of breath.\\n\\n FINDINGS: Compared to prior studies dating back to .\\n\\n There has been worsening of the increased pulmonary vascular markings and more\\n focal opacities in the left perihilar and right basilar regions. These\\n findings are worrisome for congestive heart failure. The opacities may\\n represent underlying pneumonia and these changes have increased. Cardiac size\\n and mediastinum are within normal limits.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2192-12-04 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 895461,\n \"text\": \" 10:01 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: please assess lung infiltrate and pulmonary edema in attempt\\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with pneumonia and apparent CHF, unclear which component is the\\n overriding problem\\n REASON FOR THIS EXAMINATION:\\n please assess lung infiltrate and pulmonary edema in attempt to assess pts\\n primary process\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 71-year-old with CHF and pneumonia. Patient has history of\\n cancer of the neck and soft palate.\\n\\n CT CHEST WITHOUT CONTRAST.\\n\\n TECHNIQUE: MDCT of the chest was performed from the thoracic inlet through\\n the adrenals without injection of intravenous contrast.\\n\\n Comparison done to serial chest x-rays done between , to\\n and a PET/CT of .\\n\\n FINDINGS: There are bilateral moderate-to-large pleural effusions. Bibasilar\\n atelectasis is noted. There is an area of consolidation in the left lingula\\n (image 3:34 and right upper lobe image 3:29). The airways are patent up to\\n the segmental bronchi. There is diffuse moderate emphysema more on the right\\n than the left.\\n\\n There is no significant mediastinal or hilar lymphadenopathy, though small\\n subcentimeter mediastinal lymph nodes are seen which do not meet the CT\\n criteria for lymphadenopathy. There is severe atherosclerotic aortic\\n calcification extending up to the abdominal aorta and the renal arteries.\\n Severe coronary artery calcifications are noted. There is no pericardial\\n effusion.\\n\\n In the imaged portion of the upper abdomen, the liver, spleen, and adrenals\\n are unremarkable. A hypodense stable cyst is seen in the right kidney.\\n\\n Degenerative changes are noted in the thoracic vertebral bodies. There is no\\n suspicious lytic or blastic lesion in the bones.\\n\\n IMPRESSION:\\n 1. Left lower lobe pneumonia with additional focal patchy areas of\\n consolidation in the lingula and right upper lobe.\\n 2. Moderate-to-large bilateral pleural effusions with bibasilar atelectasis.\\n 3. Severe atherosclerotic aortic calcification extending into the renal\\n arteries.\\n 4. Severe coronary artery calcifications.\\n 5. Emphysema.\\n 6. 12-13 mm hypodense stable right renal cyst.\\n (Over)\\n\\n 10:01 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: please assess lung infiltrate and pulmonary edema in attempt\\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2192-12-02 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 895243,\n \"text\": \" 2:25 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate for interval change, worsening of infiltrate\\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with head&neck SCC, with LLL PNA, now with worsening SOB,\\n )2sat down to 85% on RA.\\n REASON FOR THIS EXAMINATION:\\n please evaluate for interval change, worsening of infiltrates\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: AP chest, performed on .\\n\\n HISTORY: 71-year-old male with head and neck squamous cell cancer and left\\n lower lobe pneumonia. Now with worsening shortness of breath.\\n\\n FINDINGS: Compared to the previous studies from through , .\\n\\n The cardiac silhouette is within normal limits and is unchanged.\\n Calcifications of the thoracic aorta is again seen. There is prominence of\\n the interstitial markings with more focal opacities in the left mid and left\\n lower lung fields. These findings appeared to have worsened slightly and are\\n again suspicious for multifocal pneumonia. The increased interstitial\\n markings raises an element of underlying pulmonary edema as well.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2192-12-06 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 895784,\n \"text\": \" 9:40 AM\\n CHEST (PA & LAT) Clip # \\n Reason: Please assess for progression of pulmonary edema and pleural\\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with history of head and neck cancer, LLL pneumonia, CHF\\n exacerbation.\\n REASON FOR THIS EXAMINATION:\\n Please assess for progression of pulmonary edema and pleural effusions\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 70 y/o man with history of head and neck cancer, left lower lobe\\n pneumonia and CHF exacerbation. Evaluate progression of pulmonary edema and\\n pleural effusions.\\n\\n COMPARISON: .\\n\\n AP & LATERAL CHEST: The heart size is within normal limits. Mild pulmonary\\n edema has decreased. Small to moderate bilateral pleural effusions and\\n bibasilar pulmonary opacities are unchanged.\\n\\n IMPRESSION:\\n 1) Decreased mild pulmonary edema.\\n 2) Unchanged bilateral pleural effusions and bibasilar opacities.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2192-11-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 894866,\n \"text\": \" 12:32 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for infiltrates, any CP abnormalities\\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with head&neck SCC, admitted for hypotension with temp spike to\\n 101.6; productive cough\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrates, any CP abnormalities\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Squamous cell carcinoma of the neck. Fever.\\n\\n FINDINGS:\\n\\n The heart size is normal. No pneumothorax or effusions are seen. No\\n pulmonary nodules are identified. New multifocal parenchymal opacity is seen\\n in the left lung compared to .\\n\\n IMPRESSION: Multifocal pneumonia in the left lung.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2192-12-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 895184,\n \"text\": \" 10:38 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval for interval change in PNA\\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with head&neck SCC, with LLL PNA\\n REASON FOR THIS EXAMINATION:\\n please eval for interval change in PNA\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: AP chest, .\\n\\n HISTORY: 71-year-old man with head and neck squamous cell cancer with left\\n lower lobe pneumonia.\\n\\n FINDINGS: Compared to previous study from .\\n\\n There is again seen an infiltrate in the left mid lung and left lower lobe,\\n which is more apparent on today's study and slightly more confluent.\\n Followup to resolution recommended. The right lung remains clear. There is\\n calcification of the thoracic aorta.\\n Cardiac size is normal.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2192-12-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 895392,\n \"text\": \" 5:42 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: eval for interval change\\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with head&neck SCC, with LLL PNA, now with worsening SOB,\\n O2sat down to 85% on 50% shovel mask again.\\n REASON FOR THIS EXAMINATION:\\n eval for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: AP chest, .\\n\\n HISTORY: 71-year-old man with head and neck cancer and left lower lobe\\n pneumonia. Now with worsening shortness of breath.\\n\\n FINDINGS: There is again seen marked prominence of the pulmonary vasculature\\n bilaterally with more focal airspace opacities forming within the left mid\\n lung field as well as a left retrocardiac opacity. These findings have\\n worsened slightly since the previous study. They are again most consistent\\n with a prominent pulmonary edema. Underlying pneumonia especially at the left\\n mid lung and left base will be difficult to exclude.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2192-12-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 895430,\n \"text\": \" 6:37 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please eval for CHF and progression of infiltrate.\\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with head&neck SCC, with LLL PNA, now with SOB.\\n REASON FOR THIS EXAMINATION:\\n Please eval for CHF and progression of infiltrate.\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST 7:03 A.M. .\\n\\n HISTORY: Head and neck carcinoma. Left lower lobe pneumonia. New shortness\\n of breath.\\n\\n IMPRESSION: AP chest compared to and :\\n\\n Mild pulmonary edema asymmetrically distributed is clearing. Improvement in\\n perihilar consolidation in the left lung probably reflects resolving\\n deposition of edema in the region of pneumonia. Moderate-sized right pleural\\n effusion has enlarged. The heart is normal size and midline.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2192-12-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 278807,\n \"text\": \"Sinus rhythm\\nLeft atrial abnormality\\nPoor R wave progression - probable normal variant\\nLateral T wave changes may be due to myocardial ischemia\\nSince previous tracing of -o5, poor R wave progression seen\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2192-11-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 278808,\n \"text\": \"Sinus rhythm. Normal ECG. Compared to the previous tracing first degree\\nA-V conduction delay is no longer present.\\n\\n\"\n }\n]"}}},{"rowIdx":24664,"cells":{"subject_id":{"kind":"number","value":9454,"string":"9,454"},"hadm_id":{"kind":"number","value":157067,"string":"157,067"},"target_text":{"kind":"string","value":"85yo woman with CAD, CHF, a.fib, temporal arteritis, dementia with axillary thrombosis s/p thrombectomy with neck hematoma after CVC attempt, acute renal failure and gardnerella in urine. . 1) left axillary artery thrombosis: s/p thrombectomy . Patient was therapeutic on coumadin with INR of 2.6 on admission though subtheraputic INR (1.4) on per coumadin clinic with no intervention in terms of coumadin dose. Rheumatology (Dr. doubts related to TA, ? thromboembolic event given a.fib/potentially subtheraputic inr. Cardiology (Dr. recommended tighter INR control with goal 2.0-3.0 but no further imaging at this time. She was bridged post-opperatively on a heparin gtt to coumadin to theraputic INR (2.2) and coumadin was restarted, however INR fell to 1.8 so she was covered with lovenox injection, 60mg (based on 1mg/kg) dosed qdaily based on renal function. She should continue lovenox until INR 2.0-3.0, and is discharged on coumadin 3mg po qhs, to be titrated to maintain INR at goal. She will follow-up with vascular surgery to have wounds checked and staples removed, additionally should have dry gauze to cover these wounds changed daily. . 2) Neck Hematoma: Secondary to carotid puncture during CVC placement in the ED on admission. This wound was explored by vascular surgery when in surgery for thrombectomy and noted to have no active bleeding. This site was closed with staples and had no further swelling or bleeding, but has marked ecchymosis and edema. Wound care and staple removal as above. . 3) Respiratory failure: Patient was intubated for general anesthesia and weaned/extubated with relative ease , oxygen has been steadily titrated down to 1L by nasal canula and will need to be further titrated with diuresis to prevent pulmonary edema as postopperative edeam revascularizes. She should continue oxygen to maintain sat >90%, albuterol/ipratropium nebulizers as needed, chest pt, and incentive spirometry. . 4) Cardiomyopathy/CHF: Patient has EF of 25% by Echo , severe AS, + AR, + MR and mod PAH. pro-BNP 31K on admission. Has pulm edema on exam and in CXR but improved on CXR. CVP is currently flat, she required gentle IVF and diuresis in the ICU and further diuresis on the general medicine floor. She is total body volume overload by weight (142, up from dry weight of 136) likely related to edema at her surgical sites and may require additional diursis with IV lasix as that edema revascularizes. She was given 40mg IV lasix priro to discharge with good effect. She was continued on carvedilol, losartan was held during renal failure but restarted on discharge, aspirin and lipitor. She is to restart her home lasix regimen of 40mg by mouth twice daily, with IV as needed depending on her respiratory and volume status, and weight. . 5) Atrial fibrialation: on coumadin outpt, recently had coumadin increased for subtherapeutic level, to be discharged on 3mg po qhs, to be titrated as an outpatient to INR 2.0-3.0. On discharge INR 1.9 and likely will be theraputic soon as this medication was recently restarted after being held for surgery. She is on lovenox 60mg qd as a bridge to theraputic INR (based on renal function). This lovenox should be stopped once she reaches theraputic INR. She is also restarted on digoxin, which was held while she was in acute renal failure, at the time of discharge. She was continued on rate control with carvedilol. . 6) CAD: Troponin rose (peak 0.61, now trending down), but in the setting of renal failure and flat CK's unlikely to be acute ischemia. She was continued on aspirin, carvedilol, statin, and restarted on cozaar once renal failure improved. . 7) Acute renal failure: baseline Cr 1.1, peak in house 1.7, fell to 1.2 by time of discharge. This could have been secondary to overdiuresis vs poor forward flow, given FeUREA 8.4% and urine sodium undetectable indicates prerenal etiology rather than renal. By discharge improved, able to restart cozaar, digoxin, tolerated lasix with renal improvement. . 8) Leukocytosis: w/ left shift initially ? stress reaction, trending down, resolved to 9.8 by the time of discharge, possibly related to gardnerella vaginalis in urine though less likely, treated with metronidazole for 5 days, afebrile. . 9) Hypertension: controlled with carvedilol, restarted cozaar on discharge. . 10) History of bradycardia: s/p pacemaker, V paced. . 11) Temporal arteritis: Followed by Dr. outpatient. Was on a 6-8month long taper (initally high dose) but it was stopped , he noted angiography, he feels, would be low-yeild, favors not restarting prednisone given CNS side-effects. . 12) Diabetes Mellitus: Poor PO intake post-operatively initially but improved, restarted on NPH at 16units though home dose 18 units so will need to be uptitrated at rehab depending on PO intake and blood glucose, also with Humolog per sliding scale. . 13) Dementia/Delirium: She was continued on home dose of aricept. . 14) Hyperlipidemia: continued on atorvastatin. . 15) Hypothyroid: continued on synthroid, repeat TSH 0.32. . 16) Depression: continued on home dose of zoloft. . 17) Contact: cell (HCP) . 18) FEN: Diabetic diet, low salt diet, electrolytes prn . 19) Prophylaxis: PPI, theraputic coumadin/lovenox, bowel regimen . 20) Code: FULL In brief this 85 yo woamn with multiple medical problems including CAD s/p stent, CHF (EF 25%), AF on coumadin, temporal arteritis (stopped month prednisone taper ), was admitted on with a cold left hand and found to have left proximal axillary artery thrombosis by CTA. Vascular surgery followed her and she went to the OR for thrombectomy. Her hospital course was complicated by carotid artery perforation with hematoma after CVC atttempt in the ED. This was explored at the time of surgery and found not to be bleeding. She received 100cc NS, unit PRBC in OR, and about 1L of fluid on . She was intubated for the surgery and brought to the ICU for further management. Patient remained intubated because of multiple medical problems, even though her ABG and hemodynamics had been stable. Patient was given multiple lasix doses overnight for decreased urine output. She was successfully extubated . She was also noted to have Gardnerella in her urine so was started on metronidazole iv . . Currently she feels well, has little recolection of surgery, denies pain at surgical sites, dizziness, lightheadedness, fevers, chills, nausea, vomitting, constipation, abdominal pain, diarrhea, shortness of breath, cough, chest pain or pressure. She does note a sensation of having to go to the bathroom (has foley catheter in). Her daughter notes she has been more somnolent since her discharge in early Decemeber, with DOE that seems more severe. . Medications on Admission: Furosemide 40 QAM, 20/40QPM (alternating with extra if SOB by VNA) Aricept 10 QAM coreg 6.25 Protonix 40 synthroid 0.125mcg QD potassium 20mg calcitonin 200 spray cozaar 25mg QD calcium and vit D 500mg tid ECASA 81mg Digoxin 0.0625 iron Coumadin 2 (TTSS) and 3mg(MWF) QHS Atorvastatin 10 QHS zoloft 75mg tylenol PRN NPH 18u QD HISS 100-140 6U, 141-180 8U, 181+ 10U Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: Tablet PO once a day. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Potassium Chloride Granules Sig: One (1) Miscell. once a day: HOLD if potassium >40 MeQ. 5. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 6. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO once a day: please give 0830 in am. 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO QHS (once a day (at bedtime)). 9. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) Nasal DAILY (Daily): please give 0830. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily): please give at 1300. 13. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q3-4H (Every 3 to 4 Hours) as needed for wheezing, dyspnea. 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for dyspnea, wheezing. 15. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime: please adjust coumadin dose to INR 2.0-3.0. Tablet(s) 16. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily): please continue this medication until INR 2.0-3.0, then stop. 17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day: Please give at 0830 and 1630. She normally takes 40mg in the am and either 20 or 40 in the pm so as lungs become more clear may need to change pm dose. 18. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Sixteen (16) units Subcutaneous once a day: please give at 0830. Home dose 18 units, may need to be increased once eating better. 19. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: 1-10 units Subcutaneous four times a day as needed for per sliding scale: with meals: see attached sliding scale. 20. Cozaar 25 mg Tablet Sig: One (1) Tablet PO once a day. 21. CALCIUM 500+D 500-200 mg-unit Tablet Sig: One (1) Tablet PO three times a day. Tablet(s) 22. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO twice a day. 23. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: not to exceed 4gm/day. Discharge Disposition: Extended Care Facility: for the Aged - MACU Discharge Diagnosis: Left axillary thrombus, s/p thrombectomy, right carotid puncture . Coronary artery disease, Rheumatic Heart Disease with aortic stenosis, Atrial fibrillation, history of bradycardia: s/p pacemaker, hypertension, dyslipidemia, dementia, diabetes mellitus-on insulin, history of GI bleed, hypothyroidism, congestive heart failure, ejection fraction 25%. 12. Temporal arteritis Discharge Condition: Stable. Discharge Instructions: Please take all medications as prescribed. Please keep all follow-up appointments. Please notify your doctor if you experience fevers, chills, lightheadedness, shortness of breath, chest pain, arm pain, numbness, weakness, or any symptoms Followup Instructions: Please follow-up with Dr. within 1-2 weeks after release from rehab. Please follow-up with Dr. of vascular surgery, on at 1:00pm. Please call ( if questions for Dr. ."},"extractive_notes_summ":{"kind":"string","value":"r neck staples c/d/i with no drainage noted.psy-soc: dtr in to visit...updated on status and plan of care. Mae/perrl, patient denies pain.CV: Vpaced, underlying rhythm afib, sbp 130's/30's. pt start diebetic diet, pt had apllesause and water w/o any difficulties, able to take PO meds w/o problem.skin: Hematoma at R side of neck unchaged,staples intact. cough/gag intact.cv: monitor shows v-paced rhythm with no ectopy noted. heparin gtt d/c'd as ordered. remains on flagyl for +urine.endo: remains on fingersticks q6hr with humalog s/s.skin: l upper forearm dsg c/d/i with sm amt old staining noted. l arm pulses dopplerable.resp: ls with bibasilar crackles noted. diet.gu: foley intact and patent draining yellow urine with sm amt sedimentation noted.i-d: afebrile. Abd soft, bs present.Skin: Surfaces grossly intact, hematoma at right neck unchanged. ?resumption of diuresis vs further hydration for low urine output. No dyspnea/sob noted or voiced.Gu: Uo 14-20cc/hr clear yellow, fluid bolus x2 without increase.GI: Currently npo s/p extubation. Pt up to MICU 7 from PACU, weaned and extubated without problems. Assess swallowing capability and resume po meds when pt more alert. pt has weak cough.cv: HR 70 Vpaced, 1 episode of HR up to 120-134 withVpaced for less 1min, no changes in BP, no c/o of chest pain from pt, MD aware. pt follows simple commands, PERL 3mm/brisk. Post op left arm pulses palpable by doppler.Endo: Ssc with regular insulin by .Soc: Two daughters, \"\" is HCP, copy on chart.P: Prn analgesics, follow PTT with heparin adjustment per protocol. currently on 2l np.gi: abd soft and nontender. Tracing is unchanged compared to the previous tracingof . Encourage pulmonary hygiene, follow abg's/02 sats. left arm pulses palpable by doppler.id: afevrile, cont flagyl.social: full code, daughter visited and called for updated, very concerns about pt mental status.plan: cont monitoring neuro/resp/cardio status monitorng i&O update and given emotional support to family monitoring hematoma, PTT. +bs noted. Compared to the previous tracing of nosignificant change. Transfer out of ICU when medically appropriate. ABP 112-129/30's, MAP 56-70, CVP 10-12. pt cont Heparin 500cc/hr, at PTT 71.2 mornihg labs pending.gi/gu: foley in place drainge yellow/clear urine 8-10cc/hr, at 2200 given Lasix 20mg IV with minimal response u/o 30-35cc/hr after LAsix.ABD soft, BS+,no stool this shift. Keep family up to date on poc, advance activity/diet as ordered. no c/o pain. respiratory care:Please disregard the above RC note, it is on the wrong Pt.... Seems to get over them in a short time. see carevue for details. +mae noted. She has had a couple of \"choking\" spell of UKO. remains full code. Monitor neck hematoma and csm left arm/hand for any change. See data, MD notes/orders and admission data.Neuro: Wakes to verbal stimuli and follows commands, nods head to y/n questions. c/o to floor. per daughter pt at baseline A/Ox3.resp: received on NC 4L, sat 100%, attempt to wean O2 to RA pt desat to 90%, put back to NC 2L,ast 97-99%, pt denies SOB, LS clear and crackles at bases. Bs's occasionally coarse, Sx'd for small to moderate amounts of yellow thick sputum when doing the vent care. No ABG's today Sat = 98->100%. 1900-0700 rn notes micuneuro: pt arousable to voice, at time oriented in place, pt const asking what's wrong with her and what happening, after explained several times, pt still cont to ask the same guestions and could not get what's happening to her. neuro: alert and oriented to person and place...needs frequent reminders as to why she is in the hospital. Upper and lower dentures in place, glasses at bedside with eye glass case. drop in sats to 88 with O2 removal. Ventricular pacing. Respiratory Care:Pt remains on PSV all day; no PMV trial today due to other unit issues. Adendum: Valuables brought in by daughter. Cvp 9, heparin gtt at 500units/hr.Pulm: Extubated this afternoon, currently on nc with 02 sat 100%. Ventricular paced rhythm."},"n_notes":{"kind":"number","value":9,"string":"9"},"notes":{"kind":"list like","value":[{"category":"ECG","chartdate":"2134-12-06 00:00:00.000","description":"Report","row_id":280990,"text":"Ventricular paced rhythm. Compared to the previous tracing of no\nsignificant change.\n\n"},{"category":"ECG","chartdate":"2134-12-04 00:00:00.000","description":"Report","row_id":280991,"text":"Ventricular pacing. Tracing is unchanged compared to the previous tracing\nof .\n\n"},{"category":"Nursing/other","chartdate":"2134-12-06 00:00:00.000","description":"Report","row_id":1387239,"text":"See data, MD notes/orders and admission data.\n\nNeuro: Wakes to verbal stimuli and follows commands, nods head to y/n questions. Mae/perrl, patient denies pain.\n\nCV: Vpaced, underlying rhythm afib, sbp 130's/30's. Cvp 9, heparin gtt at 500units/hr.\n\nPulm: Extubated this afternoon, currently on nc with 02 sat 100%. No dyspnea/sob noted or voiced.\n\nGu: Uo 14-20cc/hr clear yellow, fluid bolus x2 without increase.\n\nGI: Currently npo s/p extubation. Abd soft, bs present.\n\nSkin: Surfaces grossly intact, hematoma at right neck unchanged. Post op left arm pulses palpable by doppler.\n\nEndo: Ssc with regular insulin by .\n\nSoc: Two daughters, \"\" is HCP, copy on chart.\n\nP: Prn analgesics, follow PTT with heparin adjustment per protocol. Encourage pulmonary hygiene, follow abg's/02 sats. ?resumption of diuresis vs further hydration for low urine output. Assess swallowing capability and resume po meds when pt more alert. Monitor neck hematoma and csm left arm/hand for any change. Keep family up to date on poc, advance activity/diet as ordered. Transfer out of ICU when medically appropriate.\n"},{"category":"Nursing/other","chartdate":"2134-12-07 00:00:00.000","description":"Report","row_id":1387245,"text":"neuro: alert and oriented to person and place...needs frequent reminders as to why she is in the hospital. +mae noted. cough/gag intact.\ncv: monitor shows v-paced rhythm with no ectopy noted. heparin gtt d/c'd as ordered. l arm pulses dopplerable.\nresp: ls with bibasilar crackles noted. drop in sats to 88 with O2 removal. currently on 2l np.\ngi: abd soft and nontender. +bs noted. diet.\ngu: foley intact and patent draining yellow urine with sm amt sedimentation noted.\ni-d: afebrile. remains on flagyl for +urine.\nendo: remains on fingersticks q6hr with humalog s/s.\nskin: l upper forearm dsg c/d/i with sm amt old staining noted. r neck staples c/d/i with no drainage noted.\npsy-soc: dtr in to visit...updated on status and plan of care. c/o to floor. remains full code.\n"},{"category":"Nursing/other","chartdate":"2134-12-06 00:00:00.000","description":"Report","row_id":1387240,"text":"Respiratory Care:\nPt remains on PSV all day; no PMV trial today due to other unit issues. Bs's occasionally coarse, Sx'd for small to moderate amounts of yellow thick sputum when doing the vent care. No ABG's today Sat = 98->100%. She has had a couple of \"choking\" spell of UKO. Seems to get over them in a short time. No other events today. see carevue for details.\n"},{"category":"Nursing/other","chartdate":"2134-12-06 00:00:00.000","description":"Report","row_id":1387241,"text":"respiratory care:\nPlease disregard the above RC note, it is on the wrong Pt....\n"},{"category":"Nursing/other","chartdate":"2134-12-06 00:00:00.000","description":"Report","row_id":1387242,"text":"Pt up to MICU 7 from PACU, weaned and extubated without problems.\n"},{"category":"Nursing/other","chartdate":"2134-12-06 00:00:00.000","description":"Report","row_id":1387243,"text":"Adendum: Valuables brought in by daughter. Upper and lower dentures in place, glasses at bedside with eye glass case.\n"},{"category":"Nursing/other","chartdate":"2134-12-07 00:00:00.000","description":"Report","row_id":1387244,"text":"1900-0700 rn notes micu\n\nneuro: pt arousable to voice, at time oriented in place, pt const asking what's wrong with her and what happening, after explained several times, pt still cont to ask the same guestions and could not get what's happening to her. pt follows simple commands, PERL 3mm/brisk. no c/o pain. per daughter pt at baseline A/Ox3.\n\nresp: received on NC 4L, sat 100%, attempt to wean O2 to RA pt desat to 90%, put back to NC 2L,ast 97-99%, pt denies SOB, LS clear and crackles at bases. pt has weak cough.\n\ncv: HR 70 Vpaced, 1 episode of HR up to 120-134 withVpaced for less 1min, no changes in BP, no c/o of chest pain from pt, MD aware. ABP 112-129/30's, MAP 56-70, CVP 10-12. pt cont Heparin 500cc/hr, at PTT 71.2 mornihg labs pending.\n\ngi/gu: foley in place drainge yellow/clear urine 8-10cc/hr, at 2200 given Lasix 20mg IV with minimal response u/o 30-35cc/hr after LAsix.\nABD soft, BS+,no stool this shift. pt start diebetic diet, pt had apllesause and water w/o any difficulties, able to take PO meds w/o problem.\n\nskin: Hematoma at R side of neck unchaged,staples intact. left arm pulses palpable by doppler.\n\nid: afevrile, cont flagyl.\n\nsocial: full code, daughter visited and called for updated, very concerns about pt mental status.\n\nplan: cont monitoring neuro/resp/cardio status\n monitorng i&O\n update and given emotional support to family\n monitoring hematoma, PTT.\n"}],"string":"[\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2134-12-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 280990,\n \"text\": \"Ventricular paced rhythm. Compared to the previous tracing of no\\nsignificant change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2134-12-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 280991,\n \"text\": \"Ventricular pacing. Tracing is unchanged compared to the previous tracing\\nof .\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-12-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1387239,\n \"text\": \"See data, MD notes/orders and admission data.\\n\\nNeuro: Wakes to verbal stimuli and follows commands, nods head to y/n questions. Mae/perrl, patient denies pain.\\n\\nCV: Vpaced, underlying rhythm afib, sbp 130's/30's. Cvp 9, heparin gtt at 500units/hr.\\n\\nPulm: Extubated this afternoon, currently on nc with 02 sat 100%. No dyspnea/sob noted or voiced.\\n\\nGu: Uo 14-20cc/hr clear yellow, fluid bolus x2 without increase.\\n\\nGI: Currently npo s/p extubation. Abd soft, bs present.\\n\\nSkin: Surfaces grossly intact, hematoma at right neck unchanged. Post op left arm pulses palpable by doppler.\\n\\nEndo: Ssc with regular insulin by .\\n\\nSoc: Two daughters, \\\"\\\" is HCP, copy on chart.\\n\\nP: Prn analgesics, follow PTT with heparin adjustment per protocol. Encourage pulmonary hygiene, follow abg's/02 sats. ?resumption of diuresis vs further hydration for low urine output. Assess swallowing capability and resume po meds when pt more alert. Monitor neck hematoma and csm left arm/hand for any change. Keep family up to date on poc, advance activity/diet as ordered. Transfer out of ICU when medically appropriate.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1387245,\n \"text\": \"neuro: alert and oriented to person and place...needs frequent reminders as to why she is in the hospital. +mae noted. cough/gag intact.\\ncv: monitor shows v-paced rhythm with no ectopy noted. heparin gtt d/c'd as ordered. l arm pulses dopplerable.\\nresp: ls with bibasilar crackles noted. drop in sats to 88 with O2 removal. currently on 2l np.\\ngi: abd soft and nontender. +bs noted. diet.\\ngu: foley intact and patent draining yellow urine with sm amt sedimentation noted.\\ni-d: afebrile. remains on flagyl for +urine.\\nendo: remains on fingersticks q6hr with humalog s/s.\\nskin: l upper forearm dsg c/d/i with sm amt old staining noted. r neck staples c/d/i with no drainage noted.\\npsy-soc: dtr in to visit...updated on status and plan of care. c/o to floor. remains full code.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-12-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1387240,\n \"text\": \"Respiratory Care:\\nPt remains on PSV all day; no PMV trial today due to other unit issues. Bs's occasionally coarse, Sx'd for small to moderate amounts of yellow thick sputum when doing the vent care. No ABG's today Sat = 98->100%. She has had a couple of \\\"choking\\\" spell of UKO. Seems to get over them in a short time. No other events today. see carevue for details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-12-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1387241,\n \"text\": \"respiratory care:\\nPlease disregard the above RC note, it is on the wrong Pt....\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-12-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1387242,\n \"text\": \"Pt up to MICU 7 from PACU, weaned and extubated without problems.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-12-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1387243,\n \"text\": \"Adendum: Valuables brought in by daughter. Upper and lower dentures in place, glasses at bedside with eye glass case.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1387244,\n \"text\": \"1900-0700 rn notes micu\\n\\nneuro: pt arousable to voice, at time oriented in place, pt const asking what's wrong with her and what happening, after explained several times, pt still cont to ask the same guestions and could not get what's happening to her. pt follows simple commands, PERL 3mm/brisk. no c/o pain. per daughter pt at baseline A/Ox3.\\n\\nresp: received on NC 4L, sat 100%, attempt to wean O2 to RA pt desat to 90%, put back to NC 2L,ast 97-99%, pt denies SOB, LS clear and crackles at bases. pt has weak cough.\\n\\ncv: HR 70 Vpaced, 1 episode of HR up to 120-134 withVpaced for less 1min, no changes in BP, no c/o of chest pain from pt, MD aware. ABP 112-129/30's, MAP 56-70, CVP 10-12. pt cont Heparin 500cc/hr, at PTT 71.2 mornihg labs pending.\\n\\ngi/gu: foley in place drainge yellow/clear urine 8-10cc/hr, at 2200 given Lasix 20mg IV with minimal response u/o 30-35cc/hr after LAsix.\\nABD soft, BS+,no stool this shift. pt start diebetic diet, pt had apllesause and water w/o any difficulties, able to take PO meds w/o problem.\\n\\nskin: Hematoma at R side of neck unchaged,staples intact. left arm pulses palpable by doppler.\\n\\nid: afevrile, cont flagyl.\\n\\nsocial: full code, daughter visited and called for updated, very concerns about pt mental status.\\n\\nplan: cont monitoring neuro/resp/cardio status\\n monitorng i&O\\n update and given emotional support to family\\n monitoring hematoma, PTT.\\n\"\n }\n]"}}},{"rowIdx":24665,"cells":{"subject_id":{"kind":"number","value":8114,"string":"8,114"},"hadm_id":{"kind":"number","value":107484,"string":"107,484"},"target_text":{"kind":"string","value":"The patient was admitted on and was the wound was cultured and she was started on Vanco, Gent, and Flagyl. She was taken to the OR and underwent sternal debridement and pectoralis flap advancement with the plastic surgery service. She tolerated the procedure well and was transferred to the CSRU in stable condition. She was extubated on POD#1 and ID was consulted. On POD#3 her chest tube was d/c'd and she was transferred to the the floor. Her wound grew out MRSA and she was continued on Vancomycin. She continued to progress and had a PICC placed. She initially had 4 JP drains in and had 2 of them d/c'd. She needs 6 weeks of IV vanco form the date of her debridement. She will be seen in Plastic Surgery Clinic in 1 week for evaluation of JP removal."},"extractive_notes_summ":{"kind":"string","value":"Vanco, gent dose adjusted. CV: Neo off, NTG on briefly, began metoprolol. Under fluorscopic guidance, 0.018 guide wire was advanced into the superior vena cava. A final fluoroscopic spot film demonstrated the tip to be in the superior vena cava. Rehab: OOB to chair, tol well but c/o hemmorhoids. Respiratory CarePt was received from o.r. FINDINGS: The patient is status post removal of sternotomy wires. Resp: Weaned and extubated. LEFT LOWER EXTREMITY VENOUS ULTRASOUND: scale and Doppler son of the left common femoral, superficial femoral and popliteal veins were performed. There has been removal of an endotracheal tube. Bilateral breath sounds and +ETCO2 were confirmed. PLASIC IN THIS AM DID REMIVE DSG INCISION HEALING NEW DSD PLACED. Restart preop psych meds. The PICC line was trimmed to length and advanced over a 4 French introducer sheath under fluoroscopic guidance into the superior vena cava. There has been interval development of a moderate size left pleural effusion, which tracks to the left apex. FINDINGS: An endotracheal tube, central venous catheter, nasogastric tube, and left-sided chest tube are in satisfactory position. Heme: Heparin sq. There has been interval removal of sternal wires and placement of a chest wall drain. Serosang drg from JPS. GI: Tol cl liqs. intubated, 7.o oral et tube taped at 19 cm mark. WAKE AND WEAN LATER TODAY, WEAN NEO GTT IF TOLERATES, MONITOR BLOOD SUGARS. The sheath was removed and the catheter was flushed. INTALLY C/O HEMMORHOIDS TUCKS GOTTEN PLACED , DECREASED PAIN. Cardiac and mediastinal contours are stable, compared to the preoperative radiograph allowing for differences in technique. IMPRESSION: Moderate left pleural effusion tracking to the apex. Laxative/suppository/tucks. IMPRESSION: Improving left lower lobe atelectasis with persistent moderate sized left pleural effusion tracking to the apex. There is a persistent moderate left pleural effusion tracking to the left apex. suppository on days, encourage to cough and deep breath, ? Note is made of a large left groin mixed echogenic collection likely representing a hematoma. Flagyl dcd. The basilic and brachial vein were patent and compressible. A vascular sheath and left-sided chest tube remain in place as well as additional chest wall drains. REASON FOR THIS EXAMINATION: Eval for presence of DVT WET READ: AZm 3:53 PM No DVT L groin hematoma FINAL REPORT *ABNORMAL! NEURO: ALERT AND ORIENTED X 3, MAE, FOLLOWING COMMANDS CORRECTLY, PERCOCETES FOR PAIN, VERY ANXIOUS AND IS ON LORAZ PO.CARDIAC: NSR WITH NO ECTOPY NOTED, SBP'S WNL'S, PALPIBLE PEDIAL PULSES, SKIN WARM DRY AND INTACT, +2 EDEMA IN EXTREMITIES, AFEBRILE.RESP: LUNGS DIM IN BASES, ON 3 LITERS NC SATTING AT 97%, IS COUGHING AND DEEP BREATHING AND USING I/S.SKIN: CHEST WITH DSD THAT IS CDI, MAMMORY SUPPORT IS ON, JP DSDS ARE CDI, OLD CT DSD IS CDI, COCCYX IS PINK, LEFT LEG IS BRUISED AND INCISION SITES ARE CDI.GI/GU: TOLERATING PO'S, ABD IS SOFT ROUND AND OBESE, GOOD BOWEL SOUNDS, DID GET SUPPOSITOY AND RESPONED WITH X2 SMALL STOOLS, ON RISS, IS MAKING GOOD U/O.PLAN: ENCOURAGE TO COUGH AND DEEP BREATH AND TO USE I/S, MONITOR BLOOD SUGARS, CONTINUE ATIVAN PRN, INCREASE ACTIVITY AS TOLERATES. IV fluid KVO. The right arm was then prepped and draped in the usual sterile fashion. INDICATION: Status post CABG with calf tenderness and swelling. There are bibasilar atelectatic changes, left greater than right. GU U/O THIS PM DRIFTING DOWN LASIX 20MG IV GIVEN PLAN TO GIVE 20MEQ KCL IF STARTS TO DUIRESIS. Bibasilar atelectasis, left greater than right. Under local anesthesia with 1% Lidocaine, the cephalic vein was accessed with a 21 gauge needle. A Statlock was applied and the line was Heplocked. Left groin hematoma. ID: Tmax 101.9, down to 100.1 after acetaminophen. A superficial cephalic vein was identified within the right arm. Renal: Large diuresis to lasix 20 IV. The patient already had an indwelling peripheral IV placed within the left wrist, and therefore gentle hand injection of contrast through the peripheral IV was performed. NEURO ALERT ORIENTED ANXIOUS BASELINE PERSONALITY FOLLOWS ALL COMMANDS MOVES ALL EXTREMETIESC/V NSR B/P STABLE PULSES PALPRESP NC 3L SATS 99% LUNGS CLEAR NONPRODUCTIVE NO SOB OR RESP DISTRESS NOTEDGU/GI TOL PO WELL TO COMMODE X1 FOR SMALL AMT LOOSE STOOL GUAIAC NEGATIVE ADEQUATE URINE OUTPLAN TRANSFER TO 2 TODAY IMPRESSION: Successful placement of 45 cm total length, single lumen, right- sided PICC line with tip in the superior vena cava. CSRU Progress NoteS/O: Neuro: Alert and cooperative, med with Morphine and percocet for pain. Transition to SSRI. Neuro: alert and oriented x 3, mae, following commands correctly, percocets for pain.Cardiac: nsr in the 80's, no ectopy noted, sbps run low when asleep in the mid 80's but maps above 60, sbps wnl's when awake, dopplerable pedial pulses, skin warm dry and intact, afebrile, a-line and peripheral blood cultures sent.Resp: lungs dim in bases, ct system draining scant to no drainage with no air leak, on 4 liters nc satting at 97%, abgs are good, weak cough and deep breathing exersizing.Skin: chest with dsd that is cdi with mamory support on, ct dsd cdi, jp dsd are cdi, coccyx is pink in color but no breakdown, left leg is healing wnls though has some bruising.Gi/Gu: tolerating po's, abd soft round and nontender, good bowel sounds, pt c/o not having a bm in several days, on riss, good u/o did switch from po lasix to iv.Plan: ? K repleted. The left upper arm was prepped and draped in the usual sterile fashion. CLINICAL INDICATION: Status post coronary bypass surgery. PROCEDURE/FINDINGS: The procedure is performed by Dr. and Dr. . Needs long term IV antibiotics. Cardiac and mediastinal contours are stable."},"n_notes":{"kind":"number","value":11,"string":"11"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2198-12-16 00:00:00.000","description":"L UNILAT LOWER EXT VEINS LEFT","row_id":853968,"text":" 2:48 PM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: Eval for presence of DVT\n Admitting Diagnosis: STERNAL WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman s/p CAGB c/b mediastinitis; now with calf tenderness and\n swelling of the left lower extremity.\n REASON FOR THIS EXAMINATION:\n Eval for presence of DVT\n ______________________________________________________________________________\n WET READ: AZm 3:53 PM\n No DVT\n L groin hematoma\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Status post CABG with calf tenderness and swelling.\n\n LEFT LOWER EXTREMITY VENOUS ULTRASOUND: scale and Doppler son of\n the left common femoral, superficial femoral and popliteal veins were\n performed. There is normal flow, compressibility, augmentation and wave\n forms. Intraluminal thrombus was not identified. Note is made of a large\n left groin mixed echogenic collection likely representing a hematoma.\n\n IMPRESSION: No evidence of DVT. Left groin hematoma.\n\n\n"},{"category":"Radiology","chartdate":"2198-12-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":853178,"text":" 8:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u pleural effusion\n Admitting Diagnosis: STERNAL WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with CAD s/p CABG\n\n REASON FOR THIS EXAMINATION:\n f/u pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Portable chest of with clinical indication of status\n post coronary bypass surgery.\n\n COMPARISON: Made to previous study of one day earlier.\n\n FINDINGS:\n\n The patient is status post removal of sternotomy wires. A chest drain remains\n in place in a relatively midline position. There has been removal of an\n endotracheal tube. A vascular sheath and left-sided chest tube remain in\n place as well as additional chest wall drains. Cardiac and mediastinal\n contours are stable. There is a persistent moderate left pleural effusion\n tracking to the left apex. There is improvement in the degree of left\n retrocardiac atelectasis, but there is no significant change in the more minor\n areas of atelectasis in the right lower lobe.\n\n IMPRESSION:\n\n Improving left lower lobe atelectasis with persistent moderate sized left\n pleural effusion tracking to the apex.\n\n\n"},{"category":"Radiology","chartdate":"2198-12-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":853091,"text":" 10:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval CT placement/ ETT/ L pleural effusion\n Admitting Diagnosis: STERNAL WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with CAD s/p CABG\n\n REASON FOR THIS EXAMINATION:\n eval CT placement/ ETT/ L pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest, compared previous study of .\n\n CLINICAL INDICATION: Status post coronary bypass surgery.\n\n FINDINGS:\n\n An endotracheal tube, central venous catheter, nasogastric tube, and\n left-sided chest tube are in satisfactory position. There has been interval\n removal of sternal wires and placement of a chest wall drain. Cardiac and\n mediastinal contours are stable, compared to the preoperative radiograph\n allowing for differences in technique. There has been interval development of\n a moderate size left pleural effusion, which tracks to the left apex. There\n are bibasilar atelectatic changes, left greater than right. There is also a\n probable small right pleural effusion. No pneumothorax is identified on the\n supine study.\n\n IMPRESSION:\n\n Moderate left pleural effusion tracking to the apex. Bibasilar atelectasis,\n left greater than right.\n\n\n"},{"category":"Radiology","chartdate":"2198-12-12 00:00:00.000","description":"PICC W/O PORT","row_id":853480,"text":" 7:57 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: IV team unable to place PICC, note in chart\n Admitting Diagnosis: STERNAL WOUND INFECTION\n Contrast: OPTIRAY Amt: 50\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1752 CATH,HEM/PERTI DIALYSIS SHORT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with\n REASON FOR THIS EXAMINATION:\n IV team unable to place PICC, note in chart\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: S/P CEA and CABG. Infection. Needs long term IV antibiotics.\n\n PROCEDURE/FINDINGS: The procedure is performed by Dr. and Dr. . Dr.\n , the attending radiologist, was present and supervising throughout.\n\n The left upper arm was prepped and draped in the usual sterile fashion.\n Because no suitable superficial veins were visible, ultrasound was used to\n find a suitable vein. The basilic and brachial vein were patent and\n compressible. Initially, attempts were made to access the basilic vein under\n ultrasonographic guidance with a 21 gauge needle after local anesthesia with\n 1% Lidocaine, however the vein immediately collapsed upon access. Attempt was\n then made to access the brachial vein under ultrasonographic guidance, but\n again this was unsuccessful. The patient already had an indwelling peripheral\n IV placed within the left wrist, and therefore gentle hand injection of\n contrast through the peripheral IV was performed. Under fluoroscopy, multiple\n attempts were made to access the contrast enhanced vein, however this again\n was also unsuccessful secondary to viability of the patient's veins.\n\n The right arm was then prepped and draped in the usual sterile fashion. A\n superficial cephalic vein was identified within the right arm. Under local\n anesthesia with 1% Lidocaine, the cephalic vein was accessed with a 21 gauge\n needle. Under fluorscopic guidance, 0.018 guide wire was advanced into the\n superior vena cava. Based on markers on the guide wire, it is determined that\n a length of 45 cm would be suitable. The PICC line was trimmed to length and\n advanced over a 4 French introducer sheath under fluoroscopic guidance into\n the superior vena cava. The sheath was removed and the catheter was flushed.\n A final fluoroscopic spot film demonstrated the tip to be in the superior vena\n cava. The line is ready for use. A Statlock was applied and the line was\n Heplocked.\n\n IMPRESSION: Successful placement of 45 cm total length, single lumen, right-\n sided PICC line with tip in the superior vena cava. The line is ready for\n use.\n (Over)\n\n 7:57 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: IV team unable to place PICC, note in chart\n Admitting Diagnosis: STERNAL WOUND INFECTION\n Contrast: OPTIRAY Amt: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Nursing/other","chartdate":"2198-12-08 00:00:00.000","description":"Report","row_id":1370137,"text":"NEURO: SEDATED ON PROP GTT, PEARL, MORPHINE FOR PAIN, DOES MOVE EYE LIDS TO VOCAL STIMULI BUT NO OTHER MOVEMENT NOTICED.\n\nCARDIAC: NSR IN THE HIGH 90'S TO MOSTLY ST IN THE 100-110 RANGE WITH VERY RARE PVCS, WEANED OFF NITRO GTT NOW ON NEO GTT, DOPPLERABLE PEDIAL PULSES, SKIN WARM DRY AND INTACT, + 2 EDEMA IN EXTREMITIES RUNNING LOW GRADE TEMPS.\n\nRESP: LUNGS DIM IN BASES, CT SYSTEM WITH NO AIR LEAK DRAINING VERY SCANT SERO SANG, X 4 JP DRAINS DRAINING FAIR AMOUNT OF SEROSANG, ABGS GOOD ON SIMV, RA SATS ARE 99%.\n\nSKIN: CHEST WITH DSD THAT IS CDI, CT DSD CDI JP DSDS CDI, LEFT LEG HEALING WNL'S, COCCYX AND GLUTEA AREA IS PINK WITH NO SKIN BREAKDOWN.\n\nGI/GU: NPO, OG TUBE TO LWS DRAINING SCANT BILLEOUS, HYPOACTIVE BOWEL SOUNDS, ON RISS GTT, GOOD U/O.\n\nPLAN: ? WAKE AND WEAN LATER TODAY, WEAN NEO GTT IF TOLERATES, MONITOR BLOOD SUGARS.\n"},{"category":"Nursing/other","chartdate":"2198-12-08 00:00:00.000","description":"Report","row_id":1370138,"text":"Respiratory Care\nPt was received from o.r. intubated, 7.o oral et tube taped at 19 cm mark. Bilateral breath sounds and +ETCO2 were confirmed. Vent settings on simv 650 x 14 60% +5. Plan is for quick wean and extubation later today.\n"},{"category":"Nursing/other","chartdate":"2198-12-08 00:00:00.000","description":"Report","row_id":1370139,"text":"CSRU Progress Note\nS/O: Neuro: Alert and cooperative, med with Morphine and percocet for pain.\n CV: Neo off, NTG on briefly, began metoprolol.\n Resp: Weaned and extubated. SAO2 100% on 4L. Congested cough.\n Renal: Large diuresis to lasix 20 IV. IV fluid KVO. K repleted.\n Heme: Heparin sq. Serosang drg from JPS.\n ID: Tmax 101.9, down to 100.1 after acetaminophen. Vanco, gent dose adjusted. Flagyl dcd. Blood cultures sent.\n GI: Tol cl liqs.\n Endo: Insulin infusion.\n Skin: Coccyx pink. Bed changed to atmosair mattress.\n Rehab: OOB to chair, tol well but c/o hemmorhoids. Husband in to visist.\nA: Great progress.\nP: ? 2 tomorrow. Restart preop psych meds. Await culture results. Transition to SSRI. Advance diet. Laxative/suppository/tucks. Cushion for chair.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2198-12-09 00:00:00.000","description":"Report","row_id":1370140,"text":"Neuro: alert and oriented x 3, mae, following commands correctly, percocets for pain.\n\nCardiac: nsr in the 80's, no ectopy noted, sbps run low when asleep in the mid 80's but maps above 60, sbps wnl's when awake, dopplerable pedial pulses, skin warm dry and intact, afebrile, a-line and peripheral blood cultures sent.\n\nResp: lungs dim in bases, ct system draining scant to no drainage with no air leak, on 4 liters nc satting at 97%, abgs are good, weak cough and deep breathing exersizing.\n\nSkin: chest with dsd that is cdi with mamory support on, ct dsd cdi, jp dsd are cdi, coccyx is pink in color but no breakdown, left leg is healing wnls though has some bruising.\n\nGi/Gu: tolerating po's, abd soft round and nontender, good bowel sounds, pt c/o not having a bm in several days, on riss, good u/o did switch from po lasix to iv.\n\nPlan: ? suppository on days, encourage to cough and deep breath, ? d/c ct today, increase activity as tolerates.\n"},{"category":"Nursing/other","chartdate":"2198-12-09 00:00:00.000","description":"Report","row_id":1370141,"text":"PATIENT DOING WELL THIS PM, OOB TO CHAIR FOR APPROX. 2HRS. INTALLY C/O HEMMORHOIDS TUCKS GOTTEN PLACED , DECREASED PAIN. ALSO HAS NOT MOVED BOWELS SINCE MONDAY, BISACODYL SUPP PR GIVEN REPEAT THIS AM, EATING HSE DOET WITHOUT PROBLEM, ACTUALLY GREAT APPEPITE. AFEBRILE, SR IN THE 70'S SBP 100-130, LOPRESSOR DECREASED FROM 75MG TO 25MG PO BID.. RESP ON 3L NP WITH SATS 98%. TAKING DEEP BREATHES WHEN INSTRUCTED. PLASIC IN THIS AM DID REMIVE DSG INCISION HEALING NEW DSD PLACED. GU U/O THIS PM DRIFTING DOWN LASIX 20MG IV GIVEN PLAN TO GIVE 20MEQ KCL IF STARTS TO DUIRESIS. MAG 2.0 2GMS MAGNESIUM GIVEN... PATIENT WEARS MAMMARY SUPPORT AT ALL TIMES.. BS ELEVATED GIVEN 4UREGULAR INSULIN SC GIVEN BS 176.. RECHECK AT . HUSBAND IN MOST OF THE DAY..\n"},{"category":"Nursing/other","chartdate":"2198-12-10 00:00:00.000","description":"Report","row_id":1370142,"text":"NEURO: ALERT AND ORIENTED X 3, MAE, FOLLOWING COMMANDS CORRECTLY, PERCOCETES FOR PAIN, VERY ANXIOUS AND IS ON LORAZ PO.\n\nCARDIAC: NSR WITH NO ECTOPY NOTED, SBP'S WNL'S, PALPIBLE PEDIAL PULSES, SKIN WARM DRY AND INTACT, +2 EDEMA IN EXTREMITIES, AFEBRILE.\n\nRESP: LUNGS DIM IN BASES, ON 3 LITERS NC SATTING AT 97%, IS COUGHING AND DEEP BREATHING AND USING I/S.\n\nSKIN: CHEST WITH DSD THAT IS CDI, MAMMORY SUPPORT IS ON, JP DSDS ARE CDI, OLD CT DSD IS CDI, COCCYX IS PINK, LEFT LEG IS BRUISED AND INCISION SITES ARE CDI.\n\nGI/GU: TOLERATING PO'S, ABD IS SOFT ROUND AND OBESE, GOOD BOWEL SOUNDS, DID GET SUPPOSITOY AND RESPONED WITH X2 SMALL STOOLS, ON RISS, IS MAKING GOOD U/O.\n\nPLAN: ENCOURAGE TO COUGH AND DEEP BREATH AND TO USE I/S, MONITOR BLOOD SUGARS, CONTINUE ATIVAN PRN, INCREASE ACTIVITY AS TOLERATES.\n"},{"category":"Nursing/other","chartdate":"2198-12-10 00:00:00.000","description":"Report","row_id":1370143,"text":"NEURO ALERT ORIENTED ANXIOUS BASELINE PERSONALITY FOLLOWS ALL COMMANDS MOVES ALL EXTREMETIES\n\nC/V NSR B/P STABLE PULSES PALP\n\nRESP NC 3L SATS 99% LUNGS CLEAR NONPRODUCTIVE NO SOB OR RESP DISTRESS NOTED\n\nGU/GI TOL PO WELL TO COMMODE X1 FOR SMALL AMT LOOSE STOOL GUAIAC NEGATIVE ADEQUATE URINE OUT\n\nPLAN TRANSFER TO 2 TODAY\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2198-12-16 00:00:00.000\",\n \"description\": \"L UNILAT LOWER EXT VEINS LEFT\",\n \"row_id\": 853968,\n \"text\": \" 2:48 PM\\n UNILAT LOWER EXT VEINS LEFT Clip # \\n Reason: Eval for presence of DVT\\n Admitting Diagnosis: STERNAL WOUND INFECTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old woman s/p CAGB c/b mediastinitis; now with calf tenderness and\\n swelling of the left lower extremity.\\n REASON FOR THIS EXAMINATION:\\n Eval for presence of DVT\\n ______________________________________________________________________________\\n WET READ: AZm 3:53 PM\\n No DVT\\n L groin hematoma\\n ______________________________________________________________________________\\n FINAL REPORT *ABNORMAL!\\n INDICATION: Status post CABG with calf tenderness and swelling.\\n\\n LEFT LOWER EXTREMITY VENOUS ULTRASOUND: scale and Doppler son of\\n the left common femoral, superficial femoral and popliteal veins were\\n performed. There is normal flow, compressibility, augmentation and wave\\n forms. Intraluminal thrombus was not identified. Note is made of a large\\n left groin mixed echogenic collection likely representing a hematoma.\\n\\n IMPRESSION: No evidence of DVT. Left groin hematoma.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2198-12-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 853178,\n \"text\": \" 8:22 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: f/u pleural effusion\\n Admitting Diagnosis: STERNAL WOUND INFECTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old woman with CAD s/p CABG\\n\\n REASON FOR THIS EXAMINATION:\\n f/u pleural effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: Portable chest of with clinical indication of status\\n post coronary bypass surgery.\\n\\n COMPARISON: Made to previous study of one day earlier.\\n\\n FINDINGS:\\n\\n The patient is status post removal of sternotomy wires. A chest drain remains\\n in place in a relatively midline position. There has been removal of an\\n endotracheal tube. A vascular sheath and left-sided chest tube remain in\\n place as well as additional chest wall drains. Cardiac and mediastinal\\n contours are stable. There is a persistent moderate left pleural effusion\\n tracking to the left apex. There is improvement in the degree of left\\n retrocardiac atelectasis, but there is no significant change in the more minor\\n areas of atelectasis in the right lower lobe.\\n\\n IMPRESSION:\\n\\n Improving left lower lobe atelectasis with persistent moderate sized left\\n pleural effusion tracking to the apex.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2198-12-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 853091,\n \"text\": \" 10:00 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval CT placement/ ETT/ L pleural effusion\\n Admitting Diagnosis: STERNAL WOUND INFECTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old woman with CAD s/p CABG\\n\\n REASON FOR THIS EXAMINATION:\\n eval CT placement/ ETT/ L pleural effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n Portable chest, compared previous study of .\\n\\n CLINICAL INDICATION: Status post coronary bypass surgery.\\n\\n FINDINGS:\\n\\n An endotracheal tube, central venous catheter, nasogastric tube, and\\n left-sided chest tube are in satisfactory position. There has been interval\\n removal of sternal wires and placement of a chest wall drain. Cardiac and\\n mediastinal contours are stable, compared to the preoperative radiograph\\n allowing for differences in technique. There has been interval development of\\n a moderate size left pleural effusion, which tracks to the left apex. There\\n are bibasilar atelectatic changes, left greater than right. There is also a\\n probable small right pleural effusion. No pneumothorax is identified on the\\n supine study.\\n\\n IMPRESSION:\\n\\n Moderate left pleural effusion tracking to the apex. Bibasilar atelectasis,\\n left greater than right.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2198-12-12 00:00:00.000\",\n \"description\": \"PICC W/O PORT\",\n \"row_id\": 853480,\n \"text\": \" 7:57 AM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: IV team unable to place PICC, note in chart\\n Admitting Diagnosis: STERNAL WOUND INFECTION\\n Contrast: OPTIRAY Amt: 50\\n ********************************* CPT Codes ********************************\\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\\n * C1752 CATH,HEM/PERTI DIALYSIS SHORT *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old woman with\\n REASON FOR THIS EXAMINATION:\\n IV team unable to place PICC, note in chart\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: S/P CEA and CABG. Infection. Needs long term IV antibiotics.\\n\\n PROCEDURE/FINDINGS: The procedure is performed by Dr. and Dr. . Dr.\\n , the attending radiologist, was present and supervising throughout.\\n\\n The left upper arm was prepped and draped in the usual sterile fashion.\\n Because no suitable superficial veins were visible, ultrasound was used to\\n find a suitable vein. The basilic and brachial vein were patent and\\n compressible. Initially, attempts were made to access the basilic vein under\\n ultrasonographic guidance with a 21 gauge needle after local anesthesia with\\n 1% Lidocaine, however the vein immediately collapsed upon access. Attempt was\\n then made to access the brachial vein under ultrasonographic guidance, but\\n again this was unsuccessful. The patient already had an indwelling peripheral\\n IV placed within the left wrist, and therefore gentle hand injection of\\n contrast through the peripheral IV was performed. Under fluoroscopy, multiple\\n attempts were made to access the contrast enhanced vein, however this again\\n was also unsuccessful secondary to viability of the patient's veins.\\n\\n The right arm was then prepped and draped in the usual sterile fashion. A\\n superficial cephalic vein was identified within the right arm. Under local\\n anesthesia with 1% Lidocaine, the cephalic vein was accessed with a 21 gauge\\n needle. Under fluorscopic guidance, 0.018 guide wire was advanced into the\\n superior vena cava. Based on markers on the guide wire, it is determined that\\n a length of 45 cm would be suitable. The PICC line was trimmed to length and\\n advanced over a 4 French introducer sheath under fluoroscopic guidance into\\n the superior vena cava. The sheath was removed and the catheter was flushed.\\n A final fluoroscopic spot film demonstrated the tip to be in the superior vena\\n cava. The line is ready for use. A Statlock was applied and the line was\\n Heplocked.\\n\\n IMPRESSION: Successful placement of 45 cm total length, single lumen, right-\\n sided PICC line with tip in the superior vena cava. The line is ready for\\n use.\\n (Over)\\n\\n 7:57 AM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: IV team unable to place PICC, note in chart\\n Admitting Diagnosis: STERNAL WOUND INFECTION\\n Contrast: OPTIRAY Amt: 50\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2198-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370137,\n \"text\": \"NEURO: SEDATED ON PROP GTT, PEARL, MORPHINE FOR PAIN, DOES MOVE EYE LIDS TO VOCAL STIMULI BUT NO OTHER MOVEMENT NOTICED.\\n\\nCARDIAC: NSR IN THE HIGH 90'S TO MOSTLY ST IN THE 100-110 RANGE WITH VERY RARE PVCS, WEANED OFF NITRO GTT NOW ON NEO GTT, DOPPLERABLE PEDIAL PULSES, SKIN WARM DRY AND INTACT, + 2 EDEMA IN EXTREMITIES RUNNING LOW GRADE TEMPS.\\n\\nRESP: LUNGS DIM IN BASES, CT SYSTEM WITH NO AIR LEAK DRAINING VERY SCANT SERO SANG, X 4 JP DRAINS DRAINING FAIR AMOUNT OF SEROSANG, ABGS GOOD ON SIMV, RA SATS ARE 99%.\\n\\nSKIN: CHEST WITH DSD THAT IS CDI, CT DSD CDI JP DSDS CDI, LEFT LEG HEALING WNL'S, COCCYX AND GLUTEA AREA IS PINK WITH NO SKIN BREAKDOWN.\\n\\nGI/GU: NPO, OG TUBE TO LWS DRAINING SCANT BILLEOUS, HYPOACTIVE BOWEL SOUNDS, ON RISS GTT, GOOD U/O.\\n\\nPLAN: ? WAKE AND WEAN LATER TODAY, WEAN NEO GTT IF TOLERATES, MONITOR BLOOD SUGARS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2198-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370138,\n \"text\": \"Respiratory Care\\nPt was received from o.r. intubated, 7.o oral et tube taped at 19 cm mark. Bilateral breath sounds and +ETCO2 were confirmed. Vent settings on simv 650 x 14 60% +5. Plan is for quick wean and extubation later today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2198-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370139,\n \"text\": \"CSRU Progress Note\\nS/O: Neuro: Alert and cooperative, med with Morphine and percocet for pain.\\n CV: Neo off, NTG on briefly, began metoprolol.\\n Resp: Weaned and extubated. SAO2 100% on 4L. Congested cough.\\n Renal: Large diuresis to lasix 20 IV. IV fluid KVO. K repleted.\\n Heme: Heparin sq. Serosang drg from JPS.\\n ID: Tmax 101.9, down to 100.1 after acetaminophen. Vanco, gent dose adjusted. Flagyl dcd. Blood cultures sent.\\n GI: Tol cl liqs.\\n Endo: Insulin infusion.\\n Skin: Coccyx pink. Bed changed to atmosair mattress.\\n Rehab: OOB to chair, tol well but c/o hemmorhoids. Husband in to visist.\\nA: Great progress.\\nP: ? 2 tomorrow. Restart preop psych meds. Await culture results. Transition to SSRI. Advance diet. Laxative/suppository/tucks. Cushion for chair.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2198-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370140,\n \"text\": \"Neuro: alert and oriented x 3, mae, following commands correctly, percocets for pain.\\n\\nCardiac: nsr in the 80's, no ectopy noted, sbps run low when asleep in the mid 80's but maps above 60, sbps wnl's when awake, dopplerable pedial pulses, skin warm dry and intact, afebrile, a-line and peripheral blood cultures sent.\\n\\nResp: lungs dim in bases, ct system draining scant to no drainage with no air leak, on 4 liters nc satting at 97%, abgs are good, weak cough and deep breathing exersizing.\\n\\nSkin: chest with dsd that is cdi with mamory support on, ct dsd cdi, jp dsd are cdi, coccyx is pink in color but no breakdown, left leg is healing wnls though has some bruising.\\n\\nGi/Gu: tolerating po's, abd soft round and nontender, good bowel sounds, pt c/o not having a bm in several days, on riss, good u/o did switch from po lasix to iv.\\n\\nPlan: ? suppository on days, encourage to cough and deep breath, ? d/c ct today, increase activity as tolerates.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2198-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370141,\n \"text\": \"PATIENT DOING WELL THIS PM, OOB TO CHAIR FOR APPROX. 2HRS. INTALLY C/O HEMMORHOIDS TUCKS GOTTEN PLACED , DECREASED PAIN. ALSO HAS NOT MOVED BOWELS SINCE MONDAY, BISACODYL SUPP PR GIVEN REPEAT THIS AM, EATING HSE DOET WITHOUT PROBLEM, ACTUALLY GREAT APPEPITE. AFEBRILE, SR IN THE 70'S SBP 100-130, LOPRESSOR DECREASED FROM 75MG TO 25MG PO BID.. RESP ON 3L NP WITH SATS 98%. TAKING DEEP BREATHES WHEN INSTRUCTED. PLASIC IN THIS AM DID REMIVE DSG INCISION HEALING NEW DSD PLACED. GU U/O THIS PM DRIFTING DOWN LASIX 20MG IV GIVEN PLAN TO GIVE 20MEQ KCL IF STARTS TO DUIRESIS. MAG 2.0 2GMS MAGNESIUM GIVEN... PATIENT WEARS MAMMARY SUPPORT AT ALL TIMES.. BS ELEVATED GIVEN 4UREGULAR INSULIN SC GIVEN BS 176.. RECHECK AT . HUSBAND IN MOST OF THE DAY..\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2198-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370142,\n \"text\": \"NEURO: ALERT AND ORIENTED X 3, MAE, FOLLOWING COMMANDS CORRECTLY, PERCOCETES FOR PAIN, VERY ANXIOUS AND IS ON LORAZ PO.\\n\\nCARDIAC: NSR WITH NO ECTOPY NOTED, SBP'S WNL'S, PALPIBLE PEDIAL PULSES, SKIN WARM DRY AND INTACT, +2 EDEMA IN EXTREMITIES, AFEBRILE.\\n\\nRESP: LUNGS DIM IN BASES, ON 3 LITERS NC SATTING AT 97%, IS COUGHING AND DEEP BREATHING AND USING I/S.\\n\\nSKIN: CHEST WITH DSD THAT IS CDI, MAMMORY SUPPORT IS ON, JP DSDS ARE CDI, OLD CT DSD IS CDI, COCCYX IS PINK, LEFT LEG IS BRUISED AND INCISION SITES ARE CDI.\\n\\nGI/GU: TOLERATING PO'S, ABD IS SOFT ROUND AND OBESE, GOOD BOWEL SOUNDS, DID GET SUPPOSITOY AND RESPONED WITH X2 SMALL STOOLS, ON RISS, IS MAKING GOOD U/O.\\n\\nPLAN: ENCOURAGE TO COUGH AND DEEP BREATH AND TO USE I/S, MONITOR BLOOD SUGARS, CONTINUE ATIVAN PRN, INCREASE ACTIVITY AS TOLERATES.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2198-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370143,\n \"text\": \"NEURO ALERT ORIENTED ANXIOUS BASELINE PERSONALITY FOLLOWS ALL COMMANDS MOVES ALL EXTREMETIES\\n\\nC/V NSR B/P STABLE PULSES PALP\\n\\nRESP NC 3L SATS 99% LUNGS CLEAR NONPRODUCTIVE NO SOB OR RESP DISTRESS NOTED\\n\\nGU/GI TOL PO WELL TO COMMODE X1 FOR SMALL AMT LOOSE STOOL GUAIAC NEGATIVE ADEQUATE URINE OUT\\n\\nPLAN TRANSFER TO 2 TODAY\\n\"\n }\n]"}}},{"rowIdx":24666,"cells":{"subject_id":{"kind":"number","value":22938,"string":"22,938"},"hadm_id":{"kind":"number","value":121789,"string":"121,789"},"target_text":{"kind":"string","value":"1. Pancreatitis - Following admission to the Medical Intensive Care Unit the patient required modest volume resuscitation as she was briefly hemoconcentrated. On hospital day #3 her amylase and lipase dropped precipitously consistent with her previous presentation of transient pancreatitis. Since stones had not been identified in her gallbladder it was suspected that her pancreatitis was due to medications or other nonstone causes. In reviewing her medication list, it was decided to ultimately withhold her Atorvastatin as her cholesterol panel was well within the normal range and this is a medication known to cause pancreatitis, however, Ursodeoxycholic, a medication not listed above, in her outpatient medication that she was discharged with on her last presentation and this medication may have to be withheld in the future as may Furosemide. 2. Gastrointestinal bleeding - Serial evaluations of her hemoglobin and hematocrit showed a stable vascular supply. She received Proton pump inhibitor and it was decided to withhold Clopidogrel indefinitely owing to her gastrointestinal bleeding. 3. Coronary artery disease - Following admission to the Medical Intensive Care Unit serial evaluation of her cardiac markers supported evidence of myocardial infarction, medical management was pursued exclusively. Clopidogrel was held indefinitely. Metoprolol was added to her regimen and Lisinopril was ultimately restarted. Atorvastatin was discontinued as described above. 4. Hypothyroidism - Her TSH was slightly elevated on admission, however, interval evaluation of her free Levothyroxine showed it to be normal. There were no changes made to her outpatient regimen. 5. Diabetes - A modest sliding scale of subcutaneous insulin was administered. Her Sulfonylurea was withheld while she was in the hospital. She achieved good glycemic control throughout. The remainder of the hospital course was significant for one episode of flash pulmonary edema for which she received Furosemide, Nitroglycerin and nonmechanical ventilation as she and her daughter had stated previously that she does not wish to have mechanical ventilation during this hospitalization. Her daughter reiterated her mother's desire to have a Do-Not-Resuscitate, Do-Not-Intubate order written. Once her pancreatitis resolved and her cardiac issues were stabilized she was transferred to the Medical Floor for further titration of her medication. , M.D. Dictated By: MEDQUIST36 D: 19:30 T: 20:07 JOB#: "},"extractive_notes_summ":{"kind":"string","value":"BECAME HYPOTENSIVE AND NTG D/C'ED. EKG DONE. foley gravity uop q.s after lasix.integ skin intact. b.s clear except one episode of wheezing. Sinus rhythmRight bundle branch blockAcute inferior infarctSince last ECG, no significant change 2+ peripheral edema, 1+PPP bilat, reciving 1L LR over 2hrs. Given po dulcolax x1. Sinus rhythmRight bundle branch blockOld inferior infarctLow QRS voltages in precordial leadsSince last ECG, no significant change denies any pain.cv/resp nsr bbb occ pvcs noted. CPK, trop. bp stable. Since theprevious tracing of further ST-T wave changes with ST segmentelevations are now present.TRACING #1 Denies pain at presentCV: Telemetry Sr c PVC's, HR 80's, BP 130's-150's/80's-90's, KCL given as above, dose changed from IV to po d/t pt c/o of burning to infusion sites.Resp: Lungs clear bilat, o2@ 2 L NC, sat 97-100%, pt de-sats slowly with removal of o2 into high 80's, SOB with exertion noted.GI: BS + X 4 quad., hypoactive, abd soft, NGT removed at 1500 intact, green bilious drainage noticed in wall sx cannister. elevated and EKG shows ST elevation, will only tx medically, metoprolol and captopril started today. NOTED TO BE IN PACED RYTHYM FOR A SHORT PERIOD.NEURO: SLEPT AFTER PREVIOUS EPISODE, BUT AWAKE AND ALERT NOW.ENDOC: BS'S COVERED WITH SSI. MSICU NPN 0700-1900see careview for further details..A&O x3. Apetite gd. o2 sats wnl opn 4lnp. OF ISCHEMIA. Placed back on 4l nc. Low precordial lead voltage.Inferior/anterolateral myocardial infarction with ST-T wave configurationsuggest acute process. Since the previoustracing of no significant change.TRACING #2 O2sats adequate on NC. Sinus rhythm. Sinus rhythm. PT. HEMODYNAMICALLY STABLE OVERNOC W/O CARDIAC SYMPTOMS. Sinus rhythm, few paced beatsRight bundle branch blockInferior infarctLow QRS voltages in precordial leadsSince previous tracing, right bundle branch block is new Inferior (and question lateral)myocardial infarction, age indeterminate but slight ST segment elevationsuggest possible acute process. Gd wt bearing during transfer. Pt amb through today tolerated well with mild SOB on exertion, returned quickly to baseline with rest. Since theprevious tracing of paced rhythm is absent. Inferior/anterolateral myocardialinfarction with ST-T wave configuration suggesting acute process. Tol well. is now dnr/ after MD discussed with daughter. NPN 1900 - 0700NEURO : AXOXO3 , POOR SHORT TERM MEMORY, ABLE TO REORIENT EASILY.MOVES TO CHAIR W/ ASSIST OF ONE.RESP: MILD EXP WHEEZES, SATS 96-99% ON 2 LITERS.C/V: SR OCC PVC'S, RECIEVED ONE UNIT OF PRBC OVER NOC FOR HCT OF 28.8. Right bundle-branch block. Right bundle-branch block. Right bundle-branch block. AfebrileREsp: Lungs clear A&P chest, 02 Sat 99-100% on O2 at 2L NC, RR 16-20 non labored.GI: Abd soft hypoactive BS's, NPO at present, NGT to LCS with scant bld tinged drg. liquids well. for decreased UO. ECG Taken without magnetSinusPremature ventricular contractionsRight bundle branch blockOld inferior infarctLow QRS voltages in precordial leadsSince last ECG, no significant change Nursing Admission Note 1630-1900See Nursing Admission Assessment for details surrounding Admission.Neuro: Pt A&Ox3, calm and cooperative. RR ~ 20, REG, NONLABORED AT REST. O2 changed over to 100% NRB. Pt conversing appropriately. SYMPTOMS IMPROVED WITH DIURESIS. PT with stated hx of ALzeihmer's dz, no real evidence of dz. No c/o nausea or pain today, NGT removed pt tolerating clr. Pt with good response to lasix, and all other symptoms resolving. 2 PIV's. GIVEN MORPHINE IVP AND NTG PASTE AND CONSEQUENTLY IV NGT. PM HCT 31%. call out to floor if pt. Denies nausea at present although tx'd repeatedly in ER with Zofran.GU: FOley draining marginal amts of clear concentrated urine. stable. Approx. uop low at this time rx with 20 mg ivp lasix with good effect.gi/gu npo ngtube to lcs. P-MICU NPN 7p-7aSystems Review:Events:: Pt initially was comfortable, offering no complaints. Given 20mEQ of Kcl po for K 3.4. neuro. ECG Taken with magnetRegular A-V sequential pacingPacemaker rhythm - no further analysisSince previous tracing, paced rhythm with magnet Able to stand with one assist. ? Pt much improved and more comfortable within 30minutes. Recieving bolus as not above.SKIN: no breakdown noted, PIV X 2Social: PT's daughter with her, all questions answered, pt has DNR form in chart,however is only DNI at this point. PM FS 200, 4U REG INSULIN GIVEN. AM HCT 34.6.BP STABLE.F/E/N: UO 30-40CC/HR NO ABD C/O ABD SOFT.TOL REG(KOSHER) DIET,NO STOOLS OVERNOC.PLAN: C/O TO FLOOR OOB-chair x3.5hrs. Gait steady. Pt was unable to move bowels, and was noted to be slightly more tachypnic. NGT removed, pt started on clear liquid diet, no nausea, no vomiting, may advance diet as tolerated, Amylase down from 1315 to 490,Gu: Foley cath intact draining cl yellow urine, > 30 cc/hr.Skin: dry and intact. Clinical correlation is suggested. Clinical correlation is suggested. MICU resident into evaluate pt, order obtained for 20mg IVP lasix, 1\" NTP followed by an additional 1\" and 2mg IVP MSO4 administered, followed by 1mg IV. BP 130-140's/80-90's, had episodes of hypotn in the ER. NO S/ OF GIB NOTED. SATS IN HIGH 90'S ON 4 LITERS NC. Very supportive of patient. UO ~40cc/hr. moves well in the bed.pt. NO NEW CHANGES. Settled in bed, but resp status was becoming increasingly labored, audible exp wheezing, hypertensive, decreasing O2 Sats, increasing aggitation. Plan to transfer to medical bed when available. DIURESED WITH IMPROVEMENT OF PULM STATUS.GI: ICECREAM ALLOWED THIS AFTERNOON.RENAL: EXCELLENT DIURESIS FROM LASIX DOSE.CV: HYPERTENSIVE WITH THIS EPISODE OF CHF. Dgt and/or son in all day. bilious out 100cc .no stools. NTP wiped off sometime later as SBP fell to 100. am labs pending correction: ngt drained 300cc as marked in the i+o. WENT TO SLEEP AROUND 11 PM. Atrial paced rhythm. Denies pain at presentCV: Telemetry SR c BBB, HR 70-80's, hx of pacemaker for Bradycardia, no evidence of pacing on monitor. DTR FED PT IN EVENING. NPN (NOC): PT HAD A VERY GOOD NIGHT. Assisted BTB, but required more assistance. in to visit from L.A.. Plan ? Started on Iron supplement today for low Ferritin levels.Neuro: A&Ox3 talkative, hard of hearing, at times answers inappropriately d/t hearing defecit."},"n_notes":{"kind":"number","value":17,"string":"17"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2168-12-07 00:00:00.000","description":"Report","row_id":1562279,"text":"Nursing Admission Note 1630-1900\nSee Nursing Admission Assessment for details surrounding Admission.\n\nNeuro: Pt A&Ox3, calm and cooperative. PT with stated hx of ALzeihmer's dz, no real evidence of dz. Pt conversing appropriately. Denies pain at present\n\nCV: Telemetry SR c BBB, HR 70-80's, hx of pacemaker for Bradycardia, no evidence of pacing on monitor. BP 130-140's/80-90's, had episodes of hypotn in the ER. 2+ peripheral edema, 1+PPP bilat, reciving 1L LR over 2hrs. for decreased UO. Afebrile\n\nREsp: Lungs clear A&P chest, 02 Sat 99-100% on O2 at 2L NC, RR 16-20 non labored.\n\nGI: Abd soft hypoactive BS's, NPO at present, NGT to LCS with scant bld tinged drg. Denies nausea at present although tx'd repeatedly in ER with Zofran.\n\nGU: FOley draining marginal amts of clear concentrated urine. Recieving bolus as not above.\n\nSKIN: no breakdown noted, PIV X 2\n\nSocial: PT's daughter with her, all questions answered, pt has DNR form in chart,however is only DNI at this point. Code status needs to be clarified.\n\nPlan: Monitor I&o's, Bp's, continue to discuss plan of care with daughter.\n"},{"category":"Nursing/other","chartdate":"2168-12-08 00:00:00.000","description":"Report","row_id":1562280,"text":"neuro. Alert and oriented. denies any pain.\ncv/resp nsr bbb occ pvcs noted. bp stable. o2 sats wnl opn 4lnp. b.s clear except one episode of wheezing. uop low at this time rx with 20 mg ivp lasix with good effect.\ngi/gu npo ngtube to lcs. bilious out 100cc .no stools. foley gravity uop q.s after lasix.\ninteg skin intact. moves well in the bed.\npt. is now dnr/ after MD discussed with daughter. in to visit from L.A.. Plan ? call out to floor if pt. stable. am labs pending\n"},{"category":"Nursing/other","chartdate":"2168-12-08 00:00:00.000","description":"Report","row_id":1562281,"text":"correction: ngt drained 300cc as marked in the i+o.\n"},{"category":"Nursing/other","chartdate":"2168-12-08 00:00:00.000","description":"Report","row_id":1562282,"text":"NPN 0700-1900\nGeneral: Pt Talkative and alert today, son and daughter in room all day interacting with pt. No c/o nausea or pain today, NGT removed pt tolerating clr. liquids well. CPK, trop. elevated and EKG shows ST elevation, will only tx medically, metoprolol and captopril started today. Given 20mEQ of Kcl po for K 3.4. Pt amb through today tolerated well with mild SOB on exertion, returned quickly to baseline with rest. Started on Iron supplement today for low Ferritin levels.\n\nNeuro: A&Ox3 talkative, hard of hearing, at times answers inappropriately d/t hearing defecit. Amb today down to next room, gait unsteady, needs 2 person assist, able to assist nurse in turning self in bed. Denies pain at present\n\nCV: Telemetry Sr c PVC's, HR 80's, BP 130's-150's/80's-90's, KCL given as above, dose changed from IV to po d/t pt c/o of burning to infusion sites.\n\nResp: Lungs clear bilat, o2@ 2 L NC, sat 97-100%, pt de-sats slowly with removal of o2 into high 80's, SOB with exertion noted.\n\nGI: BS + X 4 quad., hypoactive, abd soft, NGT removed at 1500 intact, green bilious drainage noticed in wall sx cannister. NGT removed, pt started on clear liquid diet, no nausea, no vomiting, may advance diet as tolerated, Amylase down from 1315 to 490,\n\nGu: Foley cath intact draining cl yellow urine, > 30 cc/hr.\n\nSkin: dry and intact. 2 PIV's. PT sitting up in chair presently\n\nSocial: Cont to keep daughter and son informed of pt care.\n\nPlan: Continue to monitor I/O's, labs, repeat K, monitor sat's and cardiac status. PT is called out to floor awaiting bed.\n"},{"category":"Nursing/other","chartdate":"2168-12-09 00:00:00.000","description":"Report","row_id":1562283,"text":"NPN 1900 - 0700\n\nNEURO : AXOXO3 , POOR SHORT TERM MEMORY, ABLE TO REORIENT EASILY.MOVES TO CHAIR W/ ASSIST OF ONE.\n\nRESP: MILD EXP WHEEZES, SATS 96-99% ON 2 LITERS.\n\nC/V: SR OCC PVC'S, RECIEVED ONE UNIT OF PRBC OVER NOC FOR HCT OF 28.8. AM HCT 34.6.BP STABLE.\n\nF/E/N: UO 30-40CC/HR NO ABD C/O ABD SOFT.TOL REG(KOSHER) DIET,NO STOOLS OVERNOC.\n\nPLAN: C/O TO FLOOR\n\n"},{"category":"Nursing/other","chartdate":"2168-12-09 00:00:00.000","description":"Report","row_id":1562284,"text":"RESP: CRACKLES AND EXP WHEEZES THIS AM, AFTER CHOKING ON JELLO. BECAME SOB WITH LOW SATS. DIURESED WITH IMPROVEMENT OF PULM STATUS.\nGI: ICECREAM ALLOWED THIS AFTERNOON.\nRENAL: EXCELLENT DIURESIS FROM LASIX DOSE.\nCV: HYPERTENSIVE WITH THIS EPISODE OF CHF. ? OF ISCHEMIA. EKG DONE. NO NEW CHANGES. GIVEN MORPHINE IVP AND NTG PASTE AND CONSEQUENTLY IV NGT. SYMPTOMS IMPROVED WITH DIURESIS. BECAME HYPOTENSIVE AND NTG D/C'ED. PT. NOTED TO BE IN PACED RYTHYM FOR A SHORT PERIOD.\nNEURO: SLEPT AFTER PREVIOUS EPISODE, BUT AWAKE AND ALERT NOW.\nENDOC: BS'S COVERED WITH SSI.\n\n"},{"category":"Nursing/other","chartdate":"2168-12-10 00:00:00.000","description":"Report","row_id":1562285,"text":"NPN (NOC): PT HAD A VERY GOOD NIGHT. WENT TO SLEEP AROUND 11 PM. HER DTR HAS SPENT THE NIGHT. RR ~ 20, REG, NONLABORED AT REST. SATS IN HIGH 90'S ON 4 LITERS NC. I&O'S - 500 CC'S AT MN. HEMODYNAMICALLY STABLE OVERNOC W/O CARDIAC SYMPTOMS. DTR FED PT IN EVENING. PM FS 200, 4U REG INSULIN GIVEN. PM HCT 31%. NO S/ OF GIB NOTED.\n"},{"category":"Nursing/other","chartdate":"2168-12-10 00:00:00.000","description":"Report","row_id":1562286,"text":"MSICU NPN 0700-1900\nsee careview for further details..\n\n\nA&O x3. No c/o. Apetite gd. O2sats adequate on NC. UO ~40cc/hr. OOB-chair x3.5hrs. Gd wt bearing during transfer. Tol well. Dgt and/or son in all day. Very supportive of patient. Given po dulcolax x1. No BM as of yet. Plan to transfer to medical bed when available.\n"},{"category":"Nursing/other","chartdate":"2168-12-11 00:00:00.000","description":"Report","row_id":1562287,"text":"P-MICU NPN 7p-7a\nSystems Review:\n\nEvents:: Pt initially was comfortable, offering no complaints. Approx. 8:30pm, pt requested to go to toilet in room. Able to stand with one assist. Gait steady. Pt was unable to move bowels, and was noted to be slightly more tachypnic. Assisted BTB, but required more assistance. Settled in bed, but resp status was becoming increasingly labored, audible exp wheezing, hypertensive, decreasing O2 Sats, increasing aggitation. MICU resident into evaluate pt, order obtained for 20mg IVP lasix, 1\" NTP followed by an additional 1\" and 2mg IVP MSO4 administered, followed by 1mg IV. O2 changed over to 100% NRB. Pt with good response to lasix, and all other symptoms resolving. Pt much improved and more comfortable within 30minutes. NTP wiped off sometime later as SBP fell to 100. Placed back on 4l nc. Daughter in staying with pt for night, pt resting comfortably remainder of shift.\n\nEndo: 12am FS 304 (this was rechecked), 8u reg insulin administered, will be checked again with am labs.\n\n\n"},{"category":"ECG","chartdate":"2168-12-13 00:00:00.000","description":"Report","row_id":302224,"text":"Sinus rhythm\nRight bundle branch block\nAcute inferior infarct\nSince last ECG, no significant change\n\n"},{"category":"ECG","chartdate":"2168-12-06 00:00:00.000","description":"Report","row_id":302231,"text":"Sinus rhythm. Right bundle-branch block. Inferior/anterolateral myocardial\ninfarction with ST-T wave configuration suggesting acute process. Since the\nprevious tracing of further ST-T wave changes with ST segment\nelevations are now present.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2168-12-12 00:00:00.000","description":"Report","row_id":302225,"text":"Sinus rhythm. Right bundle-branch block. Inferior (and question lateral)\nmyocardial infarction, age indeterminate but slight ST segment elevation\nsuggest possible acute process. Clinical correlation is suggested. Since the\nprevious tracing of paced rhythm is absent.\n\n"},{"category":"ECG","chartdate":"2168-12-08 00:00:00.000","description":"Report","row_id":302226,"text":"ECG Taken with magnet\nRegular A-V sequential pacing\nPacemaker rhythm - no further analysis\nSince previous tracing, paced rhythm with magnet\n\n"},{"category":"ECG","chartdate":"2168-12-08 00:00:00.000","description":"Report","row_id":302227,"text":"ECG Taken without magnet\nSinus\nPremature ventricular contractions\nRight bundle branch block\nOld inferior infarct\nLow QRS voltages in precordial leads\nSince last ECG, no significant change\n\n"},{"category":"ECG","chartdate":"2168-12-07 00:00:00.000","description":"Report","row_id":302228,"text":"Sinus rhythm\nRight bundle branch block\nOld inferior infarct\nLow QRS voltages in precordial leads\nSince last ECG, no significant change\n\n"},{"category":"ECG","chartdate":"2168-12-07 00:00:00.000","description":"Report","row_id":302229,"text":"Sinus rhythm, few paced beats\nRight bundle branch block\nInferior infarct\nLow QRS voltages in precordial leads\nSince previous tracing, right bundle branch block is new\n\n\n"},{"category":"ECG","chartdate":"2168-12-07 00:00:00.000","description":"Report","row_id":302230,"text":"Atrial paced rhythm. Right bundle-branch block. Low precordial lead voltage.\nInferior/anterolateral myocardial infarction with ST-T wave configuration\nsuggest acute process. Clinical correlation is suggested. Since the previous\ntracing of no significant change.\nTRACING #2\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2168-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1562279,\n \"text\": \"Nursing Admission Note 1630-1900\\nSee Nursing Admission Assessment for details surrounding Admission.\\n\\nNeuro: Pt A&Ox3, calm and cooperative. PT with stated hx of ALzeihmer's dz, no real evidence of dz. Pt conversing appropriately. Denies pain at present\\n\\nCV: Telemetry SR c BBB, HR 70-80's, hx of pacemaker for Bradycardia, no evidence of pacing on monitor. BP 130-140's/80-90's, had episodes of hypotn in the ER. 2+ peripheral edema, 1+PPP bilat, reciving 1L LR over 2hrs. for decreased UO. Afebrile\\n\\nREsp: Lungs clear A&P chest, 02 Sat 99-100% on O2 at 2L NC, RR 16-20 non labored.\\n\\nGI: Abd soft hypoactive BS's, NPO at present, NGT to LCS with scant bld tinged drg. Denies nausea at present although tx'd repeatedly in ER with Zofran.\\n\\nGU: FOley draining marginal amts of clear concentrated urine. Recieving bolus as not above.\\n\\nSKIN: no breakdown noted, PIV X 2\\n\\nSocial: PT's daughter with her, all questions answered, pt has DNR form in chart,however is only DNI at this point. Code status needs to be clarified.\\n\\nPlan: Monitor I&o's, Bp's, continue to discuss plan of care with daughter.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2168-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1562280,\n \"text\": \"neuro. Alert and oriented. denies any pain.\\ncv/resp nsr bbb occ pvcs noted. bp stable. o2 sats wnl opn 4lnp. b.s clear except one episode of wheezing. uop low at this time rx with 20 mg ivp lasix with good effect.\\ngi/gu npo ngtube to lcs. bilious out 100cc .no stools. foley gravity uop q.s after lasix.\\ninteg skin intact. moves well in the bed.\\npt. is now dnr/ after MD discussed with daughter. in to visit from L.A.. Plan ? call out to floor if pt. stable. am labs pending\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2168-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1562281,\n \"text\": \"correction: ngt drained 300cc as marked in the i+o.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2168-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1562282,\n \"text\": \"NPN 0700-1900\\nGeneral: Pt Talkative and alert today, son and daughter in room all day interacting with pt. No c/o nausea or pain today, NGT removed pt tolerating clr. liquids well. CPK, trop. elevated and EKG shows ST elevation, will only tx medically, metoprolol and captopril started today. Given 20mEQ of Kcl po for K 3.4. Pt amb through today tolerated well with mild SOB on exertion, returned quickly to baseline with rest. Started on Iron supplement today for low Ferritin levels.\\n\\nNeuro: A&Ox3 talkative, hard of hearing, at times answers inappropriately d/t hearing defecit. Amb today down to next room, gait unsteady, needs 2 person assist, able to assist nurse in turning self in bed. Denies pain at present\\n\\nCV: Telemetry Sr c PVC's, HR 80's, BP 130's-150's/80's-90's, KCL given as above, dose changed from IV to po d/t pt c/o of burning to infusion sites.\\n\\nResp: Lungs clear bilat, o2@ 2 L NC, sat 97-100%, pt de-sats slowly with removal of o2 into high 80's, SOB with exertion noted.\\n\\nGI: BS + X 4 quad., hypoactive, abd soft, NGT removed at 1500 intact, green bilious drainage noticed in wall sx cannister. NGT removed, pt started on clear liquid diet, no nausea, no vomiting, may advance diet as tolerated, Amylase down from 1315 to 490,\\n\\nGu: Foley cath intact draining cl yellow urine, > 30 cc/hr.\\n\\nSkin: dry and intact. 2 PIV's. PT sitting up in chair presently\\n\\nSocial: Cont to keep daughter and son informed of pt care.\\n\\nPlan: Continue to monitor I/O's, labs, repeat K, monitor sat's and cardiac status. PT is called out to floor awaiting bed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2168-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1562283,\n \"text\": \"NPN 1900 - 0700\\n\\nNEURO : AXOXO3 , POOR SHORT TERM MEMORY, ABLE TO REORIENT EASILY.MOVES TO CHAIR W/ ASSIST OF ONE.\\n\\nRESP: MILD EXP WHEEZES, SATS 96-99% ON 2 LITERS.\\n\\nC/V: SR OCC PVC'S, RECIEVED ONE UNIT OF PRBC OVER NOC FOR HCT OF 28.8. AM HCT 34.6.BP STABLE.\\n\\nF/E/N: UO 30-40CC/HR NO ABD C/O ABD SOFT.TOL REG(KOSHER) DIET,NO STOOLS OVERNOC.\\n\\nPLAN: C/O TO FLOOR\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2168-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1562284,\n \"text\": \"RESP: CRACKLES AND EXP WHEEZES THIS AM, AFTER CHOKING ON JELLO. BECAME SOB WITH LOW SATS. DIURESED WITH IMPROVEMENT OF PULM STATUS.\\nGI: ICECREAM ALLOWED THIS AFTERNOON.\\nRENAL: EXCELLENT DIURESIS FROM LASIX DOSE.\\nCV: HYPERTENSIVE WITH THIS EPISODE OF CHF. ? OF ISCHEMIA. EKG DONE. NO NEW CHANGES. GIVEN MORPHINE IVP AND NTG PASTE AND CONSEQUENTLY IV NGT. SYMPTOMS IMPROVED WITH DIURESIS. BECAME HYPOTENSIVE AND NTG D/C'ED. PT. NOTED TO BE IN PACED RYTHYM FOR A SHORT PERIOD.\\nNEURO: SLEPT AFTER PREVIOUS EPISODE, BUT AWAKE AND ALERT NOW.\\nENDOC: BS'S COVERED WITH SSI.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2168-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1562285,\n \"text\": \"NPN (NOC): PT HAD A VERY GOOD NIGHT. WENT TO SLEEP AROUND 11 PM. HER DTR HAS SPENT THE NIGHT. RR ~ 20, REG, NONLABORED AT REST. SATS IN HIGH 90'S ON 4 LITERS NC. I&O'S - 500 CC'S AT MN. HEMODYNAMICALLY STABLE OVERNOC W/O CARDIAC SYMPTOMS. DTR FED PT IN EVENING. PM FS 200, 4U REG INSULIN GIVEN. PM HCT 31%. NO S/ OF GIB NOTED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2168-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1562286,\n \"text\": \"MSICU NPN 0700-1900\\nsee careview for further details..\\n\\n\\nA&O x3. No c/o. Apetite gd. O2sats adequate on NC. UO ~40cc/hr. OOB-chair x3.5hrs. Gd wt bearing during transfer. Tol well. Dgt and/or son in all day. Very supportive of patient. Given po dulcolax x1. No BM as of yet. Plan to transfer to medical bed when available.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2168-12-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1562287,\n \"text\": \"P-MICU NPN 7p-7a\\nSystems Review:\\n\\nEvents:: Pt initially was comfortable, offering no complaints. Approx. 8:30pm, pt requested to go to toilet in room. Able to stand with one assist. Gait steady. Pt was unable to move bowels, and was noted to be slightly more tachypnic. Assisted BTB, but required more assistance. Settled in bed, but resp status was becoming increasingly labored, audible exp wheezing, hypertensive, decreasing O2 Sats, increasing aggitation. MICU resident into evaluate pt, order obtained for 20mg IVP lasix, 1\\\" NTP followed by an additional 1\\\" and 2mg IVP MSO4 administered, followed by 1mg IV. O2 changed over to 100% NRB. Pt with good response to lasix, and all other symptoms resolving. Pt much improved and more comfortable within 30minutes. NTP wiped off sometime later as SBP fell to 100. Placed back on 4l nc. Daughter in staying with pt for night, pt resting comfortably remainder of shift.\\n\\nEndo: 12am FS 304 (this was rechecked), 8u reg insulin administered, will be checked again with am labs.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2168-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 302224,\n \"text\": \"Sinus rhythm\\nRight bundle branch block\\nAcute inferior infarct\\nSince last ECG, no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2168-12-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 302231,\n \"text\": \"Sinus rhythm. Right bundle-branch block. Inferior/anterolateral myocardial\\ninfarction with ST-T wave configuration suggesting acute process. Since the\\nprevious tracing of further ST-T wave changes with ST segment\\nelevations are now present.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2168-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 302225,\n \"text\": \"Sinus rhythm. Right bundle-branch block. Inferior (and question lateral)\\nmyocardial infarction, age indeterminate but slight ST segment elevation\\nsuggest possible acute process. Clinical correlation is suggested. Since the\\nprevious tracing of paced rhythm is absent.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2168-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 302226,\n \"text\": \"ECG Taken with magnet\\nRegular A-V sequential pacing\\nPacemaker rhythm - no further analysis\\nSince previous tracing, paced rhythm with magnet\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2168-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 302227,\n \"text\": \"ECG Taken without magnet\\nSinus\\nPremature ventricular contractions\\nRight bundle branch block\\nOld inferior infarct\\nLow QRS voltages in precordial leads\\nSince last ECG, no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2168-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 302228,\n \"text\": \"Sinus rhythm\\nRight bundle branch block\\nOld inferior infarct\\nLow QRS voltages in precordial leads\\nSince last ECG, no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2168-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 302229,\n \"text\": \"Sinus rhythm, few paced beats\\nRight bundle branch block\\nInferior infarct\\nLow QRS voltages in precordial leads\\nSince previous tracing, right bundle branch block is new\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2168-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 302230,\n \"text\": \"Atrial paced rhythm. Right bundle-branch block. Low precordial lead voltage.\\nInferior/anterolateral myocardial infarction with ST-T wave configuration\\nsuggest acute process. Clinical correlation is suggested. Since the previous\\ntracing of no significant change.\\nTRACING #2\\n\\n\"\n }\n]"}}},{"rowIdx":24667,"cells":{"subject_id":{"kind":"number","value":98273,"string":"98,273"},"hadm_id":{"kind":"number","value":109068,"string":"109,068"},"target_text":{"kind":"string","value":"83 year old female with h/o mild Alzheimer's disease, CEA in 05, HTN, elev lipids, bladder CA, who presents as a transfer from OSH with unresponsive with fixed dilated pupils, decerebrating postering and very extensive R intra cranial hemorrhage on CT, with significant shift and uncal herniation; deemed non-operable by neurosurgery and incompatible with survival. Patient was made CMO by family and expired the following day."},"extractive_notes_summ":{"kind":"string","value":"Visualized portions of the paranasal sinuses demonstrate partial opacification of the ethmoid air cells. Hemorrhage extends inferiorly into the fourth ventricle. Lungs are clear, except for a linear opacities in both lung bases, likely atelectasis. Large shift of midline structures to the right of 23 mm with subfalcine herniation and likely uncal herniation. Hemorrhage extends into the ventricles bilaterally and inferiorly into the fourth ventricle with associated obstructive hydrocephalus. There is associated obstructive hydrocephalus. Hemorrhage extends into the ventricles bilaterally with layering hemorrhage seen within the occipital horns bilaterally. Aortic arch calcifications are noted. There is significant shift of midline structures to the right of 23 mm consistent with subfalcine herniation. IMPRESSION: Appropriate position of endotracheal tube. FINDINGS: A massive intraparenchymal hemorrhage is seen centered around within the left hemisphere with significant shift of midline structures to the right measuring up to 23 mm. Chief complaint: Intracranial hemorrhage PMHx: -h/o CVA/TIA in past -HTN -h/o syncope -elev lipids -bladder CA -s/p CEA in -h/o MI -Myelodysplastic Syndrome Current medications: Morphine gtt 24 Hour Events: Allergies: Statins-Hmg-Coa Reductase Inhibitors Unknown; Last dose of Antibiotics: Infusions: Morphine Sulfate - 6 mg/hour Other ICU medications: Other medications: Flowsheet Data as of 09:00 PM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since a.m. Tmax: 34.2C (93.5 T current: 34.2C (93.5 HR: 45 (44 - 51) bpm BP: 179/55(87) {179/55(87) - 179/55(93)} mmHg RR: 18 (18 - 20) insp/min SPO2: 100% Heart rhythm: SB (Sinus Bradycardia) Total In: 5 mL PO: Tube feeding: IV Fluid: 5 mL Blood products: Total out: 0 mL 150 mL Urine: 125 mL NG: 25 mL Stool: Drains: Balance: 0 mL -145 mL Respiratory support O2 Delivery Device: None Ventilator mode: CPAP/PSV Vt (Spontaneous): 343 (343 - 343) mL RR (Spontaneous): 19 PEEP: 5 cmH2O FiO2: 100% PIP: 11 cmH2O SPO2: 100% ABG: //// Ve: 7.3 L/min Physical Examination General Appearance: No acute distress HEENT: Left pupil dilated Cardiovascular: (Rhythm: Regular), bradycardic Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA bilateral : ) Abdominal: Soft, Non-distended, Non-tender Left Extremities: (Edema: Absent) Right Extremities: (Edema: Absent) Neurologic: Sedated Labs / Radiology [image002.jpg] Assessment and Plan Assessment and Plan: Patient is an 83 year old female with h/o dementia, CVA in past, bladderCA, MDS who presents as a transfer from OSH with unresponsiveness, blown pupil and large intracranial hemorrhage on CT. Pt does not want to pursue drastic measure and would like to pt to be DNR with comfort measures only."},"n_notes":{"kind":"number","value":5,"string":"5"},"notes":{"kind":"list like","value":[{"category":"Physician ","chartdate":"2139-09-13 00:00:00.000","description":"Intensivist Note","row_id":480826,"text":"SICU\n HPI:\n 83 year old female with h/o mild Alzheimer's disease,\n CEA in 05, HTN, elev lipids, bladder CA, who\n presents as a transfer from OSH with unresponsiveness, blown pupil,\n decerebrating postering and very extensive L intra cranial hemorrhage\n on CT, with significant shift and uncal herniation. Patient is\n currently intubated and was made CMO by family.\n Chief complaint:\n Intracranial hemorrhage\n PMHx:\n -h/o CVA/TIA in past\n -HTN\n -h/o syncope\n -elev lipids\n -bladder CA\n -s/p CEA in \n -h/o MI\n -Myelodysplastic Syndrome\n Current medications:\n Morphine gtt\n 24 Hour Events:\n Allergies:\n Statins-Hmg-Coa Reductase Inhibitors\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Morphine Sulfate - 6 mg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 09:00 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 34.2\nC (93.5\n T current: 34.2\nC (93.5\n HR: 45 (44 - 51) bpm\n BP: 179/55(87) {179/55(87) - 179/55(93)} mmHg\n RR: 18 (18 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 5 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 125 mL\n NG:\n 25 mL\n Stool:\n Drains:\n Balance:\n 0 mL\n -145 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 343 (343 - 343) mL\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 7.3 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: Left pupil dilated\n Cardiovascular: (Rhythm: Regular), bradycardic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Sedated\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Assessment and Plan: Patient is an 83 year old female with h/o\n dementia, CVA in past, bladderCA, MDS who presents as a transfer from\n OSH with unresponsiveness, blown pupil and large intracranial\n hemorrhage\n on CT. Pt does not want to pursue drastic measure and would like to pt\n to be DNR with comfort measures only.\n Neurologic: Morphine gtt for sedation/pain control\n Cardiovascular: none\n Pulmonary: Extubate today, Family wishes pt to be extubated\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO\n Renal: Foley\n Hematology: none\n Endocrine: none\n Infectious Disease: none\n Lines / Tubes / Drains: Foley, OGT\n Wounds: none\n Imaging: none\n Fluids: none\n Consults: Neurology\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:44 PM\n Prophylaxis:\n DVT: none\n Stress ulcer: none\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Comfort measures only\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2139-09-14 00:00:00.000","description":"Nursing Progress Note","row_id":480827,"text":"Intracerebral hemorrhage (ICH)\n Assessment:\n Pt admitted from the ED intubated, unresponsive on Propofol and\n morphine drips\n Action:\n Pt made CMO status , extubated, morphine drip at 8 mg for comfort.\n Response:\n Pt appeared comfortable, family at bedside, pt expired at 2334.\n Plan:\n"},{"category":"Nursing","chartdate":"2139-09-14 00:00:00.000","description":"Nursing Progress Note","row_id":480828,"text":"Intracerebral hemorrhage (ICH)\n Assessment:\n Pt admitted from the ED intubated, unresponsive on Propofol and\n morphine drips\n Action:\n Pt made CMO status , extubated, morphine drip at 8 mg for comfort.\n Response:\n Pt appeared comfortable, family at bedside, pt expired at 2334.\n Plan:\n ------ Protected Section ------\n NEOB called and pt was declined as a donor.\n ------ Protected Section Addendum Entered By: , RN\n on: 00:29 ------\n"},{"category":"Radiology","chartdate":"2139-09-13 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1095667,"text":" 1:12 PM\n CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: ?ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with ICH on OSH CT\n REASON FOR THIS EXAMINATION:\n ?ICH\n ______________________________________________________________________________\n WET READ: JKSd SUN 1:36 PM\n Massive intraparenchymal hemorrhage throughout the entire left hemisphere\n extending into the ventricles and into the forth ventricle with associated\n obstructive hydrocephalus. Large shift of midline structures to the right of\n 23 mm with subfalcine herniation and likely uncal herniation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old woman with intracranial hemorrhage on outside\n hospital CT. Study is being submitted for second-read request.\n\n COMPARISON: None available.\n\n TECHNIQUE: Axially acquired images were obtained through the head without\n contrast.\n\n FINDINGS: A massive intraparenchymal hemorrhage is seen centered around\n within the left hemisphere with significant shift of midline structures to the\n right measuring up to 23 mm. Hemorrhage extends into the ventricles\n bilaterally with layering hemorrhage seen within the occipital horns\n bilaterally. Exact center of the left hemispheric hemorrhage is difficult to\n assess but probably is located around the left basal ganglia. Hemorrhage\n extends inferiorly into the fourth ventricle. There is associated obstructive\n hydrocephalus. There is associated swelling of the left hemisphere with loss\n of sulci.\n\n No fractures are identified. Visualized portions of the paranasal sinuses\n demonstrate partial opacification of the ethmoid air cells. The mastoid air\n cells are clear.\n\n IMPRESSION: Massive intraparenchymal hemorrhage centered in the left\n hemisphere extending to the vertex. Hemorrhage extends into the ventricles\n bilaterally and inferiorly into the fourth ventricle with associated\n obstructive hydrocephalus. There is significant shift of midline structures\n to the right of 23 mm consistent with subfalcine herniation. There is likely\n uncal herniation also.\n\n Findings were posted to the ED dashboard shortly after review on .\n\n"},{"category":"Radiology","chartdate":"2139-09-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1095664,"text":" 12:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman intubated for ICH\n REASON FOR THIS EXAMINATION:\n ?tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old woman intubated for intracranial hemorrhage.\n\n COMPARISON: None.\n\n SINGLE SUPINE VIEW OF THE CHEST: An endotracheal tube terminates\n approximately 3 cm above the carina. A nasogastric tube extends into the\n stomach, with the side port well below the GE junction. An underlying trauma\n board partially obscures evaluation.\n\n Lungs are clear, except for a linear opacities in both lung bases, likely\n atelectasis. There is no pleural effusion or pneumothorax. The\n cardiomediastinal silhouette is within normal limits. Aortic arch\n calcifications are noted. Pulmonary vascularity is normal.\n\n IMPRESSION: Appropriate position of endotracheal tube. Bibasilar atelectasis.\n\n DFDdp\n\n"}],"string":"[\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2139-09-13 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 480826,\n \"text\": \"SICU\\n HPI:\\n 83 year old female with h/o mild Alzheimer's disease,\\n CEA in 05, HTN, elev lipids, bladder CA, who\\n presents as a transfer from OSH with unresponsiveness, blown pupil,\\n decerebrating postering and very extensive L intra cranial hemorrhage\\n on CT, with significant shift and uncal herniation. Patient is\\n currently intubated and was made CMO by family.\\n Chief complaint:\\n Intracranial hemorrhage\\n PMHx:\\n -h/o CVA/TIA in past\\n -HTN\\n -h/o syncope\\n -elev lipids\\n -bladder CA\\n -s/p CEA in \\n -h/o MI\\n -Myelodysplastic Syndrome\\n Current medications:\\n Morphine gtt\\n 24 Hour Events:\\n Allergies:\\n Statins-Hmg-Coa Reductase Inhibitors\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Morphine Sulfate - 6 mg/hour\\n Other ICU medications:\\n Other medications:\\n Flowsheet Data as of 09:00 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 34.2\\nC (93.5\\n T current: 34.2\\nC (93.5\\n HR: 45 (44 - 51) bpm\\n BP: 179/55(87) {179/55(87) - 179/55(93)} mmHg\\n RR: 18 (18 - 20) insp/min\\n SPO2: 100%\\n Heart rhythm: SB (Sinus Bradycardia)\\n Total In:\\n 5 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 5 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 150 mL\\n Urine:\\n 125 mL\\n NG:\\n 25 mL\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -145 mL\\n Respiratory support\\n O2 Delivery Device: None\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 343 (343 - 343) mL\\n RR (Spontaneous): 19\\n PEEP: 5 cmH2O\\n FiO2: 100%\\n PIP: 11 cmH2O\\n SPO2: 100%\\n ABG: ////\\n Ve: 7.3 L/min\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: Left pupil dilated\\n Cardiovascular: (Rhythm: Regular), bradycardic\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender\\n Left Extremities: (Edema: Absent)\\n Right Extremities: (Edema: Absent)\\n Neurologic: Sedated\\n Labs / Radiology\\n [image002.jpg]\\n Assessment and Plan\\n Assessment and Plan: Patient is an 83 year old female with h/o\\n dementia, CVA in past, bladderCA, MDS who presents as a transfer from\\n OSH with unresponsiveness, blown pupil and large intracranial\\n hemorrhage\\n on CT. Pt does not want to pursue drastic measure and would like to pt\\n to be DNR with comfort measures only.\\n Neurologic: Morphine gtt for sedation/pain control\\n Cardiovascular: none\\n Pulmonary: Extubate today, Family wishes pt to be extubated\\n Gastrointestinal / Abdomen: NPO\\n Nutrition: NPO\\n Renal: Foley\\n Hematology: none\\n Endocrine: none\\n Infectious Disease: none\\n Lines / Tubes / Drains: Foley, OGT\\n Wounds: none\\n Imaging: none\\n Fluids: none\\n Consults: Neurology\\n Billing Diagnosis: (Hemorrhage, NOS)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 08:44 PM\\n Prophylaxis:\\n DVT: none\\n Stress ulcer: none\\n VAP bundle:\\n Comments:\\n Communication: Comments:\\n Code status: Comfort measures only\\n Disposition: ICU\\n Total time spent:\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2139-09-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 480827,\n \"text\": \"Intracerebral hemorrhage (ICH)\\n Assessment:\\n Pt admitted from the ED intubated, unresponsive on Propofol and\\n morphine drips\\n Action:\\n Pt made CMO status , extubated, morphine drip at 8 mg for comfort.\\n Response:\\n Pt appeared comfortable, family at bedside, pt expired at 2334.\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2139-09-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 480828,\n \"text\": \"Intracerebral hemorrhage (ICH)\\n Assessment:\\n Pt admitted from the ED intubated, unresponsive on Propofol and\\n morphine drips\\n Action:\\n Pt made CMO status , extubated, morphine drip at 8 mg for comfort.\\n Response:\\n Pt appeared comfortable, family at bedside, pt expired at 2334.\\n Plan:\\n ------ Protected Section ------\\n NEOB called and pt was declined as a donor.\\n ------ Protected Section Addendum Entered By: , RN\\n on: 00:29 ------\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-09-13 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1095667,\n \"text\": \" 1:12 PM\\n CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \\n Reason: ?ICH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 83 year old woman with ICH on OSH CT\\n REASON FOR THIS EXAMINATION:\\n ?ICH\\n ______________________________________________________________________________\\n WET READ: JKSd SUN 1:36 PM\\n Massive intraparenchymal hemorrhage throughout the entire left hemisphere\\n extending into the ventricles and into the forth ventricle with associated\\n obstructive hydrocephalus. Large shift of midline structures to the right of\\n 23 mm with subfalcine herniation and likely uncal herniation.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 83-year-old woman with intracranial hemorrhage on outside\\n hospital CT. Study is being submitted for second-read request.\\n\\n COMPARISON: None available.\\n\\n TECHNIQUE: Axially acquired images were obtained through the head without\\n contrast.\\n\\n FINDINGS: A massive intraparenchymal hemorrhage is seen centered around\\n within the left hemisphere with significant shift of midline structures to the\\n right measuring up to 23 mm. Hemorrhage extends into the ventricles\\n bilaterally with layering hemorrhage seen within the occipital horns\\n bilaterally. Exact center of the left hemispheric hemorrhage is difficult to\\n assess but probably is located around the left basal ganglia. Hemorrhage\\n extends inferiorly into the fourth ventricle. There is associated obstructive\\n hydrocephalus. There is associated swelling of the left hemisphere with loss\\n of sulci.\\n\\n No fractures are identified. Visualized portions of the paranasal sinuses\\n demonstrate partial opacification of the ethmoid air cells. The mastoid air\\n cells are clear.\\n\\n IMPRESSION: Massive intraparenchymal hemorrhage centered in the left\\n hemisphere extending to the vertex. Hemorrhage extends into the ventricles\\n bilaterally and inferiorly into the fourth ventricle with associated\\n obstructive hydrocephalus. There is significant shift of midline structures\\n to the right of 23 mm consistent with subfalcine herniation. There is likely\\n uncal herniation also.\\n\\n Findings were posted to the ED dashboard shortly after review on .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-09-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1095664,\n \"text\": \" 12:34 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?tube placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 83 year old woman intubated for ICH\\n REASON FOR THIS EXAMINATION:\\n ?tube placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 83-year-old woman intubated for intracranial hemorrhage.\\n\\n COMPARISON: None.\\n\\n SINGLE SUPINE VIEW OF THE CHEST: An endotracheal tube terminates\\n approximately 3 cm above the carina. A nasogastric tube extends into the\\n stomach, with the side port well below the GE junction. An underlying trauma\\n board partially obscures evaluation.\\n\\n Lungs are clear, except for a linear opacities in both lung bases, likely\\n atelectasis. There is no pleural effusion or pneumothorax. The\\n cardiomediastinal silhouette is within normal limits. Aortic arch\\n calcifications are noted. Pulmonary vascularity is normal.\\n\\n IMPRESSION: Appropriate position of endotracheal tube. Bibasilar atelectasis.\\n\\n DFDdp\\n\\n\"\n }\n]"}}},{"rowIdx":24668,"cells":{"subject_id":{"kind":"number","value":73454,"string":"73,454"},"hadm_id":{"kind":"number","value":109469,"string":"109,469"},"target_text":{"kind":"string","value":"Pt was admitted to the Neurosurgery service, ICU for close neurological observation. He was started on dilantin for seizure prophylaxsis, and blood pressure was kept < 140 systolic. Patient was stabilized and exubated. His c-spine was cleared. Seen by plastics for facial fractures; they placed 2 sutures on nose and recommended sinus precautions with augmentin x2 weeks. Repeat head CT on revealed no interval change in hemorrhage. Patient was subsequently transfered to the floor. Throughout his hospitalization, patient was monitored for signs of EtOH withdrawal but did not require benzodiazepines. PT was consulted and patient was deemed appropriate for discharge home. A plan was put in place with social work for the patient to discharge safely to his mother's home. At the time of discharge he was tolerating a regular diet, ambulating without difficulty, afebrile with stable vital signs."},"extractive_notes_summ":{"kind":"string","value":"Sinus bradycardia. The Q-T interval is prolonged for rate."},"n_notes":{"kind":"number","value":1,"string":"1"},"notes":{"kind":"list like","value":[{"category":"ECG","chartdate":"2121-05-22 00:00:00.000","description":"Report","row_id":230410,"text":"Sinus bradycardia. The Q-T interval is prolonged for rate. No previous\ntracing available for comparison.\n\n\n"}],"string":"[\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2121-05-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 230410,\n \"text\": \"Sinus bradycardia. The Q-T interval is prolonged for rate. No previous\\ntracing available for comparison.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":24669,"cells":{"subject_id":{"kind":"number","value":28001,"string":"28,001"},"hadm_id":{"kind":"number","value":153232,"string":"153,232"},"target_text":{"kind":"string","value":"Patient is a 80 yo man with PMH of HTN, hyperlipid, h/o afib, osteoporosis, DM2, low testosterone, prostate ca s/p radiation who is transferred from with a necrotic brain lesion in the left parietal/occipital area. There is nothing on physical exam to suggest mass effect. In his Coumadin was held, and he was started on Keppra and Decadron which we have continued. He has recent diagnosis and treatment of prostate CA, however this does not metastasize to the brain parenchyma. Primary neoplasm such as GBM, less likely CNS lymphoma. He had a repeat MRI with gad. On he underwent a brain biopsy; pathology report: Anaplastic Oligoastrocytoma, grade III On he underwent a craniotomy for removal of the left parietal mass. Post operatively he spent the night in the SICU to monitor his BP he required a Nitro drip intermittently. Neurologically he was intact. He was transferred to the surgical floor on . PT saw the patient and recommended rehab; OT was also consulted and recommended short term rehab."},"extractive_notes_summ":{"kind":"string","value":"Stable-appearing vasogenic edema within the left parietal lobe. COMPARISON: MRI head dated . There is a region of relative within the edema, likely representing an underlying neoplasm. IMPRESSION: Status post biopsy of known left parietal mass with single punctate which may represent tiny post-biopsy area of blood product. Otherwise, the findings aresimilar.TRACING #1 MRI HEAD WITH CONTRAST: Enhancing peripheral mass in the left posterior parietal lobe is again demonstrated and unchanged compared to . Small amount of residual enhancement is seen immediately and inferior to the resection site. IMPRESSION: Left-sided parietal lobe 3.1 x 2.5 cm intra-axial cortical/subcortical mass with homogeneous enhancement and low ADC values. Slightly hyponatremic-received Mannitol in OR. Large confluent area of hypodensity likely representing vasogenic edema centered within the left parietal lobe is stable. A region of relative within the edema likely represents the underlying neoplasm. Left head incision covered with DSD C/D/I.On Nitro gtt at 1.0/hr for goal SBP <140.Extubated in PACU. T1 sagittal, axial and coronal images were obtained following gadolinium. Comparison is made to MRI and head CT. NON-CONTRAST HEAD CT. NON-CONTRAST HEAD CT SCAN. IMPRESSION: Status post resection of the left parietal convexity enhancing intra-axial brain lesion. No contraindications for IV contrast FINAL REPORT HISTORY: Status post left parietal lobe tumor resection. Correlation was made with the CT of . Compared totracing #2 the rhythm is now sinus with premature atrial and ventricularectopy.TRACING #3 Sinus rhythm with premature atrial and ventricular beat. FINDINGS: The patient is status post biopsy of the known left parietal brain mass single punctate may represent a focus of intraparenchymal hemorrhage. CT Head showed left parietal mass with vasogenic edema. TECHNIQUE: Multiplanar T1- post-gadolinium images were obtained including axial MP-RAGE images. Large area of vasogenic edema with a small hyperdense nodule centered in the left parietal lobe likely secondary to patient's known underlying lesion. Enhancing left parietal lesion with associated vasogenic edema. T1 sagittal and axial as well as coronal images were obtained following gadolinium. Steriotactic biopsy done . IMPRESSION: Enhancing left parietal mass without significant change compared . Following gadolinium, enhancement is seen along the medial margin of the resection site as well as inferior margin of the resection site indicating some residual enhancement. TECHNIQUE: T1 sagittal and axial and FLAIR, T2 susceptibility and diffusion axial images were obtained before gadolinium. FINDINGS: There is a 4.0 x 1.1 cm ring enhancing lesion within the left parietal lobe with associated confluent white representing vasogenic edema. There is pneumocephalus identified. IMPRESSION: Expected postoperative changes with no evidence of hemorrhage. The appearance of the head CT is otherwise unchanged with stable mild mucosal thickening within the right maxillary sinus. 7:37 PM MR HEAD W & W/O CONTRAST Clip # Reason: follow up on postop residual tumor. FINDINGS: There is an area of brain edema identified in the left parietal lobe extending from cortical to subcortical region, extending to the ventricular margin. There is moderate brain atrophy. TECHNIQUE: Non-contrast axial images of the head. REASON FOR THIS EXAMINATION: follow up on postop residual tumor. Clinical correlationis suggested. There is mild brain atrophy and mild changes of small vessel disease. Compared to tracing #3 idioventricular rhythm is nowevident. FINDINGS: Since the previous study, the patient has undergone resection of enhancing brain lesion in the left parietal convexity region. There is an area of isointense signal identified near the cortex, which demonstrate hyperintense signal on FLAIR images with low ADC values on ADC map. Second 2 mm focus of enhancement in the left frontal lobe likely may represent confluence of vessels. this si most typical of a colloid cyst. The hilar and mediastinal contours are normal. MS waxes and wanes. Foley with c/y/u. TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion axial images of the brain were acquired before gadolinium. Normal except for rate. Post extubation ABG WNL. Sinus bradycardia. Sinus bradycardia. FINDINGS: There is a large area of confluent hypodensity likely representing vasogenic edema centered within the left parietal lobe. Surrounding signal abnormality on T1-weighted images is also again demonstrated and not significantly changed. Comparison was made with the previous study of . However, given the apparent malignant neoplasm, an MR should be obtained ad the possibility entertained that the third ventricular lesion may be another malignant deposit. The remainder of the examination is unchanged. REASON FOR THIS EXAMINATION: rule out postop ICH. Compared to tracing #1idioventricular rhythm is now apparent.TRACING #2 Stable 5 mm hyperdense lesion in the foramen of , which may represent a colloid cyst versus a hemorrhagic mass and close correlation with outside hospital MR is recommended. CLINICAL INFORMATION: Patient with new brain mass. There may be a second tiny focus of enhancement in the left frontal lobe (series 2, image 37). Continue monitor.Plan: Continue neuro checks, hemodynamic monitoring, wean NTG as tolerated, follow labs, transfer back to 11 in am. There is a tiny 2-mm rounded opacity projecting over the left second anterior rib, likely represents a vessel. Clinical correlation is suggested.TRACING #4 DSD covering sutures on left half of head.POC: Repeat head CT this morning. There is mild mucosal thickening within the maxillary antra. FINDINGS: There is expected air within the left parietal surgical bed and expected postoperative pneumocephalus and adjacent subcutaneous emphysema and swelling adjacent to the high right parietal craniotomy site."},"n_notes":{"kind":"number","value":15,"string":"15"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2198-12-06 00:00:00.000","description":"CHEST (PA & LAT)","row_id":989719,"text":" 8:46 AM\n CHEST (PA & LAT) Clip # \n Reason: please do in AM.man with new brain mass\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with new brain mass\n REASON FOR THIS EXAMINATION:\n please do in AM.man with new brain mass\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: An 80-year-old male with new brain mass.\n\n CHEST, PA AND LATERAL: There are no prior studies for comparison. Heart size\n is normal. The hilar and mediastinal contours are normal. Lungs are clear.\n There is a tiny 2-mm rounded opacity projecting over the left second anterior\n rib, likely represents a vessel. No pleural effusions are seen. Fracture\n deformities of the right fourth, fifth, and sixth posterior ribs are seen. No\n pneumothorax identified.\n\n IMPRESSION: No evidence of intrathoracic malignancy.\n\n jr\n\n"},{"category":"Radiology","chartdate":"2198-12-06 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":989674,"text":" 12:11 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: shift or mass effect?\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with new brain mass.\n REASON FOR THIS EXAMINATION:\n shift or mass effect?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 80-year-old man with new brain mass.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast axial images of the head.\n\n FINDINGS: There is a large area of confluent hypodensity likely representing\n vasogenic edema centered within the left parietal lobe. There is a region of\n relative within the edema, likely representing an underlying\n neoplasm. There is regional sulcal effacement but no shift of the normally\n midline structures or significant mass effect on the left lateral ventricle.\n There is a 5-mm hyperdense focus within the third ventricle at the foramen of\n . this si most typical of a colloid cyst. However, given the\n apparent malignant neoplasm, an MR should be obtained ad the possibility\n entertained that the third ventricular lesion may be another malignant\n deposit. There is no hydrocephalus. The osseous structures are unremarkable.\n There is mild mucosal thickening within the maxillary antra.\n\n IMPRESSION:\n 1. Large area of vasogenic edema with a small hyperdense nodule centered in\n the left parietal lobe likely secondary to patient's known underlying lesion.\n\n 2. 5-mm hyperdense lesion in the foramen of likely representing a\n colloid cyst. This should be correlated with the patient's recent outside\n hospital MR to exclude hemorrhage or metastasis.\n\n Findings discussed with Dr. on .\n\n\n\n"},{"category":"Radiology","chartdate":"2198-12-08 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":990033,"text":" 5:42 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: **Please do at 5:30 am** Assess for post-op change.\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with recent stereotactic biopsy\n REASON FOR THIS EXAMINATION:\n **Please do at 5:30 am** Assess for post-op change.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old male with recent stereotactic biopsy.\n\n COMPARISON: .\n\n NON-CONTRAST HEAD CT SCAN.\n\n FINDINGS: The patient is status post biopsy of the known left parietal brain\n mass single punctate may represent a focus of intraparenchymal\n hemorrhage. Large confluent area of hypodensity likely representing vasogenic\n edema centered within the left parietal lobe is stable. A region of relative\n within the edema likely represents the underlying neoplasm. There\n is no shift of the normally midline structures. Again seen is a 5 mm\n hyperdense focus within the third ventricle at the foramen of . There is\n no hydrocephalus. There is a new burr hole in the left parietal bone.\n\n IMPRESSION: Status post biopsy of known left parietal mass with single\n punctate which may represent tiny post-biopsy area of blood\n product. No large area of hemorrhage or increase in mass effect.\n\n"},{"category":"Radiology","chartdate":"2198-12-13 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":990890,"text":" 6:39 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: rule out postop ICH. please do before 7pm .\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with s/p craniotomy for tumor resection.\n REASON FOR THIS EXAMINATION:\n rule out postop ICH. please do before 7pm .\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post left parietal lobe tumor resection. Evaluate for\n postoperative hemorrhage.\n\n Comparison is made to MRI and head CT.\n\n NON-CONTRAST HEAD CT.\n\n FINDINGS: There is expected air within the left parietal surgical bed and\n expected postoperative pneumocephalus and adjacent subcutaneous emphysema and\n swelling adjacent to the high right parietal craniotomy site. No\n postoperative intraparenchymal or extra-axial hemorrhage is identified.\n Stable-appearing vasogenic edema within the left parietal lobe. The\n appearance of the head CT is otherwise unchanged with stable mild mucosal\n thickening within the right maxillary sinus.\n\n IMPRESSION:\n\n Expected postoperative changes with no evidence of hemorrhage.\n\n\n"},{"category":"Radiology","chartdate":"2198-12-13 00:00:00.000","description":"MR HEAD W/ CONTRAST","row_id":990781,"text":" 5:39 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: pre-op for tumor resection, please do at 5:00 am on \n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man brain tumor\n REASON FOR THIS EXAMINATION:\n pre-op for tumor resection, please do at 6:00 am on , prior to OR time\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Brain tumor, preoperative for tumor resection.\n\n COMPARISON: MRI head dated .\n\n TECHNIQUE: Multiplanar T1- post-gadolinium images were obtained including\n axial MP-RAGE images.\n\n MRI HEAD WITH CONTRAST: Enhancing peripheral mass in the left posterior\n parietal lobe is again demonstrated and unchanged compared to .\n Surrounding signal abnormality on T1-weighted images is also again\n demonstrated and not significantly changed. Ventricles are stable in size. No\n other enhancing lesions within the brain are seen.\n\n IMPRESSION: Enhancing left parietal mass without significant change compared\n .\n\n\n\n"},{"category":"Radiology","chartdate":"2198-12-07 00:00:00.000","description":"CT STEREOTAXIS W/ CONTRAST","row_id":989995,"text":" 8:42 PM\n CT STEREOTAXIS W/ CONTRAST Clip # \n Reason: Pre-op scan with frame for stereotactic biopsy\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with lesion, frame in place, going for biopsy\n REASON FOR THIS EXAMINATION:\n Pre-op scan with frame for stereotactic biopsy\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with lesion with tactic biopsy.\n\n COMPARISON: .\n\n TECHNIQUE: Axial contrast-enhanced images through the head were obtained with\n overlying VTI headset.\n\n FINDINGS: There is a 4.0 x 1.1 cm ring enhancing lesion within the left\n parietal lobe with associated confluent white representing\n vasogenic edema. There may be a second tiny focus of enhancement in the left\n frontal lobe (series 2, image 37). This may represent confluence of vessels.\n Again seen is a hyperdense focus within the third ventricle of the foramen of\n . The remainder of the examination is unchanged.\n\n IMPRESSION:\n 1. Axial contrast-enhanced CT performed with overlying VTI headset for\n stereotactic biopsy.\n 2. Enhancing left parietal lesion with associated vasogenic edema. Second 2\n mm focus of enhancement in the left frontal lobe likely may represent\n confluence of vessels. Stable 5 mm hyperdense lesion in the foramen of ,\n which may represent a colloid cyst versus a hemorrhagic mass and close\n correlation with outside hospital MR is recommended.\n\n\n"},{"category":"Radiology","chartdate":"2198-12-07 00:00:00.000","description":"MR HEAD W & W/O CONTRAST","row_id":989913,"text":" 10:42 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: patient's operative course is pending MRI, he is on the sche\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with new brain mass.\n REASON FOR THIS EXAMINATION:\n patient's operative course is pending MRI, he is on the schedule for a surgery\n today and must be done asap\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE BRAIN.\n\n CLINICAL INFORMATION: Patient with new brain mass.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR, T2 susceptibility and diffusion\n axial images were obtained before gadolinium. T1 sagittal and axial as well\n as coronal images were obtained following gadolinium. Correlation was made\n with the CT of .\n\n FINDINGS: There is an area of brain edema identified in the left parietal\n lobe extending from cortical to subcortical region, extending to the\n ventricular margin. There is an area of isointense signal identified near the\n cortex, which demonstrate hyperintense signal on FLAIR images with low ADC\n values on ADC map. The findings are consistent with intra-axial brain mass\n measuring approximately 3.1 x 2.5 cm. No other abnormal areas of enhancement\n in the brain is noted. There is mild brain atrophy and mild changes of small\n vessel disease. No evidence of acute infarct seen.\n\n IMPRESSION: Left-sided parietal lobe 3.1 x 2.5 cm intra-axial\n cortical/subcortical mass with homogeneous enhancement and low ADC values.\n Although the most likely consideration is metastatic disease given patient's\n age and location, given the low ADC, other conditions such as lymphoma should\n also be considered in the differential diagnosis.\n\n\n"},{"category":"Radiology","chartdate":"2198-12-14 00:00:00.000","description":"MR HEAD W & W/O CONTRAST","row_id":991036,"text":" 7:37 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: follow up on postop residual tumor. please do before midnigh\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with s/p craniotomy for tumor resection.\n REASON FOR THIS EXAMINATION:\n follow up on postop residual tumor. please do before midnight .\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI brain.\n\n CLINICAL INFORMATION: Patient status post craniotomy for tumor resection for\n postoperative evaluation.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images of the brain were acquired before gadolinium. T1 sagittal, axial\n and coronal images were obtained following gadolinium. Comparison was made\n with the previous study of .\n\n FINDINGS: Since the previous study, the patient has undergone resection of\n enhancing brain lesion in the left parietal convexity region. Small amount of\n blood products is seen in this region with surrounding edema. Following\n gadolinium, enhancement is seen along the medial margin of the resection site\n as well as inferior margin of the resection site indicating some residual\n enhancement. There is also evidence of small area of slow diffusion seen\n adjacent to the surgical site which could be related to surgery. There is\n pneumocephalus identified. There is no midline shift or hydrocephalus seen.\n There is moderate brain atrophy.\n\n IMPRESSION: Status post resection of the left parietal convexity enhancing\n intra-axial brain lesion. Small amount of residual enhancement is seen\n immediately and inferior to the resection site. No large hematoma seen,\n midline shift or hydrocephalus identified. No change in the surrounding edema\n noted.\n\n"},{"category":"Nursing/other","chartdate":"2198-12-13 00:00:00.000","description":"Report","row_id":1628531,"text":"Nursing Admit Note\nSee Carevue for specifics\n\nPt admitted from OR at 1600 s/p left crani for tumor resection. Pt is 80 year-old male recently admitted to for unsteadiness. CT Head showed left parietal mass with vasogenic edema. Steriotactic biopsy done . Admitted to SICU post op for frequent neuro checks.\nCurrently, pt is alert, oriented to self and date. MS waxes and wanes. PERRL. Speech clear. MAE with nml strength. Denies pain. Left head incision covered with DSD C/D/I.\nOn Nitro gtt at 1.0/hr for goal SBP <140.\nExtubated in PACU. Post extubation ABG WNL. Sats 99% 2L NC. NARD.\nNPO except meds tonight.\nI.Calcium repleted. Slightly hyponatremic-received Mannitol in OR. Continue monitor.\n\nPlan: Continue neuro checks, hemodynamic monitoring, wean NTG as tolerated, follow labs, transfer back to 11 in am.\n"},{"category":"Nursing/other","chartdate":"2198-12-14 00:00:00.000","description":"Report","row_id":1628532,"text":"Please See Carevue for Specific.\n\nPt is pleasantly A+OX3, MAE, follows commands, speech is clear but occasionally has difficult with word finding. Pt c/o discomfort in head but refuses all forms of pain medication. NSR-SB, no ectopy. SBP of less than 140 maintained. Lungs are clear, O2 sat 97% on 2L NC. ABd is soft, +BSX4, no stool this shift, remains NPO. Foley with c/y/u. DSD covering sutures on left half of head.\n\nPOC: Repeat head CT this morning. Transfer back to 11 today. Continue to closely monitor neuro status, keep SBP <140, monitor pain. ?OOB to chair. Continue to offer pt and pt family emotional support throughout hospital stay.\n"},{"category":"ECG","chartdate":"2198-12-08 00:00:00.000","description":"Report","row_id":218134,"text":"Probable idioventricular rhythm with prolonged QTc interval at a rate\nof 56 beats per minute. Compared to tracing #3 idioventricular rhythm is now\nevident. QTc interval is more polonged. Clinical correlation is suggested.\nTRACING #4\n\n"},{"category":"ECG","chartdate":"2198-12-08 00:00:00.000","description":"Report","row_id":218135,"text":"Sinus rhythm with premature atrial and ventricular beat. Compared to\ntracing #2 the rhythm is now sinus with premature atrial and ventricular\nectopy.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2198-12-07 00:00:00.000","description":"Report","row_id":218136,"text":"Initially sinus bradycardia with subsequent conversion to probable accelerated\nidioventricular rhythm at a rate of 56 beats per minute. Clinical correlation\nis suggested. Borderline prolonged QTc interval. Compared to tracing #1\nidioventricular rhythm is now apparent.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2198-12-07 00:00:00.000","description":"Report","row_id":218137,"text":"Sinus bradycardia. Borderline prolonged QTc interval. Compared to prior\ntracing of the rate is slightly slower. Otherwise, the findings are\nsimilar.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2198-12-07 00:00:00.000","description":"Report","row_id":218138,"text":"Sinus bradycardia. Normal except for rate. No previous tracing available for\ncomparison.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2198-12-06 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 989719,\n \"text\": \" 8:46 AM\\n CHEST (PA & LAT) Clip # \\n Reason: please do in AM.man with new brain mass\\n Admitting Diagnosis: BRAIN MASS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man with new brain mass\\n REASON FOR THIS EXAMINATION:\\n please do in AM.man with new brain mass\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: An 80-year-old male with new brain mass.\\n\\n CHEST, PA AND LATERAL: There are no prior studies for comparison. Heart size\\n is normal. The hilar and mediastinal contours are normal. Lungs are clear.\\n There is a tiny 2-mm rounded opacity projecting over the left second anterior\\n rib, likely represents a vessel. No pleural effusions are seen. Fracture\\n deformities of the right fourth, fifth, and sixth posterior ribs are seen. No\\n pneumothorax identified.\\n\\n IMPRESSION: No evidence of intrathoracic malignancy.\\n\\n jr\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2198-12-06 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 989674,\n \"text\": \" 12:11 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: shift or mass effect?\\n Admitting Diagnosis: BRAIN MASS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man with new brain mass.\\n REASON FOR THIS EXAMINATION:\\n shift or mass effect?\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n INDICATION: 80-year-old man with new brain mass.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Non-contrast axial images of the head.\\n\\n FINDINGS: There is a large area of confluent hypodensity likely representing\\n vasogenic edema centered within the left parietal lobe. There is a region of\\n relative within the edema, likely representing an underlying\\n neoplasm. There is regional sulcal effacement but no shift of the normally\\n midline structures or significant mass effect on the left lateral ventricle.\\n There is a 5-mm hyperdense focus within the third ventricle at the foramen of\\n . this si most typical of a colloid cyst. However, given the\\n apparent malignant neoplasm, an MR should be obtained ad the possibility\\n entertained that the third ventricular lesion may be another malignant\\n deposit. There is no hydrocephalus. The osseous structures are unremarkable.\\n There is mild mucosal thickening within the maxillary antra.\\n\\n IMPRESSION:\\n 1. Large area of vasogenic edema with a small hyperdense nodule centered in\\n the left parietal lobe likely secondary to patient's known underlying lesion.\\n\\n 2. 5-mm hyperdense lesion in the foramen of likely representing a\\n colloid cyst. This should be correlated with the patient's recent outside\\n hospital MR to exclude hemorrhage or metastasis.\\n\\n Findings discussed with Dr. on .\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2198-12-08 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 990033,\n \"text\": \" 5:42 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: **Please do at 5:30 am** Assess for post-op change.\\n Admitting Diagnosis: BRAIN MASS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man with recent stereotactic biopsy\\n REASON FOR THIS EXAMINATION:\\n **Please do at 5:30 am** Assess for post-op change.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 80-year-old male with recent stereotactic biopsy.\\n\\n COMPARISON: .\\n\\n NON-CONTRAST HEAD CT SCAN.\\n\\n FINDINGS: The patient is status post biopsy of the known left parietal brain\\n mass single punctate may represent a focus of intraparenchymal\\n hemorrhage. Large confluent area of hypodensity likely representing vasogenic\\n edema centered within the left parietal lobe is stable. A region of relative\\n within the edema likely represents the underlying neoplasm. There\\n is no shift of the normally midline structures. Again seen is a 5 mm\\n hyperdense focus within the third ventricle at the foramen of . There is\\n no hydrocephalus. There is a new burr hole in the left parietal bone.\\n\\n IMPRESSION: Status post biopsy of known left parietal mass with single\\n punctate which may represent tiny post-biopsy area of blood\\n product. No large area of hemorrhage or increase in mass effect.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2198-12-13 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 990890,\n \"text\": \" 6:39 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: rule out postop ICH. please do before 7pm .\\n Admitting Diagnosis: BRAIN MASS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man with s/p craniotomy for tumor resection.\\n REASON FOR THIS EXAMINATION:\\n rule out postop ICH. please do before 7pm .\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post left parietal lobe tumor resection. Evaluate for\\n postoperative hemorrhage.\\n\\n Comparison is made to MRI and head CT.\\n\\n NON-CONTRAST HEAD CT.\\n\\n FINDINGS: There is expected air within the left parietal surgical bed and\\n expected postoperative pneumocephalus and adjacent subcutaneous emphysema and\\n swelling adjacent to the high right parietal craniotomy site. No\\n postoperative intraparenchymal or extra-axial hemorrhage is identified.\\n Stable-appearing vasogenic edema within the left parietal lobe. The\\n appearance of the head CT is otherwise unchanged with stable mild mucosal\\n thickening within the right maxillary sinus.\\n\\n IMPRESSION:\\n\\n Expected postoperative changes with no evidence of hemorrhage.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2198-12-13 00:00:00.000\",\n \"description\": \"MR HEAD W/ CONTRAST\",\n \"row_id\": 990781,\n \"text\": \" 5:39 AM\\n MR HEAD W/ CONTRAST Clip # \\n Reason: pre-op for tumor resection, please do at 5:00 am on \\n Admitting Diagnosis: BRAIN MASS\\n Contrast: MAGNEVIST Amt: 20\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man brain tumor\\n REASON FOR THIS EXAMINATION:\\n pre-op for tumor resection, please do at 6:00 am on , prior to OR time\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Brain tumor, preoperative for tumor resection.\\n\\n COMPARISON: MRI head dated .\\n\\n TECHNIQUE: Multiplanar T1- post-gadolinium images were obtained including\\n axial MP-RAGE images.\\n\\n MRI HEAD WITH CONTRAST: Enhancing peripheral mass in the left posterior\\n parietal lobe is again demonstrated and unchanged compared to .\\n Surrounding signal abnormality on T1-weighted images is also again\\n demonstrated and not significantly changed. Ventricles are stable in size. No\\n other enhancing lesions within the brain are seen.\\n\\n IMPRESSION: Enhancing left parietal mass without significant change compared\\n .\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2198-12-07 00:00:00.000\",\n \"description\": \"CT STEREOTAXIS W/ CONTRAST\",\n \"row_id\": 989995,\n \"text\": \" 8:42 PM\\n CT STEREOTAXIS W/ CONTRAST Clip # \\n Reason: Pre-op scan with frame for stereotactic biopsy\\n Admitting Diagnosis: BRAIN MASS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man with lesion, frame in place, going for biopsy\\n REASON FOR THIS EXAMINATION:\\n Pre-op scan with frame for stereotactic biopsy\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 80-year-old man with lesion with tactic biopsy.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Axial contrast-enhanced images through the head were obtained with\\n overlying VTI headset.\\n\\n FINDINGS: There is a 4.0 x 1.1 cm ring enhancing lesion within the left\\n parietal lobe with associated confluent white representing\\n vasogenic edema. There may be a second tiny focus of enhancement in the left\\n frontal lobe (series 2, image 37). This may represent confluence of vessels.\\n Again seen is a hyperdense focus within the third ventricle of the foramen of\\n . The remainder of the examination is unchanged.\\n\\n IMPRESSION:\\n 1. Axial contrast-enhanced CT performed with overlying VTI headset for\\n stereotactic biopsy.\\n 2. Enhancing left parietal lesion with associated vasogenic edema. Second 2\\n mm focus of enhancement in the left frontal lobe likely may represent\\n confluence of vessels. Stable 5 mm hyperdense lesion in the foramen of ,\\n which may represent a colloid cyst versus a hemorrhagic mass and close\\n correlation with outside hospital MR is recommended.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2198-12-07 00:00:00.000\",\n \"description\": \"MR HEAD W & W/O CONTRAST\",\n \"row_id\": 989913,\n \"text\": \" 10:42 AM\\n MR HEAD W & W/O CONTRAST Clip # \\n Reason: patient's operative course is pending MRI, he is on the sche\\n Admitting Diagnosis: BRAIN MASS\\n Contrast: MAGNEVIST Amt: 18\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man with new brain mass.\\n REASON FOR THIS EXAMINATION:\\n patient's operative course is pending MRI, he is on the schedule for a surgery\\n today and must be done asap\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n MRI OF THE BRAIN.\\n\\n CLINICAL INFORMATION: Patient with new brain mass.\\n\\n TECHNIQUE: T1 sagittal and axial and FLAIR, T2 susceptibility and diffusion\\n axial images were obtained before gadolinium. T1 sagittal and axial as well\\n as coronal images were obtained following gadolinium. Correlation was made\\n with the CT of .\\n\\n FINDINGS: There is an area of brain edema identified in the left parietal\\n lobe extending from cortical to subcortical region, extending to the\\n ventricular margin. There is an area of isointense signal identified near the\\n cortex, which demonstrate hyperintense signal on FLAIR images with low ADC\\n values on ADC map. The findings are consistent with intra-axial brain mass\\n measuring approximately 3.1 x 2.5 cm. No other abnormal areas of enhancement\\n in the brain is noted. There is mild brain atrophy and mild changes of small\\n vessel disease. No evidence of acute infarct seen.\\n\\n IMPRESSION: Left-sided parietal lobe 3.1 x 2.5 cm intra-axial\\n cortical/subcortical mass with homogeneous enhancement and low ADC values.\\n Although the most likely consideration is metastatic disease given patient's\\n age and location, given the low ADC, other conditions such as lymphoma should\\n also be considered in the differential diagnosis.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2198-12-14 00:00:00.000\",\n \"description\": \"MR HEAD W & W/O CONTRAST\",\n \"row_id\": 991036,\n \"text\": \" 7:37 PM\\n MR HEAD W & W/O CONTRAST Clip # \\n Reason: follow up on postop residual tumor. please do before midnigh\\n Admitting Diagnosis: BRAIN MASS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man with s/p craniotomy for tumor resection.\\n REASON FOR THIS EXAMINATION:\\n follow up on postop residual tumor. please do before midnight .\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAM: MRI brain.\\n\\n CLINICAL INFORMATION: Patient status post craniotomy for tumor resection for\\n postoperative evaluation.\\n\\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\\n axial images of the brain were acquired before gadolinium. T1 sagittal, axial\\n and coronal images were obtained following gadolinium. Comparison was made\\n with the previous study of .\\n\\n FINDINGS: Since the previous study, the patient has undergone resection of\\n enhancing brain lesion in the left parietal convexity region. Small amount of\\n blood products is seen in this region with surrounding edema. Following\\n gadolinium, enhancement is seen along the medial margin of the resection site\\n as well as inferior margin of the resection site indicating some residual\\n enhancement. There is also evidence of small area of slow diffusion seen\\n adjacent to the surgical site which could be related to surgery. There is\\n pneumocephalus identified. There is no midline shift or hydrocephalus seen.\\n There is moderate brain atrophy.\\n\\n IMPRESSION: Status post resection of the left parietal convexity enhancing\\n intra-axial brain lesion. Small amount of residual enhancement is seen\\n immediately and inferior to the resection site. No large hematoma seen,\\n midline shift or hydrocephalus identified. No change in the surrounding edema\\n noted.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2198-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1628531,\n \"text\": \"Nursing Admit Note\\nSee Carevue for specifics\\n\\nPt admitted from OR at 1600 s/p left crani for tumor resection. Pt is 80 year-old male recently admitted to for unsteadiness. CT Head showed left parietal mass with vasogenic edema. Steriotactic biopsy done . Admitted to SICU post op for frequent neuro checks.\\nCurrently, pt is alert, oriented to self and date. MS waxes and wanes. PERRL. Speech clear. MAE with nml strength. Denies pain. Left head incision covered with DSD C/D/I.\\nOn Nitro gtt at 1.0/hr for goal SBP <140.\\nExtubated in PACU. Post extubation ABG WNL. Sats 99% 2L NC. NARD.\\nNPO except meds tonight.\\nI.Calcium repleted. Slightly hyponatremic-received Mannitol in OR. Continue monitor.\\n\\nPlan: Continue neuro checks, hemodynamic monitoring, wean NTG as tolerated, follow labs, transfer back to 11 in am.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2198-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1628532,\n \"text\": \"Please See Carevue for Specific.\\n\\nPt is pleasantly A+OX3, MAE, follows commands, speech is clear but occasionally has difficult with word finding. Pt c/o discomfort in head but refuses all forms of pain medication. NSR-SB, no ectopy. SBP of less than 140 maintained. Lungs are clear, O2 sat 97% on 2L NC. ABd is soft, +BSX4, no stool this shift, remains NPO. Foley with c/y/u. DSD covering sutures on left half of head.\\n\\nPOC: Repeat head CT this morning. Transfer back to 11 today. Continue to closely monitor neuro status, keep SBP <140, monitor pain. ?OOB to chair. Continue to offer pt and pt family emotional support throughout hospital stay.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2198-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 218134,\n \"text\": \"Probable idioventricular rhythm with prolonged QTc interval at a rate\\nof 56 beats per minute. Compared to tracing #3 idioventricular rhythm is now\\nevident. QTc interval is more polonged. Clinical correlation is suggested.\\nTRACING #4\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2198-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 218135,\n \"text\": \"Sinus rhythm with premature atrial and ventricular beat. Compared to\\ntracing #2 the rhythm is now sinus with premature atrial and ventricular\\nectopy.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2198-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 218136,\n \"text\": \"Initially sinus bradycardia with subsequent conversion to probable accelerated\\nidioventricular rhythm at a rate of 56 beats per minute. Clinical correlation\\nis suggested. Borderline prolonged QTc interval. Compared to tracing #1\\nidioventricular rhythm is now apparent.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2198-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 218137,\n \"text\": \"Sinus bradycardia. Borderline prolonged QTc interval. Compared to prior\\ntracing of the rate is slightly slower. Otherwise, the findings are\\nsimilar.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2198-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 218138,\n \"text\": \"Sinus bradycardia. Normal except for rate. No previous tracing available for\\ncomparison.\\n\\n\"\n }\n]"}}},{"rowIdx":24670,"cells":{"subject_id":{"kind":"number","value":23253,"string":"23,253"},"hadm_id":{"kind":"number","value":105945,"string":"105,945"},"target_text":{"kind":"string","value":"Pt was transferred from OSH for NSTEMI and Cardiac Cath. 1) CAD/NSTEMI: Pt was CP free throughout her admission. Her TnT peaked at 0.11 (CK 87) and trended down. Cath on revealed LAD-50% mid; RCA-95% mid, distal filling into collaterals. The RCA was stented. The cath was complicated by arterial perforation and hematoma formation: see below. She was continued on ASA, Plavix, Lipitor, and Metoprolol. An ECHO on showed preserved systolic dysfunction but impaired relaxation. An ACE-i was not stated because of borderline BPs. She was instructed to f/u with a cardiologist or her PCP to resume this med. 2) Arterial Perf (Ext Iliac/Common Fem)/Blood Loss Anemia: As noted, cath was complicated by external iliac/common femoral perforationAfter cath, HCT was down to 29.1 and pt had SBPs to 70s-80s. Pt was transfered to ICU where she was transufed, started on IVF, and then recovered. Per 2nd angio, no continued bleeding was noted. In total she rec'd 3 units PRBC. Her HCT remained above 30 after the 3rd unit was given and her SBPs ranged from 100-120s thereafter as well. An Abd CT confirmed a retroperitoneal bleed: \"Extraperitoneal stranding extending from the right kidney into the right deep pelvis consistent with retroperitoneal hemorrhage.\" 3) UTI: Her initial UA was positive and she was started on a 3 day course of Levofloxacin 500mg q24hr. She was given Phenazopyridine for symptomatic relief of dysuria. 4) GERD: Continue Pantoprazole and Maalox prn. 5) Pneumonia: At the conclusion of her course, she had mild decr of O2 sats from baseline (90-94%RA) and a CXR was read as mild RML PNA. She was continued on Levo for an addn't 7 days. 6) Code: Full. 7) FEN: Cont'd Cards Healthy diet. 8) Dispo. DCed to home."},"extractive_notes_summ":{"kind":"string","value":"The left ventricular inflow pattern suggests impairedrelaxation.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation. Mild (1+)aortic regurgitation is seen. Mild (1+) mitralregurgitation is seen. There is mild pulmonary artery systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.PERICARDIUM: There is no pericardial effusion.Conclusions:The left atrium is normal in size. Precordial leads appear to be right-sided chest leads. There is noaortic valve stenosis. There is mild pulmonary artery systolichypertension. Patient wrm/dry, color WNL. Mild (1+) aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Left ventricular wall thicknesses arenormal. The mitral valve leaflets are mildly thickened.Mild (1+) mitral regurgitation is seen. The pulmonary vasculature is within normal limits. This appearance is consistent with a retroperitoneal hematoma. ABDOMEN CT WITHOUT IV CONTRAST: There is atelectasis at both lung bases, right greater than left. Probable inferior myocardial infarction, age indeterminate.Prolonged QTc interval. PATIENT/TEST INFORMATION:Indication: Chest pain.Height: (in) 66Weight (lb): 170BSA (m2): 1.87 m2BP (mm Hg): 100/70HR (bpm): 93Status: InpatientDate/Time: at 11:23Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. Modest diffuse non-specific lowamplitude T wave changes. There is a small right pleural effusion. Sinus rhythmPossible inferior infarct - age undeterminedPossible anterior infarct - age undeterminedLow QRS voltages in precordial leadsMinor nonspecific ST-T abnormalitiesNo previous tracing Since the previous tracingof sinus tachycardia is present.TRACING #3 Atrial premature beats. Probable inferior myocardialinfarction, age indeterminate. Compared to the previous tracing of diffuse ST-T waveabnormalities persist. Clinicalcorrelation is suggested for possible metabolic/drug effect and/or ischemia.Since the previous tracing earlier this date atrial ectopy is not seen andfurther ST-T wave abnormalities are present.TRACING #2 Probable inferiormyocardial infarction, age indeterminate. Probable inferior myocardialinfarction. Cont' of Above NotePatient's Metoprolol held this am due to hypotension. The ascending aorta is normal indiameter. The left ventricular inflow patternsuggests impaired relaxation. Diffuse non-specific ST-T wave abnormalities. There is no pneumothorax.There is eventration of the right hemidiaprhagm. The mediastinal and hilar contours are normal. Started on Neo for Low BP Pain free on arrival from cath lab. PELVIS CT WITHOUT IV CONTRAST: There is soft tisuse stranding along the retroperitoneum extending from the infrarenal position in the right side of the abdomen along the psoas muscle into the right pelvis. There is new faint opacity in the right middle lung field, most likely representing an infectious process versus focal edema. The pulmnonary vascularity is normal in appearance. The left ventricular cavity size is normal. The aortic arch is normal in diameter.AORTIC VALVE: The aortic valve leaflets are mildly thickened. (Over) 9:40 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: CATH DECREASE IN HCT AND LOWER ABD PAIN ? There is a small collection of air within the bladder, likely due to prior Foley insertion. 9:40 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: CATH DECREASE IN HCT AND LOWER ABD PAIN ? The leftventricular cavity size is normal. Low limb lead voltage isnon-specific. Angio 30min later revealed no bleed. Overall leftventricular systolic function is normal (LVEF>55%).RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter. Now with falling Hct and lower abd pain. Cannot rule out myocardial ischemia or metabolic/drugeffect. The heart size is within normal limits. BLEED Admitting Diagnosis: UNSTABLE ANGINA FINAL REPORT (Cont) Afebrile.GI/GU: Abdomen soft and tender to palpation. Nosignificant ST segment elevation is seen. retroperitoneal bleed. Diffuse ST-T wve abnormalities. TECHNIQUE: PA and lateral chest radiographs. No deficits.CV: Was on Neo 0.58 mcg.kg/min on arrival to MICU. have cardiac diet today. Taking clear fluid overnight. IMPRESSION: New faint opacity in the right middle lung field, most likely representing a early pneumonia. Borderline left axis deviation. Borderline left axis deviation. The stomach, small bowel, and large bowel appear normal, without dilatation or wall thickening. Bandaids intact on bilateral groin from intervention site. Low QRS voltage. Did not do a whole lot but patient is not symptomatic with lower BP. REASON FOR THIS EXAMINATION: ?Bleed No contraindications for IV contrast FINAL REPORT INDICATION: 69 y/o woman status post catheterization complicated by right external iliac artery perforation, now with falling hematocrit and lower abdominal pain. Due to suboptimaltechnical quality, a focal wall motion abnormality cannot be fully excluded.Overall left ventricular systolic function is normal (LVEF>55%). The lungs are clear without focal consolidation or pleural effusions. It has been off since o0500 and has maintained BP. Sinus tachycardia. Dose decreased to 12.5mg and new parameters written, see med sheets. TECHNIQUE: Helical axial images of the abdomen and pelvis were obtained without oral and without intravenous contrast. FINDINGS: The heart is normal in size. Has been afebrile. Sinus rhythm. Sinus rhythm. Sinus rhythm. Had bilateral grion sites, no bruits,no hematoma or bleeding, pedal pulses strong. Has been Stable overnight.Neuro: Orientated x 3 spheres. Rightventricular chamber size and free wall motion are normal. Since the previoustracing earlier this date atrial ectopy is seen.TRACING #1 QTc interval appears to be prolonged but isdifficult to measure. received morphine 1 mg x2 for this and got some relief. The mediastinal and hilar contours are unremarkable. Sats 93-94%,Lungs clear.GU: Foley in till o430 when she requested it removed, Ambulated to commode and voided 200ml at 0500."},"n_notes":{"kind":"number","value":12,"string":"12"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2119-08-02 00:00:00.000","description":"Report","row_id":1566101,"text":"Admission/Progress Note: -0700\n\nPatient arrived from yesterday morning for Cardiac cath. She came to them with chest and jaw pain, ruled in for MI and tranferred here for intervention.\nPost PTCA and Stent of RCA complicated by dissection of Right Illiac artery and ? retroperitoneal bleed. Had acute abdominal pain and HCT drop to 25 which she received 2 units blood in cath lab. Started on Neo for Low BP Pain free on arrival from cath lab. Bilateral groin sites had no bleeding, no hematoma and no bruits were auscultated. Pedal pulses present. Has been Stable overnight.\n\nNeuro: Orientated x 3 spheres. No deficits.\n\nCV: Was on Neo 0.58 mcg.kg/min on arrival to MICU. Slowly weaned overnight and BP was maintained with MAP >65. It has been off since o0500 and has maintained BP. See careVue for details on weaning and BP. Had bilateral grion sites, no bruits,no hematoma or bleeding, pedal pulses strong. Has been afebrile. No complaints of chest or jaw pain. Remains in NSR all night. Held Beta blocker due to hypotension.\n\nResp: Weaned O2 overnight to 1L NC from 4L. Sats 93-94%,Lungs clear.\n\nGU: Foley in till o430 when she requested it removed, Ambulated to commode and voided 200ml at 0500. On levo for UTI. Received NS 500ml bolus at o230 to to support BP while neo was weaning. Did not do a whole lot but patient is not symptomatic with lower BP. (normally 120's). Resident aware of this. He wanted Neo off as soon as possible. Encouraged to drink.\n\nGI: Patient's abdomen painful on palpation secondary to bleed. received morphine 1 mg x2 for this and got some relief. Taking clear fluid overnight. have cardiac diet today. BS present\n\nLabs pending, drawn at 0445.\nCan be called out to floor\n\n , RN\n\n"},{"category":"Nursing/other","chartdate":"2119-08-02 00:00:00.000","description":"Report","row_id":1566103,"text":"Cont' of Above Note\nPatient's Metoprolol held this am due to hypotension. Neo gtt D/C and off since 0500. Dose decreased to 12.5mg and new parameters written, see med sheets.\n"},{"category":"Nursing/other","chartdate":"2119-08-02 00:00:00.000","description":"Report","row_id":1566102,"text":"Shift Note\nCV: HR 90's NSR with elevations 100-110 with activity. BP runs low, but stable 85-100/50-70's with MAP >65. Patient wrm/dry, color WNL. Bandaids intact on bilateral groin from intervention site. No hematoma, brusing or bruit noted. Dorsal/pedal pulses palpable. Peripheral 20guage right forearm and left hand.\n\nResp: RR teens-20's, easy and regular. RA sats 94%, lungs clear in upper lobes with fine crackles in posterior lower bases.\n\nNeuro: Intact and A&O x3. Afebrile.\n\nGI/GU: Abdomen soft and tender to palpation. Patient c/o \"pressure pain\" and morphine 1mg given at 1230. Pain still consistent 3 at rest and 8 with activity. Patient on levo for treatment of UTI and MD notified. Pyridium ordered and 1st dose given 1600. Patient voiding at BSC without assistance. Low cholesterol, low sodium diet and tolerating well.\n\nID: UTI, on levo\n\nSocial: Family present at bedside this afternoon. Patient called out and to be transferred.\n"},{"category":"Radiology","chartdate":"2119-08-03 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":836400,"text":" 9:40 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: CATH DECREASE IN HCT AND LOWER ABD PAIN ? BLEED\n Admitting Diagnosis: UNSTABLE ANGINA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with cath complicated by R external illiac perf. Angio\n 30min later revealed no bleed. Now with falling Hct and lower abd pain.\n REASON FOR THIS EXAMINATION:\n ?Bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69 y/o woman status post catheterization complicated by right\n external iliac artery perforation, now with falling hematocrit and lower\n abdominal pain.\n\n TECHNIQUE: Helical axial images of the abdomen and pelvis were obtained\n without oral and without intravenous contrast.\n\n ABDOMEN CT WITHOUT IV CONTRAST: There is atelectasis at both lung bases,\n right greater than left. There is a small right pleural effusion. The liver\n is unremarkable. There is vicarious excretion of contrast within the\n gallbladder, consistent with prior catheterization procedure. The pancreas,\n spleen, adrenal glands, and kidneys are unremarkable. The stomach, small\n bowel, and large bowel appear normal, without dilatation or wall thickening.\n\n PELVIS CT WITHOUT IV CONTRAST: There is soft tisuse stranding along the\n retroperitoneum extending from the infrarenal position in the right side of\n the abdomen along the psoas muscle into the right pelvis. There is extensive\n soft tissue stranding in the right deep pelvis and along the midline, slightly\n displacing the bladder to the left. This appearance is consistent with a\n retroperitoneal hematoma. No intraperitoneal free fluid is present. Given\n the lack of intravenous contrast, the integrity of the vessels cannot be\n assessed.\n\n The rectum and uterus are unremarkable. There is a small collection of air\n within the bladder, likely due to prior Foley insertion.\n\n The osseous structures are unremarkable.\n\n IMPRESSION:\n\n Extraperitoneal stranding extending from the right kidney into the right deep\n pelvis consistent with retroperitoneal hemorrhage. There are no prior exams\n with which to compare the size and extent of the hematoma. Given the lack of\n intravenous contrast, vessel integrity cannot be assessed. If clinically\n warranted, a pelvic CTA can be performed.\n\n (Over)\n\n 9:40 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: CATH DECREASE IN HCT AND LOWER ABD PAIN ? BLEED\n Admitting Diagnosis: UNSTABLE ANGINA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2119-08-03 00:00:00.000","description":"CHEST (PA & LAT)","row_id":836431,"text":" 1:46 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o infection, CHF\n Admitting Diagnosis: UNSTABLE ANGINA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with STEMI s/p retro bleed and now with O2 requirement upon\n ambulation.\n REASON FOR THIS EXAMINATION:\n r/o infection, CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 69-year-old woman with MI, status post retroperitoneal bleed,\n now with oxygen requirement. Evaluation for infection and CHF.\n\n TECHNIQUE: PA and lateral chest radiographs. Comparison is made with the\n previous chest radiograph dated .\n\n FINDINGS: The heart is normal in size. The mediastinal and hilar contours\n are normal.\n\n There is new faint opacity in the right middle lung field, most likely\n representing an infectious process versus focal edema.\n\n The pulmonary vasculature is within normal limits. There is no effusion.\n\n IMPRESSION: New faint opacity in the right middle lung field, most likely\n representing a early pneumonia.\n\n\n"},{"category":"Radiology","chartdate":"2119-08-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":836138,"text":" 4:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: chest pain eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with chest pain, ekg changes.\n REASON FOR THIS EXAMINATION:\n chest pain eval\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 69-year-old woman with chest pain.\n\n COMPARISON: None. See AP upright portable chest radiography. The heart size\n is within normal limits. The mediastinal and hilar contours are unremarkable.\n The pulmnonary vascularity is normal in appearance. The lungs are clear\n without focal consolidation or pleural effusions. There is no\n pneumothorax.There is eventration of the right hemidiaprhagm.\n\n IMPRESSION: No pneumonia or pneumothorax.\n\n"},{"category":"Echo","chartdate":"2119-08-02 00:00:00.000","description":"Report","row_id":77091,"text":"PATIENT/TEST INFORMATION:\nIndication: Chest pain.\nHeight: (in) 66\nWeight (lb): 170\nBSA (m2): 1.87 m2\nBP (mm Hg): 100/70\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 11:23\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Due to suboptimal technical quality, a\nfocal wall motion abnormality cannot be fully excluded. Overall left\nventricular systolic function is normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter. The aortic arch is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. There is no\naortic valve stenosis. Mild (1+) aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. The left ventricular inflow pattern suggests impaired\nrelaxation.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. There is mild pulmonary artery systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+)\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild (1+) mitral regurgitation is seen. The left ventricular inflow pattern\nsuggests impaired relaxation. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\n\n"},{"category":"ECG","chartdate":"2119-08-03 00:00:00.000","description":"Report","row_id":181722,"text":"Sinus rhythm. Borderline left axis deviation. Probable inferior myocardial\ninfarction. Compared to the previous tracing of diffuse ST-T wave\nabnormalities persist. Cannot rule out myocardial ischemia or metabolic/drug\neffect. Clinical correlation is suggested.\n\n"},{"category":"ECG","chartdate":"2119-08-02 00:00:00.000","description":"Report","row_id":181723,"text":"Sinus tachycardia. Precordial leads appear to be right-sided chest leads. No\nsignificant ST segment elevation is seen. Probable inferior myocardial\ninfarction, age indeterminate. QTc interval appears to be prolonged but is\ndifficult to measure. Diffuse ST-T wve abnormalities. Clinical correlation is\nsuggested for ischemia and/or metabolic/drug effect. Since the previous tracing\nof sinus tachycardia is present.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2119-08-01 00:00:00.000","description":"Report","row_id":181724,"text":"Sinus rhythm. Borderline left axis deviation. Low limb lead voltage is\nnon-specific. Probable inferior myocardial infarction, age indeterminate.\nProlonged QTc interval. Diffuse non-specific ST-T wave abnormalities. Clinical\ncorrelation is suggested for possible metabolic/drug effect and/or ischemia.\nSince the previous tracing earlier this date atrial ectopy is not seen and\nfurther ST-T wave abnormalities are present.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2119-08-01 00:00:00.000","description":"Report","row_id":181725,"text":"Sinus rhythm. Atrial premature beats. Low QRS voltage. Probable inferior\nmyocardial infarction, age indeterminate. Modest diffuse non-specific low\namplitude T wave changes. Clinical correlation is suggested. Since the previous\ntracing earlier this date atrial ectopy is seen.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2119-08-01 00:00:00.000","description":"Report","row_id":181726,"text":"Sinus rhythm\nPossible inferior infarct - age undetermined\nPossible anterior infarct - age undetermined\nLow QRS voltages in precordial leads\nMinor nonspecific ST-T abnormalities\nNo previous tracing\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2119-08-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566101,\n \"text\": \"Admission/Progress Note: -0700\\n\\nPatient arrived from yesterday morning for Cardiac cath. She came to them with chest and jaw pain, ruled in for MI and tranferred here for intervention.\\nPost PTCA and Stent of RCA complicated by dissection of Right Illiac artery and ? retroperitoneal bleed. Had acute abdominal pain and HCT drop to 25 which she received 2 units blood in cath lab. Started on Neo for Low BP Pain free on arrival from cath lab. Bilateral groin sites had no bleeding, no hematoma and no bruits were auscultated. Pedal pulses present. Has been Stable overnight.\\n\\nNeuro: Orientated x 3 spheres. No deficits.\\n\\nCV: Was on Neo 0.58 mcg.kg/min on arrival to MICU. Slowly weaned overnight and BP was maintained with MAP >65. It has been off since o0500 and has maintained BP. See careVue for details on weaning and BP. Had bilateral grion sites, no bruits,no hematoma or bleeding, pedal pulses strong. Has been afebrile. No complaints of chest or jaw pain. Remains in NSR all night. Held Beta blocker due to hypotension.\\n\\nResp: Weaned O2 overnight to 1L NC from 4L. Sats 93-94%,Lungs clear.\\n\\nGU: Foley in till o430 when she requested it removed, Ambulated to commode and voided 200ml at 0500. On levo for UTI. Received NS 500ml bolus at o230 to to support BP while neo was weaning. Did not do a whole lot but patient is not symptomatic with lower BP. (normally 120's). Resident aware of this. He wanted Neo off as soon as possible. Encouraged to drink.\\n\\nGI: Patient's abdomen painful on palpation secondary to bleed. received morphine 1 mg x2 for this and got some relief. Taking clear fluid overnight. have cardiac diet today. BS present\\n\\nLabs pending, drawn at 0445.\\nCan be called out to floor\\n\\n , RN\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2119-08-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566103,\n \"text\": \"Cont' of Above Note\\nPatient's Metoprolol held this am due to hypotension. Neo gtt D/C and off since 0500. Dose decreased to 12.5mg and new parameters written, see med sheets.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2119-08-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566102,\n \"text\": \"Shift Note\\nCV: HR 90's NSR with elevations 100-110 with activity. BP runs low, but stable 85-100/50-70's with MAP >65. Patient wrm/dry, color WNL. Bandaids intact on bilateral groin from intervention site. No hematoma, brusing or bruit noted. Dorsal/pedal pulses palpable. Peripheral 20guage right forearm and left hand.\\n\\nResp: RR teens-20's, easy and regular. RA sats 94%, lungs clear in upper lobes with fine crackles in posterior lower bases.\\n\\nNeuro: Intact and A&O x3. Afebrile.\\n\\nGI/GU: Abdomen soft and tender to palpation. Patient c/o \\\"pressure pain\\\" and morphine 1mg given at 1230. Pain still consistent 3 at rest and 8 with activity. Patient on levo for treatment of UTI and MD notified. Pyridium ordered and 1st dose given 1600. Patient voiding at BSC without assistance. Low cholesterol, low sodium diet and tolerating well.\\n\\nID: UTI, on levo\\n\\nSocial: Family present at bedside this afternoon. Patient called out and to be transferred.\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2119-08-03 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 836400,\n \"text\": \" 9:40 AM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: CATH DECREASE IN HCT AND LOWER ABD PAIN ? BLEED\\n Admitting Diagnosis: UNSTABLE ANGINA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 69 year old woman with cath complicated by R external illiac perf. Angio\\n 30min later revealed no bleed. Now with falling Hct and lower abd pain.\\n REASON FOR THIS EXAMINATION:\\n ?Bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 69 y/o woman status post catheterization complicated by right\\n external iliac artery perforation, now with falling hematocrit and lower\\n abdominal pain.\\n\\n TECHNIQUE: Helical axial images of the abdomen and pelvis were obtained\\n without oral and without intravenous contrast.\\n\\n ABDOMEN CT WITHOUT IV CONTRAST: There is atelectasis at both lung bases,\\n right greater than left. There is a small right pleural effusion. The liver\\n is unremarkable. There is vicarious excretion of contrast within the\\n gallbladder, consistent with prior catheterization procedure. The pancreas,\\n spleen, adrenal glands, and kidneys are unremarkable. The stomach, small\\n bowel, and large bowel appear normal, without dilatation or wall thickening.\\n\\n PELVIS CT WITHOUT IV CONTRAST: There is soft tisuse stranding along the\\n retroperitoneum extending from the infrarenal position in the right side of\\n the abdomen along the psoas muscle into the right pelvis. There is extensive\\n soft tissue stranding in the right deep pelvis and along the midline, slightly\\n displacing the bladder to the left. This appearance is consistent with a\\n retroperitoneal hematoma. No intraperitoneal free fluid is present. Given\\n the lack of intravenous contrast, the integrity of the vessels cannot be\\n assessed.\\n\\n The rectum and uterus are unremarkable. There is a small collection of air\\n within the bladder, likely due to prior Foley insertion.\\n\\n The osseous structures are unremarkable.\\n\\n IMPRESSION:\\n\\n Extraperitoneal stranding extending from the right kidney into the right deep\\n pelvis consistent with retroperitoneal hemorrhage. There are no prior exams\\n with which to compare the size and extent of the hematoma. Given the lack of\\n intravenous contrast, vessel integrity cannot be assessed. If clinically\\n warranted, a pelvic CTA can be performed.\\n\\n (Over)\\n\\n 9:40 AM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: CATH DECREASE IN HCT AND LOWER ABD PAIN ? BLEED\\n Admitting Diagnosis: UNSTABLE ANGINA\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2119-08-03 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 836431,\n \"text\": \" 1:46 PM\\n CHEST (PA & LAT) Clip # \\n Reason: r/o infection, CHF\\n Admitting Diagnosis: UNSTABLE ANGINA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 69 year old woman with STEMI s/p retro bleed and now with O2 requirement upon\\n ambulation.\\n REASON FOR THIS EXAMINATION:\\n r/o infection, CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: A 69-year-old woman with MI, status post retroperitoneal bleed,\\n now with oxygen requirement. Evaluation for infection and CHF.\\n\\n TECHNIQUE: PA and lateral chest radiographs. Comparison is made with the\\n previous chest radiograph dated .\\n\\n FINDINGS: The heart is normal in size. The mediastinal and hilar contours\\n are normal.\\n\\n There is new faint opacity in the right middle lung field, most likely\\n representing an infectious process versus focal edema.\\n\\n The pulmonary vasculature is within normal limits. There is no effusion.\\n\\n IMPRESSION: New faint opacity in the right middle lung field, most likely\\n representing a early pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2119-08-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 836138,\n \"text\": \" 4:33 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: chest pain eval\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 69 year old woman with chest pain, ekg changes.\\n REASON FOR THIS EXAMINATION:\\n chest pain eval\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: A 69-year-old woman with chest pain.\\n\\n COMPARISON: None. See AP upright portable chest radiography. The heart size\\n is within normal limits. The mediastinal and hilar contours are unremarkable.\\n The pulmnonary vascularity is normal in appearance. The lungs are clear\\n without focal consolidation or pleural effusions. There is no\\n pneumothorax.There is eventration of the right hemidiaprhagm.\\n\\n IMPRESSION: No pneumonia or pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2119-08-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 77091,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Chest pain.\\nHeight: (in) 66\\nWeight (lb): 170\\nBSA (m2): 1.87 m2\\nBP (mm Hg): 100/70\\nHR (bpm): 93\\nStatus: Inpatient\\nDate/Time: at 11:23\\nTest: Portable TTE (Complete)\\nDoppler: Full doppler and color doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: The left atrium is normal in size.\\n\\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\\nventricular cavity size is normal. Due to suboptimal technical quality, a\\nfocal wall motion abnormality cannot be fully excluded. Overall left\\nventricular systolic function is normal (LVEF>55%).\\n\\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\\nnormal.\\n\\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\\ndiameter. The aortic arch is normal in diameter.\\n\\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. There is no\\naortic valve stenosis. Mild (1+) aortic regurgitation is seen.\\n\\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\\nregurgitation is seen. The left ventricular inflow pattern suggests impaired\\nrelaxation.\\n\\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\\ntricuspid regurgitation. There is mild pulmonary artery systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\\n\\nPERICARDIUM: There is no pericardial effusion.\\n\\nConclusions:\\nThe left atrium is normal in size. Left ventricular wall thicknesses are\\nnormal. The left ventricular cavity size is normal. Due to suboptimal\\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\\nOverall left ventricular systolic function is normal (LVEF>55%). Right\\nventricular chamber size and free wall motion are normal. The aortic valve\\nleaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+)\\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\\nMild (1+) mitral regurgitation is seen. The left ventricular inflow pattern\\nsuggests impaired relaxation. There is mild pulmonary artery systolic\\nhypertension. There is no pericardial effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2119-08-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 181722,\n \"text\": \"Sinus rhythm. Borderline left axis deviation. Probable inferior myocardial\\ninfarction. Compared to the previous tracing of diffuse ST-T wave\\nabnormalities persist. Cannot rule out myocardial ischemia or metabolic/drug\\neffect. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2119-08-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 181723,\n \"text\": \"Sinus tachycardia. Precordial leads appear to be right-sided chest leads. No\\nsignificant ST segment elevation is seen. Probable inferior myocardial\\ninfarction, age indeterminate. QTc interval appears to be prolonged but is\\ndifficult to measure. Diffuse ST-T wve abnormalities. Clinical correlation is\\nsuggested for ischemia and/or metabolic/drug effect. Since the previous tracing\\nof sinus tachycardia is present.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2119-08-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 181724,\n \"text\": \"Sinus rhythm. Borderline left axis deviation. Low limb lead voltage is\\nnon-specific. Probable inferior myocardial infarction, age indeterminate.\\nProlonged QTc interval. Diffuse non-specific ST-T wave abnormalities. Clinical\\ncorrelation is suggested for possible metabolic/drug effect and/or ischemia.\\nSince the previous tracing earlier this date atrial ectopy is not seen and\\nfurther ST-T wave abnormalities are present.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2119-08-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 181725,\n \"text\": \"Sinus rhythm. Atrial premature beats. Low QRS voltage. Probable inferior\\nmyocardial infarction, age indeterminate. Modest diffuse non-specific low\\namplitude T wave changes. Clinical correlation is suggested. Since the previous\\ntracing earlier this date atrial ectopy is seen.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2119-08-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 181726,\n \"text\": \"Sinus rhythm\\nPossible inferior infarct - age undetermined\\nPossible anterior infarct - age undetermined\\nLow QRS voltages in precordial leads\\nMinor nonspecific ST-T abnormalities\\nNo previous tracing\\n\\n\"\n }\n]"}}},{"rowIdx":24671,"cells":{"subject_id":{"kind":"number","value":44644,"string":"44,644"},"hadm_id":{"kind":"number","value":138099,"string":"138,099"},"target_text":{"kind":"string","value":"The patient was brought to the operating room on where the patient underwent coronary artery bypass grafting times two with Dr. . Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Post operative day one found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on post operative day four the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to Rehab in good condition with appropriate follow up instructions."},"extractive_notes_summ":{"kind":"string","value":"There are simpleatheroma in the ascending aorta. Simple atheroma in aorticarch. Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in ascendingaorta. Mild (1+) mitral regurgitation is seen. Normal appearance of the lung parenchyma. Chest tube and central venous catheter are unchanged in position. Mild mitral annularcalcification. Elevation of the left hemidiaphragm is unchanged. Lower lung volumes with bibasilar atelectases are unchanged. Thethoracic aorta is intact after decannulation. PATIENT/TEST INFORMATION:Indication: Intraoperative TEE for CABGStatus: InpatientDate/Time: at 11:51Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement. The aorticvalve leaflets (3) are mildly thickened but aortic stenosis is not present.Trace aortic regurgitation is seen. Physiologic(normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Written informed consent was obtained from the patient. Mild (1+) MR.TRICUSPID VALVE: Tricuspid valve not well visualized. No ASD by 2D or color Doppler.LEFT VENTRICLE: Normal regional LV systolic function. Normal size of the cardiac silhouette. Right IJ catheter tip is in the lower SVC. Valvular function is unchanged from pre-bypass. There is normal biventricularsystolic function. Cardiac size is top normal. Right IJ catheter tip is at the cavoatrial junction or upper right atrium, could be withdrawn a couple of centimeters for more standard position. The mitral valve leaflets are mildlythickened. There are simple atheroma in the aortic arch.There are complex (>4mm) atheroma in the descending thoracic aorta. There is a questionable tiny left apical pneumothorax. Mediastinal chest tube remains in place. Overall normal LVEF(>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. COMPARISON: Chest radiograph dated . There is a small left pleural effusion. Regional left ventricular wall motion isnormal. Cardiomediastinal contours are stable. Rightventricular chamber size and free wall motion are normal. FINDINGS: As compared to the previous radiograph, the patient has undergone CABG. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. TECHNIQUE: Portable upright chest radiograph. Overall left ventricular systolic function is normal (LVEF>55%). Possibly old inferior myocardial infarction. The patient was under general anesthesiathroughout the procedure. Results were personally reviewed with the MD caring forthe patient.Conclusions:PRE BYPASS The left atrium is moderately dilated. Low voltage.Prolonged Q-T interval. Complex (>4mm) atheroma in thedescending thoracic aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Focal calcifications in ascending aorta. IMPRESSION: No significant changes compared to the prior study. The patient appears tobe in sinus rhythm. Left mid lung opacity is where the tip of the chest tube used to be. The other monitoring and support devices, including the left chest tube and the Swan-Ganz catheter, are in correct position. Compared to the previous tracing of sinusbradycardia is new as well as the fractionation in leads III and aVF whichcould potenitally represent an old inferior wall myocardial infarction. Physiologic TR.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. eval for ptx, effusions. FINDINGS: There are no relevant changes compared to the previous study. No pneumothorax or large pleural effusions. Sinus bradycardia. Sternal wires are aligned. There is better aeration of the right lower lobe. No atrial septal defectis seen by 2D or color Doppler. LINE PLACEMENT Clip # Reason: cardiac surgery fast track extubation. No spontaneous echo contrastor thrombus is seen in the body of the left atrium/left atrial appendage orthe body of the right atrium/right atrial appendage. page cvicu provider if there is concern with findings FINAL REPORT CHEST RADIOGRAPH INDICATION: Status post CABG, fast track extubation, evaluation for pneumothorax. No TEE related complications. No spontaneous echo contrast or thrombusin the LA/LAA or the RA/RAA. The tip of the endotracheal tube projects 3.6 cm above the carina. 11:31 AM CHEST PORT. There is no pneumothorax or enlarging pleural effusions. 2:08 PM CHEST (PORTABLE AP) Clip # Reason: please eval for pneumothorax on water seal. I certify I was present incompliance with HCFA regulations. Focal calcifications inaortic root. No pneumothorax, no pleural effusions, no pulmonary edema. Good (>20 cm/s) LAA ejection velocity. Mediastinal wires are aligned. PLEASE TAKE CXR AT 1400. thanks! There is improved lung volumes and better aeration of the lower lung zones, with reduction in while the amount of bibasilar atelectasis with when compared to study from 3 hours ago. WET READ VERSION #1 FINAL REPORT PA AND LATERAL VIEWS OF THE CHEST REASON FOR EXAM: Assess for pneumothorax after chest tube removal. ATEE was performed in the location listed above. There is no pericardialeffusion. 5:33 PM CHEST (PA & LAT) Clip # Reason: eval for pleural effusions and PTX s/p chest tube removal Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA MEDICAL CONDITION: 63 year old woman s/p CABG s/p chest tube removal REASON FOR THIS EXAMINATION: eval for pleural effusions and PTX s/p chest tube removal WET READ: 8:53 PM There is no pneumothorax after removal of the left chest tube."},"n_notes":{"kind":"number","value":6,"string":"6"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2154-08-08 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1247837,"text":" 5:33 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for pleural effusions and PTX s/p chest tube removal\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p CABG s/p chest tube removal\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions and PTX s/p chest tube removal\n ______________________________________________________________________________\n WET READ: 8:53 PM\n There is no pneumothorax after removal of the left chest tube. There is\n improved lung volumes and better aeration of the lower lung zones, with\n reduction in while the amount of bibasilar atelectasis with when compared to\n study from 3 hours ago.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: Assess for pneumothorax after chest tube removal.\n\n Comparison is made with prior study performed three hours earlier.\n\n There is a questionable tiny left apical pneumothorax. There is a small left\n pleural effusion. Elevation of the left hemidiaphragm is unchanged.\n Cardiomediastinal contours are stable. Cardiac size is top normal. There is\n better aeration of the right lower lobe. Right IJ catheter tip is in the\n lower SVC. Left mid lung opacity is where the tip of the chest tube used to\n be. Mediastinal wires are aligned. In the lateral view, plate-like\n atelectasis project in the upper lobe.\n\n\n"},{"category":"Radiology","chartdate":"2154-08-06 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1247538,"text":" 11:31 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p line change\n REASON FOR THIS EXAMINATION:\n eval placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess line.\n\n Right IJ catheter tip is at the cavoatrial junction or upper right atrium,\n could be withdrawn a couple of centimeters for more standard position.\n Mediastinal chest tube remains in place. There are lower lung volumes with\n increasing bibasilar atelectases, larger on the left side compared to prior\n study performed . There is no pneumothorax or enlarging pleural\n effusions. Sternal wires are aligned.\n\n"},{"category":"Echo","chartdate":"2154-08-05 00:00:00.000","description":"Report","row_id":94291,"text":"PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for CABG\nStatus: Inpatient\nDate/Time: at 11:51\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast or thrombus\nin the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. All four\npulmonary veins identified and enter the left atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Simple atheroma in ascending\naorta. Focal calcifications in ascending aorta. Simple atheroma in aortic\narch. Normal descending aorta diameter. Complex (>4mm) atheroma in the\ndescending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic\n(normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Written informed consent was obtained from the patient. A\nTEE was performed in the location listed above. I certify I was present in\ncompliance with HCFA regulations. The patient was under general anesthesia\nthroughout the procedure. No TEE related complications. The patient appears to\nbe in sinus rhythm. Results were personally reviewed with the MD caring for\nthe patient.\n\nConclusions:\nPRE BYPASS The left atrium is moderately dilated. No spontaneous echo contrast\nor thrombus is seen in the body of the left atrium/left atrial appendage or\nthe body of the right atrium/right atrial appendage. No atrial septal defect\nis seen by 2D or color Doppler. Regional left ventricular wall motion is\nnormal. Overall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. There are simple\natheroma in the ascending aorta. There are simple atheroma in the aortic arch.\nThere are complex (>4mm) atheroma in the descending thoracic aorta. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present.\nTrace aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Mild (1+) mitral regurgitation is seen. There is no pericardial\neffusion. Dr. was notified in person of the results in the operating room\nat the time of the study.\n\nPOST BYPASS The patient is atrially paced. There is normal biventricular\nsystolic function. Valvular function is unchanged from pre-bypass. The\nthoracic aorta is intact after decannulation.\n\n\n"},{"category":"Radiology","chartdate":"2154-08-05 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1247380,"text":" 11:14 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: cardiac surgery fast track extubation. eval for ptx, effusio\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with s/p CABG\n REASON FOR THIS EXAMINATION:\n cardiac surgery fast track extubation. eval for ptx, effusions. page cvicu\n provider if there is concern with findings\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post CABG, fast track extubation, evaluation for\n pneumothorax.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has undergone\n CABG. The tip of the endotracheal tube projects 3.6 cm above the carina. The\n other monitoring and support devices, including the left chest tube and the\n Swan-Ganz catheter, are in correct position. Normal size of the cardiac\n silhouette. Normal appearance of the lung parenchyma. No pneumothorax, no\n pleural effusions, no pulmonary edema.\n\n"},{"category":"Radiology","chartdate":"2154-08-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1247803,"text":" 2:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for pneumothorax on water seal. PLEASE TAKE CXR\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p CABG\n REASON FOR THIS EXAMINATION:\n please eval for pneumothorax on water seal. PLEASE TAKE CXR AT 1400. thanks!\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n INDICATION: 53-year-old woman status post CABG, please evaluate for\n pneumothorax.\n\n COMPARISON: Chest radiograph dated .\n\n TECHNIQUE: Portable upright chest radiograph.\n\n FINDINGS: There are no relevant changes compared to the previous study.\n Chest tube and central venous catheter are unchanged in position. Lower lung\n volumes with bibasilar atelectases are unchanged. No pneumothorax or large\n pleural effusions.\n\n IMPRESSION: No significant changes compared to the prior study.\n\n\n"},{"category":"ECG","chartdate":"2154-08-05 00:00:00.000","description":"Report","row_id":249801,"text":"Sinus bradycardia. Possibly old inferior myocardial infarction. Low voltage.\nProlonged Q-T interval. Compared to the previous tracing of sinus\nbradycardia is new as well as the fractionation in leads III and aVF which\ncould potenitally represent an old inferior wall myocardial infarction.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-08-08 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1247837,\n \"text\": \" 5:33 PM\\n CHEST (PA & LAT) Clip # \\n Reason: eval for pleural effusions and PTX s/p chest tube removal\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CORONARY ARTERY BYPASS GRAFT /SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old woman s/p CABG s/p chest tube removal\\n REASON FOR THIS EXAMINATION:\\n eval for pleural effusions and PTX s/p chest tube removal\\n ______________________________________________________________________________\\n WET READ: 8:53 PM\\n There is no pneumothorax after removal of the left chest tube. There is\\n improved lung volumes and better aeration of the lower lung zones, with\\n reduction in while the amount of bibasilar atelectasis with when compared to\\n study from 3 hours ago.\\n\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n PA AND LATERAL VIEWS OF THE CHEST\\n\\n REASON FOR EXAM: Assess for pneumothorax after chest tube removal.\\n\\n Comparison is made with prior study performed three hours earlier.\\n\\n There is a questionable tiny left apical pneumothorax. There is a small left\\n pleural effusion. Elevation of the left hemidiaphragm is unchanged.\\n Cardiomediastinal contours are stable. Cardiac size is top normal. There is\\n better aeration of the right lower lobe. Right IJ catheter tip is in the\\n lower SVC. Left mid lung opacity is where the tip of the chest tube used to\\n be. Mediastinal wires are aligned. In the lateral view, plate-like\\n atelectasis project in the upper lobe.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-08-06 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1247538,\n \"text\": \" 11:31 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: eval placement\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CORONARY ARTERY BYPASS GRAFT /SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old woman s/p line change\\n REASON FOR THIS EXAMINATION:\\n eval placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE FRONTAL VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Assess line.\\n\\n Right IJ catheter tip is at the cavoatrial junction or upper right atrium,\\n could be withdrawn a couple of centimeters for more standard position.\\n Mediastinal chest tube remains in place. There are lower lung volumes with\\n increasing bibasilar atelectases, larger on the left side compared to prior\\n study performed . There is no pneumothorax or enlarging pleural\\n effusions. Sternal wires are aligned.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2154-08-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 94291,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Intraoperative TEE for CABG\\nStatus: Inpatient\\nDate/Time: at 11:51\\nTest: TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast or thrombus\\nin the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. All four\\npulmonary veins identified and enter the left atrium.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\\nand extending into the RV. No ASD by 2D or color Doppler.\\n\\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\\n(>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\\naortic root. Normal ascending aorta diameter. Simple atheroma in ascending\\naorta. Focal calcifications in ascending aorta. Simple atheroma in aortic\\narch. Normal descending aorta diameter. Complex (>4mm) atheroma in the\\ndescending thoracic aorta.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\\ncalcification. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Tricuspid valve not well visualized. Physiologic TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic\\n(normal) PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Written informed consent was obtained from the patient. A\\nTEE was performed in the location listed above. I certify I was present in\\ncompliance with HCFA regulations. The patient was under general anesthesia\\nthroughout the procedure. No TEE related complications. The patient appears to\\nbe in sinus rhythm. Results were personally reviewed with the MD caring for\\nthe patient.\\n\\nConclusions:\\nPRE BYPASS The left atrium is moderately dilated. No spontaneous echo contrast\\nor thrombus is seen in the body of the left atrium/left atrial appendage or\\nthe body of the right atrium/right atrial appendage. No atrial septal defect\\nis seen by 2D or color Doppler. Regional left ventricular wall motion is\\nnormal. Overall left ventricular systolic function is normal (LVEF>55%). Right\\nventricular chamber size and free wall motion are normal. There are simple\\natheroma in the ascending aorta. There are simple atheroma in the aortic arch.\\nThere are complex (>4mm) atheroma in the descending thoracic aorta. The aortic\\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present.\\nTrace aortic regurgitation is seen. The mitral valve leaflets are mildly\\nthickened. Mild (1+) mitral regurgitation is seen. There is no pericardial\\neffusion. Dr. was notified in person of the results in the operating room\\nat the time of the study.\\n\\nPOST BYPASS The patient is atrially paced. There is normal biventricular\\nsystolic function. Valvular function is unchanged from pre-bypass. The\\nthoracic aorta is intact after decannulation.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-08-05 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1247380,\n \"text\": \" 11:14 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: cardiac surgery fast track extubation. eval for ptx, effusio\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CORONARY ARTERY BYPASS GRAFT /SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old woman with s/p CABG\\n REASON FOR THIS EXAMINATION:\\n cardiac surgery fast track extubation. eval for ptx, effusions. page cvicu\\n provider if there is concern with findings\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Status post CABG, fast track extubation, evaluation for\\n pneumothorax.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, the patient has undergone\\n CABG. The tip of the endotracheal tube projects 3.6 cm above the carina. The\\n other monitoring and support devices, including the left chest tube and the\\n Swan-Ganz catheter, are in correct position. Normal size of the cardiac\\n silhouette. Normal appearance of the lung parenchyma. No pneumothorax, no\\n pleural effusions, no pulmonary edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-08-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1247803,\n \"text\": \" 2:08 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval for pneumothorax on water seal. PLEASE TAKE CXR\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CORONARY ARTERY BYPASS GRAFT /SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old woman s/p CABG\\n REASON FOR THIS EXAMINATION:\\n please eval for pneumothorax on water seal. PLEASE TAKE CXR AT 1400. thanks!\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST X-RAY\\n\\n INDICATION: 53-year-old woman status post CABG, please evaluate for\\n pneumothorax.\\n\\n COMPARISON: Chest radiograph dated .\\n\\n TECHNIQUE: Portable upright chest radiograph.\\n\\n FINDINGS: There are no relevant changes compared to the previous study.\\n Chest tube and central venous catheter are unchanged in position. Lower lung\\n volumes with bibasilar atelectases are unchanged. No pneumothorax or large\\n pleural effusions.\\n\\n IMPRESSION: No significant changes compared to the prior study.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2154-08-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 249801,\n \"text\": \"Sinus bradycardia. Possibly old inferior myocardial infarction. Low voltage.\\nProlonged Q-T interval. Compared to the previous tracing of sinus\\nbradycardia is new as well as the fractionation in leads III and aVF which\\ncould potenitally represent an old inferior wall myocardial infarction.\\n\\n\"\n }\n]"}}},{"rowIdx":24672,"cells":{"subject_id":{"kind":"number","value":1902,"string":"1,902"},"hadm_id":{"kind":"number","value":135491,"string":"135,491"},"target_text":{"kind":"string","value":"The patient was admitted and had a right thoracoscopic right upper lobectomy, cervical mediastinoscopy with biopsy, mediastinal nodal dissection, and flexible bronchoscopy which he tolerated well. The patient had a chest tube and a mediastinal drain placed in his right pleural space. This was placed to suction with a leak present. On post-op day 1, the patient had an episode of repiratory distress with SaO2 in the 80s on 3 liters O2 via nasal cannula. Wheezes and rhonchi were auscultated. The patient was given albuterol/ipratropium nebulizer treatments, nasal canula was switched to shovel mask, and SaO2 increased to 100%. An ecg showed no acute changes. On post-op day 2, the patient had another episode of respiratory distress and was transferred to the ICU for further management. The patient was started on Levoquin empirically. Steroids were also started for the patient's history of COPD. In the ICU, the patient also developed atrial flutter. The patient was placed on a diltiazem drip and converted back to sinus rhythm. Serial ABGs were obtained to ensure that the patient was not becoming hypoxemic or hypercarbic. On chest tube was d/c'd, was left to bulb. He had an episode of destauration in the ICU that reslved after bronchoscopy suctioned out a lot of thick secretions. Pulm was alos consulted to help manage his COPD. He was treated with Solumedrol and weaned to PO steroids for his COPD. He was also placed on BIPAP which helped as well. He was transfused 1 PRBC for a HCT of 26 on and given lasix. He was out of bed an remained in the ICU only as long as he did mostly because of a bed issue. On was d/c'd. small leak in remaing CT. Remained chest tube was clamped and removed and he was started per pulm recs on an outpt COPD regimine. he was transferred to the floor where he did well, worked with PT and was discharged home in good condition."},"extractive_notes_summ":{"kind":"string","value":"Transfused 1u PRBC's for hct 25-Resp: Wheezes throughout off and on-improved with alb/atr nebs. See carevue for ABG values.GU/GI: Foley to gravity with adequate HUO. 1+ pitting edema to lower extremeties. CXR taken this am.GU: Foley to gd with uo 30-60cc/hr.GI: Abd soft, NT,ND with + BS. Lytes repleted prn. ALB/ATR nebs as ordered. Pneumoboots on. Trivialmitral regurgitation is seen. Trace aortic regurgitation is seen. PIGTAIL DRG S/S FLUID.NEB TX GIVEN BY RT.GI/GU- ABD SOFT.+BS. Left atrial abnormality.RSR' pattern in lead V1. BS coarse; receiving bronchodiltors. Monitor resp. Replete lytes. Mild mitralannular calcification. CT DRAINAGE MIN SEROSANGUINOUS. BUN 45 CR 0.9 ABD snt (+)BS. Heparin gtt started. see carevue for details of CT drainage.GI/GU: Abd soft, +BS. Mild [1+] TR. SBP 130-150's.RESP: I/E wheezes T.O. IV DILT GTT DC'D AND TO RESUME PO DILT. PVC'S NOTED K 4.7. Abg 7.38/62/159/38. Sinus rhythmrSr'(V1) - probable normal variantSince previous tracing, slower heart rate Normal tricuspid valvesupporting structures. Sinus tachycardiarsr' patern in leads V1- probably normal variantSince previous tracing of , ventricular ectopy absent Palpable pulses bilat. ?Transfuse PRBC. Cont IS, cough and DB. PALP PP. Compared to the previous tracing of nosignificant change. Lasix given and cxr taken on 2. The aortic root is mildly dilated at thesinus level. CT sites with DSD-D/I.Comfort: Continues on MSO4 PCA 1.5 q 6-Using appropriately with stated good effect. K 4.1-4.2. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Afebrile. Baseline artifactSinus tachycardiaVentricular premature complexModest right ventricular conduction delay pattern - may be normal variantSince previous tracing of , sinus tachycardia and ventricular ectopypresent PERL. Mild thickening of mitral valve chordae. Rt pleural CT and blakemoore to wall suction. Tachynpeic at times. HYDROCORTISONE X1. Good UO. ABG 7.44/50/170/35/8 on NIV. RT LOWER CREPITUS ALSO. Pt given 2puffs Atrovent MDI with improved aeration throughout. There is moderate pulmonary artery systolichypertension. Suboptimal image quality - poor apicalviews.Conclusions:The left atrium is normal in size. BLE ultrasound done. + palpable pulses. NEURO: EASILY AROUSABLE, APPEARS SLIGHTLY LESS CLEAR THAN YESTERDAY, ORIENTED X3, GRASPS STRONG AND EQUAL, STEADY GAIT WHEN OOB X2. RIGHT JP WITH SEROUSSANG DRG.GI-NPO. JP WITH SEROUSSANG DRG.GI-ABD SOFT, NT/ND. Received alb/atr nebs. Abd softly distended, pos BS, ?last BM. NIPPV if ^ WOB. REMAINS ON TPN.GU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW DRG.COMFORT-HALDOL GIVEN FOR AGITATION WITH GOOD EFFECT.ENDO-SSRI.ID-AFEB. R CHEST TUBE AND JP IN PLACE. NEBS GIVEN. PULM HYGIENE. PULM HYGIENE. Resp CarePt continues NIPPV. ATIVAN ATC GIVEN.CV-HR/BP STABLE. Vanco/Zosyn as ordered.GI/METABOLIC: Sips clears tolerated. HEPARIN GTT D/C'D, AND COUMADIN D/C'D.RESP-PT REMAINS TACHYPNEIC AT TIMES. Nebs q4h. Adequate u.o., nearly uvolemic. + CREPITUS. CPT DONE. SKIN W+D. SKIN W+D. PT given Q2-Q4hr neb tx's. OOB AS TOL. + BOWEL SOUNDS. BS rhonchi, intermittent wheezes improving somewhat with MDI's. Continue neb treatment. NEBS/INHALERS GIVEN WITH SOME EFFECT. ABG PER FLOW - PH 7.35-7.31 WITH CO2 62-64- DR AWARE. CT TO H2O SEAL. Normotensive, ABP 101-130s/40-60s. ENC PO'S. +PP. +PP. EKG showed aflutter. PBOOTS ON. Afebrile. AFEBRILE. GI: NPO THIS AM ? REMAINS ON DILT GTT. LS COARSE WITH INSP/EXP WHEEZES. +BS. +BS. Hct 24.5 stable. HCT 25.1. watch hct. Tried off NIV but with significant desats. Hyperglycemic 239/243, treated per RISS.PSYCHOSOCIAL: Pt calm/coop. CT TO SXN WITH SEROUS DRG. Perl. tolerating diuresis well, CVP 2-5, fluid balance -1286ml at MN, currently -780ml. REMAINS ON HEPARIN GTT, PTT 70.RESP-CON'T WITH WHEEZES THROUGHOUT. Continue to r/o for MI. FOLLOWS COMMANDS.CV-HR 80-90'S, SINUS. TO HAVE XRAY THIS AM. Pt transferred from 2 for sob/resp distress and HR 120-140's.Neuro: AAO x3. UO adequate.Pain: Morphine pca.Plan: Monitor resp status. TOL PO'S. K+ 3.9, repleted per sliding scale. SBP 102-140 via femoral A-line. TPN TO BE STOPPED TONOC.GU-ON LASIX . TOL WELL. Foley cath. Foley cath. Blakemoore with minimal serosanguinous drainage. ABD SOFT/NT/ND. Wheezing decreases when placed back on NIV. RESP: RR 30'S THIS AM,02 SATS 90-92. RIGHT CT TO H20 SEAL WITH STRAW COLORED DRG. CT today.GI/METABOLIC: Abd soft/hyperactive bowel sounds- no BM x ? Slight diurese with lasix. Rt Pleural CT x2 to wall suction. spirocare done. OOB/ ambulate as tolerated. Incentive spirometry, chest PT and CDB done. Pt on BIPAP immediately s/p bronch. bp stable.gI abd soft. pt to be bronched.cardiac: in normal sinus rythmn. serous drainage, +leak (unchanged), - crepitus, + fluctuation. chest pt. Nebs given by resp tx. Nebs given by resp tx. UpdateSee Carevue for specificsNeuro: A & O x 3, PERRL, normal strength. CXR repeated. +fluctuation, + leak (unchanged). dsg c/d/i. Thoracic sx aware. CT to suctioned, draining small amts. pulm toilet. Pulm toilet. alberterol and atrovent neb treatment given. LS w/ rhonchi throughout. neb tx's. Chest tube d/c'd and replaced by pleurovac. Became tachypneic, wheezes t/o. inhalers as ordered. inhalers as ordered. serous drainage. Continue W Respiratory follow up. c/o mild to mod. chest to h20 seal, draining small amts. CVL d/c'd once peripheral access obtained. LS w/ ins/exp wheezing. bipap ordered. Cx sent. +PP. Transfer to floor when stable and bed avail. bp stable, peripheral pulses palpable. and atr. MD aware. pt comfortable, denies sob. RISS started. Alb/Atrovent neb given W good effect. Skin otherwise intact.plan: pulmonary toileting, oob to chair/ambulat, monitor resp. MDI spacer placed W Pt's MDI's. +BS. oob. ISE encouraged and tol well. DSD placed. thoracic team called. BS well controlled. atc. Afebrile. Afebrile. BS clear on left, BS on rt only audible fine wheezes mid apex. On Heparin SC.Resp: LS clear to coarse in upper airways, diminished at bases. Alb./atrov. (+) air leak from rt CT. Albuterol/Atrovent given with slight improvement. Integ intact.Plan: continue with current plan of care per sicu/ thoracic sx teams. PRN albuteral INH given, resp at bedside. brief episode of svt, dr. aware, electrolytes wnl.resp: ls noted for insp/exp wheezes, alb. Abdomen soft, NT/ND. Pt voiding in adequate amts. Lasix 20mg iv x's 1 (standing order) with + diuresis.resp: ls wheezy/coarse - though less wheezy this am. Right chest tube to H20 seal w/ no drainage. PLAN: Cont to monitor resp status, chest pt, monitore O2 requirements."},"n_notes":{"kind":"number","value":52,"string":"52"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2193-12-19 00:00:00.000","description":"Report","row_id":82457,"text":"PATIENT/TEST INFORMATION:\nIndication: Shortness of breath. Lung cancer status post lobectomy\nHeight: (in) 70\nWeight (lb): 168\nBSA (m2): 1.94 m2\nBP (mm Hg): 128/57\nHR (bpm): 108\nStatus: Inpatient\nDate/Time: at 15:07\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nno apical window images could be obtained status post lobectomy\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve\nsupporting structures. Mild [1+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\nviews.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF 70%). Right ventricular chamber\nsize and free wall motion are normal. The aortic root is mildly dilated at the\nsinus level. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. Trace aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Trivial\nmitral regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\n\n"},{"category":"ECG","chartdate":"2193-12-27 00:00:00.000","description":"Report","row_id":206769,"text":"Sinus rhythm\nrSr'(V1) - probable normal variant\nSince previous tracing, slower heart rate\n\n"},{"category":"ECG","chartdate":"2193-12-19 00:00:00.000","description":"Report","row_id":206770,"text":"Sinus tachycardia\nrsr' pattern in lead V1 - probably normal variant\nSince previous tracing of , no significant change\n\n"},{"category":"ECG","chartdate":"2193-12-18 00:00:00.000","description":"Report","row_id":206771,"text":"Sinus tachycardia\nrsr' patern in leads V1- probably normal variant\nSince previous tracing of , ventricular ectopy absent\n\n"},{"category":"ECG","chartdate":"2193-12-14 00:00:00.000","description":"Report","row_id":206772,"text":"Sinus tachycardia with ventricular premature beats. Left atrial abnormality.\nRSR' pattern in lead V1. Compared to the previous tracing of no\nsignificant change.\n\n"},{"category":"ECG","chartdate":"2193-12-06 00:00:00.000","description":"Report","row_id":206773,"text":"Baseline artifact\nSinus tachycardia\nVentricular premature complex\nModest right ventricular conduction delay pattern - may be normal variant\nSince previous tracing of , sinus tachycardia and ventricular ectopy\npresent\n\n"},{"category":"Nursing/other","chartdate":"2193-12-18 00:00:00.000","description":"Report","row_id":1286327,"text":"Respiratory Care Note\n4:45pm Pt's sats now 88% - pt c/o increasing SOB. Pt placed back on NIV with improvement in sats to 95%. Pt states that his breathing feels better now that he is back on NIV.\n"},{"category":"Nursing/other","chartdate":"2193-12-18 00:00:00.000","description":"Report","row_id":1286328,"text":"Respiratory Care Note\n4:45pm Pt's sats now 88% - pt c/o increasing SOB. Pt placed back on NIV with improvement in sats to 95%. Pt states that his breathing feels better now that he is back on NIV.\n"},{"category":"Nursing/other","chartdate":"2193-12-18 00:00:00.000","description":"Report","row_id":1286329,"text":"Respiratory Care Note\nPt received from 2 on mask ventilation - settings as noted. Pt in respiratory distress on floors. Pt more comfortable now that he is on NIV. Pt remained on NIV 6hours. ABG 7.44/50/170/35/8 on NIV. Pt placed on 50% face tent. BS coarse on R side, but diminished throughout. Pt given 2puffs Atrovent MDI with improved aeration throughout. Plan to on aerosol and monitor for fatigue and possible NIV.\n"},{"category":"Nursing/other","chartdate":"2193-12-18 00:00:00.000","description":"Report","row_id":1286330,"text":"Addendum\nABG on bipap (NIV) at 1530, 7.44/50/170/8/35, taken off bipap for approx 30min, pt aking for mask to be put on, c/o difficulty breathing, anxious, diaphoretic, sats 88%, RR 30s, SBP>150. Bipap reapplied, bringing sats to 95%, repeat ABG 7.43/53/62/8/36/92% NP aware and MD aware, no new orders. At present time, pt more comfortable on bipap (NIV) mask, see carevue for settings. SBP 110s, RR 20s, sats 98%.\n\n\nCreptius to right upper and lower cw and upper left cw, thoracic team aware, not new per 2 RN.\n"},{"category":"Nursing/other","chartdate":"2193-12-19 00:00:00.000","description":"Report","row_id":1286331,"text":"NEURO-ALERT & ORIENTED X3.PLEASANT,COOPERATIVE AND ASSISTS WITH CARE.VERY ANXIOUS D/T RESP STATUS. IS ABLE TO CALM SELF DOWN WITH POSITIVE FEEDBACK/REINFORCEMENT.MAE. VOICES NEEDS.\n\nCV- ST 100-110 NO ECTOPY.HR/BP/RR STABLE BUT DIRECTLY CORRELATES TO ANXIETY THEN RETURNS TO BASELINE. HEPARIN GTT @ 600U/HR. PTT=35. GTT INCREASED TO 800U/HR. WILL RECHECK IN 6HRS. 4+ PITTING EDEMA BILATERAL ANKLES. NO C/O OF LEG/CALVE PAIN.\n\nRESP- REMAINED ON BIPAP ALL SHIFT WITH INCREASING NEED OF FIO2 D/T DECOMPENSATION OF RESP. STATUS.LUNG FIELDS WITH MIXED I/E WHEEZEZ,RHONCHI, UPPER AIRWAY CONGESTION. BILATERAL UPPER LOBES WITH CREPITUS. RT LOWER CREPITUS ALSO. CT DRG YELLOW FLUID. PIGTAIL DRG S/S FLUID.NEB TX GIVEN BY RT.\n\nGI/GU- ABD SOFT.+BS. FOLEY PATENT WITH CLEAR YELLOW URINE,DECRAING I HOURLY OUTPUT THIS AM. CXR WORSE FROM . ? TO START ON LASIX TODAY?\n\nLABS- NO REPLETIONS GIVEN.\n\n WIFE/DAUGHTER CALLED. VISITOR IN @ 2100. -IN-LAW DECLINED VISIT BY RN (THROUGH) SECURITY 2200 D/T PT STATUS AND INCREASED NEED OF CARE. PT NOTIFIED AND AGREED TO RN'S DECISION. NOTIFIED THIS AM OF INCIDENCE ALSO.\n\nPLAN- CONTINUE TO MONIOTR RESP.LABS,EKGS/SERIAL CK-TROPONIN, TTE. ANXIETY MEDICATION PRN.\n\n"},{"category":"Nursing/other","chartdate":"2193-12-09 00:00:00.000","description":"Report","row_id":1286324,"text":"NPN:\n\nNeuro: Alert and oriented X3, MAE with equal strength. Visiting with family throughout day. In afternoon requesting to rest in chair. Occ only able to speak few words at time without SOB but in PM feeling much better and able to speak normally.\nCV: 80-90's SR with occ PAC's and PVC's. K 4.1-4.2. Cont on diltiazem 30mg po tid, Palp pedal pulses. Pneumoboots on. BP 120-140's/. Transfused 1u PRBC's for hct 25-\nResp: Wheezes throughout off and on-improved with alb/atr nebs. Tachynpeic at times. Initially on 4l and 50% FTN with sats 93-95% improved. Able to wean to 3l and 40% OFT neb with sats> 96%. ABG's improved by PM-ON 6l nc O2 sats 98-100%. Cough prod thick pale yellow sputum. CT's to 20cm sxn with + airleaks continuois-Pleuravac changed. CXR taken this am.\nGU: Foley to gd with uo 30-60cc/hr.\nGI: Abd soft, NT,ND with + BS. Denies flatus. No N/V. Tol regular diet well with good appetite.\nEndo: Covered per CTS sliding scale with regular insulin for glucoses\n110-160's.\nIncisions: R thoracotomy incision covered with DSD-D/I. CT sites with DSD-D/I.\nComfort: Continues on MSO4 PCA 1.5 q 6-Using appropriately with stated good effect. 0-3 injections/hr. Occ noted to hit button twice at once.\nActivity: OOB to chair all day-requesting to stay in chair r/t more comfortable in chair. PT consult ordered.\nA: Slowly improving pulmonary status still requiring ^ O2 and nebs q 4-6 hrs.\nP: Awaiting PT consult, Cont inhalers/nebs as needed. Discuss with team continuation of PCA vs change to po percocet. Cont IS, cough and DB. Begin increasing activity as tolerates. \u0013\n"},{"category":"Nursing/other","chartdate":"2193-12-10 00:00:00.000","description":"Report","row_id":1286325,"text":"7P-7A\nNEURO: A/Ox3. MAE. Consistently follows commands. Appropriatley using Morphine PCA for pain with (+)effect. Afebrile.\n\nCV: NSR 90's with occasional PAC's & PVC's. Lytes repleted prn. Diltiazem PO TID with additional 30MG PO this am for increaseed BP and HR per . Palpable pulses bilat. SBP 130-150's.\n\nRESP: I/E wheezes T.O. ALB/ATR nebs as ordered. IS to . CT to H2O seal overnight per Thoracic team. Minimal S/S drainage. (+) airleak. Expectorating small amount thick yellow sputum. O2 sat >95% 6L NC. See carevue for ABG values.\n\nGU/GI: Foley to gravity with adequate HUO. BUN 45 CR 0.9 ABD snt (+)BS. Tolerating ordered diet.\n\nENDO: FSBS per CSRU protocol.\n\nPLAN: Pulmonary toileting, continue with NEBS/MDI. Monitor HR and rhythm. Increase activity, PT consult.\n"},{"category":"Nursing/other","chartdate":"2193-12-18 00:00:00.000","description":"Report","row_id":1286326,"text":"1045-1900\nPt readmitted from 2 for c/o difficulty breathing low sats. Lasix given and cxr taken on 2. BLE ultrasound done. Heparin gtt started. Placed on bipap on 2. Multi attempts to place Aline.\n\nCV: HR 90-100s SR w/ rare PACs. SBP >120, NBP. Multi attempts by thoracic and csurg team for aline. At present attempting to place femoral aline. See carevue. + palpable pulses. 1+ pitting edema to lower extremeties. heparin gtt stopped NP for line placement.\n\nResp: LS coarse. Sats >93% on bipap see carevue for details. see carevue for details of CT drainage.\n\nGI/GU: Abd soft, +BS. Foley draining adequate amts of clear yellow urine. See carevue.\n\nEndo: Per csurg scale.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Attempt to take bipap off as pt tolerates. Pain control. Monitor labs and treat as appropriate.\n\n\n"},{"category":"Nursing/other","chartdate":"2193-12-08 00:00:00.000","description":"Report","row_id":1286322,"text":"ALTERED RESPIRATORY STATUS\nS: \"I JUST WANT TO SLEEP , I'LL GET UP AT 1000\" \" MY BREATHING IS A LITTLE HARDER THAN YESTERDAY\"\nO: CARDIAC: AFLUTTER AS RAPID AS 142 TRANSIENTLY, 100-120 , RECEIVED DILTIAZEM 30 MG AT 1030 WITHOUT CHANGE THEREFORE DILTIAZEM GTT ORDERED WITH A BOLUS, THE BOLUS WAS ALMOST FINISHED WHEN PT'S HR DECREASED TO 60'S AF. IV DILT GTT DC'D AND TO RESUME PO DILT. HR REMAINS IN AF WITH A VENTRICULAR RESPONSE OF 70'S-92. PVC'S NOTED K 4.7. HCT 25 RECEIVED 1 UPC WITH REPEAT HCT PENDING. EXTREMITIES WARM AND DRY. PALP PP. CT DRAINAGE MIN SEROSANGUINOUS. SBP 110'-130'S.\n RESP: THIS AM APPEARED MORE DYSPNEIC , PT ADMITTED TO THIS, SLIGHTLY BETTER AFTER A NAP, BREATH SOUNDS WITH I/E WHEEZE RECEIVED NEBS X2, GOOD COUGH, CONTINUES TO RAISE AND SWALLOW,IS 750 , ABG PER FLOW CO2 60'S, PO2 TO 65 ON 70% OPEN FACE TENT AND 4 L NP- AFTER LASIX PO2 80'S WITH PH 7.33. CHEST TUBE REMAINS WITH LEAK AS EXPECTED. HYDROCORTISONE X1.\n NEURO: EASILY AROUSABLE, APPEARS SLIGHTLY LESS CLEAR THAN YESTERDAY, ORIENTED X3, GRASPS STRONG AND EQUAL, STEADY GAIT WHEN OOB X2. PERL.\n GI: TAKING PO'S, ABD SOFT, NO STOOL.\n GU: MARGINAL UO, RECEIVED LASIX WITH SOME DIURESIS\n ENDO: HAS NOT RECIEVED ANY SSI AS OF YET\n ID: RECIEVING LEVO\n PAIN: PAIN ACCEPTABLE FOR PT. MORPHINE PCA AS PER FLOW.\n SOCIAL: FAMILY INTO VISIT AND UPDATED\nA: SLIGHTLY MORE SLEEPIER THAN YESTERDAY-CO2 60'S, AFLUTTER RAPID TO SLOW AF WITH DILT GTT,\nP: MONITOR COMFORT, HR AND RYTHYM- DILT PO, SBP, CT DRAINAGE, RESP STATUS-PULM TOILET, NEURO STATUS, I+O , LABS-1800 HCT,K,GLUCOSE. AS PER ORDERS.\n\n"},{"category":"Nursing/other","chartdate":"2193-12-09 00:00:00.000","description":"Report","row_id":1286323,"text":"Nursing Progress Note:\nNeuro: No deficits noted\n\nCV: At 0300, Pt received dilt 15mg iv for AFib 120's. Pt is now in SR with PAC's. HR 80's. Afebrile. Pulses palpable. Skin intact. HCT decreased to 25. ABP 120/50's.\n\nResp: Pt states that he is \"breathing much better\". No c/o SOB. Sats 98% on 50% cool neb and 4lnc. Rt pleural CT and blakemoore to wall suction. Airleak noted. Minimal serosanguinous drainage.\n\nGI/GU: Abdomen soft, nondistended. Foley cath. Good UO. Clear, yellow urine.\n\nPain: RISS\n\nPlan: Pulmonary hygiene. monitor HR/rhythm. Replete lytes. ?Transfuse PRBC. Increase activity.\n"},{"category":"Nursing/other","chartdate":"2193-12-22 00:00:00.000","description":"Report","row_id":1286344,"text":"Resp care\n\nPt has remained off NIV since 7am. Placed on 50% shovel mask; fio2 weaned to 35%. Abg 7.38/62/159/38. BS coarse; receiving bronchodiltors. BS coarse wheezing\n"},{"category":"Nursing/other","chartdate":"2193-12-22 00:00:00.000","description":"Report","row_id":1286345,"text":"focus update note\npt vss, no ectopy on po cardizem , off dilt gtt\n\npt continues on lasix iv bid for diuresis- cvp 5-11, chest CT awaiting results, continues on prophalactic heparin gtt goal ptt 50-60 assessing ptt q 6 hours and coumadin for ? PE- received 1 unit prbc for hct 25- post hct 30- kcl repleated x 2\n\nresp; pt contiues to have insp/exp wheezes, in varying degrees- requiring frequent albuterol/atrovent nebulizers, overall much improved since yesterday. chest tube to wall suction, positive crepitus- positive leak- icu team and primary team aware\n\ngu/gi: diet advanced to regular tolerated well, large formed bm today, clear yellow urine via foley cath\n\nplan: discontinue heparin and coumadin after final of Chest Ct to r/o PE, continue to assess q 6 hr ptt, po prednisione to start in am, continue to monitor resp status closely, may remove femoral aline per icu resident tommorrow so that pt may get oob to chair\n\n"},{"category":"Nursing/other","chartdate":"2193-12-23 00:00:00.000","description":"Report","row_id":1286346,"text":"Resp Care\nPt on 40% face tent throughout the night. Nebs given Q4 hrs. BS coarse bilaterally and wheezy at times, wheezing resolved with neb tx's. Pt says his breathing is feeling much better than yesterday. SPO2=97%ABG shows compensated respiratory acidosis. See CareVue for details.\nPlan: Continue neb treatments. NIPPV if ^ WOB.\n"},{"category":"Nursing/other","chartdate":"2193-12-23 00:00:00.000","description":"Report","row_id":1286347,"text":"NPN\nSee carevue for detail\nNeuro:intact\nResp:Dropped sat x1 to 85 when he was found with mask on the floor. Returned to baseline as soon as mask was reinstituted.\nGI:Tol sips of water, House diet.\nGU:Diuresed s/p lasix\nCV:SR to ST.\n\n\n"},{"category":"Nursing/other","chartdate":"2193-12-23 00:00:00.000","description":"Report","row_id":1286348,"text":"nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT A+OX3.MAE. FOLLOWS COMMANDS. ATIVAN ATC GIVEN.\n\nCV-HR/BP STABLE. FEM ALINE OUT. SKIN W+D. +PP. PBOOTS ON. DENIES CARDIAC COMPLAINTS. HEPARIN GTT D/C'D, AND COUMADIN D/C'D.\n\nRESP-PT REMAINS TACHYPNEIC AT TIMES. LS COARSE WITH INSP/EXP WHEEZES. NEBS/INHALERS GIVEN WITH SOME EFFECT. CPT DONE. O2 SAT UP TO 100% AT TIMES BUT DOES DESAT TO 80'S WHEN O2 OFF. CT TO SXN WITH SEROUS DRG. NO CREPITUS AND VERY SM, AIR LEAK NOTED. DSG INTACT. JP WITH SEROUSSANG DRG.\n\nGI-ABD SOFT, NT/ND. +BS. TOL PO'S. TPN TO BE STOPPED TONOC.\n\nGU-ON LASIX . U/O ADEQ AMTS CL YELLOW.\n\nACT-PHYSICAL THERAPY FOLLOWING. PT AMB AROUND UNIT AND THEN SAT IN CHAIR X FEW HRS. TOL WELL.\n\nCOMFORT-DENIES NEED FOR PAIN MED.\n\nENDO-REMAINS ON INSULIN GTT. FS MONITORED CLOSELY.\n\nP-CON'T WITH CURRENT PLAN. PULM HYGIENE. OOB AS TOL. SUPPORT. ENC PO'S.\n"},{"category":"Nursing/other","chartdate":"2193-12-07 00:00:00.000","description":"Report","row_id":1286319,"text":"Nursing Progress Note:\nPt is s/p VATS, RUL lobectomy with Rt pleural CT and drainage. Pt transferred from 2 for sob/resp distress and HR 120-140's.\n\nNeuro: AAO x3. MAE. Follows commands. Perl. Speech clear. Good cough.\n\nResp: I/E wheezes. Nebs q4h. Pt still has episodes of SOB with sats high 80's. Team aware. Rt Pleural CT x2 to wall suction. Airleak noted. Minimal serosanguinous drainage. minimal drainage. Sats 88-92% on 50% face tent.\n\nCV: SR-ST. HR 100-115. Afebrile. Pulses palpable. PIV x2. Labs wnl. Skin intact.\n\nGi/GU: Abdomen soft, nondistended. Foley cath. UO adequate.\n\nPain: Morphine pca.\n\nPlan: Monitor resp status. Continue to r/o for MI. Pain management. Pulmonary hygiene.\n"},{"category":"Nursing/other","chartdate":"2193-12-07 00:00:00.000","description":"Report","row_id":1286320,"text":"S/P RESPIRATORY DISTRESS\nS: \"IT'S MUCH EASIER TO BREATH\" \" I HAVEN'T SLEPT ALL NIGHT\"\nO: CARDIAC: ST 100'S TO SR90'S WITH OCCASSIONAL PVCS PO LOPRESSOR GIVEN. K 4.3. SBP 110'S-150'S. EXTREMITIES WARM AND DRY, PALP PP.\n RESP: RR 30'S THIS AM,02 SATS 90-92. BETTER ONCE PAIN IN BETTER CONTROL. COURSE BREATH SOUNDS WITH AN EXPIRATORY WHEEZE, GOOD COUGH AS THE DAY PROGRESSED, IS . ABG PER FLOW - PH 7.35-7.31 WITH CO2 62-64- DR AWARE. OPEN FACE TENT AT 50% WITH 4LNP. O2 SAT >95% . = LEAK FELT DUE TO SPACE. CXR FROM 0000 UNCHANGED FROM POST OP.\n NEURO: EASILY AROUSABLE, ORIENTED X3, GRASPS STRONG AND EQUAL, MAE, FOLLOWING COMMANDS. ANXIOUS THIS AM MUCH CALMER AS MORNING PASSED.\n GI: NPO THIS AM ? BRONCH HOWEVER NOT TO BE DONE PER DR. . TOOK JELLO THIS AFTERNOON, ABD SOFT. + BOWEL SOUNDS.\n GU: ADEQUATE UO\n ID: LEVOFLOXIN STARTED\n PAIN: PCA MORPHINE, PT INSTRUCTED ON THE USE OF PCA, BETTER PAIN CONTROL .\n ENDO; HAS NOT REQUIRED ANY SSI\n SOCIAL: WIFE AND DAUGHTER INTO VISIT AND UPDATED\nA: CO2 60'S, BETTER PAIN CONTROL\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, RESP STATUS-PULM TOILET-MONITOR ABG,NEURO STATUS, I+O, LABS. AS PER ORDERS\n"},{"category":"Nursing/other","chartdate":"2193-12-08 00:00:00.000","description":"Report","row_id":1286321,"text":"Nursing Progress Note:\nNeuro: Pt anxious at times. AAO x3. MAE. No deficits noted.\n\nCV/Resp: Pt converted to aflutter last night. At ~0345, pt with c/o SOB and respiratory distress. HR increased to 140's with sats in the 80's. Dr at bedside. Pt received lasix 20mg, lopressor 5mg iv, and started on decadron. EKG showed aflutter. Anesthesia was called but intubation was cancelled. After ~40minutes, Pts respiratory distress improved and sats were in the low 90's on 100% nonrebreather. ABG po2 was 56 during the event. CXR results pending. Presently, pt is in aflutter with HR in the 100's. BP 100/40's. Sats 92% on 70% face tent and 4lnc. Pulses palpable. Rt pleural CT to wall suction. Airleak present. Blakemoore with minimal serosanguinous drainage. HCT 25.1. Team aware.\n\nGI/GU: Abdomen soft, obese. Foley cath. Slight diurese with lasix. Urine clear and yellow.\n\nEndoc: RISS\n\nPain: Morphine pca\n\nPlan: Monitor respiratory status. Continue neb treatment. watch hct. Pulmonary hygiene. Pain management. Wean o2.\nPlan: Monitor respiratory status.\n"},{"category":"Nursing/other","chartdate":"2193-12-21 00:00:00.000","description":"Report","row_id":1286340,"text":"focus update\npt experiencing q 1-2 hour episodes of increased work of breathing with bronchospasm associated with pt being taken off positive pressure mode of ventilation. pt desats to 90s as low as 86%- despite mutiple bronchodialtors, diuresis, wheezing unchanged except when on positive pressure bypap mask. small leak noted at chest tube and placed to wall suction per icu resident\n\nneuro: alert and oriented x 3, mae+, follows commands consistently.\n\npt continues on heparin gtt, to have coumadin dose tonight, ptt q 6 hours. currently running at 1000u/hr.\n\nlasix iv continues, with good diuresis, kcl repleated x 4\n\nplan: continue to monitor respitory status closely, pulm toilet, diuresis, check ptt q 6 hours, moniotr rising wbc , p[ulmonary consult later today\n"},{"category":"Nursing/other","chartdate":"2193-12-21 00:00:00.000","description":"Report","row_id":1286341,"text":"Resp Care\n\nPt with multiple episodes of coming off and on NIV; approx 10-15 minutes pt would develop increased wheezing and WOB. Pt received multiple bronchodilators. Wheezing decreases when placed back on NIV. Spo2 99% NIV with 50%.\n"},{"category":"Nursing/other","chartdate":"2193-12-22 00:00:00.000","description":"Report","row_id":1286342,"text":"Resp Care\nPt continues NIPPV. PS weaned per team request, now remains at 5 with good TV's. BS coarse & wheezy bilaterally. PT given Q2-Q4hr neb tx's. Pt has non-productive cough at this time. Pt has ^^ WOB when taken off the NIPPV Mask and does not tolerate being off for long periods of time. FiO2 weaned to 35%. See CareVue for details and specifics.\nPlan: Continue to wean settings as tolerated.\n"},{"category":"Nursing/other","chartdate":"2193-12-22 00:00:00.000","description":"Report","row_id":1286343,"text":"FOCUSED NURSING NOTE\nPlease see carevue flowsheet for further details\n\nNEURO: Slightly more lethargic this evening, A/O x 3, no changes in neuro assessments. Morphine 2mg x 3 for incr WOB and c/o general discomfort/request for sleep. Therapeutic effect observed with RR 18-20 and TV 400-500 while asleep.\n\nRESP: Mask ventilation CPAP PEEP 5 PS 8, PS titrated to 5 when sleeping comfortably- trial of no PS not tolerated by pt. ABGs with routine labs showing compensated resp acidosis- PCO2 climbing (63) in setting of high P02 (230), FiO2 titrated down to 35%, f/U ABG later this am. Awoke at 0200 with c/o feeling \"hot\" and incr WOB, audible stridor noted (afebrile)- treated with nebs q3-4hr, lungs with insp wheezes bilaterally, coarse on expiration. Strong cough, non-productive, sounds dry. Right CT patent to 20cm wall suction, 10ml drainage(serous), crepitus stable, drsg .\nSPO2 99-100%. Plan CT CHEST today, am CXR ordered.\n\nHEMODYNAMICS: NSR 80-90s on Diltiazem gtt, no ectopy, plan d/c gtt and convert to oral Diltiazem this am. Normotensive, ABP 101-130s/40-60s. tolerating diuresis well, CVP 2-5, fluid balance -1286ml at MN, currently -780ml. K+ 3.9, repleted per sliding scale. Heparin gtt titrated per PTT and MD orders, next PTT due 0700. INR 0.9, Coumadin started at 2300 as ordered. No sx bleeding, HCT stable 25.6, PLT 317. Pt denies CP.\n\nID: Feels \"hot\" periodically, afebrile (verified rectally) and glucose relatively stable. Vanco/Zosyn as ordered, sputum cx pending, blood cx pending. CT today.\n\nGI/METABOLIC: Abd soft/hyperactive bowel sounds- no BM x ? days; Dulcolax suppos given, no results. TPN at 74ml/hr. Remains hyperglycemic (180-234) with minimal response to SQ RISS, insulin gtt initiated at 0500, titrated MD ordered scale.\n\nPLAN OF CARE:\n\n\n\n"},{"category":"Nursing/other","chartdate":"2193-12-20 00:00:00.000","description":"Report","row_id":1286336,"text":"Resp Care\n\nPt was weaned from NIV this am for 2hrs; had episode of desaturation with increased wheezing and WOB; placed back on NIV. At noon again weaned to 50% face tent; abg 7.46/52/133/35; pt currently on face tent for 5hrs; fio2 titrated to 40%. Receiving scheduled bronchodilators. BS coarse. Plan to remain on face tent as tolerated.\n"},{"category":"Nursing/other","chartdate":"2193-12-20 00:00:00.000","description":"Report","row_id":1286337,"text":"FOCUS; STATUS UPDATE\nDATA;\nALERT AND ORIENTED X3. MOVING ALL EXTREMITIES IN BED, WEAK. DENIES PAIN.\nDILTIAZEM DRIP DISCONTINUED AND CHANGED TO LOPRESSOR IVP.\nCONTINUES ON HEPARIN DRIP TITRATED TO PTT GOAL OF 50-60.\nLUNGS COARSE THROUGHOUT. MINIMAL EXERTION CAUSES EXTREME SOB AND WHEEZING, DESATURATION TO 88%,ACCOMPANIED BY ANXIETY. NEBS BY RESPIRATORY THERAPY WITH GOOD EFFECT. CPAP OFF THIS AM, BUT PLACED BACK WITH SOB AND DESATURATION EVENT FOR SHORT PERIOD, NOW ON FACE TENT AT 40%. AFEBRILE. R CHEST TUBE AND JP IN PLACE. NO LEAK. CONTINUES WITH CREPITUS AROUND CHEST TUBE SITE.\nTPN FOR NUTRITION.\nADEQUATE URINE OUTPUT. CONTINUES NPO.\n\nPLAN;\nCONTINUE TO MONITOR RESPIRATORY STATUS CLOSELY.\n\n"},{"category":"Nursing/other","chartdate":"2193-12-21 00:00:00.000","description":"Report","row_id":1286338,"text":"Respiratory Care: Pt remained off NIV all night and on 40% FM. Tolerated well for the most part, except episode of desaturation with physical excursion. Received alb/atr nebs. BS coarse wheeze.\n"},{"category":"Nursing/other","chartdate":"2193-12-21 00:00:00.000","description":"Report","row_id":1286339,"text":"Focused Nursing Note\nPlease see carevue flowsheet for further details\n\nNEURO: A/O x 3, moves all extremities equally. No episodes of anxiety/agitation.\n\nRESP: CXR pending. Face tent 40% throughout night, general SPO2 94-98% with 1 episode of desaturation to 89% while sleeping soundly- ABG at that time confirmed Pa02 of 60, scheduled neb given and FiO2 incr to 70%- F/U ABG shows PaO2 135, PCo2 59. FiO2 returned to 40%, SPO2 95-98% remainder of shift. Pts lungs have Insp/Exp wheeze bilaterally, RUL coarse/bronchial sounds. Little sputum production, C/DB encouraged- unable to tolerate IS. Poor activity tolerance with labored breathing, RR 40s after little movement- recovers with coaching after 1-2 mins. Right CT intact, 30ml straw-colored drainge, ?minimal leak, MD aware. Morphine 2mg IV x 2 give for general discomfort, tachypnea, and insomnia- therapeutic effect observed.\n\nHEMODYNAMICS: NSR 70-90s, occassional PACs. Denies CP or resp distress at rest. Lopressor 5mg IVP q4hr ATC for rate control. SBP 102-140 via femoral A-line. NO edema. Adequate u.o., nearly uvolemic. Hct 24.5 stable. Heparin gtt titrated for PTT 49.1, next PTT due 0730. No sx bleeding.\n\nID: Afebrile. Vanco/Zosyn as ordered.\n\nGI/METABOLIC: Sips clears tolerated. Abd softly distended, pos BS, ?last BM. TPN at 74ml/hr. Hyperglycemic 239/243, treated per RISS.\n\nPSYCHOSOCIAL: Pt calm/coop. Visited by son, daughter called for update. Emotional support and education to pt and family provided.\n\nPLAN: Monitor resp status closely, incr activity as tolerated, Alb/Atr nebs ATC, pulm hygiene. Monitor cardiac status, Lopressor as ordered.\nTPN. Consult team for improved glycemic control while on TPN/steroids. Cont steroid taper/antibiotics. Heparin gtt, goal 50-60, next PTT due 0730. Emotional support and education ongoing.\n\n\n"},{"category":"Nursing/other","chartdate":"2193-12-19 00:00:00.000","description":"Report","row_id":1286332,"text":" 7a-7p\nneuro: a+o x3 with mild anxiety this am, increased anxiety x1 this am with ^in bp/hr/resp rate (sats remained in 90s on bipap, pt remained oriented x3), resolved with ativan 0.5mg x1; pt became confused around 1300 after returned to bipap for low sats, picking at ivs/pulling at tubes/pulling off clothing/pulling bipap off (worse after ativan ivp, haldol 5mg ivp given x1 with good result), pt still sleeping at this time; mae, perrlaa\n\ncv: sr/st 87-117 occasional pacs, sbp 107-150 (>130 with anxiety), dilt gtt started at 5 mg/hr (maintain at 5 per thoracic), heparin at 1000 units/hr (ptt at 1800), ct draining small amounts serosanguineous to wall suction, jp draining small amounts yellow drainage\n\nresp: lungs cta, diminished bilat, bilat crepitus to upper chest/right thoracotomy/bilat scapula (team aware), bipap fi02 70 ps 12 02 sats now 96%, attempted pt on face mask today, did not tolerate, returned to bipap after 02 sats dropped to mid-high 80s, when on mask able to use is 250-500ml with weak/moderate strength nonproductive cough\n\ngi: positive bowel sounds, soft non distended abdomen, tolerated sips with meds this am, started tpn this pm, no insulin coverage per np at this time\n\ngu: foley draining adequate amounts clear yellow urine\n\naccess: triple lumen catheter placed to right ij as unable to place piv (after 4 attempts)\n\nlabs: stable\n\nassess: improving\n\nplan: haldol 5mg im q4 for agitation, wean bipap as tolerated, continue heparin/diltiazem gtts\n"},{"category":"Nursing/other","chartdate":"2193-12-19 00:00:00.000","description":"Report","row_id":1286333,"text":"BS rhonchi, intermittent wheezes improving somewhat with MDI's. Tried off NIV but with significant desats. Generally very agitated pulling mask off or out of position. Not responding well to Ativan but seems better after Haldol. Now resting reasonably comfortably. Still may require intubation for increased WOB.\n"},{"category":"Nursing/other","chartdate":"2193-12-20 00:00:00.000","description":"Report","row_id":1286334,"text":"nsg note\nSEE FLOWSHEET FOT SPECIFICS.\n\nNEURO-PT A+OX3. MAE. FOLLOWS COMMANDS.\n\nCV-HR 80-90'S, SINUS. UP TO 100'S WHEN AGITATED. REMAINS ON DILT GTT. SBP STABLE. SKIN W+D. +PP. DENIES CARDIAC COMPLAINTS. REMAINS ON HEPARIN GTT, PTT 70.\n\nRESP-CON'T WITH WHEEZES THROUGHOUT. NEBS GIVEN. PT WITH STRONG COUGH PRODUCTIVE OF VERY THICK WHITE SPUTUM. ON BIPAP MASK MOST OF NOC. TOL WELL. RR WNL AND O2 SAT 98% WHEN ON BIPAP. PT AND SAT DOWN TO 91% WHEN OFF MASK. RIGHT CT TO H20 SEAL WITH STRAW COLORED DRG. + FLUCUATION, NO AIR LEAK. + CREPITUS. TEAM AWARE. TO HAVE XRAY THIS AM. RIGHT JP WITH SEROUSSANG DRG.\n\nGI-NPO. ABD SOFT/NT/ND. +BS. REMAINS ON TPN.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW DRG.\n\nCOMFORT-HALDOL GIVEN FOR AGITATION WITH GOOD EFFECT.\n\nENDO-SSRI.\n\nID-AFEB. REMAISN ON ABX.\n\nP-CON'T WITH CURRENT PLAN. PULM HYGIENE. CT TO H2O SEAL. SUPPORT. FOLLOW LABS.\n"},{"category":"Nursing/other","chartdate":"2193-12-20 00:00:00.000","description":"Report","row_id":1286335,"text":"Respiratory Care Note:\n\nPt tranfert t/o night from CSRU on NRM, placed on NIV immediatly & remain on NIV t/o shift. We were to wean FIO2 from 70 to 50%. He awoke and asked to take off NIV mask/ Nebs given and placed back on NIV. Plan: pulm hygiene & Continue present ICU monitoring and keep confortable. Will follow.\n"},{"category":"Nursing/other","chartdate":"2193-12-28 00:00:00.000","description":"Report","row_id":1286359,"text":"Respiratory Therapy\n0545 Pt presents W 6L n/c and .5 venti mask in high position. Sats mid 80's. Placed on NRBM and 6L n/c. BS clear on left, BS on rt only audible fine wheezes mid apex. MD aware. CXR revealed a worsening rt side. (+) air leak from rt CT. Albuterol/Atrovent given with slight improvement. Sats 88% after 30 minutes, sats increased to 93%. Plan: Discuss W attending. Continue W Respiratory follow up.\n"},{"category":"Nursing/other","chartdate":"2193-12-28 00:00:00.000","description":"Report","row_id":1286360,"text":"focus hemodynmics\ndata: neuro: alert and oriented. moves all extremities on the bed. oob to the chair. engages in conversation.\n\nresp: on o2 at 6 liters via nasal prongs. o2sats 90-93. coughing without raising any sputum. hob elevaated with pillows under arms. at 0600am sat dropped to 86%. resp 30's. alberterol and atrovent neb treatment given. cxr done and results per dr worse. chest tube to water seal and placed to suction. chest tube has an air leak. bipap ordered. resp therapist in room. thoracic team called. pt to be bronched.\n\ncardiac: in normal sinus rythmn. occ pvc. lopresssor 75mg via fdg tube given.\n\ngI abd soft and no stool tonite. tol po foods well.\n\ngu: voiding in the urinal qs.\n\naction: bipap added for resp distress. thoracic team at the bedside. bronch cart at the bedside. hob elevated pillows under arms. emotional support provided. daughter called this am 0700am and update given regarding difficulty breathing.\n\nrespone: monitor closely.\n"},{"category":"Nursing/other","chartdate":"2193-12-28 00:00:00.000","description":"Report","row_id":1286361,"text":"Update\nSee Carevue for specifics\n\nNeuro: A & O x 3, PERRL, normal strength. OOBTC & ambulate around room.\n\nCV: NSR/ST. SBP WNL.\n\nResp: Pt in respiratory distress this a.m. Sats in high 70s, tachypnic with labored breathing. Switched from non-rebreather to BIPAP with little effect. Bronchoscopy performed with some difficulty at approx 0800. Pt agitated and given .5 versed for comfort. 30 mg ascetylcysteine instilled via bronch for extremely thick secretions. Copious amounts of secretions removed. Cx sent. Pt on BIPAP immediately s/p bronch. Later switched to non-rebreather and currently sats at 100% and doing well. Incentive spirometry, chest PT and CDB done. Chest tube d/c'd and replaced by pleurovac. Draining serosang fluid, no crepitus, no leakage noted.\n\nGI: House diet. +BS. Small formed stool x 1.\n\nGU: Voids in urinal.\n\nSocial: Daughter and wife in to visit.\n\nPlan: Aggressive pulmonary toilet to mobilize secretions. OOB and ambulate again before sleep tonight. Provide quiet environment to sleep. Bronchoscopy tomorrow. Transfer to floor.\n\n\n"},{"category":"Nursing/other","chartdate":"2193-12-28 00:00:00.000","description":"Report","row_id":1286362,"text":"Respiratory Therapy\n\nPt received this AM w/ SpO2 70s-80s, NIPPV started and bronched at bedside by thoracic team. Multiple mucous plugs cleared, put on 100% NRB post procedure; alternating between that and NIV. See resp flowsheet for specifics.\n\nPlan: maintain support\n"},{"category":"Nursing/other","chartdate":"2193-12-25 00:00:00.000","description":"Report","row_id":1286354,"text":"Condition Update\nPlease see carevue for specifics.\n\nPt alert and oriented x 3. MAE. OOB to the chair w/ supervision only. Afebrile. NSR. No ectopy noted. No c/o pain. Right chest tube to H20 seal w/ no drainage. +fluctuation + leak. Thoracic sx aware. JP drain d/c'd today. DSD placed. Small amt of bloody drainage at jp d/c site. LS w/ ins/exp wheezing. Nebs given by resp tx. Pt also using IS at bedside. Pt voiding in adequate amts. Tolerating regular diet. RISS for bs coverage.\n\nPlan: continue with current plan of care per sicu/ thoracic sx team. xfer to fl ?. pulm toilet. neb tx's. oob.\n"},{"category":"Nursing/other","chartdate":"2193-12-26 00:00:00.000","description":"Report","row_id":1286355,"text":"Please See Carevue for Specifics.\n\nPt slept majority of the night. Received 0.25mg Ativan for sleep assistance with effect. Right chest tube to water seal with +leak and +fluc, -crepitus with sero drainage, DSD with sang staining noted.\n\nPOC: Transfer to floor when bed avail. Continue to encourage self ADl's, OOB to chair/ambulate as tolerates. Pain management as needed. Continue to offer emotional support to pt and pt family.\n"},{"category":"Nursing/other","chartdate":"2193-12-26 00:00:00.000","description":"Report","row_id":1286356,"text":"Respiratory therapy\nPt presents on 4L n/c fine wheezes bilaterally. Alb/Atrovent neb given W good effect. Increased aeration. MDI spacer placed W Pt's MDI's.\n\n"},{"category":"Nursing/other","chartdate":"2193-12-27 00:00:00.000","description":"Report","row_id":1286357,"text":"Nursing Progress Note\nSee Carevue for details\n\nNeuro: AOx3. Pleasant and cooperative. MAE with nml strength. Denies HA, dizziness, or changes in vision.\n\nCV: NSR. No ectopy. HR 70's-80's. BP 110-120/50. +PP. No edema noted. On Heparin SC.\n\nResp: LS clear to coarse in upper airways, diminished at bases. Able to administer inhalers with spacer independently.\n\nGI: Tolerating hse diet. No N/V. Abdomen soft, NT/ND. +BS.\n\nGU: voiding CYU in urinal without difficulty.\n\nSkin: Right Chest tube site covered DSD-no drainage. No crepitus. Old JP drain site covered DSD no drainage-pt reports site is painful at times-given 1 mg Morphine IVP with good effect.\n\nPlan: ?transfer to floor. Continue monitor VS, resp status, labs.\n"},{"category":"Nursing/other","chartdate":"2193-12-29 00:00:00.000","description":"Report","row_id":1286363,"text":"focus hemodymics\ndata: neuro: alert and oriented. moves all extremities on the bed. oob to chair.\n\nresp: on 80% hi flow mask. o2sats 100%. inhalers as ordered. coughing but not raising any sputum. spirocare done. chest pt done x 3. chest tube intact with small pleuravac intact. to have bronchoscopy done today.\n\ncardiac: in nsr. bp stable.\n\ngI abd soft. taking po's with difficulty. no stool tonite.\n\ngu: voiding clear yellow urine.\n\naction: oob to chair. inhalers as ordered. chest pt. 80% face mask hi flow intact. postion changed frequenty during the nite. update to daughter. tylenol given for generalized achiness.\n\nresponse: monitor closely.\n"},{"category":"Nursing/other","chartdate":"2193-12-29 00:00:00.000","description":"Report","row_id":1286364,"text":"Respiratory Care Note:\n Patient changed to a high flow continuous aerosol to facilitate secretion clearance and weaning of FIO2. He has tolerated 80% t/o shift with SpO2>99%. His RR has been 16-28. Plan for bronchoscopy today. Yesterday's bronch was done via facemask ventilation, therefore, ventilator not D/C'd at this time. He has been recieving MDIs app Q4 and uses good technique with maneuvers.\n"},{"category":"Nursing/other","chartdate":"2193-12-24 00:00:00.000","description":"Report","row_id":1286349,"text":"condition update\nneuro: alert and oriented x's 3, mae to command, no c/o pain. ativan held at 1800, pt denied anxiety and very comfortable. Pt requested ativan at 0100 for help with sleeping.\ncv: nsr 80's-90's. Very brief (5 sec) run of svt, self resolved. Dr. notified, electrolytes checked, K+ repleted. No further episodes. bp stable, peripheral pulses palpable. Lasix 20mg iv x's 1 (standing order) with + diuresis.\nresp: ls wheezy/coarse - though less wheezy this am. Alb./atrov. nebs atc per r.t. Pt denies sob, 02 sat 95-100% on 50% face tent. CT to suctioned, draining small amts. serous drainage. +fluctuation, + leak (unchanged). No crepitus noted. Coughing/deep breathing encouraged.\ngi: abd soft, nontender, +bs, no bm. swallows pills without difficulty.\ngu: foley draining adequate amts. clear yellow urine.\nendo: insulin gtt titrated.\nskin: right chest tube site dsd intact, no drainage noted. Skin otherwise intact.\nplan: pulmonary toileting, oob to chair/ambulat, monitor resp. status, chest x-ray this am, ? transfer to floor.\n"},{"category":"Nursing/other","chartdate":"2193-12-24 00:00:00.000","description":"Report","row_id":1286350,"text":"Respiratory Care\nPt continues 50% high flow via face tent. BS coarse bilaterally and becoming less wheezy. Nebs given as ordered with good effect. Spo2 98-100%. Will continue to treat pt with nebs as ordered.\n\n\n"},{"category":"Nursing/other","chartdate":"2193-12-27 00:00:00.000","description":"Report","row_id":1286358,"text":"Nursing Progress Note\n Please see carevue for details of care. Awake, alert and oriented. Pleasant, cooperative and compliant. OOB to chair w/assist tol well this am. MAEW, Denies discomfort. BS sl dim this am w/few exp wheezes noted which cleared after inhalers. ISE encouraged and tol well. Remains in NSR w/no ectopy, VSS.\n Became SOB suddenly this am w/sats quickly down to high 60's range. Became tachypneic, wheezes t/o. PRN albuteral INH given, resp at bedside. SICU team and primary MD aware and at bedside. Pulmonary team notif by SICU team. CXR repeated. Sats remain 70's after back to bed, 50% face mask + 6L NC on w/sats recovered to high 80's, changed to 100% NRB mask + 6L NC w/sats only recovering to 91-93 range. Teams aware. Sats slowly recovered to 97-98 range, O2 weaned back to 50% mask and 6L NC. Mask off early pm by patient w/sats maint 93-95, remains SOB and tachypneic w/exertion.\n R chest tube intact w/DSD intact, draining scant amt serous fluid in tube. + air leak noted, no crepitus. Old JP site covered w/DSD, drainage. Med x1 for pain w/ Morphine 1 mg this pm w/stated effect.\n PLAN: Cont to monitor resp status, chest pt, monitore O2 requirements. Transfer to floor when stable and bed avail.\n"},{"category":"Nursing/other","chartdate":"2193-12-24 00:00:00.000","description":"Report","row_id":1286351,"text":"Condition Update\nPlease see carevue for specifics.\n\nPt alert and oriented. MAE. No c/o pain. NSR> No ectopoy noted. Afebrile. Insulin gtt d/c'd. RISS started. BS well controlled. CVL d/c'd once peripheral access obtained. LS w/ rhonchi throughout. Nebs given by resp tx. Chest tube placed to water seal by thoracic sx. + leak. Thoracic team aware. Breathing much easier today per pt. 02 sats 94-100% on 15L Hi flow mask. CXR done this afternoon. JP drain in pleural space to bulb sxn. Foley d/c'd this eve. Pt is approx 2400. No BM. Pt is tolerating a regular diet well. Integ intact.\n\nPlan: continue with current plan of care per sicu/ thoracic sx teams. CT to water seal. SS for bs coverage. OOB/ ambulate as tolerated. Pulm toilet.\n"},{"category":"Nursing/other","chartdate":"2193-12-25 00:00:00.000","description":"Report","row_id":1286352,"text":"condition update\nplease see carevue for specifics;\nneuro: alert and oriented x's 3, pleasant and cooperative. Mae to command. c/o mild to mod. pain at chest tube site, morphine 1mg iv x's 2 with good relief.\ncv: nsr with occasional pac's. brief episode of svt, dr. aware, electrolytes wnl.\nresp: ls noted for insp/exp wheezes, alb. and atr. atc. chest to h20 seal, draining small amts. serous drainage, +leak (unchanged), - crepitus, + fluctuation. dsg c/d/i. 02 sat 97-99% on 50% face tent. pt comfortable, denies sob. coughing/deep breathing encouraged.\ngi: abd. soft/nontender, +bs, no bm.\ngu: pt at 2400, voided 300cc clear yellow urine at 2300.\nendo: ssri\nskin: intact\nsocial: son at bedside early this evening.\nplan: continue p.t., pulmonary toileting, monitor u/o, pain management. ? transfer to floor today.\n"},{"category":"Nursing/other","chartdate":"2193-12-25 00:00:00.000","description":"Report","row_id":1286353,"text":"BS CTAB, no wheezing now; no change with bronchodilators. Weaned to nasal cannula 5L/m. Awaiting call out to floors.\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2193-12-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 82457,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Shortness of breath. Lung cancer status post lobectomy\\nHeight: (in) 70\\nWeight (lb): 168\\nBSA (m2): 1.94 m2\\nBP (mm Hg): 128/57\\nHR (bpm): 108\\nStatus: Inpatient\\nDate/Time: at 15:07\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nno apical window images could be obtained status post lobectomy\\nLEFT ATRIUM: Normal LA size.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\\n(LVEF>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\\nof papillary muscles. No MS. Trivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve\\nsupporting structures. Mild [1+] TR. Moderate PA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\\nviews.\\n\\nConclusions:\\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\\nsize, and systolic function are normal (LVEF 70%). Right ventricular chamber\\nsize and free wall motion are normal. The aortic root is mildly dilated at the\\nsinus level. The aortic valve leaflets (3) are mildly thickened but aortic\\nstenosis is not present. Trace aortic regurgitation is seen. The mitral valve\\nleaflets are mildly thickened. There is no mitral valve prolapse. Trivial\\nmitral regurgitation is seen. There is moderate pulmonary artery systolic\\nhypertension. There is no pericardial effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2193-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 206769,\n \"text\": \"Sinus rhythm\\nrSr'(V1) - probable normal variant\\nSince previous tracing, slower heart rate\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2193-12-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 206770,\n \"text\": \"Sinus tachycardia\\nrsr' pattern in lead V1 - probably normal variant\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2193-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 206771,\n \"text\": \"Sinus tachycardia\\nrsr' patern in leads V1- probably normal variant\\nSince previous tracing of , ventricular ectopy absent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2193-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 206772,\n \"text\": \"Sinus tachycardia with ventricular premature beats. Left atrial abnormality.\\nRSR' pattern in lead V1. Compared to the previous tracing of no\\nsignificant change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2193-12-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 206773,\n \"text\": \"Baseline artifact\\nSinus tachycardia\\nVentricular premature complex\\nModest right ventricular conduction delay pattern - may be normal variant\\nSince previous tracing of , sinus tachycardia and ventricular ectopy\\npresent\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286327,\n \"text\": \"Respiratory Care Note\\n4:45pm Pt's sats now 88% - pt c/o increasing SOB. Pt placed back on NIV with improvement in sats to 95%. Pt states that his breathing feels better now that he is back on NIV.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286328,\n \"text\": \"Respiratory Care Note\\n4:45pm Pt's sats now 88% - pt c/o increasing SOB. Pt placed back on NIV with improvement in sats to 95%. Pt states that his breathing feels better now that he is back on NIV.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286329,\n \"text\": \"Respiratory Care Note\\nPt received from 2 on mask ventilation - settings as noted. Pt in respiratory distress on floors. Pt more comfortable now that he is on NIV. Pt remained on NIV 6hours. ABG 7.44/50/170/35/8 on NIV. Pt placed on 50% face tent. BS coarse on R side, but diminished throughout. Pt given 2puffs Atrovent MDI with improved aeration throughout. Plan to on aerosol and monitor for fatigue and possible NIV.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286330,\n \"text\": \"Addendum\\nABG on bipap (NIV) at 1530, 7.44/50/170/8/35, taken off bipap for approx 30min, pt aking for mask to be put on, c/o difficulty breathing, anxious, diaphoretic, sats 88%, RR 30s, SBP>150. Bipap reapplied, bringing sats to 95%, repeat ABG 7.43/53/62/8/36/92% NP aware and MD aware, no new orders. At present time, pt more comfortable on bipap (NIV) mask, see carevue for settings. SBP 110s, RR 20s, sats 98%.\\n\\n\\nCreptius to right upper and lower cw and upper left cw, thoracic team aware, not new per 2 RN.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286331,\n \"text\": \"NEURO-ALERT & ORIENTED X3.PLEASANT,COOPERATIVE AND ASSISTS WITH CARE.VERY ANXIOUS D/T RESP STATUS. IS ABLE TO CALM SELF DOWN WITH POSITIVE FEEDBACK/REINFORCEMENT.MAE. VOICES NEEDS.\\n\\nCV- ST 100-110 NO ECTOPY.HR/BP/RR STABLE BUT DIRECTLY CORRELATES TO ANXIETY THEN RETURNS TO BASELINE. HEPARIN GTT @ 600U/HR. PTT=35. GTT INCREASED TO 800U/HR. WILL RECHECK IN 6HRS. 4+ PITTING EDEMA BILATERAL ANKLES. NO C/O OF LEG/CALVE PAIN.\\n\\nRESP- REMAINED ON BIPAP ALL SHIFT WITH INCREASING NEED OF FIO2 D/T DECOMPENSATION OF RESP. STATUS.LUNG FIELDS WITH MIXED I/E WHEEZEZ,RHONCHI, UPPER AIRWAY CONGESTION. BILATERAL UPPER LOBES WITH CREPITUS. RT LOWER CREPITUS ALSO. CT DRG YELLOW FLUID. PIGTAIL DRG S/S FLUID.NEB TX GIVEN BY RT.\\n\\nGI/GU- ABD SOFT.+BS. FOLEY PATENT WITH CLEAR YELLOW URINE,DECRAING I HOURLY OUTPUT THIS AM. CXR WORSE FROM . ? TO START ON LASIX TODAY?\\n\\nLABS- NO REPLETIONS GIVEN.\\n\\n WIFE/DAUGHTER CALLED. VISITOR IN @ 2100. -IN-LAW DECLINED VISIT BY RN (THROUGH) SECURITY 2200 D/T PT STATUS AND INCREASED NEED OF CARE. PT NOTIFIED AND AGREED TO RN'S DECISION. NOTIFIED THIS AM OF INCIDENCE ALSO.\\n\\nPLAN- CONTINUE TO MONIOTR RESP.LABS,EKGS/SERIAL CK-TROPONIN, TTE. ANXIETY MEDICATION PRN.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286324,\n \"text\": \"NPN:\\n\\nNeuro: Alert and oriented X3, MAE with equal strength. Visiting with family throughout day. In afternoon requesting to rest in chair. Occ only able to speak few words at time without SOB but in PM feeling much better and able to speak normally.\\nCV: 80-90's SR with occ PAC's and PVC's. K 4.1-4.2. Cont on diltiazem 30mg po tid, Palp pedal pulses. Pneumoboots on. BP 120-140's/. Transfused 1u PRBC's for hct 25-\\nResp: Wheezes throughout off and on-improved with alb/atr nebs. Tachynpeic at times. Initially on 4l and 50% FTN with sats 93-95% improved. Able to wean to 3l and 40% OFT neb with sats> 96%. ABG's improved by PM-ON 6l nc O2 sats 98-100%. Cough prod thick pale yellow sputum. CT's to 20cm sxn with + airleaks continuois-Pleuravac changed. CXR taken this am.\\nGU: Foley to gd with uo 30-60cc/hr.\\nGI: Abd soft, NT,ND with + BS. Denies flatus. No N/V. Tol regular diet well with good appetite.\\nEndo: Covered per CTS sliding scale with regular insulin for glucoses\\n110-160's.\\nIncisions: R thoracotomy incision covered with DSD-D/I. CT sites with DSD-D/I.\\nComfort: Continues on MSO4 PCA 1.5 q 6-Using appropriately with stated good effect. 0-3 injections/hr. Occ noted to hit button twice at once.\\nActivity: OOB to chair all day-requesting to stay in chair r/t more comfortable in chair. PT consult ordered.\\nA: Slowly improving pulmonary status still requiring ^ O2 and nebs q 4-6 hrs.\\nP: Awaiting PT consult, Cont inhalers/nebs as needed. Discuss with team continuation of PCA vs change to po percocet. Cont IS, cough and DB. Begin increasing activity as tolerates. \\u0013\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286325,\n \"text\": \"7P-7A\\nNEURO: A/Ox3. MAE. Consistently follows commands. Appropriatley using Morphine PCA for pain with (+)effect. Afebrile.\\n\\nCV: NSR 90's with occasional PAC's & PVC's. Lytes repleted prn. Diltiazem PO TID with additional 30MG PO this am for increaseed BP and HR per . Palpable pulses bilat. SBP 130-150's.\\n\\nRESP: I/E wheezes T.O. ALB/ATR nebs as ordered. IS to . CT to H2O seal overnight per Thoracic team. Minimal S/S drainage. (+) airleak. Expectorating small amount thick yellow sputum. O2 sat >95% 6L NC. See carevue for ABG values.\\n\\nGU/GI: Foley to gravity with adequate HUO. BUN 45 CR 0.9 ABD snt (+)BS. Tolerating ordered diet.\\n\\nENDO: FSBS per CSRU protocol.\\n\\nPLAN: Pulmonary toileting, continue with NEBS/MDI. Monitor HR and rhythm. Increase activity, PT consult.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286326,\n \"text\": \"1045-1900\\nPt readmitted from 2 for c/o difficulty breathing low sats. Lasix given and cxr taken on 2. BLE ultrasound done. Heparin gtt started. Placed on bipap on 2. Multi attempts to place Aline.\\n\\nCV: HR 90-100s SR w/ rare PACs. SBP >120, NBP. Multi attempts by thoracic and csurg team for aline. At present attempting to place femoral aline. See carevue. + palpable pulses. 1+ pitting edema to lower extremeties. heparin gtt stopped NP for line placement.\\n\\nResp: LS coarse. Sats >93% on bipap see carevue for details. see carevue for details of CT drainage.\\n\\nGI/GU: Abd soft, +BS. Foley draining adequate amts of clear yellow urine. See carevue.\\n\\nEndo: Per csurg scale.\\n\\nPlan: Monitor hemodynamics. Monitor resp. status. Attempt to take bipap off as pt tolerates. Pain control. Monitor labs and treat as appropriate.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286322,\n \"text\": \"ALTERED RESPIRATORY STATUS\\nS: \\\"I JUST WANT TO SLEEP , I'LL GET UP AT 1000\\\" \\\" MY BREATHING IS A LITTLE HARDER THAN YESTERDAY\\\"\\nO: CARDIAC: AFLUTTER AS RAPID AS 142 TRANSIENTLY, 100-120 , RECEIVED DILTIAZEM 30 MG AT 1030 WITHOUT CHANGE THEREFORE DILTIAZEM GTT ORDERED WITH A BOLUS, THE BOLUS WAS ALMOST FINISHED WHEN PT'S HR DECREASED TO 60'S AF. IV DILT GTT DC'D AND TO RESUME PO DILT. HR REMAINS IN AF WITH A VENTRICULAR RESPONSE OF 70'S-92. PVC'S NOTED K 4.7. HCT 25 RECEIVED 1 UPC WITH REPEAT HCT PENDING. EXTREMITIES WARM AND DRY. PALP PP. CT DRAINAGE MIN SEROSANGUINOUS. SBP 110'-130'S.\\n RESP: THIS AM APPEARED MORE DYSPNEIC , PT ADMITTED TO THIS, SLIGHTLY BETTER AFTER A NAP, BREATH SOUNDS WITH I/E WHEEZE RECEIVED NEBS X2, GOOD COUGH, CONTINUES TO RAISE AND SWALLOW,IS 750 , ABG PER FLOW CO2 60'S, PO2 TO 65 ON 70% OPEN FACE TENT AND 4 L NP- AFTER LASIX PO2 80'S WITH PH 7.33. CHEST TUBE REMAINS WITH LEAK AS EXPECTED. HYDROCORTISONE X1.\\n NEURO: EASILY AROUSABLE, APPEARS SLIGHTLY LESS CLEAR THAN YESTERDAY, ORIENTED X3, GRASPS STRONG AND EQUAL, STEADY GAIT WHEN OOB X2. PERL.\\n GI: TAKING PO'S, ABD SOFT, NO STOOL.\\n GU: MARGINAL UO, RECEIVED LASIX WITH SOME DIURESIS\\n ENDO: HAS NOT RECIEVED ANY SSI AS OF YET\\n ID: RECIEVING LEVO\\n PAIN: PAIN ACCEPTABLE FOR PT. MORPHINE PCA AS PER FLOW.\\n SOCIAL: FAMILY INTO VISIT AND UPDATED\\nA: SLIGHTLY MORE SLEEPIER THAN YESTERDAY-CO2 60'S, AFLUTTER RAPID TO SLOW AF WITH DILT GTT,\\nP: MONITOR COMFORT, HR AND RYTHYM- DILT PO, SBP, CT DRAINAGE, RESP STATUS-PULM TOILET, NEURO STATUS, I+O , LABS-1800 HCT,K,GLUCOSE. AS PER ORDERS.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286323,\n \"text\": \"Nursing Progress Note:\\nNeuro: No deficits noted\\n\\nCV: At 0300, Pt received dilt 15mg iv for AFib 120's. Pt is now in SR with PAC's. HR 80's. Afebrile. Pulses palpable. Skin intact. HCT decreased to 25. ABP 120/50's.\\n\\nResp: Pt states that he is \\\"breathing much better\\\". No c/o SOB. Sats 98% on 50% cool neb and 4lnc. Rt pleural CT and blakemoore to wall suction. Airleak noted. Minimal serosanguinous drainage.\\n\\nGI/GU: Abdomen soft, nondistended. Foley cath. Good UO. Clear, yellow urine.\\n\\nPain: RISS\\n\\nPlan: Pulmonary hygiene. monitor HR/rhythm. Replete lytes. ?Transfuse PRBC. Increase activity.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286344,\n \"text\": \"Resp care\\n\\nPt has remained off NIV since 7am. Placed on 50% shovel mask; fio2 weaned to 35%. Abg 7.38/62/159/38. BS coarse; receiving bronchodiltors. BS coarse wheezing\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286345,\n \"text\": \"focus update note\\npt vss, no ectopy on po cardizem , off dilt gtt\\n\\npt continues on lasix iv bid for diuresis- cvp 5-11, chest CT awaiting results, continues on prophalactic heparin gtt goal ptt 50-60 assessing ptt q 6 hours and coumadin for ? PE- received 1 unit prbc for hct 25- post hct 30- kcl repleated x 2\\n\\nresp; pt contiues to have insp/exp wheezes, in varying degrees- requiring frequent albuterol/atrovent nebulizers, overall much improved since yesterday. chest tube to wall suction, positive crepitus- positive leak- icu team and primary team aware\\n\\ngu/gi: diet advanced to regular tolerated well, large formed bm today, clear yellow urine via foley cath\\n\\nplan: discontinue heparin and coumadin after final of Chest Ct to r/o PE, continue to assess q 6 hr ptt, po prednisione to start in am, continue to monitor resp status closely, may remove femoral aline per icu resident tommorrow so that pt may get oob to chair\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286346,\n \"text\": \"Resp Care\\nPt on 40% face tent throughout the night. Nebs given Q4 hrs. BS coarse bilaterally and wheezy at times, wheezing resolved with neb tx's. Pt says his breathing is feeling much better than yesterday. SPO2=97%ABG shows compensated respiratory acidosis. See CareVue for details.\\nPlan: Continue neb treatments. NIPPV if ^ WOB.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286347,\n \"text\": \"NPN\\nSee carevue for detail\\nNeuro:intact\\nResp:Dropped sat x1 to 85 when he was found with mask on the floor. Returned to baseline as soon as mask was reinstituted.\\nGI:Tol sips of water, House diet.\\nGU:Diuresed s/p lasix\\nCV:SR to ST.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286348,\n \"text\": \"nsg note\\nSEE FLOWSHEET FOR SPECIFICS.\\n\\nNEURO-PT A+OX3.MAE. FOLLOWS COMMANDS. ATIVAN ATC GIVEN.\\n\\nCV-HR/BP STABLE. FEM ALINE OUT. SKIN W+D. +PP. PBOOTS ON. DENIES CARDIAC COMPLAINTS. HEPARIN GTT D/C'D, AND COUMADIN D/C'D.\\n\\nRESP-PT REMAINS TACHYPNEIC AT TIMES. LS COARSE WITH INSP/EXP WHEEZES. NEBS/INHALERS GIVEN WITH SOME EFFECT. CPT DONE. O2 SAT UP TO 100% AT TIMES BUT DOES DESAT TO 80'S WHEN O2 OFF. CT TO SXN WITH SEROUS DRG. NO CREPITUS AND VERY SM, AIR LEAK NOTED. DSG INTACT. JP WITH SEROUSSANG DRG.\\n\\nGI-ABD SOFT, NT/ND. +BS. TOL PO'S. TPN TO BE STOPPED TONOC.\\n\\nGU-ON LASIX . U/O ADEQ AMTS CL YELLOW.\\n\\nACT-PHYSICAL THERAPY FOLLOWING. PT AMB AROUND UNIT AND THEN SAT IN CHAIR X FEW HRS. TOL WELL.\\n\\nCOMFORT-DENIES NEED FOR PAIN MED.\\n\\nENDO-REMAINS ON INSULIN GTT. FS MONITORED CLOSELY.\\n\\nP-CON'T WITH CURRENT PLAN. PULM HYGIENE. OOB AS TOL. SUPPORT. ENC PO'S.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286319,\n \"text\": \"Nursing Progress Note:\\nPt is s/p VATS, RUL lobectomy with Rt pleural CT and drainage. Pt transferred from 2 for sob/resp distress and HR 120-140's.\\n\\nNeuro: AAO x3. MAE. Follows commands. Perl. Speech clear. Good cough.\\n\\nResp: I/E wheezes. Nebs q4h. Pt still has episodes of SOB with sats high 80's. Team aware. Rt Pleural CT x2 to wall suction. Airleak noted. Minimal serosanguinous drainage. minimal drainage. Sats 88-92% on 50% face tent.\\n\\nCV: SR-ST. HR 100-115. Afebrile. Pulses palpable. PIV x2. Labs wnl. Skin intact.\\n\\nGi/GU: Abdomen soft, nondistended. Foley cath. UO adequate.\\n\\nPain: Morphine pca.\\n\\nPlan: Monitor resp status. Continue to r/o for MI. Pain management. Pulmonary hygiene.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286320,\n \"text\": \"S/P RESPIRATORY DISTRESS\\nS: \\\"IT'S MUCH EASIER TO BREATH\\\" \\\" I HAVEN'T SLEPT ALL NIGHT\\\"\\nO: CARDIAC: ST 100'S TO SR90'S WITH OCCASSIONAL PVCS PO LOPRESSOR GIVEN. K 4.3. SBP 110'S-150'S. EXTREMITIES WARM AND DRY, PALP PP.\\n RESP: RR 30'S THIS AM,02 SATS 90-92. BETTER ONCE PAIN IN BETTER CONTROL. COURSE BREATH SOUNDS WITH AN EXPIRATORY WHEEZE, GOOD COUGH AS THE DAY PROGRESSED, IS . ABG PER FLOW - PH 7.35-7.31 WITH CO2 62-64- DR AWARE. OPEN FACE TENT AT 50% WITH 4LNP. O2 SAT >95% . = LEAK FELT DUE TO SPACE. CXR FROM 0000 UNCHANGED FROM POST OP.\\n NEURO: EASILY AROUSABLE, ORIENTED X3, GRASPS STRONG AND EQUAL, MAE, FOLLOWING COMMANDS. ANXIOUS THIS AM MUCH CALMER AS MORNING PASSED.\\n GI: NPO THIS AM ? BRONCH HOWEVER NOT TO BE DONE PER DR. . TOOK JELLO THIS AFTERNOON, ABD SOFT. + BOWEL SOUNDS.\\n GU: ADEQUATE UO\\n ID: LEVOFLOXIN STARTED\\n PAIN: PCA MORPHINE, PT INSTRUCTED ON THE USE OF PCA, BETTER PAIN CONTROL .\\n ENDO; HAS NOT REQUIRED ANY SSI\\n SOCIAL: WIFE AND DAUGHTER INTO VISIT AND UPDATED\\nA: CO2 60'S, BETTER PAIN CONTROL\\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, RESP STATUS-PULM TOILET-MONITOR ABG,NEURO STATUS, I+O, LABS. AS PER ORDERS\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286321,\n \"text\": \"Nursing Progress Note:\\nNeuro: Pt anxious at times. AAO x3. MAE. No deficits noted.\\n\\nCV/Resp: Pt converted to aflutter last night. At ~0345, pt with c/o SOB and respiratory distress. HR increased to 140's with sats in the 80's. Dr at bedside. Pt received lasix 20mg, lopressor 5mg iv, and started on decadron. EKG showed aflutter. Anesthesia was called but intubation was cancelled. After ~40minutes, Pts respiratory distress improved and sats were in the low 90's on 100% nonrebreather. ABG po2 was 56 during the event. CXR results pending. Presently, pt is in aflutter with HR in the 100's. BP 100/40's. Sats 92% on 70% face tent and 4lnc. Pulses palpable. Rt pleural CT to wall suction. Airleak present. Blakemoore with minimal serosanguinous drainage. HCT 25.1. Team aware.\\n\\nGI/GU: Abdomen soft, obese. Foley cath. Slight diurese with lasix. Urine clear and yellow.\\n\\nEndoc: RISS\\n\\nPain: Morphine pca\\n\\nPlan: Monitor respiratory status. Continue neb treatment. watch hct. Pulmonary hygiene. Pain management. Wean o2.\\nPlan: Monitor respiratory status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286340,\n \"text\": \"focus update\\npt experiencing q 1-2 hour episodes of increased work of breathing with bronchospasm associated with pt being taken off positive pressure mode of ventilation. pt desats to 90s as low as 86%- despite mutiple bronchodialtors, diuresis, wheezing unchanged except when on positive pressure bypap mask. small leak noted at chest tube and placed to wall suction per icu resident\\n\\nneuro: alert and oriented x 3, mae+, follows commands consistently.\\n\\npt continues on heparin gtt, to have coumadin dose tonight, ptt q 6 hours. currently running at 1000u/hr.\\n\\nlasix iv continues, with good diuresis, kcl repleated x 4\\n\\nplan: continue to monitor respitory status closely, pulm toilet, diuresis, check ptt q 6 hours, moniotr rising wbc , p[ulmonary consult later today\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286341,\n \"text\": \"Resp Care\\n\\nPt with multiple episodes of coming off and on NIV; approx 10-15 minutes pt would develop increased wheezing and WOB. Pt received multiple bronchodilators. Wheezing decreases when placed back on NIV. Spo2 99% NIV with 50%.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286342,\n \"text\": \"Resp Care\\nPt continues NIPPV. PS weaned per team request, now remains at 5 with good TV's. BS coarse & wheezy bilaterally. PT given Q2-Q4hr neb tx's. Pt has non-productive cough at this time. Pt has ^^ WOB when taken off the NIPPV Mask and does not tolerate being off for long periods of time. FiO2 weaned to 35%. See CareVue for details and specifics.\\nPlan: Continue to wean settings as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286343,\n \"text\": \"FOCUSED NURSING NOTE\\nPlease see carevue flowsheet for further details\\n\\nNEURO: Slightly more lethargic this evening, A/O x 3, no changes in neuro assessments. Morphine 2mg x 3 for incr WOB and c/o general discomfort/request for sleep. Therapeutic effect observed with RR 18-20 and TV 400-500 while asleep.\\n\\nRESP: Mask ventilation CPAP PEEP 5 PS 8, PS titrated to 5 when sleeping comfortably- trial of no PS not tolerated by pt. ABGs with routine labs showing compensated resp acidosis- PCO2 climbing (63) in setting of high P02 (230), FiO2 titrated down to 35%, f/U ABG later this am. Awoke at 0200 with c/o feeling \\\"hot\\\" and incr WOB, audible stridor noted (afebrile)- treated with nebs q3-4hr, lungs with insp wheezes bilaterally, coarse on expiration. Strong cough, non-productive, sounds dry. Right CT patent to 20cm wall suction, 10ml drainage(serous), crepitus stable, drsg .\\nSPO2 99-100%. Plan CT CHEST today, am CXR ordered.\\n\\nHEMODYNAMICS: NSR 80-90s on Diltiazem gtt, no ectopy, plan d/c gtt and convert to oral Diltiazem this am. Normotensive, ABP 101-130s/40-60s. tolerating diuresis well, CVP 2-5, fluid balance -1286ml at MN, currently -780ml. K+ 3.9, repleted per sliding scale. Heparin gtt titrated per PTT and MD orders, next PTT due 0700. INR 0.9, Coumadin started at 2300 as ordered. No sx bleeding, HCT stable 25.6, PLT 317. Pt denies CP.\\n\\nID: Feels \\\"hot\\\" periodically, afebrile (verified rectally) and glucose relatively stable. Vanco/Zosyn as ordered, sputum cx pending, blood cx pending. CT today.\\n\\nGI/METABOLIC: Abd soft/hyperactive bowel sounds- no BM x ? days; Dulcolax suppos given, no results. TPN at 74ml/hr. Remains hyperglycemic (180-234) with minimal response to SQ RISS, insulin gtt initiated at 0500, titrated MD ordered scale.\\n\\nPLAN OF CARE:\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286336,\n \"text\": \"Resp Care\\n\\nPt was weaned from NIV this am for 2hrs; had episode of desaturation with increased wheezing and WOB; placed back on NIV. At noon again weaned to 50% face tent; abg 7.46/52/133/35; pt currently on face tent for 5hrs; fio2 titrated to 40%. Receiving scheduled bronchodilators. BS coarse. Plan to remain on face tent as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286337,\n \"text\": \"FOCUS; STATUS UPDATE\\nDATA;\\nALERT AND ORIENTED X3. MOVING ALL EXTREMITIES IN BED, WEAK. DENIES PAIN.\\nDILTIAZEM DRIP DISCONTINUED AND CHANGED TO LOPRESSOR IVP.\\nCONTINUES ON HEPARIN DRIP TITRATED TO PTT GOAL OF 50-60.\\nLUNGS COARSE THROUGHOUT. MINIMAL EXERTION CAUSES EXTREME SOB AND WHEEZING, DESATURATION TO 88%,ACCOMPANIED BY ANXIETY. NEBS BY RESPIRATORY THERAPY WITH GOOD EFFECT. CPAP OFF THIS AM, BUT PLACED BACK WITH SOB AND DESATURATION EVENT FOR SHORT PERIOD, NOW ON FACE TENT AT 40%. AFEBRILE. R CHEST TUBE AND JP IN PLACE. NO LEAK. CONTINUES WITH CREPITUS AROUND CHEST TUBE SITE.\\nTPN FOR NUTRITION.\\nADEQUATE URINE OUTPUT. CONTINUES NPO.\\n\\nPLAN;\\nCONTINUE TO MONITOR RESPIRATORY STATUS CLOSELY.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286338,\n \"text\": \"Respiratory Care: Pt remained off NIV all night and on 40% FM. Tolerated well for the most part, except episode of desaturation with physical excursion. Received alb/atr nebs. BS coarse wheeze.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286339,\n \"text\": \"Focused Nursing Note\\nPlease see carevue flowsheet for further details\\n\\nNEURO: A/O x 3, moves all extremities equally. No episodes of anxiety/agitation.\\n\\nRESP: CXR pending. Face tent 40% throughout night, general SPO2 94-98% with 1 episode of desaturation to 89% while sleeping soundly- ABG at that time confirmed Pa02 of 60, scheduled neb given and FiO2 incr to 70%- F/U ABG shows PaO2 135, PCo2 59. FiO2 returned to 40%, SPO2 95-98% remainder of shift. Pts lungs have Insp/Exp wheeze bilaterally, RUL coarse/bronchial sounds. Little sputum production, C/DB encouraged- unable to tolerate IS. Poor activity tolerance with labored breathing, RR 40s after little movement- recovers with coaching after 1-2 mins. Right CT intact, 30ml straw-colored drainge, ?minimal leak, MD aware. Morphine 2mg IV x 2 give for general discomfort, tachypnea, and insomnia- therapeutic effect observed.\\n\\nHEMODYNAMICS: NSR 70-90s, occassional PACs. Denies CP or resp distress at rest. Lopressor 5mg IVP q4hr ATC for rate control. SBP 102-140 via femoral A-line. NO edema. Adequate u.o., nearly uvolemic. Hct 24.5 stable. Heparin gtt titrated for PTT 49.1, next PTT due 0730. No sx bleeding.\\n\\nID: Afebrile. Vanco/Zosyn as ordered.\\n\\nGI/METABOLIC: Sips clears tolerated. Abd softly distended, pos BS, ?last BM. TPN at 74ml/hr. Hyperglycemic 239/243, treated per RISS.\\n\\nPSYCHOSOCIAL: Pt calm/coop. Visited by son, daughter called for update. Emotional support and education to pt and family provided.\\n\\nPLAN: Monitor resp status closely, incr activity as tolerated, Alb/Atr nebs ATC, pulm hygiene. Monitor cardiac status, Lopressor as ordered.\\nTPN. Consult team for improved glycemic control while on TPN/steroids. Cont steroid taper/antibiotics. Heparin gtt, goal 50-60, next PTT due 0730. Emotional support and education ongoing.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286332,\n \"text\": \" 7a-7p\\nneuro: a+o x3 with mild anxiety this am, increased anxiety x1 this am with ^in bp/hr/resp rate (sats remained in 90s on bipap, pt remained oriented x3), resolved with ativan 0.5mg x1; pt became confused around 1300 after returned to bipap for low sats, picking at ivs/pulling at tubes/pulling off clothing/pulling bipap off (worse after ativan ivp, haldol 5mg ivp given x1 with good result), pt still sleeping at this time; mae, perrlaa\\n\\ncv: sr/st 87-117 occasional pacs, sbp 107-150 (>130 with anxiety), dilt gtt started at 5 mg/hr (maintain at 5 per thoracic), heparin at 1000 units/hr (ptt at 1800), ct draining small amounts serosanguineous to wall suction, jp draining small amounts yellow drainage\\n\\nresp: lungs cta, diminished bilat, bilat crepitus to upper chest/right thoracotomy/bilat scapula (team aware), bipap fi02 70 ps 12 02 sats now 96%, attempted pt on face mask today, did not tolerate, returned to bipap after 02 sats dropped to mid-high 80s, when on mask able to use is 250-500ml with weak/moderate strength nonproductive cough\\n\\ngi: positive bowel sounds, soft non distended abdomen, tolerated sips with meds this am, started tpn this pm, no insulin coverage per np at this time\\n\\ngu: foley draining adequate amounts clear yellow urine\\n\\naccess: triple lumen catheter placed to right ij as unable to place piv (after 4 attempts)\\n\\nlabs: stable\\n\\nassess: improving\\n\\nplan: haldol 5mg im q4 for agitation, wean bipap as tolerated, continue heparin/diltiazem gtts\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286333,\n \"text\": \"BS rhonchi, intermittent wheezes improving somewhat with MDI's. Tried off NIV but with significant desats. Generally very agitated pulling mask off or out of position. Not responding well to Ativan but seems better after Haldol. Now resting reasonably comfortably. Still may require intubation for increased WOB.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286334,\n \"text\": \"nsg note\\nSEE FLOWSHEET FOT SPECIFICS.\\n\\nNEURO-PT A+OX3. MAE. FOLLOWS COMMANDS.\\n\\nCV-HR 80-90'S, SINUS. UP TO 100'S WHEN AGITATED. REMAINS ON DILT GTT. SBP STABLE. SKIN W+D. +PP. DENIES CARDIAC COMPLAINTS. REMAINS ON HEPARIN GTT, PTT 70.\\n\\nRESP-CON'T WITH WHEEZES THROUGHOUT. NEBS GIVEN. PT WITH STRONG COUGH PRODUCTIVE OF VERY THICK WHITE SPUTUM. ON BIPAP MASK MOST OF NOC. TOL WELL. RR WNL AND O2 SAT 98% WHEN ON BIPAP. PT AND SAT DOWN TO 91% WHEN OFF MASK. RIGHT CT TO H20 SEAL WITH STRAW COLORED DRG. + FLUCUATION, NO AIR LEAK. + CREPITUS. TEAM AWARE. TO HAVE XRAY THIS AM. RIGHT JP WITH SEROUSSANG DRG.\\n\\nGI-NPO. ABD SOFT/NT/ND. +BS. REMAINS ON TPN.\\n\\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW DRG.\\n\\nCOMFORT-HALDOL GIVEN FOR AGITATION WITH GOOD EFFECT.\\n\\nENDO-SSRI.\\n\\nID-AFEB. REMAISN ON ABX.\\n\\nP-CON'T WITH CURRENT PLAN. PULM HYGIENE. CT TO H2O SEAL. SUPPORT. FOLLOW LABS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286335,\n \"text\": \"Respiratory Care Note:\\n\\nPt tranfert t/o night from CSRU on NRM, placed on NIV immediatly & remain on NIV t/o shift. We were to wean FIO2 from 70 to 50%. He awoke and asked to take off NIV mask/ Nebs given and placed back on NIV. Plan: pulm hygiene & Continue present ICU monitoring and keep confortable. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286359,\n \"text\": \"Respiratory Therapy\\n0545 Pt presents W 6L n/c and .5 venti mask in high position. Sats mid 80's. Placed on NRBM and 6L n/c. BS clear on left, BS on rt only audible fine wheezes mid apex. MD aware. CXR revealed a worsening rt side. (+) air leak from rt CT. Albuterol/Atrovent given with slight improvement. Sats 88% after 30 minutes, sats increased to 93%. Plan: Discuss W attending. Continue W Respiratory follow up.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286360,\n \"text\": \"focus hemodynmics\\ndata: neuro: alert and oriented. moves all extremities on the bed. oob to the chair. engages in conversation.\\n\\nresp: on o2 at 6 liters via nasal prongs. o2sats 90-93. coughing without raising any sputum. hob elevaated with pillows under arms. at 0600am sat dropped to 86%. resp 30's. alberterol and atrovent neb treatment given. cxr done and results per dr worse. chest tube to water seal and placed to suction. chest tube has an air leak. bipap ordered. resp therapist in room. thoracic team called. pt to be bronched.\\n\\ncardiac: in normal sinus rythmn. occ pvc. lopresssor 75mg via fdg tube given.\\n\\ngI abd soft and no stool tonite. tol po foods well.\\n\\ngu: voiding in the urinal qs.\\n\\naction: bipap added for resp distress. thoracic team at the bedside. bronch cart at the bedside. hob elevated pillows under arms. emotional support provided. daughter called this am 0700am and update given regarding difficulty breathing.\\n\\nrespone: monitor closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286361,\n \"text\": \"Update\\nSee Carevue for specifics\\n\\nNeuro: A & O x 3, PERRL, normal strength. OOBTC & ambulate around room.\\n\\nCV: NSR/ST. SBP WNL.\\n\\nResp: Pt in respiratory distress this a.m. Sats in high 70s, tachypnic with labored breathing. Switched from non-rebreather to BIPAP with little effect. Bronchoscopy performed with some difficulty at approx 0800. Pt agitated and given .5 versed for comfort. 30 mg ascetylcysteine instilled via bronch for extremely thick secretions. Copious amounts of secretions removed. Cx sent. Pt on BIPAP immediately s/p bronch. Later switched to non-rebreather and currently sats at 100% and doing well. Incentive spirometry, chest PT and CDB done. Chest tube d/c'd and replaced by pleurovac. Draining serosang fluid, no crepitus, no leakage noted.\\n\\nGI: House diet. +BS. Small formed stool x 1.\\n\\nGU: Voids in urinal.\\n\\nSocial: Daughter and wife in to visit.\\n\\nPlan: Aggressive pulmonary toilet to mobilize secretions. OOB and ambulate again before sleep tonight. Provide quiet environment to sleep. Bronchoscopy tomorrow. Transfer to floor.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286362,\n \"text\": \"Respiratory Therapy\\n\\nPt received this AM w/ SpO2 70s-80s, NIPPV started and bronched at bedside by thoracic team. Multiple mucous plugs cleared, put on 100% NRB post procedure; alternating between that and NIV. See resp flowsheet for specifics.\\n\\nPlan: maintain support\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286354,\n \"text\": \"Condition Update\\nPlease see carevue for specifics.\\n\\nPt alert and oriented x 3. MAE. OOB to the chair w/ supervision only. Afebrile. NSR. No ectopy noted. No c/o pain. Right chest tube to H20 seal w/ no drainage. +fluctuation + leak. Thoracic sx aware. JP drain d/c'd today. DSD placed. Small amt of bloody drainage at jp d/c site. LS w/ ins/exp wheezing. Nebs given by resp tx. Pt also using IS at bedside. Pt voiding in adequate amts. Tolerating regular diet. RISS for bs coverage.\\n\\nPlan: continue with current plan of care per sicu/ thoracic sx team. xfer to fl ?. pulm toilet. neb tx's. oob.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286355,\n \"text\": \"Please See Carevue for Specifics.\\n\\nPt slept majority of the night. Received 0.25mg Ativan for sleep assistance with effect. Right chest tube to water seal with +leak and +fluc, -crepitus with sero drainage, DSD with sang staining noted.\\n\\nPOC: Transfer to floor when bed avail. Continue to encourage self ADl's, OOB to chair/ambulate as tolerates. Pain management as needed. Continue to offer emotional support to pt and pt family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286356,\n \"text\": \"Respiratory therapy\\nPt presents on 4L n/c fine wheezes bilaterally. Alb/Atrovent neb given W good effect. Increased aeration. MDI spacer placed W Pt's MDI's.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286357,\n \"text\": \"Nursing Progress Note\\nSee Carevue for details\\n\\nNeuro: AOx3. Pleasant and cooperative. MAE with nml strength. Denies HA, dizziness, or changes in vision.\\n\\nCV: NSR. No ectopy. HR 70's-80's. BP 110-120/50. +PP. No edema noted. On Heparin SC.\\n\\nResp: LS clear to coarse in upper airways, diminished at bases. Able to administer inhalers with spacer independently.\\n\\nGI: Tolerating hse diet. No N/V. Abdomen soft, NT/ND. +BS.\\n\\nGU: voiding CYU in urinal without difficulty.\\n\\nSkin: Right Chest tube site covered DSD-no drainage. No crepitus. Old JP drain site covered DSD no drainage-pt reports site is painful at times-given 1 mg Morphine IVP with good effect.\\n\\nPlan: ?transfer to floor. Continue monitor VS, resp status, labs.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286363,\n \"text\": \"focus hemodymics\\ndata: neuro: alert and oriented. moves all extremities on the bed. oob to chair.\\n\\nresp: on 80% hi flow mask. o2sats 100%. inhalers as ordered. coughing but not raising any sputum. spirocare done. chest pt done x 3. chest tube intact with small pleuravac intact. to have bronchoscopy done today.\\n\\ncardiac: in nsr. bp stable.\\n\\ngI abd soft. taking po's with difficulty. no stool tonite.\\n\\ngu: voiding clear yellow urine.\\n\\naction: oob to chair. inhalers as ordered. chest pt. 80% face mask hi flow intact. postion changed frequenty during the nite. update to daughter. tylenol given for generalized achiness.\\n\\nresponse: monitor closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286364,\n \"text\": \"Respiratory Care Note:\\n Patient changed to a high flow continuous aerosol to facilitate secretion clearance and weaning of FIO2. He has tolerated 80% t/o shift with SpO2>99%. His RR has been 16-28. Plan for bronchoscopy today. Yesterday's bronch was done via facemask ventilation, therefore, ventilator not D/C'd at this time. He has been recieving MDIs app Q4 and uses good technique with maneuvers.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286349,\n \"text\": \"condition update\\nneuro: alert and oriented x's 3, mae to command, no c/o pain. ativan held at 1800, pt denied anxiety and very comfortable. Pt requested ativan at 0100 for help with sleeping.\\ncv: nsr 80's-90's. Very brief (5 sec) run of svt, self resolved. Dr. notified, electrolytes checked, K+ repleted. No further episodes. bp stable, peripheral pulses palpable. Lasix 20mg iv x's 1 (standing order) with + diuresis.\\nresp: ls wheezy/coarse - though less wheezy this am. Alb./atrov. nebs atc per r.t. Pt denies sob, 02 sat 95-100% on 50% face tent. CT to suctioned, draining small amts. serous drainage. +fluctuation, + leak (unchanged). No crepitus noted. Coughing/deep breathing encouraged.\\ngi: abd soft, nontender, +bs, no bm. swallows pills without difficulty.\\ngu: foley draining adequate amts. clear yellow urine.\\nendo: insulin gtt titrated.\\nskin: right chest tube site dsd intact, no drainage noted. Skin otherwise intact.\\nplan: pulmonary toileting, oob to chair/ambulat, monitor resp. status, chest x-ray this am, ? transfer to floor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286350,\n \"text\": \"Respiratory Care\\nPt continues 50% high flow via face tent. BS coarse bilaterally and becoming less wheezy. Nebs given as ordered with good effect. Spo2 98-100%. Will continue to treat pt with nebs as ordered.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286358,\n \"text\": \"Nursing Progress Note\\n Please see carevue for details of care. Awake, alert and oriented. Pleasant, cooperative and compliant. OOB to chair w/assist tol well this am. MAEW, Denies discomfort. BS sl dim this am w/few exp wheezes noted which cleared after inhalers. ISE encouraged and tol well. Remains in NSR w/no ectopy, VSS.\\n Became SOB suddenly this am w/sats quickly down to high 60's range. Became tachypneic, wheezes t/o. PRN albuteral INH given, resp at bedside. SICU team and primary MD aware and at bedside. Pulmonary team notif by SICU team. CXR repeated. Sats remain 70's after back to bed, 50% face mask + 6L NC on w/sats recovered to high 80's, changed to 100% NRB mask + 6L NC w/sats only recovering to 91-93 range. Teams aware. Sats slowly recovered to 97-98 range, O2 weaned back to 50% mask and 6L NC. Mask off early pm by patient w/sats maint 93-95, remains SOB and tachypneic w/exertion.\\n R chest tube intact w/DSD intact, draining scant amt serous fluid in tube. + air leak noted, no crepitus. Old JP site covered w/DSD, drainage. Med x1 for pain w/ Morphine 1 mg this pm w/stated effect.\\n PLAN: Cont to monitor resp status, chest pt, monitore O2 requirements. Transfer to floor when stable and bed avail.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286351,\n \"text\": \"Condition Update\\nPlease see carevue for specifics.\\n\\nPt alert and oriented. MAE. No c/o pain. NSR> No ectopoy noted. Afebrile. Insulin gtt d/c'd. RISS started. BS well controlled. CVL d/c'd once peripheral access obtained. LS w/ rhonchi throughout. Nebs given by resp tx. Chest tube placed to water seal by thoracic sx. + leak. Thoracic team aware. Breathing much easier today per pt. 02 sats 94-100% on 15L Hi flow mask. CXR done this afternoon. JP drain in pleural space to bulb sxn. Foley d/c'd this eve. Pt is approx 2400. No BM. Pt is tolerating a regular diet well. Integ intact.\\n\\nPlan: continue with current plan of care per sicu/ thoracic sx teams. CT to water seal. SS for bs coverage. OOB/ ambulate as tolerated. Pulm toilet.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286352,\n \"text\": \"condition update\\nplease see carevue for specifics;\\nneuro: alert and oriented x's 3, pleasant and cooperative. Mae to command. c/o mild to mod. pain at chest tube site, morphine 1mg iv x's 2 with good relief.\\ncv: nsr with occasional pac's. brief episode of svt, dr. aware, electrolytes wnl.\\nresp: ls noted for insp/exp wheezes, alb. and atr. atc. chest to h20 seal, draining small amts. serous drainage, +leak (unchanged), - crepitus, + fluctuation. dsg c/d/i. 02 sat 97-99% on 50% face tent. pt comfortable, denies sob. coughing/deep breathing encouraged.\\ngi: abd. soft/nontender, +bs, no bm.\\ngu: pt at 2400, voided 300cc clear yellow urine at 2300.\\nendo: ssri\\nskin: intact\\nsocial: son at bedside early this evening.\\nplan: continue p.t., pulmonary toileting, monitor u/o, pain management. ? transfer to floor today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1286353,\n \"text\": \"BS CTAB, no wheezing now; no change with bronchodilators. Weaned to nasal cannula 5L/m. Awaiting call out to floors.\\n\"\n }\n]"}}},{"rowIdx":24673,"cells":{"subject_id":{"kind":"number","value":60548,"string":"60,548"},"hadm_id":{"kind":"number","value":159650,"string":"159,650"},"target_text":{"kind":"string","value":"Pt admitted to neurosurgery service and the ICU on . Her intial imaging appeared to be consistent with a interventricular mass that had hemorrhaged. She had no hydrocephalus and did not require an emergent procedure. An MRI/MRA of the head was obtained to evaluate this mass and showed it to be suggestive of an ACOMM aneurysm. For further evaluation, a diagnostic cerebral angiogram was performed and this confirmed the presecnce of a large thrombosed ACOMM aneurysm. After her anerusym was confirmed she was intubated with anesthesia and she underwent an umcomplicated coiling of this aneurysm. She did remain intubated overnight and was kept flat bed rest for 6 hours. On post op exam she did not follow commands but she moved all extremities purposefully and her pupils remained equal and reactive. She had no signs of groin hematoma and she had good distal pulses. She was extubated on the morning of without difficulty. Her exam improved and she was opening eyes intermittently to voice, following commands and moving all extremities with good strength. Her groin site remained clean and dry with no signs of hematoma and she had good distal pulses. Psychiatry was consulted and recommended given her altered mental status they recommended an EEG which showed an abnormal EEG due to the presence of a slower than average background. This finding may could be seen in the context of a mild to moderate encephalopathy of toxic, metabolic, or anoxic etiology. They recommened restarting her Methadone in case she was withdrawing causing her altered mental status. Haldol was also started. On she underwent an angiogram which showed Acomm artery coiling with no residual filling. On she was transferred to the Step Down Unit were she remained stable and she was transferred to the floor on . Her methadone was increased to 30mg on . Social Work continued to provide support to the patient. On her Methadone was increased to 40mg. On she was scheduled for a cerebral angio but was cancelled because patient was unable to tolerate. She underwent an angiogram on which was stable. She was discharged to on ."},"extractive_notes_summ":{"kind":"string","value":"After removal of the angle Glidewire, a left internal carotid artery cerebral angiogram was performed. Cerebral angiography at that time revealed an anterior communicating artery aneurysm which was subsequently coiled. eval vasculature FINAL REPORT HISTORY: Intracranial hemorrhage and anterior communicating artery aneurysm. Stable 1.6mm left MCA bifurcation aneurysm Multiple angiograms performed via the left internal carotid artery show excellent occlusion of the anterior communicating artery aneurysm seen previously. The wire was then removed and multiple diagnostic angiograms performed through the left internal carotid artery at varying obliquities. With the catheter at the level of the distal aorta, an aortogram was performed. Access to the left common femoral artery was attempted with adequate amount of local anesthesia. A 0.035 angled Glidewire was then inserted through the Berenstein catheter and carefully advanced into the internal carotid (Over) 9:22 AM CAROT/CEREB Clip # Reason: eval for aneurysm completion of coil Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS Contrast: OPTIRAY Amt: 148 FINAL REPORT (Cont) artery and thereafter followed by the Berenstein catheter. At this point, anesthesia was consulted for intubation. There were normal cervical, petrous, cavernous, and supraclinoid segments of the internal carotid artery. PROCEDURE: Cerebral angiogram, coil embolization of anterior communicating artery aneurysm. REASON FOR EXAM: Cerebral angiography and coil embolization of anterior communicating artery aneurysm. Following this, with aid of the angled Glidewire, the tip of the Omniflush catheter was then manipulated into the right common iliac artery and a second angiogram was performed. There were normal cervical, petrous, cavernous and supraclinoid segments of the internal carotid artery. The wire was then removed, and the catheter slowly manipulated into the left common carotid artery. FINAL REPORT HISTORY: Recently called anterior communicating artery aneurysm, follow up study. To reassess coil pack and aneurysm. Over the angled Glidewire, a straight Neuron catheter was placed with tip within the left internal carotid artery. The right and left common carotid arteries were selectively catheterized and cerebral angiogram was obtained in AP, lateral and oblique projections. Left internal carotid artery post-embolization run showed minimal residual filling of the aneurysm of the anterior communicating artery. RIGHT FEMORAL VASCULAR ULTRASOUND: Normal color flow and Doppler waveforms are noted in the right common and superficial femoral artery and vein, as well as the greater saphenous vein. VESSELS SELECTED: Right common carotid artery, left common carotid artery and left internal carotid artery. INDICATION: Evaluate for residual filling in anterior communicating arterial aneurysm and for possible right common femoral pseudoaneurysm. A post-coiling angiogram showed that the aneurysm was successfully coiled with near-complete embolization and minimal residual filling. The Berenstein catheter was retracted into the descending aorta, and wire was placed to secure access and then the catheter was removed. The left internal carotid artery was catheterized and angiograms were obtained in the lateral and oblique projections with 3D rotational images. Via the normal-appearing left A1 segment, there was filling of a 5 x 6 x 7 mm aneurysm arising at the anterior communicating artery with a 3-mm neck. Via microcatheter technique, the left internal carotid artery and left A1 ACA were also selected. Under fluoroscopic guidance, the microcatheter was advanced into the aneurysm sac of the anterior communicating artery via the left A1 segment of the anterior cerebral artery. FINDINGS: Left internal carotid artery injection demonstrated normal and brisk filling of the cervical, petrous, cavernous and supraclinoid segments. PROCEDURE: Cerebral angiogram. PROCEDURE: Cerebral angiogram. A small amount of hemorrhage appears to be present in the right sylvian fissure. Unchanged, 1.6mm aneurysm arising from the left MCA bifurcation. Using fluoroscopy, these two were advanced into the ascending aorta. After instillation of 1% lidocaine for local anesthesia into the right groin, access to the right common femoral artery was obtained using a micropuncture set. Injection of a small amount of contrast confirmed location in the left common carotid. IMPRESSION: Tubular pseudoaneurysm arising from common femoral artery, with surrounding soft tissue hematoma. VESSEL SELECTED: Left internal carotid artery. An ultrasound done after that time on raised concern for a possible right common femoral arterial pseudoaneurysm. TECHNIQUE: After verbal liaison with (neurosurgery service), a consensus was obtained to perform the procedure in view of the risks, benefits and alternative management for the patient care. IMPRESSION: Successful coiling of an anterior communicating artery aneurysm with near-complete obliteration of the aneurysm. Thereafter, a 4 French Omniflush catheter was advanced into the aorta, and the wire was removed. 9:22 AM CAROT/CEREB Clip # Reason: eval for aneurysm completion of coil Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS Contrast: OPTIRAY Amt: 148 ********************************* CPT Codes ******************************** * SEL CATH 2ND ORDER INTRO CATH AORTA * * ABD A-GRAM EXT UNILAT A-GRAM * * CAROTID/CEREBRAL UNILAT * **************************************************************************** MEDICAL CONDITION: 41 year old woman with acomm aneurysm coiling REASON FOR THIS EXAMINATION: eval for aneurysm completion of coil FINAL REPORT HISTORY: 41-year-old woman with severe headache on and intracranial hemorrhage."},"n_notes":{"kind":"number","value":14,"string":"14"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2109-11-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1162243,"text":" 4:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41F with hx IVDU found with AMS and midline frontal IPH now s/p coiling of\n Acomm aneurysm.\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf WED 1:16 PM\n No acute cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status, status post coiling of ACom aneurysm,\n assess for pneumonia.\n\n TECHNIQUE: Portable upright radiograph of the chest.\n\n COMPARISON: Semi-upright portable chest radiograph, .\n\n FINDINGS: Left IJ terminates at the confluence of brachiocephalic vessels.\n The lungs are clear without focal opacity. Heart is normal in size with\n normal cardiomediastinal silhouette. No pleural effusion seen, although the\n left base is incompletely imaged.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n"},{"category":"Radiology","chartdate":"2109-11-18 00:00:00.000","description":"INTRO CFA/SFA/ILIAC/POP GRAFT","row_id":1163183,"text":" 3:05 PM\n CAROT/CEREB Clip # \n Reason: eval for aneurysm completion of coil\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n ********************************* CPT Codes ********************************\n * INTRO CFA/SFA/ILIAC/ GRAFT *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Anterior communicating artery aneurysm coiled. For\n complete evaluation of coil.\n\n REASON FOR EXAMINATION: Apparent change in clinical status. To reassess coil\n pack and aneurysm.\n\n ATTENDING:\n NEURORADIOLOY FELLOW: Dr. , MD, MRCP and FRCR.\n\n NURSE : .\n\n DETAILS OF THE PROCEDURE: Written informed consent was obtained from the\n patient after explaining the risks, benefits and alternative management. The\n patient was brought to the neurointerventional suite and placed in the biplane\n table in the supine position. A preprocedure timeout was performed using two\n different identifiers, clinical indication and laboratory values. Both groins\n were prepped and draped in the standard sterile fashion.\n\n Access to the left common femoral artery was attempted with adequate amount of\n local anesthesia. The patient was unable to tolerate the procedure and was\n moving constantly despite multiple reassuring attempts from the staff.\n Access to the left common femoral vein was obtained, but since the patient was\n unable to cooperate and started fearing, it was considered prudent not to\n proceed and reattempt the procedure with general anesthesia.\n\n IMPRESSION: was planned to have a cerebral angiogram for\n reassessment of the anterior communicating artery aneurysm coil and change in\n clinical status. Since the patient kept constantly moving and did not\n tolerate the procedure, the procedure is incomplete and abandoned considering\n the safety of both patient and staff. Procedure would be considered under\n general anesthesia. The patient was also abusive to the staff.\n\n"},{"category":"Radiology","chartdate":"2109-11-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1161846,"text":" 3:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pna\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with AMS s/p coiling of aneurysm, fever\n REASON FOR THIS EXAMINATION:\n pna\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with altered mental status.\n\n Portable AP chest radiograph was compared to and radiographs.\n\n Right basal opacity continues to increase and may represent developing right\n lower lobe pneumonia.\n\n"},{"category":"Radiology","chartdate":"2109-11-08 00:00:00.000","description":"DISTINCT PROCEDURAL SERVICE","row_id":1161439,"text":" 7:29 AM\n MR HEAD W & W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST; MRV HEAD W/O CONTRAST\n Reason: Preop in case of OR\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 22\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with 40F IVDA on methadonelast nml 8 days agofound in bed\n with dead infantpsychotic, combative, mass vs bleed on head CTCT read: Large\n high density mass in midline anterior cranial fossa 4.8x2.5x2.8 cm, extending\n from suprasellar cistern, superiorly into septum pellucidum -- diff dx large\n acute hematoma vs giant aneurysm, +obstructive hydrocephalus\n REASON FOR THIS EXAMINATION:\n Preop in case of OR\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n TECHNIQUE: MRI of the brain without and with gad. MRA using 3D\n time-of-flight technique. MRV using 2D time-of-flight technique.\n\n FINDINGS:\n\n Comparison is made with prior examination from .\n\n There is a large acute hematoma centered in the septum pellucidum and the\n frontal , left greater than right extending into the corpus callosum and\n the cingulate gyrus anteriorly. There is also suggestion of an anterior\n communicating artery aneurysm at the base of this hematoma.\n\n A small amount of hemorrhage appears to be present in the right sylvian\n fissure. There is mild hydrocephalus with enlargement of the temporal horns.\n\n On the MRA, there is suggestion of an anterior communicating artery aneurysm\n although this is difficult to assess in the setting of extensive hemorrhage in\n that vicinity.There is some irregularity and narrowing of bilateral MCA\n branches. This could represent vasospasm or vasculitis. Consider CTA for\n further evaluation.\n\n MRV demonstrates no significant abnormality.\n\n There is mild bilateral mastoid and ethmoid opacification. No definite\n underlying mass lesion is identified.\n\n\n\n IMPRESSION:\n\n Large hematoma which is acute to subacute along the septum pellucidum, frontal\n horns, frontal lobe and cingulate gyrus with suggestion of an ACOM aneurysm at\n the base of the hematoma. Recommend correlation with CTA. There is also\n irregularity and narrowing of bilateral MCA branches which could represent\n vasospasm versus vasculitis. Findings were discussed with at\n (Over)\n\n 7:29 AM\n MR HEAD W & W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST; MRV HEAD W/O CONTRAST\n Reason: Preop in case of OR\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 22\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 11:40 a.m. on .\n\n"},{"category":"Radiology","chartdate":"2109-11-12 00:00:00.000","description":"SEL CATH 1ST ORDER","row_id":1162077,"text":" 8:51 AM\n CAROT/CEREB Clip # \n Reason: 41 year old woman with ACA aneurysm partially coiled.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n Contrast: OPTIRAY Amt: 74\n ********************************* CPT Codes ********************************\n * SEL CATH 1ST ORDER CAROTID/CEREBRAL UNILAT *\n * MOD SEDATION, FIRST 30 MIN. MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with ACA aneurysm partially coiled.\n REASON FOR THIS EXAMINATION:\n 41 year old woman with ACA aneurysm partially coiled.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Recently called anterior communicating artery aneurysm, follow up\n study.\n\n PROCEDURE: Cerebral angiogram.\n\n ATTENDING:\n NEURORADIOLOGY FELLOW: Dr. , MB, MRCP, FRCR.\n\n NURSE PRACTITIONER: .\n\n PROCEDURE: Cerebral angiogram.\n\n VESSEL SELECTED: Left internal carotid artery.\n\n SEDATION: Moderate sedation was provided by administering divided doses of\n 250 mcg of fentanyl and 5 mg of Versed over the total intraservice time of 1\n hour 5 minutes. During this time, the patient's hemodynamic parameters were\n continuously monitored.\n\n TECHNIQUE: After verbal liaison with (neurosurgery service), a\n consensus was obtained to perform the procedure in view of the risks, benefits\n and alternative management for the patient care. The patient was brought to\n the neuro-interventional suite and placed in the supine position on the\n biplane table. A preprocedure timeout and huddle was performed documenting\n the patient's identity using two different identifiers, nature of the\n procedure to be performed, laboratory parameters and patient's history. Both\n groins were prepped and draped in a standard sterile fashion. After\n instillation of 1% lidocaine for local anesthesia into the right groin, access\n to the right common femoral artery was obtained using a micropuncture set.\n Using Seldinger technique, a 4 French vascular sheath was successfully placed\n into the right common femoral artery. This was connected to the continuous\n infusion of pressurized heparin and saline.\n\n The left internal carotid artery was catheterized and angiograms were obtained\n in the lateral and oblique projections with 3D rotational images. Right groin\n (Over)\n\n 8:51 AM\n CAROT/CEREB Clip # \n Reason: 41 year old woman with ACA aneurysm partially coiled.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n Contrast: OPTIRAY Amt: 74\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hemostasis was obtained using a manual compression technique for 25 minutes.\n The patient tolerated the procedure well with no immediate complications. The\n patient was sent to the ICU with post-procedure orders.\n\n FINDINGS: Left internal carotid artery injection demonstrated normal and\n brisk filling of the cervical, petrous, cavernous and supraclinoid segments.\n The middle and anterior cerebral arteries were seen and appeared normal. The\n recently coiled anterior communicating artery aneurysm showed no evidence of\n residual filling.\n\n IMPRESSION: underwent a cerebral angiogram which demonstrates\n no evidence of residual filling within the recently coiled anterior\n communicating artery aneurysm.\n\n"},{"category":"Radiology","chartdate":"2109-11-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1161635,"text":" 3:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for pna\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with leukocytosis, ?pna\n REASON FOR THIS EXAMINATION:\n Eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Leukocytosis.\n\n Cardiomediastinal contours are normal. The lungs are clear. There is no\n pneumothorax or pleural effusion. ET tube tip is in standard position. The\n tip is approximately 6 cm above the carina. Left IJ catheter remains in\n place.\n\n\n"},{"category":"Radiology","chartdate":"2109-11-08 00:00:00.000","description":"SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR SCREENING","row_id":1161409,"text":" 2:56 AM\n SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR Clip # \n Reason: survey for MRI\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman who was found with AMS\n REASON FOR THIS EXAMINATION:\n survey for MRI\n ______________________________________________________________________________\n WET READ: YGd FRI 7:21 AM\n No radiopaque object within skull, chest, abd, or pelvis. d/ by \n \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old female here for pre-MRI surveillance.\n\n FINDINGS: Radiographs of the head, neck, chest, and abdomen demonstrate no\n evidence of radiopaque foreign body with the exception of dental amalgam\n within imaged portions of the body. Partially imaged lungs are clear.\n Cardiomediastinal silhouette is normal. Bowel gas pattern is unremarkable.\n\n IMPRESSION: No evidence of radiopaque object within the head, chest, abdomen,\n or pelvis. This was discussed with on at the time of\n exam completion.\n\n\n"},{"category":"Radiology","chartdate":"2109-11-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1162244,"text":", J. NSURG SICU-A 4:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41F with hx IVDU found with AMS and midline frontal IPH now s/p coiling of\n Acomm aneurysm.\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n PFI REPORT\n No acute cardiopulmonary process\n\n"},{"category":"Radiology","chartdate":"2109-11-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1161767,"text":" 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 41 year old woman with increase in WBC, evaluate for infecio\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with increase in WBC, evaluate for infecious process\n REASON FOR THIS EXAMINATION:\n 41 year old woman with increase in WBC, evaluate for infecious process\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Increase in white blood count.\n\n Comparison is made with prior study performed a day earlier.\n\n There are lower lung volumes. Bibasilar opacities greater on the right side\n are consistent with atelectasis. Cardiac size is top normal, accentuated by\n the low lung volumes and the projection. Left IJ catheter remains in place.\n There is no pneumothorax or pleural effusion.\n\n\n"},{"category":"Radiology","chartdate":"2109-11-08 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1161430,"text":" 4:56 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: pneumothorax, line location\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with possible IPH, s/p L IJ placement\n REASON FOR THIS EXAMINATION:\n pneumothorax, line location\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: IJ placement, questionable pneumothorax.\n\n COMPARISON: No comparison available at the time of dictation.\n\n FINDINGS: The lung volumes are normal. There are no pleural effusions and no\n pneumothorax. Borderline size of the cardiac silhouette without evidence of\n pulmonary edema. Newly placed left internal jugular vein access line. The\n tip of the line projects over the mid SVC.\n\n\n"},{"category":"Radiology","chartdate":"2109-11-08 00:00:00.000","description":"EMBO TRANSCRANIAL","row_id":1161547,"text":" 3:01 PM\n CAROT/CEREB Clip # \n Reason: 41 year old woman with corpus collosum mass/hemorrhage. eval\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n Contrast: OPTIRAY Amt: 315\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CERVICAL BILAT *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT *\n * -59 DISTINCT PROCEDURAL SERVICE SEL EA ADD'L *\n * TRANSCATH EMBO THERAPY F/U TRANS CATH THERAPY *\n * MOD SEDATION, FIRST 30 MIN. MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: Please note that there is a 1.6 mm aneurysm arising from the left\n middle cerebral artery bifurcation.\n\n\n\n 3:01 PM\n CAROT/CEREB Clip # \n Reason: 41 year old woman with corpus collosum mass/hemorrhage. eval\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n Contrast: OPTIRAY Amt: 315\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with corpus collosum mass/hemorrhage. eval vasculature\n REASON FOR THIS EXAMINATION:\n 41 year old woman with corpus collosum mass/hemorrhage. eval vasculature\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intracranial hemorrhage and anterior communicating artery aneurysm.\n\n PROCEDURE: Cerebral angiogram, coil embolization of anterior communicating\n artery aneurysm.\n\n REASON FOR EXAM: Cerebral angiography and coil embolization of anterior\n communicating artery aneurysm.\n\n OPERATOR: Dr. .\n\n FELLOW: Dr. .\n\n VESSELS SELECTED: Right common carotid artery, left common carotid artery and\n left internal carotid artery. Via microcatheter technique, the left internal\n carotid artery and left A1 ACA were also selected.\n\n ANESTHESIA: The first portion of the procedure was done under moderate\n sedation provided by 250 mcg of fentanyl in five divided doses and 5 mg of\n Versed in five divided doses throughout the intraservice time of 1 hour and 10\n minutes, during which time the patient's hemodynamic parameters were\n continuously monitored. At this time, general anesthesia was induced by the\n anesthesia team and the anesthesia team monitored the patient for the\n remainder of the procedure.\n\n Technique: Emergency consent was provided by the neurosurgery team and\n documented in the patient's chart. The patient was brought to the\n neurointerventional suite and placed in supine position on the biplane table.\n Preprocedure timeout documenting patient identity, nature of the procedure and\n relative blood work was done using two independent identifiers. Both groins\n were prepped and draped in usual sterile fashion. Using a 19-gauge\n single-wall needle, access was gained to the right common femoral artery and\n with the aid of a 0.035 Berenstein wire, a 4 French Avanti sheath was placed.\n This sheath was connected to continuous infusion of a mixture of heparin and\n normal saline with continuous drip. A 4 French Berenstein 2 catheter was\n placed over the wire and connected to continuous saline infusion of a mixture\n of heparin and saline. The right and left common carotid arteries were\n selectively catheterized and cerebral angiogram was obtained in AP, lateral\n and oblique projections. After reviewing the images and discussing the\n below-mentioned findings with the patient's clinical team, a unified decision\n dictated intervention. At this point, anesthesia was consulted for\n intubation. After the anesthesia team induced general anesthesia, the 4\n (Over)\n\n 3:01 PM\n CAROT/CEREB Clip # \n Reason: 41 year old woman with corpus collosum mass/hemorrhage. eval\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n Contrast: OPTIRAY Amt: 315\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n French Avanti sheath was exchanged for a 6 French 25-cm Terumo sheath using an\n exchange length 0.038 angled Glidewire. Over the angled Glidewire, a straight\n Neuron catheter was placed with tip within the left internal carotid artery.\n After removal of the angle Glidewire, a left internal carotid artery cerebral\n angiogram was performed. Subsequently, an Excelsior SL-10 microcatheter was\n advanced with the aid of a Synchro-2 standard microwire. Under fluoroscopic\n guidance, the microcatheter was advanced into the aneurysm sac of the anterior\n communicating artery via the left A1 segment of the anterior cerebral artery.\n Coiling of the aneurysm was done using three GDC soft coils. A post-coiling\n angiogram showed that the aneurysm was successfully coiled with near-complete\n embolization and minimal residual filling. At this point, the wire and the\n catheter were withdrawn. A 6 French Angio-Seal closure device was used to\n close the site of puncture. The patient remained intubated and was sent to\n the ICU with post-procedure orders.\n\n FINDINGS:\n The right common carotid artery showed brisk filling of both internal and\n external carotid arteries. There were normal cervical, petrous, cavernous and\n supraclinoid segments of the internal carotid artery. The middle and anterior\n cerebral arteries were seen and appeared normal. The aneurysm at the anterior\n communicating artery did not fill.\n\n Left common carotid artery showed brisk filling of both internal and external\n carotid arteries. There were normal cervical, petrous, cavernous, and\n supraclinoid segments of the internal carotid artery. The middle cerebral\n artery was seen and appeared normal. Via the normal-appearing left A1\n segment, there was filling of a 5 x 6 x 7 mm aneurysm arising at the anterior\n communicating artery with a 3-mm neck.\n\n Left internal carotid artery post-embolization run showed minimal residual\n filling of the aneurysm of the anterior communicating artery. The left\n anterior cerebral artery A1 and A2 segments showed good flow without stenosis.\n No evidence of coil herniation beyond the aneurysm sac.\n\n IMPRESSION: Successful coiling of an anterior communicating artery aneurysm\n with near-complete obliteration of the aneurysm.\n\n"},{"category":"Radiology","chartdate":"2109-11-16 00:00:00.000","description":"R FEMORAL VASCULAR US RIGHT","row_id":1162843,"text":" 10:30 AM\n FEMORAL VASCULAR US RIGHT Clip # \n Reason: R/O psuedoaneurysm\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with painful rt groin\n REASON FOR THIS EXAMINATION:\n R/O psuedoaneurysm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old female with IVDU, on methadone maintenance, painful\n right groin.\n\n No prior examinations for comparison.\n\n RIGHT FEMORAL VASCULAR ULTRASOUND: Normal color flow and Doppler waveforms\n are noted in the right common and superficial femoral artery and vein, as well\n as the greater saphenous vein. There is a tubular pseudoaneurysm arising from\n the common femoral artery, with arterial Doppler waveforms. This extends into\n the superficial soft tissues, with a large amount of heterogeneously\n hypoechoic appearance to the soft tissues likely reflecting combined hematoma\n and edema. Measurement of this lesion is difficult due to its tubular\n morphology, but the base of the lesion measures approximately 1.2 x 0.6 cm.\n\n IMPRESSION: Tubular pseudoaneurysm arising from common femoral artery, with\n surrounding soft tissue hematoma.\n\n\n"},{"category":"Radiology","chartdate":"2109-11-19 00:00:00.000","description":"SEL CATH 2ND ORDER","row_id":1163289,"text":" 9:22 AM\n CAROT/CEREB Clip # \n Reason: eval for aneurysm completion of coil\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n Contrast: OPTIRAY Amt: 148\n ********************************* CPT Codes ********************************\n * SEL CATH 2ND ORDER INTRO CATH AORTA *\n * ABD A-GRAM EXT UNILAT A-GRAM *\n * CAROTID/CEREBRAL UNILAT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with acomm aneurysm coiling\n REASON FOR THIS EXAMINATION:\n eval for aneurysm completion of coil\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 41-year-old woman with severe headache on and\n intracranial hemorrhage. Cerebral angiography at that time revealed an\n anterior communicating artery aneurysm which was subsequently coiled. An\n ultrasound done after that time on raised concern for a\n possible right common femoral arterial pseudoaneurysm.\n\n INDICATION: Evaluate for residual filling in anterior communicating arterial\n aneurysm and for possible right common femoral pseudoaneurysm.\n\n PHYSICIANS: Dr. and Dr. .\n\n ANESTHESIA: General anesthesia.\n\n PROCEDURAL DETAILS: Prior to the procedure, telephone informed consent was\n obtained from the healthcare proxy, Mr. . This consent\n was witnessed by two healthcare providers. The patient arrived in the\n angiography suite and was placed in the supine position on the angiography\n table. She was prepped and draped in the typical sterile fashion. Prior to\n the procedure, a timeout was performed using name, date of birth, and medical\n record number as identifiers. A preprocedure huddle was also performed.\n\n With son and fluoroscopic guidance, an appropriate site for arterial\n puncture was selected in the left groin at the level of the femoral head. A\n micropuncture needle was then advanced into the common femoral artery without\n difficulty. The micropuncture wire was advanced through the needle, the\n needle removed and replaced with a 5 French micropuncture sheath. Thereafter,\n the sheath, stiffener, and wire were removed and replaced with a 0.035 \n wire. The wire was advanced into the descending aorta under\n fluoroscopic guidance. At this point, the micropuncture sheath was removed, a\n small dermatotomy was made, and a 4 French Avanti sheath was placed. With the\n sheath in place, a Berenstein II catheter was advanced over the wire.\n Using fluoroscopy, these two were advanced into the ascending aorta. The wire\n was then removed, and the catheter slowly manipulated into the left common\n carotid artery. Injection of a small amount of contrast confirmed location in\n the left common carotid. A 0.035 angled Glidewire was then inserted through\n the Berenstein catheter and carefully advanced into the internal carotid\n (Over)\n\n 9:22 AM\n CAROT/CEREB Clip # \n Reason: eval for aneurysm completion of coil\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n Contrast: OPTIRAY Amt: 148\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n artery and thereafter followed by the Berenstein catheter. The wire was then\n removed and multiple diagnostic angiograms performed through the left internal\n carotid artery at varying obliquities.\n\n Attention was then turned to the right groin in site of possible\n pseudoaneurysm. The Berenstein catheter was retracted into the descending\n aorta, and wire was placed to secure access and then the catheter\n was removed. Thereafter, a 4 French Omniflush catheter was advanced into the\n aorta, and the wire was removed. With the catheter at the level of\n the distal aorta, an aortogram was performed. Following this, with aid of the\n angled Glidewire, the tip of the Omniflush catheter was then manipulated into\n the right common iliac artery and a second angiogram was performed.\n Thereafter, all catheters and the sheaths were removed and the puncture site\n was closed using a 6 French Angio-Seal device. The patient tolerated the\n procedure well, and there were no immediate complications. She was\n transferred from the angiography suite in stable condition.\n\n FINDINGS:\n 1. Multiple angiograms performed via the left internal carotid artery show\n excellent occlusion of the anterior communicating artery aneurysm seen\n previously. There is no evidence of residual filling of this aneurysm or of\n other aneurysms. There is no evidence of vasospasm.\n 2. Unchanged, 1.6mm aneurysm arising from the left MCA bifurcation.\n 3. Normal appearance of the right common femoral artery, more specifically\n with no evidence of arterial pseudoaneurysm or arteriovenous fistulae.\n\n IMPRESSION:\n 1. Successful occlusion of anterior communicating artery aneurysm with no\n residual filling of that aneurysm and no evidence of vasospasm.\n 2. No right common femoral arterial pseudoaneurysm.\n 3. Stable 1.6mm left MCA bifurcation aneurysm\n\n\n"},{"category":"ECG","chartdate":"2109-11-07 00:00:00.000","description":"Report","row_id":236958,"text":"Sinus tachycardia. Diffuse non-specific ST-T wave changes. Cannot exclude\nmyocardial ischemia. Clinical correlation is suggested. No previous tracing\navailable for comparison.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-11-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1162243,\n \"text\": \" 4:41 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o pneumonia\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41F with hx IVDU found with AMS and midline frontal IPH now s/p coiling of\\n Acomm aneurysm.\\n REASON FOR THIS EXAMINATION:\\n r/o pneumonia\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf WED 1:16 PM\\n No acute cardiopulmonary process\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Altered mental status, status post coiling of ACom aneurysm,\\n assess for pneumonia.\\n\\n TECHNIQUE: Portable upright radiograph of the chest.\\n\\n COMPARISON: Semi-upright portable chest radiograph, .\\n\\n FINDINGS: Left IJ terminates at the confluence of brachiocephalic vessels.\\n The lungs are clear without focal opacity. Heart is normal in size with\\n normal cardiomediastinal silhouette. No pleural effusion seen, although the\\n left base is incompletely imaged.\\n\\n IMPRESSION: No acute cardiopulmonary process.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-11-18 00:00:00.000\",\n \"description\": \"INTRO CFA/SFA/ILIAC/POP GRAFT\",\n \"row_id\": 1163183,\n \"text\": \" 3:05 PM\\n CAROT/CEREB Clip # \\n Reason: eval for aneurysm completion of coil\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\\n ********************************* CPT Codes ********************************\\n * INTRO CFA/SFA/ILIAC/ GRAFT *\\n ****************************************************************************\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Anterior communicating artery aneurysm coiled. For\\n complete evaluation of coil.\\n\\n REASON FOR EXAMINATION: Apparent change in clinical status. To reassess coil\\n pack and aneurysm.\\n\\n ATTENDING:\\n NEURORADIOLOY FELLOW: Dr. , MD, MRCP and FRCR.\\n\\n NURSE : .\\n\\n DETAILS OF THE PROCEDURE: Written informed consent was obtained from the\\n patient after explaining the risks, benefits and alternative management. The\\n patient was brought to the neurointerventional suite and placed in the biplane\\n table in the supine position. A preprocedure timeout was performed using two\\n different identifiers, clinical indication and laboratory values. Both groins\\n were prepped and draped in the standard sterile fashion.\\n\\n Access to the left common femoral artery was attempted with adequate amount of\\n local anesthesia. The patient was unable to tolerate the procedure and was\\n moving constantly despite multiple reassuring attempts from the staff.\\n Access to the left common femoral vein was obtained, but since the patient was\\n unable to cooperate and started fearing, it was considered prudent not to\\n proceed and reattempt the procedure with general anesthesia.\\n\\n IMPRESSION: was planned to have a cerebral angiogram for\\n reassessment of the anterior communicating artery aneurysm coil and change in\\n clinical status. Since the patient kept constantly moving and did not\\n tolerate the procedure, the procedure is incomplete and abandoned considering\\n the safety of both patient and staff. Procedure would be considered under\\n general anesthesia. The patient was also abusive to the staff.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-11-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1161846,\n \"text\": \" 3:48 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pna\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old woman with AMS s/p coiling of aneurysm, fever\\n REASON FOR THIS EXAMINATION:\\n pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of the patient with altered mental status.\\n\\n Portable AP chest radiograph was compared to and radiographs.\\n\\n Right basal opacity continues to increase and may represent developing right\\n lower lobe pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-11-08 00:00:00.000\",\n \"description\": \"DISTINCT PROCEDURAL SERVICE\",\n \"row_id\": 1161439,\n \"text\": \" 7:29 AM\\n MR HEAD W & W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \\n MRA BRAIN W/O CONTRAST; MRV HEAD W/O CONTRAST\\n Reason: Preop in case of OR\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\\n Contrast: MAGNEVIST Amt: 22\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old woman with 40F IVDA on methadonelast nml 8 days agofound in bed\\n with dead infantpsychotic, combative, mass vs bleed on head CTCT read: Large\\n high density mass in midline anterior cranial fossa 4.8x2.5x2.8 cm, extending\\n from suprasellar cistern, superiorly into septum pellucidum -- diff dx large\\n acute hematoma vs giant aneurysm, +obstructive hydrocephalus\\n REASON FOR THIS EXAMINATION:\\n Preop in case of OR\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n TECHNIQUE: MRI of the brain without and with gad. MRA using 3D\\n time-of-flight technique. MRV using 2D time-of-flight technique.\\n\\n FINDINGS:\\n\\n Comparison is made with prior examination from .\\n\\n There is a large acute hematoma centered in the septum pellucidum and the\\n frontal , left greater than right extending into the corpus callosum and\\n the cingulate gyrus anteriorly. There is also suggestion of an anterior\\n communicating artery aneurysm at the base of this hematoma.\\n\\n A small amount of hemorrhage appears to be present in the right sylvian\\n fissure. There is mild hydrocephalus with enlargement of the temporal horns.\\n\\n On the MRA, there is suggestion of an anterior communicating artery aneurysm\\n although this is difficult to assess in the setting of extensive hemorrhage in\\n that vicinity.There is some irregularity and narrowing of bilateral MCA\\n branches. This could represent vasospasm or vasculitis. Consider CTA for\\n further evaluation.\\n\\n MRV demonstrates no significant abnormality.\\n\\n There is mild bilateral mastoid and ethmoid opacification. No definite\\n underlying mass lesion is identified.\\n\\n\\n\\n IMPRESSION:\\n\\n Large hematoma which is acute to subacute along the septum pellucidum, frontal\\n horns, frontal lobe and cingulate gyrus with suggestion of an ACOM aneurysm at\\n the base of the hematoma. Recommend correlation with CTA. There is also\\n irregularity and narrowing of bilateral MCA branches which could represent\\n vasospasm versus vasculitis. Findings were discussed with at\\n (Over)\\n\\n 7:29 AM\\n MR HEAD W & W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \\n MRA BRAIN W/O CONTRAST; MRV HEAD W/O CONTRAST\\n Reason: Preop in case of OR\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\\n Contrast: MAGNEVIST Amt: 22\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 11:40 a.m. on .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-11-12 00:00:00.000\",\n \"description\": \"SEL CATH 1ST ORDER\",\n \"row_id\": 1162077,\n \"text\": \" 8:51 AM\\n CAROT/CEREB Clip # \\n Reason: 41 year old woman with ACA aneurysm partially coiled.\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\\n Contrast: OPTIRAY Amt: 74\\n ********************************* CPT Codes ********************************\\n * SEL CATH 1ST ORDER CAROTID/CEREBRAL UNILAT *\\n * MOD SEDATION, FIRST 30 MIN. MOD SEDATION, EACH ADDL 15 MIN *\\n * MOD SEDATION, EACH ADDL 15 MIN *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old woman with ACA aneurysm partially coiled.\\n REASON FOR THIS EXAMINATION:\\n 41 year old woman with ACA aneurysm partially coiled.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Recently called anterior communicating artery aneurysm, follow up\\n study.\\n\\n PROCEDURE: Cerebral angiogram.\\n\\n ATTENDING:\\n NEURORADIOLOGY FELLOW: Dr. , MB, MRCP, FRCR.\\n\\n NURSE PRACTITIONER: .\\n\\n PROCEDURE: Cerebral angiogram.\\n\\n VESSEL SELECTED: Left internal carotid artery.\\n\\n SEDATION: Moderate sedation was provided by administering divided doses of\\n 250 mcg of fentanyl and 5 mg of Versed over the total intraservice time of 1\\n hour 5 minutes. During this time, the patient's hemodynamic parameters were\\n continuously monitored.\\n\\n TECHNIQUE: After verbal liaison with (neurosurgery service), a\\n consensus was obtained to perform the procedure in view of the risks, benefits\\n and alternative management for the patient care. The patient was brought to\\n the neuro-interventional suite and placed in the supine position on the\\n biplane table. A preprocedure timeout and huddle was performed documenting\\n the patient's identity using two different identifiers, nature of the\\n procedure to be performed, laboratory parameters and patient's history. Both\\n groins were prepped and draped in a standard sterile fashion. After\\n instillation of 1% lidocaine for local anesthesia into the right groin, access\\n to the right common femoral artery was obtained using a micropuncture set.\\n Using Seldinger technique, a 4 French vascular sheath was successfully placed\\n into the right common femoral artery. This was connected to the continuous\\n infusion of pressurized heparin and saline.\\n\\n The left internal carotid artery was catheterized and angiograms were obtained\\n in the lateral and oblique projections with 3D rotational images. Right groin\\n (Over)\\n\\n 8:51 AM\\n CAROT/CEREB Clip # \\n Reason: 41 year old woman with ACA aneurysm partially coiled.\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\\n Contrast: OPTIRAY Amt: 74\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n hemostasis was obtained using a manual compression technique for 25 minutes.\\n The patient tolerated the procedure well with no immediate complications. The\\n patient was sent to the ICU with post-procedure orders.\\n\\n FINDINGS: Left internal carotid artery injection demonstrated normal and\\n brisk filling of the cervical, petrous, cavernous and supraclinoid segments.\\n The middle and anterior cerebral arteries were seen and appeared normal. The\\n recently coiled anterior communicating artery aneurysm showed no evidence of\\n residual filling.\\n\\n IMPRESSION: underwent a cerebral angiogram which demonstrates\\n no evidence of residual filling within the recently coiled anterior\\n communicating artery aneurysm.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-11-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1161635,\n \"text\": \" 3:34 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval for pna\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old woman with leukocytosis, ?pna\\n REASON FOR THIS EXAMINATION:\\n Eval for pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Leukocytosis.\\n\\n Cardiomediastinal contours are normal. The lungs are clear. There is no\\n pneumothorax or pleural effusion. ET tube tip is in standard position. The\\n tip is approximately 6 cm above the carina. Left IJ catheter remains in\\n place.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-11-08 00:00:00.000\",\n \"description\": \"SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR SCREENING\",\n \"row_id\": 1161409,\n \"text\": \" 2:56 AM\\n SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR Clip # \\n Reason: survey for MRI\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old woman who was found with AMS\\n REASON FOR THIS EXAMINATION:\\n survey for MRI\\n ______________________________________________________________________________\\n WET READ: YGd FRI 7:21 AM\\n No radiopaque object within skull, chest, abd, or pelvis. d/ by \\n \\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 41-year-old female here for pre-MRI surveillance.\\n\\n FINDINGS: Radiographs of the head, neck, chest, and abdomen demonstrate no\\n evidence of radiopaque foreign body with the exception of dental amalgam\\n within imaged portions of the body. Partially imaged lungs are clear.\\n Cardiomediastinal silhouette is normal. Bowel gas pattern is unremarkable.\\n\\n IMPRESSION: No evidence of radiopaque object within the head, chest, abdomen,\\n or pelvis. This was discussed with on at the time of\\n exam completion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-11-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1162244,\n \"text\": \", J. NSURG SICU-A 4:41 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o pneumonia\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41F with hx IVDU found with AMS and midline frontal IPH now s/p coiling of\\n Acomm aneurysm.\\n REASON FOR THIS EXAMINATION:\\n r/o pneumonia\\n ______________________________________________________________________________\\n PFI REPORT\\n No acute cardiopulmonary process\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-11-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1161767,\n \"text\": \" 4:57 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: 41 year old woman with increase in WBC, evaluate for infecio\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old woman with increase in WBC, evaluate for infecious process\\n REASON FOR THIS EXAMINATION:\\n 41 year old woman with increase in WBC, evaluate for infecious process\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Increase in white blood count.\\n\\n Comparison is made with prior study performed a day earlier.\\n\\n There are lower lung volumes. Bibasilar opacities greater on the right side\\n are consistent with atelectasis. Cardiac size is top normal, accentuated by\\n the low lung volumes and the projection. Left IJ catheter remains in place.\\n There is no pneumothorax or pleural effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-11-08 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1161430,\n \"text\": \" 4:56 AM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: pneumothorax, line location\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old woman with possible IPH, s/p L IJ placement\\n REASON FOR THIS EXAMINATION:\\n pneumothorax, line location\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: IJ placement, questionable pneumothorax.\\n\\n COMPARISON: No comparison available at the time of dictation.\\n\\n FINDINGS: The lung volumes are normal. There are no pleural effusions and no\\n pneumothorax. Borderline size of the cardiac silhouette without evidence of\\n pulmonary edema. Newly placed left internal jugular vein access line. The\\n tip of the line projects over the mid SVC.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-11-08 00:00:00.000\",\n \"description\": \"EMBO TRANSCRANIAL\",\n \"row_id\": 1161547,\n \"text\": \" 3:01 PM\\n CAROT/CEREB Clip # \\n Reason: 41 year old woman with corpus collosum mass/hemorrhage. eval\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\\n Contrast: OPTIRAY Amt: 315\\n ********************************* CPT Codes ********************************\\n * EMBO TRANSCRANIAL SEL CATH 3RD ORDER *\\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 2ND ORDER *\\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CERVICAL BILAT *\\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT *\\n * -59 DISTINCT PROCEDURAL SERVICE SEL EA ADD'L *\\n * TRANSCATH EMBO THERAPY F/U TRANS CATH THERAPY *\\n * MOD SEDATION, FIRST 30 MIN. MOD SEDATION, EACH ADDL 15 MIN *\\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\\n ****************************************************************************\\n ______________________________________________________________________________\\n FINAL ADDENDUM\\n ADDENDUM: Please note that there is a 1.6 mm aneurysm arising from the left\\n middle cerebral artery bifurcation.\\n\\n\\n\\n 3:01 PM\\n CAROT/CEREB Clip # \\n Reason: 41 year old woman with corpus collosum mass/hemorrhage. eval\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\\n Contrast: OPTIRAY Amt: 315\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old woman with corpus collosum mass/hemorrhage. eval vasculature\\n REASON FOR THIS EXAMINATION:\\n 41 year old woman with corpus collosum mass/hemorrhage. eval vasculature\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Intracranial hemorrhage and anterior communicating artery aneurysm.\\n\\n PROCEDURE: Cerebral angiogram, coil embolization of anterior communicating\\n artery aneurysm.\\n\\n REASON FOR EXAM: Cerebral angiography and coil embolization of anterior\\n communicating artery aneurysm.\\n\\n OPERATOR: Dr. .\\n\\n FELLOW: Dr. .\\n\\n VESSELS SELECTED: Right common carotid artery, left common carotid artery and\\n left internal carotid artery. Via microcatheter technique, the left internal\\n carotid artery and left A1 ACA were also selected.\\n\\n ANESTHESIA: The first portion of the procedure was done under moderate\\n sedation provided by 250 mcg of fentanyl in five divided doses and 5 mg of\\n Versed in five divided doses throughout the intraservice time of 1 hour and 10\\n minutes, during which time the patient's hemodynamic parameters were\\n continuously monitored. At this time, general anesthesia was induced by the\\n anesthesia team and the anesthesia team monitored the patient for the\\n remainder of the procedure.\\n\\n Technique: Emergency consent was provided by the neurosurgery team and\\n documented in the patient's chart. The patient was brought to the\\n neurointerventional suite and placed in supine position on the biplane table.\\n Preprocedure timeout documenting patient identity, nature of the procedure and\\n relative blood work was done using two independent identifiers. Both groins\\n were prepped and draped in usual sterile fashion. Using a 19-gauge\\n single-wall needle, access was gained to the right common femoral artery and\\n with the aid of a 0.035 Berenstein wire, a 4 French Avanti sheath was placed.\\n This sheath was connected to continuous infusion of a mixture of heparin and\\n normal saline with continuous drip. A 4 French Berenstein 2 catheter was\\n placed over the wire and connected to continuous saline infusion of a mixture\\n of heparin and saline. The right and left common carotid arteries were\\n selectively catheterized and cerebral angiogram was obtained in AP, lateral\\n and oblique projections. After reviewing the images and discussing the\\n below-mentioned findings with the patient's clinical team, a unified decision\\n dictated intervention. At this point, anesthesia was consulted for\\n intubation. After the anesthesia team induced general anesthesia, the 4\\n (Over)\\n\\n 3:01 PM\\n CAROT/CEREB Clip # \\n Reason: 41 year old woman with corpus collosum mass/hemorrhage. eval\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\\n Contrast: OPTIRAY Amt: 315\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n French Avanti sheath was exchanged for a 6 French 25-cm Terumo sheath using an\\n exchange length 0.038 angled Glidewire. Over the angled Glidewire, a straight\\n Neuron catheter was placed with tip within the left internal carotid artery.\\n After removal of the angle Glidewire, a left internal carotid artery cerebral\\n angiogram was performed. Subsequently, an Excelsior SL-10 microcatheter was\\n advanced with the aid of a Synchro-2 standard microwire. Under fluoroscopic\\n guidance, the microcatheter was advanced into the aneurysm sac of the anterior\\n communicating artery via the left A1 segment of the anterior cerebral artery.\\n Coiling of the aneurysm was done using three GDC soft coils. A post-coiling\\n angiogram showed that the aneurysm was successfully coiled with near-complete\\n embolization and minimal residual filling. At this point, the wire and the\\n catheter were withdrawn. A 6 French Angio-Seal closure device was used to\\n close the site of puncture. The patient remained intubated and was sent to\\n the ICU with post-procedure orders.\\n\\n FINDINGS:\\n The right common carotid artery showed brisk filling of both internal and\\n external carotid arteries. There were normal cervical, petrous, cavernous and\\n supraclinoid segments of the internal carotid artery. The middle and anterior\\n cerebral arteries were seen and appeared normal. The aneurysm at the anterior\\n communicating artery did not fill.\\n\\n Left common carotid artery showed brisk filling of both internal and external\\n carotid arteries. There were normal cervical, petrous, cavernous, and\\n supraclinoid segments of the internal carotid artery. The middle cerebral\\n artery was seen and appeared normal. Via the normal-appearing left A1\\n segment, there was filling of a 5 x 6 x 7 mm aneurysm arising at the anterior\\n communicating artery with a 3-mm neck.\\n\\n Left internal carotid artery post-embolization run showed minimal residual\\n filling of the aneurysm of the anterior communicating artery. The left\\n anterior cerebral artery A1 and A2 segments showed good flow without stenosis.\\n No evidence of coil herniation beyond the aneurysm sac.\\n\\n IMPRESSION: Successful coiling of an anterior communicating artery aneurysm\\n with near-complete obliteration of the aneurysm.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-11-16 00:00:00.000\",\n \"description\": \"R FEMORAL VASCULAR US RIGHT\",\n \"row_id\": 1162843,\n \"text\": \" 10:30 AM\\n FEMORAL VASCULAR US RIGHT Clip # \\n Reason: R/O psuedoaneurysm\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old woman with painful rt groin\\n REASON FOR THIS EXAMINATION:\\n R/O psuedoaneurysm\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 41-year-old female with IVDU, on methadone maintenance, painful\\n right groin.\\n\\n No prior examinations for comparison.\\n\\n RIGHT FEMORAL VASCULAR ULTRASOUND: Normal color flow and Doppler waveforms\\n are noted in the right common and superficial femoral artery and vein, as well\\n as the greater saphenous vein. There is a tubular pseudoaneurysm arising from\\n the common femoral artery, with arterial Doppler waveforms. This extends into\\n the superficial soft tissues, with a large amount of heterogeneously\\n hypoechoic appearance to the soft tissues likely reflecting combined hematoma\\n and edema. Measurement of this lesion is difficult due to its tubular\\n morphology, but the base of the lesion measures approximately 1.2 x 0.6 cm.\\n\\n IMPRESSION: Tubular pseudoaneurysm arising from common femoral artery, with\\n surrounding soft tissue hematoma.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-11-19 00:00:00.000\",\n \"description\": \"SEL CATH 2ND ORDER\",\n \"row_id\": 1163289,\n \"text\": \" 9:22 AM\\n CAROT/CEREB Clip # \\n Reason: eval for aneurysm completion of coil\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\\n Contrast: OPTIRAY Amt: 148\\n ********************************* CPT Codes ********************************\\n * SEL CATH 2ND ORDER INTRO CATH AORTA *\\n * ABD A-GRAM EXT UNILAT A-GRAM *\\n * CAROTID/CEREBRAL UNILAT *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old woman with acomm aneurysm coiling\\n REASON FOR THIS EXAMINATION:\\n eval for aneurysm completion of coil\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 41-year-old woman with severe headache on and\\n intracranial hemorrhage. Cerebral angiography at that time revealed an\\n anterior communicating artery aneurysm which was subsequently coiled. An\\n ultrasound done after that time on raised concern for a\\n possible right common femoral arterial pseudoaneurysm.\\n\\n INDICATION: Evaluate for residual filling in anterior communicating arterial\\n aneurysm and for possible right common femoral pseudoaneurysm.\\n\\n PHYSICIANS: Dr. and Dr. .\\n\\n ANESTHESIA: General anesthesia.\\n\\n PROCEDURAL DETAILS: Prior to the procedure, telephone informed consent was\\n obtained from the healthcare proxy, Mr. . This consent\\n was witnessed by two healthcare providers. The patient arrived in the\\n angiography suite and was placed in the supine position on the angiography\\n table. She was prepped and draped in the typical sterile fashion. Prior to\\n the procedure, a timeout was performed using name, date of birth, and medical\\n record number as identifiers. A preprocedure huddle was also performed.\\n\\n With son and fluoroscopic guidance, an appropriate site for arterial\\n puncture was selected in the left groin at the level of the femoral head. A\\n micropuncture needle was then advanced into the common femoral artery without\\n difficulty. The micropuncture wire was advanced through the needle, the\\n needle removed and replaced with a 5 French micropuncture sheath. Thereafter,\\n the sheath, stiffener, and wire were removed and replaced with a 0.035 \\n wire. The wire was advanced into the descending aorta under\\n fluoroscopic guidance. At this point, the micropuncture sheath was removed, a\\n small dermatotomy was made, and a 4 French Avanti sheath was placed. With the\\n sheath in place, a Berenstein II catheter was advanced over the wire.\\n Using fluoroscopy, these two were advanced into the ascending aorta. The wire\\n was then removed, and the catheter slowly manipulated into the left common\\n carotid artery. Injection of a small amount of contrast confirmed location in\\n the left common carotid. A 0.035 angled Glidewire was then inserted through\\n the Berenstein catheter and carefully advanced into the internal carotid\\n (Over)\\n\\n 9:22 AM\\n CAROT/CEREB Clip # \\n Reason: eval for aneurysm completion of coil\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\\n Contrast: OPTIRAY Amt: 148\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n artery and thereafter followed by the Berenstein catheter. The wire was then\\n removed and multiple diagnostic angiograms performed through the left internal\\n carotid artery at varying obliquities.\\n\\n Attention was then turned to the right groin in site of possible\\n pseudoaneurysm. The Berenstein catheter was retracted into the descending\\n aorta, and wire was placed to secure access and then the catheter\\n was removed. Thereafter, a 4 French Omniflush catheter was advanced into the\\n aorta, and the wire was removed. With the catheter at the level of\\n the distal aorta, an aortogram was performed. Following this, with aid of the\\n angled Glidewire, the tip of the Omniflush catheter was then manipulated into\\n the right common iliac artery and a second angiogram was performed.\\n Thereafter, all catheters and the sheaths were removed and the puncture site\\n was closed using a 6 French Angio-Seal device. The patient tolerated the\\n procedure well, and there were no immediate complications. She was\\n transferred from the angiography suite in stable condition.\\n\\n FINDINGS:\\n 1. Multiple angiograms performed via the left internal carotid artery show\\n excellent occlusion of the anterior communicating artery aneurysm seen\\n previously. There is no evidence of residual filling of this aneurysm or of\\n other aneurysms. There is no evidence of vasospasm.\\n 2. Unchanged, 1.6mm aneurysm arising from the left MCA bifurcation.\\n 3. Normal appearance of the right common femoral artery, more specifically\\n with no evidence of arterial pseudoaneurysm or arteriovenous fistulae.\\n\\n IMPRESSION:\\n 1. Successful occlusion of anterior communicating artery aneurysm with no\\n residual filling of that aneurysm and no evidence of vasospasm.\\n 2. No right common femoral arterial pseudoaneurysm.\\n 3. Stable 1.6mm left MCA bifurcation aneurysm\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2109-11-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 236958,\n \"text\": \"Sinus tachycardia. Diffuse non-specific ST-T wave changes. Cannot exclude\\nmyocardial ischemia. Clinical correlation is suggested. No previous tracing\\navailable for comparison.\\n\\n\"\n }\n]"}}},{"rowIdx":24674,"cells":{"subject_id":{"kind":"number","value":22464,"string":"22,464"},"hadm_id":{"kind":"number","value":107128,"string":"107,128"},"target_text":{"kind":"string","value":"In Brief, the patient is an 88 year old man with severe ischemic cardiomyopathy s/p BiV-ICD placement, atrial flutter, CAD, chronic kidney disease who presented with hypoxic respiratory failure and shock which was stablized. His course was further complicated by acute abdomial pain, psoas muscle hematoma, upper GI bleed, acute on chronic renal failure, heparin induced thrombocytopenia with upper extremity DVT, intermittent hypoxia, and urinary retention. . 1) Shock - Patient intially presented in shock requiring vasopressors. Cardiac index was normal with decreased SVR which were not consistent with cardiogenic shock. The likely cause of was distributive/septic shock of unclear source of infection. He completed a full course of empiric antibiotics. He completed 7 days of hydrocortisone/fludrocort for sub-optimal response to ACTH. BP stablized by time of discharge. . 2) Respiratory Failure: The patient initially presented in hypoxic respiratory failure likely secondary to CHF, hypoventilation and decreased mental status. He was intubated prior to transfer to . He was weaned from the ventilator successfully. He did have intermittent hypoxia largely secondary to pulmonary edema from inadequate diuresis. He was stabilized on standing twice daily lasix. He was started on BiPaP at night for hypoventilation. . 3) Abdominal pain - During the hospital stay he developed acute severe epigastric pain. He was transfered to the MICU for concern for mesenteric ischemia. An abominal CTA was negative for this. A surgery consult was obtained and recommended no surgical intervention. The pain resolved without specific intervention. He was subsequently found to have an psoas muscle hematoma and required several blood transfusions with appropriate response in his hematocrit. 4) Cardiovascular: a. CAD- history of MI s/p CABG. will continue ASA, simvastatin, beta-blocker. . b. Pump- Severe ischemic cardiomyopathy with EF 10-15% s/p BiV-ICD placement. No evidence of cardiogenic shock upon initial presenation as C.I. was normal. Medically managed CHF with ACEi, beta-blocker, digoxin, spironolactone, furosemide. . c. rhythm- -V paced with underlying rhythm is atrial flutter/fibrillation. Started on amiodarone for maintenance of sinus rhythm to maximize likelihood of atrial kick. Also, amiodarone to decrease in-appropriate shocks from ICD. 5) Upper GI bleed - The patient did develop guaiac positive stools in the setting of anticoagulation for the atrial fibrillation. The hematocrit drop was largely due to the psoas hematoma as above. The patient refused EGD. If the patient develops recurrent melenotic stools he could be referred to GI for endoscopy. He will continue on a PPI. . 6)Acute on Chronic Renal failure - Initial creatinine down from admission to peak 2.5 this was likely from pre-renal secondary to shock state; no evidence of ATN. By time of discharge, the creatinine had resolved to baseline. . 7) Anemia- In addition the the acute blood loss anemia as described above. The patient has a chronic microcytic anemia. Iron studies were consistent with anemia of chronic disease (labs drawn before blood transfusions were given). Also with regard to the significant microcytosis and his Italian extraction, hemoglobin electrophoresis was performed to evaluate for thallasemia. These results were pending at time of discharge. . 8) Thrombocytopenia - HIT type II. PF4 positive on , Platelets stable at around 70K with subsequent recovery to greater than 150K. He did have a left upper extremity venous clot although the developement of this was after his platelets had stabilized. Started argatroban on with transition to coumadin. He continued on argatroban until his INR on combined anti-coagulation was >4. At which time he was maintained on coumadin alone. . 9) Urinary retention: - The patient has no prior history of urinary retention, nocturia, frequency or related BPH symptoms. During one attempt at removing the foley catheter he had decreased urine output with a large volume detected on bladder scan. The foley was replaced. He was started on finasteride, not wanting to use an alpha-blocker that would likely cause hypotension when added to his extensive cardiac regimen. The catheter was left in at discharge. This should be removed in days followed by confirmation that the patient can urinate. . 10) Code Status: DNR/DNI confirmed with patient and HCP. . 11) Dispo: the patient was discharged to rehab"},"extractive_notes_summ":{"kind":"string","value":"RIGHT FEM CORDIS D&I.GI:ABD SOFT, +BS. Pt remains intubated now on MMV after sedation related low ve. SPUTUM CX SENT. BLD CX PENDING, T MAX 101.1. old right cortis site intact not drainingid: right tlcl removed and cath tip cx wbc 19.6 up from 13.0access: pt has 2 #18 piv and tlcl removed this am per micu order/endo: bs 1 vanco/zosyn.HR 85-112 Vpaced, underlying afib. phos now 3.3 k 5.1 (k+ checked at 1900 4.5) heparin gtt infusing at 700u/hr ptt 87.8 inr 2.3 (up from 2.1)gi: abd soft pt c/o of abd pain for beg of shift as stated above. MOTTLING OF FEET AND KNEES.CV:MHR AFIB, W/ VPACED BEATS, RARE PVC. RSBI completed on PS 5, PEEP 0=29. Respiratory Care Pt placed on SBT and passed this am. LS clear to diminished.RSBI pndGU: foley draining ~ 30cc/hr. troponon .02, ck 53. pt has alne and right fem cortis. WEANING DOPA SLOWLY, DP PULSES AUDIBLE W/ . SBP 89-102, off pressors. Last ABG WNL with acceptable oxygenation on present vent settings. BS dim/essentially clear sxing for minimal secretions. refused.ABG/VBG done - see carevue, labs sent. is currently DNR/DNI. Advance diet as tol, ?lactulose for constipation. MAE.RESP:VENT REMAINS ON AC/500/18/8, REPEAT ABG PENDING. Rec'ing ins per ss.Access/Skin: RIJ Trip lumen cath dressing changed RN's instructions. dopa weaned off...contin.to monitor BP. O2 weaned down to 2L nc, sats 97-100. pt repositioned for comfort w/ no relief. sats 93-96% on 4 liters pt has a dry coughcv: tele paced vent beats w/ intrinsic rythem of afib. heparin gtt or coumadin today D/T A-fib. titrated to 4.0mcq/k/min with SBP 93-100/. Pt has gen anasarca, with trace pitting to ext's. Goal -2L.Heme: Serial Hct 29-29.3, Q8hrs. Foley patent, draining adeq. w/ lasix for fluid goal ~ -1L negative. 181, COV'D W/ 2UX REG INS.A/P:CONTINUE TO WEAN DOPA TO OFF. MICU7 RN Note 0700-1900Events: Hct 29.3 stable no active bleed, Lasix +diuresis, CHF team consult implement recomendations. BS clear to slightly course sxing for minimal secretions. K and phos level this am to be replaced. Peripheral pulses 3+DP/2+DT, gen edema. Last BM am (guiac -). IVF at KVO.GU) Cont to diurese pt. Pt on protonix and given Maalox. HOB>30 degrees.GI: abd soft nontender + BS, recieved bowel regime, stool x3 soft brown, + guiac. HCT stable, 33.1, s/p iliac bleed. ck's neg. PT IS A DNR/DNI. 1+ GNR. wheezes, Alb/Ipa nebs w/ good effect. CPK neg. Central line re-dressed as oozing.ENEDO:- Blood sugars within normal limits. PT ON VANCO AND ZOSYN. gi to see pt as he has been ob+ form below.brief rosneuro- pt alert and oriented x2-3. dopa dependent. advance TF per order. pulses doppler bilat. cultures pnd from admission.CV: HR 95-110 Vpaced with baseline afib. Versed weaned to 1.5mg/hr.endo: FS 180. K+ 3.8, Mg+ 2.2.BP 95-101/50-60's MAP 64-75. dopa weaned to 3.3mcq/k/min but BP trending down to 80's/ . HCT THIS AM DOWN TO 29.2GI:TF OFF AT MN FOR WEANING AND POSSIBLE EXTUBATION. tolerating well.resp:2liters o2 via nc c o2 sats in the high 90's. wbc pnding.A/P: S/P illiac bleed, hct stable. Last ABG shows normal values with hyperoxemia. There is mild global right ventricularfree wall hypokinesis. Shock.Height: (in) 66Weight (lb): 150BSA (m2): 1.77 m2BP (mm Hg): 118/86HR (bpm): 76Status: InpatientDate/Time: at 09:30Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Mild tomoderate (+) mitral regurgitation is seen. Diurese as needed, pt on standing Lasix, although CXR does show edema. Moderate [2+] tricuspid regurgitation is seen. There is mildpulmonary artery systolic hypertension. IMPRESSION: New pulmonary edema, at least moderate. 9:19 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: H/O AAA.ON HEPARIN.HCT DROP. Again, there are diffuse atherosclerotic calcifications within the aorta. Large abdominal aortic aneurysm with mural thrombus and crescent-shaped high density within the thrombus, overall unchanged compared to the prior study. (Over) 9:19 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: H/O AAA.ON HEPARIN.HCT DROP. Moderate [2+] TR.Mild PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: No PS.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is elongated. The right internal jugular line tip terminates in distal SVC. There is periportal edema. Bilat LE 3 + edema. Since the previoustracing of ventricular pacing pattern as described is now present. There is a left-sided AICD with leads projecting in unchanged positions over the right atrium and ventricle. There has been interval decrease in the perihilar and right upper lobe infiltrates. There is a left- sided pacemaker with leads terminating within the right ventricle and right atrium, and median sternotomy wires are present, both unchanged. AP UPRIGHT CHEST: The patient has been extubated and the nasogastric tube has been removed. INDICATION: Swollen left upper extremity. Residual contrast is present within the bladder, consistent with recent CT scan. FINDINGS: Some echogenic material is seen in the left internal jugular vein consistent with some old thrombus. IMPRESSION: Standard placement of endotracheal tube and nasogastric tube. Lines and tubes are in similar position with endotracheal tube tip now 1 cm below the level of the clavicles, likely due to positioning. There continues to be a left pleural effusion. There are patchy areas of volume loss versus an early infiltrate in the right lower lobe. Partial opacification of the left mastoid air cell, which was not seen on previous CT head dated . IMPRESSION: Thrombus extending throughout the length of the left cephalic vein with some older appearing nonocclusive thrombus within the left jugular vein. There is a small left greater than right pleural effusion. The patient is status post median sternotomy and CABG. The patient is status post median sternotomy and CABG. Trachea is midline. There is ill-defined hazy vasculature and perihilar haze consistent with CHF."},"n_notes":{"kind":"number","value":72,"string":"72"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2120-12-14 00:00:00.000","description":"Report","row_id":1556127,"text":"88 YR OLD WITH ISCHEMIC CARDIOMYOPATHY ,SP CABG,ICD PLACEMENT ,AAA REPAIR ADMITTED C RESP FAILURE ,HYPOTENSION .PROBALE SEPTIC RATHER THAN CARDIOGENIC.6L FLD RESUS AT OSH.\n\nV PACED C AFLUTTER/AFIB.BP LABILE 68 TO 150 SYS C TITRATION OF DOPAMINE 3 TO 10 MIC PER KG .ATTEMPTING TO WEAN FOR 3RD TIME TODAY .AM HCT STABLE .\n\nPEEP WEANED TO 8,RR TO 18.ABG 7.40/41 /93 / 26 /99.SX FOR MIN EVEN C LAVAGE UNABLE TO GET SPEC FOR CX.BS CL TO DIMINISHED IN BASES .\n\nTF RESIDUALS 40 TO 60 ON 10CC HAVE NOT ADVANCED YET .ABD SOFT ,POS BS .\n\nHUO 30 TO 50 ,SED IN URINE CX PENDING\n\nCX REPEATED C TEMP 101.2,TYLENOL GIVEN.ON PIPRICILLIN,VANCO REPEATED .STARTED ON STEROIDS.\n\nBS COVERED ON SSRI.\n\nPT RESPONDS BY OPENING EYES TO NAME,GETS RESTLESS ,SOMETIMES NODS ,NOT FOLLOWING COMMAMNDS .PUPILS CONSTRICTED .ON 25 MICS FENTANYL,1.5 MICS VERSED .FAMILY UPDATED.AGREE C PLAN .PT IS DNR .HAS AICD TO BE ALLOWED TO FUNCTION AT PRESENT. ,MAGNET AT BEDSIDE.\n\nPROBABLE SEPSIS UNKNOWN SOURCE\n\nCONTINUE SUPPORTIVE CARE , NEED TO ADD LEVOPHED IF BP CONTINUES TO BE LABILE .\nSUPPORT FAMILY\n\n"},{"category":"Nursing/other","chartdate":"2120-12-14 00:00:00.000","description":"Report","row_id":1556128,"text":"Resp Care\n\nPt remains intubated and currently vented on full support with changes made per careview flowsheet. BS dim/essentially clear sxing for minimal secretions. ETT secured/patent. Last ABG WNL with acceptable oxygenation on present vent settings. Will cont with vent support as needed.\n"},{"category":"Nursing/other","chartdate":"2120-12-15 00:00:00.000","description":"Report","row_id":1556129,"text":"CCU NURSING PROGRESS NOTE\nS:VENTED\nO:PT W/ VERSED AND FENTANYL. PT W/ VERBAL AND TACTILE STIMULI. NOT CONSISTENTLY FOLLOWING COMMANDS. MAE.\n\nRESP:VENT REMAINS ON AC/500/18/8, REPEAT ABG PENDING. LS CLR AND DIM BILAT AT BASES. SATS 100%. SX FOR SM AMT OF PALE YELL/PINK TINGED THICK SECRETIONS. SPUTUM CX SENT. HANDS AND FEET EDEMATOUS. MOTTLING OF FEET AND KNEES.\n\nCV:MHR AFIB, W/ VPACED BEATS, RARE PVC. RARE FUSED BEAT. DOPA AT 4MCG/KG/MIN. WEANING DOPA SLOWLY, DP PULSES AUDIBLE W/ . RIGHT FEM CORDIS D&I.\n\nGI:ABD SOFT, +BS. PROBALANCE WAS NOT INCREASED D/T HIGH RESID AND STOPPED AT MN FOR RESID OF 90CC. CONSULT NUTRITION FOR INPUT. NO STOOL\n\nGU:YELL URINE, W/ SM SEDIMENT.\n\nENDO:COV AS PER SS.\n\nID:SPUTUM SENT. BLD CX PENDING, T MAX 101.1. PT REMAINS ON ZOSYN AND VANCO.\n\nA/P:PT IS A 88YROM ADM W/ ABD PAIN, NO CHANGE IN AAA. RECENT PPM. DISTRIBUTIVE VS SEPTIC SHOCK. CX PENDING, CON'T ANTIBIOTICS. CONTINUE TO WEAN DOPAMINE AS TOLERATED. CONSIDER ADDING REGLAN AT RENAL DOSES.\nPT CURRENTLY DNR/DNI, AND DECIDE ON CMO STATUS. CONTINUE MULTIDISCIPLINARY ROUNDS. LABS PENDING. KEEP FAMILY UPDATED ON PT STATUS.\n"},{"category":"Nursing/other","chartdate":"2120-12-15 00:00:00.000","description":"Report","row_id":1556130,"text":"RESPIRATORY CARE NOTE\n\nPatient remains intubated and fully ventilated on AC settings. No vent changes made during the noc. Sxn for small amount yellow with scant blood-tinged. Unable to obtain RSBI d/t no spon. respirations, even with sedation decreased (attempted x2). ABG shows aequate ventilation and oxygenation.\n\n , RRT\n"},{"category":"Nursing/other","chartdate":"2120-12-16 00:00:00.000","description":"Report","row_id":1556135,"text":"Respiratory Care\n\n Pt placed on SBT and passed this am. On PSV 5/5 for several hours with good ABG. Pt remains intubated now on MMV after sedation related low ve. B/S sl coarse sx'd x1 for small thick tan. PLAN: SBT and ??extubation in am. Will continue to follow closely.\n"},{"category":"Nursing/other","chartdate":"2120-12-16 00:00:00.000","description":"Report","row_id":1556136,"text":"CCU Progress note 0700-1900\nRESP:- Remains orally intubated and mechanically ventilated. CPAP trial this morning, On 5/+5 ABG 7.41/50/138, plan was to extuabte, however pt HR changed, and vasopressor requirments ^, therefore desision taken to keep intubated overnight. Mr very keen to have the tube out, also discussion regarding plan of care post extubation as is DNR/DNI. Bilateral air entry haerd to all lungfields, but diminished at the bases. Suctioned as needed for a small amount of thin clear secretions, weak cough on suctioning. Current vent settings, MMV, allowing him to take spontaneous breaths mixed with set breaths, settings 550/10 PS5 PEEP +%, ABG 7.44/43/116.\n\nCV:- Initially monitored in V Paced rhytham 75-85 bpm, with occationsal PVCs', however rate changed at 1130, ^ 120s, Afib and paced beats, SBP compiromised tp 79, had managed to wean Dopamine to 0.75mcg/kg/min but had to increase to 2mcg/kg/min. SBP 90-120s'. Perpierally warm to touch, pedal pulses dopplerabel. K= 3.6 post K replartion, rechecked 4.4 at 1500. Hct improved to 32.3. Given 2.5mg PO vitamin K. CVP 8-15.\n\n\nNEURO:- Initially off sedation in preparation for extubation, but when desision taken to keep intubated pt became more agiated therefore sedation re-started, currently on midazolam at 0.5mg/hr and fentanyl at 25mcg/hr, roused by voice and bale to gesture needs well. Unable to assess pupils as has cataracts. Able to move all 4 limbs well within the limits of bedrest. Soft wrist restriants inplace to protcet tubes and lines.\n\nGU:- Foley catheter draining good amounts of clear urine, which was intially yellow but has become pinkish as the day progressed, Drs .\n\nGI:- OG tube placement checked, air heard on auscltation. Feed off as not extubating, was having high aspirates last night. Abdomen soft and non-tender. Passing flatus, but bowels not moved during the day.\n\nACCESS:- 2 x PIV both satisfactory and patent. Central line re-dressed as small amount of dry blood present, site appears satisfactory. A-line site looks clean.\n\nFAMILY:- Daughter visited, spoken with Drs length regarding Mr DNR/DNI staus. Asked him whether he would wanted to be re-intubated if needed post extubation and he said yes, which uoset her as he always said that he would not want that, she also brought in copies of living will which were put in chart. DNR/DNI currently still stands.\n\nENDO:- Blood suage slightly elevated at lunch time covered with 2 units sliding scale. steroids given as per chart.\n\nID:- Afebriel during the day, antibiotics given as per chart. WCC trending down. suctioned for small amount sercretions.\n\nSKIN:- Pressure areas, intact, barrier cream applied to sacral areas and areas. Full bedbath given and sheet changed. Nursed on alternate sides and back. Pneumo-boots inplace.\n\nPLAN:- To continue with sedation overnight, and attempt to wean dopamine as tollerates. Plan to extubate tomorrow. To continue to give full explination of care to patient and family.\n"},{"category":"Nursing/other","chartdate":"2120-12-17 00:00:00.000","description":"Report","row_id":1556137,"text":"CCU NPN 1900-0700\nO:\nafeb. contin. vanco/zosyn.\nHR 85-112 Vpaced, underlying afib. no VEA.\nBP 94/63-115/72. dopa weaned to off by 0400.\n\nResp: vent on MMV /.40. sats 99%. RR 12-16. Tv 400-600. suctioned for small amt. white secretions. LS clear to diminished.\nRSBI pnd\nGU: foley draining ~ 30cc/hr. pos. 200cc for and neg. 500cc LOS.\nGI: NPO overnight for possible extubation today. OGT draining small amt. of bilious liq. no stool.\nNeuro: pt. awake and alert at times.....banging hand/feet on side rails for attention. Very frustrated at current state/wanting ETT out. responding approp. to questions....mouthing words approp.\ncontin. on fent. gtt 25mcq/hr and versed .5mg/hr with good effect. small boluses to aid sleep with good effect. wakes easily to voice.\n\nA/P: plan to wean/extubate today. dopa weaned off...contin.to monitor BP. family support. pt. is currently DNR/DNI. need to discuss when pt. is extubated.\n"},{"category":"Nursing/other","chartdate":"2120-12-17 00:00:00.000","description":"Report","row_id":1556138,"text":"RESPIRATORY CARE NOTE\n\nPatient remains intubated and ventilated on MMV ventilation 5/5 with back-up Vt=500, RR=12. most of night with the goal of extubation this AM. BLBS are mainly clear. RSBI completed on PS 5, PEEP 0=29. ABG shows adequate ventilation and oxygenation.\n\n , RRT\n"},{"category":"Nursing/other","chartdate":"2120-12-17 00:00:00.000","description":"Report","row_id":1556139,"text":"Nursing Progress Note 0700-1900\nS: \"My breathing does feel better\"\n\no: Please see carevue for complete objective data.\n\nResp: Extubated @ 1200. Strong cough and + gag reflex. Had a few apneic episodes during weaning, but has had none since ETT removal. O2 weaned down to 2L nc, sats 97-100. Lungs clr c dim bases. No c/o SOB.\n\nCV: Vpaced, 70-80's, PVC's rare. SBP 89-102, off pressors. CVP 6-10. Pulses palp. HCT-28.7 (30.0). Platlets steadily decreasing over past few days. Down to 106, team aware. Started on SC heparin and ASA.\n\nGI/GU/Endo: Pt c/o cramping in abdomen, given colace and senna. Drinking water without incident and taking pills. BS present. Foley draining clr PINK urine, team aware. Rec'ing ins per ss.\n\nAccess/Skin: RIJ Trip lumen cath dressing changed RN's instructions. 2 PIV's. Contusion on R arm.\n\nNeuro/Social: A&O x 2, forgets place but reoriented easily. Daughter and son into visit today, remarked that pt is \"seeing things that are not there\" RN did not witness episode. Pt told MD that he would want to be re-intubated if necesary. Family was there to witness and did not have any objections to pt's wishes.\n\nA/P: Successfully extubated and weaning O2 requirements. Cont to monitor resp status and hemodynamics. Advance diet as tol, ?lactulose for constipation. Monitor UO, PT consult. Emotionally support pt and family and keep updated on plan.\n"},{"category":"Nursing/other","chartdate":"2120-12-20 00:00:00.000","description":"Report","row_id":1556145,"text":"NPN 0700-1900,1735 EST\n\n88 YO MALE WITH H/O CAD,MI, AAA( S/P REPAIR, NO LEAK) RECENT AICD FOR SYNCOPAL EPISODE,SEVERE CARDIOMYOPATHY EF 10% WHO ORGINALLY PRESENTED TO OSH WITH EPIGASTRIC PAIN AND HYPOTENSIVE, WHERE INTUBATED FOR SEVERE HYPOXIC RESP FAILURE AND TRANFERED TO CCU. PATIENT THEN TRANFERED TO FLOOR AND TO MICU YESTERDAY FOR ABDOMINAL PAIN AND CONCERN FOR MESENTRIC ISCHEMIA, CT NEG.LACTATE WAS 2.4 AND DOWN TO 1.7.PATIENT WAS ON NRB 100% AND TOLERATING NC TODAY.\n\nNEURO: ALERT, ORIENTED X3, COOPERATIVE.FOLLOWING COMMANDS CONSTITENTLY AND MAE WITH NORMAL STRENGTH.C/O ABD PAIN LATER EVENING SEEN BY MD AND GIVEN SIMETHICONE PO.\n\nCV: V PACED, WITH PVC'S, POTASSIUM 80 MEQ REPLETED. SBP 100-130MMHG.\nHEPARIN GTT STOPPED FOR 1HR FOR PTT >150 AND RESTARTED TO950U/HR AND NEXT PTT DUE AT 2200.\n\nRESP: TOLERATING NC 5L, DOWN FROM 50% VIA VM. BILATERAL LS WHEEZY/CRACKLES,RRECEIVED MDI'S WITH GOOD EFFECT. WEAK UNPRODUCTIVE COUGH SPUTUM SAMPLES NEED TO BE COLECTED. O2 SATS 90-96%. CXR DONE PM.\n\nGU/GI: TOLERATING DIET, ABD SOFT,BS PRESENT, PATIENT C/O PAIN AFTER BOWEL MOVEMENT AND SEEN BY MD AND GIVEN SIMETHICONE AND PATIENT FEELS BETTER. LASIX 40 MG IV GIVE WITH GOOD EFFECT AND DRAINING VIA FOLEY'S.\n\nENDO:INSULIN AS PER SS\nID: AFEBRILE D/CED ANTIBIOTICS.\nSOCIAL: VISITED BY DAUGHTER.\n\nPLAN: CALL OUT TO FLOOR, CONTINUE MONITOR RESP STATUS AND ABD PAIN. PTT Q6HRS\n"},{"category":"Nursing/other","chartdate":"2120-12-21 00:00:00.000","description":"Report","row_id":1556146,"text":"Nursing progress notes\nEvents:\nReceived pt at 1900 c/o abd pain. #5 on pain scale (0-10) bs+ abd soft dr paged x 2 w/o call back, resident called (dr ) and notified of pt's pain. Dr at bedside pt's pain up to #9, heat pack and ms 1mg ivp given. w/ good results for a short time. pain seems to come and go and increase and decrease in intensity. pt very anxious w/ pain spells. stating he is going to die\" emotional support given. pt tachycardic afib w/ some paced beats and pvcs w/ anxiety and sob. ekg obtained eventhough pt denied cp. dr at bedside and ativan .5mg ivp ordered and given. hrt rate 70s-80s and no further c/o abd pain (after ativan given) however pt unable to get comfortable enough to fall asleep. pt repositioned for comfort w/ no relief. ambien ordered and given 5mg po. pt became restless and confused to place and time. hallucinating, seeing people in his room. he has tried to get oob frequently. bed alarm on and staff in room monitoring pt for most of shift. pt up to chair w/ 2 assist for ?comfort. He stayed in chair for 1 hr then tried to get back to bed. dr aware of pt sob, confusion and restlessness. no orders given. pt c/o left hip pain requesting motrin, 400mg po ordered and given.\n\n\nNeuro: pt was alert and oriented x 3 at the beg of this shift and has become increasingly more confused and restless throughout shift. at present pt resting comfortly in bed w/ eyes closed. pt oriented to self and month. pt re-oriented frequently whenever staff enter pt's room. pt mae and will follow simple commands/\n\nREsp: received on 5l nc ls clear w/ crackles in left base and diminished right base. lasix 40mg ivp given at 2130 pt diurresed 900cc of cloudy yellow urine. pt'd 02 now down to 4liters. he has cold extrem. and his pleth (no matter where I place o2 sat probe it would show 80s and/or straight line for wave form. staff tried to keep blanket on arms to help warm them. sats 93-96% on 4 liters pt has a dry cough\n\ncv: tele paced vent beats w/ intrinsic rythem of afib. hrt sounds s1s2 pedal pulses +2 extrem. cool. k+ 3.1 at 1800 40meq of k+packet given w/ pt ultimately vomiting. k+ changed to iv bolus. phos 1.9 k+phos given. phos now 3.3 k 5.1 (k+ checked at 1900 4.5) heparin gtt infusing at 700u/hr ptt 87.8 inr 2.3 (up from 2.1)\n\ngi: abd soft pt c/o of abd pain for beg of shift as stated above. pt has had 5 small brown loose stools this shift (he is inc at times), all guiac neg, all foul smelling. 1st stool sent for cdiff. pt vomited (as stated above) 100cc w/ small bld clot noted, anzemet 12.5mg ivp given. pt taking po ok no further vomiting notied. kub done on day shift. -unremarkable.\n\ngu: urine output trailing off this shift, lasix 40mg ivp given w/ 900cc diuresed\n\nskin:intact however lg eccymotic area noted on right upper forearm. old right cortis site intact not draining\n\nid: right tlcl removed and cath tip cx wbc 19.6 up from 13.0\n\naccess: pt has 2 #18 piv and tlcl removed this am per micu order/\n\nendo: bs 1\n"},{"category":"Nursing/other","chartdate":"2120-12-21 00:00:00.000","description":"Report","row_id":1556147,"text":"Nursing progress notes\n(Continued)\n26-141\n\ncode: pt was a dnr per poe, however dr asked pt about his code status. pt alert and oriented x3 at the time , pt decided to have everything done for him. pt now a full code.\n\nsocial: son is hcp no contact w/ family overnight.\n\nPlan:\nno ambien/ativan\ncont to watch closely for pt's safety\ncont to reorient\nadminister motrin q 8hrs prn for left hip pain.\ncont to wean 02 as tolerated.\n"},{"category":"Nursing/other","chartdate":"2120-12-21 00:00:00.000","description":"Report","row_id":1556148,"text":"7a-7p\nsee transfer note\n"},{"category":"Nursing/other","chartdate":"2120-12-21 00:00:00.000","description":"Report","row_id":1556149,"text":"BS few fine crackles (less than yesterday). No change with MDI's. Appears somewhat more confused than before. Called out to floors.\n"},{"category":"Nursing/other","chartdate":"2120-12-21 00:00:00.000","description":"Report","row_id":1556150,"text":"1900\ntransfer to floor held due to sbp < 90(85-88), 250 ns iv bolus x 2 given & po midodrine started, transfer to floor when sbp consistantly > 90\n"},{"category":"Nursing/other","chartdate":"2120-12-22 00:00:00.000","description":"Report","row_id":1556151,"text":"addendum micu 7 west npn\npt came to MICU-7 at 1800 from FAR 7 after a 10pt Hct drop.\nPt received, total of 3 units PRBCs IN and 3 unit FFP IN, 20mg Lasix given as well. Unable to insert NG tube for lavage - pt. refused.\nABG/VBG done - see carevue, labs sent. foley output clear/yellow, bs hypoactive, nonrebreather difficult to obtain o2 pleth - 95% w/ good pleht.\nPt to go to CT tonight for Abd, ? source of bleeding.\n"},{"category":"Nursing/other","chartdate":"2120-12-13 00:00:00.000","description":"Report","row_id":1556124,"text":"S: pt intubated\n\nO:see careview. DNR\n\nCV:Vpaced a flutter c weinekbach through av node. BIV ICD . CT showed large triple a _ pe and leak/rupture. troponon .02, ck 53. pt has alne and right fem cortis. inr 2.8. HR 90-80's. pt on 4.5mcg/kg/min dopa with a bp 119/84. pts bp drops when dopa was decreased to 3mcg/kg/min. maintain map goals of >65.\n\nRESP:AC/40%/TV500/RR20/PEEP10. ABG 7.39/36/160/23/-2.ett was advanced 4cm per x-ray.\n\nneuro:sedated responds to stimulation. midazolam 2mg/hr and fentanyl 25mcg/hr\n\nendo:BS 200's on ss insulin.\n\nGU:-1281cc since admission pt did receive 6liters of fluid in osh for hypotension. foley cath inplace.\n\nGI:+BS - BM ogt placement confirmed with xray and ausciltation.\n\nID: afebrile on antibiotics.\n\nsocial: 2sond and daughter into visit pt. pts son is health care proxy. Pt made it clear to son that if he ends up no able to move and can only sit and watch tv all day he does not want to live. family does not want swan line placed.\n\nA:If there is no improvement in the next 48hrs or decreased requirment for supportive care then plan will be to withdraw care + CMO.\n\nP: wean vent as tolerated, wean dopa as tolerated, start tube feeds after midnight as ordered.\n"},{"category":"Nursing/other","chartdate":"2120-12-14 00:00:00.000","description":"Report","row_id":1556125,"text":"Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made through out the night. No morning abg results at this time.\n\nNo RSBI measured due to the level of PEEP currently required.\n"},{"category":"Nursing/other","chartdate":"2120-12-14 00:00:00.000","description":"Report","row_id":1556126,"text":"CCU NPN 1900-0700\nO: 88yo male with hx CAD, Ischemic transferred from OSH following Acute resp. failure, hypotension req. intubation, dopa and fluid resusitation.\n\nCABG x3, ICD , DVT, CHF. takes lasix, amio, zoloft, statin at home (incomplete list).\nrecent hosp. for SOB- ? RLL PNX (per chart).\n\nCTA here showing 6.5cm infrarenal AAA with no evidence of rupture or leak. evidence of graft repair distally. (per chart review).\n\novernight:\nTM 99po. cultures pnd from admission.\nCV: HR 95-110 Vpaced with baseline afib. occas. to freq. PVC's. K+ 3.8, Mg+ 2.2.\nBP 95-101/50-60's MAP 64-75. dopa weaned to 3.3mcq/k/min but BP trending down to 80's/ . titrated to 4.0mcq/k/min with SBP 93-100/. MAP 70. Dr. aware.\nright fem. cordis line D/I. pulses doppler bilat. feet cool.\nHCT 38.5. CPK neg. x2.\nResp: no vent changes: AC 500x20/10peep/.40. sats 100%. suctioned for thin white secretions. LS clear. ABG 7.43-41-120\nGU: u/o 50-100cc/hr. neg. 1.6L for .\nGI: abd soft, NT. pos. BS. OGT with small amt. bilious drainage, guiac neg. tube feeds probalance started at 10cc/hr. no stool.\n\nNeuro: Eyes open to stimulation and name. nods and shakes head approp. to questions but did not respond to other commands. no acute agitation. fent. at 25mcq/hr . Versed weaned to 1.5mg/hr.\n\nendo: FS 180. SSRI.\nskin: dark bruise on right inner elbow - ? from blood stick. intact otherwise.\nno family calls.\n\nA: cardiogenic vs septic shock. family refusing swan ganz catheter. contin. dopa dependent. negative fluid balance post diuresis on admission. ck's neg. AAA stable with no evidence of rupture/leak.\nfamily requests DNR/DNI. EP consulted to assess BIV/ICD>\nP: titrate dopa as tolerated. follow cultures. titrate sedation for comfort. advance TF per order. family support.\n"},{"category":"Nursing/other","chartdate":"2120-12-15 00:00:00.000","description":"Report","row_id":1556131,"text":"Resp Care\n\nPt remains intubated and currently vented back on full vent support. Attempted to wean pt on PSV trial however pt continued to go apneic 15 minutes into the trial and was subsequently placed back A/C to rest overnoc. BS clear to slightly course sxing for minimal secretions. Will cont with vent support and reassess for readiness to wean daily.\n"},{"category":"Nursing/other","chartdate":"2120-12-15 00:00:00.000","description":"Report","row_id":1556132,"text":"V PACED C HR TO 115.ATTEMPTING TO WEAN DOPAMINE ,BP CONTINUES TO DRIFT TO 80S .4 UNITS FFP GIVEN.TLC R SUBCLAVIAN PLACED.CVP 13.FEM LINE DC\n\nATTEMPTED PSV TRIAL P SEDATION DC.PT HAD PERIODS OF APNEA, RETURNED TO CMV.SATS 100.SX SM AMT THICK TAN .\n\nPOS BS ,DENIES ABD PAIN.\n\nHUO 50 TO 75.POS 1100CC.\n\nPT ALERT AND APPROPRIATE C FAMILY.DENIES PAIN .FAMILY WANTS TO BE HERE IF EXTUBATED TOMORROW .WEDDING RING SENT HOME C FAMILY.\n\nT MAX 99.1 .\n\nDOPAMINE ,VENT DEPENDENT\n\nTRY TO WEAN DOPAMINE\nRESTART TF\n\n\n\n\n\n\n\n\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2120-12-16 00:00:00.000","description":"Report","row_id":1556133,"text":"CCU NURSING PROGRESS NOTE\nS:INTUBATED\nO:PT IS A 88YOM ADM W/ HYPOTENTION AND RESP FAILURE.\n\nNEURO:PT NOW OFF ALL SEDATION AS OF 0400. PT OPENS EYES SPONTANEOUSLY, FOLLOWS COMMANDS. MAE.\n\nRESP:LS CLR AND DIM AT BASES, NO WHEEZES. SATS 96-99%. VENT AC/500/18/40/5 W/ ABG OF 7.50/40/76/32/94%. RR DOWN TO 14/TV-600.\nWILL REPEAT ABG. SX FOR SM AMT PALE YELL SECRETIONS. SPUTUM GRAM STAIN SHOWING 2+YEAST, 1+GPC IN PAIRS/CLUSTERS. 1+ GNR. FINAL REPORT PENDING. NEW R IJ TLC PLACED YESTERDAY.\n\nID:T-MAX <98. WBC DOWN TO 10.6K. PT ON VANCO AND ZOSYN. SPUTUM AS ABOVE. BLD CX PENDING.\n\nCV:MHR 80-100, AFIB AND V-PACED, W/ OCCAS PVC OR FUSED BEAT. ATTEMPTED TO WEAN DOPA OFF EARLY LAST EVENING, SBP DOWN TO 70S. DOPA WAS RESTARTED BACK AT 2.5MCG/KG/MIN. NOW AT 2MCG/KG/MIN. RIGHT GROIN SITE D&I. DP AUDIBLE W/ . SKIN SALLOW, MUCOUS MEMBRANES PINK. CAP REFILL BRISK. EXTREMITIES WARM, SKIN WARM AND DRY. HCT THIS AM DOWN TO 29.2\n\n\nGI:TF OFF AT MN FOR WEANING AND POSSIBLE EXTUBATION. +BS , DENIES ABD DISCOMFORT. NO STOOL.\n\nGU:YELL URINE W/ SOME SEDIMENT, DECREASED OVER NOC, U/O 0 AT 0400 .F/C FLUSHED AND HAD ADEQUATE URINE OUTPUT AFTER THAT.\n\nENDO:GLUC COV AS PER SS. 181, COV'D W/ 2UX REG INS.\n\nA/P:CONTINUE TO WEAN DOPA TO OFF. SEDATION OFF WILL ATTEMPT TO WEAN FROM VENT. PT IS A DNR/DNI. FAMILY WOULD LIKE TO BE NOTIFIED AND BE ABLE TO VISIT RIGHT AFTER EXTUBATION. CONTINUE GLU COV WHILE ON STEROIDS. FOLLOW CULTURES, CON'T ANTIBIOTICS. MONITOR FOR ANY DECRESES IN HCT. NUTRITION WHEN APPROPRIATE. EMOTIONAL SUPPORT. SOC SVC FOR DISCHARGE PLANNING.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2120-12-16 00:00:00.000","description":"Report","row_id":1556134,"text":"RESPIRATORY CARE NOTE\n\nPatient remains intubated and fully ventilated on AC settings. Adjusted settings in attempt to stimulate patient to breath more on own to wean. ABG shows metabolic alkalosis. RSBI completed on PS 5=33. Placed on PS but becomes apneic often and unable to wean on PS at this time-sedation completely off also. Switched to Vt of 550, RR=12. seems to be breathing over set rate. Plan to wean support when able to tolerate.\n\n , RRT\n"},{"category":"Nursing/other","chartdate":"2120-12-29 00:00:00.000","description":"Report","row_id":1556165,"text":"Resp Care: Pt seen for attempt @ bipap...placed on 5 cm nasal cpap with 2 lpm bled in, tol ~ 10 minutes >> confused/uncoop, pulling off mask, returned to nasal prongs @ lpm with spo2 89-100%, restless with freq c/o inability to breathe, will follow for nebs/ cpap as tol.\n"},{"category":"Nursing/other","chartdate":"2120-12-18 00:00:00.000","description":"Report","row_id":1556140,"text":"S:\"I would like to eat icecream.\"\n\nO:please see careview.\n\nCV:v-paced hr 70's, bp 100/50's. pt currently receiving 75cc/hr for 1000cc of iv fluid. tolerating well.\n\nresp:2liters o2 via nc c o2 sats in the high 90's. LS clear.\n\ngu:pt 's urin output 20cc/hr-40cc/hr. red tinged urin. +200cc as of now.\n\nGI: no bm + bs pt tolerating po meds and icecream.\n\nendo:ss insulin bs 150-200's.\n\naccess:right ij and right a-line.\n\nneuro:pt a+ox3 pt became confused when he awoke from naps throughout night. pt thought he was at home and he had to go food shopping for the kids also he thought he seen 2 cigaretts on his bed burning. pt was easily reoriented.\n\nA:low platelets decreasing past 3 days.\n\nP:continue to treat and monitor lytes/platlets. continue to encourage cough and deep breath, continue to access mental status. follow blood sugars.\n\n"},{"category":"Nursing/other","chartdate":"2120-12-18 00:00:00.000","description":"Report","row_id":1556141,"text":"CCU Progress note 0700-1900\nRESP:- Remains on N/C at 3 litres, Sa02 96-99% RR 18-26 and regular. Bilateral air entry haerd to all lungfields, but diminished at the bases. Coughing but not expectoarting any sputum.\n\nCV:- Moniotred in V paced rhytham, 75-85bpm, with occational PACs'. SBP manually 93-100, A-Line removed as bleeding, sugifoam inplace and pressure held for 20 minutes. Peripherally warm to touch. For repaet labs to be checked at 1600, then for possible blood transfusion if Hct continues to fall. Q8 our heparin and pneumo boots inplace.\n\nNEURO:- A&O x2, a little low at times, wanting to go home, told him that he is doing well considering how ill he was last week. Able to move all 4 limbs within llimits of bedrest. Able to feed himsefl with supervision.\n\nGU:- Foley catheter continues to drain blood tinged urine, acceptable amounts. Team aware.\n\nGI:- Able to eat a small amount of diet during the day. Seen by speech and swallow, assessed no problems noted with swallow. eaten small amount of diet today, tollerating it well. Abdomen soft and non tender. Bowels not moved to day. Bowels sounds heard. Docusate and senna given as ordered.\n\nSKIN:- Pressure areas inatct, on back for most of the day, encourgaed to lay on sides also. Barrier cream applied to back, saccral area and heels. Full bedbath and sheet change given, with facial shave.\n\nACCESS:- Now has central line only, 2X PIVs removed as in for 3 days, A-line also removed. Central line re-dressed as oozing.\n\nENEDO:- Blood sugars within normal limits. Steroids given as per chart.\n\nID:- Afebrille during the day, not further reported grows from blood cultures. Coughing but no expectorating any sputum. Vancomycin stopped. Zocyin continues.\n\nFAMILY:- DAughter called and updated. No other enquires as yet from family today.\n\nPLAN:- CAlled out to the floor, to contiue with antibiotics and steroids. To mobilse as tollerates. To continue to give full explination of care to patient and family.\n"},{"category":"Nursing/other","chartdate":"2120-12-20 00:00:00.000","description":"Report","row_id":1556142,"text":"REspiratory Care\nPT with progressive SOB and wheeze. Treated with MDI (very good technique) but wheezing remained. XRay reported with increased CHF. ABG drawn from R radial artery without incident. Results reveal mixed respiratory and metabolic alkalosis with only fair oxygenation on 50% venti, FiO2 increased to Partial Non Rebreather. Being treated aggressively for apparent CHF.\n"},{"category":"Nursing/other","chartdate":"2120-12-20 00:00:00.000","description":"Report","row_id":1556143,"text":"Prt was transfered to MICU from 7, with Dx of ? mesenteric ischemia D/T sudden onset of sharp mid abd pain. Ct of abd neg for any leakage from AAA, absess or obstruction. BC X2 and UA/urine cx sent on adm and UA back with picture of UTI. Since his adm to MICU his resp status continued to decline until 2 am. At 2 Am pt was found to be restless, O2sat decreased to 90-91% on 5 liters NP and LS with cx's and exp wheezes. Resp status did not improve after neb tx. ABG : 7.53/35/60/30 on 50 % VM. CXR done, and showed worsening CHF,- and pt started on lasix. After lasix IV, pt's resp status improved.\n\nNeuro)\n Pt oriented x 2 on adm. Pt cooperative and follows simple commands. Pt given Ambien for sleep, and was found to become very comfused afterwards. Ambien was later D/C'd.\n\nCV)\n Pt in 100% Ventricular paced (70-80's) with PVC's. SBP stable 94-116 with MAP > 70. CVP 17-->11 (after Lasix). Pt has gen anasarca, with trace pitting to ext's. Good pulses to palp. K and phos level this am to be replaced. Inr this am 1.9 ? heparin gtt or coumadin today D/T A-fib. Access: Rt IJ TLC with good bloodreturn.\n\nResp)\n LS at 4am with cx's throughout. RR22-24. Pt present with a dry non-prod cough...less freq now. Pt remains on 100% NRB with o2sat 95-97%. CXR to be done later again today. ? repeat ABG later too and ? More Lasix for CHF.\n\nID)\n WBC down to 13.3 this am (17.8). Pt only on Zosyn IV at this time. Bc and urine cx pending.\n\nENDO)\n Steroid induced hyperglycemia, and on RISS as noted with BS at mn 167.\n\nGI)\n Abd dist, soft and with + BS. Pt started to regurgitate after taking po pills pm. KUB done. No other incidences since then and diet adv to House. Pt on protonix and given Maalox. Last BM am (guiac -). IVF at KVO.\n\nGU)\n Cont to diurese pt. Pt is now + 900 since adm to MICU.\n\nSkin)\n Skin intact.\n\n\n"},{"category":"Nursing/other","chartdate":"2120-12-20 00:00:00.000","description":"Report","row_id":1556144,"text":"BS fine crackles bilateral though in negative fluid balance. No change with MDI's. Strong non-productive cough.\n"},{"category":"Nursing/other","chartdate":"2120-12-26 00:00:00.000","description":"Report","row_id":1556161,"text":"NPN 7p-7a\nDNR/DNI\nAllergy: Benzo's-confusion\nPlease see carevue and FHP for additional data.\n\nNeuro: Continues with anxiety overnight, feeling like he is \"going to die\". Recieved Trazadone this evening with mod. effect. Requires frequent reassurance regarding health status. No c/o pain. MAE, although at times patient feels as though he \"can't move\", likely having extra fluid in lower extrem. and feeling heavy.\n\nResp: NC 3L. LS clear w/ occ. wheezes, Alb/Ipa nebs w/ good effect. No cough noted.\n\nCV: 76-82 Vpaced. Occ. pvc's noted. Sbp 111-123. RR 20-24. Sats 95-100%. HCT stable, 33.1, s/p iliac bleed. EF 10%. Recieved 20mg iv Lasix w/ good effect. On Digoxin QOD.\n\nGI/GU: abd soft, well tolerated Renal diet. Foley patent, draining adeq. clear, yellow urine.\n\nEndo: Humalog SS.\n\nSkin: eccymosis to left hip, unchanged.\n\nA/P: 10pt HCT drop- etiology unclear, iliac hematoma, now w/ stable HCT. CHF- EF 10%. Cont. w/ lasix for fluid goal ~ -1L negative. Remains on Dig. and aldactone.\nAnxiety- Seemed to respond pretty well to Trazadone over night, cont. to monitor and offer emotional support.\nLikely call out to cardiac floor.\n\n"},{"category":"Nursing/other","chartdate":"2120-12-26 00:00:00.000","description":"Report","row_id":1556162,"text":"DNR Universal Precautions Allergy: Benzos\n\n\nNeuro: AAOX3, MAEx4 - OBB to chair w/ minimal assist. In better spirits today.\n\nCV: HR=70-60s, V-paced. BP=90-110/. +periph pulses, +edema, extrems warm.\n\nResp: 3l n/p w/02sat 96-99%. Lungs clear in upper fields, few crackles bilat - more in L than R. Received aldactone at 1200. RR=18-26. SOB after any exertion, but returns to normal in a short time (5 min).\n\nGI/GU: abd soft, +BS, taking renal diet well. No BM. Foley cath w/ clear amber urine.\n\nSkin: Intact. L hip eccymottic. Buttocks/heels intact.\n\nPain: Denies discomfort\n\nSocial: No family visiting or calls as of yet today.\n\nAccess: New #20 PIV placed this am.\n\nHCT 33.1 today\n\nPlan: Tx to .\n"},{"category":"Nursing/other","chartdate":"2120-12-23 00:00:00.000","description":"Report","row_id":1556152,"text":"micu npn 1900-0700\ncont'd-\n\nS: I don't want to die in the hospital, if i'm going to die, I would rather die at home\nO: Patient overnight very restless and emotionally upset at times about not being able to go home and \"just wanting to be at home with his family\". We had a discussion this am about his poor heart, his code status and the initbility for him to be at home at this point with all the care and services he needs. He expressed a desire for me to speak with his daughter, and have her gather his family to come to some decisions regarding his code status and get him home.\nA/P: Hope to speak with family today, team aware and will have a discussion regarding code status/change in goals of care w/him.\n"},{"category":"Nursing/other","chartdate":"2120-12-23 00:00:00.000","description":"Report","row_id":1556153,"text":"micu npn 1900-0700\nPlease see fhpa for details on admission history.\n\nBriefly, pt is an 88 yo male, hx of cad, mi, aaa (s/p repair w/no leak, aneurysm 6.5 cm), a fib, recent aicd pl (), severe cardiomyopathy w/ef 10-15%, presented to osh w/c/o epigastric pain, hypotensive to 60's , intubated for hypoxic resp failure w/presumed cardiogenic shock.\nHe transferred to CCU treated and sent to the floor . Micu accepted the pt to micu6 on for c/o abdominal pain. cta neg for mesenteric ischemia, no indication for surgery, but vascular following. He had issues w/hypotension vs chf lasix and fluids, started on midodrine and put back on iv heparin for underlying afib. transferred to the floor again on w/guiac + stools.\n\nYesterday , pt w/inr's climbing since transfer to the floor, am labs showing hct drop from 31 of prev day to 25.7, then 19.4 several hrs later. The pt c/o left leg/hip pain and was hypoxic to the ?mid 70's. He was again transferred to the micu(7) for w/o of source of bleed.\nPt transported to ct overnight for ct of abdomen, showing stable aaa, noted bleeding into iliac muscle, although doesn;t account for 10 pt hct drop. gi to see pt as he has been ob+ form below.\n\nbrief ros\nneuro- pt alert and oriented x2-3. very upset overnight that he has not been able to go home. frustrated at situation. appears to be for the most part a+ox3. no defecits noted.\n\ncv- remains vpaced w/afib underlying. some fusion beats w/v paced rhythm. hr 80-100. non invasive bp has been 100-130's sys. heparin had previously been d/c'd.\n\nresp- on nrb for short time last eve, unable to get accurate o2 sat. now on 6l nc sats appear to be >94% when able to get a waveform. rr mid 20's-30. at times labored. received additional 20 iv lasix lasrt eve w/some response.\n\ngi/gu- npo except ice chips for now. gi will see pt in the am for ?ugi scope to eval additional source of bleeding since he has been guiac +. uop good. no bm this shift.\n\nheme- since episode of hct drop, pt has received total of 3 u prbc's and 4 u ffp. hct back up to 30. inr remains elevated now 1.9. no s+s of bleeding.\n"},{"category":"Nursing/other","chartdate":"2120-12-24 00:00:00.000","description":"Report","row_id":1556156,"text":"npn 1900-0700\n\nOvernight: Electrolyte repletion. Patient became very anxious at 2315 stating he was \"scared\" and he wanted to be with his mother who is \"dead and buried\". Called his daughter and he was better for a little while. Received haldol without effect and then .5mg of ativan at 0215. He was then able to sleep the rest of the night.\n\nneuro: AXOX3, follows commands. No c/o pain or discomfort. Anxiety re. hospitalization and fear of dying in the hospital--wants to die at home.\n\nresp: sats 93-98% on 3L nc. LS clear.\n\ncv: V paced with fusion beats. BP with MAP >60. Received total of 100meq of potassium overnight for a level of 2.7 at last evening.\nPartial dose of digoxin due at noon (.03mg) and begin full dose tonite at bedtime.\n\naccess: 3 piv. Able to draw blood from piv in L arm.\n\ngi/gu: Abdomen is soft with + BS. Patent foley with clear yellow urine. Output has dropped off overnight; received several doses lasix yesterday. 2 liter fluid restriction.\n\nskin: Many areas of bruising, r arm, hematoma on L hip. No open areas. Heels are reddened.\n\nendo: RISS.\n\ndispo: DNR/DNI. Pt wants to go home.\n\nsocial: Pt spoke with dtr last night.\n\nplan: Agressive diuresis, serial crits q 8 hours. AM potassium is 3.0; will hang 40meq in 500cc and then try ti have pt take po. He refused the potassium pills last night.\n\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2120-12-23 00:00:00.000","description":"Report","row_id":1556154,"text":"MICU7 RN Note 0700-1900\n\nEvents: Hct 29.3 stable no active bleed, Lasix +diuresis, CHF team consult implement recomendations. Family , PT OOB chair.\n\nNeuro: awake alert oriented x3, follows commands MAE random Equal strength, PT OOB to chair Full weight bearing with assist. Chair for 1.5hrs, pt feeling depressed and emotional weepy, wanting to go home to be with family. \"I do not want to die in hospital\". Met with Social services.\n\nCV: HR 75-95 V-paced fused beats, BP 95-119/46-67. MAPS>60. Currently hemodynamically stable, CHF team evaluation. Agressive diuresis, d/c midridone, Digoxin, Ace inhibitor, betablocker. Peripheral pulses 3+DP/2+DT, gen edema. Lasix 20mg x2 + diuresis. Goal -2L.\n\nHeme: Serial Hct 29-29.3, Q8hrs. no active bleed INR 2.1.\n\nResp: RR 18-24 Dyspneic with activity, O2 4L/min NC Sats 90-96%, Lungs clear rales bil. dim with Lasix. HOB>30 degrees.\n\nGI: abd soft nontender + BS, recieved bowel regime, stool x3 soft brown, + guiac. Started shift NPO adv to reg with restrictions. tol well No N/V.\n\nGU: Foley u/o 40-240cc/hr +diuresis from Lasix. Goal (-)2L.\n\nDerm: Skin W/D 3+ anasarca, Ecchymotic L Hip/flank denies pain.\n\nSocial: Started shift full code status to DNR per pt and family request. met with Team. pt would like to cont with plan for fluid removal and transition to home with services.\n\nPlan: seriel Hct q8hrs next @ \n Implement/resume cardiac meds\n agressive diuresis\n\n"},{"category":"Nursing/other","chartdate":"2120-12-23 00:00:00.000","description":"Report","row_id":1556155,"text":"Respiratory Care:\nPt seen for neb Tx's x 2 today At 12noon and 6 PM. He seems to be much improved over Last evening.!!\n"},{"category":"Nursing/other","chartdate":"2120-12-24 00:00:00.000","description":"Report","row_id":1556157,"text":"FOCUS; NURSING PRGRESS NOTE\n88 YEAR OLD MALE WITH CAD S/P MI, AAA S/P REPAIR, RECENT AICD, EF 10% ADMITTED TO MICU WITH 10 PT HCT DROP S/P ILIAC BLEED.\nREVEIW OF SYSTEMS-\nNEURO- HE IS ALERT AND ORIENTED X3. COOPERATIVE WITH CARE. EXPRESSING DESIRE TO GO HOME. REQUIRING FREQUENT POSITION CHANGES TO FEEL BETTER.\nRESP- ON 3L NC WITH RESP 18-25. SATS 92-98%. BS CLEAR DIMINISHED AT THE BASES.\nCARDIAC- HR 117 TO 88 VPACED WITH FUSION BEATS. SBP 112-125. K 3.0 TODAY TX WITH 40MEQ KCL PO AND 40MEQ IV. CA 6.2 TODAY CORRECTED TO 7.5 WITH ALBUMIN LEVEL TX WITH 3GMS CA GLUCONATE. REPEAT LYTES DUE AT 1600. REVCEIVED 20MG IV LASIX WITH GOAL OF KEEPING PATIENT NEG TODAY. ALSO RESTARTED ALDACTONE. ACE TO BE STARTED TOMMORROW.\nGI- ABD SOFT WITH POS BS. NO STOOL TODAY. LAST STOOL YESTERDY. TOLERATING RENAL CARDIAC DIET WELL. PPI CHANGED FROM IV TO PO. LFT'S INCREASED TODAY. DR AWARE.\nGU- FOLEY PATENT DRAINING YELLOW URINE. DIURESING FROM LASIX.\nENDO- BS UP TO 209 AT TX WITH SS HUMOLOGUE\nHEME- HCT STABLE AT 30.6. INR STABLE AT 2.1. REPEAT LABS DUE AT 1600.\nID- AFEBRILE. WBC DOWN TO 11.9. ALLL CULT NEG TO DATE.\nACCESS- 2 # 18 PERIPHERALS INTACT.\nSKIN- OLD ECCHYMOSIS ON LEFT HIP AREA.\nSOCIAL- DAUGHTER CALLED AND WAS UPDATED BY THIS NURSE.\nDISPO- DNR DNI. ? C/O TO FLOOR.\nPLAN- DIURESE TO KEEP PATIENT NEG.\n START ACE TOMMORROW IF STABLE.\n STABALIZE AND THEN SEND HOME.\n"},{"category":"Nursing/other","chartdate":"2120-12-24 00:00:00.000","description":"Report","row_id":1556158,"text":"FOCUS; ADDENDUM\nCARDIAC- PATIENT STILL POS AND DIURESING SLOWING DOWN. DR NOTIFIED AND 20MG IV LASIX ORDERED AND GIVEN.\nPLAN- CHECKED WITH DR . TEAM WANTS TO SEE HOW PATIENT DOES OVERNIGHT. THEN ? C/O TO TEAM IN AM.\n"},{"category":"Nursing/other","chartdate":"2120-12-28 00:00:00.000","description":"Report","row_id":1556163,"text":"NPN 7p-7a\nPt is an 88 y/o with extensive cardiac history. Of note, CAD s/p MI, CHF with an EF 10%, V-paced. Pt has allergies to Benzos and newly HIT +. Pt was on Medicine floor s/p MICU stay, and developed LUE DVT. Pt started on Argatroban gtt. Last night pt became increasingly agitated and confused, medicated with Haldol and Ativan. Today, pt was more somulent and lethargic, c/o SOB feeling \"that he was not breathing\". Pt was also requiring more O2, with sats 83% on usual 3.0L. Pt was transfered to MICU for bipap and monitor MS. Once in MICU, bipap was not intiated pt becoming more alert with less O2. MICU team believes pt CO2 retainer and was most likely over , follwed by too much O2. Head CT was negative for any bleeding. Pt does have significant apnea 20-30secs with sats dropping to mids 80s.\n\nNEURO: Pt is lethargic, alert to voice. Pt is calling out for family at times, says he needs to say goodbye. Pt MAE weakly. Pt is oriented to person and place. No c/o pain.\n\nCV: Vpaced, HR 70s-80s with occas PVCs. BP 90s-100s/60s-70s. Weak palpable pulses bilaterally. Pt on Argatroban @ 0.50mcg/hr, PTT 46.8. Next due @ 2100.\n\nRESP: Sats mostly >94% on 2.0L NC, pt does desat as stated above. LS with crackles @ bases. RR 15-30s.\n\nGI/GU: ABD is soft, +BS. Pt NPO now until more alert. Pt is taking ice chips fine. U/O has been ample 120-300cc/hr clear yellow urine.\n\nSKIN: Pt has large old echymosis over left hip from previous admission. Also small area on Right hip. Pt does have echymosis over arms, as well.\n\nSocial: Pt has children who were with him on pt's transfer. They were updated by this RN and Dr. . They will be back this evening.\n\nPLAN: Continue to monitor MS, resp status ? check another ABG tonight for possible bipap. Diurese as needed, pt on standing Lasix, although CXR does show edema.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2120-12-29 00:00:00.000","description":"Report","row_id":1556164,"text":"npn\nneuro: aox3, pt has been sleeping off and on thru out shift. pt needs to be told that he has been sleeping, this seems to relieve his anxiety and he falls back to sleep.\n\npain: denies\n\ncad hr 70's v-paced with occass. pvc's. nbp 98/70 to 129/89 range. pt remains on argatroban gtt at .5mcg , held for one hour at 515am for ptt of 92.6, to be restarted at 615 am at .25mcg\n\nresp: ls clear with dim. bases, ls shallow, non-productive cough, rr teens with sats high 80 to 100% on 3l nc, pt received neb tx as ordered\n\ngi: abd firm, bs+, pt has had one large bm at 3am. taking sips of water and apple juice.\n\ngu uo >60cc/hr up to 320 with lasix, foley patent and draining yellow . 1 lter negatve at\n\nskin: bruising over left falnk.\n\nsocial: family into visit lasnight.\n\nplan: monitor ptt with argatroban gtt, cont to monitor vs, resp status.\n\n"},{"category":"Nursing/other","chartdate":"2120-12-13 00:00:00.000","description":"Report","row_id":1556123,"text":"resp care - Pt received from ED on full vent support. FiO2 decreased during shift per ABGs. Last ABG shows normal values with hyperoxemia. Slight rhonchi in the upper lobes cleared on suction of scant amounts of frothy white secretions. ETT was advanced 4cm per xray. Continued resp support planned.\n"},{"category":"Nursing/other","chartdate":"2120-12-25 00:00:00.000","description":"Report","row_id":1556159,"text":"NPN 7p-7a\nPlease see carevue for additional data.\nAllergy: Benzo's- confusion.\nDNR/DNI\n\nNeuro: AOx3. MAE. Anxious, unable to sleep despite prn Ativan (0.5mg) ,Haldol (1mg), Morphine (1mg x2), and Ambien (5mg). Little effect until recieved Ambien, seemed to sleep after this, occ. awaking for repositioning.\n\nResp: 3L NC. LS Clear to auscultation after recieving 20mg iv Lasix. Sats 95-100%.\n\nCV: 88-105 Vpaced, occ. pvc's. Sbp 109-144. Recieved 20mg iv Lasix, fluid goal negative, presently negative ~380. Lower extrem. edema noted. EF 10%. s/p iliac bleed. HCT 30. lytes pnding. Plan to restart ACT in am.\n\nGI/GU: abd soft, +BS. no stool overnight. Well tolerated renal/cv diet. Continuing diuresis as above for goal of negative fluid balance.\n\nEndo: SS Humalog.\nSkin: Eccymotic area to left hip, does not appear to be increasing. Left arm s/p infiltrate, keeping elevated.\nID: afeb. wbc pnding.\n\nA/P: S/P illiac bleed, hct stable. HCT QD. Likely call out to floor, team CV med.\n"},{"category":"Nursing/other","chartdate":"2120-12-25 00:00:00.000","description":"Report","row_id":1556160,"text":"88 y.o. male with hx. of AAA repair, MI/CAD, s/p CABG, DVT, GERD, HTN, pacemaker, s/p septic shock, extubated . S/p iliac bleed, Hct and coags stable.\nNeuro: A&O x3, cooperative, follows commands, denies pain. MAE. OOB to chair x2 with 2 people assist.\nResp: On 3L NC sats 96-99%. Episodes of SOB at rest and on exertion. LS bibasilar crackles. Got Lasix total of 40mg IVP with ~ 750cc diuresis. Goal to take 1L off today. Given nebs tx. prn with minimal response.\nCV: HR 80s-100s, V-paced with frequent PVCs. BP 110s-120s/70s-80s. Bilat LE 3 + edema. Lt. arm elevated on pillow swelling due to infiltrated IV. Started on Metoprolol today.\nGI/GU: Tolerating renal diet. Abd. soft, nontender, +BS, no BM today.\nFoley patent with dark yellow urine out.\nEndo: BS checked q4 hrs ranging from 110-220. Covered per sliding scale.\nSocial: Both sons visited, spoke to case management, updated on status and plan of care. Rehab screening initiated.\nPt. is called out to cardiac floor, no bed available yet.\n"},{"category":"Echo","chartdate":"2120-12-13 00:00:00.000","description":"Report","row_id":82428,"text":"PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Wall motion. Shock.\nHeight: (in) 66\nWeight (lb): 150\nBSA (m2): 1.77 m2\nBP (mm Hg): 118/86\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 09:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Severe\nglobal LV hypokinesis. No LV mass/thrombus. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild to moderate\n(+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\nMild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. The right atrium is moderately dilated. No\natrial septal defect is seen by 2D or color Doppler. Left ventricular wall\nthicknesses are normal. The left ventricular cavity is moderately dilated.\nThere is severe global left ventricular hypokinesis. No masses or thrombi are\nseen in the left ventricle. There is no ventricular septal defect. The right\nventricular cavity is mildly dilated. There is mild global right ventricular\nfree wall hypokinesis. The ascending aorta is mildly dilated. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Mild to\nmoderate (+) mitral regurgitation is seen. The tricuspid valve leaflets are\nmildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\n\n"},{"category":"ECG","chartdate":"2120-12-14 00:00:00.000","description":"Report","row_id":208773,"text":"Demand pacing\nSince previous tracing, ventricular paced beats with occasional native\nventricular premature complexes, sinus beats\n\n"},{"category":"ECG","chartdate":"2120-12-13 00:00:00.000","description":"Report","row_id":208774,"text":"Ventricular paced rhythm at a rate of 120. QRS morphology raises the\npossibility of biventricular pacing. There are probably P waves in the\nST segment raising the possibility of pacemaker mediated tachycardia. Clinical\ncorrelation is suggested.\n\n"},{"category":"ECG","chartdate":"2120-12-22 00:00:00.000","description":"Report","row_id":208770,"text":"Ventricular paced rhythm. Compared to the previous tracing of the\ngroup beating with tachycardia absent.\n\n"},{"category":"ECG","chartdate":"2120-12-16 00:00:00.000","description":"Report","row_id":208771,"text":"Ventricular paced rhythm with pattern of group beating with tachycardia.\nQuestion upper rate limit. Atrial mechanism is uncertain. Since the previous\ntracing of ventricular pacing pattern as described is now present.\n\n"},{"category":"ECG","chartdate":"2120-12-13 00:00:00.000","description":"Report","row_id":208772,"text":"Ventricular pacing\nPacemaker rhythm - no further analysis\nSince previous tracing, rate slower\n\n"},{"category":"Radiology","chartdate":"2120-12-22 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":940367,"text":" 9:19 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: H/O AAA.ON HEPARIN.HCT DROP.?RP BLEED\n Admitting Diagnosis: CARDIOGENIC SHOCK\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with h/o AAA, on heparin, guaiac positive stools, 10 pt hct\n drop\n REASON FOR THIS EXAMINATION:\n please eval for RP bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old male with history of AAA on heparin, guaiac positive\n stool. Drop of hematocrit.\n\n TECHNIQUE: Contiguous axial CT images of the abdomen and pelvis were obtained\n without the administration of intravenous contrast . Multiplanar\n reformation images were reconstructed.\n\n COMPARISON: Abdominal CT dated .\n\n FINDINGS: The evaluation of abdominal aorta, major vessels and major organs\n are limited due to lack of intravenous contrast .\n\n There is a new enlargement of the left iliac muscle with heterogeneous high-\n density with several fluid-fluid levels, most likely representing hematoma\n within the muscle, measuring 8.2 x 4.5 cm, new since prior study. On the\n right side, there is 2-cm focal hyperdensity in the right iliacus muscle,\n which also can represent small amount of hemorrhage.\n\n Again note is made of large abdominal aortic aneurysm with crescent-shaped\n hypodensity, measuring 6.3 x 5.1 cm at the level of kidneys, overall unchanged\n since prior study, however, the evaluation of the aorta is limited on this\n non-contrast study. There is small amount of ascites anterior to the liver\n and posterior to the spleen, unchanged since prior study.\n Diffusely Hyperdense liver is again noted, probably due to amiodarone\n accumulation. Spleen, pancreas, adrenal glands and kidneys, the visualized\n portion of large and small intestines are overall unchanged since prior study.\n There is increased attenuation of the intraperitoneal fat diffusely as noted\n previously, as well as fluid and edema in the subcutaneous tissue due to third\n spacing. There is no free air.\n\n PELVIS: The visualized portion of large and small intestines are within\n normal limits. Edematous appearance of peritoneal fat is noted.\n\n Again note is made of marked cardiomegaly with bilateral pleural effusion with\n bibasilar atelectasis and interstitial edema at the lung bases.\n\n There is degenerative changes of the lower lumbar spine. No suspicious lytic\n or blastic lesion is noted.\n\n (Over)\n\n 9:19 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: H/O AAA.ON HEPARIN.HCT DROP.?RP BLEED\n Admitting Diagnosis: CARDIOGENIC SHOCK\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Again note is made of bilateral iliac grafts.\n\n IMPRESSION:\n 1. Enlarged left iliac muscle with hyperdensity with fluid-fluid levels,\n measuring 8 x 4 cm, representing hematoma due to acute hemorrhage, new since\n prior study three days ago. Small area of hyperdensity in the right iliacus\n muscle, which can also represent a small amount of hematoma.\n 2. Limited study for the aorta, major abdominal organs and vessels due to\n lack of intravenous contrast . Large abdominal aortic aneurysm, overall\n unchanged since prior study.\n 3. Amiodarone accumulation of the liver with small amount of ascites.\n 4. Cardiomegaly with bilateral pleural effusion.\n 5. Persistent marked third spacing and edema.\n\n Dr. was informed by telephone at 10:30 p.m. on the day of the study.\n\n\n"},{"category":"Radiology","chartdate":"2120-12-19 00:00:00.000","description":"CTA CHEST W&W/O C &RECONS","row_id":940021,"text":" 6:21 PM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CTA PELVIS W&W/O C & RECONS\n Reason: r/o bleed, other source of abdominal pain (disection, mesent\n Admitting Diagnosis: CARDIOGENIC SHOCK\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with severe abdominal pain out of proportion to exam, with h/o\n AAA s/p graft, recently on heparin bridge to coumadin for a.fib,\n REASON FOR THIS EXAMINATION:\n r/o bleed, other source of abdominal pain (disection, mesenteric ischemia)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old man with severe abdominal pain, out of proportion to\n exam. History of AAA, status post graft.\n\n TECHNIQUE: Contiguous axial CT images of the chest and abdomen are obtained\n with and without the administration of intravenous contrast , 90 cc of\n Optiray. Multiplanar reformation images are reconstructed.\n\n COMPARISON: Comparison was made with the prior CT study dated .\n\n FINDINGS:\n\n CHEST: Extreme lung bases are not included in the present study. Again note\n is made of markedly tortuous and dilated aorta with calcification, measuring\n 3.6 cm at the arch. There is coronary artery calcification and cardiomegaly,\n in this patient status post CABG and pacemaker placement. There is bilateral\n pleural effusion with bibasilar atelectasis. Again, note is made of markedly\n enlarged pulmonary artery measuring 4.4 cm, probably due to pulmonary arterial\n hypertension. Note is made of motion artifact throughout the scan of the\n lung, which limits the evaluation of the details of the lung parenchyma. In\n the lung window, note is made of increased interstitial markings in bilateral\n upper lobes, most likely due to atypical pattern of pulmonary edema, however,\n other interstitial process cannot be totally excluded. There is no central\n endobronchial lesion.\n\n ABDOMEN: There is a large abdominal aneurysm with mural thrombus, extending\n from the level of SMA bifurcation down to the level of iliac bifurcation,\n measuring 5.2 x 4.9 cm at the level of right renal artery, overall unchanged\n compared to the prior study. There is crescent-shaped high density within the\n mural clot, as noted previously. There is aortic graft inferiorly. The\n superior mesenteric artery and its branches are patent, and there is no\n evidence of SMA thrombosis. was not identified and is probably occluded\n in this patient status post graft. Note is made of small amount of free fluid\n in the abdomen, with fat stranding, especially surrounding the kidney,\n slightly decreased since prior study. There is no evidence of bowel\n dilatation. There is no secondary sign of bowel wall ischemia.\n\n Again, note is made of diffusely hyperdense liver, most likely due to\n amiodarone. The patient is status post cholecystectomy. Spleen, pancreas,\n (Over)\n\n 6:21 PM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CTA PELVIS W&W/O C & RECONS\n Reason: r/o bleed, other source of abdominal pain (disection, mesent\n Admitting Diagnosis: CARDIOGENIC SHOCK\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n adrenal glands, and kidneys are within normal limits. There is no significant\n lymphadenopathy. Diffuse anasarca is again noted.\n\n PELVIS: Small amount of free fluid is noted, decreased since prior study. The\n visualized portion of large and small intestines are within normal limits.\n\n There is no suspicious lytic or blastic lesion in skeletal structures.\n\n\n IMPRESSION:\n\n 1. Large abdominal aortic aneurysm with mural thrombus and crescent-shaped\n high density within the thrombus, overall unchanged compared to the prior\n study.\n\n 2. Patent SMA without evidence of thrombosis. No evidence of bowel\n dilatation or secondary sign of ischemia in the bowel.\n\n 3. Decreased free fluid in the abdomen and pelvis, with diffuse anasarca.\n\n 4. Enlarged pulmonary artery and dilated aorta.\n\n 5. Bilateral pleural effusion with atelectasis. Increased interstitial\n markings in bilateral upper lobes, probably due to atypical edema, however,\n other interstitial process cannot be totally excluded.\n\n The information was discussed with Dr. by telephone in the evening of\n .\n\n\n"},{"category":"Radiology","chartdate":"2120-12-15 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":939429,"text":" 4:21 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: assess RIJ placement.\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with sepsis and cardiomyopathy, with RIJ central line\n placement, need assessment.\n REASON FOR THIS EXAMINATION:\n assess RIJ placement.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Right IJ line placement.\n\n FINDINGS: There is a new right IJ line with tip in the SVC near the right\n atrium junction. The pacemaker is unchanged. There is no pneumothorax.\n There is increased retrocardiac opacity compared to the film from earlier the\n same day consistent with increased volume loss/consolidation. There is also a\n new patchy area of infiltrate/volume loss in the right lower lobe.\n Endotracheal tube and NG tube are unchanged.\n\n\n"},{"category":"Radiology","chartdate":"2120-12-13 00:00:00.000","description":"CT PELVIS W&W/O C","row_id":939144,"text":" 2:33 AM\n CTA CHEST W&W/O C &RECONS; CT ABD W&W/O C Clip # \n CT PELVIS W&W/O C\n Reason: CHEST/ABD PAIN, H/O AORTIC ANEURYSM REPAIR.\n Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with chest pain/abd pain, h/o aortic aneurysm repair,\n subsequently became hypotensive/hypoxic & intubated on pressors\n REASON FOR THIS EXAMINATION:\n eval for aortic aneurysm/dissection or PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MJGe FRI 9:26 AM\n 1. no dissection or PE. contrast bolus took 2 minutes to get to descending\n aorta probably due to pt's heart failure\n 2. 6.5 cm infrarenal abd aortic aneurysm with evidence of graft repair\n distally. no evidence of AAA rupture or leak.\n 3. pulmonary vascular congestion, intraabdominal ascites, periportal edema,\n and anasarca suggest CHF vs volume overload vs both.\n 4. bibasilar atelectasis\n 5. cardiomegaly.\n WET READ VERSION #1 MJGe FRI 3:32 AM\n 1. no dissection or PE. contrast bolus took 2 minutes to get to\n descending aorta probably due to pt's heart failure\n 2. 6.5 cm infrarenal abd aortic aneurysm with evidence of graft repair\n distally. no evidence of AAA rupture or leak.\n 3. pulmonary vascular congestion, intraabdominal ascites, periportal edema,\n and anasarca suggest CHF vs volume overload vs both.\n 4. bibasilar atelectasis\n 5. cardiomegaly.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest pain, abdominal pain, history of aortic aneurysm repair\n with hypotension and hypoxia.\n\n TECHNIQUE: Multidetector CT images were obtained through the chest without\n contrast followed by CT angiogram through the chest and abdomen. Coronal and\n sagittal reformatted images were obtained.\n\n CT ANGIOGRAM OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: There is no\n evidence of aortic dissection or pulmonary embolus. Extensive atherosclerotic\n calcifications are seen within the left anterior descending, left circumflex,\n and right coronary arteries as well as throughout the aorta. There is no\n pulmonary embolus. The airways are patent to the segmental level bilaterally.\n There is smooth intralobular septal thickening, primarily at the lung apices,\n consistent with pulmonary venous congestion. There is minimal small airways\n disease in the right upper lung lobe. There is bibasilar subsegmental\n atelectasis with small bilateral pleural effusions, right greater than left.\n The patient is status post median sternotomy and CABG and multiple clips are\n seen about the heart. There is no pathologically enlarged axillary, hilar, or\n mediastinal lymphadenopathy.\n\n (Over)\n\n 2:33 AM\n CTA CHEST W&W/O C &RECONS; CT ABD W&W/O C Clip # \n CT PELVIS W&W/O C\n Reason: CHEST/ABD PAIN, H/O AORTIC ANEURYSM REPAIR.\n Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT ANGIOGRAM OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: There is\n no evidence of aortic dissection. There is a 6.5-cm infrarenal abdominal\n aortic aneurysm with evidence of a graft repair distally. There is no\n evidence of abdominal aortic aneurysm rupture or leak. Again, there are\n diffuse atherosclerotic calcifications within the aorta. The liver is normal\n in contour. No focal liver lesions are identified. There is periportal\n edema. The patient is status post cholecystectomy. The pancreas is somewhat\n fatty replaced. There is no pancreatic ductal dilatation. The spleen and\n adrenal glands are normal. The kidneys show bilateral thin cortices. However,\n they enhance symmetrically. The left kidney contains a 1-cm rounded low-\n density focus in the lower pole and the right kidney contains a 2.8-cm rounded\n focus in the upper pole, both of which likely represent simple renal cysts.\n There is no evidence of hydronephrosis or hydroureter. The stomach and intra-\n abdominal loops of small and large bowel are normal in appearance and caliber.\n There is no bowel dilatation or bowel wall thickening. There is a moderate-\n to-large amount of intra-abdominal ascites throughout the mesentery and within\n the bilateral pericolic gutters and perihepatic region. There is no free air.\n There is no pathologically enlarged mesenteric or retroperitoneal\n lymphadenopathy. The surrounding soft tissues show anasarca.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n Degenerative changes are seen within the visualized thoracolumbar spine.\n\n CT REFORMATS: Coronal and sagittal reformatted images confirm the axial\n findings.\n\n IMPRESSION:\n 1. No evidence for aortic dissection or pulmonary embolus.\n 2. 6.5-cm infrarenal abdominal aortic aneurysm with evidence of graft repair\n distally. No evidence of aneurysm rupture or leak.\n 3. Pulmonary vascular congestion, intra-abdominal ascites, periportal edema,\n and anasarca suggest congestive heart failure versus volume overload or both.\n 4. Cardiomegaly.\n 5. Bibasilar subsegmental atelectasis with small bilateral pleural effusions.\n\n"},{"category":"Radiology","chartdate":"2120-12-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":940058,"text":" 3:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: hypoxic, r/o infiltrate\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with sepsis and cardiomyopathy,worsening oxygenation,\n wheezing,\n REASON FOR THIS EXAMINATION:\n hypoxic, r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypoxia.\n\n Portable AP chest radiograph compared to .\n\n The heart size is enlarged but stable in a patient with previous CABG. The\n pacemaker leads are in unchanged position. The right internal jugular line\n tip terminates in distal SVC.\n\n There is worsening of perihilar consolidations extending into the upper lungs\n most likely representing pulmonary edema. In addition, there is worsening of\n left lower lobe retrocardiac atelectasis and unchanged amount of small left\n pleural effusion.\n\n IMPRESSION: New pulmonary edema, at least moderate.\n\n Left lower lobe retrocardiac atelectasis, unchanged.\n\n Small unchanged left pleural effusion.\n\n"},{"category":"Radiology","chartdate":"2120-12-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":939143,"text":" 2:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: S/P INTUBATION\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Status post hypotension and intubation.\n\n Portable AP chest dated has no prior films for comparison. The\n endotracheal tube terminates in appropriate position 5.7 cm above the carina.\n The nasogastric tube courses below the diaphragm and off the area imaged. A\n left pacemaker is seen with leads terminating in the right atrium and right\n ventricle. The patient is status post median sternotomy and CABG. The heart\n is enlarged. There is no evidence of mediastinal widening. There are\n perihilar infiltrates bilaterally. Additionally, there is retrocardiac\n opacity. There is no large pleural effusion, although the right\n costodiaphragmatic angle is excluded from the film. The surrounding osseous\n and soft tissue structures are unremarkable.\n\n IMPRESSION:\n 1. Lines and tubes as described above.\n 2. Cardiomegaly with perihilar infiltrates most consistent with pulmonary\n vascular congestion.\n 3. Retrocardiac opacity most likely represents atelectasis or consolidation.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2120-12-20 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":940151,"text":" 5:45 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o obstruction\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with abdominal pain.\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain.\n\n Portable abdomen dated is compared to the prior from .\n Surgical clips are seen within the pelvis and right upper quadrant. Gas is\n seen throughout the visualized bowel extending into the rectum. There is no\n evidence of bowel dilatation, air-fluid level, or free air on this single\n portable supine view. Degenerative changes are seen within the visualized\n lumbosacral spine. Vascular calcifications are seen within the abdomen and\n pelvis. The surrounding osseous structures otherwise are unremarkable.\n\n IMPRESSION: Unremarkable bowel gas pattern without evidence for obstruction.\n\n\n"},{"category":"Radiology","chartdate":"2120-12-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":940799,"text":" 4:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for pulmonary edema\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CHF and CAD currently dyspneic, RR to 30's\n REASON FOR THIS EXAMINATION:\n Please eval for pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 88-year-old man with congestive heart failure and coronary\n artery disease with dyspnea and tachypnea. Question pulmonary edema.\n\n CHEST, SINGLE SEMI-UPRIGHT PORTABLE VIEW: Comparison is made to . There is a pacemaker device in a similar position. The patient is\n status post coronary artery bypass graft surgery. The heart is enlarged. The\n aortic contour is unchanged.\n\n There is persistent left lower lobe opacity obscuring the left hemidiaphragm,\n although less confluent than before, with a small left effusion. There is\n persistent pulmonary edema, but less severe.\n\n There is a more prominent focal opacity overlying the left heart border, which\n is more confluent and extensive.\n\n IMPRESSION:\n 1. Persistent pulmonary edema.\n 2. More confluent focal opacity along the left heart border, which may\n represent a pneumonic consolidation. Follow up radiographs are suggested to\n ensure resolution.\n\n"},{"category":"Radiology","chartdate":"2120-12-26 00:00:00.000","description":"LIVER OR GALLBLADDER US (SINGLE ORGAN)","row_id":940950,"text":" 3:26 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Please evaluate for biliary process, liver lesion\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CHF and increasing LFTs\n REASON FOR THIS EXAMINATION:\n Please evaluate for biliary process, liver lesion\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Liver ultrasound.\n\n INDICATION: Increasing LFTs.\n\n FINDINGS: The liver is of normal echogenicity. No focal liver lesions\n identified. There is some fullness of the hepatic veins extending into the\n IVC consistent with patient's known congestive heart failure. Note is also\n made of a right pleural effusion. There is normal flow within the portal\n veins. The patient is status post cholecystectomy. The CBD is not dilated at\n 0.5 cm. No evidence of any intrahepatic bile duct dilatation.\n\n IMPRESSION: Limited hepatic ultrasound reveals some hepatic venous congestion\n with no focal lesion or intrahepatic bile duct dilatation.\n\n\n"},{"category":"Radiology","chartdate":"2120-12-19 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":940042,"text":" 9:08 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o SBO\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with abdominal pain. evaluate loop size\n REASON FOR THIS EXAMINATION:\n r/o SBO\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMINAL RADIOGRAPH\n\n INDICATION: 88-year-old male with abdominal pain. Please evaluate for bowel\n loops size and evaluate for small-bowel obstruction.\n\n COMPARISON: CT study from .\n\n FINDINGS: There is no evidence of free air. No dilated loops of bowel are\n present. A moderate amount of air is seen within the colon. Surgical clips\n are seen in the right upper quadrant, consistent with prior cholecystectomy.\n Epicardial pacing wire is seen in the upper left abdomen. Surgical clips are\n also seen in the left lower abdomen. Osseous structures are unremarkable.\n Residual contrast is present within the bladder, consistent with recent CT\n scan.\n\n IMPRESSION:\n\n 1. Unremarkable bowel gas pattern. No evidence of obstruction.\n\n"},{"category":"Radiology","chartdate":"2120-12-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":940325,"text":" 12:16 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: r/o CHF\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CHF and CAD, with continued O2 requirement now w/\n acute desat.\n REASON FOR THIS EXAMINATION:\n r/o CHF\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW ON \n\n HISTORY: CHF and CAD, continued O2 requirement with acute desaturation.\n\n FINDINGS: Again seen is an enlarged heart with pacemaker. There is\n ill-defined hazy vasculature and perihilar haze consistent with CHF. There is\n a new right lower lobe infiltrate. There is increased retrocardiac\n consolidation. There continues to be a left pleural effusion.\n\n IMPRESSION: CHF with new right lower lobe infiltrate.\n\n\n"},{"category":"Radiology","chartdate":"2120-12-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":940027,"text":" 6:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with sepsis and cardiomyopathy,with tachypnea, abdominal\n pain.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old man with sepsis and cardiomyopathy and tachypnea and\n abdominal pain. Rule out infiltrate.\n\n COMPARISON: CT torso one hour prior.\n\n There is a triple lead AICD device in standard positioning. Surgical clips\n are overlying the cardiac silhouette and median sternotomy wires are present\n consistent with prior cardiothoracic surgery. There is a right internal\n jugular catheter with tip at the distal SVC. The heart size is at the upper\n limits of normal. Mediastinal and hilar contours are otherwise unremarkable.\n There is a small left greater than right pleural effusion. There is some\n fissural thickening within the left lower lung. There are diffuse areas of\n interstitial opacities bilaterally confirmed on CT from one hour prior.\n\n IMPRESSION:\n Diffuse patchy interstitial opacities bilaterally, which could represent early\n onset of multifocal or atypical pneumonia.\n\n"},{"category":"Radiology","chartdate":"2120-12-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":940304,"text":" 9:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval edema/effusions\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CHF and CAD, with continued O2 requirement\n REASON FOR THIS EXAMINATION:\n please eval edema/effusions\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW ON \n\n HISTORY: CHF and CAD.\n\n REFERENCE EXAM: .\n\n FINDINGS: There is no significant change in moderate cardiomegaly, pacemaker,\n sternotomy wires and surgical clips, right IJ line has been removed. There\n has been interval decrease in the perihilar and right upper lobe infiltrates.\n There continues to be dense retrocardiac opacity that could be due to volume\n loss or infiltrate. There continues to be a small left effusion.\n\n\n"},{"category":"Radiology","chartdate":"2120-12-26 00:00:00.000","description":"L UNILAT UP EXT VEINS US LEFT","row_id":940951,"text":" 3:27 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: Please evaluate for clot\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CHF and swolle LUE\n REASON FOR THIS EXAMINATION:\n Please evaluate for clot\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Ultrasound of left upper limb.\n\n INDICATION: Swollen left upper extremity.\n\n FINDINGS: Some echogenic material is seen in the left internal jugular vein\n consistent with some old thrombus. It does compress normally, however, no\n definite thrombus is seen within the left subclavian vein. No thrombus within\n the left axillary vein. The left brachial vein and left basilic are normal to\n compression and augmentation. In the left cephalic vein, there is echogenic\n material within the central lumen which does not compress. This appearance is\n consistent with thrombus which extends throughout the length of the left\n cephalic vein.\n\n IMPRESSION: Thrombus extending throughout the length of the left cephalic\n vein with some older appearing nonocclusive thrombus within the left jugular\n vein. This case should be monitored for extension of the thrombus in one to\n two days.\n\n\n"},{"category":"Radiology","chartdate":"2120-12-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":939162,"text":" 7:04 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: pls check placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with shock, ng tube\n REASON FOR THIS EXAMINATION:\n pls check placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CHEST X-RAY PORTABLE AP.\n\n INDICATION: NG tube placement position.\n\n COMPARISONS: Comparison is made to the earlier film from 0214 hours.\n\n The endotracheal tube is approximately 7 cm superior to the carina. The\n proximal NG sideport is 5cm above the diaphragm; to move all the sideports\n into the stomach, the tube would need to be advanced approximately 10cm.\n Moderate cardiomegaly is slightly less prominent. The pulmonary vasculature is\n less engorged and there is some interval resolution of the pulmonary edema.\n The right costophrenic angle is slightly cutoff by this film, however, there\n is no evidence of pleural effusion, right or left. There is a left- sided\n pacemaker with leads terminating within the right ventricle and right atrium,\n and median sternotomy wires are present, both unchanged.\n\n IMPRESSION:\n 1. NG tube should be advanced 10 cm to move all the sideports into the\n stomach.\n 2. Endotracheal tube 2-3 cm above optimal position.\n 3. Some interval resolution of vascular congestion and intersitial edema\n compared to the film five hours prior.\n 4. Persistent moderate cardiomegaly.\n\n\n"},{"category":"Radiology","chartdate":"2120-12-13 00:00:00.000","description":"BY DIFFERENT PHYSICIAN","row_id":939249,"text":" 4:46 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: pls evaluate posititon of ETT and NGT\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with shock, ETT and NGT advanced.\n REASON FOR THIS EXAMINATION:\n pls evaluate posititon of ETT and NGT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old man with shock, ETT and NG tube advance. Check\n positioning of endotracheal tube and nasogastric tube.\n\n COMPARISON: Ten hours prior.\n\n SINGLE SUPINE PORTABLE CHEST RADIOGRAPH:\n\n The endotracheal tube tip is at the level of the inferior aspect of the\n clavicles, approximately 5 cm from the carina in standard positioning. The\n nasogastric tube tip has been advanced with side port below the GE junction.\n Multiple surgical clips are seen overlying the cardiac silhouette and\n sternotomy wires are also again noted. A biventricular pacer AICD device is\n in stable positioning. Limited views of the lung fields are grossly unchanged\n with exclusion of the left lateral lung.\n\n IMPRESSION:\n\n Standard placement of endotracheal tube and nasogastric tube. Otherwise,\n unchanged exam.\n\n"},{"category":"Radiology","chartdate":"2120-12-13 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":939171,"text":" 8:11 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute bleed\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88M h/o CAD, AICD, CHF, on anticoagulation for DVT, here w/ shock of unclear\n etiology, poor brainstem reflexes.\n REASON FOR THIS EXAMINATION:\n eval for acute bleed\n CONTRAINDICATIONS for IV CONTRAST:\n Cr 2.5\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for acute bleed. 88-year-old on anticoagulation for DVT\n here with unclear etiology of shock. Poor brainstem reflexes. Evaluate for\n acute bleed.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no intracranial hemorrhage. There is no midline shift,\n mass effect or hydrocephalus. The -white matter differentiation is\n preserved. There are sulcal and ventricular prominence due to mild\n generalized brain atrophy. There are periventricular and subcortical white\n matter hypodensities consistent with chronic microvascular ischemic change.\n There are atherosclerotic calcifications.\n\n There are small air-fluid levels noted in both maxillary and sphenoid sinuses\n due to the patient being intubated.\n\n IMPRESSION: No intracranial hemorrhage. No mass effect.\n\n"},{"category":"Radiology","chartdate":"2120-12-27 00:00:00.000","description":"B UNILAT UP EXT VEINS US BILAT","row_id":941074,"text":" 1:45 PM\n UNILAT UP EXT VEINS US BILAT Clip # \n Reason: foloow-up: progress and/or new clots?\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CHF and swollen LUE and DVTs on US\n\n REASON FOR THIS EXAMINATION:\n foloow-up: progress and/or new clots?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Swollen left upper extremity and deep vein thrombosis on\n ultrasound. Please follow for progression of previously identified\n superficial vein thrombosis.\n\n UNILATERAL UPPER EXTREMITY VEINS, LEFT: Comparison is made to the examination\n from yesterday. Again seen is peripheral echogenic material within the left\n internal jugular vein. There is wall-to-wall color flow within this vessel\n and the internal jugular vein compresses. There is normal color Doppler flow\n with normal respiratory variation within the internal jugular vein.\n Similarly, the left subclavian demonstrates normal patency, wall-to-wall color\n flow with Doppler waveform, with normal respiratory variation and\n augmentation.\n\n IMPRESSION:\n 1. Likely old thrombus within the left internal jugular vein because it is\n peripheral in location and normal color blood flow is seen through this\n vessel.\n 2. No evidence of deep vein thrombosis in the left subclavian vein.\n\n\n"},{"category":"Radiology","chartdate":"2120-12-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":939257,"text":" 6:12 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please assess for ETT placement\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with shock, ETT and NGT advanced.\n\n REASON FOR THIS EXAMINATION:\n please assess for ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old male with endotracheal tube and NG tube advanced.\n Assess for endotracheal tube placement.\n\n COMPARISON: One hour prior.\n\n Lines and tubes are in similar position with endotracheal tube tip now 1 cm\n below the level of the clavicles, likely due to positioning. The endotracheal\n tube tip is similarly approximately 6 cm from the carina. The\n cardiomediastinal silhouette and lung fields are stable.\n\n IMPRESSION:\n\n Endotracheal tube tip 6 cm from the carina just below the inferior aspect of\n the clavicles in good positioning.\n\n"},{"category":"Radiology","chartdate":"2120-12-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":939381,"text":" 7:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change, line placement\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with shock, ETT and NGT advanced.\n\n REASON FOR THIS EXAMINATION:\n assess for interval change, line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW ON .\n\n HISTORY: Shock, ET tube and NG tube advanced.\n\n FINDINGS: The ET tube is 5.3 cm above the carina. The NG tube is in the\n proximal stomach with proximal port at the GE junction. Left-sided pacemaker\n is unchanged. There are patchy areas of volume loss versus an early\n infiltrate in the right lower lobe.\n\n\n"},{"category":"Radiology","chartdate":"2120-12-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":941148,"text":" 10:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for etiol of SOB\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CHF and CAD currently dyspneic, RR to 30's\n\n REASON FOR THIS EXAMINATION:\n Eval for etiol of SOB\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CHF. Shortness of breath.\n\n Single portable radiograph of the chest again demonstrates the patient to be\n status post CABG. Increased bibasilar airspace pulmonary opacities and small\n bilateral pleural effusions are slightly worse when compared to .\n Dual-lead left thoracic cardiac pacer is unchanged. Trachea is midline. No\n pneumothorax.\n\n IMPRESSION:\n\n Worsening CHF. Superimposed pneumonia is not excluded.\n\n\n"},{"category":"Radiology","chartdate":"2120-12-28 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":941185,"text":" 4:19 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for acute bleed/stroke\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with acute MS change on IV Argatroban\n REASON FOR THIS EXAMINATION:\n Eval for acute bleed/stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 88-year-old male with acute mental status changes on IV\n agatroban. Evaluate for bleed/stroke.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: No hemorrhage, mass, hydrocephalus, shift of normally midline\n structures. -white matter differentiation is preserved. No major\n vascular territorial infarct is apparent. There are regions of\n hypoattenuation within the periventricular white matter, which reflect chronic\n microvascular ischemic disease. The ventricles and sulci are prominent,\n reflecting age associated involutional changes. Vascular calcifications are\n seen within the cavernous carotid. The visualized paranasal sinuses remain\n normally aerated. There is increased partial opacification of the left\n mastoid air cells compared to prior exam dated .\n\n IMPRESSION:\n 1. No hemorrhage.\n 2. Partial opacification of the left mastoid air cell, which was not seen on\n previous CT head dated .\n\n"},{"category":"Radiology","chartdate":"2120-12-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":939762,"text":" 8:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for CHF\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with sepsis and cardiomyopathy, with RIJ central line\n placement, need assessment.\n REASON FOR THIS EXAMINATION:\n assess for CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis and cardiomyopathy.\n\n COMPARISON: .\n\n AP UPRIGHT CHEST: The patient has been extubated and the nasogastric tube has\n been removed. There is a left-sided AICD with leads projecting in unchanged\n positions over the right atrium and ventricle. The patient is status post\n median sternotomy and CABG. Moderate enlargement of the cardiac silhouette is\n unchanged allowing for low lung volumes. There is slight improvement in\n asymmetric pulmonary interstitial edema, right greater than left. Retrocardiac\n opacification is unchanged. Moderate left and small right pleural effusions\n are stable.\n\n IMPRESSION:\n 1) Interval improvement in mild pulmonary interstitial edema.\n 2) Left basal atelectasis, less likely pneumonia.\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556127,\n \"text\": \"88 YR OLD WITH ISCHEMIC CARDIOMYOPATHY ,SP CABG,ICD PLACEMENT ,AAA REPAIR ADMITTED C RESP FAILURE ,HYPOTENSION .PROBALE SEPTIC RATHER THAN CARDIOGENIC.6L FLD RESUS AT OSH.\\n\\nV PACED C AFLUTTER/AFIB.BP LABILE 68 TO 150 SYS C TITRATION OF DOPAMINE 3 TO 10 MIC PER KG .ATTEMPTING TO WEAN FOR 3RD TIME TODAY .AM HCT STABLE .\\n\\nPEEP WEANED TO 8,RR TO 18.ABG 7.40/41 /93 / 26 /99.SX FOR MIN EVEN C LAVAGE UNABLE TO GET SPEC FOR CX.BS CL TO DIMINISHED IN BASES .\\n\\nTF RESIDUALS 40 TO 60 ON 10CC HAVE NOT ADVANCED YET .ABD SOFT ,POS BS .\\n\\nHUO 30 TO 50 ,SED IN URINE CX PENDING\\n\\nCX REPEATED C TEMP 101.2,TYLENOL GIVEN.ON PIPRICILLIN,VANCO REPEATED .STARTED ON STEROIDS.\\n\\nBS COVERED ON SSRI.\\n\\nPT RESPONDS BY OPENING EYES TO NAME,GETS RESTLESS ,SOMETIMES NODS ,NOT FOLLOWING COMMAMNDS .PUPILS CONSTRICTED .ON 25 MICS FENTANYL,1.5 MICS VERSED .FAMILY UPDATED.AGREE C PLAN .PT IS DNR .HAS AICD TO BE ALLOWED TO FUNCTION AT PRESENT. ,MAGNET AT BEDSIDE.\\n\\nPROBABLE SEPSIS UNKNOWN SOURCE\\n\\nCONTINUE SUPPORTIVE CARE , NEED TO ADD LEVOPHED IF BP CONTINUES TO BE LABILE .\\nSUPPORT FAMILY\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556128,\n \"text\": \"Resp Care\\n\\nPt remains intubated and currently vented on full support with changes made per careview flowsheet. BS dim/essentially clear sxing for minimal secretions. ETT secured/patent. Last ABG WNL with acceptable oxygenation on present vent settings. Will cont with vent support as needed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556129,\n \"text\": \"CCU NURSING PROGRESS NOTE\\nS:VENTED\\nO:PT W/ VERSED AND FENTANYL. PT W/ VERBAL AND TACTILE STIMULI. NOT CONSISTENTLY FOLLOWING COMMANDS. MAE.\\n\\nRESP:VENT REMAINS ON AC/500/18/8, REPEAT ABG PENDING. LS CLR AND DIM BILAT AT BASES. SATS 100%. SX FOR SM AMT OF PALE YELL/PINK TINGED THICK SECRETIONS. SPUTUM CX SENT. HANDS AND FEET EDEMATOUS. MOTTLING OF FEET AND KNEES.\\n\\nCV:MHR AFIB, W/ VPACED BEATS, RARE PVC. RARE FUSED BEAT. DOPA AT 4MCG/KG/MIN. WEANING DOPA SLOWLY, DP PULSES AUDIBLE W/ . RIGHT FEM CORDIS D&I.\\n\\nGI:ABD SOFT, +BS. PROBALANCE WAS NOT INCREASED D/T HIGH RESID AND STOPPED AT MN FOR RESID OF 90CC. CONSULT NUTRITION FOR INPUT. NO STOOL\\n\\nGU:YELL URINE, W/ SM SEDIMENT.\\n\\nENDO:COV AS PER SS.\\n\\nID:SPUTUM SENT. BLD CX PENDING, T MAX 101.1. PT REMAINS ON ZOSYN AND VANCO.\\n\\nA/P:PT IS A 88YROM ADM W/ ABD PAIN, NO CHANGE IN AAA. RECENT PPM. DISTRIBUTIVE VS SEPTIC SHOCK. CX PENDING, CON'T ANTIBIOTICS. CONTINUE TO WEAN DOPAMINE AS TOLERATED. CONSIDER ADDING REGLAN AT RENAL DOSES.\\nPT CURRENTLY DNR/DNI, AND DECIDE ON CMO STATUS. CONTINUE MULTIDISCIPLINARY ROUNDS. LABS PENDING. KEEP FAMILY UPDATED ON PT STATUS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556130,\n \"text\": \"RESPIRATORY CARE NOTE\\n\\nPatient remains intubated and fully ventilated on AC settings. No vent changes made during the noc. Sxn for small amount yellow with scant blood-tinged. Unable to obtain RSBI d/t no spon. respirations, even with sedation decreased (attempted x2). ABG shows aequate ventilation and oxygenation.\\n\\n , RRT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556135,\n \"text\": \"Respiratory Care\\n\\n Pt placed on SBT and passed this am. On PSV 5/5 for several hours with good ABG. Pt remains intubated now on MMV after sedation related low ve. B/S sl coarse sx'd x1 for small thick tan. PLAN: SBT and ??extubation in am. Will continue to follow closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556136,\n \"text\": \"CCU Progress note 0700-1900\\nRESP:- Remains orally intubated and mechanically ventilated. CPAP trial this morning, On 5/+5 ABG 7.41/50/138, plan was to extuabte, however pt HR changed, and vasopressor requirments ^, therefore desision taken to keep intubated overnight. Mr very keen to have the tube out, also discussion regarding plan of care post extubation as is DNR/DNI. Bilateral air entry haerd to all lungfields, but diminished at the bases. Suctioned as needed for a small amount of thin clear secretions, weak cough on suctioning. Current vent settings, MMV, allowing him to take spontaneous breaths mixed with set breaths, settings 550/10 PS5 PEEP +%, ABG 7.44/43/116.\\n\\nCV:- Initially monitored in V Paced rhytham 75-85 bpm, with occationsal PVCs', however rate changed at 1130, ^ 120s, Afib and paced beats, SBP compiromised tp 79, had managed to wean Dopamine to 0.75mcg/kg/min but had to increase to 2mcg/kg/min. SBP 90-120s'. Perpierally warm to touch, pedal pulses dopplerabel. K= 3.6 post K replartion, rechecked 4.4 at 1500. Hct improved to 32.3. Given 2.5mg PO vitamin K. CVP 8-15.\\n\\n\\nNEURO:- Initially off sedation in preparation for extubation, but when desision taken to keep intubated pt became more agiated therefore sedation re-started, currently on midazolam at 0.5mg/hr and fentanyl at 25mcg/hr, roused by voice and bale to gesture needs well. Unable to assess pupils as has cataracts. Able to move all 4 limbs well within the limits of bedrest. Soft wrist restriants inplace to protcet tubes and lines.\\n\\nGU:- Foley catheter draining good amounts of clear urine, which was intially yellow but has become pinkish as the day progressed, Drs .\\n\\nGI:- OG tube placement checked, air heard on auscltation. Feed off as not extubating, was having high aspirates last night. Abdomen soft and non-tender. Passing flatus, but bowels not moved during the day.\\n\\nACCESS:- 2 x PIV both satisfactory and patent. Central line re-dressed as small amount of dry blood present, site appears satisfactory. A-line site looks clean.\\n\\nFAMILY:- Daughter visited, spoken with Drs length regarding Mr DNR/DNI staus. Asked him whether he would wanted to be re-intubated if needed post extubation and he said yes, which uoset her as he always said that he would not want that, she also brought in copies of living will which were put in chart. DNR/DNI currently still stands.\\n\\nENDO:- Blood suage slightly elevated at lunch time covered with 2 units sliding scale. steroids given as per chart.\\n\\nID:- Afebriel during the day, antibiotics given as per chart. WCC trending down. suctioned for small amount sercretions.\\n\\nSKIN:- Pressure areas, intact, barrier cream applied to sacral areas and areas. Full bedbath given and sheet changed. Nursed on alternate sides and back. Pneumo-boots inplace.\\n\\nPLAN:- To continue with sedation overnight, and attempt to wean dopamine as tollerates. Plan to extubate tomorrow. To continue to give full explination of care to patient and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556137,\n \"text\": \"CCU NPN 1900-0700\\nO:\\nafeb. contin. vanco/zosyn.\\nHR 85-112 Vpaced, underlying afib. no VEA.\\nBP 94/63-115/72. dopa weaned to off by 0400.\\n\\nResp: vent on MMV /.40. sats 99%. RR 12-16. Tv 400-600. suctioned for small amt. white secretions. LS clear to diminished.\\nRSBI pnd\\nGU: foley draining ~ 30cc/hr. pos. 200cc for and neg. 500cc LOS.\\nGI: NPO overnight for possible extubation today. OGT draining small amt. of bilious liq. no stool.\\nNeuro: pt. awake and alert at times.....banging hand/feet on side rails for attention. Very frustrated at current state/wanting ETT out. responding approp. to questions....mouthing words approp.\\ncontin. on fent. gtt 25mcq/hr and versed .5mg/hr with good effect. small boluses to aid sleep with good effect. wakes easily to voice.\\n\\nA/P: plan to wean/extubate today. dopa weaned off...contin.to monitor BP. family support. pt. is currently DNR/DNI. need to discuss when pt. is extubated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556138,\n \"text\": \"RESPIRATORY CARE NOTE\\n\\nPatient remains intubated and ventilated on MMV ventilation 5/5 with back-up Vt=500, RR=12. most of night with the goal of extubation this AM. BLBS are mainly clear. RSBI completed on PS 5, PEEP 0=29. ABG shows adequate ventilation and oxygenation.\\n\\n , RRT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556139,\n \"text\": \"Nursing Progress Note 0700-1900\\nS: \\\"My breathing does feel better\\\"\\n\\no: Please see carevue for complete objective data.\\n\\nResp: Extubated @ 1200. Strong cough and + gag reflex. Had a few apneic episodes during weaning, but has had none since ETT removal. O2 weaned down to 2L nc, sats 97-100. Lungs clr c dim bases. No c/o SOB.\\n\\nCV: Vpaced, 70-80's, PVC's rare. SBP 89-102, off pressors. CVP 6-10. Pulses palp. HCT-28.7 (30.0). Platlets steadily decreasing over past few days. Down to 106, team aware. Started on SC heparin and ASA.\\n\\nGI/GU/Endo: Pt c/o cramping in abdomen, given colace and senna. Drinking water without incident and taking pills. BS present. Foley draining clr PINK urine, team aware. Rec'ing ins per ss.\\n\\nAccess/Skin: RIJ Trip lumen cath dressing changed RN's instructions. 2 PIV's. Contusion on R arm.\\n\\nNeuro/Social: A&O x 2, forgets place but reoriented easily. Daughter and son into visit today, remarked that pt is \\\"seeing things that are not there\\\" RN did not witness episode. Pt told MD that he would want to be re-intubated if necesary. Family was there to witness and did not have any objections to pt's wishes.\\n\\nA/P: Successfully extubated and weaning O2 requirements. Cont to monitor resp status and hemodynamics. Advance diet as tol, ?lactulose for constipation. Monitor UO, PT consult. Emotionally support pt and family and keep updated on plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556145,\n \"text\": \"NPN 0700-1900,1735 EST\\n\\n88 YO MALE WITH H/O CAD,MI, AAA( S/P REPAIR, NO LEAK) RECENT AICD FOR SYNCOPAL EPISODE,SEVERE CARDIOMYOPATHY EF 10% WHO ORGINALLY PRESENTED TO OSH WITH EPIGASTRIC PAIN AND HYPOTENSIVE, WHERE INTUBATED FOR SEVERE HYPOXIC RESP FAILURE AND TRANFERED TO CCU. PATIENT THEN TRANFERED TO FLOOR AND TO MICU YESTERDAY FOR ABDOMINAL PAIN AND CONCERN FOR MESENTRIC ISCHEMIA, CT NEG.LACTATE WAS 2.4 AND DOWN TO 1.7.PATIENT WAS ON NRB 100% AND TOLERATING NC TODAY.\\n\\nNEURO: ALERT, ORIENTED X3, COOPERATIVE.FOLLOWING COMMANDS CONSTITENTLY AND MAE WITH NORMAL STRENGTH.C/O ABD PAIN LATER EVENING SEEN BY MD AND GIVEN SIMETHICONE PO.\\n\\nCV: V PACED, WITH PVC'S, POTASSIUM 80 MEQ REPLETED. SBP 100-130MMHG.\\nHEPARIN GTT STOPPED FOR 1HR FOR PTT >150 AND RESTARTED TO950U/HR AND NEXT PTT DUE AT 2200.\\n\\nRESP: TOLERATING NC 5L, DOWN FROM 50% VIA VM. BILATERAL LS WHEEZY/CRACKLES,RRECEIVED MDI'S WITH GOOD EFFECT. WEAK UNPRODUCTIVE COUGH SPUTUM SAMPLES NEED TO BE COLECTED. O2 SATS 90-96%. CXR DONE PM.\\n\\nGU/GI: TOLERATING DIET, ABD SOFT,BS PRESENT, PATIENT C/O PAIN AFTER BOWEL MOVEMENT AND SEEN BY MD AND GIVEN SIMETHICONE AND PATIENT FEELS BETTER. LASIX 40 MG IV GIVE WITH GOOD EFFECT AND DRAINING VIA FOLEY'S.\\n\\nENDO:INSULIN AS PER SS\\nID: AFEBRILE D/CED ANTIBIOTICS.\\nSOCIAL: VISITED BY DAUGHTER.\\n\\nPLAN: CALL OUT TO FLOOR, CONTINUE MONITOR RESP STATUS AND ABD PAIN. PTT Q6HRS\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556146,\n \"text\": \"Nursing progress notes\\nEvents:\\nReceived pt at 1900 c/o abd pain. #5 on pain scale (0-10) bs+ abd soft dr paged x 2 w/o call back, resident called (dr ) and notified of pt's pain. Dr at bedside pt's pain up to #9, heat pack and ms 1mg ivp given. w/ good results for a short time. pain seems to come and go and increase and decrease in intensity. pt very anxious w/ pain spells. stating he is going to die\\\" emotional support given. pt tachycardic afib w/ some paced beats and pvcs w/ anxiety and sob. ekg obtained eventhough pt denied cp. dr at bedside and ativan .5mg ivp ordered and given. hrt rate 70s-80s and no further c/o abd pain (after ativan given) however pt unable to get comfortable enough to fall asleep. pt repositioned for comfort w/ no relief. ambien ordered and given 5mg po. pt became restless and confused to place and time. hallucinating, seeing people in his room. he has tried to get oob frequently. bed alarm on and staff in room monitoring pt for most of shift. pt up to chair w/ 2 assist for ?comfort. He stayed in chair for 1 hr then tried to get back to bed. dr aware of pt sob, confusion and restlessness. no orders given. pt c/o left hip pain requesting motrin, 400mg po ordered and given.\\n\\n\\nNeuro: pt was alert and oriented x 3 at the beg of this shift and has become increasingly more confused and restless throughout shift. at present pt resting comfortly in bed w/ eyes closed. pt oriented to self and month. pt re-oriented frequently whenever staff enter pt's room. pt mae and will follow simple commands/\\n\\nREsp: received on 5l nc ls clear w/ crackles in left base and diminished right base. lasix 40mg ivp given at 2130 pt diurresed 900cc of cloudy yellow urine. pt'd 02 now down to 4liters. he has cold extrem. and his pleth (no matter where I place o2 sat probe it would show 80s and/or straight line for wave form. staff tried to keep blanket on arms to help warm them. sats 93-96% on 4 liters pt has a dry cough\\n\\ncv: tele paced vent beats w/ intrinsic rythem of afib. hrt sounds s1s2 pedal pulses +2 extrem. cool. k+ 3.1 at 1800 40meq of k+packet given w/ pt ultimately vomiting. k+ changed to iv bolus. phos 1.9 k+phos given. phos now 3.3 k 5.1 (k+ checked at 1900 4.5) heparin gtt infusing at 700u/hr ptt 87.8 inr 2.3 (up from 2.1)\\n\\ngi: abd soft pt c/o of abd pain for beg of shift as stated above. pt has had 5 small brown loose stools this shift (he is inc at times), all guiac neg, all foul smelling. 1st stool sent for cdiff. pt vomited (as stated above) 100cc w/ small bld clot noted, anzemet 12.5mg ivp given. pt taking po ok no further vomiting notied. kub done on day shift. -unremarkable.\\n\\ngu: urine output trailing off this shift, lasix 40mg ivp given w/ 900cc diuresed\\n\\nskin:intact however lg eccymotic area noted on right upper forearm. old right cortis site intact not draining\\n\\nid: right tlcl removed and cath tip cx wbc 19.6 up from 13.0\\n\\naccess: pt has 2 #18 piv and tlcl removed this am per micu order/\\n\\nendo: bs 1\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556147,\n \"text\": \"Nursing progress notes\\n(Continued)\\n26-141\\n\\ncode: pt was a dnr per poe, however dr asked pt about his code status. pt alert and oriented x3 at the time , pt decided to have everything done for him. pt now a full code.\\n\\nsocial: son is hcp no contact w/ family overnight.\\n\\nPlan:\\nno ambien/ativan\\ncont to watch closely for pt's safety\\ncont to reorient\\nadminister motrin q 8hrs prn for left hip pain.\\ncont to wean 02 as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556148,\n \"text\": \"7a-7p\\nsee transfer note\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556149,\n \"text\": \"BS few fine crackles (less than yesterday). No change with MDI's. Appears somewhat more confused than before. Called out to floors.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556150,\n \"text\": \"1900\\ntransfer to floor held due to sbp < 90(85-88), 250 ns iv bolus x 2 given & po midodrine started, transfer to floor when sbp consistantly > 90\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556151,\n \"text\": \"addendum micu 7 west npn\\npt came to MICU-7 at 1800 from FAR 7 after a 10pt Hct drop.\\nPt received, total of 3 units PRBCs IN and 3 unit FFP IN, 20mg Lasix given as well. Unable to insert NG tube for lavage - pt. refused.\\nABG/VBG done - see carevue, labs sent. foley output clear/yellow, bs hypoactive, nonrebreather difficult to obtain o2 pleth - 95% w/ good pleht.\\nPt to go to CT tonight for Abd, ? source of bleeding.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556124,\n \"text\": \"S: pt intubated\\n\\nO:see careview. DNR\\n\\nCV:Vpaced a flutter c weinekbach through av node. BIV ICD . CT showed large triple a _ pe and leak/rupture. troponon .02, ck 53. pt has alne and right fem cortis. inr 2.8. HR 90-80's. pt on 4.5mcg/kg/min dopa with a bp 119/84. pts bp drops when dopa was decreased to 3mcg/kg/min. maintain map goals of >65.\\n\\nRESP:AC/40%/TV500/RR20/PEEP10. ABG 7.39/36/160/23/-2.ett was advanced 4cm per x-ray.\\n\\nneuro:sedated responds to stimulation. midazolam 2mg/hr and fentanyl 25mcg/hr\\n\\nendo:BS 200's on ss insulin.\\n\\nGU:-1281cc since admission pt did receive 6liters of fluid in osh for hypotension. foley cath inplace.\\n\\nGI:+BS - BM ogt placement confirmed with xray and ausciltation.\\n\\nID: afebrile on antibiotics.\\n\\nsocial: 2sond and daughter into visit pt. pts son is health care proxy. Pt made it clear to son that if he ends up no able to move and can only sit and watch tv all day he does not want to live. family does not want swan line placed.\\n\\nA:If there is no improvement in the next 48hrs or decreased requirment for supportive care then plan will be to withdraw care + CMO.\\n\\nP: wean vent as tolerated, wean dopa as tolerated, start tube feeds after midnight as ordered.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556125,\n \"text\": \"Respiratory Care:\\nPatient remains on A/C ventilatory support with no parameter changes made through out the night. No morning abg results at this time.\\n\\nNo RSBI measured due to the level of PEEP currently required.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556126,\n \"text\": \"CCU NPN 1900-0700\\nO: 88yo male with hx CAD, Ischemic transferred from OSH following Acute resp. failure, hypotension req. intubation, dopa and fluid resusitation.\\n\\nCABG x3, ICD , DVT, CHF. takes lasix, amio, zoloft, statin at home (incomplete list).\\nrecent hosp. for SOB- ? RLL PNX (per chart).\\n\\nCTA here showing 6.5cm infrarenal AAA with no evidence of rupture or leak. evidence of graft repair distally. (per chart review).\\n\\novernight:\\nTM 99po. cultures pnd from admission.\\nCV: HR 95-110 Vpaced with baseline afib. occas. to freq. PVC's. K+ 3.8, Mg+ 2.2.\\nBP 95-101/50-60's MAP 64-75. dopa weaned to 3.3mcq/k/min but BP trending down to 80's/ . titrated to 4.0mcq/k/min with SBP 93-100/. MAP 70. Dr. aware.\\nright fem. cordis line D/I. pulses doppler bilat. feet cool.\\nHCT 38.5. CPK neg. x2.\\nResp: no vent changes: AC 500x20/10peep/.40. sats 100%. suctioned for thin white secretions. LS clear. ABG 7.43-41-120\\nGU: u/o 50-100cc/hr. neg. 1.6L for .\\nGI: abd soft, NT. pos. BS. OGT with small amt. bilious drainage, guiac neg. tube feeds probalance started at 10cc/hr. no stool.\\n\\nNeuro: Eyes open to stimulation and name. nods and shakes head approp. to questions but did not respond to other commands. no acute agitation. fent. at 25mcq/hr . Versed weaned to 1.5mg/hr.\\n\\nendo: FS 180. SSRI.\\nskin: dark bruise on right inner elbow - ? from blood stick. intact otherwise.\\nno family calls.\\n\\nA: cardiogenic vs septic shock. family refusing swan ganz catheter. contin. dopa dependent. negative fluid balance post diuresis on admission. ck's neg. AAA stable with no evidence of rupture/leak.\\nfamily requests DNR/DNI. EP consulted to assess BIV/ICD>\\nP: titrate dopa as tolerated. follow cultures. titrate sedation for comfort. advance TF per order. family support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556131,\n \"text\": \"Resp Care\\n\\nPt remains intubated and currently vented back on full vent support. Attempted to wean pt on PSV trial however pt continued to go apneic 15 minutes into the trial and was subsequently placed back A/C to rest overnoc. BS clear to slightly course sxing for minimal secretions. Will cont with vent support and reassess for readiness to wean daily.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556132,\n \"text\": \"V PACED C HR TO 115.ATTEMPTING TO WEAN DOPAMINE ,BP CONTINUES TO DRIFT TO 80S .4 UNITS FFP GIVEN.TLC R SUBCLAVIAN PLACED.CVP 13.FEM LINE DC\\n\\nATTEMPTED PSV TRIAL P SEDATION DC.PT HAD PERIODS OF APNEA, RETURNED TO CMV.SATS 100.SX SM AMT THICK TAN .\\n\\nPOS BS ,DENIES ABD PAIN.\\n\\nHUO 50 TO 75.POS 1100CC.\\n\\nPT ALERT AND APPROPRIATE C FAMILY.DENIES PAIN .FAMILY WANTS TO BE HERE IF EXTUBATED TOMORROW .WEDDING RING SENT HOME C FAMILY.\\n\\nT MAX 99.1 .\\n\\nDOPAMINE ,VENT DEPENDENT\\n\\nTRY TO WEAN DOPAMINE\\nRESTART TF\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556133,\n \"text\": \"CCU NURSING PROGRESS NOTE\\nS:INTUBATED\\nO:PT IS A 88YOM ADM W/ HYPOTENTION AND RESP FAILURE.\\n\\nNEURO:PT NOW OFF ALL SEDATION AS OF 0400. PT OPENS EYES SPONTANEOUSLY, FOLLOWS COMMANDS. MAE.\\n\\nRESP:LS CLR AND DIM AT BASES, NO WHEEZES. SATS 96-99%. VENT AC/500/18/40/5 W/ ABG OF 7.50/40/76/32/94%. RR DOWN TO 14/TV-600.\\nWILL REPEAT ABG. SX FOR SM AMT PALE YELL SECRETIONS. SPUTUM GRAM STAIN SHOWING 2+YEAST, 1+GPC IN PAIRS/CLUSTERS. 1+ GNR. FINAL REPORT PENDING. NEW R IJ TLC PLACED YESTERDAY.\\n\\nID:T-MAX <98. WBC DOWN TO 10.6K. PT ON VANCO AND ZOSYN. SPUTUM AS ABOVE. BLD CX PENDING.\\n\\nCV:MHR 80-100, AFIB AND V-PACED, W/ OCCAS PVC OR FUSED BEAT. ATTEMPTED TO WEAN DOPA OFF EARLY LAST EVENING, SBP DOWN TO 70S. DOPA WAS RESTARTED BACK AT 2.5MCG/KG/MIN. NOW AT 2MCG/KG/MIN. RIGHT GROIN SITE D&I. DP AUDIBLE W/ . SKIN SALLOW, MUCOUS MEMBRANES PINK. CAP REFILL BRISK. EXTREMITIES WARM, SKIN WARM AND DRY. HCT THIS AM DOWN TO 29.2\\n\\n\\nGI:TF OFF AT MN FOR WEANING AND POSSIBLE EXTUBATION. +BS , DENIES ABD DISCOMFORT. NO STOOL.\\n\\nGU:YELL URINE W/ SOME SEDIMENT, DECREASED OVER NOC, U/O 0 AT 0400 .F/C FLUSHED AND HAD ADEQUATE URINE OUTPUT AFTER THAT.\\n\\nENDO:GLUC COV AS PER SS. 181, COV'D W/ 2UX REG INS.\\n\\nA/P:CONTINUE TO WEAN DOPA TO OFF. SEDATION OFF WILL ATTEMPT TO WEAN FROM VENT. PT IS A DNR/DNI. FAMILY WOULD LIKE TO BE NOTIFIED AND BE ABLE TO VISIT RIGHT AFTER EXTUBATION. CONTINUE GLU COV WHILE ON STEROIDS. FOLLOW CULTURES, CON'T ANTIBIOTICS. MONITOR FOR ANY DECRESES IN HCT. NUTRITION WHEN APPROPRIATE. EMOTIONAL SUPPORT. SOC SVC FOR DISCHARGE PLANNING.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556134,\n \"text\": \"RESPIRATORY CARE NOTE\\n\\nPatient remains intubated and fully ventilated on AC settings. Adjusted settings in attempt to stimulate patient to breath more on own to wean. ABG shows metabolic alkalosis. RSBI completed on PS 5=33. Placed on PS but becomes apneic often and unable to wean on PS at this time-sedation completely off also. Switched to Vt of 550, RR=12. seems to be breathing over set rate. Plan to wean support when able to tolerate.\\n\\n , RRT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556165,\n \"text\": \"Resp Care: Pt seen for attempt @ bipap...placed on 5 cm nasal cpap with 2 lpm bled in, tol ~ 10 minutes >> confused/uncoop, pulling off mask, returned to nasal prongs @ lpm with spo2 89-100%, restless with freq c/o inability to breathe, will follow for nebs/ cpap as tol.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556140,\n \"text\": \"S:\\\"I would like to eat icecream.\\\"\\n\\nO:please see careview.\\n\\nCV:v-paced hr 70's, bp 100/50's. pt currently receiving 75cc/hr for 1000cc of iv fluid. tolerating well.\\n\\nresp:2liters o2 via nc c o2 sats in the high 90's. LS clear.\\n\\ngu:pt 's urin output 20cc/hr-40cc/hr. red tinged urin. +200cc as of now.\\n\\nGI: no bm + bs pt tolerating po meds and icecream.\\n\\nendo:ss insulin bs 150-200's.\\n\\naccess:right ij and right a-line.\\n\\nneuro:pt a+ox3 pt became confused when he awoke from naps throughout night. pt thought he was at home and he had to go food shopping for the kids also he thought he seen 2 cigaretts on his bed burning. pt was easily reoriented.\\n\\nA:low platelets decreasing past 3 days.\\n\\nP:continue to treat and monitor lytes/platlets. continue to encourage cough and deep breath, continue to access mental status. follow blood sugars.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556141,\n \"text\": \"CCU Progress note 0700-1900\\nRESP:- Remains on N/C at 3 litres, Sa02 96-99% RR 18-26 and regular. Bilateral air entry haerd to all lungfields, but diminished at the bases. Coughing but not expectoarting any sputum.\\n\\nCV:- Moniotred in V paced rhytham, 75-85bpm, with occational PACs'. SBP manually 93-100, A-Line removed as bleeding, sugifoam inplace and pressure held for 20 minutes. Peripherally warm to touch. For repaet labs to be checked at 1600, then for possible blood transfusion if Hct continues to fall. Q8 our heparin and pneumo boots inplace.\\n\\nNEURO:- A&O x2, a little low at times, wanting to go home, told him that he is doing well considering how ill he was last week. Able to move all 4 limbs within llimits of bedrest. Able to feed himsefl with supervision.\\n\\nGU:- Foley catheter continues to drain blood tinged urine, acceptable amounts. Team aware.\\n\\nGI:- Able to eat a small amount of diet during the day. Seen by speech and swallow, assessed no problems noted with swallow. eaten small amount of diet today, tollerating it well. Abdomen soft and non tender. Bowels not moved to day. Bowels sounds heard. Docusate and senna given as ordered.\\n\\nSKIN:- Pressure areas inatct, on back for most of the day, encourgaed to lay on sides also. Barrier cream applied to back, saccral area and heels. Full bedbath and sheet change given, with facial shave.\\n\\nACCESS:- Now has central line only, 2X PIVs removed as in for 3 days, A-line also removed. Central line re-dressed as oozing.\\n\\nENEDO:- Blood sugars within normal limits. Steroids given as per chart.\\n\\nID:- Afebrille during the day, not further reported grows from blood cultures. Coughing but no expectorating any sputum. Vancomycin stopped. Zocyin continues.\\n\\nFAMILY:- DAughter called and updated. No other enquires as yet from family today.\\n\\nPLAN:- CAlled out to the floor, to contiue with antibiotics and steroids. To mobilse as tollerates. To continue to give full explination of care to patient and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556142,\n \"text\": \"REspiratory Care\\nPT with progressive SOB and wheeze. Treated with MDI (very good technique) but wheezing remained. XRay reported with increased CHF. ABG drawn from R radial artery without incident. Results reveal mixed respiratory and metabolic alkalosis with only fair oxygenation on 50% venti, FiO2 increased to Partial Non Rebreather. Being treated aggressively for apparent CHF.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556143,\n \"text\": \"Prt was transfered to MICU from 7, with Dx of ? mesenteric ischemia D/T sudden onset of sharp mid abd pain. Ct of abd neg for any leakage from AAA, absess or obstruction. BC X2 and UA/urine cx sent on adm and UA back with picture of UTI. Since his adm to MICU his resp status continued to decline until 2 am. At 2 Am pt was found to be restless, O2sat decreased to 90-91% on 5 liters NP and LS with cx's and exp wheezes. Resp status did not improve after neb tx. ABG : 7.53/35/60/30 on 50 % VM. CXR done, and showed worsening CHF,- and pt started on lasix. After lasix IV, pt's resp status improved.\\n\\nNeuro)\\n Pt oriented x 2 on adm. Pt cooperative and follows simple commands. Pt given Ambien for sleep, and was found to become very comfused afterwards. Ambien was later D/C'd.\\n\\nCV)\\n Pt in 100% Ventricular paced (70-80's) with PVC's. SBP stable 94-116 with MAP > 70. CVP 17-->11 (after Lasix). Pt has gen anasarca, with trace pitting to ext's. Good pulses to palp. K and phos level this am to be replaced. Inr this am 1.9 ? heparin gtt or coumadin today D/T A-fib. Access: Rt IJ TLC with good bloodreturn.\\n\\nResp)\\n LS at 4am with cx's throughout. RR22-24. Pt present with a dry non-prod cough...less freq now. Pt remains on 100% NRB with o2sat 95-97%. CXR to be done later again today. ? repeat ABG later too and ? More Lasix for CHF.\\n\\nID)\\n WBC down to 13.3 this am (17.8). Pt only on Zosyn IV at this time. Bc and urine cx pending.\\n\\nENDO)\\n Steroid induced hyperglycemia, and on RISS as noted with BS at mn 167.\\n\\nGI)\\n Abd dist, soft and with + BS. Pt started to regurgitate after taking po pills pm. KUB done. No other incidences since then and diet adv to House. Pt on protonix and given Maalox. Last BM am (guiac -). IVF at KVO.\\n\\nGU)\\n Cont to diurese pt. Pt is now + 900 since adm to MICU.\\n\\nSkin)\\n Skin intact.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556144,\n \"text\": \"BS fine crackles bilateral though in negative fluid balance. No change with MDI's. Strong non-productive cough.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556161,\n \"text\": \"NPN 7p-7a\\nDNR/DNI\\nAllergy: Benzo's-confusion\\nPlease see carevue and FHP for additional data.\\n\\nNeuro: Continues with anxiety overnight, feeling like he is \\\"going to die\\\". Recieved Trazadone this evening with mod. effect. Requires frequent reassurance regarding health status. No c/o pain. MAE, although at times patient feels as though he \\\"can't move\\\", likely having extra fluid in lower extrem. and feeling heavy.\\n\\nResp: NC 3L. LS clear w/ occ. wheezes, Alb/Ipa nebs w/ good effect. No cough noted.\\n\\nCV: 76-82 Vpaced. Occ. pvc's noted. Sbp 111-123. RR 20-24. Sats 95-100%. HCT stable, 33.1, s/p iliac bleed. EF 10%. Recieved 20mg iv Lasix w/ good effect. On Digoxin QOD.\\n\\nGI/GU: abd soft, well tolerated Renal diet. Foley patent, draining adeq. clear, yellow urine.\\n\\nEndo: Humalog SS.\\n\\nSkin: eccymosis to left hip, unchanged.\\n\\nA/P: 10pt HCT drop- etiology unclear, iliac hematoma, now w/ stable HCT. CHF- EF 10%. Cont. w/ lasix for fluid goal ~ -1L negative. Remains on Dig. and aldactone.\\nAnxiety- Seemed to respond pretty well to Trazadone over night, cont. to monitor and offer emotional support.\\nLikely call out to cardiac floor.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556162,\n \"text\": \"DNR Universal Precautions Allergy: Benzos\\n\\n\\nNeuro: AAOX3, MAEx4 - OBB to chair w/ minimal assist. In better spirits today.\\n\\nCV: HR=70-60s, V-paced. BP=90-110/. +periph pulses, +edema, extrems warm.\\n\\nResp: 3l n/p w/02sat 96-99%. Lungs clear in upper fields, few crackles bilat - more in L than R. Received aldactone at 1200. RR=18-26. SOB after any exertion, but returns to normal in a short time (5 min).\\n\\nGI/GU: abd soft, +BS, taking renal diet well. No BM. Foley cath w/ clear amber urine.\\n\\nSkin: Intact. L hip eccymottic. Buttocks/heels intact.\\n\\nPain: Denies discomfort\\n\\nSocial: No family visiting or calls as of yet today.\\n\\nAccess: New #20 PIV placed this am.\\n\\nHCT 33.1 today\\n\\nPlan: Tx to .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556152,\n \"text\": \"micu npn 1900-0700\\ncont'd-\\n\\nS: I don't want to die in the hospital, if i'm going to die, I would rather die at home\\nO: Patient overnight very restless and emotionally upset at times about not being able to go home and \\\"just wanting to be at home with his family\\\". We had a discussion this am about his poor heart, his code status and the initbility for him to be at home at this point with all the care and services he needs. He expressed a desire for me to speak with his daughter, and have her gather his family to come to some decisions regarding his code status and get him home.\\nA/P: Hope to speak with family today, team aware and will have a discussion regarding code status/change in goals of care w/him.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556153,\n \"text\": \"micu npn 1900-0700\\nPlease see fhpa for details on admission history.\\n\\nBriefly, pt is an 88 yo male, hx of cad, mi, aaa (s/p repair w/no leak, aneurysm 6.5 cm), a fib, recent aicd pl (), severe cardiomyopathy w/ef 10-15%, presented to osh w/c/o epigastric pain, hypotensive to 60's , intubated for hypoxic resp failure w/presumed cardiogenic shock.\\nHe transferred to CCU treated and sent to the floor . Micu accepted the pt to micu6 on for c/o abdominal pain. cta neg for mesenteric ischemia, no indication for surgery, but vascular following. He had issues w/hypotension vs chf lasix and fluids, started on midodrine and put back on iv heparin for underlying afib. transferred to the floor again on w/guiac + stools.\\n\\nYesterday , pt w/inr's climbing since transfer to the floor, am labs showing hct drop from 31 of prev day to 25.7, then 19.4 several hrs later. The pt c/o left leg/hip pain and was hypoxic to the ?mid 70's. He was again transferred to the micu(7) for w/o of source of bleed.\\nPt transported to ct overnight for ct of abdomen, showing stable aaa, noted bleeding into iliac muscle, although doesn;t account for 10 pt hct drop. gi to see pt as he has been ob+ form below.\\n\\nbrief ros\\nneuro- pt alert and oriented x2-3. very upset overnight that he has not been able to go home. frustrated at situation. appears to be for the most part a+ox3. no defecits noted.\\n\\ncv- remains vpaced w/afib underlying. some fusion beats w/v paced rhythm. hr 80-100. non invasive bp has been 100-130's sys. heparin had previously been d/c'd.\\n\\nresp- on nrb for short time last eve, unable to get accurate o2 sat. now on 6l nc sats appear to be >94% when able to get a waveform. rr mid 20's-30. at times labored. received additional 20 iv lasix lasrt eve w/some response.\\n\\ngi/gu- npo except ice chips for now. gi will see pt in the am for ?ugi scope to eval additional source of bleeding since he has been guiac +. uop good. no bm this shift.\\n\\nheme- since episode of hct drop, pt has received total of 3 u prbc's and 4 u ffp. hct back up to 30. inr remains elevated now 1.9. no s+s of bleeding.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556156,\n \"text\": \"npn 1900-0700\\n\\nOvernight: Electrolyte repletion. Patient became very anxious at 2315 stating he was \\\"scared\\\" and he wanted to be with his mother who is \\\"dead and buried\\\". Called his daughter and he was better for a little while. Received haldol without effect and then .5mg of ativan at 0215. He was then able to sleep the rest of the night.\\n\\nneuro: AXOX3, follows commands. No c/o pain or discomfort. Anxiety re. hospitalization and fear of dying in the hospital--wants to die at home.\\n\\nresp: sats 93-98% on 3L nc. LS clear.\\n\\ncv: V paced with fusion beats. BP with MAP >60. Received total of 100meq of potassium overnight for a level of 2.7 at last evening.\\nPartial dose of digoxin due at noon (.03mg) and begin full dose tonite at bedtime.\\n\\naccess: 3 piv. Able to draw blood from piv in L arm.\\n\\ngi/gu: Abdomen is soft with + BS. Patent foley with clear yellow urine. Output has dropped off overnight; received several doses lasix yesterday. 2 liter fluid restriction.\\n\\nskin: Many areas of bruising, r arm, hematoma on L hip. No open areas. Heels are reddened.\\n\\nendo: RISS.\\n\\ndispo: DNR/DNI. Pt wants to go home.\\n\\nsocial: Pt spoke with dtr last night.\\n\\nplan: Agressive diuresis, serial crits q 8 hours. AM potassium is 3.0; will hang 40meq in 500cc and then try ti have pt take po. He refused the potassium pills last night.\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556154,\n \"text\": \"MICU7 RN Note 0700-1900\\n\\nEvents: Hct 29.3 stable no active bleed, Lasix +diuresis, CHF team consult implement recomendations. Family , PT OOB chair.\\n\\nNeuro: awake alert oriented x3, follows commands MAE random Equal strength, PT OOB to chair Full weight bearing with assist. Chair for 1.5hrs, pt feeling depressed and emotional weepy, wanting to go home to be with family. \\\"I do not want to die in hospital\\\". Met with Social services.\\n\\nCV: HR 75-95 V-paced fused beats, BP 95-119/46-67. MAPS>60. Currently hemodynamically stable, CHF team evaluation. Agressive diuresis, d/c midridone, Digoxin, Ace inhibitor, betablocker. Peripheral pulses 3+DP/2+DT, gen edema. Lasix 20mg x2 + diuresis. Goal -2L.\\n\\nHeme: Serial Hct 29-29.3, Q8hrs. no active bleed INR 2.1.\\n\\nResp: RR 18-24 Dyspneic with activity, O2 4L/min NC Sats 90-96%, Lungs clear rales bil. dim with Lasix. HOB>30 degrees.\\n\\nGI: abd soft nontender + BS, recieved bowel regime, stool x3 soft brown, + guiac. Started shift NPO adv to reg with restrictions. tol well No N/V.\\n\\nGU: Foley u/o 40-240cc/hr +diuresis from Lasix. Goal (-)2L.\\n\\nDerm: Skin W/D 3+ anasarca, Ecchymotic L Hip/flank denies pain.\\n\\nSocial: Started shift full code status to DNR per pt and family request. met with Team. pt would like to cont with plan for fluid removal and transition to home with services.\\n\\nPlan: seriel Hct q8hrs next @ \\n Implement/resume cardiac meds\\n agressive diuresis\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556155,\n \"text\": \"Respiratory Care:\\nPt seen for neb Tx's x 2 today At 12noon and 6 PM. He seems to be much improved over Last evening.!!\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556157,\n \"text\": \"FOCUS; NURSING PRGRESS NOTE\\n88 YEAR OLD MALE WITH CAD S/P MI, AAA S/P REPAIR, RECENT AICD, EF 10% ADMITTED TO MICU WITH 10 PT HCT DROP S/P ILIAC BLEED.\\nREVEIW OF SYSTEMS-\\nNEURO- HE IS ALERT AND ORIENTED X3. COOPERATIVE WITH CARE. EXPRESSING DESIRE TO GO HOME. REQUIRING FREQUENT POSITION CHANGES TO FEEL BETTER.\\nRESP- ON 3L NC WITH RESP 18-25. SATS 92-98%. BS CLEAR DIMINISHED AT THE BASES.\\nCARDIAC- HR 117 TO 88 VPACED WITH FUSION BEATS. SBP 112-125. K 3.0 TODAY TX WITH 40MEQ KCL PO AND 40MEQ IV. CA 6.2 TODAY CORRECTED TO 7.5 WITH ALBUMIN LEVEL TX WITH 3GMS CA GLUCONATE. REPEAT LYTES DUE AT 1600. REVCEIVED 20MG IV LASIX WITH GOAL OF KEEPING PATIENT NEG TODAY. ALSO RESTARTED ALDACTONE. ACE TO BE STARTED TOMMORROW.\\nGI- ABD SOFT WITH POS BS. NO STOOL TODAY. LAST STOOL YESTERDY. TOLERATING RENAL CARDIAC DIET WELL. PPI CHANGED FROM IV TO PO. LFT'S INCREASED TODAY. DR AWARE.\\nGU- FOLEY PATENT DRAINING YELLOW URINE. DIURESING FROM LASIX.\\nENDO- BS UP TO 209 AT TX WITH SS HUMOLOGUE\\nHEME- HCT STABLE AT 30.6. INR STABLE AT 2.1. REPEAT LABS DUE AT 1600.\\nID- AFEBRILE. WBC DOWN TO 11.9. ALLL CULT NEG TO DATE.\\nACCESS- 2 # 18 PERIPHERALS INTACT.\\nSKIN- OLD ECCHYMOSIS ON LEFT HIP AREA.\\nSOCIAL- DAUGHTER CALLED AND WAS UPDATED BY THIS NURSE.\\nDISPO- DNR DNI. ? C/O TO FLOOR.\\nPLAN- DIURESE TO KEEP PATIENT NEG.\\n START ACE TOMMORROW IF STABLE.\\n STABALIZE AND THEN SEND HOME.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556158,\n \"text\": \"FOCUS; ADDENDUM\\nCARDIAC- PATIENT STILL POS AND DIURESING SLOWING DOWN. DR NOTIFIED AND 20MG IV LASIX ORDERED AND GIVEN.\\nPLAN- CHECKED WITH DR . TEAM WANTS TO SEE HOW PATIENT DOES OVERNIGHT. THEN ? C/O TO TEAM IN AM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556163,\n \"text\": \"NPN 7p-7a\\nPt is an 88 y/o with extensive cardiac history. Of note, CAD s/p MI, CHF with an EF 10%, V-paced. Pt has allergies to Benzos and newly HIT +. Pt was on Medicine floor s/p MICU stay, and developed LUE DVT. Pt started on Argatroban gtt. Last night pt became increasingly agitated and confused, medicated with Haldol and Ativan. Today, pt was more somulent and lethargic, c/o SOB feeling \\\"that he was not breathing\\\". Pt was also requiring more O2, with sats 83% on usual 3.0L. Pt was transfered to MICU for bipap and monitor MS. Once in MICU, bipap was not intiated pt becoming more alert with less O2. MICU team believes pt CO2 retainer and was most likely over , follwed by too much O2. Head CT was negative for any bleeding. Pt does have significant apnea 20-30secs with sats dropping to mids 80s.\\n\\nNEURO: Pt is lethargic, alert to voice. Pt is calling out for family at times, says he needs to say goodbye. Pt MAE weakly. Pt is oriented to person and place. No c/o pain.\\n\\nCV: Vpaced, HR 70s-80s with occas PVCs. BP 90s-100s/60s-70s. Weak palpable pulses bilaterally. Pt on Argatroban @ 0.50mcg/hr, PTT 46.8. Next due @ 2100.\\n\\nRESP: Sats mostly >94% on 2.0L NC, pt does desat as stated above. LS with crackles @ bases. RR 15-30s.\\n\\nGI/GU: ABD is soft, +BS. Pt NPO now until more alert. Pt is taking ice chips fine. U/O has been ample 120-300cc/hr clear yellow urine.\\n\\nSKIN: Pt has large old echymosis over left hip from previous admission. Also small area on Right hip. Pt does have echymosis over arms, as well.\\n\\nSocial: Pt has children who were with him on pt's transfer. They were updated by this RN and Dr. . They will be back this evening.\\n\\nPLAN: Continue to monitor MS, resp status ? check another ABG tonight for possible bipap. Diurese as needed, pt on standing Lasix, although CXR does show edema.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556164,\n \"text\": \"npn\\nneuro: aox3, pt has been sleeping off and on thru out shift. pt needs to be told that he has been sleeping, this seems to relieve his anxiety and he falls back to sleep.\\n\\npain: denies\\n\\ncad hr 70's v-paced with occass. pvc's. nbp 98/70 to 129/89 range. pt remains on argatroban gtt at .5mcg , held for one hour at 515am for ptt of 92.6, to be restarted at 615 am at .25mcg\\n\\nresp: ls clear with dim. bases, ls shallow, non-productive cough, rr teens with sats high 80 to 100% on 3l nc, pt received neb tx as ordered\\n\\ngi: abd firm, bs+, pt has had one large bm at 3am. taking sips of water and apple juice.\\n\\ngu uo >60cc/hr up to 320 with lasix, foley patent and draining yellow . 1 lter negatve at\\n\\nskin: bruising over left falnk.\\n\\nsocial: family into visit lasnight.\\n\\nplan: monitor ptt with argatroban gtt, cont to monitor vs, resp status.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556123,\n \"text\": \"resp care - Pt received from ED on full vent support. FiO2 decreased during shift per ABGs. Last ABG shows normal values with hyperoxemia. Slight rhonchi in the upper lobes cleared on suction of scant amounts of frothy white secretions. ETT was advanced 4cm per xray. Continued resp support planned.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556159,\n \"text\": \"NPN 7p-7a\\nPlease see carevue for additional data.\\nAllergy: Benzo's- confusion.\\nDNR/DNI\\n\\nNeuro: AOx3. MAE. Anxious, unable to sleep despite prn Ativan (0.5mg) ,Haldol (1mg), Morphine (1mg x2), and Ambien (5mg). Little effect until recieved Ambien, seemed to sleep after this, occ. awaking for repositioning.\\n\\nResp: 3L NC. LS Clear to auscultation after recieving 20mg iv Lasix. Sats 95-100%.\\n\\nCV: 88-105 Vpaced, occ. pvc's. Sbp 109-144. Recieved 20mg iv Lasix, fluid goal negative, presently negative ~380. Lower extrem. edema noted. EF 10%. s/p iliac bleed. HCT 30. lytes pnding. Plan to restart ACT in am.\\n\\nGI/GU: abd soft, +BS. no stool overnight. Well tolerated renal/cv diet. Continuing diuresis as above for goal of negative fluid balance.\\n\\nEndo: SS Humalog.\\nSkin: Eccymotic area to left hip, does not appear to be increasing. Left arm s/p infiltrate, keeping elevated.\\nID: afeb. wbc pnding.\\n\\nA/P: S/P illiac bleed, hct stable. HCT QD. Likely call out to floor, team CV med.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2120-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1556160,\n \"text\": \"88 y.o. male with hx. of AAA repair, MI/CAD, s/p CABG, DVT, GERD, HTN, pacemaker, s/p septic shock, extubated . S/p iliac bleed, Hct and coags stable.\\nNeuro: A&O x3, cooperative, follows commands, denies pain. MAE. OOB to chair x2 with 2 people assist.\\nResp: On 3L NC sats 96-99%. Episodes of SOB at rest and on exertion. LS bibasilar crackles. Got Lasix total of 40mg IVP with ~ 750cc diuresis. Goal to take 1L off today. Given nebs tx. prn with minimal response.\\nCV: HR 80s-100s, V-paced with frequent PVCs. BP 110s-120s/70s-80s. Bilat LE 3 + edema. Lt. arm elevated on pillow swelling due to infiltrated IV. Started on Metoprolol today.\\nGI/GU: Tolerating renal diet. Abd. soft, nontender, +BS, no BM today.\\nFoley patent with dark yellow urine out.\\nEndo: BS checked q4 hrs ranging from 110-220. Covered per sliding scale.\\nSocial: Both sons visited, spoke to case management, updated on status and plan of care. Rehab screening initiated.\\nPt. is called out to cardiac floor, no bed available yet.\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2120-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 82428,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Coronary artery disease. Left ventricular function. Wall motion. Shock.\\nHeight: (in) 66\\nWeight (lb): 150\\nBSA (m2): 1.77 m2\\nBP (mm Hg): 118/86\\nHR (bpm): 76\\nStatus: Inpatient\\nDate/Time: at 09:30\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Elongated LA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\\nwire is seen in the RA and extending into the RV. Normal interatrial septum.\\nNo ASD by 2D or color Doppler.\\n\\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Severe\\nglobal LV hypokinesis. No LV mass/thrombus. No resting LVOT gradient. No VSD.\\n\\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\\nhypokinesis.\\n\\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild to moderate\\n(+) MR.\\n\\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\\nMild PA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nConclusions:\\nThe left atrium is elongated. The right atrium is moderately dilated. No\\natrial septal defect is seen by 2D or color Doppler. Left ventricular wall\\nthicknesses are normal. The left ventricular cavity is moderately dilated.\\nThere is severe global left ventricular hypokinesis. No masses or thrombi are\\nseen in the left ventricle. There is no ventricular septal defect. The right\\nventricular cavity is mildly dilated. There is mild global right ventricular\\nfree wall hypokinesis. The ascending aorta is mildly dilated. The mitral valve\\nleaflets are mildly thickened. There is no mitral valve prolapse. Mild to\\nmoderate (+) mitral regurgitation is seen. The tricuspid valve leaflets are\\nmildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild\\npulmonary artery systolic hypertension. There is no pericardial effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2120-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 208773,\n \"text\": \"Demand pacing\\nSince previous tracing, ventricular paced beats with occasional native\\nventricular premature complexes, sinus beats\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2120-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 208774,\n \"text\": \"Ventricular paced rhythm at a rate of 120. QRS morphology raises the\\npossibility of biventricular pacing. There are probably P waves in the\\nST segment raising the possibility of pacemaker mediated tachycardia. Clinical\\ncorrelation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2120-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 208770,\n \"text\": \"Ventricular paced rhythm. Compared to the previous tracing of the\\ngroup beating with tachycardia absent.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2120-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 208771,\n \"text\": \"Ventricular paced rhythm with pattern of group beating with tachycardia.\\nQuestion upper rate limit. Atrial mechanism is uncertain. Since the previous\\ntracing of ventricular pacing pattern as described is now present.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2120-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 208772,\n \"text\": \"Ventricular pacing\\nPacemaker rhythm - no further analysis\\nSince previous tracing, rate slower\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-22 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 940367,\n \"text\": \" 9:19 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: H/O AAA.ON HEPARIN.HCT DROP.?RP BLEED\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n Field of view: 40\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with h/o AAA, on heparin, guaiac positive stools, 10 pt hct\\n drop\\n REASON FOR THIS EXAMINATION:\\n please eval for RP bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 88-year-old male with history of AAA on heparin, guaiac positive\\n stool. Drop of hematocrit.\\n\\n TECHNIQUE: Contiguous axial CT images of the abdomen and pelvis were obtained\\n without the administration of intravenous contrast . Multiplanar\\n reformation images were reconstructed.\\n\\n COMPARISON: Abdominal CT dated .\\n\\n FINDINGS: The evaluation of abdominal aorta, major vessels and major organs\\n are limited due to lack of intravenous contrast .\\n\\n There is a new enlargement of the left iliac muscle with heterogeneous high-\\n density with several fluid-fluid levels, most likely representing hematoma\\n within the muscle, measuring 8.2 x 4.5 cm, new since prior study. On the\\n right side, there is 2-cm focal hyperdensity in the right iliacus muscle,\\n which also can represent small amount of hemorrhage.\\n\\n Again note is made of large abdominal aortic aneurysm with crescent-shaped\\n hypodensity, measuring 6.3 x 5.1 cm at the level of kidneys, overall unchanged\\n since prior study, however, the evaluation of the aorta is limited on this\\n non-contrast study. There is small amount of ascites anterior to the liver\\n and posterior to the spleen, unchanged since prior study.\\n Diffusely Hyperdense liver is again noted, probably due to amiodarone\\n accumulation. Spleen, pancreas, adrenal glands and kidneys, the visualized\\n portion of large and small intestines are overall unchanged since prior study.\\n There is increased attenuation of the intraperitoneal fat diffusely as noted\\n previously, as well as fluid and edema in the subcutaneous tissue due to third\\n spacing. There is no free air.\\n\\n PELVIS: The visualized portion of large and small intestines are within\\n normal limits. Edematous appearance of peritoneal fat is noted.\\n\\n Again note is made of marked cardiomegaly with bilateral pleural effusion with\\n bibasilar atelectasis and interstitial edema at the lung bases.\\n\\n There is degenerative changes of the lower lumbar spine. No suspicious lytic\\n or blastic lesion is noted.\\n\\n (Over)\\n\\n 9:19 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: H/O AAA.ON HEPARIN.HCT DROP.?RP BLEED\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n Field of view: 40\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n Again note is made of bilateral iliac grafts.\\n\\n IMPRESSION:\\n 1. Enlarged left iliac muscle with hyperdensity with fluid-fluid levels,\\n measuring 8 x 4 cm, representing hematoma due to acute hemorrhage, new since\\n prior study three days ago. Small area of hyperdensity in the right iliacus\\n muscle, which can also represent a small amount of hematoma.\\n 2. Limited study for the aorta, major abdominal organs and vessels due to\\n lack of intravenous contrast . Large abdominal aortic aneurysm, overall\\n unchanged since prior study.\\n 3. Amiodarone accumulation of the liver with small amount of ascites.\\n 4. Cardiomegaly with bilateral pleural effusion.\\n 5. Persistent marked third spacing and edema.\\n\\n Dr. was informed by telephone at 10:30 p.m. on the day of the study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-19 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C &RECONS\",\n \"row_id\": 940021,\n \"text\": \" 6:21 PM\\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \\n CTA PELVIS W&W/O C & RECONS\\n Reason: r/o bleed, other source of abdominal pain (disection, mesent\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n Field of view: 36\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with severe abdominal pain out of proportion to exam, with h/o\\n AAA s/p graft, recently on heparin bridge to coumadin for a.fib,\\n REASON FOR THIS EXAMINATION:\\n r/o bleed, other source of abdominal pain (disection, mesenteric ischemia)\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 88-year-old man with severe abdominal pain, out of proportion to\\n exam. History of AAA, status post graft.\\n\\n TECHNIQUE: Contiguous axial CT images of the chest and abdomen are obtained\\n with and without the administration of intravenous contrast , 90 cc of\\n Optiray. Multiplanar reformation images are reconstructed.\\n\\n COMPARISON: Comparison was made with the prior CT study dated .\\n\\n FINDINGS:\\n\\n CHEST: Extreme lung bases are not included in the present study. Again note\\n is made of markedly tortuous and dilated aorta with calcification, measuring\\n 3.6 cm at the arch. There is coronary artery calcification and cardiomegaly,\\n in this patient status post CABG and pacemaker placement. There is bilateral\\n pleural effusion with bibasilar atelectasis. Again, note is made of markedly\\n enlarged pulmonary artery measuring 4.4 cm, probably due to pulmonary arterial\\n hypertension. Note is made of motion artifact throughout the scan of the\\n lung, which limits the evaluation of the details of the lung parenchyma. In\\n the lung window, note is made of increased interstitial markings in bilateral\\n upper lobes, most likely due to atypical pattern of pulmonary edema, however,\\n other interstitial process cannot be totally excluded. There is no central\\n endobronchial lesion.\\n\\n ABDOMEN: There is a large abdominal aneurysm with mural thrombus, extending\\n from the level of SMA bifurcation down to the level of iliac bifurcation,\\n measuring 5.2 x 4.9 cm at the level of right renal artery, overall unchanged\\n compared to the prior study. There is crescent-shaped high density within the\\n mural clot, as noted previously. There is aortic graft inferiorly. The\\n superior mesenteric artery and its branches are patent, and there is no\\n evidence of SMA thrombosis. was not identified and is probably occluded\\n in this patient status post graft. Note is made of small amount of free fluid\\n in the abdomen, with fat stranding, especially surrounding the kidney,\\n slightly decreased since prior study. There is no evidence of bowel\\n dilatation. There is no secondary sign of bowel wall ischemia.\\n\\n Again, note is made of diffusely hyperdense liver, most likely due to\\n amiodarone. The patient is status post cholecystectomy. Spleen, pancreas,\\n (Over)\\n\\n 6:21 PM\\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \\n CTA PELVIS W&W/O C & RECONS\\n Reason: r/o bleed, other source of abdominal pain (disection, mesent\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n Field of view: 36\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n adrenal glands, and kidneys are within normal limits. There is no significant\\n lymphadenopathy. Diffuse anasarca is again noted.\\n\\n PELVIS: Small amount of free fluid is noted, decreased since prior study. The\\n visualized portion of large and small intestines are within normal limits.\\n\\n There is no suspicious lytic or blastic lesion in skeletal structures.\\n\\n\\n IMPRESSION:\\n\\n 1. Large abdominal aortic aneurysm with mural thrombus and crescent-shaped\\n high density within the thrombus, overall unchanged compared to the prior\\n study.\\n\\n 2. Patent SMA without evidence of thrombosis. No evidence of bowel\\n dilatation or secondary sign of ischemia in the bowel.\\n\\n 3. Decreased free fluid in the abdomen and pelvis, with diffuse anasarca.\\n\\n 4. Enlarged pulmonary artery and dilated aorta.\\n\\n 5. Bilateral pleural effusion with atelectasis. Increased interstitial\\n markings in bilateral upper lobes, probably due to atypical edema, however,\\n other interstitial process cannot be totally excluded.\\n\\n The information was discussed with Dr. by telephone in the evening of\\n .\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-15 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 939429,\n \"text\": \" 4:21 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: assess RIJ placement.\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with sepsis and cardiomyopathy, with RIJ central line\\n placement, need assessment.\\n REASON FOR THIS EXAMINATION:\\n assess RIJ placement.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST ON \\n\\n HISTORY: Right IJ line placement.\\n\\n FINDINGS: There is a new right IJ line with tip in the SVC near the right\\n atrium junction. The pacemaker is unchanged. There is no pneumothorax.\\n There is increased retrocardiac opacity compared to the film from earlier the\\n same day consistent with increased volume loss/consolidation. There is also a\\n new patchy area of infiltrate/volume loss in the right lower lobe.\\n Endotracheal tube and NG tube are unchanged.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-13 00:00:00.000\",\n \"description\": \"CT PELVIS W&W/O C\",\n \"row_id\": 939144,\n \"text\": \" 2:33 AM\\n CTA CHEST W&W/O C &RECONS; CT ABD W&W/O C Clip # \\n CT PELVIS W&W/O C\\n Reason: CHEST/ABD PAIN, H/O AORTIC ANEURYSM REPAIR.\\n Contrast: OPTIRAY Amt: 120\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with chest pain/abd pain, h/o aortic aneurysm repair,\\n subsequently became hypotensive/hypoxic & intubated on pressors\\n REASON FOR THIS EXAMINATION:\\n eval for aortic aneurysm/dissection or PE\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: MJGe FRI 9:26 AM\\n 1. no dissection or PE. contrast bolus took 2 minutes to get to descending\\n aorta probably due to pt's heart failure\\n 2. 6.5 cm infrarenal abd aortic aneurysm with evidence of graft repair\\n distally. no evidence of AAA rupture or leak.\\n 3. pulmonary vascular congestion, intraabdominal ascites, periportal edema,\\n and anasarca suggest CHF vs volume overload vs both.\\n 4. bibasilar atelectasis\\n 5. cardiomegaly.\\n WET READ VERSION #1 MJGe FRI 3:32 AM\\n 1. no dissection or PE. contrast bolus took 2 minutes to get to\\n descending aorta probably due to pt's heart failure\\n 2. 6.5 cm infrarenal abd aortic aneurysm with evidence of graft repair\\n distally. no evidence of AAA rupture or leak.\\n 3. pulmonary vascular congestion, intraabdominal ascites, periportal edema,\\n and anasarca suggest CHF vs volume overload vs both.\\n 4. bibasilar atelectasis\\n 5. cardiomegaly.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Chest pain, abdominal pain, history of aortic aneurysm repair\\n with hypotension and hypoxia.\\n\\n TECHNIQUE: Multidetector CT images were obtained through the chest without\\n contrast followed by CT angiogram through the chest and abdomen. Coronal and\\n sagittal reformatted images were obtained.\\n\\n CT ANGIOGRAM OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: There is no\\n evidence of aortic dissection or pulmonary embolus. Extensive atherosclerotic\\n calcifications are seen within the left anterior descending, left circumflex,\\n and right coronary arteries as well as throughout the aorta. There is no\\n pulmonary embolus. The airways are patent to the segmental level bilaterally.\\n There is smooth intralobular septal thickening, primarily at the lung apices,\\n consistent with pulmonary venous congestion. There is minimal small airways\\n disease in the right upper lung lobe. There is bibasilar subsegmental\\n atelectasis with small bilateral pleural effusions, right greater than left.\\n The patient is status post median sternotomy and CABG and multiple clips are\\n seen about the heart. There is no pathologically enlarged axillary, hilar, or\\n mediastinal lymphadenopathy.\\n\\n (Over)\\n\\n 2:33 AM\\n CTA CHEST W&W/O C &RECONS; CT ABD W&W/O C Clip # \\n CT PELVIS W&W/O C\\n Reason: CHEST/ABD PAIN, H/O AORTIC ANEURYSM REPAIR.\\n Contrast: OPTIRAY Amt: 120\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n CT ANGIOGRAM OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: There is\\n no evidence of aortic dissection. There is a 6.5-cm infrarenal abdominal\\n aortic aneurysm with evidence of a graft repair distally. There is no\\n evidence of abdominal aortic aneurysm rupture or leak. Again, there are\\n diffuse atherosclerotic calcifications within the aorta. The liver is normal\\n in contour. No focal liver lesions are identified. There is periportal\\n edema. The patient is status post cholecystectomy. The pancreas is somewhat\\n fatty replaced. There is no pancreatic ductal dilatation. The spleen and\\n adrenal glands are normal. The kidneys show bilateral thin cortices. However,\\n they enhance symmetrically. The left kidney contains a 1-cm rounded low-\\n density focus in the lower pole and the right kidney contains a 2.8-cm rounded\\n focus in the upper pole, both of which likely represent simple renal cysts.\\n There is no evidence of hydronephrosis or hydroureter. The stomach and intra-\\n abdominal loops of small and large bowel are normal in appearance and caliber.\\n There is no bowel dilatation or bowel wall thickening. There is a moderate-\\n to-large amount of intra-abdominal ascites throughout the mesentery and within\\n the bilateral pericolic gutters and perihepatic region. There is no free air.\\n There is no pathologically enlarged mesenteric or retroperitoneal\\n lymphadenopathy. The surrounding soft tissues show anasarca.\\n\\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\\n Degenerative changes are seen within the visualized thoracolumbar spine.\\n\\n CT REFORMATS: Coronal and sagittal reformatted images confirm the axial\\n findings.\\n\\n IMPRESSION:\\n 1. No evidence for aortic dissection or pulmonary embolus.\\n 2. 6.5-cm infrarenal abdominal aortic aneurysm with evidence of graft repair\\n distally. No evidence of aneurysm rupture or leak.\\n 3. Pulmonary vascular congestion, intra-abdominal ascites, periportal edema,\\n and anasarca suggest congestive heart failure versus volume overload or both.\\n 4. Cardiomegaly.\\n 5. Bibasilar subsegmental atelectasis with small bilateral pleural effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 940058,\n \"text\": \" 3:25 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: hypoxic, r/o infiltrate\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with sepsis and cardiomyopathy,worsening oxygenation,\\n wheezing,\\n REASON FOR THIS EXAMINATION:\\n hypoxic, r/o infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Hypoxia.\\n\\n Portable AP chest radiograph compared to .\\n\\n The heart size is enlarged but stable in a patient with previous CABG. The\\n pacemaker leads are in unchanged position. The right internal jugular line\\n tip terminates in distal SVC.\\n\\n There is worsening of perihilar consolidations extending into the upper lungs\\n most likely representing pulmonary edema. In addition, there is worsening of\\n left lower lobe retrocardiac atelectasis and unchanged amount of small left\\n pleural effusion.\\n\\n IMPRESSION: New pulmonary edema, at least moderate.\\n\\n Left lower lobe retrocardiac atelectasis, unchanged.\\n\\n Small unchanged left pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 939143,\n \"text\": \" 2:13 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: S/P INTUBATION\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n INDICATION: Status post hypotension and intubation.\\n\\n Portable AP chest dated has no prior films for comparison. The\\n endotracheal tube terminates in appropriate position 5.7 cm above the carina.\\n The nasogastric tube courses below the diaphragm and off the area imaged. A\\n left pacemaker is seen with leads terminating in the right atrium and right\\n ventricle. The patient is status post median sternotomy and CABG. The heart\\n is enlarged. There is no evidence of mediastinal widening. There are\\n perihilar infiltrates bilaterally. Additionally, there is retrocardiac\\n opacity. There is no large pleural effusion, although the right\\n costodiaphragmatic angle is excluded from the film. The surrounding osseous\\n and soft tissue structures are unremarkable.\\n\\n IMPRESSION:\\n 1. Lines and tubes as described above.\\n 2. Cardiomegaly with perihilar infiltrates most consistent with pulmonary\\n vascular congestion.\\n 3. Retrocardiac opacity most likely represents atelectasis or consolidation.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-20 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 940151,\n \"text\": \" 5:45 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: r/o obstruction\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with abdominal pain.\\n REASON FOR THIS EXAMINATION:\\n r/o obstruction\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Abdominal pain.\\n\\n Portable abdomen dated is compared to the prior from .\\n Surgical clips are seen within the pelvis and right upper quadrant. Gas is\\n seen throughout the visualized bowel extending into the rectum. There is no\\n evidence of bowel dilatation, air-fluid level, or free air on this single\\n portable supine view. Degenerative changes are seen within the visualized\\n lumbosacral spine. Vascular calcifications are seen within the abdomen and\\n pelvis. The surrounding osseous structures otherwise are unremarkable.\\n\\n IMPRESSION: Unremarkable bowel gas pattern without evidence for obstruction.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 940799,\n \"text\": \" 4:41 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please eval for pulmonary edema\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with CHF and CAD currently dyspneic, RR to 30's\\n REASON FOR THIS EXAMINATION:\\n Please eval for pulmonary edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: 88-year-old man with congestive heart failure and coronary\\n artery disease with dyspnea and tachypnea. Question pulmonary edema.\\n\\n CHEST, SINGLE SEMI-UPRIGHT PORTABLE VIEW: Comparison is made to . There is a pacemaker device in a similar position. The patient is\\n status post coronary artery bypass graft surgery. The heart is enlarged. The\\n aortic contour is unchanged.\\n\\n There is persistent left lower lobe opacity obscuring the left hemidiaphragm,\\n although less confluent than before, with a small left effusion. There is\\n persistent pulmonary edema, but less severe.\\n\\n There is a more prominent focal opacity overlying the left heart border, which\\n is more confluent and extensive.\\n\\n IMPRESSION:\\n 1. Persistent pulmonary edema.\\n 2. More confluent focal opacity along the left heart border, which may\\n represent a pneumonic consolidation. Follow up radiographs are suggested to\\n ensure resolution.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-26 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 940950,\n \"text\": \" 3:26 PM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \\n Reason: Please evaluate for biliary process, liver lesion\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with CHF and increasing LFTs\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for biliary process, liver lesion\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION: Liver ultrasound.\\n\\n INDICATION: Increasing LFTs.\\n\\n FINDINGS: The liver is of normal echogenicity. No focal liver lesions\\n identified. There is some fullness of the hepatic veins extending into the\\n IVC consistent with patient's known congestive heart failure. Note is also\\n made of a right pleural effusion. There is normal flow within the portal\\n veins. The patient is status post cholecystectomy. The CBD is not dilated at\\n 0.5 cm. No evidence of any intrahepatic bile duct dilatation.\\n\\n IMPRESSION: Limited hepatic ultrasound reveals some hepatic venous congestion\\n with no focal lesion or intrahepatic bile duct dilatation.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-19 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 940042,\n \"text\": \" 9:08 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: r/o SBO\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with abdominal pain. evaluate loop size\\n REASON FOR THIS EXAMINATION:\\n r/o SBO\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE ABDOMINAL RADIOGRAPH\\n\\n INDICATION: 88-year-old male with abdominal pain. Please evaluate for bowel\\n loops size and evaluate for small-bowel obstruction.\\n\\n COMPARISON: CT study from .\\n\\n FINDINGS: There is no evidence of free air. No dilated loops of bowel are\\n present. A moderate amount of air is seen within the colon. Surgical clips\\n are seen in the right upper quadrant, consistent with prior cholecystectomy.\\n Epicardial pacing wire is seen in the upper left abdomen. Surgical clips are\\n also seen in the left lower abdomen. Osseous structures are unremarkable.\\n Residual contrast is present within the bladder, consistent with recent CT\\n scan.\\n\\n IMPRESSION:\\n\\n 1. Unremarkable bowel gas pattern. No evidence of obstruction.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 940325,\n \"text\": \" 12:16 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: r/o CHF\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with CHF and CAD, with continued O2 requirement now w/\\n acute desat.\\n REASON FOR THIS EXAMINATION:\\n r/o CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST, SINGLE VIEW ON \\n\\n HISTORY: CHF and CAD, continued O2 requirement with acute desaturation.\\n\\n FINDINGS: Again seen is an enlarged heart with pacemaker. There is\\n ill-defined hazy vasculature and perihilar haze consistent with CHF. There is\\n a new right lower lobe infiltrate. There is increased retrocardiac\\n consolidation. There continues to be a left pleural effusion.\\n\\n IMPRESSION: CHF with new right lower lobe infiltrate.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 940027,\n \"text\": \" 6:58 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o infiltrate\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with sepsis and cardiomyopathy,with tachypnea, abdominal\\n pain.\\n REASON FOR THIS EXAMINATION:\\n r/o infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 88-year-old man with sepsis and cardiomyopathy and tachypnea and\\n abdominal pain. Rule out infiltrate.\\n\\n COMPARISON: CT torso one hour prior.\\n\\n There is a triple lead AICD device in standard positioning. Surgical clips\\n are overlying the cardiac silhouette and median sternotomy wires are present\\n consistent with prior cardiothoracic surgery. There is a right internal\\n jugular catheter with tip at the distal SVC. The heart size is at the upper\\n limits of normal. Mediastinal and hilar contours are otherwise unremarkable.\\n There is a small left greater than right pleural effusion. There is some\\n fissural thickening within the left lower lung. There are diffuse areas of\\n interstitial opacities bilaterally confirmed on CT from one hour prior.\\n\\n IMPRESSION:\\n Diffuse patchy interstitial opacities bilaterally, which could represent early\\n onset of multifocal or atypical pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 940304,\n \"text\": \" 9:24 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval edema/effusions\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with CHF and CAD, with continued O2 requirement\\n REASON FOR THIS EXAMINATION:\\n please eval edema/effusions\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST, SINGLE VIEW ON \\n\\n HISTORY: CHF and CAD.\\n\\n REFERENCE EXAM: .\\n\\n FINDINGS: There is no significant change in moderate cardiomegaly, pacemaker,\\n sternotomy wires and surgical clips, right IJ line has been removed. There\\n has been interval decrease in the perihilar and right upper lobe infiltrates.\\n There continues to be dense retrocardiac opacity that could be due to volume\\n loss or infiltrate. There continues to be a small left effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-26 00:00:00.000\",\n \"description\": \"L UNILAT UP EXT VEINS US LEFT\",\n \"row_id\": 940951,\n \"text\": \" 3:27 PM\\n UNILAT UP EXT VEINS US LEFT Clip # \\n Reason: Please evaluate for clot\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with CHF and swolle LUE\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for clot\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION: Ultrasound of left upper limb.\\n\\n INDICATION: Swollen left upper extremity.\\n\\n FINDINGS: Some echogenic material is seen in the left internal jugular vein\\n consistent with some old thrombus. It does compress normally, however, no\\n definite thrombus is seen within the left subclavian vein. No thrombus within\\n the left axillary vein. The left brachial vein and left basilic are normal to\\n compression and augmentation. In the left cephalic vein, there is echogenic\\n material within the central lumen which does not compress. This appearance is\\n consistent with thrombus which extends throughout the length of the left\\n cephalic vein.\\n\\n IMPRESSION: Thrombus extending throughout the length of the left cephalic\\n vein with some older appearing nonocclusive thrombus within the left jugular\\n vein. This case should be monitored for extension of the thrombus in one to\\n two days.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 939162,\n \"text\": \" 7:04 AM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: pls check placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with shock, ng tube\\n REASON FOR THIS EXAMINATION:\\n pls check placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: CHEST X-RAY PORTABLE AP.\\n\\n INDICATION: NG tube placement position.\\n\\n COMPARISONS: Comparison is made to the earlier film from 0214 hours.\\n\\n The endotracheal tube is approximately 7 cm superior to the carina. The\\n proximal NG sideport is 5cm above the diaphragm; to move all the sideports\\n into the stomach, the tube would need to be advanced approximately 10cm.\\n Moderate cardiomegaly is slightly less prominent. The pulmonary vasculature is\\n less engorged and there is some interval resolution of the pulmonary edema.\\n The right costophrenic angle is slightly cutoff by this film, however, there\\n is no evidence of pleural effusion, right or left. There is a left- sided\\n pacemaker with leads terminating within the right ventricle and right atrium,\\n and median sternotomy wires are present, both unchanged.\\n\\n IMPRESSION:\\n 1. NG tube should be advanced 10 cm to move all the sideports into the\\n stomach.\\n 2. Endotracheal tube 2-3 cm above optimal position.\\n 3. Some interval resolution of vascular congestion and intersitial edema\\n compared to the film five hours prior.\\n 4. Persistent moderate cardiomegaly.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-13 00:00:00.000\",\n \"description\": \"BY DIFFERENT PHYSICIAN\",\n \"row_id\": 939249,\n \"text\": \" 4:46 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: pls evaluate posititon of ETT and NGT\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with shock, ETT and NGT advanced.\\n REASON FOR THIS EXAMINATION:\\n pls evaluate posititon of ETT and NGT\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 88-year-old man with shock, ETT and NG tube advance. Check\\n positioning of endotracheal tube and nasogastric tube.\\n\\n COMPARISON: Ten hours prior.\\n\\n SINGLE SUPINE PORTABLE CHEST RADIOGRAPH:\\n\\n The endotracheal tube tip is at the level of the inferior aspect of the\\n clavicles, approximately 5 cm from the carina in standard positioning. The\\n nasogastric tube tip has been advanced with side port below the GE junction.\\n Multiple surgical clips are seen overlying the cardiac silhouette and\\n sternotomy wires are also again noted. A biventricular pacer AICD device is\\n in stable positioning. Limited views of the lung fields are grossly unchanged\\n with exclusion of the left lateral lung.\\n\\n IMPRESSION:\\n\\n Standard placement of endotracheal tube and nasogastric tube. Otherwise,\\n unchanged exam.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-13 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 939171,\n \"text\": \" 8:11 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval for acute bleed\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88M h/o CAD, AICD, CHF, on anticoagulation for DVT, here w/ shock of unclear\\n etiology, poor brainstem reflexes.\\n REASON FOR THIS EXAMINATION:\\n eval for acute bleed\\n CONTRAINDICATIONS for IV CONTRAST:\\n Cr 2.5\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Evaluate for acute bleed. 88-year-old on anticoagulation for DVT\\n here with unclear etiology of shock. Poor brainstem reflexes. Evaluate for\\n acute bleed.\\n\\n TECHNIQUE: Non-contrast head CT.\\n\\n FINDINGS: There is no intracranial hemorrhage. There is no midline shift,\\n mass effect or hydrocephalus. The -white matter differentiation is\\n preserved. There are sulcal and ventricular prominence due to mild\\n generalized brain atrophy. There are periventricular and subcortical white\\n matter hypodensities consistent with chronic microvascular ischemic change.\\n There are atherosclerotic calcifications.\\n\\n There are small air-fluid levels noted in both maxillary and sphenoid sinuses\\n due to the patient being intubated.\\n\\n IMPRESSION: No intracranial hemorrhage. No mass effect.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-27 00:00:00.000\",\n \"description\": \"B UNILAT UP EXT VEINS US BILAT\",\n \"row_id\": 941074,\n \"text\": \" 1:45 PM\\n UNILAT UP EXT VEINS US BILAT Clip # \\n Reason: foloow-up: progress and/or new clots?\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with CHF and swollen LUE and DVTs on US\\n\\n REASON FOR THIS EXAMINATION:\\n foloow-up: progress and/or new clots?\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Swollen left upper extremity and deep vein thrombosis on\\n ultrasound. Please follow for progression of previously identified\\n superficial vein thrombosis.\\n\\n UNILATERAL UPPER EXTREMITY VEINS, LEFT: Comparison is made to the examination\\n from yesterday. Again seen is peripheral echogenic material within the left\\n internal jugular vein. There is wall-to-wall color flow within this vessel\\n and the internal jugular vein compresses. There is normal color Doppler flow\\n with normal respiratory variation within the internal jugular vein.\\n Similarly, the left subclavian demonstrates normal patency, wall-to-wall color\\n flow with Doppler waveform, with normal respiratory variation and\\n augmentation.\\n\\n IMPRESSION:\\n 1. Likely old thrombus within the left internal jugular vein because it is\\n peripheral in location and normal color blood flow is seen through this\\n vessel.\\n 2. No evidence of deep vein thrombosis in the left subclavian vein.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 939257,\n \"text\": \" 6:12 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: please assess for ETT placement\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with shock, ETT and NGT advanced.\\n\\n REASON FOR THIS EXAMINATION:\\n please assess for ETT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 88-year-old male with endotracheal tube and NG tube advanced.\\n Assess for endotracheal tube placement.\\n\\n COMPARISON: One hour prior.\\n\\n Lines and tubes are in similar position with endotracheal tube tip now 1 cm\\n below the level of the clavicles, likely due to positioning. The endotracheal\\n tube tip is similarly approximately 6 cm from the carina. The\\n cardiomediastinal silhouette and lung fields are stable.\\n\\n IMPRESSION:\\n\\n Endotracheal tube tip 6 cm from the carina just below the inferior aspect of\\n the clavicles in good positioning.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 939381,\n \"text\": \" 7:18 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess for interval change, line placement\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with shock, ETT and NGT advanced.\\n\\n REASON FOR THIS EXAMINATION:\\n assess for interval change, line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST, SINGLE VIEW ON .\\n\\n HISTORY: Shock, ET tube and NG tube advanced.\\n\\n FINDINGS: The ET tube is 5.3 cm above the carina. The NG tube is in the\\n proximal stomach with proximal port at the GE junction. Left-sided pacemaker\\n is unchanged. There are patchy areas of volume loss versus an early\\n infiltrate in the right lower lobe.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 941148,\n \"text\": \" 10:58 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval for etiol of SOB\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with CHF and CAD currently dyspneic, RR to 30's\\n\\n REASON FOR THIS EXAMINATION:\\n Eval for etiol of SOB\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: CHF. Shortness of breath.\\n\\n Single portable radiograph of the chest again demonstrates the patient to be\\n status post CABG. Increased bibasilar airspace pulmonary opacities and small\\n bilateral pleural effusions are slightly worse when compared to .\\n Dual-lead left thoracic cardiac pacer is unchanged. Trachea is midline. No\\n pneumothorax.\\n\\n IMPRESSION:\\n\\n Worsening CHF. Superimposed pneumonia is not excluded.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-28 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 941185,\n \"text\": \" 4:19 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: Eval for acute bleed/stroke\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with acute MS change on IV Argatroban\\n REASON FOR THIS EXAMINATION:\\n Eval for acute bleed/stroke\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: 88-year-old male with acute mental status changes on IV\\n agatroban. Evaluate for bleed/stroke.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Non-contrast head CT.\\n\\n FINDINGS: No hemorrhage, mass, hydrocephalus, shift of normally midline\\n structures. -white matter differentiation is preserved. No major\\n vascular territorial infarct is apparent. There are regions of\\n hypoattenuation within the periventricular white matter, which reflect chronic\\n microvascular ischemic disease. The ventricles and sulci are prominent,\\n reflecting age associated involutional changes. Vascular calcifications are\\n seen within the cavernous carotid. The visualized paranasal sinuses remain\\n normally aerated. There is increased partial opacification of the left\\n mastoid air cells compared to prior exam dated .\\n\\n IMPRESSION:\\n 1. No hemorrhage.\\n 2. Partial opacification of the left mastoid air cell, which was not seen on\\n previous CT head dated .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2120-12-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 939762,\n \"text\": \" 8:42 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess for CHF\\n Admitting Diagnosis: CARDIOGENIC SHOCK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 88 year old man with sepsis and cardiomyopathy, with RIJ central line\\n placement, need assessment.\\n REASON FOR THIS EXAMINATION:\\n assess for CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Sepsis and cardiomyopathy.\\n\\n COMPARISON: .\\n\\n AP UPRIGHT CHEST: The patient has been extubated and the nasogastric tube has\\n been removed. There is a left-sided AICD with leads projecting in unchanged\\n positions over the right atrium and ventricle. The patient is status post\\n median sternotomy and CABG. Moderate enlargement of the cardiac silhouette is\\n unchanged allowing for low lung volumes. There is slight improvement in\\n asymmetric pulmonary interstitial edema, right greater than left. Retrocardiac\\n opacification is unchanged. Moderate left and small right pleural effusions\\n are stable.\\n\\n IMPRESSION:\\n 1) Interval improvement in mild pulmonary interstitial edema.\\n 2) Left basal atelectasis, less likely pneumonia.\\n\\n\"\n }\n]"}}},{"rowIdx":24675,"cells":{"subject_id":{"kind":"number","value":4787,"string":"4,787"},"hadm_id":{"kind":"number","value":135926,"string":"135,926"},"target_text":{"kind":"string","value":"82 yom with history of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presented to the hospital with one day of nausea, vomiting and weakness. . # Viral Gastroenteritis: Mr. presented with symptoms of nausea, vomiting, weakness and diarrhea which are all consistent with a viral gastroenteritis. Symptoms resolved within 1 day. Concern initially was for sepsis as he presented with SBP in the 80s and leukocytosis to 22. He was initially treated with Vanco/Zosyn which was then changed to Linezolid/Meropenem based on previous culture data. The patient remained afebrile and blood pressures remained stable. Blood cultures show no growth to date. Stool cultures sent and also show no growth to date. C.diff was negative. Urine culture showed yeast and foley was . ID was consulted given significant history of bactermias and resistant organisms. Linezolid and Meropenem were continued for two days and then as no source of bacterial infection was found. Patient has now remained afebrile off of antibiotics and is ready to be discharged home. Of note, patient had Guaiac positive stools while in the hospital and HCT remained stable. Patient will need to follow up with Gastroenterology as an outpatient for further workup. . # ESRD on HD: Patient was continued on his T/Th/Sat dialysis. . # COPD: cont home spiriva, atrovent. . # Atrial Fibrillation: Patient with history of atrial fibrillation on on anticoagulation. He was admitted with atrial fibrillation which was thought secondary to infection. Cardiac enzymes were done and were negative. . # Depression: patient was continued on her home Fluoxetine ."},"extractive_notes_summ":{"kind":"string","value":"# Prophylaxis: Subcutaneous heparin . # Prophylaxis: Subcutaneous heparin . -- d/c Linezolid -- cont for now -- follow up cultures -- trend fever WBC curve -- f/u ID recs # ESRD on HD: Patient on T/Th/Sat dialysis. -- cont Linezolid/Meropenem -- follow up cultures -- trend fever WBC curve -- ID consult . Patient was ROMI. Action: Cont on linezolid and meropenem. -- cont Vanco/Zosyn -- D/C CTX -- send UA/UCx -- repeat lactate -- repeat CBC, Chem 7 -- 1L IVF bolus -- trend fever WBC curve . He was given Vancomycin 1gm IV x 1, CTX 1gm IV x 2 and Zosyn 4.5gm IV x 1. He was given Vancomycin 1gm IV x 1, CTX 1gm IV x 2 and Zosyn 4.5gm IV x 1. He was given Vancomycin 1gm IV x 1, CTX 1gm IV x 2 and Zosyn 4.5gm IV x 1. Action: Cont on linezolid and meropenum. Action: Cont on linezolid and meropenum. Linezolid was added yesterdy to cover his previous MRSA and VRE. # COPD: cont home spiriva, atrovent. # COPD: cont home spiriva, atrovent. # COPD: cont home spiriva, atrovent. # COPD: cont home spiriva, atrovent. TSH normal -- cont home ASA # Depression: cont home Fluoxetine # FEN: Renal Diet, replete lytes # Prophylaxis: Subcutaneous heparin # Access: PIV # Code: Full # Communication: Patient # Disposition: will work with PT one additional time before likely d/c to home TSH normal -- cont home ASA # Depression: cont home Fluoxetine # FEN: Renal Diet, replete lytes # Prophylaxis: Subcutaneous heparin # Access: PIV # Code: Full # Communication: Patient # Disposition: will work with PT one additional time before likely d/c to home ICU Care Nutrition: Glycemic Control: Lines: Dialysis Catheter - 12:43 AM 20 Gauge - 06:00 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Disposition: TSH normal -- cont home ASA # Depression: cont home Fluoxetine # FEN: Renal Diet, replete lytes # Prophylaxis: Subcutaneous heparin # Access: PIV # Code: Full # Communication: Patient # Disposition: will work with PT one additional time before likely d/c to home ICU Care Nutrition: Glycemic Control: Lines: Dialysis Catheter - 12:43 AM 20 Gauge - 06:00 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Disposition: Chief Complaint: HPI: 82 yo M with hx of ESRD on HD Atrial Fibrillation/Flutter not anticoagulated C.diff, CVA x 2 CAD s/p MI, diastolic CHF presents with weakness/N/V (non bloody)/D x 1 day went to OSH SBP 70-80 improved with fluids got Vanc and transferred to lactate 4.1, WBC 22, 90%N, Hct 51 got Zosyn in ED, 3.5L NS, SBP 90s. EKG: irregular rate and rhythm, no acute ST or T wave changes Assessment and Plan 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and weakness. EKG: irregular rate and rhythm, no acute ST or T wave changes Assessment and Plan 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and weakness. EKG: irregular rate and rhythm, no acute ST or T wave changes Assessment and Plan 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and weakness. # Prophylaxis: Subcutaneous heparin . Patient was ROMI. Action: Cont on linezolid and meropenem. Action: Cont on linezolid and meropenum. Action: Cont on linezolid and meropenum. Action: Cont on linezolid and meropenum. # COPD: cont home spiriva, atrovent. # COPD: cont home spiriva, atrovent. # COPD: cont home spiriva, atrovent. # COPD: cont home spiriva, atrovent. -- d/c Linezolid -- cont for now -- follow up cultures -- trend fever WBC curve -- f/u ID recs # ESRD on HD: Patient on T/Th/Sat dialysis. -- cont Vanco/Zosyn -- D/C CTX -- send UA/UCx -- repeat lactate -- repeat CBC, Chem 7 -- 1L IVF bolus -- trend fever WBC curve . He was given Vancomycin 1gm IV x 1, CTX 1gm IV x 2 and Zosyn 4.5gm IV x 1. He was given Vancomycin 1gm IV x 1, CTX 1gm IV x 2 and Zosyn 4.5gm IV x 1. He was given Vancomycin 1gm IV x 1, CTX 1gm IV x 2 and Zosyn 4.5gm IV x 1. Cdiff cult neg. Cdiff cult neg. Cdiff cult neg. Plan: Cont antiobidics as ordered. Plan: Cont antiobidics as ordered. Plan: Cont antiobidics as ordered. Retrocardiac atelectasis."},"n_notes":{"kind":"number","value":65,"string":"65"},"notes":{"kind":"list like","value":[{"category":"Physician ","chartdate":"2126-01-25 00:00:00.000","description":"Physician Attending Progress Note","row_id":364118,"text":"Chief Complaint: shock resolved\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n none, stable\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 08:46 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.2\nC (97.2\n HR: 96 (76 - 105) bpm\n BP: 124/78(87) {91/58(66) - 142/90(97)} mmHg\n RR: 19 (14 - 24) insp/min\n SpO2: 93%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 1,154 mL\n PO:\n 720 mL\n TF:\n IVF:\n 434 mL\n Blood products:\n Total out:\n 3,300 mL\n 100 mL\n Urine:\n 300 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,146 mL\n -100 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ////\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles new since yesterday.\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 11.8 g/dL\n 139 K/uL\n 84 mg/dL\n 3.8 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 6.3 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n WBC\n 18.6\n 7.6\n 6.3\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n Plt\n 162\n 133\n 139\n Cr\n 4.7\n 3.3\n 3.8\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension....all cultures still neg to date this admission\nsepsis\n resolved, off all abx.\n - Will get surveillance cxs during HD\n - LGI bleed: still has diarrhea, outpt GI w/u.....might need\n proctoscopy once he recovers.\n - COPD: on home meds, small O2 reqmt due to atelectasis, cont IS\n - Afib: rate controlled, not anticoagulated\n - Depression: cont home Fluoxetine\n - FEN: Taking good po, SBP appears at baseline\n - Dispo: walk with pt b4 discharge home...patient upset\nmay go AMA if\n he refuses rehab.\n ICU Care\n Nutrition:\n Comments: good po\n Glycemic Control: stable\n Lines:\n Dialysis Catheter - 12:43 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Code status: Full code\n Disposition :Home once he walks vs rehab, PT c/s, SW input\n Total time spent:\n"},{"category":"Physician ","chartdate":"2126-01-25 00:00:00.000","description":"Physician Resident Progress Note","row_id":364095,"text":"Chief Complaint:\n 24 Hour Events:\n No Events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.6\nC (96\n HR: 96 (76 - 99) bpm\n BP: 124/77(89) {91/56(66) - 127/90(96)} mmHg\n RR: 19 (14 - 24) insp/min\n SpO2: 96%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 1,154 mL\n PO:\n 720 mL\n TF:\n IVF:\n 434 mL\n Blood products:\n Total out:\n 3,300 mL\n 100 mL\n Urine:\n 300 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,146 mL\n -100 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///28/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 139 K/uL\n 11.8 g/dL\n 84 mg/dL\n 3.8 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 6.3 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n WBC\n 18.6\n 7.6\n 6.3\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n Plt\n 162\n 133\n 139\n Cr\n 4.7\n 3.3\n 3.8\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2126-01-25 00:00:00.000","description":"Physician Resident Progress Note","row_id":364098,"text":"Chief Complaint:\n 24 Hour Events:\n No Events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.6\nC (96\n HR: 96 (76 - 99) bpm\n BP: 124/77(89) {91/56(66) - 127/90(96)} mmHg\n RR: 19 (14 - 24) insp/min\n SpO2: 96%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 1,154 mL\n PO:\n 720 mL\n TF:\n IVF:\n 434 mL\n Blood products:\n Total out:\n 3,300 mL\n 100 mL\n Urine:\n 300 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,146 mL\n -100 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///28/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 139 K/uL\n 11.8 g/dL\n 84 mg/dL\n 3.8 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 6.3 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n WBC\n 18.6\n 7.6\n 6.3\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n Plt\n 162\n 133\n 139\n Cr\n 4.7\n 3.3\n 3.8\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n # Sepsis: Mr. has history of MDR bactermias and presented with\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\n were are all concerning for sepsis. He was given Vancomycin 1gm IV x\n 1, CTX 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn have\n now been discontined. Linezolid was added two days ago to cover his\n previous MRSA and VRE. Meropenem has been added to cover his previous\n MDR E.coli and ESBL Klebsiella. ID was consulted yesterday and\n recommended to discontinue his linezolid. Blood cultures from the OSH\n are negative. Blood cultures from here show NGTD. Urine culture shows\n +yeast. .\n -- d/c Linezolid\n -- cont for now\n -- follow up cultures\n -- trend fever WBC curve\n -- f/u ID recs\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- HD today\n -- may need new line placed if +blood cultures.\n # COPD: cont home spiriva, atrovent.\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. Patient was ROMI. TSH normal\n -- cont home ASA\n # Depression: cont home Fluoxetine\n # FEN: Renal Diet, replete lytes\n # Prophylaxis: Subcutaneous heparin\n # Access: PIV\n # Code: Full\n # Communication: Patient\n # Disposition: call out to medical floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2126-01-25 00:00:00.000","description":"Nursing Progress Note","row_id":364194,"text":"83yo M with extensive PMH including ESRD on HD, CAD s/p MI, CVA x2, and\n multiple hospitalizations for sepsis (kelbsiella, MRSA, VRE, Cdiff) who\n presented with NVD.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Known ESRD,on HD Tu/th/sat,pt had Hd yesterday,voiding yellow urine in\n small amounts,mg level 1.3,tele with frequent bigeminies and\n trigeminies,lungs with crackles at base,no iv acess,left chest wall\n tesio cath,mild redness,as per the pt left arm is saved for AVF\n Action:\n Monitored lytes,20g iv line has been inserted by the IV team,receiving\n mgso4 iv currently\n Response:\n Pending,\n Plan:\n Plan to do HD in am at HD unit,\n DIposition:,pt want to go home today inspite of the plan to sent to\n rehab ,of note pt was incontinant of stool and urine last night and\n never been out of bed,and refused PT evaluation yesterday,consulted\n case mgt,PT regarding the disposition in presence of family,pt and\n family agreed for PT consult,pt did walk with PT and final plan to\n reevaluate again in the morning and d/c home.&keep the pt overnight in\n the ICU,pt was continent of urine and stool in this shift,\n"},{"category":"Physician ","chartdate":"2126-01-26 00:00:00.000","description":"Physician Resident Progress Note","row_id":364265,"text":"Chief Complaint:\n 24 Hour Events:\n no events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.1\n HR: 87 (76 - 108) bpm\n BP: 107/68(76) {106/59(66) - 142/118(122)} mmHg\n RR: 17 (13 - 32) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 86 kg\n Height: 66 Inch\n Total In:\n 990 mL\n PO:\n 890 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 490 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 138 K/uL\n 11.6 g/dL\n 93 mg/dL\n 3.1 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 104 mEq/L\n 140 mEq/L\n 37.2 %\n 4.8 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n 10:40 AM\n WBC\n 18.6\n 7.6\n 6.3\n 4.8\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n 37.2\n Plt\n 162\n 133\n 139\n 138\n Cr\n 4.7\n 3.3\n 3.8\n 3.1\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n 93\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 20 Gauge - 06:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2126-01-26 00:00:00.000","description":"Nursing Progress Note","row_id":364249,"text":"Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Stable vital signs, no BM in this shift.\n Action:\n Pt slept through night .\n Response:\n Pt found to be incontinent of urine @ 0400, perineal area very red\n aloe vesta cream applied.\n Plan:\n No labs drawn this am. Plan to discharge the pt to home after PT/OT\n consult and HD in am.\n Obstructive sleep apnea (OSA)\n Assessment:\n Pt cont to have sleep apnea, O2 1lt NC sat\ns droped to 80\n occasionally but picked upto mid 90\ns without any intervention. Lung\n sounds clear and diminished at the bases.\n Action:\n Pt turned freq and encouraged deep breathing.\n Response:\n Pt slept well during the night. Maintaining o2 sats in mid to high\n 90\n Plan:\n Discuss bipap at home.\n"},{"category":"Nursing","chartdate":"2126-01-25 00:00:00.000","description":"Nursing Progress Note","row_id":364171,"text":"83yo M with extensive PMH including ESRD on HD, CAD s/p MI, CVA x2, and\n multiple hospitalizations for sepsis (kelbsiella, MRSA, VRE, Cdiff) who\n presented with NVD.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Known ESRD,on HD Tu/th/sat,pt had Hd yesterday,voiding yellow urine in\n small amounts,mg level 1.3,tele with frequent bigeminies and\n trigeminies,lungs with crackles at base,no iv acess,left chest wall\n tesio cath,mild redness,as per the pt left arm is saved for AVF\n Action:\n Monitored lytes,20g iv line has been inserted by the IV team\n Response:\n Pending,\n Plan:\n Plan to do HD in am at HD unit,plan to give magnesim IV given diarrhea\n and poor GI absorption\n DIposition:,pt want to go home today inspite of the plan to sent to\n rehab ,of note pt was incontinat of stool and urine last night and\n never been out of bed,and refused PT evaluation yesterday,consulted\n case mgt,PT regarding the disposition in presence of family,pt and\n family agreed for PT consult,pt did walk with PT and final plan to\n reevaluate again in the morning and d/c home.&keep the pt overnight in\n the ICU\n"},{"category":"Nursing","chartdate":"2126-01-22 00:00:00.000","description":"Nursing Progress Note","row_id":363657,"text":"This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\n vomiting and weakness. Patient went to lunch today with his wife and\n began to feel weak, +lightheadedness. He then had nausea with one\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\n of diarrhea since that time, non-bloody, no melena. He denies any\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\n hematuria, urinary frequency or back pain. he does report abdominal\n cramping with his diarrhea today. Wife became worried at the restaurant\n and called EMS. He was taken to hospital and BPs noted to\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\n IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Hypotension (not Shock)\n Assessment:\n BP high 80\ns to low 90\n Action:\n Received fluid bolus 500ml\n Response:\n Currently BP maintaining @ >90\n Plan:\n Monitor BP and bolus PRN\n Sepsis without organ dysfunction\n Assessment:\n In ED Lactate 4.1, Right arm was infiltrated on arrival to ICU. Foley\n drained small amount sludge urine. Received 4lit fluid and abx zosyn in\n ED .\n Action:\n Urine routine and C/S sent to lab. Repeat lactate 1.3. ( Very hard\n stick, Pt refuses to do blood draws in the left arm claiming he will\n get fistula done after few days. But pt came w/ 2 peripheral IV lines\n from OSH in the lt arm. AM labs drawn by MD arterial stick.)\n Response:\n Pending\n Plan:\n Follow up culture reports.\n"},{"category":"Physician ","chartdate":"2126-01-23 00:00:00.000","description":"Physician Attending Progress Note","row_id":363808,"text":"Chief Complaint: Septic shock,\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n N/V,weakness\n 24 Hour Events:\n HD yesterday...no fluid taken off...got a few fluid boluses for low\n SBP...responded well to fluids but asymptomatic w/o tachycardia.\n Afebrile\n Brown stool with flecks, guiac positive, ? hemorrhoids\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 01:37 PM\n Linezolid - 02:21 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.9\nC (96.6\n HR: 86 (84 - 98) bpm\n BP: 103/65(73) {83/41(54) - 104/69(73)} mmHg\n RR: 20 (14 - 25) insp/min\n SpO2: 99%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 6,347 mL\n 1,254 mL\n PO:\n 540 mL\n 360 mL\n TF:\n IVF:\n 1,807 mL\n 894 mL\n Blood products:\n Total out:\n 405 mL\n 135 mL\n Urine:\n 205 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,942 mL\n 1,119 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles new since yesterday.\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, mild tender RUQ, non-distended, bowel sounds present,\n no rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 11.2 g/dL\n 133 K/uL\n 89 mg/dL\n 3.3 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 107 mEq/L\n 143 mEq/L\n 35.6 %\n 7.6 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n WBC\n 18.6\n 7.6\n Hct\n 41.9\n 35.6\n Plt\n 162\n 133\n Cr\n 4.7\n 3.3\n TropT\n 0.05\n Glucose\n 129\n 89\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\n Troponin-T:25/6/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\n Microbiology: cdiff neg\n all cxs pend\n UA pos\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension....all cultures still neg to date this admission.\n # Shock: likely sepsis.\n Sources: history of MDR bactermias (ESBL Kleb, MRSA, VRE) in urine and\n HD line.\n - On Linezolid and Meropenem...Id c/s for input\n - f/u cxs here and \n # ESRD on HD: Patient on T/Th/Sat dialysis. HD line site with mild\n erythema but non tender\n # LGI bleed: cscope with diverticulosis in ...might need\n proctoscopy once he recovers. Follow Hct.\n # COPD: cont home spiriva, atrovent. Wean off O2. Hx of OSA, not on\n Rx...watch for progression of crackles. Use Incentive spirometry.\n .\n # Atrial Fibrillation: rate controlled, not anticoagulated\n # Depression: cont home Fluoxetine\n # FEN: Taking good po, SBP appears at baseline\n ICU Care\n Nutrition:\n Comments: po\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Comments: in for picc if needs iv abx not able tpo dose with dialysis\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n"},{"category":"Physician ","chartdate":"2126-01-23 00:00:00.000","description":"Physician Resident Progress Note","row_id":363812,"text":"Chief Complaint:\n 24 Hour Events:\n Blood pressure dropped into the 80s transiently and responded to IVF\n boluses.\n Dr. passed by and recommended ID consult.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 01:37 PM\n Linezolid - 02:21 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.9\nC (96.7\n HR: 84 (84 - 99) bpm\n BP: 89/65(70) {83/41(54) - 104/67(75)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 6,347 mL\n 879 mL\n PO:\n 540 mL\n TF:\n IVF:\n 1,807 mL\n 879 mL\n Blood products:\n Total out:\n 405 mL\n 80 mL\n Urine:\n 205 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,942 mL\n 799 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 133 K/uL\n 11.2 g/dL\n 89 mg/dL\n 3.3 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 107 mEq/L\n 143 mEq/L\n 35.6 %\n 7.6 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n WBC\n 18.6\n 7.6\n Hct\n 41.9\n 35.6\n Plt\n 162\n 133\n Cr\n 4.7\n 3.3\n TropT\n 0.05\n Glucose\n 129\n 89\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\n Troponin-T:25/6/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n .\n # Sepsis: Mr. has history of MDR bactermias and presents with\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn have now been\n discontined. Linezolid was added yesterdy to cover his previous MRSA\n and VRE. Meropenem has been added to cover his previous MDR E.coli\n and ESBL Klebsiella. will cont with that regimen for now.\n -- cont Linezolid/Meropenem\n -- follow up cultures\n -- trend fever WBC curve\n -- ID consult\n .\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- likely HD tomorrow\n -- may need new line placed if +blood cultures\n .\n # COPD: cont home spiriva, atrovent.\n .\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. Cardiac enzymes sent yesterday and were\n negative, will repeat today. TSH normal\n -- f/u cardiac enzymes\n -- monitor on tele\n -- cont home ASA\n .\n # Depression: cont home Fluoxetine\n .\n # FEN: Renal Diet, replete lytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: PIV\n .\n # Code: Full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition: Regular Renal\n Glycemic Control: None\n Lines:\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer: PPI\n VAP: None\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2126-01-24 00:00:00.000","description":"Nursing Transfer Note","row_id":363967,"text":"82 yo M with PMH significant for ESRD on HD T/Th/S, Atrial\n Fibrillation/Flutter, C.diff colitis, CVA x 2 with residual right sided\n weakness, CAD s/p MI, diastolic CHF with EF 60%, klebsiella urosepsis,\n multi-drug resistant E.Coli Sepsis, and MRSA Sepsis who presented to\n Hospital with N/V/D and weakness. At OSH, SBPs were\n noted to be in the 70s and 80s. He was then transferred to for\n further care of probable sepsis. Upon arrival to ED, his VS were\n stable but he was noted to have a lactate of 4.1. He was then\n transferred to the MICU for further management.\n Sepsis without organ dysfunction\n Assessment:\n Pt afebrile. WBC Sbp 90 or greater today. Cdiff cult neg. urine and\n bc pending.\n Action:\n Cont on linezolid and meropenum. Team decided not to place picc till\n final cult results back. Id consulted. Survelliance cult x2 done one\n peripheral and one via hd cath line\n Response:\n Bp improved. Afebrile.\n Plan:\n Cont antiobidics as ordered. Monitor for temp spike. Follow up on cult\n Obstructive sleep apnea (OSA)\n Assessment:\n Patient with known hx of sleep apnea. Does not wear bipap at home. Had\n been on home o2 per wife but none in the past week.\n Action:\n Taken off o2 to see how his sats would do.\n Response:\n Sats 92 or greater when awake. Fell to 87% when he fell asleep. O2\n replaced at 1l nc.\n Plan:\n Cont to monitor sats.\n wife in to visit. Updated on plan of care.\n Activity.- pt consult placed. Patient s/p cva with residual right sided\n weakness. Uses walker at home. OOb to chair with assist of 2. Tolerated\n well.\n"},{"category":"Nursing","chartdate":"2126-01-24 00:00:00.000","description":"Nursing Transfer Note","row_id":363968,"text":"82 yo M with PMH significant for ESRD on HD T/Th/S, Atrial\n Fibrillation/Flutter, C.diff colitis, CVA x 2 with residual right sided\n weakness, CAD s/p MI, diastolic CHF with EF 60%, klebsiella urosepsis,\n multi-drug resistant E.Coli Sepsis, and MRSA Sepsis who presented to\n Hospital with N/V/D and weakness. At OSH, SBPs were\n noted to be in the 70s and 80s. He was then transferred to for\n further care of probable sepsis. Upon arrival to ED, his VS were\n stable but he was noted to have a lactate of 4.1. He was then\n transferred to the MICU for further management.\n Sepsis without organ dysfunction\n Assessment:\n Pt afebrile. WBC 6.3 this AM. SBP remains >90 today. Cdiff cult\n negative thus far. Urine and blood cultures with no growth to date.\n Action:\n Cont on linezolid and meropenem.\n Response:\n Plan:\n Cont antibiotics as ordered. Monitor for temp spike. Follow up on\n culture results.\n wife in to visit. Updated on plan of care.\n Activity.- pt consult placed. Patient s/p cva with residual right sided\n weakness. Uses walker at home. OOb to chair with assist of 2. Tolerated\n well.\n"},{"category":"Physician ","chartdate":"2126-01-23 00:00:00.000","description":"Physician Resident Progress Note","row_id":363790,"text":"Chief Complaint:\n 24 Hour Events:\n Blood pressure dropped into the 80s transiently and responded to IVF\n boluses.\n Dr. passed by and recommended ID consult.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 01:37 PM\n Linezolid - 02:21 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.9\nC (96.7\n HR: 84 (84 - 99) bpm\n BP: 89/65(70) {83/41(54) - 104/67(75)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 6,347 mL\n 879 mL\n PO:\n 540 mL\n TF:\n IVF:\n 1,807 mL\n 879 mL\n Blood products:\n Total out:\n 405 mL\n 80 mL\n Urine:\n 205 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,942 mL\n 799 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 133 K/uL\n 11.2 g/dL\n 89 mg/dL\n 3.3 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 107 mEq/L\n 143 mEq/L\n 35.6 %\n 7.6 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n WBC\n 18.6\n 7.6\n Hct\n 41.9\n 35.6\n Plt\n 162\n 133\n Cr\n 4.7\n 3.3\n TropT\n 0.05\n Glucose\n 129\n 89\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\n Troponin-T:25/6/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2126-01-23 00:00:00.000","description":"Physician Resident Progress Note","row_id":363792,"text":"Chief Complaint:\n 24 Hour Events:\n Blood pressure dropped into the 80s transiently and responded to IVF\n boluses.\n Dr. passed by and recommended ID consult.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 01:37 PM\n Linezolid - 02:21 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.9\nC (96.7\n HR: 84 (84 - 99) bpm\n BP: 89/65(70) {83/41(54) - 104/67(75)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 6,347 mL\n 879 mL\n PO:\n 540 mL\n TF:\n IVF:\n 1,807 mL\n 879 mL\n Blood products:\n Total out:\n 405 mL\n 80 mL\n Urine:\n 205 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,942 mL\n 799 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 133 K/uL\n 11.2 g/dL\n 89 mg/dL\n 3.3 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 107 mEq/L\n 143 mEq/L\n 35.6 %\n 7.6 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n WBC\n 18.6\n 7.6\n Hct\n 41.9\n 35.6\n Plt\n 162\n 133\n Cr\n 4.7\n 3.3\n TropT\n 0.05\n Glucose\n 129\n 89\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\n Troponin-T:25/6/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n .\n # Sepsis: Mr. has history of MDR bactermias and presents with\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn cover his\n previous MRSA, MDR E.coli and ESBL Klebsiella. will cont with that\n regimen for now.\n -- cont Vanco/Zosyn\n -- D/C CTX\n -- send UA/UCx\n -- repeat lactate\n -- repeat CBC, Chem 7\n -- 1L IVF bolus\n -- trend fever WBC curve\n .\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- likely HD tomorrow\n -- may need new line placed if +blood cultures\n .\n # COPD: cont home spiriva, atrovent.\n .\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. will ROMI\n -- cycle cardiac enzymes\n -- monitor on tele\n -- check TSH\n -- cont home ASA\n .\n # Depression: cont home Fluoxetine\n .\n # FEN: Renal Diet, replete lytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: PIV\n .\n # Code: Full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition: Regular Renal\n Glycemic Control: None\n Lines:\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer: PPI\n VAP: None\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2126-01-23 00:00:00.000","description":"Physician Attending Progress Note","row_id":363801,"text":"Chief Complaint: Septic shock,\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n N/V,weakness\n 24 Hour Events:\n HD yesterday...no fluid taken off...got a few fluid boluses for low\n SBP...responded well to fluids but asymptomatic w/o tachycardia.\n Afebrile\n Brown stool with flecks, guiac positive, ? hemorrhoids\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 01:37 PM\n Linezolid - 02:21 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.9\nC (96.6\n HR: 86 (84 - 98) bpm\n BP: 103/65(73) {83/41(54) - 104/69(73)} mmHg\n RR: 20 (14 - 25) insp/min\n SpO2: 99%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 6,347 mL\n 1,254 mL\n PO:\n 540 mL\n 360 mL\n TF:\n IVF:\n 1,807 mL\n 894 mL\n Blood products:\n Total out:\n 405 mL\n 135 mL\n Urine:\n 205 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,942 mL\n 1,119 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles new since yesterday.\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, mild tender RUQ, non-distended, bowel sounds present,\n no rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 11.2 g/dL\n 133 K/uL\n 89 mg/dL\n 3.3 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 107 mEq/L\n 143 mEq/L\n 35.6 %\n 7.6 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n WBC\n 18.6\n 7.6\n Hct\n 41.9\n 35.6\n Plt\n 162\n 133\n Cr\n 4.7\n 3.3\n TropT\n 0.05\n Glucose\n 129\n 89\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\n Troponin-T:25/6/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\n Microbiology: cdiff neg\n all cxs pend\n UA pos\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension....all cultures still neg to date this admission.\n # Shock: likely sepsis.\n Sources: history of MDR bactermias (ESBL Kleb, MRSA, VRE) in urine and\n HD line.\n - On Linezolid and Meropenem...Id c/s for input\n - f/u cxs here and \n # ESRD on HD: Patient on T/Th/Sat dialysis. HD line site with mild\n erythema but non tender\n # LGI bleed: cscope with diverticulosis in ...might need\n proctoscopy once he recovers. Follow Hct.\n # COPD: cont home spiriva, atrovent. Wean off O2. Hx of OSA, not on\n Rx...watch for progression of crackles. Use Incentive spirometry.\n .\n # Atrial Fibrillation: rate controlled, not anticoagulated\n # Depression: cont home Fluoxetine\n # FEN: Taking good po, SBP appears at baseline\n ICU Care\n Nutrition:\n Comments: po\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Comments: in for picc if needs iv abx not able tpo dose with dialysis\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n"},{"category":"Nursing","chartdate":"2126-01-23 00:00:00.000","description":"Nursing Progress Note","row_id":363814,"text":"82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2126-01-24 00:00:00.000","description":"Nursing Transfer Note","row_id":363965,"text":"82 yo M with PMH significant for ESRD on HD T/Th/S, Atrial\n Fibrillation/Flutter, C.diff colitis, CVA x 2 with residual right sided\n weakness, CAD s/p MI, diastolic CHF with EF 60%, klebsiella urosepsis,\n multi-drug resistant E.Coli Sepsis, and MRSA Sepsis who presents with\n one day of N/V and weakness.\n Sepsis without organ dysfunction\n Assessment:\n Wbc down to 7.6. afebrile. Sbp 90 or greater today. Cdiff cult neg.\n urine and bc pending.\n Action:\n Cont on linezolid and meropenum. Team decided not to place picc till\n final cult results back. Id consulted. Survelliance cult x2 done one\n peripheral and one via hd cath line\n Response:\n Bp improved. Afebrile.\n Plan:\n Cont antiobidics as ordered. Monitor for temp spike. Follow up on cult\n Obstructive sleep apnea (OSA)\n Assessment:\n Patient with known hx of sleep apnea. Does not wear bipap at home. Had\n been on home o2 per wife but none in the past week.\n Action:\n Taken off o2 to see how his sats would do.\n Response:\n Sats 92 or greater when awake. Fell to 87% when he fell asleep. O2\n replaced at 1l nc.\n Plan:\n Cont to monitor sats.\n wife in to visit. Updated on plan of care.\n Activity.- pt consult placed. Patient s/p cva with residual right sided\n weakness. Uses walker at home. OOb to chair with assist of 2. Tolerated\n well.\n"},{"category":"Rehab Services","chartdate":"2126-01-26 00:00:00.000","description":"Physical Therapy Progress Note","row_id":364327,"text":"Subjective:\n I feel good and want to go home\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n To Right c mailing support\n\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n C railing support\n T\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n T\n\n\n\n\n\n Ambulation:\n C RW\n T\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Sit\n 88\n 119/78\n 95\n Activity\n Sit\n 102\n 132/82\n 96*\n Recovery\n Sit\n 76\n 112/65\n 99\n Total distance walked: 100'\n Minutes:\n Unable to get clear of O2 sats during activity\n * Immediately following activity.\n Gait: pt amb I 100' c RW and R AFO. pt genu recurvatum in R knee c\n flexed trunk, equal step length and normal cadence.\n Balance: pt could I sit on EOB without UE support. pt LOB post\n from recliner during sit-stand, however I sit-stand from EOB\n without LOB d/t increased hieght. EOB more charactersitic of height of\n chairs at home. pt could and dof AFO from EOB.\n Education / Communication: pt education RE: Role of PT, poc, d/c plan,\n importance of family member A c OOB activity. RN communication RE: pt\n status, d/c plan\n Other:\n Assessment: pt is an 82 y.o. male c HTN and n/v/d p/w the above\n impairments that is currently presenting at baseline described as\n functionally I c all mobility. Assuming pt is medically stable,\n anticipate pt to be safe for d/c home provided the pt has S from family\n memberat night time c amb to bathroom and c the recommendation of home\n PT to regain maximum functional I.\n Anticipated Discharge: Home with Home PT\n : d/c planning, d/c from acute PT c Home PT. Wife has agreed to\n assist pt at night c amb to bathroom.\n Treated by PT/s 2:50p-3:25p\n"},{"category":"Nursing","chartdate":"2126-01-23 00:00:00.000","description":"Nursing Progress Note","row_id":363795,"text":"82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2126-01-24 00:00:00.000","description":"Physician Attending Progress Note","row_id":363962,"text":"Chief Complaint: Septic shock\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ID agreed with current abx\n Hct stable with guiac + stools and diarrhea overnight. Cdiff neg.\n SBP stable\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.4\nC (95.8\n HR: 82 (77 - 94) bpm\n BP: 98/64(70) {91/52(63) - 118/80(85)} mmHg\n RR: 19 (11 - 25) insp/min\n SpO2: 95%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 2,240 mL\n 647 mL\n PO:\n 800 mL\n 240 mL\n TF:\n IVF:\n 1,440 mL\n 407 mL\n Blood products:\n Total out:\n 335 mL\n 175 mL\n Urine:\n 335 mL\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,905 mL\n 472 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles new since yesterday.\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 11.8 g/dL\n 139 K/uL\n 84 mg/dL\n 3.8 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 6.3 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n WBC\n 18.6\n 7.6\n 6.3\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n Plt\n 162\n 133\n 139\n Cr\n 4.7\n 3.3\n 3.8\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\n Microbiology: All cxs: ngtd\n Urine: yeast\n Assessment and Plan\n OBSTRUCTIVE SLEEP APNEA (OSA)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension....all cultures still neg to date this admission.\n # Shock: likely sepsis from urine..potivive UA but grew only yeast. On\n Linezolid and Meropenem. D/c per ID recs since all cxs neg. D/c foley\n # ESRD on HD: Patient on T/Th/Sat dialysis. HD line site with mild\n erythema but non tender\n # LGI bleed: diarrhea overnight. Still blood tinged. GI\n consult....might need proctoscopy once he recovers. Follow Hct.\n # COPD: cont home spiriva, atrovent. Wean off O2. Hx of OSA, not on\n Rx...watch for progression of crackles. Use Incentive spirometry.\n # Atrial Fibrillation: rate controlled, not anticoagulated\n # Depression: cont home Fluoxetine\n # FEN: Taking good po, SBP appears at baseline\n ICU Care\n Nutrition:\n Comments: good po\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n picc based on decision reg duration of abx per ID\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n"},{"category":"Nursing","chartdate":"2126-01-22 00:00:00.000","description":"Nursing Progress Note","row_id":363643,"text":"This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\n vomiting and weakness. Patient went to lunch today with his wife and\n began to feel weak, +lightheadedness. He then had nausea with one\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\n of diarrhea since that time, non-bloody, no melena. He denies any\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\n hematuria, urinary frequency or back pain. he does report abdominal\n cramping with his diarrhea today. Wife became worried at the restaurant\n and called EMS. He was taken to hospital and BPs noted to\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\n IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Hypotension (not Shock)\n Assessment:\n BP high 80\ns to low 90\n Action:\n Received fluid bolus 500ml\n Response:\n Currently BP maintaining @ >90\n Plan:\n Monitor BP and bolus PRN\n Sepsis without organ dysfunction\n Assessment:\n In ED Lactate 4.1, Foley drained small amount sludge urine. Received\n 4lit fluid and abx zosyn in ED .\n Action:\n Urine routine and C/S sent to lab. Repeat lactate 1.3. ( Very hard\n stick, Pt refuses to do blood draws in the left arm claiming he will\n get fistula done after few days. But pt came w/ 2 peripheral IV lines\n from OSH in the lt arm. AM labs drawn by MD arterial stick.)\n Response:\n Pending\n Plan:\n Follow up culture reports.\n"},{"category":"Physician ","chartdate":"2126-01-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":363937,"text":"Chief Complaint: Sepsis\n 24 Hour Events:\n ID consult obtained, continues on Linezolid/Meropenem\n HCT stable, guaiac + stools\n BP stable overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:12 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.6\nC (96.1\n HR: 87 (77 - 94) bpm\n BP: 109/67(75) {90/52(63) - 118/80(85)} mmHg\n RR: 19 (11 - 25) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 2,240 mL\n 353 mL\n PO:\n 800 mL\n TF:\n IVF:\n 1,440 mL\n 353 mL\n Blood products:\n Total out:\n 335 mL\n 140 mL\n Urine:\n 335 mL\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,905 mL\n 213 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 133 K/uL\n 11.2 g/dL\n 89 mg/dL\n 3.3 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 107 mEq/L\n 143 mEq/L\n 36.2 %\n 7.6 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n WBC\n 18.6\n 7.6\n Hct\n 41.9\n 35.6\n 36.2\n Plt\n 162\n 133\n Cr\n 4.7\n 3.3\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n .\n # Sepsis: Mr. has history of MDR bactermias and presents with\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn have now been\n discontined. Linezolid was added yesterdy to cover his previous MRSA\n and VRE. Meropenem has been added to cover his previous MDR E.coli\n and ESBL Klebsiella. will cont with that regimen for now.\n -- cont Linezolid/Meropenem\n -- follow up cultures\n -- trend fever WBC curve\n -- ID consult\n .\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- likely HD tomorrow\n -- may need new line placed if +blood cultures\n .\n # COPD: cont home spiriva, atrovent.\n .\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. Cardiac enzymes sent yesterday and were\n negative, will repeat today. TSH normal\n -- f/u cardiac enzymes\n -- monitor on tele\n -- cont home ASA\n .\n # Depression: cont home Fluoxetine\n .\n # FEN: Renal Diet, replete lytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: PIV\n .\n # Code: Full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2126-01-26 00:00:00.000","description":"Physician Attending Progress Note","row_id":364315,"text":"Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Dialysis today.\n D/c home after PT today\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.1\n HR: 95 (76 - 108) bpm\n BP: 127/70(86) {106/59(66) - 142/118(122)} mmHg\n RR: 18 (13 - 32) insp/min\n SpO2: 76% --poor pleth\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 86 kg\n Height: 66 Inch\n Total In:\n 990 mL\n PO:\n 890 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 490 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 76%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 11.6 g/dL\n 138 K/uL\n 93 mg/dL\n 3.1 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 104 mEq/L\n 140 mEq/L\n 37.2 %\n 4.8 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n 10:40 AM\n WBC\n 18.6\n 7.6\n 6.3\n 4.8\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n 37.2\n Plt\n 162\n 133\n 139\n 138\n Cr\n 4.7\n 3.3\n 3.8\n 3.1\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n 93\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presented with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension....all cultures still neg to date this admission\nsepsis\n resolved, off all abx.\n - Will get surveillance cxs during HD\n - LGI bleed: still has diarrhea, outpt GI w/u.....might need\n proctoscopy once he recovers.\n - COPD: on home meds, small O2 reqmt due to atelectasis, cont IS\n - Afib: rate controlled, not anticoagulated\n - Depression: cont home Fluoxetine\n - FEN: Taking good po, SBP appears at baseline\n - Dispo: walk with pt b4 discharge home...patient upset\nmay go AMA if\n he refuses rehab.\n ICU Care\n Nutrition:\n Comments: good po\n Glycemic Control: stable\n Lines:\n Dialysis Catheter - 12:43 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Code status: Full code\n Disposition :Home once he walks vs rehab\n Total time spent: 35 min\n"},{"category":"Physician ","chartdate":"2126-01-26 00:00:00.000","description":"Physician Resident Progress Note","row_id":364306,"text":"Chief Complaint:\n 24 Hour Events:\n no events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.1\n HR: 87 (76 - 108) bpm\n BP: 107/68(76) {106/59(66) - 142/118(122)} mmHg\n RR: 17 (13 - 32) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 86 kg\n Height: 66 Inch\n Total In:\n 990 mL\n PO:\n 890 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 490 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, OP clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles, not clearing with cough\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, left subclavian HD cath; very mild erythema at\n insertion site\n Labs / Radiology\n 138 K/uL\n 11.6 g/dL\n 93 mg/dL\n 3.1 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 104 mEq/L\n 140 mEq/L\n 37.2 %\n 4.8 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n 10:40 AM\n WBC\n 18.6\n 7.6\n 6.3\n 4.8\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n 37.2\n Plt\n 162\n 133\n 139\n 138\n Cr\n 4.7\n 3.3\n 3.8\n 3.1\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n 93\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\n 2/2 Blood Cx\n NGTD\n Blood Cx\n NGTD\n C. Diff neg\n C. Diff neg\n Assessment and Plan\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n # Culture negative Sepsis: nothing isolated on cultures. All\n antibiotics stopped.\n - will have surveillance cultures as outpatient.\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n # COPD: cont home spiriva, atrovent.\n # Atrial Fibrillation: currently in sinus with frequent ectopy. Afib\n was likely in setting of infection. Patient was ROMI. TSH normal\n -- cont home ASA\n # Depression: cont home Fluoxetine\n # FEN: Renal Diet, replete lytes\n # Prophylaxis: Subcutaneous heparin\n # Access: PIV\n # Code: Full\n # Communication: Patient\n # Disposition: will work with PT one additional time before likely d/c\n to home\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 20 Gauge - 06:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2126-01-26 00:00:00.000","description":"Physician Resident Progress Note","row_id":364307,"text":"Chief Complaint:\n 24 Hour Events:\n no events\n Plan for HD today\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.1\n HR: 87 (76 - 108) bpm\n BP: 107/68(76) {106/59(66) - 142/118(122)} mmHg\n RR: 17 (13 - 32) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 86 kg\n Height: 66 Inch\n Total In:\n 990 mL\n PO:\n 890 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 490 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, OP clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles, not clearing with cough\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, left subclavian HD cath; very mild erythema at\n insertion site\n Labs / Radiology\n 138 K/uL\n 11.6 g/dL\n 93 mg/dL\n 3.1 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 104 mEq/L\n 140 mEq/L\n 37.2 %\n 4.8 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n 10:40 AM\n WBC\n 18.6\n 7.6\n 6.3\n 4.8\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n 37.2\n Plt\n 162\n 133\n 139\n 138\n Cr\n 4.7\n 3.3\n 3.8\n 3.1\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n 93\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\n 2/2 Blood Cx\n NGTD\n Blood Cx\n NGTD\n C. Diff neg\n C. Diff neg\n Assessment and Plan\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n # Culture negative Sepsis: nothing isolated on cultures. All\n antibiotics stopped.\n - will have surveillance cultures as outpatient.\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware, HD today\n # COPD: cont home spiriva, atrovent.\n # Atrial Fibrillation: currently in sinus with frequent ectopy. Afib\n was likely in setting of infection. Patient was ROMI. TSH normal\n -- cont home ASA\n # Depression: cont home Fluoxetine\n # FEN: Renal Diet, replete lytes\n # Prophylaxis: Subcutaneous heparin\n # Access: PIV\n # Code: Full\n # Communication: Patient\n # Disposition: will work with PT one additional time before likely d/c\n to home\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 20 Gauge - 06:00 PM\n Prophylaxis:\n DVT: SC heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: likely DC home post HD and PT eval\n"},{"category":"Physician ","chartdate":"2126-01-26 00:00:00.000","description":"Physician Resident Progress Note","row_id":364309,"text":"Chief Complaint:\n 24 Hour Events:\n no events\n Plan for HD today\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.1\n HR: 87 (76 - 108) bpm\n BP: 107/68(76) {106/59(66) - 142/118(122)} mmHg\n RR: 17 (13 - 32) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 86 kg\n Height: 66 Inch\n Total In:\n 990 mL\n PO:\n 890 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 490 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, OP clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles, not clearing with cough\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, left subclavian HD cath; very mild erythema at\n insertion site\n Labs / Radiology\n 138 K/uL\n 11.6 g/dL\n 93 mg/dL\n 3.1 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 104 mEq/L\n 140 mEq/L\n 37.2 %\n 4.8 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n 10:40 AM\n WBC\n 18.6\n 7.6\n 6.3\n 4.8\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n 37.2\n Plt\n 162\n 133\n 139\n 138\n Cr\n 4.7\n 3.3\n 3.8\n 3.1\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n 93\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\n 2/2 Blood Cx\n NGTD\n Blood Cx\n NGTD\n C. Diff neg\n C. Diff neg\n Assessment and Plan\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n # Culture negative Sepsis: nothing isolated on cultures. All\n antibiotics stopped.\n - will have surveillance cultures as outpatient.\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware, HD today\n # COPD: cont home spiriva, atrovent.\n # Atrial Fibrillation: currently in sinus with frequent ectopy. Afib\n was likely in setting of infection. Patient was ROMI. TSH normal\n -- cont home ASA\n # Depression: cont home Fluoxetine\n # FEN: Renal Diet, replete lytes\n # Prophylaxis: Subcutaneous heparin\n # Access: PIV\n # Code: Full\n # Communication: Patient\n # Disposition: will work with PT one additional time before likely d/c\n to home\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 20 Gauge - 06:00 PM\n Prophylaxis:\n DVT: SC heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: likely DC home post HD and PT eval\n ------ Protected Section ------\n Called Hospital Microbiology lab\n Blood Cx drawn on\n finalized as no growth X 5days today.\n ------ Protected Section Addendum Entered By: , MD\n on: 13:34 ------\n"},{"category":"Nursing","chartdate":"2126-01-22 00:00:00.000","description":"Nursing Progress Note","row_id":363632,"text":"This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\n vomiting and weakness. Patient went to lunch today with his wife and\n began to feel weak, +lightheadedness. He then had nausea with one\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\n of diarrhea since that time, non-bloody, no melena. He denies any\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\n hematuria, urinary frequency or back pain. he does report abdominal\n cramping with his diarrhea today. Wife became worried at the restaurant\n and called EMS. He was taken to hospital and BPs noted to\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\n IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nutrition","chartdate":"2126-01-25 00:00:00.000","description":"Clinical Nutrition Note","row_id":364130,"text":"Comments:\n 82 year old male with history of ESRD on HD, afib/flutter, CVA x 2\n presenting with n/v/d and weakness in the setting of hypotension and\n leukocytosis. Patient\ns diet was advanced to Renal Diet and patient is\n tolerating with good PO intake. Noted possible plans for d/c. Will\n continue to follow. Recommend encouraging PO intake PRN and adding\n supplements if PO intake decreases.\n 13:42\n"},{"category":"Physician ","chartdate":"2126-01-25 00:00:00.000","description":"Physician Attending Progress Note","row_id":364133,"text":"Chief Complaint: shock resolved\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n none, stable\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 08:46 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.2\nC (97.2\n HR: 96 (76 - 105) bpm\n BP: 124/78(87) {91/58(66) - 142/90(97)} mmHg\n RR: 19 (14 - 24) insp/min\n SpO2: 93%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 1,154 mL\n PO:\n 720 mL\n TF:\n IVF:\n 434 mL\n Blood products:\n Total out:\n 3,300 mL\n 100 mL\n Urine:\n 300 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,146 mL\n -100 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ////\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles new since yesterday.\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 11.8 g/dL\n 139 K/uL\n 84 mg/dL\n 3.8 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 6.3 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n WBC\n 18.6\n 7.6\n 6.3\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n Plt\n 162\n 133\n 139\n Cr\n 4.7\n 3.3\n 3.8\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension....all cultures still neg to date this admission\nsepsis\n resolved, off all abx.\n - Will get surveillance cxs during HD\n - LGI bleed: still has diarrhea, outpt GI w/u.....might need\n proctoscopy once he recovers.\n - COPD: on home meds, small O2 reqmt due to atelectasis, cont IS\n - Afib: rate controlled, not anticoagulated\n - Depression: cont home Fluoxetine\n - FEN: Taking good po, SBP appears at baseline\n - Dispo: walk with pt b4 discharge home...patient upset\nmay go AMA if\n he refuses rehab.\n ICU Care\n Nutrition:\n Comments: good po\n Glycemic Control: stable\n Lines:\n Dialysis Catheter - 12:43 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Code status: Full code\n Disposition :Home once he walks vs rehab, PT c/s, SW input\n Total time spent: 35 min\n"},{"category":"Rehab Services","chartdate":"2126-01-25 00:00:00.000","description":"Physical Therapy Evaluation Note","row_id":364136,"text":"Attending Physician:\n date: \n Medical Diagnosis / ICD 9: /\n Reason of :\n History of Present Illness / Subjective Complaint: 82 yo M with PMH\n significant for ESRD on HD, Atrial Fibrillation/Flutter, C.diff\n colitis, CVA x 2 with residual right sided weakness, CAD s/p MI,\n diastolic CHF with EF 60%, klebsiella urosepsis, multi-drug resistant\n E.Coli Sepsis, and MRSA Sepsis who presented to Hospital\n with N/V/D and weakness. At OSH, SBPs were noted to be in the 70s\n and 80s. He was then transferred to for further care of\n probable sepsis. Upon arrival to ED, his VS were stable but he was\n noted to have a lactate of 4.1. He was then transferred to the MICU for\n further management.\n Past Medical / Surgical History: LUE fistulagram , -Multiple\n UTIs, including VRE and klebsiella.\n - Atrial fibrillation\n - h/o GI bleed, diverticulitis\n - C. Diff colitis\n - CVA years ago w/ right-sided weakness; second stroke 5 years\n ago\n - h/o nephrolithiasis w/ stent and nephrostomy tube (now removed)\n - CAD s/p MI\n - sleep apnea not on cpap\n - depression\n - PFTs with mild restrictive ventilatory defect\n -Anemia with h/o iron deficiency\n Medications: Ondansetron, Heparin\n Radiology: cxr: Moderate cardiomegaly without signs of overhydration.\n Retrocardiac atelectasis. Potential minimal left-sided pleural\n effusion. Unchanged position of the left-sided central venous access\n line\n Labs:\n 37.2\n 11.6\n 138\n 4.8\n [image002.jpg]\n Other labs:\n Activity Orders: OOB c A\n Social / Occupational History: Lives with wife, dtr lives down stairs\n Living Environment: Private home with electric chair lift\n Prior Functional Status / Activity Level: PTA amb short household\n distances with RW, and R AFO, has w/c for distance.\n Objective Test\n Arousal / Attention / Cognition / Communication: A and O x 3\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 102\n 126/68\n 96% 2L\n Rest\n /\n Sit\n /\n Activity\n 126-156\n 136/72\n 28\n 90% 2L\n Stand\n /\n Recovery\n 110\n 139/110\n 16\n 98% 2L\n Total distance walked: 30'x2\n Minutes: 5'\n Pulmonary Status: Nonproductive cough, rapid shallow breathing pattern\n Integumentary / Vascular: L midline, multiple areas of ecchymosis on B\n UE\n Sensory Integrity: Intact to LT t/o\n Pain / Limiting Symptoms: no reports of pain t/o\n Posture: increased thoracic kyphosis\n Range of Motion\n Muscle Performance\n B UE and LE grossly WFL, R DF to approx neutral\n B UE > \n L LE > 3+/5\n R LE > x DF\n Motor Function:\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt ambulated 30'x 2 with seated rest, flexed posture,\n increased lateral sway. rapid fatigue. distance limited by fatigue and\n HR increase to 150's.\n AFO donned for ambulation with Min A\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n T\n\n\n Transfer:\n\n\n T\n\n\n Sit to Stand:\n\n\n T\n\n\n Ambulation:\n\n T\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Pt has good sitting balance, fair static and dynamic standing\n balance c RW\n Education / Communication: Pt status discussed with RN and MD. MD made\n aware of HR with activity. Pt and wife educated on role of PT and\n safety concerns regarding home d/c.\n Intervention:\n Other:\n Diagnosis:\n 1.\n Balance, Impaired\n 2.\n Gait, Impaired\n 3.\n Knowledge, Impaired\n 4.\n Muscle Performance, Impaired\n 5.\n Transfers, Impaired\n 6.\n Respiration / Gas Exchange, Impaired\n Clinical impression / Prognosis: 82 yo m admitted with hypotension and\n n/v/d presents with above impairments c/w deconditioining. Pts gait\n impairments are likely close to baseline given h/o CVA and residual R\n LE weakness. Feel he is not Independent and is at not safe for d/c home\n at this time given his endurance, and rehab may be beneficial. Pt and\n family do not wish d/c to rehab, they are in agreement to continue with\n inpatient PT in an attempt to optimize safety prior to d/c home with\n services. Pt should be ambulating with nursing using RW to increase\n activity tolerance.\n Goals\n Time frame: 1 wk\n 1.\n I bed mobility\n 2.\n I amb > 150' c RW\n 3.\n I transfers c RW\n 4.\n 5.\n 6.\n Anticipated Discharge: Home without PT\n Treatment :\n Frequency / Duration: 3-5x/wk\n f/u gait and mobility progress, formal balance assessment.\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"},{"category":"Physician ","chartdate":"2126-01-25 00:00:00.000","description":"Physician Resident Progress Note","row_id":364140,"text":"Chief Complaint:\n 24 Hour Events:\n No Events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: feels well, no complaints\n Flowsheet Data as of 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.6\nC (96\n HR: 96 (76 - 99) bpm\n BP: 124/77(89) {91/56(66) - 127/90(96)} mmHg\n RR: 19 (14 - 24) insp/min\n SpO2: 96%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 1,154 mL\n PO:\n 720 mL\n TF:\n IVF:\n 434 mL\n Blood products:\n Total out:\n 3,300 mL\n 100 mL\n Urine:\n 300 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,146 mL\n -100 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, OP clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles, not clearing with cough\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, left subclavian HD cath; very mild erythema at\n insertion site\n Labs / Radiology\n 139 K/uL\n 11.8 g/dL\n 84 mg/dL\n 3.8 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 6.3 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n WBC\n 18.6\n 7.6\n 6.3\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n Plt\n 162\n 133\n 139\n Cr\n 4.7\n 3.3\n 3.8\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n # Culture negative Sepsis: nothing isolated on cultures. All\n antibiotics stopped.\n - will have surveillance cultures as outpatient.\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n # COPD: cont home spiriva, atrovent.\n # Atrial Fibrillation: currently in sinus with frequent ectopy. Afib\n was likely in setting of infection. Patient was ROMI. TSH normal\n -- cont home ASA\n # Depression: cont home Fluoxetine\n # FEN: Renal Diet, replete lytes\n # Prophylaxis: Subcutaneous heparin\n # Access: PIV\n # Code: Full\n # Communication: Patient\n # Disposition: will work with PT one additional time before likely d/c\n to home\n"},{"category":"Physician ","chartdate":"2126-01-26 00:00:00.000","description":"Physician Resident Progress Note","row_id":364274,"text":"Chief Complaint:\n 24 Hour Events:\n no events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.1\n HR: 87 (76 - 108) bpm\n BP: 107/68(76) {106/59(66) - 142/118(122)} mmHg\n RR: 17 (13 - 32) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 86 kg\n Height: 66 Inch\n Total In:\n 990 mL\n PO:\n 890 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 490 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 138 K/uL\n 11.6 g/dL\n 93 mg/dL\n 3.1 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 104 mEq/L\n 140 mEq/L\n 37.2 %\n 4.8 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n 10:40 AM\n WBC\n 18.6\n 7.6\n 6.3\n 4.8\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n 37.2\n Plt\n 162\n 133\n 139\n 138\n Cr\n 4.7\n 3.3\n 3.8\n 3.1\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n 93\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n # Culture negative Sepsis: nothing isolated on cultures. All\n antibiotics stopped.\n - will have surveillance cultures as outpatient.\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n # COPD: cont home spiriva, atrovent.\n # Atrial Fibrillation: currently in sinus with frequent ectopy. Afib\n was likely in setting of infection. Patient was ROMI. TSH normal\n -- cont home ASA\n # Depression: cont home Fluoxetine\n # FEN: Renal Diet, replete lytes\n # Prophylaxis: Subcutaneous heparin\n # Access: PIV\n # Code: Full\n # Communication: Patient\n # Disposition: will work with PT one additional time before likely d/c\n to home\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 20 Gauge - 06:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2126-01-26 00:00:00.000","description":"Physician Resident Progress Note","row_id":364275,"text":"Chief Complaint:\n 24 Hour Events:\n no events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.1\n HR: 87 (76 - 108) bpm\n BP: 107/68(76) {106/59(66) - 142/118(122)} mmHg\n RR: 17 (13 - 32) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 86 kg\n Height: 66 Inch\n Total In:\n 990 mL\n PO:\n 890 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 490 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 138 K/uL\n 11.6 g/dL\n 93 mg/dL\n 3.1 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 104 mEq/L\n 140 mEq/L\n 37.2 %\n 4.8 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n 10:40 AM\n WBC\n 18.6\n 7.6\n 6.3\n 4.8\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n 37.2\n Plt\n 162\n 133\n 139\n 138\n Cr\n 4.7\n 3.3\n 3.8\n 3.1\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n 93\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\n 2/2 Blood Cx\n NGTD\n Blood Cx\n NGTD\n C. Diff neg\n C. Diff neg\n Assessment and Plan\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n # Culture negative Sepsis: nothing isolated on cultures. All\n antibiotics stopped.\n - will have surveillance cultures as outpatient.\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n # COPD: cont home spiriva, atrovent.\n # Atrial Fibrillation: currently in sinus with frequent ectopy. Afib\n was likely in setting of infection. Patient was ROMI. TSH normal\n -- cont home ASA\n # Depression: cont home Fluoxetine\n # FEN: Renal Diet, replete lytes\n # Prophylaxis: Subcutaneous heparin\n # Access: PIV\n # Code: Full\n # Communication: Patient\n # Disposition: will work with PT one additional time before likely d/c\n to home\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 20 Gauge - 06:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2126-01-26 00:00:00.000","description":"Physician Attending Progress Note","row_id":364278,"text":"Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.1\n HR: 95 (76 - 108) bpm\n BP: 127/70(86) {106/59(66) - 142/118(122)} mmHg\n RR: 18 (13 - 32) insp/min\n SpO2: 76%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 86 kg\n Height: 66 Inch\n Total In:\n 990 mL\n PO:\n 890 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 490 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 76%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles new since yesterday.\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 11.6 g/dL\n 138 K/uL\n 93 mg/dL\n 3.1 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 104 mEq/L\n 140 mEq/L\n 37.2 %\n 4.8 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n 10:40 AM\n WBC\n 18.6\n 7.6\n 6.3\n 4.8\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n 37.2\n Plt\n 162\n 133\n 139\n 138\n Cr\n 4.7\n 3.3\n 3.8\n 3.1\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n 93\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension....all cultures still neg to date this admission\nsepsis\n resolved, off all abx.\n - Will get surveillance cxs during HD\n - LGI bleed: still has diarrhea, outpt GI w/u.....might need\n proctoscopy once he recovers.\n - COPD: on home meds, small O2 reqmt due to atelectasis, cont IS\n - Afib: rate controlled, not anticoagulated\n - Depression: cont home Fluoxetine\n - FEN: Taking good po, SBP appears at baseline\n - Dispo: walk with pt b4 discharge home...patient upset\nmay go AMA if\n he refuses rehab.\n ICU Care\n Nutrition:\n Comments: good po\n Glycemic Control: stable\n Lines:\n Dialysis Catheter - 12:43 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Code status: Full code\n Disposition :Home once he walks vs rehab, PT c/s, SW input\n Total time spent: 35 min\n"},{"category":"Physician ","chartdate":"2126-01-26 00:00:00.000","description":"Physician Attending Progress Note","row_id":364293,"text":"Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Dialysis today.\n D/c home after PT today\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.1\n HR: 95 (76 - 108) bpm\n BP: 127/70(86) {106/59(66) - 142/118(122)} mmHg\n RR: 18 (13 - 32) insp/min\n SpO2: 76% --poor pleth\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 86 kg\n Height: 66 Inch\n Total In:\n 990 mL\n PO:\n 890 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 490 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 76%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 11.6 g/dL\n 138 K/uL\n 93 mg/dL\n 3.1 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 104 mEq/L\n 140 mEq/L\n 37.2 %\n 4.8 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n 10:40 AM\n WBC\n 18.6\n 7.6\n 6.3\n 4.8\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n 37.2\n Plt\n 162\n 133\n 139\n 138\n Cr\n 4.7\n 3.3\n 3.8\n 3.1\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n 93\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presented with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension....all cultures still neg to date this admission\nsepsis\n resolved, off all abx.\n - Will get surveillance cxs during HD\n - LGI bleed: still has diarrhea, outpt GI w/u.....might need\n proctoscopy once he recovers.\n - COPD: on home meds, small O2 reqmt due to atelectasis, cont IS\n - Afib: rate controlled, not anticoagulated\n - Depression: cont home Fluoxetine\n - FEN: Taking good po, SBP appears at baseline\n - Dispo: walk with pt b4 discharge home...patient upset\nmay go AMA if\n he refuses rehab.\n ICU Care\n Nutrition:\n Comments: good po\n Glycemic Control: stable\n Lines:\n Dialysis Catheter - 12:43 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Code status: Full code\n Disposition :Home once he walks vs rehab\n Total time spent: 35 min\n"},{"category":"Nursing","chartdate":"2126-01-22 00:00:00.000","description":"Nursing Progress Note","row_id":363706,"text":"This is an 82 year old male with hx of ESRD on HD, Atrial\n Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of\n Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with\n one day of nausea, vomiting and weakness. Patient went to lunch today\n with his wife and began to feel weak, +lightheadedness. He then had\n nausea with one episode of non-bloody emesis, no coffee ground. He\n reports 3 episodes of diarrhea since that time, non-bloody, no melena.\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\n dysuria, hematuria, urinary frequency or back pain. He does report\n abdominal cramping with his diarrhea today. Wife became worried at the\n restaurant and called EMS. He was taken to hospital and\n BPs noted to be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x\n 1, Vanco 1gm IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Hypotension (not Shock)\n Assessment:\n Afebrile with max temp 97.8. sbp down to 88 this afternoon. Hr 90\n afib with lots of ectopi. Occasionally in bigemony.\n Action:\n Given a 500cc ns bolus for sbp 88. zosyn dc\nd and placed on linezolid\n and meropenum. Dr made aware of frequent ectopi.\n Response:\n Sbp up to the 90\ns with map>60.\n Plan:\n Cont antibiodics as ordered. Follow up on cult result.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Min uo that is cloudy looking.\n Action:\n Hd done today. Only 200cc of fluid removed.\n Response:\n Stable hd run.\n Plan:\n Renal following.\n Access- patient has 2 peripheral iv\ns in right arm that has old non\n functioning av fistula. Unable to place iv or draw bloods in right arm.\n Dr made aware. Order placed for iv to place picc in arm.\n Order placed late in day.\n wife here most of day. Updated by this nurse, Dr and\n Dr .\n"},{"category":"Nursing","chartdate":"2126-01-22 00:00:00.000","description":"Nursing Progress Note","row_id":363708,"text":"This is an 82 year old male with hx of ESRD on HD, Atrial\n Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of\n Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with\n one day of nausea, vomiting and weakness. Patient went to lunch today\n with his wife and began to feel weak, +lightheadedness. He then had\n nausea with one episode of non-bloody emesis, no coffee ground. He\n reports 3 episodes of diarrhea since that time, non-bloody, no melena.\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\n dysuria, hematuria, urinary frequency or back pain. He does report\n abdominal cramping with his diarrhea today. Wife became worried at the\n restaurant and called EMS. He was taken to hospital and\n BPs noted to be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x\n 1, Vanco 1gm IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Hypotension (not Shock)\n Assessment:\n Afebrile with max temp 97.8. sbp down to 88 this afternoon. Hr 90\n afib with lots of ectopi. Occasionally in bigemony.\n Action:\n Given a 500cc ns bolus for sbp 88. zosyn dc\nd and placed on linezolid\n and meropenum. Dr made aware of frequent ectopi.\n Response:\n Sbp up to the 90\ns with map>60.\n Plan:\n Cont antibiodics as ordered. Follow up on cult result.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Min uo that is cloudy looking.\n Action:\n Hd done today. Only 200cc of fluid removed.\n Response:\n Stable hd run.\n Plan:\n Renal following.\n Access- patient has 2 peripheral iv\ns in right arm that has old non\n functioning av fistula. Unable to place iv or draw bloods in right arm.\n Dr made aware. Order placed for iv to place picc in arm.\n Order placed late in day.\n wife here most of day. Updated by this nurse, Dr and\n Dr .\n ------ Protected Section ------\n Pleth very difficult to obtain on this patient. Best off left\n foot. Of note right foot colder than left. Per patient and wife this is\n baseline for him. Toes on right foot reddish blue. This is also his\n baseline per patient\n ------ Protected Section Addendum Entered By: , RN\n on: 17:57 ------\n"},{"category":"Nursing","chartdate":"2126-01-22 00:00:00.000","description":"Nursing Progress Note","row_id":363626,"text":"This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\n vomiting and weakness. Patient went to lunch today with his wife and\n began to feel weak, +lightheadedness. He then had nausea with one\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\n of diarrhea since that time, non-bloody, no melena. He denies any\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\n hematuria, urinary frequency or back pain. he does report abdominal\n cramping with his diarrhea today. Wife became worried at the restaurant\n and called EMS. He was taken to hospital and BPs noted to\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\n IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n"},{"category":"Nursing","chartdate":"2126-01-22 00:00:00.000","description":"Nursing Progress Note","row_id":363704,"text":"This is an 82 year old male with hx of ESRD on HD, Atrial\n Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of\n Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with\n one day of nausea, vomiting and weakness. Patient went to lunch today\n with his wife and began to feel weak, +lightheadedness. He then had\n nausea with one episode of non-bloody emesis, no coffee ground. He\n reports 3 episodes of diarrhea since that time, non-bloody, no melena.\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\n dysuria, hematuria, urinary frequency or back pain. He does report\n abdominal cramping with his diarrhea today. Wife became worried at the\n restaurant and called EMS. He was taken to hospital and\n BPs noted to be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x\n 1, Vanco 1gm IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Hypotension (not Shock)\n Assessment:\n Afebrile with max temp 97.8. sbp down to 88 this afternoon.\n Action:\n Given a 500cc ns bolus for sbp 88. zosyn dc\nd and placed on linezolid\n and meropenum.\n Response:\n Sbp up to the 90\ns with map>60.\n Plan:\n Cont antibiodics as ordered. Follow up on cult result.\n"},{"category":"Nursing","chartdate":"2126-01-23 00:00:00.000","description":"Nursing Progress Note","row_id":363761,"text":"This is an 82 year old male with hx of ESRD on HD, Atrial\n Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of\n Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with\n one day of nausea, vomiting and weakness. Patient went to lunch today\n with his wife and began to feel weak, +lightheadedness. He then had\n nausea with one episode of non-bloody emesis, no coffee ground. He\n reports 3 episodes of diarrhea since that time, non-bloody, no melena.\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\n dysuria, hematuria, urinary frequency or back pain. He does report\n abdominal cramping with his diarrhea today. Wife became worried at the\n restaurant and called EMS. He was taken to hospital and\n BPs noted to be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x\n 1, Vanco 1gm IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Hypotension (not Shock)\n Assessment:\n Pt\ns map occ would dip down less than 60 while sleeping. When awake\n map\ns greater than 60. hr in afib with rates in the 80\ns with freq\n pvc\n Action:\n Pt received a 500cc fluid bolus x 1.\n Response:\n Maps greater than 60. bp would come back up when pt was stimulated or\n woken up.\n Plan:\n Cont to monitor bp and notify md of any drops.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt with foley catheter draining minimal amt\ns of yellow sludgey\n looking urine. Urine also has foul odor.\n Action:\n Pt had a fluid bolus x 1 for low bp\n Response:\n Minimal response to urine output.\n Plan:\n Follow bun/cr, follow culture results. Pt to have picc line placement\n today. Cont with abx\n"},{"category":"Nursing","chartdate":"2126-01-24 00:00:00.000","description":"Nursing Progress Note","row_id":364008,"text":"Difficult IV Access\n Assessment:\n Pt called out to floor but lost peripheral access.\n Action:\n Attempt by RN and IVRNx3 without success.\n Response:\n Floor team refusing to accept pt without access.\n Plan:\n Temporary plan was to have PICC placed in IR but further discussion\n with ID and Renal team led to decision to defer floor transfer and keep\n pt in ICU for observation over night with plan to DC to home in AM if\n stable.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt with CKD on HD T/Th/S. BUN/Cr 24/3.8 this AM.\n Action:\n HD today.\n Response:\n 3L removed with HD.\n Plan:\n Cont with regularly scheduled HD. Renal team following.\n Sepsis without organ dysfunction\n Assessment:\n Pt afebrile. WBC 6.3 this AM. SBP remains >90 today. Cdiff cult\n negative thus far. Urine and blood cultures with no growth to date.\n Action:\n Cont meropenem.\n Response:\n Cultures still with NGTD. Pt remains afebrile with no white count.\n Plan:\n Cont antibiotics as ordered. Monitor for temp spike. Follow up on\n culture results.\n"},{"category":"Nursing","chartdate":"2126-01-24 00:00:00.000","description":"Nursing Progress Note","row_id":364011,"text":"83yo M with extensive PMH including ESRD on HD, CAD s/p MI, CVA x2, and\n multiple hospitalizations for sepsis (kelbsiella, MRSA, VRE, Cdiff) who\n presented with NVD.\n Difficult IV Access\n Assessment:\n Pt called out to floor but lost peripheral access.\n Action:\n Attempt by RN and IVRNx3 without success.\n Response:\n Floor team refusing to accept pt without access.\n Plan:\n Temporary plan was to have PICC placed in IR but further discussion\n with ID and Renal team led to decision to defer floor transfer and keep\n pt in ICU for observation over night with plan to DC to home in AM if\n stable.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt with CKD on HD T/Th/S. BUN/Cr 24/3.8 this AM.\n Action:\n HD today.\n Response:\n 3L removed with HD.\n Plan:\n Cont with regularly scheduled HD. Renal team following.\n Sepsis without organ dysfunction\n Assessment:\n Pt afebrile. WBC 6.3 this AM. SBP remains >90 today. Cdiff cult\n negative thus far. Urine and blood cultures with no growth to date.\n Action:\n All antibiotics DCd per ID recs.\n Response:\n Cultures still with NGTD. Pt remains afebrile with no white count.\n Plan:\n F/U re: culture results, cont to monitor pt for further s/s sepsis.\n"},{"category":"Physician ","chartdate":"2126-01-22 00:00:00.000","description":"Physician Resident Admission Note","row_id":363623,"text":"Chief Complaint:\n HPI:\n History of Present Illness:\n This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\n vomiting and weakness. Patient went to lunch today with his wife and\n began to feel weak, +lightheadedness. He then had nausea with one\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\n of diarrhea since that time, non-bloody, no melena. He denies any\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\n hematuria, urinary frequency or back pain. he does report abdominal\n cramping with his diarrhea today. Wife became worried at the restaurant\n and called EMS. He was taken to hospital and BPs noted to\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\n IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs sent and\n lactate noted to be elevated at 4.1. He was given 3.5 L of NS IVF in\n the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 12:46 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n -Stage V CKD on HD with h/o nephrolithiasis w/ stent and nephrostomy\n tube (AV fistula )\n -Atrial fibrillation/flutter not on coumadin\n -h/o GI bleed, diverticulitis\n -C. Diff colitis\n -CVA years ago w/ right-sided weakness; second CVA 5 years ago\n -CAD s/p MI, diastolic HF EF 60%\n -sleep apnea not on cpap\n -klebsiella(ESBL) urosepsis\n -depression\n -PFTs with mild restrictive ventilatory defect\n -Anemia with h/o iron deficiency\n .\n .\n Home Medications:\n Tiotropium Bromide 18 mcg Capsule daily\n Pantoprazole 40mg daily\n Aspirin 325mg daily\n Fluoxetine 10 mg daily\n Multivitamin\n B Complex-Vitamin C-Folic Acid 1 mg Capsule\n Atrovent MDI 1 puff q4h PRN\n Bisacodyl 5mg PRN\n Docusate 100mg \n Fish Oil\n Lives with wife , h/o smoking PPD for 50 years, quit\n 20 years ago, does not drink alcohol, no drugs.\n Review of systems:\n Flowsheet Data as of 02:26 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.4\nC (95.7\n Tcurrent: 35.4\nC (95.7\n HR: 108 (101 - 108) bpm\n BP: 81/58(64) {81/58(64) - 95/61(112)} mmHg\n RR: 18 (15 - 18) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,600 mL\n PO:\n TF:\n IVF:\n 600 mL\n Blood products:\n Total out:\n 0 mL\n 15 mL\n Urine:\n 15 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,585 mL\n Respiratory\n SpO2: 96%\n Physical Examination\n Vitals: T: 95.7 BP: 98/57 P: 102 R: 18 94% RA\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n [image002.jpg]\n Images:\n CXR: no acute process\n .\n EKG: irregular rate and rhythm, no acute ST or T wave changes\n Assessment and Plan\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n .\n # Sepsis: Mr. has history of MDR bactermias and presents with\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn cover his\n previous MRSA, MDR E.coli and ESBL Klebsiella. will cont with that\n regimen for now.\n -- cont Vanco/Zosyn\n -- D/C CTX\n -- send UA/UCx\n -- repeat lactate\n -- 1L IVF bolus\n -- trend fever WBC curve\n .\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- likely HD tomorrow\n -- may need new line placed if +blood cultures\n .\n # COPD: cont home spiriva, atrovent.\n .\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. will ROMI\n -- cycle cardiac enzymes\n -- monitor on tele\n -- check TSH\n .\n # Depression: cont home Fluoxetine\n .\n # FEN: Renal Diet, replete lytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: peripherals\n .\n # Code: presumed full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition: Regular Renal\n Glycemic Control: None\n Lines:\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer: PPI\n VAP: None\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2126-01-22 00:00:00.000","description":"Physician Resident Admission Note","row_id":363625,"text":"Chief Complaint:\n HPI:\n History of Present Illness:\n This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\n vomiting and weakness. Patient went to lunch today with his wife and\n began to feel weak, +lightheadedness. He then had nausea with one\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\n of diarrhea since that time, non-bloody, no melena. He denies any\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\n hematuria, urinary frequency or back pain. he does report abdominal\n cramping with his diarrhea today. Wife became worried at the restaurant\n and called EMS. He was taken to hospital and BPs noted to\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\n IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs sent and\n lactate noted to be elevated at 4.1. He was given 3.5 L of NS IVF in\n the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 12:46 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n -Stage V CKD on HD with h/o nephrolithiasis w/ stent and nephrostomy\n tube (AV fistula )\n -Atrial fibrillation/flutter not on coumadin\n -h/o GI bleed, diverticulitis\n -C. Diff colitis\n -CVA years ago w/ right-sided weakness; second CVA 5 years ago\n -CAD s/p MI, diastolic HF EF 60%\n -sleep apnea not on cpap\n -klebsiella(ESBL) urosepsis\n -depression\n -PFTs with mild restrictive ventilatory defect\n -Anemia with h/o iron deficiency\n .\n .\n Home Medications:\n Tiotropium Bromide 18 mcg Capsule daily\n Pantoprazole 40mg daily\n Aspirin 325mg daily\n Fluoxetine 10 mg daily\n Multivitamin\n B Complex-Vitamin C-Folic Acid 1 mg Capsule\n Atrovent MDI 1 puff q4h PRN\n Bisacodyl 5mg PRN\n Docusate 100mg \n Fish Oil\n NC\n Lives with wife , h/o smoking PPD for 50 years, quit\n 20 years ago, does not drink alcohol, no drugs.\n Review of systems:\n Flowsheet Data as of 02:26 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.4\nC (95.7\n Tcurrent: 35.4\nC (95.7\n HR: 108 (101 - 108) bpm\n BP: 81/58(64) {81/58(64) - 95/61(112)} mmHg\n RR: 18 (15 - 18) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,600 mL\n PO:\n TF:\n IVF:\n 600 mL\n Blood products:\n Total out:\n 0 mL\n 15 mL\n Urine:\n 15 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,585 mL\n Respiratory\n SpO2: 96%\n Physical Examination\n Vitals: T: 95.7 BP: 98/57 P: 102 R: 18 94% RA\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot,\n dopplerable right pedal pulse, dopplerable right tibial pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 208\n 16.9\n 149\n 4.7\n 33\n 23\n 101\n 4.6\n 144\n 53.9\n 22.2\n [image002.jpg]\n Lactate 4.1.\n Images:\n CXR: no acute process\n .\n EKG: irregular rate and rhythm, no acute ST or T wave changes\n Assessment and Plan\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n .\n # Sepsis: Mr. has history of MDR bactermias and presents with\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn cover his\n previous MRSA, MDR E.coli and ESBL Klebsiella. will cont with that\n regimen for now.\n -- cont Vanco/Zosyn\n -- D/C CTX\n -- send UA/UCx\n -- repeat lactate\n -- repeat CBC, Chem 7\n -- 1L IVF bolus\n -- trend fever WBC curve\n .\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- likely HD tomorrow\n -- may need new line placed if +blood cultures\n .\n # COPD: cont home spiriva, atrovent.\n .\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. will ROMI\n -- cycle cardiac enzymes\n -- monitor on tele\n -- check TSH\n -- cont home ASA\n .\n # Depression: cont home Fluoxetine\n .\n # FEN: Renal Diet, replete lytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: PIV\n .\n # Code: Full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition: Regular Renal\n Glycemic Control: None\n Lines:\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer: PPI\n VAP: None\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n"},{"category":"Nursing","chartdate":"2126-01-24 00:00:00.000","description":"Nursing Progress Note","row_id":363907,"text":"82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n Sepsis without organ dysfunction\n Assessment:\n Wbc down to 7.6. afebrile. Sbp 90 or greater today. Cdiff cult neg.\n urine and bc pending.\n Action:\n Cont on linezolid and meropenum. Team decided not to place picc till\n final cult results back. Id consulted. Survelliance cult x2 done one\n peripheral and one via hd cath line\n Response:\n Bp improved. Afebrile.\n Plan:\n Cont antiobidics as ordered. Monitor for temp spike. Follow up on cult\n Obstructive sleep apnea (OSA)\n Assessment:\n Patient with known hx of sleep apnea. Does not wear bipap at home. Had\n been on home o2 per wife but none in the past week.\n Action:\n Taken off o2 to see how his sats would do.\n Response:\n Sats 92 or greater when awake. Fell to 87% when he fell asleep. O2\n replaced at 1l nc.\n Plan:\n Cont to monitor sats.\n"},{"category":"Nursing","chartdate":"2126-01-25 00:00:00.000","description":"Nursing Progress Note","row_id":364070,"text":"83yo M with extensive PMH including ESRD on HD, CAD s/p MI, CVA x2, and\n multiple hospitalizations for sepsis (kelbsiella, MRSA, VRE, Cdiff) who\n presented with NVD.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt had foley removed earlier last evening and was due to void between\n 8-10pm. Pt was offered the urinal but found pt to be incontinent. Pt\n stated that he was unaware that he was incontinent. Pt also has been\n incontinent of loose brown stool. When asked why he did not ask for a\n bedpan pt stated that it comes out too fast.\n Action:\n Pt checked freq and asked if he could use a urinal but pt stated that\n he did not have to void.\n Response:\n Pt found to be incontinent of urine and stool x 2 during the night . a\n diaper was placed on the pt and aloe vesta cream applied to perianal\n area because it is beginning to look very red.\n Plan:\n Check pt freq and offer bedpan/urinal. No labs drawn this am. Pt is due\n to be discharged today to home. The issue of his incontinence will need\n to be addressed with pt and pt\ns wife.\n Obstructive sleep apnea (OSA)\n Assessment:\n Pt cont to have sleep apnea but o2 sat\ns have remained in the 90\n with 1lnc. Lung sounds clear and diminished at the bases.\n Action:\n Pt turned freq and encouraged deep breathing.\n Response:\n Pt slept well during the night. Maintaining o2 sats in mid to high\n 90\n Plan:\n Keep hob elevated. Discuss bipap at home.\n"},{"category":"Nursing","chartdate":"2126-01-24 00:00:00.000","description":"Nursing Progress Note","row_id":364004,"text":" Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2126-01-22 00:00:00.000","description":"Physician Resident Admission Note","row_id":363680,"text":"Chief Complaint:\n HPI:\n History of Present Illness:\n This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\n vomiting and weakness. Patient went to lunch today with his wife and\n began to feel weak, +lightheadedness. He then had nausea with one\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\n of diarrhea since that time, non-bloody, no melena. He denies any\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\n hematuria, urinary frequency or back pain. he does report abdominal\n cramping with his diarrhea today. Wife became worried at the restaurant\n and called EMS. He was taken to hospital and BPs noted to\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\n IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs sent and\n lactate noted to be elevated at 4.1. He was given 3.5 L of NS IVF in\n the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 12:46 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n -Stage V CKD on HD with h/o nephrolithiasis w/ stent and nephrostomy\n tube (AV fistula )\n -Atrial fibrillation/flutter not on coumadin\n -h/o GI bleed, diverticulitis\n -C. Diff colitis\n -CVA years ago w/ right-sided weakness; second CVA 5 years ago\n -CAD s/p MI, diastolic HF EF 60%\n -sleep apnea not on cpap\n -klebsiella(ESBL) urosepsis\n -depression\n -PFTs with mild restrictive ventilatory defect\n -Anemia with h/o iron deficiency\n .\n .\n Home Medications:\n Tiotropium Bromide 18 mcg Capsule daily\n Pantoprazole 40mg daily\n Aspirin 325mg daily\n Fluoxetine 10 mg daily\n Multivitamin\n B Complex-Vitamin C-Folic Acid 1 mg Capsule\n Atrovent MDI 1 puff q4h PRN\n Bisacodyl 5mg PRN\n Docusate 100mg \n Fish Oil\n NC\n Lives with wife , h/o smoking PPD for 50 years, quit\n 20 years ago, does not drink alcohol, no drugs.\n Review of systems:\n Flowsheet Data as of 02:26 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.4\nC (95.7\n Tcurrent: 35.4\nC (95.7\n HR: 108 (101 - 108) bpm\n BP: 81/58(64) {81/58(64) - 95/61(112)} mmHg\n RR: 18 (15 - 18) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,600 mL\n PO:\n TF:\n IVF:\n 600 mL\n Blood products:\n Total out:\n 0 mL\n 15 mL\n Urine:\n 15 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,585 mL\n Respiratory\n SpO2: 96%\n Physical Examination\n Vitals: T: 95.7 BP: 98/57 P: 102 R: 18 94% RA\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot,\n dopplerable right pedal pulse, dopplerable right tibial pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 208\n 16.9\n 149\n 4.7\n 33\n 23\n 101\n 4.6\n 144\n 53.9\n 22.2\n [image002.jpg]\n Lactate 4.1.\n Images:\n CXR: no acute process\n .\n EKG: irregular rate and rhythm, no acute ST or T wave changes\n Assessment and Plan\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n .\n # Sepsis: Mr. has history of MDR bactermias and presents with\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn cover his\n previous MRSA, MDR E.coli and ESBL Klebsiella. will cont with that\n regimen for now.\n -- cont Vanco/Zosyn\n -- D/C CTX\n -- send UA/UCx\n -- repeat lactate\n -- repeat CBC, Chem 7\n -- 1L IVF bolus\n -- trend fever WBC curve\n .\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- likely HD tomorrow\n -- may need new line placed if +blood cultures\n .\n # COPD: cont home spiriva, atrovent.\n .\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. will ROMI\n -- cycle cardiac enzymes\n -- monitor on tele\n -- check TSH\n -- cont home ASA\n .\n # Depression: cont home Fluoxetine\n .\n # FEN: Renal Diet, replete lytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: PIV\n .\n # Code: Full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition: Regular Renal\n Glycemic Control: None\n Lines:\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer: PPI\n VAP: None\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n ------ Protected Section ------\n Called Micro Lab\n 1 set blood cultures NGTD\n ------ Protected Section Addendum Entered By: , MD\n on: 11:06 ------\n"},{"category":"Physician ","chartdate":"2126-01-22 00:00:00.000","description":"Physician Attending Admission Note - MICU","row_id":363684,"text":"Chief Complaint:\n HPI:\n 82 yo M with hx of\n ESRD on HD\n Atrial Fibrillation/Flutter not anticoagulated\n C.diff, CVA x 2\n CAD s/p MI, diastolic CHF\n presents with weakness/N/V (non bloody)/D x 1 day\n went to OSH\n SBP\n 70-80 improved with fluids\n got Vanc and \n transferred to\n \n lactate 4.1, WBC 22, 90%N, Hct 51\n got Zosyn in ED, 3.5L NS,\n SBP 90s.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n Tiotropium Bromide 18 mcg Capsule daily\n Pantoprazole 40mg daily\n Aspirin 325mg daily\n Fluoxetine 10 mg daily\n Multivitamin\n B Complex-Vitamin C-Folic Acid 1 mg Capsule\n Atrovent MDI 1 puff q4h PRN\n Bisacodyl 5mg PRN\n Docusate 100mg \n Fish Oil\n Past medical history:\n Family history:\n Social History:\n -Stage V CKD on HD with h/o nephrolithiasis w/ stent and nephrostomy\n tube (AV fistula )\n - hx of ESBL Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis, hx\n VRE UTI : since / : associated with HD line\n -Atrial fibrillation/flutter not on coumadin\n -h/o GI bleed, diverticulitis\n -C. Diff colitis\n -CVA years ago w/ right-sided weakness; second CVA 5 years ago\n -CAD s/p MI, diastolic HF EF 60%\n -sleep apnea not on cpap\n -depression\n -PFTs with mild restrictive ventilatory defect\n -Anemia with h/o iron deficiency\n NC\n Occupation:\n Drugs: no\n Tobacco: h/o smoking PPD for 50 years, quit 20 years ago\n Alcohol: no\n Other: Lives with wife in \n Review of systems:\n +lightheadedness\n no melena\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\n dysuria, hematuria, urinary frequency or back pain.\n Flowsheet Data as of 08:24 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 96 (92 - 108) bpm\n BP: 93/64(71) {81/52(62) - 106/67(112)} mmHg\n RR: 19 (15 - 21) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,751 mL\n PO:\n TF:\n IVF:\n 751 mL\n Blood products:\n Total out:\n 0 mL\n 50 mL\n Urine:\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,701 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///20/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, bibasilar\n crackles and dullness to percussion\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, mild tender RUQ, non-distended, bowel sounds present,\n no rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 162 K/uL\n 41.9 %\n 13.8 g/dL\n 129 mg/dL\n 4.7 mg/dL\n 36 mg/dL\n 20 mEq/L\n 105 mEq/L\n 4.7 mEq/L\n 138 mEq/L\n 18.6 K/uL\n [image002.jpg]\n 03:25 AM\n WBC\n 18.6\n Hct\n 41.9\n Plt\n 162\n Cr\n 4.7\n Glucose\n 129\n Other labs: CK / CKMB / Troponin-T:25//, Lactic Acid:1.3 mmol/L,\n Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:5.7 mg/dL\n CXR: small bilateral effusions, small atelectasis R base\n EKG: irreg, afib, no ST-T changes\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension.\n # Shock: likely sepsis.\n Sources: history of MDR bactermias (ESBL Kleb, MRSA, VRE) in urine and\n HD line. He was given Vancomycin 1gm IV x 1, CTX 1gm IV x 2 and Zosyn\n 4.5gm IV x 1.\n - Broaden to Linezolid and Meropenem\n - check cdiff\n - send LFTs (abd pain)\n - f/u urine, line, blood cxs\n .\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- likely HD tomorrow\n -- may need new line placed if +blood cultures\n GI: monitor diarrhea/N/V, check LFTs\n .\n # COPD: cont home spiriva, atrovent. Wean off O2\n .\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. will ROMI\n -- cycle cardiac enzymes\n -- monitor on tele\n -- check TSH\n -- cont home ASA\n # Depression: cont home Fluoxetine\n .\n # FEN: Renal Diet, replete lytes\n # I/O: Bolus per SBP, see how he does with dialysis\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Comments:\n Prophylaxis:\n DVT: sq hep\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments: patient\n Code status: Full\n Disposition: ICU\n Total time spent:\n"},{"category":"Nursing","chartdate":"2126-01-25 00:00:00.000","description":"Nursing Progress Note","row_id":364069,"text":"Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt had foley removed earlier last evening and was due to void between\n 8-10pm. Pt was offered the urinal but found pt to be incontinent. Pt\n stated that he was unaware that he was incontinent. Pt also has been\n incontinent of loose brown stool. When asked why he did not ask for a\n bedpan pt stated that it comes out too fast.\n Action:\n Pt checked freq and asked if he could use a urinal but pt stated that\n he did not have to void.\n Response:\n Pt found to be incontinent of urine and stool x 2 during the night . a\n diaper was placed on the pt and aloe vesta cream applied to perianal\n area because it is beginning to look very red.\n Plan:\n Check pt freq and offer bedpan/urinal. No labs drawn this am. Pt is due\n to be discharged today to home. The issue of his incontinence will need\n to be addressed with pt and pt\ns wife.\n Obstructive sleep apnea (OSA)\n Assessment:\n Pt cont to have sleep apnea but o2 sat\ns have remained in the 90\n with 1lnc. Lung sounds clear and diminished at the bases.\n Action:\n Pt turned freq and encouraged deep breathing.\n Response:\n Pt slept well during the night. Maintaining o2 sats in mid to high\n 90\n Plan:\n Keep hob elevated. Discuss bipap at home.\n"},{"category":"Nursing","chartdate":"2126-01-22 00:00:00.000","description":"Nursing Progress Note","row_id":363668,"text":"This is an 82 year old male with hx of ESRD on HD, Atrial\n Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of\n Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with\n one day of nausea, vomiting and weakness. Patient went to lunch today\n with his wife and began to feel weak, +lightheadedness. He then had\n nausea with one episode of non-bloody emesis, no coffee ground. He\n reports 3 episodes of diarrhea since that time, non-bloody, no melena.\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\n dysuria, hematuria, urinary frequency or back pain. He does report\n abdominal cramping with his diarrhea today. Wife became worried at the\n restaurant and called EMS. He was taken to hospital and\n BPs noted to be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x\n 1, Vanco 1gm IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2126-01-22 00:00:00.000","description":"Physician Attending Admission Note - MICU","row_id":363670,"text":"Chief Complaint:\n HPI:\n 82 yo M with hx of\n ESRD on HD\n Atrial Fibrillation/Flutter not anticoagulated\n C.diff, CVA x 2\n CAD s/p MI, diastolic CHF\n presents with weakness/N/V (non bloody)/D x 1 day\n went to OSH\n SBP\n 70-80 improved with fluids\n got Vanc and \n transferred to\n \n lactate 4.1, WBC 22, 90%N, Hct 51\n got Zosyn in ED, 3.5L NS,\n SBP 90s.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n Tiotropium Bromide 18 mcg Capsule daily\n Pantoprazole 40mg daily\n Aspirin 325mg daily\n Fluoxetine 10 mg daily\n Multivitamin\n B Complex-Vitamin C-Folic Acid 1 mg Capsule\n Atrovent MDI 1 puff q4h PRN\n Bisacodyl 5mg PRN\n Docusate 100mg \n Fish Oil\n Past medical history:\n Family history:\n Social History:\n -Stage V CKD on HD with h/o nephrolithiasis w/ stent and nephrostomy\n tube (AV fistula )\n - hx of ESBL Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis, hx\n VRE UTI : since / : associated with HD line\n -Atrial fibrillation/flutter not on coumadin\n -h/o GI bleed, diverticulitis\n -C. Diff colitis\n -CVA years ago w/ right-sided weakness; second CVA 5 years ago\n -CAD s/p MI, diastolic HF EF 60%\n -sleep apnea not on cpap\n -depression\n -PFTs with mild restrictive ventilatory defect\n -Anemia with h/o iron deficiency\n NC\n Occupation:\n Drugs: no\n Tobacco: h/o smoking PPD for 50 years, quit 20 years ago\n Alcohol: no\n Other: Lives with wife in \n Review of systems:\n +lightheadedness\n no melena\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\n dysuria, hematuria, urinary frequency or back pain.\n Flowsheet Data as of 08:24 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 96 (92 - 108) bpm\n BP: 93/64(71) {81/52(62) - 106/67(112)} mmHg\n RR: 19 (15 - 21) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,751 mL\n PO:\n TF:\n IVF:\n 751 mL\n Blood products:\n Total out:\n 0 mL\n 50 mL\n Urine:\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,701 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///20/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, bibasilar\n crackles and dullness to percussion\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, mild tender RUQ, non-distended, bowel sounds present,\n no rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 162 K/uL\n 41.9 %\n 13.8 g/dL\n 129 mg/dL\n 4.7 mg/dL\n 36 mg/dL\n 20 mEq/L\n 105 mEq/L\n 4.7 mEq/L\n 138 mEq/L\n 18.6 K/uL\n [image002.jpg]\n 03:25 AM\n WBC\n 18.6\n Hct\n 41.9\n Plt\n 162\n Cr\n 4.7\n Glucose\n 129\n Other labs: CK / CKMB / Troponin-T:25//, Lactic Acid:1.3 mmol/L,\n Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:5.7 mg/dL\n CXR: small bilateral effusions, small atelectasis R base\n EKG: irreg, afib, no ST-T changes\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension.\n # Shock: likely sepsis.\n Sources: history of MDR bactermias (ESBL Kleb, MRSA, VRE) in urine and\n HD line. He was given Vancomycin 1gm IV x 1, CTX 1gm IV x 2 and Zosyn\n 4.5gm IV x 1.\n - Broaden to Linezolid and Meropenem\n - check cdiff\n - send LFTs (abd pain)\n - f/u urine, line, blood cxs\n .\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- likely HD tomorrow\n -- may need new line placed if +blood cultures\n GI: monitor diarrhea/N/V, check LFTs\n .\n # COPD: cont home spiriva, atrovent. Wean off O2\n .\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. will ROMI\n -- cycle cardiac enzymes\n -- monitor on tele\n -- check TSH\n -- cont home ASA\n # Depression: cont home Fluoxetine\n .\n # FEN: Renal Diet, replete lytes\n # I/O: Bolus per SBP, see how he does with dialysis\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Comments:\n Prophylaxis:\n DVT: sq hep\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments: patient\n Code status: Full\n Disposition: ICU\n Total time spent:\n"},{"category":"Nursing","chartdate":"2126-01-23 00:00:00.000","description":"Nursing Progress Note","row_id":363838,"text":"82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n Sepsis without organ dysfunction\n Assessment:\n Wbc down to 7.6. afebrile. Sbp 90 or greater today. Cdiff cult neg.\n urine and bc pending.\n Action:\n Cont on linezolid and meropenum. Team decided not to place picc till\n final cult results back. Id consulted. Survelliance cult x2 done one\n peripheral and one via hd cath line\n Response:\n Bp improved. Afebrile.\n Plan:\n Cont antiobidics as ordered. Monitor for temp spike. Follow up on cult\n Obstructive sleep apnea (OSA)\n Assessment:\n Patient with known hx of sleep apnea. Does not wear bipap at home. Had\n been on home o2 per wife but none in the past week.\n Action:\n Taken off o2 to see how his sats would do.\n Response:\n Sats 92 or greater when awake. Fell to 87% when he fell asleep. O2\n replaced at 1l nc.\n Plan:\n Cont to monitor sats.\n wife in to visit. Updated on plan of care.\n Activity.- pt consult placed. Patient s/p cva with residual right sided\n weakness. Uses walker at home. OOb to chair with assist of 2. Tolerated\n well.\n"},{"category":"Rehab Services","chartdate":"2126-01-24 00:00:00.000","description":"Generic Note","row_id":363990,"text":"TITLE:\n Rehab Services Physical Therapy:\n Consult received and appreciated. Attempted to see patient this\n afternoon for evaluation, and mobilization. Pt declined PT intervention\n at this time. Educated patient on the role of Physical Therapy and\n importance of increasing time OOB. We will f/u as able for evaluation.\n Thank you. PT \n"},{"category":"Nursing","chartdate":"2126-01-26 00:00:00.000","description":"Nursing Progress Note","row_id":364236,"text":"Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Stable vital signs, no BM and not voided in this shift.\n Action:\n Pt slept through night .\n Response:\n Pt found to be incontinent of urine and stool x 2 during the night . a\n diaper was placed on the pt and aloe vesta cream applied to perianal\n area because it is beginning to look very red.\n Plan:\n Check pt freq and offer bedpan/urinal. No labs drawn this am. Pt is due\n to be discharged today to home. The issue of his incontinence will need\n to be addressed with pt and pt\ns wife.\n Obstructive sleep apnea (OSA)\n Assessment:\n Pt cont to have sleep apnea but o2 sat\ns have remained in the 90\n with 1lnc. Lung sounds clear and diminished at the bases.\n Action:\n Pt turned freq and encouraged deep breathing.\n Response:\n Pt slept well during the night. Maintaining o2 sats in mid to high\n 90\n Plan:\n Keep hob elevated. Discuss bipap at home.\n"},{"category":"Physician ","chartdate":"2126-01-24 00:00:00.000","description":"Physician Attending Progress Note","row_id":363976,"text":"Chief Complaint: Septic shock\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ID agreed with current abx\n Hct stable with guiac + stools and diarrhea overnight. Cdiff neg.\n SBP stable\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.4\nC (95.8\n HR: 82 (77 - 94) bpm\n BP: 98/64(70) {91/52(63) - 118/80(85)} mmHg\n RR: 19 (11 - 25) insp/min\n SpO2: 95%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 2,240 mL\n 647 mL\n PO:\n 800 mL\n 240 mL\n TF:\n IVF:\n 1,440 mL\n 407 mL\n Blood products:\n Total out:\n 335 mL\n 175 mL\n Urine:\n 335 mL\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,905 mL\n 472 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles new since yesterday.\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 11.8 g/dL\n 139 K/uL\n 84 mg/dL\n 3.8 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 6.3 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n WBC\n 18.6\n 7.6\n 6.3\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n Plt\n 162\n 133\n 139\n Cr\n 4.7\n 3.3\n 3.8\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\n Microbiology: All cxs: ngtd\n Urine: yeast\n Assessment and Plan\n OBSTRUCTIVE SLEEP APNEA (OSA)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension....all cultures still neg to date this admission.\n # Shock: likely sepsis from urine..potivive UA but grew only yeast. On\n Linezolid and Meropenem. D/c per ID recs since all cxs neg. D/c foley\n # ESRD on HD: Patient on T/Th/Sat dialysis. HD line site with mild\n erythema but non tender\n # LGI bleed: diarrhea overnight. Still blood tinged. GI\n consult....might need proctoscopy once he recovers. Follow Hct.\n # COPD: cont home spiriva, atrovent. Wean off O2. Hx of OSA, not on\n Rx...watch for progression of crackles. Use Incentive spirometry.\n # Atrial Fibrillation: rate controlled, not anticoagulated\n # Depression: cont home Fluoxetine\n # FEN: Taking good po, SBP appears at baseline\n ICU Care\n Nutrition:\n Comments: good po\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n picc based on decision reg duration of abx per ID\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 min\n"},{"category":"Physician ","chartdate":"2126-01-22 00:00:00.000","description":"Physician Attending Admission Note - MICU","row_id":363667,"text":"Chief Complaint:\n HPI:\n This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\n vomiting and weakness. Patient went to lunch today with his wife and\n began to feel weak, +lightheadedness. He then had nausea with one\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\n of diarrhea since that time, non-bloody, no melena. He denies any\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\n hematuria, urinary frequency or back pain. he does report abdominal\n cramping with his diarrhea today. Wife became worried at the restaurant\n and called EMS. He was taken to hospital and BPs noted to\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\n IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs sent and\n lactate noted to be elevated at 4.1. He was given 3.5 L of NS IVF in\n the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n Tiotropium Bromide 18 mcg Capsule daily\n Pantoprazole 40mg daily\n Aspirin 325mg daily\n Fluoxetine 10 mg daily\n Multivitamin\n B Complex-Vitamin C-Folic Acid 1 mg Capsule\n Atrovent MDI 1 puff q4h PRN\n Bisacodyl 5mg PRN\n Docusate 100mg \n Fish Oil\n Past medical history:\n Family history:\n Social History:\n -Stage V CKD on HD with h/o nephrolithiasis w/ stent and nephrostomy\n tube (AV fistula )\n -Atrial fibrillation/flutter not on coumadin\n -h/o GI bleed, diverticulitis\n -C. Diff colitis\n -CVA years ago w/ right-sided weakness; second CVA 5 years ago\n -CAD s/p MI, diastolic HF EF 60%\n -sleep apnea not on cpap\n -klebsiella(ESBL) urosepsis\n -depression\n -PFTs with mild restrictive ventilatory defect\n -Anemia with h/o iron deficiency\n Occupation:\n Drugs: no\n Tobacco: h/o smoking PPD for 50 years, quit 20 years ago\n Alcohol: no\n Other: Lives with wife \n Review of systems:\n Flowsheet Data as of 08:24 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 96 (92 - 108) bpm\n BP: 93/64(71) {81/52(62) - 106/67(112)} mmHg\n RR: 19 (15 - 21) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,751 mL\n PO:\n TF:\n IVF:\n 751 mL\n Blood products:\n Total out:\n 0 mL\n 50 mL\n Urine:\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,701 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///20/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot,\n dopplerable right pedal pulse, dopplerable right tibial pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 162 K/uL\n 41.9 %\n 13.8 g/dL\n 129 mg/dL\n 4.7 mg/dL\n 36 mg/dL\n 20 mEq/L\n 105 mEq/L\n 4.7 mEq/L\n 138 mEq/L\n 18.6 K/uL\n [image002.jpg]\n 03:25 AM\n WBC\n 18.6\n Hct\n 41.9\n Plt\n 162\n Cr\n 4.7\n Glucose\n 129\n Other labs: CK / CKMB / Troponin-T:25//, Lactic Acid:1.3 mmol/L,\n Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:5.7 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n .\n # Sepsis: Mr. has history of MDR bactermias and presents with\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn cover his\n previous MRSA, MDR E.coli and ESBL Klebsiella. will cont with that\n regimen for now.\n -- cont Vanco/Zosyn\n -- D/C CTX\n -- send UA/UCx\n -- repeat lactate\n -- repeat CBC, Chem 7\n -- 1L IVF bolus\n -- trend fever WBC curve\n .\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- likely HD tomorrow\n -- may need new line placed if +blood cultures\n .\n # COPD: cont home spiriva, atrovent.\n .\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. will ROMI\n -- cycle cardiac enzymes\n -- monitor on tele\n -- check TSH\n -- cont home ASA\n .\n # Depression: cont home Fluoxetine\n .\n # FEN: Renal Diet, replete lytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: PIV\n .\n # Code: Full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n"},{"category":"Nursing","chartdate":"2126-01-23 00:00:00.000","description":"Nursing Progress Note","row_id":363815,"text":"82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n Sepsis without organ dysfunction\n Assessment:\n Wbc down to 7.6. afebrile. Sbp 90 or greater today. Cdiff cult neg.\n urine and bc pending.\n Action:\n Cont on linezolid and meropenum. Team decided not to place picc till\n final cult results back.\n Response:\n Bp improved. Afebrile.\n Plan:\n Cont antiobidics as ordered. Monitor for temp spike. Follow up on cult\n"},{"category":"Nursing","chartdate":"2126-01-23 00:00:00.000","description":"Nursing Progress Note","row_id":363818,"text":"82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n Sepsis without organ dysfunction\n Assessment:\n Wbc down to 7.6. afebrile. Sbp 90 or greater today. Cdiff cult neg.\n urine and bc pending.\n Action:\n Cont on linezolid and meropenum. Team decided not to place picc till\n final cult results back.\n Response:\n Bp improved. Afebrile.\n Plan:\n Cont antiobidics as ordered. Monitor for temp spike. Follow up on cult\n Obstructive sleep apnea (OSA)\n Assessment:\n Patient with known hx of sleep apnea. Does not wear bipap at home. Had\n been on home o2 per wife but none in the past week.\n Action:\n Taken off o2 to see how his sats would do.\n Response:\n Sats 92 or greater when awake. Fell to 87% when he fell asleep. O2\n replaced at 1l nc.\n Plan:\n Cont to monitor sats.\n wife in to visit. Updated on plan of care.\n Activity.- pt consult placed. Patient s/p cva with residual right sided\n weakness. Uses walker at home. OOb to chair with assist of 2. Tolerated\n well.\n"},{"category":"Physician ","chartdate":"2126-01-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":363980,"text":"Chief Complaint: Sepsis\n 24 Hour Events:\n ID consult obtained, continues on Linezolid/Meropenem\n HCT stable, guaiac + stools\n BP stable overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:12 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.6\nC (96.1\n HR: 87 (77 - 94) bpm\n BP: 109/67(75) {90/52(63) - 118/80(85)} mmHg\n RR: 19 (11 - 25) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 2,240 mL\n 353 mL\n PO:\n 800 mL\n TF:\n IVF:\n 1,440 mL\n 353 mL\n Blood products:\n Total out:\n 335 mL\n 140 mL\n Urine:\n 335 mL\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,905 mL\n 213 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 133 K/uL\n 11.2 g/dL\n 89 mg/dL\n 3.3 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 107 mEq/L\n 143 mEq/L\n 36.2 %\n 7.6 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n WBC\n 18.6\n 7.6\n Hct\n 41.9\n 35.6\n 36.2\n Plt\n 162\n 133\n Cr\n 4.7\n 3.3\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n # Sepsis: Mr. has history of MDR bactermias and presented with\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\n were are all concerning for sepsis. He was given Vancomycin 1gm IV x\n 1, CTX 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn have\n now been discontined. Linezolid was added two days ago to cover his\n previous MRSA and VRE. Meropenem has been added to cover his previous\n MDR E.coli and ESBL Klebsiella. ID was consulted yesterday and\n recommended to discontinue his linezolid. Blood cultures from the OSH\n are negative. Blood cultures from here show NGTD. Urine culture shows\n +yeast. .\n -- d/c Linezolid\n -- cont for now\n -- follow up cultures\n -- trend fever WBC curve\n -- f/u ID recs\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- HD today\n -- may need new line placed if +blood cultures.\n # COPD: cont home spiriva, atrovent.\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. Patient was ROMI. TSH normal\n -- cont home ASA\n # Depression: cont home Fluoxetine\n # FEN: Renal Diet, replete lytes\n # Prophylaxis: Subcutaneous heparin\n # Access: PIV\n # Code: Full\n # Communication: Patient\n # Disposition: call out to medical floor\n"},{"category":"Nursing","chartdate":"2126-01-24 00:00:00.000","description":"Nursing Transfer Note","row_id":363982,"text":"82 yo M with PMH significant for ESRD on HD T/Th/S, Atrial\n Fibrillation/Flutter, C.diff colitis, CVA x 2 with residual right sided\n weakness, CAD s/p MI, diastolic CHF with EF 60%, klebsiella urosepsis,\n multi-drug resistant E.Coli Sepsis, and MRSA Sepsis who presented to\n Hospital with N/V/D and weakness. At OSH, SBPs were\n noted to be in the 70s and 80s. He was then transferred to for\n further care of probable sepsis. Upon arrival to ED, his VS were\n stable but he was noted to have a lactate of 4.1. He was then\n transferred to the MICU for further management.\n Sepsis without organ dysfunction\n Assessment:\n Pt afebrile. WBC 6.3 this AM. SBP remains >90 today. Cdiff cult\n negative thus far. Urine and blood cultures with no growth to date.\n Action:\n Cont on linezolid and meropenem.\n Response:\n Plan:\n Cont antibiotics as ordered. Monitor for temp spike. Follow up on\n culture results.\n wife in to visit. Updated on plan of care.\n Activity.- pt consult placed. Patient s/p cva with residual right sided\n weakness. Uses walker at home. OOb to chair with assist of 2. Tolerated\n well.\n"},{"category":"Nursing","chartdate":"2126-01-24 00:00:00.000","description":"Nursing Transfer Note","row_id":363983,"text":"82 yo M with PMH significant for ESRD on HD T/Th/S, Atrial\n Fibrillation/Flutter, C.diff colitis, CVA x 2 with residual right sided\n weakness, CAD s/p MI, diastolic CHF with EF 60%, klebsiella urosepsis,\n multi-drug resistant E.Coli Sepsis, and MRSA Sepsis who presented to\n Hospital with N/V/D and weakness. At OSH, SBPs were\n noted to be in the 70s and 80s. He was then transferred to for\n further care of probable sepsis. Upon arrival to ED, his VS were\n stable but he was noted to have a lactate of 4.1. He was then\n transferred to the MICU for further management.\n Sepsis without organ dysfunction\n Assessment:\n Pt afebrile. WBC 6.3 this AM. SBP remains >90 today. Cdiff cult\n negative thus far. Urine and blood cultures with no growth to date.\n Action:\n Cont meropenem.\n Response:\n Cultures still with NGTD. Pt remains afebrile with no white count.\n Plan:\n Cont antibiotics as ordered. Monitor for temp spike. Follow up on\n culture results.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n SEPSIS\n Code status:\n Height:\n Admission weight:\n 86 kg\n Daily weight:\n 92.6 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia\n CV-PMH: Arrhythmias, CAD, MI\n Additional history: Stage V CKD on HD with h/o nephrolithiasis w/ stent\n and nephrostomy tube (AV fistula ), Atrial fibrillation/flutter not\n on coumadin, h/o GI bleed, diverticulitis ,C. Diff colitis, CVA \n years ago w/ right-sided weakness; second CVA 5 years ago\n -CAD s/p MI, diastolic HF EF 60% , sleep apnea not on cpap,\n klebsiella(ESBL), depression, PFTs with mild restrictive\n ventilatory defect ,\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:91\n D:65\n Temperature:\n 96.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n A Flut (Atrial Flutter)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 1 L/min\n FiO2 set:\n 24h total in:\n 674 mL\n 24h total out:\n 3,280 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 08:01 AM\n Potassium:\n 4.2 mEq/L\n 08:01 AM\n Chloride:\n 106 mEq/L\n 08:01 AM\n CO2:\n 28 mEq/L\n 08:01 AM\n BUN:\n 24 mg/dL\n 08:01 AM\n Creatinine:\n 3.8 mg/dL\n 08:01 AM\n Glucose:\n 84 mg/dL\n 08:01 AM\n Hematocrit:\n 37.2 %\n 08:01 AM\n Finger Stick Glucose:\n 148\n 12:00 PM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU786\n Transferred to: CC704\n Date & time of Transfer: \n"},{"category":"ECG","chartdate":"2126-01-21 00:00:00.000","description":"Report","row_id":118021,"text":"Indeterminate irregular supraventricular rhythm, most likely atrial\nfibrillation with baseline artifact. Compared to the previous tracing\nof multiple abnormalities as previously noted persist without\nmajor change.\n\n"},{"category":"Radiology","chartdate":"2126-01-24 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1060888,"text":" 3:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for evidence of infiltrate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with sepsis\n REASON FOR THIS EXAMINATION:\n Please eval for evidence of infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Sepsis, evaluation of interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Moderate cardiomegaly without signs of overhydration. Retrocardiac\n atelectasis. Potential minimal left-sided pleural effusion. Unchanged\n position of the left-sided central venous access line.\n\n\n"},{"category":"Radiology","chartdate":"2126-01-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1060430,"text":" 11:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: acute change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with sepsis\n REASON FOR THIS EXAMINATION:\n acute change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Sepsis, followup.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the old central venous\n access line has been removed, there is a new double-lumen catheter inserted\n via the left internal jugular vein and projecting with its tip against the\n lateral wall of the superior vena cava. The lung volumes are low, there is a\n small retrocardiac atelectasis, but no evidence of focal parenchymal opacity\n suggestive of pneumonia. No evidence of overhydration. Mild aortic\n tortuosity.\n\n\n"}],"string":"[\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-25 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 364118,\n \"text\": \"Chief Complaint: shock resolved\\n I saw and examined the patient, and was physically present with the ICU\\n Fellow for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n none, stable\\n History obtained from Patient\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Meropenem - 12:57 PM\\n Linezolid - 02:06 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:46 AM\\n Heparin Sodium (Prophylaxis) - 08:46 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:57 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.2\\nC (97.2\\n HR: 96 (76 - 105) bpm\\n BP: 124/78(87) {91/58(66) - 142/90(97)} mmHg\\n RR: 19 (14 - 24) insp/min\\n SpO2: 93%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Total In:\\n 1,154 mL\\n PO:\\n 720 mL\\n TF:\\n IVF:\\n 434 mL\\n Blood products:\\n Total out:\\n 3,300 mL\\n 100 mL\\n Urine:\\n 300 mL\\n 100 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,146 mL\\n -100 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 93%\\n ABG: ////\\n Physical Examination\\n General: Alert, oriented, no acute distress\\n HEENT: Sclera anicteric, MMM, oropharynx dry\\n Neck: supple, JVP not elevated, no LAD\\n Lungs: Bibasilar crackles new since yesterday.\\n CV: normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness, mild guarding RUQ, no organomegaly\\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\\n pulse\\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\\n insertion site, no TTP of inserstion site\\n Labs / Radiology\\n 11.8 g/dL\\n 139 K/uL\\n 84 mg/dL\\n 3.8 mg/dL\\n 28 mEq/L\\n 4.2 mEq/L\\n 24 mg/dL\\n 106 mEq/L\\n 141 mEq/L\\n 37.2 %\\n 6.3 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n 03:45 PM\\n 08:01 AM\\n WBC\\n 18.6\\n 7.6\\n 6.3\\n Hct\\n 41.9\\n 35.6\\n 36.2\\n 37.2\\n Plt\\n 162\\n 133\\n 139\\n Cr\\n 4.7\\n 3.3\\n 3.8\\n TropT\\n 0.05\\n 0.05\\n Glucose\\n 129\\n 89\\n 84\\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\\n Assessment and Plan\\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\\n and hypotension....all cultures still neg to date this admission\\nsepsis\\n resolved, off all abx.\\n - Will get surveillance cxs during HD\\n - LGI bleed: still has diarrhea, outpt GI w/u.....might need\\n proctoscopy once he recovers.\\n - COPD: on home meds, small O2 reqmt due to atelectasis, cont IS\\n - Afib: rate controlled, not anticoagulated\\n - Depression: cont home Fluoxetine\\n - FEN: Taking good po, SBP appears at baseline\\n - Dispo: walk with pt b4 discharge home...patient upset\\nmay go AMA if\\n he refuses rehab.\\n ICU Care\\n Nutrition:\\n Comments: good po\\n Glycemic Control: stable\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n Code status: Full code\\n Disposition :Home once he walks vs rehab, PT c/s, SW input\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-25 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 364095,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n No Events\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin - 08:00 AM\\n Meropenem - 12:57 PM\\n Linezolid - 02:06 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 AM\\n Heparin Sodium (Prophylaxis) - 08:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:18 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 35.6\\nC (96\\n HR: 96 (76 - 99) bpm\\n BP: 124/77(89) {91/56(66) - 127/90(96)} mmHg\\n RR: 19 (14 - 24) insp/min\\n SpO2: 96%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Total In:\\n 1,154 mL\\n PO:\\n 720 mL\\n TF:\\n IVF:\\n 434 mL\\n Blood products:\\n Total out:\\n 3,300 mL\\n 100 mL\\n Urine:\\n 300 mL\\n 100 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,146 mL\\n -100 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 96%\\n ABG: ///28/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 139 K/uL\\n 11.8 g/dL\\n 84 mg/dL\\n 3.8 mg/dL\\n 28 mEq/L\\n 4.2 mEq/L\\n 24 mg/dL\\n 106 mEq/L\\n 141 mEq/L\\n 37.2 %\\n 6.3 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n 03:45 PM\\n 08:01 AM\\n WBC\\n 18.6\\n 7.6\\n 6.3\\n Hct\\n 41.9\\n 35.6\\n 36.2\\n 37.2\\n Plt\\n 162\\n 133\\n 139\\n Cr\\n 4.7\\n 3.3\\n 3.8\\n TropT\\n 0.05\\n 0.05\\n Glucose\\n 129\\n 89\\n 84\\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\\n Assessment and Plan\\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-25 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 364098,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n No Events\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin - 08:00 AM\\n Meropenem - 12:57 PM\\n Linezolid - 02:06 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 AM\\n Heparin Sodium (Prophylaxis) - 08:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:18 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 35.6\\nC (96\\n HR: 96 (76 - 99) bpm\\n BP: 124/77(89) {91/56(66) - 127/90(96)} mmHg\\n RR: 19 (14 - 24) insp/min\\n SpO2: 96%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Total In:\\n 1,154 mL\\n PO:\\n 720 mL\\n TF:\\n IVF:\\n 434 mL\\n Blood products:\\n Total out:\\n 3,300 mL\\n 100 mL\\n Urine:\\n 300 mL\\n 100 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,146 mL\\n -100 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 96%\\n ABG: ///28/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 139 K/uL\\n 11.8 g/dL\\n 84 mg/dL\\n 3.8 mg/dL\\n 28 mEq/L\\n 4.2 mEq/L\\n 24 mg/dL\\n 106 mEq/L\\n 141 mEq/L\\n 37.2 %\\n 6.3 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n 03:45 PM\\n 08:01 AM\\n WBC\\n 18.6\\n 7.6\\n 6.3\\n Hct\\n 41.9\\n 35.6\\n 36.2\\n 37.2\\n Plt\\n 162\\n 133\\n 139\\n Cr\\n 4.7\\n 3.3\\n 3.8\\n TropT\\n 0.05\\n 0.05\\n Glucose\\n 129\\n 89\\n 84\\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\\n Assessment and Plan\\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n # Sepsis: Mr. has history of MDR bactermias and presented with\\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\\n were are all concerning for sepsis. He was given Vancomycin 1gm IV x\\n 1, CTX 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn have\\n now been discontined. Linezolid was added two days ago to cover his\\n previous MRSA and VRE. Meropenem has been added to cover his previous\\n MDR E.coli and ESBL Klebsiella. ID was consulted yesterday and\\n recommended to discontinue his linezolid. Blood cultures from the OSH\\n are negative. Blood cultures from here show NGTD. Urine culture shows\\n +yeast. .\\n -- d/c Linezolid\\n -- cont for now\\n -- follow up cultures\\n -- trend fever WBC curve\\n -- f/u ID recs\\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\\n -- HD today\\n -- may need new line placed if +blood cultures.\\n # COPD: cont home spiriva, atrovent.\\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\\n setting of infection. Patient was ROMI. TSH normal\\n -- cont home ASA\\n # Depression: cont home Fluoxetine\\n # FEN: Renal Diet, replete lytes\\n # Prophylaxis: Subcutaneous heparin\\n # Access: PIV\\n # Code: Full\\n # Communication: Patient\\n # Disposition: call out to medical floor\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 364194,\n \"text\": \"83yo M with extensive PMH including ESRD on HD, CAD s/p MI, CVA x2, and\\n multiple hospitalizations for sepsis (kelbsiella, MRSA, VRE, Cdiff) who\\n presented with NVD.\\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\\n disease)\\n Assessment:\\n Known ESRD,on HD Tu/th/sat,pt had Hd yesterday,voiding yellow urine in\\n small amounts,mg level 1.3,tele with frequent bigeminies and\\n trigeminies,lungs with crackles at base,no iv acess,left chest wall\\n tesio cath,mild redness,as per the pt left arm is saved for AVF\\n Action:\\n Monitored lytes,20g iv line has been inserted by the IV team,receiving\\n mgso4 iv currently\\n Response:\\n Pending,\\n Plan:\\n Plan to do HD in am at HD unit,\\n DIposition:,pt want to go home today inspite of the plan to sent to\\n rehab ,of note pt was incontinant of stool and urine last night and\\n never been out of bed,and refused PT evaluation yesterday,consulted\\n case mgt,PT regarding the disposition in presence of family,pt and\\n family agreed for PT consult,pt did walk with PT and final plan to\\n reevaluate again in the morning and d/c home.&keep the pt overnight in\\n the ICU,pt was continent of urine and stool in this shift,\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 364265,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n no events\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Meropenem - 12:57 PM\\n Linezolid - 02:06 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:46 AM\\n Heparin Sodium (Prophylaxis) - 10:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:11 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98\\n Tcurrent: 36.2\\nC (97.1\\n HR: 87 (76 - 108) bpm\\n BP: 107/68(76) {106/59(66) - 142/118(122)} mmHg\\n RR: 17 (13 - 32) insp/min\\n SpO2: 92%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Height: 66 Inch\\n Total In:\\n 990 mL\\n PO:\\n 890 mL\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 500 mL\\n 0 mL\\n Urine:\\n 500 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 490 mL\\n 0 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 92%\\n ABG: ///28/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 138 K/uL\\n 11.6 g/dL\\n 93 mg/dL\\n 3.1 mg/dL\\n 28 mEq/L\\n 3.9 mEq/L\\n 16 mg/dL\\n 104 mEq/L\\n 140 mEq/L\\n 37.2 %\\n 4.8 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n 03:45 PM\\n 08:01 AM\\n 10:40 AM\\n WBC\\n 18.6\\n 7.6\\n 6.3\\n 4.8\\n Hct\\n 41.9\\n 35.6\\n 36.2\\n 37.2\\n 37.2\\n Plt\\n 162\\n 133\\n 139\\n 138\\n Cr\\n 4.7\\n 3.3\\n 3.8\\n 3.1\\n TropT\\n 0.05\\n 0.05\\n Glucose\\n 129\\n 89\\n 84\\n 93\\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\\n Assessment and Plan\\n BALANCE, IMPAIRED\\n GAIT, IMPAIRED\\n KNOWLEDGE, IMPAIRED\\n MUSCLE PERFORMACE, IMPAIRED\\n TRANSFERS, IMPAIRED\\n RESPIRATION / GAS EXCHANGE, IMPAIRED\\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n 20 Gauge - 06:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 364249,\n \"text\": \"Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\\n disease)\\n Assessment:\\n Stable vital signs, no BM in this shift.\\n Action:\\n Pt slept through night .\\n Response:\\n Pt found to be incontinent of urine @ 0400, perineal area very red\\n aloe vesta cream applied.\\n Plan:\\n No labs drawn this am. Plan to discharge the pt to home after PT/OT\\n consult and HD in am.\\n Obstructive sleep apnea (OSA)\\n Assessment:\\n Pt cont to have sleep apnea, O2 1lt NC sat\\ns droped to 80\\n occasionally but picked upto mid 90\\ns without any intervention. Lung\\n sounds clear and diminished at the bases.\\n Action:\\n Pt turned freq and encouraged deep breathing.\\n Response:\\n Pt slept well during the night. Maintaining o2 sats in mid to high\\n 90\\n Plan:\\n Discuss bipap at home.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 364171,\n \"text\": \"83yo M with extensive PMH including ESRD on HD, CAD s/p MI, CVA x2, and\\n multiple hospitalizations for sepsis (kelbsiella, MRSA, VRE, Cdiff) who\\n presented with NVD.\\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\\n disease)\\n Assessment:\\n Known ESRD,on HD Tu/th/sat,pt had Hd yesterday,voiding yellow urine in\\n small amounts,mg level 1.3,tele with frequent bigeminies and\\n trigeminies,lungs with crackles at base,no iv acess,left chest wall\\n tesio cath,mild redness,as per the pt left arm is saved for AVF\\n Action:\\n Monitored lytes,20g iv line has been inserted by the IV team\\n Response:\\n Pending,\\n Plan:\\n Plan to do HD in am at HD unit,plan to give magnesim IV given diarrhea\\n and poor GI absorption\\n DIposition:,pt want to go home today inspite of the plan to sent to\\n rehab ,of note pt was incontinat of stool and urine last night and\\n never been out of bed,and refused PT evaluation yesterday,consulted\\n case mgt,PT regarding the disposition in presence of family,pt and\\n family agreed for PT consult,pt did walk with PT and final plan to\\n reevaluate again in the morning and d/c home.&keep the pt overnight in\\n the ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 363657,\n \"text\": \"This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\\n vomiting and weakness. Patient went to lunch today with his wife and\\n began to feel weak, +lightheadedness. He then had nausea with one\\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\\n of diarrhea since that time, non-bloody, no melena. He denies any\\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\\n hematuria, urinary frequency or back pain. he does report abdominal\\n cramping with his diarrhea today. Wife became worried at the restaurant\\n and called EMS. He was taken to hospital and BPs noted to\\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\\n IV x 1 and transferred here.\\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\\n transferred to the ICU for further care.\\n Hypotension (not Shock)\\n Assessment:\\n BP high 80\\ns to low 90\\n Action:\\n Received fluid bolus 500ml\\n Response:\\n Currently BP maintaining @ >90\\n Plan:\\n Monitor BP and bolus PRN\\n Sepsis without organ dysfunction\\n Assessment:\\n In ED Lactate 4.1, Right arm was infiltrated on arrival to ICU. Foley\\n drained small amount sludge urine. Received 4lit fluid and abx zosyn in\\n ED .\\n Action:\\n Urine routine and C/S sent to lab. Repeat lactate 1.3. ( Very hard\\n stick, Pt refuses to do blood draws in the left arm claiming he will\\n get fistula done after few days. But pt came w/ 2 peripheral IV lines\\n from OSH in the lt arm. AM labs drawn by MD arterial stick.)\\n Response:\\n Pending\\n Plan:\\n Follow up culture reports.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-23 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 363808,\n \"text\": \"Chief Complaint: Septic shock,\\n I saw and examined the patient, and was physically present with the ICU\\n Fellow for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n N/V,weakness\\n 24 Hour Events:\\n HD yesterday...no fluid taken off...got a few fluid boluses for low\\n SBP...responded well to fluids but asymptomatic w/o tachycardia.\\n Afebrile\\n Brown stool with flecks, guiac positive, ? hemorrhoids\\n History obtained from Patient\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin - 08:00 AM\\n Meropenem - 01:37 PM\\n Linezolid - 02:21 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 12:09 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:41 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 35.9\\nC (96.6\\n HR: 86 (84 - 98) bpm\\n BP: 103/65(73) {83/41(54) - 104/69(73)} mmHg\\n RR: 20 (14 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Total In:\\n 6,347 mL\\n 1,254 mL\\n PO:\\n 540 mL\\n 360 mL\\n TF:\\n IVF:\\n 1,807 mL\\n 894 mL\\n Blood products:\\n Total out:\\n 405 mL\\n 135 mL\\n Urine:\\n 205 mL\\n 135 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 5,942 mL\\n 1,119 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 99%\\n ABG: ///27/\\n Physical Examination\\n General: Alert, oriented, no acute distress\\n HEENT: Sclera anicteric, MMM, oropharynx dry\\n Neck: supple, JVP not elevated, no LAD\\n Lungs: Bibasilar crackles new since yesterday.\\n CV: normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, mild tender RUQ, non-distended, bowel sounds present,\\n no rebound tenderness, mild guarding RUQ, no organomegaly\\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\\n pulse\\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\\n insertion site, no TTP of inserstion site\\n Labs / Radiology\\n 11.2 g/dL\\n 133 K/uL\\n 89 mg/dL\\n 3.3 mg/dL\\n 27 mEq/L\\n 3.9 mEq/L\\n 20 mg/dL\\n 107 mEq/L\\n 143 mEq/L\\n 35.6 %\\n 7.6 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n WBC\\n 18.6\\n 7.6\\n Hct\\n 41.9\\n 35.6\\n Plt\\n 162\\n 133\\n Cr\\n 4.7\\n 3.3\\n TropT\\n 0.05\\n Glucose\\n 129\\n 89\\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\\n Troponin-T:25/6/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\\n Microbiology: cdiff neg\\n all cxs pend\\n UA pos\\n Assessment and Plan\\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\\n DISEASE)\\n HYPOTENSION (NOT SHOCK)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\\n and hypotension....all cultures still neg to date this admission.\\n # Shock: likely sepsis.\\n Sources: history of MDR bactermias (ESBL Kleb, MRSA, VRE) in urine and\\n HD line.\\n - On Linezolid and Meropenem...Id c/s for input\\n - f/u cxs here and \\n # ESRD on HD: Patient on T/Th/Sat dialysis. HD line site with mild\\n erythema but non tender\\n # LGI bleed: cscope with diverticulosis in ...might need\\n proctoscopy once he recovers. Follow Hct.\\n # COPD: cont home spiriva, atrovent. Wean off O2. Hx of OSA, not on\\n Rx...watch for progression of crackles. Use Incentive spirometry.\\n .\\n # Atrial Fibrillation: rate controlled, not anticoagulated\\n # Depression: cont home Fluoxetine\\n # FEN: Taking good po, SBP appears at baseline\\n ICU Care\\n Nutrition:\\n Comments: po\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n 22 Gauge - 12:43 AM\\n 20 Gauge - 12:44 AM\\n Comments: in for picc if needs iv abx not able tpo dose with dialysis\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :Transfer to floor\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-23 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 363812,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Blood pressure dropped into the 80s transiently and responded to IVF\\n boluses.\\n Dr. passed by and recommended ID consult.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin - 08:00 AM\\n Meropenem - 01:37 PM\\n Linezolid - 02:21 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 12:09 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:56 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 35.9\\nC (96.7\\n HR: 84 (84 - 99) bpm\\n BP: 89/65(70) {83/41(54) - 104/67(75)} mmHg\\n RR: 18 (14 - 25) insp/min\\n SpO2: 98%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Total In:\\n 6,347 mL\\n 879 mL\\n PO:\\n 540 mL\\n TF:\\n IVF:\\n 1,807 mL\\n 879 mL\\n Blood products:\\n Total out:\\n 405 mL\\n 80 mL\\n Urine:\\n 205 mL\\n 80 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 5,942 mL\\n 799 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 98%\\n ABG: ///27/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 133 K/uL\\n 11.2 g/dL\\n 89 mg/dL\\n 3.3 mg/dL\\n 27 mEq/L\\n 3.9 mEq/L\\n 20 mg/dL\\n 107 mEq/L\\n 143 mEq/L\\n 35.6 %\\n 7.6 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n WBC\\n 18.6\\n 7.6\\n Hct\\n 41.9\\n 35.6\\n Plt\\n 162\\n 133\\n Cr\\n 4.7\\n 3.3\\n TropT\\n 0.05\\n Glucose\\n 129\\n 89\\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\\n Troponin-T:25/6/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\\n Assessment and Plan\\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\\n DISEASE)\\n HYPOTENSION (NOT SHOCK)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n .\\n # Sepsis: Mr. has history of MDR bactermias and presents with\\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn have now been\\n discontined. Linezolid was added yesterdy to cover his previous MRSA\\n and VRE. Meropenem has been added to cover his previous MDR E.coli\\n and ESBL Klebsiella. will cont with that regimen for now.\\n -- cont Linezolid/Meropenem\\n -- follow up cultures\\n -- trend fever WBC curve\\n -- ID consult\\n .\\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\\n -- likely HD tomorrow\\n -- may need new line placed if +blood cultures\\n .\\n # COPD: cont home spiriva, atrovent.\\n .\\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\\n setting of infection. Cardiac enzymes sent yesterday and were\\n negative, will repeat today. TSH normal\\n -- f/u cardiac enzymes\\n -- monitor on tele\\n -- cont home ASA\\n .\\n # Depression: cont home Fluoxetine\\n .\\n # FEN: Renal Diet, replete lytes\\n .\\n # Prophylaxis: Subcutaneous heparin\\n .\\n # Access: PIV\\n .\\n # Code: Full\\n .\\n # Communication: Patient\\n .\\n # Disposition: pending above\\n ICU Care\\n Nutrition: Regular Renal\\n Glycemic Control: None\\n Lines:\\n 22 Gauge - 12:43 AM\\n 20 Gauge - 12:44 AM\\n Prophylaxis:\\n DVT: Hep SQ\\n Stress ulcer: PPI\\n VAP: None\\n Comments:\\n Communication: Comments:\\n Code status: Full\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n 22 Gauge - 12:43 AM\\n 20 Gauge - 12:44 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-24 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 363967,\n \"text\": \"82 yo M with PMH significant for ESRD on HD T/Th/S, Atrial\\n Fibrillation/Flutter, C.diff colitis, CVA x 2 with residual right sided\\n weakness, CAD s/p MI, diastolic CHF with EF 60%, klebsiella urosepsis,\\n multi-drug resistant E.Coli Sepsis, and MRSA Sepsis who presented to\\n Hospital with N/V/D and weakness. At OSH, SBPs were\\n noted to be in the 70s and 80s. He was then transferred to for\\n further care of probable sepsis. Upon arrival to ED, his VS were\\n stable but he was noted to have a lactate of 4.1. He was then\\n transferred to the MICU for further management.\\n Sepsis without organ dysfunction\\n Assessment:\\n Pt afebrile. WBC Sbp 90 or greater today. Cdiff cult neg. urine and\\n bc pending.\\n Action:\\n Cont on linezolid and meropenum. Team decided not to place picc till\\n final cult results back. Id consulted. Survelliance cult x2 done one\\n peripheral and one via hd cath line\\n Response:\\n Bp improved. Afebrile.\\n Plan:\\n Cont antiobidics as ordered. Monitor for temp spike. Follow up on cult\\n Obstructive sleep apnea (OSA)\\n Assessment:\\n Patient with known hx of sleep apnea. Does not wear bipap at home. Had\\n been on home o2 per wife but none in the past week.\\n Action:\\n Taken off o2 to see how his sats would do.\\n Response:\\n Sats 92 or greater when awake. Fell to 87% when he fell asleep. O2\\n replaced at 1l nc.\\n Plan:\\n Cont to monitor sats.\\n wife in to visit. Updated on plan of care.\\n Activity.- pt consult placed. Patient s/p cva with residual right sided\\n weakness. Uses walker at home. OOb to chair with assist of 2. Tolerated\\n well.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-24 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 363968,\n \"text\": \"82 yo M with PMH significant for ESRD on HD T/Th/S, Atrial\\n Fibrillation/Flutter, C.diff colitis, CVA x 2 with residual right sided\\n weakness, CAD s/p MI, diastolic CHF with EF 60%, klebsiella urosepsis,\\n multi-drug resistant E.Coli Sepsis, and MRSA Sepsis who presented to\\n Hospital with N/V/D and weakness. At OSH, SBPs were\\n noted to be in the 70s and 80s. He was then transferred to for\\n further care of probable sepsis. Upon arrival to ED, his VS were\\n stable but he was noted to have a lactate of 4.1. He was then\\n transferred to the MICU for further management.\\n Sepsis without organ dysfunction\\n Assessment:\\n Pt afebrile. WBC 6.3 this AM. SBP remains >90 today. Cdiff cult\\n negative thus far. Urine and blood cultures with no growth to date.\\n Action:\\n Cont on linezolid and meropenem.\\n Response:\\n Plan:\\n Cont antibiotics as ordered. Monitor for temp spike. Follow up on\\n culture results.\\n wife in to visit. Updated on plan of care.\\n Activity.- pt consult placed. Patient s/p cva with residual right sided\\n weakness. Uses walker at home. OOb to chair with assist of 2. Tolerated\\n well.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-23 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 363790,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Blood pressure dropped into the 80s transiently and responded to IVF\\n boluses.\\n Dr. passed by and recommended ID consult.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin - 08:00 AM\\n Meropenem - 01:37 PM\\n Linezolid - 02:21 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 12:09 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:56 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 35.9\\nC (96.7\\n HR: 84 (84 - 99) bpm\\n BP: 89/65(70) {83/41(54) - 104/67(75)} mmHg\\n RR: 18 (14 - 25) insp/min\\n SpO2: 98%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Total In:\\n 6,347 mL\\n 879 mL\\n PO:\\n 540 mL\\n TF:\\n IVF:\\n 1,807 mL\\n 879 mL\\n Blood products:\\n Total out:\\n 405 mL\\n 80 mL\\n Urine:\\n 205 mL\\n 80 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 5,942 mL\\n 799 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 98%\\n ABG: ///27/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 133 K/uL\\n 11.2 g/dL\\n 89 mg/dL\\n 3.3 mg/dL\\n 27 mEq/L\\n 3.9 mEq/L\\n 20 mg/dL\\n 107 mEq/L\\n 143 mEq/L\\n 35.6 %\\n 7.6 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n WBC\\n 18.6\\n 7.6\\n Hct\\n 41.9\\n 35.6\\n Plt\\n 162\\n 133\\n Cr\\n 4.7\\n 3.3\\n TropT\\n 0.05\\n Glucose\\n 129\\n 89\\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\\n Troponin-T:25/6/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\\n Assessment and Plan\\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\\n DISEASE)\\n HYPOTENSION (NOT SHOCK)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n 22 Gauge - 12:43 AM\\n 20 Gauge - 12:44 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-23 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 363792,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Blood pressure dropped into the 80s transiently and responded to IVF\\n boluses.\\n Dr. passed by and recommended ID consult.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin - 08:00 AM\\n Meropenem - 01:37 PM\\n Linezolid - 02:21 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 12:09 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:56 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 35.9\\nC (96.7\\n HR: 84 (84 - 99) bpm\\n BP: 89/65(70) {83/41(54) - 104/67(75)} mmHg\\n RR: 18 (14 - 25) insp/min\\n SpO2: 98%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Total In:\\n 6,347 mL\\n 879 mL\\n PO:\\n 540 mL\\n TF:\\n IVF:\\n 1,807 mL\\n 879 mL\\n Blood products:\\n Total out:\\n 405 mL\\n 80 mL\\n Urine:\\n 205 mL\\n 80 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 5,942 mL\\n 799 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 98%\\n ABG: ///27/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 133 K/uL\\n 11.2 g/dL\\n 89 mg/dL\\n 3.3 mg/dL\\n 27 mEq/L\\n 3.9 mEq/L\\n 20 mg/dL\\n 107 mEq/L\\n 143 mEq/L\\n 35.6 %\\n 7.6 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n WBC\\n 18.6\\n 7.6\\n Hct\\n 41.9\\n 35.6\\n Plt\\n 162\\n 133\\n Cr\\n 4.7\\n 3.3\\n TropT\\n 0.05\\n Glucose\\n 129\\n 89\\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\\n Troponin-T:25/6/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\\n Assessment and Plan\\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\\n DISEASE)\\n HYPOTENSION (NOT SHOCK)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n .\\n # Sepsis: Mr. has history of MDR bactermias and presents with\\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn cover his\\n previous MRSA, MDR E.coli and ESBL Klebsiella. will cont with that\\n regimen for now.\\n -- cont Vanco/Zosyn\\n -- D/C CTX\\n -- send UA/UCx\\n -- repeat lactate\\n -- repeat CBC, Chem 7\\n -- 1L IVF bolus\\n -- trend fever WBC curve\\n .\\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\\n -- likely HD tomorrow\\n -- may need new line placed if +blood cultures\\n .\\n # COPD: cont home spiriva, atrovent.\\n .\\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\\n setting of infection. will ROMI\\n -- cycle cardiac enzymes\\n -- monitor on tele\\n -- check TSH\\n -- cont home ASA\\n .\\n # Depression: cont home Fluoxetine\\n .\\n # FEN: Renal Diet, replete lytes\\n .\\n # Prophylaxis: Subcutaneous heparin\\n .\\n # Access: PIV\\n .\\n # Code: Full\\n .\\n # Communication: Patient\\n .\\n # Disposition: pending above\\n ICU Care\\n Nutrition: Regular Renal\\n Glycemic Control: None\\n Lines:\\n 22 Gauge - 12:43 AM\\n 20 Gauge - 12:44 AM\\n Prophylaxis:\\n DVT: Hep SQ\\n Stress ulcer: PPI\\n VAP: None\\n Comments:\\n Communication: Comments:\\n Code status: Full\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n 22 Gauge - 12:43 AM\\n 20 Gauge - 12:44 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-23 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 363801,\n \"text\": \"Chief Complaint: Septic shock,\\n I saw and examined the patient, and was physically present with the ICU\\n Fellow for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n N/V,weakness\\n 24 Hour Events:\\n HD yesterday...no fluid taken off...got a few fluid boluses for low\\n SBP...responded well to fluids but asymptomatic w/o tachycardia.\\n Afebrile\\n Brown stool with flecks, guiac positive, ? hemorrhoids\\n History obtained from Patient\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin - 08:00 AM\\n Meropenem - 01:37 PM\\n Linezolid - 02:21 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 12:09 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:41 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 35.9\\nC (96.6\\n HR: 86 (84 - 98) bpm\\n BP: 103/65(73) {83/41(54) - 104/69(73)} mmHg\\n RR: 20 (14 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Total In:\\n 6,347 mL\\n 1,254 mL\\n PO:\\n 540 mL\\n 360 mL\\n TF:\\n IVF:\\n 1,807 mL\\n 894 mL\\n Blood products:\\n Total out:\\n 405 mL\\n 135 mL\\n Urine:\\n 205 mL\\n 135 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 5,942 mL\\n 1,119 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 99%\\n ABG: ///27/\\n Physical Examination\\n General: Alert, oriented, no acute distress\\n HEENT: Sclera anicteric, MMM, oropharynx dry\\n Neck: supple, JVP not elevated, no LAD\\n Lungs: Bibasilar crackles new since yesterday.\\n CV: normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, mild tender RUQ, non-distended, bowel sounds present,\\n no rebound tenderness, mild guarding RUQ, no organomegaly\\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\\n pulse\\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\\n insertion site, no TTP of inserstion site\\n Labs / Radiology\\n 11.2 g/dL\\n 133 K/uL\\n 89 mg/dL\\n 3.3 mg/dL\\n 27 mEq/L\\n 3.9 mEq/L\\n 20 mg/dL\\n 107 mEq/L\\n 143 mEq/L\\n 35.6 %\\n 7.6 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n WBC\\n 18.6\\n 7.6\\n Hct\\n 41.9\\n 35.6\\n Plt\\n 162\\n 133\\n Cr\\n 4.7\\n 3.3\\n TropT\\n 0.05\\n Glucose\\n 129\\n 89\\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\\n Troponin-T:25/6/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\\n Microbiology: cdiff neg\\n all cxs pend\\n UA pos\\n Assessment and Plan\\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\\n DISEASE)\\n HYPOTENSION (NOT SHOCK)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\\n and hypotension....all cultures still neg to date this admission.\\n # Shock: likely sepsis.\\n Sources: history of MDR bactermias (ESBL Kleb, MRSA, VRE) in urine and\\n HD line.\\n - On Linezolid and Meropenem...Id c/s for input\\n - f/u cxs here and \\n # ESRD on HD: Patient on T/Th/Sat dialysis. HD line site with mild\\n erythema but non tender\\n # LGI bleed: cscope with diverticulosis in ...might need\\n proctoscopy once he recovers. Follow Hct.\\n # COPD: cont home spiriva, atrovent. Wean off O2. Hx of OSA, not on\\n Rx...watch for progression of crackles. Use Incentive spirometry.\\n .\\n # Atrial Fibrillation: rate controlled, not anticoagulated\\n # Depression: cont home Fluoxetine\\n # FEN: Taking good po, SBP appears at baseline\\n ICU Care\\n Nutrition:\\n Comments: po\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n 22 Gauge - 12:43 AM\\n 20 Gauge - 12:44 AM\\n Comments: in for picc if needs iv abx not able tpo dose with dialysis\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :Transfer to floor\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 363814,\n \"text\": \"82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n Sepsis without organ dysfunction\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-24 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 363965,\n \"text\": \"82 yo M with PMH significant for ESRD on HD T/Th/S, Atrial\\n Fibrillation/Flutter, C.diff colitis, CVA x 2 with residual right sided\\n weakness, CAD s/p MI, diastolic CHF with EF 60%, klebsiella urosepsis,\\n multi-drug resistant E.Coli Sepsis, and MRSA Sepsis who presents with\\n one day of N/V and weakness.\\n Sepsis without organ dysfunction\\n Assessment:\\n Wbc down to 7.6. afebrile. Sbp 90 or greater today. Cdiff cult neg.\\n urine and bc pending.\\n Action:\\n Cont on linezolid and meropenum. Team decided not to place picc till\\n final cult results back. Id consulted. Survelliance cult x2 done one\\n peripheral and one via hd cath line\\n Response:\\n Bp improved. Afebrile.\\n Plan:\\n Cont antiobidics as ordered. Monitor for temp spike. Follow up on cult\\n Obstructive sleep apnea (OSA)\\n Assessment:\\n Patient with known hx of sleep apnea. Does not wear bipap at home. Had\\n been on home o2 per wife but none in the past week.\\n Action:\\n Taken off o2 to see how his sats would do.\\n Response:\\n Sats 92 or greater when awake. Fell to 87% when he fell asleep. O2\\n replaced at 1l nc.\\n Plan:\\n Cont to monitor sats.\\n wife in to visit. Updated on plan of care.\\n Activity.- pt consult placed. Patient s/p cva with residual right sided\\n weakness. Uses walker at home. OOb to chair with assist of 2. Tolerated\\n well.\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2126-01-26 00:00:00.000\",\n \"description\": \"Physical Therapy Progress Note\",\n \"row_id\": 364327,\n \"text\": \"Subjective:\\n I feel good and want to go home\\n Objective:\\n Follow up PT visit to address goals of: . Patient seen today\\n for balance training, patient education\\n Updated medical status:\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Rolling:\\n To Right c mailing support\\n\\n\\n\\n\\n\\n\\n Supine/\\n Sidelying to Sit:\\n C railing support\\n T\\n\\n\\n\\n\\n\\n Transfer:\\n\\n\\n\\n\\n\\n Sit to Stand:\\n T\\n\\n\\n\\n\\n\\n Ambulation:\\n C RW\\n T\\n\\n\\n\\n\\n\\n Stairs:\\n\\n\\n\\n\\n\\n Aerobic Activity Response:\\n Position\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Rest\\n Sit\\n 88\\n 119/78\\n 95\\n Activity\\n Sit\\n 102\\n 132/82\\n 96*\\n Recovery\\n Sit\\n 76\\n 112/65\\n 99\\n Total distance walked: 100'\\n Minutes:\\n Unable to get clear of O2 sats during activity\\n * Immediately following activity.\\n Gait: pt amb I 100' c RW and R AFO. pt genu recurvatum in R knee c\\n flexed trunk, equal step length and normal cadence.\\n Balance: pt could I sit on EOB without UE support. pt LOB post\\n from recliner during sit-stand, however I sit-stand from EOB\\n without LOB d/t increased hieght. EOB more charactersitic of height of\\n chairs at home. pt could and dof AFO from EOB.\\n Education / Communication: pt education RE: Role of PT, poc, d/c plan,\\n importance of family member A c OOB activity. RN communication RE: pt\\n status, d/c plan\\n Other:\\n Assessment: pt is an 82 y.o. male c HTN and n/v/d p/w the above\\n impairments that is currently presenting at baseline described as\\n functionally I c all mobility. Assuming pt is medically stable,\\n anticipate pt to be safe for d/c home provided the pt has S from family\\n memberat night time c amb to bathroom and c the recommendation of home\\n PT to regain maximum functional I.\\n Anticipated Discharge: Home with Home PT\\n : d/c planning, d/c from acute PT c Home PT. Wife has agreed to\\n assist pt at night c amb to bathroom.\\n Treated by PT/s 2:50p-3:25p\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 363795,\n \"text\": \"82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n Sepsis without organ dysfunction\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-24 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 363962,\n \"text\": \"Chief Complaint: Septic shock\\n I saw and examined the patient, and was physically present with the ICU\\n Fellow for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n ID agreed with current abx\\n Hct stable with guiac + stools and diarrhea overnight. Cdiff neg.\\n SBP stable\\n History obtained from Patient\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin - 08:00 AM\\n Meropenem - 12:57 PM\\n Linezolid - 02:06 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 AM\\n Heparin Sodium (Prophylaxis) - 08:00 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:50 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 35.4\\nC (95.8\\n HR: 82 (77 - 94) bpm\\n BP: 98/64(70) {91/52(63) - 118/80(85)} mmHg\\n RR: 19 (11 - 25) insp/min\\n SpO2: 95%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Total In:\\n 2,240 mL\\n 647 mL\\n PO:\\n 800 mL\\n 240 mL\\n TF:\\n IVF:\\n 1,440 mL\\n 407 mL\\n Blood products:\\n Total out:\\n 335 mL\\n 175 mL\\n Urine:\\n 335 mL\\n 175 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,905 mL\\n 472 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 95%\\n ABG: ///28/\\n Physical Examination\\n General: Alert, oriented, no acute distress\\n HEENT: Sclera anicteric, MMM, oropharynx dry\\n Neck: supple, JVP not elevated, no LAD\\n Lungs: Bibasilar crackles new since yesterday.\\n CV: normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness, mild guarding RUQ, no organomegaly\\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\\n pulse\\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\\n insertion site, no TTP of inserstion site\\n Labs / Radiology\\n 11.8 g/dL\\n 139 K/uL\\n 84 mg/dL\\n 3.8 mg/dL\\n 28 mEq/L\\n 4.2 mEq/L\\n 24 mg/dL\\n 106 mEq/L\\n 141 mEq/L\\n 37.2 %\\n 6.3 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n 03:45 PM\\n 08:01 AM\\n WBC\\n 18.6\\n 7.6\\n 6.3\\n Hct\\n 41.9\\n 35.6\\n 36.2\\n 37.2\\n Plt\\n 162\\n 133\\n 139\\n Cr\\n 4.7\\n 3.3\\n 3.8\\n TropT\\n 0.05\\n 0.05\\n Glucose\\n 129\\n 89\\n 84\\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\\n Microbiology: All cxs: ngtd\\n Urine: yeast\\n Assessment and Plan\\n OBSTRUCTIVE SLEEP APNEA (OSA)\\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\\n DISEASE)\\n HYPOTENSION (NOT SHOCK)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\\n and hypotension....all cultures still neg to date this admission.\\n # Shock: likely sepsis from urine..potivive UA but grew only yeast. On\\n Linezolid and Meropenem. D/c per ID recs since all cxs neg. D/c foley\\n # ESRD on HD: Patient on T/Th/Sat dialysis. HD line site with mild\\n erythema but non tender\\n # LGI bleed: diarrhea overnight. Still blood tinged. GI\\n consult....might need proctoscopy once he recovers. Follow Hct.\\n # COPD: cont home spiriva, atrovent. Wean off O2. Hx of OSA, not on\\n Rx...watch for progression of crackles. Use Incentive spirometry.\\n # Atrial Fibrillation: rate controlled, not anticoagulated\\n # Depression: cont home Fluoxetine\\n # FEN: Taking good po, SBP appears at baseline\\n ICU Care\\n Nutrition:\\n Comments: good po\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n 22 Gauge - 12:43 AM\\n picc based on decision reg duration of abx per ID\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :Transfer to floor\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 363643,\n \"text\": \"This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\\n vomiting and weakness. Patient went to lunch today with his wife and\\n began to feel weak, +lightheadedness. He then had nausea with one\\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\\n of diarrhea since that time, non-bloody, no melena. He denies any\\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\\n hematuria, urinary frequency or back pain. he does report abdominal\\n cramping with his diarrhea today. Wife became worried at the restaurant\\n and called EMS. He was taken to hospital and BPs noted to\\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\\n IV x 1 and transferred here.\\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\\n transferred to the ICU for further care.\\n Hypotension (not Shock)\\n Assessment:\\n BP high 80\\ns to low 90\\n Action:\\n Received fluid bolus 500ml\\n Response:\\n Currently BP maintaining @ >90\\n Plan:\\n Monitor BP and bolus PRN\\n Sepsis without organ dysfunction\\n Assessment:\\n In ED Lactate 4.1, Foley drained small amount sludge urine. Received\\n 4lit fluid and abx zosyn in ED .\\n Action:\\n Urine routine and C/S sent to lab. Repeat lactate 1.3. ( Very hard\\n stick, Pt refuses to do blood draws in the left arm claiming he will\\n get fistula done after few days. But pt came w/ 2 peripheral IV lines\\n from OSH in the lt arm. AM labs drawn by MD arterial stick.)\\n Response:\\n Pending\\n Plan:\\n Follow up culture reports.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 363937,\n \"text\": \"Chief Complaint: Sepsis\\n 24 Hour Events:\\n ID consult obtained, continues on Linezolid/Meropenem\\n HCT stable, guaiac + stools\\n BP stable overnight\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin - 08:00 AM\\n Meropenem - 12:57 PM\\n Linezolid - 02:06 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:12 PM\\n Heparin Sodium (Prophylaxis) - 12:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:06 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 35.6\\nC (96.1\\n HR: 87 (77 - 94) bpm\\n BP: 109/67(75) {90/52(63) - 118/80(85)} mmHg\\n RR: 19 (11 - 25) insp/min\\n SpO2: 94%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Total In:\\n 2,240 mL\\n 353 mL\\n PO:\\n 800 mL\\n TF:\\n IVF:\\n 1,440 mL\\n 353 mL\\n Blood products:\\n Total out:\\n 335 mL\\n 140 mL\\n Urine:\\n 335 mL\\n 140 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,905 mL\\n 213 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ////\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 133 K/uL\\n 11.2 g/dL\\n 89 mg/dL\\n 3.3 mg/dL\\n 27 mEq/L\\n 3.9 mEq/L\\n 20 mg/dL\\n 107 mEq/L\\n 143 mEq/L\\n 36.2 %\\n 7.6 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n 03:45 PM\\n WBC\\n 18.6\\n 7.6\\n Hct\\n 41.9\\n 35.6\\n 36.2\\n Plt\\n 162\\n 133\\n Cr\\n 4.7\\n 3.3\\n TropT\\n 0.05\\n 0.05\\n Glucose\\n 129\\n 89\\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\\n Troponin-T:15/3/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\\n Assessment and Plan\\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\\n DISEASE)\\n HYPOTENSION (NOT SHOCK)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n .\\n # Sepsis: Mr. has history of MDR bactermias and presents with\\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn have now been\\n discontined. Linezolid was added yesterdy to cover his previous MRSA\\n and VRE. Meropenem has been added to cover his previous MDR E.coli\\n and ESBL Klebsiella. will cont with that regimen for now.\\n -- cont Linezolid/Meropenem\\n -- follow up cultures\\n -- trend fever WBC curve\\n -- ID consult\\n .\\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\\n -- likely HD tomorrow\\n -- may need new line placed if +blood cultures\\n .\\n # COPD: cont home spiriva, atrovent.\\n .\\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\\n setting of infection. Cardiac enzymes sent yesterday and were\\n negative, will repeat today. TSH normal\\n -- f/u cardiac enzymes\\n -- monitor on tele\\n -- cont home ASA\\n .\\n # Depression: cont home Fluoxetine\\n .\\n # FEN: Renal Diet, replete lytes\\n .\\n # Prophylaxis: Subcutaneous heparin\\n .\\n # Access: PIV\\n .\\n # Code: Full\\n .\\n # Communication: Patient\\n .\\n # Disposition: pending above\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n 22 Gauge - 12:43 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-26 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 364315,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Fellow for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n Dialysis today.\\n D/c home after PT today\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Meropenem - 12:57 PM\\n Linezolid - 02:06 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:46 AM\\n Heparin Sodium (Prophylaxis) - 10:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:30 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98\\n Tcurrent: 36.2\\nC (97.1\\n HR: 95 (76 - 108) bpm\\n BP: 127/70(86) {106/59(66) - 142/118(122)} mmHg\\n RR: 18 (13 - 32) insp/min\\n SpO2: 76% --poor pleth\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Height: 66 Inch\\n Total In:\\n 990 mL\\n PO:\\n 890 mL\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 500 mL\\n 0 mL\\n Urine:\\n 500 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 490 mL\\n 0 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 76%\\n ABG: ///28/\\n Physical Examination\\n General: Alert, oriented, no acute distress\\n HEENT: Sclera anicteric, MMM, oropharynx dry\\n Neck: supple, JVP not elevated, no LAD\\n Lungs: Bibasilar crackles\\n CV: normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness, mild guarding RUQ, no organomegaly\\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\\n pulse\\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\\n insertion site, no TTP of inserstion site\\n Labs / Radiology\\n 11.6 g/dL\\n 138 K/uL\\n 93 mg/dL\\n 3.1 mg/dL\\n 28 mEq/L\\n 3.9 mEq/L\\n 16 mg/dL\\n 104 mEq/L\\n 140 mEq/L\\n 37.2 %\\n 4.8 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n 03:45 PM\\n 08:01 AM\\n 10:40 AM\\n WBC\\n 18.6\\n 7.6\\n 6.3\\n 4.8\\n Hct\\n 41.9\\n 35.6\\n 36.2\\n 37.2\\n 37.2\\n Plt\\n 162\\n 133\\n 139\\n 138\\n Cr\\n 4.7\\n 3.3\\n 3.8\\n 3.1\\n TropT\\n 0.05\\n 0.05\\n Glucose\\n 129\\n 89\\n 84\\n 93\\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\\n Assessment and Plan\\n BALANCE, IMPAIRED\\n GAIT, IMPAIRED\\n KNOWLEDGE, IMPAIRED\\n MUSCLE PERFORMACE, IMPAIRED\\n TRANSFERS, IMPAIRED\\n RESPIRATION / GAS EXCHANGE, IMPAIRED\\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presented with one day of\\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\\n and hypotension....all cultures still neg to date this admission\\nsepsis\\n resolved, off all abx.\\n - Will get surveillance cxs during HD\\n - LGI bleed: still has diarrhea, outpt GI w/u.....might need\\n proctoscopy once he recovers.\\n - COPD: on home meds, small O2 reqmt due to atelectasis, cont IS\\n - Afib: rate controlled, not anticoagulated\\n - Depression: cont home Fluoxetine\\n - FEN: Taking good po, SBP appears at baseline\\n - Dispo: walk with pt b4 discharge home...patient upset\\nmay go AMA if\\n he refuses rehab.\\n ICU Care\\n Nutrition:\\n Comments: good po\\n Glycemic Control: stable\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n Code status: Full code\\n Disposition :Home once he walks vs rehab\\n Total time spent: 35 min\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 364306,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n no events\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Meropenem - 12:57 PM\\n Linezolid - 02:06 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:46 AM\\n Heparin Sodium (Prophylaxis) - 10:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:11 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98\\n Tcurrent: 36.2\\nC (97.1\\n HR: 87 (76 - 108) bpm\\n BP: 107/68(76) {106/59(66) - 142/118(122)} mmHg\\n RR: 17 (13 - 32) insp/min\\n SpO2: 92%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Height: 66 Inch\\n Total In:\\n 990 mL\\n PO:\\n 890 mL\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 500 mL\\n 0 mL\\n Urine:\\n 500 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 490 mL\\n 0 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 92%\\n ABG: ///28/\\n Physical Examination\\n General: Alert, oriented, no acute distress\\n HEENT: Sclera anicteric, MMM, OP clear\\n Neck: supple, JVP not elevated, no LAD\\n Lungs: Bibasilar crackles, not clearing with cough\\n CV: normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness, no organomegaly\\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\\n pulse\\n SKIN: no rashes, left subclavian HD cath; very mild erythema at\\n insertion site\\n Labs / Radiology\\n 138 K/uL\\n 11.6 g/dL\\n 93 mg/dL\\n 3.1 mg/dL\\n 28 mEq/L\\n 3.9 mEq/L\\n 16 mg/dL\\n 104 mEq/L\\n 140 mEq/L\\n 37.2 %\\n 4.8 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n 03:45 PM\\n 08:01 AM\\n 10:40 AM\\n WBC\\n 18.6\\n 7.6\\n 6.3\\n 4.8\\n Hct\\n 41.9\\n 35.6\\n 36.2\\n 37.2\\n 37.2\\n Plt\\n 162\\n 133\\n 139\\n 138\\n Cr\\n 4.7\\n 3.3\\n 3.8\\n 3.1\\n TropT\\n 0.05\\n 0.05\\n Glucose\\n 129\\n 89\\n 84\\n 93\\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\\n 2/2 Blood Cx\\n NGTD\\n Blood Cx\\n NGTD\\n C. Diff neg\\n C. Diff neg\\n Assessment and Plan\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n # Culture negative Sepsis: nothing isolated on cultures. All\\n antibiotics stopped.\\n - will have surveillance cultures as outpatient.\\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\\n # COPD: cont home spiriva, atrovent.\\n # Atrial Fibrillation: currently in sinus with frequent ectopy. Afib\\n was likely in setting of infection. Patient was ROMI. TSH normal\\n -- cont home ASA\\n # Depression: cont home Fluoxetine\\n # FEN: Renal Diet, replete lytes\\n # Prophylaxis: Subcutaneous heparin\\n # Access: PIV\\n # Code: Full\\n # Communication: Patient\\n # Disposition: will work with PT one additional time before likely d/c\\n to home\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n 20 Gauge - 06:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 364307,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n no events\\n Plan for HD today\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Meropenem - 12:57 PM\\n Linezolid - 02:06 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:46 AM\\n Heparin Sodium (Prophylaxis) - 10:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:11 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98\\n Tcurrent: 36.2\\nC (97.1\\n HR: 87 (76 - 108) bpm\\n BP: 107/68(76) {106/59(66) - 142/118(122)} mmHg\\n RR: 17 (13 - 32) insp/min\\n SpO2: 92%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Height: 66 Inch\\n Total In:\\n 990 mL\\n PO:\\n 890 mL\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 500 mL\\n 0 mL\\n Urine:\\n 500 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 490 mL\\n 0 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 92%\\n ABG: ///28/\\n Physical Examination\\n General: Alert, oriented, no acute distress\\n HEENT: Sclera anicteric, MMM, OP clear\\n Neck: supple, JVP not elevated, no LAD\\n Lungs: Bibasilar crackles, not clearing with cough\\n CV: normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness, no organomegaly\\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\\n pulse\\n SKIN: no rashes, left subclavian HD cath; very mild erythema at\\n insertion site\\n Labs / Radiology\\n 138 K/uL\\n 11.6 g/dL\\n 93 mg/dL\\n 3.1 mg/dL\\n 28 mEq/L\\n 3.9 mEq/L\\n 16 mg/dL\\n 104 mEq/L\\n 140 mEq/L\\n 37.2 %\\n 4.8 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n 03:45 PM\\n 08:01 AM\\n 10:40 AM\\n WBC\\n 18.6\\n 7.6\\n 6.3\\n 4.8\\n Hct\\n 41.9\\n 35.6\\n 36.2\\n 37.2\\n 37.2\\n Plt\\n 162\\n 133\\n 139\\n 138\\n Cr\\n 4.7\\n 3.3\\n 3.8\\n 3.1\\n TropT\\n 0.05\\n 0.05\\n Glucose\\n 129\\n 89\\n 84\\n 93\\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\\n 2/2 Blood Cx\\n NGTD\\n Blood Cx\\n NGTD\\n C. Diff neg\\n C. Diff neg\\n Assessment and Plan\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n # Culture negative Sepsis: nothing isolated on cultures. All\\n antibiotics stopped.\\n - will have surveillance cultures as outpatient.\\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware, HD today\\n # COPD: cont home spiriva, atrovent.\\n # Atrial Fibrillation: currently in sinus with frequent ectopy. Afib\\n was likely in setting of infection. Patient was ROMI. TSH normal\\n -- cont home ASA\\n # Depression: cont home Fluoxetine\\n # FEN: Renal Diet, replete lytes\\n # Prophylaxis: Subcutaneous heparin\\n # Access: PIV\\n # Code: Full\\n # Communication: Patient\\n # Disposition: will work with PT one additional time before likely d/c\\n to home\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n 20 Gauge - 06:00 PM\\n Prophylaxis:\\n DVT: SC heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full\\n Disposition: likely DC home post HD and PT eval\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 364309,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n no events\\n Plan for HD today\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Meropenem - 12:57 PM\\n Linezolid - 02:06 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:46 AM\\n Heparin Sodium (Prophylaxis) - 10:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:11 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98\\n Tcurrent: 36.2\\nC (97.1\\n HR: 87 (76 - 108) bpm\\n BP: 107/68(76) {106/59(66) - 142/118(122)} mmHg\\n RR: 17 (13 - 32) insp/min\\n SpO2: 92%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Height: 66 Inch\\n Total In:\\n 990 mL\\n PO:\\n 890 mL\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 500 mL\\n 0 mL\\n Urine:\\n 500 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 490 mL\\n 0 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 92%\\n ABG: ///28/\\n Physical Examination\\n General: Alert, oriented, no acute distress\\n HEENT: Sclera anicteric, MMM, OP clear\\n Neck: supple, JVP not elevated, no LAD\\n Lungs: Bibasilar crackles, not clearing with cough\\n CV: normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness, no organomegaly\\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\\n pulse\\n SKIN: no rashes, left subclavian HD cath; very mild erythema at\\n insertion site\\n Labs / Radiology\\n 138 K/uL\\n 11.6 g/dL\\n 93 mg/dL\\n 3.1 mg/dL\\n 28 mEq/L\\n 3.9 mEq/L\\n 16 mg/dL\\n 104 mEq/L\\n 140 mEq/L\\n 37.2 %\\n 4.8 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n 03:45 PM\\n 08:01 AM\\n 10:40 AM\\n WBC\\n 18.6\\n 7.6\\n 6.3\\n 4.8\\n Hct\\n 41.9\\n 35.6\\n 36.2\\n 37.2\\n 37.2\\n Plt\\n 162\\n 133\\n 139\\n 138\\n Cr\\n 4.7\\n 3.3\\n 3.8\\n 3.1\\n TropT\\n 0.05\\n 0.05\\n Glucose\\n 129\\n 89\\n 84\\n 93\\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\\n 2/2 Blood Cx\\n NGTD\\n Blood Cx\\n NGTD\\n C. Diff neg\\n C. Diff neg\\n Assessment and Plan\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n # Culture negative Sepsis: nothing isolated on cultures. All\\n antibiotics stopped.\\n - will have surveillance cultures as outpatient.\\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware, HD today\\n # COPD: cont home spiriva, atrovent.\\n # Atrial Fibrillation: currently in sinus with frequent ectopy. Afib\\n was likely in setting of infection. Patient was ROMI. TSH normal\\n -- cont home ASA\\n # Depression: cont home Fluoxetine\\n # FEN: Renal Diet, replete lytes\\n # Prophylaxis: Subcutaneous heparin\\n # Access: PIV\\n # Code: Full\\n # Communication: Patient\\n # Disposition: will work with PT one additional time before likely d/c\\n to home\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n 20 Gauge - 06:00 PM\\n Prophylaxis:\\n DVT: SC heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full\\n Disposition: likely DC home post HD and PT eval\\n ------ Protected Section ------\\n Called Hospital Microbiology lab\\n Blood Cx drawn on\\n finalized as no growth X 5days today.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 13:34 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 363632,\n \"text\": \"This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\\n vomiting and weakness. Patient went to lunch today with his wife and\\n began to feel weak, +lightheadedness. He then had nausea with one\\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\\n of diarrhea since that time, non-bloody, no melena. He denies any\\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\\n hematuria, urinary frequency or back pain. he does report abdominal\\n cramping with his diarrhea today. Wife became worried at the restaurant\\n and called EMS. He was taken to hospital and BPs noted to\\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\\n IV x 1 and transferred here.\\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\\n transferred to the ICU for further care.\\n Hypotension (not Shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Sepsis without organ dysfunction\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2126-01-25 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 364130,\n \"text\": \"Comments:\\n 82 year old male with history of ESRD on HD, afib/flutter, CVA x 2\\n presenting with n/v/d and weakness in the setting of hypotension and\\n leukocytosis. Patient\\ns diet was advanced to Renal Diet and patient is\\n tolerating with good PO intake. Noted possible plans for d/c. Will\\n continue to follow. Recommend encouraging PO intake PRN and adding\\n supplements if PO intake decreases.\\n 13:42\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-25 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 364133,\n \"text\": \"Chief Complaint: shock resolved\\n I saw and examined the patient, and was physically present with the ICU\\n Fellow for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n none, stable\\n History obtained from Patient\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Meropenem - 12:57 PM\\n Linezolid - 02:06 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:46 AM\\n Heparin Sodium (Prophylaxis) - 08:46 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:57 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.2\\nC (97.2\\n HR: 96 (76 - 105) bpm\\n BP: 124/78(87) {91/58(66) - 142/90(97)} mmHg\\n RR: 19 (14 - 24) insp/min\\n SpO2: 93%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Total In:\\n 1,154 mL\\n PO:\\n 720 mL\\n TF:\\n IVF:\\n 434 mL\\n Blood products:\\n Total out:\\n 3,300 mL\\n 100 mL\\n Urine:\\n 300 mL\\n 100 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,146 mL\\n -100 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 93%\\n ABG: ////\\n Physical Examination\\n General: Alert, oriented, no acute distress\\n HEENT: Sclera anicteric, MMM, oropharynx dry\\n Neck: supple, JVP not elevated, no LAD\\n Lungs: Bibasilar crackles new since yesterday.\\n CV: normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness, mild guarding RUQ, no organomegaly\\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\\n pulse\\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\\n insertion site, no TTP of inserstion site\\n Labs / Radiology\\n 11.8 g/dL\\n 139 K/uL\\n 84 mg/dL\\n 3.8 mg/dL\\n 28 mEq/L\\n 4.2 mEq/L\\n 24 mg/dL\\n 106 mEq/L\\n 141 mEq/L\\n 37.2 %\\n 6.3 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n 03:45 PM\\n 08:01 AM\\n WBC\\n 18.6\\n 7.6\\n 6.3\\n Hct\\n 41.9\\n 35.6\\n 36.2\\n 37.2\\n Plt\\n 162\\n 133\\n 139\\n Cr\\n 4.7\\n 3.3\\n 3.8\\n TropT\\n 0.05\\n 0.05\\n Glucose\\n 129\\n 89\\n 84\\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\\n Assessment and Plan\\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\\n and hypotension....all cultures still neg to date this admission\\nsepsis\\n resolved, off all abx.\\n - Will get surveillance cxs during HD\\n - LGI bleed: still has diarrhea, outpt GI w/u.....might need\\n proctoscopy once he recovers.\\n - COPD: on home meds, small O2 reqmt due to atelectasis, cont IS\\n - Afib: rate controlled, not anticoagulated\\n - Depression: cont home Fluoxetine\\n - FEN: Taking good po, SBP appears at baseline\\n - Dispo: walk with pt b4 discharge home...patient upset\\nmay go AMA if\\n he refuses rehab.\\n ICU Care\\n Nutrition:\\n Comments: good po\\n Glycemic Control: stable\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n Code status: Full code\\n Disposition :Home once he walks vs rehab, PT c/s, SW input\\n Total time spent: 35 min\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2126-01-25 00:00:00.000\",\n \"description\": \"Physical Therapy Evaluation Note\",\n \"row_id\": 364136,\n \"text\": \"Attending Physician:\\n date: \\n Medical Diagnosis / ICD 9: /\\n Reason of :\\n History of Present Illness / Subjective Complaint: 82 yo M with PMH\\n significant for ESRD on HD, Atrial Fibrillation/Flutter, C.diff\\n colitis, CVA x 2 with residual right sided weakness, CAD s/p MI,\\n diastolic CHF with EF 60%, klebsiella urosepsis, multi-drug resistant\\n E.Coli Sepsis, and MRSA Sepsis who presented to Hospital\\n with N/V/D and weakness. At OSH, SBPs were noted to be in the 70s\\n and 80s. He was then transferred to for further care of\\n probable sepsis. Upon arrival to ED, his VS were stable but he was\\n noted to have a lactate of 4.1. He was then transferred to the MICU for\\n further management.\\n Past Medical / Surgical History: LUE fistulagram , -Multiple\\n UTIs, including VRE and klebsiella.\\n - Atrial fibrillation\\n - h/o GI bleed, diverticulitis\\n - C. Diff colitis\\n - CVA years ago w/ right-sided weakness; second stroke 5 years\\n ago\\n - h/o nephrolithiasis w/ stent and nephrostomy tube (now removed)\\n - CAD s/p MI\\n - sleep apnea not on cpap\\n - depression\\n - PFTs with mild restrictive ventilatory defect\\n -Anemia with h/o iron deficiency\\n Medications: Ondansetron, Heparin\\n Radiology: cxr: Moderate cardiomegaly without signs of overhydration.\\n Retrocardiac atelectasis. Potential minimal left-sided pleural\\n effusion. Unchanged position of the left-sided central venous access\\n line\\n Labs:\\n 37.2\\n 11.6\\n 138\\n 4.8\\n [image002.jpg]\\n Other labs:\\n Activity Orders: OOB c A\\n Social / Occupational History: Lives with wife, dtr lives down stairs\\n Living Environment: Private home with electric chair lift\\n Prior Functional Status / Activity Level: PTA amb short household\\n distances with RW, and R AFO, has w/c for distance.\\n Objective Test\\n Arousal / Attention / Cognition / Communication: A and O x 3\\n Hemodynamic Response\\n Aerobic Capacity\\n HR\\n BP\\n RR\\n O[2 ]sat\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Supine\\n 102\\n 126/68\\n 96% 2L\\n Rest\\n /\\n Sit\\n /\\n Activity\\n 126-156\\n 136/72\\n 28\\n 90% 2L\\n Stand\\n /\\n Recovery\\n 110\\n 139/110\\n 16\\n 98% 2L\\n Total distance walked: 30'x2\\n Minutes: 5'\\n Pulmonary Status: Nonproductive cough, rapid shallow breathing pattern\\n Integumentary / Vascular: L midline, multiple areas of ecchymosis on B\\n UE\\n Sensory Integrity: Intact to LT t/o\\n Pain / Limiting Symptoms: no reports of pain t/o\\n Posture: increased thoracic kyphosis\\n Range of Motion\\n Muscle Performance\\n B UE and LE grossly WFL, R DF to approx neutral\\n B UE > \\n L LE > 3+/5\\n R LE > x DF\\n Motor Function:\\n Functional Status:\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Gait, Locomotion: Pt ambulated 30'x 2 with seated rest, flexed posture,\\n increased lateral sway. rapid fatigue. distance limited by fatigue and\\n HR increase to 150's.\\n AFO donned for ambulation with Min A\\n Rolling:\\n\\n\\n\\n\\n\\n\\n Supine /\\n Sidelying to Sit:\\n\\n\\n T\\n\\n\\n Transfer:\\n\\n\\n T\\n\\n\\n Sit to Stand:\\n\\n\\n T\\n\\n\\n Ambulation:\\n\\n T\\n\\n\\n\\n Stairs:\\n\\n\\n\\n\\n\\n Balance: Pt has good sitting balance, fair static and dynamic standing\\n balance c RW\\n Education / Communication: Pt status discussed with RN and MD. MD made\\n aware of HR with activity. Pt and wife educated on role of PT and\\n safety concerns regarding home d/c.\\n Intervention:\\n Other:\\n Diagnosis:\\n 1.\\n Balance, Impaired\\n 2.\\n Gait, Impaired\\n 3.\\n Knowledge, Impaired\\n 4.\\n Muscle Performance, Impaired\\n 5.\\n Transfers, Impaired\\n 6.\\n Respiration / Gas Exchange, Impaired\\n Clinical impression / Prognosis: 82 yo m admitted with hypotension and\\n n/v/d presents with above impairments c/w deconditioining. Pts gait\\n impairments are likely close to baseline given h/o CVA and residual R\\n LE weakness. Feel he is not Independent and is at not safe for d/c home\\n at this time given his endurance, and rehab may be beneficial. Pt and\\n family do not wish d/c to rehab, they are in agreement to continue with\\n inpatient PT in an attempt to optimize safety prior to d/c home with\\n services. Pt should be ambulating with nursing using RW to increase\\n activity tolerance.\\n Goals\\n Time frame: 1 wk\\n 1.\\n I bed mobility\\n 2.\\n I amb > 150' c RW\\n 3.\\n I transfers c RW\\n 4.\\n 5.\\n 6.\\n Anticipated Discharge: Home without PT\\n Treatment :\\n Frequency / Duration: 3-5x/wk\\n f/u gait and mobility progress, formal balance assessment.\\n T Patient agrees with the above goals and is willing to participate in\\n the rehabilitation program.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-25 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 364140,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n No Events\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin - 08:00 AM\\n Meropenem - 12:57 PM\\n Linezolid - 02:06 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 AM\\n Heparin Sodium (Prophylaxis) - 08:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: feels well, no complaints\\n Flowsheet Data as of 07:18 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 35.6\\nC (96\\n HR: 96 (76 - 99) bpm\\n BP: 124/77(89) {91/56(66) - 127/90(96)} mmHg\\n RR: 19 (14 - 24) insp/min\\n SpO2: 96%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Total In:\\n 1,154 mL\\n PO:\\n 720 mL\\n TF:\\n IVF:\\n 434 mL\\n Blood products:\\n Total out:\\n 3,300 mL\\n 100 mL\\n Urine:\\n 300 mL\\n 100 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,146 mL\\n -100 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 96%\\n ABG: ///28/\\n Physical Examination\\n General: Alert, oriented, no acute distress\\n HEENT: Sclera anicteric, MMM, OP clear\\n Neck: supple, JVP not elevated, no LAD\\n Lungs: Bibasilar crackles, not clearing with cough\\n CV: normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness, no organomegaly\\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\\n pulse\\n SKIN: no rashes, left subclavian HD cath; very mild erythema at\\n insertion site\\n Labs / Radiology\\n 139 K/uL\\n 11.8 g/dL\\n 84 mg/dL\\n 3.8 mg/dL\\n 28 mEq/L\\n 4.2 mEq/L\\n 24 mg/dL\\n 106 mEq/L\\n 141 mEq/L\\n 37.2 %\\n 6.3 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n 03:45 PM\\n 08:01 AM\\n WBC\\n 18.6\\n 7.6\\n 6.3\\n Hct\\n 41.9\\n 35.6\\n 36.2\\n 37.2\\n Plt\\n 162\\n 133\\n 139\\n Cr\\n 4.7\\n 3.3\\n 3.8\\n TropT\\n 0.05\\n 0.05\\n Glucose\\n 129\\n 89\\n 84\\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\\n Assessment and Plan\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n # Culture negative Sepsis: nothing isolated on cultures. All\\n antibiotics stopped.\\n - will have surveillance cultures as outpatient.\\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\\n # COPD: cont home spiriva, atrovent.\\n # Atrial Fibrillation: currently in sinus with frequent ectopy. Afib\\n was likely in setting of infection. Patient was ROMI. TSH normal\\n -- cont home ASA\\n # Depression: cont home Fluoxetine\\n # FEN: Renal Diet, replete lytes\\n # Prophylaxis: Subcutaneous heparin\\n # Access: PIV\\n # Code: Full\\n # Communication: Patient\\n # Disposition: will work with PT one additional time before likely d/c\\n to home\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 364274,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n no events\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Meropenem - 12:57 PM\\n Linezolid - 02:06 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:46 AM\\n Heparin Sodium (Prophylaxis) - 10:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:11 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98\\n Tcurrent: 36.2\\nC (97.1\\n HR: 87 (76 - 108) bpm\\n BP: 107/68(76) {106/59(66) - 142/118(122)} mmHg\\n RR: 17 (13 - 32) insp/min\\n SpO2: 92%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Height: 66 Inch\\n Total In:\\n 990 mL\\n PO:\\n 890 mL\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 500 mL\\n 0 mL\\n Urine:\\n 500 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 490 mL\\n 0 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 92%\\n ABG: ///28/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 138 K/uL\\n 11.6 g/dL\\n 93 mg/dL\\n 3.1 mg/dL\\n 28 mEq/L\\n 3.9 mEq/L\\n 16 mg/dL\\n 104 mEq/L\\n 140 mEq/L\\n 37.2 %\\n 4.8 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n 03:45 PM\\n 08:01 AM\\n 10:40 AM\\n WBC\\n 18.6\\n 7.6\\n 6.3\\n 4.8\\n Hct\\n 41.9\\n 35.6\\n 36.2\\n 37.2\\n 37.2\\n Plt\\n 162\\n 133\\n 139\\n 138\\n Cr\\n 4.7\\n 3.3\\n 3.8\\n 3.1\\n TropT\\n 0.05\\n 0.05\\n Glucose\\n 129\\n 89\\n 84\\n 93\\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\\n Assessment and Plan\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n # Culture negative Sepsis: nothing isolated on cultures. All\\n antibiotics stopped.\\n - will have surveillance cultures as outpatient.\\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\\n # COPD: cont home spiriva, atrovent.\\n # Atrial Fibrillation: currently in sinus with frequent ectopy. Afib\\n was likely in setting of infection. Patient was ROMI. TSH normal\\n -- cont home ASA\\n # Depression: cont home Fluoxetine\\n # FEN: Renal Diet, replete lytes\\n # Prophylaxis: Subcutaneous heparin\\n # Access: PIV\\n # Code: Full\\n # Communication: Patient\\n # Disposition: will work with PT one additional time before likely d/c\\n to home\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n 20 Gauge - 06:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 364275,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n no events\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Meropenem - 12:57 PM\\n Linezolid - 02:06 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:46 AM\\n Heparin Sodium (Prophylaxis) - 10:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:11 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98\\n Tcurrent: 36.2\\nC (97.1\\n HR: 87 (76 - 108) bpm\\n BP: 107/68(76) {106/59(66) - 142/118(122)} mmHg\\n RR: 17 (13 - 32) insp/min\\n SpO2: 92%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Height: 66 Inch\\n Total In:\\n 990 mL\\n PO:\\n 890 mL\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 500 mL\\n 0 mL\\n Urine:\\n 500 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 490 mL\\n 0 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 92%\\n ABG: ///28/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 138 K/uL\\n 11.6 g/dL\\n 93 mg/dL\\n 3.1 mg/dL\\n 28 mEq/L\\n 3.9 mEq/L\\n 16 mg/dL\\n 104 mEq/L\\n 140 mEq/L\\n 37.2 %\\n 4.8 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n 03:45 PM\\n 08:01 AM\\n 10:40 AM\\n WBC\\n 18.6\\n 7.6\\n 6.3\\n 4.8\\n Hct\\n 41.9\\n 35.6\\n 36.2\\n 37.2\\n 37.2\\n Plt\\n 162\\n 133\\n 139\\n 138\\n Cr\\n 4.7\\n 3.3\\n 3.8\\n 3.1\\n TropT\\n 0.05\\n 0.05\\n Glucose\\n 129\\n 89\\n 84\\n 93\\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\\n 2/2 Blood Cx\\n NGTD\\n Blood Cx\\n NGTD\\n C. Diff neg\\n C. Diff neg\\n Assessment and Plan\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n # Culture negative Sepsis: nothing isolated on cultures. All\\n antibiotics stopped.\\n - will have surveillance cultures as outpatient.\\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\\n # COPD: cont home spiriva, atrovent.\\n # Atrial Fibrillation: currently in sinus with frequent ectopy. Afib\\n was likely in setting of infection. Patient was ROMI. TSH normal\\n -- cont home ASA\\n # Depression: cont home Fluoxetine\\n # FEN: Renal Diet, replete lytes\\n # Prophylaxis: Subcutaneous heparin\\n # Access: PIV\\n # Code: Full\\n # Communication: Patient\\n # Disposition: will work with PT one additional time before likely d/c\\n to home\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n 20 Gauge - 06:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-26 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 364278,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Fellow for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Meropenem - 12:57 PM\\n Linezolid - 02:06 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:46 AM\\n Heparin Sodium (Prophylaxis) - 10:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:30 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98\\n Tcurrent: 36.2\\nC (97.1\\n HR: 95 (76 - 108) bpm\\n BP: 127/70(86) {106/59(66) - 142/118(122)} mmHg\\n RR: 18 (13 - 32) insp/min\\n SpO2: 76%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Height: 66 Inch\\n Total In:\\n 990 mL\\n PO:\\n 890 mL\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 500 mL\\n 0 mL\\n Urine:\\n 500 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 490 mL\\n 0 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 76%\\n ABG: ///28/\\n Physical Examination\\n General: Alert, oriented, no acute distress\\n HEENT: Sclera anicteric, MMM, oropharynx dry\\n Neck: supple, JVP not elevated, no LAD\\n Lungs: Bibasilar crackles new since yesterday.\\n CV: normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness, mild guarding RUQ, no organomegaly\\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\\n pulse\\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\\n insertion site, no TTP of inserstion site\\n Labs / Radiology\\n 11.6 g/dL\\n 138 K/uL\\n 93 mg/dL\\n 3.1 mg/dL\\n 28 mEq/L\\n 3.9 mEq/L\\n 16 mg/dL\\n 104 mEq/L\\n 140 mEq/L\\n 37.2 %\\n 4.8 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n 03:45 PM\\n 08:01 AM\\n 10:40 AM\\n WBC\\n 18.6\\n 7.6\\n 6.3\\n 4.8\\n Hct\\n 41.9\\n 35.6\\n 36.2\\n 37.2\\n 37.2\\n Plt\\n 162\\n 133\\n 139\\n 138\\n Cr\\n 4.7\\n 3.3\\n 3.8\\n 3.1\\n TropT\\n 0.05\\n 0.05\\n Glucose\\n 129\\n 89\\n 84\\n 93\\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\\n Assessment and Plan\\n BALANCE, IMPAIRED\\n GAIT, IMPAIRED\\n KNOWLEDGE, IMPAIRED\\n MUSCLE PERFORMACE, IMPAIRED\\n TRANSFERS, IMPAIRED\\n RESPIRATION / GAS EXCHANGE, IMPAIRED\\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\\n and hypotension....all cultures still neg to date this admission\\nsepsis\\n resolved, off all abx.\\n - Will get surveillance cxs during HD\\n - LGI bleed: still has diarrhea, outpt GI w/u.....might need\\n proctoscopy once he recovers.\\n - COPD: on home meds, small O2 reqmt due to atelectasis, cont IS\\n - Afib: rate controlled, not anticoagulated\\n - Depression: cont home Fluoxetine\\n - FEN: Taking good po, SBP appears at baseline\\n - Dispo: walk with pt b4 discharge home...patient upset\\nmay go AMA if\\n he refuses rehab.\\n ICU Care\\n Nutrition:\\n Comments: good po\\n Glycemic Control: stable\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n Code status: Full code\\n Disposition :Home once he walks vs rehab, PT c/s, SW input\\n Total time spent: 35 min\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-26 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 364293,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Fellow for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n Dialysis today.\\n D/c home after PT today\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Meropenem - 12:57 PM\\n Linezolid - 02:06 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:46 AM\\n Heparin Sodium (Prophylaxis) - 10:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:30 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98\\n Tcurrent: 36.2\\nC (97.1\\n HR: 95 (76 - 108) bpm\\n BP: 127/70(86) {106/59(66) - 142/118(122)} mmHg\\n RR: 18 (13 - 32) insp/min\\n SpO2: 76% --poor pleth\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Height: 66 Inch\\n Total In:\\n 990 mL\\n PO:\\n 890 mL\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 500 mL\\n 0 mL\\n Urine:\\n 500 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 490 mL\\n 0 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 76%\\n ABG: ///28/\\n Physical Examination\\n General: Alert, oriented, no acute distress\\n HEENT: Sclera anicteric, MMM, oropharynx dry\\n Neck: supple, JVP not elevated, no LAD\\n Lungs: Bibasilar crackles\\n CV: normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness, mild guarding RUQ, no organomegaly\\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\\n pulse\\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\\n insertion site, no TTP of inserstion site\\n Labs / Radiology\\n 11.6 g/dL\\n 138 K/uL\\n 93 mg/dL\\n 3.1 mg/dL\\n 28 mEq/L\\n 3.9 mEq/L\\n 16 mg/dL\\n 104 mEq/L\\n 140 mEq/L\\n 37.2 %\\n 4.8 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n 03:45 PM\\n 08:01 AM\\n 10:40 AM\\n WBC\\n 18.6\\n 7.6\\n 6.3\\n 4.8\\n Hct\\n 41.9\\n 35.6\\n 36.2\\n 37.2\\n 37.2\\n Plt\\n 162\\n 133\\n 139\\n 138\\n Cr\\n 4.7\\n 3.3\\n 3.8\\n 3.1\\n TropT\\n 0.05\\n 0.05\\n Glucose\\n 129\\n 89\\n 84\\n 93\\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\\n Assessment and Plan\\n BALANCE, IMPAIRED\\n GAIT, IMPAIRED\\n KNOWLEDGE, IMPAIRED\\n MUSCLE PERFORMACE, IMPAIRED\\n TRANSFERS, IMPAIRED\\n RESPIRATION / GAS EXCHANGE, IMPAIRED\\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presented with one day of\\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\\n and hypotension....all cultures still neg to date this admission\\nsepsis\\n resolved, off all abx.\\n - Will get surveillance cxs during HD\\n - LGI bleed: still has diarrhea, outpt GI w/u.....might need\\n proctoscopy once he recovers.\\n - COPD: on home meds, small O2 reqmt due to atelectasis, cont IS\\n - Afib: rate controlled, not anticoagulated\\n - Depression: cont home Fluoxetine\\n - FEN: Taking good po, SBP appears at baseline\\n - Dispo: walk with pt b4 discharge home...patient upset\\nmay go AMA if\\n he refuses rehab.\\n ICU Care\\n Nutrition:\\n Comments: good po\\n Glycemic Control: stable\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n Code status: Full code\\n Disposition :Home once he walks vs rehab\\n Total time spent: 35 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 363706,\n \"text\": \"This is an 82 year old male with hx of ESRD on HD, Atrial\\n Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of\\n Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with\\n one day of nausea, vomiting and weakness. Patient went to lunch today\\n with his wife and began to feel weak, +lightheadedness. He then had\\n nausea with one episode of non-bloody emesis, no coffee ground. He\\n reports 3 episodes of diarrhea since that time, non-bloody, no melena.\\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\\n dysuria, hematuria, urinary frequency or back pain. He does report\\n abdominal cramping with his diarrhea today. Wife became worried at the\\n restaurant and called EMS. He was taken to hospital and\\n BPs noted to be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x\\n 1, Vanco 1gm IV x 1 and transferred here.\\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\\n transferred to the ICU for further care.\\n Hypotension (not Shock)\\n Assessment:\\n Afebrile with max temp 97.8. sbp down to 88 this afternoon. Hr 90\\n afib with lots of ectopi. Occasionally in bigemony.\\n Action:\\n Given a 500cc ns bolus for sbp 88. zosyn dc\\nd and placed on linezolid\\n and meropenum. Dr made aware of frequent ectopi.\\n Response:\\n Sbp up to the 90\\ns with map>60.\\n Plan:\\n Cont antibiodics as ordered. Follow up on cult result.\\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\\n disease)\\n Assessment:\\n Min uo that is cloudy looking.\\n Action:\\n Hd done today. Only 200cc of fluid removed.\\n Response:\\n Stable hd run.\\n Plan:\\n Renal following.\\n Access- patient has 2 peripheral iv\\ns in right arm that has old non\\n functioning av fistula. Unable to place iv or draw bloods in right arm.\\n Dr made aware. Order placed for iv to place picc in arm.\\n Order placed late in day.\\n wife here most of day. Updated by this nurse, Dr and\\n Dr .\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 363708,\n \"text\": \"This is an 82 year old male with hx of ESRD on HD, Atrial\\n Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of\\n Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with\\n one day of nausea, vomiting and weakness. Patient went to lunch today\\n with his wife and began to feel weak, +lightheadedness. He then had\\n nausea with one episode of non-bloody emesis, no coffee ground. He\\n reports 3 episodes of diarrhea since that time, non-bloody, no melena.\\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\\n dysuria, hematuria, urinary frequency or back pain. He does report\\n abdominal cramping with his diarrhea today. Wife became worried at the\\n restaurant and called EMS. He was taken to hospital and\\n BPs noted to be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x\\n 1, Vanco 1gm IV x 1 and transferred here.\\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\\n transferred to the ICU for further care.\\n Hypotension (not Shock)\\n Assessment:\\n Afebrile with max temp 97.8. sbp down to 88 this afternoon. Hr 90\\n afib with lots of ectopi. Occasionally in bigemony.\\n Action:\\n Given a 500cc ns bolus for sbp 88. zosyn dc\\nd and placed on linezolid\\n and meropenum. Dr made aware of frequent ectopi.\\n Response:\\n Sbp up to the 90\\ns with map>60.\\n Plan:\\n Cont antibiodics as ordered. Follow up on cult result.\\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\\n disease)\\n Assessment:\\n Min uo that is cloudy looking.\\n Action:\\n Hd done today. Only 200cc of fluid removed.\\n Response:\\n Stable hd run.\\n Plan:\\n Renal following.\\n Access- patient has 2 peripheral iv\\ns in right arm that has old non\\n functioning av fistula. Unable to place iv or draw bloods in right arm.\\n Dr made aware. Order placed for iv to place picc in arm.\\n Order placed late in day.\\n wife here most of day. Updated by this nurse, Dr and\\n Dr .\\n ------ Protected Section ------\\n Pleth very difficult to obtain on this patient. Best off left\\n foot. Of note right foot colder than left. Per patient and wife this is\\n baseline for him. Toes on right foot reddish blue. This is also his\\n baseline per patient\\n ------ Protected Section Addendum Entered By: , RN\\n on: 17:57 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 363626,\n \"text\": \"This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\\n vomiting and weakness. Patient went to lunch today with his wife and\\n began to feel weak, +lightheadedness. He then had nausea with one\\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\\n of diarrhea since that time, non-bloody, no melena. He denies any\\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\\n hematuria, urinary frequency or back pain. he does report abdominal\\n cramping with his diarrhea today. Wife became worried at the restaurant\\n and called EMS. He was taken to hospital and BPs noted to\\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\\n IV x 1 and transferred here.\\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\\n transferred to the ICU for further care.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 363704,\n \"text\": \"This is an 82 year old male with hx of ESRD on HD, Atrial\\n Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of\\n Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with\\n one day of nausea, vomiting and weakness. Patient went to lunch today\\n with his wife and began to feel weak, +lightheadedness. He then had\\n nausea with one episode of non-bloody emesis, no coffee ground. He\\n reports 3 episodes of diarrhea since that time, non-bloody, no melena.\\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\\n dysuria, hematuria, urinary frequency or back pain. He does report\\n abdominal cramping with his diarrhea today. Wife became worried at the\\n restaurant and called EMS. He was taken to hospital and\\n BPs noted to be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x\\n 1, Vanco 1gm IV x 1 and transferred here.\\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\\n transferred to the ICU for further care.\\n Hypotension (not Shock)\\n Assessment:\\n Afebrile with max temp 97.8. sbp down to 88 this afternoon.\\n Action:\\n Given a 500cc ns bolus for sbp 88. zosyn dc\\nd and placed on linezolid\\n and meropenum.\\n Response:\\n Sbp up to the 90\\ns with map>60.\\n Plan:\\n Cont antibiodics as ordered. Follow up on cult result.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 363761,\n \"text\": \"This is an 82 year old male with hx of ESRD on HD, Atrial\\n Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of\\n Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with\\n one day of nausea, vomiting and weakness. Patient went to lunch today\\n with his wife and began to feel weak, +lightheadedness. He then had\\n nausea with one episode of non-bloody emesis, no coffee ground. He\\n reports 3 episodes of diarrhea since that time, non-bloody, no melena.\\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\\n dysuria, hematuria, urinary frequency or back pain. He does report\\n abdominal cramping with his diarrhea today. Wife became worried at the\\n restaurant and called EMS. He was taken to hospital and\\n BPs noted to be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x\\n 1, Vanco 1gm IV x 1 and transferred here.\\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\\n transferred to the ICU for further care.\\n Hypotension (not Shock)\\n Assessment:\\n Pt\\ns map occ would dip down less than 60 while sleeping. When awake\\n map\\ns greater than 60. hr in afib with rates in the 80\\ns with freq\\n pvc\\n Action:\\n Pt received a 500cc fluid bolus x 1.\\n Response:\\n Maps greater than 60. bp would come back up when pt was stimulated or\\n woken up.\\n Plan:\\n Cont to monitor bp and notify md of any drops.\\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\\n disease)\\n Assessment:\\n Pt with foley catheter draining minimal amt\\ns of yellow sludgey\\n looking urine. Urine also has foul odor.\\n Action:\\n Pt had a fluid bolus x 1 for low bp\\n Response:\\n Minimal response to urine output.\\n Plan:\\n Follow bun/cr, follow culture results. Pt to have picc line placement\\n today. Cont with abx\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 364008,\n \"text\": \"Difficult IV Access\\n Assessment:\\n Pt called out to floor but lost peripheral access.\\n Action:\\n Attempt by RN and IVRNx3 without success.\\n Response:\\n Floor team refusing to accept pt without access.\\n Plan:\\n Temporary plan was to have PICC placed in IR but further discussion\\n with ID and Renal team led to decision to defer floor transfer and keep\\n pt in ICU for observation over night with plan to DC to home in AM if\\n stable.\\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\\n disease)\\n Assessment:\\n Pt with CKD on HD T/Th/S. BUN/Cr 24/3.8 this AM.\\n Action:\\n HD today.\\n Response:\\n 3L removed with HD.\\n Plan:\\n Cont with regularly scheduled HD. Renal team following.\\n Sepsis without organ dysfunction\\n Assessment:\\n Pt afebrile. WBC 6.3 this AM. SBP remains >90 today. Cdiff cult\\n negative thus far. Urine and blood cultures with no growth to date.\\n Action:\\n Cont meropenem.\\n Response:\\n Cultures still with NGTD. Pt remains afebrile with no white count.\\n Plan:\\n Cont antibiotics as ordered. Monitor for temp spike. Follow up on\\n culture results.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 364011,\n \"text\": \"83yo M with extensive PMH including ESRD on HD, CAD s/p MI, CVA x2, and\\n multiple hospitalizations for sepsis (kelbsiella, MRSA, VRE, Cdiff) who\\n presented with NVD.\\n Difficult IV Access\\n Assessment:\\n Pt called out to floor but lost peripheral access.\\n Action:\\n Attempt by RN and IVRNx3 without success.\\n Response:\\n Floor team refusing to accept pt without access.\\n Plan:\\n Temporary plan was to have PICC placed in IR but further discussion\\n with ID and Renal team led to decision to defer floor transfer and keep\\n pt in ICU for observation over night with plan to DC to home in AM if\\n stable.\\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\\n disease)\\n Assessment:\\n Pt with CKD on HD T/Th/S. BUN/Cr 24/3.8 this AM.\\n Action:\\n HD today.\\n Response:\\n 3L removed with HD.\\n Plan:\\n Cont with regularly scheduled HD. Renal team following.\\n Sepsis without organ dysfunction\\n Assessment:\\n Pt afebrile. WBC 6.3 this AM. SBP remains >90 today. Cdiff cult\\n negative thus far. Urine and blood cultures with no growth to date.\\n Action:\\n All antibiotics DCd per ID recs.\\n Response:\\n Cultures still with NGTD. Pt remains afebrile with no white count.\\n Plan:\\n F/U re: culture results, cont to monitor pt for further s/s sepsis.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-22 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 363623,\n \"text\": \"Chief Complaint:\\n HPI:\\n History of Present Illness:\\n This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\\n vomiting and weakness. Patient went to lunch today with his wife and\\n began to feel weak, +lightheadedness. He then had nausea with one\\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\\n of diarrhea since that time, non-bloody, no melena. He denies any\\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\\n hematuria, urinary frequency or back pain. he does report abdominal\\n cramping with his diarrhea today. Wife became worried at the restaurant\\n and called EMS. He was taken to hospital and BPs noted to\\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\\n IV x 1 and transferred here.\\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs sent and\\n lactate noted to be elevated at 4.1. He was given 3.5 L of NS IVF in\\n the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\\n transferred to the ICU for further care.\\n Patient admitted from: ER\\n History obtained from Patient\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin - 12:46 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n -Stage V CKD on HD with h/o nephrolithiasis w/ stent and nephrostomy\\n tube (AV fistula )\\n -Atrial fibrillation/flutter not on coumadin\\n -h/o GI bleed, diverticulitis\\n -C. Diff colitis\\n -CVA years ago w/ right-sided weakness; second CVA 5 years ago\\n -CAD s/p MI, diastolic HF EF 60%\\n -sleep apnea not on cpap\\n -klebsiella(ESBL) urosepsis\\n -depression\\n -PFTs with mild restrictive ventilatory defect\\n -Anemia with h/o iron deficiency\\n .\\n .\\n Home Medications:\\n Tiotropium Bromide 18 mcg Capsule daily\\n Pantoprazole 40mg daily\\n Aspirin 325mg daily\\n Fluoxetine 10 mg daily\\n Multivitamin\\n B Complex-Vitamin C-Folic Acid 1 mg Capsule\\n Atrovent MDI 1 puff q4h PRN\\n Bisacodyl 5mg PRN\\n Docusate 100mg \\n Fish Oil\\n Lives with wife , h/o smoking PPD for 50 years, quit\\n 20 years ago, does not drink alcohol, no drugs.\\n Review of systems:\\n Flowsheet Data as of 02:26 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.4\\nC (95.7\\n Tcurrent: 35.4\\nC (95.7\\n HR: 108 (101 - 108) bpm\\n BP: 81/58(64) {81/58(64) - 95/61(112)} mmHg\\n RR: 18 (15 - 18) insp/min\\n SpO2: 96%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Total In:\\n 4,600 mL\\n PO:\\n TF:\\n IVF:\\n 600 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 15 mL\\n Urine:\\n 15 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 4,585 mL\\n Respiratory\\n SpO2: 96%\\n Physical Examination\\n Vitals: T: 95.7 BP: 98/57 P: 102 R: 18 94% RA\\n General: Alert, oriented, no acute distress\\n HEENT: Sclera anicteric, MMM, oropharynx dry\\n Neck: supple, JVP not elevated, no LAD\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\\n insertion site, no TTP of inserstion site\\n Labs / Radiology\\n [image002.jpg]\\n Images:\\n CXR: no acute process\\n .\\n EKG: irregular rate and rhythm, no acute ST or T wave changes\\n Assessment and Plan\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n .\\n # Sepsis: Mr. has history of MDR bactermias and presents with\\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn cover his\\n previous MRSA, MDR E.coli and ESBL Klebsiella. will cont with that\\n regimen for now.\\n -- cont Vanco/Zosyn\\n -- D/C CTX\\n -- send UA/UCx\\n -- repeat lactate\\n -- 1L IVF bolus\\n -- trend fever WBC curve\\n .\\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\\n -- likely HD tomorrow\\n -- may need new line placed if +blood cultures\\n .\\n # COPD: cont home spiriva, atrovent.\\n .\\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\\n setting of infection. will ROMI\\n -- cycle cardiac enzymes\\n -- monitor on tele\\n -- check TSH\\n .\\n # Depression: cont home Fluoxetine\\n .\\n # FEN: Renal Diet, replete lytes\\n .\\n # Prophylaxis: Subcutaneous heparin\\n .\\n # Access: peripherals\\n .\\n # Code: presumed full\\n .\\n # Communication: Patient\\n .\\n # Disposition: pending above\\n ICU Care\\n Nutrition: Regular Renal\\n Glycemic Control: None\\n Lines:\\n 22 Gauge - 12:43 AM\\n 20 Gauge - 12:44 AM\\n Prophylaxis:\\n DVT: Hep SQ\\n Stress ulcer: PPI\\n VAP: None\\n Comments:\\n Communication: Comments:\\n Code status: Full\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-22 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 363625,\n \"text\": \"Chief Complaint:\\n HPI:\\n History of Present Illness:\\n This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\\n vomiting and weakness. Patient went to lunch today with his wife and\\n began to feel weak, +lightheadedness. He then had nausea with one\\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\\n of diarrhea since that time, non-bloody, no melena. He denies any\\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\\n hematuria, urinary frequency or back pain. he does report abdominal\\n cramping with his diarrhea today. Wife became worried at the restaurant\\n and called EMS. He was taken to hospital and BPs noted to\\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\\n IV x 1 and transferred here.\\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs sent and\\n lactate noted to be elevated at 4.1. He was given 3.5 L of NS IVF in\\n the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\\n transferred to the ICU for further care.\\n Patient admitted from: ER\\n History obtained from Patient\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin - 12:46 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n -Stage V CKD on HD with h/o nephrolithiasis w/ stent and nephrostomy\\n tube (AV fistula )\\n -Atrial fibrillation/flutter not on coumadin\\n -h/o GI bleed, diverticulitis\\n -C. Diff colitis\\n -CVA years ago w/ right-sided weakness; second CVA 5 years ago\\n -CAD s/p MI, diastolic HF EF 60%\\n -sleep apnea not on cpap\\n -klebsiella(ESBL) urosepsis\\n -depression\\n -PFTs with mild restrictive ventilatory defect\\n -Anemia with h/o iron deficiency\\n .\\n .\\n Home Medications:\\n Tiotropium Bromide 18 mcg Capsule daily\\n Pantoprazole 40mg daily\\n Aspirin 325mg daily\\n Fluoxetine 10 mg daily\\n Multivitamin\\n B Complex-Vitamin C-Folic Acid 1 mg Capsule\\n Atrovent MDI 1 puff q4h PRN\\n Bisacodyl 5mg PRN\\n Docusate 100mg \\n Fish Oil\\n NC\\n Lives with wife , h/o smoking PPD for 50 years, quit\\n 20 years ago, does not drink alcohol, no drugs.\\n Review of systems:\\n Flowsheet Data as of 02:26 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.4\\nC (95.7\\n Tcurrent: 35.4\\nC (95.7\\n HR: 108 (101 - 108) bpm\\n BP: 81/58(64) {81/58(64) - 95/61(112)} mmHg\\n RR: 18 (15 - 18) insp/min\\n SpO2: 96%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Total In:\\n 4,600 mL\\n PO:\\n TF:\\n IVF:\\n 600 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 15 mL\\n Urine:\\n 15 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 4,585 mL\\n Respiratory\\n SpO2: 96%\\n Physical Examination\\n Vitals: T: 95.7 BP: 98/57 P: 102 R: 18 94% RA\\n General: Alert, oriented, no acute distress\\n HEENT: Sclera anicteric, MMM, oropharynx dry\\n Neck: supple, JVP not elevated, no LAD\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot,\\n dopplerable right pedal pulse, dopplerable right tibial pulse\\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\\n insertion site, no TTP of inserstion site\\n Labs / Radiology\\n 208\\n 16.9\\n 149\\n 4.7\\n 33\\n 23\\n 101\\n 4.6\\n 144\\n 53.9\\n 22.2\\n [image002.jpg]\\n Lactate 4.1.\\n Images:\\n CXR: no acute process\\n .\\n EKG: irregular rate and rhythm, no acute ST or T wave changes\\n Assessment and Plan\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n .\\n # Sepsis: Mr. has history of MDR bactermias and presents with\\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn cover his\\n previous MRSA, MDR E.coli and ESBL Klebsiella. will cont with that\\n regimen for now.\\n -- cont Vanco/Zosyn\\n -- D/C CTX\\n -- send UA/UCx\\n -- repeat lactate\\n -- repeat CBC, Chem 7\\n -- 1L IVF bolus\\n -- trend fever WBC curve\\n .\\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\\n -- likely HD tomorrow\\n -- may need new line placed if +blood cultures\\n .\\n # COPD: cont home spiriva, atrovent.\\n .\\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\\n setting of infection. will ROMI\\n -- cycle cardiac enzymes\\n -- monitor on tele\\n -- check TSH\\n -- cont home ASA\\n .\\n # Depression: cont home Fluoxetine\\n .\\n # FEN: Renal Diet, replete lytes\\n .\\n # Prophylaxis: Subcutaneous heparin\\n .\\n # Access: PIV\\n .\\n # Code: Full\\n .\\n # Communication: Patient\\n .\\n # Disposition: pending above\\n ICU Care\\n Nutrition: Regular Renal\\n Glycemic Control: None\\n Lines:\\n 22 Gauge - 12:43 AM\\n 20 Gauge - 12:44 AM\\n Prophylaxis:\\n DVT: Hep SQ\\n Stress ulcer: PPI\\n VAP: None\\n Comments:\\n Communication: Comments:\\n Code status: Full\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 363907,\n \"text\": \"82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n Sepsis without organ dysfunction\\n Assessment:\\n Wbc down to 7.6. afebrile. Sbp 90 or greater today. Cdiff cult neg.\\n urine and bc pending.\\n Action:\\n Cont on linezolid and meropenum. Team decided not to place picc till\\n final cult results back. Id consulted. Survelliance cult x2 done one\\n peripheral and one via hd cath line\\n Response:\\n Bp improved. Afebrile.\\n Plan:\\n Cont antiobidics as ordered. Monitor for temp spike. Follow up on cult\\n Obstructive sleep apnea (OSA)\\n Assessment:\\n Patient with known hx of sleep apnea. Does not wear bipap at home. Had\\n been on home o2 per wife but none in the past week.\\n Action:\\n Taken off o2 to see how his sats would do.\\n Response:\\n Sats 92 or greater when awake. Fell to 87% when he fell asleep. O2\\n replaced at 1l nc.\\n Plan:\\n Cont to monitor sats.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 364070,\n \"text\": \"83yo M with extensive PMH including ESRD on HD, CAD s/p MI, CVA x2, and\\n multiple hospitalizations for sepsis (kelbsiella, MRSA, VRE, Cdiff) who\\n presented with NVD.\\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\\n disease)\\n Assessment:\\n Pt had foley removed earlier last evening and was due to void between\\n 8-10pm. Pt was offered the urinal but found pt to be incontinent. Pt\\n stated that he was unaware that he was incontinent. Pt also has been\\n incontinent of loose brown stool. When asked why he did not ask for a\\n bedpan pt stated that it comes out too fast.\\n Action:\\n Pt checked freq and asked if he could use a urinal but pt stated that\\n he did not have to void.\\n Response:\\n Pt found to be incontinent of urine and stool x 2 during the night . a\\n diaper was placed on the pt and aloe vesta cream applied to perianal\\n area because it is beginning to look very red.\\n Plan:\\n Check pt freq and offer bedpan/urinal. No labs drawn this am. Pt is due\\n to be discharged today to home. The issue of his incontinence will need\\n to be addressed with pt and pt\\ns wife.\\n Obstructive sleep apnea (OSA)\\n Assessment:\\n Pt cont to have sleep apnea but o2 sat\\ns have remained in the 90\\n with 1lnc. Lung sounds clear and diminished at the bases.\\n Action:\\n Pt turned freq and encouraged deep breathing.\\n Response:\\n Pt slept well during the night. Maintaining o2 sats in mid to high\\n 90\\n Plan:\\n Keep hob elevated. Discuss bipap at home.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 364004,\n \"text\": \" Problem - Description In Comments\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\\n disease)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Sepsis without organ dysfunction\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-22 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 363680,\n \"text\": \"Chief Complaint:\\n HPI:\\n History of Present Illness:\\n This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\\n vomiting and weakness. Patient went to lunch today with his wife and\\n began to feel weak, +lightheadedness. He then had nausea with one\\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\\n of diarrhea since that time, non-bloody, no melena. He denies any\\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\\n hematuria, urinary frequency or back pain. he does report abdominal\\n cramping with his diarrhea today. Wife became worried at the restaurant\\n and called EMS. He was taken to hospital and BPs noted to\\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\\n IV x 1 and transferred here.\\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs sent and\\n lactate noted to be elevated at 4.1. He was given 3.5 L of NS IVF in\\n the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\\n transferred to the ICU for further care.\\n Patient admitted from: ER\\n History obtained from Patient\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin - 12:46 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n -Stage V CKD on HD with h/o nephrolithiasis w/ stent and nephrostomy\\n tube (AV fistula )\\n -Atrial fibrillation/flutter not on coumadin\\n -h/o GI bleed, diverticulitis\\n -C. Diff colitis\\n -CVA years ago w/ right-sided weakness; second CVA 5 years ago\\n -CAD s/p MI, diastolic HF EF 60%\\n -sleep apnea not on cpap\\n -klebsiella(ESBL) urosepsis\\n -depression\\n -PFTs with mild restrictive ventilatory defect\\n -Anemia with h/o iron deficiency\\n .\\n .\\n Home Medications:\\n Tiotropium Bromide 18 mcg Capsule daily\\n Pantoprazole 40mg daily\\n Aspirin 325mg daily\\n Fluoxetine 10 mg daily\\n Multivitamin\\n B Complex-Vitamin C-Folic Acid 1 mg Capsule\\n Atrovent MDI 1 puff q4h PRN\\n Bisacodyl 5mg PRN\\n Docusate 100mg \\n Fish Oil\\n NC\\n Lives with wife , h/o smoking PPD for 50 years, quit\\n 20 years ago, does not drink alcohol, no drugs.\\n Review of systems:\\n Flowsheet Data as of 02:26 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.4\\nC (95.7\\n Tcurrent: 35.4\\nC (95.7\\n HR: 108 (101 - 108) bpm\\n BP: 81/58(64) {81/58(64) - 95/61(112)} mmHg\\n RR: 18 (15 - 18) insp/min\\n SpO2: 96%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Total In:\\n 4,600 mL\\n PO:\\n TF:\\n IVF:\\n 600 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 15 mL\\n Urine:\\n 15 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 4,585 mL\\n Respiratory\\n SpO2: 96%\\n Physical Examination\\n Vitals: T: 95.7 BP: 98/57 P: 102 R: 18 94% RA\\n General: Alert, oriented, no acute distress\\n HEENT: Sclera anicteric, MMM, oropharynx dry\\n Neck: supple, JVP not elevated, no LAD\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot,\\n dopplerable right pedal pulse, dopplerable right tibial pulse\\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\\n insertion site, no TTP of inserstion site\\n Labs / Radiology\\n 208\\n 16.9\\n 149\\n 4.7\\n 33\\n 23\\n 101\\n 4.6\\n 144\\n 53.9\\n 22.2\\n [image002.jpg]\\n Lactate 4.1.\\n Images:\\n CXR: no acute process\\n .\\n EKG: irregular rate and rhythm, no acute ST or T wave changes\\n Assessment and Plan\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n .\\n # Sepsis: Mr. has history of MDR bactermias and presents with\\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn cover his\\n previous MRSA, MDR E.coli and ESBL Klebsiella. will cont with that\\n regimen for now.\\n -- cont Vanco/Zosyn\\n -- D/C CTX\\n -- send UA/UCx\\n -- repeat lactate\\n -- repeat CBC, Chem 7\\n -- 1L IVF bolus\\n -- trend fever WBC curve\\n .\\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\\n -- likely HD tomorrow\\n -- may need new line placed if +blood cultures\\n .\\n # COPD: cont home spiriva, atrovent.\\n .\\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\\n setting of infection. will ROMI\\n -- cycle cardiac enzymes\\n -- monitor on tele\\n -- check TSH\\n -- cont home ASA\\n .\\n # Depression: cont home Fluoxetine\\n .\\n # FEN: Renal Diet, replete lytes\\n .\\n # Prophylaxis: Subcutaneous heparin\\n .\\n # Access: PIV\\n .\\n # Code: Full\\n .\\n # Communication: Patient\\n .\\n # Disposition: pending above\\n ICU Care\\n Nutrition: Regular Renal\\n Glycemic Control: None\\n Lines:\\n 22 Gauge - 12:43 AM\\n 20 Gauge - 12:44 AM\\n Prophylaxis:\\n DVT: Hep SQ\\n Stress ulcer: PPI\\n VAP: None\\n Comments:\\n Communication: Comments:\\n Code status: Full\\n Disposition: ICU\\n ------ Protected Section ------\\n Called Micro Lab\\n 1 set blood cultures NGTD\\n ------ Protected Section Addendum Entered By: , MD\\n on: 11:06 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-22 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note - MICU\",\n \"row_id\": 363684,\n \"text\": \"Chief Complaint:\\n HPI:\\n 82 yo M with hx of\\n ESRD on HD\\n Atrial Fibrillation/Flutter not anticoagulated\\n C.diff, CVA x 2\\n CAD s/p MI, diastolic CHF\\n presents with weakness/N/V (non bloody)/D x 1 day\\n went to OSH\\n SBP\\n 70-80 improved with fluids\\n got Vanc and \\n transferred to\\n \\n lactate 4.1, WBC 22, 90%N, Hct 51\\n got Zosyn in ED, 3.5L NS,\\n SBP 90s.\\n Patient admitted from: ER\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin - 08:00 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Home Medications:\\n Tiotropium Bromide 18 mcg Capsule daily\\n Pantoprazole 40mg daily\\n Aspirin 325mg daily\\n Fluoxetine 10 mg daily\\n Multivitamin\\n B Complex-Vitamin C-Folic Acid 1 mg Capsule\\n Atrovent MDI 1 puff q4h PRN\\n Bisacodyl 5mg PRN\\n Docusate 100mg \\n Fish Oil\\n Past medical history:\\n Family history:\\n Social History:\\n -Stage V CKD on HD with h/o nephrolithiasis w/ stent and nephrostomy\\n tube (AV fistula )\\n - hx of ESBL Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis, hx\\n VRE UTI : since / : associated with HD line\\n -Atrial fibrillation/flutter not on coumadin\\n -h/o GI bleed, diverticulitis\\n -C. Diff colitis\\n -CVA years ago w/ right-sided weakness; second CVA 5 years ago\\n -CAD s/p MI, diastolic HF EF 60%\\n -sleep apnea not on cpap\\n -depression\\n -PFTs with mild restrictive ventilatory defect\\n -Anemia with h/o iron deficiency\\n NC\\n Occupation:\\n Drugs: no\\n Tobacco: h/o smoking PPD for 50 years, quit 20 years ago\\n Alcohol: no\\n Other: Lives with wife in \\n Review of systems:\\n +lightheadedness\\n no melena\\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\\n dysuria, hematuria, urinary frequency or back pain.\\n Flowsheet Data as of 08:24 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.4\\nC (97.5\\n Tcurrent: 36.4\\nC (97.5\\n HR: 96 (92 - 108) bpm\\n BP: 93/64(71) {81/52(62) - 106/67(112)} mmHg\\n RR: 19 (15 - 21) insp/min\\n SpO2: 95%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Total In:\\n 4,751 mL\\n PO:\\n TF:\\n IVF:\\n 751 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 50 mL\\n Urine:\\n 50 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 4,701 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 95%\\n ABG: ///20/\\n Physical Examination\\n General: Alert, oriented, no acute distress\\n HEENT: Sclera anicteric, MMM, oropharynx dry\\n Neck: supple, JVP not elevated, no LAD\\n Lungs: Clear to auscultation bilaterally, no wheezes, bibasilar\\n crackles and dullness to percussion\\n CV: normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, mild tender RUQ, non-distended, bowel sounds present,\\n no rebound tenderness, mild guarding RUQ, no organomegaly\\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\\n pulse\\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\\n insertion site, no TTP of inserstion site\\n Labs / Radiology\\n 162 K/uL\\n 41.9 %\\n 13.8 g/dL\\n 129 mg/dL\\n 4.7 mg/dL\\n 36 mg/dL\\n 20 mEq/L\\n 105 mEq/L\\n 4.7 mEq/L\\n 138 mEq/L\\n 18.6 K/uL\\n [image002.jpg]\\n 03:25 AM\\n WBC\\n 18.6\\n Hct\\n 41.9\\n Plt\\n 162\\n Cr\\n 4.7\\n Glucose\\n 129\\n Other labs: CK / CKMB / Troponin-T:25//, Lactic Acid:1.3 mmol/L,\\n Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:5.7 mg/dL\\n CXR: small bilateral effusions, small atelectasis R base\\n EKG: irreg, afib, no ST-T changes\\n Assessment and Plan\\n HYPOTENSION (NOT SHOCK)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\\n and hypotension.\\n # Shock: likely sepsis.\\n Sources: history of MDR bactermias (ESBL Kleb, MRSA, VRE) in urine and\\n HD line. He was given Vancomycin 1gm IV x 1, CTX 1gm IV x 2 and Zosyn\\n 4.5gm IV x 1.\\n - Broaden to Linezolid and Meropenem\\n - check cdiff\\n - send LFTs (abd pain)\\n - f/u urine, line, blood cxs\\n .\\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\\n -- likely HD tomorrow\\n -- may need new line placed if +blood cultures\\n GI: monitor diarrhea/N/V, check LFTs\\n .\\n # COPD: cont home spiriva, atrovent. Wean off O2\\n .\\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\\n setting of infection. will ROMI\\n -- cycle cardiac enzymes\\n -- monitor on tele\\n -- check TSH\\n -- cont home ASA\\n # Depression: cont home Fluoxetine\\n .\\n # FEN: Renal Diet, replete lytes\\n # I/O: Bolus per SBP, see how he does with dialysis\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines / Intubation:\\n Dialysis Catheter - 12:43 AM\\n 22 Gauge - 12:43 AM\\n 20 Gauge - 12:44 AM\\n Comments:\\n Prophylaxis:\\n DVT: sq hep\\n Stress ulcer: ppi\\n VAP:\\n Comments:\\n Communication: Comments: patient\\n Code status: Full\\n Disposition: ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 364069,\n \"text\": \"Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\\n disease)\\n Assessment:\\n Pt had foley removed earlier last evening and was due to void between\\n 8-10pm. Pt was offered the urinal but found pt to be incontinent. Pt\\n stated that he was unaware that he was incontinent. Pt also has been\\n incontinent of loose brown stool. When asked why he did not ask for a\\n bedpan pt stated that it comes out too fast.\\n Action:\\n Pt checked freq and asked if he could use a urinal but pt stated that\\n he did not have to void.\\n Response:\\n Pt found to be incontinent of urine and stool x 2 during the night . a\\n diaper was placed on the pt and aloe vesta cream applied to perianal\\n area because it is beginning to look very red.\\n Plan:\\n Check pt freq and offer bedpan/urinal. No labs drawn this am. Pt is due\\n to be discharged today to home. The issue of his incontinence will need\\n to be addressed with pt and pt\\ns wife.\\n Obstructive sleep apnea (OSA)\\n Assessment:\\n Pt cont to have sleep apnea but o2 sat\\ns have remained in the 90\\n with 1lnc. Lung sounds clear and diminished at the bases.\\n Action:\\n Pt turned freq and encouraged deep breathing.\\n Response:\\n Pt slept well during the night. Maintaining o2 sats in mid to high\\n 90\\n Plan:\\n Keep hob elevated. Discuss bipap at home.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 363668,\n \"text\": \"This is an 82 year old male with hx of ESRD on HD, Atrial\\n Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of\\n Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with\\n one day of nausea, vomiting and weakness. Patient went to lunch today\\n with his wife and began to feel weak, +lightheadedness. He then had\\n nausea with one episode of non-bloody emesis, no coffee ground. He\\n reports 3 episodes of diarrhea since that time, non-bloody, no melena.\\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\\n dysuria, hematuria, urinary frequency or back pain. He does report\\n abdominal cramping with his diarrhea today. Wife became worried at the\\n restaurant and called EMS. He was taken to hospital and\\n BPs noted to be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x\\n 1, Vanco 1gm IV x 1 and transferred here.\\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\\n transferred to the ICU for further care.\\n Hypotension (not Shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-22 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note - MICU\",\n \"row_id\": 363670,\n \"text\": \"Chief Complaint:\\n HPI:\\n 82 yo M with hx of\\n ESRD on HD\\n Atrial Fibrillation/Flutter not anticoagulated\\n C.diff, CVA x 2\\n CAD s/p MI, diastolic CHF\\n presents with weakness/N/V (non bloody)/D x 1 day\\n went to OSH\\n SBP\\n 70-80 improved with fluids\\n got Vanc and \\n transferred to\\n \\n lactate 4.1, WBC 22, 90%N, Hct 51\\n got Zosyn in ED, 3.5L NS,\\n SBP 90s.\\n Patient admitted from: ER\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin - 08:00 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Home Medications:\\n Tiotropium Bromide 18 mcg Capsule daily\\n Pantoprazole 40mg daily\\n Aspirin 325mg daily\\n Fluoxetine 10 mg daily\\n Multivitamin\\n B Complex-Vitamin C-Folic Acid 1 mg Capsule\\n Atrovent MDI 1 puff q4h PRN\\n Bisacodyl 5mg PRN\\n Docusate 100mg \\n Fish Oil\\n Past medical history:\\n Family history:\\n Social History:\\n -Stage V CKD on HD with h/o nephrolithiasis w/ stent and nephrostomy\\n tube (AV fistula )\\n - hx of ESBL Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis, hx\\n VRE UTI : since / : associated with HD line\\n -Atrial fibrillation/flutter not on coumadin\\n -h/o GI bleed, diverticulitis\\n -C. Diff colitis\\n -CVA years ago w/ right-sided weakness; second CVA 5 years ago\\n -CAD s/p MI, diastolic HF EF 60%\\n -sleep apnea not on cpap\\n -depression\\n -PFTs with mild restrictive ventilatory defect\\n -Anemia with h/o iron deficiency\\n NC\\n Occupation:\\n Drugs: no\\n Tobacco: h/o smoking PPD for 50 years, quit 20 years ago\\n Alcohol: no\\n Other: Lives with wife in \\n Review of systems:\\n +lightheadedness\\n no melena\\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\\n dysuria, hematuria, urinary frequency or back pain.\\n Flowsheet Data as of 08:24 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.4\\nC (97.5\\n Tcurrent: 36.4\\nC (97.5\\n HR: 96 (92 - 108) bpm\\n BP: 93/64(71) {81/52(62) - 106/67(112)} mmHg\\n RR: 19 (15 - 21) insp/min\\n SpO2: 95%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Total In:\\n 4,751 mL\\n PO:\\n TF:\\n IVF:\\n 751 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 50 mL\\n Urine:\\n 50 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 4,701 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 95%\\n ABG: ///20/\\n Physical Examination\\n General: Alert, oriented, no acute distress\\n HEENT: Sclera anicteric, MMM, oropharynx dry\\n Neck: supple, JVP not elevated, no LAD\\n Lungs: Clear to auscultation bilaterally, no wheezes, bibasilar\\n crackles and dullness to percussion\\n CV: normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, mild tender RUQ, non-distended, bowel sounds present,\\n no rebound tenderness, mild guarding RUQ, no organomegaly\\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\\n pulse\\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\\n insertion site, no TTP of inserstion site\\n Labs / Radiology\\n 162 K/uL\\n 41.9 %\\n 13.8 g/dL\\n 129 mg/dL\\n 4.7 mg/dL\\n 36 mg/dL\\n 20 mEq/L\\n 105 mEq/L\\n 4.7 mEq/L\\n 138 mEq/L\\n 18.6 K/uL\\n [image002.jpg]\\n 03:25 AM\\n WBC\\n 18.6\\n Hct\\n 41.9\\n Plt\\n 162\\n Cr\\n 4.7\\n Glucose\\n 129\\n Other labs: CK / CKMB / Troponin-T:25//, Lactic Acid:1.3 mmol/L,\\n Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:5.7 mg/dL\\n CXR: small bilateral effusions, small atelectasis R base\\n EKG: irreg, afib, no ST-T changes\\n Assessment and Plan\\n HYPOTENSION (NOT SHOCK)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\\n and hypotension.\\n # Shock: likely sepsis.\\n Sources: history of MDR bactermias (ESBL Kleb, MRSA, VRE) in urine and\\n HD line. He was given Vancomycin 1gm IV x 1, CTX 1gm IV x 2 and Zosyn\\n 4.5gm IV x 1.\\n - Broaden to Linezolid and Meropenem\\n - check cdiff\\n - send LFTs (abd pain)\\n - f/u urine, line, blood cxs\\n .\\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\\n -- likely HD tomorrow\\n -- may need new line placed if +blood cultures\\n GI: monitor diarrhea/N/V, check LFTs\\n .\\n # COPD: cont home spiriva, atrovent. Wean off O2\\n .\\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\\n setting of infection. will ROMI\\n -- cycle cardiac enzymes\\n -- monitor on tele\\n -- check TSH\\n -- cont home ASA\\n # Depression: cont home Fluoxetine\\n .\\n # FEN: Renal Diet, replete lytes\\n # I/O: Bolus per SBP, see how he does with dialysis\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines / Intubation:\\n Dialysis Catheter - 12:43 AM\\n 22 Gauge - 12:43 AM\\n 20 Gauge - 12:44 AM\\n Comments:\\n Prophylaxis:\\n DVT: sq hep\\n Stress ulcer: ppi\\n VAP:\\n Comments:\\n Communication: Comments: patient\\n Code status: Full\\n Disposition: ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 363838,\n \"text\": \"82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n Sepsis without organ dysfunction\\n Assessment:\\n Wbc down to 7.6. afebrile. Sbp 90 or greater today. Cdiff cult neg.\\n urine and bc pending.\\n Action:\\n Cont on linezolid and meropenum. Team decided not to place picc till\\n final cult results back. Id consulted. Survelliance cult x2 done one\\n peripheral and one via hd cath line\\n Response:\\n Bp improved. Afebrile.\\n Plan:\\n Cont antiobidics as ordered. Monitor for temp spike. Follow up on cult\\n Obstructive sleep apnea (OSA)\\n Assessment:\\n Patient with known hx of sleep apnea. Does not wear bipap at home. Had\\n been on home o2 per wife but none in the past week.\\n Action:\\n Taken off o2 to see how his sats would do.\\n Response:\\n Sats 92 or greater when awake. Fell to 87% when he fell asleep. O2\\n replaced at 1l nc.\\n Plan:\\n Cont to monitor sats.\\n wife in to visit. Updated on plan of care.\\n Activity.- pt consult placed. Patient s/p cva with residual right sided\\n weakness. Uses walker at home. OOb to chair with assist of 2. Tolerated\\n well.\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2126-01-24 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 363990,\n \"text\": \"TITLE:\\n Rehab Services Physical Therapy:\\n Consult received and appreciated. Attempted to see patient this\\n afternoon for evaluation, and mobilization. Pt declined PT intervention\\n at this time. Educated patient on the role of Physical Therapy and\\n importance of increasing time OOB. We will f/u as able for evaluation.\\n Thank you. PT \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 364236,\n \"text\": \"Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\\n disease)\\n Assessment:\\n Stable vital signs, no BM and not voided in this shift.\\n Action:\\n Pt slept through night .\\n Response:\\n Pt found to be incontinent of urine and stool x 2 during the night . a\\n diaper was placed on the pt and aloe vesta cream applied to perianal\\n area because it is beginning to look very red.\\n Plan:\\n Check pt freq and offer bedpan/urinal. No labs drawn this am. Pt is due\\n to be discharged today to home. The issue of his incontinence will need\\n to be addressed with pt and pt\\ns wife.\\n Obstructive sleep apnea (OSA)\\n Assessment:\\n Pt cont to have sleep apnea but o2 sat\\ns have remained in the 90\\n with 1lnc. Lung sounds clear and diminished at the bases.\\n Action:\\n Pt turned freq and encouraged deep breathing.\\n Response:\\n Pt slept well during the night. Maintaining o2 sats in mid to high\\n 90\\n Plan:\\n Keep hob elevated. Discuss bipap at home.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-24 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 363976,\n \"text\": \"Chief Complaint: Septic shock\\n I saw and examined the patient, and was physically present with the ICU\\n Fellow for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n ID agreed with current abx\\n Hct stable with guiac + stools and diarrhea overnight. Cdiff neg.\\n SBP stable\\n History obtained from Patient\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin - 08:00 AM\\n Meropenem - 12:57 PM\\n Linezolid - 02:06 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 AM\\n Heparin Sodium (Prophylaxis) - 08:00 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:50 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 35.4\\nC (95.8\\n HR: 82 (77 - 94) bpm\\n BP: 98/64(70) {91/52(63) - 118/80(85)} mmHg\\n RR: 19 (11 - 25) insp/min\\n SpO2: 95%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Total In:\\n 2,240 mL\\n 647 mL\\n PO:\\n 800 mL\\n 240 mL\\n TF:\\n IVF:\\n 1,440 mL\\n 407 mL\\n Blood products:\\n Total out:\\n 335 mL\\n 175 mL\\n Urine:\\n 335 mL\\n 175 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,905 mL\\n 472 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 95%\\n ABG: ///28/\\n Physical Examination\\n General: Alert, oriented, no acute distress\\n HEENT: Sclera anicteric, MMM, oropharynx dry\\n Neck: supple, JVP not elevated, no LAD\\n Lungs: Bibasilar crackles new since yesterday.\\n CV: normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness, mild guarding RUQ, no organomegaly\\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\\n pulse\\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\\n insertion site, no TTP of inserstion site\\n Labs / Radiology\\n 11.8 g/dL\\n 139 K/uL\\n 84 mg/dL\\n 3.8 mg/dL\\n 28 mEq/L\\n 4.2 mEq/L\\n 24 mg/dL\\n 106 mEq/L\\n 141 mEq/L\\n 37.2 %\\n 6.3 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n 03:45 PM\\n 08:01 AM\\n WBC\\n 18.6\\n 7.6\\n 6.3\\n Hct\\n 41.9\\n 35.6\\n 36.2\\n 37.2\\n Plt\\n 162\\n 133\\n 139\\n Cr\\n 4.7\\n 3.3\\n 3.8\\n TropT\\n 0.05\\n 0.05\\n Glucose\\n 129\\n 89\\n 84\\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\\n Microbiology: All cxs: ngtd\\n Urine: yeast\\n Assessment and Plan\\n OBSTRUCTIVE SLEEP APNEA (OSA)\\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\\n DISEASE)\\n HYPOTENSION (NOT SHOCK)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\\n and hypotension....all cultures still neg to date this admission.\\n # Shock: likely sepsis from urine..potivive UA but grew only yeast. On\\n Linezolid and Meropenem. D/c per ID recs since all cxs neg. D/c foley\\n # ESRD on HD: Patient on T/Th/Sat dialysis. HD line site with mild\\n erythema but non tender\\n # LGI bleed: diarrhea overnight. Still blood tinged. GI\\n consult....might need proctoscopy once he recovers. Follow Hct.\\n # COPD: cont home spiriva, atrovent. Wean off O2. Hx of OSA, not on\\n Rx...watch for progression of crackles. Use Incentive spirometry.\\n # Atrial Fibrillation: rate controlled, not anticoagulated\\n # Depression: cont home Fluoxetine\\n # FEN: Taking good po, SBP appears at baseline\\n ICU Care\\n Nutrition:\\n Comments: good po\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 12:43 AM\\n 22 Gauge - 12:43 AM\\n picc based on decision reg duration of abx per ID\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :Transfer to floor\\n Total time spent: 35 min\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-22 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note - MICU\",\n \"row_id\": 363667,\n \"text\": \"Chief Complaint:\\n HPI:\\n This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\\n vomiting and weakness. Patient went to lunch today with his wife and\\n began to feel weak, +lightheadedness. He then had nausea with one\\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\\n of diarrhea since that time, non-bloody, no melena. He denies any\\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\\n hematuria, urinary frequency or back pain. he does report abdominal\\n cramping with his diarrhea today. Wife became worried at the restaurant\\n and called EMS. He was taken to hospital and BPs noted to\\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\\n IV x 1 and transferred here.\\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs sent and\\n lactate noted to be elevated at 4.1. He was given 3.5 L of NS IVF in\\n the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\\n transferred to the ICU for further care.\\n Patient admitted from: ER\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin - 08:00 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Home Medications:\\n Tiotropium Bromide 18 mcg Capsule daily\\n Pantoprazole 40mg daily\\n Aspirin 325mg daily\\n Fluoxetine 10 mg daily\\n Multivitamin\\n B Complex-Vitamin C-Folic Acid 1 mg Capsule\\n Atrovent MDI 1 puff q4h PRN\\n Bisacodyl 5mg PRN\\n Docusate 100mg \\n Fish Oil\\n Past medical history:\\n Family history:\\n Social History:\\n -Stage V CKD on HD with h/o nephrolithiasis w/ stent and nephrostomy\\n tube (AV fistula )\\n -Atrial fibrillation/flutter not on coumadin\\n -h/o GI bleed, diverticulitis\\n -C. Diff colitis\\n -CVA years ago w/ right-sided weakness; second CVA 5 years ago\\n -CAD s/p MI, diastolic HF EF 60%\\n -sleep apnea not on cpap\\n -klebsiella(ESBL) urosepsis\\n -depression\\n -PFTs with mild restrictive ventilatory defect\\n -Anemia with h/o iron deficiency\\n Occupation:\\n Drugs: no\\n Tobacco: h/o smoking PPD for 50 years, quit 20 years ago\\n Alcohol: no\\n Other: Lives with wife \\n Review of systems:\\n Flowsheet Data as of 08:24 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.4\\nC (97.5\\n Tcurrent: 36.4\\nC (97.5\\n HR: 96 (92 - 108) bpm\\n BP: 93/64(71) {81/52(62) - 106/67(112)} mmHg\\n RR: 19 (15 - 21) insp/min\\n SpO2: 95%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Total In:\\n 4,751 mL\\n PO:\\n TF:\\n IVF:\\n 751 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 50 mL\\n Urine:\\n 50 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 4,701 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 95%\\n ABG: ///20/\\n Physical Examination\\n General: Alert, oriented, no acute distress\\n HEENT: Sclera anicteric, MMM, oropharynx dry\\n Neck: supple, JVP not elevated, no LAD\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot,\\n dopplerable right pedal pulse, dopplerable right tibial pulse\\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\\n insertion site, no TTP of inserstion site\\n Labs / Radiology\\n 162 K/uL\\n 41.9 %\\n 13.8 g/dL\\n 129 mg/dL\\n 4.7 mg/dL\\n 36 mg/dL\\n 20 mEq/L\\n 105 mEq/L\\n 4.7 mEq/L\\n 138 mEq/L\\n 18.6 K/uL\\n [image002.jpg]\\n 03:25 AM\\n WBC\\n 18.6\\n Hct\\n 41.9\\n Plt\\n 162\\n Cr\\n 4.7\\n Glucose\\n 129\\n Other labs: CK / CKMB / Troponin-T:25//, Lactic Acid:1.3 mmol/L,\\n Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:5.7 mg/dL\\n Assessment and Plan\\n HYPOTENSION (NOT SHOCK)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n .\\n # Sepsis: Mr. has history of MDR bactermias and presents with\\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn cover his\\n previous MRSA, MDR E.coli and ESBL Klebsiella. will cont with that\\n regimen for now.\\n -- cont Vanco/Zosyn\\n -- D/C CTX\\n -- send UA/UCx\\n -- repeat lactate\\n -- repeat CBC, Chem 7\\n -- 1L IVF bolus\\n -- trend fever WBC curve\\n .\\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\\n -- likely HD tomorrow\\n -- may need new line placed if +blood cultures\\n .\\n # COPD: cont home spiriva, atrovent.\\n .\\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\\n setting of infection. will ROMI\\n -- cycle cardiac enzymes\\n -- monitor on tele\\n -- check TSH\\n -- cont home ASA\\n .\\n # Depression: cont home Fluoxetine\\n .\\n # FEN: Renal Diet, replete lytes\\n .\\n # Prophylaxis: Subcutaneous heparin\\n .\\n # Access: PIV\\n .\\n # Code: Full\\n .\\n # Communication: Patient\\n .\\n # Disposition: pending above\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines / Intubation:\\n Dialysis Catheter - 12:43 AM\\n 22 Gauge - 12:43 AM\\n 20 Gauge - 12:44 AM\\n Comments:\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 363815,\n \"text\": \"82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n Sepsis without organ dysfunction\\n Assessment:\\n Wbc down to 7.6. afebrile. Sbp 90 or greater today. Cdiff cult neg.\\n urine and bc pending.\\n Action:\\n Cont on linezolid and meropenum. Team decided not to place picc till\\n final cult results back.\\n Response:\\n Bp improved. Afebrile.\\n Plan:\\n Cont antiobidics as ordered. Monitor for temp spike. Follow up on cult\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 363818,\n \"text\": \"82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n Sepsis without organ dysfunction\\n Assessment:\\n Wbc down to 7.6. afebrile. Sbp 90 or greater today. Cdiff cult neg.\\n urine and bc pending.\\n Action:\\n Cont on linezolid and meropenum. Team decided not to place picc till\\n final cult results back.\\n Response:\\n Bp improved. Afebrile.\\n Plan:\\n Cont antiobidics as ordered. Monitor for temp spike. Follow up on cult\\n Obstructive sleep apnea (OSA)\\n Assessment:\\n Patient with known hx of sleep apnea. Does not wear bipap at home. Had\\n been on home o2 per wife but none in the past week.\\n Action:\\n Taken off o2 to see how his sats would do.\\n Response:\\n Sats 92 or greater when awake. Fell to 87% when he fell asleep. O2\\n replaced at 1l nc.\\n Plan:\\n Cont to monitor sats.\\n wife in to visit. Updated on plan of care.\\n Activity.- pt consult placed. Patient s/p cva with residual right sided\\n weakness. Uses walker at home. OOb to chair with assist of 2. Tolerated\\n well.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2126-01-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 363980,\n \"text\": \"Chief Complaint: Sepsis\\n 24 Hour Events:\\n ID consult obtained, continues on Linezolid/Meropenem\\n HCT stable, guaiac + stools\\n BP stable overnight\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin - 08:00 AM\\n Meropenem - 12:57 PM\\n Linezolid - 02:06 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:12 PM\\n Heparin Sodium (Prophylaxis) - 12:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:06 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 35.6\\nC (96.1\\n HR: 87 (77 - 94) bpm\\n BP: 109/67(75) {90/52(63) - 118/80(85)} mmHg\\n RR: 19 (11 - 25) insp/min\\n SpO2: 94%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 92.6 kg (admission): 86 kg\\n Total In:\\n 2,240 mL\\n 353 mL\\n PO:\\n 800 mL\\n TF:\\n IVF:\\n 1,440 mL\\n 353 mL\\n Blood products:\\n Total out:\\n 335 mL\\n 140 mL\\n Urine:\\n 335 mL\\n 140 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,905 mL\\n 213 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ////\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 133 K/uL\\n 11.2 g/dL\\n 89 mg/dL\\n 3.3 mg/dL\\n 27 mEq/L\\n 3.9 mEq/L\\n 20 mg/dL\\n 107 mEq/L\\n 143 mEq/L\\n 36.2 %\\n 7.6 K/uL\\n [image002.jpg]\\n 03:25 AM\\n 04:26 AM\\n 03:45 PM\\n WBC\\n 18.6\\n 7.6\\n Hct\\n 41.9\\n 35.6\\n 36.2\\n Plt\\n 162\\n 133\\n Cr\\n 4.7\\n 3.3\\n TropT\\n 0.05\\n 0.05\\n Glucose\\n 129\\n 89\\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\\n Troponin-T:15/3/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\\n Assessment and Plan\\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\\n weakness.\\n # Sepsis: Mr. has history of MDR bactermias and presented with\\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\\n were are all concerning for sepsis. He was given Vancomycin 1gm IV x\\n 1, CTX 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn have\\n now been discontined. Linezolid was added two days ago to cover his\\n previous MRSA and VRE. Meropenem has been added to cover his previous\\n MDR E.coli and ESBL Klebsiella. ID was consulted yesterday and\\n recommended to discontinue his linezolid. Blood cultures from the OSH\\n are negative. Blood cultures from here show NGTD. Urine culture shows\\n +yeast. .\\n -- d/c Linezolid\\n -- cont for now\\n -- follow up cultures\\n -- trend fever WBC curve\\n -- f/u ID recs\\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\\n -- HD today\\n -- may need new line placed if +blood cultures.\\n # COPD: cont home spiriva, atrovent.\\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\\n setting of infection. Patient was ROMI. TSH normal\\n -- cont home ASA\\n # Depression: cont home Fluoxetine\\n # FEN: Renal Diet, replete lytes\\n # Prophylaxis: Subcutaneous heparin\\n # Access: PIV\\n # Code: Full\\n # Communication: Patient\\n # Disposition: call out to medical floor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-24 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 363982,\n \"text\": \"82 yo M with PMH significant for ESRD on HD T/Th/S, Atrial\\n Fibrillation/Flutter, C.diff colitis, CVA x 2 with residual right sided\\n weakness, CAD s/p MI, diastolic CHF with EF 60%, klebsiella urosepsis,\\n multi-drug resistant E.Coli Sepsis, and MRSA Sepsis who presented to\\n Hospital with N/V/D and weakness. At OSH, SBPs were\\n noted to be in the 70s and 80s. He was then transferred to for\\n further care of probable sepsis. Upon arrival to ED, his VS were\\n stable but he was noted to have a lactate of 4.1. He was then\\n transferred to the MICU for further management.\\n Sepsis without organ dysfunction\\n Assessment:\\n Pt afebrile. WBC 6.3 this AM. SBP remains >90 today. Cdiff cult\\n negative thus far. Urine and blood cultures with no growth to date.\\n Action:\\n Cont on linezolid and meropenem.\\n Response:\\n Plan:\\n Cont antibiotics as ordered. Monitor for temp spike. Follow up on\\n culture results.\\n wife in to visit. Updated on plan of care.\\n Activity.- pt consult placed. Patient s/p cva with residual right sided\\n weakness. Uses walker at home. OOb to chair with assist of 2. Tolerated\\n well.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2126-01-24 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 363983,\n \"text\": \"82 yo M with PMH significant for ESRD on HD T/Th/S, Atrial\\n Fibrillation/Flutter, C.diff colitis, CVA x 2 with residual right sided\\n weakness, CAD s/p MI, diastolic CHF with EF 60%, klebsiella urosepsis,\\n multi-drug resistant E.Coli Sepsis, and MRSA Sepsis who presented to\\n Hospital with N/V/D and weakness. At OSH, SBPs were\\n noted to be in the 70s and 80s. He was then transferred to for\\n further care of probable sepsis. Upon arrival to ED, his VS were\\n stable but he was noted to have a lactate of 4.1. He was then\\n transferred to the MICU for further management.\\n Sepsis without organ dysfunction\\n Assessment:\\n Pt afebrile. WBC 6.3 this AM. SBP remains >90 today. Cdiff cult\\n negative thus far. Urine and blood cultures with no growth to date.\\n Action:\\n Cont meropenem.\\n Response:\\n Cultures still with NGTD. Pt remains afebrile with no white count.\\n Plan:\\n Cont antibiotics as ordered. Monitor for temp spike. Follow up on\\n culture results.\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n SEPSIS\\n Code status:\\n Height:\\n Admission weight:\\n 86 kg\\n Daily weight:\\n 92.6 kg\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH: Anemia\\n CV-PMH: Arrhythmias, CAD, MI\\n Additional history: Stage V CKD on HD with h/o nephrolithiasis w/ stent\\n and nephrostomy tube (AV fistula ), Atrial fibrillation/flutter not\\n on coumadin, h/o GI bleed, diverticulitis ,C. Diff colitis, CVA \\n years ago w/ right-sided weakness; second CVA 5 years ago\\n -CAD s/p MI, diastolic HF EF 60% , sleep apnea not on cpap,\\n klebsiella(ESBL), depression, PFTs with mild restrictive\\n ventilatory defect ,\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:91\\n D:65\\n Temperature:\\n 96.5\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 22 insp/min\\n Heart Rate:\\n 96 bpm\\n Heart rhythm:\\n A Flut (Atrial Flutter)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 94% %\\n O2 flow:\\n 1 L/min\\n FiO2 set:\\n 24h total in:\\n 674 mL\\n 24h total out:\\n 3,280 mL\\n Pertinent Lab Results:\\n Sodium:\\n 141 mEq/L\\n 08:01 AM\\n Potassium:\\n 4.2 mEq/L\\n 08:01 AM\\n Chloride:\\n 106 mEq/L\\n 08:01 AM\\n CO2:\\n 28 mEq/L\\n 08:01 AM\\n BUN:\\n 24 mg/dL\\n 08:01 AM\\n Creatinine:\\n 3.8 mg/dL\\n 08:01 AM\\n Glucose:\\n 84 mg/dL\\n 08:01 AM\\n Hematocrit:\\n 37.2 %\\n 08:01 AM\\n Finger Stick Glucose:\\n 148\\n 12:00 PM\\n Valuables / Signature\\n Patient valuables: Glasses\\n Other valuables:\\n Clothes: Transferred with patient\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: MICU786\\n Transferred to: CC704\\n Date & time of Transfer: \\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2126-01-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 118021,\n \"text\": \"Indeterminate irregular supraventricular rhythm, most likely atrial\\nfibrillation with baseline artifact. Compared to the previous tracing\\nof multiple abnormalities as previously noted persist without\\nmajor change.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2126-01-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1060888,\n \"text\": \" 3:48 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please eval for evidence of infiltrate\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with sepsis\\n REASON FOR THIS EXAMINATION:\\n Please eval for evidence of infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Sepsis, evaluation of interval change.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, there is no relevant\\n change. Moderate cardiomegaly without signs of overhydration. Retrocardiac\\n atelectasis. Potential minimal left-sided pleural effusion. Unchanged\\n position of the left-sided central venous access line.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2126-01-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1060430,\n \"text\": \" 11:26 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: acute change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with sepsis\\n REASON FOR THIS EXAMINATION:\\n acute change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Sepsis, followup.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, the old central venous\\n access line has been removed, there is a new double-lumen catheter inserted\\n via the left internal jugular vein and projecting with its tip against the\\n lateral wall of the superior vena cava. The lung volumes are low, there is a\\n small retrocardiac atelectasis, but no evidence of focal parenchymal opacity\\n suggestive of pneumonia. No evidence of overhydration. Mild aortic\\n tortuosity.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":24676,"cells":{"subject_id":{"kind":"number","value":69655,"string":"69,655"},"hadm_id":{"kind":"number","value":143688,"string":"143,688"},"target_text":{"kind":"string","value":""},"extractive_notes_summ":{"kind":"string","value":"FINDINGS: Single abdominal radiograph is obtained. IMPRESSION: Choledocholithiasis with diffusely dilated common biliary duct. Incidental note of degenerative change of the right shoulder, thoracolumbar spinal fusion hardware is incompletely imaged. PFI REPORT PFI: Plastic common bile duct stent seen in appropriate location. 1:54 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: ? There is prominent joint space narrowing and osteoarthritis involving the triscaphe and adjacent first MP joints bilaterally. IMPRESSION: Plastic common bile duct stent seen in appropriate location. On initial image, a plastic stent is seen in the common bile duct which was removed. There is bilateral acetabular degenerative change. Possible old anterior myocardial infarction. FINAL REPORT INDICATION: ERCP stent not visualized by ultrasound. Findings consistent with tophaceous gout. Subsequent images demonstrate cannulation and opacification of the common bile duct with multiple filling defects compatible with stones. Intraventricular conduction delay. Injection of contrast in the common bile duct demonstrates a diffusely dilated duct with numerous filling defects. A plastic stent is seen in the region of the common bile duct. Atrial fibrillation. PROVISIONAL FINDINGS IMPRESSION (PFI): 6:06 PM PFI: Plastic common bile duct stent seen in appropriate location. , R. CC6A 3:59 PM ABDOMEN (SUPINE & ERECT) PORT Clip # Reason: ? IMPRESSION: Severe multi-joint osteoarthritis. FINAL REPORT HISTORY: Acute gout with known tophi. In the lateral left kidney there is an anechoic lesion consistent with a simple renal cyst measuring 2.5 x 2.6 x 2.9 cm. There is dilatation of the common bile duct. The gallbladder is not well opacified. There is marked soft tissue swelling and subtle periarticular soft tissue erosion/destruction at the PIP joint of the left fifth finger (a nonspecific finding but suggestive of tophaceous gout). Occasional ventricular premature beats. 3:59 PM ABDOMEN (SUPINE & ERECT) PORT Clip # Reason: ? location of stent. location of stent. location of stent. location of stent. Spinal fusion hardware overlies the field of view and limits evaluation. The visualized portion of the inferior vena cava appear normal. COMPARISON: ERCP . Compared to theprevious tracing ectopy is resolved.TRACING #3 Sinus rhythm. Sinus rhythm. COMPARISON: ERCP fluoroscopic images from . Biliary sludge and seen within the gallbladder without any evidence of cholecystitis. There is prominent generalized demineralization. Moderate first carpo-metacrapal DJD. Initial spot fluoroscopic image demonstrates multilevel spinal fusion with pedicle screws and rods. The patient is status post surgical fusion of L1 through L5. IMPRESSION: Bibasilar atelectasis. cholecystitis FINAL REPORT INDICATION: 86-year-old female status post ERCP with continued epigastric tenderness to palpation as well as elevated LFTs. Air is seen in small and large bowel. Please refer to the endoscopist's report in OMR for further details of the procedure involving removal of stones with balloon catheter basket and lithotripsy. Moderate DIP and PIP DJD. Concern for possible cholangitis. Per the ERCP report, a plastic stent was placed but no images are provided. TECHNIQUE: Complete abdominal ultrasound. A dual-lead nerve stimulator projects over the lower lumbar spine with leads coursing cranially. There are several granulomas seen within the spleen. The gallbladder contains layering sludge; however, there are discrete no gallstones. Admitting Diagnosis: GALLSTONE PANCREATITIS MEDICAL CONDITION: 86 year old woman with known ERCP stent, unable to view with US and now elevated LFTs REASON FOR THIS EXAMINATION: ? Admitting Diagnosis: GALLSTONE PANCREATITIS MEDICAL CONDITION: 86 year old woman with known ERCP stent, unable to view with US and now elevated LFTs REASON FOR THIS EXAMINATION: ? cholecystitis Admitting Diagnosis: GALLSTONE PANCREATITIS MEDICAL CONDITION: 86 year old woman s/p ERCP, now with continued epigastric TTP as well as elevated LFTs. The spleen measures 13 cm; however, it is thin and does appear enlarged. The left kidney measures 10.2 cm while the right kidney measures 10.3 cm. The biliary stent is not visualized. Compared to theprevious tracing the rhythm has changed.TRACING #2 The heart size is normal, the mediastinal contours are unremarkable. No previous tracingavailable for comparison.TRACING #1 10:27 AM ERCP BILIARY&PANCREAS BY GI UNIT Clip # Reason: Please review ERCP images from Admitting Diagnosis: GALLSTONE PANCREATITIS MEDICAL CONDITION: 86 year old woman with recent ERCP for gall stone pancreatitis.Sphincterotomy and stent inserted for multiple CBD stones.Persistently elevated LFTs.For ERCP and duct clearance REASON FOR THIS EXAMINATION: Please review ERCP images from FINAL REPORT INDICATION: Gallstone pancreatitis, choledocholithiasis."},"n_notes":{"kind":"number","value":10,"string":"10"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2195-04-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1179638,"text":" 10:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pre-procedure\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with gallstone pancreatitis\n REASON FOR THIS EXAMINATION:\n pre-procedure\n ______________________________________________________________________________\n FINAL REPORT\n FINDINGS: Portable AP chest with no prior for comparison demonstrates\n bibasilar opacities. The heart size is normal, the mediastinal contours are\n unremarkable. Incidental note of degenerative change of the right shoulder,\n thoracolumbar spinal fusion hardware is incompletely imaged.\n\n IMPRESSION: Bibasilar atelectasis.\n\n\n"},{"category":"Radiology","chartdate":"2195-04-10 00:00:00.000","description":"ERCP BILIARY&PANCREAS BY GI UNIT","row_id":1180085,"text":" 9:31 AM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: Please review ERCP images from \n Admitting Diagnosis: GALLSTONE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with gallstone pancreatitis [abd pain, elevated lipase,\n lft's] and imaging demonstrating stones in the CBD. WBC elevating and concern\n for possible cholangitis\n REASON FOR THIS EXAMINATION:\n Please review ERCP images from \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old female with gallstone pancreatitis and imaging\n demonstrating stones in the CBD. Concern for possible cholangitis.\n\n COMPARISON: No prior study available for comparison.\n\n FINDINGS: Ten spot fluoroscopic images were obtained during ERCP performed by\n Dr. on without a radiologist present. Initial spot\n fluoroscopic image demonstrates multilevel spinal fusion with pedicle screws\n and rods. Subsequent images demonstrate cannulation and opacification of the\n common bile duct with multiple filling defects compatible with stones. There\n is dilatation of the common bile duct. The gallbladder is not well opacified.\n Per the ERCP report, a plastic stent was placed but no images are provided.\n Please see the ERCP report in OMR for further details.\n\n"},{"category":"Radiology","chartdate":"2195-04-16 00:00:00.000","description":"LIVER OR GALLBLADDER US (SINGLE ORGAN)","row_id":1180614,"text":" 1:54 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ? cholecystitis\n Admitting Diagnosis: GALLSTONE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman s/p ERCP, now with continued epigastric TTP as well as\n elevated LFTs.\n REASON FOR THIS EXAMINATION:\n ? cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old female status post ERCP with continued epigastric\n tenderness to palpation as well as elevated LFTs.\n\n COMPARISON: ERCP fluoroscopic images from .\n\n TECHNIQUE: Complete abdominal ultrasound.\n\n FINDINGS: The liver shows no focal or textural abnormalities. The\n gallbladder contains layering sludge; however, there are discrete no\n gallstones. There is no evidence of gallbladder wall thickening or other\n signs to suggest cholecystitis. The common bile duct is not dilated and\n measures 5 mm. There is no evidence of a biliary stent that was placed\n according to the ERCP endoscopy note.\n\n The kidneys are normal with no evidence of hydronephrosis. In the lateral\n left kidney there is an anechoic lesion consistent with a simple renal cyst\n measuring 2.5 x 2.6 x 2.9 cm. Otherwise, there is no evidence of\n hydronephrosis. The left kidney measures 10.2 cm while the right kidney\n measures 10.3 cm. There are several granulomas seen within the spleen. The\n spleen measures 13 cm; however, it is thin and does appear enlarged. The\n aorta is normal in caliber throughout. The visualized portion of the inferior\n vena cava appear normal.\n\n IMPRESSION:\n 1. Biliary sludge and seen within the gallbladder without any evidence\n of cholecystitis. The biliary stent is not visualized.\n\n"},{"category":"Radiology","chartdate":"2195-04-14 00:00:00.000","description":"B HAND (AP, LAT & OBLIQUE) BILAT","row_id":1180324,"text":" 5:11 PM\n HAND (AP, LAT & OBLIQUE) BILAT Clip # \n Reason: assess for degree of bony destruction by gout/tophi\n Admitting Diagnosis: GALLSTONE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with acute gout flare/tophi both hands\n REASON FOR THIS EXAMINATION:\n assess for degree of bony destruction by gout/tophi\n ______________________________________________________________________________\n WET READ: IPf TUE 6:23 PM\n Degenerative changes and soft tissue swelling at the 5th PIP concerning for\n gout flare/tophi.\n Moderate first carpo-metacrapal DJD.\n Moderate DIP and PIP DJD.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Acute gout with known tophi.\n\n These two exams consist of three views of each hand and wrist. There is\n prominent generalized demineralization. There is marked soft tissue swelling\n and subtle periarticular soft tissue erosion/destruction at the PIP joint of\n the left fifth finger (a nonspecific finding but suggestive of tophaceous\n gout). There is prominent joint space narrowing and osteoarthritis involving\n the triscaphe and adjacent first MP joints bilaterally. Similar findings are\n present in most of the DIP joints (most prominent in both index fingers\n suggesting superimposed trauma). No acute fracture or chondrocalcinosis.\n\n IMPRESSION: Severe multi-joint osteoarthritis. Findings consistent with\n tophaceous gout. No comparison exams at this facility.\n\n"},{"category":"Radiology","chartdate":"2195-04-16 00:00:00.000","description":"P ABDOMEN (SUPINE & ERECT) PORT","row_id":1180637,"text":" 3:59 PM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: ? location of stent.\n Admitting Diagnosis: GALLSTONE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with known ERCP stent, unable to view with US and now\n elevated LFTs\n REASON FOR THIS EXAMINATION:\n ? location of stent.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:06 PM\n PFI: Plastic common bile duct stent seen in appropriate location.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ERCP stent not visualized by ultrasound.\n\n COMPARISONS: Abdominal ultrasound earlier the same day.\n\n FINDINGS: Single abdominal radiograph is obtained. A plastic stent is seen\n in the region of the common bile duct. The patient is status post surgical\n fusion of L1 through L5. A dual-lead nerve stimulator projects over the lower\n lumbar spine with leads coursing cranially. Air is seen in small and large\n bowel. There is bilateral acetabular degenerative change.\n\n IMPRESSION: Plastic common bile duct stent seen in appropriate location.\n\n"},{"category":"Radiology","chartdate":"2195-04-16 00:00:00.000","description":"P ABDOMEN (SUPINE & ERECT) PORT","row_id":1180638,"text":", R. CC6A 3:59 PM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: ? location of stent.\n Admitting Diagnosis: GALLSTONE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with known ERCP stent, unable to view with US and now\n elevated LFTs\n REASON FOR THIS EXAMINATION:\n ? location of stent.\n ______________________________________________________________________________\n PFI REPORT\n PFI: Plastic common bile duct stent seen in appropriate location.\n\n"},{"category":"Radiology","chartdate":"2195-04-21 00:00:00.000","description":"ERCP BILIARY&PANCREAS BY GI UNIT","row_id":1181251,"text":" 10:27 AM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: Please review ERCP images from \n Admitting Diagnosis: GALLSTONE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with recent ERCP for gall stone pancreatitis.Sphincterotomy\n and stent inserted for multiple CBD stones.Persistently elevated LFTs.For ERCP\n and duct clearance\n REASON FOR THIS EXAMINATION:\n Please review ERCP images from \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Gallstone pancreatitis, choledocholithiasis.\n\n COMPARISON: ERCP .\n\n FINDINGS: 27 fluoroscopic spot films are submitted for review. Spinal fusion\n hardware overlies the field of view and limits evaluation. On initial image,\n a plastic stent is seen in the common bile duct which was removed. Injection\n of contrast in the common bile duct demonstrates a diffusely dilated duct with\n numerous filling defects.\n\n IMPRESSION: Choledocholithiasis with diffusely dilated common biliary duct.\n Please refer to the endoscopist's report in OMR for further details of the\n procedure involving removal of stones with balloon catheter basket and\n lithotripsy.\n\n\n"},{"category":"ECG","chartdate":"2195-04-10 00:00:00.000","description":"Report","row_id":179536,"text":"Sinus rhythm. Possible old anterior myocardial infarction. Compared to the\nprevious tracing ectopy is resolved.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2195-04-10 00:00:00.000","description":"Report","row_id":179767,"text":"Sinus rhythm. Occasional ventricular premature beats. Compared to the\nprevious tracing the rhythm has changed.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2195-04-09 00:00:00.000","description":"Report","row_id":179768,"text":"Atrial fibrillation. Intraventricular conduction delay. No previous tracing\navailable for comparison.\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-04-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1179638,\n \"text\": \" 10:56 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pre-procedure\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old woman with gallstone pancreatitis\\n REASON FOR THIS EXAMINATION:\\n pre-procedure\\n ______________________________________________________________________________\\n FINAL REPORT\\n FINDINGS: Portable AP chest with no prior for comparison demonstrates\\n bibasilar opacities. The heart size is normal, the mediastinal contours are\\n unremarkable. Incidental note of degenerative change of the right shoulder,\\n thoracolumbar spinal fusion hardware is incompletely imaged.\\n\\n IMPRESSION: Bibasilar atelectasis.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-04-10 00:00:00.000\",\n \"description\": \"ERCP BILIARY&PANCREAS BY GI UNIT\",\n \"row_id\": 1180085,\n \"text\": \" 9:31 AM\\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \\n Reason: Please review ERCP images from \\n Admitting Diagnosis: GALLSTONE PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old woman with gallstone pancreatitis [abd pain, elevated lipase,\\n lft's] and imaging demonstrating stones in the CBD. WBC elevating and concern\\n for possible cholangitis\\n REASON FOR THIS EXAMINATION:\\n Please review ERCP images from \\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 86-year-old female with gallstone pancreatitis and imaging\\n demonstrating stones in the CBD. Concern for possible cholangitis.\\n\\n COMPARISON: No prior study available for comparison.\\n\\n FINDINGS: Ten spot fluoroscopic images were obtained during ERCP performed by\\n Dr. on without a radiologist present. Initial spot\\n fluoroscopic image demonstrates multilevel spinal fusion with pedicle screws\\n and rods. Subsequent images demonstrate cannulation and opacification of the\\n common bile duct with multiple filling defects compatible with stones. There\\n is dilatation of the common bile duct. The gallbladder is not well opacified.\\n Per the ERCP report, a plastic stent was placed but no images are provided.\\n Please see the ERCP report in OMR for further details.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-04-16 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 1180614,\n \"text\": \" 1:54 PM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \\n Reason: ? cholecystitis\\n Admitting Diagnosis: GALLSTONE PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old woman s/p ERCP, now with continued epigastric TTP as well as\\n elevated LFTs.\\n REASON FOR THIS EXAMINATION:\\n ? cholecystitis\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 86-year-old female status post ERCP with continued epigastric\\n tenderness to palpation as well as elevated LFTs.\\n\\n COMPARISON: ERCP fluoroscopic images from .\\n\\n TECHNIQUE: Complete abdominal ultrasound.\\n\\n FINDINGS: The liver shows no focal or textural abnormalities. The\\n gallbladder contains layering sludge; however, there are discrete no\\n gallstones. There is no evidence of gallbladder wall thickening or other\\n signs to suggest cholecystitis. The common bile duct is not dilated and\\n measures 5 mm. There is no evidence of a biliary stent that was placed\\n according to the ERCP endoscopy note.\\n\\n The kidneys are normal with no evidence of hydronephrosis. In the lateral\\n left kidney there is an anechoic lesion consistent with a simple renal cyst\\n measuring 2.5 x 2.6 x 2.9 cm. Otherwise, there is no evidence of\\n hydronephrosis. The left kidney measures 10.2 cm while the right kidney\\n measures 10.3 cm. There are several granulomas seen within the spleen. The\\n spleen measures 13 cm; however, it is thin and does appear enlarged. The\\n aorta is normal in caliber throughout. The visualized portion of the inferior\\n vena cava appear normal.\\n\\n IMPRESSION:\\n 1. Biliary sludge and seen within the gallbladder without any evidence\\n of cholecystitis. The biliary stent is not visualized.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-04-14 00:00:00.000\",\n \"description\": \"B HAND (AP, LAT & OBLIQUE) BILAT\",\n \"row_id\": 1180324,\n \"text\": \" 5:11 PM\\n HAND (AP, LAT & OBLIQUE) BILAT Clip # \\n Reason: assess for degree of bony destruction by gout/tophi\\n Admitting Diagnosis: GALLSTONE PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old woman with acute gout flare/tophi both hands\\n REASON FOR THIS EXAMINATION:\\n assess for degree of bony destruction by gout/tophi\\n ______________________________________________________________________________\\n WET READ: IPf TUE 6:23 PM\\n Degenerative changes and soft tissue swelling at the 5th PIP concerning for\\n gout flare/tophi.\\n Moderate first carpo-metacrapal DJD.\\n Moderate DIP and PIP DJD.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Acute gout with known tophi.\\n\\n These two exams consist of three views of each hand and wrist. There is\\n prominent generalized demineralization. There is marked soft tissue swelling\\n and subtle periarticular soft tissue erosion/destruction at the PIP joint of\\n the left fifth finger (a nonspecific finding but suggestive of tophaceous\\n gout). There is prominent joint space narrowing and osteoarthritis involving\\n the triscaphe and adjacent first MP joints bilaterally. Similar findings are\\n present in most of the DIP joints (most prominent in both index fingers\\n suggesting superimposed trauma). No acute fracture or chondrocalcinosis.\\n\\n IMPRESSION: Severe multi-joint osteoarthritis. Findings consistent with\\n tophaceous gout. No comparison exams at this facility.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-04-16 00:00:00.000\",\n \"description\": \"P ABDOMEN (SUPINE & ERECT) PORT\",\n \"row_id\": 1180637,\n \"text\": \" 3:59 PM\\n ABDOMEN (SUPINE & ERECT) PORT Clip # \\n Reason: ? location of stent.\\n Admitting Diagnosis: GALLSTONE PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old woman with known ERCP stent, unable to view with US and now\\n elevated LFTs\\n REASON FOR THIS EXAMINATION:\\n ? location of stent.\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:06 PM\\n PFI: Plastic common bile duct stent seen in appropriate location.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: ERCP stent not visualized by ultrasound.\\n\\n COMPARISONS: Abdominal ultrasound earlier the same day.\\n\\n FINDINGS: Single abdominal radiograph is obtained. A plastic stent is seen\\n in the region of the common bile duct. The patient is status post surgical\\n fusion of L1 through L5. A dual-lead nerve stimulator projects over the lower\\n lumbar spine with leads coursing cranially. Air is seen in small and large\\n bowel. There is bilateral acetabular degenerative change.\\n\\n IMPRESSION: Plastic common bile duct stent seen in appropriate location.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-04-16 00:00:00.000\",\n \"description\": \"P ABDOMEN (SUPINE & ERECT) PORT\",\n \"row_id\": 1180638,\n \"text\": \", R. CC6A 3:59 PM\\n ABDOMEN (SUPINE & ERECT) PORT Clip # \\n Reason: ? location of stent.\\n Admitting Diagnosis: GALLSTONE PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old woman with known ERCP stent, unable to view with US and now\\n elevated LFTs\\n REASON FOR THIS EXAMINATION:\\n ? location of stent.\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: Plastic common bile duct stent seen in appropriate location.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-04-21 00:00:00.000\",\n \"description\": \"ERCP BILIARY&PANCREAS BY GI UNIT\",\n \"row_id\": 1181251,\n \"text\": \" 10:27 AM\\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \\n Reason: Please review ERCP images from \\n Admitting Diagnosis: GALLSTONE PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old woman with recent ERCP for gall stone pancreatitis.Sphincterotomy\\n and stent inserted for multiple CBD stones.Persistently elevated LFTs.For ERCP\\n and duct clearance\\n REASON FOR THIS EXAMINATION:\\n Please review ERCP images from \\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Gallstone pancreatitis, choledocholithiasis.\\n\\n COMPARISON: ERCP .\\n\\n FINDINGS: 27 fluoroscopic spot films are submitted for review. Spinal fusion\\n hardware overlies the field of view and limits evaluation. On initial image,\\n a plastic stent is seen in the common bile duct which was removed. Injection\\n of contrast in the common bile duct demonstrates a diffusely dilated duct with\\n numerous filling defects.\\n\\n IMPRESSION: Choledocholithiasis with diffusely dilated common biliary duct.\\n Please refer to the endoscopist's report in OMR for further details of the\\n procedure involving removal of stones with balloon catheter basket and\\n lithotripsy.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2195-04-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 179536,\n \"text\": \"Sinus rhythm. Possible old anterior myocardial infarction. Compared to the\\nprevious tracing ectopy is resolved.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2195-04-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 179767,\n \"text\": \"Sinus rhythm. Occasional ventricular premature beats. Compared to the\\nprevious tracing the rhythm has changed.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2195-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 179768,\n \"text\": \"Atrial fibrillation. Intraventricular conduction delay. No previous tracing\\navailable for comparison.\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":24677,"cells":{"subject_id":{"kind":"number","value":27547,"string":"27,547"},"hadm_id":{"kind":"number","value":103061,"string":"103,061"},"target_text":{"kind":"string","value":"#C diff colitis: No response to Flagyl and so started on po vancomycin with good response. Plan to continue vancomycin with taper."},"extractive_notes_summ":{"kind":"string","value":"wheezes, nebs given w/ moderate effect. Note is made of compression deformities of the L1 and T11 vertebral bodies of undetermined chronicity. Mild neural foraminal narrowing is identified at the right T9-T10 and T10-T11 level secondary to uncovertebral spurring and endplate osteophytes. There is mild widening of the superior aspect of the right sacroiliac joint of unclear etiology. improved with ativan.cv: hypotensive at start of shift, bp 60s. CHEST, TWO VIEWS: There is moderate cardiomegaly. Has h/o CHF, resp. IN I/E WHEEZES. FINDINGS: Image portion of the lower thoracic and lumbar spine demonstrate diffuse demineralization and severe degenerative change with compression deformities, most marked in L1 and T11. febrile, tmax 101.1 ax. AS WELL AS AN I.CA+ AND LACTATE LEVELS.ID: TEMP 99.8AX. There are mild degenerative changes of bilateral sacroiliac joints. RESPIRATORY CARE: PT W/ MILD EXP. Diffuse atherosclerotic calcification is present. Again demonstrated are right axillary dissection clips. BS scattered wheezes. Markedly distended bladder, containing a moderate amount of air. at 3am became tachy 130s-140s, PO metoprolol given w/ good effect. S-shaped scoliosis of the thoracolumbar spine is noted. WHEEZE. Slight improvement with Rx. dropped to 70s-80s at 1am, 1L NSx1 given with good effect. CVC placed, 1L LRx1 given with good effect. RR regular and unlabored. ativan x1 given for agitation w/ good effect. replace lytes as necessary. There is severe facet arthropathy at L5-S1 on the right. Febrile to 102. Also, rec'd lasix, vanco, ceftriaxone, flagyl, azithromycin.Review of system:Neuro: Lethargic, but easily arouable. Severe osteopenia. Poor access w/ several attempts at IV's (#22 to R Upper arm).GI/GU: Abd is soft, nt, nd. There is moderate streak artifact from bilateral hip prostheses limiting interpretation or evaluation of the pelvic viscera. CHRONIC BACK PAIN CONTROLLED W/ DARVOCET AND LIDO PATCH. Foley in place w/ adequate uo.Plan: Cont. FINDINGS: A left CVL has been placed and the tip is in the SVC - no PTX. IVF-KVO. failure, NSTIMI (cath stent), delirium, + c. diff in , low back pain, CAD, breast CA - bilat mats, HTN, pulm, stenosis, anxiety, MGUS, GERD. Strong prod cough.Pt weak otherwise stable. Note is made of moderate spinal canal narrowing at L4- L5 due to endplate osteophytes and ligamentum flavum hypertrophy. 3:00 PM CT PELVIS ORTHO W/O C Clip # Reason: Eval for Sacral/pelvic fx. multiple myeloma. Severe atherosclerotic disease. + ppp x 4. CAN HAVE HER DARVOCETT. SI joint; MR completed but essentially uninterpretable due to motion artifact despite sedation REASON FOR THIS EXAMINATION: Eval for Sacral/pelvic fx. sump to right nares in place. DUODERM INTACT.PAIN CONTROL: BACK PAIN TX'ED WITH LIDO PATCH. FIRST C-DIFF SAMPLE POSITIVE.SKIN INTEGRITY: PRESSURE SORE ON BACK NOTED. Lungs w/ rhonchi throughout. Notify MD care RN with any deterioration D/C rectal tube. Notify MD care RN with any deterioration D/C rectal tube. Oriiented X3 but does occas makes inappropriate statements Action: Received calcitonin & pamidronate X1 Response: Plan: Recheck PMlabs after pamridronate infusion myeloma, sob REASON FOR THIS EXAMINATION: eval for interval change - ? Transfers, Impaired Clinical impression / Prognosis: 78 y.o. Transfers, Impaired Clinical impression / Prognosis: 78 y.o. InferiorQ waves represent prior myocardial infarction. On, zosyn , Vanco (Po/IV), Action: Metrprlol & ASA, statin Response: Stable, Diarrhea diminishing. On, zosyn , Vanco (Po/IV), Action: Metrprlol & ASA, statin Response: Stable, Diarrhea diminishing. On, zosyn , Vanco (Po/IV), Action: Metrprlol & ASA, statin Response: Stable, Diarrhea diminishing. Attending: Referral date: Medical Diagnosis / ICD 9: 428.0 CHF Reason of referral: eval and treat History of Present Illness / Subjective Complaint: 78 y.o. Coordinated breathing pattern Integumentary / Vascular: L CVP line, flexiseal, foley catheter, telemetry, thoracic stage 2 wound per wound care note Sensory Integrity: Detects all LT sensation UE/UE Pain / Limiting Symptoms: Unable to grade on VAS scale. Coordinated breathing pattern Integumentary / Vascular: L CVP line, flexiseal, foley catheter, telemetry, thoracic stage 2 wound per wound care note Sensory Integrity: Detects all LT sensation UE/UE Pain / Limiting Symptoms: Unable to grade on VAS scale. Impaired Skin Integrity Assessment: Stage II pressure ulcer thoracic spine area 1.5cm X 1.5 CM. Impaired Skin Integrity Assessment: Stage II pressure ulcer thoracic spine area 1.5cm X 1.5 CM. Anterior Q waves could representprior anteroseptal myocardial infarction. Attending Physician: Referral date: Medical Diagnosis / ICD 9: 428.0 / CHF Reason of referral: eval and treat History of Present Illness / Subjective Complaint: 78 y.o. Hypoxia with PNA versus flash pulmonary edema and acute on chronic diastolic HF. Hypoxia with PNA versus flash pulmonary edema and acute on chronic diastolic HF. pulm edema FINAL REPORT CHEST X-RAY HISTORY: Myeloma, shortness of breath. There is remodeling of the proximal humeral shafts bilaterally, apparently related to the inferior margins of the glenoids and osteophytes in that region. understands and verbalizes need to call for A when mobilizing Hemodynamic Response Aerobic Capacity HR BP RR O[2 ]sat HR BP RR O[2] sat RPE Supine 76 112/70 18 97 RA Rest / Sit 145/60 24 98 RA Activity / Stand / Recovery 82 111/54 17 95 RA Total distance walked: Minutes: Pulmonary Status: strong mildly congested cough, raises to upper airway."},"n_notes":{"kind":"number","value":30,"string":"30"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2201-02-28 00:00:00.000","description":"CHEST (PA & LAT)","row_id":995920,"text":" 11:30 AM\n CHEST (PA & LAT) Clip # \n Reason: pls assess interval change for blossoming of infiltrate\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with MGUS, CAD s/p MI, HTN, admitted with mild prod cough and\n ? infiltrate on imaging. Hx of cdif to Abx. s/p aggressive IVF hydration\n REASON FOR THIS EXAMINATION:\n pls assess interval change for blossoming of infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON AT 11:35\n\n INDICATION: Cough.\n\n COMPARISON: at 21:38.\n\n FINDINGS:\n\n Similar to the prior film, there is some increased density projecting over the\n lower thoracic spine on the lateral view, but there appears to be even further\n increased opacity there. An element of atelectasis versus an evolving\n pneumonia is in the differential. A staple appearance to the left hilum is\n seen, most consistent with pulmonary artery enlargement. This has been stable\n for a few years.\n\n The pulmonary vascular markings are within normal limits.\n\n IMPRESSION:\n\n Further increase in the opacity projecting over the lower thoracic spine.\n This is not clearly localized on the frontal view, but I suspect is in the\n left lower lobe. Atelectasis versus developing pneumonia.\n\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2201-02-27 00:00:00.000","description":"CHEST (PA & LAT)","row_id":995846,"text":" 9:33 PM\n CHEST (PA & LAT) Clip # \n Reason: pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with cough, phlegm\n REASON FOR THIS EXAMINATION:\n pna\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 78-year-old female with cough and phlegm production with concern\n for pneumonia.\n\n COMPARISON: .\n\n CHEST, TWO VIEWS: There is moderate cardiomegaly. The mediastinal contours\n are unchanged. Again demonstrated is evidence of aortic tortuosity and\n markedly enlarged pulmonary arterial contour. There is no pleural effusion or\n pneumothorax. The lung volumes are relatively low. No consolidation is seen\n on the frontal view. There has been slight increase in opacity projecting\n over the lower spine on the lateral view which could be due to crowding\n secondary to low volumes. Again demonstrated are right axillary dissection\n clips. A mottled appearance of the bones suggestive of multiple myeloma has\n not changed. There are marked degenerative changes of the shoulder joints.\n\n IMPRESSION: New subtle opacity overlying the lower thoracic spine on the\n lateral view is more likely explained by crowding due to low lung volumes.\n\n"},{"category":"Radiology","chartdate":"2201-03-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":996008,"text":" 5:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulmonary edema\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with emegency need\n REASON FOR THIS EXAMINATION:\n pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 5:12\n\n INDICATION: Edema.\n\n COMPARISON: at 11:35.\n\n FINDINGS:\n\n Diffusely increased interstitial and parenchymal opacities are visualized in a\n pattern consistent with sudden pulmonary edema. Continued followup is\n recommended to see if this evolves into more persistent consolidations. The\n right CP angle is cut off from view and there is no pneumothorax.\n\n IMPRESSION: Flash pulmonary edema.\n\n\n"},{"category":"Radiology","chartdate":"2201-03-01 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":996087,"text":" 8:20 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Please evaluate for central line placement\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with central line placed for fluid resuscitation\n REASON FOR THIS EXAMINATION:\n Please evaluate for central line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 20:26\n\n INDICATION: CVL placement.\n\n COMPARISON: at 18:42.\n\n FINDINGS:\n\n A left CVL has been placed and the tip is in the SVC - no PTX. The lungs are\n stable without evidence of new consolidation or exacerbation in fluid status.\n\n\n"},{"category":"Nursing/other","chartdate":"2201-03-02 00:00:00.000","description":"Report","row_id":1622679,"text":"NURSING NOTES 7AM-19PM\nRESP: NO C/O SOB. RESP MORE REGULAR. R BS'S CLEAR AND LEFT CONT. IN I/E WHEEZES. NEBS GIVEN Q6HRS. SAT 98% ON 4L NP. HAS A CONGESTED NON-PRODUCTIVE COUGH.\nGI: NPO X ICE CHIPS, BUT TOOK SMALL AMT OF WATER WITHOUT PROBLEMS. MOUTH IS VERY DRY. LIQUID STOOL CONT. FROM MUSHROOM CATHETER.\nRENAL: GIVEN 40MG LASIX IVP WITH MODERATE DIURESES. IVF-KVO. CREAT 2,0.\nNEURO: VERY SLEEPY THIS AM, BUT SHE HAS PROGRESSIVELY BECOME MORE AWAKE. DAUGHTER STATED THAT SHE WAS VERY TIRED AT HOME AS WELL. UNABLE TO UNDERSTAND HER WELL D/T DRY MOUTH. CONT. TO BE RESTRAINED AS SHE DOES FORGET THAT SHE HAS A NGT.\nCV: HEMODYNAMICALLY STABLE. WAS IN NSR IN 90'S. GIVEN AN ADDITIONAL 12.5MG OF LOPRESSOR VIA NGT AND DOSE INCREASED TO 37.5MG.\nENDOC: K+ REPLETED THIS AM. PM LYTES JUST SENT OFF. AS WELL AS AN I.CA+ AND LACTATE LEVELS.\nID: TEMP 99.8AX. NO FURTHER SPIKES. CONT. ON ANTIBIOTICS. FIRST C-DIFF SAMPLE POSITIVE.\nSKIN INTEGRITY: PRESSURE SORE ON BACK NOTED. TURNED OFTEN. DUODERM INTACT.\nPAIN CONTROL: BACK PAIN TX'ED WITH LIDO PATCH. IF NEEDED PT. CAN HAVE HER DARVOCETT. NOT REQUIRED YET.\nHEM: HCT 23.7. NO TX NEEDED YET.\nSOCIAL: DAUGHTER AND SON-IN-LAW IN WITH PT. MOST OF THE DAY. PLAN IS FOR HER DAUGHTER TO STAY OVERNIGHT AGAIN.\nDAUGHTER HAS REQUESTED THAT PT. NOT BE INFORMED OF POSSIBLE DX OF MULTIPLE MYELOMA. ATTENDING AGREES AT THIS TIME.\n"},{"category":"Nursing/other","chartdate":"2201-03-03 00:00:00.000","description":"Report","row_id":1622680,"text":"NPN 1900 -0700\n\nNEURO PLEASANTLY CONFUSED AT TIMES, POOR SHORT TERM MEMORY. CHRONIC BACK PAIN CONTROLLED W/ DARVOCET AND LIDO PATCH. DOES OCC BECOME ANXIOUS. RECIEVED .5 ATIVAN OVERNOC FOR SLEEP W/ POOR RESULTS (?? SUGGEST TRAZADONE)\n\nRESP: LOOSE NON PRODUCTIVE COUGH,NEBS NOW Q 6 PRN, OCC I/E WHEEZES, MAINT SATS 99-100%\n\nC/V: PM HCT 22 (TRANSFUSE FOR< 21) SR -ST NO ECTOPY, BP STABLE, 1TEENS, LOPRESSOR DOSE INCREASED YESTERDAY TO 37.5 , TOL WELL.\n\nF/E/N: REPLETED PM K+ OF 3.2 W/ 40 KCL IV, RECIEVED ADDITIONAL 40MEQ LASIX W/ MOD RESPONSE ~ 500CC,NOW NEG FLUID BALANCE OF ~ .5 LITER. LOOSE STOOL VIA MUSHROOM CATH ( C DIFF POS) AM LYTES PENDING.TOL PO'S , ABLE TO SWALLOW PILLS.\n\nPLAN: D/C NGT IF CONT TO BE ABLE TO TOL PO'S, CONT AB TX, PAIN MANAGEMENT , DAUGHTER STILL DOES NOT WANT PT TO KNOW DX, FEARS THAT THE WORD \"MYELOMA\" BE TOO STRESS PRODUCING FOR PT AT THIS TIME . DAUGHTERS WISHES RESPECTED\n"},{"category":"Nursing/other","chartdate":"2201-03-03 00:00:00.000","description":"Report","row_id":1622681,"text":"Resp Care Note, Pt seen for Q6 prn nebs.Last done 0530. BS scattered wheezes. Strong prod cough.Pt weak otherwise stable. Will cont to monitor resp status.\n\n"},{"category":"Nursing/other","chartdate":"2201-03-01 00:00:00.000","description":"Report","row_id":1622674,"text":"Admitting and nursing progress note;\n\nThis is a 78 y/o lady admitted to 11R around 5am for delirium d/t low sodium and ? RF. Has h/o CHF, resp. failure, NSTIMI (cath stent), delirium, + c. diff in , low back pain, CAD, breast CA - bilat mats, HTN, pulm, stenosis, anxiety, MGUS, GERD. She was tx'd to FN ICU around 13:45 today d/t resp distress requiring NRB mask (metabolic acidosis), low u/o, febrile to 103.9 (rectally), rales/wheezing noted and decreased MS. morphine overnight, which she has an documented sensitivity too. Also, rec'd lasix, vanco, ceftriaxone, flagyl, azithromycin.\n\nReview of system:\n\nNeuro: Lethargic, but easily arouable. Confused and yells out the name (her grandson). Soft wrist restraints on for safety of lines/tubes. MAE.\n\nPulm: Wean from NRB to Hi-flow to 3L NC w/ stable o2 sats. RR regular and unlabored. Lungs w/ rhonchi throughout. No cough noted.\n\nCV: ST w/ occassional PVC's. Febrile to 102. BP stable. No edema noted. + ppp x 4. Poor access w/ several attempts at IV's (#22 to R Upper arm).\n\nGI/GU: Abd is soft, nt, nd. + hyperactive bs. Constant diarrhea w/ mushroom catheter placed. sump to right nares in place. Awaiting x-ray confirmation. Foley in place w/ adequate uo.\n\nPlan: Cont. w/ antibiotic treatment. Question placement of central line vs. picc line for better IV access. Monitor per protocol. Will attempt to sent labs.\n\n"},{"category":"Nursing/other","chartdate":"2201-03-01 00:00:00.000","description":"Report","row_id":1622675,"text":"RESPIRATORY CARE: D: PT FROM 11 FOR RESPIRATORY DISTRESS\nAND WHEEZING.\nA: GIVEN 2.5 MG ALBUTEROL/ 0.5 MG ATROVENT SVN.\nR: SLIGHT SUBJECTIVE/ OBJECTIVE RX.\nP: FOLLOW Q4 FOR ALBUTEROL/ATROVENT SVN.\n"},{"category":"Nursing/other","chartdate":"2201-03-02 00:00:00.000","description":"Report","row_id":1622676,"text":"Respiratory Care:\nPatient received albuterol/atrovent unit dose medication in SVN via aerosol mask. Slight improvement with Rx.\n"},{"category":"Nursing/other","chartdate":"2201-03-02 00:00:00.000","description":"Report","row_id":1622677,"text":"neuro: dozing, agitated at times, confused. febrile, tmax 101.1 ax. tylenol given, cooling blanket on. ativan x1 given for agitation w/ good effect. bilat wrist restraints to prevent pulling lines.\n\nresp: exp. wheezes, nebs given w/ moderate effect. O2 sat 96-99%. RR increased to 3040s with agitation, c/o being unable to breath. improved with ativan.\n\ncv: hypotensive at start of shift, bp 60s. CVC placed, 1L LRx1 given with good effect. dropped to 70s-80s at 1am, 1L NSx1 given with good effect. at 3am became tachy 130s-140s, PO metoprolol given w/ good effect. current bp in 90s, ST 100s-110s. cvp 9-11.\n\ngi/gu: foley patent draining small amount of yellow urine. mushroom cath in place draining large amount of liq stool, c-diff+. +BS.\n\nplan: monitor bp and temp. replace lytes as necessary.\n"},{"category":"Nursing/other","chartdate":"2201-03-02 00:00:00.000","description":"Report","row_id":1622678,"text":"RESPIRATORY CARE: PT W/ MILD EXP. WHEEZE. GIVEN\n2.G MG ALBUTEROL/ 0.5 MG ATROVENT SVN X 2 THIS\nSHIFT. MILD SUB/OBJ. RX TO TX. FOLLOW Q4.\n"},{"category":"Radiology","chartdate":"2201-03-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":996229,"text":" 4:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o progressive RUL consolidation, effusions, assess resolut\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with CHF, CAD, h/o c. diff trasnferred to ICU for hypoxia,\n tachypnea, fevers.\n REASON FOR THIS EXAMINATION:\n r/o progressive RUL consolidation, effusions, assess resolution or worsening of\n pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH:\n\n INDICATION: Followup.\n\n COMPARISON: .\n\n FINDINGS: The external parts of the nasogastric tube projects over the left\n hemithorax. Nasogastric tube and left-sided central venous access are\n unchanged. The size of the cardiac silhouette and the morphology of the lung\n parenchyma show no major changes as compared to previous examination.\n\n IMPRESSION: No relevant interval changes.\n\n\n DR. \n"},{"category":"Radiology","chartdate":"2201-03-08 00:00:00.000","description":"CT L-SPINE W/O CONTRAST","row_id":997126,"text":" 2:59 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: eval for fracture\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with multiple myeloma, focal pain of the rt. SI joint; MR\n completed but essentially uninterpretable due to motion artifact despite\n sedation\n REASON FOR THIS EXAMINATION:\n eval for fracture\n CONTRAINDICATIONS for IV CONTRAST:\n myeloma\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n CLINICAL HISTORY: 78-year-old female with multiple myeloma. Focal pain right\n over the SI joint.\n\n Evaluate for fracture.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast MDCT acquired axial images of the lumbar spine from\n T10 to the coccyx. Multiplanar reformatted images were obtained.\n\n FINDINGS: Image portion of the lower thoracic and lumbar spine demonstrate\n diffuse demineralization and severe degenerative change with compression\n deformities, most marked in L1 and T11. S-shaped scoliosis of the\n thoracolumbar spine is noted.\n\n Mild neural foraminal narrowing is identified at the right T9-T10 and T10-T11\n level secondary to uncovertebral spurring and endplate osteophytes. Note is\n made of moderate spinal canal narrowing at L4- L5 due to endplate osteophytes\n and ligamentum flavum hypertrophy. Limited views of the lung show small\n bilateral pleural effusions and atelectasis. Diffuse atherosclerotic\n calcification is present.\n\n IMPRESSION:\n 1. Severe demineralization of the bones which may be partially related to a\n systemic process, ie. multiple myeloma.\n 2. Extensive degenerative change involving the thoracolumbar spine. Note is\n made of compression deformities of the L1 and T11 vertebral bodies of\n undetermined chronicity.\n\n\n NOTE ADDED AT ATTENDING REVIEW: There are innumerable lytic lesions throughout\n the lumbar spine, sacrum, and iliac bones, compatible with myeloma. There is\n moderate spinal stenosis at L3-4 and severe spinal stenosis at L4-5 and L5-\n S1, apparently due to degenerative disk disease. However, the soft tissue\n component may be a combination of disk material, thick ligamentum flavum, and\n epidural tumor. The very limited MR does not demonstrate tumor in the canal,\n but it is not adequate to exclude this diagnosis.\n (Over)\n\n 2:59 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: eval for fracture\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2201-03-08 00:00:00.000","description":"CT PELVIS ORTHO W/O C","row_id":997127,"text":" 3:00 PM\n CT PELVIS ORTHO W/O C Clip # \n Reason: Eval for Sacral/pelvic fx. in region of rt. SI joint, focal\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with multiple myeloma, focal pain of the rt. SI joint; MR\n completed but essentially uninterpretable due to motion artifact despite\n sedation\n REASON FOR THIS EXAMINATION:\n Eval for Sacral/pelvic fx. in region of rt. SI joint, focal area of pain\n CONTRAINDICATIONS for IV CONTRAST:\n myeloma\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE PELVIS WITHOUT CONTRAST, \n\n CLINICAL INFORMATION: 78-year-old female with multiple myeloma and focal pain\n of the right sacroiliac joint. MRI was completed, but essentially\n uninterpretable due to motion artifact despite sedation. Evaluate for sacral\n and pelvic fracture in region of the right sacroiliac joint.\n\n FINDINGS:\n\n The bones are markedly osteopenic. There are innumerable lytic lesions within\n both the medullary cavity as well as within the cortex; some of the lesions\n breach the cortex. Innumerable lytic lesions are seen throughout the lumbar\n spine and throughout the iliac bones and sacrum. Lytic lesions are also seen\n within bilateral acetabula and proximal femora. There are bilateral dynamic\n compression screws in place traversing old intertrochanteric fractures. There\n are severe degenerative changes of the lower lumbar spine.\n\n There is mild widening of the superior aspect of the right sacroiliac joint of\n unclear etiology. No discrete erosive changes are identified in the right\n sacroiliac joint. No fracture is identified in the right sacroiliac joint.\n There are mild degenerative changes of bilateral sacroiliac joints. There is\n severe facet arthropathy at L5-S1 on the right.\n\n Evaluation of the pelvic contents demonstrates severe atherosclerotic disease\n of the abdominal aorta, extending into bilateral common iliac arteries. There\n is residual barium from a previous contrast study within the small bowel. The\n bladder is markedly distended. The bladder contains a moderate amount of air.\n Could this be secondary to recent instrumentation or catheterization?\n\n There is moderate streak artifact from bilateral hip prostheses limiting\n interpretation or evaluation of the pelvic viscera. There is moderate colonic\n diverticulosis without complication.\n\n IMPRESSION:\n\n 1. Severe osteopenia. Severe myelomatous involvement of the osseous\n structures, with innumerable lytic lesions involving both the medullary cavity\n and breaching the cortex of all visualized osseous structures. No displaced\n (Over)\n\n 3:00 PM\n CT PELVIS ORTHO W/O C Clip # \n Reason: Eval for Sacral/pelvic fx. in region of rt. SI joint, focal\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n fractures identified.\n\n 2. Mild widening of the right sacroiliac joint with respect to the left. No\n erosive change is identified at the right sacroiliac joint.\n\n 3. Severe degenerative changes of the lower lumbar spine, particularly at the\n right L5-S1 facet joint.\n\n 4. Severe atherosclerotic disease.\n\n 5. Markedly distended bladder, containing a moderate amount of air. Has the\n patient recently been instrumented?\n\n 6. Moderate sigmoid diverticulosis without complication.\n\n"},{"category":"Radiology","chartdate":"2201-03-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":997000,"text":" 11:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change - ? evolving consolidation, ? pulm\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with mult. myeloma, sob\n REASON FOR THIS EXAMINATION:\n eval for interval change - ? evolving consolidation, ? pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n HISTORY: Myeloma, shortness of breath.\n\n One portable view. Comparison with the previous studies of and\n .\n\n Bronchovascular markings are prominent, as before. Increased density is\n projected over the heart. The central pulmonary arteries are prominent. The\n heart appears enlarged. The aorta is calcified. Mediastinal structures are\n unchanged. A left subclavian catheter remains in place. A nasogastric tube\n has been withdrawn. Severe degenerative changes are noted in the spine and\n shoulders.\n\n IMPRESSION: Prominent interstitial markings which may reflect pulmonary\n vascular congestion, unchanged. Increased density projected over the heart\n which may represent a left lower lobe infiltrate. PA and lateral views would\n be helpful for further evaluation.\n\n\n"},{"category":"Radiology","chartdate":"2201-03-04 00:00:00.000","description":"SKELETAL SURVEY (INCLUD LONG BONES)","row_id":996506,"text":" 1:51 PM\n SKELETAL SURVEY (INCLUD LONG BONES) Clip # \n Reason: eval for lesions c/w multiple myeloma\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with likely multiple myeloma, low back pain\n REASON FOR THIS EXAMINATION:\n eval for lesions c/w multiple myeloma\n ______________________________________________________________________________\n FINAL REPORT\n SKELETAL SURVEY\n\n CLINICAL HISTORY: Multiple myeloma.\n\n No prior skeletal survey is available.\n\n Two lateral films of the skull were obtained showing multiple lytic lesions\n consistent with the history of multiple myeloma.\n\n Frontal and lateral films of the thoracic spine show osteopenia. There is a\n moderate diffuse compression fracture of T8. On the lateral film, T10-11 are\n distorted by scoliosis but no fracture of them is seen on the frontal view.\n\n Frontal and lateral films of the lumbar spine show fracture of L1. There is\n scoliosis and there are degenerative disc disease changes. Vascular\n calcifications are noted.\n\n AP view of the pelvis shows multiple small lucent lesions throughout the bony\n pelvis and proximal femurs. There are bilateral dynamic compression screws\n and rods.\n\n AP views of the femurs show innumerable small lytic lesions.\n\n AP views of both humeri show marked superior subluxation of the humeral heads\n relative to the glenoid with a bone-on-bone appearance, large osteophytes and\n subchondral sclerosis. There is remodeling of the proximal humeral shafts\n bilaterally, apparently related to the inferior margins of the glenoids and\n osteophytes in that region. Multiple small lytic lesions are seen throughout\n the humeri. There is deformity of the right radius perhaps related to surgery\n or old non-united fracture. Extensive myelomatous involvement was seen on a\n CT examination of the abdomen on . Due to osteopenia, the thoracic\n vertebral bodies are very difficult to evaluate on prior chest films. The T8\n fracture is new since .\n\n IMPRESSION: Innumerable small lytic lesions are seen throughout the\n visualized osseous structures consistent with the widespread myelomatous\n involvement seen on prior abdominal CT. Fractures of T8 and L1 are now\n visualized. There is marked deformity of the glenohumeral joints with\n superior subluxation of the humeral heads relative to the glenoids, sclerosis,\n osteophyte formation and remodeling of the proximal medial humeral diaphyseal\n regions.\n\n (Over)\n\n 1:51 PM\n SKELETAL SURVEY (INCLUD LONG BONES) Clip # \n Reason: eval for lesions c/w multiple myeloma\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2201-03-07 00:00:00.000","description":"MR L SPINE W/O CONTRAST","row_id":996996,"text":" 10:40 AM\n MR L SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST Clip # \n Reason: eval for L and T spine stability of vertbrae\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with multiple myeloma, back pain at lumbar and T spine, eval\n for acute fracture, neural compression\n REASON FOR THIS EXAMINATION:\n eval for L and T spine stability of vertbrae\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI SCAN OF THE THORACIC AND LUMBAR SPINE\n\n HISTORY: 78-year-old woman with multiple myeloma. Back pain within the\n lumbar and thoracic regions. Evaluate for acute fracture, compression and\n stability of the vertebra.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the thoracic spine was\n attempted.\n\n FINDINGS: This study is nearly uninterpretable due to gross motion artifacts.\n The axial T2-weighted scans of the thoracic spine, while also degraded by\n patient motion are of sufficient quality to show no definite sign of spinal\n cord compression. However, it appears that there is generalized low T1 signal\n throughout the visualized spinal column, a finding which would raise concern\n for the presence of diffuse infiltration of the bone, as in the setting of\n myeloma. There is a likely mild compression fracture of the T7 body. There is\n probable moderate spinal stenosis in the lumbar spine at L4/5, as well as\n L5/S1, but the absence of axial scans in the lumbar region reduces the ability\n of this study to assess for central canal stenosis. There is likely moderate\n distention of the urinary bladder. No further evaluation of this study with\n reliability can be undertaken at this time.\n\n CONCLUSION: Nearly uninterpretable study due to gross patient motion. CT\n might provide improved bony imaging, provided the patient can remain still.\n\n COMMENT: As noted above, the only axial images supplied at this time\n encompass the thoracic region.\n\n Findings were discussed with Dr. , hospitalist caring for this\n patient on .\n\n\n\n"},{"category":"Radiology","chartdate":"2201-03-02 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":996146,"text":" 10:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval changes\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman transferred to ICU for PNA, fluid overload\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n FOLLOWUP EXAMINATION.\n\n The left CVL and NGT remain in place. Less prominent and better defined\n pulmonary vasculature is noted, suggesting some improvement in fluid status.\n There are no new consolidations.\n\n"},{"category":"Radiology","chartdate":"2201-03-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":996084,"text":" 6:36 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please evaluate for NGT placement and any interval changes i\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with respiratory distress after flash pulm edema this AM,\n ?evolving PNA, NGT placed\n REASON FOR THIS EXAMINATION:\n please evaluate for NGT placement and any interval changes in\n effusions/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 18:42.\n\n INDICATION: Respiratory distress. NGT placement.\n\n COMPARISON: at 5:12.\n\n FINDINGS: Compared to the prior study, there is marked improvement in\n aeration of the lungs zones with resolution of much of the previously seen\n airspace and interstitial markings and better-defined pulmonary vasculature.\n A slight patchiness is seen in the right upper lung, and this could represent\n pneumonia. There is no pneumothorax, and the NGT is seen extending below the\n level of the left hemidiaphragm. Heart size still demonstrates cardiomegaly\n and a prominent left hilum is again noted.\n\n IMPRESSION: Marked improvement with resolution of pulmonary edema changes;\n residual consolidation of right upper lobe could represent pneumonia.\n\n\n"},{"category":"ECG","chartdate":"2201-03-02 00:00:00.000","description":"Report","row_id":165375,"text":"Normal sinus rhythm, rate 99. Borderline first degree A-V block. Borderline\nleft atrial abnormality. Inferior myocardial infarction of indeterminate age.\nExtensive anterior myocardial infarction of indeterminate age. Compared to the\nprevious tracing of the sinus rate is faster.\n\n"},{"category":"ECG","chartdate":"2201-02-27 00:00:00.000","description":"Report","row_id":165376,"text":"Sinus arrhythmia. Prolonged P-R interval. Right bundle-branch block. Inferior\nQ waves represent prior myocardial infarction. Anterior Q waves could represent\nprior anteroseptal myocardial infarction. Compared to the previous tracing\nof no significant change.\n\n"},{"category":"Nursing","chartdate":"2201-03-03 00:00:00.000","description":"Nursing Transfer Note","row_id":314530,"text":"Hypotension (not Shock)\n Assessment:\n Normotensive, Afeb. WBC 8.5. On, zosyn , Vanco (Po/IV),\n Action:\n Metrprlol & ASA, statin\n Response:\n Stable, Diarrhea diminishing.\n Plan:\n Cont to assess, cont antibiotics for c-diff colitis & ? pneumonia\n .Contact precautions. D/C rectal tube.\n Hypoxemia\n Assessment:\n Sats 94-97% on RA. Denies SOB. BS with wheezes, Occas\n productive of yellow to white secretions\n Action:\n OOB to chair by PT, Encouraged to C, DB\n Response:\n Maintaining sats, RR, denies resp distress\n Plan:\n Follow RR, sat, BS . Assess need for duiresis. Goal I&O even to 500 cc\n negative\n Hypercalcemia (high Calcium)\n Assessment:\n Clacium 10.5 this AM. Oriented X3 but does occas makes inappropriate\n statements.\n Action:\n Received calcitonin & pamidronate X1\n Response:\n No change in previous exam\n Plan:\n Recheck PM labs after pamridronate infusion\n Multiple myeloma (Cancer, Malignant Neoplasm)\n Assessment:\n Myeloma labs coming back positive. Family concerned about using the\n words\nmyeloma\ncancer\n with pt as they are concerned about her\n response and the fact her MS continues to wax & wane. Pt has had BM BX\n in the past. Dtr, reports pt states pt became extremely anxious\n &agitiated\n Action:\n met with dtr. Family meeting with DR \n (ICU attending), (dtr), dtr\ns husband, social service, & this\n RN. Dtr voiced concerns as above as well as concern her mother will\njust give up\n. requested onc consult be deferred until she has an\n opportunity to speak with pt\ns oncologist , Dr. . Dr\n in agreement at this point given pt\ns waxing & MS.\n also conveyed his obligation as pt\ns physician to give pt\n information about their care, DX & treatment options so they can make\n informed decisions. Post meeting Dr. phoned Dr. &\n informed him about the meeting. Dr. will phone dtr this\n eve.\n Response:\n ICU team members & family aware of issues of care re: myeloma\n Plan:\n Called out to 12R. Convey plan with 12R multidisciplinary team\n Oncology consult deferred until meeting, input with Dr. \n ** Will not use terms\nmyeloma, cancer\n for the time being.\n Continue to evaluate MS.\n will follow up with dtr .\n Impaired Skin Integrity\n Assessment:\n Stage II pressure ulcer thoracic spine area 1.5cm X 1.5 CM. Skin\n excoriated/yeast perianal, gluteals as well as yeast rash.\n Action:\n Consulted by care RN\n Response:\n No change\n Plan:\n Criicare Qd and PRN. to perianal area & gluteal areas\n stage II thoracic ulcers cleanse with NS, pat dry, apply thin layer\n of gel then cover with Allevyn foam Q3 daysQD.\n Notify MD care RN with any deterioration\n D/C rectal tube. Replace with flexiseal tube if necessary\n First step mattress\n Demographics\n Attending MD:\n , \n Admit diagnosis:\n HYPONATREMIA\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 56.4 kg\n Daily weight:\n Allergies/Reactions:\n Morphine\n Unknown;\n Oxycodone\n Unknown;\n Dilaudid (Injection) (Hydromorphone Hcl/Pf)\n Confusion/Delir\n Precautions: Contact\n PMH: Anemia\n CV-PMH: CAD, CHF, Hypertension, MI\n Additional history: falls, delerium, c-diff, LBP.Breast ca, anxiety,\n elevated chol, GERD, pulm valvuloplasty, MGUS\n Surgery / Procedure and date: S/p bilat mastectomy\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:141\n D:70\n Temperature:\n 97.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 93 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,224 mL\n 24h total out:\n 1,410 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 06:01 AM\n Potassium:\n 3.3 mEq/L\n 06:01 AM\n Chloride:\n 106 mEq/L\n 06:01 AM\n CO2:\n 21 mEq/L\n 06:01 AM\n BUN:\n 24 mg/dL\n 06:01 AM\n Creatinine:\n 1.7 mg/dL\n 06:01 AM\n Glucose:\n 115 mg/dL\n 06:01 AM\n Hematocrit:\n 23.6 %\n 06:01 AM\n Additional pertinent labs:\n Due for labs at \n Lines / Tubes / Drains:\n L sc TL\n Valuables / Signature\n Patient valuables: none\n Other valuables:\n Clothes: Sent home with: dtr, \n / Money:\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4 \n Transferred to: 1280, 12R\n Date & time of Transfer: , 2230\n"},{"category":"Nursing","chartdate":"2201-03-03 00:00:00.000","description":"Nursing Transfer Note","row_id":314523,"text":"Hypotension (not Shock)\n Assessment:\n Normotensive, Afeb. WBC 8.5. On, zosyn , Vanco (Po/IV),\n Action:\n Metrprlol & ASA, statin\n Response:\n Stable, Diarrhea diminishing.\n Plan:\n Cont to assess, cont antibiotics for c-diff colitis & ? pneumonia\n .Contact precautions. D/C rectal tube.\n Hypoxemia\n Assessment:\n Sats 94-97% on RA. Denies SOB. BS with wheezes, Occas\n productive of yellow to white secretions\n Action:\n OOB to chair by PT, Encouraged to C, DB\n Response:\n Maintaining sats, RR, denies resp distress\n Plan:\n Follow RR, sat, BS . Assess need for duiresis. Goal I&O even to 500 cc\n negative\n Hypercalcemia (high Calcium)\n Assessment:\n Clacium 10.5 this AM. Oriented X3 but does occas makes inappropriate\n statements.\n Action:\n Received calcitonin & pamidronate X1\n Response:\n No change in previous exam\n Plan:\n Recheck PM labs after pamridronate infusion\n Multiple myeloma (Cancer, Malignant Neoplasm)\n Assessment:\n Myeloma labs coming back positive. Family concerned about using the\n words\nmyeloma\ncancer\n with pt as they are concerned about her\n response and the fact her MS continues to wax & wane. Pt has had BM BX\n in the past. Dtr, reports pt states pt became extremely anxious\n &agitiated\n Action:\n met with dtr. Family meeting with DR \n (ICU attending), (dtr), dtr\ns husband, social service, & this\n RN. Dtr voiced concerns as above as well as concern her mother will\njust give up\n. requested onc consult be deferred until she has an\n opportunity to speak with pt\ns oncologist , Dr. . Dr\n in agreement at this point given pt\ns waxing & MS.\n also conveyed his obligation as pt\ns physician to give pt\n information about their care, DX & treatment options so they can make\n informed decisions. Post meeting Dr. phoned Dr. &\n informed him about the meeting. Dr. will phone dtr this\n eve.\n Response:\n ICU team members & family aware of issues of care re: myeloma\n Plan:\n Called out to 12R. Convey plan with 12R multidisciplinary team\n Oncology consult deferrd until meeting, input with Dr. \n ** Will not use terms\nmyeloma, cancer\n for the time being.\n Continue to evaluate MS.\n will follow up with dtr .\n Impaired Skin Integrity\n Assessment:\n Stage II pressure ulcer thoracic spine area 1.5cm X 1.5 CM. Skin\n excoriated/yeast perianal, gluteals as well as yeast rash.\n Action:\n Consulted by care RN\n Response:\n No change\n Plan:\n Criicare Qd and PRN. to perianal area & gluteal areas\n stage II thoracic ulcers cleanse with NS, pat dry, apply thin layer\n of gel then cover with Allevyn foam Q3 daysQD.\n Notify MD care RN with any deterioration\n D/C rectal tube. Replace with flexiseal tube if necessary\n"},{"category":"Nursing","chartdate":"2201-03-03 00:00:00.000","description":"Nursing Transfer Note","row_id":314513,"text":"Hypotension (not Shock)\n Assessment:\n Normotensive\n Action:\n Metrprlol & ASA\n Response:\n Stable\n Plan:\n Cont to assess\n Hypoxemia\n Assessment:\n Sats 94-97% on RA. Denies SOB. BS with wheezes, Occasproductive of\n yellow to white secretions\n Action:\n Response:\n Plan:\n Follow RR, sats. Assess need for duiresis\n Hypercalcemia (high Calcium)\n Assessment:\n Clacium 10.5 this AM. Oriiented X3 but does occas makes inappropriate\n statements\n Action:\n Received calcitonin & pamidronate X1\n Response:\n Plan:\n Recheck PMlabs after pamridronate infusion\n"},{"category":"Nursing","chartdate":"2201-03-03 00:00:00.000","description":"Nursing Transfer Note","row_id":314514,"text":"Hypotension (not Shock)\n Assessment:\n Normotensive, Afeb. WBC 8.5. On, zosyn , Vanco (Po/IV),\n Action:\n Metrprlol & ASA, statin\n Response:\n Stable, Diarrhea diminishing.\n Plan:\n Cont to assess, cont antibiotics for c-diff colitis & ? pneumonia\n .Contact precautions. D/C rectal tube.\n Hypoxemia\n Assessment:\n Sats 94-97% on RA. Denies SOB. BS with wheezes, Occas\n productive of yellow to white secretions\n Action:\n Response:\n Plan:\n Follow RR, sat, BS . Assess need for duiresis\n Hypercalcemia (high Calcium)\n Assessment:\n Clacium 10.5 this AM. Oriented X3 but does occas makes inappropriate\n statements.\n Action:\n Received calcitonin & pamidronate X1\n Response:\n Plan:\n Recheck PM labs after pamridronate infusion\n Multiple myeloma (Cancer, Malignant Neoplasm)\n Assessment:\n Family concerned about the use of\nmyeloma\ncancer\n with\n Action:\n Response:\n Plan:\n"},{"category":"Social Work","chartdate":"2201-03-03 00:00:00.000","description":"Social Work Progress Note","row_id":314504,"text":"Family Meeting:\n The patient\ns daughter, , wanted to speak with a s\n"},{"category":"Rehab Services","chartdate":"2201-03-03 00:00:00.000","description":"Physical Therapy Evaluation Note","row_id":314508,"text":"Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 428.0 / CHF\n Reason of referral: eval and treat\n History of Present Illness / Subjective Complaint: 78 y.o. Female found\n to be delerious and sliightly confused with hypercalcemia/hyponatremia.\n 5 days of productive cough with whitish sputum. Hypoxia with PNA versus\n flash pulmonary edema and acute on chronic diastolic HF. SPEP +\n suggesting myeloma\n Past Medical / Surgical History: HTN, CAd, s/p MI, B ORIF, R olecranon\n fracture, ulnar n. injury, pulmonary stenosis s/p valvuloplasty, appy,\n anxiety, GERd, C-diff, URI\n Medications: lorazepam, heparin, vancomycin, lasix\n Radiology: CXR 1.20: no evidence of new consolidation\n Labs:\n 23.6\n 7.9\n 134\n 8.5\n [image002.jpg]\n Other labs:\n Activity Orders: activity as tolerated\n Social / Occupational History: lives alone, dtr and son in law live\n across the street, dtr assists with shopping\n Living Environment: stairs to enter w/ rails and stairs to , tub bench, rails in BR\n Prior Functional Status / Activity Level: I amb w/ RW, was at rehab for\n short time but recently at home\n Objective Test\n Arousal / Attention / Cognition / Communication: Alert, oriented x\n self, iniitally eager to get oob>chair but became slightly upset at EOB\n but calmed. not oriented x hospital. thought at rehab but easily\n reoriented. Occasional non sensical statements. Understands use of call\n light. understands and verbalizes need to call for A when mobilizing\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 76\n 112/70\n 18\n 97 RA\n Rest\n /\n Sit\n 145/60\n 24\n 98 RA\n Activity\n /\n Stand\n /\n Recovery\n 82\n 111/54\n 17\n 95 RA\n Total distance walked:\n Minutes:\n Pulmonary Status: strong mildly congested cough, raises to upper\n airway. Coordinated breathing pattern\n Integumentary / Vascular: L CVP line, flexiseal, foley catheter,\n telemetry, thoracic stage 2 wound per wound care note\n Sensory Integrity: Detects all LT sensation UE/UE\n Pain / Limiting Symptoms: Unable to grade on VAS scale. C/o back pain\n in bed\n Posture: forward head and shoulders, kyphotic\n Range of Motion\n Muscle Performance\n WFL B throughout\n Able to move all extremities against gravity. UE/LE grossly \n Motor Function: moves all extremities, no abnormal movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Mod A to perform stand step transfer to chair with\n gait belt. No noted knee bucking.\n Rolling:\n\n\n\n T\n\n\n Supine /\n Sidelying to Sit:\n With HOB elevated\n\n\n\n\n T\n\n Transfer:\n Stand step transfer\n\n\n\n\n T\n\n Sit to Stand:\n\n\n\n T\n\n Ambulation:\n N/a\n\n\n\n\n\n\n Stairs:\n n/A\n\n\n\n\n\n\n Balance: sat EOB initially with Min A progressing to S with B UE\n support, requires mod A for balance during stand step transfer bed >\n Chair,\n Education / Communication: Communicated with RN to discuss case; RN\n aware pt in chair and prefers to have pt upright in chair. Pt\n understands use of call light and verbalizes need to call for A. RN to\n provide frequent checks for safety; recommend 2 A for staff to transfer\n patient back to bed - pt's dtr and son in law left to speak w/ MD at\n end of session and will need to discuss d/c plan with them\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Arousal, Attention, and Cognition, Impaired\n 3.\n Balance, Impaired\n 4.\n Knowledge, Impaired\n 5.\n Muscle Performace, Impaired\n 6.\n Transfers, Impaired\n Clinical impression / Prognosis: 78 y.o. female with confusion,\n hypercalcemia, hyponatremia, productive cough and acute on chronic\n diastolic heart failure presents with above impairments consistent with\n deconditioning. Pt was ambulating household distances I PTA and is now\n well below baseline and requiring A for all mobilizing. At this time do\n not feel pt is safe to return home, and will likely require inpatient\n rehab to maximize functional I and safety and return home. If daughter\n prefers to take patient home, would still require increased mobility to\n get to a level by which the dtr can safety care for patient. Likely 3\n days of extrememly limited mobility in combination with medical factors\n have led to current functional status, but anticipate pt could return\n to modified Independent ambulation with rolling walker with short term\n rehab stay.\n Goals\n Time frame: 1 week\n 1.\n Rolling CG A\n 2.\n Min A sup>sit with hob flat\n 3.\n sit>stand min A\n 4.\n ambulation w/ RW 50 ft w/ CGA\n 5.\n A & O x 3\n 6.\n Sits at EOB I with UE support\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: x/wk x 1 wk\n Rolling/Sup>sit hob flat, sit>stand, transfers, ambulation w/ RW,\n discussion w/ patient's family re: wishes, pt education - role of PT,\n d/c plan, increase upright tolerance, Recommend 2 A for nursing staff\n OOB>chair/back to bed from chair.\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n ( pt initially eager to get oob and participate- at EOB but wanted to\n get BTB but encouraged to get to chair and agreed)\n"},{"category":"General","chartdate":"2201-03-03 00:00:00.000","description":"ICU Event Note","row_id":314512,"text":"Clinician: Attending\n I had a 60 minute meeting with the patient's daughter and son-in-law.\n They expressed the wish that the patient not be told about the\n diagnosis of myeloma. They are concerned that she will not be able to\n handle the information, that she might\ngive up\n, and that it would\n provoke severe anxiety.\n Since the patient's mental status is not completely clear now, this is\n a moot point at the moment. I conveyed to the family that I would share\n their wishes with the team and the nurses. When her mental status\n clears, however, I strongly urged them to be truthful with Ms \n since patient's often discern or become aware of their diagnosis\n despite the best efforts to protect them from the information;\n deception erodes the credibility of the caregivers and the family\n should this happen and often results in great anger within the patient.\n I also spoke with Dr. by phone. He agrees that the patient\n now meets diagnostic criteria for myeloma, and suspects the\n hypercalcemia is due to this condition. If so, the myeloma will likely\n need to be treated. Dr. will speak with Ms \ns daughter by\n telephone tonight.\n"},{"category":"Rehab Services","chartdate":"2201-03-03 00:00:00.000","description":"Physical Therapy Evaluation Note","row_id":314510,"text":"Attending: \n Referral date: \n Medical Diagnosis / ICD 9: 428.0 CHF\n Reason of referral: eval and treat\n History of Present Illness / Subjective Complaint: 78 y.o. Female found\n to be delerious and sliightly confused with hypercalcemia/hyponatremia.\n 5 days of productive cough with whitish sputum. Hypoxia with PNA versus\n flash pulmonary edema and acute on chronic diastolic HF. SPEP +\n suggesting myeloma\n Past Medical / Surgical History: HTN, CAd, s/p MI, B ORIF, R olecranon\n fracture, ulnar n. injury, pulmonary stenosis s/p valvuloplasty, appy,\n anxiety, GERd, C-diff, URI\n Medications: lorazepam, heparin, vancomycin, lasix\n Radiology: CXR 1.20: no evidence of new consolidation\n Labs:\n 23.6\n 7.9\n 134\n 8.5\n [image002.jpg]\n Other labs:\n Activity Orders: activity as tolerated\n Social / Occupational History: lives alone, dtr and son in law live\n across the street, dtr assists with shopping\n Living Environment: stairs to enter w/ rails and stairs to , tub bench, rails in BR\n Prior Functional Status / Activity Level: I amb w/ RW, was at rehab for\n short time but recently at home\n Objective Test\n Arousal / Attention / Cognition / Communication: Alert, oriented x\n self, iniitally eager to get oob>chair but became slightly upset at EOB\n but calmed. not oriented x hospital. thought at rehab but easily\n reoriented. Occasional non sensical statements. Understands use of call\n light. understands and verbalizes need to call for A when mobilizing\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 76\n 112/70\n 18\n 97 RA\n Rest\n /\n Sit\n 145/60\n 24\n 98 RA\n Activity\n /\n Stand\n /\n Recovery\n 82\n 111/54\n 17\n 95 RA\n Total distance walked:\n Minutes:\n Pulmonary Status: strong mildly congested cough, raises to upper\n airway. Coordinated breathing pattern\n Integumentary / Vascular: L CVP line, flexiseal, foley catheter,\n telemetry, thoracic stage 2 wound per wound care note\n Sensory Integrity: Detects all LT sensation UE/UE\n Pain / Limiting Symptoms: Unable to grade on VAS scale. C/o back pain\n in bed\n Posture: forward head and shoulders, kyphotic\n Range of Motion\n Muscle Performance\n WFL B throughout\n Able to move all extremities against gravity. UE/LE grossly \n Motor Function: moves all extremities, no abnormal movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Mod A to perform stand step transfer to chair with\n gait belt. No noted knee bucking.\n Rolling:\n\n\n\n T\n\n\n Supine /\n Sidelying to Sit:\n With HOB elevated\n\n\n\n\n T\n\n Transfer:\n Stand step transfer\n\n\n\n\n T\n\n Sit to Stand:\n\n\n\n T\n\n Ambulation:\n N/a\n\n\n\n\n\n\n Stairs:\n n/A\n\n\n\n\n\n\n Balance: sat EOB initially with Min A progressing to S with B UE\n support, requires mod A for balance during stand step transfer bed >\n Chair,\n Education / Communication: Communicated with RN to discuss case; RN\n aware pt in chair and prefers to have pt upright in chair. Pt\n understands use of call light and verbalizes need to call for A. RN to\n provide frequent checks for safety; recommend 2 A for staff to transfer\n patient back to bed - pt's dtr and son in law left to speak w/ MD at\n end of session and will need to discuss d/c plan with them\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Arousal, Attention, and Cognition, Impaired\n 3.\n Balance, Impaired\n 4.\n Knowledge, Impaired\n 5.\n Muscle Performace, Impaired\n 6.\n Transfers, Impaired\n Clinical impression / Prognosis: 78 y.o. female with confusion,\n hypercalcemia, hyponatremia, productive cough and acute on chronic\n diastolic heart failure presents with above impairments consistent with\n deconditioning. Pt was ambulating household distances I PTA and is now\n well below baseline and requiring A for all mobilizing. At this time do\n not feel pt is safe to return home, and will likely require inpatient\n rehab to maximize functional I and safety and return home. If daughter\n prefers to take patient home, would still require increased mobility to\n get to a level by which the dtr can safety care for patient. Likely 3\n days of extrememly limited mobility in combination with medical factors\n have led to current functional status, but anticipate pt could return\n to modified Independent ambulation with rolling walker with short term\n rehab stay.\n Goals\n Time frame: 1 week\n 1.\n Rolling CG A\n 2.\n Min A sup>sit with hob flat\n 3.\n sit>stand min A\n 4.\n ambulation w/ RW 50 ft w/ CGA\n 5.\n A & O x 3\n 6.\n Sits at EOB I with UE support\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: x/wk x 1 wk\n Rolling/Sup>sit hob flat, sit>stand, transfers, ambulation w/ RW,\n discussion w/ patient's family re: wishes, pt education - role of PT,\n d/c plan, increase upright tolerance, Recommend 2 A for nursing staff\n OOB>chair/back to bed from chair.\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n ( pt initially eager to get oob and participate- at EOB but wanted to\n get BTB but encouraged to get to chair and agreed)\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2201-02-28 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 995920,\n \"text\": \" 11:30 AM\\n CHEST (PA & LAT) Clip # \\n Reason: pls assess interval change for blossoming of infiltrate\\n Admitting Diagnosis: HYPONATREMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old woman with MGUS, CAD s/p MI, HTN, admitted with mild prod cough and\\n ? infiltrate on imaging. Hx of cdif to Abx. s/p aggressive IVF hydration\\n REASON FOR THIS EXAMINATION:\\n pls assess interval change for blossoming of infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n PA AND LATERAL CHEST ON AT 11:35\\n\\n INDICATION: Cough.\\n\\n COMPARISON: at 21:38.\\n\\n FINDINGS:\\n\\n Similar to the prior film, there is some increased density projecting over the\\n lower thoracic spine on the lateral view, but there appears to be even further\\n increased opacity there. An element of atelectasis versus an evolving\\n pneumonia is in the differential. A staple appearance to the left hilum is\\n seen, most consistent with pulmonary artery enlargement. This has been stable\\n for a few years.\\n\\n The pulmonary vascular markings are within normal limits.\\n\\n IMPRESSION:\\n\\n Further increase in the opacity projecting over the lower thoracic spine.\\n This is not clearly localized on the frontal view, but I suspect is in the\\n left lower lobe. Atelectasis versus developing pneumonia.\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2201-02-27 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 995846,\n \"text\": \" 9:33 PM\\n CHEST (PA & LAT) Clip # \\n Reason: pna\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old woman with cough, phlegm\\n REASON FOR THIS EXAMINATION:\\n pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: A 78-year-old female with cough and phlegm production with concern\\n for pneumonia.\\n\\n COMPARISON: .\\n\\n CHEST, TWO VIEWS: There is moderate cardiomegaly. The mediastinal contours\\n are unchanged. Again demonstrated is evidence of aortic tortuosity and\\n markedly enlarged pulmonary arterial contour. There is no pleural effusion or\\n pneumothorax. The lung volumes are relatively low. No consolidation is seen\\n on the frontal view. There has been slight increase in opacity projecting\\n over the lower spine on the lateral view which could be due to crowding\\n secondary to low volumes. Again demonstrated are right axillary dissection\\n clips. A mottled appearance of the bones suggestive of multiple myeloma has\\n not changed. There are marked degenerative changes of the shoulder joints.\\n\\n IMPRESSION: New subtle opacity overlying the lower thoracic spine on the\\n lateral view is more likely explained by crowding due to low lung volumes.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2201-03-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 996008,\n \"text\": \" 5:02 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pulmonary edema\\n Admitting Diagnosis: HYPONATREMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old woman with emegency need\\n REASON FOR THIS EXAMINATION:\\n pulmonary edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST ON AT 5:12\\n\\n INDICATION: Edema.\\n\\n COMPARISON: at 11:35.\\n\\n FINDINGS:\\n\\n Diffusely increased interstitial and parenchymal opacities are visualized in a\\n pattern consistent with sudden pulmonary edema. Continued followup is\\n recommended to see if this evolves into more persistent consolidations. The\\n right CP angle is cut off from view and there is no pneumothorax.\\n\\n IMPRESSION: Flash pulmonary edema.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2201-03-01 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 996087,\n \"text\": \" 8:20 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: Please evaluate for central line placement\\n Admitting Diagnosis: HYPONATREMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old woman with central line placed for fluid resuscitation\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for central line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST ON AT 20:26\\n\\n INDICATION: CVL placement.\\n\\n COMPARISON: at 18:42.\\n\\n FINDINGS:\\n\\n A left CVL has been placed and the tip is in the SVC - no PTX. The lungs are\\n stable without evidence of new consolidation or exacerbation in fluid status.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2201-03-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1622679,\n \"text\": \"NURSING NOTES 7AM-19PM\\nRESP: NO C/O SOB. RESP MORE REGULAR. R BS'S CLEAR AND LEFT CONT. IN I/E WHEEZES. NEBS GIVEN Q6HRS. SAT 98% ON 4L NP. HAS A CONGESTED NON-PRODUCTIVE COUGH.\\nGI: NPO X ICE CHIPS, BUT TOOK SMALL AMT OF WATER WITHOUT PROBLEMS. MOUTH IS VERY DRY. LIQUID STOOL CONT. FROM MUSHROOM CATHETER.\\nRENAL: GIVEN 40MG LASIX IVP WITH MODERATE DIURESES. IVF-KVO. CREAT 2,0.\\nNEURO: VERY SLEEPY THIS AM, BUT SHE HAS PROGRESSIVELY BECOME MORE AWAKE. DAUGHTER STATED THAT SHE WAS VERY TIRED AT HOME AS WELL. UNABLE TO UNDERSTAND HER WELL D/T DRY MOUTH. CONT. TO BE RESTRAINED AS SHE DOES FORGET THAT SHE HAS A NGT.\\nCV: HEMODYNAMICALLY STABLE. WAS IN NSR IN 90'S. GIVEN AN ADDITIONAL 12.5MG OF LOPRESSOR VIA NGT AND DOSE INCREASED TO 37.5MG.\\nENDOC: K+ REPLETED THIS AM. PM LYTES JUST SENT OFF. AS WELL AS AN I.CA+ AND LACTATE LEVELS.\\nID: TEMP 99.8AX. NO FURTHER SPIKES. CONT. ON ANTIBIOTICS. FIRST C-DIFF SAMPLE POSITIVE.\\nSKIN INTEGRITY: PRESSURE SORE ON BACK NOTED. TURNED OFTEN. DUODERM INTACT.\\nPAIN CONTROL: BACK PAIN TX'ED WITH LIDO PATCH. IF NEEDED PT. CAN HAVE HER DARVOCETT. NOT REQUIRED YET.\\nHEM: HCT 23.7. NO TX NEEDED YET.\\nSOCIAL: DAUGHTER AND SON-IN-LAW IN WITH PT. MOST OF THE DAY. PLAN IS FOR HER DAUGHTER TO STAY OVERNIGHT AGAIN.\\nDAUGHTER HAS REQUESTED THAT PT. NOT BE INFORMED OF POSSIBLE DX OF MULTIPLE MYELOMA. ATTENDING AGREES AT THIS TIME.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2201-03-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1622680,\n \"text\": \"NPN 1900 -0700\\n\\nNEURO PLEASANTLY CONFUSED AT TIMES, POOR SHORT TERM MEMORY. CHRONIC BACK PAIN CONTROLLED W/ DARVOCET AND LIDO PATCH. DOES OCC BECOME ANXIOUS. RECIEVED .5 ATIVAN OVERNOC FOR SLEEP W/ POOR RESULTS (?? SUGGEST TRAZADONE)\\n\\nRESP: LOOSE NON PRODUCTIVE COUGH,NEBS NOW Q 6 PRN, OCC I/E WHEEZES, MAINT SATS 99-100%\\n\\nC/V: PM HCT 22 (TRANSFUSE FOR< 21) SR -ST NO ECTOPY, BP STABLE, 1TEENS, LOPRESSOR DOSE INCREASED YESTERDAY TO 37.5 , TOL WELL.\\n\\nF/E/N: REPLETED PM K+ OF 3.2 W/ 40 KCL IV, RECIEVED ADDITIONAL 40MEQ LASIX W/ MOD RESPONSE ~ 500CC,NOW NEG FLUID BALANCE OF ~ .5 LITER. LOOSE STOOL VIA MUSHROOM CATH ( C DIFF POS) AM LYTES PENDING.TOL PO'S , ABLE TO SWALLOW PILLS.\\n\\nPLAN: D/C NGT IF CONT TO BE ABLE TO TOL PO'S, CONT AB TX, PAIN MANAGEMENT , DAUGHTER STILL DOES NOT WANT PT TO KNOW DX, FEARS THAT THE WORD \\\"MYELOMA\\\" BE TOO STRESS PRODUCING FOR PT AT THIS TIME . DAUGHTERS WISHES RESPECTED\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2201-03-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1622681,\n \"text\": \"Resp Care Note, Pt seen for Q6 prn nebs.Last done 0530. BS scattered wheezes. Strong prod cough.Pt weak otherwise stable. Will cont to monitor resp status.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2201-03-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1622674,\n \"text\": \"Admitting and nursing progress note;\\n\\nThis is a 78 y/o lady admitted to 11R around 5am for delirium d/t low sodium and ? RF. Has h/o CHF, resp. failure, NSTIMI (cath stent), delirium, + c. diff in , low back pain, CAD, breast CA - bilat mats, HTN, pulm, stenosis, anxiety, MGUS, GERD. She was tx'd to FN ICU around 13:45 today d/t resp distress requiring NRB mask (metabolic acidosis), low u/o, febrile to 103.9 (rectally), rales/wheezing noted and decreased MS. morphine overnight, which she has an documented sensitivity too. Also, rec'd lasix, vanco, ceftriaxone, flagyl, azithromycin.\\n\\nReview of system:\\n\\nNeuro: Lethargic, but easily arouable. Confused and yells out the name (her grandson). Soft wrist restraints on for safety of lines/tubes. MAE.\\n\\nPulm: Wean from NRB to Hi-flow to 3L NC w/ stable o2 sats. RR regular and unlabored. Lungs w/ rhonchi throughout. No cough noted.\\n\\nCV: ST w/ occassional PVC's. Febrile to 102. BP stable. No edema noted. + ppp x 4. Poor access w/ several attempts at IV's (#22 to R Upper arm).\\n\\nGI/GU: Abd is soft, nt, nd. + hyperactive bs. Constant diarrhea w/ mushroom catheter placed. sump to right nares in place. Awaiting x-ray confirmation. Foley in place w/ adequate uo.\\n\\nPlan: Cont. w/ antibiotic treatment. Question placement of central line vs. picc line for better IV access. Monitor per protocol. Will attempt to sent labs.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2201-03-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1622675,\n \"text\": \"RESPIRATORY CARE: D: PT FROM 11 FOR RESPIRATORY DISTRESS\\nAND WHEEZING.\\nA: GIVEN 2.5 MG ALBUTEROL/ 0.5 MG ATROVENT SVN.\\nR: SLIGHT SUBJECTIVE/ OBJECTIVE RX.\\nP: FOLLOW Q4 FOR ALBUTEROL/ATROVENT SVN.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2201-03-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1622676,\n \"text\": \"Respiratory Care:\\nPatient received albuterol/atrovent unit dose medication in SVN via aerosol mask. Slight improvement with Rx.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2201-03-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1622677,\n \"text\": \"neuro: dozing, agitated at times, confused. febrile, tmax 101.1 ax. tylenol given, cooling blanket on. ativan x1 given for agitation w/ good effect. bilat wrist restraints to prevent pulling lines.\\n\\nresp: exp. wheezes, nebs given w/ moderate effect. O2 sat 96-99%. RR increased to 3040s with agitation, c/o being unable to breath. improved with ativan.\\n\\ncv: hypotensive at start of shift, bp 60s. CVC placed, 1L LRx1 given with good effect. dropped to 70s-80s at 1am, 1L NSx1 given with good effect. at 3am became tachy 130s-140s, PO metoprolol given w/ good effect. current bp in 90s, ST 100s-110s. cvp 9-11.\\n\\ngi/gu: foley patent draining small amount of yellow urine. mushroom cath in place draining large amount of liq stool, c-diff+. +BS.\\n\\nplan: monitor bp and temp. replace lytes as necessary.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2201-03-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1622678,\n \"text\": \"RESPIRATORY CARE: PT W/ MILD EXP. WHEEZE. GIVEN\\n2.G MG ALBUTEROL/ 0.5 MG ATROVENT SVN X 2 THIS\\nSHIFT. MILD SUB/OBJ. RX TO TX. FOLLOW Q4.\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2201-03-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 996229,\n \"text\": \" 4:25 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o progressive RUL consolidation, effusions, assess resolut\\n Admitting Diagnosis: HYPONATREMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old woman with CHF, CAD, h/o c. diff trasnferred to ICU for hypoxia,\\n tachypnea, fevers.\\n REASON FOR THIS EXAMINATION:\\n r/o progressive RUL consolidation, effusions, assess resolution or worsening of\\n pulmonary edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH:\\n\\n INDICATION: Followup.\\n\\n COMPARISON: .\\n\\n FINDINGS: The external parts of the nasogastric tube projects over the left\\n hemithorax. Nasogastric tube and left-sided central venous access are\\n unchanged. The size of the cardiac silhouette and the morphology of the lung\\n parenchyma show no major changes as compared to previous examination.\\n\\n IMPRESSION: No relevant interval changes.\\n\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2201-03-08 00:00:00.000\",\n \"description\": \"CT L-SPINE W/O CONTRAST\",\n \"row_id\": 997126,\n \"text\": \" 2:59 PM\\n CT L-SPINE W/O CONTRAST Clip # \\n Reason: eval for fracture\\n Admitting Diagnosis: HYPONATREMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old woman with multiple myeloma, focal pain of the rt. SI joint; MR\\n completed but essentially uninterpretable due to motion artifact despite\\n sedation\\n REASON FOR THIS EXAMINATION:\\n eval for fracture\\n CONTRAINDICATIONS for IV CONTRAST:\\n myeloma\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n CLINICAL HISTORY: 78-year-old female with multiple myeloma. Focal pain right\\n over the SI joint.\\n\\n Evaluate for fracture.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Non-contrast MDCT acquired axial images of the lumbar spine from\\n T10 to the coccyx. Multiplanar reformatted images were obtained.\\n\\n FINDINGS: Image portion of the lower thoracic and lumbar spine demonstrate\\n diffuse demineralization and severe degenerative change with compression\\n deformities, most marked in L1 and T11. S-shaped scoliosis of the\\n thoracolumbar spine is noted.\\n\\n Mild neural foraminal narrowing is identified at the right T9-T10 and T10-T11\\n level secondary to uncovertebral spurring and endplate osteophytes. Note is\\n made of moderate spinal canal narrowing at L4- L5 due to endplate osteophytes\\n and ligamentum flavum hypertrophy. Limited views of the lung show small\\n bilateral pleural effusions and atelectasis. Diffuse atherosclerotic\\n calcification is present.\\n\\n IMPRESSION:\\n 1. Severe demineralization of the bones which may be partially related to a\\n systemic process, ie. multiple myeloma.\\n 2. Extensive degenerative change involving the thoracolumbar spine. Note is\\n made of compression deformities of the L1 and T11 vertebral bodies of\\n undetermined chronicity.\\n\\n\\n NOTE ADDED AT ATTENDING REVIEW: There are innumerable lytic lesions throughout\\n the lumbar spine, sacrum, and iliac bones, compatible with myeloma. There is\\n moderate spinal stenosis at L3-4 and severe spinal stenosis at L4-5 and L5-\\n S1, apparently due to degenerative disk disease. However, the soft tissue\\n component may be a combination of disk material, thick ligamentum flavum, and\\n epidural tumor. The very limited MR does not demonstrate tumor in the canal,\\n but it is not adequate to exclude this diagnosis.\\n (Over)\\n\\n 2:59 PM\\n CT L-SPINE W/O CONTRAST Clip # \\n Reason: eval for fracture\\n Admitting Diagnosis: HYPONATREMIA\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2201-03-08 00:00:00.000\",\n \"description\": \"CT PELVIS ORTHO W/O C\",\n \"row_id\": 997127,\n \"text\": \" 3:00 PM\\n CT PELVIS ORTHO W/O C Clip # \\n Reason: Eval for Sacral/pelvic fx. in region of rt. SI joint, focal\\n Admitting Diagnosis: HYPONATREMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old woman with multiple myeloma, focal pain of the rt. SI joint; MR\\n completed but essentially uninterpretable due to motion artifact despite\\n sedation\\n REASON FOR THIS EXAMINATION:\\n Eval for Sacral/pelvic fx. in region of rt. SI joint, focal area of pain\\n CONTRAINDICATIONS for IV CONTRAST:\\n myeloma\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT OF THE PELVIS WITHOUT CONTRAST, \\n\\n CLINICAL INFORMATION: 78-year-old female with multiple myeloma and focal pain\\n of the right sacroiliac joint. MRI was completed, but essentially\\n uninterpretable due to motion artifact despite sedation. Evaluate for sacral\\n and pelvic fracture in region of the right sacroiliac joint.\\n\\n FINDINGS:\\n\\n The bones are markedly osteopenic. There are innumerable lytic lesions within\\n both the medullary cavity as well as within the cortex; some of the lesions\\n breach the cortex. Innumerable lytic lesions are seen throughout the lumbar\\n spine and throughout the iliac bones and sacrum. Lytic lesions are also seen\\n within bilateral acetabula and proximal femora. There are bilateral dynamic\\n compression screws in place traversing old intertrochanteric fractures. There\\n are severe degenerative changes of the lower lumbar spine.\\n\\n There is mild widening of the superior aspect of the right sacroiliac joint of\\n unclear etiology. No discrete erosive changes are identified in the right\\n sacroiliac joint. No fracture is identified in the right sacroiliac joint.\\n There are mild degenerative changes of bilateral sacroiliac joints. There is\\n severe facet arthropathy at L5-S1 on the right.\\n\\n Evaluation of the pelvic contents demonstrates severe atherosclerotic disease\\n of the abdominal aorta, extending into bilateral common iliac arteries. There\\n is residual barium from a previous contrast study within the small bowel. The\\n bladder is markedly distended. The bladder contains a moderate amount of air.\\n Could this be secondary to recent instrumentation or catheterization?\\n\\n There is moderate streak artifact from bilateral hip prostheses limiting\\n interpretation or evaluation of the pelvic viscera. There is moderate colonic\\n diverticulosis without complication.\\n\\n IMPRESSION:\\n\\n 1. Severe osteopenia. Severe myelomatous involvement of the osseous\\n structures, with innumerable lytic lesions involving both the medullary cavity\\n and breaching the cortex of all visualized osseous structures. No displaced\\n (Over)\\n\\n 3:00 PM\\n CT PELVIS ORTHO W/O C Clip # \\n Reason: Eval for Sacral/pelvic fx. in region of rt. SI joint, focal\\n Admitting Diagnosis: HYPONATREMIA\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n fractures identified.\\n\\n 2. Mild widening of the right sacroiliac joint with respect to the left. No\\n erosive change is identified at the right sacroiliac joint.\\n\\n 3. Severe degenerative changes of the lower lumbar spine, particularly at the\\n right L5-S1 facet joint.\\n\\n 4. Severe atherosclerotic disease.\\n\\n 5. Markedly distended bladder, containing a moderate amount of air. Has the\\n patient recently been instrumented?\\n\\n 6. Moderate sigmoid diverticulosis without complication.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2201-03-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 997000,\n \"text\": \" 11:22 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for interval change - ? evolving consolidation, ? pulm\\n Admitting Diagnosis: HYPONATREMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old woman with mult. myeloma, sob\\n REASON FOR THIS EXAMINATION:\\n eval for interval change - ? evolving consolidation, ? pulm edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST X-RAY\\n\\n HISTORY: Myeloma, shortness of breath.\\n\\n One portable view. Comparison with the previous studies of and\\n .\\n\\n Bronchovascular markings are prominent, as before. Increased density is\\n projected over the heart. The central pulmonary arteries are prominent. The\\n heart appears enlarged. The aorta is calcified. Mediastinal structures are\\n unchanged. A left subclavian catheter remains in place. A nasogastric tube\\n has been withdrawn. Severe degenerative changes are noted in the spine and\\n shoulders.\\n\\n IMPRESSION: Prominent interstitial markings which may reflect pulmonary\\n vascular congestion, unchanged. Increased density projected over the heart\\n which may represent a left lower lobe infiltrate. PA and lateral views would\\n be helpful for further evaluation.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2201-03-04 00:00:00.000\",\n \"description\": \"SKELETAL SURVEY (INCLUD LONG BONES)\",\n \"row_id\": 996506,\n \"text\": \" 1:51 PM\\n SKELETAL SURVEY (INCLUD LONG BONES) Clip # \\n Reason: eval for lesions c/w multiple myeloma\\n Admitting Diagnosis: HYPONATREMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old woman with likely multiple myeloma, low back pain\\n REASON FOR THIS EXAMINATION:\\n eval for lesions c/w multiple myeloma\\n ______________________________________________________________________________\\n FINAL REPORT\\n SKELETAL SURVEY\\n\\n CLINICAL HISTORY: Multiple myeloma.\\n\\n No prior skeletal survey is available.\\n\\n Two lateral films of the skull were obtained showing multiple lytic lesions\\n consistent with the history of multiple myeloma.\\n\\n Frontal and lateral films of the thoracic spine show osteopenia. There is a\\n moderate diffuse compression fracture of T8. On the lateral film, T10-11 are\\n distorted by scoliosis but no fracture of them is seen on the frontal view.\\n\\n Frontal and lateral films of the lumbar spine show fracture of L1. There is\\n scoliosis and there are degenerative disc disease changes. Vascular\\n calcifications are noted.\\n\\n AP view of the pelvis shows multiple small lucent lesions throughout the bony\\n pelvis and proximal femurs. There are bilateral dynamic compression screws\\n and rods.\\n\\n AP views of the femurs show innumerable small lytic lesions.\\n\\n AP views of both humeri show marked superior subluxation of the humeral heads\\n relative to the glenoid with a bone-on-bone appearance, large osteophytes and\\n subchondral sclerosis. There is remodeling of the proximal humeral shafts\\n bilaterally, apparently related to the inferior margins of the glenoids and\\n osteophytes in that region. Multiple small lytic lesions are seen throughout\\n the humeri. There is deformity of the right radius perhaps related to surgery\\n or old non-united fracture. Extensive myelomatous involvement was seen on a\\n CT examination of the abdomen on . Due to osteopenia, the thoracic\\n vertebral bodies are very difficult to evaluate on prior chest films. The T8\\n fracture is new since .\\n\\n IMPRESSION: Innumerable small lytic lesions are seen throughout the\\n visualized osseous structures consistent with the widespread myelomatous\\n involvement seen on prior abdominal CT. Fractures of T8 and L1 are now\\n visualized. There is marked deformity of the glenohumeral joints with\\n superior subluxation of the humeral heads relative to the glenoids, sclerosis,\\n osteophyte formation and remodeling of the proximal medial humeral diaphyseal\\n regions.\\n\\n (Over)\\n\\n 1:51 PM\\n SKELETAL SURVEY (INCLUD LONG BONES) Clip # \\n Reason: eval for lesions c/w multiple myeloma\\n Admitting Diagnosis: HYPONATREMIA\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2201-03-07 00:00:00.000\",\n \"description\": \"MR L SPINE W/O CONTRAST\",\n \"row_id\": 996996,\n \"text\": \" 10:40 AM\\n MR L SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST Clip # \\n Reason: eval for L and T spine stability of vertbrae\\n Admitting Diagnosis: HYPONATREMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old woman with multiple myeloma, back pain at lumbar and T spine, eval\\n for acute fracture, neural compression\\n REASON FOR THIS EXAMINATION:\\n eval for L and T spine stability of vertbrae\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n MRI SCAN OF THE THORACIC AND LUMBAR SPINE\\n\\n HISTORY: 78-year-old woman with multiple myeloma. Back pain within the\\n lumbar and thoracic regions. Evaluate for acute fracture, compression and\\n stability of the vertebra.\\n\\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the thoracic spine was\\n attempted.\\n\\n FINDINGS: This study is nearly uninterpretable due to gross motion artifacts.\\n The axial T2-weighted scans of the thoracic spine, while also degraded by\\n patient motion are of sufficient quality to show no definite sign of spinal\\n cord compression. However, it appears that there is generalized low T1 signal\\n throughout the visualized spinal column, a finding which would raise concern\\n for the presence of diffuse infiltration of the bone, as in the setting of\\n myeloma. There is a likely mild compression fracture of the T7 body. There is\\n probable moderate spinal stenosis in the lumbar spine at L4/5, as well as\\n L5/S1, but the absence of axial scans in the lumbar region reduces the ability\\n of this study to assess for central canal stenosis. There is likely moderate\\n distention of the urinary bladder. No further evaluation of this study with\\n reliability can be undertaken at this time.\\n\\n CONCLUSION: Nearly uninterpretable study due to gross patient motion. CT\\n might provide improved bony imaging, provided the patient can remain still.\\n\\n COMMENT: As noted above, the only axial images supplied at this time\\n encompass the thoracic region.\\n\\n Findings were discussed with Dr. , hospitalist caring for this\\n patient on .\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2201-03-02 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 996146,\n \"text\": \" 10:38 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please evaluate for interval changes\\n Admitting Diagnosis: HYPONATREMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old woman transferred to ICU for PNA, fluid overload\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for interval changes\\n ______________________________________________________________________________\\n FINAL REPORT\\n FOLLOWUP EXAMINATION.\\n\\n The left CVL and NGT remain in place. Less prominent and better defined\\n pulmonary vasculature is noted, suggesting some improvement in fluid status.\\n There are no new consolidations.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2201-03-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 996084,\n \"text\": \" 6:36 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: please evaluate for NGT placement and any interval changes i\\n Admitting Diagnosis: HYPONATREMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old woman with respiratory distress after flash pulm edema this AM,\\n ?evolving PNA, NGT placed\\n REASON FOR THIS EXAMINATION:\\n please evaluate for NGT placement and any interval changes in\\n effusions/infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST ON AT 18:42.\\n\\n INDICATION: Respiratory distress. NGT placement.\\n\\n COMPARISON: at 5:12.\\n\\n FINDINGS: Compared to the prior study, there is marked improvement in\\n aeration of the lungs zones with resolution of much of the previously seen\\n airspace and interstitial markings and better-defined pulmonary vasculature.\\n A slight patchiness is seen in the right upper lung, and this could represent\\n pneumonia. There is no pneumothorax, and the NGT is seen extending below the\\n level of the left hemidiaphragm. Heart size still demonstrates cardiomegaly\\n and a prominent left hilum is again noted.\\n\\n IMPRESSION: Marked improvement with resolution of pulmonary edema changes;\\n residual consolidation of right upper lobe could represent pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2201-03-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 165375,\n \"text\": \"Normal sinus rhythm, rate 99. Borderline first degree A-V block. Borderline\\nleft atrial abnormality. Inferior myocardial infarction of indeterminate age.\\nExtensive anterior myocardial infarction of indeterminate age. Compared to the\\nprevious tracing of the sinus rate is faster.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2201-02-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 165376,\n \"text\": \"Sinus arrhythmia. Prolonged P-R interval. Right bundle-branch block. Inferior\\nQ waves represent prior myocardial infarction. Anterior Q waves could represent\\nprior anteroseptal myocardial infarction. Compared to the previous tracing\\nof no significant change.\\n\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2201-03-03 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 314530,\n \"text\": \"Hypotension (not Shock)\\n Assessment:\\n Normotensive, Afeb. WBC 8.5. On, zosyn , Vanco (Po/IV),\\n Action:\\n Metrprlol & ASA, statin\\n Response:\\n Stable, Diarrhea diminishing.\\n Plan:\\n Cont to assess, cont antibiotics for c-diff colitis & ? pneumonia\\n .Contact precautions. D/C rectal tube.\\n Hypoxemia\\n Assessment:\\n Sats 94-97% on RA. Denies SOB. BS with wheezes, Occas\\n productive of yellow to white secretions\\n Action:\\n OOB to chair by PT, Encouraged to C, DB\\n Response:\\n Maintaining sats, RR, denies resp distress\\n Plan:\\n Follow RR, sat, BS . Assess need for duiresis. Goal I&O even to 500 cc\\n negative\\n Hypercalcemia (high Calcium)\\n Assessment:\\n Clacium 10.5 this AM. Oriented X3 but does occas makes inappropriate\\n statements.\\n Action:\\n Received calcitonin & pamidronate X1\\n Response:\\n No change in previous exam\\n Plan:\\n Recheck PM labs after pamridronate infusion\\n Multiple myeloma (Cancer, Malignant Neoplasm)\\n Assessment:\\n Myeloma labs coming back positive. Family concerned about using the\\n words\\nmyeloma\\ncancer\\n with pt as they are concerned about her\\n response and the fact her MS continues to wax & wane. Pt has had BM BX\\n in the past. Dtr, reports pt states pt became extremely anxious\\n &agitiated\\n Action:\\n met with dtr. Family meeting with DR \\n (ICU attending), (dtr), dtr\\ns husband, social service, & this\\n RN. Dtr voiced concerns as above as well as concern her mother will\\njust give up\\n. requested onc consult be deferred until she has an\\n opportunity to speak with pt\\ns oncologist , Dr. . Dr\\n in agreement at this point given pt\\ns waxing & MS.\\n also conveyed his obligation as pt\\ns physician to give pt\\n information about their care, DX & treatment options so they can make\\n informed decisions. Post meeting Dr. phoned Dr. &\\n informed him about the meeting. Dr. will phone dtr this\\n eve.\\n Response:\\n ICU team members & family aware of issues of care re: myeloma\\n Plan:\\n Called out to 12R. Convey plan with 12R multidisciplinary team\\n Oncology consult deferred until meeting, input with Dr. \\n ** Will not use terms\\nmyeloma, cancer\\n for the time being.\\n Continue to evaluate MS.\\n will follow up with dtr .\\n Impaired Skin Integrity\\n Assessment:\\n Stage II pressure ulcer thoracic spine area 1.5cm X 1.5 CM. Skin\\n excoriated/yeast perianal, gluteals as well as yeast rash.\\n Action:\\n Consulted by care RN\\n Response:\\n No change\\n Plan:\\n Criicare Qd and PRN. to perianal area & gluteal areas\\n stage II thoracic ulcers cleanse with NS, pat dry, apply thin layer\\n of gel then cover with Allevyn foam Q3 daysQD.\\n Notify MD care RN with any deterioration\\n D/C rectal tube. Replace with flexiseal tube if necessary\\n First step mattress\\n Demographics\\n Attending MD:\\n , \\n Admit diagnosis:\\n HYPONATREMIA\\n Code status:\\n Full code\\n Height:\\n 60 Inch\\n Admission weight:\\n 56.4 kg\\n Daily weight:\\n Allergies/Reactions:\\n Morphine\\n Unknown;\\n Oxycodone\\n Unknown;\\n Dilaudid (Injection) (Hydromorphone Hcl/Pf)\\n Confusion/Delir\\n Precautions: Contact\\n PMH: Anemia\\n CV-PMH: CAD, CHF, Hypertension, MI\\n Additional history: falls, delerium, c-diff, LBP.Breast ca, anxiety,\\n elevated chol, GERD, pulm valvuloplasty, MGUS\\n Surgery / Procedure and date: S/p bilat mastectomy\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:141\\n D:70\\n Temperature:\\n 97.1\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 20 insp/min\\n Heart Rate:\\n 93 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 96% %\\n O2 flow:\\n FiO2 set:\\n 24h total in:\\n 1,224 mL\\n 24h total out:\\n 1,410 mL\\n Pertinent Lab Results:\\n Sodium:\\n 137 mEq/L\\n 06:01 AM\\n Potassium:\\n 3.3 mEq/L\\n 06:01 AM\\n Chloride:\\n 106 mEq/L\\n 06:01 AM\\n CO2:\\n 21 mEq/L\\n 06:01 AM\\n BUN:\\n 24 mg/dL\\n 06:01 AM\\n Creatinine:\\n 1.7 mg/dL\\n 06:01 AM\\n Glucose:\\n 115 mg/dL\\n 06:01 AM\\n Hematocrit:\\n 23.6 %\\n 06:01 AM\\n Additional pertinent labs:\\n Due for labs at \\n Lines / Tubes / Drains:\\n L sc TL\\n Valuables / Signature\\n Patient valuables: none\\n Other valuables:\\n Clothes: Sent home with: dtr, \\n / Money:\\n No money / \\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: 4 \\n Transferred to: 1280, 12R\\n Date & time of Transfer: , 2230\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2201-03-03 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 314523,\n \"text\": \"Hypotension (not Shock)\\n Assessment:\\n Normotensive, Afeb. WBC 8.5. On, zosyn , Vanco (Po/IV),\\n Action:\\n Metrprlol & ASA, statin\\n Response:\\n Stable, Diarrhea diminishing.\\n Plan:\\n Cont to assess, cont antibiotics for c-diff colitis & ? pneumonia\\n .Contact precautions. D/C rectal tube.\\n Hypoxemia\\n Assessment:\\n Sats 94-97% on RA. Denies SOB. BS with wheezes, Occas\\n productive of yellow to white secretions\\n Action:\\n OOB to chair by PT, Encouraged to C, DB\\n Response:\\n Maintaining sats, RR, denies resp distress\\n Plan:\\n Follow RR, sat, BS . Assess need for duiresis. Goal I&O even to 500 cc\\n negative\\n Hypercalcemia (high Calcium)\\n Assessment:\\n Clacium 10.5 this AM. Oriented X3 but does occas makes inappropriate\\n statements.\\n Action:\\n Received calcitonin & pamidronate X1\\n Response:\\n No change in previous exam\\n Plan:\\n Recheck PM labs after pamridronate infusion\\n Multiple myeloma (Cancer, Malignant Neoplasm)\\n Assessment:\\n Myeloma labs coming back positive. Family concerned about using the\\n words\\nmyeloma\\ncancer\\n with pt as they are concerned about her\\n response and the fact her MS continues to wax & wane. Pt has had BM BX\\n in the past. Dtr, reports pt states pt became extremely anxious\\n &agitiated\\n Action:\\n met with dtr. Family meeting with DR \\n (ICU attending), (dtr), dtr\\ns husband, social service, & this\\n RN. Dtr voiced concerns as above as well as concern her mother will\\njust give up\\n. requested onc consult be deferred until she has an\\n opportunity to speak with pt\\ns oncologist , Dr. . Dr\\n in agreement at this point given pt\\ns waxing & MS.\\n also conveyed his obligation as pt\\ns physician to give pt\\n information about their care, DX & treatment options so they can make\\n informed decisions. Post meeting Dr. phoned Dr. &\\n informed him about the meeting. Dr. will phone dtr this\\n eve.\\n Response:\\n ICU team members & family aware of issues of care re: myeloma\\n Plan:\\n Called out to 12R. Convey plan with 12R multidisciplinary team\\n Oncology consult deferrd until meeting, input with Dr. \\n ** Will not use terms\\nmyeloma, cancer\\n for the time being.\\n Continue to evaluate MS.\\n will follow up with dtr .\\n Impaired Skin Integrity\\n Assessment:\\n Stage II pressure ulcer thoracic spine area 1.5cm X 1.5 CM. Skin\\n excoriated/yeast perianal, gluteals as well as yeast rash.\\n Action:\\n Consulted by care RN\\n Response:\\n No change\\n Plan:\\n Criicare Qd and PRN. to perianal area & gluteal areas\\n stage II thoracic ulcers cleanse with NS, pat dry, apply thin layer\\n of gel then cover with Allevyn foam Q3 daysQD.\\n Notify MD care RN with any deterioration\\n D/C rectal tube. Replace with flexiseal tube if necessary\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2201-03-03 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 314513,\n \"text\": \"Hypotension (not Shock)\\n Assessment:\\n Normotensive\\n Action:\\n Metrprlol & ASA\\n Response:\\n Stable\\n Plan:\\n Cont to assess\\n Hypoxemia\\n Assessment:\\n Sats 94-97% on RA. Denies SOB. BS with wheezes, Occasproductive of\\n yellow to white secretions\\n Action:\\n Response:\\n Plan:\\n Follow RR, sats. Assess need for duiresis\\n Hypercalcemia (high Calcium)\\n Assessment:\\n Clacium 10.5 this AM. Oriiented X3 but does occas makes inappropriate\\n statements\\n Action:\\n Received calcitonin & pamidronate X1\\n Response:\\n Plan:\\n Recheck PMlabs after pamridronate infusion\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2201-03-03 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 314514,\n \"text\": \"Hypotension (not Shock)\\n Assessment:\\n Normotensive, Afeb. WBC 8.5. On, zosyn , Vanco (Po/IV),\\n Action:\\n Metrprlol & ASA, statin\\n Response:\\n Stable, Diarrhea diminishing.\\n Plan:\\n Cont to assess, cont antibiotics for c-diff colitis & ? pneumonia\\n .Contact precautions. D/C rectal tube.\\n Hypoxemia\\n Assessment:\\n Sats 94-97% on RA. Denies SOB. BS with wheezes, Occas\\n productive of yellow to white secretions\\n Action:\\n Response:\\n Plan:\\n Follow RR, sat, BS . Assess need for duiresis\\n Hypercalcemia (high Calcium)\\n Assessment:\\n Clacium 10.5 this AM. Oriented X3 but does occas makes inappropriate\\n statements.\\n Action:\\n Received calcitonin & pamidronate X1\\n Response:\\n Plan:\\n Recheck PM labs after pamridronate infusion\\n Multiple myeloma (Cancer, Malignant Neoplasm)\\n Assessment:\\n Family concerned about the use of\\nmyeloma\\ncancer\\n with\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Social Work\",\n \"chartdate\": \"2201-03-03 00:00:00.000\",\n \"description\": \"Social Work Progress Note\",\n \"row_id\": 314504,\n \"text\": \"Family Meeting:\\n The patient\\ns daughter, , wanted to speak with a s\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2201-03-03 00:00:00.000\",\n \"description\": \"Physical Therapy Evaluation Note\",\n \"row_id\": 314508,\n \"text\": \"Attending Physician: \\n Referral date: \\n Medical Diagnosis / ICD 9: 428.0 / CHF\\n Reason of referral: eval and treat\\n History of Present Illness / Subjective Complaint: 78 y.o. Female found\\n to be delerious and sliightly confused with hypercalcemia/hyponatremia.\\n 5 days of productive cough with whitish sputum. Hypoxia with PNA versus\\n flash pulmonary edema and acute on chronic diastolic HF. SPEP +\\n suggesting myeloma\\n Past Medical / Surgical History: HTN, CAd, s/p MI, B ORIF, R olecranon\\n fracture, ulnar n. injury, pulmonary stenosis s/p valvuloplasty, appy,\\n anxiety, GERd, C-diff, URI\\n Medications: lorazepam, heparin, vancomycin, lasix\\n Radiology: CXR 1.20: no evidence of new consolidation\\n Labs:\\n 23.6\\n 7.9\\n 134\\n 8.5\\n [image002.jpg]\\n Other labs:\\n Activity Orders: activity as tolerated\\n Social / Occupational History: lives alone, dtr and son in law live\\n across the street, dtr assists with shopping\\n Living Environment: stairs to enter w/ rails and stairs to , tub bench, rails in BR\\n Prior Functional Status / Activity Level: I amb w/ RW, was at rehab for\\n short time but recently at home\\n Objective Test\\n Arousal / Attention / Cognition / Communication: Alert, oriented x\\n self, iniitally eager to get oob>chair but became slightly upset at EOB\\n but calmed. not oriented x hospital. thought at rehab but easily\\n reoriented. Occasional non sensical statements. Understands use of call\\n light. understands and verbalizes need to call for A when mobilizing\\n Hemodynamic Response\\n Aerobic Capacity\\n HR\\n BP\\n RR\\n O[2 ]sat\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Supine\\n 76\\n 112/70\\n 18\\n 97 RA\\n Rest\\n /\\n Sit\\n 145/60\\n 24\\n 98 RA\\n Activity\\n /\\n Stand\\n /\\n Recovery\\n 82\\n 111/54\\n 17\\n 95 RA\\n Total distance walked:\\n Minutes:\\n Pulmonary Status: strong mildly congested cough, raises to upper\\n airway. Coordinated breathing pattern\\n Integumentary / Vascular: L CVP line, flexiseal, foley catheter,\\n telemetry, thoracic stage 2 wound per wound care note\\n Sensory Integrity: Detects all LT sensation UE/UE\\n Pain / Limiting Symptoms: Unable to grade on VAS scale. C/o back pain\\n in bed\\n Posture: forward head and shoulders, kyphotic\\n Range of Motion\\n Muscle Performance\\n WFL B throughout\\n Able to move all extremities against gravity. UE/LE grossly \\n Motor Function: moves all extremities, no abnormal movement patterns\\n Functional Status:\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Gait, Locomotion: Mod A to perform stand step transfer to chair with\\n gait belt. No noted knee bucking.\\n Rolling:\\n\\n\\n\\n T\\n\\n\\n Supine /\\n Sidelying to Sit:\\n With HOB elevated\\n\\n\\n\\n\\n T\\n\\n Transfer:\\n Stand step transfer\\n\\n\\n\\n\\n T\\n\\n Sit to Stand:\\n\\n\\n\\n T\\n\\n Ambulation:\\n N/a\\n\\n\\n\\n\\n\\n\\n Stairs:\\n n/A\\n\\n\\n\\n\\n\\n\\n Balance: sat EOB initially with Min A progressing to S with B UE\\n support, requires mod A for balance during stand step transfer bed >\\n Chair,\\n Education / Communication: Communicated with RN to discuss case; RN\\n aware pt in chair and prefers to have pt upright in chair. Pt\\n understands use of call light and verbalizes need to call for A. RN to\\n provide frequent checks for safety; recommend 2 A for staff to transfer\\n patient back to bed - pt's dtr and son in law left to speak w/ MD at\\n end of session and will need to discuss d/c plan with them\\n Intervention:\\n Other:\\n Diagnosis:\\n 1.\\n Aerobic Capacity / Endurance, Impaired\\n 2.\\n Arousal, Attention, and Cognition, Impaired\\n 3.\\n Balance, Impaired\\n 4.\\n Knowledge, Impaired\\n 5.\\n Muscle Performace, Impaired\\n 6.\\n Transfers, Impaired\\n Clinical impression / Prognosis: 78 y.o. female with confusion,\\n hypercalcemia, hyponatremia, productive cough and acute on chronic\\n diastolic heart failure presents with above impairments consistent with\\n deconditioning. Pt was ambulating household distances I PTA and is now\\n well below baseline and requiring A for all mobilizing. At this time do\\n not feel pt is safe to return home, and will likely require inpatient\\n rehab to maximize functional I and safety and return home. If daughter\\n prefers to take patient home, would still require increased mobility to\\n get to a level by which the dtr can safety care for patient. Likely 3\\n days of extrememly limited mobility in combination with medical factors\\n have led to current functional status, but anticipate pt could return\\n to modified Independent ambulation with rolling walker with short term\\n rehab stay.\\n Goals\\n Time frame: 1 week\\n 1.\\n Rolling CG A\\n 2.\\n Min A sup>sit with hob flat\\n 3.\\n sit>stand min A\\n 4.\\n ambulation w/ RW 50 ft w/ CGA\\n 5.\\n A & O x 3\\n 6.\\n Sits at EOB I with UE support\\n Anticipated Discharge: Rehab\\n Treatment Plan:\\n Frequency / Duration: x/wk x 1 wk\\n Rolling/Sup>sit hob flat, sit>stand, transfers, ambulation w/ RW,\\n discussion w/ patient's family re: wishes, pt education - role of PT,\\n d/c plan, increase upright tolerance, Recommend 2 A for nursing staff\\n OOB>chair/back to bed from chair.\\n Patient agrees with the above goals and is willing to participate in\\n the rehabilitation program.\\n ( pt initially eager to get oob and participate- at EOB but wanted to\\n get BTB but encouraged to get to chair and agreed)\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2201-03-03 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 314512,\n \"text\": \"Clinician: Attending\\n I had a 60 minute meeting with the patient's daughter and son-in-law.\\n They expressed the wish that the patient not be told about the\\n diagnosis of myeloma. They are concerned that she will not be able to\\n handle the information, that she might\\ngive up\\n, and that it would\\n provoke severe anxiety.\\n Since the patient's mental status is not completely clear now, this is\\n a moot point at the moment. I conveyed to the family that I would share\\n their wishes with the team and the nurses. When her mental status\\n clears, however, I strongly urged them to be truthful with Ms \\n since patient's often discern or become aware of their diagnosis\\n despite the best efforts to protect them from the information;\\n deception erodes the credibility of the caregivers and the family\\n should this happen and often results in great anger within the patient.\\n I also spoke with Dr. by phone. He agrees that the patient\\n now meets diagnostic criteria for myeloma, and suspects the\\n hypercalcemia is due to this condition. If so, the myeloma will likely\\n need to be treated. Dr. will speak with Ms \\ns daughter by\\n telephone tonight.\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2201-03-03 00:00:00.000\",\n \"description\": \"Physical Therapy Evaluation Note\",\n \"row_id\": 314510,\n \"text\": \"Attending: \\n Referral date: \\n Medical Diagnosis / ICD 9: 428.0 CHF\\n Reason of referral: eval and treat\\n History of Present Illness / Subjective Complaint: 78 y.o. Female found\\n to be delerious and sliightly confused with hypercalcemia/hyponatremia.\\n 5 days of productive cough with whitish sputum. Hypoxia with PNA versus\\n flash pulmonary edema and acute on chronic diastolic HF. SPEP +\\n suggesting myeloma\\n Past Medical / Surgical History: HTN, CAd, s/p MI, B ORIF, R olecranon\\n fracture, ulnar n. injury, pulmonary stenosis s/p valvuloplasty, appy,\\n anxiety, GERd, C-diff, URI\\n Medications: lorazepam, heparin, vancomycin, lasix\\n Radiology: CXR 1.20: no evidence of new consolidation\\n Labs:\\n 23.6\\n 7.9\\n 134\\n 8.5\\n [image002.jpg]\\n Other labs:\\n Activity Orders: activity as tolerated\\n Social / Occupational History: lives alone, dtr and son in law live\\n across the street, dtr assists with shopping\\n Living Environment: stairs to enter w/ rails and stairs to , tub bench, rails in BR\\n Prior Functional Status / Activity Level: I amb w/ RW, was at rehab for\\n short time but recently at home\\n Objective Test\\n Arousal / Attention / Cognition / Communication: Alert, oriented x\\n self, iniitally eager to get oob>chair but became slightly upset at EOB\\n but calmed. not oriented x hospital. thought at rehab but easily\\n reoriented. Occasional non sensical statements. Understands use of call\\n light. understands and verbalizes need to call for A when mobilizing\\n Hemodynamic Response\\n Aerobic Capacity\\n HR\\n BP\\n RR\\n O[2 ]sat\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Supine\\n 76\\n 112/70\\n 18\\n 97 RA\\n Rest\\n /\\n Sit\\n 145/60\\n 24\\n 98 RA\\n Activity\\n /\\n Stand\\n /\\n Recovery\\n 82\\n 111/54\\n 17\\n 95 RA\\n Total distance walked:\\n Minutes:\\n Pulmonary Status: strong mildly congested cough, raises to upper\\n airway. Coordinated breathing pattern\\n Integumentary / Vascular: L CVP line, flexiseal, foley catheter,\\n telemetry, thoracic stage 2 wound per wound care note\\n Sensory Integrity: Detects all LT sensation UE/UE\\n Pain / Limiting Symptoms: Unable to grade on VAS scale. C/o back pain\\n in bed\\n Posture: forward head and shoulders, kyphotic\\n Range of Motion\\n Muscle Performance\\n WFL B throughout\\n Able to move all extremities against gravity. UE/LE grossly \\n Motor Function: moves all extremities, no abnormal movement patterns\\n Functional Status:\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Gait, Locomotion: Mod A to perform stand step transfer to chair with\\n gait belt. No noted knee bucking.\\n Rolling:\\n\\n\\n\\n T\\n\\n\\n Supine /\\n Sidelying to Sit:\\n With HOB elevated\\n\\n\\n\\n\\n T\\n\\n Transfer:\\n Stand step transfer\\n\\n\\n\\n\\n T\\n\\n Sit to Stand:\\n\\n\\n\\n T\\n\\n Ambulation:\\n N/a\\n\\n\\n\\n\\n\\n\\n Stairs:\\n n/A\\n\\n\\n\\n\\n\\n\\n Balance: sat EOB initially with Min A progressing to S with B UE\\n support, requires mod A for balance during stand step transfer bed >\\n Chair,\\n Education / Communication: Communicated with RN to discuss case; RN\\n aware pt in chair and prefers to have pt upright in chair. Pt\\n understands use of call light and verbalizes need to call for A. RN to\\n provide frequent checks for safety; recommend 2 A for staff to transfer\\n patient back to bed - pt's dtr and son in law left to speak w/ MD at\\n end of session and will need to discuss d/c plan with them\\n Intervention:\\n Other:\\n Diagnosis:\\n 1.\\n Aerobic Capacity / Endurance, Impaired\\n 2.\\n Arousal, Attention, and Cognition, Impaired\\n 3.\\n Balance, Impaired\\n 4.\\n Knowledge, Impaired\\n 5.\\n Muscle Performace, Impaired\\n 6.\\n Transfers, Impaired\\n Clinical impression / Prognosis: 78 y.o. female with confusion,\\n hypercalcemia, hyponatremia, productive cough and acute on chronic\\n diastolic heart failure presents with above impairments consistent with\\n deconditioning. Pt was ambulating household distances I PTA and is now\\n well below baseline and requiring A for all mobilizing. At this time do\\n not feel pt is safe to return home, and will likely require inpatient\\n rehab to maximize functional I and safety and return home. If daughter\\n prefers to take patient home, would still require increased mobility to\\n get to a level by which the dtr can safety care for patient. Likely 3\\n days of extrememly limited mobility in combination with medical factors\\n have led to current functional status, but anticipate pt could return\\n to modified Independent ambulation with rolling walker with short term\\n rehab stay.\\n Goals\\n Time frame: 1 week\\n 1.\\n Rolling CG A\\n 2.\\n Min A sup>sit with hob flat\\n 3.\\n sit>stand min A\\n 4.\\n ambulation w/ RW 50 ft w/ CGA\\n 5.\\n A & O x 3\\n 6.\\n Sits at EOB I with UE support\\n Anticipated Discharge: Rehab\\n Treatment Plan:\\n Frequency / Duration: x/wk x 1 wk\\n Rolling/Sup>sit hob flat, sit>stand, transfers, ambulation w/ RW,\\n discussion w/ patient's family re: wishes, pt education - role of PT,\\n d/c plan, increase upright tolerance, Recommend 2 A for nursing staff\\n OOB>chair/back to bed from chair.\\n Patient agrees with the above goals and is willing to participate in\\n the rehabilitation program.\\n ( pt initially eager to get oob and participate- at EOB but wanted to\\n get BTB but encouraged to get to chair and agreed)\\n\"\n }\n]"}}},{"rowIdx":24678,"cells":{"subject_id":{"kind":"number","value":13934,"string":"13,934"},"hadm_id":{"kind":"number","value":118258,"string":"118,258"},"target_text":{"kind":"string","value":"/P: 83M with h/o CAD, HTN, DM found unresponsive and hypoglycemic, now with multifocal pna concerning for aspiration, large left MCA stroke . Pt was found down in the field with hypoglycemia and respitaory failure. He was intubated in the field and transferred to for further care. There he was found to be in septic shock due to multi-focal PNA. He had end organ damage to kidneys, heart, lungs. He was treated with levo, flagyl, vanco. He was maintained on mechanical ventilation and on pressors. On antibiotics he slowly improved from a respiratory standpoint. His sedation and ventilation were weaned. After extubating the patient he was found to be unresponsive to verbal/painful stimuli. He was also noted to have a new right sided facial droop and he was not moving his right side. CT head then demonstrated a massive evolving left sided MCA infarct. Neuro stroke service was consulted. Follow up CT showed progression of the infarct as well as old right sided infarcts. Neuro felt his prognosis was extremely poor given the extent of his infarct. Family meeting was held and the patient was made DNR/DNI/CMO. He was then transferred to the floor from the MICU. He was maintained on morphine, ativan, scopolamine, tylenol for comfort. Palliative care was consulted and it was initially decided to transfer the patient to hospice. However, on the AM of anticipated transfer, it was noted that the patient was having significant periods of apnea, though he exhibited no signs of distress. Transfer was placed on hold, and the patient died later that afternoon."},"extractive_notes_summ":{"kind":"string","value":"Noaortic regurgitation is seen. There is abnormalseptal motion/position consistent with right ventricular pressure/volumeoverload. Nomasses or thrombi are seen in the left ventricle. There is mild symmetric leftventricular hypertrophy with mildy dilated cavity and moderate global leftventricular hypokinesis with akinesis of the distal third of the ventricle. Moderate [2+] TR.Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: Small pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor subcostal views. No LV mass/thrombus.LV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex -akinetic; septal apex- akinetic; inferior apex - akinetic; lateral apex -akinetic; apex - akinetic;RIGHT VENTRICLE: Mildly dilated RV cavity. Abnormalseptal motion/position consistent with RV pressure/volume overload.AORTA: Mildly dilated aortic root. Myocardial infarction.Height: (in) 68Weight (lb): 165BSA (m2): 1.89 m2BP (mm Hg): 132/64HR (bpm): 70Status: InpatientDate/Time: at 13:58Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.LEFT VENTRICLE: Mild symmetric LVH. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. The aorticvalve leaflets (3) are mildly thickened but aortic stenosis is not present. large area of low attenuation in right temporal lobe with loss of sulci, consistent with chronic infarct in right MCA distribution. Again seen is encephalomalacia in the right posterior temporal lobe, unchanged from the prior study. There is a verysmall pericardial effusion.IMPRESSION: Mild symmetric left ventricular hypertrophy with global andregional systolic dysfunction c/w diffuse process (toxin, metabolic,multivessel CAD, etc.) Ventricular paced rhythmAtrial mechanism is probable atrial fibrillationSince previous tracing of , no significant change The right ventricular cavityis mildly dilated. Ventricular paced rhythmAtrial mechanism is probably atrial fibrillationSince previous tracing of , no significant change Moderate globalLV hypokinesis. A right-sided pacemaker is seen with a single lead overlying the area of the right ventricle. The right costophrenic angle is not seen. Hypodense region within the right posterior temporal lobe with associated ex vacuo dilatation of the right occipital of the lateral ventricle, findings consistent with chronic infarction. The aortic root and ascending aorta are mildly dilated. General 1+ edema t/o.Pulm: Remains vented on CPAP settings. BS are diminished and rhoncherous on exam c slight clearing following sxn'ing. Recent ABG witin normal limits. LS coarse upper, diminished lower,C-V: HR 70-74, V-paced with occasional PAC's. Nursing Progress Note.EVENTS: Pt remains c fairly stable VS.RESP: Pt requires Q2-3 hr NTS for moderate amounts of thick bloody sec. Pt remains on QD IV Levofloxacin & Ceftriaxone dosing. Fluid balance -1700c at midnite.GI - Abd soft, +BS. resume outpt antihypertensives as indicated. Respiratory care Pt continues on PSV in NARD. On ceftriaxone/vanco/levo.Neuro - Exam has gradually improved a little o/n. Attempting to diurese.ROS:NEURO: Noted to be minimally responsive at start of shift, withdrawing only to deep and vigorous sternal rub. Pan cx, also stool c-diff sent. remains intubated on A/C. Extremities warm at start of shift, a bit cooler now.ACCESS: RIJ PreSep catheter removed; has a-line and 3 PIV's.SOCIAL: dtr called for update.A: could use better BP control; tolerating diureses; MS concerning.P: follow MS closely; if he does not wake up ? AM ABG c the following acceptable values; 7.47-40-97, no MV setting changes made today. AM WBCC cont to trend down c a value of 19.8. s/p pan C&S this AM. V-paced EKG waveform noted c no ectopy. Resp: Pt remains intubated on a/c 14/450/+5/40%. Freq oral care provided. Bs are clear with diminished bases, some wheezing was noted earlier, lasix given?Suctioned for moderate amounts of yellow bloody tinged secretions. Bs are clear bilaterally with diminished bases. +3 Anasarcoid.SOC: HCP dtr called this AM and kept up-to-date c POC/pt status. No restraints in place.CV: Hemodynamically stable c a tmax of 100.0, most recently 98.6. No breakdown on backside noted.Pts dtr called last pm, was updated by RN on pts condition.Plan: ?extubation today. Tylenol with T->98.6. Started on Lopressor; given 25mg X 2 per NGT and 5mg IV once with modest effect. cont to diurese as ordered. Cont neuro checks q2hr. LS mostly clear and diminished at bases, coarse at times as well.GI/GU: Tolerating TF Promote with fiber at 40cc/hr via NGT. V-paced EKG waveform c occ PAC's. ABG at 3am ph 7.28, Co2 42, O2-138GI: abd softly distended. LS fairly clear in upper apices today, diminished @ bases. Resp pattern fairly nl asside from occ slowing/speeding up of rate c nl sats maintained. Last ABG = 7/31-44-122. AM ABG's 7.47/40/97/30. Short periods of agonal breathing when hypertensive, resp pattern now normal.CV - BP 170s->190s (200s)/70s. ABGS within normal limits for pt. pt extubated to nasal cannula as ordered through status. BUN=28/ Creat.=1.1.Skin: remains edematous ---periorbital and facial edema unchanged. pt is +10L (h/o CAD,HTN,CABG, CHF,Pacer)Resp: vented on PS 15, Peep 10, 40%, #8.0 ETT 24cm at lips. Hct stable, WBC slightly decreased. Lactic Acid range from 2.5-3.3.GI: OGT intact placement checked by auscultation and confirmed by CXR. Left radial Aline with good waveform and correlation to NBP....BP= 111-135/58-70. AM lytes WNL. HR 70 and V-paced with occas. Versad drip at 1mg, fentanyl at 50mcg, Levo remains offID: afebrile max temp 98.9 tonight. self sufficent. CVP13-17,SVO2 67-70. Scant thick tan sec per ETT today. Continues with peripheral and facial edema. Turned q 3 hrs, skin care given. Lungs clear bilat upper lobes and with rales at bilateral lower lobes. The pt is +2 anasarcoid. BP 91-129/ 48-64. NGT to rt nare. ?IV/Access: Right IJ TLC with precep line. Withdraws left extremities and right LE to stimuli. on Vanco, Levaquin, flagyl. CT Head neg in ER. pt is purposeful.Cardiac: Levo off since 1am. admitting shift note 2100-700Pt admitted from ER intubated, on Levophed drip for BP control, low urinary output, WBC 13.9, continue on sepsis protocol.Neuro: opens eyes to noise and spontanously. V-paced 70s. Bowel sounds hypoactive. PERRL though R eye now deviated to the L of center. FSBS WNL.GU - UOP 30-100cc/hr. minimial output. Pt switched from CPAP to A/ M.D.. Suctioned moderate amt of thick bloody secretions. MICU nursing progress note 7P-7AEvents - Pt became increasingly hypertensive, BP refractory to lopressor and hydralazine, started on nipride gtt with gradual decrease in BP, goal SBP 140-160."},"n_notes":{"kind":"number","value":42,"string":"42"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2154-09-24 00:00:00.000","description":"Report","row_id":64802,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 68\nWeight (lb): 165\nBSA (m2): 1.89 m2\nBP (mm Hg): 132/64\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 13:58\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity. Moderate global\nLV hypokinesis. No LV mass/thrombus.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex -\nakinetic; septal apex- akinetic; inferior apex - akinetic; lateral apex -\nakinetic; apex - akinetic;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. RV function depressed. Abnormal\nseptal motion/position consistent with RV pressure/volume overload.\n\nAORTA: Mildly dilated aortic root. Focal calcifications in aortic root. Mildly\ndilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Small pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Based on\n AHA endocarditis prophylaxis recommendations, the echo findings indicate\na low risk (prophylaxis not recommended). Clinical decisions regarding the\nneed for prophylaxis should be based on clinical and echocardiographic data.\n\nConclusions:\nThe left and right atrium are moderately dilated. There is mild symmetric left\nventricular hypertrophy with mildy dilated cavity and moderate global left\nventricular hypokinesis with akinesis of the distal third of the ventricle. No\nmasses or thrombi are seen in the left ventricle. The right ventricular cavity\nis mildly dilated. Systolic function appears depressed. There is abnormal\nseptal motion/position consistent with right ventricular pressure/volume\noverload. The aortic root and ascending aorta are mildly dilated. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild to moderate (+) mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen.\nThere is moderate pulmonary artery systolic hypertension. There is a very\nsmall pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with global and\nregional systolic dysfunction c/w diffuse process (toxin, metabolic,\nmultivessel CAD, etc.) Pulmonary artery systolic hypertension. Mild-moderate\nmitral regurgitation.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"},{"category":"Radiology","chartdate":"2154-09-25 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":880270,"text":" 2:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Acute hemorrhage\n Admitting Diagnosis: SEPSIS,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with PNA sepsis, intubated, now off sedative meds and minimally\n responsive.\n REASON FOR THIS EXAMINATION:\n Acute hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old with pneumonia and sepsis with acute mental status\n changes, evaluate for hemorrhage.\n\n COMPARISONS: CT head of .\n TECHNIQUE: Axial MDCT images through the brain without IV contrast.\n\n CT HEAD FINDINGS: There has been interval development of a large left MCA\n distribution subacute infarction, which was not present on the prior study of\n . probable clot within a dense left MCA is visualized. There is no\n associated hemorrhagic component. There is mild local mass effect without\n shift of midline structures. Again seen is encephalomalacia in the right\n posterior temporal lobe, unchanged from the prior study.\n\n IMPRESSION:\n 1) Interval development of large left MCA distribution infarction, with\n probable clot in the hyperdense proximal MCA. There is no evidence of a\n hemorrhagic component.\n 2) Stable encephalomalacia in the right posterior temporal lobe.\n\n Findings phoned to Dr. after the study.\n\n\n"},{"category":"ECG","chartdate":"2154-09-25 00:00:00.000","description":"Report","row_id":132888,"text":"Continuous ventricular pacing. No organized atrial activity. Compared to the\nprevious tracing of no significant change.\n\n"},{"category":"ECG","chartdate":"2154-09-25 00:00:00.000","description":"Report","row_id":132889,"text":"Ventricular paced rhythm\nAtrial mechanism is probably atrial fibrillation\nSince previous tracing of same date, no significant change\n\n"},{"category":"ECG","chartdate":"2154-09-25 00:00:00.000","description":"Report","row_id":132890,"text":"Ventricular paced rhythm\nAtrial mechanism is probably atrial fibrillation\nSince previous tracing of , no significant change\n\n"},{"category":"ECG","chartdate":"2154-09-24 00:00:00.000","description":"Report","row_id":132891,"text":"Ventricular paced rhythm\nAtrial mechanism is probable atrial fibrillation\nSince previous tracing of , no significant change\n\n"},{"category":"ECG","chartdate":"2154-09-23 00:00:00.000","description":"Report","row_id":132892,"text":"Ventricular paced rhythm. compared to the previous tracing of no change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2154-09-22 00:00:00.000","description":"Report","row_id":132893,"text":"Ventricular paced rhythm. Probable underlying atrial fibrillation. No previous\ntracing available for comparison.\nTRACING #1\n\n"},{"category":"Radiology","chartdate":"2154-09-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":879940,"text":" 3:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess progression of PNA\n Admitting Diagnosis: SEPSIS,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man unresponsive, intubated for hypoxic respiratory failure\n REASON FOR THIS EXAMINATION:\n assess progression of PNA\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Patient unresponsive, hypoxic.\n\n CHEST: Diffuse alveolar opacifications are again seen in both the right and\n left lungs. Appearances are essentially unchanged since the prior chest x-ray\n of . The position of the various support lines and tubes is\n unchanged.\n\n IMPRESSION: Extensive alveolar infiltrates still present.\n\n\n"},{"category":"Radiology","chartdate":"2154-09-23 00:00:00.000","description":"P RENAL U.S. PORT","row_id":879973,"text":" 10:26 AM\n RENAL U.S. PORT Clip # \n Reason: low UOP, blood at meatus, large volume infused\n Admitting Diagnosis: SEPSIS,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with septic shock/b/l PNA, ? NSTEMI\n REASON FOR THIS EXAMINATION:\n low UOP, blood at meatus, large volume infused\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Low urine output with septic shock, and possible recent MI.\n\n RENAL ULTRASOUND, PORTABLE: Examination limited secondary to patient body\n habitus and portable technique. The left kidney measures 13 cm and contains\n two large rounded anechoic cystic structures consistent with simple renal\n cysts, the largest measuring 6.3 x 6.1 x 6.1 cm. The right kidney measures 12\n cm. Neither kidney displays hydronephrosis or contains stones. The cortices\n demonstrate normal echogenicity. Scan done in the area of the bladder shows\n no evidence for bladder distention.\n\n IMPRESSION: No evidence for hydronephrosis. Large simple renal cyst on the\n left kidney as described above. Otherwise, normal appearing kidneys\n bilaterally.\n\n\n"},{"category":"Radiology","chartdate":"2154-09-22 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":879922,"text":" 6:07 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval for placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man unresponsive, intubated s/p line placement\n\n REASON FOR THIS EXAMINATION:\n eval for placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old man, unresponsive, intubated, status post line\n placement. Evaluate placement.\n\n COMPARISON: AP supine portable chest x-ray dated at 16:36.\n\n AP SUPINE PORTABLE CHEST X-RAY: There has been interval placement of a right\n internal jugular central venous catheter with the tip in the mid SVC. An\n endotracheal tube remains in unchanged position approximately 6 cm above the\n carina. There is no pneumothorax identified on the supine radiograph. There\n has been interval worsening of multifocal patchy opacities primarily within\n the left mid, and right lower lung zones, concerning for aspiration pneumonia.\n The surrounding soft tissue and osseous structures are unchanged. Old healed\n rib fractures are again identified within multiple left posterior vertebral\n bodies.\n\n IMPRESSION:\n 1) Right IJ in mid SVC. No pneurmothorax.\n 2) Worsening bilateral multifocal opacities concerning for aspiration.\n\n"},{"category":"Radiology","chartdate":"2154-09-26 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":880359,"text":" 8:09 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: determine extent of cva and edema\n Admitting Diagnosis: SEPSIS,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with new l cva discovered \n REASON FOR THIS EXAMINATION:\n determine extent of cva and edema\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Follow up left MCA stroke.\n\n COMPARISONS: CT head of .\n TECHNIQUE: Axial MDCT images through the brain without IV contrast.\n\n CT HEAD FINDINGS: There is an evolving left middle cerebral arterial\n distribution infarction. Compared to the prior day, there is slightly more\n edema and mass effect with further impression of the left lateral ventricle.\n There is no hemorrhagic transformation within this infarction, and no evidence\n of hemorrhage elsewhere within the brain parenchyma. Stable appearance of\n encephalomalacia in the right posterior temporal region, unchanged from\n multiple prior studies. No other short interval change.\n\n IMPRESSION: Evolving left MCA distribution infarction, with slightly more\n edema and mass effect compared to the prior day's study.\n\n\n"},{"category":"Radiology","chartdate":"2154-09-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":879913,"text":" 4:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: tube placement, r/o aspiration\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man unresponsive, intubated\n REASON FOR THIS EXAMINATION:\n tube placement, r/o aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old man unresponsive, intubated. Evaluate tube\n placement.\n\n COMPARISON: None.\n\n AP SUPINE PORTABLE CHEST X-RAY: The study si limited due to patient\n positioning. An endotracheal tube is positioned approximately 7 cm superior\n to the carina. Sternal wires and sutures indicate prior coronary artery bypass\n graft. A right-sided pacemaker is seen with a single lead overlying the area\n of the right ventricle. The cardiac silhouette is prominent with intramural\n aortic calcifications. Multifocal patchy opacities in bilateral lungs are\n concerning for aspiration pneumonia. There is no left pleural effusion. The\n right costophrenic angle is not seen. Multiple old, healed left sided\n posterior rib fractures are seen.\n\n IMPRESSION:\n 1. Endotracheal tube approximately 7 cm superior to the carina.\n 2. Multifocal pneumonia concerning for aspiration.\n\n These findings were called to Dr. at 5 p.m. on .\n\n"},{"category":"Radiology","chartdate":"2154-09-22 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":879914,"text":" 4:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o stroke, bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man found unresponsive\n REASON FOR THIS EXAMINATION:\n r/o stroke, bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DFDdp SUN 5:23 PM\n no intracranial hemorrhage or mass effect. large area of low attenuation in\n right temporal lobe with loss of sulci, consistent with chronic infarct in\n right MCA distribution. atrophy.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Unresponsive.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n HEAD CT WITHOUT IV CONTRAST: No intracranial hemorrhage, mass effect, or\n shift of normally midline structures is noted. Large area of hypodensity with\n encephalomalacic change is noted within the posterior right temporal lobe with\n associated ex vacuo dilatation of the occipital of the right lateral\n ventricle, findings likely representing chronic infarction in the territory of\n the right middle cerebral artery. Additionally, bilateral periventricular\n white matter hypodensities are present, consistent with chronic microvascular\n infarction. There is widening of the sulci and ventricles, consistent with\n cerebral atrophy. There is opacification of the left sphenoid sinus and\n mucosal thickening involving the right sphenoid sinus and ethmoid air cells.\n The mastoid air cells and remaining visualized paranasal sinuses are clear.\n Surrounding osseous and soft tissue structures are unremarkable.\n\n IMPRESSION:\n 1. Hypodense region within the right posterior temporal lobe with associated\n ex vacuo dilatation of the right occipital of the lateral ventricle,\n findings consistent with chronic infarction.\n 2. Chronic small vessel ischemic disease.\n 3. No intracranial hemorrhage or mass effect.\n\n DFDdp\n\n"},{"category":"Nursing/other","chartdate":"2154-09-25 00:00:00.000","description":"Report","row_id":1443923,"text":"Respiratory Care Note:\n Patient remains on full vent support and appears non-responsive. Taken to CT for scan of head this afternoon. Results pending. Plan to maintain on present settings at this time. See Carevue flowsheet for specifics.\n"},{"category":"Nursing/other","chartdate":"2154-09-25 00:00:00.000","description":"Report","row_id":1443924,"text":"ADDENDUM 18:35\n\nMedical and Neuro team spoke with family about prognosis, and the critical nature of the next 24-48hrs with regards to pt survival.\nPt's daughter very upset due to losing mother suddenly in this hospital also, and also recently losing her brother. SW called and saw briefly, support given and will follow up in am.\nFamily now home for the night\nNeuro team recommend keeping SBP between 140-160mmHg, so 20mg IV Hydralazine given and Lopressor increased to 75mg to start at 12mn.\n\nRepeat lytes and CK-MB/Troponin sent at 18:00.\n"},{"category":"Nursing/other","chartdate":"2154-09-26 00:00:00.000","description":"Report","row_id":1443925,"text":"MICU nursing progress note 7P-7A\nEvents - T 101.4. Pan cx, also stool c-diff sent. Tylenol with T->98.6. WBC 21.6 (18.5). On ceftriaxone/vanco/levo.\n\nNeuro - Exam has gradually improved a little o/n. PERL, 2mm, sluggish. + cough, impaired gag. will occ move LUE and LLE spontaneously. Moves left side and RLE to stimulus, initially only to nailbed pressure but now to touch. Gave a squeeze with left hand when asked and able to repeat it again x 2. No eye opening. Biting down during mouth care.\n\nResp - Received on AC 14 x 450, + 5, 40%. RR 22-28. Sats 97-100%. Lungs clear, diminished at bases. Sx several times for sm/mod thick tan, sometimes bloody tinged secretions. Frank blood from mouth during turning, no ulcers visible. Thick yellow secretions orally x 1.\n\nCV - BP 181/66, hydralazine 20mg x 2 with no effect. Lopressor 75 mg (scheduled dose) and BP decreased to 140s-150s/60s. V-paced 70, no ectopy. K 3.8, repleted->4.2. +3 anasarca. Fluid balance -1700c at midnite.\n\nGI - Abd soft, +BS. Inc foul smelling soft brown stool, OB (-). TF at goal 40cc/hr, no residuals. FSBS WNL.\n\nGU - UOP 35-110cc/hr. Small clots in urine.\n\nSocial - Son in last night to see pt and spoke with RN, he has been estranged from father for several years. Daughter called for update.\n\nPlan - Follow fever curve. Vanco trough before 12noon dose. Head Ct today. Neuro checks q 2 hrs. Goal SBP 140-160.\n\n\n"},{"category":"Nursing/other","chartdate":"2154-09-26 00:00:00.000","description":"Report","row_id":1443926,"text":"Resp: Pt remains intubated on a/c 14/450/+5/40%. Bs are clear bilaterally with diminished bases. Suctioning small to moderate amounts of bloody tinged thick yellow secretions. No abg's or changes this shift. RSBI=56. RN reports following some commands. Will continue full vent support.\n"},{"category":"Nursing/other","chartdate":"2154-09-26 00:00:00.000","description":"Report","row_id":1443927,"text":"Respiratory Care\n\n Pt changed to PSV 5/5 .40 In NARD. B/S sl coarse sx sm-mod amount thick yellow. Will continue to follow closely.\n"},{"category":"Nursing/other","chartdate":"2154-09-24 00:00:00.000","description":"Report","row_id":1443918,"text":"Nursing note (0700-1900) 16:00\n\nEVENTS:\n\nECHO and SBT.\n\n\nNeuro.\nPt responding to verbal stimuli, opening eyes and moving limbs on bed, pt trying to mouth words around ETT.\nPt continues on Fent 50mcg/hr and Versed 1mg/hr to keep comfortable, with good effect. Pt following commands intermittantly ? due to lack of hearing.\n\nResp.\nPt back on AC 25/450/peep5/40% following SBT this pm for 30mins, which pt tollerated well, abg 7.38/49/76.\nLS clear to coarse with minimal secretions sx'd during the day, continue to be blood tinged.\n\nCVS.\nHR 70's V-Paced with rare ectopy seen, BP 110's-130's/50's-60's, remains off pressors, no further fluid boluses required either.\nCVP 12-20 depending on position.\nAwaiting verified results of echo from today, Cards consult to follow at some point.\nVit K 5mg given for INR of 2.2.\n\nGI/GU.\nPt tollerating TF's at goal of 40mls/hr with no residuals, pt with +BS though no BM as yet this shift.\nPt with continued poor UOP via foley (20-30mls/hr), plan is to diurese if remains stable heamodynamicaly and aim for even balance for the day, pt currently 800+ve.\n\nSkin.\nPt's skin remains intact, pressure areas all within normal, skin is warm and a little pale.\n\nSocial.\nVisited by daughter this am, updated as to plan of care. She states facial swelling is much improved from previous days.\n\nPlan.\n? Diurese.\nPull precept catheter.\nFollow Troponin etc in am labs.\n\n\n"},{"category":"Nursing/other","chartdate":"2154-09-24 00:00:00.000","description":"Report","row_id":1443919,"text":"Respiratory Care\nPt. remains intubated on A/C. Pt. Placed on SBT for 1hr and tol well.\nRSBI during trial was 33 and NIF was -25. Recent ABG witin normal limits.\n"},{"category":"Nursing/other","chartdate":"2154-09-25 00:00:00.000","description":"Report","row_id":1443920,"text":"NPN 1900-0700:\n\nEVENTS: Less responsive than previously documented. Becoming hypertensive. Attempting to diurese.\n\nROS:\nNEURO: Noted to be minimally responsive at start of shift, withdrawing only to deep and vigorous sternal rub. Sedation halved without much improvement, then D/C'd entirely. He has been off all sedation since MN and remains minimally responsive, though perhaps slightly improved. Very little spontaneous movement noted; pupils pinpoint and sluggish. No seizure activity observed. Pt had not recieved Depakote since admission, but it was resumed tonight; unclear from chart why he is on it.\nRESP: No vent changes, no ABG's ordered. Sats mid-high 90's. Current vent settings: CMV .4/450/25/5 with rare spontaneous breaths. Suctioned several times w/NS lavage for thick pluggy red/brown secretions. LS coarse upper, diminished lower,\nC-V: HR 70-74, V-paced with occasional PAC's. Initially BP 140's-150's, rising to 160's-170's. Started on Lopressor; given 25mg X 2 per NGT and 5mg IV once with modest effect. BP has improved as he has been diuresed and is now 120's. Phos 2.o, others lytes WNL.\nID: Afebrile, WBC up to 18.9 (15.7). PreSep catheter tip sent for cx; no change in abx.\nGI: Belly benign, no stool, tolerating TF's.\nGU: Given 10mg IV Lasix at 2100 with minimal effect; remained nearly 1L positive for the day. Given additional 20mg IV Lasix at 0400 with better response, and he is now running negative.\nENDO: Sugars well-controlled on current regimen.\nHEME: INR down to 1.5 (2.2); ordered for 2 more doses Vit K to be given today and tomorrow. Hct 26-27, stable, no evidence of active bleeding.\nSKIN: intact. Extremities warm at start of shift, a bit cooler now.\nACCESS: RIJ PreSep catheter removed; has a-line and 3 PIV's.\nSOCIAL: dtr called for update.\n\nA: could use better BP control; tolerating diureses; MS concerning.\n\nP: follow MS closely; if he does not wake up ? if he may need head CT to r/o bleed. wean from vent as able. resume outpt antihypertensives as indicated. bowel meds. cont to diurese as ordered. continue supportive care; inform and support family.\n"},{"category":"Nursing/other","chartdate":"2154-09-25 00:00:00.000","description":"Report","row_id":1443921,"text":"Resp: Pt rec'd on a/c 25/450/5+/40%. Bs are clear with diminished bases, some wheezing was noted earlier, lasix given?\nSuctioned for moderate amounts of yellow bloody tinged secretions. Ett #8 retaped & secured @ 24 lip. RSBI=69. No orders to attempt wean. Will continue full support.\n"},{"category":"Nursing/other","chartdate":"2154-09-25 00:00:00.000","description":"Report","row_id":1443922,"text":"Nursing note (0700-1900) 16:00\n\nEVENTS: Head CT.\n\n\nNeuro.\nPt remains minimaly responsive to noxious stimuli, pupils remain sluggish to light, not following commands, some non-purposeful movement to the limbs on the Left, non to the the right.\nCT head done this pm showing areas of infarct, family coming back later to speak with medics regarding implications.\n\nRESP.\nPt remains on AC, with rate now set to 14, pt overbreathing to rate of 25. No plans to wean due to change in MS. LS clear to coarse UL's with diminished LL's. Pt for thick yellow/tan/bloody secretions Q3-4hrs.\n\nCVS.\nHR 70's V-Paced with rare PAC's, EKG performed this am, unchanged from previous.\nBP 160's-170's/70's-80's, Lopressor increased to 50mg BD, with little effect as yet.\n\nID.\nPt with low grade temp, continues on multiple antibiotics, awaiting results from catheter tip cultures.\n\nGI/GU.\nPt remains on TF's at goal of 40mls/hr, min. residuals, +BS with medium sized brown soft stool passed this pm, Guiac -ve.\nPt with good response to further dose of Lasix 20mg this pm, pt currently -ve 1500mls (goal of -1 to -2L). Urine remains amber in colour with sediment.\n\nSkin.\nPt's skin is pale as previous and remains cool to the touch at the extremeties, all pressure areas are intact.\n\nSocial.\nPt's daughter is coming in to discuss the results of the head CT this pm with medics, so as to help decide future POC.\n"},{"category":"Nursing/other","chartdate":"2154-09-29 00:00:00.000","description":"Report","row_id":1443938,"text":"Nursing Progress Note.\n\nEVENTS: Pt remains c fairly stable VS.\n\nRESP: Pt requires Q2-3 hr NTS for moderate amounts of thick bloody sec. Sats drift down between sxn'ing c values in the 70's and up to the 90's s/p successful sxn'ing. Of note, L nare appears to be easier to pass sxn'ing cath to perform NTS. Now considering placing nasal trumpet to facilitate passage of sxn cath to minimize airway trauma. Resp pattern is agonal c death rattle noted, Scopolamine patch placed this afternoon to minimize airway sec. BS are diminished and rhoncherous on exam c slight clearing following sxn'ing. Freq oral care provided. Cough reflex is weak but intact, no gag reflex evident. RR ranges from 20's to 30's.\n\nMS: Pt does not appear uncomfortable or in pain c no response to noxious stimuli, will utilize IV Morphine Sulfate if pt appears distressed/SOB. PERRL, sluggishly.\n\nCV: Rectal Tmax of 101.5 this AM, med c 650mg Acetaminophen PR. +3 Anasarcoid.\n\nSOC: HCP dtr called this AM and kept up-to-date c POC/pt status. The pt is .\n\nOTHER: Please see CareVue for additional pt care data/comments. Universal isolation precautions in place.\n"},{"category":"Nursing/other","chartdate":"2154-09-27 00:00:00.000","description":"Report","row_id":1443930,"text":"MICU A NPN 7p-7a\nNeuro: Neuro checks done q2hr overnight, no changes in neuro assessment noted. Pt cont to have nonpurposeful movement on left side, no movement noted on right side. PERRL, roving eye movement noted as well. +cough. Withdraws to painful stimuli, no eye opening noted at all.\n\nCV: VPaced at 70 bpm, some occasional ectopy noted this morning. SBP has been elevated most of shift, pt requiring lopressor ivp and hydralazine ivp in addition to scheduled po lopressor dose to get SBP to goal range of 140-160. BP rises significantly with any nursing care or stimuli. Tmax 101.5, pt was pancx and given tylenol 650mg. 2 new PIVs placed,? if pt will need central access, currently not on any cont. gtts. General 1+ edema t/o.\n\nPulm: Remains vented on CPAP settings. ABG done in am and pt appears to be tolerating settings well. Currently on Peep 5 PS 5 40%, RR 20's and O2 sat high 90's. Sxned for thick tan/yellow secretions in mod. to copious amts. LS mostly clear and diminished at bases, coarse at times as well.\n\nGI/GU: Tolerating TF Promote with fiber at 40cc/hr via NGT. No residuals. Abd soft, obese, +BS. +BM this am, brown and loose, guiac -. FSBS checks done q6hr, pt did not require SS coverage, but did get scheduled 70/30 dose this am. U/O 30-85cc/hr of clear yellow urine.\n\nSkin: Warm, dry and pale. Pt with general + edema, and scrotal edema as well. No breakdown on backside noted.\n\nPts dtr called last pm, was updated by RN on pts condition.\n\nPlan: ?extubation today. Pt is tolerating CPAP settings well. ?Family meeting to discuss code status. Cont neuro checks q2hr. Maintain SBP in 140-160 range. Cont to follow cultures.\n\n\n"},{"category":"Nursing/other","chartdate":"2154-09-27 00:00:00.000","description":"Report","row_id":1443931,"text":"Respiratory care\n\n Pt continues on PSV in NARD. B/S sl coarse sx for sm/mod thick tan secretions. Will continue to follow closely.\n"},{"category":"Nursing/other","chartdate":"2154-09-27 00:00:00.000","description":"Report","row_id":1443932,"text":"Nursing Progress Note.\n\nEVENTS: Family conference.\n\nMS: The pt remains non-purposeful off all sedation. PERRL. Pt does not follow commands. Pt rarely lifting LUE, LE's but does not move RUE. Pt moves LUE & LE's to noxious stimuli. No overt seizure activity evident. Pt bites down during mouth care. Good cough reflex, impaired/non-existent gag reflex. CT results from s improvement in findings c massive L sided MCA infarct and old R sided infarct. No restraints in place.\n\nCV: Hemodynamically stable c a tmax of 100.0, most recently 98.6. V-paced EKG waveform noted c no ectopy. Plus two anasarcoid. AM magnesium value of 1.9 repleted c 3gm IV Magnesium Sulfate. AM WBCC cont to trend down c a value of 19.8. s/p pan C&S this AM. IV Vanco dosing changed from Q24 hr to Q12 hr today. Adequate hourly UO, the pt is currently net positive 400ml input today and is net input 16 liters LOS. Urine is yellow c + sedimentation noted. Pt remains on QD IV Levofloxacin & Ceftriaxone dosing. AM sodium lab value of 134 noted, will limit free H2O intake. Pt SBP maintained in the 140-160 range today, required 5mg IV Lopressor @ 13:00 for SBP transiently in the 160 range.\n\nRESP: Pt received and maintained on CPAP/PS 5/5 c 40% FiO2 in place c nl sats, RR in the 20's and nl resp pattern. Pt c good cough reflex requiring Q2-3 hr sxning for thick tan/mucoid sec per ETT. ETT rotated and changed today. AM ABG c the following acceptable values; 7.47-40-97, no MV setting changes made today. Minute vol in the liter/min range. LS fairly clear in upper lobes today, diminished @ bases.\n\nGI: Pt received/maintained on Promote c Fiber @ target rate of 40ml/hr via NGT c low residuals noted all day. Pt passed one medium sized soft brown stool today, guaic negative.\n\nSOC: Pts HCP (HCP) accompanied by fiance () met c Neuro & MICU teams to discuss pt clinical status and prognosis s/p repeat head CT on . Per team, the pt has a grim prognosis & uncertain rehab potential s/p massive CVA. Family now moving in direction of extubating pt and making CMO. Family will now discuss pts case among themselves before making any pt care changes @ this time. Social work was able to meet/discuss care issues @ length today. Family members (including son by phone) kept up-to-date c POC/pt status. Verbal & non-verbal support also provided to family. Family declined religious consult. The pt remains a Full Code @ this time.\n\nDERM: Intact @ this time, turning Q3-4 hrs.\n\nOTHER: Please see CareVue for additional pt care data/comments. Univ isolation precautions in place.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2154-09-28 00:00:00.000","description":"Report","row_id":1443933,"text":"MICU nursing progress note 7P-7A\nEvents - Pt became increasingly hypertensive, BP refractory to lopressor and hydralazine, started on nipride gtt with gradual decrease in BP, goal SBP 140-160. Pt is DNR, family to decide today whether to make pt d/t poor prognosis S/P L MCA infarct.\n\nNeuro - Exam unchanged. PERL, brisk. Withdraws left extremities and right LE to stimuli. No movement right UE. Occ spontaneous movement left arm. Bites down on ETT, turns head slightly side->side. No response to voice. +cough, no gag. ? pain during hypertensive episode 200s from excoriated skin on upper thighs and urine on skin, MSO4 2 mg x 2 with some decrease in BP.\n\nResp - CPAP 5 + 5, 40%. RR high 20s-30 when hypertensive, decreased to 18-22 with BP decrease. Sx x 3 thick tan secretions, lavaged for small plugs. Lungs clear, decreased at bases. Sats 99-100%->95%. Short periods of agonal breathing when hypertensive, resp pattern now normal.\n\nCV - BP 170s->190s (200s)/70s. Lopressor 5 mg x 3 doses with transient effect to 160s. Hydralazine 20 mg x 2 with no decrease. Pt became more hypertensive to 200s/. Also increased PO lopressor to 100mg which had no effect. Nipride gtt started, titrated to SBP 140-160. See Careview. V-paced 70s. Hct stable, WBC slightly decreased. +3 anasarca. Lytes WNL, Na 138.\n\nGI - Abd obese, +BS, no stool. TF at goal 40cc/hr, no residuals. FSBS WNL.\n\nGU - UOP 30-100cc/hr. Foley leaking, irrigated easily, no further leaking.\n\nSkin - Areas of excoriation on right inner thigh, looks like open blisters. Nystatin and aloe . Fluid filled blisters on right lower arm. Areas of excoriation, bleeding slightly, on left ant thigh, also looks like open blisters.\n\nID - T max 101.4, tylenol given. On vanco/ceftriaxone/levo. Many Cx pending.\n\nSocial - No phone calls O/N.\n\nPlan - Family to make decision today re , pt is DNR. Titrate nipride gtt to SBP 140-160. Neuro checks q 2 hrs.\n"},{"category":"Nursing/other","chartdate":"2154-09-28 00:00:00.000","description":"Report","row_id":1443934,"text":"resp care\nPt remained on psv5/peep5 and 40% all night. Generally mv ranged from 9-11L with rr 20-24. Pt became hypertensive with an increase in rr to 30. BS coarse but clear. Suct for thick tan sput.Sats also a bit lower ranging from 93-96. Will cont to follow.\n"},{"category":"Nursing/other","chartdate":"2154-09-28 00:00:00.000","description":"Report","row_id":1443935,"text":"Nursing Progress Note.\n\nEVENTS: Pt made extubated and made c family @ BS.\n\nRESP: Pt received on CPAP/PS 5/5 c 40% FiO2 in place c nl sats, RR in the teens/twenties, and nl resp effort. Scant thick tan sec per ETT today. LS fairly clear in upper apices today, diminished @ bases. After long discussion c team during family conference on the dtr (HCP) decided that under the situation that the pt would not have wanted to be kept on a MV c such a poor prognosis and therefore it was decided to extubate the pt and make @ 14:00. The pt was subsequently extubated (+cuff leak noted) @ 14:30 to 2LNCO2. The pt has been stable since extubation c sats in the low/mid 90's, pt occ coughing up sec and RR gen in the 20's. Resp pattern fairly nl asside from occ slowing/speeding up of rate c nl sats maintained. Pt BS now more rhoncherous (more pronounced during exhalation) c some upper airway rhonchi as well. Pt does not appear dyspneic or SOB. Morphine Sulfate and/or NTS to be provided when/if pt developes resp distress. All procedures explained to pts HCP who appears to be coping normatively @ this time. Freq mouth care provided.\n\nMS: Pt less responsive to noxious stimuli today c no spontaneous movements of LUE. Pt cont to move feet to noxious stimuli. Pt bites and grimaces when mouth care provided. PERRL though R eye now deviated to the L of center. No agitation or overt discomfort noted. Will provide IV Morphine Sulfate if pt becomes distressed, no need for Morphine gtt @ this time.\n\nCV: Pt remains hemodynamically stable and afebrile. V-paced EKG waveform c occ PAC's. AM lytes WNL. A-line to be d/c'ed shortly. The pt is currently net positive 700ml input today and is net positive 17 liters LOS. The pt is +2 anasarcoid. Urine is yellow in coloration, sedimentated and slightly cloudy.\n\nSOC: HCP dtr visiting since lunchtime c fiancee (), both kept up-to-date c POC/pt status.\n\nOTHER: Please see CareVue for additional pt care data/comments. Univ isolation precautions in place.\n\nGI: NGT d/c'ed prior to extubation after discussion c family/team. The pt is now NPO.\n"},{"category":"Nursing/other","chartdate":"2154-09-23 00:00:00.000","description":"Report","row_id":1443911,"text":"admitting shift note 2100-700\nPt admitted from ER intubated, on Levophed drip for BP control, low urinary output, WBC 13.9, continue on sepsis protocol.\n\nNeuro: opens eyes to noise and spontanously. follows simple commands like squeezing hand, but inconsistant.moves all extremities, PEARL. CT Head neg in ER. (was found at nursing home unresponsive with glucose of 20.).Family was here earlier, pt responded to them. wrist restraints on bilaterally, off for small period of time. pt is purposeful.\n\nCardiac: Levo off since 1am. ABP 110-140's, map65-80. Paced at 70. Positive cardiac enzymes. CVP13-17,SVO2 67-70. Replaced Mg with 4Grams and came up to 2.0, replaced Calcium with 2grams, but still low at 7.7. facial and periorbital edema. venodynes boots on.pale in color. pt is +10L (h/o CAD,HTN,CABG, CHF,Pacer)\n\nResp: vented on PS 15, Peep 10, 40%, #8.0 ETT 24cm at lips. Lungs coarse with crackles to bilaterally bases. ABG at 3am ph 7.28, Co2 42, O2-138\n\nGI: abd softly distended. had small BM on admission to MICU. Bowel sounds hypoactive. NGT to rt nare. awaiting xray verification. BS 181 at 6am\n\nGU: #14 foley in ER. minimial output. bloody drainage with blood at penis site. irrigated and manipulated catheter with no improved urinary output. pt with 4L plus given in MICU A. output starting to pick up at 5am for 33ml output, but also incontinence noted to pad and on gown. no urologist on call tonight, will need one this am. Bun 23/creat 1.2. h/o left nephrectomy years ago??\n\nIV/Access: Right IJ TLC with precep line. Aline to left radial, saline locks to bilateral AC and rt wrist. Versad drip at 1mg, fentanyl at 50mcg, Levo remains off\n\nID: afebrile max temp 98.9 tonight. Lactate level 3.2, WBC up to 17 this am. on Vanco, Levaquin, flagyl. was swabs on admission for STAR.\n\nSocial: lives at , uses electric wheelchair. baseline mentation A&Ox3 with slightly dementia. self sufficent. Daughter and son-in-law at bedside earlier. supportive and visits him regularly (weekly) at home.\n\n"},{"category":"Nursing/other","chartdate":"2154-09-23 00:00:00.000","description":"Report","row_id":1443912,"text":"admitting shift note 2100-700\nupdate: 1000ml LR given at 6:15 :ABP 90-100'a, SVO2 65, Lactate level 3.9. Order for Calcium 2Gm obtained, waiting for run\n"},{"category":"Nursing/other","chartdate":"2154-09-23 00:00:00.000","description":"Report","row_id":1443913,"text":"Respiratory Care\nPt received intubated, 8.0 oet tube taped at 24cm. Bilateral breath sounds, rales at bases. Breathing spontaneously on psv with good oxygenation, met. acidosis. RSBI = 50. Plan to maintain support.\n"},{"category":"Nursing/other","chartdate":"2154-09-23 00:00:00.000","description":"Report","row_id":1443914,"text":"Respiratory Care\n\nPt. remains intubated. Pt switched from CPAP to A/ M.D.. Suctioned moderate amt of thick bloody secretions.\n"},{"category":"Nursing/other","chartdate":"2154-09-23 00:00:00.000","description":"Report","row_id":1443915,"text":"Nursing Note 7A-7P Review of Systems:\nNEURO: Sedated on Fentanyl drip at 50mcg/hr and Versed at 1mg/hr. Opens eyes to voice inconsistently. Moves all extremities on bed. Does not follow simple commands. PERLA 2mm/ briskly reactive. Bilaterial wrist restraints remain on.\nC/V: V paced at a rate of 70. Levophed remained off all day. BP 91-129/ 48-64. Continues with peripheral and facial edema. Venodyne boots remain on. Patient currently 17 liters positive For LOS and 9800cc positive in the past 24 hour.\nRESP: Remains orally intubated, sucioned X3 thick bloody secretions. Lung sounds clear upper airways and crackles bibasilar. O2 Sat 96-100%. Vent settings changed from CPAP to AC (Please see flow sheet). Last ABG = 7/31-44-122. Lactic Acid range from 2.5-3.3.\nGI: OGT intact placement checked by auscultation and confirmed by CXR. Tube feedings Promote with fiber FS infusing at 20cc/hr to be increased by 10cc q 4 hr till goal rate of 40cc/hr. Abdomen distended positive bowel sounds no flatus or stools this shift.\nGU: Foley patent draining bloody urine minimal output 14- 43cc/hr. Foley cath irrigation attempted today without success Foley removed and # 14 replaced with minimal output. Fluids of D5 with 3 amps Bicarb infused 1Liter per hour times 3 hours. Output increased slightly to 30-40/hr. Total of 9800cc positve today. Renal U/S done results pending.\nID: Afebrile, Tmax 98.3 orally, cotninues on Levofloxacin, Metronidazole, Vancomycin and Ceftriazone.\nSOCIAL: Patients daughter into visit and updated by MD as to patients POC.\n"},{"category":"Nursing/other","chartdate":"2154-09-24 00:00:00.000","description":"Report","row_id":1443916,"text":"MICU Nursing Note 1900-0700\nEvents: Uneventful night. Remains off vasopressors. Received 1 liter IV fluid bolus for low urine output with good effect. Remains intubated on AC on vent. Stable hemodynamics throughout night.\n\nNeuro: Sedated on IV Versed at 1 mg/hr and IV Fentanyl at 50mcgs/hr. Arouses to voice...opens eyes to voice and physical stimulation. Follows some commands---will squeeze hands on commands. Moving all extremities on bed when stimulated. Withdraws to painful stimuli. Pupils 2 mm and brisk. Bilat soft wrist restraints on to prevent pt from pulling at tubes and lines.\n\nCardiac: Remains off vasopressors. HR 70 and V-paced with occas. PVC noted. Right IJ TLC-Presep catheter site C/D/I. SV02 ranging from 79-82. CVP= 13-19. Left radial Aline with good waveform and correlation to NBP....BP= 111-135/58-70. Received 1 liter bolus of NS for low urine output and CVP=13 with good effect. Calcium level down to 7.3 earlier and repleted with 2 amps calcium gluconate. CPK up to 358 with MB and Troponin still pending.\n\nResp: Remains intubated on AC 25/ TV=450/ FI02=40%/Peep=10cm. Overbreathing Vent by 1-3 breaths when stimulated. MV= . Pips= 30-35. O2 Sats= 95-98%. ETtube suctioned for small amts blood-tinged thick sputum. Lungs clear bilat upper lobes and with rales at bilateral lower lobes. Last ABG=7.38-50-94-2-31...team aware and no vent changes made at this time.\n\nGI: Abd softly distended with + bowel sounds all quads and no BM. NGtube placement checked by auscultation. Tolerating TF FS Impact with fiber at goal rate of 40 ml/hr with residuals of 0-5 ml.\n\nEndo: fingersticks QID....fingerstick at MN=256---covered with 6 units of regular insulin as per sliding scale.\n\nGU: Urine output blood-tinged to amber in color and with sediment. No clots noted. Urine output down to 10 ml/hr with CVP=13 during evening....bolused with 1 liter NS with urine output 30-60 ml/hr the rest of the night. BUN=28/ Creat.=1.1.\n\nSkin: remains edematous ---periorbital and facial edema unchanged. No skin breakdown noted. Reddened area over right upper thigh---cream applied. Venodyne boots on . Turned and repostioned Q2-3hours.\n\nSocial: No contact from family members during the night.\n\nPlan: Continue to monitor hemodynamics, urine output, labs closely. Wean vent as tolerated. ? Obtain Cardiology consult in r/t + MI.\nWean Sedation and vent when stable. Support pt and family.\n"},{"category":"Nursing/other","chartdate":"2154-09-24 00:00:00.000","description":"Report","row_id":1443917,"text":"Respiratory Care\nRemained intubated and ventilated on a/c with no remarkable changes overnight. ABGS within normal limits for pt.\n"},{"category":"Nursing/other","chartdate":"2154-09-28 00:00:00.000","description":"Report","row_id":1443936,"text":"pt extubated to nasal cannula as ordered through status. vent pulled from room.\n"},{"category":"Nursing/other","chartdate":"2154-09-29 00:00:00.000","description":"Report","row_id":1443937,"text":"MICU nursing progress note 7P-7A\nPt is now . Continues unresponsive. No spontaneous movement. Will move left foot slightly to stimulation, no other response elicited from extremities. Bites down during mouth care, oral Sx. Resp pattern agonal, high 20s-30. MSO4 2 mg x 1 with no change in resp pattern. NTS x 1 thick tan secretions. Lungs are slightly coarse upper lobes, diminished at bases. Sats have decreased low 90s->low 70s on 2L NC. Remains HD stable, V-paced in 70s. UOP 35-100cc/hr. Skin warm and slightly diaphoretic. Turned q 3 hrs, skin care given. Daughter called O/N for update on pt condition.\n"},{"category":"Nursing/other","chartdate":"2154-09-26 00:00:00.000","description":"Report","row_id":1443928,"text":"Nursing note (0700-1900) 16:15\n\n\nNeuro.\nPt for repeat head CT this am, showed increase in amount of edema now compressing right side of brain. Pt moving left side only, moves leg on bed, and has managed on occasion to lift left arm from bed, though with out any purpose. Patient not following commands for this nurse, though medics felt that pt did sqeeze with left hand on command. no eye opening as yet, pupils remain 2mm and suggish to react to light.\nPt does have cough and gag reflexes.\n\n\nResp.\nPt placed on CPAP (5/5/40%) with slight improvement in resp alkalosis, pt tollerating well so far, so no plans to rest on ac overnight as yet.\nLS are clear to upper lobes, diminished in bases. Pt sx'd for thick yellow secretions Q4hrs.\n\n\nCVS.\nHR 70's V-Paced with no ectopy seen this shift.\nBP 130-160/60's on Lopressor 75mg to keep within these limits per Neuro team.\n\n\nID.\nPt has remained a-febrile this shift, continues on previous antibiotics of Vanco, Levo and Ceftriaxone. Awaiting micro data on cultures sent overnight.\n\nAccess.\nPt is for placement of TLC this shift as PIV sites expiring today.\n\nEndo.\nNo RISS coverage needed this shift, recieving usual doses of 70/30 BD.\n\nGI/GU.\nTollerating TF's at goal with no residual, +BS with no BM as yet this shift.\nGood UOP via foley of yellow urine with occasional sediment.\n\nSkin.\nPt's skin remains edematous generaly, extremeties are warm to touch and skin is of less pale appearance.\n\n\nSocial.\nDaughter () and her fiance () in for much of the day waiting to speak with Neuro for update as to repeat CT, Neuro explained that as there was an increase in edema that we were still at a critical point.\n and now home for the day, will call later for update.\nNo contact from Son during the day.\n\nPlan.\nFollow MS, Q2hr neuro checks.\nSW and case management support for family.\n\n"},{"category":"Nursing/other","chartdate":"2154-09-27 00:00:00.000","description":"Report","row_id":1443929,"text":"Resp: Pt remains intubated on psv 5/5/40%. Bs are slightly coarse bilaterally. Sucitoned for small to moderate thick yellow. Sputum sample sent. No changes noc. AM ABG's 7.47/40/97/30. RSBI=74. Family meeting to discuss possible extubation today.\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2154-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 64802,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Myocardial infarction.\\nHeight: (in) 68\\nWeight (lb): 165\\nBSA (m2): 1.89 m2\\nBP (mm Hg): 132/64\\nHR (bpm): 70\\nStatus: Inpatient\\nDate/Time: at 13:58\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Moderate LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\\n\\nLEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity. Moderate global\\nLV hypokinesis. No LV mass/thrombus.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex -\\nakinetic; septal apex- akinetic; inferior apex - akinetic; lateral apex -\\nakinetic; apex - akinetic;\\n\\nRIGHT VENTRICLE: Mildly dilated RV cavity. RV function depressed. Abnormal\\nseptal motion/position consistent with RV pressure/volume overload.\\n\\nAORTA: Mildly dilated aortic root. Focal calcifications in aortic root. Mildly\\ndilated ascending aorta.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\\nMR.\\n\\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\\nModerate PA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\\nphysiologic PR.\\n\\nPERICARDIUM: Small pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Based on\\n AHA endocarditis prophylaxis recommendations, the echo findings indicate\\na low risk (prophylaxis not recommended). Clinical decisions regarding the\\nneed for prophylaxis should be based on clinical and echocardiographic data.\\n\\nConclusions:\\nThe left and right atrium are moderately dilated. There is mild symmetric left\\nventricular hypertrophy with mildy dilated cavity and moderate global left\\nventricular hypokinesis with akinesis of the distal third of the ventricle. No\\nmasses or thrombi are seen in the left ventricle. The right ventricular cavity\\nis mildly dilated. Systolic function appears depressed. There is abnormal\\nseptal motion/position consistent with right ventricular pressure/volume\\noverload. The aortic root and ascending aorta are mildly dilated. The aortic\\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present. No\\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\\nMild to moderate (+) mitral regurgitation is seen. The tricuspid valve\\nleaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen.\\nThere is moderate pulmonary artery systolic hypertension. There is a very\\nsmall pericardial effusion.\\n\\nIMPRESSION: Mild symmetric left ventricular hypertrophy with global and\\nregional systolic dysfunction c/w diffuse process (toxin, metabolic,\\nmultivessel CAD, etc.) Pulmonary artery systolic hypertension. Mild-moderate\\nmitral regurgitation.\\n\\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\\nindicate a low risk (prophylaxis not recommended). Clinical decisions\\nregarding the need for prophylaxis should be based on clinical and\\nechocardiographic data.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-09-25 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 880270,\n \"text\": \" 2:00 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: Acute hemorrhage\\n Admitting Diagnosis: SEPSIS,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 83 year old man with PNA sepsis, intubated, now off sedative meds and minimally\\n responsive.\\n REASON FOR THIS EXAMINATION:\\n Acute hemorrhage\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 83-year-old with pneumonia and sepsis with acute mental status\\n changes, evaluate for hemorrhage.\\n\\n COMPARISONS: CT head of .\\n TECHNIQUE: Axial MDCT images through the brain without IV contrast.\\n\\n CT HEAD FINDINGS: There has been interval development of a large left MCA\\n distribution subacute infarction, which was not present on the prior study of\\n . probable clot within a dense left MCA is visualized. There is no\\n associated hemorrhagic component. There is mild local mass effect without\\n shift of midline structures. Again seen is encephalomalacia in the right\\n posterior temporal lobe, unchanged from the prior study.\\n\\n IMPRESSION:\\n 1) Interval development of large left MCA distribution infarction, with\\n probable clot in the hyperdense proximal MCA. There is no evidence of a\\n hemorrhagic component.\\n 2) Stable encephalomalacia in the right posterior temporal lobe.\\n\\n Findings phoned to Dr. after the study.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2154-09-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 132888,\n \"text\": \"Continuous ventricular pacing. No organized atrial activity. Compared to the\\nprevious tracing of no significant change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2154-09-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 132889,\n \"text\": \"Ventricular paced rhythm\\nAtrial mechanism is probably atrial fibrillation\\nSince previous tracing of same date, no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2154-09-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 132890,\n \"text\": \"Ventricular paced rhythm\\nAtrial mechanism is probably atrial fibrillation\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2154-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 132891,\n \"text\": \"Ventricular paced rhythm\\nAtrial mechanism is probable atrial fibrillation\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2154-09-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 132892,\n \"text\": \"Ventricular paced rhythm. compared to the previous tracing of no change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2154-09-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 132893,\n \"text\": \"Ventricular paced rhythm. Probable underlying atrial fibrillation. No previous\\ntracing available for comparison.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-09-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 879940,\n \"text\": \" 3:46 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess progression of PNA\\n Admitting Diagnosis: SEPSIS,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 83 year old man unresponsive, intubated for hypoxic respiratory failure\\n REASON FOR THIS EXAMINATION:\\n assess progression of PNA\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Patient unresponsive, hypoxic.\\n\\n CHEST: Diffuse alveolar opacifications are again seen in both the right and\\n left lungs. Appearances are essentially unchanged since the prior chest x-ray\\n of . The position of the various support lines and tubes is\\n unchanged.\\n\\n IMPRESSION: Extensive alveolar infiltrates still present.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-09-23 00:00:00.000\",\n \"description\": \"P RENAL U.S. PORT\",\n \"row_id\": 879973,\n \"text\": \" 10:26 AM\\n RENAL U.S. PORT Clip # \\n Reason: low UOP, blood at meatus, large volume infused\\n Admitting Diagnosis: SEPSIS,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 83 year old man with septic shock/b/l PNA, ? NSTEMI\\n REASON FOR THIS EXAMINATION:\\n low UOP, blood at meatus, large volume infused\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Low urine output with septic shock, and possible recent MI.\\n\\n RENAL ULTRASOUND, PORTABLE: Examination limited secondary to patient body\\n habitus and portable technique. The left kidney measures 13 cm and contains\\n two large rounded anechoic cystic structures consistent with simple renal\\n cysts, the largest measuring 6.3 x 6.1 x 6.1 cm. The right kidney measures 12\\n cm. Neither kidney displays hydronephrosis or contains stones. The cortices\\n demonstrate normal echogenicity. Scan done in the area of the bladder shows\\n no evidence for bladder distention.\\n\\n IMPRESSION: No evidence for hydronephrosis. Large simple renal cyst on the\\n left kidney as described above. Otherwise, normal appearing kidneys\\n bilaterally.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-09-22 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 879922,\n \"text\": \" 6:07 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: eval for placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 83 year old man unresponsive, intubated s/p line placement\\n\\n REASON FOR THIS EXAMINATION:\\n eval for placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 83-year-old man, unresponsive, intubated, status post line\\n placement. Evaluate placement.\\n\\n COMPARISON: AP supine portable chest x-ray dated at 16:36.\\n\\n AP SUPINE PORTABLE CHEST X-RAY: There has been interval placement of a right\\n internal jugular central venous catheter with the tip in the mid SVC. An\\n endotracheal tube remains in unchanged position approximately 6 cm above the\\n carina. There is no pneumothorax identified on the supine radiograph. There\\n has been interval worsening of multifocal patchy opacities primarily within\\n the left mid, and right lower lung zones, concerning for aspiration pneumonia.\\n The surrounding soft tissue and osseous structures are unchanged. Old healed\\n rib fractures are again identified within multiple left posterior vertebral\\n bodies.\\n\\n IMPRESSION:\\n 1) Right IJ in mid SVC. No pneurmothorax.\\n 2) Worsening bilateral multifocal opacities concerning for aspiration.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-09-26 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 880359,\n \"text\": \" 8:09 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: determine extent of cva and edema\\n Admitting Diagnosis: SEPSIS,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 83 year old man with new l cva discovered \\n REASON FOR THIS EXAMINATION:\\n determine extent of cva and edema\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Follow up left MCA stroke.\\n\\n COMPARISONS: CT head of .\\n TECHNIQUE: Axial MDCT images through the brain without IV contrast.\\n\\n CT HEAD FINDINGS: There is an evolving left middle cerebral arterial\\n distribution infarction. Compared to the prior day, there is slightly more\\n edema and mass effect with further impression of the left lateral ventricle.\\n There is no hemorrhagic transformation within this infarction, and no evidence\\n of hemorrhage elsewhere within the brain parenchyma. Stable appearance of\\n encephalomalacia in the right posterior temporal region, unchanged from\\n multiple prior studies. No other short interval change.\\n\\n IMPRESSION: Evolving left MCA distribution infarction, with slightly more\\n edema and mass effect compared to the prior day's study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-09-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 879913,\n \"text\": \" 4:36 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: tube placement, r/o aspiration\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 83 year old man unresponsive, intubated\\n REASON FOR THIS EXAMINATION:\\n tube placement, r/o aspiration\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 83-year-old man unresponsive, intubated. Evaluate tube\\n placement.\\n\\n COMPARISON: None.\\n\\n AP SUPINE PORTABLE CHEST X-RAY: The study si limited due to patient\\n positioning. An endotracheal tube is positioned approximately 7 cm superior\\n to the carina. Sternal wires and sutures indicate prior coronary artery bypass\\n graft. A right-sided pacemaker is seen with a single lead overlying the area\\n of the right ventricle. The cardiac silhouette is prominent with intramural\\n aortic calcifications. Multifocal patchy opacities in bilateral lungs are\\n concerning for aspiration pneumonia. There is no left pleural effusion. The\\n right costophrenic angle is not seen. Multiple old, healed left sided\\n posterior rib fractures are seen.\\n\\n IMPRESSION:\\n 1. Endotracheal tube approximately 7 cm superior to the carina.\\n 2. Multifocal pneumonia concerning for aspiration.\\n\\n These findings were called to Dr. at 5 p.m. on .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-09-22 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 879914,\n \"text\": \" 4:36 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: r/o stroke, bleed\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 83 year old man found unresponsive\\n REASON FOR THIS EXAMINATION:\\n r/o stroke, bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: DFDdp SUN 5:23 PM\\n no intracranial hemorrhage or mass effect. large area of low attenuation in\\n right temporal lobe with loss of sulci, consistent with chronic infarct in\\n right MCA distribution. atrophy.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Unresponsive.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Non-contrast head CT.\\n\\n HEAD CT WITHOUT IV CONTRAST: No intracranial hemorrhage, mass effect, or\\n shift of normally midline structures is noted. Large area of hypodensity with\\n encephalomalacic change is noted within the posterior right temporal lobe with\\n associated ex vacuo dilatation of the occipital of the right lateral\\n ventricle, findings likely representing chronic infarction in the territory of\\n the right middle cerebral artery. Additionally, bilateral periventricular\\n white matter hypodensities are present, consistent with chronic microvascular\\n infarction. There is widening of the sulci and ventricles, consistent with\\n cerebral atrophy. There is opacification of the left sphenoid sinus and\\n mucosal thickening involving the right sphenoid sinus and ethmoid air cells.\\n The mastoid air cells and remaining visualized paranasal sinuses are clear.\\n Surrounding osseous and soft tissue structures are unremarkable.\\n\\n IMPRESSION:\\n 1. Hypodense region within the right posterior temporal lobe with associated\\n ex vacuo dilatation of the right occipital of the lateral ventricle,\\n findings consistent with chronic infarction.\\n 2. Chronic small vessel ischemic disease.\\n 3. No intracranial hemorrhage or mass effect.\\n\\n DFDdp\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443923,\n \"text\": \"Respiratory Care Note:\\n Patient remains on full vent support and appears non-responsive. Taken to CT for scan of head this afternoon. Results pending. Plan to maintain on present settings at this time. See Carevue flowsheet for specifics.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443924,\n \"text\": \"ADDENDUM 18:35\\n\\nMedical and Neuro team spoke with family about prognosis, and the critical nature of the next 24-48hrs with regards to pt survival.\\nPt's daughter very upset due to losing mother suddenly in this hospital also, and also recently losing her brother. SW called and saw briefly, support given and will follow up in am.\\nFamily now home for the night\\nNeuro team recommend keeping SBP between 140-160mmHg, so 20mg IV Hydralazine given and Lopressor increased to 75mg to start at 12mn.\\n\\nRepeat lytes and CK-MB/Troponin sent at 18:00.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443925,\n \"text\": \"MICU nursing progress note 7P-7A\\nEvents - T 101.4. Pan cx, also stool c-diff sent. Tylenol with T->98.6. WBC 21.6 (18.5). On ceftriaxone/vanco/levo.\\n\\nNeuro - Exam has gradually improved a little o/n. PERL, 2mm, sluggish. + cough, impaired gag. will occ move LUE and LLE spontaneously. Moves left side and RLE to stimulus, initially only to nailbed pressure but now to touch. Gave a squeeze with left hand when asked and able to repeat it again x 2. No eye opening. Biting down during mouth care.\\n\\nResp - Received on AC 14 x 450, + 5, 40%. RR 22-28. Sats 97-100%. Lungs clear, diminished at bases. Sx several times for sm/mod thick tan, sometimes bloody tinged secretions. Frank blood from mouth during turning, no ulcers visible. Thick yellow secretions orally x 1.\\n\\nCV - BP 181/66, hydralazine 20mg x 2 with no effect. Lopressor 75 mg (scheduled dose) and BP decreased to 140s-150s/60s. V-paced 70, no ectopy. K 3.8, repleted->4.2. +3 anasarca. Fluid balance -1700c at midnite.\\n\\nGI - Abd soft, +BS. Inc foul smelling soft brown stool, OB (-). TF at goal 40cc/hr, no residuals. FSBS WNL.\\n\\nGU - UOP 35-110cc/hr. Small clots in urine.\\n\\nSocial - Son in last night to see pt and spoke with RN, he has been estranged from father for several years. Daughter called for update.\\n\\nPlan - Follow fever curve. Vanco trough before 12noon dose. Head Ct today. Neuro checks q 2 hrs. Goal SBP 140-160.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443926,\n \"text\": \"Resp: Pt remains intubated on a/c 14/450/+5/40%. Bs are clear bilaterally with diminished bases. Suctioning small to moderate amounts of bloody tinged thick yellow secretions. No abg's or changes this shift. RSBI=56. RN reports following some commands. Will continue full vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443927,\n \"text\": \"Respiratory Care\\n\\n Pt changed to PSV 5/5 .40 In NARD. B/S sl coarse sx sm-mod amount thick yellow. Will continue to follow closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443918,\n \"text\": \"Nursing note (0700-1900) 16:00\\n\\nEVENTS:\\n\\nECHO and SBT.\\n\\n\\nNeuro.\\nPt responding to verbal stimuli, opening eyes and moving limbs on bed, pt trying to mouth words around ETT.\\nPt continues on Fent 50mcg/hr and Versed 1mg/hr to keep comfortable, with good effect. Pt following commands intermittantly ? due to lack of hearing.\\n\\nResp.\\nPt back on AC 25/450/peep5/40% following SBT this pm for 30mins, which pt tollerated well, abg 7.38/49/76.\\nLS clear to coarse with minimal secretions sx'd during the day, continue to be blood tinged.\\n\\nCVS.\\nHR 70's V-Paced with rare ectopy seen, BP 110's-130's/50's-60's, remains off pressors, no further fluid boluses required either.\\nCVP 12-20 depending on position.\\nAwaiting verified results of echo from today, Cards consult to follow at some point.\\nVit K 5mg given for INR of 2.2.\\n\\nGI/GU.\\nPt tollerating TF's at goal of 40mls/hr with no residuals, pt with +BS though no BM as yet this shift.\\nPt with continued poor UOP via foley (20-30mls/hr), plan is to diurese if remains stable heamodynamicaly and aim for even balance for the day, pt currently 800+ve.\\n\\nSkin.\\nPt's skin remains intact, pressure areas all within normal, skin is warm and a little pale.\\n\\nSocial.\\nVisited by daughter this am, updated as to plan of care. She states facial swelling is much improved from previous days.\\n\\nPlan.\\n? Diurese.\\nPull precept catheter.\\nFollow Troponin etc in am labs.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443919,\n \"text\": \"Respiratory Care\\nPt. remains intubated on A/C. Pt. Placed on SBT for 1hr and tol well.\\nRSBI during trial was 33 and NIF was -25. Recent ABG witin normal limits.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443920,\n \"text\": \"NPN 1900-0700:\\n\\nEVENTS: Less responsive than previously documented. Becoming hypertensive. Attempting to diurese.\\n\\nROS:\\nNEURO: Noted to be minimally responsive at start of shift, withdrawing only to deep and vigorous sternal rub. Sedation halved without much improvement, then D/C'd entirely. He has been off all sedation since MN and remains minimally responsive, though perhaps slightly improved. Very little spontaneous movement noted; pupils pinpoint and sluggish. No seizure activity observed. Pt had not recieved Depakote since admission, but it was resumed tonight; unclear from chart why he is on it.\\nRESP: No vent changes, no ABG's ordered. Sats mid-high 90's. Current vent settings: CMV .4/450/25/5 with rare spontaneous breaths. Suctioned several times w/NS lavage for thick pluggy red/brown secretions. LS coarse upper, diminished lower,\\nC-V: HR 70-74, V-paced with occasional PAC's. Initially BP 140's-150's, rising to 160's-170's. Started on Lopressor; given 25mg X 2 per NGT and 5mg IV once with modest effect. BP has improved as he has been diuresed and is now 120's. Phos 2.o, others lytes WNL.\\nID: Afebrile, WBC up to 18.9 (15.7). PreSep catheter tip sent for cx; no change in abx.\\nGI: Belly benign, no stool, tolerating TF's.\\nGU: Given 10mg IV Lasix at 2100 with minimal effect; remained nearly 1L positive for the day. Given additional 20mg IV Lasix at 0400 with better response, and he is now running negative.\\nENDO: Sugars well-controlled on current regimen.\\nHEME: INR down to 1.5 (2.2); ordered for 2 more doses Vit K to be given today and tomorrow. Hct 26-27, stable, no evidence of active bleeding.\\nSKIN: intact. Extremities warm at start of shift, a bit cooler now.\\nACCESS: RIJ PreSep catheter removed; has a-line and 3 PIV's.\\nSOCIAL: dtr called for update.\\n\\nA: could use better BP control; tolerating diureses; MS concerning.\\n\\nP: follow MS closely; if he does not wake up ? if he may need head CT to r/o bleed. wean from vent as able. resume outpt antihypertensives as indicated. bowel meds. cont to diurese as ordered. continue supportive care; inform and support family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443921,\n \"text\": \"Resp: Pt rec'd on a/c 25/450/5+/40%. Bs are clear with diminished bases, some wheezing was noted earlier, lasix given?\\nSuctioned for moderate amounts of yellow bloody tinged secretions. Ett #8 retaped & secured @ 24 lip. RSBI=69. No orders to attempt wean. Will continue full support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443922,\n \"text\": \"Nursing note (0700-1900) 16:00\\n\\nEVENTS: Head CT.\\n\\n\\nNeuro.\\nPt remains minimaly responsive to noxious stimuli, pupils remain sluggish to light, not following commands, some non-purposeful movement to the limbs on the Left, non to the the right.\\nCT head done this pm showing areas of infarct, family coming back later to speak with medics regarding implications.\\n\\nRESP.\\nPt remains on AC, with rate now set to 14, pt overbreathing to rate of 25. No plans to wean due to change in MS. LS clear to coarse UL's with diminished LL's. Pt for thick yellow/tan/bloody secretions Q3-4hrs.\\n\\nCVS.\\nHR 70's V-Paced with rare PAC's, EKG performed this am, unchanged from previous.\\nBP 160's-170's/70's-80's, Lopressor increased to 50mg BD, with little effect as yet.\\n\\nID.\\nPt with low grade temp, continues on multiple antibiotics, awaiting results from catheter tip cultures.\\n\\nGI/GU.\\nPt remains on TF's at goal of 40mls/hr, min. residuals, +BS with medium sized brown soft stool passed this pm, Guiac -ve.\\nPt with good response to further dose of Lasix 20mg this pm, pt currently -ve 1500mls (goal of -1 to -2L). Urine remains amber in colour with sediment.\\n\\nSkin.\\nPt's skin is pale as previous and remains cool to the touch at the extremeties, all pressure areas are intact.\\n\\nSocial.\\nPt's daughter is coming in to discuss the results of the head CT this pm with medics, so as to help decide future POC.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443938,\n \"text\": \"Nursing Progress Note.\\n\\nEVENTS: Pt remains c fairly stable VS.\\n\\nRESP: Pt requires Q2-3 hr NTS for moderate amounts of thick bloody sec. Sats drift down between sxn'ing c values in the 70's and up to the 90's s/p successful sxn'ing. Of note, L nare appears to be easier to pass sxn'ing cath to perform NTS. Now considering placing nasal trumpet to facilitate passage of sxn cath to minimize airway trauma. Resp pattern is agonal c death rattle noted, Scopolamine patch placed this afternoon to minimize airway sec. BS are diminished and rhoncherous on exam c slight clearing following sxn'ing. Freq oral care provided. Cough reflex is weak but intact, no gag reflex evident. RR ranges from 20's to 30's.\\n\\nMS: Pt does not appear uncomfortable or in pain c no response to noxious stimuli, will utilize IV Morphine Sulfate if pt appears distressed/SOB. PERRL, sluggishly.\\n\\nCV: Rectal Tmax of 101.5 this AM, med c 650mg Acetaminophen PR. +3 Anasarcoid.\\n\\nSOC: HCP dtr called this AM and kept up-to-date c POC/pt status. The pt is .\\n\\nOTHER: Please see CareVue for additional pt care data/comments. Universal isolation precautions in place.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443930,\n \"text\": \"MICU A NPN 7p-7a\\nNeuro: Neuro checks done q2hr overnight, no changes in neuro assessment noted. Pt cont to have nonpurposeful movement on left side, no movement noted on right side. PERRL, roving eye movement noted as well. +cough. Withdraws to painful stimuli, no eye opening noted at all.\\n\\nCV: VPaced at 70 bpm, some occasional ectopy noted this morning. SBP has been elevated most of shift, pt requiring lopressor ivp and hydralazine ivp in addition to scheduled po lopressor dose to get SBP to goal range of 140-160. BP rises significantly with any nursing care or stimuli. Tmax 101.5, pt was pancx and given tylenol 650mg. 2 new PIVs placed,? if pt will need central access, currently not on any cont. gtts. General 1+ edema t/o.\\n\\nPulm: Remains vented on CPAP settings. ABG done in am and pt appears to be tolerating settings well. Currently on Peep 5 PS 5 40%, RR 20's and O2 sat high 90's. Sxned for thick tan/yellow secretions in mod. to copious amts. LS mostly clear and diminished at bases, coarse at times as well.\\n\\nGI/GU: Tolerating TF Promote with fiber at 40cc/hr via NGT. No residuals. Abd soft, obese, +BS. +BM this am, brown and loose, guiac -. FSBS checks done q6hr, pt did not require SS coverage, but did get scheduled 70/30 dose this am. U/O 30-85cc/hr of clear yellow urine.\\n\\nSkin: Warm, dry and pale. Pt with general + edema, and scrotal edema as well. No breakdown on backside noted.\\n\\nPts dtr called last pm, was updated by RN on pts condition.\\n\\nPlan: ?extubation today. Pt is tolerating CPAP settings well. ?Family meeting to discuss code status. Cont neuro checks q2hr. Maintain SBP in 140-160 range. Cont to follow cultures.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443931,\n \"text\": \"Respiratory care\\n\\n Pt continues on PSV in NARD. B/S sl coarse sx for sm/mod thick tan secretions. Will continue to follow closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443932,\n \"text\": \"Nursing Progress Note.\\n\\nEVENTS: Family conference.\\n\\nMS: The pt remains non-purposeful off all sedation. PERRL. Pt does not follow commands. Pt rarely lifting LUE, LE's but does not move RUE. Pt moves LUE & LE's to noxious stimuli. No overt seizure activity evident. Pt bites down during mouth care. Good cough reflex, impaired/non-existent gag reflex. CT results from s improvement in findings c massive L sided MCA infarct and old R sided infarct. No restraints in place.\\n\\nCV: Hemodynamically stable c a tmax of 100.0, most recently 98.6. V-paced EKG waveform noted c no ectopy. Plus two anasarcoid. AM magnesium value of 1.9 repleted c 3gm IV Magnesium Sulfate. AM WBCC cont to trend down c a value of 19.8. s/p pan C&S this AM. IV Vanco dosing changed from Q24 hr to Q12 hr today. Adequate hourly UO, the pt is currently net positive 400ml input today and is net input 16 liters LOS. Urine is yellow c + sedimentation noted. Pt remains on QD IV Levofloxacin & Ceftriaxone dosing. AM sodium lab value of 134 noted, will limit free H2O intake. Pt SBP maintained in the 140-160 range today, required 5mg IV Lopressor @ 13:00 for SBP transiently in the 160 range.\\n\\nRESP: Pt received and maintained on CPAP/PS 5/5 c 40% FiO2 in place c nl sats, RR in the 20's and nl resp pattern. Pt c good cough reflex requiring Q2-3 hr sxning for thick tan/mucoid sec per ETT. ETT rotated and changed today. AM ABG c the following acceptable values; 7.47-40-97, no MV setting changes made today. Minute vol in the liter/min range. LS fairly clear in upper lobes today, diminished @ bases.\\n\\nGI: Pt received/maintained on Promote c Fiber @ target rate of 40ml/hr via NGT c low residuals noted all day. Pt passed one medium sized soft brown stool today, guaic negative.\\n\\nSOC: Pts HCP (HCP) accompanied by fiance () met c Neuro & MICU teams to discuss pt clinical status and prognosis s/p repeat head CT on . Per team, the pt has a grim prognosis & uncertain rehab potential s/p massive CVA. Family now moving in direction of extubating pt and making CMO. Family will now discuss pts case among themselves before making any pt care changes @ this time. Social work was able to meet/discuss care issues @ length today. Family members (including son by phone) kept up-to-date c POC/pt status. Verbal & non-verbal support also provided to family. Family declined religious consult. The pt remains a Full Code @ this time.\\n\\nDERM: Intact @ this time, turning Q3-4 hrs.\\n\\nOTHER: Please see CareVue for additional pt care data/comments. Univ isolation precautions in place.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443933,\n \"text\": \"MICU nursing progress note 7P-7A\\nEvents - Pt became increasingly hypertensive, BP refractory to lopressor and hydralazine, started on nipride gtt with gradual decrease in BP, goal SBP 140-160. Pt is DNR, family to decide today whether to make pt d/t poor prognosis S/P L MCA infarct.\\n\\nNeuro - Exam unchanged. PERL, brisk. Withdraws left extremities and right LE to stimuli. No movement right UE. Occ spontaneous movement left arm. Bites down on ETT, turns head slightly side->side. No response to voice. +cough, no gag. ? pain during hypertensive episode 200s from excoriated skin on upper thighs and urine on skin, MSO4 2 mg x 2 with some decrease in BP.\\n\\nResp - CPAP 5 + 5, 40%. RR high 20s-30 when hypertensive, decreased to 18-22 with BP decrease. Sx x 3 thick tan secretions, lavaged for small plugs. Lungs clear, decreased at bases. Sats 99-100%->95%. Short periods of agonal breathing when hypertensive, resp pattern now normal.\\n\\nCV - BP 170s->190s (200s)/70s. Lopressor 5 mg x 3 doses with transient effect to 160s. Hydralazine 20 mg x 2 with no decrease. Pt became more hypertensive to 200s/. Also increased PO lopressor to 100mg which had no effect. Nipride gtt started, titrated to SBP 140-160. See Careview. V-paced 70s. Hct stable, WBC slightly decreased. +3 anasarca. Lytes WNL, Na 138.\\n\\nGI - Abd obese, +BS, no stool. TF at goal 40cc/hr, no residuals. FSBS WNL.\\n\\nGU - UOP 30-100cc/hr. Foley leaking, irrigated easily, no further leaking.\\n\\nSkin - Areas of excoriation on right inner thigh, looks like open blisters. Nystatin and aloe . Fluid filled blisters on right lower arm. Areas of excoriation, bleeding slightly, on left ant thigh, also looks like open blisters.\\n\\nID - T max 101.4, tylenol given. On vanco/ceftriaxone/levo. Many Cx pending.\\n\\nSocial - No phone calls O/N.\\n\\nPlan - Family to make decision today re , pt is DNR. Titrate nipride gtt to SBP 140-160. Neuro checks q 2 hrs.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443934,\n \"text\": \"resp care\\nPt remained on psv5/peep5 and 40% all night. Generally mv ranged from 9-11L with rr 20-24. Pt became hypertensive with an increase in rr to 30. BS coarse but clear. Suct for thick tan sput.Sats also a bit lower ranging from 93-96. Will cont to follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443935,\n \"text\": \"Nursing Progress Note.\\n\\nEVENTS: Pt made extubated and made c family @ BS.\\n\\nRESP: Pt received on CPAP/PS 5/5 c 40% FiO2 in place c nl sats, RR in the teens/twenties, and nl resp effort. Scant thick tan sec per ETT today. LS fairly clear in upper apices today, diminished @ bases. After long discussion c team during family conference on the dtr (HCP) decided that under the situation that the pt would not have wanted to be kept on a MV c such a poor prognosis and therefore it was decided to extubate the pt and make @ 14:00. The pt was subsequently extubated (+cuff leak noted) @ 14:30 to 2LNCO2. The pt has been stable since extubation c sats in the low/mid 90's, pt occ coughing up sec and RR gen in the 20's. Resp pattern fairly nl asside from occ slowing/speeding up of rate c nl sats maintained. Pt BS now more rhoncherous (more pronounced during exhalation) c some upper airway rhonchi as well. Pt does not appear dyspneic or SOB. Morphine Sulfate and/or NTS to be provided when/if pt developes resp distress. All procedures explained to pts HCP who appears to be coping normatively @ this time. Freq mouth care provided.\\n\\nMS: Pt less responsive to noxious stimuli today c no spontaneous movements of LUE. Pt cont to move feet to noxious stimuli. Pt bites and grimaces when mouth care provided. PERRL though R eye now deviated to the L of center. No agitation or overt discomfort noted. Will provide IV Morphine Sulfate if pt becomes distressed, no need for Morphine gtt @ this time.\\n\\nCV: Pt remains hemodynamically stable and afebrile. V-paced EKG waveform c occ PAC's. AM lytes WNL. A-line to be d/c'ed shortly. The pt is currently net positive 700ml input today and is net positive 17 liters LOS. The pt is +2 anasarcoid. Urine is yellow in coloration, sedimentated and slightly cloudy.\\n\\nSOC: HCP dtr visiting since lunchtime c fiancee (), both kept up-to-date c POC/pt status.\\n\\nOTHER: Please see CareVue for additional pt care data/comments. Univ isolation precautions in place.\\n\\nGI: NGT d/c'ed prior to extubation after discussion c family/team. The pt is now NPO.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443911,\n \"text\": \"admitting shift note 2100-700\\nPt admitted from ER intubated, on Levophed drip for BP control, low urinary output, WBC 13.9, continue on sepsis protocol.\\n\\nNeuro: opens eyes to noise and spontanously. follows simple commands like squeezing hand, but inconsistant.moves all extremities, PEARL. CT Head neg in ER. (was found at nursing home unresponsive with glucose of 20.).Family was here earlier, pt responded to them. wrist restraints on bilaterally, off for small period of time. pt is purposeful.\\n\\nCardiac: Levo off since 1am. ABP 110-140's, map65-80. Paced at 70. Positive cardiac enzymes. CVP13-17,SVO2 67-70. Replaced Mg with 4Grams and came up to 2.0, replaced Calcium with 2grams, but still low at 7.7. facial and periorbital edema. venodynes boots on.pale in color. pt is +10L (h/o CAD,HTN,CABG, CHF,Pacer)\\n\\nResp: vented on PS 15, Peep 10, 40%, #8.0 ETT 24cm at lips. Lungs coarse with crackles to bilaterally bases. ABG at 3am ph 7.28, Co2 42, O2-138\\n\\nGI: abd softly distended. had small BM on admission to MICU. Bowel sounds hypoactive. NGT to rt nare. awaiting xray verification. BS 181 at 6am\\n\\nGU: #14 foley in ER. minimial output. bloody drainage with blood at penis site. irrigated and manipulated catheter with no improved urinary output. pt with 4L plus given in MICU A. output starting to pick up at 5am for 33ml output, but also incontinence noted to pad and on gown. no urologist on call tonight, will need one this am. Bun 23/creat 1.2. h/o left nephrectomy years ago??\\n\\nIV/Access: Right IJ TLC with precep line. Aline to left radial, saline locks to bilateral AC and rt wrist. Versad drip at 1mg, fentanyl at 50mcg, Levo remains off\\n\\nID: afebrile max temp 98.9 tonight. Lactate level 3.2, WBC up to 17 this am. on Vanco, Levaquin, flagyl. was swabs on admission for STAR.\\n\\nSocial: lives at , uses electric wheelchair. baseline mentation A&Ox3 with slightly dementia. self sufficent. Daughter and son-in-law at bedside earlier. supportive and visits him regularly (weekly) at home.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443912,\n \"text\": \"admitting shift note 2100-700\\nupdate: 1000ml LR given at 6:15 :ABP 90-100'a, SVO2 65, Lactate level 3.9. Order for Calcium 2Gm obtained, waiting for run\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443913,\n \"text\": \"Respiratory Care\\nPt received intubated, 8.0 oet tube taped at 24cm. Bilateral breath sounds, rales at bases. Breathing spontaneously on psv with good oxygenation, met. acidosis. RSBI = 50. Plan to maintain support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443914,\n \"text\": \"Respiratory Care\\n\\nPt. remains intubated. Pt switched from CPAP to A/ M.D.. Suctioned moderate amt of thick bloody secretions.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443915,\n \"text\": \"Nursing Note 7A-7P Review of Systems:\\nNEURO: Sedated on Fentanyl drip at 50mcg/hr and Versed at 1mg/hr. Opens eyes to voice inconsistently. Moves all extremities on bed. Does not follow simple commands. PERLA 2mm/ briskly reactive. Bilaterial wrist restraints remain on.\\nC/V: V paced at a rate of 70. Levophed remained off all day. BP 91-129/ 48-64. Continues with peripheral and facial edema. Venodyne boots remain on. Patient currently 17 liters positive For LOS and 9800cc positive in the past 24 hour.\\nRESP: Remains orally intubated, sucioned X3 thick bloody secretions. Lung sounds clear upper airways and crackles bibasilar. O2 Sat 96-100%. Vent settings changed from CPAP to AC (Please see flow sheet). Last ABG = 7/31-44-122. Lactic Acid range from 2.5-3.3.\\nGI: OGT intact placement checked by auscultation and confirmed by CXR. Tube feedings Promote with fiber FS infusing at 20cc/hr to be increased by 10cc q 4 hr till goal rate of 40cc/hr. Abdomen distended positive bowel sounds no flatus or stools this shift.\\nGU: Foley patent draining bloody urine minimal output 14- 43cc/hr. Foley cath irrigation attempted today without success Foley removed and # 14 replaced with minimal output. Fluids of D5 with 3 amps Bicarb infused 1Liter per hour times 3 hours. Output increased slightly to 30-40/hr. Total of 9800cc positve today. Renal U/S done results pending.\\nID: Afebrile, Tmax 98.3 orally, cotninues on Levofloxacin, Metronidazole, Vancomycin and Ceftriazone.\\nSOCIAL: Patients daughter into visit and updated by MD as to patients POC.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443916,\n \"text\": \"MICU Nursing Note 1900-0700\\nEvents: Uneventful night. Remains off vasopressors. Received 1 liter IV fluid bolus for low urine output with good effect. Remains intubated on AC on vent. Stable hemodynamics throughout night.\\n\\nNeuro: Sedated on IV Versed at 1 mg/hr and IV Fentanyl at 50mcgs/hr. Arouses to voice...opens eyes to voice and physical stimulation. Follows some commands---will squeeze hands on commands. Moving all extremities on bed when stimulated. Withdraws to painful stimuli. Pupils 2 mm and brisk. Bilat soft wrist restraints on to prevent pt from pulling at tubes and lines.\\n\\nCardiac: Remains off vasopressors. HR 70 and V-paced with occas. PVC noted. Right IJ TLC-Presep catheter site C/D/I. SV02 ranging from 79-82. CVP= 13-19. Left radial Aline with good waveform and correlation to NBP....BP= 111-135/58-70. Received 1 liter bolus of NS for low urine output and CVP=13 with good effect. Calcium level down to 7.3 earlier and repleted with 2 amps calcium gluconate. CPK up to 358 with MB and Troponin still pending.\\n\\nResp: Remains intubated on AC 25/ TV=450/ FI02=40%/Peep=10cm. Overbreathing Vent by 1-3 breaths when stimulated. MV= . Pips= 30-35. O2 Sats= 95-98%. ETtube suctioned for small amts blood-tinged thick sputum. Lungs clear bilat upper lobes and with rales at bilateral lower lobes. Last ABG=7.38-50-94-2-31...team aware and no vent changes made at this time.\\n\\nGI: Abd softly distended with + bowel sounds all quads and no BM. NGtube placement checked by auscultation. Tolerating TF FS Impact with fiber at goal rate of 40 ml/hr with residuals of 0-5 ml.\\n\\nEndo: fingersticks QID....fingerstick at MN=256---covered with 6 units of regular insulin as per sliding scale.\\n\\nGU: Urine output blood-tinged to amber in color and with sediment. No clots noted. Urine output down to 10 ml/hr with CVP=13 during evening....bolused with 1 liter NS with urine output 30-60 ml/hr the rest of the night. BUN=28/ Creat.=1.1.\\n\\nSkin: remains edematous ---periorbital and facial edema unchanged. No skin breakdown noted. Reddened area over right upper thigh---cream applied. Venodyne boots on . Turned and repostioned Q2-3hours.\\n\\nSocial: No contact from family members during the night.\\n\\nPlan: Continue to monitor hemodynamics, urine output, labs closely. Wean vent as tolerated. ? Obtain Cardiology consult in r/t + MI.\\nWean Sedation and vent when stable. Support pt and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443917,\n \"text\": \"Respiratory Care\\nRemained intubated and ventilated on a/c with no remarkable changes overnight. ABGS within normal limits for pt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443936,\n \"text\": \"pt extubated to nasal cannula as ordered through status. vent pulled from room.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443937,\n \"text\": \"MICU nursing progress note 7P-7A\\nPt is now . Continues unresponsive. No spontaneous movement. Will move left foot slightly to stimulation, no other response elicited from extremities. Bites down during mouth care, oral Sx. Resp pattern agonal, high 20s-30. MSO4 2 mg x 1 with no change in resp pattern. NTS x 1 thick tan secretions. Lungs are slightly coarse upper lobes, diminished at bases. Sats have decreased low 90s->low 70s on 2L NC. Remains HD stable, V-paced in 70s. UOP 35-100cc/hr. Skin warm and slightly diaphoretic. Turned q 3 hrs, skin care given. Daughter called O/N for update on pt condition.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443928,\n \"text\": \"Nursing note (0700-1900) 16:15\\n\\n\\nNeuro.\\nPt for repeat head CT this am, showed increase in amount of edema now compressing right side of brain. Pt moving left side only, moves leg on bed, and has managed on occasion to lift left arm from bed, though with out any purpose. Patient not following commands for this nurse, though medics felt that pt did sqeeze with left hand on command. no eye opening as yet, pupils remain 2mm and suggish to react to light.\\nPt does have cough and gag reflexes.\\n\\n\\nResp.\\nPt placed on CPAP (5/5/40%) with slight improvement in resp alkalosis, pt tollerating well so far, so no plans to rest on ac overnight as yet.\\nLS are clear to upper lobes, diminished in bases. Pt sx'd for thick yellow secretions Q4hrs.\\n\\n\\nCVS.\\nHR 70's V-Paced with no ectopy seen this shift.\\nBP 130-160/60's on Lopressor 75mg to keep within these limits per Neuro team.\\n\\n\\nID.\\nPt has remained a-febrile this shift, continues on previous antibiotics of Vanco, Levo and Ceftriaxone. Awaiting micro data on cultures sent overnight.\\n\\nAccess.\\nPt is for placement of TLC this shift as PIV sites expiring today.\\n\\nEndo.\\nNo RISS coverage needed this shift, recieving usual doses of 70/30 BD.\\n\\nGI/GU.\\nTollerating TF's at goal with no residual, +BS with no BM as yet this shift.\\nGood UOP via foley of yellow urine with occasional sediment.\\n\\nSkin.\\nPt's skin remains edematous generaly, extremeties are warm to touch and skin is of less pale appearance.\\n\\n\\nSocial.\\nDaughter () and her fiance () in for much of the day waiting to speak with Neuro for update as to repeat CT, Neuro explained that as there was an increase in edema that we were still at a critical point.\\n and now home for the day, will call later for update.\\nNo contact from Son during the day.\\n\\nPlan.\\nFollow MS, Q2hr neuro checks.\\nSW and case management support for family.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-09-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1443929,\n \"text\": \"Resp: Pt remains intubated on psv 5/5/40%. Bs are slightly coarse bilaterally. Sucitoned for small to moderate thick yellow. Sputum sample sent. No changes noc. AM ABG's 7.47/40/97/30. RSBI=74. Family meeting to discuss possible extubation today.\\n\"\n }\n]"}}},{"rowIdx":24679,"cells":{"subject_id":{"kind":"number","value":13551,"string":"13,551"},"hadm_id":{"kind":"number","value":160378,"string":"160,378"},"target_text":{"kind":"string","value":"1. Respiratory: The infant was intubated on admission and quickly extubated by about 15 to 20 minutes of life to room air. He was never actually placed on the mechanical ventilation. He went from bagged ET tube ventilation to room air as he started to wake and remained stable on room air at the time of discharge from the NICU. He has had no issues with apnea or desaturation. 2. Cardiovascular: He remained hemodynamically stable throughout his course in the NICU with a normal heart rate, blood pressure and rhythm and no audible murmur. 3. Fluids, electrolytes and nutrition: He was n.p.o. on admission due to the perinatal depression. Intravenous fluids were started at 60 ml per kg per day of D-10-W through a peripheral IV. He started enteral foods on the newborn day and weaned quickly to full feeds by the end of day one of life. He is ad lib breast feeding and no IV fluid at the time of transfer. Most recent set of electrolytes was on . Sodium was 145; potassium of 5.5; chloride of 110; C02 21; BUN 10; creatinine 0.4. His weight on the day of discharge from the NICU was 2605. 4. Gastrointestinal: He had LFTs drawn on day of life 1. The ALT was 21; AST 87; alk phos 181 and those were drawn due to the perinatal depression. A bilirubin of 10.8 over 0.3 was drawn on . The infant is not under any phototherapy at this time and will need follow-up bilirubin levels. 5. Hematology: The hematocrit at birth was 47. 6. Infectious disease: Sepsis suspect at birth. Blood culture and CBC were screened. The CBC was normal with 34 whites, 32 polys and 4 bands. The blood culture was sent and remained negative after 48 hours. He received a total of 48 hours of Ampicillin and Gentamycin. The Gentamycin peak and trough levels at 24 hours were a peak of 8.2, trough of 1.3. The infant is presently off antibiotics when discharged from the NICU. 7. Neurologically: Once the infant's tone improved by about a half hour of age, the infant has maintained a normal neurologic exam since that time. No further studies have been done per neurologic sequella. 8. Sensory: A hearing screen needs to be performed prior to discharge from the newborn nursery and has not been done yet from the NICU. 9. Ophthalmology: The infant does not meet criteria for ophthalmology exam at this time. 10. Psychosocial: If there are concerns with social issues, social worker can be reached at ."},"extractive_notes_summ":{"kind":"string","value":"Updated by this RN. sent this AM10.8/0.3. D-stick this AM 68, nursing well. Addendum:Infant cont's on IV Ampi and Gent.Gent levels drawn and presently pnd'ing.HSV CX sent along with lytes,bili,LFT'S,BUN and Cr presently pnd'ing. Parentsin briefly with L&D RN. HypoactiveBS. Passing stool.GI: LFTS: AP 101, AST 87, ALT 21.ID: On amp/gent. Nursing Progress Note1. Extubated rapidly, now comfortable in RA. I will place EIP & VNA options in record. P: Cont to monitor.#2 O: TF= 60cc/kg/d. Dstiks 96, 67. A: Mom. P. Feed q3hrs, if infant does not nurse well feedbottle. To NICU with bagging. HCT 47, PLT 282. A: Resolving resp issues. P: Continue to monitor.2.O: Weight 2605gms down 110gms. DS 72-109. Asking appropriatequestions. BW2630g. RR 30-50s, LS clear bilat.,mild SC retractions noted at times; resolving. P:Cont to support and update. A: AGA. DTV/DTS. BUN/Cr 13/1.0. Mildintercostal retractions, RR40's-50's. Nospells noted. Tempin open crib 97.8-97.9 axillary. Pt intub in DR noresp effort. P: Monitor I&O's. RR 40's-70's with mild SCretractions. LS clear and =. Abdomen soft with good bowel sounds,passing meconium now. NPN 0700-1500#1 O: Infant remains in RA. Woke for next feed. in AM. Asking appropquestions. HR 140-180s, BP means stable (42-60). Infant receiving IVF of D10 infusingvia PIV. Pt started on Amp and gent for 48hrr/o sepsis. Mom would like to BF. P: Inform and support. NeonatologyDOL #1, CGA 36 wks.CVR: Remains in RA, O2sats 99-100%. A:Stable in RA. Initial DS= 210, 186 at 0400. Nursing Progress Note1.O: Remains in roomair with O2 sats high 90's-100. Admission NotePt admitted to NICU for decr resp effort. P. Support.4. A.Developmentally appropriate. Nestedwith boundaries in place. A: NPO. Infant bottled10cc's of BM instead. 36 weeker ready for transfer to regularnursery. Gent levels with 2nd dose: 1.3/8.2. IV D10 running well inLhand, site soft, pink. Good bowel sounds. Oriented to unit. Bottled 12cc's ofBM. Baby meds given. IV antibiotics dc'ed this shift. Wakes for feedings, feeds10 minutes. O2 sats95-100%. A. A. A. A. P.Monitor.2. ABG drawn at 0430: 7.36/30/129/18/-6. Gent levels to be drawn at 2nd dose. PIV placed L hand, patent and infusing D10W at60cc/k/day. Total fluids at 60cc/kg/d IV/po. Pt NPO. Pt onopen warmer, temps stable. Support. Working up on po feedings,nursing well. Infant was able to be extubated to RA approx15min after transfer to NICU. Rooting to hands. P: Cont to supportdevelopment.#4 O: Both parents in to visit. Mom loving andinvolved. ROM 9.5 hrs ptd. Did diaper change and temp. Nursing Transfer NoteInfant remains in room air with sats >95, lungs clear andequal, RR40-60's. A: Needs to improve on nursing. Monitor for s&s of sepsis.3.O: Waking for feeds. Continue to support and update as needed. Tolerating breast-feeding. Surfaceswab for HSV to be done at 24H age. Briefly shown to parents. h/o recurrent herpes on valtrex. A: Infant not voiding in large amounts. Lungs clear and equal, well aerated. DS 75 and 77. A: Involved. Tolerated procedure well. Sucking onpacifier intermittently. NNP Physical ExamPE: pink, mild jaundice, AFOF, breath sounds clear/equal with mild retracting, no murmur, abd soft, active with good tone. AFSF. 30cc NS bolus given at 0300 for volumeexpansion. Cord prolapsed through incision. Active herpes lesions noted. RR 50-60s, mild intermittent retractions, overall comfortable. Infant depressed (floppy, HR <100, no resp effort) requiring BMV, vigorous stimulation then intubation by SNP under my supervision. HSV surface swabs sent yesterday.DEV: Now wrapped in off-warmer, temp stable.IMP: 1 day old infant with neonatal depression, overall appears to be rapidly improving. O2 sats 99-100%. Infant more alert, active,better perfusion and cap refill. Taken to C/S under combined epidural/spinal anesthesia. Hemodynamically stable. Tube secured with tape at 9.5 at upper lip. At risk for sequelae. Active and alert for car4es. Color jaundiced. Please seeattending note for further details. Temp stable in crib. P. Offer pc bottles, wean IV and monitord-sticks.3. IV running at 30cc/kg thenhep locked at 0100. P: Cont to monitor.#3 O: Maintaining temp on open warmer set in servo. Breast-fed several times overnight, with good latch. Neonatology NP Procedure NoteEndotracheal IntubationIndication: Respiratory failure3.5 ETT passed orally through cords under direct larygonscopy. In room air with sats >95 consistently. Neonatology Attending Progress Note:DOL #2remains in RA, no desats.HR=130-150's, no murmur,ad lib BF, off IVF, dstx=68-77=10.8off antibioticsHSV surface cultures pendinglytes: 145/5.5/110/21/10/0.4Imp/Plan: premie infant with perinatal depression, resolving lung disease, s/p r/o sepsis--check HSV cultures--continue ad lib feeds--continue rest of present management WBC 34.3, 32P, 4B,43L. stool.G/D:AF soft and flat.Alert and active with cares.Infantremains on Warmer with nested boundaries.MAE.Bringing handsto face and mouth.Parenting:Parents in tonight updated by NNP .Parents asking appropriate questions very loving andinvested. Abd flat, soft,hypo BS. Breath sounds clear and equal. Good chest wall movement and equal breath sounds present. Urine output improving, although creatinine mildly elevated at 24 hrs.PLANS:- Continue monitoring of room air.- Allow to ad lib feed, wean IVF as able.- Monitor urine output, repeat chem 7 in am.- D/c amp/gent at 48 hrs if cx negative.- Monitor neuro exam. O2 sats - 95-100%RR 30-50s.ABG - 7.36/30/129 at 4:30 this morning.HR 140-180s BP 61/44 49Wt. Case Management NoteChart reviewed and events noted. Call Mom when infant wants to nurse. Blood workdrawn. Encouraged parents to restand visit later. is high, discuss with the Mom the need for more fluids.Monitor weight. Nursing Progress Note 1900-0700Resp:Infant remains in RA saturating 96-100%.RR mainly50-60's however noted transient tachypnea with RR 80-100.LSremain clear equal with sc retractions.No A's and B's ordesats thus far.F/E/N:Infant cont's on TF 40cc's/kg/day.IVF D10 infusing at4.5cc's/hr in L hand.Site intact.Mom did attempt to breastfeed x 1.Infant did latch but tired easily.Dsick=96/67.Weight=2.715kg up 85 grams.Abd soft and flat withpos bs,no loops or spits,girth=26.UO=1.2cc's/kg/day over 12hrs.Noted trace mec. She was very comfortablewith trying to nurse him. Voided only 23 and 8cc's.Abdomen soft and flat. Awake and alert with feedings, nursing well. Neonatology NP Discharge Physicalswaddled in open cribAFOf, sutures approximated+ bilateral red reflex, small amount of white eye drainage from left eyeoral mucosa without lesionsneck supple and without massesclavicles intactcomfortable respirations in room air, lungs clear/=RRR, no murmur, pink and well perfused, femoral pulses presentabdomen soft, nontender and nondistended, active bowel sounds, cord on/dry, jaundiced to lower extremiitestestes descended bilaterallyno sacral anomaliesstable hip exam, normal digits and creasesactive with age appropriate tone and reflexes"},"n_notes":{"kind":"number","value":15,"string":"15"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2105-12-07 00:00:00.000","description":"Report","row_id":1870841,"text":"Neonatology Attending\n\n2630 gram 36 week male admitted s/p perinatal depression\n\n2630 gram 36 week male born to a 42 yo G1 P0->1 white female\nPNS: B+/Ab-/RPR NR/RI/HBsAg-/GBS-\nUncomplicated pregnancy. h/o recurrent herpes on valtrex. ROM 9.5 hrs ptd. Presented to L&D after midnight (>7 hrs after ROM). Active herpes lesions noted. Taken to C/S under combined epidural/spinal anesthesia. Cord prolapsed through incision. Head needed to be pushed up. Infant depressed (floppy, HR <100, no resp effort) requiring BMV, vigorous stimulation then intubation by SNP under my supervision. Floppy with poor perfusion and slow to pink up. Briefly shown to parents. To NICU with bagging. Apgars 1/3/4/8.\n\nExam Near term male orally intubated with beginnings of spontaneous respiratory effort, poor tone\nT 97.5 P 184 R bagging BP 68/54 mean 60 O2 sat 95%\nWt 2630 grams (~50%) Lt 51 cm (~90%) HC 32 cm (~40%)\nAF soft, flat, nondysmorphic, intact palate, gradually increasing spontaneous respirations, coarse bs, clearing after suctioning, no murmur, soft abd, 3 vessel cord, no hsm, normal male genitalia, testes descended into scrotum, no hip click, patent anus, no sacral dimple, poor tone but activity and tone increasing over first 15 minutes in NICU, no evidence of seizure activity, no skin lesions (examined scalp, extremities, trunk, genitalia closely), mmm, no mucosal lesions seen, slow capillary refill\n\nOver course of ~15 minutes in NICU spontaneous respirations increased, progressed from bagging to CPAP to extubation\n\nDS 210\n\nA: 36 week male s/p perinatal depression likely secondary to volume depletion and cord prolapse. At risk for sequelae. At risk for HSV secondary to recurrent maternal HSV infection with active lesions and ROM >4 hrs before C/S delivery. Infant has no lesions. Must also rule out sepsis in light of difficult start.\n\nP: Monitor\n O2 as needed\n NS bolus\n NPO with IV fluids\n Usual attention to lytes and DS\n Follow UO closely\n CBC, BC\n A/G for R/O sepsis\n Check gent levels before 2nd dose\n Check BUN, Cr, LFTs to monitor for end organ effect\n Surface cultures (, NP, rectal) for herpes in 24-48 hours\n Hold acyclovir unless he develops lesions or has positive culture\n Support parents\n Pediatrician is \n\n"},{"category":"Nursing/other","chartdate":"2105-12-07 00:00:00.000","description":"Report","row_id":1870842,"text":"Neonatology NP Procedure Note\n\nEndotracheal Intubation\nIndication: Respiratory failure\n3.5 ETT passed orally through cords under direct larygonscopy. Tube secured with tape at 9.5 at upper lip. Good chest wall movement and equal breath sounds present. Tolerated procedure well. No complications.\n"},{"category":"Nursing/other","chartdate":"2105-12-08 00:00:00.000","description":"Report","row_id":1870847,"text":"Nursing Progress Note 1900-0700\n\n\nResp:Infant remains in RA saturating 96-100%.RR mainly\n50-60's however noted transient tachypnea with RR 80-100.LS\nremain clear equal with sc retractions.No A's and B's or\ndesats thus far.\n\nF/E/N:Infant cont's on TF 40cc's/kg/day.IVF D10 infusing at\n4.5cc's/hr in L hand.Site intact.Mom did attempt to breast\nfeed x 1.Infant did latch but tired easily.D\nsick=96/67.Weight=2.715kg up 85 grams.Abd soft and flat with\npos bs,no loops or spits,girth=26.UO=1.2cc's/kg/day over 12\nhrs.Noted trace mec. stool.\n\nG/D:AF soft and flat.Alert and active with cares.Infant\nremains on Warmer with nested boundaries.MAE.Bringing hands\nto face and mouth.\n\nParenting:Parents in tonight updated by NNP \n.Parents asking appropriate questions very loving and\ninvested.\n\n\n"},{"category":"Nursing/other","chartdate":"2105-12-08 00:00:00.000","description":"Report","row_id":1870848,"text":"Addendum:Infant cont's on IV Ampi and Gent.Gent levels drawn and presently pnd'ing.HSV CX sent along with lytes,bili,LFT'S,BUN and Cr presently pnd'ing.\n"},{"category":"Nursing/other","chartdate":"2105-12-08 00:00:00.000","description":"Report","row_id":1870849,"text":"Neonatology\nDOL #1, CGA 36 wks.\n\nCVR: Remains in RA, O2sats 99-100%. RR 50-60s, mild intermittent retractions, overall comfortable. Hemodynamically stable. No murmur. No spells.\n\nFEN: Lytes 140/4.4/104/22. BUN/Cr 13/1.0. Breast-fed several times overnight, with good latch. On IVF D10W at 40 cc/kg/day. Dstiks 96, 67. Urine output now increasing. Passing stool.\n\nGI: LFTS: AP 101, AST 87, ALT 21.\n\nID: On amp/gent. Gent levels with 2nd dose: 1.3/8.2. HSV surface swabs sent yesterday.\n\nDEV: Now wrapped in off-warmer, temp stable.\n\nIMP: 1 day old infant with neonatal depression, overall appears to be rapidly improving. Extubated rapidly, now comfortable in RA. Tolerating breast-feeding. Urine output improving, although creatinine mildly elevated at 24 hrs.\n\nPLANS:\n- Continue monitoring of room air.\n- Allow to ad lib feed, wean IVF as able.\n- Monitor urine output, repeat chem 7 in am.\n- D/c amp/gent at 48 hrs if cx negative.\n- Monitor neuro exam.\n"},{"category":"Nursing/other","chartdate":"2105-12-07 00:00:00.000","description":"Report","row_id":1870843,"text":"Admission Note\n\n\nPt admitted to NICU for decr resp effort. Please see\nattending note for further details. Pt intub in DR no\nresp effort. Infant was able to be extubated to RA approx\n15min after transfer to NICU. RR 30-50s, LS clear bilat.,\nmild SC retractions noted at times; resolving. O2 sats\n95-100%. ABG drawn at 0430: 7.36/30/129/18/-6. No murmur\nauscultated. HR 140-180s, BP means stable (42-60). BW\n2630g. Pt NPO. 30cc NS bolus given at 0300 for volume\nexpansion. PIV placed L hand, patent and infusing D10W at\n60cc/k/day. Initial DS= 210, 186 at 0400. Abd flat, soft,\nhypo BS. DTV/DTS. CBC and BC drawn. WBC 34.3, 32P, 4B,\n43L. HCT 47, PLT 282. Pt started on Amp and gent for 48hr\nr/o sepsis. Gent levels to be drawn at 2nd dose. Surface\nswab for HSV to be done at 24H age. Baby meds given. Pt on\nopen warmer, temps stable. Infant more alert, active,\nbetter perfusion and cap refill. Rooting to hands. Parents\nin briefly with L&D RN. Updated by this RN. Asking approp\nquestions. Oriented to unit. Encouraged parents to rest\nand visit later. Continue to support and update as needed.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2105-12-07 00:00:00.000","description":"Report","row_id":1870844,"text":"Neonatology Attending - Progress Note\n\nNow 7 hours of life for this infant with neonatal depression.\nBaby's respiratory status much improved - breathing comfortably in RA. O2 sats - 95-100%\nRR 30-50s.\n\nABG - 7.36/30/129 at 4:30 this morning.\nHR 140-180s BP 61/44 49\n\nWt. 2630gm - on 60ml/kg/d of IV D10W.\nNPO\nNo urine or stool output yet.\n\nDS 210 at birth - then 186 - 72 this morning.\n\nID -\nMother noted to have a herpes lesion on her thigh 1 month ago and has been treated with Valtrex for the past month. Noted to have active lesions in the vaginal region just prior to delivery.\nBaby has no lesions.\n\nwbc 34,300 32P 4B 43L plat 282,000 Hct 47%\nOn amp and gent\n\nAssessment/plan:\n36 week gestation infant with perinatal depression most likely secondary to prolapsed cord - much improved now.\nAt increased risk for HSV infection - will check surface cultures at 24 hours. If baby develops any suspicious skin lesions or other signs of infection will initiate therapy with acyclovir.\n\nAmpicillin and gentamicin therapy to continue for at least 48 hours.\nFU cbc planned to follow hight white count.\n"},{"category":"Nursing/other","chartdate":"2105-12-07 00:00:00.000","description":"Report","row_id":1870845,"text":"Case Management Note\nChart reviewed and events noted. I will place EIP & VNA options in record. I will be providing clinical updates to insurance and will assist w/any d'c planning needs along with team & family\n"},{"category":"Nursing/other","chartdate":"2105-12-07 00:00:00.000","description":"Report","row_id":1870846,"text":"NPN 0700-1500\n\n\n#1 O: Infant remains in RA. RR 40's-70's with mild SC\nretractions. LS clear and =. O2 sats 99-100%. No spells. A:\nStable in RA. P: Cont to monitor.\n\n#2 O: TF= 60cc/kg/d. Infant receiving IVF of D10 infusing\nvia PIV. Abdomen benign; voiding only 3cc's so far this\nshift since birth. No stool as yet. DS 72-109. Hypoactive\nBS. Mom would like to BF. A: NPO. P: Cont to monitor.\n\n#3 O: Maintaining temp on open warmer set in servo. Awake\nand alert with cares; opening eyes and crying when\ndisturbed; otherwise sleeping between cares. AFSF. Nested\nwith boundaries in place. A: AGA. P: Cont to support\ndevelopment.\n\n#4 O: Both parents in to visit. Asking appropriate\nquestions. Mom pretty tired from delivery. A: Involved. P:\nCont to support and update.\n\n\n"},{"category":"Nursing/other","chartdate":"2105-12-08 00:00:00.000","description":"Report","row_id":1870850,"text":"Nursing Progress Note\n\n\n1. In room air with sats >95 consistently. No desats or\nbradys. Lungs clear and equal, well aerated. Mild\nintercostal retractions, RR40's-50's. A. No distress. P.\nMonitor.\n2. Total fluids at 60cc/kg/d IV/po. IV D10 running well in\nLhand, site soft, pink. Nursed several times today thus\nfar, latches on well and sucks vigorously for 5-10 minutes.\nNo bottles offered yet but will offer one after this nursing\nsession. Urine output significantly increased,\n30-35cc/diaper change. Abdomen soft with good bowel sounds,\npassing meconium now. A. Working up on po feedings,\nnursing well. P. Offer pc bottles, wean IV and monitor\nd-sticks.\n3. Awake and alert with feedings, nursing well. Temp\nstable on warmer, swaddled with hat and 2 blankets. A.\nDevelopmentally appropriate. P. Support.\n4. Mom up for feedings today, nursing and handling baby\nwell. Did diaper change and temp. A. Mom loving and\ninvolved. Support.\n\n\n"},{"category":"Nursing/other","chartdate":"2105-12-08 00:00:00.000","description":"Report","row_id":1870851,"text":"NNP Physical Exam\nPE: pink, mild jaundice, AFOF, breath sounds clear/equal with mild retracting, no murmur, abd soft, active with good tone.\n"},{"category":"Nursing/other","chartdate":"2105-12-09 00:00:00.000","description":"Report","row_id":1870852,"text":"Nursing Progress Note\n\n\n1.O: Remains in roomair with O2 sats high 90's-100. No\nspells noted. Breath sounds clear and equal.\n A: Resolving resp issues.\n P: Continue to monitor.\n2.O: Weight 2605gms down 110gms. IV running at 30cc/kg then\nhep locked at 0100. DS 75 and 77. Voided only 23 and 8cc's.\nAbdomen soft and flat. Good bowel sounds. Mom attempted to\nnurse infant and infant didn't even latch on. Infant bottled\n10cc's of BM instead. Woke for next feed. Bottled 12cc's of\nBM. Mom doesn't want infant to get formula. Blood work\ndrawn. IV antibiotics dc'ed this shift.\n A: Infant not voiding in large amounts. Color jaundiced.\n P: Monitor I&O's. Call Mom when infant wants to nurse. \n is high, discuss with the Mom the need for more fluids.\nMonitor weight. Monitor for s&s of sepsis.\n3.O: Waking for feeds. Active and alert for car4es. Infant\nbecomes sleepy when Mom wants to nurse him. Sucking on\npacifier intermittently. Temp stable in crib.\n A: Needs to improve on nursing.\n P: Continue to monitor.\n4.O: Mom came up to feed her baby. She was very comfortable\nwith trying to nurse him. She stated that she was tired and\nwouldn't be up for the 4AM feeding.\n A: Mom.\n P: Inform and support. Call Mom when the infant is ready\nto eat.\n\n\n"},{"category":"Nursing/other","chartdate":"2105-12-09 00:00:00.000","description":"Report","row_id":1870853,"text":"Neonatology Attending Progress Note:\nDOL #2\nremains in RA, no desats.\nHR=130-150's, no murmur,\nad lib BF, off IVF, dstx=68-77\n=10.8\noff antibiotics\nHSV surface cultures pending\nlytes: 145/5.5/110/21/10/0.4\nImp/Plan: premie infant with perinatal depression, resolving lung disease, s/p r/o sepsis\n--check HSV cultures\n--continue ad lib feeds\n--continue rest of present management\n"},{"category":"Nursing/other","chartdate":"2105-12-09 00:00:00.000","description":"Report","row_id":1870854,"text":"Neonatology NP Discharge Physical\n\nswaddled in open crib\nAFOf, sutures approximated\n+ bilateral red reflex, small amount of white eye drainage from left eye\noral mucosa without lesions\nneck supple and without masses\nclavicles intact\ncomfortable respirations in room air, lungs clear/=\nRRR, no murmur, pink and well perfused, femoral pulses present\nabdomen soft, nontender and nondistended, active bowel sounds, cord on/dry, jaundiced to lower extremiites\ntestes descended bilaterally\nno sacral anomalies\nstable hip exam, normal digits and creases\nactive with age appropriate tone and reflexes\n"},{"category":"Nursing/other","chartdate":"2105-12-09 00:00:00.000","description":"Report","row_id":1870855,"text":"Nursing Transfer Note\n\n\nInfant remains in room air with sats >95, lungs clear and\nequal, RR40-60's. D-stick this AM 68, nursing well. Temp\nin open crib 97.8-97.9 axillary. Wakes for feedings, feeds\n10 minutes. Parents visiting frequently. sent this AM\n10.8/0.3. A. 36 weeker ready for transfer to regular\nnursery. P. Feed q3hrs, if infant does not nurse well feed\nbottle. in AM.\n\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2105-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1870841,\n \"text\": \"Neonatology Attending\\n\\n2630 gram 36 week male admitted s/p perinatal depression\\n\\n2630 gram 36 week male born to a 42 yo G1 P0->1 white female\\nPNS: B+/Ab-/RPR NR/RI/HBsAg-/GBS-\\nUncomplicated pregnancy. h/o recurrent herpes on valtrex. ROM 9.5 hrs ptd. Presented to L&D after midnight (>7 hrs after ROM). Active herpes lesions noted. Taken to C/S under combined epidural/spinal anesthesia. Cord prolapsed through incision. Head needed to be pushed up. Infant depressed (floppy, HR <100, no resp effort) requiring BMV, vigorous stimulation then intubation by SNP under my supervision. Floppy with poor perfusion and slow to pink up. Briefly shown to parents. To NICU with bagging. Apgars 1/3/4/8.\\n\\nExam Near term male orally intubated with beginnings of spontaneous respiratory effort, poor tone\\nT 97.5 P 184 R bagging BP 68/54 mean 60 O2 sat 95%\\nWt 2630 grams (~50%) Lt 51 cm (~90%) HC 32 cm (~40%)\\nAF soft, flat, nondysmorphic, intact palate, gradually increasing spontaneous respirations, coarse bs, clearing after suctioning, no murmur, soft abd, 3 vessel cord, no hsm, normal male genitalia, testes descended into scrotum, no hip click, patent anus, no sacral dimple, poor tone but activity and tone increasing over first 15 minutes in NICU, no evidence of seizure activity, no skin lesions (examined scalp, extremities, trunk, genitalia closely), mmm, no mucosal lesions seen, slow capillary refill\\n\\nOver course of ~15 minutes in NICU spontaneous respirations increased, progressed from bagging to CPAP to extubation\\n\\nDS 210\\n\\nA: 36 week male s/p perinatal depression likely secondary to volume depletion and cord prolapse. At risk for sequelae. At risk for HSV secondary to recurrent maternal HSV infection with active lesions and ROM >4 hrs before C/S delivery. Infant has no lesions. Must also rule out sepsis in light of difficult start.\\n\\nP: Monitor\\n O2 as needed\\n NS bolus\\n NPO with IV fluids\\n Usual attention to lytes and DS\\n Follow UO closely\\n CBC, BC\\n A/G for R/O sepsis\\n Check gent levels before 2nd dose\\n Check BUN, Cr, LFTs to monitor for end organ effect\\n Surface cultures (, NP, rectal) for herpes in 24-48 hours\\n Hold acyclovir unless he develops lesions or has positive culture\\n Support parents\\n Pediatrician is \\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2105-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1870842,\n \"text\": \"Neonatology NP Procedure Note\\n\\nEndotracheal Intubation\\nIndication: Respiratory failure\\n3.5 ETT passed orally through cords under direct larygonscopy. Tube secured with tape at 9.5 at upper lip. Good chest wall movement and equal breath sounds present. Tolerated procedure well. No complications.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2105-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1870847,\n \"text\": \"Nursing Progress Note 1900-0700\\n\\n\\nResp:Infant remains in RA saturating 96-100%.RR mainly\\n50-60's however noted transient tachypnea with RR 80-100.LS\\nremain clear equal with sc retractions.No A's and B's or\\ndesats thus far.\\n\\nF/E/N:Infant cont's on TF 40cc's/kg/day.IVF D10 infusing at\\n4.5cc's/hr in L hand.Site intact.Mom did attempt to breast\\nfeed x 1.Infant did latch but tired easily.D\\nsick=96/67.Weight=2.715kg up 85 grams.Abd soft and flat with\\npos bs,no loops or spits,girth=26.UO=1.2cc's/kg/day over 12\\nhrs.Noted trace mec. stool.\\n\\nG/D:AF soft and flat.Alert and active with cares.Infant\\nremains on Warmer with nested boundaries.MAE.Bringing hands\\nto face and mouth.\\n\\nParenting:Parents in tonight updated by NNP \\n.Parents asking appropriate questions very loving and\\ninvested.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2105-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1870848,\n \"text\": \"Addendum:Infant cont's on IV Ampi and Gent.Gent levels drawn and presently pnd'ing.HSV CX sent along with lytes,bili,LFT'S,BUN and Cr presently pnd'ing.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2105-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1870849,\n \"text\": \"Neonatology\\nDOL #1, CGA 36 wks.\\n\\nCVR: Remains in RA, O2sats 99-100%. RR 50-60s, mild intermittent retractions, overall comfortable. Hemodynamically stable. No murmur. No spells.\\n\\nFEN: Lytes 140/4.4/104/22. BUN/Cr 13/1.0. Breast-fed several times overnight, with good latch. On IVF D10W at 40 cc/kg/day. Dstiks 96, 67. Urine output now increasing. Passing stool.\\n\\nGI: LFTS: AP 101, AST 87, ALT 21.\\n\\nID: On amp/gent. Gent levels with 2nd dose: 1.3/8.2. HSV surface swabs sent yesterday.\\n\\nDEV: Now wrapped in off-warmer, temp stable.\\n\\nIMP: 1 day old infant with neonatal depression, overall appears to be rapidly improving. Extubated rapidly, now comfortable in RA. Tolerating breast-feeding. Urine output improving, although creatinine mildly elevated at 24 hrs.\\n\\nPLANS:\\n- Continue monitoring of room air.\\n- Allow to ad lib feed, wean IVF as able.\\n- Monitor urine output, repeat chem 7 in am.\\n- D/c amp/gent at 48 hrs if cx negative.\\n- Monitor neuro exam.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2105-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1870843,\n \"text\": \"Admission Note\\n\\n\\nPt admitted to NICU for decr resp effort. Please see\\nattending note for further details. Pt intub in DR no\\nresp effort. Infant was able to be extubated to RA approx\\n15min after transfer to NICU. RR 30-50s, LS clear bilat.,\\nmild SC retractions noted at times; resolving. O2 sats\\n95-100%. ABG drawn at 0430: 7.36/30/129/18/-6. No murmur\\nauscultated. HR 140-180s, BP means stable (42-60). BW\\n2630g. Pt NPO. 30cc NS bolus given at 0300 for volume\\nexpansion. PIV placed L hand, patent and infusing D10W at\\n60cc/k/day. Initial DS= 210, 186 at 0400. Abd flat, soft,\\nhypo BS. DTV/DTS. CBC and BC drawn. WBC 34.3, 32P, 4B,\\n43L. HCT 47, PLT 282. Pt started on Amp and gent for 48hr\\nr/o sepsis. Gent levels to be drawn at 2nd dose. Surface\\nswab for HSV to be done at 24H age. Baby meds given. Pt on\\nopen warmer, temps stable. Infant more alert, active,\\nbetter perfusion and cap refill. Rooting to hands. Parents\\nin briefly with L&D RN. Updated by this RN. Asking approp\\nquestions. Oriented to unit. Encouraged parents to rest\\nand visit later. Continue to support and update as needed.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2105-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1870844,\n \"text\": \"Neonatology Attending - Progress Note\\n\\nNow 7 hours of life for this infant with neonatal depression.\\nBaby's respiratory status much improved - breathing comfortably in RA. O2 sats - 95-100%\\nRR 30-50s.\\n\\nABG - 7.36/30/129 at 4:30 this morning.\\nHR 140-180s BP 61/44 49\\n\\nWt. 2630gm - on 60ml/kg/d of IV D10W.\\nNPO\\nNo urine or stool output yet.\\n\\nDS 210 at birth - then 186 - 72 this morning.\\n\\nID -\\nMother noted to have a herpes lesion on her thigh 1 month ago and has been treated with Valtrex for the past month. Noted to have active lesions in the vaginal region just prior to delivery.\\nBaby has no lesions.\\n\\nwbc 34,300 32P 4B 43L plat 282,000 Hct 47%\\nOn amp and gent\\n\\nAssessment/plan:\\n36 week gestation infant with perinatal depression most likely secondary to prolapsed cord - much improved now.\\nAt increased risk for HSV infection - will check surface cultures at 24 hours. If baby develops any suspicious skin lesions or other signs of infection will initiate therapy with acyclovir.\\n\\nAmpicillin and gentamicin therapy to continue for at least 48 hours.\\nFU cbc planned to follow hight white count.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2105-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1870845,\n \"text\": \"Case Management Note\\nChart reviewed and events noted. I will place EIP & VNA options in record. I will be providing clinical updates to insurance and will assist w/any d'c planning needs along with team & family\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2105-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1870846,\n \"text\": \"NPN 0700-1500\\n\\n\\n#1 O: Infant remains in RA. RR 40's-70's with mild SC\\nretractions. LS clear and =. O2 sats 99-100%. No spells. A:\\nStable in RA. P: Cont to monitor.\\n\\n#2 O: TF= 60cc/kg/d. Infant receiving IVF of D10 infusing\\nvia PIV. Abdomen benign; voiding only 3cc's so far this\\nshift since birth. No stool as yet. DS 72-109. Hypoactive\\nBS. Mom would like to BF. A: NPO. P: Cont to monitor.\\n\\n#3 O: Maintaining temp on open warmer set in servo. Awake\\nand alert with cares; opening eyes and crying when\\ndisturbed; otherwise sleeping between cares. AFSF. Nested\\nwith boundaries in place. A: AGA. P: Cont to support\\ndevelopment.\\n\\n#4 O: Both parents in to visit. Asking appropriate\\nquestions. Mom pretty tired from delivery. A: Involved. P:\\nCont to support and update.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2105-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1870850,\n \"text\": \"Nursing Progress Note\\n\\n\\n1. In room air with sats >95 consistently. No desats or\\nbradys. Lungs clear and equal, well aerated. Mild\\nintercostal retractions, RR40's-50's. A. No distress. P.\\nMonitor.\\n2. Total fluids at 60cc/kg/d IV/po. IV D10 running well in\\nLhand, site soft, pink. Nursed several times today thus\\nfar, latches on well and sucks vigorously for 5-10 minutes.\\nNo bottles offered yet but will offer one after this nursing\\nsession. Urine output significantly increased,\\n30-35cc/diaper change. Abdomen soft with good bowel sounds,\\npassing meconium now. A. Working up on po feedings,\\nnursing well. P. Offer pc bottles, wean IV and monitor\\nd-sticks.\\n3. Awake and alert with feedings, nursing well. Temp\\nstable on warmer, swaddled with hat and 2 blankets. A.\\nDevelopmentally appropriate. P. Support.\\n4. Mom up for feedings today, nursing and handling baby\\nwell. Did diaper change and temp. A. Mom loving and\\ninvolved. Support.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2105-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1870851,\n \"text\": \"NNP Physical Exam\\nPE: pink, mild jaundice, AFOF, breath sounds clear/equal with mild retracting, no murmur, abd soft, active with good tone.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2105-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1870852,\n \"text\": \"Nursing Progress Note\\n\\n\\n1.O: Remains in roomair with O2 sats high 90's-100. No\\nspells noted. Breath sounds clear and equal.\\n A: Resolving resp issues.\\n P: Continue to monitor.\\n2.O: Weight 2605gms down 110gms. IV running at 30cc/kg then\\nhep locked at 0100. DS 75 and 77. Voided only 23 and 8cc's.\\nAbdomen soft and flat. Good bowel sounds. Mom attempted to\\nnurse infant and infant didn't even latch on. Infant bottled\\n10cc's of BM instead. Woke for next feed. Bottled 12cc's of\\nBM. Mom doesn't want infant to get formula. Blood work\\ndrawn. IV antibiotics dc'ed this shift.\\n A: Infant not voiding in large amounts. Color jaundiced.\\n P: Monitor I&O's. Call Mom when infant wants to nurse. \\n is high, discuss with the Mom the need for more fluids.\\nMonitor weight. Monitor for s&s of sepsis.\\n3.O: Waking for feeds. Active and alert for car4es. Infant\\nbecomes sleepy when Mom wants to nurse him. Sucking on\\npacifier intermittently. Temp stable in crib.\\n A: Needs to improve on nursing.\\n P: Continue to monitor.\\n4.O: Mom came up to feed her baby. She was very comfortable\\nwith trying to nurse him. She stated that she was tired and\\nwouldn't be up for the 4AM feeding.\\n A: Mom.\\n P: Inform and support. Call Mom when the infant is ready\\nto eat.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2105-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1870853,\n \"text\": \"Neonatology Attending Progress Note:\\nDOL #2\\nremains in RA, no desats.\\nHR=130-150's, no murmur,\\nad lib BF, off IVF, dstx=68-77\\n=10.8\\noff antibiotics\\nHSV surface cultures pending\\nlytes: 145/5.5/110/21/10/0.4\\nImp/Plan: premie infant with perinatal depression, resolving lung disease, s/p r/o sepsis\\n--check HSV cultures\\n--continue ad lib feeds\\n--continue rest of present management\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2105-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1870854,\n \"text\": \"Neonatology NP Discharge Physical\\n\\nswaddled in open crib\\nAFOf, sutures approximated\\n+ bilateral red reflex, small amount of white eye drainage from left eye\\noral mucosa without lesions\\nneck supple and without masses\\nclavicles intact\\ncomfortable respirations in room air, lungs clear/=\\nRRR, no murmur, pink and well perfused, femoral pulses present\\nabdomen soft, nontender and nondistended, active bowel sounds, cord on/dry, jaundiced to lower extremiites\\ntestes descended bilaterally\\nno sacral anomalies\\nstable hip exam, normal digits and creases\\nactive with age appropriate tone and reflexes\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2105-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1870855,\n \"text\": \"Nursing Transfer Note\\n\\n\\nInfant remains in room air with sats >95, lungs clear and\\nequal, RR40-60's. D-stick this AM 68, nursing well. Temp\\nin open crib 97.8-97.9 axillary. Wakes for feedings, feeds\\n10 minutes. Parents visiting frequently. sent this AM\\n10.8/0.3. A. 36 weeker ready for transfer to regular\\nnursery. P. Feed q3hrs, if infant does not nurse well feed\\nbottle. in AM.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":24680,"cells":{"subject_id":{"kind":"number","value":3999,"string":"3,999"},"hadm_id":{"kind":"number","value":104816,"string":"104,816"},"target_text":{"kind":"string","value":"1. Apparent seizure - The patient as mentioned was loaded on fosphenytoin 1 gm and started no Keppra 500 mg p.o. b.i.d. She was monitored closely in the Intensive Care Unit and extubated on . She did also receive 1 dose of Ceftriaxone prophylactically as she was having fevers. This was thought to be aspiration pneumonia by chest x-ray done on . She was started on Levofloxacin and Flagyl. She did well over night and was transferred to the floor on . At the time of the transfer, she denied any major complaints and was talking fluently. She had amnesia for the event and was somewhat confused about to where she was but she was oriented to time. Review of systems was negative for shortness of breath, cough, abdominal pain, nausea, vomiting or diarrhea. As mentioned she was started on Keppra 500 mg p.o. b.i.d. and increased to 1 gm p.o. b.i.d. She was discontinued off of Neurontin. She will be continued on Dilantin and Keppra together. 2. Pneumonia - She completed the seven day course of Levofloxacin and Flagyl. 3. With the history of myocardial infarction she was ruled out with enzymes. She was kept on her Aspirin and statin. 4. Diabetes monitoring - The patient should have a hemoglobin A1c done by her primary care physician."},"extractive_notes_summ":{"kind":"string","value":"TEMP 100.4 ORALLY, WBC CAME DOWN SLIGHTLY THIS AM. SXTED FOR NOTHING.GI/GU: ABD SOFT WITH +BS. IMPRESSION: Mild cardiomegaly with interstitial edema. Sx for small amt thin sputum.ID: CXR questionable pna (per team). MICU NPN 3A-7ANEURO: RECEIVED PATIENT ON LOW DOSE PROPOFOL, PT RESTLESS. Low grade temp, tmax 100.6 PO start of shift.C/V: HR 80-90s SR, no ectopy. TECHNIQUE: Multiple axial images of the head were obtained without IV contrast. The previously described focal lineare atelectasis at the left base appears unchanged. After administration of gadolinium intravenous contrast, axial and coronal short TR, short TE spin echo imaging was performed. There is mild periventricular and subcortical white matter hyperintensity on the long TR images suggesting chronic small vessel ischemia. Lopressor d/c'd. FOLLOWS COMMANDS, MAE WELL, NO SEIZURE ACTIVITY OVERNIGHT. IMPRESSION: No acute intracranial hemorrhage. OGT IN PLACE WITH BILIOUS ASPIRATES, OB-. Sinus rhythm, without diagnostic abnormality. The patient has been intubated during the interval and the NG tube has been removed. No overt CHF. SUPINE AP CHEST RADIOGRAPH: The ET tube is slightly low, approximately 1.5 cm above the carina. Foley patent for CYU, quantities sufficient. The ventricles, cisterns and sulci are slightly prominent consistent with age related atrophy. The heart and mediastinal contours are unchanged with no overt CHF. She is on small amount of propofol and is awaiting of EEG prior to extubation planned for today. IMPRESSION: Satisfactory position of ET tube with no significant changes. Comparison to a head CT of . U/O 16-80CC/HR YELLOW AND CLEAR.ID: TMAX 101.4 RECTALLY DOWN TO 100.3. NO SEIZURE ACTIVITY NOTED.CARDIAC: HR 85-91 SR WITH NO ECTOPY. ONCE PATIENT UNDER CONTROL WITH PROPOFOL, EXAM WAS UNCHANGED OTHER THAN SHE WOULD NOT OPEN EYES. Incidentally noted is a small infundibulum at the origin of the left posterior communicating artery. FINDINGS: There is no acute intra or extra-axial hemorrhage. NOT OVERBREATHING VENT. IMPRESSION: ET tube slightly low. GAG IMPAIRED, COUGH INTACT. FINDINGS: There is no evidence of acute infarction. ONE ADDITIONAL SET OF BLD CX'S SENT.SKIN: INTACT.ACCESS: PIV X2.SOCIAL/DISPO: FULL CODE. CONCLUSION: No evidence of infarction. Patient placed back on propofol gtt at 25mcg/kg/min. PORTABLE CHEST: The cardiac silhouette is at the upper limits of normal for size and there is bilateral interstitial edema. Nursing Process Note: 0700-1900NEURO: Received patient lightly sedated on Propofol gtt 25mcg/kg/min. The MRA demonstrates a normal appearance of the internal carotid arteries, distal vertebral arteries, basilar artery and their major branches. The grey/white matter differentiation is preserved. Technical quality of today's film is less high most likely related to some motion blurring secondary to patient's inability to hold respiration. Abdomen soft, present sounds. SX FOR MOD AMT'S OF THICK WHITE SECRETIONS, LUNG SOUNDS COARSE THROUGHOUT. Now off in plan to extubate; awaiting definitive results of EEG before extubation. The partially visualized paranasal sinuses are clear. Respiratory Care Note: Patient remains intubated at this time and is spontaneously breathing with good tidal volumes and respiratory rate. 4:59 PM MR HEAD W & W/O CONTRAST; MR-ANGIO HEAD Clip # MR CONTRAST GADOLIN Reason: H/O SEIZURES, ? should extubate in AM There are no significant pleural effusions. pt.on ac ventilation for the noc, at 0400 pt put on spont.breathing trial and tol.well, propofol being weaned, rsbi 50, abg within acceptable range, bs coarse, sx for white to clear secretion, plan is to extubate in a.m. SATS 100%, LS RHONCHEROUS. Currently has OGT patent for PO meds. THEN PLACED ON PRESSURE SUPPORT THIS AM. The lungs are better expanded on the current film and there has been a decrease in the amount of the left lower lobe atelectasis. IMPRESSION: 1) No evidence of parenchymal infiltrates such as aspiration pneumonia during latest one day interval. 3:39 PM CT HEAD W/O CONTRAST Clip # Reason: sudden o/s of L weakness and shaking - poss stroke - eval fo MEDICAL CONDITION: 77 year old woman with sz hx, hx MI REASON FOR THIS EXAMINATION: sudden o/s of L weakness and shaking - poss stroke - eval for bleed No contraindications for IV contrast WET READ: SMLe TUE 4:59 PM no acute bleed. NG tube tip is in the distal stomach. FINDINGS: The AP single view chest film obtained with patient in semi erect position is analyzed in direct comparison with similar study obtained one day earlier. Comparison is made to prior chest x-ray on . Sagittal and axial short TR, short TE spin echo imaging was performed through the brain. ON LOPRESSOR. SBP 100s. CONT ON PROPOFOL AT 25MCQ'S. Axial imaging was performed with long TR, long TE fast spin echo technique, FLAIR technique, gradient echo technique and technique. NURSING PROGRESS NOTE:REMAINS INTUB/VENTED ON A/C TO REST OVERNIGHT. BP 112-124/49-57. There is retrocardiac opacity in the left lower lobe. This measures approximately 2 mm in greatest dimension. There is persistent linear atelectasis in the left lower lobe. No previous tracing available forcomparison. Heart size is mildly enlarged. The ventricles and sulci are prominent in an atrophic pattern. Slurred speech. There is an NG tube present in satisfactory position. There are no new consolidations. LS coarse, sats consistently high 90s-100%. ABD SOFT WITH BOWEL SOUNDS, NO STOOL BUT PASSING FLATUS.GU: FOLEY CATH PATENT DRAINING ADEQUATE AMT'S OF CLEAR YELLOW URINE.IV FLUID CONT AT 100/HR NS WITH 20KCL.DAUGHTER CALLED DURING NIGHT AND WAS UPDATED.PT IS FULL CODE. BREATHING IN TEENS TO TWENTIES.GI: OGT CLAMPED AND DRAINING BILIOUS ASPIRATES WHEN PLACED TO SX."},"n_notes":{"kind":"number","value":14,"string":"14"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2173-02-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":815792,"text":" 7:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumonia\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with fever, seizure, concern for aspiration.\n\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77 year-old woman, evaluate for pneumonia. The patient has fever\n and seizures.\n\n COMPARISON: .\n\n PORTABLE CHEST: The cardiac silhouette is at the upper limits of normal for\n size and there is bilateral interstitial edema. The lungs are better expanded\n on the current film and there has been a decrease in the amount of the left\n lower lobe atelectasis. There are no new consolidations. There are no\n significant pleural effusions.\n\n IMPRESSION: Mild cardiomegaly with interstitial edema.\n\n\n"},{"category":"Radiology","chartdate":"2173-02-17 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":815599,"text":" 12:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pna ETT placment\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with fever, seizure\n\n REASON FOR THIS EXAMINATION:\n ?pna ETT placment\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever and seizure, ET placement.\n\n Comparison is made to prior chest x-ray on .\n\n AP CHEST: There is an ET tube present with the tip terninating approximately\n 3 cm above the carina. There is an NG tube present in satisfactory position.\n The heart and mediastinal contours are unchanged with no overt CHF. There is\n persistent linear atelectasis in the left lower lobe.\n\n IMPRESSION: Satisfactory position of ET tube with no significant changes.\n\n"},{"category":"Radiology","chartdate":"2173-02-16 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":815489,"text":" 3:39 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: sudden o/s of L weakness and shaking - poss stroke - eval fo\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with sz hx, hx MI\n REASON FOR THIS EXAMINATION:\n sudden o/s of L weakness and shaking - poss stroke - eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SMLe TUE 4:59 PM\n no acute bleed.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77 y/o woman with seizures and left sided weakness and shaking.\n\n TECHNIQUE: Multiple axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: There is no acute intra or extra-axial hemorrhage. There is no\n mass effect or shift of normally midline structures. The ventricles, cisterns\n and sulci are slightly prominent consistent with age related atrophy. The\n grey/white matter differentiation is preserved. The partially visualized\n paranasal sinuses are clear. Bone windows demonstrate no fractures.\n\n IMPRESSION:\n\n No acute intracranial hemorrhage. If there is a clinical suspicion for\n stroke, MR is more sensitive for detecting this condition.\n\n"},{"category":"Radiology","chartdate":"2173-02-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":815738,"text":" 2:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumonia\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with fever, seizure, concern for aspiration.\n\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, seizure, concerns for aspiration. Evaluate for\n infiltrates.\n\n FINDINGS: The AP single view chest film obtained with patient in semi erect\n position is analyzed in direct comparison with similar study obtained one day\n earlier. The patient has been intubated during the interval and the NG tube\n has been removed. There is no pneumothorax or any other complication related\n to instrument removal. Technical quality of today's film is less high most\n likely related to some motion blurring secondary to patient's inability to\n hold respiration. There is, however, no evidence of any new parenchymal\n infiltrate or significant pulmonary vascular congestion. The previously\n described focal lineare atelectasis at the left base appears unchanged.\n\n IMPRESSION:\n\n 1) No evidence of parenchymal infiltrates such as aspiration pneumonia during\n latest one day interval.\n\n"},{"category":"Radiology","chartdate":"2173-02-16 00:00:00.000","description":"MR HEAD W & W/O CONTRAST","row_id":815507,"text":" 4:59 PM\n MR HEAD W & W/O CONTRAST; MR-ANGIO HEAD Clip # \n MR CONTRAST GADOLIN\n Reason: H/O SEIZURES, ? MASS\n Contrast: MAGNEVIST Amt: 14\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with hx of MI and SZ\n REASON FOR THIS EXAMINATION:\n 2:45 pm - sudden o/s of L sided paralysis and L facial droop with slurred\n speech - followed by tremors STROKE PROTOCOL - with DWI\n ______________________________________________________________________________\n FINAL REPORT\n MRI/MRA OF THE BRAIN:\n\n HISTORY: Seizures and sudden onset of left sided paralysis and left facial\n droop. Slurred speech.\n\n Sagittal and axial short TR, short TE spin echo imaging was performed through\n the brain. Axial imaging was performed with long TR, long TE fast spin echo\n technique, FLAIR technique, gradient echo technique and technique.\n 3D TOF MRA was performed through the brain. After administration of\n gadolinium intravenous contrast, axial and coronal short TR, short TE spin\n echo imaging was performed. Comparison to a head CT of .\n\n FINDINGS: There is no evidence of acute infarction. The ventricles and sulci\n are prominent in an atrophic pattern. There is mild periventricular and\n subcortical white matter hyperintensity on the long TR images suggesting\n chronic small vessel ischemia. There is no evidence of hemorrhage, edema,\n masses, or mass effect.\n\n The MRA demonstrates a normal appearance of the internal carotid arteries,\n distal vertebral arteries, basilar artery and their major branches.\n Incidentally noted is a small infundibulum at the origin of the left posterior\n communicating artery. This measures approximately 2 mm in greatest dimension.\n\n CONCLUSION:\n\n No evidence of infarction.\n\n"},{"category":"Radiology","chartdate":"2173-02-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":815501,"text":" 4:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p intubation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p intubation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubation.\n\n SUPINE AP CHEST RADIOGRAPH: The ET tube is slightly low, approximately 1.5 cm\n above the carina. NG tube tip is in the distal stomach. Heart size is mildly\n enlarged. No overt CHF. There is retrocardiac opacity in the left lower\n lobe.\n\n IMPRESSION: ET tube slightly low.\n\n ET Tube position was called to Dr. at 5:05 PM on .\n\n"},{"category":"Nursing/other","chartdate":"2173-02-17 00:00:00.000","description":"Report","row_id":1314735,"text":"Nursing Process Note: 0700-1900\nNEURO: Received patient lightly sedated on Propofol gtt 25mcg/kg/min. Now off in plan to extubate; awaiting definitive results of EEG before extubation. MAE, agitated at times but able to redirect. Following commands inconsistently. Family at bedside good part of shift. No seizure activity noted today.\n\nRESP: Continues on CPAP 5/5/Fio2 40%; TVs 350 as of 1700. LS coarse, sats consistently high 90s-100%. Sx for small amt thin sputum.\n\nID: CXR questionable pna (per team). Low grade temp, tmax 100.6 PO start of shift.\n\nC/V: HR 80-90s SR, no ectopy. SBP 100s. Lopressor d/c'd. Maintenance fliud NS with 20Kcl @ 100/hr.\n\nGI/GU: NPO. Currently has OGT patent for PO meds. Abdomen soft, present sounds. Foley patent for CYU, quantities sufficient. No BM today.\n\nSOCIAL: Family supportive, visiting most of day. Brought personal belongings home.\n\nPLAN: Question extubation; awaiting results of EEG\n Monitor temp\n Monitor for sz activity\n\n\n\n"},{"category":"Nursing/other","chartdate":"2173-02-17 00:00:00.000","description":"Report","row_id":1314736,"text":"Nursing Addendum: 0700-1900\nWill not extubate patient this eve, rather, will rest overnight on , RSBI in AM and plan to extubate tomorrow. Patient placed back on propofol gtt at 25mcg/kg/min.\n"},{"category":"Nursing/other","chartdate":"2173-02-18 00:00:00.000","description":"Report","row_id":1314737,"text":"pt.on ac ventilation for the noc, at 0400 pt put on spont.breathing trial and tol.well, propofol being weaned, rsbi 50, abg within acceptable range, bs coarse, sx for white to clear secretion, plan is to extubate in a.m.\n"},{"category":"Nursing/other","chartdate":"2173-02-18 00:00:00.000","description":"Report","row_id":1314738,"text":"NURSING PROGRESS NOTE:\nREMAINS INTUB/VENTED ON A/C TO REST OVERNIGHT. THEN PLACED ON PRESSURE SUPPORT THIS AM. SX FOR MOD AMT'S OF THICK WHITE SECRETIONS, LUNG SOUNDS COARSE THROUGHOUT. CONT ON PROPOFOL AT 25MCQ'S. FOLLOWS COMMANDS, MAE WELL, NO SEIZURE ACTIVITY OVERNIGHT. HAVE NOT SEEN ANY TREMORS. PT VERY RESTLESS WHEN AWAKE, PT RESTRAINED AND CONT TO ATTEMPT TO CLIMB OUT OF BED.\nCV: HR NSR TO ST NO ECTOPY, BP STABLE SEE FLOWSHEET FOR DATA. TEMP 100.4 ORALLY, WBC CAME DOWN SLIGHTLY THIS AM. BREATHING IN TEENS TO TWENTIES.\nGI: OGT CLAMPED AND DRAINING BILIOUS ASPIRATES WHEN PLACED TO SX. ABD SOFT WITH BOWEL SOUNDS, NO STOOL BUT PASSING FLATUS.\nGU: FOLEY CATH PATENT DRAINING ADEQUATE AMT'S OF CLEAR YELLOW URINE.\nIV FLUID CONT AT 100/HR NS WITH 20KCL.\nDAUGHTER CALLED DURING NIGHT AND WAS UPDATED.\nPT IS FULL CODE.\n"},{"category":"Nursing/other","chartdate":"2173-02-17 00:00:00.000","description":"Report","row_id":1314732,"text":"MICU NPN 3A-7A\nNEURO: RECEIVED PATIENT ON LOW DOSE PROPOFOL, PT RESTLESS. INITIAL ASSESSMENT PATINT WOULD OPEN EYES AND FOLLOW COMMANDS INCONSISTENTLY. MOVING ALL EXTREMITIES PURPOSEFULLY. PERL @3MM AND BRISK. ONCE PATIENT UNDER CONTROL WITH PROPOFOL, EXAM WAS UNCHANGED OTHER THAN SHE WOULD NOT OPEN EYES. GAG IMPAIRED, COUGH INTACT. NO SEIZURE ACTIVITY NOTED.\n\nCARDIAC: HR 85-91 SR WITH NO ECTOPY. BP 112-124/49-57. ON LOPRESSOR. PPP. LABS PER CAREVUE.\n\nRESP: ON A/C 500X16 60% +5 PEEP. NO ALINE TO DRAW ABG. NOT OVERBREATHING VENT. SATS 100%, LS RHONCHEROUS. SXTED FOR NOTHING.\n\nGI/GU: ABD SOFT WITH +BS. NO STOOL. NPO. OGT IN PLACE WITH BILIOUS ASPIRATES, OB-. U/O 16-80CC/HR YELLOW AND CLEAR.\n\nID: TMAX 101.4 RECTALLY DOWN TO 100.3. WBC 14.6 UP FROM 8.2 IN THE ER. ONE ADDITIONAL SET OF BLD CX'S SENT.\n\nSKIN: INTACT.\n\nACCESS: PIV X2.\n\nSOCIAL/DISPO: FULL CODE. SPOKE BRIEFLY WITH PT'S DAUGHTER. PLAN IS TO EXTUBATE THIS MORNING.\n"},{"category":"Nursing/other","chartdate":"2173-02-17 00:00:00.000","description":"Report","row_id":1314733,"text":"pt intubated for airway for airway protection during seizure activity. should extubate in AM\n"},{"category":"Nursing/other","chartdate":"2173-02-17 00:00:00.000","description":"Report","row_id":1314734,"text":"Respiratory Care Note:\n Patient remains intubated at this time and is spontaneously breathing with good tidal volumes and respiratory rate. She is on small amount of propofol and is awaiting of EEG prior to extubation planned for today.\n"},{"category":"ECG","chartdate":"2173-02-16 00:00:00.000","description":"Report","row_id":187055,"text":"Sinus rhythm, without diagnostic abnormality. No previous tracing available for\ncomparison.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-02-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 815792,\n \"text\": \" 7:29 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for pneumonia\\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old woman with fever, seizure, concern for aspiration.\\n\\n REASON FOR THIS EXAMINATION:\\n evaluate for pneumonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 77 year-old woman, evaluate for pneumonia. The patient has fever\\n and seizures.\\n\\n COMPARISON: .\\n\\n PORTABLE CHEST: The cardiac silhouette is at the upper limits of normal for\\n size and there is bilateral interstitial edema. The lungs are better expanded\\n on the current film and there has been a decrease in the amount of the left\\n lower lobe atelectasis. There are no new consolidations. There are no\\n significant pleural effusions.\\n\\n IMPRESSION: Mild cardiomegaly with interstitial edema.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-02-17 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 815599,\n \"text\": \" 12:36 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?pna ETT placment\\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old woman with fever, seizure\\n\\n REASON FOR THIS EXAMINATION:\\n ?pna ETT placment\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Fever and seizure, ET placement.\\n\\n Comparison is made to prior chest x-ray on .\\n\\n AP CHEST: There is an ET tube present with the tip terninating approximately\\n 3 cm above the carina. There is an NG tube present in satisfactory position.\\n The heart and mediastinal contours are unchanged with no overt CHF. There is\\n persistent linear atelectasis in the left lower lobe.\\n\\n IMPRESSION: Satisfactory position of ET tube with no significant changes.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-02-16 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 815489,\n \"text\": \" 3:39 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: sudden o/s of L weakness and shaking - poss stroke - eval fo\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old woman with sz hx, hx MI\\n REASON FOR THIS EXAMINATION:\\n sudden o/s of L weakness and shaking - poss stroke - eval for bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: SMLe TUE 4:59 PM\\n no acute bleed.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 77 y/o woman with seizures and left sided weakness and shaking.\\n\\n TECHNIQUE: Multiple axial images of the head were obtained without IV\\n contrast.\\n\\n FINDINGS: There is no acute intra or extra-axial hemorrhage. There is no\\n mass effect or shift of normally midline structures. The ventricles, cisterns\\n and sulci are slightly prominent consistent with age related atrophy. The\\n grey/white matter differentiation is preserved. The partially visualized\\n paranasal sinuses are clear. Bone windows demonstrate no fractures.\\n\\n IMPRESSION:\\n\\n No acute intracranial hemorrhage. If there is a clinical suspicion for\\n stroke, MR is more sensitive for detecting this condition.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-02-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 815738,\n \"text\": \" 2:15 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for pneumonia\\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old woman with fever, seizure, concern for aspiration.\\n\\n REASON FOR THIS EXAMINATION:\\n evaluate for pneumonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Fever, seizure, concerns for aspiration. Evaluate for\\n infiltrates.\\n\\n FINDINGS: The AP single view chest film obtained with patient in semi erect\\n position is analyzed in direct comparison with similar study obtained one day\\n earlier. The patient has been intubated during the interval and the NG tube\\n has been removed. There is no pneumothorax or any other complication related\\n to instrument removal. Technical quality of today's film is less high most\\n likely related to some motion blurring secondary to patient's inability to\\n hold respiration. There is, however, no evidence of any new parenchymal\\n infiltrate or significant pulmonary vascular congestion. The previously\\n described focal lineare atelectasis at the left base appears unchanged.\\n\\n IMPRESSION:\\n\\n 1) No evidence of parenchymal infiltrates such as aspiration pneumonia during\\n latest one day interval.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-02-16 00:00:00.000\",\n \"description\": \"MR HEAD W & W/O CONTRAST\",\n \"row_id\": 815507,\n \"text\": \" 4:59 PM\\n MR HEAD W & W/O CONTRAST; MR-ANGIO HEAD Clip # \\n MR CONTRAST GADOLIN\\n Reason: H/O SEIZURES, ? MASS\\n Contrast: MAGNEVIST Amt: 14\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old woman with hx of MI and SZ\\n REASON FOR THIS EXAMINATION:\\n 2:45 pm - sudden o/s of L sided paralysis and L facial droop with slurred\\n speech - followed by tremors STROKE PROTOCOL - with DWI\\n ______________________________________________________________________________\\n FINAL REPORT\\n MRI/MRA OF THE BRAIN:\\n\\n HISTORY: Seizures and sudden onset of left sided paralysis and left facial\\n droop. Slurred speech.\\n\\n Sagittal and axial short TR, short TE spin echo imaging was performed through\\n the brain. Axial imaging was performed with long TR, long TE fast spin echo\\n technique, FLAIR technique, gradient echo technique and technique.\\n 3D TOF MRA was performed through the brain. After administration of\\n gadolinium intravenous contrast, axial and coronal short TR, short TE spin\\n echo imaging was performed. Comparison to a head CT of .\\n\\n FINDINGS: There is no evidence of acute infarction. The ventricles and sulci\\n are prominent in an atrophic pattern. There is mild periventricular and\\n subcortical white matter hyperintensity on the long TR images suggesting\\n chronic small vessel ischemia. There is no evidence of hemorrhage, edema,\\n masses, or mass effect.\\n\\n The MRA demonstrates a normal appearance of the internal carotid arteries,\\n distal vertebral arteries, basilar artery and their major branches.\\n Incidentally noted is a small infundibulum at the origin of the left posterior\\n communicating artery. This measures approximately 2 mm in greatest dimension.\\n\\n CONCLUSION:\\n\\n No evidence of infarction.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-02-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 815501,\n \"text\": \" 4:25 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p intubation\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old woman with\\n REASON FOR THIS EXAMINATION:\\n s/p intubation\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Intubation.\\n\\n SUPINE AP CHEST RADIOGRAPH: The ET tube is slightly low, approximately 1.5 cm\\n above the carina. NG tube tip is in the distal stomach. Heart size is mildly\\n enlarged. No overt CHF. There is retrocardiac opacity in the left lower\\n lobe.\\n\\n IMPRESSION: ET tube slightly low.\\n\\n ET Tube position was called to Dr. at 5:05 PM on .\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-02-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1314735,\n \"text\": \"Nursing Process Note: 0700-1900\\nNEURO: Received patient lightly sedated on Propofol gtt 25mcg/kg/min. Now off in plan to extubate; awaiting definitive results of EEG before extubation. MAE, agitated at times but able to redirect. Following commands inconsistently. Family at bedside good part of shift. No seizure activity noted today.\\n\\nRESP: Continues on CPAP 5/5/Fio2 40%; TVs 350 as of 1700. LS coarse, sats consistently high 90s-100%. Sx for small amt thin sputum.\\n\\nID: CXR questionable pna (per team). Low grade temp, tmax 100.6 PO start of shift.\\n\\nC/V: HR 80-90s SR, no ectopy. SBP 100s. Lopressor d/c'd. Maintenance fliud NS with 20Kcl @ 100/hr.\\n\\nGI/GU: NPO. Currently has OGT patent for PO meds. Abdomen soft, present sounds. Foley patent for CYU, quantities sufficient. No BM today.\\n\\nSOCIAL: Family supportive, visiting most of day. Brought personal belongings home.\\n\\nPLAN: Question extubation; awaiting results of EEG\\n Monitor temp\\n Monitor for sz activity\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-02-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1314736,\n \"text\": \"Nursing Addendum: 0700-1900\\nWill not extubate patient this eve, rather, will rest overnight on , RSBI in AM and plan to extubate tomorrow. Patient placed back on propofol gtt at 25mcg/kg/min.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-02-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1314737,\n \"text\": \"pt.on ac ventilation for the noc, at 0400 pt put on spont.breathing trial and tol.well, propofol being weaned, rsbi 50, abg within acceptable range, bs coarse, sx for white to clear secretion, plan is to extubate in a.m.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-02-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1314738,\n \"text\": \"NURSING PROGRESS NOTE:\\nREMAINS INTUB/VENTED ON A/C TO REST OVERNIGHT. THEN PLACED ON PRESSURE SUPPORT THIS AM. SX FOR MOD AMT'S OF THICK WHITE SECRETIONS, LUNG SOUNDS COARSE THROUGHOUT. CONT ON PROPOFOL AT 25MCQ'S. FOLLOWS COMMANDS, MAE WELL, NO SEIZURE ACTIVITY OVERNIGHT. HAVE NOT SEEN ANY TREMORS. PT VERY RESTLESS WHEN AWAKE, PT RESTRAINED AND CONT TO ATTEMPT TO CLIMB OUT OF BED.\\nCV: HR NSR TO ST NO ECTOPY, BP STABLE SEE FLOWSHEET FOR DATA. TEMP 100.4 ORALLY, WBC CAME DOWN SLIGHTLY THIS AM. BREATHING IN TEENS TO TWENTIES.\\nGI: OGT CLAMPED AND DRAINING BILIOUS ASPIRATES WHEN PLACED TO SX. ABD SOFT WITH BOWEL SOUNDS, NO STOOL BUT PASSING FLATUS.\\nGU: FOLEY CATH PATENT DRAINING ADEQUATE AMT'S OF CLEAR YELLOW URINE.\\nIV FLUID CONT AT 100/HR NS WITH 20KCL.\\nDAUGHTER CALLED DURING NIGHT AND WAS UPDATED.\\nPT IS FULL CODE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-02-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1314732,\n \"text\": \"MICU NPN 3A-7A\\nNEURO: RECEIVED PATIENT ON LOW DOSE PROPOFOL, PT RESTLESS. INITIAL ASSESSMENT PATINT WOULD OPEN EYES AND FOLLOW COMMANDS INCONSISTENTLY. MOVING ALL EXTREMITIES PURPOSEFULLY. PERL @3MM AND BRISK. ONCE PATIENT UNDER CONTROL WITH PROPOFOL, EXAM WAS UNCHANGED OTHER THAN SHE WOULD NOT OPEN EYES. GAG IMPAIRED, COUGH INTACT. NO SEIZURE ACTIVITY NOTED.\\n\\nCARDIAC: HR 85-91 SR WITH NO ECTOPY. BP 112-124/49-57. ON LOPRESSOR. PPP. LABS PER CAREVUE.\\n\\nRESP: ON A/C 500X16 60% +5 PEEP. NO ALINE TO DRAW ABG. NOT OVERBREATHING VENT. SATS 100%, LS RHONCHEROUS. SXTED FOR NOTHING.\\n\\nGI/GU: ABD SOFT WITH +BS. NO STOOL. NPO. OGT IN PLACE WITH BILIOUS ASPIRATES, OB-. U/O 16-80CC/HR YELLOW AND CLEAR.\\n\\nID: TMAX 101.4 RECTALLY DOWN TO 100.3. WBC 14.6 UP FROM 8.2 IN THE ER. ONE ADDITIONAL SET OF BLD CX'S SENT.\\n\\nSKIN: INTACT.\\n\\nACCESS: PIV X2.\\n\\nSOCIAL/DISPO: FULL CODE. SPOKE BRIEFLY WITH PT'S DAUGHTER. PLAN IS TO EXTUBATE THIS MORNING.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-02-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1314733,\n \"text\": \"pt intubated for airway for airway protection during seizure activity. should extubate in AM\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2173-02-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1314734,\n \"text\": \"Respiratory Care Note:\\n Patient remains intubated at this time and is spontaneously breathing with good tidal volumes and respiratory rate. She is on small amount of propofol and is awaiting of EEG prior to extubation planned for today.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2173-02-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 187055,\n \"text\": \"Sinus rhythm, without diagnostic abnormality. No previous tracing available for\\ncomparison.\\n\\n\"\n }\n]"}}},{"rowIdx":24681,"cells":{"subject_id":{"kind":"number","value":8799,"string":"8,799"},"hadm_id":{"kind":"number","value":100914,"string":"100,914"},"target_text":{"kind":"string","value":"35 y/o F with hx of T1DM with severe gastroparesis, prior episodes of DKA, acquired hemophilia, htn, multiple recent admissions for nausea and vomiting, initially presented with nausea, vomiting, diarrhea found to have multifocal pneumonia requiring ICU monitoring, acute exacerbation of diastolic heart failure, difficult to control blood sugars, and acute kidney injury. Pt was s/p 2mg IV ativan in the ED for management of nausea and she initially presented to the floor extremely lethargic and barely responsive. She triggered for hypoxia 46% on RA but was never cyanotic and rapidly improved to 100% on RA. She was also hyperglycemic to 500 which improved with insulin and IVF. ABG did not demonstrate hypoxia or hypercarbia or acidosis. Her symptoms improved over half an hour when she was mildly lethargic but responding to questions appropriately and conversant, falling easily into sleep but arousable. When awake patient endorsed symptoms of dysuria and diarrhea. She was started on bactrim for UTI. For renal failure IVF were given and home diuretics held. The following day, her lethargy was resolved and she was having fever to 101, productive cough and diarrhea. CXR demonstrated multifocal PNA. Given numerous allergies to antibiotics she was started on meropenem and vancomycin for hospital acquired pneumonia, though aspiration pneumonia remained on the differential. Legionella was considered and urine legionella sent and ultimately returned negative twice. She remained on 3L O2 with sats dropping to high 80s and low 90s. On she desaturated to low 80s on 4L requiring nonrebreather and transferred to the ICU. In the ICU, she was observed to be volume overloaded and treated with diuretics in addition to broadening her antibiotics to include antiviral treatment and azithromycin for legionella. During her ICU course she was diuresed with 40mg IV lasix, her O2 requirement improved. ID was consulted who recommended discontinuation of antiviral treatment after negative influenza swab. She was also found to have hypoglycemia, was consulted, who recommended reducing insulin. She continued to have intermittent diarrhea and nausea/vomiting. After 3 days in the ICU and addressing the above issues, she was transferred back to the floor. On the floor, her oxygen requirement continued to improve such that she was on room air. She continued to have fevers to 101, for which drug fever was a concern per ID. So per their recommendation Meropenem and Vancomycin were discontinued after a 7 day course. Per ID recommendations Azithroymycin was discontinued on day 9 due to thrombocytosis. Upon return to the floor she continued to have fluctuating high and low blood sugars requiring frequent and daily adjustments of her lantus dose and sliding scale. At time of discharge she was on 4units of lantus with sliding scale recommended by . During her hospitalization she required 2 units of blood products for hematocrit of 21 thought to be secondary to acute illness and phlebotomization. Hct was 25 at time of admission dropped to 21 during the course of her ICU stay. Her Hct remained stable at 32 for several days prior to her discharge. She was also given IV Iron given concern for occult GIB. Unclear remain the cause of her diarrhea which may have been viral in nature. Stool studies were all negative. Though this had resolved by time of discharge. Nausea vomiting, initially thought to be gastroparesis were minimal during this hospitalization compared to prior. She was tolerating regular diet at time of discharge. Renal failure had improved to creatinime of 1.2 on day of discharge. She was restarted on her home diuretics at time of d/c. She was not started on ACE/ due to history of hyperkalemia. Hospital course was also complicated by a number of social issues. Her mother and grandfather continued to be major supports. Pt admitted to not feeling supported by her husband with her medical issues. She was very stressed and was in a low mood during her hospitalization with flat affect. She was never suicidal or homicidal. She was seen by social work who did not feel that an inpatient psychiatry evaluation was needed. She was started on buspar and continued on zoloft."},"extractive_notes_summ":{"kind":"string","value":"Indeterminate pulmonary artery systolic pressure.Compared with the prior study (images reviewed) of , a very small tosmall pericardial effusion is present. An eccentric, posteriorly directedjet of at least mild (1+) mitral regurgitation is seen. Concomitant mild interstitial pulmonary edema is present. There is likely concomitant mild interstitial pulmonary edema given evidence of peribronchial cuffing in the left upper lung and probable Kerley B lines. Previously, at leastborderline pulmonary artery systolic hypertension was appreciated. Trace aortic regurgitation is seen. FINDINGS: Single frontal view of the chest again demonstrates multifocal pneumonia which has worsened from prior. Small hiatal hernia is noted. Bilateral asymmetrically distributed ground-glass and consolidative opacities involving the left lung to greater degree than the right, accompanied by smooth septal thickening and bilateral pleural effusions. Now febrile, question pneumonia. The bilateral consolidations are denser and have resulted in obscuration of the left hemidiaphragm and left heart border. Compared to prior, there has been a decrease in the degree of opacification suggesting interval diuresis of pulmonary edema. At least a moderate left pleural effusion is presumed. Probable worsening of pulmonary edema is seen as well. Lateral view shows a new severe consolidation at one of the lung bases, although on the frontal view I am not sure which one. Sinus tachycardia. Mild(1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. IMPRESSION: Worsening multifocal pneumonia and pulmonary edema. IMPRESSION: PA and lateral chest compared to and : Abnormalities in both lower lobes have worsened since . IMPRESSION: AP chest compared to : Severe bilateral pneumonia has not improved since . IMPRESSION: AP chest compared to through 7: Large scale bibasilar pneumonia has worsened, accompanied by increasing small bilateral pleural effusions. IMPRESSION: AP chest compared to through 9: Since , relatively symmetric bilateral perihilar consolidation, most likely edema, has improved substantially in the right lung, not on the left, where there is new moderate left pleural effusion. FINDINGS: Frontal and lateral views of the chest again demonstrate bilateral consolidations consistent with multifocal pneumonia. A left pleural effusion is likely. These findings likely represent a combination of multifocal pneumonia and pulmonary edema. 4:51 AM CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: pulm edema? Overall, the findings are still most suggestive of cardiac decompensation, given the persistence of mediastinal vascular and pulmonary vascular engorgement. 4:57 AM CHEST (PORTABLE AP) Clip # Reason: Evidence of consolidation or worsening pneumonia. IMPRESSION: Persistent bilateral multifocal pneumonia with interval improvement of pulmonary edema. There is also a component of mild pulmonary edema which is probably worsened. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Small pericardial effusion. REASON FOR THIS EXAMINATION: Evidence of consolidation or worsening pneumonia. Assessment of the hila is limited in the absence of intravenous contrast, but there is likely mild hilar lymphadenopathy present as well. Bilateral pleural effusions are most likely present as well. No PS.Physiologic PR.PERICARDIUM: Very small pericardial effusion. Left ventricular function. Discrete regions of sclerosis in the anterior ribs probably new since earlier in . Small-to-moderate dependent pleural effusions are also demonstrated as well as a small pericardial effusion. There is a very small pericardialeffusion measuring up to 0.8 centimeters in greatest dimension.. Upright conventional views would be very helpful to determine if there is additionally left lower lobe pneumonia, but the chest CT scan on suggested concurrent residual pulmonary edema and scattered bronchopneumonia in the upper lungs and possibly more severe consolidative pneumonia in the left lower lobe. Left pleuraleffusion. At least mildmitral regurgitation. PNA, persistant lung opacities REASON FOR THIS EXAMINATION: Further define b/l lung opacities CONTRAINDICATIONS for IV CONTRAST: diabetes FINAL REPORT CT CHEST WITHOUT CONTRAST DATED COMPARISON: CTA of the chest and serial chest radiographs dating between and . Please evaluate for worsening pneumonia, volume overload. No RAor RV diastolic collapse.GENERAL COMMENTS: Left pleural effusion.Conclusions:The left atrium is normal in size. FINAL REPORT INDICATION: History of diastolic heart failure admitted with pneumonia, now with acute desaturation. worsening pneumonia, volume overload. worsening pneumonia, volume overload. FINDINGS: Frontal and lateral chest radiographs were obtained. worsening PNA? worsening PNA? If it is necessary to determine whether this abnormality is unilateral or bilateral, oblique view should be obtained, but I am confident that there is new and progressive pneumonia relative to and respectively. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV systolic function.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Diabetes.Height: (in) 63Weight (lb): 128BSA (m2): 1.60 m2BP (mm Hg): 120/68HR (bpm): 86Status: InpatientDate/Time: at 11:40Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. IMPRESSION: (Over) 1:03 PM CT CHEST W/O CONTRAST Clip # Reason: Further define b/l lung opacities Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION FINAL REPORT (Cont) 1."},"n_notes":{"kind":"number","value":11,"string":"11"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2140-02-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1222971,"text":" 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evidence of consolidation or worsening pneumonia. Thanks!\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with fever and pneumonia.\n REASON FOR THIS EXAMINATION:\n Evidence of consolidation or worsening pneumonia. Thanks!\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:56 A.M. \n\n HISTORY: 35-year-old woman with fever and pneumonia.\n\n IMPRESSION: AP chest compared to :\n\n Severe bilateral pneumonia has not improved since . There is also a\n component of mild pulmonary edema which is probably worsened. Heart size is\n top normal. No pneumothorax. At least a moderate left pleural effusion is\n presumed.\n\n\n"},{"category":"Radiology","chartdate":"2140-01-31 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1222874,"text":" 8:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for progression\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with hypoxia, pneumonia\n REASON FOR THIS EXAMINATION:\n evaluate for progression\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:51 A.M., \n\n HISTORY: Hypoxia and pneumonia.\n\n IMPRESSION: AP chest compared to through 7:\n\n Large scale bibasilar pneumonia has worsened, accompanied by increasing small\n bilateral pleural effusions. Heart size is normal. No pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2140-02-01 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1223055,"text":" 1:03 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Further define b/l lung opacities\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with t1DM, dCHF, ? PNA, persistant lung opacities\n REASON FOR THIS EXAMINATION:\n Further define b/l lung opacities\n CONTRAINDICATIONS for IV CONTRAST:\n diabetes\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST WITHOUT CONTRAST DATED \n\n COMPARISON: CTA of the chest and serial chest radiographs\n dating between and .\n\n TECHNIQUE: Volumetric, multidetector CT of the chest was performed without\n intravenous or oral contrast. Images are presented for display in the axial\n plane at 5-mm and 1.25-mm collimation. A series of multiplanar reformation\n images were also submitted for review.\n\n FINDINGS: Widespread areas of ground-glass opacity and consolidation are\n present in both lungs, with a predominantly peribronchovascular and perihilar\n distribution. The left lung is involved to a greater degree than the right\n lung, and the left lower lobe is most extensively involved. The areas of\n conglomerate ground glass and consolidation are relatively amorphous, but have\n a nodular configuration within the anterior right upper lobe. These findings\n are accompanied by mild smooth septal thickening with a basilar predominance.\n Small-to-moderate dependent pleural effusions are also demonstrated as well as\n a small pericardial effusion. Anasarca is present in the chest wall.\n\n Mediastinal lymphadenopathy is present with enlarged nodes measuring up to\n approximately 1.2 cm in diameter in the precarinal region. Enlarged\n mediastinal nodes involve multiple compartments bilaterally. Assessment of\n the hila is limited in the absence of intravenous contrast, but there is\n likely mild hilar lymphadenopathy present as well. Small hiatal hernia is\n noted.\n\n Exam was not specifically tailored to evaluate the subdiaphragmatic region,\n but note is made of a small amount of ascites. Remaining imaged upper abdomen\n is unremarkable on this limited assessment.\n\n Skeletal structures demonstrate multiple healed anterior rib fractures. Mild\n compression deformity in the upper thoracic spine best visualized on sagittal\n reformations is unchanged since , but a healing transverse\n fracture involving the inferior aspect of the sternum is not clearly seen on\n that prior study. Several of the anterior rib fractures on today's study are\n also apparently new since that time.\n\n IMPRESSION:\n\n (Over)\n\n 1:03 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Further define b/l lung opacities\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Bilateral asymmetrically distributed ground-glass and consolidative\n opacities involving the left lung to greater degree than the right,\n accompanied by smooth septal thickening and bilateral pleural effusions.\n These findings likely represent a combination of multifocal pneumonia and\n pulmonary edema.\n\n 2. Small pericardial effusion.\n\n 3. Anasarca and small amount of ascites.\n\n 4. Healing sternal fracture and several anterior rib fractures, which are not\n appreciated on the older CT of but are age indeterminate.\n\n"},{"category":"Radiology","chartdate":"2140-02-04 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1223495,"text":" 9:25 AM\n CHEST (PA & LAT) Clip # \n Reason: please evaluate for change\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with PNA, prior CXR recommended repeat to evaluate bases\n REASON FOR THIS EXAMINATION:\n please evaluate for change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Diastolic heart failure admitted with pneumonia, evaluate change.\n\n COMPARISON: at 0508 hours and .\n\n FINDINGS: Frontal and lateral views of the chest again demonstrate bilateral\n consolidations consistent with multifocal pneumonia. Within the largest\n consolidation of the left lower lobe there is a suggestion of cavity formation\n demonstrated by a rounded opacification with lucent center, follow up is\n recommended. Compared to prior, there has been a decrease in the degree of\n opacification suggesting interval diuresis of pulmonary edema. Cardiac\n silhouette is unchanged. There is no pneumothorax or new consolidation.\n Abdominal coils are noted.\n\n IMPRESSION: Persistent bilateral multifocal pneumonia with interval\n improvement of pulmonary edema. Close attention on follow up should be paid\n to the left lower lobe consolidation for evaluation of cavity formation.\n\n"},{"category":"Radiology","chartdate":"2140-01-28 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1222497,"text":" 11:56 AM\n CHEST (PA & LAT) Clip # \n Reason: cardiopulm\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with cough, no fever\n REASON FOR THIS EXAMINATION:\n cardiopulm\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 35-year-old woman with cough, no fever.\n\n COMPARISON: .\n\n FINDINGS: Frontal and lateral chest radiographs were obtained. Lung volumes\n are low. Cardiomediastinal silhouette is unremarkable. Patchy opacities in\n the retrocardiac space may be atelectasis, but infection cannot be excluded.\n No pleural effusion or pneumothorax is present.\n\n IMPRESSION: Low lung volumes with patchy opacities in the left lung base,\n likely atelectasis, but infection cannot be ruled out in the correct clinical\n setting.\n\n"},{"category":"Echo","chartdate":"2140-02-04 00:00:00.000","description":"Report","row_id":75646,"text":"PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function. Diabetes.\nHeight: (in) 63\nWeight (lb): 128\nBSA (m2): 1.60 m2\nBP (mm Hg): 120/68\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 11:40\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<=2.1cm)\nwith >50% decrease with sniff (estimated RA pressure (0-5 mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV systolic function.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels. No 2D\nor Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Eccentric MR jet. Mild\n(1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Very small pericardial effusion. Effusion circumferential. No RA\nor RV diastolic collapse.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium is normal in size. The estimated right atrial pressure is 0-5\nmmHg. Left ventricular wall thickness, cavity size and regional/global\nsystolic function are normal (LVEF >55%). with normal free wall contractility.\nThe diameters of aorta at the sinus, ascending and arch levels are normal. The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis. Trace aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. An eccentric, posteriorly directed\njet of at least mild (1+) mitral regurgitation is seen. The pulmonary artery\nsystolic pressure could not be determined. There is a very small pericardial\neffusion measuring up to 0.8 centimeters in greatest dimension.. The effusion\nappears circumferential. No right atrial or right ventricular diastolic\ncollapse is seen.\n\nIMPRESSION: Normal left ventricular cavity size and wall thickness with\npreserved global and regional biventricular systolic function. At least mild\nmitral regurgitation. Very small to small, circumferential pericardial\neffusion without echocardiographic evidence of tamponade. Left pleural\neffusion. Indeterminate pulmonary artery systolic pressure.\n\nCompared with the prior study (images reviewed) of , a very small to\nsmall pericardial effusion is present. The pulmonary artery systolic pressure\nwas not able to be determined on the current study. Previously, at least\nborderline pulmonary artery systolic hypertension was appreciated. The left\npleural effusion is new.\n\n\n"},{"category":"Radiology","chartdate":"2140-01-29 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1222650,"text":" 11:14 AM\n CHEST (PA & LAT) Clip # \n Reason: please eval for PNA, prior CXR\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with cough, fever\n REASON FOR THIS EXAMINATION:\n please eval for PNA, prior CXR\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST \n\n HISTORY: 35-year-old woman with a cough, suspect pneumonia.\n\n IMPRESSION: PA and lateral chest compared to and :\n\n Abnormalities in both lower lobes have worsened since . Lateral view\n shows a new severe consolidation at one of the lung bases, although on the\n frontal view I am not sure which one. There is also peribronchial\n opacification in the right lower lung extending laterally. If it is necessary\n to determine whether this abnormality is unilateral or bilateral, oblique view\n should be obtained, but I am confident that there is new and progressive\n pneumonia relative to and respectively. Discrete\n regions of sclerosis in the anterior ribs probably new since earlier in .\n They could be posttraumatic. Heart size is normal. Dr. was paged.\n\n\n"},{"category":"Radiology","chartdate":"2140-01-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1222836,"text":" 5:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? worsening pneumonia, volume overload.\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with multifocal pneumonia, dCHF. Increasing oxygen\n requirement. Please evaluate for worsening pneumonia, volume overload.\n REASON FOR THIS EXAMINATION:\n ? worsening pneumonia, volume overload.\n ______________________________________________________________________________\n WET READ: SAT 8:22 PM\n Marked interval increase in bilateral mid-to-lower lung heterogenously\n opacities, left greater than right, consistent with worsening pneumonia.\n There is likely concomitant mild interstitial pulmonary edema given evidence\n of peribronchial cuffing in the left upper lung and probable Kerley B lines.\n A left pleural effusion is likely.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with multifocal pneumonia and\n diastolic congestive heart failure.\n\n AP radiograph of the chest was compared to .\n\n It has been marked interval increase in bilateral mid to lower lung\n consolidations, left greater than right, but both substantial, highly\n concerning for worsening pneumonia with potential intraparenchymal hemorrhage.\n Concomitant mild interstitial pulmonary edema is present. Bilateral pleural\n effusions are most likely present as well.\n\n Findings were discussed with Dr. at 8:21 p.m. by Dr. over the\n phone.\n\n\n"},{"category":"Radiology","chartdate":"2140-02-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1223465,"text":" 4:51 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: pulm edema? worsening PNA?\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with diastolic CHF, admitted for PNA, now with acute\n desaturation concerning for worsening PNA vs. pulmonary edema vs. mucus\n plugging vs. PE\n REASON FOR THIS EXAMINATION:\n pulm edema? worsening PNA?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of diastolic heart failure admitted with pneumonia, now\n with acute desaturation.\n\n COMPARISON: and CT of the chest .\n\n FINDINGS: Single frontal view of the chest again demonstrates multifocal\n pneumonia which has worsened from prior. The bilateral consolidations are\n denser and have resulted in obscuration of the left hemidiaphragm and left\n heart border. Probable worsening of pulmonary edema is seen as well. The\n small left pleural effusion is unchanged and there is no pneumothorax.\n\n IMPRESSION: Worsening multifocal pneumonia and pulmonary edema.\n\n"},{"category":"Radiology","chartdate":"2140-02-02 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1223135,"text":" 12:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with dHF and bilateral infiltrates now febrile.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 12:06 A.M., \n\n HISTORY: Diastolic CHF and bilateral infiltrates. Now febrile, question\n pneumonia.\n\n IMPRESSION: AP chest compared to through 9:\n\n Since , relatively symmetric bilateral perihilar consolidation, most\n likely edema, has improved substantially in the right lung, not on the left,\n where there is new moderate left pleural effusion. Overall, the findings are\n still most suggestive of cardiac decompensation, given the persistence of\n mediastinal vascular and pulmonary vascular engorgement. Upright conventional\n views would be very helpful to determine if there is additionally left lower\n lobe pneumonia, but the chest CT scan on suggested concurrent\n residual pulmonary edema and scattered bronchopneumonia in the upper lungs and\n possibly more severe consolidative pneumonia in the left lower lobe.\n\n\n"},{"category":"ECG","chartdate":"2140-01-31 00:00:00.000","description":"Report","row_id":181377,"text":"Sinus tachycardia. Non-specific repolarization abnormalities. Compared to the\nprevious tracing of no significant difference.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-02-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1222971,\n \"text\": \" 4:57 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Evidence of consolidation or worsening pneumonia. Thanks!\\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 35 year old woman with fever and pneumonia.\\n REASON FOR THIS EXAMINATION:\\n Evidence of consolidation or worsening pneumonia. Thanks!\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST 4:56 A.M. \\n\\n HISTORY: 35-year-old woman with fever and pneumonia.\\n\\n IMPRESSION: AP chest compared to :\\n\\n Severe bilateral pneumonia has not improved since . There is also a\\n component of mild pulmonary edema which is probably worsened. Heart size is\\n top normal. No pneumothorax. At least a moderate left pleural effusion is\\n presumed.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-01-31 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1222874,\n \"text\": \" 8:00 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for progression\\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 35 year old woman with hypoxia, pneumonia\\n REASON FOR THIS EXAMINATION:\\n evaluate for progression\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 7:51 A.M., \\n\\n HISTORY: Hypoxia and pneumonia.\\n\\n IMPRESSION: AP chest compared to through 7:\\n\\n Large scale bibasilar pneumonia has worsened, accompanied by increasing small\\n bilateral pleural effusions. Heart size is normal. No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-02-01 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1223055,\n \"text\": \" 1:03 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: Further define b/l lung opacities\\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 35 year old woman with t1DM, dCHF, ? PNA, persistant lung opacities\\n REASON FOR THIS EXAMINATION:\\n Further define b/l lung opacities\\n CONTRAINDICATIONS for IV CONTRAST:\\n diabetes\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT CHEST WITHOUT CONTRAST DATED \\n\\n COMPARISON: CTA of the chest and serial chest radiographs\\n dating between and .\\n\\n TECHNIQUE: Volumetric, multidetector CT of the chest was performed without\\n intravenous or oral contrast. Images are presented for display in the axial\\n plane at 5-mm and 1.25-mm collimation. A series of multiplanar reformation\\n images were also submitted for review.\\n\\n FINDINGS: Widespread areas of ground-glass opacity and consolidation are\\n present in both lungs, with a predominantly peribronchovascular and perihilar\\n distribution. The left lung is involved to a greater degree than the right\\n lung, and the left lower lobe is most extensively involved. The areas of\\n conglomerate ground glass and consolidation are relatively amorphous, but have\\n a nodular configuration within the anterior right upper lobe. These findings\\n are accompanied by mild smooth septal thickening with a basilar predominance.\\n Small-to-moderate dependent pleural effusions are also demonstrated as well as\\n a small pericardial effusion. Anasarca is present in the chest wall.\\n\\n Mediastinal lymphadenopathy is present with enlarged nodes measuring up to\\n approximately 1.2 cm in diameter in the precarinal region. Enlarged\\n mediastinal nodes involve multiple compartments bilaterally. Assessment of\\n the hila is limited in the absence of intravenous contrast, but there is\\n likely mild hilar lymphadenopathy present as well. Small hiatal hernia is\\n noted.\\n\\n Exam was not specifically tailored to evaluate the subdiaphragmatic region,\\n but note is made of a small amount of ascites. Remaining imaged upper abdomen\\n is unremarkable on this limited assessment.\\n\\n Skeletal structures demonstrate multiple healed anterior rib fractures. Mild\\n compression deformity in the upper thoracic spine best visualized on sagittal\\n reformations is unchanged since , but a healing transverse\\n fracture involving the inferior aspect of the sternum is not clearly seen on\\n that prior study. Several of the anterior rib fractures on today's study are\\n also apparently new since that time.\\n\\n IMPRESSION:\\n\\n (Over)\\n\\n 1:03 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: Further define b/l lung opacities\\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 1. Bilateral asymmetrically distributed ground-glass and consolidative\\n opacities involving the left lung to greater degree than the right,\\n accompanied by smooth septal thickening and bilateral pleural effusions.\\n These findings likely represent a combination of multifocal pneumonia and\\n pulmonary edema.\\n\\n 2. Small pericardial effusion.\\n\\n 3. Anasarca and small amount of ascites.\\n\\n 4. Healing sternal fracture and several anterior rib fractures, which are not\\n appreciated on the older CT of but are age indeterminate.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-02-04 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1223495,\n \"text\": \" 9:25 AM\\n CHEST (PA & LAT) Clip # \\n Reason: please evaluate for change\\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 35 year old woman with PNA, prior CXR recommended repeat to evaluate bases\\n REASON FOR THIS EXAMINATION:\\n please evaluate for change\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Diastolic heart failure admitted with pneumonia, evaluate change.\\n\\n COMPARISON: at 0508 hours and .\\n\\n FINDINGS: Frontal and lateral views of the chest again demonstrate bilateral\\n consolidations consistent with multifocal pneumonia. Within the largest\\n consolidation of the left lower lobe there is a suggestion of cavity formation\\n demonstrated by a rounded opacification with lucent center, follow up is\\n recommended. Compared to prior, there has been a decrease in the degree of\\n opacification suggesting interval diuresis of pulmonary edema. Cardiac\\n silhouette is unchanged. There is no pneumothorax or new consolidation.\\n Abdominal coils are noted.\\n\\n IMPRESSION: Persistent bilateral multifocal pneumonia with interval\\n improvement of pulmonary edema. Close attention on follow up should be paid\\n to the left lower lobe consolidation for evaluation of cavity formation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-01-28 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1222497,\n \"text\": \" 11:56 AM\\n CHEST (PA & LAT) Clip # \\n Reason: cardiopulm\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 35 year old woman with cough, no fever\\n REASON FOR THIS EXAMINATION:\\n cardiopulm\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: 35-year-old woman with cough, no fever.\\n\\n COMPARISON: .\\n\\n FINDINGS: Frontal and lateral chest radiographs were obtained. Lung volumes\\n are low. Cardiomediastinal silhouette is unremarkable. Patchy opacities in\\n the retrocardiac space may be atelectasis, but infection cannot be excluded.\\n No pleural effusion or pneumothorax is present.\\n\\n IMPRESSION: Low lung volumes with patchy opacities in the left lung base,\\n likely atelectasis, but infection cannot be ruled out in the correct clinical\\n setting.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2140-02-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 75646,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Congestive heart failure. Left ventricular function. Diabetes.\\nHeight: (in) 63\\nWeight (lb): 128\\nBSA (m2): 1.60 m2\\nBP (mm Hg): 120/68\\nHR (bpm): 86\\nStatus: Inpatient\\nDate/Time: at 11:40\\nTest: TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<=2.1cm)\\nwith >50% decrease with sniff (estimated RA pressure (0-5 mmHg).\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\\nsystolic function (LVEF >55%). No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: Normal RV systolic function.\\n\\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels. No 2D\\nor Doppler evidence of distal arch coarctation.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Eccentric MR jet. Mild\\n(1+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\nIndeterminate PA systolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR.\\n\\nPERICARDIUM: Very small pericardial effusion. Effusion circumferential. No RA\\nor RV diastolic collapse.\\n\\nGENERAL COMMENTS: Left pleural effusion.\\n\\nConclusions:\\nThe left atrium is normal in size. The estimated right atrial pressure is 0-5\\nmmHg. Left ventricular wall thickness, cavity size and regional/global\\nsystolic function are normal (LVEF >55%). with normal free wall contractility.\\nThe diameters of aorta at the sinus, ascending and arch levels are normal. The\\naortic valve leaflets (3) appear structurally normal with good leaflet\\nexcursion and no aortic stenosis. Trace aortic regurgitation is seen. The\\nmitral valve leaflets are mildly thickened. An eccentric, posteriorly directed\\njet of at least mild (1+) mitral regurgitation is seen. The pulmonary artery\\nsystolic pressure could not be determined. There is a very small pericardial\\neffusion measuring up to 0.8 centimeters in greatest dimension.. The effusion\\nappears circumferential. No right atrial or right ventricular diastolic\\ncollapse is seen.\\n\\nIMPRESSION: Normal left ventricular cavity size and wall thickness with\\npreserved global and regional biventricular systolic function. At least mild\\nmitral regurgitation. Very small to small, circumferential pericardial\\neffusion without echocardiographic evidence of tamponade. Left pleural\\neffusion. Indeterminate pulmonary artery systolic pressure.\\n\\nCompared with the prior study (images reviewed) of , a very small to\\nsmall pericardial effusion is present. The pulmonary artery systolic pressure\\nwas not able to be determined on the current study. Previously, at least\\nborderline pulmonary artery systolic hypertension was appreciated. The left\\npleural effusion is new.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-01-29 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1222650,\n \"text\": \" 11:14 AM\\n CHEST (PA & LAT) Clip # \\n Reason: please eval for PNA, prior CXR\\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 35 year old woman with cough, fever\\n REASON FOR THIS EXAMINATION:\\n please eval for PNA, prior CXR\\n ______________________________________________________________________________\\n FINAL REPORT\\n PA AND LATERAL CHEST \\n\\n HISTORY: 35-year-old woman with a cough, suspect pneumonia.\\n\\n IMPRESSION: PA and lateral chest compared to and :\\n\\n Abnormalities in both lower lobes have worsened since . Lateral view\\n shows a new severe consolidation at one of the lung bases, although on the\\n frontal view I am not sure which one. There is also peribronchial\\n opacification in the right lower lung extending laterally. If it is necessary\\n to determine whether this abnormality is unilateral or bilateral, oblique view\\n should be obtained, but I am confident that there is new and progressive\\n pneumonia relative to and respectively. Discrete\\n regions of sclerosis in the anterior ribs probably new since earlier in .\\n They could be posttraumatic. Heart size is normal. Dr. was paged.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-01-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1222836,\n \"text\": \" 5:33 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? worsening pneumonia, volume overload.\\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 35 year old woman with multifocal pneumonia, dCHF. Increasing oxygen\\n requirement. Please evaluate for worsening pneumonia, volume overload.\\n REASON FOR THIS EXAMINATION:\\n ? worsening pneumonia, volume overload.\\n ______________________________________________________________________________\\n WET READ: SAT 8:22 PM\\n Marked interval increase in bilateral mid-to-lower lung heterogenously\\n opacities, left greater than right, consistent with worsening pneumonia.\\n There is likely concomitant mild interstitial pulmonary edema given evidence\\n of peribronchial cuffing in the left upper lung and probable Kerley B lines.\\n A left pleural effusion is likely.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of the patient with multifocal pneumonia and\\n diastolic congestive heart failure.\\n\\n AP radiograph of the chest was compared to .\\n\\n It has been marked interval increase in bilateral mid to lower lung\\n consolidations, left greater than right, but both substantial, highly\\n concerning for worsening pneumonia with potential intraparenchymal hemorrhage.\\n Concomitant mild interstitial pulmonary edema is present. Bilateral pleural\\n effusions are most likely present as well.\\n\\n Findings were discussed with Dr. at 8:21 p.m. by Dr. over the\\n phone.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-02-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1223465,\n \"text\": \" 4:51 AM\\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \\n Reason: pulm edema? worsening PNA?\\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 35 year old woman with diastolic CHF, admitted for PNA, now with acute\\n desaturation concerning for worsening PNA vs. pulmonary edema vs. mucus\\n plugging vs. PE\\n REASON FOR THIS EXAMINATION:\\n pulm edema? worsening PNA?\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: History of diastolic heart failure admitted with pneumonia, now\\n with acute desaturation.\\n\\n COMPARISON: and CT of the chest .\\n\\n FINDINGS: Single frontal view of the chest again demonstrates multifocal\\n pneumonia which has worsened from prior. The bilateral consolidations are\\n denser and have resulted in obscuration of the left hemidiaphragm and left\\n heart border. Probable worsening of pulmonary edema is seen as well. The\\n small left pleural effusion is unchanged and there is no pneumothorax.\\n\\n IMPRESSION: Worsening multifocal pneumonia and pulmonary edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-02-02 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1223135,\n \"text\": \" 12:11 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for interval change\\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 35 year old woman with dHF and bilateral infiltrates now febrile.\\n REASON FOR THIS EXAMINATION:\\n eval for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 12:06 A.M., \\n\\n HISTORY: Diastolic CHF and bilateral infiltrates. Now febrile, question\\n pneumonia.\\n\\n IMPRESSION: AP chest compared to through 9:\\n\\n Since , relatively symmetric bilateral perihilar consolidation, most\\n likely edema, has improved substantially in the right lung, not on the left,\\n where there is new moderate left pleural effusion. Overall, the findings are\\n still most suggestive of cardiac decompensation, given the persistence of\\n mediastinal vascular and pulmonary vascular engorgement. Upright conventional\\n views would be very helpful to determine if there is additionally left lower\\n lobe pneumonia, but the chest CT scan on suggested concurrent\\n residual pulmonary edema and scattered bronchopneumonia in the upper lungs and\\n possibly more severe consolidative pneumonia in the left lower lobe.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-01-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 181377,\n \"text\": \"Sinus tachycardia. Non-specific repolarization abnormalities. Compared to the\\nprevious tracing of no significant difference.\\n\\n\"\n }\n]"}}},{"rowIdx":24682,"cells":{"subject_id":{"kind":"number","value":23318,"string":"23,318"},"hadm_id":{"kind":"number","value":169689,"string":"169,689"},"target_text":{"kind":"string","value":"74 year-old female with stage IV sarcoidosis with combined restrictive/obstructive disease, asthma, dCHF, pulmonary HTN a/w COPD flare. . # COPD Flare, pulmonary sarcoidosis, pulmonary hypertension: The patient was admitted to the ICU in respiratory distress attributed to a COPD flare. She improved with steroids, nebulizer treatments, and Levofloxacin and was transferred to the floor where these therapies continued; she was never intubated. She was discharged on home dose advair and montelukast unchanged. Sarcoidosis contributed to the presentation by decreasing pulmonary reserve; pulmonary hypertension also contributed and sildenafil was continued. . # Hypertrophic C.Myopathy, dCHF, HTN: Continued home verapamil and furosemide 20. . INACTIVE ISSUES: . # Osteoporosis: Continued Ca/Vit D, alendronate . TRANSITIONAL ISSUES: # Prednisone taper will be overseen by PCP."},"extractive_notes_summ":{"kind":"string","value":"Compared to the previous tracingof premature atrial contractions are seen on the current tracing. Sinus tachycardia with premature atrial contractions. Left atrial abnormality.Non-specific inferior ST-T wave changes."},"n_notes":{"kind":"number","value":1,"string":"1"},"notes":{"kind":"list like","value":[{"category":"ECG","chartdate":"2155-06-26 00:00:00.000","description":"Report","row_id":273010,"text":"Sinus tachycardia with premature atrial contractions. Left atrial abnormality.\nNon-specific inferior ST-T wave changes. Compared to the previous tracing\nof premature atrial contractions are seen on the current tracing. The\nother findings are similar.\n\n"}],"string":"[\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2155-06-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 273010,\n \"text\": \"Sinus tachycardia with premature atrial contractions. Left atrial abnormality.\\nNon-specific inferior ST-T wave changes. Compared to the previous tracing\\nof premature atrial contractions are seen on the current tracing. The\\nother findings are similar.\\n\\n\"\n }\n]"}}},{"rowIdx":24683,"cells":{"subject_id":{"kind":"number","value":25217,"string":"25,217"},"hadm_id":{"kind":"number","value":190100,"string":"190,100"},"target_text":{"kind":"string","value":"Patient was admitted under Dr. service. Chest x-ray was performed on admission demonstrating no CHF, no pneumonia. Duplex of his liver was performed on demonstrating patent portal vein, a small amount of ascites around the liver. On , the patient had an abdominal CT because of elevated total bilirubin and lipase demonstrating cirrhosis and portal hypertension, moderate to large amount of ascites, abnormal IVC with collapse of the intrahepatic IVC and string appearance of the retrohepatic IVC, may be seen with low intravascular volume, small thrombus in the retrohepatic IVC cannot be excluded. Doppler ultrasound recommended in addition due to hypodense region in the confluence of the hepatic veins probably from volume average. Transplant surgery was consulted on for possible liver transplant. On , IVC study was obtained and tributaries were examined via ultrasound demonstrating no evidence of IVC thrombus. However, with each arterial pulsation there is external compression of the intrahepatic IVC likely by the hypertrophied caudate lobe. MELD score on was 27. Transplant surgery continued to see patient on Dr. service. On , no acute events. Patient's sodium slowly decreased to 129. Other remarkable labs - ALT 83, AST 184, alkaline phosphatase 143, total bilirubin 16.6, albumin 2.4. The patient's rifaximine was increased to 400 t.i.d., continue lactulose, fluid restrict him with less than 1.5 liters, with soft diet. MELD score increased to 29 on . Nutrition saw patient on for assistance in optimizing his p.o. intake. On , his MELD score increased to 31. On that day, he had increased nausea, increased abdominal pain, not feeling well, afebrile, vital signs stable. On , ultrasound was obtained because of abdominal distention due to ascites, in which he had a therapeutic tap. Social work had met with Mr. . Just of note, on , the patient had a series of blood work which included blood cultures, influenza AB, rapid respiratory viral screen cultures which were all unremarkable. Also had a UA, UC which were unremarkable. On , MELD score increased to 32. His labs on included sodium 128, 3.8, 96, 25, 16, 0.7, glucose of 88, ALT 68, AST 173, alkaline phosphatase 170, total bilirubin 24.5. On , the patient had increased lethargy, afebrile, vital signs stable. General - patient appears jaundiced, pleasant, in no acute distress. Abdomen soft, but distended, mild tenderness to palpation deeply in the right upper quadrant. Awake, oriented x3, not lethargic, nonfocal. Patient also had labs including a WBC of 5.2, hematocrit of 31.0, platelets 44, INR 3.4. On , the patient had NG tube placement because of nutritional depletion, which demonstrated that the feeding tube was in the distal duodenum. On , the patient had an orthotopic deceased donor liver transplant (piggyback, portal vein-portal vein anastomosis, common bile duct-common bile duct, no T-tube, common hepatic artery which is the donor to common hepatic artery which is recipient) performed by Doctors , . Please see detailed operative note for more information regarding the surgery. Postoperatively, the patient went to the unit. On , the patient went to the ICU. The patient was afebrile. Vital signs stable. Labs - sodium 132, 3.5, chloride 95, CO2 24, BUN and creatinine at 39 and 2.4, glucose 188, calcium, phosphorus, magnesium 10.1, 5.8, 3.3, AST 476, 289 is the ALT, alkaline phosphatase 85, total bilirubin 13.3. The patient was placed on Unasyn, fluconazole, ganciclovir, insulin, heparin, morphine. He was placed on MMF 1 gram b.i.d., Solu-Medrol 500. Continued to be improved in the ICU and patient was transferred to the floor on to Far-10. On that day, the patient was afebrile with vital signs stable. Two JPs were putting out from the medial 298, lateral 700. Sodium 6.4, hematocrit 31.0, platelets 59, sodium 136, 2.5, 100, 28, 40, creatinine 1.2, glucose 131, AST 91, 110, alkaline phosphatase 71, total bilirubin is 4.6. Of note, on , the patient had a Doppler ultrasound demonstrating somewhat attenuated but patent extrahepatic main hepatic artery but excellent intrahepatic left hepatic artery. The remainder of the examination is unremarkable. Continue with MMF, Solu-Medrol which the patient received a total of 5 doses of Solu-Medrol which ended on . The patient was started on FK or tacrolimus on . Because his platelets were decreasing, a HIT panel was sent off which was unremarkable. On , postop day 6, good pain control, ambulatory, continued on MMF, prednisone was started 20 mg once daily __________. Patient had a T-max of 1001, otherwise vital signs stable. Abdomen moderate distention. Dressing was clean, dry and intact. On , 1 of his JP drains was removed. PT was consulted. Occupational was consulted as well. met with patient for blood glucose control. On , another ultrasound was obtained, because of elevated LFTs, that demonstrated patent portal venous, common hepatic venous and hepatic arterial vasculature with appropriate direction of flow and waveforms. The patient was advanced to regular diet. Good I's and O's. Both JP drains were removed by . On , percutaneous liver biopsy was performed, because of elevated LFTs, demonstrating minute fragments of nerve, fibrous tear, rare hepatocytes, insufficient for evaluation. A repeat liver biopsy was performed on demonstrating liver parenchymal with focal minimal portal mononuclear cell inflammation, nonspecific. There were no features of acute cellular reduction or bile duct injury seen. An ERCP was performed on demonstrating no stricture at the surgical anastomosis, essentially post surgical cholangiogram without evidence of obstruction, no evidence of biliary leak."},"extractive_notes_summ":{"kind":"string","value":"Physiologic mitral regurgitation is seen(within normal limits). Physiologic MR (withinnormal limits).TRICUSPID VALVE: Normal tricuspid valve leaflets. PATIENT/TEST INFORMATION:Indication: Liver transplant, hemodynamic monitoringStatus: InpatientDate/Time: at 08:33Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thicknesses and cavity size.LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Pt intubated with pa in place- (see flow sheet for co, cvp, svo2, etc) JP x2 with sang drg, no t tube, ogt lcws with bili drg, abd drsg sang drg- drsg . Physiologic(normal) PR.GENERAL COMMENTS: A TEE was performed in the location listed above. The right, middle and left hepatic veins appear patent. In addition, there is a hypodense region at the confluence of the hepatic veins; probably from volume average. The infrahepatic inferior vena cava is patent. At the confluence of the hepatic veins there is an hypodense round region in the left side of the IVC - uncertain if is partial volume or thrombus in the IVC given it is seen only on one image. Admitting Diagnosis: SHORTNESS OF BREATH Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) island in the left ilium. oriented x 3.cv: stablepulm: bs clear, diminished rt base. Small thromus in the retrohepatic IVC cannot be excluded; doppler ultrasound recommended. The patient was undergeneral anesthesia throughout the procedure.Conclusions:The left atrium is moderately dilated. bowel sounds present, hypoactive.gu: u/o qs.Plan: wean as tolerated, check abg's as ordered. The IVC and hepatic veins are patent. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Unchanged tiny bone (Over) 3:08 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: evaluate biliary ducts for patency, r/o focal mass in liver. On duplex Doppler examination, the main portal vein shows mild turbulence, but the main portal vein and its major tributaries, including the left portal vein, the anterior and posterior right portal venous branches, are patent with appropriate hepatopetal flow. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. (Over) 2:28 PM LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # DUPLEX DOPP ABD/PEL Reason: please mark for liver biopsy as well as assess arterial/ Admitting Diagnosis: SHORTNESS OF BREATH FINAL REPORT (Cont) New since the previous exam is a small amount of free fluid inferior to the right lobe of liver. Normal hepatic vasculature. The ascending, transverse and descending thoracic aorta are normalin diameter and free of atherosclerotic plaque. Unchanged moderate-to-large amount of ascites. Abnormal IVC with collapse of the infrahepatic IVC and string appeareance of the retrohepatic IVC; may be seen with low intravascular volume. The hepatic veins are patent. 3:08 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: evaluate biliary ducts for patency, r/o focal mass in liver. 7:35 PM US ABD LIMIT, SINGLE ORGAN; -59 DISTINCT PROCEDURAL SERVICE Clip # DUPLEX DOP ABD/PEL LIMITED Reason: Please evaluate for portal vein clot, ascites. dsd changed x 1m then again this am by ho's.Possible repeat liver U/S today. Since the previous tracing of the T waves aremore inverted in lead III. Resistive index in the right hepatic artery is 0.78, the RI in the left hepatic artery is 0.74. to repeat liver US to noc. Foley to gravity- uo 100-500/hr- did rec lasix x1 in OR. Cirrhosis and portal hypertension. Within the gallbladder fossa, there is a small fluid collection, which may represent post-surgical fluid collection status post cholecystectomy. TECHNIQUE: Multidetector CT through the abdomen and pelvis with and without IV and oral contrast. Propofol gtt weaning as tol, but not able to turn off as sbp >170 when off. npn Pt is a+o, c/o pain q1-2- rx with 2 mg ivp mso4 q with relief, pearl, mae. The right and left portal veins are patent. Liver US done at bedside this pm and ? s/p liver transplantplease see careview for details.neuro: sedated on propofol, but following commands, nodding appropriately. REASON FOR THIS EXAMINATION: Please evaluate for portal vein clot, ascites. New since the previous exam is a small 3-6 cm collection of free fluid inferior to the liver. Resistive index in the main hepatic artery is 0.71. In segment II of the liver, there is a tiny 4-mm transient hyperenhancing foci seen only in the arterial phase."},"n_notes":{"kind":"number","value":15,"string":"15"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2169-02-26 00:00:00.000","description":"Report","row_id":1591301,"text":"s/p liver transplant\nplease see careview for details.\n\nneuro: sedated on propofol, but following commands, nodding appropriately. perl. mae.\n\ncv: afeb, nsr, bp stable. filling pressures low. 2 u ffp for inr 1.8, with subsequent temporary increase in pressures.\n\npulm: vented 50%, cmv, alkalotic. decrease in tv. bs coarse to rhonchorous. sx for thick bloody.\n\ngi: ng to lcws draining bilious. bowel sounds present, hypoactive.\n\ngu: u/o qs.\n\nPlan: wean as tolerated, check abg's as ordered. medicate for pain as needed.\n\n"},{"category":"Nursing/other","chartdate":"2169-02-26 00:00:00.000","description":"Report","row_id":1591302,"text":"npn\n Pt is a+o, c/o pain q1-2- rx with 2 mg ivp mso4 q with relief, pearl, mae. Did receive 100 mcg fentanyl in Angio.\n\nResp- extubated this am and tol hh face tent with .40 fio2. lungs clear upper- at bases. coughing up old lg blood clots- nasal packing cont in place from nose bleed in OR- no new nose bleeding seen.\n\nGI- ogt dc when extubated- denies nausea. Cont npo. Liver US done at bedside this pm and ? of low arterial flow reported- pt taken to angio for more eval- transplant team plan at this time is to cont to follow lab trends and redo US- also plan to repeat angio in days- lfts's/amylase have been trending down since OR_ will cont to check labs pr transplant request.\n\nHemodynmics- Pa stilll in place- see flow sheet for all #'S. Sbp 130's 160's, nsr, denies chest pain,\n\nHeme- rec 2 ffp this am for inr 1.8 and rec 2 pack platelets in angio for count 66.\nPLAN_ cont to follow q1 labs pr sicu protocl, labs pr transplant req, ? to repeat liver US to noc.\n"},{"category":"Nursing/other","chartdate":"2169-02-27 00:00:00.000","description":"Report","row_id":1591303,"text":"Please see careview for details\n\nneuro: . some slight tremors of arms and hands, pt states they were worse pre-op. oriented x 3.\n\ncv: stable\n\npulm: bs clear, diminished rt base. sats mid 90's on 50% face shovel.\n\nENT: nasal packing removed this am with no signs of repeat epistaxis at this time.\n\ngi: bowel sounds present, no flatus. taking ice chips.\n\ngu: u/o qs.\n\npain: pt states his pain is , dropping to only after each dose of pain medication. will approach team for change or increase im mso4.\n\nincision: sm amts serous drainage. dsd changed x 1m then again this am by ho's.\nPossible repeat liver U/S today.\n"},{"category":"Nursing/other","chartdate":"2169-02-25 00:00:00.000","description":"Report","row_id":1591298,"text":"respiratory care\npt admitted from OR placed on vent tol well see respiratory page of care view for more information\n"},{"category":"Nursing/other","chartdate":"2169-02-25 00:00:00.000","description":"Report","row_id":1591299,"text":"Nsg admit Note\n51 yo male with hx iv drug/etoh use in past with etoh cirrhosis/hep c. S/P liver transplant - requiring multi blood produsts in OR_ (see I+O flow sheet or OR flow sheet for totals). In SICU rec 1 unit prbc for hct 28- 1 pack platelet for count 92- and 2 ffp for INR 1.6. Pt intubated with pa in place- (see flow sheet for co, cvp, svo2, etc) JP x2 with sang drg, no t tube, ogt lcws with bili drg, abd drsg sang drg- drsg . Nasal packing in place as nose bleed in OR- cont md aware- labs to be done q8- next due 8 pm tonoc. Requiring insulin gtt for glucose >200- gtt at 5u/hr with 10 cc d5w pr Dr request. Propofol gtt weaning as tol, but not able to turn off as sbp >170 when off. Dr aware- propofol now at 20mcg/kg/min. Pearl, not following commands at this time- was not reversed from sedation/paralytic rec. in OR. Foley to gravity- uo 100-500/hr- did rec lasix x1 in OR. sister is his proxy- family in this pm- plan to call for updates- they also spoke with Dr for surgical updates post op.\n"},{"category":"Nursing/other","chartdate":"2169-02-26 00:00:00.000","description":"Report","row_id":1591300,"text":"RESPIRATORY CARE 1900-0700\nPT REMAINS ORALLY INTUBATED ON AC. Vt CHANGED FROM 600ml TO 550ml, NO OTHER CHANGES MADE TO VENT THROUGHOUT THE NIGHT. BS CLEAR TO COARSE SX FOR MINIMAL RETURN. RSBI THIS AM= 29. SEE CAREVUE FOR FURTHER QUESTIONS.\n"},{"category":"Echo","chartdate":"2169-02-25 00:00:00.000","description":"Report","row_id":64347,"text":"PATIENT/TEST INFORMATION:\nIndication: Liver transplant, hemodynamic monitoring\nStatus: Inpatient\nDate/Time: at 08:33\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Physiologic MR (within\nnormal limits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\n(normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thicknesses and\ncavity size are normal. Right ventricular chamber size and free wall motion\nare normal. The ascending, transverse and descending thoracic aorta are normal\nin diameter and free of atherosclerotic plaque. The aortic valve leaflets (3)\nare mildly thickened. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Physiologic mitral regurgitation is seen\n(within normal limits).\n\n\n"},{"category":"ECG","chartdate":"2169-03-06 00:00:00.000","description":"Report","row_id":135398,"text":"Sinus rhythm, rate 73. Since the previous tracing of the T waves are\nmore inverted in lead III. No other changes are present.\n\n"},{"category":"ECG","chartdate":"2169-02-10 00:00:00.000","description":"Report","row_id":135399,"text":"Sinus rhythm. Long QTc interval. Compared to the previous tracing\nof no significant change.\n\n"},{"category":"Radiology","chartdate":"2169-02-12 00:00:00.000","description":"CT PELVIS W/CONTRAST","row_id":901385,"text":" 3:08 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: evaluate biliary ducts for patency, r/o focal mass in liver.\n Admitting Diagnosis: SHORTNESS OF BREATH\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with hep C/ETOH cirrhosis,on transplant list now presenting\n with epigastric pain, elevated total bilirubin, and elevated lipase.\n REASON FOR THIS EXAMINATION:\n evaluate biliary ducts for patency, r/o focal mass in liver. assess degree of\n bowel edema (if any)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Abdomen and pelvis CT.\n\n HISTORY: 51-year-old man with hepatitis C/ETOH cirrhosis with epigastric\n pain, elevated total bilirubin and elevated lipase. Assess for focal liver\n masses and biliary duct.\n\n TECHNIQUE: Multidetector CT through the abdomen and pelvis with and without\n IV and oral contrast. Arterial, venous and delayed images were obtained,\n coronal and sagittal reformations are also provided.\n\n FINDINGS: There is a small liver with nodular contours. In segment II of the\n liver, there is a tiny 4-mm transient hyperenhancing foci seen only in the\n arterial phase. Also in segment II, there is a hypodense nonenhancing foci\n too small to be characterized unchanged from the prior study. There is no\n biliary duct dilatation. The gallbladder, pancreas, adrenal glands and kidneys\n are unremarkable. There is no hydronephrosis. The aorta is normal in\n caliber. The portal vein, celiac, SMA, renal arteries, and splenic veins\n are widely patent. Multiple dilated varices are seen in the upper left\n quadrant. There is an unchanged moderate splenomegaly.\n\n The entire infrahepatic IVC is markedly collapsed and slit-like. The\n retrohepatic segment of the IVC is very stenotic with a string appeareance. At\n the confluence of the hepatic veins there is an hypodense round region in the\n left side of the IVC - uncertain if is partial volume or thrombus in the IVC\n given it is seen only on one image. The hepatic veins are patent. These\n findings are stable from but new from .\n\n Multiple portal, celiac and retroperitoneal lymph nodes are present, none of\n which meet CT criteria of pathology.\n\n Unchanged moderate-to-large amount of ascites. The bowel loops are\n unremarkable. There is no colonic wall thickening.\n\n PELVIC CT WITH ORAL AND IV CONTRAST: The rectum, sigmoid colon and bladder\n are unremarkable. There is no lymphadenopathy.\n\n BONE WINDOWS: There are no concerning bone lesions. Unchanged tiny bone\n (Over)\n\n 3:08 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: evaluate biliary ducts for patency, r/o focal mass in liver.\n Admitting Diagnosis: SHORTNESS OF BREATH\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n island in the left ilium.\n\n CT reformations confirm the findings seen in the axial images and were\n invaluable in the assessment of the IVC.\n\n IMPRESSION:\n 1. Cirrhosis and portal hypertension.\n 2. Moderate-to-large amount of ascites.\n 3. Abnormal IVC with collapse of the infrahepatic IVC and string appeareance\n of the retrohepatic IVC; may be seen with low intravascular volume. Small\n thromus in the retrohepatic IVC cannot be excluded; doppler ultrasound\n recommended. In addition, there is a hypodense region at the confluence of the\n hepatic veins; probably from volume average.\n\n\n\n"},{"category":"Radiology","chartdate":"2169-02-10 00:00:00.000","description":"DISTINCT PROCEDURAL SERVICE","row_id":901243,"text":" 7:35 PM\n US ABD LIMIT, SINGLE ORGAN; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Please evaluate for portal vein clot, ascites. If ascites,\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with hep C cirrhosis, increasing abdominal pain and ascites,\n please r/p portal vein clot, ascites.\n REASON FOR THIS EXAMINATION:\n Please evaluate for portal vein clot, ascites. If ascites, please mark for\n diagnostic tap.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hepatitis C cirrhosis, increasing abdominal pain.\n\n COMPARISON: .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is again echogenic consistent with\n cirrhosis. There is a small amount of ascites surrounding the liver. The\n gallbladder wall is again thickened, consistent with the background of\n ascites. The main portal vein is patent with appropriate direction of flow.\n There is no intrahepatic biliary ductal dilatation. The right kidney does not\n have hydronephrosis and measures 13 cm. There is a small amount of fluid\n within the right lower quadrant, left upper quadrant, and no significant free\n fluid in the left lower quadrant.\n\n IMPRESSION:\n\n 1. Patent portal vein.\n\n 2. Small amount of ascites around the liver.\n\n"},{"category":"Radiology","chartdate":"2169-03-06 00:00:00.000","description":"DISTINCT PROCEDURAL SERVICE","row_id":904290,"text":" 2:28 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: please mark for liver biopsy as well as assess arterial/\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p liver transplant with elevated lfts now 11 days postop\n REASON FOR THIS EXAMINATION:\n please mark for liver biopsy as well as assess arterial/venous flow and ductal\n obstruction\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND OF THE TRANSPLANTED LIVER\n\n There is a comparison exam from .\n\n CLINICAL HISTORY: 11 days post-op liver transplant, now elevated LFTs.\n\n FINDINGS: The liver echotexture and echogenicity are normal. There is no\n biliary dilatation. No masses are present in the liver.\n\n Portal venous flow is hepatopetal, peak velocity is approximately 100 cm/sec.\n Hepatic arterial waveform tracings demonstrate brisk upstroke. Resistive\n index in the right hepatic artery is 0.78, the RI in the left hepatic artery\n is 0.74. Resistive index in the main hepatic artery is 0.71. The right and\n left portal veins are patent. The IVC and hepatic veins are patent.\n\n The common duct is not dilated measuring 3 mm in diameter.\n\n The spleen is enlarged measuring 16 cm in length.\n\n New since the previous exam is a small amount of free fluid inferior to the\n right lobe of liver.\n\n The right kidney measures 11.8 cm in length, images of the left kidney were\n not acquired.\n\n IMPRESSION:\n 1. Normal hepatic vasculature.\n 2. New since the previous exam is a small 3-6 cm collection of free fluid\n inferior to the liver. This may represent a bile leak or a small amount of\n ascites. These findings were relayed to the clinical service on .\n\n\n\n\n\n (Over)\n\n 2:28 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: please mark for liver biopsy as well as assess arterial/\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2169-03-06 00:00:00.000","description":"GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)","row_id":904285,"text":" 2:28 PM\n BX-NEEDLE LIVER BY RADIOLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \n Reason: please do liver transplant u/s guided biopsy. assess art/\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with rising lfts s/p liver transplant\n REASON FOR THIS EXAMINATION:\n please do liver transplant u/s guided biopsy. assess art/venuos flow as well as\n for ductal obstruction. please call pathology for rush processing. Txs\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Elevated LFTs, status post liver transplant x11 days.\n\n FINDINGS: The risks and benefits of the procedure were explained to the\n patient. Informed written consent was obtained. A suitable region of the\n liver for biopsy was identified using ultrasound. The skin over the liver was\n prepped and draped in the usual sterile fashion. A preprocedure timeout was\n called to confirm the patient's identity and type of procedure to be\n performed. The patient was given lidocaine as a local anesthetic. A nurse\n administered fentanyl and versed intravenously. An 18 gauge core biopsy\n needle was inserted into the liver. A single specimen was obtained. The\n patient tolerated the procedure satisfactorily. The attending physician, .\n , was present throughout the entire procedure.\n\n IMPRESSION: Successful core biopsy of the transplanted liver.\n\n"},{"category":"Radiology","chartdate":"2169-03-04 00:00:00.000","description":"DISTINCT PROCEDURAL SERVICE","row_id":904096,"text":" 1:31 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: now with elevated LFT, please assess for flow to hepatic art\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n now with elevated LFT, please assess for flow to hepatic artery, hepatic vein\n and portal vein.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old man status post liver transplant with elevated LFTs.\n Evaluate hepatic artery, hepatic vein and portal vein.\n\n 2-D, color flow, and Doppler exams of the abdomen were performed. No focal\n abnormalities are seen within the liver. Within the gallbladder fossa, there\n is a small fluid collection, which may represent post-surgical fluid\n collection status post cholecystectomy. The right kidney is unremarkable and\n measures 13.7 cm.\n\n Unremarkable flow and waveforms are seen within the hepatic arterial, portal\n venous, and hepatic venous systems. There is no visualized thrombus or\n stenosis.\n\n IMPRESSION: Patent portal venous, hepatic venous and hepatic arterial\n vasculature with appropriate directional flow and waveforms. The findings\n were discussed with Transplant team at the time of dictation.\n\n"},{"category":"Radiology","chartdate":"2169-02-26 00:00:00.000","description":"DISTINCT PROCEDURAL SERVICE","row_id":903170,"text":" 10:30 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: S/P TRANSPLANT PLEASE ASSESS PATENCY OF VESSELS\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p liver transplant\n REASON FOR THIS EXAMINATION:\n Please assess for patency of hepatic vein/artery, portal vein\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 51-year-old man status post liver transplant. Postoperative day\n #1.\n\n COMPARISONS: and .\n\n TECHNIQUE: Right upper quadrant ultrasound examination, with duplex Doppler\n evaluation of the transplanted liver.\n\n FINDINGS: The echotexture of the transplanted liver is somewhat coarse, as is\n anticipated in a recent transplant, but no focal lesions or surrounding fluid\n or hematoma are identified. There is no intrahepatic biliary ductal\n dilatation.\n\n On duplex Doppler examination, the main portal vein shows mild turbulence, but\n the main portal vein and its major tributaries, including the left portal\n vein, the anterior and posterior right portal venous branches, are patent with\n appropriate hepatopetal flow. The right, middle and left hepatic veins appear\n patent.\n\n No hepatic arterial flow is seen upon examination of the porta hepatis, or at\n the expected positions of the right and left hepatic arteries. This appearance\n is concerning for occlusion.\n\n The infrahepatic inferior vena cava is patent.\n\n IMPRESSION: No hepatic arterial flow identified, concerning for occlusion.\n Findings were discussed in the course of the study by the technologist, and\n immediately afterward with Dr. by Dr. .\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-02-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1591301,\n \"text\": \"s/p liver transplant\\nplease see careview for details.\\n\\nneuro: sedated on propofol, but following commands, nodding appropriately. perl. mae.\\n\\ncv: afeb, nsr, bp stable. filling pressures low. 2 u ffp for inr 1.8, with subsequent temporary increase in pressures.\\n\\npulm: vented 50%, cmv, alkalotic. decrease in tv. bs coarse to rhonchorous. sx for thick bloody.\\n\\ngi: ng to lcws draining bilious. bowel sounds present, hypoactive.\\n\\ngu: u/o qs.\\n\\nPlan: wean as tolerated, check abg's as ordered. medicate for pain as needed.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-02-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1591302,\n \"text\": \"npn\\n Pt is a+o, c/o pain q1-2- rx with 2 mg ivp mso4 q with relief, pearl, mae. Did receive 100 mcg fentanyl in Angio.\\n\\nResp- extubated this am and tol hh face tent with .40 fio2. lungs clear upper- at bases. coughing up old lg blood clots- nasal packing cont in place from nose bleed in OR- no new nose bleeding seen.\\n\\nGI- ogt dc when extubated- denies nausea. Cont npo. Liver US done at bedside this pm and ? of low arterial flow reported- pt taken to angio for more eval- transplant team plan at this time is to cont to follow lab trends and redo US- also plan to repeat angio in days- lfts's/amylase have been trending down since OR_ will cont to check labs pr transplant request.\\n\\nHemodynmics- Pa stilll in place- see flow sheet for all #'S. Sbp 130's 160's, nsr, denies chest pain,\\n\\nHeme- rec 2 ffp this am for inr 1.8 and rec 2 pack platelets in angio for count 66.\\nPLAN_ cont to follow q1 labs pr sicu protocl, labs pr transplant req, ? to repeat liver US to noc.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-02-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1591303,\n \"text\": \"Please see careview for details\\n\\nneuro: . some slight tremors of arms and hands, pt states they were worse pre-op. oriented x 3.\\n\\ncv: stable\\n\\npulm: bs clear, diminished rt base. sats mid 90's on 50% face shovel.\\n\\nENT: nasal packing removed this am with no signs of repeat epistaxis at this time.\\n\\ngi: bowel sounds present, no flatus. taking ice chips.\\n\\ngu: u/o qs.\\n\\npain: pt states his pain is , dropping to only after each dose of pain medication. will approach team for change or increase im mso4.\\n\\nincision: sm amts serous drainage. dsd changed x 1m then again this am by ho's.\\nPossible repeat liver U/S today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-02-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1591298,\n \"text\": \"respiratory care\\npt admitted from OR placed on vent tol well see respiratory page of care view for more information\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-02-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1591299,\n \"text\": \"Nsg admit Note\\n51 yo male with hx iv drug/etoh use in past with etoh cirrhosis/hep c. S/P liver transplant - requiring multi blood produsts in OR_ (see I+O flow sheet or OR flow sheet for totals). In SICU rec 1 unit prbc for hct 28- 1 pack platelet for count 92- and 2 ffp for INR 1.6. Pt intubated with pa in place- (see flow sheet for co, cvp, svo2, etc) JP x2 with sang drg, no t tube, ogt lcws with bili drg, abd drsg sang drg- drsg . Nasal packing in place as nose bleed in OR- cont md aware- labs to be done q8- next due 8 pm tonoc. Requiring insulin gtt for glucose >200- gtt at 5u/hr with 10 cc d5w pr Dr request. Propofol gtt weaning as tol, but not able to turn off as sbp >170 when off. Dr aware- propofol now at 20mcg/kg/min. Pearl, not following commands at this time- was not reversed from sedation/paralytic rec. in OR. Foley to gravity- uo 100-500/hr- did rec lasix x1 in OR. sister is his proxy- family in this pm- plan to call for updates- they also spoke with Dr for surgical updates post op.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-02-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1591300,\n \"text\": \"RESPIRATORY CARE 1900-0700\\nPT REMAINS ORALLY INTUBATED ON AC. Vt CHANGED FROM 600ml TO 550ml, NO OTHER CHANGES MADE TO VENT THROUGHOUT THE NIGHT. BS CLEAR TO COARSE SX FOR MINIMAL RETURN. RSBI THIS AM= 29. SEE CAREVUE FOR FURTHER QUESTIONS.\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2169-02-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 64347,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Liver transplant, hemodynamic monitoring\\nStatus: Inpatient\\nDate/Time: at 08:33\\nTest: TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Moderate LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size.\\n\\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\\natherosclerotic plaque.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Physiologic MR (within\\nnormal limits).\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\\n(normal) PR.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. The patient was under\\ngeneral anesthesia throughout the procedure.\\n\\nConclusions:\\nThe left atrium is moderately dilated. Left ventricular wall thicknesses and\\ncavity size are normal. Right ventricular chamber size and free wall motion\\nare normal. The ascending, transverse and descending thoracic aorta are normal\\nin diameter and free of atherosclerotic plaque. The aortic valve leaflets (3)\\nare mildly thickened. No aortic regurgitation is seen. The mitral valve\\nleaflets are mildly thickened. Physiologic mitral regurgitation is seen\\n(within normal limits).\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-03-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 135398,\n \"text\": \"Sinus rhythm, rate 73. Since the previous tracing of the T waves are\\nmore inverted in lead III. No other changes are present.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-02-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 135399,\n \"text\": \"Sinus rhythm. Long QTc interval. Compared to the previous tracing\\nof no significant change.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-02-12 00:00:00.000\",\n \"description\": \"CT PELVIS W/CONTRAST\",\n \"row_id\": 901385,\n \"text\": \" 3:08 PM\\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \\n CT 150CC NONIONIC CONTRAST\\n Reason: evaluate biliary ducts for patency, r/o focal mass in liver.\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with hep C/ETOH cirrhosis,on transplant list now presenting\\n with epigastric pain, elevated total bilirubin, and elevated lipase.\\n REASON FOR THIS EXAMINATION:\\n evaluate biliary ducts for patency, r/o focal mass in liver. assess degree of\\n bowel edema (if any)\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n PROCEDURE: Abdomen and pelvis CT.\\n\\n HISTORY: 51-year-old man with hepatitis C/ETOH cirrhosis with epigastric\\n pain, elevated total bilirubin and elevated lipase. Assess for focal liver\\n masses and biliary duct.\\n\\n TECHNIQUE: Multidetector CT through the abdomen and pelvis with and without\\n IV and oral contrast. Arterial, venous and delayed images were obtained,\\n coronal and sagittal reformations are also provided.\\n\\n FINDINGS: There is a small liver with nodular contours. In segment II of the\\n liver, there is a tiny 4-mm transient hyperenhancing foci seen only in the\\n arterial phase. Also in segment II, there is a hypodense nonenhancing foci\\n too small to be characterized unchanged from the prior study. There is no\\n biliary duct dilatation. The gallbladder, pancreas, adrenal glands and kidneys\\n are unremarkable. There is no hydronephrosis. The aorta is normal in\\n caliber. The portal vein, celiac, SMA, renal arteries, and splenic veins\\n are widely patent. Multiple dilated varices are seen in the upper left\\n quadrant. There is an unchanged moderate splenomegaly.\\n\\n The entire infrahepatic IVC is markedly collapsed and slit-like. The\\n retrohepatic segment of the IVC is very stenotic with a string appeareance. At\\n the confluence of the hepatic veins there is an hypodense round region in the\\n left side of the IVC - uncertain if is partial volume or thrombus in the IVC\\n given it is seen only on one image. The hepatic veins are patent. These\\n findings are stable from but new from .\\n\\n Multiple portal, celiac and retroperitoneal lymph nodes are present, none of\\n which meet CT criteria of pathology.\\n\\n Unchanged moderate-to-large amount of ascites. The bowel loops are\\n unremarkable. There is no colonic wall thickening.\\n\\n PELVIC CT WITH ORAL AND IV CONTRAST: The rectum, sigmoid colon and bladder\\n are unremarkable. There is no lymphadenopathy.\\n\\n BONE WINDOWS: There are no concerning bone lesions. Unchanged tiny bone\\n (Over)\\n\\n 3:08 PM\\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \\n CT 150CC NONIONIC CONTRAST\\n Reason: evaluate biliary ducts for patency, r/o focal mass in liver.\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n island in the left ilium.\\n\\n CT reformations confirm the findings seen in the axial images and were\\n invaluable in the assessment of the IVC.\\n\\n IMPRESSION:\\n 1. Cirrhosis and portal hypertension.\\n 2. Moderate-to-large amount of ascites.\\n 3. Abnormal IVC with collapse of the infrahepatic IVC and string appeareance\\n of the retrohepatic IVC; may be seen with low intravascular volume. Small\\n thromus in the retrohepatic IVC cannot be excluded; doppler ultrasound\\n recommended. In addition, there is a hypodense region at the confluence of the\\n hepatic veins; probably from volume average.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-02-10 00:00:00.000\",\n \"description\": \"DISTINCT PROCEDURAL SERVICE\",\n \"row_id\": 901243,\n \"text\": \" 7:35 PM\\n US ABD LIMIT, SINGLE ORGAN; -59 DISTINCT PROCEDURAL SERVICE Clip # \\n DUPLEX DOP ABD/PEL LIMITED\\n Reason: Please evaluate for portal vein clot, ascites. If ascites,\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with hep C cirrhosis, increasing abdominal pain and ascites,\\n please r/p portal vein clot, ascites.\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for portal vein clot, ascites. If ascites, please mark for\\n diagnostic tap.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Hepatitis C cirrhosis, increasing abdominal pain.\\n\\n COMPARISON: .\\n\\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is again echogenic consistent with\\n cirrhosis. There is a small amount of ascites surrounding the liver. The\\n gallbladder wall is again thickened, consistent with the background of\\n ascites. The main portal vein is patent with appropriate direction of flow.\\n There is no intrahepatic biliary ductal dilatation. The right kidney does not\\n have hydronephrosis and measures 13 cm. There is a small amount of fluid\\n within the right lower quadrant, left upper quadrant, and no significant free\\n fluid in the left lower quadrant.\\n\\n IMPRESSION:\\n\\n 1. Patent portal vein.\\n\\n 2. Small amount of ascites around the liver.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-03-06 00:00:00.000\",\n \"description\": \"DISTINCT PROCEDURAL SERVICE\",\n \"row_id\": 904290,\n \"text\": \" 2:28 PM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \\n DUPLEX DOPP ABD/PEL\\n Reason: please mark for liver biopsy as well as assess arterial/\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man s/p liver transplant with elevated lfts now 11 days postop\\n REASON FOR THIS EXAMINATION:\\n please mark for liver biopsy as well as assess arterial/venous flow and ductal\\n obstruction\\n ______________________________________________________________________________\\n FINAL REPORT\\n ULTRASOUND OF THE TRANSPLANTED LIVER\\n\\n There is a comparison exam from .\\n\\n CLINICAL HISTORY: 11 days post-op liver transplant, now elevated LFTs.\\n\\n FINDINGS: The liver echotexture and echogenicity are normal. There is no\\n biliary dilatation. No masses are present in the liver.\\n\\n Portal venous flow is hepatopetal, peak velocity is approximately 100 cm/sec.\\n Hepatic arterial waveform tracings demonstrate brisk upstroke. Resistive\\n index in the right hepatic artery is 0.78, the RI in the left hepatic artery\\n is 0.74. Resistive index in the main hepatic artery is 0.71. The right and\\n left portal veins are patent. The IVC and hepatic veins are patent.\\n\\n The common duct is not dilated measuring 3 mm in diameter.\\n\\n The spleen is enlarged measuring 16 cm in length.\\n\\n New since the previous exam is a small amount of free fluid inferior to the\\n right lobe of liver.\\n\\n The right kidney measures 11.8 cm in length, images of the left kidney were\\n not acquired.\\n\\n IMPRESSION:\\n 1. Normal hepatic vasculature.\\n 2. New since the previous exam is a small 3-6 cm collection of free fluid\\n inferior to the liver. This may represent a bile leak or a small amount of\\n ascites. These findings were relayed to the clinical service on .\\n\\n\\n\\n\\n\\n (Over)\\n\\n 2:28 PM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \\n DUPLEX DOPP ABD/PEL\\n Reason: please mark for liver biopsy as well as assess arterial/\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-03-06 00:00:00.000\",\n \"description\": \"GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)\",\n \"row_id\": 904285,\n \"text\": \" 2:28 PM\\n BX-NEEDLE LIVER BY RADIOLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \\n Reason: please do liver transplant u/s guided biopsy. assess art/\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 52 year old man with rising lfts s/p liver transplant\\n REASON FOR THIS EXAMINATION:\\n please do liver transplant u/s guided biopsy. assess art/venuos flow as well as\\n for ductal obstruction. please call pathology for rush processing. Txs\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Elevated LFTs, status post liver transplant x11 days.\\n\\n FINDINGS: The risks and benefits of the procedure were explained to the\\n patient. Informed written consent was obtained. A suitable region of the\\n liver for biopsy was identified using ultrasound. The skin over the liver was\\n prepped and draped in the usual sterile fashion. A preprocedure timeout was\\n called to confirm the patient's identity and type of procedure to be\\n performed. The patient was given lidocaine as a local anesthetic. A nurse\\n administered fentanyl and versed intravenously. An 18 gauge core biopsy\\n needle was inserted into the liver. A single specimen was obtained. The\\n patient tolerated the procedure satisfactorily. The attending physician, .\\n , was present throughout the entire procedure.\\n\\n IMPRESSION: Successful core biopsy of the transplanted liver.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-03-04 00:00:00.000\",\n \"description\": \"DISTINCT PROCEDURAL SERVICE\",\n \"row_id\": 904096,\n \"text\": \" 1:31 PM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \\n DUPLEX DOPP ABD/PEL\\n Reason: now with elevated LFT, please assess for flow to hepatic art\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man s/p liver transplant\\n\\n REASON FOR THIS EXAMINATION:\\n now with elevated LFT, please assess for flow to hepatic artery, hepatic vein\\n and portal vein.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 51-year-old man status post liver transplant with elevated LFTs.\\n Evaluate hepatic artery, hepatic vein and portal vein.\\n\\n 2-D, color flow, and Doppler exams of the abdomen were performed. No focal\\n abnormalities are seen within the liver. Within the gallbladder fossa, there\\n is a small fluid collection, which may represent post-surgical fluid\\n collection status post cholecystectomy. The right kidney is unremarkable and\\n measures 13.7 cm.\\n\\n Unremarkable flow and waveforms are seen within the hepatic arterial, portal\\n venous, and hepatic venous systems. There is no visualized thrombus or\\n stenosis.\\n\\n IMPRESSION: Patent portal venous, hepatic venous and hepatic arterial\\n vasculature with appropriate directional flow and waveforms. The findings\\n were discussed with Transplant team at the time of dictation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-02-26 00:00:00.000\",\n \"description\": \"DISTINCT PROCEDURAL SERVICE\",\n \"row_id\": 903170,\n \"text\": \" 10:30 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \\n DUPLEX DOPP ABD/PEL\\n Reason: S/P TRANSPLANT PLEASE ASSESS PATENCY OF VESSELS\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man s/p liver transplant\\n REASON FOR THIS EXAMINATION:\\n Please assess for patency of hepatic vein/artery, portal vein\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: 51-year-old man status post liver transplant. Postoperative day\\n #1.\\n\\n COMPARISONS: and .\\n\\n TECHNIQUE: Right upper quadrant ultrasound examination, with duplex Doppler\\n evaluation of the transplanted liver.\\n\\n FINDINGS: The echotexture of the transplanted liver is somewhat coarse, as is\\n anticipated in a recent transplant, but no focal lesions or surrounding fluid\\n or hematoma are identified. There is no intrahepatic biliary ductal\\n dilatation.\\n\\n On duplex Doppler examination, the main portal vein shows mild turbulence, but\\n the main portal vein and its major tributaries, including the left portal\\n vein, the anterior and posterior right portal venous branches, are patent with\\n appropriate hepatopetal flow. The right, middle and left hepatic veins appear\\n patent.\\n\\n No hepatic arterial flow is seen upon examination of the porta hepatis, or at\\n the expected positions of the right and left hepatic arteries. This appearance\\n is concerning for occlusion.\\n\\n The infrahepatic inferior vena cava is patent.\\n\\n IMPRESSION: No hepatic arterial flow identified, concerning for occlusion.\\n Findings were discussed in the course of the study by the technologist, and\\n immediately afterward with Dr. by Dr. .\\n\\n\"\n }\n]"}}},{"rowIdx":24684,"cells":{"subject_id":{"kind":"number","value":14535,"string":"14,535"},"hadm_id":{"kind":"number","value":162571,"string":"162,571"},"target_text":{"kind":"string","value":"Pt. was a same day admit to the operating room. She was brought to the OR and after general anesthesia pt. underwent a mitral valve replcement for severe MR/MVP. Please see operative note for full surgical details. Pt. tolerated the procedure well with a total CPB time of 115 minutes and XCT of 94 minutes. Pt. was transferred to CSRU in stable condition with a MAP of 76, CVP 13, PAD 16, 23, HR 77 A-paced and being titrated on neosynephrine and propofol drips. That night pt. suddenly went into V. Fib. arrest and was quickly converted with electric cardioversion. A lidocaine bolus and Iv drip were also started. Pt. remained sedated and intubated overnight. POD #1 - Pt. was in NSR and Propofol was weaned early morning and pt. became awake and alert. She was then extubated, breathing well and neurologically intact. Lidocaine was d/c'd and lopressor and lasix was started. POD #2 - Remained in the ICU secondary to Neo support. HR sinus in 50-60s (paced in 80s). Chest Tubes & Foley removed. Coumadin Started. POD #3 - Pt. had run of A.Fib/A. Flutter in AM. Back in SR after lopressor. POD #4 - Pt. had another brief run of A. flutter and self converted. She is stable and was trnaferred to 2 today. POD #5 - Pacing wires removed. Pt. hemodynam. stable. Encouraged pt to continue PT and increase activity. POD #6 - Pt. at level 5. Doing well with some complications post-op. D'C'd home today with VNA. D/C PE: VS: T 97.7 P 83 SR BP 125/53 RR 18 Neuro: alert, oriented, non-focal Pulm: CTAB Cardiac: RRR Sternum: stable, incision c&d, -drainage/erythema Abd: soft, NT/ND +BS Ext: Warm, 1+ edema"},"extractive_notes_summ":{"kind":"string","value":"TOL CLEAR LIQS.ENDO: FS QID. LIDOCAINE GTT DC'D THIS AM. continue with lidocaine and neo gtts. ATTEMPT TO WEAN NEO GTT AS TOLERATES. will wake and wean this am.gi/gu: foley to gravity. CT WITH MOD SEROSANG DRNG. PT BP LABILE , INITIAL CI 1.4 TX 1L LR NOW 2.1. TITRATE NEO PRN. RECIEVED COUMADIN THIS PM.RESP: LUNGS CLEAR WITH DIM BILATERAL BASES. CT dc'dgi/gu: pt with + bs. using IS gi/gu: pt with + bs. wake and wean to extubate this am. CONTINUES ON NEO AND LIDO. ALINE DAMPENED AND NBP APPLIED FOR READINGS. COVER PER RISS. BS POSITIVE-> HYPOACTIVE. There is aortic calcification. ABD SOFT.GU: PT WITH LARGE UOP AFTER AM LASIX. PM LASIX UNTIL BP IMPROVES. HAD HR IN THE LOW 90'S NSR.REVERTS BACK TO PACING.VOIDING IN GOOD QUANTITIES POST FOLEY REMOVAL; (PO LASIX GIVEN).DENIES PAIN. IMPRESSION: Status post mitral valve replacement, with multiple tubes and lines positioned as described. DRAINING MODERATE SEROSANGUINOUS FLUID. pad 13-17, cvp 6-11, ci > 2.1. dopplerable pedal pulses bilaterally.resp: lungs clear. MAE and able to follow commandsCV: pt in NSR. ABSENT BSGU: LG AMT CLEAR UOPPLAN: REMAIN INTUBATED OVERNGIHT, CHECK NEURO STATUS, HAVE READY TO EXTUBATE FOR ROUNDS AT 0600. CONT ASSESS CARDIO/RESP STATUS, AND REPLETE LYTES PRN. SUPINE AP CHEST: There has been interval median sternotomy. VAVLE EXTREMELY CALCIFIED PER DR. . S/P MVR,EZ intubation # 7.0 @ 18 cm lips.Not much past med story.BS clear,on mechanical ventilation will wean to extubate. ambulated x2. A mediastinal drain and left chest tube are in place. Sternotomy wires and a mitral valve replacement are noted. CONTINUE WITH COUMADIN FOR ANTICOAGULATION. BP stable. PLACEMENT CONFIRMED BY AUSCULTATION. PT. PT. OOB TO COMMODE X1. SWAN DC'D, CORDIS ALINE IN. FOLEY PATENT.ENDO: BS HIGHER AFTER PM ANTBX AND JUICE, COVERED WITH SSR PER PROTOCOLPLAN: CONT TO TRY TO WEAN NEO TO KEEP MAP>60. OCC. PERRRLACV: SEE EVENTS ABOVE. tolerated cardiac diet. PERSISTENT NEO REQUIREMNT AT 1MCG WITH MAP 60-67. Cannot exclude myocardial ischemia.Compared to the previous tracing of the rhythm has changed. ONCE PT SPONT INTO VF AT 1830 (<1 MIN) PT 200J X1 TO NSR 80'S, LIDO BOLUS AND GTT STARTED, MAG UP , DR. AND DR. TOL. perrl.cv: sr 60-70's, rare pvc noted. PT STARTED ON COUMADIN THIS PM FOR CALCIFIED AORTA PER DR. .RESP: LUNG DIM AT BASE BUT OTHERWISE CLEAR. ENCOURAGE COUGH, DEEP BREATHING, AND IS USE.GI/GU: FOLEY TO GRAVITY. CONTINUE LIDO OVERNIGHT. PT UNEVENTFUL OR RECIEVED IUPRBC. pt recieved 4 mg coumadin this eveningresp: LS clear with dim bases bil. requiring fluid replacement. tolerting cardiac diet. CONT CURRENT PLAN OF CARE pt recieved 2 mg coumadin this evening.resp: LS clear. SBP dropped into the 80's this am -> neo gtt started. PT NEEDING FREQUENT LYTE REPLACEMENT SECONDARY DIURESIS. VERY HYPOACTIVE BS. PM DOSE LOWERED . GOOD HUO. EXTUBATED AT 0630 WITHOUT DIFFICULTY. MONITOR PT/PTT/INR FOR COUMADIN DOSE. DR. ADVANCE DIET PRN, FOLLOW COAGS NOW ON COUMADIN. COMPARISON: . ct to 20 cm suction, minimal serosanguinous drainage noted. continue with phenylephrine gtt to keep map 60-90. required 3 liters of volume r/t autodiuresis. large uo immediately post-op. MONITOR PT/INR WHILE ON COUMADIN THERAPY. 7P-7A:NEURO: ALERT AND ORIENTED X 3. An endotracheal tube is in place, with the tip approximately 2 cm from the carina. ASSESS UNDERLYING RHYTHM. PT ALSO C/O DIZZINESS AND NEO WHEN OOB, TX WITH REGLAN 5MG IV CONT ONLY TOL CLEARS. PLAN: CONT TITRATE NEO AS TOL TO MAINTIAN MAPS>60. WANTS PT AWOKEN AND NEURO STATUS CHECKED AND THEN CAN BE RESEDATED. remains on RA -> o2 sats 94-96%. CURRENTLY NSR 80'S NO FURTHER ECTOPY. o2 sat remains > 99%. PT C/O LOWER BACK PAIN THAT IS POSITIONAL, AND STERNAL INCISION PAIN PERCOCET STARTEDCV: HR 70'S NSR RARE PVC AND COUPLET NOTED. ExtensiveST-T wave changes may be due to rate. physical therapy into see pt. PT REQUIRING INCREASE NEO. PALP PEDAL PULSES. PALPABLE PEDAL PULSES BILATERALLY. REEVAL NEED FOR LASIX LYTES BEING REPLETED. abdomen soft, nd. ABDOMEN SOFT, ND. TRANSFERRING BED TO CHAIR/COMMODE WITH EASE.REMAINS A-PACED FOR BP. complete post-op antibiotic course. 7am-7pm updateNEURO: pt alert and orientated x 3. foley dc'd at 1500 -> pt has not voided sinceendo: elvated bs treated with ss reg insulin per protocolplan: transfer to 2, pulm toliet, pain control, advance diet and activity as tolerated propofol weaned to off-> pt able to follow all commands and mae. The course of the Swan-Ganz catheter is mostly smooth, except for a slight angulation at the cavoatrial junction. 7am-7pm updateneuro: pt alert and orienated x3. GLUCOSE MANAGEMENT AS NEEDED. NEO GTT CONTINUES TO KEEP MAP> 60. neo gtt weaned to off this afternoon. NEURO: ALERT AND ORIENTED X3. suctioned for scant amount thick clear secretions. orally intubated on full ventilator support. USING CALL LIGHT TO CALL FOR COMMODE PRIVELAGES. percocets given for incisional painplan: monitor rhythm, 2 in am, pulm toliet, pain control, advance activity as tolerated, continue coumadin ABD SOFT. There is a right internal jugular approach Swan-Ganz catheter, with the tip overlying the expected right pulmonary artery. CONTINUE TO ADVANCE ACTIVITIES AND DAT. Atrial flutter with rapid ventricular response with 2:1 A-V block. PALP PEDAL PULSES, MINIMAL CT DRNG--A WIRES SENSE AND CAPTURE, V WIRES NOT CHECKED DUE TO VF.RESP: LUNGS CLEAR THROUGHOUT. INCISIONS CDI.PLAN: MONITOR HEMODYNAMICS. FILLING PRESSURE EUVOLEMIC, SVO2 70-80%. ogt to lws suction draining bilious drainage. 7p-7a:neuro: sedated on propofol. electrolytes repleted. ELECTROLYTES REPLETED. carafate and zantac for gi prophylaxis.endo: regular insulin gtt started for bg 160. titrated per protocol with bs 100 presently.plan: monitor hemodynamics. An NG tube terminates with the tip in the fundus of the stomach. SBP now 90-100's. ADDENDUM:LIDOCAINE AT 2 MG/MIN. NOW TOLERATING PO MEDS AND CLEARS, WILL ADVANCE DIET. PERCOCET PRN BACK PAIN.CV: A PACED AT 80 FOR BP SUPPORT, NO ECTOPY NOTED."},"n_notes":{"kind":"number","value":15,"string":"15"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2148-03-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":857760,"text":" 7:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for lines, tube, and pneumothorax\n Admitting Diagnosis: MR\\MITRAL VALVE REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman s/p mitral valve replacement\n REASON FOR THIS EXAMINATION:\n eval for lines, tube, and pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post mitral valve replacement.\n\n COMPARISON: .\n\n SUPINE AP CHEST: There has been interval median sternotomy. Sternotomy wires\n and a mitral valve replacement are noted. An endotracheal tube is in place,\n with the tip approximately 2 cm from the carina. There is a right internal\n jugular approach Swan-Ganz catheter, with the tip overlying the expected right\n pulmonary artery. The course of the Swan-Ganz catheter is mostly smooth,\n except for a slight angulation at the cavoatrial junction. An NG tube\n terminates with the tip in the fundus of the stomach. A mediastinal drain and\n left chest tube are in place. The cardiac and mediastinal contours are\n relatively stable. There is aortic calcification. The lungs are clear,\n without vascular congestion or consolidation. There may be a small left\n effusion. No pneumothorax detected on this supine radiograph.\n\n IMPRESSION:\n\n Status post mitral valve replacement, with multiple tubes and lines positioned\n as described. No pneumothorax detected.\n\n\n"},{"category":"ECG","chartdate":"2148-03-10 00:00:00.000","description":"Report","row_id":193023,"text":"Atrial flutter with rapid ventricular response with 2:1 A-V block. Extensive\nST-T wave changes may be due to rate. Cannot exclude myocardial ischemia.\nCompared to the previous tracing of the rhythm has changed.\n\n"},{"category":"ECG","chartdate":"2148-03-07 00:00:00.000","description":"Report","row_id":193024,"text":"Sinus rhythm\nInferior/lateral ST-T changes may be due to myocardial ischemia\nSince previous tracing of , no significant change\n\n"},{"category":"Nursing/other","chartdate":"2148-03-09 00:00:00.000","description":"Report","row_id":1451916,"text":"7P-7A:\nNEURO: ALERT AND ORIENTED X 3. MAE, ABLE TO FOLOW ALL COMMANDS. PERCOCET PRN BACK PAIN.\n\nCV: A PACED AT 80 FOR BP SUPPORT, NO ECTOPY NOTED. ELECTROLYTES REPLETED. NEO GTT CONTINUES TO KEEP MAP> 60. LASIX DOSE HELD LAST NIGHT SECONDARY TO OVERDIURESIS AND BP SUPPORT. PALPABLE PEDAL PULSES BILATERALLY. RECIEVED COUMADIN THIS PM.\n\nRESP: LUNGS CLEAR WITH DIM BILATERAL BASES. O2 SAT 98% ON 2L NC. CT TO 20 CM SXN, NO AIRLEAK NOTED. DRAINING MODERATE SEROSANGUINOUS FLUID. ENCOURAGE COUGH, DEEP BREATHING, AND IS USE.\n\nGI/GU: FOLEY TO GRAVITY. GOOD HUO. ABDOMEN SOFT, ND. BS POSITIVE-> HYPOACTIVE. TOL CLEAR LIQS.\n\nENDO: FS QID. COVER PER RISS. INCISIONS CDI.\n\nPLAN: MONITOR HEMODYNAMICS. ATTEMPT TO WEAN NEO GTT AS TOLERATES. INCREASE ACTIVITY AND DIET AS TOLERATES. CONTINUE WITH COUMADIN FOR ANTICOAGULATION.\n"},{"category":"Nursing/other","chartdate":"2148-03-09 00:00:00.000","description":"Report","row_id":1451917,"text":"7am-7pm update\nneuro: pt alert and orienated x3. MAE and able to follow commands. PERRL\n\nCv: Pt A paced at 88 (for bp support), underlything rhythm NSR in the 70's. no ectopy noted. SBP dropped into the 80's this am -> neo gtt started. SBP now 90-100's. neo gtt weaned to off this afternoon. pt recieved 4 mg coumadin this evening\n\n\nresp: LS clear with dim bases bil. pt on 2 l nc, o2 sats >96%. CT dc'd\n\ngi/gu: pt with + bs. tolerated cardiac diet. foley dc'd at 1500 -> pt has not voided since\n\nendo: elvated bs treated with ss reg insulin per protocol\n\nplan: transfer to 2, pulm toliet, pain control, advance diet and activity as tolerated\n"},{"category":"Nursing/other","chartdate":"2148-03-10 00:00:00.000","description":"Report","row_id":1451918,"text":"PT. ALERT AND COOPERATIVE. USING CALL LIGHT TO CALL FOR COMMODE PRIVELAGES. TRANSFERRING BED TO CHAIR/COMMODE WITH EASE.\nREMAINS A-PACED FOR BP. ALINE DAMPENED AND NBP APPLIED FOR READINGS. ARTERIAL LINE 20 POINTS LOWER THAN CUFF AT TIMES.\nPT. OCC. HAD HR IN THE LOW 90'S NSR.REVERTS BACK TO PACING.\nVOIDING IN GOOD QUANTITIES POST FOLEY REMOVAL; (PO LASIX GIVEN).\nDENIES PAIN. SLEEPING IN THE CHAIR SINCE O300 DUE TO SLIGHT BACK DISCOMFORT IN BED.\nPLAN: D/C ALINE. MONITOR PT/PTT/INR FOR COUMADIN DOSE. TRANSFER TO FLOOR WHEN BED AVAILABLE. CONTINUE TO ADVANCE ACTIVITIES AND DAT.\n"},{"category":"Nursing/other","chartdate":"2148-03-10 00:00:00.000","description":"Report","row_id":1451919,"text":"7am-7pm update\npt voiding in commode\n"},{"category":"Nursing/other","chartdate":"2148-03-10 00:00:00.000","description":"Report","row_id":1451920,"text":"7am-7pm update\nNEURO: pt alert and orientated x 3. MAE and able to follow commands\n\nCV: pt in NSR. pt had 1 episode of AFlutter this am -> SBP 70-80's with Aflutter -> treated with fluid bolus and given 2.5 mg iv lopressor x 2. after lopressor pt in ST -> HR in the 110-120's (A wire trace done and EKG done) after about 2 hours pt in NSR in the 80's. BP stable. pt with 2 a wires and 2 v wires (V wire do not sense appropiately). pt recieved 2 mg coumadin this evening.\n\nresp: LS clear. remains on RA -> o2 sats 94-96%. pt with strong cough. using IS \n\ngi/gu: pt with + bs. tolerting cardiac diet. pt voiding clear yellow urine in urinal\n\nendo: elvatated bs treated with ss reg insulin\n\nactivity/comfort: pt oob to chair with 1 assist. ambulated x2. physical therapy into see pt. percocets given for incisional pain\n\nplan: monitor rhythm, 2 in am, pulm toliet, pain control, advance activity as tolerated, continue coumadin\n"},{"category":"Nursing/other","chartdate":"2148-03-11 00:00:00.000","description":"Report","row_id":1451921,"text":"PT. ALERT AND PLEASANT. REQUESTING TO GO TO BED AT . FELL ASLEEP AFTER ONE PERCOCET GIVEN. OOB TO COMMODE X1. RHYTHM REMAINS NSR WITHOUT ANY EPISODES OF AFLUTTER. TOL. ALL ACTIVITY IN & OOB.\nPLAN: TRANSFER TO FLOOR TODAY. GLUCOSE MANAGEMENT AS NEEDED. MONITOR PT/INR WHILE ON COUMADIN THERAPY.\n"},{"category":"Nursing/other","chartdate":"2148-03-08 00:00:00.000","description":"Report","row_id":1451912,"text":"7p-7a:\nneuro: sedated on propofol. orally intubated on full ventilator support. propofol weaned to off-> pt able to follow all commands and mae. perrl.\n\ncv: sr 60-70's, rare pvc noted. electrolytes repleted. continue with phenylephrine gtt to keep map 60-90. required 3 liters of volume r/t autodiuresis. lidocaine gtt remains at 2mcg/kg/min, no furthur vt noted. pad 13-17, cvp 6-11, ci > 2.1. dopplerable pedal pulses bilaterally.\n\nresp: lungs clear. o2 sat remains > 99%. remains orally intubated on SIMV 40%: 5 peep, 5 psupp, 450 x 12 with normal abg. suctioned for scant amount thick clear secretions. ct to 20 cm suction, minimal serosanguinous drainage noted. will wake and wean this am.\n\ngi/gu: foley to gravity. large uo immediately post-op. requiring fluid replacement. abdomen soft, nd. bs absent. ogt to lws suction draining bilious drainage. carafate and zantac for gi prophylaxis.\n\nendo: regular insulin gtt started for bg 160. titrated per protocol with bs 100 presently.\n\nplan: monitor hemodynamics. wake and wean to extubate this am. continue with lidocaine and neo gtts. complete post-op antibiotic course.\n"},{"category":"Nursing/other","chartdate":"2148-03-08 00:00:00.000","description":"Report","row_id":1451913,"text":"ADDENDUM:\nLIDOCAINE AT 2 MG/MIN. EXTUBATED AT 0630 WITHOUT DIFFICULTY. REMAINS ON 50% FACE TENT WITH O2SAT 98%.\n"},{"category":"Nursing/other","chartdate":"2148-03-08 00:00:00.000","description":"Report","row_id":1451914,"text":"NEURO: ALERT AND ORIENTED X3. MAE, NO DEFICIT NOTED. PT C/O LOWER BACK PAIN THAT IS POSITIONAL, AND STERNAL INCISION PAIN PERCOCET STARTED\nCV: HR 70'S NSR RARE PVC AND COUPLET NOTED. LIDOCAINE GTT DC'D THIS AM. PT NEEDING FREQUENT LYTE REPLACEMENT SECONDARY DIURESIS. PERSISTENT NEO REQUIREMNT AT 1MCG WITH MAP 60-67. PALP PEDAL PULSES. CT WITH MOD SEROSANG DRNG. NO LEAK. WIRES TO BOX BUT OFF. SWAN DC'D, CORDIS ALINE IN. PT STARTED ON COUMADIN THIS PM FOR CALCIFIED AORTA PER DR. .\nRESP: LUNG DIM AT BASE BUT OTHERWISE CLEAR. SATS >93% ON 1L NC BUT DROP TO 88-91% RA.\nGI: NAUSEA THIS AM WITH ICE CHIPS, REGLAN GIVEN. NOW TOLERATING PO MEDS AND CLEARS, WILL ADVANCE DIET. VERY HYPOACTIVE BS. ABD SOFT.\nGU: PT WITH LARGE UOP AFTER AM LASIX. PM DOSE LOWERED . FOLEY PATENT.\nENDO: BS HIGHER AFTER PM ANTBX AND JUICE, COVERED WITH SSR PER PROTOCOL\nPLAN: CONT TO TRY TO WEAN NEO TO KEEP MAP>60. CONT ASSESS CARDIO/RESP STATUS, AND REPLETE LYTES PRN. ADVANCE DIET PRN, FOLLOW COAGS NOW ON COUMADIN.\n"},{"category":"Nursing/other","chartdate":"2148-03-08 00:00:00.000","description":"Report","row_id":1451915,"text":"ADDENDUM: PT BRADY IN 50'S AFTER GETTING OOB, NSR. PT REQUIRING INCREASE NEO. PT AT 80 PER DR. , AND ALBUMIN 25% X1 GIVEIN WITH SOME IMPROVEMENT IN BP. PM LASIX UNTIL BP IMPROVES. UOP APPROX 30-40CC/HR. PT ALSO C/O DIZZINESS AND NEO WHEN OOB, TX WITH REGLAN 5MG IV CONT ONLY TOL CLEARS. PLAN: CONT TITRATE NEO AS TOL TO MAINTIAN MAPS>60. ASSESS UNDERLYING RHYTHM. REEVAL NEED FOR LASIX\n"},{"category":"Nursing/other","chartdate":"2148-03-07 00:00:00.000","description":"Report","row_id":1451910,"text":"75 yr old female with PMHX: HTN,Mitral valve regurgitation. S/P MVR,EZ intubation # 7.0 @ 18 cm lips.Not much past med story.BS clear,on mechanical ventilation will wean to extubate.\n"},{"category":"Nursing/other","chartdate":"2148-03-07 00:00:00.000","description":"Report","row_id":1451911,"text":"ARRIVED CSRU AFTER MVR AT 1750 ON NEO/PROP NSR. PT UNEVENTFUL OR RECIEVED IUPRBC. VAVLE EXTREMELY CALCIFIED PER DR. . ONCE PT SPONT INTO VF AT 1830 (<1 MIN) PT 200J X1 TO NSR 80'S, LIDO BOLUS AND GTT STARTED, MAG UP , DR. AND DR. IN ROOM AT TIME.\nNEURO: PT STILL SEDATED ON PROP, NOT REVERESED AT TPRESENT. DR. WANTS PT AWOKEN AND NEURO STATUS CHECKED AND THEN CAN BE RESEDATED. PERRRLA\nCV: SEE EVENTS ABOVE. CURRENTLY NSR 80'S NO FURTHER ECTOPY. LYTES BEING REPLETED. CONTINUES ON NEO AND LIDO. PT BP LABILE , INITIAL CI 1.4 TX 1L LR NOW 2.1. FILLING PRESSURE EUVOLEMIC, SVO2 70-80%. PALP PEDAL PULSES, MINIMAL CT DRNG--A WIRES SENSE AND CAPTURE, V WIRES NOT CHECKED DUE TO VF.\nRESP: LUNGS CLEAR THROUGHOUT. CONT ON IMV FIO2 WEANED TO 50%, NO OVERBREATHING ABG WNL\nGI: OGT TO LCWS. PLACEMENT CONFIRMED BY AUSCULTATION. MINIMAL BILIOUS OUTPUT. ABD SOFT. ABSENT BS\nGU: LG AMT CLEAR UOP\nPLAN: REMAIN INTUBATED OVERNGIHT, CHECK NEURO STATUS, HAVE READY TO EXTUBATE FOR ROUNDS AT 0600. CONTINUE LIDO OVERNIGHT. TITRATE NEO PRN. CONT CURRENT PLAN OF CARE\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-03-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 857760,\n \"text\": \" 7:06 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for lines, tube, and pneumothorax\\n Admitting Diagnosis: MR\\\\MITRAL VALVE REPLACEMENT/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old woman s/p mitral valve replacement\\n REASON FOR THIS EXAMINATION:\\n eval for lines, tube, and pneumothorax\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post mitral valve replacement.\\n\\n COMPARISON: .\\n\\n SUPINE AP CHEST: There has been interval median sternotomy. Sternotomy wires\\n and a mitral valve replacement are noted. An endotracheal tube is in place,\\n with the tip approximately 2 cm from the carina. There is a right internal\\n jugular approach Swan-Ganz catheter, with the tip overlying the expected right\\n pulmonary artery. The course of the Swan-Ganz catheter is mostly smooth,\\n except for a slight angulation at the cavoatrial junction. An NG tube\\n terminates with the tip in the fundus of the stomach. A mediastinal drain and\\n left chest tube are in place. The cardiac and mediastinal contours are\\n relatively stable. There is aortic calcification. The lungs are clear,\\n without vascular congestion or consolidation. There may be a small left\\n effusion. No pneumothorax detected on this supine radiograph.\\n\\n IMPRESSION:\\n\\n Status post mitral valve replacement, with multiple tubes and lines positioned\\n as described. No pneumothorax detected.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2148-03-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 193023,\n \"text\": \"Atrial flutter with rapid ventricular response with 2:1 A-V block. Extensive\\nST-T wave changes may be due to rate. Cannot exclude myocardial ischemia.\\nCompared to the previous tracing of the rhythm has changed.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2148-03-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 193024,\n \"text\": \"Sinus rhythm\\nInferior/lateral ST-T changes may be due to myocardial ischemia\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-03-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1451916,\n \"text\": \"7P-7A:\\nNEURO: ALERT AND ORIENTED X 3. MAE, ABLE TO FOLOW ALL COMMANDS. PERCOCET PRN BACK PAIN.\\n\\nCV: A PACED AT 80 FOR BP SUPPORT, NO ECTOPY NOTED. ELECTROLYTES REPLETED. NEO GTT CONTINUES TO KEEP MAP> 60. LASIX DOSE HELD LAST NIGHT SECONDARY TO OVERDIURESIS AND BP SUPPORT. PALPABLE PEDAL PULSES BILATERALLY. RECIEVED COUMADIN THIS PM.\\n\\nRESP: LUNGS CLEAR WITH DIM BILATERAL BASES. O2 SAT 98% ON 2L NC. CT TO 20 CM SXN, NO AIRLEAK NOTED. DRAINING MODERATE SEROSANGUINOUS FLUID. ENCOURAGE COUGH, DEEP BREATHING, AND IS USE.\\n\\nGI/GU: FOLEY TO GRAVITY. GOOD HUO. ABDOMEN SOFT, ND. BS POSITIVE-> HYPOACTIVE. TOL CLEAR LIQS.\\n\\nENDO: FS QID. COVER PER RISS. INCISIONS CDI.\\n\\nPLAN: MONITOR HEMODYNAMICS. ATTEMPT TO WEAN NEO GTT AS TOLERATES. INCREASE ACTIVITY AND DIET AS TOLERATES. CONTINUE WITH COUMADIN FOR ANTICOAGULATION.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-03-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1451917,\n \"text\": \"7am-7pm update\\nneuro: pt alert and orienated x3. MAE and able to follow commands. PERRL\\n\\nCv: Pt A paced at 88 (for bp support), underlything rhythm NSR in the 70's. no ectopy noted. SBP dropped into the 80's this am -> neo gtt started. SBP now 90-100's. neo gtt weaned to off this afternoon. pt recieved 4 mg coumadin this evening\\n\\n\\nresp: LS clear with dim bases bil. pt on 2 l nc, o2 sats >96%. CT dc'd\\n\\ngi/gu: pt with + bs. tolerated cardiac diet. foley dc'd at 1500 -> pt has not voided since\\n\\nendo: elvated bs treated with ss reg insulin per protocol\\n\\nplan: transfer to 2, pulm toliet, pain control, advance diet and activity as tolerated\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-03-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1451918,\n \"text\": \"PT. ALERT AND COOPERATIVE. USING CALL LIGHT TO CALL FOR COMMODE PRIVELAGES. TRANSFERRING BED TO CHAIR/COMMODE WITH EASE.\\nREMAINS A-PACED FOR BP. ALINE DAMPENED AND NBP APPLIED FOR READINGS. ARTERIAL LINE 20 POINTS LOWER THAN CUFF AT TIMES.\\nPT. OCC. HAD HR IN THE LOW 90'S NSR.REVERTS BACK TO PACING.\\nVOIDING IN GOOD QUANTITIES POST FOLEY REMOVAL; (PO LASIX GIVEN).\\nDENIES PAIN. SLEEPING IN THE CHAIR SINCE O300 DUE TO SLIGHT BACK DISCOMFORT IN BED.\\nPLAN: D/C ALINE. MONITOR PT/PTT/INR FOR COUMADIN DOSE. TRANSFER TO FLOOR WHEN BED AVAILABLE. CONTINUE TO ADVANCE ACTIVITIES AND DAT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-03-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1451919,\n \"text\": \"7am-7pm update\\npt voiding in commode\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-03-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1451920,\n \"text\": \"7am-7pm update\\nNEURO: pt alert and orientated x 3. MAE and able to follow commands\\n\\nCV: pt in NSR. pt had 1 episode of AFlutter this am -> SBP 70-80's with Aflutter -> treated with fluid bolus and given 2.5 mg iv lopressor x 2. after lopressor pt in ST -> HR in the 110-120's (A wire trace done and EKG done) after about 2 hours pt in NSR in the 80's. BP stable. pt with 2 a wires and 2 v wires (V wire do not sense appropiately). pt recieved 2 mg coumadin this evening.\\n\\nresp: LS clear. remains on RA -> o2 sats 94-96%. pt with strong cough. using IS \\n\\ngi/gu: pt with + bs. tolerting cardiac diet. pt voiding clear yellow urine in urinal\\n\\nendo: elvatated bs treated with ss reg insulin\\n\\nactivity/comfort: pt oob to chair with 1 assist. ambulated x2. physical therapy into see pt. percocets given for incisional pain\\n\\nplan: monitor rhythm, 2 in am, pulm toliet, pain control, advance activity as tolerated, continue coumadin\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-03-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1451921,\n \"text\": \"PT. ALERT AND PLEASANT. REQUESTING TO GO TO BED AT . FELL ASLEEP AFTER ONE PERCOCET GIVEN. OOB TO COMMODE X1. RHYTHM REMAINS NSR WITHOUT ANY EPISODES OF AFLUTTER. TOL. ALL ACTIVITY IN & OOB.\\nPLAN: TRANSFER TO FLOOR TODAY. GLUCOSE MANAGEMENT AS NEEDED. MONITOR PT/INR WHILE ON COUMADIN THERAPY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-03-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1451912,\n \"text\": \"7p-7a:\\nneuro: sedated on propofol. orally intubated on full ventilator support. propofol weaned to off-> pt able to follow all commands and mae. perrl.\\n\\ncv: sr 60-70's, rare pvc noted. electrolytes repleted. continue with phenylephrine gtt to keep map 60-90. required 3 liters of volume r/t autodiuresis. lidocaine gtt remains at 2mcg/kg/min, no furthur vt noted. pad 13-17, cvp 6-11, ci > 2.1. dopplerable pedal pulses bilaterally.\\n\\nresp: lungs clear. o2 sat remains > 99%. remains orally intubated on SIMV 40%: 5 peep, 5 psupp, 450 x 12 with normal abg. suctioned for scant amount thick clear secretions. ct to 20 cm suction, minimal serosanguinous drainage noted. will wake and wean this am.\\n\\ngi/gu: foley to gravity. large uo immediately post-op. requiring fluid replacement. abdomen soft, nd. bs absent. ogt to lws suction draining bilious drainage. carafate and zantac for gi prophylaxis.\\n\\nendo: regular insulin gtt started for bg 160. titrated per protocol with bs 100 presently.\\n\\nplan: monitor hemodynamics. wake and wean to extubate this am. continue with lidocaine and neo gtts. complete post-op antibiotic course.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-03-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1451913,\n \"text\": \"ADDENDUM:\\nLIDOCAINE AT 2 MG/MIN. EXTUBATED AT 0630 WITHOUT DIFFICULTY. REMAINS ON 50% FACE TENT WITH O2SAT 98%.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-03-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1451914,\n \"text\": \"NEURO: ALERT AND ORIENTED X3. MAE, NO DEFICIT NOTED. PT C/O LOWER BACK PAIN THAT IS POSITIONAL, AND STERNAL INCISION PAIN PERCOCET STARTED\\nCV: HR 70'S NSR RARE PVC AND COUPLET NOTED. LIDOCAINE GTT DC'D THIS AM. PT NEEDING FREQUENT LYTE REPLACEMENT SECONDARY DIURESIS. PERSISTENT NEO REQUIREMNT AT 1MCG WITH MAP 60-67. PALP PEDAL PULSES. CT WITH MOD SEROSANG DRNG. NO LEAK. WIRES TO BOX BUT OFF. SWAN DC'D, CORDIS ALINE IN. PT STARTED ON COUMADIN THIS PM FOR CALCIFIED AORTA PER DR. .\\nRESP: LUNG DIM AT BASE BUT OTHERWISE CLEAR. SATS >93% ON 1L NC BUT DROP TO 88-91% RA.\\nGI: NAUSEA THIS AM WITH ICE CHIPS, REGLAN GIVEN. NOW TOLERATING PO MEDS AND CLEARS, WILL ADVANCE DIET. VERY HYPOACTIVE BS. ABD SOFT.\\nGU: PT WITH LARGE UOP AFTER AM LASIX. PM DOSE LOWERED . FOLEY PATENT.\\nENDO: BS HIGHER AFTER PM ANTBX AND JUICE, COVERED WITH SSR PER PROTOCOL\\nPLAN: CONT TO TRY TO WEAN NEO TO KEEP MAP>60. CONT ASSESS CARDIO/RESP STATUS, AND REPLETE LYTES PRN. ADVANCE DIET PRN, FOLLOW COAGS NOW ON COUMADIN.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-03-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1451915,\n \"text\": \"ADDENDUM: PT BRADY IN 50'S AFTER GETTING OOB, NSR. PT REQUIRING INCREASE NEO. PT AT 80 PER DR. , AND ALBUMIN 25% X1 GIVEIN WITH SOME IMPROVEMENT IN BP. PM LASIX UNTIL BP IMPROVES. UOP APPROX 30-40CC/HR. PT ALSO C/O DIZZINESS AND NEO WHEN OOB, TX WITH REGLAN 5MG IV CONT ONLY TOL CLEARS. PLAN: CONT TITRATE NEO AS TOL TO MAINTIAN MAPS>60. ASSESS UNDERLYING RHYTHM. REEVAL NEED FOR LASIX\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-03-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1451910,\n \"text\": \"75 yr old female with PMHX: HTN,Mitral valve regurgitation. S/P MVR,EZ intubation # 7.0 @ 18 cm lips.Not much past med story.BS clear,on mechanical ventilation will wean to extubate.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-03-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1451911,\n \"text\": \"ARRIVED CSRU AFTER MVR AT 1750 ON NEO/PROP NSR. PT UNEVENTFUL OR RECIEVED IUPRBC. VAVLE EXTREMELY CALCIFIED PER DR. . ONCE PT SPONT INTO VF AT 1830 (<1 MIN) PT 200J X1 TO NSR 80'S, LIDO BOLUS AND GTT STARTED, MAG UP , DR. AND DR. IN ROOM AT TIME.\\nNEURO: PT STILL SEDATED ON PROP, NOT REVERESED AT TPRESENT. DR. WANTS PT AWOKEN AND NEURO STATUS CHECKED AND THEN CAN BE RESEDATED. PERRRLA\\nCV: SEE EVENTS ABOVE. CURRENTLY NSR 80'S NO FURTHER ECTOPY. LYTES BEING REPLETED. CONTINUES ON NEO AND LIDO. PT BP LABILE , INITIAL CI 1.4 TX 1L LR NOW 2.1. FILLING PRESSURE EUVOLEMIC, SVO2 70-80%. PALP PEDAL PULSES, MINIMAL CT DRNG--A WIRES SENSE AND CAPTURE, V WIRES NOT CHECKED DUE TO VF.\\nRESP: LUNGS CLEAR THROUGHOUT. CONT ON IMV FIO2 WEANED TO 50%, NO OVERBREATHING ABG WNL\\nGI: OGT TO LCWS. PLACEMENT CONFIRMED BY AUSCULTATION. MINIMAL BILIOUS OUTPUT. ABD SOFT. ABSENT BS\\nGU: LG AMT CLEAR UOP\\nPLAN: REMAIN INTUBATED OVERNGIHT, CHECK NEURO STATUS, HAVE READY TO EXTUBATE FOR ROUNDS AT 0600. CONTINUE LIDO OVERNIGHT. TITRATE NEO PRN. CONT CURRENT PLAN OF CARE\\n\"\n }\n]"}}},{"rowIdx":24685,"cells":{"subject_id":{"kind":"number","value":14585,"string":"14,585"},"hadm_id":{"kind":"number","value":197080,"string":"197,080"},"target_text":{"kind":"string","value":""},"extractive_notes_summ":{"kind":"string","value":"Normal ascending aorta diameter. Denies pain.Resp: LS clear bil. IMPRESSION: Normal position of the central venous line. The mitralvalve appears structurally normal with trivial mitral regurgitation. The right-sided PICC terminates in the mid to distal SVC. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal LV cavity size. flat soft, BS+. Fluid status +2.3L for LOS and +0.4L since midnight.Skin: Intact. No c/o pain.CV: HR 64-69, nsr, st depression noted. Noprevious tracing available for comparison. Mediastinum has normal position, width, and shape. Tachycardia.Height: (in) 66Weight (lb): 75BSA (m2): 1.32 m2BP (mm Hg): 98/72HR (bpm): 110Status: InpatientDate/Time: at 09:51Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. The left ventricular cavity size is normal. BS Q6 hr and covered with Humolog SS.GU: No foley cath but Pt. Heart size normal. Right ventricular chamber size andfree wall motion are normal. BP 110's/70's, HR 79-93 NSR with no ectopy noted. There is atrivial/physiologic pericardial effusion. IVF remain the same at 150cc/hr. Left ventricular wall thicknesses arenormal. 40meq kcl given by mouth at 0540 and iv running as above.Resp: LS clear, sats 99-100 on RA.GI: Abd soft, nt, +BS. Lungs clear. Right PICC line was inserted with its tip lying before the cavoatrial junction. Mild to moderate [+] TR.Borderline PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Resting tachycardia (HR>100bpm).Conclusions:The left atrium is normal in size. Pt. Pt. Pt. Pt. Sinus rhythm. Diffuse non-specific ST-T wave changes. with end stage AIDS. PO intake good. Normalaortic arch diameter.AORTIC VALVE: Normal aortic valve leaflets (3). Admition wt. Pt cachectic, weak. The aortic valve leaflets (3) appear structurallynormal with good leaflet excursion and no aortic regurgitation. 9:02 AM CHEST PORT. O2 sat 100% on RA. no cough noted. The heart is normal. HISTORY: Hypokalemia, new shortness of breath. Extensive T wave changes are non-specific. reg diet, low residue, lactose restricted. Abd. Overallnormal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. No AS. Long QTc interval. CXR ordered for AM rounds.CV: VSS. is a full code.Plan: Cont. No edema. The lungs are clear. Overall left ventricularsystolic function is normal (LVEF>55%). No open areas noted.Social: Pt. IMPRESSION: AP chest compared to : Tip of the right PIC catheter projects over the superior cavoatrial junction. mae. MAE. very thin, skin dry. PORTABLE UPRIGHT FRONTAL RADIOGRAPH, TWO VIEWS. Sinus rhythmEarly R wave progressionAnterolateral ST-T changesSince previous tracing of , early R wave progression lethargic. K up to 2.2 by abg at 0500. No other changes. Lung fields remain clear. Pt states has poor appetite and sometimes has difficulty swallowing.No diarrhea thus far in MICU.GU: Voids, no urine thus far since admit.Access: piv in R wrist.Skin: Dry, no breakdown.Social: Friend will be spokesperson.Plan: Continue Kcl iv, give po kcl per orders. Repeat K on floor was 1.6, after 60meq K po given. NPN 1900-0700Neuro: Alert and oriented x3. Replenish lytes as needed. voiding to commode with diarrhea. AM labs pending.GI: Pt. Possible call out if Labs remain stable. Sinus tachycardia. place second piv and draw am labs. There isborderline pulmonary artery systolic hypertension. There is no pneumothorax or pleural effusion. IVF changed to D5W NaHCO3 50 meq and KCL 60 meq @ 200cc/hr for 1L. K 2.9 last evening labs with Na 151 and CO2 11. Comparison is made to one day earlier. monitor labd. There is no evidence of pleural effusion. No pleural abnormality or evidence of central adenopathy. Chronic diarrhea on Opium and Lomotil on time. 35 kg. Compared to theprevious tracing of the rate is significantly faster. HIV/AIDS. started on TPN at 42 cc/hr last evening. Labs repeated with a stick revealed hypokalemia 2.9, Potassium was resumed and rate increased to 150 ml/hr, Calcium stopped, started on TPN at 42 ml/hr. Adm note40 yo ma HIV/AIDS pt dx in 94, adm for picc placement to start TPN. NPN 0700-1900:Pt is alert, oriented x3, calm and cooperative, breathing regularly on room air, SPO2 above 95%, V/S stable, afebrile, eating regular diet well tolerated, passed BM in commode mixed with urine, so U/O couldn't be measured, given potassium with bicarbonate at 100 ml/hr then bld drawn from PIC line revealed hyperkalemia, potassium stopped and Calcium gluconate given 4G in 25o ml NS for 2 hrs. PATIENT/TEST INFORMATION:Indication: R/O cardiomyopathy. 40KCL in 500 d5w hung prior to transfer here. States he has been having ~6 loose stools per day.ROS:Neuro: A&O x3. defibrillator pads placed on pt per team. One time dose of 40 meq of PO KCL given to increase serum K level.Labs repeated at 0020 and K up to 3.6, Na 146 and CO2 13. talking on the phone this evening but no visitors. Pt lost ~ 30 lbs over last few months from diarrhea which is being worked up. drinking and eating. LINE PLACEMENT Clip # Reason: confirm placement of new double lumen left picc Admitting Diagnosis: FAILURE TO THRIVE MEDICAL CONDITION: 40 year old man with HIV/AIDS admitted w/ profound hypokalemia and now w/ PICC placed REASON FOR THIS EXAMINATION: confirm placement of new double lumen left picc FINAL REPORT REASON FOR EXAMINATION: Evaluation of the line placement. 4:19 AM CHEST (PORTABLE AP) Clip # Reason: 40 year old man with HIV/AIDS admitted w/ profound hypokal Admitting Diagnosis: FAILURE TO THRIVE MEDICAL CONDITION: hiv+ REASON FOR THIS EXAMINATION: 40 year old man with HIV/AIDS admitted w/ profound hypokalemia and now w/ new sob FINAL REPORT AP CHEST, 3:34 A.M. ."},"n_notes":{"kind":"number","value":10,"string":"10"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2150-06-10 00:00:00.000","description":"Report","row_id":80592,"text":"PATIENT/TEST INFORMATION:\nIndication: R/O cardiomyopathy. HIV/AIDS. Tachycardia.\nHeight: (in) 66\nWeight (lb): 75\nBSA (m2): 1.32 m2\nBP (mm Hg): 98/72\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 09:51\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\nnormal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\naortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nBorderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. There is\nborderline pulmonary artery systolic hypertension. There is a\ntrivial/physiologic pericardial effusion.\n\n\n"},{"category":"ECG","chartdate":"2150-06-08 00:00:00.000","description":"Report","row_id":204013,"text":"Sinus tachycardia. Diffuse non-specific ST-T wave changes. Compared to the\nprevious tracing of the rate is significantly faster.\n\n"},{"category":"ECG","chartdate":"2150-06-04 00:00:00.000","description":"Report","row_id":204014,"text":"Sinus rhythm\nEarly R wave progression\nAnterolateral ST-T changes\nSince previous tracing of , early R wave progression\n\n"},{"category":"ECG","chartdate":"2150-06-04 00:00:00.000","description":"Report","row_id":204015,"text":"Sinus rhythm. Long QTc interval. Extensive T wave changes are non-specific. No\nprevious tracing available for comparison.\n\n"},{"category":"Radiology","chartdate":"2150-06-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":912888,"text":" 4:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 40 year old man with HIV/AIDS admitted w/ profound hypokal\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n hiv+\n REASON FOR THIS EXAMINATION:\n 40 year old man with HIV/AIDS admitted w/ profound hypokalemia and now w/ new\n sob\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:34 A.M. .\n\n HISTORY: Hypokalemia, new shortness of breath.\n\n IMPRESSION: AP chest compared to :\n\n Tip of the right PIC catheter projects over the superior cavoatrial junction.\n Lungs clear. Heart size normal. No pleural abnormality or evidence of\n central adenopathy.\n\n\n"},{"category":"Radiology","chartdate":"2150-06-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":912538,"text":" 5:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval line placement\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with HIV/AIDS admitted w/ profound hypokalemia and now w/ PICC\n placed\n REASON FOR THIS EXAMINATION:\n eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old with HIV and hypokalemia, assess PICC position.\n\n PORTABLE UPRIGHT FRONTAL RADIOGRAPH, TWO VIEWS. Comparison is made to one day\n earlier.\n\n The right-sided PICC terminates in the mid to distal SVC. Lung fields remain\n clear. No other changes.\n\n\n"},{"category":"Radiology","chartdate":"2150-06-04 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":912402,"text":" 9:02 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: confirm placement of new double lumen left picc\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with HIV/AIDS admitted w/ profound hypokalemia and now w/ PICC\n placed\n REASON FOR THIS EXAMINATION:\n confirm placement of new double lumen left picc\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the line placement.\n\n Right PICC line was inserted with its tip lying before the cavoatrial\n junction.\n\n There is no pneumothorax or pleural effusion.\n\n The heart is normal. Mediastinum has normal position, width, and shape.\n\n The lungs are clear. There is no evidence of pleural effusion.\n\n IMPRESSION: Normal position of the central venous line.\n\n\n"},{"category":"Nursing/other","chartdate":"2150-06-04 00:00:00.000","description":"Report","row_id":1452475,"text":"Adm note\n40 yo ma HIV/AIDS pt dx in 94, adm for picc placement to start TPN. Pt lost ~ 30 lbs over last few months from diarrhea which is being worked up. Repeat K on floor was 1.6, after 60meq K po given. 40KCL in 500 d5w hung prior to transfer here. Pt cachectic, weak. States he has been having ~6 loose stools per day.\n\nROS:\n\nNeuro: A&O x3. mae. lethargic. No c/o pain.\n\nCV: HR 64-69, nsr, st depression noted. defibrillator pads placed on pt per team. K up to 2.2 by abg at 0500. 40meq kcl given by mouth at 0540 and iv running as above.\n\nResp: LS clear, sats 99-100 on RA.\n\nGI: Abd soft, nt, +BS. reg diet, low residue, lactose restricted. Pt states has poor appetite and sometimes has difficulty swallowing.\nNo diarrhea thus far in MICU.\n\nGU: Voids, no urine thus far since admit.\n\nAccess: piv in R wrist.\n\nSkin: Dry, no breakdown.\n\nSocial: Friend will be spokesperson.\n\nPlan: Continue Kcl iv, give po kcl per orders. place second piv and draw am labs.\n\n"},{"category":"Nursing/other","chartdate":"2150-06-04 00:00:00.000","description":"Report","row_id":1452476,"text":"NPN 0700-1900:\nPt is alert, oriented x3, calm and cooperative, breathing regularly on room air, SPO2 above 95%, V/S stable, afebrile, eating regular diet well tolerated, passed BM in commode mixed with urine, so U/O couldn't be measured, given potassium with bicarbonate at 100 ml/hr then bld drawn from PIC line revealed hyperkalemia, potassium stopped and Calcium gluconate given 4G in 25o ml NS for 2 hrs. Labs repeated with a stick revealed hypokalemia 2.9, Potassium was resumed and rate increased to 150 ml/hr, Calcium stopped, started on TPN at 42 ml/hr.\n"},{"category":"Nursing/other","chartdate":"2150-06-05 00:00:00.000","description":"Report","row_id":1452477,"text":"NPN 1900-0700\nNeuro: Alert and oriented x3. MAE. Denies pain.\n\nResp: LS clear bil. O2 sat 100% on RA. no cough noted. CXR ordered for AM rounds.\n\nCV: VSS. BP 110's/70's, HR 79-93 NSR with no ectopy noted. No edema. K 2.9 last evening labs with Na 151 and CO2 11. IVF changed to D5W NaHCO3 50 meq and KCL 60 meq @ 200cc/hr for 1L. One time dose of 40 meq of PO KCL given to increase serum K level.Labs repeated at 0020 and K up to 3.6, Na 146 and CO2 13. IVF remain the same at 150cc/hr. AM labs pending.\n\nGI: Pt. with end stage AIDS. Admition wt. 35 kg. Pt. started on TPN at 42 cc/hr last evening. PO intake good. Pt. drinking and eating. Chronic diarrhea on Opium and Lomotil on time. Abd. flat soft, BS+. BS Q6 hr and covered with Humolog SS.\n\nGU: No foley cath but Pt. voiding to commode with diarrhea. Fluid status +2.3L for LOS and +0.4L since midnight.\n\nSkin: Intact. Pt. very thin, skin dry. No open areas noted.\n\nSocial: Pt. talking on the phone this evening but no visitors. Pt. is a full code.\n\nPlan: Cont. monitor labd. Replenish lytes as needed. Possible call out if Labs remain stable.\n\n\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2150-06-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 80592,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: R/O cardiomyopathy. HIV/AIDS. Tachycardia.\\nHeight: (in) 66\\nWeight (lb): 75\\nBSA (m2): 1.32 m2\\nBP (mm Hg): 98/72\\nHR (bpm): 110\\nStatus: Inpatient\\nDate/Time: at 09:51\\nTest: TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\\nnormal LVEF (>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\\naortic arch diameter.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\\nBorderline PA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\\nphysiologic PR.\\n\\nPERICARDIUM: Trivial/physiologic pericardial effusion.\\n\\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\\n\\nConclusions:\\nThe left atrium is normal in size. Left ventricular wall thicknesses are\\nnormal. The left ventricular cavity size is normal. Overall left ventricular\\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\\nfree wall motion are normal. The aortic valve leaflets (3) appear structurally\\nnormal with good leaflet excursion and no aortic regurgitation. The mitral\\nvalve appears structurally normal with trivial mitral regurgitation. There is\\nborderline pulmonary artery systolic hypertension. There is a\\ntrivial/physiologic pericardial effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2150-06-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 204013,\n \"text\": \"Sinus tachycardia. Diffuse non-specific ST-T wave changes. Compared to the\\nprevious tracing of the rate is significantly faster.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2150-06-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 204014,\n \"text\": \"Sinus rhythm\\nEarly R wave progression\\nAnterolateral ST-T changes\\nSince previous tracing of , early R wave progression\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2150-06-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 204015,\n \"text\": \"Sinus rhythm. Long QTc interval. Extensive T wave changes are non-specific. No\\nprevious tracing available for comparison.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-06-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 912888,\n \"text\": \" 4:19 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: 40 year old man with HIV/AIDS admitted w/ profound hypokal\\n Admitting Diagnosis: FAILURE TO THRIVE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n hiv+\\n REASON FOR THIS EXAMINATION:\\n 40 year old man with HIV/AIDS admitted w/ profound hypokalemia and now w/ new\\n sob\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 3:34 A.M. .\\n\\n HISTORY: Hypokalemia, new shortness of breath.\\n\\n IMPRESSION: AP chest compared to :\\n\\n Tip of the right PIC catheter projects over the superior cavoatrial junction.\\n Lungs clear. Heart size normal. No pleural abnormality or evidence of\\n central adenopathy.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-06-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 912538,\n \"text\": \" 5:03 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval line placement\\n Admitting Diagnosis: FAILURE TO THRIVE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old man with HIV/AIDS admitted w/ profound hypokalemia and now w/ PICC\\n placed\\n REASON FOR THIS EXAMINATION:\\n eval line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 40-year-old with HIV and hypokalemia, assess PICC position.\\n\\n PORTABLE UPRIGHT FRONTAL RADIOGRAPH, TWO VIEWS. Comparison is made to one day\\n earlier.\\n\\n The right-sided PICC terminates in the mid to distal SVC. Lung fields remain\\n clear. No other changes.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-06-04 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 912402,\n \"text\": \" 9:02 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: confirm placement of new double lumen left picc\\n Admitting Diagnosis: FAILURE TO THRIVE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old man with HIV/AIDS admitted w/ profound hypokalemia and now w/ PICC\\n placed\\n REASON FOR THIS EXAMINATION:\\n confirm placement of new double lumen left picc\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Evaluation of the line placement.\\n\\n Right PICC line was inserted with its tip lying before the cavoatrial\\n junction.\\n\\n There is no pneumothorax or pleural effusion.\\n\\n The heart is normal. Mediastinum has normal position, width, and shape.\\n\\n The lungs are clear. There is no evidence of pleural effusion.\\n\\n IMPRESSION: Normal position of the central venous line.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-06-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1452475,\n \"text\": \"Adm note\\n40 yo ma HIV/AIDS pt dx in 94, adm for picc placement to start TPN. Pt lost ~ 30 lbs over last few months from diarrhea which is being worked up. Repeat K on floor was 1.6, after 60meq K po given. 40KCL in 500 d5w hung prior to transfer here. Pt cachectic, weak. States he has been having ~6 loose stools per day.\\n\\nROS:\\n\\nNeuro: A&O x3. mae. lethargic. No c/o pain.\\n\\nCV: HR 64-69, nsr, st depression noted. defibrillator pads placed on pt per team. K up to 2.2 by abg at 0500. 40meq kcl given by mouth at 0540 and iv running as above.\\n\\nResp: LS clear, sats 99-100 on RA.\\n\\nGI: Abd soft, nt, +BS. reg diet, low residue, lactose restricted. Pt states has poor appetite and sometimes has difficulty swallowing.\\nNo diarrhea thus far in MICU.\\n\\nGU: Voids, no urine thus far since admit.\\n\\nAccess: piv in R wrist.\\n\\nSkin: Dry, no breakdown.\\n\\nSocial: Friend will be spokesperson.\\n\\nPlan: Continue Kcl iv, give po kcl per orders. place second piv and draw am labs.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-06-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1452476,\n \"text\": \"NPN 0700-1900:\\nPt is alert, oriented x3, calm and cooperative, breathing regularly on room air, SPO2 above 95%, V/S stable, afebrile, eating regular diet well tolerated, passed BM in commode mixed with urine, so U/O couldn't be measured, given potassium with bicarbonate at 100 ml/hr then bld drawn from PIC line revealed hyperkalemia, potassium stopped and Calcium gluconate given 4G in 25o ml NS for 2 hrs. Labs repeated with a stick revealed hypokalemia 2.9, Potassium was resumed and rate increased to 150 ml/hr, Calcium stopped, started on TPN at 42 ml/hr.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-06-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1452477,\n \"text\": \"NPN 1900-0700\\nNeuro: Alert and oriented x3. MAE. Denies pain.\\n\\nResp: LS clear bil. O2 sat 100% on RA. no cough noted. CXR ordered for AM rounds.\\n\\nCV: VSS. BP 110's/70's, HR 79-93 NSR with no ectopy noted. No edema. K 2.9 last evening labs with Na 151 and CO2 11. IVF changed to D5W NaHCO3 50 meq and KCL 60 meq @ 200cc/hr for 1L. One time dose of 40 meq of PO KCL given to increase serum K level.Labs repeated at 0020 and K up to 3.6, Na 146 and CO2 13. IVF remain the same at 150cc/hr. AM labs pending.\\n\\nGI: Pt. with end stage AIDS. Admition wt. 35 kg. Pt. started on TPN at 42 cc/hr last evening. PO intake good. Pt. drinking and eating. Chronic diarrhea on Opium and Lomotil on time. Abd. flat soft, BS+. BS Q6 hr and covered with Humolog SS.\\n\\nGU: No foley cath but Pt. voiding to commode with diarrhea. Fluid status +2.3L for LOS and +0.4L since midnight.\\n\\nSkin: Intact. Pt. very thin, skin dry. No open areas noted.\\n\\nSocial: Pt. talking on the phone this evening but no visitors. Pt. is a full code.\\n\\nPlan: Cont. monitor labd. Replenish lytes as needed. Possible call out if Labs remain stable.\\n\\n\\n\\n\"\n }\n]"}}},{"rowIdx":24686,"cells":{"subject_id":{"kind":"number","value":79900,"string":"79,900"},"hadm_id":{"kind":"number","value":120644,"string":"120,644"},"target_text":{"kind":"string","value":"Primary Reason for Admission 70yoF with h/o dilated cardiomyopathy (EF 35%), AICD p/w SOB and poor urine output for several days found to have hyponatremia, now transferred from medicine to CCU due to hypotension. . Active Issues: . #Acute on chronic systolic heart failure: The patient was hypervolemic on exam with elevated JVP and increased abdominal distension at presentation. Given the patient had been refractory to diuretic therapy requiring ultrafiltration during her last hospitalization and was oliguric and hyponatremic on admission, ultrafiltration was initiated rather than diuretic therapy. She experienced significant muscle cramping and hypotension while on CVVHD requiring dopamine. CVVHD was discontinued on HD#2 and she was diuresed with IV lasix and metolazone. Pressures improved and she was weaned off of dopamine. It was noted that urine and blood pressure improved when the patient was in her native sinus rhythm with asynchronous ventricular pacing. Therefore the patients pacemaker escape rate was lowered to allow for increased native rhythm and the mode was changed to AAIR. Despite this change urine output remained poor and she was therefore started on a lasix drip ultimately requiring milrinone to augment diuresis. On HD#6 patient underwent placement of a tunneled dialysis catheter, and on HD#7 she continued HD using the tunneled line (see below). Lasix and metolazone were discontinued as patient will be HD dependent. . #Hypotension: Patient was hypotensive on admission in the setting of volume overload. Her hypotension was believed to be due to worsening cardiac output in setting of dilated cardiomyopathy. She was temporarily on a dopamine gtt, but this was weaned by HD#2. In addition, she experienced episodes of hypotension with CVVH with diuresis and antihypertensive medications, so her antihypertensive medications were held. On discharge, her BP was stable. She was asked to continue to hold her carvedilol and to follow up with her PCP about restarting as tolerated. . # Hyponatremia: Pts sodium was 119 on admission and likely cause of her AMS, thought to be hypervolemic hyponatremia with poor renal perfusion given e/o volume overload on exam and low urine Na. Her fluid intake was restricted to 1.5L daily, and she started CVVH as above with improvement in her hyponatremia as well as her mental status. At the time of discharge her sodium was 135. . # Acute on chronic renal failure: Patient was noted to have a creat of 5.4, baseline 3.5-4.0, and oliguria x 2-3 days on admission. As stated above she had previously required ultrafiltration during hospitalizations for heart failure exacerbation. Renal was consulted and felt that the patient would require chronic HD. Given her hypotension she was initally started on CVVH with dopamine gtt for pressure support. However as above she did not tolerate CVVH and it was discontinued. She was diuresed with lasix gtt and milrinone as above until she had her tunneled line placed on HD#6. She tolerated HD well, with stable BP and no muscle cramping. Outpatient dialysis was arranged with Dialysis Center for mondays, wednesdays and fridays. . # Afib: Pt has a history of atrial fibrillation on coumadin at home. On admission her coumadin was held in preparation for placement of a tunneled dialysis catheter. As stated above her pacemaker settings were changed and she was in sinus rhythm for most of her CCU course with heart rates in the 50-70s. Her mode was changed to AAIR to allow for intrinsice AV conduction and minimize ventricular pacing in an abnormal heart. Her coumadin was restarted at her home dose on HD#7. Her INR at the time of discharge was 1.4."},"extractive_notes_summ":{"kind":"string","value":"FINDINGS: There is a left-sided pacemaker/ICD with right atrial and right ventricular leads, as before. Left bundle-branch block.Compared to tracing #1 ventricular pacing is no longer present and atrialfibrillation is present.TRACING #2 The needle was then exchanged for a micropuncture sheath, the inner dilator and wire were removed, and wire was passed through the sheath and to the right atrium. Atrial fibrillation with ventricular premature beat. FINDINGS: There is a new right IJ central venous catheter with distal lead tip in the distal SVC. There is intermittent ventricular pacing with capture, non-specificST-T wave flattening as recorded previously and appearance of ventricularectopy and ventricular pacing. FINDINGS: Single AP view of the chest shows a tunneled catheter whose tip terminates within the right atrium. PROCEDURE: 27 cm tip-to-cuff right IJ hemodialysis catheter placement. The hemodialysis catheter was passed through this and the cuff secured subcutaneously. The wire and inner dilator were then removed, and hemodialysis catheter was inserted through the peel-away sheath. The wire was then measured, and a 27 cm tip-to-cuff hemodialysis catheter was selected. Occasional ventricular ectopy. Otherwise, no diagnostic interim change.Clinical correlation is suggested. COMPARISON: Chest radiograph from . The wire was then passed into a hepatic vein. A followup fluoroscopic image demonstrated the catheter tip to be positioned at the right atrium. pna FINAL REPORT INDICATION: Sputum and shortness of breath. Compared to the previous tracing of the rhythm isnow ventricular paced with capture and occasional ventricular ectopy. The rhythm may be of ectopic atrial origin in the context of priorinferolateral myocardial infarction and frequent ventricular ectopy. IMPRESSION: Successful placement of a 27 cm tip-to-cuff right IJ tunneled hemodialysis catheter with its tip located in the right atrium. The patient was brought to the angiography suite and placed supine, the right neck and upper chest were prepped and draped in the usual sterile fashion. Under ultrasound guidance, a 21- gauge micropuncture needle was used to access the right internal jugular vein, and a wire was passed over this. Clinicalcorrelation is suggested. Pulmonary venous congestion is seen without definite interstitial pulmonary edema. Compared to the previous tracing of theventricular premature beat is absent.TRACING #1 She was accompanied by anesthesia and radiology to the cardiac care unit. Serial dilation was then undertaken over the wire under constant fluoroscopic guidance, and a peel-away sheath was placed. OPERATORS: Dr. attending, Dr. , Dr. . Unchanged massive cardiomegaly with pulmonary vascular congestion, but no definite pulmonary edema. There is again seen pulmonary edema which is stable. The catheter was flushed, and dressed. A preprocedure timeout confirmed the patient identity and the procedure to be performed. A 2-0 Vicryl subcutaneous stitch was used to close the (Over) 2:27 PM TUNNELED DIALYSIS LINE PLACEME Clip # Reason: Please place hemodialysis line Admitting Diagnosis: CONGESTIVE HEART FAILURE Type of Port: None FINAL REPORT (Cont) venostomy site in the neck. No change in the mild pulmonary edema or massive cardiomegaly. At this point, the patient was propped up using a wedge to limit her symptoms of heart failure. An appropriate site for a cuff was chosen, and local anesthesia was obtained with approximately 10 cc of 1% lidocaine with epinephrine along the anticipated tunnel tract to the original venotomy site in the right neck. Attention was then directed to the right chest. 2:27 PM TUNNELED DIALYSIS LINE PLACEME Clip # Reason: Please place hemodialysis line Admitting Diagnosis: CONGESTIVE HEART FAILURE Type of Port: None ********************************* CPT Codes ******************************** * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS. The catheter was then sewn in place with 2-0 silk sutures. FINAL REPORT STUDY: AP chest . Under ultrasound guidance with hard copy images on file, an appropriate site to access the right internal jugular vein was chosen, and local anesthesia was obtained with approximately 5 cc of 1% buffered lidocaine. There is a left-sided AICD, which is unchanged in position. There is marked cardiomegaly and left retrocardiac opacity, which has worsened since the previous study. Compared to the previous tracing regularsupraventricular rhythm is again recorded. There islow limb lead voltage. Evaluate for pneumonia. TECHNIQUE AND FINDINGS: The procedure was explained to the patient and written informed consent was obtained. 11:36 PM CHEST (PA & LAT) Clip # Reason: ? Pulmonary congestion. The peel-away sheath was removed. There is minimal right basilar atelectasis."},"n_notes":{"kind":"number","value":8,"string":"8"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2194-07-17 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1203464,"text":" 11:36 PM\n CHEST (PA & LAT) Clip # \n Reason: ? pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with sputum, sob\n REASON FOR THIS EXAMINATION:\n ? pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sputum and shortness of breath. Evaluate for pneumonia.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: There is a left-sided pacemaker/ICD with right atrial and right\n ventricular leads, as before. Severe cardiomegaly is not significantly\n changed. Pulmonary venous congestion is seen without definite interstitial\n pulmonary edema. No focal consolidations are seen. There are no pleural\n effusions. No pneumothorax is seen. There is minimal right basilar\n atelectasis.\n\n IMPRESSION:\n\n 1. Unchanged massive cardiomegaly with pulmonary vascular congestion, but no\n definite pulmonary edema.\n\n 2. No consolidations concerning for pneumonia.\n\n"},{"category":"Radiology","chartdate":"2194-07-18 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1203606,"text":" 6:15 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with newly placed RIJ CVVH line\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n WET READ: ENYa FRI 9:25 PM\n New R IJ CVVH line terminates in the lower SVC. No PTX. Marked\n cardiomegaly. Pulmonary congestion.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: 70-year-old woman with newly placed right IJ central venous\n line.\n\n FINDINGS: There is a new right IJ central venous catheter with distal lead\n tip in the distal SVC. There is a left-sided AICD, which is unchanged in\n position. There is again seen pulmonary edema which is stable. There are no\n pneumothoraces. There is marked cardiomegaly and left retrocardiac opacity,\n which has worsened since the previous study.\n\n\n"},{"category":"Radiology","chartdate":"2194-07-23 00:00:00.000","description":"TUNNELED W/O PORT","row_id":1204236,"text":" 2:27 PM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: Please place hemodialysis line\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Type of Port: None\n ********************************* CPT Codes ********************************\n * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with cardiomyopathy, ESRD, p/w volume overload and anuria\n REASON FOR THIS EXAMINATION:\n Please place hemodialysis line\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 70-year-old female with CHF and associated renal\n failure in need of hemodialysis for line placement.\n\n OPERATORS: Dr. attending, Dr. , Dr. \n .\n\n PROCEDURE: 27 cm tip-to-cuff right IJ hemodialysis catheter placement.\n\n TECHNIQUE AND FINDINGS: The procedure was explained to the patient and\n written informed consent was obtained. A preprocedure timeout confirmed the\n patient identity and the procedure to be performed. The patient was brought\n to the angiography suite and placed supine, the right neck and upper chest\n were prepped and draped in the usual sterile fashion. Under ultrasound\n guidance with hard copy images on file, an appropriate site to access the\n right internal jugular vein was chosen, and local anesthesia was obtained with\n approximately 5 cc of 1% buffered lidocaine. Under ultrasound guidance, a 21-\n gauge micropuncture needle was used to access the right internal jugular vein,\n and a wire was passed over this. The needle was then exchanged for a\n micropuncture sheath, the inner dilator and wire were removed, and \n wire was passed through the sheath and to the right atrium. At this point,\n the patient was propped up using a wedge to limit her symptoms of heart\n failure. The wire was then measured, and a 27 cm tip-to-cuff hemodialysis\n catheter was selected. The wire was then passed into a hepatic vein. Attention\n was then directed to the right chest. An appropriate site for a cuff was\n chosen, and local anesthesia was obtained with approximately 10 cc of 1%\n lidocaine with epinephrine along the anticipated tunnel tract to the original\n venotomy site in the right neck. A stab incision was then performed on the\n chest, and using a blunt tunneling device, a tunnel was created between the\n right chest incision and the venotomy site in the right internal jugular vein.\n The hemodialysis catheter was passed through this and the cuff secured\n subcutaneously. Serial dilation was then undertaken over the wire under\n constant fluoroscopic guidance, and a peel-away sheath was placed. The wire\n and inner dilator were then removed, and hemodialysis catheter was inserted\n through the peel-away sheath. The peel-away sheath was removed. The cuff was\n then positioned. A followup fluoroscopic image demonstrated the catheter tip\n to be positioned at the right atrium. The catheter was then sewn in place\n with 2-0 silk sutures. A 2-0 Vicryl subcutaneous stitch was used to close the\n (Over)\n\n 2:27 PM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: Please place hemodialysis line\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Type of Port: None\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n venostomy site in the neck. The catheter was flushed, and dressed. The\n patient tolerated the procedure well, though was demonstrating symptoms of\n heart failure upon termination of the procedure. She was accompanied by\n anesthesia and radiology to the cardiac care unit.\n\n IMPRESSION: Successful placement of a 27 cm tip-to-cuff right IJ tunneled\n hemodialysis catheter with its tip located in the right atrium.\n\n The attending, Dr. was present and participated in the entire\n procedure.\n\n"},{"category":"Radiology","chartdate":"2194-07-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1204496,"text":" 9:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?line placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with tunneled HD line, needs confirmation for O/P HD\n REASON FOR THIS EXAMINATION:\n ?line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate HD line.\n\n FINDINGS: Single AP view of the chest shows a tunneled catheter whose tip\n terminates within the right atrium. A left pacemaker is unchanged. No change\n in the mild pulmonary edema or massive cardiomegaly. Bibasilar atelectasis,\n worse on the left. No pleural effusion or pneumothorax.\n\n IMPRESSION: Properly positioned line.\n\n\n"},{"category":"ECG","chartdate":"2194-07-21 00:00:00.000","description":"Report","row_id":107255,"text":"The rhythm may be of ectopic atrial origin in the context of prior\ninferolateral myocardial infarction and frequent ventricular ectopy. There is\nlow limb lead voltage. Compared to the previous tracing regular\nsupraventricular rhythm is again recorded. Atrial activity is difficult to\ndiscern. There is intermittent ventricular pacing with capture, non-specific\nST-T wave flattening as recorded previously and appearance of ventricular\nectopy and ventricular pacing. Otherwise, no diagnostic interim change.\nClinical correlation is suggested.\n\n"},{"category":"ECG","chartdate":"2194-07-19 00:00:00.000","description":"Report","row_id":107256,"text":"Atrial fibrillation with ventricular premature beat. Left bundle-branch block.\nCompared to tracing #1 ventricular pacing is no longer present and atrial\nfibrillation is present.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2194-07-18 00:00:00.000","description":"Report","row_id":107257,"text":"Ventricular paced rhythm. Compared to the previous tracing of the\nventricular premature beat is absent.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2194-07-17 00:00:00.000","description":"Report","row_id":107258,"text":"Ventricular paced rhythm. Occasional ventricular ectopy. The QRS interval is\nmarkedly prolonged. Compared to the previous tracing of the rhythm is\nnow ventricular paced with capture and occasional ventricular ectopy. Clinical\ncorrelation is suggested.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2194-07-17 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1203464,\n \"text\": \" 11:36 PM\\n CHEST (PA & LAT) Clip # \\n Reason: ? pna\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 70 year old woman with sputum, sob\\n REASON FOR THIS EXAMINATION:\\n ? pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Sputum and shortness of breath. Evaluate for pneumonia.\\n\\n COMPARISON: Chest radiograph from .\\n\\n FINDINGS: There is a left-sided pacemaker/ICD with right atrial and right\\n ventricular leads, as before. Severe cardiomegaly is not significantly\\n changed. Pulmonary venous congestion is seen without definite interstitial\\n pulmonary edema. No focal consolidations are seen. There are no pleural\\n effusions. No pneumothorax is seen. There is minimal right basilar\\n atelectasis.\\n\\n IMPRESSION:\\n\\n 1. Unchanged massive cardiomegaly with pulmonary vascular congestion, but no\\n definite pulmonary edema.\\n\\n 2. No consolidations concerning for pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2194-07-18 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1203606,\n \"text\": \" 6:15 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: line placement\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 70 year old woman with newly placed RIJ CVVH line\\n REASON FOR THIS EXAMINATION:\\n line placement\\n ______________________________________________________________________________\\n WET READ: ENYa FRI 9:25 PM\\n New R IJ CVVH line terminates in the lower SVC. No PTX. Marked\\n cardiomegaly. Pulmonary congestion.\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: AP chest .\\n\\n CLINICAL HISTORY: 70-year-old woman with newly placed right IJ central venous\\n line.\\n\\n FINDINGS: There is a new right IJ central venous catheter with distal lead\\n tip in the distal SVC. There is a left-sided AICD, which is unchanged in\\n position. There is again seen pulmonary edema which is stable. There are no\\n pneumothoraces. There is marked cardiomegaly and left retrocardiac opacity,\\n which has worsened since the previous study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2194-07-23 00:00:00.000\",\n \"description\": \"TUNNELED W/O PORT\",\n \"row_id\": 1204236,\n \"text\": \" 2:27 PM\\n TUNNELED DIALYSIS LINE PLACEME Clip # \\n Reason: Please place hemodialysis line\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\n Type of Port: None\\n ********************************* CPT Codes ********************************\\n * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE *\\n * US GUID FOR VAS. ACCESS *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 70 year old woman with cardiomyopathy, ESRD, p/w volume overload and anuria\\n REASON FOR THIS EXAMINATION:\\n Please place hemodialysis line\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INFORMATION: 70-year-old female with CHF and associated renal\\n failure in need of hemodialysis for line placement.\\n\\n OPERATORS: Dr. attending, Dr. , Dr. \\n .\\n\\n PROCEDURE: 27 cm tip-to-cuff right IJ hemodialysis catheter placement.\\n\\n TECHNIQUE AND FINDINGS: The procedure was explained to the patient and\\n written informed consent was obtained. A preprocedure timeout confirmed the\\n patient identity and the procedure to be performed. The patient was brought\\n to the angiography suite and placed supine, the right neck and upper chest\\n were prepped and draped in the usual sterile fashion. Under ultrasound\\n guidance with hard copy images on file, an appropriate site to access the\\n right internal jugular vein was chosen, and local anesthesia was obtained with\\n approximately 5 cc of 1% buffered lidocaine. Under ultrasound guidance, a 21-\\n gauge micropuncture needle was used to access the right internal jugular vein,\\n and a wire was passed over this. The needle was then exchanged for a\\n micropuncture sheath, the inner dilator and wire were removed, and \\n wire was passed through the sheath and to the right atrium. At this point,\\n the patient was propped up using a wedge to limit her symptoms of heart\\n failure. The wire was then measured, and a 27 cm tip-to-cuff hemodialysis\\n catheter was selected. The wire was then passed into a hepatic vein. Attention\\n was then directed to the right chest. An appropriate site for a cuff was\\n chosen, and local anesthesia was obtained with approximately 10 cc of 1%\\n lidocaine with epinephrine along the anticipated tunnel tract to the original\\n venotomy site in the right neck. A stab incision was then performed on the\\n chest, and using a blunt tunneling device, a tunnel was created between the\\n right chest incision and the venotomy site in the right internal jugular vein.\\n The hemodialysis catheter was passed through this and the cuff secured\\n subcutaneously. Serial dilation was then undertaken over the wire under\\n constant fluoroscopic guidance, and a peel-away sheath was placed. The wire\\n and inner dilator were then removed, and hemodialysis catheter was inserted\\n through the peel-away sheath. The peel-away sheath was removed. The cuff was\\n then positioned. A followup fluoroscopic image demonstrated the catheter tip\\n to be positioned at the right atrium. The catheter was then sewn in place\\n with 2-0 silk sutures. A 2-0 Vicryl subcutaneous stitch was used to close the\\n (Over)\\n\\n 2:27 PM\\n TUNNELED DIALYSIS LINE PLACEME Clip # \\n Reason: Please place hemodialysis line\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\n Type of Port: None\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n venostomy site in the neck. The catheter was flushed, and dressed. The\\n patient tolerated the procedure well, though was demonstrating symptoms of\\n heart failure upon termination of the procedure. She was accompanied by\\n anesthesia and radiology to the cardiac care unit.\\n\\n IMPRESSION: Successful placement of a 27 cm tip-to-cuff right IJ tunneled\\n hemodialysis catheter with its tip located in the right atrium.\\n\\n The attending, Dr. was present and participated in the entire\\n procedure.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2194-07-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1204496,\n \"text\": \" 9:23 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?line placement\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 70 year old woman with tunneled HD line, needs confirmation for O/P HD\\n REASON FOR THIS EXAMINATION:\\n ?line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Evaluate HD line.\\n\\n FINDINGS: Single AP view of the chest shows a tunneled catheter whose tip\\n terminates within the right atrium. A left pacemaker is unchanged. No change\\n in the mild pulmonary edema or massive cardiomegaly. Bibasilar atelectasis,\\n worse on the left. No pleural effusion or pneumothorax.\\n\\n IMPRESSION: Properly positioned line.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2194-07-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 107255,\n \"text\": \"The rhythm may be of ectopic atrial origin in the context of prior\\ninferolateral myocardial infarction and frequent ventricular ectopy. There is\\nlow limb lead voltage. Compared to the previous tracing regular\\nsupraventricular rhythm is again recorded. Atrial activity is difficult to\\ndiscern. There is intermittent ventricular pacing with capture, non-specific\\nST-T wave flattening as recorded previously and appearance of ventricular\\nectopy and ventricular pacing. Otherwise, no diagnostic interim change.\\nClinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2194-07-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 107256,\n \"text\": \"Atrial fibrillation with ventricular premature beat. Left bundle-branch block.\\nCompared to tracing #1 ventricular pacing is no longer present and atrial\\nfibrillation is present.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2194-07-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 107257,\n \"text\": \"Ventricular paced rhythm. Compared to the previous tracing of the\\nventricular premature beat is absent.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2194-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 107258,\n \"text\": \"Ventricular paced rhythm. Occasional ventricular ectopy. The QRS interval is\\nmarkedly prolonged. Compared to the previous tracing of the rhythm is\\nnow ventricular paced with capture and occasional ventricular ectopy. Clinical\\ncorrelation is suggested.\\n\\n\"\n }\n]"}}},{"rowIdx":24687,"cells":{"subject_id":{"kind":"number","value":76974,"string":"76,974"},"hadm_id":{"kind":"number","value":145550,"string":"145,550"},"target_text":{"kind":"string","value":"The patient was admitted to under the Oncology team for evaulation of his left hemiplegia. MRI revealed a region of contrast enhancement in the right frontal lobe and extensive surrounding edema. He was taken to the operating room on for a R frontal craniotomy for lesion resection. The preliminary pathology report was positive for radiation necrosis. His neurological exam remained stable and unchanged post-operatively. He remained on the mannitol and dexamethasone for the vasogenic edema. He had an MRI on which revealed persistent VG edema, but no new hemorrhage or infarct. He was tapered off of the mannitol until , and the dexamethasone was kept at 4mg Q 6. He was transferred to the floor on , and was seen by the physical therapists. They determined that he met criteria for a rehab facility. He was discharged to the rehab on ."},"extractive_notes_summ":{"kind":"string","value":"The right perimesencephalic cistern remains obliterated and the right cerebellopontine angle cistern remains enlarged, consistent with slight or early right uncal herniation. early/slight right uncal herniation simliar to post op CT. There is now a relatively well-defined 2.1 (AP) x 2.2 (TRV) predominantly T2-hyper- and T1-hypointense resection cavity, at the site of the previous dominant mass, superficially located the right frontal lobe. At least four small enhancing foci with marked \"blooming\" susceptibility artifact in the right frontal corona radiata and forceps minor, as described, also unchanged and likely representing metastases. At least four small enhancing foci with marked \"blooming\" susceptibility artifact in right frontal corona radiata and forceps minor, as described, also unchanged and likely representing metastases. At least four small enhancing foci with marked \"blooming\" susceptibility artifact in right frontal corona radiata and forceps minor, as described, also unchanged and likely representing metastases. Effacement of the right cerebral sulci and mass effect on the right lateral ventricle is likely unchanged from MRI . Degree of early/slight right uncal herniation is unchanged from . There remains some mass effect on the right lateral ventricle. Eval for post op infarct/edema/completeness of resection No contraindications for IV contrast PFI REPORT PFI: 1. Status post very recent right frontal craniotomy with resection of the dominant mass superficially located in the right frontal lobe; however, there is persistent band-like enhancement at the posterior and caudal margin of the resection cavity, highly suggestive of residual tumor. Status post very recent right frontal craniotomy with resection of the dominant mass superficially located in the right frontal lobe; however, there is persistent band-like enhancement at the posterior and caudal margin of the resection cavity, highly suggestive of residual tumor. TECHNIQUE: Non-contrast head CT was obtained. TECHNIQUE: Non-contrast head CT was obtained. Plea Admitting Diagnosis: METASTATIC BRAIN TUMOR Contrast: MAGNEVIST Amt: 18 FINAL REPORT (Cont) are well aerated. COMPARISON: Head CT, and . There is new right uncal herniation, with obliteration of the right perimesencephalic cistern and mass effect on the right cerebral peduncle. New right uncal herniation, with effacement of the right perimesencephalic cistern and mass effect on the right cerebral peduncle. new right uncal herniation, effacement of right perimesencephalic cistern, mass effect on right cerebral peduncle. The amount of edema of the right hemisphere is similar to the prior study. IMPRESSION: Status post resection of right frontal lobe mass with expected post-surgical changes. Mass effect on the right lateral ventricle persists. Additionally, the clustered intrinsically T1-hyperintense lesions in the right corona radiata, caudate head and forceps minor, as well as the subependymal enhancing lesion in the frontal of the right lateral ventricle are all unchanged. There is FLAIR/T2-hyperintensity within the bilateral cerebral hemispheres, which extends up to but does not involve the subcortical U-fibers, stable when compared with prior studies dating back to . cystic surgical cavity w/ new depending hyperdensity c/w hemorrhage. There is a small focal area of atelectasis and/or consolidation at the left base and streaky density at the right base consistent with subsegmental atelectasis as demonstrated previously. Sulcal effacement of the right hemisphere persists. There remains mass effect on the brainstem with uncal herniation. Non- contrast head CT, . FINDINGS: The patient is status post right frontal craniectomy, with resection of the right frontal lobe enhancing lesion. FINDINGS: Since the previous study, the patient has undergone resection of right frontal lobe enhancing lesion. The principal intracranial vascular flow voids are preserved. COMPARISON: Multiple MRIs of the head, most recent . Eval Admitting Diagnosis: METASTATIC BRAIN TUMOR Contrast: MAGNEVIST Amt: FINAL REPORT (Cont) the posterior and inferior margin of the cavity, measuring up to 2.3 (TRV) x 0.08 cm (AP), likely representing residual tumor at this site. Similar to minimally increased leftward shift of midline structures, now 9 (Over) 9:45 AM CT HEAD W/O CONTRAST Clip # Reason: Eval for interval changes Admitting Diagnosis: METASTATIC BRAIN TUMOR FINAL REPORT (Cont) mm. 7mm leftward shift of midline structures similar to MRI . The intracranial arterial flow voids are patent. The left hemidiaphragm is elevated as before. CLINICAL INFORMATION: Patient with right-sided frontal craniotomy. Status post very recent right frontal craniotomy with resection of the dominant mass superficially located in the right frontal lobe; however, there is persistent band-like enhancement at the posterior and caudal margin of the resection cavity, highly suspicious for residual tumor."},"n_notes":{"kind":"number","value":11,"string":"11"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2179-04-24 00:00:00.000","description":"MR HEAD W & W/O CONTRAST","row_id":1132833,"text":" 9:52 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 62 year old man s/p R frontal crani for mass resection. Eval\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n Contrast: MAGNEVIST Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p R frontal crani for mass resection. Eval for post op\n infarct/edema/completeness of resection\n REASON FOR THIS EXAMINATION:\n 62 year old man s/p R frontal crani for mass resection. Eval for post op\n infarct/edema/completeness of resection\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DRT SAT 6:01 PM\n PFI:\n\n 1. Status post very recent right frontal craniotomy with resection of the\n dominant mass superficially located in the right frontal lobe; however, there\n is persistent band-like enhancement at the posterior and caudal margin of the\n resection cavity, highly suggestive of residual tumor.\n\n 2. Separate discrete 8-mm enhancing focus in the right temporal operculum,\n unchanged.\n\n 3. At least four small enhancing foci with marked \"blooming\" susceptibility\n artifact in right frontal corona radiata and forceps minor, as described, also\n unchanged and likely representing metastases.\n\n 4. No definite hemorrhage or acute infarction elsewhere in the brain.\n ______________________________________________________________________________\n FINAL REPORT\n MR OF THE BRAIN, .\n\n HISTORY: 62-year-old male status post recent right frontal craniotomy and\n resection of mass; evaluate for post-op infarct, edema and completeness of\n resection.\n\n TECHNIQUE: Routine enhanced MR examination of the brain was performed.\n\n FINDINGS: The study is compared with most recent enhanced MR of and\n post-operative NECT of .\n\n There is extensive FLAIR-signal abnormality representing edema in the right\n frontoparietal vertex extracalvarial soft tissues, related to the recent\n surgery. Along with this, there is extensive susceptibility artifact in the\n subjacent extra-axial compartment, likely representing a combination of\n diamagnetic susceptibility from residual pneumocephalus, as well as blood\n products at this site. There is now a relatively well-defined 2.1 (AP) x 2.2\n (TRV) predominantly T2-hyper- and T1-hypointense resection cavity, at the site\n of the previous dominant mass, superficially located the right frontal lobe.\n However, allowing for the ill-defined intrinsic T1-hyperintensity at the\n medial aspect of the cavity, there is persistent thick C-shaped enhancement at\n (Over)\n\n 9:52 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 62 year old man s/p R frontal crani for mass resection. Eval\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n Contrast: MAGNEVIST Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the posterior and inferior margin of the cavity, measuring up to 2.3 (TRV) x\n 0.08 cm (AP), likely representing residual tumor at this site. Additionally,\n the clustered intrinsically T1-hyperintense lesions in the right corona\n radiata, caudate head and forceps minor, as well as the subependymal enhancing\n lesion in the frontal of the right lateral ventricle are all unchanged.\n These demonstrate marked \"blooming\" susceptibility artifact, likely\n representing hemorrhage, melanin or a combination of the two, and likely\n represent persistent metastatic foci, at a remove from the resection cavity.\n No new focus suspicious for metastasis is seen.\n\n Allowing for the extensive susceptibility artifacts at the right frontovertex,\n related to the recent surgery, with associated artifact on the DWI sequence,\n there is no evidence of intra- or extra-axial hemorrhage or acute infarction,\n elsewhere. The principal intracranial vascular flow voids are preserved.\n Again demonstrated is the extensive white matter abnormality involving both\n cerebral hemispheres, unchanged, with a distribution suggestive of radiation\n effect. Also noted is fluid-opacification of the mastoid air cells, left more\n than right, which may also be seen post-operatively.\n\n IMPRESSION:\n\n 1. Status post very recent right frontal craniotomy with resection of the\n dominant mass superficially located in the right frontal lobe; however, there\n is persistent band-like enhancement at the posterior and caudal margin of the\n resection cavity, highly suspicious for residual tumor.\n\n 2. Separate discrete 8-mm enhancing focus in the right temporal operculum,\n unchanged.\n\n 3. At least four small enhancing foci with marked \"blooming\" susceptibility\n artifact in the right frontal corona radiata and forceps minor, as described,\n also unchanged and likely representing metastases.\n\n 4. No definite hemorrhage or acute infarction elsewhere in the brain.\n\n"},{"category":"Radiology","chartdate":"2179-04-24 00:00:00.000","description":"MR HEAD W & W/O CONTRAST","row_id":1132834,"text":", T. NMED SICU-A 9:52 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 62 year old man s/p R frontal crani for mass resection. Eval\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n Contrast: MAGNEVIST Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p R frontal crani for mass resection. Eval for post op\n infarct/edema/completeness of resection\n REASON FOR THIS EXAMINATION:\n 62 year old man s/p R frontal crani for mass resection. Eval for post op\n infarct/edema/completeness of resection\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n 1. Status post very recent right frontal craniotomy with resection of the\n dominant mass superficially located in the right frontal lobe; however, there\n is persistent band-like enhancement at the posterior and caudal margin of the\n resection cavity, highly suggestive of residual tumor.\n\n 2. Separate discrete 8-mm enhancing focus in the right temporal operculum,\n unchanged.\n\n 3. At least four small enhancing foci with marked \"blooming\" susceptibility\n artifact in right frontal corona radiata and forceps minor, as described, also\n unchanged and likely representing metastases.\n\n 4. No definite hemorrhage or acute infarction elsewhere in the brain.\n\n"},{"category":"Radiology","chartdate":"2179-04-28 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1133381,"text":" 9:45 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for interval changes\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with R brain mass, s/p crani. Now with increased confusion\n REASON FOR THIS EXAMINATION:\n Eval for interval changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: WED 11:09 AM\n expansion of extra-axial collection overlying surgical bed, now 11mm\n (previously 6mm on ). cystic surgical cavity w/ new depending\n hyperdensity c/w hemorrhage. this largely fluid-filled cavity also appears to\n be expanding now 3.2 x 2.6cm. similar to minimally increased leftward midlind\n shift of 8-9mm. early/slight right uncal herniation simliar to post op\n CT.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old male with right brain mass, status post craniotomy, now\n with increased confusion.\n\n COMPARISON: Head CT, and .\n\n TECHNIQUE: Non-contrast head CT was obtained.\n\n FINDINGS: The patient is status post right frontal craniectomy, with\n resection of the right frontal lobe enhancing lesion. The subdural collection\n overlying the surgical bed has enlarged, and remains of mixed or\n increasing attenuation, raising concern for accumulating hemorrhage, now\n measures 11 mm in thickness, previously was 6 mm. A hypodense fluid-filled\n cavity of the right frontal lobe at the resection site also appears larger,\n measuring approximately 3.2 cm (AP) x 2.6 cm (TRV), previously 2.3 cm x 1.9\n cm. The amount of pneumocephalus has decreased. Leftward shift of midline\n structures persist, similar to minimally increased, now measuring 9 mm,\n previously 8 mm.\n\n The right perimesencephalic cistern remains obliterated and the right\n cerebellopontine angle cistern remains enlarged, consistent with slight or\n early right uncal herniation. -white matter differentiation is preserved,\n without evidence of PCA distribution infarct on this non-contrast head CT.\n\n The amount of edema of the right hemisphere is similar to the prior study.\n Focal hyperdensity is likely blood layering in the surgical cavity (2:13), new\n from the prior study. There is no hydrocephalus.\n\n IMPRESSION:\n 1. Expansion of the mixed-density extra-axial collection overlying the\n surgical bed, now 11 mm (previously 6 mm).\n 2. Apparent increase in the fluid-filled surgical cavity, with new dependent\n hyperdensity consistent with hemorrhage.\n 3. Similar to minimally increased leftward shift of midline structures, now 9\n (Over)\n\n 9:45 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for interval changes\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n mm. Degree of early/slight right uncal herniation is unchanged from .\n\n COMMENT: Dr. provided a preliminary report to \n of neurosurgery at 11:50 a.m. on .\n\n\n"},{"category":"Radiology","chartdate":"2179-04-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1132934,"text":" 4:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for hemothorax\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p d/c of left subclavian arterial line\n REASON FOR THIS EXAMINATION:\n eval for hemothorax\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n HISTORY: Removal of line.\n\n One portable view. Comparison with the previous study done . There is\n streaky density at the lung bases consistent with subsegmental atelectasis as\n before. The left hemidiaphragm is mildly elevated. There is a focal area of\n increased density at the medial aspect of the left base that may represent\n atelectasis or consolidation. Mediastinal structures are unchanged. A left\n subclavian catheter has been withdrawn.\n\n IMPRESSION: Withdrawal of left subclavian catheter. No other significant\n change.\n\n\n"},{"category":"Radiology","chartdate":"2179-04-25 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1133019,"text":" 2:20 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Good placement?\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with dobhoff\n REASON FOR THIS EXAMINATION:\n Good placement?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Dobbhoff tube placement.\n\n One view. Comparison with . The left hemidiaphragm is elevated as\n before. There is a small focal area of atelectasis and/or consolidation at\n the left base and streaky density at the right base consistent with\n subsegmental atelectasis as demonstrated previously. The heart and\n mediastinal structures are unchanged. A Dobbhoff feeding tube has been\n re-inserted and now terminates just below the level of the diaphragm in the\n region of the stomach.\n\n IMPRESSION: The Dobbhoff feeding tube now appears to terminate in the\n stomach. No other significant change.\n\n\n"},{"category":"Radiology","chartdate":"2179-04-22 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1132572,"text":" 4:22 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for intracerebral hemorrhage\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with known metastatic melanoma, radiation necrosis, transferred\n for acute ICH, has dense paraparesis of left side and left sided neglect\n REASON FOR THIS EXAMINATION:\n eval for intracerebral hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 5:27 PM\n extensive low density of white matter of right hemisphere c/w edema similar\n to MRI . Right frontal hyperdense lesion (2:25) may be new from MR\n , but difficult to definitely determine due to patient positioning. New\n subcortical small hyperdense foci may be hemorrhage, measure up to 8mm. 7mm\n leftward shift of midline structures similar to MRI .\n\n new right uncal herniation, effacement of right perimesencephalic cistern,\n mass effect on right cerebral peduncle. effacement of right cerebral sulci\n and mass effect on right lateral ventricle.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old male with known metastatic melanoma and radiation\n necrosis with left-sided neglect and dense hemiparesis.\n\n COMPARISON: Multiple prior brain MRIs, most recently . Non-\n contrast head CT, .\n\n TECHNIQUE: Non-contrast head CT was obtained.\n\n FINDINGS: Extensive white matter hypoattenuation of the hemispheres, right\n greater than left, is likely similar to MRI of allowing for\n differences in technique. Punctate hyperdense foci of the subcortical white\n matter (2:21, 2:20), measuring up to 8 mm are new from prior studies. A right\n frontal lesion measuring 6 mm (2:25) may correspond to the right frontal\n lesion on the previous study, although this is difficult to determine due to\n differences in modality and patient positioning. Sulcal effacement of the\n right hemisphere persists. Leftward shift of midline structures by 7 mm is\n unchanged. There is new right uncal herniation, with obliteration of the\n right perimesencephalic cistern and mass effect on the right cerebral\n peduncle. Mass effect on the right lateral ventricle persists. There is no\n tonsillar herniation.\n\n The visualized paranasal sinuses and mastoid air cells are normally\n pneumatized and aerated. There are no concerning osseous lesions.\n\n IMPRESSION:\n 1. New right uncal herniation, with effacement of the right perimesencephalic\n cistern and mass effect on the right cerebral peduncle. Effacement of the\n right cerebral sulci and mass effect on the right lateral ventricle is likely\n unchanged from MRI .\n (Over)\n\n 4:22 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for intracerebral hemorrhage\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. New punctate subcortical white matter hyperdense foci, which may be\n hemorrhage, measuring up to 8 mm.\n 3. Hyperdense 6 mm right frontal lesion, difficult to determine whether this\n is a new finding from MRI .\n 4. Extensive white matter hypoattenuation consistent with edema/radiation\n effect, likely similar to MRI, , allowing for differences in\n technique.\n\n Preliminary report was provided by Dr. to Dr. at 5:30\n p.m. on .\n\n"},{"category":"Radiology","chartdate":"2179-04-25 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1132987,"text":" 11:19 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Is Dobhoff in good placement?\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with hx melanoma brain mets in need of feeeding tube\n REASON FOR THIS EXAMINATION:\n Is Dobhoff in good placement?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Brain mets, Dobbhoff feeding tube placement.\n\n ONE PORTABLE VIEW. Comparison with . The left chest wall is not\n entirely included. Bibasilar subsegmental atelectasis and a small focal area\n of increased density at the left base that may represent parenchymal\n consolidation are again demonstrated. The heart and mediastinal structures\n are unchanged. A feeding tube has been inserted and is coiled in the cervical\n region. Its tip off the top of the image.\n\n IMPRESSION: The feeding tube not in place. Result called to SICU.\n\n\n"},{"category":"Radiology","chartdate":"2179-04-22 00:00:00.000","description":"MR HEAD W & W/O CONTRAST","row_id":1132609,"text":" 10:18 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: eval for acute ICH, radiation necrosis interval change. Plea\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with known metastatic melanoma, radiation necrosis, transferred\n for acute ICH, has dense paraparesis of left side and left sided neglect\n REASON FOR THIS EXAMINATION:\n eval for acute ICH, radiation necrosis interval change. Please also do MRI WAND\n sequence-place fiducials. MUST be completed within 4hrs for surgical\n planning-needed to assess urgency for OR\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: MR head with and without contrast.\n\n HISTORY: 62-year-old male with known metastatic melanoma and radiation\n necrosis transferred for acute intracranial hemorrhage, presenting with\n paraparesis of the left side and left-sided neglect to evaluate for acute\n intracranial hemorrhage and interval change of radiation necrosis.\n\n TECHNIQUE: Multiplanar MRI of the head was performed with and without\n intravenous gadolinium administration. Examination was performed with scalp\n fiducials in place for MRI Wand study.\n\n COMPARISON: Multiple MRIs of the head, most recent .\n\n FINDINGS:\n\n There has been no significant interval change in size or appearance of the\n irregular peripherally enhancing lesion involving the post-surgical bed in the\n right frontal lobe measuring approximately 3.6 (AP) x 2.3 (TRV) x 2.5 cm (CC)\n when compared with the prior examination of . There has been interval\n decrease in size of the satellite lesion just inferior to the dominant lesion\n medial to the sylvian fissure, now measuring 7 (AP) x 7 (TRV) x 7 mm (CC).\n\n There is a cluster of four new enhancing lesions, as follows, in the: Right\n corona radiata; right caudate head; and two new enhancing lesions in the right\n forceps minor. These demonstrate marked blooming with hemosiderin rings.\n\n There is FLAIR/T2-hyperintensity within the bilateral cerebral hemispheres,\n which extends up to but does not involve the subcortical U-fibers, stable when\n compared with prior studies dating back to . There is stable mass\n effect and effacement on the body of the right lateral ventricle. There has\n been slight interval decrease in shift of the normally midline structures, now\n measuring 6.5 mm and previously measuring 8.5 mm.\n\n There is no calvarial, upper cervical, or clival bone marrow abnormality.\n\n The ventricles are stable in size. There is no acute infarction. The\n intracranial arterial flow voids are patent. The visualized paranasal sinuses\n (Over)\n\n 10:18 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: eval for acute ICH, radiation necrosis interval change. Plea\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n are well aerated. There is fluid within the mastoid air cells, bilaterally.\n\n IMPRESSION:\n 1. Four new enhancing lesions, as described above, with marked \"blooming\"\n artifact consistent with blood products, melanin or both, with stability size\n and appearance of the dominant enhancing lesion and interval decrease in size\n of the adjacent \"satellite\" lesion. Findings are consistent with\n mixed-response to treatment.\n 2. Persistent confluent FLAIR-hyperintensity extending to, but not including,\n the subcortical U-fibers with persistent mass effect and decreased shift of\n the normally midline structures; the appearance is consistent with radiation\n toxicity.\n 3. No acute infarction.\n\n"},{"category":"Radiology","chartdate":"2179-04-23 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1132714,"text":" 2:13 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 62 year old man s/p R frontal crani for mass resection. Eval\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p R frontal crani for mass resection. Eval for post op\n hemorrhage. Please perform within 4 hours from surgery\n REASON FOR THIS EXAMINATION:\n 62 year old man s/p R frontal crani for mass resection. Eval for post op\n hemorrhage. Please perform within 4 hours from surgery\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CT of the head.\n\n CLINICAL INFORMATION: Patient with right-sided frontal craniotomy.\n\n TECHNIQUE: Axial images of the head were obtained without contrast.\n Correlation was made with the head MRI of .\n\n FINDINGS: Since the previous study, the patient has undergone resection of\n right frontal lobe enhancing lesion. There are post-surgical changes\n including blood products and air in the right frontal lobe region. Again seen\n is edema extending from frontal to the parietal region and temporal region.\n There remains some mass effect on the right lateral ventricle. A small area\n of blood products seen in the deep white matter adjacent to the ventricle, as\n on the previous MRI. There is no hydrocephalus. There remains mass effect on\n the brainstem with uncal herniation.\n\n IMPRESSION: Status post resection of right frontal lobe mass with expected\n post-surgical changes. No new area of brain edema seen or evidence of\n hydrocephalus.\n\n\n"},{"category":"Radiology","chartdate":"2179-04-24 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1132883,"text":" 8:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for position, PTX\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p left SCV line placement\n REASON FOR THIS EXAMINATION:\n eval for position, PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Subclavian line placement. Evaluate for pneumothorax.\n\n One portable view. No previous studies are available for comparison at this\n time. There is streaky density at the lung bases consistent with subsegmental\n atelectasis. There is more confluent increased density in the retrocardiac\n area that may represent parenchymal consolidation. The cardiac silhouette is\n prominent but may be exaggerated by AP technique. Mediastinal structures are\n otherwise unremarkable. A left subclavian catheter has been inserted. It\n does not course along the top of the left brachiocephalic vein and instead\n extends inferiorly with its tip projected to the left of the thoracic spine\n over the descending aorta.\n\n The central venous catheter does not appear to be in correct position. Its\n position could be further evaluated by a lateral chest x-ray. Clinical\n correlation is recommended.\n\n Bibasilar subsegmental atelectasis. Possible focal consolidation left base.\n\n\n"},{"category":"Radiology","chartdate":"2179-04-24 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1132913,"text":" 11:36 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for PTX\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p RIJ CVL attempt\n REASON FOR THIS EXAMINATION:\n eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right IJ line placement.\n\n One portable view. Comparison with the previous study done earlier the same\n day. There is streaky density at the lung bases consistent with subsegmental\n atelectasis and possibly a small focal area of consolidation at the left lung\n base, as before. Mediastinal structures are unchanged. A catheter is again\n demonstrated in the left chest. This appears to proceed from the region of\n the subclavian vein but does not follow the course of the left brachiocephalic\n vein and terminates to the left of the spine, with its tip projected over the\n descending aorta, as before. No other central catheter is identified. There\n is no significant change.\n\n IMPRESSION: No significant interval change.\n\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-04-24 00:00:00.000\",\n \"description\": \"MR HEAD W & W/O CONTRAST\",\n \"row_id\": 1132833,\n \"text\": \" 9:52 AM\\n MR HEAD W & W/O CONTRAST Clip # \\n Reason: 62 year old man s/p R frontal crani for mass resection. Eval\\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\\n Contrast: MAGNEVIST Amt:\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man s/p R frontal crani for mass resection. Eval for post op\\n infarct/edema/completeness of resection\\n REASON FOR THIS EXAMINATION:\\n 62 year old man s/p R frontal crani for mass resection. Eval for post op\\n infarct/edema/completeness of resection\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): DRT SAT 6:01 PM\\n PFI:\\n\\n 1. Status post very recent right frontal craniotomy with resection of the\\n dominant mass superficially located in the right frontal lobe; however, there\\n is persistent band-like enhancement at the posterior and caudal margin of the\\n resection cavity, highly suggestive of residual tumor.\\n\\n 2. Separate discrete 8-mm enhancing focus in the right temporal operculum,\\n unchanged.\\n\\n 3. At least four small enhancing foci with marked \\\"blooming\\\" susceptibility\\n artifact in right frontal corona radiata and forceps minor, as described, also\\n unchanged and likely representing metastases.\\n\\n 4. No definite hemorrhage or acute infarction elsewhere in the brain.\\n ______________________________________________________________________________\\n FINAL REPORT\\n MR OF THE BRAIN, .\\n\\n HISTORY: 62-year-old male status post recent right frontal craniotomy and\\n resection of mass; evaluate for post-op infarct, edema and completeness of\\n resection.\\n\\n TECHNIQUE: Routine enhanced MR examination of the brain was performed.\\n\\n FINDINGS: The study is compared with most recent enhanced MR of and\\n post-operative NECT of .\\n\\n There is extensive FLAIR-signal abnormality representing edema in the right\\n frontoparietal vertex extracalvarial soft tissues, related to the recent\\n surgery. Along with this, there is extensive susceptibility artifact in the\\n subjacent extra-axial compartment, likely representing a combination of\\n diamagnetic susceptibility from residual pneumocephalus, as well as blood\\n products at this site. There is now a relatively well-defined 2.1 (AP) x 2.2\\n (TRV) predominantly T2-hyper- and T1-hypointense resection cavity, at the site\\n of the previous dominant mass, superficially located the right frontal lobe.\\n However, allowing for the ill-defined intrinsic T1-hyperintensity at the\\n medial aspect of the cavity, there is persistent thick C-shaped enhancement at\\n (Over)\\n\\n 9:52 AM\\n MR HEAD W & W/O CONTRAST Clip # \\n Reason: 62 year old man s/p R frontal crani for mass resection. Eval\\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\\n Contrast: MAGNEVIST Amt:\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n the posterior and inferior margin of the cavity, measuring up to 2.3 (TRV) x\\n 0.08 cm (AP), likely representing residual tumor at this site. Additionally,\\n the clustered intrinsically T1-hyperintense lesions in the right corona\\n radiata, caudate head and forceps minor, as well as the subependymal enhancing\\n lesion in the frontal of the right lateral ventricle are all unchanged.\\n These demonstrate marked \\\"blooming\\\" susceptibility artifact, likely\\n representing hemorrhage, melanin or a combination of the two, and likely\\n represent persistent metastatic foci, at a remove from the resection cavity.\\n No new focus suspicious for metastasis is seen.\\n\\n Allowing for the extensive susceptibility artifacts at the right frontovertex,\\n related to the recent surgery, with associated artifact on the DWI sequence,\\n there is no evidence of intra- or extra-axial hemorrhage or acute infarction,\\n elsewhere. The principal intracranial vascular flow voids are preserved.\\n Again demonstrated is the extensive white matter abnormality involving both\\n cerebral hemispheres, unchanged, with a distribution suggestive of radiation\\n effect. Also noted is fluid-opacification of the mastoid air cells, left more\\n than right, which may also be seen post-operatively.\\n\\n IMPRESSION:\\n\\n 1. Status post very recent right frontal craniotomy with resection of the\\n dominant mass superficially located in the right frontal lobe; however, there\\n is persistent band-like enhancement at the posterior and caudal margin of the\\n resection cavity, highly suspicious for residual tumor.\\n\\n 2. Separate discrete 8-mm enhancing focus in the right temporal operculum,\\n unchanged.\\n\\n 3. At least four small enhancing foci with marked \\\"blooming\\\" susceptibility\\n artifact in the right frontal corona radiata and forceps minor, as described,\\n also unchanged and likely representing metastases.\\n\\n 4. No definite hemorrhage or acute infarction elsewhere in the brain.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-04-24 00:00:00.000\",\n \"description\": \"MR HEAD W & W/O CONTRAST\",\n \"row_id\": 1132834,\n \"text\": \", T. NMED SICU-A 9:52 AM\\n MR HEAD W & W/O CONTRAST Clip # \\n Reason: 62 year old man s/p R frontal crani for mass resection. Eval\\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\\n Contrast: MAGNEVIST Amt:\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man s/p R frontal crani for mass resection. Eval for post op\\n infarct/edema/completeness of resection\\n REASON FOR THIS EXAMINATION:\\n 62 year old man s/p R frontal crani for mass resection. Eval for post op\\n infarct/edema/completeness of resection\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI:\\n\\n 1. Status post very recent right frontal craniotomy with resection of the\\n dominant mass superficially located in the right frontal lobe; however, there\\n is persistent band-like enhancement at the posterior and caudal margin of the\\n resection cavity, highly suggestive of residual tumor.\\n\\n 2. Separate discrete 8-mm enhancing focus in the right temporal operculum,\\n unchanged.\\n\\n 3. At least four small enhancing foci with marked \\\"blooming\\\" susceptibility\\n artifact in right frontal corona radiata and forceps minor, as described, also\\n unchanged and likely representing metastases.\\n\\n 4. No definite hemorrhage or acute infarction elsewhere in the brain.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-04-28 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1133381,\n \"text\": \" 9:45 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: Eval for interval changes\\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man with R brain mass, s/p crani. Now with increased confusion\\n REASON FOR THIS EXAMINATION:\\n Eval for interval changes\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: WED 11:09 AM\\n expansion of extra-axial collection overlying surgical bed, now 11mm\\n (previously 6mm on ). cystic surgical cavity w/ new depending\\n hyperdensity c/w hemorrhage. this largely fluid-filled cavity also appears to\\n be expanding now 3.2 x 2.6cm. similar to minimally increased leftward midlind\\n shift of 8-9mm. early/slight right uncal herniation simliar to post op\\n CT.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 62-year-old male with right brain mass, status post craniotomy, now\\n with increased confusion.\\n\\n COMPARISON: Head CT, and .\\n\\n TECHNIQUE: Non-contrast head CT was obtained.\\n\\n FINDINGS: The patient is status post right frontal craniectomy, with\\n resection of the right frontal lobe enhancing lesion. The subdural collection\\n overlying the surgical bed has enlarged, and remains of mixed or\\n increasing attenuation, raising concern for accumulating hemorrhage, now\\n measures 11 mm in thickness, previously was 6 mm. A hypodense fluid-filled\\n cavity of the right frontal lobe at the resection site also appears larger,\\n measuring approximately 3.2 cm (AP) x 2.6 cm (TRV), previously 2.3 cm x 1.9\\n cm. The amount of pneumocephalus has decreased. Leftward shift of midline\\n structures persist, similar to minimally increased, now measuring 9 mm,\\n previously 8 mm.\\n\\n The right perimesencephalic cistern remains obliterated and the right\\n cerebellopontine angle cistern remains enlarged, consistent with slight or\\n early right uncal herniation. -white matter differentiation is preserved,\\n without evidence of PCA distribution infarct on this non-contrast head CT.\\n\\n The amount of edema of the right hemisphere is similar to the prior study.\\n Focal hyperdensity is likely blood layering in the surgical cavity (2:13), new\\n from the prior study. There is no hydrocephalus.\\n\\n IMPRESSION:\\n 1. Expansion of the mixed-density extra-axial collection overlying the\\n surgical bed, now 11 mm (previously 6 mm).\\n 2. Apparent increase in the fluid-filled surgical cavity, with new dependent\\n hyperdensity consistent with hemorrhage.\\n 3. Similar to minimally increased leftward shift of midline structures, now 9\\n (Over)\\n\\n 9:45 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: Eval for interval changes\\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n mm. Degree of early/slight right uncal herniation is unchanged from .\\n\\n COMMENT: Dr. provided a preliminary report to \\n of neurosurgery at 11:50 a.m. on .\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-04-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1132934,\n \"text\": \" 4:00 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for hemothorax\\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man s/p d/c of left subclavian arterial line\\n REASON FOR THIS EXAMINATION:\\n eval for hemothorax\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST X-RAY\\n\\n HISTORY: Removal of line.\\n\\n One portable view. Comparison with the previous study done . There is\\n streaky density at the lung bases consistent with subsegmental atelectasis as\\n before. The left hemidiaphragm is mildly elevated. There is a focal area of\\n increased density at the medial aspect of the left base that may represent\\n atelectasis or consolidation. Mediastinal structures are unchanged. A left\\n subclavian catheter has been withdrawn.\\n\\n IMPRESSION: Withdrawal of left subclavian catheter. No other significant\\n change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-04-25 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1133019,\n \"text\": \" 2:20 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: Good placement?\\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man with dobhoff\\n REASON FOR THIS EXAMINATION:\\n Good placement?\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST\\n\\n HISTORY: Dobbhoff tube placement.\\n\\n One view. Comparison with . The left hemidiaphragm is elevated as\\n before. There is a small focal area of atelectasis and/or consolidation at\\n the left base and streaky density at the right base consistent with\\n subsegmental atelectasis as demonstrated previously. The heart and\\n mediastinal structures are unchanged. A Dobbhoff feeding tube has been\\n re-inserted and now terminates just below the level of the diaphragm in the\\n region of the stomach.\\n\\n IMPRESSION: The Dobbhoff feeding tube now appears to terminate in the\\n stomach. No other significant change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-04-22 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1132572,\n \"text\": \" 4:22 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval for intracerebral hemorrhage\\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man with known metastatic melanoma, radiation necrosis, transferred\\n for acute ICH, has dense paraparesis of left side and left sided neglect\\n REASON FOR THIS EXAMINATION:\\n eval for intracerebral hemorrhage\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: 5:27 PM\\n extensive low density of white matter of right hemisphere c/w edema similar\\n to MRI . Right frontal hyperdense lesion (2:25) may be new from MR\\n , but difficult to definitely determine due to patient positioning. New\\n subcortical small hyperdense foci may be hemorrhage, measure up to 8mm. 7mm\\n leftward shift of midline structures similar to MRI .\\n\\n new right uncal herniation, effacement of right perimesencephalic cistern,\\n mass effect on right cerebral peduncle. effacement of right cerebral sulci\\n and mass effect on right lateral ventricle.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 62-year-old male with known metastatic melanoma and radiation\\n necrosis with left-sided neglect and dense hemiparesis.\\n\\n COMPARISON: Multiple prior brain MRIs, most recently . Non-\\n contrast head CT, .\\n\\n TECHNIQUE: Non-contrast head CT was obtained.\\n\\n FINDINGS: Extensive white matter hypoattenuation of the hemispheres, right\\n greater than left, is likely similar to MRI of allowing for\\n differences in technique. Punctate hyperdense foci of the subcortical white\\n matter (2:21, 2:20), measuring up to 8 mm are new from prior studies. A right\\n frontal lesion measuring 6 mm (2:25) may correspond to the right frontal\\n lesion on the previous study, although this is difficult to determine due to\\n differences in modality and patient positioning. Sulcal effacement of the\\n right hemisphere persists. Leftward shift of midline structures by 7 mm is\\n unchanged. There is new right uncal herniation, with obliteration of the\\n right perimesencephalic cistern and mass effect on the right cerebral\\n peduncle. Mass effect on the right lateral ventricle persists. There is no\\n tonsillar herniation.\\n\\n The visualized paranasal sinuses and mastoid air cells are normally\\n pneumatized and aerated. There are no concerning osseous lesions.\\n\\n IMPRESSION:\\n 1. New right uncal herniation, with effacement of the right perimesencephalic\\n cistern and mass effect on the right cerebral peduncle. Effacement of the\\n right cerebral sulci and mass effect on the right lateral ventricle is likely\\n unchanged from MRI .\\n (Over)\\n\\n 4:22 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval for intracerebral hemorrhage\\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 2. New punctate subcortical white matter hyperdense foci, which may be\\n hemorrhage, measuring up to 8 mm.\\n 3. Hyperdense 6 mm right frontal lesion, difficult to determine whether this\\n is a new finding from MRI .\\n 4. Extensive white matter hypoattenuation consistent with edema/radiation\\n effect, likely similar to MRI, , allowing for differences in\\n technique.\\n\\n Preliminary report was provided by Dr. to Dr. at 5:30\\n p.m. on .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-04-25 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1132987,\n \"text\": \" 11:19 AM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: Is Dobhoff in good placement?\\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man with hx melanoma brain mets in need of feeeding tube\\n REASON FOR THIS EXAMINATION:\\n Is Dobhoff in good placement?\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST\\n\\n HISTORY: Brain mets, Dobbhoff feeding tube placement.\\n\\n ONE PORTABLE VIEW. Comparison with . The left chest wall is not\\n entirely included. Bibasilar subsegmental atelectasis and a small focal area\\n of increased density at the left base that may represent parenchymal\\n consolidation are again demonstrated. The heart and mediastinal structures\\n are unchanged. A feeding tube has been inserted and is coiled in the cervical\\n region. Its tip off the top of the image.\\n\\n IMPRESSION: The feeding tube not in place. Result called to SICU.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-04-22 00:00:00.000\",\n \"description\": \"MR HEAD W & W/O CONTRAST\",\n \"row_id\": 1132609,\n \"text\": \" 10:18 PM\\n MR HEAD W & W/O CONTRAST Clip # \\n Reason: eval for acute ICH, radiation necrosis interval change. Plea\\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\\n Contrast: MAGNEVIST Amt: 18\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man with known metastatic melanoma, radiation necrosis, transferred\\n for acute ICH, has dense paraparesis of left side and left sided neglect\\n REASON FOR THIS EXAMINATION:\\n eval for acute ICH, radiation necrosis interval change. Please also do MRI WAND\\n sequence-place fiducials. MUST be completed within 4hrs for surgical\\n planning-needed to assess urgency for OR\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION: MR head with and without contrast.\\n\\n HISTORY: 62-year-old male with known metastatic melanoma and radiation\\n necrosis transferred for acute intracranial hemorrhage, presenting with\\n paraparesis of the left side and left-sided neglect to evaluate for acute\\n intracranial hemorrhage and interval change of radiation necrosis.\\n\\n TECHNIQUE: Multiplanar MRI of the head was performed with and without\\n intravenous gadolinium administration. Examination was performed with scalp\\n fiducials in place for MRI Wand study.\\n\\n COMPARISON: Multiple MRIs of the head, most recent .\\n\\n FINDINGS:\\n\\n There has been no significant interval change in size or appearance of the\\n irregular peripherally enhancing lesion involving the post-surgical bed in the\\n right frontal lobe measuring approximately 3.6 (AP) x 2.3 (TRV) x 2.5 cm (CC)\\n when compared with the prior examination of . There has been interval\\n decrease in size of the satellite lesion just inferior to the dominant lesion\\n medial to the sylvian fissure, now measuring 7 (AP) x 7 (TRV) x 7 mm (CC).\\n\\n There is a cluster of four new enhancing lesions, as follows, in the: Right\\n corona radiata; right caudate head; and two new enhancing lesions in the right\\n forceps minor. These demonstrate marked blooming with hemosiderin rings.\\n\\n There is FLAIR/T2-hyperintensity within the bilateral cerebral hemispheres,\\n which extends up to but does not involve the subcortical U-fibers, stable when\\n compared with prior studies dating back to . There is stable mass\\n effect and effacement on the body of the right lateral ventricle. There has\\n been slight interval decrease in shift of the normally midline structures, now\\n measuring 6.5 mm and previously measuring 8.5 mm.\\n\\n There is no calvarial, upper cervical, or clival bone marrow abnormality.\\n\\n The ventricles are stable in size. There is no acute infarction. The\\n intracranial arterial flow voids are patent. The visualized paranasal sinuses\\n (Over)\\n\\n 10:18 PM\\n MR HEAD W & W/O CONTRAST Clip # \\n Reason: eval for acute ICH, radiation necrosis interval change. Plea\\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\\n Contrast: MAGNEVIST Amt: 18\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n are well aerated. There is fluid within the mastoid air cells, bilaterally.\\n\\n IMPRESSION:\\n 1. Four new enhancing lesions, as described above, with marked \\\"blooming\\\"\\n artifact consistent with blood products, melanin or both, with stability size\\n and appearance of the dominant enhancing lesion and interval decrease in size\\n of the adjacent \\\"satellite\\\" lesion. Findings are consistent with\\n mixed-response to treatment.\\n 2. Persistent confluent FLAIR-hyperintensity extending to, but not including,\\n the subcortical U-fibers with persistent mass effect and decreased shift of\\n the normally midline structures; the appearance is consistent with radiation\\n toxicity.\\n 3. No acute infarction.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-04-23 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1132714,\n \"text\": \" 2:13 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: 62 year old man s/p R frontal crani for mass resection. Eval\\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man s/p R frontal crani for mass resection. Eval for post op\\n hemorrhage. Please perform within 4 hours from surgery\\n REASON FOR THIS EXAMINATION:\\n 62 year old man s/p R frontal crani for mass resection. Eval for post op\\n hemorrhage. Please perform within 4 hours from surgery\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAM: CT of the head.\\n\\n CLINICAL INFORMATION: Patient with right-sided frontal craniotomy.\\n\\n TECHNIQUE: Axial images of the head were obtained without contrast.\\n Correlation was made with the head MRI of .\\n\\n FINDINGS: Since the previous study, the patient has undergone resection of\\n right frontal lobe enhancing lesion. There are post-surgical changes\\n including blood products and air in the right frontal lobe region. Again seen\\n is edema extending from frontal to the parietal region and temporal region.\\n There remains some mass effect on the right lateral ventricle. A small area\\n of blood products seen in the deep white matter adjacent to the ventricle, as\\n on the previous MRI. There is no hydrocephalus. There remains mass effect on\\n the brainstem with uncal herniation.\\n\\n IMPRESSION: Status post resection of right frontal lobe mass with expected\\n post-surgical changes. No new area of brain edema seen or evidence of\\n hydrocephalus.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-04-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1132883,\n \"text\": \" 8:17 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for position, PTX\\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man s/p left SCV line placement\\n REASON FOR THIS EXAMINATION:\\n eval for position, PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST\\n\\n HISTORY: Subclavian line placement. Evaluate for pneumothorax.\\n\\n One portable view. No previous studies are available for comparison at this\\n time. There is streaky density at the lung bases consistent with subsegmental\\n atelectasis. There is more confluent increased density in the retrocardiac\\n area that may represent parenchymal consolidation. The cardiac silhouette is\\n prominent but may be exaggerated by AP technique. Mediastinal structures are\\n otherwise unremarkable. A left subclavian catheter has been inserted. It\\n does not course along the top of the left brachiocephalic vein and instead\\n extends inferiorly with its tip projected to the left of the thoracic spine\\n over the descending aorta.\\n\\n The central venous catheter does not appear to be in correct position. Its\\n position could be further evaluated by a lateral chest x-ray. Clinical\\n correlation is recommended.\\n\\n Bibasilar subsegmental atelectasis. Possible focal consolidation left base.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-04-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1132913,\n \"text\": \" 11:36 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: eval for PTX\\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man s/p RIJ CVL attempt\\n REASON FOR THIS EXAMINATION:\\n eval for PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Right IJ line placement.\\n\\n One portable view. Comparison with the previous study done earlier the same\\n day. There is streaky density at the lung bases consistent with subsegmental\\n atelectasis and possibly a small focal area of consolidation at the left lung\\n base, as before. Mediastinal structures are unchanged. A catheter is again\\n demonstrated in the left chest. This appears to proceed from the region of\\n the subclavian vein but does not follow the course of the left brachiocephalic\\n vein and terminates to the left of the spine, with its tip projected over the\\n descending aorta, as before. No other central catheter is identified. There\\n is no significant change.\\n\\n IMPRESSION: No significant interval change.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":24688,"cells":{"subject_id":{"kind":"number","value":950,"string":"950"},"hadm_id":{"kind":"number","value":101579,"string":"101,579"},"target_text":{"kind":"string","value":"At this time the patient was diagnosed with having peripheral vascular disease despite his long history of claudication. The patient was put on heparin for anticoagulation and the patient was admitted to the Vascular Surgery Service. Emergent arteriogram showed acute thrombosis of the right atrial artery. The patient was begun on total parenteral alimentation treatment and Cardiology was called to assess the patient's risk for bypass surgery. Cardiology cleared the patient for bypass surgery. The patient had preoperative laboratory work done which showed an ejection fraction of 30%. The patient was taken to the Operating Room on and underwent a right femoral tibial bypass graft with greater saphenous vein in situ graft with valve lysis by Dr. . On postoperative day #1 the patient was noted to have loss of pulse signal and graft pulse was no longer palpable. The patient was also noted to have oozing from the incision site. The patient's pulse was noted to be decreased on postoperative day #1 and the patient's condition was guarded at that time. On postoperative day #1 the patient had a brief episode of bradycardia and a pacing Swan was placed and from electrocardiogram the patient appeared to have a right bundle branch block that was newly developed. Cardiology was on board and Lopressor beta blockade was discontinued. At the time due to the critical nature of the patient's condition the patient was transferred to the Intensive Care Unit and the patient's renal function appeared to be worsening and Nephrology was consulted. With their recommendation the ACE inhibitor was discontinued and non-steroidal anti-inflammatory drugs were discontinued. The patient was begun to be given transfusion. The patient appeared to have an acute myocardial infarction postoperatively and renal failure secondary to lack of volume resuscitation. The patient was transferred onto the Intensive Care Unit in guarded condition. On postoperative day #2, on repeat enzymes, the patient's peak CK appeared to be around 700 and it was clear that the patient had perioperative myocardial infarction and the patient was kept in the Intensive Care Unit to stabilize his cardiac and renal status. On postoperative day #3 the patient's graft appeared to be viable. The patient has a warm foot and palpable dorsalis pedis on the right foot. The incision appeared to be still slightly oozy and the patient had Ace bandage wrap around the right leg. On postoperative day #6 the patient was noted to have a lower gastrointestinal bleed and bled in stool and Gastroenterology was consulted. It was on their recommendation heparin was discontinued and the patient's bleeding appeared to stop and Gastroenterology recommended outpatient colonoscopy in the future. On postoperative day #8 the patient's condition appeared to be improving and the patient's renal function appeared to be improving and the patient appeared to be recovering from the acute tubular necrosis and renal failure. From the cardiology point of view, the patient's condition is stabilizing and the patient was transferred onto the Vascular Intensive Care Unit on , which was postoperative day #9. Under Cardiology's recommendation the ACE inhibitor was increased. Chest x-ray was taken to assess his cardiac status. The patient was put on sips for p.o. intakes and the patient appeared to be improving. On postoperative day #10 after discussion with the family the patient was made Do-Not-Resuscitate following the family and patient's wishes. On postoperative day #10 at approximately 6 PM the patient went into respiratory distress with audible wheezes bilaterally and a copious amount of secretion and respiratory treatment with Albuterol inhaler given and suctioning was carried out. At that time it was clear that the patient does not want to be nasotracheal suctioned and appears to be better coherent. The patient at that time was sating at 96% on 5 liters and it appeared that the patient went into bronchospasm and retained secretions with impaired secretion clearance, although after numerous Albuterol treatment the patient was not able to clear his secretion and the patient was made Do-Not-Intubate. The patient expired at 9:30 on . The patient is deceased on with final cause, the patient is a year old gentleman status post right femoral-tibial bypass graft. His course was complicated by myocardial infarction and renal failure. His condition appeared to be improving, however, on , the patient had absolute bradycardia and became acutely apneic and the patient developed bronchospasm and retained secretion which was not able to be cleared by suctioning and the patient was made Do-Not-Intubate and no intubation was carried out. The patient deceased from respiratory distress. The patient underwent autopsy, results pending. , M.D. Dictated By: MEDQUIST36 D: 16:59 T: 18:01 JOB#: "},"extractive_notes_summ":{"kind":"string","value":"focusdata: post hct 29.0. mso4 1mg x3 given with relief. OCC AUDIBLE WHEEZES NOTED ALBUTEROL NEB X1 WITH EFFECT. There ismoderate mitral annular calcification.Conclusions:1. ?soe.Height: (in) 65Weight (lb): 146BSA (m2): 1.73 m2BP (mm Hg): 154/64Status: InpatientDate/Time: at 16:30Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is moderately dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. Moderate (2+)mitral regurgitation is seen. WBC FLAT.SKIN: LLE INCISION WITH DSG INTACT WITH SMALL AMT OF SEROSANG. (has LV clot). There is interval development of faint patchy air space opacity in the left mid and upper lung zones and the right upper lung zone compatible with acute aspiration event. L WITH PALPABLE PEDAL PULSE WITH +GRAFT PULSE.RESP: L/S CLEAR IN UPPER LOBES WITH CRACKLES IN L BASE AND DIMINISHED ON R. O2 5LNC WITH SATS 93-98%. There ismoderate mitral annular calcification. Moderate (2+) mitral regurgitation isseen.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation.PERICARDIUM: There is no pericardial effusion.Conclusions:There is severe global left ventricular hypokinesis. There is an apical left ventricularaneurysm. Cardiology following.Remains on heparin gtt w/ acceptable ptt. A mild stenosis is present involving the takeoff of the profunda femoris, with diffuse eccentric disease throughout an otherwise patent vessel. Transferred to NSICU yesterday for close managment.ROS:CARDIAC/HEMODYNAMICS: Yesterday low filling pressures-> prbc and fluid w/ normalized pressures today. There is mild symmetric left ventricular hypertrophy. Started low dose lopressor. He had alot of ventricular activity this am which resolved when pacer turned off. A left ventricularmass/thrombus cannot be excluded.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened.MITRAL VALVE: The mitral valve leaflets are mildly thickened. The ostea are suboptimally visualized, but there is a probable left proximal renal artery stenosis present. Severe diffuse hypokinesis ispresent with some preservation of basal wall motion.3. Distally, the anterior tibial and peroneal arteries reconstitute. CONTS ON CAPOTEN BUT LOPRESSOR HELD PER SICU HO. The aortic valve leaflets (3) are mildlythickened. Left ventricular function.Height: (in) 65Weight (lb): 166BSA (m2): 1.83 m2BP (mm Hg): 150/68Status: InpatientDate/Time: at 15:55Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in theright atrium and/or right ventricle.LEFT VENTRICLE: There is severe global left ventricular hypokinesis. The heart size and mediastinal contour are within normal limits. The left ventricularcavity is mildly dilated. Feeding tube appears post-pyloric. Single frontal chest radiograph dated is compared with prior chest radiograph dated . rr 20's unlabored.RENAL: new renal failure w/ bun 39/cr 2.0. N/SICU NURSING NOTE 11P-7AREVIEW OF SYSTEMSNEURO: PT 2 WITH PERIODS OF AGITATION AND DISORIENTATION. OCC DRY COUGH NOTED. There is no pericardial effusion.Compared to the Echo dated , which was reviewed, LV function hasdecreased further, LV thrombus is not noted as clearly as in the previousstudy. SG catheter is positioned at the right PA. and are available by phone.ASSESS: stable s/p mi, renal failure, metabolic acidosis (r/t renal failure/ cardiogenic compromise). PP DOPPLED.RESP: HAS COURSE BREATHSOUNDS. FINAL REPORT INDICATIONS: S/P fem/tib bypass. Sinus rhythm with atrial ectopy. Probableold inferior myocardial infarction as well.TRACING #2 The right sided central venous catheter has been slightly withdrawn with the tip now overlying the mid to distal SVC. Perineum and (L) glut w/ ecchymosis slowly resolving. Resid 0cc. abg done and ph 7.32-with po2-104. Marked P-R interval prolongation. Marked P-R interval prolongation. CardiacD: pt. with end exp wheezes. CVP 11-20.RESP: LS intermit coarse -> exp wheeze. Rule out ischemia. Severe P-R interval prolongation. RespD: pt. At the adductor canal is a filling defect consistent with thrombus material. Left anterior fascicular block. Left anterior fascicular block. IMPRESSION: 1) Partial collapse of right upper lobe. Sinus arrhythmia with atrial ectopy. Sinus arrhythmia with atrial ectopy. Poor R wave progression inleads V3-V6 consistent with old anterior myocardial infarction. Lasix pNGT given w/effect.SKIN: RLE inc w/ staples intact w/ scant serosanguinous drainage. cxr done. Borderline leftaxis deviation. P-R interval 0.36. There is partial collapse of the right upper lobe. Pt tol OOB -> chr w/ PT.PLAN: Cont NPO and TF w/ mouthcare. Compared to the previous tracing the heartrate is now irregular and the ST segments in lead V3 appear to be elevated.There is now evidence of probable old anterior myocardial infarction. no accessory use.A:endo suctioned for mod amt thick sputumNeb per resp therapyDr. Consider prior anteroseptal myocardial infarction.Clinical correlation is suggested. Wandering atrial pacemaker, rate 93. Monitor resp status, provide neb tx's prn. Reccomending cont NPO until pt more alert for Barium swallow. filling of the mid/distal dorsalis pedis artery or plantar vessels. RT providing neb tx's. Compared tothe previous tracing of T wave inversions in the lateral leads are lesspronounced. Assess position of central line that has been partially pulled out by the patient. Condition update A:ROS - please refer to flowsheet. P-R interval 0.32. Diffuse ST-T wave changes. Leftatrial abnormality. Leftatrial abnormality. co-3.2 ci- 2.1 with svr 1800. ho notified. There are bilateral pleural effusions present and adjacent basilar opacities which probably reflect atelectasis. Just distal to this is a focal stenosis, followed by an abrupt occlusion of the distal SFA/above knee popliteal artery. Monitor RLE inc, change per orders. Incompleteright bundle-branch block and left axis deviation. Post-operative patient. ATTEMPTED TO CALM WITH ONLY FAIR RESULTS.CV: AFIB WITH OCC PVC AND PAC. Speach up for bedside swallow eval. Ectopic atrial rhythm, rate 94, with P-R interval prolongation. At the level of the previous occlusion, there is improved filling through the superficial femoral artery down to the level approximately 1-2 cm distal to the adductor canal. REASON FOR THIS EXAMINATION: assess position of tip of central line -- line has been partially self d/c'ed by patient. bp 140-160syst/ one unit of prbc infused. pt noted to have episode have exp wheezes on exertion, albuterol neb given.pt continues on heparin drip, goal to reach theraputic levels of ptt-60-80, pt currently on 600u/hr."},"n_notes":{"kind":"number","value":35,"string":"35"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2169-03-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":758344,"text":" 7:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p fem-tib bypass\n\n REASON FOR THIS EXAMINATION:\n ?CHF\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: Fem/tib bypass and shortness of breath, Swan-Ganz placement.\n\n Swan-Ganz catheter is in right main pulmonary artery. No pneumothorax. Heart\n size is within normal limits for technique. No evidence for CHF. Apart from\n linear atelectasis at the left base, the lungs are clear.\n\n IMPRESSION: No evidence for CHF or pneumonia. No pneumothorax. No change\n since prior study.\n\n\n"},{"category":"Radiology","chartdate":"2169-04-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":758436,"text":" 6:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pulm edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p fem-tib bypass\n\n REASON FOR THIS EXAMINATION:\n evaluate for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fem/tib bypass, shortness of breath, evaluate for\n pulmonary edema.\n\n Single frontal chest radiograph dated is compared with prior chest\n radiograph dated .\n\n When compared to the prior study, there is no interval change in position of\n lines and tubes. There is no interval change in appearance of the chest.\n\n"},{"category":"Radiology","chartdate":"2169-04-02 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":758474,"text":" 12:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: acute SOB\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p fem-tib bypass a\n\n REASON FOR THIS EXAMINATION:\n acute SOB\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Patient with fem-tib bypass.\n\n Given technical differences, there is not a very significant change in the\n appearance of the chest since .\n\n\n"},{"category":"Radiology","chartdate":"2169-04-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":758568,"text":" 2:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p fem-tib bypass a\n\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post lower extremity bypass surgery. Check line placement.\n\n PORTABLE AP CHEST RADIOGRAPH: Comparison is made to an exam of . The\n tip of a right IJ catheter terminates deep within the right atrium. The\n cardiac silhouette and mediastinal/hilar contours are stable. There is\n persistent air-space opacification of the right upper lobe with further\n improvement of air-space disease within the left upper lobe. There are no new\n effusions or focal consolidations. No evidence of pneumothorax.\n\n IMPRESSION:\n 1) Tip of right-sided central venous catheter deep within the right atrium.\n This finding was immediately telephoned to Dr. .\n\n 2) Probable resolving asymmetric pulmonary edema within the upper lobes, right\n side greater than left. An underlying infectious etiology, however, cannot be\n completely excluded.\n\n\n"},{"category":"Radiology","chartdate":"2169-04-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":758461,"text":" 3:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: worsening CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p fem-tib bypass\n\n REASON FOR THIS EXAMINATION:\n worsening CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Recent fem/tib bypass, worsening CHF.\n\n Comparison with the patient's prior chest xray at 6:37 AM on .\n\n The heart is enlarged. The feeding tube and Swan-Ganz catheter are relatively\n unchanged since the prior study. Once again there is bilateral upper lobe\n early air space disease versus pulmonary edema. There is no pneumothorax.\n\n IMPRESSION: No change in the chest since the earlier chest xray this morning.\n\n"},{"category":"Radiology","chartdate":"2169-03-27 00:00:00.000","description":"VEN DUP EXTEXT BIL (MAP/DVT)","row_id":758092,"text":" 1:52 PM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: look for suitable bypass vein.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with R popliteal a. thrombus/embolus. Prior Hx vein stripping\n ? side. Please map B lower ext veins.\n REASON FOR THIS EXAMINATION:\n look for suitable bypass vein.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Patient with ischemic leg and need for bypass. Evaluate for conduit.\n\n FINDINGS: Duplex evaluation was performed of both lower extremity superficial\n venous systems. On the right leg the greater saphenous vein is patent. The\n lesser saphenous vein is not visualized. The diameters of the greater\n saphenous vein in centimeters are as follows: 0.28, 0.31, 0.35 and 0.44 at\n the ankle, mid calf, low thigh and saphenofemoral junctions respectively.\n\n On the left, the lesser saphenous vein could not be evaluated due to the\n patient having a TPA catheter in place. The greater saphenous vein is patent\n with diameters in centimeters as follows: 0.41, 0.39, 0.44 and 0.43 cm at\n the ankle, knee, thigh and saphenofemoral junctions respectively.\n\n IMPRESSION: Patent right greater saphenous vein. The right lesser saphenous\n vein was not visualized. On the left, the greater saphenous vein is patent.\n The lesser saphenous vein could not be evaluated due to reasons as stated\n above.\n\n"},{"category":"Radiology","chartdate":"2169-03-27 00:00:00.000","description":"MULTI-PROCEDURE SAME DAY","row_id":758048,"text":" 7:45 AM\n UNI-LAT FEMORAL Clip # \n Reason: r/o thrombosis\n Contrast: OPTIRAY Amt: 200CC\n ********************************* CPT Codes ********************************\n * TRANSCATHETER INFUSION FOR LYS INITAL 3RD ORDER ABD/PEL/LOWER *\n * -51 MULTI-PROCEDURE SAME DAY TRANSCATHETER INFUSION *\n * ABDOMINAL A-GRAM EXT UNILAT A-GRAM *\n * NON-IONIC 200 CC SUPPLY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with acute numbness of R foot. On exam has a cold R foot with\n no doppler signals or pulses.\n REASON FOR THIS EXAMINATION:\n r/o thrombosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: year old male with symptoms and signs of acute right foot\n ischemia without Dopplerable signals or pulses.\n\n RADIOLOGISTS: Drs. and . Dr. , staff radiologist,\n was presenting during throughout the procedure.\n\n CONTRAST/MEDICATIONS: 200 ml of Optiray 320 at 30%; 1.5 mg versed and 50 mcg\n fentanyl in divided doses under continued hemodynamic monitoring.\n\n PROCEDURE/TECHNIQUE/FINDINGS: The procedure was described to the patient and\n informed consent was obtained. Access was gained into the left common femoral\n artery using a 19g single wall needle. An 0.035 wire was advanced through a\n heavily calcified left external and common iliac artery under fluoroscopic\n guidance without difficulty. A 5 french sheath was then exchanged over the\n wire, followed by placement of a 4 french omni flush catheter. With the\n catheter in the abdominal aorta, an AP aortogram was obtained. The catheter\n was pulled into the infrarenal aorta, and a left anterior oblique pelvic\n arteriogram was obtained. Over an 0.035 angled glide wire, catheter was then\n advanced into the distal right external iliac artery, and sequential right\n lower extremity arteriograms were obtained.\n\n A mild degree of aortoiliac calcification is present. There are single renal\n arteries bilaterally. The ostea are suboptimally visualized, but there is a\n probable left proximal renal artery stenosis present. The infrarenal aorta is\n mildly aneurysmal, with a focal eccentric stenosis that projects over L3-4.\n Both hypogastric arteries are widely patent. There is a significant degree of\n tortuousity of both iliac vessels, but no common or external iliac stenoses\n are present. Incidental note is made of a right hip prosthesis. Extensive\n calcification is noted throughout superficial and deep femoral vessels. A mild\n stenosis is present involving the takeoff of the profunda femoris, with\n diffuse eccentric disease throughout an otherwise patent vessel. The proximal\n portion of the superficial femoral artery is widely patent, but demonstrates\n mild multifocal disease proximally. At the mid portion, above the adductor\n canal, is a meniscus shaped filling defect involving the medial wall of the\n superficial femoral artery most consistent with thrombus. A small lateral\n (Over)\n\n 7:45 AM\n UNI-LAT FEMORAL Clip # \n Reason: r/o thrombosis\n Contrast: OPTIRAY Amt: 200CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n vessel arises from the lateral aspect of the superficial femoral artery at\n this level, and courses medially along the knee joint. An AP view obtained\n over the trifurcation shows no filling of the runoff vessels proximally. There\n is an extensive small collateral network over the thigh. Distally, the\n anterior tibial and peroneal arteries reconstitute. The anterior tibial artery\n continues as the dorsalis pedis artery, which proximally has a corkscrew\n attenuated appearance and does no opacify at its mid or distal portions. The\n plantar vessels do not fill, nor do the arch vessels.\n\n An 0.035 angled glide wire was then advanced through the catheter down to the\n abrupt filling defect, which was able to be crossed without difficulty.\n However, approximately 3-4 cm beyond, the glidewire could not be passed. For\n this reason, the glidewire was removed, and a 9 cm infusion wire was\n advanced under fluoroscopic guidance to the level of occlusion. 1 mg TPA was\n then bolus-injected intraarterially, and this was repeated four times for a\n total of 5 mg TPA bolus at the site of thrombus.\n\n TPA was then commenced at a rate of 0.5 mg per hour, with 200 units of heparin\n infusing through the sidearm sheath for patency. The patient will return to\n the interventional radiology department on for reassessment.\n\n COMPLICATIONS: None.\n\n IMPRESSION: Findings suggesting an acute on chronic thrombus of the\n superficial femoral artery just proximal to the adductor canal. 5 mg bolus of\n TPA infused through wire, followed by continuous infusion of TPA at a\n rate of 0.5 mg per hour. The patient will return on for angiographic\n reassessment.\n\n\n"},{"category":"Radiology","chartdate":"2169-03-27 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":758108,"text":" 7:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please do tonight -- pt preop for OR -- can not travel d\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with\n\n acute limb ischemia\n REASON FOR THIS EXAMINATION:\n Please do tonight -- pt preop for OR -- can not travel downstairs -\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: year old man with acute limb ischemia, preoperative exam.\n\n PORTABLE AP SUPINE VIEW OF THE CHEST PERFORMED AT 19:29 HOURS: No\n prior images for comparison. The heart size and mediastinal contour are\n within normal limits. The aorta is tortuous and calcified. There is some\n prominence of the pulmonary vasculature peripherally, predominantly within the\n upper lobes. Although this may in part reflect the patient's supine\n positioning a component of volume overload cannot be excluded. There is\n increased luceny of the right lower lung. Streaky opacities at the left base\n are consistent with minimal left basilar atelectasis.\n\n Surgical clips are noted within the right upper quadrant.\n\n IMPRESSION: No evidence of pneumonia. Mild upper zone redistribution likely\n represents a component of volume overload. Relative increased lucency of the\n right lower lung of uncertain significance. Possible etiologies include\n bullous change or chronic or acute pulmonry embolism. Recommend comparison\n with prior studies. Surgical resident notified 10:20 pm.\n\n\n"},{"category":"Radiology","chartdate":"2169-03-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":758186,"text":" 6:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess swan placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p fem-tib bypass\n REASON FOR THIS EXAMINATION:\n assess swan placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess Swan-Ganz placement in post vascular surgery patient.\n\n COMPARISON: \n\n AP CHEST: In the interval since the prior study a Swan-Ganz catheter has been\n placed via right internal jugular access and the tip is positioned at the\n junction of the right pulmonary artery in its interlobar branch. There is no\n evidence of pneumothorax. Minimal atelectasis is again seen at the left base.\n Otherwise there are no changes since the study 1 day prior.\n\n"},{"category":"Radiology","chartdate":"2169-03-31 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":758413,"text":" 4:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: CONFIRM DUBOFF TUBE PLACEMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p fem-tib bypass\n\n REASON FOR THIS EXAMINATION:\n CONFIRM DUBOFF TUBE PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dophoff tube tube placement.\n\n COMPARISON: .\n\n AP UPRIGHT CHEST: The tip of the feeding tube is positioned in the first\n portion of the duodenum. SG catheter is positioned at the right PA. There is\n no pneumothorax. There is interval development of faint patchy air space\n opacity in the left mid and upper lung zones and the right upper lung zone\n compatible with acute aspiration event. There are no pleural effusions.\n\n IMPRESSION:\n 1. Feeding tube appears post-pyloric.\n 2. Interval development of air space opacity in mid and upper lung zones;\n question acute aspiration event vs. asymmetric edema.\n\n"},{"category":"Echo","chartdate":"2169-03-27 00:00:00.000","description":"Report","row_id":70703,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Embolus to popliteal artery.?soe.\nHeight: (in) 65\nWeight (lb): 146\nBSA (m2): 1.73 m2\nBP (mm Hg): 154/64\nStatus: Inpatient\nDate/Time: at 16:30\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity is mildly dilated. There is an apical left ventricular\naneurysm. There is severe global left ventricular hypokinesis. Overall left\nventricular systolic function is severely depressed. A large thrombus is seen\nin the left ventricle.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is\nmoderate mitral annular calcification.\n\nConclusions:\n1. The left atrium is moderately dilated.\n2. There is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity is mildly dilated. There is an apical left ventricular aneurysm.\nOverall left ventricular systolic function is severely depressed. A large\nthrombus is seen in the left ventricular apex. Severe diffuse hypokinesis is\npresent with some preservation of basal wall motion.\n3. The aortic valve leaflets are mildly thickened.\n4. The mitral valve leaflets are mildly thickened.\n\n\n"},{"category":"Echo","chartdate":"2169-03-30 00:00:00.000","description":"Report","row_id":70664,"text":"PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter. Left ventricular function.\nHeight: (in) 65\nWeight (lb): 166\nBSA (m2): 1.83 m2\nBP (mm Hg): 150/68\nStatus: Inpatient\nDate/Time: at 15:55\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the\nright atrium and/or right ventricle.\n\nLEFT VENTRICLE: There is severe global left ventricular hypokinesis. Overall\nleft ventricular systolic function is severely depressed. A left ventricular\nmass/thrombus cannot be excluded.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is\nmoderate mitral annular calcification. Moderate (2+) mitral regurgitation is\nseen.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThere is severe global left ventricular hypokinesis. Overall left ventricular\nsystolic function is severely depressed.LV apex is aneurysmal. A left\nventricular mass/thrombus cannot be excluded. Right ventricular chamber size\nand free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened. The mitral valve leaflets are mildly thickened. Moderate (2+)\nmitral regurgitation is seen. There is no pericardial effusion.\nCompared to the Echo dated , which was reviewed, LV function has\ndecreased further, LV thrombus is not noted as clearly as in the previous\nstudy. Mitral insufficency has increased.\n\n\n"},{"category":"Nursing/other","chartdate":"2169-04-02 00:00:00.000","description":"Report","row_id":1274325,"text":"focus\ndata: post hct 29.0. mso4 1mg x3 given with relief. slept in short naps. tube fdgs held during the nite due to fluid status. lasix 10mg iv x1 given with fair diuresis. k 3.5. mag 1.9. ho aware of these results. pacer on a vdemand of 60. pt appears calmer this am and not stating he wants to die. r leg dsg changed and incision clean and intact with mod amt of serosang drainage. dsg with loose kling wrapped.\naction: labs as ordered. prbc given with post hct of 29. hob at 30degrees. albuterol rx for resp\nresponse: monitor closely.\n"},{"category":"Nursing/other","chartdate":"2169-04-02 00:00:00.000","description":"Report","row_id":1274326,"text":"nursing progress note see carview for details.\n\nneuro:awake,alert, oriented x3.follows commands and moves all extremities on command.conversation is appropriate,speech is easy to understand.\n\ncv:remains in atrial fib rate is 80 to 100 with rare pvcs.pacing wire in swan does not work,dr attempted to advance.captopril was increased to 18.75 mg q8hrs.remains on ntg gtt to keep systolic bp 130 to 150.ci remains stable,pa does not wedge team aware.right foot warmer than left foot,bil dp and pt pulses and graft pulse present,right graft pulse and right dp is palpablealso.\n\nresp:resp rate 14 to 24.sp02 96 to 99% on 2l np,and 60% open face mask.has loose cough without production.breath sounds have i/e wheezes getting alb/atro nebs,upper lobes clear at times with coarseness in bases.\n\ngi:mouth wet with swabs,pt has frequent cough.tube feeds were restarted ,promote with fiber to goal of 60cc today.has had no stool today.abd soft with positive bowel sounds.\n\ngu:foley to cd draining clear yellow urine today.in small amounts.\n\nid:no issues.\n\nskin:has multiple old ecchymotic areas in scrotum,sides of abd and around arms.has generalized edema in extremities.\n\nsocial:full and involved discussion with patient and son at bedside by dr and team prognosis and medical and cardiac condition discussed a dnr/dni status was determined. pt states that.\" i am dying please let me \".\n\nplan:comfort measures.\n\n"},{"category":"Nursing/other","chartdate":"2169-04-01 00:00:00.000","description":"Report","row_id":1274322,"text":"N/SICU NURSING NOTE 11P-7A\nREVIEW OF SYSTEMS\n\nNEURO: PT 2 WITH PERIODS OF AGITATION AND DISORIENTATION. PT ABLE TO BE TALKED DOWN. FOLLOWING COMMANDS AND MOVING ALL EXTRMETIES. SLEPT POORLY LAST NIGHT.\n\nCV: HR 70-80'S AFIB WITH OCC PVCS AND PACED BEATS. CONTS WITH PACING SWAN AND PACER SET AT VDEMAND 60 AND PACING APPROPRIATELY. SBP 130-160. PA 70-50/35-48 WITH WEDGE . CVP 8-13. CO/CI GRATUALLY DECREASING OVER LAST SHIFT WITH THERMO CO 3.39-2.90 WITH INDEX 1.8-1.6. FICK CO 4.0-3.70 WITH INDEX 2.21-2.O4. TEAM AWARE. TROPONIN ADDED TO THIS AMS LABS. ATTEMPTED 250CC FLUID CHALLENGE INITIALLY FOR LOW CO WITH NO EFFECT. PT PRESENTLY GETTING 1UPRBC OVER 4HRS. CONTS ON CAPOTEN BUT LOPRESSOR HELD PER SICU HO. MIXED VENOUS O2 45-49. DOPPLERABLE PULSES ON R WITH EXTREMTY COOL TO TOUCH. L WITH PALPABLE PEDAL PULSE WITH +GRAFT PULSE.\n\nRESP: L/S CLEAR IN UPPER LOBES WITH CRACKLES IN L BASE AND DIMINISHED ON R. O2 5LNC WITH SATS 93-98%. SOB ON EXCERTION AND WITH AGITATION. OCC AUDIBLE WHEEZES NOTED ALBUTEROL NEB X1 WITH EFFECT. OCC DRY COUGH NOTED. ABG ADEQUATE. ISOLATED EPISODE WHERE PT C/O SOB BUT ASSOCIATED WITH AGITATION THAT SUBSIDED.\n\nGI: ABD SOFT WITH +BS. TOL ICE CHIPS. POST PYLORIC TUBE WITH PROMOTE AT 20CC/HR. NO STOOL OR FLATUS. DENIES TENDERNESS ON PALPATION.\n\nGU: U/O 30-40CC/HR. LASIX HELD THIS AM.\n\nHEME: HCT 25-28. 1UPRBC GIVEN. PTT 60 HEPARIN GTT REMAINS AT 700U/HR.\n\nENDO: NO ISSUES.\n\nID: AFEBRILE. WBC FLAT.\n\nSKIN: LLE INCISION WITH DSG INTACT WITH SMALL AMT OF SEROSANG. DRAINAGE NOTED.\n\nSOCIAL: NO CONTACT WITH FAMILY THIS SHIFT.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2169-04-01 00:00:00.000","description":"Report","row_id":1274323,"text":"nursing progress note see carview for details\n\nneuro:awake alert,easily agitated and disoriented at times.reoriented easily.follows commands and moves all extremities.recognizes all family members.aware that he is in a hospital.\n\ncv:remains in atrial fib with rare pvcs.systolic bp greater than 150 started on ntg gtt,continues at 3 mcq /kg/min. dr aware not to increase ntg.captopril dose was increased to 12.5 mg q8hrs. ci has been stable.swan has not wedged ,has been repositioned multiple times by dr .pacer remains in vdemand mode , rate at 60,ventricular sensitivity 2.0,ma at 5.pacing and sensing checked on rounds this am.had one dose of lopressor 2.5mg iv and tolerated well.\n\nresp:had chest xray which dr reports as improved.had increasing oxygen requirements,nasal prongs at 2lmin,open face mask at 60%.breath sounds have had wheezes present which have been treated with albuteral nebs.crackles bibasilar which was treated with lasix 10mg/iv.otherwise bs are clear and diminished bibasilar.resp rate 17 to 26.has loose nonproductive cough.\n\ngi:abd soft with positive bowel sounds present,has not had any stool today.tube feed continues at 40cc/hr promote with fiber.will advance tonight for total goal rate of 60cc.\n\ngu:foley to cd draining small amounts of clear urine,had lasix 10mg iv with some diuresis.\n\nskin:intact,on airmatress.right leg incision line intact with dsg.\n\npulses:has bildpand pt and graft present by doppler.\n\nsocial:visited by family.\n\n"},{"category":"Nursing/other","chartdate":"2169-03-30 00:00:00.000","description":"Report","row_id":1274319,"text":"PROGRESS NOTE\nPT , ORIENTED TO NAME AND 'HOSPITAL', REORIENTED TO DATE. MOVES ALL LIMBS AND FOLLOWS COMMANDS APPROPRIATELY. BILAT WRISTS RESTRAINTS APPLIED, DUE TO PT PULLING AT SWAN LINE.\nCV: PT TRANSFERRED FROM VICU ON , RULING IN FOR +MI, F/U BY CARDIOLOGY, SWAN PACER IN SITU AND ATTACHED. RESTARTED ON HEPARIN DRIP @ 2130 SECONDARY TO LV THROMBUS, INITIALLY STOPPED DUE TO RT LEG WOUND OOZING. INITIALLY PT'S CVP 0-3, PCWP: , CO, CI APPEARED ACCEPTABLE SEE FLOWSHEET. LOW URINE OUTPUT: 10-20CC PT FOLLOWED BY RENAL TEAM.\nRECEIVED PT WITH STABLE BP DESPITE LOW CVP AND WEDGE, WAS GIVEN SEVERAL BOLUSES AND I UNIT PRBCS FOR LOW HCT TO IMPROVE ON FLUID STATUS. PCWP FOLLOWED CLOSELY AS PER HO AND CARDIOLOGY. CVP AND PCWP FLUCTUATE: ; . CPK'S WITH MB AND TROPONIN LEVELS ELEVATED CURRENTLY CYCLING X 3. HR 85-90S, WITH FREQUENT PVC'S. WILL REPLETE LYTES AS OREDERED. PAP 40-60 SYSTOLIC. PT IN AND OUT OF A-FIB WHILE BOLUSES INFUSING, HO AWARE EKG DONE, PT BACK IN SR. ION CA .97 WAS GIVEN 2GM.\nRT LEG INCISION, CHANGED AND CLEANSED WITH NS GRAFT SITE PALPABLE, PEDAL PULSES ABSENT REPORTED TO HO, WARM BLANKETS APPLIED TO IMPROVE CIRCULATION TO EXTREMITIES.\nGU: URINE OUTPUT IMPROVED SLIGHTLY- 25CC/HR AFTER BOLUSES.\n"},{"category":"Nursing/other","chartdate":"2169-03-30 00:00:00.000","description":"Report","row_id":1274320,"text":"CCU NSG PROG NOTE: 7-3PM\nRemains stable PO day 2, c/w MI, renal failure. Transferred to NSICU yesterday for close managment.\n\nROS:\n\nCARDIAC/HEMODYNAMICS: Yesterday low filling pressures-> prbc and fluid w/ normalized pressures today.(pa 40's, pad 25, pcw 19, cvp 10-12.)\nThey want his pcw around 19-20 and cvp 10). IVF decreased to 75cc/hr.\nSwan placement adjusted w/ improved tracings. Wedges easily w/ good tracing. He had alot of ventricular activity this am which resolved when pacer turned off. The pacer was inappropriately firing and did not sense. Remains off. Rhythm AF a/w first degree avb (pr .40)w/ rates 65-100. Started low dose lopressor. Transient brady to 50's w/ coughing. (noted to have vagal drops on floor w/ vomiting...hx tacky/brady syndrome.). Cardiac Index 2.08. Cardiology following.Remains on heparin gtt w/ acceptable ptt. (has LV clot). For Echo today. Contnue to serial enzymes. R upper back pain.\n\nRESP: diminished at R base. Remains stable w/ sats 97% on 3L nc. rr 20's unlabored.\n\nRENAL: new renal failure w/ bun 39/cr 2.0. Urine output consistently 20-25cc/hr. Renal following.\n\nGI: NPO today except med and ice chips. Takes crushed meds. Will reevaluate tomorrow regarding eating. No stool. Abd soft . No nausea\n\nHEME: received 2nd unit prbc for today w/ follow up hct 29.8.\n\nNEURO: A&Ox2. Able to converse and follow commands, has periods of confusion.Did not require restraints today. Cooperative.\n\nSKIN/WOUND: R leg dsg dry and intact w/ dopplerable pulses at graft, DP, L dp, absent L PT pulse. R foot warm to touch w/ good color. L foot cool to touch. Last dsg change 2am.\n\nID: afebrile. wbc 12.4. Is not on abx.\n\nMETABOLIC: metabolic acidosis. abg 7.28/29/107/-. Receiving ivf w/ 2 amps bicarb x 1 liter only. ABG pnd.\n\nSTATUS: Son, , is health care proxy.(copy is in chart). The patient remains a full code. If pt's condition or prognosis changes, he will readdress status w/ the team. A sister , , is also involved. There is a daughter, , who is coming from . and described an emotional instability of that could interfere w/ patient care and reminded me that is the legal proxy. They are attempting to be here to monitor visits but in the event that they are not, they said we can give her information but ask that we not honor unreasonable requests of her's. (i.e. decision making or asking for physician .) and are available by phone.\n\nASSESS: stable s/p mi, renal failure, metabolic acidosis (r/t renal failure/ cardiogenic compromise). Stable filling pressures. Stable b/p. Stable resp status.\n\nPLAN; labs sent and pnd. Monitor acidosis. Keep cvp approx 10, pcw approx 19-20. Mso4 for discomfort. Monitor surgical incision. Restrain if necessary. For Echo.\n"},{"category":"Nursing/other","chartdate":"2169-03-31 00:00:00.000","description":"Report","row_id":1274321,"text":"Progress Note\nneuro unchanged, bilat wrist restraints still on as pt accidentally pulls on swan line. moves all ext in bed.\nCV: hr a-fib with rare pvc's, k+ low 2.8 was given 20meq centrally, ion ca low-.87, was replaced x 2. bp stable during the night, co, ci unchanged from admission. pcwp 17 and cvp 10. afebrile.\nrt leg drsg with amt of serosang drainage, wound cleansed with normal saline and applied DSD. rt graft site palpable, no bilat pedal pulses able to doppler, feet cool to touch, warm blankets applied.\nresp: 4l np 02 sat fluctuates between 92-96% bilat breath sounds clear but diminshed at the bases. pt noted to have episode have exp wheezes on exertion, albuterol neb given.\npt continues on heparin drip, goal to reach theraputic levels of ptt-60-80, pt currently on 600u/hr.\n"},{"category":"Nursing/other","chartdate":"2169-04-05 00:00:00.000","description":"Report","row_id":1274332,"text":"NPN: PROGRESS AND TRANSFER NOTE\nNEURO: ALERT AND ORIENTED. FREQUENTLY CALLING OUT FOR ICE AND WATER DESPITE BEING INSTRUCTED RE: ASPIRATION. DOES BECOME AGITATED WHEN HE IS REFUSED. ATTEMPTED TO CALM WITH ONLY FAIR RESULTS.\n\nCV: AFIB WITH OCC PVC AND PAC. A LINE TO L RADIAL, VSS. PP DOPPLED.\n\nRESP: HAS COURSE BREATHSOUNDS. HAS WEAK, LOOSE SOUNDING COUGH. WAS ON NC BUT CHANGED TO HUMIDIFIED FM JUST TO PROVIDE HIM SOME MORE MOISTURE TO HIS MOUTH. CPT COMPLETED.\n\nGI: NPO DUE TO PROBABLE ASPIRATIONS. SPPECH THERAPY WAS HERE TO DO AN EVALUATION EAARLIER IN DAY BUT THE PATIENT WAS TOO GROGGY FROM A DOSE OF ONE PERCOCET GIVEN EARIER IN DAY. THEY WILL FOLLOW UP TOMORROW. DOES HAVE FEEDING TUBE AND HAD A SMALL BROWN STOOL THIS EVENING.\n\nGU: FOLEY PATENT OF CLEAR YELLOW URINE.\n\nSKIN: ECCYMOSIS TO R HIP. BYPASS INCISION TO RLU WITH SOME OOZING AT UPPER THIGH.\n\nPSYCH/SOC/SPIRITUAL: SON IS ALSO MD. WIFE WAS TAKING TO TONIGHT WITH GIB AND IS ICU. INITIALLY IT WAS THOUGHT THAT SHE WAS GOING TO BE UNSTABLE BUT IT APPEARS SHE HAVE STABLIZED A BIT. HE STATED THAT IF PATIENT WHY HE HAS NOT VISITED TONIGHT, THAT WE COULD TELL HIM THAT SHE WAS TAKEN TO THE HOSPITAL AND THAT HE WAS THERE WITH HER. IT IS OKAY TO TELL HIM THAT SHE HAS A GIB AND THAT SHE IS IN THE ICU.\n"},{"category":"ECG","chartdate":"2169-03-27 00:00:00.000","description":"Report","row_id":158436,"text":"Sinus arrhythmia with atrial ectopy. Marked P-R interval prolongation. Left\natrial abnormality. P-R interval 0.36. Left axis deviation. Right bundle-branch\nblock. Left anterior fascicular block. Diffuse ST-T wave changes which are in\npart primary - cannot exclude ischemia. No previous tracing available for\ncomparison.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2169-03-28 00:00:00.000","description":"Report","row_id":158434,"text":"Sinus rhythm with atrial ectopy. There are group beating patterns with\nsubsequent QRS followed by prolonged P-R intervals. However, there is no\nblocked atrial conduction. Marked P-R interval prolongation. Borderline left\naxis deviation. Right bundle-branch block. T wave inversions in V3-V5 most\nlikely due to rhythm but cannot rule out anterolateral ischemia. Compared to\nthe previous tracing of T wave inversions in the lateral leads are less\npronounced. Clinical correlation is suggested.\n\n"},{"category":"ECG","chartdate":"2169-03-27 00:00:00.000","description":"Report","row_id":158435,"text":"Sinus arrhythmia with atrial ectopy. Severe P-R interval prolongation. Left\natrial abnormality. P-R interval 0.32. Left axis deviation. Right bundle-branch\nblock. Left anterior fascicular block. Diffuse ST-T wave changes. Cannot\nexclude lateral ischemia. Consider prior anteroseptal myocardial infarction.\nClinical correlation is suggested. Compared to the previous tracing of \nthere is no significant change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2169-03-30 00:00:00.000","description":"Report","row_id":158431,"text":"Wandering atrial pacemakeR, RATE 99. Compared to tracing #2 there are more R\nwaves in leads V4-V6. Otherwise, no diagnostic changes.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2169-03-29 00:00:00.000","description":"Report","row_id":158432,"text":"Wandering atrial pacemaker, rate 93. Compared to the previous tracing the heart\nrate is now irregular and the ST segments in lead V3 appear to be elevated.\nThere is now evidence of probable old anterior myocardial infarction. Probable\nold inferior myocardial infarction as well.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2169-03-29 00:00:00.000","description":"Report","row_id":158433,"text":"Ectopic atrial rhythm, rate 94, with P-R interval prolongation. Incomplete\nright bundle-branch block and left axis deviation. Poor R wave progression in\nleads V3-V6 consistent with old anterior myocardial infarction. T wave\nabnormalities in leads V3-V4 appear more prominent compared to the previous\ntracing of . Rule out ischemia. The heart rate is faster than on the\nprevious tracing.\nTRACING #1\n\n"},{"category":"Nursing/other","chartdate":"2169-04-03 00:00:00.000","description":"Report","row_id":1274327,"text":"nursing progress note see carview for details.\n\nneuro:awake,alert,appears oriented x3,does not always know what hospital he is in.follows commands and moves all extremities with equal strenght.speech is clear and recognizes all family members.\n\ncv:remains in atrial fib rate 70 to 90 with rare pvcs.bp stable less than 150 systolic .tolerates captopril and lopressor.has bil dp and ptp by doppler with good palpable graft pulse.left foot is cooler than right foot,left pt is weaker than other pulses.swan was dcd.seen and evaluated by cardiolgy.\n\nresp:resp rate 14 to 20.has audible i/e wheezes appears to be upper airway.sp02 96 to 98% on 6lnp. had albuterol/atrovent nebs.chest xray revealed some failure treated with lasix.has loose cough without production.\n\ngu:foley to cd draining clear yellow urine in small amounts.\n\ngi:had large stool this am with about 300cc of bright red blood.had two ther small formed stools with no visible blood but one was heme positive.abd soft appears nontender,pt denies pain.surgery was notified,came and did rectal exam.heparin gtt was dcd,tube feeds were dcd.has positive bowel sounds present.\n\nsocial:dr spoke with pt this am code status was changed to dni.son spoke with social service.family has been update on pts condition.\n\naccess:swan was dcd,changed over a wire ,triple lumen was placed,line was repositioned by dr .\n"},{"category":"Nursing/other","chartdate":"2169-04-04 00:00:00.000","description":"Report","row_id":1274328,"text":"Cardiac\nD: pt. con'ts to be in afib with stable B/P in the 140's to 150's. HR decreasing to brady in the 40's after 1st dose of increased lopressor. B/P decreasing with decreased HR to ~110 systolic. pedal pulses (+) by doppler. K 4.1 after a.m. bolus\nA: lopressor dose decreased to 12.5 mg po bid\ntube feeds restarted\nLasix 20 mg IVP x 1 given\nNS con't @ 40 ml/hr until TF increased\nR:gd response from diuresis, k not needing repletion, HR and B/P increased after time..await results of decreased lopressor dose,? transfer to VICU\n"},{"category":"Nursing/other","chartdate":"2169-04-04 00:00:00.000","description":"Report","row_id":1274329,"text":"Resp\nD: pt. c/o difficulty breathing this afternoon. BS bil. with end exp wheezes. O2 sat 99%. denies c.p. RR low 20's. no accessory use.\nA:endo suctioned for mod amt thick sputum\nNeb per resp therapy\nDr. aware\n40% humidified face tent added\n4L np\nR: pt more comfortable con't having gd Sats, Neb being administered @ present.\n\n"},{"category":"Nursing/other","chartdate":"2169-04-05 00:00:00.000","description":"Report","row_id":1274330,"text":"2.5MG Albuterol via neb/Mask X2 HR 88 RR 18 BS exp Wheeze O24L/min O2 sat99%.\n"},{"category":"Nursing/other","chartdate":"2169-04-05 00:00:00.000","description":"Report","row_id":1274331,"text":"Condition update A:\nROS - please refer to flowsheet.\n NEURO: Lethargic in am s/p 1Percocet at 0830 for c/o back pain. Pt more alert this afternoon. Oriented x3. MAE.\n\nCARDIO: Afeb. HR 60-70's cont's Afib w/ PAC's and PVC's. SBP<160. Denies CP. CVP 11-20.\n\nRESP: LS intermit coarse -> exp wheeze. RT providing neb tx's. Weak cough unable to raise secretions.\n\nGI/GU: NPO. Tol TF at goal. Resid 0cc. Scant stool in smears x2. Speach up for bedside swallow eval. Reccomending cont NPO until pt more alert for Barium swallow. Foley patent yellow clear urine. Lasix pNGT given w/effect.\n\nSKIN: RLE inc w/ staples intact w/ scant serosanguinous drainage. Perineum and (L) glut w/ ecchymosis slowly resolving. Pt tol OOB -> chr w/ PT.\n\nPLAN: Cont NPO and TF w/ mouthcare. Monitor RLE inc, change per orders. Monitor resp status, provide neb tx's prn. Monitor hemodynamics.\n"},{"category":"Nursing/other","chartdate":"2169-04-02 00:00:00.000","description":"Report","row_id":1274324,"text":"focus hemodynmics\ndata: pt lying bed in semi position. asking for swabs for his mouth. bp 140-160syst/ one unit of prbc infused. pt complaining of breathing difficulty. o2sats= 94-96%. abg done and ph 7.32-with po2-104. morphine 1mg iv given. co-3.2 ci- 2.1 with svr 1800. ho notified. dr in the room and spoke to pt as pt states he would like to die. dr explained condition and treatement for him. pt requesing that son be called and ho called son. cxr done.\n"},{"category":"Radiology","chartdate":"2169-04-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":758834,"text":" 8:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess position of tip of central line -- line has been part\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p fem-tib bypass.\n REASON FOR THIS EXAMINATION:\n assess position of tip of central line -- line has been partially self d/c'ed\n by patient.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: S/P fem/tib bypass. Assess position of central line that has\n been partially pulled out by the patient.\n\n PORTABLE AP CHEST: Comparison is made to previous films from . The\n right sided central venous catheter has been slightly withdrawn with the tip\n now overlying the mid to distal SVC. The heart size and mediastinal/hilar\n contours are stable. The lung fields are unchanged in appearance since the\n previous exam. The soft tissues and osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1. Tip of right sided central venous catheter in satisfactory position,\n overlying the mid to distal SVC.\n\n 2. No interval change in the collapse/consolidation of the left lower lobe\n and air space opacities, predominantly involving the upper lung zones.\n\n"},{"category":"Radiology","chartdate":"2169-04-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":758915,"text":" 5:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for infiltrate/effusion/CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p fem-tib bypass.\n REASON FOR THIS EXAMINATION:\n Eval for infiltrate/effusion/CHF\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest compaerd to 1 day earlier.\n\n INDICATION: Congestive heart failure symptoms. Post-operative patient.\n\n A right internal jugular central venous catheter remains in place, terminating\n near the junction of the superior vena cava and right atrium. Cardiac and\n mediastinal contours are stable. There is partial collapse of the right upper\n lobe. There are bilateral pleural effusions present and adjacent basilar\n opacities which probably reflect atelectasis. No definite congestive heart\n failure is identified.\n\n IMPRESSION: 1) Partial collapse of right upper lobe.\n\n 2) Persistent bilateral pleural effusions with interval increase compared to\n previous study.\n\n 3) No evidence of congestive heart failure.\n\n"},{"category":"Radiology","chartdate":"2169-03-28 00:00:00.000","description":"F/U STATUS INFUSION/EMBO","row_id":758129,"text":" 7:48 AM\n UNI-LAT FEMORAL Clip # \n Reason: PLEASE DO PT IN AM\n Contrast: OPTIRAY Amt: 105\n ********************************* CPT Codes ********************************\n * F/U STATUS INFUSION/EMBO *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Followup TPA/heparin infusion.\n\n RADIOLOGISTS: Drs. , and . Drs. and ,\n radiologists, were present throughout the procedure.\n\n CONTRAST/MEDICATIONS: 105 ml of Optiray 320 at 30%; 0.5 mg versed and 75 mcg\n fentanyl in divided under continued hemodynamic monitoring.\n\n PROCEDURE/TECHNIQUE/FINDINGS: TPA infusion was discontinued at 1900 hours on\n , following son evidence of left ventricular thrombus. The\n wire was subsequently removed at the bedside, and the heparin dose was\n increased to 1000 units per hour.\n\n Through the existing 5 french sheath in the left groin, a sos Omni catheter\n was advanced over a wire into the right external iliac artery, and sequential\n right lower extremity arteriograms were obtained. At the level of the previous\n occlusion, there is improved filling through the superficial femoral artery\n down to the level approximately 1-2 cm distal to the adductor canal. At the\n adductor canal is a filling defect consistent with thrombus material. Just\n distal to this is a focal stenosis, followed by an abrupt occlusion of the\n distal SFA/above knee popliteal artery. There is improved vascular flow\n through collaterals over the mid thigh as well as over the calf. The below\n knee popliteal artery and trifurcation vessels are not visualized proximally.\n Distally, the caliber of the reconstituted anterior tibial artery appears\n larger than the previous arteriogram. There continues to be irregularity at\n the proximal portion of the dorsalis pedis artery, again with virtually no\n flow demonstrated at its mid/distal portion. Plantar vessels again do not\n fill. There is no filling of the arch vessels.\n\n IMPRESSION: Status post 6 hours TPA and 24 hour heparin infusion,\n demonstrating improved flow through the mid superficial femoral artery, with\n an occlusion demonstrated at the distal SFA/above knee popliteal artery. There\n is increased flow through collaterals of the thigh and calf, with a larger\n appearing anterior tibial artery in today's study relative to . \n filling of the mid/distal dorsalis pedis artery or plantar vessels.\n\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-03-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 758344,\n \"text\": \" 7:17 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?CHF\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old man s/p fem-tib bypass\\n\\n REASON FOR THIS EXAMINATION:\\n ?CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST SINGLE AP FILM:\\n\\n HISTORY: Fem/tib bypass and shortness of breath, Swan-Ganz placement.\\n\\n Swan-Ganz catheter is in right main pulmonary artery. No pneumothorax. Heart\\n size is within normal limits for technique. No evidence for CHF. Apart from\\n linear atelectasis at the left base, the lungs are clear.\\n\\n IMPRESSION: No evidence for CHF or pneumonia. No pneumothorax. No change\\n since prior study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-04-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 758436,\n \"text\": \" 6:36 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for pulm edema\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old man s/p fem-tib bypass\\n\\n REASON FOR THIS EXAMINATION:\\n evaluate for pulm edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post fem/tib bypass, shortness of breath, evaluate for\\n pulmonary edema.\\n\\n Single frontal chest radiograph dated is compared with prior chest\\n radiograph dated .\\n\\n When compared to the prior study, there is no interval change in position of\\n lines and tubes. There is no interval change in appearance of the chest.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-04-02 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 758474,\n \"text\": \" 12:54 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: acute SOB\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old man s/p fem-tib bypass a\\n\\n REASON FOR THIS EXAMINATION:\\n acute SOB\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Patient with fem-tib bypass.\\n\\n Given technical differences, there is not a very significant change in the\\n appearance of the chest since .\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-04-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 758568,\n \"text\": \" 2:09 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: line placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old man s/p fem-tib bypass a\\n\\n REASON FOR THIS EXAMINATION:\\n line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post lower extremity bypass surgery. Check line placement.\\n\\n PORTABLE AP CHEST RADIOGRAPH: Comparison is made to an exam of . The\\n tip of a right IJ catheter terminates deep within the right atrium. The\\n cardiac silhouette and mediastinal/hilar contours are stable. There is\\n persistent air-space opacification of the right upper lobe with further\\n improvement of air-space disease within the left upper lobe. There are no new\\n effusions or focal consolidations. No evidence of pneumothorax.\\n\\n IMPRESSION:\\n 1) Tip of right-sided central venous catheter deep within the right atrium.\\n This finding was immediately telephoned to Dr. .\\n\\n 2) Probable resolving asymmetric pulmonary edema within the upper lobes, right\\n side greater than left. An underlying infectious etiology, however, cannot be\\n completely excluded.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-04-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 758461,\n \"text\": \" 3:20 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: worsening CHF\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old man s/p fem-tib bypass\\n\\n REASON FOR THIS EXAMINATION:\\n worsening CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Recent fem/tib bypass, worsening CHF.\\n\\n Comparison with the patient's prior chest xray at 6:37 AM on .\\n\\n The heart is enlarged. The feeding tube and Swan-Ganz catheter are relatively\\n unchanged since the prior study. Once again there is bilateral upper lobe\\n early air space disease versus pulmonary edema. There is no pneumothorax.\\n\\n IMPRESSION: No change in the chest since the earlier chest xray this morning.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-03-27 00:00:00.000\",\n \"description\": \"VEN DUP EXTEXT BIL (MAP/DVT)\",\n \"row_id\": 758092,\n \"text\": \" 1:52 PM\\n DUP EXTEXT BIL (MAP/DVT) Clip # \\n Reason: look for suitable bypass vein.\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old man with R popliteal a. thrombus/embolus. Prior Hx vein stripping\\n ? side. Please map B lower ext veins.\\n REASON FOR THIS EXAMINATION:\\n look for suitable bypass vein.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Patient with ischemic leg and need for bypass. Evaluate for conduit.\\n\\n FINDINGS: Duplex evaluation was performed of both lower extremity superficial\\n venous systems. On the right leg the greater saphenous vein is patent. The\\n lesser saphenous vein is not visualized. The diameters of the greater\\n saphenous vein in centimeters are as follows: 0.28, 0.31, 0.35 and 0.44 at\\n the ankle, mid calf, low thigh and saphenofemoral junctions respectively.\\n\\n On the left, the lesser saphenous vein could not be evaluated due to the\\n patient having a TPA catheter in place. The greater saphenous vein is patent\\n with diameters in centimeters as follows: 0.41, 0.39, 0.44 and 0.43 cm at\\n the ankle, knee, thigh and saphenofemoral junctions respectively.\\n\\n IMPRESSION: Patent right greater saphenous vein. The right lesser saphenous\\n vein was not visualized. On the left, the greater saphenous vein is patent.\\n The lesser saphenous vein could not be evaluated due to reasons as stated\\n above.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-03-27 00:00:00.000\",\n \"description\": \"MULTI-PROCEDURE SAME DAY\",\n \"row_id\": 758048,\n \"text\": \" 7:45 AM\\n UNI-LAT FEMORAL Clip # \\n Reason: r/o thrombosis\\n Contrast: OPTIRAY Amt: 200CC\\n ********************************* CPT Codes ********************************\\n * TRANSCATHETER INFUSION FOR LYS INITAL 3RD ORDER ABD/PEL/LOWER *\\n * -51 MULTI-PROCEDURE SAME DAY TRANSCATHETER INFUSION *\\n * ABDOMINAL A-GRAM EXT UNILAT A-GRAM *\\n * NON-IONIC 200 CC SUPPLY *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old man with acute numbness of R foot. On exam has a cold R foot with\\n no doppler signals or pulses.\\n REASON FOR THIS EXAMINATION:\\n r/o thrombosis\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: year old male with symptoms and signs of acute right foot\\n ischemia without Dopplerable signals or pulses.\\n\\n RADIOLOGISTS: Drs. and . Dr. , staff radiologist,\\n was presenting during throughout the procedure.\\n\\n CONTRAST/MEDICATIONS: 200 ml of Optiray 320 at 30%; 1.5 mg versed and 50 mcg\\n fentanyl in divided doses under continued hemodynamic monitoring.\\n\\n PROCEDURE/TECHNIQUE/FINDINGS: The procedure was described to the patient and\\n informed consent was obtained. Access was gained into the left common femoral\\n artery using a 19g single wall needle. An 0.035 wire was advanced through a\\n heavily calcified left external and common iliac artery under fluoroscopic\\n guidance without difficulty. A 5 french sheath was then exchanged over the\\n wire, followed by placement of a 4 french omni flush catheter. With the\\n catheter in the abdominal aorta, an AP aortogram was obtained. The catheter\\n was pulled into the infrarenal aorta, and a left anterior oblique pelvic\\n arteriogram was obtained. Over an 0.035 angled glide wire, catheter was then\\n advanced into the distal right external iliac artery, and sequential right\\n lower extremity arteriograms were obtained.\\n\\n A mild degree of aortoiliac calcification is present. There are single renal\\n arteries bilaterally. The ostea are suboptimally visualized, but there is a\\n probable left proximal renal artery stenosis present. The infrarenal aorta is\\n mildly aneurysmal, with a focal eccentric stenosis that projects over L3-4.\\n Both hypogastric arteries are widely patent. There is a significant degree of\\n tortuousity of both iliac vessels, but no common or external iliac stenoses\\n are present. Incidental note is made of a right hip prosthesis. Extensive\\n calcification is noted throughout superficial and deep femoral vessels. A mild\\n stenosis is present involving the takeoff of the profunda femoris, with\\n diffuse eccentric disease throughout an otherwise patent vessel. The proximal\\n portion of the superficial femoral artery is widely patent, but demonstrates\\n mild multifocal disease proximally. At the mid portion, above the adductor\\n canal, is a meniscus shaped filling defect involving the medial wall of the\\n superficial femoral artery most consistent with thrombus. A small lateral\\n (Over)\\n\\n 7:45 AM\\n UNI-LAT FEMORAL Clip # \\n Reason: r/o thrombosis\\n Contrast: OPTIRAY Amt: 200CC\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n vessel arises from the lateral aspect of the superficial femoral artery at\\n this level, and courses medially along the knee joint. An AP view obtained\\n over the trifurcation shows no filling of the runoff vessels proximally. There\\n is an extensive small collateral network over the thigh. Distally, the\\n anterior tibial and peroneal arteries reconstitute. The anterior tibial artery\\n continues as the dorsalis pedis artery, which proximally has a corkscrew\\n attenuated appearance and does no opacify at its mid or distal portions. The\\n plantar vessels do not fill, nor do the arch vessels.\\n\\n An 0.035 angled glide wire was then advanced through the catheter down to the\\n abrupt filling defect, which was able to be crossed without difficulty.\\n However, approximately 3-4 cm beyond, the glidewire could not be passed. For\\n this reason, the glidewire was removed, and a 9 cm infusion wire was\\n advanced under fluoroscopic guidance to the level of occlusion. 1 mg TPA was\\n then bolus-injected intraarterially, and this was repeated four times for a\\n total of 5 mg TPA bolus at the site of thrombus.\\n\\n TPA was then commenced at a rate of 0.5 mg per hour, with 200 units of heparin\\n infusing through the sidearm sheath for patency. The patient will return to\\n the interventional radiology department on for reassessment.\\n\\n COMPLICATIONS: None.\\n\\n IMPRESSION: Findings suggesting an acute on chronic thrombus of the\\n superficial femoral artery just proximal to the adductor canal. 5 mg bolus of\\n TPA infused through wire, followed by continuous infusion of TPA at a\\n rate of 0.5 mg per hour. The patient will return on for angiographic\\n reassessment.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-03-27 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 758108,\n \"text\": \" 7:02 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please do tonight -- pt preop for OR -- can not travel d\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old man with\\n\\n acute limb ischemia\\n REASON FOR THIS EXAMINATION:\\n Please do tonight -- pt preop for OR -- can not travel downstairs -\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: year old man with acute limb ischemia, preoperative exam.\\n\\n PORTABLE AP SUPINE VIEW OF THE CHEST PERFORMED AT 19:29 HOURS: No\\n prior images for comparison. The heart size and mediastinal contour are\\n within normal limits. The aorta is tortuous and calcified. There is some\\n prominence of the pulmonary vasculature peripherally, predominantly within the\\n upper lobes. Although this may in part reflect the patient's supine\\n positioning a component of volume overload cannot be excluded. There is\\n increased luceny of the right lower lung. Streaky opacities at the left base\\n are consistent with minimal left basilar atelectasis.\\n\\n Surgical clips are noted within the right upper quadrant.\\n\\n IMPRESSION: No evidence of pneumonia. Mild upper zone redistribution likely\\n represents a component of volume overload. Relative increased lucency of the\\n right lower lung of uncertain significance. Possible etiologies include\\n bullous change or chronic or acute pulmonry embolism. Recommend comparison\\n with prior studies. Surgical resident notified 10:20 pm.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-03-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 758186,\n \"text\": \" 6:07 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess swan placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old man s/p fem-tib bypass\\n REASON FOR THIS EXAMINATION:\\n assess swan placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Assess Swan-Ganz placement in post vascular surgery patient.\\n\\n COMPARISON: \\n\\n AP CHEST: In the interval since the prior study a Swan-Ganz catheter has been\\n placed via right internal jugular access and the tip is positioned at the\\n junction of the right pulmonary artery in its interlobar branch. There is no\\n evidence of pneumothorax. Minimal atelectasis is again seen at the left base.\\n Otherwise there are no changes since the study 1 day prior.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-03-31 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 758413,\n \"text\": \" 4:23 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: CONFIRM DUBOFF TUBE PLACEMENT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old man s/p fem-tib bypass\\n\\n REASON FOR THIS EXAMINATION:\\n CONFIRM DUBOFF TUBE PLACEMENT\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Dophoff tube tube placement.\\n\\n COMPARISON: .\\n\\n AP UPRIGHT CHEST: The tip of the feeding tube is positioned in the first\\n portion of the duodenum. SG catheter is positioned at the right PA. There is\\n no pneumothorax. There is interval development of faint patchy air space\\n opacity in the left mid and upper lung zones and the right upper lung zone\\n compatible with acute aspiration event. There are no pleural effusions.\\n\\n IMPRESSION:\\n 1. Feeding tube appears post-pyloric.\\n 2. Interval development of air space opacity in mid and upper lung zones;\\n question acute aspiration event vs. asymmetric edema.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2169-03-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 70703,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Embolus to popliteal artery.?soe.\\nHeight: (in) 65\\nWeight (lb): 146\\nBSA (m2): 1.73 m2\\nBP (mm Hg): 154/64\\nStatus: Inpatient\\nDate/Time: at 16:30\\nTest: Portable TTE(Complete)\\nDoppler: Complete pulse and color flow\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: The left atrium is moderately dilated.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\\n\\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\\nventricular cavity is mildly dilated. There is an apical left ventricular\\naneurysm. There is severe global left ventricular hypokinesis. Overall left\\nventricular systolic function is severely depressed. A large thrombus is seen\\nin the left ventricle.\\n\\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\\n\\nAORTA: The aortic root is normal in diameter.\\n\\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\\n\\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is\\nmoderate mitral annular calcification.\\n\\nConclusions:\\n1. The left atrium is moderately dilated.\\n2. There is mild symmetric left ventricular hypertrophy. The left ventricular\\ncavity is mildly dilated. There is an apical left ventricular aneurysm.\\nOverall left ventricular systolic function is severely depressed. A large\\nthrombus is seen in the left ventricular apex. Severe diffuse hypokinesis is\\npresent with some preservation of basal wall motion.\\n3. The aortic valve leaflets are mildly thickened.\\n4. The mitral valve leaflets are mildly thickened.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2169-03-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 70664,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Atrial fibrillation/flutter. Left ventricular function.\\nHeight: (in) 65\\nWeight (lb): 166\\nBSA (m2): 1.83 m2\\nBP (mm Hg): 150/68\\nStatus: Inpatient\\nDate/Time: at 15:55\\nTest: Portable TTE(Complete)\\nDoppler: Complete pulse and color flow\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the\\nright atrium and/or right ventricle.\\n\\nLEFT VENTRICLE: There is severe global left ventricular hypokinesis. Overall\\nleft ventricular systolic function is severely depressed. A left ventricular\\nmass/thrombus cannot be excluded.\\n\\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\\nnormal.\\n\\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened.\\n\\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is\\nmoderate mitral annular calcification. Moderate (2+) mitral regurgitation is\\nseen.\\n\\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\\ntricuspid regurgitation.\\n\\nPERICARDIUM: There is no pericardial effusion.\\n\\nConclusions:\\nThere is severe global left ventricular hypokinesis. Overall left ventricular\\nsystolic function is severely depressed.LV apex is aneurysmal. A left\\nventricular mass/thrombus cannot be excluded. Right ventricular chamber size\\nand free wall motion are normal. The aortic valve leaflets (3) are mildly\\nthickened. The mitral valve leaflets are mildly thickened. Moderate (2+)\\nmitral regurgitation is seen. There is no pericardial effusion.\\nCompared to the Echo dated , which was reviewed, LV function has\\ndecreased further, LV thrombus is not noted as clearly as in the previous\\nstudy. Mitral insufficency has increased.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-04-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1274325,\n \"text\": \"focus\\ndata: post hct 29.0. mso4 1mg x3 given with relief. slept in short naps. tube fdgs held during the nite due to fluid status. lasix 10mg iv x1 given with fair diuresis. k 3.5. mag 1.9. ho aware of these results. pacer on a vdemand of 60. pt appears calmer this am and not stating he wants to die. r leg dsg changed and incision clean and intact with mod amt of serosang drainage. dsg with loose kling wrapped.\\naction: labs as ordered. prbc given with post hct of 29. hob at 30degrees. albuterol rx for resp\\nresponse: monitor closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-04-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1274326,\n \"text\": \"nursing progress note see carview for details.\\n\\nneuro:awake,alert, oriented x3.follows commands and moves all extremities on command.conversation is appropriate,speech is easy to understand.\\n\\ncv:remains in atrial fib rate is 80 to 100 with rare pvcs.pacing wire in swan does not work,dr attempted to advance.captopril was increased to 18.75 mg q8hrs.remains on ntg gtt to keep systolic bp 130 to 150.ci remains stable,pa does not wedge team aware.right foot warmer than left foot,bil dp and pt pulses and graft pulse present,right graft pulse and right dp is palpablealso.\\n\\nresp:resp rate 14 to 24.sp02 96 to 99% on 2l np,and 60% open face mask.has loose cough without production.breath sounds have i/e wheezes getting alb/atro nebs,upper lobes clear at times with coarseness in bases.\\n\\ngi:mouth wet with swabs,pt has frequent cough.tube feeds were restarted ,promote with fiber to goal of 60cc today.has had no stool today.abd soft with positive bowel sounds.\\n\\ngu:foley to cd draining clear yellow urine today.in small amounts.\\n\\nid:no issues.\\n\\nskin:has multiple old ecchymotic areas in scrotum,sides of abd and around arms.has generalized edema in extremities.\\n\\nsocial:full and involved discussion with patient and son at bedside by dr and team prognosis and medical and cardiac condition discussed a dnr/dni status was determined. pt states that.\\\" i am dying please let me \\\".\\n\\nplan:comfort measures.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-04-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1274322,\n \"text\": \"N/SICU NURSING NOTE 11P-7A\\nREVIEW OF SYSTEMS\\n\\nNEURO: PT 2 WITH PERIODS OF AGITATION AND DISORIENTATION. PT ABLE TO BE TALKED DOWN. FOLLOWING COMMANDS AND MOVING ALL EXTRMETIES. SLEPT POORLY LAST NIGHT.\\n\\nCV: HR 70-80'S AFIB WITH OCC PVCS AND PACED BEATS. CONTS WITH PACING SWAN AND PACER SET AT VDEMAND 60 AND PACING APPROPRIATELY. SBP 130-160. PA 70-50/35-48 WITH WEDGE . CVP 8-13. CO/CI GRATUALLY DECREASING OVER LAST SHIFT WITH THERMO CO 3.39-2.90 WITH INDEX 1.8-1.6. FICK CO 4.0-3.70 WITH INDEX 2.21-2.O4. TEAM AWARE. TROPONIN ADDED TO THIS AMS LABS. ATTEMPTED 250CC FLUID CHALLENGE INITIALLY FOR LOW CO WITH NO EFFECT. PT PRESENTLY GETTING 1UPRBC OVER 4HRS. CONTS ON CAPOTEN BUT LOPRESSOR HELD PER SICU HO. MIXED VENOUS O2 45-49. DOPPLERABLE PULSES ON R WITH EXTREMTY COOL TO TOUCH. L WITH PALPABLE PEDAL PULSE WITH +GRAFT PULSE.\\n\\nRESP: L/S CLEAR IN UPPER LOBES WITH CRACKLES IN L BASE AND DIMINISHED ON R. O2 5LNC WITH SATS 93-98%. SOB ON EXCERTION AND WITH AGITATION. OCC AUDIBLE WHEEZES NOTED ALBUTEROL NEB X1 WITH EFFECT. OCC DRY COUGH NOTED. ABG ADEQUATE. ISOLATED EPISODE WHERE PT C/O SOB BUT ASSOCIATED WITH AGITATION THAT SUBSIDED.\\n\\nGI: ABD SOFT WITH +BS. TOL ICE CHIPS. POST PYLORIC TUBE WITH PROMOTE AT 20CC/HR. NO STOOL OR FLATUS. DENIES TENDERNESS ON PALPATION.\\n\\nGU: U/O 30-40CC/HR. LASIX HELD THIS AM.\\n\\nHEME: HCT 25-28. 1UPRBC GIVEN. PTT 60 HEPARIN GTT REMAINS AT 700U/HR.\\n\\nENDO: NO ISSUES.\\n\\nID: AFEBRILE. WBC FLAT.\\n\\nSKIN: LLE INCISION WITH DSG INTACT WITH SMALL AMT OF SEROSANG. DRAINAGE NOTED.\\n\\nSOCIAL: NO CONTACT WITH FAMILY THIS SHIFT.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-04-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1274323,\n \"text\": \"nursing progress note see carview for details\\n\\nneuro:awake alert,easily agitated and disoriented at times.reoriented easily.follows commands and moves all extremities.recognizes all family members.aware that he is in a hospital.\\n\\ncv:remains in atrial fib with rare pvcs.systolic bp greater than 150 started on ntg gtt,continues at 3 mcq /kg/min. dr aware not to increase ntg.captopril dose was increased to 12.5 mg q8hrs. ci has been stable.swan has not wedged ,has been repositioned multiple times by dr .pacer remains in vdemand mode , rate at 60,ventricular sensitivity 2.0,ma at 5.pacing and sensing checked on rounds this am.had one dose of lopressor 2.5mg iv and tolerated well.\\n\\nresp:had chest xray which dr reports as improved.had increasing oxygen requirements,nasal prongs at 2lmin,open face mask at 60%.breath sounds have had wheezes present which have been treated with albuteral nebs.crackles bibasilar which was treated with lasix 10mg/iv.otherwise bs are clear and diminished bibasilar.resp rate 17 to 26.has loose nonproductive cough.\\n\\ngi:abd soft with positive bowel sounds present,has not had any stool today.tube feed continues at 40cc/hr promote with fiber.will advance tonight for total goal rate of 60cc.\\n\\ngu:foley to cd draining small amounts of clear urine,had lasix 10mg iv with some diuresis.\\n\\nskin:intact,on airmatress.right leg incision line intact with dsg.\\n\\npulses:has bildpand pt and graft present by doppler.\\n\\nsocial:visited by family.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-03-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1274319,\n \"text\": \"PROGRESS NOTE\\nPT , ORIENTED TO NAME AND 'HOSPITAL', REORIENTED TO DATE. MOVES ALL LIMBS AND FOLLOWS COMMANDS APPROPRIATELY. BILAT WRISTS RESTRAINTS APPLIED, DUE TO PT PULLING AT SWAN LINE.\\nCV: PT TRANSFERRED FROM VICU ON , RULING IN FOR +MI, F/U BY CARDIOLOGY, SWAN PACER IN SITU AND ATTACHED. RESTARTED ON HEPARIN DRIP @ 2130 SECONDARY TO LV THROMBUS, INITIALLY STOPPED DUE TO RT LEG WOUND OOZING. INITIALLY PT'S CVP 0-3, PCWP: , CO, CI APPEARED ACCEPTABLE SEE FLOWSHEET. LOW URINE OUTPUT: 10-20CC PT FOLLOWED BY RENAL TEAM.\\nRECEIVED PT WITH STABLE BP DESPITE LOW CVP AND WEDGE, WAS GIVEN SEVERAL BOLUSES AND I UNIT PRBCS FOR LOW HCT TO IMPROVE ON FLUID STATUS. PCWP FOLLOWED CLOSELY AS PER HO AND CARDIOLOGY. CVP AND PCWP FLUCTUATE: ; . CPK'S WITH MB AND TROPONIN LEVELS ELEVATED CURRENTLY CYCLING X 3. HR 85-90S, WITH FREQUENT PVC'S. WILL REPLETE LYTES AS OREDERED. PAP 40-60 SYSTOLIC. PT IN AND OUT OF A-FIB WHILE BOLUSES INFUSING, HO AWARE EKG DONE, PT BACK IN SR. ION CA .97 WAS GIVEN 2GM.\\nRT LEG INCISION, CHANGED AND CLEANSED WITH NS GRAFT SITE PALPABLE, PEDAL PULSES ABSENT REPORTED TO HO, WARM BLANKETS APPLIED TO IMPROVE CIRCULATION TO EXTREMITIES.\\nGU: URINE OUTPUT IMPROVED SLIGHTLY- 25CC/HR AFTER BOLUSES.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-03-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1274320,\n \"text\": \"CCU NSG PROG NOTE: 7-3PM\\nRemains stable PO day 2, c/w MI, renal failure. Transferred to NSICU yesterday for close managment.\\n\\nROS:\\n\\nCARDIAC/HEMODYNAMICS: Yesterday low filling pressures-> prbc and fluid w/ normalized pressures today.(pa 40's, pad 25, pcw 19, cvp 10-12.)\\nThey want his pcw around 19-20 and cvp 10). IVF decreased to 75cc/hr.\\nSwan placement adjusted w/ improved tracings. Wedges easily w/ good tracing. He had alot of ventricular activity this am which resolved when pacer turned off. The pacer was inappropriately firing and did not sense. Remains off. Rhythm AF a/w first degree avb (pr .40)w/ rates 65-100. Started low dose lopressor. Transient brady to 50's w/ coughing. (noted to have vagal drops on floor w/ vomiting...hx tacky/brady syndrome.). Cardiac Index 2.08. Cardiology following.Remains on heparin gtt w/ acceptable ptt. (has LV clot). For Echo today. Contnue to serial enzymes. R upper back pain.\\n\\nRESP: diminished at R base. Remains stable w/ sats 97% on 3L nc. rr 20's unlabored.\\n\\nRENAL: new renal failure w/ bun 39/cr 2.0. Urine output consistently 20-25cc/hr. Renal following.\\n\\nGI: NPO today except med and ice chips. Takes crushed meds. Will reevaluate tomorrow regarding eating. No stool. Abd soft . No nausea\\n\\nHEME: received 2nd unit prbc for today w/ follow up hct 29.8.\\n\\nNEURO: A&Ox2. Able to converse and follow commands, has periods of confusion.Did not require restraints today. Cooperative.\\n\\nSKIN/WOUND: R leg dsg dry and intact w/ dopplerable pulses at graft, DP, L dp, absent L PT pulse. R foot warm to touch w/ good color. L foot cool to touch. Last dsg change 2am.\\n\\nID: afebrile. wbc 12.4. Is not on abx.\\n\\nMETABOLIC: metabolic acidosis. abg 7.28/29/107/-. Receiving ivf w/ 2 amps bicarb x 1 liter only. ABG pnd.\\n\\nSTATUS: Son, , is health care proxy.(copy is in chart). The patient remains a full code. If pt's condition or prognosis changes, he will readdress status w/ the team. A sister , , is also involved. There is a daughter, , who is coming from . and described an emotional instability of that could interfere w/ patient care and reminded me that is the legal proxy. They are attempting to be here to monitor visits but in the event that they are not, they said we can give her information but ask that we not honor unreasonable requests of her's. (i.e. decision making or asking for physician .) and are available by phone.\\n\\nASSESS: stable s/p mi, renal failure, metabolic acidosis (r/t renal failure/ cardiogenic compromise). Stable filling pressures. Stable b/p. Stable resp status.\\n\\nPLAN; labs sent and pnd. Monitor acidosis. Keep cvp approx 10, pcw approx 19-20. Mso4 for discomfort. Monitor surgical incision. Restrain if necessary. For Echo.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-03-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1274321,\n \"text\": \"Progress Note\\nneuro unchanged, bilat wrist restraints still on as pt accidentally pulls on swan line. moves all ext in bed.\\nCV: hr a-fib with rare pvc's, k+ low 2.8 was given 20meq centrally, ion ca low-.87, was replaced x 2. bp stable during the night, co, ci unchanged from admission. pcwp 17 and cvp 10. afebrile.\\nrt leg drsg with amt of serosang drainage, wound cleansed with normal saline and applied DSD. rt graft site palpable, no bilat pedal pulses able to doppler, feet cool to touch, warm blankets applied.\\nresp: 4l np 02 sat fluctuates between 92-96% bilat breath sounds clear but diminshed at the bases. pt noted to have episode have exp wheezes on exertion, albuterol neb given.\\npt continues on heparin drip, goal to reach theraputic levels of ptt-60-80, pt currently on 600u/hr.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-04-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1274332,\n \"text\": \"NPN: PROGRESS AND TRANSFER NOTE\\nNEURO: ALERT AND ORIENTED. FREQUENTLY CALLING OUT FOR ICE AND WATER DESPITE BEING INSTRUCTED RE: ASPIRATION. DOES BECOME AGITATED WHEN HE IS REFUSED. ATTEMPTED TO CALM WITH ONLY FAIR RESULTS.\\n\\nCV: AFIB WITH OCC PVC AND PAC. A LINE TO L RADIAL, VSS. PP DOPPLED.\\n\\nRESP: HAS COURSE BREATHSOUNDS. HAS WEAK, LOOSE SOUNDING COUGH. WAS ON NC BUT CHANGED TO HUMIDIFIED FM JUST TO PROVIDE HIM SOME MORE MOISTURE TO HIS MOUTH. CPT COMPLETED.\\n\\nGI: NPO DUE TO PROBABLE ASPIRATIONS. SPPECH THERAPY WAS HERE TO DO AN EVALUATION EAARLIER IN DAY BUT THE PATIENT WAS TOO GROGGY FROM A DOSE OF ONE PERCOCET GIVEN EARIER IN DAY. THEY WILL FOLLOW UP TOMORROW. DOES HAVE FEEDING TUBE AND HAD A SMALL BROWN STOOL THIS EVENING.\\n\\nGU: FOLEY PATENT OF CLEAR YELLOW URINE.\\n\\nSKIN: ECCYMOSIS TO R HIP. BYPASS INCISION TO RLU WITH SOME OOZING AT UPPER THIGH.\\n\\nPSYCH/SOC/SPIRITUAL: SON IS ALSO MD. WIFE WAS TAKING TO TONIGHT WITH GIB AND IS ICU. INITIALLY IT WAS THOUGHT THAT SHE WAS GOING TO BE UNSTABLE BUT IT APPEARS SHE HAVE STABLIZED A BIT. HE STATED THAT IF PATIENT WHY HE HAS NOT VISITED TONIGHT, THAT WE COULD TELL HIM THAT SHE WAS TAKEN TO THE HOSPITAL AND THAT HE WAS THERE WITH HER. IT IS OKAY TO TELL HIM THAT SHE HAS A GIB AND THAT SHE IS IN THE ICU.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-03-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 158436,\n \"text\": \"Sinus arrhythmia with atrial ectopy. Marked P-R interval prolongation. Left\\natrial abnormality. P-R interval 0.36. Left axis deviation. Right bundle-branch\\nblock. Left anterior fascicular block. Diffuse ST-T wave changes which are in\\npart primary - cannot exclude ischemia. No previous tracing available for\\ncomparison.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-03-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 158434,\n \"text\": \"Sinus rhythm with atrial ectopy. There are group beating patterns with\\nsubsequent QRS followed by prolonged P-R intervals. However, there is no\\nblocked atrial conduction. Marked P-R interval prolongation. Borderline left\\naxis deviation. Right bundle-branch block. T wave inversions in V3-V5 most\\nlikely due to rhythm but cannot rule out anterolateral ischemia. Compared to\\nthe previous tracing of T wave inversions in the lateral leads are less\\npronounced. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-03-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 158435,\n \"text\": \"Sinus arrhythmia with atrial ectopy. Severe P-R interval prolongation. Left\\natrial abnormality. P-R interval 0.32. Left axis deviation. Right bundle-branch\\nblock. Left anterior fascicular block. Diffuse ST-T wave changes. Cannot\\nexclude lateral ischemia. Consider prior anteroseptal myocardial infarction.\\nClinical correlation is suggested. Compared to the previous tracing of \\nthere is no significant change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-03-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 158431,\n \"text\": \"Wandering atrial pacemakeR, RATE 99. Compared to tracing #2 there are more R\\nwaves in leads V4-V6. Otherwise, no diagnostic changes.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-03-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 158432,\n \"text\": \"Wandering atrial pacemaker, rate 93. Compared to the previous tracing the heart\\nrate is now irregular and the ST segments in lead V3 appear to be elevated.\\nThere is now evidence of probable old anterior myocardial infarction. Probable\\nold inferior myocardial infarction as well.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-03-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 158433,\n \"text\": \"Ectopic atrial rhythm, rate 94, with P-R interval prolongation. Incomplete\\nright bundle-branch block and left axis deviation. Poor R wave progression in\\nleads V3-V6 consistent with old anterior myocardial infarction. T wave\\nabnormalities in leads V3-V4 appear more prominent compared to the previous\\ntracing of . Rule out ischemia. The heart rate is faster than on the\\nprevious tracing.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-04-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1274327,\n \"text\": \"nursing progress note see carview for details.\\n\\nneuro:awake,alert,appears oriented x3,does not always know what hospital he is in.follows commands and moves all extremities with equal strenght.speech is clear and recognizes all family members.\\n\\ncv:remains in atrial fib rate 70 to 90 with rare pvcs.bp stable less than 150 systolic .tolerates captopril and lopressor.has bil dp and ptp by doppler with good palpable graft pulse.left foot is cooler than right foot,left pt is weaker than other pulses.swan was dcd.seen and evaluated by cardiolgy.\\n\\nresp:resp rate 14 to 20.has audible i/e wheezes appears to be upper airway.sp02 96 to 98% on 6lnp. had albuterol/atrovent nebs.chest xray revealed some failure treated with lasix.has loose cough without production.\\n\\ngu:foley to cd draining clear yellow urine in small amounts.\\n\\ngi:had large stool this am with about 300cc of bright red blood.had two ther small formed stools with no visible blood but one was heme positive.abd soft appears nontender,pt denies pain.surgery was notified,came and did rectal exam.heparin gtt was dcd,tube feeds were dcd.has positive bowel sounds present.\\n\\nsocial:dr spoke with pt this am code status was changed to dni.son spoke with social service.family has been update on pts condition.\\n\\naccess:swan was dcd,changed over a wire ,triple lumen was placed,line was repositioned by dr .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-04-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1274328,\n \"text\": \"Cardiac\\nD: pt. con'ts to be in afib with stable B/P in the 140's to 150's. HR decreasing to brady in the 40's after 1st dose of increased lopressor. B/P decreasing with decreased HR to ~110 systolic. pedal pulses (+) by doppler. K 4.1 after a.m. bolus\\nA: lopressor dose decreased to 12.5 mg po bid\\ntube feeds restarted\\nLasix 20 mg IVP x 1 given\\nNS con't @ 40 ml/hr until TF increased\\nR:gd response from diuresis, k not needing repletion, HR and B/P increased after time..await results of decreased lopressor dose,? transfer to VICU\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-04-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1274329,\n \"text\": \"Resp\\nD: pt. c/o difficulty breathing this afternoon. BS bil. with end exp wheezes. O2 sat 99%. denies c.p. RR low 20's. no accessory use.\\nA:endo suctioned for mod amt thick sputum\\nNeb per resp therapy\\nDr. aware\\n40% humidified face tent added\\n4L np\\nR: pt more comfortable con't having gd Sats, Neb being administered @ present.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-04-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1274330,\n \"text\": \"2.5MG Albuterol via neb/Mask X2 HR 88 RR 18 BS exp Wheeze O24L/min O2 sat99%.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-04-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1274331,\n \"text\": \"Condition update A:\\nROS - please refer to flowsheet.\\n NEURO: Lethargic in am s/p 1Percocet at 0830 for c/o back pain. Pt more alert this afternoon. Oriented x3. MAE.\\n\\nCARDIO: Afeb. HR 60-70's cont's Afib w/ PAC's and PVC's. SBP<160. Denies CP. CVP 11-20.\\n\\nRESP: LS intermit coarse -> exp wheeze. RT providing neb tx's. Weak cough unable to raise secretions.\\n\\nGI/GU: NPO. Tol TF at goal. Resid 0cc. Scant stool in smears x2. Speach up for bedside swallow eval. Reccomending cont NPO until pt more alert for Barium swallow. Foley patent yellow clear urine. Lasix pNGT given w/effect.\\n\\nSKIN: RLE inc w/ staples intact w/ scant serosanguinous drainage. Perineum and (L) glut w/ ecchymosis slowly resolving. Pt tol OOB -> chr w/ PT.\\n\\nPLAN: Cont NPO and TF w/ mouthcare. Monitor RLE inc, change per orders. Monitor resp status, provide neb tx's prn. Monitor hemodynamics.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2169-04-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1274324,\n \"text\": \"focus hemodynmics\\ndata: pt lying bed in semi position. asking for swabs for his mouth. bp 140-160syst/ one unit of prbc infused. pt complaining of breathing difficulty. o2sats= 94-96%. abg done and ph 7.32-with po2-104. morphine 1mg iv given. co-3.2 ci- 2.1 with svr 1800. ho notified. dr in the room and spoke to pt as pt states he would like to die. dr explained condition and treatement for him. pt requesing that son be called and ho called son. cxr done.\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-04-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 758834,\n \"text\": \" 8:38 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess position of tip of central line -- line has been part\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old man s/p fem-tib bypass.\\n REASON FOR THIS EXAMINATION:\\n assess position of tip of central line -- line has been partially self d/c'ed\\n by patient.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: S/P fem/tib bypass. Assess position of central line that has\\n been partially pulled out by the patient.\\n\\n PORTABLE AP CHEST: Comparison is made to previous films from . The\\n right sided central venous catheter has been slightly withdrawn with the tip\\n now overlying the mid to distal SVC. The heart size and mediastinal/hilar\\n contours are stable. The lung fields are unchanged in appearance since the\\n previous exam. The soft tissues and osseous structures are unremarkable.\\n\\n IMPRESSION:\\n\\n 1. Tip of right sided central venous catheter in satisfactory position,\\n overlying the mid to distal SVC.\\n\\n 2. No interval change in the collapse/consolidation of the left lower lobe\\n and air space opacities, predominantly involving the upper lung zones.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-04-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 758915,\n \"text\": \" 5:27 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval for infiltrate/effusion/CHF\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old man s/p fem-tib bypass.\\n REASON FOR THIS EXAMINATION:\\n Eval for infiltrate/effusion/CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n Portable chest compaerd to 1 day earlier.\\n\\n INDICATION: Congestive heart failure symptoms. Post-operative patient.\\n\\n A right internal jugular central venous catheter remains in place, terminating\\n near the junction of the superior vena cava and right atrium. Cardiac and\\n mediastinal contours are stable. There is partial collapse of the right upper\\n lobe. There are bilateral pleural effusions present and adjacent basilar\\n opacities which probably reflect atelectasis. No definite congestive heart\\n failure is identified.\\n\\n IMPRESSION: 1) Partial collapse of right upper lobe.\\n\\n 2) Persistent bilateral pleural effusions with interval increase compared to\\n previous study.\\n\\n 3) No evidence of congestive heart failure.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-03-28 00:00:00.000\",\n \"description\": \"F/U STATUS INFUSION/EMBO\",\n \"row_id\": 758129,\n \"text\": \" 7:48 AM\\n UNI-LAT FEMORAL Clip # \\n Reason: PLEASE DO PT IN AM\\n Contrast: OPTIRAY Amt: 105\\n ********************************* CPT Codes ********************************\\n * F/U STATUS INFUSION/EMBO *\\n ****************************************************************************\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n INDICATION: Followup TPA/heparin infusion.\\n\\n RADIOLOGISTS: Drs. , and . Drs. and ,\\n radiologists, were present throughout the procedure.\\n\\n CONTRAST/MEDICATIONS: 105 ml of Optiray 320 at 30%; 0.5 mg versed and 75 mcg\\n fentanyl in divided under continued hemodynamic monitoring.\\n\\n PROCEDURE/TECHNIQUE/FINDINGS: TPA infusion was discontinued at 1900 hours on\\n , following son evidence of left ventricular thrombus. The\\n wire was subsequently removed at the bedside, and the heparin dose was\\n increased to 1000 units per hour.\\n\\n Through the existing 5 french sheath in the left groin, a sos Omni catheter\\n was advanced over a wire into the right external iliac artery, and sequential\\n right lower extremity arteriograms were obtained. At the level of the previous\\n occlusion, there is improved filling through the superficial femoral artery\\n down to the level approximately 1-2 cm distal to the adductor canal. At the\\n adductor canal is a filling defect consistent with thrombus material. Just\\n distal to this is a focal stenosis, followed by an abrupt occlusion of the\\n distal SFA/above knee popliteal artery. There is improved vascular flow\\n through collaterals over the mid thigh as well as over the calf. The below\\n knee popliteal artery and trifurcation vessels are not visualized proximally.\\n Distally, the caliber of the reconstituted anterior tibial artery appears\\n larger than the previous arteriogram. There continues to be irregularity at\\n the proximal portion of the dorsalis pedis artery, again with virtually no\\n flow demonstrated at its mid/distal portion. Plantar vessels again do not\\n fill. There is no filling of the arch vessels.\\n\\n IMPRESSION: Status post 6 hours TPA and 24 hour heparin infusion,\\n demonstrating improved flow through the mid superficial femoral artery, with\\n an occlusion demonstrated at the distal SFA/above knee popliteal artery. There\\n is increased flow through collaterals of the thigh and calf, with a larger\\n appearing anterior tibial artery in today's study relative to . \\n filling of the mid/distal dorsalis pedis artery or plantar vessels.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":24689,"cells":{"subject_id":{"kind":"number","value":12135,"string":"12,135"},"hadm_id":{"kind":"number","value":197838,"string":"197,838"},"target_text":{"kind":"string","value":"It was determined that the patient had end-stage liver disease and he was admitted to the Medical Service under Dr. . On , the patient underwent paracentesis to drain his markedly ascitic abdomen. This was repeated five times over the next few days. On one of these paracenteses, there was a culture that grew out Pneumococcus strep pneumoniae and the patient did have spontaneous bacterial peritonitis. On , the patient underwent an endoscopy examination which failed to reveal any varices. On , the patient received a Psychiatry consult which confirmed that the patient had a pre-existing major depressive disorder. At about this time, the patient was evaluated by the Transplant Surgery Team. After evaluation by the Transplant Surgery Team, the patient was deemed for a transplant and added to the liver donor list. On , a liver was obtained and the patient was pre-opped. On , the patient underwent a transplant operation by Dr. , Dr. , and Dr. . Please refer to the previously dictated operative note from by Dr. for the specific details of this operation. Immediately postoperatively, the patient was treated with intravenous antibiotics, vancomycin, and Zosyn as well as immunosuppressants, CellCept, Solu-Medrol, and Simulect. He was transferred to the unit where he stayed for the next few days. He was hemodynamically monitored. He received several transfusions for decreasing hematocrit and platelet transfusions for decreasing platelets. During this time, he also developed several bouts of postoperative atelectasis and was eventually diuresed with Lasix. By , postoperative day number seven, the patient was doing much better. His lungs were clear. He was hemodynamically stable. It was decided that he should be extubated and he was. He tolerated this well and on the next day, postoperative day number eight, the patient was stable enough to be transferred to the floors. In addition, it should be noted that during the patient's SICU stay, his nutritional status was maintained with total parenteral nutrition and once extubated he was able to be sustained on an oral diet which was slowly advanced while he was on the floor to a regular diet which he tolerated without nausea, vomiting, or abdominal pain. Once on the floor, the patient was evaluated by Physical Therapy. It was determined that he was stable enough and in good enough condition to be discharged home once he was cleared medically. Several radiologic studies were performed over the final few days of his admission, first on postoperative day number 13, , a cholangiogram was performed through the patient's T tube. This revealed a stricture at the biliary anastomosis. On the next day, the patient underwent ERCP and this previously mentioned stricture was dilated. Later on , a duplex ultrasound of the liver was obtained which showed adequate blood flow through the hepatic arteries and portal veins indicating the transplanted liver was well perfused. Therefore, on , hospital day number 33, postoperative day number 20, the patient is afebrile with stable vital signs. He is tolerating a solid oral diet, making good urine, and having good bowel movements. His abdominal examination is benign and his laboratory work from is as follows; white blood cell count 13.1, hematocrit 32.3, platelets 304,000. Chemistries: Sodium 137, potassium 4.3, chloride 104, bicarbonate 24, BUN 20, creatinine 1.6, glucose 80. Liver function tests: ALT 43, AST 29, alkaline phosphatase 261, total bilirubin 5.5, albumin 2.9, and his latest cyclosporin level was 351 on a 400 b.i.d. dose. He is being discharged home in good condition with the following discharge diagnoses."},"extractive_notes_summ":{"kind":"string","value":"2) Patchy alveolar opacity including new or progressed right sided opacity. A left-sided subclavian catheter terminates in the upper SVC. Please hepatic vasculature, volumetrics, gadolinium for hepatoma, and MRC for question of obstruction. The gallbladder remains distended containing gallstones. Splenomegaly, ascites and patent umbilical vessel; findings consistent with portal hypertension. 5) Subdiaphragmatic right upper quadrant drain. There is stable cardiomegaly with slight worsening of vascular indistinctness and engorgement. There is contrast filling of the native and donor biliary ducts with evidence of a short segment of slightly irregular narrowing in the region of the anastomosis consistent with anastomotic stricture. There is now loss of translucency in the left upper lung zone with fluid seen tracking over the apex, consistent with a posterior layering pleural efffusion in this supine patient. 3) Left-sided posteriorly layering pleural effusion. Pulmonary artery catheter enters via the right internal jugular parallel to the separate venous access catheter, the tip appears to have been pulled back and now terminates in the proximal right main pulmonary artery. There is a surgical drain beneath the right diaphragm. IMPRESSION: 1) Cirrhotic liver, without focal masses. FINDINGS: A PA catheter placed via the right IJ terminates in the main pulmonary artery. There is a left subclavian central venous catheter in place with its tip in the superior vena cava. Status-post placement of biliary stent bridging region of anastomotic stricture. The liver is samll, with a slightly nodular contour consistent with cirrhosis. Right IJ central line is present with tip over distal SVC. There is lymphadenopathy around the celiac axis. Differential diagnosis includes atypical distribution of CHF, pneumonic infiltrate and ARDS. Assess for perforated bowel. 2) Partly resolved pulmonary infiltrates bilaterally, consistent with resolving pulmonary edema. Distinct right and left hepatic arteries are visualized. A right IJ cordis terminates in the distal right brachiocephalic vein. Findings consistent with mild colonic ileus. Right IJ swan ganz catheter is present with tip over right pulmonary artery. 4) Residual left effusion. response to diuresis. Beginning to developed compensated resp acidosis. Mild (1+)mitral regurgitation is seen. EKG ORDERED AND DONE. JP medial - site d/c/i - serosangious drainge. NG tube with tip beneath diaphragm. Follow up after diuresis. Most likely etiology is alveolar edema. NG tube is present, tip in the diaphragm. Respiratory Care:Pt. IMPRESSION: 1) Endotracheal tube tip terminates above level of the thoracic inlet. Pt rec'd at approx. FINAL REPORT INDICATION: Ascites. Since the previous tracingof right precordial T wave changes are seen. Right internal jugular sheath terminates in upper SVC. CONDITION UPDATEVSS. +PP'S. THIS A.M. C/O CPAIN - RADIATING \"DOWN MIDDLE OF CHEST\". Skin staples and right upper quadrant drain present. Left retrocardiac opacity with obscuration of left hemidiaphragm. MODERATE AMOUNT OF SEROSANG DRAINAGE AROUND LATERAL JP(#2) SITE, DRESSING CHANGED X2. Left subclavian venous access catheter terminates in upper SVC. REASON FOR THIS EXAMINATION: Please mark spot for paracentesis. CHEST, SINGLE AP PORTABLE VIEW: There is probable mild cardiomegaly. PA CATH D/C'D EARLIER TODAY.GI: ABD DISTENDED. FLEETS ENEMA GIVEN X1, DULCOLAX ENEMA GIVEN X1 - SMALL BOWEL MOVEMENT. LUNGS CTA BILAT. Respiratory note:Pt is intubated/agitated. TRANSFUSED WITH 1U PRBC'S, FOLLOW UP HCT 31. KUB done. HYDRALAZINE/LOPRESSOR CONTINUE. CONT PER CURRENT MGMT. CONT TPN. Tender in am on light palpation (HO notify). The inner dilator was removed. NGT TO LWCS - MIN CLEAR DRAINAGE OUT. Sinus rhythm. TRANSPLANT TEAM INFORMED.RESP: LS CLEAR BUT DIM AT BASES. agitation at times, mso4 2 mg ivp q1 prn. 7p-7a; Full assessment in flow sheet.neuro; A+OX3. M.D. The referring physician, . CONT CURRENT ICU CARE AND ASSESSMENT. Titrated to maintain BS btwn 80-120. IS GIVEN TO PT AND INSTRUCTED, BUT UNABLE TO USE CURRENTLY D/T GAS PAIN.CV: AFEBRILE. FINDINGS: An endotracheal tube terminates with tip 7.6 cm above the carina and located above the thoracic inlet. Afebrile. NURSING UPDATE TMAX 99, HR 70'S NSR, SLIGHT HTN SBP 170'S. NGT cont to LCWS with clear output. The ascending aorta is normal indiameter. pt weaned to cpap+ps - pt tol well, w/good abg's. c/w psv as tolerates, sbt in a.m. Suture site - d/c/i. ETT MOVED TO RIGHTSIDE OF MOUTH AND RETAPED. temp. b/s clear on rt, sl coarse lul. K+ AND ICA+ REPLETED. FORMODERATE AMTS. D/C PA in AM. condition updateneuro: pt seems oriented, nods appropriately, mea, gestures to communicate.cardiovasc: hypertensive to low 200's. ETT RETAPED AND MOVED TOLEFT SIDE OF MOUTH. NURSING UPDATE AFEBRILE, REMAINS MODERATELY HYPERTENSIVE WITH SBP 170'S. Resp Care Note, Pt remains on current vent settings. co/ci hr stable. RESPIRATORY CARE: PT. RESPIRATORY CARE: PT. B/S clear, Sx mod. CPAP 15/8 in am.gu/gi; soft distended abd. plan: cont w/mech support, wean ps as tol. see flow sheet for details.resp: abg's on cpap with po2 60's. ABG - wnl. Will cont to wean to extubate condition updateD: pt alert and oriented. REMAINS INTUBATED AND ONAN SIMV MODE AS PER CAREVUE. , RRT , RRT condition updateD: pt cooperative and follows commands. extubation SX. SX. REMAINS INTUBATED AND ONSIMV MODE AS PER CAREVUE. JP #1 - d/c/i - ss drainage. dr. aware. RSBI 113 this AM and probable extubation in AM. RESPIRATORY CAREPT REMAIN INTUBATED, and on vent support, thick yelow rusty sputm Sx,am RSBI 113 . slightly tachypneic on , incr to with good results. 7a-7p; Full assessment in flow sheet.neuro; A+OX3. PERL. continue to monitor I&o. lungs clear- left base, minimal secretions with sxn.Hemodynamics- cco pa in place- see flow sheet for #'s. ABG STABLE. dr. aware and in to see pt. extra ms04 dose of 2mg x1. FORRUSTY COLORED SPUTUM. STABLE ABG. start to wean vent today. CONDITION UPDATED: NEURO: ALERT AND APPEARS ORIENTED X 3. pt c/0 incisional pain. MSO4 1MG IVP FOR C/ /INCISION PAIN, PT LOCALIZING. max is 98.6. pa numbers are 30/14 and co is . incision continues to ooze serous/sanginous drainage. more diuresis today.r: doing well post transplant. DSD for JP site X3.skin intact."},"n_notes":{"kind":"number","value":58,"string":"58"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2147-10-18 00:00:00.000","description":"P ABDOMEN (SUPINE ONLY) PORT","row_id":802213,"text":" 5:27 AM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: please eval ileus vs obstruction\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p liver transplant with increasing abd dist\n REASON FOR THIS EXAMINATION:\n please eval ileus vs obstruction\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SINGLE FILM:\n\n HISTORY: Liver transplant and increasing abdominal distention.\n\n Gas is present throughout the colon and in the rectum. There are a few gas\n filled non-dilated loops of small bowel. No evidence for intestinal\n obstruction. The cecum is not undully dilated. NG tube is in cardia of\n stomach.\n\n IMPRESSION: No evidence for intestinal obstruction. Findings consistent\n with mild colonic ileus.\n\n\n"},{"category":"Radiology","chartdate":"2147-10-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":802214,"text":" 5:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, s/p liver\n transplant\n REASON FOR THIS EXAMINATION:\n pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant for hepatitis C cirrhosis. Evaluate\n pneumonic consolidation.\n\n FINDINGS: A single AP semiupright view. Comparison study dated . There is again evidence of left lower lobe collapse and consolidation and\n there has been slight resolution of the ill-defined infiltrate previously\n present in the partially aerated left upper lobe. There has also been slight\n resolution of the faint opacities in the right lower zone. The endotracheal\n tube, the NG line and the right IJ line remain in good position. The right IJ\n Swan-Ganz catheter tip is also well placed. No new pulmonary infiltrates are\n seen. Numerous skin staples overlie the left upper quadrant of the abdomen.\n\n IMPRESSION: Slight resolution of the infiltrates previously demonstrated in\n the left upper lobe and right lower zone. There is persistent left lower lobe\n collapse/consolidation. The heart shows slight LV enlargement but there is no\n evidence to indicate cardiac failure at this time.\n\n"},{"category":"Radiology","chartdate":"2147-10-25 00:00:00.000","description":"ERCP S&I (74330)","row_id":803599,"text":" 10:58 PM\n ERCP S&I () Clip # \n Reason: R/O anastomotic stricture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p OLTX 2 weeks ago. Now with increased LFTs and T-Tube\n cholangiogram showing anastomotic stricture.\n Exam performed , req sent \n REASON FOR THIS EXAMINATION:\n R/O anastomotic stricture\n ______________________________________________________________________________\n FINAL REPORT\n History of recent liver transplant with increasing liver function studies and\n tube cholangiogram demonstrating anastomotic stricture.\n\n Four fluoroscopic spot films are provided. There is contrast filling of the\n native and donor biliary ducts with evidence of a short segment of slightly\n irregular narrowing in the region of the anastomosis consistent with\n anastomotic stricture. No significant dilatation of visualized ducts proximal\n to the narrowing. Status-post placement of biliary stent bridging region of\n anastomotic stricture.\n\n"},{"category":"Radiology","chartdate":"2147-10-24 00:00:00.000","description":"CHALNAGIOGRAPHY VIA EXISTING CATHETER","row_id":802832,"text":" 7:51 AM\n CATH CHEK/REMV Clip # \n Reason: S/P OTL\n Admitting Diagnosis: LIVER FAILURE\n Contrast: OPTIRAY Amt: 10\n ********************************* CPT Codes ********************************\n * CHALNAGIOGRAPHY VIA EXISTING C TUBE CHOLANGIOGRAM *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Status post orthotopic liver transplant, two weeks previously.\n First tube check.\n\n REFERRING PHYSICIAN; Dr. .\n\n RADIOLOGISTS: Dr. .\n\n PROCEDURE/FINDINGS: An antegrade cholangiogram was performed with only 10 cc\n of Optiray 320 60%. There was poor transit of contrast material from the\n catheter through the anastomosis, with all contrast refluxing into the biliary\n tree. This was followed by injection of cc of saline, at which time,\n contrast was visualized in the common bile duct. The findings suggest\n significant stricture at the anastomosis. The cystic duct fills proximal to\n the anastomosis. The biliary ducts are relatively decompressed and smooth in\n appearance.\n\n IMPRESSION: Findings suggesting a significant stricture at the anastomosis.\n Findings were discussed with Dr. at the time of the study.\n\n\n\n"},{"category":"Radiology","chartdate":"2147-10-25 00:00:00.000","description":"DUPLEX DOPP ABD/PEL","row_id":803043,"text":" 3:03 PM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: eval portal vein, hepatic artery, & hepatic veins with B mod\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with history of hep C cirrhosis, s/p liver transplant, now\n with increasing bili.\n REASON FOR THIS EXAMINATION:\n eval portal vein, hepatic artery, & hepatic veins with B mode ultrasound please\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58 y/o man with history of Hep C cirrhosis status post liver\n transplant. Now with increasing bilirubin.\n\n LIVER ULTRASOUND: Comparison . The liver demonstrates normal echo\n texture without focal masses. There is normal direction of flow and waveforms\n within the portal vein, hepatic artery and hepatic veins. There is no\n ascites. There are no masses and there is no ascites.\n\n IMPRESSION: Doppler hepatic ultrasound demonstrates normal flow without\n evidence of mass or ascites.\n\n"},{"category":"Radiology","chartdate":"2147-10-17 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":802084,"text":" 3:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval interval change\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n please eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Hepatitis C-cirrhosis. S/P liver transplant. Evaluate for\n interval change.\n\n VIEWS: Supine AP view is compared with semi-erect AP view from .\n\n FINDINGS: The ET tube, NG tube, right IJ Swan-Ganz catheter, second right\n internal jugular central venous line, and right-sided subdiaphragmatic\n surgical drain all remain in stable and satisfactory position. There is\n slight LV enlargement and upper zone redistribution, which is probably related\n to the patient's supine positioning. There continues to be left lower lobe\n collapse/consolidation. There is no change in the bilateral ill-defined\n patchy opacities. There is now loss of translucency in the left upper lung\n zone with fluid seen tracking over the apex, consistent with a posterior\n layering pleural efffusion in this supine patient. No pneumothorax is\n identified.\n\n IMPRESSION:\n 1) Slight LV enlargement and upper zone redistribution which may be related to\n patient's supine positioning, although mild LV failure cannot be excluded.\n\n 2) Persistent left lower lobe consolidation/collapse.\n\n 3) Left-sided posteriorly layering pleural effusion.\n\n\n\n"},{"category":"Radiology","chartdate":"2147-10-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":801326,"text":" 12:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for any evidence of abdominal free air.\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, has multiple paracentesis.\n Please assess for any free air under diaphragm.\n REASON FOR THIS EXAMINATION:\n Please assess for any evidence of abdominal free air.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hepatitis C cirrhosis, multiple paracenteses, please assess for\n free air under the diaphragm.\n\n VIEWS: Single AP portable upright view, comparison dated .\n\n FINDINGS: No free intraperitoneal air. Previously seen left-sided PICC line\n remains in stable and satisfactory position. The heart size, mediastinal\n contours, and pulmonary vasculature appear unchanged without congestive heart\n failure. Minimal linear atelectasis at the left base. No areas of focal\n consolidation. No pneumothorax. The visualized osseous structures are\n unchanged.\n\n IMPRESSION: No radiographic evidence of intraperitoneal free air. Minimal\n left lower lobe atelectasis.\n\n"},{"category":"Radiology","chartdate":"2147-10-09 00:00:00.000","description":"US ABD LIMIT, SINGLE ORGAN","row_id":801344,"text":" 3:16 PM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: Left lower quadrant tenderness, please rule out haematoma.\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with history of hep C cirrhosis, comes with rising bilirubin,\n worsening INR. Has had multiple paracentesis in the LLQ.\n REASON FOR THIS EXAMINATION:\n Left lower quadrant tenderness, please rule out haematoma.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hepatitis C cirrhosis with multiple prior paracenteses and pain\n in the left lower quadrant.\n\n LIMITED ABDOMEN ULTRASOUND: Selective evaluation was performed of the left\n lower quadrant. A moderate amount of ascites is present. No fluid\n collections are identified within the abdominal wall. The visualized loops of\n bowel are unremarkable.\n\n IMPRESSION:\n\n 1) Ascites.\n\n 2) No evidence of a hematoma.\n\n\n"},{"category":"Radiology","chartdate":"2147-10-04 00:00:00.000","description":"UD GUID FOR NEEDLE PLACMENT","row_id":800887,"text":" 12:35 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Patient with advanced liver disease and INR 3+ needs venous\n Admitting Diagnosis: LIVER FAILURE\n ********************************* CPT Codes ********************************\n * UD GUID FOR NEEDLE PLACMENT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with liver failure from Hep C and likely SBP.\n REASON FOR THIS EXAMINATION:\n Patient with advanced liver disease and INR 3+ needs venous access for contrast\n MRI in anticipation of liver transplant. Has PICC but can't use for MRI\n contrast. No obvious peripheral access. Need is only temporary to facilitate\n study -- ext jugular or IJ or whatever you feel appropriate. Thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Liver failure from Hep-C. Likely SBP, INR greater than 3.\n Pulmonary medicine not able to place central line. Needs a peripheral IV to\n perform an MRI study.\n\n RADIOLOGISTS PERFORMING PROCEDURE: Dr. , Dr. ,\n staff radiologist supervised the procedure.\n\n PROCEDURE/TECHNIQUE: Ultrasound guidance was provided for placement of an 18\n gauge angiocatheter into the right antecubital vein. The angiocath was\n secured to the skin using Tegaderm and steristrips. The patient was sent to\n MRI for their injection.\n\n IMPRESSION: Successful placement of an 18 gauge angiocath in the right\n antecubital vein.\n\n"},{"category":"Radiology","chartdate":"2147-10-06 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":801044,"text":" 12:21 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: H/O ASCITES, CIRRHOSIS, HEP C. ? PERFORATION.\n Admitting Diagnosis: LIVER FAILURE\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with Hep C decompensated cirrhosis and ascites, s/p three\n paracentesis showing SBP. Also developing hepatorenal syndrome. Please give\n oral Gastrograffin contrast.Thank You.\n REASON FOR THIS EXAMINATION:\n Please evaluate for perforated bowel\n CONTRAINDICATIONS for IV CONTRAST:\n Developing Hepatorenal Syndrome\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Decompensated cirrhosis and ascites with SVP by paracentesis x 3.\n Assess for perforated bowel.\n\n Comparison: CT abdomen and pelvis and ultrasound \n\n TECHNIQUE: Contiguous axial images through the abdomen and pelvis were\n obtained following the administration of oral contrast. Intravenous contrast\n was not used due to patient's history of renal failure.\n\n ABDOMEN: There are dependent changes at both lung bases. There are no pleural\n effusions. The liver is samll, with a slightly nodular contour consistent with\n cirrhosis. There is a large amount of ascites within the abdomen. At least two\n gallstones are noted within the gallbladder. There are at least four stones\n within the left kidney, the largest of which measures 1.7 cm in greatest\n dimension and is located within the renal pelvis. No right-sided kidney stones\n are seen. The adrenal glands are not well visualized due to the ascites. The\n pancreas is grossly unremarkable within the limits of this unenhanced scan.\n Incomplete distension of right colon makes evaluation for previously described\n wall thickening limited. Contrast material passes to the level of the colon\n without obstruction. There is stool within the terminal ileum.\n\n PELVIS: There is a large amount of fluid within the pelvis. The bladder is\n unremarkable. Anasarca is present. There is no inguinal or pelvic lymph\n adenopathy.\n\n Bone windows: There are no suspicious lytic or sclerotic bony lesions.\n\n CT RECONSTRUCTIONS: These images confirm the above findings.\n\n IMPRESSION:\n No evidence of bowel perforation. Large amount of ascites. Thickening within\n the transverse and right colon as previously described difficult to confirm\n in view of incomplete distension of colon.\n\n (Over)\n\n 12:21 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: H/O ASCITES, CIRRHOSIS, HEP C. ? PERFORATION.\n Admitting Diagnosis: LIVER FAILURE\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2147-10-06 00:00:00.000","description":"PERSANTINE MIBI","row_id":801057,"text":"PERSANTINE MIBI Clip # \n Reason: CAD.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CAD.\n\n SUMMARY OF EXERCISE DATA FROM THE REPORT OF THE EXERCISE LAB:\n Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142\n mg/kg/min. Two minutes after the cessation of infusion, Tc-m sestamibi was\n administered IV.\n\n INTERPRETATION:\n\n Image Protocol: Gated SPECT.\n\n Resting perfusion images were obtained with thallium-201.\n Tracer was injected 15 minutes prior to obtaining the resting images.\n\n Stress images show normal left ventricular cavity size. There is normal tracer\n distribution and intensity.\n\n Resting perfusion images show no abnormality.\n\n Ejection fraction calculated from gated wall motion images obtained after\n Dipyridamole administration is 61%. There is normal wall motion.\n\n IMPRESSION: Normal pharmacological stress test. There is normal wall motion\n with an EF of 61%.\n\n /nkg\n\n\n , M.D.\n , M.D. Approved: MON 11:19 AM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"},{"category":"Radiology","chartdate":"2147-10-06 00:00:00.000","description":"CHEST (PA & LAT)","row_id":801126,"text":" 8:20 PM\n CHEST (PA & LAT) Clip # \n Reason: Please evaluate for infiltrative process in pt growing Strep\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with decompensated Hep C cirrhosis with increasing bili,\n developed increased ascites and worsened liver function found to have SBP\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrative process in pt growing Strep Pneumo in ascitic\n fluid\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 50 y/o man with decompensated Hepatitis C cirrhosis. Please evaluate\n for infiltrative process in patient now growing strep.\n\n PA AND LATERAL CHEST: Comparison is made to prior chest exam of six days\n earlier. There is a left subclavian central venous catheter in place with its\n tip in the superior vena cava. There is no evidence of a pneumothorax. The\n patient has taken a poor inspiration and there is compressive atelectasis at\n both bases. I cannot rule out pneumonia.\n\n IMPRESSION: Expiratory film. No definite pneumonia. Compressive atelectasis\n at both bases.\n\n"},{"category":"Radiology","chartdate":"2147-10-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":801648,"text":" 12:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm line replacement\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n confirm line replacement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51 y/o man with history of hepatitis C and cirrhosis s/p liver\n transplant.\n\n Confirm line replacement.\n\n FINDINGS: An AP portable study of the chest at 12:29 HR and is compared with\n the previous study that was obtained at 5:10 a.m. The tip of the ETT is way\n above the carina. The left subclavian CVP line remains in place, the tip is in\n the superior vena cava. The tip of the Swan-Ganz catheter is in the right\n lower lobe branch of the right pulmonary artery at this time. Another right\n subclavian CVP line is in place the tip is in the right atrium at this time.\n Massive left pleural effusion is noted unchanged since the previous study. NG\n tube also remains in place.\n\n IMPRESSION: There has been advancement of the Swan-Ganz catheter to the right\n lower lobe branch of the pulmonary artery at this time. Also there has been\n advancement of the right subclavian CVP line the tip is in the right atrium at\n this time. The tip of the ETT is in proper position. The tip of the NG tube is\n in the mid gastric body.\n\n Massive right pleural effusion unchanged.\n\n"},{"category":"Radiology","chartdate":"2147-09-30 00:00:00.000","description":"LIVER OR GALLBLADDER US (SINGLE ORGAN)","row_id":800502,"text":" 10:24 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Please evaluate for any liver mass, any evidence of vascular\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with history of hep C cirrhosis, comes with rising bilirubin,\n worsening INR.\n REASON FOR THIS EXAMINATION:\n Please evaluate for any liver mass, any evidence of vascular\n obstruction/thrombosis. Please also mark area for paracentesis. Thank you.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hx of hepatitis C cirrhosis now with rising bilirubin and\n worsening INR.\n\n RIGHT UPPER QUADRANT US: Limited evaluation was performed focusing on the\n liver, gallbladder, and bile ducts. A moderate amount of ascites is present in\n the abdomen. The liver is small and has a irregular contour consistent with\n cirrhosis. No focal masses are appreciated. The gallbladder is enlarged and\n there is a small amount of pericholecystic fluid. Sludge is present at the\n base of the gallbladder. There is no intra or extrahepatic ductal dilatation.\n There is normal portal venous flow.\n\n All four quadrants of the abdomen were imaged and a spot was marked in the\n left lower quadrant for paracentesis to be performed by the primary service.\n\n IMPRESSION:\n\n 1) Cirrhotic liver, without focal masses.\n 2) An enlarged gallbladder with pericholecystic fluid. These findings were\n observed on prior CT of and are likely related to the patient's\n chronic liver disease.\n 3) Sludge within the gallbladder.\n 4) A spot was marked in the left lower quadrant for paracentesis to be\n performed by the clinical service.\n\n\n"},{"category":"Radiology","chartdate":"2147-10-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":801832,"text":" 10:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n f/u\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: History of Hepatitis C cirhorris. status post liver transplant.\n\n CHEST, SINGLE AP VIEW\n\n An ET tube is present in satisfactory position 3.7 cm above the carina. Right\n IJ central line is present with tip over distal SVC. Right IJ swan ganz\n catheter is present with tip over right pulmonary artery. There is probably\n mild cardiomegaly. There are patchy alveolar opacities throughout both lungs\n most pronounced in the left mid and upper zones and right base. Possible small\n effusion but tracking left effusion seen on appears to have become\n much smaller. An NG tube is present with tip beneath diaphragm off film.\n Multiple upper abdominal surgical staples are noted.\n\n IMPRESSION:\n\n 1) Lines and tubes as described. Left subclavian line and PICC line have been\n removed in the interval.\n 2) Patchy alveolar opacity including new or progressed right sided opacity.\n Differential diagnosis includes atypical distribution of CHF, pneumonic\n infiltrate and ARDS.\n\n"},{"category":"Radiology","chartdate":"2147-10-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":801955,"text":" 5:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for pna\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n please eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Hepatitis C-cirrhosis. S/P liver transplant. Ck. for pneumonia.\n\n SINGLE AP SEMI-URIGHT VIEW: Comparison: .\n\n The heart again shows slight LV enlargement. There is evidence of upper zone\n redistribution. Bilateral ill-defined pulmonary infiltrates are again noted,\n significantly resolved since the prior study. There is persistent left lower\n lobe collapse/consolidation behind the heart. The left CP angle remains\n blunted suggesting a small effusion on this side. The right CP angle is\n sharp. The ET tube, right IJ Swan-Ganz catheter and the NG line all remain in\n good position. A second right IJ central line has its tip probably in the\n mid-SVC. There is a surgical drain beneath the right diaphragm.\n\n IMPRESSION:\n 1) Stable lines in satisfactory position.\n\n 2) Partly resolved pulmonary infiltrates bilaterally, consistent with\n resolving pulmonary edema.\n\n 3) Persistent left lower lobe collapse/consolidation.\n\n 4) Residual left effusion.\n\n 5) Subdiaphragmatic right upper quadrant drain.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2147-10-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":801716,"text":" 4:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: follow effusions, consolidations\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n follow effusions, consolidations\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hep C cirrhosis s/p liver transplant following effusions and\n consolidation.\n\n VIEWS: Single AP portable supine view, comparison dated .\n\n FINDINGS: The ETT, NG tube, right IJ venous access catheter, and left\n subclavian venous access catheter remain in stable and satisfactory position.\n Left sided PICC line terminates in left brachiocephalic vein. Pulmonary artery\n catheter enters via the right internal jugular parallel to the separate venous\n access catheter, the tip appears to have been pulled back and now terminates\n in the proximal right main pulmonary artery. The heart size and mediastinal\n contours are unchanged. Slightly decreased aeration of both lungs. Persistent\n large layering pleural effusion appears somewhat increased in size. No\n pneumothorax. 2 tubular opacities, metallic skin staples, and surgical clips\n are seen overlying the upper abdomen.\n\n IMPRESSION: 1) Satisfactory position of lines and tubes. 2) Slightly increased\n size of large left pleural effusion with decreased aeration of both lungs.\n\n"},{"category":"Radiology","chartdate":"2147-10-11 00:00:00.000","description":"DUPLEX DOPP ABD/PEL","row_id":801545,"text":" 1:26 PM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: assess liver transplant for intra and extrahepatic doppler f\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with history of hep C cirrhosis, s/p liver transplant\n REASON FOR THIS EXAMINATION:\n assess liver transplant for intra and extrahepatic doppler flow of hep art,\n portal vein, and hepatic veins as well as us of livers/p liver transplant\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status-post liver transplant.\n\n FINDINGS: The transplant liver demonstrates normal echogenicity. No\n intrahepatic biliary ductal dilatation.\n\n The main portal vein, as well as left and right portal veins demonstrate\n patency with proper direction of flow. The main hepatic vein, as well as the\n left and right hepatic veins demonstrate patency with proper direction of\n flow. The main hepatic artery and left hepatic artery demonstrate patency with\n proper direction of flow. The IVC is patent.\n\n IMPRESSION:\n Patent vasculature to the transplant liver.\n\n"},{"category":"Radiology","chartdate":"2147-10-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":801608,"text":" 5:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: follow for ?chf/ards\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n follow for ?chf/ards\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH:\n\n INDICATION: Continued shortness of breath post liver transplant.\n\n Comparison is made to a study from the prior day.\n\n FINDINGS:\n\n A PA catheter placed via the right IJ terminates in the main pulmonary artery.\n A right IJ cordis terminates in the distal right brachiocephalic vein. A\n left-sided subclavian catheter terminates in the upper SVC. The ETT is 4 cm\n above the carina.\n\n There is stable cardiomegaly with slight worsening of vascular indistinctness\n and engorgement. A right-sided pleural effusion has increased in size. The\n left-sided effusion appears stable. There is persistent opacification in the\n retrocardiac region. There are no new areas of consolidation.\n\n IMPRESSION:\n\n 1) Worsening of CHF and pulmonary edema.\n\n 2) Stable left lower lobe atelectasis.\n\n"},{"category":"Radiology","chartdate":"2147-10-04 00:00:00.000","description":"MR ABDOMEN W&W/O CONTRAST","row_id":800866,"text":" 3:42 PM\n MR ABDOMEN W&W/O CONTRAST Clip # \n Reason: Please evaluate liver in pt with decomensated Hep C cirrhosi\n Admitting Diagnosis: LIVER FAILURE\n Contrast: MAGNEVIST Amt: 20CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with Hep C cirrhosis, DM, Migraine's, presents with elevated\n bili and decompensation\n REASON FOR THIS EXAMINATION:\n Please evaluate liver in pt with decomensated Hep C cirrhosis, evaluating for\n transplant. Please hepatic vasculature, volumetrics, gadolinium for hepatoma,\n and MRC for question of obstruction.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Cirrhotic patient. Evaluate for pretransplant.\n\n MRCP AND MRI OF THE ABDOMEN:\n\n TECHNIQUE: MRI of the abdomen was performed with multiplanar T1 in and out\n of phase, STIR, HASTE, 2D time of flight, thick slabs of T2W and dynamic T1W\n with fat saturated sequences before and after the administration of\n gadolinium. Multiplanar reconstruction was performed at the workstation.\n\n COMPARISON: CT of .\n\n FINDINGS: Images are acquired by non-breath hold technique, therefore\n degrading image quality. The liver is diffusely nodular with enlargement of\n the caudate lobe, consistent with cirrhosis. No focal hepatic enhancing\n lesions are identified. The portal vein is patent with hepatopetal flow. The\n origin of the celiac artery is not well visualized. Distinct right and left\n hepatic arteries are visualized. There is no evidence for an aberrant hepatic\n artery. There is a patent peri-umbilical vessel. The gallbladder remains\n distended containing gallstones. There is minimal pericholecystic fluid. The\n liver volume is 1690 cc.\n\n The pancreas is unremarkable. The spleen is enlarged, measuring at least 14\n cm. There is lymphadenopathy around the celiac axis. There is a large amount\n of intra-abdominal ascites.\n\n Within the visualized kidney, there is a single right cortical cyst. A 6 mm\n dark focus is noted within the left collecting system, correlating to a stone\n within the renal pelvis. There is no evidence of hydronephrosis. Peripelvic\n cysts are present in the left renal pelvis.\n\n Multiplanar reconstructed images were essential for confirming the vascular\n anatomy and establishing the liver volume.\n\n IMPRESSION:\n\n 1. Cirrhotic liver. No evidence for an arterial enhancing lesion or aberrant\n anatomy. Liver volume = 1690 cc's.\n (Over)\n\n 3:42 PM\n MR ABDOMEN W&W/O CONTRAST Clip # \n Reason: Please evaluate liver in pt with decomensated Hep C cirrhosi\n Admitting Diagnosis: LIVER FAILURE\n Contrast: MAGNEVIST Amt: 20CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Splenomegaly, ascites and patent umbilical vessel; findings consistent with\n portal hypertension.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2147-10-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":801488,"text":" 6:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: central line\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\n REASON FOR THIS EXAMINATION:\n central line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hepatitis C cirrhosis. Status post liver transplant. Check\n central line.\n\n TECHNIQUE: Single AP portable supine view.\n\n Comparison study dated .\n\n FINDINGS: An endotracheal tube terminates with tip 7.6 cm above the carina\n and located above the thoracic inlet. Nasogastric tube extends below the\n diaphragm with tip terminating in the distal stomach. Right internal jugular\n sheath terminates in upper SVC. Pulmonary artery catheter enters via the\n right internal jugular vein parallel to the sheath and terminates with tip in\n the main pulmonary artery. Left subclavian venous access catheter terminates\n in upper SVC. Large left pleural effusion layers posteriorly and tracks to\n the apex. Left retrocardiac opacity with obscuration of left hemidiaphragm.\n The heart size and mediastinal contours appear unchanged without cardiac\n failure. No pneumothorax. Note is made of a drain in the right upper\n quadrant, and surgical clips and metallic skin staples overlying the right\n upper quadrant and upper abdomen.\n\n IMPRESSION:\n\n 1) Endotracheal tube tip terminates above level of the thoracic inlet. Other\n lines and tubes in satisfactory position. Large left pleural effusion and left\n lower lobe collapse and/or consolidation. No pneumothorax. Findings were\n communicated to the clinical team at time of interpretation.\n\n"},{"category":"Radiology","chartdate":"2147-10-03 00:00:00.000","description":"CVL/PICC","row_id":800803,"text":" 4:56 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: IV nurse for bedside PICC, but highly unlikely t\n Admitting Diagnosis: LIVER FAILURE\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with cirrhosis, possible SBP, requires albumin, may need\n antibiotics.\n REASON FOR THIS EXAMINATION:\n IV nurse for bedside PICC, but highly unlikely to be successful.\n Will call when confirmed.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: No IV access requiring IV antibiotics.\n\n RADIOLOGISTS: Dr. and Dr. , the staff radiologist,\n was present throughout the entire procedure.\n\n PROCEDURE/TECHNIQUE: Patient was placed supine on the angiography table with\n the left arm prepped and draped in the usual sterile fashion. Through an\n anesthetized skin approach utilizing realtime ultrasound guidance a micro-\n puncture set was used to access the left brachial vein. The measuring wire was\n advanced into the distal superior vena cava. The needle was then exchanged for\n the micropuncture dilator and peel-away sheath. The catheter was then\n appropriately sized to 38 cm. The inner dilator was removed. The catheter was\n then advanced over the wire into the distal SVC. The peel-away sheath was\n removed. The catheter was secured to the skin.\n\n Post procedure x-ray was performed and confirmed position within distal\n superior vena cava.\n\n CONTRAST/MEDICATIONS: 2 cc of 1% lidocaine for local anesthetic.\n\n COMPLICATIONS: None.\n\n IMPRESSION: Successful placement of a 38 cm single lumen vaxcel catheter in\n the distal superior vena cava via the left brachial vein.\n\n\n\n"},{"category":"Radiology","chartdate":"2147-10-09 00:00:00.000","description":"US ABD LIMIT, SINGLE ORGAN","row_id":801347,"text":" 3:40 PM\n US ABD LIMIT, SINGLE ORGAN; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: Please mark spot for paracentesis. Thank you.\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with history of hep C cirrhosis, comes with rising bilirubin,\n worsening INR. Has had multiple paracentesis in the LLQ.\n REASON FOR THIS EXAMINATION:\n Please mark spot for paracentesis. Thank you.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ascites.\n\n LIMITED ABDOMEN ULTRASOUND: All four quadrants of the abdomen were imaged and\n a spot was chosen in the suprapubic midline region for paracentesis. The spot\n was marked.\n\n IMPRESSION: Spot marked in the midline suprapubic region for paracentesis to\n be performed by the clinical team.\n\n The referring physician, . , was contact following the examination.\n\n\n"},{"category":"Radiology","chartdate":"2147-10-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":801865,"text":" 5:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u of morning cxr after diuresis\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n f/u of morning cxr after diuresis\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: S/P liver transplant for hep C cirrhosis. ? response to diuresis.\n\n CHEST, SINGLE AP PORTABLE UPRIGHT VIEW: Lordotic positioning.\n There are confluent opacities in a patchy distribution, but diffuse throughout\n both lungs. The left CP angle is obscured, suggesting a small pleural\n effusion. There is increased retrocardiac density. No gross right effusion\n is identified. Probable mild upper zone redistribution. Heart size upper\n limits of normal or slightly enlarged. Skin staples and right upper quadrant\n drain present. ET tube in satisfactory position above carina. NG tube with\n tip beneath diaphragm.\n\n IMPRESSION:\n 1) Patchy confluent alveolar opacities throughout both lungs with largest\n area of confluent opacity at left base. While this could represent residual\n alveolar edema, the possibility of multifocal infectious infiltrate or ARDS\n should be considered. Please note that, on the right side, these opacities\n have relatively peripheral distribution.\n\n\n\n"},{"category":"Radiology","chartdate":"2147-10-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":801893,"text":" 4:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u after diuresis\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n f/u after diuresis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hep C cirrhosis status post liver transplant. Follow up after\n diuresis.\n\n CHEST, SINGLE AP PORTABLE VIEW:\n\n There is probable mild cardiomegaly. There is diffuse alveolar opacity, more\n confluent than on the film from one day earlier. There is a probable small\n left pleural effusion. There is increased retrocardiac density. The ET tube\n tip is at the level of the upper clavicular heads, slightly high, 6.9 cm from\n the carina. NG tube is present, tip in the diaphragm. A SG catheter is\n present, tip over right pulmonary artery. An additional right IJ line appears\n present, but tip is obscured. No pneumothorax was detected.\n\n IMPRESSION:\n\n Confluent alveolar opacity diffusely throughout both lungs, with small left\n effusion. Most likely etiology is alveolar edema. This appears more\n extensive than on the film from one day earlier.\n\n Left lower lobe collaspe and/or consolidation, unchanged.\n\n Relatively high position of the ET tube. Clinical correlation regarding\n possible advancement is requested.\n\n\n"},{"category":"Echo","chartdate":"2147-10-02 00:00:00.000","description":"Report","row_id":102839,"text":"PATIENT/TEST INFORMATION:\nIndication: Murmur.\nHeight: (in) 69\nWeight (lb): 175\nBSA (m2): 1.95 m2\nBP (mm Hg): 134/72\nStatus: Inpatient\nDate/Time: at 16:03\nTest: TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter. The aortic arch is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: Mild (1+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: No tricuspid regurgitation is seen. The pulmonary artery\nsystolic pressure could not be determined.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. Mild (1+)\nmitral regurgitation is seen. The pulmonary artery systolic pressure could not\nbe determined. There is no pericardial effusion.\n\n\n"},{"category":"ECG","chartdate":"2147-10-19 00:00:00.000","description":"Report","row_id":313229,"text":"Sinus rhythm. T wave inversions in leads V1-V2 are non-specific and could be in\npart, positional. Clinical correlation is suggested. Since the previous tracing\nof right precordial T wave changes are seen.\n\n"},{"category":"Nursing/other","chartdate":"2147-10-11 00:00:00.000","description":"Report","row_id":1421784,"text":"nsg note\nPt is s/p liver transplant:\n\nNeuro- propofol off on arrival from OR this am at 615- waking up by 11 am and beginning to follow some simple command. agitation at times, mso4 2 mg ivp q1 prn. 3 pm becoming extremly agitated, swinging head and kicking legs with attempts to get oob, attempting to hit staff, req 3 assist to prevent from extubating or pulling out pa line, transplant notified and propofol gtt started, cont agitated and attempt to pull at ett, (bilat swr on)- trnasplant to restart methadone as pt was on it preop.\n\nRenal- uo 50- 110 hr, cr 1.6, ivf 100hr.\n\nEncocrine- glucose as high as 340, insulin gtt with prn insulin bolus, to get glucsoe <130, glucose at 3 pm 108, cont 2 u insulin gtt/hr, chemsticks q1.\n\nLiver u.s done at bedside, all labs done q4 pr md orders, rec 3 prbc, 6 ffp and 1 5pk platelet this shift, jp x2, t tube to gravity.\nPa line in place, c.0 , see flow sheet for all other #s\n"},{"category":"Nursing/other","chartdate":"2147-10-12 00:00:00.000","description":"Report","row_id":1421785,"text":"NURSING UPDATE\n TMAX 99, HR 70'S NSR, SLIGHT HTN SBP 170'S. CCO ELEVATED 8.8-10.8, SVR DIMINSHED 688-880.\n TRANSFUSED WITH 1U PRBC'S, FOLLOW UP HCT 31. PLTS 73, TX WITH 1 5-PACK PLATELETS, FOLLOW UP PLTS 89, DR AWARE, PLAN TO TRANSFUSE ANOTHER 5-PACK WHEN AVAILABLE. DR AWARE OF DIMINISHED K+ AND MG+ LEVELS, NO REPLETIONS ORDERED. BLOOD GLUCOSE MANAGED ON INSULIN GTTS.\n VERY AGITATED EARLY EVENING, ATTEMPTING TO SIT UP IN BED AND CONSTANTLY TRYING TO REACH ETT, IV'S AND DRAINS EVEN THOUGH RESTRAINED. PROPOFOL GTTS INITIALLY INCREASED AND MSO4 2MG ADMINISTERED IV Q2 PER PRN ORDER. ON THIS REGIMEN, WAS ABLE TO WEAN PROPOFOL DOWN TO DESIRED RATE OF 55MCG/KG/MIN AND MAINTAIN AS SAME. BRIEF BREAKTHROUGH PERIODS OF AGITATION AND RESTLESSNESS THROUGHOUT NOC, BUT MUCH MORE MANAGEABLE, AND ENVIRONMENT SAFER FOR PT AND STAFF. PT OPENING EYES AND FOLLOWING COMMANDS INCONSISTENTLY. SHAKING/NODDING HEAD IN RESPONSE TO QUESTION @ TIMES ALSO.\n MODERATE AMOUNT OF SEROSANG DRAINAGE AROUND LATERAL JP(#2) SITE, DRESSING CHANGED X2. DRAINS STRIPPED AND EMPTIED Q2.\n\n"},{"category":"Nursing/other","chartdate":"2147-10-12 00:00:00.000","description":"Report","row_id":1421786,"text":"Resp Care: Pt remains on vent,SIMV/PS with the only changes to the RR.\nPt's RR was decreased from 12 to 8 without incident,ABG is within normal limits.B/S coarse and sl decreased with sct rhonchi.The plan is\nto continue wean.\n"},{"category":"Nursing/other","chartdate":"2147-10-12 00:00:00.000","description":"Report","row_id":1421787,"text":"nsg progress note\nNeuro- sedated with propofol gtt, withdraws to pain, weaning propofol as tol this pm, cont mso4 1 mg prn q1, methadone changed to 45 mbg , psych svc by to see pt this am.\n\nResp- failed cpap trial this am as rr up to 40, return to simv, abg wnl, minimal secretions with sxn, lungs cta bilat. will attempt to wean to cpap again in am.\n\nHemodynamics- pa advanced to 55, pcwp 14-17. cvp 9-13, rec lasix 40 mg iv x2. See flow sheet for u.o.\n\nLft's cont to decrease, hct, platelet and inr all within transplant team acceptable range so no blood products this shift.\n\nNutrition- npo, hypo bs, tpn started.\n"},{"category":"Nursing/other","chartdate":"2147-10-18 00:00:00.000","description":"Report","row_id":1421811,"text":"CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nASSUMED CARE OF PT AT APPROX 1600.\nNEURO: ALERT AND ORIENTED X3. MEDICATED WITH MSO4 FOR ABD PAIN WITH POS EFFECT. PT NOW C/O GAS PAIN. TRANSPLANT TEAM INFORMED.\nRESP: LS CLEAR BUT DIM AT BASES. PT . O2SATS 98-100% ON 3LNC. IS GIVEN TO PT AND INSTRUCTED, BUT UNABLE TO USE CURRENTLY D/T GAS PAIN.\nCV: AFEBRILE. NSR. +PP'S. HYDRALAZINE/LOPRESSOR CONTINUE. PA CATH D/C'D EARLIER TODAY.\nGI: ABD DISTENDED. POS BOWEL SOUNDS. GAS PAIN. DK GOLDEN BILE VIA T-TUBE. SEROSANG DRG VIA MEDIAL JP.\nGU: AMBER U/O VIA FOLEY.\nENDO: FSBG COVERED PER RISS.\nPLAN: ENCOURAGE T/C/DB AND IS USE. INCREASE ACTIVITY. ?DULC SUPP V. ENEMA (AWAITING ORDERS FROM TRANSPLANT). CONT PER CURRENT MGMT.\n"},{"category":"Nursing/other","chartdate":"2147-10-19 00:00:00.000","description":"Report","row_id":1421812,"text":"CONDITION UPDATE\nVSS. PT A/OX3. FREQUENT C/O ABD PAIN - TX'D W/ MORPHINE W/ EFFECT. THIS A.M. C/O CPAIN - RADIATING \"DOWN MIDDLE OF CHEST\". TXPLANT RESIDENT, DR. NOTIFIED. EKG ORDERED AND DONE. M.D. NO CHANGE IN EKG NOTED. NGT TO LWCS - MIN CLEAR DRAINAGE OUT. LUNGS CTA BILAT. O2 SAT GOOD ON 3L N.P. ABD SOFTLY DISTENDED. BOWEL SOUNDS PRESENT. PT C/O FREQUENT GAS PAIN. FLEETS ENEMA GIVEN X1, DULCOLAX ENEMA GIVEN X1 - SMALL BOWEL MOVEMENT. PT W/ 40MG IV LASIX W/ GOOD EFFECT. REMAINS ON INSULIN DRIP - BSUGARS LABILE. CONT TPN. CONT TO ASSESS FOR S/S OF INFECTION/ BLEEDING. PAIN MANAGEMENT. PT TEACHING. CONT CURRENT ICU CARE AND ASSESSMENT. D/C PLANNING.\n"},{"category":"Nursing/other","chartdate":"2147-10-11 00:00:00.000","description":"Report","row_id":1421782,"text":"Pt rec'd at approx. 0600 following liver transplant. Pt placed on CMV 700,12,100, 5 peep. ABG results pending.\n"},{"category":"Nursing/other","chartdate":"2147-10-11 00:00:00.000","description":"Report","row_id":1421783,"text":"Respiratory note:\nPt is intubated/agitated. ETT advanced in 2cm and taped at 25cm at the lip. Noted to have frequent cuff leak.Tol psv trial on ps 20/5 peep for a while with good abg but than tachypenic with RR up to back on simv. Will obtain ABG on current simv 750x12,50%,5peep,0ps.Will cont vent support and wean as tol to extubate.\n"},{"category":"Nursing/other","chartdate":"2147-10-17 00:00:00.000","description":"Report","row_id":1421806,"text":"resp care:pt remains intubated and vented at this time with no resp distress noted.b/s diminished bilat,secretions minimal.present vent settings ps10 peep5 40% and tol well.will cont to re-assess as needed and wean as tolerated\n"},{"category":"Nursing/other","chartdate":"2147-10-17 00:00:00.000","description":"Report","row_id":1421807,"text":"Condition Update\nD: See carevue for specifics\n Swan remains in place with CCO monitoring. Afebrile. HR 60's NSR no ectopy. BP 140's/60's. CVP 6-8. For today the plan was to continue to diurese patient. Pt received 40mg lasix this am with good diuresis. Currently -2L for the day. Transplant team wanting pt more negative prior to making any major vent changes. However patient tolerating vent changes well and as previously mentioned is -2L for the day. AM RSBI 40's. ABG's stable throughout day. Beginning to developed compensated resp acidosis. Gradually decreased vent to current settings of CPAP with 10PS, 5PEEP, FIO2 40%, RR 16-20, with spont tidal volumes 500's. Minimal secretions in afternoon in am noted to have some thick yellow.\n Transplant resident plans to D/C lateral drain this eve (putting out min amts), no change in color other JP or Ttube. NGT cont to LCWS with clear output. ABD dressing leaking ?from around lateral tube site (serous).\n Pt comfortable and reporting good pain control with MSO4 4mg Q3-4hrs. A/Ox3. MAE.\n Continues on insulin gtt for blood sugar control. Titrated to maintain BS btwn 80-120. Cont on TPN for nutrition.\nPLAN:\n Check with transplant team re: goal for diuresis\n Wean vent as tol\n Cont pain management with MSO4\n Frequent blood sugars\n Notify H.O. with any changes.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2147-10-18 00:00:00.000","description":"Report","row_id":1421808,"text":"Respiratory Care:\nPt. had a quiet noc untill about 5 am when he C/O pain and discomfort.\nRn gave pain meds.\nPt's RSBI = 25 and was subsequently placed on a spontanious breathing trial. up to two hours if tolerated.\n"},{"category":"Nursing/other","chartdate":"2147-10-18 00:00:00.000","description":"Report","row_id":1421809,"text":"7p-7a; Full assessment in flow sheet.\n\nneuro; A+OX3. MAE. mouth words. Follow commands. Pain in abd. Inc pain in AM - HO and transplant MD notify - KUB and Biscodyl supportory order and done. Morphine ivp effective.\n\ncv; VSS, afebrile. CVP 6-8. Svo 2 80-88. CCO 7.2-9.8 (HO and neurosurg notify.). Swan unable to wedge - Dr. notify.\n\nresp; Clear in upper lobes. dimish at bases. CPAP 10/5 tolerate, do not breath over vent. Encourage deep breath and cough - productive cough thick/white sputum.\n\ngu/gi; soft distended abd. Tender in am on light palpation (HO notify). +BSX4. KUB done. no flatus. no bm. JP medial - site d/c/i - serosangious drainge. T-bile - bilious. NG - +placement, clear drainage. suture site d/c/i.\n\nint; Skin intact. Insulin drip titrate 80-120. AM lab done - potassium replace.\n\nPlan; Continue to monitor.\n"},{"category":"Nursing/other","chartdate":"2147-10-18 00:00:00.000","description":"Report","row_id":1421810,"text":"Respiratory Care Note:\n Patient weaned and extubated today. BS with good aeration. Cough and voice intact. SpO2 100% on 40% FIO2 and plan to wean as tolerated and use of incentive spirometer.\n"},{"category":"Nursing/other","chartdate":"2147-10-16 00:00:00.000","description":"Report","row_id":1421800,"text":"condition update\nD: pt alert and oriented. he follows commands. temp. max is 98.6. pa numbers are 30/14 and co is . svo2 remains 76-80. pt more comfortable on 4mg of ms04 requiring it appoximately every 2 hours. abgs remain good on simv. urine output remains greater than 100cc/hr and pt was 1800 neg for past 24hrs. sbp still greater than 200 after starting on lopressor and being medicated with ms04 for pain. dr. aware and pt given hypralozine 10mg x 2. sbp to 180-190. pt suctioned frequently for thick yellow sputum. incision continues to ooze serous/sanginous drainage. lateral jp drainage appears more bloody this evening. dr. aware and in to see pt. insuling drip titrated for blood sugars. pt is currently on 1unit/hour. platelet count 71. pt transfused with one unit of platelets.\na: monitor fluid status. medicate for pain as needed. continue to monitor jp drainage. ? start to wean vent today. ? more diuresis today.\nr: doing well post transplant. post transfusion count 98. pt appears more comfortable today on 4mg of ms04 for pain. jp continue to put out bloody drainage but amt has not increased. Approximately 20cc. dr. aware.\n"},{"category":"Nursing/other","chartdate":"2147-10-16 00:00:00.000","description":"Report","row_id":1421801,"text":"RESPIRATORY CARE\nPT REMAIN INTUBATED, and on vent support, thick yelow rusty sputm Sx,am RSBI 113 .\n"},{"category":"Nursing/other","chartdate":"2147-10-16 00:00:00.000","description":"Report","row_id":1421802,"text":"See CareVue for objective data.\n\nVent settings changed to 15 PS/8PEEP. Tolerated well and ABG's adequate. RSBI 113 this AM and probable extubation in AM. Diuresised with a total of 60 mg lasix IV with excellent results. See CareVue for total I&O.\nPA #'s remain relatively the same. ? D/C PA in AM. NSR-no ectopy.\nHydralazine added to therapy 10 mg Q6H for BP control.\nTPN infusing as ordered.\nLeft JP drain leaking large amts of serosangious fluid around tube.\nDSD changed Q2-3H.\nMedicated with MSO4 for C/O left quadrant abdominal pain. Also, receives methadone .\nPlts at 1400: 110 which is adequate and no intervention required at this time.\nInsulin gtt remains and see CareVue for FSBS/titration of gtt.\nAlert/oriented/cooperative.\n\n\n"},{"category":"Nursing/other","chartdate":"2147-10-16 00:00:00.000","description":"Report","row_id":1421803,"text":"resp care\npt remains intubated and mech ventilated. pt weaned to cpap+ps - pt tol well, w/good abg's. b/s clear on rt, sl coarse lul. plan: cont w/mech support, wean ps as tol.\n"},{"category":"Nursing/other","chartdate":"2147-10-17 00:00:00.000","description":"Report","row_id":1421804,"text":"Respiratory Care\nPt remain intubated and on vent support, changed to SIMV for over night rest.\n"},{"category":"Nursing/other","chartdate":"2147-10-17 00:00:00.000","description":"Report","row_id":1421805,"text":"7a-7p; Full assessment in flow sheet.\n\nneuro; A+OX3. Follow directions. MAE. Good cough and gag reflex. PERL. Pain in abd - morphine ivp given - good effect. Slept on and off most of night.\n\ncv; VSS, afebrile. Warm, dry, no edema.\n\nresp; Clear in upper lobes. dimish at bases. SIMV to rest at night. Did not overbreath. ABG - wnl. CPAP 15/8 in am.\n\ngu/gi; soft distended abd. +BSX4. Suture site - d/c/i. JP #2 - leaking (HO and trasplant team aware) - more bloody drainage. JP #1 - d/c/i - ss drainage. T-bile - bile drainage. NG - +Placement, negative guiac, bilious drainage. DSD for JP site X3.\n\nskin intact. Insulin drip. AM lab and night lab done - no new order for lytes replacemnet from HO.\n\nPlan; continue to monitor.\n"},{"category":"Nursing/other","chartdate":"2147-10-13 00:00:00.000","description":"Report","row_id":1421788,"text":"NURSING UPDATE\n AFEBRILE, REMAINS MODERATELY HYPERTENSIVE WITH SBP 170'S. K+ AND ICA+ REPLETED. CONT ON INSULIN GTTS.\n AWAKE AND APPROPRIATE, NO AGITATION OR RESTLESSNESS. COOPERATIVE WITH CARE. PROPOFOL WEANED TO OFF BY 0500. MSO4 1MG IVP FOR C/ /INCISION PAIN, PT LOCALIZING.\n PLATELETS 88 @ 1800, TRANSFUSED WITH 1 5-PACK PLATELETS, POST TX LEVEL 109.\n PICC LINE OCCLUDED, DISCONTINUED PER DR .\n"},{"category":"Nursing/other","chartdate":"2147-10-15 00:00:00.000","description":"Report","row_id":1421796,"text":"condition update\nD: pt cooperative and follows commands. pt remains hypertensive to 200 and co is 8 and sv02 is 80. pt treated with second does of iv lasix 40mg with good diuresis. he was 2400 negative for the day. platelets remain greater than 100 and hct was 37 at 2200. po2 down to 77 on 50% and 5 of peep. peep increased to 7.5. pt suctioned for rust colored sputum. pt c/0 incisional pain. he remains on methadone . pt appears uncomfortable splinting stomache and wincing. when asked he states that he is in pain. pt continues to receive 2mg of mso4 q1hr pt still uncomfortable after receiving dose at 2am.\na: dr. aware and ordered. extra ms04 dose of 2mg x1. continue to monitor I&o. check labs as ordered.\nr: pt still uncomfortable with mso4. ? change to different pain med when team rounds. incision continues to drain large amts of serous/sanginous drainage. frequent dsg changes done. urine output remains good after lasix dose.\n"},{"category":"Nursing/other","chartdate":"2147-10-15 00:00:00.000","description":"Report","row_id":1421797,"text":"Resp Care Note, Pt remains on current vent settings increased to 8 peep for low PaO2. RSBI 40.8. Suctioning mod amts thick bile looking secretions. Having belly pain otherwise stable. Will cont to monitor resp status for further weaning\n"},{"category":"Nursing/other","chartdate":"2147-10-15 00:00:00.000","description":"Report","row_id":1421798,"text":"RESPIRATORY CARE: PT. REMAINS INTUBATED AND ON\nAN SIMV MODE AS PER CAREVUE. ABG STABLE. SX. FOR\nMODERATE AMTS. OF RUSTY SPUTUM. ETT MOVED TO RIGHT\nSIDE OF MOUTH AND RETAPED. PLATEAU PRESSURES ARE\nBETWEEN 30 - 34 CM H2O - WILL MONITOR AND LOWER\nTIDAL VOLUME TO 700 CC IF NECESSARY IF LIVER\nAND SICU TEAM AGREES.\n\n , RRT\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2147-10-15 00:00:00.000","description":"Report","row_id":1421799,"text":"CONDITION UPDATE\nD: NEURO: ALERT AND APPEARS ORIENTED X 3. FOLLOWING COMMANDS, COOPERATIVE\nCV: CONTINUES TO BE HYPERTENSIVE TO 200 SYSTOLIC- STARTED ON LOPRESSOR 5MG IV Q6HRS, OTHER VSS- SEE CAREVUE FOR SPECIFICS\nRESP: BS REMAIN COARSE IN UPPER AIRWAYS AND DIMINISHED IN BASES. SX FOR RUST COLORED SPUTUM. NO VENT CHANGES- ABG IMPROVED AFTER DIURESIS\nGI: NPO, ABD SOFT AND NON-TENDER, + FLATUS, NO STOOL, NGT PATENT AND DRAINING BILIOUS, LESS DRAINAGE FROM AROUND LATERAL JP THIS AFTERNOON.\nGU: LASIX 40 MG IV X 1 WITH GOOD DIURESIS\nENDO: CONTINUES ON INSULIN GTT AT 2-5UNITS PER HR\nA: PAIN MED INCREASED TO 4MG IV Q1HR PRN WITH SOME IMPROVEMENT IN PT COMFORT, HEMODYNAMICS MONITORED\nR: STABLE, CONTINUE TO DIURESIS\n\n"},{"category":"Nursing/other","chartdate":"2147-10-13 00:00:00.000","description":"Report","row_id":1421789,"text":"Resp care\nPt remains intubated & supported, placed on SIMV/PS mode\nover night. B/S clear, Sx mod. amounts of thick bloody\nsecretions. RSBI= 87, Pt currently on SBT\nPlan: poss. extubation\n"},{"category":"Nursing/other","chartdate":"2147-10-13 00:00:00.000","description":"Report","row_id":1421790,"text":"nsg note\nNeuro- propofol off since 5 am- mso4 prn, follws simple command, moves all ext on bed.\n\nResp- attempt to wean to cpap 5/5 but rr up to 35-40- ips increased to 10- abg wnl. lungs clear- left base, minimal secretions with sxn.\n\nHemodynamics- cco pa in place- see flow sheet for #'s. cvp 9-12, uo 50-80, ivf tko.\n\nlft cont to decrease, platelet count noon labs 76- rec 1 5pk, creatanine 2.0, no lasix today.\n"},{"category":"Nursing/other","chartdate":"2147-10-13 00:00:00.000","description":"Report","row_id":1421791,"text":"Resp care\nremains ett/vent support in psv mode. slightly tachypneic on , incr to with good results. still volume overloaded, no further weaning done today. sxned scant sma amts brownish secretions. c/w psv as tolerates, sbt in a.m.\n"},{"category":"Nursing/other","chartdate":"2147-10-14 00:00:00.000","description":"Report","row_id":1421792,"text":"Resp Care Note, Pt remains on current vent settings. See vent flow sheet for further details. RSBI 91.7. suction lrg amts thick rusty bile looking secretions. Awake and alert. Will cont to wean to extubate\n"},{"category":"Nursing/other","chartdate":"2147-10-14 00:00:00.000","description":"Report","row_id":1421793,"text":"condition update\nneuro: pt seems oriented, nods appropriately, mea, gestures to communicate.\ncardiovasc: hypertensive to low 200's. co/ci hr stable. see flow sheet for details.\nresp: abg's on cpap with po2 60's. changed to simv, will recheck abg after 30 mins. sx for thick rust colored sputum.\ngi: min bowel sounds.\ngu: u/o good.\nincision: jp's milked q 1 hr, draining minimally, leaking profusely from around lateral jp.\nPAIN issues: pt c/o pain in abd, around incision. med q 2 hrs with ms 1 mg iv. pt has minimal pain relief. methadone 45 mg po bid.\n"},{"category":"Nursing/other","chartdate":"2147-10-14 00:00:00.000","description":"Report","row_id":1421794,"text":"condition update\nd: neuro: alert, appears oriented, cooperative, mae to command\nresp: changed to simv early in am secondary to poor abg and tiring, bs clear in upper airways but diminished in bases, sx for rust colored sputum- cx sent\ngi: abd soft, hypoactive bs, no stool\ngu: lasix 40 mg iv x1 with good diuresis\nendo: bs tx'd with insulin gtt- see carevue for specifics\ncv- remains hypertensive- team aware, other vss- see carevue for specifics\na: hemodyanmics monitored, cxr done x2\nr: stable at present,\n"},{"category":"Nursing/other","chartdate":"2147-10-14 00:00:00.000","description":"Report","row_id":1421795,"text":"RESPIRATORY CARE: PT. REMAINS INTUBATED AND ON\nSIMV MODE AS PER CAREVUE. STABLE ABG. SX. FOR\nRUSTY COLORED SPUTUM. ETT RETAPED AND MOVED TO\nLEFT SIDE OF MOUTH.\n\n , RRT\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-18 00:00:00.000\",\n \"description\": \"P ABDOMEN (SUPINE ONLY) PORT\",\n \"row_id\": 802213,\n \"text\": \" 5:27 AM\\n ABDOMEN (SUPINE ONLY) PORT Clip # \\n Reason: please eval ileus vs obstruction\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man s/p liver transplant with increasing abd dist\\n REASON FOR THIS EXAMINATION:\\n please eval ileus vs obstruction\\n ______________________________________________________________________________\\n FINAL REPORT\\n ABDOMEN SINGLE FILM:\\n\\n HISTORY: Liver transplant and increasing abdominal distention.\\n\\n Gas is present throughout the colon and in the rectum. There are a few gas\\n filled non-dilated loops of small bowel. No evidence for intestinal\\n obstruction. The cecum is not undully dilated. NG tube is in cardia of\\n stomach.\\n\\n IMPRESSION: No evidence for intestinal obstruction. Findings consistent\\n with mild colonic ileus.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 802214,\n \"text\": \" 5:29 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pneumonia\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with history of hep C cirrhosis, s/p liver\\n transplant\\n REASON FOR THIS EXAMINATION:\\n pneumonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post liver transplant for hepatitis C cirrhosis. Evaluate\\n pneumonic consolidation.\\n\\n FINDINGS: A single AP semiupright view. Comparison study dated . There is again evidence of left lower lobe collapse and consolidation and\\n there has been slight resolution of the ill-defined infiltrate previously\\n present in the partially aerated left upper lobe. There has also been slight\\n resolution of the faint opacities in the right lower zone. The endotracheal\\n tube, the NG line and the right IJ line remain in good position. The right IJ\\n Swan-Ganz catheter tip is also well placed. No new pulmonary infiltrates are\\n seen. Numerous skin staples overlie the left upper quadrant of the abdomen.\\n\\n IMPRESSION: Slight resolution of the infiltrates previously demonstrated in\\n the left upper lobe and right lower zone. There is persistent left lower lobe\\n collapse/consolidation. The heart shows slight LV enlargement but there is no\\n evidence to indicate cardiac failure at this time.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-25 00:00:00.000\",\n \"description\": \"ERCP S&I (74330)\",\n \"row_id\": 803599,\n \"text\": \" 10:58 PM\\n ERCP S&I () Clip # \\n Reason: R/O anastomotic stricture\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man s/p OLTX 2 weeks ago. Now with increased LFTs and T-Tube\\n cholangiogram showing anastomotic stricture.\\n Exam performed , req sent \\n REASON FOR THIS EXAMINATION:\\n R/O anastomotic stricture\\n ______________________________________________________________________________\\n FINAL REPORT\\n History of recent liver transplant with increasing liver function studies and\\n tube cholangiogram demonstrating anastomotic stricture.\\n\\n Four fluoroscopic spot films are provided. There is contrast filling of the\\n native and donor biliary ducts with evidence of a short segment of slightly\\n irregular narrowing in the region of the anastomosis consistent with\\n anastomotic stricture. No significant dilatation of visualized ducts proximal\\n to the narrowing. Status-post placement of biliary stent bridging region of\\n anastomotic stricture.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-24 00:00:00.000\",\n \"description\": \"CHALNAGIOGRAPHY VIA EXISTING CATHETER\",\n \"row_id\": 802832,\n \"text\": \" 7:51 AM\\n CATH CHEK/REMV Clip # \\n Reason: S/P OTL\\n Admitting Diagnosis: LIVER FAILURE\\n Contrast: OPTIRAY Amt: 10\\n ********************************* CPT Codes ********************************\\n * CHALNAGIOGRAPHY VIA EXISTING C TUBE CHOLANGIOGRAM *\\n ****************************************************************************\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: Status post orthotopic liver transplant, two weeks previously.\\n First tube check.\\n\\n REFERRING PHYSICIAN; Dr. .\\n\\n RADIOLOGISTS: Dr. .\\n\\n PROCEDURE/FINDINGS: An antegrade cholangiogram was performed with only 10 cc\\n of Optiray 320 60%. There was poor transit of contrast material from the\\n catheter through the anastomosis, with all contrast refluxing into the biliary\\n tree. This was followed by injection of cc of saline, at which time,\\n contrast was visualized in the common bile duct. The findings suggest\\n significant stricture at the anastomosis. The cystic duct fills proximal to\\n the anastomosis. The biliary ducts are relatively decompressed and smooth in\\n appearance.\\n\\n IMPRESSION: Findings suggesting a significant stricture at the anastomosis.\\n Findings were discussed with Dr. at the time of the study.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-25 00:00:00.000\",\n \"description\": \"DUPLEX DOPP ABD/PEL\",\n \"row_id\": 803043,\n \"text\": \" 3:03 PM\\n DUPLEX DOPP ABD/PEL Clip # \\n Reason: eval portal vein, hepatic artery, & hepatic veins with B mod\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 year old man with history of hep C cirrhosis, s/p liver transplant, now\\n with increasing bili.\\n REASON FOR THIS EXAMINATION:\\n eval portal vein, hepatic artery, & hepatic veins with B mode ultrasound please\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 58 y/o man with history of Hep C cirrhosis status post liver\\n transplant. Now with increasing bilirubin.\\n\\n LIVER ULTRASOUND: Comparison . The liver demonstrates normal echo\\n texture without focal masses. There is normal direction of flow and waveforms\\n within the portal vein, hepatic artery and hepatic veins. There is no\\n ascites. There are no masses and there is no ascites.\\n\\n IMPRESSION: Doppler hepatic ultrasound demonstrates normal flow without\\n evidence of mass or ascites.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-17 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 802084,\n \"text\": \" 3:32 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval interval change\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\\n\\n REASON FOR THIS EXAMINATION:\\n please eval interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n INDICATION: Hepatitis C-cirrhosis. S/P liver transplant. Evaluate for\\n interval change.\\n\\n VIEWS: Supine AP view is compared with semi-erect AP view from .\\n\\n FINDINGS: The ET tube, NG tube, right IJ Swan-Ganz catheter, second right\\n internal jugular central venous line, and right-sided subdiaphragmatic\\n surgical drain all remain in stable and satisfactory position. There is\\n slight LV enlargement and upper zone redistribution, which is probably related\\n to the patient's supine positioning. There continues to be left lower lobe\\n collapse/consolidation. There is no change in the bilateral ill-defined\\n patchy opacities. There is now loss of translucency in the left upper lung\\n zone with fluid seen tracking over the apex, consistent with a posterior\\n layering pleural efffusion in this supine patient. No pneumothorax is\\n identified.\\n\\n IMPRESSION:\\n 1) Slight LV enlargement and upper zone redistribution which may be related to\\n patient's supine positioning, although mild LV failure cannot be excluded.\\n\\n 2) Persistent left lower lobe consolidation/collapse.\\n\\n 3) Left-sided posteriorly layering pleural effusion.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 801326,\n \"text\": \" 12:17 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please assess for any evidence of abdominal free air.\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with history of hep C cirrhosis, has multiple paracentesis.\\n Please assess for any free air under diaphragm.\\n REASON FOR THIS EXAMINATION:\\n Please assess for any evidence of abdominal free air.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Hepatitis C cirrhosis, multiple paracenteses, please assess for\\n free air under the diaphragm.\\n\\n VIEWS: Single AP portable upright view, comparison dated .\\n\\n FINDINGS: No free intraperitoneal air. Previously seen left-sided PICC line\\n remains in stable and satisfactory position. The heart size, mediastinal\\n contours, and pulmonary vasculature appear unchanged without congestive heart\\n failure. Minimal linear atelectasis at the left base. No areas of focal\\n consolidation. No pneumothorax. The visualized osseous structures are\\n unchanged.\\n\\n IMPRESSION: No radiographic evidence of intraperitoneal free air. Minimal\\n left lower lobe atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-09 00:00:00.000\",\n \"description\": \"US ABD LIMIT, SINGLE ORGAN\",\n \"row_id\": 801344,\n \"text\": \" 3:16 PM\\n US ABD LIMIT, SINGLE ORGAN Clip # \\n Reason: Left lower quadrant tenderness, please rule out haematoma.\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 year old man with history of hep C cirrhosis, comes with rising bilirubin,\\n worsening INR. Has had multiple paracentesis in the LLQ.\\n REASON FOR THIS EXAMINATION:\\n Left lower quadrant tenderness, please rule out haematoma.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Hepatitis C cirrhosis with multiple prior paracenteses and pain\\n in the left lower quadrant.\\n\\n LIMITED ABDOMEN ULTRASOUND: Selective evaluation was performed of the left\\n lower quadrant. A moderate amount of ascites is present. No fluid\\n collections are identified within the abdominal wall. The visualized loops of\\n bowel are unremarkable.\\n\\n IMPRESSION:\\n\\n 1) Ascites.\\n\\n 2) No evidence of a hematoma.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-04 00:00:00.000\",\n \"description\": \"UD GUID FOR NEEDLE PLACMENT\",\n \"row_id\": 800887,\n \"text\": \" 12:35 PM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: Patient with advanced liver disease and INR 3+ needs venous\\n Admitting Diagnosis: LIVER FAILURE\\n ********************************* CPT Codes ********************************\\n * UD GUID FOR NEEDLE PLACMENT *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 year old man with liver failure from Hep C and likely SBP.\\n REASON FOR THIS EXAMINATION:\\n Patient with advanced liver disease and INR 3+ needs venous access for contrast\\n MRI in anticipation of liver transplant. Has PICC but can't use for MRI\\n contrast. No obvious peripheral access. Need is only temporary to facilitate\\n study -- ext jugular or IJ or whatever you feel appropriate. Thanks.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Liver failure from Hep-C. Likely SBP, INR greater than 3.\\n Pulmonary medicine not able to place central line. Needs a peripheral IV to\\n perform an MRI study.\\n\\n RADIOLOGISTS PERFORMING PROCEDURE: Dr. , Dr. ,\\n staff radiologist supervised the procedure.\\n\\n PROCEDURE/TECHNIQUE: Ultrasound guidance was provided for placement of an 18\\n gauge angiocatheter into the right antecubital vein. The angiocath was\\n secured to the skin using Tegaderm and steristrips. The patient was sent to\\n MRI for their injection.\\n\\n IMPRESSION: Successful placement of an 18 gauge angiocath in the right\\n antecubital vein.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-06 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 801044,\n \"text\": \" 12:21 AM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: H/O ASCITES, CIRRHOSIS, HEP C. ? PERFORATION.\\n Admitting Diagnosis: LIVER FAILURE\\n Field of view: 36\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 year old man with Hep C decompensated cirrhosis and ascites, s/p three\\n paracentesis showing SBP. Also developing hepatorenal syndrome. Please give\\n oral Gastrograffin contrast.Thank You.\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for perforated bowel\\n CONTRAINDICATIONS for IV CONTRAST:\\n Developing Hepatorenal Syndrome\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Decompensated cirrhosis and ascites with SVP by paracentesis x 3.\\n Assess for perforated bowel.\\n\\n Comparison: CT abdomen and pelvis and ultrasound \\n\\n TECHNIQUE: Contiguous axial images through the abdomen and pelvis were\\n obtained following the administration of oral contrast. Intravenous contrast\\n was not used due to patient's history of renal failure.\\n\\n ABDOMEN: There are dependent changes at both lung bases. There are no pleural\\n effusions. The liver is samll, with a slightly nodular contour consistent with\\n cirrhosis. There is a large amount of ascites within the abdomen. At least two\\n gallstones are noted within the gallbladder. There are at least four stones\\n within the left kidney, the largest of which measures 1.7 cm in greatest\\n dimension and is located within the renal pelvis. No right-sided kidney stones\\n are seen. The adrenal glands are not well visualized due to the ascites. The\\n pancreas is grossly unremarkable within the limits of this unenhanced scan.\\n Incomplete distension of right colon makes evaluation for previously described\\n wall thickening limited. Contrast material passes to the level of the colon\\n without obstruction. There is stool within the terminal ileum.\\n\\n PELVIS: There is a large amount of fluid within the pelvis. The bladder is\\n unremarkable. Anasarca is present. There is no inguinal or pelvic lymph\\n adenopathy.\\n\\n Bone windows: There are no suspicious lytic or sclerotic bony lesions.\\n\\n CT RECONSTRUCTIONS: These images confirm the above findings.\\n\\n IMPRESSION:\\n No evidence of bowel perforation. Large amount of ascites. Thickening within\\n the transverse and right colon as previously described difficult to confirm\\n in view of incomplete distension of colon.\\n\\n (Over)\\n\\n 12:21 AM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: H/O ASCITES, CIRRHOSIS, HEP C. ? PERFORATION.\\n Admitting Diagnosis: LIVER FAILURE\\n Field of view: 36\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-06 00:00:00.000\",\n \"description\": \"PERSANTINE MIBI\",\n \"row_id\": 801057,\n \"text\": \"PERSANTINE MIBI Clip # \\n Reason: CAD.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: CAD.\\n\\n SUMMARY OF EXERCISE DATA FROM THE REPORT OF THE EXERCISE LAB:\\n Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142\\n mg/kg/min. Two minutes after the cessation of infusion, Tc-m sestamibi was\\n administered IV.\\n\\n INTERPRETATION:\\n\\n Image Protocol: Gated SPECT.\\n\\n Resting perfusion images were obtained with thallium-201.\\n Tracer was injected 15 minutes prior to obtaining the resting images.\\n\\n Stress images show normal left ventricular cavity size. There is normal tracer\\n distribution and intensity.\\n\\n Resting perfusion images show no abnormality.\\n\\n Ejection fraction calculated from gated wall motion images obtained after\\n Dipyridamole administration is 61%. There is normal wall motion.\\n\\n IMPRESSION: Normal pharmacological stress test. There is normal wall motion\\n with an EF of 61%.\\n\\n /nkg\\n\\n\\n , M.D.\\n , M.D. Approved: MON 11:19 AM\\n\\n\\n\\n\\n RADLINE ; A radiology consult service.\\n To hear preliminary results, prior to transcription, call the\\n Radiology Listen Line .\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-06 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 801126,\n \"text\": \" 8:20 PM\\n CHEST (PA & LAT) Clip # \\n Reason: Please evaluate for infiltrative process in pt growing Strep\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 year old man with decompensated Hep C cirrhosis with increasing bili,\\n developed increased ascites and worsened liver function found to have SBP\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for infiltrative process in pt growing Strep Pneumo in ascitic\\n fluid\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 50 y/o man with decompensated Hepatitis C cirrhosis. Please evaluate\\n for infiltrative process in patient now growing strep.\\n\\n PA AND LATERAL CHEST: Comparison is made to prior chest exam of six days\\n earlier. There is a left subclavian central venous catheter in place with its\\n tip in the superior vena cava. There is no evidence of a pneumothorax. The\\n patient has taken a poor inspiration and there is compressive atelectasis at\\n both bases. I cannot rule out pneumonia.\\n\\n IMPRESSION: Expiratory film. No definite pneumonia. Compressive atelectasis\\n at both bases.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 801648,\n \"text\": \" 12:38 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: confirm line replacement\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\\n\\n REASON FOR THIS EXAMINATION:\\n confirm line replacement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 51 y/o man with history of hepatitis C and cirrhosis s/p liver\\n transplant.\\n\\n Confirm line replacement.\\n\\n FINDINGS: An AP portable study of the chest at 12:29 HR and is compared with\\n the previous study that was obtained at 5:10 a.m. The tip of the ETT is way\\n above the carina. The left subclavian CVP line remains in place, the tip is in\\n the superior vena cava. The tip of the Swan-Ganz catheter is in the right\\n lower lobe branch of the right pulmonary artery at this time. Another right\\n subclavian CVP line is in place the tip is in the right atrium at this time.\\n Massive left pleural effusion is noted unchanged since the previous study. NG\\n tube also remains in place.\\n\\n IMPRESSION: There has been advancement of the Swan-Ganz catheter to the right\\n lower lobe branch of the pulmonary artery at this time. Also there has been\\n advancement of the right subclavian CVP line the tip is in the right atrium at\\n this time. The tip of the ETT is in proper position. The tip of the NG tube is\\n in the mid gastric body.\\n\\n Massive right pleural effusion unchanged.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-09-30 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 800502,\n \"text\": \" 10:24 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \\n Reason: Please evaluate for any liver mass, any evidence of vascular\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 year old man with history of hep C cirrhosis, comes with rising bilirubin,\\n worsening INR.\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for any liver mass, any evidence of vascular\\n obstruction/thrombosis. Please also mark area for paracentesis. Thank you.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Hx of hepatitis C cirrhosis now with rising bilirubin and\\n worsening INR.\\n\\n RIGHT UPPER QUADRANT US: Limited evaluation was performed focusing on the\\n liver, gallbladder, and bile ducts. A moderate amount of ascites is present in\\n the abdomen. The liver is small and has a irregular contour consistent with\\n cirrhosis. No focal masses are appreciated. The gallbladder is enlarged and\\n there is a small amount of pericholecystic fluid. Sludge is present at the\\n base of the gallbladder. There is no intra or extrahepatic ductal dilatation.\\n There is normal portal venous flow.\\n\\n All four quadrants of the abdomen were imaged and a spot was marked in the\\n left lower quadrant for paracentesis to be performed by the primary service.\\n\\n IMPRESSION:\\n\\n 1) Cirrhotic liver, without focal masses.\\n 2) An enlarged gallbladder with pericholecystic fluid. These findings were\\n observed on prior CT of and are likely related to the patient's\\n chronic liver disease.\\n 3) Sludge within the gallbladder.\\n 4) A spot was marked in the left lower quadrant for paracentesis to be\\n performed by the clinical service.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 801832,\n \"text\": \" 10:28 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: f/u\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\\n\\n REASON FOR THIS EXAMINATION:\\n f/u\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: History of Hepatitis C cirhorris. status post liver transplant.\\n\\n CHEST, SINGLE AP VIEW\\n\\n An ET tube is present in satisfactory position 3.7 cm above the carina. Right\\n IJ central line is present with tip over distal SVC. Right IJ swan ganz\\n catheter is present with tip over right pulmonary artery. There is probably\\n mild cardiomegaly. There are patchy alveolar opacities throughout both lungs\\n most pronounced in the left mid and upper zones and right base. Possible small\\n effusion but tracking left effusion seen on appears to have become\\n much smaller. An NG tube is present with tip beneath diaphragm off film.\\n Multiple upper abdominal surgical staples are noted.\\n\\n IMPRESSION:\\n\\n 1) Lines and tubes as described. Left subclavian line and PICC line have been\\n removed in the interval.\\n 2) Patchy alveolar opacity including new or progressed right sided opacity.\\n Differential diagnosis includes atypical distribution of CHF, pneumonic\\n infiltrate and ARDS.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 801955,\n \"text\": \" 5:16 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval for pna\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\\n\\n REASON FOR THIS EXAMINATION:\\n please eval for pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n INDICATION: Hepatitis C-cirrhosis. S/P liver transplant. Ck. for pneumonia.\\n\\n SINGLE AP SEMI-URIGHT VIEW: Comparison: .\\n\\n The heart again shows slight LV enlargement. There is evidence of upper zone\\n redistribution. Bilateral ill-defined pulmonary infiltrates are again noted,\\n significantly resolved since the prior study. There is persistent left lower\\n lobe collapse/consolidation behind the heart. The left CP angle remains\\n blunted suggesting a small effusion on this side. The right CP angle is\\n sharp. The ET tube, right IJ Swan-Ganz catheter and the NG line all remain in\\n good position. A second right IJ central line has its tip probably in the\\n mid-SVC. There is a surgical drain beneath the right diaphragm.\\n\\n IMPRESSION:\\n 1) Stable lines in satisfactory position.\\n\\n 2) Partly resolved pulmonary infiltrates bilaterally, consistent with\\n resolving pulmonary edema.\\n\\n 3) Persistent left lower lobe collapse/consolidation.\\n\\n 4) Residual left effusion.\\n\\n 5) Subdiaphragmatic right upper quadrant drain.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 801716,\n \"text\": \" 4:13 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: follow effusions, consolidations\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\\n\\n REASON FOR THIS EXAMINATION:\\n follow effusions, consolidations\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Hep C cirrhosis s/p liver transplant following effusions and\\n consolidation.\\n\\n VIEWS: Single AP portable supine view, comparison dated .\\n\\n FINDINGS: The ETT, NG tube, right IJ venous access catheter, and left\\n subclavian venous access catheter remain in stable and satisfactory position.\\n Left sided PICC line terminates in left brachiocephalic vein. Pulmonary artery\\n catheter enters via the right internal jugular parallel to the separate venous\\n access catheter, the tip appears to have been pulled back and now terminates\\n in the proximal right main pulmonary artery. The heart size and mediastinal\\n contours are unchanged. Slightly decreased aeration of both lungs. Persistent\\n large layering pleural effusion appears somewhat increased in size. No\\n pneumothorax. 2 tubular opacities, metallic skin staples, and surgical clips\\n are seen overlying the upper abdomen.\\n\\n IMPRESSION: 1) Satisfactory position of lines and tubes. 2) Slightly increased\\n size of large left pleural effusion with decreased aeration of both lungs.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-11 00:00:00.000\",\n \"description\": \"DUPLEX DOPP ABD/PEL\",\n \"row_id\": 801545,\n \"text\": \" 1:26 PM\\n DUPLEX DOPP ABD/PEL Clip # \\n Reason: assess liver transplant for intra and extrahepatic doppler f\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 year old man with history of hep C cirrhosis, s/p liver transplant\\n REASON FOR THIS EXAMINATION:\\n assess liver transplant for intra and extrahepatic doppler flow of hep art,\\n portal vein, and hepatic veins as well as us of livers/p liver transplant\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status-post liver transplant.\\n\\n FINDINGS: The transplant liver demonstrates normal echogenicity. No\\n intrahepatic biliary ductal dilatation.\\n\\n The main portal vein, as well as left and right portal veins demonstrate\\n patency with proper direction of flow. The main hepatic vein, as well as the\\n left and right hepatic veins demonstrate patency with proper direction of\\n flow. The main hepatic artery and left hepatic artery demonstrate patency with\\n proper direction of flow. The IVC is patent.\\n\\n IMPRESSION:\\n Patent vasculature to the transplant liver.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 801608,\n \"text\": \" 5:16 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: follow for ?chf/ards\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\\n\\n REASON FOR THIS EXAMINATION:\\n follow for ?chf/ards\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST RADIOGRAPH:\\n\\n INDICATION: Continued shortness of breath post liver transplant.\\n\\n Comparison is made to a study from the prior day.\\n\\n FINDINGS:\\n\\n A PA catheter placed via the right IJ terminates in the main pulmonary artery.\\n A right IJ cordis terminates in the distal right brachiocephalic vein. A\\n left-sided subclavian catheter terminates in the upper SVC. The ETT is 4 cm\\n above the carina.\\n\\n There is stable cardiomegaly with slight worsening of vascular indistinctness\\n and engorgement. A right-sided pleural effusion has increased in size. The\\n left-sided effusion appears stable. There is persistent opacification in the\\n retrocardiac region. There are no new areas of consolidation.\\n\\n IMPRESSION:\\n\\n 1) Worsening of CHF and pulmonary edema.\\n\\n 2) Stable left lower lobe atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-04 00:00:00.000\",\n \"description\": \"MR ABDOMEN W&W/O CONTRAST\",\n \"row_id\": 800866,\n \"text\": \" 3:42 PM\\n MR ABDOMEN W&W/O CONTRAST Clip # \\n Reason: Please evaluate liver in pt with decomensated Hep C cirrhosi\\n Admitting Diagnosis: LIVER FAILURE\\n Contrast: MAGNEVIST Amt: 20CC\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 year old man with Hep C cirrhosis, DM, Migraine's, presents with elevated\\n bili and decompensation\\n REASON FOR THIS EXAMINATION:\\n Please evaluate liver in pt with decomensated Hep C cirrhosis, evaluating for\\n transplant. Please hepatic vasculature, volumetrics, gadolinium for hepatoma,\\n and MRC for question of obstruction.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: Cirrhotic patient. Evaluate for pretransplant.\\n\\n MRCP AND MRI OF THE ABDOMEN:\\n\\n TECHNIQUE: MRI of the abdomen was performed with multiplanar T1 in and out\\n of phase, STIR, HASTE, 2D time of flight, thick slabs of T2W and dynamic T1W\\n with fat saturated sequences before and after the administration of\\n gadolinium. Multiplanar reconstruction was performed at the workstation.\\n\\n COMPARISON: CT of .\\n\\n FINDINGS: Images are acquired by non-breath hold technique, therefore\\n degrading image quality. The liver is diffusely nodular with enlargement of\\n the caudate lobe, consistent with cirrhosis. No focal hepatic enhancing\\n lesions are identified. The portal vein is patent with hepatopetal flow. The\\n origin of the celiac artery is not well visualized. Distinct right and left\\n hepatic arteries are visualized. There is no evidence for an aberrant hepatic\\n artery. There is a patent peri-umbilical vessel. The gallbladder remains\\n distended containing gallstones. There is minimal pericholecystic fluid. The\\n liver volume is 1690 cc.\\n\\n The pancreas is unremarkable. The spleen is enlarged, measuring at least 14\\n cm. There is lymphadenopathy around the celiac axis. There is a large amount\\n of intra-abdominal ascites.\\n\\n Within the visualized kidney, there is a single right cortical cyst. A 6 mm\\n dark focus is noted within the left collecting system, correlating to a stone\\n within the renal pelvis. There is no evidence of hydronephrosis. Peripelvic\\n cysts are present in the left renal pelvis.\\n\\n Multiplanar reconstructed images were essential for confirming the vascular\\n anatomy and establishing the liver volume.\\n\\n IMPRESSION:\\n\\n 1. Cirrhotic liver. No evidence for an arterial enhancing lesion or aberrant\\n anatomy. Liver volume = 1690 cc's.\\n (Over)\\n\\n 3:42 PM\\n MR ABDOMEN W&W/O CONTRAST Clip # \\n Reason: Please evaluate liver in pt with decomensated Hep C cirrhosi\\n Admitting Diagnosis: LIVER FAILURE\\n Contrast: MAGNEVIST Amt: 20CC\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 2. Splenomegaly, ascites and patent umbilical vessel; findings consistent with\\n portal hypertension.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 801488,\n \"text\": \" 6:35 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: central line\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\\n REASON FOR THIS EXAMINATION:\\n central line\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Hepatitis C cirrhosis. Status post liver transplant. Check\\n central line.\\n\\n TECHNIQUE: Single AP portable supine view.\\n\\n Comparison study dated .\\n\\n FINDINGS: An endotracheal tube terminates with tip 7.6 cm above the carina\\n and located above the thoracic inlet. Nasogastric tube extends below the\\n diaphragm with tip terminating in the distal stomach. Right internal jugular\\n sheath terminates in upper SVC. Pulmonary artery catheter enters via the\\n right internal jugular vein parallel to the sheath and terminates with tip in\\n the main pulmonary artery. Left subclavian venous access catheter terminates\\n in upper SVC. Large left pleural effusion layers posteriorly and tracks to\\n the apex. Left retrocardiac opacity with obscuration of left hemidiaphragm.\\n The heart size and mediastinal contours appear unchanged without cardiac\\n failure. No pneumothorax. Note is made of a drain in the right upper\\n quadrant, and surgical clips and metallic skin staples overlying the right\\n upper quadrant and upper abdomen.\\n\\n IMPRESSION:\\n\\n 1) Endotracheal tube tip terminates above level of the thoracic inlet. Other\\n lines and tubes in satisfactory position. Large left pleural effusion and left\\n lower lobe collapse and/or consolidation. No pneumothorax. Findings were\\n communicated to the clinical team at time of interpretation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-03 00:00:00.000\",\n \"description\": \"CVL/PICC\",\n \"row_id\": 800803,\n \"text\": \" 4:56 PM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: IV nurse for bedside PICC, but highly unlikely t\\n Admitting Diagnosis: LIVER FAILURE\\n ********************************* CPT Codes ********************************\\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\\n * C1751 CATH ,/CENT/MID(NOT D *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 year old man with cirrhosis, possible SBP, requires albumin, may need\\n antibiotics.\\n REASON FOR THIS EXAMINATION:\\n IV nurse for bedside PICC, but highly unlikely to be successful.\\n Will call when confirmed.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: No IV access requiring IV antibiotics.\\n\\n RADIOLOGISTS: Dr. and Dr. , the staff radiologist,\\n was present throughout the entire procedure.\\n\\n PROCEDURE/TECHNIQUE: Patient was placed supine on the angiography table with\\n the left arm prepped and draped in the usual sterile fashion. Through an\\n anesthetized skin approach utilizing realtime ultrasound guidance a micro-\\n puncture set was used to access the left brachial vein. The measuring wire was\\n advanced into the distal superior vena cava. The needle was then exchanged for\\n the micropuncture dilator and peel-away sheath. The catheter was then\\n appropriately sized to 38 cm. The inner dilator was removed. The catheter was\\n then advanced over the wire into the distal SVC. The peel-away sheath was\\n removed. The catheter was secured to the skin.\\n\\n Post procedure x-ray was performed and confirmed position within distal\\n superior vena cava.\\n\\n CONTRAST/MEDICATIONS: 2 cc of 1% lidocaine for local anesthetic.\\n\\n COMPLICATIONS: None.\\n\\n IMPRESSION: Successful placement of a 38 cm single lumen vaxcel catheter in\\n the distal superior vena cava via the left brachial vein.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-09 00:00:00.000\",\n \"description\": \"US ABD LIMIT, SINGLE ORGAN\",\n \"row_id\": 801347,\n \"text\": \" 3:40 PM\\n US ABD LIMIT, SINGLE ORGAN; -59 DISTINCT PROCEDURAL SERVICE Clip # \\n Reason: Please mark spot for paracentesis. Thank you.\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 year old man with history of hep C cirrhosis, comes with rising bilirubin,\\n worsening INR. Has had multiple paracentesis in the LLQ.\\n REASON FOR THIS EXAMINATION:\\n Please mark spot for paracentesis. Thank you.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Ascites.\\n\\n LIMITED ABDOMEN ULTRASOUND: All four quadrants of the abdomen were imaged and\\n a spot was chosen in the suprapubic midline region for paracentesis. The spot\\n was marked.\\n\\n IMPRESSION: Spot marked in the midline suprapubic region for paracentesis to\\n be performed by the clinical team.\\n\\n The referring physician, . , was contact following the examination.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 801865,\n \"text\": \" 5:36 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: f/u of morning cxr after diuresis\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\\n\\n REASON FOR THIS EXAMINATION:\\n f/u of morning cxr after diuresis\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n HISTORY: S/P liver transplant for hep C cirrhosis. ? response to diuresis.\\n\\n CHEST, SINGLE AP PORTABLE UPRIGHT VIEW: Lordotic positioning.\\n There are confluent opacities in a patchy distribution, but diffuse throughout\\n both lungs. The left CP angle is obscured, suggesting a small pleural\\n effusion. There is increased retrocardiac density. No gross right effusion\\n is identified. Probable mild upper zone redistribution. Heart size upper\\n limits of normal or slightly enlarged. Skin staples and right upper quadrant\\n drain present. ET tube in satisfactory position above carina. NG tube with\\n tip beneath diaphragm.\\n\\n IMPRESSION:\\n 1) Patchy confluent alveolar opacities throughout both lungs with largest\\n area of confluent opacity at left base. While this could represent residual\\n alveolar edema, the possibility of multifocal infectious infiltrate or ARDS\\n should be considered. Please note that, on the right side, these opacities\\n have relatively peripheral distribution.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-10-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 801893,\n \"text\": \" 4:58 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: f/u after diuresis\\n Admitting Diagnosis: LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\\n\\n REASON FOR THIS EXAMINATION:\\n f/u after diuresis\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Hep C cirrhosis status post liver transplant. Follow up after\\n diuresis.\\n\\n CHEST, SINGLE AP PORTABLE VIEW:\\n\\n There is probable mild cardiomegaly. There is diffuse alveolar opacity, more\\n confluent than on the film from one day earlier. There is a probable small\\n left pleural effusion. There is increased retrocardiac density. The ET tube\\n tip is at the level of the upper clavicular heads, slightly high, 6.9 cm from\\n the carina. NG tube is present, tip in the diaphragm. A SG catheter is\\n present, tip over right pulmonary artery. An additional right IJ line appears\\n present, but tip is obscured. No pneumothorax was detected.\\n\\n IMPRESSION:\\n\\n Confluent alveolar opacity diffusely throughout both lungs, with small left\\n effusion. Most likely etiology is alveolar edema. This appears more\\n extensive than on the film from one day earlier.\\n\\n Left lower lobe collaspe and/or consolidation, unchanged.\\n\\n Relatively high position of the ET tube. Clinical correlation regarding\\n possible advancement is requested.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2147-10-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 102839,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Murmur.\\nHeight: (in) 69\\nWeight (lb): 175\\nBSA (m2): 1.95 m2\\nBP (mm Hg): 134/72\\nStatus: Inpatient\\nDate/Time: at 16:03\\nTest: TTE (Complete)\\nDoppler: Complete pulse and color flow\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: The left atrium is normal in size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\\n\\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\\nventricular cavity size is normal. Overall left ventricular systolic function\\nis normal (LVEF>55%).\\n\\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\\nnormal.\\n\\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\\ndiameter. The aortic arch is normal in diameter.\\n\\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\\ngood leaflet excursion and no aortic regurgitation.\\n\\nMITRAL VALVE: Mild (1+) mitral regurgitation is seen.\\n\\nTRICUSPID VALVE: No tricuspid regurgitation is seen. The pulmonary artery\\nsystolic pressure could not be determined.\\n\\nPERICARDIUM: There is no pericardial effusion.\\n\\nConclusions:\\nThe left atrium is normal in size. Left ventricular wall thicknesses are\\nnormal. The left ventricular cavity size is normal. Overall left ventricular\\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\\nfree wall motion are normal. The aortic valve leaflets (3) appear structurally\\nnormal with good leaflet excursion and no aortic regurgitation. Mild (1+)\\nmitral regurgitation is seen. The pulmonary artery systolic pressure could not\\nbe determined. There is no pericardial effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2147-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 313229,\n \"text\": \"Sinus rhythm. T wave inversions in leads V1-V2 are non-specific and could be in\\npart, positional. Clinical correlation is suggested. Since the previous tracing\\nof right precordial T wave changes are seen.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421784,\n \"text\": \"nsg note\\nPt is s/p liver transplant:\\n\\nNeuro- propofol off on arrival from OR this am at 615- waking up by 11 am and beginning to follow some simple command. agitation at times, mso4 2 mg ivp q1 prn. 3 pm becoming extremly agitated, swinging head and kicking legs with attempts to get oob, attempting to hit staff, req 3 assist to prevent from extubating or pulling out pa line, transplant notified and propofol gtt started, cont agitated and attempt to pull at ett, (bilat swr on)- trnasplant to restart methadone as pt was on it preop.\\n\\nRenal- uo 50- 110 hr, cr 1.6, ivf 100hr.\\n\\nEncocrine- glucose as high as 340, insulin gtt with prn insulin bolus, to get glucsoe <130, glucose at 3 pm 108, cont 2 u insulin gtt/hr, chemsticks q1.\\n\\nLiver u.s done at bedside, all labs done q4 pr md orders, rec 3 prbc, 6 ffp and 1 5pk platelet this shift, jp x2, t tube to gravity.\\nPa line in place, c.0 , see flow sheet for all other #s\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421785,\n \"text\": \"NURSING UPDATE\\n TMAX 99, HR 70'S NSR, SLIGHT HTN SBP 170'S. CCO ELEVATED 8.8-10.8, SVR DIMINSHED 688-880.\\n TRANSFUSED WITH 1U PRBC'S, FOLLOW UP HCT 31. PLTS 73, TX WITH 1 5-PACK PLATELETS, FOLLOW UP PLTS 89, DR AWARE, PLAN TO TRANSFUSE ANOTHER 5-PACK WHEN AVAILABLE. DR AWARE OF DIMINISHED K+ AND MG+ LEVELS, NO REPLETIONS ORDERED. BLOOD GLUCOSE MANAGED ON INSULIN GTTS.\\n VERY AGITATED EARLY EVENING, ATTEMPTING TO SIT UP IN BED AND CONSTANTLY TRYING TO REACH ETT, IV'S AND DRAINS EVEN THOUGH RESTRAINED. PROPOFOL GTTS INITIALLY INCREASED AND MSO4 2MG ADMINISTERED IV Q2 PER PRN ORDER. ON THIS REGIMEN, WAS ABLE TO WEAN PROPOFOL DOWN TO DESIRED RATE OF 55MCG/KG/MIN AND MAINTAIN AS SAME. BRIEF BREAKTHROUGH PERIODS OF AGITATION AND RESTLESSNESS THROUGHOUT NOC, BUT MUCH MORE MANAGEABLE, AND ENVIRONMENT SAFER FOR PT AND STAFF. PT OPENING EYES AND FOLLOWING COMMANDS INCONSISTENTLY. SHAKING/NODDING HEAD IN RESPONSE TO QUESTION @ TIMES ALSO.\\n MODERATE AMOUNT OF SEROSANG DRAINAGE AROUND LATERAL JP(#2) SITE, DRESSING CHANGED X2. DRAINS STRIPPED AND EMPTIED Q2.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421786,\n \"text\": \"Resp Care: Pt remains on vent,SIMV/PS with the only changes to the RR.\\nPt's RR was decreased from 12 to 8 without incident,ABG is within normal limits.B/S coarse and sl decreased with sct rhonchi.The plan is\\nto continue wean.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421787,\n \"text\": \"nsg progress note\\nNeuro- sedated with propofol gtt, withdraws to pain, weaning propofol as tol this pm, cont mso4 1 mg prn q1, methadone changed to 45 mbg , psych svc by to see pt this am.\\n\\nResp- failed cpap trial this am as rr up to 40, return to simv, abg wnl, minimal secretions with sxn, lungs cta bilat. will attempt to wean to cpap again in am.\\n\\nHemodynamics- pa advanced to 55, pcwp 14-17. cvp 9-13, rec lasix 40 mg iv x2. See flow sheet for u.o.\\n\\nLft's cont to decrease, hct, platelet and inr all within transplant team acceptable range so no blood products this shift.\\n\\nNutrition- npo, hypo bs, tpn started.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421811,\n \"text\": \"CONDITION UPDATE\\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\\nASSUMED CARE OF PT AT APPROX 1600.\\nNEURO: ALERT AND ORIENTED X3. MEDICATED WITH MSO4 FOR ABD PAIN WITH POS EFFECT. PT NOW C/O GAS PAIN. TRANSPLANT TEAM INFORMED.\\nRESP: LS CLEAR BUT DIM AT BASES. PT . O2SATS 98-100% ON 3LNC. IS GIVEN TO PT AND INSTRUCTED, BUT UNABLE TO USE CURRENTLY D/T GAS PAIN.\\nCV: AFEBRILE. NSR. +PP'S. HYDRALAZINE/LOPRESSOR CONTINUE. PA CATH D/C'D EARLIER TODAY.\\nGI: ABD DISTENDED. POS BOWEL SOUNDS. GAS PAIN. DK GOLDEN BILE VIA T-TUBE. SEROSANG DRG VIA MEDIAL JP.\\nGU: AMBER U/O VIA FOLEY.\\nENDO: FSBG COVERED PER RISS.\\nPLAN: ENCOURAGE T/C/DB AND IS USE. INCREASE ACTIVITY. ?DULC SUPP V. ENEMA (AWAITING ORDERS FROM TRANSPLANT). CONT PER CURRENT MGMT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421812,\n \"text\": \"CONDITION UPDATE\\nVSS. PT A/OX3. FREQUENT C/O ABD PAIN - TX'D W/ MORPHINE W/ EFFECT. THIS A.M. C/O CPAIN - RADIATING \\\"DOWN MIDDLE OF CHEST\\\". TXPLANT RESIDENT, DR. NOTIFIED. EKG ORDERED AND DONE. M.D. NO CHANGE IN EKG NOTED. NGT TO LWCS - MIN CLEAR DRAINAGE OUT. LUNGS CTA BILAT. O2 SAT GOOD ON 3L N.P. ABD SOFTLY DISTENDED. BOWEL SOUNDS PRESENT. PT C/O FREQUENT GAS PAIN. FLEETS ENEMA GIVEN X1, DULCOLAX ENEMA GIVEN X1 - SMALL BOWEL MOVEMENT. PT W/ 40MG IV LASIX W/ GOOD EFFECT. REMAINS ON INSULIN DRIP - BSUGARS LABILE. CONT TPN. CONT TO ASSESS FOR S/S OF INFECTION/ BLEEDING. PAIN MANAGEMENT. PT TEACHING. CONT CURRENT ICU CARE AND ASSESSMENT. D/C PLANNING.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421782,\n \"text\": \"Pt rec'd at approx. 0600 following liver transplant. Pt placed on CMV 700,12,100, 5 peep. ABG results pending.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421783,\n \"text\": \"Respiratory note:\\nPt is intubated/agitated. ETT advanced in 2cm and taped at 25cm at the lip. Noted to have frequent cuff leak.Tol psv trial on ps 20/5 peep for a while with good abg but than tachypenic with RR up to back on simv. Will obtain ABG on current simv 750x12,50%,5peep,0ps.Will cont vent support and wean as tol to extubate.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421806,\n \"text\": \"resp care:pt remains intubated and vented at this time with no resp distress noted.b/s diminished bilat,secretions minimal.present vent settings ps10 peep5 40% and tol well.will cont to re-assess as needed and wean as tolerated\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421807,\n \"text\": \"Condition Update\\nD: See carevue for specifics\\n Swan remains in place with CCO monitoring. Afebrile. HR 60's NSR no ectopy. BP 140's/60's. CVP 6-8. For today the plan was to continue to diurese patient. Pt received 40mg lasix this am with good diuresis. Currently -2L for the day. Transplant team wanting pt more negative prior to making any major vent changes. However patient tolerating vent changes well and as previously mentioned is -2L for the day. AM RSBI 40's. ABG's stable throughout day. Beginning to developed compensated resp acidosis. Gradually decreased vent to current settings of CPAP with 10PS, 5PEEP, FIO2 40%, RR 16-20, with spont tidal volumes 500's. Minimal secretions in afternoon in am noted to have some thick yellow.\\n Transplant resident plans to D/C lateral drain this eve (putting out min amts), no change in color other JP or Ttube. NGT cont to LCWS with clear output. ABD dressing leaking ?from around lateral tube site (serous).\\n Pt comfortable and reporting good pain control with MSO4 4mg Q3-4hrs. A/Ox3. MAE.\\n Continues on insulin gtt for blood sugar control. Titrated to maintain BS btwn 80-120. Cont on TPN for nutrition.\\nPLAN:\\n Check with transplant team re: goal for diuresis\\n Wean vent as tol\\n Cont pain management with MSO4\\n Frequent blood sugars\\n Notify H.O. with any changes.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421808,\n \"text\": \"Respiratory Care:\\nPt. had a quiet noc untill about 5 am when he C/O pain and discomfort.\\nRn gave pain meds.\\nPt's RSBI = 25 and was subsequently placed on a spontanious breathing trial. up to two hours if tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421809,\n \"text\": \"7p-7a; Full assessment in flow sheet.\\n\\nneuro; A+OX3. MAE. mouth words. Follow commands. Pain in abd. Inc pain in AM - HO and transplant MD notify - KUB and Biscodyl supportory order and done. Morphine ivp effective.\\n\\ncv; VSS, afebrile. CVP 6-8. Svo 2 80-88. CCO 7.2-9.8 (HO and neurosurg notify.). Swan unable to wedge - Dr. notify.\\n\\nresp; Clear in upper lobes. dimish at bases. CPAP 10/5 tolerate, do not breath over vent. Encourage deep breath and cough - productive cough thick/white sputum.\\n\\ngu/gi; soft distended abd. Tender in am on light palpation (HO notify). +BSX4. KUB done. no flatus. no bm. JP medial - site d/c/i - serosangious drainge. T-bile - bilious. NG - +placement, clear drainage. suture site d/c/i.\\n\\nint; Skin intact. Insulin drip titrate 80-120. AM lab done - potassium replace.\\n\\nPlan; Continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421810,\n \"text\": \"Respiratory Care Note:\\n Patient weaned and extubated today. BS with good aeration. Cough and voice intact. SpO2 100% on 40% FIO2 and plan to wean as tolerated and use of incentive spirometer.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421800,\n \"text\": \"condition update\\nD: pt alert and oriented. he follows commands. temp. max is 98.6. pa numbers are 30/14 and co is . svo2 remains 76-80. pt more comfortable on 4mg of ms04 requiring it appoximately every 2 hours. abgs remain good on simv. urine output remains greater than 100cc/hr and pt was 1800 neg for past 24hrs. sbp still greater than 200 after starting on lopressor and being medicated with ms04 for pain. dr. aware and pt given hypralozine 10mg x 2. sbp to 180-190. pt suctioned frequently for thick yellow sputum. incision continues to ooze serous/sanginous drainage. lateral jp drainage appears more bloody this evening. dr. aware and in to see pt. insuling drip titrated for blood sugars. pt is currently on 1unit/hour. platelet count 71. pt transfused with one unit of platelets.\\na: monitor fluid status. medicate for pain as needed. continue to monitor jp drainage. ? start to wean vent today. ? more diuresis today.\\nr: doing well post transplant. post transfusion count 98. pt appears more comfortable today on 4mg of ms04 for pain. jp continue to put out bloody drainage but amt has not increased. Approximately 20cc. dr. aware.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421801,\n \"text\": \"RESPIRATORY CARE\\nPT REMAIN INTUBATED, and on vent support, thick yelow rusty sputm Sx,am RSBI 113 .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421802,\n \"text\": \"See CareVue for objective data.\\n\\nVent settings changed to 15 PS/8PEEP. Tolerated well and ABG's adequate. RSBI 113 this AM and probable extubation in AM. Diuresised with a total of 60 mg lasix IV with excellent results. See CareVue for total I&O.\\nPA #'s remain relatively the same. ? D/C PA in AM. NSR-no ectopy.\\nHydralazine added to therapy 10 mg Q6H for BP control.\\nTPN infusing as ordered.\\nLeft JP drain leaking large amts of serosangious fluid around tube.\\nDSD changed Q2-3H.\\nMedicated with MSO4 for C/O left quadrant abdominal pain. Also, receives methadone .\\nPlts at 1400: 110 which is adequate and no intervention required at this time.\\nInsulin gtt remains and see CareVue for FSBS/titration of gtt.\\nAlert/oriented/cooperative.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421803,\n \"text\": \"resp care\\npt remains intubated and mech ventilated. pt weaned to cpap+ps - pt tol well, w/good abg's. b/s clear on rt, sl coarse lul. plan: cont w/mech support, wean ps as tol.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421804,\n \"text\": \"Respiratory Care\\nPt remain intubated and on vent support, changed to SIMV for over night rest.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421805,\n \"text\": \"7a-7p; Full assessment in flow sheet.\\n\\nneuro; A+OX3. Follow directions. MAE. Good cough and gag reflex. PERL. Pain in abd - morphine ivp given - good effect. Slept on and off most of night.\\n\\ncv; VSS, afebrile. Warm, dry, no edema.\\n\\nresp; Clear in upper lobes. dimish at bases. SIMV to rest at night. Did not overbreath. ABG - wnl. CPAP 15/8 in am.\\n\\ngu/gi; soft distended abd. +BSX4. Suture site - d/c/i. JP #2 - leaking (HO and trasplant team aware) - more bloody drainage. JP #1 - d/c/i - ss drainage. T-bile - bile drainage. NG - +Placement, negative guiac, bilious drainage. DSD for JP site X3.\\n\\nskin intact. Insulin drip. AM lab and night lab done - no new order for lytes replacemnet from HO.\\n\\nPlan; continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421788,\n \"text\": \"NURSING UPDATE\\n AFEBRILE, REMAINS MODERATELY HYPERTENSIVE WITH SBP 170'S. K+ AND ICA+ REPLETED. CONT ON INSULIN GTTS.\\n AWAKE AND APPROPRIATE, NO AGITATION OR RESTLESSNESS. COOPERATIVE WITH CARE. PROPOFOL WEANED TO OFF BY 0500. MSO4 1MG IVP FOR C/ /INCISION PAIN, PT LOCALIZING.\\n PLATELETS 88 @ 1800, TRANSFUSED WITH 1 5-PACK PLATELETS, POST TX LEVEL 109.\\n PICC LINE OCCLUDED, DISCONTINUED PER DR .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421796,\n \"text\": \"condition update\\nD: pt cooperative and follows commands. pt remains hypertensive to 200 and co is 8 and sv02 is 80. pt treated with second does of iv lasix 40mg with good diuresis. he was 2400 negative for the day. platelets remain greater than 100 and hct was 37 at 2200. po2 down to 77 on 50% and 5 of peep. peep increased to 7.5. pt suctioned for rust colored sputum. pt c/0 incisional pain. he remains on methadone . pt appears uncomfortable splinting stomache and wincing. when asked he states that he is in pain. pt continues to receive 2mg of mso4 q1hr pt still uncomfortable after receiving dose at 2am.\\na: dr. aware and ordered. extra ms04 dose of 2mg x1. continue to monitor I&o. check labs as ordered.\\nr: pt still uncomfortable with mso4. ? change to different pain med when team rounds. incision continues to drain large amts of serous/sanginous drainage. frequent dsg changes done. urine output remains good after lasix dose.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421797,\n \"text\": \"Resp Care Note, Pt remains on current vent settings increased to 8 peep for low PaO2. RSBI 40.8. Suctioning mod amts thick bile looking secretions. Having belly pain otherwise stable. Will cont to monitor resp status for further weaning\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421798,\n \"text\": \"RESPIRATORY CARE: PT. REMAINS INTUBATED AND ON\\nAN SIMV MODE AS PER CAREVUE. ABG STABLE. SX. FOR\\nMODERATE AMTS. OF RUSTY SPUTUM. ETT MOVED TO RIGHT\\nSIDE OF MOUTH AND RETAPED. PLATEAU PRESSURES ARE\\nBETWEEN 30 - 34 CM H2O - WILL MONITOR AND LOWER\\nTIDAL VOLUME TO 700 CC IF NECESSARY IF LIVER\\nAND SICU TEAM AGREES.\\n\\n , RRT\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421799,\n \"text\": \"CONDITION UPDATE\\nD: NEURO: ALERT AND APPEARS ORIENTED X 3. FOLLOWING COMMANDS, COOPERATIVE\\nCV: CONTINUES TO BE HYPERTENSIVE TO 200 SYSTOLIC- STARTED ON LOPRESSOR 5MG IV Q6HRS, OTHER VSS- SEE CAREVUE FOR SPECIFICS\\nRESP: BS REMAIN COARSE IN UPPER AIRWAYS AND DIMINISHED IN BASES. SX FOR RUST COLORED SPUTUM. NO VENT CHANGES- ABG IMPROVED AFTER DIURESIS\\nGI: NPO, ABD SOFT AND NON-TENDER, + FLATUS, NO STOOL, NGT PATENT AND DRAINING BILIOUS, LESS DRAINAGE FROM AROUND LATERAL JP THIS AFTERNOON.\\nGU: LASIX 40 MG IV X 1 WITH GOOD DIURESIS\\nENDO: CONTINUES ON INSULIN GTT AT 2-5UNITS PER HR\\nA: PAIN MED INCREASED TO 4MG IV Q1HR PRN WITH SOME IMPROVEMENT IN PT COMFORT, HEMODYNAMICS MONITORED\\nR: STABLE, CONTINUE TO DIURESIS\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421789,\n \"text\": \"Resp care\\nPt remains intubated & supported, placed on SIMV/PS mode\\nover night. B/S clear, Sx mod. amounts of thick bloody\\nsecretions. RSBI= 87, Pt currently on SBT\\nPlan: poss. extubation\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421790,\n \"text\": \"nsg note\\nNeuro- propofol off since 5 am- mso4 prn, follws simple command, moves all ext on bed.\\n\\nResp- attempt to wean to cpap 5/5 but rr up to 35-40- ips increased to 10- abg wnl. lungs clear- left base, minimal secretions with sxn.\\n\\nHemodynamics- cco pa in place- see flow sheet for #'s. cvp 9-12, uo 50-80, ivf tko.\\n\\nlft cont to decrease, platelet count noon labs 76- rec 1 5pk, creatanine 2.0, no lasix today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421791,\n \"text\": \"Resp care\\nremains ett/vent support in psv mode. slightly tachypneic on , incr to with good results. still volume overloaded, no further weaning done today. sxned scant sma amts brownish secretions. c/w psv as tolerates, sbt in a.m.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421792,\n \"text\": \"Resp Care Note, Pt remains on current vent settings. See vent flow sheet for further details. RSBI 91.7. suction lrg amts thick rusty bile looking secretions. Awake and alert. Will cont to wean to extubate\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421793,\n \"text\": \"condition update\\nneuro: pt seems oriented, nods appropriately, mea, gestures to communicate.\\ncardiovasc: hypertensive to low 200's. co/ci hr stable. see flow sheet for details.\\nresp: abg's on cpap with po2 60's. changed to simv, will recheck abg after 30 mins. sx for thick rust colored sputum.\\ngi: min bowel sounds.\\ngu: u/o good.\\nincision: jp's milked q 1 hr, draining minimally, leaking profusely from around lateral jp.\\nPAIN issues: pt c/o pain in abd, around incision. med q 2 hrs with ms 1 mg iv. pt has minimal pain relief. methadone 45 mg po bid.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421794,\n \"text\": \"condition update\\nd: neuro: alert, appears oriented, cooperative, mae to command\\nresp: changed to simv early in am secondary to poor abg and tiring, bs clear in upper airways but diminished in bases, sx for rust colored sputum- cx sent\\ngi: abd soft, hypoactive bs, no stool\\ngu: lasix 40 mg iv x1 with good diuresis\\nendo: bs tx'd with insulin gtt- see carevue for specifics\\ncv- remains hypertensive- team aware, other vss- see carevue for specifics\\na: hemodyanmics monitored, cxr done x2\\nr: stable at present,\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-10-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421795,\n \"text\": \"RESPIRATORY CARE: PT. REMAINS INTUBATED AND ON\\nSIMV MODE AS PER CAREVUE. STABLE ABG. SX. FOR\\nRUSTY COLORED SPUTUM. ETT RETAPED AND MOVED TO\\nLEFT SIDE OF MOUTH.\\n\\n , RRT\\n\"\n }\n]"}}},{"rowIdx":24690,"cells":{"subject_id":{"kind":"number","value":15876,"string":"15,876"},"hadm_id":{"kind":"number","value":119894,"string":"119,894"},"target_text":{"kind":"string","value":"A/P: 72 yo woman c T2 DM, HTN, admitted c elevated BS up to 400, metabolic acidosis c hyperkalemia , renal failure, UTI and respiratory failure most likely d/2 aspiration and heart failure. . #Respiratory failure- Patient was intubated at OSH after witnessed aspiration event after receiving kayexelate. She remained intubated after transfer initially and was slowly weaned off the ventilator. Once her metabolic status was improved, she was extubated. Post extubation she continued to have high oxygen requirement with one or two episodes of desaturation. CXR was consistent with volume overload and she was given lasix for diuresis. She diuresed well with IV lasix and her O2 requirement improved. She was also treated with levoflox for aspiration Pneumonia. . # Hyperkalemia - at OSH, patient was given Calcium gluconate, bicarb. Renal was consulted on transfer to ICU. They recommended IVF and lasix, along with calcium, bacarbinate,insulin, glucose, albuterol and kayexalate. Her potassium steadily improved and by the following day she was hypokalemic. It was unclear why patient was hyperkalemic, not clearly medication related. She had elevated blood sugars on admission and acute renal insufficiency. . # Renal failure- Initially her renal function improved with aggressive iv fluids and then tapered off. She was diresed and her renal function improved to 1.7 on day of discharge. Prior to discharge she was started on Losartan. Her potassium and renal function should be monitored closely. . # CHF- Initially given concern for infection and elevated lactate she received aggresive IV fluids. After high O2 requirements post extubation she was given lasix for diuresis. Her oxygen saturation improved drastically. Echo was done which showed EF 40-45%. She was also restarted on her and hydral/imdur were added for afterload reduction. Aspirin was continued. Her creatinine and potassium should be monitored daily. . # UTI - Urine with GPC, She received a 7 day course of Vancomycin. . # T2DM - Cont SSI. She should be restarted on her PO diabetic regimen after discharge. # FEN - Patient received tube feeds while she was intubated. Post extubation she underwent a Speech and Swallow evaluation given her history of aspiration pneumonia. Her swallow eval was ok and her diet was advance to po diet."},"extractive_notes_summ":{"kind":"string","value":"Paradoxic septal motion consistent with conductionabnormality/ventricular pacing.AORTA: Mildly dilated aortic root. Likely left pleural effusion. Mild (1+) mitral regurgitation is seen. Breaths unlabored.Caridac: Rare ectopy on monitor. Mild mitral annularcalcification. Mildly dilatedascending aorta.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a low risk (prophylaxis not recommended). There is mild symmetric left ventricularwall hypertrophy with normal cavity size. Mild mitral regurgitation. The aortic root is mildly dilated. There is mild symmetric leftventricular hypertrophy with normal cavity size. Again note is made of patchy bibasilar opacity. Again note is made of endotracheal tube and nasogastric tube, unchanged compared to the prior study. Remains hypertensive with sbp 130-160's. Mild (1+) MR.TRICUSPID VALVE: Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Now extubated presenting with right lower lung crackles. Shortness of breath.Height: (in) 69Weight (lb): 192BSA (m2): 2.03 m2BP (mm Hg): 158/64HR (bpm): 73Status: InpatientDate/Time: at 10:38Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.RIGHT VENTRICLE: Normal RV chamber size. Overall systolic function is mildly reduced.Right ventricular cavity size is normal. Otherwise, unremarkable evaluation of the kidneys. IMPRESSION: Persistent low lung volumes status post extubation. Again note is made of patchy bibasilar opacity with low lung volumes. Borderline normal RV systolicfunction. Based on AHA endocarditis prophylaxis recommendations, the echo findings indicate a lowrisk (prophylaxis not recommended). Septal motion is abnormal(?related to IVCD/postoperative). There is no pericardial effusion.IMPRESSION: Mild symmetric left ventricular hypertrophy with mildly reducedleft ventricular systolic function. First degree A-V delay. Quad lumen in L subclavian site benign.ID: Continues on levofloxacin. SINGLE PORTABLE AP SUPINE VIEW OF THE CHEST: The endotracheal tube terminates at the thoracic inlet. Low lung volumes are again demonstrated which exaggerate the heart size which is probably normal. Normalascending aorta diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). IMPRESSION: Distended loops of colon to the sigmoid without air in the rectum. The aortic valve leaflets (3) aremildly thickened but aortic stenosis is not present. Baseline artifactSinus rhythmFirst degree A-V delayProbable left atrial abnormalityLeft bundle branch block with intermittent left axis deviationSince previous tracing of , intermittent shift of axis to left axisdeviation now present FINDINGS: The central venous line from left subclavian vein is terminating in upper SVC. No AR.MITRAL VALVE: Normal mitral valve leaflets. Bilateral lower lobe atelectasis. Elevation of the right hemidiaphragm. R lower lung crackes. R lower lung crackes. IMPRESSION: AP chest compared to : Lung volumes remain quite low due to marked elevation of the diaphragm or perhaps function of intestinal distention, is seen in the upper abdomen. The left hilum is prominent as before. AM lytes pending voiding 150-220cc/hr via foley.Derm: Grossly intact. There is bilateral lower lobe atelectasis. FINDINGS: The gallbladder appears normal without stones. There is elevation of the right hemidiaphragm. morning ABG 7.30/46/79, pt needs to be encourge to cough.cv: HR 60-70's, 1st degree AV block and LBBB. per chest xray from pleural effusion on left side.cv: HR 60-70's, 1st degree AV block, LBBB, during respiratory distress was done ECG, no changes shown, cardio ensymes sent CPK 38, troponin 0.05, second set of ensymes sent at 0700, please send 3nd set in 8hr.pt received Nitro SL, start Aspirin Po, LOsartan PO. Albuterol DC'ed. pedal and tib pulses weakEndo finger stick 121-190, evening bs covered with 4U reg tonight now that pt has started clear ligs.A/p Continue with pul toilet, cpt, alb nebs, continue with lasix as needed, attempt to ween fio2 if possible htn meds still need to be adjusted to bring DBP down under 100. FOR DILAYSIS IF K DOES NOT COME DOWNSKIN..INTACTLINES..ART LINE CENTRAL LINE PLACED OK TO USESOCIAL..SON , HAS BEEN UPDATED BY TEAM AND AWARE OF PLAN OF CAREPLAN..AGRESSIVE BLOOD SUGAR MANAGENNT/AGRESSIVE FLUID MANAGEMENT..RESP SUPPORT..FOLLOW K/BUN/CREAT ASPIRATION REQUIRING INTUBATION....K REMAIJNS ELEVTAED > 6.0NEURO...RECEIVED ON PROPOFOL @ 10MCGS/KG..INCRESAED TO 15 AS ATTEMPTING TO PULKL AT ET TUBE..PRESENTLY SEEMS COMFORTABLE..EASY TO ROUSE FOLLOWS SIMPLE COMMNADS...PUPILS EQUAL /REACTIVECVS....ART LINE PLACED, B/P 120-130 SYSTOLIC..HR SINUS RYTHM/BRDAY @ 55-60BPM [ ON BBLOCKERS AT HOME ]...AFEBRILE..ON AB'S FOR ? 1900-0700 rn notes micuneuro: pt's lethargic, arousable to voice, orientedx3, follows commands, mae. admin albuterol neb x2. EKG with LBBB 2nd degree a-v block. CVP in the beginning of shift , after fluid bolus CVP 17-19, currently 14-15. afebrile, cont ABX.gi/gu: foley in place, in the begining of shift 0cc urine, given Fluid bolus 500cc with good response, u/o 60-120cc, @ 0300 u/o dropped to 0cc, MD notiefed, fluid bolus held d/t crakles in Rt side of lungs, given Lasix 20mg IV. Hyperkalemia resolving. 1900-0700 rn notes micuneuro: A/Ox3, mae folows commands.resp: cont hi flow mask, o2 down to 60%, sat 92-95, pt desat to 88% on rt side. BP 120-160/50-60, start Hydralasin 10mg po. c/w albut nebs q6prn. LS crakles on Rt side, clear left, per chest Xray, small pleural efussion on left side, received Lasix IV 20mg. 12 noon blood sugar 319 pt recieved 10U sq, K 3.3 was repleated with 40 of kcl.A/P pul poilet ween fio2 if tol, follow labs and repleat K as needed, extubated on , put on hi flow mask 80-95% , unable to wean O2->pt deast to low 80's.neuro: A/Ox3, mae, follows comands, opens eyes spont. Cont to pass mod amts liquid stool.Resp- Intub/vent on ac 550x12 5 peep fio2 decreased to 40% with sats 97-98% Last abg 81/30/7.39. CVP 9-15gi/gu: foely in place, rceived Lasix 40mg,goal neg 1000L, u/o 100-120cc/hr. cont Hydralasin 20mg for BP 140-160, A-line positional, time to time does not collertae with NBP.pt received Potassium 40meqx2 for K+3.2 and Mag 400mg for MAg 1.8. morning labs pending. bs rhonchorous, occas exp wheezing. WILL NEED DILAYSIS IN FUTURE....EXTUBATED @ 11.30HRS BUT HAS REQUIRED INCREASING AMOUNTS OF O2 THIS PM [ LOW TOLERANCE TO CPAP PATIENT]NEURO..RECEIVED ON PROPOFOL BUT SWICHED OF EARLY AM IN ANTICIPATION TO EXTUBATE..SINCE EXTUBATION LETHARGIC/TIRED BUT ORIENTATED TO PERSON/PLACE MOVING ALL 4 LIMBS, PARTAKING IN CARE ANSWERIN QUESTIONS APPROPRAITLY...DENIES ANY PAINRESP...EXTUBATED AND PUT TO FACE TENT @ 50% SATS @ 94% ABG SHOWED LOW PO2 FIO2 INCRESAED TO 70 % , RECEIVED CHEST P/T INCENTIVE SPIROMETER AND ENCOURAGEMENT TO COUGH DEEP BREATH, WEAK COUGH...DOES SOUND DIMINISHED ON RT, POSSIBLY RELATED TO ASPIRATION FROM YESTERDAY THAT REQUIRED INTUBATION...REPEAT BLOOD GAS SHOWED NO IMPROVEMENT WITH PO2 THEREFORE DISCUSSED WITH TEAM AND SWITCHED TO HIGH FLOW @ 80% ..WILL REPEAT ABG..DENIES ANY DISCOMFORT OR SOB....AS DISCUSSED WITH TEAM LOW THRESHOLD DOR PLACING PATIENT ON NON-INVASIVE VENTILATIONCVS...HR SHOWS LBBB WITH FIRST DEGREE HB ,RATE @ 70-73..LAST PM EPISODE OF BRADYCARDIA TO 40, 2:1 BLOCK SPONTANEOUSLY RIVERTED /NO INTERVENTION REQUIRED, NO FURTHER EPIOSDES TODAY AND PACING PADS REMOVED...B/P HAS REMAINED STABLE 120-135 SYTSOLICCVP 8-10 THIS AM..PM DOWN TO 3-5 THEREFORE RECEIVED BOLUS FLUID, PRESNTLY @ 7ID...INCRESAING WBC TODAY TO 18, CONTINUES ON LEVO AND VANC COMMENCED TODAY..TREATED FOR UTI AND POSSIBLE ASPIRATION PNEUMONIARENAL... RENAL TEAM FOLLOWING CLOSELY...U/O OVERNIGHT 10-20CC/HR DESPITE BOLUSES OF FLUID...INCREASED THIS AM 20-60CC/HR BUT TAILED OF AGAIN THIS PM TO 15-25CC..CVP DOWN THEFORE BOLUS OF 500CC GIVEN AT 1700HRS, TO MONITOR FOR EFFECTRENAL FOLLOWING, CREAT /BUN SLOWLY CLIMBING , WELL REQUIRE DILAYSIS IN NEAR FUTUREK STABLE THIS AM >4.0 AWAITING PM LYTES...ENDO...NOW OF INSULIN DRIP AND ON S/S ..Q4HRLY CHECKS..HAVE REMIANED < 200 BUT S/S NEEDS TO BE ADJUSTED TO GAIN BETTER CONTROLGI...LETHARGIC AND INCRESAING O2 REQUIREMENTS THEREFORE ONLY GIVEN PATIENT ICE CHIPS AND APPERAS TO BE TOLERATING..HAS MUSHROOM CATH IN PLACE..CONTINUES TO PUT OUT {>1000MLS LIQUID STOOL FOR THE DAY} POST KAYEXALATE FROM YESTERDAY BUT IS SLOWING DOWN THIS PMSKIN..PALE BUT INTACT [ HCT STABLE]..RECENT CATARCT SURGERY, NEEDS ETE DROPS ORDERINGLINES..ART/CENTRAL LINE INTACTSOCIAL..SON IN TO VISIST THIS AM AND UPDATED...HE SAYS THAT HIS MOTHER RECENTLY DIAGNOSED AS INSULIN DEPENDENT DIABETIC BUT CHOSE NOT TO TAKE THE INSULIN..HE SAYS THAT SHE HAS KEPT THIS INFORMATION FROM HIM ?"},"n_notes":{"kind":"number","value":30,"string":"30"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2136-04-02 00:00:00.000","description":"Report","row_id":81779,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Shortness of breath.\nHeight: (in) 69\nWeight (lb): 192\nBSA (m2): 2.03 m2\nBP (mm Hg): 158/64\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 10:38\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size.\n\nRIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV systolic\nfunction. Paradoxic septal motion consistent with conduction\nabnormality/ventricular pacing.\n\nAORTA: Mildly dilated aortic root. Focal calcifications in aortic root. Normal\nascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild mitral annular\ncalcification. Calcified tips of papillary muscles. Mild (1+) MR.\n\nTRICUSPID VALVE: Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Based on \nAHA endocarditis prophylaxis recommendations, the echo findings indicate a low\nrisk (prophylaxis not recommended). Clinical decisions regarding the need for\nprophylaxis should be based on clinical and echocardiographic data.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nwall hypertrophy with normal cavity size. There is mild symmetric left\nventricular hypertrophy with normal cavity size. Septal motion is abnormal\n(?related to IVCD/postoperative). Overall systolic function is mildly reduced.\nRight ventricular cavity size is normal. Free wall motion is borderline\nnormal. The aortic root is mildly dilated. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. No aortic regurgitation\nis seen. The mitral valve leaflets are structurally normal. There is no mitral\nvalve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery\nsystolic pressure could not be quantified. There is no pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with mildly reduced\nleft ventricular systolic function. Mild mitral regurgitation. Mildly dilated\nascending aorta.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"},{"category":"ECG","chartdate":"2136-04-01 00:00:00.000","description":"Report","row_id":203424,"text":"Baseline artifact\nSinus rhythm\nFirst degree A-V delay\nProbable left atrial abnormality\nLeft bundle branch block with intermittent left axis deviation\nSince previous tracing of , intermittent shift of axis to left axis\ndeviation now present\n\n"},{"category":"ECG","chartdate":"2136-03-31 00:00:00.000","description":"Report","row_id":203425,"text":"Probable sinus rhythm, rate 75. Since the previous tracing of \nsignificant technical artifacts are noted. Positional changes are seen over the\nlateral precordium.\n\n"},{"category":"ECG","chartdate":"2136-03-30 00:00:00.000","description":"Report","row_id":203426,"text":"Sinus rhythm, rate 66. Since the previous tracing the heart rate is faster.\nPositional changes are seen over the lateral precordium.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2136-03-29 00:00:00.000","description":"Report","row_id":203427,"text":"Sinus rhythm, rate 53. Since the previous tracing of the heart rate\nhas slowed. The Q-T interval is further prolonged. Positional changes are seen\nover the lateral precordium.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2136-03-29 00:00:00.000","description":"Report","row_id":203428,"text":"Sinus rhythm. First degree A-V delay. Left bundle-branch block. No previous\ntracing available for comparison.\n\n"},{"category":"Radiology","chartdate":"2136-03-29 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":903728,"text":" 6:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p intubation\n REASON FOR THIS EXAMINATION:\n eval ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post intubation, evaluate endotracheal tube placement.\n\n SINGLE PORTABLE AP SUPINE VIEW OF THE CHEST: The endotracheal tube terminates\n at the thoracic inlet. Note that the distal tip of the endotracheal tube\n abuts the right tracheal wall. Heart size is borderline for technique. There\n is bilateral lower lobe atelectasis. There is elevation of the right\n hemidiaphragm. No evidence of pneumothorax.\n\n IMPRESSION:\n\n 1. Endotracheal tube terminating at the thoracic inlet with distal tip\n abutting the right lateral wall of the trachea.\n 2. Elevation of the right hemidiaphragm.\n 3. Bilateral lower lobe atelectasis.\n\n"},{"category":"Radiology","chartdate":"2136-03-29 00:00:00.000","description":"BY DIFFERENT PHYSICIAN","row_id":903842,"text":" 5:07 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate line\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p line placemnent\n\n REASON FOR THIS EXAMINATION:\n evaluate line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old woman with line placement.\n\n TECHNIQUE: Portable chest radiograph.\n\n COMPARISON: Chest radiograph dated , taken approximately 12\n hours earlier.\n\n FINDINGS: The central venous line from left subclavian vein is terminating in\n upper SVC. No pneumothorax. Again note is made of endotracheal tube and\n nasogastric tube, unchanged compared to the prior study. There is persistent\n opacity at the right hilum, overlying the tip of subclavian venous line, which\n may represent atelectasis; however, mediastinal pathology such as\n lymphadenopathy cannot be totally excluded. Again note is made of patchy\n bibasilar opacity with low lung volumes.\n\n IMPRESSION: Tubes and lines as described above. Persistent opacity overlying\n the right hilum, which may represent atelectasis; however, underlying\n mediastinal pathology such as lymphadenopathy cannot be totally excluded.\n Bibasilar atelectasis. Prominent colon gases. Clinical correlation is\n recommended.\n\n The referring physician, . , has been paged.\n\n"},{"category":"Radiology","chartdate":"2136-03-29 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":903822,"text":" 4:04 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o intestinal obstruction\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with n/v r/o obstruction\n REASON FOR THIS EXAMINATION:\n r/o intestinal obstruction\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 72-year-old female with nausea, vomiting. Rule out obstruction.\n\n There are distended loops of large bowel to the level of the sigmoid. There is\n no air in the rectum. Supine positioning does not allow adequate evaluation\n for obstruction. No bowel gas is seen within the rectum. The intestinal tube\n is seen overlying the distal stomach.\n\n IMPRESSION: Distended loops of colon to the sigmoid without air in the\n rectum. This may represent distal large bowel obstruction. Repeat films in two\n views (including upright/decubitus view) could be obtained. Alternatively, a\n gastrografin enema would be helpful to exclude distal obstruction.\n\n"},{"category":"Radiology","chartdate":"2136-03-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":904029,"text":" 7:56 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: pls eval for chf vs. infiltrate\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman adm to MICU s/p aspiration event and intubation. Now\n extubated. R lower lung crackes.\n REASON FOR THIS EXAMINATION:\n pls eval for chf vs. infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female admitted to MICU status post aspiration and\n intubation. Now extubated presenting with right lower lung crackles.\n\n COMPARISON: AP chest dated earlier today at 0334 hours.\n\n AP ERECT CHEST RADIOGRAPH: There has been interval removal of the\n endotracheal tube. A left subclavian catheter remains in an unchanged\n position. Low lung volumes are again demonstrated which exaggerate the heart\n size which is probably normal. There is no evidence of pneumothorax. The\n mediastinal and hilar contours are stable. Again note is made of patchy\n bibasilar opacity. There is likely left lower lobe effusion.\n\n IMPRESSION: Persistent low lung volumes status post extubation. Likely left\n pleural effusion. No evidence of pneumothorax. Plate-like atelectasis at the\n right base.\n\n\n"},{"category":"Radiology","chartdate":"2136-04-02 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":904212,"text":" 3:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate after diuresis\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman adm to MICU s/p aspiration event and intubation. Now c\n CHF exacerbation\n REASON FOR THIS EXAMINATION:\n evaluate after diuresis\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:40 A.M., \n\n HISTORY: Aspiration. CHF exacerbation.\n\n IMPRESSION: AP chest compared to , and 12:\n\n Dense bilateral perihilar consolidation which progressed from through\n is now joined by moderate pulmonary edema worsened since ,\n accompanied by increasing moderate bilateral pleural effusion. Mediastinal\n contour indicates elevated central venous pressure. Lung volumes are quite\n low exaggerating heart size which is probably top normal and only slightly\n enlarged. No pneumothorax. Tip of the left subclavian line projects over the\n junction of the brachiocephalic veins. No indication of pneumothorax.\n Colonic distention seen in the splenic flexure is unchanged over the past\n several days.\n\n\n"},{"category":"Radiology","chartdate":"2136-04-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":904208,"text":" 10:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?etiology of frequent desaturation\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman adm to MICU s/p aspiration event and intubation. Now\n extubated. R lower lung crackes.\n REASON FOR THIS EXAMINATION:\n ?etiology of frequent desaturation\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: New right lower lung crackles. Frequent desaturations.\n\n CHEST PORTABLE AP, AT 22:42 HOURS:\n\n Findings; compared to , lung volumes remain decreased, likely related\n to inspiratory effort. Left subclavian CVL is in stable position. There are\n new large right perihilar consolidations. The left hilum is prominent as\n before. There are bilateral pleural effusions.\n\n Gaseous distention of the colon throughout the abdomen is not significantly\n changed.\n\n IMPRESSION: New large perihilar consolidations, right significantly worse\n than left.\n\n"},{"category":"Radiology","chartdate":"2136-03-29 00:00:00.000","description":"ABDOMEN U.S. (PORTABLE)","row_id":903827,"text":" 3:45 PM\n ABDOMEN U.S. (PORTABLE) Clip # \n Reason: r/o cholecystitis and please eval kidney size.R?O obstructio\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with nausea and vomiting.renal failure\n REASON FOR THIS EXAMINATION:\n r/o cholecystitis and please eval kidney size.R?O obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 72-year-old woman with nausea, vomiting, and renal failure.\n\n COMPARISONS: None.\n\n TECHNIQUE: Abdominal ultrasound examination.\n\n FINDINGS: The gallbladder appears normal without stones. There is no intra-\n or extra-hepatic biliary ductal dilatation. The main portal vein shows\n appropriate hepatopetal flow. The echotexture of the liver appears normal,\n and no focal hepatic lesions are identified. The pancreas is not well seen\n because of overlying bowel gas. However, a portion of the proximal pancreas\n appears unremarkable, the tail being completely obscured. The spleen is\n normal in size and appearance. The right kidney measures 9.4 cm in length,\n somewhat small. The left kidney measures 11.4 cm. Otherwise, both kidneys\n appear normal without stones, masses, or hydronephrosis. There is trace\n ascites about the liver.\n\n IMPRESSION:\n 1. No evidence of hepatobiliary abnormality.\n 2. Slightly small size of right kidney. Otherwise, unremarkable evaluation\n of the kidneys.\n\n\n"},{"category":"Radiology","chartdate":"2136-03-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":903884,"text":" 3:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evolution of aspiration PNA\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p line placemnent\n\n REASON FOR THIS EXAMINATION:\n evolution of aspiration PNA\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:34 A.M, :\n\n HISTORY: Line placement. Evolving aspiration.\n\n IMPRESSION: AP chest compared to :\n\n Lung volumes remain quite low due to marked elevation of the diaphragm or\n perhaps function of intestinal distention, is seen in the upper abdomen.\n\n Opacification at the lung bases could represent either a small to moderate\n degree of atelectasis or pneumonia.\n\n Low lung volumes exaggerate the heart size, which is probably normal. There\n is no pneumothorax. Small bilateral pleural effusions are probably present.\n Tip of endotracheal tube with the chin elevated is above the clavicles at\n least 6 cm from the carina, 2-3 cm above optimal placement. The tip of the\n left subclavian line projects over the SVC. Nasogastric tube passes into the\n stomach and out of view.\n\n Dr. was paged to report these findings, at the time of dictation.\n\n\n"},{"category":"Nursing/other","chartdate":"2136-04-03 00:00:00.000","description":"Report","row_id":1468858,"text":"Uneventful night for Ms . Slept on and off. No further diuretics given this shift.\n\nNeuro: Pt a+ox3, MAE, following commands consistently, C/O R hip pain on and off. Tx with repositioning.\n\nResp: Lung sounds continue with bibasilar crackles. O2 sat mid to high 90's on 3L O2. No c/o difficulty breathing. Breaths unlabored.\n\nCaridac: Rare ectopy on monitor. Remains hypertensive with sbp 130-160's. Hydralazine increased to 30mg PO q6 Isordil increased to 20mg po TID tolerating both well. EF yestereday showed EF of 40%.\n\nGI: Positive bowel sounds. No BM this shift. C/O lack of appetite.\n\nGu: Ended day negative 1750cc's. AM lytes pending voiding 150-220cc/hr via foley.\n\nDerm: Grossly intact. Quad lumen in L subclavian site benign.\n\nID: Continues on levofloxacin. Vancomycin increased to QD. Afebrile\n\nPlan: Continue to diurese with goal neg 1500-2L neg, call out to floor. titrate B/P meds to effect. oob as tolerated.\n"},{"category":"Nursing/other","chartdate":"2136-04-03 00:00:00.000","description":"Report","row_id":1468859,"text":"nsg transfer note\nPt was screened and acceptted @ in . Was cleared by MICU team as stable for transfer to Rehab. VS- stable no SOB, ambulance called for, awaiting arrival.\n"},{"category":"Nursing/other","chartdate":"2136-04-01 00:00:00.000","description":"Report","row_id":1468854,"text":"1900-0700 rn notes micu\n\nneuro: A/Ox3, mae folows commands.\n\nresp: cont hi flow mask, o2 down to 60%, sat 92-95, pt desat to 88% on rt side. LS crackles on rt side and wheezing, received neb.cough/gag reflex intact. pt's been encourge to cough. in the morning sat 87-89%, put O2 80%, sat 94%.\n\ncv: HR 70's, 1st degree AV block, LBBB, with ocass PVC's. cont Hydralasin 20mg for BP 140-160, A-line positional, time to time does not collertae with NBP.pt received Potassium 40meqx2 for K+3.2 and Mag 400mg for MAg 1.8. morning labs pending. CVP 9-15\n\ngi/gu: foely in place, rceived Lasix 40mg,goal neg 1000L, u/o 100-120cc/hr. abd soft BS +, no BM, tolerate ice chips and small amount water.\n\n\nid: still requred bear hugger for low temp 94.4, currently 97.1.\n\nendo: cont RISS, see carevue.\n\nsocial: full code, family viseted/updated.\n\nplan: cont monitoring resp/cardio status. u/o.\n"},{"category":"Nursing/other","chartdate":"2136-04-01 00:00:00.000","description":"Report","row_id":1468855,"text":"Micu nurisng note 7-7a\n\nNeuro Pt is awake and alert,following commands pt OOb to chair for 3 hrs this am. pt did have difficulty getting back to bed at noon because of fitigue.\n\nCV Pt Bp in better control today 130/103-122/72 hr LBBB, pt co of chest pain at 3 pm, ekg done no changes pt given 30cc myanta for GI distress this happend 30min after taking po K, pt states by 445 heart burn is gone.\n\nResp pt On hi flow at 90% able to ween pt down for sever hrs to 80% but then ending up ^ back to 90% when sats staying in the low 90's, Lung sounds crackles on right and course LLL, no sputum production.\n\nGI pt advanced to renal diet today, tol well, abd soft non tender,bowel sound x4.\n\nGU pt continues to recieve lasix Iv x1 today followed with 40 of kcl at 230 pm, u/o 80 cc hr, after lasix, u/o had dropped down durring the day to 30 cc prior.\n\nId pt off bear hugger temp back to 97, pt remains on IV antibiotics\n\nEndo. 12 noon blood sugar 319 pt recieved 10U sq, K 3.3 was repleated with 40 of kcl.\n\nA/P pul poilet ween fio2 if tol, follow labs and repleat K as needed,\n"},{"category":"Nursing/other","chartdate":"2136-04-02 00:00:00.000","description":"Report","row_id":1468856,"text":"73 y.o female initailly admitted to from OSH d/t hyperkalemia 7.2, lactate 5.2-?sepsis, ?new ARF with Creat 2.2 CHF , IDDM, recieved Keayxalat,was intubated d/t aspiration. extubated on , put on hi flow mask 80-95% , unable to wean O2->pt deast to low 80's.\n\nneuro: A/Ox3, mae, follows comands, opens eyes spont. at the beginning of shift c/o of back pain, became agitated,desat to 83-84%, received Morphine 2mg with good response.\n\nresp: received with hi flow mask 95% and NC 5L, unable to wean O2 down. at begining of shift pt became agitated d/t back pain, desat to 83-84% breathing became labor, LS bilat crackles and wheezing, pt c/o SOB, chest xray was done, shown pulmonary edema, CHF-> received Lasix 40mgx1 and 80mg x2 and Morphine 2mg, nebs,ABG 7.33/50/60. overnight pulmonary edema resolved, LS coarse on rt side, clear left, SAT up to 97-99%, attempt to wean O2 to 80% failed, pt start c/o of SOB and sat down to 95%. cough intact, but weak and non productive,pt needs to be encourge to cough and deep breathing. per chest xray from pleural effusion on left side.\n\ncv: HR 60-70's, 1st degree AV block, LBBB, during respiratory distress was done ECG, no changes shown, cardio ensymes sent CPK 38, troponin 0.05, second set of ensymes sent at 0700, please send 3nd set in 8hr.\npt received Nitro SL, start Aspirin Po, LOsartan PO. BP 120-140/50's. cvp 8-13. pt given Lasix for diuresed goal neg 1-2L, currently neg 700cc. at 2100 K+ 2.9 mag 1.7, repleted. morning labs pending. Cardio ECHO ordered.\n\ngi/gu: foley in place, drainge yellow clear urine 200cc/hr. per renal consult pt may need dialisis in the future. ABD soft, BS +, no BM. pt on renal diet, able to take PO meds with small amount of water, but start coughing, needs speech and swallow eval. after receiving calcium acetat , pt c/o of epigastric pain, received MAALOX with good effect.\n\nid: temp 93.3 d/t ?cold mist of hi flow mask, put bear hugger, temp 95.6. cont Vanco, levoflaxacin for UTI.\n\nendo: cont RISS, at 0000 BS 179, cover by insulin SC.\n\naccess: left SCL,A-line d/ced d/t leak and no tracing.\n\nsocial: full code, family visited/updated.\n\nplan: cont monitoring resp/cardio status labs, lytes, ensymes.\n cardio ECHO.\n keep neg 1-2L.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2136-04-02 00:00:00.000","description":"Report","row_id":1468857,"text":"MICU NPN 0700-1900\n 72 YEAR OLD WOMAN WITH CRI, HTN, ASPIRATION PNEUMONIA, DIABETES NEWLY INSULIN DEPENDENT, +UTI\n\nEVENTS: BEDSIDE ECHO DONE, BEDSIDE SWALLOW EVAL DONE, FIO2 WEAN TO 3L N/C\n\nNEURO: ALERT ORIENT X3, ANXIOUS AT TIMES, REVEALED WITH REASSURANCE\nCV: HR 70-80 1ST AVB, NO VEA, BP 130-157/80'S, EXTREM WARM PALPABLE PULSES, PRELIM EF 35-40%, CK'S FLAT X3, TROP FLAT X3, CVP 10-12,\nRESP: LUNGS WITH CRACKLES, FIO2 INITIALLY 80% HI FLOW AND 5L N/C, WEANED TO 3L N/C WITH O2 SAT 95-98%\nGI: ABD OBESE SOFT +BS, NO STOOL, DIET ADVANCED TO RENAL/DIABETIC EATING SMALL AMTS, POOR APPETITE, PASSED SWALLOW STUDY\nGU: FOLEY INTACT WITH CLEAR YELLOW URINE, CR 1.9, RECIEVED K REPLETION, RECEIVED IV LASIX 80MG AT 3PM, CURRENTLY FLUID BALANCE 1.7L NEGATIVE\nID: AFEBRILE, CONT LEVAFLOX FOR ASPIRATION, CONT VANCO FOR UTI\nACCESS: LEFT SC TL\nACTIVITY: OOB TO CHAIR FOR 3HRS, STOOD PIVOT WITH ASSIST OF TWO\nSOCIAL: SON VISITED BRIEFLY THIS AFTERNOON, UPDATE ON PLAN BY THIS RN\n\nPLAN: WEAN FIO2, DIURESE, FOLLOW FLUID BALANCE, FOLLOW CR, REPLETE LYTES AS NEEDED, SUPPORTIVE CARE\n"},{"category":"Nursing/other","chartdate":"2136-03-30 00:00:00.000","description":"Report","row_id":1468846,"text":"Micu nsg progress note\n Pt with episode bradycardia to 40 with stable bp. Potassium at time 4.5 with normal mg/cal. Spontaneously returning to hr 50's. EKG with LBBB 2nd degree a-v block. HO notified. Atropine placed at bedside. Pacing pads placed on pt. By 4am hr in 60's with EKG nsr with LBBB 1st degree av block. Bp stable thoughout. Pt being r/o for mi. Cont on iv 1/2ns at 250/hr. Hyperkalemia resolving. No futher kayexalate. Cont to pass mod amts liquid stool.\n\nResp- Intub/vent on ac 550x12 5 peep fio2 decreased to 40% with sats 97-98% Last abg 81/30/7.39. Suctioned for scant amts clear secretion. Will try spontaneous breathing trial in am weaning and extubating as able.\n\nGi/endocrine- Cont to pass mod amts loose brown ob neg stool. No s/s active bleeding. Last hct 27. Initially on insulin gtt at 10u/hr. Fs followed q1hr thoughout night and insulin decreased and d/c'd at 2am.\n\nNeuro- Initially heavily sedated on 15mcg propofol. Weaned to 8mcg. Will open eyes to stimulation. Able to squeeze hand on command. Restraints on for safety.\n\nRenal- Cont with poor urine output 5-10cc/hr. Bun/creat without change. K stable. Holding on dialysis for now. Pt may need in future.\n\nPlan- Cont to follow electrolytes. Tx as needed. Wean from vent as able. Follow cardiac status. Atropine at bedside.\n"},{"category":"Nursing/other","chartdate":"2136-03-30 00:00:00.000","description":"Report","row_id":1468847,"text":"Resp Care\nPt remains on MV as noted on Careview. Currently in AC mode. RSBI 47-plan is to change pt to SBT at 0600 if stable. BBS-CTA. Albuterol DC'ed. Bag and mask at bedside. Alarms on and functioning. Continue to monitor closely.\n"},{"category":"Nursing/other","chartdate":"2136-03-30 00:00:00.000","description":"Report","row_id":1468848,"text":"NURSING NOTE 0700HRS - 1700HRS\n\n\nADMIT WITH ACUTE RENAL FAILURE ??CAUSE..? RELATED TO RECENT ^ IN BLOOD SUGARS BUT PATIENT NOT WILLING TO TAKE S/C INSULIN + DEHYDRATION + UTI.... ^^ K/BUN/CREAT/^B/S RECEIVED SEVERAL DOSES KAYEXLATAE AND INSULIN DRIP....\n\n\nEVENTS..NOW OF INSULIN DRIP B/S <200, K STABLE @ 4.2 [ CHECK Q 4-6HRLY]..BUN/CREAT RAISED BUT STABLE, RENAL FOLLOWING...? WILL NEED DILAYSIS IN FUTURE....EXTUBATED @ 11.30HRS BUT HAS REQUIRED INCREASING AMOUNTS OF O2 THIS PM [ LOW TOLERANCE TO CPAP PATIENT]\n\n\n\nNEURO..RECEIVED ON PROPOFOL BUT SWICHED OF EARLY AM IN ANTICIPATION TO EXTUBATE..SINCE EXTUBATION LETHARGIC/TIRED BUT ORIENTATED TO PERSON/PLACE MOVING ALL 4 LIMBS, PARTAKING IN CARE ANSWERIN QUESTIONS APPROPRAITLY...DENIES ANY PAIN\n\n\nRESP...EXTUBATED AND PUT TO FACE TENT @ 50% SATS @ 94% ABG SHOWED LOW PO2 FIO2 INCRESAED TO 70 % , RECEIVED CHEST P/T INCENTIVE SPIROMETER AND ENCOURAGEMENT TO COUGH DEEP BREATH, WEAK COUGH...DOES SOUND DIMINISHED ON RT, POSSIBLY RELATED TO ASPIRATION FROM YESTERDAY THAT REQUIRED INTUBATION...REPEAT BLOOD GAS SHOWED NO IMPROVEMENT WITH PO2 THEREFORE DISCUSSED WITH TEAM AND SWITCHED TO HIGH FLOW @ 80% ..WILL REPEAT ABG..DENIES ANY DISCOMFORT OR SOB....AS DISCUSSED WITH TEAM LOW THRESHOLD DOR PLACING PATIENT ON NON-INVASIVE VENTILATION\n\n\n\nCVS...HR SHOWS LBBB WITH FIRST DEGREE HB ,RATE @ 70-73..LAST PM EPISODE OF BRADYCARDIA TO 40, 2:1 BLOCK SPONTANEOUSLY RIVERTED /NO INTERVENTION REQUIRED, NO FURTHER EPIOSDES TODAY AND PACING PADS REMOVED...B/P HAS REMAINED STABLE 120-135 SYTSOLIC\nCVP 8-10 THIS AM..PM DOWN TO 3-5 THEREFORE RECEIVED BOLUS FLUID, PRESNTLY @ 7\n\n\nID...INCRESAING WBC TODAY TO 18, CONTINUES ON LEVO AND VANC COMMENCED TODAY..TREATED FOR UTI AND POSSIBLE ASPIRATION PNEUMONIA\n\n\nRENAL... RENAL TEAM FOLLOWING CLOSELY...U/O OVERNIGHT 10-20CC/HR DESPITE BOLUSES OF FLUID...INCREASED THIS AM 20-60CC/HR BUT TAILED OF AGAIN THIS PM TO 15-25CC..CVP DOWN THEFORE BOLUS OF 500CC GIVEN AT 1700HRS, TO MONITOR FOR EFFECT\nRENAL FOLLOWING, CREAT /BUN SLOWLY CLIMBING , WELL REQUIRE DILAYSIS IN NEAR FUTURE\nK STABLE THIS AM >4.0 AWAITING PM LYTES...\n\n\nENDO...NOW OF INSULIN DRIP AND ON S/S ..Q4HRLY CHECKS..HAVE REMIANED < 200 BUT S/S NEEDS TO BE ADJUSTED TO GAIN BETTER CONTROL\n\n\nGI...LETHARGIC AND INCRESAING O2 REQUIREMENTS THEREFORE ONLY GIVEN PATIENT ICE CHIPS AND APPERAS TO BE TOLERATING..HAS MUSHROOM CATH IN PLACE..CONTINUES TO PUT OUT {>1000MLS LIQUID STOOL FOR THE DAY} POST KAYEXALATE FROM YESTERDAY BUT IS SLOWING DOWN THIS PM\n\n\nSKIN..PALE BUT INTACT [ HCT STABLE]..RECENT CATARCT SURGERY, NEEDS ETE DROPS ORDERING\n\n\nLINES..ART/CENTRAL LINE INTACT\n\n\nSOCIAL..SON IN TO VISIST THIS AM AND UPDATED...HE SAYS THAT HIS MOTHER RECENTLY DIAGNOSED AS INSULIN DEPENDENT DIABETIC BUT CHOSE NOT TO TAKE THE INSULIN..HE SAYS THAT SHE HAS KEPT THIS INFORMATION FROM HIM ? WHY PATINET NOT COMPLIANT WITH CARE AT HOME .... WORKER ASLO INVOLVED\n\n\n"},{"category":"Nursing/other","chartdate":"2136-03-30 00:00:00.000","description":"Report","row_id":1468849,"text":"Resp Care\nPt received on mech vent-parameters noted. Following , pt extubated to 50% cool mist. Pt has required increased oxygentation for low Pa02. Pt does not appear to be in any resp distress. Breath sounds are relatively clear in upper lobes, diminshed in bases. Working with IS.\n"},{"category":"Nursing/other","chartdate":"2136-03-30 00:00:00.000","description":"Report","row_id":1468850,"text":"ADDENDUM..U/O RESPONDED TO BOLUS OF 500CC N/SLAINE.. K THIS PM LOW @ 3.4 THEREFORE GIVEN 20 IV, FOR RE-CHECK THIS EVE....PO2 STABLE ON REPEAT ABG....@ 1900HRS, NO URINE OUTPUT TEAM AWARE AND WILL REVIEW RE FURTHER FLUID...? NEEDS CXR AS SLIGHT CRACKLES AUDIBLE RT SIDE OF CHEST THIS EVE..AWAIT REVIEW\n"},{"category":"Nursing/other","chartdate":"2136-03-29 00:00:00.000","description":"Report","row_id":1468844,"text":"resp care\npt received from eu with #7.0/24 lip. placed on ac mode. +spont efforts. abg within adequate parameters. +bilat bs. ordered for albuterol for hyperkalemia, discussed with pharmacy and correct dosage is to be 1200 mcg which is 13 puffs, however per resident initial dosage given as 6 puffs. receiving other rx for hyperkalemia ,such as insulin drip. will follow and monitor necessity for albuterol.\n"},{"category":"Nursing/other","chartdate":"2136-03-29 00:00:00.000","description":"Report","row_id":1468845,"text":"ADMIT WITH ACUTE RENAL FAILURE ? CAUSE...? ASPIRATION REQUIRING INTUBATION....K REMAIJNS ELEVTAED > 6.0\n\n\n\nNEURO...RECEIVED ON PROPOFOL @ 10MCGS/KG..INCRESAED TO 15 AS ATTEMPTING TO PULKL AT ET TUBE..PRESENTLY SEEMS COMFORTABLE..EASY TO ROUSE FOLLOWS SIMPLE COMMNADS...PUPILS EQUAL /REACTIVE\n\n\n\nCVS....ART LINE PLACED, B/P 120-130 SYSTOLIC..HR SINUS RYTHM/BRDAY @ 55-60BPM [ ON BBLOCKERS AT HOME ]...\nAFEBRILE..ON AB'S FOR ? ASPIRTION PNEUMONIA/UTI\nHCT STABLE...\nB/S >400 ON ADMISSION TO UNIT WITH K > 6.5, DESPITE DEXT/INSULIN, KAYEXALATE AND CALCIUM GLUC IN EMERGENCY..RECEIVED X2 FURTHER DOSES OF KAYEXLATE THIS PM, WITH INSULIN DRIP @ 10U/HR PLUS BOLUS 10 TO CONTROL B/S....AGGRESSIVE FLUID MANAGEMENT WITH BOLUSES [AS PER CARE VIEW] WITH LASIX @ 40MGS GIVEN [AS PER RECOMMENDATIONS FROM RENAL[..PREVIUOS K < 6.0] ..AWAITING PM LABS...\n\n\nRESP..ON AC 550X12/5 BREATHING SATISFACTORY..LUNGS SOUND CLEAR DIMINSHED AT BASES\n\n\nGI...KAYEXLATE FOR HIGH K HAS STOOLED COPIOUS AMOUNTS AND HAS BUTT BAG IN PLACE AND IS DOING WELL...PHARMACY RECOMMEND TO HAVE STANDING ORDER OF KAYEXLATAE FOR K >6.0.. SOFT DISTENDED VBOWEL SOUNDS PRESNT... U/S PM SATISAFACTORY\n\n\nGU...20-40CC/HR DESPIT BOLSUS OF FLUID AND RECEIVED LASIX @ 1800HRS..CREAT @ 2.2AND K @ 5.6 THIS AFTERNOON ..PM LABS PENDIND>>>?? FOR DILAYSIS IF K DOES NOT COME DOWN\n\n\nSKIN..INTACT\n\n\nLINES..ART LINE CENTRAL LINE PLACED OK TO USE\n\n\nSOCIAL..SON , HAS BEEN UPDATED BY TEAM AND AWARE OF PLAN OF CARE\n\n\nPLAN..AGRESSIVE BLOOD SUGAR MANAGENNT/AGRESSIVE FLUID MANAGEMENT..RESP SUPPORT..FOLLOW K/BUN/CREAT\n"},{"category":"Nursing/other","chartdate":"2136-03-31 00:00:00.000","description":"Report","row_id":1468851,"text":"1900-0700 rn notes micu\n\nneuro: pt's lethargic, arousable to voice, orientedx3, follows commands, mae. puples R3 mm (recent cataract surgery)/L 4mm/brisk.\n\nresp: received extubated with Hi flow face tent 80%, sat 95-96%, pt desats to low 80's when pulls mask off and when turn to the left side. LS crakles on Rt side, clear left, per chest Xray, small pleural efussion on left side, received Lasix IV 20mg. cough/gag reflex intact. morning ABG 7.30/46/79, pt needs to be encourge to cough.\n\ncv: HR 60-70's, 1st degree AV block and LBBB. BP 120-160/50-60, start Hydralasin 10mg po. last K+ 3.5, given Po potassium 20. morning labs pending. CVP in the beginning of shift , after fluid bolus CVP 17-19, currently 14-15. afebrile, cont ABX.\n\ngi/gu: foley in place, in the begining of shift 0cc urine, given Fluid bolus 500cc with good response, u/o 60-120cc, @ 0300 u/o dropped to 0cc, MD notiefed, fluid bolus held d/t crakles in Rt side of lungs, given Lasix 20mg IV. ABD soft/dis BS +, loose stool via mashroom cath.\npt tolerated ice chips, but start coughing with water in the morning.\n\nendo: increased RISS d/t BSFS>200.\n\nsocial: full code, family visited/updated.\n\nplan: cont monitoring neuro/resp/cardio statu, u/o.labs.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2136-03-31 00:00:00.000","description":"Report","row_id":1468852,"text":"resp care\nremains on high flow neb at 80%, spo2's low 90's. bs rhonchorous, occas exp wheezing. admin albuterol neb x2. encouraging db +cough with good results. cough stronger after oob to chair. c/w albut nebs q6prn.\n"},{"category":"Nursing/other","chartdate":"2136-03-31 00:00:00.000","description":"Report","row_id":1468853,"text":"Micu nursing note 7p-7a\n\nNeuro. pt awake and allert following commands pt OOB to chair x2 hrs tol well needed 2 assists.\n\nResp pt remains on 15L hi flow, RR 16-24, lung sound course thought out had crackels in bases this am andR base still with crackles, pt also had exp wheezing, pt recieving nebs Q4, attempt to nasl suction but was unabl to get any secreations, pt cpt x1 today, pt encouraged to cough deep breath, this am was unable to break face mask without o2 sats dropping, now able to take O2 off and pt can hold sats for several minutes.\n\nGI abd soft non tender, pt has mod amts soft stoolx3 today, mushroom cath d/c because stool to thick. pt also started on clear liquids using asperation precausions, been cruching pills in applesause and pt able to take meds, have also given pt clear lig with instrucion on how to swallow and no asperation with ligs. pt in for a swallow eval.\n\nGI pt given lasix 40 mg this am, u/o 100-200 most of the day now y/o down to 60 cc hr, pt neg about 130 cc for 24 hrs goal to keep pt neg\nfoley cath changed because it was leaking this am was under the assumtion that she had no u/o for several hrs but after foley changed to 16 fr, no leaking around cath.\n\nId pt hypothermic today was placed on bear hugger at 5apm temp down to 95.5 at 6 pm temp 97.2 ax pt still low orally. pt remain on Iv antiobiotics levofloxin\n\nCV pt still remains htn 126/89-154/10g po hydrazine increased to 20 mg today pt also given extra dose of iv hyralazine at 2 pm because dbp 104, dyastolic bp still ^ will need to Increase meds again. pedal and tib pulses weak\n\nEndo finger stick 121-190, evening bs covered with 4U reg tonight now that pt has started clear ligs.\n\nA/p Continue with pul toilet, cpt, alb nebs, continue with lasix as needed, attempt to ween fio2 if possible htn meds still need to be adjusted to bring DBP down under 100.\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2136-04-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 81779,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Shortness of breath.\\nHeight: (in) 69\\nWeight (lb): 192\\nBSA (m2): 2.03 m2\\nBP (mm Hg): 158/64\\nHR (bpm): 73\\nStatus: Inpatient\\nDate/Time: at 10:38\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size.\\n\\nRIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV systolic\\nfunction. Paradoxic septal motion consistent with conduction\\nabnormality/ventricular pacing.\\n\\nAORTA: Mildly dilated aortic root. Focal calcifications in aortic root. Normal\\nascending aorta diameter.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild mitral annular\\ncalcification. Calcified tips of papillary muscles. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Indeterminate PA systolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Based on \\nAHA endocarditis prophylaxis recommendations, the echo findings indicate a low\\nrisk (prophylaxis not recommended). Clinical decisions regarding the need for\\nprophylaxis should be based on clinical and echocardiographic data.\\n\\nConclusions:\\nThe left atrium is normal in size. There is mild symmetric left ventricular\\nwall hypertrophy with normal cavity size. There is mild symmetric left\\nventricular hypertrophy with normal cavity size. Septal motion is abnormal\\n(?related to IVCD/postoperative). Overall systolic function is mildly reduced.\\nRight ventricular cavity size is normal. Free wall motion is borderline\\nnormal. The aortic root is mildly dilated. The aortic valve leaflets (3) are\\nmildly thickened but aortic stenosis is not present. No aortic regurgitation\\nis seen. The mitral valve leaflets are structurally normal. There is no mitral\\nvalve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery\\nsystolic pressure could not be quantified. There is no pericardial effusion.\\n\\nIMPRESSION: Mild symmetric left ventricular hypertrophy with mildly reduced\\nleft ventricular systolic function. Mild mitral regurgitation. Mildly dilated\\nascending aorta.\\n\\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\\nindicate a low risk (prophylaxis not recommended). Clinical decisions\\nregarding the need for prophylaxis should be based on clinical and\\nechocardiographic data.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2136-04-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203424,\n \"text\": \"Baseline artifact\\nSinus rhythm\\nFirst degree A-V delay\\nProbable left atrial abnormality\\nLeft bundle branch block with intermittent left axis deviation\\nSince previous tracing of , intermittent shift of axis to left axis\\ndeviation now present\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2136-03-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203425,\n \"text\": \"Probable sinus rhythm, rate 75. Since the previous tracing of \\nsignificant technical artifacts are noted. Positional changes are seen over the\\nlateral precordium.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2136-03-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203426,\n \"text\": \"Sinus rhythm, rate 66. Since the previous tracing the heart rate is faster.\\nPositional changes are seen over the lateral precordium.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2136-03-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203427,\n \"text\": \"Sinus rhythm, rate 53. Since the previous tracing of the heart rate\\nhas slowed. The Q-T interval is further prolonged. Positional changes are seen\\nover the lateral precordium.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2136-03-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203428,\n \"text\": \"Sinus rhythm. First degree A-V delay. Left bundle-branch block. No previous\\ntracing available for comparison.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2136-03-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 903728,\n \"text\": \" 6:00 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval ETT placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman s/p intubation\\n REASON FOR THIS EXAMINATION:\\n eval ETT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post intubation, evaluate endotracheal tube placement.\\n\\n SINGLE PORTABLE AP SUPINE VIEW OF THE CHEST: The endotracheal tube terminates\\n at the thoracic inlet. Note that the distal tip of the endotracheal tube\\n abuts the right tracheal wall. Heart size is borderline for technique. There\\n is bilateral lower lobe atelectasis. There is elevation of the right\\n hemidiaphragm. No evidence of pneumothorax.\\n\\n IMPRESSION:\\n\\n 1. Endotracheal tube terminating at the thoracic inlet with distal tip\\n abutting the right lateral wall of the trachea.\\n 2. Elevation of the right hemidiaphragm.\\n 3. Bilateral lower lobe atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2136-03-29 00:00:00.000\",\n \"description\": \"BY DIFFERENT PHYSICIAN\",\n \"row_id\": 903842,\n \"text\": \" 5:07 PM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: evaluate line\\n Admitting Diagnosis: ACUTE RENAL FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman s/p line placemnent\\n\\n REASON FOR THIS EXAMINATION:\\n evaluate line\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 72-year-old woman with line placement.\\n\\n TECHNIQUE: Portable chest radiograph.\\n\\n COMPARISON: Chest radiograph dated , taken approximately 12\\n hours earlier.\\n\\n FINDINGS: The central venous line from left subclavian vein is terminating in\\n upper SVC. No pneumothorax. Again note is made of endotracheal tube and\\n nasogastric tube, unchanged compared to the prior study. There is persistent\\n opacity at the right hilum, overlying the tip of subclavian venous line, which\\n may represent atelectasis; however, mediastinal pathology such as\\n lymphadenopathy cannot be totally excluded. Again note is made of patchy\\n bibasilar opacity with low lung volumes.\\n\\n IMPRESSION: Tubes and lines as described above. Persistent opacity overlying\\n the right hilum, which may represent atelectasis; however, underlying\\n mediastinal pathology such as lymphadenopathy cannot be totally excluded.\\n Bibasilar atelectasis. Prominent colon gases. Clinical correlation is\\n recommended.\\n\\n The referring physician, . , has been paged.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2136-03-29 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 903822,\n \"text\": \" 4:04 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: r/o intestinal obstruction\\n Admitting Diagnosis: ACUTE RENAL FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with n/v r/o obstruction\\n REASON FOR THIS EXAMINATION:\\n r/o intestinal obstruction\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n INDICATION: 72-year-old female with nausea, vomiting. Rule out obstruction.\\n\\n There are distended loops of large bowel to the level of the sigmoid. There is\\n no air in the rectum. Supine positioning does not allow adequate evaluation\\n for obstruction. No bowel gas is seen within the rectum. The intestinal tube\\n is seen overlying the distal stomach.\\n\\n IMPRESSION: Distended loops of colon to the sigmoid without air in the\\n rectum. This may represent distal large bowel obstruction. Repeat films in two\\n views (including upright/decubitus view) could be obtained. Alternatively, a\\n gastrografin enema would be helpful to exclude distal obstruction.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2136-03-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 904029,\n \"text\": \" 7:56 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: pls eval for chf vs. infiltrate\\n Admitting Diagnosis: ACUTE RENAL FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman adm to MICU s/p aspiration event and intubation. Now\\n extubated. R lower lung crackes.\\n REASON FOR THIS EXAMINATION:\\n pls eval for chf vs. infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 72-year-old female admitted to MICU status post aspiration and\\n intubation. Now extubated presenting with right lower lung crackles.\\n\\n COMPARISON: AP chest dated earlier today at 0334 hours.\\n\\n AP ERECT CHEST RADIOGRAPH: There has been interval removal of the\\n endotracheal tube. A left subclavian catheter remains in an unchanged\\n position. Low lung volumes are again demonstrated which exaggerate the heart\\n size which is probably normal. There is no evidence of pneumothorax. The\\n mediastinal and hilar contours are stable. Again note is made of patchy\\n bibasilar opacity. There is likely left lower lobe effusion.\\n\\n IMPRESSION: Persistent low lung volumes status post extubation. Likely left\\n pleural effusion. No evidence of pneumothorax. Plate-like atelectasis at the\\n right base.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2136-04-02 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 904212,\n \"text\": \" 3:24 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate after diuresis\\n Admitting Diagnosis: ACUTE RENAL FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman adm to MICU s/p aspiration event and intubation. Now c\\n CHF exacerbation\\n REASON FOR THIS EXAMINATION:\\n evaluate after diuresis\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 2:40 A.M., \\n\\n HISTORY: Aspiration. CHF exacerbation.\\n\\n IMPRESSION: AP chest compared to , and 12:\\n\\n Dense bilateral perihilar consolidation which progressed from through\\n is now joined by moderate pulmonary edema worsened since ,\\n accompanied by increasing moderate bilateral pleural effusion. Mediastinal\\n contour indicates elevated central venous pressure. Lung volumes are quite\\n low exaggerating heart size which is probably top normal and only slightly\\n enlarged. No pneumothorax. Tip of the left subclavian line projects over the\\n junction of the brachiocephalic veins. No indication of pneumothorax.\\n Colonic distention seen in the splenic flexure is unchanged over the past\\n several days.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2136-04-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 904208,\n \"text\": \" 10:33 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?etiology of frequent desaturation\\n Admitting Diagnosis: ACUTE RENAL FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman adm to MICU s/p aspiration event and intubation. Now\\n extubated. R lower lung crackes.\\n REASON FOR THIS EXAMINATION:\\n ?etiology of frequent desaturation\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: New right lower lung crackles. Frequent desaturations.\\n\\n CHEST PORTABLE AP, AT 22:42 HOURS:\\n\\n Findings; compared to , lung volumes remain decreased, likely related\\n to inspiratory effort. Left subclavian CVL is in stable position. There are\\n new large right perihilar consolidations. The left hilum is prominent as\\n before. There are bilateral pleural effusions.\\n\\n Gaseous distention of the colon throughout the abdomen is not significantly\\n changed.\\n\\n IMPRESSION: New large perihilar consolidations, right significantly worse\\n than left.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2136-03-29 00:00:00.000\",\n \"description\": \"ABDOMEN U.S. (PORTABLE)\",\n \"row_id\": 903827,\n \"text\": \" 3:45 PM\\n ABDOMEN U.S. (PORTABLE) Clip # \\n Reason: r/o cholecystitis and please eval kidney size.R?O obstructio\\n Admitting Diagnosis: ACUTE RENAL FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with nausea and vomiting.renal failure\\n REASON FOR THIS EXAMINATION:\\n r/o cholecystitis and please eval kidney size.R?O obstruction.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: 72-year-old woman with nausea, vomiting, and renal failure.\\n\\n COMPARISONS: None.\\n\\n TECHNIQUE: Abdominal ultrasound examination.\\n\\n FINDINGS: The gallbladder appears normal without stones. There is no intra-\\n or extra-hepatic biliary ductal dilatation. The main portal vein shows\\n appropriate hepatopetal flow. The echotexture of the liver appears normal,\\n and no focal hepatic lesions are identified. The pancreas is not well seen\\n because of overlying bowel gas. However, a portion of the proximal pancreas\\n appears unremarkable, the tail being completely obscured. The spleen is\\n normal in size and appearance. The right kidney measures 9.4 cm in length,\\n somewhat small. The left kidney measures 11.4 cm. Otherwise, both kidneys\\n appear normal without stones, masses, or hydronephrosis. There is trace\\n ascites about the liver.\\n\\n IMPRESSION:\\n 1. No evidence of hepatobiliary abnormality.\\n 2. Slightly small size of right kidney. Otherwise, unremarkable evaluation\\n of the kidneys.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2136-03-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 903884,\n \"text\": \" 3:07 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evolution of aspiration PNA\\n Admitting Diagnosis: ACUTE RENAL FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman s/p line placemnent\\n\\n REASON FOR THIS EXAMINATION:\\n evolution of aspiration PNA\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 3:34 A.M, :\\n\\n HISTORY: Line placement. Evolving aspiration.\\n\\n IMPRESSION: AP chest compared to :\\n\\n Lung volumes remain quite low due to marked elevation of the diaphragm or\\n perhaps function of intestinal distention, is seen in the upper abdomen.\\n\\n Opacification at the lung bases could represent either a small to moderate\\n degree of atelectasis or pneumonia.\\n\\n Low lung volumes exaggerate the heart size, which is probably normal. There\\n is no pneumothorax. Small bilateral pleural effusions are probably present.\\n Tip of endotracheal tube with the chin elevated is above the clavicles at\\n least 6 cm from the carina, 2-3 cm above optimal placement. The tip of the\\n left subclavian line projects over the SVC. Nasogastric tube passes into the\\n stomach and out of view.\\n\\n Dr. was paged to report these findings, at the time of dictation.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2136-04-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1468858,\n \"text\": \"Uneventful night for Ms . Slept on and off. No further diuretics given this shift.\\n\\nNeuro: Pt a+ox3, MAE, following commands consistently, C/O R hip pain on and off. Tx with repositioning.\\n\\nResp: Lung sounds continue with bibasilar crackles. O2 sat mid to high 90's on 3L O2. No c/o difficulty breathing. Breaths unlabored.\\n\\nCaridac: Rare ectopy on monitor. Remains hypertensive with sbp 130-160's. Hydralazine increased to 30mg PO q6 Isordil increased to 20mg po TID tolerating both well. EF yestereday showed EF of 40%.\\n\\nGI: Positive bowel sounds. No BM this shift. C/O lack of appetite.\\n\\nGu: Ended day negative 1750cc's. AM lytes pending voiding 150-220cc/hr via foley.\\n\\nDerm: Grossly intact. Quad lumen in L subclavian site benign.\\n\\nID: Continues on levofloxacin. Vancomycin increased to QD. Afebrile\\n\\nPlan: Continue to diurese with goal neg 1500-2L neg, call out to floor. titrate B/P meds to effect. oob as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2136-04-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1468859,\n \"text\": \"nsg transfer note\\nPt was screened and acceptted @ in . Was cleared by MICU team as stable for transfer to Rehab. VS- stable no SOB, ambulance called for, awaiting arrival.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2136-04-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1468854,\n \"text\": \"1900-0700 rn notes micu\\n\\nneuro: A/Ox3, mae folows commands.\\n\\nresp: cont hi flow mask, o2 down to 60%, sat 92-95, pt desat to 88% on rt side. LS crackles on rt side and wheezing, received neb.cough/gag reflex intact. pt's been encourge to cough. in the morning sat 87-89%, put O2 80%, sat 94%.\\n\\ncv: HR 70's, 1st degree AV block, LBBB, with ocass PVC's. cont Hydralasin 20mg for BP 140-160, A-line positional, time to time does not collertae with NBP.pt received Potassium 40meqx2 for K+3.2 and Mag 400mg for MAg 1.8. morning labs pending. CVP 9-15\\n\\ngi/gu: foely in place, rceived Lasix 40mg,goal neg 1000L, u/o 100-120cc/hr. abd soft BS +, no BM, tolerate ice chips and small amount water.\\n\\n\\nid: still requred bear hugger for low temp 94.4, currently 97.1.\\n\\nendo: cont RISS, see carevue.\\n\\nsocial: full code, family viseted/updated.\\n\\nplan: cont monitoring resp/cardio status. u/o.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2136-04-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1468855,\n \"text\": \"Micu nurisng note 7-7a\\n\\nNeuro Pt is awake and alert,following commands pt OOb to chair for 3 hrs this am. pt did have difficulty getting back to bed at noon because of fitigue.\\n\\nCV Pt Bp in better control today 130/103-122/72 hr LBBB, pt co of chest pain at 3 pm, ekg done no changes pt given 30cc myanta for GI distress this happend 30min after taking po K, pt states by 445 heart burn is gone.\\n\\nResp pt On hi flow at 90% able to ween pt down for sever hrs to 80% but then ending up ^ back to 90% when sats staying in the low 90's, Lung sounds crackles on right and course LLL, no sputum production.\\n\\nGI pt advanced to renal diet today, tol well, abd soft non tender,bowel sound x4.\\n\\nGU pt continues to recieve lasix Iv x1 today followed with 40 of kcl at 230 pm, u/o 80 cc hr, after lasix, u/o had dropped down durring the day to 30 cc prior.\\n\\nId pt off bear hugger temp back to 97, pt remains on IV antibiotics\\n\\nEndo. 12 noon blood sugar 319 pt recieved 10U sq, K 3.3 was repleated with 40 of kcl.\\n\\nA/P pul poilet ween fio2 if tol, follow labs and repleat K as needed,\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2136-04-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1468856,\n \"text\": \"73 y.o female initailly admitted to from OSH d/t hyperkalemia 7.2, lactate 5.2-?sepsis, ?new ARF with Creat 2.2 CHF , IDDM, recieved Keayxalat,was intubated d/t aspiration. extubated on , put on hi flow mask 80-95% , unable to wean O2->pt deast to low 80's.\\n\\nneuro: A/Ox3, mae, follows comands, opens eyes spont. at the beginning of shift c/o of back pain, became agitated,desat to 83-84%, received Morphine 2mg with good response.\\n\\nresp: received with hi flow mask 95% and NC 5L, unable to wean O2 down. at begining of shift pt became agitated d/t back pain, desat to 83-84% breathing became labor, LS bilat crackles and wheezing, pt c/o SOB, chest xray was done, shown pulmonary edema, CHF-> received Lasix 40mgx1 and 80mg x2 and Morphine 2mg, nebs,ABG 7.33/50/60. overnight pulmonary edema resolved, LS coarse on rt side, clear left, SAT up to 97-99%, attempt to wean O2 to 80% failed, pt start c/o of SOB and sat down to 95%. cough intact, but weak and non productive,pt needs to be encourge to cough and deep breathing. per chest xray from pleural effusion on left side.\\n\\ncv: HR 60-70's, 1st degree AV block, LBBB, during respiratory distress was done ECG, no changes shown, cardio ensymes sent CPK 38, troponin 0.05, second set of ensymes sent at 0700, please send 3nd set in 8hr.\\npt received Nitro SL, start Aspirin Po, LOsartan PO. BP 120-140/50's. cvp 8-13. pt given Lasix for diuresed goal neg 1-2L, currently neg 700cc. at 2100 K+ 2.9 mag 1.7, repleted. morning labs pending. Cardio ECHO ordered.\\n\\ngi/gu: foley in place, drainge yellow clear urine 200cc/hr. per renal consult pt may need dialisis in the future. ABD soft, BS +, no BM. pt on renal diet, able to take PO meds with small amount of water, but start coughing, needs speech and swallow eval. after receiving calcium acetat , pt c/o of epigastric pain, received MAALOX with good effect.\\n\\nid: temp 93.3 d/t ?cold mist of hi flow mask, put bear hugger, temp 95.6. cont Vanco, levoflaxacin for UTI.\\n\\nendo: cont RISS, at 0000 BS 179, cover by insulin SC.\\n\\naccess: left SCL,A-line d/ced d/t leak and no tracing.\\n\\nsocial: full code, family visited/updated.\\n\\nplan: cont monitoring resp/cardio status labs, lytes, ensymes.\\n cardio ECHO.\\n keep neg 1-2L.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2136-04-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1468857,\n \"text\": \"MICU NPN 0700-1900\\n 72 YEAR OLD WOMAN WITH CRI, HTN, ASPIRATION PNEUMONIA, DIABETES NEWLY INSULIN DEPENDENT, +UTI\\n\\nEVENTS: BEDSIDE ECHO DONE, BEDSIDE SWALLOW EVAL DONE, FIO2 WEAN TO 3L N/C\\n\\nNEURO: ALERT ORIENT X3, ANXIOUS AT TIMES, REVEALED WITH REASSURANCE\\nCV: HR 70-80 1ST AVB, NO VEA, BP 130-157/80'S, EXTREM WARM PALPABLE PULSES, PRELIM EF 35-40%, CK'S FLAT X3, TROP FLAT X3, CVP 10-12,\\nRESP: LUNGS WITH CRACKLES, FIO2 INITIALLY 80% HI FLOW AND 5L N/C, WEANED TO 3L N/C WITH O2 SAT 95-98%\\nGI: ABD OBESE SOFT +BS, NO STOOL, DIET ADVANCED TO RENAL/DIABETIC EATING SMALL AMTS, POOR APPETITE, PASSED SWALLOW STUDY\\nGU: FOLEY INTACT WITH CLEAR YELLOW URINE, CR 1.9, RECIEVED K REPLETION, RECEIVED IV LASIX 80MG AT 3PM, CURRENTLY FLUID BALANCE 1.7L NEGATIVE\\nID: AFEBRILE, CONT LEVAFLOX FOR ASPIRATION, CONT VANCO FOR UTI\\nACCESS: LEFT SC TL\\nACTIVITY: OOB TO CHAIR FOR 3HRS, STOOD PIVOT WITH ASSIST OF TWO\\nSOCIAL: SON VISITED BRIEFLY THIS AFTERNOON, UPDATE ON PLAN BY THIS RN\\n\\nPLAN: WEAN FIO2, DIURESE, FOLLOW FLUID BALANCE, FOLLOW CR, REPLETE LYTES AS NEEDED, SUPPORTIVE CARE\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2136-03-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1468846,\n \"text\": \"Micu nsg progress note\\n Pt with episode bradycardia to 40 with stable bp. Potassium at time 4.5 with normal mg/cal. Spontaneously returning to hr 50's. EKG with LBBB 2nd degree a-v block. HO notified. Atropine placed at bedside. Pacing pads placed on pt. By 4am hr in 60's with EKG nsr with LBBB 1st degree av block. Bp stable thoughout. Pt being r/o for mi. Cont on iv 1/2ns at 250/hr. Hyperkalemia resolving. No futher kayexalate. Cont to pass mod amts liquid stool.\\n\\nResp- Intub/vent on ac 550x12 5 peep fio2 decreased to 40% with sats 97-98% Last abg 81/30/7.39. Suctioned for scant amts clear secretion. Will try spontaneous breathing trial in am weaning and extubating as able.\\n\\nGi/endocrine- Cont to pass mod amts loose brown ob neg stool. No s/s active bleeding. Last hct 27. Initially on insulin gtt at 10u/hr. Fs followed q1hr thoughout night and insulin decreased and d/c'd at 2am.\\n\\nNeuro- Initially heavily sedated on 15mcg propofol. Weaned to 8mcg. Will open eyes to stimulation. Able to squeeze hand on command. Restraints on for safety.\\n\\nRenal- Cont with poor urine output 5-10cc/hr. Bun/creat without change. K stable. Holding on dialysis for now. Pt may need in future.\\n\\nPlan- Cont to follow electrolytes. Tx as needed. Wean from vent as able. Follow cardiac status. Atropine at bedside.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2136-03-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1468847,\n \"text\": \"Resp Care\\nPt remains on MV as noted on Careview. Currently in AC mode. RSBI 47-plan is to change pt to SBT at 0600 if stable. BBS-CTA. Albuterol DC'ed. Bag and mask at bedside. Alarms on and functioning. Continue to monitor closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2136-03-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1468848,\n \"text\": \"NURSING NOTE 0700HRS - 1700HRS\\n\\n\\nADMIT WITH ACUTE RENAL FAILURE ??CAUSE..? RELATED TO RECENT ^ IN BLOOD SUGARS BUT PATIENT NOT WILLING TO TAKE S/C INSULIN + DEHYDRATION + UTI.... ^^ K/BUN/CREAT/^B/S RECEIVED SEVERAL DOSES KAYEXLATAE AND INSULIN DRIP....\\n\\n\\nEVENTS..NOW OF INSULIN DRIP B/S <200, K STABLE @ 4.2 [ CHECK Q 4-6HRLY]..BUN/CREAT RAISED BUT STABLE, RENAL FOLLOWING...? WILL NEED DILAYSIS IN FUTURE....EXTUBATED @ 11.30HRS BUT HAS REQUIRED INCREASING AMOUNTS OF O2 THIS PM [ LOW TOLERANCE TO CPAP PATIENT]\\n\\n\\n\\nNEURO..RECEIVED ON PROPOFOL BUT SWICHED OF EARLY AM IN ANTICIPATION TO EXTUBATE..SINCE EXTUBATION LETHARGIC/TIRED BUT ORIENTATED TO PERSON/PLACE MOVING ALL 4 LIMBS, PARTAKING IN CARE ANSWERIN QUESTIONS APPROPRAITLY...DENIES ANY PAIN\\n\\n\\nRESP...EXTUBATED AND PUT TO FACE TENT @ 50% SATS @ 94% ABG SHOWED LOW PO2 FIO2 INCRESAED TO 70 % , RECEIVED CHEST P/T INCENTIVE SPIROMETER AND ENCOURAGEMENT TO COUGH DEEP BREATH, WEAK COUGH...DOES SOUND DIMINISHED ON RT, POSSIBLY RELATED TO ASPIRATION FROM YESTERDAY THAT REQUIRED INTUBATION...REPEAT BLOOD GAS SHOWED NO IMPROVEMENT WITH PO2 THEREFORE DISCUSSED WITH TEAM AND SWITCHED TO HIGH FLOW @ 80% ..WILL REPEAT ABG..DENIES ANY DISCOMFORT OR SOB....AS DISCUSSED WITH TEAM LOW THRESHOLD DOR PLACING PATIENT ON NON-INVASIVE VENTILATION\\n\\n\\n\\nCVS...HR SHOWS LBBB WITH FIRST DEGREE HB ,RATE @ 70-73..LAST PM EPISODE OF BRADYCARDIA TO 40, 2:1 BLOCK SPONTANEOUSLY RIVERTED /NO INTERVENTION REQUIRED, NO FURTHER EPIOSDES TODAY AND PACING PADS REMOVED...B/P HAS REMAINED STABLE 120-135 SYTSOLIC\\nCVP 8-10 THIS AM..PM DOWN TO 3-5 THEREFORE RECEIVED BOLUS FLUID, PRESNTLY @ 7\\n\\n\\nID...INCRESAING WBC TODAY TO 18, CONTINUES ON LEVO AND VANC COMMENCED TODAY..TREATED FOR UTI AND POSSIBLE ASPIRATION PNEUMONIA\\n\\n\\nRENAL... RENAL TEAM FOLLOWING CLOSELY...U/O OVERNIGHT 10-20CC/HR DESPITE BOLUSES OF FLUID...INCREASED THIS AM 20-60CC/HR BUT TAILED OF AGAIN THIS PM TO 15-25CC..CVP DOWN THEFORE BOLUS OF 500CC GIVEN AT 1700HRS, TO MONITOR FOR EFFECT\\nRENAL FOLLOWING, CREAT /BUN SLOWLY CLIMBING , WELL REQUIRE DILAYSIS IN NEAR FUTURE\\nK STABLE THIS AM >4.0 AWAITING PM LYTES...\\n\\n\\nENDO...NOW OF INSULIN DRIP AND ON S/S ..Q4HRLY CHECKS..HAVE REMIANED < 200 BUT S/S NEEDS TO BE ADJUSTED TO GAIN BETTER CONTROL\\n\\n\\nGI...LETHARGIC AND INCRESAING O2 REQUIREMENTS THEREFORE ONLY GIVEN PATIENT ICE CHIPS AND APPERAS TO BE TOLERATING..HAS MUSHROOM CATH IN PLACE..CONTINUES TO PUT OUT {>1000MLS LIQUID STOOL FOR THE DAY} POST KAYEXALATE FROM YESTERDAY BUT IS SLOWING DOWN THIS PM\\n\\n\\nSKIN..PALE BUT INTACT [ HCT STABLE]..RECENT CATARCT SURGERY, NEEDS ETE DROPS ORDERING\\n\\n\\nLINES..ART/CENTRAL LINE INTACT\\n\\n\\nSOCIAL..SON IN TO VISIST THIS AM AND UPDATED...HE SAYS THAT HIS MOTHER RECENTLY DIAGNOSED AS INSULIN DEPENDENT DIABETIC BUT CHOSE NOT TO TAKE THE INSULIN..HE SAYS THAT SHE HAS KEPT THIS INFORMATION FROM HIM ? WHY PATINET NOT COMPLIANT WITH CARE AT HOME .... WORKER ASLO INVOLVED\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2136-03-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1468849,\n \"text\": \"Resp Care\\nPt received on mech vent-parameters noted. Following , pt extubated to 50% cool mist. Pt has required increased oxygentation for low Pa02. Pt does not appear to be in any resp distress. Breath sounds are relatively clear in upper lobes, diminshed in bases. Working with IS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2136-03-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1468850,\n \"text\": \"ADDENDUM..U/O RESPONDED TO BOLUS OF 500CC N/SLAINE.. K THIS PM LOW @ 3.4 THEREFORE GIVEN 20 IV, FOR RE-CHECK THIS EVE....PO2 STABLE ON REPEAT ABG....@ 1900HRS, NO URINE OUTPUT TEAM AWARE AND WILL REVIEW RE FURTHER FLUID...? NEEDS CXR AS SLIGHT CRACKLES AUDIBLE RT SIDE OF CHEST THIS EVE..AWAIT REVIEW\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2136-03-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1468844,\n \"text\": \"resp care\\npt received from eu with #7.0/24 lip. placed on ac mode. +spont efforts. abg within adequate parameters. +bilat bs. ordered for albuterol for hyperkalemia, discussed with pharmacy and correct dosage is to be 1200 mcg which is 13 puffs, however per resident initial dosage given as 6 puffs. receiving other rx for hyperkalemia ,such as insulin drip. will follow and monitor necessity for albuterol.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2136-03-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1468845,\n \"text\": \"ADMIT WITH ACUTE RENAL FAILURE ? CAUSE...? ASPIRATION REQUIRING INTUBATION....K REMAIJNS ELEVTAED > 6.0\\n\\n\\n\\nNEURO...RECEIVED ON PROPOFOL @ 10MCGS/KG..INCRESAED TO 15 AS ATTEMPTING TO PULKL AT ET TUBE..PRESENTLY SEEMS COMFORTABLE..EASY TO ROUSE FOLLOWS SIMPLE COMMNADS...PUPILS EQUAL /REACTIVE\\n\\n\\n\\nCVS....ART LINE PLACED, B/P 120-130 SYSTOLIC..HR SINUS RYTHM/BRDAY @ 55-60BPM [ ON BBLOCKERS AT HOME ]...\\nAFEBRILE..ON AB'S FOR ? ASPIRTION PNEUMONIA/UTI\\nHCT STABLE...\\nB/S >400 ON ADMISSION TO UNIT WITH K > 6.5, DESPITE DEXT/INSULIN, KAYEXALATE AND CALCIUM GLUC IN EMERGENCY..RECEIVED X2 FURTHER DOSES OF KAYEXLATE THIS PM, WITH INSULIN DRIP @ 10U/HR PLUS BOLUS 10 TO CONTROL B/S....AGGRESSIVE FLUID MANAGEMENT WITH BOLUSES [AS PER CARE VIEW] WITH LASIX @ 40MGS GIVEN [AS PER RECOMMENDATIONS FROM RENAL[..PREVIUOS K < 6.0] ..AWAITING PM LABS...\\n\\n\\nRESP..ON AC 550X12/5 BREATHING SATISFACTORY..LUNGS SOUND CLEAR DIMINSHED AT BASES\\n\\n\\nGI...KAYEXLATE FOR HIGH K HAS STOOLED COPIOUS AMOUNTS AND HAS BUTT BAG IN PLACE AND IS DOING WELL...PHARMACY RECOMMEND TO HAVE STANDING ORDER OF KAYEXLATAE FOR K >6.0.. SOFT DISTENDED VBOWEL SOUNDS PRESNT... U/S PM SATISAFACTORY\\n\\n\\nGU...20-40CC/HR DESPIT BOLSUS OF FLUID AND RECEIVED LASIX @ 1800HRS..CREAT @ 2.2AND K @ 5.6 THIS AFTERNOON ..PM LABS PENDIND>>>?? FOR DILAYSIS IF K DOES NOT COME DOWN\\n\\n\\nSKIN..INTACT\\n\\n\\nLINES..ART LINE CENTRAL LINE PLACED OK TO USE\\n\\n\\nSOCIAL..SON , HAS BEEN UPDATED BY TEAM AND AWARE OF PLAN OF CARE\\n\\n\\nPLAN..AGRESSIVE BLOOD SUGAR MANAGENNT/AGRESSIVE FLUID MANAGEMENT..RESP SUPPORT..FOLLOW K/BUN/CREAT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2136-03-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1468851,\n \"text\": \"1900-0700 rn notes micu\\n\\nneuro: pt's lethargic, arousable to voice, orientedx3, follows commands, mae. puples R3 mm (recent cataract surgery)/L 4mm/brisk.\\n\\nresp: received extubated with Hi flow face tent 80%, sat 95-96%, pt desats to low 80's when pulls mask off and when turn to the left side. LS crakles on Rt side, clear left, per chest Xray, small pleural efussion on left side, received Lasix IV 20mg. cough/gag reflex intact. morning ABG 7.30/46/79, pt needs to be encourge to cough.\\n\\ncv: HR 60-70's, 1st degree AV block and LBBB. BP 120-160/50-60, start Hydralasin 10mg po. last K+ 3.5, given Po potassium 20. morning labs pending. CVP in the beginning of shift , after fluid bolus CVP 17-19, currently 14-15. afebrile, cont ABX.\\n\\ngi/gu: foley in place, in the begining of shift 0cc urine, given Fluid bolus 500cc with good response, u/o 60-120cc, @ 0300 u/o dropped to 0cc, MD notiefed, fluid bolus held d/t crakles in Rt side of lungs, given Lasix 20mg IV. ABD soft/dis BS +, loose stool via mashroom cath.\\npt tolerated ice chips, but start coughing with water in the morning.\\n\\nendo: increased RISS d/t BSFS>200.\\n\\nsocial: full code, family visited/updated.\\n\\nplan: cont monitoring neuro/resp/cardio statu, u/o.labs.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2136-03-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1468852,\n \"text\": \"resp care\\nremains on high flow neb at 80%, spo2's low 90's. bs rhonchorous, occas exp wheezing. admin albuterol neb x2. encouraging db +cough with good results. cough stronger after oob to chair. c/w albut nebs q6prn.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2136-03-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1468853,\n \"text\": \"Micu nursing note 7p-7a\\n\\nNeuro. pt awake and allert following commands pt OOB to chair x2 hrs tol well needed 2 assists.\\n\\nResp pt remains on 15L hi flow, RR 16-24, lung sound course thought out had crackels in bases this am andR base still with crackles, pt also had exp wheezing, pt recieving nebs Q4, attempt to nasl suction but was unabl to get any secreations, pt cpt x1 today, pt encouraged to cough deep breath, this am was unable to break face mask without o2 sats dropping, now able to take O2 off and pt can hold sats for several minutes.\\n\\nGI abd soft non tender, pt has mod amts soft stoolx3 today, mushroom cath d/c because stool to thick. pt also started on clear liquids using asperation precausions, been cruching pills in applesause and pt able to take meds, have also given pt clear lig with instrucion on how to swallow and no asperation with ligs. pt in for a swallow eval.\\n\\nGI pt given lasix 40 mg this am, u/o 100-200 most of the day now y/o down to 60 cc hr, pt neg about 130 cc for 24 hrs goal to keep pt neg\\nfoley cath changed because it was leaking this am was under the assumtion that she had no u/o for several hrs but after foley changed to 16 fr, no leaking around cath.\\n\\nId pt hypothermic today was placed on bear hugger at 5apm temp down to 95.5 at 6 pm temp 97.2 ax pt still low orally. pt remain on Iv antiobiotics levofloxin\\n\\nCV pt still remains htn 126/89-154/10g po hydrazine increased to 20 mg today pt also given extra dose of iv hyralazine at 2 pm because dbp 104, dyastolic bp still ^ will need to Increase meds again. pedal and tib pulses weak\\n\\nEndo finger stick 121-190, evening bs covered with 4U reg tonight now that pt has started clear ligs.\\n\\nA/p Continue with pul toilet, cpt, alb nebs, continue with lasix as needed, attempt to ween fio2 if possible htn meds still need to be adjusted to bring DBP down under 100.\\n\"\n }\n]"}}},{"rowIdx":24691,"cells":{"subject_id":{"kind":"number","value":11256,"string":"11,256"},"hadm_id":{"kind":"number","value":188208,"string":"188,208"},"target_text":{"kind":"string","value":"Pt. was brought to the operating room on and after general anesthesia, pt. underwent a coronary artery bypass graft surgery x 3. Please refer to operative not for full surgical details. Pt. tolerated the procedure well and was transferred to CSRU in stable condition with a HR 78 NSD, MAP 71, CVP 16, PAD 20, 27. He was being titrated on propofol and receiving Neo for BP support. Later that day propofol was weaned, sedation reversed, and pt. became awake and was extubated successfully. Pt. was fully awake and alert and neurologically intact. POD #1 - Neo was being weaned off. CVL was removed. Pt. was OOB into chair and later that day transferred to telemetry floor. POD #2 - Chest tubes, pacing wires, and foley removed. Pt. cont. to progress well. Hemodynamically stable. POD # - Pt. cont. to improve. PE was unremarkble. No events the last 2 days. Pt. encouraged to ambulate. POD #5 - Pt. improved to level 5 today. No issues during post-op course. Lab work stable. Pt. went home today with VNA services. PE at D/c: VS: 99.4 91 SR 120/54 18 Neuro: Alert, oriented, non-focal Pulm: CTAB -w/r/r Cardiac: RRR -c/r/m/g Sternum: Inc. C/D/I, -drainage/erythema Abd: Soft, NT/ND, +BS Ext: Warm, -edeme, Inc. C/D/I"},"extractive_notes_summ":{"kind":"string","value":"Single AP bedside chest apparently obtained in O.R. CT's w/ mod amts serousang dng.Resp: BS clear, slightly decreased in bases bilat. SINGLE AP UPRIGHT CHEST: Comparison to portable AP supine chest of . PAD 17-28, CVP 10-23, CI > 3.0. FINDINGS: The heart size and mediastinal contours are within normal limits. HCT STABLE POST-OP.RESP: LUNGS CLEAR, DIMINISHED AT THE BASES. Minimal atelectasis left lung base. Median sternotomy wires are again noted. NEURO: AWOKE WITH DC PROPOFOL, CALM AT PRESENT, MAE, PERL, FOLLOWING COMMANDS, GI: OGT TO LCS, +PLACEMENT, ABD SOFT, ABSENT BOWEL SOUNDS. TECHNIQUE: PA and lateral chest. DSGS HAVE REMAINED D+I. Within normal limits. DRY COUGH NOTED. MAE.CV: HR and BP stable. SANGUINOUS DRAINAGE.GI/GU: HYPOACTIVE BS. IMPRESSION: Normal chest. Pt self administering MDI's as ordered.GI: Abd soft. Mediastinal and bilateral lower zone chest tubes in situ. CI>2.2 AFTER LR. K REPLACED. Status post CABG. Status post CABG. MINIMAL CT DRAINAGE. D/C SWAN IN AM. Sinus rhythm with baseline artifact. 2:46 PM CHEST (PORTABLE AP) Clip # Reason: r/o PTX/Effusion/Tamponade. Pt. Pt. IMPRESSION: Bibasilar linear atelectases. Using IS independently. Heart size is within normal limits. HCT 31. FINAL REPORT Chest, single AP film. FOLEY TO GRAVITY. ABD SOFT, ND. Preop for CABG. The patient has been extubated. RECIEVED 1.5 L LR. GOOD HUO. BS DIMINISHED BIBASILAR, RR LO TWENTIES. GU: ADEQUATE UO ENDO: INSULIN GTT STARTED AT . Heart size is within normal limits and unchanged. Cough unproductive. The bilateral chest tubes have been removed. NEO GTT TITRATED TO KEEP SBP> 90. The Swan-Ganz catheter has been removed. SBP 88-110'S. still in OR, please perform when in CSRU. Sinus tachycardiaNormal ECG except for rateSince previous tracing, no significant change EXTREMITIES WARM, PALP PP,. AS PER ORDERS. HISTORY: CABG. PAD'S MIDDLE TO LO TWENTIES. NG tube is in stomach. RESP: FAILED INITIAL CPAP 10/5 , PLACED BACK ON IMV. There are linear atelectases in both lower zones, improved aeration since prior film of , 05. Mediastinal and hilar contours are unremarkable. At the lower lung zones bilaterally, there is prominent linear opacity, likely secondary to atelectasis. 2:27 PM CHEST (PORTABLE AP) IN O.R. The pulmonary vasculature appears unremarkable. Tolerating po's.GU: Adequate u/o via foley.Endo: SSRI per protocol.Activity/Comfort: Med w/ percocet q 4 hrs for pain. History of CABG. ? Lungs are otherwise clear without evidence of consolidation or effusion. EASILY PALPABLE PEDAL PULSES BILATERALLY. O2 SAT >98%. NEURO ALERT ORIENTED NO DEFECITS NOTEDRESP NC 4L SATS 96-97% LUNGS CLEAR NO WHEEZES NOTED CHEST TUBES DRAINING MOD AMTS THIN USING IS WELLC/V NSR B/P STABLE LOPRESSOR STARTED 12.5 MG TOL WELL EPI WIRES INTACT FUNCTIONAL PULSES EASILY PALPGU/GI ABD SOFT TOL PO WELL ADEQUATE URINE OUT WITH LASIXPLAN TRANSFER TO 2 TODAY CSRU NPNNeuro: Alert and oriented x 3. The stomach is mildly distended with gas. No pneumothorax. No pneumothorax. No pneumothorax. S/P CABG X3O: CARDIAC: SR WITH ISOLATED, CUPLET NOTED RECIEVED 2 GM MAGNESIUM SULPHATE WITH CESSATION OF VEA. No pleural effusion. EXTUBATED AT 12 AM WITHOUT DIFFICULTY. c/o mod amtspain but pain has decreased as day has progressed. SEE CAREVUE FOR ALL VENT CHANGES AND ABG'S. No previous tracingavailable for comparison. COMPARISON: None. 7P-7A:NEURO: ALERT AND ORIENTED X 3, MAE. Pulmonary hygiene. NO CHEST TUBE LEAK. The lungs are clear. IMPRESSION: No evidence of pneumothorax. PLACED BACK ON SIMV WITHOUT SUCCESS, PT WRITING \"I FEEL AS THOUGH I AM DROWNING.\" O2SAT REMAINS > 95% ON 6 L NC. OOB-> CHAIR. MORPHINE AND TORADOL PRN PAIN WITH GOOD EFFECT.CV: SR 90-ST 100, RARE PVC'S NOTED. IS USE TO 1000CC. ; -77 BY DIFFERENT PHYSICIAN # Reason: MISSING TORNIQUET Admitting Diagnosis: +ETT;CORONARY ARTERY DISEASE\\CATH FINAL REPORT HISTORY: CABG ?missing tourniquet. SWITCHED BACK TO CPAP 5/5 WITH INCREASED PT COMFORT ALTHOUGH ABG WITH PERSISTENT ACIDOSIS. No pleural effusion and no pneumothorax. Endotracheal tube is 6 cm above carina. The osseous structures are unremarkable. Tip of Swan-Ganz catheter is in right main pulmonary artery. ELECTROLYTES REPLETED. CT TO 20 CM SXN, NO AIRLEAK NOTED. The surrounding osseous structures appear unremarkable. The NG tube has been removed as well. Since pre-operative exam 1 day ago, sternal wire sutures and mediastinal staples present along with bilateral chest tubes, endotracheal tube, and poorly visualized right IJ line. REASON FOR THIS EXAMINATION: assess for pneumotohrax FINAL REPORT CHEST TWO VIEWS, PA AND LATERAL. There is no evidence of residual pneumothorax. No other radiopaque foreign body. Increase activity as tolerated. POST-OP CR WNL.ENDO: REGULAR INSULIN GTT TITRATED PER PROTOCOL.PLAN: MONITOR HEMODYNAMICS. REASON FOR THIS EXAMINATION: pre-op CABG FINAL REPORT INDICATION: Coronary artery disease. TOL ICE CHIPS. Transfer to 2 this evening. PAIN: RECIEVED 2 MG MSO4 AND 30 MG IM TORADOL ID: TO RECIEVE VANCO SOCIAL: WIFE INTO VISIT AND UPDATEDA: STABLE POST CABG, FAILED CPAPP: MONITOR COMFORT, HR AND RYTHYM, SBP, CI, DSGS, CT DRAINAGE, RESP STATUS- REATTEMPT CPAP WEAN TO EXTUBATE, NEURO STATUS, I+O, LABS."},"n_notes":{"kind":"number","value":11,"string":"11"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2146-05-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":861040,"text":" 2:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX/Effusion/Tamponade. Pt. still in OR, please perform\n Admitting Diagnosis: +ETT;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with CAD s/p CABG\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion/Tamponade. Pt. still in OR, please perform when in CSRU.\n ______________________________________________________________________________\n FINAL REPORT\n Chest, single AP film.\n\n HISTORY: CABG.\n\n Status post CABG. Endotracheal tube is 6 cm above carina. Tip of Swan-Ganz\n catheter is in right main pulmonary artery. NG tube is in stomach.\n Mediastinal and bilateral lower zone chest tubes in situ. No pneumothorax.\n Minimal atelectasis left lung base.\n\n\n"},{"category":"Radiology","chartdate":"2146-05-10 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":860919,"text":" 5:00 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: +ETT;CORONARY ARTERY DISEASE\\CATH\n Admitting Diagnosis: +ETT;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with CAD, for CABG.\n REASON FOR THIS EXAMINATION:\n pre-op CABG\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Coronary artery disease. Preop for CABG.\n\n COMPARISON: None.\n\n TECHNIQUE: PA and lateral chest.\n\n FINDINGS: The heart size and mediastinal contours are within normal limits.\n The pulmonary vasculature appears unremarkable. The lungs are clear. No\n pleural effusion and no pneumothorax. The surrounding osseous structures\n appear unremarkable.\n\n IMPRESSION: Normal chest.\n\n\n"},{"category":"Radiology","chartdate":"2146-05-11 00:00:00.000","description":"O CHEST (PORTABLE AP) IN O.R.","row_id":861036,"text":" 2:27 PM\n CHEST (PORTABLE AP) IN O.R.; -77 BY DIFFERENT PHYSICIAN # \n Reason: MISSING TORNIQUET\n Admitting Diagnosis: +ETT;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG ?missing tourniquet.\n\n Single AP bedside chest apparently obtained in O.R. Since pre-operative exam\n 1 day ago, sternal wire sutures and mediastinal staples present along with\n bilateral chest tubes, endotracheal tube, and poorly visualized right IJ line.\n There is also an unusual large caliber tube in the region of the esophagus\n which may represent mediastinal or GI scope. No other radiopaque foreign\n body.\n\n"},{"category":"Radiology","chartdate":"2146-05-13 00:00:00.000","description":"CHEST (SINGLE VIEW)","row_id":861314,"text":" 6:24 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: ro ptx\n Admitting Diagnosis: +ETT;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p cabg and ct removal\n REASON FOR THIS EXAMINATION:\n ro ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old man status post CABG and chest tube removal, rule out\n pneumothorax.\n\n SINGLE AP UPRIGHT CHEST: Comparison to portable AP supine chest of .\n Median sternotomy wires are again noted. The bilateral chest tubes have been\n removed. There is no evidence of residual pneumothorax. The patient has been\n extubated. The Swan-Ganz catheter has been removed. The NG tube has been\n removed as well. At the lower lung zones bilaterally, there is prominent\n linear opacity, likely secondary to atelectasis. Heart size is within normal\n limits and unchanged. Mediastinal and hilar contours are unremarkable. The\n stomach is mildly distended with gas. Lungs are otherwise clear without\n evidence of consolidation or effusion. The osseous structures are\n unremarkable.\n\n IMPRESSION: No evidence of pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2146-05-15 00:00:00.000","description":"CHEST (PA & LAT)","row_id":861432,"text":" 10:49 AM\n CHEST (PA & LAT) Clip # \n Reason: assess for pneumotohrax\n Admitting Diagnosis: +ETT;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with CAD, for CABG.\n\n REASON FOR THIS EXAMINATION:\n assess for pneumotohrax\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS, PA AND LATERAL.\n\n History of CABG.\n\n Status post CABG. Heart size is within normal limits. There are linear\n atelectases in both lower zones, improved aeration since prior film of , 05. No pneumothorax. No pleural effusion.\n\n IMPRESSION: Bibasilar linear atelectases. No pneumothorax.\n\n\n"},{"category":"ECG","chartdate":"2146-05-11 00:00:00.000","description":"Report","row_id":190917,"text":"Sinus tachycardia\nNormal ECG except for rate\nSince previous tracing, no significant change\n\n"},{"category":"ECG","chartdate":"2146-05-10 00:00:00.000","description":"Report","row_id":190918,"text":"Sinus rhythm with baseline artifact. Within normal limits. No previous tracing\navailable for comparison.\n\n"},{"category":"Nursing/other","chartdate":"2146-05-11 00:00:00.000","description":"Report","row_id":1410348,"text":"S/P CABG X3\nO: CARDIAC: SR WITH ISOLATED, CUPLET NOTED RECIEVED 2 GM MAGNESIUM SULPHATE WITH CESSATION OF VEA. SBP 88-110'S. MINIMAL CT DRAINAGE. DSGS HAVE REMAINED D+I. CI>2.2 AFTER LR. PAD'S MIDDLE TO LO TWENTIES. HCT 31. K REPLACED. EXTREMITIES WARM, PALP PP,.\n RESP: FAILED INITIAL CPAP 10/5 , PLACED BACK ON IMV. BS DIMINISHED BIBASILAR, RR LO TWENTIES. O2 SAT >98%. NO CHEST TUBE LEAK.\n NEURO: AWOKE WITH DC PROPOFOL, CALM AT PRESENT, MAE, PERL, FOLLOWING COMMANDS,\n GI: OGT TO LCS, +PLACEMENT, ABD SOFT, ABSENT BOWEL SOUNDS.\n GU: ADEQUATE UO\n ENDO: INSULIN GTT STARTED AT .\n PAIN: RECIEVED 2 MG MSO4 AND 30 MG IM TORADOL\n ID: TO RECIEVE VANCO\n SOCIAL: WIFE INTO VISIT AND UPDATED\nA: STABLE POST CABG, FAILED CPAP\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, CI, DSGS, CT DRAINAGE, RESP STATUS- REATTEMPT CPAP WEAN TO EXTUBATE, NEURO STATUS, I+O, LABS. AS PER ORDERS.\n"},{"category":"Nursing/other","chartdate":"2146-05-12 00:00:00.000","description":"Report","row_id":1410349,"text":"7P-7A:\nNEURO: ALERT AND ORIENTED X 3, MAE. EXTUBATED AT 12 AM WITHOUT DIFFICULTY. MORPHINE AND TORADOL PRN PAIN WITH GOOD EFFECT.\n\nCV: SR 90-ST 100, RARE PVC'S NOTED. ELECTROLYTES REPLETED. NEO GTT TITRATED TO KEEP SBP> 90. PAD 17-28, CVP 10-23, CI > 3.0. RECIEVED 1.5 L LR. EASILY PALPABLE PEDAL PULSES BILATERALLY. HCT STABLE POST-OP.\n\nRESP: LUNGS CLEAR, DIMINISHED AT THE BASES. PT RECIEVED ON CPAP 50% 5/5 WITH ACIDOTIC ABG. PLACED BACK ON SIMV WITHOUT SUCCESS, PT WRITING \"I FEEL AS THOUGH I AM DROWNING.\" SWITCHED BACK TO CPAP 5/5 WITH INCREASED PT COMFORT ALTHOUGH ABG WITH PERSISTENT ACIDOSIS. PRESSURE SUPPORT INCREASED TO 10 AND EVENTUALLY WEANED AND EXTUBATED. SEE CAREVUE FOR ALL VENT CHANGES AND ABG'S. O2SAT REMAINS > 95% ON 6 L NC. IS USE TO 1000CC. DRY COUGH NOTED. CT TO 20 CM SXN, NO AIRLEAK NOTED. SANGUINOUS DRAINAGE.\n\nGI/GU: HYPOACTIVE BS. ABD SOFT, ND. TOL ICE CHIPS. FOLEY TO GRAVITY. GOOD HUO. POST-OP CR WNL.\n\nENDO: REGULAR INSULIN GTT TITRATED PER PROTOCOL.\n\nPLAN: MONITOR HEMODYNAMICS. ? D/C SWAN IN AM. OOB-> CHAIR.\n\n\n"},{"category":"Nursing/other","chartdate":"2146-05-12 00:00:00.000","description":"Report","row_id":1410350,"text":"NEURO ALERT ORIENTED NO DEFECITS NOTED\n\nRESP NC 4L SATS 96-97% LUNGS CLEAR NO WHEEZES NOTED CHEST TUBES DRAINING MOD AMTS THIN USING IS WELL\n\nC/V NSR B/P STABLE LOPRESSOR STARTED 12.5 MG TOL WELL EPI WIRES INTACT FUNCTIONAL PULSES EASILY PALP\n\nGU/GI ABD SOFT TOL PO WELL ADEQUATE URINE OUT WITH LASIX\n\nPLAN TRANSFER TO 2 TODAY\n"},{"category":"Nursing/other","chartdate":"2146-05-12 00:00:00.000","description":"Report","row_id":1410351,"text":"CSRU NPN\n\nNeuro: Alert and oriented x 3. MAE.\n\nCV: HR and BP stable. CT's w/ mod amts serousang dng.\n\nResp: BS clear, slightly decreased in bases bilat. Using IS independently. Cough unproductive. Pt self administering MDI's as ordered.\n\nGI: Abd soft. Tolerating po's.\n\nGU: Adequate u/o via foley.\n\nEndo: SSRI per protocol.\n\nActivity/Comfort: Med w/ percocet q 4 hrs for pain. c/o mod amts\npain but pain has decreased as day has progressed. OOB to chair x 2->tolerated better second time.\n\nSocial: Wife in visiting and updated on pt's condition.\n\nA: Stable.\n\nP: Pain med prn. Pulmonary hygiene. Increase activity as tolerated. Transfer to 2 this evening.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-05-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 861040,\n \"text\": \" 2:46 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o PTX/Effusion/Tamponade. Pt. still in OR, please perform\\n Admitting Diagnosis: +ETT;CORONARY ARTERY DISEASE\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with CAD s/p CABG\\n REASON FOR THIS EXAMINATION:\\n r/o PTX/Effusion/Tamponade. Pt. still in OR, please perform when in CSRU.\\n ______________________________________________________________________________\\n FINAL REPORT\\n Chest, single AP film.\\n\\n HISTORY: CABG.\\n\\n Status post CABG. Endotracheal tube is 6 cm above carina. Tip of Swan-Ganz\\n catheter is in right main pulmonary artery. NG tube is in stomach.\\n Mediastinal and bilateral lower zone chest tubes in situ. No pneumothorax.\\n Minimal atelectasis left lung base.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-05-10 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 860919,\n \"text\": \" 5:00 PM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: +ETT;CORONARY ARTERY DISEASE\\\\CATH\\n Admitting Diagnosis: +ETT;CORONARY ARTERY DISEASE\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with CAD, for CABG.\\n REASON FOR THIS EXAMINATION:\\n pre-op CABG\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Coronary artery disease. Preop for CABG.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: PA and lateral chest.\\n\\n FINDINGS: The heart size and mediastinal contours are within normal limits.\\n The pulmonary vasculature appears unremarkable. The lungs are clear. No\\n pleural effusion and no pneumothorax. The surrounding osseous structures\\n appear unremarkable.\\n\\n IMPRESSION: Normal chest.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-05-11 00:00:00.000\",\n \"description\": \"O CHEST (PORTABLE AP) IN O.R.\",\n \"row_id\": 861036,\n \"text\": \" 2:27 PM\\n CHEST (PORTABLE AP) IN O.R.; -77 BY DIFFERENT PHYSICIAN # \\n Reason: MISSING TORNIQUET\\n Admitting Diagnosis: +ETT;CORONARY ARTERY DISEASE\\\\CATH\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: CABG ?missing tourniquet.\\n\\n Single AP bedside chest apparently obtained in O.R. Since pre-operative exam\\n 1 day ago, sternal wire sutures and mediastinal staples present along with\\n bilateral chest tubes, endotracheal tube, and poorly visualized right IJ line.\\n There is also an unusual large caliber tube in the region of the esophagus\\n which may represent mediastinal or GI scope. No other radiopaque foreign\\n body.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-05-13 00:00:00.000\",\n \"description\": \"CHEST (SINGLE VIEW)\",\n \"row_id\": 861314,\n \"text\": \" 6:24 PM\\n CHEST (SINGLE VIEW) Clip # \\n Reason: ro ptx\\n Admitting Diagnosis: +ETT;CORONARY ARTERY DISEASE\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man s/p cabg and ct removal\\n REASON FOR THIS EXAMINATION:\\n ro ptx\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 57-year-old man status post CABG and chest tube removal, rule out\\n pneumothorax.\\n\\n SINGLE AP UPRIGHT CHEST: Comparison to portable AP supine chest of .\\n Median sternotomy wires are again noted. The bilateral chest tubes have been\\n removed. There is no evidence of residual pneumothorax. The patient has been\\n extubated. The Swan-Ganz catheter has been removed. The NG tube has been\\n removed as well. At the lower lung zones bilaterally, there is prominent\\n linear opacity, likely secondary to atelectasis. Heart size is within normal\\n limits and unchanged. Mediastinal and hilar contours are unremarkable. The\\n stomach is mildly distended with gas. Lungs are otherwise clear without\\n evidence of consolidation or effusion. The osseous structures are\\n unremarkable.\\n\\n IMPRESSION: No evidence of pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-05-15 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 861432,\n \"text\": \" 10:49 AM\\n CHEST (PA & LAT) Clip # \\n Reason: assess for pneumotohrax\\n Admitting Diagnosis: +ETT;CORONARY ARTERY DISEASE\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with CAD, for CABG.\\n\\n REASON FOR THIS EXAMINATION:\\n assess for pneumotohrax\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST TWO VIEWS, PA AND LATERAL.\\n\\n History of CABG.\\n\\n Status post CABG. Heart size is within normal limits. There are linear\\n atelectases in both lower zones, improved aeration since prior film of , 05. No pneumothorax. No pleural effusion.\\n\\n IMPRESSION: Bibasilar linear atelectases. No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2146-05-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 190917,\n \"text\": \"Sinus tachycardia\\nNormal ECG except for rate\\nSince previous tracing, no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2146-05-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 190918,\n \"text\": \"Sinus rhythm with baseline artifact. Within normal limits. No previous tracing\\navailable for comparison.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2146-05-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410348,\n \"text\": \"S/P CABG X3\\nO: CARDIAC: SR WITH ISOLATED, CUPLET NOTED RECIEVED 2 GM MAGNESIUM SULPHATE WITH CESSATION OF VEA. SBP 88-110'S. MINIMAL CT DRAINAGE. DSGS HAVE REMAINED D+I. CI>2.2 AFTER LR. PAD'S MIDDLE TO LO TWENTIES. HCT 31. K REPLACED. EXTREMITIES WARM, PALP PP,.\\n RESP: FAILED INITIAL CPAP 10/5 , PLACED BACK ON IMV. BS DIMINISHED BIBASILAR, RR LO TWENTIES. O2 SAT >98%. NO CHEST TUBE LEAK.\\n NEURO: AWOKE WITH DC PROPOFOL, CALM AT PRESENT, MAE, PERL, FOLLOWING COMMANDS,\\n GI: OGT TO LCS, +PLACEMENT, ABD SOFT, ABSENT BOWEL SOUNDS.\\n GU: ADEQUATE UO\\n ENDO: INSULIN GTT STARTED AT .\\n PAIN: RECIEVED 2 MG MSO4 AND 30 MG IM TORADOL\\n ID: TO RECIEVE VANCO\\n SOCIAL: WIFE INTO VISIT AND UPDATED\\nA: STABLE POST CABG, FAILED CPAP\\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, CI, DSGS, CT DRAINAGE, RESP STATUS- REATTEMPT CPAP WEAN TO EXTUBATE, NEURO STATUS, I+O, LABS. AS PER ORDERS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2146-05-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410349,\n \"text\": \"7P-7A:\\nNEURO: ALERT AND ORIENTED X 3, MAE. EXTUBATED AT 12 AM WITHOUT DIFFICULTY. MORPHINE AND TORADOL PRN PAIN WITH GOOD EFFECT.\\n\\nCV: SR 90-ST 100, RARE PVC'S NOTED. ELECTROLYTES REPLETED. NEO GTT TITRATED TO KEEP SBP> 90. PAD 17-28, CVP 10-23, CI > 3.0. RECIEVED 1.5 L LR. EASILY PALPABLE PEDAL PULSES BILATERALLY. HCT STABLE POST-OP.\\n\\nRESP: LUNGS CLEAR, DIMINISHED AT THE BASES. PT RECIEVED ON CPAP 50% 5/5 WITH ACIDOTIC ABG. PLACED BACK ON SIMV WITHOUT SUCCESS, PT WRITING \\\"I FEEL AS THOUGH I AM DROWNING.\\\" SWITCHED BACK TO CPAP 5/5 WITH INCREASED PT COMFORT ALTHOUGH ABG WITH PERSISTENT ACIDOSIS. PRESSURE SUPPORT INCREASED TO 10 AND EVENTUALLY WEANED AND EXTUBATED. SEE CAREVUE FOR ALL VENT CHANGES AND ABG'S. O2SAT REMAINS > 95% ON 6 L NC. IS USE TO 1000CC. DRY COUGH NOTED. CT TO 20 CM SXN, NO AIRLEAK NOTED. SANGUINOUS DRAINAGE.\\n\\nGI/GU: HYPOACTIVE BS. ABD SOFT, ND. TOL ICE CHIPS. FOLEY TO GRAVITY. GOOD HUO. POST-OP CR WNL.\\n\\nENDO: REGULAR INSULIN GTT TITRATED PER PROTOCOL.\\n\\nPLAN: MONITOR HEMODYNAMICS. ? D/C SWAN IN AM. OOB-> CHAIR.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2146-05-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410350,\n \"text\": \"NEURO ALERT ORIENTED NO DEFECITS NOTED\\n\\nRESP NC 4L SATS 96-97% LUNGS CLEAR NO WHEEZES NOTED CHEST TUBES DRAINING MOD AMTS THIN USING IS WELL\\n\\nC/V NSR B/P STABLE LOPRESSOR STARTED 12.5 MG TOL WELL EPI WIRES INTACT FUNCTIONAL PULSES EASILY PALP\\n\\nGU/GI ABD SOFT TOL PO WELL ADEQUATE URINE OUT WITH LASIX\\n\\nPLAN TRANSFER TO 2 TODAY\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2146-05-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410351,\n \"text\": \"CSRU NPN\\n\\nNeuro: Alert and oriented x 3. MAE.\\n\\nCV: HR and BP stable. CT's w/ mod amts serousang dng.\\n\\nResp: BS clear, slightly decreased in bases bilat. Using IS independently. Cough unproductive. Pt self administering MDI's as ordered.\\n\\nGI: Abd soft. Tolerating po's.\\n\\nGU: Adequate u/o via foley.\\n\\nEndo: SSRI per protocol.\\n\\nActivity/Comfort: Med w/ percocet q 4 hrs for pain. c/o mod amts\\npain but pain has decreased as day has progressed. OOB to chair x 2->tolerated better second time.\\n\\nSocial: Wife in visiting and updated on pt's condition.\\n\\nA: Stable.\\n\\nP: Pain med prn. Pulmonary hygiene. Increase activity as tolerated. Transfer to 2 this evening.\\n\"\n }\n]"}}},{"rowIdx":24692,"cells":{"subject_id":{"kind":"number","value":30101,"string":"30,101"},"hadm_id":{"kind":"number","value":105529,"string":"105,529"},"target_text":{"kind":"string","value":"87yo F with known CKD s/p B/L renal artery stents who was admitted with back pain, concerning for growth of her AAA. She was initially admitted to vascular surgery, but transfered to the MICU for hypotension, new O2 requirement, and urosepsis."},"extractive_notes_summ":{"kind":"string","value":"Mild tomoderate (+) aortic regurgitation is seen. Moderate PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. The aortic valve leaflets are moderatelythickened. Mild to moderate (+)mitral regurgitation is seen. Right ventricular functionHeight: (in) 60Weight (lb): 100BSA (m2): 1.39 m2BP (mm Hg): 123/41HR (bpm): 62Status: InpatientDate/Time: at 11:27Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.LEFT VENTRICLE: Normal LV wall thickness. Mild to moderate (+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. There is moderate pulmonary artery systolic hypertension. Mild to moderate (+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild mitralannular calcification. Normal main PA. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.Conclusions:The left atrium is mildly dilated. Mild thickening of mitral valve chordae. of themitral chordae (normal variant). The tricuspid valve leaflets are mildlythickened. Left ventricular wall thicknesses arenormal. There isno pericardial effusion.Compared with the findings of the prior study (images reviewed) of , the aortic valve effective orifice area is further reduced. The inner dilator and microwire were then removed, and wire was passed into the right atrium. The wire was then passed into the inferior vena cava, and attention was directed to the chest. TDI E/e' >15, suggesting PCWP>18mmHg.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTIC VALVE: Moderately thickened aortic valve leaflets. Right ventricular chamber size andfree wall motion are normal. Normal tricuspidvalve supporting structures. The inner dilator and wire were removed, and the hemodialysis catheter was passed through the peel-away sheath, and the peel-away sheath removed. A final fluoroscopic image demonstrated an appropriately positioned right IJ hemodialysis catheter with its tip in the right atrium. PATIENT/TEST INFORMATION:Indication: Left ventricular function. Overall leftventricular systolic function is normal (LVEF 65%). The left ventricular cavity is unusually small. Mild to moderate [+] TR. Calcified tips ofpapillary muscles. Sinus rhythm. After a small skin incision was made, the needle was removed and replaced with a micropuncture sheath. The venotomy site in the neck was closed with 2-0 Vicryl, and the catheter was sewn in place with 2-0 silk sutures, and dressed. PROCEDURE: 19-cm tip-to-cuff tunneled right IJ hemodialysis catheter placement. OPERATORS: Dr. , Dr. . There is severe aortic valve stenosis (valve area 0.9 cm2). Small LV cavity. Tissue Doppler imaging suggests an increased leftventricular filling pressure (PCWP>18mmHg). The venotomy was then serially dilated, and a 14 French peel-away sheath was placed under fluoroscopic guidance. This was used to measure catheter length, and a 19-cm tip-to-cuff hemodialysis catheter was selected. 9:22 AM TUNNELED DIALYSIS LINE PLACEME Clip # Reason: please place HD line Admitting Diagnosis: ACUTE RENAL FAILURE Type of Port: None ********************************* CPT Codes ******************************** * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS. Sinus rhythm with prolonged P-R interval. Then, under ultrasound guidance, a 21-gauge micropuncture needle was inserted into the right internal jugular vein, and a 0.018 wire was passed through this and into the superior vena cava. Left bundle-branch block. Left axis deviation. Atrial fibrillation with rapid ventricular response. A site for the tunnel was chosen, and local anesthesia was obtained with approximately 10 cc of 1% lidocaine with epinephrine. Severe AS (area0.8-1.0cm2). Compared to the previous tracingof no diagnostic interim change. Overall normal LVEF(>55%). Under ultrasound guidance with hard copy images on file, an appropriate site to access the right internal jugular vein was chosen, and the area over the neck was anesthetized with approximately 5 cc of 1% buffered lidocaine. (Over) 9:22 AM TUNNELED DIALYSIS LINE PLACEME Clip # Reason: please place HD line Admitting Diagnosis: ACUTE RENAL FAILURE Type of Port: None FINAL REPORT (Cont) IMPRESSION: Successful placement of 19-cm tip-to-cuff right IJ hemodialysis catheter with the tip in the right atrium, ready for immediate use. Leftbundle-branch block. The patient was brought to the angiography suite and prepped and draped in the usual sterile fashion. Compared to the previous tracing of theQRS voltage is more prominent and the rhythm is sinus. However, mechanicaldyssynchrony is present. Left bundle-branch block.Compared to the previous tracing of atrial fibrillation with a rapidventricular response has appeared and the rate has increased. The patient tolerated the procedure well without immediate complications. A preprocedure timeout confirmed the patient identity and the procedure to be performed. There is no mitral valve prolapse. The mitral valve leaflets aremildly thickened. No PS.Physiologic PR. A stab incision was made over the chest, and using a blunt tunneling device, a tunnel was created between the stab incision on the chest and the original venostomy site in the neck. TECHNIQUE AND FINDINGS: The procedure was explained to the patient, and written informed consent was obtained after questions were answered. No resting LVOT gradient. No MVP. No TS. No MS."},"n_notes":{"kind":"number","value":5,"string":"5"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2122-09-10 00:00:00.000","description":"US GUID FOR VAS. ACCESS","row_id":1204358,"text":" 9:22 AM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: please place HD line\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Type of Port: None\n ********************************* CPT Codes ********************************\n * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with new renal failure, initiated on HD\n REASON FOR THIS EXAMINATION:\n please place HD line\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 87-year-old female with new renal failure, initiated on\n hemodialysis, please place tunneled HD line.\n\n OPERATORS: Dr. , Dr. .\n\n PROCEDURE: 19-cm tip-to-cuff tunneled right IJ hemodialysis catheter\n placement.\n\n TECHNIQUE AND FINDINGS: The procedure was explained to the patient, and\n written informed consent was obtained after questions were answered. A\n preprocedure timeout confirmed the patient identity and the procedure to be\n performed. The patient was brought to the angiography suite and prepped and\n draped in the usual sterile fashion. Under ultrasound guidance with hard copy\n images on file, an appropriate site to access the right internal jugular vein\n was chosen, and the area over the neck was anesthetized with approximately 5\n cc of 1% buffered lidocaine. Then, under ultrasound guidance, a 21-gauge\n micropuncture needle was inserted into the right internal jugular vein, and a\n 0.018 wire was passed through this and into the superior vena cava. After a\n small skin incision was made, the needle was removed and replaced with a\n micropuncture sheath. The inner dilator and microwire were then removed, and\n wire was passed into the right atrium. This was used to measure\n catheter length, and a 19-cm tip-to-cuff hemodialysis catheter was selected.\n The wire was then passed into the inferior vena cava, and attention was\n directed to the chest. A site for the tunnel was chosen, and local anesthesia\n was obtained with approximately 10 cc of 1% lidocaine with epinephrine. A\n stab incision was made over the chest, and using a blunt tunneling device, a\n tunnel was created between the stab incision on the chest and the original\n venostomy site in the neck. The venotomy was then serially dilated, and a 14\n French peel-away sheath was placed under fluoroscopic guidance. The inner\n dilator and wire were removed, and the hemodialysis catheter was passed\n through the peel-away sheath, and the peel-away sheath removed. A final\n fluoroscopic image demonstrated an appropriately positioned right IJ\n hemodialysis catheter with its tip in the right atrium. The venotomy site in\n the neck was closed with 2-0 Vicryl, and the catheter was sewn in place with\n 2-0 silk sutures, and dressed. The patient tolerated the procedure well\n without immediate complications.\n\n (Over)\n\n 9:22 AM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: please place HD line\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Type of Port: None\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: Successful placement of 19-cm tip-to-cuff right IJ hemodialysis\n catheter with the tip in the right atrium, ready for immediate use.\n\n"},{"category":"Echo","chartdate":"2122-09-05 00:00:00.000","description":"Report","row_id":99896,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function\nHeight: (in) 60\nWeight (lb): 100\nBSA (m2): 1.39 m2\nBP (mm Hg): 123/41\nHR (bpm): 62\nStatus: Inpatient\nDate/Time: at 11:27\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Normal LV wall thickness. Small LV cavity. Overall normal LVEF\n(>55%). TDI E/e' >15, suggesting PCWP>18mmHg.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Severe AS (area\n0.8-1.0cm2). Mild to moderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. of the\nmitral chordae (normal variant). No resting LVOT gradient. Calcified tips of\npapillary muscles. No MS. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Mild to moderate [+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is unusually small. Overall left\nventricular systolic function is normal (LVEF 65%). However, mechanical\ndyssynchrony is present. Tissue Doppler imaging suggests an increased left\nventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets are moderately\nthickened. There is severe aortic valve stenosis (valve area 0.9 cm2). Mild to\nmoderate (+) aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. Mild to moderate (+)\nmitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. There is moderate pulmonary artery systolic hypertension. There is\nno pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , the aortic valve effective orifice area is further reduced.\n\n\n"},{"category":"ECG","chartdate":"2122-09-09 00:00:00.000","description":"Report","row_id":283690,"text":"Sinus rhythm with prolonged P-R interval. Left axis deviation. Left\nbundle-branch block. Compared to the previous tracing of the\nQRS voltage is more prominent and the rhythm is sinus.\n\n"},{"category":"ECG","chartdate":"2122-09-08 00:00:00.000","description":"Report","row_id":283691,"text":"Atrial fibrillation with rapid ventricular response. Left bundle-branch block.\nCompared to the previous tracing of atrial fibrillation with a rapid\nventricular response has appeared and the rate has increased.\n\n"},{"category":"ECG","chartdate":"2122-09-03 00:00:00.000","description":"Report","row_id":283692,"text":"Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\nof no diagnostic interim change.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-09-10 00:00:00.000\",\n \"description\": \"US GUID FOR VAS. ACCESS\",\n \"row_id\": 1204358,\n \"text\": \" 9:22 AM\\n TUNNELED DIALYSIS LINE PLACEME Clip # \\n Reason: please place HD line\\n Admitting Diagnosis: ACUTE RENAL FAILURE\\n Type of Port: None\\n ********************************* CPT Codes ********************************\\n * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE *\\n * US GUID FOR VAS. ACCESS *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 87 year old woman with new renal failure, initiated on HD\\n REASON FOR THIS EXAMINATION:\\n please place HD line\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INFORMATION: 87-year-old female with new renal failure, initiated on\\n hemodialysis, please place tunneled HD line.\\n\\n OPERATORS: Dr. , Dr. .\\n\\n PROCEDURE: 19-cm tip-to-cuff tunneled right IJ hemodialysis catheter\\n placement.\\n\\n TECHNIQUE AND FINDINGS: The procedure was explained to the patient, and\\n written informed consent was obtained after questions were answered. A\\n preprocedure timeout confirmed the patient identity and the procedure to be\\n performed. The patient was brought to the angiography suite and prepped and\\n draped in the usual sterile fashion. Under ultrasound guidance with hard copy\\n images on file, an appropriate site to access the right internal jugular vein\\n was chosen, and the area over the neck was anesthetized with approximately 5\\n cc of 1% buffered lidocaine. Then, under ultrasound guidance, a 21-gauge\\n micropuncture needle was inserted into the right internal jugular vein, and a\\n 0.018 wire was passed through this and into the superior vena cava. After a\\n small skin incision was made, the needle was removed and replaced with a\\n micropuncture sheath. The inner dilator and microwire were then removed, and\\n wire was passed into the right atrium. This was used to measure\\n catheter length, and a 19-cm tip-to-cuff hemodialysis catheter was selected.\\n The wire was then passed into the inferior vena cava, and attention was\\n directed to the chest. A site for the tunnel was chosen, and local anesthesia\\n was obtained with approximately 10 cc of 1% lidocaine with epinephrine. A\\n stab incision was made over the chest, and using a blunt tunneling device, a\\n tunnel was created between the stab incision on the chest and the original\\n venostomy site in the neck. The venotomy was then serially dilated, and a 14\\n French peel-away sheath was placed under fluoroscopic guidance. The inner\\n dilator and wire were removed, and the hemodialysis catheter was passed\\n through the peel-away sheath, and the peel-away sheath removed. A final\\n fluoroscopic image demonstrated an appropriately positioned right IJ\\n hemodialysis catheter with its tip in the right atrium. The venotomy site in\\n the neck was closed with 2-0 Vicryl, and the catheter was sewn in place with\\n 2-0 silk sutures, and dressed. The patient tolerated the procedure well\\n without immediate complications.\\n\\n (Over)\\n\\n 9:22 AM\\n TUNNELED DIALYSIS LINE PLACEME Clip # \\n Reason: please place HD line\\n Admitting Diagnosis: ACUTE RENAL FAILURE\\n Type of Port: None\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n IMPRESSION: Successful placement of 19-cm tip-to-cuff right IJ hemodialysis\\n catheter with the tip in the right atrium, ready for immediate use.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2122-09-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 99896,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Right ventricular function\\nHeight: (in) 60\\nWeight (lb): 100\\nBSA (m2): 1.39 m2\\nBP (mm Hg): 123/41\\nHR (bpm): 62\\nStatus: Inpatient\\nDate/Time: at 11:27\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Mild LA enlargement.\\n\\nLEFT VENTRICLE: Normal LV wall thickness. Small LV cavity. Overall normal LVEF\\n(>55%). TDI E/e' >15, suggesting PCWP>18mmHg.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Severe AS (area\\n0.8-1.0cm2). Mild to moderate (+) AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\\nannular calcification. Mild thickening of mitral valve chordae. of the\\nmitral chordae (normal variant). No resting LVOT gradient. Calcified tips of\\npapillary muscles. No MS. Mild to moderate (+) MR.\\n\\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\\nvalve supporting structures. No TS. Mild to moderate [+] TR. Moderate PA\\nsystolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nConclusions:\\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\\nnormal. The left ventricular cavity is unusually small. Overall left\\nventricular systolic function is normal (LVEF 65%). However, mechanical\\ndyssynchrony is present. Tissue Doppler imaging suggests an increased left\\nventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and\\nfree wall motion are normal. The aortic valve leaflets are moderately\\nthickened. There is severe aortic valve stenosis (valve area 0.9 cm2). Mild to\\nmoderate (+) aortic regurgitation is seen. The mitral valve leaflets are\\nmildly thickened. There is no mitral valve prolapse. Mild to moderate (+)\\nmitral regurgitation is seen. The tricuspid valve leaflets are mildly\\nthickened. There is moderate pulmonary artery systolic hypertension. There is\\nno pericardial effusion.\\n\\nCompared with the findings of the prior study (images reviewed) of , the aortic valve effective orifice area is further reduced.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2122-09-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 283690,\n \"text\": \"Sinus rhythm with prolonged P-R interval. Left axis deviation. Left\\nbundle-branch block. Compared to the previous tracing of the\\nQRS voltage is more prominent and the rhythm is sinus.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2122-09-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 283691,\n \"text\": \"Atrial fibrillation with rapid ventricular response. Left bundle-branch block.\\nCompared to the previous tracing of atrial fibrillation with a rapid\\nventricular response has appeared and the rate has increased.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2122-09-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 283692,\n \"text\": \"Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\\nof no diagnostic interim change.\\n\\n\"\n }\n]"}}},{"rowIdx":24693,"cells":{"subject_id":{"kind":"number","value":40066,"string":"40,066"},"hadm_id":{"kind":"number","value":169733,"string":"169,733"},"target_text":{"kind":"string","value":"Following admission workup was undertaken.Dental extractions were performed on . Carotids ultrasounds were nonobstructive. On he was taken to the Operating Room where aortic valve replacement was done. See operative note for details. He weaned from bypass with ventricular ectopy which resolved with deairing and an Amiodarone bolus. Low dose neosynephrine and Propofol were running at the end of the operation. He was extubated later that night, and transferred to the floor on POD #2 to begin increasing his activity level. CTs were removed according to protocol and temporary pacing wires were likewise removed (on POD 3). Physical therapy worked with him for strength and mobility. Beta blockade and diuretics were begun. He remained stable, he diuresed nicely and remained in sinus rhythm. He was ready for discharge and went to a rehabilitation facility for further recovery before returning home. medications, wound care and postoperative instructions were included in the paperwork sent with the patient. STOP "},"extractive_notes_summ":{"kind":"string","value":"Pneumococcal Vac Polyvalent 24. Metoprolol Tartrate 19. restart PO Metformin. Metoprolol Tartrate 17. Metoprolol Tartrate 17. Metoprolol Tartrate 17. Metoprolol Tartrate 17. Allopurinol 7. Renal: Foley, Adequate UO, Creat 0.8. Morphine Sulfate 19. Morphine Sulfate 19. Morphine Sulfate 19. Morphine Sulfate 19. Nitroglycerin 22. Aspirin EC 7. Aspirin EC 7. Aspirin EC 7. Aspirin EC 7. Pneumococcal Vac Polyvalent 22. Pneumococcal Vac Polyvalent 22. Pneumococcal Vac Polyvalent 22. Then titrate insulin gtt off if FS remains<120. Then titrate insulin gtt off if FS remains<120. Milk of Magnesia 18. Milk of Magnesia 18. Milk of Magnesia 18. Milk of Magnesia 18. Sodium Chloride 0.9% Flush 29. Nitroglycerin 20. Nitroglycerin 20. Nitroglycerin 20. Nitroglycerin 20. Docusate Sodium 10. Docusate Sodium 10. Docusate Sodium 10. Docusate Sodium 10. Found to have a metabolic acidosis on ABG, fluid boluses given with correction of acidosis. Found to have a metabolic acidosis on ABG, fluid boluses given with correction of acidosis. Aspirin EC 8. When C&DB, pt c/o pain and given 1 percocet at 1030. Calcium Gluconate 9. Sodium Chloride 0.9% Flush 30. Sodium Chloride 0.9% Flush 27. Sodium Chloride 0.9% Flush 27. Sodium Chloride 0.9% Flush 27. Milk of Magnesia 20. start lasix diuresis Hematology: Stable anemia. Metoclopramide 18. Morphine Sulfate 21. Ranitidine 24. Ranitidine 24. Ranitidine 24. Ranitidine 24. Allopurinol 6. Allopurinol 6. Allopurinol 6. Allopurinol 6. Calcium Gluconate 8. Calcium Gluconate 8. Calcium Gluconate 8. Calcium Gluconate 8. Sodium Chloride 0.9% Flush 28. and 20mg lasix IV given NP order. and 20mg lasix IV given NP order. and 20mg lasix IV given NP order. and 20mg lasix IV given NP order. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush 26. Action: Ntg gtt titrated to keep SBP < 120. Action: IV bolus administered & Insulin Gtt restarted per protocol. Cepacol (Menthol) 10. Morphine prn, transition to percocet Hematology: Stable anemia. Hematology: Stable anemia. K-4.7 and ionized calcium 1.16 with am labs. K-4.7 and ionized calcium 1.16 with am labs. K-4.7 and ionized calcium 1.16 with am labs. K-4.7 and ionized calcium 1.16 with am labs. K-4.7 and ionized calcium 1.16 with am labs. Furosemide 11. Furosemide 11. Furosemide 11. Furosemide 11. Ketorolac . Response: Hyperglycemia continues. Docusate Sodium 12. Holding metformin while being diuresed. Patient admit to CVICU stable on propofol, neo, insulin gtt. Patient admit to CVICU stable on propofol, neo, insulin gtt. Patient admit to CVICU stable on propofol, neo, insulin gtt. Nutrition: Sips, ADAT. Doppler pulses. Doppler pulses. Pneumococcal Vac Polyvalent 24. Pneumococcal Vac Polyvalent 24. Moderate functional mitral stenosisfrom MAC. Trace aortic regurgitation is seen. Renal: Foley, Adequate UO, Creat 0.8. Renal: Foley, Adequate UO, Creat 0.8. On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 55/18, 88/25, 77/22 cm/sec. Moderate [2+] tricuspid regurgitation is seen. Preoperative assessment.Height: (in) 70Weight (lb): 236BSA (m2): 2.24 m2BP (mm Hg): 150/82HR (bpm): 76Status: InpatientDate/Time: at 15:47Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: DefinityTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated aortic sinus. Moderate [2+] TR.Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Mild symmetric left ventricular hypertrophy with preserved globaland regional biventricular systolic function. PA and lateral upright chest radiographs were compared to . Allopurinol 7. Allopurinol 7. Physiologic MR (withinnormal limits).TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Mod functional MS due to MAC.TRICUSPID VALVE: Normal tricuspid valve leaflets. Good (>20 cm/s) LAA ejectionvelocity.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal ascending aorta diameter.AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Metoprolol Tartrate 19. Metoprolol Tartrate 19. 7:05 AM CHEST (PORTABLE AP) Clip # Reason: s/p ct removal ? Single AP chest radiograph compared to shows repositioning of a right IJ central venous catheter with tip now located in the distal SVC/right cavoatrial junction. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 44/10, 55/16, 55/15 cm/sec. Chest tubes D/Cd in am and chest x-ray performed showing atelectasis NP . Severe MAC was seen and mitral valve area by presssurehalf-time was 2.0 cm2. Sodium Chloride 0.9% Flush 29. Sodium Chloride 0.9% Flush 29. Action: Pt given toradol/percocets. Metoclopramide 18. Metoclopramide 18. There is nopericardial effusion. Nitroglycerin 22. Nitroglycerin 22. WJMLEFT ATRIUM: Normal LA and RA cavity sizes. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. The right extreme CP angle has been excluded. Right internal jugular line tip is at the cavoatrial junction. FINDINGS: In comparison with the study of , there are now metallic sternal sutures in place. Left anterior hemiblock. Sodium Chloride 0.9% Flush 28. Sodium Chloride 0.9% Flush 28. Nutrition: diabetic diet Renal: Foley, Adequate UO, Creat 0.8. Apaced for blood pressure support.. Latest Vital Signs and I/O Non-invasive BP: S:109 D:55 Temperature: 98.5 Arterial BP: S:115 D:47 Respiratory rate: 21 insp/min Heart Rate: 66 bpm Heart rhythm: SR (Sinus Rhythm) O2 delivery device: Nasal cannula O2 saturation: 98% % O2 flow: 2 L/min FiO2 set: 40% % 24h total in: 196 mL 24h total out: 1,935 mL Pacer Data Temporary pacemaker type: Epicardial Wires Temporary pacemaker mode: Atrial demand Temporary pacemaker rate: 50 bpm Temporary atrial sensitivity: Yes Temporary atrial sensitivity threshold: 1.2 mV Temporary atrial sensitivity setting: 0.6 mV Temporary atrial stimulation threshold : 12 mA Temporary atrial stimulation setting: 20 mA Temporary ventricular sensitivity: Yes Temporary ventricular sensitivity threshold: 0.8 mV Temporary pacemaker wire condition: Attached-Pacer Temporary pacemaker wires atrial: 2 Temporary pacemaker wires ventricular: 2 Pertinent Lab Results: Sodium: 135 mEq/L 02:06 AM Potassium: 3.9 mEq/L 02:06 AM Chloride: 101 mEq/L 02:06 AM CO2: 28 mEq/L 02:06 AM BUN: 17 mg/dL 02:06 AM Creatinine: 0.8 mg/dL 02:06 AM Glucose: 120 mg/dL 02:06 AM Hematocrit: 25.1 % 02:06 AM Finger Stick Glucose: 160 02:00 PM Valuables / Signature Patient valuables: Other valuables: Valuables in safe on 6 per pt."},"n_notes":{"kind":"number","value":36,"string":"36"},"notes":{"kind":"list like","value":[{"category":"Nursing","chartdate":"2174-08-02 00:00:00.000","description":"Nursing Transfer Note","row_id":581757,"text":"Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt A&O, follows all commands and appropriate.\n HR-NSR 60\ns-80\ns. SBP 100\ns-110\ns. Doppler pulses. K-4.7 and ionized\n calcium 1.16 with am labs.\n LS-CTA/Dim at bases. 3-4LO2 NC- 96-99%. Chest tubes draining minimal\n amounts of serosang. drainage.\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\n diet.\n Foley intact draining good amounts of clear yellow urine.\n Action:\n Pt weaned off nitro drip and started on lopressor 25mg po bid at 0800.\n Epicardial wires tested with A\ns sensing and capturing appropriately\n and V\ns sensing but not capturing. Pt set on A demand at 50.\n Pt encouraged to C&DB and IS used 500-750.\n Pt started on lasix 20mg last night and continued.\n Response:\n Vitals unchanged at this time. Pt OOB to chair and chest tubes with\n minimal amount of output. At 1100, pt with only 40cc\ns of urine past 2\n hrs. and 20mg lasix IV given NP order.\n Plan:\n Continue to administer beta blocker, monitor lytes and replete, monitor\n UOP and diurese.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o incisional pain with movement/C&DB.\n Action:\n Pt given toridol 15mg IV at 0800.\n Response:\n Pt appears comfortable in chair at this time. When C&DB, pt c/o \n pain and given percoets in am/afternoon.\n Plan:\n Continue to monitor pain level and administer toradol q6h/percocets.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with blood sugars 130\ns-140\ns and received on insulin drip at 8\n units/hr.\n Action:\n Pt continuing on insulin drip. At 0900, pt on 7 units/hr of insulin\n with blood sugar 148 and given 70 units lantus SC. At 1000, drip\n increased to 8 units/hr and given 16 units regular insulin SC.\n Response:\n At 1200, pt with blood sugar 177 and given additional 4 units regular\n insulin SC NP order.\n Plan:\n Continue to check blood sugars and administer insulin per CVICU\n protocol.\n"},{"category":"Nursing","chartdate":"2174-08-02 00:00:00.000","description":"Nursing Progress Note","row_id":581830,"text":"H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt continues to be hyperglycemic >200.\n Action:\n IV bolus administered & Insulin Gtt restarted per protocol. PO\n Glyburide restarted and administered @ 1400.\n Response:\n Hyperglycemia continues. Insulin Gtt continues.\n Plan:\n Monitor Q1hr FSBS. Wean Insulin Gtt as tolerated. ? restart PO\n Metformin.\n"},{"category":"Nursing","chartdate":"2174-08-03 00:00:00.000","description":"Nursing Progress Note","row_id":581893,"text":"Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n -NSR 70\ns and no vea. BP wnl\n -Lungs are clear bilaterally with sats> 94% on 3L nc\n -HUO <40ml/hr\n -Chest tubes drained small amounts of serosanquinous drainage\n Action:\n -Patient is receiving po Lopressor 25mg po twice daily.\n -Administered IV Lasix 20mg\n -Patient used IS with good inspiratory effort.\n -Serum potassium and magnesium repleted\n Response:\n -Patient diuresed> 100ml/hr after receiving IV Lasix 20mg\n -Remains in NSR while receiving po beta blockers.\n Plan:\n -Continue with beta blockers for management of heart rate.\n -Continue with pulmonary toileting\n -Diurese with IV Lasix\n -? CT to be d/c\nd by team today\n Pain control (acute pain, chronic pain)\n Assessment:\n -Patient c/o sternotomy incisional pain\n Action:\n -Administered 2 percocet tabs and IV Toradol for pain\n Response:\n -Pain decreased after receiving the pain meds.\n Plan:\n -Administer Percocet tabs every 4 hous and IV Toradol every 6 hours for\n management of incisional pain\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n -At onset of shift, FS >170-203\n Action:\n -Titrated Insulin gtt up to a maximum dose of 9units/hr and gave\n regular insulin bolus according to unit protocol.\n Response:\n -FS eventually decreased to >120->96. The insulin gtt was slowly\n decreased to 2 units/hr. Notified PA for further orders\n regarding the Lantus dosage\n Plan:\n -Continue insulin gtt until Lantus dose given per team. Then titrate\n insulin gtt off if FS remains<120.\n -Monitor hourly FS while patient is receiving Insulin gtt\n -Check with team for restarting the Metformin today\n -Discharge to floor after Insulin gtt d/c\n"},{"category":"Nursing","chartdate":"2174-08-02 00:00:00.000","description":"Nursing Transfer Note","row_id":581744,"text":"Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt A&O, follows all commands and appropriate.\n HR-NSR 60\ns-80\ns. SBP 100\ns-110\ns. Doppler pulses. K-4.7 and ionized\n calcium 1.16 with am labs.\n LS-CTA/Dim at bases. 4LO2 NC- 96-99%. Chest tubes draining minimal\n amounts of serosang. drainage.\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\n diet.\n Foley intact draining good amounts of clear yellow urine.\n Action:\n Pt weaned off nitro drip and started on lopressor 25mg po bid at 0800.\n Epicardial wires tested with A\ns sensing and capturing appropriately\n and V\ns sensing but not capturing. Pt set on A demand at 50.\n Pt encouraged to C&DB and IS used 500-750.\n Pt started on lasix 20mg last night and continued.\n Response:\n Vitals unchanged at this time. Pt OOB to chair and chest with minimal\n amount of output. At 1100, pt with only 40cc\ns of urine past 2 hrs.\n and 20mg lasix IV given NP order.\n Plan:\n Continue to administer beta blocker, monitor lytes and replete, monitor\n UOP and diurese.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o incisional pain with movement/C&DB.\n Action:\n Pt given toridol 15mg IV at 0800.\n Response:\n Pt appears comfortable in chair at this time. When C&DB, pt c/o \n pain and given 1 percocet at 1030.\n Plan:\n Continue to monitor pain level and administer pain meds prn.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with blood sugars 130\ns-140\ns and received on insulin drip at 8\n units/hr.\n Action:\n Pt continuing on insulin drip. At 0900, pt on 7 units/hr of insulin\n with blood sugar 148 and given 70 units lantus SC. At 1000,\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2174-08-04 00:00:00.000","description":"Intensivist Note","row_id":582167,"text":"CVICU\n HPI:\n POD 2 s/p AVR (25 tissue)\n PMHx:\n EF > 65 Wt 104K Cr. 0.8 HgbA1C: 7.1\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\n fem- bypass, L shoulder, removal of calcium , L knee surgery\n , ?renal stent in \n : Allopurinol 300', ASA 81', glyburide 5\", lisinopril 20', lovasa\n 2\", metformin 500\"', ocuvite, simvastatin 40'\n Current medications:\n . 2. 3. 4. 250 mL D5W 5. Acetaminophen 6. Allopurinol 7. Aspirin EC 8.\n Calcium Gluconate 9. Cepacol (Menthol) 10. Dextrose 50% 11. Docusate\n Sodium 12. Furosemide 13. GlyBURIDE 14. Insulin 15. Insulin 16.\n Magnesium Sulfate 17. Metoclopramide 18. Metoprolol Tartrate 19. Milk\n of Magnesia 20. Morphine Sulfate 21. Nitroglycerin 22.\n Oxycodone-Acetaminophen 23. Pneumococcal Vac Polyvalent 24. Potassium\n Chloride 25. Ranitidine 26. Simvastatin 27. Sodium Chloride 0.9% Flush\n 28. Sodium Chloride 0.9% Flush 29. Sodium Chloride 0.9% Flush 30.\n Vancomycin\n 24 Hour Events:\n PA CATHETER - STOP 08:05 AM\n CORDIS/INTRODUCER - STOP 06:00 PM\n MULTI LUMEN - START 06:00 PM\n - Remained in ICU for elevated BS, on insulin gtt\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:16 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:04 AM\n Flowsheet Data as of 12:16 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.9\nC (98.5\n HR: 63 (63 - 80) bpm\n BP: 109/39(57) {104/39(56) - 136/77(89)} mmHg\n RR: 15 (14 - 21) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111 kg (admission): 104 kg\n Height: 70 Inch\n Total In:\n 1,158 mL\n 196 mL\n PO:\n 580 mL\n Tube feeding:\n IV Fluid:\n 578 mL\n 196 mL\n Blood products:\n Total out:\n 2,260 mL\n 1,785 mL\n Urine:\n 1,995 mL\n 1,725 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,102 mL\n -1,589 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress, Comfortable\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 164 K/uL\n 8.9 g/dL\n 120 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 17 mg/dL\n 101 mEq/L\n 135 mEq/L\n 25.1 %\n 5.8 K/uL\n [image002.jpg]\n 01:36 PM\n 02:15 PM\n 02:22 PM\n 03:23 PM\n 04:49 PM\n 05:52 PM\n 05:54 PM\n 02:09 AM\n 02:24 AM\n 02:06 AM\n WBC\n 8.0\n 5.3\n 5.8\n Hct\n 27.5\n 28.6\n 26.9\n 25.1\n Plt\n 233\n 178\n 164\n Creatinine\n 0.8\n 0.7\n 0.8\n TCO2\n 25\n 22\n 27\n 24\n 26\n Glucose\n 198\n 163\n 121\n 120\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\n Lactic Acid:1.5 mmol/L, Ca:8.7 mg/dL, Mg:1.5 mg/dL\n Imaging:\n CXR: s/p removal of CT, no ptx, post-op changes noted, line in\n place\n Microbiology:\n MRSA: negative\n Assessment and Plan\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 79 M s/p AVR (25 tissue), POD 2\n Neurologic: Neuro checks Q: hr, Pain controlled.\n Cardiovascular: Aspirin, Beta-blocker\n Pulmonary: IS, Cough, IS, OOB to chair.\n Gastrointestinal / Abdomen: Bowel regimen.\n Nutrition: Sips, ADAT.\n Renal: Foley, Adequate UO, Creat 0.8. Diurese with goal negative 1 L.\n Hematology: Stable anemia, no active bleeding.\n Endocrine: RISS, Insulin drip, Lantus (R), Transition from gtt to\n Lantus, increased Glyburide to home dose, RISS. Goal BS < 150. Holding\n metformin while being diuresed.\n Infectious Disease: Check cultures, Received peri-op Vanco. Afebrile,\n nomral WBC, no active ID issues at this time.\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: None\n Fluids: KVO\n Consults: CT surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\n Lantus (R) protocol\n Lines:\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"},{"category":"Nursing","chartdate":"2174-08-03 00:00:00.000","description":"Nursing Progress Note","row_id":581919,"text":"Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n -NSR 70\ns and no vea. BP wnl\n -Lungs are clear bilaterally with sats> 94% on 3L nc\n -HUO <40ml/hr\n -Chest tubes drained small amounts of serosanquinous drainage\n Action:\n -Patient is receiving po Lopressor 25mg po twice daily.\n -Administered IV Lasix 20mg\n -Patient used IS with good inspiratory effort.\n -Serum potassium and magnesium repleted\n Response:\n -Patient diuresed> 100ml/hr after receiving IV Lasix 20mg\n -Remains in NSR while receiving po beta blockers.\n Plan:\n -Continue with beta blockers for management of heart rate.\n -Continue with pulmonary toileting\n -Diurese with IV Lasix\n -? CT to be d/c\nd by team today\n Pain control (acute pain, chronic pain)\n Assessment:\n -Patient c/o sternotomy incisional pain\n Action:\n -Administered 2 percocet tabs and IV Toradol for pain\n Response:\n -Pain decreased after receiving the pain meds.\n Plan:\n -Administer Percocet tabs every 4 hours and IV Toradol every 6 hours\n for management of incisional pain\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n -At onset of shift, FS >170-203\n Action:\n -Titrated Insulin gtt up to a maximum dose of 9units/hr and gave\n regular insulin bolus according to unit protocol.\n Response:\n -FS eventually decreased to >120->96. The insulin gtt was slowly\n decreased to 2 units/hr. Notified PA for further orders\n regarding the Lantus dosage\n Plan:\n -Continue insulin gtt until Lantus dose given per team. Then titrate\n insulin gtt off if FS remains<120.\n -Monitor hourly FS while patient is receiving Insulin gtt\n -Check with team for restarting the Metformin today\n -Discharge to floor after Insulin gtt d/c\n"},{"category":"Nursing","chartdate":"2174-08-01 00:00:00.000","description":"Nursing Progress Note","row_id":581622,"text":"Patient is a 79yo with SOB to OR for 25mm tissue valve. In OR\n patient with elevated blood glucose difficult to control despite\n insulin bolus and gtt. Patient admit to CVICU stable on propofol, neo,\n insulin gtt.\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Received patient with BP in 80\ns systolic.\n Neo titrated with minimal result.\n CI >2 with admission.\n Potassium low.\n Action:\n Patient apaced for blood pressure control with good result.\n Found to have a metabolic acidosis on ABG, fluid boluses\n given with correction of acidosis.\n CI remains >2.\n Patient hypertensive with waking, nitro started. Titrated to\n maintain BP <120.\n Repeat potassium and Hct pending\n Response:\n Patient with stable VS, in NSR with ademand backup.\n Plan:\n Plan for extubation\n Pain control (acute pain, chronic pain)\n Assessment:\n Received patient on propofol gtt. Reversed, propofol off.\n Action:\n Patient woke agitated, restless. Morphine 2mg x2 given. Patient calmer,\n following commands.\n Response:\n Continue to assess for pain. Extubate tonight.\n Plan:\n Continue to assess for pain. Morphine prn, transition to percocet\n"},{"category":"Respiratory ","chartdate":"2174-08-01 00:00:00.000","description":"Respiratory Care Shift Note","row_id":581618,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Destination (R/T)\n Time\n Complications\n Comments\n Comments:\n Pt was admitted to CVICU via OR intubated and placed on the vent tol\n well. See respiratory page of meta vision for more information.\n"},{"category":"Nursing","chartdate":"2174-08-01 00:00:00.000","description":"Nursing Progress Note","row_id":581620,"text":"Patient is a 79yo with SOB to OR for 25mm tissue valve. In OR\n patient with elevated blood glucose difficult to control despite\n insulin bolus and gtt. Patient admit to CVICU stable on propofol, neo,\n insulin gtt.\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Received patient with BP in 80\ns systolic.\n Neo titrated with minimal result.\n CI >2 with admission.\n Potassium low.\n Action:\n Patient apaced for blood pressure control with good result.\n Found to have a metabolic acidosis on ABG, fluid boluses\n given\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2174-08-02 00:00:00.000","description":"Nursing Progress Note","row_id":581761,"text":"Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt A&O, follows all commands and appropriate.\n HR-NSR 60\ns-80\ns. SBP 100\ns-110\ns. Doppler pulses. K-4.7 and ionized\n calcium 1.16 with am labs.\n LS-CTA/Dim at bases. 3-4LO2 NC- 96-99%. Chest tubes draining minimal\n amounts of serosang. drainage.\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\n diet.\n Foley intact draining good amounts of clear yellow urine.\n Action:\n Pt weaned off nitro drip and started on lopressor 25mg po bid at 0800.\n Epicardial wires tested with A\ns sensing and capturing appropriately\n and V\ns sensing but not capturing. Pt set on A demand at 50.\n Pt encouraged to C&DB and IS used 500-750.\n Pt started on lasix 20mg last night and continued.\n Response:\n Vitals unchanged at this time. Pt OOB to chair and chest tubes with\n minimal amount of output. At 1100, pt with only 40cc\ns of urine past 2\n hrs. and 20mg lasix IV given NP order.\n Plan:\n Continue to administer beta blocker, monitor lytes and replete, monitor\n UOP and diurese.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o incisional pain with movement/C&DB.\n Action:\n Pt given toridol 15mg IV at 0800.\n Response:\n Pt appears comfortable in chair at this time. When C&DB, pt c/o \n pain and given percoets in am/afternoon.\n Plan:\n Continue to monitor pain level and administer toradol q6h/percocets.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with blood sugars 130\ns-140\ns and received on insulin drip at 8\n units/hr.\n Action:\n Pt continuing on insulin drip. At 0900, pt on 7 units/hr of insulin\n with blood sugar 148 and given 70 units lantus SC. At 1000, drip\n increased to 8 units/hr and given 16 units regular insulin SC.\n Response:\n At 1200, pt with blood sugar 177 and given additional 4 units regular\n insulin SC NP order.\n Plan:\n Continue to check blood sugars and administer insulin per CVICU\n protocol.\n"},{"category":"Nursing","chartdate":"2174-08-02 00:00:00.000","description":"Nursing Transfer Note","row_id":581743,"text":"Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt A&O, follows all commands and appropriate.\n HR-NSR 60\ns-80\ns. SBP 100\ns-110\ns. Doppler pulses. K-4.7 and ionized\n calcium 1.16 with am labs.\n LS-CTA/Dim at bases. 4LO2 NC- 96-99%. Chest tubes draining minimal\n amounts of serosang. drainage.\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\n diet.\n Foley intact draining good amounts of clear yellow urine.\n Action:\n Pt weaned off nitro drip and started on lopressor 25mg po bid at 0800.\n Epicardial wires tested with A\ns sensing and capturing appropriately\n and V\ns sensing but not capturing. Pt set on A demand at 50.\n Pt encouraged to C&DB and IS used 500-750.\n Pt started on lasix 20mg last night and continued.\n Response:\n Vitals unchanged at this time. Pt OOB to chair and chest with minimal\n amount of output. At 1100, pt with only 40cc\ns of urine past 2 hrs.\n and 20mg lasix IV given NP order.\n Plan:\n Continue to administer beta blocker, monitor lytes and replete, monitor\n UOP and diurese.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o incisional pain with movement/C&DB.\n Action:\n Pt given toridol 15mg IV at 0800.\n Response:\n Pt appears comfortable in chair at this time. When C&DB, pt c/o \n pain and given 1 percocet at 1030\n Plan:\n Continue to monitor pain level and administer pain meds prn.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2174-08-02 00:00:00.000","description":"Nursing Progress Note","row_id":581717,"text":"Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n NSR without ectopy, HR 70\ns-80\ns. RIJ Cordis, PA line, CO/CI WNL. SBP\n 120-140\ns. Pedal pulses doppled, extremities cool/dry. Chest tubes to\n Suction, small amounts serosanguinous drainage, no air leak, no\n creptius.\n Action:\n Ntg gtt titrated to keep SBP < 120.\n Response:\n SBP 115-140\ns. stable hemodynamics.\n Plan:\n DC PA line, leave cordis in for now. OOB to chair. ? DC chest tubes if\n no dump when Transfer to 6 today.\n Pain control (acute pain, chronic pain)\n Assessment:\n Unable to rate pain, moaning continually,\nOh my chest. It hurts in my\n backtoo.\n shallow respirations, poor deep breathing efforts. Also c/o\n mouth being sore. Refusing oral care, flinches when lips touched.\n Action:\n Morphine 2mg IV q1-2h without effect. Toradol 30mg IV at 0145.\n Response:\nit feels a lot better.\n Good response from Toradol.\n Plan:\n Start po pain meds, Toradol 15mg IV q6h x 24h.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Blood sugars 79-154\n Action:\n Insulin gtt 1-8 units/hr.\n Response:\n Fairly good BS control on insulin gtt\n Plan:\n ? clinic to consult this am for Blood sugar management\n"},{"category":"Nursing","chartdate":"2174-08-02 00:00:00.000","description":"Nursing Transfer Note","row_id":581731,"text":"Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt A&O, follows all commands and appropriate.\n HR-NSR 60\ns-80\ns. SBP 100\ns-110\ns. Doppler pulses. K-4.7 and ionized\n calcium 1.16 with am labs.\n LS-CTA/Dim at bases. 4LO2 NC- 96-99%. Chest tubes draining minimal\n amounts of serosang. drainage.\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\n diet.\n Foley intact draining good amounts of clear yellow urine.\n Action:\n Pt weaned off nitro drip and started on lopressor 25mg po bid at 0800.\n Epicardial wires tested with A\ns sensing and capturing appropriately\n and V\ns sensing but not capturing. Pt set on A demand at 50.\n Pt encouraged to C&DB and IS used 500-750.\n Pt started on lasix 20mg last night and continued.\n Response:\n Vitals unchanged at this time. Pt OOB to chair and chest with minimal\n amount of output.\n Plan:\n Continue to administer beta blocker, monitor lytes and replete, monitor\n UOP and diurese.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o incisional pain with movement/C&DB.\n Action:\n Pt given toridol 15mg IV at 0800.\n Response:\n Pt appears comfortable in chair at this time with no complaints.\n Plan:\n Continue to monitor pain level and administer pain meds prn.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2174-08-02 00:00:00.000","description":"Intensivist Note","row_id":581732,"text":"CVICU\n HPI:\n POD 1\n s/p AVR (25 tissue) \n Chief complaint:\n PMHx:\n EF > 65 Wt Cr. 0.8 HgbA1C: 7.1\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\n fem- bypass, L shoulder, removal of calcium , L knee surgery\n , ?renal stent in \n : Allopurinol 300', ASA 81', glyburide 5\", lisinopril 20', lovasa\n 2\", metformin 500\"', ocuvite, simvastatin 40'\n Current medications:\n 1. 2. 3. 250 mL D5W 4. Acetaminophen 5. Allopurinol 6. Aspirin EC 7.\n Calcium Gluconate 8. Dextrose 50%\n 9. Docusate Sodium 10. Furosemide 11. Insulin 12. Ketorolac 13.\n Ketorolac 14. Magnesium Sulfate\n 15. Metoclopramide 16. Metoprolol Tartrate 17. Milk of Magnesia 18.\n Morphine Sulfate 19. Nitroglycerin\n 20. Oxycodone-Acetaminophen 21. Pneumococcal Vac Polyvalent 22.\n Potassium Chloride 23. Ranitidine\n 24. Simvastatin 25. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9%\n Flush 27. Vancomycin\n 24 Hour Events:\n ARTERIAL LINE - START 02:00 PM\n PA CATHETER - START 02:00 PM\n INVASIVE VENTILATION - START 02:00 PM\n CORDIS/INTRODUCER - START 02:00 PM\n EKG - At 04:00 PM\n INVASIVE VENTILATION - STOP 06:15 PM\n ARTERIAL LINE - STOP 06:28 AM\n - Extubtaed, no issues overnight\n - Remains in ICU on NTG gtt and insulin gtt\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 07:30 PM\n Infusions:\n Insulin - Regular - 8 units/hour\n Other ICU medications:\n Insulin - Regular - 02:38 PM\n Morphine Sulfate - 12:24 AM\n Furosemide (Lasix) - 01:50 AM\n Other medications:\n Flowsheet Data as of 10:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 37.1\nC (98.8\n HR: 75 (61 - 82) bpm\n BP: 115/58(71) {106/50(64) - 115/58(71)} mmHg\n RR: 14 (12 - 21) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CVP: 3 (3 - 16) mmHg\n PAP: (20 mmHg) / (8 mmHg)\n CO/CI (Thermodilution): (5.22 L/min) / (2.9 L/min/m2)\n SVR: 845 dynes*sec/cm5\n SV: 79 mL\n SVI: 36 mL/m2\n Total In:\n 5,655 mL\n 250 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,155 mL\n 250 mL\n Blood products:\n 500 mL\n Total out:\n 1,000 mL\n 1,115 mL\n Urine:\n 570 mL\n 970 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,655 mL\n -865 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 634 (386 - 634) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n Plateau: 11 cmH2O\n SPO2: 98%\n ABG: 7.40/41/110/24/0\n Ve: 9.5 L/min\n Physical Examination\n General: No acute distress\n HEENt: PERRL, anicteric\n Heart: s1s2 RRR\n Chest: Lungs CTA bilaterally, sternum stable\n Abd: Soft, NT/ND\n Ext: No edema; DP palp B\n Skin: Warm, dry\n Labs / Radiology\n 178 K/uL\n 9.4 g/dL\n 121 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.7 mEq/L\n 15 mg/dL\n 105 mEq/L\n 135 mEq/L\n 26.9 %\n 5.3 K/uL\n [image002.jpg]\n 01:06 PM\n 01:36 PM\n 02:15 PM\n 02:22 PM\n 03:23 PM\n 04:49 PM\n 05:52 PM\n 05:54 PM\n 02:09 AM\n 02:24 AM\n WBC\n 10.1\n 8.0\n 5.3\n Hct\n 25.8\n 27.5\n 28.6\n 26.9\n Plt\n 261\n 233\n 178\n Creatinine\n 0.8\n 0.7\n TCO2\n 25\n 25\n 22\n 27\n 24\n 26\n Glucose\n 21\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\n Lactic Acid:1.5 mmol/L\n Imaging: CXR: FINDINGS: In comparison with the study of\n , there are now metallic\n sternal sutures in place. Endotracheal tube tip lies approximately 5.7\n cm\n above the carina. Right IJ catheter extends to the proximal portion of\n the\n right pulmonary artery. Nasogastric tube extends well into the\n stomach.\n Bibasilar atelectasis, more prominent on the left. No evidence of\n pneumothorax.\n IMPRESSION: Standard appearance following cardiac surgery.\n Microbiology: MRSA: P\n Assessment and Plan\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan:\n 79M s/p AVR (25 tissue) , POD 1\n Neurologic: Neuro checks Q: 4 hr, Pain controlled\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor\n Pulmonary: IS, Cough, deep breathe, OOB.\n Gastrointestinal / Abdomen: Sips, ADAT. Bowel regimen.\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, Normal creatinine.\n Hematology: Stable anemia. No active bleeding.\n Endocrine: RISS, Insulin drip, Lantus (R), Transition from insulin gtt\n to RISS. Goal BS <150.\n Infectious Disease: Check cultures, Peri-op Vanco.\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults: CT surgery\n Billing Diagnosis: Post-op hypertension\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\n Lantus (R) protocol\n Lines:\n Cordis/Introducer - 02:00 PM\n 18 Gauge - 02:06 PM\n Comments: Change cordis to triple lumen CVL\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"},{"category":"Physician ","chartdate":"2174-08-02 00:00:00.000","description":"Intensivist Note","row_id":581733,"text":"CVICU\n HPI:\n POD 1\n s/p AVR (25 tissue) \n PMHx:\n EF > 65 Wt Cr. 0.8 HgbA1C: 7.1\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\n fem- bypass, L shoulder, removal of calcium , L knee surgery\n , ?renal stent in \n : Allopurinol 300', ASA 81', glyburide 5\", lisinopril 20', lovasa\n 2\", metformin 500\"', ocuvite, simvastatin 40'\n Current medications:\n 1. 2. 3. 250 mL D5W 4. Acetaminophen 5. Allopurinol 6. Aspirin EC 7.\n Calcium Gluconate 8. Dextrose 50% 9. Docusate Sodium 10. Furosemide 11.\n Insulin 12. Ketorolac 13. Ketorolac 14. Magnesium Sulfate 15.\n Metoclopramide 16. Metoprolol Tartrate 17. Milk of Magnesia 18.\n Morphine Sulfate 19. Nitroglycerin\n 20. Oxycodone-Acetaminophen 21. Pneumococcal Vac Polyvalent 22.\n Potassium Chloride 23. Ranitidine 24. Simvastatin 25. Sodium Chloride\n 0.9% Flush 26. Sodium Chloride 0.9% Flush 27. Vancomycin\n 24 Hour Events:\n ARTERIAL LINE - START 02:00 PM\n PA CATHETER - START 02:00 PM\n INVASIVE VENTILATION - START 02:00 PM\n CORDIS/INTRODUCER - START 02:00 PM\n EKG - At 04:00 PM\n INVASIVE VENTILATION - STOP 06:15 PM\n ARTERIAL LINE - STOP 06:28 AM\n - Extubtaed, no issues overnight\n - Remains in ICU on NTG gtt (now off) and insulin gtt (transitioning)\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 07:30 PM\n Infusions:\n Insulin - Regular - 8 units/hour\n Other ICU medications:\n Insulin - Regular - 02:38 PM\n Morphine Sulfate - 12:24 AM\n Furosemide (Lasix) - 01:50 AM\n Flowsheet Data as of 10:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 37.1\nC (98.8\n HR: 75 (61 - 82) bpm\n BP: 115/58(71) {106/50(64) - 115/58(71)} mmHg\n RR: 14 (12 - 21) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CVP: 3 (3 - 16) mmHg\n PAP: (20 mmHg) / (8 mmHg)\n CO/CI (Thermodilution): (5.22 L/min) / (2.9 L/min/m2)\n SVR: 845 dynes*sec/cm5\n SV: 79 mL\n SVI: 36 mL/m2\n Total In:\n 5,655 mL\n 250 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,155 mL\n 250 mL\n Blood products:\n 500 mL\n Total out:\n 1,000 mL\n 1,115 mL\n Urine:\n 570 mL\n 970 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,655 mL\n -865 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 634 (386 - 634) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n Plateau: 11 cmH2O\n SPO2: 98%\n ABG: 7.40/41/110/24/0\n Ve: 9.5 L/min\n Physical Examination\n General: No acute distress\n HEENt: PERRL, anicteric; s/p multiple upper teeth extractions, no\n purulence noted\n Heart: s1s2 RRR\n Chest: Lungs CTA bilaterally, sternum stable\n Abd: Soft, NT/ND\n Ext: No edema; DP palp B\n Skin: Warm, dry\n Labs / Radiology\n 178 K/uL\n 9.4 g/dL\n 121 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.7 mEq/L\n 15 mg/dL\n 105 mEq/L\n 135 mEq/L\n 26.9 %\n 5.3 K/uL\n [image002.jpg]\n 01:06 PM\n 01:36 PM\n 02:15 PM\n 02:22 PM\n 03:23 PM\n 04:49 PM\n 05:52 PM\n 05:54 PM\n 02:09 AM\n 02:24 AM\n WBC\n 10.1\n 8.0\n 5.3\n Hct\n 25.8\n 27.5\n 28.6\n 26.9\n Plt\n 261\n 233\n 178\n Creatinine\n 0.8\n 0.7\n TCO2\n 25\n 25\n 22\n 27\n 24\n 26\n Glucose\n 21\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\n Lactic Acid:1.5 mmol/L\n Imaging:\n CXR: FINDINGS: In comparison with the study of , there\n are now metallic\n sternal sutures in place. Endotracheal tube tip lies approximately 5.7\n cm\n above the carina. Right IJ catheter extends to the proximal portion of\n the\n right pulmonary artery. Nasogastric tube extends well into the\n stomach.\n Bibasilar atelectasis, more prominent on the left. No evidence of\n pneumothorax.\n IMPRESSION: Standard appearance following cardiac surgery.\n Microbiology:\n MRSA: P\n Assessment and Plan\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 79M s/p AVR (25 tissue) , POD 1\n Neurologic: Neuro checks Q: 4 hr, Pain controlled\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor\n Pulmonary: IS, Cough, deep breathe, OOB.\n Gastrointestinal / Abdomen: Sips, ADAT. Bowel regimen.\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, Normal creatinine.\n Hematology: Stable anemia. No active bleeding.\n Endocrine: RISS, Insulin drip, Lantus (R), Transition from insulin gtt\n to RISS. Goal BS <150.\n Infectious Disease: Check cultures, Peri-op Vanco.\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults: CT surgery\n Billing Diagnosis: Post-op hypertension\n ICU Care\n Nutrition: ADAT\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\n Lantus (R) protocol\n Lines:\n Cordis/Introducer - 02:00 PM\n 18 Gauge - 02:06 PM\n Comments: Change cordis to triple lumen CVL\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"},{"category":"Physician ","chartdate":"2174-08-02 00:00:00.000","description":"ICU Note - CVI","row_id":581739,"text":"CVICU\n HPI:\n POD 1\n s/p AVR (25 tissue)\n EF > 65 Wt Cr. 0.8 HgbA1C: 7.1\n PMHx:\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\n fem- bypass, L shoulder, removal of calcium , L knee surgery\n , ?renal stent in \n : Allopurinol 300', ASA 81', glyburide 5\", lisinopril 20', lovasa\n 2\", metformin 500\"', ocuvite, simvastatin 40'\n Current medications:\n Acetaminophen 5. Allopurinol 6. Aspirin EC 7. Calcium Gluconate 8.\n Dextrose 50% 9. Docusate Sodium 10. Furosemide 11. Insulin 12.\n Ketorolac . Magnesium Sulfate 15. Metoclopramide 16. Metoprolol\n Tartrate 17. Milk of Magnesia 18. Morphine Sulfate 19. Nitroglycerin\n 20. Oxycodone-Acetaminophen . Potassium Chloride 23. Ranitidine 24.\n Simvastatin Vancomycin\n 24 Hour Events:\n PA CATHETER - START 02:00 PM\n ARTERIAL LINE - START 02:00 PM\n INVASIVE VENTILATION - START 02:00 PM\n CORDIS/INTRODUCER - START 02:00 PM\n EKG - At 04:00 PM\n INVASIVE VENTILATION - STOP 06:15 PM\n ARTERIAL LINE - STOP 06:28 AM\n Post operative day:\n POD 1\n s/p AVR (25 tissue)\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 07:30 PM\n Infusions:\n Insulin - Regular - 8 units/hour\n Other ICU medications:\n Insulin - Regular - 02:38 PM\n Morphine Sulfate - 12:24 AM\n Furosemide (Lasix) - 01:50 AM\n Flowsheet Data as of 10:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 37.1\nC (98.8\n HR: 73 (61 - 82) bpm\n BP: 102/47(60) {102/47(60) - 115/58(71)} mmHg\n RR: 15 (12 - 21) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CVP: 3 (3 - 16) mmHg\n PAP: (20 mmHg) / (8 mmHg)\n CO/CI (Thermodilution): (5.22 L/min) / (2.9 L/min/m2)\n SVR: 757 dynes*sec/cm5\n SV: 81 mL\n SVI: 37 mL/m2\n Total In:\n 5,655 mL\n 740 mL\n PO:\n 480 mL\n Tube feeding:\n IV Fluid:\n 5,155 mL\n 260 mL\n Blood products:\n 500 mL\n Total out:\n 1,000 mL\n 1,195 mL\n Urine:\n 570 mL\n 990 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,655 mL\n -455 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 634 (386 - 634) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n Plateau: 11 cmH2O\n SPO2: 100%\n ABG: 7.40/41/110/24/0\n Ve: 9.5 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\n Left Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 178 K/uL\n 9.4 g/dL\n 121 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.7 mEq/L\n 15 mg/dL\n 105 mEq/L\n 135 mEq/L\n 26.9 %\n 5.3 K/uL\n [image002.jpg]\n 01:06 PM\n 01:36 PM\n 02:15 PM\n 02:22 PM\n 03:23 PM\n 04:49 PM\n 05:52 PM\n 05:54 PM\n 02:09 AM\n 02:24 AM\n WBC\n 10.1\n 8.0\n 5.3\n Hct\n 25.8\n 27.5\n 28.6\n 26.9\n Plt\n 261\n 233\n 178\n Creatinine\n 0.8\n 0.7\n TCO2\n 25\n 25\n 22\n 27\n 24\n 26\n Glucose\n 21\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\n Lactic Acid:1.5 mmol/L\n Assessment and Plan\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 79yo man s/p AVR(tissue) doing well\n post-operatively. Ready for transfer to stepdown floor\n Neurologic: Pain controlled, Morphine and percocet for pain control\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor,\n titrate Bblockers to HR/BP\n Pulmonary: IS, OOB-ambulate\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, start diuretic to make net negative 1-1.5\n liters today\n Hematology: stable hct\n Endocrine: RISS, Lantus (R)\n Infectious Disease: no active issues\n afebrie, normal wbc\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today, after ct removal\n Consults: CT surgery, \n ICU Care\n Nutrition: ADAT\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n Cordis/Introducer - 02:00 PM\n 18 Gauge - 02:06 PM\n Prophylaxis:\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2174-08-02 00:00:00.000","description":"Intensivist Note","row_id":581802,"text":"CVICU\n HPI:\n POD 1\n s/p AVR (25 tissue) \n PMHx:\n EF > 65 Wt Cr. 0.8 HgbA1C: 7.1\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\n fem- bypass, L shoulder, removal of calcium , L knee surgery\n , ?renal stent in \n : Allopurinol 300', ASA 81', glyburide 5\", lisinopril 20', lovasa\n 2\", metformin 500\"', ocuvite, simvastatin 40'\n Current medications:\n 1. 2. 3. 250 mL D5W 4. Acetaminophen 5. Allopurinol 6. Aspirin EC 7.\n Calcium Gluconate 8. Dextrose 50% 9. Docusate Sodium 10. Furosemide 11.\n Insulin 12. Ketorolac 13. Ketorolac 14. Magnesium Sulfate 15.\n Metoclopramide 16. Metoprolol Tartrate 17. Milk of Magnesia 18.\n Morphine Sulfate 19. Nitroglycerin\n 20. Oxycodone-Acetaminophen 21. Pneumococcal Vac Polyvalent 22.\n Potassium Chloride 23. Ranitidine 24. Simvastatin 25. Sodium Chloride\n 0.9% Flush 26. Sodium Chloride 0.9% Flush 27. Vancomycin\n 24 Hour Events:\n ARTERIAL LINE - START 02:00 PM\n PA CATHETER - START 02:00 PM\n INVASIVE VENTILATION - START 02:00 PM\n CORDIS/INTRODUCER - START 02:00 PM\n EKG - At 04:00 PM\n INVASIVE VENTILATION - STOP 06:15 PM\n ARTERIAL LINE - STOP 06:28 AM\n - Extubtaed, no issues overnight\n - Remains in ICU on NTG gtt (now off) and insulin gtt (transitioning)\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 07:30 PM\n Infusions:\n Insulin - Regular - 8 units/hour\n Other ICU medications:\n Insulin - Regular - 02:38 PM\n Morphine Sulfate - 12:24 AM\n Furosemide (Lasix) - 01:50 AM\n Flowsheet Data as of 10:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 37.1\nC (98.8\n HR: 75 (61 - 82) bpm\n BP: 115/58(71) {106/50(64) - 115/58(71)} mmHg\n RR: 14 (12 - 21) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CVP: 3 (3 - 16) mmHg\n PAP: (20 mmHg) / (8 mmHg)\n CO/CI (Thermodilution): (5.22 L/min) / (2.9 L/min/m2)\n SVR: 845 dynes*sec/cm5\n SV: 79 mL\n SVI: 36 mL/m2\n Total In:\n 5,655 mL\n 250 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,155 mL\n 250 mL\n Blood products:\n 500 mL\n Total out:\n 1,000 mL\n 1,115 mL\n Urine:\n 570 mL\n 970 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,655 mL\n -865 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 634 (386 - 634) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n Plateau: 11 cmH2O\n SPO2: 98%\n ABG: 7.40/41/110/24/0\n Ve: 9.5 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\n Left Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 178 K/uL\n 9.4 g/dL\n 121 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.7 mEq/L\n 15 mg/dL\n 105 mEq/L\n 135 mEq/L\n 26.9 %\n 5.3 K/uL\n [image002.jpg]\n 01:06 PM\n 01:36 PM\n 02:15 PM\n 02:22 PM\n 03:23 PM\n 04:49 PM\n 05:52 PM\n 05:54 PM\n 02:09 AM\n 02:24 AM\n WBC\n 10.1\n 8.0\n 5.3\n Hct\n 25.8\n 27.5\n 28.6\n 26.9\n Plt\n 261\n 233\n 178\n Creatinine\n 0.8\n 0.7\n TCO2\n 25\n 25\n 22\n 27\n 24\n 26\n Glucose\n 21\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\n Lactic Acid:1.5 mmol/L\n Imaging:\n CXR: FINDINGS: In comparison with the study of , there\n are now metallic\n sternal sutures in place. Endotracheal tube tip lies approximately 5.7\n cm\n above the carina. Right IJ catheter extends to the proximal portion of\n the\n right pulmonary artery. Nasogastric tube extends well into the\n stomach.\n Bibasilar atelectasis, more prominent on the left. No evidence of\n pneumothorax.\n IMPRESSION: Standard appearance following cardiac surgery.\n Microbiology:\n MRSA: P\n Assessment and Plan\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 79M s/p AVR (25 tissue) , POD 1\n Neurologic: Neuro checks Q: 4 hr, Pain controlled\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor\n Pulmonary: IS, Cough, deep breathe, OOB.\n Gastrointestinal / Abdomen: Sips, ADAT. Bowel regimen.\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, Normal creatinine.\n start lasix diuresis\n \n Hematology: Stable anemia. No active bleeding.\n Endocrine: RISS, Insulin drip\n start Lantus (R), Transition from\n insulin gtt to RISS. Goal BS <150.\n Infectious Disease: Check cultures, Peri-op Vanco.\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging: none\n Fluids: KVO\n Consults: CT surgery\n Billing Diagnosis: Post-op hypertension; Post-op hyperglycemia\n ICU Care\n Nutrition: ADAT\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\n Lantus (R) protocol\n Lines:\n Cordis/Introducer - 02:00 PM\n 18 Gauge - 02:06 PM\n Comments: Change cordis to triple lumen CVL\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"},{"category":"Nursing","chartdate":"2174-08-01 00:00:00.000","description":"Nursing Progress Note","row_id":581632,"text":"Patient is a 79yo with SOB to OR for 25mm tissue valve. In OR\n patient with elevated blood glucose difficult to control despite\n insulin bolus and gtt. Patient admit to CVICU stable on propofol, neo,\n insulin gtt.\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Received patient with BP in 80\ns systolic.\n Neo titrated with minimal result.\n CI >2 with admission.\n Potassium low.\n Action:\n Patient apaced for blood pressure control with good result.\n Found to have a metabolic acidosis on ABG, fluid boluses\n given with correction of acidosis.\n CI remains >2.\n Patient hypertensive with waking, nitro started. Titrated to\n maintain BP <120.\n Repeat potassium and Hct pending\n Response:\n Patient with stable VS, in NSR with ademand backup.\n Plan:\n Plan for extubation\n Pain control (acute pain, chronic pain)\n Assessment:\n Received patient on propofol gtt. Reversed, propofol off.\n Action:\n Patient woke agitated, restless. Morphine 2mg x2 given. Patient calmer,\n following commands.\n Response:\n Continue to assess for pain. Extubate tonight.\n Plan:\n Continue to assess for pain. Morphine prn, transition to percocet\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Patient with hx of DDM type I on oral meds at baseline. Difficult\n control in OR\n Action:\n Insulin gtt titrated postop per protocol with max dose increased to\n 15units.\n Response:\n Patient with stable glucose levels on insulin gtt, titrated per CVICU\n protocol\n Plan:\n Continue insulin gtt, ? consult in am for control\n"},{"category":"Nursing","chartdate":"2174-08-03 00:00:00.000","description":"Nursing Transfer Note","row_id":582009,"text":"Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt A&O, follows all commands and appropriate.\n HR-NSR 60\ns-80\ns. SBP 90\ns-110\ns. Doppler pulses.\n LS-CTA/Dim at bases. LO2 NC- 96-99%. Chest tubes draining minimal\n amounts of serosang. drainage.\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\n diet.\n Foley intact draining good amounts of clear yellow urine.\n Action:\n Pt received 3 doses of lopressor po since yesterday. Epicardial wires\n tested with A\ns sensing and capturing appropriately and V\ns sensing but\n not capturing. Pt set on A demand at 50.\n Pt encouraged to C&DB and IS used .\n Pt continued on lasix drip 20mg IV bid.\n Response:\n Vitals unchanged at this time. Pt OOB to chair and chest tubes with\n minimal amount of output. Chest tubes D/C\nd in am and chest x-ray\n performed showing atelectasis NP .\n Plan:\n Continue to administer beta blocker, monitor lytes and replete, monitor\n UOP and diurese.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o incisional pain with movement/C&DB.\n Action:\n Pt given toradol/percocets.\n Response:\n Pt appears comfortable in chair at this time. When C&DB, pt c/o \n pain and given percoets in am/afternoon.\n Plan:\n Continue to monitor pain level and administer pain meds.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with blood sugars 110\ns-170\ns and received on insulin drip at 3\n units/hr.\n Action:\n Pt continuing on insulin drip. At 0700, pt given 50units lantus SC \n NP . Pt also started on own humalog ISS and given 6 units of\n humalog SC for BS 117 at 0800. At 0900, drip shut off and at 1000 pt\n with BS 150\n Response:\n At 1200, pt with blood sugar 178 and given 14 units humalog insulin SC\n per ISS.\n Plan:\n Continue to check blood sugars and administer insulin per own ISS.\n Pt with R IJ TLC that was changed over wire on . Pt last received\n 2 percocets at 1200 and finished with toradol. Pt with last blood\n sugar 160 at 1400 with no coverage. NP and check next sugar\n before dinner. Pt refused lunch at this time. Foley D/C\nd at 1430.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n AORTIC STENOSIS\n Code status:\n Full code\n Height:\n 70 Inch\n Admission weight:\n 104 kg\n Daily weight:\n 111 kg\n Allergies/Reactions:\n Penicillins\n Unknown;\n Precautions: No Additional Precautions\n PMH: Diabetes - Oral \n CV-PMH: PVD\n Additional history: Patient with hx of BPH, gout, macular degeneration.\n s/p B fem- bypass 3-4 years PTA, L shoulder removal of calcium ,\n L knee surgery , ?renal stent in \n Surgery / Procedure and date: AVR 25mm tissue valve.\n XCL 75, bypass 51. Stable OR course. Blood glucose >200 thru case with\n 25units blous, insulin gtt to 12units. Difficult to come off\n pump->ectopy, RAF treated with amio bolus. Admit CVICU on neo, prop.\n Apaced for blood pressure support..\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:109\n D:55\n Temperature:\n 98.5\n Arterial BP:\n S:115\n D:47\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 66 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 196 mL\n 24h total out:\n 1,935 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 50 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 1.2 mV\n Temporary atrial sensitivity setting:\n 0.6 mV\n Temporary atrial stimulation threshold :\n 12 mA\n Temporary atrial stimulation setting:\n 20 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 0.8 mV\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 02:06 AM\n Potassium:\n 3.9 mEq/L\n 02:06 AM\n Chloride:\n 101 mEq/L\n 02:06 AM\n CO2:\n 28 mEq/L\n 02:06 AM\n BUN:\n 17 mg/dL\n 02:06 AM\n Creatinine:\n 0.8 mg/dL\n 02:06 AM\n Glucose:\n 120 mg/dL\n 02:06 AM\n Hematocrit:\n 25.1 %\n 02:06 AM\n Finger Stick Glucose:\n 160\n 02:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables: Valuables in safe on 6 per pt.\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 6\n Date & time of Transfer: 1500\n"},{"category":"Physician ","chartdate":"2174-08-03 00:00:00.000","description":"Intensivist Note","row_id":581978,"text":"CVICU\n HPI:\n POD 2\n s/p AVR (25 tissue)\n PMHx:\n EF > 65 Wt 104K Cr. 0.8 HgbA1C: 7.1\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\n fem- bypass, L shoulder, removal of calcium , L knee surgery\n , ?renal stent in \n : Allopurinol 300', ASA 81', glyburide 5\", lisinopril 20', lovasa\n 2\", metformin 500\"', ocuvite, simvastatin 40'\n Current medications:\n . 2. 3. 4. 250 mL D5W 5. Acetaminophen 6. Allopurinol 7. Aspirin EC 8.\n Calcium Gluconate 9. Cepacol (Menthol) 10. Dextrose 50% 11. Docusate\n Sodium 12. Furosemide 13. GlyBURIDE 14. Insulin 15. Insulin 16.\n Magnesium Sulfate 17. Metoclopramide 18. Metoprolol Tartrate 19. Milk\n of Magnesia 20. Morphine Sulfate 21. Nitroglycerin 22.\n Oxycodone-Acetaminophen 23. Pneumococcal Vac Polyvalent 24. Potassium\n Chloride 25. Ranitidine 26. Simvastatin 27. Sodium Chloride 0.9% Flush\n 28. Sodium Chloride 0.9% Flush 29. Sodium Chloride 0.9% Flush 30.\n Vancomycin\n 24 Hour Events:\n PA CATHETER - STOP 08:05 AM\n CORDIS/INTRODUCER - STOP 06:00 PM\n MULTI LUMEN - START 06:00 PM\n - Remained in ICU for elevated BS, on insulin gtt\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:16 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:04 AM\n Flowsheet Data as of 12:16 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.9\nC (98.5\n HR: 63 (63 - 80) bpm\n BP: 109/39(57) {104/39(56) - 136/77(89)} mmHg\n RR: 15 (14 - 21) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111 kg (admission): 104 kg\n Height: 70 Inch\n Total In:\n 1,158 mL\n 196 mL\n PO:\n 580 mL\n Tube feeding:\n IV Fluid:\n 578 mL\n 196 mL\n Blood products:\n Total out:\n 2,260 mL\n 1,785 mL\n Urine:\n 1,995 mL\n 1,725 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,102 mL\n -1,589 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress, Comfortable\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 164 K/uL\n 8.9 g/dL\n 120 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 17 mg/dL\n 101 mEq/L\n 135 mEq/L\n 25.1 %\n 5.8 K/uL\n [image002.jpg]\n 01:36 PM\n 02:15 PM\n 02:22 PM\n 03:23 PM\n 04:49 PM\n 05:52 PM\n 05:54 PM\n 02:09 AM\n 02:24 AM\n 02:06 AM\n WBC\n 8.0\n 5.3\n 5.8\n Hct\n 27.5\n 28.6\n 26.9\n 25.1\n Plt\n 233\n 178\n 164\n Creatinine\n 0.8\n 0.7\n 0.8\n TCO2\n 25\n 22\n 27\n 24\n 26\n Glucose\n 198\n 163\n 121\n 120\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\n Lactic Acid:1.5 mmol/L, Ca:8.7 mg/dL, Mg:1.5 mg/dL\n Imaging:\n CXR: s/p removal of CT, no ptx, post-op changes noted, line in\n place\n Microbiology:\n MRSA: negative\n Assessment and Plan\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 79 M s/p AVR (25 tissue), POD 2\n Neurologic: Neuro checks Q: hr, Pain controlled.\n Cardiovascular: Aspirin, Beta-blocker\n Pulmonary: IS, Cough, IS, OOB to chair.\n Gastrointestinal / Abdomen: Bowel regimen.\n Nutrition: Sips, ADAT.\n Renal: Foley, Adequate UO, Creat 0.8. Diurese with goal negative 1 L.\n Hematology: Stable anemia, no active bleeding.\n Endocrine: RISS, Insulin drip, Lantus (R), Transition from gtt to\n Lantus, RISS. Goal BS < 150.\n Infectious Disease: Check cultures, Received peri-op Vanco. Afebrile,\n nomral WBC, no active ID issues at this time.\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: None\n Fluids: KVO\n Consults: CT surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\n Lantus (R) protocol\n Lines:\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"},{"category":"Physician ","chartdate":"2174-08-03 00:00:00.000","description":"Intensivist Note","row_id":581980,"text":"CVICU\n HPI:\n POD 2 s/p AVR (25 tissue)\n PMHx:\n EF > 65 Wt 104K Cr. 0.8 HgbA1C: 7.1\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\n fem- bypass, L shoulder, removal of calcium , L knee surgery\n , ?renal stent in \n : Allopurinol 300', ASA 81', glyburide 5\", lisinopril 20', lovasa\n 2\", metformin 500\"', ocuvite, simvastatin 40'\n Current medications:\n . 2. 3. 4. 250 mL D5W 5. Acetaminophen 6. Allopurinol 7. Aspirin EC 8.\n Calcium Gluconate 9. Cepacol (Menthol) 10. Dextrose 50% 11. Docusate\n Sodium 12. Furosemide 13. GlyBURIDE 14. Insulin 15. Insulin 16.\n Magnesium Sulfate 17. Metoclopramide 18. Metoprolol Tartrate 19. Milk\n of Magnesia 20. Morphine Sulfate 21. Nitroglycerin 22.\n Oxycodone-Acetaminophen 23. Pneumococcal Vac Polyvalent 24. Potassium\n Chloride 25. Ranitidine 26. Simvastatin 27. Sodium Chloride 0.9% Flush\n 28. Sodium Chloride 0.9% Flush 29. Sodium Chloride 0.9% Flush 30.\n Vancomycin\n 24 Hour Events:\n PA CATHETER - STOP 08:05 AM\n CORDIS/INTRODUCER - STOP 06:00 PM\n MULTI LUMEN - START 06:00 PM\n - Remained in ICU for elevated BS, on insulin gtt\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:16 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:04 AM\n Flowsheet Data as of 12:16 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.9\nC (98.5\n HR: 63 (63 - 80) bpm\n BP: 109/39(57) {104/39(56) - 136/77(89)} mmHg\n RR: 15 (14 - 21) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111 kg (admission): 104 kg\n Height: 70 Inch\n Total In:\n 1,158 mL\n 196 mL\n PO:\n 580 mL\n Tube feeding:\n IV Fluid:\n 578 mL\n 196 mL\n Blood products:\n Total out:\n 2,260 mL\n 1,785 mL\n Urine:\n 1,995 mL\n 1,725 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,102 mL\n -1,589 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress, Comfortable\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 164 K/uL\n 8.9 g/dL\n 120 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 17 mg/dL\n 101 mEq/L\n 135 mEq/L\n 25.1 %\n 5.8 K/uL\n [image002.jpg]\n 01:36 PM\n 02:15 PM\n 02:22 PM\n 03:23 PM\n 04:49 PM\n 05:52 PM\n 05:54 PM\n 02:09 AM\n 02:24 AM\n 02:06 AM\n WBC\n 8.0\n 5.3\n 5.8\n Hct\n 27.5\n 28.6\n 26.9\n 25.1\n Plt\n 233\n 178\n 164\n Creatinine\n 0.8\n 0.7\n 0.8\n TCO2\n 25\n 22\n 27\n 24\n 26\n Glucose\n 198\n 163\n 121\n 120\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\n Lactic Acid:1.5 mmol/L, Ca:8.7 mg/dL, Mg:1.5 mg/dL\n Imaging:\n CXR: s/p removal of CT, no ptx, post-op changes noted, line in\n place\n Microbiology:\n MRSA: negative\n Assessment and Plan\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 79 M s/p AVR (25 tissue), POD 2\n Neurologic: Neuro checks Q: hr, Pain controlled.\n Cardiovascular: Aspirin, Beta-blocker\n Pulmonary: IS, Cough, IS, OOB to chair.\n Gastrointestinal / Abdomen: Bowel regimen.\n Nutrition: Sips, ADAT.\n Renal: Foley, Adequate UO, Creat 0.8. Diurese with goal negative 1 L.\n Hematology: Stable anemia, no active bleeding.\n Endocrine: RISS, Insulin drip, Lantus (R), Transition from gtt to\n Lantus, increased Glyburide to home dose, RISS. Goal BS < 150. Holding\n metformin while being diuresed.\n Infectious Disease: Check cultures, Received peri-op Vanco. Afebrile,\n nomral WBC, no active ID issues at this time.\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: None\n Fluids: KVO\n Consults: CT surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\n Lantus (R) protocol\n Lines:\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"},{"category":"Rehab Services","chartdate":"2174-08-03 00:00:00.000","description":"Physical Therapy Evaluation Note","row_id":581986,"text":"Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 424.1 / AVR\n Reason of referral: PT consult\n History of Present Illness / Subjective Complaint: Pt is a 79 y/o male\n admitted with SOB, ECHO revealed severe aortic stenosis. Pt now\n s/p AVR ( tissue), POD #2. BPT 54 minutes and XCL 75 minutes.\n and pt extubated . Pt doing well post-operatively and is ready for\n transfer to stepdown floor.\n Past Medical / Surgical History: DM 2, HTN, hyperlipidemia, B fem-\n bypass yrs/ago, L knee surgery '\n Medications: glyburide, metoprolol, furosemide, allopurinol,\n simvastatin, rantidine, ASA, acetaminophen, oxycodone, vancomycin,\n morphine\n Radiology: CT chest: no PTX, lung volumes sl decreased\n Labs:\n 25.1\n 8.9\n 164\n 5.8\n [image002.jpg]\n Other labs:\n Activity Orders: Advance per C- guidelines\n Social / Occupational History: lives with wife, wife has dementia but\n is I with amb, ADLS and limited IADLS ( can do laundry, can't drive)\n supportive children live 1 hr/away; supportive neighbors; enjoys\n golfing 1-2x/week\n Living Environment: FOS to bedroom, laundry\n house cleaner 1x/2 weeks\n Prior Functional Status / Activity Level: I PTA without AD, with\n ADLS/IADLS\n + driving\n denies hx of falls other that 1 in which pt slipped and fell off roof\n Objective Test\n Arousal / Attention / Cognition / Communication: Axox3\n Comm: pleasant, NAD and willing to participate\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n Pt found sitting in chair\n /\n Rest\n 64\n 103/46\n 16\n 97% on 3 L 02 NC\n Sit\n 68\n 134/54\n 21\n 100% on 3 L o2 NC\n Activity\n 77\n 107/51\n 20\n 100% on 3 L o2 NC\n 13\n Stand\n 70\n 105/62\n 16\n 98% on 3 L 02 NC\n Recovery\n 72\n 110/71\n 21\n 96% on 3 L o2 NC\n Total distance walked:\n Minutes:\n Pulmonary Status: CTA B'lly, diminished BS at bases, +\n dry/strong/nonproductive cough, breathing non-labored\n IS to 1250 mL\n Integumentary / Vascular: PIV, central line, telemetry, pacer + wires,\n foley/catheter, \\\n increase swelling B UEs/ -pitting\n Sensory Integrity: B UEs / to light touch\n Pain / Limiting Symptoms: pt denies any pain at this time\n Posture: pt found sitting up in recliner\n Range of Motion\n Muscle Performance\n WFL B UEs/LEs\n B UEs/LEs except B she motions >3/5 sternal precautions\n Motor Function: pt MAE in isolation\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: sit-stand with cgA x1 and ambulated 120' pushing\n wheelchair with cgA x1, normal speed/step length, no LOB noted\n Rolling:\n NT\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n NT\n\n\n\n\n\n\n Transfer:\n\n T\n\n\n\n Sit to Stand:\n\n T\n\n\n\n Ambulation:\n 120\n pushing w/c\n\n\n T\n\n\n\n Stairs:\n NT\n\n\n\n\n\n\n Balance: S with static standing without UE support, no LOB\n cgA with dynamic standing with UE support, no LOB\n Education / Communication: Educ: Educated pt on role of PT, progress\n thus far, pt status, sternal precautions/ activity guidelines, and\n discharge plan- pt verbalized good understanding\n Comm: communicated with RN and NP re: pt status and discharge plan\n Intervention: Issued cardiac booklet and reviewed activity guidelines/\n sternal precautions\n Diagnosis:\n Impaired functional mobility\n Impaired HDR with functional mobility\n Impaired balance\n Knowledge deficit\n Impaired gas exchange\n Clinical impression / Prognosis: Pt is a 79 y/o male s/p AVR, now POD\n #2. Pt p/w above impairments c/w cardiovascular pump dysfunction. Pt\n lives with wife and was I and very active PTA. Pt cgA with sit-stand\n and ambulated 120' pushing w/c with cgA- no LOB. Pt reports his wife\n can A with laundry at d/c and has neighbors/children who can assist\n with IADLS as needed. Anticipate pt will be safe for discharge home in\n treatments. Will continue to follow as appropriate.\n Goals\n Time frame: 1-2x more\n 1.\n 500' s AD c I no LOB\n 2.\n I with bed mobility with HOB flat\n 3.\n I with FOS no LOB\n 4.\n I verbalize sternal precautions\n 5.\n 02 sat >92% on RA with all functional mobility\n 6.\n Stable HDR with all functional mobility\n Anticipated Discharge: Home without PT\n Treatment :\n Frequency / Duration: 1-2x more x 1 week\n bed mobility, transfers, progress ambulation, stair negotiation, pt\n education, discharge planning, issue walking program, wean o2\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n Addendum: Pt open to d/c home but not 100% agreeable at this time.\n Recommendations for NSG: Ambulate 3x/day with cgA\n Face Time: 10:35-11:15\n"},{"category":"Physician ","chartdate":"2174-08-03 00:00:00.000","description":"CVICU","row_id":581987,"text":"CVICU\n HPI:\n POD 2 s/p AVR (25 tissue)\n PMHx:\n EF > 65 Wt 104K Cr. 0.8 HgbA1C: 7.1\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\n fem- bypass, L shoulder, removal of calcium , L knee surgery\n , ?renal stent in \n : Allopurinol 300', ASA 81', glyburide 5\", lisinopril 20', lovasa\n 2\", metformin 500\"', ocuvite, simvastatin 40'\n Current medications:\n Acetaminophen, Allopurinol, Aspirin EC, Cepacol (Menthol), Docusate\n Sodium, Furosemide, GlyBURIDE, Insulin, Metoprolol Tartrate, Morphine\n Sulfate, Oxycodone-Acetaminophen, Ranitidine, Simvastatin, Vancomycin\n 24 Hour Events:\n Remained in ICU for blood glucose management, requiring insulin drip\n PA CATHETER - STOP 08:05 AM\n CORDIS/INTRODUCER - STOP 06:00 PM\n MULTI LUMEN - START 06:00 PM\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:16 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:04 AM\n Flowsheet Data as of 12:16 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.9\nC (98.5\n HR: 63 (63 - 80) bpm\n BP: 109/39(57) {104/39(56) - 136/77(89)} mmHg\n RR: 15 (14 - 21) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111 kg (admission): 104 kg\n Height: 70 Inch\n Total In:\n 1,158 mL\n 196 mL\n PO:\n 580 mL\n Tube feeding:\n IV Fluid:\n 578 mL\n 196 mL\n Blood products:\n Total out:\n 2,260 mL\n 1,785 mL\n Urine:\n 1,995 mL\n 1,725 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,102 mL\n -1,589 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress, Comfortable\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 164 K/uL\n 8.9 g/dL\n 120 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 17 mg/dL\n 101 mEq/L\n 135 mEq/L\n 25.1 %\n 5.8 K/uL\n 01:36 PM\n 02:15 PM\n 02:22 PM\n 03:23 PM\n 04:49 PM\n 05:52 PM\n 05:54 PM\n 02:09 AM\n 02:24 AM\n 02:06 AM\n WBC\n 8.0\n 5.3\n 5.8\n Hct\n 27.5\n 28.6\n 26.9\n 25.1\n Plt\n 233\n 178\n 164\n Creatinine\n 0.8\n 0.7\n 0.8\n TCO2\n 25\n 22\n 27\n 24\n 26\n Glucose\n 198\n 163\n 121\n 120\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\n Lactic Acid:1.5 mmol/L, Ca:8.7 mg/dL, Mg:1.5 mg/dL\n Imaging:\n CXR: s/p removal of CT, no ptx, post-op changes noted, line in\n place\n Microbiology: MRSA: negative\n Assessment and Plan\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Neurologic: Neuro checks Q: hr, Pain controlled. Percocet prn pain\n Cardiovascular: Aspirin, Beta-blocker statin\n Pulmonary: IS, Cough, IS, OOB to chair.\n Gastrointestinal / Abdomen: Bowel regimen.\n Nutrition: diabetic diet\n Renal: Foley, Adequate UO, Creat 0.8. Diurese with goal negative 1000\n ml for 24 hours\n Hematology: Stable anemia, no active bleeding.\n Endocrine: RISS, Insulin drip, Lantus (R), Transition from gtt to\n Lantus, increased Glyburide to home dose, RISS. Goal BS < 150. Holding\n metformin while being diuresed.\n Infectious Disease: Check cultures, Received peri-op Vancomycin.\n Afebrile, nomral WBC, no evidence of infection\n Lines / Tubes / Drains: Foley, pacing wires\n Wounds: Dry dressings\n Consults: PT\n ICU \n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\n Lantus (R) protocol\n Lines:\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n"},{"category":"Nursing","chartdate":"2174-08-03 00:00:00.000","description":"Nursing Transfer Note","row_id":581993,"text":"Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt A&O, follows all commands and appropriate.\n HR-NSR 60\ns-80\ns. SBP 100\ns-110\ns. Doppler pulses. K-4.7 and ionized\n calcium 1.16 with am labs.\n LS-CTA/Dim at bases. 3-4LO2 NC- 96-99%. Chest tubes draining minimal\n amounts of serosang. drainage.\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\n diet.\n Foley intact draining good amounts of clear yellow urine.\n Action:\n Pt weaned off nitro drip and started on lopressor 25mg po bid at 0800.\n Epicardial wires tested with A\ns sensing and capturing appropriately\n and V\ns sensing but not capturing. Pt set on A demand at 50.\n Pt encouraged to C&DB and IS used 500-750.\n Pt started on lasix 20mg last night and continued.\n Response:\n Vitals unchanged at this time. Pt OOB to chair and chest tubes with\n minimal amount of output. At 1100, pt with only 40cc\ns of urine past 2\n hrs. and 20mg lasix IV given NP order.\n Plan:\n Continue to administer beta blocker, monitor lytes and replete, monitor\n UOP and diurese.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o incisional pain with movement/C&DB.\n Action:\n Pt given toridol 15mg IV at 0800.\n Response:\n Pt appears comfortable in chair at this time. When C&DB, pt c/o \n pain and given percoets in am/afternoon.\n Plan:\n Continue to monitor pain level and administer pain meds.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with blood sugars 110\ns-170\ns and received on insulin drip at 3\n units/hr.\n Action:\n Pt continuing on insulin drip. At 0700, pt given 50units lantus SC \n NP . Pt also started on own humalog ISS and given 6 units of\n humalog SC for BS 117 at 0800. At 0900, drip shut off and at 1000 pt\n with BS 150\n Response:\n At 1200, pt with blood sugar 178 and given 14 units humalog insulin SC\n per ISS.\n Plan:\n Continue to check blood sugars and administer insulin per own ISS.\n"},{"category":"Echo","chartdate":"2174-08-01 00:00:00.000","description":"Report","row_id":89237,"text":"PATIENT/TEST INFORMATION:\nIndication: aortic stenosis\nHeight: (in) 71\nWeight (lb): 236\nBSA (m2): 2.26 m2\nBP (mm Hg): 160/90\nHR (bpm): 69\nStatus: Inpatient\nDate/Time: at 11:43\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\npre-CPB: 79 yr old male w/ pmhx of htn, hyperlipidemia, and NIDDM with aortic\nstenosis symptomology of progressive dyspnea. Intra-operative TEE revealed\npreserved left ventricular systolic function with no detectable wall motion\nabnormalities. Continuity evaluation confirmed pre-operative diagnosis of\nsevere aortic stenosis. Severe MAC was seen and mitral valve area by presssure\nhalf-time was 2.0 cm2. There was no evidence of ASD/PFO via interrogation with\ncolor flow doppler. Findings were communicated to the surgeon prior to\nincision.\n\n Internal billing error corrected. No changes made to findings. WJM\nLEFT ATRIUM: Normal LA and RA cavity sizes. Good (>20 cm/s) LAA ejection\nvelocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA. A catheter or pacing wire is seen in the RA and extending into\nthe RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic\nvalve leaflets. Severe AS (area 0.8-1.0cm2). No AR.\n\nMITRAL VALVE: Severely thickened/deformed mitral valve leaflets. Severe mitral\nannular calcification. Mild functional MS due to MAC. Physiologic MR (within\nnormal limits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. A TEE was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was under general anesthesia throughout the procedure.\nThe patient received antibiotic prophylaxis. The TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\ncomplications.\npost-CPB: Patient was weaned off CPB with 0.5 mcg/kg/min of phenylephrine.\nAorta was evaluated and no evidence of dissection was seen. LV systolic\nfunction was similar to the pre-bypass period with no new recognizable RWMA. A\nwell seated aortic bioprosthesis was noted without residual regurgitation.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. No atrial septal\ndefect is seen by 2D or color Doppler. Left ventricular wall thicknesses and\ncavity size are normal. Overall left ventricular systolic function is normal\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThere are three aortic valve leaflets. The aortic valve leaflets are severely\nthickened/deformed. There is severe aortic valve stenosis (valve area\n0.8-1.0cm2). No aortic regurgitation is seen. The mitral valve leaflets are\nseverely thickened/deformed. There is severe mitral annular calcification.\nThere is mild functional mitral stenosis due to mitral annular calcification.\nPhysiologic mitral regurgitation is seen (within normal limits). There is no\npericardial effusion.\n\n\n"},{"category":"Echo","chartdate":"2174-07-27 00:00:00.000","description":"Report","row_id":89238,"text":"PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Preoperative assessment.\nHeight: (in) 70\nWeight (lb): 236\nBSA (m2): 2.24 m2\nBP (mm Hg): 150/82\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 15:47\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Definity\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS\n(area 0.8-1.0cm2). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Severe mitral annular\ncalcification. Mild thickening of mitral valve chordae. Calcified tips of\npapillary muscles. Mod functional MS due to MAC.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size and regional/global systolic\nfunction (LVEF>55%). The aortic root is mildly dilated at the sinus level. The\naortic valve leaflets are severely thickened/deformed. There is severe aortic\nvalve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is severe mitral annular\ncalcification leading to moderate functional mitral stenosis (mean gradient 4\nmmHg). Moderate [2+] tricuspid regurgitation is seen. The pulmonary artery\nsystolic pressure could not be determined. There is no pericardial effusion.\n\nIMPRESSION: Severe aortic valve stenosis. Moderate functional mitral stenosis\nfrom MAC. Mild symmetric left ventricular hypertrophy with preserved global\nand regional biventricular systolic function. Dilated thoracic aorta.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"},{"category":"ECG","chartdate":"2174-08-01 00:00:00.000","description":"Report","row_id":233027,"text":"Sinus rhythm. Prolonged Q-T interval;. Intraventricular conduction delay.\nCompared to the previous tracing of the Q-T interval is now prolonged.\n\n"},{"category":"ECG","chartdate":"2174-07-28 00:00:00.000","description":"Report","row_id":233028,"text":"Normal sinus rhythm, rate 85. Left anterior hemiblock. Borderline\nintraventricular conduction delay. No previous tracing available for\ncomparison.\n\n"},{"category":"Radiology","chartdate":"2174-08-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1085369,"text":" 7:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ct removal ? ptx\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with s/p avr\n REASON FOR THIS EXAMINATION:\n s/p ct removal ? ptx\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after aortic valve\n replacement.\n\n Portable AP chest radiograph was compared to .\n\n The right internal jugular line tip is at the cavoatrial junction. There is\n improvement of left basal atelectasis with minimal opacity still present. The\n lungs otherwise are essentially clear with no evidence of substantial pleural\n effusion or pneumothorax. Cardiomediastinal silhouette is stable.\n\n\n"},{"category":"Radiology","chartdate":"2174-08-02 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1085328,"text":" 6:07 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o ptx assess line placement\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man s/p avr and CVL change\n REASON FOR THIS EXAMINATION:\n r/o ptx assess line placement\n ______________________________________________________________________________\n WET READ: AGLc TUE 10:50 PM\n ETT/NGT removed. Swan and sheath removed, replaced with Rt IJ CVL which\n terminates in mid-SVC. mediastinal/pleural drains remain in place. No new\n PTX, mediastinal widening or large effusio, although Rt lateral sulcus\n excluded. lung volumes sl decreased.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: A 79-year-old male status post aortic valve replacement and\n central venous line change. Evaluate for pneumothorax.\n\n Single AP chest radiograph compared to shows repositioning of a\n right IJ central venous catheter with tip now located in the distal SVC/right\n cavoatrial junction. Chest tubes and mediastinal drains are again identified.\n There is mild left retrocardiac atelectasis, unchanged. The right lung is\n clear. The right extreme CP angle has been excluded. No pneumothorax.\n\n IMPRESSION: No pneumothorax.\n\n"},{"category":"Radiology","chartdate":"2174-08-05 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1085727,"text":" 10:11 AM\n CHEST (PA & LAT) Clip # \n Reason: f/u atelectasis\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with s/p AVR\n REASON FOR THIS EXAMINATION:\n f/u atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after aortic valve\n replacement.\n\n PA and lateral upright chest radiographs were compared to .\n\n Right internal jugular line tip is at the cavoatrial junction.\n Cardiomediastinal silhouette is stable. There are bibasilar opacities\n consistent with atelectasis accompanied by small amount of pleural effusion.\n Anterior mediastinal air cannot be excluded most likely related to prior\n surgery but there is no evidence of pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2174-08-01 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1085130,"text":" 4:16 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pleural effusion, pulmonary edema, tamponade, pneumothorax.\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with AVR\n REASON FOR THIS EXAMINATION:\n Pleural effusion, pulmonary edema, tamponade, pneumothorax. \n with issues.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: AVR.\n\n FINDINGS: In comparison with the study of , there are now metallic\n sternal sutures in place. Endotracheal tube tip lies approximately 5.7 cm\n above the carina. Right IJ catheter extends to the proximal portion of the\n right pulmonary artery. Nasogastric tube extends well into the stomach.\n Bibasilar atelectasis, more prominent on the left. No evidence of\n pneumothorax.\n\n IMPRESSION: Standard appearance following cardiac surgery.\n\n\n"},{"category":"Radiology","chartdate":"2174-07-27 00:00:00.000","description":"TEETH (PANOREX FOR DENTAL)","row_id":1084257,"text":" 3:54 PM\n TEETH (PANOREX FOR DENTAL) Clip # \n Reason: eval for caries\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man pre-op AVR\n REASON FOR THIS EXAMINATION:\n eval for caries\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Panorex.\n\n HISTORY: Pre-op AVR, evaluate for caries.\n\n FINDINGS:\n\n The mandibular teeth appear unremarkable without evidence of periapical\n lucency. Multiple maxillary teeth are absent. Evaluation of the maxillary\n teeth for carries is limited due to overlap from the adjacent osseous\n structures.\n\n IMPRESSION:\n\n 1. Normal mandibular teeth.\n\n 2. Limited evaluation of the maxillary teeth. The collapse due to overlap\n affirmed adjacent osseous structures.\n\n\n"},{"category":"Radiology","chartdate":"2174-07-27 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":1084256,"text":" 3:54 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: AORTIC STENOSIS\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man pre-op AVR\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions pre-op AVR\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old male preop for AVR. Evaluate for pleural effusion.\n\n PA and lateral chest radiographs without comparison shows clear lungs. The\n lungs are mildly hyperinflated. The heart, mediastinum, hila and pulmonary\n vascularity are normal.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n"},{"category":"Radiology","chartdate":"2174-07-28 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1084432,"text":" 11:53 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval for aortic anatomy, mitral calcifications.NO contrast r\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with knwon AS- Mitral calcifications seen on ech and dilated Ao\n root\n REASON FOR THIS EXAMINATION:\n eval for aortic anatomy, mitral calcifications.NO contrast recent dye load for\n cath and has been on metformin- no on hold\n CONTRAINDICATIONS for IV CONTRAST:\n recent dye load for cath\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old male with known aortic stenosis and mitral annular\n calcification with dilated aortic root seen on echo. Evaluate anatomy.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast MDCT-acquired axial images of the chest from the\n thoracic inlet to the upper abdomen. Multiplanar reformatted images were\n obtained.\n\n CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: There is heavy calcification at\n the base of the aorta, arch, and desceding aorta. The aortic valve and mitral\n annulus are heavily calcified. The aorta is normal in caliber. The heart size\n is normal. Small amount of pericardial fluid may be physiologic.\n\n The lungs are clear. The tracheobronchial tree is normal to the subsegmental\n level. There is no pleural abnormality. The central lymph nodes are not\n enlarged. The bones show no lesion worrisome for osseous metastases. There is\n three vessel coronary artery calcification. Limited view of the upper abdomen\n is unremarkable. The bones show no lesion worrisome for osseous metastasis.\n\n IMPRESSION: Heavy calcification at the base of the aorta, arch, and desceding\n aorta. The aortic valve and mitral annulus are also heavily calcified. These\n images are available for review for surgical planning.\n\n\n"},{"category":"Radiology","chartdate":"2174-07-28 00:00:00.000","description":"CAROTID SERIES COMPLETE","row_id":1084389,"text":" 9:14 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: PREOP AVR\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man pre-op AVR\n REASON FOR THIS EXAMINATION:\n eval for stenosis\n ______________________________________________________________________________\n FINAL REPORT\n\n Standard Report Carotid US\n\n Study: Carotid Series Complete\n\n Reason: Pre op AVR\n\n Findings: Duplex evaluation was performed of bilateral carotid arteries. On\n the right there is mild heterogeneous plaque with calcifications in the ICA.\n On the left there is mild heterogeneous plaque in the ICA.\n\n On the right systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 55/18, 88/25, 77/22 cm/sec. CCA peak systolic\n velocity is 65 cm/sec. ECA peak systolic velocity is 258 cm/sec. The ICA/CCA\n ratio is ?. These findings are consistent with <40%stenosis.\n\n On the left systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 44/10, 55/16, 55/15 cm/sec. CCA peak systolic\n velocity is 73 cm/sec. ECA peak systolic velocity is 85 cm/sec. The ICA/CCA\n ratio is .75. These findings are consistent with <40% stenosis.\n\n There is antegrade right vertebral artery flow.\n There is antegrade left vertebral artery flow.\n\n Impression: Right ICA stenosis <40%.\n Left ICA stenosis <40%.\n\n"}],"string":"[\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2174-08-02 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 581757,\n \"text\": \"Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n Pt A&O, follows all commands and appropriate.\\n HR-NSR 60\\ns-80\\ns. SBP 100\\ns-110\\ns. Doppler pulses. K-4.7 and ionized\\n calcium 1.16 with am labs.\\n LS-CTA/Dim at bases. 3-4LO2 NC- 96-99%. Chest tubes draining minimal\\n amounts of serosang. drainage.\\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\\n diet.\\n Foley intact draining good amounts of clear yellow urine.\\n Action:\\n Pt weaned off nitro drip and started on lopressor 25mg po bid at 0800.\\n Epicardial wires tested with A\\ns sensing and capturing appropriately\\n and V\\ns sensing but not capturing. Pt set on A demand at 50.\\n Pt encouraged to C&DB and IS used 500-750.\\n Pt started on lasix 20mg last night and continued.\\n Response:\\n Vitals unchanged at this time. Pt OOB to chair and chest tubes with\\n minimal amount of output. At 1100, pt with only 40cc\\ns of urine past 2\\n hrs. and 20mg lasix IV given NP order.\\n Plan:\\n Continue to administer beta blocker, monitor lytes and replete, monitor\\n UOP and diurese.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt c/o incisional pain with movement/C&DB.\\n Action:\\n Pt given toridol 15mg IV at 0800.\\n Response:\\n Pt appears comfortable in chair at this time. When C&DB, pt c/o \\n pain and given percoets in am/afternoon.\\n Plan:\\n Continue to monitor pain level and administer toradol q6h/percocets.\\n .H/O diabetes Mellitus (DM), Type II\\n Assessment:\\n Pt with blood sugars 130\\ns-140\\ns and received on insulin drip at 8\\n units/hr.\\n Action:\\n Pt continuing on insulin drip. At 0900, pt on 7 units/hr of insulin\\n with blood sugar 148 and given 70 units lantus SC. At 1000, drip\\n increased to 8 units/hr and given 16 units regular insulin SC.\\n Response:\\n At 1200, pt with blood sugar 177 and given additional 4 units regular\\n insulin SC NP order.\\n Plan:\\n Continue to check blood sugars and administer insulin per CVICU\\n protocol.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2174-08-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 581830,\n \"text\": \"H/O diabetes Mellitus (DM), Type II\\n Assessment:\\n Pt continues to be hyperglycemic >200.\\n Action:\\n IV bolus administered & Insulin Gtt restarted per protocol. PO\\n Glyburide restarted and administered @ 1400.\\n Response:\\n Hyperglycemia continues. Insulin Gtt continues.\\n Plan:\\n Monitor Q1hr FSBS. Wean Insulin Gtt as tolerated. ? restart PO\\n Metformin.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2174-08-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 581893,\n \"text\": \"Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n -NSR 70\\ns and no vea. BP wnl\\n -Lungs are clear bilaterally with sats> 94% on 3L nc\\n -HUO <40ml/hr\\n -Chest tubes drained small amounts of serosanquinous drainage\\n Action:\\n -Patient is receiving po Lopressor 25mg po twice daily.\\n -Administered IV Lasix 20mg\\n -Patient used IS with good inspiratory effort.\\n -Serum potassium and magnesium repleted\\n Response:\\n -Patient diuresed> 100ml/hr after receiving IV Lasix 20mg\\n -Remains in NSR while receiving po beta blockers.\\n Plan:\\n -Continue with beta blockers for management of heart rate.\\n -Continue with pulmonary toileting\\n -Diurese with IV Lasix\\n -? CT to be d/c\\nd by team today\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n -Patient c/o sternotomy incisional pain\\n Action:\\n -Administered 2 percocet tabs and IV Toradol for pain\\n Response:\\n -Pain decreased after receiving the pain meds.\\n Plan:\\n -Administer Percocet tabs every 4 hous and IV Toradol every 6 hours for\\n management of incisional pain\\n .H/O diabetes Mellitus (DM), Type II\\n Assessment:\\n -At onset of shift, FS >170-203\\n Action:\\n -Titrated Insulin gtt up to a maximum dose of 9units/hr and gave\\n regular insulin bolus according to unit protocol.\\n Response:\\n -FS eventually decreased to >120->96. The insulin gtt was slowly\\n decreased to 2 units/hr. Notified PA for further orders\\n regarding the Lantus dosage\\n Plan:\\n -Continue insulin gtt until Lantus dose given per team. Then titrate\\n insulin gtt off if FS remains<120.\\n -Monitor hourly FS while patient is receiving Insulin gtt\\n -Check with team for restarting the Metformin today\\n -Discharge to floor after Insulin gtt d/c\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2174-08-02 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 581744,\n \"text\": \"Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n Pt A&O, follows all commands and appropriate.\\n HR-NSR 60\\ns-80\\ns. SBP 100\\ns-110\\ns. Doppler pulses. K-4.7 and ionized\\n calcium 1.16 with am labs.\\n LS-CTA/Dim at bases. 4LO2 NC- 96-99%. Chest tubes draining minimal\\n amounts of serosang. drainage.\\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\\n diet.\\n Foley intact draining good amounts of clear yellow urine.\\n Action:\\n Pt weaned off nitro drip and started on lopressor 25mg po bid at 0800.\\n Epicardial wires tested with A\\ns sensing and capturing appropriately\\n and V\\ns sensing but not capturing. Pt set on A demand at 50.\\n Pt encouraged to C&DB and IS used 500-750.\\n Pt started on lasix 20mg last night and continued.\\n Response:\\n Vitals unchanged at this time. Pt OOB to chair and chest with minimal\\n amount of output. At 1100, pt with only 40cc\\ns of urine past 2 hrs.\\n and 20mg lasix IV given NP order.\\n Plan:\\n Continue to administer beta blocker, monitor lytes and replete, monitor\\n UOP and diurese.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt c/o incisional pain with movement/C&DB.\\n Action:\\n Pt given toridol 15mg IV at 0800.\\n Response:\\n Pt appears comfortable in chair at this time. When C&DB, pt c/o \\n pain and given 1 percocet at 1030.\\n Plan:\\n Continue to monitor pain level and administer pain meds prn.\\n .H/O diabetes Mellitus (DM), Type II\\n Assessment:\\n Pt with blood sugars 130\\ns-140\\ns and received on insulin drip at 8\\n units/hr.\\n Action:\\n Pt continuing on insulin drip. At 0900, pt on 7 units/hr of insulin\\n with blood sugar 148 and given 70 units lantus SC. At 1000,\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2174-08-04 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 582167,\n \"text\": \"CVICU\\n HPI:\\n POD 2 s/p AVR (25 tissue)\\n PMHx:\\n EF > 65 Wt 104K Cr. 0.8 HgbA1C: 7.1\\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\\n fem- bypass, L shoulder, removal of calcium , L knee surgery\\n , ?renal stent in \\n : Allopurinol 300', ASA 81', glyburide 5\\\", lisinopril 20', lovasa\\n 2\\\", metformin 500\\\"', ocuvite, simvastatin 40'\\n Current medications:\\n . 2. 3. 4. 250 mL D5W 5. Acetaminophen 6. Allopurinol 7. Aspirin EC 8.\\n Calcium Gluconate 9. Cepacol (Menthol) 10. Dextrose 50% 11. Docusate\\n Sodium 12. Furosemide 13. GlyBURIDE 14. Insulin 15. Insulin 16.\\n Magnesium Sulfate 17. Metoclopramide 18. Metoprolol Tartrate 19. Milk\\n of Magnesia 20. Morphine Sulfate 21. Nitroglycerin 22.\\n Oxycodone-Acetaminophen 23. Pneumococcal Vac Polyvalent 24. Potassium\\n Chloride 25. Ranitidine 26. Simvastatin 27. Sodium Chloride 0.9% Flush\\n 28. Sodium Chloride 0.9% Flush 29. Sodium Chloride 0.9% Flush 30.\\n Vancomycin\\n 24 Hour Events:\\n PA CATHETER - STOP 08:05 AM\\n CORDIS/INTRODUCER - STOP 06:00 PM\\n MULTI LUMEN - START 06:00 PM\\n - Remained in ICU for elevated BS, on insulin gtt\\n Allergies:\\n Penicillins\\n Unknown;\\n Last dose of Antibiotics:\\n Vancomycin - 08:16 PM\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 01:04 AM\\n Flowsheet Data as of 12:16 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.4\\nC (99.4\\n T current: 36.9\\nC (98.5\\n HR: 63 (63 - 80) bpm\\n BP: 109/39(57) {104/39(56) - 136/77(89)} mmHg\\n RR: 15 (14 - 21) insp/min\\n SPO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 111 kg (admission): 104 kg\\n Height: 70 Inch\\n Total In:\\n 1,158 mL\\n 196 mL\\n PO:\\n 580 mL\\n Tube feeding:\\n IV Fluid:\\n 578 mL\\n 196 mL\\n Blood products:\\n Total out:\\n 2,260 mL\\n 1,785 mL\\n Urine:\\n 1,995 mL\\n 1,725 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,102 mL\\n -1,589 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SPO2: 97%\\n ABG: ///28/\\n Physical Examination\\n General Appearance: No acute distress, Comfortable\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: Follows simple commands, Moves all extremities\\n Labs / Radiology\\n 164 K/uL\\n 8.9 g/dL\\n 120 mg/dL\\n 0.8 mg/dL\\n 28 mEq/L\\n 3.9 mEq/L\\n 17 mg/dL\\n 101 mEq/L\\n 135 mEq/L\\n 25.1 %\\n 5.8 K/uL\\n [image002.jpg]\\n 01:36 PM\\n 02:15 PM\\n 02:22 PM\\n 03:23 PM\\n 04:49 PM\\n 05:52 PM\\n 05:54 PM\\n 02:09 AM\\n 02:24 AM\\n 02:06 AM\\n WBC\\n 8.0\\n 5.3\\n 5.8\\n Hct\\n 27.5\\n 28.6\\n 26.9\\n 25.1\\n Plt\\n 233\\n 178\\n 164\\n Creatinine\\n 0.8\\n 0.7\\n 0.8\\n TCO2\\n 25\\n 22\\n 27\\n 24\\n 26\\n Glucose\\n 198\\n 163\\n 121\\n 120\\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\\n Lactic Acid:1.5 mmol/L, Ca:8.7 mg/dL, Mg:1.5 mg/dL\\n Imaging:\\n CXR: s/p removal of CT, no ptx, post-op changes noted, line in\\n place\\n Microbiology:\\n MRSA: negative\\n Assessment and Plan\\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\\n Assessment and Plan: 79 M s/p AVR (25 tissue), POD 2\\n Neurologic: Neuro checks Q: hr, Pain controlled.\\n Cardiovascular: Aspirin, Beta-blocker\\n Pulmonary: IS, Cough, IS, OOB to chair.\\n Gastrointestinal / Abdomen: Bowel regimen.\\n Nutrition: Sips, ADAT.\\n Renal: Foley, Adequate UO, Creat 0.8. Diurese with goal negative 1 L.\\n Hematology: Stable anemia, no active bleeding.\\n Endocrine: RISS, Insulin drip, Lantus (R), Transition from gtt to\\n Lantus, increased Glyburide to home dose, RISS. Goal BS < 150. Holding\\n metformin while being diuresed.\\n Infectious Disease: Check cultures, Received peri-op Vanco. Afebrile,\\n nomral WBC, no active ID issues at this time.\\n Lines / Tubes / Drains: Foley\\n Wounds: Dry dressings\\n Imaging: None\\n Fluids: KVO\\n Consults: CT surgery\\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\\n Lantus (R) protocol\\n Lines:\\n Multi Lumen - 06:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: Transfer to floor\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2174-08-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 581919,\n \"text\": \"Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n -NSR 70\\ns and no vea. BP wnl\\n -Lungs are clear bilaterally with sats> 94% on 3L nc\\n -HUO <40ml/hr\\n -Chest tubes drained small amounts of serosanquinous drainage\\n Action:\\n -Patient is receiving po Lopressor 25mg po twice daily.\\n -Administered IV Lasix 20mg\\n -Patient used IS with good inspiratory effort.\\n -Serum potassium and magnesium repleted\\n Response:\\n -Patient diuresed> 100ml/hr after receiving IV Lasix 20mg\\n -Remains in NSR while receiving po beta blockers.\\n Plan:\\n -Continue with beta blockers for management of heart rate.\\n -Continue with pulmonary toileting\\n -Diurese with IV Lasix\\n -? CT to be d/c\\nd by team today\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n -Patient c/o sternotomy incisional pain\\n Action:\\n -Administered 2 percocet tabs and IV Toradol for pain\\n Response:\\n -Pain decreased after receiving the pain meds.\\n Plan:\\n -Administer Percocet tabs every 4 hours and IV Toradol every 6 hours\\n for management of incisional pain\\n .H/O diabetes Mellitus (DM), Type II\\n Assessment:\\n -At onset of shift, FS >170-203\\n Action:\\n -Titrated Insulin gtt up to a maximum dose of 9units/hr and gave\\n regular insulin bolus according to unit protocol.\\n Response:\\n -FS eventually decreased to >120->96. The insulin gtt was slowly\\n decreased to 2 units/hr. Notified PA for further orders\\n regarding the Lantus dosage\\n Plan:\\n -Continue insulin gtt until Lantus dose given per team. Then titrate\\n insulin gtt off if FS remains<120.\\n -Monitor hourly FS while patient is receiving Insulin gtt\\n -Check with team for restarting the Metformin today\\n -Discharge to floor after Insulin gtt d/c\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2174-08-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 581622,\n \"text\": \"Patient is a 79yo with SOB to OR for 25mm tissue valve. In OR\\n patient with elevated blood glucose difficult to control despite\\n insulin bolus and gtt. Patient admit to CVICU stable on propofol, neo,\\n insulin gtt.\\n Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n Received patient with BP in 80\\ns systolic.\\n Neo titrated with minimal result.\\n CI >2 with admission.\\n Potassium low.\\n Action:\\n Patient apaced for blood pressure control with good result.\\n Found to have a metabolic acidosis on ABG, fluid boluses\\n given with correction of acidosis.\\n CI remains >2.\\n Patient hypertensive with waking, nitro started. Titrated to\\n maintain BP <120.\\n Repeat potassium and Hct pending\\n Response:\\n Patient with stable VS, in NSR with ademand backup.\\n Plan:\\n Plan for extubation\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Received patient on propofol gtt. Reversed, propofol off.\\n Action:\\n Patient woke agitated, restless. Morphine 2mg x2 given. Patient calmer,\\n following commands.\\n Response:\\n Continue to assess for pain. Extubate tonight.\\n Plan:\\n Continue to assess for pain. Morphine prn, transition to percocet\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2174-08-01 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 581618,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 1\\n Ideal body weight: 75.3 None\\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location: OR\\n Tube Type\\n ETT:\\n Position: 19 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: /\\n Sputum source/amount: / None\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Comments:\\n Pt was admitted to CVICU via OR intubated and placed on the vent tol\\n well. See respiratory page of meta vision for more information.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2174-08-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 581620,\n \"text\": \"Patient is a 79yo with SOB to OR for 25mm tissue valve. In OR\\n patient with elevated blood glucose difficult to control despite\\n insulin bolus and gtt. Patient admit to CVICU stable on propofol, neo,\\n insulin gtt.\\n Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n Received patient with BP in 80\\ns systolic.\\n Neo titrated with minimal result.\\n CI >2 with admission.\\n Potassium low.\\n Action:\\n Patient apaced for blood pressure control with good result.\\n Found to have a metabolic acidosis on ABG, fluid boluses\\n given\\n Response:\\n Plan:\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2174-08-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 581761,\n \"text\": \"Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n Pt A&O, follows all commands and appropriate.\\n HR-NSR 60\\ns-80\\ns. SBP 100\\ns-110\\ns. Doppler pulses. K-4.7 and ionized\\n calcium 1.16 with am labs.\\n LS-CTA/Dim at bases. 3-4LO2 NC- 96-99%. Chest tubes draining minimal\\n amounts of serosang. drainage.\\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\\n diet.\\n Foley intact draining good amounts of clear yellow urine.\\n Action:\\n Pt weaned off nitro drip and started on lopressor 25mg po bid at 0800.\\n Epicardial wires tested with A\\ns sensing and capturing appropriately\\n and V\\ns sensing but not capturing. Pt set on A demand at 50.\\n Pt encouraged to C&DB and IS used 500-750.\\n Pt started on lasix 20mg last night and continued.\\n Response:\\n Vitals unchanged at this time. Pt OOB to chair and chest tubes with\\n minimal amount of output. At 1100, pt with only 40cc\\ns of urine past 2\\n hrs. and 20mg lasix IV given NP order.\\n Plan:\\n Continue to administer beta blocker, monitor lytes and replete, monitor\\n UOP and diurese.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt c/o incisional pain with movement/C&DB.\\n Action:\\n Pt given toridol 15mg IV at 0800.\\n Response:\\n Pt appears comfortable in chair at this time. When C&DB, pt c/o \\n pain and given percoets in am/afternoon.\\n Plan:\\n Continue to monitor pain level and administer toradol q6h/percocets.\\n .H/O diabetes Mellitus (DM), Type II\\n Assessment:\\n Pt with blood sugars 130\\ns-140\\ns and received on insulin drip at 8\\n units/hr.\\n Action:\\n Pt continuing on insulin drip. At 0900, pt on 7 units/hr of insulin\\n with blood sugar 148 and given 70 units lantus SC. At 1000, drip\\n increased to 8 units/hr and given 16 units regular insulin SC.\\n Response:\\n At 1200, pt with blood sugar 177 and given additional 4 units regular\\n insulin SC NP order.\\n Plan:\\n Continue to check blood sugars and administer insulin per CVICU\\n protocol.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2174-08-02 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 581743,\n \"text\": \"Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n Pt A&O, follows all commands and appropriate.\\n HR-NSR 60\\ns-80\\ns. SBP 100\\ns-110\\ns. Doppler pulses. K-4.7 and ionized\\n calcium 1.16 with am labs.\\n LS-CTA/Dim at bases. 4LO2 NC- 96-99%. Chest tubes draining minimal\\n amounts of serosang. drainage.\\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\\n diet.\\n Foley intact draining good amounts of clear yellow urine.\\n Action:\\n Pt weaned off nitro drip and started on lopressor 25mg po bid at 0800.\\n Epicardial wires tested with A\\ns sensing and capturing appropriately\\n and V\\ns sensing but not capturing. Pt set on A demand at 50.\\n Pt encouraged to C&DB and IS used 500-750.\\n Pt started on lasix 20mg last night and continued.\\n Response:\\n Vitals unchanged at this time. Pt OOB to chair and chest with minimal\\n amount of output. At 1100, pt with only 40cc\\ns of urine past 2 hrs.\\n and 20mg lasix IV given NP order.\\n Plan:\\n Continue to administer beta blocker, monitor lytes and replete, monitor\\n UOP and diurese.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt c/o incisional pain with movement/C&DB.\\n Action:\\n Pt given toridol 15mg IV at 0800.\\n Response:\\n Pt appears comfortable in chair at this time. When C&DB, pt c/o \\n pain and given 1 percocet at 1030\\n Plan:\\n Continue to monitor pain level and administer pain meds prn.\\n .H/O diabetes Mellitus (DM), Type II\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2174-08-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 581717,\n \"text\": \"Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n NSR without ectopy, HR 70\\ns-80\\ns. RIJ Cordis, PA line, CO/CI WNL. SBP\\n 120-140\\ns. Pedal pulses doppled, extremities cool/dry. Chest tubes to\\n Suction, small amounts serosanguinous drainage, no air leak, no\\n creptius.\\n Action:\\n Ntg gtt titrated to keep SBP < 120.\\n Response:\\n SBP 115-140\\ns. stable hemodynamics.\\n Plan:\\n DC PA line, leave cordis in for now. OOB to chair. ? DC chest tubes if\\n no dump when Transfer to 6 today.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Unable to rate pain, moaning continually,\\nOh my chest. It hurts in my\\n backtoo.\\n shallow respirations, poor deep breathing efforts. Also c/o\\n mouth being sore. Refusing oral care, flinches when lips touched.\\n Action:\\n Morphine 2mg IV q1-2h without effect. Toradol 30mg IV at 0145.\\n Response:\\nit feels a lot better.\\n Good response from Toradol.\\n Plan:\\n Start po pain meds, Toradol 15mg IV q6h x 24h.\\n .H/O diabetes Mellitus (DM), Type II\\n Assessment:\\n Blood sugars 79-154\\n Action:\\n Insulin gtt 1-8 units/hr.\\n Response:\\n Fairly good BS control on insulin gtt\\n Plan:\\n ? clinic to consult this am for Blood sugar management\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2174-08-02 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 581731,\n \"text\": \"Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n Pt A&O, follows all commands and appropriate.\\n HR-NSR 60\\ns-80\\ns. SBP 100\\ns-110\\ns. Doppler pulses. K-4.7 and ionized\\n calcium 1.16 with am labs.\\n LS-CTA/Dim at bases. 4LO2 NC- 96-99%. Chest tubes draining minimal\\n amounts of serosang. drainage.\\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\\n diet.\\n Foley intact draining good amounts of clear yellow urine.\\n Action:\\n Pt weaned off nitro drip and started on lopressor 25mg po bid at 0800.\\n Epicardial wires tested with A\\ns sensing and capturing appropriately\\n and V\\ns sensing but not capturing. Pt set on A demand at 50.\\n Pt encouraged to C&DB and IS used 500-750.\\n Pt started on lasix 20mg last night and continued.\\n Response:\\n Vitals unchanged at this time. Pt OOB to chair and chest with minimal\\n amount of output.\\n Plan:\\n Continue to administer beta blocker, monitor lytes and replete, monitor\\n UOP and diurese.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt c/o incisional pain with movement/C&DB.\\n Action:\\n Pt given toridol 15mg IV at 0800.\\n Response:\\n Pt appears comfortable in chair at this time with no complaints.\\n Plan:\\n Continue to monitor pain level and administer pain meds prn.\\n .H/O diabetes Mellitus (DM), Type II\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2174-08-02 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 581732,\n \"text\": \"CVICU\\n HPI:\\n POD 1\\n s/p AVR (25 tissue) \\n Chief complaint:\\n PMHx:\\n EF > 65 Wt Cr. 0.8 HgbA1C: 7.1\\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\\n fem- bypass, L shoulder, removal of calcium , L knee surgery\\n , ?renal stent in \\n : Allopurinol 300', ASA 81', glyburide 5\\\", lisinopril 20', lovasa\\n 2\\\", metformin 500\\\"', ocuvite, simvastatin 40'\\n Current medications:\\n 1. 2. 3. 250 mL D5W 4. Acetaminophen 5. Allopurinol 6. Aspirin EC 7.\\n Calcium Gluconate 8. Dextrose 50%\\n 9. Docusate Sodium 10. Furosemide 11. Insulin 12. Ketorolac 13.\\n Ketorolac 14. Magnesium Sulfate\\n 15. Metoclopramide 16. Metoprolol Tartrate 17. Milk of Magnesia 18.\\n Morphine Sulfate 19. Nitroglycerin\\n 20. Oxycodone-Acetaminophen 21. Pneumococcal Vac Polyvalent 22.\\n Potassium Chloride 23. Ranitidine\\n 24. Simvastatin 25. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9%\\n Flush 27. Vancomycin\\n 24 Hour Events:\\n ARTERIAL LINE - START 02:00 PM\\n PA CATHETER - START 02:00 PM\\n INVASIVE VENTILATION - START 02:00 PM\\n CORDIS/INTRODUCER - START 02:00 PM\\n EKG - At 04:00 PM\\n INVASIVE VENTILATION - STOP 06:15 PM\\n ARTERIAL LINE - STOP 06:28 AM\\n - Extubtaed, no issues overnight\\n - Remains in ICU on NTG gtt and insulin gtt\\n Allergies:\\n Penicillins\\n Unknown;\\n Last dose of Antibiotics:\\n Vancomycin - 07:30 PM\\n Infusions:\\n Insulin - Regular - 8 units/hour\\n Other ICU medications:\\n Insulin - Regular - 02:38 PM\\n Morphine Sulfate - 12:24 AM\\n Furosemide (Lasix) - 01:50 AM\\n Other medications:\\n Flowsheet Data as of 10:13 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.1\\nC (98.8\\n T current: 37.1\\nC (98.8\\n HR: 75 (61 - 82) bpm\\n BP: 115/58(71) {106/50(64) - 115/58(71)} mmHg\\n RR: 14 (12 - 21) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 70 Inch\\n CVP: 3 (3 - 16) mmHg\\n PAP: (20 mmHg) / (8 mmHg)\\n CO/CI (Thermodilution): (5.22 L/min) / (2.9 L/min/m2)\\n SVR: 845 dynes*sec/cm5\\n SV: 79 mL\\n SVI: 36 mL/m2\\n Total In:\\n 5,655 mL\\n 250 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 5,155 mL\\n 250 mL\\n Blood products:\\n 500 mL\\n Total out:\\n 1,000 mL\\n 1,115 mL\\n Urine:\\n 570 mL\\n 970 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 4,655 mL\\n -865 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 550 (550 - 550) mL\\n Vt (Spontaneous): 634 (386 - 634) mL\\n PS : 5 cmH2O\\n RR (Set): 16\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 16 cmH2O\\n Plateau: 11 cmH2O\\n SPO2: 98%\\n ABG: 7.40/41/110/24/0\\n Ve: 9.5 L/min\\n Physical Examination\\n General: No acute distress\\n HEENt: PERRL, anicteric\\n Heart: s1s2 RRR\\n Chest: Lungs CTA bilaterally, sternum stable\\n Abd: Soft, NT/ND\\n Ext: No edema; DP palp B\\n Skin: Warm, dry\\n Labs / Radiology\\n 178 K/uL\\n 9.4 g/dL\\n 121 mg/dL\\n 0.7 mg/dL\\n 24 mEq/L\\n 4.7 mEq/L\\n 15 mg/dL\\n 105 mEq/L\\n 135 mEq/L\\n 26.9 %\\n 5.3 K/uL\\n [image002.jpg]\\n 01:06 PM\\n 01:36 PM\\n 02:15 PM\\n 02:22 PM\\n 03:23 PM\\n 04:49 PM\\n 05:52 PM\\n 05:54 PM\\n 02:09 AM\\n 02:24 AM\\n WBC\\n 10.1\\n 8.0\\n 5.3\\n Hct\\n 25.8\\n 27.5\\n 28.6\\n 26.9\\n Plt\\n 261\\n 233\\n 178\\n Creatinine\\n 0.8\\n 0.7\\n TCO2\\n 25\\n 25\\n 22\\n 27\\n 24\\n 26\\n Glucose\\n 21\\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\\n Lactic Acid:1.5 mmol/L\\n Imaging: CXR: FINDINGS: In comparison with the study of\\n , there are now metallic\\n sternal sutures in place. Endotracheal tube tip lies approximately 5.7\\n cm\\n above the carina. Right IJ catheter extends to the proximal portion of\\n the\\n right pulmonary artery. Nasogastric tube extends well into the\\n stomach.\\n Bibasilar atelectasis, more prominent on the left. No evidence of\\n pneumothorax.\\n IMPRESSION: Standard appearance following cardiac surgery.\\n Microbiology: MRSA: P\\n Assessment and Plan\\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\\n Assessment and Plan:\\n 79M s/p AVR (25 tissue) , POD 1\\n Neurologic: Neuro checks Q: 4 hr, Pain controlled\\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor\\n Pulmonary: IS, Cough, deep breathe, OOB.\\n Gastrointestinal / Abdomen: Sips, ADAT. Bowel regimen.\\n Nutrition: Advance diet as tolerated\\n Renal: Foley, Adequate UO, Normal creatinine.\\n Hematology: Stable anemia. No active bleeding.\\n Endocrine: RISS, Insulin drip, Lantus (R), Transition from insulin gtt\\n to RISS. Goal BS <150.\\n Infectious Disease: Check cultures, Peri-op Vanco.\\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\\n mediastinal, Pacing wires\\n Wounds: Dry dressings\\n Imaging:\\n Fluids:\\n Consults: CT surgery\\n Billing Diagnosis: Post-op hypertension\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\\n Lantus (R) protocol\\n Lines:\\n Cordis/Introducer - 02:00 PM\\n 18 Gauge - 02:06 PM\\n Comments: Change cordis to triple lumen CVL\\n Prophylaxis:\\n DVT:\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: Transfer to floor\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2174-08-02 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 581733,\n \"text\": \"CVICU\\n HPI:\\n POD 1\\n s/p AVR (25 tissue) \\n PMHx:\\n EF > 65 Wt Cr. 0.8 HgbA1C: 7.1\\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\\n fem- bypass, L shoulder, removal of calcium , L knee surgery\\n , ?renal stent in \\n : Allopurinol 300', ASA 81', glyburide 5\\\", lisinopril 20', lovasa\\n 2\\\", metformin 500\\\"', ocuvite, simvastatin 40'\\n Current medications:\\n 1. 2. 3. 250 mL D5W 4. Acetaminophen 5. Allopurinol 6. Aspirin EC 7.\\n Calcium Gluconate 8. Dextrose 50% 9. Docusate Sodium 10. Furosemide 11.\\n Insulin 12. Ketorolac 13. Ketorolac 14. Magnesium Sulfate 15.\\n Metoclopramide 16. Metoprolol Tartrate 17. Milk of Magnesia 18.\\n Morphine Sulfate 19. Nitroglycerin\\n 20. Oxycodone-Acetaminophen 21. Pneumococcal Vac Polyvalent 22.\\n Potassium Chloride 23. Ranitidine 24. Simvastatin 25. Sodium Chloride\\n 0.9% Flush 26. Sodium Chloride 0.9% Flush 27. Vancomycin\\n 24 Hour Events:\\n ARTERIAL LINE - START 02:00 PM\\n PA CATHETER - START 02:00 PM\\n INVASIVE VENTILATION - START 02:00 PM\\n CORDIS/INTRODUCER - START 02:00 PM\\n EKG - At 04:00 PM\\n INVASIVE VENTILATION - STOP 06:15 PM\\n ARTERIAL LINE - STOP 06:28 AM\\n - Extubtaed, no issues overnight\\n - Remains in ICU on NTG gtt (now off) and insulin gtt (transitioning)\\n Allergies:\\n Penicillins\\n Unknown;\\n Last dose of Antibiotics:\\n Vancomycin - 07:30 PM\\n Infusions:\\n Insulin - Regular - 8 units/hour\\n Other ICU medications:\\n Insulin - Regular - 02:38 PM\\n Morphine Sulfate - 12:24 AM\\n Furosemide (Lasix) - 01:50 AM\\n Flowsheet Data as of 10:13 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.1\\nC (98.8\\n T current: 37.1\\nC (98.8\\n HR: 75 (61 - 82) bpm\\n BP: 115/58(71) {106/50(64) - 115/58(71)} mmHg\\n RR: 14 (12 - 21) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 70 Inch\\n CVP: 3 (3 - 16) mmHg\\n PAP: (20 mmHg) / (8 mmHg)\\n CO/CI (Thermodilution): (5.22 L/min) / (2.9 L/min/m2)\\n SVR: 845 dynes*sec/cm5\\n SV: 79 mL\\n SVI: 36 mL/m2\\n Total In:\\n 5,655 mL\\n 250 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 5,155 mL\\n 250 mL\\n Blood products:\\n 500 mL\\n Total out:\\n 1,000 mL\\n 1,115 mL\\n Urine:\\n 570 mL\\n 970 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 4,655 mL\\n -865 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 550 (550 - 550) mL\\n Vt (Spontaneous): 634 (386 - 634) mL\\n PS : 5 cmH2O\\n RR (Set): 16\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 16 cmH2O\\n Plateau: 11 cmH2O\\n SPO2: 98%\\n ABG: 7.40/41/110/24/0\\n Ve: 9.5 L/min\\n Physical Examination\\n General: No acute distress\\n HEENt: PERRL, anicteric; s/p multiple upper teeth extractions, no\\n purulence noted\\n Heart: s1s2 RRR\\n Chest: Lungs CTA bilaterally, sternum stable\\n Abd: Soft, NT/ND\\n Ext: No edema; DP palp B\\n Skin: Warm, dry\\n Labs / Radiology\\n 178 K/uL\\n 9.4 g/dL\\n 121 mg/dL\\n 0.7 mg/dL\\n 24 mEq/L\\n 4.7 mEq/L\\n 15 mg/dL\\n 105 mEq/L\\n 135 mEq/L\\n 26.9 %\\n 5.3 K/uL\\n [image002.jpg]\\n 01:06 PM\\n 01:36 PM\\n 02:15 PM\\n 02:22 PM\\n 03:23 PM\\n 04:49 PM\\n 05:52 PM\\n 05:54 PM\\n 02:09 AM\\n 02:24 AM\\n WBC\\n 10.1\\n 8.0\\n 5.3\\n Hct\\n 25.8\\n 27.5\\n 28.6\\n 26.9\\n Plt\\n 261\\n 233\\n 178\\n Creatinine\\n 0.8\\n 0.7\\n TCO2\\n 25\\n 25\\n 22\\n 27\\n 24\\n 26\\n Glucose\\n 21\\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\\n Lactic Acid:1.5 mmol/L\\n Imaging:\\n CXR: FINDINGS: In comparison with the study of , there\\n are now metallic\\n sternal sutures in place. Endotracheal tube tip lies approximately 5.7\\n cm\\n above the carina. Right IJ catheter extends to the proximal portion of\\n the\\n right pulmonary artery. Nasogastric tube extends well into the\\n stomach.\\n Bibasilar atelectasis, more prominent on the left. No evidence of\\n pneumothorax.\\n IMPRESSION: Standard appearance following cardiac surgery.\\n Microbiology:\\n MRSA: P\\n Assessment and Plan\\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\\n Assessment and Plan: 79M s/p AVR (25 tissue) , POD 1\\n Neurologic: Neuro checks Q: 4 hr, Pain controlled\\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor\\n Pulmonary: IS, Cough, deep breathe, OOB.\\n Gastrointestinal / Abdomen: Sips, ADAT. Bowel regimen.\\n Nutrition: Advance diet as tolerated\\n Renal: Foley, Adequate UO, Normal creatinine.\\n Hematology: Stable anemia. No active bleeding.\\n Endocrine: RISS, Insulin drip, Lantus (R), Transition from insulin gtt\\n to RISS. Goal BS <150.\\n Infectious Disease: Check cultures, Peri-op Vanco.\\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\\n mediastinal, Pacing wires\\n Wounds: Dry dressings\\n Imaging:\\n Fluids:\\n Consults: CT surgery\\n Billing Diagnosis: Post-op hypertension\\n ICU Care\\n Nutrition: ADAT\\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\\n Lantus (R) protocol\\n Lines:\\n Cordis/Introducer - 02:00 PM\\n 18 Gauge - 02:06 PM\\n Comments: Change cordis to triple lumen CVL\\n Prophylaxis:\\n DVT:\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: Transfer to floor\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2174-08-02 00:00:00.000\",\n \"description\": \"ICU Note - CVI\",\n \"row_id\": 581739,\n \"text\": \"CVICU\\n HPI:\\n POD 1\\n s/p AVR (25 tissue)\\n EF > 65 Wt Cr. 0.8 HgbA1C: 7.1\\n PMHx:\\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\\n fem- bypass, L shoulder, removal of calcium , L knee surgery\\n , ?renal stent in \\n : Allopurinol 300', ASA 81', glyburide 5\\\", lisinopril 20', lovasa\\n 2\\\", metformin 500\\\"', ocuvite, simvastatin 40'\\n Current medications:\\n Acetaminophen 5. Allopurinol 6. Aspirin EC 7. Calcium Gluconate 8.\\n Dextrose 50% 9. Docusate Sodium 10. Furosemide 11. Insulin 12.\\n Ketorolac . Magnesium Sulfate 15. Metoclopramide 16. Metoprolol\\n Tartrate 17. Milk of Magnesia 18. Morphine Sulfate 19. Nitroglycerin\\n 20. Oxycodone-Acetaminophen . Potassium Chloride 23. Ranitidine 24.\\n Simvastatin Vancomycin\\n 24 Hour Events:\\n PA CATHETER - START 02:00 PM\\n ARTERIAL LINE - START 02:00 PM\\n INVASIVE VENTILATION - START 02:00 PM\\n CORDIS/INTRODUCER - START 02:00 PM\\n EKG - At 04:00 PM\\n INVASIVE VENTILATION - STOP 06:15 PM\\n ARTERIAL LINE - STOP 06:28 AM\\n Post operative day:\\n POD 1\\n s/p AVR (25 tissue)\\n Allergies:\\n Penicillins\\n Unknown;\\n Last dose of Antibiotics:\\n Vancomycin - 07:30 PM\\n Infusions:\\n Insulin - Regular - 8 units/hour\\n Other ICU medications:\\n Insulin - Regular - 02:38 PM\\n Morphine Sulfate - 12:24 AM\\n Furosemide (Lasix) - 01:50 AM\\n Flowsheet Data as of 10:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.1\\nC (98.8\\n T current: 37.1\\nC (98.8\\n HR: 73 (61 - 82) bpm\\n BP: 102/47(60) {102/47(60) - 115/58(71)} mmHg\\n RR: 15 (12 - 21) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 70 Inch\\n CVP: 3 (3 - 16) mmHg\\n PAP: (20 mmHg) / (8 mmHg)\\n CO/CI (Thermodilution): (5.22 L/min) / (2.9 L/min/m2)\\n SVR: 757 dynes*sec/cm5\\n SV: 81 mL\\n SVI: 37 mL/m2\\n Total In:\\n 5,655 mL\\n 740 mL\\n PO:\\n 480 mL\\n Tube feeding:\\n IV Fluid:\\n 5,155 mL\\n 260 mL\\n Blood products:\\n 500 mL\\n Total out:\\n 1,000 mL\\n 1,195 mL\\n Urine:\\n 570 mL\\n 990 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 4,655 mL\\n -455 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 550 (550 - 550) mL\\n Vt (Spontaneous): 634 (386 - 634) mL\\n PS : 5 cmH2O\\n RR (Set): 16\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 16 cmH2O\\n Plateau: 11 cmH2O\\n SPO2: 100%\\n ABG: 7.40/41/110/24/0\\n Ve: 9.5 L/min\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), (Sternum: Stable )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\\n Left Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\\n Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\\n Present), (Pulse - Posterior tibial: Present)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n (Responds to: Verbal stimuli), Moves all extremities\\n Labs / Radiology\\n 178 K/uL\\n 9.4 g/dL\\n 121 mg/dL\\n 0.7 mg/dL\\n 24 mEq/L\\n 4.7 mEq/L\\n 15 mg/dL\\n 105 mEq/L\\n 135 mEq/L\\n 26.9 %\\n 5.3 K/uL\\n [image002.jpg]\\n 01:06 PM\\n 01:36 PM\\n 02:15 PM\\n 02:22 PM\\n 03:23 PM\\n 04:49 PM\\n 05:52 PM\\n 05:54 PM\\n 02:09 AM\\n 02:24 AM\\n WBC\\n 10.1\\n 8.0\\n 5.3\\n Hct\\n 25.8\\n 27.5\\n 28.6\\n 26.9\\n Plt\\n 261\\n 233\\n 178\\n Creatinine\\n 0.8\\n 0.7\\n TCO2\\n 25\\n 25\\n 22\\n 27\\n 24\\n 26\\n Glucose\\n 21\\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\\n Lactic Acid:1.5 mmol/L\\n Assessment and Plan\\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\\n Assessment and Plan: 79yo man s/p AVR(tissue) doing well\\n post-operatively. Ready for transfer to stepdown floor\\n Neurologic: Pain controlled, Morphine and percocet for pain control\\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor,\\n titrate Bblockers to HR/BP\\n Pulmonary: IS, OOB-ambulate\\n Gastrointestinal / Abdomen:\\n Nutrition: Advance diet as tolerated\\n Renal: Foley, Adequate UO, start diuretic to make net negative 1-1.5\\n liters today\\n Hematology: stable hct\\n Endocrine: RISS, Lantus (R)\\n Infectious Disease: no active issues\\n afebrie, normal wbc\\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\\n mediastinal, Pacing wires\\n Wounds: Dry dressings\\n Imaging: CXR today, after ct removal\\n Consults: CT surgery, \\n ICU Care\\n Nutrition: ADAT\\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\\n Lines:\\n Cordis/Introducer - 02:00 PM\\n 18 Gauge - 02:06 PM\\n Prophylaxis:\\n Stress ulcer: H2 blocker\\n VAP bundle: HOB elevation, Mouth care\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2174-08-02 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 581802,\n \"text\": \"CVICU\\n HPI:\\n POD 1\\n s/p AVR (25 tissue) \\n PMHx:\\n EF > 65 Wt Cr. 0.8 HgbA1C: 7.1\\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\\n fem- bypass, L shoulder, removal of calcium , L knee surgery\\n , ?renal stent in \\n : Allopurinol 300', ASA 81', glyburide 5\\\", lisinopril 20', lovasa\\n 2\\\", metformin 500\\\"', ocuvite, simvastatin 40'\\n Current medications:\\n 1. 2. 3. 250 mL D5W 4. Acetaminophen 5. Allopurinol 6. Aspirin EC 7.\\n Calcium Gluconate 8. Dextrose 50% 9. Docusate Sodium 10. Furosemide 11.\\n Insulin 12. Ketorolac 13. Ketorolac 14. Magnesium Sulfate 15.\\n Metoclopramide 16. Metoprolol Tartrate 17. Milk of Magnesia 18.\\n Morphine Sulfate 19. Nitroglycerin\\n 20. Oxycodone-Acetaminophen 21. Pneumococcal Vac Polyvalent 22.\\n Potassium Chloride 23. Ranitidine 24. Simvastatin 25. Sodium Chloride\\n 0.9% Flush 26. Sodium Chloride 0.9% Flush 27. Vancomycin\\n 24 Hour Events:\\n ARTERIAL LINE - START 02:00 PM\\n PA CATHETER - START 02:00 PM\\n INVASIVE VENTILATION - START 02:00 PM\\n CORDIS/INTRODUCER - START 02:00 PM\\n EKG - At 04:00 PM\\n INVASIVE VENTILATION - STOP 06:15 PM\\n ARTERIAL LINE - STOP 06:28 AM\\n - Extubtaed, no issues overnight\\n - Remains in ICU on NTG gtt (now off) and insulin gtt (transitioning)\\n Allergies:\\n Penicillins\\n Unknown;\\n Last dose of Antibiotics:\\n Vancomycin - 07:30 PM\\n Infusions:\\n Insulin - Regular - 8 units/hour\\n Other ICU medications:\\n Insulin - Regular - 02:38 PM\\n Morphine Sulfate - 12:24 AM\\n Furosemide (Lasix) - 01:50 AM\\n Flowsheet Data as of 10:13 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.1\\nC (98.8\\n T current: 37.1\\nC (98.8\\n HR: 75 (61 - 82) bpm\\n BP: 115/58(71) {106/50(64) - 115/58(71)} mmHg\\n RR: 14 (12 - 21) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 70 Inch\\n CVP: 3 (3 - 16) mmHg\\n PAP: (20 mmHg) / (8 mmHg)\\n CO/CI (Thermodilution): (5.22 L/min) / (2.9 L/min/m2)\\n SVR: 845 dynes*sec/cm5\\n SV: 79 mL\\n SVI: 36 mL/m2\\n Total In:\\n 5,655 mL\\n 250 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 5,155 mL\\n 250 mL\\n Blood products:\\n 500 mL\\n Total out:\\n 1,000 mL\\n 1,115 mL\\n Urine:\\n 570 mL\\n 970 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 4,655 mL\\n -865 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 550 (550 - 550) mL\\n Vt (Spontaneous): 634 (386 - 634) mL\\n PS : 5 cmH2O\\n RR (Set): 16\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 16 cmH2O\\n Plateau: 11 cmH2O\\n SPO2: 98%\\n ABG: 7.40/41/110/24/0\\n Ve: 9.5 L/min\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), (Sternum: Stable )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\\n Left Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\\n Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\\n Present), (Pulse - Posterior tibial: Present)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n (Responds to: Verbal stimuli), Moves all extremities\\n Labs / Radiology\\n 178 K/uL\\n 9.4 g/dL\\n 121 mg/dL\\n 0.7 mg/dL\\n 24 mEq/L\\n 4.7 mEq/L\\n 15 mg/dL\\n 105 mEq/L\\n 135 mEq/L\\n 26.9 %\\n 5.3 K/uL\\n [image002.jpg]\\n 01:06 PM\\n 01:36 PM\\n 02:15 PM\\n 02:22 PM\\n 03:23 PM\\n 04:49 PM\\n 05:52 PM\\n 05:54 PM\\n 02:09 AM\\n 02:24 AM\\n WBC\\n 10.1\\n 8.0\\n 5.3\\n Hct\\n 25.8\\n 27.5\\n 28.6\\n 26.9\\n Plt\\n 261\\n 233\\n 178\\n Creatinine\\n 0.8\\n 0.7\\n TCO2\\n 25\\n 25\\n 22\\n 27\\n 24\\n 26\\n Glucose\\n 21\\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\\n Lactic Acid:1.5 mmol/L\\n Imaging:\\n CXR: FINDINGS: In comparison with the study of , there\\n are now metallic\\n sternal sutures in place. Endotracheal tube tip lies approximately 5.7\\n cm\\n above the carina. Right IJ catheter extends to the proximal portion of\\n the\\n right pulmonary artery. Nasogastric tube extends well into the\\n stomach.\\n Bibasilar atelectasis, more prominent on the left. No evidence of\\n pneumothorax.\\n IMPRESSION: Standard appearance following cardiac surgery.\\n Microbiology:\\n MRSA: P\\n Assessment and Plan\\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\\n Assessment and Plan: 79M s/p AVR (25 tissue) , POD 1\\n Neurologic: Neuro checks Q: 4 hr, Pain controlled\\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor\\n Pulmonary: IS, Cough, deep breathe, OOB.\\n Gastrointestinal / Abdomen: Sips, ADAT. Bowel regimen.\\n Nutrition: Advance diet as tolerated\\n Renal: Foley, Adequate UO, Normal creatinine.\\n start lasix diuresis\\n \\n Hematology: Stable anemia. No active bleeding.\\n Endocrine: RISS, Insulin drip\\n start Lantus (R), Transition from\\n insulin gtt to RISS. Goal BS <150.\\n Infectious Disease: Check cultures, Peri-op Vanco.\\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\\n mediastinal, Pacing wires\\n Wounds: Dry dressings\\n Imaging: none\\n Fluids: KVO\\n Consults: CT surgery\\n Billing Diagnosis: Post-op hypertension; Post-op hyperglycemia\\n ICU Care\\n Nutrition: ADAT\\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\\n Lantus (R) protocol\\n Lines:\\n Cordis/Introducer - 02:00 PM\\n 18 Gauge - 02:06 PM\\n Comments: Change cordis to triple lumen CVL\\n Prophylaxis:\\n DVT:\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: Transfer to floor\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2174-08-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 581632,\n \"text\": \"Patient is a 79yo with SOB to OR for 25mm tissue valve. In OR\\n patient with elevated blood glucose difficult to control despite\\n insulin bolus and gtt. Patient admit to CVICU stable on propofol, neo,\\n insulin gtt.\\n Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n Received patient with BP in 80\\ns systolic.\\n Neo titrated with minimal result.\\n CI >2 with admission.\\n Potassium low.\\n Action:\\n Patient apaced for blood pressure control with good result.\\n Found to have a metabolic acidosis on ABG, fluid boluses\\n given with correction of acidosis.\\n CI remains >2.\\n Patient hypertensive with waking, nitro started. Titrated to\\n maintain BP <120.\\n Repeat potassium and Hct pending\\n Response:\\n Patient with stable VS, in NSR with ademand backup.\\n Plan:\\n Plan for extubation\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Received patient on propofol gtt. Reversed, propofol off.\\n Action:\\n Patient woke agitated, restless. Morphine 2mg x2 given. Patient calmer,\\n following commands.\\n Response:\\n Continue to assess for pain. Extubate tonight.\\n Plan:\\n Continue to assess for pain. Morphine prn, transition to percocet\\n .H/O diabetes Mellitus (DM), Type II\\n Assessment:\\n Patient with hx of DDM type I on oral meds at baseline. Difficult\\n control in OR\\n Action:\\n Insulin gtt titrated postop per protocol with max dose increased to\\n 15units.\\n Response:\\n Patient with stable glucose levels on insulin gtt, titrated per CVICU\\n protocol\\n Plan:\\n Continue insulin gtt, ? consult in am for control\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2174-08-03 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 582009,\n \"text\": \"Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n Pt A&O, follows all commands and appropriate.\\n HR-NSR 60\\ns-80\\ns. SBP 90\\ns-110\\ns. Doppler pulses.\\n LS-CTA/Dim at bases. LO2 NC- 96-99%. Chest tubes draining minimal\\n amounts of serosang. drainage.\\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\\n diet.\\n Foley intact draining good amounts of clear yellow urine.\\n Action:\\n Pt received 3 doses of lopressor po since yesterday. Epicardial wires\\n tested with A\\ns sensing and capturing appropriately and V\\ns sensing but\\n not capturing. Pt set on A demand at 50.\\n Pt encouraged to C&DB and IS used .\\n Pt continued on lasix drip 20mg IV bid.\\n Response:\\n Vitals unchanged at this time. Pt OOB to chair and chest tubes with\\n minimal amount of output. Chest tubes D/C\\nd in am and chest x-ray\\n performed showing atelectasis NP .\\n Plan:\\n Continue to administer beta blocker, monitor lytes and replete, monitor\\n UOP and diurese.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt c/o incisional pain with movement/C&DB.\\n Action:\\n Pt given toradol/percocets.\\n Response:\\n Pt appears comfortable in chair at this time. When C&DB, pt c/o \\n pain and given percoets in am/afternoon.\\n Plan:\\n Continue to monitor pain level and administer pain meds.\\n .H/O diabetes Mellitus (DM), Type II\\n Assessment:\\n Pt with blood sugars 110\\ns-170\\ns and received on insulin drip at 3\\n units/hr.\\n Action:\\n Pt continuing on insulin drip. At 0700, pt given 50units lantus SC \\n NP . Pt also started on own humalog ISS and given 6 units of\\n humalog SC for BS 117 at 0800. At 0900, drip shut off and at 1000 pt\\n with BS 150\\n Response:\\n At 1200, pt with blood sugar 178 and given 14 units humalog insulin SC\\n per ISS.\\n Plan:\\n Continue to check blood sugars and administer insulin per own ISS.\\n Pt with R IJ TLC that was changed over wire on . Pt last received\\n 2 percocets at 1200 and finished with toradol. Pt with last blood\\n sugar 160 at 1400 with no coverage. NP and check next sugar\\n before dinner. Pt refused lunch at this time. Foley D/C\\nd at 1430.\\n Demographics\\n Attending MD:\\n R.\\n Admit diagnosis:\\n AORTIC STENOSIS\\n Code status:\\n Full code\\n Height:\\n 70 Inch\\n Admission weight:\\n 104 kg\\n Daily weight:\\n 111 kg\\n Allergies/Reactions:\\n Penicillins\\n Unknown;\\n Precautions: No Additional Precautions\\n PMH: Diabetes - Oral \\n CV-PMH: PVD\\n Additional history: Patient with hx of BPH, gout, macular degeneration.\\n s/p B fem- bypass 3-4 years PTA, L shoulder removal of calcium ,\\n L knee surgery , ?renal stent in \\n Surgery / Procedure and date: AVR 25mm tissue valve.\\n XCL 75, bypass 51. Stable OR course. Blood glucose >200 thru case with\\n 25units blous, insulin gtt to 12units. Difficult to come off\\n pump->ectopy, RAF treated with amio bolus. Admit CVICU on neo, prop.\\n Apaced for blood pressure support..\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:109\\n D:55\\n Temperature:\\n 98.5\\n Arterial BP:\\n S:115\\n D:47\\n Respiratory rate:\\n 21 insp/min\\n Heart Rate:\\n 66 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 98% %\\n O2 flow:\\n 2 L/min\\n FiO2 set:\\n 40% %\\n 24h total in:\\n 196 mL\\n 24h total out:\\n 1,935 mL\\n Pacer Data\\n Temporary pacemaker type:\\n Epicardial Wires\\n Temporary pacemaker mode:\\n Atrial demand\\n Temporary pacemaker rate:\\n 50 bpm\\n Temporary atrial sensitivity:\\n Yes\\n Temporary atrial sensitivity threshold:\\n 1.2 mV\\n Temporary atrial sensitivity setting:\\n 0.6 mV\\n Temporary atrial stimulation threshold :\\n 12 mA\\n Temporary atrial stimulation setting:\\n 20 mA\\n Temporary ventricular sensitivity:\\n Yes\\n Temporary ventricular sensitivity threshold:\\n 0.8 mV\\n Temporary pacemaker wire condition:\\n Attached-Pacer\\n Temporary pacemaker wires atrial:\\n 2\\n Temporary pacemaker wires ventricular:\\n 2\\n Pertinent Lab Results:\\n Sodium:\\n 135 mEq/L\\n 02:06 AM\\n Potassium:\\n 3.9 mEq/L\\n 02:06 AM\\n Chloride:\\n 101 mEq/L\\n 02:06 AM\\n CO2:\\n 28 mEq/L\\n 02:06 AM\\n BUN:\\n 17 mg/dL\\n 02:06 AM\\n Creatinine:\\n 0.8 mg/dL\\n 02:06 AM\\n Glucose:\\n 120 mg/dL\\n 02:06 AM\\n Hematocrit:\\n 25.1 %\\n 02:06 AM\\n Finger Stick Glucose:\\n 160\\n 02:00 PM\\n Valuables / Signature\\n Patient valuables:\\n Other valuables: Valuables in safe on 6 per pt.\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: \\n Transferred to: 6\\n Date & time of Transfer: 1500\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2174-08-03 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 581978,\n \"text\": \"CVICU\\n HPI:\\n POD 2\\n s/p AVR (25 tissue)\\n PMHx:\\n EF > 65 Wt 104K Cr. 0.8 HgbA1C: 7.1\\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\\n fem- bypass, L shoulder, removal of calcium , L knee surgery\\n , ?renal stent in \\n : Allopurinol 300', ASA 81', glyburide 5\\\", lisinopril 20', lovasa\\n 2\\\", metformin 500\\\"', ocuvite, simvastatin 40'\\n Current medications:\\n . 2. 3. 4. 250 mL D5W 5. Acetaminophen 6. Allopurinol 7. Aspirin EC 8.\\n Calcium Gluconate 9. Cepacol (Menthol) 10. Dextrose 50% 11. Docusate\\n Sodium 12. Furosemide 13. GlyBURIDE 14. Insulin 15. Insulin 16.\\n Magnesium Sulfate 17. Metoclopramide 18. Metoprolol Tartrate 19. Milk\\n of Magnesia 20. Morphine Sulfate 21. Nitroglycerin 22.\\n Oxycodone-Acetaminophen 23. Pneumococcal Vac Polyvalent 24. Potassium\\n Chloride 25. Ranitidine 26. Simvastatin 27. Sodium Chloride 0.9% Flush\\n 28. Sodium Chloride 0.9% Flush 29. Sodium Chloride 0.9% Flush 30.\\n Vancomycin\\n 24 Hour Events:\\n PA CATHETER - STOP 08:05 AM\\n CORDIS/INTRODUCER - STOP 06:00 PM\\n MULTI LUMEN - START 06:00 PM\\n - Remained in ICU for elevated BS, on insulin gtt\\n Allergies:\\n Penicillins\\n Unknown;\\n Last dose of Antibiotics:\\n Vancomycin - 08:16 PM\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 01:04 AM\\n Flowsheet Data as of 12:16 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.4\\nC (99.4\\n T current: 36.9\\nC (98.5\\n HR: 63 (63 - 80) bpm\\n BP: 109/39(57) {104/39(56) - 136/77(89)} mmHg\\n RR: 15 (14 - 21) insp/min\\n SPO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 111 kg (admission): 104 kg\\n Height: 70 Inch\\n Total In:\\n 1,158 mL\\n 196 mL\\n PO:\\n 580 mL\\n Tube feeding:\\n IV Fluid:\\n 578 mL\\n 196 mL\\n Blood products:\\n Total out:\\n 2,260 mL\\n 1,785 mL\\n Urine:\\n 1,995 mL\\n 1,725 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,102 mL\\n -1,589 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SPO2: 97%\\n ABG: ///28/\\n Physical Examination\\n General Appearance: No acute distress, Comfortable\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: Follows simple commands, Moves all extremities\\n Labs / Radiology\\n 164 K/uL\\n 8.9 g/dL\\n 120 mg/dL\\n 0.8 mg/dL\\n 28 mEq/L\\n 3.9 mEq/L\\n 17 mg/dL\\n 101 mEq/L\\n 135 mEq/L\\n 25.1 %\\n 5.8 K/uL\\n [image002.jpg]\\n 01:36 PM\\n 02:15 PM\\n 02:22 PM\\n 03:23 PM\\n 04:49 PM\\n 05:52 PM\\n 05:54 PM\\n 02:09 AM\\n 02:24 AM\\n 02:06 AM\\n WBC\\n 8.0\\n 5.3\\n 5.8\\n Hct\\n 27.5\\n 28.6\\n 26.9\\n 25.1\\n Plt\\n 233\\n 178\\n 164\\n Creatinine\\n 0.8\\n 0.7\\n 0.8\\n TCO2\\n 25\\n 22\\n 27\\n 24\\n 26\\n Glucose\\n 198\\n 163\\n 121\\n 120\\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\\n Lactic Acid:1.5 mmol/L, Ca:8.7 mg/dL, Mg:1.5 mg/dL\\n Imaging:\\n CXR: s/p removal of CT, no ptx, post-op changes noted, line in\\n place\\n Microbiology:\\n MRSA: negative\\n Assessment and Plan\\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\\n Assessment and Plan: 79 M s/p AVR (25 tissue), POD 2\\n Neurologic: Neuro checks Q: hr, Pain controlled.\\n Cardiovascular: Aspirin, Beta-blocker\\n Pulmonary: IS, Cough, IS, OOB to chair.\\n Gastrointestinal / Abdomen: Bowel regimen.\\n Nutrition: Sips, ADAT.\\n Renal: Foley, Adequate UO, Creat 0.8. Diurese with goal negative 1 L.\\n Hematology: Stable anemia, no active bleeding.\\n Endocrine: RISS, Insulin drip, Lantus (R), Transition from gtt to\\n Lantus, RISS. Goal BS < 150.\\n Infectious Disease: Check cultures, Received peri-op Vanco. Afebrile,\\n nomral WBC, no active ID issues at this time.\\n Lines / Tubes / Drains: Foley\\n Wounds: Dry dressings\\n Imaging: None\\n Fluids: KVO\\n Consults: CT surgery\\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\\n Lantus (R) protocol\\n Lines:\\n Multi Lumen - 06:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: Transfer to floor\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2174-08-03 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 581980,\n \"text\": \"CVICU\\n HPI:\\n POD 2 s/p AVR (25 tissue)\\n PMHx:\\n EF > 65 Wt 104K Cr. 0.8 HgbA1C: 7.1\\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\\n fem- bypass, L shoulder, removal of calcium , L knee surgery\\n , ?renal stent in \\n : Allopurinol 300', ASA 81', glyburide 5\\\", lisinopril 20', lovasa\\n 2\\\", metformin 500\\\"', ocuvite, simvastatin 40'\\n Current medications:\\n . 2. 3. 4. 250 mL D5W 5. Acetaminophen 6. Allopurinol 7. Aspirin EC 8.\\n Calcium Gluconate 9. Cepacol (Menthol) 10. Dextrose 50% 11. Docusate\\n Sodium 12. Furosemide 13. GlyBURIDE 14. Insulin 15. Insulin 16.\\n Magnesium Sulfate 17. Metoclopramide 18. Metoprolol Tartrate 19. Milk\\n of Magnesia 20. Morphine Sulfate 21. Nitroglycerin 22.\\n Oxycodone-Acetaminophen 23. Pneumococcal Vac Polyvalent 24. Potassium\\n Chloride 25. Ranitidine 26. Simvastatin 27. Sodium Chloride 0.9% Flush\\n 28. Sodium Chloride 0.9% Flush 29. Sodium Chloride 0.9% Flush 30.\\n Vancomycin\\n 24 Hour Events:\\n PA CATHETER - STOP 08:05 AM\\n CORDIS/INTRODUCER - STOP 06:00 PM\\n MULTI LUMEN - START 06:00 PM\\n - Remained in ICU for elevated BS, on insulin gtt\\n Allergies:\\n Penicillins\\n Unknown;\\n Last dose of Antibiotics:\\n Vancomycin - 08:16 PM\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 01:04 AM\\n Flowsheet Data as of 12:16 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.4\\nC (99.4\\n T current: 36.9\\nC (98.5\\n HR: 63 (63 - 80) bpm\\n BP: 109/39(57) {104/39(56) - 136/77(89)} mmHg\\n RR: 15 (14 - 21) insp/min\\n SPO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 111 kg (admission): 104 kg\\n Height: 70 Inch\\n Total In:\\n 1,158 mL\\n 196 mL\\n PO:\\n 580 mL\\n Tube feeding:\\n IV Fluid:\\n 578 mL\\n 196 mL\\n Blood products:\\n Total out:\\n 2,260 mL\\n 1,785 mL\\n Urine:\\n 1,995 mL\\n 1,725 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,102 mL\\n -1,589 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SPO2: 97%\\n ABG: ///28/\\n Physical Examination\\n General Appearance: No acute distress, Comfortable\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: Follows simple commands, Moves all extremities\\n Labs / Radiology\\n 164 K/uL\\n 8.9 g/dL\\n 120 mg/dL\\n 0.8 mg/dL\\n 28 mEq/L\\n 3.9 mEq/L\\n 17 mg/dL\\n 101 mEq/L\\n 135 mEq/L\\n 25.1 %\\n 5.8 K/uL\\n [image002.jpg]\\n 01:36 PM\\n 02:15 PM\\n 02:22 PM\\n 03:23 PM\\n 04:49 PM\\n 05:52 PM\\n 05:54 PM\\n 02:09 AM\\n 02:24 AM\\n 02:06 AM\\n WBC\\n 8.0\\n 5.3\\n 5.8\\n Hct\\n 27.5\\n 28.6\\n 26.9\\n 25.1\\n Plt\\n 233\\n 178\\n 164\\n Creatinine\\n 0.8\\n 0.7\\n 0.8\\n TCO2\\n 25\\n 22\\n 27\\n 24\\n 26\\n Glucose\\n 198\\n 163\\n 121\\n 120\\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\\n Lactic Acid:1.5 mmol/L, Ca:8.7 mg/dL, Mg:1.5 mg/dL\\n Imaging:\\n CXR: s/p removal of CT, no ptx, post-op changes noted, line in\\n place\\n Microbiology:\\n MRSA: negative\\n Assessment and Plan\\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\\n Assessment and Plan: 79 M s/p AVR (25 tissue), POD 2\\n Neurologic: Neuro checks Q: hr, Pain controlled.\\n Cardiovascular: Aspirin, Beta-blocker\\n Pulmonary: IS, Cough, IS, OOB to chair.\\n Gastrointestinal / Abdomen: Bowel regimen.\\n Nutrition: Sips, ADAT.\\n Renal: Foley, Adequate UO, Creat 0.8. Diurese with goal negative 1 L.\\n Hematology: Stable anemia, no active bleeding.\\n Endocrine: RISS, Insulin drip, Lantus (R), Transition from gtt to\\n Lantus, increased Glyburide to home dose, RISS. Goal BS < 150. Holding\\n metformin while being diuresed.\\n Infectious Disease: Check cultures, Received peri-op Vanco. Afebrile,\\n nomral WBC, no active ID issues at this time.\\n Lines / Tubes / Drains: Foley\\n Wounds: Dry dressings\\n Imaging: None\\n Fluids: KVO\\n Consults: CT surgery\\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\\n Lantus (R) protocol\\n Lines:\\n Multi Lumen - 06:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: Transfer to floor\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2174-08-03 00:00:00.000\",\n \"description\": \"Physical Therapy Evaluation Note\",\n \"row_id\": 581986,\n \"text\": \"Attending Physician: \\n Referral date: \\n Medical Diagnosis / ICD 9: 424.1 / AVR\\n Reason of referral: PT consult\\n History of Present Illness / Subjective Complaint: Pt is a 79 y/o male\\n admitted with SOB, ECHO revealed severe aortic stenosis. Pt now\\n s/p AVR ( tissue), POD #2. BPT 54 minutes and XCL 75 minutes.\\n and pt extubated . Pt doing well post-operatively and is ready for\\n transfer to stepdown floor.\\n Past Medical / Surgical History: DM 2, HTN, hyperlipidemia, B fem-\\n bypass yrs/ago, L knee surgery '\\n Medications: glyburide, metoprolol, furosemide, allopurinol,\\n simvastatin, rantidine, ASA, acetaminophen, oxycodone, vancomycin,\\n morphine\\n Radiology: CT chest: no PTX, lung volumes sl decreased\\n Labs:\\n 25.1\\n 8.9\\n 164\\n 5.8\\n [image002.jpg]\\n Other labs:\\n Activity Orders: Advance per C- guidelines\\n Social / Occupational History: lives with wife, wife has dementia but\\n is I with amb, ADLS and limited IADLS ( can do laundry, can't drive)\\n supportive children live 1 hr/away; supportive neighbors; enjoys\\n golfing 1-2x/week\\n Living Environment: FOS to bedroom, laundry\\n house cleaner 1x/2 weeks\\n Prior Functional Status / Activity Level: I PTA without AD, with\\n ADLS/IADLS\\n + driving\\n denies hx of falls other that 1 in which pt slipped and fell off roof\\n Objective Test\\n Arousal / Attention / Cognition / Communication: Axox3\\n Comm: pleasant, NAD and willing to participate\\n Hemodynamic Response\\n Aerobic Capacity\\n HR\\n BP\\n RR\\n O[2 ]sat\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Supine\\n Pt found sitting in chair\\n /\\n Rest\\n 64\\n 103/46\\n 16\\n 97% on 3 L 02 NC\\n Sit\\n 68\\n 134/54\\n 21\\n 100% on 3 L o2 NC\\n Activity\\n 77\\n 107/51\\n 20\\n 100% on 3 L o2 NC\\n 13\\n Stand\\n 70\\n 105/62\\n 16\\n 98% on 3 L 02 NC\\n Recovery\\n 72\\n 110/71\\n 21\\n 96% on 3 L o2 NC\\n Total distance walked:\\n Minutes:\\n Pulmonary Status: CTA B'lly, diminished BS at bases, +\\n dry/strong/nonproductive cough, breathing non-labored\\n IS to 1250 mL\\n Integumentary / Vascular: PIV, central line, telemetry, pacer + wires,\\n foley/catheter, \\\\\\n increase swelling B UEs/ -pitting\\n Sensory Integrity: B UEs / to light touch\\n Pain / Limiting Symptoms: pt denies any pain at this time\\n Posture: pt found sitting up in recliner\\n Range of Motion\\n Muscle Performance\\n WFL B UEs/LEs\\n B UEs/LEs except B she motions >3/5 sternal precautions\\n Motor Function: pt MAE in isolation\\n Functional Status:\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Gait, Locomotion: sit-stand with cgA x1 and ambulated 120' pushing\\n wheelchair with cgA x1, normal speed/step length, no LOB noted\\n Rolling:\\n NT\\n\\n\\n\\n\\n\\n\\n Supine /\\n Sidelying to Sit:\\n NT\\n\\n\\n\\n\\n\\n\\n Transfer:\\n\\n T\\n\\n\\n\\n Sit to Stand:\\n\\n T\\n\\n\\n\\n Ambulation:\\n 120\\n pushing w/c\\n\\n\\n T\\n\\n\\n\\n Stairs:\\n NT\\n\\n\\n\\n\\n\\n\\n Balance: S with static standing without UE support, no LOB\\n cgA with dynamic standing with UE support, no LOB\\n Education / Communication: Educ: Educated pt on role of PT, progress\\n thus far, pt status, sternal precautions/ activity guidelines, and\\n discharge plan- pt verbalized good understanding\\n Comm: communicated with RN and NP re: pt status and discharge plan\\n Intervention: Issued cardiac booklet and reviewed activity guidelines/\\n sternal precautions\\n Diagnosis:\\n Impaired functional mobility\\n Impaired HDR with functional mobility\\n Impaired balance\\n Knowledge deficit\\n Impaired gas exchange\\n Clinical impression / Prognosis: Pt is a 79 y/o male s/p AVR, now POD\\n #2. Pt p/w above impairments c/w cardiovascular pump dysfunction. Pt\\n lives with wife and was I and very active PTA. Pt cgA with sit-stand\\n and ambulated 120' pushing w/c with cgA- no LOB. Pt reports his wife\\n can A with laundry at d/c and has neighbors/children who can assist\\n with IADLS as needed. Anticipate pt will be safe for discharge home in\\n treatments. Will continue to follow as appropriate.\\n Goals\\n Time frame: 1-2x more\\n 1.\\n 500' s AD c I no LOB\\n 2.\\n I with bed mobility with HOB flat\\n 3.\\n I with FOS no LOB\\n 4.\\n I verbalize sternal precautions\\n 5.\\n 02 sat >92% on RA with all functional mobility\\n 6.\\n Stable HDR with all functional mobility\\n Anticipated Discharge: Home without PT\\n Treatment :\\n Frequency / Duration: 1-2x more x 1 week\\n bed mobility, transfers, progress ambulation, stair negotiation, pt\\n education, discharge planning, issue walking program, wean o2\\n T Patient agrees with the above goals and is willing to participate in\\n the rehabilitation program.\\n Addendum: Pt open to d/c home but not 100% agreeable at this time.\\n Recommendations for NSG: Ambulate 3x/day with cgA\\n Face Time: 10:35-11:15\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2174-08-03 00:00:00.000\",\n \"description\": \"CVICU\",\n \"row_id\": 581987,\n \"text\": \"CVICU\\n HPI:\\n POD 2 s/p AVR (25 tissue)\\n PMHx:\\n EF > 65 Wt 104K Cr. 0.8 HgbA1C: 7.1\\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\\n fem- bypass, L shoulder, removal of calcium , L knee surgery\\n , ?renal stent in \\n : Allopurinol 300', ASA 81', glyburide 5\\\", lisinopril 20', lovasa\\n 2\\\", metformin 500\\\"', ocuvite, simvastatin 40'\\n Current medications:\\n Acetaminophen, Allopurinol, Aspirin EC, Cepacol (Menthol), Docusate\\n Sodium, Furosemide, GlyBURIDE, Insulin, Metoprolol Tartrate, Morphine\\n Sulfate, Oxycodone-Acetaminophen, Ranitidine, Simvastatin, Vancomycin\\n 24 Hour Events:\\n Remained in ICU for blood glucose management, requiring insulin drip\\n PA CATHETER - STOP 08:05 AM\\n CORDIS/INTRODUCER - STOP 06:00 PM\\n MULTI LUMEN - START 06:00 PM\\n Allergies:\\n Penicillins\\n Unknown;\\n Last dose of Antibiotics:\\n Vancomycin - 08:16 PM\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 01:04 AM\\n Flowsheet Data as of 12:16 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.4\\nC (99.4\\n T current: 36.9\\nC (98.5\\n HR: 63 (63 - 80) bpm\\n BP: 109/39(57) {104/39(56) - 136/77(89)} mmHg\\n RR: 15 (14 - 21) insp/min\\n SPO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 111 kg (admission): 104 kg\\n Height: 70 Inch\\n Total In:\\n 1,158 mL\\n 196 mL\\n PO:\\n 580 mL\\n Tube feeding:\\n IV Fluid:\\n 578 mL\\n 196 mL\\n Blood products:\\n Total out:\\n 2,260 mL\\n 1,785 mL\\n Urine:\\n 1,995 mL\\n 1,725 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,102 mL\\n -1,589 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SPO2: 97%\\n ABG: ///28/\\n Physical Examination\\n General Appearance: No acute distress, Comfortable\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Neurologic: Follows simple commands, Moves all extremities\\n Labs / Radiology\\n 164 K/uL\\n 8.9 g/dL\\n 120 mg/dL\\n 0.8 mg/dL\\n 28 mEq/L\\n 3.9 mEq/L\\n 17 mg/dL\\n 101 mEq/L\\n 135 mEq/L\\n 25.1 %\\n 5.8 K/uL\\n 01:36 PM\\n 02:15 PM\\n 02:22 PM\\n 03:23 PM\\n 04:49 PM\\n 05:52 PM\\n 05:54 PM\\n 02:09 AM\\n 02:24 AM\\n 02:06 AM\\n WBC\\n 8.0\\n 5.3\\n 5.8\\n Hct\\n 27.5\\n 28.6\\n 26.9\\n 25.1\\n Plt\\n 233\\n 178\\n 164\\n Creatinine\\n 0.8\\n 0.7\\n 0.8\\n TCO2\\n 25\\n 22\\n 27\\n 24\\n 26\\n Glucose\\n 198\\n 163\\n 121\\n 120\\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\\n Lactic Acid:1.5 mmol/L, Ca:8.7 mg/dL, Mg:1.5 mg/dL\\n Imaging:\\n CXR: s/p removal of CT, no ptx, post-op changes noted, line in\\n place\\n Microbiology: MRSA: negative\\n Assessment and Plan\\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\\n Neurologic: Neuro checks Q: hr, Pain controlled. Percocet prn pain\\n Cardiovascular: Aspirin, Beta-blocker statin\\n Pulmonary: IS, Cough, IS, OOB to chair.\\n Gastrointestinal / Abdomen: Bowel regimen.\\n Nutrition: diabetic diet\\n Renal: Foley, Adequate UO, Creat 0.8. Diurese with goal negative 1000\\n ml for 24 hours\\n Hematology: Stable anemia, no active bleeding.\\n Endocrine: RISS, Insulin drip, Lantus (R), Transition from gtt to\\n Lantus, increased Glyburide to home dose, RISS. Goal BS < 150. Holding\\n metformin while being diuresed.\\n Infectious Disease: Check cultures, Received peri-op Vancomycin.\\n Afebrile, nomral WBC, no evidence of infection\\n Lines / Tubes / Drains: Foley, pacing wires\\n Wounds: Dry dressings\\n Consults: PT\\n ICU \\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\\n Lantus (R) protocol\\n Lines:\\n Multi Lumen - 06:00 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: Transfer to floor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2174-08-03 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 581993,\n \"text\": \"Valve replacement, aortic bioprosthetic (AVR)\\n Assessment:\\n Pt A&O, follows all commands and appropriate.\\n HR-NSR 60\\ns-80\\ns. SBP 100\\ns-110\\ns. Doppler pulses. K-4.7 and ionized\\n calcium 1.16 with am labs.\\n LS-CTA/Dim at bases. 3-4LO2 NC- 96-99%. Chest tubes draining minimal\\n amounts of serosang. drainage.\\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\\n diet.\\n Foley intact draining good amounts of clear yellow urine.\\n Action:\\n Pt weaned off nitro drip and started on lopressor 25mg po bid at 0800.\\n Epicardial wires tested with A\\ns sensing and capturing appropriately\\n and V\\ns sensing but not capturing. Pt set on A demand at 50.\\n Pt encouraged to C&DB and IS used 500-750.\\n Pt started on lasix 20mg last night and continued.\\n Response:\\n Vitals unchanged at this time. Pt OOB to chair and chest tubes with\\n minimal amount of output. At 1100, pt with only 40cc\\ns of urine past 2\\n hrs. and 20mg lasix IV given NP order.\\n Plan:\\n Continue to administer beta blocker, monitor lytes and replete, monitor\\n UOP and diurese.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt c/o incisional pain with movement/C&DB.\\n Action:\\n Pt given toridol 15mg IV at 0800.\\n Response:\\n Pt appears comfortable in chair at this time. When C&DB, pt c/o \\n pain and given percoets in am/afternoon.\\n Plan:\\n Continue to monitor pain level and administer pain meds.\\n .H/O diabetes Mellitus (DM), Type II\\n Assessment:\\n Pt with blood sugars 110\\ns-170\\ns and received on insulin drip at 3\\n units/hr.\\n Action:\\n Pt continuing on insulin drip. At 0700, pt given 50units lantus SC \\n NP . Pt also started on own humalog ISS and given 6 units of\\n humalog SC for BS 117 at 0800. At 0900, drip shut off and at 1000 pt\\n with BS 150\\n Response:\\n At 1200, pt with blood sugar 178 and given 14 units humalog insulin SC\\n per ISS.\\n Plan:\\n Continue to check blood sugars and administer insulin per own ISS.\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2174-08-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 89237,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: aortic stenosis\\nHeight: (in) 71\\nWeight (lb): 236\\nBSA (m2): 2.26 m2\\nBP (mm Hg): 160/90\\nHR (bpm): 69\\nStatus: Inpatient\\nDate/Time: at 11:43\\nTest: TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\npre-CPB: 79 yr old male w/ pmhx of htn, hyperlipidemia, and NIDDM with aortic\\nstenosis symptomology of progressive dyspnea. Intra-operative TEE revealed\\npreserved left ventricular systolic function with no detectable wall motion\\nabnormalities. Continuity evaluation confirmed pre-operative diagnosis of\\nsevere aortic stenosis. Severe MAC was seen and mitral valve area by presssure\\nhalf-time was 2.0 cm2. There was no evidence of ASD/PFO via interrogation with\\ncolor flow doppler. Findings were communicated to the surgeon prior to\\nincision.\\n\\n Internal billing error corrected. No changes made to findings. WJM\\nLEFT ATRIUM: Normal LA and RA cavity sizes. Good (>20 cm/s) LAA ejection\\nvelocity.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\\nseen in the RA. A catheter or pacing wire is seen in the RA and extending into\\nthe RV. No ASD by 2D or color Doppler.\\n\\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Overall normal LVEF\\n(>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter.\\n\\nAORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic\\nvalve leaflets. Severe AS (area 0.8-1.0cm2). No AR.\\n\\nMITRAL VALVE: Severely thickened/deformed mitral valve leaflets. Severe mitral\\nannular calcification. Mild functional MS due to MAC. Physiologic MR (within\\nnormal limits).\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. A TEE was performed in the\\nlocation listed above. I certify I was present in compliance with HCFA\\nregulations. The patient was monitored by a nurse throughout the\\nprocedure. The patient was under general anesthesia throughout the procedure.\\nThe patient received antibiotic prophylaxis. The TEE probe was passed with\\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\\ncomplications.\\npost-CPB: Patient was weaned off CPB with 0.5 mcg/kg/min of phenylephrine.\\nAorta was evaluated and no evidence of dissection was seen. LV systolic\\nfunction was similar to the pre-bypass period with no new recognizable RWMA. A\\nwell seated aortic bioprosthesis was noted without residual regurgitation.\\n\\nConclusions:\\nThe left atrium and right atrium are normal in cavity size. No atrial septal\\ndefect is seen by 2D or color Doppler. Left ventricular wall thicknesses and\\ncavity size are normal. Overall left ventricular systolic function is normal\\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\\nThere are three aortic valve leaflets. The aortic valve leaflets are severely\\nthickened/deformed. There is severe aortic valve stenosis (valve area\\n0.8-1.0cm2). No aortic regurgitation is seen. The mitral valve leaflets are\\nseverely thickened/deformed. There is severe mitral annular calcification.\\nThere is mild functional mitral stenosis due to mitral annular calcification.\\nPhysiologic mitral regurgitation is seen (within normal limits). There is no\\npericardial effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2174-07-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 89238,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Aortic valve disease. Preoperative assessment.\\nHeight: (in) 70\\nWeight (lb): 236\\nBSA (m2): 2.24 m2\\nBP (mm Hg): 150/82\\nHR (bpm): 76\\nStatus: Inpatient\\nDate/Time: at 15:47\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: Definity\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Moderate LA enlargement.\\n\\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\\nsystolic function (LVEF>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter.\\n\\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS\\n(area 0.8-1.0cm2). Trace AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Severe mitral annular\\ncalcification. Mild thickening of mitral valve chordae. Calcified tips of\\npapillary muscles. Mod functional MS due to MAC.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR.\\nIndeterminate PA systolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views.\\n\\nConclusions:\\nThe left atrium is moderately dilated. There is mild symmetric left\\nventricular hypertrophy with normal cavity size and regional/global systolic\\nfunction (LVEF>55%). The aortic root is mildly dilated at the sinus level. The\\naortic valve leaflets are severely thickened/deformed. There is severe aortic\\nvalve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. The\\nmitral valve leaflets are mildly thickened. There is severe mitral annular\\ncalcification leading to moderate functional mitral stenosis (mean gradient 4\\nmmHg). Moderate [2+] tricuspid regurgitation is seen. The pulmonary artery\\nsystolic pressure could not be determined. There is no pericardial effusion.\\n\\nIMPRESSION: Severe aortic valve stenosis. Moderate functional mitral stenosis\\nfrom MAC. Mild symmetric left ventricular hypertrophy with preserved global\\nand regional biventricular systolic function. Dilated thoracic aorta.\\n\\nCLINICAL IMPLICATIONS:\\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\\nfor prophylaxis should be based on clinical and echocardiographic data.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2174-08-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 233027,\n \"text\": \"Sinus rhythm. Prolonged Q-T interval;. Intraventricular conduction delay.\\nCompared to the previous tracing of the Q-T interval is now prolonged.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2174-07-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 233028,\n \"text\": \"Normal sinus rhythm, rate 85. Left anterior hemiblock. Borderline\\nintraventricular conduction delay. No previous tracing available for\\ncomparison.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2174-08-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1085369,\n \"text\": \" 7:05 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p ct removal ? ptx\\n Admitting Diagnosis: AORTIC STENOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with s/p avr\\n REASON FOR THIS EXAMINATION:\\n s/p ct removal ? ptx\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of the patient after aortic valve\\n replacement.\\n\\n Portable AP chest radiograph was compared to .\\n\\n The right internal jugular line tip is at the cavoatrial junction. There is\\n improvement of left basal atelectasis with minimal opacity still present. The\\n lungs otherwise are essentially clear with no evidence of substantial pleural\\n effusion or pneumothorax. Cardiomediastinal silhouette is stable.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2174-08-02 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1085328,\n \"text\": \" 6:07 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: r/o ptx assess line placement\\n Admitting Diagnosis: AORTIC STENOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man s/p avr and CVL change\\n REASON FOR THIS EXAMINATION:\\n r/o ptx assess line placement\\n ______________________________________________________________________________\\n WET READ: AGLc TUE 10:50 PM\\n ETT/NGT removed. Swan and sheath removed, replaced with Rt IJ CVL which\\n terminates in mid-SVC. mediastinal/pleural drains remain in place. No new\\n PTX, mediastinal widening or large effusio, although Rt lateral sulcus\\n excluded. lung volumes sl decreased.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: A 79-year-old male status post aortic valve replacement and\\n central venous line change. Evaluate for pneumothorax.\\n\\n Single AP chest radiograph compared to shows repositioning of a\\n right IJ central venous catheter with tip now located in the distal SVC/right\\n cavoatrial junction. Chest tubes and mediastinal drains are again identified.\\n There is mild left retrocardiac atelectasis, unchanged. The right lung is\\n clear. The right extreme CP angle has been excluded. No pneumothorax.\\n\\n IMPRESSION: No pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2174-08-05 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1085727,\n \"text\": \" 10:11 AM\\n CHEST (PA & LAT) Clip # \\n Reason: f/u atelectasis\\n Admitting Diagnosis: AORTIC STENOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with s/p AVR\\n REASON FOR THIS EXAMINATION:\\n f/u atelectasis\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of the patient after aortic valve\\n replacement.\\n\\n PA and lateral upright chest radiographs were compared to .\\n\\n Right internal jugular line tip is at the cavoatrial junction.\\n Cardiomediastinal silhouette is stable. There are bibasilar opacities\\n consistent with atelectasis accompanied by small amount of pleural effusion.\\n Anterior mediastinal air cannot be excluded most likely related to prior\\n surgery but there is no evidence of pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2174-08-01 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1085130,\n \"text\": \" 4:16 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: Pleural effusion, pulmonary edema, tamponade, pneumothorax.\\n Admitting Diagnosis: AORTIC STENOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with AVR\\n REASON FOR THIS EXAMINATION:\\n Pleural effusion, pulmonary edema, tamponade, pneumothorax. \\n with issues.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: AVR.\\n\\n FINDINGS: In comparison with the study of , there are now metallic\\n sternal sutures in place. Endotracheal tube tip lies approximately 5.7 cm\\n above the carina. Right IJ catheter extends to the proximal portion of the\\n right pulmonary artery. Nasogastric tube extends well into the stomach.\\n Bibasilar atelectasis, more prominent on the left. No evidence of\\n pneumothorax.\\n\\n IMPRESSION: Standard appearance following cardiac surgery.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2174-07-27 00:00:00.000\",\n \"description\": \"TEETH (PANOREX FOR DENTAL)\",\n \"row_id\": 1084257,\n \"text\": \" 3:54 PM\\n TEETH (PANOREX FOR DENTAL) Clip # \\n Reason: eval for caries\\n Admitting Diagnosis: AORTIC STENOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man pre-op AVR\\n REASON FOR THIS EXAMINATION:\\n eval for caries\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION: Panorex.\\n\\n HISTORY: Pre-op AVR, evaluate for caries.\\n\\n FINDINGS:\\n\\n The mandibular teeth appear unremarkable without evidence of periapical\\n lucency. Multiple maxillary teeth are absent. Evaluation of the maxillary\\n teeth for carries is limited due to overlap from the adjacent osseous\\n structures.\\n\\n IMPRESSION:\\n\\n 1. Normal mandibular teeth.\\n\\n 2. Limited evaluation of the maxillary teeth. The collapse due to overlap\\n affirmed adjacent osseous structures.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2174-07-27 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 1084256,\n \"text\": \" 3:54 PM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: AORTIC STENOSIS\\n Admitting Diagnosis: AORTIC STENOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man pre-op AVR\\n REASON FOR THIS EXAMINATION:\\n eval for pleural effusions pre-op AVR\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 79-year-old male preop for AVR. Evaluate for pleural effusion.\\n\\n PA and lateral chest radiographs without comparison shows clear lungs. The\\n lungs are mildly hyperinflated. The heart, mediastinum, hila and pulmonary\\n vascularity are normal.\\n\\n IMPRESSION: No acute cardiopulmonary process.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2174-07-28 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1084432,\n \"text\": \" 11:53 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: eval for aortic anatomy, mitral calcifications.NO contrast r\\n Admitting Diagnosis: AORTIC STENOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man with knwon AS- Mitral calcifications seen on ech and dilated Ao\\n root\\n REASON FOR THIS EXAMINATION:\\n eval for aortic anatomy, mitral calcifications.NO contrast recent dye load for\\n cath and has been on metformin- no on hold\\n CONTRAINDICATIONS for IV CONTRAST:\\n recent dye load for cath\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 79-year-old male with known aortic stenosis and mitral annular\\n calcification with dilated aortic root seen on echo. Evaluate anatomy.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Non-contrast MDCT-acquired axial images of the chest from the\\n thoracic inlet to the upper abdomen. Multiplanar reformatted images were\\n obtained.\\n\\n CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: There is heavy calcification at\\n the base of the aorta, arch, and desceding aorta. The aortic valve and mitral\\n annulus are heavily calcified. The aorta is normal in caliber. The heart size\\n is normal. Small amount of pericardial fluid may be physiologic.\\n\\n The lungs are clear. The tracheobronchial tree is normal to the subsegmental\\n level. There is no pleural abnormality. The central lymph nodes are not\\n enlarged. The bones show no lesion worrisome for osseous metastases. There is\\n three vessel coronary artery calcification. Limited view of the upper abdomen\\n is unremarkable. The bones show no lesion worrisome for osseous metastasis.\\n\\n IMPRESSION: Heavy calcification at the base of the aorta, arch, and desceding\\n aorta. The aortic valve and mitral annulus are also heavily calcified. These\\n images are available for review for surgical planning.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2174-07-28 00:00:00.000\",\n \"description\": \"CAROTID SERIES COMPLETE\",\n \"row_id\": 1084389,\n \"text\": \" 9:14 AM\\n CAROTID SERIES COMPLETE Clip # \\n Reason: PREOP AVR\\n Admitting Diagnosis: AORTIC STENOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old man pre-op AVR\\n REASON FOR THIS EXAMINATION:\\n eval for stenosis\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n Standard Report Carotid US\\n\\n Study: Carotid Series Complete\\n\\n Reason: Pre op AVR\\n\\n Findings: Duplex evaluation was performed of bilateral carotid arteries. On\\n the right there is mild heterogeneous plaque with calcifications in the ICA.\\n On the left there is mild heterogeneous plaque in the ICA.\\n\\n On the right systolic/end diastolic velocities of the ICA proximal, mid and\\n distal respectively are 55/18, 88/25, 77/22 cm/sec. CCA peak systolic\\n velocity is 65 cm/sec. ECA peak systolic velocity is 258 cm/sec. The ICA/CCA\\n ratio is ?. These findings are consistent with <40%stenosis.\\n\\n On the left systolic/end diastolic velocities of the ICA proximal, mid and\\n distal respectively are 44/10, 55/16, 55/15 cm/sec. CCA peak systolic\\n velocity is 73 cm/sec. ECA peak systolic velocity is 85 cm/sec. The ICA/CCA\\n ratio is .75. These findings are consistent with <40% stenosis.\\n\\n There is antegrade right vertebral artery flow.\\n There is antegrade left vertebral artery flow.\\n\\n Impression: Right ICA stenosis <40%.\\n Left ICA stenosis <40%.\\n\\n\"\n }\n]"}}},{"rowIdx":24694,"cells":{"subject_id":{"kind":"number","value":4556,"string":"4,556"},"hadm_id":{"kind":"number","value":137689,"string":"137,689"},"target_text":{"kind":"string","value":"The patient was seen by Dr. who felt the patient would require emergent evacuation of the left subdural hematoma. He was, therefore, taken to the OR and underwent a left frontal craniotomy for excision of the subdural hematoma without intraoperative complication. Postoperatively, the patient was monitored in the ICU for close neurologic observation. The vital signs were stable. He was afebrile. His pupils were 1 mm and reactive bilaterally, moving all extremities, and responds to pain - left greater than right. His right lower extremity toes were upgoing and he withdrew his lower extremities to pain. The left lower extremity was downgoing. His incision was clean, dry, and intact. He had a JP drain in which drained 60 cc of bloody fluid. On postoperative day number one, the patient was extubated. Continued to follow commands and speech was clear once extubated. A repeat head CT showed good evacuation of the subdural hematoma. The patient remained neurologically stable and was transferred to the regular floor on . He has remained neurologically stable, awake, alert, oriented times three, moving all extremities with good strength. He was cleared by physical therapy for discharge home. He will follow-up with Dr. in one month with a repeat head CT. He will follow-up with his primary care doctor this week for a blood pressure check and glucose check. His glucose checks, here at the hospital, have been anywhere from 100-195, receiving two units of subcutaneous insulin on two occasions. His blood pressure medications, metoprolol 25 mg PO b.i.d., amlodipine 5 mg PO q day, and Dilantin for one day - 100 mg PO t.i.d."},"extractive_notes_summ":{"kind":"string","value":"PT STABLE SXN FOR SM AMT THIN SEC. T/SICU NPN-Brief ROS: Pt. COMPARISONS: Noncontrast head CT of . Palpable periph pulses.Resp- Remains on rm air, adequate sats this shift. Minimal periph edema. Hct stable at 38.2.Resp - LS clear. Prn hydralzine/metoprol utilized to keep sbp <130. Initial assessment completed (see flow record for details of that assessment).ROS:Neuro: Sedate ? S/P EVAC OF R SDH. anasthesia residual?? CV: SR/no etopy. + palp peripheral pulses. IMPRESSION: 1) Stable appearance of residual left sided subdural hemorrhage with mass effect. Pt admitted to on s/p mva. Compression sleves on bilat.Resp: Resp rate even and non labored. BS DECR CTA BILAT. Abd soft w/hypoactive BS. On pt underwent evacuation of r subudural. Probable mild CHF. Speach clear. Head drsg and . Nipride gtt titrated to keep SBP < 130. Vertebral body alignment is within normal limits. BS are reletively clear. RESP CARE NOTEPT RECEIVED FROM O.R. Head in neut allignment w/ on. Right radial ABP. TECHNIQUE: Noncontrast head CT. There continues to be a moderate amount of mass effect with slight compression of the left lateral ventricle and loss of left-sided sulci. Keep sbp 130 or less. repeat head CT this am. There is upper zone redistribution and mild diffuse vascular blurring. ON dilantin q 8 hr.CV: RSR no ectopy. A tiny left sided residual subdural hemorrhage remains. RESPIRATORY CARE: PT. FINDINGS: ET and NG tubes are present. ABGs pH 7.42, pco2 37, po2 160. HR stable, sinus without ectopy. Pulm: on room air, lungs clear, decreased at bases. On RA ABG 7.50/28/107/0/23. Pt s/p nipride infusion. Peripheral pulses strong and =. Peripheral pulses strong and =. SBP 110 -> 180. +BS. Perrl. call-out to floor if pt remains stable. DRAIN COMPRESSED W/THUMB PRINT SUCTION ONLY. SaO2 100%.CV: Sinus rhythm no ectopy. Denies numbness/tinglining in extremities. There is mild cardiomegaly. AM ABG REFLECTS NORMAL ACID BASE W/HYPEROXIA, RSBI 47.5. Lung sounds clear thoughout. Denies pain.Pt. CHEST, SINGLE AP VIEW. Abd soft, NT with bowel sounds. The paranasal sinuses are otherwise well aerated. There is minimal loss of vertebral body height at L5/S1. Previous nipride gtt weaned to off, pt restarted on po norvasc. Sx x's 1 w/o any sputum obtained. IMPRESSION: 1. On heparin q 12hr sub q. IMPRESSION: Normal chest radiograph. Extub on and JP drain dcd on .Neuro - Pt alert and oriented, MAE. JP drain placed. PEARLA. Transferred to . Notify team of unresolved or increased temp. PELVIS: There is normal mineralization. There is slight displacement of the left lateral ventricle to the right. Pg . There is a minimal amount of residual subdural blood. PERL. FINDINGS: Again seen is a left sided craniotomy and a subdural drain. There is a minimal amount of residual subdural blood and residual mass effect. Pt experienced some R sided weakness. Dorsi plantor/flexion strong and equal. Crani dressing clean dry and . , RRT BP 120-140/44-60 via ABP. Neuro resident EJ and MD aware. There is a small amount of pneumocephalus layering anteriorly on the left. There is minimal wedging of the few of the mid thoracic vertebral bodies, which appears chronic. Accuchecks not requiring SSI coverage.Plan: CT head today. Dilantin level 13.6 today. Heparin to begin this AM. Connected to monitor and vent. has been appropriate all shift. PLACED ON IN SIMV/PS MODE. Cough, gag, and corneal reflex +. IMPRESSION: S/P left-sided craniectomy with subdural drain placement. Update 0600Awake, following commands w/all extremities. 02 sats > 96%.GI - Abd soft. VSS. K 3.9 this am.ID - Max temp 100.1 po. No BM's this shift, he did have some flatus.GU- Making adequate amts of urine via foley.ID- Low grade temp. Withdrawls all except RUE to nailbed presure. Pupils equal and reactive. Sclerosis of the weight bearing areas of the acetabulum is noted. S1S2. S1S2. RSBI 80 ANDGOOD ABG ON . There continues to be a small amount of pneumocephalus within the left frontal area. MAINT'D,TLS CLEARED THIS PM BY DR ,CT HEAD AND C SPINE THIS AM.CV-PT REMAINS ON SNP GTT TO KEEP SBP <140, SNP GTT @.2-1 MCG/KG/MIN,HYDRALIZINE IVP 10MG ADDED THIS PM NOW ABLE TO WEAN SNP GTT,3+DP/PT .HR 60'S-70'S NSR NO VEA,LYTES REPLETED PRN.RESP-PT ON THIS AM ABG WNL,PT W/ OUT DIFF @ 11AM,INITIALLY ON 50% COOL NEB,O2 SAT 99-100%,NOW ON RA O2 SATS 95-98%.RR 20-30.NARD.PT DENIES SOB.GI/GU-NPO,OGT DC'D ON EXTUBATION,SM AMTS BILIOUS VIA OGT,ABD SOFT ABSENT BS,NO N/V NOTED,U/O ADEQ AMTS CLEAR YELLOW URINE VIA FOLEY CATH.SKIN-HEAD DSGS CDI,PT BACK + BUTTOCK GROSSLY INTACT. Receiving scheduled lopressor and hydralazine ivp for HTN management. Equal rise and fall of chest. Equal rise and fall of chest. Patchy retrocardiac density consistent with left lower lobe collapse and/or consolidation. The soft tissues and osseous structures remain unchanged. IMPRESSION: Cardiomegaly. There is subtle hypodensity within the left posterior temporal lobe. Mild degenerative changes seen throughout the cervical spine. There continues to be air fluid levels within the ethmoid and right sphenoid sinus. Rx with 1 gm iv kefzol q 8hrs.Skin - Head dssg d+i.A+P - Continue to monitor neuro status closely. There is also mild mass effect within this left temporoparietal area. Hand grasps strong and equal. ? ? ? Evaluate for interval change. D: See data, MD notes/orders. The mediastinal and hilar contours are unremarkable. There is a small amount of hyperattenuation in this area too which most likely represents subarachnoid blood. PEARRLA. The joint spaces are preserved. No resp distress noted. No resp distress noted. 2. Urine culture sent today.Integ- . There is patchy increased retrocardiac density. Crani dressing clean dry and intact. Trauma. IMPRESSION: Slight wedging of a few mid thoracic vertebrae, which appears chronic with evidence of demineralization. Degenerative changes. MAE. No flatus noted. 2) Subtle area of hypodensity with surrounding hyperdensity within the left posterior temporal lobe which may represent edema with a small amount of subarachnoid hemorrhage."},"n_notes":{"kind":"number","value":18,"string":"18"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2174-03-04 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":817316,"text":" 8:34 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: post subdural evac\n Admitting Diagnosis: LEFT SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with\n REASON FOR THIS EXAMINATION:\n post subdural evac\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P MVC, post-subdural evacuation.\n\n TECHNIQUE: Axial non-contrast head CT.\n\n CT HEAD WITHOUT CONTRAST: The patient has had a left-sided craniectomy with\n subdural drain placement. There is a minimal amount of residual subdural\n blood. No previous studies are available for comparison. There is a small\n amount of pneumocephalus layering anteriorly on the left. There is also mild\n mass effect within this left temporoparietal area. There is slight\n displacement of the left lateral ventricle to the right. The ventricles are\n widely patent without evidence of hydrocephalus.\n\n There is subtle hypodensity within the left posterior temporal lobe. There is\n a small amount of hyperattenuation in this area too which most likely\n represents subarachnoid blood. The white matter differentiation is\n otherwise intact throughout.\n\n There is air fluid levels within the sphenoid and ethmoid air cells. The\n paranasal sinuses are otherwise well aerated.\n\n IMPRESSION: S/P left-sided craniectomy with subdural drain placement. There\n is a minimal amount of residual subdural blood and residual mass effect.\n Subtle hypodensities within the posterior left temporal lobe which may\n represent edema or evolving infarction and follow up is recommended.\n\n"},{"category":"Radiology","chartdate":"2174-03-04 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":817317,"text":" 8:35 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o fracture\n Admitting Diagnosis: LEFT SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p MVC\n REASON FOR THIS EXAMINATION:\n r/o fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVC. Trauma.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial non-contrast CT scanning of the cervical spine was\n performed. Sagittal and coronal reconstructions were also obtained.\n\n CT C-SPINE: There is no evidence of fracture or subluxation of the component\n vertebrae. There are mild degenerative changes seen within the cervical spine\n with osteophyte formation at multiple levels. CT is not able to provide any\n intrathecal detail; however, the thecal sac outline appears unremarkable.\n\n There is a focal area of sclerosis within the right side of the C3 vertebral\n body. This most likely represents a bone island. Note is also made of a\n heterogneous-appearing thyroid with calcifications.\n\n IMPRESSION:\n\n 1. No evidence of fracture or subluxation of the component vertebrae.\n 2. Mild degenerative changes seen throughout the cervical spine.\n\n"},{"category":"Radiology","chartdate":"2174-03-04 00:00:00.000","description":"T-SPINE","row_id":817322,"text":" 9:05 AM\n T-SPINE; LUMBO-SACRAL SPINE (AP & LAT) Clip # \n Reason: r/o fracture\n Admitting Diagnosis: LEFT SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p mvc\n REASON FOR THIS EXAMINATION:\n r/o fracture\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: MVA.\n\n FINDINGS: ET and NG tubes are present. There is minimal wedging of the few\n of the mid thoracic vertebral bodies, which appears chronic. There are no\n acute fractures. Vertebral body alignment is within normal limits. There is\n minimal loss of vertebral body height at L5/S1. Posterior elements of the\n thoracic spine are not well visualized. There are bridging osteophytes\n multiple thoracic and lumbar spines.\n\n IMPRESSION: Slight wedging of a few mid thoracic vertebrae, which appears\n chronic with evidence of demineralization. No evidence for an acute injury.\n Degenerative changes.\n\n"},{"category":"Radiology","chartdate":"2174-03-03 00:00:00.000","description":"TRAUMA #2 (AP CXR & PELVIS PORT)","row_id":817262,"text":" 5:03 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: 5\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n CHEST, AP: The heart size is borderline enlarged. The endotracheal tube is\n about 5 cm above the carina. The tip of the NG tube is visualized in the\n fundus of the stomach. The mediastinal and hilar contours are unremarkable.\n No pleural effusions are seen. The surrounding osseous and soft tissue\n structures are unremarkable. The lungs are clear.\n\n IMPRESSION: Normal chest radiograph.\n\n PELVIS: There is normal mineralization. No focal lesions are present. No\n fractures, effusions, or dislocations are seen. Small brachy therapy seeds\n are seen. The joint spaces are preserved. The soft tissues are normal.\n Sclerosis of the weight bearing areas of the acetabulum is noted.\n\n IMPRESSION: No evidence of fracture or dislocation.\n\n\n"},{"category":"Radiology","chartdate":"2174-03-05 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":817442,"text":" 11:37 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for interval change\n Admitting Diagnosis: LEFT SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p evacuation l SDH\n\n REASON FOR THIS EXAMINATION:\n Eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post evacuation of subdural hemorrhage. Evaluate for\n interval change.\n\n TECHNIQUE: Noncontrast head CT.\n\n COMPARISONS: Noncontrast head CT of .\n\n FINDINGS: Again seen is a left sided craniotomy and a subdural drain. A tiny\n left sided residual subdural hemorrhage remains. There continues to be a\n moderate amount of mass effect with slight compression of the left lateral\n ventricle and loss of left-sided sulci. Within the posterior left temporal\n lobe, there is an area of subtle hypodensity with surrounding hyperdensity\n which may represent edema with possible small amount of subarachnoid blood. No\n new areas of intra axial or extra axial hemorrhage is identified. There\n continues to be a small amount of pneumocephalus within the left frontal area.\n There is no evidence of hydrocephalus. There continues to be air fluid levels\n within the ethmoid and right sphenoid sinus. The soft tissues and osseous\n structures remain unchanged.\n\n IMPRESSION:\n\n 1) Stable appearance of residual left sided subdural hemorrhage with mass\n effect.\n 2) Subtle area of hypodensity with surrounding hyperdensity within the left\n posterior temporal lobe which may represent edema with a small amount of\n subarachnoid hemorrhage. An evolving infarction again is also a possibility\n and follow up is recommended.\n\n\n"},{"category":"Radiology","chartdate":"2174-03-05 00:00:00.000","description":"CHEST (SINGLE VIEW)","row_id":817443,"text":" 11:46 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: LEFT SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with tachypnea\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tachypnea, rule out pneumonia.\n\n CHEST, SINGLE AP VIEW.\n\n There is mild cardiomegaly. There is upper zone redistribution and mild\n diffuse vascular blurring. There is patchy increased retrocardiac density.\n No effusion.\n\n IMPRESSION: Cardiomegaly. Probable mild CHF. Patchy retrocardiac density\n consistent with left lower lobe collapse and/or consolidation.\n\n\n"},{"category":"Nursing/other","chartdate":"2174-03-06 00:00:00.000","description":"Report","row_id":1321039,"text":"1am - 7 am Micu Progress Note\n\nBriefly pt is a 74 yo male who was transferred from SICU to MICU A on . Pt admitted to on s/p mva. Pt was unrestrained driver who hit his head on the windshield. Ambulatory at scene, but while sitting on curb became unresponsive. Taken To St E hospital where he was intubated and CT showed a lg subdural hematoma. Transferred to . On pt underwent evacuation of r subudural. JP drain placed. Pt experienced some R sided weakness. Extub on and JP drain dcd on .\n\nNeuro - Pt alert and oriented, MAE. Equal strength in all exts. PERL. No sz activity noted. Rx with 100 mg dilantin iv q8hrs. Dilantin level 13.6 today. Plan is for repeat head CT today.\n\nC-V - HR 80-90 NSR. BP 120-140/44-60 via ABP. Pt s/p nipride infusion. Rx with iv hydralazine and lopressor. + palp peripheral pulses. Hct stable at 38.2.\n\nResp - LS clear. On RA ABG 7.50/28/107/0/23. RR 20-25. 02 sats > 96%.\n\nGI - Abd soft. +BS. Tolerating liquids without difficulty.\n\nF/E - Urine output 20-130ccs/hr via foley cath. Rx with 40 meq kcl po tid x 24 hrs. K 3.9 this am.\n\nID - Max temp 100.1 po. WBC 8.3, previously 10.4. Rx with 1 gm iv kefzol q 8hrs.\n\nSkin - Head dssg d+i.\n\nA+P - Continue to monitor neuro status closely. ? repeat head CT this am. ? call-out to floor if pt remains stable.\n"},{"category":"Nursing/other","chartdate":"2174-03-06 00:00:00.000","description":"Report","row_id":1321040,"text":"addendum - Phos 1.3 - pt to receive k-phos 15 mmol/250 ns.\n"},{"category":"Nursing/other","chartdate":"2174-03-05 00:00:00.000","description":"Report","row_id":1321036,"text":"nsg note\nneuro: pt arouses easily to voice but falls asleep immediately when not stimulated oriented times three denies headache or any discomfor. mae to command pupils equal and recting.\n\npt with stable bp <130 until 330am then bp climing to 140's given hydralazine, lopressor and then placed on nipride gtt. titrated up to .8 mcgs this am.hr 80's nsr.\nuo qs temp max 100.9 blood and urine cultures sent.\npts lytes repleted this am potassium, phosphat, ca gluc and mg so4.\nivf at 80 ccs per hr.\np pt to satart po.s and bp control can be liberalized to 150.\n"},{"category":"Nursing/other","chartdate":"2174-03-05 00:00:00.000","description":"Report","row_id":1321037,"text":"T/SICU NPN-\nBrief ROS:\n Pt. has been appropriate all shift. Completely cooperative and communicative all shift. MAE. Pupils equal and reactive. Denies pain.Pt. went for a repeat CT scan of his head this am, not improved from yesterday- will need to remain the T/SICU over night.\n\nCV- SBP stable since discontinuing nipride this am. He was started on IV hydralazine and metoprolol q 6 hr rather than prn. HR stable, sinus without ectopy. Repleted potassium this afternoon, po. IV potassium boluses uncomfortable at site for pt. He had a bld gas K+ of 2.1 and the following serum K+ was 3.5, in the interim he rcv'd 40meq KCl x 2.\nSkin warm and dry. Minimal periph edema. Palpable periph pulses.\n\nResp- Remains on rm air, adequate sats this shift. Resp rate in the 20's. Coughs and deep breaths, productive cough. BS are reletively clear. Bld gas is unchanged.\n\nEndo- Has not required insulin coverage this shift.\n\nGI- Started a diet this am, has tolerated diet well all day. Drinking ample amts of liquids all shift. Abd soft, NT with bowel sounds. No BM's this shift, he did have some flatus.\n\nGU- Making adequate amts of urine via foley.\n\nID- Low grade temp. No abx in progress. Urine culture sent today.\n\nInteg- . Head drsg and .\n\n\n"},{"category":"Nursing/other","chartdate":"2174-03-06 00:00:00.000","description":"Report","row_id":1321038,"text":" 1900 -> 0100\n\nROS:\n\nNeuro: Alert oriented x's 4. Follows all commands. When asked to show me 2 thumbs he raised both arms. When I showed him what I wanted him to do he was then able to show me two thumbs. PEARRLA. Denies numbness/tinglining in extremities. Hand grasps strong and equal. Dorsi plantor/flexion strong and equal. Speach clear. Crani dressing clean dry and . No seizure activity noted. ON dilantin q 8 hr.\n\nCV: RSR no ectopy. VSS. Receiving scheduled lopressor and hydralazine ivp for HTN management. S1S2. No edema. Skin warm dry and pink. Peripheral pulses strong and =. On heparin q 12hr sub q. Compression sleves on bilat.\n\nResp: Resp rate even and non labored. Equal rise and fall of chest. No resp distress noted. ON room air sao2 95-98 %.\n\nGU: Foley cath patent draining clear yellow urine in amt sufficiant.\n\nGI: Abd soft w/active BS. Taking in po diet w/o c/o difficulties swallowing or nausea.\n\nTransfered to MICU A\n\n\n"},{"category":"Nursing/other","chartdate":"2174-03-04 00:00:00.000","description":"Report","row_id":1321032,"text":"S/P MVC-HEAD TRAUMA SDH EVAC.-T/SICU NPN 7-3P\nS-\"SABASTINO DANICO.HOSPITAL, FRIDAY\"\nO-NEURO-PT AROUSES TO VOICE OPENS EYES FOLLOWS COMMANDS MAE'S,PERRLA 3MM,CALM COOPERATIVE.STRONG COUGH + GAG.A+O X 3 CURRENTLY.SUBDURAL JP DRAINING SM AMT BLOODY DRAINAGE.C-SPINE PREC. MAINT'D,TLS CLEARED THIS PM BY DR ,CT HEAD AND C SPINE THIS AM.\nCV-PT REMAINS ON SNP GTT TO KEEP SBP <140, SNP GTT @.2-1 MCG/KG/MIN,HYDRALIZINE IVP 10MG ADDED THIS PM NOW ABLE TO WEAN SNP GTT,3+DP/PT .HR 60'S-70'S NSR NO VEA,LYTES REPLETED PRN.\nRESP-PT ON THIS AM ABG WNL,PT W/ OUT DIFF @ 11AM,INITIALLY ON 50% COOL NEB,O2 SAT 99-100%,NOW ON RA O2 SATS 95-98%.RR 20-30.NARD.PT DENIES SOB.\nGI/GU-NPO,OGT DC'D ON EXTUBATION,SM AMTS BILIOUS VIA OGT,ABD SOFT ABSENT BS,NO N/V NOTED,U/O ADEQ AMTS CLEAR YELLOW URINE VIA FOLEY CATH.\nSKIN-HEAD DSGS CDI,PT BACK + BUTTOCK GROSSLY INTACT.\n BROTHER CALLED THIS AM, BROTHER (SPOKESPERSON) VISITED THIS PM,SPOKE W/ DR PM. BROTHER EXPRESSING CONCERN OVER TIME FROM ACCIDENT-> SURGICAL INTERVENTION.\nENDO-BS 144 NO SS COVERAGE/ORDERS.\nID-AFEBRILE.CONT'S ON CEFAZ IV Q8HR.\nA-NEURODYNAMICALLY STABLE\nP-NEURO CHECKS,VS,ANTIHYPERTENSIVES/ORDERS,TITRATE TO SBP<140,O2 PRN,I+O,MONITOR SKIN INTEGRITY QS AND PRN,FAMILY SUPPORT PRN.FSBS,IV ABX/ORDERS.\n"},{"category":"Nursing/other","chartdate":"2174-03-04 00:00:00.000","description":"Report","row_id":1321033,"text":"SOCIAL WORK\nSW contact pts brother by phone to introduce role of sw and for support. states that he was in to visit briefly earlier and had all his questions answered by MD. Explained role of SW and offered support as needed. not interested in SW involvement at this time. Contact info for SW provided. I am available to meet with family as indicated. Pg .\n"},{"category":"Nursing/other","chartdate":"2174-03-04 00:00:00.000","description":"Report","row_id":1321034,"text":"RESPIRATORY CARE: PT. THIS AM\nAFTER CT SCAN AND TLS FILMS. RSBI 80 AND\nGOOD ABG ON . TO 50 % AEROSOL\nMASK. DOING WELL.\n\n , RRT\n"},{"category":"Nursing/other","chartdate":"2174-03-04 00:00:00.000","description":"Report","row_id":1321035,"text":"D: See data, MD notes/orders. Neuro: Pt sleeping unless stimulated, wakes easliy to verbal stimuli and is A&Ox3. Recognizes family members, mae with equal strength, follows commands. Perrl. JP drain removed this pm by Dr. with two sutures placed and incisions redressed. CV: SR/no etopy. SBP teens when sleeping 120-130 range when awake. Previous nipride gtt weaned to off, pt restarted on po norvasc. Prn hydralzine/metoprol utilized to keep sbp <130. Pulm: on room air, lungs clear, decreased at bases. 02 sats 95-97%. GU: foley draining clear yellow urine to gravity at >50cc/hr. GI: Abd flat, bs +, pt taking sow without difficulty.Endo: Per ssc Skin: grossly intact, 3+peripheral pulses x4. Soc: Several brothers in this evening, very attentive, have many questions re: current condition and outcome.\nP: Q2hr neuro checks, observe for s/s blood reaccumultation. Tylenol for temp, ?need for blood cx, continue abx as ordered. Notify team of unresolved or increased temp. Keep sbp 130 or less. Keep family updated on plan of care, direct to sicu team in am prn.\n"},{"category":"Nursing/other","chartdate":"2174-03-04 00:00:00.000","description":"Report","row_id":1321029,"text":"Admission note: 74 yo male admitted at 2115 from OR per bed to post evacuation of right subdural hematoma post MVC. Connected to monitor and vent. Initial assessment completed (see flow record for details of that assessment).\n\nROS:\n\nNeuro: Sedate ? anasthesia residual?? Becoming lighter as shift progresses. Inconsistant b/t hourly neuro exams. PEARLA. At times slight attempts made to open eyes, eyes open slightly. Eyes deviate upward and at times to the right. Cough, gag, and corneal reflex +. Crani dressing clean dry and intact. JP drains bright red to less bright red fluid as shift progresses in amt 45 -> 80 cc/hr. amt decreasing as shift progresses. Neuro resident EJ and MD aware. DRAIN COMPRESSED W/THUMB PRINT SUCTION ONLY. Moving all extremites at random,RUE less then all others. Withdrawls all except RUE to nailbed presure. Moves RUE to chest wall pinching and only after much stimuli, this too is inconsistant b/t hourly neuro exams. Log role precautions maintained at all times. Head in neut allignment w/ on. Log roled w/3 person assist, one to immobilize head.\n\nResp: Intubated and on Vent, SIMV 800x12, peep 5, ps 5, 40%. ABGs pH 7.42, pco2 37, po2 160. Pco2 goal 35-40. Lung sounds clear thoughout. Sx x's 1 w/o any sputum obtained. Equal rise and fall of chest. No resp distress noted. SaO2 100%.\n\nCV: Sinus rhythm no ectopy. S1S2. Right radial ABP. Peripheral pulses strong and =. Warm, dry, and pink. SBP 110 -> 180. Nipride gtt titrated to keep SBP < 130. Nipride at 0.05 mcg/kg/min (please note flow record indicates 0.1 mcg/kg/min as system rounds up). Heparin to begin this AM. Compression sleves on bilat legs. IV access limited to peripheral sites only.\n\nGI: Oral sump to LCS draining bile colored fluid. Abd soft w/hypoactive BS. No flatus noted. Receiving protonix.\n\nGU: Foley patent draining clear yellow urine in amt sufficant.\n\nLabs: K=2.9 repleated w/20 KCL, Mg=1.6 repleated w/2 gm Mgso4. Accuchecks not requiring SSI coverage.\n\nPlan: CT head today. Attempt to wean and potentially extubate today???\n"},{"category":"Nursing/other","chartdate":"2174-03-04 00:00:00.000","description":"Report","row_id":1321030,"text":"Update 0600\n\nAwake, following commands w/all extremities. Nods head and mouths words to answere questions asked.\n\nRSBI: 47.5. Spontanious Breathing Trial started @ 0600 check ABGs at 0800.\n\nSBP ^ w/vent changes. Nipride titrating ^ to keep SBP < 130\n\nK+ 3.4 waiting for dose of KCL from pharmacy\n\n\n"},{"category":"Nursing/other","chartdate":"2174-03-04 00:00:00.000","description":"Report","row_id":1321031,"text":"RESP CARE NOTE\nPT RECEIVED FROM O.R. S/P EVAC OF R SDH. PLACED ON IN SIMV/PS MODE. PT STABLE SXN FOR SM AMT THIN SEC. BS DECR CTA BILAT. AM ABG REFLECTS NORMAL ACID BASE W/HYPEROXIA, RSBI 47.5. SBT STARTED @ 0600. PLAN TO ASSESS FOR POSS EXTUBATION PENDING SUCCESSFUL COMPLETION OF SBT.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2174-03-04 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 817316,\n \"text\": \" 8:34 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: post subdural evac\\n Admitting Diagnosis: LEFT SUBDURAL HEMATOMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with\\n REASON FOR THIS EXAMINATION:\\n post subdural evac\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: S/P MVC, post-subdural evacuation.\\n\\n TECHNIQUE: Axial non-contrast head CT.\\n\\n CT HEAD WITHOUT CONTRAST: The patient has had a left-sided craniectomy with\\n subdural drain placement. There is a minimal amount of residual subdural\\n blood. No previous studies are available for comparison. There is a small\\n amount of pneumocephalus layering anteriorly on the left. There is also mild\\n mass effect within this left temporoparietal area. There is slight\\n displacement of the left lateral ventricle to the right. The ventricles are\\n widely patent without evidence of hydrocephalus.\\n\\n There is subtle hypodensity within the left posterior temporal lobe. There is\\n a small amount of hyperattenuation in this area too which most likely\\n represents subarachnoid blood. The white matter differentiation is\\n otherwise intact throughout.\\n\\n There is air fluid levels within the sphenoid and ethmoid air cells. The\\n paranasal sinuses are otherwise well aerated.\\n\\n IMPRESSION: S/P left-sided craniectomy with subdural drain placement. There\\n is a minimal amount of residual subdural blood and residual mass effect.\\n Subtle hypodensities within the posterior left temporal lobe which may\\n represent edema or evolving infarction and follow up is recommended.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2174-03-04 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 817317,\n \"text\": \" 8:35 AM\\n CT C-SPINE W/O CONTRAST Clip # \\n Reason: r/o fracture\\n Admitting Diagnosis: LEFT SUBDURAL HEMATOMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man s/p MVC\\n REASON FOR THIS EXAMINATION:\\n r/o fracture\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post MVC. Trauma.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Axial non-contrast CT scanning of the cervical spine was\\n performed. Sagittal and coronal reconstructions were also obtained.\\n\\n CT C-SPINE: There is no evidence of fracture or subluxation of the component\\n vertebrae. There are mild degenerative changes seen within the cervical spine\\n with osteophyte formation at multiple levels. CT is not able to provide any\\n intrathecal detail; however, the thecal sac outline appears unremarkable.\\n\\n There is a focal area of sclerosis within the right side of the C3 vertebral\\n body. This most likely represents a bone island. Note is also made of a\\n heterogneous-appearing thyroid with calcifications.\\n\\n IMPRESSION:\\n\\n 1. No evidence of fracture or subluxation of the component vertebrae.\\n 2. Mild degenerative changes seen throughout the cervical spine.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2174-03-04 00:00:00.000\",\n \"description\": \"T-SPINE\",\n \"row_id\": 817322,\n \"text\": \" 9:05 AM\\n T-SPINE; LUMBO-SACRAL SPINE (AP & LAT) Clip # \\n Reason: r/o fracture\\n Admitting Diagnosis: LEFT SUBDURAL HEMATOMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man s/p mvc\\n REASON FOR THIS EXAMINATION:\\n r/o fracture\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: MVA.\\n\\n FINDINGS: ET and NG tubes are present. There is minimal wedging of the few\\n of the mid thoracic vertebral bodies, which appears chronic. There are no\\n acute fractures. Vertebral body alignment is within normal limits. There is\\n minimal loss of vertebral body height at L5/S1. Posterior elements of the\\n thoracic spine are not well visualized. There are bridging osteophytes\\n multiple thoracic and lumbar spines.\\n\\n IMPRESSION: Slight wedging of a few mid thoracic vertebrae, which appears\\n chronic with evidence of demineralization. No evidence for an acute injury.\\n Degenerative changes.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2174-03-03 00:00:00.000\",\n \"description\": \"TRAUMA #2 (AP CXR & PELVIS PORT)\",\n \"row_id\": 817262,\n \"text\": \" 5:03 PM\\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \\n Reason: 5\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Trauma.\\n\\n CHEST, AP: The heart size is borderline enlarged. The endotracheal tube is\\n about 5 cm above the carina. The tip of the NG tube is visualized in the\\n fundus of the stomach. The mediastinal and hilar contours are unremarkable.\\n No pleural effusions are seen. The surrounding osseous and soft tissue\\n structures are unremarkable. The lungs are clear.\\n\\n IMPRESSION: Normal chest radiograph.\\n\\n PELVIS: There is normal mineralization. No focal lesions are present. No\\n fractures, effusions, or dislocations are seen. Small brachy therapy seeds\\n are seen. The joint spaces are preserved. The soft tissues are normal.\\n Sclerosis of the weight bearing areas of the acetabulum is noted.\\n\\n IMPRESSION: No evidence of fracture or dislocation.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2174-03-05 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 817442,\n \"text\": \" 11:37 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: Eval for interval change\\n Admitting Diagnosis: LEFT SUBDURAL HEMATOMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man s/p evacuation l SDH\\n\\n REASON FOR THIS EXAMINATION:\\n Eval for interval change\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post evacuation of subdural hemorrhage. Evaluate for\\n interval change.\\n\\n TECHNIQUE: Noncontrast head CT.\\n\\n COMPARISONS: Noncontrast head CT of .\\n\\n FINDINGS: Again seen is a left sided craniotomy and a subdural drain. A tiny\\n left sided residual subdural hemorrhage remains. There continues to be a\\n moderate amount of mass effect with slight compression of the left lateral\\n ventricle and loss of left-sided sulci. Within the posterior left temporal\\n lobe, there is an area of subtle hypodensity with surrounding hyperdensity\\n which may represent edema with possible small amount of subarachnoid blood. No\\n new areas of intra axial or extra axial hemorrhage is identified. There\\n continues to be a small amount of pneumocephalus within the left frontal area.\\n There is no evidence of hydrocephalus. There continues to be air fluid levels\\n within the ethmoid and right sphenoid sinus. The soft tissues and osseous\\n structures remain unchanged.\\n\\n IMPRESSION:\\n\\n 1) Stable appearance of residual left sided subdural hemorrhage with mass\\n effect.\\n 2) Subtle area of hypodensity with surrounding hyperdensity within the left\\n posterior temporal lobe which may represent edema with a small amount of\\n subarachnoid hemorrhage. An evolving infarction again is also a possibility\\n and follow up is recommended.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2174-03-05 00:00:00.000\",\n \"description\": \"CHEST (SINGLE VIEW)\",\n \"row_id\": 817443,\n \"text\": \" 11:46 AM\\n CHEST (SINGLE VIEW) Clip # \\n Reason: r/o pneumonia\\n Admitting Diagnosis: LEFT SUBDURAL HEMATOMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with tachypnea\\n REASON FOR THIS EXAMINATION:\\n r/o pneumonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Tachypnea, rule out pneumonia.\\n\\n CHEST, SINGLE AP VIEW.\\n\\n There is mild cardiomegaly. There is upper zone redistribution and mild\\n diffuse vascular blurring. There is patchy increased retrocardiac density.\\n No effusion.\\n\\n IMPRESSION: Cardiomegaly. Probable mild CHF. Patchy retrocardiac density\\n consistent with left lower lobe collapse and/or consolidation.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2174-03-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1321039,\n \"text\": \"1am - 7 am Micu Progress Note\\n\\nBriefly pt is a 74 yo male who was transferred from SICU to MICU A on . Pt admitted to on s/p mva. Pt was unrestrained driver who hit his head on the windshield. Ambulatory at scene, but while sitting on curb became unresponsive. Taken To St E hospital where he was intubated and CT showed a lg subdural hematoma. Transferred to . On pt underwent evacuation of r subudural. JP drain placed. Pt experienced some R sided weakness. Extub on and JP drain dcd on .\\n\\nNeuro - Pt alert and oriented, MAE. Equal strength in all exts. PERL. No sz activity noted. Rx with 100 mg dilantin iv q8hrs. Dilantin level 13.6 today. Plan is for repeat head CT today.\\n\\nC-V - HR 80-90 NSR. BP 120-140/44-60 via ABP. Pt s/p nipride infusion. Rx with iv hydralazine and lopressor. + palp peripheral pulses. Hct stable at 38.2.\\n\\nResp - LS clear. On RA ABG 7.50/28/107/0/23. RR 20-25. 02 sats > 96%.\\n\\nGI - Abd soft. +BS. Tolerating liquids without difficulty.\\n\\nF/E - Urine output 20-130ccs/hr via foley cath. Rx with 40 meq kcl po tid x 24 hrs. K 3.9 this am.\\n\\nID - Max temp 100.1 po. WBC 8.3, previously 10.4. Rx with 1 gm iv kefzol q 8hrs.\\n\\nSkin - Head dssg d+i.\\n\\nA+P - Continue to monitor neuro status closely. ? repeat head CT this am. ? call-out to floor if pt remains stable.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2174-03-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1321040,\n \"text\": \"addendum - Phos 1.3 - pt to receive k-phos 15 mmol/250 ns.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2174-03-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1321036,\n \"text\": \"nsg note\\nneuro: pt arouses easily to voice but falls asleep immediately when not stimulated oriented times three denies headache or any discomfor. mae to command pupils equal and recting.\\n\\npt with stable bp <130 until 330am then bp climing to 140's given hydralazine, lopressor and then placed on nipride gtt. titrated up to .8 mcgs this am.hr 80's nsr.\\nuo qs temp max 100.9 blood and urine cultures sent.\\npts lytes repleted this am potassium, phosphat, ca gluc and mg so4.\\nivf at 80 ccs per hr.\\np pt to satart po.s and bp control can be liberalized to 150.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2174-03-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1321037,\n \"text\": \"T/SICU NPN-\\nBrief ROS:\\n Pt. has been appropriate all shift. Completely cooperative and communicative all shift. MAE. Pupils equal and reactive. Denies pain.Pt. went for a repeat CT scan of his head this am, not improved from yesterday- will need to remain the T/SICU over night.\\n\\nCV- SBP stable since discontinuing nipride this am. He was started on IV hydralazine and metoprolol q 6 hr rather than prn. HR stable, sinus without ectopy. Repleted potassium this afternoon, po. IV potassium boluses uncomfortable at site for pt. He had a bld gas K+ of 2.1 and the following serum K+ was 3.5, in the interim he rcv'd 40meq KCl x 2.\\nSkin warm and dry. Minimal periph edema. Palpable periph pulses.\\n\\nResp- Remains on rm air, adequate sats this shift. Resp rate in the 20's. Coughs and deep breaths, productive cough. BS are reletively clear. Bld gas is unchanged.\\n\\nEndo- Has not required insulin coverage this shift.\\n\\nGI- Started a diet this am, has tolerated diet well all day. Drinking ample amts of liquids all shift. Abd soft, NT with bowel sounds. No BM's this shift, he did have some flatus.\\n\\nGU- Making adequate amts of urine via foley.\\n\\nID- Low grade temp. No abx in progress. Urine culture sent today.\\n\\nInteg- . Head drsg and .\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2174-03-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1321038,\n \"text\": \" 1900 -> 0100\\n\\nROS:\\n\\nNeuro: Alert oriented x's 4. Follows all commands. When asked to show me 2 thumbs he raised both arms. When I showed him what I wanted him to do he was then able to show me two thumbs. PEARRLA. Denies numbness/tinglining in extremities. Hand grasps strong and equal. Dorsi plantor/flexion strong and equal. Speach clear. Crani dressing clean dry and . No seizure activity noted. ON dilantin q 8 hr.\\n\\nCV: RSR no ectopy. VSS. Receiving scheduled lopressor and hydralazine ivp for HTN management. S1S2. No edema. Skin warm dry and pink. Peripheral pulses strong and =. On heparin q 12hr sub q. Compression sleves on bilat.\\n\\nResp: Resp rate even and non labored. Equal rise and fall of chest. No resp distress noted. ON room air sao2 95-98 %.\\n\\nGU: Foley cath patent draining clear yellow urine in amt sufficiant.\\n\\nGI: Abd soft w/active BS. Taking in po diet w/o c/o difficulties swallowing or nausea.\\n\\nTransfered to MICU A\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2174-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1321032,\n \"text\": \"S/P MVC-HEAD TRAUMA SDH EVAC.-T/SICU NPN 7-3P\\nS-\\\"SABASTINO DANICO.HOSPITAL, FRIDAY\\\"\\nO-NEURO-PT AROUSES TO VOICE OPENS EYES FOLLOWS COMMANDS MAE'S,PERRLA 3MM,CALM COOPERATIVE.STRONG COUGH + GAG.A+O X 3 CURRENTLY.SUBDURAL JP DRAINING SM AMT BLOODY DRAINAGE.C-SPINE PREC. MAINT'D,TLS CLEARED THIS PM BY DR ,CT HEAD AND C SPINE THIS AM.\\nCV-PT REMAINS ON SNP GTT TO KEEP SBP <140, SNP GTT @.2-1 MCG/KG/MIN,HYDRALIZINE IVP 10MG ADDED THIS PM NOW ABLE TO WEAN SNP GTT,3+DP/PT .HR 60'S-70'S NSR NO VEA,LYTES REPLETED PRN.\\nRESP-PT ON THIS AM ABG WNL,PT W/ OUT DIFF @ 11AM,INITIALLY ON 50% COOL NEB,O2 SAT 99-100%,NOW ON RA O2 SATS 95-98%.RR 20-30.NARD.PT DENIES SOB.\\nGI/GU-NPO,OGT DC'D ON EXTUBATION,SM AMTS BILIOUS VIA OGT,ABD SOFT ABSENT BS,NO N/V NOTED,U/O ADEQ AMTS CLEAR YELLOW URINE VIA FOLEY CATH.\\nSKIN-HEAD DSGS CDI,PT BACK + BUTTOCK GROSSLY INTACT.\\n BROTHER CALLED THIS AM, BROTHER (SPOKESPERSON) VISITED THIS PM,SPOKE W/ DR PM. BROTHER EXPRESSING CONCERN OVER TIME FROM ACCIDENT-> SURGICAL INTERVENTION.\\nENDO-BS 144 NO SS COVERAGE/ORDERS.\\nID-AFEBRILE.CONT'S ON CEFAZ IV Q8HR.\\nA-NEURODYNAMICALLY STABLE\\nP-NEURO CHECKS,VS,ANTIHYPERTENSIVES/ORDERS,TITRATE TO SBP<140,O2 PRN,I+O,MONITOR SKIN INTEGRITY QS AND PRN,FAMILY SUPPORT PRN.FSBS,IV ABX/ORDERS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2174-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1321033,\n \"text\": \"SOCIAL WORK\\nSW contact pts brother by phone to introduce role of sw and for support. states that he was in to visit briefly earlier and had all his questions answered by MD. Explained role of SW and offered support as needed. not interested in SW involvement at this time. Contact info for SW provided. I am available to meet with family as indicated. Pg .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2174-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1321034,\n \"text\": \"RESPIRATORY CARE: PT. THIS AM\\nAFTER CT SCAN AND TLS FILMS. RSBI 80 AND\\nGOOD ABG ON . TO 50 % AEROSOL\\nMASK. DOING WELL.\\n\\n , RRT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2174-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1321035,\n \"text\": \"D: See data, MD notes/orders. Neuro: Pt sleeping unless stimulated, wakes easliy to verbal stimuli and is A&Ox3. Recognizes family members, mae with equal strength, follows commands. Perrl. JP drain removed this pm by Dr. with two sutures placed and incisions redressed. CV: SR/no etopy. SBP teens when sleeping 120-130 range when awake. Previous nipride gtt weaned to off, pt restarted on po norvasc. Prn hydralzine/metoprol utilized to keep sbp <130. Pulm: on room air, lungs clear, decreased at bases. 02 sats 95-97%. GU: foley draining clear yellow urine to gravity at >50cc/hr. GI: Abd flat, bs +, pt taking sow without difficulty.Endo: Per ssc Skin: grossly intact, 3+peripheral pulses x4. Soc: Several brothers in this evening, very attentive, have many questions re: current condition and outcome.\\nP: Q2hr neuro checks, observe for s/s blood reaccumultation. Tylenol for temp, ?need for blood cx, continue abx as ordered. Notify team of unresolved or increased temp. Keep sbp 130 or less. Keep family updated on plan of care, direct to sicu team in am prn.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2174-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1321029,\n \"text\": \"Admission note: 74 yo male admitted at 2115 from OR per bed to post evacuation of right subdural hematoma post MVC. Connected to monitor and vent. Initial assessment completed (see flow record for details of that assessment).\\n\\nROS:\\n\\nNeuro: Sedate ? anasthesia residual?? Becoming lighter as shift progresses. Inconsistant b/t hourly neuro exams. PEARLA. At times slight attempts made to open eyes, eyes open slightly. Eyes deviate upward and at times to the right. Cough, gag, and corneal reflex +. Crani dressing clean dry and intact. JP drains bright red to less bright red fluid as shift progresses in amt 45 -> 80 cc/hr. amt decreasing as shift progresses. Neuro resident EJ and MD aware. DRAIN COMPRESSED W/THUMB PRINT SUCTION ONLY. Moving all extremites at random,RUE less then all others. Withdrawls all except RUE to nailbed presure. Moves RUE to chest wall pinching and only after much stimuli, this too is inconsistant b/t hourly neuro exams. Log role precautions maintained at all times. Head in neut allignment w/ on. Log roled w/3 person assist, one to immobilize head.\\n\\nResp: Intubated and on Vent, SIMV 800x12, peep 5, ps 5, 40%. ABGs pH 7.42, pco2 37, po2 160. Pco2 goal 35-40. Lung sounds clear thoughout. Sx x's 1 w/o any sputum obtained. Equal rise and fall of chest. No resp distress noted. SaO2 100%.\\n\\nCV: Sinus rhythm no ectopy. S1S2. Right radial ABP. Peripheral pulses strong and =. Warm, dry, and pink. SBP 110 -> 180. Nipride gtt titrated to keep SBP < 130. Nipride at 0.05 mcg/kg/min (please note flow record indicates 0.1 mcg/kg/min as system rounds up). Heparin to begin this AM. Compression sleves on bilat legs. IV access limited to peripheral sites only.\\n\\nGI: Oral sump to LCS draining bile colored fluid. Abd soft w/hypoactive BS. No flatus noted. Receiving protonix.\\n\\nGU: Foley patent draining clear yellow urine in amt sufficant.\\n\\nLabs: K=2.9 repleated w/20 KCL, Mg=1.6 repleated w/2 gm Mgso4. Accuchecks not requiring SSI coverage.\\n\\nPlan: CT head today. Attempt to wean and potentially extubate today???\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2174-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1321030,\n \"text\": \"Update 0600\\n\\nAwake, following commands w/all extremities. Nods head and mouths words to answere questions asked.\\n\\nRSBI: 47.5. Spontanious Breathing Trial started @ 0600 check ABGs at 0800.\\n\\nSBP ^ w/vent changes. Nipride titrating ^ to keep SBP < 130\\n\\nK+ 3.4 waiting for dose of KCL from pharmacy\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2174-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1321031,\n \"text\": \"RESP CARE NOTE\\nPT RECEIVED FROM O.R. S/P EVAC OF R SDH. PLACED ON IN SIMV/PS MODE. PT STABLE SXN FOR SM AMT THIN SEC. BS DECR CTA BILAT. AM ABG REFLECTS NORMAL ACID BASE W/HYPEROXIA, RSBI 47.5. SBT STARTED @ 0600. PLAN TO ASSESS FOR POSS EXTUBATION PENDING SUCCESSFUL COMPLETION OF SBT.\\n\"\n }\n]"}}},{"rowIdx":24695,"cells":{"subject_id":{"kind":"number","value":30374,"string":"30,374"},"hadm_id":{"kind":"number","value":110926,"string":"110,926"},"target_text":{"kind":"string","value":"A/P: 88 yo F with Alzheimer's dementia p/w a fall resulting in a hip fx, s/p hemiathroplasty, complicated by C. diff infection. She was transferred to MICU w/ hypoxic respiratory failure 2' to evolving MI, CHF, and pulmonary edema. Poor prognosis and level of consciousness. She was made CMO per family meeting on , and passed away on while on the medicine floor on . . # R hip fracture: associated w/ fall at rehab. s/p R hip arthroplasty. Unable to assess pain due to decreased mental status. Morphine PO was given for pain and continued with code status was made CMO. . # Acute myocardial infarction. Pt suffered an MI that was likely the cause of her tachypnea. She ruled in with positive troponin and MBI; she had ECG changes (ST elevation in III and aVF). She had a peak Troponin of 1.01 She was managed medically w/ Lovenox, plavix, B-, . All of her medications were d/c-ed with her code status change to CMO. . # Tachypnea/Volume Overload/Pulmonary Edema. Likely related to acute MI, leading to CHF and pulmonary edema. Pt was oxygenating and ventilating well in the MICU, but had very poor mental status. She did have a significant non-gap metabolic acidosis, could be contributing as source of increased ventilation. She was managed for her MI as above. Her acidosis was corrected by lactated ringers and free water boluses 400cc q4h to reduce hypercholemic acidosis. She was also treated w/ gentle diuresis. With her changed to CMO status, her diuresis was stopped. The patient was placed on morphine PO. . # C.diff colitis: Likely related to peri-operative antibiotics. She was started PO vancomycin due to her worsening mental status. With the change in her CMO status, the antibiotic was stopped. . # Depressed mental status/decreased responsiveness: Pt had dementia with subacute delerium. Over her hospital stay, she became less responsive. She waxed and waned in her mental status, which was likely delerium related to her MI and infection. With her multiple medical problems and her progressing non-responsive mental status, her prognosis was deemed extremely poor. A family meeting was held, code status was changed to CMO. She was given Morphine and Zydis PRN for agitation. . # Leukocytosis. Likely related to significant C.diff, plus UTI, plus possible MI. Worsened despite C.diff treatment. D/C-ed antibiotics with change in code status. . # UTI. E.coli related. No antibiotics w/ change in code status to CMO. . # Hypernatremia. Likely due to intravascular volume depletion and diuresis. She received free water via NGT 400ml q4h, with a calculated free water deficit to 1.5 L. With her CMO status, her labs were d/c-ed and she stopped receiving water through her NGT. . # Dementia. Advanced. Held antipsychotics given depressed mental status and change in CMO status. . # Atrial fibrillation. Irregularly irregular on floor during exam, reverted to sinus w/ PACs. Nursing reports brief episodes of tachycardia to 160s. With her CMO status, her tele and vital signs were d/c-ed. . # Depression: CMO as above, no meds. . # FEN: NPO given poor mental status and CMO. # PPx: All d/c-ed as patient is CMO. # Access: PIV d/c-ed w/ CMO status. # Dispo: Expired while in hospital. Death Certificate filled out. . # Code: CMO on after discussion with son and daughter () (power of attn) . Medications on Admission: 81mg daily Pepto-Bismol q4-6hrs prn Celexa 20mg daily Colace 100mg Namenda 5mg daily Vitamin E 400units daily Oxazepam 15mg prn Milk of Mag"},"extractive_notes_summ":{"kind":"string","value":"albuterol neb prn. resps even + appear unlabored post-neb treatment. vanco & flagyl for CDiff, ceftriaxone for UTI.MSKLT: s/p right hemiarthroplasty ; pt. upper & LE pitting edema. Is on lovenox sq/asa/ plavix/lopressor as medical managment of MI, also compression sleeves on.RESP: LS currently are clear-diminished from bil. Top normal/borderline dilated LV cavitysize. NGT D/C'd. LS rales 1/2 up, diminished apices. for CDiff- on vanco po & flagyl IV. U/L extremities. inc. RR, moaning, repos. Mild (1+) aortic regurgitationis seen. Palliative care consult ordered. areas of ecchymosis and errythema to bil. conts w/ + bil. Mild mitral annularcalcification. + Cdiff- on no abx. Consider posterior myocardialinfarction. Mild regional LV systolic dysfunction. UTI, on ceftriaxone IV. aertgqeart There is mild regional left ventricular systolicdysfunction with inferior/inferolateral hypokinesis. There ismild aortic valve stenosis (area 1.2-1.9cm2). UE's. ortho following & are aware of use of plavix/asa/lovenox. LS coarse/wheezes. Sinus rhythm at upper limits of normal rate. Consider inferior myocardial infarctionof indeterminate age. abx. hx. & fam. The left ventricular cavity size is topnormal/borderline dilated. To have TTE in am. distress & pos. K+ of 3.3 repleted w/ 60 meq and MG+ of 1.7 repleted w/ 2 gm IV. The tricuspid valve leaflets are mildlythickened. Sinus rhythm. Sinus rhythm. Mild to moderate(+) mitral regurgitation is seen. Mildly depressed LVEF. There is mild symmetric leftventricular hypertrophy. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. at this time.SKIN: is thin, areas of ecchymosis and errythema on bil upper and lower extremities. + bil. Short P-R interval. PRN IV morphine and ativan ordered. CKs trendind down.Resp- RR 20s. family determined POC would be CMO- remains in CCU although is called -out to floor on po prn morphine/zyprexa.S: unresponsiveO: please see careview for all objective data.ACV: HR NSR w/ freq. Frequently assess pt's comfort and medicate PRN. T waveabnormalities are more prominent.TRACING #1 Mildly dilated ascendingaorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). right hip dsg changed.PAIN/MSKLT: given po morphine freq. cont. Purposeful mvts on L side. Early R wave progression. The ascending aorta ismildly dilated. Mild AS (AoVA1.2-1.9cm2). distress w. ekg changes and elevated CE's. upper and LE pitting edema from feet to thighs. alzheimer's dementia @ rehab, w. diminishing ms on floor, now mostly unresponsive.GI: ng tube placed to right nare; placement confirmed by cxray/MD. PATIENT/TEST INFORMATION:Indication: Myocardial infarction.Height: (in) 65Weight (lb): 195BSA (m2): 1.96 m2BP (mm Hg): 117/62HR (bpm): 76Status: InpatientDate/Time: at 12:11Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the report of the prior study (images notavailable) of .LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH. active bs x 4.GU: pos. no diuresis overnight.ID: afebrile overnight. +BSx4. Significant PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is moderately dilated. Mild to moderate (+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. +UTI- on no abx. Awaiting palliative care consult. emotional support to pt. to monitor resp/ pain status; prn morphine/zyprexa & albuterol nebs as needed. Nursing Note 7a-7pNeuro- Remains unresponsive.CV- SR-ST w/ freq PACs, HR 80s-110. active bs x 4. ST-T wave abnormalities are moremarked.TRACING #2 crackles 1/3 up from bil. Per notes- to get LR if needs volume acidosis.NEURO: primarily unresponsive overnight; groaning w. placement of NG tube and repos. npo; active bs x4. distress requiring trxfr to CCU as MICU border () also w. MI discovered in setting of resp. IV morphine/ativan changed to PO morphine and zyprexa. Since the previoustracing of the Q wave in lead aVF is more prominent. SPO2 97% 4LNC.GI-NGT removed. taking po morphine; freq. There is borderline pulmonary artery systolic hypertension.Significant pulmonic regurgitation is seen. pac's. Within normal limits. No restingLVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -hypo;AORTA: Normal aortic diameter at the sinus level. No iv access.Resp- Conts on 2L nc w/ sat >95%, LS w/ crackles bibasilary. NPO. status. RR 20's, w. resps appear. to monitor card & resp. NBP remains 111-117/50's. PM lopressor dose held SBP <90. Called out to medical floor. palliative care also consulted & following. continue skin & incision care/turn & repos. 4 L NC w. sats > 93%.GI: CDiff prec. dementia admit from Rehab s/p fall w. hip fx; rec'd hemiarthroplasty ; post-op course c/b CDiff & now w/ UTI and s/p resp. Pos. Addendum To NPN 0700-1900PIV infiltrated. Call-out to floor when bed available or poss tnsf to hospice. NBPs 109-125/50s-60s. Mild [1+] TR.Borderline PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: No PS. All other meds D/Cd. continue to follow labs as able-phleb. monitor for further n Breathing appears unlabored.GI/GU- NPO, no bm. MI w/ EKG changes and elevated CE's.S: patient primarily unresponsive w/minimal groaning only.O: Please see careview for all objective data.A: CV: remained in NSR overnight w. frequent PAC'S. DSD applied.Access- PIVx one.PLAN- Call out to medical floor as CMO. 1.01. NPN 0700-1900S: Pt minimally responsive.O:Please see carevue for objective data and trends.CODE STATUS: After discussion and agreement among 3 children, decision made to change code status to comfort measures given poor long-term prognosis. Receiving free H20 boluses via NGTube to correct hypernatremia (Na+ 148). next wbc w. am labs; had been elevated per team may be from CDiff/UTI or MI. social work consult for family dynamics.CODE STATUS: DNR/DNI w. stipulations for central access, short-term pressors, shock ok for VT w/pulse/CV, but no chest compressions.PLAN: cont. overnight for various reasons incl. monitor for pain/ discomfort/sob. The aortic valve leaflets (3) are mildly thickened. Made CMO by family . BP 85-114/40'S-50s. bases. 88 YR OLD NSG HOME PT ,FELL AT NSG HOME ,FX R HIP.HEMIARTHROPLASTY .MS ,DEVELOPED CDIFF .PT TACHYPNEIC TODAY ON FLOOR ADMITTED TO MICU ,HAS RI FOR MI PROBABLY TODAY.HAS ALZHHEIMERS OX1 ONLY BUT INTERACTIVE,NOW VERY LETHARGIC UNABLE TO TAKE PO.IS DNR/DNI C SOME STIPULATIONS .HX FALLS,DEPRESSION,REFLUX,MACULAR DEGENERATION,HEARING LOSS.HAS ECOLI IN URINE,POSSIBLE PNA/CHF.ALSO POSSIBLE PERICARDIAL EFFUSSION ,ECHO TOMORROW,STAT IF HYPOTENSIVE .THREE CHILDREN,SON AND DAUGHTER CARE PROXY.PT MOANS WHEN MOVED ,OPENS EYES WHEN NAME CALLED.INCISION C STAPLES C/D R HIP.AFIB,HR 110 TO 80 SLOWED C IV LOPRESSER 5 MG.RECTAL ASA GIVEN.CARDIAC MEDS TO BE STARTED ONCE NG IN,LOVENOX STARTED .PT HAS ONLY 22 IV, NEED CENTRAL LINE,PICC.HAS HYPERNATREMIA.BS C WHEEZES ,SAT 99 4L NP .ABD SOFT,POS BS.HAS HAD DIARRHEA ON FLOOR.DIAPER IN PLACE ,SKIN INTACT .PERINUEM SL REDHUO 40 CC/HR.EXTREMITIES EDEMATOUS .FRAGILE ELDERLY WOMAN C FX,MI,POSSIBLE PNA.MONITOR FOR WORSENING RESP STATUS,BLEEDINGRECHECK LYTESPLACE NG TUBESKIN CARE"},"n_notes":{"kind":"number","value":13,"string":"13"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2104-09-01 00:00:00.000","description":"Report","row_id":1653404,"text":"88 YR OLD NSG HOME PT ,FELL AT NSG HOME ,FX R HIP.HEMIARTHROPLASTY .MS ,DEVELOPED CDIFF .PT TACHYPNEIC TODAY ON FLOOR ADMITTED TO MICU ,HAS RI FOR MI PROBABLY TODAY.HAS ALZHHEIMERS OX1 ONLY BUT INTERACTIVE,NOW VERY LETHARGIC UNABLE TO TAKE PO.IS DNR/DNI C SOME STIPULATIONS .HX FALLS,DEPRESSION,REFLUX,MACULAR DEGENERATION,HEARING LOSS.HAS ECOLI IN URINE,POSSIBLE PNA/CHF.ALSO POSSIBLE PERICARDIAL EFFUSSION ,ECHO TOMORROW,STAT IF HYPOTENSIVE .THREE CHILDREN,SON AND DAUGHTER CARE PROXY.\n\nPT MOANS WHEN MOVED ,OPENS EYES WHEN NAME CALLED.INCISION C STAPLES C/D R HIP.\nAFIB,HR 110 TO 80 SLOWED C IV LOPRESSER 5 MG.RECTAL ASA GIVEN.CARDIAC MEDS TO BE STARTED ONCE NG IN,LOVENOX STARTED .PT HAS ONLY 22 IV, NEED CENTRAL LINE,PICC.HAS HYPERNATREMIA.\n\nBS C WHEEZES ,SAT 99 4L NP .\n\nABD SOFT,POS BS.HAS HAD DIARRHEA ON FLOOR.DIAPER IN PLACE ,SKIN INTACT .PERINUEM SL RED\n\nHUO 40 CC/HR.EXTREMITIES EDEMATOUS .\n\nFRAGILE ELDERLY WOMAN C FX,MI,POSSIBLE PNA.\n\nMONITOR FOR WORSENING RESP STATUS,BLEEDING\nRECHECK LYTES\nPLACE NG TUBE\nSKIN CARE\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2104-09-02 00:00:00.000","description":"Report","row_id":1653405,"text":"Nursing Progress Note (1900-0700)\n88 yo female w. alzheimer's dementia admit from Rehab s/p fall w/ hip fracture & hemiarthroplasty ;later post-op course c/b CDiff, now transfered to CCU as MICU border () for resp. distress & pos. MI w/ EKG changes and elevated CE's.\n\nS: patient primarily unresponsive w/minimal groaning only.\nO: Please see careview for all objective data.\nA: CV: remained in NSR overnight w. frequent PAC'S. BP 85-114/40'S-50s. PM lopressor dose held SBP <90. Continuing to have increasing CE's at 7pm - CK 210, MB 21 and Trop. 1.01. Unable to collect CE's at 2 am- team aware. + bil. upper and LE pitting edema from feet to thighs. K+ of 3.3 repleted w/ 60 meq and MG+ of 1.7 repleted w/ 2 gm IV. Unable to voice c/o pain or CP. To have TTE in am. Is on lovenox sq/asa/ plavix/lopressor as medical managment of MI, also compression sleeves on.\n\nRESP: LS currently are clear-diminished from bil. apex to bases. RR 20's, w. resps appear. unlabored. O2sats 98-100% on 4 L nc. Per notes- to get LR if needs volume acidosis.\n\nNEURO: primarily unresponsive overnight; groaning w. placement of NG tube and repos. no response to voice stimulus. noted some purposeful hand grasp w. L hand, moves L arm off bed & moves left leg; no movement of right side noted. patient consistently tilts head to left side, and keeps left eye tightly shut which makes bil. pupil assessment difficult. hx. alzheimer's dementia @ rehab, w. diminishing ms on floor, now mostly unresponsive.\n\nGI: ng tube placed to right nare; placement confirmed by cxray/MD. Pos. for CDiff- on vanco po & flagyl IV. no diarrhea/stool overnight. active bs x 4.\n\nGU: pos. UTI, on ceftriaxone IV. urine in foley is dark amber. Receiving free H20 boluses via NGTube to correct hypernatremia (Na+ 148). no diuresis overnight.\n\nID: afebrile overnight. next wbc w. am labs; had been elevated per team may be from CDiff/UTI or MI. vanco & flagyl for CDiff, ceftriaxone for UTI.\n\nMSKLT: s/p right hemiarthroplasty ; pt. unable to express pain/discomfort at this time. ortho following & are aware of use of plavix/asa/lovenox. pillow placed between legs w. all turns.\n\nSKIN: paper -thin skin. areas of ecchymosis and errythema to bil. UE's. some red splotchy areas that are intact on thighs. barrier cream to heels/buttocks, etc.left hip surgical site- dressing intact w. small, unchanged area of dried yellow drainage.\n\nACCESS: left wrist #22 is only access. team to consider picc v. central line placement should further access become necessary. requires phlebotomy for venipunctures.\n\nSOCIAL: 3 children; 2 sons & 1 . Son from NJ in to visit & stayed overnight. team meeting to discuss plan/goals of care w. all family members together, as well as , would likely be helpful.? social work consult for family dynamics.\n\nCODE STATUS: DNR/DNI w. stipulations for central access, short-term pressors, shock ok for VT w/pulse/CV, but no chest compressions.\n\nPLAN: cont. to monitor card & resp. status. monitor for further n\n"},{"category":"Nursing/other","chartdate":"2104-09-02 00:00:00.000","description":"Report","row_id":1653406,"text":"Nursing Progress Note (1900-0700)\n(Continued)\neuro/ms changes. continue to follow labs as able-phleb. to collect am labs. continue skin & incision care/turn & repos. emotional support to pt. & fam. monitor for s/s pain/ discomfort. abx. as ordered. await further team/family plans for care.\n"},{"category":"Nursing/other","chartdate":"2104-09-02 00:00:00.000","description":"Report","row_id":1653407,"text":"NPN 0700-1900\nS: Pt minimally responsive.\n\nO:Please see carevue for objective data and trends.\n\nCODE STATUS: After discussion and agreement among 3 children, decision made to change code status to comfort measures given poor long-term prognosis. PRN IV morphine and ativan ordered. NGT D/C'd. All other meds D/Cd. Called out to medical floor. Team to reevaluate situation after 1-2 days and possibly D/C to ECF or hospice at that time. Social wk met w/ Son and Dtr to provide extra emotional support given pt's strained relations and altered family dynamics. Palliative care consult ordered. Rabbi in to see pt today at family's request.\n\nNeuro- Minimally responsive. Occasionally opening eyes to verbal and tactile stimuli. No mvt R side of body. Purposeful mvts on L side. Pupils @ 4mm bilat, brisk.\n\nCV- Tele w/ HR 80s NSR w/ freqent APCs, occas PVCs, episode HR up to 160s x 2 this am. Edema all 4 extremities- R arm weeping. CKs trendind down.\n\nResp- RR 20s. LS rales 1/2 up, diminished apices. SPO2 97% 4LNC.\n\nGI-NGT removed. +BSx4. Small green liquidy stool today.\n\nGU- Foley w/ dark brown urine.\n\nSkin- R hip dsg changed. Staples intact, site pink but not hot or swollen. DSD applied.\n\nAccess- PIVx one.\n\nPLAN- Call out to medical floor as CMO. Frequently assess pt's comfort and medicate PRN. Awaiting palliative care consult. Emotional support to pt and family.\n\n\n"},{"category":"Nursing/other","chartdate":"2104-09-02 00:00:00.000","description":"Report","row_id":1653408,"text":"Addendum To NPN 0700-1900\nPIV infiltrated. IV morphine/ativan changed to PO morphine and zyprexa. Awaiting availability from pharmacy. Palliative care physician in to see pt and 2 sons. readdress placement facility issues if needed in future.\n"},{"category":"Nursing/other","chartdate":"2104-09-03 00:00:00.000","description":"Report","row_id":1653409,"text":"Nursing Progress Note (1900-0700)\n88 yo female w. alzh. dementia admit from Rehab s/p fall w. hip fx; rec'd hemiarthroplasty ; post-op course c/b CDiff & now w/ UTI and s/p resp. distress requiring trxfr to CCU as MICU border () also w. MI discovered in setting of resp. distress w. ekg changes and elevated CE's. family determined POC would be CMO- remains in CCU although is called -out to floor on po prn morphine/zyprexa.\n\nS: unresponsive\nO: please see careview for all objective data.\nA\nCV: HR NSR w/ freq. pac's. NBP remains 111-117/50's. 4 + pitting edema to all 4 extremeties; R arm weeping. no further labs to be collected.\n\nRESP: RR 18-22 overnight; breaths appear even and unlabored. crackles 1/3 up from bil. bases. continues on 2 L via NC w. sats 96-99%.\n\nGI: no stool overnight. NPO. active bs x 4. + Cdiff- on no abx. @ this time.\n\nGU: foley in, patent, draining dark brown urine. +UTI- on no abx. at this time.\n\nSKIN: is thin, areas of ecchymosis and errythema on bil upper and lower extremities. right hip dressing remains intact overnight.\n\nACCESS: none\n\nSOCIAL: social work following family given some strained dynamics between siblings, although appears all are in agreement w. current POC. palliative care also consulted & following. placement to facility will be discussed if required.\n\nPLAN: CMO- called out to floor. cont. to monitor resp/ pain status; prn morphine/zyprexa & albuterol nebs as needed. emotional support to patient and family.\n"},{"category":"Nursing/other","chartdate":"2104-09-03 00:00:00.000","description":"Report","row_id":1653410,"text":"Nursing Note 7a-7p\nNeuro- Remains unresponsive.\nCV- SR-ST w/ freq PACs, HR 80s-110. NBPs 109-125/50s-60s. No iv access.\nResp- Conts on 2L nc w/ sat >95%, LS w/ crackles bibasilary. Breathing appears unlabored.\nGI/GU- NPO, no bm. Voiding 20-30cc/hr brown urine via foley.\nID- Conts on C-diff precautions, no abx.\nSkin- 4+ pitting edema bil U/L extremities.\nA/P- 88yo female s/p hip fx c/b c-diff, uti, resp distress-> +MI. Made CMO by family . Call-out to floor when bed available or poss tnsf to hospice. Cont plan of care, support family.\n"},{"category":"Nursing/other","chartdate":"2104-09-04 00:00:00.000","description":"Report","row_id":1653411,"text":"Nursing Progress Note (1900-0700)\n88 yo female, unresponsive w/ recent peri-operative MI now CMO status awaiting bed on floor w/ potential for transfer to hospice.\n\nS: unresponsive\nO: please see careview for all objective data.\nCV: HR 80s-low 100's SR/ST w. PVC's/PAC's. SBP > 100/ 50'60s. conts w/ + bil. upper & LE pitting edema. no IV access and no labs collected.\nRESP: RR 13-25 overnight. LS coarse/wheezes. albuterol neb prn. resps even + appear unlabored post-neb treatment. 4 L NC w. sats > 93%.\nGI: CDiff prec. but no bm overnight. npo; active bs x4. taking po morphine; freq. mouth swab to keep oral cavity moist/ assess swallow.\nGU: foley patent draining clear, brown urine.\nSKIN: thin, tight skin edema, w. some areas errythema & ecchymosis on bil. U/L extremities. right hip dsg changed.\nPAIN/MSKLT: given po morphine freq. overnight for various reasons incl. inc. RR, moaning, repos. - see careview for details.\nSOCIAL: supportive son in to visit & slept in ICU waiting room overnight.\n\nPLAN: CMO & awaiting bed on floor. monitor for pain/ discomfort/sob. provide emotional support to patient & family.\n\n"},{"category":"Echo","chartdate":"2104-09-02 00:00:00.000","description":"Report","row_id":96433,"text":"PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction.\nHeight: (in) 65\nWeight (lb): 195\nBSA (m2): 1.96 m2\nBP (mm Hg): 117/62\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 12:11\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline dilated LV cavity\nsize. Mild regional LV systolic dysfunction. Mildly depressed LVEF. No resting\nLVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo;\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild AS (AoVA\n1.2-1.9cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nBorderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS. Significant PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity size is top\nnormal/borderline dilated. There is mild regional left ventricular systolic\ndysfunction with inferior/inferolateral hypokinesis. Overall left ventricular\nsystolic function is mildly depressed (LVEF= 50 %). The ascending aorta is\nmildly dilated. The aortic valve leaflets (3) are mildly thickened. There is\nmild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic regurgitation\nis seen. The mitral valve leaflets are mildly thickened. Mild to moderate\n(+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. There is borderline pulmonary artery systolic hypertension.\nSignificant pulmonic regurgitation is seen. There is no pericardial effusion.\n\nCompared with the report of the prior study (images unavailable for review) of\n, left ventricular systolic dysfunction is new.\n\n\n"},{"category":"ECG","chartdate":"2104-09-01 00:00:00.000","description":"Report","row_id":265800,"text":"Sinus rhythm at upper limits of normal rate. Since the previous tracing\nearlier the same date the rate has increased. ST-T wave abnormalities are more\nmarked.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2104-09-01 00:00:00.000","description":"Report","row_id":265801,"text":"Sinus rhythm. Short P-R interval. Consider inferior myocardial infarction\nof indeterminate age. Early R wave progression. Consider posterior myocardial\ninfarction. There are other ST-T wave abnormalities. Since the previous\ntracing of the Q wave in lead aVF is more prominent. T wave\nabnormalities are more prominent.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2104-08-25 00:00:00.000","description":"Report","row_id":265802,"text":"Sinus rhythm. Within normal limits.\n\n"},{"category":"Nursing","chartdate":"2104-09-04 00:00:00.000","description":"Nursing Progress Note","row_id":332699,"text":"aertgqeart\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2104-09-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1653404,\n \"text\": \"88 YR OLD NSG HOME PT ,FELL AT NSG HOME ,FX R HIP.HEMIARTHROPLASTY .MS ,DEVELOPED CDIFF .PT TACHYPNEIC TODAY ON FLOOR ADMITTED TO MICU ,HAS RI FOR MI PROBABLY TODAY.HAS ALZHHEIMERS OX1 ONLY BUT INTERACTIVE,NOW VERY LETHARGIC UNABLE TO TAKE PO.IS DNR/DNI C SOME STIPULATIONS .HX FALLS,DEPRESSION,REFLUX,MACULAR DEGENERATION,HEARING LOSS.HAS ECOLI IN URINE,POSSIBLE PNA/CHF.ALSO POSSIBLE PERICARDIAL EFFUSSION ,ECHO TOMORROW,STAT IF HYPOTENSIVE .THREE CHILDREN,SON AND DAUGHTER CARE PROXY.\\n\\nPT MOANS WHEN MOVED ,OPENS EYES WHEN NAME CALLED.INCISION C STAPLES C/D R HIP.\\nAFIB,HR 110 TO 80 SLOWED C IV LOPRESSER 5 MG.RECTAL ASA GIVEN.CARDIAC MEDS TO BE STARTED ONCE NG IN,LOVENOX STARTED .PT HAS ONLY 22 IV, NEED CENTRAL LINE,PICC.HAS HYPERNATREMIA.\\n\\nBS C WHEEZES ,SAT 99 4L NP .\\n\\nABD SOFT,POS BS.HAS HAD DIARRHEA ON FLOOR.DIAPER IN PLACE ,SKIN INTACT .PERINUEM SL RED\\n\\nHUO 40 CC/HR.EXTREMITIES EDEMATOUS .\\n\\nFRAGILE ELDERLY WOMAN C FX,MI,POSSIBLE PNA.\\n\\nMONITOR FOR WORSENING RESP STATUS,BLEEDING\\nRECHECK LYTES\\nPLACE NG TUBE\\nSKIN CARE\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2104-09-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1653405,\n \"text\": \"Nursing Progress Note (1900-0700)\\n88 yo female w. alzheimer's dementia admit from Rehab s/p fall w/ hip fracture & hemiarthroplasty ;later post-op course c/b CDiff, now transfered to CCU as MICU border () for resp. distress & pos. MI w/ EKG changes and elevated CE's.\\n\\nS: patient primarily unresponsive w/minimal groaning only.\\nO: Please see careview for all objective data.\\nA: CV: remained in NSR overnight w. frequent PAC'S. BP 85-114/40'S-50s. PM lopressor dose held SBP <90. Continuing to have increasing CE's at 7pm - CK 210, MB 21 and Trop. 1.01. Unable to collect CE's at 2 am- team aware. + bil. upper and LE pitting edema from feet to thighs. K+ of 3.3 repleted w/ 60 meq and MG+ of 1.7 repleted w/ 2 gm IV. Unable to voice c/o pain or CP. To have TTE in am. Is on lovenox sq/asa/ plavix/lopressor as medical managment of MI, also compression sleeves on.\\n\\nRESP: LS currently are clear-diminished from bil. apex to bases. RR 20's, w. resps appear. unlabored. O2sats 98-100% on 4 L nc. Per notes- to get LR if needs volume acidosis.\\n\\nNEURO: primarily unresponsive overnight; groaning w. placement of NG tube and repos. no response to voice stimulus. noted some purposeful hand grasp w. L hand, moves L arm off bed & moves left leg; no movement of right side noted. patient consistently tilts head to left side, and keeps left eye tightly shut which makes bil. pupil assessment difficult. hx. alzheimer's dementia @ rehab, w. diminishing ms on floor, now mostly unresponsive.\\n\\nGI: ng tube placed to right nare; placement confirmed by cxray/MD. Pos. for CDiff- on vanco po & flagyl IV. no diarrhea/stool overnight. active bs x 4.\\n\\nGU: pos. UTI, on ceftriaxone IV. urine in foley is dark amber. Receiving free H20 boluses via NGTube to correct hypernatremia (Na+ 148). no diuresis overnight.\\n\\nID: afebrile overnight. next wbc w. am labs; had been elevated per team may be from CDiff/UTI or MI. vanco & flagyl for CDiff, ceftriaxone for UTI.\\n\\nMSKLT: s/p right hemiarthroplasty ; pt. unable to express pain/discomfort at this time. ortho following & are aware of use of plavix/asa/lovenox. pillow placed between legs w. all turns.\\n\\nSKIN: paper -thin skin. areas of ecchymosis and errythema to bil. UE's. some red splotchy areas that are intact on thighs. barrier cream to heels/buttocks, etc.left hip surgical site- dressing intact w. small, unchanged area of dried yellow drainage.\\n\\nACCESS: left wrist #22 is only access. team to consider picc v. central line placement should further access become necessary. requires phlebotomy for venipunctures.\\n\\nSOCIAL: 3 children; 2 sons & 1 . Son from NJ in to visit & stayed overnight. team meeting to discuss plan/goals of care w. all family members together, as well as , would likely be helpful.? social work consult for family dynamics.\\n\\nCODE STATUS: DNR/DNI w. stipulations for central access, short-term pressors, shock ok for VT w/pulse/CV, but no chest compressions.\\n\\nPLAN: cont. to monitor card & resp. status. monitor for further n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2104-09-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1653406,\n \"text\": \"Nursing Progress Note (1900-0700)\\n(Continued)\\neuro/ms changes. continue to follow labs as able-phleb. to collect am labs. continue skin & incision care/turn & repos. emotional support to pt. & fam. monitor for s/s pain/ discomfort. abx. as ordered. await further team/family plans for care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2104-09-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1653407,\n \"text\": \"NPN 0700-1900\\nS: Pt minimally responsive.\\n\\nO:Please see carevue for objective data and trends.\\n\\nCODE STATUS: After discussion and agreement among 3 children, decision made to change code status to comfort measures given poor long-term prognosis. PRN IV morphine and ativan ordered. NGT D/C'd. All other meds D/Cd. Called out to medical floor. Team to reevaluate situation after 1-2 days and possibly D/C to ECF or hospice at that time. Social wk met w/ Son and Dtr to provide extra emotional support given pt's strained relations and altered family dynamics. Palliative care consult ordered. Rabbi in to see pt today at family's request.\\n\\nNeuro- Minimally responsive. Occasionally opening eyes to verbal and tactile stimuli. No mvt R side of body. Purposeful mvts on L side. Pupils @ 4mm bilat, brisk.\\n\\nCV- Tele w/ HR 80s NSR w/ freqent APCs, occas PVCs, episode HR up to 160s x 2 this am. Edema all 4 extremities- R arm weeping. CKs trendind down.\\n\\nResp- RR 20s. LS rales 1/2 up, diminished apices. SPO2 97% 4LNC.\\n\\nGI-NGT removed. +BSx4. Small green liquidy stool today.\\n\\nGU- Foley w/ dark brown urine.\\n\\nSkin- R hip dsg changed. Staples intact, site pink but not hot or swollen. DSD applied.\\n\\nAccess- PIVx one.\\n\\nPLAN- Call out to medical floor as CMO. Frequently assess pt's comfort and medicate PRN. Awaiting palliative care consult. Emotional support to pt and family.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2104-09-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1653408,\n \"text\": \"Addendum To NPN 0700-1900\\nPIV infiltrated. IV morphine/ativan changed to PO morphine and zyprexa. Awaiting availability from pharmacy. Palliative care physician in to see pt and 2 sons. readdress placement facility issues if needed in future.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2104-09-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1653409,\n \"text\": \"Nursing Progress Note (1900-0700)\\n88 yo female w. alzh. dementia admit from Rehab s/p fall w. hip fx; rec'd hemiarthroplasty ; post-op course c/b CDiff & now w/ UTI and s/p resp. distress requiring trxfr to CCU as MICU border () also w. MI discovered in setting of resp. distress w. ekg changes and elevated CE's. family determined POC would be CMO- remains in CCU although is called -out to floor on po prn morphine/zyprexa.\\n\\nS: unresponsive\\nO: please see careview for all objective data.\\nA\\nCV: HR NSR w/ freq. pac's. NBP remains 111-117/50's. 4 + pitting edema to all 4 extremeties; R arm weeping. no further labs to be collected.\\n\\nRESP: RR 18-22 overnight; breaths appear even and unlabored. crackles 1/3 up from bil. bases. continues on 2 L via NC w. sats 96-99%.\\n\\nGI: no stool overnight. NPO. active bs x 4. + Cdiff- on no abx. @ this time.\\n\\nGU: foley in, patent, draining dark brown urine. +UTI- on no abx. at this time.\\n\\nSKIN: is thin, areas of ecchymosis and errythema on bil upper and lower extremities. right hip dressing remains intact overnight.\\n\\nACCESS: none\\n\\nSOCIAL: social work following family given some strained dynamics between siblings, although appears all are in agreement w. current POC. palliative care also consulted & following. placement to facility will be discussed if required.\\n\\nPLAN: CMO- called out to floor. cont. to monitor resp/ pain status; prn morphine/zyprexa & albuterol nebs as needed. emotional support to patient and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2104-09-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1653410,\n \"text\": \"Nursing Note 7a-7p\\nNeuro- Remains unresponsive.\\nCV- SR-ST w/ freq PACs, HR 80s-110. NBPs 109-125/50s-60s. No iv access.\\nResp- Conts on 2L nc w/ sat >95%, LS w/ crackles bibasilary. Breathing appears unlabored.\\nGI/GU- NPO, no bm. Voiding 20-30cc/hr brown urine via foley.\\nID- Conts on C-diff precautions, no abx.\\nSkin- 4+ pitting edema bil U/L extremities.\\nA/P- 88yo female s/p hip fx c/b c-diff, uti, resp distress-> +MI. Made CMO by family . Call-out to floor when bed available or poss tnsf to hospice. Cont plan of care, support family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2104-09-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1653411,\n \"text\": \"Nursing Progress Note (1900-0700)\\n88 yo female, unresponsive w/ recent peri-operative MI now CMO status awaiting bed on floor w/ potential for transfer to hospice.\\n\\nS: unresponsive\\nO: please see careview for all objective data.\\nCV: HR 80s-low 100's SR/ST w. PVC's/PAC's. SBP > 100/ 50'60s. conts w/ + bil. upper & LE pitting edema. no IV access and no labs collected.\\nRESP: RR 13-25 overnight. LS coarse/wheezes. albuterol neb prn. resps even + appear unlabored post-neb treatment. 4 L NC w. sats > 93%.\\nGI: CDiff prec. but no bm overnight. npo; active bs x4. taking po morphine; freq. mouth swab to keep oral cavity moist/ assess swallow.\\nGU: foley patent draining clear, brown urine.\\nSKIN: thin, tight skin edema, w. some areas errythema & ecchymosis on bil. U/L extremities. right hip dsg changed.\\nPAIN/MSKLT: given po morphine freq. overnight for various reasons incl. inc. RR, moaning, repos. - see careview for details.\\nSOCIAL: supportive son in to visit & slept in ICU waiting room overnight.\\n\\nPLAN: CMO & awaiting bed on floor. monitor for pain/ discomfort/sob. provide emotional support to patient & family.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2104-09-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 96433,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Myocardial infarction.\\nHeight: (in) 65\\nWeight (lb): 195\\nBSA (m2): 1.96 m2\\nBP (mm Hg): 117/62\\nHR (bpm): 76\\nStatus: Inpatient\\nDate/Time: at 12:11\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the report of the prior study (images not\\navailable) of .\\n\\n\\nLEFT ATRIUM: Moderate LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline dilated LV cavity\\nsize. Mild regional LV systolic dysfunction. Mildly depressed LVEF. No resting\\nLVOT gradient.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\\n- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\\nhypo;\\n\\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\\naorta.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild AS (AoVA\\n1.2-1.9cm2). Mild (1+) AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\\ncalcification. Mild to moderate (+) MR.\\n\\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\\nBorderline PA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: No PS. Significant PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nConclusions:\\nThe left atrium is moderately dilated. There is mild symmetric left\\nventricular hypertrophy. The left ventricular cavity size is top\\nnormal/borderline dilated. There is mild regional left ventricular systolic\\ndysfunction with inferior/inferolateral hypokinesis. Overall left ventricular\\nsystolic function is mildly depressed (LVEF= 50 %). The ascending aorta is\\nmildly dilated. The aortic valve leaflets (3) are mildly thickened. There is\\nmild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic regurgitation\\nis seen. The mitral valve leaflets are mildly thickened. Mild to moderate\\n(+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly\\nthickened. There is borderline pulmonary artery systolic hypertension.\\nSignificant pulmonic regurgitation is seen. There is no pericardial effusion.\\n\\nCompared with the report of the prior study (images unavailable for review) of\\n, left ventricular systolic dysfunction is new.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2104-09-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 265800,\n \"text\": \"Sinus rhythm at upper limits of normal rate. Since the previous tracing\\nearlier the same date the rate has increased. ST-T wave abnormalities are more\\nmarked.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2104-09-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 265801,\n \"text\": \"Sinus rhythm. Short P-R interval. Consider inferior myocardial infarction\\nof indeterminate age. Early R wave progression. Consider posterior myocardial\\ninfarction. There are other ST-T wave abnormalities. Since the previous\\ntracing of the Q wave in lead aVF is more prominent. T wave\\nabnormalities are more prominent.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2104-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 265802,\n \"text\": \"Sinus rhythm. Within normal limits.\\n\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2104-09-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 332699,\n \"text\": \"aertgqeart\\n\"\n }\n]"}}},{"rowIdx":24696,"cells":{"subject_id":{"kind":"number","value":81334,"string":"81,334"},"hadm_id":{"kind":"number","value":133641,"string":"133,641"},"target_text":{"kind":"string","value":""},"extractive_notes_summ":{"kind":"string","value":"(Over) 2:09 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: r/o obstruction/collectionCT with IV AND PO contrast Admitting Diagnosis: PERFORATED DIVERTICULITIS Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) 2. FINDINGS: Small to moderate right pleural effusion and right basilar atelectasis are noted. Status post sigmoid colectomy and end colostomy. CT ABDOMEN: There is mild-to-moderate bibasilar dependent atelectasis, right greater than left. His post-operative pain has been managed with dilaudid PCA. INDICATION: Leukocytosis. Ngt to lws w clear to tan drng Mid abd transparent drsg of serosang stain. Ngt to lws w clear to tan drng Mid abd transparent drsg of serosang stain. Colostomy stoma dusky w serous drng. Colostomy stoma dusky w serous drng. or ileus FINAL REPORT HISTORY: Status post end-colostomy. Glucagon 12. Glucagon 12. Glucagon 12. This finidng is suggestive of interloop abscess. Bilateral subsegmental atelectasis. Surgical drain is noted within the right lower quadrant area . Diffuse distention of the small bowel, ascending colon, and transverse colon is mostly compatible with ileus. Piperacillin-Tazobactam 21. Piperacillin-Tazobactam 21. Piperacillin-Tazobactam 21. Assess PRN IV dilaudid doses and consider upping PCA if needed Cardiovascular: -- SIRS: tachycardic to 120's, MAPs maintianing >60 without pressors, 2.5 L LR bolus given Pulmonary: -- extubated in OR, stable on NC Gastrointestinal / Abdomen: -- NG in place to suction -- GI proph with PPI -- coags elevated for unknown reason, LFT's seem WNL, hepatitis serologies sent Nutrition: --NPO Renal: --Baseline creatinine 0.9 --AUOP Hematology: -- DVT proph with heparin SC and boots -- HCT elecated, possible due to hemoconcentration, min EBL in OR Endocrine: - - RISS for glycemic control Infectious Disease: -- vanc /zosyn for empiric coverage (started ) -- febrile likely secondary to abd source, will CTM cx Lines / Tubes / Drains: PIV, Foley, A-line (), NG, TLC () Wounds: abd Consults: General surgery Billing Diagnosis: ICU Care Glycemic Control: Lines: Multi Lumen - 12:30 AM Arterial Line - 12:30 AM 18 Gauge - 12:30 AM Prophylaxis: DVT: Boots, SQ UF Heparin Stress ulcer: PPI Communication: Comments: Code status: Full code Disposition: SICU ; possible transfer Total time spent: 31 minutes Assess PRN IV dilaudid doses and consider upping PCA if needed Cardiovascular: -- SIRS: tachycardic to 120's, MAPs maintianing >60 without pressors, 2.5 L LR bolus given Pulmonary: -- extubated in OR, stable on NC Gastrointestinal / Abdomen: -- NG in place to suction -- GI proph with PPI -- coags elevated for unknown reason, LFT's seem WNL, hepatitis serologies sent Nutrition: --NPO Renal: --Baseline creatinine 0.9 --AUOP Hematology: -- DVT proph with heparin SC and boots -- HCT elecated, possible due to hemoconcentration, min EBL in OR Endocrine: - - RISS for glycemic control Infectious Disease: -- vanc /zosyn for empiric coverage (started ) -- febrile likely secondary to abd source, will CTM cx Lines / Tubes / Drains: PIV, Foley, A-line (), NG, TLC () Wounds: abd Consults: General surgery Billing Diagnosis: ICU Care Glycemic Control: Lines: Multi Lumen - 12:30 AM Arterial Line - 12:30 AM 18 Gauge - 12:30 AM Prophylaxis: DVT: Boots, SQ UF Heparin Stress ulcer: PPI Communication: Comments: Code status: Full code Disposition: SICU ; possible transfer Total time spent: 31 minutes Assess PRN IV dilaudid doses and consider upping PCA if needed Cardiovascular: -- SIRS: tachycardic to 120's, MAPs maintianing >60 without pressors, 2.5 L LR bolus given Pulmonary: -- extubated in OR, stable on NC Gastrointestinal / Abdomen: -- NG in place to suction -- GI proph with PPI -- coags elevated for unknown reason, LFT's seem WNL, hepatitis serologies sent Nutrition: --NPO Renal: --Baseline creatinine 0.9 --AUOP Hematology: -- DVT proph with heparin SC and boots -- HCT elecated, possible due to hemoconcentration, min EBL in OR Endocrine: -- RISS for glycemic control Infectious Disease: -- vanc /zosyn for empiric coverage (started ) -- febrile likely secondary to abd source, will CTM cx Lines / Tubes / Drains: PIV, Foley, A-line (), NG, TLC () Wounds: abd Imaging: Fluids: Consults: General surgery Billing Diagnosis: ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 12:30 AM Arterial Line - 12:30 AM 18 Gauge - 12:30 AM Prophylaxis: DVT: Boots, SQ UF Heparin Stress ulcer: PPI VAP bundle: Comments: Communication: Comments: Code status: Full code Disposition: Total time spent: 31 minutes"},"n_notes":{"kind":"number","value":13,"string":"13"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2136-02-27 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1127948,"text":" 2:07 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: location of left brachial 50 cm power picc tip\n Admitting Diagnosis: PERFORATED DIVERTICULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with infection\n REASON FOR THIS EXAMINATION:\n location of left brachial 50 cm power picc tip\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old male with left PICC placement.\n\n COMPARISON: .\n\n CHEST, AP: A new left PICC is coiled in the SVC. Right upper lobe and\n lingular opacities have improved, with persistent right perihilar\n consolidation. There is no pneumothorax. Trace bilateral pleural effusions\n are unchanged.\n\n IMPRESSION:\n 1. Left PICC coiled in SVC, recommend retraction by 3 cm. This was discussed\n with on at 2:30 p.m.\n 2. Improving multifocal pneumonia.\n\n"},{"category":"Radiology","chartdate":"2136-02-29 00:00:00.000","description":"ABDOMEN (SUPINE & ERECT)","row_id":1128203,"text":" 5:34 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: ?. or ileus\n Admitting Diagnosis: PERFORATED DIVERTICULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with diverticulitis s/p end colostomy; new abdominal tenderness\n and distension\n REASON FOR THIS EXAMINATION:\n ?. or ileus\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post end-colostomy.\n\n COMPARISON: CT .\n\n SUPINE AND UPRIGHT ABDOMEN:\n\n There are multiple air-filled dilated loops of small bowel. Small amount of\n gas is seen in the ascending and transverse colon with no evident bowel gas\n seen in the rectum. These findings are concerning for pos-operative ileus.\n There is no free intraperitoneal air or pneumatosis. In the right lower lung\n there is a small opacification and small pleural effusion.\n\n IMPRESSION: Multiple air-filled loops of dilated small bowel, concerning for\n ileus.\n\n These findings were reported to Dr. on the time of reporting by phone.\n\n"},{"category":"Radiology","chartdate":"2136-02-26 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1127826,"text":" 3:45 PM\n CHEST (PA & LAT) Clip # \n Reason: PNA\n Admitting Diagnosis: PERFORATED DIVERTICULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with leukocytosis of unkown origin\n REASON FOR THIS EXAMINATION:\n PNA\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST \n\n COMPARISON: .\n\n INDICATION: Leukocytosis.\n\n FINDINGS: New confluent consolidation has developed in the right perihilar\n region corresponding to the superior and posterior basilar segments of the\n right lower lobe as well as some involvement of the right middle lobe\n resulting in obscuration of the right heart border. Additional new opacity\n has developed peripherally in the right upper lobe. Previously present\n predominantly linear opacities in the left lung have progressed and a new\n patchy opacity has developed in the lingula. Small pleural effusions are also\n new. Cardiomediastinal contours are similar.\n\n IMPRESSION:\n New multifocal right lung opacities suspicious for multifocal pneumonia, with\n possible additional lesser involvement in the left lung.\n\n"},{"category":"Nursing","chartdate":"2136-02-25 00:00:00.000","description":"Nursing Transfer Note","row_id":529475,"text":"SICU\n HPI:\n 52yM with h/o multiple episodes diverticulitis. Was in the ER 1 week\n ago with abd pain, no evid of diverticulitis on CT but treated\n empirically with cipro/flagyl. Pain improved but this morning could\n not void and had excrutiating abd pain. Came\n to ED and foley placed, no improvement. CT done which showed free\n air. Patient went to the OR for \ns procedure and was sent to\n the PACU for post-op management.\n He was tachycardic and slightly hypoxic in the PACU and was transferred\n overnight to the SICU for further fluid resuscitation. Central line\n was placed and 3.5 liters of LR were given overnight and this morning.\n His hemodynamics have improved, he is less tachycardic.\n His post-operative pain has been managed with dilaudid PCA. His pain\n was initially difficult to manage, and this morning he was slightly\n lethargic, frequently falling to sleep with short periods of apnea.\n His PCA dose has been decreased this morning and his apnea has\n resolved. His oxygen has been weaned and he is comfortable, denying\n pain. He ambulated well this morning, out of bed and into the chair\n easily. His abdomen is soft and non distended. His ostomy is dark red\n and appears congested and it continues to produce serosanguine\n drainage. Continues to receive vanco and zoysn IV.\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n PERFORATED DIVERTICULITIS\n Code status:\n Full code\n Height:\n Admission weight:\n 92.2 kg\n Daily weight:\n 92.2 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: abd pain 1 wk ago- CT at that time neg. Rx'd w\n triple antibx coverage empirically.\n Presented w severe abd pain, + perf divertic\n PSHx- CX 5-C6 screws placed, Rotator cuff repair lt 06, Lt knee\n repair ,70's, Exp lap for stab wound .\n Surgery / Procedure and date: Exp lap, colostomy, placement of jp\n drain\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:131\n D:65\n Temperature:\n 96.9\n Arterial BP:\n S:131\n D:65\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 93 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Face tent\n O2 saturation:\n 95% %\n O2 flow:\n 15 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 7,085 mL\n 24h total out:\n 1,975 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 12:41 AM\n Potassium:\n 4.8 mEq/L\n 12:41 AM\n Chloride:\n 105 mEq/L\n 12:41 AM\n CO2:\n 24 mEq/L\n 12:41 AM\n BUN:\n 9 mg/dL\n 12:41 AM\n Creatinine:\n 0.9 mg/dL\n 12:41 AM\n Glucose:\n 155 mg/dL\n 12:41 AM\n Hematocrit:\n 45.9 %\n 09:29 AM\n Finger Stick Glucose:\n 143\n 04:00 AM\n Valuables / Signature\n Patient valuables: Sent home with family.\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU B\n Transferred to: 621\n Date & time of Transfer: \n"},{"category":"Physician ","chartdate":"2136-02-25 00:00:00.000","description":"Intensivist Note","row_id":529433,"text":"SICU\n HPI:\n 52yM with h/o multiple episodes diverticulitis. Was in the\n ER 1 week ago with abd pain, no evid of diverticulitis on CT but\n treated empirically with cipro/flagyl. Pain improved but then\n this morning could not void and had excrutiating abd pain. Came\n to ED and foley placed, no improvement. CT done which showed\n free air.\n Chief complaint:\n abd pain\n PMHx:\n diverticulitis\n PSH: exploratory laparoscopy, exploratory laparotomy (s/p stabbing),\n left knee surgery, neck surgery\n Current medications:\n Acetaminophen 9. Calcium Gluconate\n 10. Dextrose 50% 11. Glucagon 12. HYDROmorphone (Dilaudid) 13.\n HYDROmorphone (Dilaudid) 14. Heparin\n 15. Insulin 16. Magnesium Sulfate 17. Magnesium Sulfate 18. Ondansetron\n 19. Pantoprazole 20. Piperacillin-Tazobactam\n 21. Potassium Chloride 22. Sodium Chloride 0.9% Flush 23. Sodium\n Chloride 0.9% Flush 24. Vancomycin\n 24 Hour Events:\n MULTI LUMEN - START 12:30 AM\n ARTERIAL LINE - START 12:30 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 36.7\nC (98\n HR: 105 (96 - 115) bpm\n BP: 137/80(99) {132/80(99) - 140/92(107)} mmHg\n RR: 25 (19 - 25) insp/min\n SPO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 92.2 kg (admission): 92.2 kg\n CVP: 8 (3 - 8) mmHg\n Total In:\n 4,477 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,227 mL\n Blood products:\n 250 mL\n Total out:\n 0 mL\n 1,335 mL\n Urine:\n 595 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,142 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 94%\n ABG: 7.33/46/77./24/-1\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular), +s1/s2\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, No(t) Non-tender\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 357 K/uL\n 17.3 g/dL\n 155 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.8 mEq/L\n 9 mg/dL\n 105 mEq/L\n 137 mEq/L\n 52.5 %\n 14.5 K/uL\n [image002.jpg]\n 12:41 AM\n 12:50 AM\n WBC\n 14.5\n Hct\n 52.5\n Plt\n 357\n Creatinine\n 0.9\n TCO2\n 25\n Glucose\n 155\n Other labs: PT / PTT / INR:17.0/32.0/1.5, Lactic Acid:1.9 mmol/L,\n Ca:7.9 mg/dL, Mg:3.4 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n .H/O DIVERTICULITIS\n Assessment and Plan: 52yM with free air/ frank stool due to perf\n diverticulitis s/p sigmoid resection and end colostomy \n Neurologic:\n -- dailudid PCA for pain control with extra dilaudid IV prn for\n breakthrough in immediate post op period. Assess PRN IV dilaudid doses\n and consider upping PCA if needed\n Cardiovascular:\n -- SIRS: tachycardic to 120's, MAPs maintianing >60 without pressors,\n 2.5 L LR bolus given\n Pulmonary:\n -- extubated in OR, stable on NC\n Gastrointestinal / Abdomen:\n -- NG in place to suction\n -- GI proph with PPI\n -- coags elevated for unknown reason, LFT's seem WNL, hepatitis\n serologies sent\n Nutrition:\n --NPO\n Renal:\n --Baseline creatinine 0.9\n --AUOP\n Hematology:\n -- DVT proph with heparin SC and boots\n -- HCT elecated, possible due to hemoconcentration, min EBL in OR\n Endocrine: -\n - RISS for glycemic control\n Infectious Disease:\n -- vanc /zosyn for empiric coverage (started )\n -- febrile likely secondary to abd source, will CTM cx\n Lines / Tubes / Drains: PIV, Foley, A-line (), NG, TLC ()\n Wounds: abd\n Consults: General surgery\n Billing Diagnosis:\n ICU Care\n Glycemic Control:\n Lines:\n Multi Lumen - 12:30 AM\n Arterial Line - 12:30 AM\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n Communication: Comments:\n Code status: Full code\n Disposition: SICU ; possible transfer\n Total time spent: 31 minutes\n"},{"category":"Physician ","chartdate":"2136-02-25 00:00:00.000","description":"Intensivist Note","row_id":529444,"text":"SICU\n HPI:\n 52yM with h/o multiple episodes diverticulitis. Was in the\n ER 1 week ago with abd pain, no evid of diverticulitis on CT but\n treated empirically with cipro/flagyl. Pain improved but then\n this morning could not void and had excrutiating abd pain. Came\n to ED and foley placed, no improvement. CT done which showed\n free air.\n Chief complaint:\n abd pain\n PMHx:\n diverticulitis\n PSH: exploratory laparoscopy, exploratory laparotomy (s/p stabbing),\n left knee surgery, neck surgery\n Current medications:\n Acetaminophen 9. Calcium Gluconate\n 10. Dextrose 50% 11. Glucagon 12. HYDROmorphone (Dilaudid) 13.\n HYDROmorphone (Dilaudid) 14. Heparin\n 15. Insulin 16. Magnesium Sulfate 17. Magnesium Sulfate 18. Ondansetron\n 19. Pantoprazole 20. Piperacillin-Tazobactam\n 21. Potassium Chloride 22. Sodium Chloride 0.9% Flush 23. Sodium\n Chloride 0.9% Flush 24. Vancomycin\n 24 Hour Events:\n MULTI LUMEN - START 12:30 AM\n ARTERIAL LINE - START 12:30 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 36.7\nC (98\n HR: 105 (96 - 115) bpm\n BP: 137/80(99) {132/80(99) - 140/92(107)} mmHg\n RR: 25 (19 - 25) insp/min\n SPO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 92.2 kg (admission): 92.2 kg\n CVP: 8 (3 - 8) mmHg\n Total In:\n 4,477 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,227 mL\n Blood products:\n 250 mL\n Total out:\n 0 mL\n 1,335 mL\n Urine:\n 595 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,142 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 94%\n ABG: 7.33/46/77./24/-1\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular), +s1/s2\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, No(t) Non-tender\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 357 K/uL\n 17.3 g/dL\n 155 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.8 mEq/L\n 9 mg/dL\n 105 mEq/L\n 137 mEq/L\n 52.5 %\n 14.5 K/uL\n [image002.jpg]\n 12:41 AM\n 12:50 AM\n WBC\n 14.5\n Hct\n 52.5\n Plt\n 357\n Creatinine\n 0.9\n TCO2\n 25\n Glucose\n 155\n Other labs: PT / PTT / INR:17.0/32.0/1.5, Lactic Acid:1.9 mmol/L,\n Ca:7.9 mg/dL, Mg:3.4 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n .H/O DIVERTICULITIS\n Assessment and Plan: 52yM with free air/ frank stool due to perf\n diverticulitis s/p sigmoid resection and end colostomy \n Neurologic:\n -- dailudid PCA for pain control with extra dilaudid IV prn for\n breakthrough in immediate post op period. Assess PRN IV dilaudid doses\n and consider upping PCA if needed\n Cardiovascular:\n -- SIRS: tachycardic to 120's, MAPs maintianing >60 without pressors,\n 2.5 L LR bolus given\n Pulmonary:\n -- extubated in OR, stable on NC\n Gastrointestinal / Abdomen:\n -- NG in place to suction\n -- GI proph with PPI\n -- coags elevated for unknown reason, LFT's seem WNL, hepatitis\n serologies sent\n Nutrition:\n --NPO\n Renal:\n --Baseline creatinine 0.9\n --AUOP\n Hematology:\n -- DVT proph with heparin SC and boots\n -- HCT elecated, possible due to hemoconcentration, min EBL in OR\n Endocrine: -\n - RISS for glycemic control\n Infectious Disease:\n -- vanc /zosyn for empiric coverage (started )\n -- febrile likely secondary to abd source, will CTM cx\n Lines / Tubes / Drains: PIV, Foley, A-line (), NG, TLC ()\n Wounds: abd\n Consults: General surgery\n Billing Diagnosis:\n ICU Care\n Glycemic Control:\n Lines:\n Multi Lumen - 12:30 AM\n Arterial Line - 12:30 AM\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n Communication: Comments:\n Code status: Full code\n Disposition: SICU ; possible transfer\n Total time spent: 31 minutes\n"},{"category":"Physician ","chartdate":"2136-02-25 00:00:00.000","description":"Intensivist Note","row_id":529386,"text":"SICU\n HPI:\n 52yM with h/o multiple episodes diverticulitis. Was in the\n ER 1 week ago with abd pain, no evid of diverticulitis on CT but\n treated empirically with cipro/flagyl. Pain improved but then\n this morning could not void and had excrutiating abd pain. Came\n to ED and foley placed, no improvement. CT done which showed\n free air.\n Chief complaint:\n abd pain\n PMHx:\n diverticulitis\n PSH: exploratory laparoscopy, exploratory laparotomy (s/p stabbing),\n left knee surgery, neck surgery\n Current medications:\n Acetaminophen 9. Calcium Gluconate\n 10. Dextrose 50% 11. Glucagon 12. HYDROmorphone (Dilaudid) 13.\n HYDROmorphone (Dilaudid) 14. Heparin\n 15. Insulin 16. Magnesium Sulfate 17. Magnesium Sulfate 18. Ondansetron\n 19. Pantoprazole 20. Piperacillin-Tazobactam\n 21. Potassium Chloride 22. Sodium Chloride 0.9% Flush 23. Sodium\n Chloride 0.9% Flush 24. Vancomycin\n 24 Hour Events:\n MULTI LUMEN - START 12:30 AM\n ARTERIAL LINE - START 12:30 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 36.7\nC (98\n HR: 105 (96 - 115) bpm\n BP: 137/80(99) {132/80(99) - 140/92(107)} mmHg\n RR: 25 (19 - 25) insp/min\n SPO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 92.2 kg (admission): 92.2 kg\n CVP: 8 (3 - 8) mmHg\n Total In:\n 4,477 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,227 mL\n Blood products:\n 250 mL\n Total out:\n 0 mL\n 1,335 mL\n Urine:\n 595 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,142 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 94%\n ABG: 7.33/46/77./24/-1\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular), +s1/s2\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, No(t) Non-tender\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 357 K/uL\n 17.3 g/dL\n 155 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.8 mEq/L\n 9 mg/dL\n 105 mEq/L\n 137 mEq/L\n 52.5 %\n 14.5 K/uL\n [image002.jpg]\n 12:41 AM\n 12:50 AM\n WBC\n 14.5\n Hct\n 52.5\n Plt\n 357\n Creatinine\n 0.9\n TCO2\n 25\n Glucose\n 155\n Other labs: PT / PTT / INR:17.0/32.0/1.5, Lactic Acid:1.9 mmol/L,\n Ca:7.9 mg/dL, Mg:3.4 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n .H/O DIVERTICULITIS\n Assessment and Plan: 52yM with free air/ frank stool due to perf\n diverticulitis s/p sigmoid resection and end colostomy \n Neurologic: -- dailudid PCA for pain control with extra dilaudid IV prn\n for breakthrough in immediate post op period. Assess PRN IV dilaudid\n doses and consider upping PCA if needed\n Cardiovascular: -- SIRS: tachycardic to 120's, MAPs maintianing >60\n without pressors, 2.5 L LR bolus given\n Pulmonary: -- extubated in OR, stable on NC\n Gastrointestinal / Abdomen: -- NG in place to suction\n -- GI proph with PPI\n -- coags elevated for unknown reason, LFT's seem WNL, hepatitis\n serologies sent\n Nutrition: --NPO\n Renal: --Baseline creatinine 0.9\n --AUOP\n Hematology: -- DVT proph with heparin SC and boots\n -- HCT elecated, possible due to hemoconcentration, min EBL in OR\n Endocrine: -- RISS for glycemic control\n Infectious Disease: -- vanc /zosyn for empiric coverage (started )\n -- febrile likely secondary to abd source, will CTM cx\n Lines / Tubes / Drains: PIV, Foley, A-line (), NG, TLC ()\n Wounds: abd\n Imaging:\n Fluids:\n Consults: General surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:30 AM\n Arterial Line - 12:30 AM\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent: 31 minutes\n"},{"category":"Nursing","chartdate":"2136-02-25 00:00:00.000","description":"Nursing Progress Note","row_id":529348,"text":"TITLE:\n 52 yo disabled prison guard w h/o multiple episodes diverticulitis.\n Presented to E.D 1 wk ago and abd CT showed no evidence of\n diverticulitis but empirically treated w cipro/flagyl symptoms improved\n until a.m. Presented to after acute onset of abd pain.\n Free air on CT noted.\n Intraop findings include perforated diverticulum w lg amts feculent\n material intraabd cavity.\n PSHx includes: C4 C5 C6 screws placed( after assault at work), exp lap\n (stabbing), lt knee repair, lt rotator cuff repair\n .H/O diverticulitis- S/P sigmoid colectomy and colostomy\n Assessment:\n Received pt from PACU awake, alert, moaning in pain , diaphoretic\n w temp 100.6 (*8 hx temp 102.7 in PACU). Pt admits to abd pain\n (increased w movement on transfer) CV- 110-120 RR 28-30 Sbp 100.\n CVP-0-2\n Resp- BBS clear dim at bases nasal at 3lpm and Face tent at 35%\n Abd firm, distended, tender. No active bowel sounds. Ngt to lws w clear\n to tan drng\n Mid abd transparent drsg of serosang stain. JP to bulb w\n serousy drng. Colostomy stoma dusky w serous drng.\n Action:\n Antibiotics\nVanco & Zosyn\n Cooling blanket on bed for temp spikes\n PCA dilaudid given to pt and instructed on proper use.\n Labs sent w lactate and abg\n LR Bolus x 2 liters for fld volume resusc (post op Hct 52) & IVF\n mainten @ 125cc/hr\n O2 sats 92-93% on 3 nc and 35%-> incr to 50 % FT and 3 nc\n Pt teaching done re: DBC and incentive spirometry once pain threshold <\n 5\n UOP 25cc x 1 hr ** fld bolus as noted x 2\n Dr notified of dusky stoma.\n Response:\n Tachycardia and low uop resolving w fld resusc\n O2 sats improved w fio2 increase\n Pain under control w PCA dilaudid\n Pt needs encouragement to DBC and use Incentive spirometry.\n Plan:\n Turn and repositioning q2h\n Dilaudid prn IVB for breakthrough pain as ordered.\n Cont to monitor stoma color\n"},{"category":"Nursing","chartdate":"2136-02-25 00:00:00.000","description":"Nursing Progress Note","row_id":529406,"text":"TITLE:\n 52 yo disabled prison guard w h/o multiple episodes diverticulitis.\n Presented to E.D 1 wk ago and abd CT showed no evidence of\n diverticulitis but empirically treated w cipro/flagyl symptoms improved\n until a.m. Presented to after acute onset of abd pain.\n Free air on CT noted.\n Intraop findings include perforated diverticulum w lg amts feculent\n material intraabd cavity.\n PSHx includes: C4 C5 C6 screws placed( assault at work), exp lap\n (stabbing), lt knee repair, lt rotator cuff repair\n .H/O diverticulitis- S/P sigmoid colectomy and colostomy\n Assessment:\n Received pt from PACU awake, alert, moaning in pain , diaphoretic\n w temp 100.6 (*8 hx temp 102.7 in PACU). Pt admits to abd pain\n (increased w movement on transfer) CV- 110-120 RR 28-30 Sbp 100.\n CVP-0-2\n Resp- BBS clear dim at bases nasal at 3lpm and Face tent at 35%\n Abd firm, distended, tender. No active bowel sounds. Ngt to lws w clear\n to tan drng\n Mid abd transparent drsg of serosang stain. JP to bulb w\n serousy drng. Colostomy stoma dusky w serous drng.\n Action:\n Antibiotics\nVanco & Zosyn\n Cooling blanket on bed for temp spikes\n PCA dilaudid given to pt and instructed on proper use.\n Labs sent w lactate and abg\n LR Bolus x 2 liters for fld volume resusc (post op Hct 52) & IVF\n mainten @ 125cc/hr\n O2 sats 92-93% on 3 nc and 35%-> incr to 50 % FT and 3 nc\n Pt teaching done re: DBC and incentive spirometry once pain threshold <\n 5\n UOP 25cc x 1 hr ** fld bolus as noted x 2\n Dr notified of dusky stoma.\n Response:\n Tachycardia and low uop resolving w fld resusc\n O2 sats improved w fio2 increase\n Pt reports pain under control w PCA dilaudid\n Pt needs encouragement to DBC and use Incentive spirometry.\n Plan:\n Turn and repositioning q2h\n Cont to monitor pain and management w PCA dilaudid\n Cont to monitor stoma color\n Empty and record Jp drainage\n"},{"category":"Nursing","chartdate":"2136-02-25 00:00:00.000","description":"Nursing Progress Note","row_id":529344,"text":"TITLE:\n 52 yo disabled prison guard w h/o multiple episodes diverticulitis.\n Presented to E.D 1 wk ago and abd CT showed no evidence of\n diverticulitis but empirically treated w cipro/flagyl symptoms improved\n until a.m. Presented to after acute onset of abd pain.\n Free air on CT noted.\n Intraop findings include perforated diverticulum w lg amts feculent\n material intraabd cavity.\n PSHx includes: C4 C5 C6 screws placed( after assault at work), exp lap\n (stabbing), lt knee repair, lt rotator cuff repair\n .H/O diverticulitis- S/P sigmoid colectomy and colostomy\n Assessment:\n Received pt from PACU awake, alert, moaning in pain . Pt admits to\n abd pain (increased w movement on transfer)\n Abd firm, distended, tender.\n Action:\n Response:\n Plan:\n"},{"category":"Radiology","chartdate":"2136-02-25 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1127634,"text":" 12:04 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please eval central line placement\n Admitting Diagnosis: PERFORATED DIVERTICULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man s/p exlap, small bowel resection.\n REASON FOR THIS EXAMINATION:\n please eval central line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Central line placement.\n\n One supine portable view. Lung volumes are low. There is streaky density at\n the lung bases most consistent with subsegmental atelectasis. There is\n suggestion of air bronchograms in the retrocardiac area and a small focal area\n of consolidation in the left lower lobe cannot be excluded. The cardiac\n silhouette is prominent but may be exaggerated by portable technique.\n Mediastinal structures are otherwise unremarkable. A nasogastric tube\n terminates below the diaphragm. Its side hole is just below the level of the\n diaphragm. A right subclavian line is present and terminates at the level of\n the cavoatrial junction.\n\n IMPRESSION: Limited study as described. Bilateral subsegmental atelectasis.\n A small retrocardiac infiltrate cannot be excluded.\n\n\n"},{"category":"Radiology","chartdate":"2136-03-05 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":1128970,"text":" 2:09 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o obstruction/collectionCT with IV AND PO contrast\n Admitting Diagnosis: PERFORATED DIVERTICULITIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52M with perf diverticulitis s/p sigmoid resection and end colostomy \n REASON FOR THIS EXAMINATION:\n r/o obstruction/collectionCT with IV AND PO contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old male with perforated diverticulitis treated with\n sigmoid resection and end colostomy placement.\n\n Comparison is made to the prior study of .\n\n TECHNIQUE: Axial MDCT images of the abdomen and pelvis were obtained after\n administration of 130 cc of Optiray intravenously. Sagittal and coronal\n reformatted images were then acquired.\n\n FINDINGS: Small to moderate right pleural effusion and right basilar\n atelectasis are noted. The visualized portion of the left lung base is\n normal. A small hiatal hernia is visualized.\n\n There is a 10-mm hypodense lesion within the segment of the liver which is\n too small to characterize.\n\n The ring-enhancing collection is noted in the subcapsular part of the right\n lobe of the liver. The findings are compatible with subcapsular abscess\n collection, the largest pocket of subcapsular collection measures 6.3 x 1.8\n cm.Complex-appearing fluid collection is noted within the right lower quadrant\n area with the largest pocket of collection measuring 3.7 x 2.2 cm. This\n finidng is suggestive of interloop abscess.\n\n The gallbladder, adrenal glands, kidneys, spleen, pancreas appear\n unremarkable. Diffusely distended small bowel loops and ascending colon and\n transverse colon are most likely compatible with ileus rather than\n obstruction. Normal appearance of ileostomy is noted within the left lower\n quadrant area. Surgical drain is noted within the right lower quadrant area\n .\n\n CT OF THE PELVIS WITH CONTRAST: The urinary bladder, distal ureters, and\n Hartmann pouch appear unremarkable. No free fluid is noted within the pelvis.\n\n BONE WINDOWS: No concerning lytic or sclerotic lesions are identified.\n\n IMPRESSION:\n 1. Status post sigmoid colectomy and end colostomy. Complex collection is\n noted in the right lower quadrant area and in the subcapsular location within\n the liver. These collections are relatively small and cannot be drained\n percutaneously.\n (Over)\n\n 2:09 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o obstruction/collectionCT with IV AND PO contrast\n Admitting Diagnosis: PERFORATED DIVERTICULITIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Diffuse distention of the small bowel, ascending colon, and transverse\n colon is mostly compatible with ileus.\n\n Findings were discussed with Dr. Dibs at the time of dictation by Dr.\n .\n\n"},{"category":"Radiology","chartdate":"2136-02-24 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":1127544,"text":" 10:59 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o abscess, perfed tic\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with diverticulitis, worse pain\n REASON FOR THIS EXAMINATION:\n r/o abscess, perfed tic\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: YGd FRI 1:09 PM\n Perforated sigmoid diverticulitis with 3cm air/fluid collection (predomly\n air), compatible with abscess, though no drainable collection. Multiple foci\n of free intraperitoneal air. Small ascites. Inflammatory changes in distal\n ileum likely 2ndary to acute diverticulitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old man with diverticulitis with increased pain. Study\n to rule out abscess or perforated diverticulitis.\n\n COMPARISON: CT abdomen from .\n\n TECHNIQUE: MDCT images were performed from the lung bases through the pubic\n symphysis following administration of intravenous contrast. Coronal and\n sagittal reformats were provided.\n\n CT ABDOMEN: There is mild-to-moderate bibasilar dependent atelectasis, right\n greater than left. The heart is top normal in size. There is no pericardial\n effusion.\n\n There is pneumoperitoneum with foci of free air along the anterior margin of\n liver, in the porta hepatis, and scattered throughout the abdomen. A small\n amount of perihepatic ascites is identified with a larger amount of fluid in\n the right lower quadrant as well as within adjacent mesentery (301b, 29).\n There are scattered diverticula involving the sigmoid colon extending into the\n ascending colon. There is moderate wall thickening and hyperemia within a\n segment of sigmoid colon with extensive adjacent fat stranding in the lower\n abdomen (2, 76). Adjacent to the inflamed sigmoid colon, there is a 2.5 x 3.1\n cm air-fluid collection which is primarily composed of air, compatible with a\n small abscess (2, 74). No drainable focal collection is identified. There\n are inflammatory changes extending to the right lower quadrant with fluid,\n stranding, and mild lateral conal thickening. There is moderate mural\n thickening and stranding involving the distal ileum, likely due to reactive\n inflammatory changes. Enhancement and thickening of the peritoneum,\n particularly on the right, is compatible with peritonitis.\n\n The liver, gallbladder, spleen, pancreas, and adrenal glands appear\n unremarkable. Bilateral kidneys enhance and excrete contrast symmetrically\n without hydronephrosis or hydroureter. The appendix appears within normal\n limits. Scattered atherosclerotic calcifications involve predominantly the\n infrarenal aorta, with extension into iliac arteries.\n\n (Over)\n\n 10:59 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o abscess, perfed tic\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT PELVIS: The bladder is collapsed, with a urinary Foley catheter in place.\n The prostate, rectum, and distal ureters appear unremarkable. Small inguinal\n and pelvic lymph nodes do not meet CT size criteria for pathologic\n enlargement.\n\n BONE WINDOW: Osseous structures are unremarkable.\n\n IMPRESSION: Perforated sigmoid diverticulitis with adjacent 3-cm air and\n fluid collection (primarily composed of air), compatible with an abscess,\n pneumoperitoneum, and peritonitis. No focal drainable collections seen. Small\n amount with reactive inflammatory changes in the distal small\n bowel. Findings discussed with Dr. at 1:30 p.m. on .\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2136-02-27 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1127948,\n \"text\": \" 2:07 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: location of left brachial 50 cm power picc tip\\n Admitting Diagnosis: PERFORATED DIVERTICULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 52 year old man with infection\\n REASON FOR THIS EXAMINATION:\\n location of left brachial 50 cm power picc tip\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 52-year-old male with left PICC placement.\\n\\n COMPARISON: .\\n\\n CHEST, AP: A new left PICC is coiled in the SVC. Right upper lobe and\\n lingular opacities have improved, with persistent right perihilar\\n consolidation. There is no pneumothorax. Trace bilateral pleural effusions\\n are unchanged.\\n\\n IMPRESSION:\\n 1. Left PICC coiled in SVC, recommend retraction by 3 cm. This was discussed\\n with on at 2:30 p.m.\\n 2. Improving multifocal pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2136-02-29 00:00:00.000\",\n \"description\": \"ABDOMEN (SUPINE & ERECT)\",\n \"row_id\": 1128203,\n \"text\": \" 5:34 AM\\n ABDOMEN (SUPINE & ERECT) Clip # \\n Reason: ?. or ileus\\n Admitting Diagnosis: PERFORATED DIVERTICULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 52 year old man with diverticulitis s/p end colostomy; new abdominal tenderness\\n and distension\\n REASON FOR THIS EXAMINATION:\\n ?. or ileus\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post end-colostomy.\\n\\n COMPARISON: CT .\\n\\n SUPINE AND UPRIGHT ABDOMEN:\\n\\n There are multiple air-filled dilated loops of small bowel. Small amount of\\n gas is seen in the ascending and transverse colon with no evident bowel gas\\n seen in the rectum. These findings are concerning for pos-operative ileus.\\n There is no free intraperitoneal air or pneumatosis. In the right lower lung\\n there is a small opacification and small pleural effusion.\\n\\n IMPRESSION: Multiple air-filled loops of dilated small bowel, concerning for\\n ileus.\\n\\n These findings were reported to Dr. on the time of reporting by phone.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2136-02-26 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1127826,\n \"text\": \" 3:45 PM\\n CHEST (PA & LAT) Clip # \\n Reason: PNA\\n Admitting Diagnosis: PERFORATED DIVERTICULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 52 year old man with leukocytosis of unkown origin\\n REASON FOR THIS EXAMINATION:\\n PNA\\n ______________________________________________________________________________\\n FINAL REPORT\\n TWO VIEW CHEST \\n\\n COMPARISON: .\\n\\n INDICATION: Leukocytosis.\\n\\n FINDINGS: New confluent consolidation has developed in the right perihilar\\n region corresponding to the superior and posterior basilar segments of the\\n right lower lobe as well as some involvement of the right middle lobe\\n resulting in obscuration of the right heart border. Additional new opacity\\n has developed peripherally in the right upper lobe. Previously present\\n predominantly linear opacities in the left lung have progressed and a new\\n patchy opacity has developed in the lingula. Small pleural effusions are also\\n new. Cardiomediastinal contours are similar.\\n\\n IMPRESSION:\\n New multifocal right lung opacities suspicious for multifocal pneumonia, with\\n possible additional lesser involvement in the left lung.\\n\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2136-02-25 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 529475,\n \"text\": \"SICU\\n HPI:\\n 52yM with h/o multiple episodes diverticulitis. Was in the ER 1 week\\n ago with abd pain, no evid of diverticulitis on CT but treated\\n empirically with cipro/flagyl. Pain improved but this morning could\\n not void and had excrutiating abd pain. Came\\n to ED and foley placed, no improvement. CT done which showed free\\n air. Patient went to the OR for \\ns procedure and was sent to\\n the PACU for post-op management.\\n He was tachycardic and slightly hypoxic in the PACU and was transferred\\n overnight to the SICU for further fluid resuscitation. Central line\\n was placed and 3.5 liters of LR were given overnight and this morning.\\n His hemodynamics have improved, he is less tachycardic.\\n His post-operative pain has been managed with dilaudid PCA. His pain\\n was initially difficult to manage, and this morning he was slightly\\n lethargic, frequently falling to sleep with short periods of apnea.\\n His PCA dose has been decreased this morning and his apnea has\\n resolved. His oxygen has been weaned and he is comfortable, denying\\n pain. He ambulated well this morning, out of bed and into the chair\\n easily. His abdomen is soft and non distended. His ostomy is dark red\\n and appears congested and it continues to produce serosanguine\\n drainage. Continues to receive vanco and zoysn IV.\\n Demographics\\n Attending MD:\\n S.\\n Admit diagnosis:\\n PERFORATED DIVERTICULITIS\\n Code status:\\n Full code\\n Height:\\n Admission weight:\\n 92.2 kg\\n Daily weight:\\n 92.2 kg\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH:\\n CV-PMH:\\n Additional history: abd pain 1 wk ago- CT at that time neg. Rx'd w\\n triple antibx coverage empirically.\\n Presented w severe abd pain, + perf divertic\\n PSHx- CX 5-C6 screws placed, Rotator cuff repair lt 06, Lt knee\\n repair ,70's, Exp lap for stab wound .\\n Surgery / Procedure and date: Exp lap, colostomy, placement of jp\\n drain\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:131\\n D:65\\n Temperature:\\n 96.9\\n Arterial BP:\\n S:131\\n D:65\\n Respiratory rate:\\n 21 insp/min\\n Heart Rate:\\n 93 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n Face tent\\n O2 saturation:\\n 95% %\\n O2 flow:\\n 15 L/min\\n FiO2 set:\\n 35% %\\n 24h total in:\\n 7,085 mL\\n 24h total out:\\n 1,975 mL\\n Pertinent Lab Results:\\n Sodium:\\n 137 mEq/L\\n 12:41 AM\\n Potassium:\\n 4.8 mEq/L\\n 12:41 AM\\n Chloride:\\n 105 mEq/L\\n 12:41 AM\\n CO2:\\n 24 mEq/L\\n 12:41 AM\\n BUN:\\n 9 mg/dL\\n 12:41 AM\\n Creatinine:\\n 0.9 mg/dL\\n 12:41 AM\\n Glucose:\\n 155 mg/dL\\n 12:41 AM\\n Hematocrit:\\n 45.9 %\\n 09:29 AM\\n Finger Stick Glucose:\\n 143\\n 04:00 AM\\n Valuables / Signature\\n Patient valuables: Sent home with family.\\n Other valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: SICU B\\n Transferred to: 621\\n Date & time of Transfer: \\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2136-02-25 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 529433,\n \"text\": \"SICU\\n HPI:\\n 52yM with h/o multiple episodes diverticulitis. Was in the\\n ER 1 week ago with abd pain, no evid of diverticulitis on CT but\\n treated empirically with cipro/flagyl. Pain improved but then\\n this morning could not void and had excrutiating abd pain. Came\\n to ED and foley placed, no improvement. CT done which showed\\n free air.\\n Chief complaint:\\n abd pain\\n PMHx:\\n diverticulitis\\n PSH: exploratory laparoscopy, exploratory laparotomy (s/p stabbing),\\n left knee surgery, neck surgery\\n Current medications:\\n Acetaminophen 9. Calcium Gluconate\\n 10. Dextrose 50% 11. Glucagon 12. HYDROmorphone (Dilaudid) 13.\\n HYDROmorphone (Dilaudid) 14. Heparin\\n 15. Insulin 16. Magnesium Sulfate 17. Magnesium Sulfate 18. Ondansetron\\n 19. Pantoprazole 20. Piperacillin-Tazobactam\\n 21. Potassium Chloride 22. Sodium Chloride 0.9% Flush 23. Sodium\\n Chloride 0.9% Flush 24. Vancomycin\\n 24 Hour Events:\\n MULTI LUMEN - START 12:30 AM\\n ARTERIAL LINE - START 12:30 AM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Flowsheet Data as of 05:34 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.9\\nC (100.2\\n T current: 36.7\\nC (98\\n HR: 105 (96 - 115) bpm\\n BP: 137/80(99) {132/80(99) - 140/92(107)} mmHg\\n RR: 25 (19 - 25) insp/min\\n SPO2: 94%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 92.2 kg (admission): 92.2 kg\\n CVP: 8 (3 - 8) mmHg\\n Total In:\\n 4,477 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 4,227 mL\\n Blood products:\\n 250 mL\\n Total out:\\n 0 mL\\n 1,335 mL\\n Urine:\\n 595 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 3,142 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SPO2: 94%\\n ABG: 7.33/46/77./24/-1\\n PaO2 / FiO2: 156\\n Physical Examination\\n General Appearance: No acute distress\\n Cardiovascular: (Rhythm: Regular), +s1/s2\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, No(t) Non-tender\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n Moves all extremities\\n Labs / Radiology\\n 357 K/uL\\n 17.3 g/dL\\n 155 mg/dL\\n 0.9 mg/dL\\n 24 mEq/L\\n 4.8 mEq/L\\n 9 mg/dL\\n 105 mEq/L\\n 137 mEq/L\\n 52.5 %\\n 14.5 K/uL\\n [image002.jpg]\\n 12:41 AM\\n 12:50 AM\\n WBC\\n 14.5\\n Hct\\n 52.5\\n Plt\\n 357\\n Creatinine\\n 0.9\\n TCO2\\n 25\\n Glucose\\n 155\\n Other labs: PT / PTT / INR:17.0/32.0/1.5, Lactic Acid:1.9 mmol/L,\\n Ca:7.9 mg/dL, Mg:3.4 mg/dL, PO4:4.6 mg/dL\\n Assessment and Plan\\n .H/O DIVERTICULITIS\\n Assessment and Plan: 52yM with free air/ frank stool due to perf\\n diverticulitis s/p sigmoid resection and end colostomy \\n Neurologic:\\n -- dailudid PCA for pain control with extra dilaudid IV prn for\\n breakthrough in immediate post op period. Assess PRN IV dilaudid doses\\n and consider upping PCA if needed\\n Cardiovascular:\\n -- SIRS: tachycardic to 120's, MAPs maintianing >60 without pressors,\\n 2.5 L LR bolus given\\n Pulmonary:\\n -- extubated in OR, stable on NC\\n Gastrointestinal / Abdomen:\\n -- NG in place to suction\\n -- GI proph with PPI\\n -- coags elevated for unknown reason, LFT's seem WNL, hepatitis\\n serologies sent\\n Nutrition:\\n --NPO\\n Renal:\\n --Baseline creatinine 0.9\\n --AUOP\\n Hematology:\\n -- DVT proph with heparin SC and boots\\n -- HCT elecated, possible due to hemoconcentration, min EBL in OR\\n Endocrine: -\\n - RISS for glycemic control\\n Infectious Disease:\\n -- vanc /zosyn for empiric coverage (started )\\n -- febrile likely secondary to abd source, will CTM cx\\n Lines / Tubes / Drains: PIV, Foley, A-line (), NG, TLC ()\\n Wounds: abd\\n Consults: General surgery\\n Billing Diagnosis:\\n ICU Care\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 12:30 AM\\n Arterial Line - 12:30 AM\\n 18 Gauge - 12:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n Communication: Comments:\\n Code status: Full code\\n Disposition: SICU ; possible transfer\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2136-02-25 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 529444,\n \"text\": \"SICU\\n HPI:\\n 52yM with h/o multiple episodes diverticulitis. Was in the\\n ER 1 week ago with abd pain, no evid of diverticulitis on CT but\\n treated empirically with cipro/flagyl. Pain improved but then\\n this morning could not void and had excrutiating abd pain. Came\\n to ED and foley placed, no improvement. CT done which showed\\n free air.\\n Chief complaint:\\n abd pain\\n PMHx:\\n diverticulitis\\n PSH: exploratory laparoscopy, exploratory laparotomy (s/p stabbing),\\n left knee surgery, neck surgery\\n Current medications:\\n Acetaminophen 9. Calcium Gluconate\\n 10. Dextrose 50% 11. Glucagon 12. HYDROmorphone (Dilaudid) 13.\\n HYDROmorphone (Dilaudid) 14. Heparin\\n 15. Insulin 16. Magnesium Sulfate 17. Magnesium Sulfate 18. Ondansetron\\n 19. Pantoprazole 20. Piperacillin-Tazobactam\\n 21. Potassium Chloride 22. Sodium Chloride 0.9% Flush 23. Sodium\\n Chloride 0.9% Flush 24. Vancomycin\\n 24 Hour Events:\\n MULTI LUMEN - START 12:30 AM\\n ARTERIAL LINE - START 12:30 AM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Flowsheet Data as of 05:34 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.9\\nC (100.2\\n T current: 36.7\\nC (98\\n HR: 105 (96 - 115) bpm\\n BP: 137/80(99) {132/80(99) - 140/92(107)} mmHg\\n RR: 25 (19 - 25) insp/min\\n SPO2: 94%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 92.2 kg (admission): 92.2 kg\\n CVP: 8 (3 - 8) mmHg\\n Total In:\\n 4,477 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 4,227 mL\\n Blood products:\\n 250 mL\\n Total out:\\n 0 mL\\n 1,335 mL\\n Urine:\\n 595 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 3,142 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SPO2: 94%\\n ABG: 7.33/46/77./24/-1\\n PaO2 / FiO2: 156\\n Physical Examination\\n General Appearance: No acute distress\\n Cardiovascular: (Rhythm: Regular), +s1/s2\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, No(t) Non-tender\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n Moves all extremities\\n Labs / Radiology\\n 357 K/uL\\n 17.3 g/dL\\n 155 mg/dL\\n 0.9 mg/dL\\n 24 mEq/L\\n 4.8 mEq/L\\n 9 mg/dL\\n 105 mEq/L\\n 137 mEq/L\\n 52.5 %\\n 14.5 K/uL\\n [image002.jpg]\\n 12:41 AM\\n 12:50 AM\\n WBC\\n 14.5\\n Hct\\n 52.5\\n Plt\\n 357\\n Creatinine\\n 0.9\\n TCO2\\n 25\\n Glucose\\n 155\\n Other labs: PT / PTT / INR:17.0/32.0/1.5, Lactic Acid:1.9 mmol/L,\\n Ca:7.9 mg/dL, Mg:3.4 mg/dL, PO4:4.6 mg/dL\\n Assessment and Plan\\n .H/O DIVERTICULITIS\\n Assessment and Plan: 52yM with free air/ frank stool due to perf\\n diverticulitis s/p sigmoid resection and end colostomy \\n Neurologic:\\n -- dailudid PCA for pain control with extra dilaudid IV prn for\\n breakthrough in immediate post op period. Assess PRN IV dilaudid doses\\n and consider upping PCA if needed\\n Cardiovascular:\\n -- SIRS: tachycardic to 120's, MAPs maintianing >60 without pressors,\\n 2.5 L LR bolus given\\n Pulmonary:\\n -- extubated in OR, stable on NC\\n Gastrointestinal / Abdomen:\\n -- NG in place to suction\\n -- GI proph with PPI\\n -- coags elevated for unknown reason, LFT's seem WNL, hepatitis\\n serologies sent\\n Nutrition:\\n --NPO\\n Renal:\\n --Baseline creatinine 0.9\\n --AUOP\\n Hematology:\\n -- DVT proph with heparin SC and boots\\n -- HCT elecated, possible due to hemoconcentration, min EBL in OR\\n Endocrine: -\\n - RISS for glycemic control\\n Infectious Disease:\\n -- vanc /zosyn for empiric coverage (started )\\n -- febrile likely secondary to abd source, will CTM cx\\n Lines / Tubes / Drains: PIV, Foley, A-line (), NG, TLC ()\\n Wounds: abd\\n Consults: General surgery\\n Billing Diagnosis:\\n ICU Care\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 12:30 AM\\n Arterial Line - 12:30 AM\\n 18 Gauge - 12:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n Communication: Comments:\\n Code status: Full code\\n Disposition: SICU ; possible transfer\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2136-02-25 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 529386,\n \"text\": \"SICU\\n HPI:\\n 52yM with h/o multiple episodes diverticulitis. Was in the\\n ER 1 week ago with abd pain, no evid of diverticulitis on CT but\\n treated empirically with cipro/flagyl. Pain improved but then\\n this morning could not void and had excrutiating abd pain. Came\\n to ED and foley placed, no improvement. CT done which showed\\n free air.\\n Chief complaint:\\n abd pain\\n PMHx:\\n diverticulitis\\n PSH: exploratory laparoscopy, exploratory laparotomy (s/p stabbing),\\n left knee surgery, neck surgery\\n Current medications:\\n Acetaminophen 9. Calcium Gluconate\\n 10. Dextrose 50% 11. Glucagon 12. HYDROmorphone (Dilaudid) 13.\\n HYDROmorphone (Dilaudid) 14. Heparin\\n 15. Insulin 16. Magnesium Sulfate 17. Magnesium Sulfate 18. Ondansetron\\n 19. Pantoprazole 20. Piperacillin-Tazobactam\\n 21. Potassium Chloride 22. Sodium Chloride 0.9% Flush 23. Sodium\\n Chloride 0.9% Flush 24. Vancomycin\\n 24 Hour Events:\\n MULTI LUMEN - START 12:30 AM\\n ARTERIAL LINE - START 12:30 AM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Flowsheet Data as of 05:34 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.9\\nC (100.2\\n T current: 36.7\\nC (98\\n HR: 105 (96 - 115) bpm\\n BP: 137/80(99) {132/80(99) - 140/92(107)} mmHg\\n RR: 25 (19 - 25) insp/min\\n SPO2: 94%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 92.2 kg (admission): 92.2 kg\\n CVP: 8 (3 - 8) mmHg\\n Total In:\\n 4,477 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 4,227 mL\\n Blood products:\\n 250 mL\\n Total out:\\n 0 mL\\n 1,335 mL\\n Urine:\\n 595 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 3,142 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SPO2: 94%\\n ABG: 7.33/46/77./24/-1\\n PaO2 / FiO2: 156\\n Physical Examination\\n General Appearance: No acute distress\\n Cardiovascular: (Rhythm: Regular), +s1/s2\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, No(t) Non-tender\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n Moves all extremities\\n Labs / Radiology\\n 357 K/uL\\n 17.3 g/dL\\n 155 mg/dL\\n 0.9 mg/dL\\n 24 mEq/L\\n 4.8 mEq/L\\n 9 mg/dL\\n 105 mEq/L\\n 137 mEq/L\\n 52.5 %\\n 14.5 K/uL\\n [image002.jpg]\\n 12:41 AM\\n 12:50 AM\\n WBC\\n 14.5\\n Hct\\n 52.5\\n Plt\\n 357\\n Creatinine\\n 0.9\\n TCO2\\n 25\\n Glucose\\n 155\\n Other labs: PT / PTT / INR:17.0/32.0/1.5, Lactic Acid:1.9 mmol/L,\\n Ca:7.9 mg/dL, Mg:3.4 mg/dL, PO4:4.6 mg/dL\\n Assessment and Plan\\n .H/O DIVERTICULITIS\\n Assessment and Plan: 52yM with free air/ frank stool due to perf\\n diverticulitis s/p sigmoid resection and end colostomy \\n Neurologic: -- dailudid PCA for pain control with extra dilaudid IV prn\\n for breakthrough in immediate post op period. Assess PRN IV dilaudid\\n doses and consider upping PCA if needed\\n Cardiovascular: -- SIRS: tachycardic to 120's, MAPs maintianing >60\\n without pressors, 2.5 L LR bolus given\\n Pulmonary: -- extubated in OR, stable on NC\\n Gastrointestinal / Abdomen: -- NG in place to suction\\n -- GI proph with PPI\\n -- coags elevated for unknown reason, LFT's seem WNL, hepatitis\\n serologies sent\\n Nutrition: --NPO\\n Renal: --Baseline creatinine 0.9\\n --AUOP\\n Hematology: -- DVT proph with heparin SC and boots\\n -- HCT elecated, possible due to hemoconcentration, min EBL in OR\\n Endocrine: -- RISS for glycemic control\\n Infectious Disease: -- vanc /zosyn for empiric coverage (started )\\n -- febrile likely secondary to abd source, will CTM cx\\n Lines / Tubes / Drains: PIV, Foley, A-line (), NG, TLC ()\\n Wounds: abd\\n Imaging:\\n Fluids:\\n Consults: General surgery\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 12:30 AM\\n Arterial Line - 12:30 AM\\n 18 Gauge - 12:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP bundle:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2136-02-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 529348,\n \"text\": \"TITLE:\\n 52 yo disabled prison guard w h/o multiple episodes diverticulitis.\\n Presented to E.D 1 wk ago and abd CT showed no evidence of\\n diverticulitis but empirically treated w cipro/flagyl symptoms improved\\n until a.m. Presented to after acute onset of abd pain.\\n Free air on CT noted.\\n Intraop findings include perforated diverticulum w lg amts feculent\\n material intraabd cavity.\\n PSHx includes: C4 C5 C6 screws placed( after assault at work), exp lap\\n (stabbing), lt knee repair, lt rotator cuff repair\\n .H/O diverticulitis- S/P sigmoid colectomy and colostomy\\n Assessment:\\n Received pt from PACU awake, alert, moaning in pain , diaphoretic\\n w temp 100.6 (*8 hx temp 102.7 in PACU). Pt admits to abd pain\\n (increased w movement on transfer) CV- 110-120 RR 28-30 Sbp 100.\\n CVP-0-2\\n Resp- BBS clear dim at bases nasal at 3lpm and Face tent at 35%\\n Abd firm, distended, tender. No active bowel sounds. Ngt to lws w clear\\n to tan drng\\n Mid abd transparent drsg of serosang stain. JP to bulb w\\n serousy drng. Colostomy stoma dusky w serous drng.\\n Action:\\n Antibiotics\\nVanco & Zosyn\\n Cooling blanket on bed for temp spikes\\n PCA dilaudid given to pt and instructed on proper use.\\n Labs sent w lactate and abg\\n LR Bolus x 2 liters for fld volume resusc (post op Hct 52) & IVF\\n mainten @ 125cc/hr\\n O2 sats 92-93% on 3 nc and 35%-> incr to 50 % FT and 3 nc\\n Pt teaching done re: DBC and incentive spirometry once pain threshold <\\n 5\\n UOP 25cc x 1 hr ** fld bolus as noted x 2\\n Dr notified of dusky stoma.\\n Response:\\n Tachycardia and low uop resolving w fld resusc\\n O2 sats improved w fio2 increase\\n Pain under control w PCA dilaudid\\n Pt needs encouragement to DBC and use Incentive spirometry.\\n Plan:\\n Turn and repositioning q2h\\n Dilaudid prn IVB for breakthrough pain as ordered.\\n Cont to monitor stoma color\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2136-02-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 529406,\n \"text\": \"TITLE:\\n 52 yo disabled prison guard w h/o multiple episodes diverticulitis.\\n Presented to E.D 1 wk ago and abd CT showed no evidence of\\n diverticulitis but empirically treated w cipro/flagyl symptoms improved\\n until a.m. Presented to after acute onset of abd pain.\\n Free air on CT noted.\\n Intraop findings include perforated diverticulum w lg amts feculent\\n material intraabd cavity.\\n PSHx includes: C4 C5 C6 screws placed( assault at work), exp lap\\n (stabbing), lt knee repair, lt rotator cuff repair\\n .H/O diverticulitis- S/P sigmoid colectomy and colostomy\\n Assessment:\\n Received pt from PACU awake, alert, moaning in pain , diaphoretic\\n w temp 100.6 (*8 hx temp 102.7 in PACU). Pt admits to abd pain\\n (increased w movement on transfer) CV- 110-120 RR 28-30 Sbp 100.\\n CVP-0-2\\n Resp- BBS clear dim at bases nasal at 3lpm and Face tent at 35%\\n Abd firm, distended, tender. No active bowel sounds. Ngt to lws w clear\\n to tan drng\\n Mid abd transparent drsg of serosang stain. JP to bulb w\\n serousy drng. Colostomy stoma dusky w serous drng.\\n Action:\\n Antibiotics\\nVanco & Zosyn\\n Cooling blanket on bed for temp spikes\\n PCA dilaudid given to pt and instructed on proper use.\\n Labs sent w lactate and abg\\n LR Bolus x 2 liters for fld volume resusc (post op Hct 52) & IVF\\n mainten @ 125cc/hr\\n O2 sats 92-93% on 3 nc and 35%-> incr to 50 % FT and 3 nc\\n Pt teaching done re: DBC and incentive spirometry once pain threshold <\\n 5\\n UOP 25cc x 1 hr ** fld bolus as noted x 2\\n Dr notified of dusky stoma.\\n Response:\\n Tachycardia and low uop resolving w fld resusc\\n O2 sats improved w fio2 increase\\n Pt reports pain under control w PCA dilaudid\\n Pt needs encouragement to DBC and use Incentive spirometry.\\n Plan:\\n Turn and repositioning q2h\\n Cont to monitor pain and management w PCA dilaudid\\n Cont to monitor stoma color\\n Empty and record Jp drainage\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2136-02-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 529344,\n \"text\": \"TITLE:\\n 52 yo disabled prison guard w h/o multiple episodes diverticulitis.\\n Presented to E.D 1 wk ago and abd CT showed no evidence of\\n diverticulitis but empirically treated w cipro/flagyl symptoms improved\\n until a.m. Presented to after acute onset of abd pain.\\n Free air on CT noted.\\n Intraop findings include perforated diverticulum w lg amts feculent\\n material intraabd cavity.\\n PSHx includes: C4 C5 C6 screws placed( after assault at work), exp lap\\n (stabbing), lt knee repair, lt rotator cuff repair\\n .H/O diverticulitis- S/P sigmoid colectomy and colostomy\\n Assessment:\\n Received pt from PACU awake, alert, moaning in pain . Pt admits to\\n abd pain (increased w movement on transfer)\\n Abd firm, distended, tender.\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2136-02-25 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1127634,\n \"text\": \" 12:04 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: please eval central line placement\\n Admitting Diagnosis: PERFORATED DIVERTICULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 52 year old man s/p exlap, small bowel resection.\\n REASON FOR THIS EXAMINATION:\\n please eval central line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST\\n\\n HISTORY: Central line placement.\\n\\n One supine portable view. Lung volumes are low. There is streaky density at\\n the lung bases most consistent with subsegmental atelectasis. There is\\n suggestion of air bronchograms in the retrocardiac area and a small focal area\\n of consolidation in the left lower lobe cannot be excluded. The cardiac\\n silhouette is prominent but may be exaggerated by portable technique.\\n Mediastinal structures are otherwise unremarkable. A nasogastric tube\\n terminates below the diaphragm. Its side hole is just below the level of the\\n diaphragm. A right subclavian line is present and terminates at the level of\\n the cavoatrial junction.\\n\\n IMPRESSION: Limited study as described. Bilateral subsegmental atelectasis.\\n A small retrocardiac infiltrate cannot be excluded.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2136-03-05 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 1128970,\n \"text\": \" 2:09 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: r/o obstruction/collectionCT with IV AND PO contrast\\n Admitting Diagnosis: PERFORATED DIVERTICULITIS\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 52M with perf diverticulitis s/p sigmoid resection and end colostomy \\n REASON FOR THIS EXAMINATION:\\n r/o obstruction/collectionCT with IV AND PO contrast\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 52-year-old male with perforated diverticulitis treated with\\n sigmoid resection and end colostomy placement.\\n\\n Comparison is made to the prior study of .\\n\\n TECHNIQUE: Axial MDCT images of the abdomen and pelvis were obtained after\\n administration of 130 cc of Optiray intravenously. Sagittal and coronal\\n reformatted images were then acquired.\\n\\n FINDINGS: Small to moderate right pleural effusion and right basilar\\n atelectasis are noted. The visualized portion of the left lung base is\\n normal. A small hiatal hernia is visualized.\\n\\n There is a 10-mm hypodense lesion within the segment of the liver which is\\n too small to characterize.\\n\\n The ring-enhancing collection is noted in the subcapsular part of the right\\n lobe of the liver. The findings are compatible with subcapsular abscess\\n collection, the largest pocket of subcapsular collection measures 6.3 x 1.8\\n cm.Complex-appearing fluid collection is noted within the right lower quadrant\\n area with the largest pocket of collection measuring 3.7 x 2.2 cm. This\\n finidng is suggestive of interloop abscess.\\n\\n The gallbladder, adrenal glands, kidneys, spleen, pancreas appear\\n unremarkable. Diffusely distended small bowel loops and ascending colon and\\n transverse colon are most likely compatible with ileus rather than\\n obstruction. Normal appearance of ileostomy is noted within the left lower\\n quadrant area. Surgical drain is noted within the right lower quadrant area\\n .\\n\\n CT OF THE PELVIS WITH CONTRAST: The urinary bladder, distal ureters, and\\n Hartmann pouch appear unremarkable. No free fluid is noted within the pelvis.\\n\\n BONE WINDOWS: No concerning lytic or sclerotic lesions are identified.\\n\\n IMPRESSION:\\n 1. Status post sigmoid colectomy and end colostomy. Complex collection is\\n noted in the right lower quadrant area and in the subcapsular location within\\n the liver. These collections are relatively small and cannot be drained\\n percutaneously.\\n (Over)\\n\\n 2:09 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: r/o obstruction/collectionCT with IV AND PO contrast\\n Admitting Diagnosis: PERFORATED DIVERTICULITIS\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 2. Diffuse distention of the small bowel, ascending colon, and transverse\\n colon is mostly compatible with ileus.\\n\\n Findings were discussed with Dr. Dibs at the time of dictation by Dr.\\n .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2136-02-24 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 1127544,\n \"text\": \" 10:59 AM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: r/o abscess, perfed tic\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 52 year old man with diverticulitis, worse pain\\n REASON FOR THIS EXAMINATION:\\n r/o abscess, perfed tic\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: YGd FRI 1:09 PM\\n Perforated sigmoid diverticulitis with 3cm air/fluid collection (predomly\\n air), compatible with abscess, though no drainable collection. Multiple foci\\n of free intraperitoneal air. Small ascites. Inflammatory changes in distal\\n ileum likely 2ndary to acute diverticulitis.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 52-year-old man with diverticulitis with increased pain. Study\\n to rule out abscess or perforated diverticulitis.\\n\\n COMPARISON: CT abdomen from .\\n\\n TECHNIQUE: MDCT images were performed from the lung bases through the pubic\\n symphysis following administration of intravenous contrast. Coronal and\\n sagittal reformats were provided.\\n\\n CT ABDOMEN: There is mild-to-moderate bibasilar dependent atelectasis, right\\n greater than left. The heart is top normal in size. There is no pericardial\\n effusion.\\n\\n There is pneumoperitoneum with foci of free air along the anterior margin of\\n liver, in the porta hepatis, and scattered throughout the abdomen. A small\\n amount of perihepatic ascites is identified with a larger amount of fluid in\\n the right lower quadrant as well as within adjacent mesentery (301b, 29).\\n There are scattered diverticula involving the sigmoid colon extending into the\\n ascending colon. There is moderate wall thickening and hyperemia within a\\n segment of sigmoid colon with extensive adjacent fat stranding in the lower\\n abdomen (2, 76). Adjacent to the inflamed sigmoid colon, there is a 2.5 x 3.1\\n cm air-fluid collection which is primarily composed of air, compatible with a\\n small abscess (2, 74). No drainable focal collection is identified. There\\n are inflammatory changes extending to the right lower quadrant with fluid,\\n stranding, and mild lateral conal thickening. There is moderate mural\\n thickening and stranding involving the distal ileum, likely due to reactive\\n inflammatory changes. Enhancement and thickening of the peritoneum,\\n particularly on the right, is compatible with peritonitis.\\n\\n The liver, gallbladder, spleen, pancreas, and adrenal glands appear\\n unremarkable. Bilateral kidneys enhance and excrete contrast symmetrically\\n without hydronephrosis or hydroureter. The appendix appears within normal\\n limits. Scattered atherosclerotic calcifications involve predominantly the\\n infrarenal aorta, with extension into iliac arteries.\\n\\n (Over)\\n\\n 10:59 AM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: r/o abscess, perfed tic\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n CT PELVIS: The bladder is collapsed, with a urinary Foley catheter in place.\\n The prostate, rectum, and distal ureters appear unremarkable. Small inguinal\\n and pelvic lymph nodes do not meet CT size criteria for pathologic\\n enlargement.\\n\\n BONE WINDOW: Osseous structures are unremarkable.\\n\\n IMPRESSION: Perforated sigmoid diverticulitis with adjacent 3-cm air and\\n fluid collection (primarily composed of air), compatible with an abscess,\\n pneumoperitoneum, and peritonitis. No focal drainable collections seen. Small\\n amount with reactive inflammatory changes in the distal small\\n bowel. Findings discussed with Dr. at 1:30 p.m. on .\\n\\n\"\n }\n]"}}},{"rowIdx":24697,"cells":{"subject_id":{"kind":"number","value":5843,"string":"5,843"},"hadm_id":{"kind":"number","value":132002,"string":"132,002"},"target_text":{"kind":"string","value":"A/P: 66yo woman with hx of stage IV NSCLC dx in with known liver mets, s/p recent change in chemo regimen and initiation of Ritalin on , who presents to ED with AMS s/p fall at home, found to have hyponatremia to 119, possible new brain mets on CT, high Anion gap, leukopenia, macrocytic anemia. 1. AMS: hyponatremia vs. new brain mets. She was hyponatremic on admission (? SIADH), and this was corrected with fluid restriction and was stable upon discharge. MRI of the brain showed bilateral occipital changes consistent with reversible encephalopathy of unclear etiology with no evidence of brain metastases. Neurology was consulted and felt that she did not necessarily have this encephalopathy and required no further imaging or treatment. Her Mental status continued to improve as her sodium was corrected. She was at her baseline at discharge, alert and oriented x 3, with a stable sodium. She was discharged to continue with her fluid restriction. 2. E. coli Urosepsis: Although initially afebrile and hemodynamically stable, she became febrile, hypotensive, and was found to have blood cultures growing E. Coli on (presumed urinary source). She was in the briefly, started on Levofloxacin and gentamicin (to double cover for gram negatives; E. coli was sensitive to these antibiotics), and she defervesced, became hemodynamically stable. She returned to the floor, and only the Levofloxacin was continued (to complete a 10 day course). On , she spiked on antibiotics, and vancomycin was added (? of a superficial thrombophlebitis on her right forearm). She remained afebrile and stable after the addition of this antibiotic, and she will complete a 10-day course of both the levofloxacin and vancomycin. Her foley was taken out prior to discharge. She was bolused as necessary (with good response) for symptomatic hypotension. 3. Thrombocytopenia: Her platelets trended down in-house (never any signs of bleeding; nadir was 25,000). HIT antibody was checked and was negative. At time of discharge, platelets were trending up (she never required any platelet transfusion). The cause of this was thought to be secondary to infection/sepsis. These should be monitored as an outpatient to ensure that they remain stable. 4. Fall: witnessed at home with minor head trauma, no LOC. Neuro exam was followed in-house and was stable. She was on fall precautions. Physical therapy worked with her prior to discharge, and she will continue with this at rehabilitation. 5. Macrocytic anemia: likely from chemo; folate and b12 were within normal limits, transfusion threshold was 28 (given her history of CAD). She required 1 U PRBC on with good response. Hematocrit was stable at time of discharge. 6. Nutrition: she had poor PO intake while in-house and was followed by nutrition. She was started on 40 mg Prednisone which improved her appetite. She was discharged on 20 mg Prednisone (to be tapered as an outpatient by Dr. and Megace to improve her appetite. 7. PPx: colace, senna, PO diet, OOB as tolerated, SQ heparin given risk from NSCLCA; the SQ heparin should be continued at rehabilitation. Bowel regimen was used as necessary; her stools were loose at time of discharge (therefore bowel medications held). 8. Code: DNR/DNI per conversation with patient, HCP/son; corroborated with Dr. at 830pm on 9. Dispo: She was discharged to where she will continue with PT and complete her antibiotic course. After she leaves , she should follow up with Dr. (within 1 week of leaving )."},"extractive_notes_summ":{"kind":"string","value":"with CA -also, area of calcification in the right cerebellum, without mass effect - uncertain etiology FINAL REPORT *ABNORMAL! Right cerebellar calcifications without associated mass effect of uncertain etiology. Otherwise, no diagnostic interim change.TRACING #1 TECHNIQUE: Noncontrast head CT. FINDINGS: The heart size and mediastinal contours are within normal limits. FINDINGS: On diffusion images, no evidence of slow diffusion is seen to indicate acute infarct. LS clear and diminished at bases. Right IJ catheter is unchanged. IMPRESSION: 1) No evidence of pulmonary edema. FINDINGS: No change from prior study dated . FINDINGS: There is no acute intracranial hemorrhage. No acute disease. Compared to theprevious no diagnostic interim change.TRACING #2 No acute intracranial hemorrhage. No acute cardiopulmonary disease. Sinus tachycardiaNormal ECG except for rateSince previous tracing of , sinus tachycardia present Following gadolinium administration no evidence of abnormal parenchymal, vascular or meningeal enhancement is seen. Denies any pain. MAEx4 but weak.CV: Tmax 99.9. IMPRESSION: No evidence of pneumonia. T1 axial, coronal and sagittal images were obtained following the administration of gadolinium. In the right cerebellar lobe, there are scattered areas of calcification of uncertain etiology. Other than tube placement, there is no short-interval change. Ectopic atrial rhythmSince last ECG, ectopic atrial rhythm is new No restricted diffusion is seen in this region. The heart size, mediastinal, and hilar contours are within normal limits and stable. Pneumoboots applied. The ventricles are normal in appearance. Trace LE edema. Complaining of congestion but no SOB. There is no shift of normally midline structures. No osseous abnormalities are seen. On sq heparin. Sinus tachycardia with slowing of the rate as compared to the prior tracing.There is frequent ventricular ectopy at a regular interval. The left upper lobe nodule seen best on prior radiographs is decreased in size and is not well seen on today's examination. Delayed precordial R waveprogression. HR 90s-130s SR/ST with occ. There is no enhancement or slow diffusion is seen in this region. Sinus tachycardia and occasional atrial ectopy. Compared to the previous tracing of the rate hasincreased, ventricular ectopy has appeared and there is variation in precordiallead placement. IMPRESSION: No evidence of acute infarct or anbormal enhancement to indicate metastatic disease. No cardiomegaly, vascular congestion, consolidations, effusions, PTX, or lung nodules. The lungs demonstrate no focal areas of consolidation or pleural effusion. Areas of low attenuation in the periventricular white matter are consistent with chronic microvascular infarcts. A more rounded focus in the high left parietal lobe may also represent a small infarct, however, in a patient with known metastatic disease, a metastatic lesion cannot be excluded. Low attenuation foci which likely represent chronic microvascular infarcts, however, metastatic lesions cannot be excluded. Foley with poor u/o on arrival but now picking up to 40-100cc/hr.SKIN: Intact. SBP 80s-110s. Skin warm and dry with palpable pedal pulses bilat. IMPRESSION: 1. A chronic infarct is visualized in the right cerebellar hemisphere. There is no associated mass effect. Osseous and soft tissue structures are unremarkable. On clear liquids and to receive speech and swallow consult today. -white matter differentiation is preserved. 2:04 PM CHEST (PA & LAT) Clip # Reason: ? Now with mental status post changes. Bilateral occipital hyperintensities suspicious for posterior reversible encephalopathy. No evidence of pneumothorax, pleural effusion, or pulmonary parenchymal consolidation. As seen on the previous CT exam, an area of high signal is seen in the left pareital convexity region in the subcortical area. TECHNIQUE: AP and lateral chest. No apparent problems swallowing liquids this shift with aspiration precautions maintained and HOB upright with swallowing or pills. IMPRESSION: Satisfactory line placement. No evidence of midline shift or hydrocephalus seen. 5:31 PM CHEST (PA & LAT) Clip # Reason: ? Question CHF. There is no involvement of the cortex seen. Received 2u PRBCs without incident overnight with am labs pending. Large loose-liquid BM overnight, heme negative and sample sent for C-diff. soft and slightly distended with positive bowel sounds. Pt. CVP on arrival and now . K+ and MG repleted overnight. R IJ central line placed on arrival with placement confirmed by CXR. 12:52 PM CT HEAD W/O CONTRAST Clip # Reason: r/o bleed MEDICAL CONDITION: 66 year old woman with s/p fall now w mental status changes REASON FOR THIS EXAMINATION: r/o bleed No contraindications for IV contrast WET READ: DFDgf 2:13 PM -no acute intracranial hemorrhage -areas of chronic microvascular infarction in the white matter -focus of low attenuation in the high left parietal lobe - cannot exclude a metastasis in a pt. TECHNIQUE: T1 sagittal and axial and FLAIR, T2 susceptibility, and diffusion axial images of the brain were obtained before gadolinium. Evaluate for pulmonary edema. PVCs. Fever. Fever. is a full code. 3. Line placement. MICU NPN:NEURO: A&Ox3. Also received 1L NS bolus on arrival.RESP: Currently on 3L O2 via NC with O2 Sat >94%."},"n_notes":{"kind":"number","value":11,"string":"11"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2197-12-22 00:00:00.000","description":"Report","row_id":1338883,"text":"MICU NPN:\nNEURO: A&Ox3. Pleasant and cooperative. Denies any pain. MAEx4 but weak.\nCV: Tmax 99.9. HR 90s-130s SR/ST with occ. PVCs. K+ and MG repleted overnight. SBP 80s-110s. Skin warm and dry with palpable pedal pulses bilat. Pneumoboots applied. On sq heparin. Trace LE edema. Received 2u PRBCs without incident overnight with am labs pending. CVP on arrival and now . Also received 1L NS bolus on arrival.\nRESP: Currently on 3L O2 via NC with O2 Sat >94%. LS clear and diminished at bases. Complaining of congestion but no SOB. RR 20s. Dangled on side of bed this am with chest PT given and deep breathing and coughing with non-productive cough.\nGI/GU: Abd. soft and slightly distended with positive bowel sounds. Large loose-liquid BM overnight, heme negative and sample sent for C-diff. On clear liquids and to receive speech and swallow consult today. No apparent problems swallowing liquids this shift with aspiration precautions maintained and HOB upright with swallowing or pills. Foley with poor u/o on arrival but now picking up to 40-100cc/hr.\nSKIN: Intact. R IJ central line placed on arrival with placement confirmed by CXR. Two peripheral IVs intact.\nSOCIAL: Brother is health care proxy and made aware of transfer to ICU overnight by MDs. Pt. is a full code.\n\n"},{"category":"Radiology","chartdate":"2197-12-19 00:00:00.000","description":"CHEST (PA & LAT)","row_id":853431,"text":" 5:31 PM\n CHEST (PA & LAT) Clip # \n Reason: ? pulmonary edema\n Admitting Diagnosis: S/P FALL;DEHYDRATION;ALTERED MENTAL CHANGES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with hx NSCLC who presents with hyponatremia and now\n complains of SOB\n REASON FOR THIS EXAMINATION:\n ? pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 66-year-old female with non-small cell lung cancer with\n hyponatremia and shortness of breath. Evaluate for pulmonary edema.\n\n FINDINGS:\n\n The heart size and mediastinal contours are within normal limits. No evidence\n of pneumothorax, pleural effusion, or pulmonary parenchymal consolidation. The\n left upper lobe nodule seen best on prior radiographs is decreased in size and\n is not well seen on today's examination. No osseous abnormalities are seen.\n\n IMPRESSION:\n\n 1) No evidence of pulmonary edema.\n\n 2) Decreased size of the patient's known lung cancer within the left upper\n lobe which is better assessed on a recent chest CT from .\n\n"},{"category":"Radiology","chartdate":"2197-12-15 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":853004,"text":" 12:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with s/p fall now w mental status changes\n REASON FOR THIS EXAMINATION:\n r/o bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DFDgf 2:13 PM\n -no acute intracranial hemorrhage\n -areas of chronic microvascular infarction in the white matter\n -focus of low attenuation in the high left parietal lobe - cannot exclude a\n metastasis in a pt. with CA\n -also, area of calcification in the right cerebellum, without mass effect -\n uncertain etiology\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: 66 year old woman status post fall. Now with mental status post\n changes. History of metastatic lung cancer.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is no acute intracranial hemorrhage. Areas of low\n attenuation in the periventricular white matter are consistent with chronic\n microvascular infarcts. A more rounded focus in the high left parietal lobe\n may also represent a small infarct, however, in a patient with known\n metastatic disease, a metastatic lesion cannot be excluded. In the right\n cerebellar lobe, there are scattered areas of calcification of uncertain\n etiology. There is no associated mass effect. The ventricles are normal in\n appearance. There is no shift of normally midline structures. -white\n matter differentiation is preserved. Osseous and soft tissue structures are\n unremarkable.\n\n IMPRESSION:\n\n 1. No acute intracranial hemorrhage.\n\n 2. Low attenuation foci which likely represent chronic microvascular\n infarcts, however, metastatic lesions cannot be excluded. Gadolinium enhanced\n MRI can be performed for evaluation for metastatic disease.\n\n 3. Right cerebellar calcifications without associated mass effect of\n uncertain etiology.\n\n\n\n"},{"category":"Radiology","chartdate":"2197-12-24 00:00:00.000","description":"CHEST (PA & LAT)","row_id":853966,"text":" 2:04 PM\n CHEST (PA & LAT) Clip # \n Reason: ? CHF\n Admitting Diagnosis: S/P FALL;DEHYDRATION;ALTERED MENTAL CHANGES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with hx NSCLC who has SOB after recent volume resuscitation\n in the ICU for urosepsis\n REASON FOR THIS EXAMINATION:\n ? CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 66-year-old woman with history of non-small-cell lung cancer who\n has shortness of breath after recent volume resuscitation in the ICU for\n urosepsis. Question CHF.\n\n TECHNIQUE: AP and lateral chest.\n\n FINDINGS:\n\n No change from prior study dated . No acute cardiopulmonary\n disease. Right IJ catheter is unchanged.\n\n\n"},{"category":"Radiology","chartdate":"2197-12-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":853691,"text":" 9:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate right IJ CVL placement\n Admitting Diagnosis: S/P FALL;DEHYDRATION;ALTERED MENTAL CHANGES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with stage iv lung ca now w/ fevers, hypotension\n\n REASON FOR THIS EXAMINATION:\n Evaluate right IJ CVL placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Stage 4 lung CA. Fever. Line placement.\n\n AP BEDSIDE CHEST: Since exam eight hours earlier on same day, a right IJ line\n has been placed with its tip in the distal SVC. No cardiomegaly, vascular\n congestion, consolidations, effusions, PTX, or lung nodules. Other than tube\n placement, there is no short-interval change.\n\n IMPRESSION: Satisfactory line placement. No acute disease.\n\n"},{"category":"Radiology","chartdate":"2197-12-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":853639,"text":" 12:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: S/P FALL;DEHYDRATION;ALTERED MENTAL CHANGES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with stage iv lung ca now w/ fevers, hypotension\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest , compared to previous study of 2 days earlier.\n\n INDICATIONS: Lung cancer. Fever.\n\n The heart size, mediastinal, and hilar contours are within normal limits and\n stable. The lungs demonstrate no focal areas of consolidation or pleural\n effusion.\n\n IMPRESSION:\n\n No evidence of pneumonia.\n\n\n"},{"category":"Radiology","chartdate":"2197-12-15 00:00:00.000","description":"MR HEAD W & W/O CONTRAST","row_id":853036,"text":" 4:22 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: Evaluate for further metastasis\n Admitting Diagnosis: S/P FALL;DEHYDRATION;ALTERED MENTAL CHANGES\n Contrast: MAGNEVIST Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with hx of Lung CA, Altered mental status,new lesion on Head\n CT\n REASON FOR THIS EXAMINATION:\n Evaluate for further metastasis\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Patient with history of lung cancer and altered mental\n status, with new lesion on head CT, for further evaluation.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR, T2 susceptibility, and diffusion\n axial images of the brain were obtained before gadolinium. T1 axial, coronal\n and sagittal images were obtained following the administration of gadolinium.\n FINDINGS: On diffusion images, no evidence of slow diffusion is seen to\n indicate acute infarct. As seen on the previous CT exam, an area of high\n signal is seen in the left pareital convexity region in the subcortical area.\n No restricted diffusion is seen in this region. Additionally, there are areas\n of hyperintense T2 signal seen bilaterally in the occipital lobes\n symmetrically. There is no enhancement or slow diffusion is seen in this\n region. There is no involvement of the cortex seen. Increased signal is seen\n diffusely in the pons and also foci of hyperintense T2 signal are seen in the\n periventricular white matter in the frontal and parietal lobes. Following\n gadolinium administration no evidence of abnormal parenchymal, vascular or\n meningeal enhancement is seen. A chronic infarct is visualized in the right\n cerebellar hemisphere.\n\n IMPRESSION:\n No evidence of acute infarct or anbormal enhancement to indicate metastatic\n disease. Bilateral occipital hyperintensities suspicious for posterior\n reversible encephalopathy. However, given some increased signal in the pons,\n this could also be secondary to osmotic myelinolysis. The pontine changes\n could be also due to small vessel disease. No evidence of midline shift or\n hydrocephalus seen. The findings were discussed with Dr. at the\n time of interpretation of this study, on , at 13:00.\n\n"},{"category":"ECG","chartdate":"2197-12-24 00:00:00.000","description":"Report","row_id":186653,"text":"Sinus tachycardia with slowing of the rate as compared to the prior tracing.\nThere is frequent ventricular ectopy at a regular interval. Compared to the\nprevious no diagnostic interim change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2197-12-23 00:00:00.000","description":"Report","row_id":186654,"text":"Sinus tachycardia and occasional atrial ectopy. Delayed precordial R wave\nprogression. Compared to the previous tracing of the rate has\nincreased, ventricular ectopy has appeared and there is variation in precordial\nlead placement. Otherwise, no diagnostic interim change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2197-12-22 00:00:00.000","description":"Report","row_id":186655,"text":"Ectopic atrial rhythm\nSince last ECG, ectopic atrial rhythm is new\n\n"},{"category":"ECG","chartdate":"2197-12-15 00:00:00.000","description":"Report","row_id":186656,"text":"Sinus tachycardia\nNormal ECG except for rate\nSince previous tracing of , sinus tachycardia present\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1338883,\n \"text\": \"MICU NPN:\\nNEURO: A&Ox3. Pleasant and cooperative. Denies any pain. MAEx4 but weak.\\nCV: Tmax 99.9. HR 90s-130s SR/ST with occ. PVCs. K+ and MG repleted overnight. SBP 80s-110s. Skin warm and dry with palpable pedal pulses bilat. Pneumoboots applied. On sq heparin. Trace LE edema. Received 2u PRBCs without incident overnight with am labs pending. CVP on arrival and now . Also received 1L NS bolus on arrival.\\nRESP: Currently on 3L O2 via NC with O2 Sat >94%. LS clear and diminished at bases. Complaining of congestion but no SOB. RR 20s. Dangled on side of bed this am with chest PT given and deep breathing and coughing with non-productive cough.\\nGI/GU: Abd. soft and slightly distended with positive bowel sounds. Large loose-liquid BM overnight, heme negative and sample sent for C-diff. On clear liquids and to receive speech and swallow consult today. No apparent problems swallowing liquids this shift with aspiration precautions maintained and HOB upright with swallowing or pills. Foley with poor u/o on arrival but now picking up to 40-100cc/hr.\\nSKIN: Intact. R IJ central line placed on arrival with placement confirmed by CXR. Two peripheral IVs intact.\\nSOCIAL: Brother is health care proxy and made aware of transfer to ICU overnight by MDs. Pt. is a full code.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2197-12-19 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 853431,\n \"text\": \" 5:31 PM\\n CHEST (PA & LAT) Clip # \\n Reason: ? pulmonary edema\\n Admitting Diagnosis: S/P FALL;DEHYDRATION;ALTERED MENTAL CHANGES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with hx NSCLC who presents with hyponatremia and now\\n complains of SOB\\n REASON FOR THIS EXAMINATION:\\n ? pulmonary edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: A 66-year-old female with non-small cell lung cancer with\\n hyponatremia and shortness of breath. Evaluate for pulmonary edema.\\n\\n FINDINGS:\\n\\n The heart size and mediastinal contours are within normal limits. No evidence\\n of pneumothorax, pleural effusion, or pulmonary parenchymal consolidation. The\\n left upper lobe nodule seen best on prior radiographs is decreased in size and\\n is not well seen on today's examination. No osseous abnormalities are seen.\\n\\n IMPRESSION:\\n\\n 1) No evidence of pulmonary edema.\\n\\n 2) Decreased size of the patient's known lung cancer within the left upper\\n lobe which is better assessed on a recent chest CT from .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2197-12-15 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 853004,\n \"text\": \" 12:52 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: r/o bleed\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with s/p fall now w mental status changes\\n REASON FOR THIS EXAMINATION:\\n r/o bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: DFDgf 2:13 PM\\n -no acute intracranial hemorrhage\\n -areas of chronic microvascular infarction in the white matter\\n -focus of low attenuation in the high left parietal lobe - cannot exclude a\\n metastasis in a pt. with CA\\n -also, area of calcification in the right cerebellum, without mass effect -\\n uncertain etiology\\n ______________________________________________________________________________\\n FINAL REPORT *ABNORMAL!\\n INDICATION: 66 year old woman status post fall. Now with mental status post\\n changes. History of metastatic lung cancer.\\n\\n TECHNIQUE: Noncontrast head CT.\\n\\n FINDINGS: There is no acute intracranial hemorrhage. Areas of low\\n attenuation in the periventricular white matter are consistent with chronic\\n microvascular infarcts. A more rounded focus in the high left parietal lobe\\n may also represent a small infarct, however, in a patient with known\\n metastatic disease, a metastatic lesion cannot be excluded. In the right\\n cerebellar lobe, there are scattered areas of calcification of uncertain\\n etiology. There is no associated mass effect. The ventricles are normal in\\n appearance. There is no shift of normally midline structures. -white\\n matter differentiation is preserved. Osseous and soft tissue structures are\\n unremarkable.\\n\\n IMPRESSION:\\n\\n 1. No acute intracranial hemorrhage.\\n\\n 2. Low attenuation foci which likely represent chronic microvascular\\n infarcts, however, metastatic lesions cannot be excluded. Gadolinium enhanced\\n MRI can be performed for evaluation for metastatic disease.\\n\\n 3. Right cerebellar calcifications without associated mass effect of\\n uncertain etiology.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2197-12-24 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 853966,\n \"text\": \" 2:04 PM\\n CHEST (PA & LAT) Clip # \\n Reason: ? CHF\\n Admitting Diagnosis: S/P FALL;DEHYDRATION;ALTERED MENTAL CHANGES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with hx NSCLC who has SOB after recent volume resuscitation\\n in the ICU for urosepsis\\n REASON FOR THIS EXAMINATION:\\n ? CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: A 66-year-old woman with history of non-small-cell lung cancer who\\n has shortness of breath after recent volume resuscitation in the ICU for\\n urosepsis. Question CHF.\\n\\n TECHNIQUE: AP and lateral chest.\\n\\n FINDINGS:\\n\\n No change from prior study dated . No acute cardiopulmonary\\n disease. Right IJ catheter is unchanged.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2197-12-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 853691,\n \"text\": \" 9:43 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Evaluate right IJ CVL placement\\n Admitting Diagnosis: S/P FALL;DEHYDRATION;ALTERED MENTAL CHANGES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with stage iv lung ca now w/ fevers, hypotension\\n\\n REASON FOR THIS EXAMINATION:\\n Evaluate right IJ CVL placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Stage 4 lung CA. Fever. Line placement.\\n\\n AP BEDSIDE CHEST: Since exam eight hours earlier on same day, a right IJ line\\n has been placed with its tip in the distal SVC. No cardiomegaly, vascular\\n congestion, consolidations, effusions, PTX, or lung nodules. Other than tube\\n placement, there is no short-interval change.\\n\\n IMPRESSION: Satisfactory line placement. No acute disease.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2197-12-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 853639,\n \"text\": \" 12:26 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for infiltrate\\n Admitting Diagnosis: S/P FALL;DEHYDRATION;ALTERED MENTAL CHANGES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with stage iv lung ca now w/ fevers, hypotension\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n Portable chest , compared to previous study of 2 days earlier.\\n\\n INDICATIONS: Lung cancer. Fever.\\n\\n The heart size, mediastinal, and hilar contours are within normal limits and\\n stable. The lungs demonstrate no focal areas of consolidation or pleural\\n effusion.\\n\\n IMPRESSION:\\n\\n No evidence of pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2197-12-15 00:00:00.000\",\n \"description\": \"MR HEAD W & W/O CONTRAST\",\n \"row_id\": 853036,\n \"text\": \" 4:22 PM\\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \\n Reason: Evaluate for further metastasis\\n Admitting Diagnosis: S/P FALL;DEHYDRATION;ALTERED MENTAL CHANGES\\n Contrast: MAGNEVIST Amt: 10\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old woman with hx of Lung CA, Altered mental status,new lesion on Head\\n CT\\n REASON FOR THIS EXAMINATION:\\n Evaluate for further metastasis\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INFORMATION: Patient with history of lung cancer and altered mental\\n status, with new lesion on head CT, for further evaluation.\\n\\n TECHNIQUE: T1 sagittal and axial and FLAIR, T2 susceptibility, and diffusion\\n axial images of the brain were obtained before gadolinium. T1 axial, coronal\\n and sagittal images were obtained following the administration of gadolinium.\\n FINDINGS: On diffusion images, no evidence of slow diffusion is seen to\\n indicate acute infarct. As seen on the previous CT exam, an area of high\\n signal is seen in the left pareital convexity region in the subcortical area.\\n No restricted diffusion is seen in this region. Additionally, there are areas\\n of hyperintense T2 signal seen bilaterally in the occipital lobes\\n symmetrically. There is no enhancement or slow diffusion is seen in this\\n region. There is no involvement of the cortex seen. Increased signal is seen\\n diffusely in the pons and also foci of hyperintense T2 signal are seen in the\\n periventricular white matter in the frontal and parietal lobes. Following\\n gadolinium administration no evidence of abnormal parenchymal, vascular or\\n meningeal enhancement is seen. A chronic infarct is visualized in the right\\n cerebellar hemisphere.\\n\\n IMPRESSION:\\n No evidence of acute infarct or anbormal enhancement to indicate metastatic\\n disease. Bilateral occipital hyperintensities suspicious for posterior\\n reversible encephalopathy. However, given some increased signal in the pons,\\n this could also be secondary to osmotic myelinolysis. The pontine changes\\n could be also due to small vessel disease. No evidence of midline shift or\\n hydrocephalus seen. The findings were discussed with Dr. at the\\n time of interpretation of this study, on , at 13:00.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2197-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 186653,\n \"text\": \"Sinus tachycardia with slowing of the rate as compared to the prior tracing.\\nThere is frequent ventricular ectopy at a regular interval. Compared to the\\nprevious no diagnostic interim change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2197-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 186654,\n \"text\": \"Sinus tachycardia and occasional atrial ectopy. Delayed precordial R wave\\nprogression. Compared to the previous tracing of the rate has\\nincreased, ventricular ectopy has appeared and there is variation in precordial\\nlead placement. Otherwise, no diagnostic interim change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2197-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 186655,\n \"text\": \"Ectopic atrial rhythm\\nSince last ECG, ectopic atrial rhythm is new\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2197-12-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 186656,\n \"text\": \"Sinus tachycardia\\nNormal ECG except for rate\\nSince previous tracing of , sinus tachycardia present\\n\\n\"\n }\n]"}}},{"rowIdx":24698,"cells":{"subject_id":{"kind":"number","value":3866,"string":"3,866"},"hadm_id":{"kind":"number","value":156747,"string":"156,747"},"target_text":{"kind":"string","value":"# Respiratory failure: The pt was originally admitted with Respiratory failure/Hemoptysis. Patient became hypoxic in the setting of HD with hemoptysis. CTA was negative for PE. MI ruled out. Bronchoscopy showed diffusely friable airways, with respiratory cultures positive for MRSA. The most likely etiology of his failure was therefore believed to be hemorrhagic pneumonia in the setting of uremic platelets. Per infectious disease, the relatively rare GPCs on his culture were concerning for a second infective proces (gram negative vs. fungal involvement). A positive blood glucan on was concerning for disseminated aspergillosis in the setting of his longstanding mycetoma, for which he has been on itraconazole for many years. No gram negative organisms were isolated. . His pneumonia was initially treated with meropenem, vancomycin, and gentamicin, and his itraconazole was continued. He was extubated after 36 hours and weaned his oxygen requirement over the next two days. With clinical improvement, he was transferred to the floor from the MICU with a minimal O2 requirement that was quickly weaned. His gentamicin was D/Ced and his meropenem was changed to levaquin for a 7 day course of gram negative coverage. Once the positive blood glucan was discovered, the test was repeated as well as a galactomannin (still pending), and the patient was switched to voriconazole for better aspergillosis coverage. the patient complained of a dry cough on the floor well-controlled with guaniefesin - his CXR showed resolution of an acute process. . # MRSA bacteremia/MV endocarditis: The patient had a recent admission for sepsis with a vegetation seen on his mitral valve, but has had a negative TTE and surveillance cultures this admission. - Plan to Ccontinue vanc HD protocol at dialysis for six weeks from 9/3 per ID. . # Hypotension: Upon tranfer to the MICU the patient was hypotensive, likely hypovolemia in the setting of ultrafiltration and blood loss. Pts ECHO showed LVEF 60-70%. Pt originally met criteria to qualify for SIRS, but sepsis was thought ot be less likely in this setting. Blood cultures were negative. Hypotension may also have been augmented by his adrenal insufficiency. He was given IVF in the MICU and stress dose steroids, which were tapered to his home does of prednisone (5mg) through his hospital stay. . # CP/Cardiac: Patient's examination clinically significant for fluid overload on admission per report. Patient was somewhat unclear on the duration/quality of his chest pain, but it appeared atypical for cardiac etiology. Negative MIBI . The patient had his cardiac enzymes cycled and ruled out for MI. ASA and coumadin were held for his pulmonary bleeding. Metoprolol was initially held for hypotension and then resumed at a dosing of 25mg , which masd ethe patient normotensive with an SBP in the 120s to 130s. . # Pt had transient neutropenia, possibly secondary to zosyn exposure (vs. post-infectious, drugs, HD membranes) Resolved without an etiology being found. . # Hematemesis: Pt treated in the MICU for ? hematemesis due to episode of hematemesis (IV protonix 40mg ). After an initial 120cc of bloody fluid drained form the stomach via OG, no other fluid returned. Bronchoscopy results and further review suggested the blood was likely form a respiratory source. IV protonix was switched to PO upon transfer to the floor and D/Ced on . The patient denied any epigastric complaints. . # Cervical abscess: Improved according to last neck CT on . Vancomycin was continued as above. . # ESRD: Thought to be due to amyloidosis. He is status post failed renal transplant. He is maintained on chronic HD on a Tues-Thurs-Sat schedule. Dr is his nephrologist. - Right fem line placed / exchanged - Phosphate binders were switched to IV (zemplar + AlOH) while pt had OG tube in the MICU --> switched back to low dose sevalemer on discharge - He received dosing of epogen, vitamin D, vancomycin (and gentamicin until D/Ced ) during hemodialysis - He was found to be iron deficient and startd on IV iron - Nephrocaps and cinacalcet were continued once the patient could take POs . # Glucose Control: ISS - rarely needed when not on stress-dose steroids. . # Paroxysmal Afib: Not found ot be in atrial fibrillation on the floor. Metoprolol was continued excpet when pt hypotensive. Coumadin was held in the setting of hemoptysis. . # Depression: Treated with Celexa . # Access: The patient had no central or peripheral venous access other than the tunneled hemodialysis catheter line. While in the MICU an A-line was also placed . # Prophylaxis: while in the MICU, the patient was prophylaxed for VTE with thigh pneumoboots. Upon transfer to the floor, pneumoboots were not placed regularly and it was decided to begin him on SC heparin. He needed no other prophylaxis."},"extractive_notes_summ":{"kind":"string","value":"CCU NSG PROGRESS NOTE 7P-7A/ S/P HEMOPTOSIS/ARRESTS- INTUBATEDO-SEE FLOWSHEET FOR OBJECTIVE DATA PT REMAINS HEMODYNAMICALLY STABLE- HR- 68-73 SR, MINIMAL VEA.BP- 150-160/70-80'S VIA ALINE- RT BRACHIAL.PT NPO AFTER MN FOR POSSIBLE CV CATH TODAY. Conts on Vanco/Gent given w/ HD & starting on meropenum today.GI/ Pt removed his NGT, HO aware. CURRENTLY ABLE TO DRAW LABS/CHECK ABG.ALSO WITH (+) RT FEMORAL QUENTIN CATH THROUGH WHICH ONE PORT IVF/SEDATION/ANTIBX ARE INFUSING- THE OTHER PORT BY REPORT IS HEPARINIZED/CLAMPED OFF. Pt developed hemoptysis from ett, bedside bronch done. STOPPED BOTH D/T NEED TO USE ONLY INFUSION PORT( VIA QUENTIN) FOR HD.D/C D5W OVERALL AND SWITCHED OVER FROM GTT TO SLIDE SCALE.ALSO INCREASED SCALE TO BETTER CONTROL SUGARS.BS- 230- GIVEN 5 HUMALOG- DECREASED TO 132 AND 113 THIS AM.GI- NG TUBE PLACED YESTERDAY AND D/C OG TUBE IN ANTICIPATION OF EXTUBATION. D/C ARGATROBAN 8PM PER ORDER AS LEVEL /LAB RESULTS SHOW HIT (-).PT ORDERED FOR PNEUMOBOOTS/TEDS- NO FURTHER SC HEPARIN.LYTES- K- 3.0- 60 KCL GIVEN FREE CA- 0.96- GIVEN 2 AMPS CAGLUC- UP TO 1.12 PT REMAINS WITH HEMPTOSIS- DECREASING SUCTIONING- HOLDING OFF UNLESS NEEDED- 2-3 EPISODES OF RED BLOOD VIA ETT- REQUIRING SX.PT PUT BACK ON A/C MODE LATE AFTERNOON D/T TIRING OUT- REMAINS ON A/C CURRENTLY, RESTING. ASPIRATED SOME OLD DARKER BLOOD FROM NG TUBE- ON INTERMITTEN SX- APPEARS TO BE DRAINAGE FROM EARLIER NOSE BLEED.HCT STABLE- 28-31- CHECKED FREQUENTLY SINCE ADMIT.NO FURTHER Q 4 HOUR CHECKS CURRENTLY.A/ PT S/P RESP ARREST/HEMOPTOSIS CURRENTLY CONTINUES WITH HEMOPTOSIS AND INTUBATED FOR AIRWAY PROTECTION.HCT STABLE CURRENTLY, NO NEED FOR TRANSFUSION.TOLERATED HD AND TOOK OFF 1.5 L.CONTINUE TO CLOSELY MONITOR HEMODYNAMICS/RESP STATUS.FOLLOW HCTS AS NEEDED- CONSIDER TRANSFUSION IF HCT DROPS.FOLLOW AMT OF BLEEDING VIA LUNGS AND PLAN FOR ? mod amt thin bloody oral secretions.gi: OGT changed to NGT, some oozing from R nare from unsucessful attempt of ngt.In l nare confirmed by xray. (+) BS.MOUTH CARE PER VAP PROTOCOL. AND RECEIVE DOSES OF GENT/VANCO. HEMODYNAMICS IMPROVED WITH CURRENT BP 87/- 96/.NO FURTHER IVF AT THIS TIME, LEVO ORDERED FOR MAP LESS THAN 55 BUT TO ATTEMPT FLUID AGAIN AS 1ST INTERVENTION.LINES- RT AXILLARY ALINE INSERTED BY ANESTHESIA. Metoprolol was restarted today , BP 95/61--129/68 MAP 70-80. pt was ruled out for PE, had Bronchoscopy which showed diffuse friable airways and LLL PNA. TO REPEAT SUGAR CHECK CURRENTLY.MS- SEE PT STARTED ON FENT 25/VERSED 1 FOR SEDATION/COMFORT.APPEARS TO BE TOLERATING WELL, LESS DROP IN BP THAN PROPOFOL GTT.PROPOFOL GTT D/C.LYTES - K-4.2; MG-2.2GI- OG TUBE INSERTED ON ARRIVAL- 125-150CC FRANK RED BLOOD ASPIRATED VIA WALL MOUNTED SX DEVICE. He is currently on Vanco and Gentamycin only and they are given on dialysis days POST HD. PT ARRIVED WITH (+) BLOODY SPUTUM- SX FOR THICK BLOODY SPUTUM- BUT DECREASING IN AMT AND BRIGHTNESS/COLOR TONE OF THE BLOOD.INTIALLY INTUBATED AND PUT ON VENT IN DIALYSIS UNIT WHERE HE STARTED COUGHING AND (+) HEMOPTOSIS AND /OR HEMATASIS.LUNG SOUNDS DIM, SOME CX AT BASES.REPEAT CXR X 2 PERFORMED.UNABLE TO OBTAIN AN O2 SAT VIA EXTREMITIES OR NOSE/EAR.CHECKED ABG ONCE ALINE INSERTED- LATEST ONE- 7.37-45-73= PT REMAINS ON 50-440-22 A/C 5 PEEP.MINIMAL SPUTUM- OBTAINED SAMPLE AS ORDERED.ID- AFEBRILE, SL HYPOTHERMIC- STARTED ON ZOSYN AND TO RECEIVE VANCO/GENT AT HD TODAY.2 BLOOD CULTURES SENT OFF- TO R/O SEPSIS.S/P RECENT ADMIT FOR SEPSIS- D/C .DM- BLOOD SUGAR IN 50'S AT HD- GIVEN SOME D 50 BY REPORT.THIS AM ALL LABS CHECKED - BLOOD SUGAR- 57- GIVEN AMP D50 AS PER PROTOCOL. No AR.MITRAL VALVE: Moderately thickened mitral valve leaflets. Noaortic regurgitation is seen. CCU NSG PROGRESS NOTE 7P-7A/ S/P RESP ARREST; CHFS- INTUBATED, SEDATED..O- SEE FLOWSHEET FOR OBJECTIVE DATA PT REMAINS HEMODYNAMICALLY STABLE - NO PRESSORS/ NO IVF BOLUSES THIS SHIFT. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild (1+) mitralregurgitation is seen. Mild PA systolichypertension.PULMONIC VALVE/PULMONARY ARTERY: No PS.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. HD TODAY.REMAINS ANURIC.GI- OG TUBE IN PLACE- ASPIRATE FOR MINIMAL BILIOUS MATERIAL- ON INTERMITTENT SX. Mild tomoderate [+] TR. Mild mitral annular calcification. Moderatethickening of mitral valve chordae. No VSD.RIGHT VENTRICLE: Borderline normal RV systolic function.AORTA: Normal aortic diameter at the sinus level. Right ventricular systolic function is borderlinenormal. Normal tricuspid valve supporting structures. Mild to moderate (+)mitral regurgitation is seen. A small perforation of the anterior mitralleaflet cannot be excluded. CURRENTLLY REMAINS WITHOUT HEMOPTOSIS OR HEMATEMESIS. Mild to moderate (+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. The aortic valve leaflets (3) are mildly thickened butaortic stenosis is not present. Left ventricular wall thickness, cavitysize and regional/global systolic function are normal (LVEF 60-70%) There isno ventricular septal defect. There are filamentous strands on the aortic leaflets consistent withLambl's excresences (normal variant). No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Mild mitral annular calcification.Moderate thickening of mitral valve chordae. The aortic valve leaflets (3) are mildly thickened but aortic stenosisis not present. Otherwise, no diagnostic interimchange. Aortic valvevegetation/mass cannot be excluded. Normal main PA. NoDoppler evidence for PDAConclusions:The left atrium is normal in size. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Borderline PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. The mitral valve leaflets are moderatelythickened. Mild to moderate [+] TR. Sinus rhythmMild long QTc intervalLow limb lead voltageSince previous tracing of , no significant change Endocarditis.Height: (in) 65Weight (lb): 147BSA (m2): 1.74 m2BP (mm Hg): 106/64HR (bpm): 81Status: InpatientDate/Time: at 11:23Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). There is no mitral valveprolapse. Focal calcifications inaortic root.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Cannot exclude massor vegetation on mitral valve. No vegetation/mass is seen on the pulmonic valve.Compared with the findings of the prior study (images reviewed) of , the mitral leaflets appear somewhat less thickened; a definitevegetation is no longer identified, but cannot be excluded with certainty. Filamentous strands on the aortic leafletsc/with Lambl's excresences (normal variant).MITRAL VALVE: Moderately thickened mitral valve leaflets. There is no pericardialeffusion.Compared with the prior study (images reviewed) of , no change. Normal interatrial septum.No ASD by 2D or color Doppler.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). Right ventricular chamber size and free wallmotion are normal. Sinus rhythmConsider left ventricular hypertrophyModest T wave changes with prolonged Q-Tc interval - clinical correlation issuggested for possible drug/electrolyte/metabolic effectSince previous tracing of the same date, no significant change"},"n_notes":{"kind":"number","value":21,"string":"21"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2134-10-13 00:00:00.000","description":"Report","row_id":1312246,"text":" NPN\n\n0700-1900\n\nneuro: versed and fentanyl d/c at 0900, pt has remained unresponsive except opening eyes to stimuli. Not moving extremeties, not following commands.\ncv; hemodynamically stable w/ hr 65-70, 93-133/55-75.K 5.7\nresp: most of day w/ good abg. ~ 1900 RR^, TV down, changed back to AC. please see carevue for all settings. Sx this afternoon for mod-lg amts thick bloody secretions HO aware. mod amt thin bloody oral secretions.\ngi: OGT changed to NGT, some oozing from R nare from unsucessful attempt of ngt.In l nare confirmed by xray. HO aware. ~ 50cc bilious drainage from ogt. to LIS\ngu: no u/o. Dialysis started at 1800\nid: afebrile, to receive merepenem, vanc and gent post HD. WBC 3.0 this am.Zosyn changed to merepenem, cont on gent and vanc. to receive after dialysis.\nheme: hct stable at 31 this am, to be rechecked this eve.\nskin: intact\nsocial: girlfriend called and given update\nA: tolerated PS wean, not extubated d/t poor mental status.\n bloody secretions from ETT, oozing from r nare.\nP: MOnitor mental status, ? extubate in am, cont abx.\n\n"},{"category":"Nursing/other","chartdate":"2134-10-14 00:00:00.000","description":"Report","row_id":1312247,"text":"rESP CARE: pt remains intubated/on vent on settings per carevue.No changes in settings. Hemoptysis all shift, mod amts. No deep sxing via ETT this shift.Pt more awake, coughing. Lungs coarse rhonchi bilat. AM RSBI-72. Plan is to extubate today.\n"},{"category":"Nursing/other","chartdate":"2134-10-14 00:00:00.000","description":"Report","row_id":1312248,"text":"CCU NSG PROGRESS NOTE 7P-7A/ S/P HEMOPTOSIS/ARREST\n\nS- INTUBATED\n\nO-SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS HEMODYNAMICALLY STABLE- HR- 68-73 SR, MINIMAL VEA.\nBP- 150-160/70-80'S VIA ALINE- RT BRACHIAL.\nPT NPO AFTER MN FOR POSSIBLE CV CATH TODAY. TO BE RE-CONSULTED BY CT - HIT (-) RE: POSSIBLE AVR. D/C ARGATROBAN 8PM PER ORDER AS LEVEL /LAB RESULTS SHOW HIT (-).\nPT ORDERED FOR PNEUMOBOOTS/TEDS- NO FURTHER SC HEPARIN.\n\nLYTES- K- 3.0- 60 KCL GIVEN\n FREE CA- 0.96- GIVEN 2 AMPS CAGLUC- UP TO 1.12\n\n PT REMAINS WITH HEMPTOSIS- DECREASING SUCTIONING- HOLDING OFF UNLESS NEEDED- 2-3 EPISODES OF RED BLOOD VIA ETT- REQUIRING SX.\nPT PUT BACK ON A/C MODE LATE AFTERNOON D/T TIRING OUT- REMAINS ON A/C CURRENTLY, RESTING. 50-440-20 5 PEEP. ABG'S CHECKED THIS SHIFT WITH RESP ALK- CURRENTLY DROPPED RATE TO 16 FROM 20 FOR AM ABG OF 7.54-33-240.\n\n PT AWAKE, MAINTAINING EYE CONTACT WHEN SPOKEN TO.\nMUCH COUGHING, AND GAGGING WITH ETT IN - ADDED BACK SOME LOW DOSE VERSED AND FENTANYL AFTER HOLDING MEDS SINCE YESTERDAY MORNING/EARLY AFTERNOON. TOLERATING MEDS AND APPEARING MORE COMFORTABLE, LESS STRESS AND DISCOMFORT.\n\n PT SWITCHED FROM ZOSYN FOR MERIPENUM- WC UP TO 4.6 FROM 3.\nRECEIEVED VANCO AND GENT AS WELL WITH HD. AFEBRILE.\n\nGU/ PT GOT HD 7-10:30 P AND TOLERATED WELL- TOOK OFF 1500CC BY REPORT.\nPT HAD BEEN ON D5W AT 150CC/HOUR WITH HIGH BS AND HAD STARTED INSULIN GTT. STOPPED BOTH D/T NEED TO USE ONLY INFUSION PORT( VIA QUENTIN) FOR HD.\nD/C D5W OVERALL AND SWITCHED OVER FROM GTT TO SLIDE SCALE.\nALSO INCREASED SCALE TO BETTER CONTROL SUGARS.\nBS- 230- GIVEN 5 HUMALOG- DECREASED TO 132 AND 113 THIS AM.\n\nGI- NG TUBE PLACED YESTERDAY AND D/C OG TUBE IN ANTICIPATION OF EXTUBATION. SOME TRAUMA/BLEEDING WITH PLACEMENT- NARES PACKED, NO FURTHER ACTIVE BLEEDING. ASPIRATED SOME OLD DARKER BLOOD FROM NG TUBE- ON INTERMITTEN SX- APPEARS TO BE DRAINAGE FROM EARLIER NOSE BLEED.\nHCT STABLE- 28-31- CHECKED FREQUENTLY SINCE ADMIT.\nNO FURTHER Q 4 HOUR CHECKS CURRENTLY.\n\nA/ PT S/P RESP ARREST/HEMOPTOSIS CURRENTLY CONTINUES WITH HEMOPTOSIS AND INTUBATED FOR AIRWAY PROTECTION.\nHCT STABLE CURRENTLY, NO NEED FOR TRANSFUSION.\nTOLERATED HD AND TOOK OFF 1.5 L.\n\nCONTINUE TO CLOSELY MONITOR HEMODYNAMICS/RESP STATUS.\nFOLLOW HCTS AS NEEDED- CONSIDER TRANSFUSION IF HCT DROPS.\nFOLLOW AMT OF BLEEDING VIA LUNGS AND PLAN FOR ? EXTUBATION .\nSTOP SEDATION THIS AM FOR RE-ASSESSMENT BY TEAM RE: PLAN OF CARE REGARDING RESP STATUS.\nKEEP CLOSE WATCH ON BLOOD SUGARS - SLIDING SCALE HUMALOG AS ORDERED.\nKEEP PT AND FRIEND AWARE OF PLAN OF CARE.\nCOMFORT/DECREASE ANXIETY.\n\n"},{"category":"Nursing/other","chartdate":"2134-10-14 00:00:00.000","description":"Report","row_id":1312249,"text":"NPN 7 Am --7PM\n\ns: \" what day is it?\"\n\no: Please see careview for vitals and other objective data. Pt here with MRSA pneumonia, and hemoptosis. Pt is S/P MRSA infection cervical abcess and endocarditis with + blood cultures for MRSA. pt was ruled out for PE, had Bronchoscopy which showed diffuse friable airways and LLL PNA. Pt has complicated history, was just dc'd from here sp MRSA bacteremia. HX of DM, ESRD from Amyliodosis, sarciodosis and Fungal lung infection aspergillosis. SVC stent, DVT,\nA fib ( was on coumadin), HTN, chronic hep C, CDIFF, Bilateral BKA, and several fingers amputated on right hand. ESRD on Hemodialysis 3x week ( HD due tomorrow, former schedule was TU- thurs- saturday)He has had access issues and has new right femoral tunnel permacath for dialysis which was REplaced last admission as pt had his previous dialysis line removed due to infection. We are using one port of this line for meds and IV's.\n Pt has been on antibiotics and ID has seen him for antibiotic adjustment. He is currently on Vanco and Gentamycin only and they are given on dialysis days POST HD. He had been having hemoptosis and received two doses DDAVP, last dose this AM. He had been intubated for\nhemoptosis and airway management, extubated today at 2:15 in the afternoon. Doing well post extubation, he did have some hemoptosis this morning and bloody secreations in nasal/tracheal pharanx. GI contents bile looking but positive for blood ( Team aware). This afternoon he has been stable, o2 sats on 50 percent shovel mask 94-100\npercent. Pt coughing and has been taken ice chips, ok per team and dr. . Although pt did gag earlier with yankaur suctioning, I could not get a gag response to tounge depressor MD's state only ice chips for now. Metoprolol was restarted today , BP 95/61--129/68 MAP 70-80. Pt in SR HR 67-74. Neuro wise pt is alert asking questions, remembers he is at , asking about his illness, requesting food.\nAnswered pt question and Dr updated pt.\n pt has a significant other who did call this Am and will come by to seem him this evening. other family also called and plan to visit.\n\nA: Pt with likely MRSA pneumonia, hemoptosis, now extubated adn improving, afebrile.\n\nP: Continue to monitor CV and Resp status, ice chips only per MICUteam as pt may lack gag, continue to monitor LABS HD on friday and antibiotics due. ? decrease metoprolol per team.\n"},{"category":"Nursing/other","chartdate":"2134-10-15 00:00:00.000","description":"Report","row_id":1312250,"text":"Nursing Note 7p-7a\nNeuro- A+Ox2-3, cooperative. No c/o c-pain/sob, has +gag. MAE in bed, slept in naps.\nCV- NSR no vea, HR 70s-80s. ABPs 90-117/50s-60s, A-line in R brachial.\nNew Hickman line in R fem, ? 1st line infected. Receives HD M,W,F. HCT 30.2, other AM labs pending.\nResp- Taken off face tent & placed on 3L nc @ 10pm. Tol well, sats >95%. LS coarse, has a weak cough. No further hemoptosis but did expectorated lg blood clot. Received DDAVP x2 yesterday.\nID- Afeb, wbc 6.3, on contact precautions for likely MRSA+ PNA. Conts on Vanco/Gent given w/ HD & starting on meropenum today.\nGI/ Pt removed his NGT, HO aware. Is now able to tol soft solids.\nVoided lg OB+ loose stool on bedpan x1, smear incont x1. Anuric.\nENDO- Sugar 313 @ MN p eating ice cream. Conts on RISS.\nA/P- Stable post extubation, now on 3L nc sats >95%. No further hemoptosis, lg OB+ bm & tol soft solids. Cont plan of care monitoring resp status & for bleeding in lungs.\n"},{"category":"Nursing/other","chartdate":"2134-10-12 00:00:00.000","description":"Report","row_id":1312238,"text":"RESP CARE: Pt recieved intubated/on vent. Presently on AC 440/22/.50/5 PEEP. ABG pending. Lungs coarse/sxd thick frank blood. RSBI deferred due to hemodynamic instability. Continue full support.\n"},{"category":"Nursing/other","chartdate":"2134-10-12 00:00:00.000","description":"Report","row_id":1312239,"text":"CCU NSG PROGRESS/ADMIT NOTE 12A-7A/ S/P RESP ARREST\n\nS- INTUBATED/SEDATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA- PLEASE REFER TO TEAM ADMIT NOTE AND CCU NSG FHPA FOR DETAILS R/T HPI/PMH.\n\n\n PT ARRIVED TO CCU FROM RESP ARREST/NEED FOR INTUBATION IN DIALYSIS UNIT AT 12AM.\nBP- 87/50'S WITH MAP >60. STARTED ON PROPOFOL FOR AGITATION, GAGGING ON ETT- 10-5 MCG/KG. EVEN WITH SMALL PT DROPPING 72/47- 80/50. MAPS- 55-60. CHANGED OVER TO FENTANYL 25 MCG/VERSED 1 MG PER HOUR AND D/C PROPOFOL BY 2AM. BETTER HEMODYNAMICS WITH THAT INTERVENTION AS WELL AS WITH GIVING BACK 2 LITERS OF UF TAKEN OFF IN DIALYSIS. PT WITH MV ENDOCARDITIS THOUGHT TO BE TOO PRELOAD /DRY. TOLERATED IVF BOLUSES OVER 2 HOURS- RECEIVED 2 LITERS IN TOTAL OF NS. HEMODYNAMICS IMPROVED WITH CURRENT BP 87/- 96/.\nNO FURTHER IVF AT THIS TIME, LEVO ORDERED FOR MAP LESS THAN 55 BUT TO ATTEMPT FLUID AGAIN AS 1ST INTERVENTION.\n\nLINES- RT AXILLARY ALINE INSERTED BY ANESTHESIA. GOOD WAVEFORM/CORRELATION. CURRENTLY ABLE TO DRAW LABS/CHECK ABG.\nALSO WITH (+) RT FEMORAL QUENTIN CATH THROUGH WHICH ONE PORT IVF/SEDATION/ANTIBX ARE INFUSING- THE OTHER PORT BY REPORT IS HEPARINIZED/CLAMPED OFF.\n\n PT ARRIVED WITH (+) BLOODY SPUTUM- SX FOR THICK BLOODY SPUTUM- BUT DECREASING IN AMT AND BRIGHTNESS/COLOR TONE OF THE BLOOD.\nINTIALLY INTUBATED AND PUT ON VENT IN DIALYSIS UNIT WHERE HE STARTED COUGHING AND (+) HEMOPTOSIS AND /OR HEMATASIS.\nLUNG SOUNDS DIM, SOME CX AT BASES.\nREPEAT CXR X 2 PERFORMED.\nUNABLE TO OBTAIN AN O2 SAT VIA EXTREMITIES OR NOSE/EAR.\n\nCHECKED ABG ONCE ALINE INSERTED- LATEST ONE- 7.37-45-73= PT REMAINS ON 50-440-22 A/C 5 PEEP.\n\nMINIMAL SPUTUM- OBTAINED SAMPLE AS ORDERED.\n\nID- AFEBRILE, SL HYPOTHERMIC- STARTED ON ZOSYN AND TO RECEIVE VANCO/GENT AT HD TODAY.\n2 BLOOD CULTURES SENT OFF- TO R/O SEPSIS.\nS/P RECENT ADMIT FOR SEPSIS- D/C .\n\nDM- BLOOD SUGAR IN 50'S AT HD- GIVEN SOME D 50 BY REPORT.\nTHIS AM ALL LABS CHECKED - BLOOD SUGAR- 57- GIVEN AMP D50 AS PER PROTOCOL. TO REPEAT SUGAR CHECK CURRENTLY.\n\nMS- SEE PT STARTED ON FENT 25/VERSED 1 FOR SEDATION/COMFORT.\nAPPEARS TO BE TOLERATING WELL, LESS DROP IN BP THAN PROPOFOL GTT.\nPROPOFOL GTT D/C.\n\n\nLYTES - K-4.2; MG-2.2\n\nGI- OG TUBE INSERTED ON ARRIVAL- 125-150CC FRANK RED BLOOD ASPIRATED VIA WALL MOUNTED SX DEVICE. (+) BS.\nMOUTH CARE PER VAP PROTOCOL. FREQ MOUTH CARE. OGT PLACEMENT WNL PER REPORT FROM RESIDENT.\n\n\nA/ PT ADMITTED TO CCU FROM DIALYSIS UNIT FOR RESP ARREST/GIB\n\n- CURRENTLY HEMODYNAMICALLY STABLE AFTER IVF BOLUSES.\n\nCV-CONTINUE TO WATCH BP- FLUID BOLUS AS NEEDED- PLAN FOR AM ECHO.\nLEVO ON STANDBY IF IVF NOT WORKING.\n\nRESP-CONTINUE TO MAINTAIN VENTILATION ON CURRENT VENT SETTINGS- PULM TOILET, VAP ORAL CARE.\nCHECK ABG 8-9AM TO SEE TREND OF ABG.\nSX/MAINTAIN AIRWAY AS NEEDED.\n\nHEME/GI-CONTINUE TO CLOSELY WATCH AMT OF BLEEDING/TYPE VIA OGT.\nCHECK HCT AS ORDERED- NEXT LEVEL- 8AM.\nTRANSFUSE AS NEEDED.\n\n\nID- AWAIT ID APPROVAL FOR ZOSYN.\nPT TO GET HD TODAY ? AND RECEIVE DOSES OF GENT/VANCO.\n\n\n KEEP PT COMFORTABLE, WELL SEDATED ON CURRENT VERSED\n"},{"category":"Nursing/other","chartdate":"2134-10-12 00:00:00.000","description":"Report","row_id":1312240,"text":"CCU NSG PROGRESS/ADMIT NOTE 12A-7A/ S/P RESP ARREST\n(Continued)\n/FENT COMBINATION OF MEDS.\n\nKEEP FAMILY /FRIENDS/ NEXT OF AWARE OF CURRENT PROGRESS/PLAN OF CARE.\n\nLINES- ? OBTAIN ANOTHER CENTRAL LINE AS ABLE.\nMAINTAIN PATENCY OF ALINE. CHECK LABS AS NEEDED.\n\nDM- CLOSE ASSESSMENT OF BLOOD SUGARS- D 50/SLIDE SCALE INSULIN AS NEEDED.\n\n\n"},{"category":"Nursing/other","chartdate":"2134-10-12 00:00:00.000","description":"Report","row_id":1312241,"text":"NPN 0700-1900\nevents;\ncardiac echo showed not much change from previous continued hemoptisis;travelled to ct, ct r/o for PE.showed worsening area in rt upper lobe\nbronchoscopy showed no specific bleeding areas but generalised friable bleeding areas over lung tissue prob due to chronic disease and poor platlets superimposed with poss infection .sedated with 100mcgs fentanylx3 and versed 1mgx1 mnd 2mgsx1 i.v with good effect.diphoretiv towards end of procedure,\n\nros; neuro;sedated with 25 mcgs/hr fentanyl and versed 1mg /hr i.v. opens eyes to voice and following simple commanmds.withdraws equally in all 4 limbs.\n\nresp; lungs diminished upper with bibasilar crackles,no vent changes made sats 100% couple of episodes of hemoptysis prioir to 12md no further suctioning done hct stable abg pending.\n\ncvs; tmax 98 po nsr improved over the course of shift .85-120/65.up to 170 sys with stimulation during bronch.\n\ngu;aneuruic no hd today. s/b renal team.\n\ngi; min output via ngtno further bloody drainage. noted belly soft pos bs no stool no flatus. npo except meds.bs improved over course of day after dex 50% for bs 59.currently 103.\n\nheme hct stable at 32 .with 1 pending.\n\nskin ;very dry but intact mutiple scarring from precious hospitalisations double amputee with some fingers missing on right hand.\n\nsoc; girlfriend into visit and updated with pts\n\naccess;; remains an issue 22 g placed by i.v infiltrated in st scan therefore continuing to use dialysis permacath.s/ md rt side ultrasound for poss access, appears to be quite scarred with small lumen therefore will continue to use permacath and will try for picc or midline in ir tomorrow.\n\na/p to rest overnight on vent no suctioning unless nec. no routine suctioning for poss extubation to morrow if hemoptysisis lessens\ncontinue to follow hct\noffer emotional support to pt and family.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2134-10-12 00:00:00.000","description":"Report","row_id":1312242,"text":"Resp Care\nPt remains intubated on CMV, no vent changes. Pt developed hemoptysis from ett, bedside bronch done. Sx for lg amts blood clots, diffuse blood throughout. Plan to maintain current vent and limit ett sx.\n"},{"category":"Nursing/other","chartdate":"2134-10-13 00:00:00.000","description":"Report","row_id":1312243,"text":"RESP CARE: Pt remains intubated/on vent on settings per carevue. Vent settings changed per ABGs. Lungs coarse. Not sxd this shift. No blood from ETT. No RSBI due to absence of spont. respirations at this time.\n"},{"category":"Nursing/other","chartdate":"2134-10-13 00:00:00.000","description":"Report","row_id":1312244,"text":"CCU NSG PROGRESS NOTE 7P-7A/ S/P RESP ARREST; CHF\n\n\nS- INTUBATED, SEDATED..\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS HEMODYNAMICALLY STABLE - NO PRESSORS/ NO IVF BOLUSES THIS SHIFT. BP STABLE SINCE 2 LITERS BOLUS BACK LAST NITE ON ADMISSION. HR- 70-67 SR, NO VEA. BP- 129/66-133/69 VIA RT AXILLARY ALINE.\n\n PT S/P CT SCAN TO R/O PE/ASSESS ETIOLOGY OF HEMOPTOSIS EVENT LEADING TO ETT/ADMIT TO CCU. CURRENTLLY REMAINS WITHOUT HEMOPTOSIS OR HEMATEMESIS. CHECKING HCT Q 4 HOUR- REMAINS STABLE, VERY GRADUAL TREND DOWN THIS AM- 33-30.9.\nHOLDING OFF SUCTIONING PER ORDER, AS PT WITH /FRIABLE TISSUE OBSERVED VIA BRONCH PROCEDURE YESTERDAY AS WELL.\n? IF PT HAS NECROTIZING PNA LEADING TO EROSION/BLEEDING ISSUES. STARTED ON STRESS DOSE STEROIDS - SOLUMEDROL- HOLDING STANDING DOSE OF PREDNISONE CURRENTLY.\nAM ABG WNL- 7.40-33-216 ON 50-440-20 5 PEEP.\n\nID- AFEBRILE- STARTED ON TID ZOSYN. REMAINS ON Q 48 HOUR VANCO/GENT- TO RECEIVE THOSE DOSES TODAY IF ? HD.\nSPUTUM SENT (-) AS OF THIS AM.\n\nGU/ PT WITH BUN/CREAT- 75/8.7; K- 5.7. ? HD TODAY.\nREMAINS ANURIC.\n\nGI- OG TUBE IN PLACE- ASPIRATE FOR MINIMAL BILIOUS MATERIAL- ON INTERMITTENT SX. (+) BOWEL SOUNDS, NO STOOL\nNPO.\nREMAINS ON SL SCALE INSULIN AND D5W AT 75/HOUR-\n2 SUGAR CHECKS- 190'S- GIVEN 2 U HUMALOG EACH TIME.\nNO FURTHER HYPOTENSIVE EVENTS.\n\n PT ON 25/VERSED 1.- MOVING WITH AGITATION /STIMULATION- TOLERATING SMALL BOLUSES. GIRLFRIEND CALLED AND FILLED IN AS TO STATUS. APPEARS TO UNDERSTAND PLAN.\n\nA/ PT S/P RESP ARREST CURRENTLY HEMODYNAMICALLY STABLE AND NO SIGN OF BLEEDING CURRENTLY.\n\nCONTINUE TO CHECK HCT Q 4 HOURS. CHECK WITH TEAM RE: TRANSFUSION PARAMETERS.\nWATCH CLOSELY FOR BLEEDING/ACUTE HCT DROPS.\n\nCONTINUE TO MONITOR RESP CV STATUS- CONSIDER NS BOLUS IF BECOME HYPOTENSIVE S/P DIALYSIS.\n\nCONTINUE ANTIBX/AWAIT FINAL RESULT FOR SPUTUM SPEC.\n\nKEEP PT COMFORTABLE/SEDATE AS NEEDED. ? WEAN OFF CENT SUPPORT TODAY.\n\nKEEP FRIEND AWARE OF PLAN OF CARE, AS WELL AS PT ONCE HE GETS EXTUBATED.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2134-10-13 00:00:00.000","description":"Report","row_id":1312245,"text":"Resp Care\nPt remains intubated, was weaned to PSV. Pt passed his SBT. Sx for bloody secretions x 1. Plan to remain on current settings for now.\n"},{"category":"Nursing/other","chartdate":"2134-10-15 00:00:00.000","description":"Report","row_id":1312251,"text":" NPN\n\n0700-1900\n\nneuro: alert, x3 cooperative w/ care\ncv: hr 70-88 sr, bp 105-145/58-78\nresp: SATs 95-98% on RA\ngi: fair appitite, 2 med liq stools\ngu: HD today, UF for 1.5 L, stable rx.\nid: afebrile, cont on vanc, gent, merepenem(received vanc and gent post hd today)\nend: bs labile, covered per sliding scale\nskin: intact\nheme: hct stable, started on EPO post HD.\naccess: has only HD catheter in r femoral, iv RN to come attemp PIV placement. Team unable to place central line. HD catheter has heparin 5000units/cc for catheter fill volume, needs to be withdrawn prior to use, and replaced after.\nsocial: called, updated on status and \nA: hemodynamically stable, improved resp status, resolved hemoptysis\nP: cont abx, attempt to place PIV by IV\n\n"},{"category":"Echo","chartdate":"2134-10-12 00:00:00.000","description":"Report","row_id":100481,"text":"PATIENT/TEST INFORMATION:\nIndication: Chronic lung disease. Endocarditis.\nHeight: (in) 65\nWeight (lb): 147\nBSA (m2): 1.74 m2\nBP (mm Hg): 106/64\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 11:23\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Aortic valve\nvegetation/mass cannot be excluded. Filamentous strands on the aortic leaflets\nc/with Lambl's excresences (normal variant).\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. No MVP. Cannot\nexclude mass or vegetation on mitral valve. Mild mitral annular calcification.\nModerate thickening of mitral valve chordae. Calcified tips of papillary\nmuscles. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Normal tricuspid valve supporting structures. No TS. Mild to\nmoderate [+] TR. Borderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. No vegetation/mass on pulmonic valve. Normal main PA. No\nDoppler evidence for PDA\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF 60-70%) There is\nno ventricular septal defect. Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. An aortic valve vegetation/mass cannot be\nexcluded. There are filamentous strands on the aortic leaflets consistent with\nLambl's excresences (normal variant). The mitral valve leaflets are moderately\nthickened, with focal pattern of thickening. There is no mitral valve\nprolapse. A mass or vegetation on the mitral valve cannot be excluded. There\nis moderate thickening of the mitral valve chordae. Mild (1+) mitral\nregurgitation is seen. There is borderline pulmonary artery systolic\nhypertension. No vegetation/mass is seen on the pulmonic valve.\n\nCompared with the findings of the prior study (images reviewed) of , the mitral leaflets appear somewhat less thickened; a definite\nvegetation is no longer identified, but cannot be excluded with certainty.\n\n\n"},{"category":"Echo","chartdate":"2134-10-13 00:00:00.000","description":"Report","row_id":100474,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Mitral valve endocarditis now resp. failure.\nHeight: (in) 68\nWeight (lb): 106\nBSA (m2): 1.56 m2\nBP (mm Hg): 115/68\nHR (bpm): 68\nStatus: Inpatient\nDate/Time: at 12:15\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Borderline normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Cannot exclude mass\nor vegetation on mitral valve. Mild mitral annular calcification. Moderate\nthickening of mitral valve chordae. No MS. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. Mild to moderate [+] TR. Mild PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thickness, cavity size and\nregional/global systolic function are normal (LVEF >55%) There is no\nventricular septal defect. Right ventricular systolic function is borderline\nnormal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis\nis not present. No masses or vegetations are seen on the aortic valve. No\naortic regurgitation is seen. The mitral valve leaflets are moderately\nthickened. A mass or vegetation on the mitral valve cannot be excluded. There\nis moderate thickening of the mitral valve chordae. Mild to moderate (+)\nmitral regurgitation is seen. A small perforation of the anterior mitral\nleaflet cannot be excluded. The tricuspid valve leaflets are mildly thickened.\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , no change. A TEE\nis recommended if recurrent/active endocarditis is suspected.\n\n\n"},{"category":"ECG","chartdate":"2134-10-20 00:00:00.000","description":"Report","row_id":275179,"text":"Sinus rhythm\nMild long QTc interval\nLow limb lead voltage\nSince previous tracing of , no significant change\n\n"},{"category":"ECG","chartdate":"2134-10-13 00:00:00.000","description":"Report","row_id":275180,"text":"Sinus rhythm. Low limb lead voltage. Q-T interval prolongation. Variation\nin precordial lead placement as compared with tracing of . The rate has\nslowed. The T wave flattening has improved. Otherwise, no diagnostic interim\nchange.\n\n"},{"category":"ECG","chartdate":"2134-10-12 00:00:00.000","description":"Report","row_id":275181,"text":"Sinus rhythm. Q-T interval prolongation as compared with prior tracing\nof . Clinical correlation is suggested.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2134-10-11 00:00:00.000","description":"Report","row_id":275182,"text":"Sinus rhythm. Compared to the prior tracing of the rate has slowed.\nThe lateral ST-T wave changes have improved. There is delayed precordial\nR wave transition. Clinical correlation is suggested.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2134-10-20 00:00:00.000","description":"Report","row_id":275178,"text":"Sinus rhythm\nConsider left ventricular hypertrophy\nModest T wave changes with prolonged Q-Tc interval - clinical correlation is\nsuggested for possible drug/electrolyte/metabolic effect\nSince previous tracing of the same date, no significant change\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-10-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1312246,\n \"text\": \" NPN\\n\\n0700-1900\\n\\nneuro: versed and fentanyl d/c at 0900, pt has remained unresponsive except opening eyes to stimuli. Not moving extremeties, not following commands.\\ncv; hemodynamically stable w/ hr 65-70, 93-133/55-75.K 5.7\\nresp: most of day w/ good abg. ~ 1900 RR^, TV down, changed back to AC. please see carevue for all settings. Sx this afternoon for mod-lg amts thick bloody secretions HO aware. mod amt thin bloody oral secretions.\\ngi: OGT changed to NGT, some oozing from R nare from unsucessful attempt of ngt.In l nare confirmed by xray. HO aware. ~ 50cc bilious drainage from ogt. to LIS\\ngu: no u/o. Dialysis started at 1800\\nid: afebrile, to receive merepenem, vanc and gent post HD. WBC 3.0 this am.Zosyn changed to merepenem, cont on gent and vanc. to receive after dialysis.\\nheme: hct stable at 31 this am, to be rechecked this eve.\\nskin: intact\\nsocial: girlfriend called and given update\\nA: tolerated PS wean, not extubated d/t poor mental status.\\n bloody secretions from ETT, oozing from r nare.\\nP: MOnitor mental status, ? extubate in am, cont abx.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-10-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1312247,\n \"text\": \"rESP CARE: pt remains intubated/on vent on settings per carevue.No changes in settings. Hemoptysis all shift, mod amts. No deep sxing via ETT this shift.Pt more awake, coughing. Lungs coarse rhonchi bilat. AM RSBI-72. Plan is to extubate today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-10-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1312248,\n \"text\": \"CCU NSG PROGRESS NOTE 7P-7A/ S/P HEMOPTOSIS/ARREST\\n\\nS- INTUBATED\\n\\nO-SEE FLOWSHEET FOR OBJECTIVE DATA\\n\\n PT REMAINS HEMODYNAMICALLY STABLE- HR- 68-73 SR, MINIMAL VEA.\\nBP- 150-160/70-80'S VIA ALINE- RT BRACHIAL.\\nPT NPO AFTER MN FOR POSSIBLE CV CATH TODAY. TO BE RE-CONSULTED BY CT - HIT (-) RE: POSSIBLE AVR. D/C ARGATROBAN 8PM PER ORDER AS LEVEL /LAB RESULTS SHOW HIT (-).\\nPT ORDERED FOR PNEUMOBOOTS/TEDS- NO FURTHER SC HEPARIN.\\n\\nLYTES- K- 3.0- 60 KCL GIVEN\\n FREE CA- 0.96- GIVEN 2 AMPS CAGLUC- UP TO 1.12\\n\\n PT REMAINS WITH HEMPTOSIS- DECREASING SUCTIONING- HOLDING OFF UNLESS NEEDED- 2-3 EPISODES OF RED BLOOD VIA ETT- REQUIRING SX.\\nPT PUT BACK ON A/C MODE LATE AFTERNOON D/T TIRING OUT- REMAINS ON A/C CURRENTLY, RESTING. 50-440-20 5 PEEP. ABG'S CHECKED THIS SHIFT WITH RESP ALK- CURRENTLY DROPPED RATE TO 16 FROM 20 FOR AM ABG OF 7.54-33-240.\\n\\n PT AWAKE, MAINTAINING EYE CONTACT WHEN SPOKEN TO.\\nMUCH COUGHING, AND GAGGING WITH ETT IN - ADDED BACK SOME LOW DOSE VERSED AND FENTANYL AFTER HOLDING MEDS SINCE YESTERDAY MORNING/EARLY AFTERNOON. TOLERATING MEDS AND APPEARING MORE COMFORTABLE, LESS STRESS AND DISCOMFORT.\\n\\n PT SWITCHED FROM ZOSYN FOR MERIPENUM- WC UP TO 4.6 FROM 3.\\nRECEIEVED VANCO AND GENT AS WELL WITH HD. AFEBRILE.\\n\\nGU/ PT GOT HD 7-10:30 P AND TOLERATED WELL- TOOK OFF 1500CC BY REPORT.\\nPT HAD BEEN ON D5W AT 150CC/HOUR WITH HIGH BS AND HAD STARTED INSULIN GTT. STOPPED BOTH D/T NEED TO USE ONLY INFUSION PORT( VIA QUENTIN) FOR HD.\\nD/C D5W OVERALL AND SWITCHED OVER FROM GTT TO SLIDE SCALE.\\nALSO INCREASED SCALE TO BETTER CONTROL SUGARS.\\nBS- 230- GIVEN 5 HUMALOG- DECREASED TO 132 AND 113 THIS AM.\\n\\nGI- NG TUBE PLACED YESTERDAY AND D/C OG TUBE IN ANTICIPATION OF EXTUBATION. SOME TRAUMA/BLEEDING WITH PLACEMENT- NARES PACKED, NO FURTHER ACTIVE BLEEDING. ASPIRATED SOME OLD DARKER BLOOD FROM NG TUBE- ON INTERMITTEN SX- APPEARS TO BE DRAINAGE FROM EARLIER NOSE BLEED.\\nHCT STABLE- 28-31- CHECKED FREQUENTLY SINCE ADMIT.\\nNO FURTHER Q 4 HOUR CHECKS CURRENTLY.\\n\\nA/ PT S/P RESP ARREST/HEMOPTOSIS CURRENTLY CONTINUES WITH HEMOPTOSIS AND INTUBATED FOR AIRWAY PROTECTION.\\nHCT STABLE CURRENTLY, NO NEED FOR TRANSFUSION.\\nTOLERATED HD AND TOOK OFF 1.5 L.\\n\\nCONTINUE TO CLOSELY MONITOR HEMODYNAMICS/RESP STATUS.\\nFOLLOW HCTS AS NEEDED- CONSIDER TRANSFUSION IF HCT DROPS.\\nFOLLOW AMT OF BLEEDING VIA LUNGS AND PLAN FOR ? EXTUBATION .\\nSTOP SEDATION THIS AM FOR RE-ASSESSMENT BY TEAM RE: PLAN OF CARE REGARDING RESP STATUS.\\nKEEP CLOSE WATCH ON BLOOD SUGARS - SLIDING SCALE HUMALOG AS ORDERED.\\nKEEP PT AND FRIEND AWARE OF PLAN OF CARE.\\nCOMFORT/DECREASE ANXIETY.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-10-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1312249,\n \"text\": \"NPN 7 Am --7PM\\n\\ns: \\\" what day is it?\\\"\\n\\no: Please see careview for vitals and other objective data. Pt here with MRSA pneumonia, and hemoptosis. Pt is S/P MRSA infection cervical abcess and endocarditis with + blood cultures for MRSA. pt was ruled out for PE, had Bronchoscopy which showed diffuse friable airways and LLL PNA. Pt has complicated history, was just dc'd from here sp MRSA bacteremia. HX of DM, ESRD from Amyliodosis, sarciodosis and Fungal lung infection aspergillosis. SVC stent, DVT,\\nA fib ( was on coumadin), HTN, chronic hep C, CDIFF, Bilateral BKA, and several fingers amputated on right hand. ESRD on Hemodialysis 3x week ( HD due tomorrow, former schedule was TU- thurs- saturday)He has had access issues and has new right femoral tunnel permacath for dialysis which was REplaced last admission as pt had his previous dialysis line removed due to infection. We are using one port of this line for meds and IV's.\\n Pt has been on antibiotics and ID has seen him for antibiotic adjustment. He is currently on Vanco and Gentamycin only and they are given on dialysis days POST HD. He had been having hemoptosis and received two doses DDAVP, last dose this AM. He had been intubated for\\nhemoptosis and airway management, extubated today at 2:15 in the afternoon. Doing well post extubation, he did have some hemoptosis this morning and bloody secreations in nasal/tracheal pharanx. GI contents bile looking but positive for blood ( Team aware). This afternoon he has been stable, o2 sats on 50 percent shovel mask 94-100\\npercent. Pt coughing and has been taken ice chips, ok per team and dr. . Although pt did gag earlier with yankaur suctioning, I could not get a gag response to tounge depressor MD's state only ice chips for now. Metoprolol was restarted today , BP 95/61--129/68 MAP 70-80. Pt in SR HR 67-74. Neuro wise pt is alert asking questions, remembers he is at , asking about his illness, requesting food.\\nAnswered pt question and Dr updated pt.\\n pt has a significant other who did call this Am and will come by to seem him this evening. other family also called and plan to visit.\\n\\nA: Pt with likely MRSA pneumonia, hemoptosis, now extubated adn improving, afebrile.\\n\\nP: Continue to monitor CV and Resp status, ice chips only per MICUteam as pt may lack gag, continue to monitor LABS HD on friday and antibiotics due. ? decrease metoprolol per team.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-10-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1312250,\n \"text\": \"Nursing Note 7p-7a\\nNeuro- A+Ox2-3, cooperative. No c/o c-pain/sob, has +gag. MAE in bed, slept in naps.\\nCV- NSR no vea, HR 70s-80s. ABPs 90-117/50s-60s, A-line in R brachial.\\nNew Hickman line in R fem, ? 1st line infected. Receives HD M,W,F. HCT 30.2, other AM labs pending.\\nResp- Taken off face tent & placed on 3L nc @ 10pm. Tol well, sats >95%. LS coarse, has a weak cough. No further hemoptosis but did expectorated lg blood clot. Received DDAVP x2 yesterday.\\nID- Afeb, wbc 6.3, on contact precautions for likely MRSA+ PNA. Conts on Vanco/Gent given w/ HD & starting on meropenum today.\\nGI/ Pt removed his NGT, HO aware. Is now able to tol soft solids.\\nVoided lg OB+ loose stool on bedpan x1, smear incont x1. Anuric.\\nENDO- Sugar 313 @ MN p eating ice cream. Conts on RISS.\\nA/P- Stable post extubation, now on 3L nc sats >95%. No further hemoptosis, lg OB+ bm & tol soft solids. Cont plan of care monitoring resp status & for bleeding in lungs.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-10-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1312238,\n \"text\": \"RESP CARE: Pt recieved intubated/on vent. Presently on AC 440/22/.50/5 PEEP. ABG pending. Lungs coarse/sxd thick frank blood. RSBI deferred due to hemodynamic instability. Continue full support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-10-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1312239,\n \"text\": \"CCU NSG PROGRESS/ADMIT NOTE 12A-7A/ S/P RESP ARREST\\n\\nS- INTUBATED/SEDATED\\n\\nO- SEE FLOWSHEET FOR OBJECTIVE DATA- PLEASE REFER TO TEAM ADMIT NOTE AND CCU NSG FHPA FOR DETAILS R/T HPI/PMH.\\n\\n\\n PT ARRIVED TO CCU FROM RESP ARREST/NEED FOR INTUBATION IN DIALYSIS UNIT AT 12AM.\\nBP- 87/50'S WITH MAP >60. STARTED ON PROPOFOL FOR AGITATION, GAGGING ON ETT- 10-5 MCG/KG. EVEN WITH SMALL PT DROPPING 72/47- 80/50. MAPS- 55-60. CHANGED OVER TO FENTANYL 25 MCG/VERSED 1 MG PER HOUR AND D/C PROPOFOL BY 2AM. BETTER HEMODYNAMICS WITH THAT INTERVENTION AS WELL AS WITH GIVING BACK 2 LITERS OF UF TAKEN OFF IN DIALYSIS. PT WITH MV ENDOCARDITIS THOUGHT TO BE TOO PRELOAD /DRY. TOLERATED IVF BOLUSES OVER 2 HOURS- RECEIVED 2 LITERS IN TOTAL OF NS. HEMODYNAMICS IMPROVED WITH CURRENT BP 87/- 96/.\\nNO FURTHER IVF AT THIS TIME, LEVO ORDERED FOR MAP LESS THAN 55 BUT TO ATTEMPT FLUID AGAIN AS 1ST INTERVENTION.\\n\\nLINES- RT AXILLARY ALINE INSERTED BY ANESTHESIA. GOOD WAVEFORM/CORRELATION. CURRENTLY ABLE TO DRAW LABS/CHECK ABG.\\nALSO WITH (+) RT FEMORAL QUENTIN CATH THROUGH WHICH ONE PORT IVF/SEDATION/ANTIBX ARE INFUSING- THE OTHER PORT BY REPORT IS HEPARINIZED/CLAMPED OFF.\\n\\n PT ARRIVED WITH (+) BLOODY SPUTUM- SX FOR THICK BLOODY SPUTUM- BUT DECREASING IN AMT AND BRIGHTNESS/COLOR TONE OF THE BLOOD.\\nINTIALLY INTUBATED AND PUT ON VENT IN DIALYSIS UNIT WHERE HE STARTED COUGHING AND (+) HEMOPTOSIS AND /OR HEMATASIS.\\nLUNG SOUNDS DIM, SOME CX AT BASES.\\nREPEAT CXR X 2 PERFORMED.\\nUNABLE TO OBTAIN AN O2 SAT VIA EXTREMITIES OR NOSE/EAR.\\n\\nCHECKED ABG ONCE ALINE INSERTED- LATEST ONE- 7.37-45-73= PT REMAINS ON 50-440-22 A/C 5 PEEP.\\n\\nMINIMAL SPUTUM- OBTAINED SAMPLE AS ORDERED.\\n\\nID- AFEBRILE, SL HYPOTHERMIC- STARTED ON ZOSYN AND TO RECEIVE VANCO/GENT AT HD TODAY.\\n2 BLOOD CULTURES SENT OFF- TO R/O SEPSIS.\\nS/P RECENT ADMIT FOR SEPSIS- D/C .\\n\\nDM- BLOOD SUGAR IN 50'S AT HD- GIVEN SOME D 50 BY REPORT.\\nTHIS AM ALL LABS CHECKED - BLOOD SUGAR- 57- GIVEN AMP D50 AS PER PROTOCOL. TO REPEAT SUGAR CHECK CURRENTLY.\\n\\nMS- SEE PT STARTED ON FENT 25/VERSED 1 FOR SEDATION/COMFORT.\\nAPPEARS TO BE TOLERATING WELL, LESS DROP IN BP THAN PROPOFOL GTT.\\nPROPOFOL GTT D/C.\\n\\n\\nLYTES - K-4.2; MG-2.2\\n\\nGI- OG TUBE INSERTED ON ARRIVAL- 125-150CC FRANK RED BLOOD ASPIRATED VIA WALL MOUNTED SX DEVICE. (+) BS.\\nMOUTH CARE PER VAP PROTOCOL. FREQ MOUTH CARE. OGT PLACEMENT WNL PER REPORT FROM RESIDENT.\\n\\n\\nA/ PT ADMITTED TO CCU FROM DIALYSIS UNIT FOR RESP ARREST/GIB\\n\\n- CURRENTLY HEMODYNAMICALLY STABLE AFTER IVF BOLUSES.\\n\\nCV-CONTINUE TO WATCH BP- FLUID BOLUS AS NEEDED- PLAN FOR AM ECHO.\\nLEVO ON STANDBY IF IVF NOT WORKING.\\n\\nRESP-CONTINUE TO MAINTAIN VENTILATION ON CURRENT VENT SETTINGS- PULM TOILET, VAP ORAL CARE.\\nCHECK ABG 8-9AM TO SEE TREND OF ABG.\\nSX/MAINTAIN AIRWAY AS NEEDED.\\n\\nHEME/GI-CONTINUE TO CLOSELY WATCH AMT OF BLEEDING/TYPE VIA OGT.\\nCHECK HCT AS ORDERED- NEXT LEVEL- 8AM.\\nTRANSFUSE AS NEEDED.\\n\\n\\nID- AWAIT ID APPROVAL FOR ZOSYN.\\nPT TO GET HD TODAY ? AND RECEIVE DOSES OF GENT/VANCO.\\n\\n\\n KEEP PT COMFORTABLE, WELL SEDATED ON CURRENT VERSED\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-10-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1312240,\n \"text\": \"CCU NSG PROGRESS/ADMIT NOTE 12A-7A/ S/P RESP ARREST\\n(Continued)\\n/FENT COMBINATION OF MEDS.\\n\\nKEEP FAMILY /FRIENDS/ NEXT OF AWARE OF CURRENT PROGRESS/PLAN OF CARE.\\n\\nLINES- ? OBTAIN ANOTHER CENTRAL LINE AS ABLE.\\nMAINTAIN PATENCY OF ALINE. CHECK LABS AS NEEDED.\\n\\nDM- CLOSE ASSESSMENT OF BLOOD SUGARS- D 50/SLIDE SCALE INSULIN AS NEEDED.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-10-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1312241,\n \"text\": \"NPN 0700-1900\\nevents;\\ncardiac echo showed not much change from previous continued hemoptisis;travelled to ct, ct r/o for PE.showed worsening area in rt upper lobe\\nbronchoscopy showed no specific bleeding areas but generalised friable bleeding areas over lung tissue prob due to chronic disease and poor platlets superimposed with poss infection .sedated with 100mcgs fentanylx3 and versed 1mgx1 mnd 2mgsx1 i.v with good effect.diphoretiv towards end of procedure,\\n\\nros; neuro;sedated with 25 mcgs/hr fentanyl and versed 1mg /hr i.v. opens eyes to voice and following simple commanmds.withdraws equally in all 4 limbs.\\n\\nresp; lungs diminished upper with bibasilar crackles,no vent changes made sats 100% couple of episodes of hemoptysis prioir to 12md no further suctioning done hct stable abg pending.\\n\\ncvs; tmax 98 po nsr improved over the course of shift .85-120/65.up to 170 sys with stimulation during bronch.\\n\\ngu;aneuruic no hd today. s/b renal team.\\n\\ngi; min output via ngtno further bloody drainage. noted belly soft pos bs no stool no flatus. npo except meds.bs improved over course of day after dex 50% for bs 59.currently 103.\\n\\nheme hct stable at 32 .with 1 pending.\\n\\nskin ;very dry but intact mutiple scarring from precious hospitalisations double amputee with some fingers missing on right hand.\\n\\nsoc; girlfriend into visit and updated with pts\\n\\naccess;; remains an issue 22 g placed by i.v infiltrated in st scan therefore continuing to use dialysis permacath.s/ md rt side ultrasound for poss access, appears to be quite scarred with small lumen therefore will continue to use permacath and will try for picc or midline in ir tomorrow.\\n\\na/p to rest overnight on vent no suctioning unless nec. no routine suctioning for poss extubation to morrow if hemoptysisis lessens\\ncontinue to follow hct\\noffer emotional support to pt and family.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-10-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1312242,\n \"text\": \"Resp Care\\nPt remains intubated on CMV, no vent changes. Pt developed hemoptysis from ett, bedside bronch done. Sx for lg amts blood clots, diffuse blood throughout. Plan to maintain current vent and limit ett sx.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-10-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1312243,\n \"text\": \"RESP CARE: Pt remains intubated/on vent on settings per carevue. Vent settings changed per ABGs. Lungs coarse. Not sxd this shift. No blood from ETT. No RSBI due to absence of spont. respirations at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-10-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1312244,\n \"text\": \"CCU NSG PROGRESS NOTE 7P-7A/ S/P RESP ARREST; CHF\\n\\n\\nS- INTUBATED, SEDATED..\\n\\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\\n\\n PT REMAINS HEMODYNAMICALLY STABLE - NO PRESSORS/ NO IVF BOLUSES THIS SHIFT. BP STABLE SINCE 2 LITERS BOLUS BACK LAST NITE ON ADMISSION. HR- 70-67 SR, NO VEA. BP- 129/66-133/69 VIA RT AXILLARY ALINE.\\n\\n PT S/P CT SCAN TO R/O PE/ASSESS ETIOLOGY OF HEMOPTOSIS EVENT LEADING TO ETT/ADMIT TO CCU. CURRENTLLY REMAINS WITHOUT HEMOPTOSIS OR HEMATEMESIS. CHECKING HCT Q 4 HOUR- REMAINS STABLE, VERY GRADUAL TREND DOWN THIS AM- 33-30.9.\\nHOLDING OFF SUCTIONING PER ORDER, AS PT WITH /FRIABLE TISSUE OBSERVED VIA BRONCH PROCEDURE YESTERDAY AS WELL.\\n? IF PT HAS NECROTIZING PNA LEADING TO EROSION/BLEEDING ISSUES. STARTED ON STRESS DOSE STEROIDS - SOLUMEDROL- HOLDING STANDING DOSE OF PREDNISONE CURRENTLY.\\nAM ABG WNL- 7.40-33-216 ON 50-440-20 5 PEEP.\\n\\nID- AFEBRILE- STARTED ON TID ZOSYN. REMAINS ON Q 48 HOUR VANCO/GENT- TO RECEIVE THOSE DOSES TODAY IF ? HD.\\nSPUTUM SENT (-) AS OF THIS AM.\\n\\nGU/ PT WITH BUN/CREAT- 75/8.7; K- 5.7. ? HD TODAY.\\nREMAINS ANURIC.\\n\\nGI- OG TUBE IN PLACE- ASPIRATE FOR MINIMAL BILIOUS MATERIAL- ON INTERMITTENT SX. (+) BOWEL SOUNDS, NO STOOL\\nNPO.\\nREMAINS ON SL SCALE INSULIN AND D5W AT 75/HOUR-\\n2 SUGAR CHECKS- 190'S- GIVEN 2 U HUMALOG EACH TIME.\\nNO FURTHER HYPOTENSIVE EVENTS.\\n\\n PT ON 25/VERSED 1.- MOVING WITH AGITATION /STIMULATION- TOLERATING SMALL BOLUSES. GIRLFRIEND CALLED AND FILLED IN AS TO STATUS. APPEARS TO UNDERSTAND PLAN.\\n\\nA/ PT S/P RESP ARREST CURRENTLY HEMODYNAMICALLY STABLE AND NO SIGN OF BLEEDING CURRENTLY.\\n\\nCONTINUE TO CHECK HCT Q 4 HOURS. CHECK WITH TEAM RE: TRANSFUSION PARAMETERS.\\nWATCH CLOSELY FOR BLEEDING/ACUTE HCT DROPS.\\n\\nCONTINUE TO MONITOR RESP CV STATUS- CONSIDER NS BOLUS IF BECOME HYPOTENSIVE S/P DIALYSIS.\\n\\nCONTINUE ANTIBX/AWAIT FINAL RESULT FOR SPUTUM SPEC.\\n\\nKEEP PT COMFORTABLE/SEDATE AS NEEDED. ? WEAN OFF CENT SUPPORT TODAY.\\n\\nKEEP FRIEND AWARE OF PLAN OF CARE, AS WELL AS PT ONCE HE GETS EXTUBATED.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-10-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1312245,\n \"text\": \"Resp Care\\nPt remains intubated, was weaned to PSV. Pt passed his SBT. Sx for bloody secretions x 1. Plan to remain on current settings for now.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2134-10-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1312251,\n \"text\": \" NPN\\n\\n0700-1900\\n\\nneuro: alert, x3 cooperative w/ care\\ncv: hr 70-88 sr, bp 105-145/58-78\\nresp: SATs 95-98% on RA\\ngi: fair appitite, 2 med liq stools\\ngu: HD today, UF for 1.5 L, stable rx.\\nid: afebrile, cont on vanc, gent, merepenem(received vanc and gent post hd today)\\nend: bs labile, covered per sliding scale\\nskin: intact\\nheme: hct stable, started on EPO post HD.\\naccess: has only HD catheter in r femoral, iv RN to come attemp PIV placement. Team unable to place central line. HD catheter has heparin 5000units/cc for catheter fill volume, needs to be withdrawn prior to use, and replaced after.\\nsocial: called, updated on status and \\nA: hemodynamically stable, improved resp status, resolved hemoptysis\\nP: cont abx, attempt to place PIV by IV\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2134-10-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 100481,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Chronic lung disease. Endocarditis.\\nHeight: (in) 65\\nWeight (lb): 147\\nBSA (m2): 1.74 m2\\nBP (mm Hg): 106/64\\nHR (bpm): 81\\nStatus: Inpatient\\nDate/Time: at 11:23\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\\naortic root.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Aortic valve\\nvegetation/mass cannot be excluded. Filamentous strands on the aortic leaflets\\nc/with Lambl's excresences (normal variant).\\n\\nMITRAL VALVE: Moderately thickened mitral valve leaflets. No MVP. Cannot\\nexclude mass or vegetation on mitral valve. Mild mitral annular calcification.\\nModerate thickening of mitral valve chordae. Calcified tips of papillary\\nmuscles. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\\ntricuspid valve. Normal tricuspid valve supporting structures. No TS. Mild to\\nmoderate [+] TR. Borderline PA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\\nphysiologic PR. No vegetation/mass on pulmonic valve. Normal main PA. No\\nDoppler evidence for PDA\\n\\nConclusions:\\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\\nsize and regional/global systolic function are normal (LVEF 60-70%) There is\\nno ventricular septal defect. Right ventricular chamber size and free wall\\nmotion are normal. The aortic valve leaflets (3) are mildly thickened but\\naortic stenosis is not present. An aortic valve vegetation/mass cannot be\\nexcluded. There are filamentous strands on the aortic leaflets consistent with\\nLambl's excresences (normal variant). The mitral valve leaflets are moderately\\nthickened, with focal pattern of thickening. There is no mitral valve\\nprolapse. A mass or vegetation on the mitral valve cannot be excluded. There\\nis moderate thickening of the mitral valve chordae. Mild (1+) mitral\\nregurgitation is seen. There is borderline pulmonary artery systolic\\nhypertension. No vegetation/mass is seen on the pulmonic valve.\\n\\nCompared with the findings of the prior study (images reviewed) of , the mitral leaflets appear somewhat less thickened; a definite\\nvegetation is no longer identified, but cannot be excluded with certainty.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2134-10-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 100474,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Mitral valve endocarditis now resp. failure.\\nHeight: (in) 68\\nWeight (lb): 106\\nBSA (m2): 1.56 m2\\nBP (mm Hg): 115/68\\nHR (bpm): 68\\nStatus: Inpatient\\nDate/Time: at 12:15\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\\nNo ASD by 2D or color Doppler.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\\n\\nRIGHT VENTRICLE: Borderline normal RV systolic function.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\\nvegetations on aortic valve. No AR.\\n\\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Cannot exclude mass\\nor vegetation on mitral valve. Mild mitral annular calcification. Moderate\\nthickening of mitral valve chordae. No MS. Mild to moderate (+) MR.\\n\\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\\nvegetation on tricuspid valve. Mild to moderate [+] TR. Mild PA systolic\\nhypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nConclusions:\\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\\ncolor Doppler. Left ventricular wall thickness, cavity size and\\nregional/global systolic function are normal (LVEF >55%) There is no\\nventricular septal defect. Right ventricular systolic function is borderline\\nnormal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis\\nis not present. No masses or vegetations are seen on the aortic valve. No\\naortic regurgitation is seen. The mitral valve leaflets are moderately\\nthickened. A mass or vegetation on the mitral valve cannot be excluded. There\\nis moderate thickening of the mitral valve chordae. Mild to moderate (+)\\nmitral regurgitation is seen. A small perforation of the anterior mitral\\nleaflet cannot be excluded. The tricuspid valve leaflets are mildly thickened.\\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\\neffusion.\\n\\nCompared with the prior study (images reviewed) of , no change. A TEE\\nis recommended if recurrent/active endocarditis is suspected.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2134-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 275179,\n \"text\": \"Sinus rhythm\\nMild long QTc interval\\nLow limb lead voltage\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2134-10-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 275180,\n \"text\": \"Sinus rhythm. Low limb lead voltage. Q-T interval prolongation. Variation\\nin precordial lead placement as compared with tracing of . The rate has\\nslowed. The T wave flattening has improved. Otherwise, no diagnostic interim\\nchange.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2134-10-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 275181,\n \"text\": \"Sinus rhythm. Q-T interval prolongation as compared with prior tracing\\nof . Clinical correlation is suggested.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2134-10-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 275182,\n \"text\": \"Sinus rhythm. Compared to the prior tracing of the rate has slowed.\\nThe lateral ST-T wave changes have improved. There is delayed precordial\\nR wave transition. Clinical correlation is suggested.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2134-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 275178,\n \"text\": \"Sinus rhythm\\nConsider left ventricular hypertrophy\\nModest T wave changes with prolonged Q-Tc interval - clinical correlation is\\nsuggested for possible drug/electrolyte/metabolic effect\\nSince previous tracing of the same date, no significant change\\n\\n\"\n }\n]"}}},{"rowIdx":24699,"cells":{"subject_id":{"kind":"number","value":48087,"string":"48,087"},"hadm_id":{"kind":"number","value":117796,"string":"117,796"},"target_text":{"kind":"string","value":"ASSESSMENT AND PLAN: 56M with HCV cirrhosis on the transplant list who was admitted with an episode of confusion/altered mental status which required intubation for airway protection. He was initially admitted to the SICU. Mental status improved significantly with aggressive lactulose. . ACTIVE ISSUES . # Altered Mental Status: Mental status changes likely due to hepatic encephalopathy. As above he required intubation for airway protection and admission to the SICU. He was started lactulose and rifaximin with improvement in his mental status. He was successful extubated and transferred to the floor. Precipitant was initially unclear (as the patient had no evidence of active infection or new metabolic derangement). Blood and urine cultures were negative. The patient only had minimal ascites making spontaneous bacterial peritonitis unlikely. However, on further questioning of the patient's girlfriend reported he has been having a productive cough a few days prior to presentation. CXR did show a small area concerning for consolidation and sputum culture grew S. pneumonae and Moraxella Catarrhalis. He was started on levofloxacin for a planned 5 day course. His home cyclobenzaprine and gabapentin were also held. The patient's mental status was at baseline at the time of discharge. Patient was instructed to consider a vegetarian diet should instances of encephalopathy continue. . # ? Pneumonia- As above sputum showing moraxella and s. pneumo. Original CXR concerning for possible RUL infiltrate. Given patient was having low grade temps, cough, and a positive sputum cough he was started on levofloxacin for a 5 day course. . # Ear pain- Patient complained of R sided ear pain. Otoscopic exam was unremarkable. It was felt pain might be reflective of TMJ. Pain was controlled with Tylenol. . STABLE ISSUES . # HCV Cirrhosis: Patient is on the transplant list. Course has been complicated by hepatic encephalopathy (on lactulose and rifaximin), peripheral edema and ascites (managed with diuretics and albumin infusions Q2wks) and grade varices II (on nadolol). Patient was continued on his home diuretics, nadolol, lactulose and rifaximin as above. . # Thrombocytopenia: This was felt to likely be due to liver disease. Platelets remained stable throughout admission. . # Muscle Spasms: Patient has a history of muscle spasms for which he receives infusions of 50 g of IV albumin every 2 weeks. The patient received this infusion while hospitalized. . # Dyspnea- Patient was scheduled for an echo as an outpatient. He was scheduled of an echo. Therefore study was performed while the patient was in-house. Echo was notable only for biatrial enlargement. . # OSA: On CPAP at home . # Back, shoulder pain: Patient has chronic pain on narcotics, gabapentin and cyclobenzaprine at home. These medications were initially held give confusion. His home oxycodone was restarted with caution on discharge. The patient was instructed to minimize use of narcotics. Gabapentin and cyclobenzaprine were held at the time of discharge. . TRANSITIONAL ISSUES - Blood cultures were pending at the time of discharge - Patient will follow-up at the liver center - Patient was full code throughout this hospitalization"},"extractive_notes_summ":{"kind":"string","value":"Normal ascending aortadiameter. No PS.Physiologic PR.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.Conclusions:The left atrium is mildly dilated. Normal left ventricular cavity size and wallthickness with preserved global and regional biventricular systolic function.No clinically significant valvular disease. The mitral valve appears structurally normal withtrivial mitral regurgitation. IMPRESSION: Scant trace of ascites seen in the abdomen. Normal pulmonary artery systolicpressure. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. FINDINGS: Single supine AP portable view of the chest was obtained. Mildly dilated aortic arch. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. The aorticarch is now mildly dilated. A scant trace of ascites is again seen within the abdomen predominantly in the perihepatic space. Right ventricular chamber size and free wall motionare normal. No overt pulmonary edema. The aortic arch is mildly dilated. Mild engorgement of pulmonary and mediastinal vasculature is explained by supine positioning. The aortic valve leaflets (3)appear structurally normal with good leaflet excursion and no aortic stenosisor aortic regurgitation. No ASD or PFO by 2D, colorDoppler or saline contrast with maneuvers.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). No 2D or Doppler evidence of distal archcoarctation.AORTIC VALVE: Normal aortic valve leaflets (3). Dyspnea on exertion.Height: (in) 69Weight (lb): 198BSA (m2): 2.06 m2BP (mm Hg): 133/75HR (bpm): 60Status: InpatientDate/Time: at 10:31Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. There is borderline pulmonary artery systolichypertension. The ventricles and sulci are normal in size and configuration. IMPRESSION: No acute fracture or malalignment. The cardiac and mediastinal silhouettes are likely accentuated by supine, AP technique. Heart size is top normal. FINDINGS: No acute intracranial hemorrhage, edema, mass effect or acute territorial infarction. IMPRESSION: No acute intracranial process. FINDINGS: The heights of the vertebral bodies of the C-spine are preserved. No prevertbral hematoma is seen. No pneumothorax or pleural effusion. No atrial septal defect or patent foramenovale is seen by 2D, color Doppler or saline contrast with maneuvers. Patchy right upper lobe opacity could relate to low lung volumes and artifact, although an underlying consolidation can be present. The right costophrenic angle is not included on the image. There are low lung volumes. The lung apices are clear. Leftventricular wall thickness, cavity size and regional/global systolic functionare normal (LVEF >55%). Nasogastric tube ends in the stomach. There is no pleural effusion or pneumothorax. The patient is intubated and a nasogastric tube is partially visualized. There are small posterior osteophytes at C4/C5 and C5/C6 with mild spinal canal stenosis. No fractures are identified. There is no malalignment. Gaseous distention of the colon is incidentally noted. The mastoid air cells are clear. IMPRESSION: AP chest compared to , 7:13 p.m.: Endotracheal tube has been advanced. Lungs are clear. TECHNIQUE: Contiguous MDCT images through the C-spine were obtained. 6:54 AM US ABD LIMIT, SINGLE ORGAN PORT Clip # Reason: ? FINDINGS: A limited study of the four quadrants of the abdomen was performed. Sinus tachycardia. There is no fracture. There is an anterior space which most likely represents aprominent fat pad.IMPRESSION: Biatrial enlargement. Axial, coronal, and sagittal reformats were acquired. The tip is between 4 and 5 cm from the carina, standard placement. No additional consolidation is seen. Coronal and sagittal reformats were acquired. The -white matter differentiation is well preserved. PATIENT/TEST INFORMATION:Indication: Cirrhosis. Some late bubbles are appreciated with Valsalva maneuver, but giventhat this was after the third injection of saline contrast it is unlikely thatthey represent clinically significant pulmonary shunting.Compared with the prior study (images reviewed) of , mild to moderatepulmonary artery systolic hypertension is no longer appreciated. There is circumferential mucosal thickening of the left maxillary sinus and mucosal thickening of the ethmoid air cells. Baseline artifact. Endotracheal tube is seen, terminating approximately 5.5 cm above the level of the carina. Secretions are seen in the nasopharynx likely due to intubation. ascites, amenable to drainage Admitting Diagnosis: ENCEPHALOPATHY MEDICAL CONDITION: 56 m HCV cirr, now w recurrent encephalopathy REASON FOR THIS EXAMINATION: ? COMPARISON: None. No AS. Evaluate for ascites. TECHNIQUE: Axial CT images of the head were obtained. 7:47 PM CT C-SPINE W/O CONTRAST Clip # Reason: r/o fx MEDICAL CONDITION: 56 year old man with found down REASON FOR THIS EXAMINATION: r/o fx No contraindications for IV contrast WET READ: JBRe MON 8:31 PM No fracture, no malalignment. The neural foramina are patent. Cannot rule out ST-T waveabnormalities but much of it may be artifact. COMPARISON: Liver ultrasound, . 7:16 PM CHEST (PORTABLE AP) Clip # Reason: et tube FINAL ADDENDUM ADDENDUM: There are multiple rounded calcifications in the right upper quadrant measuring on the order of 2 cm may represent gallstones."},"n_notes":{"kind":"number","value":7,"string":"7"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2182-01-29 00:00:00.000","description":"P US ABD LIMIT, SINGLE ORGAN PORT","row_id":1226044,"text":" 6:54 AM\n US ABD LIMIT, SINGLE ORGAN PORT Clip # \n Reason: ? ascites, amenable to drainage\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 m HCV cirr, now w recurrent encephalopathy\n REASON FOR THIS EXAMINATION:\n ? ascites, amenable to drainage\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man with recurrent encephalopathy. Evaluate for\n ascites.\n\n COMPARISON: Liver ultrasound, .\n\n FINDINGS: A limited study of the four quadrants of the abdomen was performed.\n A scant trace of ascites is again seen within the abdomen predominantly in the\n perihepatic space.\n\n IMPRESSION: Scant trace of ascites seen in the abdomen.\n\n\n"},{"category":"Radiology","chartdate":"2182-01-28 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1226004,"text":" 7:47 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with found down\n REASON FOR THIS EXAMINATION:\n r/o bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe MON 8:26 PM\n No acute process.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old with trauma.\n\n TECHNIQUE: Axial CT images of the head were obtained. Coronal and sagittal\n reformats were acquired.\n\n COMPARISON: There are no comparison studies available.\n\n FINDINGS:\n No acute intracranial hemorrhage, edema, mass effect or acute territorial\n infarction. The -white matter differentiation is well preserved. The\n ventricles and sulci are normal in size and configuration.\n There is circumferential mucosal thickening of the left maxillary sinus and\n mucosal thickening of the ethmoid air cells. The mastoid air cells are clear.\n No fractures are identified. Secretions are seen in the nasopharynx likely\n due to intubation.\n\n IMPRESSION:\n No acute intracranial process.\n\n"},{"category":"Radiology","chartdate":"2182-01-28 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":1226005,"text":" 7:47 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with found down\n REASON FOR THIS EXAMINATION:\n r/o fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe MON 8:31 PM\n No fracture, no malalignment.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old with trauma.\n\n TECHNIQUE:\n Contiguous MDCT images through the C-spine were obtained. Axial, coronal, and\n sagittal reformats were acquired.\n\n COMPARISON: There are no comparison studies available.\n\n FINDINGS:\n The heights of the vertebral bodies of the C-spine are preserved. There is no\n malalignment. There is no fracture. There are small posterior osteophytes at\n C4/C5 and C5/C6 with mild spinal canal stenosis. The neural foramina are\n patent.\n The patient is intubated and a nasogastric tube is partially visualized.\n No prevertbral hematoma is seen. The lung apices are clear.\n\n IMPRESSION:\n No acute fracture or malalignment.\n\n"},{"category":"Radiology","chartdate":"2182-01-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1226003,"text":" 7:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: et tube\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: There are multiple rounded calcifications in the right upper\n quadrant measuring on the order of 2 cm may represent gallstones.\n\n\n\n 7:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: et tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with intubated\n REASON FOR THIS EXAMINATION:\n et tube\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest AP supine portable view.\n\n CLINICAL INFORMATION: 50-year-old male with history of intubation.\n\n COMPARISON: None.\n\n FINDINGS: Single supine AP portable view of the chest was obtained.\n Endotracheal tube is seen, terminating approximately 5.5 cm above the level of\n the carina. There are low lung volumes. Patchy right upper lobe opacity\n could relate to low lung volumes and artifact, although an underlying\n consolidation can be present. No additional consolidation is seen. The right\n costophrenic angle is not included on the image. There is no pleural effusion\n or pneumothorax. The cardiac and mediastinal silhouettes are likely\n accentuated by supine, AP technique. No overt pulmonary edema. Gaseous\n distention of the colon is incidentally noted.\n\n"},{"category":"Radiology","chartdate":"2182-01-28 00:00:00.000","description":"CHEST (SINGLE VIEW)","row_id":1226006,"text":" 8:02 PM\n CHEST (SINGLE VIEW); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for tube placment\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man intubated, with ETT adjustement\n REASON FOR THIS EXAMINATION:\n eval for tube placment\n ______________________________________________________________________________\n WET READ: OXZa MON 11:34 PM\n ETT tip approximately 5 cm above carina. esophageal catheter tip in stomach\n with side-port at level of GE junction and could be advanced 3 cm or more to\n ensure sideport within stomach\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:52 P.M. ON \n\n HISTORY: ET tube adjusted.\n\n IMPRESSION: AP chest compared to , 7:13 p.m.:\n\n Endotracheal tube has been advanced. The tip is between 4 and 5 cm from the\n carina, standard placement. Nasogastric tube ends in the stomach. Mild\n engorgement of pulmonary and mediastinal vasculature is explained by supine\n positioning. Heart size is top normal. Lungs are clear. No pneumothorax or\n pleural effusion.\n\n\n"},{"category":"Echo","chartdate":"2182-01-31 00:00:00.000","description":"Report","row_id":85541,"text":"PATIENT/TEST INFORMATION:\nIndication: Cirrhosis. Pre-transplant evaluation. Dyspnea on exertion.\nHeight: (in) 69\nWeight (lb): 198\nBSA (m2): 2.06 m2\nBP (mm Hg): 133/75\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 10:31\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD or PFO by 2D, color\nDoppler or saline contrast with maneuvers.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Mildly dilated aortic arch. No 2D or Doppler evidence of distal arch\ncoarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect or patent foramen\novale is seen by 2D, color Doppler or saline contrast with maneuvers. Left\nventricular wall thickness, cavity size and regional/global systolic function\nare normal (LVEF >55%). Right ventricular chamber size and free wall motion\nare normal. The aortic arch is mildly dilated. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion and no aortic stenosis\nor aortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is borderline pulmonary artery systolic\nhypertension. There is an anterior space which most likely represents a\nprominent fat pad.\n\nIMPRESSION: Biatrial enlargement. Normal left ventricular cavity size and wall\nthickness with preserved global and regional biventricular systolic function.\nNo clinically significant valvular disease. Normal pulmonary artery systolic\npressure. Some late bubbles are appreciated with Valsalva maneuver, but given\nthat this was after the third injection of saline contrast it is unlikely that\nthey represent clinically significant pulmonary shunting.\n\nCompared with the prior study (images reviewed) of , mild to moderate\npulmonary artery systolic hypertension is no longer appreciated. The aortic\narch is now mildly dilated.\n\n\n"},{"category":"ECG","chartdate":"2182-01-28 00:00:00.000","description":"Report","row_id":219280,"text":"Baseline artifact. Sinus tachycardia. Cannot rule out ST-T wave\nabnormalities but much of it may be artifact. Since the previous tracing\nof the rate has increased.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2182-01-29 00:00:00.000\",\n \"description\": \"P US ABD LIMIT, SINGLE ORGAN PORT\",\n \"row_id\": 1226044,\n \"text\": \" 6:54 AM\\n US ABD LIMIT, SINGLE ORGAN PORT Clip # \\n Reason: ? ascites, amenable to drainage\\n Admitting Diagnosis: ENCEPHALOPATHY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 m HCV cirr, now w recurrent encephalopathy\\n REASON FOR THIS EXAMINATION:\\n ? ascites, amenable to drainage\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 56-year-old man with recurrent encephalopathy. Evaluate for\\n ascites.\\n\\n COMPARISON: Liver ultrasound, .\\n\\n FINDINGS: A limited study of the four quadrants of the abdomen was performed.\\n A scant trace of ascites is again seen within the abdomen predominantly in the\\n perihepatic space.\\n\\n IMPRESSION: Scant trace of ascites seen in the abdomen.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2182-01-28 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1226004,\n \"text\": \" 7:47 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: r/o bleed\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with found down\\n REASON FOR THIS EXAMINATION:\\n r/o bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JBRe MON 8:26 PM\\n No acute process.\\n\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 56-year-old with trauma.\\n\\n TECHNIQUE: Axial CT images of the head were obtained. Coronal and sagittal\\n reformats were acquired.\\n\\n COMPARISON: There are no comparison studies available.\\n\\n FINDINGS:\\n No acute intracranial hemorrhage, edema, mass effect or acute territorial\\n infarction. The -white matter differentiation is well preserved. The\\n ventricles and sulci are normal in size and configuration.\\n There is circumferential mucosal thickening of the left maxillary sinus and\\n mucosal thickening of the ethmoid air cells. The mastoid air cells are clear.\\n No fractures are identified. Secretions are seen in the nasopharynx likely\\n due to intubation.\\n\\n IMPRESSION:\\n No acute intracranial process.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2182-01-28 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 1226005,\n \"text\": \" 7:47 PM\\n CT C-SPINE W/O CONTRAST Clip # \\n Reason: r/o fx\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with found down\\n REASON FOR THIS EXAMINATION:\\n r/o fx\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JBRe MON 8:31 PM\\n No fracture, no malalignment.\\n\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 56-year-old with trauma.\\n\\n TECHNIQUE:\\n Contiguous MDCT images through the C-spine were obtained. Axial, coronal, and\\n sagittal reformats were acquired.\\n\\n COMPARISON: There are no comparison studies available.\\n\\n FINDINGS:\\n The heights of the vertebral bodies of the C-spine are preserved. There is no\\n malalignment. There is no fracture. There are small posterior osteophytes at\\n C4/C5 and C5/C6 with mild spinal canal stenosis. The neural foramina are\\n patent.\\n The patient is intubated and a nasogastric tube is partially visualized.\\n No prevertbral hematoma is seen. The lung apices are clear.\\n\\n IMPRESSION:\\n No acute fracture or malalignment.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2182-01-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1226003,\n \"text\": \" 7:16 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: et tube\\n ______________________________________________________________________________\\n FINAL ADDENDUM\\n ADDENDUM: There are multiple rounded calcifications in the right upper\\n quadrant measuring on the order of 2 cm may represent gallstones.\\n\\n\\n\\n 7:16 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: et tube\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with intubated\\n REASON FOR THIS EXAMINATION:\\n et tube\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAM: Chest AP supine portable view.\\n\\n CLINICAL INFORMATION: 50-year-old male with history of intubation.\\n\\n COMPARISON: None.\\n\\n FINDINGS: Single supine AP portable view of the chest was obtained.\\n Endotracheal tube is seen, terminating approximately 5.5 cm above the level of\\n the carina. There are low lung volumes. Patchy right upper lobe opacity\\n could relate to low lung volumes and artifact, although an underlying\\n consolidation can be present. No additional consolidation is seen. The right\\n costophrenic angle is not included on the image. There is no pleural effusion\\n or pneumothorax. The cardiac and mediastinal silhouettes are likely\\n accentuated by supine, AP technique. No overt pulmonary edema. Gaseous\\n distention of the colon is incidentally noted.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2182-01-28 00:00:00.000\",\n \"description\": \"CHEST (SINGLE VIEW)\",\n \"row_id\": 1226006,\n \"text\": \" 8:02 PM\\n CHEST (SINGLE VIEW); -77 BY DIFFERENT PHYSICIAN # \\n Reason: eval for tube placment\\n Admitting Diagnosis: ENCEPHALOPATHY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man intubated, with ETT adjustement\\n REASON FOR THIS EXAMINATION:\\n eval for tube placment\\n ______________________________________________________________________________\\n WET READ: OXZa MON 11:34 PM\\n ETT tip approximately 5 cm above carina. esophageal catheter tip in stomach\\n with side-port at level of GE junction and could be advanced 3 cm or more to\\n ensure sideport within stomach\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 7:52 P.M. ON \\n\\n HISTORY: ET tube adjusted.\\n\\n IMPRESSION: AP chest compared to , 7:13 p.m.:\\n\\n Endotracheal tube has been advanced. The tip is between 4 and 5 cm from the\\n carina, standard placement. Nasogastric tube ends in the stomach. Mild\\n engorgement of pulmonary and mediastinal vasculature is explained by supine\\n positioning. Heart size is top normal. Lungs are clear. No pneumothorax or\\n pleural effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2182-01-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 85541,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Cirrhosis. Pre-transplant evaluation. Dyspnea on exertion.\\nHeight: (in) 69\\nWeight (lb): 198\\nBSA (m2): 2.06 m2\\nBP (mm Hg): 133/75\\nHR (bpm): 60\\nStatus: Inpatient\\nDate/Time: at 10:31\\nTest: TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Mild LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD or PFO by 2D, color\\nDoppler or saline contrast with maneuvers.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\\nsystolic function (LVEF >55%). No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter. Mildly dilated aortic arch. No 2D or Doppler evidence of distal arch\\ncoarctation.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\\nsystolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR.\\n\\nPERICARDIUM: There is an anterior space which most likely represents a fat\\npad, though a loculated anterior pericardial effusion cannot be excluded.\\n\\nConclusions:\\nThe left atrium is mildly dilated. No atrial septal defect or patent foramen\\novale is seen by 2D, color Doppler or saline contrast with maneuvers. Left\\nventricular wall thickness, cavity size and regional/global systolic function\\nare normal (LVEF >55%). Right ventricular chamber size and free wall motion\\nare normal. The aortic arch is mildly dilated. The aortic valve leaflets (3)\\nappear structurally normal with good leaflet excursion and no aortic stenosis\\nor aortic regurgitation. The mitral valve appears structurally normal with\\ntrivial mitral regurgitation. There is borderline pulmonary artery systolic\\nhypertension. There is an anterior space which most likely represents a\\nprominent fat pad.\\n\\nIMPRESSION: Biatrial enlargement. Normal left ventricular cavity size and wall\\nthickness with preserved global and regional biventricular systolic function.\\nNo clinically significant valvular disease. Normal pulmonary artery systolic\\npressure. Some late bubbles are appreciated with Valsalva maneuver, but given\\nthat this was after the third injection of saline contrast it is unlikely that\\nthey represent clinically significant pulmonary shunting.\\n\\nCompared with the prior study (images reviewed) of , mild to moderate\\npulmonary artery systolic hypertension is no longer appreciated. The aortic\\narch is now mildly dilated.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2182-01-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 219280,\n \"text\": \"Baseline artifact. Sinus tachycardia. Cannot rule out ST-T wave\\nabnormalities but much of it may be artifact. Since the previous tracing\\nof the rate has increased.\\n\\n\"\n }\n]"}}}],"truncated":false,"partial":false},"paginationData":{"pageIndex":246,"numItemsPerPage":100,"numTotalItems":24993,"offset":24600,"length":100}},"jwt":"eyJhbGciOiJFZERTQSJ9.eyJyZWFkIjp0cnVlLCJwZXJtaXNzaW9ucyI6eyJyZXBvLmNvbnRlbnQucmVhZCI6dHJ1ZX0sImlhdCI6MTczMTg1ODg0Mywic3ViIjoiL2RhdGFzZXRzL2RtYWNyZXMvbWltaWNpaWktaG9zcGl0YWxjb3Vyc2UtbWV0YSIsImV4cCI6MTczMTg2MjQ0MywiaXNzIjoiaHR0cHM6Ly9odWdnaW5nZmFjZS5jbyJ9.1Edq3lnEa1YuVDEgCqRcYTU794ut2sk5QSnT8EQXGNHZzHZPhgCrtwMAUsr4B2Sra-cCAltonriRTiScLwScCA","displayUrls":true},"discussionsStats":{"closed":0,"open":1,"total":1},"fullWidth":true,"hasGatedAccess":true,"hasFullAccess":true,"isEmbedded":false}">
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29,003 | 170,234 | Pt underwent a LEFT upper lobectomy and mediastinal lymph node sampling through a thoracotomy incision. He tolerated the procedure well and was extubated without difficulty. Postoperative pain control was initially accomplished with an epidural catheter but this was capped due to hypotension requiring Neo in PACU. He was rapidly transitioned to oral pain medication wtih IV narcotics for breakthrough pain. Chest tubes placed during surgery were transitioned from suction to water seal and then removed POD#2. Chest x-ray demonstrated no significant pneumothroax but was indeterminate concerning an effusion or consolidation. A chest CT was therefore obtained and this demonstrated trace dependent fluid in the surgical cavity and no evidence of pulmonary consolidation. By POD#3 the patient's pain was well-controlled on oral pain medications, no longer requiring supplemental oxygen, ambulating without difficulty or need for assistance and tolerating a regular diet. After evaluation by the thoracic surgery team, including attending surgeon Dr. , he was able to be discharged home with his wife. | Left-sided thoracotomy changes are as noted. The right lung is essentially clear except for some residual atelectatic change at the base. The trachea has been pulled over to this side and there is mild mediastinal shift. There is mild atrophy in the visualized extent of the pancreas. The left upper lobe bronchial stump appears within normal limits. The right lung is aerated. Airways are patent on the right, with small amount of adherent secretion in the tracheal bifurcation. This is associated with a small amount of post-procedural subcutaneous emphysema tracking along the chest wall. Subcentimeter pretracheal, precarinal, and hilar lymph nodes are noted. The left lower lobe is reasonably aerated, with a small component of basal pneumothorax. Limited subdiaphragmatic evaluation demonstrates a subcentimeter hypodensity in hepatic segment VIII, too small to fully characterize. Post-sternotomy wires appear unchanged including two upper broken wires. A surgical defect is present in the posterior left sixth rib consistent with thoracotomy site. Post-surgical opacification is seen at the left base consistent with atelectasis, effusion, and possible consolidation. TOTAL DLP: 683.50 mGy-cm CT CHEST: Patient is status post recent left upper lobectomy with a postoperative pneumothorax and a small amount of aerosolized fluid in the dependent surgical cavity. The gallbladder, spleen, and adrenal glands are within normal limits. FINDINGS: In comparison with the study of , post-operative changes are again seen in the left hemithorax with shift of the mediastinum to this side. Status post left upper lobectomy with post-surgical pneumothorax and trace fluid in the dependent surgical cavity. Several right renal cysts are seen, the largest of which measuring 17 mm and intermediate in density, indeterminate. Left posterior sixth rib surgical thoracotomy and postoperative subcutaneous emphysema along the posterior left chest wall. 1.7 cm right renal lesion measuring over 40 Hounsfield units, which could represent a hyperdense cyst, but indeterminate and could be further assessed by ultrasound on a non-emergent basis. The right lobe of thyroid appears unremarkable. The gas along the upper chest border on the left and subcutaneous tissues is decreasing. FINDINGS: In comparison with the study of , there has been a lobectomy performed on the left. (Over) 4:54 PM CT CHEST W/CONTRAST Clip # Reason: eval for interval change Admitting Diagnosis: LUNG CA/SDA Contrast: OMNIPAQUE Amt: 75 FINAL REPORT (Cont) IMPRESSION: 1. AP radiograph of the chest was reviewed in comparison to . A linear opacity in the left base likely represents atelectasis. Sinus bradycardia. Chest tube is in place and there is no definite pneumothorax. Of incidental note is small amount of gas along the upper chest border on the left. Subcentimeter liver hypodensity within segment VIII, too small to fully characterize. 8:02 AM CHEST (PORTABLE AP) Clip # Reason: 70yM s/p L thoracotomy, upper lobectomy Admitting Diagnosis: LUNG CA/SDA MEDICAL CONDITION: 70yM s/p L thoracotomy, upper lobectomy REASON FOR THIS EXAMINATION: 70yM s/p L thoracotomy, upper lobectomy FINAL REPORT HISTORY: Left thoracotomy with upper lobectomy. Heart size and mediastinum are stable in appearance including left mediastinal shift, expected. Severe centrilobular emphysema is present bilaterally. The lower lobe bronchi appear patent. 2:51 PM CHEST (PORTABLE AP) Clip # Reason: 70yM s/p L thoracotomy, upper lobectomy Admitting Diagnosis: LUNG CA/SDA MEDICAL CONDITION: 70yM s/p L thoracotomy, upper lobectomy REASON FOR THIS EXAMINATION: 70yM s/p L thoracotomy, upper lobectomy FINAL REPORT HISTORY: Upper lobectomy. Patient is status post resection of left lobe of thyroid. There appears to be some increase in the extensive opacification in the left hemithorax. The chronic interstitial changes are unchanged as well. Non-specific ST-T wave changes. Dense mitral annular calcifications and multivessel coronary arterial calcifications are present. TECHNIQUE: CT of the chest was performed following administration of intravenous contrast using soft tissue and lung algorithms. Atelectatic changes are seen at the right base. Compared to the previoustracing of ST-T wave changes are new. REASON FOR THIS EXAMINATION: eval for interval change No contraindications for IV contrast FINAL REPORT ]INDICATION: 70-year-old male status post left thoracotomy and left upper lobectomy for lung cancer. Axial images were displayed at 5 mm and 1.25 mm collimation with multiplanar reconstructions as well as maximum intensity projection images. The heart is normal in size without pericardial effusion. | 5 | [
{
"category": "Radiology",
"chartdate": "2153-03-30 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1233097,
"text": " 5:13 PM\n CHEST (PA & LAT) Clip # \n Reason: post chest tube pull film, please do at 6 pm\n Admitting Diagnosis: LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p left thoracotomy left upper lobectomy for lung cancer\n REASON FOR THIS EXAMINATION:\n post chest tube pull film, please do at 6 pm\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after left thoracotomy and\n left upper lobectomy for lung cancer, assessment after chest tube\n discontinuation.\n\n AP radiograph of the chest was reviewed in comparison to .\n\n Heart size and mediastinum are stable in appearance including left mediastinal\n shift, expected. No evidence of pneumothorax or interval increase of pleural\n effusion is demonstrated. Post-sternotomy wires appear unchanged including\n two upper broken wires. The chronic interstitial changes are unchanged as\n well.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-03-30 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1233095,
"text": " 4:54 PM\n CT CHEST W/CONTRAST Clip # \n Reason: eval for interval change\n Admitting Diagnosis: LUNG CA/SDA\n Contrast: OMNIPAQUE Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p left thoracotomy LUL lobectomy for lung cancer.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n ]INDICATION: 70-year-old male status post left thoracotomy and left upper\n lobectomy for lung cancer. Question interval change.\n\n COMPARISON: FDG PET study dated .\n\n TECHNIQUE: CT of the chest was performed following administration of\n intravenous contrast using soft tissue and lung algorithms. Axial images were\n displayed at 5 mm and 1.25 mm collimation with multiplanar reconstructions as\n well as maximum intensity projection images.\n\n TOTAL DLP: 683.50 mGy-cm\n\n CT CHEST: Patient is status post recent left upper lobectomy with a\n postoperative pneumothorax and a small amount of aerosolized fluid in the\n dependent surgical cavity. The left upper lobe bronchial stump appears within\n normal limits. The lower lobe bronchi appear patent. The left lower lobe is\n reasonably aerated, with a small component of basal pneumothorax. A surgical\n defect is present in the posterior left sixth rib consistent with thoracotomy\n site. This is associated with a small amount of post-procedural subcutaneous\n emphysema tracking along the chest wall. The right lung is aerated. Severe\n centrilobular emphysema is present bilaterally. A linear opacity in the left\n base likely represents atelectasis. There is no large effusion. Airways are\n patent on the right, with small amount of adherent secretion in the tracheal\n bifurcation.\n\n The heart is normal in size without pericardial effusion. Dense mitral\n annular calcifications and multivessel coronary arterial calcifications are\n present. Patient is status post resection of left lobe of thyroid. The right\n lobe of thyroid appears unremarkable. Subcentimeter pretracheal, precarinal,\n and hilar lymph nodes are noted. There is no axillary lymphadenopathy.\n\n Limited subdiaphragmatic evaluation demonstrates a subcentimeter hypodensity\n in hepatic segment VIII, too small to fully characterize. The gallbladder,\n spleen, and adrenal glands are within normal limits. There is mild atrophy in\n the visualized extent of the pancreas. Several right renal cysts are seen,\n the largest of which measuring 17 mm and intermediate in density,\n indeterminate.\n\n BONE WINDOW: Median sternotomy wires are intact. Left-sided thoracotomy\n changes are as noted. No concerning focal lesion.\n (Over)\n\n 4:54 PM\n CT CHEST W/CONTRAST Clip # \n Reason: eval for interval change\n Admitting Diagnosis: LUNG CA/SDA\n Contrast: OMNIPAQUE Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Status post left upper lobectomy with post-surgical pneumothorax and trace\n fluid in the dependent surgical cavity.\n 2. Left posterior sixth rib surgical thoracotomy and postoperative\n subcutaneous emphysema along the posterior left chest wall.\n 3. Subcentimeter liver hypodensity within segment VIII, too small to fully\n characterize.\n 4. 1.7 cm right renal lesion measuring over 40 Hounsfield units, which could\n represent a hyperdense cyst, but indeterminate and could be further assessed\n by ultrasound on a non-emergent basis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-03-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1232768,
"text": " 2:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 70yM s/p L thoracotomy, upper lobectomy\n Admitting Diagnosis: LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70yM s/p L thoracotomy, upper lobectomy\n REASON FOR THIS EXAMINATION:\n 70yM s/p L thoracotomy, upper lobectomy\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Upper lobectomy.\n\n FINDINGS: In comparison with the study of , there has been a lobectomy\n performed on the left. Chest tube is in place and there is no definite\n pneumothorax. Post-surgical opacification is seen at the left base consistent\n with atelectasis, effusion, and possible consolidation. The trachea has been\n pulled over to this side and there is mild mediastinal shift.\n\n Atelectatic changes are seen at the right base.\n\n Of incidental note is small amount of gas along the upper chest border on the\n left.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-03-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1232860,
"text": " 8:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 70yM s/p L thoracotomy, upper lobectomy\n Admitting Diagnosis: LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70yM s/p L thoracotomy, upper lobectomy\n REASON FOR THIS EXAMINATION:\n 70yM s/p L thoracotomy, upper lobectomy\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left thoracotomy with upper lobectomy.\n\n FINDINGS: In comparison with the study of , post-operative changes are\n again seen in the left hemithorax with shift of the mediastinum to this side.\n Chest tube remains in place and there is no evidence of pneumothorax. The\n right lung is essentially clear except for some residual atelectatic change at\n the base.\n\n The gas along the upper chest border on the left and subcutaneous tissues is\n decreasing. There appears to be some increase in the extensive opacification\n in the left hemithorax. This could reflect additional pleural fluid, though\n in the appropriate clinical setting, the possibility of supervening pneumonia\n would have to be considered.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2153-03-30 00:00:00.000",
"description": "Report",
"row_id": 112730,
"text": "Sinus bradycardia. Non-specific ST-T wave changes. Compared to the previous\ntracing of ST-T wave changes are new.\n\n"
}
] |
88,446 | 159,149 | 87 year old man with AFib, h/o CVA, HTN, who presented with fever and vomiting, found to have hypoxia and AFib with RVR thought to be secondary to aspiration pneumonia and pulmonary edema, and found to be positive for influenza A. Admitted to the medical floor . Transfer to MICU for hypoxia. Transfer back to floor . . # Fever/Leukocytosis: Likely related to flu versus aspiration event after vomiting and recent dental procedure. He was empirically treated with vancomycin, levofloxacin, and clindamycin for HCAP and aspiration pneumonia. He will be discharged on clindaymycin/levaquin to complete a total 7 day course of antibiotics to end on . He was also empirically treated with oseltamavir which was continued once his respiratory viral culture returned positive for influenza A. His leukocytosis resolved and he remained afebrile. He will continue tamiflu for a total 5 day course to end on . . # Pulmonary Edema: On , patient was noted to have high blood pressure (SBP 180s) and rapid heart rate (140s) with decreasing oxygen saturation (down to 60s although difficult to get accurate read) and mottled appearance on physical exam. He was trated with lasix, metoprolol, diltiazem, morphine, and respiratory suctioning. He did produce significant mucus suggesting a component of aspiration/mucus plugging. Chest x-ray showed worsening edema which may have also contributed to his symptoms. He was transfered to the ICU for monitoring. In the ICU, it was felt that the edema was likely related to RVR along with fluid boluses received for tachycardia while on the floor. He was diuresed with lasix with good response. He was stable on room air prior to transfer back to the medical floor. He is currently stable on room air on discharge. . # AFib with RVR: Likely exacerbated by influenza. TSH wnl. ECHO revealed normal biventricular cavity sizes with preserved systolic function. He was noted to have dynamic ST depressions which were felt to be rate-related changed. The patient was asymptomatic and cardiac enzymes were flat. The patient was initially treated with a diltiazem gtt in the intensive care unit which was later transitioned to PO metoprolol with prn IV metoprolol for rvr. His heart rate stabilized on PO metoprolol. Heart rate was in 90-120s on discharge. He was continued on warfarin. He was initially started on 5 mg warfarin daily but this was decreased down to 2 mg given elevated INR. He was decreaed to 1 mg on for INR of 3.7. INR on day of discharge is 4.5. Elevation in INR likely related to antibiotics. He will be discharged on 1 mg of coumadin although we recommend close monitoring of INR and adjustment of warfarin dose appropriately until stable. . # H/o CVA: The patient was continued on aspirin and plavix. . # Renal Lesion: Incidentally seen on CT. Recommend f/u per radiology. . # DM: Insulin sliding scale while in patient. Blood glucose levels in 100s. . # HTN: Initially held home HCTZ. Restarted prior to discharge. . #Code status: Patient's daughter (HCP) and wife confirmed that code status is DNR/DNI with emphasis on comfort. | No LA mass/thrombus (best excluded by TEE).RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Minimal interstitial edema is again seen. Normal PAsystolic pressure.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is mildly dilated. The estimated pulmonary artery systolic pressure is normal.There is an anterior space which most likely represents a prominent fat pad.IMPRESSION: Suboptimal image quality. Mild mitral annularcalcification. Normal biventricular cavity sizes withpreserved global biventricular systolic function. Mild thickening of mitral valve chordae.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. There appears to be mild central pulmonary vascular engorgement. Trace aortic regurgitation is seen. FINDINGS: The previously visualized left retrocardiac opacity is again seen. IMPRESSION: Mild central pulmonary vascular engorgement. Pancreas appears slightly atrophic. Calcified aortic arch is again noted. There are bilateral fat-containing inguinal hernias, 2:86. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTIC VALVE: Mildly thickened aortic valve leaflets. Minor non-specificST-T wave abnormalities. The right atrium is moderatelydilated. Abnormal ECG.Height: (in) 68Weight (lb): 260BSA (m2): 2.29 m2BP (mm Hg): 101/52HR (bpm): 85Status: InpatientDate/Time: at 10:16Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement. Renal cyst and bilateral renal hypodensities, too small to be characterized. There are moderate atherosclerotic changes in the abdominal vessels. Right retrocardiac opacity is also visualized. Seminal vesicles appear normal. Left kidney upper pole subcentimeter exophytic hyperattenuated lesion, similar in size compared to CT from , and incompletely characterized due to its small size. Compared tothe previous tracing of ventricular ectopy is new.TRACING #1 OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion. No left atrial mass/thrombus seen (bestexcluded by transesophageal echocardiography). Atrial fibrillation is suggested. Right ventricular chambersize and free wall motion are normal. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Left ventricular function. Ventricular couplet is seen. Coronary calcifications are seen. Atrial fibrillation. Atrial fibrillation. Although no change in size is reassuring, please consider renal ultrasound in a non-urgent setting to evaluate further. FINDINGS: There are subtle bibasilar opacities at the lung bases. Biatrial enlargement.CLINICAL IMPLICATIONS:Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate prophylaxis is NOT recommended. Lipomatous hypertrophyof the interatrial septum.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolicfunction (LVEF>55%). Compared to the previous tracing of nosignificant change. The spleen and bilateral adrenal glands are normal. The hilar and mediastinal silhouettes are unchanged. IMPRESSION: (Over) 3:07 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: please eval r/o diverticulitis Field of view: 48 Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) 1. Suboptimal technical quality, a focal LV wall motionabnormality cannot be fully excluded. TECHNIQUE: Frontal radiographs of the chest were obtained. COMPARISON: CT torso . PATIENT/TEST INFORMATION:Indication: Atrial fibrillation. At the upper pole of the left kidney (2:20), there is a small exophytic hyperattenuated lesion similar compared to CT from , but incompletely characterized due to its small size. There is a Foley catheter in the urinary bladder and foci of air, presumably from placement of catheter; however, correlate clinically. COMPARISONS: Chest radiograph of . Coronal and sagittal reformatted images provided. There is a likely dropped clip in the mid abdomen (2:26). TECHNIQUE: CT abdomen and pelvis with IV contrast. There are small hypodensities in the kidneys bilaterally, too small to be characterized. The left retrocardiac opacity is slightly more pronounced than on the prior studies, still most likely consistent with atelectasis but continued followup of this area is recommended to exclude the possibility of developing infection. Portable AP chest radiograph was compared to obtained at 12:54 p.m. Current study demonstrates stable appearance of the cardiomediastinal silhouette and no new consolidations, but the patient has mild interstitial pulmonary edema. The heart size is top normal. The portal vein is patent. Diverticulosis with no evidence of diverticulitis. CT PELVIS: Sigmoid diverticulosis is noted; however, no evidence of diverticulitis on CT. No free fluid in the pelvis. Compared to the previous tracing ectopy is resolved.TRACING #2 Liver is enhancing homogeneously. The patient is status post cholecystectomy. Atrial fibrillation with a rapid ventricular response. There are no pathologically enlarged lymph nodes in the retroperitoneum or mesentery. There is no aortic valvestenosis. IMPRESSION: Persistent left retrocardiac density and new right retrocardiac density, which could represent atelectasis or infection. Left ventricular wall thickness, cavity size, and global systolicfunction are normal (LVEF>55%). The aortic valve leaflets (?#) appearmildly thickened but with good leaflet excursion. There are no pathologically enlarged lymph nodes in the pelvic or inguinal area. Due to suboptimal technical quality, a focalwall motion abnormality cannot be fully excluded. Compared to the previous tracing no change.TRACING #3 There is no pericardial or pleural effusion. FINDINGS: There is no pleural effusion, focal consolidations, or pneumothorax. There is diverticulosis; however, there is no evidence of diverticulitis in the colon. Kidneys enhance symmetrically. Multilevel degenerative changes in the thoracolumbar spine. No pleural effusion or pneumothorax is seen on these frontal views. There is no evidence of bowel obstruction. | 9 | [
{
"category": "Radiology",
"chartdate": "2175-03-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1181468,
"text": " 12:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval r/o infectious process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with fever, cough\n REASON FOR THIS EXAMINATION:\n please eval r/o infectious process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with fever and cough.\n\n COMPARISONS: Chest radiograph of .\n\n FINDINGS:\n\n There is no pleural effusion, focal consolidations, or pneumothorax. The\n hilar and mediastinal silhouettes are unchanged. There appears to be mild\n central pulmonary vascular engorgement. The heart size is top normal.\n Calcified aortic arch is again noted.\n\n IMPRESSION:\n\n Mild central pulmonary vascular engorgement. No focal consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-03-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1181599,
"text": " 10:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for worsening pna vs flash\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 yo male w/ aspiration pna and acute desats\n REASON FOR THIS EXAMINATION:\n evaluate for worsening pna vs flash\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Acute desaturations in a patient with aspiration\n pneumonia.\n\n Portable AP chest radiograph was compared to obtained at 12:54\n p.m.\n\n Current study demonstrates stable appearance of the cardiomediastinal\n silhouette and no new consolidations, but the patient has mild interstitial\n pulmonary edema. The left retrocardiac opacity is slightly more pronounced\n than on the prior studies, still most likely consistent with atelectasis but\n continued followup of this area is recommended to exclude the possibility of\n developing infection.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-03-22 00:00:00.000",
"description": "CT ABD & PELVIS WITH CONTRAST",
"row_id": 1181483,
"text": " 3:07 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: please eval r/o diverticulitis\n Field of view: 48 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with fever, vomiting\n REASON FOR THIS EXAMINATION:\n please eval r/o diverticulitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf WED 5:50 PM\n Diverticulosis; however no CT evidence for diverticulitis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever and vomiting.\n\n TECHNIQUE: CT abdomen and pelvis with IV contrast. Coronal and sagittal\n reformatted images provided. Oral contrast was not administered.\n\n COMPARISON: CT torso .\n\n FINDINGS: There are subtle bibasilar opacities at the lung bases. There is\n no pericardial or pleural effusion. Coronary calcifications are seen.\n\n Liver is enhancing homogeneously. The patient is status post cholecystectomy.\n Surgical clips are seen at the gallbladder fossa. There is a likely dropped\n clip in the mid abdomen (2:26). The spleen and bilateral adrenal glands are\n normal. Kidneys enhance symmetrically. There is a large cyst in the\n interpolar region of the right kidney measuring 10 x 9.6 cm, (2:28), with mild\n interval increase in size compared to last CT. There are small hypodensities\n in the kidneys bilaterally, too small to be characterized. At the upper pole\n of the left kidney (2:20), there is a small exophytic hyperattenuated lesion\n similar compared to CT from , but incompletely characterized due to its\n small size. Pancreas appears slightly atrophic. The portal vein is patent.\n There are moderate atherosclerotic changes in the abdominal vessels.\n\n There is no evidence of bowel obstruction. There is diverticulosis; however,\n there is no evidence of diverticulitis in the colon. There is no free fluid\n or free air. There are no pathologically enlarged lymph nodes in the\n retroperitoneum or mesentery.\n\n CT PELVIS: Sigmoid diverticulosis is noted; however, no evidence of\n diverticulitis on CT. No free fluid in the pelvis. Seminal vesicles appear\n normal. There is a Foley catheter in the urinary bladder and foci of air,\n presumably from placement of catheter; however, correlate clinically. There\n are no pathologically enlarged lymph nodes in the pelvic or inguinal area.\n There are bilateral fat-containing inguinal hernias, 2:86.\n\n OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion. Multilevel\n degenerative changes in the thoracolumbar spine.\n\n IMPRESSION:\n (Over)\n\n 3:07 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: please eval r/o diverticulitis\n Field of view: 48 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Diverticulosis with no evidence of diverticulitis.\n 2. Renal cyst and bilateral renal hypodensities, too small to be\n characterized.\n 3. Left kidney upper pole subcentimeter exophytic hyperattenuated lesion,\n similar in size compared to CT from , and incompletely characterized due\n to its small size. Although no change in size is reassuring, please consider\n renal ultrasound in a non-urgent setting to evaluate further.\n\n Peetkovska d/w Dr. at 6:40 pm by phone on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-03-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1181738,
"text": " 9:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change?\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with flu, ?pna.\n REASON FOR THIS EXAMINATION:\n interval change?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old male with influenza, concern for pneumonia.\n\n COMPARISON: .\n\n TECHNIQUE: Frontal radiographs of the chest were obtained.\n\n FINDINGS: The previously visualized left retrocardiac opacity is again seen.\n Right retrocardiac opacity is also visualized. Minimal interstitial edema is\n again seen. No pleural effusion or pneumothorax is seen on these frontal\n views.\n\n IMPRESSION: Persistent left retrocardiac density and new right retrocardiac\n density, which could represent atelectasis or infection.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2175-03-24 00:00:00.000",
"description": "Report",
"row_id": 87341,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Left ventricular function. Abnormal ECG.\nHeight: (in) 68\nWeight (lb): 260\nBSA (m2): 2.29 m2\nBP (mm Hg): 101/52\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 10:16\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. No LA mass/thrombus (best excluded by TEE).\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Lipomatous hypertrophy\nof the interatrial septum.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. No left atrial mass/thrombus seen (best\nexcluded by transesophageal echocardiography). The right atrium is moderately\ndilated. Left ventricular wall thickness, cavity size, and global systolic\nfunction are normal (LVEF>55%). Due to suboptimal technical quality, a focal\nwall motion abnormality cannot be fully excluded. Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (?#) appear\nmildly thickened but with good leaflet excursion. There is no aortic valve\nstenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. The estimated pulmonary artery systolic pressure is normal.\nThere is an anterior space which most likely represents a prominent fat pad.\n\nIMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with\npreserved global biventricular systolic function. Biatrial enlargement.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2175-03-23 00:00:00.000",
"description": "Report",
"row_id": 221412,
"text": "Atrial fibrillation. Compared to the previous tracing ectopy is resolved.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2175-03-23 00:00:00.000",
"description": "Report",
"row_id": 221413,
"text": "Atrial fibrillation is suggested. Ventricular couplet is seen. Compared to\nthe previous tracing of ventricular ectopy is new.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2175-03-22 00:00:00.000",
"description": "Report",
"row_id": 221414,
"text": "Atrial fibrillation with a rapid ventricular response. Minor non-specific\nST-T wave abnormalities. Compared to the previous tracing of no\nsignificant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2175-03-23 00:00:00.000",
"description": "Report",
"row_id": 221411,
"text": "Atrial fibrillation. Compared to the previous tracing no change.\nTRACING #3\n\n"
}
] |
88,882 | 166,780 | Following admission a Pulmonary Medicine consult was obtained due to his chronic cough. Symptoms were felt to be likely due to gastric reflux and bronchodilators and Flonase were recommended. On he went to the Operating Room, where via a median sternotomy, a full MAZE was performed. He remained stable, was extubated easily and was briefly in sinus rhythm. On POD 2 he developed rapid atrial fibrillation and Amiodarone and beta blockers were titrated. Coumadin and Heparin were begun. He remained in controlled fibrillation and cardioversion was performed on . This was unsuccessful after two attempts, however, upom return to the floor he converted to sinus rhythm, but reverted to controlled atrial fibrillation several hours later. Arrangements for follow up, Coumadin management will be done by the patient as he did preoperatively. He self tests. | Normaldescending aorta diameter. Normal ascending aortadiameter. Normal ascending aortadiameter. Normal aortic arch diameter. Normal aortic arch diameter. No TEE relatedcomplications.Conclusions:The left atrium is markedly dilated. Simple atheroma in aortic arch. with moderate global free wall hypokinesis.There are simple atheroma in the aortic arch. Normal main PA. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.Conclusions:The left atrium is markedly dilated. There are simple atheroma in thedescending thoracic aorta. Normal RVsystolic function.AORTA: Normal aortic diameter at the sinus level. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Moderate retrocardiac atelectasis, mild left basal atelectasis, the presence of a minimal left pleural effusion cannot be excluded. Mild tomoderate (+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. The aorta is normal in caliber with no atherosclerotic calcification. The mitralvalve appears structurally normal with trivial mitral regurgitation.PostThe patient is s/p LAA ligation with a maze procedureThe Left atrial appendage is no longer visible with echoLV function is preserved similar to prebypass The right ventricular cavity is mildlydilated with normal free wall contractility. Normal tricuspid valvesupporting structures. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Borderline PA systolichypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. The right internal jugular line tip is at the level of low SVC. No ASD by 2D or color Doppler.LEFT VENTRICLE: Mild symmetric LVH. Mild mitralannular calcification. There is anRSR' pattern in lead V1 which is probably normal. Mild [1+] TR. There are tiny R waves inthe inferior leads consistent with possible prior myocardial infarction.Non-specific ST-T wave changes. There is only minimal residual apical pneumothorax on the right. The mediastinal silhouette, hilar contours, and pleural surfaces are normal. Regionalleft ventricular wall motion is normal. Small right apical pneumothorax after removal of chest tube. FINDINGS: A right apical pneumothorax is small after chest tube removal. The left ventricular cavity size is normal. Mild to moderate (+) mitral regurgitation is seen. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV wall thickness. There are tiny R waves in the inferior leads consistentwith possible prior myocardial infarction. The sternotomy wires are unchanged in position. There is mild symmetric leftventricular hypertrophy. Simple atheroma in descending aorta.AORTIC VALVE: Normal aortic valve leaflets (3). Left ventricular wall thicknesses are normal. Low lung volume, without ptx. Normal LV cavity size. Compared to the previous tracing atrialpacing has replaced atrial fibrillation.TRACING #1 Normal LV wall thickness. Mild thickening of mitral valve chordae. Cardiomediastinal silhouette is stable. No 2D or Doppler evidence of distalarch coarctation.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Normal regional LV systolic function.Overall normal LVEF (>55%).LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Moderate global RV free wall hypokinesis.AORTA: Normal aortic diameter at the sinus level. Atrial fibrillation with borderline left axis deviation. The aortic valve leaflets (3) aremildly thickened but aortic stenosis is not present. FINDINGS: An interatrial septum closure device is in satisfactory position. The aortic valve leaflets (3) appear structurallynormal with good leaflet excursion and no aortic regurgitation. Bilateral lower lobe bronchial wall thickening and linear atelectasis is mild. Exclude pneumothorax. The cardiac size is normal. Moderate cardiomegaly is stable. Mildly dilated RV cavity. TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed without intravenous or oral contrast. The right-sided central venous access line is in correct position. PATIENT/TEST INFORMATION:Indication: Eval ValvesHeight: (in) 72Weight (lb): 240BSA (m2): 2.30 m2BP (mm Hg): 120/76HR (bpm): 110Status: OutpatientDate/Time: at 15:00Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Marked LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. COMPARISON: Chest radiograph dated . Lung volumes are accordingly mildly decreased and bilateral lower lobe atelectasis has slightly progressed. Overall left ventricular systolicfunction is normal (LVEF>55%). No thoracic aortic calcification. Regular atrial pacing with native ventricular conduction. Overallleft ventricular systolic function is normal (LVEF 60%). No pulmonary edema. Study is not tailored for subdiaphragmatic evaluation, only to confirm normal-appearing adrenals and bilateral nonspecific perinephric fat stranding. The cardiac silhouette is mildly enlarged. No PS.Physiologic PR.GENERAL COMMENTS: A TEE was performed in the location listed above. AP and lateral upright chest radiographs were reviewed in comparison to . Atrial fibrillation. There isborderline pulmonary artery systolic hypertension. No contraindications for IV contrast FINAL REPORT INDICATION: Preoperative evaluation for Maze procedure, cough. A septal occluder deviceis seen across the interatrial septum. Probable atrial fibrillation. Possible sinus rhythm with low amplitude P waves at the beginning of the stripwith ventricular ectopy and unclear rhythm at the end of the strip which may beatrial fibrillation. Chest pain.Status: InpatientDate/Time: at 13:20Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Marked LA enlargement. A septal occluder device is seen across theinteratrial septum. Non-specific ST-T wave changes.Compared to the previous tracing the rhythm has changed and ventricular ectopyis new.TRACING #2 Mid thoracic anterior osteophytosis is moderately severe. ST-T wave abnormalities. No pleural effusions or pneumothoraces are present. The right atrium is markedly dilated. There is no pleural or pericardial effusion. Baseline artifact. Evaluate for aortic calcification. There is no mitralvalve prolapse. A healed left anterior seventh rib fracture is associated with mild pleural thickening (2:39). Evaluate left lower lobe opacity. No focal parenchymal opacity suggesting pneumonia. Widened upper mediastinum likely postsurgical. IMPRESSION: 1. IMPRESSION: 1. No PS.Physiologic PR. RSR' patternin lead V1. Aseptal occluder device is seen across the interatrial septum. d/w Dr. , by x pg on . | 11 | [
{
"category": "Radiology",
"chartdate": "2127-10-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1160390,
"text": " 7:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: ATRIAL FIBRILLATION\\FULL MAZE PROCEDURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p sternotomy and ct removal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sternotomy and chest tube removal. Exclude pneumothorax.\n\n COMPARISON: Prior radiograph dated and most recently .\n\n FINDINGS: A right apical pneumothorax is small after chest tube removal. The\n endotracheal tube has also been removed. Lung volumes are accordingly mildly\n decreased and bilateral lower lobe atelectasis has slightly progressed.\n Moderate cardiomegaly is stable. The sternotomy wires are unchanged in\n position.\n\n IMPRESSION:\n 1. Small right apical pneumothorax after removal of chest tube.\n\n 2. Decrease in lung volumes and progression of bilateral lower lobe\n atelectasis after extubation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-10-09 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1160315,
"text": " 5:23 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EXTUBATION CARDIAC SURGERY;R/O effusions,HTX,PTX;\n Admitting Diagnosis: ATRIAL FIBRILLATION\\FULL MAZE PROCEDURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p sternotomy/Maze/resect BAAs\n REASON FOR THIS EXAMINATION:\n FAST TRACK EXTUBATION CARDIAC SURGERY;R/O effusions,HTX,PTX;contact NP\n # if abnormal\n ______________________________________________________________________________\n WET READ: 9:58 PM\n ETT 2 cm above carina; recommend retract by 2 cm. Other lines and tubes in\n satisfactory position. Low lung volume, without ptx. LLL atx. Widened upper\n mediastinum likely postsurgical. d/w Dr. , by x pg \n on .\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post surgery.\n\n COMPARISON: Pre-operative chest x-ray from .\n\n FINDINGS: As compared to the previous radiograph, the patient has undergone\n cardiac surgery. The alignment of the sternotomy wires is unremarkable. The\n tip of the endotracheal tube is 2.3 cm above the carina. The right-sided\n central venous access line is in correct position. The tube is also in\n correct position.\n\n Moderate retrocardiac atelectasis, mild left basal atelectasis, the presence\n of a minimal left pleural effusion cannot be excluded. No focal parenchymal\n opacity suggesting pneumonia. No pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-10-09 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1160196,
"text": " 7:40 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: pneumonia?\n Admitting Diagnosis: ATRIAL FIBRILLATION\\FULL MAZE PROCEDURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man preop MAZE with cough/CXR LLL finding\n REASON FOR THIS EXAMINATION:\n pneumonia?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preoperative evaluation for Maze procedure, cough. Evaluate left\n lower lobe opacity. Evaluate for aortic calcification.\n\n TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed\n without intravenous or oral contrast. The images are presented for display in\n the axial plane at 1.25- and 5-mm collimation. Multiplanar reformation images\n are also submitted for review.\n\n COMPARISON: Chest radiograph dated .\n\n FINDINGS:\n\n An interatrial septum closure device is in satisfactory position. There is no\n pathologic enlargement of the supraclavicular, axillary, or mediastinal lymph\n nodes, ranging up to 9 mm and 6 mm, in the precarinal and subcarinal\n stations, respectively (2:24, 28).\n\n The aorta is normal in caliber with no atherosclerotic calcification. The\n cardiac size is normal. There is no pleural or pericardial effusion. The\n central airways are patent. A healed left anterior seventh rib fracture is\n associated with mild pleural thickening (2:39). Bilateral lower lobe\n bronchial wall thickening and linear atelectasis is mild.\n\n Study is not tailored for subdiaphragmatic evaluation, only to confirm\n normal-appearing adrenals and bilateral nonspecific perinephric fat stranding.\n\n Mid thoracic anterior osteophytosis is moderately severe.\n\n IMPRESSION:\n 1. Healed left anterior seventh rib fracture, associated pleural thickening\n and minor lingular atelectasis.\n\n 2. No thoracic aortic calcification.\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-10-13 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1160861,
"text": " 3:43 PM\n CHEST (PA & LAT) Clip # \n Reason: f/u effusions\n Admitting Diagnosis: ATRIAL FIBRILLATION\\FULL MAZE PROCEDURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with MAZE\n REASON FOR THIS EXAMINATION:\n f/u effusions\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after MAZE procedure.\n\n AP and lateral upright chest radiographs were reviewed in comparison to\n .\n\n There is only minimal residual apical pneumothorax on the right. There is\n high position of the right hemidiaphragm that might potentially reflect the\n presence of the pleural effusion better appreciated on the lateral view.\n Cardiomediastinal silhouette is stable. The right internal jugular line tip\n is at the level of low SVC. The ASD closure device is better appreciated on\n the lateral view.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-10-08 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1160148,
"text": " 9:09 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: ATRIAL FIBRILLATION\\FULL MAZE PROCEDURE\n Admitting Diagnosis: ATRIAL FIBRILLATION\\FULL MAZE PROCEDURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man preop MAZE\n REASON FOR THIS EXAMINATION:\n cardiopulmonary dz\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old man pre-op for maze procedure.\n\n COMPARISON: None available.\n\n TWO VIEWS OF THE CHEST:\n\n The lungs are well expanded and show a left lower lobe nodular density. The\n cardiac silhouette is mildly enlarged. The mediastinal silhouette, hilar\n contours, and pleural surfaces are normal. No pleural effusions or\n pneumothoraces are present.\n\n IMPRESSION:\n\n Left lower lobe nodular density may represent a pulmonary parenchymal\n abnormality or a nipple shadow. Dedicated radiographs with nipple markers are\n recommended for further evaluation.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2127-10-09 00:00:00.000",
"description": "Report",
"row_id": 96158,
"text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Atrial fibrillation. Chest pain.\nStatus: Inpatient\nDate/Time: at 13:20\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Marked LA enlargement. No mass/thrombus in the LAA. All\nfour pulmonary veins identified and enter the left atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A septal occluder device is seen across the\ninteratrial septum.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thickness. Normal regional LV systolic function.\nOverall normal LVEF (>55%).\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Moderate global RV free wall hypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal\ndescending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications.\n\nConclusions:\nThe left atrium is markedly dilated. No mass/thrombus is seen in the left\natrium or left atrial appendage. A septal occluder device is seen across the\ninteratrial septum. Left ventricular wall thicknesses are normal. Regional\nleft ventricular wall motion is normal. Overall left ventricular systolic\nfunction is normal (LVEF>55%). with moderate global free wall hypokinesis.\nThere are simple atheroma in the aortic arch. There are simple atheroma in the\ndescending thoracic aorta. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. The mitral\nvalve appears structurally normal with trivial mitral regurgitation.\nPost\nThe patient is s/p LAA ligation with a maze procedure\nThe Left atrial appendage is no longer visible with echo\nLV function is preserved similar to prebypass\n\n\n"
},
{
"category": "Echo",
"chartdate": "2127-10-08 00:00:00.000",
"description": "Report",
"row_id": 96159,
"text": "PATIENT/TEST INFORMATION:\nIndication: Eval Valves\nHeight: (in) 72\nWeight (lb): 240\nBSA (m2): 2.30 m2\nBP (mm Hg): 120/76\nHR (bpm): 110\nStatus: Outpatient\nDate/Time: at 15:00\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Marked LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. A septal occluder device\nis seen across the interatrial septum. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%). Beat-to-beat variability on LVEF due to irregular rhythm/premature\nbeats. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV wall thickness. Mildly dilated RV cavity. Normal RV\nsystolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. No 2D or Doppler evidence of distal\narch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. No MS. Mild to\nmoderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve\nsupporting structures. No TS. Mild [1+] TR. Borderline PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is markedly dilated. The right atrium is markedly dilated. A\nseptal occluder device is seen across the interatrial septum. No atrial septal\ndefect is seen by 2D or color Doppler. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity size is normal. Overall\nleft ventricular systolic function is normal (LVEF 60%). There is considerable\nbeat-to-beat variability of the left ventricular ejection fraction due to an\nirregular rhythm/premature beats. The right ventricular cavity is mildly\ndilated with normal free wall contractility. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. No aortic regurgitation\nis seen. The mitral valve leaflets are mildly thickened. There is no mitral\nvalve prolapse. Mild to moderate (+) mitral regurgitation is seen. There is\nborderline pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2127-10-14 00:00:00.000",
"description": "Report",
"row_id": 259036,
"text": "Baseline artifact. Probable atrial fibrillation. Leftward axis. RSR' pattern\nin lead V1. ST-T wave abnormalities. Since the previous tracing of \nthe rate is faster and more irregular. Atrial fibrillation appears to be new.\nClinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2127-10-09 00:00:00.000",
"description": "Report",
"row_id": 259037,
"text": "Possible sinus rhythm with low amplitude P waves at the beginning of the strip\nwith ventricular ectopy and unclear rhythm at the end of the strip which may be\natrial fibrillation. There are tiny R waves in the inferior leads consistent\nwith possible prior myocardial infarction. Non-specific ST-T wave changes.\nCompared to the previous tracing the rhythm has changed and ventricular ectopy\nis new.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2127-10-09 00:00:00.000",
"description": "Report",
"row_id": 259038,
"text": "Regular atrial pacing with native ventricular conduction. There is an\nRSR' pattern in lead V1 which is probably normal. There are tiny R waves in\nthe inferior leads consistent with possible prior myocardial infarction.\nNon-specific ST-T wave changes. Compared to the previous tracing atrial\npacing has replaced atrial fibrillation.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2127-10-08 00:00:00.000",
"description": "Report",
"row_id": 259039,
"text": "Atrial fibrillation with borderline left axis deviation. No previous tracing\navailable for comparison.\n\n"
}
] |
51,821 | 182,983 | Patient is a 55yoF with a h/o Hodgkin's lymphoma diagnosed in , treated with 6 cycles of chemotherapy - (no radiation), and asthma who presents with 5 months of B-symptoms (afternoon fevers to 102, chills, night sweats, progressive shortness of breath, easy bruising); admitted after developing tachycardia, hypotension, and fever in the PACU status post rigid bronchoscopy for mediastinal LN biopsy. Following extensive work up, patient was found to have hypogammaglobulinemia and prolonged EBV viremia, possibly resulting in her abnormal LFTs, nephrotic syndrome, and macrophage activation syndrome. | No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium and right atrium are normal in cavity size. There is no pericardial effusion.IMPRESSION: Normal global and regional biventricular systolic function. Mildpulmonary hypertension. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Normal aortic valve leaflets (3). The mitral valveappears structurally normal with trivial mitral regurgitation. Left atrial abnormality. There is mildpulmonary artery systolic hypertension. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 62Weight (lb): 236BSA (m2): 2.05 m2BP (mm Hg): 111/64HR (bpm): 91Status: InpatientDate/Time: at 15:37Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA and RA cavity sizes.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Theaortic valve leaflets (3) appear structurally normal with good leafletexcursion and no aortic stenosis or aortic regurgitation. Right ventricular chamber size and free wall motion are normal.The diameters of aorta at the sinus, ascending and arch levels are normal. Non-specific ST segment changes in the inferolateral leads. No AS. Leftventricular hypertrophy. Delayed R waveprogression. Leftward axis. Left ventricularwall thickness, cavity size and regional/global systolic function are normal(LVEF >55%). Sinus tachycardia. Normal IVC diameter (<=2.1cm)with >50% decrease with sniff (estimated RA pressure (0-5 mmHg).LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). | 2 | [
{
"category": "Echo",
"chartdate": "2160-08-08 00:00:00.000",
"description": "Report",
"row_id": 98476,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 62\nWeight (lb): 236\nBSA (m2): 2.05 m2\nBP (mm Hg): 111/64\nHR (bpm): 91\nStatus: Inpatient\nDate/Time: at 15:37\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<=2.1cm)\nwith >50% decrease with sniff (estimated RA pressure (0-5 mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thickness, cavity size and regional/global systolic function are normal\n(LVEF >55%). Right ventricular chamber size and free wall motion are normal.\nThe diameters of aorta at the sinus, ascending and arch levels are normal. The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis or aortic regurgitation. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Normal global and regional biventricular systolic function. Mild\npulmonary hypertension.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2160-08-06 00:00:00.000",
"description": "Report",
"row_id": 275416,
"text": "Sinus tachycardia. Leftward axis. Left atrial abnormality. Delayed R wave\nprogression. Non-specific ST segment changes in the inferolateral leads. Left\nventricular hypertrophy. No previous tracing available for comparison.\n\n\n"
}
] |
353 | 108,923 | 61 yo man with ESRD on HD, DM 2, CAD presents with line sepsis. . 1) Line sepsis - Patient presenting with signs of symptoms of line infection. Blood cultures and cath tip returned with MRSA. A temp groin cath was placed at IR for HD. Patient was started on Vanc and was still febrile for 3 days. His cultures cleared on and remained negfative for the rest of the admission. Patient was ruled out for endocarditis with a negative TTE and negative TEE . He required central access for meds. On he had a tunneled cath placed for HD access. . 2) Bilateral IJ clot - in the work up to receive his tunneled cath patient was found on MRA to have clot inn both of his IJ's. He was started on heparin gtt and coumadin. The patient was sent out on coumadin and heparin was stopped once therapeutic. . 3) DM 2 - continued on glipizide and ISS . 4) CAD s/p CABG - no symptoms of ischemia. Continued on ASA, Zocor, and lopressor. . Full Code | Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Mild PA systolic hypertension.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality.Conclusions:1. There has been interval removal of the patient's right-sided Hickman catheter. Interval removal of the patient's right-sided Hickman catheter. 2) Removal of temporary right femoral dialysis catheter. TECHNIQUE: Multiplanar T1- and T2-weighted sequences of the chest were obtained with and without gadolinium for angiographic and venographic technique. The right groin temporary dialysis catheter was removed and hemostasis obtained. The patient currently has a temporary right femoral dialysis catheter. There has been interval placement of a left internal jugular central venous catheter, which appears to terminate at the junction of the left brachiocephalic vein and the superior vena cava. No aortic regurgitation is seen.7.The mitral valve leaflets are mildly thickened. Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.LEFT VENTRICLE: Mild symmetric LVH. The patient's existing left subclavian triple lumen site was prepped and draped in the usual sterile fashion. There is mild global left ventricular hypokinesis.3. The patient is status post median sternotomy and right Hickman catheter placement. IMPRESSION: 1.Non occlusive thrombus within the right internal jugular vein, extending into the superior vena cava. Will treat with fluid boluses for CVP less than 7.ID: tmax 100.5. cx pnd. Mild (1+) mitral regurgitation is seen.7. PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 70Weight (lb): 239BSA (m2): 2.25 m2BP (mm Hg): 90/50HR (bpm): 80Status: InpatientDate/Time: at 14:36Test: TEE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.LEFT VENTRICLE: Mild global LV hypokinesis.RIGHT VENTRICLE: RV function depressed.AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque.AORTIC VALVE: Normal aortic valve leaflets (3). IMPRESSION: 1) Occluded right internal jugular vein. PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 70Weight (lb): 248BSA (m2): 2.29 m2BP (mm Hg): 114/70Status: InpatientDate/Time: at 10:17Test: TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement. 7:24 AM TUNNEDLED DIALYSIS CATH PLACE Clip # Reason: can be on either side Admitting Diagnosis: SEPSIS ********************************* CPT Codes ******************************** * TUNNELED W/O PORT 79 UNRELATED PROCEDURE/SERVICE DURIN * * FLUOR GUID PLCT/REPLCT/REMOVE C1750 CATH,HEMO/PERTI DIALYSIS LONG * * C1894 INT.SHTH NOT/GUID,EP,NONLASER * **************************************************************************** MEDICAL CONDITION: 61 year old man with ESRD who has no access needs tunneled line placement for HD. The ascending, transverse and descending thoracic aorta are normal indiameter and free of atherosclerotic plaque.5. Unremarkable right internal jugular vein. Has precept catheter in place but could not calibrate machine-will follow CVP and lactate levels for modified sepsis protocol.Neuro: pt. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Normal RVsystolic function.AORTA: Moderately dilated aortic root.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). FINDINGS: Thoracic aorta is normal in appearance, without evidence of aneurysm or dissection. Left subclavian and left internal jugular venous central lines in place, with likely areas of clot within the left internal jugular vein as described, and possibly a small focus of thrombus surrounding one of the central lines, within the left brachiocephalic vein. Trivial MR.TRICUSPID VALVE: Mild [1+] TR. Right ventricular systolicfunction is normal.5.The aortic root is moderately dilated.6.The aortic valve leaflets (3) are mildly thickened. Left subclavian vein is patent, though appears somewhat attenuated within the level of the expected area of the basilic vein. IMPRESSION: Interval placement of a left internal jugular central venous catheter terminating at the junction of the left brachiocephalic vein and the superior vena cava. Monitor CV/hemodynamics.reviewed and cosigned: , RN A left subclavian catheter has been inserted. NPN 7a-7pPt with multiple medical problems, chronic HD/ESRD admitted from EW for ? The catheter tip is within the mid superior vena cava. More specifically, the interrogated portions of the right internal jugular vein are unremarkable. The left atrium is elongated.2.The right atrium is moderately dilated.3.There is mild symmetric left ventricular hypertrophy. (Over) 7:24 AM TUNNEDLED DIALYSIS CATH PLACE Clip # Reason: can be on either side Admitting Diagnosis: SEPSIS FINAL REPORT (Cont) IMPRESSION: 1) Successful conversion of left subclavian triple lumen to dialysis tunneled line. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Tubular filling defects are seen within the left subclavian vein and left internal jugular vein, corresponding to central lines, as previously shown on chest x-ray dated . admitted via EW with sepsis from infected Hickman (dialysis) catheter. wire was advanced through the needle under fluoroscopic guidance into the inferior vena cava after local administration of 1% lidocaine. RIGHT UPPER EXTREMITY VEINS ULTRASOUND: Grayscale and color Doppler images of the right internal jugular, subclavian, axillary, brachial and basilic veins were obtained. We then injected contrast through the needle, which demonstrated occlusion of the right internal jugular vein at the junction with the subclavian vein. Blood Cx neg since REASON FOR THIS EXAMINATION: can be on either side FINAL REPORT INDICATION: Renal failure. | 12 | [
{
"category": "Echo",
"chartdate": "2151-04-02 00:00:00.000",
"description": "Report",
"row_id": 68105,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 70\nWeight (lb): 239\nBSA (m2): 2.25 m2\nBP (mm Hg): 90/50\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 14:36\nTest: TEE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.\n\nLEFT VENTRICLE: Mild global LV hypokinesis.\n\nRIGHT VENTRICLE: RV function depressed.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve.\n\nMITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral\nvalve. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. No TEE related\ncomplications. 0.1 mg of IV glycopyrrolate was given as an antisialogogue\nprior to TEE probe insertion. The patient appears to be in sinus rhythm.\n\nConclusions:\n1. The left atrium is moderately dilated.\n2. There is mild global left ventricular hypokinesis.\n3. Right ventricular function is depressed.\n4. The ascending, transverse and descending thoracic aorta are normal in\ndiameter and free of atherosclerotic plaque.\n5. The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. No masses or vegetations are seen on\nthe aortic valve.\n6. The mitral valve leaflets are structurally normal. No mass or vegetation is\nseen on the mitral valve. Mild (1+) mitral regurgitation is seen.\n7. There is no pericardial effusion.\n\nNo echocardiographic evidence of endocarditis.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2151-04-01 00:00:00.000",
"description": "Report",
"row_id": 68106,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 70\nWeight (lb): 248\nBSA (m2): 2.29 m2\nBP (mm Hg): 114/70\nStatus: Inpatient\nDate/Time: at 10:17\nTest: TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Moderately dilated aortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Mild [1+] TR. Mild PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality.\n\nConclusions:\n1. The left atrium is moderately dilated. The left atrium is elongated.\n2.The right atrium is moderately dilated.\n3.There is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity is mildly dilated. Due to suboptimal technical quality, a focal wall\nmotion abnormality cannot be fully excluded. Overall left ventricular systolic\nfunction is probably normal (LVEF>55%) but given the limited views, difficult\nto be sure.\n4.Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n5.The aortic root is moderately dilated.\n6.The aortic valve leaflets (3) are mildly thickened. No masses or vegetations\nare seen on the aortic valve. No aortic regurgitation is seen.\n7.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen. No masses or vegetations are seen on the aortic valve.\n8.There is mild pulmonary artery systolic hypertension.\n9.There is no pericardial effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-03-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 864683,
"text": " 5:18 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: eval for line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with sepsis, LIJ line\n REASON FOR THIS EXAMINATION:\n eval for line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old man with sepsis. Please evaluate placement of left\n internal jugular vein central line.\n\n Portable chest x-ray dated , at 17:45 is compared with the PA and\n lateral chest x-ray from 3 hours earlier. There has been interval placement\n of a left internal jugular central venous catheter, which appears to terminate\n at the junction of the left brachiocephalic vein and the superior vena cava.\n There is no pneumothorax. The lung fields show interval slight increased\n prominence of the pulmonary vasculature, suggesting fluid overload. There are\n no focal opacities to suggest pneumonia. There are no pleural effusions.\n There has been interval removal of the patient's right-sided Hickman catheter.\n\n IMPRESSION: Interval placement of a left internal jugular central venous\n catheter terminating at the junction of the left brachiocephalic vein and the\n superior vena cava. Interval removal of the patient's right-sided Hickman\n catheter. Interval development of mild pulmonary vasculature congestion,\n consistent with fluid overload. No pneumothorax or focal consolidations.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-03-30 00:00:00.000",
"description": "NON-TUNNELED",
"row_id": 864857,
"text": " 8:56 AM\n TUNNEDLED DIALYSIS CATH PLACE Clip # \n Reason: please place TUNNELED DIALYSIS CATHETER\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 15\n ********************************* CPT Codes ********************************\n * NON-TUNNELED 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * FLUOR GUID PLCT/REPLCT/REMOVE C1751 CATH ,/CENT/MID(NOT D *\n * C1751 CATH ,/CENT/MID(NOT D C1769 GUID WIRES INCL INF *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with renal Failure and line infection.\n\n REASON FOR THIS EXAMINATION:\n please place TUNNELED DIALYSIS CATHETER\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61-year-old male with renal failure, line infections.\n\n PROCEDURE/FINDINGS:\n The procedure was performed by Dr. and Dr. with Dr.\n , attending radiologist, present and supervising.\n\n After obtaining written informed consent, the patient was placed supine on the\n angiographic table. The right neck was prepped and draped in standard sterile\n fashion. After local administration of 1% lidocaine, the right internal\n jugular vein was accessed with a 21-gauge micropuncture needle. An attempt\n was made to pass an 018 guide wire through the needle; however, this guide\n wire was felt to buckle under fluoroscopic visualization. Multiple attempts\n were made to pass the guide wire; however, these were not successful. We then\n injected contrast through the needle, which demonstrated occlusion of the\n right internal jugular vein at the junction with the subclavian vein. We then\n decided to place a temporary hemodialysis catheter in the right common femoral\n vein after discussion with the medical team. The patient was\n prepped and draped in standard sterile fashion around the right groin.\n Ultrasound guidance was used to access the right common femoral vein with a\n 19-gauge needle. wire was advanced through the needle under\n fluoroscopic guidance into the inferior vena cava after local administration\n of 1% lidocaine. The needle was exchanged for sequential 10, 12 and 14 French\n dilators. A 14-French 28-cm tip to cuff catheter was then advanced over the\n wire into the inferior vena cava under fluoroscopic guidance. Good\n bidirectional flow was seen through the catheter. The catheter was flushed,\n capped, and heplocked and secured to the skin using 2-0 silk sutures, Steri-\n Strips, and Op-Site.\n\n COMPLICATIONS: None.\n\n IMPRESSION:\n 1) Occluded right internal jugular vein.\n 2) Successful placement of right common femoral temporary hemodialysis\n catheter 28-cm tip to cuff with tip in the inferior vena cava, ready for use.\n (Over)\n\n 8:56 AM\n TUNNEDLED DIALYSIS CATH PLACE Clip # \n Reason: please place TUNNELED DIALYSIS CATHETER\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-04-06 00:00:00.000",
"description": "MRA CHEST W&W/O CONTRAST",
"row_id": 865764,
"text": " 3:41 PM\n MRA CHEST W&W/O CONTRAST Clip # \n Reason: patient needs an MR venogram of his chest and neck for dialy\n Admitting Diagnosis: SEPSIS\n Contrast: MAGNEVIST Amt: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with ESRD needing repeat dialysis line placement.\n REASON FOR THIS EXAMINATION:\n patient needs an MR venogram of his chest and neck for dialysis cath placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage renal disease, needs dialysis catheter placement.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted sequences of the chest were\n obtained with and without gadolinium for angiographic and venographic\n technique. Multiplanar reconstructions were generated and were essential for\n diagnosis. No prior MRIs available. Correlation is made with a portable AP\n chest x-ray dated .\n\n FINDINGS: Thoracic aorta is normal in appearance, without evidence of\n aneurysm or dissection. At the level of the pulmonary artery bifurcation, in\n the axial plane, the ascending thoracic aorta measures 2.7 cm in diameter, and\n the descending thoracic aorta measures 2.4 cm. Incidental note is made of\n bovine arch anatomy. No evidence of stenosis or occlusion of the arch\n vessels. Both common carotid arteries are likewise widely patent.\n\n There is thrombus within the right internal jugular vein, extending into the\n superior vena cava. An approximately 7 cm length of right internal jugular\n vein and superior vena cava is involved. Right subclavian vein is patent, as\n well as the right external jugular vein. Tubular filling defects are seen\n within the left subclavian vein and left internal jugular vein, corresponding\n to central lines, as previously shown on chest x-ray dated . Minimal\n areas of irregularity within the left brachiocephalic vein may represent clot\n surrounding one of the central lines. Additionally, there is suggestion of\n expansion of an approximately 1 cm long segment of the distal left internal\n jugular vein surrounding the catheter, which may represent a small focus of\n thrombus surrounding a central line. Left subclavian vein is patent, though\n appears somewhat attenuated within the level of the expected area of the\n basilic vein.\n\n No mediastinal adenopathy. No gross pleural effusion.\n\n Multiplanar reconstructions confirm the above findings, and were essential for\n diagnosis.\n\n IMPRESSION:\n 1.Non occlusive thrombus within the right internal jugular vein, extending\n into the superior vena cava.\n 2. Left subclavian and left internal jugular venous central lines in place,\n with likely areas of clot within the left internal jugular vein as described,\n and possibly a small focus of thrombus surrounding one of the central lines,\n within the left brachiocephalic vein.\n (Over)\n\n 3:41 PM\n MRA CHEST W&W/O CONTRAST Clip # \n Reason: patient needs an MR venogram of his chest and neck for dialy\n Admitting Diagnosis: SEPSIS\n Contrast: MAGNEVIST Amt: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-04-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 865177,
"text": " 2:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with sepsis, lf subclavian placement\n REASON FOR THIS EXAMINATION:\n confirm placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Line placement.\n\n A left subclavian catheter has been inserted. Terminating in the\n brachiocephalic vein.\n\n A left IJ catheter is also present, unchanged since . There is no\n pneumothorax following the line insertion, and the heart is normal in size.\n The lungs are clear. Post-sternotomy changes are evident.\n\n IMPRESSION: Left subclavian catheter insertion as described. There is no\n pneumothorax following insertion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-04-07 00:00:00.000",
"description": "TUNNELED W/O PORT",
"row_id": 865825,
"text": " 7:24 AM\n TUNNEDLED DIALYSIS CATH PLACE Clip # \n Reason: can be on either side\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * TUNNELED W/O PORT 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * FLUOR GUID PLCT/REPLCT/REMOVE C1750 CATH,HEMO/PERTI DIALYSIS LONG *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with ESRD who has no access needs tunneled line placement for\n HD. Recently had line infection. Blood Cx neg since \n REASON FOR THIS EXAMINATION:\n can be on either side\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Renal failure. Recently admitted for line sepsis, but cultures\n have been negative for 6 days. The patient currently has a temporary right\n femoral dialysis catheter.\n\n RADIOLOGISTS: Drs. and , the Attending Radiologist, present and\n supervising the entire procedure.\n\n Written informed consent was obtained from the patient after the patient's\n questions were answered. A preprocedure timeout checklist including patient\n identity and nature of the procedure was completed. The patient's existing\n left subclavian triple lumen site was prepped and draped in the usual sterile\n fashion. Initial scout image demonstrated the subclavian line tip to be\n within the SVC. wire was advanced under fluoroscopic guidance into\n the SVC and then into the IVC.\n\n Attention was then directed towards the creation of a tunnel. 15 cc of 1%\n lidocaine was instilled into the subcutaneous tissues of the left upper chest.\n Using blunt dissection, a tract was created. Following this, the subclavian\n access site was sequentially dilated, and a 14-French dual lumen dialysis\n catheter was advanced through the tract and into the subclavien vein through a\n peel-away sheath. Final fluoroscopic image demonstrates the tip to be within\n the right atrium. Both ports aspirated and flushed easily. The line was\n sutured in place, and dressed sterilely.\n\n Throughout the procedure, the patient was in extensive pain, most notably in\n his lower back region, despite being administered conscious sedation under\n continuous cardiac monitoring by the radiology nurse. At the end of the\n dialysis catheter placement, the patient could not tolerate lying on his back\n any longer, and thus was moved to a stretcher, where one of the radiology\n nurses placed a peripheral IV. If desired, the patient can return at a later\n date for PICC. The patient could not tolerate positioning for PICC placement\n at the time of the dialysis line placement.\n\n The right groin temporary dialysis catheter was removed and hemostasis\n obtained.\n\n (Over)\n\n 7:24 AM\n TUNNEDLED DIALYSIS CATH PLACE Clip # \n Reason: can be on either side\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1) Successful conversion of left subclavian triple lumen to dialysis tunneled\n line.\n 2) Removal of temporary right femoral dialysis catheter.\n 3) Due to patient discomfort lying supine on the fluoroscopy table, a PICC\n could not be placed. However, a peripheral access was established by the\n radiology nurse. If desired, the patient may return at a later date for PICC.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-03-31 00:00:00.000",
"description": "R UNILAT UP EXT VEINS US RIGHT",
"row_id": 865063,
"text": " 3:50 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: evalaute for occlusion, thrombosis\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with ?occluded right ij,\n REASON FOR THIS EXAMINATION:\n evalaute for occlusion, thrombosis\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Evaluate for occlusion or thrombosis of the right\n internal jugular vein.\n\n RIGHT UPPER EXTREMITY VEINS ULTRASOUND: Grayscale and color Doppler images of\n the right internal jugular, subclavian, axillary, brachial and basilic veins\n were obtained. Normal waveforms, compressibility and augmentation was\n demonstrated. No intraluminal thrombus was identified. More specifically,\n the interrogated portions of the right internal jugular vein are unremarkable.\n\n IMPRESSION: No evidence of right upper extremity DVT. Unremarkable right\n internal jugular vein.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-03-28 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 864673,
"text": " 2:20 PM\n CHEST (PA & LAT) Clip # \n Reason: r/out PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with fever chills\n REASON FOR THIS EXAMINATION:\n r/out PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old man with fever and chills.\n\n PA and lateral chest x-ray dated has no prior films available at\n this time for comparison. The patient is status post median sternotomy and\n right Hickman catheter placement. The catheter tip is within the mid superior\n vena cava. The heart is enlarged. The hilar, and mediastinal contours are\n unremarkable. Assessment of the lung fields is limited secondary to extensive\n soft tissue attenuation, however, the lungs are grossly clear without focal\n opacity to suggest consolidation. There is no prominence of the pulmonary\n vasculature to suggest congestive heart failure. There are no pleural\n effusions. There is no pneumothorax. The surrounding osseous and soft tissue\n structures are unremarkable.\n\n IMPRESSION: No acute cardiopulmonary abnormality. Cardiomegaly.\n\n"
},
{
"category": "ECG",
"chartdate": "2151-03-28 00:00:00.000",
"description": "Report",
"row_id": 150314,
"text": "Baseline artifact\nSinus rhythm\nRight bundle branch block\nSince previous tracing of , probably no significant change\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-03-28 00:00:00.000",
"description": "Report",
"row_id": 1265161,
"text": "NPN 6p-7p\nPt. admitted via EW with sepsis from infected Hickman (dialysis) catheter. Hickman cath was pulled in EW. Pt. had hx of MSSA, MRSA, VRE, and c-diff which was treated recently. Has precept catheter in place but could not calibrate machine-will follow CVP and lactate levels for modified sepsis protocol.\n\nNeuro: pt. alert and oriented.\n\nResp: on 3L NC with sats 96-98%. Clear breath sounds bilaterally. No sputum.\n\nCV: BP 90's. CVP 7 received 250cc NS fluid bolus. BP increased to 95. Will treat with fluid boluses for CVP less than 7.\n\nID: tmax 100.5. cx pnd. Will need /stim test and clot to BB.\n\nSocial: Brother is spokesperson-he has been updated. Pt. stated that he did not want to be resesutated if he deteriortates. Official order has not been written.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-03-29 00:00:00.000",
"description": "Report",
"row_id": 1265162,
"text": "NPN 7a-7p\nPt with multiple medical problems, chronic HD/ESRD admitted from EW for ? sepsis from infected Hickman cath. Line pulled, Left IJ TLC placed in ED with sepsis cath, unable to calibrate monitor. Pt placed in MICU for modified sepsis protocol. Given doses of Vanco/Gent in EW.\n\nNeuro: Pleasant, A&Ox3. PERRL @ 3-5mm. No c/o pain over noc.\n\nCV: NSR with occasional PVCs. HR 60s-70s. BPs variable, 100s-140s/40s-70s. Potassium high on admission. Given a total of 60g of -exelate. Morning labs pending. Fluid boluses for CVP <7, not needed over noc.\n\nResp: 2.5 LPM via NC with sats 100% while awake. Pt exhibiting signs of sleep apnea over noc with frequent periods of apnea and desating to high 60s. Dr made aware. Pt states he's never been dx with sleep apnea, however family hx: father.\n\nGI/GU: ABD obese, soft non-tender. Lactulose enema following -ex. Now freq voiding large amounts of loose light brown stools to bedpan. Renal po diet. Foley draining minimal uo.\n\nEndo: DM II, controlled with oral agents. BS at 00:00 was 54, given amp of D50, PO juices. Repeat BS 124.\n\nID: TMAX 99.6. No ABX ordered. Blood cx from EW pending. WBC 9.6.\n\nAccess: LIJ TLC with sepsis cath. 1 PIV 18g in R AC. Both placed prior to arrival.\n\nDISPO: DNR/DNI. Allergic to ativan and tetracycline. Brother is spokesperson, no contact with RN over noc, did speak to pt directly.\n\nPlan: Tx infection as ordered pending results of blood cx. Monitor CV/hemodynamics.\n\nreviewed and cosigned: , RN\n"
}
] |
17,314 | 179,183 | This patient was admitted to on status post motorcycle accident. He was evaluated in the trauma bay, where both urology and orthopedics were consulted for his injuries: - b/l pneumothoracies - Diastasis of the pubic symphysis and widening of the left SI joint - Left distal radial/ulnar fracture - extraperitoneal bladder rupture tracking into Left scrotum/thigh. . Per urology, a Foley was inserted (and to be left in 14 days total), and a RUG ordered. The patient was taken to the TSICU, and the following day, went into the OR with orthopedics for: 1. ORIF left segmental radius fracture. 2. ORIF DRUJ. . There were no intra-operative or postoperative complications. In the recovery room, his bilateral chest tubes were put to water seal, and a chest xray was completed. At this time, there were no changes in his bilateral apical pneumothoraces and hence his chest tubes remained to water seal. . On the floor, Mr had some issues with pain control, especially at the site of chest tube insertion. He slowly began a regular diet, which he was able to tolerate and did not have any other medical difficulties. . The patient's chest tubes were removed on without any complications. A chest xray done the following morning showed a Tiny left apical neumothorax but the patient was not experiencing any respiratory difficulties. . On , the patient began therapy with physical and occupational therapy. Urology advised follow-up with Dr catheter removal. The patient was tolerating a regular diet and had no new issues of note. His RUG was completed today and read as: no filling defects, no evidence of urethral injury. . After working extensively and progressing very well with phyiscal and occupational therapy, patient was discharged to home with VNA services for further physical therapy on . Earlier on, the patient was educated on how to maintain his Foley catheter and how to use Lovenox. The patient has a strong support system in his family at home. | The right-sided chest tube has been removed. There is a small right apical pneumothorax. SUPINE AP PELVIS: A trauma board obscures detail. pelvic fracture and foley placed with sign hematuria. TECHNIQUE: Non-contrast head CT. IMPRESSION: AP chest compared to through 11: Juxtacardiac left lung nodules and an artifact of recent thoracostomy tube, since removed. FINDINGS: There are small bilateral residual pneumothoraces. HISTORY: Bilateral chest tubes removed. Bilateral pneumothoraces. There is a symmetric and relatively appearance of the falx and tentorium bilaterally. Bilateral pleural tubes are unchanged in their respective positions. A trauma board obscures detail. There has been interval removal of a left-sided chest tube. Small bilateral pneumothoraces with chest tubes in place. The remaining soft tissues of the pelvis and extra- articular soft tissues are unremarkable. IMPRESSION: AP chest compared to and 10: Tiny volume of apical pneumothorax is seen on both sides of the chest today, not detectable on . There is no definite pleural effusion, though there are small bilateral pneumothoraces and bilateral chest tubes in place. Probable small pericardial effusion. There is diastasis of the pubic symphysis. FINDINGS: There are small bilateral apical pneumothoraces. Postop from orthopedic procedure. No definite pneumothorax is appreciated. Bilateral chest tubes are again seen. LEFT FOREARM, TWO VIEWS: Overlying splint material obscures detail. Check for pneumothorax. The aorta is of normal caliber. Interval removal of left-sided chest tube. There is disruption of the radioulnar reticulation of the wrist. There is contrast in the retropubic space of Retzius and tracking anteriorly superficial to the left rectus abdominus. Findings are consistent with extraperitoneal bladder rupture. FINAL REPORT INDICATION: Obvious deformity. FINAL REPORT INDICATION: Obvious deformity. The cardiomediastinal silhouette is unchanged. FINDINGS: Again seen are bilateral chest tubes. 3. diastasis of pubic symphysis and left SI joint 4. bilat small ptx with chest tubes in. FINDINGS: There is diastasis of the left sacroiliac joint as well as diastasis of the pubic symphysis. There is a fracture of the ulnar styloid. Left radial comminuted fracture seen on scout view. The ankle mortise appears congruent. Mild prominence of the prevertebral soft tissues, which are not convex however to suggest a hematoma. HISTORY: Bilateral pneumothorax. The left pneumothorax is not appreciated. needs TLS cleared. These are likely unchanged compared to prior. Visualized non-contrast appearance of the soft tissues of the neck is otherwise unremarkable. Diastasis of the left sacroiliac joint and pubic symphysis. Findings consistent with extraperitoneal bladder rupture with Foley catheter in place. There are bilateral chest tubes in place. COMPARISON: at 11:17 a.m. AP UPRIGHT CHEST RADIOGRAPH: A right-sided chest tube is in unchanged position. GI/GU- Abd soft, +BS. The pulmonary vasculature is within normal limits. Lungs clear with diminished bases. Intial to LGH and dx with bilateral pneumothoraces and CTx2 placed, L radial fx, ? IMPRESSION: ORIF distal radius fracture. The osseous structures are unchanged. 1:43 AM FOREARM (AP & LAT) LEFT Clip # Reason: s/p closed reduction. Diastasis of the pubic symphysis and subtle widening of the left sacroiliac joint. The prostate, seminal vesicles, rectum and sigmoid appear normal. Delayed images were obtained through the pelvis and proximal thighs, demonstrating the degree of extravasated contrast. Skin w/d. Cervical Ct neg. The overall alignment of the cervical spine is preserved without listhesis. Overlying splint material obscures detail. Cannot exclude subtle arterial injury given degree of , close hemodynamic monitoring recommended. Coronal and sagittal reformats provided. PCA for pain, dilaudid. Assess for pneumothorax and chest tube location. IMPRESSION: No fracture of the left ankle identified. No contraindications for IV contrast FINAL REPORT CT PELVIS, TECHNIQUE: Multiple contiguous axial images were obtained through the pelvis with coronal and sagittal reformats. Visualized paranasal sinuses and mastoid air cells are clear, other than for mild ethmoid mucosal thickening. The scout view demonstrates a comminuted fracture of the mid to distal left radius. Although not ideal for visualization of the thecal contents, the visualized intrathecal contents appear unremarkable by CT. There are mild dependent changes bilaterally. A tiny sliver of air are noted between 2 right anterior ribs (series 2, image 56), that appears to be within the chest wall related to a nearby chest tube. Limited view of the most distal aspect of this plate is unremarkable. There is a small amount of subcutaneous emphysema on the right. No change in appearance of biapical pneumothoraces. REASON FOR THIS EXAMINATION: s/p closed reduction. FINDINGS: Volar plate and screws are noted along the distal radius. There is a question of intraarticular involvement of this comminuted fracture at the distal radial articular surface. Evidence of extraperitoneal bladder rupture, with contrast in scrotum, throughout left thigh and left pelvic sidewall. Left lateral chest wall is off the film. Aside from contrast along the left pelvic side wall, there is no additional free fluid in the pelvis visualized. No evidence of pneumothorax, with bilateral chest tubes in place. IMPRESSION: No evidence of injury to the penile urethra. INDICATION: Status post removal of right chest tube, evaluate for changes in pneumothorax. Evaluate for fracture or dislocation. L radial fx splinted in EW. Both lungs remain well expanded and the minimally sized apical pneumothoraces have regressed further. No discrete osseous fractures are visualized. The heart and great vessels appear normal. If indicated, a retrograde urethrogram should be performed. REASON FOR THIS EXAMINATION: fx/dislocation? | 19 | [
{
"category": "Radiology",
"chartdate": "2179-08-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 927489,
"text": " 8:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p removal of Rt chest tube - eval for change in pneumothor\n Admitting Diagnosis: RETROPERITONEAL BLADDER RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man s/p removal of bil chest tubes on \n\n REASON FOR THIS EXAMINATION:\n s/p removal of Rt chest tube - eval for change in pneumothorax - PLEASE DO AT\n 9PM - THANKS\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest, AP portable single view.\n\n INDICATION: Status post removal of right chest tube, evaluate for changes in\n pneumothorax.\n\n FINDINGS: AP single view of the chest is analyzed in direct comparison with a\n similar examination obtained seven hours earlier during the same date. The\n right-sided chest tube has been removed. Both lungs remain well expanded and\n the minimally sized apical pneumothoraces have regressed further. No new\n infiltrates are seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-08-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 927425,
"text": " 11:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess PTX and whether still present (chest tubes to water s\n Admitting Diagnosis: RETROPERITONEAL BLADDER RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with Bilateral PTX and Tube thoracostomies\n\n REASON FOR THIS EXAMINATION:\n Assess PTX and whether still present (chest tubes to water seal currently). Pls\n perform at 4am on Monday . Thank you.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 11:17 A.M. ON .\n\n HISTORY: Bilateral pneumothorax. Thoracostomy.\n\n IMPRESSION: AP chest compared to and 10:\n\n Tiny volume of apical pneumothorax is seen on both sides of the chest today,\n not detectable on . Bilateral pleural tubes are unchanged\n in their respective positions. There is no pneumothorax. Lungs clear. Heart\n size normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-08-21 00:00:00.000",
"description": "L WRIST(3 + VIEWS) LEFT",
"row_id": 927200,
"text": " 12:11 AM\n WRIST(3 + VIEWS) LEFT Clip # \n Reason: fx/dislocation?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with obvious deformity. N/v intact.\n REASON FOR THIS EXAMINATION:\n fx/dislocation?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Obvious deformity. Evaluate for fracture or dislocation.\n\n There are no prior studies for comparison.\n\n Overlying splint material obscures detail. There is a comminuted fracture of\n the left mid and distal radius with the distal fracture fragments displaced\n dorsally. There is a question of intraarticular involvement of this\n comminuted fracture at the distal radial articular surface. There is a\n fracture of the ulnar styloid. There is disruption of the radioulnar\n reticulation of the wrist.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-08-21 00:00:00.000",
"description": "L ANKLE (AP, MORTISE & LAT) LEFT",
"row_id": 927201,
"text": " 12:11 AM\n ANKLE (AP, MORTISE & LAT) LEFT Clip # \n Reason: fx?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with abrasion on ankle s/p motorcycle accident.\n REASON FOR THIS EXAMINATION:\n fx?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abrasion on ankle, status post motorcycle accident. Evaluate for\n fracture.\n\n There are no prior studies for comparison.\n\n LEFT ANKLE, THREE VIEWS: No fracture of the left ankle is identified. There\n is mild soft tissue swelling at the medial aspect of the left ankle. The\n ankle mortise appears congruent.\n\n IMPRESSION: No fracture of the left ankle identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-08-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 927273,
"text": " 4:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Residual PTX\n Admitting Diagnosis: RETROPERITONEAL BLADDER RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with bilateral PTX now post op from orthopaedic procedure\n\n REASON FOR THIS EXAMINATION:\n Residual PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW ON \n\n HISTORY: Bilateral pneumothorax. Postop from orthopedic procedure.\n\n FINDINGS: Again seen are bilateral chest tubes. There is a small right\n apical pneumothorax. The left pneumothorax is not appreciated. There is a\n small amount of subcutaneous emphysema on the right. Left lateral chest wall\n is off the film.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-08-20 00:00:00.000",
"description": "CT PELVIS ORTHO W/O C",
"row_id": 927198,
"text": " 11:33 PM\n CT PELVIS ORTHO W/O C Clip # \n Reason: MOTORCYCLE ACCIDENT.PAIN.R/O FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with MVC, thrown from motorcycle\n REASON FOR THIS EXAMINATION:\n please check for fracture reported from OSH, known dislocation.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT PELVIS, \n\n TECHNIQUE: Multiple contiguous axial images were obtained through the pelvis\n with coronal and sagittal reformats.\n\n FINDINGS: There is diastasis of the left sacroiliac joint as well as\n diastasis of the pubic symphysis. No discrete fracture line is present.\n\n Foley catheter is present with contrast in the bladder and bilateral ureters.\n There is contrast in the retropubic space of Retzius and tracking anteriorly\n superficial to the left rectus abdominus. Findings are consistent with\n extraperitoneal bladder rupture. Urethral injury is not evaluated on this\n examination. If indicated, a retrograde urethrogram should be performed. The\n remaining soft tissues of the pelvis and extra- articular soft tissues are\n unremarkable.\n\n IMPRESSION:\n\n 1. Diastasis of the left sacroiliac joint and pubic symphysis. No discrete\n fracture line is present.\n\n 2. Findings consistent with extraperitoneal bladder rupture with Foley\n catheter in place. This examination does not evaluate for urethral injury and\n if indicated, a retrograde urethrogram is recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-08-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 927476,
"text": " 4:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: at 17:00 please eval s/p d/c L chest tube\n Admitting Diagnosis: RETROPERITONEAL BLADDER RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man s/p removal of L chest tube 15:00 .\n\n REASON FOR THIS EXAMINATION:\n at 17:00 please eval s/p d/c L chest tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old man status post left sided chest tube removal.\n\n COMPARISON: at 11:17 a.m.\n\n AP UPRIGHT CHEST RADIOGRAPH: A right-sided chest tube is in unchanged\n position. There has been interval removal of a left-sided chest tube. Small\n biapical pneumothoraces have not changed in size when compared to the prior\n examination. The cardiomediastinal silhouette is unchanged. The pulmonary\n vasculature is within normal limits. The osseous structures are unchanged.\n\n IMPRESSION:\n\n 1. Interval removal of left-sided chest tube. No change in appearance of\n biapical pneumothoraces.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-08-21 00:00:00.000",
"description": "LP FOREARM (AP & LAT) LEFT PORT",
"row_id": 927250,
"text": " 12:22 PM\n FOREARM (AP & LAT) LEFT PORT Clip # \n Reason: s/p orif L forearm\n Admitting Diagnosis: RETROPERITONEAL BLADDER RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with obvious deformity. N/v intact.\n\n REASON FOR THIS EXAMINATION:\n s/p orif L forearm\n ______________________________________________________________________________\n FINAL REPORT\n WRIST FILMS ON \n\n HISTORY: Status post ORIF left forearm.\n\n FINDINGS: There has been interval placement of a plate with multiple screws\n spanning the comminuted radius fracture with two pins extending through the\n radius and ulna. Overlying plaster somewhat obscures bony detail. The\n alignment is much improved compared to the preoperative films.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-08-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 927302,
"text": " 7:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Question PTX residual Please perform at 0500\n Admitting Diagnosis: RETROPERITONEAL BLADDER RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with Bilateral PTX and Tube thoracostomies\n\n REASON FOR THIS EXAMINATION:\n Question PTX residual Please perform at 0500\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Bilateral pneumothorax followup.\n\n REFERENCE EXAM: .\n\n FINDINGS: There are small bilateral apical pneumothoraces. These are likely\n unchanged compared to prior. They are very difficult to visualize. Bilateral\n chest tubes are again seen. There is no focal infiltrate or effusion. The\n heart is mildly enlarged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-08-20 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 927194,
"text": " 11:11 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: assess for pneumothorax, chest tube location\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with\n REASON FOR THIS EXAMINATION:\n assess for pneumothorax, chest tube location\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma. Assess for pneumothorax and chest tube location.\n\n There are no prior studies for comparison.\n\n AP CHEST: The examination was performed with the patient in supine position.\n A trauma board obscures detail. There are bilateral chest tubes in place. No\n definite pneumothorax is appreciated. The heart size is normal. The\n mediastinal contours are normal. There are low lung volumes. No pleural\n effusion. Contrast is being excreted from the renal collecting systems\n bilaterally, related to an outside hospital CT scan.\n\n SUPINE AP PELVIS: A trauma board obscures detail. There is a Foley catheter\n within the bladder, and contrast is seen within the bladder and within the\n soft tissues about the proximal left thigh. Contrast is also seen within the\n left side of the pelvis, these findings are consistent with an extraperitoneal\n bladder rupture, much better demonstrated on CT. There is diastasis of the\n pubic symphysis. There is also widening of the left SI joint. No fracture is\n identified.\n\n IMPRESSION:\n 1. No evidence of pneumothorax, with bilateral chest tubes in place.\n 2. Diastasis of the pubic symphysis and widening of the left SI joint, with\n evidence of extraperitoneal bladder rupture, better appreciated on CT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-08-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 927195,
"text": " 11:32 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for injury to trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with MVC, thrown from motorcycle\n REASON FOR THIS EXAMINATION:\n evaluate for injury to trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AEBc SAT 12:36 AM\n no evidence of acute injury\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old man status post motor vehicle collision, thrown from\n motorcycle.\n\n COMPARISONS: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Earlier on the same day, intravenous contrast administered for\n earlier CT at an outside hospital, which are not available for review at this\n time. There is a symmetric and relatively appearance of the falx and\n tentorium bilaterally. In the context of recent contrast administration, this\n appearance is not suspicious for intracranial hemorrhage, but makes it\n somewhat more difficult to evaluate for subtle subdural hemorrhage in these\n areas. There is no mass effect, hydrocephalus or shift of the normally\n midline structures. The ventricles, cisterns and sulci are unremarkable\n without effacement. -white matter differentiation appears preserved.\n\n Visualized paranasal sinuses and mastoid air cells are clear, other than for\n mild ethmoid mucosal thickening. The osseous structures are unremarkable.\n\n IMPRESSION:\n 1. No evidence of intracranial hemorrhage or acute injury. The presence of\n intravenous contrast from an earlier examination on the same day makes it\n difficult to exclude subtle subdural hematoma, but the appearance is not\n suggestive of one.\n 2. Sinus mucosal thickening.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-08-20 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 927196,
"text": " 11:32 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: MOTORCYCLE ACCIDENT.PAIN.R/O FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with MCC helmeted no LOC GCS 15\n REASON FOR THIS EXAMINATION:\n eval for c-spine injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AEBc SAT 12:45 AM\n no fx or dislocation; slight prevertebral soft tissue prominence; bilateral\n small pneumothoraces\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 32-year-old man status post motor vehicle collision, thrown from\n motorcycle.\n\n COMPARISONS: None available.\n\n TECHNIQUE: Axial non-contrast CT images of the cervical spine were obtained\n and sagittal and coronal reconstructions were also performed.\n\n FINDINGS: There are small bilateral residual pneumothoraces. Visualized\n non-contrast appearance of the soft tissues of the neck is otherwise\n unremarkable.\n\n The overall alignment of the cervical spine is preserved without listhesis.\n There is no evidence of fracture, dislocation, or bony destruction. There is\n slight prominence of the prevertebral soft tissues up to 5 mm in diameter,\n although there is no evidence of osseous injury.\n\n Although not ideal for visualization of the thecal contents, the visualized\n intrathecal contents appear unremarkable by CT.\n\n IMPRESSION:\n\n 1. No evidence of fracture or alignment abnormality.\n\n 2. Mild prominence of the prevertebral soft tissues, which are not convex\n however to suggest a hematoma. Please correlate clinically.\n\n 3. Bilateral pneumothoraces.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-08-20 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 927197,
"text": " 11:33 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: MVC THROWN FROM MOTORCYCLE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with MVC, thrown from motorcycle\n REASON FOR THIS EXAMINATION:\n please evaluate for injuries\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKXa SAT 12:40 AM\n 1. Evidence of extraperitoneal bladder rupture, with contrast in\n scrotum, throughout left thigh and left pelvic sidewall. The contrast is toxic\n to the tissue so additional cystogram not performed. Consider getting plastics\n involved given the risk of tissue necrosis.\n\n 2. Cannot exclude subtle arterial injury given degree of , close\n hemodynamic monitoring recommended.\n\n 3. diastasis of pubic symphysis and left SI joint\n\n 4. bilat small ptx with chest tubes in.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient in a motor vehicle accident, thrown from a motorcycle.\n Evaluate for injury.\n\n There are no prior studies available for comparison. The disc was brought\n with the patient, but the studies were not easily accessible for review.\n\n TECHNIQUE: Contiguous axial images through the chest, abdomen and pelvis were\n obtained following the administration of 130 cc of IV Optiray contrast. The\n patient also received IV contrast from an outside hospital.\n\n The scout view demonstrates a comminuted fracture of the mid to distal\n left radius.\n\n CT OF THE CHEST WITH CONTRAST: There is no evidence of aortic injury. The\n aorta is of normal caliber. The heart and great vessels appear normal. There\n is no pericardial effusion. There is no definite pleural effusion, though\n there are small bilateral pneumothoraces and bilateral chest tubes in place.\n No consolidations within the lungs. No pulmonary nodules visualized. There\n are mild dependent changes bilaterally. The central airways are patent.\n Subcutaneous air is noted within the chest wall related to the chest tubes.\n\n CT OF THE ABDOMEN WITH CONTRAST: The liver, gallbladder, spleen, pancreas and\n adrenal glands are normal. The kidneys enhance symmetrically and excrete\n normally. The stomach, small and large bowel loops appear normal. There is\n no definite free air in the abdomen. A tiny sliver of air are noted between 2\n right anterior ribs (series 2, image 56), that appears to be within the chest\n wall related to a nearby chest tube. The aorta is of normal caliber, and the\n (Over)\n\n 11:33 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: MVC THROWN FROM MOTORCYCLE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n proximal celiac, SMA and are patent. No pathologically enlarged\n mesenteric or retroperitoneal lymph nodes. There is no definite free fluid\n within the abdomen. There is apparent thickening of the right lower abdominal\n transversalis muscle (on series 2, image 71).\n\n CT OF THE PELVIS WITH CONTRAST: The bladder contains a Foley catheter, and\n air. The air could be related to instrumentation. There is a large amount of\n contrast seen along the left pelvic side wall, in the soft tissues anterior to\n pubic symphysis, extending into the scrotum and insinuating between left thigh\n muscles and within the subcutaneous fat. Given that the patient was scanned\n in an outside hospital and contrast was administered, this is likely related\n to an extraperitoneal bladder rupture. This contrast tracks along the\n anterior abdominal wall anterior to the rectus abdominis muscles on the left\n side inferiorly. Given the degree of contrast spillage in the soft tissues, a\n subtle focus of arterial extravasation cannot be entirely excluded. The\n prostate, seminal vesicles, rectum and sigmoid appear normal. Aside from\n contrast along the left pelvic side wall, there is no additional free fluid in\n the pelvis visualized. No pathologically enlarged pelvic or inguinal lymph\n nodes.\n\n BONE WINDOWS: There is diastasis of the pubic symphysis, to 15 mm. There is\n also widening of the left sacroiliac joint. No discrete osseous fractures are\n visualized.\n\n Delayed images were obtained through the pelvis and proximal thighs,\n demonstrating the degree of extravasated contrast.\n\n IMPRESSION:\n 1. Evidence of extraperitoneal bladder rupture, with a significant amount of\n contrast noted along the left pelvic side wall, anterior to the pubic\n symphysis, extending into the scrotal soft tissues and insinuating between the\n musculature of the left thigh. A CT cystogram was not performed as there is\n already a significant amount of contrast extravasated in these tissues. The\n leak site may be at the bladder neck. Contrast is toxic to these tissues, and\n close monitoring/plastics consultation is recommended. Given the degree of\n extravasation of contrast, a subtle arterial injury cannot be excluded, and\n close hemodynamic monitoring is recommended.\n 2. Diastasis of the pubic symphysis and subtle widening of the left\n sacroiliac joint.\n 3. Small bilateral pneumothoraces with chest tubes in place.\n 4. Left radial comminuted fracture seen on scout view.\n\n The findings were discussed with Dr. at the conclusion of the exam.\n (Over)\n\n 11:33 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: MVC THROWN FROM MOTORCYCLE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-08-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 927505,
"text": " 3:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Perform at 5AM to eval for PTX\n Admitting Diagnosis: RETROPERITONEAL BLADDER RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man s/p removal of bil chest tubes on \n REASON FOR THIS EXAMINATION:\n Perform at 5AM to eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:29 A.M., .\n\n HISTORY: Bilateral chest tubes removed.\n\n Check for pneumothorax.\n\n IMPRESSION: AP chest compared to through 11:\n\n Juxtacardiac left lung nodules and an artifact of recent thoracostomy tube,\n since removed. Tiny left apical pneumothorax is of no clinical significance.\n There is no pleural effusion. Heart size normal. Probable small pericardial\n effusion. No pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-08-24 00:00:00.000",
"description": "CT UP EXT W/O C",
"row_id": 927548,
"text": " 10:13 AM\n CT UP EXT W/O C Clip # \n Reason: eval for right scaphoid fracture\n Admitting Diagnosis: RETROPERITONEAL BLADDER RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with R snuff box ttp since MVA trauma 5 days ago\n REASON FOR THIS EXAMINATION:\n eval for right scaphoid fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT WRIST\n\n HISTORY: Fracture.\n\n TECHNIQUE: Multiple contiguous axial images were obtained through the wrist.\n Coronal and sagittal reformats provided.\n\n FINDINGS: Volar plate and screws are noted along the distal radius. Limited\n view of the most distal aspect of this plate is unremarkable. Ulnar styloid\n fracture also noted. Images of the carpal bones demonstrate no significant\n abnormality without evidence of dislocation, fracture, or indirect evidence of\n ligamentous injury.\n\n IMPRESSION: ORIF distal radius fracture. No evidence of carpal bone\n fracture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-08-21 00:00:00.000",
"description": "L FOREARM (AP & LAT) LEFT",
"row_id": 927204,
"text": " 1:43 AM\n FOREARM (AP & LAT) LEFT Clip # \n Reason: s/p closed reduction. Please include wrist.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with obvious deformity. N/v intact.\n\n REASON FOR THIS EXAMINATION:\n s/p closed reduction. Please include wrist.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Obvious deformity. Neurovascularly intact. Status post close\n reduction.\n\n COMPARISON: at 0018.\n\n LEFT FOREARM, TWO VIEWS: Overlying splint material obscures detail. Again\n seen is a comminuted fracture of the left mid and distal radius. Alignment\n appears relatively similar to the prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-08-25 00:00:00.000",
"description": "RETROGRADE URETHROCYSTOGRAM",
"row_id": 927717,
"text": " 11:31 AM\n RETROGRADE URETHROCYSTOGRAM Clip # \n Reason: This patient is a trauma patient. WE need to have the study\n Admitting Diagnosis: RETROPERITONEAL BLADDER RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with extraperitoneal bladder GU injury.\n REASON FOR THIS EXAMINATION:\n This patient is a trauma patient. WE need to have the study done as follows\n per GU service. \"Take a 16 or 18 g angiocath without the needle, hook to a 60\n cc syringe with contrast and with a little lobe place next to foley about 3 cm\n beyond meatus. Pinch off the urethra and put in contrast to define urethral\n extravasation and more importantly a bladder neck disruption\" Please page GU\n resident when study takes place. You can page either and we\n will come to observe the study. Thank you.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 32-year-old man with extraperitoneal bladder injury.\n\n FINDINGS: An 18-gauge angiocatheter was advanced into the distal penis\n superior to the patient's Foley catheter. Injection of Conray through the\n angiocatheter with exertion on the patient's glands demonstrated opacification\n of the penile urethra. There is no evidence of contrast extravasation.\n Contrast emptied promptly, and there were no filling defects identified.\n\n IMPRESSION: No evidence of injury to the penile urethra.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-08-21 00:00:00.000",
"description": "Report",
"row_id": 1488938,
"text": "Admit Note\n Pt is a 32yo helmeted driver of motorcycle which struck minivan. Pt thrown est 25 feet wih sign helmet damage. Intial to LGH and dx with bilateral pneumothoraces and CTx2 placed, L radial fx, ? pelvic fracture and foley placed with sign hematuria. Transferred to via . Head CT (-), abd and pelvic CT with contrast showed extraperitoneal bladder rupture with extravastion of dye into scrotum, L thigh and pelvic sidewall and SI joint dislocation. L radial fx splinted in EW. Pt to ICU for hemodynamic monitoring as radiology unable to r/o arterial injury due to extravascation.\n Pt intact. Started on Dilaudid PCA with min effect, bolus given and dose increased with much better effect. Pt able to sleep on and off. refused in Ew to wear collar. Cervical Ct neg. needs TLS cleared.\n Resp- When asleep sats drifted down to 91%. 3LNC added and sats 98%. Lungs clear with diminished bases. Bil CT to 20cmH2O, no airleak or crepitus, trace serosang drainage on RCT none on L.\n CV- SR, VSS. Afebrile. Skin w/d. Several areas of abrasions. L fingers warm, able to move and intact sensation. Labs pending.\n GI/GU- Abd soft, +BS. Foley patent with clear pink tinged urine.\nPlan- Treat any abn lytes, repeat hct this afternoon. transfer to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-08-21 00:00:00.000",
"description": "Report",
"row_id": 1488939,
"text": "T/SICU NPN\nPt. is stable this am. He has been seen by anesthesia and surgery HO for OR this am, procedure to left arm. Pelvis will be evaluated during the week. Pt. has been called out to floor so he will go to OR, then PACU, then to floor. Pt. girlfriend with pt. VSS. PCA for pain, dilaudid. Pt. is alert and awake.\n"
}
] |
738 | 101,840 | The patient was status post stent mid right coronary artery. For his coronary artery disease three vessel disease. He was continued on aspirin and Plavix and did well. His beta blockers were initially held secondary to bradycardia and negative inotropic effects. At that point later on he was switched over two days later to beta blockers. On discharge date his beta blockers were switched over from Metoprolol 75 b.i.d. to Toprol XL 150 q.d. His lipids were checked and liver function tests were checked. He had an elevated AST, slightly elevated ALT at which point Lipitor was not started, but the day of discharge Lipitor was started given that his AST rise was most likely secondary to his myocardial infarction insult. He may need future percutaneous intervention on left anterior descending coronary artery and D1. His CKs were followed post intervention and the goal was to keep the CVP around 18 to 20. He did well after transfer to the Emergency Department and was extubated the next day and weaned off of his O2 and transferred to the floor. For his pump status he was later on started on Captopril and on the day of discharge his Captopril t.i.d. was switched to Lisinopril q.d. for after load reduction. Rhythm, his electrolytes were checked regularly. The goal was to keep his K over 4 and his magnesium over 2. Initially he was continued on the Lidocaine drip until the morning after admission to the Coronary Care Unit at which point he was discontinued off the Lidocaine. He had an atropine at bedside for possible bradycardia and secondary hypotension secondary to bradycardia, which was not used and his beta blockers as we noted earlier was held on the first day and later on started as he tolerated it. The day after admission he was started on Levaquin for presumed right lower lobe consolidation secondary to community acquired pneumonia. The patient did well and has been afebrile and white blood cell count decreasing daily since transfer to the floor. For him to continue a ten day course of Levaquin. He is now on day three of ten and will continue the next seven days when discharged to home or to rehab. Gastrointestinal, no issues. Tolerating his medications and his diet well. The patient was sent to rehab center for further evaluation and further treatment. | Most recent with Dopa off times 3 1/2hr CO/CI 5.0/2.63 with MVO2 69. CCU NSG NOTE: ALT IN CVO: For complete VS see CCU flow sheet.ID: Pt initally hypothermic. IMPRESSION: ET tube withdrawn to satisfactory position. pulled this am.R groin d/i, pulses dopplerable. U/O > 60CC/HRSKIN: INTACT.ID: TEMP MAX 100.6 WBC 9.7 CON'T ON LEVOFLOX IV. IABP weaned to 1:3 with CI stable at 2.6. Sinus rhythmInferior infarct - age undeterminedSince previous tracing, apical lateral ST segment elevation resolved IABP with good systolic and diastolic unloading. OCCASSIONAL MULTIFOCAL PVC'S NOTED. He has very decreased bowel sounds.RENAL: During am U/O was 90-140cc/hr. Sinus arrhythmiaInferior infarct - age undetermined, probably acuteLate R wave progression consider anteroseptal infarct - age undeterminedSince previous tracing, heart rate decreased, R wave progression later, STsegment elevation in V5-6Clinical correlation is suggested Groin CDI with palpable pulses.RESP: AC 700/12/.40/5 PEEP. There is mild regional left ventricular systolicdysfunction with focal hypokinesis of the distal half of the septum and thedistal anterior wall. was left in R groin. D/C'D OWN NGT(NOT NEEDED SINCE EXTUBATED IN AM). HUO 90S OT 100CC/HR.BUN/CREAT STABLE. Myocardial infarction.Height: (in) 67Weight (lb): 135BSA (m2): 1.71 m2BP (mm Hg): 137/67HR (bpm): 87Status: InpatientDate/Time: at 10:34Test: Portable TTE (Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.LEFT VENTRICLE: Left ventricular wall thicknesses and cavity size are normal.There is mild regional left ventricular systolic dysfunction.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: mid anteroseptal - hypokinetic; anterior apex -hypokinetic; septal apex - hypokinetic;RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter. CK continue to trend down, 3848(4564). heparin ^ to 1250/hr and bolused w/ 900u at 1800 d/t ptt 39.gi: ngt remains in place for meds, taking small amts cl liqs, tolerating well, no stoolgu: foley draining cyu, currently ~ 900cc neg.id: afebrile, cont on levoend: bs wnlskin: intactneuro: propofol d/c prior to extubation. PAD'S STARTED ON LOW DOSE LOPRESSOR 12.5 MG TOL WELL BY PT. ATIVAN PRN GIVEN WITH ADEQAUATE EFFECT. PTT 49.7, goal 50-80, Heparin left at 700u/hr with AM PTT pending. BS CLEAR BUT DIMINISHED AT BASES. U/O 40-115CC/HR.ID: T(MAX)99.9(PO). BP 108-138/50-72. There appears to be a right chest tube. CO/CI 7.2 3.79. SL.DIS- TENDED. Post Dopa UOs falling off. ABD SOFT WITH (+) BS. Pulses are palpable, feet are cool and pale.RESP: Pt continues on AC 700 X 12 overbreathing when he lightens up, 5 PEEP and 40% with last gas 7.37/35/154/-3. Current settings Vt 700, A/c 12, Fio2 40%, and Peep 5. K+ 4.0RESP: REMAINS MECH VENT. CK INTIALLY 70S WITH TROP.04 AT OSH AM CKS AND TROP PENDING.RESP: AC/700/10/.40/5 PEEP. CCU NSG NOTE: ALT IN CVO: For complete VS see CCU flow sheet.ID: T-max today 100R. IABP WITH INITIAL FLAT TRACING BUT STILL WITH FAIR UNLOADING. He is ~ 300cc positive for the day and 3600cc pos LOS.GI: Pt initally had coffee ground residual. Heparin was restarted at 800u without a bolus.BP by dinamap has ranged 112-126/50s-60s. RIGHT GROIN SITE CDI WITH PALPABLE PULSES DISTAL. He does not seem aggitated, though he seems anxious.A: Stable off IABP/increased secretions.P: Monitor for drop in CO/CI. lopressor ^ to 25mg , captopril to 12.5mg tid, tolerating well. Monitor for ETOH withdrawal. Crit stable.MS: Pt mildly sedated on 35mic/kilo of propofol. Vent settings are AC 12 X 700 40% and last gas at 7am was good.RENAL: Creat remains stable at 1.0. HR has been high 60s to low 80s. COMPARISON: None CHEST, PORTABLE: Supine portable chest demonstrates the endotracheal at the orifice of the right mainstem bronchus. Dopa weaned to off at 130AM. O2 WEANED TO 3L NP WITH O2 SATS 94-97%.CARDIAC: HR 69-85 SR WITH RARE PVC. Supraventricular tachycardia, 140 bpmProbable acute inferior myocardial infarctionConsider acute apical lateral myocardial infarctClinical correlation is suggested Atrial flutter with 2:1 block. CO/CI on Dopa wean 5.4-7.5/2.84-3.95 with MVO2 71-79%. Respiratory Care Note: Patient extubated this am. NO STOOL NOTED.GU: BUN 9 CREAT 1.0 @ MN PT WAS NEG 156. IABP remains 1:1 with AS 72-100/ AD 92-120/ BAEDP in the 50s with maps ranging 65-90. Current vent settings Vt 700, A/c 12, Fio2 40%, Peep 5. The mitral valve appears structurally normal with trivialmitral regurgitation. Suction PRN. During day residuals decreased and are now bile colored though remain G+. Repsonds to voice and verbal commands, attempting to mouth needs, following simple commands consistently.CV: HR 60s to 70s, NSR with some PVCs, rarely multifoci. CXR WITH SOME CARDIOMEGALY AND SOME ATELECTASIS BUT NO CHF. IVF boluses given as stated above, HUOs 30-35cc/hr. NGT TO LCWS. Tracing occasionally dampening out.MAPs 60s to 70s. BS+. PTT 51.4. Sputum culture (+) for GPCs. PORTABLE AP CHEST: The tip of the ET tube now lies 0.5 cm from the carinal angle. Abd soft and passing flatus. BS equal bilat with occassional rhonchi that clear with coughing. PLAN IS TO CON'T WEAN PROPOFOL WITH ATIVAN ATC.GI: NGT CLAMPED,BILIOUS DRAINAGE NOTED. Decrease dopa as tolerated. CCU Nursing Progress Note 1900-0700: IMI, RV INFARCS-Sedated and intubatedSEE CAREVUE FOR ALL SUBJECTIVE DATA AND TRENDS IN VSSO-MS:Sedated and intubated on Propofol, slightly decreased secondary to Ativan effect. PAP 30s/. PLAN IS TO CHG TO PS AS PROPOFOL WEAN.NEURO: PROPOFOL WEANED DOWN TO 30MCG. Mg wnls. CHEST: The tip of the endotracheal tube now lies 4 cm from the carinal angle. HEPARIN GTT IN- FUSING AT 1250U/HR. At MN even, and for LOS 3.8Ls. Delayed R wave progression. BS COURSE. Compared to the previous tracing of there is newatrial flutter. CCU NPNresp: extubated at 0900 w/o difficulty. K repleted. Left ventricular function. There are focal calcificationsin the aortic root. WHEN IVF OFF MAPS DOWN INTO 50S. | 20 | [
{
"category": "Radiology",
"chartdate": "2188-09-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 803304,
"text": " 7:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: chf\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with acute IMI\n\n REASON FOR THIS EXAMINATION:\n chf\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Prior chest showed ET tube too low. Reassess position.\n\n PORTABLE AP CHEST: The tip of the ET tube now lies 0.5 cm from the carinal\n angle. A SG catheter is present with the tip in the main pulmonary artery.\n The tip of the NG tube lies below the diaphragm. The coarsening of the lung\n markings likely representing chronic changes.\n\n IMPRESSION: ET tube withdrawn to satisfactory position.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-09-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 803301,
"text": " 1:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with\n REASON FOR THIS EXAMINATION:\n assess ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51 year old man, assess endotracheal tube placement.\n\n COMPARISON: None\n\n CHEST, PORTABLE: Supine portable chest demonstrates the endotracheal at the\n orifice of the right mainstem bronchus. A nasogastric tube is in place who's\n tip is not included on the radiograph but seen superimposed over a distended\n stomach. There is diffuse coarsened appearance of the pulmonary parenchyma.\n Without prior radiographs, the acquity of this finding cannot be determined.\n There is a focal more dense area in the left retrocardiac region.\n\n IMPRESSION:\n\n 1) Endotracheal tube tip at the orifice of the right mainstem bronchus.\n\n 2) Coarsened appearance to the pulmonary parenchyma and opacity in the left\n retrocardiac region. An underlying pneumonia vs atelectasis are\n considerations.\n\n The endotracheal tube position was telephoned to Dr. at 2:45\n am on . This will be withdrawn.\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-09-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 803383,
"text": " 7:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate pulmonary status\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with acute IMI,e valuate pulmonary status\n\n REASON FOR THIS EXAMINATION:\n evaluate pulmonary status\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Acute IMI.\n\n CHEST: The tip of the endotracheal tube now lies 4 cm from the carinal angle.\n There appears to be a balloon catheter within the aorta with the tip close to\n the aortic knob. The tip of the Swan-Ganz catheter is in the main pulmonary\n artery. There appears to be a right chest tube. No pneumothorax is seen. No\n evidence of failure. Some small areas of atelectasis are present but no\n pneumonic consolidations are present.\n\n IMPRESSION: No failure. No pneumonia. IABT slightly high.\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-09-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 803457,
"text": " 8:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?CHF\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with acute IMI,e valuate pulmonary status\n\n REASON FOR THIS EXAMINATION:\n ?CHF\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Acute IMI.\n\n CHEST: Alveolar opacification in the right lower lobe is now seen and was not\n present on the previous chest x-ray of . This is thought to\n represent a pneumonic consolidation rather than failure. The costophrenic\n angles are sharp. There is no significant upper zone redistribution. The\n position of the various lines and tubes remains unaltered.\n\n IMPRESSION: New onset right lower lobe pneumonia.\n\n"
},
{
"category": "Echo",
"chartdate": "2188-09-09 00:00:00.000",
"description": "Report",
"row_id": 75152,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Coronary artery disease. Left ventricular function. Myocardial infarction.\nHeight: (in) 67\nWeight (lb): 135\nBSA (m2): 1.71 m2\nBP (mm Hg): 137/67\nHR (bpm): 87\nStatus: Inpatient\nDate/Time: at 10:34\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses and cavity size are normal.\nThere is mild regional left ventricular systolic dysfunction.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: mid anteroseptal - hypokinetic; anterior apex -\nhypokinetic; septal apex - hypokinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. There are focal calcifications\nin the aortic root. The ascending aorta is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no mitral valve prolapse.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. The estimated pulmonary artery systolic pressure is\nnormal.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a low risk (prophylaxis not recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses and\ncavity size are normal. There is mild regional left ventricular systolic\ndysfunction with focal hypokinesis of the distal half of the septum and the\ndistal anterior wall. The remaining segments contract well. Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion and no aortic\nregurgitation. The mitral valve appears structurally normal with trivial\nmitral regurgitation. There is no mitral valve prolapse. The estimated\npulmonary artery systolic pressure is normal. There is no pericardial\neffusion.\n\nIMPRESSION: Regional left ventricular systolic dysfunction c/w CAD.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2188-09-11 00:00:00.000",
"description": "Report",
"row_id": 194743,
"text": "Atrial flutter with 2:1 block. Delayed R wave progression. Possible inferior\nmyocardial infarction. Compared to the previous tracing of there is new\natrial flutter.\n\n"
},
{
"category": "ECG",
"chartdate": "2188-09-06 00:00:00.000",
"description": "Report",
"row_id": 194744,
"text": "Sinus arrhythmia\nInferior infarct - age undetermined, probably acute\nLate R wave progression consider anteroseptal infarct - age undetermined\nSince previous tracing, heart rate decreased, R wave progression later, ST\nsegment elevation in V5-6\nClinical correlation is suggested\n\n"
},
{
"category": "ECG",
"chartdate": "2188-09-06 00:00:00.000",
"description": "Report",
"row_id": 194745,
"text": "Supraventricular tachycardia, 140 bpm\nProbable acute inferior myocardial infarction\nConsider acute apical lateral myocardial infarct\nClinical correlation is suggested\n\n"
},
{
"category": "ECG",
"chartdate": "2188-09-06 00:00:00.000",
"description": "Report",
"row_id": 194746,
"text": "Sinus rhythm\nInferior infarct - age undetermined\nSince previous tracing, apical lateral ST segment elevation resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-09-07 00:00:00.000",
"description": "Report",
"row_id": 1270528,
"text": "CCU NSG NOTE: ALT IN CV\nO: For complete VS see CCU flow sheet.\nID: T-max today 100R. WBCs 9.7. With increasing yellow secretion thru ET tube new sputum sample sent and levofloxacin IV begun.\nCV: Pt more stable today. IABP weaned to 1:3 with CI stable at 2.6. Heparin was shut off at 1pm and IABP pulled at 1510 without problem. was left in R groin. Pressure dsg was applied and all pulses palpable. Feet remain cool, but pt moves on command. HR has been 62-65 NSR with occasional PVCs and self limiting runs of VT this am, but none with afternoon. Heparin was restarted at 800u without a bolus.BP by dinamap has ranged 112-126/50s-60s. PAP 30s/. CO/CI 2 hours after IABP pull was 5.6/2.9. CKs continue to decrease down to 3258/12 today.\nRESP: Pt will remain intubated until tomorrow. He has greatly increased yellow thick secretions. He requires suctioning nearly every hour. He continue to sat well and has strong cough and nearly clear breath sounds. Vent settings are AC 12 X 700 40% and last gas at 7am was good.\nRENAL: Creat remains stable at 1.0. Urine output had dropped off after dopamine was shut off but has picked up to ~100cc/hr. He is ~ 300cc positive for the day and 3600cc pos LOS.\nGI: Pt initally had coffee ground residual. During day residuals decreased and are now bile colored though remain G+. He now has good bowel sounds and is passing gas. NO BM. He tolerated plavix and as a this am. Crit stable.\nMS: Pt mildly sedated on 35mic/kilo of propofol. He follows commands consistently. He tries to talk but I cannot understand him. He does not seem aggitated, though he seems anxious.\nA: Stable off IABP/increased secretions.\nP: Monitor for drop in CO/CI. Assist pt with position changes. ? start lopressor tonight. Keep careful I & O.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-09-08 00:00:00.000",
"description": "Report",
"row_id": 1270529,
"text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Current settings Vt 700, A/c 12, Fio2 40%, and Peep 5. Minimal spont effort. Unable to obtain RSBI this am. Bs clear bilaterally. Sx'd for sm amounts of thick white/yellow sputum. O2 sats 97-99%. Pt. sedated with propofol.\nNo further changes made. Continue with mechanical support and wean to Psv as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-09-08 00:00:00.000",
"description": "Report",
"row_id": 1270530,
"text": "NSG NOTE\n\nCV: REMAINS IN NSR WITH HR 64-83. SBP 94-133/55-65. PAD'S STARTED ON LOW DOSE LOPRESSOR 12.5 MG TOL WELL BY PT. CO/CI 7.2 3.79. PTT SUB THERAPEUTIC HEPARIN INCREASED TO 900 U/HR. AM PTT PENDING. OCCASSIONAL MULTIFOCAL PVC'S NOTED. K+ 4.0\n\nRESP: REMAINS MECH VENT. AC 700X12 40%,PEEP 5. FREQ SUCTIONED WITH LAVAGE FOR THICK YELLOW SECRETIONS. ALSO HAS COPIOUS ORAL SECRETIONS. BS COURSE. O2 SATS 100%. PLAN IS TO CHG TO PS AS PROPOFOL WEAN.\n\nNEURO: PROPOFOL WEANED DOWN TO 30MCG. PT AWAKES TO VOICE. HE CAN FOLLOW SIMPLE COMMANDS AND HAS PURPOSEFUL MOVEMENTS. AT TIMES PT AWAKES ATTEMPTING TO SIT UP AND PULL AT TUBES. ATIVAN PRN GIVEN WITH ADEQAUATE EFFECT. PT HAS KNOW ETHO USES AND IS \" ANXIOUS BY NATURE\" ACCORDING TO FAMILY AND FRIENDS. PLAN IS TO CON'T WEAN PROPOFOL WITH ATIVAN ATC.\n\nGI: NGT CLAMPED,BILIOUS DRAINAGE NOTED. ABD IS SOFT. NO STOOL NOTED.\n\nGU: BUN 9 CREAT 1.0 @ MN PT WAS NEG 156. LOS POSITIVE BY 3L. U/O > 60CC/HR\n\nSKIN: INTACT.\n\nID: TEMP MAX 100.6 WBC 9.7 CON'T ON LEVOFLOX IV. + GM COCCI IN ANEROBIC BOTTLES (CALLED TO UNIT ON AM) HOUSE STAFF NOTIFIED.\n\nSOCIAL: NO INQUIERES OVERNOC\n\nA: GUARDED\n\nP: POSSIBLE RESP WEAN\n CON'T PER NSG JUDGEMENT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-09-06 00:00:00.000",
"description": "Report",
"row_id": 1270523,
"text": "CCU NSG ADMISSION NOTE 1900-0700: IMI W/ RV INFARCT\nS-SEDATED AND INTUBATED\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VSS\n\nO-MS: ARRIVED ATTEMPTING TO PULL AT TUBE AND APPEARING AGITATED. RECIEVING 4MG OF VERSED IN CATH LAB. UPON ARRIVAL UNABLE TO FOLLOW COMMANDS BUT MAKING PURPOSEFUL MOVEMENTS. PROPOFOL STARTED AT 20MCGS.\nRESPONDING TO PAIN STIMULI STILL UNABLE TO FOLLOW COMMANDS. ANTICIPATE PROPOFOL WEAN WITH POSSIBLE EXTUBATION LATER TODAY.\n\nCV: HR 58 TO 90S. SB/NSR WITH PVC ANS PACS. OCCASIONAL PAUSES. WIRE IN CATH LAB REMOVED. ONE 12 BEAT RUN OF VT. REMAINS ON 2MG/MIN OF LIDO. PACER PADS IN PLACE. IABP WITH INITIAL FLAT TRACING BUT STILL WITH FAIR UNLOADING. IABP TIMING ADJUSTED AND WITH UNLOADING AND AUGMENTATION. MAPS 50S TO 90S. DOPA DECREASED UPON ARRIVAL TO 5MCG FROM 10MCG FOR MAPS IN THE 90S. MAPS DOWN INTO 50S AND PADS . IVF BOLUS GIVEN TIME THREE IN AMOUNTS OF 250CCS. MAPS 60S TO 70S. WHEN IVF OFF MAPS DOWN INTO 50S. MAITENANCE FLUID INCREASED TO 200CC/HR FROM 100CC/HR AND CHANGED TO NS. TOWARDS MORNING, CARD FELLOW WANTING TO INCREASE DOPA TO 7.5MCGS AND DECREASED IVFS. DOPA AND FLUIDS CHANGED WITH MAPS IN THE 90S. DOPA DECREASED TO 6MCGS AND MAPS IN THE 80S. IVF CURRENTLY RUNNING AT 150CC/HR. CO/CI IMPROVING TO 5/2.73 WITH MVO2 OF 73% ON 5MCGS OF DOPA. RIGHT GROIN SITE CDI WITH PALPABLE PULSES DISTAL. CK INTIALLY 70S WITH TROP.04 AT OSH AM CKS AND TROP PENDING.\n\nRESP: AC/700/10/.40/5 PEEP. LSCTA WITH SLIGHT CRACKLES AT RIGHT BASES. CXR WITH SOME CARDIOMEGALY AND SOME ATELECTASIS BUT NO CHF. SUCTG FOR BLOOD TINGED SECRETIONS IN SCANT AMOUNTS. ABG METABOLIC ACIDOSIS BUT STEADILY IMPROVING. *SEE CAREVUE FOR TRENDS*. FIO2 WEANED TO 100% TO 40%. AM CXR PENDING.\n\nGU/GI: FOLEY DRAINING SLIGHTLY PINK TINGED URINE. HUO 90S OT 100CC/HR.\nBUN/CREAT STABLE. ABD SOFT WITH (+) BS. NGT TO LCWS. SUCTION FOR MODERATE AMOUNT OF FOOD PARTICLES AND SOME COFFEE GROUNDS.\n\nID: SLIGHTLY HYPOTHERMIC AT 96.8. BLANKETS APPLIED. WBC UP 24. BLOOD AND URINE CX SENT. SPUTUM UNABLE TO OBTAIN SECONDARY TO SMALL AMOUUNT.\n\nHEME: HCT STABLE AT 43.\n\nSOC: ONLY LIVING RELATIVE IS BROTHER WHO LIVES IN , CARDS FELLOW CONTACTING AND EXPLAINING SITUATION. BROTHER DECLINING TO COME DOWN AT CURRENT TIME AND WILL PROBABLY COME DOWN TODAY. APPARENTLY, MOTHER AND OTHER SIBLINGS ALL HAVE DIED FROM MI'S.\n\nA/P: S/P IMI W/ RV INFARCT C/B CARDIGENIC SHOCK REQ IABP SUPPORT AND PRESSOR\n\nCONTINUE TO MONITOR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-09-06 00:00:00.000",
"description": "Report",
"row_id": 1270524,
"text": "Patient remains on mechanical ventilation,no changes made. ABG normal,patient vomited this afternoon apparently did not aspirate. No evidence of gastric contents observed in sputum. Patient has thick bloody sputum more so via mouth then from ETT.Remains on IABP DX: IMI,RV infarct recently stented not ready yet for weaning from vent; will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-09-06 00:00:00.000",
"description": "Report",
"row_id": 1270525,
"text": "CCU NSG NOTE: ALT IN CV\nO: For complete VS see CCU flow sheet.\nID: Pt initally hypothermic. By 1600 Temp up to 101R. Pt already cultured\nCV: Pt started the day on 6mic/kilo of dopamine. It was weaned to 4mic/kilo, but CI dropped to 2.05, maps dropped to 60s and urine output also dropped. Dopa returned to 6mic/kilo with co now 5.4/2.8 and improved urine output. HR has been high 60s to low 80s. He had rare PVCs and rare runs until dopa wean which coincided with lidocaine being shut off, when he had very frequent self limiting runs of VT. ONce dopa back up to 6mic/kilo runs have greatly decreased. Pt is also receiving 4amp Mag SO4 for mag of 1.4, and 20meq KCL IV for K+ of 4.1 in setting of auto-diuresis. IABP remains 1:1 with AS 72-100/ AD 92-120/ BAEDP in the 50s with maps ranging 65-90. He has good augmentation and is unloading 15-20 points. PAP has ranged 27-35/11-15. PAD has been in lower range since IVF of NS at 150/hr was shut off at 1400. His PTT this afternoon was subtheraputic and he was bolused with 900u and drip was increased to 700u/hr at 1430. His CKs continue to increase to 4564/407. His groin remains dry with no ooze or hematoma. Pulses are palpable, feet are cool and pale.\nRESP: Pt continues on AC 700 X 12 overbreathing when he lightens up, 5 PEEP and 40% with last gas 7.37/35/154/-3. No longer able to obtain blood gas from side port of IABP. He has clear breath sounds and is suctioned for small amts blood tinged sputums.He still has a lot of old blood in the back of his throat. He is sating 99-100%. He has a very strong gag.\nGI: Pt received 225mg plavix at 11am and at noon, while awake, aggitated, and gagging, he vomited a lg amt of incompletely digested food. Food was salmon colored and G+pos but only mildly. Some of this must be coming from the back of his throat. He cntinues on intermittent suction and continues to drain gastric contents. He has very decreased bowel sounds.\nRENAL: During am U/O was 90-140cc/hr. It dropped to 30-40cc/hr while on lower dose dopamine, but now on higher dose, and off IVF has been ~160-250cc/hr. While he remains 3500cc pos, he has been neg every hour since back on dopa.\nMS: Pt has been on propofol at 20mic/kilo during most of the day. He is intermittently rouseable and will follow commands. He does try to talk and appears distressed. He gags on tube and will thrash around, though calms with reassurance. He received .5mg IV ativan at 1400, but propofol has since had to be increased to 30mic/kilo.\nSOCIAL: His brother was in to visit. He lives with his brother is divorced and estranged from ex-wife and daughter. is a daily drinker, though his brother is unsure of how much as he drinks in bars.\nA: Continues to require inotrop/vomiting/\nP: Pt will need PTT, CK and electrolytes at 10p. Keep careful I & O. Monitor for ETOH withdrawal. Decrease dopa as tolerated. Monitor for GI bleeding. Suction PRN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-09-07 00:00:00.000",
"description": "Report",
"row_id": 1270526,
"text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. No changes made in vent settings. Current vent settings Vt 700, A/c 12, Fio2 40%, Peep 5. Bs clear bilaterally. Sx'd for sm-moderate amounts of thick tan sputum. Adequte O2 sats. Pt. sedated on Propofol. No further changes made Continue with mechanical support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-09-07 00:00:00.000",
"description": "Report",
"row_id": 1270527,
"text": "CCU Nursing Progress Note 1900-0700: IMI, RV INFARC\nS-Sedated and intubated\n\nSEE CAREVUE FOR ALL SUBJECTIVE DATA AND TRENDS IN VSS\n\nO-MS:Sedated and intubated on Propofol, slightly decreased secondary to Ativan effect. Currently at 25mcgs/kg/min. Continues Ativan 0.5mg for anxiety and anticipated DTs. Repsonds to voice and verbal commands, attempting to mouth needs, following simple commands consistently.\n\nCV: HR 60s to 70s, NSR with some PVCs, rarely multifoci. One 12 beat on of AIVR BP into 70s with run. K repleted. Mg wnls. IABP with good systolic and diastolic unloading. Tracing occasionally dampening out.\nMAPs 60s to 70s. Dopa weaned to off at 130AM. CO/CI on Dopa wean 5.4-7.5/2.84-3.95 with MVO2 71-79%. Most recent with Dopa off times 3 1/2hr CO/CI 5.0/2.63 with MVO2 69. PADs . IVF boluses times two in 250cc incruments. PTT 49.7, goal 50-80, Heparin left at 700u/hr with AM PTT pending. CK continue to trend down, 3848(4564). AM pending. Groin CDI with palpable pulses.\n\nRESP: AC 700/12/.40/5 PEEP. No vent changes overnight. LSCTA. O2Sats 100%. Suctioning for tan thick to thin secretions in small amounts.\nOccasionally breathing over vent by 4-10 breaths.\n\nGU/GI: Foley draining adequate amounts of urine with Dopa on. Post Dopa UOs falling off. IVF boluses given as stated above, HUOs 30-35cc/hr. At MN even, and for LOS 3.8Ls. Abd soft and passing flatus. No BM overnight. NGT to LIS and draining brown asp, heme (+).\n\nID: Tm 101.1 and Tc 99.8. Sputum culture (+) for GPCs. CCU team aware.\nBlood and urine pending.\n\nHEME: HCT 34.3 on eves and this AM 36. Continue to follow.\n\nA/P: s/p IMI, RV INFARCT requiring IABP support, currently off Dopa and doing fair, PADs low recieving IVFs overnight.\n\nContinue to monitor.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-09-08 00:00:00.000",
"description": "Report",
"row_id": 1270531,
"text": "Respiratory Care Note:\n Patient extubated this am. Voice is raspy and cough is intact. BS equal bilat with occassional rhonchi that clear with coughing. Patient with SpO2>96% on 50% cool mist via face tent. He has been coughing spontaneously and clearing secretions fairly well thus far.\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-09-08 00:00:00.000",
"description": "Report",
"row_id": 1270532,
"text": "CCU NPN\nresp: extubated at 0900 w/o difficulty. Now on 50% cool neb face mask w/ sats 96-98%. lung sounds coarse.Voice very raspy, Weak, congested cough.\ncv: hr 85-107 sr no vea. bp 125-155/50-60. lopressor ^ to 25mg , captopril to 12.5mg tid, tolerating well. pulled this am.R groin d/i, pulses dopplerable. heparin ^ to 1250/hr and bolused w/ 900u at 1800 d/t ptt 39.\ngi: ngt remains in place for meds, taking small amts cl liqs, tolerating well, no stool\ngu: foley draining cyu, currently ~ 900cc neg.\nid: afebrile, cont on levo\nend: bs wnl\nskin: intact\nneuro: propofol d/c prior to extubation. Now awake, alert, oriented x2, asking appropriate questions, cooperative w/ care.\nsocial: brother in to visit\nA: tolerating extubation, hemodynamically stable\nP: monitor resp status, advance diet as tolerated, ptt at mn, monitor response to change in cv meds\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-09-09 00:00:00.000",
"description": "Report",
"row_id": 1270533,
"text": "NEURO: A&O X3. COOPERATIVE WITH CARE. SPEECH DIFFICULT TO UNDERSTAND\n D/T HOARSENESS SINCE EXTUBATION.\nRESP: 02->50% OFT WEANED TO 40% OFT. O2 SATS 99-100%. BS CLEAR BUT\n DIMINISHED AT BASES. RR 17-23. O2 WEANED TO 3L NP WITH O2 SATS\n 94-97%.\nCARDIAC: HR 69-85 SR WITH RARE PVC. BP 108-138/50-72. HEPARIN GTT IN-\n FUSING AT 1250U/HR. PTT 51.4. R. GROIN SITE C&D. NO EVIDENCE\n BLEEDING/HEMATOMA.\nGI: PT. D/C'D OWN NGT(NOT NEEDED SINCE EXTUBATED IN AM). ABD. SL.DIS-\n TENDED. BS+. NO STOOL. SOME DIFFICULTY SWALLOWING MEDS. TOOK THEM\n CRUSHED IN CUSTARD.\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 40-115CC/HR.\nID: T(MAX)99.9(PO). IV LEVOFLOX CHANGED TO PO.\nAM LABS PENDING.\nPLAN: OOB->CHAIR\n D/C FOLEY\n CO TO FLOOR\n"
}
] |
81,475 | 101,662 | In ED, initial VS 96.8 193/113 78 24 100% NRB. He desatted to 91% on RA. He had a CXR which did not show any infiltrate or effusion. His labs were notable for acute renal failure and hypernatremia, BNP lower than last value from . His shortness of breath worsened acutely and he was tried on BiPap which he did not tolerate. He was admitted to the for further monitoring in setting of elevated BP and transient need for BiPap. He detereorated further and was intubated. Abdominal exam became more distended and a tranplant Surgery consult was requested . Initially, he was persistently hypertensive and was treated with nitro and nicardipine drips. On HD #2, renal U/S showed no abnormalities. On HD #3, he was intubated for progressive pulmonary decompensation. On HD #4, renal biopsy concerning for rejection with superimposed ATN. Progressive acidosis at this time. On HD #7, acute hypotensive episode, SBP 70, minimally responsive to fluid resuscitation and vasopressors, guiac positive stool, KUB showing bowel dilatation. CT abdomen showed bowel pneumatosis. On HD #8, approximately 6 hours after initial surgical consultation, the patient was taken to the OR. At this point, he was on three vasopressors, LFT markedly elevated, coagulopathic, and anemic. Also of note, he demonstrated a methemoglobinemia as high as 13% (nl 0-2%) on the day of his decompensation. There was frankly necrotic and perforated bowel, encompassing the majority of his small bowel and transverse/proximal left colon, as well patchy necrosis of his liver. These portions of dead bowel were resected and the patient was left in discontinuity, abdomen open, and returned to the and then later transferred to the SICU. Massive resuscitation continued, with copious blood product transfusions, CVVH initiated. On POD #1, he was taken back to the OR and there was a large amount of hematoma evacuated without obvious source of bleeding, omentectomy was performed, bowel looked viable, abdomen left open. On POD #2, he went into rapid afib with associated hypotension, treated with electrical cardioversion and rate control. Later that day, he was taken back to the OR and an end jejunostomy was performed after failed attempts at re-establishing continuity secondary to tissue friability. On POD #, vasopressors on and off, continued CVVH, developed neutropenia (WBC 0.3) treated with Neupogen, gradual increase in ventilator requirements (increased FiO2 and PEEP). On POD #7, he was taken back to the OR for abdominal wash-out, vicryl mesh closure of abdomen, and VAC dressing placement. Bowel looked viable at this time. On POD #8, the patient went back into rapid afib with hypotension, treated with electrical cardioversion, but progressed to refractory shock requiring three vasopressors. On POD #9, precipitous decompensation ensued, family was consulted, CMO status and expiration shortly thereafter. | Chlorhexidine Gluconate 0.12% Oral Rinse 12. Chlorhexidine Gluconate 0.12% Oral Rinse 12. Chlorhexidine Gluconate 0.12% Oral Rinse 12. 4) Advance TPN (on Day 3) to 2060mL (310dextrose/115amino acid/ 50fat). 4) Advance TPN (on Day 3) to 2060mL (310dextrose/115amino acid/ 50fat). TITLE: Hypotension (not Shock) Assessment: 105 at begin of shift w low sbp 70-130s w transient hypertension with fld volume resuscitation, Neo gtt . Attempt to remove H2O if tolerating Hematology: Serial Hct, Hct 25.8, stable Endocrine: euglycemic. Atrial fibrillation (Afib) Assessment: Pt into rapid afib from NSR @ approx 1645 HR up to 135 SBP down to 60 Action: Neo bolus given Lopressor 5mg IV given x2 Labs sent Cardioversion Response: Pt converted to NSR with cardioversion Pt remains in NSR with HR 60-80 Plan: Lopressor and cardioversion if rapid afib occurs again Hypotension (not Shock) Assessment: Pt with labile SBP 70-150 Requiring pressors intermittently Action: Neo gtt intermittently Blood products as required monitor initiated Response: Pt with appropriate increase in SBP with blood products and pressors Plan: Continue with pressors as needed Blood products as needed Ineffective Coping Assessment: Mother and other family members requiring multiple conversations with MDs and this RN regarding pts condition Mother forgetful at times and states that she has moments where she forgets Family requiring extra support to cope with situation Family not quite able to state the severity of the situation or express understanding Action: Teaching done with family by RN and MD Reinforcing information that has been given Social work into evaluate Response: Family slowly accepting severity of the situation Plan: Continue to reinforce information that has been given Provide emotional support to family\ Social work consult Intestinal ischemia (including mesenteric venous / arterial thrombosis, bowel ischemia) Assessment: Abd open, dsg intact, JP x2 to wall suction, serosang drainage BP labile Mod amount of drainage from abd Liver shock noted Action: To OR for hematoma evacuation and wash out ABD left open Multiple blood products Labs followed Response: Pt remains with labile BP Post transfusion labs pnd LFTs trending down Plan: Back to OR tomorrow for possible closure Renal failure, acute (Acute renal failure, ARF) Assessment: Elevated BUN and Cr K+ elevated to 6.2 Action: CRRT Following labs Repleting lytes as needed Response: K trending down No change in BUN and Cr Plan: Continue with CRRT Continue to monitor labs Ipratropium Bromide MDI 6 PUFF IH QID Order date: @ 1031 3. Ipratropium Bromide MDI 6 PUFF IH QID Order date: @ 1031 3. Fluticasone Propionate 110mcg 2 PUFF IH Order date: @ 1031 21. Fluticasone Propionate 110mcg 2 PUFF IH Order date: @ 1031 21. Piperacillin-Tazobactam Na 2.25 g IV Q6H Order date: @ 1031 12. Fluticasone Propionate 110mcg 2 PUFF IH Order date: @ 1031 38. Piperacillin-Tazobactam Na 2.25 g IV Q6H Order date: @ 1031 8. Fluconazole 200 mg IV Q24H Order date: @ 0716 39. IV access: PICC, heparin dependent Location: Left basilic, Date inserted: Order date: @ 1031 23. Vasopressin 1.2 UNIT/HR IV DRIP TITRATE TO SBP>90 Order date: @ 0716 20. ?Pain v. frequent nebs v. meds withdrawal. 60 yo M with esrd post transplant, copd, htn with progressive resp failure, hypotension, progressive ARF. 60 yo M with esrd post transplant, copd, htn with progressive resp failure, hypotension, progressive ARF. Action: Intubated, sedated w/propofol now requiring pressor to maintain b/p. Consider uptitrating hydral and amlodipine if stil no responsive. TSH 0.62, AM cortisol 14.9 For high residuals, bowel regimen and Reglan started. ?Pain v. frequent nebs v. meds withdrawal. -Start fentanyl gtt as may not be absorbing po pain meds -Consider hydral prn or nicardipine gtt if persistently elevated BP -Holding due to ARF and beta blockers due to resp status -F/u renal recs # Decreased gastric motility: High residuals from tube feeds. HPI: 60 yo M with COPD, immunosupressed s/p renal transplant admitted with progressive resp distress requiring intubation----had tachypnea, weezing minimally responsive to racemic epinephrine, albuterol, and high dose steroidsparainfleunza +, significant expiratory limitation and ventilatory defect concerning for possiblity of contribution from TBM or small airways reactivity, now with progressive hypotension on triple pressors, severe metabolic + resp acidosis, ARF on CRI, leukocytosis, and GNR in sputum treating empirically for vap 24 Hour Events: MULTI LUMEN - START 05:27 AM TRIPLE INTRODUCER - START 05:29 AM Developed progressive hypotension overnightnow on three pressors for HD support--vasop, neo, levo Sepsis/VAP--vanco/zosyn started Changed to PCV History obtained from Medical records Patient unable to provide history: Sedated Allergies: Enalapril Hives; Last dose of Antibiotics: Vancomycin - 12:59 PM Piperacillin/Tazobactam (Zosyn) - 12:48 AM Metronidazole - 04:03 AM Infusions: Vasopressin - 2.4 units/hour Norepinephrine - 0.15 mcg/Kg/min Other ICU medications: Hydralazine - 10:36 AM Heparin Sodium (Prophylaxis) - 11:49 PM Other medications: per (reviewed) Changes to medical and family history: PMH, SH, FH and ROS are unchanged from Admission except where noted above and below Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 09:39 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 38C (100.4 Tcurrent: 37.4C (99.3 HR: 110 (102 - 121) bpm BP: 126/81(96) {76/58(65) - 196/100(130)} mmHg RR: 31 (18 - 33) insp/min SpO2: 100% Heart rhythm: ST (Sinus Tachycardia) Height: 80 Inch CVP: 5 (3 - 16)mmHg CO/CI (Fick): (14.8 L/min) / (6.4 L/min/m2) Mixed Venous O2% Sat: 81 - 81 Total In: 6,245 mL 3,069 mL PO: TF: 39 mL IVF: 5,865 mL 3,069 mL Blood products: Total out: 1,690 mL 1,175 mL Urine: 1,580 mL 175 mL NG: 110 mL 1,000 mL Stool: Drains: Balance: 4,555 mL 1,894 mL Respiratory support O2 Delivery Device: Endotracheal tube Ventilator mode: CMV/ASSIST/AutoFlow Vt (Set): 500 (500 - 500) mL Vt (Spontaneous): 490 (482 - 586) mL PS : 15 cmH2O RR (Set): 30 RR (Spontaneous): 0 PEEP: 5 cmH2O FiO2: 100% RSBI Deferred: FiO2 > 60% PIP: 35 cmH2O Plateau: 20 cmH2O Compliance: 51 cmH2O/mL SpO2: 100% ABG: 7.16/49/205/17/-11 Ve: 16.7 L/min PaO2 / FiO2: 205 Physical Examination General Appearance: Overweight / Obese Eyes / Conjunctiva: No(t) Sclera edema Head, Ears, Nose, Throat: Endotracheal tube, NG tube Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic) Peripheral Vascular: (Right radial pulse: Diminished), (Left radial pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse: Diminished) Respiratory / Chest: (Expansion: Symmetric), decreased BS, minimal air movement Abdominal: Bowel sounds present, Distended, No(t) Tender: , Obese, decreased BS Extremities: Right: Absent, Left: Absent Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand Skin: cool Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds to: Noxious stimuli, Movement: Not assessed, Tone: Not assessed Labs / Radiology 10.4 g/dL 369 K/uL 70 mg/dL 3.6 mg/dL 17 mEq/L 5.1 mEq/L 71 mg/dL 102 mEq/L 134 mEq/L 32.5 % 28.2 K/uL [image002.jpg] 04:18 AM 04:26 PM 08:08 PM 10:13 PM 12:02 AM 02:20 AM 02:24 AM 03:19 AM 04:05 AM 05:43 AM WBC 23.2 28.2 Hct 30.3 32.5 Plt 364 369 Cr 3.8 3.6 TCO2 21 20 21 20 21 19 20 18 Glucose 150 70 Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB / Troponin-T:210/8/0.05, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %, Mono:8.0 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:9.2 mg/dL, Mg++:1.8 mg/dL, PO4:5.9 mg/dL Imaging: progressive R > L lower lung infiltrates ET/R IJ in position Microbiology: sputum --GNR, GPC --blood pending c diff neg --nasal asp --parainflu Assessment and Plan HYPOTENSION (NOT SHOCK) RESPIRATORY FAILURE, ACUTE (NOT ARDS/) CONSTIPATION (OBSTIPATION, FOS) RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) HYPERTENSION, BENIGN CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITHOUT ACUTE EXACERBATION 60 yo M with COPD, immunosupressed s/p renal transplant admitted with progressive resp distress requiring intubation----tachypnea, weezing minimally responsive to racemic epinephrine, albuterol, and high dose steroidsparainfleunza +, significant expiratory limitation and ventilatory defect concerning for possibility of contribution from TBM or small airways reactivity now with progressive hypotension on triple pressors, severe metabolic + resp acidosis, ARF on CRI, leukocytosis, and GNR in sputum treating empirically for vap # hypotension/shock most concerning for septic shock with gnr sputum and now with worsening infil on cxr also possible component of adrenal insuf in this immunosupressed host Given low CVPScardiogenic shock seems less likely ---continue aggressive IVF to maintain cvp > 10--would give 1 L bicarb and then LR alternating with NS given worsening met acidosis --continue pressor support--now on triple-- to maintain MAP > 60--wean as able --f/u TTE results --continue stress steroids --continue current broad antbx--vanco/zosyn/flagyl following cx results --check bladder pressure to eval for compartment syndrome contributing to hypotension and renal failure, though lower clinical suspicion # resp failure-- copd, small airways ds, with parainfluenza, and developing b/l lower zone infiltrates with gnr in sputum concerning for HPA/VAP ventilation is worsening--now with met and resp acidosisworse after compensatory increase in resp rate has sig autopeep --continue ACV --attempt matching peep, decrease resp rate and increase TV slightly to see if helps w/ ventilatory picture / expiration --continue broad coverage as above --change nebs to MDIs --discuss worsening status with renal as cvvh may help with metabolic picture/severe acidosis # Acute renal failure on CRI--urine output decreasing but CVPs low--will give bicarb, renal following and aware of decline (? Hypertension, benign Assessment: Received patient on phenylephrine at 0.9mkm, weaned off and is currently off at time of reporting. HPI: 60 yo M with COPD, immunosupressed s/p renal transplant admitted with progressive resp distress requiring intubation----tachypnea, weezing minimally responsive to racemic epinephrine, albuterol, and high dose steroidsparainfleunza +, significant expiratory limitation and ventilatory defect concerning for possible TBM or small airways reactivity, now with progressive hypotension, severe metabolic + resp acidosis, ARF on CRI, leukocytosis, and GNR in sputum treating empirically for vap 24 Hour Events: MULTI LUMEN - START 05:27 AM TRIPLE INTRODUCER - START 05:29 AM Developed progressive hypotension overnightnow on three pressors for HD support--vasop, neo, levo Sepsis/VAP--vanco/zosyn started Changed to PCV History obtained from Medical records Patient unable to provide history: Sedated Allergies: Enalapril Hives; Last dose of Antibiotics: Vancomycin - 12:59 PM Piperacillin/Tazobactam (Zosyn) - 12:48 AM Metronidazole - 04:03 AM Infusions: Vasopressin - 2.4 units/hour Norepinephrine - 0.15 mcg/Kg/min Other ICU medications: Hydralazine - 10:36 AM Heparin Sodium (Prophylaxis) - 11:49 PM Other medications: per (reviewed) Changes to medical and family history: PMH, SH, FH and ROS are unchanged from Admission except where noted above and below Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 09:39 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 38C (100.4 Tcurrent: 37.4C (99.3 HR: 110 (102 - 121) bpm BP: 126/81(96) {76/58(65) - 196/100(130)} mmHg RR: 31 (18 - 33) insp/min SpO2: 100% Heart rhythm: ST (Sinus Tachycardia) Height: 80 Inch CVP: 5 (3 - 16)mmHg CO/CI (Fick): (14.8 L/min) / (6.4 L/min/m2) Mixed Venous O2% Sat: 81 - 81 Total In: 6,245 mL 3,069 mL PO: TF: 39 mL IVF: 5,865 mL 3,069 mL Blood products: Total out: 1,690 mL 1,175 mL Urine: 1,580 mL 175 mL NG: 110 mL 1,000 mL Stool: Drains: Balance: 4,555 mL 1,894 mL Respiratory support O2 Delivery Device: Endotracheal tube Ventilator mode: CMV/ASSIST/AutoFlow Vt (Set): 500 (500 - 500) mL Vt (Spontaneous): 490 (482 - 586) mL PS : 15 cmH2O RR (Set): 30 RR (Spontaneous): 0 PEEP: 5 cmH2O FiO2: 100% RSBI Deferred: FiO2 > 60% PIP: 35 cmH2O Plateau: 20 cmH2O Compliance: 51 cmH2O/mL SpO2: 100% ABG: 7.16/49/205/17/-11 Ve: 16.7 L/min PaO2 / FiO2: 205 Physical Examination General Appearance: Overweight / Obese Eyes / Conjunctiva: No(t) Sclera edema Head, Ears, Nose, Throat: Endotracheal tube, NG tube Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic) Peripheral Vascular: (Right radial pulse: Diminished), (Left radial pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse: Diminished) Respiratory / Chest: (Expansion: Symmetric), decreased BS, minimal air movement Abdominal: Bowel sounds present, Distended, No(t) Tender: , Obese, decreased BS Extremities: Right: Absent, Left: Absent Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand Skin: cool Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds to: Noxious stimuli, Movement: Not assessed, Tone: Not assessed Labs / Radiology 10.4 g/dL 369 K/uL 70 mg/dL 3.6 mg/dL 17 mEq/L 5.1 mEq/L 71 mg/dL 102 mEq/L 134 mEq/L 32.5 % 28.2 K/uL [image002.jpg] 04:18 AM 04:26 PM 08:08 PM 10:13 PM 12:02 AM 02:20 AM 02:24 AM 03:19 AM 04:05 AM 05:43 AM WBC 23.2 28.2 Hct 30.3 32.5 Plt 364 369 Cr 3.8 3.6 TCO2 21 20 21 20 21 19 20 18 Glucose 150 70 Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB / Troponin-T:210/8/0.05, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %, Mono:8.0 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:9.2 mg/dL, Mg++:1.8 mg/dL, PO4:5.9 mg/dL Imaging: progressive R > L lower lung infiltrates ET/R IJ in position Microbiology: sputum --GNR, GPC --blood pending c diff neg --nasal asp --parainflu Assessment and Plan HYPOTENSION (NOT SHOCK) RESPIRATORY FAILURE, ACUTE (NOT ARDS/) CONSTIPATION (OBSTIPATION, FOS) RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) HYPERTENSION, BENIGN CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITHOUT ACUTE EXACERBATION 60 yo M with COPD, immunosupressed s/p renal transplant admitted with progressive resp distress requiring intubation----tachypnea, weezing minimally responsive to racemic epinephrine, albuterol, and high dose steroidsparainfleunza +, significant expiratory limitation and ventilatory defect concerning for possible TBM or small airways reactivity now with progressive hypotension, severe metabolic + resp acidosis, ARF on CRI, leukocytosis, and GNR in sputum treating empirically for vap # hypotension/shock most concerning for septic shock with gnr sputum and now with worsening infil on cxr also possible component of adrenal insuf in this immunosupressed host Given low CVPScardiogenic shock seems less likely ---continue aggressive IVF to maintain cvp > 10--would give 1 L bicarb and then LR alternating with NS given worsening met acidosis --continue pressor support--now on triple-- to maintain MAP > 60--wean as able --f/u TTE results --continue stress steroids --continue current broad antbx--vanco/zosyn/flagyl following cx results --check bladder pressure to eval for compartment syndrome contributing to hypotension and renal failure, though lower clinical suspicion # resp failure-- copd, small airways ds, with parainfluenza, and developing b/l lower zone infiltrates with gnr in sputum concerning for HPA/VAP ventilation is worsening--now with met and resp acidosisworse after compensatory increase in resp rate has sig autopeep --continue ACV --attempt matching peep, decrease resp rate and increase TV slightly to see if helps w/ ventilatory picture / expiration --continue broad coverage as above --change nebs to MDIs --discuss worsening status with renal as cvvh may help with metabolic picture/severe acidosis # Acute renal failure on CRI--urine output decreasing but CVPs low--will give bicarb, renal following and aware of decline (? 60 yo M with esrd post transplant, copd, htn with progressive resp failure, hypotension, progressive ARF. 60 yo M with esrd post transplant, copd, htn with progressive resp failure, hypotension, progressive ARF. Temp this AM 100.4 axillary, wbc 28 suggesting sepsis, likely from VAP. Fluticasone Propionate 110mcg 2 PUFF IH Order date: @ 1031 36. Renal failure, acute (Acute renal failure, ARF) Assessment: Creat 4.6 K-6.6 UOP minimal Action: Bicarb 50meq given and Bicarb drip started at 150cc/hr, renal follows; continue on steroids/prograf/cellcept. Renal failure, acute (Acute renal failure, ARF) Assessment: Creatinine trending down. Of note, attempt to wean sedation for possible extubation Respiratory failure, acute (not ARDS/) Assessment: Pt. Action: Weaned off of NTG, remains on Nicardipine drip. Noted ?rejection of chronic transplant nephropathy. Noted ?rejection of chronic transplant nephropathy. Noted ?rejection of chronic transplant nephropathy. Noted ?rejection of chronic transplant nephropathy. 60 yo M with esrd post transplant, copd, htn with progressive resp failure, hypotension, progressive ARF. Tachycardic in w/occasional PACs. Action: Weaned off of NTG, remains on Nicardipine drip. B/P down to 120 nicardipine gtt on hold in case hypertension persists Response: B/P remains in 120-130s. B/P down to 120 nicardipine gtt on hold in case hypertension persists Response: B/P remains in 120-130s. Action: Response: Plan: Hypotension (not Shock) Assessment: Action: Response: Plan: Constipation (Obstipation, FOS) Assessment: Known decreased gastric motility. Consider uptitrating hydral and amlodipine if stil no responsive. Progressive respiratory distress required intubation on . There are diffuse expiratory wheezes with I/E=. Blood pressure has been elevatd despite IV TNG. Fluticasone Propionate 110mcg 2 PUFF IH Order date: @ 1237 36. Fluticasone Propionate 110mcg 2 PUFF IH Order date: @ 1237 36. Fluconazole 200 mg IV Q24H Order date: @ 0716 39. Fluticasone Propionate 110mcg 2 PUFF IH Order date: @ 1031 38. Piperacillin-Tazobactam Na 2.25 g IV Q6H Order date: @ 1031 8. Right ventricular function.Height: (in) 80Weight (lb): 200BSA (m2): 2.30 m2BP (mm Hg): 82/56HR (bpm): 102Status: InpatientDate/Time: at 15:27Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: LA not well visualized.RIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically ventilated. S/p renal transplant--not clearly volume overloaded.Height: (in) 72Weight (lb): 180BSA (m2): 2.04 m2BP (mm Hg): 150/90HR (bpm): 98Status: InpatientDate/Time: at 10:03Test: Portable TTE (Focused views)Doppler: Color Doppler onlyContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: LV not well seen. Probableold inferior wall myocardial infarction. The rhythm is probably sinus with left atrial abnormalitybut consider also ectopic atrial rhythm and baseline artifact makes assessmentdifficult. Possible anteroseptal myocardialinfarction of indeterminate age. Left atrial abnormality. Left atrial abnormality. Delayed R wave transition.Left axis deviation. HISTORY: Decreased right breath sounds. DelayedR wave progression may be positional/non-specific or possible prior septalmyocardial infarction. Baselineinstability mimics atrial fibrillation but the rhythm is likely sinus withleft atrial abnormality and first degree A-V block.TRACING #2 | 262 | [
{
"category": "Physician ",
"chartdate": "2104-06-05 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 673315,
"text": "Chief Complaint: Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n MIDLINE - START 10:00 AM\n Not a PICC line, midline\n PICC LINE - STOP 10:01 AM\n -BP control enhanced and moved to PO medications alone\n -IVF required for low urine output\n -Patient on room air\n History obtained from Medical records\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:24 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Tachypnea\n Flowsheet Data as of 09:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35\nC (95\n HR: 80 (75 - 96) bpm\n BP: 161/51(78) {114/48(46) - 191/128(135)} mmHg\n RR: 23 (16 - 25) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n Total In:\n 1,653 mL\n 1,019 mL\n PO:\n 720 mL\n TF:\n IVF:\n 933 mL\n 1,019 mL\n Blood products:\n Total out:\n 1,275 mL\n 350 mL\n Urine:\n 1,250 mL\n 350 mL\n NG:\n 25 mL\n Stool:\n Drains:\n Balance:\n 378 mL\n 669 mL\n Respiratory support\n SpO2: 94%\n ABG: ///13/\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Wheezes : prolonged expiratory phase noted)\nhe has\n profound and significant expiratory airflow obstruction which is really\n dominantly central.\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.1 g/dL\n 248 K/uL\n 166 mg/dL\n 4.1 mg/dL\n 13 mEq/L\n 5.3 mEq/L\n 61 mg/dL\n 92 mEq/L\n 122 mEq/L\n 30.5 %\n 10.5 K/uL\n [image002.jpg]\n 07:57 AM\n 12:51 PM\n 09:53 PM\n 11:01 PM\n 03:22 AM\n 05:23 AM\n 04:15 AM\n 06:45 AM\n WBC\n 4.3\n 7.4\n 10.5\n Hct\n 28.8\n 26.3\n 30.5\n Plt\n 170\n 214\n 248\n Cr\n 3.9\n 3.6\n 3.8\n 3.5\n 3.7\n 3.7\n 4.1\n TropT\n 0.08\n 0.05\n TCO2\n 21\n Glucose\n 129\n 529\n 178\n 497\n 211\n 148\n 166\n Other labs: PT / PTT / INR:13.9/35.5/1.2, CK / CKMB /\n Troponin-T:210/8/0.05, Ca++:8.4 mg/dL, Mg++:1.8 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n 60 yo male admit with significant respiratory distress and now with\n Parainfluenza seen on viral screen as likely trigger and patient with\n slow move towards improvement but with persistent wheezes noted. He\n has tolerated wean of steroid Rx to baseline doses without clear\n worsening in respiratory status.\n 1)Respiratory Failure-_Persistent and signficant wheezes seen and worse\n than yesterday.\n -Recemic epi\n -Will increase steroid dosing given worsening from yesterday if durable\n response not seen from yesterday\n -Will need to move to intubation if clinical improvement not seen with\n epinephrine\n -With intubation will move to bronch and CT with evaluation needed\n -CXR this morning\n -Concerning worsening across time in regards to continued distress,\n limited capacity to perform further investigations.\n -He has worsening HCO3- and will need to evaluate for evidence of\n lactic acidosis which may result from respiratory distress\nwhich would\n be a n indicator for need for intubation and support\n -Need to achieve adequate stability for CT scan to evaluate airway\n lesions further\n 2)Hypertension-\n -Continue BP control with multiple medications and look to wean off of\n IV support\n 3)Renal Failure--S/P Transplant-\n -Continue with renal support\n -no change in medications.\n HYPERTENSION, BENIGN\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITHOUT ACUTE EXACERBATION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 10:00 AM\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Discussed with patient\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-14 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 675412,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Comments:\n Patient remains intubated and on mechanical ventilation, breath sounds\n bilaterally diminished, crackly at the bases, suctioned for moderate\n amount of thick yellow secretions, ABGs revealing of an acute metabolic\n acidosis with mild hypoxemia, CVVHD still running,treated with\n Albuterol , atrovent and Flovent inhalers, no distress occurred, will\n continues to be followed.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 675472,
"text": "Ineffective Coping\n Assessment:\n patients mother and her sister in to visit today\n Action:\n family spoke with MD regarding plans for surgery tomorrow\n MD answering questions\n Response:\n family questions answered and family voicing thankfulness for care of\n patient\n Plan:\n continue to support family and answer questions as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CRRT with normal acid base balance\n +blood clots with citrate infusing\n Action:\n CRRT continues\n replacement rate increased\n Response:\n blood clots still present\n acid base balance continues to be normal\n Plan:\n cont CRRT\n goal negative 1-2 L if patient tolerates\n question adding heparin to circuit after OR tomorrow if transplant\n surgery ok with this\n prime new circuit with heparin if circuit goes down\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n abd remains open with JP x2 to wall suction\n ileostomy pink\n borderline BP on neo\n preload numbers stating patient dry,\n hypotensive to 70\ns systolic, patient cont to deteriorate to co 3, CI\n 1.7, high SVR and all numbers appearing volume depleted,\n sr 80-90\ns with no ectopy\n Action:\n abd continues to drain serosang drainage\n neo titrated up accordingly to keep sys >90, patient bloused with 1 L\n D5 with 3 amps bicarb,\n echo done showing patient dry per fellow with possible poor\n contractility\n patient then bloused with plasmalyte\n CRRT changed to even\n Esmolol off\n Response:\n BP responding to ivf and able to wean neo when volume infusing\n Patient quickly drops BP again to 80\ns post ivf infused (appears\n patient is third spacing)\n HR to 110-120 with esmolol off, quickly back to 80\ns when turned back\n on md\n Plan:\n bolus with plasmalyte\n keep even with CRRT if tolerates\n question adding dobutamine if CO/CI numbers do not stay up after\n plasmalyte 1total\n follow labs\n OR in AM for washout and possible closure\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt opening eyes but not following commands\n Appears in deep sedation\n Initial Borderline hypotension\n Action:\n Fentanyl and versed weaned\n Response:\n Tachypnic to low 30\n Opening eyes, not following commands\n Using abd accessory muscles to breathe\n Remains hypotensive\n Fentanyl and versed back to starting doses\n Plan:\n Cont fentanyl and versed for sedation\n Assess use of accessory muscles and increase drips as needed\n See NCP\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-11 00:00:00.000",
"description": "Intensivist Note",
"row_id": 674298,
"text": "SICU\n HPI:\n Pt is a 60yo male who presents s/p exlap, SBR, open abd for ischemic\n bowel\n Chief complaint:\n hypotension\n PMHx:\n COPD, HTN, high chol, ESRD s/p CRT2002, baseline Cr-, DM 2, former\n smoker, hx of alcoholism, Coag negative staph right hip joint\n infection, chronic pain, prostate ca s/p radiation therapy in ,\n bilateral avascular necrosis\n Current medications:\n 20 gm Calcium Gluconate/ 500 mL D5W\n 9. Albuterol Inhaler 10. Calcium Chloride 11. Chlorhexidine Gluconate\n 0.12% Oral Rinse 12. Fentanyl Citrate\n 13. Fluticasone Propionate 110mcg 14. Heparin Flush (10 units/ml) 15.\n Heparin Flush (10 units/ml)\n 16. Hydrocortisone Na Succ. 17. Insulin 18. Ipratropium Bromide MDI 19.\n Magnesium Sulfate 20. MetRONIDAZOLE (FLagyl)\n 21. Mycophenolate Mofetil 22. Pantoprazole 23. Phenylephrine 24.\n Piperacillin-Tazobactam Na\n 26. Potassium Chloride 27. Prismasate (B32 K2)* 28. Prismasate (B32 K2)\n 29. Sodium Chloride 0.9% Flush\n 30. Sodium CITRATE 4% 31. Sodium Chloride 0.9% Flush 32. Sodium CITRATE\n 4% 33. Tacrolimus 34. Vancomycin\n 24 Hour Events:\n DIALYSIS CATHETER - START 05:35 PM\n Post operative day:\n POD#1 - expl lap\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:29 PM\n Piperacillin/Tazobactam (Zosyn) - 10:55 PM\n Metronidazole - 04:06 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Phenylephrine - 1.5 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 09:32 AM\n Other medications:\n Flowsheet Data as of 05:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 35.6\nC (96.1\n HR: 90 (87 - 106) bpm\n BP: 90/59(70) {77/47(58) - 198/94(134)} mmHg\n RR: 25 (22 - 29) insp/min\n SPO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111.4 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 9 (0 - 299) mmHg\n Total In:\n 16,582 mL\n 2,029 mL\n PO:\n Tube feeding:\n IV Fluid:\n 12,813 mL\n 1,106 mL\n Blood products:\n 3,669 mL\n 923 mL\n Total out:\n 2,817 mL\n 1,069 mL\n Urine:\n 353 mL\n 65 mL\n NG:\n 850 mL\n 350 mL\n Stool:\n Drains:\n 875 mL\n 500 mL\n Balance:\n 13,765 mL\n 960 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 23 cmH2O\n Plateau: 14 cmH2O\n Compliance: 92.3 cmH2O/mL\n SPO2: 89%\n ABG: 7.30/39/117/19/-6\n Ve: 15.1 L/min\n PaO2 / FiO2: 195\n Physical Examination\n General Appearance: intubated and sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : throughout bilaterally, Diminished: breath sounds at\n bases)\n Abdominal: Soft, abdominal wound left open\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact), open abomen\n Neurologic: (Responds to: Unresponsive), Sedated\n Labs / Radiology\n 95 K/uL\n 8.9 g/dL\n 59 mg/dL\n 3.8 mg/dL\n 19 mEq/L\n 5.8 mEq/L\n 63 mg/dL\n 107 mEq/L\n 133 mEq/L\n 26\n 21.9 K/uL\n [image002.jpg]\n 03:26 PM\n 05:50 PM\n 05:59 PM\n 08:17 PM\n 08:24 PM\n 10:36 PM\n 11:52 PM\n 02:34 AM\n 02:47 AM\n 04:48 AM\n WBC\n 19.3\n 21.3\n 21.9\n Hct\n 24\n 26.2\n 29\n 28.0\n 32\n 29\n 26\n 24.5\n 26\n Plt\n 108\n 107\n 95\n Creatinine\n 4.7\n 4.5\n 3.8\n Troponin T\n 0.04\n TCO2\n 20\n 20\n 22\n 21\n 20\n 21\n 20\n Glucose\n 134\n 166\n 153\n 131\n 102\n 81\n 83\n 59\n Other labs: PT / PTT / INR:21.9/52.5/2.1, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:1850/5333, Alk-Phos / T bili:219/7.1, Amylase\n / Lipase:831/21, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %,\n Mono:8.0 %, Eos:0.0 %, Fibrinogen:319 mg/dL, Lactic Acid:4.9 mmol/L,\n Albumin:1.8 g/dL, LDH: IU/L, Ca:7.8 mg/dL, Mg:2.3 mg/dL, PO4:8.5\n mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INEFFECTIVE COPING, INTESTINAL ISCHEMIA (INCLUDING MESENTERIC VENOUS /\n ARTERIAL THROMBOSIS, BOWEL ISCHEMIA), RENAL FAILURE, ACUTE (ACUTE RENAL\n FAILURE, ARF), HYPERTENSION, BENIGN, CHRONIC OBSTRUCTIVE PULMONARY\n DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION, CHRONIC\n OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITHOUT\n ACUTE EXACERBATION\n Assessment and Plan: Pt is a 60yo male who presents s/p exlap, SBR,\n open abd for ischemic bowel\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Restraints, pt not\n sedated and not moving, follow neuro exam, pain controlled with\n fentanyl drip\n Cardiovascular: hypotensive, requiring multiple fluid boluses and\n phenylephrine gtt to keep SBP>90mmHg\n Pulmonary: Cont ETT, (Ventilator mode: CMV), intubated on ventillator,\n CMV, cont flovent/atrovent/albuterol\n Gastrointestinal / Abdomen: open abdomen-to OR in am, PPI, NPO\n Nutrition: NPO\n Renal: Foley, CVVH, UOP low 20ml/hr, following lytes q6h, plasmalyte\n 100ml/hr\n Hematology: Serial Hct, monitor Hct, transfused rbcx4, pt\n coagulopathic-ffpx4 cont to monitor coags and CBC\n Endocrine: RISS, BS low this AM- given half amp of D50, continue to\n monitor\n Infectious Disease: treating c diff and pneumonia, cont zosyn, flagyl,\n vanc, check cultures, vanc level\n Lines / Tubes / Drains: Foley, NGT, ETT, aline, ett, foley, JPx2,\n central line, dialysis catheter\n Wounds: open abdomen covered with dry dressing\n Imaging: none planned\n Fluids: plasmalyte at 100ml/hr\n Consults: Transplant, Nephrology, endocrine\n Billing Diagnosis: (Respiratory distress: Failure), (Shock: Septic),\n Acute renal failure\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 04:50 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n Prophylaxis:\n DVT: (pt is coagulopathic)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "General",
"chartdate": "2104-06-12 00:00:00.000",
"description": "ICU Event Note",
"row_id": 674701,
"text": "Clinician: Attending\n I spoke with Dr. minutes ago about the code status of Mr.\n . The issue is that up until now Mr. mother -- the\n only known next of -- was making the decisions as far as medical\n management. It is a feeling of the entire medical staff -- Dr. \n and his team, nurses caring for Mr. and myself -- that Ms.\n is significantly forgetful and that she is having difficult\n understanding Ms. \n medical condition and act on his best\n interest.\n It is my experience with Ms. earlier this week that she was\n forgetful and changed her mind on the code status twice in a short\n time-span. When I initially met her in the patient\ns room and\n introduced myself, she expressed her wishes to make him DNR. However,\n roughly two hours later when I had a family meeting with them, she was\n surprised to learn that his code status was DNR and she said that she\n didn\nt understand why, as she wanted everything done for him. This and\n other interactions with her by the medical team, including today when\n she called Dr. from the surgical team and telling him that she\n wants to change the code status to DNR and 5 minutes after this\n discussion with him calling again and asking for Dr. , led me, RN\n ( ), and Dr. believe that Ms. cannot\n represent \n interests and that we should look for\n alternative legal guardian. no documentation in our records that\n she is the official HCP (only by nature of next of ), and that Mr.\n discussed his code status with the medical team caring for him\n in the on the 6^th (please see note, saying\nCode status: Full\n code (discussed with patient and confirmed Full Code today by Dr.\n \n, we will not change the code to DNR at this point and\n respect the patients last known wishes for full code.\n I also discussed this with the legal team\n Mr. at extension\n \n and he agreed with this decision. Per Mr. , if there is no\n documentation of Ms. as the official HCP and the patient chose\n to be full code, we should follow his last known wishes. In addition,\n we consulted ethics and working with social worker in hopefully\n identifying an appropriate legal guardian.\n Time spent: 65 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 674214,
"text": "Tube Type\n ETT:\n Position: 27 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: pt remains orally intubated,\n transferred from east ICU to SICU w/out complication, paralytics on,\n not overbreathing set rate, plan to take paralytics off.\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Not triggering\n"
},
{
"category": "Nutrition",
"chartdate": "2104-06-11 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 674420,
"text": "Objective\n Current Wt: 111.4kg\n Adm Wt: 91.7kg\n Pertinent medications: Fentanyl, Phenylephrine, ABx, RISS,Colace,\n lactulose, others noted\n Labs:\n Value\n Date\n Glucose\n 72 mg/dL\n 10:08 AM\n Glucose Finger Stick\n 91\n 11:00 AM\n BUN\n 56 mg/dL\n 08:39 AM\n Creatinine\n 3.5 mg/dL\n 08:39 AM\n Sodium\n 129 mEq/L\n 10:08 AM\n Potassium\n 5.9 mEq/L\n 10:08 AM\n Chloride\n 100 mEq/L\n 10:08 AM\n TCO2\n 19 mEq/L\n 08:39 AM\n PO2 (arterial)\n 122 mm Hg\n 11:24 AM\n PO2 (venous)\n 35 mm Hg\n 03:48 AM\n PCO2 (arterial)\n 37 mm Hg\n 11:24 AM\n PCO2 (venous)\n 39 mm Hg\n 03:48 AM\n pH (arterial)\n 7.36 units\n 11:24 AM\n pH (venous)\n 7.31 units\n 03:48 AM\n pH (urine)\n 5.5 units\n 11:28 AM\n CO2 (Calc) arterial\n 22 mEq/L\n 11:24 AM\n CO2 (Calc) venous\n 21 mEq/L\n 03:48 AM\n Albumin\n 1.8 g/dL\n 05:50 PM\n Calcium non-ionized\n 8.0 mg/dL\n 08:39 AM\n Phosphorus\n 7.6 mg/dL\n 08:39 AM\n Ionized Calcium\n 1.04 mmol/L\n 10:08 AM\n Magnesium\n 2.0 mg/dL\n 08:39 AM\n ALT\n 1850 IU/L\n 02:34 AM\n Alkaline Phosphate\n 219 IU/L\n 02:34 AM\n AST\n 5333 IU/L\n 02:34 AM\n Amylase\n 831 IU/L\n 06:09 AM\n Total Bilirubin\n 7.1 mg/dL\n 02:34 AM\n WBC\n 20.1 K/uL\n 08:39 AM\n Hgb\n 8.2 g/dL\n 08:39 AM\n Hematocrit\n 24\n 10:08 AM\n Current diet order / nutrition support: Diet: NPO\n GI: Abd firm, absent bowel sounds, 850cc OGT o/p \n Assessment of Nutritional Status\n 60 y.o. M with ESRD admitted with COPD/respiratory distress, found to\n have ischemic bowel, now s/p ex lap and SBR . Abdomen left open.\n Patient was taken back to OR today for hematoma; abdomen left open with\n possible return to OR tomorrow for closure. Patient is currently NPO,\n intubated, sedated and on pressor support. CVVHD started .\n Patient has been NPO for ~9days, thus recommend starting nutrition\n support within the next 24-48hrs. Patient will likely need TPN\n initially until bowel function returns; will provide recommendations\n below.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) If TPN started, rec start with Day 1 standard with lytes per\n daily chem. 10.\n 2) If Day 1 is tolerated without hyperglycemia, advance to Day 2\n standard.\n 3) Check Triglycerides, if less than 400, ok to add lipid to TPN.\n 4) Advance TPN (on Day 3) to 2060mL (310dextrose/115amino acid/\n 50fat).\n 5) Goal TPN to be 2060mL (390dextrose/ 115amino acid/ 50fat) =\n 2286kcals.\n 6) Continue with FSBG, cover with RISS as needed.\n 7) Following, please page with any questions #\n 12:15\n"
},
{
"category": "Nutrition",
"chartdate": "2104-06-11 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 674421,
"text": "Objective\n Current Wt: 111.4kg\n Adm Wt: 91.7kg\n Pertinent medications: Fentanyl, Phenylephrine, ABx, RISS,Colace,\n lactulose, others noted\n Labs:\n Value\n Date\n Glucose\n 72 mg/dL\n 10:08 AM\n Glucose Finger Stick\n 91\n 11:00 AM\n BUN\n 56 mg/dL\n 08:39 AM\n Creatinine\n 3.5 mg/dL\n 08:39 AM\n Sodium\n 129 mEq/L\n 10:08 AM\n Potassium\n 5.9 mEq/L\n 10:08 AM\n Chloride\n 100 mEq/L\n 10:08 AM\n TCO2\n 19 mEq/L\n 08:39 AM\n PO2 (arterial)\n 122 mm Hg\n 11:24 AM\n PO2 (venous)\n 35 mm Hg\n 03:48 AM\n PCO2 (arterial)\n 37 mm Hg\n 11:24 AM\n PCO2 (venous)\n 39 mm Hg\n 03:48 AM\n pH (arterial)\n 7.36 units\n 11:24 AM\n pH (venous)\n 7.31 units\n 03:48 AM\n pH (urine)\n 5.5 units\n 11:28 AM\n CO2 (Calc) arterial\n 22 mEq/L\n 11:24 AM\n CO2 (Calc) venous\n 21 mEq/L\n 03:48 AM\n Albumin\n 1.8 g/dL\n 05:50 PM\n Calcium non-ionized\n 8.0 mg/dL\n 08:39 AM\n Phosphorus\n 7.6 mg/dL\n 08:39 AM\n Ionized Calcium\n 1.04 mmol/L\n 10:08 AM\n Magnesium\n 2.0 mg/dL\n 08:39 AM\n ALT\n 1850 IU/L\n 02:34 AM\n Alkaline Phosphate\n 219 IU/L\n 02:34 AM\n AST\n 5333 IU/L\n 02:34 AM\n Amylase\n 831 IU/L\n 06:09 AM\n Total Bilirubin\n 7.1 mg/dL\n 02:34 AM\n WBC\n 20.1 K/uL\n 08:39 AM\n Hgb\n 8.2 g/dL\n 08:39 AM\n Hematocrit\n 24\n 10:08 AM\n Current diet order / nutrition support: Diet: NPO\n GI: Abd firm, absent bowel sounds, 850cc OGT o/p \n Assessment of Nutritional Status\n 60 y.o. M with ESRD admitted with COPD/respiratory distress, found to\n have ischemic bowel, now s/p ex lap and SBR . Abdomen left open.\n Patient was taken back to OR today for hematoma; abdomen left open with\n possible return to OR tomorrow for closure. Patient is currently NPO,\n intubated, sedated and on pressor support. CVVHD started .\n Patient has been NPO for ~9days, thus recommend starting nutrition\n support within the next 24-48hrs. Patient will likely need TPN\n initially until bowel function returns; will provide recommendations\n below.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) If TPN started, rec start with Day 1 standard with lytes per\n daily chem. 10.\n 2) If Day 1 is tolerated without hyperglycemia, advance to Day 2\n standard.\n 3) Check Triglycerides, if less than 400, ok to add lipid to TPN.\n 4) Advance TPN (on Day 3) to 2060mL (310dextrose/115amino acid/\n 50fat).\n 5) Goal TPN to be 2060mL (390dextrose/ 115amino acid/ 50fat) =\n 2286kcals.\n 6) Continue with FSBG, cover with RISS as needed.\n 7) Following, please page with any questions #\n 12:15\n ------ Protected Section ------\n Agree with above note.\n #\n ------ Protected Section Addendum Entered By: , RD, \n on: 12:16 ------\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-11 00:00:00.000",
"description": "Intensivist Note",
"row_id": 674426,
"text": "SICU\n HPI:\n Pt is a 60yo male who presents s/p exlap, SBR, open abd for ischemic\n bowel\n Chief complaint:\n hypotension\n PMHx:\n COPD, HTN, high chol, ESRD s/p CRT2002, baseline Cr-, DM 2, former\n smoker, hx of alcoholism, Coag negative staph right hip joint\n infection, chronic pain, prostate ca s/p radiation therapy in ,\n bilateral avascular necrosis\n Current medications:\n 20 gm Calcium Gluconate/ 500 mL D5W\n 9. Albuterol Inhaler 10. Calcium Chloride 11. Chlorhexidine Gluconate\n 0.12% Oral Rinse 12. Fentanyl Citrate\n 13. Fluticasone Propionate 110mcg 14. Heparin Flush (10 units/ml) 15.\n Heparin Flush (10 units/ml)\n 16. Hydrocortisone Na Succ. 17. Insulin 18. Ipratropium Bromide MDI 19.\n Magnesium Sulfate 20. MetRONIDAZOLE (FLagyl)\n 21. Mycophenolate Mofetil 22. Pantoprazole 23. Phenylephrine 24.\n Piperacillin-Tazobactam Na\n 26. Potassium Chloride 27. Prismasate (B32 K2)* 28. Prismasate (B32 K2)\n 29. Sodium Chloride 0.9% Flush\n 30. Sodium CITRATE 4% 31. Sodium Chloride 0.9% Flush 32. Sodium CITRATE\n 4% 33. Tacrolimus 34. Vancomycin\n 24 Hour Events:\n DIALYSIS CATHETER - START 05:35 PM\n Post operative day:\n POD#1 - expl lap\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:29 PM\n Piperacillin/Tazobactam (Zosyn) - 10:55 PM\n Metronidazole - 04:06 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Phenylephrine - 1.5 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 09:32 AM\n Other medications:\n Flowsheet Data as of 05:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 35.6\nC (96.1\n HR: 90 (87 - 106) bpm\n BP: 90/59(70) {77/47(58) - 198/94(134)} mmHg\n RR: 25 (22 - 29) insp/min\n SPO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111.4 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 9 (0 - 299) mmHg\n Total In:\n 16,582 mL\n 2,029 mL\n PO:\n Tube feeding:\n IV Fluid:\n 12,813 mL\n 1,106 mL\n Blood products:\n 3,669 mL\n 923 mL\n Total out:\n 2,817 mL\n 1,069 mL\n Urine:\n 353 mL\n 65 mL\n NG:\n 850 mL\n 350 mL\n Stool:\n Drains:\n 875 mL\n 500 mL\n Balance:\n 13,765 mL\n 960 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 23 cmH2O\n Plateau: 14 cmH2O\n Compliance: 92.3 cmH2O/mL\n SPO2: 89%\n ABG: 7.30/39/117/19/-6\n Ve: 15.1 L/min\n PaO2 / FiO2: 195\n Physical Examination\n General Appearance: intubated and sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : throughout bilaterally, Diminished: breath sounds at\n bases)\n Abdominal: Soft, abdominal wound left open\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact), open abomen\n Neurologic: (Responds to: Unresponsive), Sedated\n Labs / Radiology\n 95 K/uL\n 8.9 g/dL\n 59 mg/dL\n 3.8 mg/dL\n 19 mEq/L\n 5.8 mEq/L\n 63 mg/dL\n 107 mEq/L\n 133 mEq/L\n 26\n 21.9 K/uL\n [image002.jpg]\n 03:26 PM\n 05:50 PM\n 05:59 PM\n 08:17 PM\n 08:24 PM\n 10:36 PM\n 11:52 PM\n 02:34 AM\n 02:47 AM\n 04:48 AM\n WBC\n 19.3\n 21.3\n 21.9\n Hct\n 24\n 26.2\n 29\n 28.0\n 32\n 29\n 26\n 24.5\n 26\n Plt\n 108\n 107\n 95\n Creatinine\n 4.7\n 4.5\n 3.8\n Troponin T\n 0.04\n TCO2\n 20\n 20\n 22\n 21\n 20\n 21\n 20\n Glucose\n 134\n 166\n 153\n 131\n 102\n 81\n 83\n 59\n Other labs: PT / PTT / INR:21.9/52.5/2.1, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:1850/5333, Alk-Phos / T bili:219/7.1, Amylase\n / Lipase:831/21, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %,\n Mono:8.0 %, Eos:0.0 %, Fibrinogen:319 mg/dL, Lactic Acid:4.9 mmol/L,\n Albumin:1.8 g/dL, LDH: IU/L, Ca:7.8 mg/dL, Mg:2.3 mg/dL, PO4:8.5\n mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INEFFECTIVE COPING, INTESTINAL ISCHEMIA (INCLUDING MESENTERIC VENOUS /\n ARTERIAL THROMBOSIS, BOWEL ISCHEMIA), RENAL FAILURE, ACUTE (ACUTE RENAL\n FAILURE, ARF), HYPERTENSION, BENIGN, CHRONIC OBSTRUCTIVE PULMONARY\n DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION, CHRONIC\n OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITHOUT\n ACUTE EXACERBATION\n Assessment and Plan: Pt is a 60yo male who presents s/p exlap, SBR,\n open abd for ischemic bowel\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Restraints, pt not\n sedated and not moving, follow neuro exam, pain controlled with\n fentanyl drip\n Cardiovascular: septic shock. hypotensive, requiring multiple fluid\n boluses and phenylephrine gtt to keep SBP>90mmHg\n Pulmonary: Cont ETT,\n (Ventilator mode: CMV), intubated on ventillator, CMV, cont\n flovent/atrovent/albuterol\n Gastrointestinal / Abdomen: open abdomen-to OR this am, PPI, NPO\n Nutrition: NPO\n Renal: hyperkalemia controlled. Foley, CVVH, UOP low 20ml/hr, following\n lytes q6h, plasmalyte 100ml/hr\n Hematology: Serial Hct, monitor Hct, transfused rbcx4, pt\n coagulopathic-ffpx4 cont to monitor coags and CBC\n Endocrine: RISS, hypoglycemic\n BS low this AM- given half amp of D50,\n continue to monitor\n Infectious Disease: treating c diff and pneumonia, cont zosyn, flagyl,\n vanc, check cultures, vanc level\n Lines / Tubes / Drains: Foley, NGT, ETT, aline, ett, foley, JPx2,\n central line, dialysis catheter\n Wounds: open abdomen covered with dry dressing\n Imaging: none planned\n Fluids: plasmalyte at 100ml/hr\n Consults: Transplant, Nephrology, endocrine\n Billing Diagnosis: (Respiratory distress: Failure), (Shock: Septic),\n Acute renal failure\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 04:50 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n Prophylaxis:\n DVT: (pt is coagulopathic)\n Stress ulcer: PPI\n switch to H2 blocker as no clear indication from\n PMHx, and patient has C-diff\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU. Will discuss plan with team postop.\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-12 00:00:00.000",
"description": "Intensivist Note",
"row_id": 674574,
"text": "HPI:\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n Post operative day:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Respiratory support\n Physical Examination\n Labs / Radiology\n [image002.jpg]\n WBC\n Hct\n Plt\n Creatinine\n Troponin T\n TCO2\n Glucose\n Imaging:\n Microbiology:\n ECG:\n Assessment and Plan\n Assessment and Plan:\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 675467,
"text": "Ineffective Coping\n Assessment:\n patients mother and her sister in to visit today\n Action:\n family spoke with MD regarding plans for surgery tomorrow\n MD answering questions\n Response:\n family questions answered and family voicing thankfulness for care of\n patient\n Plan:\n continue to support family and answer questions as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CRRT with normal acid base balance\n +blood clots with citrate infusing\n Action:\n CRRT continues\n replacement rate increased\n Response:\n blood clots still present\n acid base balance continues to be normal\n Plan:\n cont CRRT\n goal negative 1-2 L if patient tolerates\n question adding heparin to circuit after OR tomorrow if transplant\n surgery ok with this\n prime new circuit with heparin if circuit goes down\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n abd remains open with JP x2 to wall suction\n ileostomy pink\n borderline BP on neo\n preload numbers stating patient dry,\n hypotensive to 70\ns systolic, patient cont to deteriorate to co 3, CI\n 1.7, high SVR and all numbers appearing volume depleted,\n sr 80-90\ns with no ectopy\n Action:\n abd continues to drain serosang drainage\n neo titrated up accordingly to keep sys >90, patient bloused with 1 L\n D5 with 3 amps bicarb,\n echo done showing patient dry per fellow with possible poor\n contractility\n patient then bloused with plasmalyte\n CRRT changed to even\n Esmolol off\n Response:\n BP responding to ivf and able to wean neo when volume infusing\n Patient quickly drops BP again to 80\ns post ivf infused (appears\n patient is third spacing)\n HR to 110-120 with esmolol off, quickly back to 80\ns when turned back\n on md\n Plan:\n bolus with plasmalyte\n keep even with CRRT if tolerates\n question adding dobutamine if CO/CI numbers do not stay up after\n plasmalyte 1total\n follow labs\n OR in AM for washout and possible closure\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt opening eyes but not following commands\n Appears in deep sedation\n Initial Borderline hypotension\n Action:\n Fentanyl and versed weaned\n Response:\n Tachypnic to low 30\n Opening eyes, not following commands\n Using abd accessory muscles to breathe\n Remains hypotensive\n Fentanyl and versed back to starting doses\n Plan:\n Cont fentanyl and versed for sedation\n Assess use of accessory muscles and increase drips as needed\n See NCP\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-10 00:00:00.000",
"description": "MICU staff progress note",
"row_id": 674192,
"text": "TITLE: MICU ATTNEDING PROGRESS NOTE\n I saw and examined the patient and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n Yesterday with concern for worsening abd distention and slightly\n increasing lactates-->KUB obtained\n concerning for SBO for which\n surgical c/s called. CT abd then showed pneumotosis\n taken to OR for\n ex lap with SBR for necrotic gut.\n Oernight to have methemoglobinemia --> methylene blue given prior\n to OR.\n Exam notable for Tm AF BP 91/55 HR 90's 600/24/5/60%-->7.29/37/163,\n 7.25/42/274\n Intubated and sedated, coarse BS, RR, decreased BS, open abd dressed,\n drains in place, no preipheral edema, warm ext, decreased distal pulses\n Labs reviewed: notable for transminitis 13,000/ WBC18.8 K, HCT 24,\n chem 7-pending INR 2\n Micro--c diff pos \n PSA in sputum \n bl ngtd\n A/P: 60 yo M with COPD, immunosupressed s/p renal transplant admitted\n with progressive resp distress requiring intubation, parainfleunza +,\n significant expiratory limitation and ventilatory defect concerning for\n possibility of contribution from TBM or small airways reactivity,\n developed progressive shock/hypotension with pressor requirement,\n severe metabolic + resp acidosis, ARF on CRI, vap and now s/p ex lap\n with SBR for necrotic bowel\n # hypotension/shock\n septic shock\n necrotic bowel post resection\n component of adrenal insuf in immunosupressed host\n ---Continue aggressive IVF to maintain cvp > 10\n --Transfuse blood to goal hct > 30\n --Able to wean pressors off post OR but now w/ recurrent hypotension-->\n resume pressors as needed to maintain MAPs > 60 (on low dose neo)\n --continue stress steroids\n --continue broad antbx--vanco/zosyn/flagyl for bowel/vap\n # transminitis\n c/w shock liver--trend lfts\n monitor INR\n follow DIC labs/fibrinogen\n #ischemic bowel post resection\n transferring to surgical service for post-op management\n follow Q 6 hr hct\n monitor plt and coags\n follow i ca\n # c diff infection\n continue flagyl IV\n # resp failure\n copd, small airways ds, with parainfluenza, and developing b/l lower\n zone infiltrates with gnr in sputum concerning for HPA/VAP now growing\n PSA in sputum\n --continue ACV support, oxygenation adequate on 60% Fio2\n --continue broad coverage as above and f/ on PSA\n --continue MDIs\n #Hyperk--\n ARF, transfusions may further worsen this\n temporize with ins, glu, bicarb\n renal following--> moving toward cvvh\n # Acute renal failure on CRI--now anuric\n continue supportive care with aggressive fluids, blood, pressors\n cvvh-d/w renal\n renal transplant meds/dosing\n Prognosis remains extremely poor with multiorgan system failure.\n Continue to address goals of care with family.\n Need to clarify post op code status with surgical team/family as pt had\n been made DNR yesterday rpior to OR.\n Remainder as per resident note\n Patient is critically ill\n Total time: 50 min\n"
},
{
"category": "General",
"chartdate": "2104-06-12 00:00:00.000",
"description": "ICU Event Note",
"row_id": 674693,
"text": "Clinician: Attending\n I spoke with Dr. minutes ago about the code status of Mr.\n . The issue is that up until now Mr. mother -- the\n only known next of -- was making the decisions as far as medical\n management. It is a feeling of the entire medical staff -- Dr. \n and his team, nurses caring for Mr. and myself -- that Ms.\n is significantelly forgetfull and that she is having\n difficult understanding the medical condition.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 675403,
"text": "Ineffective Coping\n Assessment:\n patients mother and her sister in to visit today\n Action:\n family spoke with MD regarding plans for surgery tomorrow\n MD answering questions\n Response:\n family questions answered and family voicing thankfulness for care of\n patient\n Plan:\n continue to support family and answer questions as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CRRT with normal acid base balance\n +blood clots with citrate infusing\n Action:\n CRRT continues\n replacement rate increased\n Response:\n blood clots still present\n acid base balance continues to be normal\n Plan:\n cont CRRT\n goal negative 1-2 L if patient tolerates\n question adding heparin to circuit after OR tomorrow if transplant\n surgery ok with this\n prime new circuit with heparin if circuit goes down\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n abd remains open with JP x2 to wall suction\n ileostomy pink\n borderline BP on neo\n preload numbers stating patient dry,\n hypotensive to 70\ns systolic\n Action:\n abd continues to drain serosang drainage\n neo titrated up accordingly to keep sys >90\n bolused via CRRT circuit with hypotension\n Response:\n BP responding to ivf.\n Plan:\n bolus with bicarb for hypotension per primary team\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-11 00:00:00.000",
"description": "Intensivist Note",
"row_id": 674390,
"text": "SICU\n HPI:\n Pt is a 60yo male who presents s/p exlap, SBR, open abd for ischemic\n bowel\n Chief complaint:\n hypotension\n PMHx:\n COPD, HTN, high chol, ESRD s/p CRT2002, baseline Cr-, DM 2, former\n smoker, hx of alcoholism, Coag negative staph right hip joint\n infection, chronic pain, prostate ca s/p radiation therapy in ,\n bilateral avascular necrosis\n Current medications:\n 20 gm Calcium Gluconate/ 500 mL D5W\n 9. Albuterol Inhaler 10. Calcium Chloride 11. Chlorhexidine Gluconate\n 0.12% Oral Rinse 12. Fentanyl Citrate\n 13. Fluticasone Propionate 110mcg 14. Heparin Flush (10 units/ml) 15.\n Heparin Flush (10 units/ml)\n 16. Hydrocortisone Na Succ. 17. Insulin 18. Ipratropium Bromide MDI 19.\n Magnesium Sulfate 20. MetRONIDAZOLE (FLagyl)\n 21. Mycophenolate Mofetil 22. Pantoprazole 23. Phenylephrine 24.\n Piperacillin-Tazobactam Na\n 26. Potassium Chloride 27. Prismasate (B32 K2)* 28. Prismasate (B32 K2)\n 29. Sodium Chloride 0.9% Flush\n 30. Sodium CITRATE 4% 31. Sodium Chloride 0.9% Flush 32. Sodium CITRATE\n 4% 33. Tacrolimus 34. Vancomycin\n 24 Hour Events:\n DIALYSIS CATHETER - START 05:35 PM\n Post operative day:\n POD#1 - expl lap\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:29 PM\n Piperacillin/Tazobactam (Zosyn) - 10:55 PM\n Metronidazole - 04:06 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Phenylephrine - 1.5 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 09:32 AM\n Other medications:\n Flowsheet Data as of 05:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 35.6\nC (96.1\n HR: 90 (87 - 106) bpm\n BP: 90/59(70) {77/47(58) - 198/94(134)} mmHg\n RR: 25 (22 - 29) insp/min\n SPO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111.4 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 9 (0 - 299) mmHg\n Total In:\n 16,582 mL\n 2,029 mL\n PO:\n Tube feeding:\n IV Fluid:\n 12,813 mL\n 1,106 mL\n Blood products:\n 3,669 mL\n 923 mL\n Total out:\n 2,817 mL\n 1,069 mL\n Urine:\n 353 mL\n 65 mL\n NG:\n 850 mL\n 350 mL\n Stool:\n Drains:\n 875 mL\n 500 mL\n Balance:\n 13,765 mL\n 960 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 23 cmH2O\n Plateau: 14 cmH2O\n Compliance: 92.3 cmH2O/mL\n SPO2: 89%\n ABG: 7.30/39/117/19/-6\n Ve: 15.1 L/min\n PaO2 / FiO2: 195\n Physical Examination\n General Appearance: intubated and sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : throughout bilaterally, Diminished: breath sounds at\n bases)\n Abdominal: Soft, abdominal wound left open\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact), open abomen\n Neurologic: (Responds to: Unresponsive), Sedated\n Labs / Radiology\n 95 K/uL\n 8.9 g/dL\n 59 mg/dL\n 3.8 mg/dL\n 19 mEq/L\n 5.8 mEq/L\n 63 mg/dL\n 107 mEq/L\n 133 mEq/L\n 26\n 21.9 K/uL\n [image002.jpg]\n 03:26 PM\n 05:50 PM\n 05:59 PM\n 08:17 PM\n 08:24 PM\n 10:36 PM\n 11:52 PM\n 02:34 AM\n 02:47 AM\n 04:48 AM\n WBC\n 19.3\n 21.3\n 21.9\n Hct\n 24\n 26.2\n 29\n 28.0\n 32\n 29\n 26\n 24.5\n 26\n Plt\n 108\n 107\n 95\n Creatinine\n 4.7\n 4.5\n 3.8\n Troponin T\n 0.04\n TCO2\n 20\n 20\n 22\n 21\n 20\n 21\n 20\n Glucose\n 134\n 166\n 153\n 131\n 102\n 81\n 83\n 59\n Other labs: PT / PTT / INR:21.9/52.5/2.1, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:1850/5333, Alk-Phos / T bili:219/7.1, Amylase\n / Lipase:831/21, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %,\n Mono:8.0 %, Eos:0.0 %, Fibrinogen:319 mg/dL, Lactic Acid:4.9 mmol/L,\n Albumin:1.8 g/dL, LDH: IU/L, Ca:7.8 mg/dL, Mg:2.3 mg/dL, PO4:8.5\n mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INEFFECTIVE COPING, INTESTINAL ISCHEMIA (INCLUDING MESENTERIC VENOUS /\n ARTERIAL THROMBOSIS, BOWEL ISCHEMIA), RENAL FAILURE, ACUTE (ACUTE RENAL\n FAILURE, ARF), HYPERTENSION, BENIGN, CHRONIC OBSTRUCTIVE PULMONARY\n DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION, CHRONIC\n OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITHOUT\n ACUTE EXACERBATION\n Assessment and Plan: Pt is a 60yo male who presents s/p exlap, SBR,\n open abd for ischemic bowel\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Restraints, pt not\n sedated and not moving, follow neuro exam, pain controlled with\n fentanyl drip\n Cardiovascular: septic shock. hypotensive, requiring multiple fluid\n boluses and phenylephrine gtt to keep SBP>90mmHg\n Pulmonary: Cont ETT,\n (Ventilator mode: CMV), intubated on ventillator, CMV, cont\n flovent/atrovent/albuterol\n Gastrointestinal / Abdomen: open abdomen-to OR this am, PPI, NPO\n Nutrition: NPO\n Renal: hyperkalemia controlled. Foley, CVVH, UOP low 20ml/hr, following\n lytes q6h, plasmalyte 100ml/hr\n Hematology: Serial Hct, monitor Hct, transfused rbcx4, pt\n coagulopathic-ffpx4 cont to monitor coags and CBC\n Endocrine: RISS, hypoglycemic\n BS low this AM- given half amp of D50,\n continue to monitor\n Infectious Disease: treating c diff and pneumonia, cont zosyn, flagyl,\n vanc, check cultures, vanc level\n Lines / Tubes / Drains: Foley, NGT, ETT, aline, ett, foley, JPx2,\n central line, dialysis catheter\n Wounds: open abdomen covered with dry dressing\n Imaging: none planned\n Fluids: plasmalyte at 100ml/hr\n Consults: Transplant, Nephrology, endocrine\n Billing Diagnosis: (Respiratory distress: Failure), (Shock: Septic),\n Acute renal failure\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 04:50 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n Prophylaxis:\n DVT: (pt is coagulopathic)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU. Will discuss plan with team postop.\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 674284,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 7\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 27 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing, High\n flow demand; Comments: Pt requiring large MV to keep PCO2 near 40.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Pending procedure /\n OR, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674356,
"text": "TITLE:\n Hypotension (not Shock)\n Assessment:\n 105 at begin of shift w low sbp 70-130\ns w transient hypertension\n with fld volume resuscitation, Neo gtt . cvp 7-10 range\n Action:\n Multiple 500c (x5)crystalloid boluses for low sbp and cvp. Ca chloride\n x4gm overnight in addition to Ca Gluconate drip for crrt\n Response:\n Persistent periods of hypotension despite crystalloid boluses\n 2.5lters. Prbc x2 and ffp x 2 for coag correction, decreased hct and\n colloid resuscitation with improved bp response- less frequent bouts of\n hypotension after colloid. Neo remains on at 1.5-2mcg/kg/min.Plasmalyte\n maintainence fluid at 100cc/hr.\n Plan:\n Titrate neo to sbp > 90 , notify ho if pt requires > 5mcg./kg/min neo .\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Abd open with jp drains to wall suction w lg amts of sanguinous\n drainage.Metabolic acidosis w lactate 3-.8 -4.9. NaHCO3 gtt infusing\n until crrt initiated.\n Action:\n Crystalloid and colloid Fld boluses as noted above. Crrt b32k2.\n repleted w prbc and ffp for low hct and elevated coags.Trending lft\n Response:\n No appreciable bump in hct after prbc.Metabolic acidosis persists\n despite crrt and fld boluses. Lfts\n trending down slightly, coags\n remain elevated, Dr aware of all lab values overnight.\n Plan:\n Pt scheduled to return to O.R. today. Continue to follow labs as\n ordered q6h while on crrt. Rx elevated coags with ffp.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Hyperkalemia, bun/creat elevated, scant amts of green urine (methylene\n blue preop).\n Action:\n Labs q1-2h overnight, Ca gluconate titrated per sliding scale .Crrt B32\n K2 goal- no fluid removal overnight.\n Response:\n Transient improvement in serum K+. Crrt running well, no additional\n fluid removed overnight.\n Plan:\n Continue crrt to for hyperkalemia, elevated bun/creat.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674358,
"text": "TITLE: Pt is a 60yo male who presents s/p exlap, SBR, open abd for\n ischemic bowel c/b hypotension.\n PMHx:\n COPD, HTN, high chol, ESRD s/p CRT2002, baseline Cr-, DM 2, former\n smoker, hx of alcoholism, Coag negative staph right hip joint\n infection, chronic pain, prostate ca s/p radiation therapy in ,\n bilateral avascular necrosis\n Hypotension (not Shock)\n Assessment:\n 105 at begin of shift w low sbp 70-130\ns w transient hypertension\n with fld volume resuscitation, Neo gtt . cvp 7-10 range\n Action:\n Multiple 500c (x5)crystalloid boluses for low sbp and cvp. Ca chloride\n x4gm overnight in addition to Ca Gluconate drip for crrt\n Response:\n Persistent periods of hypotension despite crystalloid boluses\n 2.5lters. Prbc x2 and ffp x 2 for coag correction, decreased hct and\n colloid resuscitation with improved bp response- less frequent bouts of\n hypotension after colloid. Neo remains on at 1.5-2mcg/kg/min.Plasmalyte\n maintainence fluid at 100cc/hr.\n Plan:\n Titrate neo to sbp > 90 , notify ho if pt requires > 5mcg./kg/min neo .\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Abd open with jp drains to wall suction w lg amts of sanguinous\n drainage.Metabolic acidosis w lactate 3-.8 -4.9. NaHCO3 gtt infusing\n until crrt initiated.Ogt w copious amts of thick bilious drainage. Abd\n distended, firm, no active bowel sounds, steridrape over open abd w mod\n serosang drainage.\n Action:\n Crystalloid and colloid Fld boluses as noted above. Crrt b32k2.\n repleted w prbc and ffp for low hct and elevated coags.Trending lft\n Received tacrolimus sublingual per orders. Am tacro level done prior to\n a.m. dose.\n Response:\n No appreciable bump in hct after prbc. Metabolic acidosis persists\n despite crrt and fld boluses. Lfts\n trending down slightly, coags\n remain elevated, Dr aware of all lab values overnight.\n Plan:\n Pt scheduled to return to O.R. today. Continue to follow labs as\n ordered q6h while on crrt. Rx elevated coags with ffp.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Hyperkalemia, bun/creat elevated, scant amts of green urine (methylene\n blue preop).\n Action:\n Labs q1-2h overnight, Ca gluconate titrated per sliding scale .Crrt B32\n K2 goal- no fluid removal overnight.\n Response:\n Transient improvement in serum K+. Crrt running well, no additional\n fluid removed overnight.\n Plan:\n Continue crrt to for hyperkalemia, elevated bun/creat.\n"
},
{
"category": "General",
"chartdate": "2104-06-12 00:00:00.000",
"description": "ICU Event Note",
"row_id": 674691,
"text": "Clinician: Attending\n I just finished a conversation with Mr. mother who is the\n next of and was making the decision up until now. Ms. \nyed to me her wishes to change the code status to DNR and also\n said that she did not want any more surgeries. I explained to her that\n given the magnitude of this decision and that it is an irreversible\n process, and the fact that she felt very strongly two days ago in our\n face-to-face conversation to have everything done to save Mr. ,\n I request that she come here with all family available and have another\n face-to face conversation so we can explain to her and the family his\n medical condition and understand exactly what her wishes are.\n Total time spent: 10 minutes\n Patient is critically ill.\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-15 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 675536,
"text": "Demographics\n Day of intubation: 11\n Day of mechanical ventilation: 11\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL / Air\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Crackles\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Nasal flaring, Gasping efforts,\n High flow demand\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Vigorous inspiratory efforts, Erratic exhaled\n Tidal Volumes\n COMMENTS:\n : Patient has increased WOB, nasal flaring. Progressively becoming\n more hypoxic this AM. Attempted to increase peep, but did not\n tolerate--BP dropped from 90's to 70's immediately and came up just as\n fast when peep removed. Increased FiO2.\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-10 00:00:00.000",
"description": "Resident Progress Note- MICU",
"row_id": 674267,
"text": "Chief Complaint:\n 24 Hour Events:\n -2200 labs notable for increasing lactate. CVP also falling-->NS\n boluses\n -O2 Sat low although PaO2 OK. Methemoglobin elevated at 10%-->12%.\n Concern that this may be contributing to poor O2 delivery and rising\n lactate. Thus, treated with methylene blue.\n -advanced ET tube by 4 cm (has been too high for several days)\n -distended abdomen and constipated x 6 days: KUB showed likely SBO.\n Surgery was consulted and recommended CT with PO contrast, which showed\n pneumatosis. Surgery took him to the OR and resected all but ~60 cm of\n small bowel that was necrotic.\n -c-diff positive-->started IV flagyl\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:59 PM\n Metronidazole - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:02 AM\n Sodium Bicarbonate 8.4% (Amp) - 12:56 PM\n Heparin Sodium (Prophylaxis) - 11:42 PM\n Insulin - Regular - 12:30 AM\n Dextrose 50% - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 35.3\nC (95.6\n HR: 99 (91 - 118) bpm\n BP: 109/58(76) {76/52(60) - 172/86(117)} mmHg\n RR: 22 (22 - 35) insp/min\n SpO2: 88%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n CVP: 245 (2 - 270)mmHg\n Bladder pressure: 12 (12 - 18) mmHg\n Total In:\n 9,192 mL\n 3,725 mL\n PO:\n TF:\n IVF:\n 8,027 mL\n 3,249 mL\n Blood products:\n 426 mL\n Total out:\n 3,230 mL\n 838 mL\n Urine:\n 430 mL\n 138 mL\n NG:\n 2,800 mL\n 700 mL\n Stool:\n Drains:\n Balance:\n 5,962 mL\n 2,887 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (500 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 27 cmH2O\n Plateau: 19 cmH2O\n Compliance: 81.1 cmH2O/mL\n SpO2: 88%\n ABG: 7.29/37/163/16/-7\n Ve: 14.2 L/min\n PaO2 / FiO2: 272\n Physical Examination\n General: intubated, sedated\n Pulmonary: poor air movement bilaterally, no wheezes\n Neck: R IJ in place\n Cardiac: tachycardic, regular, normal S1/S2\n Abdomen: Ioban in place covering open wound with 2 JP drains, bloody\n material and some blood leakage to groin.\n Extremities: No edema. Has non-functional right UE fistula. A-line in\n place LUE. Left midline.\n Skin: Multiple keloids\n Neurologic: sedated as above, not arousable to voice\n Labs / Radiology\n 166 K/uL\n 8.1 g/dL\n 106 mg/dL\n 4.7 mg/dL\n 16 mEq/L\n 6.1 mEq/L\n 83 mg/dL\n 100 mEq/L\n 127 mEq/L\n 23.9 %\n 18.8 K/uL\n [image002.jpg]\n 03:17 PM\n 05:16 PM\n 09:11 PM\n 09:38 PM\n 12:31 AM\n 01:49 AM\n 02:02 AM\n 03:39 AM\n 05:22 AM\n 06:09 AM\n WBC\n 22.3\n 18.8\n Hct\n 23.3\n 20\n 23.9\n Plt\n 211\n 166\n Cr\n 4.6\n 4.7\n TCO2\n 20\n 18\n 20\n 19\n 19\n 19\n Glucose\n 113\n 175\n 106\n Other labs: PT / PTT / INR:20.9/56.0/2.0, CK / CKMB /\n Troponin-T:210/8/0.05, ALT / AST:5468/, Alk Phos / T Bili:300/3.1,\n Amylase / Lipase:905/18, Differential-Neuts:80.0 %, Band:4.0 %,\n Lymph:7.0 %, Mono:8.0 %, Eos:0.0 %, Lactic Acid:3.0 mmol/L, Albumin:2.3\n g/dL, LDH: IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:9.1 mg/dL\n Fluid analysis / Other labs: Most recent BMP & LFTs pending\n Tacro level P\n MetHb: 10\n T4: 2.7\n calcTBG: 0.81\n TUptake: 1.23\n T4Index: 3.3\n Imaging: CT Torso: Dilated loops of small bowel, measuring up to 4 cm\n without definite evidence of obstruction. However, there is extensive\n pneumatosis, involving ileal loops as well as involving the ascending\n and transverse colon. Linear foci of air in the liver may indicate\n portal venous air.\n CXR: ET Tube 4.5cm from carina. No significant change from prior.\n Microbiology: C. Diff (+) \n Sputum Cx : PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.\n , BCx Pending\n Assessment and Plan\n 60 yo man with ESRD s/p CRT, HTN, COPD presented with severe\n hypertension and dyspnea, intubated for progressive respiratory\n distress. He is s/p small bowel resection and has intermittent pressor\n requirements. Surgical service has requested transfer to the SICU for\n further management.\n # Respiratory failure: The patient\ns respiratory failure is likely due\n to parainfluenzae small bronchiolitis. The growth of Pseudomonas in\n his sputum is concerning for infection versus colonization due to his\n ET tube. After the emergent bowel resection overnight his respiratory\n function has actually improved.\n - Continue Zosyn for Pseudomonas (Vanc/ as well) while following\n cultures/sensitivites\n - CXR in am to re-evaluate status\n - Continue intubation/mechanical ventilation, although patient\ns status\n may allow for progression towards extubation.\n # Hypotension: The patient\ns blood pressure is actually stable s/p\n bowel resection requiring only intermittent neosynephrine. His\n hypotension is likely hypovolemic given his blood loss and CVP ~ .\n - Maintain CVP 10 with continuous HCO3 and alternative NS boluses\n - Transfuse 3 units pRBCs\n - Neosynephrine as needed for MAP >65\n # Methemoglobinemia: The patient was discovered to be methemoglobinemic\n overnight, possibly from Reglan. After administration of methylene\n blue his methemoglobin levels have improved as has his oxygenation.\n - Monitor with blood gases otherwise obtained\n # Hyperkalemia/Acute renal failure s/p transplant: The patient has a\n persistently elevated potassium and lacks both functioning kidneys\n through which to diurese and bowel in which he could excrete. We will\n temporize with Insulin, Glucose and Bicarb, but the patient will\n require renal replacement therapy.\n # Hepatic failure: The patient\ns markedly elevated liver enzymes in\n his clinical picture are consistent with shock liver. The damage is\n done and his enzymes are trending down, so improved BP control will be\n necessary to prevent further hepatic injury.\n - FFP as needed to keep INR <= 2.0\n # s/p Bowel Resection: The patient\ns status is overall improved after\n resection. His wound care and progression will be per his surgical\n team.\n # GERD:\n -Home PPI \n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 04:50 AM\n Multi Lumen - 05:27 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: Vap Bundle\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: DNR (do not resuscitate)\n Disposition:ICU ->SICU transfer\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-10 00:00:00.000",
"description": "Resident Progress Note- MICU",
"row_id": 674268,
"text": "Chief Complaint:\n 24 Hour Events:\n -2200 labs notable for increasing lactate. CVP also falling-->NS\n boluses\n -O2 Sat low although PaO2 OK. Methemoglobin elevated at 10%-->12%.\n Concern that this may be contributing to poor O2 delivery and rising\n lactate. Thus, treated with methylene blue.\n -advanced ET tube by 4 cm (has been too high for several days)\n -distended abdomen and constipated x 6 days: KUB showed likely SBO.\n Surgery was consulted and recommended CT with PO contrast, which showed\n pneumatosis. Surgery took him to the OR and resected all but ~60 cm of\n small bowel that was necrotic.\n -c-diff positive-->started IV flagyl\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:59 PM\n Metronidazole - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:02 AM\n Sodium Bicarbonate 8.4% (Amp) - 12:56 PM\n Heparin Sodium (Prophylaxis) - 11:42 PM\n Insulin - Regular - 12:30 AM\n Dextrose 50% - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 35.3\nC (95.6\n HR: 99 (91 - 118) bpm\n BP: 109/58(76) {76/52(60) - 172/86(117)} mmHg\n RR: 22 (22 - 35) insp/min\n SpO2: 88%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n CVP: 245 (2 - 270)mmHg\n Bladder pressure: 12 (12 - 18) mmHg\n Total In:\n 9,192 mL\n 3,725 mL\n PO:\n TF:\n IVF:\n 8,027 mL\n 3,249 mL\n Blood products:\n 426 mL\n Total out:\n 3,230 mL\n 838 mL\n Urine:\n 430 mL\n 138 mL\n NG:\n 2,800 mL\n 700 mL\n Stool:\n Drains:\n Balance:\n 5,962 mL\n 2,887 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (500 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 27 cmH2O\n Plateau: 19 cmH2O\n Compliance: 81.1 cmH2O/mL\n SpO2: 88%\n ABG: 7.29/37/163/16/-7\n Ve: 14.2 L/min\n PaO2 / FiO2: 272\n Physical Examination\n General: intubated, sedated\n Pulmonary: poor air movement bilaterally, no wheezes\n Neck: R IJ in place\n Cardiac: tachycardic, regular, normal S1/S2\n Abdomen: Ioban in place covering open wound with 2 JP drains, bloody\n material and some blood leakage to groin.\n Extremities: No edema. Has non-functional right UE fistula. A-line in\n place LUE. Left midline.\n Skin: Multiple keloids\n Neurologic: sedated as above, not arousable to voice\n Labs / Radiology\n 166 K/uL\n 8.1 g/dL\n 106 mg/dL\n 4.7 mg/dL\n 16 mEq/L\n 6.1 mEq/L\n 83 mg/dL\n 100 mEq/L\n 127 mEq/L\n 23.9 %\n 18.8 K/uL\n [image002.jpg]\n 03:17 PM\n 05:16 PM\n 09:11 PM\n 09:38 PM\n 12:31 AM\n 01:49 AM\n 02:02 AM\n 03:39 AM\n 05:22 AM\n 06:09 AM\n WBC\n 22.3\n 18.8\n Hct\n 23.3\n 20\n 23.9\n Plt\n 211\n 166\n Cr\n 4.6\n 4.7\n TCO2\n 20\n 18\n 20\n 19\n 19\n 19\n Glucose\n 113\n 175\n 106\n Other labs: PT / PTT / INR:20.9/56.0/2.0, CK / CKMB /\n Troponin-T:210/8/0.05, ALT / AST:5468/, Alk Phos / T Bili:300/3.1,\n Amylase / Lipase:905/18, Differential-Neuts:80.0 %, Band:4.0 %,\n Lymph:7.0 %, Mono:8.0 %, Eos:0.0 %, Lactic Acid:3.0 mmol/L, Albumin:2.3\n g/dL, LDH: IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:9.1 mg/dL\n Fluid analysis / Other labs: Most recent BMP & LFTs pending\n Tacro level P\n MetHb: 10\n T4: 2.7\n calcTBG: 0.81\n TUptake: 1.23\n T4Index: 3.3\n Imaging: CT Torso: Dilated loops of small bowel, measuring up to 4 cm\n without definite evidence of obstruction. However, there is extensive\n pneumatosis, involving ileal loops as well as involving the ascending\n and transverse colon. Linear foci of air in the liver may indicate\n portal venous air.\n CXR: ET Tube 4.5cm from carina. No significant change from prior.\n Microbiology: C. Diff (+) \n Sputum Cx : PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.\n , BCx Pending\n Assessment and Plan\n 60 yo man with ESRD s/p CRT, HTN, COPD presented with severe\n hypertension and dyspnea, intubated for progressive respiratory\n distress. He is s/p small bowel resection and has intermittent pressor\n requirements. Surgical service has requested transfer to the SICU for\n further management.\n # Respiratory failure: The patient\ns respiratory failure is likely due\n to parainfluenzae small bronchiolitis. The growth of Pseudomonas in\n his sputum is concerning for infection versus colonization due to his\n ET tube. After the emergent bowel resection overnight his respiratory\n function has actually improved.\n - Continue Zosyn for Pseudomonas (Vanc/ as well) while following\n cultures/sensitivites\n - CXR in am to re-evaluate status\n - Continue intubation/mechanical ventilation, although patient\ns status\n may allow for progression towards extubation.\n # Hypotension: The patient\ns blood pressure is actually stable s/p\n bowel resection requiring only intermittent neosynephrine. His\n hypotension is likely hypovolemic given his blood loss and CVP ~ .\n - Maintain CVP 10 with continuous HCO3 and alternative NS boluses\n - Transfuse 3 units pRBCs\n - Neosynephrine as needed for MAP >65\n # Methemoglobinemia: The patient was discovered to be methemoglobinemic\n overnight, possibly from Reglan. After administration of methylene\n blue his methemoglobin levels have improved as has his oxygenation.\n - Monitor with blood gases otherwise obtained\n # Hyperkalemia/Acute renal failure s/p transplant: The patient has a\n persistently elevated potassium and lacks both functioning kidneys\n through which to diurese and bowel in which he could excrete. We will\n temporize with Insulin, Glucose and Bicarb, but the patient will\n require renal replacement therapy.\n # Hepatic failure: The patient\ns markedly elevated liver enzymes in\n his clinical picture are consistent with shock liver. The damage is\n done and his enzymes are trending down, so improved BP control will be\n necessary to prevent further hepatic injury.\n - FFP as needed to keep INR <= 2.0\n # s/p Bowel Resection: The patient\ns status is overall improved after\n resection. His wound care and progression will be per his surgical\n team.\n # GERD:\n -Home PPI \n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 04:50 AM\n Multi Lumen - 05:27 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: Vap Bundle\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: DNR (do not resuscitate)\n Disposition:ICU ->SICU transfer\n ------ Protected Section ------\n Addendum to A/P\n C Diff positivity: The patient\ns stool turned positive for c. Diff. We\n will continue IV Flagyl and administer PO Vancomycin for a 14 day\n course post other antibiotics.\n ------ Protected Section Addendum Entered By: , MD\n on: 20:17 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 674497,
"text": "Demographics\n Day of mechanical ventilation: 7\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Tube Type\n ETT:\n Position: 27 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n MDIs given as documented\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: pt remains orally intubated on\n full mechanical support; no vent changes made this shift, continues on\n A/C w/ PIP/Pplat = 26/18. Not overbreathing set vent rate of 24.\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated; Comments: maintain support\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-12 00:00:00.000",
"description": "Intensivist Note",
"row_id": 674655,
"text": "SICU\n HPI:\n 60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation .\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-ass R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n Current medications:\n 1. 20 gm Calcium Gluconate/ 500 mL D5W\n 2. Albuterol Inhaler\n 3. Calcium Chloride\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse\n 5. Famotidine\n 6. Fentanyl Citrate\n 7. Fluticasone Propionate 110mcg\n 8. Hydrocortisone Na Succ.\n 9. Insulin\n 10. Ipratropium Bromide MDI\n 11. Magnesium Sulfate\n 12. MetRONIDAZOLE (FLagyl)\n 13. Midazolam\n 14. Mycophenolate Mofetil\n 15. Phenylephrine\n 16. Piperacillin-Tazobactam Na\n 17. Potassium Chloride\n 18. Tacrolimus\n 19. Vancomycin\n 24 Hour Events:\n OR SENT - At 09:45 AM\n OR RECEIVED - At 11:00 AM\n ARTERIAL LINE - START 04:05 PM\n CARDIOVERSION/DEFIBRILLATION - At 05:17 PM\n ARTERIAL LINE - STOP 09:00 PM\n CARDIOVERSION/DEFIBRILLATION - At 04:56 AM\n HR 120s\n CARDIOVERSION/DEFIBRILLATION - At 05:12 AM\n 300 joules\n CARDIOVERSION/DEFIBRILLATION - At 05:15 AM\n 360 J\n Post operative day:\n POD#2 - expl lap\n POD#1 - Hematoma cleaned out, one area on bowel to watch, ABD left\n open, will return to OR tomorrow \n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:29 PM\n Piperacillin/Tazobactam (Zosyn) - 10:30 PM\n Metronidazole - 11:00 PM\n Infusions:\n Fentanyl - 100 mcg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Phenylephrine - 5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 04:33 PM\n Metoprolol - 05:11 AM\n Other medications:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 36.1\nC (97\n HR: 101 (68 - 132) bpm\n BP: 143/83(107) {62/46(53) - 161/83(114)} mmHg\n RR: 24 (0 - 27) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111.4 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 12 (3 - 20) mmHg\n CO/CI (Thermodilution): (6.81 L/min) / (3 L/min/m2)\n SVR: 811 dynes*sec/cm5\n SV: 72 mL\n SVI: 31 mL/m2\n Total In:\n 8,221 mL\n 1,068 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,567 mL\n 718 mL\n Blood products:\n 3,654 mL\n 350 mL\n Total out:\n 3,957 mL\n 1,348 mL\n Urine:\n 175 mL\n 60 mL\n NG:\n 1,375 mL\n 300 mL\n Stool:\n Drains:\n 1,510 mL\n 750 mL\n Balance:\n 4,264 mL\n -280 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 31 cmH2O\n Plateau: 15 cmH2O\n Compliance: 71.4 cmH2O/mL\n SPO2: 100%\n ABG: 7.44/34/125/24/0\n Ve: 13.9 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Open abdomen covered with sterile towels and ioban\n Left Extremities: (Edema: 1+), (Temperature: Cool)\n Right Extremities: (Edema: 1+), (Temperature: Cool)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Sedated\n Labs / Radiology\n 75 K/uL\n 9.7 g/dL\n 80 mg/dL\n 2.5 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 38 mg/dL\n 99 mEq/L\n 134 mEq/L\n 25.8 %\n 22.8 K/uL\n [image002.jpg]\n 11:09 AM\n 11:24 AM\n 12:23 PM\n 04:32 PM\n 05:00 PM\n 11:26 PM\n 11:32 PM\n 03:23 AM\n 03:31 AM\n 05:18 AM\n WBC\n 20.2\n 25.0\n 22.5\n 22.8\n Hct\n 23.7\n 24.3\n 25.9\n 25.8\n Plt\n 65\n 63\n 73\n 75\n Creatinine\n 3.6\n 3.0\n 2.6\n 2.5\n TCO2\n 22\n 22\n 24\n 27\n 26\n 24\n Glucose\n 82\n 81\n 86\n 95\n 97\n 86\n 80\n Other labs: PT / PTT / INR:20.6/42.2/1.9, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:1067/2303, Alk-Phos / T bili:226/11.4,\n Amylase / Lipase:831/21, Differential-Neuts:80.0 %, Band:4.0 %,\n Lymph:7.0 %, Mono:8.0 %, Eos:0.0 %, Fibrinogen:336 mg/dL, Lactic\n Acid:2.8 mmol/L, Albumin:1.8 g/dL, LDH: IU/L, Ca:7.8 mg/dL, Mg:2.1\n mg/dL, PO4:4.1 mg/dL\n Microbiology: sputum: Pseudomonas (pan S)\n urine: GPC ~1K\n bld x2: P\n bld x2: P\n C.diff: positive\n Fungal Cx: P\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), HYPOTENSION (NOT SHOCK), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INEFFECTIVE COPING, INTESTINAL ISCHEMIA\n (INCLUDING MESENTERIC VENOUS / ARTERIAL THROMBOSIS, BOWEL ISCHEMIA),\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), HYPERTENSION, BENIGN,\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION, CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD,\n BRONCHITIS, EMPHYSEMA) WITHOUT ACUTE EXACERBATION\n Assessment and Plan: 60M admitted to for COPD exacerbation, became\n septic, developed ischemic bowel, s/p exlap, SBR, open abd , s/p ex\n lap, hematoma evacuation .\n Neurologic: Restraints, pt not sedated and not moving, follow neuro\n exam, fentanyl gtt\n Cardiovascular: Off pressors, cardiovert x4 for unstable Afiib, but\n currently stable. Mild hypotension likely fluid responsive in the\n presence low GEDI. Will give bolus of plasmalyte.\n Pulmonary: Cont ETT, (Ventilator mode: CMV), attempt to wean, cont\n flovent/atrovent/albuterol\n Gastrointestinal / Abdomen: to OR for 3rd look in AM, H2blockers, NPO,\n LFTs trending down\n Nutrition: NPO\n Renal: Foley, CVVH, Cr 2.5. hyperkalemia resolved.\n Hematology: Serial Hct, Hct 25.8, stable\n Endocrine: euglycemic. RISS\n Infectious Disease: Check cultures, Cont broad spectrum abx:\n Vanc/Zosyn/Flagyl\n Lines / Tubes / Drains: Foley, ETT, Surgical drains (hemovac, JP)\n Wounds: Open abdomen\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: Arrhythmia, (Respiratory distress), Post-op\n hypotension, (Shock: Septic), Acute renal failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n 18 Gauge - 08:00 AM\n Arterial Line - 04:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-12 00:00:00.000",
"description": "Intensivist Note",
"row_id": 674682,
"text": "SICU\n HPI:\n 60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation .\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-ass R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n Current medications:\n 1. 20 gm Calcium Gluconate/ 500 mL D5W\n 2. Albuterol Inhaler\n 3. Calcium Chloride\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse\n 5. Famotidine\n 6. Fentanyl Citrate\n 7. Fluticasone Propionate 110mcg\n 8. Hydrocortisone Na Succ.\n 9. Insulin\n 10. Ipratropium Bromide MDI\n 11. Magnesium Sulfate\n 12. MetRONIDAZOLE (FLagyl)\n 13. Midazolam\n 14. Mycophenolate Mofetil\n 15. Phenylephrine\n 16. Piperacillin-Tazobactam Na\n 17. Potassium Chloride\n 18. Tacrolimus\n 19. Vancomycin\n 24 Hour Events:\n OR SENT - At 09:45 AM\n OR RECEIVED - At 11:00 AM\n ARTERIAL LINE - START 04:05 PM\n CARDIOVERSION/DEFIBRILLATION - At 05:17 PM\n ARTERIAL LINE - STOP 09:00 PM\n CARDIOVERSION/DEFIBRILLATION - At 04:56 AM\n HR 120s\n CARDIOVERSION/DEFIBRILLATION - At 05:12 AM\n 300 joules\n CARDIOVERSION/DEFIBRILLATION - At 05:15 AM\n 360 J\n Post operative day:\n POD#2 - expl lap\n POD#1 - Hematoma cleaned out, one area on bowel to watch, ABD left\n open, will return to OR tomorrow \n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:29 PM\n Piperacillin/Tazobactam (Zosyn) - 10:30 PM\n Metronidazole - 11:00 PM\n Infusions:\n Fentanyl - 100 mcg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Phenylephrine - 5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 04:33 PM\n Metoprolol - 05:11 AM\n Other medications:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 36.1\nC (97\n HR: 101 (68 - 132) bpm\n BP: 143/83(107) {62/46(53) - 161/83(114)} mmHg\n RR: 24 (0 - 27) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111.4 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 12 (3 - 20) mmHg\n CO/CI (Thermodilution): (6.81 L/min) / (3 L/min/m2)\n SVR: 811 dynes*sec/cm5\n SV: 72 mL\n SVI: 31 mL/m2\n Total In:\n 8,221 mL\n 1,068 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,567 mL\n 718 mL\n Blood products:\n 3,654 mL\n 350 mL\n Total out:\n 3,957 mL\n 1,348 mL\n Urine:\n 175 mL\n 60 mL\n NG:\n 1,375 mL\n 300 mL\n Stool:\n Drains:\n 1,510 mL\n 750 mL\n Balance:\n 4,264 mL\n -280 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 31 cmH2O\n Plateau: 15 cmH2O\n Compliance: 71.4 cmH2O/mL\n SPO2: 100%\n ABG: 7.44/34/125/24/0\n Ve: 13.9 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Open abdomen covered with sterile towels and ioban\n Left Extremities: (Edema: 1+), (Temperature: Cool)\n Right Extremities: (Edema: 1+), (Temperature: Cool)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Sedated\n Labs / Radiology\n 75 K/uL\n 9.7 g/dL\n 80 mg/dL\n 2.5 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 38 mg/dL\n 99 mEq/L\n 134 mEq/L\n 25.8 %\n 22.8 K/uL\n [image002.jpg]\n 11:09 AM\n 11:24 AM\n 12:23 PM\n 04:32 PM\n 05:00 PM\n 11:26 PM\n 11:32 PM\n 03:23 AM\n 03:31 AM\n 05:18 AM\n WBC\n 20.2\n 25.0\n 22.5\n 22.8\n Hct\n 23.7\n 24.3\n 25.9\n 25.8\n Plt\n 65\n 63\n 73\n 75\n Creatinine\n 3.6\n 3.0\n 2.6\n 2.5\n TCO2\n 22\n 22\n 24\n 27\n 26\n 24\n Glucose\n 82\n 81\n 86\n 95\n 97\n 86\n 80\n Other labs: PT / PTT / INR:20.6/42.2/1.9, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:1067/2303, Alk-Phos / T bili:226/11.4,\n Amylase / Lipase:831/21, Differential-Neuts:80.0 %, Band:4.0 %,\n Lymph:7.0 %, Mono:8.0 %, Eos:0.0 %, Fibrinogen:336 mg/dL, Lactic\n Acid:2.8 mmol/L, Albumin:1.8 g/dL, LDH: IU/L, Ca:7.8 mg/dL, Mg:2.1\n mg/dL, PO4:4.1 mg/dL\n Microbiology: sputum: Pseudomonas (pan S)\n urine: GPC ~1K\n bld x2: P\n bld x2: P\n C.diff: positive\n Fungal Cx: P\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), HYPOTENSION (NOT SHOCK), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INEFFECTIVE COPING, INTESTINAL ISCHEMIA\n (INCLUDING MESENTERIC VENOUS / ARTERIAL THROMBOSIS, BOWEL ISCHEMIA),\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), HYPERTENSION, BENIGN,\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION, CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD,\n BRONCHITIS, EMPHYSEMA) WITHOUT ACUTE EXACERBATION\n Assessment and Plan: 60M admitted to for COPD exacerbation, became\n septic, developed ischemic bowel, s/p exlap, SBR, open abd , s/p ex\n lap, hematoma evacuation .\n Neurologic: Restraints, pt not sedated and not moving, follow neuro\n exam, fentanyl gtt. Concern that patient has not followed commands\n since SICU admission. Post\n op, if abdomen is closed please stop\n Cardiovascular: Off pressors, cardiovert x4 for unstable Afiib, but\n currently stable. Mild hypotension likely fluid responsive in the\n presence low GEDI. Will give bolus of plasmalyte.\n Pulmonary: Cont ETT, (Ventilator mode: CMV), cont\n flovent/atrovent/albuterol\n Gastrointestinal / Abdomen: to OR for 3rd look in AM, H2blockers, NPO,\n LFTs trending down\n Nutrition: NPO, Will start TPN today as patient will not be eating for\n a while.\n Renal: Foley, CVVH, Cr 2.5. hyperkalemia resolved. Attempt to remove\n H2O if tolerating\n Hematology: Serial Hct, Hct 25.8, stable\n Endocrine: euglycemic. RISS. Keep < 150\n Infectious Disease: Check cultures, Cont broad spectrum abx:\n Empirically on Vanc/Zosyn/Flagyl. Increase vanco to 1 g twice daily and\n check levels tomorrow.\n Lines / Tubes / Drains: Foley, ETT, Surgical drains (hemovac, JP)\n Wounds: Open abdomen\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: Arrhythmia, (Respiratory distress), Post-op\n hypotension, (Shock: Septic), Acute renal failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n 18 Gauge - 08:00 AM\n Arterial Line - 04:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674256,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rising K\n Rising Cr\n Minimal urine output\n Action:\n CRRT line placed in L IJ\n Response:\n Awaiting CRRT start\n Plan:\n Start CRRT when line placed\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Labile BP\n Large blood volume loss approx 250cc in bed when turned\n Action:\n Labs followed\n 2u FFP and total 2u PRBC given over day\n Multiple fluid boluses, ca chloride given throughout day\n Neo on/off titrated to keep map >60, sys >90\n Response:\n Transient BP\n HCT drop that responded to blood\n Cont to have transient bp drops that respond to neo and IVF for approx\n 30 minutes.\n Plan:\n Monitor for further signs of bleeding, follow labs\n CRRT to begin\n OR tomorrow for washout and attempt at closure\n Ineffective Coping\n Assessment:\n Patient was dnr and mother asking questions regarding second surgery\n Patients mother who is HCP (no report in chart) was repeating questions\n and this self concerned for memory issues\n Action:\n Social worker paged x2 for consult with no return call\n Family meeting with self and \n Family supported throughout day and asking appropriate questions\n Per grand-daughter- patients mother remembers perfectly and has no\n dementia like symptoms\n Response:\n md note for full detail of family meeting\n Plan:\n Social worker to see on Wednesday\n Patient full code with plan to return to OR in am\n Continue full support with family\n Monitor mother and memory for appropriateness of herself as designated\n spokesperson\n Attempt to locate documentation for official HCP\n"
},
{
"category": "General",
"chartdate": "2104-06-10 00:00:00.000",
"description": "ICU Event Note",
"row_id": 674241,
"text": "Clinician: Attending\n We had a meeting with Mr. ' family (15:40-16:16). Present in\n the meeting: Mr. mother , her sister, mother's nephew\n and grandaughter. From : RN ( K.) and myself.\n We updated the family about Mr. ' critical condition, about the\n fact that he may not survive this hospitalization and that he is\n expected to undergo a few more surgeries and procedures. In addition, I\n explained to them that if Mr. survive this hospitalization,\n they should expect prolonged rehabilitation course, with potential more\n hospitalization down the road and even potentially lifelong TPN.\n The nephew initially was hostile, argumentative and accusative. He was\n concerned that we perform human experimentation on Mr. and\n that we may abuse the DNR status and would not perform CPR if needed.\n I explained to the family at length that since we don't know Mr.\n ' wishes, we meet with them to get an input from the family,\n specifically from his mother (as she is his next of and HCP).\n Earlier today when I met with Ms. in the pt's room she told me\n that he wouldn't have wanted to live like this. During the meeting,\n though, she told and myself that she never had a discussion with\n him about this issue, and that someone told her that he signed a form\n stating this, but that she never saw the form. The conclusion of the\n meeting was that all family members agreed that the code status should\n reverse to \"full code\" and that we should proceed with CVVH and\n whatever madical or surgical measures needed to get him through this\n critical state. I verified four times that this is everyone's wishes.\n We agreed that if down the road they change their mind (i.e reverse to\n DNR or withdrawal care) they will let us know and we will respect their\n wishes. As of now, the patient's code is \"full code\". RN and house\n offiecer notified.\n Total time spent: 36 minutes\n Patient is critically ill.\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-10 00:00:00.000",
"description": "Resident Progress Note- MICU",
"row_id": 674250,
"text": "Chief Complaint:\n 24 Hour Events:\n -2200 labs notable for increasing lactate. CVP also falling-->NS\n boluses\n -O2 Sat low although PaO2 OK. Methemoglobin elevated at 10%-->12%.\n Concern that this may be contributing to poor O2 delivery and rising\n lactate. Thus, treated with methylene blue.\n -advanced ET tube by 4 cm (has been too high for several days)\n -distended abdomen and constipated x 6 days: KUB showed likely SBO.\n Surgery was consulted and recommended CT with PO contrast, which showed\n pneumatosis. Surgery took him to the OR and resected all but ~60 cm of\n small bowel that was necrotic.\n -c-diff positive-->started IV flagyl\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:59 PM\n Metronidazole - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:02 AM\n Sodium Bicarbonate 8.4% (Amp) - 12:56 PM\n Heparin Sodium (Prophylaxis) - 11:42 PM\n Insulin - Regular - 12:30 AM\n Dextrose 50% - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 35.3\nC (95.6\n HR: 99 (91 - 118) bpm\n BP: 109/58(76) {76/52(60) - 172/86(117)} mmHg\n RR: 22 (22 - 35) insp/min\n SpO2: 88%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n CVP: 245 (2 - 270)mmHg\n Bladder pressure: 12 (12 - 18) mmHg\n Total In:\n 9,192 mL\n 3,725 mL\n PO:\n TF:\n IVF:\n 8,027 mL\n 3,249 mL\n Blood products:\n 426 mL\n Total out:\n 3,230 mL\n 838 mL\n Urine:\n 430 mL\n 138 mL\n NG:\n 2,800 mL\n 700 mL\n Stool:\n Drains:\n Balance:\n 5,962 mL\n 2,887 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (500 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 27 cmH2O\n Plateau: 19 cmH2O\n Compliance: 81.1 cmH2O/mL\n SpO2: 88%\n ABG: 7.29/37/163/16/-7\n Ve: 14.2 L/min\n PaO2 / FiO2: 272\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 166 K/uL\n 8.1 g/dL\n 106 mg/dL\n 4.7 mg/dL\n 16 mEq/L\n 6.1 mEq/L\n 83 mg/dL\n 100 mEq/L\n 127 mEq/L\n 23.9 %\n 18.8 K/uL\n [image002.jpg]\n 03:17 PM\n 05:16 PM\n 09:11 PM\n 09:38 PM\n 12:31 AM\n 01:49 AM\n 02:02 AM\n 03:39 AM\n 05:22 AM\n 06:09 AM\n WBC\n 22.3\n 18.8\n Hct\n 23.3\n 20\n 23.9\n Plt\n 211\n 166\n Cr\n 4.6\n 4.7\n TCO2\n 20\n 18\n 20\n 19\n 19\n 19\n Glucose\n 113\n 175\n 106\n Other labs: PT / PTT / INR:20.9/56.0/2.0, CK / CKMB /\n Troponin-T:210/8/0.05, ALT / AST:5468/, Alk Phos / T Bili:300/3.1,\n Amylase / Lipase:905/18, Differential-Neuts:80.0 %, Band:4.0 %,\n Lymph:7.0 %, Mono:8.0 %, Eos:0.0 %, Lactic Acid:3.0 mmol/L, Albumin:2.3\n g/dL, LDH: IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:9.1 mg/dL\n Fluid analysis / Other labs: Most recent BMP & LFTs pending\n Tacro level P\n MetHb: 10\n T4: 2.7\n calcTBG: 0.81\n TUptake: 1.23\n T4Index: 3.3\n Imaging: CT Torso: Dilated loops of small bowel, measuring up to 4 cm\n without definite evidence of obstruction. However, there is extensive\n pneumatosis, involving ileal loops as well as involving the ascending\n and transverse colon. Linear foci of air in the liver may indicate\n portal venous air.\n CXR: ET Tube 4.5cm from carina. No significant change from prior.\n Microbiology: C. Diff (+) \n Sputum Cx : PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.\n , BCx Pending\n Assessment and Plan\n 60 yo man with ESRD s/p CRT, HTN, COPD presented with severe\n hypertension and dyspnea, intubated for progressive respiratory\n distress. He is s/p small bowel resection and has intermittent pressor\n requirements.\n # Respiratory failure: The patient\ns respiratory failure is likely due\n to parainfluenzae small bronchiolitis. The growth of Pseudomonas in\n his sputum is concerning for infection versus colonization due to his\n ET tube. After the emergent bowel resection overnight his respiratory\n function has actually improved.\n # Hypotension:\n # Methemoglobinemia\n # Hepatic failure\n # Acute renal failure:\n # s/p Bowel Resection\n # Abnormal TFTs: Sick Euthyroid\n # DM:\n # Chronic pain:\n -Fentanyl gtt\n -holding po pain meds for now due to poor gastric motility (home\n oxycontin, methadone, and dilaudid prn)\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation:\n -senna, colace, bisacodyl pr, miralax, raglan\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 04:50 AM\n Multi Lumen - 05:27 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: DNR (do not resuscitate)\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674253,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rising K\n Rising Cr\n Minimal urine output\n Action:\n CRRT line placed in L IJ\n Response:\n Awaiting CRRT start\n Plan:\n Start CRRT when line placed\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-10 00:00:00.000",
"description": "Resident Progress Note- MICU",
"row_id": 674255,
"text": "Chief Complaint:\n 24 Hour Events:\n -2200 labs notable for increasing lactate. CVP also falling-->NS\n boluses\n -O2 Sat low although PaO2 OK. Methemoglobin elevated at 10%-->12%.\n Concern that this may be contributing to poor O2 delivery and rising\n lactate. Thus, treated with methylene blue.\n -advanced ET tube by 4 cm (has been too high for several days)\n -distended abdomen and constipated x 6 days: KUB showed likely SBO.\n Surgery was consulted and recommended CT with PO contrast, which showed\n pneumatosis. Surgery took him to the OR and resected all but ~60 cm of\n small bowel that was necrotic.\n -c-diff positive-->started IV flagyl\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:59 PM\n Metronidazole - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:02 AM\n Sodium Bicarbonate 8.4% (Amp) - 12:56 PM\n Heparin Sodium (Prophylaxis) - 11:42 PM\n Insulin - Regular - 12:30 AM\n Dextrose 50% - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 35.3\nC (95.6\n HR: 99 (91 - 118) bpm\n BP: 109/58(76) {76/52(60) - 172/86(117)} mmHg\n RR: 22 (22 - 35) insp/min\n SpO2: 88%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n CVP: 245 (2 - 270)mmHg\n Bladder pressure: 12 (12 - 18) mmHg\n Total In:\n 9,192 mL\n 3,725 mL\n PO:\n TF:\n IVF:\n 8,027 mL\n 3,249 mL\n Blood products:\n 426 mL\n Total out:\n 3,230 mL\n 838 mL\n Urine:\n 430 mL\n 138 mL\n NG:\n 2,800 mL\n 700 mL\n Stool:\n Drains:\n Balance:\n 5,962 mL\n 2,887 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (500 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 27 cmH2O\n Plateau: 19 cmH2O\n Compliance: 81.1 cmH2O/mL\n SpO2: 88%\n ABG: 7.29/37/163/16/-7\n Ve: 14.2 L/min\n PaO2 / FiO2: 272\n Physical Examination\n General: intubated, sedated\n Pulmonary: poor air movement bilaterally, no wheezes\n Neck: R IJ in place\n Cardiac: tachycardic, regular, normal S1/S2\n Abdomen: Ioban in place covering open wound with 2 JP drains, bloody\n material and some blood leakage to groin.\n Extremities: No edema. Has non-functional right UE fistula. A-line in\n place LUE. Left midline.\n Skin: Multiple keloids\n Neurologic: sedated as above, not arousable to voice\n Labs / Radiology\n 166 K/uL\n 8.1 g/dL\n 106 mg/dL\n 4.7 mg/dL\n 16 mEq/L\n 6.1 mEq/L\n 83 mg/dL\n 100 mEq/L\n 127 mEq/L\n 23.9 %\n 18.8 K/uL\n [image002.jpg]\n 03:17 PM\n 05:16 PM\n 09:11 PM\n 09:38 PM\n 12:31 AM\n 01:49 AM\n 02:02 AM\n 03:39 AM\n 05:22 AM\n 06:09 AM\n WBC\n 22.3\n 18.8\n Hct\n 23.3\n 20\n 23.9\n Plt\n 211\n 166\n Cr\n 4.6\n 4.7\n TCO2\n 20\n 18\n 20\n 19\n 19\n 19\n Glucose\n 113\n 175\n 106\n Other labs: PT / PTT / INR:20.9/56.0/2.0, CK / CKMB /\n Troponin-T:210/8/0.05, ALT / AST:5468/, Alk Phos / T Bili:300/3.1,\n Amylase / Lipase:905/18, Differential-Neuts:80.0 %, Band:4.0 %,\n Lymph:7.0 %, Mono:8.0 %, Eos:0.0 %, Lactic Acid:3.0 mmol/L, Albumin:2.3\n g/dL, LDH: IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:9.1 mg/dL\n Fluid analysis / Other labs: Most recent BMP & LFTs pending\n Tacro level P\n MetHb: 10\n T4: 2.7\n calcTBG: 0.81\n TUptake: 1.23\n T4Index: 3.3\n Imaging: CT Torso: Dilated loops of small bowel, measuring up to 4 cm\n without definite evidence of obstruction. However, there is extensive\n pneumatosis, involving ileal loops as well as involving the ascending\n and transverse colon. Linear foci of air in the liver may indicate\n portal venous air.\n CXR: ET Tube 4.5cm from carina. No significant change from prior.\n Microbiology: C. Diff (+) \n Sputum Cx : PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.\n , BCx Pending\n Assessment and Plan\n 60 yo man with ESRD s/p CRT, HTN, COPD presented with severe\n hypertension and dyspnea, intubated for progressive respiratory\n distress. He is s/p small bowel resection and has intermittent pressor\n requirements. Surgical service has requested transfer to the SICU for\n further management.\n # Respiratory failure: The patient\ns respiratory failure is likely due\n to parainfluenzae small bronchiolitis. The growth of Pseudomonas in\n his sputum is concerning for infection versus colonization due to his\n ET tube. After the emergent bowel resection overnight his respiratory\n function has actually improved.\n - Continue Zosyn for Pseudomonas (Vanc/ as well) while following\n cultures/sensitivites\n - Continue Intubation.\n # Hypotension: The patient\ns blood pressure is actually stable s/p\n bowel resection requiring only intermittent neosynephrine. His\n hypotension is likely hypovolemic given his blood loss and CVP ~ .\n - Maintain CVP 10 with continuous HCO3 and alternative NS boluses\n - Transfuse 3 units pRBCs\n - Neosynephrine as needed for MAP >65\n # Methemoglobinemia: The patient was discovered to be methemoglobinemic\n overnight, possibly from Reglan. After administration of methylene\n blue his methemoglobin levels have improved as has his oxygenation.\n - Monitor with blood gases otherwise obtained\n # Hepatic failure: The patient\ns markedly elevated liver enzymes\n # Acute renal failure:\n # s/p Bowel Resection\n # Abnormal TFTs: Sick Euthyroid\n # DM:\n # Chronic pain:\n -Fentanyl gtt\n -holding po pain meds for now due to poor gastric motility (home\n oxycontin, methadone, and dilaudid prn)\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation:\n -senna, colace, bisacodyl pr, miralax, raglan\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 04:50 AM\n Multi Lumen - 05:27 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: DNR (do not resuscitate)\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674330,
"text": "TITLE:\n Hypotension (not Shock)\n Assessment:\n 105 at begin of shift w low sbp 70-130\ns w transient hypertension\n with fld volume resuscitation, Neo gtt . cvp 7-10 range\n Action:\n Multiple 500c (x5)crystalloid boluses for low sbp and cvp. Ca chloride\n x4gm overnight in addition to Ca Gluconate drip for crrt\n Response:\n Persistent periods of hypotension despite crystalloid boluses\n 2.5lters. Prbc x2 and ffp x 2 for coag correction, decreased hct and\n colloid resuscitation with improved bp response- less frequent bouts of\n hypotension after colloid. Neo remains on at 1.5-2mcg/kg/min.Plasmalyte\n maintainence fluid at 100cc/hr.\n Plan:\n Titrate neo to sbp > 90 , notify ho if pt requires > 5mcg./kg/min neo .\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Abd open with jp drains to wall suction w lg amts of sanguinous\n drainage.Metabolic acidosis w lactate 3-.8 -4.9. NaHCO3 gtt infusing\n until crrt initiated.\n Action:\n Crystalloid and colloid Fld boluses as noted above. Crrt b32k2.\n repleted w prbc and ffp for low hct and elevated coags.Trending lft\n Response:\n No appreciable bump in hct after prbc.Metabolic acidosis persists\n despite crrt and fld boluses. Lfts\n trending down slightly, coags\n remain elevated, Dr aware of all lab values overnight.\n Plan:\n Pt scheduled to return to O.R. today. Continue to follow labs as\n ordered q6h while on crrt. Rx elevated coags with ffp.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Hyperkalemia, bun/creat elevated, scant amts of green urine (methylene\n blue preop).\n Action:\n Labs q1-2h overnight, Ca gluconate titrated per sliding scale .Crrt B32\n K2 goal- no fluid removal overnight.\n Response:\n Transient improvement in serum K+. Crrt running well, no additional\n fluid removed overnight.\n Plan:\n Continue crrt to dialyze hyperkalemia.\n"
},
{
"category": "General",
"chartdate": "2104-06-12 00:00:00.000",
"description": "ICU Event Note",
"row_id": 674774,
"text": "Clinician: Attending\n We just finished a family meeting. Family: Mother, son, mother's\n sister, grandaughter and her husband. From medical side: Dr. ,\n RN (), ICU resident -- Dr. , social worker and myself.\n Dr. updated the family on Mr. ' condition, about the\n fact that his condition has improved and that he is more stable. We\n explained to the family that things may change to the worst, but as of\n now, it seems as if he may pull through this critical illness.\n Family raised concerns regarding his suffering and conveyed to us their\n wishes to not resuscitate him should his heart stop beating. Dr.\n about the atrial fibrillation rhythm that he went\n into, and that we may shock him for this reason as we have yesterday\n and today. Family agree for cardioversion but requested not to do CPR\n or shock him should his heart stop beating. We all agreed to respect\n their wishes and will change his code status to DNR. All of the family\n questions were answered.\n Total time spent: 30 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674535,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt into rapid afib from NSR @ approx 1645\n HR up to 135\n SBP down to 60\n Action:\n Neo bolus given\n Lopressor 5mg IV given x2\n Labs sent\n Cardioversion\n Response:\n Pt converted to NSR with cardioversion\n Pt remains in NSR with HR 60-80\n Plan:\n Lopressor and cardioversion if rapid afib occurs again\n Hypotension (not Shock)\n Assessment:\n Pt with labile SBP 70-150\n Requiring pressors intermittently\n Action:\n Neo gtt intermittently\n Blood products as required\n monitor initiated\n Response:\n Pt with appropriate increase in SBP with blood products and pressors\n Plan:\n Continue with pressors as needed\n Blood products as needed\n Ineffective Coping\n Assessment:\n Mother and other family members requiring multiple conversations with\n MD\ns and this RN regarding pt\ns condition\n Mother forgetful at times and states that she has moments where she\n forgets\n Family requiring extra support to cope with situation\n Family not quite able to state the severity of the situation or express\n understading\n Action:\n Teaching done with family by RN and MD\n Reinforcing information that has been given\n Social work into evaluate\n Response:\n Family slowly accepting severity of the situation\n Plan:\n Continue to reinforce information that has been given\n Provide emotional support to family\\\n Social work consult\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Abd open, dsg intact, JP x2 to wall suction, serosang drainage\n BP labile\n Mod amount of drainage from abd\n Liver shock noted\n Action:\n To OR for hematoma evacuation and wash out\n ABD left open\n Multiple blood products\n Labs followed\n Response:\n Pt remains with labile BP\n Post transfusion labs pnd\n LFT\ns trending down\n Plan:\n Back to OR tomorrow for possible closure\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Elevated BUN and Cr\n K+ elevated to 6.2\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674536,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt into rapid afib from NSR @ approx 1645\n HR up to 135\n SBP down to 60\n Action:\n Neo bolus given\n Lopressor 5mg IV given x2\n Labs sent\n Cardioversion\n Response:\n Pt converted to NSR with cardioversion\n Pt remains in NSR with HR 60-80\n Plan:\n Lopressor and cardioversion if rapid afib occurs again\n Hypotension (not Shock)\n Assessment:\n Pt with labile SBP 70-150\n Requiring pressors intermittently\n Action:\n Neo gtt intermittently\n Blood products as required\n monitor initiated\n Response:\n Pt with appropriate increase in SBP with blood products and pressors\n Plan:\n Continue with pressors as needed\n Blood products as needed\n Ineffective Coping\n Assessment:\n Mother and other family members requiring multiple conversations with\n MD\ns and this RN regarding pt\ns condition\n Mother forgetful at times and states that she has moments where she\n forgets\n Family requiring extra support to cope with situation\n Family not quite able to state the severity of the situation or express\n understanding\n Action:\n Teaching done with family by RN and MD\n Reinforcing information that has been given\n Social work into evaluate\n Response:\n Family slowly accepting severity of the situation\n Plan:\n Continue to reinforce information that has been given\n Provide emotional support to family\\\n Social work consult\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Abd open, dsg intact, JP x2 to wall suction, serosang drainage\n BP labile\n Mod amount of drainage from abd\n Liver shock noted\n Action:\n To OR for hematoma evacuation and wash out\n ABD left open\n Multiple blood products\n Labs followed\n Response:\n Pt remains with labile BP\n Post transfusion labs pnd\n LFT\ns trending down\n Plan:\n Back to OR tomorrow for possible closure\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Elevated BUN and Cr\n K+ elevated to 6.2\n Action:\n CRRT\n Following labs\n Repleting lytes as needed\n Response:\n K trending down\n No change in BUN and Cr\n Plan:\n Continue with CRRT\n Continue to monitor labs\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 674777,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Pending procedure / OR, Underlying\n illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-13 00:00:00.000",
"description": "Intensivist Note",
"row_id": 675024,
"text": "SICU\n HPI:\n 60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n .\n Chief complaint:\n ischemic bowel\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-ass R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n : Albuterol IH Q4h, atorvastatin 20, duloxetine 30, ezetimibe 10,\n Fosamax 70, Lasix 40, Gabapentin 900\"', hydromorphone 4, methadone\n 7.5\"', Reglan 10\"', Metoprolol 50\", MMF 500\", Prilosec 20\", oxycodone\n SR 30\", prednisone 5, salmeterol 50\", tacrolimus 4\", Valsartan 160\",\n Varenicline 0.5\", Iron 325\n Current medications:\n IV 1. Insulin SC (per Insulin Flowsheet) Sliding Scale Order date:\n @ 1031\n 2. Ipratropium Bromide MDI 6 PUFF IH QID Order date: @ 1031\n 3. Magnesium Sulfate IV Sliding Scale Order date: @ 1031\n 4. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Day 1 Order date:\n @ 1031\n 6. Midazolam 0.5-2 mg/hr IV DRIP TITRATE TO sedation Order date: \n @ 1712\n 7. Mycophenolate Mofetil 500 mg IV BID Order date: @ 1031\n 8. 20 gm Calcium Gluconate/ 500 mL D5W Continuous Initial Rate: 30\n ml/hr w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 1031\n 9. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO sbp>90mmHg Order\n date: @ 1031\n 10. Albuterol Inhaler PUFF IH Q1H:PRN dyspnea Order date: @\n 1031\n 11. Piperacillin-Tazobactam Na 2.25 g IV Q6H Order date: @ 1031\n 12. Calcium Chloride IV Sliding Scale Order date: @ 1031\n 13. Potassium Chloride 20 mEq / 50 ml SW IV PRN for K < 3.5 To\n supplement CRRT KCL infusion sliding scale protocol. Order date: \n @ 1031\n 14. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL Use only if\n patient is on mechanical ventilation. Order date: @ 1031\n 15. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1031\n 16. Prismasate (B22 K4)*Continuous at 500 ml/hr Dialysate Solution for\n CRRT Order date: @ 1818\n 17. Esmolol 50 MCG/KG/MIN IV DRIP INFUSION Duration: 24 Hours Start:\n After completion of bolus dose Order date: @ 1424\n 18. Prismasate (B32 K2) Continuous at 1500 ml/hr Infuse Replacement\n fluid: Prefilter Rate: Postfilter Rate: Replacement Solution for CRRT\n Order date: @ 1838\n 19. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \n @ 1031\n 20. Fluticasone Propionate 110mcg 2 PUFF IH Order date: @\n 1031\n 21. Tacrolimus Suspension 2 mg NG Q 12H Dose to be admin. at 6pm \n and 6am Order date: @ 1831\n 22. Hydrocortisone Na Succ. 100 mg IV Q8H Order date: @ 1031\n 23. Vancomycin 1000 mg IV Q 24H Order date: @ 1312\n 24 Hour Events:\n Afib -> cardioverted x5. 3U PRBC, 2U FFP, 1U plts. To OR for ex lap,\n end jejunostomy. 1U PRBC. Afib -> cardioverted x 2, started\n neo/esmolol gtt, bolused Plasmalyte 500cc x 3. Family meeting -> made\n DNR.\n Post operative day:\n POD#3 - expl lap\n POD#2 - Hematoma cleaned out, one area on bowel to watch, ABD left\n open, will return to OR tomorrow \n POD#1 - exlap\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:29 PM\n Piperacillin/Tazobactam (Zosyn) - 09:30 PM\n Metronidazole - 10:00 PM\n Infusions:\n Fentanyl - 100 mcg/hour\n Phenylephrine - 0.3 mcg/Kg/min\n Midazolam (Versed) - 2 mg/hour\n Calcium Gluconate (CRRT) - 1 grams/hour\n Esmolol - 75 mcg/Kg/min\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Metoprolol - 02:18 PM\n Other medications:\n Flowsheet Data as of 05:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 35.9\nC (96.6\n HR: 74 (73 - 127) bpm\n BP: 105/67(81) {82/42(54) - 168/83(116)} mmHg\n RR: 24 (0 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111.4 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 8 (6 - 291) mmHg\n CO/CI (Thermodilution): (6.45 L/min) / (2.8 L/min/m2)\n SVR: 794 dynes*sec/cm5\n SV: 79 mL\n SVI: 34 mL/m2\n Total In:\n 6,545 mL\n 1,059 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,124 mL\n 1,059 mL\n Blood products:\n 350 mL\n Total out:\n 4,435 mL\n 1,343 mL\n Urine:\n 95 mL\n NG:\n 1,170 mL\n Stool:\n Drains:\n 1,790 mL\n Balance:\n 2,110 mL\n -284 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 15 cmH2O\n SPO2: 100%\n ABG: 7.45/36/96./23/1\n Ve: 12.5 L/min\n PaO2 / FiO2: 194\n Physical Examination\n General Appearance: intubated, sedated\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, open abd\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Skin: Jaundice\n Neurologic: (Awake / Alert / Oriented: No(t) x 3, No(t) x 2, No(t) x\n 1), No(t) Follows simple commands, No(t) Moves all extremities,\n Sedated, unresponsive\n Labs / Radiology\n 38 K/uL\n 10.4 g/dL\n 164 mg/dL\n 2.1 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 47 mg/dL\n 102 mEq/L\n 129 mEq/L\n 29.0 %\n 17.6 K/uL\n [image002.jpg]\n 11:32 PM\n 03:23 AM\n 03:31 AM\n 05:18 AM\n 12:31 PM\n 02:30 PM\n 02:38 PM\n 08:24 PM\n 01:29 AM\n 02:05 AM\n WBC\n 22.8\n 19.8\n 17.6\n Hct\n 25.8\n 30\n 28.1\n 29.0\n Plt\n 75\n 44\n 38\n Creatinine\n 2.4\n 2.3\n 2.1\n TCO2\n 27\n 26\n 24\n 24\n 26\n 26\n 26\n Glucose\n 84\n 80\n 111\n 110\n 127\n 182\n 164\n Other labs: PT / PTT / INR:19.0/42.6/1.8, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:684/821, Alk-Phos / T bili:207/10.4, Amylase\n / Lipase:831/21, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %,\n Mono:8.0 %, Eos:0.0 %, Fibrinogen:336 mg/dL, Lactic Acid:2.4 mmol/L,\n Albumin:1.8 g/dL, LDH: IU/L, Ca:8.5 mg/dL, Mg:2.1 mg/dL, PO4:3.9\n mg/dL\n Microbiology: pleural fluid: P\n pleural tissue: P\n pleural tissue: P\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), HYPOTENSION (NOT SHOCK), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INEFFECTIVE COPING, INTESTINAL ISCHEMIA\n (INCLUDING MESENTERIC VENOUS / ARTERIAL THROMBOSIS, BOWEL ISCHEMIA),\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), HYPERTENSION, BENIGN,\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION, CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD,\n BRONCHITIS, EMPHYSEMA) WITHOUT ACUTE EXACERBATION\n Assessment and Plan: 60M w/ ischemic bowel, s/p exlap, SBR, open abd\n , s/p ex lap, hematoma evacuation , s/p ex lap, end jejunostomy\n (150 cm SB), open abd .\n Neurologic: Midaz & fentanyl gtts.\n Cardiovascular: septic shock on pressors. Esmolol gtts for Afib, neo to\n maintain BP (weaning neo). s/p cardioversion yesterday and two days\n ago. Currently in SR. Would keep sedated as abdomen is open and may\n help in preventing AF. Will sync defib if unstable afib recurs. No\n shock for vtach/vifib.\n Pulmonary: Cont ETT, (Ventilator mode: CMV), Normal ABG on FiO2 50%,\n PEEP 5. Continue nebs. Will stop stress dose steroids today.\n Gastrointestinal / Abdomen: OR tomorrow per team. LFTs trending\n down. Continue NPO/NGT.\n Nutrition: TPN started yest.\n Renal: Foley, CVVH, Minimal UOP. Continue CVVH as per Renal. Lytes\n improved. Cr improved @ 2.1. will continue prednisone 5mg for\n immunosuppression (s/p renal transplant.) Hard to assess long-term\n renal outcome. If overcoming this critical illness may require chronic\n HD.\n Hematology: Serial Hct, Hct stable (29), coags stable (INR 1.8),\n thrombocytopenia, continue to trend down, question of functionality.\n transfuse plt today. Please send HIT panel today. Although less likely\n HIT, but given significant decrease in PLT and some exposure to heparin\n (even in CVL), would send it today.\n Endocrine: RISS, Goal FS<150. Stop for hydrocort stress dose, but\n continue with baseline home dose. Prograft per transplant service recs.\n Infectious Disease: Please send surveillance cultures today, Continue\n immunosuppression as per Transplant. Continue empiric vanc, Zosyn,\n Flagyl. Please start antifungal prophylaxis as patient is\n immunosuppressed and septic. Vanco level is low, please increase to 1\n gm twice daily\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP)\n Wounds: Wound vacuum\n Imaging:\n Fluids: Other, dialysate\n Consults: Transplant, Nephrology\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Insufficiency /\n Post-op), Post-op complication, (Shock: Septic), Liver failure, Acute\n renal failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n 18 Gauge - 08:00 AM\n Arterial Line - 04:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: DNR\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "General",
"chartdate": "2104-06-13 00:00:00.000",
"description": "ICU Event Note",
"row_id": 675026,
"text": "Clinician: Resident\n Pt went into atrial fibrillation with rate 140s, hypotensive to SBP\n 70s. Started neo w/ some improvement in rate 110-120s. Gradually\n returned to 140s. Premedicated w/ 1 mg midaz and fentanyl.\n Synchronized shocke 200 J (not converted) then 360 J\n returned to\n sinus tachy. Gave Lopressor while awaiting esmolol gtt. Fellow &\n attending present.\n Total time spent: 20 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674533,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674534,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt into rapid afib from NSR @ approx 1645\n HR up to 135\n SBP down to 60\n Action:\n Neo bolus given\n Lopressor 5mg IV given x2\n Labs sent\n Cardioversion\n Response:\n Pt converted to NSR with cardioversion\n Pt remains in NSR with HR 60-80\n Plan:\n Lopressor and cardioversion if rapid afib occurs again\n Hypotension (not Shock)\n Assessment:\n Pt with labile SBP 70-150\n Requiring pressors intermittently\n Action:\n Neo gtt intermittently\n Blood products as required\n monitor initiated\n Response:\n Pt with appropriate increase in SBP with blood products and pressors\n Plan:\n Continue with pressors as needed\n Blood products as needed\n Ineffective Coping\n Assessment:\n Mother and other family members requiring multiple conversations with\n MD\ns and this RN regarding pt\ns condition\n Mother forgetful at times and states that she has moments where she\n forgets\n Family requiring extra support to cope with situation\n Family not quite able to state the severity of the situation or express\n understading\n Action:\n Teaching done with family by RN and MD\n Reinforcing information that has been given\n Social work into evaluate\n Response:\n Family slowly accepting severity of the situation\n Plan:\n Continue to reinforce information that has been given\n Provide emotional support to family\\\n Social work consult\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Abd open, dsg intact, JP x2 to wall suction, serosang drainage\n BP labile\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674604,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt with HR in NSR with occ PVC\ns most of shift until approx\n 450 am\n Pt in RAF with subsequent drop in SBP.\n Action:\n Pt Cardioverted at 200J at approx 0450 am\n Response:\n Pt remaining in RAF post cardioversion\n Pt with pressors restarted hypotension from RAF\n Lopressor given with no effect Cardioversion X2 at 5am\n Pt remaining in Afib and SBP now neo requirement increasing\n Cardioversion X3 at 300jules pt in/out of AF. SBP\n responsive to neo and pt given 2^nd dose of lopressor. Pt still\n remaining in/out of afib\n Caridioversion X4 at 360 with success. Pt now in NSR\n 70-80\ns with normal SBP. All pressors off. Pt is receiving 1 Unit or\n PRBC\ns post event\n Plan:\n Cont to monitor HR and rhythm closely\n Cardiovert for unstable RAF.\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Pt with open abd and JP\ns to wall sxn\n WBC\ns starting to rise\n OR on for ? closure\n Action:\n Open abd drsg \n \ns to wall sxn drng mod amts s/s drng\n Response:\n Open abd site remains unchanged\n Drsg when needed\n Plan:\n OR today for closure\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CVVH running even\n K down to 4.8\n Action:\n CVVHD cont, Running pt even\n Response:\n + response to CVVH BUN/Creatinine trending down and\n Potassium normalizing\n CVVH stopped during cardioversion\n Plan:\n Restart CVVH\n Monitor labs Q6 and PRN\n Ineffective Coping\n Assessment:\n RN spoke with pt\ns mother this evening\n Mother was appropriate asking appropriate questions to RN\n Mother consented for anesthesia for OR today\n Action:\n Cont support to family\n Response:\n Pt\ns mother is aware of cardioversion on and is aware\n of OR today. Pt\ns mother will be in on .\n Plan:\n See care plan\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674606,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt with HR in NSR with occ PVC\ns most of shift until approx\n 450 am\n Pt in RAF with subsequent drop in SBP.\n Action:\n Pt Cardioverted at 200J at approx 0450 am\n Response:\n Pt remaining in RAF post cardioversion\n Pt with pressors restarted hypotension from RAF\n Lopressor given with no effect Cardioversion X2 at 5am\n Pt remaining in Afib and SBP now neo requirement increasing\n Cardioversion X3 at 300jules pt in/out of AF. SBP\n responsive to neo and pt given 2^nd dose of lopressor. Pt still\n remaining in/out of afib\n Caridioversion X4 at 360 with success. Pt now in NSR\n 70-80\ns with normal SBP. All pressors off. Pt is receiving 1 Unit or\n PRBC\ns post event\n Plan:\n Cont to monitor HR and rhythm closely\n Cardiovert for unstable RAF.\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Pt with open abd and JP\ns to wall sxn\n WBC\ns starting to rise\n OR on for ? closure\n Action:\n Open abd drsg \n \ns to wall sxn drng mod amts s/s drng\n Response:\n Open abd site remains unchanged\n Drsg when needed\n Plan:\n OR today for closure\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CVVH running even\n K down to 4.8\n Action:\n CVVHD cont, Running pt even\n Response:\n + response to CVVH BUN/Creatinine trending down and\n Potassium normalizing\n CVVH stopped during cardioversion\n Plan:\n Restart CVVH\n Monitor labs Q6 and PRN\n Ineffective Coping\n Assessment:\n RN spoke with pt\ns mother this evening\n Mother was appropriate asking appropriate questions to RN\n Mother consented for anesthesia for OR today\n Action:\n Cont support to family\n Response:\n Pt\ns mother is aware of cardioversion on and is aware\n of OR today. Pt\ns mother will be in on .\n Plan:\n See care plan\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-12 00:00:00.000",
"description": "Intensivist Note",
"row_id": 674589,
"text": "SICU\n HPI:\n 60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation .\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-ass R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n Current medications:\n 1. 20 gm Calcium Gluconate/ 500 mL D5W\n 2. Albuterol Inhaler\n 3. Calcium Chloride\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse\n 5. Famotidine\n 6. Fentanyl Citrate\n 7. Fluticasone Propionate 110mcg\n 8. Hydrocortisone Na Succ.\n 9. Insulin\n 10. Ipratropium Bromide MDI\n 11. Magnesium Sulfate\n 12. MetRONIDAZOLE (FLagyl)\n 13. Midazolam\n 14. Mycophenolate Mofetil\n 15. Phenylephrine\n 16. Piperacillin-Tazobactam Na\n 17. Potassium Chloride\n 18. Tacrolimus\n 19. Vancomycin\n 24 Hour Events:\n OR SENT - At 09:45 AM\n OR RECEIVED - At 11:00 AM\n ARTERIAL LINE - START 04:05 PM\n CARDIOVERSION/DEFIBRILLATION - At 05:17 PM\n ARTERIAL LINE - STOP 09:00 PM\n CARDIOVERSION/DEFIBRILLATION - At 04:56 AM\n HR 120s\n CARDIOVERSION/DEFIBRILLATION - At 05:12 AM\n 300 joules\n CARDIOVERSION/DEFIBRILLATION - At 05:15 AM\n 360 J\n Post operative day:\n POD#2 - expl lap\n POD#1 - Hematoma cleaned out, one area on bowel to watch, ABD left\n open, will return to OR tomorrow \n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:29 PM\n Piperacillin/Tazobactam (Zosyn) - 10:30 PM\n Metronidazole - 11:00 PM\n Infusions:\n Fentanyl - 100 mcg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Phenylephrine - 5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 04:33 PM\n Metoprolol - 05:11 AM\n Other medications:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 36.1\nC (97\n HR: 101 (68 - 132) bpm\n BP: 143/83(107) {62/46(53) - 161/83(114)} mmHg\n RR: 24 (0 - 27) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111.4 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 12 (3 - 20) mmHg\n CO/CI (Thermodilution): (6.81 L/min) / (3 L/min/m2)\n SVR: 811 dynes*sec/cm5\n SV: 72 mL\n SVI: 31 mL/m2\n Total In:\n 8,221 mL\n 1,068 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,567 mL\n 718 mL\n Blood products:\n 3,654 mL\n 350 mL\n Total out:\n 3,957 mL\n 1,348 mL\n Urine:\n 175 mL\n 60 mL\n NG:\n 1,375 mL\n 300 mL\n Stool:\n Drains:\n 1,510 mL\n 750 mL\n Balance:\n 4,264 mL\n -280 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 31 cmH2O\n Plateau: 15 cmH2O\n Compliance: 71.4 cmH2O/mL\n SPO2: 100%\n ABG: 7.44/34/125/24/0\n Ve: 13.9 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Open abdomen covered with sterile towels and ioban\n Left Extremities: (Edema: 1+), (Temperature: Cool)\n Right Extremities: (Edema: 1+), (Temperature: Cool)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Sedated\n Labs / Radiology\n 75 K/uL\n 9.7 g/dL\n 80 mg/dL\n 2.5 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 38 mg/dL\n 99 mEq/L\n 134 mEq/L\n 25.8 %\n 22.8 K/uL\n [image002.jpg]\n 11:09 AM\n 11:24 AM\n 12:23 PM\n 04:32 PM\n 05:00 PM\n 11:26 PM\n 11:32 PM\n 03:23 AM\n 03:31 AM\n 05:18 AM\n WBC\n 20.2\n 25.0\n 22.5\n 22.8\n Hct\n 23.7\n 24.3\n 25.9\n 25.8\n Plt\n 65\n 63\n 73\n 75\n Creatinine\n 3.6\n 3.0\n 2.6\n 2.5\n TCO2\n 22\n 22\n 24\n 27\n 26\n 24\n Glucose\n 82\n 81\n 86\n 95\n 97\n 86\n 80\n Other labs: PT / PTT / INR:20.6/42.2/1.9, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:1067/2303, Alk-Phos / T bili:226/11.4,\n Amylase / Lipase:831/21, Differential-Neuts:80.0 %, Band:4.0 %,\n Lymph:7.0 %, Mono:8.0 %, Eos:0.0 %, Fibrinogen:336 mg/dL, Lactic\n Acid:2.8 mmol/L, Albumin:1.8 g/dL, LDH: IU/L, Ca:7.8 mg/dL, Mg:2.1\n mg/dL, PO4:4.1 mg/dL\n Microbiology: sputum: Pseudomonas (pan S)\n urine: GPC ~1K\n bld x2: P\n bld x2: P\n C.diff: positive\n Fungal Cx: P\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), HYPOTENSION (NOT SHOCK), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INEFFECTIVE COPING, INTESTINAL ISCHEMIA\n (INCLUDING MESENTERIC VENOUS / ARTERIAL THROMBOSIS, BOWEL ISCHEMIA),\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), HYPERTENSION, BENIGN,\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION, CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD,\n BRONCHITIS, EMPHYSEMA) WITHOUT ACUTE EXACERBATION\n Assessment and Plan: 60M admitted to for COPD exacerbation, became\n septic, developed ischemic bowel, s/p exlap, SBR, open abd , s/p ex\n lap, hematoma evacuation .\n Neurologic: Restraints, pt not sedated and not moving, follow neuro\n exam, fentanyl gtt\n Cardiovascular: Off pressors, cardiovert if in Afib\n Pulmonary: Cont ETT, (Ventilator mode: CMV), attempt to wean, cont\n flovent/atrovent/albuterol\n Gastrointestinal / Abdomen: to OR for 3rd look in AM, PPI, NPO, LFTs\n trending down\n Nutrition: NPO\n Renal: Foley, CVVH, Cr 2.5\n Hematology: Serial Hct, Hct 25.8, stable\n Endocrine: RISS\n Infectious Disease: Check cultures, Cont broad spectrum abx:\n Vanc/Zosyn/Flagyl\n Lines / Tubes / Drains: Foley, ETT, Surgical drains (hemovac, JP)\n Wounds: Open abdomen\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: Arrhythmia, (Respiratory distress), Post-op\n hypotension, (Shock: Septic), Acute renal failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n 18 Gauge - 08:00 AM\n Arterial Line - 04:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-13 00:00:00.000",
"description": "Intensivist Note",
"row_id": 674891,
"text": "SICU\n HPI:\n 60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n .\n Chief complaint:\n ischemic bowel\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-ass R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n : Albuterol IH Q4h, atorvastatin 20, duloxetine 30, ezetimibe 10,\n Fosamax 70, Lasix 40, Gabapentin 900\"', hydromorphone 4, methadone\n 7.5\"', Reglan 10\"', Metoprolol 50\", MMF 500\", Prilosec 20\", oxycodone\n SR 30\", prednisone 5, salmeterol 50\", tacrolimus 4\", Valsartan 160\",\n Varenicline 0.5\", Iron 325\n Current medications:\n IV 1. Insulin SC (per Insulin Flowsheet) Sliding Scale Order date:\n @ 1031\n 2. Ipratropium Bromide MDI 6 PUFF IH QID Order date: @ 1031\n 3. Magnesium Sulfate IV Sliding Scale Order date: @ 1031\n 4. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Day 1 Order date:\n @ 1031\n 6. Midazolam 0.5-2 mg/hr IV DRIP TITRATE TO sedation Order date: \n @ 1712\n 7. Mycophenolate Mofetil 500 mg IV BID Order date: @ 1031\n 8. 20 gm Calcium Gluconate/ 500 mL D5W Continuous Initial Rate: 30\n ml/hr w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 1031\n 9. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO sbp>90mmHg Order\n date: @ 1031\n 10. Albuterol Inhaler PUFF IH Q1H:PRN dyspnea Order date: @\n 1031\n 11. Piperacillin-Tazobactam Na 2.25 g IV Q6H Order date: @ 1031\n 12. Calcium Chloride IV Sliding Scale Order date: @ 1031\n 13. Potassium Chloride 20 mEq / 50 ml SW IV PRN for K < 3.5 To\n supplement CRRT KCL infusion sliding scale protocol. Order date: \n @ 1031\n 14. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL Use only if\n patient is on mechanical ventilation. Order date: @ 1031\n 15. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1031\n 16. Prismasate (B22 K4)*Continuous at 500 ml/hr Dialysate Solution for\n CRRT Order date: @ 1818\n 17. Esmolol 50 MCG/KG/MIN IV DRIP INFUSION Duration: 24 Hours Start:\n After completion of bolus dose Order date: @ 1424\n 18. Prismasate (B32 K2) Continuous at 1500 ml/hr Infuse Replacement\n fluid: Prefilter Rate: Postfilter Rate: Replacement Solution for CRRT\n Order date: @ 1838\n 19. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \n @ 1031\n 20. Fluticasone Propionate 110mcg 2 PUFF IH Order date: @\n 1031\n 21. Tacrolimus Suspension 2 mg NG Q 12H Dose to be admin. at 6pm \n and 6am Order date: @ 1831\n 22. Hydrocortisone Na Succ. 100 mg IV Q8H Order date: @ 1031\n 23. Vancomycin 1000 mg IV Q 24H Order date: @ 1312\n 24 Hour Events:\n Afib -> cardioverted x5. 3U PRBC, 2U FFP, 1U plts. To OR for ex lap,\n end jejunostomy. 1U PRBC. Afib -> cardioverted x 2, started\n neo/esmolol gtt, bolused Plasmalyte 500cc x 3. Family meeting -> made\n DNR.\n Post operative day:\n POD#3 - expl lap\n POD#2 - Hematoma cleaned out, one area on bowel to watch, ABD left\n open, will return to OR tomorrow \n POD#1 - exlap\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:29 PM\n Piperacillin/Tazobactam (Zosyn) - 09:30 PM\n Metronidazole - 10:00 PM\n Infusions:\n Fentanyl - 100 mcg/hour\n Phenylephrine - 0.3 mcg/Kg/min\n Midazolam (Versed) - 2 mg/hour\n Calcium Gluconate (CRRT) - 1 grams/hour\n Esmolol - 75 mcg/Kg/min\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Metoprolol - 02:18 PM\n Other medications:\n Flowsheet Data as of 05:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 35.9\nC (96.6\n HR: 74 (73 - 127) bpm\n BP: 105/67(81) {82/42(54) - 168/83(116)} mmHg\n RR: 24 (0 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111.4 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 8 (6 - 291) mmHg\n CO/CI (Thermodilution): (6.45 L/min) / (2.8 L/min/m2)\n SVR: 794 dynes*sec/cm5\n SV: 79 mL\n SVI: 34 mL/m2\n Total In:\n 6,545 mL\n 1,059 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,124 mL\n 1,059 mL\n Blood products:\n 350 mL\n Total out:\n 4,435 mL\n 1,343 mL\n Urine:\n 95 mL\n NG:\n 1,170 mL\n Stool:\n Drains:\n 1,790 mL\n Balance:\n 2,110 mL\n -284 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 15 cmH2O\n SPO2: 100%\n ABG: 7.45/36/96./23/1\n Ve: 12.5 L/min\n PaO2 / FiO2: 194\n Physical Examination\n General Appearance: intubated, sedated\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, open abd\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Skin: Jaundice\n Neurologic: (Awake / Alert / Oriented: No(t) x 3, No(t) x 2, No(t) x\n 1), No(t) Follows simple commands, No(t) Moves all extremities,\n Sedated, unresponsive\n Labs / Radiology\n 38 K/uL\n 10.4 g/dL\n 164 mg/dL\n 2.1 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 47 mg/dL\n 102 mEq/L\n 129 mEq/L\n 29.0 %\n 17.6 K/uL\n [image002.jpg]\n 11:32 PM\n 03:23 AM\n 03:31 AM\n 05:18 AM\n 12:31 PM\n 02:30 PM\n 02:38 PM\n 08:24 PM\n 01:29 AM\n 02:05 AM\n WBC\n 22.8\n 19.8\n 17.6\n Hct\n 25.8\n 30\n 28.1\n 29.0\n Plt\n 75\n 44\n 38\n Creatinine\n 2.4\n 2.3\n 2.1\n TCO2\n 27\n 26\n 24\n 24\n 26\n 26\n 26\n Glucose\n 84\n 80\n 111\n 110\n 127\n 182\n 164\n Other labs: PT / PTT / INR:19.0/42.6/1.8, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:684/821, Alk-Phos / T bili:207/10.4, Amylase\n / Lipase:831/21, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %,\n Mono:8.0 %, Eos:0.0 %, Fibrinogen:336 mg/dL, Lactic Acid:2.4 mmol/L,\n Albumin:1.8 g/dL, LDH: IU/L, Ca:8.5 mg/dL, Mg:2.1 mg/dL, PO4:3.9\n mg/dL\n Microbiology: pleural fluid: P\n pleural tissue: P\n pleural tissue: P\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), HYPOTENSION (NOT SHOCK), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INEFFECTIVE COPING, INTESTINAL ISCHEMIA\n (INCLUDING MESENTERIC VENOUS / ARTERIAL THROMBOSIS, BOWEL ISCHEMIA),\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), HYPERTENSION, BENIGN,\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION, CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD,\n BRONCHITIS, EMPHYSEMA) WITHOUT ACUTE EXACERBATION\n Assessment and Plan: 60M w/ ischemic bowel, s/p exlap, SBR, open abd\n , s/p ex lap, hematoma evacuation , s/p ex lap, end jejunostomy\n (150 cm SB), open abd .\n Neurologic: Midaz & fentanyl gtts.\n Cardiovascular: Esmolol & neo gtts for Afib (weaning neo). Currently\n HD stable.\n Pulmonary: Cont ETT, (Ventilator mode: CMV), Normal ABG on FiO2 50%,\n PEEP 5. Continue nebs.\n Gastrointestinal / Abdomen: ?To OR for 4th look today. LFTs trending\n down. Continue NPO/NGT.\n Nutrition: NPO\n Renal: Foley, CVVH, Minimal UOP. Continue CVVH as per Renal. Lytes\n improved. Cr improved @ 2.1.\n Hematology: Serial Hct, Hct stable (29), coags stable (INR 1.8), plt\n decreasing (38). Continue to trend.\n Endocrine: RISS, Goal FS<150. Hydrocort for adrenal suppression.\n Infectious Disease: Check cultures, Continue immunosuppression as per\n Transplant. Continue vanc, Zosyn, Flagyl.\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP)\n Wounds: Wound vacuum\n Imaging:\n Fluids: Other, dialysate\n Consults: Transplant, Nephrology\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Insufficiency /\n Post-op), Post-op complication, (Shock: Septic), Liver failure, Acute\n renal failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n 18 Gauge - 08:00 AM\n Arterial Line - 04:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674903,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Hr in NSR over noc\n No episodes of RAF\n Esmolol gtt at 100\n SBP remain stable\n Action:\n Hr in low 60\ns at times\n Esmolol decreased to 75\n Response:\n Hr Remains in NSR\n Tolerated decrease in Esmolol\n Plan:\n Cont to monitor closely for unstable HR/SBP\n Pt is DNR but ok to cardiovert for RAF\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Abd remains open\n Jp\ns X2 to wall sxn\n OGt to LCS\n Iliostomy site remains very dusky\n Action:\n Cont to asses abd site\n Response:\n Jp\ns cont to put out moderate amtsof s/s drng\n Primary team aware of dusky iliostomy\n OR today again for another washout\n Plan:\n Cont to monitor abd site\n OR today for possible closure\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cont on CVVHD running even\n Electrolyte status stable\n Ionized Ca running 1.13-1.19 K 4.0\n Action:\n Labs Q6 hrs and prn\n Dialysis bath changed to K4 B22\n Response:\n Electrolyte balance maintained\n ABG\ns WNL\n Plan:\n Cont to monitor labs closely\n ? when to start removing fluid pt is ^^ 1 kilo in weight\n Titrate Calcium and Potassium per SS\n Ineffective Coping\n Assessment:\n Family meeting held on day shift.\n Pt made DNR but okay to cardiovert for RAF\n Pt cousin from calling pm . Family member very\n abrupt and ? if we () were trying to undercut pt\ns mother by\n involving pt\ns estranged son in the decision making of his care.\n Family member also asking this RN if I felt pt was being\n adequately cared for.\n Action:\n RN informed family member that pt\ns mother is still the\n spokesperson for the pt. RN also informing pt that he should speak\n with pt\ns mother in ref: to the family meeting that was held on .\n Response:\n Family member stated he did not want to call pt\ns mother as\n she is frail and overwhelmed and family.\n Family member informed the pt\ns mother is the spokesperson\n and that this RN was not going to give him any information.\n Family member clearly not aware of 2^nd family meeting on\n and stated that he would call pt\ns mother to get updated on\n current social issues\n Plan:\n Cont support to pt and family\n SW involved\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-13 00:00:00.000",
"description": "Intensivist Note",
"row_id": 674977,
"text": "SICU\n HPI:\n 60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n .\n Chief complaint:\n ischemic bowel\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-ass R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n : Albuterol IH Q4h, atorvastatin 20, duloxetine 30, ezetimibe 10,\n Fosamax 70, Lasix 40, Gabapentin 900\"', hydromorphone 4, methadone\n 7.5\"', Reglan 10\"', Metoprolol 50\", MMF 500\", Prilosec 20\", oxycodone\n SR 30\", prednisone 5, salmeterol 50\", tacrolimus 4\", Valsartan 160\",\n Varenicline 0.5\", Iron 325\n Current medications:\n IV 1. Insulin SC (per Insulin Flowsheet) Sliding Scale Order date:\n @ 1031\n 2. Ipratropium Bromide MDI 6 PUFF IH QID Order date: @ 1031\n 3. Magnesium Sulfate IV Sliding Scale Order date: @ 1031\n 4. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Day 1 Order date:\n @ 1031\n 6. Midazolam 0.5-2 mg/hr IV DRIP TITRATE TO sedation Order date: \n @ 1712\n 7. Mycophenolate Mofetil 500 mg IV BID Order date: @ 1031\n 8. 20 gm Calcium Gluconate/ 500 mL D5W Continuous Initial Rate: 30\n ml/hr w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 1031\n 9. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO sbp>90mmHg Order\n date: @ 1031\n 10. Albuterol Inhaler PUFF IH Q1H:PRN dyspnea Order date: @\n 1031\n 11. Piperacillin-Tazobactam Na 2.25 g IV Q6H Order date: @ 1031\n 12. Calcium Chloride IV Sliding Scale Order date: @ 1031\n 13. Potassium Chloride 20 mEq / 50 ml SW IV PRN for K < 3.5 To\n supplement CRRT KCL infusion sliding scale protocol. Order date: \n @ 1031\n 14. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL Use only if\n patient is on mechanical ventilation. Order date: @ 1031\n 15. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1031\n 16. Prismasate (B22 K4)*Continuous at 500 ml/hr Dialysate Solution for\n CRRT Order date: @ 1818\n 17. Esmolol 50 MCG/KG/MIN IV DRIP INFUSION Duration: 24 Hours Start:\n After completion of bolus dose Order date: @ 1424\n 18. Prismasate (B32 K2) Continuous at 1500 ml/hr Infuse Replacement\n fluid: Prefilter Rate: Postfilter Rate: Replacement Solution for CRRT\n Order date: @ 1838\n 19. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \n @ 1031\n 20. Fluticasone Propionate 110mcg 2 PUFF IH Order date: @\n 1031\n 21. Tacrolimus Suspension 2 mg NG Q 12H Dose to be admin. at 6pm \n and 6am Order date: @ 1831\n 22. Hydrocortisone Na Succ. 100 mg IV Q8H Order date: @ 1031\n 23. Vancomycin 1000 mg IV Q 24H Order date: @ 1312\n 24 Hour Events:\n Afib -> cardioverted x5. 3U PRBC, 2U FFP, 1U plts. To OR for ex lap,\n end jejunostomy. 1U PRBC. Afib -> cardioverted x 2, started\n neo/esmolol gtt, bolused Plasmalyte 500cc x 3. Family meeting -> made\n DNR.\n Post operative day:\n POD#3 - expl lap\n POD#2 - Hematoma cleaned out, one area on bowel to watch, ABD left\n open, will return to OR tomorrow \n POD#1 - exlap\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:29 PM\n Piperacillin/Tazobactam (Zosyn) - 09:30 PM\n Metronidazole - 10:00 PM\n Infusions:\n Fentanyl - 100 mcg/hour\n Phenylephrine - 0.3 mcg/Kg/min\n Midazolam (Versed) - 2 mg/hour\n Calcium Gluconate (CRRT) - 1 grams/hour\n Esmolol - 75 mcg/Kg/min\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Metoprolol - 02:18 PM\n Other medications:\n Flowsheet Data as of 05:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 35.9\nC (96.6\n HR: 74 (73 - 127) bpm\n BP: 105/67(81) {82/42(54) - 168/83(116)} mmHg\n RR: 24 (0 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111.4 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 8 (6 - 291) mmHg\n CO/CI (Thermodilution): (6.45 L/min) / (2.8 L/min/m2)\n SVR: 794 dynes*sec/cm5\n SV: 79 mL\n SVI: 34 mL/m2\n Total In:\n 6,545 mL\n 1,059 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,124 mL\n 1,059 mL\n Blood products:\n 350 mL\n Total out:\n 4,435 mL\n 1,343 mL\n Urine:\n 95 mL\n NG:\n 1,170 mL\n Stool:\n Drains:\n 1,790 mL\n Balance:\n 2,110 mL\n -284 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 15 cmH2O\n SPO2: 100%\n ABG: 7.45/36/96./23/1\n Ve: 12.5 L/min\n PaO2 / FiO2: 194\n Physical Examination\n General Appearance: intubated, sedated\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, open abd\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Skin: Jaundice\n Neurologic: (Awake / Alert / Oriented: No(t) x 3, No(t) x 2, No(t) x\n 1), No(t) Follows simple commands, No(t) Moves all extremities,\n Sedated, unresponsive\n Labs / Radiology\n 38 K/uL\n 10.4 g/dL\n 164 mg/dL\n 2.1 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 47 mg/dL\n 102 mEq/L\n 129 mEq/L\n 29.0 %\n 17.6 K/uL\n [image002.jpg]\n 11:32 PM\n 03:23 AM\n 03:31 AM\n 05:18 AM\n 12:31 PM\n 02:30 PM\n 02:38 PM\n 08:24 PM\n 01:29 AM\n 02:05 AM\n WBC\n 22.8\n 19.8\n 17.6\n Hct\n 25.8\n 30\n 28.1\n 29.0\n Plt\n 75\n 44\n 38\n Creatinine\n 2.4\n 2.3\n 2.1\n TCO2\n 27\n 26\n 24\n 24\n 26\n 26\n 26\n Glucose\n 84\n 80\n 111\n 110\n 127\n 182\n 164\n Other labs: PT / PTT / INR:19.0/42.6/1.8, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:684/821, Alk-Phos / T bili:207/10.4, Amylase\n / Lipase:831/21, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %,\n Mono:8.0 %, Eos:0.0 %, Fibrinogen:336 mg/dL, Lactic Acid:2.4 mmol/L,\n Albumin:1.8 g/dL, LDH: IU/L, Ca:8.5 mg/dL, Mg:2.1 mg/dL, PO4:3.9\n mg/dL\n Microbiology: pleural fluid: P\n pleural tissue: P\n pleural tissue: P\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), HYPOTENSION (NOT SHOCK), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INEFFECTIVE COPING, INTESTINAL ISCHEMIA\n (INCLUDING MESENTERIC VENOUS / ARTERIAL THROMBOSIS, BOWEL ISCHEMIA),\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), HYPERTENSION, BENIGN,\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION, CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD,\n BRONCHITIS, EMPHYSEMA) WITHOUT ACUTE EXACERBATION\n Assessment and Plan: 60M w/ ischemic bowel, s/p exlap, SBR, open abd\n , s/p ex lap, hematoma evacuation , s/p ex lap, end jejunostomy\n (150 cm SB), open abd .\n Neurologic: Midaz & fentanyl gtts.\n Cardiovascular: septic shock on pressors. Esmolol & neo gtts for Afib\n (weaning neo). Will sync defib if unstable afib recurs. No shock for\n vtach/vifib. Currently HD stable.\n Pulmonary: Cont ETT, (Ventilator mode: CMV), Normal ABG on FiO2 50%,\n PEEP 5. Continue nebs. Will stop stress dose steroids today.\n Gastrointestinal / Abdomen: OR tomorrow per team. LFTs trending\n down. Continue NPO/NGT.\n Nutrition: TPN started yest.\n Renal: Foley, CVVH, Minimal UOP. Continue CVVH as per Renal. Lytes\n improved. Cr improved @ 2.1. may continue prednisone 5mg for\n immunosuppression.\n Hematology: Serial Hct, Hct stable (29), coags stable (INR 1.8),\n thrombocytopenia, continue to trend down, question of functionality.\n transfuse plt today.\n Endocrine: RISS, Goal FS<180. stop for hydrocort for adrenal\n suppression.\n Infectious Disease: surveillance check cultures, Continue\n immunosuppression as per Transplant. Continue vanc, Zosyn, Flagyl. \n start antifungals.\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP)\n Wounds: Wound vacuum\n Imaging:\n Fluids: Other, dialysate\n Consults: Transplant, Nephrology\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Insufficiency /\n Post-op), Post-op complication, (Shock: Septic), Liver failure, Acute\n renal failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n 18 Gauge - 08:00 AM\n Arterial Line - 04:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674760,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt into afib with HR to 130\ns with drop in BP to 70\ns systolic\n Action:\n IVF given\n Neosynephrine restarted\n MD aware and in to room, patient cardioverted x2 with success to SR in\n 80\n Patient then quickly back into afib with HR 130\ns, neo increased to\n keep sys >100 and lopressor given to slow rate\n Esmolol started and titrated up accordingly to 100 mcg/kg/min\n Patient rebolused with low svr\n Response:\n Patient spontaneous converted to nsr with rate 80\ns on 100 mcg esmolol\n Plan:\n Cont esmolol gtt and titrate accordingly for hr control\n Neo as needed to keep sys >90\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 675164,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated/sedated\n Lung fields very diminished throughout\n Action:\n No weaning\n VAP prevention\n Response:\n ABGS good and improved\n Plan:\n Continue to check abgs q 6 hrs, adjust according to lab values.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CRRT running, goal to make patient 1 lter negative\n Action:\n Running 50 cc negative\n Occassionally needed to give fluid during day, but over all negative\n Citrate added this pm for increasing clots in filter.\n Response:\n Tolerating fairly well.\n One liter negative so far.\n Plan:\n Continue with CRRt\n Keep even once goal of one liter fluid off met.\n Hypotension (not Shock)\n Assessment:\n Blood pressure stable on neo .3-.8\n Responds well to fluid returned duing dialysis\n Action:\n Neo between .3-.8\n Response:\n SBP>90 most of shift\n Plan:\n Keep neo at current dose\n Take off fluid with dialysis if tolerated.\n Atrial fibrillation (Afib)\n Assessment:\n Patient with episodes of afib, requiring cardioversion.\n Stable today, in NSR with rare PAC\n Esmolol at 50 mcg\n Action:\n Lytes checked q 6 hrs, replaced as ordered\n Response:\n Remains in NSR\n Plan:\n Keep sedation at current doses, may increase if needed\n Frequent electrolyte checks if more frequent ectopy\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 675342,
"text": "SICU\n HPI:\n 60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n .\n Chief complaint:\n shock, postoperative respiratory failure\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-ass R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n Current medications:\n 20 gm Calcium Gluconate/ 500 mL D5W 8. Albuterol Inhaler 9. Calcium\n Chloride\n 10. Chlorhexidine Gluconate 0.12% Oral Rinse 11. Citrate Dextrose 3%\n (ACD-A) CRRT 12. Famotidine 13. Fentanyl Citrate\n 14. Fluticasone Propionate 110mcg 15. Heparin Flush (10 units/ml) 16.\n Heparin Flush (10 units/ml)\n 17. Heparin Flush (5000 Units/mL) 18. Insulin 19. Ipratropium Bromide\n MDI 20. Magnesium Sulfate 21. MetRONIDAZOLE (FLagyl)\n 22. MethylPREDNISolone Sodium Succ 23. Midazolam 24. Mycophenolate\n Mofetil 25. Phenylephrine 26. Piperacillin-Tazobactam Na\n 27. Potassium Chloride 28. Potassium Chloride 10 mEq / 100 mL SW (CRRT\n Only) 29. Prismasate (B22 K4)*\n 30. Prismasate (B22 K4) 31. Sodium Chloride 0.9% Flush 32. Sodium\n CITRATE 4% 33. Sodium Chloride 0.9% Flush\n 34. Sodium CITRATE 4% 35. Tacrolimus Suspension 36. Vancomycin\n 24 Hour Events:\n No events.\n Post operative day:\n POD#4 - expl lap\n POD#3 - Hematoma cleaned out, one area on bowel to watch, ABD left\n open, will return to OR tomorrow \n POD#2 - exlap\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 08:28 AM\n Metronidazole - 02:05 PM\n Piperacillin/Tazobactam (Zosyn) - 11:09 PM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Midazolam (Versed) - 3 mg/hour\n Esmolol - 50 mcg/Kg/min\n Insulin - Regular - 10 units/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 10:31 AM\n Other medications:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 37.2\nC (99\n HR: 88 (74 - 88) bpm\n BP: 116/63(79) {88/55(65) - 124/71(89)} mmHg\n RR: 27 (20 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 114.9 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 11 (5 - 19) mmHg\n CO/CI (Thermodilution): (4.91 L/min) / (2.1 L/min/m2)\n SVR: -4,024 dynes*sec/cm5\n SV: 61 mL\n SVI: 27 mL/m2\n Total In:\n 6,277 mL\n 2,332 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,010 mL\n 2,332 mL\n Blood products:\n 237 mL\n Total out:\n 7,630 mL\n 1,730 mL\n Urine:\n 100 mL\n 11 mL\n NG:\n 650 mL\n Stool:\n 30 mL\n 100 mL\n Drains:\n 900 mL\n 625 mL\n Balance:\n -1,353 mL\n 602 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 27 cmH2O\n Plateau: 14 cmH2O\n SPO2: 100%\n ABG: 7.38/40/113/22/0\n Ve: 17.4 L/min\n PaO2 / FiO2: 226\n Physical Examination\n General Appearance: Overweight / Obese, intubated and sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: throughout)\n Abdominal: Soft, Distended, Obese\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Posterior\n tibial: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: open abomen\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 48 K/uL\n 10.6 g/dL\n 245 mg/dL\n 2.2 mg/dL\n 22 mEq/L\n 4.1 mEq/L\n 55 mg/dL\n 100 mEq/L\n 133 mEq/L\n 30.1 %\n 11.0 K/uL\n [image002.jpg]\n 08:24 PM\n 01:29 AM\n 02:05 AM\n 07:48 AM\n 02:21 PM\n 02:22 PM\n 07:27 PM\n 07:47 PM\n 01:57 AM\n 02:18 AM\n WBC\n 17.6\n 12.0\n 11.0\n Hct\n 29.0\n 27.5\n 30.1\n Plt\n 38\n 80\n 49\n 48\n Creatinine\n 2.1\n 2.2\n 2.2\n TCO2\n 26\n 26\n 23\n 25\n 28\n 25\n Glucose\n 127\n 182\n 164\n 179\n 198\n 226\n 208\n 245\n Other labs: PT / PTT / INR:17.1/42.2/1.6, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:469/423, Alk-Phos / T bili:175/8.8, Amylase /\n Lipase:831/21, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %,\n Mono:8.0 %, Eos:0.0 %, Fibrinogen:267 mg/dL, Lactic Acid:2.2 mmol/L,\n Albumin:1.8 g/dL, LDH: IU/L, Ca:9.3 mg/dL, Mg:2.3 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), HYPOTENSION (NOT SHOCK), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INEFFECTIVE COPING, INTESTINAL ISCHEMIA\n (INCLUDING MESENTERIC VENOUS / ARTERIAL THROMBOSIS, BOWEL ISCHEMIA),\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), HYPERTENSION, BENIGN,\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION, CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD,\n BRONCHITIS, EMPHYSEMA) WITHOUT ACUTE EXACERBATION\n Assessment and Plan: 60M admitted to for COPD exacerbation, became\n septic, developed ischemic bowel, s/p exlap, SBR, open abd , s/p ex\n lap, hematoma evacuation , s/p ex lap, end jejunostomy (150 cm SB),\n open abd .\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, wean fentanyl gtt\n from 150 to 100mcg. Wean midaz gtt to intermittent blousing prn.\n Cardiovascular: AFIB. Beta-blocker. Rate controlled, weaning esmolol\n gtt to off as tolerated. Hypotensive on Neo. No amio or dilt for afib\n given recent shock liver (amio) and interaction with prograf (dilt).\n Pulmonary: Cont ETT, (Ventilator mode: CMV). Oxygenating/ ventilating\n well on current settings. Flovent/Atrovent/albuterol\n Gastrointestinal / Abdomen: NPO, shock liver improving. LFTs trending\n down, TPN\n Nutrition: TPN\n Renal: Foley, UOP minimal, ARF on CRF, Cr 2.1 trending down, cont\n tacrolimus and Cellcept, check levels, CVVH, -1L neg\n Hematology: thrombocytopenia\n slightly improved. Serial Hct, stable\n anemia, plts, coags, f/u HIT panel. Patient does not receive heparin.\n Endocrine: hyperglycemia. Insulin drip for bs-200's, started insulin\n drip. Keep < 150\n Infectious Disease: leukocytosis improving. Check cultures, cont\n empiric Zosyn, Flagyl, vanc, f/u cx, vanc level, surveilance cx.\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP),\n Aline, dialysis catheter, central line, open abd\n Wounds: open abdomen covered in ioban\n Imaging: none\n Fluids: CVVH\n Consults: Transplant, Nephrology\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n (Shock: Septic)\n ICU Care\n Nutrition:\n Comments: TPN\n Glycemic Control: Insulin infusion\n Lines:\n Midline - 10:00 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n Arterial Line - 04:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 25 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 675232,
"text": "Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 675233,
"text": "Hypotension (not Shock)\n Assessment:\n SBP 90-120\n Neo gtt to keep SBP >90\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "General",
"chartdate": "2104-06-12 00:00:00.000",
"description": "ICU Event Note",
"row_id": 674734,
"text": "Clinician: Resident\n Pt went into atrial fibrillation with rate 140s, hypotensive to SBP\n 70s. Started neo w/ some improvement in rate 110-120s. Gradually\n returned to 140s. Premedicated w/ midaz and fentanyl. Shocked 200kJ\n then 360kJ, then returned to sinus tachy. Gave Lopressor while\n awaiting esmolol gtt. Fellow & attending present.\n Total time spent: 45 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674800,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt into afib with HR to 130\ns with drop in BP to 70\ns systolic\n Action:\n IVF given\n Neosynephrine restarted\n MD aware and in to room, patient cardioverted x2 with success to SR in\n 80\n Patient then quickly back into afib with HR 130\ns, neo increased to\n keep sys >100 and lopressor given to slow rate\n Esmolol started and titrated up accordingly to 100 mcg/kg/min\n Patient rebolused with low svr\n Response:\n Patient spontaneous converted to nsr with rate 80\ns on 100 mcg esmolol\n Plan:\n Cont esmolol gtt and titrate accordingly for hr control\n Neo as needed to keep sys >90\n Ineffective Coping\n Assessment:\n mother abruptly calling and speaking with MD to make patient DNR\n Action:\n family meeting today with mother, son, patient cousin and patients\n aunt, MD and MD , SW \n Response:\n family feeling supported by health care team\n family happy with results of family meeting and with updates\n Plan:\n Patient is DNR but cardioversion ok for afib\n cont to update family prn\n MD\ns will continue to update mother with status and mother to inform\n family of patient condition, OK to call son as well with concerns\n SW to follow up with mother regarding legal guardian so mother can pay\n bills on behalf of patient\n reconvene with family if patient status declines\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n remains on CVVHDF\n Action:\n CVVHDF, unable to remove any fluid secondary to pressor requirement\n Response:\n acid base balance normalized\n K and ca with sliding scale\n Plan:\n cont CVVHDF\n renal to change to lower bicard solution secondary to improved overall\n acid base picture\n remove fluid as tolerated\n prograf and vanco levels in am and dose accordingly\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n abd remains open\n dusky appearing ileostomy\n Action:\n return to OR s/p washout and end ileostomy\n Response:\n illeostomy remains dusky\n JP x2 to wall suction\n Plan:\n cont to monitor abdominal status\n follow JP output\n follow labs\n OR over weekend for washout and possible closure\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 675236,
"text": "Hypotension (not Shock)\n Assessment:\n SBP 90-120\n Neo gtt to keep SBP >90\n Action:\n Titrating neo gtt to keep SBP >90\n Response:\n BP stable on neo gtt 0.5-0.8mcg/kg/hr\n Plan:\n Continue to wean neo gtt as tolerated\n Keep SBP >90\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in NSR, rare PVC\ns and PAC\ns noted\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 675238,
"text": "Hypotension (not Shock)\n Assessment:\n SBP 90-120\n Neo gtt to keep SBP >90\n Action:\n Titrating neo gtt to keep SBP >90\n Response:\n BP stable on neo gtt 0.5-0.8mcg/kg/hr\n Plan:\n Continue to wean neo gtt as tolerated\n Keep SBP >90\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in NSR, rare PVC\ns and PAC\ns noted\n Esmolol gtt continues\n Action:\n Continue with esmolol gtt\n Monitor lytes/labs\n Response:\n Pt remains in NSR\n Plan:\n Continue with esmolol gtt\n Cardioversion if pt converts to afib\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CRRT continues\n Pt approx 1200cc negative as of MN\n BUN 5\n Action:\n Response:\n Plan:\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-14 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 675239,
"text": "Demographics\n Day of intubation: 10\n Day of mechanical ventilation: 10\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL / Air\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n"
},
{
"category": "Nutrition",
"chartdate": "2104-06-13 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 675061,
"text": "Objective\n Adm wt: 91.7kg\n Current Wt: 113.1kg\n Pertinent medications: Phenylephrine, Fentanyl, Versed, RISS, ABx,\n Pepcid, others noted\n Labs:\n Value\n Date\n Glucose\n 198 mg/dL\n 02:22 PM\n Glucose Finger Stick\n 257\n 02:00 PM\n BUN\n 47 mg/dL\n 01:29 AM\n Creatinine\n 2.1 mg/dL\n 01:29 AM\n Sodium\n 129 mEq/L\n 02:22 PM\n Potassium\n 3.9 mEq/L\n 02:22 PM\n Chloride\n 102 mEq/L\n 01:29 AM\n TCO2\n 23 mEq/L\n 01:29 AM\n PO2 (arterial)\n 116 mm Hg\n 02:22 PM\n PO2 (venous)\n 35 mm Hg\n 03:48 AM\n PCO2 (arterial)\n 36 mm Hg\n 02:22 PM\n PCO2 (venous)\n 39 mm Hg\n 03:48 AM\n pH (arterial)\n 7.44 units\n 02:22 PM\n pH (venous)\n 7.31 units\n 03:48 AM\n pH (urine)\n 5.5 units\n 11:28 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 02:22 PM\n CO2 (Calc) venous\n 21 mEq/L\n 03:48 AM\n Albumin\n 1.8 g/dL\n 05:50 PM\n Calcium non-ionized\n 8.5 mg/dL\n 01:29 AM\n Phosphorus\n 3.9 mg/dL\n 01:29 AM\n Ionized Calcium\n 1.19 mmol/L\n 02:22 PM\n Magnesium\n 2.1 mg/dL\n 01:29 AM\n ALT\n 684 IU/L\n 01:29 AM\n Alkaline Phosphate\n 207 IU/L\n 01:29 AM\n AST\n 821 IU/L\n 01:29 AM\n Amylase\n 831 IU/L\n 06:09 AM\n Total Bilirubin\n 10.4 mg/dL\n 01:29 AM\n Triglyceride\n 119 mg/dL\n 02:30 PM\n WBC\n 17.6 K/uL\n 01:29 AM\n Current diet order / nutrition support: TPN: Day 2 std. with non-std\n lytes\n GI: 1170mL OGT o/p \n Assessment of Nutritional Status\n 60 y.o. M with ESRD admitted with COPD/respiratory distress, found to\n have ischemic bowel, now s/p ex lap and SBR , takeback to OR \n for hematoma evacuation, and for washout, bowel resection and end\n ileostomy. Abdomen left open. TPN was started for nutrition\n support given inability to use gut for feeding. Patient is on CRRT,\n requiring pressor support, and remains intubated and sedated. Patient\n has high BG; recommend only increasing dextrose in TPN if BG are less\n than 175. Triglycerides are less than 400, so ok to add lipid to TPN.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) If BG less than 175, advance TPN to 2060mL (310dextrose/\n 115amino acid/ 50fat). If BG still high, recommend reordering same TPN\n as today. (Day 2 std).\n 2) Goal TPN: 2060mL (390dextrose/ 115amino acids/ 50fat) =\n 2286kcals.\n 3) Following, will make TPN recs daily based on FSBG and lytes.\n Please page with any questions. #\n"
},
{
"category": "Social Work",
"chartdate": "2104-06-13 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 675068,
"text": "Family Information\n Next of : / mother\n Health Proxy appointed: Yes - But NO copy of signed proxy form in\n medical record\n Family Spokesperson designated: mother and son \n Communication or visitation restriction: NA\n Patient Information:\n Previous living situation:\n Previous level of functioning: Independent, Required assistance with\n care\n Previous or other hospital admissions: multiple medical\n admissions, well known to transplant dept.\n Past psychiatric history: unknown\n Past addictions history: ETOH\n Employment status: Disabled\n Legal involvement: NA\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment:\n Family meeting held yesterday , present are pt's mother, son,\n grand-daughter and aunt. Pt's surgical Attending and SICU Attending\n presented medical update, pt noted to have a better prognosis at the\n time of this meeting than was initially anticipated. Family requests\n that the medical team move forward with care on behalf of the pt,\n wanted to be re-assured that pt would be pain free. Family also\n requesting close communication re: medical status as they want\n pt's quality of life to be a priority, family reviewed all of pt's past\n medical history stating that they believe pt is medically fragile going\n into current surgery's. mother requesting assistance to legally\n manage pt's social security check in order to pay his rent and manage\n his financial matters. Temporary Guardianship paperwork in process,\n mother to present it to the court next week. Will follow pt's progress\n and assist family with concrete needs.\n Clergy Contact:\n Communication with Team:\n Plan / Follow up:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 675301,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt remains in NSR\n PAC\ns and PVC\ns noted\n Esmolol gtt continues\n Action:\n Continue with esmolol gtt\n Monitor labs\n Replete lytes prn\n Response:\n Pt remains in NSR throughout shift\n PAC\ns and PVC\ns continue\n Labs remain wnl\n Plan:\n Continue to monitor labs\n Cardioversion if pt converts to Afib\n Continue with esmolol\n Hypotension (not Shock)\n Assessment:\n SBP remains 90-120\n Neo gtt to maintain SBP >90\n Pt with labile BP, especially with turning, worsening after fluid\n removal with CRRT\n Action:\n Fluid removal stopped\n Neo gtt titrated to maintain SBP >90\n Fluid bolus as needed\n Response:\n SBP remains relativ\n Plan:\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 675307,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt remains in NSR\n PAC\ns and PVC\ns noted\n Esmolol gtt continues\n Action:\n Continue with esmolol gtt\n Monitor labs\n Replete lytes prn\n Response:\n Pt remains in NSR throughout shift\n PAC\ns and PVC\ns continue\n Labs remain wnl\n Plan:\n Continue to monitor labs\n Cardioversion if pt converts to Afib\n Continue with esmolol\n Hypotension (not Shock)\n Assessment:\n SBP remains 90-120\n Neo gtt to maintain SBP >90\n Pt with labile BP, especially with turning, worsening after fluid\n removal with CRRT\n Action:\n Fluid removal stopped\n Neo gtt titrated to maintain SBP >90\n Fluid bolus as needed\n Response:\n SBP remains relatively stable with neo gtt 0.5-1mcg/kg/min\n Noted improvement in BP with fluid\n Plan:\n Continue to wean neo gtt as tolerated\n Maintain SBP >90\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n ABD remains open\n Ileostomy remain red in color, green loose stool and maroon liquid\n stool noted\n JP x2 to wall suction, serosang drainage in mod amounts\n Action:\n Continue to remove fluid as tolerated to prepare for OR closure of ABD\n Monitoring labs\n Response:\n Labs remain wnl with LFT\ns improving\n Pt ABD remains wnl\n Stoma improving in color\n Plan:\n Monitor labs\n Monitor stoma\n OR \n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt remains on CRRT\n Labs wnl\n BUN 55 Cr 2.2\n Remains oliguric with green clear urine\n Action:\n Removing fluid as tolerates\n Replacement and dialysate solution changed to B22 K4\n Monitoring labs\n Lyte repletion prn\n Response:\n BUN and Cr remain the same\n No improvement in urine output\n Plan:\n Continue with CRRT for goal of negative 1-2L\n Continue with dialysis for renal function\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 675326,
"text": "SICU\n HPI:\n 60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n .\n Chief complaint:\n shock, postoperative respiratory failure\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-ass R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n Current medications:\n 20 gm Calcium Gluconate/ 500 mL D5W 8. Albuterol Inhaler 9. Calcium\n Chloride\n 10. Chlorhexidine Gluconate 0.12% Oral Rinse 11. Citrate Dextrose 3%\n (ACD-A) CRRT 12. Famotidine 13. Fentanyl Citrate\n 14. Fluticasone Propionate 110mcg 15. Heparin Flush (10 units/ml) 16.\n Heparin Flush (10 units/ml)\n 17. Heparin Flush (5000 Units/mL) 18. Insulin 19. Ipratropium Bromide\n MDI 20. Magnesium Sulfate 21. MetRONIDAZOLE (FLagyl)\n 22. MethylPREDNISolone Sodium Succ 23. Midazolam 24. Mycophenolate\n Mofetil 25. Phenylephrine 26. Piperacillin-Tazobactam Na\n 27. Potassium Chloride 28. Potassium Chloride 10 mEq / 100 mL SW (CRRT\n Only) 29. Prismasate (B22 K4)*\n 30. Prismasate (B22 K4) 31. Sodium Chloride 0.9% Flush 32. Sodium\n CITRATE 4% 33. Sodium Chloride 0.9% Flush\n 34. Sodium CITRATE 4% 35. Tacrolimus Suspension 36. Vancomycin\n 24 Hour Events:\n No events.\n Post operative day:\n POD#4 - expl lap\n POD#3 - Hematoma cleaned out, one area on bowel to watch, ABD left\n open, will return to OR tomorrow \n POD#2 - exlap\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 08:28 AM\n Metronidazole - 02:05 PM\n Piperacillin/Tazobactam (Zosyn) - 11:09 PM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Midazolam (Versed) - 3 mg/hour\n Esmolol - 50 mcg/Kg/min\n Insulin - Regular - 10 units/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 10:31 AM\n Other medications:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 37.2\nC (99\n HR: 88 (74 - 88) bpm\n BP: 116/63(79) {88/55(65) - 124/71(89)} mmHg\n RR: 27 (20 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 114.9 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 11 (5 - 19) mmHg\n CO/CI (Thermodilution): (4.91 L/min) / (2.1 L/min/m2)\n SVR: -4,024 dynes*sec/cm5\n SV: 61 mL\n SVI: 27 mL/m2\n Total In:\n 6,277 mL\n 2,332 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,010 mL\n 2,332 mL\n Blood products:\n 237 mL\n Total out:\n 7,630 mL\n 1,730 mL\n Urine:\n 100 mL\n 11 mL\n NG:\n 650 mL\n Stool:\n 30 mL\n 100 mL\n Drains:\n 900 mL\n 625 mL\n Balance:\n -1,353 mL\n 602 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 27 cmH2O\n Plateau: 14 cmH2O\n SPO2: 100%\n ABG: 7.38/40/113/22/0\n Ve: 17.4 L/min\n PaO2 / FiO2: 226\n Physical Examination\n General Appearance: Overweight / Obese, intubated and sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: throughout)\n Abdominal: Soft, Distended, Obese\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Posterior\n tibial: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: open abomen\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 48 K/uL\n 10.6 g/dL\n 245 mg/dL\n 2.2 mg/dL\n 22 mEq/L\n 4.1 mEq/L\n 55 mg/dL\n 100 mEq/L\n 133 mEq/L\n 30.1 %\n 11.0 K/uL\n [image002.jpg]\n 08:24 PM\n 01:29 AM\n 02:05 AM\n 07:48 AM\n 02:21 PM\n 02:22 PM\n 07:27 PM\n 07:47 PM\n 01:57 AM\n 02:18 AM\n WBC\n 17.6\n 12.0\n 11.0\n Hct\n 29.0\n 27.5\n 30.1\n Plt\n 38\n 80\n 49\n 48\n Creatinine\n 2.1\n 2.2\n 2.2\n TCO2\n 26\n 26\n 23\n 25\n 28\n 25\n Glucose\n 127\n 182\n 164\n 179\n 198\n 226\n 208\n 245\n Other labs: PT / PTT / INR:17.1/42.2/1.6, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:469/423, Alk-Phos / T bili:175/8.8, Amylase /\n Lipase:831/21, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %,\n Mono:8.0 %, Eos:0.0 %, Fibrinogen:267 mg/dL, Lactic Acid:2.2 mmol/L,\n Albumin:1.8 g/dL, LDH: IU/L, Ca:9.3 mg/dL, Mg:2.3 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), HYPOTENSION (NOT SHOCK), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INEFFECTIVE COPING, INTESTINAL ISCHEMIA\n (INCLUDING MESENTERIC VENOUS / ARTERIAL THROMBOSIS, BOWEL ISCHEMIA),\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), HYPERTENSION, BENIGN,\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION, CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD,\n BRONCHITIS, EMPHYSEMA) WITHOUT ACUTE EXACERBATION\n Assessment and Plan: 60M admitted to for COPD exacerbation, became\n septic, developed ischemic bowel, s/p exlap, SBR, open abd , s/p ex\n lap, hematoma evacuation , s/p ex lap, end jejunostomy (150 cm SB),\n open abd .\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, wean fentanyl gtt\n from 150 to 100mcg. Wean midaz gtt to intermittent blousing prn.\n Cardiovascular: AFIB. Beta-blocker. Rate controlled, weaning esmolol\n gtt to off as tolerated. Hypotensive on Neo. No amio or dilt for afib\n given recent shock liver.\n Pulmonary: Cont ETT, (Ventilator mode: CMV), overbreathing vent. Will\n attempt weaning to CPAP/PS. Oxygenating/ ventilating well on current\n settings. Flovent/Atrovent/albuterol\n Gastrointestinal / Abdomen: NPO, shock liver improving. LFTs trending\n down, TPN\n Nutrition: TPN\n Renal: Foley, UOP minimal, ARF on CRF, Cr 2.1 trending down, cont\n tacrolimus and Cellcept, check levels, CVVH, -1L neg\n Hematology: thrombocytopenic. Serial Hct, hct-stable, plts, coags, f/u\n HIT panel.\n Endocrine: hyperglycemia. Insulin drip for bs-200's, started insulin\n drip.\n Infectious Disease: leukocytosis improving. Check cultures, cont Zosyn,\n Flagyl, vanc, f/u cx, vanc level, surveilance cx.\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP),\n Aline, dialysis catheter, central line, open abd\n Wounds: open abdomen covered in ioban\n Imaging: none\n Fluids: CVVH\n Consults: Transplant, Nephrology\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n (Shock: Septic)\n ICU Care\n Nutrition:\n Comments: TPN\n Glycemic Control: Insulin infusion\n Lines:\n Midline - 10:00 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n Arterial Line - 04:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 675132,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CRRT running, goal to make patient 1 lter negative\n Action:\n Running 50 cc negative\n Occassionally needed to give fluid during day, but over all negative\n Citrate added this pm for increasing clots in filter.\n Response:\n Tolerating fairly well.\n One liter negative so far.\n Plan:\n Continue with CRRt\n Keep even once goal of one liter fluid off met.\n Hypotension (not Shock)\n Assessment:\n Blood pressure stable on neo .3-.8\n Responds well to fluid returned duing dialysis\n Action:\n Neo between .3-.8\n Response:\n SBP>90 most of shift\n Plan:\n Keep neo at current dose\n Take off fluid with dialysis if tolerated.\n Atrial fibrillation (Afib)\n Assessment:\n Patient with episodes of afib, requiring cardioversion.\n Stable today, in NSR with rare PAC\n Esmolol at 50 mcg\n Action:\n Lytes checked q 6 hrs, replaced as ordered\n Response:\n Remains in NSR\n Plan:\n Keep sedation at current doses, may increase if needed\n Frequent electrolyte checks if more frequent ectopy\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 675287,
"text": "SICU\n HPI:\n 60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n .\n Chief complaint:\n shock, postoperative respiratory failure\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-ass R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n Current medications:\n 20 gm Calcium Gluconate/ 500 mL D5W 8. Albuterol Inhaler 9. Calcium\n Chloride\n 10. Chlorhexidine Gluconate 0.12% Oral Rinse 11. Citrate Dextrose 3%\n (ACD-A) CRRT 12. Famotidine 13. Fentanyl Citrate\n 14. Fluticasone Propionate 110mcg 15. Heparin Flush (10 units/ml) 16.\n Heparin Flush (10 units/ml)\n 17. Heparin Flush (5000 Units/mL) 18. Insulin 19. Ipratropium Bromide\n MDI 20. Magnesium Sulfate 21. MetRONIDAZOLE (FLagyl)\n 22. MethylPREDNISolone Sodium Succ 23. Midazolam 24. Mycophenolate\n Mofetil 25. Phenylephrine 26. Piperacillin-Tazobactam Na\n 27. Potassium Chloride 28. Potassium Chloride 10 mEq / 100 mL SW (CRRT\n Only) 29. Prismasate (B22 K4)*\n 30. Prismasate (B22 K4) 31. Sodium Chloride 0.9% Flush 32. Sodium\n CITRATE 4% 33. Sodium Chloride 0.9% Flush\n 34. Sodium CITRATE 4% 35. Tacrolimus Suspension 36. Vancomycin\n 24 Hour Events:\n Post operative day:\n POD#4 - expl lap\n POD#3 - Hematoma cleaned out, one area on bowel to watch, ABD left\n open, will return to OR tomorrow \n POD#2 - exlap\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 08:28 AM\n Metronidazole - 02:05 PM\n Piperacillin/Tazobactam (Zosyn) - 11:09 PM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Midazolam (Versed) - 3 mg/hour\n Esmolol - 50 mcg/Kg/min\n Insulin - Regular - 10 units/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 10:31 AM\n Other medications:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 37.2\nC (99\n HR: 88 (74 - 88) bpm\n BP: 116/63(79) {88/55(65) - 124/71(89)} mmHg\n RR: 27 (20 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 114.9 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 11 (5 - 19) mmHg\n CO/CI (Thermodilution): (4.91 L/min) / (2.1 L/min/m2)\n SVR: -4,024 dynes*sec/cm5\n SV: 61 mL\n SVI: 27 mL/m2\n Total In:\n 6,277 mL\n 2,332 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,010 mL\n 2,332 mL\n Blood products:\n 237 mL\n Total out:\n 7,630 mL\n 1,730 mL\n Urine:\n 100 mL\n 11 mL\n NG:\n 650 mL\n Stool:\n 30 mL\n 100 mL\n Drains:\n 900 mL\n 625 mL\n Balance:\n -1,353 mL\n 602 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 27 cmH2O\n Plateau: 14 cmH2O\n SPO2: 100%\n ABG: 7.38/40/113/22/0\n Ve: 17.4 L/min\n PaO2 / FiO2: 226\n Physical Examination\n General Appearance: Overweight / Obese, intubated and sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: throughout)\n Abdominal: Soft, Distended, Obese\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Posterior\n tibial: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: open abomen\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 48 K/uL\n 10.6 g/dL\n 245 mg/dL\n 2.2 mg/dL\n 22 mEq/L\n 4.1 mEq/L\n 55 mg/dL\n 100 mEq/L\n 133 mEq/L\n 30.1 %\n 11.0 K/uL\n [image002.jpg]\n 08:24 PM\n 01:29 AM\n 02:05 AM\n 07:48 AM\n 02:21 PM\n 02:22 PM\n 07:27 PM\n 07:47 PM\n 01:57 AM\n 02:18 AM\n WBC\n 17.6\n 12.0\n 11.0\n Hct\n 29.0\n 27.5\n 30.1\n Plt\n 38\n 80\n 49\n 48\n Creatinine\n 2.1\n 2.2\n 2.2\n TCO2\n 26\n 26\n 23\n 25\n 28\n 25\n Glucose\n 127\n 182\n 164\n 179\n 198\n 226\n 208\n 245\n Other labs: PT / PTT / INR:17.1/42.2/1.6, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:469/423, Alk-Phos / T bili:175/8.8, Amylase /\n Lipase:831/21, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %,\n Mono:8.0 %, Eos:0.0 %, Fibrinogen:267 mg/dL, Lactic Acid:2.2 mmol/L,\n Albumin:1.8 g/dL, LDH: IU/L, Ca:9.3 mg/dL, Mg:2.3 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), HYPOTENSION (NOT SHOCK), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INEFFECTIVE COPING, INTESTINAL ISCHEMIA\n (INCLUDING MESENTERIC VENOUS / ARTERIAL THROMBOSIS, BOWEL ISCHEMIA),\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), HYPERTENSION, BENIGN,\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION, CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD,\n BRONCHITIS, EMPHYSEMA) WITHOUT ACUTE EXACERBATION\n Assessment and Plan: 60M admitted to for COPD exacerbation, became\n septic, developed ischemic bowel, s/p exlap, SBR, open abd , s/p ex\n lap, hematoma evacuation , s/p ex lap, end jejunostomy (150 cm SB),\n open abd .\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, fentanyl & midaz gtt\n Cardiovascular: Beta-blocker, esmolol gtt/neo for Afib (no amio or\n dilt)\n Pulmonary: Cont ETT, (Ventilator mode: CMV), CMV, wean, cont\n Flovent/Atrovent/albuterol\n Gastrointestinal / Abdomen: NPO, LFTs trending down, TPN\n Nutrition: TPN\n Renal: Foley, UOP minimal, ARF on CRF, Cr 2.1 trending down, cont\n tacrolimus and Cellcept, check levels, CVVH, -1L neg\n Hematology: Serial Hct, hct-stable, plts, coags, f/u HIT panel\n Endocrine: Insulin drip, bs-200's, started insulin drip\n Infectious Disease: Check cultures, cont Zosyn, Flagyl, vanc, f/u cx,\n vanc level, surveilance cx\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP),\n Aline, dialysis catheter, central line, open abd\n Wounds: open abdomen covered in ioban\n Imaging:\n Fluids: CVVH\n Consults: Transplant, Nephrology\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n (Shock: Septic)\n ICU Care\n Nutrition:\n Comments: TPN\n Glycemic Control: Insulin infusion\n Lines:\n Midline - 10:00 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n Arterial Line - 04:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 675904,
"text": "Hypotension (not Shock)\n Assessment:\n Received on pitressin and phenylephrine to maintain SBP >90.\n Tachycardiac, hct drop to 23.5.\n Plt to 14.\n CRRT running to keep pt even though had episode of\n hypotension for the day shift.\n SVV ranging from 10 -18 throughout the shift. CO/CI approx\n 7-9/3.1-4.8. GEDI approx 700.\n Action:\n Received 2 units of red cells this shift and 1 unit of\n platelets.\n Weaned phenyleprine to off. Attempted to wean pitressin when\n SBPs 110s-120s after discussion with Dr. .\n Albumin given as ordered.\n HIT panel was sent yesterday during the day shift and all\n heparin flushes/meds etc were discontinued.\n Response:\n Tolerated neo wean well though hypotensive to mid 80s after\n pitressin was turned off.\n Slightly more tachycardia, high 90s to low 100s, most of\n this shift compared to the day shift.\n Hct stable at 26-27. Plts at 29. goal PLT >20 per Dr. .\n Pt was even fluid balance for yesterday.\n Responds well hemodynamically to Albumin and blood products.\n Plan:\n Continue with pitressin to maintain SBP parameters. Frequent checking\n of labs esp Hct and PLts. Products as indicated. Follow up with HIT\n panel, do not use any heparin products.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CVVHDF with goal of running patient even.\n BUN/Cr 48/2. Oliguric with greenish clear urine.\n K slightly elevated (4.7) and bicarb 21. Replacement and\n Dialysate fluids are bicarb 22/ K 4.\n Normal acid/base balance with slight lean towards alkalosis.\n Normal pCO2 and paO2 levels.\n Labile FS, on moderate doses of insulin gtt.\n Action:\n Ran CRRT exactly even yesterday.\n Titrated insulin gtt to maintain good glycemic control.\n Calcium and pH wnl though K is >4.6 and bicarb on the lower\n side of normal.\n Tacro & Vanco levels to be drawn at 0600.\n Response:\n Pt tolerated CRRT goal well this shift.\n No episodes of hypotension r/t fluid removal.\n Responded well to insulin gtt and blood sugars have ranged\n from 110-170s this shift.\n Plan:\n Monitor lytes frequently. Titrate insulin as indicated.\n D/w renal team switching of dialysis fluids to b32/k2 if K continues to\n climb and bicarb drops (as it did to 19 at approx midnight). If able to\n keep even or even remove fluid, team may have a better chance of\n closing abdomen today in the OR- assess/d/w renal and eval pt\n response.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n On multiple ABX.\n White count down to 0.6.\n Home dose of steroids initiated yesterday as well as\n addition of two more antibiotics.\n Abd open, JP to wall suction with large amounts of output.\n Absent bowel sounds, LS clear.\n Action:\n Bair Hugger on to maintain normal body temp vs. hypothermic.\n Team notified of drop in white count.\n Response:\n Very edematous. Continues to third space.\n Temp 98.2-98.6 with bair hugger.\n Plan:\n Plan for OR today for washout and attempt to close belly.\n Continue with antibiotics and follow ID recs. Maintain intravascular\n volume with products/albumin etc as needed. Provide comfort and\n support.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n CMV 50%/600/28 PEEP 7.\n Action:\n No vent changes made this shift.\n Fent/Versed gtts to manage sedation and decrease\n overbreathing.\n Response:\n Occasionally over breathing vent by 1-2 breaths.\n ? shallow\nguppy\n breaths though oxygenation/ventilation wnl\n according to ABG.\n Plan:\n See nursing care plan. Closely follow ABGs.\n Hx of afib though has remained in sinus rhythm overnight. Would\n cardiovert if needed d/t Diltiazem and Amiodarone\ns interaction with\n tacrolimus. Multiple skin impairments-see metavision flow sheet. Would\n consider switch to Kinair or other pressure reducing bed to manage\n moderate amounts of weeping/seeping fluid from abdominal wound, scrotal\n edema, and increase air circulation. ? wound care consult and if\n already ordered, follow up with wound care for recs for bed and\n management of ozzing. Mother , updated re: .\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-16 00:00:00.000",
"description": "Intensivist Note",
"row_id": 675917,
"text": "SICU\n HPI:\n 60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n .\n Chief complaint:\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-ass R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n Current medications:\n 1. IV access: Peripheral line Order date: @ 1031\n 22. Insulin 100 Units/100 ml NS @ 2 UNIT/HR IV DRIP INFUSION\n Fingersticks every hour Order date: @ 2238\n 2. IV access: PICC, heparin dependent Location: Left basilic, Date\n inserted: Order date: @ 1031\n 23. Ipratropium Bromide MDI 6 PUFF IH Q6H Order date: @ 0150\n 3. IV access: Temporary central access (ICU) Order date: @ 1031\n 24. Magnesium Sulfate IV Sliding Scale Order date: @ 1031\n 4. IV access: Mid-line, heparin dependent Order date: @ 1031\n 25. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n Day 1 Order date: @ 1031\n 5. IV access: Dialysis Catheter (Temporary 2-Lumen) Location: Left\n Internal Jugular, Date inserted: Order date: @ 1031\n 26. Midazolam 0.5-3 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 1639\n 6. IV access: None Order date: @ 1031\n 27. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO sbp>90mmHg Order\n date: @ 1031\n 7. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 1031\n 28. Piperacillin-Tazobactam Na 2.25 g IV Q6H Order date: @ 1031\n 8. Albuterol Inhaler 6 PUFF IH Q6H:PRN dyspnea Order date: @\n 0150\n 29. Potassium Chloride 20 mEq / 50 ml SW IV PRN for K < 3.5\n To supplement CRRT KCL infusion sliding scale protocol. Order date:\n @ 1031\n 9. Albumin 25% (12.5g / 50mL) 12.5 g IV Q8H Duration: 48 Hours Order\n date: @ 0741\n 30. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1031\n 10. Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes Order date: \n @ 2155\n 31. Prismasate (B22 K4)*\n Continuous at 500 ml/hr\n Dialysate Solution for CRRT Order date: @ 1818\n 11. Calcium Chloride IV Sliding Scale Order date: @ 1031\n 32. Prismasate (B22 K4)\n Continuous at ml/hr\n Infuse Replacement fluid: Prefilter Rate:1500 Postfilter Rate:200\n Replacement Solution for CRRT Order date: @ 1140\n 12. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1031\n 33. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1031\n 13. Citrate Dextrose 3% (ACD-A) CRRT 150 mL/hr DIALYS ASDIR\n CRRT Protocol. Monitor systemic ionized calcium q6h. Adjust according\n to renal recommendations. Order date: @ 1611\n 34. Sodium CITRATE 4% 3 mL DWELL ASDIR catheter not in use\n dwell to catheter volume written on catheter Order date: @ 1031\n 14. Ciprofloxacin 400 mg IV Q12H Order date: @ 0716\n 35. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1031\n 15. Famotidine 20 mg IV Q24H Order date: @ 0530\n 36. Sodium CITRATE 4% 2 mL DWELL ASDIR catheter not in use\n dwell to catheter volume printed on lumens Order date: @ 1031\n 16. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \n @ 1031\n 37. Tacrolimus Suspension 1 mg NG QAM Duration: 1 Doses\n Dose to be admin at 5/17 am. No PM dose on Order date: @\n 1734\n 17. Fluticasone Propionate 110mcg 2 PUFF IH Order date: @\n 1031\n 38. Tacrolimus Suspension 0.5 mg PO BID\n Dose to be admin. at 6pm and 6am Order date: @ 1650\n 18. Fluconazole 200 mg IV Q24H Order date: @ 0716\n 39. Vancomycin 1250 mg IV Q 24H Order date: @ 2252\n 19. Fluconazole 200 mg IV ONCE Duration: 1 Doses Start: Order\n date: @ 0757\n 40. Vasopressin 1.2 UNIT/HR IV DRIP TITRATE TO SBP>90 Order date:\n @ 0716\n 20. Hydrocortisone Na Succ. 100 mg IV ONCE Duration: 1 Doses Order\n date: @ 0736\n 41. Vecuronium Bromide 5 mg IV ONCE Duration: 1 Doses\n Patient must be intubated and sedated prior to administering NMBAs\n Order date: @ 0720\n 21. Hydrocortisone Na Succ. 50 mg IV Q8H Order date: @ 1206\n 24 Hour Events:\n - started albumin q8\n - started hydrocortisone q8\n - started vasopressin\n - d/c'd cellcept\n - transfused 2 units plts, 2 units RBC\n Post operative day:\n POD#6 - expl lap\n POD#5 - Hematoma cleaned out, one area on bowel to watch, ABD left\n open, will return to OR tomorrow \n POD#4 - exlap\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Piperacillin - 10:00 PM\n Vancomycin - 08:20 AM\n Fluconazole - 08:41 AM\n Metronidazole - 11:34 PM\n Piperacillin/Tazobactam (Zosyn) - 03:00 AM\n Ciprofloxacin - 05:05 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Insulin - Regular - 12 units/hour\n Calcium Gluconate (CRRT) - 1 grams/hour\n Vasopressin - 1.2 units/hour\n KCl (CRRT) - 1 mEq./hour\n Other ICU medications:\n Vecuronium - 07:15 AM\n Famotidine (Pepcid) - 08:38 AM\n Other medications:\n Flowsheet Data as of 06:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 36.9\nC (98.4\n HR: 99 (88 - 104) bpm\n BP: 115/63(78) {82/49(60) - 119/64(79)} mmHg\n RR: 28 (14 - 33) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 116.4 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 14 (9 - 18) mmHg\n CO/CI (Thermodilution): (9.17 L/min) / (4 L/min/m2)\n SVR: 471 dynes*sec/cm5\n SV: 91 mL\n SVI: 39 mL/m2\n Total In:\n 12,876 mL\n 2,322 mL\n PO:\n Tube feeding:\n IV Fluid:\n 9,690 mL\n 1,767 mL\n Blood products:\n 1,096 mL\n 50 mL\n Total out:\n 5,185 mL\n 1,961 mL\n Urine:\n 30 mL\n 15 mL\n NG:\n 600 mL\n 100 mL\n Stool:\n Drains:\n 2,350 mL\n 550 mL\n Balance:\n 7,691 mL\n 361 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 7 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 24 cmH2O\n Plateau: 16 cmH2O\n SPO2: 99%\n ABG: 7.36/40/108/21/-2\n Ve: 16.6 L/min\n PaO2 / FiO2: 216\n Physical Examination\n General Appearance: intubated, sedated\n HEENT: PERRL, pinpoint pupils\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: diffusely)\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: (Responds to: Noxious stimuli), Sedated\n Labs / Radiology\n 29 K/uL\n 9.3 g/dL\n 106 mg/dL\n 2.0 mg/dL\n 21 mEq/L\n 4.7 mEq/L\n 48 mg/dL\n 104 mEq/L\n 134 mEq/L\n 27.4 %\n 0.6 K/uL\n [image002.jpg]\n 11:47 AM\n 02:07 PM\n 05:22 PM\n 05:37 PM\n 08:39 PM\n 08:44 PM\n 11:11 PM\n 11:24 PM\n 02:14 AM\n 02:27 AM\n WBC\n 0.8\n 0.8\n 0.6\n Hct\n 23.5\n 26.2\n 27.4\n Plt\n 14\n 36\n 33\n 29\n Creatinine\n 1.9\n 2.0\n TCO2\n 24\n 23\n 24\n 22\n 24\n 24\n Glucose\n 157\n 154\n 143\n 149\n 134\n 128\n 115\n 106\n Other labs: PT / PTT / INR:17.6/41.0/1.6, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:176/120, Alk-Phos / T bili:96/9.0, Amylase /\n Lipase:831/21, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %,\n Mono:8.0 %, Eos:0.0 %, Fibrinogen:267 mg/dL, Lactic Acid:2.0 mmol/L,\n Albumin:1.8 g/dL, LDH: IU/L, Ca:9.4 mg/dL, Mg:2.1 mg/dL, PO4:3.0\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), INEFFECTIVE COPING,\n INTESTINAL ISCHEMIA (INCLUDING MESENTERIC VENOUS / ARTERIAL THROMBOSIS,\n BOWEL ISCHEMIA), SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), CHRONIC OBSTRUCTIVE\n PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION\n Assessment and Plan: 60M admitted to for COPD exacerbation, became\n septic, developed ischemic bowel, s/p exlap, SBR, open abd , s/p ex\n lap, hematoma evacuation , s/p ex lap, end jejunostomy (150 cm SB),\n open abd .\n Neurologic: Continue fentanyl gtt & midaz gtt for sedation.\n Cardiovascular: Currently in NSR, rate controlled, weaned off neo gtt,\n on low dose vasopressin gtt. CI/SVRI c/w vasodilatory shock, though\n well compensated. Continue monitoring.\n Pulmonary: Cont ETT, (Ventilator mode: CMV), Improving on current vent\n settings. Wean if possible. Following ABGs, cont\n Flovent/Atrovent/albuterol.\n Gastrointestinal / Abdomen: NPO. LFTs trending down. Continue on\n TPN. ?OR today for exlap, possible closure.\n Nutrition: TPN, NPO\n Renal: Foley, CVVH, Pt making minimal urine. Lytes stabilized on\n CVVH. Cont tacrolimus, follow levels. Off Cellcept. Remove volume as\n pressure tolerates. Stop albumin boluses.\n Hematology: Serial Hct, Received 2 units pRBC yesterday. Plts continue\n to be low. Transfused 1 unit yesterday for plt count 14, will\n transfuse today for plt count 29 (likely OR today). F/u on HIT panel.\n Neutropenic now. ? sepsis\n Endocrine: RISS, Continue hydrocortisone q8.\n Infectious Disease: WBC down to 0.6. Cont Zosyn/Flagyl/vanc/fluc.\n Daily vanc levels. Reculture , including isolator bottles for\n neutropenia.\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP),\n A-line, central line\n Wounds: Open abd.\n Imaging:\n Fluids:\n Consults: Transplant, Nephrology\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Failure), Sepsis,\n (Shock: Septic), Acute renal failure, Thrombocytopenia\n ICU Care\n Nutrition:\n TPN w/ Lipids - 04:28 PM 85. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n Arterial Line - 04:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 676031,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Breath sounds diminished throughout. Suctioned for sm amt brown sputum\n Action:\n Resp parameters monitored, sputum sent for cx., remains on CMV with\n Fio2 50%, tv 600, rate 28 and 7 peep\n Response:\n Abg improved from yesterday, no vent changes made\n Plan:\n Continue on current vent settings, monitor abg\ns, await sputum cx\n report\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Abdomen open with packing in place. Jp\ns to wall suction draining mod\n amt foul smelling brown material, ostomy patent and draining mod amts\n green liquid stool. Stoma red and protruding well\n Action:\n Abdominal dressing checked frequently for leaks,\n Response:\n unchanged\n Plan:\n ? or tonight or early tomorrow morning for washout and removal of packs\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Neutropenic, wbc unresponsive on fentanyl and versed gtts, abdomin\n remains open\n Action:\n Antibiotics given as ordered, placed on neutropenic precautions,\n filgastim x 1 given, pan cultured\n Response:\n unchanged\n Plan:\n Continue to administer antiobiotics as ordered, monitor culture\n reports, monitor lab reports especially wbc, maintain neutropenic\n precautions\n Hypotension (not Shock)\n Assessment:\n Off all pressors since 0600\n Action:\n Hemodynamics monitored, catheter in place and values monitored\n Response:\n Hemodynamically stable off pressors\n Plan:\n Continue to monitor closely, goal of sbp>90, resume pressors as\n needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Minimal urine output, CRRT running with even exchanges\n Action:\n Attempting to remove small amts of fluid with hourly exchanges, renal\n labs sent as ordered, potassium and calcium infusing via protocol\n Response:\n Tolerating CRRT\n Plan:\n Continue CRRT and attempt to remove fluid as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 676033,
"text": "60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n .\n Chief complaint:\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-ass R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Breath sounds diminished throughout. Suctioned for sm amt brown sputum\n Action:\n Resp parameters monitored, sputum sent for cx., remains on CMV with\n Fio2 50%, tv 600, rate 28 and 7 peep\n Response:\n Abg improved from yesterday, no vent changes made\n Plan:\n Continue on current vent settings, monitor abg\ns, await sputum cx\n report\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Abdomen open with packing in place. Jp\ns to wall suction draining mod\n amt foul smelling brown material, ostomy patent and draining mod amts\n green liquid stool. Stoma red and protruding well\n Action:\n Abdominal dressing checked frequently for leaks,\n Response:\n unchanged\n Plan:\n ? or tonight or early tomorrow morning for washout and removal of packs\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Neutropenic, wbc 0.5 unresponsive on fentanyl and versed gtts,\n abdomin remains open\n Action:\n Antibiotics given as ordered, placed on neutropenic precautions,\n filgastim x 1 given, pan cultured\n Response:\n unchanged\n Plan:\n Continue to administer antiobiotics as ordered, monitor culture\n reports, monitor lab reports especially wbc, maintain neutropenic\n precautions\n Hypotension (not Shock)\n Assessment:\n Off all pressors since 0600\n Action:\n Hemodynamics monitored, catheter in place and values monitored\n Response:\n Hemodynamically stable off pressors\n Plan:\n Continue to monitor closely, goal of sbp>90, resume pressors as\n needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Minimal urine output, CRRT running with even exchanges\n Action:\n Attempting to remove small amts of fluid with hourly exchanges, renal\n labs sent as ordered, potassium and calcium infusing via protocol\n Response:\n Tolerating CRRT\n Plan:\n Continue CRRT and attempt to remove fluid as tolerated\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-17 00:00:00.000",
"description": "Intensivist Note",
"row_id": 676172,
"text": "SICU\n HPI:\n 60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n .\n Chief complaint:\n postoperative respiratory failure, septic shock\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-ass R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n Current medications:\n Calcium Gluconate/ 500 mL D5W 8. Albuterol Inhaler 9. Artificial Tears\n 10. Calcium Chloride 11. Chlorhexidine Gluconate 0.12% Oral Rinse 12.\n Citrate Dextrose 3% (ACD-A) CRRT\n 13. Ciprofloxacin 14. Famotidine 15. Fentanyl Citrate 16. Filgrastim\n 17. Fluticasone Propionate 110mcg\n 18. Fluconazole 19. Hydrocortisone Na Succ. 20. Insulin 21. Ipratropium\n Bromide MDI 22. Magnesium Sulfate\n 23. MetRONIDAZOLE (FLagyl) 24. Midazolam 25. Phenylephrine 26.\n Piperacillin-Tazobactam Na 27. Potassium Chloride 28. Potassium\n Chloride 10 mEq / 100 mL SW (CRRT Only) 29. Prismasate (B22 K4)* 30.\n Prismasate (B22 K4) 31. Sodium Chloride 0.9% Flush 32. Sodium CITRATE\n 4% 33. Sodium Chloride 0.9% Flush 34. Sodium CITRATE 4% 35. Tacrolimus\n Suspension 36. Tacrolimus Suspension 37. Vancomycin 38. Vasopressin\n 24 Hour Events:\n BLOOD CULTURED - At 10:06 AM\n via rij triple lumen\n SPUTUM CULTURE - At 11:06 AM\n URINE CULTURE - At 11:06 AM\n Post operative day:\n POD#7 - expl lap\n POD#6 - Hematoma cleaned out, one area on bowel to watch, ABD left\n open, will return to OR tomorrow \n POD#5 - exlap\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Piperacillin - 10:00 PM\n Ciprofloxacin - 05:05 AM\n Vancomycin - 08:37 AM\n Fluconazole - 10:10 AM\n Metronidazole - 10:00 PM\n Piperacillin/Tazobactam (Zosyn) - 04:07 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Calcium Gluconate (CRRT) - 1 grams/hour\n Insulin - Regular - 11 units/hour\n Fentanyl - 150 mcg/hour\n Vasopressin - 2.4 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Other medications:\n Flowsheet Data as of 05:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 37\nC (98.6\n HR: 101 (92 - 105) bpm\n BP: 90/57(66) {80/47(57) - 129/67(84)} mmHg\n RR: 16 (14 - 30) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 121.1 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 15 (12 - 20) mmHg\n CO/CI (Thermodilution): (6.85 L/min) / (3 L/min/m2)\n SVR: 689 dynes*sec/cm5\n SV: 74 mL\n SVI: 32 mL/m2\n Total In:\n 9,932 mL\n 2,172 mL\n PO:\n Tube feeding:\n IV Fluid:\n 7,523 mL\n 1,673 mL\n Blood products:\n 346 mL\n Total out:\n 10,442 mL\n 2,465 mL\n Urine:\n 46 mL\n 20 mL\n NG:\n 1,500 mL\n 750 mL\n Stool:\n Drains:\n 1,850 mL\n 250 mL\n Balance:\n -510 mL\n -293 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 28\n RR (Spontaneous): 1\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 28 cmH2O\n Plateau: 22 cmH2O\n Compliance: 66.7 cmH2O/mL\n SPO2: 95%\n ABG: 7.40/40/91./23/0\n Ve: 18.1 L/min\n PaO2 / FiO2: 153\n Physical Examination\n General Appearance: intubated and sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachycardic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: throughout)\n Abdominal: Soft, Distended, No(t) Tender:\n Left Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: open abdomen\n Neurologic: (Responds to: Tactile stimuli, Noxious stimuli), No(t)\n Moves all extremities, Sedated\n Labs / Radiology\n 41 K/uL\n 9.6 g/dL\n 105 mg/dL\n 2.1 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 51 mg/dL\n 99 mEq/L\n 130 mEq/L\n 27.2 %\n 0.4 K/uL\n [image002.jpg]\n 07:50 AM\n 02:26 PM\n 02:42 PM\n 08:07 PM\n 08:26 PM\n 12:53 AM\n 01:15 AM\n 01:58 AM\n 02:09 AM\n 02:54 AM\n WBC\n 0.4\n 0.4\n Hct\n 27.5\n 27.2\n Plt\n 41\n 41\n Creatinine\n 2.1\n 2.2\n 2.1\n TCO2\n 24\n 23\n 24\n 26\n 25\n 27\n 26\n Glucose\n 128\n 120\n 110\n 82\n 76\n 97\n 119\n 105\n Other labs: PT / PTT / INR:17.8/41.5/1.6, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:144/107, Alk-Phos / T bili:93/10.3, Amylase /\n Lipase:831/21, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %,\n Mono:8.0 %, Eos:0.0 %, Fibrinogen:267 mg/dL, Lactic Acid:1.6 mmol/L,\n Albumin:1.8 g/dL, LDH: IU/L, Ca:9.3 mg/dL, Mg:2.0 mg/dL, PO4:3.0\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), INEFFECTIVE COPING,\n INTESTINAL ISCHEMIA (INCLUDING MESENTERIC VENOUS / ARTERIAL THROMBOSIS,\n BOWEL ISCHEMIA), SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), CHRONIC OBSTRUCTIVE\n PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION\n Assessment and Plan: 60M admitted to for COPD exacerbation, became\n septic, developed ischemic bowel, s/p exlap, SBR, open abd , s/p ex\n lap, hematoma evacuation , s/p ex lap, end jejunostomy (150 cm SB),\n open abd .\n Neurologic: Neuro checks Q: hr, Pain controlled, wean fentanyl gtt &\n midaz\n Cardiovascular: Currently in NSR, rate controlled, restarted on\n vasopressin\n Pulmonary: Cont ETT, (Ventilator mode: CMV), CXR, serial ABGs, cont\n Flovent/Atrovent/albuterol\n Gastrointestinal / Abdomen: NPO, LFTs trending down, TPN, OR this AM\n Nutrition: TPN, NPO\n Renal: Foley, UOP minimal, ARF on CRF, Cr 2.1, stable, cont tacrolimus,\n Cellcept dc'd, check levels, CVVH, remove volume as pressure tolerates\n Hematology: Serial Hct, hct-27.2 stable, plts 41, inr-1.5, f/u HIT\n panel\n Endocrine: Insulin drip, goal FS<150, Hydrocortisone q8\n Infectious Disease: Check cultures, WBC down to 046, cont\n VancZosyn/Cipro/Flagyl/Fluc, f/u cx, daily vanc levels, neupogen\n started\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP),\n Aline, CVL, HD line, JPx2, open abd\n Wounds: Dry dressings\n Imaging: OR today\n Fluids: KVO\n Consults: General surgery, Nephrology\n Billing Diagnosis: (Respiratory distress: Failure), (Shock: Septic)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 03:43 PM 85. mL/hour\n Glycemic Control:\n Lines:\n Midline - 10:00 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n Arterial Line - 04:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nutrition",
"chartdate": "2104-06-17 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 676281,
"text": "Subjective Patient intubated/sedated. RN and labs, BG remains high\n Objective\n Current Wt: 121.1 kg () - fluid\n Admit Wt: 91.7 kg\n Pertinent medications: Fentanyl, vasopression, midazolam, Abx, calcium\n gluconate, KCl, hydrocortisone Na succ, Insulin drip (12 units/hr),\n others noted\n Labs:\n Value\n Date\n Glucose\n 88 mg/dL\n 08:31 AM\n Glucose Finger Stick\n 96\n 10:00 AM\n BUN\n 51 mg/dL\n 01:58 AM\n Creatinine\n 2.1 mg/dL\n 01:58 AM\n Sodium\n 134 mEq/L\n 08:31 AM\n Potassium\n 4.5 mEq/L\n 08:31 AM\n Chloride\n 105 mEq/L\n 08:31 AM\n TCO2\n 23 mEq/L\n 01:58 AM\n PO2 (arterial)\n 108 mm Hg\n 08:31 AM\n PO2 (venous)\n 35 mm Hg\n 03:48 AM\n PCO2 (arterial)\n 46 mm Hg\n 08:31 AM\n PCO2 (venous)\n 39 mm Hg\n 03:48 AM\n pH (arterial)\n 7.34 units\n 08:31 AM\n pH (venous)\n 7.31 units\n 03:48 AM\n pH (urine)\n 5.0 units\n 09:27 AM\n CO2 (Calc) arterial\n 26 mEq/L\n 08:31 AM\n CO2 (Calc) venous\n 21 mEq/L\n 03:48 AM\n Albumin\n 1.8 g/dL\n 05:50 PM\n Calcium non-ionized\n 9.3 mg/dL\n 01:58 AM\n Phosphorus\n 3.0 mg/dL\n 01:58 AM\n Ionized Calcium\n 1.31 mmol/L\n 08:31 AM\n Magnesium\n 2.0 mg/dL\n 01:58 AM\n ALT\n 144 IU/L\n 01:58 AM\n Alkaline Phosphate\n 93 IU/L\n 01:58 AM\n AST\n 107 IU/L\n 01:58 AM\n Amylase\n 831 IU/L\n 06:09 AM\n Total Bilirubin\n 10.3 mg/dL\n 01:58 AM\n Triglyceride\n 119 mg/dL\n 02:30 PM\n WBC\n 0.4 K/uL\n 01:58 AM\n Hgb\n 9.6 g/dL\n 01:58 AM\n Hematocrit\n 27\n 08:31 AM\n Current diet order / nutrition support: NPO\n TPN: 2060ml (310g dextrose/115g protein/50g lipid)\n GI: bowel sounds not present, abd open\n Assessment of Nutritional Status\n 60 year old male admitted for COPD exacerbation, patient became septic,\n developed ischemic bowel, s/p ex-lap, SBR, open abd , s/p ex-lap,\n hematoma evacuation , s/p ex-lap, end ileostomy . Patient to OR\n this morning for abd closure. BG remains high despite insulin drip\n running at 12 units/hour. CRRT continues for clearance with minimal\n fluid removal hypotension. Patient on pressor support, remains\n intubated and sedated. TPN not currently at goal high BG. Goal is\n 2060 ml (390g dextrose/115g protein/150g lipid) providing 2286\n kcal/day.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. TPN as ordered for today. Recommend increasing TPN to goal when BG\n stable at < 150. When increased to goal, recommend increasing TPN\n insulin to 65 units with insulin drip @ 12 units/hour (totaling average\n of 14.4 units/hr).\n 2. Daily CHEM 10. Monitor and replete lytes PRN\n 3. FSBG q4 hour. Consider increasing insulin drip for high BG.\n 4. Will follow\n"
},
{
"category": "Nutrition",
"chartdate": "2104-06-17 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 676282,
"text": "Subjective Patient intubated/sedated. RN and labs, BG remains high\n Objective\n Current Wt: 121.1 kg () - fluid\n Admit Wt: 91.7 kg\n Pertinent medications: Fentanyl, vasopression, midazolam, Abx, calcium\n gluconate, KCl, hydrocortisone Na succ, Insulin drip (12 units/hr),\n others noted\n Labs:\n Value\n Date\n Glucose\n 88 mg/dL\n 08:31 AM\n Glucose Finger Stick\n 96\n 10:00 AM\n BUN\n 51 mg/dL\n 01:58 AM\n Creatinine\n 2.1 mg/dL\n 01:58 AM\n Sodium\n 134 mEq/L\n 08:31 AM\n Potassium\n 4.5 mEq/L\n 08:31 AM\n Chloride\n 105 mEq/L\n 08:31 AM\n TCO2\n 23 mEq/L\n 01:58 AM\n PO2 (arterial)\n 108 mm Hg\n 08:31 AM\n PO2 (venous)\n 35 mm Hg\n 03:48 AM\n PCO2 (arterial)\n 46 mm Hg\n 08:31 AM\n PCO2 (venous)\n 39 mm Hg\n 03:48 AM\n pH (arterial)\n 7.34 units\n 08:31 AM\n pH (venous)\n 7.31 units\n 03:48 AM\n pH (urine)\n 5.0 units\n 09:27 AM\n CO2 (Calc) arterial\n 26 mEq/L\n 08:31 AM\n CO2 (Calc) venous\n 21 mEq/L\n 03:48 AM\n Albumin\n 1.8 g/dL\n 05:50 PM\n Calcium non-ionized\n 9.3 mg/dL\n 01:58 AM\n Phosphorus\n 3.0 mg/dL\n 01:58 AM\n Ionized Calcium\n 1.31 mmol/L\n 08:31 AM\n Magnesium\n 2.0 mg/dL\n 01:58 AM\n ALT\n 144 IU/L\n 01:58 AM\n Alkaline Phosphate\n 93 IU/L\n 01:58 AM\n AST\n 107 IU/L\n 01:58 AM\n Amylase\n 831 IU/L\n 06:09 AM\n Total Bilirubin\n 10.3 mg/dL\n 01:58 AM\n Triglyceride\n 119 mg/dL\n 02:30 PM\n WBC\n 0.4 K/uL\n 01:58 AM\n Hgb\n 9.6 g/dL\n 01:58 AM\n Hematocrit\n 27\n 08:31 AM\n Current diet order / nutrition support: NPO\n TPN: 2060ml (310g dextrose/115g protein/50g lipid)\n GI: bowel sounds not present, abd open\n Assessment of Nutritional Status\n 60 year old male admitted for COPD exacerbation, patient became septic,\n developed ischemic bowel, s/p ex-lap, SBR, open abd , s/p ex-lap,\n hematoma evacuation , s/p ex-lap, end ileostomy . Patient to OR\n this morning for abd closure. BG remains high despite insulin drip\n running at 12 units/hour. CRRT continues for clearance with minimal\n fluid removal hypotension. Patient on pressor support, remains\n intubated and sedated. TPN not currently at goal high BG. Goal is\n 2060 ml (390g dextrose/115g protein/150g lipid) providing 2286\n kcal/day.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. TPN as ordered for today. Recommend increasing TPN to goal when BG\n stable at < 150. When increased to goal, recommend increasing TPN\n insulin to 65 units with insulin drip @ 12 units/hour (totaling average\n of 14.4 units/hr).\n 2. Daily CHEM 10. Monitor and replete lytes PRN\n 3. FSBG q4 hour\n 4. Will follow\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-17 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 676374,
"text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 13\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: plan is to keep pt on full support and revaluate in\n AM rounds\n Reason for continuing current ventilatory support: Cannot protect\n airway\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-18 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 676430,
"text": "Demographics\n Day of mechanical ventilation: 14\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL /\n Airway problems:\n Comments: ETT advanced to 26 lip/CXR stated tube was\n 6.7cm above carina.\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use, Gasping\n efforts\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Frequent failed trigger efforts, Abnormal\n trigger efforts (efforts during inspiratory)\n Dysynchrony assessment: Possible air trapping, Erratic exhaled Tidal\n Volumes\n Comments: Pts breathing pattern not in sync with set rate of 28. Pt\n with sign auto-peep, diminished breath sounds. Set rate decreased to\n 25, bronchodilators given in attempt to decrease auto-peep but pt still\n out of sync with vent.\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 675726,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Po2 in 60\n CXR with edema MD\n numbers with high ELWI\n Action:\n PEEP increased to 7\n Bloused only x1 for low bp\n Unable to remove fluid via cvvhdf\n Response:\n BP with initial sharp drop in BP to 70\ns with increase in PEEP\n PO2 slowly improved throughout day\n Plan:\n Cont to monitor ABG\n Pulm toilet\n Turn as tolerated q3 minimum\n Attempt to remove fluid as tolerated\n Ineffective Coping\n Assessment:\n Mother calling for updates\n Action:\n Mothers questions answered\n Response:\n Mother feels supported by team\n Plan:\n Cont to answer mothers questions prn\n Social work to touch base with mother on \n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CRRT continues\n Action:\n CRRT continues for clearance with minimal fluid removal\n Response:\n Normal acid base balance and elctrolytes\n Plan:\n Cont crrt\n Fluid removal if tolerates\n Prime new circuit with heparin if goes down\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n numbers consistent with sepsis\n Cont to drop BP with turns to 80\n Abd remains open with JP x2 to wall suction\n Ileostomy more red today with brown liquid stool output\n Action:\n Bolused with prismalyte x1\n Pitressin added at 1.2 units per hour\n Solumendrol 100 mg x1\n Albumin added\n CRRT with no removal\n Cipro and fluconazle added to antibiotic regimen of vanco, zosyn,\n flagyl\n HIT resent\n Response:\n Responding to bolus with increase in Co/CI numbers and GEDI from 620 to\n 710\n Stable BP after bolus\n Aboe to wean neo throughout day\n Less hypotensive with turns\n Plan:\n Cont to monitor numbers\n Notify MD for drop in BP <90 for decision on fluid bolus vs increase in\n neo\n CRRT without removal, OK to take off small amounts of fluid if patient\n tolerates\n Cont albumin q8\n Cont abx as ordered\n Await HIT panel\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 675719,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Po2 in 60\n CXR with edema MD\n numbers with high ELWI\n Action:\n PEEP increased to 7\n Bloused only x1 for low bp\n Unable to remove fluid via cvvhdf\n Response:\n BP with initial sharp drop in BP to 70\ns with increase in PEEP\n PO2 slowly improved throughout day\n Plan:\n Cont to monitor ABG\n Pulm toilet\n Turn as tolerated q3 minimum\n Attempt to remove fluid as tolerated\n Ineffective Coping\n Assessment:\n Mother calling for updates\n Action:\n Mothers questions answered\n Response:\n Mother feels supported by team\n Plan:\n Cont to answer mothers questions prn\n Social work to touch base with mother on \n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CRRT continues\n Action:\n CRRT continues for clearance with minimal fluid removal\n Response:\n Normal acid base balance and elctrolytes\n Plan:\n Cont crrt\n Fluid removal if tolerates\n Prime new circuit with heparin if goes down\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n numbers consistent with sepsis\n Cont to drop BP with turns to 80\n Action:\n Bloused with prismalyte x1\n Pitressin added at 1.2 units per hour\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 675824,
"text": "Hypotension (not Shock)\n Assessment:\n Received on pitressin and phenylephrine to maintain SBP >90.\n Tachycardiac, hct drop to 23.5.\n Plt to 14.\n CRRT running to keep pt even though had episode of\n hypotension for the day shift.\n SVV ranging from 10 -18 throughout the shift. CO/CI approx\n 7-9/3.1-4.8. GEDI approx 700.\n Action:\n Received 2 units of red cells this shift and 1 unit of\n platelets.\n Weaned phenyleprine to off. Attempted to wean pitressin when\n SBPs 110s-120s after discussion with Dr. .\n Albumin given as ordered.\n HIT panel was sent yesterday during the day shift and all\n heparin flushes/meds etc were discontinued.\n Response:\n Tolerated neo wean well though hypotensive to mid 80s after\n pitressin was turned off.\n Slightly more tachycardia, high 90s to low 100s, most of\n this shift compared to the day shift.\n Hct stable at 26-27. Plts at 29. goal PLT >20 per Dr. .\n Pt was even fluid balance for yesterday.\n Responds well hemodynamically to Albumin and blood products.\n Plan:\n Continue with pitressin to maintain SBP parameters. Frequent checking\n of labs esp Hct and PLts. Products as indicated. Follow up with HIT\n panel, do not use any heparin products.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CVVHDF with goal of running patient even.\n BUN/Cr 48/2. Oliguric with greenish clear urine.\n K slightly elevated (4.7) and bicarb 21. Replacement and\n Dialysate fluids are bicarb 22/ K 4.\n Normal acid/base balance with slight lean towards alkalosis.\n Normal pCO2 and paO2 levels.\n Labile FS, on moderate doses of insulin gtt.\n Action:\n Ran CRRT exactly even yesterday.\n Titrated insulin gtt to maintain good glycemic control.\n Calcium and pH wnl though K is >4.6 and bicarb on the lower\n side of normal.\n Tacro & Vanco levels to be drawn at 0600.\n Response:\n Pt tolerated CRRT goal well this shift.\n No episodes of hypotension r/t fluid removal.\n Responded well to insulin gtt and blood sugars have ranged\n from 110-170s this shift.\n Plan:\n Monitor lytes frequently. Titrate insulin as indicated.\n D/w renal team switching of dialysis fluids to b32/k2 if K continues to\n climb and bicarb drops (as it did to 19 at approx midnight). If able to\n keep even or even remove fluid, team may have a better chance of\n closing abdomen today in the OR- assess/d/w renal and eval pt\n response.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n On multiple ABX.\n White count down to 0.6.\n Home dose of steroids initiated yesterday as well as\n addition of two more antibiotics.\n Abd open,\n Action:\n Bair Hugger on to maintain normal body temp vs. hypothermic.\n Response:\n Very edematous. Continues to third space.\n Plan:\n Plan for OR today for washout and attempt to close belly.\n Continue with antibiotics and follow ID recs. Maintain intravascular\n volume with products/albumin etc as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n CMV 50%/600/28 PEEP 7.\n Action:\n No vent changes made this shift.\n Fent/Versed gtts to manage sedation and decrease\n overbreathing.\n Response:\n Occasionally over breathing vent by 1-2 breaths.\n ? shallow\nguppy\n breaths though oxygenation/ventilation wnl\n according to ABG.\n Plan:\n See nursing care plan.\n Hx of afib though has remained in sinus rhythm overnight. Would\n cardiovert if needed d/t Diltiazem and Amiodarone\ns interaction with\n tacrolimus. Multiple skin impairments-see metavision flow sheet. Would\n consider switch to Kinair or other pressure reducing bed to manage\n moderate amounts of weeping/seeping fluid from abdominal wound, scrotal\n edema, and increase air circulation. ? wound care consult and if\n already ordered, follow up with wound care for recs for bed and\n management of ozzing. Mother , updated re: .\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 676050,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 676046,
"text": "60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n .\n Chief complaint:\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-ass R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Breath sounds diminished throughout. Suctioned for sm amt brown sputum\n Action:\n Resp parameters monitored, sputum sent for cx., remains on CMV with\n Fio2 50%, tv 600, rate 28 and 7 peep\n Response:\n Abg improved from yesterday, no vent changes made\n Plan:\n Continue on current vent settings, monitor abg\ns, await sputum cx\n report\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Abdomen open with packing in place. Jp\ns to wall suction draining mod\n amt foul smelling brown material, ostomy patent and draining mod amts\n green liquid stool. Stoma red and protruding well\n Action:\n Abdominal dressing checked frequently for leaks,\n Response:\n unchanged\n Plan:\n ? or tonight or early tomorrow morning for washout and removal of packs\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Neutropenic, wbc 0.5 unresponsive on fentanyl and versed gtts,\n abdomin remains open\n Action:\n Antibiotics given as ordered, placed on neutropenic precautions,\n filgastim x 1 given, pan cultured\n Response:\n unchanged\n Plan:\n Continue to administer antiobiotics as ordered, monitor culture\n reports, monitor lab reports especially wbc, maintain neutropenic\n precautions\n Hypotension (not Shock)\n Assessment:\n Off all pressors since 0600\n Action:\n Hemodynamics monitored, catheter in place and values monitored\n Response:\n Hemodynamically stable off pressors\n Plan:\n Continue to monitor closely, goal of sbp>90, resume pressors as\n needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Minimal urine output, CRRT running with even exchanges\n Action:\n Attempting to remove small amts of fluid with hourly exchanges, renal\n labs sent as ordered, potassium and calcium infusing via protocol\n Response:\n Tolerating CRRT\n Plan:\n Continue CRRT and attempt to remove fluid as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673602,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n SHIFT EVENTS\n * K-excelate given for hyperkalemia (k+ 5.7)\n * TFeeds at goal rate of 25cc/hr\n * No vent changes\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt. remains intubated and vented on PSV 40% 10/5 with sats at high 90\n RR in 10\ns. Breath sounds diminished throughout. Some wheezes noted but\n clear with nebs. Non productive cough noted. Remains on 80mcg/kg\n propofol. Episodes of tachypnea and hypertension noted.\n Action:\n MDIs given as ordered. Mouth care q4hr and prn, suction as needed. Pt.\n turned Q2h. PRN IV fentanyl ordered to maintain pt. comfort.\n Response:\n Pt. remains stable on current vent settings. Ongoing respiratory\n assessment.\n Plan:\n Continue to monitor resp status, wean vent as tolerated, meds ASDIR,\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat- 4.3, BUN 72, K-5.7. UOP about 30 to 50cc/hr\n Action:\n Renal biopsy done yesterday. All meds renally dosed. Cellcept\n administered as ordered. Prograf held d/t level. Will recheck level\n with am labs as med adjusted to daily level. K-excelate x1 dose\n given.\n Response:\n Pt. remains with elevated BUN/Creat, hyperkalemia.\n Plan:\n Continue to monitor renal functions, f/u renal recs. f/u biopsy\n results. AM prograf level pending.\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 673699,
"text": "TITLE:\n 24 Hour Events:\n - Pt continued on azithromycin but high-dose steroids were stopped\n - Quantification of pulmonary function on paralytics consistent with\n small airway resistance. No evidence of central airway obstruction on\n CT chest.\n - Pt started on sodium bicarb and transplant biopsy done for renal\n dysfunction. Cymbalta stopped.\n - BP had initially dropped in setting of intubation but became\n hypertensive again overnight, managed with fentanyl boluses.\n - Started on tube feeds overnight but noted to have high residuals. No\n BM since admission.\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Propofol - 80 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:23 AM\n Cisatracurium - 04:00 PM\n Heparin Sodium (Prophylaxis) - 10:53 PM\n Fentanyl - 04:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.2\nC (99\n HR: 112 (86 - 121) bpm\n BP: 155/84(107) {100/67(78) - 155/92(111)} mmHg\n RR: 19 (9 - 25) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 80 Inch\n Total In:\n 5,093 mL\n 630 mL\n PO:\n TF:\n 53 mL\n 143 mL\n IVF:\n 4,600 mL\n 386 mL\n Blood products:\n Total out:\n 1,060 mL\n 320 mL\n Urine:\n 1,060 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,033 mL\n 310 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 650 (650 - 650) mL\n Vt (Spontaneous): 860 (666 - 870) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 21 cmH2O\n Plateau: 11 cmH2O\n SpO2: 98%\n ABG: 7.27/40/123/17/-7\n Ve: 13.3 L/min\n PaO2 / FiO2: 308\n Physical Examination\n General: intubated, sedated\n Pulmonary: mild expiratory wheezes b/l\n Cardiac: tachycardic, regular, normal S1/S2\n Abdomen: Soft, hypoactive BS\n Extremities: No edema. Has non-functional right UE fistula. A-line in\n place LUE. Left midline.\n Skin: Multiple keloids\n Neurologic: sedated as above, not arousable to voice\n Labs / Radiology\n 305 K/uL\n 9.3 g/dL\n 137 mg/dL\n 4.3 mg/dL\n 17 mEq/L\n 5.2 mEq/L\n 72 mg/dL\n 95 mEq/L\n 125 mEq/L\n 28.3 %\n 16.3 K/uL\n [image002.jpg]\n 06:45 AM\n 02:35 PM\n 06:28 PM\n 11:05 PM\n 02:59 AM\n 03:26 AM\n 06:07 PM\n 06:19 PM\n 02:40 AM\n 03:41 AM\n WBC\n 9.3\n 16.3\n Hct\n 27.9\n 28.3\n Plt\n 198\n 305\n Cr\n 4.1\n 4.1\n 4.1\n 4.3\n TCO2\n 20\n 18\n 20\n 19\n 18\n 19\n Glucose\n 166\n 164\n 166\n 137\n Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB /\n Troponin-T:210/8/0.05, Lactic Acid:0.6 mmol/L, Ca++:8.2 mg/dL, Mg++:2.2\n mg/dL, PO4:5.7 mg/dL. Tacro level pending.\n Micro: Contaminated sputum sample. CMV viral load negative.\n Assessment and Plan\n 60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n # Dyspnea: Underlying COPD with possible exacerbation in setting of\n parainfluenza, also with ?component of CHF. Ruled out for ACS.\n Progressive respiratory distress and fatigue required intubation on\n . ABGs now consistent with adequate oxygenation and ventilation. CT\n scan without significant pulm dz and vent physiology most consistent\n with small airways obstruction.\n -Continue frequent bronchodilator therapy\n -Azithromycin 5-day course completed yesterday\n -Discontinued high-dose steroids yesterday dose (d/t lack of benefit x\n three days) and restarted on usual renal transplant prednisone\n -F/u micro data\n # Volatile blood pressure: Has known difficult to control HTN, with\n hypertensive nephropathy/ESRD s/p transplant. Reports med adherence.\n be due to respiratory distress, HD steroids, narcotic withdrawal,\n renal failure, volume overload. No evidence of RAS on renal US. Had\n been on hydral 75mg q6H, clonidine 0.1mg PO TID, Amlodipine 10mg daily,\n and Nicardipine gtt; however, post-intubation his blood pressure\n dropped and he has since required fluid boluses to maintain MAP >65.\n -Continue fluid boluses to maintain MAP >65\n -Holding due to ARF\n -F/u renal recs\n # Acute renal failure: History of ESRD due to hypertensive nephropathy,\n had been on dialysis before CRT in . Reports adherence with\n immunosuppresants. FeNa yesterday 1.4. Unclear precipitant for ARF,\n ddx includes dehydration, although unlikely given hypertension;\n transplant nephropathy. Question of rejection on most recent\n ultrasound. Tacrolimus level in nl range. BK virus DNA not detected.\n -Continue steroids, cellcept, prograf\n -F/u renal transplant recs; consider biopsy\n -Cont to hold and gabapentin for now\n # Hyponatremia: Suspect SIADH secondary to pulmonary process; urine\n osms 314 suggests that he may be inappropriately concentrating urine.\n Consider fluid restriction.\n -F/u renal recs\n -Consider free water restriction\n -Q12h serum sodium checks\n # Hyperlipidemia:\n -continue statin and ezetimibe\n # DM:\n -HISS\n -diabetic diet\n # Chronic pain:\n -continue home oxycontin, methadone, and dilaudid prn per OMR\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation:\n -senna, colace\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 06:45 PM 25 mL/hour\n Glycemic Control:\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 12:41 AM\n Prophylaxis:\n DVT: Heparin SC 5000 tid\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "General",
"chartdate": "2104-06-07 00:00:00.000",
"description": "ICU Event Note",
"row_id": 673701,
"text": "Clinician: Attending\n Patient with continued ventilatory support--he has had continued normal\n CO2 values but with continued and substantial expiratory flow\n limitation.\n This has failed to improve with continued time and support.\n No new cultures\n Will continue wtih--.\n Atrovent\n Albuterol\n Flovent to be added\n Will keep Prednisone at baseline levels\n PSV appears to provide reasonable support despite continued significant\n expiratory airflow obstruction.\n Total time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673868,
"text": "60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n Of note, attempt to wean sedation for possible extubation\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. received intubated on pressure support 40%/. Labored breathing\n noted. Suctioned for scant amounts of thick green sputum. Culture + for\n gram negative rods. Sedated on propofol gtt but unable to increase\n sedation as pt. was hypotensive.\n Action:\n Vent changed to 40%/15/5. Started on IV vanco and zosyn for probable\n VAP pneumonia. Blood gas drawn. Results:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Constipation (Obstipation, FOS)\n Assessment:\n Known decreased gastric motility. Abd soft distended, positive for BS\n and flatus, TFeeds restarted at at 10cc/hr. Residuals at 2200\n >360cc.\n Action:\n TFeeds off. Continue Reglan, lactulose and aggressive bowel regimen\n Response:\n Pending\n Plan:\n Continue to monitor patient status, aggressive bowel regiment until\n clears, may attempt to restart TF today if no residuals.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n s/p renal transplant, UOP decreased to 30-40cc/hr\n Action:\n Fluid boluses as noted above. Assessed UO Q1h. Steroids, cellcept, and\n prograf, administered as ordered.\n Response:\n Continue to follow GU status.\n Plan:\n Continue to monitor patient renal status, f/u renal recs. Fluid\n boluses as ordered. Replete sodium bicarb as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674037,
"text": "60 yo M with esrd post transplant, copd, htn with progressive resp\n failure, hypotension, progressive ARF.\n Shift events:\n - spike temp to 101.1 BC sent, Tylenol X1 given , cont w/abx\n - -lactate up to 3.2 1 L NS given\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient intubated and vented on AC 100% 500X30/5 w/sats on ABG\n at 90. B/L diminished, still irregular breathing w/use of accessory\n muscles. No secretions w/suctioning. Last sputum positive for GNR. CXR\n w/ worsening infiltrates.\n Action:\n Remains intubated and vented, Fio2 down to 60%\n ABG: 7.20/54/94. Mouth\n care, MDI\ns ASDIR. Abg to eval. ABX for possible VAP\n Response:\n Pending abg: 7.26/38/131\n Plan:\n Continue to monitor resp status, f/u cultures, continue ABX, wean,\n SBT/RSBI, wean off when able.\n Hypotension (not Shock)\n Assessment:\n Received patient on maxed Neo and Vasopressin, after 7L IVF. Still\n hypotensive to 70\ns. Started on levophed. Patient also on steroids \n possible component of adrenal insufficiency. Tachycardic in \n w/occasional PAC\ns. General edema, peripheral pulses present w/doppler\n only, extr cool w/abnormal capillary refill. CVP 12-14, minimal UOP.\n Bladder pressure - 18\n Action:\n Pressors support (triple pressors) to maintain MAP >60 IVF to maintain\n CVP > 10, got 1 L bolus of Bicarb in D5W. stress steroids, abx to treat\n infection\n Response:\n Levophed weaned to 0.05 mcg/kg/min, rest remains w/o change.\n Plan:\n Continue to monitor patient\ns hemodynamic status, wean off pressors\n when able. F/u CX data, f/t ECHO read.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat\n 4.2 K-6.7 UOP minimal, bladder pressures -18\n Action:\n Total of 200MEq of Bicarb given, Insulin w/D50 given, calcium gluconate\n given, renal follows, continue on steroids/prograf/cellcept.\n Response:\n Pending K-5.7\n Plan:\n Continue to monitor patient\ns renal status, f/u renal recs, eval for\n need of CVVH\n Constipation (Obstipation, FOS)\n Assessment:\n Since admission on either Fentanyl or methadone/oxycodone. No BM. abd\n distended, no BS or flatus. OGT to suction w/ 1500cc of bilious output\n over 2HR. Cdiff negative. Bladder pressure -18\n Action:\n NPO, OGT to suction, aggressive bowel regimen, KUB done, continues on\n Reglan q6hr.\n Response:\n Medium loose BM this afternoon\ncdiff sent, OGT still to suction with\n large output\n Plan:\n Continue to monitor patient status, f/u CX and KUB results, surgical\n consult???\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 673226,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -Left PICC placed ending in brachiocephalic vein\n -Nasopharyngeal swab positive for parainfluenza. LDH to r/o PCP was nl.\n Urine legionella, CMV vL all pending-Ruled out for acute ischemia (CK\n 172->185, MB 5->6, TropT 0.09->0.08)\n -Given 80 mg IV Lasix in morning for possible CHF. Echo ordered for\n .\n -BP difficult to control. Nitro gtt uptitrated, written for hydralazine\n and amlodipine, home metoprolol. Given another dose of lasix overnight\n for SBP > 200. Nicardipine gtt started. CXR with no significant chnages\n -Restarted on home dose methadone and prn hydromorphone 4mg 5x daily\n restarted\n -Urine lytes with FeUrea 37.7 (borderline for pre-renal ARF).\n Renal/transplant recs: ARF d/t hypertension vs tacro tox (level 5.9) vs\n rejection vs BK. Kidney u/s: performed but not read. BK virus pending.\n -Reports improvement in resp status with nebs this AM\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Nitroglycerin - 2 mcg/Kg/min\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Morphine Sulfate - 04:06 AM\n Furosemide (Lasix) - 04:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.7\nC (96.2\n Tcurrent: 35.6\nC (96\n HR: 88 (67 - 100) bpm\n BP: 192/92(114) {162/79(108) - 206/115(148)} mmHg\n RR: 18 (14 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n Total In:\n 2,338 mL\n 634 mL\n PO:\n 1,110 mL\n 360 mL\n TF:\n IVF:\n 478 mL\n 274 mL\n Blood products:\n Total out:\n 1,295 mL\n 700 mL\n Urine:\n 1,295 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,043 mL\n -66 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Other\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 730 (730 - 730) mL\n PS : 8 cmH2O\n PEEP: 5 cmH2O\n FiO2: 30%\n SpO2: 98%\n ABG: 7.32/39/52/20/-5\n Ve: 13.4 L/min\n PaO2 / FiO2: 173\n Physical Examination\n General: Awake, alert, appears comfortable.\n HEENT: NCAT, PERRL, EOMI, no scleral icterus, MM slightly dry. Muddy\n sclera.\n Neck: supple, no significant JVD or carotid bruits appreciated\n Pulmonary: Diffuse wheezes b/l. No crackles, no rhonchi.\n Cardiac: RRR, S-S2 nl.\n Abdomen: BS present throughout, no tenderness on limited eval due to pt\n uncooperativeness\n Extremities: No edema. Has non-functional right UE fistula.\n Skin: Multiple keloids\n Neurologic: Alert, oriented x 3.\n Labs / Radiology\n 214 K/uL\n 8.6 g/dL\n 211 mg/dL\n 3.7 mg/dL\n 20 mEq/L\n 4.4 mEq/L\n 50 mg/dL\n 92 mEq/L\n 126 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 07:57 AM\n 12:51 PM\n 09:53 PM\n 11:01 PM\n 03:22 AM\n 05:23 AM\n WBC\n 4.3\n 7.4\n Hct\n 28.8\n 26.3\n Plt\n 170\n 214\n Cr\n 3.9\n 3.6\n 3.8\n 3.5\n 3.7\n TropT\n 0.08\n 0.05\n TCO2\n 21\n Glucose\n 129\n 529\n 178\n 497\n 211\n Other labs: PT / PTT / INR:13.9/35.5/1.2, CK / CKMB /\n Troponin-T:210/8/0.05, Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n 60M with ESRD s/p CRT, HTN, COPD p/w severe hypertension and dyspnea\n # Dyspnea: Underlying COPD with possible exacerabtion in setting of\n parainfluenza, also with component of CHF. Ruled out for ACS.\n -Continue frequent nebs.\n -Azithromycin x total 5 day course.\n -Consider decreasing prednisone dose as tx for parainfluenza mostly\n supportive but aided by reduction in steroids\n -F/u pending micro\n -Monitor I/O with goal net even to neg 500, consider diuresis\n -Completed ROMI\n #Hypertension: Has known difficult to control HTN, with hypertensive\n nephropathy/ESRD s/p transplant. Reports med adherence. be due to\n respiratory distress, HD steroids, narcotic withdrawal, renal failure,\n volume overload. No evidence of RAS on renal US.\n -Cont hydral, amlodipine, and lopressor. Will wean off nitro gtt and\n add clonidine po. Consider uptitrating hydral and amlodipine if stil no\n responsive.\n -Holding due to ARF\n -F/u renal recs\n # Acute renal failure: History of ESRD due to hypertensive nephropathy,\n had been on dialysis before CRT in . Reports adherence with\n immunosuppresants. Unclear precipitant for ARF, ddx includes\n dehydration, although unlikely given hypertension; transplant\n nephropathy. No evidence of RAS on ultrasound. Tacrolimus level in nl\n range.\n -F/u AM tacrolimus level\n -Continue prednisone (will d/w renal dose), cellcept, prograf\n -F/u renal transplant recs\n -F/u ultrasound read\n -Could consider bx to r/o acute transplant rejection\n -Cont to hold and gabapentin for now\n -Consider lasix, would be ok to give per Renal\n # Hyperlipidemia:\n -continue statin and ezetimibe\n # DM:\n -HISS\n -diabetic diet\n # Chronic pain:\n -continue home oxycontin and dilaudid prn per OMR\n -Holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation:\n -senna, colace\n ICU Care\n Nutrition: Cardiac, low salt, diabetic diet, replete lytes prn\n Glycemic Control: RISS\n Lines:\n PICC Line - 04:26 PM\n Prophylaxis:\n DVT: Heparin SC 5000 tid\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU, call out to floor when BP better controlled\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 673463,
"text": "TITLE:\n Chief Complaint: respiratory distress\n 24 Hour Events:\n -patient intubated\n -a-line placed\n -racemic epinephrine - didn't help\n -CT chest\n evaluation limited by respiratory motion; lungs are grossly\n clear with mild emphysema. ETT appropriately positioned. Intrathoracic\n trachea grossly patent, as are mainstem and proximal bronchi.\n -increase steroids --> solumedrol 125 q8\n -renal to consider Tx biopsy tomorrow.\n -decreased urine output, unable to obtain lytes\n -was hypotensive --> stopped HTN meds --> was on phenylephrine gtt for\n a little. Weaned off and bolused with NS to keep MAP > 65\n -no new micro data\n -transplant ultrasound: elevated resistive indices on Doppler, greater\n than 2 days earlier, suggesting rejection. No hydro or fluid\n collection.\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 12:30 PM\n Fentanyl - 12:30 PM\n Heparin Sodium (Prophylaxis) - 03:46 PM\n Propofol - 05:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 82 (77 - 124) bpm\n BP: 140/71(88) {94/44(63) - 206/118(121)} mmHg\n RR: 8 (7 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n Total In:\n 2,039 mL\n 3,440 mL\n PO:\n TF:\n IVF:\n 1,919 mL\n 3,280 mL\n Blood products:\n Total out:\n 786 mL\n 315 mL\n Urine:\n 786 mL\n 315 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,253 mL\n 3,125 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 750 (600 - 750) mL\n PS : 15 cmH2O\n RR (Set): 10\n RR (Spontaneous): 7\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 14\n PIP: 14 cmH2O\n SpO2: 100%\n ABG: 7.27/39/129/14/-8\n Ve: 10.4 L/min\n PaO2 / FiO2: 322\n Physical Examination\n General: sedated but opens eyes to voice, responds to simple commands,\n intubated\n Pulmonary: faint scattered expiratory wheezes, decreased from prior\n Cardiac: RRR, normal S1/S2\n Abdomen: BS present throughout, soft and non-tender abdomen\n Extremities: No edema. Has non-functional right UE fistula. A-line in\n place LUE.\n Skin: Multiple keloids\n Neurologic: sedated as above; moving all extremities; responds to voice\n Labs / Radiology\n 198 K/uL\n 9.2 g/dL\n 164 mg/dL\n 4.1 mg/dL\n 14 mEq/L\n 5.3 mEq/L\n 71 mg/dL\n 97 mEq/L\n 125 mEq/L\n 27.9 %\n 9.3 K/uL\n [image002.jpg]\n 11:01 PM\n 03:22 AM\n 05:23 AM\n 04:15 AM\n 06:45 AM\n 02:35 PM\n 06:28 PM\n 11:05 PM\n 02:59 AM\n 03:26 AM\n WBC\n 7.4\n 10.5\n 9.3\n Hct\n 26.3\n 30.5\n 27.9\n Plt\n \n Cr\n 3.8\n 3.5\n 3.7\n 3.7\n 4.1\n 4.1\n TropT\n 0.05\n TCO2\n 20\n 18\n 20\n 19\n Glucose\n 178\n 497\n 211\n 148\n 166\n 164\n Other labs: PT / PTT / INR:13.9/35.5/1.2, CK / CKMB /\n Troponin-T:210/8/0.05, Lactic Acid:0.7 mmol/L, Ca++:7.2 mg/dL, Mg++:1.9\n mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n 60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n # Dyspnea: Underlying COPD with possible exacerbation in setting of\n parainfluenza, also with ?component of CHF. Ruled out for ACS.\n Progressive respiratory distress and fatigue required intubation on\n . ABGs now consistent with adequate oxygenation and ventilation.\n -Continue frequent bronchodilator therapy\n -Azithromycin x total 5 day course (today is d3/5)\n -Continue steroids at 125 mg Solumedrol q8h\n -F/u micro data\n -Consider weaning down PEEP today (now 15\nwean to 12)\n # Volatile blood pressure: Has known difficult to control HTN, with\n hypertensive nephropathy/ESRD s/p transplant. Reports med adherence.\n be due to respiratory distress, HD steroids, narcotic withdrawal,\n renal failure, volume overload. No evidence of RAS on renal US. Had\n been on hydral 75mg q6H, clonidine 0.1mg PO TID, Amlodipine 10mg daily,\n and Nicardipine gtt; however, post-intubation his blood pressure\n dropped and he has since required fluid boluses to maintain MAP >65.\n -Continue fluid boluses to maintain MAP >65\n -Holding due to ARF\n -F/u renal recs\n # Acute renal failure: History of ESRD due to hypertensive nephropathy,\n had been on dialysis before CRT in . Reports adherence with\n immunosuppresants. FeNa yesterday 1.4. Unclear precipitant for ARF,\n ddx includes dehydration, although unlikely given hypertension;\n transplant nephropathy. Question of rejection on most recent\n ultrasound. Tacrolimus level in nl range. BK virus DNA not detected.\n -Continue steroids, cellcept, prograf\n -F/u renal transplant recs; consider biopsy\n -Cont to hold and gabapentin for now\n -Consider lasix, would be ok to give per Renal\n # Hyponatremia: Suspect SIADH secondary to pulmonary process; urine\n osms 314 suggests that he may be inappropriately concentrating urine.\n Consider fluid restriction.\n -F/u renal recs\n -Consider free water restriction\n # Hyperlipidemia:\n -continue statin and ezetimibe\n # DM:\n -HISS\n -diabetic diet\n # Chronic pain:\n -continue home oxycontin, methadone, and dilaudid prn per OMR\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation:\n -senna, colace\n ICU Care\n Nutrition: start tube feeds today\n Glycemic Control: RISS\n Lines:\n PICC Line - 04:26 PM\n Prophylaxis:\n DVT: Heparin SC 5000 tid\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 673704,
"text": "TITLE:\n 24 Hour Events:\n - Pt continued on azithromycin but high-dose steroids were stopped\n - Quantification of pulmonary function on paralytics consistent with\n small airway resistance. No evidence of central airway obstruction on\n CT chest.\n - Pt started on sodium bicarb and transplant biopsy done for renal\n dysfunction. Cymbalta stopped.\n - BP had initially dropped in setting of intubation but became\n hypertensive again overnight, managed with fentanyl boluses.\n - Started on tube feeds overnight but noted to have high residuals. No\n BM since admission.\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Propofol - 80 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:23 AM\n Cisatracurium - 04:00 PM\n Heparin Sodium (Prophylaxis) - 10:53 PM\n Fentanyl - 04:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.2\nC (99\n HR: 112 (86 - 121) bpm\n BP: 155/84(107) {100/67(78) - 155/92(111)} mmHg\n RR: 19 (9 - 25) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 80 Inch\n Total In:\n 5,093 mL\n 630 mL\n PO:\n TF:\n 53 mL\n 143 mL\n IVF:\n 4,600 mL\n 386 mL\n Blood products:\n Total out:\n 1,060 mL\n 320 mL\n Urine:\n 1,060 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,033 mL\n 310 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 650 (650 - 650) mL\n Vt (Spontaneous): 860 (666 - 870) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 21 cmH2O\n Plateau: 11 cmH2O\n SpO2: 98%\n ABG: 7.27/40/123/17/-7\n Ve: 13.3 L/min\n PaO2 / FiO2: 308\n Physical Examination\n General: intubated, sedated\n Pulmonary: mild expiratory wheezes b/l\n Cardiac: tachycardic, regular, normal S1/S2\n Abdomen: Soft, hypoactive BS\n Extremities: No edema. Has non-functional right UE fistula. A-line in\n place LUE. Left midline.\n Skin: Multiple keloids\n Neurologic: sedated as above, not arousable to voice\n Labs / Radiology\n 305 K/uL\n 9.3 g/dL\n 137 mg/dL\n 4.3 mg/dL\n 17 mEq/L\n 5.2 mEq/L\n 72 mg/dL\n 95 mEq/L\n 125 mEq/L\n 28.3 %\n 16.3 K/uL\n [image002.jpg]\n 06:45 AM\n 02:35 PM\n 06:28 PM\n 11:05 PM\n 02:59 AM\n 03:26 AM\n 06:07 PM\n 06:19 PM\n 02:40 AM\n 03:41 AM\n WBC\n 9.3\n 16.3\n Hct\n 27.9\n 28.3\n Plt\n 198\n 305\n Cr\n 4.1\n 4.1\n 4.1\n 4.3\n TCO2\n 20\n 18\n 20\n 19\n 18\n 19\n Glucose\n 166\n 164\n 166\n 137\n Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB /\n Troponin-T:210/8/0.05, Lactic Acid:0.6 mmol/L, Ca++:8.2 mg/dL, Mg++:2.2\n mg/dL, PO4:5.7 mg/dL. Tacro level pending.\n Micro: Contaminated sputum sample. CMV viral load negative.\n Assessment and Plan\n 60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n # Dyspnea: Underlying COPD with possible exacerbation in setting of\n parainfluenza, also with ?component of CHF. Ruled out for ACS.\n Progressive respiratory distress and fatigue required intubation on\n . ABGs now consistent with adequate oxygenation and ventilation. CT\n scan without significant pulm dz and vent physiology most consistent\n with small airways obstruction, bronchospasm. I:E ratio improving with\n decreased wheezes on exam but not candidate for extubation today\n -Continue frequent bronchodilator therapy with albuterol and atrovent\n -Azithromycin 5-day course completed yesterday\n -Discontinued high-dose steroids yesterday dose (d/t lack of benefit x\n three days) and restarted on usual renal transplant prednisone\n -F/u micro data\n -RSBI/SBT tomorrow\n # Volatile blood pressure: Has known difficult to control HTN, with\n hypertensive nephropathy/ESRD s/p transplant. Reports med adherence.\n be due to respiratory distress, HD steroids, narcotic withdrawal,\n renal failure, volume overload. No evidence of RAS on renal US. Had\n been on hydral 75mg q6H, clonidine 0.1mg PO TID, Amlodipine 10mg daily,\n and Nicardipine gtt; however, post-intubation his blood pressure\n dropped and he has since required fluid boluses to maintain MAP >65.\n Now BP increasing again, ?in setting of inadequate pain control with\n poor gastric motility.\n -Start fentanyl gtt as may not be absorbing po pain meds\n -Consider hydral prn or nicardipine gtt if persistently elevated BP\n -Holding due to ARF and beta blockers due to resp status\n -F/u renal recs\n # Decreased gastric motility: High residuals from tube feeds. H/o poor\n motility on prior gastric emptying study, may be DM. Likely also\n exacerbated by narcotics and has not had bowel mvt in days.\n -KUB to evaluate for ileus\n -Reglan\n -aggressive bowel regimen\n -may need placement of post-pyloric dobhoff for nutrition if not\n improving\n # Acute renal failure: History of ESRD due to hypertensive nephropathy,\n had been on dialysis before CRT in . Reports adherence with\n immunosuppresants. FeNa 1.4. Unclear precipitant for ARF, ddx includes\n dehydration, although unlikely given hypertension; transplant\n nephropathy. Question of rejection on most recent ultrasound and now\n s/p transplant bx. Tacrolimus level in nl range. BK virus DNA not\n detected.\n -F/u renal recs\n -Await transplant bx result\n -Continue steroids, cellcept, prograf\n -Replete sodium and bicarb per renal recs\n -Cont to hold and gabapentin for now\n # Hyponatremia: Suspect SIADH secondary to pulmonary process; urine\n osms 314 suggests that he may be inappropriately concentrating urine.\n Consider fluid restriction.\n -Sodium bicarb repletion per renal recs\n -Repeat lytes in PM\n # Hyperlipidemia:\n -continue statin and ezetimibe\n # DM:\n -HISS\n -diabetic diet\n # Chronic pain:\n -Fentanyl gtt\n -holding po pain meds for now due to poor gastric motility (home\n oxycontin, methadone, and dilaudid prn)\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation:\n -senna, colace, bisacodyl pr, miralax, raglan\n broader as needed\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 06:45 PM 25 mL/hour\n pending\n improving in gastric motility\n Glycemic Control:\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 12:41 AM\n Prophylaxis:\n DVT: Heparin SC 5000 tid\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 673770,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - HTN: Changed fentanyl boluses to gtt with improvement in BP 180-200\n to 130-140. TSH 0.062, T4 5.3. Cortisol 14.9. Consider checking urine\n metanephrines. ? inadequate pain control v. duloxetine withdrawal v.\n pain med withdrawal given poor GI motility. BP trending up again to\n 180s despite increased fentanyl -> Hydral 10mg IV q6h with improvement.\n - Tachycardia: Sinus. ?Pain v. frequent nebs v. meds withdrawal.\n Improved to low 100s.\n - ARF: Transplant biopsy pending. Tacro 8.2. Given D5W with 3 amps\n bicarb.\n - GI motility: High residuals, no BM. H/o impaired gastric emptying,\n narcotics. Started reglan tid, bisacodyl pr, miralax, lactulose added.\n Changed po meds to IV. KUB limited but: \"some borderline distended\n parts of the colon are seen. There is no safe evidence of air-fluid\n levels. No free air.\"\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Propofol - 90 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 07:24 AM\n Propofol - 12:48 PM\n Fentanyl - 12:49 PM\n Heparin Sodium (Prophylaxis) - 11:04 PM\n Hydralazine - 11:04 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.3\nC (99.2\n HR: 110 (103 - 117) bpm\n BP: 140/75(95) {110/65(80) - 194/97(130)} mmHg\n RR: 21 (14 - 25) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 80 Inch\n Total In:\n 2,482 mL\n 940 mL\n PO:\n TF:\n 158 mL\n IVF:\n 1,974 mL\n 900 mL\n Blood products:\n Total out:\n 3,050 mL\n 650 mL\n Urine:\n 2,010 mL\n 540 mL\n NG:\n 1,040 mL\n 110 mL\n Stool:\n Drains:\n Balance:\n -568 mL\n 290 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 570 (498 - 775) mL\n PS : 10 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.29/37/95./19/-7\n Ve: 10.1 L/min\n PaO2 / FiO2: 240\n Physical Examination\n General: intubated, sedated\n Pulmonary: course breath sounds, occasional wheezes, +rhonchi\n Cardiac: tachycardic, regular, normal S1/S2\n Abdomen: Soft, hypoactive BS\n Extremities: No edema. Has non-functional right UE fistula. A-line in\n place LUE. Left midline.\n Skin: Multiple keloids\n Neurologic: sedated as above, not arousable to voice\n Labs / Radiology\n 364 K/uL\n 9.9 g/dL\n 150 mg/dL\n 3.8 mg/dL\n 19 mEq/L\n 4.9 mEq/L\n 75 mg/dL\n 99 mEq/L\n 129 mEq/L\n 30.3 %\n 23.2 K/uL\n [image002.jpg]\n 11:05 PM\n 02:59 AM\n 03:26 AM\n 06:07 PM\n 06:19 PM\n 02:40 AM\n 03:41 AM\n 10:08 AM\n 08:30 PM\n 04:18 AM\n WBC\n 9.3\n 16.3\n 23.2\n Hct\n 27.9\n 28.3\n 30.3\n Plt\n 198\n 305\n 364\n Cr\n 4.1\n 4.1\n 4.3\n 3.9\n 3.8\n TCO2\n 20\n 19\n 18\n 19\n 19\n Glucose\n 164\n 166\n 137\n 160\n 150\n Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB /\n Troponin-T:210/8/0.05, Differential-Neuts:87.4 %, Lymph:3.2 %, Mono:8.7\n %, Eos:0.5 %, Lactic Acid:0.6 mmol/L, Ca++:8.9 mg/dL, Mg++:2.0 mg/dL,\n PO4:5.6 mg/dL\n Assessment and Plan\n 60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n # Dyspnea: Underlying COPD with possible exacerbation in setting of\n parainfluenza, also with ?component of CHF. Ruled out for ACS.\n Progressive respiratory distress and fatigue required intubation on\n . ABGs now consistent with adequate oxygenation and ventilation. CT\n scan without significant pulm dz and vent physiology most consistent\n with small airways obstruction, bronchospasm. I:E ratio improving with\n decreased wheezes on exam but not candidate for extubation today\n -Continue frequent bronchodilator therapy with albuterol and atrovent\n -Azithromycin 5-day course completed yesterday\n -Discontinued high-dose steroids yesterday dose (d/t lack of benefit x\n three days) and restarted on usual renal transplant prednisone\n -F/u micro data\n -RSBI/SBT tomorrow\n # Volatile blood pressure: Has known difficult to control HTN, with\n hypertensive nephropathy/ESRD s/p transplant. Reports med adherence.\n be due to respiratory distress, HD steroids, narcotic withdrawal,\n renal failure, volume overload. No evidence of RAS on renal US. Had\n been on hydral 75mg q6H, clonidine 0.1mg PO TID, Amlodipine 10mg daily,\n and Nicardipine gtt; however, post-intubation his blood pressure\n dropped and he has since required fluid boluses to maintain MAP >65.\n Now BP increasing again, ?in setting of inadequate pain control with\n poor gastric motility.\n - fentanyl gtt as may not be absorbing po pain meds\n -Consider hydral prn or nicardipine gtt if persistently elevated BP\n -Holding due to ARF and beta blockers due to resp status\n -F/u renal recs\n # Decreased gastric motility: High residuals from tube feeds. H/o poor\n motility on prior gastric emptying study, may be DM. Likely also\n exacerbated by narcotics and has not had bowel mvt in days.\n -KUB to evaluate for ileus\n -Reglan\n -aggressive bowel regimen\n -may need placement of post-pyloric dobhoff for nutrition if not\n improving\n # Acute renal failure: History of ESRD due to hypertensive nephropathy,\n had been on dialysis before CRT in . Reports adherence with\n immunosuppresants. FeNa 1.4. Unclear precipitant for ARF, ddx includes\n dehydration, although unlikely given hypertension; transplant\n nephropathy. Question of rejection on most recent ultrasound and now\n s/p transplant bx. Tacrolimus level in nl range. BK virus DNA not\n detected.\n -F/u renal recs\n -Await transplant bx result\n -Continue steroids, cellcept, prograf\n -Replete sodium and bicarb per renal recs\n -Cont to hold and gabapentin for now\n # Hyponatremia: Suspect SIADH secondary to pulmonary process; urine\n osms 314 suggests that he may be inappropriately concentrating urine.\n Consider fluid restriction.\n -Sodium bicarb repletion per renal recs\n -Repeat lytes\n # Hyperlipidemia:\n -continue statin and ezetimibe\n # DM:\n -HISS\n -diabetic diet\n # Chronic pain:\n -Fentanyl gtt\n -holding po pain meds for now due to poor gastric motility (home\n oxycontin, methadone, and dilaudid prn)\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation: passing gas, positive BS, small BM overnight.\n -senna, colace, bisacodyl pr, miralax, raglan\n broader as needed\n ICU Care\n Nutrition: TF currently being held high residuals. Will start\n again today after BM\n Glycemic Control:\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 12:41 AM\n Prophylaxis:\n DVT: Heparin SC 5000 tid\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673852,
"text": "60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n Shift event:\n - Plan to extubate however when taken off sedation patient\n hypertensive to 200\ns, tachycardic to 130\ns tachypneic to 20-30\n Labored breathing. propofol restarted again. B/P down to 130\ns hr\n remained in 110-120\ns. Breathing still appears labored RR-27.\n - At 1700 B/P down to 100\ns. Per previous report patient is\n symptomatic at SBP of 100-110\ns. sedation down to 25mcg/hr. IVF bolus\n given.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Underline COPD with possible exacerbation in setting of parainfluenza.\n Received patient intubated and vented on PSV 40% 10/5 w/sats at high\n 90\ns. RR in 20\ns. B/L LS diminished w/transient wheezes. Green colored\n secretion w/suctioning. CXR w/o change however white count up w/bands.\n Action:\n SBT for 2hr, switched to PSV 5/5, Continue frequent bronchodilator\n therapy with albuterol and atrovent, f/u sputum cultures, started on\n Vanc/Zosyn for possible VAP. Continue w/VAP precautions, mouth care\n q4hr and PRN, suction PRN.\n Response:\n Pending abg: 7.25/46/99 off propofol on PS 5/5\n Plan:\n Continue to monitor resp status, f/u cx data, meds ASDIR, wean off vent\n and extubate when able.\n Hypertension, benign\n Assessment:\n Has known difficult to control HTN, with hypertensive nephropathy/ESRD\n s/p transplant. Currently on hydralazine 10mg iV q6hr. B/P at\n 120-130\ns. However during late morning b/p up to 170\ns. Hr in\n 100-110\ns w/frequent PAC\ns. extr edema. Peripheral pulses present.\n Action:\n Additional dose of hydralazine 10mg X1 given. B/P down to 120\n nicardipine gtt on hold in case hypertension persists\n Response:\n B/P remains in 120-130\ns. nicardipine gtt never started.\n Plan:\n Continue to monitor patient\n s hemodynamic status, meds ASDIR, if\n needed start nicardipine gtt\n Constipation (Obstipation, FOS)\n Assessment:\n Known decreased gastric motility. Abd soft distended, positive for BS\n and flatus, much smaller residuals 25cc. NPO but may restart TF later\n on today.\n Action:\n Continue Reglan, continue aggressive bowel regimen\n Response:\n pending\n Plan:\n Continue to monitor patient status, aggressive bowel regiment until\n clears, may restart TF later on if no residuals.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n s/p renal transplant, UOP 70-100cc/hr, creat trending down\n Action:\n F/u renal recs, Await transplant bx result, Continue steroids,\n cellcept, prograf, Replete sodium and bicarb per renal recs\n Response:\n pending\n Plan:\n Continue to monitor patient renal status, f/u renal recs.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673866,
"text": "60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674032,
"text": "60 yo M with esrd post transplant, copd, htn with progressive resp\n failure, hypotension, progressive ARF.\n Shift events:\n - spike temp to 101.1 BC sent, Tylenol X1 given , cont w/abx\n - -lactate up to 3.2 1 L NS given\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient intubated and vented on AC 100% 500X30/5 w/sats on ABG\n at 90. B/L diminished, still irregular breathing w/use of accessory\n muscles. No secretions w/suctioning. Last sputum positive for GNR. CXR\n w/ worsening infiltrates.\n Action:\n Remains intubated and vented, Fio2 down to 60%\n ABG: 7.20/54/94. Mouth\n care, MDI\ns ASDIR. Abg to eval. ABX for possible VAP\n Response:\n Pending abg: 7.26/38/131\n Plan:\n Continue to monitor resp status, f/u cultures, continue ABX, wean,\n SBT/RSBI, wean off when able.\n Hypotension (not Shock)\n Assessment:\n Received patient on maxed Neo and Vasopressin, after 7L IVF. Still\n hypotensive to 70\ns. Started on levophed. Patient also on steroids \n possible component of adrenal insufficiency. Tachycardic in \n w/occasional PAC\ns. General edema, peripheral pulses present w/doppler\n only, extr cool w/abnormal capillary refill. CVP 12-14, minimal UOP.\n Bladder pressure - 18\n Action:\n Pressors support (triple pressors) to maintain MAP >60 IVF to maintain\n CVP > 10, got 1 L bolus of Bicarb in D5W. stress steroids, abx to treat\n infection\n Response:\n Levophed weaned to 0.05 mcg/kg/min, rest remains w/o change.\n Plan:\n Continue to monitor patient\ns hemodynamic status, wean off pressors\n when able. F/u CX data, f/t ECHO read.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat\n 4.2 K-6.7 UOP minimal, bladder pressures -18\n Action:\n Total of 200MEq of Bicarb given, Insulin w/D50 given, calcium gluconate\n given, renal follows, continue on steroids/prograf/cellcept.\n Response:\n Pending K-5.7\n Plan:\n Continue to monitor patient\ns renal status, f/u renal recs, eval for\n need of CVVH\n Constipation (Obstipation, FOS)\n Assessment:\n Since admission on either Fentanyl or methadone/oxycodone. No BM. abd\n distended, no BS or flatus. OGT to suction w/ 1500cc of bilious output\n over 2HR. Cdiff negative. Bladder pressure -18\n Action:\n NPO, OGT to suction, aggressive bowel regimen, KUB done, continues on\n Reglan q6hr.\n Response:\n NO BM\n Plan:\n Continue to monitor patient status\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673102,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Overnight Mr. continued to be non compliant with most nursing\n care, he was started on a continuous Albuterol neb which he\n intermittently took on and off, on multiple occasions he took himself\n off all monitoring equipment and only after significant persuasion\n allowed this RN to place him back on telemetry.\n Events:\n * Nitro gtt remains @ 2mcg/kg/min\n * Hydral increased to 60mg PO qid\n * No other significant events\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received patient on NC 3 L and continues nebs w/sats > 90. Incompliant\n w/nebs (takes the mask off) bil LS ins/exp wheezes, DOE.\n Action:\n BiPAP trail failed, patient unable to tolerate the mask, continue on\n cont nebs however patient keeps taking the mask off despite multiple\n explanations. Nebs changed to q4hr. Nasopharyngeal swab ordered.\n Refuses ABG\ns, continue on prednisone for COPD flare. Got lasix 80mg\n X1.\n Response:\n Pending, remains wheezing. Sats at high 90\n Plan:\n Continue to monitor resp status, f/u CX data, CXR to eval progress,\n ABg\ns if needed, meds ASDIR.\n Hypertension, benign\n Assessment:\n Received patient on NITRO gtt at 1mcg/kg/min. b/p in 190-200\ns. HR at\n 70\ns peripheral pulses present. Minimal pedal edema. Denies headaches,\n nausea,, vomiting\n Action:\n Nitro titrated up to 2mcg/kg/min (long periods of OFF nitro due to\n inability to establish iv access and patient refusing IV access),\n hydralazine added Q6hr, cont on metoprolol . In addition hydralazyne\n 25mg X1 given at 1800 for persistent b/p of 180\n Response:\n Pending, however patient is incompliant w/care.\n Plan:\n Continue to monitor patient status, meds ASDIR.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673379,
"text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt with worsening respiratory distress, attempted dose of\n racemicepinephrine patient finally in agreement to try face mask\n ventilation however, not working, continued use of accessory muscles\n and significant work of breathing and required intubation. Pt intubated\n by anesthesia without apparent complications. Attempted to sedate\n w/fentanyl and versed drips however, despite boluses patient able to\n wake up, sit upright and attempts made to self extubate. Pt required\n wrist restraints to prevent self extubation and assist of 3 people to\n keep in bed before effects of bolus meds achieved. Sedation switched\n to propofol and then required phenylephrine drip to keep SBP <100. Pt\n continued to require intermittent boluses of 2-3cc of propofol as when\n awakens attempts to sit up and then bring head to hand to self\n extubate.\n Action:\n Intubated, sedated w/propofol now requiring pressor to maintain b/p.\n Renal US done.\n Transthoracic US done.\n Chest CT done.\n Response:\n Continued noted respiratory effort despite sedation.\n Plan:\n Sedate to ventilate and prevent self extubation, wrist restraints to\n prevent self harm, propofol as ordered. VAP prevention measures as per\n protocol. ICU team aware of need for more access as now on pressor and\n propofol, will discuss on evening rounds. Renal transplant team may\n perform kidney biopsy tomorrow. Will need to start nutrition soon.\n Hypertension, benign\n Assessment:\n Tolerated PO pills this morning prior to intubation. B/P dropping with\n sedation, B/P responed with fluid bolus. Now on pressor to maintain SBP\n > 100. Foley cath placed after intubated, initially urine output 250cc,\n now urine output 10-12cc/hr for last 3 hours.\n Action:\n Phenylephrine for b/p support. All PO B/P meds on hold while on\n pressor.\n Response:\n B/P responsive to fluid bolus, now requiring pressor support.\n Plan:\n Cont to support b/p as needed. Cont to monitor urine output.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673551,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received patient intubated and vented on PSV 40% 15/5 w/sats at high\n 90\ns RR in 10\ns. B/L LS exp wheezes. Intermittent non productive cough.\n Around 10 am appears in resp distress RR\ns, tachycardic to 120\n LS w/worsening wheezes. Sats remained in 90\ns. Patient appears\n fighting the vent, trying to get the ETT out.\n Action:\n Sedation increased to 100mcg/kg/min. MDI given. Paralytics given X1 to\n assess for flow obstruction/resistance. VAP precautions, mouth care\n q4hr and prn, suction prn. High dose steroids d/c since there was no\n improvement w/administration.\n Response:\n pending\n Plan:\n Continue to monitor resp status, wean off vent when able, meds ASDIR,\n f/u CX.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat- 4.1 K-5.3 UOP about 60cc/hr\n Action:\n Renal follows, renal biopsy done today, meds renally dosed. Continue\n cellcept, prograf( adjusted to daily level) /prednisone\n Response:\n pending\n Plan:\n Continue to monitor renal functions, f/u renal recs. f/u biopsy\n results.\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-08 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 673789,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n SPUTUM CULTURE - At 01:09 AM\n Fentanyl boluses switched to drip.\n TSH 0.62, AM cortisol 14.9\n For high residuals, bowel regimen and Reglan started.\n Flovent MDI added for bronchospasm, Off systemic steroids \n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Propofol - 90 mcg/Kg/min\n Other ICU medications:\n Propofol - 12:48 PM\n Pantoprazole (Protonix) - 07:33 AM\n Heparin Sodium (Prophylaxis) - 07:33 AM\n Fentanyl - 07:33 AM\n Hydralazine - 10:36 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.2\nC (98.9\n HR: 108 (103 - 117) bpm\n BP: 162/98(118) {110/65(80) - 194/100(130)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n Total In:\n 2,482 mL\n 1,407 mL\n PO:\n TF:\n 158 mL\n IVF:\n 1,974 mL\n 1,267 mL\n Blood products:\n Total out:\n 3,050 mL\n 925 mL\n Urine:\n 2,010 mL\n 815 mL\n NG:\n 1,040 mL\n 110 mL\n Stool:\n Drains:\n Balance:\n -568 mL\n 482 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 655 (498 - 740) mL\n PS : 10 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: ///19/\n Ve: 12.8 L/min\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: Breath Sounds: prolonged expiratory phase,\n occasional wheezes\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: No(t) Follows simple commands, Sedated, Tone: Not assessed\n Labs / Radiology\n 9.9 g/dL\n 364 K/uL\n 150 mg/dL\n 3.8 mg/dL\n 19 mEq/L\n 4.9 mEq/L\n 75 mg/dL\n 99 mEq/L\n 129 mEq/L\n 30.3 %\n 23.2 K/uL\n [image002.jpg]\n 11:05 PM\n 02:59 AM\n 03:26 AM\n 06:07 PM\n 06:19 PM\n 02:40 AM\n 03:41 AM\n 10:08 AM\n 08:30 PM\n 04:18 AM\n WBC\n 9.3\n 16.3\n 23.2\n Hct\n 27.9\n 28.3\n 30.3\n Plt\n 198\n 305\n 364\n Cr\n 4.1\n 4.1\n 4.3\n 3.9\n 3.8\n TCO2\n 20\n 19\n 18\n 19\n 19\n Glucose\n 164\n 166\n 137\n 160\n 150\n Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB /\n Troponin-T:210/8/0.05, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0\n %, Mono:8.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca++:8.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:5.6 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPERTENSION, BENIGN\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n 60 yo male with history of ESRD and s/p renal transplant now with\n intubation in the setting of progressive respiratory\n distress--tachypnea, weezing not responseive to racemic epinephrine or\n albuterol. Following intubation patient with persistent and\n significant expiratory flow limitation and CT scan not showing\n prominent abnormality. This leaves possible ongoing trigger for\n persistent bronchospasm or allergic reaction/anaphylaxis or TBM\n potentially driving findings which is one which has persisted despite\n high dose of steroids.\n What we are left with now is a need to explain possible sources as best\n as they can be defined. For Bronchomalacia\ncertainly with the forced\n exhalations he is undertaking this may promote collapse which will\n overwhelm the effects of PEEP. Will need to paralyze\nif paralytics\n used and expiratory airflow back to normal with PEEP this would argue\n for central airway. Alternatively parooxyms may be\n allergen/anaphylactic triggered (Cymbalta, insulin, heparin, cellcept,\n colace, methylpred, lansoprazole all given before most recent\n paroxysm), alternatively patient does have infectious insult as\n possible trigger with course made worse or prolonged in the setting of\n immunosupression.\n 1) Acute Respiratory Failure\n -minimize medications\n -Continue PSV --> SBT today, may be ready to extubate\n -Off high dose steroids, on Flovent MDI only, bronchospasm much\n improved\n -Azithro completed, off Cymbalta empirically to eliminate possible\n causes though unlikely\n - f/u on echo report\n 2) Leukocytosis with 4% bands\n Concern for brewing infection, VAP but no infiltrate on CXR, no fever\n 3) Chronic and Acute Renal Failure-\n -Tacrolimus, Mycophenilate, usual prednisone now dex IV\n -Will need to follow up on renal biopsy.\n 3) DM\n 4) Nutrition\n high residuals are improving.\n - gastroparesis by study in , likely related to DM.\n - continue trial of Reglan, if not successful, will insert post-pyloric\n dobhoff. Consider TPN if necessary.\n 5) Constipation\n - c/w bowel regimen\n - check KUB\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 12:41 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 39 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673842,
"text": "60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n Shift event:\n - Plan to extubate however when taken off sedation patient\n hypertensive to 200\ns, tachycardic to 130\ns tachypneic to 20-30\n Labored breathing. propofol restarted again. B/P down to 130\ns hr\n remained in 110-120\ns. Breathing still appears labored RR-27.\n - At 1700 B/P down to 100\ns. Per previous report patient is\n symptomatic at SBP of 100-110\ns. sedation down to 25mcg/hr. IVF bolus\n given.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Underline COPD with possible exacerbation in setting of parainfluenza.\n Received patient intubated and vented on PSV 40% 10/5 w/sats at high\n 90\ns. RR in 20\ns. B/L LS diminished w/transient wheezes. Green colored\n secretion w/suctioning. CXR w/o change however white count up w/bands.\n Action:\n SBT for 2hr, switched to PSV 5/5, Continue frequent bronchodilator\n therapy with albuterol and atrovent, f/u sputum cultures, started on\n Vanc/Zosyn for possible VAP. Continue w/VAP precautions, mouth care\n q4hr and PRN, suction PRN.\n Response:\n pending\n Plan:\n Continue to monitor resp status, f/u cx data, meds ASDIR, wean off vent\n and extubate when able.\n Hypertension, benign\n Assessment:\n Has known difficult to control HTN, with hypertensive nephropathy/ESRD\n s/p transplant. Currently on hydralazine 10mg iV q6hr. B/P at\n 120-130\ns. However during late morning b/p up to 170\ns. Hr in\n 100-110\ns w/frequent PAC\ns. extr edema. Peripheral pulses present.\n Action:\n Additional dose of hydralazine 10mg X1 given. B/P down to 120\n nicardipine gtt on hold in case hypertension persists\n Response:\n B/P remains in 120-130\ns. nicardipine gtt never started.\n Plan:\n Continue to monitor patient\n s hemodynamic status, meds ASDIR, if\n needed start nicardipine gtt\n Constipation (Obstipation, FOS)\n Assessment:\n Known decreased gastric motility. Abd soft distended, positive for BS\n and flatus, much smaller residuals 25cc. NPO but may restart TF later\n on today.\n Action:\n Continue Reglan, continue aggressive bowel regimen\n Response:\n pending\n Plan:\n Continue to monitor patient status, aggressive bowel regiment until\n clears, may restart TF later on if no residuals.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n s/p renal transplant, UOP 70-100cc/hr, creat trending down\n Action:\n F/u renal recs, Await transplant bx result, Continue steroids,\n cellcept, prograf, Replete sodium and bicarb per renal recs\n Response:\n pending\n Plan:\n Continue to monitor patient renal status, f/u renal recs.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673843,
"text": "60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n Shift event:\n - Plan to extubate however when taken off sedation patient\n hypertensive to 200\ns, tachycardic to 130\ns tachypneic to 20-30\n Labored breathing. propofol restarted again. B/P down to 130\ns hr\n remained in 110-120\ns. Breathing still appears labored RR-27.\n - At 1700 B/P down to 100\ns. Per previous report patient is\n symptomatic at SBP of 100-110\ns. sedation down to 25mcg/hr. IVF bolus\n given.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Underline COPD with possible exacerbation in setting of parainfluenza.\n Received patient intubated and vented on PSV 40% 10/5 w/sats at high\n 90\ns. RR in 20\ns. B/L LS diminished w/transient wheezes. Green colored\n secretion w/suctioning. CXR w/o change however white count up w/bands.\n Action:\n SBT for 2hr, switched to PSV 5/5, Continue frequent bronchodilator\n therapy with albuterol and atrovent, f/u sputum cultures, started on\n Vanc/Zosyn for possible VAP. Continue w/VAP precautions, mouth care\n q4hr and PRN, suction PRN.\n Response:\n pending\n Plan:\n Continue to monitor resp status, f/u cx data, meds ASDIR, wean off vent\n and extubate when able.\n Hypertension, benign\n Assessment:\n Has known difficult to control HTN, with hypertensive nephropathy/ESRD\n s/p transplant. Currently on hydralazine 10mg iV q6hr. B/P at\n 120-130\ns. However during late morning b/p up to 170\ns. Hr in\n 100-110\ns w/frequent PAC\ns. extr edema. Peripheral pulses present.\n Action:\n Additional dose of hydralazine 10mg X1 given. B/P down to 120\n nicardipine gtt on hold in case hypertension persists\n Response:\n B/P remains in 120-130\ns. nicardipine gtt never started.\n Plan:\n Continue to monitor patient\n s hemodynamic status, meds ASDIR, if\n needed start nicardipine gtt\n Constipation (Obstipation, FOS)\n Assessment:\n Known decreased gastric motility. Abd soft distended, positive for BS\n and flatus, much smaller residuals 25cc. NPO but may restart TF later\n on today.\n Action:\n Continue Reglan, continue aggressive bowel regimen\n Response:\n pending\n Plan:\n Continue to monitor patient status, aggressive bowel regiment until\n clears, may restart TF later on if no residuals.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n s/p renal transplant, UOP 70-100cc/hr, creat trending down\n Action:\n F/u renal recs, Await transplant bx result, Continue steroids,\n cellcept, prograf, Replete sodium and bicarb per renal recs\n Response:\n pending\n Plan:\n Continue to monitor patient renal status, f/u renal recs.\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 673942,
"text": "Chief Complaint: resp failure, htn, ARF on CRI, parainfluenza\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n immunosupressed M s/p renal transplant with progessive resp failure,\n hypotension, severe metabolic/resp acidosis, ARF on CRI, parainfluenze\n on sputum cxnow with woresning leukocytosis, GNR on sputum treating\n empirically for vap\n 24 Hour Events:\n MULTI LUMEN - START 05:27 AM\n TRIPLE INTRODUCER - START 05:29 AM\n progressive hypotension overnight--three pressors started--vasop, neo,\n levo\n concern for VAP/sepsis--vanco/zosyn started\n ACV started\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:59 PM\n Piperacillin/Tazobactam (Zosyn) - 12:48 AM\n Metronidazole - 04:03 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 10:36 AM\n Heparin Sodium (Prophylaxis) - 11:49 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.4\nC (99.3\n HR: 110 (102 - 121) bpm\n BP: 126/81(96) {76/58(65) - 196/100(130)} mmHg\n RR: 31 (18 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 80 Inch\n CVP: 5 (3 - 16)mmHg\n CO/CI (Fick): (14.8 L/min) / (6.4 L/min/m2)\n Mixed Venous O2% Sat: 81 - 81\n Total In:\n 6,245 mL\n 3,069 mL\n PO:\n TF:\n 39 mL\n IVF:\n 5,865 mL\n 3,069 mL\n Blood products:\n Total out:\n 1,690 mL\n 1,175 mL\n Urine:\n 1,580 mL\n 175 mL\n NG:\n 110 mL\n 1,000 mL\n Stool:\n Drains:\n Balance:\n 4,555 mL\n 1,894 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 490 (482 - 586) mL\n PS : 15 cmH2O\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 35 cmH2O\n Plateau: 20 cmH2O\n Compliance: 51 cmH2O/mL\n SpO2: 100%\n ABG: 7.16/49/205/17/-11\n Ve: 16.7 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: No(t) Sclera edema\n Head, Ears, Nose, Throat: Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), decreased BS, prolonged\n exp\n Abdominal: Bowel sounds present, Distended, No(t) Tender: , Obese\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.4 g/dL\n 369 K/uL\n 70 mg/dL\n 3.6 mg/dL\n 17 mEq/L\n 5.1 mEq/L\n 71 mg/dL\n 102 mEq/L\n 134 mEq/L\n 32.5 %\n 28.2 K/uL\n [image002.jpg]\n 04:18 AM\n 04:26 PM\n 08:08 PM\n 10:13 PM\n 12:02 AM\n 02:20 AM\n 02:24 AM\n 03:19 AM\n 04:05 AM\n 05:43 AM\n WBC\n 23.2\n 28.2\n Hct\n 30.3\n 32.5\n Plt\n 364\n 369\n Cr\n 3.8\n 3.6\n TCO2\n 21\n 20\n 21\n 20\n 21\n 19\n 20\n 18\n Glucose\n 150\n 70\n Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB /\n Troponin-T:210/8/0.05, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0\n %, Mono:8.0 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:9.2 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.9 mg/dL\n Imaging: progressive R > L lower lung infiltrates\n ET/R IJ in position\n Microbiology: sputum --GNR, GPC\n --blood pending\n c diff neg \n --nasal asp --parainflu\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n CONSTIPATION (OBSTIPATION, FOS)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPERTENSION, BENIGN\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITHOUT ACUTE EXACERBATION\n 60 yo M with esrd post transplant, copd, htn with progressive resp\n failure, hypotension, progressive arf on criresp failure\n # hypotension--most concerning for sepsis with gnr sputum and\n worsening infil on cxr, also possible component of adrenal insuf in\n immunosupressed host, cvps now low lower concern for cardiogenic\n continue aggressive IVF to maintain cvp > 10--would give 1 L bicarb and\n then LR alternating with NS given worsening met acidosis\n continue pressor support--now on triple to maintain MAP > 60--weann if\n able\n f/u TTE results\n continue stress steroids\n f/u cx data\n continue current antbx--vanco/zosyn/flagyl\n check bladder pressure to eval for compartment syndrome\n # resp failure--\n copd, small airways ds, with parainfluenza, and developing b/l lower\n zone infiltrates with gnr in sputum\n ventilation is worsening--now with met and resp acidosis lwith\n compensatory increased rate on vent worsening overall picture, has sig\n autopeep\n try mathcing peep, decrease rate and increase TV slightly to see if\n helps his venitaltory picture\n Fio2 weaned to 60\n follow gases\n continue broad coverage as above\n MDIs\n # Acute renal failure on CRI--urine output decreasing but CVPs\n low--will give bicarb, renal following and aware of decline (? need for\n CVVH)\n check bladder pressure as above\n #abd distension--bladder pressure, kub, follow c diff\n # thyroid fx--confusing picture, appears suppressed--liekly sickj\n suthyroid--will consult endo for input\n Remainder as per resident note\n ICU Care\n Nutrition:\n Comments: holding TF\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 04:50 AM\n Multi Lumen - 05:27 AM\n Triple Introducer - 05:29 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 60 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674085,
"text": "Hypotension (not Shock)\n Assessment:\n Sbp > 98,mean ~70 lactate up to 4.2 hct decreased to 23.3\n Action:\n Fluid boluses 2 liters of ns,neo weaned to off at 03;30.pt continues on\n vasopressin 2.4 units/hr transfused 1 unit prbc\ns and 1 unit ffp\n enroute ot OR.\n Response:\n Pt bp improved with fluid.tolerating neo off.\n Plan:\n Continue to hydrate with fluids as ordered,check lactate pt now in OR\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Fio2 at 60 % with adequate po2.. o2 sats only 86% methyglobin\n initially 10 and increased to 13\n Action:\n Methyline blue given iv at 0400,reglan discontinued.\n Response:\n To be evaluated..pt taken to or\n Plan:\n Check abg post methyline blue ..pt now in OR\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine ouput ~ 20 cc/hr very dark amber urine.creatinine up to 4.7,K 6.6\n at 2400\n Action:\n Fluid boluses,pt given bicarb in d5w 500 cc bolus,d50 25gm,10 units\n regular insulin,and calcium gluconate 2 grams at 0030.EKG done\n Response:\n Urine continues borderline~ 20 cc/hr,f/u K decreased to 6.2\n Plan:\n Follow urine,creatinine,lactate,potassium\n Constipation (Obstipation, FOS)\n Assessment:\n Abdomen distended, bowel sounds hypoactive ,large amount of og\n drainage..bilious.\n Action:\n Abdominal catscan done\n Response:\n Plan:\n To OR at 0420\n Pt also had head scan, pt continues nonresponsive, pupils are reactive\n and equal.\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-04 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 673211,
"text": "Chief Complaint: dyspnea\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 60M with htn, copd, tobacco use, esrd s/p kidney tx, p/w arf, dysnea\n with wheezing, parainfluenza positive:\n 24 Hour Events:\n ULTRASOUND - At 01:51 PM\n ULTRASOUND - At 02:16 PM\n PICC LINE - START 04:26 PM\n NON-INVASIVE VENTILATION - START 04:00 AM\n NON-INVASIVE VENTILATION - STOP 04:15 AM\n Difficult night with increased wheezing and sob; bipap for a few mins\n but refused. NEBS help but refusing.\n BP control challenging, started on nicardipine gtt (on LEG).\n Kidney u/s normal per verbal report.\n PICC placed.\n History obtained from Medical records\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Nitroglycerin - 0.5 mcg/Kg/min\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 PM\n Morphine Sulfate - 04:06 AM\n Furosemide (Lasix) - 04:06 AM\n Heparin Sodium (Prophylaxis) - 08:28 AM\n Other medications:\n duloxetine, azithro, atorvast, oxycodone 30 q12, riss, sqh, zetia, mmf,\n omepr, tacro 4q12, methadone tid, albut, hydral, methylpred 80 q8,\n hydral 50 q6, nidacrdipine, clonidine, amlodipine, dilaudid prn; lasix\n x1 at 4am, hydral iv, morphine x1\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: Chest pain, No(t) Palpitations, No(t) Edema, No(t)\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, Wheeze\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis, No(t)\n Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley, No(t) Dialysis\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Signs or concerns for abuse\n Pain: Minimal\n Pain location: abdomen and chest\n Flowsheet Data as of 01:31 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.7\nC (96.2\n Tcurrent: 35.6\nC (96\n HR: 82 (67 - 102) bpm\n BP: 158/74(92) {141/60(91) - 206/115(148)} mmHg\n RR: 23 (15 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n Total In:\n 2,338 mL\n 927 mL\n PO:\n 1,110 mL\n 480 mL\n TF:\n IVF:\n 478 mL\n 447 mL\n Blood products:\n Total out:\n 1,295 mL\n 1,000 mL\n Urine:\n 1,295 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,043 mL\n -73 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Other\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 730 (730 - 730) mL\n PS : 8 cmH2O\n PEEP: 5 cmH2O\n FiO2: 30%\n SpO2: 97%\n ABG: VBG 7.39/35/39\n Ve: 13.4 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n Wheezes : expiratory bilateral / central, No(t) Diminished: , No(t)\n Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, No(t)\n Distended, Tender: mildly throughout\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.6 g/dL\n 214 K/uL\n 211 mg/dL\n 3.7 mg/dL\n 20 mEq/L\n 4.4 mEq/L\n 50 mg/dL\n 92 mEq/L\n 126 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 07:57 AM\n 12:51 PM\n 09:53 PM\n 11:01 PM\n 03:22 AM\n 05:23 AM\n WBC\n 4.3\n 7.4\n Hct\n 28.8\n 26.3\n Plt\n 170\n 214\n Cr\n 3.9\n 3.6\n 3.8\n 3.5\n 3.7\n TropT\n 0.08\n 0.05\n TCO2\n 21\n Glucose\n 129\n 529\n 178\n 497\n 211\n Other labs: PT / PTT / INR:13.9/35.5/1.2, CK / CKMB /\n Troponin-T:210/8/0.05, Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:5.1 mg/dL\n Fluid analysis / Other labs: tacro 7.4\n spot protein ~3 g, comparable to 2 moonths ago\n Microbiology: Positive for Parainfluenza type 3 viral antigen.\n Other tests pending\n Assessment and Plan\n 60M with htn, copd, esrd s/p kidney tx in , presents with dyspnea\n and wheezing, with parainfluanza isolated, along with severe htn and\n arf:\n WHEEZING / RESP DISTRESS: likely mostly copd exac, possible from viral\n infection, vs mainly viral infection (given lack of prior frequent\n admits for copd exacerbation and normal pCO2):\n -will consider steroids back down to prednisone 5 daily (home dose)\n unless renal has concern for rejection and higher dose is recommended;\n -cont nebs; make ipratropium standing and continue albuterol standing\n and prn\n -no specific treatment for parainfluenza at this time\n -would benefit from cpap if able to tolerate but declining\n ANEMIA:\n -check iron panel\n ARF/TRANSPLANT: Cr remains elevated\n -fu final read on kidney and discuss with transplant additional imaging\n / tests\n -will avoid nephrotoxins and renal adjust meds\n HTN: can only check on leg; thus likely falsely elevated in\n part\n -start clonidine and titrate off drips\n -clarify \"goal bp\" with renal\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code (discussed with patient and confirmed Full Code\n today by Dr \n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n ------ Protected Section ------\n I was physicall present with the resident and fellow team on this date\n for the key portions of the service provided. I reviewed the history,\n exam, ROS, data and assessment and plan with which I agree. In\n addition, I would add the following remarks.\n patient with increasing wheezing and tachypnea and trialed on\n BIPAP\n Increased Steroids dosing\n Lasix/Better BP control with IV agents (TNG and Hydralazine overnight)\n Patient also had return of viral cultures as positive with\n Parainfluenza 3.\n EXAM-patient with persistent prolonged expiratory phase and signficant\n abdominal rounding on expiration\n CXR-Suggestion of right mid lung zone opacity\n Very interesting 60 yo male with presentation with bronchospasm and now\n with likely viral pathogen trigger. He has shown modest improvement in\n past 24 hours but with persistent respiratory distress\n -Continue NEBS\n -Given risk of prolonging acute infection and minimal change in\n bronchospasm will decrease steroids to baseline dosing\n -Azithro reasonable empirically with minimal risk\n -Patient on room air\n Critical Care Time-35 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 17:09 ------\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673850,
"text": "60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n Shift event:\n - Plan to extubate however when taken off sedation patient\n hypertensive to 200\ns, tachycardic to 130\ns tachypneic to 20-30\n Labored breathing. propofol restarted again. B/P down to 130\ns hr\n remained in 110-120\ns. Breathing still appears labored RR-27.\n - At 1700 B/P down to 100\ns. Per previous report patient is\n symptomatic at SBP of 100-110\ns. sedation down to 25mcg/hr. IVF bolus\n given.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Underline COPD with possible exacerbation in setting of parainfluenza.\n Received patient intubated and vented on PSV 40% 10/5 w/sats at high\n 90\ns. RR in 20\ns. B/L LS diminished w/transient wheezes. Green colored\n secretion w/suctioning. CXR w/o change however white count up w/bands.\n Action:\n SBT for 2hr, switched to PSV 5/5, Continue frequent bronchodilator\n therapy with albuterol and atrovent, f/u sputum cultures, started on\n Vanc/Zosyn for possible VAP. Continue w/VAP precautions, mouth care\n q4hr and PRN, suction PRN.\n Response:\n Pending abg: 7.25/46/99 off propofol on PS 5/5\n Plan:\n Continue to monitor resp status, f/u cx data, meds ASDIR, wean off vent\n and extubate when able.\n Hypertension, benign\n Assessment:\n Has known difficult to control HTN, with hypertensive nephropathy/ESRD\n s/p transplant. Currently on hydralazine 10mg iV q6hr. B/P at\n 120-130\ns. However during late morning b/p up to 170\ns. Hr in\n 100-110\ns w/frequent PAC\ns. extr edema. Peripheral pulses present.\n Action:\n Additional dose of hydralazine 10mg X1 given. B/P down to 120\n nicardipine gtt on hold in case hypertension persists\n Response:\n B/P remains in 120-130\ns. nicardipine gtt never started.\n Plan:\n Continue to monitor patient\n s hemodynamic status, meds ASDIR, if\n needed start nicardipine gtt\n Constipation (Obstipation, FOS)\n Assessment:\n Known decreased gastric motility. Abd soft distended, positive for BS\n and flatus, much smaller residuals 25cc. NPO but may restart TF later\n on today.\n Action:\n Continue Reglan, continue aggressive bowel regimen\n Response:\n pending\n Plan:\n Continue to monitor patient status, aggressive bowel regiment until\n clears, may restart TF later on if no residuals.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n s/p renal transplant, UOP 70-100cc/hr, creat trending down\n Action:\n F/u renal recs, Await transplant bx result, Continue steroids,\n cellcept, prograf, Replete sodium and bicarb per renal recs\n Response:\n pending\n Plan:\n Continue to monitor patient renal status, f/u renal recs.\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 673917,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 05:27 AM\n TRIPLE INTRODUCER - START 05:29 AM\n -Renal: am tacro level\n -SBT: Numbers were good per respiratory, but patient appeared to have\n increase work of breathing. Could not wean sedation enough to\n extubate, patient became agitated and had increased work of breathing.\n -Labile BP Sbp: 76 - 190s. Hypotension responded to fluid boluses,\n received a lot of fluid as suspecting sepsis.\n -Started on Vanc/Zosyn for presumed VAP\n -TF started then held for high residuals a few hours later\n -Changed from PS to CMV/Assist.\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:59 PM\n Piperacillin/Tazobactam (Zosyn) - 12:48 AM\n Metronidazole - 04:03 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Phenylephrine - 3.8 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:33 AM\n Fentanyl - 07:33 AM\n Hydralazine - 10:36 AM\n Heparin Sodium (Prophylaxis) - 11:49 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 109 (103 - 121) bpm\n BP: 106/73(85) {89/58(71) - 196/100(130)} mmHg\n RR: 33 (18 - 33) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 80 Inch\n CVP: 9 (9 - 16)mmHg\n CO/CI (Fick): (14.8 L/min) / (6.4 L/min/m2)\n Mixed Venous O2% Sat: 81 - 81\n Total In:\n 6,245 mL\n 2,888 mL\n PO:\n TF:\n 39 mL\n IVF:\n 5,865 mL\n 2,888 mL\n Blood products:\n Total out:\n 1,690 mL\n 1,175 mL\n Urine:\n 1,580 mL\n 175 mL\n NG:\n 110 mL\n 1,000 mL\n Stool:\n Drains:\n Balance:\n 4,555 mL\n 1,713 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 490 (482 - 655) mL\n PS : 15 cmH2O\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 28 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SpO2: 95%\n ABG: 7.16/49/205/17/-11\n Ve: 18.9 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General: intubated, sedated\n Pulmonary: course breath sounds, occasional wheezes, +rhonchi\n Cardiac: tachycardic, regular, normal S1/S2\n Abdomen: Soft, hypoactive BS\n Extremities: No edema. Has non-functional right UE fistula. A-line in\n place LUE. Left midline.\n Skin: Multiple keloids\n Neurologic: sedated as above, not arousable to voice\n Labs / Radiology\n 369 K/uL\n 10.4 g/dL\n 70 mg/dL\n 3.6 mg/dL\n 17 mEq/L\n 5.1 mEq/L\n 71 mg/dL\n 102 mEq/L\n 134 mEq/L\n 32.5 %\n 28.2 K/uL\n [image002.jpg]\n 04:18 AM\n 04:26 PM\n 08:08 PM\n 10:13 PM\n 12:02 AM\n 02:20 AM\n 02:24 AM\n 03:19 AM\n 04:05 AM\n 05:43 AM\n WBC\n 23.2\n 28.2\n Hct\n 30.3\n 32.5\n Plt\n 364\n 369\n Cr\n 3.8\n 3.6\n TCO2\n 21\n 20\n 21\n 20\n 21\n 19\n 20\n 18\n Glucose\n 150\n 70\n Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB /\n Troponin-T:210/8/0.05, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0\n %, Mono:8.0 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:9.2 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n CONSTIPATION (OBSTIPATION, FOS)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPERTENSION, BENIGN\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITHOUT ACUTE EXACERBATION\n 60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n # Dyspnea: Underlying COPD with possible exacerbation in setting of\n parainfluenza, also with ?component of CHF. Ruled out for ACS.\n Progressive respiratory distress and fatigue required intubation on\n . ABGs now consistent with adequate oxygenation and ventilation. CT\n scan without significant pulm dz and vent physiology most consistent\n with small airways obstruction, bronchospasm. I:E ratio improving with\n decreased wheezes on exam but not candidate for extubation today\n -Continue frequent bronchodilator therapy with albuterol and atrovent\n -Azithromycin 5-day course completed yesterday\n -Discontinued high-dose steroids yesterday dose (d/t lack of benefit x\n three days) and restarted on usual renal transplant prednisone\n -F/u micro data\n -RSBI/SBT tomorrow\n # Volatile blood pressure: Has known difficult to control HTN, with\n hypertensive nephropathy/ESRD s/p transplant. Reports med adherence.\n be due to respiratory distress, HD steroids, narcotic withdrawal,\n renal failure, volume overload. No evidence of RAS on renal US. Had\n been on hydral 75mg q6H, clonidine 0.1mg PO TID, Amlodipine 10mg daily,\n and Nicardipine gtt; however, post-intubation his blood pressure\n dropped and he has since required fluid boluses to maintain MAP >65.\n Now BP increasing again, ?in setting of inadequate pain control with\n poor gastric motility.\n - fentanyl gtt as may not be absorbing po pain meds\n -Consider hydral prn or nicardipine gtt if persistently elevated BP\n -Holding due to ARF and beta blockers due to resp status\n -F/u renal recs\n # Decreased gastric motility: High residuals from tube feeds. H/o poor\n motility on prior gastric emptying study, may be DM. Likely also\n exacerbated by narcotics and has not had bowel mvt in days.\n -KUB to evaluate for ileus\n -Reglan\n -aggressive bowel regimen\n -may need placement of post-pyloric dobhoff for nutrition if not\n improving\n # Acute renal failure: History of ESRD due to hypertensive nephropathy,\n had been on dialysis before CRT in . Reports adherence with\n immunosuppresants. FeNa 1.4. Unclear precipitant for ARF, ddx includes\n dehydration, although unlikely given hypertension; transplant\n nephropathy. Question of rejection on most recent ultrasound and now\n s/p transplant bx. Tacrolimus level in nl range. BK virus DNA not\n detected.\n -F/u renal recs\n -Await transplant bx result\n -Continue steroids, cellcept, prograf\n -Replete sodium and bicarb per renal recs\n -Cont to hold and gabapentin for now\n # Hyponatremia: Suspect SIADH secondary to pulmonary process; urine\n osms 314 suggests that he may be inappropriately concentrating urine.\n Consider fluid restriction.\n -Sodium bicarb repletion per renal recs\n -Repeat lytes\n # Hyperlipidemia:\n -continue statin and ezetimibe\n # DM:\n -HISS\n -diabetic diet\n # Chronic pain:\n -Fentanyl gtt\n -holding po pain meds for now due to poor gastric motility (home\n oxycontin, methadone, and dilaudid prn)\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation: passing gas, positive BS, small BM overnight.\n -senna, colace, bisacodyl pr, miralax, raglan\n broader as \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 04:50 AM\n Multi Lumen - 05:27 AM\n Triple Introducer - 05:29 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674081,
"text": "Hypotension (not Shock)\n Assessment:\n Sbp > 98,mean ~70 lactate up to 4.2 hct decreased to 23.3\n Action:\n Fluid boluses 2 liters of ns,neo weaned to off at 03;30.pt continues on\n vasopressin 2.4 units/hr transfused 1 unit prbc\ns and 1 unit ffp\n enroute ot OR.\n Response:\n Pt bp improved with fluid.tolerating neo off.\n Plan:\n Continue to hydrate with fluids as ordered,check lactate pt now in OR\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Fio2 at 60 % with adequate po2.. o2 sats only 86% methyglobin\n initially 10 and increased to 13\n Action:\n Methyline blue given iv at 0400\n Response:\n To be evaluated..pt taken to or\n Plan:\n Check abg post methyline blue ..pt now in OR\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine ouput ~ 20 cc/hr very dark amber urine.creatinine up to 4.7,K 6.6\n at 2400\n Action:\n Fluid boluses,pt given bicarb in d5w 500 cc bolus,d50 25gm,10 units\n regular insulin,and calcium gluconate 2 grams at 0030.EKG done\n Response:\n Urine continues borderline~ 20 cc/hr,f/u K decreased to 6.2\n Plan:\n Follow urine,creatinine,lactate,potassium\n Constipation (Obstipation, FOS)\n Assessment:\n Abdomen distended, bowel sounds hypoactive ,large amount of og\n drainage..bilious.\n Action:\n Abdominal catscan done\n Response:\n Plan:\n To OR at 0420\n Pt also had head scan, pt continues nonresponsive, pupils are reactive\n and equal.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673075,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, 25mg PO labetolol and was transferred to the\n M/SICU for further management of a COPD exacerbation and hypertension.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received patient on NC 3 L and continues nebs w/sats > 90. Incompliant\n w/nebs (takes the mask off) bil LS ins/exp wheezes, DOE.\n Action:\n BiPAP trail failed, patient unable to tolerate the mask, continue on\n cont nebs however patient keeps taking the mask off despite multiple\n explanations. Nebs changed to q4hr. Nasopharyngeal swab ordered.\n Refuses ABG\ns, continue on prednisone for COPD flare. Got lasix 80mg\n X1.\n Response:\n Pending, remains wheezing. Sats at high 90\n Plan:\n Continue to monitor resp status, f/u CX data, CXR to eval progress,\n ABg\ns if needed, meds ASDIR.\n Hypertension, benign\n Assessment:\n Received patient on NITRO gtt at 1mcg/kg/min. b/p in 190-200\ns. HR at\n 70\ns peripheral pulses present. Minimal pedal edema. Denies headaches,\n nausea,, vomiting\n Action:\n Nitro titrated up to 2mcg/kg/min (long periods of OFF nitro due to\n inability to establish iv access and patient refusing IV access),\n hydralazine added Q6hr, cont on metoprolol . In addition hydralazyne\n 25mg X1 given at 1800 for persistent b/p of 180\n Response:\n Pending, however patient is incompliant w/care.\n Plan:\n Continue to monitor patient status, meds ASDIR.\n Neuro: alert oriented, follows commands, stable gait. Incompliant\n w/treatment and safety precautions (refuses bipap, cont nebs, labs, IV\n access, non-slips socks when gets up/gets up by himself w/o supervision\n despite multiple explanations and etc.)\n GI: abd soft non tender positive for BS. No BM this shift. Renal\n regular diet. Denies nausea/vomiting.\n GU: voiding clear yellow urine. Renal following. K-5.6 refused\n kayexalate. Repleted w/Mg for Mg- 1.4 will have 28pm labs to reeval.\n IV access: picc placed at bedside\nper CXR not central but Ok to use.\n Social: full code.\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-04 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 673206,
"text": "Chief Complaint: dyspnea\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 60M with htn, copd, tobacco use, esrd s/p kidney tx, p/w arf, dysnea\n with wheezing, parainfluenza positive:\n 24 Hour Events:\n ULTRASOUND - At 01:51 PM\n ULTRASOUND - At 02:16 PM\n PICC LINE - START 04:26 PM\n NON-INVASIVE VENTILATION - START 04:00 AM\n NON-INVASIVE VENTILATION - STOP 04:15 AM\n Difficult night with increased wheezing and sob; bipap for a few mins\n but refused. NEBS help but refusing.\n BP control challenging, started on nicardipine gtt (on LEG).\n Kidney u/s normal per verbal report.\n PICC placed.\n History obtained from Medical records\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Nitroglycerin - 0.5 mcg/Kg/min\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 PM\n Morphine Sulfate - 04:06 AM\n Furosemide (Lasix) - 04:06 AM\n Heparin Sodium (Prophylaxis) - 08:28 AM\n Other medications:\n duloxetine, azithro, atorvast, oxycodone 30 q12, riss, sqh, zetia, mmf,\n omepr, tacro 4q12, methadone tid, albut, hydral, methylpred 80 q8,\n hydral 50 q6, nidacrdipine, clonidine, amlodipine, dilaudid prn; lasix\n x1 at 4am, hydral iv, morphine x1\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: Chest pain, No(t) Palpitations, No(t) Edema, No(t)\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, Wheeze\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis, No(t)\n Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley, No(t) Dialysis\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Signs or concerns for abuse\n Pain: Minimal\n Pain location: abdomen and chest\n Flowsheet Data as of 01:31 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.7\nC (96.2\n Tcurrent: 35.6\nC (96\n HR: 82 (67 - 102) bpm\n BP: 158/74(92) {141/60(91) - 206/115(148)} mmHg\n RR: 23 (15 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n Total In:\n 2,338 mL\n 927 mL\n PO:\n 1,110 mL\n 480 mL\n TF:\n IVF:\n 478 mL\n 447 mL\n Blood products:\n Total out:\n 1,295 mL\n 1,000 mL\n Urine:\n 1,295 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,043 mL\n -73 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Other\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 730 (730 - 730) mL\n PS : 8 cmH2O\n PEEP: 5 cmH2O\n FiO2: 30%\n SpO2: 97%\n ABG: VBG 7.39/35/39\n Ve: 13.4 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n Wheezes : expiratory bilateral / central, No(t) Diminished: , No(t)\n Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, No(t)\n Distended, Tender: mildly throughout\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.6 g/dL\n 214 K/uL\n 211 mg/dL\n 3.7 mg/dL\n 20 mEq/L\n 4.4 mEq/L\n 50 mg/dL\n 92 mEq/L\n 126 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 07:57 AM\n 12:51 PM\n 09:53 PM\n 11:01 PM\n 03:22 AM\n 05:23 AM\n WBC\n 4.3\n 7.4\n Hct\n 28.8\n 26.3\n Plt\n 170\n 214\n Cr\n 3.9\n 3.6\n 3.8\n 3.5\n 3.7\n TropT\n 0.08\n 0.05\n TCO2\n 21\n Glucose\n 129\n 529\n 178\n 497\n 211\n Other labs: PT / PTT / INR:13.9/35.5/1.2, CK / CKMB /\n Troponin-T:210/8/0.05, Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:5.1 mg/dL\n Fluid analysis / Other labs: tacro 7.4\n spot protein ~3 g, comparable to 2 moonths ago\n Microbiology: Positive for Parainfluenza type 3 viral antigen.\n Other tests pending\n Assessment and Plan\n 60M with htn, copd, esrd s/p kidney tx in , presents with dyspnea\n and wheezing, with parainfluanza isolated, along with severe htn and\n arf:\n WHEEZING / RESP DISTRESS: likely mostly copd exac, possible from viral\n infection, vs mainly viral infection (given lack of prior frequent\n admits for copd exacerbation and normal pCO2):\n -will consider steroids back down to prednisone 5 daily (home dose)\n unless renal has concern for rejection and higher dose is recommended;\n -cont nebs; make ipratropium standing and continue albuterol standing\n and prn\n -no specific treatment for parainfluenza at this time\n -would benefit from cpap if able to tolerate but declining\n ANEMIA:\n -check iron panel\n ARF/TRANSPLANT: Cr remains elevated\n -fu final read on kidney and discuss with transplant additional imaging\n / tests\n -will avoid nephrotoxins and renal adjust meds\n HTN: can only check on leg; thus likely falsely elevated in\n part\n -start clonidine and titrate off drips\n -clarify \"goal bp\" with renal\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code (discussed with patient and confirmed Full Code\n today by Dr \n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 673209,
"text": "Lung sounds\n RLL Lung Sounds: Insp/Exp Wheeze\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Ins/Exp Wheeze\n Plan\n Continue given atrovent nebs Q6hrs and continuous Albuterol nebs.\n Respiratory Care Shift Procedures\n Comments: Pt not compliant with neb treatment, takes off mask, pt\n keeps continuous neb most of the times on the forehead or the mandible.\n Hr stable with Albuterol neb treatments, not tachycardia noted.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673376,
"text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt with worsening respiratory distress, attempted dose of\n racemicepinephrine patient finally in agreement to try face mask\n ventilation however, not working, continued use of accessory muscles\n and significant work of breathing and required intubation. Pt intubated\n by anesthesia without apparent complications. Attempted to sedate\n w/fentanyl and versed drips however, despite boluses patient able to\n wake up, sit upright and attempts made to self extubate. Pt required\n wrist restraints to prevent self extubation and assist of 3 people to\n keep in bed before effects of bolus meds achieved. Sedation switched\n to propofol and then required phenylephrine drip to keep SBP <100. Pt\n continued to require intermittent boluses of 2-3cc of propofol as when\n awakens attempts to sit up and then bring head to hand to self\n extubate.\n Action:\n Intubated, sedated w/propofol now requiring pressor to maintain b/p.\n Response:\n Continued noted respiratory effort despite sedation.\n Plan:\n Sedate to ventilate and prevent self extubation, wrist restraints to\n prevent self harm, propofol as ordered. VAP prevention measures as per\n protocol.\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673443,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Hypertension, benign\n Assessment:\n Received patient on phenylephrine at 0.9mkm, weaned off and is\n currently off at time of reporting.\n Action:\n Patient did become hypotensive post wean off phenylephrine, treated\n with 3l of N/S.\n Response:\n Maintain SBP 110\n 130\ns, is to try and keep MAP greater than 65mmHg.\n Plan:\n All antihypertensive have since been d/c\nd BP at this time.\n Continue to monitor BP and urinary output. Follow lab trends.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Mechanically ventilated on CPAP 15/5 at this time with TV in the \n hundreds.\n Action:\n Vent settings had to be manipulated several times overnight, but\n patient remains in acidosis.\n Response:\n Blood gases has improved last one being done at 0300 this am\n 7.27/39/129/19. Lung sounds are better and respiratory exertion less.\n Maintaining saturation greater than 95% consistently.\n Plan:\n Continue to follow lab trends and make adjustments to ventilatory\n settings as recommended.\n Urinary output still poor, however improved from previous day, it is\n approximately 25-30cc/hr.\n Patient is difficult to sedate, propofol going at 50mkm currently with\n patient opening eyes to verbal stimuli and will sit up in bed at\n times. His BP is sensitive to propofol boluses. Bilateral soft wrist\n restraints on for patient safety.\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 675120,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Patient remains intubated and on mechanical ventilation,\n breath sounds bilaterally diminished, suctioned intermittently for no\n secretion, ABGs showed good acid-base with mild hyperoxemia, will\n continues to be followed.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673693,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received patient intubated and vented on PSV 40% 15/5 w/sats at high\n 90\ns RR in 10\ns. B/L LS insp wheezes / diminished. However some\n improved from yesterday.\n Action:\n Switched to PSV 10/5. Continue w/MDI. Ipratropium added. VAP\n precautions, mouth care q4hr and prn, suction prn.\n Response:\n pending\n Plan:\n Continue to monitor resp status, wean off vent when able, meds ASDIR,\n f/u CX.\n Hypertension, benign\n Assessment:\n B/P at 160-170\ns Hr at 80\ns SR, pedal edema, peripheral pulses\n present. After pain meds administration b/p at 140\ns and patient\n appears more comfortable. Later during the day b/p up to 190\ns HR at\n 110\ns w/frequent PAC\ns despite sedation and pain meds.\n Action:\n Started on fentanyl gtt and hydralazyne q6hr.\n Response:\n B/P at 120\n 130\ns. Hr still tachycardia at 110\n Plan:\n Continue to monitor patient hemodynamic status, increase hydralazyne\n dose if needed.\n Neuro: sedated on propofol /fentanyl. Arousable w/stimulation.\n Otherwise does not follow commands.\n GI: abd soft distended, minimal BS. No BM for 5 Days. High residuals\n 850cc over 12hr. OGT to LCS. KUB done, started on reglan and aggressive\n bowel regimen. At 1800 OGT clamped to eval for residuals. Meds switched\n to IV.\n GU: clear yellow urine via foley, adequate amnt.\n IV access: LT midline, RT pIV, LT A-line.\n Social: patient is a FULL CODE. Family called, updated by RN.\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 673757,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - HTN: Changed fentanyl boluses to gtt with improvement in BP 180-200\n to 130-140. TSH 0.062, T4 5.3. Cortisol 14.9. Consider checking urine\n metanephrines. ? inadequate pain control v. duloxetine withdrawal v.\n pain med withdrawal given poor GI motility. BP trending up again to\n 180s despite increased fentanyl -> Hydral 10mg IV q6h with improvement.\n - Tachycardia: Sinus. ?Pain v. frequent nebs v. meds withdrawal.\n Improved to low 100s.\n - ARF: Transplant biopsy pending. Tacro 8.2. Given D5W with 3 amps\n bicarb.\n - GI motility: High residuals, no BM. H/o impaired gastric emptying,\n narcotics. Started reglan tid, bisacodyl pr, miralax, lactulose added.\n Changed po meds to IV. KUB limited but: \"some borderline distended\n parts of the colon are seen. There is no safe evidence of air-fluid\n levels. No free air.\"\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Propofol - 90 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 07:24 AM\n Propofol - 12:48 PM\n Fentanyl - 12:49 PM\n Heparin Sodium (Prophylaxis) - 11:04 PM\n Hydralazine - 11:04 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.3\nC (99.2\n HR: 110 (103 - 117) bpm\n BP: 140/75(95) {110/65(80) - 194/97(130)} mmHg\n RR: 21 (14 - 25) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 80 Inch\n Total In:\n 2,482 mL\n 940 mL\n PO:\n TF:\n 158 mL\n IVF:\n 1,974 mL\n 900 mL\n Blood products:\n Total out:\n 3,050 mL\n 650 mL\n Urine:\n 2,010 mL\n 540 mL\n NG:\n 1,040 mL\n 110 mL\n Stool:\n Drains:\n Balance:\n -568 mL\n 290 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 570 (498 - 775) mL\n PS : 10 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.29/37/95./19/-7\n Ve: 10.1 L/min\n PaO2 / FiO2: 240\n Physical Examination\n General: intubated, sedated\n Pulmonary: mild expiratory wheezes b/l\n Cardiac: tachycardic, regular, normal S1/S2\n Abdomen: Soft, hypoactive BS\n Extremities: No edema. Has non-functional right UE fistula. A-line in\n place LUE. Left midline.\n Skin: Multiple keloids\n Neurologic: sedated as above, not arousable to voice\n Labs / Radiology\n 364 K/uL\n 9.9 g/dL\n 150 mg/dL\n 3.8 mg/dL\n 19 mEq/L\n 4.9 mEq/L\n 75 mg/dL\n 99 mEq/L\n 129 mEq/L\n 30.3 %\n 23.2 K/uL\n [image002.jpg]\n 11:05 PM\n 02:59 AM\n 03:26 AM\n 06:07 PM\n 06:19 PM\n 02:40 AM\n 03:41 AM\n 10:08 AM\n 08:30 PM\n 04:18 AM\n WBC\n 9.3\n 16.3\n 23.2\n Hct\n 27.9\n 28.3\n 30.3\n Plt\n 198\n 305\n 364\n Cr\n 4.1\n 4.1\n 4.3\n 3.9\n 3.8\n TCO2\n 20\n 19\n 18\n 19\n 19\n Glucose\n 164\n 166\n 137\n 160\n 150\n Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB /\n Troponin-T:210/8/0.05, Differential-Neuts:87.4 %, Lymph:3.2 %, Mono:8.7\n %, Eos:0.5 %, Lactic Acid:0.6 mmol/L, Ca++:8.9 mg/dL, Mg++:2.0 mg/dL,\n PO4:5.6 mg/dL\n Assessment and Plan\n 60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n # Dyspnea: Underlying COPD with possible exacerbation in setting of\n parainfluenza, also with ?component of CHF. Ruled out for ACS.\n Progressive respiratory distress and fatigue required intubation on\n . ABGs now consistent with adequate oxygenation and ventilation. CT\n scan without significant pulm dz and vent physiology most consistent\n with small airways obstruction, bronchospasm. I:E ratio improving with\n decreased wheezes on exam but not candidate for extubation today\n -Continue frequent bronchodilator therapy with albuterol and atrovent\n -Azithromycin 5-day course completed yesterday\n -Discontinued high-dose steroids yesterday dose (d/t lack of benefit x\n three days) and restarted on usual renal transplant prednisone\n -F/u micro data\n -RSBI/SBT tomorrow\n # Volatile blood pressure: Has known difficult to control HTN, with\n hypertensive nephropathy/ESRD s/p transplant. Reports med adherence.\n be due to respiratory distress, HD steroids, narcotic withdrawal,\n renal failure, volume overload. No evidence of RAS on renal US. Had\n been on hydral 75mg q6H, clonidine 0.1mg PO TID, Amlodipine 10mg daily,\n and Nicardipine gtt; however, post-intubation his blood pressure\n dropped and he has since required fluid boluses to maintain MAP >65.\n Now BP increasing again, ?in setting of inadequate pain control with\n poor gastric motility.\n -Start fentanyl gtt as may not be absorbing po pain meds\n -Consider hydral prn or nicardipine gtt if persistently elevated BP\n -Holding due to ARF and beta blockers due to resp status\n -F/u renal recs\n # Decreased gastric motility: High residuals from tube feeds. H/o poor\n motility on prior gastric emptying study, may be DM. Likely also\n exacerbated by narcotics and has not had bowel mvt in days.\n -KUB to evaluate for ileus\n -Reglan\n -aggressive bowel regimen\n -may need placement of post-pyloric dobhoff for nutrition if not\n improving\n # Acute renal failure: History of ESRD due to hypertensive nephropathy,\n had been on dialysis before CRT in . Reports adherence with\n immunosuppresants. FeNa 1.4. Unclear precipitant for ARF, ddx includes\n dehydration, although unlikely given hypertension; transplant\n nephropathy. Question of rejection on most recent ultrasound and now\n s/p transplant bx. Tacrolimus level in nl range. BK virus DNA not\n detected.\n -F/u renal recs\n -Await transplant bx result\n -Continue steroids, cellcept, prograf\n -Replete sodium and bicarb per renal recs\n -Cont to hold and gabapentin for now\n # Hyponatremia: Suspect SIADH secondary to pulmonary process; urine\n osms 314 suggests that he may be inappropriately concentrating urine.\n Consider fluid restriction.\n -Sodium bicarb repletion per renal recs\n -Repeat lytes in PM\n # Hyperlipidemia:\n -continue statin and ezetimibe\n # DM:\n -HISS\n -diabetic diet\n # Chronic pain:\n -Fentanyl gtt\n -holding po pain meds for now due to poor gastric motility (home\n oxycontin, methadone, and dilaudid prn)\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation:\n -senna, colace, bisacodyl pr, miralax, raglan\n broader as needed\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 12:41 AM\n Prophylaxis:\n DVT: Heparin SC 5000 tid\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 673930,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 05:27 AM\n TRIPLE INTRODUCER - START 05:29 AM\n -Renal: am tacro level\n -SBT: Numbers were good per respiratory, but patient appeared to have\n increase work of breathing. Could not wean sedation enough to\n extubate, patient became agitated and had increased work of breathing.\n -Labile BP Sbp: 76 - 190s. Hypotension responded to fluid boluses,\n received a lot of fluid as suspecting sepsis.\n -Started on Vanc/Zosyn for presumed VAP\n -TF started then held for high residuals a few hours later\n -Changed from PS to CMV/Assist.\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:59 PM\n Piperacillin/Tazobactam (Zosyn) - 12:48 AM\n Metronidazole - 04:03 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Phenylephrine - 3.8 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:33 AM\n Fentanyl - 07:33 AM\n Hydralazine - 10:36 AM\n Heparin Sodium (Prophylaxis) - 11:49 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 109 (103 - 121) bpm\n BP: 106/73(85) {89/58(71) - 196/100(130)} mmHg\n RR: 33 (18 - 33) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 80 Inch\n CVP: 9 (9 - 16)mmHg\n CO/CI (Fick): (14.8 L/min) / (6.4 L/min/m2)\n Mixed Venous O2% Sat: 81 - 81\n Total In:\n 6,245 mL\n 2,888 mL\n PO:\n TF:\n 39 mL\n IVF:\n 5,865 mL\n 2,888 mL\n Blood products:\n Total out:\n 1,690 mL\n 1,175 mL\n Urine:\n 1,580 mL\n 175 mL\n NG:\n 110 mL\n 1,000 mL\n Stool:\n Drains:\n Balance:\n 4,555 mL\n 1,713 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 490 (482 - 655) mL\n PS : 15 cmH2O\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 28 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SpO2: 95%\n ABG: 7.16/49/205/17/-11\n Ve: 18.9 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General: intubated, sedated\n Pulmonary: course breath sounds, occasional wheezes, +rhonchi\n Cardiac: tachycardic, regular, normal S1/S2\n Abdomen: Soft, hypoactive BS\n Extremities: No edema. Has non-functional right UE fistula. A-line in\n place LUE. Left midline.\n Skin: Multiple keloids\n Neurologic: sedated as above, not arousable to voice\n Labs / Radiology\n 369 K/uL\n 10.4 g/dL\n 70 mg/dL\n 3.6 mg/dL\n 17 mEq/L\n 5.1 mEq/L\n 71 mg/dL\n 102 mEq/L\n 134 mEq/L\n 32.5 %\n 28.2 K/uL\n [image002.jpg]\n 04:18 AM\n 04:26 PM\n 08:08 PM\n 10:13 PM\n 12:02 AM\n 02:20 AM\n 02:24 AM\n 03:19 AM\n 04:05 AM\n 05:43 AM\n WBC\n 23.2\n 28.2\n Hct\n 30.3\n 32.5\n Plt\n 364\n 369\n Cr\n 3.8\n 3.6\n TCO2\n 21\n 20\n 21\n 20\n 21\n 19\n 20\n 18\n Glucose\n 150\n 70\n Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB /\n Troponin-T:210/8/0.05, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0\n %, Mono:8.0 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:9.2 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n CONSTIPATION (OBSTIPATION, FOS)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPERTENSION, BENIGN\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITHOUT ACUTE EXACERBATION\n 60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n # Dyspnea: Underlying COPD with possible exacerbation in setting of\n parainfluenza, also with ?component of CHF. Ruled out for ACS.\n Progressive respiratory distress and fatigue required intubation on\n . ABGs now consistent with adequate oxygenation and ventilation. CT\n scan without significant pulm dz and vent physiology most consistent\n with small airways obstruction, bronchospasm. I:E ratio improving with\n decreased wheezes on exam but not candidate for extubation today\n -Continue frequent bronchodilator therapy with albuterol and atrovent\n -Azithromycin 5-day course completed yesterday\n -Discontinued high-dose steroids yesterday dose (d/t lack of benefit x\n three days) and restarted on usual renal transplant prednisone\n -F/u micro data\n -RSBI/SBT tomorrow\n # Volatile blood pressure: Has known difficult to control HTN, with\n hypertensive nephropathy/ESRD s/p transplant. Reports med adherence.\n be due to respiratory distress, HD steroids, narcotic withdrawal,\n renal failure, volume overload. No evidence of RAS on renal US. Had\n been on hydral 75mg q6H, clonidine 0.1mg PO TID, Amlodipine 10mg daily,\n and Nicardipine gtt; however, post-intubation his blood pressure\n dropped and he has since required fluid boluses to maintain MAP >65.\n Now BP increasing again, ?in setting of inadequate pain control with\n poor gastric motility.\n - fentanyl gtt as may not be absorbing po pain meds\n -Consider hydral prn or nicardipine gtt if persistently elevated BP\n -Holding due to ARF and beta blockers due to resp status\n -F/u renal recs\n # Decreased gastric motility: High residuals from tube feeds. H/o poor\n motility on prior gastric emptying study, may be DM. Likely also\n exacerbated by narcotics and has not had bowel mvt in days.\n -KUB to evaluate for ileus\n -Reglan\n -aggressive bowel regimen\n -may need placement of post-pyloric dobhoff for nutrition if not\n improving\n # Acute renal failure: History of ESRD due to hypertensive nephropathy,\n had been on dialysis before CRT in . Reports adherence with\n immunosuppresants. FeNa 1.4. Unclear precipitant for ARF, ddx includes\n dehydration, although unlikely given hypertension; transplant\n nephropathy. Question of rejection on most recent ultrasound and now\n s/p transplant bx. Tacrolimus level in nl range. BK virus DNA not\n detected.\n -F/u renal recs\n -Await transplant bx result\n -Continue steroids, cellcept, prograf\n -Replete sodium and bicarb per renal recs\n -Cont to hold and gabapentin for now\n # Hyponatremia: Suspect SIADH secondary to pulmonary process; urine\n osms 314 suggests that he may be inappropriately concentrating urine.\n Consider fluid restriction.\n -Sodium bicarb repletion per renal recs\n -Repeat lytes\n # Hyperlipidemia:\n -continue statin and ezetimibe\n # DM:\n -HISS\n -diabetic diet\n # Chronic pain:\n -Fentanyl gtt\n -holding po pain meds for now due to poor gastric motility (home\n oxycontin, methadone, and dilaudid prn)\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation: passing gas, positive BS, small BM overnight.\n -senna, colace, bisacodyl pr, miralax, raglan\n broader as \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 04:50 AM\n Multi Lumen - 05:27 AM\n Triple Introducer - 05:29 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 674018,
"text": "Chief Complaint: resp failure, septic shock, ARF on CRI, parainfluenza\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60 yo M with COPD, immunosupressed s/p renal transplant admitted\n with progressive resp distress requiring intubation----had tachypnea,\n weezing minimally responsive to racemic epinephrine, albuterol, and\n high dose steroids\nparainfleunza +, significant expiratory limitation\n and ventilatory defect concerning for possiblity of contribution from\n TBM or small airways reactivity, now with progressive hypotension on\n triple pressors, severe metabolic + resp acidosis, ARF on CRI,\n leukocytosis, and GNR in sputum treating empirically for vap\n 24 Hour Events:\n MULTI LUMEN - START 05:27 AM\n TRIPLE INTRODUCER - START 05:29 AM\n Developed progressive hypotension overnight\nnow on three pressors for\n HD support--vasop, neo, levo\n Sepsis/VAP--vanco/zosyn started\n Changed to PCV\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:59 PM\n Piperacillin/Tazobactam (Zosyn) - 12:48 AM\n Metronidazole - 04:03 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 10:36 AM\n Heparin Sodium (Prophylaxis) - 11:49 PM\n Other medications: per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.4\nC (99.3\n HR: 110 (102 - 121) bpm\n BP: 126/81(96) {76/58(65) - 196/100(130)} mmHg\n RR: 31 (18 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 80 Inch\n CVP: 5 (3 - 16)mmHg\n CO/CI (Fick): (14.8 L/min) / (6.4 L/min/m2)\n Mixed Venous O2% Sat: 81 - 81\n Total In:\n 6,245 mL\n 3,069 mL\n PO:\n TF:\n 39 mL\n IVF:\n 5,865 mL\n 3,069 mL\n Blood products:\n Total out:\n 1,690 mL\n 1,175 mL\n Urine:\n 1,580 mL\n 175 mL\n NG:\n 110 mL\n 1,000 mL\n Stool:\n Drains:\n Balance:\n 4,555 mL\n 1,894 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 490 (482 - 586) mL\n PS : 15 cmH2O\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 35 cmH2O\n Plateau: 20 cmH2O\n Compliance: 51 cmH2O/mL\n SpO2: 100%\n ABG: 7.16/49/205/17/-11\n Ve: 16.7 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: No(t) Sclera edema\n Head, Ears, Nose, Throat: Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), decreased BS, minimal air\n movement\n Abdominal: Bowel sounds present, Distended, No(t) Tender: , Obese,\n decreased BS\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: cool\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.4 g/dL\n 369 K/uL\n 70 mg/dL\n 3.6 mg/dL\n 17 mEq/L\n 5.1 mEq/L\n 71 mg/dL\n 102 mEq/L\n 134 mEq/L\n 32.5 %\n 28.2 K/uL\n [image002.jpg]\n 04:18 AM\n 04:26 PM\n 08:08 PM\n 10:13 PM\n 12:02 AM\n 02:20 AM\n 02:24 AM\n 03:19 AM\n 04:05 AM\n 05:43 AM\n WBC\n 23.2\n 28.2\n Hct\n 30.3\n 32.5\n Plt\n 364\n 369\n Cr\n 3.8\n 3.6\n TCO2\n 21\n 20\n 21\n 20\n 21\n 19\n 20\n 18\n Glucose\n 150\n 70\n Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB /\n Troponin-T:210/8/0.05, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0\n %, Mono:8.0 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:9.2 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.9 mg/dL\n Imaging: progressive R > L lower lung infiltrates\n ET/R IJ in position\n Microbiology: sputum --GNR, GPC\n --blood pending\n c diff neg \n --nasal asp --parainflu\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n CONSTIPATION (OBSTIPATION, FOS)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPERTENSION, BENIGN\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITHOUT ACUTE EXACERBATION\n 60 yo M with COPD, immunosupressed s/p renal transplant admitted with\n progressive resp distress requiring intubation----tachypnea, weezing\n minimally responsive to racemic epinephrine, albuterol, and high dose\n steroids\nparainfleunza +, significant expiratory limitation and\n ventilatory defect concerning for possibility of contribution from TBM\n or small airways reactivity now with progressive hypotension on triple\n pressors, severe metabolic + resp acidosis, ARF on CRI, leukocytosis,\n and GNR in sputum treating empirically for vap\n # hypotension/shock\n most concerning for septic shock with gnr sputum and now with worsening\n infil on cxr\n also possible component of adrenal insuf in this immunosupressed host\n Given low CVPS\ncardiogenic shock seems less likely\n ---continue aggressive IVF to maintain cvp > 10--would give 1 L bicarb\n and then LR alternating with NS given worsening met acidosis\n --continue pressor support--now on triple-- to maintain MAP > 60--wean\n as able\n --f/u TTE results\n --continue stress steroids\n --continue current broad antbx--vanco/zosyn/flagyl following cx results\n --check bladder pressure to eval for compartment syndrome contributing\n to hypotension and renal failure, though lower clinical suspicion\n # resp failure--\n copd, small airways ds, with parainfluenza, and developing b/l lower\n zone infiltrates with gnr in sputum concerning for HPA/VAP\n ventilation is worsening--now with met and resp acidosis\nworse after\n compensatory increase in resp rate\n has sig autopeep\n --continue ACV\n --attempt matching peep, decrease resp rate and increase TV slightly to\n see if helps w/ ventilatory picture / expiration\n --continue broad coverage as above\n --change nebs to MDIs\n --discuss worsening status with renal as cvvh may help with metabolic\n picture/severe acidosis\n # Acute renal failure on CRI--urine output decreasing but CVPs\n low--will give bicarb, renal following and aware of decline (? need for\n CVVH)\n check bladder pressure as above\n renal transplant meds/dosing\n f/u renal bx results\n #abd distension--bladder pressure, kub, follow up c diff toxin\n # thyroid fx--confusing picture, appears suppressed\nlikely sickj\n euthyroid--will consult endo for additional input\n # Nutrition\n high residuals from TFs.\n - gastroparesis by study in , likely related to DM. now with\n probable ileus ins etting of sepsis/pressors\n - hold TF at this time\n Prognosis is poor given multiorgan system involvement and progressive\n decline. Will address goals of care with family and update them as to\n worsening clinical condition.\n Remainder as per resident note\n ICU Care\n Nutrition:\n Comments: holding TF\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 04:50 AM\n Multi Lumen - 05:27 AM\n Triple Introducer - 05:29 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 60 minutes\n Patient is critically ill\n"
},
{
"category": "General",
"chartdate": "2104-06-10 00:00:00.000",
"description": "Generic Note",
"row_id": 674078,
"text": "TITLE: Critical Care\n Eventful night. Rising lactate, incr abd distention. During evening a\n dissociation between his SaO2 and PO2 noted\n methemoglobin level 11\n then rising to 13. Only med that is likely cause is metoclopramide\n which he has been receiving. BP suprisingly improving through the\n evening with pressors weaned. KUB\n distended loops of bowel and CT\n showed dil loops of bowel with air fluid levels, ascites, no\n pancreatitis, ? pneumotocis\n of ?able signif icance given marked\n airflow obstruction and high levels of autoPEEP but surgery concerned\n about an SBO\n and wanted to do an ex lap. I am doubtful he has an\n acute surgical abdomen but I am more concerned about possible shock\n liver and tissue hypoxia secondary to methemoblobin\n we are giving\n methylene blue before surgery. Abx already broadened. Still concerned\n about VAP but infiltrate is not overwhelming and seems unlikely to\n explain his deterioration last night.\n Time spent 75 min\n Critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673201,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Hypertension, benign\n Assessment:\n Remains hypertensive w/B/P often in 170s.\n Action:\n Weaned off of NTG, remains on Nicardipine drip. Clonidine added to b/p\n regime and will increase amlodipine dose as ordered.\n Response:\n Plan:\n Goals are to keep SBP 140-160 and to wean off nicardipine gtt.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt w/I/E wheezes t/o and fair aeration. Intermittant dyspnea at rest\n w/RR 30s and accessory muscle usage. Pt usually noncompliant\n w/instruction to keep albuterol continuous nebs on and insists on\n utilizing albuterol MDI despite explanations. Pt also refusing meds\n such as insulin and solumedrol this morning and also refused cardiac\n echo.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673202,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Hypertension, benign\n Assessment:\n Remains hypertensive w/B/P often in 170s.\n Action:\n Weaned off of NTG, remains on Nicardipine drip. Clonidine added to b/p\n regime and will increase amlodipine dose as ordered.\n Response:\n Plan:\n Goals are to keep SBP 140-160 as discussed w/ICU team @ present until\n renal sets new b/p goals and to wean off nicardipine gtt.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt w/I/E wheezes t/o and fair aeration. Intermittant dyspnea at rest\n w/RR 30s and accessory muscle usage. Pt usually noncompliant\n w/instruction to keep albuterol continuous nebs on and insists on\n utilizing albuterol MDI despite explanations. Pt also refusing meds\n such as insulin and solumedrol this morning and also refused cardiac\n echo.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-10 00:00:00.000",
"description": "Resident Progress Note- MICU",
"row_id": 674136,
"text": "TITLE:\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-10 00:00:00.000",
"description": "Resident Progress Note- MICU",
"row_id": 674137,
"text": "Chief Complaint:\n 24 Hour Events:\n -2200 labs notable for increasing lactate. CVP also falling-->NS\n boluses\n -O2 Sat low although PaO2 OK. Methemoglobin elevated at 10%-->12%.\n Concern that this may be contributing to poor O2 delivery and rising\n lactate. Thus, treated with methylene blue.\n -advanced ET tube by 4 cm (has been too high for several days)\n -distended abdomen and constipated x 6 days: KUB showed likely SBO.\n Surgery was consulted and recommended CT with PO contrast, which showed\n pneumatosis. Surgery took him to the OR and resected all but ~60 cm of\n small bowel that was necrotic.\n -c-diff positive-->started IV flagyl\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:59 PM\n Metronidazole - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:02 AM\n Sodium Bicarbonate 8.4% (Amp) - 12:56 PM\n Heparin Sodium (Prophylaxis) - 11:42 PM\n Insulin - Regular - 12:30 AM\n Dextrose 50% - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 35.3\nC (95.6\n HR: 99 (91 - 118) bpm\n BP: 109/58(76) {76/52(60) - 172/86(117)} mmHg\n RR: 22 (22 - 35) insp/min\n SpO2: 88%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n CVP: 245 (2 - 270)mmHg\n Bladder pressure: 12 (12 - 18) mmHg\n Total In:\n 9,192 mL\n 3,725 mL\n PO:\n TF:\n IVF:\n 8,027 mL\n 3,249 mL\n Blood products:\n 426 mL\n Total out:\n 3,230 mL\n 838 mL\n Urine:\n 430 mL\n 138 mL\n NG:\n 2,800 mL\n 700 mL\n Stool:\n Drains:\n Balance:\n 5,962 mL\n 2,887 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (500 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 27 cmH2O\n Plateau: 19 cmH2O\n Compliance: 81.1 cmH2O/mL\n SpO2: 88%\n ABG: 7.29/37/163/16/-7\n Ve: 14.2 L/min\n PaO2 / FiO2: 272\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 166 K/uL\n 8.1 g/dL\n 106 mg/dL\n 4.7 mg/dL\n 16 mEq/L\n 6.1 mEq/L\n 83 mg/dL\n 100 mEq/L\n 127 mEq/L\n 23.9 %\n 18.8 K/uL\n [image002.jpg]\n 03:17 PM\n 05:16 PM\n 09:11 PM\n 09:38 PM\n 12:31 AM\n 01:49 AM\n 02:02 AM\n 03:39 AM\n 05:22 AM\n 06:09 AM\n WBC\n 22.3\n 18.8\n Hct\n 23.3\n 20\n 23.9\n Plt\n 211\n 166\n Cr\n 4.6\n 4.7\n TCO2\n 20\n 18\n 20\n 19\n 19\n 19\n Glucose\n 113\n 175\n 106\n Other labs: PT / PTT / INR:20.9/56.0/2.0, CK / CKMB /\n Troponin-T:210/8/0.05, ALT / AST:5468/, Alk Phos / T Bili:300/3.1,\n Amylase / Lipase:905/18, Differential-Neuts:80.0 %, Band:4.0 %,\n Lymph:7.0 %, Mono:8.0 %, Eos:0.0 %, Lactic Acid:3.0 mmol/L, Albumin:2.3\n g/dL, LDH: IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:9.1 mg/dL\n Fluid analysis / Other labs: Most recent BMP & LFTs pending\n Tacro level P\n MetHb: 10\n T4: 2.7\n calcTBG: 0.81\n TUptake: 1.23\n T4Index: 3.3\n Imaging: CT Torso: Dilated loops of small bowel, measuring up to 4 cm\n without definite evidence of obstruction. However, there is extensive\n pneumatosis, involving ileal loops as well as involving the ascending\n and transverse colon. Linear foci of air in the liver may indicate\n portal venous air.\n CXR: ET Tube 4.5cm from carina. No significant change from prior.\n Microbiology: C. Diff (+) \n Sputum Cx : PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.\n , BCx Pending\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n CONSTIPATION (OBSTIPATION, FOS)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPERTENSION, BENIGN\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITHOUT ACUTE EXACERBATION\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 04:50 AM\n Multi Lumen - 05:27 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: DNR (do not resuscitate)\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-10 00:00:00.000",
"description": "Resident Progress Note- MICU",
"row_id": 674141,
"text": "Chief Complaint:\n 24 Hour Events:\n -2200 labs notable for increasing lactate. CVP also falling-->NS\n boluses\n -O2 Sat low although PaO2 OK. Methemoglobin elevated at 10%-->12%.\n Concern that this may be contributing to poor O2 delivery and rising\n lactate. Thus, treated with methylene blue.\n -advanced ET tube by 4 cm (has been too high for several days)\n -distended abdomen and constipated x 6 days: KUB showed likely SBO.\n Surgery was consulted and recommended CT with PO contrast, which showed\n pneumatosis. Surgery took him to the OR and resected all but ~60 cm of\n small bowel that was necrotic.\n -c-diff positive-->started IV flagyl\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:59 PM\n Metronidazole - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:02 AM\n Sodium Bicarbonate 8.4% (Amp) - 12:56 PM\n Heparin Sodium (Prophylaxis) - 11:42 PM\n Insulin - Regular - 12:30 AM\n Dextrose 50% - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 35.3\nC (95.6\n HR: 99 (91 - 118) bpm\n BP: 109/58(76) {76/52(60) - 172/86(117)} mmHg\n RR: 22 (22 - 35) insp/min\n SpO2: 88%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n CVP: 245 (2 - 270)mmHg\n Bladder pressure: 12 (12 - 18) mmHg\n Total In:\n 9,192 mL\n 3,725 mL\n PO:\n TF:\n IVF:\n 8,027 mL\n 3,249 mL\n Blood products:\n 426 mL\n Total out:\n 3,230 mL\n 838 mL\n Urine:\n 430 mL\n 138 mL\n NG:\n 2,800 mL\n 700 mL\n Stool:\n Drains:\n Balance:\n 5,962 mL\n 2,887 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (500 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 27 cmH2O\n Plateau: 19 cmH2O\n Compliance: 81.1 cmH2O/mL\n SpO2: 88%\n ABG: 7.29/37/163/16/-7\n Ve: 14.2 L/min\n PaO2 / FiO2: 272\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 166 K/uL\n 8.1 g/dL\n 106 mg/dL\n 4.7 mg/dL\n 16 mEq/L\n 6.1 mEq/L\n 83 mg/dL\n 100 mEq/L\n 127 mEq/L\n 23.9 %\n 18.8 K/uL\n [image002.jpg]\n 03:17 PM\n 05:16 PM\n 09:11 PM\n 09:38 PM\n 12:31 AM\n 01:49 AM\n 02:02 AM\n 03:39 AM\n 05:22 AM\n 06:09 AM\n WBC\n 22.3\n 18.8\n Hct\n 23.3\n 20\n 23.9\n Plt\n 211\n 166\n Cr\n 4.6\n 4.7\n TCO2\n 20\n 18\n 20\n 19\n 19\n 19\n Glucose\n 113\n 175\n 106\n Other labs: PT / PTT / INR:20.9/56.0/2.0, CK / CKMB /\n Troponin-T:210/8/0.05, ALT / AST:5468/, Alk Phos / T Bili:300/3.1,\n Amylase / Lipase:905/18, Differential-Neuts:80.0 %, Band:4.0 %,\n Lymph:7.0 %, Mono:8.0 %, Eos:0.0 %, Lactic Acid:3.0 mmol/L, Albumin:2.3\n g/dL, LDH: IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:9.1 mg/dL\n Fluid analysis / Other labs: Most recent BMP & LFTs pending\n Tacro level P\n MetHb: 10\n T4: 2.7\n calcTBG: 0.81\n TUptake: 1.23\n T4Index: 3.3\n Imaging: CT Torso: Dilated loops of small bowel, measuring up to 4 cm\n without definite evidence of obstruction. However, there is extensive\n pneumatosis, involving ileal loops as well as involving the ascending\n and transverse colon. Linear foci of air in the liver may indicate\n portal venous air.\n CXR: ET Tube 4.5cm from carina. No significant change from prior.\n Microbiology: C. Diff (+) \n Sputum Cx : PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.\n , BCx Pending\n Assessment and Plan\n 60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n # Respiratory failure:\n # Hypotension:\n # Methemoglobinemia\n # Hepatic failure\n # Acute renal failure:\n # s/p Bowel Resection\n # Abnormal TFTs: Sick Euthyroid\n # DM:\n # Chronic pain:\n -Fentanyl gtt\n -holding po pain meds for now due to poor gastric motility (home\n oxycontin, methadone, and dilaudid prn)\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation:\n -senna, colace, bisacodyl pr, miralax, raglan\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 04:50 AM\n Multi Lumen - 05:27 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: DNR (do not resuscitate)\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674148,
"text": "Hypotension (not Shock)\n Assessment:\n Sbp > 98,mean ~70 lactate up to 4.2 hct decreased to 23.3\n Action:\n Fluid boluses 2 liters of ns,neo weaned to off at 03;30.pt continues on\n vasopressin 2.4 units/hr transfused 1 unit prbc\ns and 1 unit ffp\n enroute ot OR.\n Response:\n Pt bp improved with fluid.tolerating neo off.\n Plan:\n Continue to hydrate with fluids as ordered,check lactate pt now in OR\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Fio2 at 60 % with adequate po2.. o2 sats only 86% methyglobin\n initially 10 and increased to 13\n Action:\n Methyline blue given iv at 0400,reglan discontinued.\n Response:\n To be evaluated..pt taken to or\n Plan:\n Check abg post methyline blue ..pt now in OR\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine ouput ~ 20 cc/hr very dark amber urine.creatinine up to 4.7,K 6.6\n at 2400\n Action:\n Fluid boluses,pt given bicarb in d5w 500 cc bolus,d50 25gm,10 units\n regular insulin,and calcium gluconate 2 grams at 0030.EKG done\n Response:\n Urine continues borderline~ 20 cc/hr,f/u K decreased to 6.2\n Plan:\n Follow urine,creatinine,lactate,potassium\n Constipation (Obstipation, FOS)\n Assessment:\n Abdomen distended, bowel sounds hypoactive ,large amount of og\n drainage..bilious.\n Action:\n Abdominal catscan done\n Response:\n Plan:\n To OR at 0420\n Pt also had head scan, pt continues nonresponsive, pupils are reactive\n and equal.\n Post /op: pt returned to 4 post op at 0600. s/p SBO. Abdominal\n wound open,packed with ns soaked towels. 2 drains to med\n wall suction draing sanguinous. Prbc\ns # 2 infusing on arrival, # 3\n prbc up at 0700. pt unresponsive. Vasopressin off at 0600 secondary\n to sbp to 170/ . At 0700 sbp dropped to 78/ neosynephrine started and\n normal saline wide open. Morning labs including cbc and chemistry and\n coags sent. Vanco level and tacrolimus level sent with morning labs.\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-03 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 672985,
"text": "Chief Complaint: Respiratory Distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient seen with progressive dyspnea on exertion and with initial ED\n presentation showing-->\n RR-24, 100% on NRB with desaturation on RA\n CXR--minimal infiltrate\n BNP not elevated\n Patient given acute Rx for possible PNA with ABX and steroids/nebs for\n possible COPD flare and was initiated on NIPPV and admitted to ICU for\n further care.\n Here--has c/o mild/moderate pain, no headache, no chest pain but with\n significant hypertension.\n Patient trialed on repeat nebulizer Rx\n Patient trialed on BIPAP but again intolerant\n 7.32/39/52\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Nitroglycerin - 1.4 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:46 AM\n Omeprazole (Prilosec) - 07:46 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n COPD--mod OVD, no home O2\n HTN--Valsartaan, Furosemide, Atenolol\n ESRD-Baseline Cr , s/p transplant, Pred, Tacrolimus, Cellcept\n Hyperglycemia\n Osteoporosis--Chronic pain and narcotic Rx\n Non-contributory\n Occupation: Unemployed\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other:\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: No(t) Chest pain\n Nutritional Support: NPO\n Respiratory: Tachypnea\n Gastrointestinal: No(t) Abdominal pain\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Jaundice\n Allergy / Immunology: Immunocompromised, No sick contacts\n Flowsheet Data as of 09:20 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.4\nC (95.7\n HR: 88 (61 - 88) bpm\n BP: 177/109(127) {177/90(117) - 205/114(137)} mmHg\n RR: 14 (13 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n Total In:\n 806 mL\n PO:\n TF:\n IVF:\n 56 mL\n Blood products:\n Total out:\n 0 mL\n 75 mL\n Urine:\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 731 mL\n Respiratory\n O2 Delivery Device: Other\n SpO2: 100%\n ABG: 7.32/39/52//-5\n Physical Examination\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed), Fistula--non functional\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Crackles : , Wheezes : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 30\n 3.9\n 24\n 5.1\n [image002.jpg]\n 07:57 AM\n TC02\n 21\n Other labs: CK / CKMB / Troponin-T://Trop=0.09\n Fluid analysis / Other labs: U/A--no evidence of infection\n Imaging: ECHO---nl systolic function\n CXR-Slight increase in lung volumes and with prominent hila suggestive\n of increased PA size.\n ECG: Q-waves\n Assessment and Plan\n 60 yo male with significant history of obstructive pulmonary disease\n now presenting with progressive dyspnea on exertion and with severe\n wheezing and tachypnea but with relatively minimal elevation in PCO2.\n He on exam is clearly with significant presence of airways obstruction\n and with significant wheezing and intermittent inspiratory squeaks\n noted suggesting perhaps some small airways secretions. He does not\n appear to be chronically impaired because PCO2 does appear to be normal\n but this is in the setting of VBG and chronice renal failure. This\n would bear re-evaluation with repeat ABG. Pulmonary edema may be\n playing a role as well but CXR and the rest of his exam is less\n convincing for volume overload, PE is of concern but not dominantly\n hypoxic and RF\ns minimal for PE. Infectious sources\nspecifically RSV\n in the setting of significant immunosupression.\n 1)Respiratory Failure-Concerning findings for possible viral trigger of\n respiratory failure in the setting of immunsupression and persistent\n respiratory distress\n -Pred 60mg/Alb/Atr\nfor possible COPD flare\n -Will perform viral examination and look for possible RSV infection as\n dominant possible viral pathogen\n -BIPAP to be performed as needed\n -I do not see prominent evidence for volume overload as primary driver\n of respiratory failure\n -Lopressor for control of RPP\n 2)Renal Failure-_Acute on Chronic\n -Prograf, Cellcept, systemic steroids\n -Renal aware and will check renal lytes\n ICU Care\n Nutrition: npo\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 20 Gauge - 06:24 AM\n Comments:\n Prophylaxis:\n DVT: Hep Sq\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 65 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673054,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, 25mg PO labetolol and was transferred to the\n M/SICU for further management of a COPD exacerbation and hypertension.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received patient on NC 3 L and continues nebs w/sats > 90. Incompliant\n w/nebs (takes the mask off) bil LS ins/exp wheezes, DOE.\n Action:\n BiPAP trail failed, patient unable to tolerate the mask, continue on\n cont nebs however patient keeps taking the mask off despite multiple\n explanations. Nebs changed to q4hr. Nasopharyngeal swab ordered.\n Refuses ABG\ns, continue on prednisone for COPD flare. Got lasix 80mg\n X1.\n Response:\n Pending, remains wheezing. Sats at high 90\n Plan:\n Continue to monitor resp status, f/u CX data, CXR toe eval progress,\n ABg\ns if needed, meds ASDIR.\n Hypertension, benign\n Assessment:\n Received patient on NITRO gtt at 1mcg/kg/min. b/p in 190-200\ns. HR at\n 70\ns peripheral pulses present. Minimal pedal edema. Denies headaches,\n nausea,, vomiting\n Action:\n Nitro titrated up to 2mcg/kg/min (long periods of OFF nitro due to\n inability to establish iv access and patient refusing IV access),\n hydralazine added Q6hr, cont on metoprolol .\n Response:\n Pending, however patient is incompliant w/care.\n Plan:\n Continue to monitor patient status, meds ASDIR.\n Neuro: alert oriented, follows commands, stable gait. Incompliant\n w/treatment (refuses bipap, cont nebs, labs, IV access and etc.)\n GI: abd soft non tender positive for BS. No BM this shift. Renal\n regular diet. Denies nausea/vomiting.\n GU: voiding clear yellow urine. Renal following. K-5.6 refused\n kayexalate. Repleted w/Mg for Mg- 1.4\n IV access: picc placed at bedside\nper CXR not central but Ok to use.\n Social: full code.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673265,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Hypertension, benign\n Assessment:\n Patient with refractory hypertension now s/p nitroglycerin.\n Action:\n Patient started on Nicardipine infusion today with some effect. Had to\n be turned off for relative hypotension in the 110\ns. Continues on oral\n antihypertensives.\n Response:\n Patient\ns BP went to the 110\ns and he became symptomatic c/o of\nlight\n headedness\n. Now maintaining BP in the 140\n 160\ns. Urinary output\n has been poor overnight. Given two boluses totally 500cc with little\n output. Now on RL at 100ml/hr x1liter.\n Plan:\n Monitor v/s and treat hypertension as needed. Continue with oral\n antihypertensives.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Labored breathing with use of accessory muscles.\n Action:\n Remains on continuous nebs with schedules doses of atrovent/Albuterol\n nebs.\n Response:\n Patient continues with audible wheezing as well as exp. Wheezes\n throughout lobes. He is reluctant to keep the continuous nebs on and\n keeps it on intermittently.\n Plan:\n Give neb tx as ordered, asses for worsening symptoms. Follow lab\n trends.\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 673371,
"text": "Demographics\n Day of intubation: 1\n Day of mechanical ventilation: 1\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Supra-sternal retractions,\n Accessory muscle use, Prolonged exhalation, High flow demand\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously, Abnormal trigger\n efforts (efforts during inspiratory)\n Dysynchrony assessment: Possible air trapping\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1700\n no complications\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 673544,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Prolonged exhalation\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 674015,
"text": "Chief Complaint: resp failure, septic shock, ARF on CRI, parainfluenza\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60 yo M with COPD, immunosupressed s/p renal transplant admitted\n with progressive resp distress requiring intubation----tachypnea,\n weezing minimally responsive to racemic epinephrine, albuterol, and\n high dose steroids\nparainfleunza +, significant expiratory limitation\n and ventilatory defect concerning for possible TBM or small airways\n reactivity, now with progressive hypotension, severe metabolic + resp\n acidosis, ARF on CRI, leukocytosis, and GNR in sputum treating\n empirically for vap\n 24 Hour Events:\n MULTI LUMEN - START 05:27 AM\n TRIPLE INTRODUCER - START 05:29 AM\n Developed progressive hypotension overnight\nnow on three pressors for\n HD support--vasop, neo, levo\n Sepsis/VAP--vanco/zosyn started\n Changed to PCV\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:59 PM\n Piperacillin/Tazobactam (Zosyn) - 12:48 AM\n Metronidazole - 04:03 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 10:36 AM\n Heparin Sodium (Prophylaxis) - 11:49 PM\n Other medications: per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.4\nC (99.3\n HR: 110 (102 - 121) bpm\n BP: 126/81(96) {76/58(65) - 196/100(130)} mmHg\n RR: 31 (18 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 80 Inch\n CVP: 5 (3 - 16)mmHg\n CO/CI (Fick): (14.8 L/min) / (6.4 L/min/m2)\n Mixed Venous O2% Sat: 81 - 81\n Total In:\n 6,245 mL\n 3,069 mL\n PO:\n TF:\n 39 mL\n IVF:\n 5,865 mL\n 3,069 mL\n Blood products:\n Total out:\n 1,690 mL\n 1,175 mL\n Urine:\n 1,580 mL\n 175 mL\n NG:\n 110 mL\n 1,000 mL\n Stool:\n Drains:\n Balance:\n 4,555 mL\n 1,894 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 490 (482 - 586) mL\n PS : 15 cmH2O\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 35 cmH2O\n Plateau: 20 cmH2O\n Compliance: 51 cmH2O/mL\n SpO2: 100%\n ABG: 7.16/49/205/17/-11\n Ve: 16.7 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: No(t) Sclera edema\n Head, Ears, Nose, Throat: Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), decreased BS, minimal air\n movement\n Abdominal: Bowel sounds present, Distended, No(t) Tender: , Obese,\n decreased BS\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: cool\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.4 g/dL\n 369 K/uL\n 70 mg/dL\n 3.6 mg/dL\n 17 mEq/L\n 5.1 mEq/L\n 71 mg/dL\n 102 mEq/L\n 134 mEq/L\n 32.5 %\n 28.2 K/uL\n [image002.jpg]\n 04:18 AM\n 04:26 PM\n 08:08 PM\n 10:13 PM\n 12:02 AM\n 02:20 AM\n 02:24 AM\n 03:19 AM\n 04:05 AM\n 05:43 AM\n WBC\n 23.2\n 28.2\n Hct\n 30.3\n 32.5\n Plt\n 364\n 369\n Cr\n 3.8\n 3.6\n TCO2\n 21\n 20\n 21\n 20\n 21\n 19\n 20\n 18\n Glucose\n 150\n 70\n Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB /\n Troponin-T:210/8/0.05, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0\n %, Mono:8.0 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:9.2 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.9 mg/dL\n Imaging: progressive R > L lower lung infiltrates\n ET/R IJ in position\n Microbiology: sputum --GNR, GPC\n --blood pending\n c diff neg \n --nasal asp --parainflu\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n CONSTIPATION (OBSTIPATION, FOS)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPERTENSION, BENIGN\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITHOUT ACUTE EXACERBATION\n 60 yo M with COPD, immunosupressed s/p renal transplant admitted with\n progressive resp distress requiring intubation----tachypnea, weezing\n minimally responsive to racemic epinephrine, albuterol, and high dose\n steroids\nparainfleunza +, significant expiratory limitation and\n ventilatory defect concerning for possible TBM or small airways\n reactivity now with progressive hypotension, severe metabolic + resp\n acidosis, ARF on CRI, leukocytosis, and GNR in sputum treating\n empirically for vap\n # hypotension/shock\n most concerning for septic shock with gnr sputum and now with worsening\n infil on cxr\n also possible component of adrenal insuf in this immunosupressed host\n Given low CVPS\ncardiogenic shock seems less likely\n ---continue aggressive IVF to maintain cvp > 10--would give 1 L bicarb\n and then LR alternating with NS given worsening met acidosis\n --continue pressor support--now on triple-- to maintain MAP > 60--wean\n as able\n --f/u TTE results\n --continue stress steroids\n --continue current broad antbx--vanco/zosyn/flagyl following cx results\n --check bladder pressure to eval for compartment syndrome contributing\n to hypotension and renal failure, though lower clinical suspicion\n # resp failure--\n copd, small airways ds, with parainfluenza, and developing b/l lower\n zone infiltrates with gnr in sputum concerning for HPA/VAP\n ventilation is worsening--now with met and resp acidosis\nworse after\n compensatory increase in resp rate\n has sig autopeep\n --continue ACV\n --attempt matching peep, decrease resp rate and increase TV slightly to\n see if helps w/ ventilatory picture / expiration\n --continue broad coverage as above\n --change nebs to MDIs\n --discuss worsening status with renal as cvvh may help with metabolic\n picture/severe acidosis\n # Acute renal failure on CRI--urine output decreasing but CVPs\n low--will give bicarb, renal following and aware of decline (? need for\n CVVH)\n check bladder pressure as above\n renal transplant meds/dosing\n f/u renal bx results\n #abd distension--bladder pressure, kub, follow up c diff toxin\n # thyroid fx--confusing picture, appears suppressed\nlikely sickj\n euthyroid--will consult endo for additional input\n # Nutrition\n high residuals from TFs.\n - gastroparesis by study in , likely related to DM. now with\n probable ileus ins etting of sepsis/pressors\n - hold TF at this time\n Prognosis is poor given multiorgan system involvement and progressive\n decline. Will address goals of care with family and update them as to\n worsening clinical condition.\n Remainder as per resident note\n ICU Care\n Nutrition:\n Comments: holding TF\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 04:50 AM\n Multi Lumen - 05:27 AM\n Triple Introducer - 05:29 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 60 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-10 00:00:00.000",
"description": "Intensivist Note",
"row_id": 674187,
"text": "SICU\n HPI:\n Pt is a 60yo male who presents s/p exlap, SBR, open abd for ischemic\n bowel\n Chief complaint:\n hypotension\n PMHx:\n COPD, HTN, high chol, ESRD s/p CRT2002, baseline Cr-, DM 2, former\n smoker, hx of alcoholism, Coag negative staph right hip joint\n infection, chronic pain, prostate ca s/p radiation therapy in ,\n bilateral avascular necrosis\n Current medications:\n Albuterol Inhaler 7. Calcium Chloride 8. Chlorhexidine Gluconate 0.12%\n Oral Rinse 9. Fentanyl Citrate 10. Fluticasone Propionate 110mcg 11.\n Heparin Flush (10 units/ml) 12. Heparin Flush (10 units/ml) 13.\n Hydrocortisone Na Succ. 14. Insulin 15. Ipratropium Bromide MDI 16.\n MetRONIDAZOLE (FLagyl) 17. Mycophenolate Mofetil 18. Pantoprazole 19.\n Phenylephrine 20. Piperacillin-Tazobactam Na 22. Sodium CITRATE 4% 24.\n Tacrolimus 25. Vancomycin\n 24 Hour Events:\n EEG - At 05:09 PM\n OR SENT - At 04:20 AM\n OR RECEIVED - At 06:05 AM\n FEVER - 101.1\nF - 04:00 PM\n Post operative day:\n POD#0 - expl lap\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:59 PM\n Metronidazole - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 11:00 AM\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:42 PM\n Insulin - Regular - 12:30 AM\n Dextrose 50% - 12:30 AM\n Sodium Bicarbonate 8.4% (Amp) - 09:32 AM\n Other medications:\n Flowsheet Data as of 02:00 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.1\n T current: 35.7\nC (96.3\n HR: 93 (91 - 102) bpm\n BP: 114/71(85) {77/47(58) - 198/94(134)} mmHg\n RR: 27 (22 - 35) insp/min\n SPO2: 79%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n CVP: 15 (2 - 245) mmHg\n Bladder pressure: 12 (12 - 12) mmHg\n Total In:\n 9,192 mL\n 9,705 mL\n PO:\n Tube feeding:\n IV Fluid:\n 8,027 mL\n 7,580 mL\n Blood products:\n 2,025 mL\n Total out:\n 3,230 mL\n 1,970 mL\n Urine:\n 430 mL\n 260 mL\n NG:\n 2,800 mL\n 700 mL\n Stool:\n Drains:\n 400 mL\n Balance:\n 5,962 mL\n 7,737 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 26 cmH2O\n Plateau: 15 cmH2O\n Compliance: 80 cmH2O/mL\n SPO2: 79%\n ABG: 7.24/38/118/15/-10\n Ve: 12.6 L/min\n PaO2 / FiO2: 197\n Physical Examination\n General Appearance: Overweight / Obese, intubated and not sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : bilaterally, Diminished: bilateral bases)\n Abdominal: Soft, abdominal wound left open covered in pressure\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: open abdomen covered in dry dressing\n Neurologic: (Responds to: Unresponsive), No(t) Moves all extremities,\n not sedated or parylzed\n Labs / Radiology\n 166 K/uL\n 8.1 g/dL\n 111 mg/dL\n 4.6 mg/dL\n 15 mEq/L\n 6.0 mEq/L\n 78 mg/dL\n 103 mEq/L\n 135 mEq/L\n 30\n 18.8 K/uL\n [image002.jpg]\n 09:38 PM\n 12:31 AM\n 01:49 AM\n 02:02 AM\n 03:39 AM\n 05:22 AM\n 06:09 AM\n 09:29 AM\n 10:57 AM\n 01:07 PM\n WBC\n 22.3\n 18.8\n Hct\n 23.3\n 20\n 23.9\n 30\n 28\n 30\n Plt\n 211\n 166\n Creatinine\n 4.7\n 4.6\n TCO2\n 20\n 19\n 19\n 19\n 19\n 19\n 17\n Glucose\n 175\n 106\n 118\n 111\n Other labs: PT / PTT / INR:22.2/60.3/2.1, CK / CK-MB / Troponin\n T:210/8/0.05, ALT / AST:4232/, Alk-Phos / T bili:298/3.7, Amylase\n / Lipase:831/21, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %,\n Mono:8.0 %, Eos:0.0 %, Fibrinogen:357 mg/dL, Lactic Acid:3.1 mmol/L,\n Albumin:2.1 g/dL, LDH: IU/L, Ca:7.4 mg/dL, Mg:1.9 mg/dL, PO4:9.4\n mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n CONSTIPATION (OBSTIPATION, FOS), RENAL FAILURE, ACUTE (ACUTE RENAL\n FAILURE, ARF), HYPERTENSION, BENIGN, CHRONIC OBSTRUCTIVE PULMONARY\n DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION, CHRONIC\n OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITHOUT\n ACUTE EXACERBATION\n Assessment and Plan: Pt is a 60yo male who presents s/p exlap, SBR,\n open abd for ischemic bowel\n Neurologic: Neuro checks Q: hr, pt not sedated and not moving, follow\n neuro exam, pain controlled with fentanyl drip\n Cardiovascular: hypotensive, requiring phenylephrine gtt to keep\n SBP>90mmHg\n Pulmonary: Cont ETT, (Ventilator mode: CMV), intubated on ventillator,\n CMV, attempt to wean, cont flovent/atrovent/albuterol\n Gastrointestinal / Abdomen: OGT in place, open abdomen, PPI, NPO\n Nutrition: NPO\n Renal: Foley, UOP-20/hr, ARF on top of CRF, cr-4.6, cont tacrolimus and\n cellcept, considering CVVH if pt's family wants to continue care\n Hematology: Serial Hct, last hct-30, continue to monitor\n Endocrine: RISS, RISS, goal fs<150, hydrocortisone for adrenal\n suppression\n Infectious Disease: Check cultures, cont zosyn, flagyl, vanc\n Lines / Tubes / Drains: Foley, OGT, ETT, Surgical drains (hemovac, JP)\n Wounds: Dry dressings, open abdomen\n Imaging:\n Fluids: dc NS, starting NaHCO3 at 150ml/hr, will give boluses as needed\n Consults: Transplant\n Billing Diagnosis: (Respiratory distress: Failure), (Shock: Septic)\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 04:50 AM\n Multi Lumen - 05:27 AM\n Prophylaxis:\n DVT: (pt is coagulopathic)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, ICU consent signed Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 672955,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, 25mg PO labetolol and was transferred to the\n M/SICU for further management of a COPD exacerbation and hypertension.\n On admission Mr. is noncompliant with most nursing and medical\n care, he is refusing to continuously wear his blood pressure cuff, has\n refused non invasive ventilation, and will not allow any members of the\n ICU team to attempt lab draws.\n Events:\n Nitro gtt initiated @ .5mcg/kg/min and quickly titrated up\n to 1 mcg/kg/min\n 2 additional Albuterol/atrovent nebs administered\n Continuous neb ordered\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n LS insp /exp wheezes throughout all lung fields, RR 24, satting 93 % on\n 3 liters nasal cannula, hypertensive to 205 systolic.\n Action:\n Albuterol/atrovent nebs x 2, nitro gtt initiated\n Response:\n Hypertension and insp/exp wheezes persist however Mr. claims\n he feels better now then on admission\n Plan:\n Continuous neb or non invasive ventilation, attempt to obtain ABG and\n potassium levels, titrate nitro to a systolic pressure <160. Please\n refer to nursing care plan in for further detail.\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-03 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 672967,
"text": "Chief Complaint: <I>Primary care physician:</I> \n <I>Chief complaint:</I>Dyspnea\n <I>MICU admit for:</I>Dyspnea requiring BiPap, ARF\n HPI:\n 60M with PMHx of COPD, HTN, ESRD s/o CRT, DM2 presented overnight to ED\n with acute onset SOB. States he noted progressively worsening dyspnea\n over past two days. Pt is fairly poor historian. States did not change\n any recent medications, no rescent sick contacts. Had noted orthopnea\n and DOE, can no longer climb flight of stairs. Reports subjective\n fevers 99-100 at home with chills. No recent increase in sputum\n production. In ED, initial VS 96.8 193/113 78 24 100% NRB. He desatted\n to 91% on RA. He had a CXR which did not show any infiltrate or\n effusion. His labs were notable for acute renal failure and\n hypernatremia, BNP lower than last value from . UA negative. No\n leukocytosis. Flat CK and MB. He was given combivent nebs x 3,\n azithromycin and levaquin for CAP as well as his home dose of\n oxycontin, IV solumedrol and 1 dose of 10mg IV labetalol for\n hypertension. His ECG did not show any ischemic changes. His\n shortness of breath worsened acutely and he was tried on BiPap which he\n did not tolerate. ABG unable to be done. He was admitted to the \n for further monitoring in setting of elevated BP and transient need for\n BiPap. At time of transfer, his VS: 97.3 70-90s 184/110 15 96% on 3L\n NC.\n On arrival to the floor, pt reported breathing felt better, he is\n uncertain which intervention improved his symptoms. He complains of all\n over achiness, with recent new ache in left him, same chronic right hip\n pain. No headaches or vision changes, does feel thirsty. No chest\n discomfort or palpitations, as above subjective fevers, no increase in\n sputum production or sick contacts, no n/v/ab pain. Occ constipation,\n last BM yesterday, no melena or hematochezia. No dysuria or change in\n urine. No increase in LE edema. Reports adherence to all meds,\n including immunosuppressants. ROS was otherwise essentially negative.\n He was placed on nitro gtt for SBP >200. An ABG was attempted but pt\n refused. His SOB acutely worsened despite nebulizers and he was\n started on continuous nebulizers as he refused further attempts at\n BiPap.\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Nitroglycerin - 1.4 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:46 AM\n Omeprazole (Prilosec) - 07:46 AM\n Other medications:\n Albuterol inhaler 1-2 puffs Q4 hours\n Atorvastatin 20mg daily\n duloxetine 30mg daily\n ezetimibe 10mg daily\n Fosomax 70mg daily\n Furosemide 40mg daily\n Gabapentin 900mg TID\n Hydromorphone 4mg up to 5x per day prn\n Methadone 7.5mg PO TID\n Metaclopromide 10mg TID (per transplant)\n Metoprolol 50mg \n Mycophenolate mofetil 500mg \n Omeprazole 20mg \n Oxycodone SR 30mg \n Prednisone 5mg daily\n Salmeterol 50mcg 2 puffs \n Tacrolimus 4mg \n Valsartan 160mg \n Varenicline 0.5mg \n Ferrous sulfate 325mg daily\n Past medical history:\n Family history:\n Social History:\n -Coag negative staph right hip joint infection, s/p removal, spacer\n placement 9/08and prolonged abx course.\n -Chronic pain on narcotics\n -COPD, not on home 02, last spirometry from with mild to moderate\n obstructive defect.\n -HTN\n -End stage renal disease secondary to malignant hypertension\n -s/p CRT \n -baseline creat \n -Diverticulitis s/p right colectomy.\n -Prostate cancer status post radiation therapy in \n -Diabetes, not on medication\n -Perirectal abscess \n -bilateral avascular necrosis\n -s/p fall with femoral neck fracture\n malignant hyperthermia - mother, siblings\n Lives alone at home, now retired, formerly worked as a security\n guard. Tobacco x 30-40 yrs, pk/day, EtOH or illicit drugs,\n per OMR has h/o alcoholism and marijuana use.\n Review of systems:\n Flowsheet Data as of 08:03 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.4\nC (95.7\n HR: 80 (61 - 80) bpm\n BP: 184/110(128) {184/90(117) - 205/114(137)} mmHg\n RR: 18 (13 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n Total In:\n 784 mL\n PO:\n TF:\n IVF:\n 34 mL\n Blood products:\n Total out:\n 0 mL\n 75 mL\n Urine:\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 709 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n Vitals: T:96.8 BP: 190/90 P:61 R:13 SaO2: 96%3L NC\n General: Awake, alert, appears comfortable.\n HEENT: NCAT, PERRL, EOMI, no scleral icterus, MM slightly dry. Muddy\n sclera.\n Neck: supple, no significant JVD or carotid bruits appreciated\n Pulmonary: Limited air movement, quiet deep pitched wheezes anteriorly\n and posteriorly, with prolonged expiratory phase. No crackles, no\n rhonchi.\n Cardiac: Unable to appreciate through breath sounds.\n Abdomen: Minimally distended, hypoactive bowel sounds present.\n Diffusely minimally tender to palpation. No rebound or guarding. No\n tympany\n Extremities: No edema. Has non-functional right UE fistula.\n Skin: Multiple keloids\n Neurologic: Alert, oriented x 3. Able to relate history without\n difficulty. Cranial nerves II-XII intact. Normal bulk, strength and\n tone throughout.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Na 132 Cl 99 39 Glu 105\n K 4.8 HC03 24 Cr 3.9\n CK 172 MB 5 Trop 0.09\n BNP 2380\n UA negative\n WBC 5.1 Hct 30.4 Plt 161\n 78% N\n INR 1.2\n Imaging: TTE :\n Conclusions\n The left atrium is mildly dilated. Left ventricular wall thickness,\n cavity size and regional/global systolic function are normal (LVEF\n >55%) Right ventricular chamber size and free wall motion are normal.\n The aortic root is mildly dilated at the sinus level. The ascending\n aorta is moderately dilated. The number of aortic valve leaflets cannot\n be determined. No aortic regurgitation is seen. The mitral valve\n appears structurally normal with trivial mitral regurgitation. The\n estimated pulmonary artery systolic pressure is normal. There is no\n pericardial effusion. There is an anterior space which most likely\n represents a fat pad.\n .\n Spirometry :\n Mechanics: The FVC is normal. The FEV1 is mildly reduced. The FEV1/FVC\n ratio and MMEF are moderately reduced.\n Flow-Volume Loop: Moderate expiratory coving.\n Volumes: The TLC is high normal. The FRC and SVC are normal. The RV and\n RV/TLC ratio are increased.\n DLCO: Normal when uncorrected. Normal when corrected for hemoglobin and\n alveolar volume.\n Impression: Mild to moderate obstructive ventilatory defect. The\n preserved DLCO suggests chronic bronchitis. Compared to the prior study\n of the FVC has increased by 710 ml (17%) and the FEV1 has\n increased by 990 ml (59%).\n .\n CXR: Compared to (my read)\n Hyperinflated, normal cardiac sillhouette, no pleural effusions or\n iniltrate. Possible increased hilar fullnes with cephalization.\n ECG: <I>EKG:</I> NSR at 75. Slight LAD, old q waves in III, aVF. Normal\n intervals. No ST segment deviations. No change compared to prior.\n Assessment and Plan\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITHOUT ACUTE EXACERBATION\n I>ASSESSMENT:</I>60M with ESRD s/p CRT, HTN, COPD p/w severe\n hypertension and dyspnea\n <I>PLAN:</I>\n <I>## Dyspnea:</I>Differential dx includes COPD flare, pneumonia, ACS,\n CHF. No ischemic changes or elevations in cardiac enzymes, time course\n (progressive over 2 days) also atypical for ACS. No fevers or\n leukocytosis, although pt is immunosuppressed, no focal infiltrate or\n increased sputum production to suggest pneumonia. Hypertension and\n acute on chronic renal failure leading to volume overload and pulmonary\n edema would fit well with this picture and would be c/w marked anterior\n wheeze, however his JVP is flat, his BNP is not elevated from 3 years\n ago, his CXR doesn't show clear volume overload and he has no crackles\n on exam. His prolonged expiratory phase and known h/o COPD as well as\n hyperinflated lungs argue for a COPD flare.\n -Frequent nebs, trial of continuous neb mask. Bicarb WNL, no evidence\n of chronic respiratory acidosis, if this is COPD flare it is acute,\n with no time for compensation.\n -Check ABG\n -Azithromycin x total 5 day course.\n -Prednisone burst, continue 60mg per day\n -check sputum cx, urine legionella antigen\n -Consider repeat BiPap trial if nebs not effective\n -consider diuresis if above not effective\n -continue full ROMI\n <I>## Hypertension:</I>Has known difficult to control HTN, with\n hypertensive nephropathy/ESRD s/p transplant. Reports med adherence.\n be due to renal failure and volume overload or distress from COPD\n flare.\n -Nitro gtt for now, goal SBP <160\n -Continue BB\n -Hold due to ARF.\n <I>## Acute renal failure:</I>History of ESRD due to hypertensive\n nephropathy, had been on dialysis before CRT in . Reports\n adherence with immunosuppresants. Unclear precipitant for ARF, ddx\n includes dehydration, although unlikely given hypertension; rejection,\n recurrence of hypertensive nephropathy in graft.\n -Check prograf level this am (esp in setting of ARF and macrolide use\n -continue prednisone (increased per above), cellcept, prograf\n -renal transplant consult\n -urine lytes\n -graft ultrasound\n -hold \n -hold lasix for now pending urine studies and discussion with renal,\n may warrant trial if does not improve.\n <I>## Hyperlipidemia:</I>\n -continue statin and ezetimibe\n <I>## DM:</I>\n -HISS\n -diabetic diet\n <I>## Chronic pain:</I>\n -continue home oxycontin per OMR\n <I>## GERD:</I>\n -Home PPI \n <I>## Constipation:</I>\n -senna, colace\n <I>## FEN/Lytes:</I> Cardiac, low salt, diabetic diet, replete lytes\n prn\n <I>## Prophylaxis:</I> Heparin SC 5000 tid, PPI, bowel regimen.\n <I>## Code status:</I> FULL CODE, confirmed.\n <I>## Dispo:</I> Call out to floor when BP controlled, off BiPap\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 06:24 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-04 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 673187,
"text": "Chief Complaint: dyspnea\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 60M with htn, copd, tobacco use, esrd s/p kidney tx, p/w arf, dysnea\n with wheezing, parainfluenza positive:\n 24 Hour Events:\n ULTRASOUND - At 01:51 PM\n ULTRASOUND - At 02:16 PM\n PICC LINE - START 04:26 PM\n NON-INVASIVE VENTILATION - START 04:00 AM\n NON-INVASIVE VENTILATION - STOP 04:15 AM\n Difficult night with increased wheezing and sob; bipap for a few mins\n but refused. NEBS help but refusing.\n BP control challenging, started on nicardipine gtt (on LEG).\n Kidney u/s normal per verbal report.\n PICC placed.\n History obtained from Medical records\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Nitroglycerin - 0.5 mcg/Kg/min\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 PM\n Morphine Sulfate - 04:06 AM\n Furosemide (Lasix) - 04:06 AM\n Heparin Sodium (Prophylaxis) - 08:28 AM\n Other medications:\n duloxetine, azithro, atorvast, oxycodone 30 q12, riss, sqh, zetia, mmf,\n omepr, tacro 4q12, methadone tid, albut, hydral, methylpred 80 q8,\n hydral 50 q6, nidacrdipine, clonidine, amlodipine, dilaudid prn; lasix\n x1 at 4am, hydral iv, morphine x1\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: Chest pain, No(t) Palpitations, No(t) Edema, No(t)\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, Wheeze\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis, No(t)\n Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley, No(t) Dialysis\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Signs or concerns for abuse\n Pain: Minimal\n Pain location: abdomen and chest\n Flowsheet Data as of 01:31 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.7\nC (96.2\n Tcurrent: 35.6\nC (96\n HR: 82 (67 - 102) bpm\n BP: 158/74(92) {141/60(91) - 206/115(148)} mmHg\n RR: 23 (15 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n Total In:\n 2,338 mL\n 927 mL\n PO:\n 1,110 mL\n 480 mL\n TF:\n IVF:\n 478 mL\n 447 mL\n Blood products:\n Total out:\n 1,295 mL\n 1,000 mL\n Urine:\n 1,295 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,043 mL\n -73 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Other\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 730 (730 - 730) mL\n PS : 8 cmH2O\n PEEP: 5 cmH2O\n FiO2: 30%\n SpO2: 97%\n ABG: VBG 7.39/35/39\n Ve: 13.4 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n Wheezes : expiratory bilateral / central, No(t) Diminished: , No(t)\n Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, No(t)\n Distended, Tender: mildly throughout\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.6 g/dL\n 214 K/uL\n 211 mg/dL\n 3.7 mg/dL\n 20 mEq/L\n 4.4 mEq/L\n 50 mg/dL\n 92 mEq/L\n 126 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 07:57 AM\n 12:51 PM\n 09:53 PM\n 11:01 PM\n 03:22 AM\n 05:23 AM\n WBC\n 4.3\n 7.4\n Hct\n 28.8\n 26.3\n Plt\n 170\n 214\n Cr\n 3.9\n 3.6\n 3.8\n 3.5\n 3.7\n TropT\n 0.08\n 0.05\n TCO2\n 21\n Glucose\n 129\n 529\n 178\n 497\n 211\n Other labs: PT / PTT / INR:13.9/35.5/1.2, CK / CKMB /\n Troponin-T:210/8/0.05, Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:5.1 mg/dL\n Fluid analysis / Other labs: tacro 7.4\n spot protein ~3 g, comparable to 2 moonths ago\n Microbiology: Positive for Parainfluenza type 3 viral antigen.\n Other tests pending\n Assessment and Plan\n 60M with htn, copd, esrd s/p kidney tx in , presents with dyspnea\n and wheezing, with parainfluanza isolated, along with severe htn and\n arf:\n WHEEZING / RESP DISTRESS: likely mostly copd exac, possible from viral\n infection, vs mainly viral infection (given lack of prior frequent\n admits for copd exacerbation and normal pCO2):\n -will consider steroids back down to prednisone 5 daily (home dose)\n unless renal has concern for rejection and higher dose is recommended;\n -cont nebs; make ipratropium standing and continue albuterol standing\n and prn\n -no specific treatment for parainfluenza at this time\n -would benefit from cpap if able to tolerate but declining\n ANEMIA:\n -check iron panel\n ARF/TRANSPLANT: Cr remains elevated\n -fu final read on kidney and discuss with transplant additional imaging\n / tests\n -will avoid nephrotoxins and renal adjust meds\n HTN: can only check on leg; thus likely falsely elevated in\n part\n -start clonidine and titrate off drips\n -clarify \"goal bp\" with renal\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code (discussed with patient and confirmed Full Code\n today by Dr \n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673370,
"text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt with worsening respiratory distress, patient finally in agreement to\n try face mask ventilation however, not working, continued use of\n accessory muscles and required intubation. Pt intubated by anesthesia\n without apparent complications. Attempted to sedate w/fentanyl and\n versed drips however, despite boluses patient able to wake up, sit\n upright and attempts made to self extubate. Pt required wrist\n restraints to prevent self extubation and assist of 3 people to keep in\n bed before effects of bolus meds achieved. Sedation switched to\n propofol and then required phenylephrine drip to keep SBP <100. Pt\n continued to require intermittent boluses of 2-3cc of propofol as when\n awakens attempts to sit up and then bring head to hand to self\n extubate.\n Action:\n Intubated, sedated w/propofol now requiring pressor to maintain b/p.\n Response:\n Continued noted respiratory effort despite sedation.\n Plan:\n Sedate to ventilate and prevent self extubation, wrist restraints to\n prevent self harm, propofol as ordered. VAP prevention measures as per\n protocol.\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673431,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Hypertension, benign\n Assessment:\n Received patient on phenylephrine at 0.9mkm, weaned off and is\n currently off at time of reporting.\n Action:\n Patient did become hypotensive post wean off phenylephrine, treated\n with 3l of N/S.\n Response:\n Maintain SBP 110\n 130\ns, is to try and keep MAP greater than 65mmHg.\n Plan:\n All antihypertensive have since been d/c\nd BP at this time.\n Continue to monitor BP and urinary output. Follow lab trends.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Mechanically ventilated on CPAP 15/5 at this time with TV in the \n hundreds.\n Action:\n Vent settings had to be manipulated several times overnight, but\n patient remains in acidosis.\n Response:\n Blood gases has improved last one being done at 0300 this am\n 7.27/39/129/19. Lung sounds are better and respiratory exertion less.\n Maintaining saturation greater than 95% consistently.\n Plan:\n Continue to follow lab trends and make adjustments to ventilatory\n settings as recommended.\n Urinary output still poor, however improved from previous day, it is\n approximately 25-30cc/hr.\n Patient is difficult to sedate, propofol going at 50mkm currently with\n patient opening eyes to verbal stimuli and will sit up in bed at\n times. His BP is sensitive to propofol boluses. Bilateral soft wrist\n restraints on for patient safety.\n"
},
{
"category": "General",
"chartdate": "2104-06-06 00:00:00.000",
"description": "ICU Event Note",
"row_id": 673542,
"text": "Clinician: Attending\n Patient with continued expiratory airflow obstruction.\n Paralytics used transiently to allow full quantification of pulmonary\n mechanics.\n In that setting-->\n PIP-29, Plat-12 and PEEP=5\n With RR decreased to 10 clear improvement in autopeep from 3-->0\n So--will continue to treat for reactive airways disease with likely\n viral trigger with parainfluenza. Continue with A/C support and look to\n wean only when improved airflow obstruction seen. Central airway\n obstruction simply not seen.\n Total time spent: 30 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673586,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n SHIFT EVENTS\n * K-excelate given for hyperkalemia (k+ 5.7)\n * TFeeds at goal rate of 25cc/hr\n * No vent changes\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt. remains intubated and vented on PSV 40% 10/5 with sats at high 90\n RR in 10\ns. Breath sounds diminished throughout. Some wheezes noted but\n clear with nebs. Non productive cough noted. Remains on 80mcg/kg\n propofol. Episodes of tachypnea and hypertension noted.\n Action:\n MDIs given as ordered. Mouth care q4hr and prn, suction as needed. Pt.\n turned Q2h. PRN IV fentanyl ordered to maintain pt. comfort.\n Response:\n Pt. remains stable on current vent settings. Ongoing respiratory\n assessment.\n Plan:\n Continue to monitor resp status, wean vent as tolerated, meds ASDIR,\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat- 4.1 K-5.7. UOP about 40cc/hr\n Action:\n Renal biopsy done yesterday. All meds renally dosed. Cellcept\n administered as ordered. Prograf held d/t level. Will recheck level\n with am labs as med adjusted to daily level. K-excelate x1 dose\n given.\n Response:\n Pt. remains with increased BUN/Creat, hyperkalemia.\n Plan:\n Continue to monitor renal functions, f/u renal recs. f/u biopsy\n results. AM prograf level pending.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673903,
"text": "60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n Of note, attempt to wean sedation for possible extubation\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. received intubated on pressure support 40%/. Labored breathing\n noted. Suctioned for scant amounts of thick green sputum. Culture + for\n gram negative rods. Sedated on propofol gtt but unable to increase\n sedation as pt. was hypotensive. Pt. unresponsive. No cough/gag reflex\n noted. No withdrawal to noxious stimuli, however, resp rate 30\ns to\n 40\ns. Nasal flaring noted with inhalation.\n Action:\n Multiple blood gases drawn throughout shift. (see metavision) Pt.\n increasingly acidotic and hypoxic. Vent changed to AC 60%/500/20/5.\n Started on IV vanco and zosyn for probable VAP pneumonia. Attempts\n made to increase sedation unsuccessful hypotension. All sedation\n off at 0400 d/t hypotension. Pt. turned Q2h. Mouth care Q4h.\n Response:\n Pt. continues to appear to have labored breathing. Most recent pH 7.16.\n Plan:\n IV antibiotics to be administered as ordered. Aggressive pulmonary\n toilet. Titrate vent to maintain optimal resp. support. If blood\n pressure improves with pressors, re-administer sedation to maintain pt.\n comfort.\n Hypotension (not Shock)\n Assessment:\n SBP as low as 70\ns at start of shift. Fluctuated from 70\ns to low 100\n with MAPS 50\ns to 70\ns. UO 10-40cc/hr.\n Action:\n Fentanyl and propofol drip off. Total of 5L NS boluses given at start\n of shift. BP unresponsive to fluid. Phenylephrine started and titrated\n to maintain MAPS >65. Vasopressin also hung at 2.4U/hr. Central line\n placed. CVP .\n Response:\n Maps >65 at this time on phenylephrine 4mcg/kg and vasopressin 2.4U/hr.\n receiving an additional liter of fluid at this time.\n Plan:\n Wean pressor to maintain MAP >65. Continue to monitor hemodynamic\n status and UO closely. Awaiting am lab results.\n Constipation (Obstipation, FOS)\n Assessment:\n Known decreased gastric motility. Abd soft distended, positive for BS\n and flatus, TFeeds restarted at at 10cc/hr. Residuals at 2200\n >360cc.\n Action:\n TFeeds off. Continue Reglan, lactulose and aggressive bowel regimen\n Response:\n Pending\n Plan:\n Continue to monitor patient status, aggressive bowel regiment until\n clears, may attempt to restart TF today if no residuals.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n s/p renal transplant, UOP decreased to 30-40cc/hr\n Action:\n Fluid boluses as noted above. Assessed UO Q1h. Steroids, cellcept, and\n prograf, administered as ordered.\n Response:\n Continue to follow GU status.\n Plan:\n Continue to monitor patient renal status, f/u renal recs. Fluid\n boluses as ordered. Replete sodium bicarb as needed.\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 673146,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -Left PICC placed ending in brachiocephalic vein\n -LDH to r/o PCP 221. Urine BK/legionella, CMV vL all pending.\n Nasopharyngeal swab positive for parainfluenza.\n -Ruled out for acute ischemia (CK 172->185, MB 5->6, TropT 0.09->0.08)\n -Given 80 mg IV Lasix in morning for possible CHF. Echo ordered for\n .\n -BP difficult to control. Nitro gtt uptitrated, written for hydralazine\n and amlodipine, home metoprolol. Given another dose of lasix overnight\n for SBP > 200. Nicardipine gtt started. CXR with no significant\n chnages. Question of elevated BP d/t respiratory distress v. steroids\n v. narcotic withdrawal. (?try morphine or clonidine patch).\n -Restarted on home dose methadone and prn hydromorphone 4mg 5x daily\n restarted\n -Urine lytes with FeUrea 37.7 (borderline for pre-renal ARF).\n Renal/transplant recs: ARF d/t hypertension vs tacro tox (level 5.9) vs\n rejection vs BK. Kidney u/s: performed but not read.\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Nitroglycerin - 2 mcg/Kg/min\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Morphine Sulfate - 04:06 AM\n Furosemide (Lasix) - 04:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.7\nC (96.2\n Tcurrent: 35.6\nC (96\n HR: 88 (67 - 100) bpm\n BP: 192/92(114) {162/79(108) - 206/115(148)} mmHg\n RR: 18 (14 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n Total In:\n 2,338 mL\n 634 mL\n PO:\n 1,110 mL\n 360 mL\n TF:\n IVF:\n 478 mL\n 274 mL\n Blood products:\n Total out:\n 1,295 mL\n 700 mL\n Urine:\n 1,295 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,043 mL\n -66 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Other\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 730 (730 - 730) mL\n PS : 8 cmH2O\n PEEP: 5 cmH2O\n FiO2: 30%\n SpO2: 98%\n ABG: 7.32/39/52/20/-5\n Ve: 13.4 L/min\n PaO2 / FiO2: 173\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 214 K/uL\n 8.6 g/dL\n 211 mg/dL\n 3.7 mg/dL\n 20 mEq/L\n 4.4 mEq/L\n 50 mg/dL\n 92 mEq/L\n 126 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 07:57 AM\n 12:51 PM\n 09:53 PM\n 11:01 PM\n 03:22 AM\n 05:23 AM\n WBC\n 4.3\n 7.4\n Hct\n 28.8\n 26.3\n Plt\n 170\n 214\n Cr\n 3.9\n 3.6\n 3.8\n 3.5\n 3.7\n TropT\n 0.08\n 0.05\n TCO2\n 21\n Glucose\n 129\n 529\n 178\n 497\n 211\n Other labs: PT / PTT / INR:13.9/35.5/1.2, CK / CKMB /\n Troponin-T:210/8/0.05, Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n 60M with ESRD s/p CRT, HTN, COPD p/w severe hypertension and dyspnea\n <I>PLAN:</I>\n <I>## Dyspnea:</I>Differential dx includes COPD flare, pneumonia, ACS,\n CHF. No ischemic changes or elevations in cardiac enzymes, time course\n (progressive over 2 days) also atypical for ACS. No fevers or\n leukocytosis, although pt is immunosuppressed, no focal infiltrate or\n increased sputum production to suggest pneumonia. Hypertension and\n acute on chronic renal failure leading to volume overload and pulmonary\n edema would fit well with this picture and would be c/w marked anterior\n wheeze, however his JVP is flat, his BNP is not elevated from 3 years\n ago, his CXR doesn't show clear volume overload and he has no crackles\n on exam. His prolonged expiratory phase and known h/o COPD as well as\n hyperinflated lungs argue for a COPD flare.\n -Frequent nebs, trial of continuous neb mask. Bicarb WNL, no evidence\n of chronic respiratory acidosis, if this is COPD flare it is acute,\n with no time for compensation.\n -Check ABG\n -Azithromycin x total 5 day course.\n -Prednisone burst, continue 60mg per day\n -check sputum cx, urine legionella antigen\n -Consider repeat BiPap trial if nebs not effective\n -consider diuresis if above not effective\n -continue full ROMI\n <I>## Hypertension:</I>Has known difficult to control HTN, with\n hypertensive nephropathy/ESRD s/p transplant. Reports med adherence.\n be due to renal failure and volume overload or distress from COPD\n flare.\n -Nitro gtt for now, goal SBP <160\n -Continue BB\n -Hold due to ARF.\n <I>## Acute renal failure:</I>History of ESRD due to hypertensive\n nephropathy, had been on dialysis before CRT in . Reports\n adherence with immunosuppresants. Unclear precipitant for ARF, ddx\n includes dehydration, although unlikely given hypertension; rejection,\n recurrence of hypertensive nephropathy in graft.\n -Check prograf level this am (esp in setting of ARF and macrolide use\n -continue prednisone (increased per above), cellcept, prograf\n -renal transplant consult\n -urine lytes\n -graft ultrasound\n -hold \n -hold lasix for now pending urine studies and discussion with renal,\n may warrant trial if does not improve.\n <I>## Hyperlipidemia:</I>\n -continue statin and ezetimibe\n <I>## DM:</I>\n -HISS\n -diabetic diet\n <I>## Chronic pain:</I>\n -continue home oxycontin per OMR\n <I>## GERD:</I>\n -Home PPI \n <I>## Constipation:</I>\n -senna, colace\n <I>## FEN/Lytes:</I> Cardiac, low salt, diabetic diet, replete lytes\n prn\n <I>## Prophylaxis:</I> Heparin SC 5000 tid, PPI, bowel regimen.\n <I>## Code status:</I> FULL CODE, confirmed.\n <I>## Dispo:</I> Call out to floor when BP controlled, off BiPap\n ICU Care\n Nutrition:\n Glycemic Control: RISS\n Lines:\n PICC Line - 04:26 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 673689,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use, Prolonged\n exhalation\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 675525,
"text": "SICU\n HPI:\n 60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n .\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-ass R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n Current medications:\n 1. IV access: Peripheral line Order date: @ 1031\n 21. Ipratropium Bromide MDI 6 PUFF IH Q6H Order date: @ 0150\n 2. IV access: PICC, heparin dependent Location: Left basilic, Date\n inserted: Order date: @ 1031\n 22. Magnesium Sulfate IV Sliding Scale Order date: @ 1031\n 3. IV access: Temporary central access (ICU) Order date: @ 1031\n 23. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n Day 1 Order date: @ 1031\n 4. IV access: Mid-line, heparin dependent Order date: @ 1031\n 24. MethylPREDNISolone Sodium Succ 4 mg IV Q24H Order date: @\n 0933\n 5. IV access: Dialysis Catheter (Temporary 2-Lumen) Location: Left\n Internal Jugular, Date inserted: Order date: @ 1031\n 25. Midazolam 0.5-3 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 1639\n 6. IV access: None Order date: @ 1031\n 26. Mycophenolate Mofetil 500 mg IV BID Order date: @ 1031\n 7. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 1031\n 27. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO sbp>90mmHg Order\n date: @ 1031\n 8. Albuterol Inhaler 6 PUFF IH Q6H:PRN dyspnea Order date: @\n 0150\n 28. Piperacillin-Tazobactam Na 2.25 g IV Q6H Order date: @ 1031\n 9. Albumin 25% (12.5g / 50mL) 12.5 g IV ONCE Duration: 1 Doses Order\n date: @ \n 29. Potassium Chloride 20 mEq / 50 ml SW IV PRN for K < 3.5\n To supplement CRRT KCL infusion sliding scale protocol. Order date:\n @ 1031\n 10. Calcium Chloride IV Sliding Scale Order date: @ 1031\n 30. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1031\n 11. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1031\n 31. Prismasate (B22 K4)*\n Continuous at 500 ml/hr\n Dialysate Solution for CRRT Order date: @ 1818\n 12. Citrate Dextrose 3% (ACD-A) CRRT 150 mL/hr DIALYS ASDIR\n CRRT Protocol. Monitor systemic ionized calcium q6h. Adjust according\n to renal recommendations. Order date: @ 1611\n 32. Prismasate (B22 K4)\n Continuous at ml/hr\n Infuse Replacement fluid: Prefilter Rate:1500 Postfilter Rate:200\n Replacement Solution for CRRT Order date: @ 1140\n 13. Esmolol 50-150 mcg/kg/min IV TITRATE TO HR<100 Order date: @\n 1144\n 33. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1031\n 14. Famotidine 20 mg IV Q24H Order date: @ 0530\n 34. Sodium CITRATE 4% 3 mL DWELL ASDIR catheter not in use\n dwell to catheter volume written on catheter Order date: @ 1031\n 15. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \n @ 1031\n 35. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1031\n 16. Fluticasone Propionate 110mcg 2 PUFF IH Order date: @\n 1031\n 36. Sodium CITRATE 4% 2 mL DWELL ASDIR catheter not in use\n dwell to catheter volume printed on lumens Order date: @ 1031\n 17. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n PICC, heparin dependent: Flush with 10mL Normal Saline followed by\n Heparin as above daily and PRN per lumen. Order date: @ 1031\n 37. Tacrolimus Suspension 1 mg NG QAM Duration: 1 Doses\n Dose to be admin at 5/17 am. No PM dose on Order date: @\n 1734\n 18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n Mid-line, heparin dependent: Flush with 10 mL Normal Saline followed by\n Heparin as above, daily and PRN per lumen. Order date: @ 1031\n 38. Vancomycin 1250 mg IV Q 24H Order date: @ 2252\n 19. Heparin Flush (5000 Units/mL) 4000- UNIT DWELL PRN line flush\n Dialysis Catheter (Temporary 2-Lumen): DIALYSIS NURSE ONLY: Withdraw 4\n mL prior to flushing with 10 mL NS followed by Heparin as above\n according to volume per lumen. Order date: @ 1031\n 39. Vancomycin 500 mg IV ONCE Duration: 1 Doses Order date: @\n 1235\n 20. Insulin 100 Units/100 ml NS @ 2 UNIT/HR IV DRIP INFUSION\n Fingersticks every hour Order date: @ 2238\n 24 Hour Events:\n TRANS ESOPHAGEAL ECHO - At 04:43 PM\n -Continuing to require large amounts to fluid to maintain BP.\n -Esmolol weaned off\n -Continuing to require pressors\n Post operative day:\n POD#5 - expl lap\n POD#4 - Hematoma cleaned out, one area on bowel to watch, ABD left\n open, will return to OR tomorrow \n POD#3 - exlap\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 11:09 PM\n Vancomycin - 04:01 PM\n Metronidazole - 10:00 PM\n Piperacillin - 04:00 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Phenylephrine - 1.3 mcg/Kg/min\n Fentanyl - 150 mcg/hour\n Calcium Gluconate (CRRT) - 1 grams/hour\n KCl (CRRT) - 3 mEq./hour\n Insulin - Regular - 11 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 10:17 AM\n Other medications:\n Flowsheet Data as of 04:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 35.8\nC (96.4\n HR: 91 (82 - 107) bpm\n BP: 106/66(77) {70/43(51) - 121/66(85)} mmHg\n RR: 24 (13 - 34) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 116.4 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 13 (7 - 17) mmHg\n CO/CI (Thermodilution): (5.83 L/min) / (2.5 L/min/m2)\n SVR: 741 dynes*sec/cm5\n SV: 59 mL\n SVI: 26 mL/m2\n Total In:\n 12,513 mL\n 2,374 mL\n PO:\n Tube feeding:\n IV Fluid:\n 11,899 mL\n 1,996 mL\n Blood products:\n 50 mL\n Total out:\n 11,458 mL\n 892 mL\n Urine:\n 36 mL\n NG:\n 975 mL\n 250 mL\n Stool:\n 100 mL\n Drains:\n 2,035 mL\n 450 mL\n Balance:\n 1,055 mL\n 1,482 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 3\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%, Hemodynamic Instability\n PIP: 24 cmH2O\n Plateau: 17 cmH2O\n SPO2: 96%\n ABG: 7.34/40/70/22/-3\n Ve: 15.2 L/min\n PaO2 / FiO2: 117\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : , Diminished: )\n Abdominal: Soft, Abdomen opened with sterile towels and Ioban dressing\n intact\n Left Extremities: (Edema: 4+), (Temperature: Cool)\n Right Extremities: (Edema: 4+), (Temperature: Cool)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Unresponsive), Moves all extremities, Sedated\n Labs / Radiology\n 28 K/uL\n 10.0 g/dL\n 175 mg/dL\n 2.1 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 54 mg/dL\n 103 mEq/L\n 134 mEq/L\n 28.6 %\n 3.3 K/uL\n [image002.jpg]\n 10:04 AM\n 12:26 PM\n 03:04 PM\n 04:56 PM\n 05:17 PM\n 08:22 PM\n 08:39 PM\n 11:46 PM\n 01:44 AM\n 02:37 AM\n WBC\n 6.7\n 3.3\n Hct\n 34\n 27.9\n 30.7\n 28.6\n Plt\n 25\n 28\n Creatinine\n 2.1\n 2.1\n 2.1\n TCO2\n 24\n 22\n 21\n 27\n 24\n 23\n 23\n Glucose\n 127\n 123\n 120\n 327\n 76\n 200\n 175\n Other labs: PT / PTT / INR:17.9/41.8/1.6, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:312/223, Alk-Phos / T bili:139/8.7, Amylase /\n Lipase:831/21, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %,\n Mono:8.0 %, Eos:0.0 %, Fibrinogen:267 mg/dL, Lactic Acid:2.0 mmol/L,\n Albumin:1.8 g/dL, LDH: IU/L, Ca:9.2 mg/dL, Mg:2.1 mg/dL, PO4:3.3\n mg/dL\n Imaging: CT: extensive pneumatosis, involving ileal loops & asc &\n t colon, portal venous air.\n Microbiology: sputum: Pseudomonas (pan S)\n urine: GPC ~1K\n bld x2: neg\n bld x2: P\n C.diff: positive\n bld x2: P\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), HYPOTENSION (NOT SHOCK), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INEFFECTIVE COPING, INTESTINAL ISCHEMIA\n (INCLUDING MESENTERIC VENOUS / ARTERIAL THROMBOSIS, BOWEL ISCHEMIA),\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), HYPERTENSION, BENIGN,\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION, CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD,\n BRONCHITIS, EMPHYSEMA) WITHOUT ACUTE EXACERBATION\n Assessment and Plan: 60M admitted to for COPD exacerbation, became\n septic, developed ischemic bowel, s/p exlap, SBR, open abd , s/p ex\n lap, hematoma evacuation , s/p ex lap, end jejunostomy (150 cm SB),\n open abd .\n Neurologic: wean fentanyl gtt & midaz\n Cardiovascular: Currently in NSR, rate controlled, wean pressors,\n esmolol gtt/neo for Afib (no amio or dilt)\n Pulmonary: Cont ETT, (Ventilator mode: CMV), vent wean as tolerated,\n CXR, serial ABGs, cont Flovent/Atrovent/albuterol\n Gastrointestinal / Abdomen: NPO, LFTs trending down, TPN\n Nutrition: TPN, NPO\n Renal: Foley, CVVH, UOP minimal, ARF on CRF, Cr 2.1, stable, cont\n tacrolimus and Cellcept, check levels, CVVH, remove volume as pressure\n tolerates\n Hematology: Hct 28.6, stable, plts 28, cont to follow, coags, f/u HIT\n panel\n Endocrine: RISS, Solumedrol 4'\n Infectious Disease: Check cultures, Afebrile, WBC 3.3, cont Zosyn,\n Flagyl, vanc, vanc level\n Lines / Tubes / Drains: Foley, OGT, ETT, Surgical drains (hemovac, JP)\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: Plasmalyte\n Consults: Transplant\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Post-op hypotension, (Shock), Acute renal failure\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:26 PM 85. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n Arterial Line - 04:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-09 00:00:00.000",
"description": "ICU Event Note",
"row_id": 673907,
"text": "Clinician: Attending\n Progressive hypotension despite 4.5 L IV fluids since midnight and\n peripheral neo. Temp this AM 100.4 axillary, wbc 28 suggesting sepsis,\n likely from VAP. He has however had good urine output throughout the\n night and it is not clear if a-line pressures are transducing well\n given damp waveform and thigh manual BPs being 30 systolic greater.\n Central line access is certainly indicated and was inserted without\n complication - confirmed by CXR. Pressors switched over to CVL,\n currently vasopressin and neo. Will switch to levophed. Empiric stress\n dose steroids were given for concern of adrenal insufficiency. ABG/VBG\n pending. I am also concerned about a central process with low TSH/T4/T3\n which may be sick euthyroid in the setting of critical illness. Repeat\n cortisol pending.\n Total time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674009,
"text": "60 yo M with esrd post transplant, copd, htn with progressive resp\n failure, hypotension, progressive ARF.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient intubated and vented on AC 100% 500X30/5 w/sats on ABG\n at 90. B/L diminished, still irregular breathing w/use of accessory\n muscles. No secretions w/suctioning. Last sputum positive for GNR. CXR\n w/ worsening infiltrates.\n Action:\n Remains intubated and vented, Fio2 down to 60%\n ABG: 7.20/54/94. Mouth\n care, MDI\ns ASDIR. Abg to eval. ABX for possible VAP\n Response:\n pending\n Plan:\n Continue to monitor resp status, f/u cultures, continue ABX, wean,\n SBT/RSBI, wean off when able.\n Hypotension (not Shock)\n Assessment:\n Received patient on maxed Neo and Vasopressin, after 7L IVF. Still\n hypotensive to 70\ns. Started on levophed. Patient also on steroids \n possible component of adrenal insufficiency. Tachycardic in \n w/occasional PAC\ns. General edema, peripheral pulses present w/doppler\n only, extr cool w/abnormal capillary refill. CVP 12-14, minimal UOP.\n Bladder pressure - 18\n Action:\n Pressors support (triple pressors) to maintain MAP >60 IVF to maintain\n CVP > 10, got 1 L bolus of Bicarb in D5W. stress steroids, abx to treat\n infection\n Response:\n Levophed weaned to 0.05 mcg/kg/min, rest remains w/o change.\n Plan:\n Continue to monitor patient\ns hemodynamic status, wean off pressors\n when able. F/u CX data, f/t ECHO read.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat\n 4.2 K-6.7 UOP minimal, bladder pressures -18\n Action:\n Total of 200MEq of Bicarb given, Insulin w/D50 given, calcium gluconate\n given, renal follows, continue on steroids/prograf/cellcept.\n Response:\n pending\n Plan:\n Continue to monitor patient\ns renal status, f/u renal recs, eval for\n need of CVVH\n Constipation (Obstipation, FOS)\n Assessment:\n Since admission on either Fentanyl or methadone/oxycodone. No BM. abd\n distended, no BS or flatus. OGT to suction w/ 1500cc of bilious output\n over 2HR. Cdiff negative. Bladder pressure -18\n Action:\n NPO, OGT to suction, aggressive bowel regimen, KUB done, continues on\n Reglan q6hr.\n Response:\n NO BM\n Plan:\n Continue to monitor patient status\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674168,
"text": "60 yo M with esrd post transplant, copd, htn with progressive resp\n failure, hypotension, progressive ARF.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient intubated and vented on AC 60% 600x24/5 w/sats on ABG\n at 90\ns. B/L diminished, still irregular breathing w/use of accessory\n muscles. No secretions w/suctioning. Last sputum positive for GNR.\n Started VAP treatment w/vanc/zosyn.\n Action:\n Remains intubated and vented, abg: 7.25/41/103. Mouth care, MDI\n ASDIR. Abg to eval.\n Response:\n Pending\n Plan:\n Continue to monitor resp status, f/u cultures, continue ABX, wean,\n SBT/RSBI, wean off when able.\n Hypotension (not Shock)\n Assessment:\n Received patient from OR with B/P at 160\ns per report , off pressors,\n however in the unit episodes of hypotension in 70-80\ns and MAPs<60.\n Neo restarted however d/c short period after for B/P at\n 140-160\ns.Patient also on steroids possible component of adrenal\n insufficiency. HR at 90\ns SR w/occasional PAC\ns. General edema,\n peripheral pulses present w/doppler only, extr cool w/abnormal\n capillary refill. CVP 10-12, minimal UOP.\n Action:\n Pressors support to maintain MAP >60 if needed, IVF to maintain CVP >\n 10 and RBC w/goal >30. Got 1 L bolus of NS. Stress steroids, abx to\n treat infection, and was started on Bicarb at 150cc/hr\n Response:\n Off pressors with B/P at 100-110\ns and MAP>65\n Plan:\n Continue to monitor patient\ns hemodynamic status, pressors if needed,\n however for volume will prefer IVF and blood. F/u CX data, f/U ECHO\n read.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat\n 4.6 K-6.6 UOP minimal\n Action:\n Bicarb 50meq given and Bicarb drip started at 150cc/hr, renal follows;\n continue on steroids/prograf/cellcept. Per team will need\n insulin/D50/calcium to treat hyperkalemia\n Response:\n Pending K-5.9\n Plan:\n Continue to monitor patient\ns renal status, f/u renal recs, eval for\n need of CVVH\n Constipation (Obstipation, FOS)\n Assessment:\n Since admission on either Fentanyl or methadone/oxycodone.\n Loose/liquid BM since aggressive bowel regimen started, elevated\n lactate, distended abd\nCT showed SBO\n taken to OR for small bowel\n resection. Received patient w/open abd, packed and covered, with 2 JP\n to wall suction\n 200cc of sanguineous output from each, and bleeding\n from the connection, saturated dressing. CDIFF came back POSITIVE.\n Action:\n NPO, OGT to suction, JP to wall suction,\n Response:\n pending\n Plan:\n Continue to monitor patient status, transfer to SICU for further\n management.\n Neuro: remains unresponsive to any stimuli, pupils are equal but non\n reactive. Head CT pending, neuro consult was ordered.\n IV access: Lt Midline, LT A-line, RT-IJ 3 lumen.\n Social: patient is a DNR. Family contact again this am to confirm the\n status and update.\n"
},
{
"category": "General",
"chartdate": "2104-06-10 00:00:00.000",
"description": "ICU Event Note",
"row_id": 674170,
"text": "Clinician: Nurse\n Received patient after small bowel resection early this am. Remains\n unresponsive, vented, on/off pressors short episodes of\n hypotension. Patient w/open abdominal incision ---> packed in OR w/2 JP\n to wall suction. Large amnt of bloody output from JP and saturated\n dressing --> got total of 4 units of RBC, 1 L of NS, 50MEQ of Bicarb,\n started on Bicarb drip at 150cc/hr. Stabilized: b/p 110's (OFF\n pressors), Hr in 90's SR, cvp 12-14, sats at 90's UOP in 10-15cc/hr.\n Transferred to SICU West with attendance of MD (DR ) and this RN.\n"
},
{
"category": "Nutrition",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 673520,
"text": "Subjective\n Patient in respiratory distress.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 203 cm\n 91.7 kg\n 22.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 102.5 kg\n 89%\n Diagnosis: Asthma/COPD exacerbation\n PMH : COPD, HTN, ESRD secondary to malignant HTN, s/p renal transplant\n , Negative Staph Right Hip Joint, s/p remover spacer\n placement,chronic pain on narcotics, Diverticulitis s/p right\n colectomy, Prostate Cancer s/p radiation therapy in ,DM2,\n Perirectal abcess , bilateral avascular necrosis, s/p fall w/\n femoral neck failure.\n Food allergies and intolerances: None noted\n Pertinent medications: Lansoprazole, RISS, Furosemide, 500 mL NS IV\n Bolus, Duloxetine, Azithromycin, mycophenolate, colace, methadone,\n heparin, phenylephrine, methyl prednisolon 125mg q 8hrs, oxycodone,\n propofol (49.5mL/hr)\n Labs:\n Value\n Date\n Glucose\n 164 mg/dL\n 03:26 AM\n Glucose Finger Stick\n 223\n 08:00 AM\n BUN\n 71 mg/dL\n 03:26 AM\n Creatinine\n 4.1 mg/dL\n 03:26 AM\n Sodium\n 125 mEq/L\n 03:26 AM\n Potassium\n 5.3 mEq/L\n 03:26 AM\n Chloride\n 97 mEq/L\n 03:26 AM\n TCO2\n 14 mEq/L\n 03:26 AM\n PO2 (arterial)\n 129 mm Hg\n 02:59 AM\n PO2 (venous)\n 35 mm Hg\n 03:48 AM\n PCO2 (arterial)\n 39 mm Hg\n 02:59 AM\n PCO2 (venous)\n 39 mm Hg\n 03:48 AM\n pH (arterial)\n 7.27 units\n 02:59 AM\n pH (venous)\n 7.31 units\n 03:48 AM\n pH (urine)\n 5.5 units\n 11:39 AM\n CO2 (Calc) arterial\n 19 mEq/L\n 02:59 AM\n CO2 (Calc) venous\n 21 mEq/L\n 03:48 AM\n Calcium non-ionized\n 7.2 mg/dL\n 03:26 AM\n Phosphorus\n 5.2 mg/dL\n 03:26 AM\n Magnesium\n 1.9 mg/dL\n 03:26 AM\n WBC\n 9.3 K/uL\n 03:26 AM\n Hgb\n 9.2 g/dL\n 03:26 AM\n Hematocrit\n 27.9 %\n 03:26 AM\n Current diet order / nutrition support: Regular, Low Sodium/heart\n healthy, diabetic in POE\n GI: Positive bowel sounds, abdomen soft and distended\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO, ESRD\n Estimated Nutritional Needs\n Calories: 2290-2750 ( 25-30 cal/kg)\n Protein: 92-119g (1-1.3 g/kg)\n Fluid: Per team\n Estimation of previous intake: Inadequate\n Specifics:\n 60 year old male with h/o of ESRD s/p renal transplantation in\n COPD, presents with hypertension and dyspnea. Now intubated for\n progressive respiratory distress. Consulted for tube feeding\n recommendations. Noted ?rejection of chronic transplant nephropathy.\n Needs tube feed access. Goal tube feeding of Novasource renal @ 25mL/hr\n x 24 hrs, providing 1200 calories, 44g protein. Noted patient receiving\n 49.5mL/hr providing 1188 calories. Patient receiving total of 2388\n calories, 44g protein. Will continue to monitor dosage of propofol per\n patient and adjust tube feeding accordingly. need to add\n beneprotein to tube feed if remains on high dose propofol. Will adjust\n protein needs according to renal function.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Start tube feeding of Novasource renal @ 10mL/hr and increase 10mL\n q4hrs to goal 25mL/hrx 24hrs.\n 2. Check tolerance via residuals Q 4hrs, hold tube feeding for x1 hr if\n residuals greater than 150mL.\n 3. Continue to monitor FSBG, q 6hrs.\n 4. Will adjust tube feeding per propofol rate\n 5. Monitor I&0\ns and electrolytes closely.\n 6. Monitor renal function\n 7. Will follow plan and progress.\n Dietetic Intern\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673743,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Hypertension, benign\n Assessment:\n SBP 110\ns to 170\ns with HR 110\ns to 120\ns throughout shift. Pt. remains\n on fentanyl 100mcg/kg and propofol 90mcg/kg for sedation/comfort.\n Action:\n Pt. given IV hydralazine q6hr along with drips as noted above. Pt.\n bolused with 100mcg of fentanyl prior to nsg. care.\n Response:\n SBP remained labile throughout shift ranging from 110\ns to 170\n Remained tachycardic throughout shift.\n Plan:\n Continue to monitor patient hemodynamic status closely. Continue with\n propofol, fentanyl and hydralazine as ordered. If pt. remains\n hypertensive, may need to increase hydralazine dose.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt. remains intubated and vented on PSV 40% 15/5 with sats at high 90\n RR in 10\ns. Breath sounds diminished throughout. Some wheezes noted but\n clear with nebs. Pt. suctioned for copious amounts of thick green\n sputum.\n Action:\n MDIs given as ordered. Mouth care q4hr and prn, suction as needed. Pt.\n turned Q2h. Sputum sample collected and sent to lab.\n Response:\n Pt. remains stable on current vent settings. Ongoing respiratory\n assessment.\n Plan:\n Continue to monitor resp status, wean vent as tolerated, meds ASDIR,\n F/U with culture results.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatinine trending down. AM creat- 3.8, BUN 75, K-4.9. UOP gradually\n increasing to approx. 40 to 120cc/hr\n Action:\n All meds renally dosed. Cellcept and prograf administered as ordered.\n Will recheck level with am labs as med adjusted to daily level. Started\n on renagel.\n Response:\n Pt. remains with elevated BUN/Creat, however, trending down.\n Plan:\n Continue to monitor renal functions, f/u renal recs. f/u biopsy\n results. AM prograf level pending.\n Constipation (Obstipation, FOS)\n Assessment:\n Pt. has not had a BM x 6 days. KUB done yesterday which showed lots of\n stool. Abd. Distended. Bowel sounds hypoactive. TFeeds have been off\n since yesterday am as pt. continues to have high residuals.\n Action:\n Lactulose, polyethylene glycol, and colace administered as ordered.\n TFeeds remain on hold. Residuals checked frequently throughout shift.\n Response:\n Pt. had one small smear of mucoid stool. Abd remains distended and BS\n hypoactive. Increase residuals continue.\n Plan:\n Continue with strict bowel regime. Continue to hold TFeeds until\n residuals subside.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 672949,
"text": "60 y/o M w/ an extensive PMH including Total R hip replacement, Renal\n transplant\n01, who presented to ED c/o worsening SOB x 2 days. In the\n ED his vitals were sign\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 673136,
"text": "Demographics\n Day of mechanical ventilation: 0\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Exp Wheeze\n Comments:\n Level of breathing assistance:\n Visual assessment of breathing pattern: erratic\n Assessment of breathing comfort: at times accessory muscle use with\n forced exhalations\n Non-invasive ventilation assessment: for the 15 minutes he was on NIV\n he appeared comfortable and breathing nonlabored.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673416,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nutrition",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 673517,
"text": "Subjective\n Patient in respiratory distress.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 203 cm\n 91.7 kg\n 22.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 102.5 kg\n 89%\n Diagnosis: Asthma/COPD excabation\n PMH : COPD, HTN, ESRD secondary to malignant HTN, Negative Staph Right\n Hip Joint, s/p remover spacer placement,chronic pain on narcotics,\n Diverticulitis s/p right colectomy, Prostate Cancer s/p radiation\n therapy in ,DM2, Perirectal abcess , bilateral avascular\n necrosis, s/p fall w/ femoral neck failure.\n Food allergies and intolerances: None noted\n Pertinent medications: Lansoprazole, RISS, Furosemide, 500 mL NS IV\n Bolus, Duloxetine, Azithromycin, mycophenolate 500mg, colace,\n methadone, heparin, phenylephrine, methyl prednisolon 125mg, oxycodone,\n propofol (49.5mL/hr), normal saline @ 10ml/hr.\n Labs:\n Value\n Date\n Glucose\n 164 mg/dL\n 03:26 AM\n Glucose Finger Stick\n 223\n 08:00 AM\n BUN\n 71 mg/dL\n 03:26 AM\n Creatinine\n 4.1 mg/dL\n 03:26 AM\n Sodium\n 125 mEq/L\n 03:26 AM\n Potassium\n 5.3 mEq/L\n 03:26 AM\n Chloride\n 97 mEq/L\n 03:26 AM\n TCO2\n 14 mEq/L\n 03:26 AM\n PO2 (arterial)\n 129 mm Hg\n 02:59 AM\n PO2 (venous)\n 35 mm Hg\n 03:48 AM\n PCO2 (arterial)\n 39 mm Hg\n 02:59 AM\n PCO2 (venous)\n 39 mm Hg\n 03:48 AM\n pH (arterial)\n 7.27 units\n 02:59 AM\n pH (venous)\n 7.31 units\n 03:48 AM\n pH (urine)\n 5.5 units\n 11:39 AM\n CO2 (Calc) arterial\n 19 mEq/L\n 02:59 AM\n CO2 (Calc) venous\n 21 mEq/L\n 03:48 AM\n Calcium non-ionized\n 7.2 mg/dL\n 03:26 AM\n Phosphorus\n 5.2 mg/dL\n 03:26 AM\n Magnesium\n 1.9 mg/dL\n 03:26 AM\n WBC\n 9.3 K/uL\n 03:26 AM\n Hgb\n 9.2 g/dL\n 03:26 AM\n Hematocrit\n 27.9 %\n 03:26 AM\n Current diet order / nutrition support: Regular, Low Sodium/heart\n healthy, diabetic in POE\n GI: Positive bowel sounds, abdomen soft and distended\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO, ESRD\n Estimated Nutritional Needs\n Calories: 2290-2750 (BEE x or / 25-30 cal/kg)\n Protein: 73-92 (0.8-1 g/kg)\n Fluid: Per team\n Estimation of previous intake: Inadequate\n Specifics:\n 60 year old male h/o of ESRD s/p renal transplantation, COPD,\n presents with hypertension and dyspnea. Now intubated for progressive\n respiratory distress. Consulted for tube feeding recommendations.\n Noted ?rejection of chronic transplant nephropathy. Start tube feeding\n via NGT. Goal tube feeding of Novasource renal @ 25mL/hr x 24 hrs,\n providing 1200 calories, 44g protein. Noted patient receiving\n 49.5mL/hr providing 1188 calories. Patient receiving total of 2388\n calories, 44g protein. Will continue to monitor dosage of propofol per\n patient and adjust tube feeding accordingly, noted may add beneprotein\n to tube feeding once patient is more medically stable.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Start tube feeding of Novasource renal @ 10mL/hr and increase 10mL\n q4hrs to goal 25mL/hrx 24hrs.\n 2. Check tolerance via residuals, hold tube feeding for x1 hr if\n residuals greater than 150mL.\n 3. Continue to monitor FSBG, q 6hrs.\n 4. Will adjust tube feeding according to medical\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 673827,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Green / Thick\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use, Prolonged\n exhalation, Gasping efforts\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Cannot protect airway, Underlying\n illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 673491,
"text": "Chief Complaint: Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n INVASIVE VENTILATION - START 11:02 AM\n ULTRASOUND - At 03:03 PM\n kidney\n TRANSTHORACIC ECHO - At 03:25 PM\n ARTERIAL LINE - START 06:00 PM\n Intubated (details in assessment)\n A-line placed\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 12:30 PM\n Fentanyl - 12:30 PM\n Propofol - 05:30 PM\n Heparin Sodium (Prophylaxis) - 08:23 AM\n Lansoprazole (Prevacid) - 08:23 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 86 (77 - 124) bpm\n BP: 151/84(99) {94/44(63) - 206/118(121)} mmHg\n RR: 9 (7 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n Total In:\n 2,039 mL\n 4,028 mL\n PO:\n TF:\n IVF:\n 1,919 mL\n 3,768 mL\n Blood products:\n Total out:\n 786 mL\n 435 mL\n Urine:\n 786 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,253 mL\n 3,593 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 750 (600 - 750) mL\n Vt (Spontaneous): 787 (787 - 787) mL\n PS : 15 cmH2O\n RR (Set): 10\n RR (Spontaneous): 7\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 14\n PIP: 22 cmH2O\n SpO2: 98%\n ABG: 7.27/39/129/14/-8\n Ve: 10.2 L/min\n PaO2 / FiO2: 322\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.2 g/dL\n 198 K/uL\n 164 mg/dL\n 4.1 mg/dL\n 14 mEq/L\n 5.3 mEq/L\n 71 mg/dL\n 97 mEq/L\n 125 mEq/L\n 27.9 %\n 9.3 K/uL\n [image002.jpg]\n 11:01 PM\n 03:22 AM\n 05:23 AM\n 04:15 AM\n 06:45 AM\n 02:35 PM\n 06:28 PM\n 11:05 PM\n 02:59 AM\n 03:26 AM\n WBC\n 7.4\n 10.5\n 9.3\n Hct\n 26.3\n 30.5\n 27.9\n Plt\n \n Cr\n 3.8\n 3.5\n 3.7\n 3.7\n 4.1\n 4.1\n TropT\n 0.05\n TCO2\n 20\n 18\n 20\n 19\n Glucose\n 178\n 497\n 211\n 148\n 166\n 164\n Other labs: PT / PTT / INR:13.9/35.5/1.2, CK / CKMB /\n Troponin-T:210/8/0.05, Lactic Acid:0.7 mmol/L, Ca++:7.2 mg/dL, Mg++:1.9\n mg/dL, PO4:5.2 mg/dL\n Imaging: CT--Lungs clear, no airway abnormalities, no infiltrates,\n small areas of emphysema\n U/S--worsening resistive indices on renal U/S\n Assessment and Plan\n 60 yo male with history of ESRD and s/p renal transplant now with\n intubation in the setting of progressive respiratory\n distress--tachypnea, weezing not responseive to racemic epinephrine or\n albuterol. Following intubation patient with persistent and\n significant expiratory flow limitation and CT scan not showing\n prominent abnormality. This leaves possible ongoing trigger for\n persistent bronchospasm or allergic reaction/anaphylaxis or TBM\n potentially driving findings which is one which has persisted despite\n high dose of steroids.\n What we are left with now is a need to explain possible sources as best\n as they can be defined. For Bronchomalacia\ncertainly with the forced\n exhalations he is undertaking this may promote collapse which will\n overwhelm the effects of PEEP. Will need to paralyze\nif paralytics\n used and expiratory airflow back to normal with PEEP this would argue\n for central airway. Alternatively parooxyms may be\n allergen/anaphylactic triggered (Cymbalta, insulin, heparin, cellcept,\n colace, methylpred, lansoprazole all given before most recent\n paroxysm), alternatively patient does have infecitous insult as\n possible trigger with course made worse or prolonged in the setting of\n immunosupression.\n 1)Respiratory Failure-Complex picture described above to be evaluated\n by the following interventions\n -Will send tryptase\n -Will pursue paralysis on ventilator to evaluate response to PEEP of\n obstruction\n -Will minimize medications\n -Continue PSV\n -Solumedrol 125mg tid had no meaningful improvement and will move to\n off in the setting of ongoing infection\n -Azithro completed\n -Will review Cymbalta as possible contributor\n 3)Chronic and Acute Renal Failure-\n -Tacrolimus, Mycophenilate, Solumedrol as above\nwill return to baseline\n steroid dosing or steroid dosing indicated by concern for rejection on\n renal team\ns part.\n -Will need to follow up on U/S final conclusions and need for biopsy.\n HYPERTENSION, BENIGN\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITHOUT ACUTE EXACERBATION\n ICU Care\n Nutrition: Tube Feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 12:41 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 65 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 673492,
"text": "TITLE:\n Chief Complaint: respiratory distress\n 24 Hour Events:\n -patient intubated\n -a-line placed\n -racemic epinephrine - didn't help\n -CT chest\n evaluation limited by respiratory motion; lungs are grossly\n clear with mild emphysema. ETT appropriately positioned. Intrathoracic\n trachea grossly patent, as are mainstem and proximal bronchi.\n -increase steroids --> solumedrol 125 q8\n -renal to consider Tx biopsy tomorrow.\n -decreased urine output, unable to obtain lytes\n -was hypotensive --> stopped HTN meds --> was on phenylephrine gtt for\n a little. Weaned off and bolused with NS to keep MAP > 65\n -no new micro data\n -transplant ultrasound: elevated resistive indices on Doppler, greater\n than 2 days earlier, suggesting rejection. No hydro or fluid\n collection.\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 12:30 PM\n Fentanyl - 12:30 PM\n Heparin Sodium (Prophylaxis) - 03:46 PM\n Propofol - 05:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 82 (77 - 124) bpm\n BP: 140/71(88) {94/44(63) - 206/118(121)} mmHg\n RR: 8 (7 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n Total In:\n 2,039 mL\n 3,440 mL\n PO:\n TF:\n IVF:\n 1,919 mL\n 3,280 mL\n Blood products:\n Total out:\n 786 mL\n 315 mL\n Urine:\n 786 mL\n 315 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,253 mL\n 3,125 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 750 (600 - 750) mL\n PS : 15 cmH2O\n RR (Set): 10\n RR (Spontaneous): 7\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 14\n PIP: 14 cmH2O\n SpO2: 100%\n ABG: 7.27/39/129/14/-8\n Ve: 10.4 L/min\n PaO2 / FiO2: 322\n Physical Examination\n General: sedated but opens eyes to voice, responds to simple commands,\n intubated\n Pulmonary: faint scattered expiratory wheezes, decreased from prior\n Cardiac: RRR, normal S1/S2\n Abdomen: BS present throughout, soft and non-tender abdomen\n Extremities: No edema. Has non-functional right UE fistula. A-line in\n place LUE.\n Skin: Multiple keloids\n Neurologic: sedated as above; moving all extremities; responds to voice\n Labs / Radiology\n 198 K/uL\n 9.2 g/dL\n 164 mg/dL\n 4.1 mg/dL\n 14 mEq/L\n 5.3 mEq/L\n 71 mg/dL\n 97 mEq/L\n 125 mEq/L\n 27.9 %\n 9.3 K/uL\n [image002.jpg]\n 11:01 PM\n 03:22 AM\n 05:23 AM\n 04:15 AM\n 06:45 AM\n 02:35 PM\n 06:28 PM\n 11:05 PM\n 02:59 AM\n 03:26 AM\n WBC\n 7.4\n 10.5\n 9.3\n Hct\n 26.3\n 30.5\n 27.9\n Plt\n \n Cr\n 3.8\n 3.5\n 3.7\n 3.7\n 4.1\n 4.1\n TropT\n 0.05\n TCO2\n 20\n 18\n 20\n 19\n Glucose\n 178\n 497\n 211\n 148\n 166\n 164\n Other labs: PT / PTT / INR:13.9/35.5/1.2, CK / CKMB /\n Troponin-T:210/8/0.05, Lactic Acid:0.7 mmol/L, Ca++:7.2 mg/dL, Mg++:1.9\n mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n 60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n # Dyspnea: Underlying COPD with possible exacerbation in setting of\n parainfluenza, also with ?component of CHF. Ruled out for ACS.\n Progressive respiratory distress and fatigue required intubation on\n . ABGs now consistent with adequate oxygenation and ventilation. CT\n scan did not show significant underlying pulmonary disease, and there\n was no airway obstruction.\n -Continue frequent bronchodilator therapy\n -Azithromycin x total 5 day course\n -Discontinue steroids today\n -F/u micro data\n -Trial of paralytics today to determine if central versus small airways\n obstruction\n # Volatile blood pressure: Has known difficult to control HTN, with\n hypertensive nephropathy/ESRD s/p transplant. Reports med adherence.\n be due to respiratory distress, HD steroids, narcotic withdrawal,\n renal failure, volume overload. No evidence of RAS on renal US. Had\n been on hydral 75mg q6H, clonidine 0.1mg PO TID, Amlodipine 10mg daily,\n and Nicardipine gtt; however, post-intubation his blood pressure\n dropped and he has since required fluid boluses to maintain MAP >65.\n -Continue fluid boluses to maintain MAP >65\n -Holding due to ARF\n -F/u renal recs\n # Acute renal failure: History of ESRD due to hypertensive nephropathy,\n had been on dialysis before CRT in . Reports adherence with\n immunosuppresants. FeNa yesterday 1.4. Unclear precipitant for ARF,\n ddx includes dehydration, although unlikely given hypertension;\n transplant nephropathy. Question of rejection on most recent\n ultrasound. Tacrolimus level in nl range. BK virus DNA not detected.\n -Continue steroids, cellcept, prograf\n -F/u renal transplant recs; consider biopsy\n -Cont to hold and gabapentin for now\n -Consider lasix, would be ok to give per Renal\n # Hyponatremia: Suspect SIADH secondary to pulmonary process; urine\n osms 314 suggests that he may be inappropriately concentrating urine.\n Consider fluid restriction.\n -F/u renal recs\n -Consider free water restriction\n -Q12h serum sodium checks\n # Hyperlipidemia:\n -continue statin and ezetimibe\n # DM:\n -HISS\n -diabetic diet\n # Chronic pain:\n -continue home oxycontin, methadone, and dilaudid prn per OMR\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation:\n -senna, colace\n ICU Care\n Nutrition: start tube feeds today\n Glycemic Control: RISS\n Lines:\n PICC Line 04:26 PM\n Prophylaxis:\n DVT: Heparin SC 5000 tid\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL code\n Disposition: ICU\n"
},
{
"category": "Nutrition",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 673495,
"text": "Subjective\n Patient intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 203 cm\n 91.7 kg\n 22.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 102.5 kg\n 89%\n Diagnosis: Asthma/COPD excabation\n PMH : COPD, HTN, ESRD secondary to malignant HTN, Negative Staph Right\n Hip Joint, s/p remover spacer placement,chronic pain on narcotics,\n Diverticulitis s/p right colectomy, Prostate Cancer s/p radiation\n therapy in ,DM2, Perirectal abcess , bilateral avascular\n necrosis, s/p fall w/ femoral neck failure.\n Food allergies and intolerances: None noted\n Pertinent medications: Lansoprazole, RISS, Furosemide, 500 mL NS IV\n Bolus, Duloxetine, Azithromycin, mycophenolate 500mg, colace,\n methadone, heparin, phenylephrine, methyl prednisolon 125mg, oxycodone,\n propofol (50mcg/kg/min).\n Labs:\n Value\n Date\n Glucose\n 164 mg/dL\n 03:26 AM\n Glucose Finger Stick\n 223\n 08:00 AM\n BUN\n 71 mg/dL\n 03:26 AM\n Creatinine\n 4.1 mg/dL\n 03:26 AM\n Sodium\n 125 mEq/L\n 03:26 AM\n Potassium\n 5.3 mEq/L\n 03:26 AM\n Chloride\n 97 mEq/L\n 03:26 AM\n TCO2\n 14 mEq/L\n 03:26 AM\n PO2 (arterial)\n 129 mm Hg\n 02:59 AM\n PO2 (venous)\n 35 mm Hg\n 03:48 AM\n PCO2 (arterial)\n 39 mm Hg\n 02:59 AM\n PCO2 (venous)\n 39 mm Hg\n 03:48 AM\n pH (arterial)\n 7.27 units\n 02:59 AM\n pH (venous)\n 7.31 units\n 03:48 AM\n pH (urine)\n 5.5 units\n 11:39 AM\n CO2 (Calc) arterial\n 19 mEq/L\n 02:59 AM\n CO2 (Calc) venous\n 21 mEq/L\n 03:48 AM\n Calcium non-ionized\n 7.2 mg/dL\n 03:26 AM\n Phosphorus\n 5.2 mg/dL\n 03:26 AM\n Magnesium\n 1.9 mg/dL\n 03:26 AM\n WBC\n 9.3 K/uL\n 03:26 AM\n Hgb\n 9.2 g/dL\n 03:26 AM\n Hematocrit\n 27.9 %\n 03:26 AM\n Current diet order / nutrition support: Regular, Low Sodium/heart\n healthy, diabetic in POE\n GI: Positive bowel sounds, abdomen soft and distended\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO, ESRD\n Estimated Nutritional Needs\n Calories: 2290-2750 (BEE x or / 25-30 cal/kg)\n Protein: 73-92 (0.8-1 g/kg)\n Fluid: Per team\n Estimation of previous intake: Inadequate\n Specifics:\n 60 year old male h/o of ESRD s/p renal transplantation, COPD,\n presents with hypertension and dyspnea. Now intubated for progressive\n respiratory distress. Consulted for tube feeding recommendations due to\n poor PO intake. Noted ?\n Medical Nutrition Therapy Plan - Recommend the Following\n Comments:\n"
},
{
"category": "Nutrition",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 673496,
"text": "Subjective\n Patient intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 203 cm\n 91.7 kg\n 22.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 102.5 kg\n 89%\n Diagnosis: Asthma/COPD excabation\n PMH : COPD, HTN, ESRD secondary to malignant HTN, Negative Staph Right\n Hip Joint, s/p remover spacer placement,chronic pain on narcotics,\n Diverticulitis s/p right colectomy, Prostate Cancer s/p radiation\n therapy in ,DM2, Perirectal abcess , bilateral avascular\n necrosis, s/p fall w/ femoral neck failure.\n Food allergies and intolerances: None noted\n Pertinent medications: Lansoprazole, RISS, Furosemide, 500 mL NS IV\n Bolus, Duloxetine, Azithromycin, mycophenolate 500mg, colace,\n methadone, heparin, phenylephrine, methyl prednisolon 125mg, oxycodone,\n propofol (50mcg/kg/min).\n Labs:\n Value\n Date\n Glucose\n 164 mg/dL\n 03:26 AM\n Glucose Finger Stick\n 223\n 08:00 AM\n BUN\n 71 mg/dL\n 03:26 AM\n Creatinine\n 4.1 mg/dL\n 03:26 AM\n Sodium\n 125 mEq/L\n 03:26 AM\n Potassium\n 5.3 mEq/L\n 03:26 AM\n Chloride\n 97 mEq/L\n 03:26 AM\n TCO2\n 14 mEq/L\n 03:26 AM\n PO2 (arterial)\n 129 mm Hg\n 02:59 AM\n PO2 (venous)\n 35 mm Hg\n 03:48 AM\n PCO2 (arterial)\n 39 mm Hg\n 02:59 AM\n PCO2 (venous)\n 39 mm Hg\n 03:48 AM\n pH (arterial)\n 7.27 units\n 02:59 AM\n pH (venous)\n 7.31 units\n 03:48 AM\n pH (urine)\n 5.5 units\n 11:39 AM\n CO2 (Calc) arterial\n 19 mEq/L\n 02:59 AM\n CO2 (Calc) venous\n 21 mEq/L\n 03:48 AM\n Calcium non-ionized\n 7.2 mg/dL\n 03:26 AM\n Phosphorus\n 5.2 mg/dL\n 03:26 AM\n Magnesium\n 1.9 mg/dL\n 03:26 AM\n WBC\n 9.3 K/uL\n 03:26 AM\n Hgb\n 9.2 g/dL\n 03:26 AM\n Hematocrit\n 27.9 %\n 03:26 AM\n Current diet order / nutrition support: Regular, Low Sodium/heart\n healthy, diabetic in POE\n GI: Positive bowel sounds, abdomen soft and distended\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO, ESRD\n Estimated Nutritional Needs\n Calories: 2290-2750 (BEE x or / 25-30 cal/kg)\n Protein: 73-92 (0.8-1 g/kg)\n Fluid: Per team\n Estimation of previous intake: Inadequate\n Specifics:\n 60 year old male h/o of ESRD s/p renal transplantation, COPD,\n presents with hypertension and dyspnea. Now intubated for progressive\n respiratory distress. Consulted for tube feeding recommendations.\n Noted ? rejection of chronic transplant nephropathy. Goal tube feeding\n of Novasource renal\n Medical Nutrition Therapy Plan - Recommend the Following\n Comments:\n"
},
{
"category": "Nutrition",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 673499,
"text": "Subjective\n Patient in respiratory distress.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 203 cm\n 91.7 kg\n 22.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 102.5 kg\n 89%\n Diagnosis: Asthma/COPD excabation\n PMH : COPD, HTN, ESRD secondary to malignant HTN, Negative Staph Right\n Hip Joint, s/p remover spacer placement,chronic pain on narcotics,\n Diverticulitis s/p right colectomy, Prostate Cancer s/p radiation\n therapy in ,DM2, Perirectal abcess , bilateral avascular\n necrosis, s/p fall w/ femoral neck failure.\n Food allergies and intolerances: None noted\n Pertinent medications: Lansoprazole, RISS, Furosemide, 500 mL NS IV\n Bolus, Duloxetine, Azithromycin, mycophenolate 500mg, colace,\n methadone, heparin, phenylephrine, methyl prednisolon 125mg, oxycodone,\n propofol (50mcg/kg/min).\n Labs:\n Value\n Date\n Glucose\n 164 mg/dL\n 03:26 AM\n Glucose Finger Stick\n 223\n 08:00 AM\n BUN\n 71 mg/dL\n 03:26 AM\n Creatinine\n 4.1 mg/dL\n 03:26 AM\n Sodium\n 125 mEq/L\n 03:26 AM\n Potassium\n 5.3 mEq/L\n 03:26 AM\n Chloride\n 97 mEq/L\n 03:26 AM\n TCO2\n 14 mEq/L\n 03:26 AM\n PO2 (arterial)\n 129 mm Hg\n 02:59 AM\n PO2 (venous)\n 35 mm Hg\n 03:48 AM\n PCO2 (arterial)\n 39 mm Hg\n 02:59 AM\n PCO2 (venous)\n 39 mm Hg\n 03:48 AM\n pH (arterial)\n 7.27 units\n 02:59 AM\n pH (venous)\n 7.31 units\n 03:48 AM\n pH (urine)\n 5.5 units\n 11:39 AM\n CO2 (Calc) arterial\n 19 mEq/L\n 02:59 AM\n CO2 (Calc) venous\n 21 mEq/L\n 03:48 AM\n Calcium non-ionized\n 7.2 mg/dL\n 03:26 AM\n Phosphorus\n 5.2 mg/dL\n 03:26 AM\n Magnesium\n 1.9 mg/dL\n 03:26 AM\n WBC\n 9.3 K/uL\n 03:26 AM\n Hgb\n 9.2 g/dL\n 03:26 AM\n Hematocrit\n 27.9 %\n 03:26 AM\n Current diet order / nutrition support: Regular, Low Sodium/heart\n healthy, diabetic in POE\n GI: Positive bowel sounds, abdomen soft and distended\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO, ESRD\n Estimated Nutritional Needs\n Calories: 2290-2750 (BEE x or / 25-30 cal/kg)\n Protein: 73-92 (0.8-1 g/kg)\n Fluid: Per team\n Estimation of previous intake: Inadequate\n Specifics:\n 60 year old male h/o of ESRD s/p renal transplantation, COPD,\n presents with hypertension and dyspnea. Now intubated for progressive\n respiratory distress. Consulted for tube feeding recommendations.\n Noted ?rejection of chronic transplant nephropathy. Start tube feeding\n via NGT with Goal tube feeding of Novasource renal @ 50mL/hr x 24 hrs\n will provide 2400 calories, 89g protein. and meet 100% estimated\n nutritional needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Start tube feeding of Novasource renal @ 10mL/hr and increase 10mL\n q4hrs to goal 50mL/hrx 24hrs.\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673575,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n SHIFT EVENTS\n * K-excelate given for hyperkalemia (k+ 5.7)\n * TFeeds at goal rate of 25cc/hr\n * No vent changes\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt. remains intubated and vented on PSV 40% 10/5 with sats at high 90\n RR in 10\ns. Breath sounds diminished throughout. Some wheezes noted but\n clear with nebs. Non productive cough noted. Remains comfortable on\n 80mcg/kg propofol.\n Action:\n MDIs given as ordered. Mouth care q4hr and prn, suction as needed. Pt.\n turned Q2h.\n Response:\n Pt. remains stable on current vent settings. Ongoing respiratory\n assessment.\n Plan:\n Continue to monitor resp status, wean vent as tolerated, meds ASDIR,\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat- 4.1 K-5.7. UOP about 40cc/hr\n Action:\n Renal biopsy done yesterday. All meds renally dosed. Cellcept\n administered as ordered. Prograf held d/t level. Will recheck level\n with am labs as med adjusted to daily level. K-excelate x1 dose\n given.\n Response:\n Pt. remains with increased BUN/Creat, hyperkalemia.\n Plan:\n Continue to monitor renal functions, f/u renal recs. f/u biopsy\n results. AM prograf level pending.\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 673618,
"text": "TITLE:\n 24 Hour Events:\n - Pt continued on azithromycin but high-dose steroids were stopped\n - Quantification of pulmonary function on paralytics consistent with\n small airway resistance. No evidence of central airway obstruction on\n CT chest.\n - Pt started on sodium bicarb and transplant biopsy done for renal\n dysfunction. Cymbalta stopped.\n PIP-29, Plat-12 and PEEP=5\n With RR decreased to 10 clear improvement in autopeep from 3-->0\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Propofol - 80 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:23 AM\n Cisatracurium - 04:00 PM\n Heparin Sodium (Prophylaxis) - 10:53 PM\n Fentanyl - 04:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.2\nC (99\n HR: 112 (86 - 121) bpm\n BP: 155/84(107) {100/67(78) - 155/92(111)} mmHg\n RR: 19 (9 - 25) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 80 Inch\n Total In:\n 5,093 mL\n 630 mL\n PO:\n TF:\n 53 mL\n 143 mL\n IVF:\n 4,600 mL\n 386 mL\n Blood products:\n Total out:\n 1,060 mL\n 320 mL\n Urine:\n 1,060 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,033 mL\n 310 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 650 (650 - 650) mL\n Vt (Spontaneous): 860 (666 - 870) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 21 cmH2O\n Plateau: 11 cmH2O\n SpO2: 98%\n ABG: 7.27/40/123/17/-7\n Ve: 13.3 L/min\n PaO2 / FiO2: 308\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 305 K/uL\n 9.3 g/dL\n 137 mg/dL\n 4.3 mg/dL\n 17 mEq/L\n 5.2 mEq/L\n 72 mg/dL\n 95 mEq/L\n 125 mEq/L\n 28.3 %\n 16.3 K/uL\n [image002.jpg]\n 06:45 AM\n 02:35 PM\n 06:28 PM\n 11:05 PM\n 02:59 AM\n 03:26 AM\n 06:07 PM\n 06:19 PM\n 02:40 AM\n 03:41 AM\n WBC\n 9.3\n 16.3\n Hct\n 27.9\n 28.3\n Plt\n 198\n 305\n Cr\n 4.1\n 4.1\n 4.1\n 4.3\n TCO2\n 20\n 18\n 20\n 19\n 18\n 19\n Glucose\n 166\n 164\n 166\n 137\n Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB /\n Troponin-T:210/8/0.05, Lactic Acid:0.6 mmol/L, Ca++:8.2 mg/dL, Mg++:2.2\n mg/dL, PO4:5.7 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPERTENSION, BENIGN\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITHOUT ACUTE EXACERBATION\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 06:45 PM 25 mL/hour\n Glycemic Control:\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 12:41 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 673619,
"text": "TITLE:\n 24 Hour Events:\n - Pt continued on azithromycin but high-dose steroids were stopped\n - Quantification of pulmonary function on paralytics consistent with\n small airway resistance. No evidence of central airway obstruction on\n CT chest.\n - Pt started on sodium bicarb and transplant biopsy done for renal\n dysfunction. Cymbalta stopped.\n PIP-29, Plat-12 and PEEP=5\n With RR decreased to 10 clear improvement in autopeep from 3-->0\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Propofol - 80 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:23 AM\n Cisatracurium - 04:00 PM\n Heparin Sodium (Prophylaxis) - 10:53 PM\n Fentanyl - 04:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.2\nC (99\n HR: 112 (86 - 121) bpm\n BP: 155/84(107) {100/67(78) - 155/92(111)} mmHg\n RR: 19 (9 - 25) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 80 Inch\n Total In:\n 5,093 mL\n 630 mL\n PO:\n TF:\n 53 mL\n 143 mL\n IVF:\n 4,600 mL\n 386 mL\n Blood products:\n Total out:\n 1,060 mL\n 320 mL\n Urine:\n 1,060 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,033 mL\n 310 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 650 (650 - 650) mL\n Vt (Spontaneous): 860 (666 - 870) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 21 cmH2O\n Plateau: 11 cmH2O\n SpO2: 98%\n ABG: 7.27/40/123/17/-7\n Ve: 13.3 L/min\n PaO2 / FiO2: 308\n Physical Examination\n General: sedated but opens eyes to voice, responds to simple commands,\n intubated\n Pulmonary: faint scattered expiratory wheezes, decreased from prior\n Cardiac: RRR, normal S1/S2\n Abdomen: BS present throughout, soft and non-tender abdomen\n Extremities: No edema. Has non-functional right UE fistula. A-line in\n place LUE.\n Skin: Multiple keloids\n Neurologic: sedated as above; moving all extremities; responds to voice\n Labs / Radiology\n 305 K/uL\n 9.3 g/dL\n 137 mg/dL\n 4.3 mg/dL\n 17 mEq/L\n 5.2 mEq/L\n 72 mg/dL\n 95 mEq/L\n 125 mEq/L\n 28.3 %\n 16.3 K/uL\n [image002.jpg]\n 06:45 AM\n 02:35 PM\n 06:28 PM\n 11:05 PM\n 02:59 AM\n 03:26 AM\n 06:07 PM\n 06:19 PM\n 02:40 AM\n 03:41 AM\n WBC\n 9.3\n 16.3\n Hct\n 27.9\n 28.3\n Plt\n 198\n 305\n Cr\n 4.1\n 4.1\n 4.1\n 4.3\n TCO2\n 20\n 18\n 20\n 19\n 18\n 19\n Glucose\n 166\n 164\n 166\n 137\n Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB /\n Troponin-T:210/8/0.05, Lactic Acid:0.6 mmol/L, Ca++:8.2 mg/dL, Mg++:2.2\n mg/dL, PO4:5.7 mg/dL\n Assessment and Plan\n 60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n # Dyspnea: Underlying COPD with possible exacerbation in setting of\n parainfluenza, also with ?component of CHF. Ruled out for ACS.\n Progressive respiratory distress and fatigue required intubation on\n . ABGs now consistent with adequate oxygenation and ventilation. CT\n scan did not show significant underlying pulmonary disease, and there\n was no airway obstruction.\n -Continue frequent bronchodilator therapy\n -Azithromycin for total 5 day course\n -Discontinue steroids today (d/t lack of benefit in the last three\n days)\n -F/u micro data\n -Trial of paralytics today to determine if central versus small airways\n obstruction\n # Volatile blood pressure: Has known difficult to control HTN, with\n hypertensive nephropathy/ESRD s/p transplant. Reports med adherence.\n be due to respiratory distress, HD steroids, narcotic withdrawal,\n renal failure, volume overload. No evidence of RAS on renal US. Had\n been on hydral 75mg q6H, clonidine 0.1mg PO TID, Amlodipine 10mg daily,\n and Nicardipine gtt; however, post-intubation his blood pressure\n dropped and he has since required fluid boluses to maintain MAP >65.\n -Continue fluid boluses to maintain MAP >65\n -Holding due to ARF\n -F/u renal recs\n # Acute renal failure: History of ESRD due to hypertensive nephropathy,\n had been on dialysis before CRT in . Reports adherence with\n immunosuppresants. FeNa yesterday 1.4. Unclear precipitant for ARF,\n ddx includes dehydration, although unlikely given hypertension;\n transplant nephropathy. Question of rejection on most recent\n ultrasound. Tacrolimus level in nl range. BK virus DNA not detected.\n -Continue steroids, cellcept, prograf\n -F/u renal transplant recs; consider biopsy\n -Cont to hold and gabapentin for now\n # Hyponatremia: Suspect SIADH secondary to pulmonary process; urine\n osms 314 suggests that he may be inappropriately concentrating urine.\n Consider fluid restriction.\n -F/u renal recs\n -Consider free water restriction\n -Q12h serum sodium checks\n # Hyperlipidemia:\n -continue statin and ezetimibe\n # DM:\n -HISS\n -diabetic diet\n # Chronic pain:\n -continue home oxycontin, methadone, and dilaudid prn per OMR\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation:\n -senna, colace\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 06:45 PM 25 mL/hour\n Glycemic Control:\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 12:41 AM\n Prophylaxis:\n DVT: Heparin SC 5000 tid\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-07 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 673665,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 60 M intubated 2 days ago for acute resp failure\n Rest of hx reviewed\n 24 Hour Events:\n Paralysed to check compliance - plateau to PIP wide variation\n Stopped Cymbalta\n Stopped Solumedrol yesterday\n Overnight - hypertensive, tx with prn Fentanyl.\n High residuals so likely not getting PO pain meds\n No bowel movements x 4-5 days\n Completed course of Azithro yesterday\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Propofol - 80 mcg/Kg/min\n Other ICU medications:\n Cisatracurium - 04:00 PM\n Lansoprazole (Prevacid) - 07:24 AM\n Heparin Sodium (Prophylaxis) - 07:24 AM\n Fentanyl - 11:00 AM\n Other medications:\n Other meds reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:45 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 37\nC (98.6\n HR: 109 (94 - 115) bpm\n BP: 144/72(96) {100/67(78) - 164/92(113)} mmHg\n RR: 25 (10 - 25) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 80 Inch\n Total In:\n 5,093 mL\n 977 mL\n PO:\n TF:\n 53 mL\n 158 mL\n IVF:\n 4,600 mL\n 719 mL\n Blood products:\n Total out:\n 1,060 mL\n 1,675 mL\n Urine:\n 1,060 mL\n 825 mL\n NG:\n 850 mL\n Stool:\n Drains:\n Balance:\n 4,033 mL\n -698 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 650 (650 - 650) mL\n Vt (Spontaneous): 498 (498 - 870) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 16 cmH2O\n Plateau: 11 cmH2O\n SpO2: 99%\n ABG: 7.29/37/95./17/-7\n Ve: 13.2 L/min\n PaO2 / FiO2: 240\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), Tachycardic\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Wheezes : )\n Abdominal: Soft, Non-tender, Hypoactive BS\n Extremities: Right: Absent, Left: Absent, RUE fistula\n Skin: Not assessed\n Neurologic: No(t) Attentive, Responds to: Not assessed, Movement: Not\n assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 9.3 g/dL\n 305 K/uL\n 137 mg/dL\n 4.3 mg/dL\n 17 mEq/L\n 5.2 mEq/L\n 72 mg/dL\n 95 mEq/L\n 125 mEq/L\n 28.3 %\n 16.3 K/uL\n [image002.jpg]\n 02:35 PM\n 06:28 PM\n 11:05 PM\n 02:59 AM\n 03:26 AM\n 06:07 PM\n 06:19 PM\n 02:40 AM\n 03:41 AM\n 10:08 AM\n WBC\n 9.3\n 16.3\n Hct\n 27.9\n 28.3\n Plt\n 198\n 305\n Cr\n 4.1\n 4.1\n 4.3\n TCO2\n 20\n 18\n 20\n 19\n 18\n 19\n 19\n Glucose\n 164\n 166\n 137\n Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB /\n Troponin-T:210/8/0.05, Differential-Neuts:87.4 %, Lymph:3.2 %, Mono:8.7\n %, Eos:0.5 %, Lactic Acid:0.6 mmol/L, Ca++:8.2 mg/dL, Mg++:2.2 mg/dL,\n PO4:5.7 mg/dL\n Imaging: CXR - ETT and NG in good position. No new infiltrates\n Microbiology: No sputum, other cultures NGTD\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPERTENSION, BENIGN\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n 60 yo male with history of ESRD and s/p renal transplant now with\n intubation in the setting of progressive respiratory\n distress--tachypnea, weezing not responseive to racemic epinephrine or\n albuterol. Following intubation patient with persistent and\n significant expiratory flow limitation and CT scan not showing\n prominent abnormality. This leaves possible ongoing trigger for\n persistent bronchospasm or allergic reaction/anaphylaxis or TBM\n potentially driving findings which is one which has persisted despite\n high dose of steroids.\n What we are left with now is a need to explain possible sources as best\n as they can be defined. For Bronchomalacia\ncertainly with the forced\n exhalations he is undertaking this may promote collapse which will\n overwhelm the effects of PEEP. Will need to paralyze\nif paralytics\n used and expiratory airflow back to normal with PEEP this would argue\n for central airway. Alternatively parooxyms may be\n allergen/anaphylactic triggered (Cymbalta, insulin, heparin, cellcept,\n colace, methylpred, lansoprazole all given before most recent\n paroxysm), alternatively patient does have infectious insult as\n possible trigger with course made worse or prolonged in the setting of\n immunosupression.\n 1) Acute Respiratory Failure\n -Will send tryptase\n -minimize medications\n -Continue PSV\n -Off high dose steroids\n -Azithro completed, off Cymbalta empirically to eliminate possible\n causes though unlikely\n 2) Chronic and Acute Renal Failure-\n -Tacrolimus, Mycophenilate, usual prednisone as above\nwill return to\n baseline steroid dosing or steroid dosing indicated by concern for\n rejection on renal team\ns part.\n -Will need to follow up on renal biopsy.\n 3) DM\n 4) Nutrition\n assume no PO meds being absorbed. Will change PO to IV\n meds.\n - gastroparesis by study in , likely related to DM.\n - trial of Reglan, if not successful, will insert post-pyloric dobhoff.\n Consider TPN if necessary.\n 5) Constipation\n - bowel regimen\n - check KUB\n ICU Care\n Nutrition: high residuals\n Glycemic Control: RISS\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 12:41 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 673737,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments: ^sputum thick tan, sputum spec sent\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Vigorous inspiratory efforts\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments: pt. remains intubated on IPS overnoc. RSBI this am 48. Pt.\n has ^ sputum production , thick tan. MDI\ns as ordered. Maintain current\n vent settings.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673886,
"text": "60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n Of note, attempt to wean sedation for possible extubation\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. received intubated on pressure support 40%/. Labored breathing\n noted. Suctioned for scant amounts of thick green sputum. Culture + for\n gram negative rods. Sedated on propofol gtt but unable to increase\n sedation as pt. was hypotensive. Pt. unresponsive. No cough/gag reflex\n noted. No withdrawal to noxious stimuli, however, resp rate 30\ns to\n 40\ns. Nasal flaring noted with inhalation.\n Action:\n Multiple blood gases drawn throughout shift. (see metavision) Pt.\n increasingly acidotic and hypoxic. Vent changed to AC 60%/500/20/5.\n Started on IV vanco and zosyn for probable VAP pneumonia. Attempts\n made to increase sedation unsuccessful hypotension. All sedation\n off at 0400 d/t hypotension. Pt. turned Q2h. Mouth care Q4h.\n Response:\n Pt. continues to appear to have labored breathing. Awaiting most recent\n blood gas result.\n Plan:\n IV antibiotics to be administered as ordered. Aggressive pulmonary\n toilet. Titrate vent to maintain optimal resp. support. If blood\n pressure improves with pressors, re-administer sedation to maintain pt.\n comfort.\n Hypotension (not Shock)\n Assessment:\n SBP as low as 70\ns at start of shift. Fluctuated from 70\ns to low 100\n with MAPS 50\ns to 70\ns. UO 30-40cc/hr.\n Action:\n Fentanyl and propofol drip off. Total of 5L NS boluses given at start\n of shift. BP unresponsive to fluid. Phenylephrine started and titrated\n to maintain MAPS >65. Vasopressin also hung at 2.4U/hr.\n Response:\n Maps >65 at this time on phenylephrine 4mcg/kg and vasopressin 2.4U/hr.\n Plan:\n Wean pressor to maintain MAP >65. Continue to monitor hemodynamic\n status and UO closely. Awaiting am lab results.\n Constipation (Obstipation, FOS)\n Assessment:\n Known decreased gastric motility. Abd soft distended, positive for BS\n and flatus, TFeeds restarted at at 10cc/hr. Residuals at 2200\n >360cc.\n Action:\n TFeeds off. Continue Reglan, lactulose and aggressive bowel regimen\n Response:\n Pending\n Plan:\n Continue to monitor patient status, aggressive bowel regiment until\n clears, may attempt to restart TF today if no residuals.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n s/p renal transplant, UOP decreased to 30-40cc/hr\n Action:\n Fluid boluses as noted above. Assessed UO Q1h. Steroids, cellcept, and\n prograf, administered as ordered.\n Response:\n Continue to follow GU status.\n Plan:\n Continue to monitor patient renal status, f/u renal recs. Fluid\n boluses as ordered. Replete sodium bicarb as needed.\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 673900,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments: small amount thick yellow\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Gasping efforts\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n Comments: Pt changed to A/C mode due to ^RR ^WOB on IPS. ABG worsening\n metabolic acidosis. Fio2^100%. Maintain current vent settings.\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 674002,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 05:27 AM\n TRIPLE INTRODUCER - START 05:29 AM\n -Renal: am tacro level\n -SBT: Numbers were good per respiratory, but patient appeared to have\n increase work of breathing. Could not wean sedation enough to\n extubate, patient became agitated and had increased work of breathing.\n -Labile BP Sbp: 76 - 190s. Hypotension responded to fluid boluses,\n received a lot of fluid as suspecting sepsis.\n -Started on Vanc/Zosyn for presumed VAP\n -TF started then held for high residuals a few hours later\n -Changed from PS to CMV/Assist.\n -Hypotensive requiring initiation of pressors\n -Central line placed\n -Stress-dose steroids started\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:59 PM\n Piperacillin/Tazobactam (Zosyn) - 12:48 AM\n Metronidazole - 04:03 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Phenylephrine - 3.8 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:33 AM\n Fentanyl - 07:33 AM\n Hydralazine - 10:36 AM\n Heparin Sodium (Prophylaxis) - 11:49 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 109 (103 - 121) bpm\n BP: 106/73(85) {89/58(71) - 196/100(130)} mmHg\n RR: 33 (18 - 33) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 80 Inch\n CVP: 9 (9 - 16)mmHg\n CO/CI (Fick): (14.8 L/min) / (6.4 L/min/m2)\n Mixed Venous O2% Sat: 81 - 81\n Total In:\n 6,245 mL\n 2,888 mL\n PO:\n TF:\n 39 mL\n IVF:\n 5,865 mL\n 2,888 mL\n Blood products:\n Total out:\n 1,690 mL\n 1,175 mL\n Urine:\n 1,580 mL\n 175 mL\n NG:\n 110 mL\n 1,000 mL\n Stool:\n Drains:\n Balance:\n 4,555 mL\n 1,713 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 490 (482 - 655) mL\n PS : 15 cmH2O\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 28 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SpO2: 95%\n ABG: 7.16/49/205/17/-11\n Ve: 18.9 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General: intubated, sedated\n Pulmonary: course breath sounds, occasional wheezes, +rhonchi\n Cardiac: tachycardic, regular, normal S1/S2\n Abdomen: Soft, hypoactive BS\n Extremities: No edema. Has non-functional right UE fistula. A-line in\n place LUE. Left midline.\n Skin: Multiple keloids\n Neurologic: sedated as above, not arousable to voice\n Labs / Radiology\n 369 K/uL\n 10.4 g/dL\n 70 mg/dL\n 3.6 mg/dL\n 17 mEq/L\n 5.1 mEq/L\n 71 mg/dL\n 102 mEq/L\n 134 mEq/L\n 32.5 %\n 28.2 K/uL\n [image002.jpg]\n 04:18 AM\n 04:26 PM\n 08:08 PM\n 10:13 PM\n 12:02 AM\n 02:20 AM\n 02:24 AM\n 03:19 AM\n 04:05 AM\n 05:43 AM\n WBC\n 23.2\n 28.2\n Hct\n 30.3\n 32.5\n Plt\n 364\n 369\n Cr\n 3.8\n 3.6\n TCO2\n 21\n 20\n 21\n 20\n 21\n 19\n 20\n 18\n Glucose\n 150\n 70\n Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB /\n Troponin-T:210/8/0.05, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0\n %, Mono:8.0 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:9.2 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n CONSTIPATION (OBSTIPATION, FOS)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPERTENSION, BENIGN\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITHOUT ACUTE EXACERBATION\n 60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n # Hypotension: After being extremely hypertensive for several days, he\n became hypotensive overnight, not responsive to IVF and requiring the\n initiation of presors. Most likely secondary to sepsis given low CVP,\n CXR with infiltrate, and GNR in sputum. Also there is some concern\n for adrenal insufficiency, although he is currently on stress-dose\n steroids. CVP is low, so cardiogenic shock is less likely. Volume\n depletion may also be at play. Given abdominal distention there is\n also some concern for abdominal compartement syndrome.\n - continue pressure support with vasopressin, phenylephrine, levophed\n - attempt to wean levophed as tolerated to maintain MAP >60\n - f/u echo for potential cardiac cause\n - continue stress-dose steroids\n - continue vanc/zosyn for likely pulmonary source of infection\n - repeat stool for c diff\n - check bladder pressure\n .\n # Respiratory failure: Likely secondary to underlying COPD with\n reactive airway disease possibly worsened by parainfluenza causing\n small airway spasm. CT did not show any significant parenchymal\n disease. On exam he is not moving air well. ABGs show respiratory\n acidosis with adequate oxygenation\n - wean FiO2 to 60%\n - decrease RR and increase TV to try to improve ventilation\n - continue MDI as needed\n -\n # Acute renal failure: History of ESRD hypertensive nephropathy,\n now s/p CRT. Creatinine improving now, but low UOP with metabolic\n acidosis. Had bx, results pending but likely not rejection. Most\n likely cause of current renal failure is pre-renal secondary to\n hypotension.\n - f/u renal recs\n - await bx results\n - bicarbonate in fluids\n - minimize NS (will change meds to D5 solution as much as possible)\n - discuss with renal if CVVH may be indicated for volume removal.\n - continue steroids, cellcept, prograf for immunosuppresion\n # Abdominal distention: High residuals from tube feeds. H/o poor\n motility on prior gastric emptying study, may be DM. Likely also\n exacerbated by narcotics and has not had bowel mvt in days.\n - continue Reglan\n - check bladder pressure\n - may need placement of post-pyloric dobhoff for nutrition if not\n improving\n - repeat KUB\n # Abnormal TFTs: not consistent with sick euthyroid, low TSH indicates\n possible central process\n - discuss with endocrine\n - consider thyroid hormone replacement\n # Hyperlipidemia:\n -continue statin and ezetimibe\n # DM:\n -HISS\n -diabetic diet\n # Chronic pain:\n -Fentanyl gtt\n -holding po pain meds for now due to poor gastric motility (home\n oxycontin, methadone, and dilaudid prn)\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation:\n -senna, colace, bisacodyl pr, miralax, raglan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 04:50 AM\n Multi Lumen - 05:27 AM\n Triple Introducer - 05:29 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 674004,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 05:27 AM\n TRIPLE INTRODUCER - START 05:29 AM\n -Renal: am tacro level\n -SBT: Numbers were good per respiratory, but patient appeared to have\n increase work of breathing. Could not wean sedation enough to\n extubate, patient became agitated and had increased work of breathing.\n -Labile BP Sbp: 76 - 190s. Hypotension responded to fluid boluses,\n received a lot of fluid as suspecting sepsis.\n -Started on Vanc/Zosyn for presumed VAP\n -TF started then held for high residuals a few hours later\n -Changed from PS to CMV/Assist.\n -Hypotensive requiring initiation of pressors\n -Central line placed\n -Stress-dose steroids started\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:59 PM\n Piperacillin/Tazobactam (Zosyn) - 12:48 AM\n Metronidazole - 04:03 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Phenylephrine - 3.8 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:33 AM\n Fentanyl - 07:33 AM\n Hydralazine - 10:36 AM\n Heparin Sodium (Prophylaxis) - 11:49 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 109 (103 - 121) bpm\n BP: 106/73(85) {89/58(71) - 196/100(130)} mmHg\n RR: 33 (18 - 33) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 80 Inch\n CVP: 9 (9 - 16)mmHg\n CO/CI (Fick): (14.8 L/min) / (6.4 L/min/m2)\n Mixed Venous O2% Sat: 81 - 81\n Total In:\n 6,245 mL\n 2,888 mL\n PO:\n TF:\n 39 mL\n IVF:\n 5,865 mL\n 2,888 mL\n Blood products:\n Total out:\n 1,690 mL\n 1,175 mL\n Urine:\n 1,580 mL\n 175 mL\n NG:\n 110 mL\n 1,000 mL\n Stool:\n Drains:\n Balance:\n 4,555 mL\n 1,713 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 490 (482 - 655) mL\n PS : 15 cmH2O\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 28 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SpO2: 95%\n ABG: 7.16/49/205/17/-11\n Ve: 18.9 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General: intubated, sedated\n Pulmonary: poor air movement bilaterally, no wheezes\n Neck: R IJ in place\n Cardiac: tachycardic, regular, normal S1/S2\n Abdomen: Soft, hypoactive BS\n Extremities: No edema. Has non-functional right UE fistula. A-line in\n place LUE. Left midline.\n Skin: Multiple keloids\n Neurologic: sedated as above, not arousable to voice\n Labs / Radiology\n 369 K/uL\n 10.4 g/dL\n 70 mg/dL\n 3.6 mg/dL\n 17 mEq/L\n 5.1 mEq/L\n 71 mg/dL\n 102 mEq/L\n 134 mEq/L\n 32.5 %\n 28.2 K/uL\n [image002.jpg]\n 04:18 AM\n 04:26 PM\n 08:08 PM\n 10:13 PM\n 12:02 AM\n 02:20 AM\n 02:24 AM\n 03:19 AM\n 04:05 AM\n 05:43 AM\n WBC\n 23.2\n 28.2\n Hct\n 30.3\n 32.5\n Plt\n 364\n 369\n Cr\n 3.8\n 3.6\n TCO2\n 21\n 20\n 21\n 20\n 21\n 19\n 20\n 18\n Glucose\n 150\n 70\n Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB /\n Troponin-T:210/8/0.05, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0\n %, Mono:8.0 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:9.2 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n CONSTIPATION (OBSTIPATION, FOS)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPERTENSION, BENIGN\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITHOUT ACUTE EXACERBATION\n 60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n # Hypotension: After being extremely hypertensive for several days, he\n became hypotensive overnight, not responsive to IVF and requiring the\n initiation of presors. Most likely secondary to sepsis given low CVP,\n CXR with infiltrate, and GNR in sputum. Also there is some concern\n for adrenal insufficiency, although he is currently on stress-dose\n steroids. CVP is low, so cardiogenic shock is less likely. Volume\n depletion may also be at play. Given abdominal distention there is\n also some concern for abdominal compartement syndrome.\n - continue pressure support with vasopressin, phenylephrine, levophed\n - attempt to wean levophed as tolerated to maintain MAP >60\n - f/u echo for potential cardiac cause\n - continue stress-dose steroids\n - continue vanc/zosyn for likely pulmonary source of infection\n - repeat stool for c diff\n - check bladder pressure\n .\n # Respiratory failure: Likely secondary to underlying COPD with\n reactive airway disease possibly worsened by parainfluenza causing\n small airway spasm. CT did not show any significant parenchymal\n disease. On exam he is not moving air well. ABGs show respiratory\n acidosis with adequate oxygenation\n - wean FiO2 to 60%\n - decrease RR and increase TV to try to improve ventilation\n - continue MDI as needed\n -\n # Acute renal failure: History of ESRD hypertensive nephropathy,\n now s/p CRT. Creatinine improving now, but low UOP with metabolic\n acidosis. Had bx, results pending but likely not rejection. Most\n likely cause of current renal failure is pre-renal secondary to\n hypotension.\n - f/u renal recs\n - await bx results\n - bicarbonate in fluids\n - minimize NS (will change meds to D5 solution as much as possible)\n - discuss with renal if CVVH may be indicated for volume removal.\n - continue steroids, cellcept, prograf for immunosuppresion\n # Abdominal distention: High residuals from tube feeds. H/o poor\n motility on prior gastric emptying study, may be DM. Likely also\n exacerbated by narcotics and has not had bowel mvt in days.\n - continue Reglan\n - check bladder pressure\n - may need placement of post-pyloric dobhoff for nutrition if not\n improving\n - repeat KUB\n # Abnormal TFTs: not consistent with sick euthyroid, low TSH indicates\n possible central process\n - discuss with endocrine\n - consider thyroid hormone replacement\n # Hyperlipidemia:\n -continue statin and ezetimibe\n # DM:\n -HISS\n -diabetic diet\n # Chronic pain:\n -Fentanyl gtt\n -holding po pain meds for now due to poor gastric motility (home\n oxycontin, methadone, and dilaudid prn)\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation:\n -senna, colace, bisacodyl pr, miralax, raglan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 04:50 AM\n Multi Lumen - 05:27 AM\n Triple Introducer - 05:29 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 672945,
"text": "60 y/o M w/ an extensive PMH including Total R hip replacement, Renal\n transplant\n01, who presented to ED c/o worsening SOB x 2 days. In the\n ED his vitals were sign\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673240,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Hypertension, benign\n Assessment:\n Remains hypertensive w/B/P often in 170s.\n Action:\n Weaned off of NTG, remains on Nicardipine drip. Clonidine added to b/p\n regime and will increase amlodipine dose as ordered, hydralazine dose\n also increased. Urine output 300cc @ 0800, has not voided since, 250cc\n NS fluid bolus @ 1840.\n Response:\n Remains hypertensive. Poor urine output to match his poor PO intake (no\n appetite).\n Plan:\n Goals are to keep SBP 140-160 as discussed w/ICU team @ present until\n renal sets new b/p goals and to wean off nicardipine gtt if able.\n Monitor urine output.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt w/I/E wheezes t/o and fair aeration. Intermittant dyspnea at rest\n w/RR 30s and accessory muscle usage. Pt usually noncompliant\n w/instruction to keep albuterol continuous nebs on and insists on\n utilizing albuterol MDI despite explanations. Pt also refusing meds\n such as insulin and solumedrol this morning and also refused cardiac\n echo.\n Action:\n Pt intermittantly refusing medical treatment.\n Response:\n Remains in moderate respiratory distress.\n Plan:\n Cont w/NCP to encourage medication and treatment compliance. Cont to\n monitor respiratory distress.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673503,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received patient intubated and vented on PSV 40% 15/5 w/sats at high\n 90\ns RR in 10\ns. B/L LS exp wheezes. Intermittent non productive cough.\n Around 10 am appears in resp distress RR\ns. LS w/worsening\n wheezes. Sats remained in 90\ns. Patient appears fighting the vent,\n trying to get the ETT out.\n Action:\n Sedation increased to 90mcg/kg/min. MDI given.\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 673505,
"text": "TITLE:\n Chief Complaint: respiratory distress\n 24 Hour Events:\n -patient intubated\n -a-line placed\n -racemic epinephrine - didn't help\n -CT chest\n evaluation limited by respiratory motion; lungs are grossly\n clear with mild emphysema. ETT appropriately positioned. Intrathoracic\n trachea grossly patent, as are mainstem and proximal bronchi.\n -increase steroids --> solumedrol 125 q8\n -renal to consider Tx biopsy tomorrow.\n -decreased urine output, unable to obtain lytes\n -was hypotensive --> stopped HTN meds --> was on phenylephrine gtt for\n a little. Weaned off and bolused with NS to keep MAP > 65\n -no new micro data\n -transplant ultrasound: elevated resistive indices on Doppler, greater\n than 2 days earlier, suggesting rejection. No hydro or fluid\n collection.\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 12:30 PM\n Fentanyl - 12:30 PM\n Heparin Sodium (Prophylaxis) - 03:46 PM\n Propofol - 05:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 82 (77 - 124) bpm\n BP: 140/71(88) {94/44(63) - 206/118(121)} mmHg\n RR: 8 (7 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n Total In:\n 2,039 mL\n 3,440 mL\n PO:\n TF:\n IVF:\n 1,919 mL\n 3,280 mL\n Blood products:\n Total out:\n 786 mL\n 315 mL\n Urine:\n 786 mL\n 315 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,253 mL\n 3,125 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 750 (600 - 750) mL\n PS : 15 cmH2O\n RR (Set): 10\n RR (Spontaneous): 7\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 14\n PIP: 14 cmH2O\n SpO2: 100%\n ABG: 7.27/39/129/14/-8\n Ve: 10.4 L/min\n PaO2 / FiO2: 322\n Physical Examination\n General: sedated but opens eyes to voice, responds to simple commands,\n intubated\n Pulmonary: faint scattered expiratory wheezes, decreased from prior\n Cardiac: RRR, normal S1/S2\n Abdomen: BS present throughout, soft and non-tender abdomen\n Extremities: No edema. Has non-functional right UE fistula. A-line in\n place LUE.\n Skin: Multiple keloids\n Neurologic: sedated as above; moving all extremities; responds to voice\n Labs / Radiology\n 198 K/uL\n 9.2 g/dL\n 164 mg/dL\n 4.1 mg/dL\n 14 mEq/L\n 5.3 mEq/L\n 71 mg/dL\n 97 mEq/L\n 125 mEq/L\n 27.9 %\n 9.3 K/uL\n [image002.jpg]\n 11:01 PM\n 03:22 AM\n 05:23 AM\n 04:15 AM\n 06:45 AM\n 02:35 PM\n 06:28 PM\n 11:05 PM\n 02:59 AM\n 03:26 AM\n WBC\n 7.4\n 10.5\n 9.3\n Hct\n 26.3\n 30.5\n 27.9\n Plt\n \n Cr\n 3.8\n 3.5\n 3.7\n 3.7\n 4.1\n 4.1\n TropT\n 0.05\n TCO2\n 20\n 18\n 20\n 19\n Glucose\n 178\n 497\n 211\n 148\n 166\n 164\n Other labs: PT / PTT / INR:13.9/35.5/1.2, CK / CKMB /\n Troponin-T:210/8/0.05, Lactic Acid:0.7 mmol/L, Ca++:7.2 mg/dL, Mg++:1.9\n mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n 60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n # Dyspnea: Underlying COPD with possible exacerbation in setting of\n parainfluenza, also with ?component of CHF. Ruled out for ACS.\n Progressive respiratory distress and fatigue required intubation on\n . ABGs now consistent with adequate oxygenation and ventilation. CT\n scan did not show significant underlying pulmonary disease, and there\n was no airway obstruction.\n -Continue frequent bronchodilator therapy\n -Azithromycin for total 5 day course\n -Discontinue steroids today (d/t lack of benefit in the last three\n days)\n -F/u micro data\n -Trial of paralytics today to determine if central versus small airways\n obstruction\n # Volatile blood pressure: Has known difficult to control HTN, with\n hypertensive nephropathy/ESRD s/p transplant. Reports med adherence.\n be due to respiratory distress, HD steroids, narcotic withdrawal,\n renal failure, volume overload. No evidence of RAS on renal US. Had\n been on hydral 75mg q6H, clonidine 0.1mg PO TID, Amlodipine 10mg daily,\n and Nicardipine gtt; however, post-intubation his blood pressure\n dropped and he has since required fluid boluses to maintain MAP >65.\n -Continue fluid boluses to maintain MAP >65\n -Holding due to ARF\n -F/u renal recs\n # Acute renal failure: History of ESRD due to hypertensive nephropathy,\n had been on dialysis before CRT in . Reports adherence with\n immunosuppresants. FeNa yesterday 1.4. Unclear precipitant for ARF,\n ddx includes dehydration, although unlikely given hypertension;\n transplant nephropathy. Question of rejection on most recent\n ultrasound. Tacrolimus level in nl range. BK virus DNA not detected.\n -Continue steroids, cellcept, prograf\n -F/u renal transplant recs; consider biopsy\n -Cont to hold and gabapentin for now\n # Hyponatremia: Suspect SIADH secondary to pulmonary process; urine\n osms 314 suggests that he may be inappropriately concentrating urine.\n Consider fluid restriction.\n -F/u renal recs\n -Consider free water restriction\n -Q12h serum sodium checks\n # Hyperlipidemia:\n -continue statin and ezetimibe\n # DM:\n -HISS\n -diabetic diet\n # Chronic pain:\n -continue home oxycontin, methadone, and dilaudid prn per OMR\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation:\n -senna, colace\n ICU Care\n Nutrition: start tube feeds today\n Glycemic Control: RISS\n Lines:\n PICC Line 04:26 PM\n Prophylaxis:\n DVT: Heparin SC 5000 tid\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL code\n Disposition: ICU\n"
},
{
"category": "Nutrition",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 673510,
"text": "Subjective\n Patient in respiratory distress.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 203 cm\n 91.7 kg\n 22.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 102.5 kg\n 89%\n Diagnosis: Asthma/COPD excabation\n PMH : COPD, HTN, ESRD secondary to malignant HTN, Negative Staph Right\n Hip Joint, s/p remover spacer placement,chronic pain on narcotics,\n Diverticulitis s/p right colectomy, Prostate Cancer s/p radiation\n therapy in ,DM2, Perirectal abcess , bilateral avascular\n necrosis, s/p fall w/ femoral neck failure.\n Food allergies and intolerances: None noted\n Pertinent medications: Lansoprazole, RISS, Furosemide, 500 mL NS IV\n Bolus, Duloxetine, Azithromycin, mycophenolate 500mg, colace,\n methadone, heparin, phenylephrine, methyl prednisolon 125mg, oxycodone,\n propofol (90mcg/kg/min), normal saline @ 10ml/hr.\n Labs:\n Value\n Date\n Glucose\n 164 mg/dL\n 03:26 AM\n Glucose Finger Stick\n 223\n 08:00 AM\n BUN\n 71 mg/dL\n 03:26 AM\n Creatinine\n 4.1 mg/dL\n 03:26 AM\n Sodium\n 125 mEq/L\n 03:26 AM\n Potassium\n 5.3 mEq/L\n 03:26 AM\n Chloride\n 97 mEq/L\n 03:26 AM\n TCO2\n 14 mEq/L\n 03:26 AM\n PO2 (arterial)\n 129 mm Hg\n 02:59 AM\n PO2 (venous)\n 35 mm Hg\n 03:48 AM\n PCO2 (arterial)\n 39 mm Hg\n 02:59 AM\n PCO2 (venous)\n 39 mm Hg\n 03:48 AM\n pH (arterial)\n 7.27 units\n 02:59 AM\n pH (venous)\n 7.31 units\n 03:48 AM\n pH (urine)\n 5.5 units\n 11:39 AM\n CO2 (Calc) arterial\n 19 mEq/L\n 02:59 AM\n CO2 (Calc) venous\n 21 mEq/L\n 03:48 AM\n Calcium non-ionized\n 7.2 mg/dL\n 03:26 AM\n Phosphorus\n 5.2 mg/dL\n 03:26 AM\n Magnesium\n 1.9 mg/dL\n 03:26 AM\n WBC\n 9.3 K/uL\n 03:26 AM\n Hgb\n 9.2 g/dL\n 03:26 AM\n Hematocrit\n 27.9 %\n 03:26 AM\n Current diet order / nutrition support: Regular, Low Sodium/heart\n healthy, diabetic in POE\n GI: Positive bowel sounds, abdomen soft and distended\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO, ESRD\n Estimated Nutritional Needs\n Calories: 2290-2750 (BEE x or / 25-30 cal/kg)\n Protein: 73-92 (0.8-1 g/kg)\n Fluid: Per team\n Estimation of previous intake: Inadequate\n Specifics:\n 60 year old male h/o of ESRD s/p renal transplantation, COPD,\n presents with hypertension and dyspnea. Now intubated for progressive\n respiratory distress. Consulted for tube feeding recommendations.\n Noted ?rejection of chronic transplant nephropathy. Start tube feeding\n via NGT with Goal tube feeding of Novasource renal @ 50mL/hr x 24 hrs\n will provide 2400 calories, 89g protein. and meet 100% estimated\n nutritional needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Start tube feeding of Novasource renal @ 10mL/hr and increase 10mL\n q4hrs to goal 50mL/hrx 24hrs.\n Comments:\n"
},
{
"category": "Nutrition",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 673512,
"text": "Subjective\n Patient in respiratory distress.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 203 cm\n 91.7 kg\n 22.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 102.5 kg\n 89%\n Diagnosis: Asthma/COPD excabation\n PMH : COPD, HTN, ESRD secondary to malignant HTN, Negative Staph Right\n Hip Joint, s/p remover spacer placement,chronic pain on narcotics,\n Diverticulitis s/p right colectomy, Prostate Cancer s/p radiation\n therapy in ,DM2, Perirectal abcess , bilateral avascular\n necrosis, s/p fall w/ femoral neck failure.\n Food allergies and intolerances: None noted\n Pertinent medications: Lansoprazole, RISS, Furosemide, 500 mL NS IV\n Bolus, Duloxetine, Azithromycin, mycophenolate 500mg, colace,\n methadone, heparin, phenylephrine, methyl prednisolon 125mg, oxycodone,\n propofol (90mcg/kg/min), normal saline @ 10ml/hr.\n Labs:\n Value\n Date\n Glucose\n 164 mg/dL\n 03:26 AM\n Glucose Finger Stick\n 223\n 08:00 AM\n BUN\n 71 mg/dL\n 03:26 AM\n Creatinine\n 4.1 mg/dL\n 03:26 AM\n Sodium\n 125 mEq/L\n 03:26 AM\n Potassium\n 5.3 mEq/L\n 03:26 AM\n Chloride\n 97 mEq/L\n 03:26 AM\n TCO2\n 14 mEq/L\n 03:26 AM\n PO2 (arterial)\n 129 mm Hg\n 02:59 AM\n PO2 (venous)\n 35 mm Hg\n 03:48 AM\n PCO2 (arterial)\n 39 mm Hg\n 02:59 AM\n PCO2 (venous)\n 39 mm Hg\n 03:48 AM\n pH (arterial)\n 7.27 units\n 02:59 AM\n pH (venous)\n 7.31 units\n 03:48 AM\n pH (urine)\n 5.5 units\n 11:39 AM\n CO2 (Calc) arterial\n 19 mEq/L\n 02:59 AM\n CO2 (Calc) venous\n 21 mEq/L\n 03:48 AM\n Calcium non-ionized\n 7.2 mg/dL\n 03:26 AM\n Phosphorus\n 5.2 mg/dL\n 03:26 AM\n Magnesium\n 1.9 mg/dL\n 03:26 AM\n WBC\n 9.3 K/uL\n 03:26 AM\n Hgb\n 9.2 g/dL\n 03:26 AM\n Hematocrit\n 27.9 %\n 03:26 AM\n Current diet order / nutrition support: Regular, Low Sodium/heart\n healthy, diabetic in POE\n GI: Positive bowel sounds, abdomen soft and distended\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO, ESRD\n Estimated Nutritional Needs\n Calories: 2290-2750 (BEE x or / 25-30 cal/kg)\n Protein: 73-92 (0.8-1 g/kg)\n Fluid: Per team\n Estimation of previous intake: Inadequate\n Specifics:\n 60 year old male h/o of ESRD s/p renal transplantation, COPD,\n presents with hypertension and dyspnea. Now intubated for progressive\n respiratory distress. Consulted for tube feeding recommendations.\n Noted ?rejection of chronic transplant nephropathy. Start tube feeding\n via NGT. Goal tube feeding of Novasource renal @ 50mL/hr x 24 hrs will\n provide 2400 calories, 89g protein and meet 100% estimated nutritional\n needs. Noted\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Start tube feeding of Novasource renal @ 10mL/hr and increase 10mL\n q4hrs to goal 50mL/hrx 24hrs.\n 2.\n"
},
{
"category": "Nutrition",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 673513,
"text": "Subjective\n Patient in respiratory distress.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 203 cm\n 91.7 kg\n 22.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 102.5 kg\n 89%\n Diagnosis: Asthma/COPD excabation\n PMH : COPD, HTN, ESRD secondary to malignant HTN, Negative Staph Right\n Hip Joint, s/p remover spacer placement,chronic pain on narcotics,\n Diverticulitis s/p right colectomy, Prostate Cancer s/p radiation\n therapy in ,DM2, Perirectal abcess , bilateral avascular\n necrosis, s/p fall w/ femoral neck failure.\n Food allergies and intolerances: None noted\n Pertinent medications: Lansoprazole, RISS, Furosemide, 500 mL NS IV\n Bolus, Duloxetine, Azithromycin, mycophenolate 500mg, colace,\n methadone, heparin, phenylephrine, methyl prednisolon 125mg, oxycodone,\n propofol (90mcg/kg/min), normal saline @ 10ml/hr.\n Labs:\n Value\n Date\n Glucose\n 164 mg/dL\n 03:26 AM\n Glucose Finger Stick\n 223\n 08:00 AM\n BUN\n 71 mg/dL\n 03:26 AM\n Creatinine\n 4.1 mg/dL\n 03:26 AM\n Sodium\n 125 mEq/L\n 03:26 AM\n Potassium\n 5.3 mEq/L\n 03:26 AM\n Chloride\n 97 mEq/L\n 03:26 AM\n TCO2\n 14 mEq/L\n 03:26 AM\n PO2 (arterial)\n 129 mm Hg\n 02:59 AM\n PO2 (venous)\n 35 mm Hg\n 03:48 AM\n PCO2 (arterial)\n 39 mm Hg\n 02:59 AM\n PCO2 (venous)\n 39 mm Hg\n 03:48 AM\n pH (arterial)\n 7.27 units\n 02:59 AM\n pH (venous)\n 7.31 units\n 03:48 AM\n pH (urine)\n 5.5 units\n 11:39 AM\n CO2 (Calc) arterial\n 19 mEq/L\n 02:59 AM\n CO2 (Calc) venous\n 21 mEq/L\n 03:48 AM\n Calcium non-ionized\n 7.2 mg/dL\n 03:26 AM\n Phosphorus\n 5.2 mg/dL\n 03:26 AM\n Magnesium\n 1.9 mg/dL\n 03:26 AM\n WBC\n 9.3 K/uL\n 03:26 AM\n Hgb\n 9.2 g/dL\n 03:26 AM\n Hematocrit\n 27.9 %\n 03:26 AM\n Current diet order / nutrition support: Regular, Low Sodium/heart\n healthy, diabetic in POE\n GI: Positive bowel sounds, abdomen soft and distended\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO, ESRD\n Estimated Nutritional Needs\n Calories: 2290-2750 (BEE x or / 25-30 cal/kg)\n Protein: 73-92 (0.8-1 g/kg)\n Fluid: Per team\n Estimation of previous intake: Inadequate\n Specifics:\n 60 year old male h/o of ESRD s/p renal transplantation, COPD,\n presents with hypertension and dyspnea. Now intubated for progressive\n respiratory distress. Consulted for tube feeding recommendations.\n Noted ?rejection of chronic transplant nephropathy. Start tube feeding\n via NGT. Goal tube feeding of Novasource renal @ 50mL/hr x 24 hrs will\n provide 2400 calories, 89g protein and meet 100% estimated nutritional\n needs. Noted patient receiving 49\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Start tube feeding of Novasource renal @ 10mL/hr and increase 10mL\n q4hrs to goal 50mL/hrx 24hrs.\n 2.\n"
},
{
"category": "Nutrition",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 673515,
"text": "Subjective\n Patient in respiratory distress.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 203 cm\n 91.7 kg\n 22.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 102.5 kg\n 89%\n Diagnosis: Asthma/COPD excabation\n PMH : COPD, HTN, ESRD secondary to malignant HTN, Negative Staph Right\n Hip Joint, s/p remover spacer placement,chronic pain on narcotics,\n Diverticulitis s/p right colectomy, Prostate Cancer s/p radiation\n therapy in ,DM2, Perirectal abcess , bilateral avascular\n necrosis, s/p fall w/ femoral neck failure.\n Food allergies and intolerances: None noted\n Pertinent medications: Lansoprazole, RISS, Furosemide, 500 mL NS IV\n Bolus, Duloxetine, Azithromycin, mycophenolate 500mg, colace,\n methadone, heparin, phenylephrine, methyl prednisolon 125mg, oxycodone,\n propofol (49.5mL/hr), normal saline @ 10ml/hr.\n Labs:\n Value\n Date\n Glucose\n 164 mg/dL\n 03:26 AM\n Glucose Finger Stick\n 223\n 08:00 AM\n BUN\n 71 mg/dL\n 03:26 AM\n Creatinine\n 4.1 mg/dL\n 03:26 AM\n Sodium\n 125 mEq/L\n 03:26 AM\n Potassium\n 5.3 mEq/L\n 03:26 AM\n Chloride\n 97 mEq/L\n 03:26 AM\n TCO2\n 14 mEq/L\n 03:26 AM\n PO2 (arterial)\n 129 mm Hg\n 02:59 AM\n PO2 (venous)\n 35 mm Hg\n 03:48 AM\n PCO2 (arterial)\n 39 mm Hg\n 02:59 AM\n PCO2 (venous)\n 39 mm Hg\n 03:48 AM\n pH (arterial)\n 7.27 units\n 02:59 AM\n pH (venous)\n 7.31 units\n 03:48 AM\n pH (urine)\n 5.5 units\n 11:39 AM\n CO2 (Calc) arterial\n 19 mEq/L\n 02:59 AM\n CO2 (Calc) venous\n 21 mEq/L\n 03:48 AM\n Calcium non-ionized\n 7.2 mg/dL\n 03:26 AM\n Phosphorus\n 5.2 mg/dL\n 03:26 AM\n Magnesium\n 1.9 mg/dL\n 03:26 AM\n WBC\n 9.3 K/uL\n 03:26 AM\n Hgb\n 9.2 g/dL\n 03:26 AM\n Hematocrit\n 27.9 %\n 03:26 AM\n Current diet order / nutrition support: Regular, Low Sodium/heart\n healthy, diabetic in POE\n GI: Positive bowel sounds, abdomen soft and distended\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO, ESRD\n Estimated Nutritional Needs\n Calories: 2290-2750 (BEE x or / 25-30 cal/kg)\n Protein: 73-92 (0.8-1 g/kg)\n Fluid: Per team\n Estimation of previous intake: Inadequate\n Specifics:\n 60 year old male h/o of ESRD s/p renal transplantation, COPD,\n presents with hypertension and dyspnea. Now intubated for progressive\n respiratory distress. Consulted for tube feeding recommendations.\n Noted ?rejection of chronic transplant nephropathy. Start tube feeding\n via NGT. Goal tube feeding of Novasource renal @ 25mL/hr x 24 hrs,\n providing 1200 calories, 44g protein. Noted patient receiving\n 49.5mL/hr providing 1188 calories. Patient receiving total of 2388\n calories, 44g protein. Will continue to monitor dosage of propofol per\n patient and adjust tube feeding accordingly, noted may add beneprotein\n to tube feeding once patient is more medically stable.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Start tube feeding of Novasource renal @ 10mL/hr and increase 10mL\n q4hrs to goal 25mL/hrx 24hrs.\n 2. Check tolerance via residuals, hold tube feeding for x1 hr if\n residuals greater than 150mL.\n 3. Continue to monitor FSBG, q 6hrs.\n 4. Will adjust tube feeding according to medical\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 673640,
"text": "TITLE:\n 24 Hour Events:\n - Pt continued on azithromycin but high-dose steroids were stopped\n - Quantification of pulmonary function on paralytics consistent with\n small airway resistance. No evidence of central airway obstruction on\n CT chest.\n - Pt started on sodium bicarb and transplant biopsy done for renal\n dysfunction. Cymbalta stopped.\n PIP-29, Plat-12 and PEEP=5\n With RR decreased to 10 clear improvement in autopeep from 3-->0\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Propofol - 80 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:23 AM\n Cisatracurium - 04:00 PM\n Heparin Sodium (Prophylaxis) - 10:53 PM\n Fentanyl - 04:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.2\nC (99\n HR: 112 (86 - 121) bpm\n BP: 155/84(107) {100/67(78) - 155/92(111)} mmHg\n RR: 19 (9 - 25) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 80 Inch\n Total In:\n 5,093 mL\n 630 mL\n PO:\n TF:\n 53 mL\n 143 mL\n IVF:\n 4,600 mL\n 386 mL\n Blood products:\n Total out:\n 1,060 mL\n 320 mL\n Urine:\n 1,060 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,033 mL\n 310 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 650 (650 - 650) mL\n Vt (Spontaneous): 860 (666 - 870) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 21 cmH2O\n Plateau: 11 cmH2O\n SpO2: 98%\n ABG: 7.27/40/123/17/-7\n Ve: 13.3 L/min\n PaO2 / FiO2: 308\n Physical Examination\n General: intubated, sedated\n Pulmonary: mild expiratory wheezes b/l\n Cardiac: tachycardic, regular, normal S1/S2\n Abdomen: Soft, hypoactive BS\n Extremities: No edema. Has non-functional right UE fistula. A-line in\n place LUE. Left midline.\n Skin: Multiple keloids\n Neurologic: sedated as above\n Labs / Radiology\n 305 K/uL\n 9.3 g/dL\n 137 mg/dL\n 4.3 mg/dL\n 17 mEq/L\n 5.2 mEq/L\n 72 mg/dL\n 95 mEq/L\n 125 mEq/L\n 28.3 %\n 16.3 K/uL\n [image002.jpg]\n 06:45 AM\n 02:35 PM\n 06:28 PM\n 11:05 PM\n 02:59 AM\n 03:26 AM\n 06:07 PM\n 06:19 PM\n 02:40 AM\n 03:41 AM\n WBC\n 9.3\n 16.3\n Hct\n 27.9\n 28.3\n Plt\n 198\n 305\n Cr\n 4.1\n 4.1\n 4.1\n 4.3\n TCO2\n 20\n 18\n 20\n 19\n 18\n 19\n Glucose\n 166\n 164\n 166\n 137\n Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB /\n Troponin-T:210/8/0.05, Lactic Acid:0.6 mmol/L, Ca++:8.2 mg/dL, Mg++:2.2\n mg/dL, PO4:5.7 mg/dL\n Assessment and Plan\n 60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n # Dyspnea: Underlying COPD with possible exacerbation in setting of\n parainfluenza, also with ?component of CHF. Ruled out for ACS.\n Progressive respiratory distress and fatigue required intubation on\n . ABGs now consistent with adequate oxygenation and ventilation. CT\n scan did not show significant underlying pulmonary disease, and there\n was no airway obstruction.\n -Continue frequent bronchodilator therapy\n -Azithromycin for total 5 day course\n -Discontinue steroids today (d/t lack of benefit in the last three\n days)\n -F/u micro data\n -Trial of paralytics today to determine if central versus small airways\n obstruction\n # Volatile blood pressure: Has known difficult to control HTN, with\n hypertensive nephropathy/ESRD s/p transplant. Reports med adherence.\n be due to respiratory distress, HD steroids, narcotic withdrawal,\n renal failure, volume overload. No evidence of RAS on renal US. Had\n been on hydral 75mg q6H, clonidine 0.1mg PO TID, Amlodipine 10mg daily,\n and Nicardipine gtt; however, post-intubation his blood pressure\n dropped and he has since required fluid boluses to maintain MAP >65.\n -Continue fluid boluses to maintain MAP >65\n -Holding due to ARF\n -F/u renal recs\n # Acute renal failure: History of ESRD due to hypertensive nephropathy,\n had been on dialysis before CRT in . Reports adherence with\n immunosuppresants. FeNa yesterday 1.4. Unclear precipitant for ARF,\n ddx includes dehydration, although unlikely given hypertension;\n transplant nephropathy. Question of rejection on most recent\n ultrasound. Tacrolimus level in nl range. BK virus DNA not detected.\n -Continue steroids, cellcept, prograf\n -F/u renal transplant recs; consider biopsy\n -Cont to hold and gabapentin for now\n # Hyponatremia: Suspect SIADH secondary to pulmonary process; urine\n osms 314 suggests that he may be inappropriately concentrating urine.\n Consider fluid restriction.\n -F/u renal recs\n -Consider free water restriction\n -Q12h serum sodium checks\n # Hyperlipidemia:\n -continue statin and ezetimibe\n # DM:\n -HISS\n -diabetic diet\n # Chronic pain:\n -continue home oxycontin, methadone, and dilaudid prn per OMR\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation:\n -senna, colace\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 06:45 PM 25 mL/hour\n Glycemic Control:\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 12:41 AM\n Prophylaxis:\n DVT: Heparin SC 5000 tid\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 673641,
"text": "TITLE:\n 24 Hour Events:\n - Pt continued on azithromycin but high-dose steroids were stopped\n - Quantification of pulmonary function on paralytics consistent with\n small airway resistance. No evidence of central airway obstruction on\n CT chest.\n - Pt started on sodium bicarb and transplant biopsy done for renal\n dysfunction. Cymbalta stopped.\n PIP-29, Plat-12 and PEEP=5\n With RR decreased to 10 clear improvement in autopeep from 3-->0\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Propofol - 80 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:23 AM\n Cisatracurium - 04:00 PM\n Heparin Sodium (Prophylaxis) - 10:53 PM\n Fentanyl - 04:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.2\nC (99\n HR: 112 (86 - 121) bpm\n BP: 155/84(107) {100/67(78) - 155/92(111)} mmHg\n RR: 19 (9 - 25) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 80 Inch\n Total In:\n 5,093 mL\n 630 mL\n PO:\n TF:\n 53 mL\n 143 mL\n IVF:\n 4,600 mL\n 386 mL\n Blood products:\n Total out:\n 1,060 mL\n 320 mL\n Urine:\n 1,060 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,033 mL\n 310 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 650 (650 - 650) mL\n Vt (Spontaneous): 860 (666 - 870) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 21 cmH2O\n Plateau: 11 cmH2O\n SpO2: 98%\n ABG: 7.27/40/123/17/-7\n Ve: 13.3 L/min\n PaO2 / FiO2: 308\n Physical Examination\n General: intubated, sedated\n Pulmonary: mild expiratory wheezes b/l\n Cardiac: tachycardic, regular, normal S1/S2\n Abdomen: Soft, hypoactive BS\n Extremities: No edema. Has non-functional right UE fistula. A-line in\n place LUE. Left midline.\n Skin: Multiple keloids\n Neurologic: sedated as above, not responsive to voice\n Labs / Radiology\n 305 K/uL\n 9.3 g/dL\n 137 mg/dL\n 4.3 mg/dL\n 17 mEq/L\n 5.2 mEq/L\n 72 mg/dL\n 95 mEq/L\n 125 mEq/L\n 28.3 %\n 16.3 K/uL\n [image002.jpg]\n 06:45 AM\n 02:35 PM\n 06:28 PM\n 11:05 PM\n 02:59 AM\n 03:26 AM\n 06:07 PM\n 06:19 PM\n 02:40 AM\n 03:41 AM\n WBC\n 9.3\n 16.3\n Hct\n 27.9\n 28.3\n Plt\n 198\n 305\n Cr\n 4.1\n 4.1\n 4.1\n 4.3\n TCO2\n 20\n 18\n 20\n 19\n 18\n 19\n Glucose\n 166\n 164\n 166\n 137\n Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB /\n Troponin-T:210/8/0.05, Lactic Acid:0.6 mmol/L, Ca++:8.2 mg/dL, Mg++:2.2\n mg/dL, PO4:5.7 mg/dL\n Assessment and Plan\n 60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n # Dyspnea: Underlying COPD with possible exacerbation in setting of\n parainfluenza, also with ?component of CHF. Ruled out for ACS.\n Progressive respiratory distress and fatigue required intubation on\n . ABGs now consistent with adequate oxygenation and ventilation. CT\n scan did not show significant underlying pulmonary disease, and there\n was no airway obstruction.\n -Continue frequent bronchodilator therapy\n -Azithromycin for total 5 day course\n -Discontinue steroids today (d/t lack of benefit in the last three\n days)\n -F/u micro data\n -Trial of paralytics today to determine if central versus small airways\n obstruction\n # Volatile blood pressure: Has known difficult to control HTN, with\n hypertensive nephropathy/ESRD s/p transplant. Reports med adherence.\n be due to respiratory distress, HD steroids, narcotic withdrawal,\n renal failure, volume overload. No evidence of RAS on renal US. Had\n been on hydral 75mg q6H, clonidine 0.1mg PO TID, Amlodipine 10mg daily,\n and Nicardipine gtt; however, post-intubation his blood pressure\n dropped and he has since required fluid boluses to maintain MAP >65.\n -Continue fluid boluses to maintain MAP >65\n -Holding due to ARF\n -F/u renal recs\n # Acute renal failure: History of ESRD due to hypertensive nephropathy,\n had been on dialysis before CRT in . Reports adherence with\n immunosuppresants. FeNa yesterday 1.4. Unclear precipitant for ARF,\n ddx includes dehydration, although unlikely given hypertension;\n transplant nephropathy. Question of rejection on most recent\n ultrasound. Tacrolimus level in nl range. BK virus DNA not detected.\n -Continue steroids, cellcept, prograf\n -F/u renal transplant recs; consider biopsy\n -Cont to hold and gabapentin for now\n # Hyponatremia: Suspect SIADH secondary to pulmonary process; urine\n osms 314 suggests that he may be inappropriately concentrating urine.\n Consider fluid restriction.\n -F/u renal recs\n -Consider free water restriction\n -Q12h serum sodium checks\n # Hyperlipidemia:\n -continue statin and ezetimibe\n # DM:\n -HISS\n -diabetic diet\n # Chronic pain:\n -continue home oxycontin, methadone, and dilaudid prn per OMR\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation:\n -senna, colace\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 06:45 PM 25 mL/hour\n Glycemic Control:\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 12:41 AM\n Prophylaxis:\n DVT: Heparin SC 5000 tid\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673718,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Hypertension, benign\n Assessment:\n SBP 110\ns to 170\ns with HR 110\ns to 120\ns throughout shift. Pt. remains\n on fentanyl 100mcg/kg and propofol 90mcg/kg for sedation/comfort.\n Action:\n Pt. given IV hydralazine q6hr along with drips as noted above. Pt.\n bolused with 100mcg of fentanyl prior to nsg. care.\n Response:\n SBP remained labile throughout shift ranging from 110\ns to 170\n Remained tachycardic throughout shift.\n Plan:\n Continue to monitor patient hemodynamic status closely. Continue with\n propofol, fentanyl and hydralazine as ordered. If pt. remains\n hypertensive, may need to increase hydralazine dose.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt. remains intubated and vented on PSV 40% 15/5 with sats at high 90\n RR in 10\ns. Breath sounds diminished throughout. Some wheezes noted but\n clear with nebs. Pt. suctioned for copious amounts of thick green\n sputum.\n Action:\n MDIs given as ordered. Mouth care q4hr and prn, suction as needed. Pt.\n turned Q2h. Sputum sample collected and sent to lab.\n Response:\n Pt. remains stable on current vent settings. Ongoing respiratory\n assessment.\n Plan:\n Continue to monitor resp status, wean vent as tolerated, meds ASDIR,\n F/U with culture results.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatinine trending down. PM creat- 3.9, BUN 72, K-5.7. UOP about 30 to\n 50cc/hr\n Action:\n Renal biopsy done yesterday. All meds renally dosed. Cellcept\n administered as ordered. Prograf held d/t level. Will recheck level\n with am labs as med adjusted to daily level. K-excelate x1 dose\n given.\n Response:\n Pt. remains with elevated BUN/Creat, hyperkalemia.\n Plan:\n Continue to monitor renal functions, f/u renal recs. f/u biopsy\n results. AM prograf level pending.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673719,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Hypertension, benign\n Assessment:\n SBP 110\ns to 170\ns with HR 110\ns to 120\ns throughout shift. Pt. remains\n on fentanyl 100mcg/kg and propofol 90mcg/kg for sedation/comfort.\n Action:\n Pt. given IV hydralazine q6hr along with drips as noted above. Pt.\n bolused with 100mcg of fentanyl prior to nsg. care.\n Response:\n SBP remained labile throughout shift ranging from 110\ns to 170\n Remained tachycardic throughout shift.\n Plan:\n Continue to monitor patient hemodynamic status closely. Continue with\n propofol, fentanyl and hydralazine as ordered. If pt. remains\n hypertensive, may need to increase hydralazine dose.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt. remains intubated and vented on PSV 40% 15/5 with sats at high 90\n RR in 10\ns. Breath sounds diminished throughout. Some wheezes noted but\n clear with nebs. Pt. suctioned for copious amounts of thick green\n sputum.\n Action:\n MDIs given as ordered. Mouth care q4hr and prn, suction as needed. Pt.\n turned Q2h. Sputum sample collected and sent to lab.\n Response:\n Pt. remains stable on current vent settings. Ongoing respiratory\n assessment.\n Plan:\n Continue to monitor resp status, wean vent as tolerated, meds ASDIR,\n F/U with culture results.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatinine trending down. PM creat- 3.9, BUN 76, K-4.7. UOP gradually\n increasing to approx. 40 to 120cc/hr\n Action:\n All meds renally dosed. Cellcept and prograf administered as ordered.\n Will recheck level with am labs as med adjusted to daily level. Started\n on renagel.\n Response:\n Pt. remains with elevated BUN/Creat, however, trending down.\n Plan:\n Continue to monitor renal functions, f/u renal recs. f/u biopsy\n results. AM prograf level pending.\n Constipation (Obstipation, FOS)\n Assessment:\n Pt. has not had a BM x 6 days. KUB done yesterday which showed lots of\n stool. Abd. Distended. Bowel sounds hypoactive. TFeeds have been off\n since yesterday am as pt. continues to have high residuals.\n Action:\n Lactulose, polyethylene glycol, and colace administered as ordered.\n TFeeds remain on hold. Residuals checked frequently throughout shift.\n Response:\n Pt. had one small smear of mucoid stool. Abd remains distended and BS\n hypoactive. Increase residuals continue.\n Plan:\n Continue with strict bowel regime. Continue to hold TFeeds until\n residuals subside.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673818,
"text": "60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Underline COPD with possible exacerbation in setting of parainfluenza.\n Received patient intubated and vented on PSV 40% 10/5 w/sats at high\n 90\ns. RR in 20\ns. B/L LS diminished w/transient wheezes. Green colored\n secretion w/suctioning. CXR w/o change however white count up w/bands.\n Action:\n SBT for 2hr, switched to PSV 5/5, Continue frequent bronchodilator\n therapy with albuterol and atrovent, f/u sputum cultures, started on\n Vanc/Zosyn for possible VAP. Continue w/VAP precautions, mouth care\n q4hr and PRN, suction PRN.\n Response:\n pending\n Plan:\n Continue to monitor resp status, f/u cx data, meds ASDIR, wean off vent\n and extubate when able.\n Hypertension, benign\n Assessment:\n Has known difficult to control HTN, with hypertensive nephropathy/ESRD\n s/p transplant. Currently on hydralazine 10mg iV q6hr. B/P at\n 120-130\ns. However during late morning b/p up to 170\ns. Hr in\n 100-110\ns w/frequent PAC\ns. extr edema. Peripheral pulses present.\n Action:\n Additional dose of hydralazine 10mg X1 given. B/P down to 120\n nicardipine gtt on hold in case hypertension persists\n Response:\n B/P remains in 120-130\ns. nicardipine gtt never started.\n Plan:\n Continue to monitor patient\n s hemodynamic status,\n Constipation (Obstipation, FOS)\n Assessment:\n Action:\n Response:\n Plan:\n # Decreased gastric motility: High residuals from tube feeds. H/o poor\n motility on prior gastric emptying study, may be DM. Likely also\n exacerbated by narcotics and has not had bowel mvt in days.\n -KUB to evaluate for ileus\n -Reglan\n -aggressive bowel regimen\n -may need placement of post-pyloric dobhoff for nutrition if not\n improving\n # Acute renal failure: History of ESRD due to hypertensive nephropathy,\n had been on dialysis before CRT in . Reports adherence with\n immunosuppresants. FeNa 1.4. Unclear precipitant for ARF, ddx includes\n dehydration, although unlikely given hypertension; transplant\n nephropathy. Question of rejection on most recent ultrasound and now\n s/p transplant bx. Tacrolimus level in nl range. BK virus DNA not\n detected.\n -F/u renal recs\n -Await transplant bx result\n -Continue steroids, cellcept, prograf\n -Replete sodium and bicarb per renal recs\n -Cont to hold and gabapentin for now\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673821,
"text": "60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Underline COPD with possible exacerbation in setting of parainfluenza.\n Received patient intubated and vented on PSV 40% 10/5 w/sats at high\n 90\ns. RR in 20\ns. B/L LS diminished w/transient wheezes. Green colored\n secretion w/suctioning. CXR w/o change however white count up w/bands.\n Action:\n SBT for 2hr, switched to PSV 5/5, Continue frequent bronchodilator\n therapy with albuterol and atrovent, f/u sputum cultures, started on\n Vanc/Zosyn for possible VAP. Continue w/VAP precautions, mouth care\n q4hr and PRN, suction PRN.\n Response:\n pending\n Plan:\n Continue to monitor resp status, f/u cx data, meds ASDIR, wean off vent\n and extubate when able.\n Hypertension, benign\n Assessment:\n Has known difficult to control HTN, with hypertensive nephropathy/ESRD\n s/p transplant. Currently on hydralazine 10mg iV q6hr. B/P at\n 120-130\ns. However during late morning b/p up to 170\ns. Hr in\n 100-110\ns w/frequent PAC\ns. extr edema. Peripheral pulses present.\n Action:\n Additional dose of hydralazine 10mg X1 given. B/P down to 120\n nicardipine gtt on hold in case hypertension persists\n Response:\n B/P remains in 120-130\ns. nicardipine gtt never started.\n Plan:\n Continue to monitor patient\n s hemodynamic status, meds ASDIR, if\n needed start nicardipine gtt\n Constipation (Obstipation, FOS)\n Assessment:\n Known decreased gastric motility. Abd soft distended, positive for BS\n and flatus, much smaller residuals 25cc. NPO but may restart TF later\n on today.\n Action:\n Continue Reglan, continue aggressive bowel regimen\n Response:\n pending\n Plan:\n Continue to monitor patient status, aggressive bowel regiment until\n clears, may restart TF later on if no residuals.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n s/p renal transplant, UOP 70-100cc/hr, creat trending down\n Action:\n F/u renal recs, Await transplant bx result, Continue steroids,\n cellcept, prograf, Replete sodium and bicarb per renal recs\n Response:\n pending\n Plan:\n Continue to monitor patient renal status, f/u renal recs.\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 673988,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 05:27 AM\n TRIPLE INTRODUCER - START 05:29 AM\n -Renal: am tacro level\n -SBT: Numbers were good per respiratory, but patient appeared to have\n increase work of breathing. Could not wean sedation enough to\n extubate, patient became agitated and had increased work of breathing.\n -Labile BP Sbp: 76 - 190s. Hypotension responded to fluid boluses,\n received a lot of fluid as suspecting sepsis.\n -Started on Vanc/Zosyn for presumed VAP\n -TF started then held for high residuals a few hours later\n -Changed from PS to CMV/Assist.\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:59 PM\n Piperacillin/Tazobactam (Zosyn) - 12:48 AM\n Metronidazole - 04:03 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Phenylephrine - 3.8 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:33 AM\n Fentanyl - 07:33 AM\n Hydralazine - 10:36 AM\n Heparin Sodium (Prophylaxis) - 11:49 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 109 (103 - 121) bpm\n BP: 106/73(85) {89/58(71) - 196/100(130)} mmHg\n RR: 33 (18 - 33) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 80 Inch\n CVP: 9 (9 - 16)mmHg\n CO/CI (Fick): (14.8 L/min) / (6.4 L/min/m2)\n Mixed Venous O2% Sat: 81 - 81\n Total In:\n 6,245 mL\n 2,888 mL\n PO:\n TF:\n 39 mL\n IVF:\n 5,865 mL\n 2,888 mL\n Blood products:\n Total out:\n 1,690 mL\n 1,175 mL\n Urine:\n 1,580 mL\n 175 mL\n NG:\n 110 mL\n 1,000 mL\n Stool:\n Drains:\n Balance:\n 4,555 mL\n 1,713 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 490 (482 - 655) mL\n PS : 15 cmH2O\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 28 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SpO2: 95%\n ABG: 7.16/49/205/17/-11\n Ve: 18.9 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General: intubated, sedated\n Pulmonary: course breath sounds, occasional wheezes, +rhonchi\n Cardiac: tachycardic, regular, normal S1/S2\n Abdomen: Soft, hypoactive BS\n Extremities: No edema. Has non-functional right UE fistula. A-line in\n place LUE. Left midline.\n Skin: Multiple keloids\n Neurologic: sedated as above, not arousable to voice\n Labs / Radiology\n 369 K/uL\n 10.4 g/dL\n 70 mg/dL\n 3.6 mg/dL\n 17 mEq/L\n 5.1 mEq/L\n 71 mg/dL\n 102 mEq/L\n 134 mEq/L\n 32.5 %\n 28.2 K/uL\n [image002.jpg]\n 04:18 AM\n 04:26 PM\n 08:08 PM\n 10:13 PM\n 12:02 AM\n 02:20 AM\n 02:24 AM\n 03:19 AM\n 04:05 AM\n 05:43 AM\n WBC\n 23.2\n 28.2\n Hct\n 30.3\n 32.5\n Plt\n 364\n 369\n Cr\n 3.8\n 3.6\n TCO2\n 21\n 20\n 21\n 20\n 21\n 19\n 20\n 18\n Glucose\n 150\n 70\n Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB /\n Troponin-T:210/8/0.05, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0\n %, Mono:8.0 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:9.2 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n CONSTIPATION (OBSTIPATION, FOS)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPERTENSION, BENIGN\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITHOUT ACUTE EXACERBATION\n 60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n # Hypotension: Most likely secondary to sepsis given low CVP, CXR with\n infiltrate, and GNR in sputum. Also there is some concern for adrenal\n insufficiency, although he is currently on stress-dose steroids. CVP\n is low, so cardiogenic shock is less likely. Volume depletion may also\n be at play.\n - continue pressure support with vasopressin, phenylephrine, levophed\n - attempt to wean levophed as tolerated to maintain MAP >60\n - f/u echo for potential cardiac cause\n - continue stress-dose steroids\n - continue vanc/zosyn for likely pulmonary source of infection\n - repeat stool for c diff\n .\n # Respiratory failure: Likely secondary to Underlying COPD with\n possible exacerbation in setting of parainfluenza, also with ?component\n of CHF. Ruled out for ACS. Progressive respiratory distress and fatigue\n required intubation on . ABGs now consistent with adequate\n oxygenation and ventilation. CT scan without significant pulm dz and\n vent physiology most consistent with small airways obstruction,\n bronchospasm. I:E ratio improving with decreased wheezes on exam but\n not candidate for extubation today\n -Continue frequent bronchodilator therapy with albuterol and atrovent\n -Azithromycin 5-day course completed yesterday\n -Discontinued high-dose steroids yesterday dose (d/t lack of benefit x\n three days) and restarted on usual renal transplant prednisone\n -F/u micro data\n -RSBI/SBT tomorrow\n # Volatile blood pressure: Has known difficult to control HTN, with\n hypertensive nephropathy/ESRD s/p transplant. Reports med adherence.\n be due to respiratory distress, HD steroids, narcotic withdrawal,\n renal failure, volume overload. No evidence of RAS on renal US. Had\n been on hydral 75mg q6H, clonidine 0.1mg PO TID, Amlodipine 10mg daily,\n and Nicardipine gtt; however, post-intubation his blood pressure\n dropped and he has since required fluid boluses to maintain MAP >65.\n Now BP increasing again, ?in setting of inadequate pain control with\n poor gastric motility.\n - fentanyl gtt as may not be absorbing po pain meds\n -Consider hydral prn or nicardipine gtt if persistently elevated BP\n -Holding due to ARF and beta blockers due to resp status\n -F/u renal recs\n # Decreased gastric motility: High residuals from tube feeds. H/o poor\n motility on prior gastric emptying study, may be DM. Likely also\n exacerbated by narcotics and has not had bowel mvt in days.\n -KUB to evaluate for ileus\n -Reglan\n -aggressive bowel regimen\n -may need placement of post-pyloric dobhoff for nutrition if not\n improving\n # Acute renal failure: History of ESRD due to hypertensive nephropathy,\n had been on dialysis before CRT in . Reports adherence with\n immunosuppresants. FeNa 1.4. Unclear precipitant for ARF, ddx includes\n dehydration, although unlikely given hypertension; transplant\n nephropathy. Question of rejection on most recent ultrasound and now\n s/p transplant bx. Tacrolimus level in nl range. BK virus DNA not\n detected.\n -F/u renal recs\n -Await transplant bx result\n -Continue steroids, cellcept, prograf\n -Replete sodium and bicarb per renal recs\n -Cont to hold and gabapentin for now\n # Hyponatremia: Suspect SIADH secondary to pulmonary process; urine\n osms 314 suggests that he may be inappropriately concentrating urine.\n Consider fluid restriction.\n -Sodium bicarb repletion per renal recs\n -Repeat lytes\n # Hyperlipidemia:\n -continue statin and ezetimibe\n # DM:\n -HISS\n -diabetic diet\n # Chronic pain:\n -Fentanyl gtt\n -holding po pain meds for now due to poor gastric motility (home\n oxycontin, methadone, and dilaudid prn)\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation: passing gas, positive BS, small BM overnight.\n -senna, colace, bisacodyl pr, miralax, raglan\n broader as \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 04:50 AM\n Multi Lumen - 05:27 AM\n Triple Introducer - 05:29 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 673989,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 05:27 AM\n TRIPLE INTRODUCER - START 05:29 AM\n -Renal: am tacro level\n -SBT: Numbers were good per respiratory, but patient appeared to have\n increase work of breathing. Could not wean sedation enough to\n extubate, patient became agitated and had increased work of breathing.\n -Labile BP Sbp: 76 - 190s. Hypotension responded to fluid boluses,\n received a lot of fluid as suspecting sepsis.\n -Started on Vanc/Zosyn for presumed VAP\n -TF started then held for high residuals a few hours later\n -Changed from PS to CMV/Assist.\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:59 PM\n Piperacillin/Tazobactam (Zosyn) - 12:48 AM\n Metronidazole - 04:03 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Phenylephrine - 3.8 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:33 AM\n Fentanyl - 07:33 AM\n Hydralazine - 10:36 AM\n Heparin Sodium (Prophylaxis) - 11:49 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 109 (103 - 121) bpm\n BP: 106/73(85) {89/58(71) - 196/100(130)} mmHg\n RR: 33 (18 - 33) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 80 Inch\n CVP: 9 (9 - 16)mmHg\n CO/CI (Fick): (14.8 L/min) / (6.4 L/min/m2)\n Mixed Venous O2% Sat: 81 - 81\n Total In:\n 6,245 mL\n 2,888 mL\n PO:\n TF:\n 39 mL\n IVF:\n 5,865 mL\n 2,888 mL\n Blood products:\n Total out:\n 1,690 mL\n 1,175 mL\n Urine:\n 1,580 mL\n 175 mL\n NG:\n 110 mL\n 1,000 mL\n Stool:\n Drains:\n Balance:\n 4,555 mL\n 1,713 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 490 (482 - 655) mL\n PS : 15 cmH2O\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 28 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SpO2: 95%\n ABG: 7.16/49/205/17/-11\n Ve: 18.9 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General: intubated, sedated\n Pulmonary: course breath sounds, occasional wheezes, +rhonchi\n Cardiac: tachycardic, regular, normal S1/S2\n Abdomen: Soft, hypoactive BS\n Extremities: No edema. Has non-functional right UE fistula. A-line in\n place LUE. Left midline.\n Skin: Multiple keloids\n Neurologic: sedated as above, not arousable to voice\n Labs / Radiology\n 369 K/uL\n 10.4 g/dL\n 70 mg/dL\n 3.6 mg/dL\n 17 mEq/L\n 5.1 mEq/L\n 71 mg/dL\n 102 mEq/L\n 134 mEq/L\n 32.5 %\n 28.2 K/uL\n [image002.jpg]\n 04:18 AM\n 04:26 PM\n 08:08 PM\n 10:13 PM\n 12:02 AM\n 02:20 AM\n 02:24 AM\n 03:19 AM\n 04:05 AM\n 05:43 AM\n WBC\n 23.2\n 28.2\n Hct\n 30.3\n 32.5\n Plt\n 364\n 369\n Cr\n 3.8\n 3.6\n TCO2\n 21\n 20\n 21\n 20\n 21\n 19\n 20\n 18\n Glucose\n 150\n 70\n Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB /\n Troponin-T:210/8/0.05, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0\n %, Mono:8.0 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:9.2 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n CONSTIPATION (OBSTIPATION, FOS)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPERTENSION, BENIGN\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITHOUT ACUTE EXACERBATION\n 60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n # Hypotension: Most likely secondary to sepsis given low CVP, CXR with\n infiltrate, and GNR in sputum. Also there is some concern for adrenal\n insufficiency, although he is currently on stress-dose steroids. CVP\n is low, so cardiogenic shock is less likely. Volume depletion may also\n be at play.\n - continue pressure support with vasopressin, phenylephrine, levophed\n - attempt to wean levophed as tolerated to maintain MAP >60\n - f/u echo for potential cardiac cause\n - continue stress-dose steroids\n - continue vanc/zosyn for likely pulmonary source of infection\n - repeat stool for c diff\n .\n # Respiratory failure: Likely secondary to Underlying COPD with\n possible exacerbation in setting of parainfluenza, also with ?component\n of CHF. Ruled out for ACS. Progressive respiratory distress and fatigue\n required intubation on . ABGs now consistent with adequate\n oxygenation and ventilation. CT scan without significant pulm dz and\n vent physiology most consistent with small airways obstruction,\n bronchospasm. I:E ratio improving with decreased wheezes on exam but\n not candidate for extubation today\n -Continue frequent bronchodilator therapy with albuterol and atrovent\n -Azithromycin 5-day course completed yesterday\n -Discontinued high-dose steroids yesterday dose (d/t lack of benefit x\n three days) and restarted on usual renal transplant prednisone\n -F/u micro data\n -RSBI/SBT tomorrow\n # Volatile blood pressure: Has known difficult to control HTN, with\n hypertensive nephropathy/ESRD s/p transplant. Reports med adherence.\n be due to respiratory distress, HD steroids, narcotic withdrawal,\n renal failure, volume overload. No evidence of RAS on renal US. Had\n been on hydral 75mg q6H, clonidine 0.1mg PO TID, Amlodipine 10mg daily,\n and Nicardipine gtt; however, post-intubation his blood pressure\n dropped and he has since required fluid boluses to maintain MAP >65.\n Now BP increasing again, ?in setting of inadequate pain control with\n poor gastric motility.\n - fentanyl gtt as may not be absorbing po pain meds\n -Consider hydral prn or nicardipine gtt if persistently elevated BP\n -Holding due to ARF and beta blockers due to resp status\n -F/u renal recs\n # Decreased gastric motility: High residuals from tube feeds. H/o poor\n motility on prior gastric emptying study, may be DM. Likely also\n exacerbated by narcotics and has not had bowel mvt in days.\n -KUB to evaluate for ileus\n -Reglan\n -aggressive bowel regimen\n -may need placement of post-pyloric dobhoff for nutrition if not\n improving\n # Acute renal failure: History of ESRD due to hypertensive nephropathy,\n had been on dialysis before CRT in . Reports adherence with\n immunosuppresants. FeNa 1.4. Unclear precipitant for ARF, ddx includes\n dehydration, although unlikely given hypertension; transplant\n nephropathy. Question of rejection on most recent ultrasound and now\n s/p transplant bx. Tacrolimus level in nl range. BK virus DNA not\n detected.\n -F/u renal recs\n -Await transplant bx result\n -Continue steroids, cellcept, prograf\n -Replete sodium and bicarb per renal recs\n -Cont to hold and gabapentin for now\n # Hyponatremia: Suspect SIADH secondary to pulmonary process; urine\n osms 314 suggests that he may be inappropriately concentrating urine.\n Consider fluid restriction.\n -Sodium bicarb repletion per renal recs\n -Repeat lytes\n # Hyperlipidemia:\n -continue statin and ezetimibe\n # DM:\n -HISS\n -diabetic diet\n # Chronic pain:\n -Fentanyl gtt\n -holding po pain meds for now due to poor gastric motility (home\n oxycontin, methadone, and dilaudid prn)\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation: passing gas, positive BS, small BM overnight.\n -senna, colace, bisacodyl pr, miralax, raglan\n broader as \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 04:50 AM\n Multi Lumen - 05:27 AM\n Triple Introducer - 05:29 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673117,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Overnight Mr. continued to be non compliant with most nursing\n care, he was started on a continuous Albuterol neb which he\n intermittently took on and off, on multiple occasions he took himself\n off all monitoring equipment and only after significant persuasion\n allowed this RN to place him back on telemetry.\n Events:\n * Nitro gtt remains @ 2mcg/kg/min\n * Hydral increased to 60mg PO qid\n * No other significant events\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received patient on NC 3 L and continues nebs w/sats > 90. Incompliant\n w/nebs (takes the mask off) bil LS ins/exp wheezes, DOE. Overnight\n resp distress slowly worsened, now with significant\n Action:\n Refused non invasive mask ventilation multiple times until 0400, placed\n on Non invasive mask ventilation, 120mg IVP lasix, 4 mg IVP morphine,\n stat CXR\n Response:\n Pending, remains wheezing. Sats at high 90\n Plan:\n Continue to monitor resp status, f/u CX data, CXR to eval progress,\n ABg\ns if needed, meds ASDIR.\n Hypertension, benign\n Assessment:\n Received patient on NITRO gtt at 1mcg/kg/min. b/p in 190-200\ns. HR at\n 70\ns peripheral pulses present. Minimal pedal edema. Denies headaches,\n nausea,, vomiting\n Action:\n Nitro titrated up to 2mcg/kg/min (long periods of OFF nitro due to\n inability to establish iv access and patient refusing IV access),\n hydralazine added Q6hr, cont on metoprolol . In addition hydralazyne\n 25mg X1 given at 1800 for persistent b/p of 180\n Response:\n Pending, however patient is incompliant w/care.\n Plan:\n Continue to monitor patient status, meds ASDIR.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673119,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Overnight Mr. continued to be non compliant with most nursing\n care, he was started on a continuous Albuterol neb which he\n intermittently took on and off, on multiple occasions he took himself\n off all monitoring equipment and only after significant persuasion\n allowed this RN to place him back on telemetry.\n Events:\n * Nitro gtt remains @ 2mcg/kg/min\n * Hydral increased to 60mg PO qid\n * Resp distress worsened overnight\n * 120mg IV push lasix and 4mg IV push morphine\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received patient on NC 3 L and continues nebs w/sats > 90. Incompliant\n w/nebs (takes the mask off) LS ins/exp wheezes bilaterally. Overnight\n resp distress slowly worsened, now with significant exp wheezes. Viral\n cultures returned positive for para-influenza\n Action:\n Refused non invasive mask ventilation multiple times until 0400, placed\n on Non invasive mask ventilation, 120mg IVP lasix, 4 mg IVP morphine,\n stat CXR, solumdrol dose increased to 80mg q 6. Even while in moderate\n resp distress pt continued to refuse arterial sticks,a peripheral\n venous gas was obtained and shows PCO2 of 39. On droplet precautions\n ? influenza diagnosis\n Response:\n Pt demanded to be taken off non invasive mask after 15 minuets of\n therapy claiming he felt\nbetter\n though still appears to be\n experiencing a moderate amount of resp distress, intubation and\n invasive ventilation was explained by both this RN and the ICU\n resident he immediately refused to be intubated, Mr. has\n remained alert, oriented and verbally appropriate throughout the night\n and remains capable of making lucid decisions\n Plan:\n Closely monitor resp status, follow up with results of CXR, will likely\n require either non invasive or invasive ventilation.\n Hypertension\n Assessment:\n At start of shift Mr was hypertensive to 200 systolic despite\n a nitro gtt @ 2mcg/kg/min, Hypertension is likely being significantly\n exacerbated by resp. distress. NBP 190s\n 205/ 90\ns -110, NSR with no\n appreciable ventricular ectopy. Denies chest pain or headache\n Action:\n EKG obtained, hydral dose increased and amlodipine added\n Response:\n Hypertension persists, overnight attending and resident evaluated pt @\n the bedside and declined to change the nitro gtt for another as\n they feel his hypertension is likely related to resp distress\n Plan:\n Continue to monitor hemodynamic status, cont nitro gtt/ hydral/\n amlodipine at this time. Readdress current antihypertensive regimen\n during rounds or if pts condition worsens.\n"
},
{
"category": "Nutrition",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 673485,
"text": "Subjective\n Patient intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 203 cm\n 91.7 kg\n 22.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 102.5 kg\n 89%\n Diagnosis: Asthma/COPD excabation\n PMH : COPD, HTN, ESRD secondary to malignant HTN, Negative Staph Right\n Hip Joint, s/p remover spacer placement,chronic pain on narcotics,\n Diverticulitis s/p right colectomy, Prostate Cancer s/p radiation\n therapy in ,DM2, Perirectal abcess , bilateral avascular\n necrosis, s/p fall w/ femoral neck failure.\n Food allergies and intolerances: None noted\n Pertinent medications: Lansoprazole, RISS, Furosemide, 500 mL NS IV\n Bolus, Duloxetine, Azithromycin, mycophenolate 500mg, colace,\n methadone, heparin, phenylephrine, methyl prednisolon 125mg, oxycodone,\n propofol (50mcg/kg/min).\n Labs:\n Value\n Date\n Glucose\n 164 mg/dL\n 03:26 AM\n Glucose Finger Stick\n 223\n 08:00 AM\n BUN\n 71 mg/dL\n 03:26 AM\n Creatinine\n 4.1 mg/dL\n 03:26 AM\n Sodium\n 125 mEq/L\n 03:26 AM\n Potassium\n 5.3 mEq/L\n 03:26 AM\n Chloride\n 97 mEq/L\n 03:26 AM\n TCO2\n 14 mEq/L\n 03:26 AM\n PO2 (arterial)\n 129 mm Hg\n 02:59 AM\n PO2 (venous)\n 35 mm Hg\n 03:48 AM\n PCO2 (arterial)\n 39 mm Hg\n 02:59 AM\n PCO2 (venous)\n 39 mm Hg\n 03:48 AM\n pH (arterial)\n 7.27 units\n 02:59 AM\n pH (venous)\n 7.31 units\n 03:48 AM\n pH (urine)\n 5.5 units\n 11:39 AM\n CO2 (Calc) arterial\n 19 mEq/L\n 02:59 AM\n CO2 (Calc) venous\n 21 mEq/L\n 03:48 AM\n Calcium non-ionized\n 7.2 mg/dL\n 03:26 AM\n Phosphorus\n 5.2 mg/dL\n 03:26 AM\n Magnesium\n 1.9 mg/dL\n 03:26 AM\n WBC\n 9.3 K/uL\n 03:26 AM\n Hgb\n 9.2 g/dL\n 03:26 AM\n Hematocrit\n 27.9 %\n 03:26 AM\n Current diet order / nutrition support: Regular, Low Sodium/heart\n healthy, diabetic in POE\n GI: Positive bowel sounds, abdomen soft and distended\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO, ESRD\n Estimated Nutritional Needs\n Calories: 2290-2750 (BEE x or / 25-30 cal/kg)\n Protein: 73-92 (0.8-1 g/kg)\n Fluid: Per team\n Estimation of previous intake: Inadequate\n Specifics:\n 60 year old male with ESRD s/p CRT, HTN, COPD, presents with\n hypertension and dyspnea, now intubated for progressive\n respiratory distress. Consulted for tube feeding recommendations due to\n poor PO intake. Noted ?\n Medical Nutrition Therapy Plan - Recommend the Following\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673573,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n SHIFT EVENTS\n * K-excelate given for hyperkalemia\n * TFeeds at goal rate of 25cc/hr\n * No vent changes\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673574,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n SHIFT EVENTS\n * K-excelate given for hyperkalemia (k+ 5.7)\n * TFeeds at goal rate of 25cc/hr\n * No vent changes\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 674055,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Patient remains on mechanical ventilation. Air trapping but\n ABG improved on present settings.without secretion was on pressor for\n hypotension,made DNR.\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 674581,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL / Air\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: arterial blood gas 7.44/34/125 OR procedure for\n abdominal exploration.\n Reason for continuing current ventilatory support: Pending procedure /\n OR\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673715,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Hypertension, benign\n Assessment:\n B/P at 160-170\ns Hr at 80\ns SR, pedal edema, peripheral pulses\n present. After pain meds administration b/p at 140\ns and patient\n appears more comfortable. Later during the day b/p up to 190\ns HR at\n 110\ns w/frequent PAC\ns despite sedation and pain meds.\n Action:\n Started on fentanyl gtt and hydralazyne q6hr.\n Response:\n B/P at 120\n 130\ns. Hr still tachycardia at 110\n Plan:\n Continue to monitor patient hemodynamic status, increase hydralazyne\n dose if needed.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673869,
"text": "60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n Of note, attempt to wean sedation for possible extubation\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. received intubated on pressure support 40%/. Labored breathing\n noted. Suctioned for scant amounts of thick green sputum. Culture + for\n gram negative rods. Sedated on propofol gtt but unable to increase\n sedation as pt. was hypotensive. Pt. unresponsive. No cough/gag reflex\n noted. No withdrawal to noxious stimuli, however, resp rate 30\ns to\n 40\ns. Nasal flaring noted with inhalation.\n Action:\n Vent changed to 40%/15/5. Started on IV vanco and zosyn for probable\n VAP pneumonia. Multiple Blood gases drawn throughout shift. Results\n show a metabolic acidosis. PH ranging from 7.25 to 7.30. Attempts made\n to increase sedation unsuccessful hypotension. Pt. turned Q2h.\n Mouth care Q4h.\n Response:\n Pt. continues to appear to have labored breathing.\n Plan:\n IV antibiotics to be administered as ordered. Aggressive pulmonary\n toilet.\n Hypotension (not Shock)\n Assessment:\n SBP as low as 70\ns at start of shift. UO 30-40cc/hr.\n Action:\n Fentanyl drip off. Propofol down to 25mcg/kg/mmin. Total of 5L NS\n boluses given at start of shift.\n Response:\n With fluid boluses SBP would increase to 120\ns and then trend back down\n to 80\ns when bolus completed. Phenylephrine started at 0100 to maintain\n MAPS >60.\n Plan:\n Wean pressor to maintain MAP >60. Continue to monitor hemodynamic\n status closely. Awaiting am lab results.\n Constipation (Obstipation, FOS)\n Assessment:\n Known decreased gastric motility. Abd soft distended, positive for BS\n and flatus, TFeeds restarted at at 10cc/hr. Residuals at 2200\n >360cc.\n Action:\n TFeeds off. Continue Reglan, lactulose and aggressive bowel regimen\n Response:\n Pending\n Plan:\n Continue to monitor patient status, aggressive bowel regiment until\n clears, may attempt to restart TF today if no residuals.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n s/p renal transplant, UOP decreased to 30-40cc/hr\n Action:\n Fluid boluses as noted above. Assessed UO Q1h. Steroids, cellcept, and\n prograf, administered as ordered.\n Response:\n Continue to follow GU status.\n Plan:\n Continue to monitor patient renal status, f/u renal recs. Fluid\n boluses as ordered. Replete sodium bicarb as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673870,
"text": "60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n Of note, attempt to wean sedation for possible extubation\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. received intubated on pressure support 40%/. Labored breathing\n noted. Suctioned for scant amounts of thick green sputum. Culture + for\n gram negative rods. Sedated on propofol gtt but unable to increase\n sedation as pt. was hypotensive. Pt. unresponsive. No cough/gag reflex\n noted. No withdrawal to noxious stimuli, however, resp rate 30\ns to\n 40\ns. Nasal flaring noted with inhalation.\n Action:\n Vent changed to 40%/15/5. Started on IV vanco and zosyn for probable\n VAP pneumonia. Multiple Blood gases drawn throughout shift. Results\n show a metabolic acidosis. PH ranging from 7.25 to 7.30. Attempts made\n to increase sedation unsuccessful hypotension. Pt. turned Q2h.\n Mouth care Q4h.\n Response:\n Pt. continues to appear to have labored breathing.\n Plan:\n IV antibiotics to be administered as ordered. Aggressive pulmonary\n toilet.\n Hypotension (not Shock)\n Assessment:\n SBP as low as 70\ns at start of shift. UO 30-40cc/hr.\n Action:\n Fentanyl drip off. Propofol down to 25mcg/kg/mmin. Total of 5L NS\n boluses given at start of shift.\n Response:\n With fluid boluses SBP would increase to 120\ns and then trend back down\n to 80\ns when bolus completed. Phenylephrine started at 0100 to maintain\n MAPS >60.\n Plan:\n Wean pressor to maintain MAP >60. Continue to monitor hemodynamic\n status closely. Awaiting am lab results.\n Constipation (Obstipation, FOS)\n Assessment:\n Known decreased gastric motility. Abd soft distended, positive for BS\n and flatus, TFeeds restarted at at 10cc/hr. Residuals at 2200\n >360cc.\n Action:\n TFeeds off. Continue Reglan, lactulose and aggressive bowel regimen\n Response:\n Pending\n Plan:\n Continue to monitor patient status, aggressive bowel regiment until\n clears, may attempt to restart TF today if no residuals.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n s/p renal transplant, UOP decreased to 30-40cc/hr\n Action:\n Fluid boluses as noted above. Assessed UO Q1h. Steroids, cellcept, and\n prograf, administered as ordered.\n Response:\n Continue to follow GU status.\n Plan:\n Continue to monitor patient renal status, f/u renal recs. Fluid\n boluses as ordered. Replete sodium bicarb as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674054,
"text": "60 yo M with esrd post transplant, copd, htn with progressive resp\n failure, hypotension, progressive ARF.\n Shift events:\n - spike temp to 101.1 BC sent, Tylenol X1 given , cont w/abx\n - -lactate up to 3.2 1 L NS given\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient intubated and vented on AC 100% 500X30/5 w/sats on ABG\n at 90. B/L diminished, still irregular breathing w/use of accessory\n muscles. No secretions w/suctioning. Last sputum positive for GNR. CXR\n w/ worsening infiltrates.\n Action:\n Remains intubated and vented, Fio2 down to 60%\n ABG: 7.20/54/94. Mouth\n care, MDI\ns ASDIR. Abg to eval. ABX for possible VAP\n Response:\n Pending abg: 7.26/38/131\n Plan:\n Continue to monitor resp status, f/u cultures, continue ABX, wean,\n SBT/RSBI, wean off when able.\n Hypotension (not Shock)\n Assessment:\n Received patient on maxed Neo and Vasopressin, after 7L IVF. Still\n hypotensive to 70\ns. Started on levophed. Patient also on steroids \n possible component of adrenal insufficiency. Tachycardic in \n w/occasional PAC\ns. General edema, peripheral pulses present w/doppler\n only, extr cool w/abnormal capillary refill. CVP 12-14, minimal UOP.\n Bladder pressure - 18\n Action:\n Pressors support (triple pressors) to maintain MAP >60 IVF to maintain\n CVP > 10, got 1 L bolus of Bicarb in D5W. stress steroids, abx to treat\n infection\n Response:\n Levophed weaned to OFF and neo to 2mcg/kg/min\n Plan:\n Continue to monitor patient\ns hemodynamic status, wean off pressors\n when able. F/u CX data, f/t ECHO read.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat\n 4.2 K-6.7 UOP minimal, bladder pressures -18\n Action:\n Total of 200MEq of Bicarb given, Insulin w/D50 given, calcium gluconate\n given, renal follows, continue on steroids/prograf/cellcept. At 1900\n another 500cc w/Bicarb given\n Response:\n Pending K-5.7\n Plan:\n Continue to monitor patient\ns renal status, f/u renal recs, eval for\n need of CVVH\n Constipation (Obstipation, FOS)\n Assessment:\n Since admission on either Fentanyl or methadone/oxycodone. No BM. abd\n distended, no BS or flatus. OGT to suction w/ 1500cc of bilious output\n over 2HR. Cdiff negative. Bladder pressure -18\n Action:\n NPO, OGT to suction, aggressive bowel regimen, KUB done, continues on\n Reglan q6hr.\n Response:\n Medium loose BM this afternoon\ncdiff sent, OGT still to suction with\n large output\n Plan:\n Continue to monitor patient status, f/u CX and KUB results, surgical\n consult???\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673239,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Hypertension, benign\n Assessment:\n Remains hypertensive w/B/P often in 170s.\n Action:\n Weaned off of NTG, remains on Nicardipine drip. Clonidine added to b/p\n regime and will increase amlodipine dose as ordered, hydralazine dose\n also increased. Urine output 300cc @ 0800, has not voided since, 250cc\n NS fluid bolus @ 1840.\n Response:\n Remains hypertensive. Poor urine output to match his poor PO intake (no\n appetite).\n Plan:\n Goals are to keep SBP 140-160 as discussed w/ICU team @ present until\n renal sets new b/p goals and to wean off nicardipine gtt if able.\n Monitor urine output.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt w/I/E wheezes t/o and fair aeration. Intermittant dyspnea at rest\n w/RR 30s and accessory muscle usage. Pt usually noncompliant\n w/instruction to keep albuterol continuous nebs on and insists on\n utilizing albuterol MDI despite explanations. Pt also refusing meds\n such as insulin and solumedrol this morning and also refused cardiac\n echo.\n Action:\n Pt intermittantly refusing medical treatment.\n Response:\n Remains in moderate respiratory distress.\n Plan:\n Cont w/NCP to encourage medication and treatment compliance. Cont to\n monitor respiratory distress.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673716,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Hypertension, benign\n Assessment:\n SBP 110\ns to 170\ns with HR 110\ns to 120\ns throughout shift. Pt. remains\n on fentanyl 100mcg/kg and propofol 90mcg/kg for sedation/comfort.\n Action:\n Pt. given IV hydralazine q6hr along with drips as noted above. Pt.\n bolused with 100mcg of fentanyl prior to nsg. care.\n Response:\n SBP remained labile throughout shift ranging from 110\ns to 170\n Remained tachycardic throughout shift.\n Plan:\n Continue to monitor patient hemodynamic status closely. Continue with\n propofol, fentanyl and hydralazine as ordered. If pt. remains\n hypertensive, may need to increase hydralazine dose.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt. remains intubated and vented on PSV 40% 15/5 with sats at high 90\n RR in 10\ns. Breath sounds diminished throughout. Some wheezes noted but\n clear with nebs. Pt. suctioned for copious amounts of thick green\n sputum.\n Action:\n MDIs given as ordered. Mouth care q4hr and prn, suction as needed. Pt.\n turned Q2h. Sputum sample collected and sent to lab.\n Response:\n Pt. remains stable on current vent settings. Ongoing respiratory\n assessment.\n Plan:\n Continue to monitor resp status, wean vent as tolerated, meds ASDIR,\n F/U with culture results.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673875,
"text": "60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n Of note, attempt to wean sedation for possible extubation\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. received intubated on pressure support 40%/. Labored breathing\n noted. Suctioned for scant amounts of thick green sputum. Culture + for\n gram negative rods. Sedated on propofol gtt but unable to increase\n sedation as pt. was hypotensive. Pt. unresponsive. No cough/gag reflex\n noted. No withdrawal to noxious stimuli, however, resp rate 30\ns to\n 40\ns. Nasal flaring noted with inhalation.\n Action:\n Multiple blood gases drawn throughout shift. (see metavision) Pt.\n increasingly acidotic and hypoxic. Vent changed to AC 60%/15/5. Started\n on IV vanco and zosyn for probable VAP pneumonia. Multiple Blood gases\n drawn throughout shift. Results show a metabolic acidosis. PH ranging\n from 7.25 to 7.30. Attempts made to increase sedation unsuccessful \n hypotension. Pt. turned Q2h. Mouth care Q4h.\n Response:\n Pt. continues to appear to have labored breathing.\n Plan:\n IV antibiotics to be administered as ordered. Aggressive pulmonary\n toilet.\n Hypotension (not Shock)\n Assessment:\n SBP as low as 70\ns at start of shift. UO 30-40cc/hr.\n Action:\n Fentanyl drip off. Propofol down to 25mcg/kg/mmin. Total of 5L NS\n boluses given at start of shift.\n Response:\n With fluid boluses SBP would increase to 120\ns and then trend back down\n to 80\ns when bolus completed. Phenylephrine started at 0100 to maintain\n MAPS >60.\n Plan:\n Wean pressor to maintain MAP >60. Continue to monitor hemodynamic\n status closely. Awaiting am lab results.\n Constipation (Obstipation, FOS)\n Assessment:\n Known decreased gastric motility. Abd soft distended, positive for BS\n and flatus, TFeeds restarted at at 10cc/hr. Residuals at 2200\n >360cc.\n Action:\n TFeeds off. Continue Reglan, lactulose and aggressive bowel regimen\n Response:\n Pending\n Plan:\n Continue to monitor patient status, aggressive bowel regiment until\n clears, may attempt to restart TF today if no residuals.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n s/p renal transplant, UOP decreased to 30-40cc/hr\n Action:\n Fluid boluses as noted above. Assessed UO Q1h. Steroids, cellcept, and\n prograf, administered as ordered.\n Response:\n Continue to follow GU status.\n Plan:\n Continue to monitor patient renal status, f/u renal recs. Fluid\n boluses as ordered. Replete sodium bicarb as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673876,
"text": "60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n Of note, attempt to wean sedation for possible extubation\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. received intubated on pressure support 40%/. Labored breathing\n noted. Suctioned for scant amounts of thick green sputum. Culture + for\n gram negative rods. Sedated on propofol gtt but unable to increase\n sedation as pt. was hypotensive. Pt. unresponsive. No cough/gag reflex\n noted. No withdrawal to noxious stimuli, however, resp rate 30\ns to\n 40\ns. Nasal flaring noted with inhalation.\n Action:\n Multiple blood gases drawn throughout shift. (see metavision) Pt.\n increasingly acidotic and hypoxic. Vent changed to AC 60%/500/20/5.\n Started on IV vanco and zosyn for probable VAP pneumonia. Attempts\n made to increase sedation unsuccessful hypotension. Pt. turned\n Q2h. Mouth care Q4h.\n Response:\n Pt. continues to appear to have labored breathing. Awaiting most recent\n blood gas result.\n Plan:\n IV antibiotics to be administered as ordered. Aggressive pulmonary\n toilet. Titrate vent to maintain optimal resp. support. If blood\n pressure improves with pressors, increase sedation to maintain pt.\n comfort.\n Hypotension (not Shock)\n Assessment:\n SBP as low as 70\ns at start of shift. Fluctuated from 70\ns to low 100\n with MAPS 50\ns to 70\ns. UO 30-40cc/hr.\n Action:\n Fentanyl drip off. Propofol down to 25mcg/kg/mmin. Total of 5L NS\n boluses given at start of shift. BP unresponsive to fluid.\n Phenylephrine started and titrated to maintain MAPS >65. Vasopressin\n also ordered, however, did not start as MAPS >65 on phenylephrine\n only.\n Response:\n Maps >65.\n Plan:\n Wean pressor to maintain MAP >65. Continue to monitor hemodynamic\n status and UO closely. Awaiting am lab results.\n Constipation (Obstipation, FOS)\n Assessment:\n Known decreased gastric motility. Abd soft distended, positive for BS\n and flatus, TFeeds restarted at at 10cc/hr. Residuals at 2200\n >360cc.\n Action:\n TFeeds off. Continue Reglan, lactulose and aggressive bowel regimen\n Response:\n Pending\n Plan:\n Continue to monitor patient status, aggressive bowel regiment until\n clears, may attempt to restart TF today if no residuals.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n s/p renal transplant, UOP decreased to 30-40cc/hr\n Action:\n Fluid boluses as noted above. Assessed UO Q1h. Steroids, cellcept, and\n prograf, administered as ordered.\n Response:\n Continue to follow GU status.\n Plan:\n Continue to monitor patient renal status, f/u renal recs. Fluid\n boluses as ordered. Replete sodium bicarb as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673881,
"text": "60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n Of note, attempt to wean sedation for possible extubation\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. received intubated on pressure support 40%/. Labored breathing\n noted. Suctioned for scant amounts of thick green sputum. Culture + for\n gram negative rods. Sedated on propofol gtt but unable to increase\n sedation as pt. was hypotensive. Pt. unresponsive. No cough/gag reflex\n noted. No withdrawal to noxious stimuli, however, resp rate 30\ns to\n 40\ns. Nasal flaring noted with inhalation.\n Action:\n Multiple blood gases drawn throughout shift. (see metavision) Pt.\n increasingly acidotic and hypoxic. Vent changed to AC 60%/500/20/5.\n Started on IV vanco and zosyn for probable VAP pneumonia. Attempts\n made to increase sedation unsuccessful hypotension. Pt. turned\n Q2h. Mouth care Q4h.\n Response:\n Pt. continues to appear to have labored breathing. Awaiting most recent\n blood gas result.\n Plan:\n IV antibiotics to be administered as ordered. Aggressive pulmonary\n toilet. Titrate vent to maintain optimal resp. support. If blood\n pressure improves with pressors, increase sedation to maintain pt.\n comfort.\n Hypotension (not Shock)\n Assessment:\n SBP as low as 70\ns at start of shift. Fluctuated from 70\ns to low 100\n with MAPS 50\ns to 70\ns. UO 30-40cc/hr.\n Action:\n Fentanyl drip off. Propofol down to 25mcg/kg/mmin. Total of 5L NS\n boluses given at start of shift. BP unresponsive to fluid.\n Phenylephrine started and titrated to maintain MAPS >65. Vasopressin\n also ordered, however, did not start as MAPS >65 on phenylephrine\n only.\n Response:\n Maps >65.\n Plan:\n Wean pressor to maintain MAP >65. Continue to monitor hemodynamic\n status and UO closely. Awaiting am lab results.\n Constipation (Obstipation, FOS)\n Assessment:\n Known decreased gastric motility. Abd soft distended, positive for BS\n and flatus, TFeeds restarted at at 10cc/hr. Residuals at 2200\n >360cc.\n Action:\n TFeeds off. Continue Reglan, lactulose and aggressive bowel regimen\n Response:\n Pending\n Plan:\n Continue to monitor patient status, aggressive bowel regiment until\n clears, may attempt to restart TF today if no residuals.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n s/p renal transplant, UOP decreased to 30-40cc/hr\n Action:\n Fluid boluses as noted above. Assessed UO Q1h. Steroids, cellcept, and\n prograf, administered as ordered.\n Response:\n Continue to follow GU status.\n Plan:\n Continue to monitor patient renal status, f/u renal recs. Fluid\n boluses as ordered. Replete sodium bicarb as needed.\n * This RN spoke with Dr. and Dr. regarding the policy of\n administering\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673882,
"text": "60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n Of note, attempt to wean sedation for possible extubation\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. received intubated on pressure support 40%/. Labored breathing\n noted. Suctioned for scant amounts of thick green sputum. Culture + for\n gram negative rods. Sedated on propofol gtt but unable to increase\n sedation as pt. was hypotensive. Pt. unresponsive. No cough/gag reflex\n noted. No withdrawal to noxious stimuli, however, resp rate 30\ns to\n 40\ns. Nasal flaring noted with inhalation.\n Action:\n Multiple blood gases drawn throughout shift. (see metavision) Pt.\n increasingly acidotic and hypoxic. Vent changed to AC 60%/500/20/5.\n Started on IV vanco and zosyn for probable VAP pneumonia. Attempts\n made to increase sedation unsuccessful hypotension. Pt. turned\n Q2h. Mouth care Q4h.\n Response:\n Pt. continues to appear to have labored breathing. Awaiting most recent\n blood gas result.\n Plan:\n IV antibiotics to be administered as ordered. Aggressive pulmonary\n toilet. Titrate vent to maintain optimal resp. support. If blood\n pressure improves with pressors, increase sedation to maintain pt.\n comfort.\n Hypotension (not Shock)\n Assessment:\n SBP as low as 70\ns at start of shift. Fluctuated from 70\ns to low 100\n with MAPS 50\ns to 70\ns. UO 30-40cc/hr.\n Action:\n Fentanyl drip off. Propofol down to 25mcg/kg/mmin. Total of 5L NS\n boluses given at start of shift. BP unresponsive to fluid.\n Phenylephrine started and titrated to maintain MAPS >65. Vasopressin\n also ordered, however, did not start as MAPS >65 on phenylephrine\n only.\n Response:\n Maps >65.\n Plan:\n Wean pressor to maintain MAP >65. Continue to monitor hemodynamic\n status and UO closely. Awaiting am lab results.\n Constipation (Obstipation, FOS)\n Assessment:\n Known decreased gastric motility. Abd soft distended, positive for BS\n and flatus, TFeeds restarted at at 10cc/hr. Residuals at 2200\n >360cc.\n Action:\n TFeeds off. Continue Reglan, lactulose and aggressive bowel regimen\n Response:\n Pending\n Plan:\n Continue to monitor patient status, aggressive bowel regiment until\n clears, may attempt to restart TF today if no residuals.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n s/p renal transplant, UOP decreased to 30-40cc/hr\n Action:\n Fluid boluses as noted above. Assessed UO Q1h. Steroids, cellcept, and\n prograf, administered as ordered.\n Response:\n Continue to follow GU status.\n Plan:\n Continue to monitor patient renal status, f/u renal recs. Fluid\n boluses as ordered. Replete sodium bicarb as needed.\n * This RN spoke with Dr. and Dr. regarding the policy of\n administering pressors through a midline. Intern, resource RN AND\n nursing supervisor spoke with Dr. regarding lack of access,\n policy and deterioration in pt.\ns condition. Attending MD, Dr. \n felt as though the central line could wait until the morning. *\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 674102,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 26cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Comments: ETT advanced 4cms, as MD .\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Icu->ct scan->icu\n 45 mins\n none\n Comments/Plan\n Pt remains intubated, fully vent supported. Minimal change in resp\n status overnight. Administering MDI\ns as ordered. No RSBI secondary\n to FiO2 @ 60%. See flowsheet for further pt data. Will follow.\n 06:24\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 674866,
"text": "Demographics\n Day of intubation: 9\n Day of mechanical ventilation: 9\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL / Air\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 673291,
"text": "Demographics\n Day of mechanical ventilation: 0\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Lung sounds\n RLL Lung Sounds: Insp/Exp Wheeze\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Ins/Exp Wheeze\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Accessory muscle use, Active\n exhalations\n Next 24-48 hours: Continue with nebs as ordered and as pt tolerates\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 673303,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -Urine legionella neg. CMV VL, BK, beta-gluc, galactomannan pending.\n -Tacro level 7.4 (Goal ).\n -Pt refused TTE.\n -Renal ultrasound: no acute findings.\n -Renal transplant recs: Chronic transplant nephropathy. Consider bx to\n r/o acute graft rejection.\n -BP: Cont hydral, amlodipine, and nicardipine gtt. Added clonidine.\n Nitro gtt weaned off. Uptitrated hydral 75 tid as BP still elevated.\n -UO: No urine output since 8am - refusing po intake. Given 250cc NS\n bolus with 250cc output. Started on LR @ 100/h for maintenance.\n - After MN dose of hydral, SBP decreased to 94, pt with\n lightheadedness. Nifedipine gtt discontinued. SBP 114 when rechecked,\n still lightheaded so gave 250 cc bolus LR, then started maint fluids.\n -Goal I/O (neg 500 cc)-\n -Satting well on room air, using nebulizer prn\n Patient reports that is breathing is not normal, but says everything is\n fine and refuses to answer more questions.\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:24 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.8\nC (96.4\n HR: 96 (75 - 102) bpm\n BP: 156/128(135) {114/48(46) - 191/128(135)} mmHg\n RR: 21 (16 - 25) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n Total In:\n 1,653 mL\n 912 mL\n PO:\n 720 mL\n TF:\n IVF:\n 933 mL\n 912 mL\n Blood products:\n Total out:\n 1,275 mL\n 350 mL\n Urine:\n 1,250 mL\n 350 mL\n NG:\n 25 mL\n Stool:\n Drains:\n Balance:\n 378 mL\n 562 mL\n Respiratory support\n SpO2: 92%\n ABG: ///17/\n Physical Examination\n General: Awake, alert, appears to be breathing heavily. .\n Pulmonary: Diffuse wheezes b/l. No crackles, no rhonchi, prolonged\n expiratory phase.\n Cardiac: RRR, S-S2 nl.\n Abdomen: BS present throughout, no tenderness on limited eval due to pt\n uncooperativeness\n Extremities: No edema. Has non-functional right UE fistula.\n Skin: Multiple keloids\n Neurologic: Alert, oriented x 3.\n Labs / Radiology\n 248 K/uL\n 10.1 g/dL\n 148 mg/dL\n 3.7 mg/dL\n 17 mEq/L\n 5.3 mEq/L\n 60 mg/dL\n 91 mEq/L\n 122 mEq/L\n 30.5 %\n 10.5 K/uL\n [image002.jpg]\n 07:57 AM\n 12:51 PM\n 09:53 PM\n 11:01 PM\n 03:22 AM\n 05:23 AM\n 04:15 AM\n WBC\n 4.3\n 7.4\n 10.5\n Hct\n 28.8\n 26.3\n 30.5\n Plt\n 170\n 214\n 248\n Cr\n 3.9\n 3.6\n 3.8\n 3.5\n 3.7\n 3.7\n TropT\n 0.08\n 0.05\n TCO2\n 21\n Glucose\n 129\n 529\n 178\n 497\n 211\n 148\n Other labs: PT / PTT / INR:13.9/35.5/1.2, CK / CKMB /\n Troponin-T:210/8/0.05, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:5.8 mg/dL\n Assessment and Plan\n 60M with ESRD s/p CRT, HTN, COPD p/w severe hypertension and dyspnea\n # Dyspnea: Underlying COPD with possible exacerabtion in setting of\n parainfluenza, also with component of CHF. Ruled out for ACS.\n -Continue frequent nebs.\n -Azithromycin x total 5 day course.\n -Consider decreasing prednisone dose as tx for parainfluenza mostly\n supportive but aided by reduction in steroids\n -F/u pending micro\n -Monitor I/O with goal net even to neg 500, consider diuresis\n -Completed ROMI\n #Hypertension: Has known difficult to control HTN, with hypertensive\n nephropathy/ESRD s/p transplant. Reports med adherence. be due to\n respiratory distress, HD steroids, narcotic withdrawal, renal failure,\n volume overload. No evidence of RAS on renal US. Currently at hydral\n 75mg q6H, clonidine 0.1mg PO TID, Amlodipine 10mg daily, Nicardipine\n gtt currently off.\n -Cont hydral, amlodipine, and lopressor. Will wean off nitro gtt and\n add clonidine po. Consider uptitrating hydral and amlodipine if stil no\n responsive.\n -Holding due to ARF\n -F/u renal recs\n # Acute renal failure: History of ESRD due to hypertensive nephropathy,\n had been on dialysis before CRT in . Reports adherence with\n immunosuppresants. Unclear precipitant for ARF, ddx includes\n dehydration, although unlikely given hypertension; transplant\n nephropathy. No evidence of RAS on ultrasound. Tacrolimus level in nl\n range. BK virus DNA not detected.\n -Continue prednisone (will d/w renal dose), cellcept, prograf\n -F/u renal transplant recs\n -Could consider bx to r/o acute transplant rejection\n -Cont to hold and gabapentin for now\n -Consider lasix, would be ok to give per Renal\n # Hyponatremia: Repeating labs as have had some spurious Na with this\n patient before but does seem to have some element of hyponatremia.\n Suspect SIADH likely secondary to lung process. Will check urine\n labs. Consider fluid restriction.\n -F/u repeat labs\n -F/u urine lytes\n # Hyperlipidemia:\n -continue statin and ezetimibe\n # DM:\n -HISS\n -diabetic diet\n # Chronic pain:\n -continue home oxycontin and dilaudid prn per OMR\n -Holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation:\n -senna, colace\n ICU Care\n Nutrition: Cardiac, low salt, diabetic diet, replete lytes prn\n Glycemic Control: RISS\n Lines:\n PICC Line - 04:26 PM\n Prophylaxis:\n DVT: Heparin SC 5000 tid\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU, call out to floor when BP better controlled\n"
},
{
"category": "General",
"chartdate": "2104-06-05 00:00:00.000",
"description": "ICU Event Note",
"row_id": 673325,
"text": "Clinician: Attending\n Patient with progressive respiratory failure.\n This was characterized by continued and significant wheezing--most\n prominently in central regions and with decreased breath sounds heard\n throughout--worsening from yesterday and worsening from this morning.\n In addition--patient with decrease in HCO3- to 13 with evolution of\n significant anion gap noted concering for possible lactic acidosis\n evolving from increased respiratory muscle work--although differential\n remains broad.\n Given progression of respiratory decline and continued un-sustainable\n work of breathing patient intubated by anesthesia on first attempt.\n Following intubation--minimal wheezes appreciated--patient with\n continued increased work of breathing and has peak inspiratory\n pressures that appear minimally elevated--but this is with continued\n respiratory effort throughout the respiratory cycle which may confound\n pressure measurements.\n Diffuse expiratory weezing heard which when combined with a near\n complete absence to racemic epinephrine would argue against a\n significant contribution from upper airway obstruction--and no stridor\n was ever heard.\n For now will-->\n -Place A-line\n -Support with volume cycled ventilation with adequate expiratory time\n -Wean FIO2 as possible\n -Advance ETT based on follow up CXR which showed it quite proximal in\n airway\n -Return to increased dosing of steroids as significant progression is\n seen in the setting of D/C\n -When able--will move to CT--of both chest and airways given atypical\n response to current intervetions although certainly this could be\n continued and significant response to viral pneumonia.\n Total time spent: 45 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673559,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received patient intubated and vented on PSV 40% 15/5 w/sats at high\n 90\ns RR in 10\ns. B/L LS exp wheezes. Intermittent non productive cough.\n Around 10 am appears in resp distress RR\ns, tachycardic to 120\n LS w/worsening wheezes. Sats remained in 90\ns. Patient appears\n fighting the vent, trying to get the ETT out.\n Action:\n Sedation increased to 100mcg/kg/min. MDI given. Paralytics given X1 to\n assess for flow obstruction/resistance. VAP precautions, mouth care\n q4hr and prn, suction prn. High dose steroids d/c since there was no\n improvement w/administration.\n Response:\n pending\n Plan:\n Continue to monitor resp status, wean off vent when able, meds ASDIR,\n f/u CX.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat- 4.1 K-5.3 UOP about 60cc/hr\n Action:\n Renal follows, renal biopsy done today, meds renally dosed. Continue\n cellcept, prograf( adjusted to daily level) /prednisone\n Response:\n pending\n Plan:\n Continue to monitor renal functions, f/u renal recs. f/u biopsy\n results.\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 673605,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments: white thick\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments: Pt. remains intubated on IPS overnoc, decreased to IPS 10.\n due to high VT .1L. BS very diminished, expiratory wheezes. Albuterol\n MDI given x 3. ABG metabolic acidosis slightly improving. RSBI 28 this\n am.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673713,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673714,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Assessment:\n B/P at 160-170\ns Hr at 80\ns SR, pedal edema, peripheral pulses\n present. After pain meds administration b/p at 140\ns and patient\n appears more comfortable. Later during the day b/p up to 190\ns HR at\n 110\ns w/frequent PAC\ns despite sedation and pain meds.\n Action:\n Started on fentanyl gtt and hydralazyne q6hr.\n Response:\n B/P at 120\n 130\ns. Hr still tachycardia at 110\n Plan:\n Continue to monitor patient hemodynamic status, increase hydralazyne\n dose if needed.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673867,
"text": "60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n Of note, attempt to wean sedation for possible extubation\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. received intubated on pressure support.\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Constipation (Obstipation, FOS)\n Assessment:\n Known decreased gastric motility. Abd soft distended, positive for BS\n and flatus, TFeeds restarted at at 10cc/hr. Residuals at 2200\n >360cc.\n Action:\n TFeeds off. Continue Reglan, lactulose and aggressive bowel regimen\n Response:\n Pending\n Plan:\n Continue to monitor patient status, aggressive bowel regiment until\n clears, may attempt to restart TF today if no residuals.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n s/p renal transplant, UOP decreased to 30-40cc/hr\n Action:\n Fluid boluses as noted above. Assessed UO Q1h. Steroids, cellcept, and\n prograf, administered as ordered.\n Response:\n Continue to follow GU status.\n Plan:\n Continue to monitor patient renal status, f/u renal recs. Fluid\n boluses as ordered. Replete sodium bicarb as needed.\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 674034,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 05:27 AM\n TRIPLE INTRODUCER - START 05:29 AM\n -Renal: am tacro level\n -SBT: Numbers were good per respiratory, but patient appeared to have\n increase work of breathing. Could not wean sedation enough to\n extubate, patient became agitated and had increased work of breathing.\n -Labile BP Sbp: 76 - 190s. Hypotension responded to fluid boluses,\n received a lot of fluid as suspecting sepsis.\n -Started on Vanc/Zosyn for presumed VAP\n -TF started then held for high residuals a few hours later\n -Changed from PS to CMV/Assist.\n -Hypotensive requiring initiation of pressors\n -Central line placed\n -Stress-dose steroids started\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 12:59 PM\n Piperacillin/Tazobactam (Zosyn) - 12:48 AM\n Metronidazole - 04:03 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Phenylephrine - 3.8 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:33 AM\n Fentanyl - 07:33 AM\n Hydralazine - 10:36 AM\n Heparin Sodium (Prophylaxis) - 11:49 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 109 (103 - 121) bpm\n BP: 106/73(85) {89/58(71) - 196/100(130)} mmHg\n RR: 33 (18 - 33) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 80 Inch\n CVP: 9 (9 - 16)mmHg\n CO/CI (Fick): (14.8 L/min) / (6.4 L/min/m2)\n Mixed Venous O2% Sat: 81 - 81\n Total In:\n 6,245 mL\n 2,888 mL\n PO:\n TF:\n 39 mL\n IVF:\n 5,865 mL\n 2,888 mL\n Blood products:\n Total out:\n 1,690 mL\n 1,175 mL\n Urine:\n 1,580 mL\n 175 mL\n NG:\n 110 mL\n 1,000 mL\n Stool:\n Drains:\n Balance:\n 4,555 mL\n 1,713 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 490 (482 - 655) mL\n PS : 15 cmH2O\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 28 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SpO2: 95%\n ABG: 7.16/49/205/17/-11\n Ve: 18.9 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General: intubated, sedated\n Pulmonary: poor air movement bilaterally, no wheezes\n Neck: R IJ in place\n Cardiac: tachycardic, regular, normal S1/S2\n Abdomen: Soft, hypoactive BS\n Extremities: No edema. Has non-functional right UE fistula. A-line in\n place LUE. Left midline.\n Skin: Multiple keloids\n Neurologic: sedated as above, not arousable to voice\n Labs / Radiology\n 369 K/uL\n 10.4 g/dL\n 70 mg/dL\n 3.6 mg/dL\n 17 mEq/L\n 5.1 mEq/L\n 71 mg/dL\n 102 mEq/L\n 134 mEq/L\n 32.5 %\n 28.2 K/uL\n [image002.jpg]\n 04:18 AM\n 04:26 PM\n 08:08 PM\n 10:13 PM\n 12:02 AM\n 02:20 AM\n 02:24 AM\n 03:19 AM\n 04:05 AM\n 05:43 AM\n WBC\n 23.2\n 28.2\n Hct\n 30.3\n 32.5\n Plt\n 364\n 369\n Cr\n 3.8\n 3.6\n TCO2\n 21\n 20\n 21\n 20\n 21\n 19\n 20\n 18\n Glucose\n 150\n 70\n Other labs: PT / PTT / INR:12.0/36.2/1.0, CK / CKMB /\n Troponin-T:210/8/0.05, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0\n %, Mono:8.0 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:9.2 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n CONSTIPATION (OBSTIPATION, FOS)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPERTENSION, BENIGN\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITHOUT ACUTE EXACERBATION\n 60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n # Hypotension: After being extremely hypertensive for several days, he\n became hypotensive overnight, not responsive to IVF and requiring the\n initiation of presors. Most likely secondary to sepsis given low CVP,\n CXR with infiltrate, and GNR in sputum. Also there is some concern\n for adrenal insufficiency, although he is currently on stress-dose\n steroids. CVP is low, so cardiogenic shock is less likely. Volume\n depletion may also be at play. Given abdominal distention there is\n also some concern for abdominal compartement syndrome.\n - continue pressure support with vasopressin, phenylephrine, levophed\n - attempt to wean levophed as tolerated to maintain MAP >60\n - f/u echo for potential cardiac cause\n - continue stress-dose steroids\n - continue vanc/zosyn for likely pulmonary source of infection\n - repeat stool for c diff\n - check bladder pressure\n .\n # Respiratory failure: Likely secondary to underlying COPD with\n reactive airway disease possibly worsened by parainfluenza causing\n small airway spasm. CT did not show any significant parenchymal\n disease. On exam he is not moving air well. ABGs show respiratory\n acidosis with adequate oxygenation\n - wean FiO2 to 60%\n - decrease RR and increase TV to try to improve ventilation\n - continue MDI as needed\n -\n # Acute renal failure: History of ESRD hypertensive nephropathy,\n now s/p CRT. Creatinine improving now, but low UOP with metabolic\n acidosis. Had bx, results pending but likely not rejection. Most\n likely cause of current renal failure is pre-renal secondary to\n hypotension.\n - f/u renal recs\n - await bx results\n - bicarbonate in fluids\n - minimize NS (will change meds to D5 solution as much as possible)\n - discuss with renal if CVVH may be indicated for volume removal.\n - continue steroids, cellcept, prograf for immunosuppresion\n # Abdominal distention: High residuals from tube feeds. H/o poor\n motility on prior gastric emptying study, may be DM. Likely also\n exacerbated by narcotics and has not had bowel mvt in days.\n - continue Reglan\n - check bladder pressure\n - may need placement of post-pyloric dobhoff for nutrition if not\n improving\n - repeat KUB\n # Abnormal TFTs: not consistent with sick euthyroid, low TSH indicates\n possible central process\n - discuss with endocrine\n - consider thyroid hormone replacement\n # Hyperlipidemia:\n -continue statin and ezetimibe\n # DM:\n -HISS\n -diabetic diet\n # Chronic pain:\n -Fentanyl gtt\n -holding po pain meds for now due to poor gastric motility (home\n oxycontin, methadone, and dilaudid prn)\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation:\n -senna, colace, bisacodyl pr, miralax, raglan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 10:00 AM\n Arterial Line - 06:00 PM\n 18 Gauge - 04:50 AM\n Multi Lumen - 05:27 AM\n Triple Introducer - 05:29 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 673287,
"text": "60 y/o M w/ an extensive PMH including R Hip hemiarthroplasty,\n diverticulitis, Renal transplant\n01, who presented to ED complaining\n of worsening SOB x 2 days. In the ED his vitals were significant for a\n NBP 193/113, and profound insp/exp wheezes, he received several\n abluterol/atrovent nebs, and was transferred to the M/SICU for further\n management of a COPD exacerbation and hypertension.\n Hypertension, benign\n Assessment:\n Patient with refractory hypertension now s/p nitroglycerin.\n Action:\n Patient started on Nicardipine infusion today with some effect. Had to\n be turned off for relative hypotension in the 110\ns. Continues on oral\n antihypertensives.\n Response:\n Patient\ns BP went to the 110\ns and he became symptomatic c/o of\nlight\n headedness\n. Now maintaining BP in the 140\n 160\ns. Urinary output\n has been poor overnight. Given two boluses totally 500cc with little\n output. Now on RL at 100ml/hr x1liter.\n Plan:\n Monitor v/s and treat hypertension as needed. Continue with oral\n antihypertensives.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Labored breathing with use of accessory muscles.\n Action:\n Remains on continuous nebs with schedules doses of atrovent/Albuterol\n nebs.\n Response:\n Patient continues with audible wheezing as well as exp. Wheezes\n throughout lobes. He is reluctant to keep the continuous nebs on and\n keeps it on intermittently.\n Plan:\n Give neb tx as ordered, asses for worsening symptoms. Follow lab\n trends.\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 673444,
"text": "TITLE:\n Chief Complaint: respiratory distress\n 24 Hour Events:\n -patient intubated\n -a-line placed\n -racemic epinephrine - didn't help\n -CT chest\n evaluation limited by respiratory motion; lungs are grossly\n clear with mild emphysema. ETT appropriately positioned. Intrathoracic\n trachea grossly patent, as are mainstem and proximal bronchi.\n -increase steroids --> solumedrol 125 q8\n -renal to consider Tx biopsy tomorrow.\n -decreased urine output, unable to obtain lytes\n -was hypotensive --> stopped HTN meds --> was on phenylephrine gtt for\n a little. Weaned off and bolused with NS to keep MAP > 65\n -no new micro data\n -transplant ultrasound: elevated resistive indices on Doppler, greater\n than 2 days earlier, suggesting rejection. No hydro or fluid\n collection.\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 12:30 PM\n Fentanyl - 12:30 PM\n Heparin Sodium (Prophylaxis) - 03:46 PM\n Propofol - 05:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 82 (77 - 124) bpm\n BP: 140/71(88) {94/44(63) - 206/118(121)} mmHg\n RR: 8 (7 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 80 Inch\n Total In:\n 2,039 mL\n 3,440 mL\n PO:\n TF:\n IVF:\n 1,919 mL\n 3,280 mL\n Blood products:\n Total out:\n 786 mL\n 315 mL\n Urine:\n 786 mL\n 315 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,253 mL\n 3,125 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 750 (600 - 750) mL\n PS : 15 cmH2O\n RR (Set): 10\n RR (Spontaneous): 7\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 14\n PIP: 14 cmH2O\n SpO2: 100%\n ABG: 7.27/39/129/14/-8\n Ve: 10.4 L/min\n PaO2 / FiO2: 322\n Physical Examination\n General: sedated, intubated\n Pulmonary: diffuse wheezes b/l. No crackles, no rhonchi, prolonged\n expiratory phase.\n Cardiac: RRR, S-S2 nl.\n Abdomen: BS present throughout, no tenderness on limited eval due to pt\n uncooperativeness\n Extremities: No edema. Has non-functional right UE fistula.\n Skin: Multiple keloids\n Neurologic: Alert, oriented x 3.\n Labs / Radiology\n 198 K/uL\n 9.2 g/dL\n 164 mg/dL\n 4.1 mg/dL\n 14 mEq/L\n 5.3 mEq/L\n 71 mg/dL\n 97 mEq/L\n 125 mEq/L\n 27.9 %\n 9.3 K/uL\n [image002.jpg]\n 11:01 PM\n 03:22 AM\n 05:23 AM\n 04:15 AM\n 06:45 AM\n 02:35 PM\n 06:28 PM\n 11:05 PM\n 02:59 AM\n 03:26 AM\n WBC\n 7.4\n 10.5\n 9.3\n Hct\n 26.3\n 30.5\n 27.9\n Plt\n \n Cr\n 3.8\n 3.5\n 3.7\n 3.7\n 4.1\n 4.1\n TropT\n 0.05\n TCO2\n 20\n 18\n 20\n 19\n Glucose\n 178\n 497\n 211\n 148\n 166\n 164\n Other labs: PT / PTT / INR:13.9/35.5/1.2, CK / CKMB /\n Troponin-T:210/8/0.05, Lactic Acid:0.7 mmol/L, Ca++:7.2 mg/dL, Mg++:1.9\n mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n 60 yo man with ESRD s/p CRT, HTN, COPD p/w severe hypertension and\n dyspnea, now intubated for progressive respiratory distress.\n # Dyspnea: Underlying COPD with possible exacerbation in setting of\n parainfluenza, also with component of CHF. Ruled out for ACS.\n Progressive respiratory distress required intubation on .\n -Continue frequent bronchodilator therapy\n -Azithromycin x total 5 day course (today is d3/5)\n -Continue steroids at 125 mg Solumedrol q8h\n -F/u micro data\n # Volatile blood pressure: Has known difficult to control HTN, with\n hypertensive nephropathy/ESRD s/p transplant. Reports med adherence.\n be due to respiratory distress, HD steroids, narcotic withdrawal,\n renal failure, volume overload. No evidence of RAS on renal US. Had\n been on hydral 75mg q6H, clonidine 0.1mg PO TID, Amlodipine 10mg daily,\n and Nicardipine gtt; however, post-intubation his blood pressure\n dropped and he has since required fluid boluses to maintain MAP >65.\n -Continue fluid boluses to maintain MAP >65\n -Holding due to ARF\n -F/u renal recs\n # Acute renal failure: History of ESRD due to hypertensive nephropathy,\n had been on dialysis before CRT in . Reports adherence with\n immunosuppresants. FeNa yesterday 1.4. Unclear precipitant for ARF,\n ddx includes dehydration, although unlikely given hypertension;\n transplant nephropathy. Question of rejection on most recent\n ultrasound. Tacrolimus level in nl range. BK virus DNA not detected.\n -Continue steroids, cellcept, prograf\n -F/u renal transplant recs; consider biopsy\n -Cont to hold and gabapentin for now\n -Consider lasix, would be ok to give per Renal\n # Hyponatremia: Suspect SIADH secondary to pulmonary process; urine\n osms 314 suggests that he may be inappropriately concentrating urine.\n Consider fluid restriction.\n -F/u renal recs\n -Consider free water restriction\n # Hyperlipidemia:\n -continue statin and ezetimibe\n # DM:\n -HISS\n -diabetic diet\n # Chronic pain:\n -continue home oxycontin, methadone, and dilaudid prn per OMR\n -holding gabapentin due to ARF\n # GERD:\n -Home PPI \n # Constipation:\n -senna, colace\n ICU Care\n Nutrition: start tube feeds today\n Glycemic Control: RISS\n Lines:\n PICC Line - 04:26 PM\n Prophylaxis:\n DVT: Heparin SC 5000 tid\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL code\n Disposition: ICU\n"
},
{
"category": "General",
"chartdate": "2104-06-04 00:00:00.000",
"description": "ICU Event Note",
"row_id": 673114,
"text": "Clinician: Attending\n Patient with slowly progressive respiratory distress over the course of\n the night. Blood pressure has been elevatd despite IV TNG. Amlodipine\n started.\n On exam, patient is in moderate respiratory distress with easily heard\n wheezes. JVP not well seen in patient sitting at 80 degrees. Heart\n sounds are soft. Patient with diminished breath sounds. There are\n diffuse expiratory wheezes with I/E=. Trace peripheral edema.\n Patient refusing ABG. Venous blood shows PCO2=39. Patient is also\n refusing mask ventilation (doesn't like the feel of the mask).\n CXR pending.\n IMP: Suspect hypertension reflecting, in part, sympathetic response to\n his respiratory distress. Patient given lasix empirically while waiting\n for CXR. Now that we know he is not hypercapnic, would also try small\n dose of IV morphine for comfort. Continuing with nebs. Consider\n Clonidine patch for hypertension if it persists after morphine. Given\n degree of wheezing, would be cautious with beta blockers.\n Total time spent: 30 minutes\n Patient is critically ill.\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-19 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 676619,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 15\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: agonal before being paralized\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n Comments: Pt. remains intubated on A/C, see medivision for multiple\n vent changes this shift. Pt. became ^ Acidotic throughout shift. ABG\n this am is slightly improved, but acidiosis persists. PIP^50\ns/plateau\n 35. Attempted PCV without success. Pt. paralyzed to optimize\n ventilation. Maintain current vent settings.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 675613,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt remains in NSR\n Rare PAC\ns and PVC\ns noted\n HR 80-105\n Action:\n Esmolol gtt off\n Monitoring labs\n Response:\n Pt remained NSR-NST\n HR 90-105\n Plan:\n Continue to monitor labs\n Esmolol if returns to afib\n Cardioversion for afib\n Hypotension (not Shock)\n Assessment:\n Pt with very labile BP, not tolerating turning or repositioning,\n dropping SBP to the 60\n Pt with Lg fluid requirements over the course of the shift to maintain\n SBP >90\n Neo gtt titrated to maintain SBP >90, Doses ranging 1.3-2.3\n Pt appearing very dry at start of shift with CO\ns , CI 1.2-1.9\n Preload very low\n Action:\n Titrating neo gtt to maintain SBP >90\n Fluid boluses for SBP <90\n Monitoring hemodynamics\n Albumin given x1\n Response:\n Pt with noted improvement in SBP with fluid boluses although short\n lived\n SBP remains very labile despite fluid and neo\n Noted improvement in CO, with CO\ns , CI \n Preload improving according to monitor\n No result from albumin noted\n Plan:\n Continue to monitor hemodynamics\n Continue with pressors to maintain SBP >90\n ? fluid boluses for lower BP\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS diminished in upper lobes, crackles and ronchi in lower lobes\n ABG declining over the course of the shift, pt becoming more acidotic\n and PaO2 60-80\n Pt discoordinate with vent at times, tahcypnic at times\n Pt vented CMV 600x24, PEEP 5, FiO2 50%\n Suctioned prn, no sputum obtained\n Action:\n Chest xray in AM\n Increased PEEP from 5 to 10\n Increased rate from 24 to 28\n Increased FiO2 to 60%\n Response:\n PaO2 remains 60-70\n No noted improvement in acidosis\n PCO2 remains 43-45\n No change in LS\n Chest Xray consistant with pulmonary edema MD \n Pt dropped pressure to 70\ns with increase in PEEP and therefore PEEP\n was returned to 5\n Plan:\n Continue with pulmonary toilet as pt tolerates\n Increase pressors in order to increase PEEP for better ventilation\n Monitor ABG\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt remains on CRRT\n Attempted to keep pt even at beginning of shift, but unable to due to\n BP and increased fluid requirement\n BUN and Cr remain stable\n Lytes wnl\n Oliguric, clear green urine via foley cath\n Action:\n Monitoring labs\n Repleteing lytes prn\n CRRT for clearance only, as pt does not tolerate any fluid removal\n Response:\n Renal function remains stable\n Pt 1L pos as of MN\n Lytes remain wnl\n Pt remains oliguric\n Plan:\n Continue with CRRT for clearance\n Continue to monitor labs\n Continue to replete labs prn\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 676154,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 676156,
"text": "60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS diminished throughout\n CMV 600x28, FiO2 50%, PEEP 7\n O2 sat 96-99% until 0200 when pt dropped O2 sat to 89% and\n was very slow to recover, only recovering to 93%, ABG sent with paO2 in\n the 60\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-19 00:00:00.000",
"description": "Intensivist Note",
"row_id": 676616,
"text": "SICU\n HPI:\n 60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd \n closed .\n Chief complaint:\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-assist R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n Current medications:\n 1. IV access: Peripheral line Order date: @ 1237\n 26. Insulin 100 Units/100 ml NS @ 2 UNIT/HR IV DRIP INFUSION\n Fingersticks every hour Order date: @ 1237\n 2. IV access: PICC, heparin dependent Location: Left basilic, Date\n inserted: Order date: @ 1237\n 27. Ipratropium Bromide MDI 6 PUFF IH Q6H Order date: @ 1237\n 3. IV access: Temporary central access (ICU) Order date: @ 1237\n 28. Magnesium Sulfate IV Sliding Scale Order date: @ 1237\n 4. IV access: Mid-line, heparin dependent Order date: @ 1237\n 29. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n Day 1 Order date: @ 1237\n 5. IV access: Dialysis Catheter (Temporary 2-Lumen) Location: Left\n Internal Jugular, Date inserted: Order date: @ 1237\n 30. Meropenem 1000 mg IV ONCE Duration: 1 Doses Order date: @\n 1243\n 6. IV access: None Order date: @ 1237\n 31. Meropenem 500 mg IV Q8H Order date: @ 1243\n 7. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 1237\n 32. Midazolam 0.5-5 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 2147\n 8. Albuterol Inhaler 6 PUFF IH Q6H:PRN dyspnea Order date: @\n 1237\n 33. Norepinephrine 0.03-0.5 mcg/kg/min IV DRIP INFUSION Order date:\n @ 0059\n 9. Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes Order date: \n @ 1237\n 34. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO sbp>90mmHg Order\n date: @ 1237\n 10. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes Order date:\n @ 0343\n 35. Potassium Chloride 20 mEq / 50 ml SW IV PRN for K < 3.5\n To supplement CRRT KCL infusion sliding scale protocol. Order date:\n @ 1237\n 11. Calcium Chloride IV Sliding Scale Order date: @ 1237\n 36. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1237\n 12. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1237\n 37. Prismasate (B22 K4)*\n Continuous at 500 ml/hr\n Dialysate Solution for CRRT Order date: @ 1237\n 13. Citrate Dextrose 3% (ACD-A) CRRT 150 mL/hr DIALYS ASDIR\n CRRT Protocol. Monitor systemic ionized calcium q6h. Adjust according\n to renal recommendations. Order date: @ 1237\n 38. Prismasate (B32 K2)\n Continuous at ml/hr\n Infuse Replacement fluid: Prefilter Rate: 1500 Postfilter Rate: 500\n Replacement Solution for CRRT Order date: @ 0030\n 14. Ciprofloxacin 400 mg IV Q12H Order date: @ 1237\n 39. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1237\n 15. Cisatracurium Besylate 0.06 MG/KG/HR IV DRIP INFUSION Duration: 24\n Hours Start: After completion of bolus dose\n Patient should be ventilated and sedated prior to initiating NMBAs.\n Order date: @ 2251\n 40. Sodium CITRATE 4% 3 mL DWELL ASDIR catheter not in use\n dwell to catheter volume written on catheter Order date: @ 1237\n 16. Cisatracurium Besylate 10 mg IV ONCE Duration: 1 Doses\n Patient should be ventilated and sedated prior to initiating NMBAs.\n Order date: @ 0115\n 41. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1237\n 17. Cisatracurium Besylate 10 mg IV ONCE MR1 Duration: 1 Doses\n Patient should be ventilated and sedated prior to initiating NMBAs.\n Order date: @ 0332\n 42. Sodium CITRATE 4% 2 mL DWELL ASDIR catheter not in use\n dwell to catheter volume printed on lumens Order date: @ 1237\n 18. Esmolol 500 MCG/KG/MIN IV BOLUS ONCE Duration: 1 Doses Order date:\n @ 1428\n 43. Sodium Bicarbonate 50 mEq IV ONCE MR1 Duration: 1 Doses Order date:\n @ 0151\n 19. Esmolol 50-200 mcg/kg/min IV DRIP INFUSION Duration: 24 Hours\n Start: After completion of bolus dose\n Please wean to off as HR tolerates (keep <100) Order date: @\n 2255\n 44. Sodium Bicarbonate 50 mEq IV ONCE Duration: 1 Doses Order date:\n @ 0256\n 20. Famotidine 20 mg IV Q24H Order date: @ 1237\n 45. Tacrolimus Suspension 0.5 mg PO BID\n Dose to be admin. at 6am and 6pm Order date: @ 1237\n 21. Fentanyl Citrate 25-200 mcg/hr IV DRIP INFUSION Order date: \n @ 2147\n 46. Tromethamine 500 mL IV ONCE Order date: @ 0306\n 22. Filgrastim 480 mcg IV Q24H Order date: @ 1243\n 47. Vancomycin 1250 mg IV Q 24H Order date: @ 1237\n 23. Fluticasone Propionate 110mcg 2 PUFF IH Order date: @\n 1237\n 48. Vasopressin 1.2 UNIT/HR IV DRIP TITRATE TO SBP>90 Order date:\n @ 1237\n 24. Heparin Flush (5000 Units/mL) 5000 UNIT DWELL PRN priming\n To be put into priming for CRRT. Order date: @ 1521\n 49. Vasopressin 40 UNIT IV ONCE Duration: 1 Doses Order date: @\n 0256\n 25. Hydrocortisone Na Succ. 50 mg IV Q8H Order date: @ 1237\n 24 Hour Events:\n EKG - At 02:08 PM\n DIALYSIS CATHETER - START 06:09 PM\n DIALYSIS CATHETER - STOP 06:19 PM\n CARDIOVERSION/DEFIBRILLATION - At 02:15 AM\n for unstable afib\n CARDIOVERSION/DEFIBRILLATION - At 02:39 AM\n for unstable afib\n - increasing vent requirements\n - paralyzed with cisatracurium gtt\n - started on levophed for worsening hypotension\n Post operative day:\n POD#9 - expl lap\n POD#8 - Hematoma cleaned out, one area on bowel to watch, ABD left\n open, will return to OR tomorrow \n POD#7 - exlap\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:03 AM\n Fluconazole - 08:24 AM\n Vancomycin - 10:02 AM\n Ciprofloxacin - 07:00 PM\n Meropenem - 10:00 PM\n Metronidazole - 10:00 PM\n Infusions:\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n Midazolam (Versed) - 3 mg/hour\n Cisatracurium - 0.08 mg/Kg/hour\n Vasopressin - 2.4 units/hour\n Insulin - Regular - 5 units/hour\n Fentanyl - 200 mcg/hour\n Phenylephrine - 5 mcg/Kg/min\n KCl (CRRT) - 1 mEq./hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:47 AM\n Cisatracurium - 01:20 AM\n Sodium Bicarbonate 8.4% (Amp) - 02:45 AM\n Other medications:\n Flowsheet Data as of 05:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 35.6\nC (96.1\n HR: 88 (80 - 132) bpm\n BP: 93/64(74) {77/41(51) - 127/82(94)} mmHg\n RR: 34 (23 - 34) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 121.1 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 22 (13 - 24) mmHg\n CO/CI (Thermodilution): (7.41 L/min) / (3.2 L/min/m2)\n SVR: -1,619 dynes*sec/cm5\n SV: 73 mL\n SVI: 32 mL/m2\n Total In:\n 8,836 mL\n 4,975 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,777 mL\n 4,370 mL\n Blood products:\n Total out:\n 5,711 mL\n 2,312 mL\n Urine:\n 65 mL\n 25 mL\n NG:\n 900 mL\n 250 mL\n Stool:\n Drains:\n 900 mL\n Balance:\n 3,125 mL\n 2,663 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 650 (550 - 650) mL\n RR (Set): 34\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%\n PIP: 59 cmH2O\n Plateau: 35 cmH2O\n Compliance: 28.3 cmH2O/mL\n SPO2: 94%\n ABG: 7.00/76./148/18/-14\n Ve: 17.5 L/min\n PaO2 / FiO2: 211\n Physical Examination\n General Appearance: intubated\n HEENT: edematous sclera, pupils sluggish\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : , Diminished: )\n Abdominal: Soft, Non-distended, wound vac on abdomen, no drainage\n around site\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Neurologic: (Responds to: Unresponsive), Sedated, Chemically paralyzed\n Labs / Radiology\n 35 K/uL\n 7.1 g/dL\n 125 mg/dL\n 2.0 mg/dL\n 18 mEq/L\n 5.5 mEq/L\n 54 mg/dL\n 102 mEq/L\n 134 mEq/L\n 22.6 %\n 2.3 K/uL\n [image002.jpg]\n 10:21 PM\n 11:11 PM\n 12:00 AM\n 12:16 AM\n 12:53 AM\n 01:29 AM\n 01:58 AM\n 03:02 AM\n 04:05 AM\n 04:19 AM\n WBC\n 1.5\n 2.3\n Hct\n 25.9\n 22.6\n Plt\n 28\n 35\n Creatinine\n 2.4\n 2.0\n TCO2\n 25\n 23\n 22\n 20\n 20\n 23\n 21\n 20\n Glucose\n 194\n 162\n 136\n 128\n 138\n 125\n Other labs: PT / PTT / INR:24.1/96.9/2.3, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:91/123, Alk-Phos / T bili:67/8.3, Amylase /\n Lipase:25/8, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %,\n Mono:8.0 %, Eos:0.0 %, Fibrinogen:267 mg/dL, Lactic Acid:8.4 mmol/L,\n Albumin:1.8 g/dL, LDH: IU/L, Ca:8.6 mg/dL, Mg:2.3 mg/dL, PO4:6.8\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), INEFFECTIVE COPING,\n INTESTINAL ISCHEMIA (INCLUDING MESENTERIC VENOUS / ARTERIAL THROMBOSIS,\n BOWEL ISCHEMIA), SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), CHRONIC OBSTRUCTIVE\n PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION\n Assessment and Plan: 60M admitted to for COPD exacerbation, became\n septic, developed ischemic bowel, s/p exlap, SBR, open abd , s/p ex\n lap, hematoma evacuation , s/p ex lap, end jejunostomy (150 cm SB),\n open abd closed .\n Neurologic: Cont fentanyl gtt, midaz gtt, cis gtt. Neuro recommends\n LP, EEG, CT (although not at this moment as pt extremely unstable).\n multiple reasons for depressed mental status even when off sedation.\n Cardiovascular: Goes in and out of afib with RVR. Cardioversion when\n unstable. Esmolol gtt if rapid rate but stable afib. On vasopressin,\n phenylephrine, levophed. Wean as tolerated.\n Pulmonary: Cont ETT, (Ventilator mode: CMV), On increasingly higher\n vent settings. Difficult to ventilate, pCO2 elevated. Continue to\n tweak vent settings to help with resp acidosis. Follow ABGs.\n Gastrointestinal / Abdomen: open abd with wound vac. NPO.\n Nutrition:\n Renal: UOP minimal, ARF on CVVH. Cr 2.0, stable. Off all\n immunosuppression, though consider restarting once WBC increases.\n Unable to remove volume at this point. Hyperkalemic but on CVVH. Cont\n to follow ABGs, likely combined resp and metabolic acidosis. Lactate\n climbing likely repeated episodes of hypotension.\n Hematology: Hct down to 22.6, consider transfusion. Plts 35 stable.\n WBC up to 2.3, cont neupogen. INR up to 2.3. Cont to follow. HIT\n neg.\n Endocrine: Insulin drip, Goal FS<150, Hydrocortisone q8\n Infectious Disease: WBC 2.3, cont Vanc//Cipro/Flagyl, follow vanc\n levels, cont neupogen\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP),\n Wound vac to abd, A-line, left IJ HD cath, right IJ TLC\n Wounds: open abd - wound vac\n Imaging:\n Fluids: bicarb gtt\n Consults: Transplant\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Failure), Post-op\n hypotension, Post-op shock, Sepsis, (Shock)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 01:46 PM 85. mL/hour\n Glycemic Control: Insulin infusion\n Lines:\n Midline - 10:00 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n Arterial Line - 04:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 675602,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt remains in NSR\n Rare PAC\ns and PVC\ns noted\n HR 80-105\n Action:\n Esmolol gtt off\n Monitoring labs\n Response:\n Pt remained NSR-NST\n HR 90-105\n Plan:\n Continue to monitor labs\n Esmolol if returns to afib\n Cardioversion for afib\n Hypotension (not Shock)\n Assessment:\n Pt with very labile BP, not tolerating turning or repositioning,\n dropping SBP to the 60\n Pt with Lg fluid requirements over the course of the shift to maintain\n SBP >90\n Neo gtt titrated to maintain SBP >90, Doses ranging 1.3-2.3\n Pt appearing very dry at start of shift with CO\ns , CI 1.2-1.9\n Preload very low\n Action:\n Titrating neo gtt to maintain SBP >90\n Fluid boluses for SBP <90\n Monitoring hemodynamics\n Albumin given x1\n Response:\n Pt with noted improvement in SBP with fluid boluses although short\n lived\n SBP remains very labile despite fluid and neo\n Noted improvement in CO, with CO\ns , CI \n Preload improving according to monitor\n No result from albumin noted\n Plan:\n Continue to monitor hemodynamics\n Continue with pressors to maintain SBP >90\n ? fluid boluses for lower BP\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS diminished in upper lobes, crackles and ronchi in lower lobes\n ABG declining over the course of the shift, pt becoming more acidotic\n and PaO2 60-80\n Pt discoordinate with vent at times, tahcypnic at times\n Pt vented CMV\n Action:\n Chest xray in AM\n Increased PEEP from 5 to 10\n Increased rate from 26 to 28\n Increased FiO2 to 60%\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-16 00:00:00.000",
"description": "Intensivist Note",
"row_id": 675864,
"text": "SICU\n HPI:\n 60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n .\n Chief complaint:\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-ass R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n Current medications:\n 1. IV access: Peripheral line Order date: @ 1031\n 22. Insulin 100 Units/100 ml NS @ 2 UNIT/HR IV DRIP INFUSION\n Fingersticks every hour Order date: @ 2238\n 2. IV access: PICC, heparin dependent Location: Left basilic, Date\n inserted: Order date: @ 1031\n 23. Ipratropium Bromide MDI 6 PUFF IH Q6H Order date: @ 0150\n 3. IV access: Temporary central access (ICU) Order date: @ 1031\n 24. Magnesium Sulfate IV Sliding Scale Order date: @ 1031\n 4. IV access: Mid-line, heparin dependent Order date: @ 1031\n 25. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n Day 1 Order date: @ 1031\n 5. IV access: Dialysis Catheter (Temporary 2-Lumen) Location: Left\n Internal Jugular, Date inserted: Order date: @ 1031\n 26. Midazolam 0.5-3 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 1639\n 6. IV access: None Order date: @ 1031\n 27. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO sbp>90mmHg Order\n date: @ 1031\n 7. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 1031\n 28. Piperacillin-Tazobactam Na 2.25 g IV Q6H Order date: @ 1031\n 8. Albuterol Inhaler 6 PUFF IH Q6H:PRN dyspnea Order date: @\n 0150\n 29. Potassium Chloride 20 mEq / 50 ml SW IV PRN for K < 3.5\n To supplement CRRT KCL infusion sliding scale protocol. Order date:\n @ 1031\n 9. Albumin 25% (12.5g / 50mL) 12.5 g IV Q8H Duration: 48 Hours Order\n date: @ 0741\n 30. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1031\n 10. Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes Order date: \n @ 2155\n 31. Prismasate (B22 K4)*\n Continuous at 500 ml/hr\n Dialysate Solution for CRRT Order date: @ 1818\n 11. Calcium Chloride IV Sliding Scale Order date: @ 1031\n 32. Prismasate (B22 K4)\n Continuous at ml/hr\n Infuse Replacement fluid: Prefilter Rate:1500 Postfilter Rate:200\n Replacement Solution for CRRT Order date: @ 1140\n 12. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1031\n 33. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1031\n 13. Citrate Dextrose 3% (ACD-A) CRRT 150 mL/hr DIALYS ASDIR\n CRRT Protocol. Monitor systemic ionized calcium q6h. Adjust according\n to renal recommendations. Order date: @ 1611\n 34. Sodium CITRATE 4% 3 mL DWELL ASDIR catheter not in use\n dwell to catheter volume written on catheter Order date: @ 1031\n 14. Ciprofloxacin 400 mg IV Q12H Order date: @ 0716\n 35. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1031\n 15. Famotidine 20 mg IV Q24H Order date: @ 0530\n 36. Sodium CITRATE 4% 2 mL DWELL ASDIR catheter not in use\n dwell to catheter volume printed on lumens Order date: @ 1031\n 16. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \n @ 1031\n 37. Tacrolimus Suspension 1 mg NG QAM Duration: 1 Doses\n Dose to be admin at 5/17 am. No PM dose on Order date: @\n 1734\n 17. Fluticasone Propionate 110mcg 2 PUFF IH Order date: @\n 1031\n 38. Tacrolimus Suspension 0.5 mg PO BID\n Dose to be admin. at 6pm and 6am Order date: @ 1650\n 18. Fluconazole 200 mg IV Q24H Order date: @ 0716\n 39. Vancomycin 1250 mg IV Q 24H Order date: @ 2252\n 19. Fluconazole 200 mg IV ONCE Duration: 1 Doses Start: Order\n date: @ 0757\n 40. Vasopressin 1.2 UNIT/HR IV DRIP TITRATE TO SBP>90 Order date:\n @ 0716\n 20. Hydrocortisone Na Succ. 100 mg IV ONCE Duration: 1 Doses Order\n date: @ 0736\n 41. Vecuronium Bromide 5 mg IV ONCE Duration: 1 Doses\n Patient must be intubated and sedated prior to administering NMBAs\n Order date: @ 0720\n 21. Hydrocortisone Na Succ. 50 mg IV Q8H Order date: @ 1206\n 24 Hour Events:\n - started albumin q8\n - started hydrocortisone q8\n - started vasopressin\n - d/c'd cellcept\n - transfused 2 units plts, 2 units RBC\n Post operative day:\n POD#6 - expl lap\n POD#5 - Hematoma cleaned out, one area on bowel to watch, ABD left\n open, will return to OR tomorrow \n POD#4 - exlap\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Piperacillin - 10:00 PM\n Vancomycin - 08:20 AM\n Fluconazole - 08:41 AM\n Metronidazole - 11:34 PM\n Piperacillin/Tazobactam (Zosyn) - 03:00 AM\n Ciprofloxacin - 05:05 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Insulin - Regular - 12 units/hour\n Calcium Gluconate (CRRT) - 1 grams/hour\n Vasopressin - 1.2 units/hour\n KCl (CRRT) - 1 mEq./hour\n Other ICU medications:\n Vecuronium - 07:15 AM\n Famotidine (Pepcid) - 08:38 AM\n Other medications:\n Flowsheet Data as of 06:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 36.9\nC (98.4\n HR: 99 (88 - 104) bpm\n BP: 115/63(78) {82/49(60) - 119/64(79)} mmHg\n RR: 28 (14 - 33) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 116.4 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 14 (9 - 18) mmHg\n CO/CI (Thermodilution): (9.17 L/min) / (4 L/min/m2)\n SVR: 471 dynes*sec/cm5\n SV: 91 mL\n SVI: 39 mL/m2\n Total In:\n 12,876 mL\n 2,322 mL\n PO:\n Tube feeding:\n IV Fluid:\n 9,690 mL\n 1,767 mL\n Blood products:\n 1,096 mL\n 50 mL\n Total out:\n 5,185 mL\n 1,961 mL\n Urine:\n 30 mL\n 15 mL\n NG:\n 600 mL\n 100 mL\n Stool:\n Drains:\n 2,350 mL\n 550 mL\n Balance:\n 7,691 mL\n 361 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 7 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 24 cmH2O\n Plateau: 16 cmH2O\n SPO2: 99%\n ABG: 7.36/40/108/21/-2\n Ve: 16.6 L/min\n PaO2 / FiO2: 216\n Physical Examination\n General Appearance: intubated, sedated\n HEENT: PERRL, pinpoint pupils\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: diffusely)\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: (Responds to: Noxious stimuli), Sedated\n Labs / Radiology\n 29 K/uL\n 9.3 g/dL\n 106 mg/dL\n 2.0 mg/dL\n 21 mEq/L\n 4.7 mEq/L\n 48 mg/dL\n 104 mEq/L\n 134 mEq/L\n 27.4 %\n 0.6 K/uL\n [image002.jpg]\n 11:47 AM\n 02:07 PM\n 05:22 PM\n 05:37 PM\n 08:39 PM\n 08:44 PM\n 11:11 PM\n 11:24 PM\n 02:14 AM\n 02:27 AM\n WBC\n 0.8\n 0.8\n 0.6\n Hct\n 23.5\n 26.2\n 27.4\n Plt\n 14\n 36\n 33\n 29\n Creatinine\n 1.9\n 2.0\n TCO2\n 24\n 23\n 24\n 22\n 24\n 24\n Glucose\n 157\n 154\n 143\n 149\n 134\n 128\n 115\n 106\n Other labs: PT / PTT / INR:17.6/41.0/1.6, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:176/120, Alk-Phos / T bili:96/9.0, Amylase /\n Lipase:831/21, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %,\n Mono:8.0 %, Eos:0.0 %, Fibrinogen:267 mg/dL, Lactic Acid:2.0 mmol/L,\n Albumin:1.8 g/dL, LDH: IU/L, Ca:9.4 mg/dL, Mg:2.1 mg/dL, PO4:3.0\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), INEFFECTIVE COPING,\n INTESTINAL ISCHEMIA (INCLUDING MESENTERIC VENOUS / ARTERIAL THROMBOSIS,\n BOWEL ISCHEMIA), SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), CHRONIC OBSTRUCTIVE\n PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION\n Assessment and Plan: 60M admitted to for COPD exacerbation, became\n septic, developed ischemic bowel, s/p exlap, SBR, open abd , s/p ex\n lap, hematoma evacuation , s/p ex lap, end jejunostomy (150 cm SB),\n open abd .\n Neurologic: Continue fentanyl gtt & midaz gtt for sedation.\n Cardiovascular: Currently in NSR, rate controlled, weaned off neo gtt,\n on low dose vasopressin gtt. CI/SVRI c/w vasodilatory shock, though\n well compensated. Continue monitoring.\n Pulmonary: Cont ETT, (Ventilator mode: CMV), Improving on current vent\n settings. Wean if possible. Following ABGs, cont\n Flovent/Atrovent/albuterol.\n Gastrointestinal / Abdomen: NPO. LFTs trending down. Continue on\n TPN. ?OR today for exlap, possible closure.\n Nutrition: TPN, NPO\n Renal: Foley, CVVH, Pt making minimal urine. Lytes stabilized on\n CVVH. Cont tacrolimus, follow levels. Remove volume as pressure\n tolerates. Continue albumin boluses.\n Hematology: Serial Hct, Received 2 units pRBC yesterday. Plts continue\n to be low. Transfused 1 unit yesterday for plt count 14, will\n transfuse today for plt count 29 (likely OR today). F/u on HIT panel.\n Endocrine: RISS, Continue hydrocortisone q8.\n Infectious Disease: WBC down to 0.6. Cont Zosyn/Flagyl/vanc/fluc.\n Daily vanc levels\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP),\n A-line, central line\n Wounds: Open abd.\n Imaging:\n Fluids:\n Consults: Transplant, Nephrology\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Failure), Sepsis,\n (Shock: Septic), Acute renal failure, Thrombocytopenia\n ICU Care\n Nutrition:\n TPN w/ Lipids - 04:28 PM 85. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n Arterial Line - 04:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-17 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 676147,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 13\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment: Possible air trapping\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated, Reduce\n PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Hemodynimic instability, Underlying illness not\n resolved\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 676655,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Received patient with CRRT on hold awaiting line confirmation\n Attempted to initiate at following line confirmation but found to\n be very positional\n Access pressure fluctuating rapidly from extremely negative to positive\n with pt respirations\n Respirations noted to be agonal and at times dissynchronous with\n ventilator\n After bloused with sedation and pt not over breathing access\n pressures noted to be stable\n Becoming increasingly acidotic overnight with combination metabolic and\n respiratory acidosis\n Renal fellow on call contact by SICU resident and replacement fluid\n changed to K2/Bicarb 32\n Unable to tolerate fluid removal and as of this morning running patient\n with positive fluid balance and requiring\n multiple fluid bolus via rescue line\n Minimal urine output\n Action:\n Attempted to run CRRT from -2230 and unable to run d/t positional\n line\n Pt taken off CRRT and circuit put on recirculation and attempted to\n increase sedation but unable to decrease additional respirations\n Paralyzed using cisatracurium\n Response:\n Access pressure stabilized and able to run CRRT constantly\n Plan:\n Continue to run as tolerated.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Worsening hypotension over evening requiring max doses of\n neosynephrine, levophed, and pitressin\n Worsening acidosis with increasing lactate up to 8 this morning\n Persistantly hypoxic and hypercarbic overnight\n Rapid afib with associated hypotension\n Elevated ST segments noted transiently on telemetry\n Pupils noted to be fixed and dialated at 0230\n Action:\n Frequent fluid bolus for SBP <80 via rescue line per Dr \n Bicarb gtt initiated and given multiple doses IVP although noted to\n have rising Co2\n Given 1 x dose Tromethamine\n Restarted on Esmolol gtt and for afib\n SICU resident, fellow, and transplant resident aware of pupils\n Response:\n Co2 improved after tromethamine\n Remains hemodynamically unstable and acidotic this morning\n Plan:\n Follow up with family this morning regarding withdrawl of care.\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-19 00:00:00.000",
"description": "Intensivist Note",
"row_id": 676656,
"text": "SICU\n HPI:\n 60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd \n closed .\n Chief complaint:\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-assist R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n Current medications:\n 1. IV access: Peripheral line Order date: @ 1237\n 26. Insulin 100 Units/100 ml NS @ 2 UNIT/HR IV DRIP INFUSION\n Fingersticks every hour Order date: @ 1237\n 2. IV access: PICC, heparin dependent Location: Left basilic, Date\n inserted: Order date: @ 1237\n 27. Ipratropium Bromide MDI 6 PUFF IH Q6H Order date: @ 1237\n 3. IV access: Temporary central access (ICU) Order date: @ 1237\n 28. Magnesium Sulfate IV Sliding Scale Order date: @ 1237\n 4. IV access: Mid-line, heparin dependent Order date: @ 1237\n 29. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n Day 1 Order date: @ 1237\n 5. IV access: Dialysis Catheter (Temporary 2-Lumen) Location: Left\n Internal Jugular, Date inserted: Order date: @ 1237\n 30. Meropenem 1000 mg IV ONCE Duration: 1 Doses Order date: @\n 1243\n 6. IV access: None Order date: @ 1237\n 31. Meropenem 500 mg IV Q8H Order date: @ 1243\n 7. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 1237\n 32. Midazolam 0.5-5 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 2147\n 8. Albuterol Inhaler 6 PUFF IH Q6H:PRN dyspnea Order date: @\n 1237\n 33. Norepinephrine 0.03-0.5 mcg/kg/min IV DRIP INFUSION Order date:\n @ 0059\n 9. Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes Order date: \n @ 1237\n 34. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO sbp>90mmHg Order\n date: @ 1237\n 10. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes Order date:\n @ 0343\n 35. Potassium Chloride 20 mEq / 50 ml SW IV PRN for K < 3.5\n To supplement CRRT KCL infusion sliding scale protocol. Order date:\n @ 1237\n 11. Calcium Chloride IV Sliding Scale Order date: @ 1237\n 36. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1237\n 12. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1237\n 37. Prismasate (B22 K4)*\n Continuous at 500 ml/hr\n Dialysate Solution for CRRT Order date: @ 1237\n 13. Citrate Dextrose 3% (ACD-A) CRRT 150 mL/hr DIALYS ASDIR\n CRRT Protocol. Monitor systemic ionized calcium q6h. Adjust according\n to renal recommendations. Order date: @ 1237\n 38. Prismasate (B32 K2)\n Continuous at ml/hr\n Infuse Replacement fluid: Prefilter Rate: 1500 Postfilter Rate: 500\n Replacement Solution for CRRT Order date: @ 0030\n 14. Ciprofloxacin 400 mg IV Q12H Order date: @ 1237\n 39. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1237\n 15. Cisatracurium Besylate 0.06 MG/KG/HR IV DRIP INFUSION Duration: 24\n Hours Start: After completion of bolus dose\n Patient should be ventilated and sedated prior to initiating NMBAs.\n Order date: @ 2251\n 40. Sodium CITRATE 4% 3 mL DWELL ASDIR catheter not in use\n dwell to catheter volume written on catheter Order date: @ 1237\n 16. Cisatracurium Besylate 10 mg IV ONCE Duration: 1 Doses\n Patient should be ventilated and sedated prior to initiating NMBAs.\n Order date: @ 0115\n 41. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1237\n 17. Cisatracurium Besylate 10 mg IV ONCE MR1 Duration: 1 Doses\n Patient should be ventilated and sedated prior to initiating NMBAs.\n Order date: @ 0332\n 42. Sodium CITRATE 4% 2 mL DWELL ASDIR catheter not in use\n dwell to catheter volume printed on lumens Order date: @ 1237\n 18. Esmolol 500 MCG/KG/MIN IV BOLUS ONCE Duration: 1 Doses Order date:\n @ 1428\n 43. Sodium Bicarbonate 50 mEq IV ONCE MR1 Duration: 1 Doses Order date:\n @ 0151\n 19. Esmolol 50-200 mcg/kg/min IV DRIP INFUSION Duration: 24 Hours\n Start: After completion of bolus dose\n Please wean to off as HR tolerates (keep <100) Order date: @\n 2255\n 44. Sodium Bicarbonate 50 mEq IV ONCE Duration: 1 Doses Order date:\n @ 0256\n 20. Famotidine 20 mg IV Q24H Order date: @ 1237\n 45. Tacrolimus Suspension 0.5 mg PO BID\n Dose to be admin. at 6am and 6pm Order date: @ 1237\n 21. Fentanyl Citrate 25-200 mcg/hr IV DRIP INFUSION Order date: \n @ 2147\n 46. Tromethamine 500 mL IV ONCE Order date: @ 0306\n 22. Filgrastim 480 mcg IV Q24H Order date: @ 1243\n 47. Vancomycin 1250 mg IV Q 24H Order date: @ 1237\n 23. Fluticasone Propionate 110mcg 2 PUFF IH Order date: @\n 1237\n 48. Vasopressin 1.2 UNIT/HR IV DRIP TITRATE TO SBP>90 Order date:\n @ 1237\n 24. Heparin Flush (5000 Units/mL) 5000 UNIT DWELL PRN priming\n To be put into priming for CRRT. Order date: @ 1521\n 49. Vasopressin 40 UNIT IV ONCE Duration: 1 Doses Order date: @\n 0256\n 25. Hydrocortisone Na Succ. 50 mg IV Q8H Order date: @ 1237\n 24 Hour Events:\n EKG - At 02:08 PM\n DIALYSIS CATHETER - START 06:09 PM\n DIALYSIS CATHETER - STOP 06:19 PM\n CARDIOVERSION/DEFIBRILLATION - At 02:15 AM\n for unstable afib\n CARDIOVERSION/DEFIBRILLATION - At 02:39 AM\n for unstable afib\n - increasing vent requirements\n - paralyzed with cisatracurium gtt\n - started on levophed for worsening hypotension\n Post operative day:\n POD#9 - expl lap\n POD#8 - Hematoma cleaned out, one area on bowel to watch, ABD left\n open, will return to OR tomorrow \n POD#7 - exlap\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:03 AM\n Fluconazole - 08:24 AM\n Vancomycin - 10:02 AM\n Ciprofloxacin - 07:00 PM\n Meropenem - 10:00 PM\n Metronidazole - 10:00 PM\n Infusions:\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n Midazolam (Versed) - 3 mg/hour\n Cisatracurium - 0.08 mg/Kg/hour\n Vasopressin - 2.4 units/hour\n Insulin - Regular - 5 units/hour\n Fentanyl - 200 mcg/hour\n Phenylephrine - 5 mcg/Kg/min\n KCl (CRRT) - 1 mEq./hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:47 AM\n Cisatracurium - 01:20 AM\n Sodium Bicarbonate 8.4% (Amp) - 02:45 AM\n Other medications:\n Flowsheet Data as of 05:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 35.6\nC (96.1\n HR: 88 (80 - 132) bpm\n BP: 93/64(74) {77/41(51) - 127/82(94)} mmHg\n RR: 34 (23 - 34) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 121.1 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 22 (13 - 24) mmHg\n CO/CI (Thermodilution): (7.41 L/min) / (3.2 L/min/m2)\n SVR: -1,619 dynes*sec/cm5\n SV: 73 mL\n SVI: 32 mL/m2\n Total In:\n 8,836 mL\n 4,975 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,777 mL\n 4,370 mL\n Blood products:\n Total out:\n 5,711 mL\n 2,312 mL\n Urine:\n 65 mL\n 25 mL\n NG:\n 900 mL\n 250 mL\n Stool:\n Drains:\n 900 mL\n Balance:\n 3,125 mL\n 2,663 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 650 (550 - 650) mL\n RR (Set): 34\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%\n PIP: 59 cmH2O\n Plateau: 35 cmH2O\n Compliance: 28.3 cmH2O/mL\n SPO2: 94%\n ABG: 7.00/76./148/18/-14\n Ve: 17.5 L/min\n PaO2 / FiO2: 211\n Physical Examination\n General Appearance: intubated\n HEENT: edematous sclera, pupils sluggish\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : , Diminished: )\n Abdominal: Soft, Non-distended, wound vac on abdomen, no drainage\n around site\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Neurologic: (Responds to: Unresponsive), Sedated, Chemically paralyzed\n Labs / Radiology\n 35 K/uL\n 7.1 g/dL\n 125 mg/dL\n 2.0 mg/dL\n 18 mEq/L\n 5.5 mEq/L\n 54 mg/dL\n 102 mEq/L\n 134 mEq/L\n 22.6 %\n 2.3 K/uL\n [image002.jpg]\n 10:21 PM\n 11:11 PM\n 12:00 AM\n 12:16 AM\n 12:53 AM\n 01:29 AM\n 01:58 AM\n 03:02 AM\n 04:05 AM\n 04:19 AM\n WBC\n 1.5\n 2.3\n Hct\n 25.9\n 22.6\n Plt\n 28\n 35\n Creatinine\n 2.4\n 2.0\n TCO2\n 25\n 23\n 22\n 20\n 20\n 23\n 21\n 20\n Glucose\n 194\n 162\n 136\n 128\n 138\n 125\n Other labs: PT / PTT / INR:24.1/96.9/2.3, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:91/123, Alk-Phos / T bili:67/8.3, Amylase /\n Lipase:25/8, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %,\n Mono:8.0 %, Eos:0.0 %, Fibrinogen:267 mg/dL, Lactic Acid:8.4 mmol/L,\n Albumin:1.8 g/dL, LDH: IU/L, Ca:8.6 mg/dL, Mg:2.3 mg/dL, PO4:6.8\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), INEFFECTIVE COPING,\n INTESTINAL ISCHEMIA (INCLUDING MESENTERIC VENOUS / ARTERIAL THROMBOSIS,\n BOWEL ISCHEMIA), SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), CHRONIC OBSTRUCTIVE\n PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION\n Assessment and Plan: 60M admitted to for COPD exacerbation, became\n septic, developed ischemic bowel, s/p exlap, SBR, open abd , s/p ex\n lap, hematoma evacuation , s/p ex lap, end jejunostomy (150 cm SB),\n open abd closed . Making him CMO\n Neurologic: Cont fentanyl gtt, midaz gtt, cis gtt. Neuro recommends\n LP, EEG, CT (although not at this moment as pt extremely unstable).\n multiple reasons for depressed mental status even when off sedation.\n Cardiovascular: Goes in and out of afib with RVR. Cardioversion when\n unstable. Esmolol gtt if rapid rate but stable afib. On vasopressin,\n phenylephrine, levophed. Wean as tolerated. Will decrease FI02.\n keep on vent Stop pressors\n Pulmonary: Cont ETT, (Ventilator mode: CMV), On increasingly higher\n vent settings. Difficult to ventilate, pCO2 elevated. Continue to\n tweak vent settings to help with resp acidosis. Follow ABGs.\n Gastrointestinal / Abdomen: open abd with wound vac. NPO.\n Nutrition:\n Renal: UOP minimal, ARF on CVVH. Cr 2.0, stable. Off all\n immunosuppression, though consider restarting once WBC increases.\n Unable to remove volume at this point. Hyperkalemic but on CVVH. Cont\n to follow ABGs, likely combined resp and metabolic acidosis. Lactate\n climbing likely repeated episodes of hypotension.\n Hematology: Hct down to 22.6, consider transfusion. Plts 35 stable.\n WBC up to 2.3, cont neupogen. INR up to 2.3. Cont to follow. HIT\n neg.\n Endocrine: Insulin drip, Goal FS<150, Hydrocortisone q8\n Infectious Disease: WBC 2.3, cont Vanc//Cipro/Flagyl, follow vanc\n levels, cont neupogen\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP),\n Wound vac to abd, A-line, left IJ HD cath, right IJ TLC\n Wounds: open abd - wound vac\n Imaging:\n Fluids: bicarb gtt\n Consults: Transplant\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Failure), Post-op\n hypotension, Post-op shock, Sepsis, (Shock)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 01:46 PM 85. mL/hour\n Glycemic Control: Insulin infusion\n Lines:\n Midline - 10:00 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n Arterial Line - 04:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care,\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR (do not resuscitate) Now CMO Discuassed with Dr\n \n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 676665,
"text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Patient unresponsive pupils unreactive at 6mm bilaterally. BP initially\n 130 systolic after bicarb for ph 6.9, K+5.5.\n Action:\n KCL d/c At 730am BP dropping and maintained onl,y with wide open NS\n as well as the triple pressors at max. Dr. and the ICU team\n in to see patient. Futility of continuation discussed. Dr \n spoke with family in room,\n Response:\n while he was discussing futility of our efforts, the patient\ns BP and\n HR began dropping despite full therapy. He became asystolic and was\n pronounced by Dr. after 815am\n Plan:\n Support given to family. Funeral home called by son\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-17 00:00:00.000",
"description": "Intensivist Note",
"row_id": 676221,
"text": "SICU\n HPI:\n 60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n .\n Chief complaint:\n postoperative respiratory failure, septic shock\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-ass R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n Current medications:\n Calcium Gluconate/ 500 mL D5W 8. Albuterol Inhaler 9. Artificial Tears\n 10. Calcium Chloride 11. Chlorhexidine Gluconate 0.12% Oral Rinse 12.\n Citrate Dextrose 3% (ACD-A) CRRT\n 13. Ciprofloxacin 14. Famotidine 15. Fentanyl Citrate 16. Filgrastim\n 17. Fluticasone Propionate 110mcg\n 18. Fluconazole 19. Hydrocortisone Na Succ. 20. Insulin 21. Ipratropium\n Bromide MDI 22. Magnesium Sulfate\n 23. MetRONIDAZOLE (FLagyl) 24. Midazolam 25. Phenylephrine 26.\n Piperacillin-Tazobactam Na 27. Potassium Chloride 28. Potassium\n Chloride 10 mEq / 100 mL SW (CRRT Only) 29. Prismasate (B22 K4)* 30.\n Prismasate (B22 K4) 31. Sodium Chloride 0.9% Flush 32. Sodium CITRATE\n 4% 33. Sodium Chloride 0.9% Flush 34. Sodium CITRATE 4% 35. Tacrolimus\n Suspension 36. Tacrolimus Suspension 37. Vancomycin 38. Vasopressin\n 24 Hour Events:\n BLOOD CULTURED - At 10:06 AM\n via rij triple lumen\n SPUTUM CULTURE - At 11:06 AM\n URINE CULTURE - At 11:06 AM\n Post operative day:\n POD#7 - expl lap\n POD#6 - Hematoma cleaned out, one area on bowel to watch, ABD left\n open, will return to OR tomorrow \n POD#5 - exlap\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Piperacillin - 10:00 PM\n Ciprofloxacin - 05:05 AM\n Vancomycin - 08:37 AM\n Fluconazole - 10:10 AM\n Metronidazole - 10:00 PM\n Piperacillin/Tazobactam (Zosyn) - 04:07 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Calcium Gluconate (CRRT) - 1 grams/hour\n Insulin - Regular - 11 units/hour\n Fentanyl - 150 mcg/hour\n Vasopressin - 2.4 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Other medications:\n Flowsheet Data as of 05:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 37\nC (98.6\n HR: 101 (92 - 105) bpm\n BP: 90/57(66) {80/47(57) - 129/67(84)} mmHg\n RR: 16 (14 - 30) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 121.1 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 15 (12 - 20) mmHg\n CO/CI (Thermodilution): (6.85 L/min) / (3 L/min/m2)\n SVR: 689 dynes*sec/cm5\n SV: 74 mL\n SVI: 32 mL/m2\n Total In:\n 9,932 mL\n 2,172 mL\n PO:\n Tube feeding:\n IV Fluid:\n 7,523 mL\n 1,673 mL\n Blood products:\n 346 mL\n Total out:\n 10,442 mL\n 2,465 mL\n Urine:\n 46 mL\n 20 mL\n NG:\n 1,500 mL\n 750 mL\n Stool:\n Drains:\n 1,850 mL\n 250 mL\n Balance:\n -510 mL\n -293 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 28\n RR (Spontaneous): 1\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 28 cmH2O\n Plateau: 22 cmH2O\n Compliance: 66.7 cmH2O/mL\n SPO2: 95%\n ABG: 7.40/40/91./23/0\n Ve: 18.1 L/min\n PaO2 / FiO2: 153\n Physical Examination\n General Appearance: intubated and sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachycardic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: throughout)\n Abdominal: Soft, Distended, No(t) Tender:\n Left Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: open abdomen\n Neurologic: (Responds to: Tactile stimuli, Noxious stimuli), No(t)\n Moves all extremities, Sedated\n Labs / Radiology\n 41 K/uL\n 9.6 g/dL\n 105 mg/dL\n 2.1 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 51 mg/dL\n 99 mEq/L\n 130 mEq/L\n 27.2 %\n 0.4 K/uL\n [image002.jpg]\n 07:50 AM\n 02:26 PM\n 02:42 PM\n 08:07 PM\n 08:26 PM\n 12:53 AM\n 01:15 AM\n 01:58 AM\n 02:09 AM\n 02:54 AM\n WBC\n 0.4\n 0.4\n Hct\n 27.5\n 27.2\n Plt\n 41\n 41\n Creatinine\n 2.1\n 2.2\n 2.1\n TCO2\n 24\n 23\n 24\n 26\n 25\n 27\n 26\n Glucose\n 128\n 120\n 110\n 82\n 76\n 97\n 119\n 105\n Other labs: PT / PTT / INR:17.8/41.5/1.6, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:144/107, Alk-Phos / T bili:93/10.3, Amylase /\n Lipase:831/21, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %,\n Mono:8.0 %, Eos:0.0 %, Fibrinogen:267 mg/dL, Lactic Acid:1.6 mmol/L,\n Albumin:1.8 g/dL, LDH: IU/L, Ca:9.3 mg/dL, Mg:2.0 mg/dL, PO4:3.0\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), INEFFECTIVE COPING,\n INTESTINAL ISCHEMIA (INCLUDING MESENTERIC VENOUS / ARTERIAL THROMBOSIS,\n BOWEL ISCHEMIA), SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), CHRONIC OBSTRUCTIVE\n PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION\n Assessment and Plan: 60M admitted to for COPD exacerbation, became\n septic, developed ischemic bowel, s/p exlap, SBR, open abd , s/p ex\n lap, hematoma evacuation , s/p ex lap, end jejunostomy (150 cm SB),\n open abd .\n Neurologic: Neuro checks Q: hr, Pain controlled, wean fentanyl gtt &\n midaz\n Cardiovascular: Currently in NSR, rate controlled, restarted on\n vasopressin\n Pulmonary: Cont ETT, (Ventilator mode: CMV), CXR, serial ABGs, cont\n Flovent/Atrovent/albuterol\n Gastrointestinal / Abdomen: NPO, LFTs trending down, TPN, OR this AM\n Nutrition: TPN, NPO\n Renal: Foley, UOP minimal, ARF on CRF, Cr 2.1, stable, cont tacrolimus,\n Cellcept dc'd, check levels, CVVH, remove volume as pressure tolerates\n Hematology: Serial Hct, hct-27.2 stable, plts 41, inr-1.5, f/u HIT\n panel\n Endocrine: Insulin drip, goal FS<150, Hydrocortisone q8\n Infectious Disease: Check cultures, WBC down to 046, cont\n VancZosyn/Cipro/Flagyl/Fluc, f/u cx, daily vanc levels, neupogen\n started\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP),\n Aline, CVL, HD line, JPx2, open abd\n Wounds: Dry dressings\n Imaging: OR today\n Fluids: KVO\n Consults: General surgery, Nephrology\n Billing Diagnosis: (Respiratory distress: Failure), (Shock: Septic)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 03:43 PM 85. mL/hour\n Glycemic Control:\n Lines:\n Midline - 10:00 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n Arterial Line - 04:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up,\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-15 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 675700,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Bedside Procedures:\n Comments:\n Patient remains intubated and on mechanical ventilation, breath sounds\n bilaterally diminished, suctioned intermittently for moderate amounts\n of thick yellow secretions, treated with Albuterol, atrovent and\n Flovent inhalers, PEEP increased from 5 to 7 in the morning, FiO2\n weaned from 60 to 50%, CVVHD still running, SPO2 remained upper 90s,\n will continues to be followed.\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 675842,
"text": "Demographics\n Day of intubation: 12\n Day of mechanical ventilation: 12\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL / Air\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Pending procedure /\n OR, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 676346,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n PO2 60\n Minimal secretions\n Action:\n PEEP 10\n Changed to triadyne rotating bed\n Cont on vanc/zosyn/flagyl/cipro/fluconazole\n Response:\n Po2 increased to 130-140\n Plan:\n Cont triadyne bed\n Ean fio2 and PEEP as tolerated\n Pulm toilet\n Cont CRRT to goal of even\n Ineffective Coping\n Assessment:\n Mother calling in for updates\n Action:\n Updates given over the phone\n Response:\n happy with plan of care\n Questions answered\n Plan:\n Cont to support family in plan of care\n Answer questions prn\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CVVHDF cont. with minimal hypotension later in day\n Action:\n CVVHDF cont to keep patient even\n Bloused with ns via CRRT line\n Remains on low dose neo to keep sys >90 and pitressin,\n Response:\n Unable to wean pitressin\n Tolerating neo off at times\n numbers consistent with adequate resuscitation\n Plan:\n Cont CRRT with goal even\n Wean neo as tolerated followed by pitressin wean\n Bolus prn if numbers appear dry\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Action:\n Pt to OR for abdominal closure with mesh and vac placement\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-18 00:00:00.000",
"description": "Intensivist Note",
"row_id": 676476,
"text": "SICU\n HPI:\n 60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n .\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-assist R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n Current medications:\n 1. IV access: Peripheral line Order date: @ 1237\n 20. Insulin 100 Units/100 ml NS @ 2 UNIT/HR IV DRIP INFUSION\n Fingersticks every hour Order date: @ 1237\n 2. IV access: PICC, heparin dependent Location: Left basilic, Date\n inserted: Order date: @ 1237\n 21. Ipratropium Bromide MDI 6 PUFF IH Q6H Order date: @ 1237\n 3. IV access: Temporary central access (ICU) Order date: @ 1237\n 22. Magnesium Sulfate IV Sliding Scale Order date: @ 1237\n 4. IV access: Mid-line, heparin dependent Order date: @ 1237\n 23. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n Day 1 Order date: @ 1237\n 5. IV access: Dialysis Catheter (Temporary 2-Lumen) Location: Left\n Internal Jugular, Date inserted: Order date: @ 1237\n 24. Midazolam 0.5-3 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 1237\n 6. IV access: None Order date: @ 1237\n 25. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO sbp>90mmHg Order\n date: @ 1237\n 7. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 1237\n 26. Piperacillin-Tazobactam Na 2.25 g IV Q6H Order date: @ 1237\n 8. Albuterol Inhaler 6 PUFF IH Q6H:PRN dyspnea Order date: @\n 1237\n 27. Potassium Chloride 20 mEq / 50 ml SW IV PRN for K < 3.5\n To supplement CRRT KCL infusion sliding scale protocol. Order date:\n @ 1237\n 9. Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes Order date: \n @ 1237\n 28. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1237\n 10. Calcium Chloride IV Sliding Scale Order date: @ 1237\n 29. Prismasate (B22 K4)*\n Continuous at 500 ml/hr\n Dialysate Solution for CRRT Order date: @ 1237\n 11. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1237\n 30. Prismasate (B22 K4)\n Continuous at ml/hr\n Infuse Replacement fluid: Prefilter Rate:1500 Postfilter Rate:200\n Replacement Solution for CRRT Order date: @ 1237\n 12. Citrate Dextrose 3% (ACD-A) CRRT 150 mL/hr DIALYS ASDIR\n CRRT Protocol. Monitor systemic ionized calcium q6h. Adjust according\n to renal recommendations. Order date: @ 1237\n 31. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1237\n 13. Ciprofloxacin 400 mg IV Q12H Order date: @ 1237\n 32. Sodium CITRATE 4% 3 mL DWELL ASDIR catheter not in use\n dwell to catheter volume written on catheter Order date: @ 1237\n 14. Famotidine 20 mg IV Q24H Order date: @ 1237\n 33. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1237\n 15. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \n @ 1237\n 34. Sodium CITRATE 4% 2 mL DWELL ASDIR catheter not in use\n dwell to catheter volume printed on lumens Order date: @ 1237\n 16. Filgrastim 480 mcg IV ONCE Duration: 1 Doses Order date: @\n 1237\n 35. Tacrolimus Suspension 0.5 mg PO BID\n Dose to be admin. at 6am and 6pm Order date: @ 1237\n 17. Fluticasone Propionate 110mcg 2 PUFF IH Order date: @\n 1237\n 36. Vancomycin 1250 mg IV Q 24H Order date: @ 1237\n 18. Fluconazole 200 mg IV Q24H Order date: @ 1237\n 37. Vasopressin 1.2 UNIT/HR IV DRIP TITRATE TO SBP>90 Order date:\n @ 1237\n 19. Hydrocortisone Na Succ. 50 mg IV Q8H Order date: @ 1237\n 24 Hour Events:\n EKG - At 01:01 PM\n for peaked t waves\n EKG - At 11:05 PM\n for peaked t waves and ? ST elevation\n -OR for abdominal wound closure\n Post operative day:\n POD#8 - expl lap\n POD#7 - Hematoma cleaned out, one area on bowel to watch, ABD left\n open, will return to OR tomorrow \n POD#6 - exlap\n POD#1- abdominal wound closure\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 08:15 AM\n Fluconazole - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 04:03 AM\n Metronidazole - 06:04 AM\n Ciprofloxacin - 06:04 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 150 mcg/hour\n Phenylephrine - 0.8 mcg/Kg/min\n Insulin - Regular - 3 units/hour\n Calcium Gluconate (CRRT) - 1 grams/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 37.3\nC (99.1\n HR: 94 (91 - 108) bpm\n BP: 93/51(63) {85/45(57) - 127/68(87)} mmHg\n RR: 27 (0 - 29) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 121.1 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 13 (12 - 211) mmHg\n CO/CI (Thermodilution): (7.87 L/min) / (3.4 L/min/m2)\n SVR: -1,596 dynes*sec/cm5\n SV: 70 mL\n SVI: 30 mL/m2\n Total In:\n 9,468 mL\n 2,540 mL\n PO:\n Tube feeding:\n IV Fluid:\n 7,409 mL\n 1,880 mL\n Blood products:\n Total out:\n 9,520 mL\n 2,312 mL\n Urine:\n 70 mL\n 15 mL\n NG:\n 1,200 mL\n 450 mL\n Stool:\n Drains:\n 1,325 mL\n 450 mL\n Balance:\n -52 mL\n 228 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 25\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 26 cmH2O\n Plateau: 23 cmH2O\n Compliance: 66.7 cmH2O/mL\n SPO2: 97%\n ABG: 7.35/44/78./24/-1\n Ve: 15.5 L/min\n PaO2 / FiO2: 132\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : diffusely)\n Abdominal: Soft, Wound Vac to abdominal wound, holding suction, ostomy\n dusky\n Left Extremities: (Edema: 2+), (Temperature: Cool)\n Right Extremities: (Edema: 2+), (Temperature: Cool)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Unresponsive), Sedated\n Labs / Radiology\n 31 K/uL\n 8.9 g/dL\n 76 mg/dL\n 2.0 mg/dL\n 24 mEq/L\n 4.7 mEq/L\n 57 mg/dL\n 101 mEq/L\n 130 mEq/L\n 25.5 %\n 0.4 K/uL\n [image002.jpg]\n 08:31 AM\n 10:33 AM\n 01:03 PM\n 01:14 PM\n 08:17 PM\n 08:36 PM\n 10:28 PM\n 02:11 AM\n 02:23 AM\n 06:14 AM\n WBC\n 0.3\n 0.4\n Hct\n 27\n 27.1\n 25.7\n 25.5\n Plt\n 23\n 31\n Creatinine\n 2.2\n 2.1\n 2.0\n TCO2\n 26\n 24\n 25\n 26\n 25\n 26\n 25\n Glucose\n 88\n 73\n 75\n 98\n 89\n 86\n 85\n 76\n Other labs: PT / PTT / INR:18.3/44.9/1.7, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:121/103, Alk-Phos / T bili:80/11.7, Amylase /\n Lipase:25/8, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %,\n Mono:8.0 %, Eos:0.0 %, Fibrinogen:267 mg/dL, Lactic Acid:1.8 mmol/L,\n Albumin:1.8 g/dL, LDH: IU/L, Ca:9.2 mg/dL, Mg:2.0 mg/dL, PO4:3.4\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), INEFFECTIVE COPING,\n INTESTINAL ISCHEMIA (INCLUDING MESENTERIC VENOUS / ARTERIAL THROMBOSIS,\n BOWEL ISCHEMIA), SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), CHRONIC OBSTRUCTIVE\n PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION\n Assessment and Plan: 60M admitted to for COPD exacerbation, became\n septic, developed ischemic bowel, s/p exlap, SBR, open abd , s/p ex\n lap, hematoma evacuation , s/p ex lap, end jejunostomy (150 cm SB),\n open abd .\n Neurologic: wean fentanyl gtt & midaz\n Cardiovascular: Currently in NSR, rate controlled, restarted on\n vasopressin/neo, PCCO indicates low SVR and adequate preload\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), serial ABGs, cont\n Flovent/Atrovent/albuterol\n Gastrointestinal / Abdomen: NPO, LFTs trending down, full TPN\n Nutrition: TPN\n Renal: Foley, CVVH\n Hematology: Hct 25.5, stable, plts 31, WBC remains 0.4, f/u coags, HIT\n neg, neupogen\n Endocrine: Insulin drip, Hydrocortisone q8\n Infectious Disease: Check cultures, WBC 0.4, cont\n Vanc/Zosyn/Cipro/Flagyl/Fluc, f/u cx, daily vanc levels, neupogen\n started\n Lines / Tubes / Drains: Foley, OGT, ETT, Surgical drains (hemovac, JP)\n Wounds: Dry dressings, Wound vacuum\n Imaging:\n Fluids: KVO\n Consults: Transplant\n Billing Diagnosis: Arrhythmia, Post-op hypotension, Sepsis, (Shock:\n Septic), Acute renal failure, Thrombocytopenia\n ICU Care\n Nutrition:\n TPN w/ Lipids - 02:42 PM 85. mL/hour\n Glycemic Control: Insulin infusion\n Lines:\n Midline - 10:00 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n Arterial Line - 04:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-18 00:00:00.000",
"description": "Intensivist Note",
"row_id": 676488,
"text": "SICU\n HPI:\n 60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n .\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-assist R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n Current medications:\n 1. IV access: Peripheral line Order date: @ 1237\n 20. Insulin 100 Units/100 ml NS @ 2 UNIT/HR IV DRIP INFUSION\n Fingersticks every hour Order date: @ 1237\n 2. IV access: PICC, heparin dependent Location: Left basilic, Date\n inserted: Order date: @ 1237\n 21. Ipratropium Bromide MDI 6 PUFF IH Q6H Order date: @ 1237\n 3. IV access: Temporary central access (ICU) Order date: @ 1237\n 22. Magnesium Sulfate IV Sliding Scale Order date: @ 1237\n 4. IV access: Mid-line, heparin dependent Order date: @ 1237\n 23. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n Day 1 Order date: @ 1237\n 5. IV access: Dialysis Catheter (Temporary 2-Lumen) Location: Left\n Internal Jugular, Date inserted: Order date: @ 1237\n 24. Midazolam 0.5-3 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 1237\n 6. IV access: None Order date: @ 1237\n 25. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO sbp>90mmHg Order\n date: @ 1237\n 7. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 1237\n 26. Piperacillin-Tazobactam Na 2.25 g IV Q6H Order date: @ 1237\n 8. Albuterol Inhaler 6 PUFF IH Q6H:PRN dyspnea Order date: @\n 1237\n 27. Potassium Chloride 20 mEq / 50 ml SW IV PRN for K < 3.5\n To supplement CRRT KCL infusion sliding scale protocol. Order date:\n @ 1237\n 9. Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes Order date: \n @ 1237\n 28. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1237\n 10. Calcium Chloride IV Sliding Scale Order date: @ 1237\n 29. Prismasate (B22 K4)*\n Continuous at 500 ml/hr\n Dialysate Solution for CRRT Order date: @ 1237\n 11. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1237\n 30. Prismasate (B22 K4)\n Continuous at ml/hr\n Infuse Replacement fluid: Prefilter Rate:1500 Postfilter Rate:200\n Replacement Solution for CRRT Order date: @ 1237\n 12. Citrate Dextrose 3% (ACD-A) CRRT 150 mL/hr DIALYS ASDIR\n CRRT Protocol. Monitor systemic ionized calcium q6h. Adjust according\n to renal recommendations. Order date: @ 1237\n 31. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1237\n 13. Ciprofloxacin 400 mg IV Q12H Order date: @ 1237\n 32. Sodium CITRATE 4% 3 mL DWELL ASDIR catheter not in use\n dwell to catheter volume written on catheter Order date: @ 1237\n 14. Famotidine 20 mg IV Q24H Order date: @ 1237\n 33. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1237\n 15. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \n @ 1237\n 34. Sodium CITRATE 4% 2 mL DWELL ASDIR catheter not in use\n dwell to catheter volume printed on lumens Order date: @ 1237\n 16. Filgrastim 480 mcg IV ONCE Duration: 1 Doses Order date: @\n 1237\n 35. Tacrolimus Suspension 0.5 mg PO BID\n Dose to be admin. at 6am and 6pm Order date: @ 1237\n 17. Fluticasone Propionate 110mcg 2 PUFF IH Order date: @\n 1237\n 36. Vancomycin 1250 mg IV Q 24H Order date: @ 1237\n 18. Fluconazole 200 mg IV Q24H Order date: @ 1237\n 37. Vasopressin 1.2 UNIT/HR IV DRIP TITRATE TO SBP>90 Order date:\n @ 1237\n 19. Hydrocortisone Na Succ. 50 mg IV Q8H Order date: @ 1237\n 24 Hour Events:\n EKG - At 01:01 PM\n for peaked t waves\n EKG - At 11:05 PM\n for peaked t waves and ? ST elevation\n -OR for abdominal wound closure\n Post operative day:\n POD#8 - expl lap\n POD#7 - Hematoma cleaned out, one area on bowel to watch, ABD left\n open, will return to OR tomorrow \n POD#6 - exlap\n POD#1- abdominal wound closure\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 08:15 AM\n Fluconazole - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 04:03 AM\n Metronidazole - 06:04 AM\n Ciprofloxacin - 06:04 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 150 mcg/hour\n Phenylephrine - 0.8 mcg/Kg/min\n Insulin - Regular - 3 units/hour\n Calcium Gluconate (CRRT) - 1 grams/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 37.3\nC (99.1\n HR: 94 (91 - 108) bpm\n BP: 93/51(63) {85/45(57) - 127/68(87)} mmHg\n RR: 27 (0 - 29) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 121.1 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 13 (12 - 211) mmHg\n CO/CI (Thermodilution): (7.87 L/min) / (3.4 L/min/m2)\n SVR: -1,596 dynes*sec/cm5\n SV: 70 mL\n SVI: 30 mL/m2\n Total In:\n 9,468 mL\n 2,540 mL\n PO:\n Tube feeding:\n IV Fluid:\n 7,409 mL\n 1,880 mL\n Blood products:\n Total out:\n 9,520 mL\n 2,312 mL\n Urine:\n 70 mL\n 15 mL\n NG:\n 1,200 mL\n 450 mL\n Stool:\n Drains:\n 1,325 mL\n 450 mL\n Balance:\n -52 mL\n 228 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 25\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 26 cmH2O\n Plateau: 23 cmH2O\n Compliance: 66.7 cmH2O/mL\n SPO2: 97%\n ABG: 7.35/44/78./24/-1\n Ve: 15.5 L/min\n PaO2 / FiO2: 132\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : diffusely)\n Abdominal: Soft, Wound Vac to abdominal wound, holding suction, ostomy\n dusky\n Left Extremities: (Edema: 2+), (Temperature: Cool)\n Right Extremities: (Edema: 2+), (Temperature: Cool)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Unresponsive), Sedated\n Labs / Radiology\n 31 K/uL\n 8.9 g/dL\n 76 mg/dL\n 2.0 mg/dL\n 24 mEq/L\n 4.7 mEq/L\n 57 mg/dL\n 101 mEq/L\n 130 mEq/L\n 25.5 %\n 0.4 K/uL\n [image002.jpg]\n 08:31 AM\n 10:33 AM\n 01:03 PM\n 01:14 PM\n 08:17 PM\n 08:36 PM\n 10:28 PM\n 02:11 AM\n 02:23 AM\n 06:14 AM\n WBC\n 0.3\n 0.4\n Hct\n 27\n 27.1\n 25.7\n 25.5\n Plt\n 23\n 31\n Creatinine\n 2.2\n 2.1\n 2.0\n TCO2\n 26\n 24\n 25\n 26\n 25\n 26\n 25\n Glucose\n 88\n 73\n 75\n 98\n 89\n 86\n 85\n 76\n Other labs: PT / PTT / INR:18.3/44.9/1.7, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:121/103, Alk-Phos / T bili:80/11.7, Amylase /\n Lipase:25/8, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %,\n Mono:8.0 %, Eos:0.0 %, Fibrinogen:267 mg/dL, Lactic Acid:1.8 mmol/L,\n Albumin:1.8 g/dL, LDH: IU/L, Ca:9.2 mg/dL, Mg:2.0 mg/dL, PO4:3.4\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), INEFFECTIVE COPING,\n INTESTINAL ISCHEMIA (INCLUDING MESENTERIC VENOUS / ARTERIAL THROMBOSIS,\n BOWEL ISCHEMIA), SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), CHRONIC OBSTRUCTIVE\n PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION\n Assessment and Plan: 60M admitted to for COPD exacerbation, became\n septic, developed ischemic bowel, s/p exlap, SBR, open abd , s/p ex\n lap, hematoma evacuation , s/p ex lap, end jejunostomy (150 cm SB),\n open abd .\n Neurologic: wean fentanyl gtt & midaz\n Cardiovascular: Currently in NSR, rate controlled, restarted on\n vasopressin/neo, PCCO indicates low SVR and adequate preload\n Pulmonary: Cont ETT, (Ventilator mode: CMV), serial ABGs, cont\n Flovent/Atrovent/albuterol. Not improving.\n Gastrointestinal / Abdomen: NPO, LFTs trending down, full TPN\n Nutrition: TPN\n Renal: Foley, CVVH\n Hematology: Hct 25.5, stable, plts 31, WBC remains 0.4, f/u coags, HIT\n neg, neupogen\n Endocrine: Insulin drip, Hydrocortisone q8\n Infectious Disease: Check cultures, WBC 0.4, cont\n Vanc/Zosyn/Cipro/Flagyl/Fluc, f/u cx, daily vanc levels, neupogen\n started\n Lines / Tubes / Drains: Foley, OGT, ETT, Surgical drains (hemovac, JP)\n Wounds: Dry dressings, Wound vacuum\n Imaging:\n Fluids: KVO\n Consults: Transplant\n Billing Diagnosis: Arrhythmia, Post-op hypotension, Sepsis, (Shock:\n Septic), Acute renal failure, Thrombocytopenia\n ICU Care\n Nutrition:\n TPN w/ Lipids - 02:42 PM 85. mL/hour\n Glycemic Control: Insulin infusion\n Lines:\n Midline - 10:00 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n Arterial Line - 04:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2104-06-18 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 676565,
"text": "Demographics\n Day of mechanical ventilation: 14\n Ideal body weight: 102.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Sedated ,\n Hemodynamic instability, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 676567,
"text": "Above note written by , not .\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 675768,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Po2 in 60\n CXR with edema MD\n numbers with high ELWI\n Action:\n PEEP increased to 7\n Bloused only x1 for low bp\n Unable to remove fluid via cvvhdf\n Response:\n BP with initial sharp drop in BP to 70\ns with increase in PEEP\n PO2 slowly improved throughout day\n Plan:\n Cont to monitor ABG\n Pulm toilet\n Turn as tolerated q3 minimum\n Attempt to remove fluid as tolerated\n Ineffective Coping\n Assessment:\n Mother calling for updates\n Action:\n Mothers questions answered\n Response:\n Mother feels supported by team\n Plan:\n Cont to answer mothers questions prn\n Social work to touch base with mother on \n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CRRT continues\n Action:\n CRRT continues for clearance with minimal fluid removal\n Response:\n Normal acid base balance and elctrolytes\n Plan:\n Cont crrt\n Fluid removal if tolerates\n Prime new circuit with heparin if goes down\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n numbers consistent with sepsis\n Cont to drop BP with turns to 80\n Abd remains open with JP x2 to wall suction\n Ileostomy more red today with brown liquid stool output\n Action:\n Bolused with prismalyte x1\n Pitressin added at 1.2 units per hour\n Solumendrol 100 mg x1\n Albumin added\n CRRT with no removal\n Cipro and fluconazle added to antibiotic regimen of vanco, zosyn,\n flagyl\n HIT resent\n Response:\n Responding to bolus with increase in Co/CI numbers and GEDI from 620 to\n 710\n Stable BP after bolus\n Aboe to wean neo throughout day\n Less hypotensive with turns\n Plan:\n Cont to monitor numbers\n Notify MD for drop in BP <90 for decision on fluid bolus vs increase in\n neo\n CRRT without removal, OK to take off small amounts of fluid if patient\n tolerates\n Cont albumin q8\n Cont abx as ordered\n Await HIT panel\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 676563,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds dim throughout, scant sputum suctioned, no cough/gag. No\n vent changes. Sats mostly 97-98% though when sedation lightened sats\n dropping to 88-92% and pt. more out of sync w/vent , shallow breathing\n noted, increased rate. P02 62 when sats lower and sedation off. ELWI\n 9.\n Action:\n Sedation resumed after neuro in to see pt, suctioned/mouth care PRN, on\n triadyne bed.\n Response:\n Pt. continues w/shallow breathing but appearing more comfortable when\n sedation replaced, ABGs pending. Pt. not tolerating Triadyne bed well\n today, dropping SBP to 60s with any care given.\n Plan:\n Continue to monitor ABGs, sedation to keep pt. comfortable and in sync\n with vent, pulm hygiene, rotating bed as tolerated.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Normothermic, WBCs remain low, no new culture data, VAC dressing intact\n to abd. Hyperglycemic on insulin drip. Stoma dusky in appearance. SVR\n and Co/CI lower today\n see Metavision flow sheets for detailed\n hemodynamic info. SBP dropping to 60s w/any care , pressor\n requirements going up through day.\n Action:\n IV abx and steroids given a/o. Neupogen given IV today, neutropenic\n precautions. Insulin drip in attempts to better control glucose levels.\n Response:\n Glucose remains elevated. Labs pending. SBP more stable this afternoon\n , pressors titrated accordingly.\n Plan:\n Cont. to closely monitor above parameters, f/u culture results.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Bun /Crt Remain elevated. CVVHDF running until 1330 to keep pt. even,\n then line continually kinking/alarming. Minimal dark amber urine via\n Foley. Pt. fluid overloaded but unable to successfully take off much\n fluid d/t sepsis.\n Action:\n Lytes repleted per sliding scale, new dialysis access to be placed this\n evening by sicu team.\n Response:\n Lytes stable, pt. becoming fluid positive while CRRT down.\n Plan:\n Cont. per above, line to bed placed and CRRT to resume.\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 676443,
"text": "60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n , wash out and closure with mesh and VAC dsg placed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS diminished throughout\n CMV 600x28, FiO2 60%, PEEP 10\n Occasionally over breathing vent by 1-2 breaths\n Auto-peeping noted\n O2 sat 96-99% although PaO2 70-80\n EVLI \n ETT 6.5cm above carina on chest xray\n Action:\n Suctioned prn for scant sputum\n Monitoring ABG\n Rate reduced to 25 to attempt to decrease Auto-PEEP\n Remains on rotating bed\n ETT advanced\n Response:\n LS clear in upper lobes and diminished in bases\n PaO2 remains 79, MD aware\n O2 sat remains 95-99%\n Plan:\n Monitor ABG\n Pulm toileting\n Continue rotating bed\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Low grade temps to normothermic\n WBC down to 0.4\n Cultures pnd\n Abd closed with mesh, VAC dsg intact\n Brown drainage in lg amounts from JP\ns and OGT\n Pt hyperglycemic\n Action:\n Abx as ordered\n Steroids as ordered\n Neutropenic precautions\n Insulin gtt to keep BS\ns 100-150\n Response:\n WBC remains low\n Awaiting cultures\n BS\ns wnl\n Plan:\n Continue to monitor labs\n Continue with BS control\n Continue with abx\n Continue with steroids\n Continue with precautions\n Nupogen\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN and Cr remain unchanged\n CVVHDF continues to keep pt even in fluid balance\n Lytes wnl\n Remains oliguric with dark amber urine via foley cath\n Action:\n CVVHDF\n Lyte repletions per sliding scales\n Monitoring renal function\n Response:\n Pt even as of MN\n BUN and Cr remain unchanged with each set of labs sent\n Remains oliguric\n Plan:\n Continue with CVVHDF\n Continue to follow labs\n Continue to replete lytes per sliding scale\n Hypotension (not Shock)\n Assessment:\n SBP 90-110 with pressors\n Dopplerable pulses, warm extremities\n CO/CI 7-8/3-4, GEDI 800, CVP 13-16\n Hct stable @ 25\n HR 90-110, rare PAC\ns noted\n SBP dropped to high 70\ns/low 80\ns after bath and\n repositioning, MD present in pt\ns room at time of event\n Action:\n Vasopressin @ 2.4 units, Neo gtt titrated up\n Hemodynamics monitored, no fluid given as pt appears to have\n sufficient intravascular volume\n Response:\n SBP remains 90-110 with pressors and able to wean down neo\n gtt to 0.5mcg/kg/min\n Hemodynamics remain unchanged\n Pulses remain dopplerable, extremities warm\n Plan:\n Titrate pressors to maintain SBP >90\n Monitor hemodynamics\n Monitor labs\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 676160,
"text": "60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS diminished throughout\n CMV 600x28, FiO2 50%, PEEP 7\n Occationally over breathing vent by 1-2 breaths\n Auto-peeping noted\n O2 sat 96-99% until 0200 when pt dropped O2 sat to 89% and\n was very slow to recover, only recovering to 93%, ABG sent with paO2 in\n the 60\n EVLI \n Action:\n FiO2 increased to 60%\n PEEP increased to 10\n Suctioned prn for scant sputum\n Monitoring ABG\n Response:\n LS remain diminished throughout\n PaO2 improved to 92\n O2 sat remains 95-99%, continues to dip O2 sat with\n repositioning, but only to 92% and remains slow to recover\n Plan:\n Monitor ABG\n Pulm toileting\n Place pt on rotating be as pt is at high risk for developing\n ARDS\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt hypothermic without bairhugger\n WBC down to 0.4\n Cultures pnd\n Open Abd\n Brown drainage in lg amounts from JP\ns and OGT\n Pt hyperglycemic\n Action:\n Abx as ordered\n Steroids as ordered\n Neutropenic precautions\n Insulin gtt to keep BS\ns 100-150\n Response:\n WBC remains low\n Normothermic with bairhugger\n Awaiting cultures\n BS\ns wnl\n Plan:\n Continue to monitor labs\n Continue with BS control\n Continue with abx\n Continue with steroids\n Continue with precautions\n OR today for washout and possible closure\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN and Cr remain unchanged\n CVVHDF continues to keep pt even in fluid balance\n Lytes wnl\n Remains oliguric with green urine via foley cath\n Action:\n CVVHDF\n Lyte repletions per sliding scales\n Monitoring renal function\n Response:\n Pt negative 500cc as of MN\n BUN and Cr remain unchanged with each set of labs sent\n Remains oliguric\n Plan:\n Continue with CVVHDF\n Continue to flollow labs\n Continue to replete lytes per sliding scale\n Hypotension (not Shock)\n Assessment:\n Pt off pressors at start of shift\n SBP 90-110\n Dopplerable pulses, warm extremities\n CO/CI 6-7/2-3.5, GEDI 750, CVP 15\n Hct stable @ 27.5\n SBP dropped to high 70\ns/low80\ns with increase in PEEP\n Action:\n Vasopressin restarted\n Hemodynamics monitored, no fluid given as pt appears to have\n sufficient intravascular volume\n Response:\n SBP remains 90-110 with vasopressin\n Hemodynamics remain unchanged\n Pulses remain dopplerable, extremities warm\n Plan:\n Titrate Vasopressin to maintain SBP >90\n Monitor hemodynamics\n Monitor labs\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 676162,
"text": "60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS diminished throughout\n CMV 600x28, FiO2 50%, PEEP 7\n Occasionally over breathing vent by 1-2 breaths\n Auto-peeping noted\n O2 sat 96-99% until 0200 when pt dropped O2 sat to 89% and\n was very slow to recover, only recovering to 93%, ABG sent with paO2 in\n the 60\n EVLI \n Action:\n FiO2 increased to 60%\n PEEP increased to 10\n Suctioned prn for scant sputum\n Monitoring ABG\n Response:\n LS remain diminished throughout\n PaO2 improved to 92\n O2 sat remains 95-99%, continues to dip O2 sat with\n repositioning, but only to 92% and remains slow to recover\n Plan:\n Monitor ABG\n Pulm toileting\n Place pt on rotating be as pt is at high risk for developing\n ARDS\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt hypothermic without bairhugger\n WBC down to 0.4\n Cultures pnd\n Open Abd\n Brown drainage in lg amounts from JP\ns and OGT\n Pt hyperglycemic\n Action:\n Abx as ordered\n Steroids as ordered\n Neutropenic precautions\n Insulin gtt to keep BS\ns 100-150\n Response:\n WBC remains low\n Normothermic with bairhugger\n Awaiting cultures\n BS\ns wnl\n Plan:\n Continue to monitor labs\n Continue with BS control\n Continue with abx\n Continue with steroids\n Continue with precautions\n OR today for washout and possible closure\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN and Cr remain unchanged\n CVVHDF continues to keep pt even in fluid balance\n Lytes wnl\n Remains oliguric with green urine via foley cath\n Action:\n CVVHDF\n Lyte repletions per sliding scales\n Monitoring renal function\n Response:\n Pt negative 500cc as of MN\n BUN and Cr remain unchanged with each set of labs sent\n Remains oliguric\n Plan:\n Continue with CVVHDF\n Continue to follow labs\n Continue to replete lytes per sliding scale\n Hypotension (not Shock)\n Assessment:\n Pt off pressors at start of shift\n SBP 90-110\n Dopplerable pulses, warm extremities\n CO/CI 6-7/2-3.5, GEDI 750, CVP 15\n Hct stable @ 27.5\n HR 90-105, rare PAC\ns noted\n SBP dropped to high 70\ns/low80\ns with increase in PEEP\n Action:\n Vasopressin restarted\n Hemodynamics monitored, no fluid given as pt appears to have\n sufficient intravascular volume\n Response:\n SBP remains 90-110 with vasopressin\n Hemodynamics remain unchanged\n Pulses remain dopplerable, extremities warm\n Plan:\n Titrate Vasopressin to maintain SBP >90\n Monitor hemodynamics\n Monitor labs\n"
},
{
"category": "Nutrition",
"chartdate": "2104-06-17 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 676326,
"text": "Subjective Patient intubated/sedated.\n Objective\n Current Wt: 121.1 kg () - fluid\n Admit Wt: 91.7 kg\n Pertinent medications: Fentanyl, vasopression, midazolam, Abx, calcium\n gluconate, KCl, hydrocortisone Na succ, Insulin drip (12 units/hr),\n others noted\n Labs:\n Value\n Date\n Glucose\n 88 mg/dL\n 08:31 AM\n Glucose Finger Stick\n 96\n 10:00 AM\n BUN\n 51 mg/dL\n 01:58 AM\n Creatinine\n 2.1 mg/dL\n 01:58 AM\n Sodium\n 134 mEq/L\n 08:31 AM\n Potassium\n 4.5 mEq/L\n 08:31 AM\n Chloride\n 105 mEq/L\n 08:31 AM\n TCO2\n 23 mEq/L\n 01:58 AM\n PO2 (arterial)\n 108 mm Hg\n 08:31 AM\n PO2 (venous)\n 35 mm Hg\n 03:48 AM\n PCO2 (arterial)\n 46 mm Hg\n 08:31 AM\n PCO2 (venous)\n 39 mm Hg\n 03:48 AM\n pH (arterial)\n 7.34 units\n 08:31 AM\n pH (venous)\n 7.31 units\n 03:48 AM\n pH (urine)\n 5.0 units\n 09:27 AM\n CO2 (Calc) arterial\n 26 mEq/L\n 08:31 AM\n CO2 (Calc) venous\n 21 mEq/L\n 03:48 AM\n Albumin\n 1.8 g/dL\n 05:50 PM\n Calcium non-ionized\n 9.3 mg/dL\n 01:58 AM\n Phosphorus\n 3.0 mg/dL\n 01:58 AM\n Ionized Calcium\n 1.31 mmol/L\n 08:31 AM\n Magnesium\n 2.0 mg/dL\n 01:58 AM\n ALT\n 144 IU/L\n 01:58 AM\n Alkaline Phosphate\n 93 IU/L\n 01:58 AM\n AST\n 107 IU/L\n 01:58 AM\n Amylase\n 831 IU/L\n 06:09 AM\n Total Bilirubin\n 10.3 mg/dL\n 01:58 AM\n Triglyceride\n 119 mg/dL\n 02:30 PM\n WBC\n 0.4 K/uL\n 01:58 AM\n Hgb\n 9.6 g/dL\n 01:58 AM\n Hematocrit\n 27\n 08:31 AM\n Current diet order / nutrition support: NPO\n TPN: 2060ml (310g dextrose/115g protein/50g lipid)\n GI: bowel sounds not present, abd open\n Assessment of Nutritional Status\n 60 year old male admitted for COPD exacerbation, patient became septic,\n developed ischemic bowel, s/p ex-lap, SBR, open abd , s/p ex-lap,\n hematoma evacuation , s/p ex-lap, end ileostomy . Patient to OR\n this morning for abd closure. BG remains high despite insulin drip\n running at 12 units/hour. Increasing TPN insulin may help wean patient\n off insulin drip. CRRT continues for clearance with minimal fluid\n removal hypotension. Patient on pressor support, remains intubated\n and sedated. TPN not currently at goal high BG. Goal is 2060 ml\n (390g dextrose/115g protein/150g lipid) providing 2286 kcal/day.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Recommend increasing TPN to goal when BG stable at < 175. When\n increasing dextrose to goal, recommend increasing TPN insulin by adding\n half the amount of insulin the patient received the day before.\n 2. Daily CHEM 10. Monitor and replete lytes PRN.\n 3. FSBG q4 hour\n 4. Will follow\n"
},
{
"category": "Nutrition",
"chartdate": "2104-06-17 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 676328,
"text": "Subjective Patient intubated/sedated.\n Objective\n Current Wt: 121.1 kg () - fluid\n Admit Wt: 91.7 kg\n Pertinent medications: Fentanyl, vasopression, midazolam, Abx, calcium\n gluconate, KCl, hydrocortisone Na succ, Insulin drip (12 units/hr),\n others noted\n Labs:\n Value\n Date\n Glucose\n 88 mg/dL\n 08:31 AM\n Glucose Finger Stick\n 96\n 10:00 AM\n BUN\n 51 mg/dL\n 01:58 AM\n Creatinine\n 2.1 mg/dL\n 01:58 AM\n Sodium\n 134 mEq/L\n 08:31 AM\n Potassium\n 4.5 mEq/L\n 08:31 AM\n Chloride\n 105 mEq/L\n 08:31 AM\n TCO2\n 23 mEq/L\n 01:58 AM\n PO2 (arterial)\n 108 mm Hg\n 08:31 AM\n PO2 (venous)\n 35 mm Hg\n 03:48 AM\n PCO2 (arterial)\n 46 mm Hg\n 08:31 AM\n PCO2 (venous)\n 39 mm Hg\n 03:48 AM\n pH (arterial)\n 7.34 units\n 08:31 AM\n pH (venous)\n 7.31 units\n 03:48 AM\n pH (urine)\n 5.0 units\n 09:27 AM\n CO2 (Calc) arterial\n 26 mEq/L\n 08:31 AM\n CO2 (Calc) venous\n 21 mEq/L\n 03:48 AM\n Albumin\n 1.8 g/dL\n 05:50 PM\n Calcium non-ionized\n 9.3 mg/dL\n 01:58 AM\n Phosphorus\n 3.0 mg/dL\n 01:58 AM\n Ionized Calcium\n 1.31 mmol/L\n 08:31 AM\n Magnesium\n 2.0 mg/dL\n 01:58 AM\n ALT\n 144 IU/L\n 01:58 AM\n Alkaline Phosphate\n 93 IU/L\n 01:58 AM\n AST\n 107 IU/L\n 01:58 AM\n Amylase\n 831 IU/L\n 06:09 AM\n Total Bilirubin\n 10.3 mg/dL\n 01:58 AM\n Triglyceride\n 119 mg/dL\n 02:30 PM\n WBC\n 0.4 K/uL\n 01:58 AM\n Hgb\n 9.6 g/dL\n 01:58 AM\n Hematocrit\n 27\n 08:31 AM\n Current diet order / nutrition support: NPO\n TPN: 2060ml (310g dextrose/115g protein/50g lipid)\n GI: bowel sounds not present, abd open\n Assessment of Nutritional Status\n 60 year old male admitted for COPD exacerbation, patient became septic,\n developed ischemic bowel, s/p ex-lap, SBR, open abd , s/p ex-lap,\n hematoma evacuation , s/p ex-lap, end ileostomy . Patient to OR\n this morning for abd closure. BG remains high despite insulin drip\n running at 12 units/hour. Increasing TPN insulin may help wean patient\n off insulin drip. CRRT continues for clearance with minimal fluid\n removal hypotension. Patient on pressor support, remains intubated\n and sedated. TPN not currently at goal high BG. Goal is 2060 ml\n (390g dextrose/115g protein/150g lipid) providing 2286 kcal/day.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Recommend increasing TPN to goal when BG stable at < 175. When\n increasing dextrose to goal, recommend increasing TPN insulin by adding\n half the amount of insulin the patient received the day before.\n 2. Daily CHEM 10. Monitor and replete lytes PRN.\n 3. FSBG q4 hour\n 4. Will follow\n ------ Protected Section ------\n Agree with above note. Please page with any questions. #\n ------ Protected Section Addendum Entered By: , RD, \n on: 15:59 ------\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 676157,
"text": "60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS diminished throughout\n CMV 600x28, FiO2 50%, PEEP 7\n Occationally over breathing vent by 1-2 breaths\n Auto-peeping noted\n O2 sat 96-99% until 0200 when pt dropped O2 sat to 89% and\n was very slow to recover, only recovering to 93%, ABG sent with paO2 in\n the 60\n EVLI \n Action:\n FiO2 increased to 60%\n PEEP increased to 10\n Suctioned prn for scant sputum\n Monitoring ABG\n Response:\n LS remain diminished throughout\n PaO2 improved to 92\n O2 sat remains 95-99%, continues to dip O2 sat with\n repositioning, but only to 92% and remains slow to recover\n Plan:\n Monitor ABG\n Pulm toileting\n Place pt on rotating be as pt is at high risk for developing\n ARDS\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt hypothermic without bairhugger\n WBC down to 0.4\n Cultures pnd\n Open Abd\n Action:\n Abx as ordered\n Steroids as ordered\n Neutropenic precautions\n Response:\n WBC remains low\n Normothermic with bairhugger\n Awaiting cultures\n Plan:\n Continue to monitor labs\n Continue with abx\n Continue with steroids\n Continue with precautions\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 676367,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n PO2 60\n Minimal secretions\n Action:\n PEEP 10\n Changed to triadyne rotating bed\n Cont on vanc/zosyn/flagyl/cipro/fluconazole\n Pulm hygiene\n Response:\n Po2 increased to 130-140\n Plan:\n Cont triadyne bed\n wean fio2 and PEEP as tolerated\n Pulm toilet\n Cont CRRT to goal of even\n Follow NCP\n Ineffective Coping\n Assessment:\n Mother calling in for updates\n Action:\n Updates given over the phone\n Response:\n happy with plan of care\n Questions answered\n Plan:\n Cont to support family in plan of care\n Answer questions prn\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CVVHDF cont. with minimal hypotension later in day\n Action:\n CVVHDF cont to keep patient even\n Bloused with ns via CRRT line\n Remains on low dose neo to keep sys >90 and pitressin,\n Response:\n numbers consistent with adequate resuscitation\n Patient even for day thus far\n Plan:\n Cont CRRT with goal even\n Wean neo as tolerated followed by pitressin wean\n Bolus prn if numbers appear dry\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Abd open with jp for drainage, patient with anasarca\n Periods of acute hypotension to 70\ns, mostly with turns (on triadyne)\n St 2 to coccyx, abrasion to scrotum that is oozing\n Action:\n Pt to OR for abdominal closure with mesh and vac placement\n Remains on pitressin weaned to 1.2 and low dose neo\n numbers recalculated secondary to high CO, with numbers revealing\n adequate preload, decision made to continue to increase neo at this\n time and keep CRRT even\n Skin care, mepilex to coccyx, scrotum left open with aloe vesta\n Penis draining yellow drainage from old blister that popped, adaptic to\n site\n Response:\n Periods of hypotension with turns that level out after turn complete\n Vac draining serosang drainage\n No further breakdown noted, patient remains with anasarca\n Plan:\n Cont low dose neo and ptiressin\n Follow numbers\n CRRT to even\n Abd assessment, vac in place\n Skin care\n Follow NCP\n DNR:vfib and vtach, OK to cardiovert for afib per mother \n"
},
{
"category": "Nursing",
"chartdate": "2104-06-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 676368,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n PO2 60\n Minimal secretions\n Action:\n PEEP 10\n Changed to triadyne rotating bed\n Cont on vanc/zosyn/flagyl/cipro/fluconazole\n Pulm hygiene\n Response:\n Po2 increased to 130-140\n Plan:\n Cont triadyne bed\n wean fio2 and PEEP as tolerated\n Pulm toilet\n Cont CRRT to goal of even\n Follow NCP\n Ineffective Coping\n Assessment:\n Mother calling in for updates\n Action:\n Updates given over the phone\n Response:\n happy with plan of care\n Questions answered\n Plan:\n Cont to support family in plan of care\n Answer questions prn\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CVVHDF cont. with minimal hypotension later in day\n Action:\n CVVHDF cont to keep patient even\n Bloused with ns via CRRT line\n Remains on low dose neo to keep sys >90 and pitressin,\n Response:\n numbers consistent with adequate resuscitation\n Patient even for day thus far\n Plan:\n Cont CRRT with goal even\n Wean neo as tolerated followed by pitressin wean\n Bolus prn if numbers appear dry\n Intestinal ischemia (including mesenteric venous / arterial thrombosis,\n bowel ischemia)\n Assessment:\n Abd open with jp for drainage, patient with anasarca\n Periods of acute hypotension to 70\ns, mostly with turns (on triadyne)\n St 2 to coccyx, abrasion to scrotum that is oozing\n Action:\n Pt to OR for abdominal closure with mesh and vac placement\n Remains on pitressin weaned to 1.2 and low dose neo\n numbers recalculated secondary to high CO, with numbers revealing\n adequate preload, low SVR decision made to continue to increase neo at\n this time and keep CRRT even\n Skin care, mepilex to coccyx, scrotum left open with aloe vesta\n Penis draining yellow drainage from old blister that popped, adaptic to\n site\n Response:\n Periods of hypotension with turns that level out after turn complete\n Vac draining serosang drainage\n No further breakdown noted, patient remains with anasarca\n Plan:\n Cont low dose neo and ptiressin\n Follow numbers\n CRRT to even\n Abd assessment, vac in place\n Skin care\n Follow NCP\n DNR:vfib and vtach, OK to cardiovert for afib per mother \n"
},
{
"category": "Nursing",
"chartdate": "2104-06-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 676439,
"text": "60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n , wash out and closure with mesh and VAC dsg placed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS diminished throughout\n CMV 600x28, FiO2 60%, PEEP 10\n Occasionally over breathing vent by 1-2 breaths\n Auto-peeping noted\n O2 sat 96-99% although PaO2 70-80\n EVLI \n ETT 6.5cm above carina on chest xray\n Action:\n Suctioned prn for scant sputum\n Monitoring ABG\n Rate reduced to 25 to attempt to decrease Auto-PEEP\n Remains on rotating bed\n ETT advanced\n Response:\n LS clear in upper lobes and diminished in bases\n PaO2\n O2 sat remains 95-99%\n Plan:\n Monitor ABG\n Pulm toileting\n Place pt on rotating be as pt is at high risk for developing\n ARDS\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt hypothermic without bairhugger\n WBC down to 0.4\n Cultures pnd\n Open Abd\n Brown drainage in lg amounts from JP\ns and OGT\n Pt hyperglycemic\n Action:\n Abx as ordered\n Steroids as ordered\n Neutropenic precautions\n Insulin gtt to keep BS\ns 100-150\n Response:\n WBC remains low\n Normothermic with bairhugger\n Awaiting cultures\n BS\ns wnl\n Plan:\n Continue to monitor labs\n Continue with BS control\n Continue with abx\n Continue with steroids\n Continue with precautions\n OR today for washout and possible closure\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN and Cr remain unchanged\n CVVHDF continues to keep pt even in fluid balance\n Lytes wnl\n Remains oliguric with green urine via foley cath\n Action:\n CVVHDF\n Lyte repletions per sliding scales\n Monitoring renal function\n Response:\n Pt negative 500cc as of MN\n BUN and Cr remain unchanged with each set of labs sent\n Remains oliguric\n Plan:\n Continue with CVVHDF\n Continue to follow labs\n Continue to replete lytes per sliding scale\n Hypotension (not Shock)\n Assessment:\n Pt off pressors at start of shift\n SBP 90-110\n Dopplerable pulses, warm extremities\n CO/CI 6-7/2-3.5, GEDI 750, CVP 15\n Hct stable @ 27.5\n HR 90-105, rare PAC\ns noted\n SBP dropped to high 70\ns/low80\ns with increase in PEEP\n Action:\n Vasopressin restarted\n Hemodynamics monitored, no fluid given as pt appears to have\n sufficient intravascular volume\n Response:\n SBP remains 90-110 with vasopressin\n Hemodynamics remain unchanged\n Pulses remain dopplerable, extremities warm\n Plan:\n Titrate Vasopressin to maintain SBP >90\n Monitor hemodynamics\n Monitor labs\n"
},
{
"category": "Physician ",
"chartdate": "2104-06-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 675616,
"text": "SICU\n HPI:\n 60M admitted to for COPD exacerbation, became septic, developed\n ischemic bowel, s/p exlap, SBR, open abd , s/p ex lap, hematoma\n evacuation , s/p ex lap, end jejunostomy (150 cm SB), open abd\n .\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: COPD, HTN, high chol, ESRD baseline Cr-, DM2, former smoker,\n EtOH, coag neg Staph R hip joint infection, chronic pain, prostate ca\n s/p XRT , b/l avascular necrosis, cecal diverticulitis\n PSH: CRT , L perirectal abscess s/p I&D , s/p lap-ass R\n colectomy , R hip joint removal/spacer placement , ORIF femoral\n neck fracture\n Current medications:\n 1. IV access: Peripheral line Order date: @ 1031\n 21. Ipratropium Bromide MDI 6 PUFF IH Q6H Order date: @ 0150\n 2. IV access: PICC, heparin dependent Location: Left basilic, Date\n inserted: Order date: @ 1031\n 22. Magnesium Sulfate IV Sliding Scale Order date: @ 1031\n 3. IV access: Temporary central access (ICU) Order date: @ 1031\n 23. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n Day 1 Order date: @ 1031\n 4. IV access: Mid-line, heparin dependent Order date: @ 1031\n 24. MethylPREDNISolone Sodium Succ 4 mg IV Q24H Order date: @\n 0933\n 5. IV access: Dialysis Catheter (Temporary 2-Lumen) Location: Left\n Internal Jugular, Date inserted: Order date: @ 1031\n 25. Midazolam 0.5-3 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 1639\n 6. IV access: None Order date: @ 1031\n 26. Mycophenolate Mofetil 500 mg IV BID Order date: @ 1031\n 7. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 1031\n 27. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO sbp>90mmHg Order\n date: @ 1031\n 8. Albuterol Inhaler 6 PUFF IH Q6H:PRN dyspnea Order date: @\n 0150\n 28. Piperacillin-Tazobactam Na 2.25 g IV Q6H Order date: @ 1031\n 9. Albumin 25% (12.5g / 50mL) 12.5 g IV ONCE Duration: 1 Doses Order\n date: @ \n 29. Potassium Chloride 20 mEq / 50 ml SW IV PRN for K < 3.5\n To supplement CRRT KCL infusion sliding scale protocol. Order date:\n @ 1031\n 10. Calcium Chloride IV Sliding Scale Order date: @ 1031\n 30. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1031\n 11. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1031\n 31. Prismasate (B22 K4)*\n Continuous at 500 ml/hr\n Dialysate Solution for CRRT Order date: @ 1818\n 12. Citrate Dextrose 3% (ACD-A) CRRT 150 mL/hr DIALYS ASDIR\n CRRT Protocol. Monitor systemic ionized calcium q6h. Adjust according\n to renal recommendations. Order date: @ 1611\n 32. Prismasate (B22 K4)\n Continuous at ml/hr\n Infuse Replacement fluid: Prefilter Rate:1500 Postfilter Rate:200\n Replacement Solution for CRRT Order date: @ 1140\n 13. Esmolol 50-150 mcg/kg/min IV TITRATE TO HR<100 Order date: @\n 1144\n 33. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1031\n 14. Famotidine 20 mg IV Q24H Order date: @ 0530\n 34. Sodium CITRATE 4% 3 mL DWELL ASDIR catheter not in use\n dwell to catheter volume written on catheter Order date: @ 1031\n 15. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \n @ 1031\n 35. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1031\n 16. Fluticasone Propionate 110mcg 2 PUFF IH Order date: @\n 1031\n 36. Sodium CITRATE 4% 2 mL DWELL ASDIR catheter not in use\n dwell to catheter volume printed on lumens Order date: @ 1031\n 17. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n PICC, heparin dependent: Flush with 10mL Normal Saline followed by\n Heparin as above daily and PRN per lumen. Order date: @ 1031\n 37. Tacrolimus Suspension 1 mg NG QAM Duration: 1 Doses\n Dose to be admin at 5/17 am. No PM dose on Order date: @\n 1734\n 18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n Mid-line, heparin dependent: Flush with 10 mL Normal Saline followed by\n Heparin as above, daily and PRN per lumen. Order date: @ 1031\n 38. Vancomycin 1250 mg IV Q 24H Order date: @ 2252\n 19. Heparin Flush (5000 Units/mL) 4000- UNIT DWELL PRN line flush\n Dialysis Catheter (Temporary 2-Lumen): DIALYSIS NURSE ONLY: Withdraw 4\n mL prior to flushing with 10 mL NS followed by Heparin as above\n according to volume per lumen. Order date: @ 1031\n 39. Vancomycin 500 mg IV ONCE Duration: 1 Doses Order date: @\n 1235\n 20. Insulin 100 Units/100 ml NS @ 2 UNIT/HR IV DRIP INFUSION\n Fingersticks every hour Order date: @ 2238\n 24 Hour Events:\n TRANS ESOPHAGEAL ECHO - At 04:43 PM\n -Continuing to require large amounts to fluid to maintain BP.\n -Esmolol weaned off\n -Continuing to require pressors\n Post operative day:\n POD#5 - expl lap\n POD#4 - Hematoma cleaned out, one area on bowel to watch, ABD left\n open, will return to OR tomorrow \n POD#3 - exlap\n Allergies:\n Enalapril\n Hives;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 11:09 PM\n Vancomycin - 04:01 PM\n Metronidazole - 10:00 PM\n Piperacillin - 04:00 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Phenylephrine - 1.3 mcg/Kg/min\n Fentanyl - 150 mcg/hour\n Calcium Gluconate (CRRT) - 1 grams/hour\n KCl (CRRT) - 3 mEq./hour\n Insulin - Regular - 11 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 10:17 AM\n Other medications:\n Flowsheet Data as of 04:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 35.8\nC (96.4\n HR: 91 (82 - 107) bpm\n BP: 106/66(77) {70/43(51) - 121/66(85)} mmHg\n RR: 24 (13 - 34) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 116.4 kg (admission): 91.7 kg\n Height: 80 Inch\n CVP: 13 (7 - 17) mmHg\n CO/CI (Thermodilution): (5.83 L/min) / (2.5 L/min/m2)\n SVR: 741 dynes*sec/cm5\n SV: 59 mL\n SVI: 26 mL/m2\n Total In:\n 12,513 mL\n 2,374 mL\n PO:\n Tube feeding:\n IV Fluid:\n 11,899 mL\n 1,996 mL\n Blood products:\n 50 mL\n Total out:\n 11,458 mL\n 892 mL\n Urine:\n 36 mL\n NG:\n 975 mL\n 250 mL\n Stool:\n 100 mL\n Drains:\n 2,035 mL\n 450 mL\n Balance:\n 1,055 mL\n 1,482 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 24\n RR (Spontaneous): 3\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%, Hemodynamic Instability\n PIP: 24 cmH2O\n Plateau: 17 cmH2O\n SPO2: 96%\n ABG: 7.34/40/70/22/-3\n Ve: 15.2 L/min\n PaO2 / FiO2: 117\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : , Diminished: )\n Abdominal: Soft, Abdomen opened with sterile towels and Ioban dressing\n intact\n Left Extremities: (Edema: 4+), (Temperature: Cool)\n Right Extremities: (Edema: 4+), (Temperature: Cool)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Unresponsive), Moves all extremities, Sedated\n Labs / Radiology\n 28 K/uL\n 10.0 g/dL\n 175 mg/dL\n 2.1 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 54 mg/dL\n 103 mEq/L\n 134 mEq/L\n 28.6 %\n 3.3 K/uL\n [image002.jpg]\n 10:04 AM\n 12:26 PM\n 03:04 PM\n 04:56 PM\n 05:17 PM\n 08:22 PM\n 08:39 PM\n 11:46 PM\n 01:44 AM\n 02:37 AM\n WBC\n 6.7\n 3.3\n Hct\n 34\n 27.9\n 30.7\n 28.6\n Plt\n 25\n 28\n Creatinine\n 2.1\n 2.1\n 2.1\n TCO2\n 24\n 22\n 21\n 27\n 24\n 23\n 23\n Glucose\n 127\n 123\n 120\n 327\n 76\n 200\n 175\n Other labs: PT / PTT / INR:17.9/41.8/1.6, CK / CK-MB / Troponin\n T:2499/22/0.04, ALT / AST:312/223, Alk-Phos / T bili:139/8.7, Amylase /\n Lipase:831/21, Differential-Neuts:80.0 %, Band:4.0 %, Lymph:7.0 %,\n Mono:8.0 %, Eos:0.0 %, Fibrinogen:267 mg/dL, Lactic Acid:2.0 mmol/L,\n Albumin:1.8 g/dL, LDH: IU/L, Ca:9.2 mg/dL, Mg:2.1 mg/dL, PO4:3.3\n mg/dL\n Imaging: CT: extensive pneumatosis, involving ileal loops & asc &\n t colon, portal venous air.\n Microbiology: sputum: Pseudomonas (pan S)\n urine: GPC ~1K\n bld x2: neg\n bld x2: P\n C.diff: positive\n bld x2: P\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), HYPOTENSION (NOT SHOCK), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INEFFECTIVE COPING, INTESTINAL ISCHEMIA\n (INCLUDING MESENTERIC VENOUS / ARTERIAL THROMBOSIS, BOWEL ISCHEMIA),\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), HYPERTENSION, BENIGN,\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION, CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD,\n BRONCHITIS, EMPHYSEMA) WITHOUT ACUTE EXACERBATION\n Assessment and Plan: 60M admitted to for COPD exacerbation, became\n septic, developed ischemic bowel, s/p exlap, SBR, open abd , s/p ex\n lap, hematoma evacuation , s/p ex lap, end jejunostomy (150 cm SB),\n open abd .\n Neurologic: Keep fentanyl gtt & midaz for sedation\n Cardiovascular: AF post-op, converted to SR after two cardioversions,\n esmolol gtt is off. Currently in NSR, rate controlled. Overnight\n increased pressors requirements with what seems to be another episode\n of severe sepsis vs. steroid deficiency. Will give one dose of steroids\n to see if hemodynamic improves. Add vasopressin to neo for neo gtt.\n Pulmonary: Cont ETT, (Ventilator mode: CMV), worsening CXR, serial\n ABGs, indeces, patient has no pulmonary edema, although CXR\n demonstrates pulmonary congestion. Would attempt go up on PEEP to open\n up the lungs. cont Flovent/Atrovent/albuterol\n Gastrointestinal / Abdomen: NPO, LFTs trending down, TPN\n Nutrition: TPN, NPO\n Renal: Foley, CVVH, UOP minimal, ARF on CRF, Cr 2.1, stable, cont\n tacrolimus and Cellcept, check levels, CVVH, remove volume as pressure\n tolerates if hemodynamic improves. Will resuscitate with albumin and\n hypertonic saline and try to minimize.\n Hematology: Hct 28.6, stable, plts 28, cont to follow, coags, f/u HIT\n panel\n Endocrine: RISS, Solumedrol 4'. Will give one dose stress steroids and\n if responding, will add around the clock.\n Infectious Disease: Check cultures, Afebrile, WBC 3.3, cont Zosyn,\n Flagyl, vanc, vanc level. Will add fluconazole and cipro (sputum\n positive for pseudomas a few days ago).\n Lines / Tubes / Drains: Foley, OGT, ETT, Surgical drains (hemovac, JP)\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: Please change plasmalyte to albumin 25% Q 8 and 3% saline.\n Consults: Transplant\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Post-op hypotension, (Shock), Acute renal failure\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:26 PM 85. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 10:00 AM\n Multi Lumen - 05:27 AM\n Dialysis Catheter - 05:35 PM\n Arterial Line - 04:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 675634,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2104-06-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 675636,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Mother calling for updates\n Action:\n Mothers questions answered\n Response:\n Mother feels supported by team\n Plan:\n Cont to answer mothers questions prn\n Social work to touch base with mother on \n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CRRT continues\n Action:\n CRRT continues for clearance with minimal fluid removal\n Response:\n Normal acid base balance and elctrolytes\n Plan:\n Cont crrt\n Fluid removal if tolerates\n Prime new circuit with heparin if goes down\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nutrition",
"chartdate": "2104-06-17 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 676270,
"text": "Subjective Patient intubated/sedated. RN and labs, BG remains high\n Objective\n Current Wt: 121.1 kg () - fluid\n Admit Wt: 91.7 kg\n Pertinent medications: Fentanyl, vasopression, midazolam, Abx, calcium\n gluconate, KCl, hydrocortisone Na succ, Insulin drip (14 units/hr),\n others noted\n Labs:\n Value\n Date\n Glucose\n 88 mg/dL\n 08:31 AM\n Glucose Finger Stick\n 96\n 10:00 AM\n BUN\n 51 mg/dL\n 01:58 AM\n Creatinine\n 2.1 mg/dL\n 01:58 AM\n Sodium\n 134 mEq/L\n 08:31 AM\n Potassium\n 4.5 mEq/L\n 08:31 AM\n Chloride\n 105 mEq/L\n 08:31 AM\n TCO2\n 23 mEq/L\n 01:58 AM\n PO2 (arterial)\n 108 mm Hg\n 08:31 AM\n PO2 (venous)\n 35 mm Hg\n 03:48 AM\n PCO2 (arterial)\n 46 mm Hg\n 08:31 AM\n PCO2 (venous)\n 39 mm Hg\n 03:48 AM\n pH (arterial)\n 7.34 units\n 08:31 AM\n pH (venous)\n 7.31 units\n 03:48 AM\n pH (urine)\n 5.0 units\n 09:27 AM\n CO2 (Calc) arterial\n 26 mEq/L\n 08:31 AM\n CO2 (Calc) venous\n 21 mEq/L\n 03:48 AM\n Albumin\n 1.8 g/dL\n 05:50 PM\n Calcium non-ionized\n 9.3 mg/dL\n 01:58 AM\n Phosphorus\n 3.0 mg/dL\n 01:58 AM\n Ionized Calcium\n 1.31 mmol/L\n 08:31 AM\n Magnesium\n 2.0 mg/dL\n 01:58 AM\n ALT\n 144 IU/L\n 01:58 AM\n Alkaline Phosphate\n 93 IU/L\n 01:58 AM\n AST\n 107 IU/L\n 01:58 AM\n Amylase\n 831 IU/L\n 06:09 AM\n Total Bilirubin\n 10.3 mg/dL\n 01:58 AM\n Triglyceride\n 119 mg/dL\n 02:30 PM\n WBC\n 0.4 K/uL\n 01:58 AM\n Hgb\n 9.6 g/dL\n 01:58 AM\n Hematocrit\n 27\n 08:31 AM\n Current diet order / nutrition support: NPO\n TPN: 2060ml (310g dextrose/115g protein/50g lipid)\n GI: bowel sounds not present, abd open\n Assessment of Nutritional Status\n 60 year old male admitted for COPD exacerbation, patient became septic\n , developed ischemic bowel, s/p ex-lap, SBR, open abd , s/p ex-lap,\n hematoma evacuation , s/p ex-lap, end ileostomy . Patient to OP\n this morning for abd closure\n Medical Nutrition Therapy Plan - Recommend the Following\n"
},
{
"category": "Nutrition",
"chartdate": "2104-06-17 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 676273,
"text": "Subjective Patient intubated/sedated. RN and labs, BG remains high\n Objective\n Current Wt: 121.1 kg () - fluid\n Admit Wt: 91.7 kg\n Pertinent medications: Fentanyl, vasopression, midazolam, Abx, calcium\n gluconate, KCl, hydrocortisone Na succ, Insulin drip (14 units/hr),\n others noted\n Labs:\n Value\n Date\n Glucose\n 88 mg/dL\n 08:31 AM\n Glucose Finger Stick\n 96\n 10:00 AM\n BUN\n 51 mg/dL\n 01:58 AM\n Creatinine\n 2.1 mg/dL\n 01:58 AM\n Sodium\n 134 mEq/L\n 08:31 AM\n Potassium\n 4.5 mEq/L\n 08:31 AM\n Chloride\n 105 mEq/L\n 08:31 AM\n TCO2\n 23 mEq/L\n 01:58 AM\n PO2 (arterial)\n 108 mm Hg\n 08:31 AM\n PO2 (venous)\n 35 mm Hg\n 03:48 AM\n PCO2 (arterial)\n 46 mm Hg\n 08:31 AM\n PCO2 (venous)\n 39 mm Hg\n 03:48 AM\n pH (arterial)\n 7.34 units\n 08:31 AM\n pH (venous)\n 7.31 units\n 03:48 AM\n pH (urine)\n 5.0 units\n 09:27 AM\n CO2 (Calc) arterial\n 26 mEq/L\n 08:31 AM\n CO2 (Calc) venous\n 21 mEq/L\n 03:48 AM\n Albumin\n 1.8 g/dL\n 05:50 PM\n Calcium non-ionized\n 9.3 mg/dL\n 01:58 AM\n Phosphorus\n 3.0 mg/dL\n 01:58 AM\n Ionized Calcium\n 1.31 mmol/L\n 08:31 AM\n Magnesium\n 2.0 mg/dL\n 01:58 AM\n ALT\n 144 IU/L\n 01:58 AM\n Alkaline Phosphate\n 93 IU/L\n 01:58 AM\n AST\n 107 IU/L\n 01:58 AM\n Amylase\n 831 IU/L\n 06:09 AM\n Total Bilirubin\n 10.3 mg/dL\n 01:58 AM\n Triglyceride\n 119 mg/dL\n 02:30 PM\n WBC\n 0.4 K/uL\n 01:58 AM\n Hgb\n 9.6 g/dL\n 01:58 AM\n Hematocrit\n 27\n 08:31 AM\n Current diet order / nutrition support: NPO\n TPN: 2060ml (310g dextrose/115g protein/50g lipid)\n GI: bowel sounds not present, abd open\n Assessment of Nutritional Status\n 60 year old male admitted for COPD exacerbation, patient became septic\n , developed ischemic bowel, s/p ex-lap, SBR, open abd , s/p ex-lap,\n hematoma evacuation , s/p ex-lap, end ileostomy . Patient to OP\n this morning for abd closure. BG remains high with insulin drip\n Medical Nutrition Therapy Plan - Recommend the Following\n"
},
{
"category": "Nutrition",
"chartdate": "2104-06-17 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 676275,
"text": "Subjective Patient intubated/sedated. RN and labs, BG remains high\n Objective\n Current Wt: 121.1 kg () - fluid\n Admit Wt: 91.7 kg\n Pertinent medications: Fentanyl, vasopression, midazolam, Abx, calcium\n gluconate, KCl, hydrocortisone Na succ, Insulin drip (12 units/hr),\n others noted\n Labs:\n Value\n Date\n Glucose\n 88 mg/dL\n 08:31 AM\n Glucose Finger Stick\n 96\n 10:00 AM\n BUN\n 51 mg/dL\n 01:58 AM\n Creatinine\n 2.1 mg/dL\n 01:58 AM\n Sodium\n 134 mEq/L\n 08:31 AM\n Potassium\n 4.5 mEq/L\n 08:31 AM\n Chloride\n 105 mEq/L\n 08:31 AM\n TCO2\n 23 mEq/L\n 01:58 AM\n PO2 (arterial)\n 108 mm Hg\n 08:31 AM\n PO2 (venous)\n 35 mm Hg\n 03:48 AM\n PCO2 (arterial)\n 46 mm Hg\n 08:31 AM\n PCO2 (venous)\n 39 mm Hg\n 03:48 AM\n pH (arterial)\n 7.34 units\n 08:31 AM\n pH (venous)\n 7.31 units\n 03:48 AM\n pH (urine)\n 5.0 units\n 09:27 AM\n CO2 (Calc) arterial\n 26 mEq/L\n 08:31 AM\n CO2 (Calc) venous\n 21 mEq/L\n 03:48 AM\n Albumin\n 1.8 g/dL\n 05:50 PM\n Calcium non-ionized\n 9.3 mg/dL\n 01:58 AM\n Phosphorus\n 3.0 mg/dL\n 01:58 AM\n Ionized Calcium\n 1.31 mmol/L\n 08:31 AM\n Magnesium\n 2.0 mg/dL\n 01:58 AM\n ALT\n 144 IU/L\n 01:58 AM\n Alkaline Phosphate\n 93 IU/L\n 01:58 AM\n AST\n 107 IU/L\n 01:58 AM\n Amylase\n 831 IU/L\n 06:09 AM\n Total Bilirubin\n 10.3 mg/dL\n 01:58 AM\n Triglyceride\n 119 mg/dL\n 02:30 PM\n WBC\n 0.4 K/uL\n 01:58 AM\n Hgb\n 9.6 g/dL\n 01:58 AM\n Hematocrit\n 27\n 08:31 AM\n Current diet order / nutrition support: NPO\n TPN: 2060ml (310g dextrose/115g protein/50g lipid)\n GI: bowel sounds not present, abd open\n Assessment of Nutritional Status\n 60 year old male admitted for COPD exacerbation, patient became septic,\n developed ischemic bowel, s/p ex-lap, SBR, open abd , s/p ex-lap,\n hematoma evacuation , s/p ex-lap, end ileostomy . Patient to OR\n this morning for abd closure. BG remains high despite insulin drip\n running at 12units/hour. CRRT continues for clearance with minimal\n fluid removal hypotension.\n Medical Nutrition Therapy Plan - Recommend the Following\n"
},
{
"category": "Echo",
"chartdate": "2104-06-10 00:00:00.000",
"description": "Report",
"row_id": 100335,
"text": "PATIENT/TEST INFORMATION:\nIndication: 60M s/p exlap, ischemic bowel, ESRD, septic shock. Left ventricular function. Right ventricular function.\nHeight: (in) 80\nWeight (lb): 200\nBSA (m2): 2.30 m2\nBP (mm Hg): 82/56\nHR (bpm): 102\nStatus: Inpatient\nDate/Time: at 15:27\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: LA not well visualized.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically ventilated. The\nIVC is small, consistent with an RA pressure of <10mmHg.\n\nLEFT VENTRICLE: LV not well seen. Suboptimal technical quality, a focal LV\nwall motion abnormality cannot be fully excluded. Cannot assess LVEF.\n\nRIGHT VENTRICLE: Normal RV systolic function.\n\nAORTA: Normal descending aorta diameter.\n\nAORTIC VALVE: Aortic valve not well seen.\n\nMITRAL VALVE: Mitral valve leaflets not well seen. No MR.\n\nTRICUSPID VALVE: No TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views.\nSuboptimal image quality - poor apical views. Suboptimal image quality as the\npatient was difficult to position. Suboptimal image quality - body habitus.\nSuboptimal image quality - ventilator. The patient appears to be in sinus\nrhythm. Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nThe patient is mechanically ventilated. The IVC is small, consistent with an\nRA pressure of <10mmHg. The left ventricle is not well seen. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nOverall left ventricular systolic function cannot be reliably assessed. Right\nventricular systolic function is normal with normal free wall contractility.\nThe aortic valve is not well seen. The mitral valve leaflets are not well\nseen. No mitral regurgitation is seen. There is a small pericardial effusion.\nThere are no echocardiographic signs of tamponade.\n\nImpression: poor windows with normal right venricular systolic function and\nsmall IVC diameter.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2104-06-05 00:00:00.000",
"description": "Report",
"row_id": 100336,
"text": "PATIENT/TEST INFORMATION:\nIndication: Shortness of breath/Dyspnea. Hypertension. S/p renal transplant--not clearly volume overloaded.\nHeight: (in) 72\nWeight (lb): 180\nBSA (m2): 2.04 m2\nBP (mm Hg): 150/90\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 10:03\nTest: Portable TTE (Focused views)\nDoppler: Color Doppler only\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: LV not well seen. Suboptimal technical quality, a focal LV\nwall motion abnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: RV not well seen. RV hypertrophy. Mildly dilated RV cavity.\nNormal RV systolic function.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - ventilator.\n\nConclusions:\nThe left ventricle is not well seen. Due to suboptimal technical quality, a\nfocal wall motion abnormality cannot be fully excluded. The right ventricular\nfree wall is hypertrophied. The right ventricular cavity is mildly dilated\nwith normal free wall contractility. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic stenosis. The\nmitral valve leaflets are mildly thickened. There is an anterior space which\nmost likely represents a fat pad.\n\nIMPRESSION: Very poor technical quality. Left ventricular function is probably\nnormal, a focal wall motion abnormality cannot be fully excluded. The right\nventricle is not well seen but is probably mildly dilated with normal function\nand thickened walls. Cannot exclude valvular abnormality. Pulmonary artery\nsystolic pressure could not be determined.\n\nCompared with the prior study (images reviewed) of , image quality\nis worse. The RV appears dilated on the current study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-06-10 00:00:00.000",
"description": "CT PELVIS W/O CONTRAST",
"row_id": 1077962,
"text": " 1:48 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ABD DISTENSION\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with abdominal distension and possible SBO.\n REASON FOR THIS EXAMINATION:\n SBO? please do CT with PO contrast.\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure;ARF\n ______________________________________________________________________________\n WET READ: JXKc TUE 4:39 AM\n Dilated loops of small bowel, measuring up to 4 cm without definite evidence\n of obstruction. However, there is extensive pneumatosis, involving ileal\n loops as well as involving the ascending and transverse colon. Linear foci of\n air in the liver may indicate portal venous air. These findings can be seen\n with bowel infarction, but can also be seen with various benign entities such\n as with medications, i.e. steroid use, infection, chronic pulmonary disease,\n IBD. d/w Dr. and Dr. immediately at 3:30 a.m. -jkang.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Abdominal distention and possible small-bowel obstruction.\n\n TECHNIQUE: CT abdomen and pelvis without IV contrast and with oral contrast.\n\n COMPARISON: Compared to CT of .\n\n FINDINGS:\n\n LUNG BASES: There are bilateral small pleural effusions with adjacent small\n dependent atelectasis. No nodules are present at the lung bases. There is no\n large pericardial effusion.\n\n CT ABDOMEN: There are dilated loops of small bowel, measuring up to 4 cm,\n without definite evidence of obstruction. However, there is extensive\n pneumatosis, involving the ileal loops as well as involving the ascending and\n transverse colon. Linear foci of air at the liver may indicate portal venous\n air; however, this finding also could be due to biliary air. These findings\n can be seen with bowel infarction, but also can be seen with various benign\n entities such as the medications, steroid use, infection, chronic pulmonary\n disease, and IBD.\n\n There is a small amount of free fluid in the abdomen. There is no evidence of\n free abdominal air. The small hypodensity seen within the liver on the prior\n study is not definitely appreciated on the current scan likely due to\n difference in technique. The liver appears grossly normal. The gallbladder,\n pancreas, and adrenals appear within normal limits. The hypodense lesions\n seen in the spleen on the prior study, is not clearly visualized on the\n current scan, likely due to technique, however there is suggestion that might\n be unchanged. There is a moderate-sized hiatal hernia. Calcifications are seen\n throughout the abdominal arterial vasculature. Please note that no IV\n contrast was given, and we are not able to comment on vessel occlusion. There\n (Over)\n\n 1:48 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ABD DISTENSION\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n is an NG tube in place. No significant mesenteric or retroperitoneal\n lymphadenopathy is seen.\n\n CT PELVIS: Pneumatosis seen in the ileal loops. There is small amount of\n free fluid in the pelvis. There is a Foley catheter in place, with small\n amount of air within the bladder, likely due to Foley placement. There is a\n transplant kidney in the right lower quadrant. No significant lymphadenopathy\n is seen.\n\n OSSEOUS STRUCTURES: There is a total hip replacement on the right. There are\n no suspicious lytic or sclerotic lesions seen in the bones. There is loss of\n height of L4 vertebral body, of indeterminate age.\n\n IMPRESSION:\n\n 1. Dilated loops of small bowel, measuring up to 4 cm, without definite\n evidence of obstruction. There is extensive pneumatosis involving ileal loops\n as well as involving the ascending and transverse colon. Linear foci of air\n in the liver may indicate portal venous air; however, this finding could also\n be seen in biliary air. These findings can be seen with bowel infarction, but\n can also be seen with various benign entities such as the medications, steroid\n use, infection, chronic pulmonary disease, and IBD.\n Findings were discussed with Dr. and Dr. at 3:38 a.m. on\n by Dr. .\n\n 2. Splenic mass less appreciated on current scan due to difference in\n technique, however it appears similar, and is hard to evaluate.\n\n 3. Small bilateral pleural effusion with small associated dependent\n atelectasis at the lung bases.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-06-03 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1076947,
"text": " 4:55 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Please eval PICC placement.\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man s/p PICC line placement.\n REASON FOR THIS EXAMINATION:\n Please eval PICC placement.\n ______________________________________________________________________________\n WET READ: ARHb TUE 7:07 PM\n While the left PICC is seen coursing through the left axilla, it is difficult\n to track its intrathoracic course and mediastinal positioning cannot be\n confirmed.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:56 P.M. \n\n HISTORY: PICC line placement.\n\n IMPRESSION: AP chest compared to 11:41 a.m.\n\n Left PICC line crosses the left axilla but cannot be identified with certainty\n inside the chest. Previously it ran into the junction of the brachiocephalic\n veins. Lungs clear. Heart size normal. No pleural abnormality.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-06-09 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1077953,
"text": " 9:54 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please evaluate for interval change.\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with decreased right sided breath sounds.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:12 P.M. ON .\n\n HISTORY: Decreased right breath sounds. Evaluate for change.\n\n IMPRESSION:\n AP chest compared to to :\n\n Atelectasis in the right lower lung has worsened since earlier in the day, but\n opacity in the left lower lobe may have cleared, subject to differences in\n projection. Variation in atelectasis suggests difficulty in clearing\n secretions, perhaps complicated by aspiration. Upper lungs are clear. Heart\n size is normal. ET tube ends at the thoracic inlets, right jugular line tip\n projects over the SVC and a nasogastric tube ends in the stomach. No\n pneumothorax. Pleural effusion if any is minimal, on the right.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-06-05 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 1077278,
"text": " 1:23 PM\n RENAL TRANSPLANT U.S.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Ultrasound with doppler to evalute for impaired blood flow t\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with uncontrolled hypertension, acute on chronic renal failure.\n REASON FOR THIS EXAMINATION:\n Ultrasound with doppler to evalute for impaired blood flow to tranplant kidney.\n ______________________________________________________________________________\n WET READ: 5:47 PM\n Elevated resistive indices on Doppler examination, greater than 2 days\n earlier, suggesting rejection. No hydronephrosis or fluid collection.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 60-year-old man with hypertension and acute on chronic renal\n failure.\n\n COMPARISONS: .\n\n TECHNIQUE: Renal transplant ultrasound.\n\n FINDINGS: This examination is markedly limited by significant motion due to\n respiratory effort. The transplant kidney in the right lower quadrant measures\n 11.5 cm in length. There is no hydronephrosis, solid mass, or perinephric\n fluid collection. Although Doppler studies show a sharp upstroke of interlobar\n arterial waveforms, resistive indices are elevated, ranging from 0.7-0.85,\n comparing to approximately 0.65 on the prior exam. It is noted, however, that\n the study is limited because of motion artifact and it is also possible that\n some of the spectral waveforms that appeared to represent diastolic arterial\n flow may be due to venous contamination, which would imply that diastolic flow\n could in fact be absent in some areas. This appearance does represent a\n change from two days earlier. The main renal artery and vein are patent.\n\n IMPRESSION: Increase in resistive indices in the transplanted kidney since\n the prior study, with possible absent diastolic flow observed (evaluation very\n limited by respiratory motion) suggesting rejection among other causes for\n increased vascular resistance. No hydronephrosis.\n\n Results discussed with the clinical team caring for the patient at the time of\n image acquisition in the ICU.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-06-05 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1077265,
"text": " 12:35 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Confirm endotracheal tube placement.\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man intubated.\n REASON FOR THIS EXAMINATION:\n Confirm endotracheal tube placement.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 5:02 PM\n PFI: Endotracheal tube appropriately positioned 6 cm from carina.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old male status post intubation. Confirm endotracheal\n tube placement.\n\n COMPARISON: , approximately one and half hours earlier.\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: There is a newly placed endotracheal tube\n which terminates 6 cm from the carina. A nasogastric tube is again noted but\n projects beyond the field of view. The remainder of the exam is unchanged\n compared to 1.5 hours earlier.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-06-05 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1077266,
"text": ", S. MED 12:35 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Confirm endotracheal tube placement.\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man intubated.\n REASON FOR THIS EXAMINATION:\n Confirm endotracheal tube placement.\n ______________________________________________________________________________\n PFI REPORT\n PFI: Endotracheal tube appropriately positioned 6 cm from carina.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-06-06 00:00:00.000",
"description": "GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)",
"row_id": 1077486,
"text": " 2:11 PM\n BX-NEEDLE KIDNEY BY NEPHROLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \n Reason: ? rejection\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ********************************* CPT Codes ********************************\n * BX-NEEDLE KIDNEY BY NEPHROLOGIST GUIDANCE/LOCALIZATION FOR NEEDLE BIO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with transplanted kidney, concern for rejection\n REASON FOR THIS EXAMINATION:\n ? rejection\n CONTRAINDICATIONS for IV CONTRAST:\n cr\n ______________________________________________________________________________\n WET READ: FRI 5:28 PM\n Assistance provided for renal biopsy.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Assistance with ultrasound-guided non-targeted biopsy of renal\n transplant.\n\n TECHNIQUE: Ultrasound guidance was provided to nephrology in obtaining two\n 16-gauge core needle biopsy specimens from the lower medial part of a\n transplant kidney located in the right lower quadrant. The procedure was\n performed by the nephrologist. Please refer to nephrology report for details\n of the procedure.\n\n IMPRESSION: Ultrasound guidance for renal transplant biopsy by nephrologist.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-06-03 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1076877,
"text": " 11:27 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 52cm DL L basilic PICC placed ? tip\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with COPD exacerbation\n REASON FOR THIS EXAMINATION:\n 52cm DL L basilic PICC placed ? tip\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old male with COPD exacerbation. Evaluate PICC.\n\n COMPARISON: from nine hours earlier.\n\n UPRIGHT AP VIEW OF THE CHEST: There is a newly placed central venous access\n line from the left upper extremity. The course alignment is unremarkable.\n Distal tip of the wire projects at the junction of the brachiocephalic and\n SVC. No pneumothorax or other immediate complication is noted. The remainder\n of the exam is essentially unchanged from nine hours prior.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-06-03 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1076790,
"text": " 2:29 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for interval change, pulm edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with dyspnea, now with acute worsening in RR and work of\n breathing\n REASON FOR THIS EXAMINATION:\n eval for interval change, pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man with dyspnea, now with acute worsening\n respiratory rate and work of breathing. Query pulmonary edema.\n\n COMPARISON: , 00:28.\n\n SINGLE PORTABLE UPRIGHT AP CHEST RADIOGRAPH: Heart size, mediastinal and\n hilar contours are unchanged. There is hyperinflation. There is\n calcification of the aorta which is mildly unfolded. Right pulmonary artery\n is prominent. No consolidation, effusion or pneumothorax, although both\n cardiophrenic angles are incompletely visualized which limits the study.\n Pulmonary vasculature is normal.\n\n IMPRESSION: No acute intrathoracic pathology.\n\n"
},
{
"category": "ECG",
"chartdate": "2104-06-18 00:00:00.000",
"description": "Report",
"row_id": 277411,
"text": "Probable \"fine\" atrial fibrillation with rapid ventricular response\nIndeterminate axis\nLow QRS voltage\nDelayed R wave progression with late precordial QRS transition\nFindings are nonspecific but clinical correlation is suggested for possible in\npart chronic pulmonary disease\nSince previous tracing of , probably atrial fibrillation now present\n\n"
},
{
"category": "ECG",
"chartdate": "2104-06-17 00:00:00.000",
"description": "Report",
"row_id": 277412,
"text": "Sinus tachycardia with diffuse low voltage. Delayed R wave transition.\nLeft axis deviation. Compared to the previous tracing of no\ndiagnostic interval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2104-06-12 00:00:00.000",
"description": "Report",
"row_id": 277413,
"text": "Baseline artifact. The rhythm is probably sinus with left atrial abnormality\nbut consider also ectopic atrial rhythm and baseline artifact makes assessment\ndifficult. Low QRS voltage. Left axis deviation may be due to left anterior\nfascicular block or possible prior inferior myocardial infarction. Delayed\nR wave progression may be positional/non-specific or possible prior septal\nmyocardial infarction. Modest ST-T wave changes are suggested but baseline\nartifact makes asssessment difficult. Findings are non-specific but clinical\ncorrelation is suggested. Since the previous tracing of no significant\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2104-06-09 00:00:00.000",
"description": "Report",
"row_id": 274046,
"text": "Sinus rhythm. Left atrial abnormality. A-V conduction delay. Left anterior\nfascicular block. Prior anteroseptal myocardial infarction infarction.\nCompared to the previous tracing of no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2104-06-04 00:00:00.000",
"description": "Report",
"row_id": 274047,
"text": "Sinus rhythm with first degree A-V block. Left axis deviation. Probable\nold inferior wall myocardial infarction. Poor R wave progression. Compared to\nthe previous tracing of no diagnostic change.\n\n"
},
{
"category": "ECG",
"chartdate": "2104-06-02 00:00:00.000",
"description": "Report",
"row_id": 274048,
"text": "Sinus rhythm. A-V conduction delay. Left atrial abnormality. Delayed\nprecordial R wave transition. Compared to the previous tracing of the\nrate has slowed. The recording is of improved technical quality but without\ndiagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2104-06-12 00:00:00.000",
"description": "Report",
"row_id": 274044,
"text": "Compared to the previous tracing probably no significant change. Baseline\ninstability mimics atrial fibrillation but the rhythm is likely sinus with\nleft atrial abnormality and first degree A-V block.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2104-06-12 00:00:00.000",
"description": "Report",
"row_id": 274045,
"text": "Normal sinus rhythm, rate 78, with left atrial abnormality and first degree\nA-V block. Generalized low voltage. Possible anteroseptal myocardial\ninfarction of indeterminate age. Generalized non-specific repolarization\nabnormality. Boderline Q-T interval prolongation. Compared to the previous\ntracing of T waves are less deeply inverted in lead aVL. Otherwise\nno significant change.\nTRACING #1\n\n"
}
] |
15,276 | 138,479 | Ultimately Dr. felt the patient was appropriate to go to the OR. He went for a three vessel coronary artery bypass graft on . Grafts included a LIMA to the LAD, a left saphenous vein graft to the OM1 and a left saphenous vein graft to the PDA. The patient tolerated the procedure well. Intraoperative TEE revealed an ejection fraction of 30-40%. Post-operatively out of the OR he was maintained on Epinephrine, Aprotinin, Levophed, an insulin drip and Propofol for sedation. He was brought to the cardiac surgical care recovery unit where his postoperative labs were noted to have a hematocrit of 30, normal coagulation parameters, INR of 1.2, PTT 33, potassium was noted to be 4.4, BUN and creatinine at this time were 63 and 1.5. He was started on Levaquin and Flagyl not only to cover his lower extremity leg ulcers, but also to cover some viscous pulmonary secretions that were noted. He was extubated on postoperative day #1 and was maintained on a non rebreather. He was satting at 93% with gases of 7.26, 63, 167, 31 and 0. Given the tenuous nature of his gases, he had serial ABGs followed on postoperative day #1, was given aggressive pulmonary toilet. He was started with diuresis. His Aspirin was started and his Neo-Synephrine was weaned. His insulin drip was maintained at 5 units per hour and he was normoglycemic. By postoperative day #2 the patient remained in the cardiac surgical care recovery unit. He was on Levaquin and Flagyl, his perioperative Vancomycin dose was finished at his third dose, insulin drip was titrated to 6 units to maintain normoglycemia. He was started on prophylaxis with Zantac as well as stool softeners with Colace. His oral diet was a diabetic , 1800 kilocalories with cardiac diet as well. His day #2 labs included a hematocrit of 23 for which he was ultimately transfused two units. This was thought to be secondary to small oozing that was in his chest tube. BUN and creatinine were 69 and 1.8. After his volume being repleted as well as his transfusion being completed, he was continued on progressive pulmonary toilet and diuresis. By postoperative day #3 the patient was deemed appropriate for discharge to the floor. He was maintained on chest tube suction because of high chest tube output, his sanguineous discharges on the first two days changed to more serosanguineous and his hematocrit was stable at 30 on postoperative day #3. BUN and creatinine were noted to be 71 and 1.9. He was changed to a q day Lasix regimen instead of and Lopressor was started as well as adding on a full dose Aspirin. consultation was obtained for assistance with the patient's diabetic management. He was tolerating his diet although he was complaining at this time of intermittent regurgitation. This was felt to be due secondary to his probable underlying gastroparesis and autonomic neuropathy from his end stage diabetes. Consequently the patient was started on Reglan which had satisfactory results and eliminated the majority of the patient's complaints of nausea and regurgitation. Of note, on postoperative day #3 the patient's Foley was removed, however, he failed to void in 9 hours post Foley removal and after attempts by the house officer and nursing staff to insert a Foley catheter, these failed, urology consultation was obtained. The patient had his catheter inserted by the urology service who felt that he probably failed to void secondary to retention issues of the post-operative state with narcotic use and his autonomic neuropathy and perhaps small degree of benign prostatic hypertrophy. FOley was instructed to stay in until which time the chest tube is removed so that once his pain requirements became less he would use less narcotic and as a consequence have less urinary sphincter tone. By postoperative day #4 the patient was undergoing transfers with physical therapy, was out of bed to a chair, tolerating it well. He was noted to go into atrial fibrillation with rapid ventricular response to the 110's. This was easily treated and controlled with Lopressor and he was started on Amiodarone, converted to normal sinus rhythm after approximately 12 hours of therapy. By postoperative day #5 the patient was in sinus rhythm, was afebrile, tolerating his diet without complaints. He had a Foley catheter and chest tube at this time. By postoperative day #6 his chest tubes were removed, chest x-ray showed a small left effusion with pneumothorax, normal cardiac silhouette, no focal infiltrate was identified. He additionally had Foley catheter removed at midnight prior to discharge. Labs prior to discharge were notable for hematocrit of 35, BUN and creatinine of 64 and 1.6. His exam was notable for temperature of 98.3, pressure of 90/50, pulse rate of 64 and sinus. On exam he has a stable sternum with staples in place, no erythema or drainage. Heart was regular with no murmur or rub or gallop. Lungs with decreased breath sounds at the bases with crackles bilaterally. Left lower extremity was noted to have trace edema. Saphenous vein harvest was well approximated, intact, no drainage or erythema were present. He did have a macular rash in the inguinal regions that was felt to be intertrigonal, likely secondary to Candidiasis. Ultimately patient was accepted to Rehab facility where he will undergo aggressive rehabilitation regimen to get him back to his baseline of being wheelchair bound. His activity restriction will include no pushing off with his arms as he is dependent on his upper extremities for mobility. This cannot be utilized for 30 days so his sternal wound be allowed to adequately heal. Additionally he will be put on subcu Heparin for DVT prophylaxis. He should be continued with an aggressive pulmonary rehabilitation effort including incentive spirometry, coughing and deep breathing, nebulizers as needed. Follow-up will include seeing Dr. in 30 days from the time of discharge. He is to see his PCP weeks from the time of discharge and the Rehabilitation facility will be able to evaluate his wounds. | COMPARISON: PORTABLE AP CHEST: There has been median sternotomy and CABG. Post-operative changes and mild CHF. PRESENTLY, ABLE TO CLEAR SECRETIONS.PMH--DM-', R BKA,L HEEL ULCER, +NEUROPATHY,ISCHIORECTAL ABSESS, R HIP REMOVAL '.TODAY, PT IS AFEBRILE, BP STABLE AT 110-120'S. BS HYPO. Since the previous tracing of diffuse ST-T waveabnormalities are seen consistent with acute ischemia.TRACING #1 The patchy right upper lobe opacity has resolved. Rule out retroperitoneal bleed. Slightly improved congestive failure. Findings consistent with left heart failure and/or fluid overload. Allowing for AP and lordotic technique, the overall heart size is probably within normal limits and the mediastinal and hilar contours are unremarkable. CT ABDOMEN WITHOUT CONTRAST: There are moderate pleural effusions bilaterally. There is persistent bibasilar atelectasis and small effusions, left greater than right. 2 u ffp, 1 upc. CT PELVIS WITHOUT CONTRAST: There is marked atrophy of the right hemipelvis. Minimal increase in ST-T wave abnormalities is seen.TRACING #1 Lungs are diminished but otherwise CTA. STARTED ALB/ATRO HHN. MI, AWAITING CABG, LOW BP, ABD PAIN, DIAPHORETIC, ? MI, AWAITING CABG, LOW BP, ABD PAIN, DIAPHORETIC, ? RETROPERITONEAL BLEED Field of view: 48 FINAL REPORT (Cont) obstruction. Shift NotePt is neurologically intact, MAE to command, uncomfortable on vent. REC'G LASIX.INTEG: INC TO LT LEG/STERNUM INTACT. There is persistent mild upper zone vascular redistribution and blurring of vascular detail. RECEIVED LASIX, REQUIRED SUCTIONING. ON , CALLED EMS. Skin staples and median sternotomy wires are again seen. Pt sleepy at this time, am labs sent. DP PULSE AUDIBLE WITH DOPPLER TO LT FOOT. There are bilateral chest tubes and a mediastinal drain. Bilateral small pleural effusions and left lower lobe collapse and consolidation are still present. Hemodynamics as per flowsheet, neo weaned to off. Small left and right sided pleural effusions are present. ENC TO C&DB. Sinus rhythm. Sinus rhythm. Sinus rhythm. Since the previous tracing of ischemic appearingST-T wave abnormalities are slightly improved.TRACING #3 Sinus rhythm, rate 74. PT came out from OR after CABG x3. Left lung very diminished as compared to the right and earlier in shift. Both hemidiaphragms are obscured, likely from bilateral pleural effusions. CTX3 INTACT.GI: PT REMAINS NPO. Since the previous tracing the heart rate is somewhatfaster. LUNGS CLEAR-COARSE BILATERALLY. LYTES REPLEATED.RESP: LS EXTREMELY COARSE THIS AM. ABLE TO MAE.CV: PT DENIES CP, PALP, SOB. There is a moderately-large anterior herniation of bowel without evidence for obstruction. In the interval since the prior study, the bilateral chest tubes have been removed. PROBLEMS WITH SECRETIONS POST EXT. CHEST: COMPARISONS: . Noother changes are seen.TRACING #2 s/p cabg x 3arrived on .o2mcq epi,15 mcq propofol, neo .6 mcq.cardiac: av paced to sr without vea. NEW ONSET ON CHF WITH AMI. RECEIVED PULM TOILET. ABG with P02 of 71mmHg and PCO2 of 71mmHg, pt encouraged to cough and deep breathe. There also appears to be involvement of the right acetabulum. IMPRESSION: Lines and tubes as described. TO EW . NO DRNG NOTED.PAIN: PT PERCOCET FOR PAIN WITH GOOD EFFECT.PLAN: CONTINUE PULM TOILET, C&DB. Standard PA and lateral radiographs following diuresis may be of help for clarification. The cardiac silhouette is enlarged but stable. A right internal jugular Swan-Ganz catheter terminates with tip just into the main pulmonary artery. HR 80'S SR WITHOUT ECTOPY. hct 24 prior to 1upc,post transfusion hct 28, hct 21 recieved 1 upc #2upc up and infusing.dsgs d+i. 3) Large anterior and smaller right lateral hernias without evidence for (Over) 1:14 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: ? Since the previous tracing of the heart ratehas slowed somewhat. Pt with weak cough. ci >2.1. IMPRESSION: 1. The T waves are slightly more inverted over the inferior leads. The opacified loops of large and small bowel are otherwise unremarkable. FINDINGS: The cardiac silhouette is enlarged with left ventricular and left atrial predominance. A Foley catheter appears intact. LEG COVERED WITH ACE. There is soft- tissue attenuation surrounding the right hip. CHECK POST TX HCT. CSRU NURSING NOTE:NEURO: PT ALERT AND ORIENTED. Sinus rhythm, rate 86. sbp labile epi dcd, neo continues @ .5mcq. ON AFTERNOON, WENT INTO PULM EDEMA. Pt on 5L via nasal cannula with SA02 96-97%, pt encouraged to C+DB. Degenerative changes are noted in the left hip. TELE: MP: NSR. Two AP upright portable radiographs of the chest were obtained. TX TO FLOOR. 4) Comminuted fracture of right femoral head with involvement of the right acetabulum, as described above. placed on mech vent 7200, simv 800x12, 40% FIO2 ,.Last ABG shows 7.42/37/128/25/98%.Plan to continue vent support and wean as tol. 1:14 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: ? ON Q4 HR FS. PT HAD BLEEDING INTRAOP AND RECEIVED APROTIN, PLTS AND BLOOD. extubate, i+O, neuro status, glucose as per orders. EPICARDIAL WIRES 2A/2V INTACT. TECHNIQUE: Contiguous axial images were obtained from the lung bases to the femoral heads without intravenous contrast. 2) Gallstones without evidence for acute cholecystitis. There is upper zone redistribution of the pulmonary vascularity with blurring of the vascular detail, consistent with fluid overload and/or left heart failure. | 15 | [
{
"category": "ECG",
"chartdate": "2121-01-20 00:00:00.000",
"description": "Report",
"row_id": 268565,
"text": "Sinus rhythm. No change since earlier this date.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2121-01-20 00:00:00.000",
"description": "Report",
"row_id": 268566,
"text": "Sinus rhythm. Since the previous tracing of diffuse ST-T wave\nabnormalities are seen consistent with acute ischemia.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2121-01-22 00:00:00.000",
"description": "Report",
"row_id": 268326,
"text": "Sinus rhythm, rate 86. Since the previous tracing the heart rate is somewhat\nfaster. The T waves are slightly more inverted over the inferior leads. No\nother changes are seen.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2121-01-21 00:00:00.000",
"description": "Report",
"row_id": 268327,
"text": "Sinus rhythm, rate 74. Since the previous tracing of the heart rate\nhas slowed somewhat. Minimal increase in ST-T wave abnormalities is seen.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2121-01-21 00:00:00.000",
"description": "Report",
"row_id": 268328,
"text": "Sinus rhythm. Since the previous tracing of ischemic appearing\nST-T wave abnormalities are slightly improved.\nTRACING #3\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-01-21 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 748224,
"text": " 1:14 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? MI, AWAITING CABG, LOW BP, ABD PAIN, DIAPHORETIC, ? RETROPERITONEAL BLEED\n Field of view: 48\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with ruled in for mi last night awaiting cabg on 2b3a and\n heparin, now diaphoretic, BP newly 85, mild abd pain.\n REASON FOR THIS EXAMINATION:\n r/o retroperitoneal bleed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55 year old male with recent MI, now on 2B3A and heparin,\n awaiting CABG. Rule out retroperitoneal bleed.\n\n TECHNIQUE: Contiguous axial images were obtained from the lung bases to the\n femoral heads without intravenous contrast.\n\n No prior CTs are available for comparison.\n\n CT ABDOMEN WITHOUT CONTRAST: There are moderate pleural effusions\n bilaterally. There is also bilateral dependent atelectasis.\n\n There are stones within the gallbladder. There is no pericholecystic fluid or\n wall thickening. The liver, spleen, pancreas, adrenals, and kidneys appear\n unremarkable. There is no mesenteric or retroperitoneal adenopathy. There is\n no evidence for a retroperitoneal bleed. There is a moderately-large anterior\n herniation of bowel without evidence for obstruction. There is also a smaller\n herniation of bowel in the right lateral abdominal wall. The opacified loops\n of large and small bowel are otherwise unremarkable.\n\n CT PELVIS WITHOUT CONTRAST: There is marked atrophy of the right hemipelvis.\n A Foley catheter appears intact. The bladder appears unremarkable. There is\n no pelvic lymphadenopathy.\n\n Bone windows demonstrate a comminuted fracture of the right femoral head.\n There also appears to be involvement of the right acetabulum. There is soft-\n tissue attenuation surrounding the right hip. This may be secondary to\n bleeding or chronic inflammation. An MRI may be useful to evaluate this area\n in the proper clinical setting. Degenerative changes are noted in the left\n hip.\n\n The above findings were relayed to the primary team. Additional history was\n obtained by telephone. The patient's right hemipelvis was surgically removed\n due to infection and had a long postoperative course.\n\n IMPRESSION:\n\n 1) No evidence for retroperitoneal hemorrhage.\n\n 2) Gallstones without evidence for acute cholecystitis.\n\n 3) Large anterior and smaller right lateral hernias without evidence for\n (Over)\n\n 1:14 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? MI, AWAITING CABG, LOW BP, ABD PAIN, DIAPHORETIC, ? RETROPERITONEAL BLEED\n Field of view: 48\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n obstruction.\n\n 4) Comminuted fracture of right femoral head with involvement of the right\n acetabulum, as described above. There is soft-tissue density in this area\n which may be consistent with blood or inflammation. An MRI may be useful in\n the proper clinical setting.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-01-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 748156,
"text": " 5:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Cough, dyspnea\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with IDDM, with 2 days of cough, SOB, bibasilar rales and\n rhonchi on right.\n REASON FOR THIS EXAMINATION:\n Cough, dyspnea\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 55 year old man with diabetes, cough and shortness of\n breath.\n\n Two AP upright portable radiographs of the chest were obtained. No priors are\n available for comparison.\n\n Allowing for AP and lordotic technique, the overall heart size is probably\n within normal limits and the mediastinal and hilar contours are unremarkable.\n Both hemidiaphragms are obscured, likely from bilateral pleural effusions.\n There is upper zone redistribution of the pulmonary vascularity with blurring\n of the vascular detail, consistent with fluid overload and/or left heart\n failure. Vague increased opacities are also present in the right upper lobe,\n right middle lobe and left lower lobe in the retrocardiac region. These\n findings suggest there may be an underlying infectious process present.\n\n IMPRESSION: 1. Findings consistent with left heart failure and/or fluid\n overload. 2. Increased opacities involving the right upper lobe, right middle\n lobe and left lower lobe raise the suspicion for underlying infection.\n Standard PA and lateral radiographs following diuresis may be of help for\n clarification.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-01-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 748327,
"text": " 5:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p cabg, post extubation poor oxygenation with diminished b\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n s/p cabg, post extubation poor oxygenation with diminished breath sounds on\n left - ?PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P CABG with poor oxygenation after extubation.\n\n COMPARISON: \n\n PORTABLE AP CHEST: There has been median sternotomy and CABG. A right\n internal jugular Swan-Ganz catheter terminates with tip just into the main\n pulmonary artery. There are bilateral chest tubes and a mediastinal drain.\n The cardiac silhouette is enlarged but stable. There is persistent mild upper\n zone vascular redistribution and blurring of vascular detail. The patchy\n right upper lobe opacity has resolved. There is persistent bibasilar\n atelectasis and small effusions, left greater than right.\n\n IMPRESSION: Lines and tubes as described. Post-operative changes and mild\n CHF. Slightly improved congestive failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-01-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 748733,
"text": " 7:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p chest tube removal, please evaluate for PTX/effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n s/p chest tube removal, please evaluate for PTX/effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: S/P chest tube removal and S/P CABG.\n\n CHEST:\n\n COMPARISONS: .\n\n FINDINGS: The cardiac silhouette is enlarged with left ventricular and left\n atrial predominance. Small left and right sided pleural effusions are\n present. There is collapse in consolidation of the left lower lobe. The lung\n volumes have improved since the prior study. There is no pneumothorax. Skin\n staples and median sternotomy wires are again seen. In the interval since the\n prior study, the bilateral chest tubes have been removed.\n\n IMPRESSION: Overall improvement in the appearance of the lungs with increased\n lung volumes. Bilateral small pleural effusions and left lower lobe collapse\n and consolidation are still present.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-01-24 00:00:00.000",
"description": "Report",
"row_id": 1460966,
"text": "NEURO ALERT ORIENTED MOVES ALL EXTREMETIES NO DEFECITS NOTED\n\nC/V NSR NO ECT B/P STABLE PALP PULSES L FOOT EPI WIRES INTACT INCISION INTACT\n\nRESP NC 4L 99% SATS LUNGS COARSE GOOD COUGHING AND DEEP BREATHING MOVING SECRETIONS CT INTACT DRAINING SMALL TO MOD AMTS SEROSANG\n\nLABS BS INCREASE GREATER THAN 200 X2 INSULIN DRIP RESTARTED PER PROTOCOL WITH DECREASING BS INSULIN DRIP MAINTAINED PER PROTOCOL C/O FEELING LIGHTHEADED 6AM PREVIOUS BS CHECKED 3O MINUTES PRIOR 113 INSULIN DRIP TURNED OFF WITH C/O FEELING WEAK BS FINGERSTICK 71 AMP D50 PER PROTOCOL WITH RELIEF OF SYMPTOMS REPEAT BS 0630 87 INSULING REMAINS OFF NP NOTIFIED HCT 23.3 IUPC INFUSING SLOWLY CALCIUM REPLACED X1\n\nDSG L FOOT DSG CHANGE NO DRAINAGE 2X3 AREA OPEN CLEAN FOOT ELEVATED\n\nLINES ALINE DC/D DUE TO INCREASE SWELLING AT SITE POOR WAVE\n\nPLAN TRANSFUSE PC CONTINUE TO CLOSELY MONITOR BS TX TO 6 TODAY\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-01-24 00:00:00.000",
"description": "Report",
"row_id": 1460967,
"text": "NURSING TRANSFER NOTE\nPT IS A 55 YO MALE WITH SUDDEN ONSET ON SOB. ON , CALLED EMS. TO EW . NEW ONSET ON CHF WITH AMI. EF~35%.\nON , PT UNDERWENT 3 WITH LIMA LAD, SVG->OM/PDA. PT HAD BLEEDING INTRAOP AND RECEIVED APROTIN, PLTS AND BLOOD. EXTUBATED ON AT 0300. PROBLEMS WITH SECRETIONS POST EXT. RECEIVED PULM TOILET. ON AFTERNOON, WENT INTO PULM EDEMA. RECEIVED LASIX, REQUIRED SUCTIONING. PRESENTLY, ABLE TO CLEAR SECRETIONS.\n\nPMH--DM-', R BKA,L HEEL ULCER, +NEUROPATHY,ISCHIORECTAL ABSESS, R HIP REMOVAL '.\n\nTODAY, PT IS AFEBRILE, BP STABLE AT 110-120'S. HR 80'S SR WITHOUT ECTOPY. ALL INCISIONS DRY AND INTACT. LEG COVERED WITH ACE. CHEST OPEN TO AIR. HEEL ULCER CHANGED AT 0600 AND IS Q12 HRS. MCT DRAINING >50 CC HR OF SEROSANGINOUS DRAINAGE. TEAM AWARE. RECEIVED 2 U PRBC FOR PRE HCT OF 23.\n\nRESP--SAO2 99%. LUNGS CLEAR-COARSE BILATERALLY. STRONG PRODUCTIVE COUGH. AT TIMES RR 30 WHEN AT REST 20.\n\nGI--PT SIPS LIQUIDS. DOES NOT WANT TO EAT YET. NO STOOL REFUSING COLACE THIS AM.\n\nGU--FOLEY CATH PATENT DRAINING>30 CC HR. RECEIVED 40 MG IV LASIX BETWEEN BLOOD PRODUCTS.\n\nENDO--BS AT 0700 87, AT 1000 170, RECEIVED 3 U SQ REG INSULIN. ON Q4 HR FS. NEXT DUE AT 1400.\nNO INSULIN GTT AT THIS TIME.\n\nSKIN--HEALED OVER BUTTOCKS WOUND, L HEEL ULCER NOT ASSESSED AT THIS TIME.\n\nCOPING--NO FAMILY MEMBERS HAVE PHONED OR VISITED AT THIS TIME.\n\nPT IS A LIFT TO CHAIR. HAS NOT BEEN OOB TODAY.\n\nPLAN--CON'T PULM TOILET, ENCOURAGE TO C&DB. TX TO FLOOR. CHECK POST TX HCT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-01-22 00:00:00.000",
"description": "Report",
"row_id": 1460962,
"text": "Respiratory note:\n55yr M PMHx CAD, CHF, IDDM with severe diffuse vascular disease.\nc-xray pulm edema. PT came out from OR after CABG x3. placed on mech vent 7200, simv 800x12, 40% FIO2 ,.Last ABG shows 7.42/37/128/25/98%.\nPlan to continue vent support and wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-01-23 00:00:00.000",
"description": "Report",
"row_id": 1460963,
"text": "s/p cabg x 3\narrived on .o2mcq epi,15 mcq propofol, neo .6 mcq.\ncardiac: av paced to sr without vea. sbp labile epi dcd, neo continues @ .5mcq. ci >2.1. ct drainage 255 ml after turning, act 150 recieved 50 mg protamine x 2. 2 u ffp, 1 upc. hct 24 prior to 1upc,post transfusion hct 28, hct 21 recieved 1 upc #2upc up and infusing.dsgs d+i. left pp via doppler.\nresp: continues on fio2 40% rate 10 pt not weaned due to hct and sbp.bs diminished bibasilar, no ct leak.abg per flow.\nneuro: sedated on propofol, awake initially, mae, would not -could not follow commands, as shift progressed squeezed my hand with his right hand, admitted to having pain.\ngi: coffee grounds, carafate x 2. absent bowel sounds.\ngu: marginal uo as shift progressed.\nendo: insulin gtt continues @ 7 units/hr.\npain: recieved 2 mg mso4 x1.\nsocial: no family called or visited, no emergency contact listed\na: hct 21, labile sbp,\np: monitor comfort, hr and rythym, sbp, ct drainage, labs, resp status if stable ? wean to ? extubate, i+O, neuro status, glucose as per orders. as per orders.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-01-23 00:00:00.000",
"description": "Report",
"row_id": 1460964,
"text": "Shift Note\nPt is neurologically intact, MAE to command, uncomfortable on vent. Hemodynamics as per flowsheet, neo weaned to off. Lungs are diminished but otherwise CTA. Pt weaned from vent and extubated without incident. Pt on 5L via nasal cannula with SA02 96-97%, pt encouraged to C+DB. Pt with weak cough. U/O qs, hypoactive bowel sounds, tolerating po ice chips.\nPt this am developed hypoxia, SA02 to 70's, Fi02 up to 100% via NRB with SA02 to 88-92%, Dr into see pt. Left lung very diminished as compared to the right and earlier in shift. Pt sleepy at this time, am labs sent. ABG with P02 of 71mmHg and PCO2 of 71mmHg, pt encouraged to cough and deep breathe. PCXR obtained, SA02 improved without intervention, pt remains on NRB at 100% with SA02 being 99-100%. ABG pending.\nInsulin gtt on hold for hypoglycemia.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-01-23 00:00:00.000",
"description": "Report",
"row_id": 1460965,
"text": "CSRU NURSING NOTE:\n\nNEURO: PT ALERT AND ORIENTED. ABLE TO MAE.\n\nCV: PT DENIES CP, PALP, SOB. TELE: MP: NSR. HR 90'S. NO ECTOPY NOTED. NO GTTS. EPICARDIAL WIRES 2A/2V INTACT. DP PULSE AUDIBLE WITH DOPPLER TO LT FOOT. LYTES REPLEATED.\n\nRESP: LS EXTREMELY COARSE THIS AM. NEEDED AGGRESSIVE PULM TOILET THIS AM. STARTED ALB/ATRO HHN. ENC TO C&DB. USING IS WITH ENCOURAGEMENT. CTX3 INTACT.\n\nGI: PT REMAINS NPO. ABD SOFT, NONTENDER. BS HYPO. NO BM. TOL ICE CHIPS WITHOUT DIFFICULTY.\n\nGU: FOLEY INTACT. REC'G LASIX.\n\nINTEG: INC TO LT LEG/STERNUM INTACT. NO DRNG NOTED.\n\nPAIN: PT PERCOCET FOR PAIN WITH GOOD EFFECT.\n\nPLAN: CONTINUE PULM TOILET, C&DB. TX TO 6 IN AM.\n\n\n"
}
] |
32,402 | 197,976 | The patient was admitted, and found to complete heart block, in inferior ST elevations. She was taken immediately for cardiac catheterization where she was found to have a proximal RCA lesion, into which a bare metal stent was placed. At the time of the procedure a temporary pacing wire was inserted to help manage the bradycardia. Post stenting, the temporary pacing wire was removed, and an echocardiogram was performed which showed segmental wall motion abnormalities consistent with the distribution of her myocardial infarction, with a preserved ejection fraction of 50%. She was discharged on an appropriate regimen for her CAD. | Moderate mitral regurgitation. Mild (1+) aortic regurgitation is seen. Normal ascending aortadiameter. Mildaortic regurgitation. Moderate trucuspidregurgitation. Moderate (2+) MR.TRICUSPID VALVE: Moderate [2+] TR. Moderate [2+] tricuspidregurgitation is seen. Mild mitralannular calcification. There is mild regional left ventricular systolicdysfunction with basal and mid-inferior hypokinesis. EKG- Inf STEMI with CHB. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Likes to be called "".CV: HR 90s, 1st degree HB. Normal aortic arch diameter. Mild regional LVsystolic dysfunction. PATIENT/TEST INFORMATION:Indication: Coronary artery disease.Height: (in) 60Weight (lb): 130BSA (m2): 1.56 m2BP (mm Hg): 118/52HR (bpm): 84Status: InpatientDate/Time: at 11:57Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Tested MA and MV and good placement.capture at 1 MA. BPs via transduced arterial sheath 130s/70s. Foley draining adequate amts CYU. The right apical pleural thickening with the adjacent fibronodular opacities is demonstrated most likely representing previous granulomatous exposure. pt has been stable overnight, HR 80'sBP 105/54--117/60, weaned o2 from 4L to off o2 sats 96-97 pt denies SOB. Mediastinal contours are unremarkable except for minimal aortic calcification. Pt is DNR, . The estimated pulmonary artery systolic pressure isnormal. Sinus rhythm. Sinus rhythm. Sinus rhythm. There is no pericardial effusion.IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. groin site C&D,pulses palpable.Echo done:very mild inf hypokenesis.Resp: RA sats 94-99 rr 16-22 lungs clear.GU: urine output 70-100/hr +489GI: large soft BM OB-,good appetiteID:tmax 98.8 poNeuro: alert and oriented x3,currently living with sister who has . Pt has cool feet but gooddistal pulses, palpable and confirmed by doppler. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- hypo; mid inferior - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. No PS.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. Right grion insertion site looks good no hematoma, art sheath out at 1800 and venous sheath still in, pacer wires secured, pt laying flat, tolerating, not moving right extremity. No HCP.ACCESS: 2 pivs, venous sheath with temp wire--side portSKIN: intact- sm 1x1 cm red area on R buttock. Normal PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Left axisdeviation. SBP 70s/-started IVF, ASA 325mg, Lipitor, 600mg Plavix, started heparin gtt. Left axis deviation.Left bundle-branch block. and stim threshold done--see careview. The evaluation of the lungs demonstrates left lower lung haziness with minimal obscuration of the left heart border which demonstrates developing consolidation in the lingula/left lower lobe. Wean O2 as tol, Diet as tol. No 2D or Doppler evidence of distalarch coarctation.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Lung sounds diminished and pt co of congested cough, no sputum,but lungs are dim posterior with exp wheeze, spoke with MD ordered for am. Left ventricular wall thicknesses andcavity size are normal. Evidence of previous granulomatous exposure. EMS--> CHB rate 40s. There is no mitral valve prolapse.Moderate (2+) mitral regurgitation is seen. Monitor skin, T&R for comfort as pt is on bestrest with temp wire. To Hosp given 1 mg atropine and trancutaneously paced per report. Right ventricular chamber size and free wallmotion are normal. ?Echo in Am and d/c wire. Transferred to for urgent cath. is spokesperson.A/P: s/p IMI,hemodynamically stable.called out to 3. emotional support pt and family Left bundle-branch block. Left bundle-branch block. Left bundle-branch block. IMPRESSION: Left lower lung opacity worrisome for developing lingular/left lower lobe consolidation. Continue fluids for ? The aortic valve leaflets (3) are mildly thickened butaortic stenosis is not present. Compared to theprevious tracing of no significant change. Themitral valve leaflets are mildly thickened. Pacer set at--VVI, rate 40, mV 2, mA 5. Moisture barrier cream applied.A/P: S/P IMI c/b CHB. RV infarct--IVF at 150cc/hr x 1L and Sodium Bicarb gtt, off at 0100 for total 6 hrs. Left axis deviation. Left axis deviation. A catheter or pacing wire isseen in the RA and extending into the RV.LEFT VENTRICLE: Normal LV wall thickness and cavity size. she received bicarb drip x 6 hours and d5 1/2 ns x one liter post cath hydration for creatinine 1.2. tolerated. DR. Sodium Bicarb ordered to run at 75cc/hr x 6 hrs--OFF at 0100. pt currently dosing with blanket over her head.Neuro: pt alert ox3, follows commands, converses.A: pt S/P Inf MI, sp two stents to RCA, complicated by CHB, currently SR, and hemodynamically stable.p: Continue to follow rhythm, C/V and resp status, follow labs, ( plts droppped and team aware 210 to 160), cht, CPK, pt likely to have pacer pulled this AM, echo also planned, keep pt and family updated on POC as discussed in CCU rounds. Sent to CCU with temp ventricular pacer and on Integrillin gtt (renal dosed).NEURO: A&Ox3. trazadone given then later cough med. Integrillin running at 0.96mcg/k/min x 18 hrs--off at 11am.RESP: LSCTA bilat. Compared to theprevious tracing the P-R interval is shorter.TRACING #3 Pedal pulses palp bilat. Compared to the previous tracing theP-R interval is prolonged.TRACING #2 Post cath labs at 2300 tonite. SP procedure pt was feeling well and CP free. "O: 84 y/o F hx Mitral insuffiencency and LBBB, was active at adult daycare today and experienced CP. The remaining segmentscontract normally (LVEF = 50%). Integrillin x18hrs off at 1100 . Monitor R groin, pedal pulses, u/o. K 3.6 repleted with 40 po. Addt'l D5 1/2NS ordered at 150cc/hr x1L.SOCIAL: Nephew in at bedside, Neice Called-updated per pt request. Heart size is moderately enlarged. O2 sats >97% on 4L NC. see careview. Arterial sheath pulled at 1835, hemastasis at 1850. denies cold or flu symptoms. The P-R interval is prolonged. ACT 157. Not needing pacer. NPN 7 PM-- 7 AMS: "I feel much better, can't sleep tonight. Sinus rhythm with an eight beat run of atrial tachycardia. Long 90% mid RCA lesion with extensive thrombus-->2 overlapping BMS. | 9 | [
{
"category": "Radiology",
"chartdate": "2175-02-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 994772,
"text": " 10:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for airspace disease\n Admitting Diagnosis: STEMI\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with wheezes and a cough\n REASON FOR THIS EXAMINATION:\n Evaluate for airspace disease\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Wheezes and cough.\n\n Portable AP chest radiograph was reviewed with no prior films available for\n comparison.\n\n Heart size is moderately enlarged. Mediastinal contours are unremarkable\n except for minimal aortic calcification. The evaluation of the lungs\n demonstrates left lower lung haziness with minimal obscuration of the left\n heart border which demonstrates developing consolidation in the lingula/left\n lower lobe. The right apical pleural thickening with the adjacent\n fibronodular opacities is demonstrated most likely representing previous\n granulomatous exposure. There is no pleural effusion or pneumothorax.\n\n IMPRESSION: Left lower lung opacity worrisome for developing lingular/left\n lower lobe consolidation. PA and lateral chest radiograph would be\n recommended for precise characterization of this finding worrisome for\n pneumonia.\n\n Evidence of previous granulomatous exposure.\n\n\n DR. \n"
},
{
"category": "Echo",
"chartdate": "2175-02-10 00:00:00.000",
"description": "Report",
"row_id": 86201,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease.\nHeight: (in) 60\nWeight (lb): 130\nBSA (m2): 1.56 m2\nBP (mm Hg): 118/52\nHR (bpm): 84\nStatus: Inpatient\nDate/Time: at 11:57\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. No 2D or Doppler evidence of distal\narch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Moderate (2+) MR.\n\nTRICUSPID VALVE: Moderate [2+] TR. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. There is mild regional left ventricular systolic\ndysfunction with basal and mid-inferior hypokinesis. The remaining segments\ncontract normally (LVEF = 50%). Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is no mitral valve prolapse.\nModerate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid\nregurgitation is seen. The estimated pulmonary artery systolic pressure is\nnormal. There is no pericardial effusion.\n\nIMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Mild\naortic regurgitation. Moderate mitral regurgitation. Moderate trucuspid\nregurgitation.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-09 00:00:00.000",
"description": "Report",
"row_id": 1672587,
"text": "CCU admission note 1700-1900\nS: \"Is it alright if I go to sleep now?\"\n\nO: 84 y/o F hx Mitral insuffiencency and LBBB, was active at adult daycare today and experienced CP. Per pt, \"they took her BP and then called an ambulance.\" EMS--> CHB rate 40s. To Hosp given 1 mg atropine and trancutaneously paced per report. EKG- Inf STEMI with CHB. SBP 70s/-started IVF, ASA 325mg, Lipitor, 600mg Plavix, started heparin gtt. Transferred to for urgent cath. Long 90% mid RCA lesion with extensive thrombus-->2 overlapping BMS. Sent to CCU with temp ventricular pacer and on Integrillin gtt (renal dosed).\n\nNEURO: A&Ox3. Very pleasant and cooperative. Likes to be called \"\".\n\nCV: HR 90s, 1st degree HB. Pacer set at--VVI, rate 40, mV 2, mA 5. Not needing pacer. and stim threshold done--see careview. BPs via transduced arterial sheath 130s/70s. ACT 157. Arterial sheath pulled at 1835, hemastasis at 1850. Pedal pulses palp bilat. Integrillin running at 0.96mcg/k/min x 18 hrs--off at 11am.\n\nRESP: LSCTA bilat. O2 sats >97% on 4L NC. No c/o SOB\n\nGI/GU: Cardiac diet ordered for supper. Foley draining adequate amts CYU. Sodium Bicarb ordered to run at 75cc/hr x 6 hrs--OFF at 0100. Addt'l D5 1/2NS ordered at 150cc/hr x1L.\n\nSOCIAL: Nephew in at bedside, Neice Called-updated per pt request. Pt is DNR, . No HCP.\n\nACCESS: 2 pivs, venous sheath with temp wire--side port\n\nSKIN: intact- sm 1x1 cm red area on R buttock. Moisture barrier cream applied.\n\nA/P: S/P IMI c/b CHB. Monitor R groin, pedal pulses, u/o. Continue fluids for ? RV infarct--IVF at 150cc/hr x 1L and Sodium Bicarb gtt, off at 0100 for total 6 hrs. Integrillin x18hrs off at 1100 . Post cath labs at 2300 tonite. Wean O2 as tol, Diet as tol. Monitor skin, T&R for comfort as pt is on bestrest with temp wire. ?Echo in Am and d/c wire.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-10 00:00:00.000",
"description": "Report",
"row_id": 1672588,
"text": "NPN 7 PM-- 7 AM\n\nS: \"I feel much better, can't sleep tonight. \"\n\no: Please see careview for labs, vitals and other objective data,\nand nursing admission note for PMH and events up until admission.\nPT is S/P inf MI and complicated By CHB at yesterday afternoon. Came to cath lab and had two overlaping stents placed to long lesion in RCA. SP procedure pt was feeling well and CP free. She had experienced CHB and hypotension at , and pacing wire was placed in the lab. Here pt has been stable all night and has not required pacer. she is in SR with long PR, pacer at bedside and set for demand at a rate of 40. Tested MA and MV and good placement.\ncapture at 1 MA. see careview. pt has been stable overnight, HR 80's\nBP 105/54--117/60, weaned o2 from 4L to off o2 sats 96-97 pt denies SOB. Lung sounds diminished and pt co of congested cough, no sputum,\nbut lungs are dim posterior with exp wheeze, spoke with MD ordered for am. Pt has cool feet but gooddistal pulses, palpable and confirmed by doppler. Right grion insertion site looks good no hematoma, art sheath out at 1800 and venous sheath still in, pacer wires secured, pt laying flat, tolerating, not moving right extremity.\n she received bicarb drip x 6 hours and d5 1/2 ns x one liter post cath hydration for creatinine 1.2. tolerated. IVF now finished, putting out 25-30 cc per hour overnight.\n\nPt co insomia, R/T noisy ICU environment and also RT nasal drip and cough. denies cold or flu symptoms. trazadone given then later cough med. pt currently dosing with blanket over her head.\n\nNeuro: pt alert ox3, follows commands, converses.\n\nA: pt S/P Inf MI, sp two stents to RCA, complicated by CHB, currently SR, and hemodynamically stable.\n\np: Continue to follow rhythm, C/V and resp status, follow labs, ( plts droppped and team aware 210 to 160), cht, CPK, pt likely to have pacer pulled this AM, echo also planned, keep pt and family updated on POC as discussed in CCU rounds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-10 00:00:00.000",
"description": "Report",
"row_id": 1672589,
"text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: HR 76-90 1st degree AVB BP 105-122/48-51 pacer d/ced captopril 6.25 started at noon. K 3.6 repleted with 40 po. groin site C&D,pulses palpable.Echo done:very mild inf hypokenesis.\n\nResp: RA sats 94-99 rr 16-22 lungs clear.\n\nGU: urine output 70-100/hr +489\n\nGI: large soft BM OB-,good appetite\n\nID:tmax 98.8 po\n\nNeuro: alert and oriented x3,currently living with sister who has . has own home in . very active at Senior centers in both and . is spokesperson.\n\nA/P: s/p IMI,hemodynamically stable.called out to 3.\n emotional support pt and family\n\n\n"
},
{
"category": "ECG",
"chartdate": "2175-02-10 00:00:00.000",
"description": "Report",
"row_id": 220577,
"text": "Sinus rhythm. Left axis deviation. Left bundle-branch block. Compared to the\nprevious tracing the P-R interval is shorter.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2175-02-09 00:00:00.000",
"description": "Report",
"row_id": 220578,
"text": "Sinus rhythm. The P-R interval is prolonged. Left axis deviation.\nLeft bundle-branch block. Compared to the previous tracing the\nP-R interval is prolonged.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2175-02-09 00:00:00.000",
"description": "Report",
"row_id": 220579,
"text": "Sinus rhythm with an eight beat run of atrial tachycardia. Left axis\ndeviation. Left bundle-branch block. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2175-02-11 00:00:00.000",
"description": "Report",
"row_id": 220576,
"text": "Sinus rhythm. Left axis deviation. Left bundle-branch block. Compared to the\nprevious tracing of no significant change.\n\n"
}
] |
53,459 | 187,772 | This is a 63 year old male with PMH significant for COPD, obesity, and diabetes c/b peripheral neuropathy who was recently discharged on a steroid taper and azithromycin for a COPD exacerbation on now presenting with RUQ pain that has been increasing in severity since . . #. Lower rib cage/RUQ pain: On imaging it appeared as though the patient has herniation of his right lung through his posterior chest wall. EKG without ischemic changes and cardiac bio markers were negative. Pain control was initiated, but pt reported a previous poor reaction to Vicodin, Percocet, Oxycodone, including personality changes/agitation. Thoracic surgery was consulted, and initial plan for conservative management. Pain service consulted for pain recs, but pt declined PCA, and pain team felt pt too high-risk for epidural without concurrent surgical correction. No Tramadol given SSRI, and no Ketorolac given hematoma. However, pain continued to worsen, not controlled even with Lidocaine patches and IV pain medications to extent that patient with desaturation on opioid regimen. Repeat CT torso on with worsened lung hernia, and given worsening pain and discomfort. | right chest tube, ETT unchnaged in position. Non-distended loops of large bowel contain residual barium. Right sided chest tube unchanged. A right-sided chest tube is unchanged in position. There is no appreciable pneumothorax demonstrated but there is presence of right pleural effusion. Since the previous tracing of sinustachycardia is now absent. There is persistent right lower lobe atelectasis is unchanged in appearance. The opacity projecting over the right hemithorax is unchanged. W/in limitation, nonobstructive bowel gas pattern with gas in small and large bowel and rectum. The opacity involving the most of the right upper hemithorax is unchanged compared to the most recent prior radiograph, most likely related to the surgery. The thoracic aorta is normal in caliber without evidence of dissection. TECHNIQUE: MDCT axial images were obtained through the chest, abdomen and pelvis with and without the administration of IV contrast. IMPRESSION: Lucency along the lateral inferior right chest wall, unclear whether artifactual versus subcutaneous emphysema versus herniation of lung. The cardiac and mediastinal silhouettes are unchanged. Questionable small right pleural effusion. Outpouching of mesenteric fat through the esophageal hiatus is unchanged since . Outpouching of mesenteric fat through the esophageal hiatus is unchanged since . IMPRESSION: Mildly dilated loops of colon and non-specific small bowel gas pattern suggestive of probable post-operative ileus. (Over) 5:26 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTU (ABD/PEL) W/&W/O CONTRASTClip # Reason: without and with contrast, eval for nephrolithiasis, appendi Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) OSSEOUS STRUCTURES: Degenerative changes are noted throughout the visualized thoracolumbar spine. This is slightly larger than on the previous study, but normal lung markings are evident throughout the lung parenchyma, no pneumothorax seen. No acute aortic injury 3. CT OF THE PELVIS: The bladder, distal ureters, rectum, and sigmoid colon appear within normal limits. Dense opacity projecting over the right upper and mid lung zone is stable likely representing loculated effusion. HISTORY: Right chest wall hernia repair. Mild degenerative changes at bilateral acromioclavicular joints are seen. No e/o pneumoperitoneum. Left PIC catheter ends in the region of the superior cavoatrial junction. This appearance is unchanged compared with thte previous study. Right chest tube remains in place. The appendix is within normal limits. COMPARISON: CT abdomen and pelvis with contrast ; chest PA and lateral . The gallbladder is unremarkable in appearance. Intra-abdominal loops of large and small bowel appear unremarkable. PTX FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Tachycardia and hypotension. The pericardium and great vessels are within normal limits. Retroperitoneal and mesenteric lymph nodes do not meet CT size criteria for pathologic enlargement. Retroperitoneal and mesenteric lymph nodes do not meet CT size criteria for pathologic enlargement. COMPARISON: CT torso with contrast, . Cardiomediastinum is unchanged with cardiac size top normal and prominent fat in the mediastinum and pericardial fat pads. A small exophytic hypodensity measuring 7 mm (3B, 106) arising from the interpolar region of the left kidney measures fluid density is new since . Pelvic lymph nodes do not meet CT size criteria for pathologic enlargement. hematoma? hematoma? hematoma? CT CHEST WITH IV CONTRAST: No axillary or mediastinal lymphadenopathy seen. Supraventricular tachycardia cannot be fullyexcluded. CT OF THE PELVIS WITH IV CONTRAST: The rectum, urinary bladder, and prostate are unremarkable in appearance. COMPARISON: CT abdomen and pelvis with contrast, . Right chest tube is in place. A right chest tube is in place. Modest low amplitude T wave changes.Findings are non-specific. Low lung volumes w/ bibasilar atelectasis. Otherwise, no significant change when compared to prior exam. The right lower lung continues to be well aerated. There is no left pleural effusion. Lucency along the lateral inferior right hemithorax is new since the prior study, unclear whether subcutaneous emphysema or artifactual. No retroperitoneal hemorrhage seen. W/in limitation, s/p removal of ETT and NG tubes. The left lung is also essentially unremarkable. The pancreas is unremarkable. No retroperitoneal or (Over) 5:45 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: interval changes? No concerning pulmonary nodules seen. Small amount of subcutaneous air is unchanged. Bibasilar atelectases are unchanged. ABDOMINAL RADIOGRAPH, UPRIGHT AND SUPINE PORTABLE VIEWS: Residual contrast material is visualized within the colon. There is a non-specific small bowel gas appearance without definitive evidence of obstruction. Hiatus hernia noted containing omental fat as well as some higher attenuation material (mean 10) which may represent a small amount of fluid, however fat necrosis cannot be excluded. The common bile duct measures 0.3 cm and is within normal limits. No pathologically enlarged axillary, hilar, or mediastinal lymph nodes are noted. No pleural effusions. lungs unchanged. In addition, in the lateral view suggests the presence of pericardial effusion. The right chest tube is in place. Sinus tachycardia suggested. NG tube tip is not clearly visualized but appears to be at the GE junction and should be advanced for standard position, repeat radiograph is recommended. | 17 | [
{
"category": "Radiology",
"chartdate": "2148-10-21 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1153351,
"text": " 5:26 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTU (ABD/PEL) W/&W/O CONTRASTClip # \n Reason: without and with contrast, eval for nephrolithiasis, appendi\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with RUQ/flank pain\n REASON FOR THIS EXAMINATION:\n without and with contrast, eval for nephrolithiasis, appendicitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MON 6:37 PM\n 1. Trace b/l pleural effusion\n 2. No pe in main or segmental vessels. No acute aortic injury\n 3. No evidence of renal calculi or appendicitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old man with right upper quadrant flank pain. Evaluate\n for nephrolithiasis, appendicitis. Patient also presents with shortness of\n breath; evaluate for PE.\n\n COMPARISON: CT abdomen and pelvis with contrast ; chest PA and\n lateral .\n\n TECHNIQUE: MDCT axial images were obtained through the chest, abdomen and\n pelvis with and without the administration of IV contrast. Multiplanar\n reformats were generated and reviewed.\n\n CT OF THE CHEST: Pulmonary arterial vasculature is well visualized down to\n the subsegmental level. No filling defects to indicate a pulmonary embolism\n are identified. The thoracic aorta is normal in caliber without evidence of\n dissection. The pericardium and great vessels are within normal limits. No\n pathologically enlarged axillary, hilar, or mediastinal lymph nodes are noted.\n Herniation of the right lung between right posterolateral eighth and ninth\n ribs is is seen and may account for patient's pain. Outpouching of mesenteric\n fat through the esophageal hiatus is unchanged since .\n\n CT OF THE ABDOMEN: The liver, gallbladder, spleen, pancreas, bilateral\n adrenal glands appear unremarkable. Both kidneys enhance and excrete contrast\n symmetrically without evidence of hydronephrosis or stones. A small exophytic\n hypodensity measuring 7 mm (3B, 106) arising from the interpolar region of the\n left kidney measures fluid density is new since . Intra-abdominal loops\n of large and small bowel appear unremarkable. The appendix is within normal\n limits. Retroperitoneal and mesenteric lymph nodes do not meet CT size\n criteria for pathologic enlargement.\n\n CT OF THE PELVIS: The bladder, distal ureters, rectum, and sigmoid colon\n appear within normal limits. There is no free pelvic fluid. Pelvic lymph\n nodes do not meet CT size criteria for pathologic enlargement.\n\n There is no free air or free fluid within the abdomen. Retroperitoneal and\n mesenteric lymph nodes do not meet CT size criteria for pathologic\n enlargement.\n (Over)\n\n 5:26 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTU (ABD/PEL) W/&W/O CONTRASTClip # \n Reason: without and with contrast, eval for nephrolithiasis, appendi\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n OSSEOUS STRUCTURES: Degenerative changes are noted throughout the visualized\n thoracolumbar spine.\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism or acute aortic syndrome.\n 2. No evidence of renal calculi or appendicitis.\n 3. Herniation of the right lung through the right posterolateral eighth and\n ninth ribs, may account for patient's symptoms of right upper quadrant pain.\n Lucency along right inferior hemithorax chest wall on chest radiograph\n performed same date is new since prior chest radiograph of raising\n concern for recent development. The findings are also new since CT abdomen of\n \n 4. Outpouching of mesenteric fat through the esophageal hiatus is unchanged\n since .\n\n Dr. was notified of updated findings, including right lung\n herniation, at 11:28 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-21 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1153340,
"text": " 4:35 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: eval for cholelithiasis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n RUQ/flank pain\n REASON FOR THIS EXAMINATION:\n eval for cholelithiasis\n ______________________________________________________________________________\n WET READ: MON 5:40 PM\n No acute abdominal pathology. Questionable small right pleural effusion.\n Fatty liver.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old male with right upper quadrant pain.\n\n COMPARISON: CT abdomen and pelvis with contrast, .\n\n LIVER AND GALLBLADDER ULTRASOUND: The liver appears mildly echogenic\n consistent with fatty infiltration. The gallbladder appears unremarkable with\n no evidence of gallstones. The common bile duct measures 0.3 cm and is within\n normal limits. The portal vein appears patent. The pancreas is not clearly\n visualized in this study.\n\n IMPRESSION: Echogenic liver consistent with fatty infiltration. Other forms\n of liver disease and more advanced liver disease including significant hepatic\n fibrosis/cirrhosis cannot be excluded on this study. No evidence of\n cholelithiasis.\n\n\n SESHa\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-21 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1153347,
"text": " 5:08 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for PNA, CP disease\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with chestpain, dyspnea.\n REASON FOR THIS EXAMINATION:\n eval for PNA, CP disease\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest, frontal and lateral views.\n\n CLINICAL INFORMATION: 63-year-old male with history of chest pain, dyspnea.\n\n COMPARISON: .\n\n FINDINGS: Frontal and lateral views of the chest were obtained. The cardiac\n and mediastinal silhouettes are unchanged. No pleural effusion or\n pneumothorax is seen. Lucency along the lateral inferior right hemithorax is\n new since the prior study, unclear whether subcutaneous emphysema or\n artifactual. Lung herniation, although rare, could have a similar appearance.\n Mild degenerative changes at bilateral acromioclavicular joints are seen.\n There are degenerative changes along the spine.\n\n IMPRESSION: Lucency along the lateral inferior right chest wall, unclear\n whether artifactual versus subcutaneous emphysema versus herniation of lung.\n No focal consolidation or pleural effusion. CT pending.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1154100,
"text": " 12:25 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: NG tube placement\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 yo with chest wall hernia\n REASON FOR THIS EXAMINATION:\n NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess NG tube.\n\n Comparison is made with prior study performed the same day earlier in the\n morning.\n\n NG tube tip is not clearly visualized but appears to be at the GE junction and\n should be advanced for standard position, repeat radiograph is recommended.\n\n There are no other interval changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-27 00:00:00.000",
"description": "P ABDOMEN (SUPINE & ERECT) PORT",
"row_id": 1154254,
"text": " 7:30 PM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: ? obstruction\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with increased abdominal distension, s/p right chest wall\n hernia repair.\n REASON FOR THIS EXAMINATION:\n ? obstruction\n ______________________________________________________________________________\n WET READ: EAGg SUN 8:37 PM\n Limited exam due to pt motion and size. W/in limitation, nonobstructive bowel\n gas pattern with gas in small and large bowel and rectum. No e/o\n pneumoperitoneum.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old male status post right chest wall hernia repair. Patient\n with increasing abdominal distention.\n\n COMPARISON: Abdominal radiographs from .\n\n ABDOMINAL RADIOGRAPH, UPRIGHT AND SUPINE PORTABLE VIEWS: Residual contrast\n material is visualized within the colon. The proximal ascending colon\n measures 8.5 cm which is at the upper limits of normal. The transverse colon\n appears mildly distended and measures 6.2 cm in diameter. There is a\n non-specific small bowel gas appearance without definitive evidence of\n obstruction. These findings likely represent post-operative ileus. No\n significant osseous abnormalities are seen. No free air is visualized on the\n upright view suggestive of perforation.\n\n IMPRESSION: Mildly dilated loops of colon and non-specific small bowel gas\n pattern suggestive of probable post-operative ileus. No definitive evidence\n of obstruction at this time.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-29 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1154594,
"text": " 5:46 PM\n CHEST (PA & LAT) Clip # \n Reason: interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p R chest wall hernia repair CT removal\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON .\n\n HISTORY: Right chest wall hernia repair.\n\n IMPRESSION: PA and lateral chest compared to through 21 at 9:46\n a.m.\n\n The large right pleural collection, partially fissural, slowly decreasing in\n volume over the past several days and cardiomediastinal silhouette widening is\n improving. Lateral view shows opacification over the lower thoracic spine\n which might be due to a combination of atelectasis and paraspinal pleural\n fluid, presumably on the right, though difficult to identify on the frontal\n chest radiograph. There is no left pleural effusion. No pneumothorax. Left\n PIC catheter ends in the region of the superior cavoatrial junction.\n\n If there is strong suspicion of pneumonia, recommend oblique views. In\n addition, in the lateral view suggests the presence of pericardial effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1154338,
"text": " 11:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for progression or decrease in effusion/atelecta\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n POD 3 sp RLL hernia repair\n REASON FOR THIS EXAMINATION:\n please eval for progression or decrease in effusion/atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with right lower lobe\n hemorrhaging after surgery.\n\n Portable AP chest radiograph was compared to .\n\n A right chest tube is in place. The opacity projecting over the right\n hemithorax is unchanged. Small amount of subcutaneous air is unchanged.\n There is no change in the pleural effusion .\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1154253,
"text": " 7:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? change in pulmonary status\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with increased abdominal distension and shortness of breath,\n s/p right chest wall hernia repair.\n REASON FOR THIS EXAMINATION:\n ? change in pulmonary status\n ______________________________________________________________________________\n WET READ: EAGg SUN 8:34 PM\n Limited study due to noncompliance with exam. W/in limitation, s/p removal of\n ETT and NG tubes. Low lung volumes w/ bibasilar atelectasis. Right sided\n chest tube unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Increased abdominal distention and shortness of\n breath after right chest wall hernia repair.\n\n Portable AP chest radiograph was compared to .\n\n The right chest tube is in place. The opacity involving the most of the right\n upper hemithorax is unchanged compared to the most recent prior radiograph,\n most likely related to the surgery. There is no appreciable pneumothorax\n demonstrated but there is presence of right pleural effusion. The right lower\n lung continues to be well aerated. The left lung is also essentially\n unremarkable. The patient was extubated in the meantime interval.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1154132,
"text": " 6:08 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Acute changes, NGT placement\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p chest tube\n REASON FOR THIS EXAMINATION:\n Acute changes, NGT placement\n ______________________________________________________________________________\n WET READ: JKSd SAT 9:33 PM\n evaluation limited by motion; NGT tip cannot be seen; repeat recommended if\n tip location needed. right chest tube, ETT unchnaged in position. lungs\n unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess NG tube after being repositioned.\n\n Comparison is made with prior study performed six hours earlier.\n\n The evaluation of this study is limited by respiratory motion. The NG tube\n tip is out of view below the diaphragm. Repeat radiograph is recommended to\n assess the exact location. ET tube is in standard position. Right chest tube\n remains in place. Cardiac size is top normal with prominent fat pads and the\n widened mediastinum is due to prominent fat in the mediastinum. Small to\n moderate right pleural effusion has increased in amount. Bibasilar opacities\n consistent with atelectasis have improved on the left.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1154053,
"text": " 2:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PTX\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with new tachycardia, hypotension; ? PTX\n REASON FOR THIS EXAMINATION:\n ? PTX\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Tachycardia and hypotension.\n\n Comparison is made to prior study performed four hours earlier. Cardiac size\n is top normal as seen in prior CT. There are prominent fat pads. The\n mediastinum also is widened due to prominent fat. ET tube tip is in standard\n position. A fat-containing hernia in the midline is better visualized in\n prior CT from . There is no pneumothorax or pleural effusion.\n Bibasilar atelectases are unchanged. Right chest tube remains in place and\n there are no new lung abnormalities.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-26 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1154055,
"text": " 2:51 AM\n PORTABLE ABDOMEN Clip # \n Reason: ? SBO\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with distended abdomen; ? SBO\n REASON FOR THIS EXAMINATION:\n ? SBO\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN\n\n REASON FOR EXAM: Distended abdomen and shortness of breath.\n\n Non-distended loops of large bowel contain residual barium. Few non-distended\n air-filled small bowel loops are present.\n\n IMPRESSION: No evidence of obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1154045,
"text": " 10:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX, effusion\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p R chest wall hernia repair\n REASON FOR THIS EXAMINATION:\n PTX, effusion\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Status post right chest wall hernia repair.\n\n Comparison is made with prior study, and CT .\n\n Cardiomediastinum is unchanged with cardiac size top normal and prominent fat\n in the mediastinum and pericardial fat pads. There is no pneumothorax or\n large pleural effusions. ET tube is in standard position. Right chest tube\n is in place. The lungs are grossly clear.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-29 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1154497,
"text": " 9:30 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 52cm SL L brachial PICC placed ? tip\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with new L PICC\n REASON FOR THIS EXAMINATION:\n 52cm SL L brachial PICC placed ? tip\n ______________________________________________________________________________\n FINAL REPORT\n CHEST LINE PLACEMENT\n\n HISTORY: Line placement.\n\n FINDINGS: A left PICC line terminates at the cavoatrial junction. A\n right-sided chest tube is unchanged in position. Dense opacity projecting\n over the right upper and mid lung zone is stable likely representing loculated\n effusion. There is persistent right lower lobe atelectasis is unchanged in\n appearance. Small amount of subcutaneous air is similar in appearance, the\n left lung remains clear.\n\n IMPRESSION:\n Left PICC terminates at the cavoatrial junction. Otherwise, no significant\n change when compared to prior exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-24 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1153860,
"text": " 5:45 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: interval changes? rib fx? hematoma?\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with herniated lung, flank ecchymosis, migrating pain\n inferiorly\n REASON FOR THIS EXAMINATION:\n interval changes? rib fx? hematoma?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 9:05 PM\n 1. R lung herniation (between ribs 8 & 9), slightly increased from prior CT &\n now includes a portion of liver\n 2. unchanged paraesophageal herniation of mesenteric fat\n 3. no hydronephrosis\n 4. R flank hematoma, new from \n 5. no rib fx\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO WITH CONTRAST\n\n INDICATION: 63-year-old man with herniated lung, flank ecchymosis, and\n migrating pain.\n\n COMPARISON: CT torso with contrast, .\n\n TECHNIQUE: Axial MDCT images were acquired from the thoracic inlet to the\n symphysis pubis following oral and intravenous contrast. Coronal and sagittal\n reformats were produced and reviewed.\n\n CT CHEST WITH IV CONTRAST:\n No axillary or mediastinal lymphadenopathy seen. There is persistent\n herniation of a small segment the right lower lobe through the eighth\n intercostal space. This is slightly larger than on the previous study, but\n normal lung markings are evident throughout the lung parenchyma, no\n pneumothorax seen. No rib fracture is seen. The herniated lung tissue\n appears to pass through the intercostal muscles which are presumed to be\n ruptured given this appearance. No concerning pulmonary nodules seen. The\n heart and great vessels are unremarkable in appearance. No pericardial\n effusion seen. No pleural effusions. Hiatus hernia noted containing omental\n fat as well as some higher attenuation material (mean 10) which may\n represent a small amount of fluid, however fat necrosis cannot be excluded.\n This appearance is unchanged compared with thte previous study.\n\n CT ABDOMEN WITH IV CONTRAST:\n The liver enhances homogeneously. The portal vein is patent. No biliary duct\n dilatation seen. The gallbladder is unremarkable in appearance. The spleen,\n both adrenal glands, and both kidneys are unremarkable in appearance. The\n pancreas is unremarkable. No free fluid seen. No retroperitoneal or\n (Over)\n\n 5:45 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: interval changes? rib fx? hematoma?\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n mesenteric adenopathy seen. No retroperitoneal hemorrhage seen. There is new\n induration of the subcutaneous tissues over the right flank which could\n correspond to the clinical finding of a flank hematoma. No walled-off fluid\n collections seen.\n\n CT OF THE PELVIS WITH IV CONTRAST:\n The rectum, urinary bladder, and prostate are unremarkable in appearance. No\n free fluid in the pelvis. No pelvic lymphadenopathy is seen.\n\n OSSEOUS STRUCTURES:\n No concerning lytic or sclerotic bony lesions seen. No fractures seen.\n\n IMPRESSION:\n 1. Persistent herniation of lung parenchyma between the eighth and ninth ribs\n on the right laterally. No associated rib fractures seen.\n 2. Induration of the subcutaneous tissues in the right flank consistent with\n hematoma formation.\n 3. Hiatus hernia containing omental fat as well as slightly denser material\n which may be a small amount of free fluid but could represent fat necrosis.\n\n"
},
{
"category": "ECG",
"chartdate": "2148-10-25 00:00:00.000",
"description": "Report",
"row_id": 271580,
"text": "Sinus tachycardia. Compared to previous tracing of the rate is\nincreased.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2148-10-21 00:00:00.000",
"description": "Report",
"row_id": 271581,
"text": "Sinus rhythm. Low limb lead QRS voltage. Modest low amplitude T wave changes.\nFindings are non-specific. Since the previous tracing of sinus\ntachycardia is now absent.\n\n"
},
{
"category": "ECG",
"chartdate": "2148-10-26 00:00:00.000",
"description": "Report",
"row_id": 271579,
"text": "Sinus tachycardia suggested. Supraventricular tachycardia cannot be fully\nexcluded. Compared to previous tracing the rate is increased.\nTRACING #2\n\n"
}
] |
49,604 | 189,276 | HOSPITAL COURSE 51yo M PMHx strep viridans endocarditis s/p St. MVR, cirhosis p/w GIB, admitted with bacteremia, hypotension, course complicated by respiratory failure and intubation, who was subsequently extubated and transferred to general medicine floor. | Nasointestinal tube is seen with the tip ending in a stable position compared with prior radiograph in an immediately post-pyloric location. Moderate bilateral pleural effusions with bibasilar atelectasis. Otherwise unchanged CXR from 1 hr ago, with moderate bihilar opacities and left pleural effusion. Mild symmetric left ventricular hypertrophywith preserved global and regional biventricular systolic function. Right pleural effusion. Right pleural effusion. ]TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is elongated. Cholelithiasis. Median sternotomy wires are seen. Moderate ascites throughout the abdomen and pelvis. The gallbladder is moderately distended. Moderate bilateral pleural effusions, with mild-to-moderate bibasilar atelectasis. Tiny fat-containing umbilical hernia. Normal sinus rhythm with delayed R wave transition. Bibasilar atelectasis and small effusions persist. FINDINGS: As compared to the previous radiograph, the right central venous access line and the nasogastric tube has been removed. Probable small bilateral pleural effusions. IMPRESSION: Nasointestinal tube in stable position in a post-pyloric placement. Abdomen CT with contrast . GI bleed.Height: (in) 67Weight (lb): 130BSA (m2): 1.69 m2BP (mm Hg): 119/72HR (bpm): 98Status: InpatientDate/Time: at 10:18Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%). Perigastric and perisplenic varices. Stable right pleural effusion. FINDINGS: There is a normal bowel gas pattern. There issevere aortic valve stenosis (valve area 0.8cm2). Right ventricular chamber size and free wall motion are normal.The aortic root is mildly dilated at the sinus level. There has been interval removal of the endotracheal tube, feeding tube, and right IJ catheter. Small pleural effusions are again visualized in the right. Sternotomy wires. There is a right pleural effusion. Small left renal cysts. COMPARISON: CT from . The ascending aorta ismildly dilated. Small bilateral pleural effusions, larger on the right side, are grossly unchanged with associated left greater than right lower lobe atelectasis. Free fluid consistent with ascites is again visualized throughout the abdomen. Mildly dilated ascending aorta.AORTIC VALVE: Moderately thickened aortic valve leaflets. Interval removal of ETT, NG, IJ. Previously seen opacities in the bilateral upper lobes, left perihilar and lower lobe has resolved. Minimal left pleural effusion, otherwise unchanged appearance of the lung parenchyma, the cardiac silhouette and the hilar and mediastinal contours. CT OF THE PELVIS: There is moderate amount of free fluid/ascites within the pelvis. Mitral valve replacement. Moderate ascites. There are small hyperdensities likely representing calcifications within the pancreas. FINDINGS: Heart is mildly enlarged. Status post valvular repair with normal alignment of sternal wires. FINDINGS: In comparison with the earlier study of this date, there has been placement of a right IJ catheter that extends to the region of the cavoatrial junction or upper portion of the right atrium. Again seen are a right IJ line, ET tube and OG tube in unchanged position. FINDINGS: Semi-erect portable frontal view of the chest is unchanged from prior. The portal vein is patent and shows normal hepatopetal flow. Right PICC line terminates in the lower SVC. FINDINGS: In comparison with the earlier study of this date, there has been placement of an orogastric tube that extends to the body of the stomach. Cirrhotic liver. The main portal vein is patent with hepatopetal flow. There are perigastric and perisplenic varices evident. Mild cardiomegaly. Tiny focal peripheral opacity in the RLL , non-specific (image 3:2). There is nopericardial effusion.IMPRESSION: Severe aortic valve stenosis. Contrast is seen from the splenic flexure to the rectum. Improved pulmonary edema, though some remains along with bibasilar atelectasis. Gallbladder visualization; no acute cholecystitis. Splenomegaly. Splenomegaly. Splenomegaly. Splenomegaly. Ascites. Ascites. There is a small amount of pericholecystic fluid. CT OF THE ABDOMEN: The lung bases bilaterally have moderate pleural effusions along with bibasilar atelectasis. FINDINGS: In comparison with study of earlier in this date, there has been placement of an endotracheal tube with its tip approximately 3.8 cm above the carina. Calcified tips ofpapillary muscles. Rectal tube in place. As previously noted, there is perihepatic ascites as well as ascites within the lower quadrants of the abdomen. Cirrhotic liver, splenomegaly, perigastric and perisplenic varices. Cirrhosis. REASON FOR EXAM: Aortic stenosis with rhonchi and lower extremity edema. Non-diagnostic Q waves inthe inferior leads. There has been placement of a left-sided PICC line with distal lead tip at the cavoatrial junction. No AR.MITRAL VALVE: Bileaflet mitral valve prosthesis (MVR). A bileaflet mitral valve prosthesis is present. Intact midline sternal wires after valve replacement. COMPARISON: Chest radiograph . Otherwise, unchanged CXR from 2 hours ago, with low lung volumes and marked bilateral hazy opacities. There is insufflation of the rectum. IMPRESSION: Comparisons were made with prior chest radiographs through , . Small stones are again visualized throughout the dependent portion of the gallbladder as well as one adherent stone in the nondependent portion. Nasogastric tube extends at least to the upper stomach where it crosses the lower margin of the image. , M.D. , M.D. Bilateral lung volumes remain low. Portal vein is patent. Cholelithiasis without evidence of cholecystitis. Oral contrast transited to the colon. The visualized portion of the pancreas is unremarkable. Tip of NGT in the pyloric area. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildy dilated aortic root. A mitral valve replacement is seen within a moderately enlarged heart. Left PICC tip is at the cavoatrial junction. FINAL REPORT HISTORY: OG tube placement. Heart size is within normal limits. PATIENT/TEST INFORMATION:Indication: Endocarditis. Assessment for a son sign is limited secondary to analgesic administration. Dilatedascending aorta.CLINICAL IMPLICATIONS:Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate prophylaxis IS recommended. NG tube in the pyloric position. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. The aortic valve leaflets are moderately thickened. | 18 | [
{
"category": "Radiology",
"chartdate": "2161-08-09 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1202859,
"text": " 8:55 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: new line placement eval for pneumothorax and location\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with new right IJ line\n REASON FOR THIS EXAMINATION:\n new line placement eval for pneumothorax and location\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New IJ placement.\n\n FINDINGS: No previous images. Intact midline sternal wires after valve\n replacement. Nasogastric tube extends at least to the upper stomach where it\n crosses the lower margin of the image. Left IJ catheter extends to the\n mid-to-lower portion of the SVC with no evidence of pneumothorax. Mild\n atelectatic changes are seen at the left base, but no vascular congestion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-08-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1203299,
"text": " 4:19 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for PNA\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with worsening respiratory status and bilateral rhonchi\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Worsening respiratory status and bilateral rhonchi.\n\n FINDINGS: In comparison with study of earlier in this date, there has been\n placement of an endotracheal tube with its tip approximately 3.8 cm above the\n carina. There also some increasing areas of opacification in the left and\n probably also right paramediastinal regions. This raises the possibility of\n bilateral aspiration. An area of increased opacification is also seen at the\n left base that has the appearance of atelectasis, though supervening\n aspiration in this region would also have to be considered.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-08-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1203729,
"text": " 6:41 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 45cm DL L brachial PICC placed ? tip - \n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with new PICC removed RIJCL\n REASON FOR THIS EXAMINATION:\n 45cm DL L brachial PICC placed ? tip - \n ______________________________________________________________________________\n WET READ: NATg SAT 7:44 PM\n LUE PICC, tip at cavoatrial jct. Interval removal of ETT, NG, IJ. Improved\n pulmonary edema, though some remains along with bibasilar atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: 51-year-old man with new PICC line.\n\n FINDINGS: Comparison is made to previous study from .\n\n There has been interval removal of the endotracheal tube, feeding tube, and\n right IJ catheter. There has been placement of a left-sided PICC line with\n distal lead tip at the cavoatrial junction. Heart size is within normal\n limits. Median sternotomy wires are seen. There are again seen areas of\n consolidation within the upper lobes and left lower lobe which are stable. No\n pneumothoraces are present.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-08-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1203036,
"text": " 7:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with fever and bacteremia\n REASON FOR THIS EXAMINATION:\n PNA\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Fever, bacteremia.\n\n COMPARISON: Outside hospital chest film from .\n\n FINDINGS: As compared to the previous radiograph, the right central venous\n access line and the nasogastric tube has been removed. Status post valvular\n repair with normal alignment of sternal wires. Minimal left pleural effusion,\n otherwise unchanged appearance of the lung parenchyma, the cardiac silhouette\n and the hilar and mediastinal contours.\n\n Mild fluid overload cannot be excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-08-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1203474,
"text": " 4:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with respiratory failure s/p intubation\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure with intubation.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. Bilateral areas of opacification again are\n concerning for aspiration pneumonia. Bibasilar atelectasis and small\n effusions persist.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-08-13 00:00:00.000",
"description": "P ABDOMEN (SUPINE & ERECT) PORT",
"row_id": 1203462,
"text": " 11:15 PM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: evaluate for obstruction or free air\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with sepsis and abdominal distention\n REASON FOR THIS EXAMINATION:\n evaluate for obstruction or free air\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old man with sepsis and abdominal distention. Please\n evaluate for obstruction or free air.\n\n COMPARISON: Chest radiograph . Abdomen CT with contrast\n .\n\n FINDINGS: There is a normal bowel gas pattern. Contrast is seen from the\n splenic flexure to the rectum. Nasointestinal tube is seen with the tip\n ending in a stable position compared with prior radiograph in an immediately\n post-pyloric location. No evidence of free air or calcifications. Left-sided\n pleural effusion can be better evaluated with chest radiograph from . Sternotomy wires and valve prosthesis are intact.\n\n IMPRESSION: Nasointestinal tube in stable position in a post-pyloric\n placement.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-08-10 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1202864,
"text": " 12:56 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: please evaluate portal vein patency and gallbladder for sign\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with CT scan concerning for cholecystitis\n REASON FOR THIS EXAMINATION:\n please evaluate portal vein patency and gallbladder for signs of cholecystitis\n ______________________________________________________________________________\n WET READ: MON 4:12 AM\n Marked gallbladder wall thickening/edema, multiple gallstones, and dilated\n gallbladder are highly suggestive of acute cholecystitis. Portal vein is\n patent. Right pleural effusion. Splenomegaly. Ascites.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CT scan concerning for cholecystitis from outside hospital.\n Evaluate portal vein patency and assess for signs of cholecystitis.\n\n COMPARISON: None.\n\n FINDINGS: The liver echogenicity and echotexture are normal. No focal liver\n lesions are identified. There is no intrahepatic biliary duct dilatation.\n The portal vein is patent and shows normal hepatopetal flow.\n\n There is marked gallbladder wall thickening with fluid seen within the\n gallbladder wall. The maximum thickness measures 1.5 cm (image 34). Multiple\n small stones are seen within the dependent portion of the gallbladder. There\n may be pericholecystic fluid, although perihepatic ascites complicates this\n assessment. The gallbladder is moderately distended. The common bile duct\n measures 3 mm.\n\n The visualized portion of the pancreas is unremarkable. The pancreatic tail\n is not well visualized secondary to overlying bowel gas. As previously noted,\n there is perihepatic ascites as well as ascites within the lower quadrants of\n the abdomen. The spleen is mildly enlarged, measuring up to 14.4 cm. There\n is a right pleural effusion.\n\n Assessment for a son sign is limited secondary to analgesic\n administration.\n\n IMPRESSION:\n\n 1. Markedly thickened, edematous (strated) gallbladder wall with gallbladder\n distention and multiple stones seen within its lumen. The constellation of\n these findings is highly suggestive of acute cholecystitis. However some of\n the findings could be related to ascites and a HIDA scan is suggested for\n further evaluation.\n\n 2. Ascites.\n\n 3. Right pleural effusion.\n\n (Over)\n\n 12:56 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: please evaluate portal vein patency and gallbladder for sign\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4. Splenomegaly.\n\n This recommendation was discussed with Dr. by Dr. at 9:00 a.m.\n via telephone on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-08-12 00:00:00.000",
"description": "CT ABD & PELVIS WITH CONTRAST",
"row_id": 1203326,
"text": " 8:52 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: PO&IV contrast CT to eval for obstruction, infection, biliar\n Admitting Diagnosis: GI BLEED\n Field of view: 38 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with c perfringes bacteremia, pancytopenia, MVR, ?bile duct\n obstruction, with declining mental status s/p intubation\n REASON FOR THIS EXAMINATION:\n PO&IV contrast CT to eval for obstruction, infection, biliary ductal\n obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa WED 10:58 PM\n 1. Cirrhotic liver. Splenomegaly. Perigastric and perisplenic varices.\n Moderate ascites throughout the abdomen and pelvis. No free air. No bowel\n obstruction. Oral contrast transited to the colon. Rectal tube in place.\n 2. No biliary dilatation. Cholelithiasis. No specific signs for acute\n cholecystitis, allowing for liver disease and ascites.\n 3. Small left renal cysts. No hydroureteronephrosis.\n 4. NGT in post pyloric position (2nd portion of duodenum).\n 5. Moderate bilateral pleural effusions, with mild-to-moderate bibasilar\n atelectasis.\n 6. Mitral valve replacement. Sternotomy wires.\n 7. Tiny focal peripheral opacity in the RLL , non-specific (image 3:2).\n 8. Tiny fat-containing umbilical hernia.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: A 51-year-old man with bacteremia, pancytopenia and mitral\n valve replacement, now with declining mental status, status post intubation.\n Please evaluate for obstruction or infection of the biliary tract.\n\n COMPARISON: CT from .\n\n TECHNIQUE: MDCT axial images were acquired from the lung bases to the pubic\n symphysis with the aid of IV and oral contrast. Multiplanar reformations were\n obtained and reviewed.\n\n CT OF THE ABDOMEN: The lung bases bilaterally have moderate pleural effusions\n along with bibasilar atelectasis. There is a small nonspecific nodule seen\n best on image 3:2 which measures about 1 cm. This could represent an\n infectious focus. A mitral valve replacement is seen within a moderately\n enlarged heart.\n\n Within the abdomen, the liver is cirrhotic. The gallbladder shows evidence of\n cholelithiasis; however, no evidence of cholecystitis. There is no biliary\n dilatation seen on this scan. Ascites is seen around the liver. Splenomegaly\n is demonstrated with the spleen measuring 15.7 cm in its greatest dimension.\n\n There are small hypodensities within the left liver most likely representative\n of simple renal cysts, however they attenuate higher than would be expected of\n a renal cyst. There is an NG tube seen coursing into the second part of the\n (Over)\n\n 8:52 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: PO&IV contrast CT to eval for obstruction, infection, biliar\n Admitting Diagnosis: GI BLEED\n Field of view: 38 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n duodenum. Within the pancreas, there is no pancreatic ductal dilatation.\n There are small hyperdensities likely representing calcifications within the\n pancreas. The loops of bowel within the abdomen are unremarkable. There are\n perigastric and perisplenic varices evident. The loops of bowel within the\n abdomen are unremarkable.\n\n CT OF THE PELVIS: There is moderate amount of free fluid/ascites within the\n pelvis. The bladder, rectum and prostate appear unremarkable. There is\n insufflation of the rectum.\n\n BONY WINDOWS: There are no suspicious sclerotic or lytic lesions within the\n bones.\n\n IMPRESSION:\n 1. Cirrhotic liver, splenomegaly, perigastric and perisplenic varices.\n 2. No evidence of biliary dilatation. Cholelithiasis without evidence of\n cholecystitis.\n 3. Small hypodensity which attenuates higher than would be expected for a\n simple renal cyst. Would recomend follow up ultrasound as clinically\n indicated.\n 4. NG tube in the pyloric position.\n 5. Moderate bilateral pleural effusions with bibasilar atelectasis.\n 6. 1cm nodule within the right middle lobe, this may be infectious. Would\n recomend follow up in 3 months or when current clinical situtation resolves.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-08-12 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1203322,
"text": " 8:07 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: LIne placement\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man in shock\n REASON FOR THIS EXAMINATION:\n LIne placement\n ______________________________________________________________________________\n WET READ: ENYa WED 9:28 PM\n R IJ CVL terminates in the cavo-atrial junction or the upper RA. No PTX. ETT\n tip at 3.5 cm above the carina. Tip of NGT in the pyloric area. Otherwise\n unchanged CXR from 1 hr ago, with moderate bihilar opacities and left pleural\n effusion.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: For line placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a right IJ catheter that extends to the region of the cavoatrial\n junction or upper portion of the right atrium. Otherwise, little change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-08-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1203385,
"text": " 9:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 yo male with EtOH cirrhosis presents with UGIB and bacteremia in the setting\n of pancytopenia.\n REASON FOR THIS EXAMINATION:\n Interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Bacteremia, evaluate interval change.\n\n COMPARISON: .\n\n FINDINGS: Semi-erect portable frontal view of the chest is unchanged from\n prior. Again seen are a right IJ line, ET tube and OG tube in unchanged\n position. No change in bilateral consolidations concerning for aspiration\n pneumonia. Probable small bilateral pleural effusions.\n Sternotomy wires and valve prosthesis, unchanged. No pneumothorax.\n\n IMPRESSION: No change from prior.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-08-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1203190,
"text": " 5:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with ascites, tachypnea\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY \n\n COMPARISON: Portable chest x-ray .\n\n FINDINGS: Heart is mildly enlarged. Right basilar opacity has resolved in\n the interval, and area of linear atelectasis of the left lung base has\n improved. Lungs are otherwise clear, and there is no evidence of\n pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-08-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1203313,
"text": " 6:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval OG placement\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with OG placement\n REASON FOR THIS EXAMINATION:\n eval OG placement\n ______________________________________________________________________________\n WET READ: ENYa WED 9:15 PM\n OGT in the stomach. ETT tip at 3.9 cm above the carina. Otherwise, unchanged\n CXR from 2 hours ago, with low lung volumes and marked bilateral hazy\n opacities. No PTX. Mild cardiomegaly.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: OG tube placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of an orogastric tube that extends to the body of the stomach.\n Otherwise, little change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-08-10 00:00:00.000",
"description": "GALLBLADDER SCAN",
"row_id": 1202920,
"text": "GALLBLADDER SCAN Clip # \n Reason: 51 Y/O MAN WITH POSSSIBLE CHOLELITHIASIS\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 4.4 mCi Tc-m DISIDA ();\n HISTORY: 51 year old man with equivocal cholecystitis on ultrasound in setting\n of ascites. Gallbladder scan recommended for further evaluation.\n\n INTERPRETATION: Serial images over the abdomen show uptake of tracer into the\n hepatic parenchyma. At 21 minutes, the gallbladder is visualized. After 90\n minutes, there continues to be no tracer activity visualized in the bowel.\n\n IMPRESSION: 1. Gallbladder visualization; no acute cholecystitis. 2.\n Radiotracer not seen in bowel after 90 minutes; common duct not evaluated.\n\n\n , M.D.\n , M.D. Approved: WED 3:52 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2161-08-23 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1204757,
"text": " 1:52 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for pulm edema\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with aortic stenosis, MVR, and cough with rhonchi on lung exam\n and LE edema\n REASON FOR THIS EXAMINATION:\n eval for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST.\n\n REASON FOR EXAM: Aortic stenosis with rhonchi and lower extremity edema.\n\n Comparison is made with prior study .\n\n Cardiac size is normal. The aorta is tortuous. Small bilateral pleural\n effusions, larger on the right side, are grossly unchanged with associated\n left greater than right lower lobe atelectasis. Left PICC tip is at the\n cavoatrial junction. There is no pneumothorax. Cardiac size is normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-08-19 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1204193,
"text": " 10:36 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for interval change in lung consolidation\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with cirrhosis and aspiration pneumonia on broad spec abx for\n 11 days now with new onset fever to 100.9\n REASON FOR THIS EXAMINATION:\n eval for interval change in lung consolidation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for internal change of lung consolidation.\n\n TECHNIQUE: Frontal and lateral radiograph of the chest.\n\n IMPRESSION: Comparisons were made with prior chest radiographs through , . Right PICC line terminates in the lower SVC. Bilateral lung\n volumes remain low. Previously seen opacities in the bilateral upper lobes,\n left perihilar and lower lobe has resolved. These lung opacities likely\n represented a concurrently appearing upper lobe pneumonic consolidation and\n pulmonary edema manifesting as perihilar and lower lobe opacities. There are\n no new areas of lung opacity. There is no pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-08-19 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1204292,
"text": " 8:56 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Evaluate for signs of cholecystitis. ascites\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with fever and previous u/s concerning for cholecystits.\n REASON FOR THIS EXAMINATION:\n Evaluate for signs of cholecystitis. ascites\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with fever, concerning for cholecystitis.\n\n COMPARISON: Liver and gallbladder ultrasound from ,\n gallbladder HIDA scan from , and CT abdomen and pelvis with\n contrast from .\n\n FINDINGS: Again visualized is marked gallbladder wall thickening measuring up\n to 11 mm with gallbaldder wall edema. The GB is not fully distended. There is\n a small amount of pericholecystic fluid. Small stones are again visualized\n throughout the dependent portion of the gallbladder as well as one adherent\n stone in the nondependent portion. There is also sludge in the gallbladder.\n There is, however, a negative sign. Given the patient's history of\n cirrhosis and moderate ascites, these findings are likely related to patient's\n underlying liver disease and remain unchanged in comparison to prior study\n from . Otherwise, the liver appears without any focal lesions.\n The main portal vein is patent with hepatopetal flow. Free fluid consistent\n with ascites is again visualized throughout the abdomen. There is continued\n splenomegaly with the spleen measuring 16 cm. Small pleural effusions are\n again visualized in the right. There is no intra- or extra-hepatic ductal\n dilatation with the common bile duct measuring 4 mm.\n\n IMPRESSION:\n 1. Essentially no significant change in comparison to prior study from , . Markedly thickened gallbladder wall with gallstones within the\n gallbladder lumen. Given the patient's history of cirrhosis, the GB wall\n thickening is likely related to patient's underlying liver disease.\n 2. Moderate ascites.\n 3. Stable right pleural effusion.\n 4. Splenomegaly.\n\n"
},
{
"category": "Echo",
"chartdate": "2161-08-11 00:00:00.000",
"description": "Report",
"row_id": 91782,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Cirrhosis. GI bleed.\nHeight: (in) 67\nWeight (lb): 130\nBSA (m2): 1.69 m2\nBP (mm Hg): 119/72\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 10:18\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildy dilated aortic root. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Severe AS (area\n0.8-1.0cm2). No AR.\n\nMITRAL VALVE: Bileaflet mitral valve prosthesis (MVR). MVR well seated, with\nnormal leaflet/disc motion and transvalvular gradients. Calcified tips of\npapillary muscles. No MR. [Due to acoustic shadowing, the severity of MR may\nbe significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThe aortic root is mildly dilated at the sinus level. The ascending aorta is\nmildly dilated. The aortic valve leaflets are moderately thickened. There is\nsevere aortic valve stenosis (valve area 0.8cm2). No aortic regurgitation is\nseen. A bileaflet mitral valve prosthesis is present. The mitral prosthesis\nappears well seated, with normal leaflet/disc motion and transvalvular\ngradients. No mitral regurgitation is seen. [Due to acoustic shadowing, the\nseverity of mitral regurgitation may be significantly UNDERestimated.] The\npulmonary artery systolic pressure could not be determined. There is no\npericardial effusion.\n\nIMPRESSION: Severe aortic valve stenosis. Well seated, normal functioning\nbileaflet mechanical mitral valve. Mild symmetric left ventricular hypertrophy\nwith preserved global and regional biventricular systolic function. Dilated\nascending aorta.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis IS recommended. Clinical decisions regarding the need for\nprophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2161-08-12 00:00:00.000",
"description": "Report",
"row_id": 248809,
"text": "Normal sinus rhythm with delayed R wave transition. Non-diagnostic Q waves in\nthe inferior leads. No previous tracing available for comparison.\n\n"
}
] |
87,236 | 127,056 | # STEMI: The patient presented with chest pain and was found to have STEMI. He was taken to the cardiac catheterization, where a 90% stenosis of the mid-LAD was identified. PCI was performed, with placement of a Cypher drug-eluting stent to the mid-LAD. Echocardiogram subsequently revealed EF 30-35%. The patient was discharged on aspirin, Plavix, metoprolol, enalapril, atorvastatin, nitroglycerin. He was also started on warfarin for anteroapical akinesis (see below). Cardiology follow-up with Dr. was arranged. . # Anteroapical akinesis: Tranthoracic echocardiogram revealed akinesis of the mid- and distal anterior wall, anterior septum and apex. Due to the risk of intracardiac thrombus formation, anticoagulation with warfarin was initiated. The patient will need to have his INR checked 1-2 times weekly for the while his warfarin dose is titrated. Repeat echocardiogram should be performed in months, at which time the need for anticoagulation can be reconsidered. . # Anti-E antibody: A routine type and screen identified an anti-E antibody. The blood bank will send a wallet card and letter to the patient. . # Impaired glucose tolerance: HbA1c was checked for risk stratification and was 6.4. The patient will follow up with his primary care doctor for further management of this. . # Dyslipidemia: Changed simvastatin to atorvastatin. . # Benign prostatic hypertrophy: Continued terazosin. | # BPH: Per last admission, was on terazosin. # BPH: Per last admission, was on terazosin. # BPH: Per last admission, was on terazosin. # BPH: Per last admission, was on terazosin. # BPH: Per last admission, was on terazosin. # PUMP: Euvolemic. # PUMP: Euvolemic. # PUMP: Euvolemic. # PUMP: Euvolemic. -asa, plavix -start bb -echo in the AM -obs for recurrence of cp -if stable to floor in AM # BPH: - Continue terazosin . Pulm: CTAB. # RHYTHM: Currently sinus. # RHYTHM: Currently sinus. # RHYTHM: Currently sinus. # RHYTHM: Currently sinus. # STEMI: Patient exhibited ST elevations that resolved post-cath. # STEMI: Patient exhibited ST elevations that resolved post-cath. # STEMI: Patient exhibited ST elevations that resolved post-cath. # STEMI: Patient exhibited ST elevations that resolved post-cath. Serial cks, troponins drawn. STE in anterior leads resolved. # HTN: ACE-I, BB. - Monitor I/Os - start anticoagulation given anteroapical akinesis - echo . Lopressor 12.5mg started. ECG: nsr with STE v2-4, improved post procedure. # RHYTHM: Currently sinus with 1:1 conduction. # RHYTHM: Currently sinus with 1:1 conduction. Trop 3.95. Trop 3.95. Pulm: CTAB anteriorly. Pulm: CTAB anteriorly. Pulm: CTAB anteriorly. Abd: +BS. Abd: +BS. Abd: +BS. Abd: +BS. - continue Keflex ICU Care Nutrition: Cardiac Glycemic Control: Lines: 18 Gauge - 12:35 AM Prophylaxis: DVT: Heparin SQ Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full (confirmed) Disposition: To 3 - PT consult for STEMI. - PT consult for STEMI. - PT consult for STEMI. ------ Protected Section Addendum Entered By: , MD on: 02:37 PM ------ started on metoprolol 12. started on metoprolol 12. Given ECG concerning for STEMI, Code STEMI was called. - Monitor I/Os - echo . - Monitor I/Os - echo . - Monitor I/Os - echo . STE in V1-V3. # HTN: Will start ACE-I and BB as above. # HTN: Will start ACE-I and BB as above. # HTN: Will start ACE-I and BB as above. # HTN: Will start ACE-I and BB as above. # HTN: Will start ACE-I and BB as above. Now s/p DES to LAD. Now s/p DES to LAD. Pulm: CTAB anteriorly Abd: S/NT/ND +bs Ext: No c/c/e, 2+ dp/pt bilaterally. Pulm: CTAB anteriorly Abd: S/NT/ND +bs Ext: No c/c/e, 2+ dp/pt bilaterally. Pulm: CTAB anteriorly Abd: S/NT/ND +bs Ext: No c/c/e, 2+ dp/pt bilaterally. - ACE-I and BB as above. - ACE-I and BB as above. - Trend cardiac biomarkers until MB peaks - PT consult for STEMI . Mild (1+) mitral regurgitation is seen. No VSD.LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -akinetic; mid anteroseptal - akinetic; anterior apex - akinetic; septal apex-akinetic; inferior apex - akinetic; apex - akinetic;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Myocardial infarction.Height: (in) 67Weight (lb): 80BSA (m2): 1.37 m2BP (mm Hg): 126/72HR (bpm): 71Status: InpatientDate/Time: at 14:00Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA and RA cavity sizes.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. There is no pericardialeffusion.IMPRESSION: Moderate regional left ventricular systolic dysfunction, c/w CAD.Mild mitral regurgitation. Trace aortic regurgitation is seen. There is moderate regional left ventricular systolicdysfunction with edema and akinesis of the mid- and distal anterior wall,anterior septum and apex (mid-LAD territory), most c/w recent infarction. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium and right atrium are normal in cavity size. Mild [1+] TR. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. Action: Remains on Lopressor, Aspirin, plavix, and simvastatin. Action: Remains on Lopressor, Aspirin, plavix, and simvastatin. Action: Remains on Lopressor, Aspirin, plavix, and simvastatin. Moderate regional LVsystolic dysfunction. Trace AR.MITRAL VALVE: Normal mitral valve leaflets. Modest right precordial leadST segment elevation. Right groin with tegaderm CDI. Right groin with tegaderm CDI. Right groin with tegaderm CDI. The estimatedpulmonary artery systolic pressure is normal. LSCA on 2L NC, pulses palpable, bowel sounds present, skin intact. LSCA on 2L NC, pulses palpable, bowel sounds present, skin intact. LSCA on 2L NC, pulses palpable, bowel sounds present, skin intact. Delayed R wave progression pattern suggests anterior myocardialinfarction of indeterminate age but clinical correlation is suggested. Left ventricular function. Low lateral limb lead T wave amplitude. FINDINGS: Single AP upright portable view of the chest was obtained. Denies pain and nausea at this time. Denies pain and nausea at this time. Denies pain and nausea at this time. Denies pain and nausea at this time. The diameters ofaorta at the sinus, ascending and arch levels are normal. The aortic valveleaflets (3) appear structurally normal with good leaflet excursion and noaortic stenosis. Clinical correlation is suggested.Since the previous tracing of findings as outlined are now present.TRACING #1 Response: Hemodynamically stable. Response: Hemodynamically stable. Response: Hemodynamically stable. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. No 2Dor Doppler evidence of distal arch coarctation.AORTIC VALVE: Normal aortic valve leaflets (3). Normal IVCdiameter (<2.1cm) with >55% decrease during respiration (estimated RA pressure(0-5mmHg).LEFT VENTRICLE: Normal LV wall thickness and cavity size. Demographics Attending MD: J. Demographics Attending MD: J. Abdomen soft, nd. Abdomen soft, nd. Abdomen soft, nd. Independent with ADLs. | 26 | [
{
"category": "Physician ",
"chartdate": "2149-03-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 528361,
"text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n Had left-sided chest pressure at 3 a.m. that responded to NTG SL x\n 2. EKG showed new TWI in V2-V4. Trop 3.95 CK\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 03:03 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.8\nC (96.4\n HR: 62 (59 - 64) bpm\n BP: 132/66(82) {104/65(74) - 141/113(118)} mmHg\n RR: 17 (9 - 17) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 576 mL\n PO:\n TF:\n IVF:\n 576 mL\n Blood products:\n Total out:\n 0 mL\n 450 mL\n Urine:\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 126 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Gen: Age appropriate male in NAD\n HEENT: PERRL, eomi, sclerae anicteric. MMM.\n CV: Nl S1+S2, no m/r/g. JVP flat.\n Pulm: CTAB anteriorly\n Abd: S/NT/ND +bs\n Ext: No c/c/e, 2+ dp/pt bilaterally.\n Neuro: AOx2, CN II-XII intact.\n Labs / Radiology\n 175 K/uL\n 15.8 g/dL\n 125 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 11 mg/dL\n 104 mEq/L\n 137 mEq/L\n 47.5 %\n 8.8 K/uL\n [image002.jpg]\n 04:51 AM\n WBC\n 8.8\n Hct\n 47.5\n Plt\n 175\n Cr\n 0.9\n Glucose\n 125\n Other labs: PT / PTT / INR:12.2/26.2/1.0, CK / CKMB /\n Troponin-T:1586/225/, Ca++:8.8 mg/dL, Mg++:2.4 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:35 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2149-03-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 528783,
"text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n Pre dinner GFS 188, nurse 8U.\n Started on sliding scale. Hemoglobin A1C 6.4.\n CE trending down.\n Echo showed Moderate regional left ventricular systolic dysfunction,\n c/w CAD. Mild mitral regurgitation. There is moderate regional left\n ventricular systolic dysfunction with edema and akinesis of the mid-\n and distal anterior wall, anterior septum and apex (mid-LAD territory),\n most c/w recent infarction.\n d/c nitro drip, SLNTG prn, could consider long acting nitrate.\n started on metoprolol 12. (may need , need ace in\n future)\n -ordered for PT consult for tomorrow\n -Med rec with ENT RE keflex.\n -PCP confirmed pt's dose of terazosin (hytrin): 2mg before bed.\n -call out to 3.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 03:03 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:34 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.8\nC (96.5\n HR: 75 (59 - 92) bpm\n BP: 112/71(81) {105/69(80) - 160/89(106)} mmHg\n RR: 14 (12 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84.1 kg (admission): 80 kg\n Height: 67 Inch\n Total In:\n 2,470 mL\n PO:\n 960 mL\n TF:\n IVF:\n 1,510 mL\n Blood products:\n Total out:\n 3,610 mL\n 875 mL\n Urine:\n 3,610 mL\n 875 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,140 mL\n -875 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Gen: NAD\n Neck: bruise in right neck at site of lymph node biopsy\n CV: JVP not elevated. RRR. Normal s1, s2. No M/G/R.\n Pulm: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: No c/c/e, 2+ DP/PT bilaterally. No femoral bruits. Right groin\n catheterization site with clean dressing in place and no hematoma.\n Neuro: A+Ox3\n Labs / Radiology\n 173 K/uL\n 17.8 g/dL\n 119 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.6 mEq/L\n 10 mg/dL\n 104 mEq/L\n 136 mEq/L\n 53.6 %\n 8.9 K/uL\n [image002.jpg]\n 04:51 AM\n 08:52 AM\n 04:46 PM\n 03:07 AM\n WBC\n 8.8\n 8.9\n Hct\n 47.5\n 51.6\n 53.6\n Plt\n 175\n 195\n 187\n 173\n Cr\n 0.9\n 1.0\n 0.9\n TropT\n 3.95\n Glucose\n 125\n 119\n Other labs: PT / PTT / INR:12.2/26.2/1.0, CK / CKMB /\n Troponin-T:928/106/3.95, Ca++:9.7 mg/dL, Mg++:2.6 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 56 yo M with HTN and hypercholestolemia p/w chest pain, diagnosed with\n STEMI, now s/p DES to LAD.\n .\n # STEMI: Patient exhibited ST elevations that resolved post-cath.\n Enzymes initially were negative but were elevated to trop 3.95. CK\n peaked at 1586 and is now trending down.\n - Continue ASA 325 daily, clopidogrel 75 daily, atorvastatin 80.\n - metoprolol 25 mg \n - lisinopril 5 mg daily\n - PT consult\n .\n # PUMP: Euvolemic. Echo shows anteroapical akinesis with EF 30-35%.\n - Monitor I/Os\n - start anticoagulation given anteroapical akinesis\n - echo\n .\n # RHYTHM: Currently sinus.\n -\n Telemetry\n - replete lytes PRN\n .\n # HTN: ACE-I, BB.\n .\n # HLD: Atorvastatin 80 mg daily\n .\n # BPH:\n - Continue terazosin\n .\n # s/p lymph node biopsy: Patient was on cephalexin prior to admission.\n - continue Keflex\n ICU Care\n Nutrition: Cardiac\n Glycemic Control:\n Lines:\n 18 Gauge - 12:35 AM\n Prophylaxis:\n DVT: Heparin SQ\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full (confirmed)\n Disposition: To 3\n"
},
{
"category": "Physician ",
"chartdate": "2149-03-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 528482,
"text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n Had left-sided chest pressure at 3 a.m. that responded to NTG SL x\n 2. EKG showed new TWI in V2-V4. Trop 3.95.\n Allergies:\n No Known Drug Allergies\n Last dose of :\n Cefazolin - 03:03 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.8\nC (96.4\n HR: 62 (59 - 64) bpm\n BP: 132/66(82) {104/65(74) - 141/113(118)} mmHg\n RR: 17 (9 - 17) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 576 mL\n PO:\n TF:\n IVF:\n 576 mL\n Blood products:\n Total out:\n 0 mL\n 450 mL\n Urine:\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 126 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Gen: NAD\n Neck: bruise in right neck at site of lymph node biopsy\n CV: JVP not elevated. RRR. Normal s1, s2. No M/G/R.\n Pulm: CTAB anteriorly.\n Abd: +BS. Soft. NT/ND.\n Ext: No c/c/e, 2+ DP/PT bilaterally. No femoral bruits. Right groin\n catheterization site with clean dressing in place.\n Neuro: A+Ox3\n Labs / Radiology\n 175 K/uL\n 15.8 g/dL\n 125 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 11 mg/dL\n 104 mEq/L\n 137 mEq/L\n 47.5 %\n 8.8 K/uL\n [image002.jpg]\n 04:51 AM\n WBC\n 8.8\n Hct\n 47.5\n Plt\n 175\n Cr\n 0.9\n Glucose\n 125\n Other labs: PT / PTT / INR:12.2/26.2/1.0, CK / CKMB /\n Troponin-T:1586/225/, Ca++:8.8 mg/dL, Mg++:2.4 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 56 yo M with HTN and hypercholestolemia p/w chest pain, diagnosed with\n STEMI, now s/p emergent cath.\n .\n # STEMI: Patient exhibited ST elevations that resolved post-cath.\n Enzymes initially were negative but were elevated to trop 3.95. CK\n peaked at 1586 and is now trending down.\n - Continue ASA 325 daily, clopidogrel 75 daily, atorvastatin 80.\n - Add beta blocker today. Consider ACE-I tomorrow.\n - PT consult for STEMI.\n .\n # PUMP: Euvolemic. No signs or symptoms of heart failure.\n - Monitor I/Os\n - echo\n .\n # RHYTHM: Currently sinus. Had frequent ventricular ectopy including\n 8-beat runs of NSVT overnight.\n - Telemetry\n - replete lytes PRN\n .\n # HTN: Will start ACE-I and BB as above.\n .\n # HLD: Atorvastatin 80 mg daily\n .\n # Asthma/COPD: Albuterol and atrovent inhalers.\n .\n # BPH: Per last admission, was on terazosin.\n - Will confirm med list with family prior to restarting.\n .\n # s/p lymph node biopsy: Patient was on cephalexin prior to admission.\n - clarify with patient/family/patient\ns doctors and give\n for appropriate course\n ICU Care\n Nutrition: Cardiac\n Glycemic Control:\n Lines:\n 18 Gauge - 12:35 AM\n Prophylaxis:\n DVT: Heparin SQ\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: ex-wife (\n Code status: Full (confirmed)\n Disposition: Likely call out to 3.\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n History\n Doing well after LAD PCI for STEMI with CK 1586.\n No CHF or sig ectopy.\n Physical Examination\n Chest clear.\n Groin intact.\n No murmurs.\n Medical Decision Making\n Echo pending today.\n If uncomplicated course, may be ready for discharge tomorrow.\n Above discussed extensively with patient.\n Total time spent on patient care: 30 minutes of critical care time.\n ------ Protected Section Addendum Entered By: , MD\n on: 02:37 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2149-03-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 528556,
"text": "Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n SR with freq to occ PVCs noted. BP up with activity for family visit.\n Occ c/o chest pain reported lasting 5-10secs, resolved without\n treatment. CCU team in to round on pt. R fem site clean and dry, no\n hematoma noted, pedal pulses palpable.\n Action:\n Echo done.\n NS for total of 1200cc.\n Serial cks, troponins drawn.\n BS 188 at noon, treated with 8units regular insulin.\n Lopressor 12.5mg started.\n Tylenol for pain with good effect.\n Response:\n Feeling better.\n CK\ns trending down.\n Plan:\n CCU resident called, lopressor dose to be increased.\n Sliding scale insulin, pt specific to be ordered.\n A1c pending.\n No bed available on F3.\n"
},
{
"category": "Nursing",
"chartdate": "2149-03-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 528630,
"text": "Mr is a 56 yo male who was at home yesterday and developed\n substernal chest pain around 3pm. It continued into evening increasing\n in intensity until his family called EMS around 2200. Pain is described\n as a burning pressure and peaked at a where he could not get uot\n of bed. It was associalted with diaphoresis, shortness of breath and\n radiating pain to right arm , back and neck. He arrived in the ED where\n a code STEMI was called he had EKG changes in leads II, III and IV. He\n was treated with ASA, Heparin, Integrellin, plavix and morphine and\n taken to the cath lab where his LAD was Stented. Pt arrived stable with\n mild chest pain he has not had full relief but is vague about\n pain.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Pt A&Ox3, MAE. Primary language is Spanish but speaks English fluently.\n HR NSR no ectopy noted, sbp 110-140\ns, no gtts. LSCA on 2L NC, pulses\n palpable, bowel sounds present, skin intact. voiding\n Action:\n Pt out of bed to chair in evening\n Glucose treated per ss\n Tolerating increased lopressor dose\n Cath site normal, no hematoma noted\n Out of bed onto commode\n UOP adequate\n O2 off, sats 95-99%\n K repleated per order\n Pt denies pain this shift\n Response:\n Pt moves independently\n Glucose treated per ss, tolerating\n Tolerating lopressor dose increase\n Small bowel movement in evening\n Washed up independently\n Taking POs\n Resting comfortably\n Pt tolerating RA, sats 95-97%%\n Pt stayed on unit due to bed availability\n Plan:\n Transfer to 3 as soon as bed opens up\n"
},
{
"category": "Physician ",
"chartdate": "2149-03-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 528462,
"text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n Had left-sided chest pressure at 3 a.m. that responded to NTG SL x\n 2. EKG showed new TWI in V2-V4. Trop 3.95.\n Allergies:\n No Known Drug Allergies\n Last dose of :\n Cefazolin - 03:03 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.8\nC (96.4\n HR: 62 (59 - 64) bpm\n BP: 132/66(82) {104/65(74) - 141/113(118)} mmHg\n RR: 17 (9 - 17) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 576 mL\n PO:\n TF:\n IVF:\n 576 mL\n Blood products:\n Total out:\n 0 mL\n 450 mL\n Urine:\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 126 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Gen: NAD\n Neck: bruise in right neck at site of lymph node biopsy\n CV: JVP not elevated. RRR. Normal s1, s2. No M/G/R.\n Pulm: CTAB anteriorly.\n Abd: +BS. Soft. NT/ND.\n Ext: No c/c/e, 2+ DP/PT bilaterally. No femoral bruits. Right groin\n catheterization site with clean dressing in place.\n Neuro: A+Ox3\n Labs / Radiology\n 175 K/uL\n 15.8 g/dL\n 125 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 11 mg/dL\n 104 mEq/L\n 137 mEq/L\n 47.5 %\n 8.8 K/uL\n [image002.jpg]\n 04:51 AM\n WBC\n 8.8\n Hct\n 47.5\n Plt\n 175\n Cr\n 0.9\n Glucose\n 125\n Other labs: PT / PTT / INR:12.2/26.2/1.0, CK / CKMB /\n Troponin-T:1586/225/, Ca++:8.8 mg/dL, Mg++:2.4 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 56 yo M with HTN and hypercholestolemia p/w chest pain, diagnosed with\n STEMI, now s/p emergent cath.\n .\n # STEMI: Patient exhibited ST elevations that resolved post-cath.\n Enzymes initially were negative but were elevated to trop 3.95. CK\n peaked at 1586 and is now trending down.\n - Continue ASA 325 daily, clopidogrel 75 daily, atorvastatin 80.\n - Add beta blocker today. Consider ACE-I tomorrow.\n - PT consult for STEMI.\n .\n # PUMP: Euvolemic. No signs or symptoms of heart failure.\n - Monitor I/Os\n - echo\n .\n # RHYTHM: Currently sinus. Had frequent ventricular ectopy including\n 8-beat runs of NSVT overnight.\n - Telemetry\n - replete lytes PRN\n .\n # HTN: Will start ACE-I and BB as above.\n .\n # HLD: Atorvastatin 80 mg daily\n .\n # Asthma/COPD: Albuterol and atrovent inhalers.\n .\n # BPH: Per last admission, was on terazosin.\n - Will confirm med list with family prior to restarting.\n .\n # s/p lymph node biopsy: Patient was on cephalexin prior to admission.\n - clarify with patient/family/patient\ns doctors and give\n for appropriate course\n ICU Care\n Nutrition: Cardiac\n Glycemic Control:\n Lines:\n 18 Gauge - 12:35 AM\n Prophylaxis:\n DVT: Heparin SQ\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: ex-wife (\n Code status: Full (confirmed)\n Disposition: Likely call out to 3.\n"
},
{
"category": "Physician ",
"chartdate": "2149-03-18 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 528322,
"text": "TITLE: Physician Resident Admission Note\n Chief Complaint: chest pain\n HPI: Mr. is a 56 year old gentleman with a PMH significant for\n HTN and transferred to the CCU s/p PCI with DES to STEMI. The\n patient reports that he developed slowly progressive substernal chest\n pain since 3 pm yesterday afternoon. Pain was described as \"burning\n chest pressure\" that started at 3/10 and peaked at 10/10, prompting his\n family calling EMS this evening. Chest pain was associated with\n diaphoresis, shortness of breath, and pain radiating to his right arm,\n jaw, and back, and the patient reports that he was unable to get out of\n bed. Denied any n/v, palpitations, LE edema, orthopnea, syncope or\n presyncope. Of note, the patient recently underwent a lymph node\n biopsy by ENT with pathology pending, and was also admitted to in\n for chest pain during which he was ruled out for ACS and\n underwent a negative persantine mibi.\n .\n In the ED, VS 72 142/92 100%RA. Given ECG concerning for STEMI,\n Code STEMI was called. The patient received ASA 162 mg, plavix 600 mg,\n heparin bolus, integrillin bolus, and morphine 4 mg IV. He was then\n taken to the cath lab, where he received a DES to his LAD. After his\n PCI, the patient had transient chest pain, and so was transferred to\n the CCU for further management.\n .\n Currently, the patient is resting comofortably wihout complaints.\n Denies CP/SOB, f/c/s, n/v/d, palpitations, diaphoresis, abd pain,\n orthopnea, pain radiating to arm or jaw. He does endorse some mild low\n back \"achiness.\" At baseline, he gets short of breath with walking 2\n blocks.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 03:03 AM\n Infusions:\n Other ICU medications:\n Home medications:\n Percocet 5/325 prn\n Terazosin 2 mg daily\n Simvastatin 80 daily\n ASA 81 daily\n Cephalexin 500 mg daily\n Enalapril 10 mg daily\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension\n 2. CARDIAC HISTORY: None\n 3. OTHER PAST MEDICAL HISTORY:\n Chronic Vertigo\n Unsteady Gait\n Asthma/COPD not currently using inhaler\n Hx bilateral ear operations.\n BPH\n Reports that Mother had ?MI at 76. Father had CVA at 87. Positive\n family history of diabetes.\n Currently unemployed. Lives with ex-wife. - 12 pack years, quit\n 8 years ago. EtOH - quit 8 years ago. Denies IV, illicit, or herbal\n drug use.\n Review of systems:\n Flowsheet Data as of 03:20 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 62 (61 - 64) bpm\n BP: 125/80(91) {104/65(74) - 141/113(118)} mmHg\n RR: 11 (11 - 17) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 366 mL\n PO:\n TF:\n IVF:\n 366 mL\n Blood products:\n Total out:\n 0 mL\n 450 mL\n Urine:\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -84 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n Physical Examination\n VS: 98 62 104/65 13 100%RA\n Gen: Age appropriate male in NAD\n HEENT: PERRL, eomi, sclerae anicteric. MMM.\n CV: Nl S1+S2, no m/r/g. JVP flat.\n Pulm: CTAB anteriorly\n Abd: S/NT/ND +bs\n Ext: No c/c/e, 2+ dp/pt bilaterally.\n Neuro: AOx2, CN II-XII intact.\n Labs / Radiology\n [image002.jpg]\n ECG (CVI): Sinus with 1:1 conduction. NA-NI. STE in anterior leads\n resolved.\n .\n ECG (ED): NSR at 66. Normal axis and intervals. STE in V1-V3. Biphasic\n T-waves in II, III, aVF.\n .\n CXR: No acute cardiopulmonary process\n .\n Persantine mibi (): Normal left ventricular myocardial perfusion,\n size and function. LFEF = 58. No anginal symptoms or ischemic ST\n segment changes. Appropriate hemodynamic response to the Persantine\n infusion. Modest atrial arrhythmia as outlined. Nuclear report sent\n separately.\n Assessment and Plan\n 56 yo M with HTN and hypercholestolemia p/w chest pain, diagnosed with\n STEMI, now s/p emergent cath.\n .\n # STEMI: Patient exhibited ST elevations that resolved post-cath,\n although his cardiac enzymes were negative despite hours of pain. It\n seems possible that the patient was experiencing unstable angina rather\n than true STEMI. Now s/p DES to LAD.\n - Continue ASA 325 daily, clopidogrel 75 daily, atorvastatin 80.\n - Will plan to start ACE-I and BB during admission.\n - Trend cardiac biomarkers until MB peaks\n - PT consult for STEMI\n .\n # PUMP: Does not appear to be volume overloaded on exam.\n - Monitor I/Os, goal TBB even to -500 mL/day.\n - ACE-I and BB as above.\n - echo in a.m.\n .\n # RHYTHM: Currently sinus with 1:1 conduction.\n - Telemetry\n .\n # HTN: Will start ACE-I and BB as above.\n .\n # HLD: Atorvastatin 80 mg daily\n .\n # Asthma/COPD: Albuterol and atrovent inhalers.\n .\n # BPH: Per last admission, was on terazosin.\n - Will confirm med list with family prior to restarting.\n ICU Care\n Nutrition: Cardiac, replete as necessary\n Glycemic Control:\n Lines:\n 18 Gauge - 12:35 AM\n Prophylaxis:\n DVT: Heparin SQ\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: ex-wife (\n Code status: Full (confirmed)\n Disposition: CCU\n"
},
{
"category": "Nursing",
"chartdate": "2149-03-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 528422,
"text": "Mr is a 56 yo male who was at home yesterday and developed\n substernal chest pain around 3pm. It continued into evening increasing\n in intensity until his family called EMS around 2200. Pain is described\n as a burning pressure and peaked at a where he could not get uot\n of bed. It was associalted with diaphoresis, shortness of breath and\n radiating pain to right arm , back and neck. He arrived in the ED where\n a code STEMI was called he had EKG changes in leads II, III and IV. He\n was treated with ASA, Heparin, Integrellin, plavix and morphine and\n taken to the cath lab where his LAD was Stented. Pt arrived stable with\n mild chest pain he has not had full relief but is vague about\n pain.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n HR in the 60\ns sinus with PVC\nS and runs of V tach. BP 110-140/80-90.\n Pt states pain gone shortly after arrival but returned around 0455 \n left side of chest pressure pain.\n Right groin site intact no hematoma or bleeding noted pt closed with\n angioseal.\n Action:\n EKG x3 during chest pain\n Nitro 0.3mg SL x2\n Pt receiving 1/2ns at 75cc/hr\n Labs sent no treatment required\n Bedrest maintained until 0200 as ordered.\n Pedal pulses and right groin site checked every hour x4\n Response:\n EKG changes noted by MD pt now has flipped t waves not see on previous\n ekg on admission\n Chest pain resolved , pt voiding qs\n Tropin elevated to 3.95 and CK 1586\n Plan:\n Follow up EKG at 0700. check with pt frequently for chest pain\n"
},
{
"category": "Nursing",
"chartdate": "2149-03-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 528369,
"text": "Mr is a 56 yo male who was at home yesterday and developed\n substernal chest pain around 3pm. It continued into evening increasing\n in intensity until his family called EMS around 2200. Pain is described\n as a burning pressure and peaked at a where he could not get uot\n of bed. It was associalted with diaphoresis, shortness of breath and\n radiating pain to right arm , back and neck. He arrived in the ED where\n a code STEMI was called he had EKG changes in leads II, III and IV. He\n was treated with ASA, Heparin, Integrellin, plavix and morphine and\n taken to the cath lab where his LAD was Stented. Pt arrived stable with\n mild chest pain he has not had full relief but is vague about\n pain.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n HR in the 60\ns sinus with PVC\nS and runs of V tach. BP 110-140/80-90.\n Pt states pain gone shortly after arrival but returned around 0455 \n left side of chest pressure pain.\n Right groin site intact no hematoma or bleeding noted pt closed with\n angioseal.\n Action:\n EKG x3 during chest pain\n Nitro 0.3mg SL x2\n Pt receiving 1/2ns at 75cc/hr\n Labs sent no treatment required\n Bedrest maintained until 0200 as ordered.\n Pedal pulses and right groin site checked every hour x4\n Response:\n Chest pain resolved , pt voiding qs\n Tropin elevated to 3.95 and CK 1586\n Plan:\n Follow up EKG at 0700. check with pt frequently for chest pain\n"
},
{
"category": "General",
"chartdate": "2149-03-18 00:00:00.000",
"description": "CCU Fellow Admit Note",
"row_id": 528313,
"text": "TITLE: CCU Fellow Admit Note\n 56M HTN, HL presented to ED with chest pain since this afternoon. ECG\n notable for ST elevations V2-4. code stemi called and taken emergently\n to cath lab. 90% mid LAD lesion found and stented with cypher. LVEDP\n 19. persistent chest pain post procedure that has slowly improved.\n 104/65 62 13 100%NC\n comfortable nad\n s1/s2 rrr no mrg\n cta anteriorly\n soft nt/nd +bs\n no c/c/e 2+dp\n labs: reviewed in OMR.\n ECG: nsr with STE v2-4, improved post procedure.\n A/P: 56M with chest pain and ECG c/f STEMI now s/p cypher to mid LAD.\n -asa, plavix\n -start bb\n -echo in the AM\n -obs for recurrence of cp\n -if stable to floor in AM\n"
},
{
"category": "Physician ",
"chartdate": "2149-03-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 528392,
"text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n Had left-sided chest pressure at 3 a.m. that responded to NTG SL x\n 2. EKG showed new TWI in V2-V4. Trop 3.95 CK\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 03:03 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.8\nC (96.4\n HR: 62 (59 - 64) bpm\n BP: 132/66(82) {104/65(74) - 141/113(118)} mmHg\n RR: 17 (9 - 17) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 576 mL\n PO:\n TF:\n IVF:\n 576 mL\n Blood products:\n Total out:\n 0 mL\n 450 mL\n Urine:\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 126 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Gen: Age appropriate male in NAD\n HEENT: PERRL, eomi, sclerae anicteric. MMM.\n CV: Nl S1+S2, no m/r/g. JVP flat.\n Pulm: CTAB anteriorly\n Abd: S/NT/ND +bs\n Ext: No c/c/e, 2+ dp/pt bilaterally.\n Neuro: AOx2, CN II-XII intact.\n Labs / Radiology\n 175 K/uL\n 15.8 g/dL\n 125 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 11 mg/dL\n 104 mEq/L\n 137 mEq/L\n 47.5 %\n 8.8 K/uL\n [image002.jpg]\n 04:51 AM\n WBC\n 8.8\n Hct\n 47.5\n Plt\n 175\n Cr\n 0.9\n Glucose\n 125\n Other labs: PT / PTT / INR:12.2/26.2/1.0, CK / CKMB /\n Troponin-T:1586/225/, Ca++:8.8 mg/dL, Mg++:2.4 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 56 yo M with HTN and hypercholestolemia p/w chest pain, diagnosed with\n STEMI, now s/p emergent cath.\n .\n # STEMI: Patient exhibited ST elevations that resolved post-cath,\n although his cardiac enzymes were negative despite hours of pain. It\n seems possible that the patient was experiencing unstable angina rather\n than true STEMI. Now s/p DES to LAD.\n - Continue ASA 325 daily, clopidogrel 75 daily, atorvastatin 80.\n - Will plan to start ACE-I and BB during admission.\n - Trend cardiac biomarkers until MB peaks\n - PT consult for STEMI\n .\n # PUMP: Does not appear to be volume overloaded on exam.\n - Monitor I/Os, goal TBB even to -500 mL/day.\n - ACE-I and BB as above.\n - echo in a.m.\n .\n # RHYTHM: Currently sinus with 1:1 conduction.\n - Telemetry\n .\n # HTN: Will start ACE-I and BB as above.\n .\n # HLD: Atorvastatin 80 mg daily\n .\n # Asthma/COPD: Albuterol and atrovent inhalers.\n .\n # BPH: Per last admission, was on terazosin.\n - Will confirm med list with family prior to restarting.\n ICU Care\n Nutrition: Cardiac, replete as necessary\n Glycemic Control:\n Lines:\n 18 Gauge - 12:35 AM\n Prophylaxis:\n DVT: Heparin SQ\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: ex-wife (\n Code status: Full (confirmed)\n Disposition: CCU\n"
},
{
"category": "Nursing",
"chartdate": "2149-03-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 528368,
"text": "Mr is a 56 yo male who was at home yesterday and developed\n substernal chest pain around 3pm. It continued into evening increasing\n in intensity until his family called EMS around 2200. Pain is described\n as a burning pressure and peaked at a where he could not get uot\n of bed. It was associalted with diaphoresis, shortness of breath and\n radiating pain to right arm , back and neck. He arrived in the ED where\n a code STEMI was called he had EKG changes in leads II, III and IV. He\n was treated with ASA, Heparin, Integrellin, plavix and morphine and\n taken to the cath lab where his LAD was Stented. Pt arrived stable with\n mild chest pain he has not had full relief but is vague about\n pain.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n HR in the 60\ns sinus with PVC\nS and runs of V tach. BP 110-140/80-90.\n Pt states pain gone shortly after arrival but returned around 0455 \n left side of chest pressure pain.\n Right groin site intact no hematoma or bleeding noted pt closed with\n angioseal.\n Action:\n EKG x3 during chest pain\n Nitro 0.3mg SL x2\n Pt receiving 1/2ns at 75cc/hr\n Labs sent no treatment required\n Bedrest maintained until 0200 as ordered.\n Pedal pulses and right groin site checked every hour x4\n Response:\n Chest pain resolved , pt voiding qs\n Tropin elevated to 3.95 and CK 1586\n Plan:\n Follow up EKG at 0700. check with pt frequently for chest pain\n"
},
{
"category": "Physician ",
"chartdate": "2149-03-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 528688,
"text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n Pre dinner GFS 188, nurse 8U.\n Started on sliding scale. Hemoglobin A1C 6.4.\n CE trending down.\n Echo showed Moderate regional left ventricular systolic dysfunction,\n c/w CAD. Mild mitral regurgitation. There is moderate regional left\n ventricular systolic dysfunction with edema and akinesis of the mid-\n and distal anterior wall, anterior septum and apex (mid-LAD territory),\n most c/w recent infarction.\n d/c nitro drip, SLNTG prn, could consider long acting nitrate.\n started on metoprolol 12. (may need , need ace in\n future)\n -ordered for PT consult for tomorrow\n -Med rec with ENT RE keflex.\n -PCP confirmed pt's dose of terazosin (hytrin): 2mg before bed.\n -call out to 3.\n Allergies:\n No Known Drug Allergies\n Last dose of :\n Cefazolin - 03:03 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:34 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.8\nC (96.5\n HR: 75 (59 - 92) bpm\n BP: 112/71(81) {105/69(80) - 160/89(106)} mmHg\n RR: 14 (12 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84.1 kg (admission): 80 kg\n Height: 67 Inch\n Total In:\n 2,470 mL\n PO:\n 960 mL\n TF:\n IVF:\n 1,510 mL\n Blood products:\n Total out:\n 3,610 mL\n 875 mL\n Urine:\n 3,610 mL\n 875 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,140 mL\n -875 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Gen: NAD\n Neck: bruise in right neck at site of lymph node biopsy\n CV: JVP not elevated. RRR. Normal s1, s2. No M/G/R.\n Pulm: CTAB anteriorly.\n Abd: +BS. Soft. NT/ND.\n Ext: No c/c/e, 2+ DP/PT bilaterally. No femoral bruits. Right groin\n catheterization site with clean dressing in place.\n Neuro: A+Ox3\n Labs / Radiology\n 173 K/uL\n 17.8 g/dL\n 119 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.6 mEq/L\n 10 mg/dL\n 104 mEq/L\n 136 mEq/L\n 53.6 %\n 8.9 K/uL\n [image002.jpg]\n 04:51 AM\n 08:52 AM\n 04:46 PM\n 03:07 AM\n WBC\n 8.8\n 8.9\n Hct\n 47.5\n 51.6\n 53.6\n Plt\n 175\n 195\n 187\n 173\n Cr\n 0.9\n 1.0\n 0.9\n TropT\n 3.95\n Glucose\n 125\n 119\n Other labs: PT / PTT / INR:12.2/26.2/1.0, CK / CKMB /\n Troponin-T:928/106/3.95, Ca++:9.7 mg/dL, Mg++:2.6 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 56 yo M with HTN and hypercholestolemia p/w chest pain, diagnosed with\n STEMI, now s/p emergent cath.\n .\n # STEMI: Patient exhibited ST elevations that resolved post-cath.\n Enzymes initially were negative but were elevated to trop 3.95. CK\n peaked at 1586 and is now trending down.\n - Continue ASA 325 daily, clopidogrel 75 daily, atorvastatin 80.\n - Add beta blocker today. Consider ACE-I tomorrow.\n - PT consult for STEMI.\n .\n # PUMP: Euvolemic. No signs or symptoms of heart failure.\n - Monitor I/Os\n - echo\n .\n # RHYTHM: Currently sinus. Had frequent ventricular ectopy including\n 8-beat runs of NSVT overnight.\n - Telemetry\n - replete lytes PRN\n .\n # HTN: Will start ACE-I and BB as above.\n .\n # HLD: Atorvastatin 80 mg daily\n .\n # Asthma/COPD: Albuterol and atrovent inhalers.\n .\n # BPH: Per last admission, was on terazosin.\n - Will confirm med list with family prior to restarting.\n .\n # s/p lymph node biopsy: Patient was on cephalexin prior to admission.\n - clarify with patient/family/patient\ns doctors and give\n for appropriate course\n ICU Care\n Nutrition: Cardiac\n Glycemic Control:\n Lines:\n 18 Gauge - 12:35 AM\n Prophylaxis:\n DVT: Heparin SQ\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full (confirmed)\n Disposition: Likely call out to 3\n"
},
{
"category": "Nursing",
"chartdate": "2149-03-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 528700,
"text": "Mr is a 56 yo male who was at home yesterday and developed\n substernal chest pain around 3pm. It continued into evening increasing\n in intensity until his family called EMS around 2200. Pain is described\n as a burning pressure and peaked at a where he could not get uot\n of bed. It was associated with diaphoresis, shortness of breath and\n radiating pain to right arm , back and neck. He arrived in the ED where\n a code STEMI was called he had EKG changes in leads II, III and IV. He\n was treated with ASA, Heparin, Integrellin, plavix and morphine and\n taken to the cath lab where his LAD was stented. Pt arrived stable with\n mild chest pain he has not had full relief but is vague about\n pain.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Alert and oriented x 3, MAE. Independent with ADLs. Denies pain and\n nausea at this time.\n NSR 70\ns, no ectopy noted. SBP 110-120. Afebrile. Strongly palpable\n pedal pulses bilaterally. Right groin with tegaderm CDI. HCT 53.6.\n Lungs clear bilaterally. O2 sat > 95% on RA.\n Abdomen soft, nd. BS positive. Tolerating regular diet.\n Voiding q shift in urinal. BUN/Cr 10/0.9.\n Blood glucose 100-120\n Skin CDI.\n Action:\n Remains on Lopressor, Aspirin, plavix, and simvastatin.\n OOB to chair and urinal.\n Tolerating po diet.\n Response:\n Hemodynamically stable.\n Plan:\n Transfer to floor.\n"
},
{
"category": "Nursing",
"chartdate": "2149-03-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 528703,
"text": "Mr is a 56 yo male who was at home yesterday and developed\n substernal chest pain around 3pm. It continued into evening increasing\n in intensity until his family called EMS around 2200. Pain is described\n as a burning pressure and peaked at a where he could not get out\n of bed. It was associated with diaphoresis, shortness of breath and\n radiating pain to right arm , back and neck. He arrived in the ED where\n a code STEMI was called he had EKG changes in leads II, III and IV. He\n was treated with ASA, Heparin, Integrellin, plavix and morphine and\n taken to the cath lab where his LAD was stented. Pt arrived stable with\n mild chest pain he has not had full relief but is vague about\n pain.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Alert and oriented x 3, MAE. Independent with ADLs. Denies pain and\n nausea at this time.\n NSR 70\ns, no ectopy noted. SBP 110-120. Afebrile. Strongly palpable\n pedal pulses bilaterally. Right groin with tegaderm CDI. HCT 53.6.\n Lungs clear bilaterally. O2 sat > 95% on RA.\n Abdomen soft, nd. BS positive. Tolerating regular diet.\n Voiding q shift in urinal. BUN/Cr 10/0.9.\n Blood glucose 100-120\n Skin CDI.\n Action:\n Remains on Lopressor, Aspirin, plavix, and simvastatin.\n OOB to chair and urinal.\n Tolerating po diet.\n Response:\n Hemodynamically stable.\n Plan:\n Transfer to floor.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n STEMI\n Code status:\n Height:\n 67 Inch\n Admission weight:\n 80 kg\n Daily weight:\n 84.1 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Asthma, COPD\n CV-PMH: Hypertension\n Additional history: Broken Jaw, gland removal from right neck ,\n Dyslipidemia, Chronic vertigo, BPH\n Surgery / Procedure and date: cardiac cath stent placed in LAD\n right femerol site closed with angioseal\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:120\n D:67\n Temperature:\n 97.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 75 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97 %\n O2 flow:\n FiO2 set:\n 24h total in:\n 24h total out:\n 875 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 03:07 AM\n Potassium:\n 4.6 mEq/L\n 03:07 AM\n Chloride:\n 104 mEq/L\n 03:07 AM\n CO2:\n 26 mEq/L\n 03:07 AM\n BUN:\n 10 mg/dL\n 03:07 AM\n Creatinine:\n 0.9 mg/dL\n 03:07 AM\n Glucose:\n 119 mg/dL\n 03:07 AM\n Hematocrit:\n 53.6 %\n 03:07 AM\n Finger Stick Glucose:\n 124\n 06:00 AM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: none\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash Amount: none\n Credit Cards: none\n Cash / Credit cards sent home with: none\n Jewelry: none\n Transferred from: cvicu a\n Transferred to: 316\n Date & time of Transfer: 0930\n"
},
{
"category": "Nursing",
"chartdate": "2149-03-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 528707,
"text": "Mr is a 56 yo male who was at home yesterday and developed\n substernal chest pain around 3pm. It continued into evening increasing\n in intensity until his family called EMS around 2200. Pain is described\n as a burning pressure and peaked at a where he could not get out\n of bed. It was associated with diaphoresis, shortness of breath and\n radiating pain to right arm , back and neck. He arrived in the ED where\n a code STEMI was called he had EKG changes in leads II, III and IV. He\n was treated with ASA, Heparin, Integrellin, plavix and morphine and\n taken to the cath lab where his LAD was stented. Pt arrived stable with\n mild chest pain he has not had full relief but is vague about\n pain.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Alert and oriented x 3, MAE. Independent with ADLs. Denies pain and\n nausea at this time.\n NSR 70\ns, no ectopy noted. SBP 110-120. Afebrile. Strongly palpable\n pedal pulses bilaterally. Right groin with tegaderm CDI. HCT 53.6.\n Lungs clear bilaterally. O2 sat > 95% on RA.\n Abdomen soft, nd. BS positive. Tolerating regular diet.\n Voiding q shift in urinal. BUN/Cr 10/0.9.\n Blood glucose 100-120\n Skin CDI.\n Action:\n Remains on Lopressor, Aspirin, plavix, and simvastatin.\n OOB to chair and urinal.\n Tolerating po diet.\n Response:\n Hemodynamically stable.\n Plan:\n Transfer to floor.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n STEMI\n Code status:\n Height:\n 67 Inch\n Admission weight:\n 80 kg\n Daily weight:\n 84.1 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Asthma, COPD\n CV-PMH: Hypertension\n Additional history: Broken Jaw, gland removal from right neck ,\n Dyslipidemia, Chronic vertigo, BPH\n Surgery / Procedure and date: cardiac cath stent placed in LAD\n right femerol site closed with angioseal\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:120\n D:67\n Temperature:\n 97.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 75 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97 %\n O2 flow:\n FiO2 set:\n 24h total in:\n 24h total out:\n 875 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 03:07 AM\n Potassium:\n 4.6 mEq/L\n 03:07 AM\n Chloride:\n 104 mEq/L\n 03:07 AM\n CO2:\n 26 mEq/L\n 03:07 AM\n BUN:\n 10 mg/dL\n 03:07 AM\n Creatinine:\n 0.9 mg/dL\n 03:07 AM\n Glucose:\n 119 mg/dL\n 03:07 AM\n Hematocrit:\n 53.6 %\n 03:07 AM\n Finger Stick Glucose:\n 124\n 06:00 AM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: none\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash Amount: none\n Credit Cards: none\n Cash / Credit cards sent home with: none\n Jewelry: none\n Transferred from: cvicu a\n Transferred to: 316\n Date & time of Transfer: 0930\n"
},
{
"category": "Nursing",
"chartdate": "2149-03-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 528590,
"text": "Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Pt A&Ox3, MAE. Primary language is Spanish but speaks English fluently.\n HR NSR no ectopy noted, sbp 110-140\ns, no gtts. LSCA on 2L NC, pulses\n palpable, bowel sounds present, skin intact. voiding\n Action:\n Pt out of bed to chair in evening\n Glucose treated per ss\n Tolerating increased lopressor dose\n Cath site normal, no hematoma noted\n Out of bed onto commode\n UOP adequate\n K repleated per order\n Pt denies pain this shift\n Response:\n Pt moves independently\n Glucose treated per ss, tolerating\n Tolerating lopressor dose increase\n Small bowel movement in evening\n Washed up independently\n Taking POs\n Resting comfortably\n Pt stayed on unit due to bed availability\n Plan:\n Transfer to 3 as soon as bed opens up\n"
},
{
"category": "Nursing",
"chartdate": "2149-03-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 528591,
"text": "Mr is a 56 yo male who was at home yesterday and developed\n substernal chest pain around 3pm. It continued into evening increasing\n in intensity until his family called EMS around 2200. Pain is described\n as a burning pressure and peaked at a where he could not get uot\n of bed. It was associalted with diaphoresis, shortness of breath and\n radiating pain to right arm , back and neck. He arrived in the ED where\n a code STEMI was called he had EKG changes in leads II, III and IV. He\n was treated with ASA, Heparin, Integrellin, plavix and morphine and\n taken to the cath lab where his LAD was Stented. Pt arrived stable with\n mild chest pain he has not had full relief but is vague about\n pain.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Pt A&Ox3, MAE. Primary language is Spanish but speaks English fluently.\n HR NSR no ectopy noted, sbp 110-140\ns, no gtts. LSCA on 2L NC, pulses\n palpable, bowel sounds present, skin intact. voiding\n Action:\n Pt out of bed to chair in evening\n Glucose treated per ss\n Tolerating increased lopressor dose\n Cath site normal, no hematoma noted\n Out of bed onto commode\n UOP adequate\n K repleated per order\n Pt denies pain this shift\n Response:\n Pt moves independently\n Glucose treated per ss, tolerating\n Tolerating lopressor dose increase\n Small bowel movement in evening\n Washed up independently\n Taking POs\n Resting comfortably\n Pt stayed on unit due to bed availability\n Plan:\n Transfer to 3 as soon as bed opens up\n"
},
{
"category": "Nursing",
"chartdate": "2149-03-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 528653,
"text": "Mr is a 56 yo male who was at home yesterday and developed\n substernal chest pain around 3pm. It continued into evening increasing\n in intensity until his family called EMS around 2200. Pain is described\n as a burning pressure and peaked at a where he could not get uot\n of bed. It was associalted with diaphoresis, shortness of breath and\n radiating pain to right arm , back and neck. He arrived in the ED where\n a code STEMI was called he had EKG changes in leads II, III and IV. He\n was treated with ASA, Heparin, Integrellin, plavix and morphine and\n taken to the cath lab where his LAD was Stented. Pt arrived stable with\n mild chest pain he has not had full relief but is vague about\n pain.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Pt A&Ox3, MAE. Primary language is Spanish but speaks English fluently.\n HR NSR no ectopy noted, sbp 110-140\ns, no gtts. LSCA on 2L NC, pulses\n palpable, bowel sounds present, skin intact. voiding\n Action:\n Pt out of bed to chair in evening\n Glucose treated per ss\n Tolerating increased lopressor dose\n Cath site normal, no hematoma noted\n Out of bed onto commode\n UOP adequate\n O2 off, sats 95-99%\n K repleated per order\n Pt denies pain this shift\n Response:\n Pt moves independently\n Glucose treated per ss, tolerating\n Tolerating lopressor dose increase\n Small bowel movement in evening\n Washed up independently\n Taking POs\n Resting comfortably\n Pt tolerating RA, sats 95-97%%\n Pt stayed on unit due to bed availability\n Plan:\n Transfer to 3 as soon as bed opens up\n"
},
{
"category": "Nursing",
"chartdate": "2149-03-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 528698,
"text": "Mr is a 56 yo male who was at home yesterday and developed\n substernal chest pain around 3pm. It continued into evening increasing\n in intensity until his family called EMS around 2200. Pain is described\n as a burning pressure and peaked at a where he could not get uot\n of bed. It was associated with diaphoresis, shortness of breath and\n radiating pain to right arm , back and neck. He arrived in the ED where\n a code STEMI was called he had EKG changes in leads II, III and IV. He\n was treated with ASA, Heparin, Integrellin, plavix and morphine and\n taken to the cath lab where his LAD was stented. Pt arrived stable with\n mild chest pain he has not had full relief but is vague about\n pain.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Alert and oriented x 3, MAE. Independent with ADLs. Denies pain and\n nausea at this time.\n NSR 70\ns, no ectopy noted. SBP 110-120. Strongly palpable pedal\n pulses bilaterally.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Echo",
"chartdate": "2149-03-18 00:00:00.000",
"description": "Report",
"row_id": 73815,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Myocardial infarction.\nHeight: (in) 67\nWeight (lb): 80\nBSA (m2): 1.37 m2\nBP (mm Hg): 126/72\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 14:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. Normal IVC\ndiameter (<2.1cm) with >55% decrease during respiration (estimated RA pressure\n(0-5mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderate regional LV\nsystolic dysfunction. No LV mass/thrombus. No resting LVOT gradient. No VSD.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nakinetic; mid anteroseptal - akinetic; anterior apex - akinetic; septal apex-\nakinetic; inferior apex - akinetic; apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels. No 2D\nor Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. The estimated\nright atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses and\ncavity size are normal. There is moderate regional left ventricular systolic\ndysfunction with edema and akinesis of the mid- and distal anterior wall,\nanterior septum and apex (mid-LAD territory), most c/w recent infarction. The\nremaining segments contract normally (LVEF = 30-35%). No masses or thrombi are\nseen in the left ventricle. There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. The diameters of\naorta at the sinus, ascending and arch levels are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets\nare structurally normal. Mild (1+) mitral regurgitation is seen. The estimated\npulmonary artery systolic pressure is normal. There is no pericardial\neffusion.\n\nIMPRESSION: Moderate regional left ventricular systolic dysfunction, c/w CAD.\nMild mitral regurgitation.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2149-03-18 00:00:00.000",
"description": "Report",
"row_id": 173461,
"text": "Sinus rhythm. Anterior myocardial infarction with ST-T wave configuration\nconsistent with acute/recent/in evolution process. Since the previous tracing\nof same date further precordial lead QRS and ST-T wave changes are present.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2149-03-18 00:00:00.000",
"description": "Report",
"row_id": 173462,
"text": "Sinus rhythm. Delayed R wave progression pattern suggests anterior myocardial\ninfarction of indeterminate age but clinical correlation is suggested. Since\nthe previous tracing of delayed R wave progression is more prominent.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2149-03-17 00:00:00.000",
"description": "Report",
"row_id": 173463,
"text": "Sinus rhythm. Delayed R wave progression. Modest right precordial lead\nST segment elevation. Low lateral limb lead T wave amplitude. Findings are\nnon-specific and tracing may be within normal limits but clinical correlation\nis suggested. Since the previous tracing of same date precordial lead ST-T wave\nchanges have decreased and lateral limb lead T wave amplitude is lower.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2149-03-17 00:00:00.000",
"description": "Report",
"row_id": 173464,
"text": "Sinus rhythm. Delayed R wave progression with ST-T wave configuration\nsuggesting acute anterior ischemic injury. Clinical correlation is suggested.\nSince the previous tracing of findings as outlined are now present.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-03-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1126945,
"text": " 10:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with chest pain\n REASON FOR THIS EXAMINATION:\n eval for ptx\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest single frontal view.\n\n CLINICAL INFORMATION: 56-year-old male with history of chest pain.\n\n COMPARISON: .\n\n FINDINGS: Single AP upright portable view of the chest was obtained. The\n lungs are clear without focal consolidation. No pleural effusion or\n pneumothorax is seen. The cardiac and mediastinal silhouettes are\n unremarkable. No overt pulmonary edema is present.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"
}
] |
66,162 | 175,541 | Pt was admitted to the Plastic Surgery Service on following radical resection of R neck mass and subsequent free TRAM flap w/ skin and nerve grafting. . POD#1 : Patient was admitted directly to Trauma ICU (TICU) from the operating room given lengthy surgery and precariousness of free flap. Flap head good capillary refill throughout ( sec) with small area at superior pole demonstrating sluggish refill and slight duskiness. Patient with continuous Vioptix monitoring of free flap. BP dipping to low 70s/40s with HR 100-120. Pt received multiple fluid boluses (~3.5L NS) and 1 unit albumin with some response but not sustained. Urine output remained high. In the setting of low BP, tachycardia, and HCT 19.9 (from 25.9) pt received 2 units of PRBCs with resolution of symptoms (one in am and one overnight). She remained intubated on propofol. . POD#2 Upper pole of free flap remained dusky with sluggish cap refill, 3-4 seconds. Pulses remained dopplerable in lower portion of flap. Donor site for STSG and recipient site continued to look healthy with good amount of oozing. Pt continued to require frequent fluid boluses to maintain HR < 100. BP 80-90/40s. Tolerating large amount of fluid with large urine output. Patient maintained on strict 'no roll' precautions given tenuousness of neck flap. Propofol was weaned and fentanyl increased to help with possible pain induced tachycardia and sedative induced hypotension. . POD#3 Patient remained in TICU. She was rolled to change bedding and inspected for pressure ulcers in am with plastics present and providing axial support of the neck. Pt did not tolerate the procedure well and sats dropped to high 80s with increased fluid oozing from around flap site. Vioptix replaced with maximum % in low 60s (94% sig quality) . POD#4 Right thigh STSG donor site was open to air and drying out well. Right lateral lower extremity sutures s/p sural nerve harvesting remained dry and intact. Flap with + doppler signal and vioptix stable. Patient remained intubated and on 'no roll precautions. A multipodus boot was applied to right foot to elevate heel off of bed and prevent foot drop. Abdominal steri strips remained dry and intact. A left brachial PICC line was placed to maintain long term access. A Dobhoff tube was placed so that patient could be started on tube feeds. . POD#5 Patient remained in TICU and was extubated and tolerated well. . POD#6 Patient remained in TICU and her neck JP drain was removed for low output. She was maintained on the heparin gtt for flap protection. The bolster over the central chest STSG site was removed, site appeared healthy and graft adherent and Xeroform dressing placed. An anterior neck hematoma had accumulated and was aspirated at bedside and iodoform gauze tape placed to wick wound. . POD#7 The anterior neck hematoma wick continued to drain moderate amount of bloody fluid. The abdominal JP drain was pulled. Chest PT and pulmonary toilet initiated. Patient was transfused 1 unit of PRBC's for HCT < 21. . POD#8 Abd JP site with large amount of serosang drainage leak, pressure dressing placed and oozing stopped. Patient transferred to floor today. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE QID initiated for eye protection due to inability to completely close eye. Occupational and Physical therapy initiated. Heparin gtt was discontinued. Heparin subcutaneous injections TID initiated. . POD#9 Posterior edge of flap with dehiscence of 2x4x1.5cm (indurated, but no purulence), wet to dry dressings initiated. Anterior neck with open wound (remained clean with some oozing, repacked loosely) & STSG with Xeroform dressings QD. R thigh donor site healing well. Right posterior lower leg with some eschar formation (3x3cm), no fluctuance, no drainage)-topical applied. Old abdominal drain site with decreased drainage. Patient OOB to chair with assist. Ipratropium Bromide Neb 1 NEB IH Q6H and Albuterol 0.083% Neb Soln 1 NEB IH Q6H initiated. . POD#10 Post edge of flap unchanged, wet to dry continued. Anterior neck wound more open laterally, packed with gauze. Foley was discontinued and patient began using bedside commode with assist. Nocturnal feeds at 100cc/hr 7p-7a (nutrition following). Patient with some episodes of diarrhea. . POD#11 Posterior flap area with open area...packed with W-D. Right inferior neck skin graft area dead and left open to air, no creams, ointments. Transverse open area (s/p hematoma I+D) base of neck: Packed with loose sterile gauze and covered. Xeroform QD to chest STSG site continued. RLE sutures intact. RLE posterior pressure ulcer from multipodus boot (?)-->Ordered softer posterior resting splint from orthotech. Calorie count initiated...pt with POOR po intake. Nocturnal TFs goal 100cc/hr x 12h continued. Lopressor 12.5 for tachycardia initiated. IV fluids discontinued and free water via NGT (800cc QD) initiated. Cefazolin IV discontinued and Flagyl initiated for continued and increasing episodes of diarrhea. C.diff stool testing ordered. Social Work consult requested for patient and family coping. Vioptix monitoring continued and flap checks Q4h continued. Patient agitated today...dilaudid discontinued and trial of oxycodone initiated. Occupational therapy working with patient on methods of taking PO nutrition. Patient transfused with 2 units of PRBCs for HCT < 21. . POD#12 Hemoglobin/hematocrit 10.3/31.2 s/p 2 units. Lopressor increased to 25mg for better control of heart rate. RLE lateral sutures by foot with para-incisional erythema and TTP. Some sutures removed and hematoma drained at bedside. Flap vioptix removed/discontinued. Psych consult-->for delirium, sundowning. Psych recommendations: d/c hydroxyzine, re-orient at night, initiate Haldol. Speech/swallow consult-->no mechanical reason patient is not eating. Santyl to posterior leg wound eschar area and boot from ortho tech-->Plantar fascia night splint with cloth lining for RLE. . POD#13 Agitation last PM despite Haldol. Psych recommendations-->Haldol 2.5mg QHS repeat dose x1 if still agitated and difficulty sleeping. Increased lopressor to 37.5 for improved rate control. RLE erythema and swelling around sutures improved. PO intake encouraged but continued poor appetite. . POD#14 Went to OR for debridement, STSG to scalp, gold weight Rt eye. + Pseudomonas UTI--->cipro 500 x 3 days. C.diff negative but continued to treat with flagyl PO. Diarrhea x 2. Protein shakes with trays: ordered Ensure plus shakes for lunch and dinner. Nocturnal tube feeds continued. Wound VAC to right face skin graft site. . POD#15/#1 Patient ambulated 2 times today with PT around part of floor with walker. PT recommended increased ROM exercises for R foot. Increased PO intake today. Nocturnal tube feeds continued. . POD#16/#2 Patient pulled out her Dobhoff overnight. Calorie counts continued and increased PO intake encouraged with good effect. Eschar debrided from R lateral ankle exposing a 1 cm deep hematoma that was washed out. Wound then packed with wet/dry dressing. VAC with clot at suction tip (lollipop). Excised and replaced with good suction. . POD#17/#3 Patient taking moderate amounts of POs. Calorie counts in progress. Pt ambulating QID. VAC holding adequate suction. . POD#18/#4 Patient continuing to increase PO intake, ambulating. . POD#19/#5 AVSS, wound VAC in place and patent to right face STSG site. Wet to wet dsg changes QID to neck wound. Bacitracin ointment to chest STSG site. Right thigh STSG donor site open to air. W-D dsg changes to 2 RLE wounds. Calorie ct continues with good PO intake. . POD#20/#6 VAC removed from R scalp. Underlying flap with healthy granulation tissue but STSG appears non-adherent and de-vitalized. Curisol gel and Adaptic applied over the R neck and scalp wounds , ensuring that both sites remain moist. PO intake stable (calories ~1400-1700 kcal/day), pt taking high calorie shakes as additional supplement. Flagyl discontinued, no further episodes of diarrhea x 5 days. . POD#21/#7 Pt wants to go home. Feels comfortable with daily activities/wound dressing changes with her daughter-in-law. Continues to eat regular meals with additional caloric supplements (ensure+). . At the time of discharge on POD#22/#8 (), the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Her right eye and face remain slack with the right eye hanging open (gold weight in place). Ointment well applied and covering the cornea. Her right scalp wound is well healing with good granulation. The aquacel and underlying tissue remain damp and there are no signs of further skin breakdown or infection. Suprasternal split thickness skin graft site is well healing and without signs of infection. Abdominal wounds are all but healed completely with no signs of cellulitis. R thigh is CDI with Xeroform dried to the most recent donor site (which will remain on until it falls off on its own). The R ankle wounds are clean and dry with wet/dry packing at the proximal and distal most wounds. All wounds have had sutures removed. | Left PICC position unchanged, junction of left brachicephalic and SVC. Cardiopulmonary findings unchanged. Left PICC line position is unchanged at the junction of the left brachiocephalic vein and SVC. Endotracheal tube remains in standard position. IMPRESSION: Left PICC best visualized up to the medial brachiocephalic vein, central positioning is not confirmed. FRONTAL VIEW, CHEST: Tip of the L PICC is best seen up to the medial left brachiocephalic vein, central extension is not visualized. Right neck clips/subQ gas expected. Endotracheal tube remains in good position. ET tube tip is in standard position and the tip is 4.2 cm above the carina. The visualized lung apices are unremarkable, other than curvilinear skin staples overlying the superior mediastinum. Cardiomediastinal contours are normal. IMPRESSION: Left PICC extending into the mid SVC. Irregularity of the right apical pleural margin corresponds to a markedly asymmetric tissue in that location, but documented on a chest CT, loaded or performed on , which should be evaluated in light of previous studies. The lungs are clear with the exception of minimal basilar atelectasis. AP FRONTAL RADIOGRAPH OF THE CHEST: The ET tube is terminating 4.5 cm above the carina. Examination is limited by patient positioning, with bony occiput and soft tissues overlying the upper neck. Left lung is clear to hyperinflation indicates substantial COPD. FINDINGS: In comparison with the earlier study of this date, there has been placement of a Dobbhoff tube with its metallic portion straddling the cardioesophageal junction. There is a paucity of bowel gas in the abdomen. Little change in the appearance of the heart and lungs. There is a left PICC extending up to the mid SVC. Heart and lungs are unchanged. Note was made that the surgery did not violate the peritoneal cavity. It is now coiled within the fundus, though the entire opaque portion of the tube is distal to the esophagogastric junction. 6:08 PM CHEST (PORTABLE AP) Clip # Reason: Eval position of tube. 4:36 AM ABDOMEN (SUPINE ONLY) IN O.R. FINAL REPORT HISTORY: Dobbhoff placement. FINAL REPORT HISTORY: Dobbhoff placement. ET tube in optimal position. There is mild architectural distortion from related underlying emphysema as noted on CT from . Rounded calcification is present in the soft tissues of the left neck. Curvilinear skin staples are seen overlying the right neck. Multiple curvilinear densities project over the mediastinum, none with the appearance of surgical needle or drain, and likely represent surgical staples. FINAL REPORT INDICATION: PICC line placement. UPPER ABDOMEN, ONE VIEW: Image includes the mid-lower chest and upper abdomen, with inferior margin projecting over the iliac crests. Examination is limited by patient positioning and slight underpenetration. Moderate degenerative disease is noted in the cervical spine. Heart size is normal. Heart size is normal. Lungs are clear without vascular congestion or pleural effusion. FINDINGS: In comparison with study of , there is little change. 9:59 PM CHEST (PORTABLE AP) Clip # Reason: Eval dobhoff placement. ET tube is terminating 4.5 cm above the carina. IMPRESSION: Somewhat limited exam, without radiographic evidence of retained surgical instruments (samples provided) within the imaged fields. Feeding tube ends in the stomach. Surgical clips are again seen in the upper chest. 5:34 AM CHEST (PORTABLE AP) Clip # Reason: interval change? Hilar contours are unremarkable. FINAL REPORT AP CHEST, 7:16 P.M., HISTORY: Right neck dissection and flap. 3:49 PM CHEST PORT. Surgical clips project in the upper-to-mid medial chest. Images of the missing needle and sponge (markers) were provided for comparison. NECK, ONE VIEW: Image includes the neck and upper chest. There is no pulmonary edema. No other short-term interval changes. No other short-term interval changes. Conventional frontal and lateral views would be helpful in that regard. IN O.R. Admitting Diagnosis: NON MELANOMA NEOPLASM OF THE FACE/SDA MEDICAL CONDITION: 56 year old woman with facial flap, remains intubated REASON FOR THIS EXAMINATION: interval change? The lungs are clear. FINDINGS: In comparison with the earlier study, the Dobbhoff tube has been pushed forward several centimeters. An endotracheal tube courses into the trachea and overlies the tissues of the left neck. There are surgical clips in the mediastinum. FINAL REPORT HISTORY: Intubation, to assess for atelectasis. WET READ: KKgc MON 9:59 PM Dobhoff tube ends in the proximal stomach, can be advanced by approx 5cm for optimal positioning.d/w TSICU team. Admitting Diagnosis: NON MELANOMA NEOPLASM OF THE FACE/SDA MEDICAL CONDITION: 56 year old woman s/p dobhoff placement REASON FOR THIS EXAMINATION: Eval position of tube. LINE PLACEMENT Clip # Reason: 50cm left picc, tip? There is no pneumothorax or pleural effusion. atelectasis? atelectasis? Dense calcific linear opacities in the left paraspinal region of the abdomen correspond to aortic calcifications on PET-CT. A surgical drain projects over the right abdomen, and a left femoral venous catheter courses in the left hemipelvis. | 8 | [
{
"category": "Radiology",
"chartdate": "2141-07-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1150065,
"text": " 5:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change? atelectasis?\n Admitting Diagnosis: NON MELANOMA NEOPLASM OF THE FACE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with facial flap, remains intubated\n REASON FOR THIS EXAMINATION:\n interval change? atelectasis?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubation, to assess for atelectasis.\n\n FINDINGS: In comparison with study of , there is little change.\n Endotracheal tube remains in standard position. Lungs are clear without\n vascular congestion or pleural effusion. Surgical clips are again seen in the\n upper chest.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-07-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1150234,
"text": " 9:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval dobhoff placement.\n Admitting Diagnosis: NON MELANOMA NEOPLASM OF THE FACE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with dobhoff placement\n REASON FOR THIS EXAMINATION:\n Eval dobhoff placement.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dobbhoff placement.\n\n FINDINGS: In comparison with the earlier study, the Dobbhoff tube has been\n pushed forward several centimeters. It is now coiled within the fundus,\n though the entire opaque portion of the tube is distal to the esophagogastric\n junction.\n\n Little change in the appearance of the heart and lungs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-07-17 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1150188,
"text": " 3:49 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Eval PICC position (please over penetrate as last study insu\n Admitting Diagnosis: NON MELANOMA NEOPLASM OF THE FACE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p PICC line placement\n REASON FOR THIS EXAMINATION:\n Eval PICC position (please over penetrate as last study insufficient to eval\n PICC)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: PICC line repositioning.\n\n AP FRONTAL RADIOGRAPH OF THE CHEST: The ET tube is terminating 4.5 cm above\n the carina. There is a left PICC extending up to the mid SVC. No other\n short-term interval changes.\n\n IMPRESSION: Left PICC extending into the mid SVC. No other short-term\n interval changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-07-14 00:00:00.000",
"description": "OO ABDOMEN (SUPINE ONLY) IN O.R. IN O.R.",
"row_id": 1149700,
"text": " 4:36 AM\n ABDOMEN (SUPINE ONLY) IN O.R. IN O.R. Clip # \n Reason: MISSING NEEDLE AND SPONGE\n Admitting Diagnosis: NON MELANOMA NEOPLASM OF THE FACE/SDA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old female post-facial tumor removal with abdominal flap,\n missing needle and sponge count.\n\n No prior examinations for comparison.\n\n Images of the missing needle and sponge (markers) were provided for\n comparison.\n\n NECK, ONE VIEW: Image includes the neck and upper chest. Examination is\n limited by patient positioning, with bony occiput and soft tissues overlying\n the upper neck. No definite radiopaque foreign bodies corresponding to the\n missing objects are seen in the surgical field.\n\n An endotracheal tube courses into the trachea and overlies the tissues of the\n left neck. Curvilinear skin staples are seen overlying the right neck.\n Rounded calcification is present in the soft tissues of the left neck. The\n visualized lung apices are unremarkable, other than curvilinear skin staples\n overlying the superior mediastinum. Moderate degenerative disease is noted in\n the cervical spine.\n\n UPPER ABDOMEN, ONE VIEW: Image includes the mid-lower chest and upper\n abdomen, with inferior margin projecting over the iliac crests. Examination\n is limited by patient positioning and slight underpenetration. No radiopaque\n foreign objects are identified corresponding to the imaged needle and sponge.\n Note was made that the surgery did not violate the peritoneal cavity.\n\n Multiple curvilinear densities project over the mediastinum, none with the\n appearance of surgical needle or drain, and likely represent surgical staples.\n\n\n Dense calcific linear opacities in the left paraspinal region of the abdomen\n correspond to aortic calcifications on PET-CT. A surgical drain projects over\n the right abdomen, and a left femoral venous catheter courses in the left\n hemipelvis. There is a paucity of bowel gas in the abdomen.\n\n IMPRESSION:\n\n Somewhat limited exam, without radiographic evidence of retained surgical\n instruments (samples provided) within the imaged fields. This was discussed by\n Dr. with Dr. by telephone on at 4:50 a.m.\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-07-17 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1150169,
"text": " 3:04 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 50cm left picc, tip?\n Admitting Diagnosis: NON MELANOMA NEOPLASM OF THE FACE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with new picc\n REASON FOR THIS EXAMINATION:\n 50cm left picc, tip?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: PICC line placement.\n\n COMPARISON: .\n\n FRONTAL VIEW, CHEST: Tip of the L PICC is best seen up to the medial left\n brachiocephalic vein, central extension is not visualized. ET tube is\n terminating 4.5 cm above the carina. There are surgical clips in the\n mediastinum.\n\n The lungs are clear with the exception of minimal basilar atelectasis. There\n is no consolidation, pleural effusion, or pneumothorax. There is no pulmonary\n edema. Heart size is normal. Hilar contours are unremarkable. There is mild\n architectural distortion from related underlying emphysema as noted on CT from\n .\n\n IMPRESSION: Left PICC best visualized up to the medial brachiocephalic vein,\n central positioning is not confirmed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-07-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1149968,
"text": " 7:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o atelectasis/collapse\n Admitting Diagnosis: NON MELANOMA NEOPLASM OF THE FACE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old womans/p paroidectomy\n REASON FOR THIS EXAMINATION:\n r/o atelectasis/collapse\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Status post thyroidectomy.\n\n Cardiomediastinal contours are normal. ET tube tip is in standard position\n and the tip is 4.2 cm above the carina. The lungs are clear. There is no\n pneumothorax or pleural effusion. Surgical clips project in the upper-to-mid\n medial chest.\n\n IMPRESSION: No evidence of atelectasis or pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-07-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1151254,
"text": " 7:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pneumonia\n Admitting Diagnosis: NON MELANOMA NEOPLASM OF THE FACE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with R neck disection/free TRAM flap now with increasing WBC\n REASON FOR THIS EXAMINATION:\n ?pneumonia\n ______________________________________________________________________________\n WET READ: RSRc TUE 1:43 AM\n No pneumonia; artifact somewhat limits eval of right chest. Right neck\n clips/subQ gas expected. Feeding tube in stomach. 1a .\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:16 P.M., \n\n HISTORY: Right neck dissection and flap. Increasing white count. Suspect\n pneumonia.\n\n IMPRESSION: AP chest compared to :\n\n Greater opacification in the right lower lung generally raises concern for\n pleural effusion or pneumonia in the lower lobe. There is artifact from\n overlying bandaging which could simulate these findings. Conventional frontal\n and lateral views would be helpful in that regard. Left lung is clear to\n hyperinflation indicates substantial COPD. Heart size is normal. Feeding\n tube ends in the stomach. Irregularity of the right apical pleural margin\n corresponds to a markedly asymmetric tissue in that location, but documented\n on a chest CT, loaded or performed on , which should be evaluated\n in light of previous studies.\n\n Dr. and I discussed these findings.\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-07-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1150214,
"text": " 6:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval position of tube.\n Admitting Diagnosis: NON MELANOMA NEOPLASM OF THE FACE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p dobhoff placement\n REASON FOR THIS EXAMINATION:\n Eval position of tube.\n ______________________________________________________________________________\n WET READ: KKgc MON 9:59 PM\n Dobhoff tube ends in the proximal stomach, can be advanced by approx 5cm for\n optimal positioning.d/w TSICU team. Left PICC position unchanged, junction of\n left brachicephalic and SVC. ET tube in optimal position. Cardiopulmonary\n findings unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dobbhoff placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a Dobbhoff tube with its metallic portion straddling the\n cardioesophageal junction. It should be advanced by at least 5 cm. Left PICC\n line position is unchanged at the junction of the left brachiocephalic vein\n and SVC. Endotracheal tube remains in good position. Heart and lungs are\n unchanged.\n\n\n"
}
] |
18,618 | 188,110 | The patient was admitted for evaluation of her vague abdominal pain as well as worsening of her shortness of breath. The patient ruled out for myocardial infarction by serial cardiac enzymes. Evaluation of her shortness of breath with her history of congestive heart failure eventually yielded catheterization. Cardiac catheterization showed an ejection fraction of approximately 35% with moderate to severe mitral regurgitation. There was also noted to be a right coronary artery system with only mild disease of the left anterior descending and left circumflex. The patient did also have an elevated left ventricular end diastolic pressure. Thoracic Surgery was called to evaluate the patient and per the patient's severe mitral regurgitation the patient was taken to the Operating Room on . At that time she had a mitral valve repair which she tolerated well. In the postoperative period she was taken to the CSRU for closure monitoring. The patient was extubated on the evening of postoperative day #0. The patient was begun on Amiodarone drip for some occasional ectopy. The Heart Failure Service was consulted for the patient's congestive heart failure. ACE inhibitor was increased as tolerated and the patient was actively and aggressively diuresed. Milrinone was weaned off. On postoperative day #3, the patient's chest tubes were discontinued and invasive monitoring was also discontinued. The patient otherwise had a fairly unremarkable course and was transferred to the floor on postoperative day #6. Her main issues again remained active diuresis as well as increasing of her ACE inhibitor. The patient was begun on Lopressor 12.5 mg b.i.d. but did not tolerate this over a 24 hour period with worsening of shortness of breath. This is felt to be likely due to her underlying asthma. Lopressor was discontinued and Captopril was again increased. The patient was then subsequent transfused 1 unit of blood on the evening of postoperative day #7. This was done for a hematocrit of 28.8 and congestive heart failure. Ultimately the patient was discharged on postoperative day #8 tolerating a regular diet, adequate pain control and p.o. pain medications and having been cleared for home discharge by Physical Therapy. | encouraged to cdb/use is q1h. cont milrinone/amio gtts. encourage cdb/is q1h. 1uprbc given. MILRINONE D/C'D. d+i. Milrinone and amiodarone gtts infusing.PULM: 2L/NC. CHECK K/HCT AFTER DIURESIS. CONTINUES ON MILRINONE. D/C THIS AM. d'line today and d/c milrinone. +2 LE edema. amiodorone bolus ^ followed by gtt at 1 mg/m. NEURO: A+O. neo weaned to off. HCT STABLE. tolerating po's. TOLERATING PO'S. tol po's well. ci~2.0. Pao2 good. + bowel sounds.integ original chest dsg d+i ct's with dsg. k+ & ca repleated. sbp>130 started on captopril. tx bs with ssri. faint rales noted at right base. I&O. MAG + K TO BE REPLACED. HCT STABLE THIS AM. X2 LG BM. Afebrile. NC CONTINUES @ 2L/MIN. pt. SBP 110-120 NOW ON 37.5 MG CAPTOPRIL TID. +PP BILATERALLY. USING IS & CDB WITH ENCOURAGEMENT.GI/GU: +BS. Tolerating increased captopril dose. DSG CHANGED TO OLD CT SITE C+D. recal pending this am. MONITOR SVO2/CCO. U/O <30cc/hr . Does seem slightly dyspneic on exertion.GI: Abd soft, + BS. BP stable. MAE w/ equal strength.CV: HR 80-90's NSR. co/ci good. Incision OTA with binder in place. Monitor WBC. ^ing amts of pac's. sbp<90 after bolus requiring neo. restarted milrinone 3mg bolus given & then 0.25mcg/kg/min. percocet 2 tabs given at 1200 with good effect. LASIX 10MG IV BID STARTED. SBP 100'S-130'S. CI >2. CA REPLEATED.RESP: LUNGS CLEAR BUT DIMINISHED AT BASES. CSRU NPNNeuro: Alert and oriented x 3. SBP 140-160's. PASSING FLATUS. SHIFT UPDATE:NEURO: A&O X3. TRANSFERING TO COMMODE WITH MINIMAL ASSIST. h.o made aware and states 20cc/hr acceptable uop. sternal & ct dsg intact with old staining. RESP: IS WITH ENCOURAGEMENT, DB+C WITHOUT RAISING.BS DIMINISHED BIBASILAR, CLEAR UPPER , RR 16-20'S INCREASED TO 30'S WITH EXERTION.OOB AMB WITH PT TOLERATED FAIRLY WELL, SBP 170'S,RETURNED TO 130'S WITH REST. ?? MILIRONE AT /125MCG/KG/MIN ? PACER OFF. BP LOWERED ON INCREASING DOSES OF CAPTOPRIL. Captopril po 6.25mg x 3. nsr no ectopy bp stable now on po captopril.gi/gu foley marginal uop. oob to chair this am and pt. CONTINUES ON .125 MCQ MILRINONE, CI PRIOR TO DC SWAN >2. chest tube output minimal, SVO254 to 56.RESP: NC at 4L with O2 sats99%, lungs clear upper lobes and dim bilatbasesGI: Abd large, hypoactive BSGU: Foley to gravity draining <30cc hr. ? ? ? ? encourage mobiltiy/independance where appropriate. MAE. Passed gas, no BM.ENDO: BG WNL.SKIN: Dsg's have serosang fluid, intact. oob->chair with assist of 2.cardiac: nsr. SVO2 ^60-70S. LASIX 40MG IV GIVEN @ 1710 WHEN #1PRBC COMPLETED. using is when awake and good cough effort. cont on amio gtt at 0.5mg/min. HR 80-90'S. TRANSFER TO 2 IN AM. sat's>97% on 2l nc. Another captopril dose just given, will re-eval in hour or two (BP), diuresis. PLAN TO DC GTT TOMORROWN AND REMOVE CCO CATHETER.BREATHSOUNDS DIMINISHED @ BASES WITH SOME BASILAR CRACKLES NOTED. SS INSULIN GIVEN.72HR STERNAL DSG REMOVED. SAts 99-100%. CO 6-6.7 CURRENTLY. Neuro: pt awake, alert and oriented x3, MAE, follows commands.CV: heartrate 89 NSR, continues on amiodarone, neo for MAP 60 to 65CI>2, PAD 26, CVP 16. The right ventricular free wall ishypertrophied. Mild tricuspid [1+] regurgitation is seen. There are noechocardiographic signs of tamponade.Conclusions:The left atrium is mildly dilated. There ismoderate pulmonary artery systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation.PERICARDIUM: There is a small pericardial effusion. Left ventricular wall thicknesses arenormal. The left ventricular cavity is moderately dilated. There is a small pericardialeffusion. There is severeglobal left ventricular hypokinesis. The leftventricular cavity is moderately dilated. Sinus tachycardiaSeptal ST elevation - repeat if myocardial injury is suspectedAnterior T wave changes are nonspecificSince previous tracing of ,the voltage has decreased There is a right IJ Swan with tip in the pulmonary outflow tract. There is a small left apical pneumothorax. Right ventricularsystolic function is borderline normal. The right ventricular cavity is dilated. There is nomitral valve prolapse. FINDINGS: The left chest tube has been removed. Right ventricular systolic function isborderline normal.AORTA: The aortic root is normal in diameter. There ismoderate pulmonary artery systolic hypertension. LESS DRAMATIC DROPS WITH SVO2'S WITH MOVEMENT TO THE COMMODE. The mitral valve supporting structures are normal.Moderate to severe (3+) mitral regurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are normal. Sinus rhythmPossible left ventricular hypertrophyDiffuse ST-T abnormalitiesSince previous tracing of , no significant change IMPRESSION: Probable left effusion and atelectasis in technically limited study. The cardiac and mediastinal contours are prominent but stable. IMPRESSION: Decreased left effusion. The rightventricular cavity is dilated. The sternal wires, cutaneous staples and epicardial pacing wires are noted. K/ICA NORMAL. The ascending aorta is normal indiameter. There is volume loss in the left mid-lung and left lower lobe with some air bronchograms. Sinus rhythm. The left pleural effusion is unchanged. The aortic arch is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic regurgitation.MITRAL VALVE: The mitral valve leaflets are mildly thickened. The cardiac silhouette continues to be moderately enlarged. Diffuse non-specific ST-T wave flattening. The aortic valve leaflets (3) appearstructurally normal with good leaflet excursion and no aortic regurgitation.The mitral valve leaflets are mildly thickened. PATIENT/TEST INFORMATION:Indication: Congestive heart failure.Height: (in) 66Weight (lb): 296BSA (m2): 2.36 m2BP (mm Hg): 172/79HR (bpm): 90Status: InpatientDate/Time: at 11:12Test: TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. Sinus arrhythmiaExtensive T wave changes may be due to myocardial ischemiaSince previous tracing , anterior and inferior ST-T wave abnormalitiesmore marked Moderate to severe (3+) mitral regurgitation is seen. ST-T wave flattening in leads I and aVL. Sinus rhythmNonspecific ST-T abnormalitiesSince previous tracing of , no significant change The left hemithorax is extensively opacified, likely due to effusion and atelectasis. There is subsegmental atelectasis in the left lower lobe. BS TREATED WITH SSINSULIN. These findings areconsistent with acute inferolateral ischemic process. There is notriscupid stenosis. The right lung is grossly clear, but evaluation is limited due to patient motion and body habitus. | 25 | [
{
"category": "Nursing/other",
"chartdate": "2107-03-11 00:00:00.000",
"description": "Report",
"row_id": 1507177,
"text": "shift update:\n\nneuro: lethargic but easily arrousable. c/o pain med with percocet 2tabs at 8a->cont to c/o pain at 0830 mso4 2mg iv given with good effect. percocet 2 tabs given at 1200 with good effect. mae with encouragement. pt requires encouragement to feed self. oob->chair with assist of 2.\n\ncardiac: nsr. no ectopy. cont on amio gtt at 0.5mg/min. svo2 45. recal done=>42%. restarted milrinone 3mg bolus given & then 0.25mcg/kg/min. 1uprbc given. svo2>50. sbp<90 after bolus requiring neo. neo weaned to off. sbp>130 started on captopril. ci~2.0. sternal & ct dsg intact with old staining. ct drainage minimal. k+ & ca repleated. pacer attached but off.\n\nresp: lungs clear but diminished at bases. sat's>97% on 2l nc. encouraged to cdb/use is q1h. expectorating thick yellow sputum.\n\ngi/gu: +bs. tolerating po's. uop<30cc/hr after prbc>30cc/hr.\n\nendo: bs covered with ss reg insulin per protocol.\n\nplan: pain management. cont to monitor hemodynamics. cont milrinone/amio gtts. encourage cdb/is q1h. encourage mobiltiy/independance where appropriate. tx bs with ssri.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-11 00:00:00.000",
"description": "Report",
"row_id": 1507178,
"text": "CV: NSR, no ectopy. Atrial and vent pacing wires attached to pacer, pacer turned off. Afebrile. SBP 140-160's. Captopril po 6.25mg x 3. SVO2 48-52%, drops to low 30's with activity. CI >2. Milrinone and amiodarone gtts infusing.\n\nPULM: 2L/NC. Pao2 good. SAts 99-100%. Lungs clear. Strong cough.\n\nNEURO: Alert, oriented. Percocet for pain control.\n\nGU: Foley, lasix given with good response.\n\nGI: Ate custard, milk for dinner. Passed gas, no BM.\n\nENDO: BG WNL.\n\nSKIN: Dsg's have serosang fluid, intact. OOB in chair when report received, assisted back to bed.\n\nDr. consulted on pt, see notes in chart. Feels SVO2 may be inaccurate due to good CI, good sats, pt \"looks good\".\n\nPLAN: Pulm toilet. Milrinone gtt until tomorrow. Another captopril dose just given, will re-eval in hour or two (BP), diuresis.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-12 00:00:00.000",
"description": "Report",
"row_id": 1507179,
"text": "neuro: Alert and oriented. med x 2 with percocet for pain.\ncv/resp 2l np pt. has difficulty breathing in the bed and appears to be grunting in her sleep. o2 sats stable and breath sounds clear. oob to chair this am and pt. states she's more comfortable breathing. reclined in chair. using is when awake and good cough effort. nsr no ectopy bp stable now on po captopril.\ngi/gu foley marginal uop. h.o made aware and states 20cc/hr acceptable uop. no stools. tol po's well. + bowel sounds.\ninteg original chest dsg d+i ct's with dsg. d+i.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-12 00:00:00.000",
"description": "Report",
"row_id": 1507180,
"text": "plan today. increase mobility. pt. does well with 2 assist needs a lot of help due to the lines. ? d'line today and d/c milrinone. co/ci good. svo2 still low. recal pending this am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-13 00:00:00.000",
"description": "Report",
"row_id": 1507185,
"text": "S/P MITRAL VALVE ANNUPLASTY\nS: \"I NEED MY PAIN MEDICINE\"\nO: CARDIAC: SR WITH RARE ISOLATED PVC'S NOTED, K 4.2 TO RECIEVE 20 MEQ KCL . SBP 100'S-130'S. CONTINUES ON .125 MCQ MILRINONE, CI PRIOR TO DC SWAN >2. CAPTOPRIL INCREASED TO 37.5 MG TOLERATED WELL. DSG CHANGED TO OLD CT SITE C+D. STERNAL INCISION C+D WITHOUT DRAINAGE.PP PALP, FEET WARM TO TOUCH. MAG + K TO BE REPLACED. HCT STABLE.\n RESP: IS WITH ENCOURAGEMENT, DB+C WITHOUT RAISING.BS DIMINISHED BIBASILAR, CLEAR UPPER , RR 16-20'S INCREASED TO 30'S WITH EXERTION.OOB AMB WITH PT TOLERATED FAIRLY WELL, SBP 170'S,RETURNED TO 130'S WITH REST.\n NEURO: A+O. PLEASANT+CALM.\n GI: GOOD APPETITE, NO STOOL TODAY, PASSING FLATUS, ZANTAC X1.\n GU: VOIDED 250 ML X2, RECIEVED 20 MG PO LASIX.\n PAIN: 2 PERCOCET X3 FOR INCISIONAL DISCOMFORT.\n ENDO: GLUCOSE <143 THROUGHOUT THE DAY.\n SOCIAL: RELATIVES INTO VISIT THROUGHOUT THE DAY.\nA: STABLE\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, DSGS, RESP STATUS-PULM STATUS,NEURO STATUS, I+O, LABS, TO PER ORDERS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-14 00:00:00.000",
"description": "Report",
"row_id": 1507186,
"text": "PATIENT SLEEPING PEACEFULLY IN THE CHAIR. SBP 110-120 NOW ON 37.5 MG CAPTOPRIL TID. MILIRONE AT /125MCG/KG/MIN ??? D/C THIS AM. HCT STABLE THIS AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-14 00:00:00.000",
"description": "Report",
"row_id": 1507187,
"text": "PATIENT SLEEPING MORE SOUNDLY AS NIGHT PROGRESSED GIVEN 2 PERCCOET IN AM. PLAN TO DC MILIRONE, INCREASE CAPTOPRIL TO 50MG TID. ???LASIX INCREASE NEEDS MORE DIURESIS.ENCOURAGE INCREASED ADLS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-14 00:00:00.000",
"description": "Report",
"row_id": 1507188,
"text": "SHIFT UPDATE:\n\nNEURO: A&O X3. MAE. TRANSFERING TO COMMODE WITH MINIMAL ASSIST. AMB IN TOLERATED WELL. C/O INCISIONAL PAIN MED WITH PERCOCET 2 TABS WITH GOOD EFFECT.\n\nCARDIAC: NSR W/RARE PVC'S. HR 80-90'S. MILRINONE D/C'D. CAPTOPRIL INCREASED TO 50MG TID. EPI WIRES ATTACHED TO PACER. PACER OFF. +PP BILATERALLY. CA REPLEATED.\n\nRESP: LUNGS CLEAR BUT DIMINISHED AT BASES. SAT'S>94% ON RA. USING IS & CDB WITH ENCOURAGEMENT.\n\nGI/GU: +BS. TOLERATING PO'S. X2 LG BM. LASIX DOSE INCREASED TO 20MG IV BID. VOIDING ON COMMODE.\n\nENDO: BS<130.\n\nSOCIAL: FAMILY INTO VISIT->VERY INVOLVED IN PT CARE.\n\nPLAN: MONITOR HEMDYNAMICS. I&O. MONITOR LABS. PAIN MANAGEMENT. ENCOURAGE MOBILITY. TRANSFER TO 2 IN AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-15 00:00:00.000",
"description": "Report",
"row_id": 1507189,
"text": "CSRU NPN\n\nNeuro: Alert and oriented x 3. MAE w/ equal strength.\n\nCV: HR 80-90's NSR. Occasional PVC noted on alarm review early in shift, none noted overnight. BP stable. Tolerating increased captopril dose. +2 LE edema. Pt feels leg swelling is improving.\n\nResp: BS diminished at lower lobes bilat. ? faint rales noted at right base. O2 sats 93% or greater on RA. Does seem slightly dyspneic on exertion.\n\nGI: Abd soft, + BS. No BM this shift.\n\nGU: Received first dose of increased lasix (40mg) at . Voiding on commode in adequate amts.\n\nEndo: Covered w/ SSRI for glucose 139 at 2200.\n\nID: Afebrile. WBC elevated yesterday morning. Will send CBC this am.\n\nSkin: Staples at chest incision clean and dry. Incision OTA with binder in place. Skin otherwise intact.\n\nComfort: Moves well with commode to chair activity. Prefers to sleep in chair for comfort. Med w/ percocet for incisonal pain w/ good effect.\n\nSocial: Family in visiting this evening.\n\nA: Hemodynamically stable.\n\nP: Meds as ordered. Increase activity as tolerated. Monitor WBC. Glucose control. Transfer to 2 today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-09 00:00:00.000",
"description": "Report",
"row_id": 1507174,
"text": "50 year old female admitted at ~1240 from or s/p mv annuloplasty. Intubated and sedated with iv propofol. Ct's dry. Iv milranone infusing at .25.\nNeuro: Iv propofol dc'd, patient reversed, mae, following commands.\nCardiac: Mp sr upon admission, became tacky, decreased with fluid. ^ing amts of pac's. amiodorone bolus ^ followed by gtt at 1 mg/m. Pac's have decreased. Milranone ^ to .5 due to co/ci, 1800 decreased to .5, will follow svo2.\nResp: Cs diminished, suctioned orally for moderate bldy. patient weaned to cpap with 20 pressure support. Plan is to extubate asap.\nGI: Og tube in place, patent for minimal bilious.\nGU: Foley patent for large amts clear yellow.\nENDO: Insulin gtt ^, protocol being followed.\nFamily in.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-09 00:00:00.000",
"description": "Report",
"row_id": 1507175,
"text": "UPDATE\nNEURO: NO CHANGE.\nCARDIAC: SVO2 DROPS WHEN TURNED TO 45, RISES TO MID TO HIGH 50'S WITH REST. AMIODORONE DECREASED TO .5M/M AT 2230. MP SR WITHOUT. CHESTBINDER ON.\nRESP: EXTUBATED AT , NP'S AT 4 LITERS. UNABLE TO DO SPIROCARE AT THIS TIME. STRONG NON PRODUCTIVE COUGH.\nGI: TAKING ICE CHIPS, TOLERATING WELL.\nGU: URINE HAS DECREASED TO 25-40 CC QH, DARKER AMBER URINE.\nENDO: INSULIN GTT AT 11 UNITS QH, FOLLOWING PROTOCOL.\nFAMILY IN\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-10 00:00:00.000",
"description": "Report",
"row_id": 1507176,
"text": "Neuro: pt awake, alert and oriented x3, MAE, follows commands.\n\nCV: heartrate 89 NSR, continues on amiodarone, neo for MAP 60 to 65\nCI>2, PAD 26, CVP 16. U/O <30cc/hr . chest tube output minimal, SVO2\n54 to 56.\n\nRESP: NC at 4L with O2 sats99%, lungs clear upper lobes and dim bilat\nbases\n\nGI: Abd large, hypoactive BS\n\nGU: Foley to gravity draining <30cc hr. amber urine\n\nEndocrine: She was on an Insulin gtt most of the night, but that is off now and she is having blood sugars covered by insulin protocol\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-12 00:00:00.000",
"description": "Report",
"row_id": 1507181,
"text": "POD #3 MV ANNULOPLASTY\nNSR, NO ECTOPICS. CCO CONTINUES IMPROVING WITH PRBC INFUSING. SVO2 ^60-70S. CO 6-6.7 CURRENTLY. BP LOWERED ON INCREASING DOSES OF CAPTOPRIL. APPROXIMATE 10MMHG DIFFERENCE IN NBP AND RADIAL ALINE PRESSURE. CONTINUES ON MILRINONE. PLAN TO DC GTT TOMORROWN AND REMOVE CCO CATHETER.\n\nBREATHSOUNDS DIMINISHED @ BASES WITH SOME BASILAR CRACKLES NOTED. NC CONTINUES @ 2L/MIN. NO WHEEZES NOTED. LASIX 10MG IV BID STARTED. LASIX 40MG IV GIVEN @ 1710 WHEN #1PRBC COMPLETED. TO RECEIVE ADDITIONAL 40MG IV AFTER #2 PRBC COMPLETES. MEDIASTINAL AND L PLEURAL CT (LATERAL SITE) CD'D EARLIER.\n\nTOLERATING FOOD AND FLUIDS. OOB TO COMMODE AND CHAIR SEVERAL TIMES. SITS ON COMMODE FOR ABOUT 1HR AT A TIME. PASSING FLATUS. REQUESTED AND GIVEN PRUNE JUICE AND RAISINS FOR CONSTIPATION.\n\nSLIGHTLY ELEVATED BS. SHE DENIES HAVING DIABETES AND STATES THAT HER PRIMARY MD TOLD HER SO. SHE ALSO STATES THAT HER MOTHER, BROTHER ...HAVE DIABETES. SS INSULIN GIVEN.\n\n72HR STERNAL DSG REMOVED. SOME ECCHYMOSIS AT BASE OF STERNAL STAPLES. CHEST BINDER PLACED BACK ON HER FOR MAMMARY SUPPORT.\n\nALERT AND ORIENTED. PERCOCET GIVEN FOR PAIN.\n\nFAMILY MEMBERS IN VISITING.\n\nPLAN TO GIVEN ADDITIONAL LASIX AFTER #2PRBC. CHECK K/HCT AFTER DIURESIS. MONITOR SVO2/CCO. PT PREFERS TO SIT IN THE CHAIR RATHER BED. ALLOW TO GET UP TO THE COMMODE WITH NURSING ASSISTANCE D/T PA CATHETER. NEED HIGHER DOSE OF CAPTOPRIL.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-13 00:00:00.000",
"description": "Report",
"row_id": 1507182,
"text": "PATIENT SLEEPING IN CHAIR AFTER HAVING 2LARGE SOFT BM, GOOD DIURESIS AS WELL.POSTTRANSFUSION HCT 33. K/ICA NORMAL. BS TREATED WITH SSINSULIN. PATIENT COMFORTABLE AFTER 2 PERCOCET GIVEN. MILIRONE AT .25MCG/KG/MIN WITH GREAT CO, CAPTOPRIL INCREASED TO 25MG Q8HRS. WITH GOOD RESULTS.PATIENT REQUEST TO KEEP LIGHTS ON WHILE SLEEPING\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-13 00:00:00.000",
"description": "Report",
"row_id": 1507183,
"text": "PATIENT REQUESTING PERCOCET WITH MOVEMENT INCREASED INCICSIONAL PAIN. WITH 4AM CAPTOPRIL SBP INTO THE 80'S. ???VULEZ IN REGARDS TO D/C MILIRONE, AWAITING RECAL OF CI/CO.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-13 00:00:00.000",
"description": "Report",
"row_id": 1507184,
"text": "PATIENT WITH GOOD NIGHT SLEEP IN THE CHAIR. LESS DRAMATIC DROPS WITH SVO2'S WITH MOVEMENT TO THE COMMODE. CO GREAT THRU THE NIGHT WITH SVO2 IN THE 60-70 RANGE. GOD DIURSIS WITH LASIX AFTER 2UPRBC GIVEN ON EVES. HCT 30 THIS AM, PERVULEZ NO TRANSFUSION AT THIS TIME. SBP IN THE 100-120 NOW ON CAPTOPRIL 25MG TID. DISCUSSED WITH VULEZ IN REGARDS TO D/C MILIRONE BUT ON HOLD FOR NOW. PERCOCET 2TABS GIVEN APPROX. Q4-6HRS WITH GOOD RELIEF.\n"
},
{
"category": "Radiology",
"chartdate": "2107-03-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 782206,
"text": " 12:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p chest tube d/c; post op\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with h/o asthma and HTN whom presents with CP, SOB,\n epigastric and RUQ pain s/p mitral valve repair\n REASON FOR THIS EXAMINATION:\n s/p chest tube d/c; post op\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW \n\n HISTORY: Mitral valve repair, status-post chest tube removal. Reference exam\n .\n\n FINDINGS: The left chest tube has been removed. There is a small left apical\n pneumothorax. The cardiac silhouette continues to be moderately enlarged.\n There is volume loss in the left mid-lung and left lower lobe with some air\n bronchograms. There is a right IJ Swan with tip in the pulmonary outflow\n tract. The left pleural effusion is unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-03-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 782040,
"text": " 7:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG w/tachypnea\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with as above\n REASON FOR THIS EXAMINATION:\n s/p CABG w/tachypnea\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tachypnea S/P CABG.\n\n PORTABLE CHEST: Comparison is made to . The patient is rotated\n slightly towards the right. There are new sternal wires, cutaneous staples and\n mediastinal drain. The tip of the SG catheter is likely in the right main\n pulmonary artery. The left hemithorax is extensively opacified, likely due to\n effusion and atelectasis. The right lung is grossly clear, but evaluation is\n limited due to patient motion and body habitus.\n\n IMPRESSION: Probable left effusion and atelectasis in technically limited\n study. Repeat exam recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-03-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1260472,
"text": " 9:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: EVAL LUNGS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P CABG.\n\n PORTABLE CHEST: Comparison is made to .\n\n The sternal wires, cutaneous staples and epicardial pacing wires are noted.\n The tip of the Swan-Ganz catheter is in the right main pulmonary artery. The\n cardiac and mediastinal contours are prominent but stable. A catheter has\n been placed in the left pleural space, with subsequent decrease in the large\n left pleural effusion present two hours earlier. There is no definite CHF.\n There is subsegmental atelectasis in the left lower lobe.\n\n IMPRESSION: Decreased left effusion. No pneumothorax.\n\n"
},
{
"category": "Echo",
"chartdate": "2107-03-03 00:00:00.000",
"description": "Report",
"row_id": 60598,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure.\nHeight: (in) 66\nWeight (lb): 296\nBSA (m2): 2.36 m2\nBP (mm Hg): 172/79\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 11:12\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity is moderately dilated. There is severe global left\nventricular hypokinesis. There is no resting left ventricular outflow tract\nobstruction.\n\nRIGHT VENTRICLE: The right ventricular free wall is hypertrophied. The right\nventricular cavity is dilated. Right ventricular systolic function is\nborderline normal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter. The aortic arch is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. The mitral valve supporting structures are normal.\nModerate to severe (3+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. There is no\ntriscupid stenosis. Mild tricuspid [1+] regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is a small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is moderately dilated. There is severe\nglobal left ventricular hypokinesis. The right ventricular free wall is\nhypertrophied. The right ventricular cavity is dilated. Right ventricular\nsystolic function is borderline normal. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. Moderate to severe (3+) mitral regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension. There is a small pericardial\neffusion. There are no echocardiographic signs of tamponade.\n\nCompared to the previous study of (report only), the left\nventricular ejectionfraction is worse.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2107-03-07 00:00:00.000",
"description": "Report",
"row_id": 110198,
"text": "Sinus rhythm\nPossible left ventricular hypertrophy\nDiffuse ST-T abnormalities\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2107-03-06 00:00:00.000",
"description": "Report",
"row_id": 110199,
"text": "Sinus arrhythmia\nExtensive T wave changes may be due to myocardial ischemia\nSince previous tracing , anterior and inferior ST-T wave abnormalities\nmore marked\n\n\n"
},
{
"category": "ECG",
"chartdate": "2107-03-04 00:00:00.000",
"description": "Report",
"row_id": 110200,
"text": "Sinus rhythm\nNonspecific ST-T abnormalities\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2107-03-02 00:00:00.000",
"description": "Report",
"row_id": 110201,
"text": "Sinus rhythm. Diffuse non-specific ST-T wave flattening. There is new T wave\ninversion in leads II, III, aVF and V4-V6 with upward coved ST segments in\nleads V2-V6. ST-T wave flattening in leads I and aVL. These findings are\nconsistent with acute inferolateral ischemic process. Followup and clinical\ncorrelation are suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2107-03-09 00:00:00.000",
"description": "Report",
"row_id": 110197,
"text": "Sinus tachycardia\nSeptal ST elevation - repeat if myocardial injury is suspected\nAnterior T wave changes are nonspecific\nSince previous tracing of ,the voltage has decreased\n\n"
}
] |
64,025 | 143,825 | Patient was electively admitted on for previously planned bifrontal craniotomy with Drs. and (ENT). Post operatively, he was transferred to the ICU where he remained intubated until . He still required nicardipine for systolic pressure control, and lethargic, but following commands. On MRI was completed and revealed expected post-surgical changes. The lumbar drain was clamped as well. On , he continued to have persistent lethargy and a repeated head CT was performed, revealing some sulcal effacement. A one time dose of mannitol was given for this indication. Head CT was repeated on ; and determined to be slightly improved from the mannitol. He continued to not have any obvious leak of CSF, so lumbar drain was removed on . On , he was significantly more lucid, with full strength throughout upper and lower extremities, passed speach and swallow, and subsequently transferred to the neurosurgical stepdown unit. On he had a short burst of bigeminy, remaining normotensive. The cardiology service was curbsided, and they recommended the addition of a beta blocker. This was done with appropriate effect. On he was seen and evaluated by PT and OT who recommended that he be discharged to home with services. On the morning of , he was discharged accordingly with instructions to follow up with his home oncologist; and instructions for suture removal. | Post-surgical changes including bifrontal craniotomy and cranialization of the frontal sinuses, with osseous metallic plates unchanged in configuration although and mild increase of complex fluid is demonstrated within the intracranial post-surgical bed. An unusual linear collection of air is demonstrated within the post-surgical fluid collection, possibly collecting underneath a faint septation or fibrous band (2:23). The patient is status post frontal craniotomy, evidence of pneumocephalus is demonstrated and post-surgical changes in the anterior skull base region, area of soft tissue density adjacent in the left side of the nose (2:11), extending on the right lateral recess, right maxillary sinus with right antrostomy, the mastoid air cells demonstrate normal pneumatization, mucus retention cysts visualized in the left maxillary sinus. The patient is status post frontal craniotomy, evidence of pneumocephalus is demonstrated and post-surgical changes in the anterior skull base region, area of soft tissue density adjacent in the left side of the nose (2:11), extending on the right lateral recess, right maxillary sinus with right antrostomy, the mastoid air cells demonstrate normal pneumatization, mucus retention cysts visualized in the left maxillary sinus. Mild increase in complex fluid within the post-surgical bed with shift of pneumocephalus, extracranially, to the right frontal subgaleal space. The mastoid air cells again demonstrate patchy opacification, bilaterally. IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Right jugular line passes to the left brachiocephalic vein. Status post frontal craniotomy with frontal pneumocephalus and soft tissue swelling, evidence of soft tissue density on the left side of the nose and adjacent to the medial aspect of the orbits, likely consistent with the previously described mass lesion in this area noted since the prior MRI of the head. The left maxillary sinus remains clear; however, there is also now new partial opacification of the mastoid air cells bilaterally. FINDINGS: The patient is status post frontal craniotomy, residual and post- surgical pneumocephalus is identified. 8:22 AM MR HEAD W & W/O CONTRAST; MR W &W/O CONTRAST Clip # Reason: please evaluate for residual mass Admitting Diagnosis: BASAL SKULL MASS/SDA Contrast: MAGNEVIST Amt: 18 FINAL ADDENDUM Since the prior report, the previous head CT scan of has become available. Action: Neuro checks q1h, SBP goal <140, prn Lopressor , & Hydralazine 10mg q6h for HT,Rt eyelid slightly open, eye ointments applied. Response: Lumbar drain pulled out by Dr. . Sedated on profopol gtt lumbar drain functioning-12-20cc clear fliud/hr head dsg w/ old staining Action: nicardipine gtt to maintain sb/p<140 Response: stable post-op Plan: cont. Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway Clearance, Cough) Assessment: Lungs clear, weak cough, needs assistance with clearing oral secretions Action: Patient turned Q2, chest pt preformed. Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway Clearance, Cough) Assessment: Lungs clear, weak cough, needs assistance with clearing oral secretions Action: Patient turned Q2, chest pt preformed. Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway Clearance, Cough) Assessment: Lungs clear, weak cough, needs assistance with clearing oral secretions Action: Patient turned Q2, chest pt preformed. oral and ett secretions lesser amts Plan: possible extubation if ok by ent- .H/O melanoma (Cancer, Malignant Neoplasm, Skin) Assessment: sb/p 120-136 on nicardipine 1mcg gtt pt mae. This was excised along with periodontal work with pathology saying it looked like fibrous tissue, possibly neurofibroma. Material was sent to Dr. at the who felt this was most consistent with a desmoplastic neurotropic melanoma. Lines / Tubes / Drains: Foley, A-line, right IJ central line Wounds: Imaging: Fluids: NS Consults: Neuro surgery, ENT Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op) ICU Care Nutrition: Glycemic Control: Regular insulin sliding scale Lines: Arterial Line - 04:58 PM Multi Lumen - 05:18 PM Prophylaxis: DVT: Boots, SQ UF Heparin Stress ulcer: PPI VAP bundle: Comments: Communication: Patient discussed on interdisciplinary rounds , ICU Code status: Full code Disposition: ICU Total time spent: 31 minutes Patient is critically ill NiCARdipine 1-3 mcg/kg/min IV DRIP TITRATE TO SBP<140 Order date: @ 1658 6. NiCARdipine 1-3 mcg/kg/min IV DRIP TITRATE TO SBP<140 Order date: @ 1658 6. Action: Neuro checks q1h, SBP goal <140, prn Lopressor , & Hydralazine 10mg q6h for HT,Rt eyelid slightly open, eye ointments applied. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN pain Order date: @ 1723 13. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN pain Order date: @ 1723 13. Pneumococcal Vac Polyvalent 20. Pneumococcal Vac Polyvalent 20. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Pneumococcal Vac Polyvalent 18. Pneumococcal Vac Polyvalent 18. Pneumococcal Vac Polyvalent 18. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes Order date: @ 0809 9. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes Order date: @ 0809 9. Metoprolol Tartrate 7.5 mg IV Q4H:PRN SBP>140 Hold for HR<60. Metoprolol Tartrate 7.5 mg IV Q4H:PRN SBP>140 Hold for HR<60. HydrALAzine 10 mg IV Q6H SBP>160 Order date: @ 1658 16. HydrALAzine 10 mg IV Q6H SBP>160 Order date: @ 1658 16. Cardiovascular: Keep SBP<140 w/ prn Lopressor & hydralazine. Cardiovascular: Keep SBP<140 w/ prn Lopressor & hydralazine. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes Order date: @ 2115 7. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes Order date: @ 2115 7. HYDROmorphone (Dilaudid) 10. HYDROmorphone (Dilaudid) 10. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 1658 8. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 1658 8. | 57 | [
{
"category": "Radiology",
"chartdate": "2131-05-10 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1076152,
"text": " 9:18 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: placement of tubes\n Admitting Diagnosis: BASAL SKULL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p intubation and cvl\n REASON FOR THIS EXAMINATION:\n placement of tubes\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:44 P.M.\n\n HISTORY: Intubated. Check central venous line placement.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:\n\n Right jugular line passes to the left brachiocephalic vein. ET tube tip at\n the thoracic inlet, at least 5 cm from the carina, in standard placement.\n Lungs grossly clear. Heart size normal. Dr. was paged to report these\n findings at the time of dictation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-05-11 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1076260,
"text": " 12:24 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval line placment R IJ (pulled back 5cm from previous)\n Admitting Diagnosis: BASAL SKULL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p craniotomy for tumor resection\n REASON FOR THIS EXAMINATION:\n eval line placment R IJ (pulled back 5cm from previous)\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 12:38 P.M. ON \n\n HISTORY: Evaluate right IJ line pulled back.\n\n IMPRESSION: AP chest compared to , 9:44 p.m.:\n\n Right jugular line has been pulled back to the junction of the brachiocephalic\n veins. No pneumothorax, mediastinal widening or right pleural effusion. Tiny\n left pleural effusion and left basal atelectasis more prominent but may not\n have increased. Heart size normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-05-10 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1076115,
"text": " 4:22 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for hemorrhage\n Admitting Diagnosis: BASAL SKULL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76M s/p crani\n REASON FOR THIS EXAMINATION:\n eval for hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 7:30 PM\n CT of the head without contrast. The patient is status post frontal\n craniotomy, evidence of pneumocephalus is demonstrated and post-surgical\n changes in the anterior skull base region, area of soft tissue density\n adjacent in the left side of the nose (2:11), extending on the right lateral\n recess, right maxillary sinus with right antrostomy, the mastoid air cells\n demonstrate normal pneumatization, mucus retention cysts visualized in the\n left maxillary sinus. There is no evidence of acute intraparenchymal\n hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the head without contrast.\n\n CLINICAL INDICATION: 76-year-old male patient, status post craniectomy,\n evaluate for hemorrhage.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n COMPARISON: Prior MRI of the head from outside institution dated .\n\n FINDINGS: The patient is status post frontal craniotomy, residual and post-\n surgical pneumocephalus is identified. Irregular areas are noted in the skull\n base anteriorly, likely consistent with packing material, fluid attenuation\n levels are noted in the right sphenoid sinus, right maxillary sinus, also\n right antrostomy is identified at this level. Mild ethmoidal mucosal\n thickening is noted on the left. Soft tissue density is identified on the\n left side of the nose and partially extending laterally, however, the left eye\n globe appears within normal limits. Soft tissue swelling is associated in the\n frontal region with subcutaneous emphysema which is expected after the\n surgical procedure. The mastoid air cells demonstrate normal pneumatization.\n The visualized intracranial structures without evidence of intraparenchymal\n hemorrhage. Apparently the pneumocephalus is producing mild narrowing of the\n frontal ventricular horns as demonstrated on the image #19, series #2. No\n evidence of intraventricular hemorrhage is seen.\n\n IMPRESSION: 1. Status post frontal craniotomy with frontal pneumocephalus and\n soft tissue swelling, evidence of soft tissue density on the left side of the\n nose and adjacent to the medial aspect of the orbits, likely consistent with\n the previously described mass lesion in this area noted since the prior MRI of\n the head.\n (Over)\n\n 4:22 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for hemorrhage\n Admitting Diagnosis: BASAL SKULL MASS/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Post-surgical changes noted on the right maxillary sinus with air- fluid\n level and blood products and also opacity of the right sphenoid sinus. There\n is no evidence of acute intracranial hemorrhage. Mild effacement of the\n frontal ventricular horns as described above.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-05-12 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1076350,
"text": " 8:22 AM\n MR HEAD W & W/O CONTRAST; MR W &W/O CONTRAST Clip # \n Reason: please evaluate for residual mass\n Admitting Diagnosis: BASAL SKULL MASS/SDA\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n FINAL ADDENDUM\n Since the prior report, the previous head CT scan of has become\n available. As noted by Dr. in the accompanying CT study obtained\n later this day, the fluid within the large bifrontal extradural cavity has\n appeared since the CT study, with accompanying increased mass effect\n upon the frontal lobes.\n\n\n\n 8:22 AM\n MR HEAD W & W/O CONTRAST; MR W &W/O CONTRAST Clip # \n Reason: please evaluate for residual mass\n Admitting Diagnosis: BASAL SKULL MASS/SDA\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with frontal sinus mass and skull base mass, s/p bifrontal\n crani\n REASON FOR THIS EXAMINATION:\n please evaluate for residual mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI SCAN OF THE BRAIN WITH SPECIAL ATTENTION TO THE INTERNAL AUDITORY CANALS:\n\n HISTORY: Status post resection of what appears to have been a sinonasal\n melanoma.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted brain imaging was obtained\n including high-resolution imaging of the internal auditory canals and\n cerebellopontine angle cisterns.\n\n COMPARISON STUDY ON PACS ARCHIVE: Preoperative MR study from the \n Medical Center from .\n\n FINDINGS: There is an enormous collection of gas, with a 2-tiered fluid\n level, with T2 hyperintense components superiorly and T2 hypointense\n components on the more dependent side of the fluid collection. This\n area/fluid mixture lies in the extradural compartment, and presumably connects\n with the operative bed. There is a considerable amount of fluid within the\n right maxillary sinus, with loss of aeration of the sphenoid sinus,\n particularly on the right side, as well as considerable high T2 signal, with\n some fluid levels within the mastoid sinuses. Within the operative bed is a\n mixture of T2 signal, some of which appears similar in distribution to the\n preoperative images of the tumor seen near the posterior aspect of the right\n cribriform plate. It is very difficult, on the basis of this study, to be\n certain whether there has been complete removal of the tumor.\n\n The large frontal air-fluid collection causes marked compression of the brain,\n with telescoped appearance of the corpus callosum. Marked compression of the\n frontal horns is seen, but there is no subfalcine or transtentorial\n herniation.\n\n There is considerable pachymeningeal enhancement throughout the supratentorial\n region. Enhancement along the clivus is seen extending into the right\n internal auditory canal. However, review of the preoperative study appears to\n show some clival enhancement extending towards the right porus acusticus.\n While the present study's pachymeningeal enhancement may be a reflection of\n the extensive recent operation, the preoperative enhancement raises the\n possibility of venous distention, versus pachymeningeal spread of tumor.\n This latter diagnosis is of some concern, particularly in light of the\n enhancement in the right internal auditory canal.\n (Over)\n\n 8:22 AM\n MR HEAD W & W/O CONTRAST; MR W &W/O CONTRAST Clip # \n Reason: please evaluate for residual mass\n Admitting Diagnosis: BASAL SKULL MASS/SDA\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is no area of pathological enhancement within the brain parenchyma\n itself.\n\n CONCLUSION: Large intracranial gas/fluid collection posteriorly displacing\n the frontal lobes. The fluid may have blood components accounting for the\n two-tiered appearance, noted above. Additional findings, as noted above.\n\n I telephoned the neurosurgical resident, Dr. , immediately after the\n study was obtained to inform her of these findings. She is contacting Dr.\n , the attending neurosurgeon to review this study immediately.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-05-10 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1076116,
"text": ", A. ENT CC1A 4:22 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for hemorrhage\n Admitting Diagnosis: BASAL SKULL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76M s/p crani\n REASON FOR THIS EXAMINATION:\n eval for hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n CT of the head without contrast. The patient is status post frontal\n craniotomy, evidence of pneumocephalus is demonstrated and post-surgical\n changes in the anterior skull base region, area of soft tissue density\n adjacent in the left side of the nose (2:11), extending on the right lateral\n recess, right maxillary sinus with right antrostomy, the mastoid air cells\n demonstrate normal pneumatization, mucus retention cysts visualized in the\n left maxillary sinus. There is no evidence of acute intraparenchymal\n hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-05-10 00:00:00.000",
"description": "O SKULL (AP, TOWNES & LAT) TRAUMA IN O.R.",
"row_id": 1076113,
"text": " 4:14 PM\n SKULL (AP, & LAT) TRAUMA IN O.R. Clip # \n Reason: LOST NEEDLE. OF SUTURE NEDDLE MISSING\n Admitting Diagnosis: BASAL SKULL MASS/SDA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Lost needle, of a needle missing.\n\n COMPARISON: None.\n\n SINGLE LATERAL VIEW OF THE SKULL AND ONE RADIOGRAPH DEMONSTRATING FIVE SAMPLES\n OF MISSING NEEDLE: No radiopaque object was noted in the single lateral view\n of the skull, compatible with the radiographed sample. This was verbally\n communicated by Dr. to Dr. on , 4:31 p.m.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-05-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1076461,
"text": " 9:40 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for increased air/fluid\n Admitting Diagnosis: BASAL SKULL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p bifrontal craniotomy w/ mental status changes\n REASON FOR THIS EXAMINATION:\n assess for increased air/fluid\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc SUN 12:33 PM\n Large gas and fluid containing collection underlying the bifrontal craniotomy\n site appears largely stable, with little interval change in substantial mass\n effect on the frontal horns of both lateral ventricles and the occipital \n of the left lateral ventricle. No subfalcine or uncal herniation at this\n time. Sulci remain effaced diffusely.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old man with mental status changes following bifrontal\n craniotomy.\n\n COMPARISON: Head CT of AT 1843 hours and .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n FINDINGS: There has been little interval change in an extensive air and fluid\n collection underlying a bifrontal craniotomy, within the extradural space.\n Associated sulcal effacement is again widespread. Mass effect on the frontal\n horns of the lateral ventricles bilaterally is unchanged. There is no\n subfalcine or uncal herniation at this time.\n\n There is no new intracranial hemorrhage, edema, or evidence of major vascular\n territorial infarct. The -white differentiation is preserved. Extensive\n changes in the paranasal sinuses are also stable, with mucosal thickening and\n fluid, completely opacifying the right sphenoid air cells and right maxillary\n sinus. To a lesser degree, there is mucosal thickening and fluid in the left\n sphenoid and ethmoid air cells. Again, fluid is present in scattered mastoid\n air cells bilaterally. The left maxillary sinus remains clear. Post-surgical\n changes are noted in the subcutaneous tissues overlying the bifrontal\n craniotomy.\n\n IMPRESSION: Largely stable appearance of large hydro-pneumocephalus, at the\n site of bifrontal craniotomy, resulting in marked mass effect upon the brain.\n Stable diffuse sulcal effacement and mass effect upon the lateral ventricles.\n No herniation at this time.\n\n\n (Over)\n\n 9:40 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for increased air/fluid\n Admitting Diagnosis: BASAL SKULL MASS/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-05-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1076462,
"text": ", M. NSURG SICU-A 9:40 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for increased air/fluid\n Admitting Diagnosis: BASAL SKULL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p bifrontal craniotomy w/ mental status changes\n REASON FOR THIS EXAMINATION:\n assess for increased air/fluid\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Large gas and fluid containing collection underlying the bifrontal craniotomy\n site appears largely stable, with little interval change in substantial mass\n effect on the frontal horns of both lateral ventricles and the occipital \n of the left lateral ventricle. No subfalcine or uncal herniation at this\n time. Sulci remain effaced diffusely.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-05-12 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1076411,
"text": " 6:37 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: decreased exam- not able to move rue, flex withdraw RLE,\n Admitting Diagnosis: BASAL SKULL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with s/p bifrontal crani\n REASON FOR THIS EXAMINATION:\n decreased exam- not able to move rue, flex withdraw RLE,\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AGLc SAT 11:55 PM\n PFI: Large intracranial gas- and fluid-containing collection underlying\n bifrontal craniotomy site causes substantial mass effect on the brain, with\n diffuse sulcal effacement and mass effect on bilateral frontal horns and the\n left occipital , which is an increase compared to two days prior, but\n unchanged from the MRI performed 10 hours prior.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old male with bifrontal craniotomy, with decreased\n neurologic function, now unable to move right upper extremity, with flexing\n withdrawal of the right lower extremity.\n\n COMPARISON: CT head from and MR brain of at 8:38 a.m.\n\n TECHNIQUE: MDCT axial imaging was performed through the brain without\n administration of IV contrast.\n\n NON-CONTRAST HEAD CT: As seen on MR of the head performed 10 hours prior,\n there is an enormous collection of gas and fluid in the extradural compartment\n and an underlying bifrontal craniotomy. Increased mass effect on the brain\n compared to CT head performed two days prior is as seen on the MRI of 10 hours\n prior. There is diffuse sulcal effacement and narrowing of the frontal horns\n bilaterally as well as the left occipital . Again no subfalcine or\n transtentorial herniation is seen.\n\n In addition to hydro-pneumocephalus, there is subcutaneous gas overlying the\n site of surgery, as before. Irregular densities at the skull base anteriorly\n again likely represent packing material. There is increased mucosal\n thickening and fluid in the paranasal sinuses, with now complete opacification\n of the right sphenoid sinus air cell and near-complete opacification of the\n right maxillary sinus, which is status post antrectomy. There is also\n increased mucosal thickening in the left sphenoid sinus and in the ethmoid air\n cells. The left maxillary sinus remains clear; however, there is also now new\n partial opacification of the mastoid air cells bilaterally. Again note is\n made of asymmetric soft tissue identified along the left side of the nose.\n\n IMPRESSION: Large intracranial gas- and fluid-containing collection again\n causes substantial mass effect on the brain, with diffuse sulcal effacement\n and mass effect on the lateral ventricles, which is increased compared to two\n days prior and unchanged from the MRI performed 10 hours prior.\n\n\n (Over)\n\n 6:37 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: decreased exam- not able to move rue, flex withdraw RLE,\n Admitting Diagnosis: BASAL SKULL MASS/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-05-12 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1076412,
"text": ", M. NSURG SICU-A 6:37 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: decreased exam- not able to move rue, flex withdraw RLE,\n Admitting Diagnosis: BASAL SKULL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with s/p bifrontal crani\n REASON FOR THIS EXAMINATION:\n decreased exam- not able to move rue, flex withdraw RLE,\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Large intracranial gas- and fluid-containing collection underlying\n bifrontal craniotomy site causes substantial mass effect on the brain, with\n diffuse sulcal effacement and mass effect on bilateral frontal horns and the\n left occipital , which is an increase compared to two days prior, but\n unchanged from the MRI performed 10 hours prior.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-05-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1076689,
"text": " 1:30 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for edema\n Admitting Diagnosis: BASAL SKULL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p bifrontal craniotomy\n REASON FOR THIS EXAMINATION:\n eval for edema\n CONTRAINDICATIONS for IV CONTRAST:\n head ct\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRCi 7:01 PM\n No new intracranial hemorrhage or evidence of herniation. Decreased\n effacement of bilateral frontal horns of the lateral ventricles.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT head without contrast.\n\n INDICATION: Status post bifrontal craniotomy, please evaluate for change.\n\n COMPARISON: CT head, MRI brain , as well as review\n of detailed Operative Note, in CareWeb.\n\n FINDINGS: Patient is status post bifrontal craniotomy for extirpation of\n extensive metastatic (melanoma) involvement of the cribriform plate and\n paranasal sinuses. Post-surgical changes including bifrontal craniotomy and\n cranialization of the frontal sinuses, with osseous metallic plates unchanged\n in configuration although and mild increase of complex fluid is demonstrated\n within the intracranial post-surgical bed. Degree of pneumocephalus has\n decreased since prior study, yet right frontal subgaleal air has increased in\n the interim. Linear region of calcified hyperattenuation separating the\n cerebral hemispheres from the post- craniotomy fluid collection remains\n stable; however, the degree of mass effect upon the frontal horns of the\n lateral ventricles has decreased, suggesting decreasing edema within the\n cerebral hemispheres. No shift of normally-midline structures is demonstrated.\n The major basal cisterns are preserved.\n\n A large amount of hemorrhage and opacification is again demonstrated within\n the right maxillary, ethmoid and sphenoid sinuses extending into the\n posteriorly-deroofed frontal sinuses which is contiguous with the intracranial\n postsurgical bed. An unusual linear collection of air is demonstrated within\n the post-surgical fluid collection, possibly collecting underneath a faint\n septation or fibrous band (2:23). No intracranial drain is identified to\n otherwise account for this finding (and none is mentioned in the operative\n report). The mastoid air cells again demonstrate patchy opacification,\n bilaterally.\n\n IMPRESSION:\n\n 1. Mild increase in complex fluid within the post-surgical bed with shift of\n pneumocephalus, extracranially, to the right frontal subgaleal space.\n\n (Over)\n\n 1:30 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for edema\n Admitting Diagnosis: BASAL SKULL MASS/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Decreased effacement of bilateral frontal horns suggests decreased edema\n within bilateral cerebral hemispheres, with decreased mass effect. No new\n intracranial herniation or shift of normally-midline structures demonstrated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-05-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1076690,
"text": ", M. NSURG SICU-A 1:30 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for edema\n Admitting Diagnosis: BASAL SKULL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p bifrontal craniotomy\n REASON FOR THIS EXAMINATION:\n eval for edema\n CONTRAINDICATIONS for IV CONTRAST:\n head ct\n ______________________________________________________________________________\n PFI REPORT\n No new intracranial hemorrhage or evidence of herniation. Decreased\n effacement of bilateral frontal horns of the lateral ventricles.\n\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570862,
"text": "Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n pt initially on cmv rate 14/ o2 50%.\n cs-clear-suctioning mod. Amt bloody drge from back of throath and down\n ett.\n Action:\n vent setting switch to cpap5/5,o2 40%\n freq. gentle mouth care given. Hob 30 degrees\n Response:\n abg\ns wnl. O2sats 97-100%. Rr-16-20 non-labored.\n oral and ett secretions lesser amts\n Plan:\n possible extubation if ok by ent-\n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n sb/p 120-136 on nicardipine 1mcg gtt\n pt mae. Not following commands. Perl. Sedated on profopol gtt\n lumbar drain functioning-12-20cc clear fliud/hr\n head dsg w/ old staining\n Action:\n nicardipine gtt to maintain sb/p<140\n Response:\n stable post-op\n Plan:\n cont. to monitor , neuro checks q1hr\n"
},
{
"category": "Physician ",
"chartdate": "2131-05-11 00:00:00.000",
"description": "Intensivist Note",
"row_id": 570863,
"text": "SICU\n HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal crainotomy for mass excision\n Chief complaint:\n metastatic desmoplastic melanoma\n PMHx:\n HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, thyphoid fever ', Warthin's tumor\n s/p Rt parotidectomy\n Current medications:\n Acetaminophen 325-650 mg PO Q6H:PRN pain, Keppra 500 mg IV BID,\n Amlodipine 5 mg PO DAILY, NiCARdipine 1-3 mcg/kg/min IV DRIP TITRATE TO\n SBP<140, Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes,\n Ondansetron 4 mg IV Q8H:PRN nausea, Chlorhexidine Gluconate 0.12% Oral\n Rinse 15 ml ORAL , Pantoprazole 40 mg IV Q24H, Docusate Sodium 100\n mg PO BID, Gentamicin 80 mg IV Q8H Duration: 3 Doses, Propofol 20-100\n mcg/kg/min IV DRIP TITRATE TO sedation, HYDROmorphone (Dilaudid) 2-4 mg\n PO Q4H:PRN pain, Ramipril 10 mg PO BID,\n HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN pain, Senna 1 TAB PO BID,\n Heparin 5000 UNIT SC TID, HydrALAzine 10 mg IV Q6H SBP>160, Vancomycin\n 1000 mg IV Q 12H\n 24 Hour Events:\n ARTERIAL LINE - START 04:58 PM\n OR RECEIVED - At 05:00 PM\n INTUBATION - At 05:04 PM\n MULTI LUMEN - START 05:18 PM\n Post operative day:\n POD 1 s/p bifrontal crainotomy for mass excision\n Allergies:\n Penicillins\n Unknown;\n Hayfever (Nasal) (Homeopathic Drugs)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:54 PM\n Gentamicin - 01:44 AM\n Infusions:\n Nicardipine - 1 mcg/Kg/min\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 06:25 PM\n Hydromorphone (Dilaudid) - 01:45 AM\n Other medications:\n Flowsheet Data as of 05:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 36.1\nC (97\n HR: 78 (68 - 96) bpm\n BP: 136/54(74) {112/49(66) - 167/91(117)} mmHg\n RR: 16 (13 - 18) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,134 mL\n 666 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,134 mL\n 666 mL\n Blood products:\n Total out:\n 3,624 mL\n 432 mL\n Urine:\n 870 mL\n 340 mL\n NG:\n Stool:\n Drains:\n 54 mL\n 92 mL\n Balance:\n -490 mL\n 234 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 600) mL\n Vt (Spontaneous): 515 (515 - 635) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 10 cmH2O\n Plateau: 12 cmH2O\n Compliance: 0 cmH2O/mL\n SPO2: 98%\n ABG: 7.40/39/104/24/0\n Ve: 8.5 L/min\n PaO2 / FiO2: 260\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 260 K/uL\n 13.5 g/dL\n 128 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.6 mEq/L\n 16 mg/dL\n 106 mEq/L\n 137 mEq/L\n 40.8 %\n 11.6 K/uL\n [image002.jpg]\n 07:31 PM\n 09:15 PM\n 02:45 AM\n 03:05 AM\n WBC\n 12.9\n 11.6\n Hct\n 42.5\n 40.8\n Plt\n 268\n 260\n Creatinine\n 1.1\n 1.1\n TCO2\n 24\n 25\n Glucose\n 133\n 128\n Other labs: PT / PTT / INR:12.4/21.8/1.0, Ca:8.7 mg/dL, Mg:1.9 mg/dL,\n PO4:3.8 mg/dL\n Assessment and Plan\n .H/O MELANOMA (CANCER, MALIGNANT NEOPLASM, SKIN), AIRWAY, INABILITY TO\n PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: 76M with metastatic desmoplastic melanoma to the\n ethmoid and frontal regions s/p bifrontal crainotomy for mass excision\n Neurologic: Neuro checks Q: 1 hr, Pain controlled, Restraints, Lumbar\n drain (10-15cc/hr), Keppra for seizure prophylaxis MRI today after\n extubation\n Cardiovascular: Keep SBP<140, nicardipine as needed. Wean. Increase\n hydralazine\n Pulmonary: Cont ETT, Extubate today, Spontaneous breathing trial,\n (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen: Stable NPO for now\n Nutrition: Advance diet as tolerated , After extubation\n Renal: Foley, Adequate UO\n Hematology: Stable\n Endocrine: RISS\n Infectious Disease: Perioperative Vanc/Gent\n Lines / Tubes / Drains: Foley, ETT, Surgical drains (hemovac, JP)\n Wounds: Dry dressings\n Imaging: MRI Head\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:58 PM\n Multi Lumen - 05:18 PM\n 18 Gauge - 06:10 PM\n 16 Gauge - 06:11 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments: SQH to start in AM\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570966,
"text": "HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal crainotomy for mass excision\n Chief complaint:\n metastatic desmoplastic melanoma\n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Patient w/history of metastitic melanoma to ethmoid and frontal regions\n of brain\n Action:\n Bifrontal crainotomoy for mass excision done \n Response:\n Recovered well from procedure.\n Slow to wake\n Follows all commands, equal strength in all extremitieis\n Slow to become verbal\n Plan:\n Continue with q 1 hr. neuro checks\n Maintain SBP,150\n Wean nicardipine as tolerated, use prn hydralazine and lopressor\n MRI in early am\n Call neurosurg/ICU team with any changes\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated this am\n Action:\n Tolerated CPAP 5/5 well\n Seen by neurosurg and ENT\n OK per these teams to extubate\n Extubation around 1300\n Response:\n Doing well with good sats on nasal prongs\n Minimal bloody secretions\n Able to cough and raise\n Plan:\n Assist with pulmonary toileting when needed\n Pain/ postop\n Assessment: After extubation, patient able to answer when he has\n pain\n Action: Per nursing care plan\n Dilaudid 1 mg given\n Response: Pain improved to level <5\n Plan: Continue per nursing care plan\n Ask and assess pain q 2 hrs.\n Medicate as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570798,
"text": "76 Male with metastatic demoplastic melanoma to the ethmoid and\n frontal regions s/p bifrontal craniotomy for mass excision.\n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Pt from OR intubated. Sedated on Propofol. Withdrawing x4 ext to\n stimuli, PERRLA 3mm. Baseline R eyelid unable to close. Parietal\n Incision with primary dsg, stained with old blood. SBP >140. Lumbar\n Drain disconnected from drainage system. PA O\n Action:\n Nicardipine gtt begun at 1.5 mcg/kg/min for SBP 150\ns s/p 10mg IV\n Hydralazine x2.\n Response:\n Pt SBP now in the 120\n Plan:\n Continue monitor closely and maintain SBP under 140 as ordered.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570799,
"text": "76 Male with metastatic demoplastic melanoma to the ethmoid and\n frontal regions s/p bifrontal craniotomy for mass excision.\n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Pt from OR intubated. Sedated on Propofol. Withdrawing x4 ext to\n stimuli, PERRLA 3mm. Baseline R eyelid unable to close. Parietal\n Incision with primary dsg, stained with old blood. SBP >140. Lumbar\n Drain disconnected from drainage system. PA made aware at\n approx 1800 by RN via telephone.\n Action:\n Nicardipine gtt begun at 1.5 mcg/kg/min for SBP 150\ns s/p 10mg IV\n Hydralazine x2. Second call to Neurosurgery Resident for\n attachment of lumbar drain to drainage system.\n Response:\n Pt SBP now in the 120\ns. LD connected.\n Plan:\n Continue monitor closely and maintain SBP under 140 as ordered. LD\n leveled at shoulder and to drain 15-20cc/hour per ordered. MRI when\n extubated.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Remains intubated. Maintaining SATs at 100% on FiO2 50%, PEEP 5 and\n Rate of 14.\n Action:\n Suctioned for moderate, bright red blood. ENT at bedside to witness\n and said it was to be expected.\n Response:\n No further blood in airway noted.\n Plan:\n Remain intubated until bloody secretions subside. Wean in am. Monitor\n ABGs.\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570961,
"text": "HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal crainotomy for mass excision\n Chief complaint:\n metastatic desmoplastic melanoma\n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2131-05-11 00:00:00.000",
"description": "Intensivist Note",
"row_id": 570825,
"text": "SICU\n HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal crainotomy for mass excision\n Chief complaint:\n metastatic desmoplastic melanoma\n PMHx:\n HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, thyphoid fever ', Warthin's tumor\n s/p Rt parotidectomy\n Current medications:\n Acetaminophen 325-650 mg PO Q6H:PRN pain, Keppra 500 mg IV BID,\n Amlodipine 5 mg PO DAILY, NiCARdipine 1-3 mcg/kg/min IV DRIP TITRATE TO\n SBP<140, Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes,\n Ondansetron 4 mg IV Q8H:PRN nausea, Chlorhexidine Gluconate 0.12% Oral\n Rinse 15 ml ORAL , Pantoprazole 40 mg IV Q24H, Docusate Sodium 100\n mg PO BID, Gentamicin 80 mg IV Q8H Duration: 3 Doses, Propofol 20-100\n mcg/kg/min IV DRIP TITRATE TO sedation, HYDROmorphone (Dilaudid) 2-4 mg\n PO Q4H:PRN pain, Ramipril 10 mg PO BID,\n HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN pain, Senna 1 TAB PO BID,\n Heparin 5000 UNIT SC TID, HydrALAzine 10 mg IV Q6H SBP>160, Vancomycin\n 1000 mg IV Q 12H\n 24 Hour Events:\n ARTERIAL LINE - START 04:58 PM\n OR RECEIVED - At 05:00 PM\n INTUBATION - At 05:04 PM\n MULTI LUMEN - START 05:18 PM\n Post operative day:\n POD 1 s/p bifrontal crainotomy for mass excision\n Allergies:\n Penicillins\n Unknown;\n Hayfever (Nasal) (Homeopathic Drugs)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:54 PM\n Gentamicin - 01:44 AM\n Infusions:\n Nicardipine - 1 mcg/Kg/min\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 06:25 PM\n Hydromorphone (Dilaudid) - 01:45 AM\n Other medications:\n Flowsheet Data as of 05:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 36.1\nC (97\n HR: 78 (68 - 96) bpm\n BP: 136/54(74) {112/49(66) - 167/91(117)} mmHg\n RR: 16 (13 - 18) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,134 mL\n 666 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,134 mL\n 666 mL\n Blood products:\n Total out:\n 3,624 mL\n 432 mL\n Urine:\n 870 mL\n 340 mL\n NG:\n Stool:\n Drains:\n 54 mL\n 92 mL\n Balance:\n -490 mL\n 234 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 600) mL\n Vt (Spontaneous): 515 (515 - 635) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 10 cmH2O\n Plateau: 12 cmH2O\n Compliance: 0 cmH2O/mL\n SPO2: 98%\n ABG: 7.40/39/104/24/0\n Ve: 8.5 L/min\n PaO2 / FiO2: 260\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 260 K/uL\n 13.5 g/dL\n 128 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.6 mEq/L\n 16 mg/dL\n 106 mEq/L\n 137 mEq/L\n 40.8 %\n 11.6 K/uL\n [image002.jpg]\n 07:31 PM\n 09:15 PM\n 02:45 AM\n 03:05 AM\n WBC\n 12.9\n 11.6\n Hct\n 42.5\n 40.8\n Plt\n 268\n 260\n Creatinine\n 1.1\n 1.1\n TCO2\n 24\n 25\n Glucose\n 133\n 128\n Other labs: PT / PTT / INR:12.4/21.8/1.0, Ca:8.7 mg/dL, Mg:1.9 mg/dL,\n PO4:3.8 mg/dL\n Assessment and Plan\n .H/O MELANOMA (CANCER, MALIGNANT NEOPLASM, SKIN), AIRWAY, INABILITY TO\n PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: 76M with metastatic desmoplastic melanoma to the\n ethmoid and frontal regions s/p bifrontal crainotomy for mass excision\n Neurologic: Neuro checks Q: 1 hr, Pain controlled, Restraints, Lumbar\n drain (10-15cc/hr), Keppra for seizure prophylaxis\n Cardiovascular: Keep SBP<140, nicardipine as needed\n Pulmonary: Cont ETT, Extubate today, Spontaneous breathing trial,\n (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen: Stable\n Nutrition: Advance diet as tolerated , After extubation\n Renal: Foley, Adequate UO\n Hematology: Stable\n Endocrine: RISS\n Infectious Disease: Perioperative Vanc/Gent\n Lines / Tubes / Drains: Foley, ETT, Surgical drains (hemovac, JP)\n Wounds: Dry dressings\n Imaging: MRI Head\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:58 PM\n Multi Lumen - 05:18 PM\n 18 Gauge - 06:10 PM\n 16 Gauge - 06:11 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments: SQH to start in AM\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2131-05-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 570777,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Wire Reinforced\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds:\n RUL Lung Sounds:\n LUL Lung Sounds:\n LLL Lung Sounds:\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570840,
"text": "Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n pt initially on cmv rate 14/ o2 50%.\n cs-clear-suctioning mod. Amt bloody drge from back of throath and down\n ett.\n Action:\n vent setting switch to cpap5/5,o2 40%\n freq. gentle mouth care given. Hob 30 degrees\n Response:\n abg\ns wnl. O2sats 97-100%. Rr-16-20 non-labored.\n oral and ett secretions lesser amts\n Plan:\n possible extubation if ok by ent-\n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n sb/p 120-136 on nicardipine 1mcg gtt\n pt mae. Not following commands. Perl. Sedated on profopol gtt\n lumbar drain functioning-12-20cc clear fliud/hr\n head dsg w/ old staining\n Action:\n nicardipine gtt to maintain sb/p<140\n Response:\n stable post-op\n Plan:\n cont. to monitor , neuro checks q1hr\n"
},
{
"category": "Respiratory ",
"chartdate": "2131-05-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 570843,
"text": "Demographics\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Wire Reinforced\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan: Potential for extubation or reintubation with standard tube for\n MRI.\n Respiratory Care Shift Procedures\n Bedside Procedures: ABG results WNL with good oxygenation.\n"
},
{
"category": "ECG",
"chartdate": "2131-05-16 00:00:00.000",
"description": "Report",
"row_id": 204016,
"text": "Sinus rhythm with ventricular premature complexes in bigeminy pattern\nModest nonspecific ST-T wave changes\nNo previous tracing available for comparison\n\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 571754,
"text": "HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal craniotomy for mass excision \n Chief complaint:\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, typhoid fever ', Warthin's tumor,\n metanephric adenoma, diverticulitis, BPH\n PSH: R parotidectomy ', R nephrectomy ', TURP ',\n diverticulectomy ' c/b post-op leak/pancreatitis, rsxn of melanoma of\n nares, skin grafts\n Pain control (acute pain, chronic pain)\n Assessment:\n Denies headache or any type of pain\n Action:\n Monitored for pain, medicate if needed\n Response:\n Stable, no pain indicated\n Plan:\n See nursing care plan\n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Alert, oriented x3, following commands, moving all extremites with\n equal strength although pt is very weak, pupils 2mm with sluggish\n reaction, head incision clean and dry\n Action:\n Neuro status monitored q2hrs, started on full liquids, oob to chair\n for 2 hrs\n Response:\n Improved neurostatus, more awake than yesterday, tolerating po fluids\n although pt does dribble sm amount of liquid from corner of his mouth\n if not sitting upright\n Plan:\n Transfer to neuro sdu when bed available, monitor neurostatus q2hrs,\n increase activity as tolerated, increase diet as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 571755,
"text": "HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal craniotomy for mass excision \n Chief complaint:\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, typhoid fever ', Warthin's tumor,\n metanephric adenoma, diverticulitis, BPH\n PSH: R parotidectomy ', R nephrectomy ', TURP ',\n diverticulectomy ' c/b post-op leak/pancreatitis, rsxn of melanoma of\n nares, skin grafts\n Pain control (acute pain, chronic pain)\n Assessment:\n Denies headache or any type of pain\n Action:\n Monitored for pain, medicate if needed\n Response:\n Stable, no pain indicated\n Plan:\n See nursing care plan\n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Alert, oriented x3, following commands, moving all extremites with\n equal strength although pt is very weak, pupils 2mm with sluggish\n reaction, head incision clean and dry\n Action:\n Neuro status monitored q2hrs, started on full liquids, oob to chair\n for 2 hrs\n Response:\n Improved neurostatus, more awake than yesterday, tolerating po fluids\n although pt does dribble sm amount of liquid from corner of his mouth\n if not sitting upright\n Plan:\n Transfer to neuro sdu when bed available, monitor neurostatus q2hrs,\n increase activity as tolerated, increase diet as tolerated\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n BASAL SKULL MASS/SDA\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 86 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Unknown;\n Hayfever (Nasal) (Homeopathic Drugs)\n Unknown;\n Precautions: No Additional Precautions\n PMH:\n CV-PMH: Hypertension\n Additional history: Dr. is a 73-year-old man whose \n problem dates back\n to . At that point he noted a growing soft tissue\n nodule on the right side of his nose. The lesion was described\n as smooth, dermal in nature, flesh-colored and measuring\n approximately 1 centimeter in diameter. This was incised and\n interpreted to be a neurofollicular hamartoma. Pathology was\n reviewed with multiple pathologists on the East Coast who\n concurred.\n The lesion recurred in and was re- excised with\n a rotation flap with pathology again being the same and margins\n being positive. Recurrence was again noted in on\n his right cheek treated with dermabrasion. He did well until\n when a small lesion was noted on the bridge of\n his nose which was treated with wide local excision and skin\n grafting. A small residual component was treated with laser\n therapy in . In there was a recurrence at the\n crease of his nose which was treated with excision followed by\n Mitomycin C local injection. Margins were again positive.\n In he developed multiple sebaceous- like lesions\n on the face and right nose with one extending to the left side of\n the nose. Biopsy of the nose and forehead lesions showed some\n spindle cells along with some inflammatory cells on the nose. In\n he underwent excision of a small lesion on his\n nose, again with positive margins, followed by laser therapy to\n the same area in and . He had additional\n surgery in and a major surgical procedure in\n for a lesion on the nose including inside the nose\n with reconstruction using cartilage from the ear. He had laser\n therapy to a similar spot in .\n In he developed a new lesion overlying the inferior\n orbital area. In he noted a lesion behind on the hard\n palate associated with a chronic gingival infection. This was\n excised along with periodontal work with pathology saying it\n looked like fibrous tissue, possibly neurofibroma. It is unclear\n of the relationship of this to the other disease. He underwent\n wide excision of a lesion on the nose in with a\n skin graft from the shin. Again, margins were felt to be\n positive, but this time the pathologist felt it was an xanthoma.\n Subsequent review of pathology felt this was possibly a malignant\n lesion including a sarcoma. Material was sent to Dr. at\n the who felt this was most\n consistent with a desmoplastic neurotropic melanoma. Over the\n past few months he has noticed thickening along the ala of the\n nose on the left side and a new subcutaneous hard nodule\n appearing just under the right eye and another lesion on the\n right cheek.\n PET scan from showed no evidence of distant uptake\n and no clear-cut uptake on the nose. A facial MRI from \n was also interpreted as unremarkable. He comes for discussion of\n the diagnosis and further management.\n Past medical history is remarkable for radiation therapy to his\n face for teenage acne and subsequent multiple basal cell cancers.\n He also had a Warthin's tumor resected from his parotid gland in\n . He had surgery for a benign kidney tumor in . He has\n a history of hypertension treated with Altase and depression\n treated with Zoloft. He also takes a muscle relaxant.\n Surgery / Procedure and date: transcranial,transfacial anterior\n tumor resection\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:128\n D:50\n Temperature:\n 97.2\n Arterial BP:\n S:157\n D:66\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 68 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 93% %\n O2 flow:\n 12 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 1,258 mL\n 24h total out:\n 830 mL\n Pertinent Lab Results:\n Sodium:\n 146 mEq/L\n 02:45 AM\n Potassium:\n 4.1 mEq/L\n 02:45 AM\n Chloride:\n 114 mEq/L\n 02:45 AM\n CO2:\n 28 mEq/L\n 02:45 AM\n BUN:\n 27 mg/dL\n 02:45 AM\n Creatinine:\n 0.8 mg/dL\n 02:45 AM\n Glucose:\n 116 mg/dL\n 02:45 AM\n Hematocrit:\n 30.7 %\n 02:45 AM\n Finger Stick Glucose:\n 122\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: sicu a\n Transferred to: 1119 bed 2\n Date & time of Transfer: \n"
},
{
"category": "Nutrition",
"chartdate": "2131-05-15 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 571736,
"text": "Subjective: Patient drank a big glass of juice this morning and\n is currently waiting for a chocolate milkshake. Per patient\ns wife,\n patient usually take a regular diet and has a good appetite.\n Objective\n Pertinent medications: NaCl 0.9% with KCl @ 75cc/hr, RISS, Heparin,\n others noted\n Labs:\n Value\n Date\n Glucose\n 116 mg/dL\n 02:45 AM\n Glucose Finger Stick\n 122\n 10:00 AM\n BUN\n 27 mg/dL\n 02:45 AM\n Creatinine\n 0.8 mg/dL\n 02:45 AM\n Sodium\n 146 mEq/L\n 02:45 AM\n Potassium\n 4.1 mEq/L\n 02:45 AM\n Chloride\n 114 mEq/L\n 02:45 AM\n TCO2\n 28 mEq/L\n 02:45 AM\n PO2 (arterial)\n 113 mm Hg\n 03:41 AM\n PCO2 (arterial)\n 35 mm Hg\n 03:41 AM\n pH (arterial)\n 7.43 units\n 03:41 AM\n CO2 (Calc) arterial\n 24 mEq/L\n 03:41 AM\n Calcium non-ionized\n 8.9 mg/dL\n 02:45 AM\n Phosphorus\n 2.9 mg/dL\n 02:45 AM\n Ionized Calcium\n 1.25 mmol/L\n 03:41 AM\n Magnesium\n 2.1 mg/dL\n 02:45 AM\n WBC\n 6.9 K/uL\n 02:45 AM\n Hgb\n 10.3 g/dL\n 02:45 AM\n Hematocrit\n 30.7 %\n 02:45 AM\n Current diet order / nutrition support: Diet: Regular\n Assessment of Nutritional Status\n 76 y.o. M with metastatic desmoplastic melanoma to the ethmoid and\n frontal regions s/p bifrontal craniotomy for mass excision .\n Patient was extubated and is currently on a regular diet. Patient\n has only taken liquids so far, but his appetite seems to be returning.\n Will continue to follow patient\ns po tolerance and intake. Will order\n a chocolate milkshake, per wife\ns request, at lunch and dinner.\n Please page with any questions. #\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 571753,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Denies headache or any type of pain\n Action:\n Monitored for pain, medicate if needed\n Response:\n Stable, no pain indicated\n Plan:\n See nursing care plan\n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Alert, oriented x3, following commands, moving all extremites with\n equal strength although pt is very weak, pupils 2mm with sluggish\n reaction, head incision clean and dry\n Action:\n Neuro status monitored q2hrs, started on full liquids, oob to chair\n for 2 hrs\n Response:\n Improved neurostatus, more awake than yesterday, tolerating po fluids\n although pt does dribble sm amount of liquid from corner of his mouth\n if not sitting upright\n Plan:\n Transfer to neuro sdu when bed available, monitor neurostatus q2hrs,\n increase activity as tolerated, increase diet as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571242,
"text": "76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal crainotomy for mass excision \n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Patient s/p mass excision on , lethargic, easily arousable,\n following commands, weaker on rt side, known to neuro team ,\n Dr. in to see the patient at 1900.\n Action:\n Neuro checks q1h, SBP goal <140, prn Lopressor , & Hydralazine 10mg q6h\n for HT,Rt eyelid slightly open, eye ointments applied. Lumbar drain\n open at 0 cm at shoulder level, draining clear CSF, goal 5cc/hr\n Response:\n Still lethargic, following commands, rt hand moves to pain only, did\n squeeze with rt hand few times, slow in answering, garbled speech,\n neuro team aware, expecting slow progress per Dr.. Denies\n any pain. Initial post op dressing intact & dry, face is slightly\n swollen up on rt side.\n Plan:\n Cont neuro checks q1h, SBP goal <140, lumbar drain still intact, open\n at 0cm shoulder level , goal 5cc/hr, plan to clamp it today.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Patient is on 100% face tent, breathing through mouth, and slight\n bleeding from mouth.\n Action:\n Frequent mouth care & moisturizing cream applied, oral suction done, pt\n is coughing out, but not able to clear sputum.\n Response:\n Needs assistance to clear airway, O 2sat 98-100%, LS clear, good cough,\n but absent gag.\n Plan:\n Pulm hygiene, suction prn, mouth care.\n Patient has very weak - absent gag, no access for feed or meds, po\n meds dc\nd by SICU MD ? need some form of nutrition\n"
},
{
"category": "Nutrition",
"chartdate": "2131-05-11 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 570918,
"text": "Subjective: Patient currently intubated and sedated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 175 cm\n 86 kg\n 27.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 72.6 kg\n 118%\n Diagnosis: Basal Skull Mass\n PMH : HTN, Depression, multiple basal cell cancers, h/o radiation tx\n for teenage acne, scarlet fever @7yr, thyphoid fever ', Warthin's\n tumor s/p Rt parotidectomy\n Food allergies and intolerances:\n Pertinent medications: Propofol drip, Nicardipine, NaCl 0.9% @75cc/hr,\n Abx, others noted\n Labs:\n Value\n Date\n Glucose\n 128 mg/dL\n 02:45 AM\n BUN\n 16 mg/dL\n 02:45 AM\n Creatinine\n 1.1 mg/dL\n 02:45 AM\n Sodium\n 137 mEq/L\n 02:45 AM\n Potassium\n 4.6 mEq/L\n 02:45 AM\n Chloride\n 106 mEq/L\n 02:45 AM\n TCO2\n 24 mEq/L\n 02:45 AM\n PO2 (arterial)\n 104 mm Hg\n 03:05 AM\n PCO2 (arterial)\n 39 mm Hg\n 03:05 AM\n pH (arterial)\n 7.40 units\n 03:05 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 03:05 AM\n Calcium non-ionized\n 8.7 mg/dL\n 02:45 AM\n Phosphorus\n 3.8 mg/dL\n 02:45 AM\n Magnesium\n 1.9 mg/dL\n 02:45 AM\n WBC\n 11.6 K/uL\n 02:45 AM\n Hgb\n 13.5 g/dL\n 02:45 AM\n Hematocrit\n 40.8 %\n 02:45 AM\n Current diet order / nutrition support: Diet: NPO\n GI: abdomen soft, + hypoactive bowel sounds\n Assessment of Nutritional Status\n Adequately nourished, At risk for malnutrition\n Pt at risk due to: metastatic cancer\n Estimated Nutritional Needs\n Calories: 2060-2410 (BEE x or / 24-28 cal/kg)\n Protein: 94-120 (1.1-1.4 g/kg)\n Fluid: per team\n Estimation of previous intake: Adequate\n Estimation of current intake: Inadequate (NPO status)\n Specifics:\n 76 y.o. M with metastatic desmoplastic melanoma to the ethmoid and\n frontal regions s/p bifrontal craniotomy for mass excision .\n Patient is currently intubated and sedated on propofol, which provides\n 1.1kcal/mL. RN, patient weaning to extubate today and does not\n currently have an OGT or an NGT. If patient is unable to be extubated,\n recommend placing OGT for enteral feeds.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Recommend tube feed goal of Fibersource @ 75cc/hr (2160kcals,\n 95g protein).\n 2) Monitor blood sugar with start of tube feeds; patient may need\n increased RISS coverage.\n 3) Following, please page with questions. #\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571354,
"text": "HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal craniotomy for mass excision \n Chief complaint:\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, typhoid fever ', Warthin's tumor\n s/p Rt parotidectomy\n PSH: s/p Rt parotidectomy ', R nephrectomy (metanephric adenoma '),\n BPH s/p TURP ', diverticulitis s/p diverticulectomy ' c/b post-op\n leak/pancreatitis, s/p desmoplastic melanoma nares, s/p rsxn, skin\n grafts\n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Patient lethargic, arouses to speech\n Minimal vocalization noted. Patient will moan and occasionally say his\n name, very garbled speech.\n Will inconsistently follow commands\n Perrla.\n Right eye remains open, orbital edema\n Lumbar drain remains open at 0cm at shoulder level.\n Patient denies pain.\n Sr with frequent pvcs noted.\n SBp maintained within parameters of <140\n Action:\n Patient neuro checks monitored Q1.\n Patient had MRI, (collection of fluid and air noted. Team aware)\n Lumbar drain remained open to drain 10-15cc hrly.\n Cream applied to right eye to prevent drying\n Iv magnesium and phos given to correct electrolytes\n Response:\n No change in neuro status at time of report.\n MRI results reviewed by team\n Lumbar drain to remained open and 10-15cc drained Hrly\n Plan:\n Continue to monitor neuro checks Hrly, report any changes to team\n Lumbar drain to remain open, head of bed elevated to 30.\n Monitor labs and give iv supplements as needed.\n Monitor pain and administer analgesia as needed.\n As patient lethargic patient unable to take , need tube feeding,\n sicu team will liase with neuro/ with regard to placement of NGt vs\n Peg tube vs starting TPN.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Lungs clear, weak cough, needs assistance with clearing oral secretions\n Action:\n Patient turned Q2, chest pt preformed.\n Deep breathing coughing encouraged.\n Suctioned as needed.\n Patient remains on open face mask, as patient appears to be a mouth\n breather and oral mucosa very dry.\n Oral hygiene maintained\n Response:\n Patient lungs remain clear.\n Afibrile\n Maintaining O2 sats >97%\n Patient clearing secretions with assistance.\n Plan:\n To continue with pulmonary toileting as needed.\n Turn patient Q2\n Encourage deep breathing and coughing.\n Monitor o2 sats and resp.\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571356,
"text": "HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal craniotomy for mass excision \n Chief complaint:\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, typhoid fever ', Warthin's tumor\n s/p Rt parotidectomy\n PSH: s/p Rt parotidectomy ', R nephrectomy (metanephric adenoma '),\n BPH s/p TURP ', diverticulitis s/p diverticulectomy ' c/b post-op\n leak/pancreatitis, s/p desmoplastic melanoma nares, s/p rsxn, skin\n grafts\n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Patient lethargic, arouses to speech\n Minimal vocalization noted. Patient will moan and occasionally say his\n name, very garbled speech.\n Will inconsistently follow commands.\n Will move left ue purposefully and move bilateral feet to command\n Occasionally patient will grasp hand on right ue, most of time no\n movement noted, will withdraw to stimuli.\n Right eye will open to speech, has facial and orbital edema.\n Perrla.\n Lumbar drain clamped\n Patient denies pain.\n Sr with frequent pvcs noted.\n SBp maintained within parameters of <140\n Action:\n Patient neuro checks monitored Q1.\n Patient had CTSCAN in am, no changes noted from MRI?CTSCAN from\n \n Lumbar drain clamped.\n Cream applied to right eye to prevent drying\n phos given to correct electrolytes\n IV mannitol 25g given x1 as ordered.\n Response:\n No change in neuro status at time of report.\n CTSCAN results reviewed by team and wife updated.\n Lumbar drain to remained clamped\n Plan:\n Continue to monitor neuro checks Hrly, report any changes to team\n Lumbar drain to remain clamped, head of bed elevated to 30.\n Monitor labs and give iv supplements as needed.\n Monitor pain and administer analgesia as needed.\n As patient lethargic patient unable to take , need tube feeding,\n sicu team will liase with neuro/ and ENT with regard to placement\n of NGt vs Peg tube vs starting TPN.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Lungs clear, weak cough, needs assistance with clearing oral secretions\n Action:\n Patient turned Q2, chest pt preformed.\n Deep breathing coughing encouraged.\n Suctioned as needed.\n Patient remains on open face mask, as patient appears to be a mouth\n breather and oral mucosa very dry.\n Oral hygiene maintained\n Response:\n Patient lungs remain clear.\n Afibrile\n Maintaining O2 sats >97%\n Patient clearing secretions with assistance.\n Plan:\n To continue with pulmonary toileting as needed.\n Turn patient Q2\n Encourage deep breathing and coughing.\n Monitor o2 sats and resp.\n"
},
{
"category": "Physician ",
"chartdate": "2131-05-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571720,
"text": "SICU\n HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal craniotomy for mass excision \n Chief complaint:\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, typhoid fever ', Warthin's tumor,\n metanephric adenoma, diverticulitis, BPH\n PSH: R parotidectomy ', R nephrectomy ', TURP ',\n diverticulectomy ' c/b post-op leak/pancreatitis, rsxn of melanoma of\n nares, skin grafts\n Current medications:\n 1. 2. 20 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4.\n Artificial Tear Ointment 5. Artificial Tear Ointment\n 6. Docusate Sodium 7. HYDROmorphone (Dilaudid) 8. Heparin 9.\n HydrALAzine 10. Insulin 11. LeVETiracetam\n 12. Metoprolol Tartrate 13. NiCARdipine 14. Ondansetron 15.\n Pantoprazole 16. Pneumococcal Vac Polyvalent\n 17. Potassium Chloride 18. Sodium Chloride 0.9% Flush 19. Sodium\n Phosphate\n 24 Hour Events:\n - lumbar drain removed\n Allergies:\n Penicillins\n Unknown;\n Hayfever (Nasal) (Homeopathic Drugs)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:47 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 06:00 PM\n Metoprolol - 08:01 PM\n Hydromorphone (Dilaudid) - 03:00 AM\n Other medications:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 36.1\nC (97\n HR: 76 (60 - 80) bpm\n BP: 153/63(90) {112/50(72) - 157/89(103)} mmHg\n RR: 17 (13 - 21) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 2,500 mL\n 443 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,500 mL\n 443 mL\n Blood products:\n Total out:\n 1,765 mL\n 450 mL\n Urine:\n 1,765 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 735 mL\n -8 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 99%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, somewhat sedated but arousable, follows\n commands, speaks more now\n Labs / Radiology\n 263 K/uL\n 10.3 g/dL\n 116 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 27 mg/dL\n 114 mEq/L\n 146 mEq/L\n 30.7 %\n 6.9 K/uL\n [image002.jpg]\n 02:45 AM\n 03:05 AM\n 05:13 PM\n 11:50 PM\n 02:51 AM\n 03:09 AM\n 02:57 AM\n 02:52 AM\n 03:41 AM\n 02:45 AM\n WBC\n 11.6\n 16.7\n 12.8\n 10.4\n 6.9\n Hct\n 40.8\n 34.0\n 32.9\n 31.7\n 30.7\n Plt\n 54\n 263\n Creatinine\n 1.1\n 0.9\n 0.8\n 0.9\n 0.8\n TCO2\n 25\n 21\n 23\n 25\n 24\n Glucose\n 128\n 116\n 123\n 114\n 110\n 116\n Other labs: PT / PTT / INR:12.4/21.8/1.0, Ca:8.9 mg/dL, Mg:2.1 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), .H/O MELANOMA (CANCER,\n MALIGNANT NEOPLASM, SKIN), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: 76M with metastatic desmoplastic melanoma to the\n ethmoid and frontal regions s/p bifrontal craniotomy for mass excision\n \n Neurologic: Neuro checks Q: 2 hr, HOB 30, Keppra for seizure\n prophylaxis, drain d/c'd yesterday, mental status improved\n Cardiovascular: Keeping SBP<140, prn hydralazine & Lopressor\n Pulmonary: pulm toilet, supplemental O2 prn\n Gastrointestinal / Abdomen: PO diet today\n Nutrition: Regular diet\n Renal: Foley, Adequate UO\n Hematology: Stable, daily HCT\n Endocrine: RISS, well controlled\n Infectious Disease: No issues, monitor fever curve and WBC daily\n Lines / Tubes / Drains: Foley, d/c A-line, right IJ central line\n Wounds: c/d/i\n Imaging: none\n Fluids: NS\n Consults: Neuro surgery, ENT\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:58 PM\n Multi Lumen - 05:18 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: floor\n Total time spent: 31 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2131-05-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571723,
"text": "SICU\n HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal craniotomy for mass excision \n Chief complaint:\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, typhoid fever ', Warthin's tumor,\n metanephric adenoma, diverticulitis, BPH\n PSH: R parotidectomy ', R nephrectomy ', TURP ',\n diverticulectomy ' c/b post-op leak/pancreatitis, rsxn of melanoma of\n nares, skin grafts\n Current medications:\n 1. 2. 20 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4.\n Artificial Tear Ointment 5. Artificial Tear Ointment\n 6. Docusate Sodium 7. HYDROmorphone (Dilaudid) 8. Heparin 9.\n HydrALAzine 10. Insulin 11. LeVETiracetam\n 12. Metoprolol Tartrate 13. NiCARdipine 14. Ondansetron 15.\n Pantoprazole 16. Pneumococcal Vac Polyvalent\n 17. Potassium Chloride 18. Sodium Chloride 0.9% Flush 19. Sodium\n Phosphate\n 24 Hour Events:\n - lumbar drain removed\n Allergies:\n Penicillins\n Unknown;\n Hayfever (Nasal) (Homeopathic Drugs)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:47 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 06:00 PM\n Metoprolol - 08:01 PM\n Hydromorphone (Dilaudid) - 03:00 AM\n Other medications:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 36.1\nC (97\n HR: 76 (60 - 80) bpm\n BP: 153/63(90) {112/50(72) - 157/89(103)} mmHg\n RR: 17 (13 - 21) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 2,500 mL\n 443 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,500 mL\n 443 mL\n Blood products:\n Total out:\n 1,765 mL\n 450 mL\n Urine:\n 1,765 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 735 mL\n -8 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 99%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, somewhat sedated but arousable, follows\n commands, speaks more now\n Labs / Radiology\n 263 K/uL\n 10.3 g/dL\n 116 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 27 mg/dL\n 114 mEq/L\n 146 mEq/L\n 30.7 %\n 6.9 K/uL\n [image002.jpg]\n 02:45 AM\n 03:05 AM\n 05:13 PM\n 11:50 PM\n 02:51 AM\n 03:09 AM\n 02:57 AM\n 02:52 AM\n 03:41 AM\n 02:45 AM\n WBC\n 11.6\n 16.7\n 12.8\n 10.4\n 6.9\n Hct\n 40.8\n 34.0\n 32.9\n 31.7\n 30.7\n Plt\n 54\n 263\n Creatinine\n 1.1\n 0.9\n 0.8\n 0.9\n 0.8\n TCO2\n 25\n 21\n 23\n 25\n 24\n Glucose\n 128\n 116\n 123\n 114\n 110\n 116\n Other labs: PT / PTT / INR:12.4/21.8/1.0, Ca:8.9 mg/dL, Mg:2.1 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), .H/O MELANOMA (CANCER,\n MALIGNANT NEOPLASM, SKIN), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: 76M with metastatic desmoplastic melanoma to the\n ethmoid and frontal regions s/p bifrontal craniotomy for mass excision\n \n Neurologic: Neuro checks Q: 2 hr, HOB 30, Keppra for seizure\n prophylaxis, drain d/c'd yesterday, mental status improved\n Cardiovascular: Keeping SBP<140, prn hydralazine & Lopressor\n Pulmonary: pulm toilet, supplemental O2 prn\n Gastrointestinal / Abdomen: PO diet today\n Nutrition: Regular diet\n Renal: Foley, Adequate UO\n Hematology: Stable, daily HCT\n Endocrine: RISS, well controlled\n Infectious Disease: No issues, monitor fever curve and WBC daily\n Lines / Tubes / Drains: Foley, d/c A-line, right IJ central line\n Wounds: c/d/i\n Imaging: none\n Fluids: NS\n Consults: Neuro surgery, ENT\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:58 PM\n Multi Lumen - 05:18 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: floor\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571477,
"text": "HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal craniotomy for mass excision \n Chief complaint:\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, typhoid fever ', Warthin's tumor\n s/p Rt parotidectomy\n PSH: s/p Rt parotidectomy ', R nephrectomy (metanephric adenoma '),\n BPH s/p TURP ', diverticulitis s/p diverticulectomy ' c/b post-op\n leak/pancreatitis, s/p desmoplastic melanoma nares, s/p rsxn, skin\n grafts\n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Metastatic desmoplastic melanoma to the ethmoid and frontal regions s/p\n bifrontal craniotomy for mass excision , extubated on , Neuro\n waxes and wanes, Following commands inconsistently, PERL, lethargic,\n Sluggish with activities, Neurosurgery team aware of patient\ns neuro\n status. Patient is in NSR with frequent pvc\ns, all electrolytes wnl.\n Sicu team aware.\n Action:\n Neuro checks q1h, SBP goal <140, still on.Lopressor & Hydralazine for\n Bld pressure control, Lumbar drain clamped from form yesterday,\n Response:\n Unchanged neuro status, communicating with single word like Yes, Okay\n etc. but not consistent. Localizing pain. Pt had CT scan yesterday\n which is unchanged from the previous one and one dose of manitol given\n yesterday.\n Plan:\n Cont monitoring, neuro checks q1h, hold heparin for 5 hours prior to\n removal of lumbar drain. Cont to monitor cardiac rhythm.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Patient was extubated on , still with face tent at 10L O2, Mouth\n breather. Coughing but not able to clear sputum, needs suction from\n mouth.\n Action:\n Oral care frequently, oral suction PRN, HOB >30,\n Response:\n LC + ronchi, O 2sat 97-99%, needs assistance with clearance of sputum,\n ABG okay.\n Plan:\n Pulm toilet, frequent mouth care, as mouth is very dry , patient\n breaths through mouth. Chest PT.Oral suction PRN.\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571230,
"text": ".H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Action:\n Response:\n Plan:\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571595,
"text": "76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal craniotomy for mass excision \n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Lethargic and not easily arousable this am, becoming more responsive\n this afternoon, now following all commands consistently. Moves all\n extremities in bed. Opens eyes slightly to command\ngeneral facial edema\n prevents him from fully opening eyes at times, PERL 3mm. Not very\n talkative but easier to understand when speaking now. He is generally a\n mouth breather and needs frequent oral care to speak clearer. Denies\n pain.\n Action:\n Head CT scan done. Dr. spoke to patient regarding nutritional\n needs and possible PEG placement.\n Response:\n Lumbar drain pulled out by Dr. . Wife not very receptive regarding\n PEG placement as she expressed concerns about need for anesthesia when\n placing feeding tube.\n Plan:\n Continue neurological exams every hour. Maintain BP sys <160 per\n neurosurg service. Continue discussion with pt\ns wife regarding\n nutritional status and need for feeding tube placement. ENT\n consultation regarding possibility of placing NGT temporarily for\n nutrition. Continue to provide emotional support to patient\ns wife.\n"
},
{
"category": "Physician ",
"chartdate": "2131-05-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571690,
"text": "SICU\n HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal craniotomy for mass excision \n Chief complaint:\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, typhoid fever ', Warthin's tumor,\n metanephric adenoma, diverticulitis, BPH\n PSH: R parotidectomy ', R nephrectomy ', TURP ',\n diverticulectomy ' c/b post-op leak/pancreatitis, rsxn of melanoma of\n nares, skin grafts\n Current medications:\n 1. 2. 20 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4.\n Artificial Tear Ointment 5. Artificial Tear Ointment\n 6. Docusate Sodium 7. HYDROmorphone (Dilaudid) 8. Heparin 9.\n HydrALAzine 10. Insulin 11. LeVETiracetam\n 12. Metoprolol Tartrate 13. NiCARdipine 14. Ondansetron 15.\n Pantoprazole 16. Pneumococcal Vac Polyvalent\n 17. Potassium Chloride 18. Sodium Chloride 0.9% Flush 19. Sodium\n Phosphate\n 24 Hour Events:\n - lumbar drain removed\n Allergies:\n Penicillins\n Unknown;\n Hayfever (Nasal) (Homeopathic Drugs)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:47 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 06:00 PM\n Metoprolol - 08:01 PM\n Hydromorphone (Dilaudid) - 03:00 AM\n Other medications:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 36.1\nC (97\n HR: 76 (60 - 80) bpm\n BP: 153/63(90) {112/50(72) - 157/89(103)} mmHg\n RR: 17 (13 - 21) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 2,500 mL\n 443 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,500 mL\n 443 mL\n Blood products:\n Total out:\n 1,765 mL\n 450 mL\n Urine:\n 1,765 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 735 mL\n -8 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 99%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, somewhat sedated but arousable, follows\n commands, speaks more now\n Labs / Radiology\n 263 K/uL\n 10.3 g/dL\n 116 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 27 mg/dL\n 114 mEq/L\n 146 mEq/L\n 30.7 %\n 6.9 K/uL\n [image002.jpg]\n 02:45 AM\n 03:05 AM\n 05:13 PM\n 11:50 PM\n 02:51 AM\n 03:09 AM\n 02:57 AM\n 02:52 AM\n 03:41 AM\n 02:45 AM\n WBC\n 11.6\n 16.7\n 12.8\n 10.4\n 6.9\n Hct\n 40.8\n 34.0\n 32.9\n 31.7\n 30.7\n Plt\n 54\n 263\n Creatinine\n 1.1\n 0.9\n 0.8\n 0.9\n 0.8\n TCO2\n 25\n 21\n 23\n 25\n 24\n Glucose\n 128\n 116\n 123\n 114\n 110\n 116\n Other labs: PT / PTT / INR:12.4/21.8/1.0, Ca:8.9 mg/dL, Mg:2.1 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), .H/O MELANOMA (CANCER,\n MALIGNANT NEOPLASM, SKIN), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: 76M with metastatic desmoplastic melanoma to the\n ethmoid and frontal regions s/p bifrontal craniotomy for mass excision\n \n Neurologic: Neuro checks Q: 1 hr, HOB 30, Keppra for seizure\n prophylaxis, mannitol, drain d/c'd\n Cardiovascular: Keeping SBP<140, prn hydralazine & Lopressor\n Pulmonary: pulm toilet, supplemental O2 prn\n Gastrointestinal / Abdomen: NPO, Dobhoff to be placed under fluoro or\n at bedside by ENT for TF\n Nutrition: NPO, Start tube feeding once Dobhoff placed\n Renal: Foley, Adequate UO\n Hematology: Stable Hct.\n Endocrine: RISS\n Infectious Disease: No issues, off vanco.\n Lines / Tubes / Drains: Foley, A-line, right IJ central line\n Wounds:\n Imaging:\n Fluids: NS\n Consults: Neuro surgery, ENT\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:58 PM\n Multi Lumen - 05:18 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571161,
"text": "HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal crainotomy for mass excision \n Chief complaint:\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, thyphoid fever ', Warthin's tumor\n s/p Rt parotidectomy\n PSH: s/p Rt parotidectomy ', R nephrectomy (metanephric adenoma '),\n BPH s/p TURP ', diverticulitis s/p diverticulectomy ' c/b post-op\n leak/pancreatitis, s/p desmoplastic melanoma nares, s/p rsxn, skin\n grafts\n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Patient lethargic, arouses to speech\n Minimal vocalization noted. Patient will moan and occassionaly say his\n name, very garbled speech.\n Follows simple commands.\n Mae equal strength.\n Perrla.\n Right eye remains open, orbital oedema\n Lumbar drain remains open at 0cm at shoulder level.\n Patient denies pain.\n Sr with frequent pvcs noted.\n SBp maintained within parameters of <140\n Action:\n Patient neuro checks monitored Q1.\n Patient had MRI, (collection of fluid and air noted. Team aware)\n Lumbar drain remained open to drain 10-15cc hrly.\n Cream applied to right eye to prevent drying\n Iv magnesium and phos given to correct electrolytes\n Response:\n No change in neuro status at time of report.\n MRI results reviewed by team\n Lumbar drain to remained open and 10-15cc drained Hrly\n Plan:\n Continue to monitor neuro checks Hrly, report any changes to team\n Lumbar drain to remain open , head of bed elevated to 30.\n Monitor labs and give iv supplements as needed.\n Monitor pain and administer analgesia as needed.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Lungs clear, weak cough, needs assistance with clearing oral secretions\n Action:\n Patient turned Q2, chest pt preformed.\n Deep breathing coughing encouraged.\n Suctioned as needed.\n Patient remains on open face mask, as patient appears to be a mouth\n breather and oral mucosa very dry.\n Oral hygiene maintained\n Response:\n patient\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571163,
"text": "HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal crainotomy for mass excision \n Chief complaint:\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, thyphoid fever ', Warthin's tumor\n s/p Rt parotidectomy\n PSH: s/p Rt parotidectomy ', R nephrectomy (metanephric adenoma '),\n BPH s/p TURP ', diverticulitis s/p diverticulectomy ' c/b post-op\n leak/pancreatitis, s/p desmoplastic melanoma nares, s/p rsxn, skin\n grafts\n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Patient lethargic, arouses to speech\n Minimal vocalization noted. Patient will moan and occassionaly say his\n name, very garbled speech.\n Follows simple commands.\n Mae equal strength.\n Perrla.\n Right eye remains open, orbital oedema\n Lumbar drain remains open at 0cm at shoulder level.\n Patient denies pain.\n Sr with frequent pvcs noted.\n SBp maintained within parameters of <140\n Action:\n Patient neuro checks monitored Q1.\n Patient had MRI, (collection of fluid and air noted. Team aware)\n Lumbar drain remained open to drain 10-15cc hrly.\n Cream applied to right eye to prevent drying\n Iv magnesium and phos given to correct electrolytes\n Response:\n No change in neuro status at time of report.\n MRI results reviewed by team\n Lumbar drain to remained open and 10-15cc drained Hrly\n Plan:\n Continue to monitor neuro checks Hrly, report any changes to team\n Lumbar drain to remain open , head of bed elevated to 30.\n Monitor labs and give iv supplements as needed.\n Monitor pain and administer analgesia as needed.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Lungs clear, weak cough, needs assistance with clearing oral secretions\n Action:\n Patient turned Q2, chest pt preformed.\n Deep breathing coughing encouraged.\n Suctioned as needed.\n Patient remains on open face mask, as patient appears to be a mouth\n breather and oral mucosa very dry.\n Oral hygiene maintained\n Response:\n Patient lungs remain clear.\n Afibrile\n Maintaining O2 sats >97%\n Patient clearing secretions with assistance.\n Plan:\n To continue with pulmonary toileting as needed.\n Turn patient Q2\n Encourage deep breathing and coughing.\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571164,
"text": "HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal craniotomy for mass excision \n Chief complaint:\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, typhoid fever ', Warthin's tumor\n s/p Rt parotidectomy\n PSH: s/p Rt parotidectomy ', R nephrectomy (metanephric adenoma '),\n BPH s/p TURP ', diverticulitis s/p diverticulectomy ' c/b post-op\n leak/pancreatitis, s/p desmoplastic melanoma nares, s/p rsxn, skin\n grafts\n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Patient lethargic, arouses to speech\n Minimal vocalization noted. Patient will moan and occasionally say his\n name, very garbled speech.\n Follows simple commands.\n Mae equal strength.\n Perrla.\n Right eye remains open, orbital edema\n Lumbar drain remains open at 0cm at shoulder level.\n Patient denies pain.\n Sr with frequent pvcs noted.\n SBp maintained within parameters of <140\n Action:\n Patient neuro checks monitored Q1.\n Patient had MRI, (collection of fluid and air noted. Team aware)\n Lumbar drain remained open to drain 10-15cc hrly.\n Cream applied to right eye to prevent drying\n Iv magnesium and phos given to correct electrolytes\n Response:\n No change in neuro status at time of report.\n MRI results reviewed by team\n Lumbar drain to remained open and 10-15cc drained Hrly\n Plan:\n Continue to monitor neuro checks Hrly, report any changes to team\n Lumbar drain to remain open, head of bed elevated to 30.\n Monitor labs and give iv supplements as needed.\n Monitor pain and administer analgesia as needed.\n As patient lethargic patient unable to take , need tube feeding,\n sicu team will liase with neuro/ with regard to placement of NGt vs\n Peg tube vs starting TPN.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Lungs clear, weak cough, needs assistance with clearing oral secretions\n Action:\n Patient turned Q2, chest pt preformed.\n Deep breathing coughing encouraged.\n Suctioned as needed.\n Patient remains on open face mask, as patient appears to be a mouth\n breather and oral mucosa very dry.\n Oral hygiene maintained\n Response:\n Patient lungs remain clear.\n Afibrile\n Maintaining O2 sats >97%\n Patient clearing secretions with assistance.\n Plan:\n To continue with pulmonary toileting as needed.\n Turn patient Q2\n Encourage deep breathing and coughing.\n Monitor o2 sats and resp.\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571231,
"text": "76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal crainotomy for mass excision \n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Patient s/p mass excision on , lethargic, easily arousable,\n following commands, weaker on rt side, known to neuro team ,\n Dr. in to see the patient at 1900\n Action:\n Response:\n Plan:\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2131-05-13 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571307,
"text": "SICU\n HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal craniotomy for mass excision \n Chief complaint:\n metastatic desmoplastic melanoma\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, typhoid fever ', Warthin's tumor,\n metanephric adenoma, diverticulitis, BPH\n PSH: R parotidectomy ', R nephrectomy ', TURP ',\n diverticulectomy ' c/b post-op leak/pancreatitis, rsxn of melanoma of\n nares, skin grafts\n : ASA 81', Norvasc 5 qhs, Prilosec 20', Altace 10\"\n Current medications:\n 1. Magnesium Sulfate 2 gm IV ONCE Duration: 1 Doses Order date: @\n 0806\n 2. 20 mEq Potassium Chloride / 1000 mL NS Continuous at 75 ml/hr Change\n to peripheral lock when taking POs Order date: @ 1658\n 3. Metoprolol Tartrate 7.5 mg IV Q4H:PRN SBP>140 Hold for HR<60. Order\n date: @ 0502\n 4. Acetaminophen 325-650 mg PO Q6H:PRN pain Order date: @ 1658\n 5. NiCARdipine 1-3 mcg/kg/min IV DRIP TITRATE TO SBP<140 Order date:\n @ 1658\n 6. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes Order date:\n @ 2115\n 7. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 1658\n 8. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes Order date:\n @ 0809\n 9. Pantoprazole 40 mg IV Q24H Order date: @ 1658\n 10. Docusate Sodium 100 mg PO BID Order date: @ 1658\n 11. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\n 1649\n 12. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN pain Order date:\n @ 1723\n 13. Potassium Chloride IV Sliding Scale Order date: @ 1718\n 14. Heparin 5000 UNIT SC TID Start: In am Order date: @ 1658\n 15. HydrALAzine 10 mg IV Q6H SBP>160 Order date: @ 1658\n 16. Sodium Phosphate IV Sliding Scale Order date: @ 0420\n 17. Insulin SC (per Insulin Flowsheet) Sliding Scale Order date:\n @ 1829\n 18. Vancomycin 1000 mg IV Q 12H ID Approval will be required for this\n order in 12 hours. Order date: @ 1658\n 19. LeVETiracetam 500 mg IV BID Order date: @ 1658\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 08:30 AM\n Intermittently following commands. Underwent CT for ?RUE weakness ->\n unchanged since MRI.\n Allergies:\n Penicillins\n Unknown;\n Hayfever (Nasal) (Homeopathic Drugs)\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 01:44 AM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Metoprolol - 08:04 PM\n Hydralazine - 11:04 PM\n Other medications:\n Flowsheet Data as of 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 36.6\nC (97.8\n HR: 81 (68 - 98) bpm\n BP: 143/55(79) {128/46(69) - 168/74(101)} mmHg\n RR: 16 (15 - 21) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 2,950 mL\n 424 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,950 mL\n 424 mL\n Blood products:\n Total out:\n 1,853 mL\n 383 mL\n Urine:\n 1,540 mL\n 345 mL\n NG:\n Stool:\n Drains:\n 313 mL\n 38 mL\n Balance:\n 1,097 mL\n 41 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 97%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress, sleeping\n HEENT: R eye irritation\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: No(t) Drainage), bloody secretions suctioned,\n no gag\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows fewer simple commands, (Responds to: Verbal\n stimuli), Moves all extremities, less on the left.intermittently\n moves all extremities to command. Poor gag\n Labs / Radiology\n 223 K/uL\n 11.1 g/dL\n 114 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 21 mg/dL\n 111 mEq/L\n 140 mEq/L\n 32.9 %\n 12.8 K/uL\n [image002.jpg]\n 07:31 PM\n 09:15 PM\n 02:45 AM\n 03:05 AM\n 05:13 PM\n 11:50 PM\n 02:51 AM\n 03:09 AM\n 02:57 AM\n WBC\n 12.9\n 11.6\n 16.7\n 12.8\n Hct\n 42.5\n 40.8\n 34.0\n 32.9\n Plt\n 23\n Creatinine\n 1.1\n 1.1\n 0.9\n 0.8\n TCO2\n 24\n 25\n 21\n 23\n 25\n Glucose\n 133\n 128\n 116\n 123\n 114\n Other labs: PT / PTT / INR:12.4/21.8/1.0, Ca:8.9 mg/dL, Mg:2.3 mg/dL,\n PO4:2.3 mg/dL\n Imaging: MRI: lg intracranial gas/fluid collection posteriorly\n displacing frontal lobes\n CT head: unchanged from MRI\n Assessment and Plan\n .H/O MELANOMA (CANCER, MALIGNANT NEOPLASM, SKIN), RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/)\n Assessment and Plan: 76M with metastatic desmoplastic melanoma to the\n ethmoid and frontal regions s/p bifrontal craniotomy for mass excision\n \n Neurologic: Neuro checks Q: 1 hr, Stable neuro exam. Lumbar drain at\n 5cc/hr overnight -> clamp in AM as . Keppra for seizure\n prophylaxis.\n Cardiovascular: Keep SBP<140 w/ prn Lopressor & hydralazine. Currently\n not requiring nicardipine gtt.\n Pulmonary: IS, Pulm toilet, suctioning, nebs, supplemental O2.\n Gastrointestinal / Abdomen: Mental status not clear enough to eat.\n Will hold off on TF for several days given risk of brain injury w/ NGT.\n Nutrition: NPO\n Renal: Foley, Adequate UO, Stable Cr & lytes.\n Hematology: Hct stable.\n Endocrine: RISS, Goal FS<150.\n Infectious Disease: WBC decreasing.\n Lines / Tubes / Drains: Foley. ENT to place feeding tube.\n Wounds:\n Imaging:\n Fluids: NS\n Consults: Neuro surgery, ENT\n Billing Diagnosis: Other: s/p brain mass excision\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:58 PM\n Multi Lumen - 05:18 PM\n 18 Gauge - 06:10 PM\n 16 Gauge - 06:11 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2131-05-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571467,
"text": "SICU\n HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal craniotomy for mass excision \n Chief complaint:\n s/p craniotomy\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, typhoid fever ', Warthin's tumor,\n metanephric adenoma, diverticulitis, BPH\n PSH: R parotidectomy ', R nephrectomy ', TURP ',\n diverticulectomy ' c/b post-op leak/pancreatitis, rsxn of melanoma of\n nares, skin grafts\n Current medications:\n 20 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4. Artificial\n Tear Ointment 5. Artificial Tear Ointment\n 6. Docusate Sodium 7. HYDROmorphone (Dilaudid) 8. Heparin 9.\n HydrALAzine 10. Insulin 11. LeVETiracetam\n 12. Mannitol 20% 13. Metoprolol Tartrate 14. NiCARdipine 15.\n Ondansetron 16. Pantoprazole 17. Pneumococcal Vac Polyvalent 18.\n Potassium Chloride 19. Sodium Chloride 0.9% Flush 20. Sodium Phosphate\n 21. Vancomycin\n 24 Hour Events:\n : repeat CT head, started on mannitol\n Allergies:\n Penicillins\n Unknown;\n Hayfever (Nasal) (Homeopathic Drugs)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:36 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Metoprolol - 04:00 AM\n Other medications:\n Flowsheet Data as of 05:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.1\nC (98.8\n HR: 72 (64 - 86) bpm\n BP: 140/54(80) {123/48(71) - 155/64(89)} mmHg\n RR: 16 (15 - 20) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 2,875 mL\n 499 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,875 mL\n 499 mL\n Blood products:\n Total out:\n 1,826 mL\n 510 mL\n Urine:\n 1,735 mL\n 510 mL\n NG:\n Stool:\n Drains:\n 91 mL\n Balance:\n 1,049 mL\n -11 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 98%\n ABG: 7.43/35/113/24/0\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , No(t) Rhonchorous : , Diminished: breath sounds at\n bases), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 1), (Responds to: Verbal\n stimuli, Tactile stimuli, Noxious stimuli), Moves all extremities,\n inconsistently moves all extremities on neuroexam\n Labs / Radiology\n 254 K/uL\n 10.8 g/dL\n 110 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 112 mEq/L\n 143 mEq/L\n 31.7 %\n 10.4 K/uL\n [image002.jpg]\n 09:15 PM\n 02:45 AM\n 03:05 AM\n 05:13 PM\n 11:50 PM\n 02:51 AM\n 03:09 AM\n 02:57 AM\n 02:52 AM\n 03:41 AM\n WBC\n 11.6\n 16.7\n 12.8\n 10.4\n Hct\n 40.8\n 34.0\n 32.9\n 31.7\n Plt\n 54\n Creatinine\n 1.1\n 0.9\n 0.8\n 0.9\n TCO2\n 24\n 25\n 21\n 23\n 25\n 24\n Glucose\n 128\n 116\n 123\n 114\n 110\n Other labs: PT / PTT / INR:12.4/21.8/1.0, Ca:8.8 mg/dL, Mg:2.2 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n .H/O MELANOMA (CANCER, MALIGNANT NEOPLASM, SKIN), RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/)\n Assessment and Plan: 76M with metastatic desmoplastic melanoma to the\n ethmoid and frontal regions s/p bifrontal craniotomy for mass excision\n \n Neurologic: Neuro checks Q: 1 hr, Pain controlled, Q1 neuro checks, HOB\n 30, Keppra for seizure prophylaxis, started on mannitol to decrease\n swelling, Lumbar clamped, NS to remove lumbar today\n Cardiovascular: Beta-blocker, SBP<140, prn hydralazine & Lopressor\n Pulmonary: pulm toilet, supplemental O2 prn\n Gastrointestinal / Abdomen: NPO, ?TF p several days (call ENT for NGT\n placement)\n Nutrition: NPO, consider starting tube feedings after ENT places NGT\n Renal: Foley, Adequate UO, Foley, adequate UOP, stable Cr & lytes.\n Hematology: HOLD heparin sc 5 hours prior to removing lumbar MON\n am \n Endocrine: RISS, RISS, goal FS<150\n Infectious Disease: Vanc for , WBC decreasing, will dc vanc when\n out\n Lines / Tubes / Drains: Foley, lumbar , , RIJ\n Wounds: Dry dressings, clean, dry, intact\n Imaging:\n Fluids: NS, 75cc/hr\n Consults: Neuro surgery, ENT\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 04:58 PM\n Multi Lumen - 05:18 PM\n 18 Gauge - 06:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571672,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n pt awake-verbalizing more. c/o gen\nl aches.\n on pain scale\n pt reposition freq.\n Action:\n medicate w/ dilaudid x2\n Response:\n good pain control- pain level\n-tolerable\n Plan:\n cont. to assess pain issue\n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n pt alert and oriented x2-3. perl. Following commands consistently\n vss. b/p<160. speech clear. c/o dry mouth/throath-able to tolerate\n small sips of water w/ straw with problem swallowing.\n Action:\n hob ^30 degrees for aspiration precautions.\n freq neuro checks.\n Hydralazine and Lopressor for b/p control\n Response:\n neuro status improving.\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571035,
"text": ".H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571039,
"text": "76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal crainotomy for mass excision \n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Patient s/p excision of frontal mass on . With lumbar drain,\n Patient having occasional PVC\ns noted on the monitor, Lytes checked &\n WNL. Dr. informed.\n Action:\n Patient was extubated yesterday, Neuro checks q1h, SBP goal <140, was\n on nicardipine gtt for blood pressure control, , weaned down & off from\n 2330.on Hydralazine q6h for Bld pressure control & Lopressor PRN, 5mg\n Lopressor given x1\n Response:\n Pt is lethargic, waking up to call easily, following commands, Equal\n strength all extremities, PERL, answering\n to pain, not talking\n in a sentence, SICU MD informed of the same, Lumbar drain draining\n clear CSF ~ 15-20cc/hr. oriented x1, aware of self not to place or\n time.\n Plan:\n Cont monitoring, neuro checks q1h, for MRI at 8am today, check list\n sent during the day.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient got extubated yesterday , LS clear, good cough, O 2sat 92-93%\n with 4 L o2 NC, Po2 66 in the ABG\n Action:\n Face tent with 10 L o2 added, encouraged deep breath & cough. Refusing\n for suction from throat.\n Response:\n Patient coughing ? Swallowing the secretions. O 2sat 97-98% Po2 110\n with repeated ABG.\n Plan:\n Pulm hygiene, encourage deep breath & cough, wean down O2 according to\n O 2sat.\n"
},
{
"category": "Physician ",
"chartdate": "2131-05-12 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571100,
"text": "SICU\n HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal crainotomy for mass excision \n Chief complaint:\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, thyphoid fever ', Warthin's tumor\n s/p Rt parotidectomy\n PSH: s/p Rt parotidectomy ', R nephrectomy (metanephric adenoma '),\n BPH s/p TURP ', diverticulitis s/p diverticulectomy ' c/b post-op\n leak/pancreatitis, s/p desmoplastic melanoma nares, s/p rsxn, skin\n grafts\n Current medications:\n 1. 2. 20 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4.\n Amlodipine 5. Artificial Tear Ointment\n 6. Artificial Tear Ointment 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Docusate Sodium 9. HYDROmorphone (Dilaudid)\n 10. HYDROmorphone (Dilaudid) 11. Heparin 12. HydrALAzine 13. Insulin\n 14. LeVETiracetam 15. Metoprolol Tartrate\n 16. NiCARdipine 17. Ondansetron 18. Pantoprazole 19. Pneumococcal Vac\n Polyvalent 20. Potassium Chloride\n 21. Propofol 22. Ramipril 23. Senna 24. Sodium Chloride 0.9% Flush 25.\n Vancomycin\n 24 Hour Events:\n EXTUBATION - At 01:22 PM\n Post operative day:\n POD#2 s/p bifrontal craniotomy\n Allergies:\n Penicillins\n Unknown;\n Hayfever (Nasal) (Homeopathic Drugs)\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 01:44 AM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 12:31 PM\n Hydromorphone (Dilaudid) - 02:09 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Flowsheet Data as of 04:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.2\nC (99\n HR: 76 (72 - 96) bpm\n BP: 135/53(74) {120/48(69) - 155/62(87)} mmHg\n RR: 17 (13 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 2,765 mL\n 356 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,765 mL\n 356 mL\n Blood products:\n Total out:\n 1,702 mL\n 272 mL\n Urine:\n 1,257 mL\n 200 mL\n NG:\n Stool:\n Drains:\n 445 mL\n 72 mL\n Balance:\n 1,063 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 573 (515 - 573) mL\n PS : 5 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 10 cmH2O\n SPO2: 98%\n ABG: 7.44/35/111/23/0\n Ve: 10.7 L/min\n PaO2 / FiO2: 277\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), occasional extra beats\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, Moves all extremities, arousable,\n can say yes/no to questions, has not talked otherwise\n Labs / Radiology\n 211 K/uL\n 11.5 g/dL\n 123 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 19 mg/dL\n 108 mEq/L\n 137 mEq/L\n 34.0 %\n 16.7 K/uL\n [image002.jpg]\n 07:31 PM\n 09:15 PM\n 02:45 AM\n 03:05 AM\n 05:13 PM\n 11:50 PM\n 02:51 AM\n 03:09 AM\n WBC\n 12.9\n 11.6\n 16.7\n Hct\n 42.5\n 40.8\n 34.0\n Plt\n \n Creatinine\n 1.1\n 1.1\n 0.9\n TCO2\n 24\n 25\n 21\n 23\n 25\n Glucose\n 133\n 128\n 116\n 123\n Other labs: PT / PTT / INR:12.4/21.8/1.0, Ca:8.8 mg/dL, Mg:2.0 mg/dL,\n PO4:2.2 mg/dL\n Assessment and Plan\n .H/O MELANOMA (CANCER, MALIGNANT NEOPLASM, SKIN), RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/)\n Assessment and Plan: 76M with metastatic desmoplastic melanoma to the\n ethmoid and frontal regions s/p bifrontal crainotomy for mass excision\n \n Neurologic: Neuro checks Q: 2 hr, Pain controlled, Keppra for seizure\n prophylaxis, to have MRI this AM, lumbar drain in place.\n Cardiovascular: Beta-blocker, Prn lopressor, hydralazine. Currently\n off nicardipine. Goal SBP<140.\n Pulmonary: Supplemental O2 prn.\n Gastrointestinal / Abdomen: NPO ? Is an NG tube safe to place???\n Will check with Neurosurg\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, Replete lytes prn.\n Hematology: Serial Hct, Hct dropped to 34, will follow.\n Endocrine: RISS\n Infectious Disease: On Vanco while drain in place. WBC 16 k . Will\n follow\n Lines / Tubes / Drains: Foley, Lumbar drain, A-line, RIJ TLC\n Wounds:\n Imaging: MRI today.\n Fluids: NS, with 20 KCl @ 75 cc/hr.\n Consults: Neuro surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:58 PM\n Multi Lumen - 05:18 PM\n 18 Gauge - 06:10 PM\n 16 Gauge - 06:11 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2131-05-12 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571025,
"text": "SICU\n HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal crainotomy for mass excision \n Chief complaint:\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, thyphoid fever ', Warthin's tumor\n s/p Rt parotidectomy\n PSH: s/p Rt parotidectomy ', R nephrectomy (metanephric adenoma '),\n BPH s/p TURP ', diverticulitis s/p diverticulectomy ' c/b post-op\n leak/pancreatitis, s/p desmoplastic melanoma nares, s/p rsxn, skin\n grafts\n Current medications:\n 1. 2. 20 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4.\n Amlodipine 5. Artificial Tear Ointment\n 6. Artificial Tear Ointment 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Docusate Sodium 9. HYDROmorphone (Dilaudid)\n 10. HYDROmorphone (Dilaudid) 11. Heparin 12. HydrALAzine 13. Insulin\n 14. LeVETiracetam 15. Metoprolol Tartrate\n 16. NiCARdipine 17. Ondansetron 18. Pantoprazole 19. Pneumococcal Vac\n Polyvalent 20. Potassium Chloride\n 21. Propofol 22. Ramipril 23. Senna 24. Sodium Chloride 0.9% Flush 25.\n Vancomycin\n 24 Hour Events:\n EXTUBATION - At 01:22 PM\n Post operative day:\n POD#2 s/p bifrontal craniotomy\n Allergies:\n Penicillins\n Unknown;\n Hayfever (Nasal) (Homeopathic Drugs)\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 01:44 AM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 12:31 PM\n Hydromorphone (Dilaudid) - 02:09 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Flowsheet Data as of 04:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.2\nC (99\n HR: 76 (72 - 96) bpm\n BP: 135/53(74) {120/48(69) - 155/62(87)} mmHg\n RR: 17 (13 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 2,765 mL\n 356 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,765 mL\n 356 mL\n Blood products:\n Total out:\n 1,702 mL\n 272 mL\n Urine:\n 1,257 mL\n 200 mL\n NG:\n Stool:\n Drains:\n 445 mL\n 72 mL\n Balance:\n 1,063 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 573 (515 - 573) mL\n PS : 5 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 10 cmH2O\n SPO2: 98%\n ABG: 7.44/35/111/23/0\n Ve: 10.7 L/min\n PaO2 / FiO2: 277\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), occasional extra beats\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, Moves all extremities, arousable,\n can say yes/no to questions, has not talked otherwise\n Labs / Radiology\n 211 K/uL\n 11.5 g/dL\n 123 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 19 mg/dL\n 108 mEq/L\n 137 mEq/L\n 34.0 %\n 16.7 K/uL\n [image002.jpg]\n 07:31 PM\n 09:15 PM\n 02:45 AM\n 03:05 AM\n 05:13 PM\n 11:50 PM\n 02:51 AM\n 03:09 AM\n WBC\n 12.9\n 11.6\n 16.7\n Hct\n 42.5\n 40.8\n 34.0\n Plt\n \n Creatinine\n 1.1\n 1.1\n 0.9\n TCO2\n 24\n 25\n 21\n 23\n 25\n Glucose\n 133\n 128\n 116\n 123\n Other labs: PT / PTT / INR:12.4/21.8/1.0, Ca:8.8 mg/dL, Mg:2.0 mg/dL,\n PO4:2.2 mg/dL\n Assessment and Plan\n .H/O MELANOMA (CANCER, MALIGNANT NEOPLASM, SKIN), RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/)\n Assessment and Plan: 76M with metastatic desmoplastic melanoma to the\n ethmoid and frontal regions s/p bifrontal crainotomy for mass excision\n \n Neurologic: Neuro checks Q: 1 hr, Pain controlled, Keppra for seizure\n prophylaxis, to have MRI this AM, lumbar drain in place.\n Cardiovascular: Beta-blocker, Prn lopressor, hydralazine. Currently\n off nicardipine. Goal SBP<140.\n Pulmonary: Supplemental O2 prn.\n Gastrointestinal / Abdomen: Advance diet as tolerated today.\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, Replete lytes prn.\n Hematology: Serial Hct, Hct dropped to 34, will follow.\n Endocrine: RISS\n Infectious Disease: On Vanco while drain in place.\n Lines / Tubes / Drains: Foley, Lumbar drain, A-line, RIJ TLC\n Wounds:\n Imaging: MRI today.\n Fluids: NS, with 20 KCl @ 75 cc/hr.\n Consults: Neuro surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:58 PM\n Multi Lumen - 05:18 PM\n 18 Gauge - 06:10 PM\n 16 Gauge - 06:11 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2131-05-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571576,
"text": "SICU\n HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal craniotomy for mass excision \n Chief complaint:\n s/p craniotomy\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, typhoid fever ', Warthin's tumor,\n metanephric adenoma, diverticulitis, BPH\n PSH: R parotidectomy ', R nephrectomy ', TURP ',\n diverticulectomy ' c/b post-op leak/pancreatitis, rsxn of melanoma of\n nares, skin grafts\n Current medications:\n 20 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4. Artificial\n Tear Ointment 5. Artificial Tear Ointment\n 6. Docusate Sodium 7. HYDROmorphone (Dilaudid) 8. Heparin 9.\n HydrALAzine 10. Insulin 11. LeVETiracetam\n 12. Mannitol 20% 13. Metoprolol Tartrate 14. NiCARdipine 15.\n Ondansetron 16. Pantoprazole 17. Pneumococcal Vac Polyvalent 18.\n Potassium Chloride 19. Sodium Chloride 0.9% Flush 20. Sodium Phosphate\n 21. Vancomycin\n 24 Hour Events:\n : repeat CT head, started on mannitol\n Allergies:\n Penicillins\n Unknown;\n Hayfever (Nasal) (Homeopathic Drugs)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:36 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Metoprolol - 04:00 AM\n Other medications:\n Flowsheet Data as of 05:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.1\nC (98.8\n HR: 72 (64 - 86) bpm\n BP: 140/54(80) {123/48(71) - 155/64(89)} mmHg\n RR: 16 (15 - 20) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 2,875 mL\n 499 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,875 mL\n 499 mL\n Blood products:\n Total out:\n 1,826 mL\n 510 mL\n Urine:\n 1,735 mL\n 510 mL\n NG:\n Stool:\n Drains:\n 91 mL\n Balance:\n 1,049 mL\n -11 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 98%\n ABG: 7.43/35/113/24/0\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : Diminished: breath sounds at bases),\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Arousable / Oriented: x 1), (Responds to: Verbal\n stimuli, Tactile stimuli, Noxious stimuli), Moves all extremities,\n inconsistently moves all extremities on neuroexam\n Labs / Radiology\n 254 K/uL\n 10.8 g/dL\n 110 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 112 mEq/L\n 143 mEq/L\n 31.7 %\n 10.4 K/uL\n [image002.jpg]\n 09:15 PM\n 02:45 AM\n 03:05 AM\n 05:13 PM\n 11:50 PM\n 02:51 AM\n 03:09 AM\n 02:57 AM\n 02:52 AM\n 03:41 AM\n WBC\n 11.6\n 16.7\n 12.8\n 10.4\n Hct\n 40.8\n 34.0\n 32.9\n 31.7\n Plt\n 54\n Creatinine\n 1.1\n 0.9\n 0.8\n 0.9\n TCO2\n 24\n 25\n 21\n 23\n 25\n 24\n Glucose\n 128\n 116\n 123\n 114\n 110\n Other labs: PT / PTT / INR:12.4/21.8/1.0, Ca:8.8 mg/dL, Mg:2.2 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n .H/O MELANOMA (CANCER, MALIGNANT NEOPLASM, SKIN), RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/)\n Assessment and Plan: 76M with metastatic desmoplastic melanoma to the\n ethmoid and frontal regions s/p bifrontal craniotomy for mass excision\n \n Neurologic: Neuro checks Q: 1 hr, Pain controlled, HOB 30, Keppra for\n seizure prophylaxis, started on mannitol to decrease swelling, Lumbar\n clamped, NS to remove lumbar today, repeat CT today\n Cardiovascular: Beta-blocker, SBP<140, prn hydralazine & Lopressor,\n PVCs (has at baseline)\n Pulmonary: pulm toilet, supplemental O2 prn\n Gastrointestinal / Abdomen: NPO, start TF (call ENT for NGT placement)\n Nutrition: NPO, consider starting tube feedings after ENT places NGT\n Renal: Foley, Adequate UOP\n Hematology: HOLD heparin sc 5 hours prior to removing lumbar MON\n am \n Endocrine: RISS, goal FS<150\n Infectious Disease: Vanc for , WBC decreasing, will dc vanc when\n out\n Lines / Tubes / Drains: Foley, lumbar , , RIJ\n Wounds: Dry dressings, clean, dry, intact\n Imaging: CT head\n Fluids: NS, 75cc/hr\n Consults: Neuro surgery, ENT\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 04:58 PM\n Multi Lumen - 05:18 PM\n 18 Gauge - 06:10 PM\n Prophylaxis:\n DVT: heparin, boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571076,
"text": "76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal crainotomy for mass excision \n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Patient s/p excision of frontal mass on . With lumbar drain,\n Patient having occasional PVC\ns noted on the monitor, Lytes checked &\n WNL. Dr. informed.\n Action:\n Patient was extubated yesterday, Neuro checks q1h, SBP goal <140, was\n on nicardipine gtt for blood pressure control, , weaned down & off from\n 2330.on Hydralazine q6h for Bld pressure control & Lopressor PRN, 5mg\n Lopressor given x1\n Response:\n Pt is lethargic, waking up to call easily, following commands, Equal\n strength all extremities, PERL, answering\n to pain, not talking\n in a sentence, SICU MD informed of the same, Lumbar drain draining\n clear CSF ~ 15-20cc/hr. oriented x1\n disoriented at times.\n Plan:\n Cont monitoring, neuro checks q1h, for MRI at 8am today, check list\n sent during the day.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient got extubated yesterday , LS clear, good cough, O 2sat 92-93%\n with 4 L o2 NC, Po2 66 in the ABG\n Action:\n Face tent with 10 L o2 added, encouraged deep breath & cough. Refusing\n for suction from throat.\n Response:\n Patient coughing ? Swallowing the secretions. O 2sat 97-98% Po2 110\n with repeated ABG.\n Plan:\n Pulm hygiene, encourage deep breath & cough, wean down O2 according to\n O 2sat., reorient as needed\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571276,
"text": "76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal crainotomy for mass excision \n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Patient s/p mass excision on , lethargic, easily arousable,\n following commands, weaker on rt side, known to neuro team ,\n Dr. in to see the patient at 1900.\n Action:\n Neuro checks q1h, SBP goal <140, prn Lopressor , & Hydralazine 10mg q6h\n for HT,Rt eyelid slightly open, eye ointments applied. Lumbar drain\n open at 0 cm at shoulder level, draining clear CSF, goal 5cc/hr\n Response:\n Still lethargic, following commands, rt hand moves to pain only, did\n squeeze with rt hand few times, slow in answering, garbled speech,\n neuro team aware, expecting slow progress per Dr.. Denies\n any pain. Initial post op dressing intact & dry, face is slightly\n swollen up on rt side.\n Plan:\n Cont neuro checks q1h, SBP goal <140, lumbar drain still intact, open\n at 0cm shoulder level , goal 5cc/hr, plan to clamp it today.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Patient is on 100% face tent, breathing through mouth, and slight\n bleeding from mouth.\n Action:\n Frequent mouth care & moisturizing cream applied, oral suction done, pt\n is coughing out, but not able to clear sputum.\n Response:\n Needs assistance to clear airway, O 2sat 98-100%, LS clear, good cough,\n but absent gag.\n Plan:\n Pulm hygiene, suction prn, mouth care.\n Patient has very weak - absent gag, no access for feed or meds, po\n meds dc\nd by SICU MD ? need some form of nutrition\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571429,
"text": ".H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Action:\n Response:\n Plan:\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571430,
"text": "HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal craniotomy for mass excision \n Chief complaint:\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, typhoid fever ', Warthin's tumor\n s/p Rt parotidectomy\n PSH: s/p Rt parotidectomy ', R nephrectomy (metanephric adenoma '),\n BPH s/p TURP ', diverticulitis s/p diverticulectomy ' c/b post-op\n leak/pancreatitis, s/p desmoplastic melanoma nares, s/p rsxn, skin\n grafts\n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Action:\n Response:\n Plan:\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2131-05-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571534,
"text": "SICU\n HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal craniotomy for mass excision \n Chief complaint:\n s/p craniotomy\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, typhoid fever ', Warthin's tumor,\n metanephric adenoma, diverticulitis, BPH\n PSH: R parotidectomy ', R nephrectomy ', TURP ',\n diverticulectomy ' c/b post-op leak/pancreatitis, rsxn of melanoma of\n nares, skin grafts\n Current medications:\n 20 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4. Artificial\n Tear Ointment 5. Artificial Tear Ointment\n 6. Docusate Sodium 7. HYDROmorphone (Dilaudid) 8. Heparin 9.\n HydrALAzine 10. Insulin 11. LeVETiracetam\n 12. Mannitol 20% 13. Metoprolol Tartrate 14. NiCARdipine 15.\n Ondansetron 16. Pantoprazole 17. Pneumococcal Vac Polyvalent 18.\n Potassium Chloride 19. Sodium Chloride 0.9% Flush 20. Sodium Phosphate\n 21. Vancomycin\n 24 Hour Events:\n : repeat CT head, started on mannitol\n Allergies:\n Penicillins\n Unknown;\n Hayfever (Nasal) (Homeopathic Drugs)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:36 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Metoprolol - 04:00 AM\n Other medications:\n Flowsheet Data as of 05:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.1\nC (98.8\n HR: 72 (64 - 86) bpm\n BP: 140/54(80) {123/48(71) - 155/64(89)} mmHg\n RR: 16 (15 - 20) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 2,875 mL\n 499 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,875 mL\n 499 mL\n Blood products:\n Total out:\n 1,826 mL\n 510 mL\n Urine:\n 1,735 mL\n 510 mL\n NG:\n Stool:\n Drains:\n 91 mL\n Balance:\n 1,049 mL\n -11 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 98%\n ABG: 7.43/35/113/24/0\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , No(t) Rhonchorous : , Diminished: breath sounds at\n bases), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 1), (Responds to: Verbal\n stimuli, Tactile stimuli, Noxious stimuli), Moves all extremities,\n inconsistently moves all extremities on neuroexam\n Labs / Radiology\n 254 K/uL\n 10.8 g/dL\n 110 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 112 mEq/L\n 143 mEq/L\n 31.7 %\n 10.4 K/uL\n [image002.jpg]\n 09:15 PM\n 02:45 AM\n 03:05 AM\n 05:13 PM\n 11:50 PM\n 02:51 AM\n 03:09 AM\n 02:57 AM\n 02:52 AM\n 03:41 AM\n WBC\n 11.6\n 16.7\n 12.8\n 10.4\n Hct\n 40.8\n 34.0\n 32.9\n 31.7\n Plt\n 54\n Creatinine\n 1.1\n 0.9\n 0.8\n 0.9\n TCO2\n 24\n 25\n 21\n 23\n 25\n 24\n Glucose\n 128\n 116\n 123\n 114\n 110\n Other labs: PT / PTT / INR:12.4/21.8/1.0, Ca:8.8 mg/dL, Mg:2.2 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n .H/O MELANOMA (CANCER, MALIGNANT NEOPLASM, SKIN), RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/)\n Assessment and Plan: 76M with metastatic desmoplastic melanoma to the\n ethmoid and frontal regions s/p bifrontal craniotomy for mass excision\n \n Neurologic: Neuro checks Q: 1 hr, Pain controlled, Q1 neuro checks, HOB\n 30, Keppra for seizure prophylaxis, started on mannitol to decrease\n swelling, Lumbar clamped, NS to remove lumbar today, repeat\n CT today\n Cardiovascular: Beta-blocker, SBP<140, prn hydralazine & Lopressor,\n PVCs (has at baseline)\n Pulmonary: pulm toilet, supplemental O2 prn\n Gastrointestinal / Abdomen: NPO, start TF (call ENT for NGT placement)\n Nutrition: NPO, consider starting tube feedings after ENT places NGT\n Renal: Foley, Adequate UO, Foley, adequate UOP, stable Cr & lytes.\n Hematology: HOLD heparin sc 5 hours prior to removing lumbar MON\n am \n Endocrine: RISS, goal FS<150\n Infectious Disease: Vanc for , WBC decreasing, will dc vanc when\n out\n Lines / Tubes / Drains: Foley, lumbar , , RIJ\n Wounds: Dry dressings, clean, dry, intact\n Imaging: CT head\n Fluids: NS, 75cc/hr\n Consults: Neuro surgery, ENT\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 04:58 PM\n Multi Lumen - 05:18 PM\n 18 Gauge - 06:10 PM\n Prophylaxis:\n DVT: heparin, boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2131-05-13 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571256,
"text": "SICU\n HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal craniotomy for mass excision \n Chief complaint:\n metastatic desmoplastic melanoma\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, typhoid fever ', Warthin's tumor,\n metanephric adenoma, diverticulitis, BPH\n PSH: R parotidectomy ', R nephrectomy ', TURP ',\n diverticulectomy ' c/b post-op leak/pancreatitis, rsxn of melanoma of\n nares, skin grafts\n : ASA 81', Norvasc 5 qhs, Prilosec 20', Altace 10\"\n Current medications:\n 1. Magnesium Sulfate 2 gm IV ONCE Duration: 1 Doses Order date: @\n 0806\n 2. 20 mEq Potassium Chloride / 1000 mL NS Continuous at 75 ml/hr Change\n to peripheral lock when taking POs Order date: @ 1658\n 3. Metoprolol Tartrate 7.5 mg IV Q4H:PRN SBP>140 Hold for HR<60. Order\n date: @ 0502\n 4. Acetaminophen 325-650 mg PO Q6H:PRN pain Order date: @ 1658\n 5. NiCARdipine 1-3 mcg/kg/min IV DRIP TITRATE TO SBP<140 Order date:\n @ 1658\n 6. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes Order date:\n @ 2115\n 7. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 1658\n 8. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes Order date:\n @ 0809\n 9. Pantoprazole 40 mg IV Q24H Order date: @ 1658\n 10. Docusate Sodium 100 mg PO BID Order date: @ 1658\n 11. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\n 1649\n 12. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN pain Order date:\n @ 1723\n 13. Potassium Chloride IV Sliding Scale Order date: @ 1718\n 14. Heparin 5000 UNIT SC TID Start: In am Order date: @ 1658\n 15. HydrALAzine 10 mg IV Q6H SBP>160 Order date: @ 1658\n 16. Sodium Phosphate IV Sliding Scale Order date: @ 0420\n 17. Insulin SC (per Insulin Flowsheet) Sliding Scale Order date:\n @ 1829\n 18. Vancomycin 1000 mg IV Q 12H ID Approval will be required for this\n order in 12 hours. Order date: @ 1658\n 19. LeVETiracetam 500 mg IV BID Order date: @ 1658\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 08:30 AM\n Intermittently following commands. Underwent CT for ?RUE weakness ->\n unchanged since MRI.\n Allergies:\n Penicillins\n Unknown;\n Hayfever (Nasal) (Homeopathic Drugs)\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 01:44 AM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Metoprolol - 08:04 PM\n Hydralazine - 11:04 PM\n Other medications:\n Flowsheet Data as of 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 36.6\nC (97.8\n HR: 81 (68 - 98) bpm\n BP: 143/55(79) {128/46(69) - 168/74(101)} mmHg\n RR: 16 (15 - 21) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 2,950 mL\n 424 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,950 mL\n 424 mL\n Blood products:\n Total out:\n 1,853 mL\n 383 mL\n Urine:\n 1,540 mL\n 345 mL\n NG:\n Stool:\n Drains:\n 313 mL\n 38 mL\n Balance:\n 1,097 mL\n 41 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 97%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress, sleeping\n HEENT: R eye irritation\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: No(t) Drainage), bloody secretions suctioned,\n no gag\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, intermittently moves all extremities to command\n Labs / Radiology\n 223 K/uL\n 11.1 g/dL\n 114 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 21 mg/dL\n 111 mEq/L\n 140 mEq/L\n 32.9 %\n 12.8 K/uL\n [image002.jpg]\n 07:31 PM\n 09:15 PM\n 02:45 AM\n 03:05 AM\n 05:13 PM\n 11:50 PM\n 02:51 AM\n 03:09 AM\n 02:57 AM\n WBC\n 12.9\n 11.6\n 16.7\n 12.8\n Hct\n 42.5\n 40.8\n 34.0\n 32.9\n Plt\n 23\n Creatinine\n 1.1\n 1.1\n 0.9\n 0.8\n TCO2\n 24\n 25\n 21\n 23\n 25\n Glucose\n 133\n 128\n 116\n 123\n 114\n Other labs: PT / PTT / INR:12.4/21.8/1.0, Ca:8.9 mg/dL, Mg:2.3 mg/dL,\n PO4:2.3 mg/dL\n Imaging: MRI: lg intracranial gas/fluid collection posteriorly\n displacing frontal lobes\n CT head: unchanged from MRI\n Assessment and Plan\n .H/O MELANOMA (CANCER, MALIGNANT NEOPLASM, SKIN), RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/)\n Assessment and Plan: 76M with metastatic desmoplastic melanoma to the\n ethmoid and frontal regions s/p bifrontal craniotomy for mass excision\n \n Neurologic: Neuro checks Q: 1 hr, Stable neuro exam. Lumbar drain at\n 5cc/hr overnight -> clamp in AM as . Keppra for seizure\n prophylaxis.\n Cardiovascular: Keep SBP<140 w/ prn Lopressor & hydralazine. Currently\n not requiring nicardipine gtt.\n Pulmonary: IS, Pulm toilet, suctioning, nebs, supplemental O2.\n Gastrointestinal / Abdomen: Mental status not clear enough to eat.\n Will hold off on TF for several days given risk of brain injury w/ NGT.\n Nutrition: NPO\n Renal: Foley, Adequate UO, Stable Cr & lytes.\n Hematology: Hct stable.\n Endocrine: RISS, Goal FS<150.\n Infectious Disease: WBC decreasing.\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: NS\n Consults: Neuro surgery, ENT\n Billing Diagnosis: Other: s/p brain mass excision\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:58 PM\n Multi Lumen - 05:18 PM\n 18 Gauge - 06:10 PM\n 16 Gauge - 06:11 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571150,
"text": "HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal crainotomy for mass excision \n Chief complaint:\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, thyphoid fever ', Warthin's tumor\n s/p Rt parotidectomy\n PSH: s/p Rt parotidectomy ', R nephrectomy (metanephric adenoma '),\n BPH s/p TURP ', diverticulitis s/p diverticulectomy ' c/b post-op\n leak/pancreatitis, s/p desmoplastic melanoma nares, s/p rsxn, skin\n grafts.\n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Action:\n Response:\n Plan:\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2131-05-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571451,
"text": "HPI:\n 76M with metastatic desmoplastic melanoma to the ethmoid and frontal\n regions s/p bifrontal craniotomy for mass excision \n Chief complaint:\n PMHx:\n PMH: HTN, Depression, multiple basal cell cancers, h/o radiation tx for\n teenage acne, scarlet fever @7yr, typhoid fever ', Warthin's tumor\n s/p Rt parotidectomy\n PSH: s/p Rt parotidectomy ', R nephrectomy (metanephric adenoma '),\n BPH s/p TURP ', diverticulitis s/p diverticulectomy ' c/b post-op\n leak/pancreatitis, s/p desmoplastic melanoma nares, s/p rsxn, skin\n grafts\n .H/O melanoma (Cancer, Malignant Neoplasm, Skin)\n Assessment:\n Metastatic desmoplastic melanoma to the ethmoid and frontal regions s/p\n bifrontal craniotomy for mass excision , extubated on , Neuro\n waxes and wanes, Following commands inconsistently, PERL, lethargic,\n Sluggish with activities, Neurosurgery team aware of patient\ns neuro\n status. Patient is in NSR with frequent pvc\ns, all electrolytes wnl.\n Sicu team aware.\n Action:\n Neuro checks q1h, SBP goal <140, still on.Lopressor & Hydralazine for\n Bld pressure control, Lumbar drain clamped from form yesterday,\n Response:\n Unchanged neuro status, communicating with single word like Yes, Okay\n etc. but not consistent. Localizing pain. Pt had CT scan yesterday\n which is unchanged from the previous one and one dose of manitol given\n yesterday.\n Plan:\n Cont monitoring, neuro checks q1h, hold heparin for 5 hours prior to\n removal of lumbar drain. Cont to monitor cardiac rhythm.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Patient was extubated on , still with face tent at 10L O2, Mouth\n breather. Coughing but not able to clear sputum, needs suction from\n mouth.\n Action:\n Oral care frequently, oral suction PRN, HOB >30,\n Response:\n LC + ronchi, O 2sat 97-99%, needs assistance with clearance of sputum,\n ABG okay.\n Plan:\n Pulm toilet, frequent mouth care, as mouth is very dry , patient\n breaths through mouth. Chest PT.Oral suction PRN.\n"
}
] |
32,552 | 126,247 | As mentioned in the HPI Mrs had a cardiac catherization. This prompted her for a redo BP. She underwent usual pre-operative work-up including labs and diagnostics. On she was brought to the operating room where he underwent a Redo off-pump coronary artery bypass graft x2,left saphenous vein graft to left anterior descending artery and obtuse marginal artery . Please see operative report for surgical details. Following surgery she was transferred to the CSRU for invasive monitoring in stable condition. Within 48 hours she was weaned from sedation, awoke neurologically intact and extubated. On post-op day day she was started on beta blockers and diuretics and gently diuresed towards his pre-op weight. Chest tubes were removed on this day and he was transferred to the SDU for further management. On post-op day three her epicardial pacing wires were removed. she remained stable post-operatively and worked with physical therapy for strength and mobility. On post-op day eight she was dischqarge to rehab and the appropriate follow-up appointments. Pt did experience atrail fibrillation. She was converted with BB and amiodorone. She will leave on a taper Medications on Admission: : ASA 325', Metoprolol 200', Quinapril 20', Lipitor 40', Omeprazole20', Amlodipine 5', Detrol LA 4' | Mild (1+) aortic regurgitation is seen. Mild (1+) aorticregurgitation is seen. Normal descending aortadiameter. No TEErelated complications.Conclusions:PRE-BYPASS: The left atrium is mildly dilated. Mild(1+) mitral regurgitation is seen. Mild aortic regurgitation. Very mild (1+) aortic regurgitation isseen. Mild mitral regurgitation. Physiologic TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Bilateral pleural chest tubes and mediastinal chest tubes draining minimal. Mild mitral annularcalcification. Mild mitral annularcalcification. Low normal LVEF.LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Mildly dilated RV cavity. Minimal calcific heterogeneous plaque involving the left common, right common, right external and right internal carotid arteries. Mild (1+) mitralregurgitation is seen. Mild (1+) mitralregurgitation is seen. There is mild symmetricleft ventricular hypertrophy. The right ventricular cavity is mildly dilated.Right ventricular systolic function is normal. The aortic valve leaflets are moderately thickened.There is moderate aortic valve stenosis (area 1.0-1.2cm2). ECG within normal limits. No resting LVOT gradient.RIGHT VENTRICLE: Paradoxic septal motion consistent with conductionabnormality/ventricular pacing.AORTA: Normal aortic diameter at the sinus level.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate AS (AoVA1.0-1.2cm2) Mild (1+) AR.MITRAL VALVE: Moderately thickened mitral valve leaflets. There is no pericardial effusion.IMPRESSION: Preserved global and regional left ventricular systolic function.Mild aortic regurgitation. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is normal in size. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild symmetric LVH. The estimated pulmonary artery systolicpressure is normal. Right ventricular systolic function isnormal. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. There is no pericardial effusion.IMPRESSION: Symmetric LVH with normal global and regional biventricularsystolic function. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 62Weight (lb): 174BSA (m2): 1.80 m2BP (mm Hg): 162/66HR (bpm): 77Status: InpatientDate/Time: at 13:56Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%). There is mild atelectasis in the right mid lung. Mediastinal and right lateral chest tubes are in place. Valvular heart disease.Status: InpatientDate/Time: at 11:01Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement. Minimal plate-like atelectasis is noted at the lung bases. Normal RV systolic function.AORTA: Complex (>4mm) atheroma in the ascending aorta. Emergencystudy performed by the cardiology fellow on call.Conclusions:Left ventricular wall thicknesses and cavity size are normal. Weaning from ventilator at present.OGT draining minimal bilious. The peak systolic velocities, however are normal bilaterally as are the ICA to CCA ratios. Compared to the prior tracingof the Q-T interval is now normal. ECG changes.Height: (in) 62Weight (lb): 175BSA (m2): 1.81 m2BP (mm Hg): 110/65HR (bpm): 87Status: InpatientDate/Time: at 20:22Test: Portable TTE (Focused views)Doppler: No DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT VENTRICLE: Normal LV wall thickness and cavity size. CCO CO running lower than fick CO.Breathsounds clear bilatrally. Normal regional LVsystolic function. Left ventricular function.Height: (in) 62Weight (lb): 175BSA (m2): 1.81 m2BP (mm Hg): 110/65HR (bpm): 84Status: InpatientDate/Time: at 20:26Test: Portable TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:Intravenous propofol was used for sedation.LEFT ATRIUM: Normal LA size. There is no pericardial effusion.The case was performed as an OP CABG and vantricular and valvular function wasmonitored with TEE during the procedure. Midline sternotomy wires and mediastinal clips are noted, compatible with history of prior CABG surgery. Tortuosity of the aorta is noted, with a lobulated contour of the descending aorta noted projecting in the right retrocardiac space. Normal sinus rhythm. Cardiomediastinal contour is unchanged. OR nurse 1cm x 8inch (right) and 1cm x 6inch (left) open skin noted after OR drapes removed. Left ventricular function. Left ventricular function. Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Complex (>4mm) atheroma in the aortic arch. Patient is post median sternotomy and CABG. Atrial paced rhythm which terminates and followed by pause and probably ectopicatrial or junctional beatProbable inferior myocardial infarction - may be acuteST-T wave abnormalities fairly diffuse ST segment elevation - consistent withacute injuryClinical correlation is suggestedSince previous tracing of , findings as described now present As compared with tracing of the rhythm is no longer atrialpaced and the acute myocardial infarction is in evolution. Normal mitralvalve supporting structures. The aortic valve leaflets (3) are mildly thickened but aorticstenosis is not present. FINAL REPORT CHEST RADIOGRAPH PERFORMED ON . Good (>20 cm/s) LAA ejection velocity.RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RAand extending into the RV.LEFT VENTRICLE: Normal LV wall thickness and cavity size. There are complex (>4mm, non-mobile)atheroma in the aortic arch and descending thoracic aorta. The patient is post median sternotomy and CABG. Moderate thickening of mitral valve chordae. Suboptimal technicalquality, a focal LV wall motion abnormality cannot be fully excluded.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. H/o polyups w/BRRB. There is mild symmetric left ventricularhypertrophy with normal cavity size and regional/global systolic function(LVEF>55%). FINDINGS: In comparison with the study of , there is little change in the appearance of the thick streaks of atelectasis at both bases following CABG procedure. Respiratory TherapyPt received from OR s/p CABG x2. | 19 | [
{
"category": "Radiology",
"chartdate": "2109-09-30 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 978850,
"text": " 1:30 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pleural effusion, pulmonary edema, tamponade, pneumothorax.\n Admitting Diagnosis: CORONARY ARTERY DISEASE;+ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with CABG\n REASON FOR THIS EXAMINATION:\n Pleural effusion, pulmonary edema, tamponade, pneumothorax. Pt will be in CSRU\n in 120 minutes. with issues. \n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: SP CABG.\n\n ET tube tip is in standard position, 4 cm above the carina. NG tube tip is in\n the stomach. Mediastinal and right lateral chest tubes are in place. There\n is left lower lobe retrocardiac atelectasis and there is no pneumothorax or\n pleural effusions. There is mild atelectasis in the right mid lung. Swan-Ganz\n catheter tip is in the main pulmonary artery. The patient is post median\n sternotomy and CABG.\n\n Findings were discussed with at the time of the interpretation of\n this study.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2109-09-27 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 978511,
"text": " 5:55 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CORONARY ARTERY DISEASE;+ETT\\CATH\n Admitting Diagnosis: CORONARY ARTERY DISEASE;+ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with CAD, preop for Redo CABG\n REASON FOR THIS EXAMINATION:\n R/o cardiopulmonary processPt is in cath lab holding area, on bedrest until\n 2:30pm\n ______________________________________________________________________________\n WET READ: JRCi 7:28 PM\n no acute cardiopulmonary process identified. evidence of previous cabg.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON .\n\n COMPARISON: None.\n\n CLINICAL HISTORY: 70-year-old woman with coronary artery disease,\n preoperative assessment for redo CABG.\n\n FINDINGS: PA and lateral views of the chest are obtained. Midline sternotomy\n wires and mediastinal clips are noted, compatible with history of prior CABG\n surgery. Minimal plate-like atelectasis is noted at the lung bases. The\n lungs are otherwise clear, demonstrating no evidence of airspace\n consolidation, effusion, or CHF. There is no pneumothorax. The\n cardiomediastinal silhouette is unremarkable. Tortuosity of the aorta is\n noted, with a lobulated contour of the descending aorta noted projecting in\n the right retrocardiac space. The visualized osseous structures are intact.\n\n IMPRESSION:\n\n No acute intrathoracic process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-10-04 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 979470,
"text": " 9:07 AM\n CHEST (PA & LAT) Clip # \n Reason: eval atelectasis postop\n Admitting Diagnosis: CORONARY ARTERY DISEASE;+ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p redo CABG\n REASON FOR THIS EXAMINATION:\n eval atelectasis postop\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Postoperative atelectasis.\n\n FINDINGS: In comparison with the study of , there is little change in the\n appearance of the thick streaks of atelectasis at both bases following CABG\n procedure. The upper lungs remain clear.\n\n\n DR. \n"
},
{
"category": "Echo",
"chartdate": "2109-09-30 00:00:00.000",
"description": "Report",
"row_id": 61398,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. H/O cardiac surgery. ECG changes. Left ventricular function.\nHeight: (in) 62\nWeight (lb): 175\nBSA (m2): 1.81 m2\nBP (mm Hg): 110/65\nHR (bpm): 84\nStatus: Inpatient\nDate/Time: at 20:26\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nIntravenous propofol was used for sedation.\nLEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal regional LV\nsystolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Complex (>4mm) atheroma in the aortic arch. Complex (>4mm) atheroma in\nthe descending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The patient was sedated for the TEE.\nMedications and dosages are listed above (see Test Information section). No\nTEE related complications. The patient appears to be in sinus rhythm.\nEmergency study performed by the cardiology fellow on call. Echocardiographic\nresults were reviewed by telephone with the MD caring for the patient.\nEchocardiographic results were reviewed with the houseofficer caring for the\npatient.\n\nConclusions:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. Left ventricular cavity size is normal with normal global and\nregional systolic function (LVEF>55%). Right ventricular systolic function is\nnormal. A catheter is seen in the right atrium and right ventricle which shows\nno evidence of clot or vegetation. There are complex (>4mm, non-mobile)\natheroma in the aortic arch and descending thoracic aorta. The aortic valve\nleaflets (3) are mildly thickened. Very mild (1+) aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. There is no pericardial effusion.\n\nIMPRESSION: Preserved global and regional left ventricular systolic function.\nMild aortic regurgitation. Mild mitral regurgitation.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2109-09-30 00:00:00.000",
"description": "Report",
"row_id": 61399,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Coronary artery disease. H/O cardiac surgery. Left ventricular function. Mitral valve disease. Valvular heart disease.\nStatus: Inpatient\nDate/Time: at 11:01\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast or thrombus in\nthe body of the LAA. All four pulmonary veins identified and enter the\nleft atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Mild symmetric LVH. Low normal LVEF.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\n\nAORTA: Complex (>4mm) atheroma in the ascending aorta. Normal descending aorta\ndiameter. Complex (>4mm) atheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Moderate AS (AoVA\n1.0-1.2cm2) Mild (1+) AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Mild mitral annular\ncalcification. Moderate thickening of mitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The TEE probe was passed\nwith assistance from the anesthesioology staff using a laryngoscope. No TEE\nrelated complications.\n\nConclusions:\nPRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or\nthrombus is seen in the body of the left atrium or left atrial appendage. No\natrial septal defect is seen by 2D or color Doppler. There is mild symmetric\nleft ventricular hypertrophy. Overall left ventricular systolic function is\nlow normal (LVEF 50-55%). The right ventricular cavity is mildly dilated.\nRight ventricular systolic function is normal. There are complex (>4mm)\natheroma in the ascending aorta. There are complex (>4mm) atheroma in the\ndescending thoracic aorta. The aortic valve leaflets are moderately thickened.\nThere is moderate aortic valve stenosis (area 1.0-1.2cm2). Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are moderately thickened.\nThere is moderate thickening of the mitral valve chordae. Mild (1+) mitral\nregurgitation is seen. There is no pericardial effusion.\n\nThe case was performed as an OP CABG and vantricular and valvular function was\nmonitored with TEE during the procedure.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2109-09-27 00:00:00.000",
"description": "Report",
"row_id": 61400,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 62\nWeight (lb): 174\nBSA (m2): 1.80 m2\nBP (mm Hg): 162/66\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 13:56\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Paradoxic septal motion consistent with conduction\nabnormality/ventricular pacing.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Normal mitral\nvalve supporting structures. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. There is no mitral valve prolapse. Mild\n(1+) mitral regurgitation is seen. The estimated pulmonary artery systolic\npressure is normal. There is no pericardial effusion.\n\nIMPRESSION: Symmetric LVH with normal global and regional biventricular\nsystolic function. Mild aortic regurgitation. Technically-difficult study.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2109-09-30 00:00:00.000",
"description": "Report",
"row_id": 61523,
"text": "PATIENT/TEST INFORMATION:\nIndication: H/O cardiac surgery. Left ventricular function. ECG changes.\nHeight: (in) 62\nWeight (lb): 175\nBSA (m2): 1.81 m2\nBP (mm Hg): 110/65\nHR (bpm): 87\nStatus: Inpatient\nDate/Time: at 20:22\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Suboptimal technical\nquality, a focal LV wall motion abnormality cannot be fully excluded.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Emergency\nstudy performed by the cardiology fellow on call.\n\nConclusions:\nLeft ventricular wall thicknesses and cavity size are normal. Mid-ventricular\nsystolic function is good. Due to suboptimal technical quality, a focal wall\nmotion abnormality cannot be fully excluded. There is no pericardial effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-09-27 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 978482,
"text": " 3:26 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: r/o carotid stenosisPt is in cath lab holding area, bedrest\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with CAD, preop for Redo CABG, s/p Right and Left CEA \n REASON FOR THIS EXAMINATION:\n r/o carotid stenosisPt is in cath lab holding area, bedrest until 2:30pmPlease\n call holding area RN to schedule\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID STUDY DATED THE 14TH\n\n HISTORY: Prior carotid endarterectomy, now preop for redo cardiac bypass.\n\n FINDINGS: No prior studies at this institution for comparison. Minimal\n calcific heterogeneous plaque involving the left common, right common, right\n external and right internal carotid arteries. The peak systolic velocities,\n however are normal bilaterally as are the ICA to CCA ratios. There is also\n normal antegrade flow involving both vertebral arteries.\n\n IMPRESSION: Scattered bilateral plaque as described however, no significant\n ICA or CCA stenosis (ICA stenoses graded as less than 40% bilaterally).\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-10-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 979037,
"text": " 3:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE;+ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p CABG and ct removal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess pneumothorax post chest tube removal.\n\n Comparison is made with prior study dated .\n\n Different tubes and lines have been removed. Discoid atelectases are present\n in the lower lobes bilaterally. There is no pneumothorax or pleural effusion.\n Cardiomediastinal contour is unchanged. Patient is post median sternotomy and\n CABG.\n\n\n DR. \n"
},
{
"category": "Nursing/other",
"chartdate": "2109-09-30 00:00:00.000",
"description": "Report",
"row_id": 1674237,
"text": "Op Day Redo CABG x 2 off pump\nA paced throughout the shift. Underlying rhythm SB/rate of 45. Pt on metoprolol 200mg and took dose this AM pre-op. 12 lead EKG not done post-op yet - waiting for rate to be higher. Initially on Neosynephrine and now on Nitroglyercine. CO/CI by fick from SVO2 of CCO. CCO CO running lower than fick CO.\n\nBreathsounds clear bilatrally. Bilateral pleural chest tubes and mediastinal chest tubes draining minimal. No air leaks from chest tubes. Weaning from ventilator at present.\n\nOGT draining minimal bilious. Abd soft, absent bowel sounds. H/o polyups w/BRRB. Plan to monitor.\n\nHourly urine output adequate via foley.\n\nAwoke and MAE. Initially denied having any pain. Now nods that she is uncomfortable. Codeine (LOC) allergy noted. Needs analgesic order. Plan to obtain analgesic.\n\nOriginal sternal, mediastinal and R leg ACE wrap dressings on. OR nurse 1cm x 8inch (right) and 1cm x 6inch (left) open skin noted after OR drapes removed. Plan to assess.\n\nGlucose elevated. CSRU glucose protocol initiated.\n\nNo phone calls from family or friends.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-09-30 00:00:00.000",
"description": "Report",
"row_id": 1674238,
"text": "Respiratory Therapy\n\nPt received from OR s/p CABG x2. Orally intubated, weaned to PSV +10/+5. SpO2 90s. ABGs good. See resp flowsheet for specifics.\n\nPlan: wean per Cardiac Surgery Fast Track protocol\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-09-30 00:00:00.000",
"description": "Report",
"row_id": 1674239,
"text": "Possible pericarditis\nST elevation noted on bedside monitor. 12 lead EKG done with ~2-4mm elevation in multiple V leads. NP notifed and reported to Dr. via phone. Pt resedated with propofol, Fi02 increased to 100%/SIMV. TEE done by cardiology and reported to show EF 50-55%. Friction rub reported to be present by cardiologist. Plan to awaken, attempt vent wean. No Motrin for pericarditis since patient starting Plavix and ASA. Plavix to start now .\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-09-30 00:00:00.000",
"description": "Report",
"row_id": 1674240,
"text": "Resp Care\nPt extubated without difficulty. Strong cough effort. O2 sat 94 on 50% face tent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-10-01 00:00:00.000",
"description": "Report",
"row_id": 1674241,
"text": "cv: apacing with 100% capture. no ectopy noted. bp stable.Rounds made pacer rate down to 70.\nResp:coughing prod. small amt.s thick, white sputum. breath sounds clear bil. o2 currently on 3l nasal prongs. underlying hr sr -rate 60\nendo: insulin drip off at 0400. will recheck bld. sugar.\nskin: thin, skin tear noted on lt.thigh approx. by 6inches. no drainage. Rt. groin skin pink area 2 inches by 4 inches.\ngu: u/o qs\nGi: c/o of nausea x1-vomited sputum. breath sounds clear bil\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-10-01 00:00:00.000",
"description": "Report",
"row_id": 1674242,
"text": "pacemaker losing capture- ma up to 8, .-2.5 and rate 72 with 100% capture.\n"
},
{
"category": "ECG",
"chartdate": "2109-10-03 00:00:00.000",
"description": "Report",
"row_id": 114010,
"text": "Baseline artifact. Atrial fibrillation with rapid ventricular response.\nThere are periods of regularity and a possibility of atrial flutter with\nvariable conduction should be considered. Possible inferior wall myocardial\ninfarction of indeterminate age. Since the previous tracing of \nthe rate has increased and is more regular. Other features as previously\nnoted. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2109-09-30 00:00:00.000",
"description": "Report",
"row_id": 114056,
"text": "Atrial paced rhythm which terminates and followed by pause and probably ectopic\natrial or junctional beat\nProbable inferior myocardial infarction - may be acute\nST-T wave abnormalities fairly diffuse ST segment elevation - consistent with\nacute injury\nClinical correlation is suggested\nSince previous tracing of , findings as described now present\n\n"
},
{
"category": "ECG",
"chartdate": "2109-09-27 00:00:00.000",
"description": "Report",
"row_id": 114057,
"text": "Normal sinus rhythm. ECG within normal limits. Compared to the prior tracing\nof the Q-T interval is now normal.\n\n"
},
{
"category": "ECG",
"chartdate": "2109-10-02 00:00:00.000",
"description": "Report",
"row_id": 114055,
"text": "Sinus rhythm. There is ST segment elevation in leads II, III, aVF and V1-V6\nconsistent with evolution of acute anterolateral and apical myocardial\ninfarction. As compared with tracing of the rhythm is no longer atrial\npaced and the acute myocardial infarction is in evolution. Clinical\ncorrelation is suggested.\n\n"
}
] |
93,557 | 170,495 | CT ABDOMEN WITH IV CONTRAST: At the lung bases, there is dependent atelectasis bilaterally, with a more focal area of consolidation at the left lung base, unchanged since . H/O respiratory failure, acute (not ARDS/) Assessment: Pt alert/appropriate. H/O respiratory failure, acute (not ARDS/) Assessment: Pt alert/appropriate. Unchanged tracheostomy tube and left-sided central venous access line. The right-sided subclavian approach central venous line has now been removed whereas the left-sided line remains in unchanged position. Ampicillin-Sulbactam 3 g IV Q6H Order date: @ 0308 4. Ampicillin-Sulbactam 3 g IV Q6H Order date: @ 0308 4. Haloperidol 2 mg PO TID:PRN through G tube Order date: @ 1032 32. 1mg IVP Ativan given and Midazolam drip to be started. Haloperidol 2 mg PO TID through G tube Order date: @ 0840 13. Chief complaint: respiratory compromise PMHx: DVT, HTN, hyperlipidemia, CAD s/p MI in Current medications: . Propofol mcg/kg/min IV DRIP TITRATE TO sedation Order date: @ 0139 5. Ampicillin-Sulbactam 3 g IV Q6H Order date: @ 0308 10. Haloperidol 2 mg PO TID through G tube Order date: @ 0840 13. .H/O respiratory failure, acute (not ARDS/) Assessment: -Trach on CPAP/50%/5PEEP/12 PS. Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @ 1209 10. PMH: DVT, HTN, Lipidemia, Hx of MI in s/p PTCA PSH: PEG/trach .H/O pancreatitis, acute Assessment: Awake and following simple commands. Haloperidol 2 mg PO TID through G tube Order date: @ 0751 16. Response: Pt contiues with temperature despite Tylenol. Propofol gtt started and titrated. Chief complaint: hypotension PMHx: PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in PSH: PEG/trach, PTCA Current medications: 1. Piperacillin-Tazobactam Na 18. CloniDINE 0.2 mg PO TID Order date: @ 0751 10. Pt taken to for ERCP. Haloperidol 2 mg PO TID through G tube Order date: @ 0751 16. Haloperidol 2 mg PO TID through G tube Order date: @ 0751 16. Haloperidol 2 mg PO TID through G tube Order date: @ 0751 16. Haloperidol 2 mg PO TID through G tube Order date: @ 0751 16. CloniDINE 0.2 mg PO TID Order date: @ 0751 11. CloniDINE 0.2 mg PO TID Order date: @ 0751 11. Ampicillin-Sulbactam 3 g IV Q6H Order date: @ 0308 10. Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @ 1209 12. Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @ 1209 12. Haloperidol 2 mg PO TID through G tube Order date: @ 0840 13. Haloperidol 2 mg PO TID through G tube Order date: @ 0840 13. -MD Legissety notified of Vancomycin trough of 22.1. Piperacillin-Tazobactam Na 18. Piperacillin-Tazobactam Na 18. -Zosyn/Vancomycin/tobramycin given. -Zosyn/Vancomycin/tobramycin given. -Zosyn/Vancomycin/tobramycin given. -Zosyn/Vancomycin/tobramycin given. Plan: -Hyperglycemia resolved. Plan: -Hyperglycemia resolved. Piperacillin-Tazobactam Na 18. Piperacillin-Tazobactam Na 22. Chief complaint: hypotension PMHx: PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in PSH: PEG/trach, PTCA Current medications: 1. Response: -LS: R+LUL Cear, diminished bibasilar. Transfer to floor if secretions diminished .H/O cholelithiasis Assessment: NPO. -Zosyn/Vancomycin given. Haloperidol 2 mg PO TID through G tube Order date: @ 0751 16. Haloperidol 2 mg PO TID:PRN through G tube Order date: @ 1032 32. CloniDINE 0.2 mg PO TID Order date: @ 0751 11. Miconazole Powder 2% 1 Appl TP TID:PRN Order date: @ 1255 9. Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @ 1209 12. Metoprolol Tartrate 5 mg IV Q4H tachycadia/HTN hold for SBP<100 HR<60 Order date: @ 0753 4. Haloperidol 1 mg PO TID through G tube Order date: @ 1014 13. Metoprolol Tartrate 5 mg IV Q6H tachycadia/HTN hold for SBP<100 HR<60 Order date: @ 1218 6. Lorazepam 2-4 mg IV Q30MIN:PRN agitation Order date: @ 0430 2. Miconazole Powder 2% 1 Appl TP TID:PRN Order date: @ 1255 10. Chlorhexidine Gluconate 0.12% Oral Rinse 5. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308 3. Haloperidol 1 mg PO TID through G tube Order date: @ 1014 20. Haloperidol 1 mg PO TID through G tube Order date: @ 1014 20. Haloperidol 1 mg PO TID through G tube Order date: @ 1014 20. Metoprolol Tartrate 5 mg IV Q6H tachycadia/HTN hold for SBP<100 HR<60 Order date: @ 1218 6. Metoprolol Tartrate 5 mg IV Q6H tachycadia/HTN hold for SBP<100 HR<60 Order date: @ 1218 6. Haloperidol 1 mg PO TID through G tube Order date: @ 1014 13. Haloperidol 1 mg PO TID through G tube Order date: @ 1014 13. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308 3. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308 3. Chlorhexidine Gluconate 0.12% Oral Rinse 6. Chlorhexidine Gluconate 0.12% Oral Rinse 6. Lorazepam 2-4 mg IV Q30MIN:PRN agitation Order date: @ 0430 2. | 207 | [
{
"category": "Radiology",
"chartdate": "2140-04-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1077677,
"text": " 5:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with pancreatitis s/p pseudocyst with ?aspiration pneumonia and\n increased agitation\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Pancreatic pseudocyst, aspiration pneumonia is suspected.\n\n FINDINGS: As compared to the previous radiograph from , the lung\n volumes have minimally decreased. In addition to the pre-existing\n retrocardiac atelectasis, there is now, behind the right heart, a subtle area\n of parenchymal opacity with sparse air bronchograms that could correspond to\n aspiration pneumonia. The volume of the middle lobe, however, is normal.\n There is no evidence of pleural effusion. Unchanged tracheostomy tube and\n left-sided central venous access line.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-12 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1076873,
"text": ", M. SICU-B 11:18 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o gas in pancreatic bed\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with increasing WBC, h/o pancreatic pseudocyst aspiration (grew\n Staph at OSH).\n REASON FOR THIS EXAMINATION:\n r/o gas in pancreatic bed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No new abnormalities in the abdomen or pelvis to explain elevated white blood\n cell count. Persistent focus of consolidation at the left lung base,\n unchanged since . Slight interval decrease in size of pancreatic\n pseudocyst. No new collections in the abdomen or pelvis. Unchanged\n cholelithiasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-12 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1076839,
"text": " 8:59 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: assess CVL placement, r/o PTX\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with new L SCL CVL.\n REASON FOR THIS EXAMINATION:\n assess CVL placement, r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Central line placement.\n\n FINDINGS: In comparison with the study of , there has been placement of a\n left subclavian catheter that extends to the mid-to-lower portion of the SVC,\n just about the same level as the right subclavian catheter. No evidence of\n pneumothorax. Continued low lung volumes. There may be minimal basilar\n atelectatic changes. Some indistinctness of pulmonary vessels is consistent\n with mild elevation of pulmonary venous pressure.\n\n Incidental note is made of a tube in the upper abdomen extending to about the\n midline at the T12 level.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-12 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1076872,
"text": " 11:18 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o gas in pancreatic bed\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with increasing WBC, h/o pancreatic pseudocyst aspiration (grew\n Staph at OSH).\n REASON FOR THIS EXAMINATION:\n r/o gas in pancreatic bed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc TUE 5:56 PM\n No new abnormalities in the abdomen or pelvis to explain elevated white blood\n cell count. Persistent focus of consolidation at the left lung base,\n unchanged since . Slight interval decrease in size of pancreatic\n pseudocyst. No new collections in the abdomen or pelvis. Unchanged\n cholelithiasis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old man with increasing white blood cell count. History\n of pancreatic pseudocyst aspiration.\n\n COMPARISON: CT torso of . CT abdomen of .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\n pelvis following administration of oral and intravenous contrast material.\n Multiplanar reformatted images were generated.\n\n CT ABDOMEN WITH IV CONTRAST: At the lung bases, there is dependent\n atelectasis bilaterally, with a more focal area of consolidation at the left\n lung base, unchanged since . There is no pleural effusion. There\n is no pericardial effusion.\n\n In the abdomen, a multifocal peripancreatic fluid collection is slightly\n decreased in size from the prior study. The more superior portion of the\n collection measures 7.8 x 3.9 cm, previously 8 x 5 cm. The more inferior,\n elongated portion of the fluid collection measures 8.5 x 1.5 cm. Previously,\n this area measured roughly 7.1 x 1.5 cm. There is no increase in inflammatory\n changes surrounding the pancreatic pseudocyst to indicate superinfection.\n There are no foci of air within or adjacent to collections. Pancreatic\n parenchyma enhances normally throughout, without evidence of necrosis. There\n is no pancreatic ductal dilatation.\n\n A percutaneous gastrostomy tube is in place. The liver again demonstrates a\n tubular hypodensity in the left lobe, unchanged. Other small hypodense areas\n are too small to characterize, and unchanged. The gallbladder is\n decompressed, again containing a hyperdense focus at the gallbladder neck,\n consistent with gallstone. There is no evidence of acute cholecystitis. There\n is no intra- or extra-hepatic biliary ductal dilatation.\n\n The spleen, adrenal glands, stomach and duodenum are unremarkable. The\n (Over)\n\n 11:18 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o gas in pancreatic bed\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n kidneys enhance and excrete contrast symmetrically without hydronephrosis or\n renal masses. Bilateral simple cysts are unchanged. There is no free air or\n free fluid in the abdomen. There is no mesenteric or retroperitoneal\n lymphadenopathy by size criteria. Small lymph nodes are scattered throughout\n the mesentery, the largest measuring 5 mm.\n\n CT PELVIS WITH IV CONTRAST: Multiple loops of large and small bowel are\n unremarkable. The urinary bladder is decompressed around a Foley catheter.\n Marked vas deferens calcifications are again noted. There is no free fluid in\n the pelvis. There is no pelvic or inguinal lymphadenopathy by size criteria.\n\n OSSEOUS STRUCTURES: There is no fracture or worrisome lytic or sclerotic\n lesion. Soft tissues are unremarkable.\n\n IMPRESSIONS:\n\n 1. No findings in the abdomen or pelvis to explain elevated white blood cell\n count.\n\n 2. Stable to slightly improved appearance of multifocal pancreatic\n pseudocyst. No pancreatic necrosis.\n\n 3. Stable cholelithiasis without cholecystitis.\n\n 4. Unchanged hepatic hypodensities.\n\n 5. Unchanged appearance of consolidation versus atelectasis at the lung bases\n bilaterally.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1076616,
"text": " 8:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for PNA\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with rising WBC and increased secretions\n REASON FOR THIS EXAMINATION:\n Eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:30 A.M., \n\n HISTORY: Increasing white count and secretions. Suspect pneumonia.\n\n IMPRESSION: AP chest compared to and 30:\n\n Mild cardiomegaly and mediastinal vascular engorgement have worsened\n suggesting volume overload. Lungs are low in volume but grossly clear.\n Tracheostomy tube in standard placement. No pleural abnormality. Right\n subclavian line tip projects over the upper right atrium. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-06 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1075956,
"text": " 11:22 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: -\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with pancreatitis\n REASON FOR THIS EXAMINATION:\n r/o loculated effusions, empyema\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SBNa WED 11:46 PM\n New b/l basilar consolidations, left greater than right. No effusions. Slight\n overall decreased enhancement of pancreas may be due to timing of contrast.\n Interval resolution of CBD stone. Cecal wall thickening (2,108) could be\n stool... correlate with colonscopy. Otherwise no sig change in size of\n pancreatic fluid collection, stranding etc.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pancreatitis. Assess for loculated effusions or empyema.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial images through the torso were obtained following\n the administration of oral and 130 cc of Optiray contrast IV. Coronal and\n sagittal reformatted images were generated.\n\n CT OF THE CHEST WITH CONTRAST: A tracheostomy tube is in place, with tip\n approximately 3.5 cm above the carina, oriented posteriorly. There is a right\n subclavian central venous catheter, with tip in the mid SVC. A nasogastric\n tube is present in the esophagus, with tip located at the GE junction.\n\n There is minimal/mild fluid in the pleural spaces, and dependent density in\n both lung bases is largely due to atelectasis/consolidation with air\n bronchograms, left greater than right. The atelectasis/consolidation is\n increased bilaterally compared to , now moderate on the left.\n Ground-glass density is seen elsewhere within the aerated lungs, which may in\n part be related to respiratory motion during the study. It is difficult to\n assess for underlying lung nodules. The central airways are patent to the\n subsegmental level.\n\n There is no axillary, mediastinal, or hilar lymphadenopathy. There is no\n pericardial effusion. Dense coronary artery calcification versus a stent in\n the left circumflex artery.\n\n CT OF THE ABDOMEN WITH CONTRAST: The timing of the IV contrast bolus(es)\n limits evaluation on this exam. A calcified granuloma is seen in the liver,\n unchanged. A tubular hypodensity in the left lobe of liver is unchanged\n (2:40). It is unclear if this represents a focal dilated intrahepatic bile\n duct or a branch of portal vein (potentially containing thrombus). The\n previously described tiny hypodensities elsewhere within the liver too small\n to characterize are not as well visualized today, possibly due to beam-\n (Over)\n\n 11:22 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: -\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hardening artifact.\n\n The gallbladder is not dilated. A small stone in the porta hepatis region\n measuring 4 mm is in unchanged position compared to . The previously\n noted stone in the distal CBD in the pancreatic head region is no longer\n visualized, consistent with stone removal via ERCP. The CBD is not dilated.\n The spleen is mildly enlarged, at 13.8 cm in AP diameter today. The pancreas\n is not significantly changed in appearance compared to , with edema\n and surrounding stranding related to pancreatitis. Fluid about the pancreas\n is unchanged in distribution. The previously described organizing collection\n anterior and superior to the pancreas, abutting the stomach, is also unchanged\n in size and appearance measuring 8.0 x 4.0 cm (2:50), previously 8.1 x 4.2 cm.\n Mild enhancement is seen throughout the pancreatic parenchyma, a finding\n apparently due to the timing of the contrast bolus on today's study. There is\n no pancreatic ductal dilatation. The splenic vein remains patent, with fluid\n seen between the splenic vein and pancreas, as before.\n\n The adrenal glands are unremarkable. The kidneys enhance symmetrically and\n excrete normally, without hydronephrosis. There are rounded hypodensities of\n the kidneys bilaterally which are not fully characterized but may represent\n cysts. There is no free air in the abdomen. A gastrostomy is unchanged.\n Small bowel loops are nondilated. Colon is unremarkable.\n\n The abdominal aorta is normal in caliber. No mesenteric or retroperitoneal\n nodes are enlarged.\n\n CT OF THE PELVIS WITH CONTRAST: There is a Foley catheter within the bladder,\n which is nearly empty. The prostate is not enlarged. Seminal vesicles are\n unremarkable, except to note calcification of the vas deferens bilaterally.\n The rectum and sigmoid are unremarkable. There is no free pelvic fluid, nor\n pathologically enlarged pelvic or inguinal nodes.\n\n BONE WINDOWS: There are no suspicious osteolytic or sclerotic lesions.\n\n IMPRESSION:\n 1. No significant change in the fluid collection anterior and superior to the\n pancreas, contiguous with the stomach. Findings related to pancreatitis are\n essentially unchanged, except for resolution of the distal CBD stone.\n 2. Minimal/trace pleural fluid. Density in the dependent portion of both\n lungs is largely related to atelectasis/consolidation, left greater than\n right, increased from .\n 3. Unchanged tubular hypodensity in the left lobe of liver, not fully\n characterized on this study. This finding could be related to a focally\n dilated intrahepatic bile duct though it is difficult to exclude thrombus\n within a left portal vein branch. Doppler ultrasound is recommended to better\n (Over)\n\n 11:22 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: -\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n characterize this finding.\n 4. Persistent stone in the porta hepatis region, potentially within the\n cystic duct. However, gallbladder distention is decreased, and there is no CT\n evidence of gallbladder inflammation or obstruction.\n 5. Orogastric tube tip is located at the GE junction, and could be advanced\n into the stomach if clinically indicated.\n\n The targetted doppler ultrasound recommendation to characterize the left\n hepatic lobe finding was discussed with Dr. on the morning of . The\n OG tube position was also textpaged to her.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-07 00:00:00.000",
"description": "DUPLEX DOPP ABD/PEL",
"row_id": 1076094,
"text": ", M. SICU-B 2:35 PM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: Doppler - assess hepatic blood flow\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with ?L portal vein branch thrombus\n REASON FOR THIS EXAMINATION:\n Doppler - assess hepatic blood flow\n ______________________________________________________________________________\n PFI REPORT\n Hypodense region within the left lobe of the liver seen on recent CT\n corresponds to an area of focal fat. For technical reasons, left portal vein\n is not visualized. Main portal vein, right anterior portal vein, and right\n posterior portal vein are all patent.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-07 00:00:00.000",
"description": "DUPLEX DOPP ABD/PEL",
"row_id": 1076093,
"text": " 2:35 PM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: Doppler - assess hepatic blood flow\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with ?L portal vein branch thrombus\n REASON FOR THIS EXAMINATION:\n Doppler - assess hepatic blood flow\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 5:17 PM\n Hypodense region within the left lobe of the liver seen on recent CT\n corresponds to an area of focal fat. For technical reasons, left portal vein\n is not visualized. Main portal vein, right anterior portal vein, and right\n posterior portal vein are all patent.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE DOPPLER ULTRASOUND, \n\n INDICATION: 42-year-old man with question left portal vein branch thrombosis.\n Please assess flow.\n\n COMPARISON: Correlation is made with abdominal CT of .\n\n FINDINGS: Adjacent to the middle hepatic vein, there is an echogenic\n structure corresponding to the abnormality seen on a recent CT. Ultrasound\n findings are suggestive of a small region of focal fat.\n\n The left portal vein is not well visualized, probably related to technical\n factors resulting from a relatively small left lobe.\n\n Main portal vein, right anterior portal vein, and right posterior portal vein\n are all patent and demonstrate normal flow direction. Middle hepatic vein and\n right hepatic vein are visualized and are patent. Left hepatic vein is not\n well visualized. Liver is grossly normal in echotexture. There is no\n intrahepatic biliary dilatation.\n\n IMPRESSION: The hypodensity within the liver appears to correspond to a\n region of focal fat within the liver.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1076921,
"text": " 2:44 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Eval for aspiration\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with bilious secretions\n REASON FOR THIS EXAMINATION:\n Eval for aspiration\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Bilious secretions, evaluate for aspiration.\n\n FINDINGS: AP single view of the chest obtained with patient in sitting semi-\n upright position is analyzed in direct comparison with a preceding similar\n study obtained six hours earlier during the same date. The patient has a\n tracheostomy cannula in unchanged position. The right-sided subclavian\n approach central venous line has now been removed whereas the left-sided line\n remains in unchanged position. No pneumothorax has developed. Heart size is\n unaltered and no pulmonary vascular congestion is noted. As before there are\n a few patchy densities on the left lung base and a crowded appearance of the\n pulmonary vasculature is identified in the retrocardiac area on the left to\n the midline suspicious for some pneumonic infiltrates.The on previous study\n identified linear density on the right side representing an atelectasis, has\n disappeared.\n\n Small patchy infiltrate on left base laterally probably representing some\n inflammatory processes.\n\n Review of a chest CT of confirms the presence of left lower\n lobe posterior infiltrates. Consequently it is recommended to follow up these\n retrocardiac left-sided parenchymal densities. Their location are compatible\n with the clinical suspicion for aspiration. Noteworthy however is that these\n infiltrates have been identified already six days earlier.\n\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 570063,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont trached and on mech vent as per Metavision. Lung\n sounds rhonchi improved with suct mod loose off white sput. ABGs stable\n on current settings; placed on PSV overnoc to rest. Cont PSV/trach mask\n as tol.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 570140,
"text": "Respiratory Care Service: Pt from an OSH w/ an 8.0 Blue Line Trach in\n place. Has been on a Trach Collar .50 and tolerating it well. Went to\n the for an ERCP today. Recovered in 4 and\n transferred back to SICU-B. Will c/w Trach Collar .50 as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570142,
"text": ".H/O pancreatitis, acute\n Assessment:\n Pt much more alert today. Consistently following commands. Denies sob\n or pain. VSS. Afebrile. Lungs clear to coarse throughout. Abd\n softly distended\n (+) bowel sounds. Urine output adequate. Moderate\n amt of loose stool via flexiseal.\n Action:\n Pt encouraged to cough and deep breathe. Pt taken to for\n ERCP. Sphincterotomy and balloon sweep performed by Dr w/\n stone extraction. Pt continues iv antibiotics md\ns orders. Pt\n turned and repositioned frequently. Pt teaching done regarding ICU\n environment.\n Response:\n Pt briefly requiring mechanical ventilation for increased work of\n breathing associated w/ desaturation into the 80\ns. Post ERCP pt able\n to wean to trach collar without difficulty. intact to\n coccyx.\n Plan:\n Cont to monitor for s/s of infection, bleeding. Aggressive pulmonary\n toilet. Cont pt and family teaching.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570144,
"text": ".H/O pancreatitis, acute\n Assessment:\n Pt much more alert today. Consistently following commands. Denies sob\n or pain. VSS. Afebrile . Lungs clear to coarse throughout. Abd\n softly distended\n (+) bowel sounds. Urine output adequate. Moderate\n amt of loose stool via flexiseal.\n Action:\n Pt encouraged to cough and deep breathe. Pt taken to for\n ERCP. Sphincterotomy and balloon sweep performed by Dr w/\n stone extraction. Pt continues iv antibiotics md\ns orders. Pt\n turned and repositioned frequently. Pt teaching done regarding ICU\n environment.\n Response:\n Pt briefly requiring mechanical ventilation for increased work of\n breathing associated w/ desaturation into the 80\ns. Post ERCP pt able\n to wean to trach collar without difficulty. Less diaphoretic.\n intact to coccyx.\n Plan:\n Cont to monitor for s/s of infection, bleeding. Aggressive pulmonary\n toilet. Cont pt and family teaching.\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 570243,
"text": "TITLE: SICU PROGRESS NOTE\n SICU\n HPI:\n Pt dx at outside hospital w/pancreatits, s/p pseudocyst\n drainage--culture + for staph. unable to wean off vent, trach'd.\n transferred here for cholangitis with hemodynamic instability requiring\n intubation/pressors, spiking temps tmax-103, currently on prophylactic\n Abx, no pressors, s/p ERCP\n Chief complaint:\n no complaints\n PMHx:\n DVT, HTN, Lipidemia, Hx of MI in s/p PTCA\n .\n PSH: PEG/trach\n Current medications:\n 1000 mL LR 3. 1000 mL LR 4. Acetaminophen 5. Ampicillin-Sulbactam 6.\n Bisacodyl 7. Chlorhexidine Gluconate0.12% Oral Rinse 8. Famotidine 9.\n Fentanyl Patch 10. Heparin 11. Insulin 12. Lidocaine 1% 13.\n MetRONIDAZOLE (FLagyl) 14. Miconazole 2% Cream 15. Nystatin Oral\n Suspension 16. Potassium Chloride 17. Propofol 18. Propofol 19. Sodium\n Chloride 0.9% Flush 20. Vancomycin\n 24 Hour Events:\n ERCP - At 08:30 AM\n transferred to on pre procedure for ERCP\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:57 PM\n Ampicillin/Sulbactam (Unasyn) - 04:26 AM\n Metronidazole - 04:27 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 04:00 PM\n Other medications:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 36.8\nC (98.2\n HR: 71 (68 - 90) bpm\n BP: 141/70(94) {114/56(77) - 148/82(107)} mmHg\n RR: 25 (14 - 40) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,474 mL\n 925 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,474 mL\n 925 mL\n Blood products:\n Total out:\n 1,865 mL\n 680 mL\n Urine:\n 1,865 mL\n 680 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,609 mL\n 245 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Aerosol-cool, T-piece\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 432 (432 - 432) mL\n PS : 10 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n SPO2: 97%\n ABG: 7.44/41/86/26/3\n Ve: 9.4 L/min\n PaO2 / FiO2: 215\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 316 K/uL\n 9.8 g/dL\n 135 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 3.1 mEq/L\n 9 mg/dL\n 110 mEq/L\n 145 mEq/L\n 30.2 %\n 7.8 K/uL\n [image002.jpg]\n 02:36 AM\n 02:55 AM\n 05:16 PM\n 02:58 AM\n 03:13 AM\n 02:28 AM\n 06:15 AM\n WBC\n 10.6\n 8.4\n 7.8\n Hct\n 30.3\n 28.7\n 30.2\n Plt\n 346\n 299\n 316\n Creatinine\n 0.5\n 0.3\n 0.4\n TCO2\n 29\n 29\n 25\n 29\n Glucose\n 151\n 146\n 131\n 135\n Other labs: PT / PTT / INR:15.5/24.7/1.4, ALT / AST:205/107, Alk-Phos /\n T bili:325/1.6, Amylase / Lipase:30/21, Differential-Neuts:80.5 %,\n Lymph:15.0 %, Mono:3.0 %, Eos:0.8 %, Lactic Acid:0.6 mmol/L,\n Albumin:3.0 g/dL, Ca:9.2 mg/dL, Mg:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n .H/O CHOLELITHIASIS, .H/O MYOCARDIAL INFARCTION, .H/O PANCREATITIS,\n ACUTE, .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS), IMPAIRED\n SKIN INTEGRITY\n Assessment and Plan: 42M w/ hx of pancreatits, presents w/septic\n picture, cholangitis, now s/p ERCP/stone extraction\n Neurologic: Neuro checks Q: 4 hr, off sedation, fentanyl patch\n Cardiovascular: no issues, HD stable\n Pulmonary: tolerating trach collar\n Gastrointestinal / Abdomen: resolving cholangitis, Tbili improving,\n Consider narrowing antibiotics after BC back\n Nutrition: restart TFs\n Renal: Foley, adequate UOP\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: follow up cultures, consider narrowing antibiotics\n after BC return\n Lines / Tubes / Drains: foley, G-tube, trach, left radial a-line, right\n subclavian CVL - could DC if PIVs placed\n Wounds: none\n Imaging: none\n Fluids: LR @ 100, switch to MIVF\n Consults: General surgery\n Billing Diagnosis: Other: cholangitis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:48 PM\n Arterial Line - 03:07 AM\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570427,
"text": "H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt alert/appropriate. Following commands\n Tolerating High flow cool mist neb at 40%.\n Moderate amt of suction required for trach yellow/white\n secretions\n Trach site w/ sutures w/ irritation d/t difficulty\n containing all secretions\n Action:\n Turned and repositioned frequently. OOB to chair x 2hrs\n Suctioned approx Q1hr. No resp distress noted/reported\n Trach care per protocol.\n CXR and sputum cx obtained\n Response:\n Continues to cough up moderate amt of yellow/white\n secretions\n O2 sats stable\n CXR- worsening. Sputum Cx pending\n Plan:\n ? Bronch per SICU team on \n Continue to monitor resp status/pulm toilet\n .H/O cholelithiasis\n Assessment:\n NPO. PEG Replete w/ fiber titrating to goal of 90cc/hr\n s/p ERCP on w/ 4mm stone removed from CBD\n No abd pain. ABD soft/distended\n LFTs trending down. Positive intermittent Diaphoresis\n Previous Pseudocyst was drained for 140cc positive for staph\n Action:\n TF titrated. No residuals\n Pain monitored q4hrs . Left arm w/ Fent patch 50mcg\n EKG/Lytes/Cardiac enzymes drawn x1 d/t ? cause of\n diaphoresis\n IVABX admin per order. Low grade temps 99.0 -99.7\n Response:\n Tolerating TF w.o residuals\n IV Vanco increased to Q8hrs\n EKG w/o change. Lytes K 3.2 -40meq of KCL po. Cardiac\n enzymes negative\n Plan:\n Continue to monitor labs and replete electrolytes PRN\n Monitor pain and response to pain management\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570762,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : T103, increased LFTs/AP, propofol gtt, prophylactic abx\n : weaned to trach collar, R SCL CVL placed, PICC d/c'd, CT abd\n : ERCP\n : started TF\n : HLIV, suctioned q1hr, sputum cx, CXR, heat rash --> miconazole,\n agitation, diaphoretic episodes (afebrile, glucose normal).\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n Impaired Skin Integrity\n Assessment:\n -Groin and peri-anal area errythema and excoriated.\n -Flexi-seal intact with small amount of golden yellow liquid stool.\n Action:\n -Wound Care consult.\n -Miconazole cream/Anti-fungal barrier cream applied every 2-4 hours\n PRN.\n -Repositioned Q 2 from side to side.\n Response:\n -Groin and peri-anal with decreased errythema and excoriation.\n Plan:\n -Miconazole cream/Antifungal barrier cream/M q 2-4 hours PRN.\n -Reposition every 2 hours from side to side.\n -Re-consult Wound Care Nurse PRN.\n -Consider Dermatology consult if no improvement.\n .H/O pancreatitis, acute\n Assessment:\n Action:\n Response:\n Plan:\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n -Trach on CPAP/50%/5PEEP/12 PS.\n -Trach site CDI.\n Action:\n -Suctioned for small to moderate amounts of thick yellow sputum.\n -Ct PT every 2-4 hours as tolerated.\n -Sputum culture from -pending.\n -Zosyn/Vancomycin given.\n Response:\n -\n Plan:\n -Aggressive pulmonary hygiene.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570424,
"text": "H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt alert/appropriate. Following commands\n Tolerating High flow cool mist neb at 40%.\n Moderate amt of suction required for trach yellow/white\n secretions\n Trach site w/ sutures w/ irritation d/t difficulty\n containing all secretions\n Action:\n Turned and repositioned frequently. OOB to chair x 2hrs\n Suctioned approx Q1hr. No resp distress noted/reported\n Trach care per protocol.\n CXR and sputum cx obtained\n Response:\n Continues to cough up moderate amt of yellow/white\n secretions\n O2 sats stable\n CXR- worsening. Sputum Cx pending\n Plan:\n ? Bronch per SICU team on \n .H/O cholelithiasis\n Assessment:\n NPO. PEG tube clamped\n s/p ERCP on w/ 4mm stone removed from CBD\n No abd pain. ABD soft/distended\n LFTs trending down. Morning K-3.0\n Previous Pseudocyst was drained for 140cc\n Action:\n TF\n Replete w/ fiber started per order. Residuals monitored\n Pain monitored q4hrs . Left arm w/ Fent patch 50mcg\n IVABX admin per order\n Total of 60meqKCL IV administered. Repeat Labs drawn this\n evening\n Response:\n Tolerating TF.\n Afebrile\n No pain\n Plan:\n Continue to monitor labs and replete electrolytes PRN\n Monitor pain and response to pain management\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-06 00:00:00.000",
"description": "Intensivist Note",
"row_id": 570545,
"text": " HD 6, PPD 3\n AB: vanc, Flagyl, Unasyn\n PPX: famotidine, SQH, boots\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : T103, increased LFTs/AP, propofol gtt, prophylactic abx\n : weaned to trach collar, R SCL CVL placed, PICC d/c'd, CT abd\n : ERCP\n : started TF\n : HLIV, suctioned q1hr, sputum cx, CXR, heat rash --> miconazole,\n agitation, diaphoretic episodes (afebrile, glucose normal)\n MICRO:\n blood: P\n urine: yeast\n MRSA: neg\n PICC tip: neg\n : sputum cx - contaminated\n IMAGING\n CT abd: acute pancreatitis w/ fluid 8x4x4 cm,\n choledocholithiasis in distal CBD, L intrahep bil dil, no\n cohlecystitis,with associated left intrahepatic biliary dilitation, no\n acute cholecystitis, splenomegaly, bibasilar atelectasis\n : CXR - Interval development of opacity in the retrocardiac space.\n Low lung volumes and simultaneous right basilar atelectasis favors\n atelectasis instead of infection\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:28 AM\n Metronidazole - 03:59 AM\n Ampicillin/Sulbactam (Unasyn) - 03:59 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:05 AM\n Famotidine (Pepcid) - 05:06 AM\n Lorazepam (Ativan) - 06:20 AM\n Other medications:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.7\nC (99.8\n HR: 99 (68 - 122) bpm\n BP: 122/75(86) {113/68(79) - 138/87(100)} mmHg\n RR: 19 (16 - 40) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 3,017 mL\n 1,058 mL\n PO:\n Tube feeding:\n 1,085 mL\n 531 mL\n IV Fluid:\n 1,711 mL\n 527 mL\n Blood products:\n Total out:\n 2,175 mL\n 475 mL\n Urine:\n 2,175 mL\n 475 mL\n NG:\n Stool:\n Drains:\n Balance:\n 842 mL\n 583 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Aerosol-cool, T-piece\n SPO2: 100%\n ABG: ///27/\n Physical Examination\n General Appearance: alert, restless, trach collar present\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : bilateral)\n Abdominal: Soft\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n Moves all extremities, mouths words\n Labs / Radiology\n 400 K/uL\n 11.6 g/dL\n 170 mg/dL\n 0.4 mg/dL\n 27 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 105 mEq/L\n 141 mEq/L\n 34.7 %\n 13.3 K/uL\n [image002.jpg]\n 02:55 AM\n 05:16 PM\n 02:58 AM\n 03:13 AM\n 02:28 AM\n 06:15 AM\n 04:45 PM\n 03:15 AM\n 12:34 PM\n 04:57 AM\n WBC\n 8.4\n 7.8\n 10.1\n 13.3\n Hct\n 28.7\n 30.2\n 33.6\n 34.7\n Plt\n 299\n 316\n 380\n 400\n Creatinine\n 0.3\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n Troponin T\n <0.01\n TCO2\n 29\n 29\n 25\n 29\n Glucose\n 146\n 131\n 135\n 126\n 160\n 151\n 170\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:76//<0.01, ALT / AST:105/32, Alk-Phos / T bili:257/1.2, Amylase /\n Lipase:35/31, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:0.6 mmol/L, Albumin:3.0 g/dL, Ca:9.3 mg/dL,\n Mg:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment & Plan:\n Neurologic: pain controlled with fentanyl patch, ativan for agitation\n CVS: HD stable\n Pulm: tolerating trach collar\n GI: TFs heading to goal of 90cc/hr (currently at 70 cc/hr)\n Renal: Adequate UOP\n Hematology: stable\n Endocrine: RISS\n ID: f/u cx, resent sputum\n TLD: Foley, G-tube, trach, L radial A-line, R SCL CVL\n Wounds: none\n Imaging: none\n Fluids: KVO\n Consults: General Surgery\n Procedures: none\n Code status: full\n Disposition: SICU\n ICU Care\n Nutrition:\n Replete (Full) - 04:41 AM 70 mL/hour\n Glycemic Control: RISS\n Lines:\n Arterial Line - 03:07 AM\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: heparin, boots\n Stress ulcer: famotidine\n VAP bundle: completed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570758,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : T103, increased LFTs/AP, propofol gtt, prophylactic abx\n : weaned to trach collar, R SCL CVL placed, PICC d/c'd, CT abd\n : ERCP\n : started TF\n : HLIV, suctioned q1hr, sputum cx, CXR, heat rash --> miconazole,\n agitation, diaphoretic episodes (afebrile, glucose normal).\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n Impaired Skin Integrity\n Assessment:\n -Groin and peri-anal area errythema and excoriated.\n -Flexi-seal intact with small amount of golden yellow liquid stool.\n Action:\n -Wound Care consult.\n -Miconazole cream/Anti-fungal barrier cream applied every 2-4 hours\n PRN.\n -Repositioned Q 2 from side to side.\n Response:\n -Groin and peri-anal with decreased errythema and excoriation.\n Plan:\n -Miconazole cream/Antifungal barrier cream/M q 2-4 hours PRN.\n -Reposition every 2 hours from side to side.\n -Re-consult Wound Care Nurse PRN.\n -Consider Dermatology consult if no improvement.\n .H/O pancreatitis, acute\n Assessment:\n Action:\n Response:\n Plan:\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n -Trach on CPAP/50%/5PEEP/12 PS.\n -Trach site CDI.\n Action:\n -Suctioned for small to moderate amounts of thick yellow sputum.\n -Ct PT every 2-4 hours as tolerated.\n -Sputum culture from -pending.\n -Zosyn/Vancomycin given.\n Response:\n -\n Plan:\n -Aggressive pulmonary hygiene.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570551,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n O2sats 96-99% large amt of secretitons and requiring frequent\n suctioning.\n Action:\n Suctioned q2hrs. sputum culture obtained. on t piece 50%.\n Response:\n Secretitioins copius. Needed to be suctioned frequently.\n Plan:\n Monitor resp status . awaiting sputum culture results.\n Impaired Skin Integrity\n Assessment:\n Buttocks extremiely reddened. Pt attempting to scratch area.\n Action:\n Turned q2hrs. nystatin powder applied to scrotal area and buttocks.\n Response:\n Buttocks continues to be reddened.\n Plan:\n Monitor skin integrity\n Pt became very agitated and attempting to climb oob. Legs hanging\n out of the bed. Moving from side to side. Not focusing while being\n spoken to. Ativan 1mg iv x2 given with small amt of relief.\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-06 00:00:00.000",
"description": "Intensivist Note",
"row_id": 570561,
"text": " HD 6, PPD 3\n AB: vanc, Flagyl, Unasyn\n PPX: famotidine, SQH, boots\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : T103, increased LFTs/AP, propofol gtt, prophylactic abx\n : weaned to trach collar, R SCL CVL placed, PICC d/c'd, CT abd\n : ERCP\n : started TF\n : HLIV, suctioned q1hr, sputum cx, CXR, heat rash --> miconazole,\n agitation, diaphoretic episodes (afebrile, glucose normal)\n MICRO:\n blood: P\n urine: yeast\n MRSA: neg\n PICC tip: neg\n : sputum cx - contaminated\n IMAGING\n CT abd: acute pancreatitis w/ fluid 8x4x4 cm,\n choledocholithiasis in distal CBD, L intrahep bil dil, no\n cohlecystitis,with associated left intrahepatic biliary dilitation, no\n acute cholecystitis, splenomegaly, bibasilar atelectasis\n : CXR - Interval development of opacity in the retrocardiac space.\n Low lung volumes and simultaneous right basilar atelectasis favors\n atelectasis instead of infection\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:28 AM\n Metronidazole - 03:59 AM\n Ampicillin/Sulbactam (Unasyn) - 03:59 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:05 AM\n Famotidine (Pepcid) - 05:06 AM\n Lorazepam (Ativan) - 06:20 AM\n Other medications:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.7\nC (99.8\n HR: 99 (68 - 122) bpm\n BP: 122/75(86) {113/68(79) - 138/87(100)} mmHg\n RR: 19 (16 - 40) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 3,017 mL\n 1,058 mL\n PO:\n Tube feeding:\n 1,085 mL\n 531 mL\n IV Fluid:\n 1,711 mL\n 527 mL\n Blood products:\n Total out:\n 2,175 mL\n 475 mL\n Urine:\n 2,175 mL\n 475 mL\n NG:\n Stool:\n Drains:\n Balance:\n 842 mL\n 583 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Aerosol-cool, T-piece\n SPO2: 100%\n ABG: ///27/\n Physical Examination\n General Appearance: alert, restless, trach collar present\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : bilateral)\n Abdominal: Soft\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n Moves all extremities, mouths words\n Labs / Radiology\n 400 K/uL\n 11.6 g/dL\n 170 mg/dL\n 0.4 mg/dL\n 27 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 105 mEq/L\n 141 mEq/L\n 34.7 %\n 13.3 K/uL\n [image002.jpg]\n 02:55 AM\n 05:16 PM\n 02:58 AM\n 03:13 AM\n 02:28 AM\n 06:15 AM\n 04:45 PM\n 03:15 AM\n 12:34 PM\n 04:57 AM\n WBC\n 8.4\n 7.8\n 10.1\n 13.3\n Hct\n 28.7\n 30.2\n 33.6\n 34.7\n Plt\n 299\n 316\n 380\n 400\n Creatinine\n 0.3\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n Troponin T\n <0.01\n TCO2\n 29\n 29\n 25\n 29\n Glucose\n 146\n 131\n 135\n 126\n 160\n 151\n 170\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:76//<0.01, ALT / AST:105/32, Alk-Phos / T bili:257/1.2, Amylase /\n Lipase:35/31, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:0.6 mmol/L, Albumin:3.0 g/dL, Ca:9.3 mg/dL,\n Mg:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment & Plan:\n Neurologic: pain controlled with fentanyl patch, ativan for agitation\n Increasing agitation. ? benzo withdrawl??? Add haldol/ clonidine (\n if BP OK)\n CVS: HD stable\n Pulm: tolerating trach collar\n GI: TFs heading to goal of 90cc/hr (currently at 70 cc/hr)\n Renal: Adequate UOP\n Hematology: stable\n Endocrine: RISS\n ID: f/u cx, resent sputum\n TLD: Foley, G-tube, trach, L radial A-line, R SCL CVL\n Wounds: none\n Imaging: none\n Fluids: KVO\n Consults: General Surgery\n Procedures: none\n Code status: full\n Disposition: SICU\n ICU Care\n Nutrition:\n Replete (Full) - 04:41 AM 70 mL/hour\n Glycemic Control: RISS\n Lines:\n Arterial Line - 03:07 AM\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: heparin, boots\n Stress ulcer: famotidine\n VAP bundle: completed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570975,
"text": "Hyperglycemia\n Assessment:\n Blood sugar 230-291\n Action:\n Pt started on insulin gtt\n Response:\n Blood sugar down to 264\n Plan:\n Titrate insulin gtt per icu protocol\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on cpap with ps\n Vanco trough back as 11.3\n Action:\n Pt continue on vancomycin and zosyn\n Suctioned pt for thick yellow sputum\n Response:\n Pt tolerating cpap\n Suctioning pt for less sputum this evening\n Plan:\n Continue to monitor\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-05 00:00:00.000",
"description": "Intensivist Note",
"row_id": 570357,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n abd pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n Current medications:\n 1. Miconazole 2% Cream 1 Appl TP :PRN Order date: @ 0139\n 2. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308\n 3. Ampicillin-Sulbactam 3 g IV Q6H Order date: @ 0308\n 4. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139\n 5. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @ 0555\n 6. Potassium Chloride PO Sliding Scale Duration: 24 Hours Hold for K\n > Order date: @ 1826\n 7. Famotidine 20 mg IV Q12H Order date: @ 0419\n 8. Potassium Phosphate IV Sliding Scale Infuse over 6 hours Order\n date: @ 0647\n 9. Fentanyl Patch 50 mcg/hr TP Q72H Order date: @ 0139\n 10. Heparin 5000 UNIT SC BID Order date: @ 0139\n 11. Insulin SC (per Insulin Flowsheet) Sliding Scale Order date: \n @ 0139\n 12. Lidocaine 1% 3-5 mL IH Q4-6 HRS PRN Order date: @ 1854\n 13. Vancomycin 1000 mg IV Q 12H ID Approval will be required for this\n order in 2 hours. Order date: @ 0308\n 14. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 0308\n 24 Hour Events:\n Started TF. HLIV.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:53 PM\n Metronidazole - 08:30 PM\n Ampicillin/Sulbactam (Unasyn) - 04:44 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 04:44 AM\n Heparin Sodium (Prophylaxis) - 05:01 AM\n Other medications:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 36.7\nC (98\n HR: 68 (68 - 86) bpm\n BP: 136/74(95) {131/68(90) - 146/83(104)} mmHg\n RR: 23 (8 - 41) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,627 mL\n 890 mL\n PO:\n Tube feeding:\n 140 mL\n 235 mL\n IV Fluid:\n 3,337 mL\n 655 mL\n Blood products:\n Total out:\n 2,515 mL\n 560 mL\n Urine:\n 2,515 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,112 mL\n 330 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Aerosol-cool, T-piece\n SPO2: 94%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : diffusely)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 380 K/uL\n 11.2 g/dL\n 160 mg/dL\n 0.4 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 104 mEq/L\n 138 mEq/L\n 33.6 %\n 10.1 K/uL\n [image002.jpg]\n 02:36 AM\n 02:55 AM\n 05:16 PM\n 02:58 AM\n 03:13 AM\n 02:28 AM\n 06:15 AM\n 04:45 PM\n 03:15 AM\n WBC\n 10.6\n 8.4\n 7.8\n 10.1\n Hct\n 30.3\n 28.7\n 30.2\n 33.6\n Plt\n 346\n 299\n 316\n 380\n Creatinine\n 0.5\n 0.3\n 0.4\n 0.4\n 0.4\n TCO2\n 29\n 29\n 25\n 29\n Glucose\n 151\n 146\n 131\n 135\n 126\n 160\n Other labs: PT / PTT / INR:15.5/24.7/1.4, ALT / AST:139/51, Alk-Phos /\n T bili:286/1.2, Amylase / Lipase:35/31, Differential-Neuts:80.5 %,\n Lymph:15.0 %, Mono:3.0 %, Eos:0.8 %, Lactic Acid:0.6 mmol/L,\n Albumin:3.0 g/dL, Ca:9.1 mg/dL, Mg:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n .H/O RESPIRATORY FAILURE, ACUTE (NOT ARDS/), .H/O CHOLELITHIASIS,\n .H/O MYOCARDIAL INFARCTION, .H/O PANCREATITIS, ACUTE, .H/O ABDOMINAL\n PAIN (INCLUDING ABDOMINAL TENDERNESS), IMPAIRED SKIN INTEGRITY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction.\n Neurologic: Pain controlled\n Cardiovascular: HD stable.\n Pulmonary: Trach, IS, (Ventilator mode: Other), Stable on trach collar.\n Gastrointestinal / Abdomen: Adv TF to goal. LFTs continue to trend\n down.\n Nutrition: Tube feeding, Adv TF to goal.\n Renal: Foley, Adequate UO, Lytes WNL, replete Kphos.\n Hematology: Hct stable.\n Endocrine: RISS, Goal FS<150.\n Infectious Disease: Check cultures, Continue vanc/Flagyl/Unasyn. F/u\n cx and tailor abx accordingly. WBC WNL.\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress), Pancreatitis\n ICU Care\n Nutrition:\n Replete (Full) - 03:18 AM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:48 PM\n Arterial Line - 03:07 AM\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"
},
{
"category": "Nutrition",
"chartdate": "2140-04-05 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 570404,
"text": "Subjective: Patient reports no abdominal pain with tube feeds via PEG.\n Pt verified height and reported UBW to be 190#.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 175 cm\n 88.7 kg\n 28.8\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 72.6 kg\n 122%\n 77kg\n 86.4kg\n 103%\n Diagnosis: Pancreatitis/ Pseudocyst\n PMH : DVT, HTN, Lipidemia, Hx of MI in s/p PTCA, PEG/trach\n Food allergies and intolerances:\n Pertinent medications: RISS< Abx, Pepcid, Famotidine, Neutra-phos,\n others noted\n Labs:\n Value\n Date\n Glucose\n 160 mg/dL\n 03:15 AM\n Glucose Finger Stick\n 157\n 12:00 PM\n BUN\n 8 mg/dL\n 03:15 AM\n Creatinine\n 0.4 mg/dL\n 03:15 AM\n Sodium\n 138 mEq/L\n 03:15 AM\n Potassium\n 3.7 mEq/L\n 03:15 AM\n Chloride\n 104 mEq/L\n 03:15 AM\n TCO2\n 24 mEq/L\n 03:15 AM\n PO2 (arterial)\n 86 mm Hg\n 06:15 AM\n PCO2 (arterial)\n 41 mm Hg\n 06:15 AM\n pH (arterial)\n 7.44 units\n 06:15 AM\n CO2 (Calc) arterial\n 29 mEq/L\n 06:15 AM\n Albumin\n 3.0 g/dL\n 02:28 AM\n Calcium non-ionized\n 9.1 mg/dL\n 03:15 AM\n Phosphorus\n 2.8 mg/dL\n 03:15 AM\n Ionized Calcium\n 1.23 mmol/L\n 06:15 AM\n Magnesium\n 2.0 mg/dL\n 03:15 AM\n ALT\n 139 IU/L\n 03:15 AM\n Alkaline Phosphate\n 286 IU/L\n 03:15 AM\n AST\n 51 IU/L\n 03:15 AM\n Amylase\n 35 IU/L\n 03:15 AM\n Total Bilirubin\n 1.2 mg/dL\n 03:15 AM\n Triglyceride\n 317 mg/dL\n 02:36 AM\n Current diet order / nutrition support: Tube Feed: Replete with Fiber\n @90cc/hr (2160kcals, 134g protein)\n GI: + Liquid golden stool, + bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: Complicated hospital course, nutrition support\n dependence\n Estimated Nutritional Needs based on adjusted wt\n Calories: -2310 (BEE x or / 25-30 cal/kg)\n Protein: 107-123 (1.4-1.6 g/kg)\n Fluid: per team\n Estimation of previous intake: Adequate\n Estimation of current intake: Adequate\n Specifics:\n 42 y.o. M originally admitted to outside hospital with pancreatitis\n and found to have pseudocyst. Patient underwent IR drainage of\n pseudocyst, and had a PEG and trach placement due to sepsis and\n inablilty to wean from vent. Patient received TPN until PEG was\n placed. Due to failure to progress and persistent fevers, patient was\n transferred to with choledocholithiasis/cholangitis. Patient now\n s/p ERCP, sphincterotomy and stone extraction . Tube feeds have\n been started via PEG, and patient is tolerating them well so far.\n Current tube feed goal will provide 28kcals/kg adjusted wt and 1.74g\n protein/kg, meeting 100% of estimated needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Recommend continue with advancement to current tube feed\n goal.\n 2) Monitor tolerance with abd exam, patient complaints and\n residual checks.\n 3) Monitor lytes and renal function.\n Will follow, please page with questions #\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-05 00:00:00.000",
"description": "Intensivist Note",
"row_id": 570410,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n abd pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n Current medications:\n 1. Miconazole 2% Cream 1 Appl TP :PRN Order date: @ 0139\n 2. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308\n 3. Ampicillin-Sulbactam 3 g IV Q6H Order date: @ 0308\n 4. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139\n 5. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @ 0555\n 6. Potassium Chloride PO Sliding Scale Duration: 24 Hours Hold for K\n > Order date: @ 1826\n 7. Famotidine 20 mg IV Q12H Order date: @ 0419\n 8. Potassium Phosphate IV Sliding Scale Infuse over 6 hours Order\n date: @ 0647\n 9. Fentanyl Patch 50 mcg/hr TP Q72H Order date: @ 0139\n 10. Heparin 5000 UNIT SC BID Order date: @ 0139\n 11. Insulin SC (per Insulin Flowsheet) Sliding Scale Order date: \n @ 0139\n 12. Lidocaine 1% 3-5 mL IH Q4-6 HRS PRN Order date: @ 1854\n 13. Vancomycin 1000 mg IV Q 12H ID Approval will be required for this\n order in 2 hours. Order date: @ 0308\n 14. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 0308\n 24 Hour Events:\n Started TF. HLIV.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:53 PM\n Metronidazole - 08:30 PM\n Ampicillin/Sulbactam (Unasyn) - 04:44 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 04:44 AM\n Heparin Sodium (Prophylaxis) - 05:01 AM\n Other medications:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 36.7\nC (98\n HR: 68 (68 - 86) bpm\n BP: 136/74(95) {131/68(90) - 146/83(104)} mmHg\n RR: 23 (8 - 41) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,627 mL\n 890 mL\n PO:\n Tube feeding:\n 140 mL\n 235 mL\n IV Fluid:\n 3,337 mL\n 655 mL\n Blood products:\n Total out:\n 2,515 mL\n 560 mL\n Urine:\n 2,515 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,112 mL\n 330 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Aerosol-cool, T-piece\n SPO2: 94%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : diffusely)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 380 K/uL\n 11.2 g/dL\n 160 mg/dL\n 0.4 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 104 mEq/L\n 138 mEq/L\n 33.6 %\n 10.1 K/uL\n [image002.jpg]\n 02:36 AM\n 02:55 AM\n 05:16 PM\n 02:58 AM\n 03:13 AM\n 02:28 AM\n 06:15 AM\n 04:45 PM\n 03:15 AM\n WBC\n 10.6\n 8.4\n 7.8\n 10.1\n Hct\n 30.3\n 28.7\n 30.2\n 33.6\n Plt\n 346\n 299\n 316\n 380\n Creatinine\n 0.5\n 0.3\n 0.4\n 0.4\n 0.4\n TCO2\n 29\n 29\n 25\n 29\n Glucose\n 151\n 146\n 131\n 135\n 126\n 160\n Other labs: PT / PTT / INR:15.5/24.7/1.4, ALT / AST:139/51, Alk-Phos /\n T bili:286/1.2, Amylase / Lipase:35/31, Differential-Neuts:80.5 %,\n Lymph:15.0 %, Mono:3.0 %, Eos:0.8 %, Lactic Acid:0.6 mmol/L,\n Albumin:3.0 g/dL, Ca:9.1 mg/dL, Mg:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n .H/O RESPIRATORY FAILURE, ACUTE (NOT ARDS/), .H/O CHOLELITHIASIS,\n .H/O MYOCARDIAL INFARCTION, .H/O PANCREATITIS, ACUTE, .H/O ABDOMINAL\n PAIN (INCLUDING ABDOMINAL TENDERNESS), IMPAIRED SKIN INTEGRITY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction.\n Neurologic: Pain controlled\n Cardiovascular: HD stable.\n Pulmonary: Trach, IS, (Ventilator mode: Other), Stable on trach collar.\n Gastrointestinal / Abdomen: Adv TF to goal. LFTs continue to trend\n down.\n Nutrition: Tube feeding, Adv TF to goal.\n Renal: Foley, Adequate UO, Lytes WNL, replete Kphos.\n Hematology: Hct stable.\n Endocrine: RISS, Goal FS<150.\n Infectious Disease: Check cultures, Continue vanc/Flagyl/Unasyn. F/u\n cx and tailor abx accordingly. WBC WNL.\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress), Pancreatitis\n ICU Care\n Nutrition:\n Replete (Full) - 03:18 AM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:48 PM\n Arterial Line - 03:07 AM\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570625,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : T103, increased LFTs/AP, gtt, prophylactic abx\n : weaned to trach collar, R SCL CVL placed, PICC d/c'd, CT abd\n : ERCP\n : started TF\n : HLIV, suctioned q1hr, sputum cx, CXR, heat rash --> miconazole,\n agitation, diaphoretic episodes (afebrile, glucose normal).\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on placed on\n CMV/50%/5 PEEP/RR 12.\n Impaired Skin Integrity\n Assessment:\n -Groin and peri-anal area errythema and excoriated.\n Action:\n -Anti-fungal cream and nystatin powder applied every 2-4 hours PRN.\n -Repositioned Q 2.\n -SICU MD Team in to examine-continue with current regime.\n Response:\n -Groin and peri-anal area remain excoriated and red.\n Plan:\n -Antifungal cream/Nystatin powder q 2-4 hours PRN.\n -Reposition every 2 hours.\n -Consider Dermatology consult if no improvement.\n .H/O pancreatitis, acute\n Assessment:\n -Alert X1. Inconsistently follows simple commands. PERRLA,brisk. MAE.\n -Overall, extremely agitated/hypertensive/tachycardic, even with\n reassurance.\n Action:\n -MD notified of extreme agitation.\n -Medicated with IVP Ativan/Haldolol/Fentanyl with minimal effect.\n -PLACED on CMV. Sedated on with good effect.\n - MD to be titrated to off. PT very\n agitated/hypertensive/tachycardic.\n -Precedex bolus given and drip started with no effect. Pt remained\n agitated/hypertensive/tachycardic.\n -MD to examine. 1mg IVP Ativan given and Midazolam drip to be\n started.\n -ABG\nS checked and WNL\n Response:\n -See above.\n Plan:\n -Continue to closely follow Neuro examine.\n -Start Midazolam drip for comfort.\n -Conitnue to provide supportive care to patient and family.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570746,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : T103, increased LFTs/AP, propofol gtt, prophylactic abx\n : weaned to trach collar, R SCL CVL placed, PICC d/c'd, CT abd\n : ERCP\n : started TF\n : HLIV, suctioned q1hr, sputum cx, CXR, heat rash --> miconazole,\n agitation, diaphoretic episodes (afebrile, glucose normal).\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n .H/O pancreatitis, acute\n Assessment:\n Action:\n Response:\n Plan:\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570748,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : T103, increased LFTs/AP, propofol gtt, prophylactic abx\n : weaned to trach collar, R SCL CVL placed, PICC d/c'd, CT abd\n : ERCP\n : started TF\n : HLIV, suctioned q1hr, sputum cx, CXR, heat rash --> miconazole,\n agitation, diaphoretic episodes (afebrile, glucose normal).\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n Impaired Skin Integrity\n Assessment:\n -Groin and peri-anal area errythema and excoriated.\n -Flexi-seal intact with small amount of golden yellow liquid stool.\n Action:\n -Wound Care consult.\n -Miconazole cream/Anti-fungal barrier cream applied every 2-4 hours\n PRN.\n -Repositioned Q 2 from side to side.\n Response:\n -Groin and peri-anal with decreased errythema and excoriation.\n Plan:\n -Miconazole cream/Antifungal barrier cream/M q 2-4 hours PRN.\n -Reposition every 2 hours from side to side.\n -Re-consult Wound Care Nurse PRN.\n -Consider Dermatology consult if no improvement.\n .H/O pancreatitis, acute\n Assessment:\n Action:\n Response:\n Plan:\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n -Trach on CPAP/50%/5PEEP/12 PS.\n -Trach site CDI.\n Action:\n -Suctioned for small to moderate amounts of thick yellow sputum.\n -Ct PT every 2-4 hours as tolerated.\n -Sputum culture from -pending.\n -Zosyn/Vancomycin given.\n Response:\n -\n Plan:\n -Aggressive pulmonary hygiene.\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-08 00:00:00.000",
"description": "Intensivist Note",
"row_id": 570886,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. Magnesium Sulfate IV Sliding Scale Order date: @ 0234\n 2. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308\n 3. Miconazole Powder 2% 1 Appl TP TID:PRN Order date: @ 1255\n 4. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139\n 5. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @ 0555\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n 7. Phenylephrine 0.5-5 mcg/kg/min IV DRIP INFUSION maintain MAP>60\n Order date: @ 2037\n 8. Famotidine 20 mg IV Q12H Order date: @ 0419\n 9. Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @ 1209\n 10. Fentanyl Patch 50 mcg/hr TP Q72H Order date: @ 0139\n 11. Potassium Chloride PO Sliding Scale Hold for K > 5 Order date:\n @ 0505\n 12. Haloperidol 2 mg PO TID through G tube Order date: @ 0840\n 13. Potassium Phosphate IV Sliding Scale Infuse over 6 hours Order\n date: @ 0647\n 14. Heparin 5000 UNIT SC BID Order date: @ 0139\n 15. Propofol 5-60 mcg/kg/min IV DRIP INFUSION Order date: @ 2052\n 16. Insulin SC (per Insulin Flowsheet) Sliding Scale Order date: \n @ 1317\n 17. Lidocaine 1% 3-5 mL IH Q4-6 HRS PRN Order date: @ 1854\n 18. Vancomycin 1000 mg IV Q 8H Order date: @ 1044\n 19. Lorazepam 2-4 mg IV Q4H:PRN Order date: @ \n 24 Hour Events:\n ULTRASOUND - At 03:34 PM\n Liver and gallbladder US performed.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 03:59 AM\n Ampicillin/Sulbactam (Unasyn) - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 12:12 AM\n Vancomycin - 12:45 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 04:20 AM\n Famotidine (Pepcid) - 06:11 AM\n Heparin Sodium (Prophylaxis) - 06:11 AM\n Other medications:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 37.3\nC (99.2\n HR: 90 (70 - 120) bpm\n BP: 117/65(82) {102/48(65) - 155/87(112)} mmHg\n RR: 42 (13 - 43) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 3,973 mL\n 1,222 mL\n PO:\n Tube feeding:\n 1,527 mL\n 599 mL\n IV Fluid:\n 2,166 mL\n 524 mL\n Blood products:\n Total out:\n 4,490 mL\n 670 mL\n Urine:\n 4,080 mL\n 470 mL\n NG:\n 410 mL\n Stool:\n Drains:\n Balance:\n -517 mL\n 552 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 434 (349 - 645) mL\n PS : 10 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 122\n PIP: 16 cmH2O\n SPO2: 99%\n ABG: ///29/\n Ve: 13.4 L/min\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), Tachycardic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : , Diminished: at the bases), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n G-tube intact\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: (Responds to: Verbal stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 344 K/uL\n 8.9 g/dL\n 207 mg/dL\n 0.4 mg/dL\n 29 mEq/L\n 3.4 mEq/L\n 5 mg/dL\n 105 mEq/L\n 142 mEq/L\n 27.3 %\n 12.8 K/uL\n [image002.jpg]\n 04:57 AM\n 01:51 PM\n 03:46 PM\n 05:47 PM\n 10:45 PM\n 11:59 PM\n 03:59 AM\n 04:11 AM\n 05:35 PM\n 02:48 AM\n WBC\n 13.3\n 18.8\n 20.9\n 25.6\n 12.8\n Hct\n 34.7\n 35.8\n 28.4\n 30.2\n 27.3\n Plt\n 400\n 517\n 327\n 431\n 344\n Creatinine\n 0.4\n 0.5\n 0.5\n 0.5\n 0.4\n 0.4\n TCO2\n 30\n 30\n 26\n 24\n Glucose\n 170\n 190\n 122\n 189\n 180\n 207\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:76//<0.01, ALT / AST:72/25, Alk-Phos / T bili:192/1.1, Amylase /\n Lipase:35/31, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.8 mmol/L, Albumin:3.0 g/dL, Ca:8.3 mg/dL,\n Mg:2.3 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), FUNGAL INFECTION, OTHER,\n HYPERGLYCEMIA, DIARRHEA, .H/O RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), .H/O CHOLELITHIASIS, .H/O MYOCARDIAL INFARCTION, .H/O\n PANCREATITIS, ACUTE, .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL\n TENDERNESS), IMPAIRED SKIN INTEGRITY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction\n Neurologic: Pain controlled, Continue ativan, haldol, fentanyl patch to\n control agitation. Wean propofol\n Cardiovascular: Remains tachycardic likely from aggitation\n Pulmonary: Trach, (Ventilator mode: CPAP + PS), Wean to trach collar\n Gastrointestinal / Abdomen: G-tube, cont TFs, monitor LFTs\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Hct drifting down, will continue to follow\n Endocrine: RISS\n Infectious Disease: Check cultures\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure), Pancreatitis\n ICU Care\n Nutrition:\n Replete (Full) - 05:53 AM 90 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 08:00 AM\n Arterial Line - 09:27 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 570613,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Frothy\n Sputum source/amount: Suctioned / Moderate\n Comments: pt suctioned very frequently for mod-copious secretions\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt placed back on vent today due to increased aggitation and\n need for sedation\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: plan to wean off vent support as tolerated dependant\n on aggitation\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570602,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : T103, increased LFTs/AP, propofol gtt, prophylactic abx\n : weaned to trach collar, R SCL CVL placed, PICC d/c'd, CT abd\n : ERCP\n : started TF\n : HLIV, suctioned q1hr, sputum cx, CXR, heat rash --> miconazole,\n agitation, diaphoretic episodes (afebrile, glucose normal).\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n Impaired Skin Integrity\n Assessment:\n -Groin and peri-anal area errythema and excoriated.\n Action:\n -Anti-fungal cream and nystatin powder applied every 2-4 hours PRN.\n -Repositioned Q 2.\n -SICU MD Team in to examine-continue with current regime.\n Response:\n -Groin and peri-anal area remain excoriated and red.\n Plan:\n -Antifungal cream/Nystatin powder q 2-4 hours PRN.\n -Reposition every 2 hours.\n -Consider Dermatology consult if no improvement.\n .H/O pancreatitis, acute\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570658,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Diarrhea\n Assessment:\n Patient had BM x3, liquid stool now, patient is on TF at goal ,\n tolerating.\n Action:\n Stool for C diff sent, Flexiseal inserted. cont with TF\n Response:\n Flexiseal draining liquid stool.\n Plan:\n Continue TF, skin care, cont with flexisael if persistent diarrhea.\n Impaired Skin Integrity\n Assessment:\n patient noted to have skin rashes all over perineal & rectal area with\n small slit in the coccycx.\n Action:\n Turned q2h, antifungal & mycostatin powder applied. Area kept clean &\n dry\n Response:\n Skin still with rashes, but no drainage.\n Plan:\n Cont with skin care, frequent turns, ? apply mepilex on the coccyx\n after consult with wound care nurse g skin with rash &\n escoriation\n .H/O pancreatitis, acute\n Assessment:\n Patient with h/o pancreatitis & s/p ERCP .Abdomen soft & distended, +\n BS, Febrile, Tachy cardic, agitating early shift, NGT to wall suction\n with very minimal drainage, Tf at goal, elevated WBC.\n Action:\n CT torso done with oral & IV contrast. On antibiotics, Pan cultured\n for fever of 102.6, prcedex & midaz stopped as patient did not respond\n to that & started with propofol , fluid bolus of 2 L for hypotension,\n Started with Neo low dose.\n Response:\n Weaned down to 20mcg/kgmin after the CT scan., weaned off neo now, Goal\n map >60, WBc still elevated 25.6 with am lab.\n Plan:\n Cont monitoring, cont anbx, wean off propofol.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Patient wit tracheostomy , on vent was on AC mode earlier.\n Action:\n Suctioned yellow thick secretion, Good cough. ABG acceptable, O 2sat\n 98-100% CXR done, Ct torso done .\n Response:\n Vent mode to CPAP/PS this morning, Sputum cultured. Strong cough.\n Plan:\n Pulm hygiene, Wean vent as tolerates\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570616,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : T103, increased LFTs/AP, propofol gtt, prophylactic abx\n : weaned to trach collar, R SCL CVL placed, PICC d/c'd, CT abd\n : ERCP\n : started TF\n : HLIV, suctioned q1hr, sputum cx, CXR, heat rash --> miconazole,\n agitation, diaphoretic episodes (afebrile, glucose normal).\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n Impaired Skin Integrity\n Assessment:\n -Groin and peri-anal area errythema and excoriated.\n Action:\n -Anti-fungal cream and nystatin powder applied every 2-4 hours PRN.\n -Repositioned Q 2.\n -SICU MD Team in to examine-continue with current regime.\n Response:\n -Groin and peri-anal area remain excoriated and red.\n Plan:\n -Antifungal cream/Nystatin powder q 2-4 hours PRN.\n -Reposition every 2 hours.\n -Consider Dermatology consult if no improvement.\n .H/O pancreatitis, acute\n Assessment:\n -\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 570675,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI=-114 arterial blood gas 7.44/34/109\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot manage secretions, Underlying illness not\n resolved; Comments: Plan on weaning down psv to possible trach collar\n trials as tolerates.\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 22:45\n none\n Bilateral pleural effusions with consolidation\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570684,
"text": "42M w/ pancreatitis s/p drainage of pseudo cyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Diarrhea\n Assessment:\n Patient had BM x3, liquid stool now, patient is on TF at goal ,\n tolerating.\n Action:\n Stool for C diff sent, Flexiseal inserted. cont with TF\n Response:\n Flexiseal draining liquid stool.\n Plan:\n Continue TF, skin care, cont with flexisael if persistent diarrhea.\n Impaired Skin Integrity\n Assessment:\n Patient noted to have skin rashes all over perineal & rectal area with\n small slit in the coccyx.\n Action:\n Turned q2h, antifungal & mycostatin powder applied. Area kept clean &\n dry\n Response:\n Skin still with rashes, but no drainage.\n Plan:\n Cont with skin care, frequent turns, ? apply mepilex on the coccyx\n after consult with wound care nurse g skin with rash &\n excoriation\n .H/O pancreatitis, acute\n Assessment:\n Patient with h/o pancreatitis & s/p ERCP .Abdomen soft & distended, +\n BS, Febrile, Tachy cardic, agitating early shift, NGT to wall suction\n with very minimal drainage, Tf at goal, elevated WBC.\n Action:\n CT torso done with oral & IV contrast. On antibiotics, Pan cultured\n for fever of 102.6, prcedex & midaz stopped as patient did not respond\n to that & started with propofol , fluid bolus of 2 L for hypotension,\n Started with Neo low dose.\n Response:\n Weaned down to 20mcg/kgmin after the CT scan., weaned off neo now, Goal\n map >60, WBc still elevated 25.6 with am lab.\n Plan:\n Cont monitoring, cont anbx, wean off propofol.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Patient wit tracheostomy , on vent was on AC mode earlier.\n Action:\n Suctioned yellow thick secretion, Good cough. ABG acceptable, O 2sat\n 98-100% CXR done, Ct torso done .\n Response:\n Vent mode to CPAP/PS this morning, Sputum cultured. Strong cough.\n Plan:\n Pulm hygiene, Wean vent as tolerates,ABG\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570685,
"text": "42M w/ pancreatitis s/p drainage of pseudo cyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Diarrhea\n Assessment:\n Patient had BM x3, liquid stool now, patient is on TF at goal ,\n tolerating.\n Action:\n Stool for C diff sent, Flexiseal inserted. cont with TF\n Response:\n Flexiseal draining liquid stool.\n Plan:\n Continue TF, skin care, cont with flexisael if persistent diarrhea.\n Impaired Skin Integrity\n Assessment:\n Patient noted to have skin rashes all over perineal & rectal area with\n small slit in the coccyx.\n Action:\n Turned q2h, antifungal & mycostatin powder applied. Area kept clean &\n dry\n Response:\n Skin still with rashes, but no drainage.\n Plan:\n Cont with skin care, frequent turns, ? apply mepilex on the coccyx\n after consult with wound care nurse g skin with rash &\n excoriation\n .H/O pancreatitis, acute\n Assessment:\n Patient with h/o pancreatitis & s/p ERCP .Abdomen soft & distended, +\n BS, Febrile, Tachy cardic, agitating early shift, NGT to wall suction\n with very minimal drainage, Tf at goal, elevated WBC.\n Action:\n CT torso done with oral & IV contrast. On antibiotics, Pan cultured\n for fever of 102.6, prcedex & midaz stopped as patient did not respond\n to that & started with propofol , fluid bolus of 2 L for hypotension,\n Started with Neo low dose.\n Response:\n Weaned down to 20mcg/kgmin after the CT scan., weaned off neo now, Goal\n map >60, WBc still elevated 25.6 with am lab.\n Plan:\n Cont monitoring, cont anbx, wean off propofol.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Patient wit tracheostomy , on vent was on AC mode earlier.\n Action:\n Suctioned yellow thick secretion, Good cough. ABG acceptable, O 2sat\n 98-100% CXR done, Ct torso done .\n Response:\n Vent mode to CPAP/PS this morning, Sputum cultured. Strong cough.\n Plan:\n Pulm hygiene, Wean vent as tolerates,ABG\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-07 00:00:00.000",
"description": "Intensivist Note",
"row_id": 570719,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n respiratory compromise\n PMHx:\n DVT, HTN, hyperlipidemia, CAD s/p MI in \n Current medications:\n . IV access: Temporary central access (ICU) Location: Right Subclavian,\n Date inserted: Order date: @ 0837 18. Lidocaine 1% 3-5\n mL IH Q4-6 HRS PRN Order date: @ 1854\n 2. 1000 mL LR Bolus 1000 ml Over 15 mins Order date: @ 1746 19.\n Lorazepam 1-2 mg IV ONCE Duration: 1 Doses Order date: @ 0503\n 3. 1000 mL LR Bolus 1000 ml Over 15 mins Order date: @ 2126 20.\n Lorazepam 1 mg IV ONCE Duration: 1 Doses Order date: @ 1001\n 4. 1000 mL LR Bolus 1000 ml Over 15 mins Order date: @ 2351 21.\n Lorazepam 1 mg IV ONCE Duration: 1 Doses Order date: @ 1029\n 5. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308 22.\n Lorazepam 2-4 mg IV Q4H:PRN Order date: @ \n 6. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139 23.\n Magnesium Sulfate IV Sliding Scale Order date: @ 0234\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1119 24. Miconazole Powder 2% 1 Appl TP TID:PRN Order date: @\n 1255\n 8. CloniDINE 0.2 mg PO TID Order date: @ 1714 25. Nystatin Oral\n Suspension 5 mL PO QID:PRN Order date: @ 0555\n 9. Famotidine 20 mg IV Q12H Order date: @ 0419 26. Phenylephrine\n 0.5-5 mcg/kg/min IV DRIP INFUSION\n maintain MAP>60 Order date: @ 2037\n 10. Fentanyl Citrate 25-50 mcg IV ONCE Duration: 1 Doses Order date:\n @ 1056 27. Piperacillin-Tazobactam Na 4.5 gm IV ONCE Duration: 1\n Doses Order date: @ 1209\n 11. Fentanyl Citrate 25-100 mcg IV ONCE Duration: 1 Doses Order date:\n @ 28. Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date:\n @ 1209\n 12. Fentanyl Patch 50 mcg/hr TP Q72H Order date: @ 0139 29.\n Potassium Chloride PO Sliding Scale Duration: 24 Hours\n please administer using 20 meq of KCl packets per peg tube. Order\n date: @ 0844\n 13. Haloperidol 1-2 mg IV ONCE Duration: 1 Doses Order date: @\n 0818 30. Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 0647\n 14. Haloperidol 1 mg IV ONCE Duration: 1 Doses Order date: @ 1001\n 31. Propofol 5-60 mcg/kg/min IV DRIP INFUSION Order date: @ 2052\n 15. Haloperidol 2 mg PO TID:PRN\n through G tube Order date: @ 1032 32. Sodium Chloride 0.9% Flush\n 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 0837\n 16. Heparin 5000 UNIT SC BID Order date: @ 0139 33. Vancomycin\n 1000 mg IV ONCE Duration: 1 Doses Order date: @ 1236\n 17. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0139 34. Vancomycin 1000 mg IV\n Q 12H Order date: @ 1746\n 24 Hour Events:\n ARTERIAL LINE - START 04:50 PM\n ARTERIAL LINE - STOP 06:53 PM\n PAN CULTURE - At 09:00 PM\n ARTERIAL LINE - START 09:27 PM\n FEVER - 102.6\nF - 08:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 03:59 AM\n Ampicillin/Sulbactam (Unasyn) - 10:00 AM\n Vancomycin - 09:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 09:20 AM\n Haloperidol (Haldol) - 10:18 AM\n Famotidine (Pepcid) - 06:56 PM\n Heparin Sodium (Prophylaxis) - 06:56 PM\n Fentanyl - 07:45 PM\n Other medications:\n Flowsheet Data as of 04:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.2\nC (102.6\n T current: 38.1\nC (100.6\n HR: 100 (69 - 142) bpm\n BP: 116/58(77) {79/37(46) - 139/77(126)} mmHg\n RR: 15 (12 - 52) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 6,738 mL\n 1,539 mL\n PO:\n Tube feeding:\n 1,774 mL\n 240 mL\n IV Fluid:\n 3,755 mL\n 1,239 mL\n Blood products:\n Total out:\n 1,180 mL\n 1,300 mL\n Urine:\n 1,180 mL\n 900 mL\n NG:\n 400 mL\n Stool:\n Drains:\n Balance:\n 5,558 mL\n 241 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 18 cmH2O\n SPO2: 99%\n ABG: 7.44/34/109/24/0\n Ve: 7.4 L/min\n PaO2 / FiO2: 218\n Physical Examination\n General Appearance: agitated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachy\n Respiratory / Chest: (Breath Sounds: Rhonchorous : b/l), (Sternum:\n Stable )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Sedated\n Labs / Radiology\n 327 K/uL\n 9.6 g/dL\n 122 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 8 mg/dL\n 106 mEq/L\n 140 mEq/L\n 28.4 %\n 20.9 K/uL\n [image002.jpg]\n 04:45 PM\n 03:15 AM\n 12:34 PM\n 04:57 AM\n 01:51 PM\n 03:46 PM\n 05:47 PM\n 10:45 PM\n 11:59 PM\n 04:11 AM\n WBC\n 10.1\n 13.3\n 18.8\n 20.9\n Hct\n 33.6\n 34.7\n 35.8\n 28.4\n Plt\n 27\n Creatinine\n 0.4\n 0.4\n 0.4\n 0.4\n 0.5\n 0.5\n Troponin T\n <0.01\n TCO2\n 30\n 30\n 26\n 24\n Glucose\n 126\n 160\n 151\n 170\n 190\n 122\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:76//<0.01, ALT / AST:72/25, Alk-Phos / T bili:192/1.1, Amylase /\n Lipase:35/31, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.8 mmol/L, Albumin:3.0 g/dL, Ca:8.7 mg/dL,\n Mg:1.7 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n .H/O RESPIRATORY FAILURE, ACUTE (NOT ARDS/), .H/O CHOLELITHIASIS,\n .H/O MYOCARDIAL INFARCTION, .H/O PANCREATITIS, ACUTE, .H/O ABDOMINAL\n PAIN (INCLUDING ABDOMINAL TENDERNESS), IMPAIRED SKIN INTEGRITY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction\n Neurologic: Neuro checks Q: 4 hr, pt currently sedated on low dose\n propofol gtt, continues to be agitated/ CT torso to r/o new\n intrabdominal or pulmonary process--New b/l basilar consolidations,\n left greater than right. no other significant changes. Haldol po\n Ativan as required. ? withdrawl????\n Cardiovascular: tachycardic, initially hypotensive--fluid given/low\n dose neo. Hold clonidine.\n Pulmonary: Trach, (Ventilator mode: CMV), wean to trach mask\n Gastrointestinal / Abdomen: NGT, G tibe\n Nutrition: Replete with fiber Full strength, 90/hr\n Renal: Foley, Adequate UO, creatinine stable at 0.5\n Hematology: stable\n Endocrine: RISS, glc 122\n Infectious Disease: pan cx pending, pt spiked at 102.6 CT odf\n abdomen- no sig change. No air in pancreas\n Lines / Tubes / Drains: Foley, Trach, Foley, G-tube, trach, A-line, R\n SCL CVL\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: LR\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Pancreatitis\n ICU Care\n Nutrition:\n Replete (Full) - 04:10 AM 70 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n Arterial Line - 09:27 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 min\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 570838,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Supra-sternal retractions,\n Accessory muscle use, Active exhalations\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Vigorous inspiratory efforts\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n RSBI ~ 200. No ABG\ns but SpO2 95-100%\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570791,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : T103, increased LFTs/AP, propofol gtt, prophylactic abx\n : weaned to trach collar, R SCL CVL placed, PICC d/c'd, CT abd\n : ERCP\n : started TF\n : HLIV, suctioned q1hr, sputum cx, CXR, heat rash --> miconazole,\n agitation, diaphoretic episodes (afebrile, glucose normal).\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation. I\n Impaired Skin Integrity\n Assessment:\n -Groin and peri-anal area errythema and excoriated.\n -Flexi-seal intact with small amount of golden yellow liquid stool.\n Action:\n -Wound Care consult.\n -Miconazole cream/Anti-fungal barrier cream applied every 2-4 hours\n PRN.\n -Repositioned Q 2 from side to side.\n Response:\n -Groin and peri-anal with decreased errythema and excoriation.\n Plan:\n -Miconazole cream/Antifungal barrier cream/M q 2-4 hours PRN.\n -Reposition every 2 hours from side to side.\n -Re-consult Wound Care Nurse PRN.\n -Consider Dermatology consult if no improvement.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n -Trach on CPAP/50%/5PEEP/12 PS.\n -Trach site CDI.\n Action:\n -Suctioned for small to moderate amounts of thick yellow sputum.\n -Ct PT every 2-4 hours as tolerated.\n -Sputum culture from -pending.\n -Wean to 10 PS.\n -Zosyn/Vancomycin given.\n Response:\n -LS: R+LUL Cear, diminished bibasilar.\n -Pox: 97-98%.\n Plan:\n -Aggressive pulmonary hygiene.\n -Titrate vent support as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570844,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : T103, increased LFTs/AP, propofol gtt, prophylactic abx\n : weaned to trach collar, R SCL CVL placed, PICC d/c'd, CT abd\n : ERCP\n : started TF\n : HLIV, suctioned q1hr, sputum cx, CXR, heat rash --> miconazole,\n agitation, diaphoretic episodes (afebrile, glucose normal).\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Low grade fever all night\n Diaphoretic\n Tachycardia\n Tachypnic\n Action:\n Tylenol\n Turn Q 2 hrs\n Bath, cool\n ABX as ordered\n Response:\n Temp continues to be low grade, but coming down.\n Hr has come down at times\n Patient less agitated with 2 mg of ativan about Q 4hrs with good\n control\n Plan:\n Continue to monitor and report any signs of infection, good infectious\n dz protocol.\n Hyperglycemia\n Assessment:\n Glucose has been high through the day. Being checked every 6 hrs.\n Action:\n SSRI given per patients SS protocol.\n 8 units at 2200\n 12 units at 0400\n Response:\n Remains hyperglycemic at this time.\n Plan:\n Watch UOP, and TF residuals\n Continue to monitor and treat per RISS\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-08 00:00:00.000",
"description": "Intensivist Note",
"row_id": 570845,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. Magnesium Sulfate IV Sliding Scale Order date: @ 0234\n 2. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308\n 3. Miconazole Powder 2% 1 Appl TP TID:PRN Order date: @ 1255\n 4. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139\n 5. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @ 0555\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n 7. Phenylephrine 0.5-5 mcg/kg/min IV DRIP INFUSION maintain MAP>60\n Order date: @ 2037\n 8. Famotidine 20 mg IV Q12H Order date: @ 0419\n 9. Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @ 1209\n 10. Fentanyl Patch 50 mcg/hr TP Q72H Order date: @ 0139\n 11. Potassium Chloride PO Sliding Scale Hold for K > 5 Order date:\n @ 0505\n 12. Haloperidol 2 mg PO TID through G tube Order date: @ 0840\n 13. Potassium Phosphate IV Sliding Scale Infuse over 6 hours Order\n date: @ 0647\n 14. Heparin 5000 UNIT SC BID Order date: @ 0139\n 15. Propofol 5-60 mcg/kg/min IV DRIP INFUSION Order date: @ 2052\n 16. Insulin SC (per Insulin Flowsheet) Sliding Scale Order date: \n @ 1317\n 17. Lidocaine 1% 3-5 mL IH Q4-6 HRS PRN Order date: @ 1854\n 18. Vancomycin 1000 mg IV Q 8H Order date: @ 1044\n 19. Lorazepam 2-4 mg IV Q4H:PRN Order date: @ \n 24 Hour Events:\n ULTRASOUND - At 03:34 PM\n Liver and gallbladder US performed.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 03:59 AM\n Ampicillin/Sulbactam (Unasyn) - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 12:12 AM\n Vancomycin - 12:45 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 04:20 AM\n Famotidine (Pepcid) - 06:11 AM\n Heparin Sodium (Prophylaxis) - 06:11 AM\n Other medications:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 37.3\nC (99.2\n HR: 90 (70 - 120) bpm\n BP: 117/65(82) {102/48(65) - 155/87(112)} mmHg\n RR: 42 (13 - 43) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 3,973 mL\n 1,222 mL\n PO:\n Tube feeding:\n 1,527 mL\n 599 mL\n IV Fluid:\n 2,166 mL\n 524 mL\n Blood products:\n Total out:\n 4,490 mL\n 670 mL\n Urine:\n 4,080 mL\n 470 mL\n NG:\n 410 mL\n Stool:\n Drains:\n Balance:\n -517 mL\n 552 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 434 (349 - 645) mL\n PS : 10 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 122\n PIP: 16 cmH2O\n SPO2: 99%\n ABG: ///29/\n Ve: 13.4 L/min\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), Tachycardic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : , Diminished: at the bases), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n G-tube intact\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: (Responds to: Verbal stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 344 K/uL\n 8.9 g/dL\n 207 mg/dL\n 0.4 mg/dL\n 29 mEq/L\n 3.4 mEq/L\n 5 mg/dL\n 105 mEq/L\n 142 mEq/L\n 27.3 %\n 12.8 K/uL\n [image002.jpg]\n 04:57 AM\n 01:51 PM\n 03:46 PM\n 05:47 PM\n 10:45 PM\n 11:59 PM\n 03:59 AM\n 04:11 AM\n 05:35 PM\n 02:48 AM\n WBC\n 13.3\n 18.8\n 20.9\n 25.6\n 12.8\n Hct\n 34.7\n 35.8\n 28.4\n 30.2\n 27.3\n Plt\n 400\n 517\n 327\n 431\n 344\n Creatinine\n 0.4\n 0.5\n 0.5\n 0.5\n 0.4\n 0.4\n TCO2\n 30\n 30\n 26\n 24\n Glucose\n 170\n 190\n 122\n 189\n 180\n 207\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:76//<0.01, ALT / AST:72/25, Alk-Phos / T bili:192/1.1, Amylase /\n Lipase:35/31, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.8 mmol/L, Albumin:3.0 g/dL, Ca:8.3 mg/dL,\n Mg:2.3 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), FUNGAL INFECTION, OTHER,\n HYPERGLYCEMIA, DIARRHEA, .H/O RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), .H/O CHOLELITHIASIS, .H/O MYOCARDIAL INFARCTION, .H/O\n PANCREATITIS, ACUTE, .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL\n TENDERNESS), IMPAIRED SKIN INTEGRITY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction\n Neurologic: Pain controlled, Continue ativan, haldol, fentanyl patch to\n control aggitation\n Cardiovascular: Remains tachycardic likely from aggitation\n Pulmonary: Trach, (Ventilator mode: CPAP + PS), Wean to trach collar\n Gastrointestinal / Abdomen: G-tube, cont TFs, monitor LFTs\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Hct drifting down, will continue to follow\n Endocrine: RISS\n Infectious Disease: Check cultures\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure), Pancreatitis\n ICU Care\n Nutrition:\n Replete (Full) - 05:53 AM 90 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 08:00 AM\n Arterial Line - 09:27 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 569944,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt received from OSH direct admit to SICUB trached and placed\n on mech vent as per Metavision. Lung sounds rhonchi improved with suct\n mod th off white sput. ABGs stable on current settings; FIO2 only\n change. Cont mech vent support.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570832,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : T103, increased LFTs/AP, propofol gtt, prophylactic abx\n : weaned to trach collar, R SCL CVL placed, PICC d/c'd, CT abd\n : ERCP\n : started TF\n : HLIV, suctioned q1hr, sputum cx, CXR, heat rash --> miconazole,\n agitation, diaphoretic episodes (afebrile, glucose normal).\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Low grade fever all night\n Diaphoretic\n Tachycardia\n Tachypnic\n Action:\n Tylenol\n Turn Q 2 hrs\n Bath, cool\n ABX as ordered\n Response:\n Temp continues to be low grade, but coming down.\n Hr has come down at times\n Patient less agitated with 2 mg of ativan about Q 4hrs with good\n control\n Plan:\n Continue to monitor and report any signs of infection, good infectious\n dz protocol.\n Hyperglycemia\n Assessment:\n Glucose has been high through the day. Being checked every 6 hrs.\n Action:\n SSRI given per patients SS protocol.\n Response:\n To be determined. Remains hyperglycemic at this time.\n Plan:\n Let MD know what is going on with this patient. Watch UOP, continue to\n follow SS\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 570946,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments: pt also suctioned for copious amt of thick oral secretions\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt continues on PSv no vent chages made this shift\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: plan to wean vent support as tolerated\n Reason for continuing current ventilatory support:\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 570088,
"text": "HPI: pt dx at outside hospital w/pancreatits, s/p pseudocyst\n drainage--culture + for staph, hemodynamically unstable, required\n intubation/pressors. unable to wean off vent, trach'd. admitted to\n sicu, spiking temps tmax-103, increased lft's/alk phos/ r/o\n cholangitiis, currently sedated, prophylactic abx, no pressors\n presently required.\n PMH: DVT, HTN, Lipidemia, Hx of MI in s/p PTCA\n PSH: PEG/trach\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n 24 HOUR EVENTS:\n : tmax-103, increased lft's/alk phos, r/o cholangitiis, propofol\n gtt, prophylactic abx, no pressors\n : weaned to trach collar, right subclavian CVL placed, PICC\n discontinued and cx sent, CT abdomen obtained\n MICRO:\n blood, urine - pending\n MRSA - pending\n : PICC tip cx - pending\n Imaging/Diagnostics:\n - CXR: tracheostomy distal tip 3 cm above carina, lungs clear, no\n pneumothoraces, Cardiac silhouette upper limits of normal.\n - CXR: right-sided subclavian CVL distal lead tip in the\n mid-to-distal SVC\n - CT abd: acute pancreatitis with fluid collection 8x4x4 cm,\n choledocholithiasis in distal common duct with associated left\n intrahepatic biliary dilitation, no acute cholecystitis, splenomegaly,\n bibasilar atelecstasis\n Allergies:\n Last dose of Antibiotics:\n Metronidazole - 08:38 PM\n Vancomycin - 08:38 PM\n Ampicillin/Sulbactam (Unasyn) - 10:43 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (101\n T current: 37.8\nC (100\n HR: 78 (76 - 92) bpm\n BP: 123/63(82) {86/43(53) - 143/4,742(102)} mmHg\n RR: 34 (7 - 34) insp/min\n SPO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,346 mL\n 501 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,346 mL\n 501 mL\n Blood products:\n Total out:\n 1,835 mL\n 420 mL\n Urine:\n 1,835 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,511 mL\n 81 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Aerosol-cool, Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 277 (277 - 542) mL\n PS : 8 cmH2O\n RR (Set): 14\n RR (Spontaneous): 36\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n Plateau: 18 cmH2O\n SPO2: 91%\n ABG: 7.46/34/95./27/0\n Ve: 9.6 L/min\n PaO2 / FiO2: 238\n Physical Examination\n General Appearance: No acute distress, trach, off sedation, nods\n appropriately\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : bilaterally)\n Abdominal: PEG tube\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 299 K/uL\n 9.5 g/dL\n 131 mg/dL\n 0.3 mg/dL\n 27 mEq/L\n 3.1 mEq/L\n 9 mg/dL\n 109 mEq/L\n 145 mEq/L\n 28.7 %\n 8.4 K/uL\n [image002.jpg]\n 02:36 AM\n 02:55 AM\n 05:16 PM\n 02:58 AM\n 03:13 AM\n WBC\n 10.6\n 8.4\n Hct\n 30.3\n 28.7\n Plt\n 346\n 299\n Creatinine\n 0.5\n 0.3\n TCO2\n 29\n 29\n 25\n Glucose\n 151\n 146\n 131\n Other labs: PT / PTT / INR:15.4/25.3/1.4, ALT / AST:257/242, Alk-Phos /\n T bili:318/5.0, Amylase / Lipase:30/21, Differential-Neuts:80.5 %,\n Lymph:15.0 %, Mono:3.0 %, Eos:0.8 %, Lactic Acid:0.6 mmol/L,\n Albumin:3.0 g/dL, Ca:9.1 mg/dL, Mg:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan: 42M w/ hx of pancreatits, presents w/septic\n picture, r/o cholangitis\n Neurologic: Neuro checks Q: 4 hr, off sedation, fentanyl patch\n Cardiovascular: hx of htn, BP stable, no pressors required\n Pulmonary: trach collar overnight, +cough on trach (topical lidocaine)\n Gastrointestinal / Abdomen: ERCP today\n Nutrition: NPO\n Renal: Foley, adequate UOP\n Endocrine: RISS\n Infectious Disease: follow up cultures, continue empiric antibiotic\n coverage (vancomycin/unasyn/flagyl)\n Lines / Tubes / Drains: foley, G-tube, trach, left radial a-line, right\n subclavian CVL\n Fluids: LR @ 100\n Consults: General surgery\n Procedures: ERCP\n Code status: full\n Disposition: for ERCP, SICU\n Billing Diagnosis- Pancreatitis and Respiratory failure\n ICU Care\n Lines:\n 20 Gauge - 11:48 PM\n Arterial Line - 03:07 AM\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: boots, heparin\n Stress ulcer: H2 blocker\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 32\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570091,
"text": ".H/O pancreatitis, acute\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570096,
"text": "hemodynamically unstable, required intubation/pressors. unable to wean\n off vent, trach'd. admitted to sicu, spiking temps tmax-103, increased\n lft's/alk phos/ r/o cholangitiis, currently sedated, prophylactic abx,\n no pressors presently required.\n PMH: DVT, HTN, Lipidemia, Hx of MI in s/p PTCA\n PSH: PEG/trach\n .H/O pancreatitis, acute\n Assessment:\n Awake and following simple commands. On trach collar and coughing and\n raising thick white sputum. O2sats 96-99%. Resp rate 20- 40.\n diaphoretic at times and bedclothes changed x4. temp 99.9-100.0 l\n liver function tests elevated this am.\n Action:\n Back on vent during the nite and able to sleep in 4hr blocks.\n Continues with iv vanco, unsyn and flagyl. Lactated ringers at\n 100cc/hr.\n Response:\n Awaiting to have ercp today. More responsive and follows simple\n commands.\n Plan:\n Monitor condition closely. Update family regarding pt\ns condition.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 570182,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont trached and on HiFlo as per Metavision. Lung sounds\n rhonchi improved with freq suct and exp mod loose off white sput. Pt\n in NARD but does cough freq;[1% Lidocaine instilled with little\n effect]; however VSS. Cont HiFlo via T-piece/pulmonary toilet as\n required.\n"
},
{
"category": "ECG",
"chartdate": "2140-04-22 00:00:00.000",
"description": "Report",
"row_id": 240021,
"text": "Artifact is present. Sinus rhythm. The P-R interval is prolonged. There is\nnon-specific intraventricular conduction delay. Left ventricular hypertrophy.\nThere is an early transition which is non-specific. Non-specific ST-T wave\nchanges. Compared to the previous tracing the P-R interval is longer.\n\n"
},
{
"category": "ECG",
"chartdate": "2140-04-05 00:00:00.000",
"description": "Report",
"row_id": 240022,
"text": "Sinus rhythm. Intraventricular conduction delay may be left anterior\nfascicular block and right bundle-branch block. Left ventricular hypertrophy.\nST-T wave changes are non-specific. Clinical correlation is suggested.\nNo previous tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-02 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1075143,
"text": " 8:42 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: CVL line placement\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with pancreatitis\n REASON FOR THIS EXAMINATION:\n CVL line placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST .\n\n HISTORY: Patient with central line placement.\n\n There are two right sided subclavian catheters. One of the tips is in the\n cavoatrial junction, the second tip is not well seen, is likely more proximal.\n There is a tracheostomy with the distal tip at the level of the aortic knob.\n Lungs are clear without pneumothoraces. The cardiac silhouette is enlarged.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1075108,
"text": " 1:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval trach placement\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with pancreatitis s/p trach\n REASON FOR THIS EXAMINATION:\n eval trach placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 42-year-old man with pancreatitis status post tracheostomy.\n\n FINDINGS: There is a tracheostomy with the distal tip 3 cm above the carina.\n Lungs are clear. There is no pneumothoraces. Cardiac silhouette is upper\n limits of normal.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-02 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1075153,
"text": " 10:19 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: CVL line placement, interval change from prior study (pulled\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with h/o pancreatitis, abd pain\n REASON FOR THIS EXAMINATION:\n CVL line placement, interval change from prior study (pulled back CVL 1.5 cm)\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: Previous central venous catheter has been pulled slightly. Evaluate\n for interval change.\n\n FINDINGS: There are two right-sided subclavian central venous catheter distal\n lead tips in the mid-to-distal SVC. No pneumothoraces are identified. Lungs\n are grossly clear. Tracheostomy is again seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-03 00:00:00.000",
"description": "ERCP BILIARY&PANCREAS BY GI UNIT",
"row_id": 1075460,
"text": " 3:03 PM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: Please review ERCP images done \n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 yr old Male with Increased LFT, Gallstone pancreatitis with pseudocyst,CBD\n stone per CT.\n REASON FOR THIS EXAMINATION:\n Please review ERCP images done \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old man with elevated LFTs, pancreatitis and pancreatic\n pseudocyst, with recurrent fevers. A prior CT demonstrated CBD stone.\n\n COMPARISON: .\n\n ERCP: 11 spot fluoroscopic images were obtained without a radiologist\n present. Initial scout image demonstrates residual oral contrast in the large\n bowel, and a G-tube overlying the abdominal midline. Subsequently,\n opacification of the biliary tree reveals a small filling defect in the lower\n CBD, near the ampulla. No other filling defects are present. There is no\n intra- or extra-hepatic biliary ductal dilatation. There is no stricture. The\n cystic duct is normal. By report, a 4-mm stone was extracted via balloon,\n along with sludge, from the lower CBD, and a sphincterotomy was performed.\n\n For further details, please refer to the procedure note.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-02 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1075160,
"text": " 11:18 AM\n CT ABDOMEN W/CONTRAST Clip # \n Reason: evaluate pseudocystIV and PO contrast through G tube\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with known pancreatitis and pseudocyst\n REASON FOR THIS EXAMINATION:\n evaluate pseudocystIV and PO contrast through G tube\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old with known pancreatitis and pseudocyst. Additional\n history obtained through CareWeb record indicates that the patient was\n transferred from Hospital after a complicated course of pancreatitis\n and apparent outside hospital CT scan showing both a pseudocyst and\n choledocholithiasis.\n\n TECHNIQUE: Axial MDCT images through the abdomen only with oral contrast\n administered through the G-tube and approximately 100 cc of nonionic\n intravenous contrast.\n\n CT ABDOMEN WITH IV AND ORAL CONTRAST: There is a small amount of dependent\n atelectasis at the dependent portion of the left lung base and minimal\n atelectasis at the right lung base. The visualized portion of the heart and\n pericardium are unremarkable. Within the liver, there is moderate left-sided\n intrahepatic biliary ductal dilatation. Tiny 3-mm low-attenuation lesion\n within segment VIII (2,11) may relate to a dilated duct. Finally, there is a\n small ill-defined low-attenuation lesion at the peripheral posterior aspect of\n segment VI (2, 38), too small to characterize. The common bile duct is mildly\n dilated down to the level of the distal common duct, at which point there is a\n 3.5-mm calculus which appears likely obstructing (2, 42; 301B, 31).\n\n There is extensive fluid surrounding the pancreas beginning to organize and\n extending along the anterior pararenal space, not yet coalescent enough to\n characterize as a pseudocyst. Anterior and superior to the pancreas, there is\n an organizing fluid collection measuring 8.1 x 4.2 x 4.4 cm (transverse, AP,\n CC). Fluid extends towards the spleen and a small tongue of fluid extends\n inferiorly 8 cm down, measuring 3.4 x 1.3 cm in the axial plane. No\n percutaneous pigtail is in place at this time. No gas is seen and within this\n collection. The pancreatic parenchyma is enhancing normally with the\n exception of a small ill-defined hypoattenuating region in the inferior\n pancreatic head (2, 42), measuring 9 mm which may represent a small pseudocyst\n but will require further imaging to ensure resolution. There are\n gallstones/layering milk of calcium in the gallbladder which is minimally\n distended but demonstrates no specific CT signs of acute cholecystitis. The\n percutaneous G-tube is in place which appears intraluminal, although it is\n slightly tenting the anterior aspect of the stomach. There is no extra-\n gastric air. The spleen is enlarged measuring up to 15 cm. Multiple presumed\n simple renal cysts, though many are too small to characterize. The adrenal\n glands are within normal limits. No free air is visualized within the\n abdomen. No evidence of extravasation of oral contrast. No evidence of\n pseudoaneurysm.\n (Over)\n\n 11:18 AM\n CT ABDOMEN W/CONTRAST Clip # \n Reason: evaluate pseudocystIV and PO contrast through G tube\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n MULTIPLANAR REFORMATS: Coronal and sagittal reformats were very helpful in\n evaluating the above findings. The coronal images demonstrate well the extent\n of the peripancreatic fluid with several loculated components which appear\n largely contiguous. The kidneys enhance normally and excrete contrast in a\n normal fashion. No osseous abnormalities are appreciated.\n\n IMPRESSION:\n 1) Findings consistent with acute pancreatitis with extensive minimally\n organized fluid within the anterior pararenal space; the largest component\n anterior and superior to the pancreas measuring approximately 8 x 4 x 4 cm.\n No pancreatic necrosis. No pseudoaneurysm.\n\n 2) 9-mm hypoattenuating focus in the inferior pancreatic head, likely also the\n sequella of pancreatitis, though followup CT is required to ensure resolution\n and exclude a cystic pancreatic neoplasm.\n\n 3) Choledocholithiasis with a 3.5-mm likely obstructing stone in the distal\n common duct, with left intrahepatic biliary dilitation.\n\n 4) Cholelithiasis without CT signs of acute cholecystitis.\n\n 5) Splenomegaly.\n\n 6) Bibasilar atelectasis.\n\n 7) Tiny hypodense lesions within segment VIII and segment VI of the liver as\n above which are too small to characterize.\n\n 8) Multiple probable simple renal cysts, many too small to characterize.\n\n\n DR. \n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 570485,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont trached and on HiFlo as per Metavision. Lung sounds\n rhonchi improved with freq suct and exp mod loose off white sput9spec\n obt). Pt in NARD but does cough freq. Cont HiFlo via T-piece/pulmonary\n toilet as required.\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 569977,
"text": "SICU\n HPI:\n pt dx at outside hospital w/pancreatits, s/p pseudocyst\n drainage--culture + for staph, hemodynamically unstable, required\n intubation/pressors. unable to wean off vent, trach'd. admitted to\n sicu, spiking temps tmax-103, increased lft's/alk phos/ r/o\n cholangitiis, currently sedated, prophylactic abx, no pressors\n presently required.\n Chief complaint:\n abdominal pain/pancreatitis/respiratory failure\n PMHx:\n DVT, HTN, Lipidemia, Hx of MI in s/p PTCA\n Current medications:\n 1. 1000 mL LR Continuous at 100 ml/hr Order date: @ 0354 8.\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 0308\n 2. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308 9.\n Miconazole 2% Cream 1 Appl TP :PRN Order date: @ 0139\n 3. Ampicillin-Sulbactam 3 g IV Q6H Order date: @ 0308 10.\n Pantoprazole 40 mg IV Q24H Order date: @ 0231 11. Propofol \n mcg/kg/min IV DRIP TITRATE TO sedation Order date: @ 0139 5.\n Fentanyl Patch 50 mcg/hr TP Q72H Order date: @ 0139 12. Propofol\n 5-40 mcg/kg/min IV DRIP INFUSION Order date: @ 0308 6. Heparin\n 5000 UNIT SC BID Order date: @ 0139 13. Vancomycin 1000 mg IV Q\n 12H @ 0308 7. Insulin SC (per Insulin Flowsheet) Sliding Scale Order\n date: @ 0139\n 24 Hour Events:\n PICC LINE - START 11:47 PM\n INVASIVE VENTILATION - START 12:00 AM\n ARTERIAL LINE - START 03:07 AM\n FEVER - 103.5\nF - 11:19 PM\n Allergies:\n Last dose of Antibiotics:\n Metronidazole - 03:27 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 03:27 AM\n Other medications:\n Flowsheet Data as of 04:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.7\nC (103.5\n T current: 38.9\nC (102\n HR: 104 (85 - 116) bpm\n BP: 106/58(72) {88/49(60) - 109/58(72)} mmHg\n RR: 15 (14 - 22) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 0 mL\n 167 mL\n PO:\n Tube feeding:\n IV Fluid:\n 0 mL\n 167 mL\n Blood products:\n Total out:\n 25 mL\n 115 mL\n Urine:\n 25 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n -25 mL\n 52 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 18 cmH2O\n Plateau: 18 cmH2O\n Compliance: 46.2 cmH2O/mL\n SPO2: 98%\n ABG: 7.47/39/155/26/5\n Ve: 10.6 L/min\n PaO2 / FiO2: 388\n Physical Examination\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: b/l)\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Responds to: Tactile stimuli, Noxious stimuli), Moves all\n extremities, Sedated\n Labs / Radiology\n 346 K/uL\n 9.9 g/dL\n 146 mg/dL\n 0.5 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 17 mg/dL\n 102 mEq/L\n 145 mEq/L\n 30.3 %\n 10.6 K/uL\n [image002.jpg]\n 02:36 AM\n 02:55 AM\n WBC\n 10.6\n Hct\n 30.3\n Plt\n 346\n Creatinine\n 0.5\n TCO2\n 29\n Glucose\n 151\n 146\n Other labs: PT / PTT / INR:15.7/27.6/1.4, ALT / AST:204/211, Alk-Phos /\n T bili:353/3.9, Amylase / Lipase:33/22, Differential-Neuts:80.5 %,\n Lymph:15.0 %, Mono:3.0 %, Eos:0.8 %, Lactic Acid:1.1 mmol/L,\n Albumin:3.0 g/dL, Ca:9.5 mg/dL, Mg:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n Assessment and Plan: 42 y/o male w/hx of pancreatits, presents w/septic\n picture, r/o cholangitis\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, sedated on propfol\n and fentanyl\n Cardiovascular: hx of htn, BP stable, no pressors required. Place\n Vigeleo to assess volume status\n Pulmonary: Trach, (Ventilator mode: CMV), wean vent as tolerated\n Gastrointestinal / Abdomen: stable, G-tube in place. D/C protonix.\n Start H2B\n Nutrition: NPO\n Renal: Foley, u/o 25-30/hr, creatinine stable at 0.5\n Hematology: stable\n Endocrine: RISS, stable\n Infectious Disease: Check cultures, empiric coverage w/vanc/ unasyn/\n flagyl, blood cx pending, urine cx pending\n Lines / Tubes / Drains: Foley, G-tube, Trach, left radial a-line. Place\n CVL today\n Wounds: none\n Imaging: CXR today\n Fluids: LR, 100 cc/hr\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure), Sepsis,\n Pancreatitis\n ICU Care:\n Lines:\n PICC Line - 11:47 PM\n 20 Gauge - 11:48 PM\n Arterial Line - 03:07 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Communication: Patient discussed on interdisciplinary rounds\n Code status:\n Disposition: ICU\n Total time spent: 31\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 570071,
"text": "Date HD 2\n Abx: vancomycin, flagyl, unasyn\n AC: H2 blocker, boots, heparin\n CC: abdominal pain/pancreatitis\n HPI: pt dx at outside hospital w/pancreatits, s/p pseudocyst\n drainage--culture + for staph, hemodynamically unstable, required\n intubation/pressors. unable to wean off vent, trach'd. admitted to\n sicu, spiking temps tmax-103, increased lft's/alk phos/ r/o\n cholangitiis, currently sedated, prophylactic abx, no pressors\n presently required.\n PMH: DVT, HTN, Lipidemia, Hx of MI in s/p PTCA\n PSH: PEG/trach\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n : home meds unknown\n ALLERGIES: unknown\n 24 HOUR EVENTS:\n : tmax-103, increased lft's/alk phos, r/o cholangitiis, propofol\n gtt, prophylactic abx, no pressors\n : weaned to trach collar, right subclavian CVL placed, PICC\n discontinued and cx sent, CT abdomen obtained\n MICRO:\n blood, urine - pending\n MRSA - pending\n : PICC tip cx - pending\n Imaging/Diagnostics:\n - CXR: tracheostomy distal tip 3 cm above carina, lungs clear, no\n pneumothoraces, Cardiac silhouette upper limits of normal.\n - CXR: right-sided subclavian CVL distal lead tip in the\n mid-to-distal SVC\n - CT abd: acute pancreatitis with fluid collection 8x4x4 cm,\n choledocholithiasis in distal common duct with associated left\n intrahepatic biliary dilitation, no acute cholecystitis, splenomegaly,\n bibasilar atelecstasis\n Allergies:\n Last dose of Antibiotics:\n Metronidazole - 08:38 PM\n Vancomycin - 08:38 PM\n Ampicillin/Sulbactam (Unasyn) - 10:43 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (101\n T current: 37.8\nC (100\n HR: 78 (76 - 92) bpm\n BP: 123/63(82) {86/43(53) - 143/4,742(102)} mmHg\n RR: 34 (7 - 34) insp/min\n SPO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,346 mL\n 501 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,346 mL\n 501 mL\n Blood products:\n Total out:\n 1,835 mL\n 420 mL\n Urine:\n 1,835 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,511 mL\n 81 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Aerosol-cool, Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 277 (277 - 542) mL\n PS : 8 cmH2O\n RR (Set): 14\n RR (Spontaneous): 36\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n Plateau: 18 cmH2O\n SPO2: 91%\n ABG: 7.46/34/95./27/0\n Ve: 9.6 L/min\n PaO2 / FiO2: 238\n Physical Examination\n General Appearance: No acute distress, trach, off sedation, nods\n appropriately\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : bilaterally)\n Abdominal: PEG tube\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 299 K/uL\n 9.5 g/dL\n 131 mg/dL\n 0.3 mg/dL\n 27 mEq/L\n 3.1 mEq/L\n 9 mg/dL\n 109 mEq/L\n 145 mEq/L\n 28.7 %\n 8.4 K/uL\n [image002.jpg]\n 02:36 AM\n 02:55 AM\n 05:16 PM\n 02:58 AM\n 03:13 AM\n WBC\n 10.6\n 8.4\n Hct\n 30.3\n 28.7\n Plt\n 346\n 299\n Creatinine\n 0.5\n 0.3\n TCO2\n 29\n 29\n 25\n Glucose\n 151\n 146\n 131\n Other labs: PT / PTT / INR:15.4/25.3/1.4, ALT / AST:257/242, Alk-Phos /\n T bili:318/5.0, Amylase / Lipase:30/21, Differential-Neuts:80.5 %,\n Lymph:15.0 %, Mono:3.0 %, Eos:0.8 %, Lactic Acid:0.6 mmol/L,\n Albumin:3.0 g/dL, Ca:9.1 mg/dL, Mg:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan: 42M w/ hx of pancreatits, presents w/septic\n picture, r/o cholangitis\n Neurologic: Neuro checks Q: 4 hr, off sedation, fentanyl patch\n Cardiovascular: hx of htn, BP stable, no pressors required\n Pulmonary: trach collar overnight, +cough on trach (topical lidocaine)\n Gastrointestinal / Abdomen: ERCP today\n Nutrition: NPO\n Renal: Foley, adequate UOP\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: follow up cultures, continue empiric antibiotic\n coverage (vancomycin/unasyn/flagyl)\n Lines / Tubes / Drains: foley, G-tube, trach, left radial a-line, right\n subclavian CVL\n Wounds: none\n Imaging: none\n Fluids: LR @ 100\n Consults: General surgery\n Procedures: ERCP\n Code status: full\n Disposition: for ERCP, SICU\n ICU Care\n Nutrition: NPO\n Glycemic Control: RISS\n Lines:\n 20 Gauge - 11:48 PM\n Arterial Line - 03:07 AM\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: boots, heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 569989,
"text": "HPI:\n pt dx at outside hospital w/pancreatits, s/p pseudocyst\n drainage--culture + for staph, hemodynamically unstable, required\n intubation/pressors. unable to wean off vent, trach'd. admitted to\n sicu, spiking temps tmax-103, increased lft's/alk phos/ r/o\n cholangitiis, currently sedated, prophylactic abx, no pressors\n presently required.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Pt admitted to the sicu from hospital. Pt is trach edwith # 8\n portex trach. Bp 70-120syst. Hr 60-90. does not open eyes to painful\n stimuli. Moves intermittently in the bed but does not follow any\n commands. Temp. 103.o\n Action:\n Iv lactated ringers at 100ccc/hr. blood culture x1 urine culture\n sent. Iv vancomycin, flagyl and unasyn given as ordered. Heparin sc\n q8hrs. Tylenol 650mg via g tube.x1. cxr done. Propofol gtt started and\n titrated. Aline inserted by dr .\n Response:\n Pt contiues with temperature despite Tylenol. Central line to be\n placed this am. Iv lactated ringers continues at 100cc/hr. cultures\n pending. Continue with antibiotics as ordered.\n Plan:\n Monitor condition closely. Update family.\n Impaired Skin Integrity\n Assessment:\n Upon admission to sicu from hospital. Pt\ns coccyx and\n buttocks reddened. Right elbow noted to have abrasion 2x3.\n Action:\n Turned q2hrs, dsg applied to coccyx and buttocks. Right elbow\n open to air.\n Response:\n Continue to monitor skin integritiy.\n Plan:\n Monitor skin and continue to turn pt.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 570043,
"text": "No significant change in large right subdural hematoma and\n pneumocephalus with subdural drain in place.\n No significant change in large right subdural hematoma and\n pneumocephalus with subdural drain in place.\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570143,
"text": ".H/O pancreatitis, acute\n Assessment:\n Pt much more alert today. Consistently following commands. Denies sob\n or pain. VSS. Afebrile . Lungs clear to coarse throughout. Abd\n softly distended\n (+) bowel sounds. Urine output adequate. Moderate\n amt of loose stool via flexiseal.\n Action:\n Pt encouraged to cough and deep breathe. Pt taken to for\n ERCP. Sphincterotomy and balloon sweep performed by Dr w/\n stone extraction. Pt continues iv antibiotics md\ns orders. Pt\n turned and repositioned frequently. Pt teaching done regarding ICU\n environment.\n Response:\n Pt briefly requiring mechanical ventilation for increased work of\n breathing associated w/ desaturation into the 80\ns. Post ERCP pt able\n to wean to trach collar without difficulty. Less diaphoretic.\n intact to coccyx.\n Plan:\n Cont to monitor for s/s of infection, bleeding. Aggressive pulmonary\n toilet. Cont pt and family teaching.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570045,
"text": ".H/O pancreatitis, acute\n Assessment:\n Tmax 101. VSS. Pt becoming more alert as shift progressed. Lungs\n rhonchorous thoroughout. Productive cough for copious amt of oral\n secretions. Abd soft, positive bowel sounds. Pt having frequent loose\n stools.\n Action:\n Aggressive pulmonary toilet. Continues antibiotic therapy. Flexiseal\n placed. PICC line d/c\nd and line sent for culture. New central line\n placed by SICU team. Pt weaned to trach collar.\n Response:\n Presently pt afebrile. Pt consistently following commands. ABG\n acceptable on trach collar.\n Plan:\n Cont aggressive pulmonary toilet. Monitor for s/s of worsening\n infection. Maintain skin integrity. ERCP in a.m.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570046,
"text": ".H/O pancreatitis, acute\n Assessment:\n Tmax 101. VSS. Pt becoming more alert as shift progressed. Lungs\n rhonchorous thoroughout. Productive cough for copious amt of oral\n secretions. Abd soft, positive bowel sounds. Pt having frequent loose\n stools.\n Action:\n Aggressive pulmonary toilet. Continues antibiotic therapy. Flexiseal\n placed. PICC line d/c\nd and line sent for culture. New central line\n placed by SICU team. Pt weaned to trach collar.\n Response:\n Presently pt afebrile. Pt consistently following commands. ABG\n acceptable on trach collar.\n Plan:\n Cont aggressive pulmonary toilet. Monitor for s/s of worsening\n infection. Maintain skin integrity. ERCP in a.m.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 570769,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: 24 mL / Air\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Expectorated / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Vigorous inspiratory efforts\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Cannot manage secretions,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient\ns ventilator settings/changes documented on flow sheet.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572225,
"text": "Hypotension (not Shock)\n Assessment:\n Borderline hypotension with SBP 90\ns to low 100\n Action:\n One unit PRBC given\n Lopressor order changed to q 6 hours from q 4 hours\n Response:\n normotenisve\n Plan:\n resolved\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max today 99.2\n Action:\n Pan culture repeated per ID\n Antibiotic regimen changed per ID due to new information\n that patient has VRE\n Around the clock antibiotics given as ordered\n Response:\n No temperature spikes\n Currently normothermic\n Plan:\n resolved\n Fungal Infection, Other\n Assessment:\n Previous urine result showing yeast\n Previously documented rash in peri area appeared to be yeast\n Action:\n Foley changed on \n Miconazole powder utilized on rash\n Response:\n Per skin nurse, peri area / coccyx area has healed\n Plan:\n resolved\n Ineffective Coping\n Assessment:\n Patient today alert and oriented x 3\n Flat affect however smiling and interacting with staff and\n family\n Action:\n Emotional support given\n Passy-muir valve placed and patient was able to speak to\n staff today\n Response:\n Patient appears to be coping appropriately\n Plan:\n Resolved\n Altered mental status (not Delirium)\n Assessment:\n Alert and oriented x3\n Following all commands\n Purposeful movement\n Assisting with care\n Action:\n Discussed plan of care and past events\n Discussed current events and continued to ask orienting\n questions\n Haldol wean in progress\n Response:\n Patient does not appear to have altered mental status\n Plan:\n resolved\n Impaired Skin Integrity\n Assessment:\n Coccyx area, peri area, and elbow abrasion have healed\n Action:\n Frequent repositioning\n Cream and miconazole powder to peri area\n Response:\n Skin impairments have healed per skin nurse\n Plan:\n resolved\n Risk for Injury\n Assessment:\n Patient with previous history of behavior that may cause\n harm to himself, however he has not exhibited any such behavior this\n shift\n Patient is alert and oriented x3\n Assisting with self care\n No restraints needed for > 24 hours\n Action:\n Emotional support\n Q 4 hour assessment of risk for injury\n Response:\n Patient remains safe\n Plan:\n resolved\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Lung sounds rhoncherous\n Patient coughing very frequently, to the point of exhaustion\n Trach site intact\n On ventilator at start of shift\n Action:\n Placed on trach collar\n Passy-muir valve on for a short time only due to secretions\n Suctioned as needed\n Patient encouraged to expectorate and cough\n Frequent trach care as area is almost constantly moist\n Patient instructed on how he can use the suction to clear\n oral secretions and if he wishes to catch and remove sputum from trach.\n OOB to chair\n VAP protocol\n Response:\n Lung sounds much more clear\n Patient is coughing less frequently\n Patient having restful periods without coughing\n Plan:\n Continue suctioning\n Continue to encourage patient to cough and deep breath\n Continue VAP protocol\n Impaired Physical Mobility\n Assessment:\n Patient able to lift and hold all extremities\n Action:\n Slid to stretcher chair\n Encouraged to move arms and legs frequently, exercise\n Response:\n Remains weak however improving\n Plan:\n Continue to increase activity as tolerated\n Continue to encourage patient to participate in care and use\n extremities\n Physical therapy and occupational therapy need to follow\n patient\n Hyperglycemia\n Assessment:\n Blood glucose max today 200 mg/dl\n Tube feeds at goal\n Action:\n NPH and Regular insulin given per standing orders and\n sliding scale\n Response:\n Latest glucose level 149 mg/dl\n Plan:\n Continue to monitor glucose levels\n Continue to administer insulin as ordered.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-14 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 572226,
"text": "Respiratory Care Service: Pt placed on a 50 Trach Collar at about 1200\n and later increased FIO2 to .70. Doing well and appears comfortable.\n Persistent thin white secretions persist.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572028,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nutrition",
"chartdate": "2140-04-08 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 570905,
"text": "Subjective\n patient sedated\n Objective\n Pertinent medications: Propofol drip, NS @ 10ml/hr, RISS< ABX,\n Famotidine, KCl 60mEq repletion\n Labs:\n Value\n Date\n Glucose\n 207 mg/dL\n 02:48 AM\n Glucose Finger Stick\n 284\n 10:30 AM\n BUN\n 5 mg/dL\n 02:48 AM\n Creatinine\n 0.4 mg/dL\n 02:48 AM\n Sodium\n 142 mEq/L\n 02:48 AM\n Potassium\n 3.4 mEq/L\n 02:48 AM\n Chloride\n 105 mEq/L\n 02:48 AM\n TCO2\n 29 mEq/L\n 02:48 AM\n PO2 (arterial)\n 109 mm Hg\n 04:11 AM\n PCO2 (arterial)\n 34 mm Hg\n 04:11 AM\n pH (arterial)\n 7.44 units\n 04:11 AM\n CO2 (Calc) arterial\n 24 mEq/L\n 04:11 AM\n Albumin\n 3.0 g/dL\n 02:28 AM\n Calcium non-ionized\n 8.3 mg/dL\n 02:48 AM\n Phosphorus\n 3.1 mg/dL\n 02:48 AM\n Ionized Calcium\n 1.24 mmol/L\n 04:11 AM\n Magnesium\n 2.3 mg/dL\n 02:48 AM\n ALT\n 72 IU/L\n 09:01 PM\n Alkaline Phosphate\n 192 IU/L\n 09:01 PM\n AST\n 25 IU/L\n 09:01 PM\n Amylase\n 35 IU/L\n 03:15 AM\n Total Bilirubin\n 1.1 mg/dL\n 09:01 PM\n Triglyceride\n 440 mg/dL\n 09:01 PM\n WBC\n 12.8 K/uL\n 02:48 AM\n Hgb\n 8.9 g/dL\n 02:48 AM\n Hematocrit\n 27.3 %\n 02:48 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feeding: Replete with Fiber @ 90ml/hr\n GI: soft/distended, (+) bs, (+) golden loose guaiac negative stool\n Assessment of Nutritional Status\n Estimation of current intake: Excessive\n Specifics:\n 42 YO male w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH,\n s/p trach/PEG, treated for sepsis cholangitis, s/p ERCP,\n sphincterotomy, stone extraction. s/p liver/gallbladder\n ultrasound . Tube feed held briefly yesterday for ultrasound, tube\n feeding now resumed at goal. Tube feeding provides 2160 calories and\n 134g protein. Propofol started agitation, providing 422 calories\n per day at current rate. RN, attempting to wean propofol, but will\n remain on. Tube feeding + propofol provides excessive calories. Noted\n loose stool, C-difficile negative . Noted elevated \n RN,\n insulin drip was discussed on rounds.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via tube feeding\n Tube feeding / TPN recommendations: Recommend decrease tube feeding\n goal will propofol on to 80ml/hr ( calories and 119g protein)\n Check chemistry 10 panel daily\n replete lytes PRN\n Recommend tighter management\n consider insulin drip or fixed dose\n insulin\n Will follow\n page if questions *\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-15 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 572306,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: trach collar, was on TC continuosly for 12 hrs\n Reason for continuing current ventilatory support: weaning process\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt continues to do well with partial trach collar days , up to 12 hrs .\n Plan to keep extending this , looking for rehab placement\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-09 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 571180,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n :\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Comments:\n Weaned to trach collar. Tolerating well. Expectorating well on own\n with minimal suctioning requirements.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571362,
"text": "Fungal Infection, Other\n Assessment:\n Pt with fungal infection to buttocks area.\n Action:\n Anti fungal ointment and powder used\n Response:\n Appears less red today than yesterday.\n Plan:\n Continue to apply as needed, nurse pt side to side as much as possible.\n Hyperglycemia\n Assessment:\n Pt received on insulin gtt at 8 units/hr. Stable blood glucose levels.\n Action:\n Insulin drip stopped at 10am\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571364,
"text": "Fungal Infection, Other\n Assessment:\n Pt with fungal infection to buttocks area.\n Action:\n Anti fungal ointment and powder used\n Response:\n Appears less red today than yesterday.\n Plan:\n Continue to apply as needed, nurse pt side to side as much as possible.\n Hyperglycemia\n Assessment:\n Pt received on insulin gtt at 8 units/hr. Stable blood glucose levels.\n Action:\n Insulin drip stopped at 10am, started on sliding scale and fixed dose\n regimen.\n Response:\n 16:00 FSG 199, given 10 units Regular insulin.\n Plan:\n Monitor Q6hr FSG. If remains off insulin drip, may be called out to\n floor in am.\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-11 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571509,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n hypotension\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. Acetaminophen 3. Bisacodyl 4. Chlorhexidine Gluconate 0.12% Oral\n Rinse 5. Famotidine 6. Fentanyl Patch\n 7. Haloperidol 8. Haloperidol 9. Heparin 10. Insulin 11. Lidocaine 1%\n 12. Lorazepam 13. Magnesium Sulfate\n 14. Miconazole 2% Cream 15. Miconazole Powder 2% 16. Nystatin Oral\n Suspension 17. Piperacillin-Tazobactam Na 18. Potassium Chloride 19.\n Potassium Phosphate\n 24 Hour Events:\n ARTERIAL LINE - STOP 10:56 AM\n : d/c'd vanc, d/c'd insulin gtt -> NPH 50\" + RISS, d/c'd aline\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:30 AM\n Piperacillin/Tazobactam (Zosyn) - 11:38 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 06:06 PM\n Heparin Sodium (Prophylaxis) - 06:06 PM\n Other medications:\n Flowsheet Data as of 04:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37.1\nC (98.8\n HR: 133 (74 - 133) bpm\n BP: 132/58(78) {82/45(47) - 148/111(116)} mmHg\n RR: 27 (13 - 40) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n Total In:\n 3,211 mL\n 425 mL\n PO:\n Tube feeding:\n 2,189 mL\n 382 mL\n IV Fluid:\n 962 mL\n 42 mL\n Blood products:\n Total out:\n 1,475 mL\n 140 mL\n Urine:\n 1,475 mL\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,736 mL\n 285 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n FiO2: 50%\n SPO2: 98%\n ABG: 7.43/49/84./34/6\n PaO2 / FiO2: 168\n Physical Examination\n General Appearance: Anxious, Cachectic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: at bilateral bases), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: Rash: under arms, (Incision: Clean / Dry / Intact, Erythema)\n Neurologic: (Awake / Alert / Oriented: x 1), (Responds to: Verbal\n stimuli, Tactile stimuli, Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 484 K/uL\n 10.7 g/dL\n 149 mg/dL\n 0.4 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 12 mg/dL\n 99 mEq/L\n 141 mEq/L\n 32.2 %\n 12.9 K/uL\n [image002.jpg]\n 04:11 AM\n 05:35 PM\n 02:48 AM\n 03:27 AM\n 04:28 AM\n 05:19 AM\n 06:00 AM\n 08:00 AM\n 10:00 AM\n 02:41 AM\n WBC\n 12.8\n 10.8\n 11.3\n 12.9\n Hct\n 27.3\n 29.6\n 31.0\n 32.2\n Plt\n 344\n 379\n 424\n 484\n Creatinine\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n TCO2\n 24\n 34\n Glucose\n 180\n 207\n 108\n 133\n 130\n 141\n 105\n 149\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:76//<0.01, ALT / AST:32/22, Alk-Phos / T bili:130/0.6, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.8 mmol/L, Albumin:3.1 g/dL, Ca:9.9 mg/dL,\n Mg:2.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n FUNGAL INFECTION, OTHER, HYPERGLYCEMIA, DIARRHEA, .H/O RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), .H/O CHOLELITHIASIS, .H/O MYOCARDIAL\n INFARCTION, .H/O PANCREATITIS, ACUTE, .H/O ABDOMINAL PAIN (INCLUDING\n ABDOMINAL TENDERNESS), IMPAIRED SKIN INTEGRITY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Haldol TID & prn,\n increase fentanyl patch, pt clearly agitated receiving boluses of\n ativan (15 mg total without effect) and haldol, change haldol back to\n previous dose, start clonidine today, check ammonia, check \n Cardiovascular: Beta-blocker, sinus tachycardia, searching for\n underlying cause. ecg show sinus tachycardia, drawing cardiac markers,\n increasing sedation, running blood gas, keep prn metoprolol\n Pulmonary: Trach, on trach collar, continue pulmonary toilet, check\n today\n Gastrointestinal / Abdomen: continue tube feeding through Gtube, serial\n abd exams, check lfts/ammonia level\n Nutrition: Tube feeding, tube feedings are at goal\n Renal: Foley, Adequate UO, Foley, adequate UOP, Cr stable\n Hematology: Serial Hct, hct stable\n Endocrine: RISS, converted to NPH insulin 50units q12h with RISS for\n backup, bs-100-150\n Infectious Disease: Check cultures, f/u cx, Continuing Zosyn, wbc\n increasing, check , need to restart Vanco, send UA and sputum\n Lines / Tubes / Drains: Foley, G-tube, Trach, R SCL CVL, Flexiseal\n Wounds: Dry dressings, trach site\n Imaging: CXR today\n Fluids: no ivf\n Consults: General surgery\n Billing Diagnosis: Sepsis , Agitation\n ICU Care\n Nutrition:\n Replete (Full) - 11:32 PM 90 mL/hour\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571510,
"text": "Ineffective Coping\n Assessment:\n Pt having symptoms of withdrawal suspected benzo withdrawal\n Action:\n CIWA scale started\n haldol started, then ativan started\n 1:1 sitter overnoc\n Response:\n Pt continues to be agitated\n QTC .46, little response to haldol or ativan\n Plan:\n Discuss treatment of benzo withdrwal on rounds\n Provide safe environment for pt\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571603,
"text": "Altered mental status (not Delirium)\n Assessment:\n restlessness associated with tachycardia and diaphoresis\n no further benzo medications given\n picture complicated by temp to102.8 and diaphoreses associated with\n tylenol and motrin administration\n Action:\n haldol given as ordered\n Tylenol and motrin as ordered\n frequent cold compresses and position changes\n MD Ballrad informed of questionable signs of withdrawal vs restlessness\n Decision made to restart propofol and place back on vent\n Response:\n Before propofol: started patient initially calmer, not crawling out of\n bed or pulling at lines followed by restlessness bordering on agitation\n with legs thrown over bed and trying repetitively to sit up\n Post propofol: patient calm, HR low 100\n PLAN:\n cont to assess for signs of withdrawal from medications\n haldol around the clock as ordered\n cont propofol as ordered\n continue to assess restlessness vs withdrawal signs\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n febrile to 102.6 rectally\n diaphoretic\n restless\n tolerating trach collar with minimal secretions\n Action:\n Tylenol given\n ibuprofen given\n pan cultured\n suctioned prn\n Response:\n remains febrile\n diaphoretic\n remains on trach collar\n Plan:\n cont to assess temperature curve\n Tylenol prn\n Question further dosing of motrin if working to suppress temperature\n await culture results\n see nursing care plan\n Fungal Infection, Other\n Assessment:\n pain fungal area to buttocks\n Action:\n moisture barrier cream with nystatin applied\n frequent repositioning\n patient encouraged to stay on side\n Response:\n no worsening of buttocks rash\n Plan:\n cont antifungal barrier cream with nystatin powder\n reposition frequently\n encourage patient to stay on side\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-13 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571938,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. Magnesium Sulfate IV Sliding Scale Order date: @ 0234\n 2. Metoprolol Tartrate 5 mg IV Q4H tachycadia/HTN hold for SBP<100\n HR<60 Order date: @ 0753\n 3. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308\n 4. Miconazole 2% Cream 1 Appl TP yeast rash Order date: @\n 2347\n 5. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139\n 6. Miconazole Powder 2% 1 Appl TP TID:PRN Order date: @ 1255\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL Use only if\n patient is on mechanical ventilation. Order date: @ 1119\n 8. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @ 0555\n 9. CloniDINE 0.2 mg PO TID Order date: @ 0751\n 10. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP>65 Order\n date: @ 0551\n 11. Famotidine 20 mg IV Q12H Order date: @ 0419\n 12. Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @ 1209\n 13. Fentanyl Patch 75 mcg/hr TP Q72H Order date: @ 0751\n 14. Potassium Chloride PO Sliding Scale Hold for K > 5 Order date:\n @ 0505\n 15. Haloperidol 2 mg PO TID through G tube Order date: @ 0751\n 16. Potassium Chloride IV Sliding Scale Order date: @ 0526\n 17. Heparin 5000 UNIT SC BID Order date: @ 0139\n 18. Potassium Phosphate IV Sliding Scale Infuse over 6 hours Order\n date: @ 0647\n 19. Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose\n Order date: @ 1234\n 20. Propofol 20-50 mcg/kg/min IV DRIP TITRATE TO adequate sedation\n Order date: @ 1659\n 21. Lidocaine 1% 3-5 mL IH Q4-6 HRS PRN Order date: @ 1854\n 22. Lorazepam 2-4 mg IV Q4H:PRN Order date: @ \n 23. Tobramycin 450 mg IV Q24H Order date: @ 1607\n 24. Lorazepam 2-4 mg IV Q30MIN:PRN agitation Order date: @ 0430\n 25. Vancomycin 750 mg IV Q 8H Order date: @ 1253\n 24 Hour Events:\n MULTI LUMEN - START 08:14 AM\n MULTI LUMEN - STOP 10:42 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Tobramycin - 08:09 PM\n Piperacillin/Tazobactam (Zosyn) - 12:27 AM\n Vancomycin - 01:27 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 06:53 PM\n Metoprolol - 04:13 AM\n Famotidine (Pepcid) - 05:14 AM\n Heparin Sodium (Prophylaxis) - 05:14 AM\n Other medications:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 36.7\nC (98\n HR: 78 (77 - 109) bpm\n BP: 100/51(65) {92/43(61) - 167/91(117)} mmHg\n RR: 20 (12 - 28) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 6,402 mL\n 1,143 mL\n PO:\n Tube feeding:\n 850 mL\n IV Fluid:\n 4,432 mL\n 1,143 mL\n Blood products:\n Total out:\n 1,765 mL\n 1,140 mL\n Urine:\n 1,615 mL\n 940 mL\n NG:\n 150 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n 4,637 mL\n 3 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 395 (347 - 541) mL\n PS : 10 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 63\n PIP: 16 cmH2O\n SPO2: 100%\n ABG: 7.42/39/114/28/1\n Ve: 6.6 L/min\n PaO2 / FiO2: 285\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, PEG\n intact\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: (Responds to: Unresponsive), Moves all extremities, Sedated\n Labs / Radiology\n 347 K/uL\n 9.0 g/dL\n 92 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 20 mg/dL\n 100 mEq/L\n 137 mEq/L\n 25.7 %\n 14.1 K/uL\n [image002.jpg]\n 06:00 AM\n 08:00 AM\n 10:00 AM\n 02:41 AM\n 04:11 AM\n 06:00 AM\n 05:27 PM\n 03:29 AM\n 01:30 AM\n 03:00 AM\n WBC\n 12.9\n 15.9\n 14.1\n Hct\n 32.2\n 31.6\n 25.7\n Plt\n \n Creatinine\n 0.4\n 0.9\n 1.0\n Troponin T\n <0.01\n TCO2\n 35\n 26\n Glucose\n 130\n 141\n 105\n 149\n 194\n 158\n 92\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.4 mmol/L, Albumin:3.6 g/dL, LDH:212 IU/L,\n Ca:9.3 mg/dL, Mg:2.1 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), INEFFECTIVE COPING, ALTERED MENTAL STATUS (NOT\n DELIRIUM), FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), FUNGAL\n INFECTION, OTHER, HYPERGLYCEMIA, IMPAIRED SKIN INTEGRITY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction.\n Neurologic: Pain controlled, Haldol TID & prn, Ativan, fentanyl patch,\n clonidine, propofol\n Cardiovascular: HD Stable, off pressors, scheduled beta blockade\n Pulmonary: (Ventilator mode: CPAP + PS), wean vent to TC\n Gastrointestinal / Abdomen: restart tube feeds today\n Nutrition: restart tube feeds\n Renal: Foley, Adequate UO, creatine increased yesterday, but stable\n today, likely was prerenal fro mline sepsis, should improve now\n Hematology: Hct 25.7 down from 31.6. Recheck at noon, HD stable\n Endocrine: RISS, restart NPH today as TF started\n Infectious Disease: Check cultures, Cont Vanc/Zosyn/tobra, GPC in blood\n from CVL, WBC decreasing now that line out, recovering from line\n sepsis, elevated tobra and vanco levels, likely from acute decrease in\n GFR, doses\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: LR, kvo once tube feeds restarted\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress), Sepsis\n ICU Care\n Nutrition: restart tube feeds\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Arterial Line - 07:53 AM\n Multi Lumen - 08:14 AM\n 22 Gauge - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-13 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571942,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. Magnesium Sulfate IV Sliding Scale Order date: @ 0234\n 2. Metoprolol Tartrate 5 mg IV Q4H tachycadia/HTN hold for SBP<100\n HR<60 Order date: @ 0753\n 3. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308\n 4. Miconazole 2% Cream 1 Appl TP yeast rash Order date: @\n 2347\n 5. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139\n 6. Miconazole Powder 2% 1 Appl TP TID:PRN Order date: @ 1255\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL Use only if\n patient is on mechanical ventilation. Order date: @ 1119\n 8. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @ 0555\n 9. CloniDINE 0.2 mg PO TID Order date: @ 0751\n 10. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP>65 Order\n date: @ 0551\n 11. Famotidine 20 mg IV Q12H Order date: @ 0419\n 12. Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @ 1209\n 13. Fentanyl Patch 75 mcg/hr TP Q72H Order date: @ 0751\n 14. Potassium Chloride PO Sliding Scale Hold for K > 5 Order date:\n @ 0505\n 15. Haloperidol 2 mg PO TID through G tube Order date: @ 0751\n 16. Potassium Chloride IV Sliding Scale Order date: @ 0526\n 17. Heparin 5000 UNIT SC BID Order date: @ 0139\n 18. Potassium Phosphate IV Sliding Scale Infuse over 6 hours Order\n date: @ 0647\n 19. Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose\n Order date: @ 1234\n 20. Propofol 20-50 mcg/kg/min IV DRIP TITRATE TO adequate sedation\n Order date: @ 1659\n 21. Lidocaine 1% 3-5 mL IH Q4-6 HRS PRN Order date: @ 1854\n 22. Lorazepam 2-4 mg IV Q4H:PRN Order date: @ \n 23. Tobramycin 450 mg IV Q24H Order date: @ 1607\n 24. Lorazepam 2-4 mg IV Q30MIN:PRN agitation Order date: @ 0430\n 25. Vancomycin 750 mg IV Q 8H Order date: @ 1253\n 24 Hour Events:\n MULTI LUMEN - START 08:14 AM\n MULTI LUMEN - STOP 10:42 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Tobramycin - 08:09 PM\n Piperacillin/Tazobactam (Zosyn) - 12:27 AM\n Vancomycin - 01:27 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 06:53 PM\n Metoprolol - 04:13 AM\n Famotidine (Pepcid) - 05:14 AM\n Heparin Sodium (Prophylaxis) - 05:14 AM\n Other medications:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 36.7\nC (98\n HR: 78 (77 - 109) bpm\n BP: 100/51(65) {92/43(61) - 167/91(117)} mmHg\n RR: 20 (12 - 28) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 6,402 mL\n 1,143 mL\n PO:\n Tube feeding:\n 850 mL\n IV Fluid:\n 4,432 mL\n 1,143 mL\n Blood products:\n Total out:\n 1,765 mL\n 1,140 mL\n Urine:\n 1,615 mL\n 940 mL\n NG:\n 150 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n 4,637 mL\n 3 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 395 (347 - 541) mL\n PS : 10 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 63\n PIP: 16 cmH2O\n SPO2: 100%\n ABG: 7.42/39/114/28/1\n Ve: 6.6 L/min\n PaO2 / FiO2: 285\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, PEG\n intact\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: (Responds to: Unresponsive), Moves all extremities, Sedated\n Labs / Radiology\n 347 K/uL\n 9.0 g/dL\n 92 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 20 mg/dL\n 100 mEq/L\n 137 mEq/L\n 25.7 %\n 14.1 K/uL\n [image002.jpg]\n 06:00 AM\n 08:00 AM\n 10:00 AM\n 02:41 AM\n 04:11 AM\n 06:00 AM\n 05:27 PM\n 03:29 AM\n 01:30 AM\n 03:00 AM\n WBC\n 12.9\n 15.9\n 14.1\n Hct\n 32.2\n 31.6\n 25.7\n Plt\n \n Creatinine\n 0.4\n 0.9\n 1.0\n Troponin T\n <0.01\n TCO2\n 35\n 26\n Glucose\n 130\n 141\n 105\n 149\n 194\n 158\n 92\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.4 mmol/L, Albumin:3.6 g/dL, LDH:212 IU/L,\n Ca:9.3 mg/dL, Mg:2.1 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), INEFFECTIVE COPING, ALTERED MENTAL STATUS (NOT\n DELIRIUM), FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), FUNGAL\n INFECTION, OTHER, HYPERGLYCEMIA, IMPAIRED SKIN INTEGRITY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction.\n Neurologic: Pain controlled, Haldol TID & prn, Ativan, fentanyl patch,\n clonidine, propofol\n Cardiovascular: HD Stable, off pressors, scheduled beta blockade\n Pulmonary: (Ventilator mode: CPAP + PS), wean vent to TC today\n Gastrointestinal / Abdomen: restart tube feeds today\n Nutrition: tube feeds\n Renal: Foley, Adequate UO, creatine increased yesterday, but stable\n today, likely was prerenal from line sepsis, should improve now\n Hematology: Hct 25.7 down from 31.6. Recheck at noon, HD stable\n Endocrine: RISS, restart NPH today as TF started\n Infectious Disease: Check cultures, Cont Vanc/Zosyn/tobra, GPC in blood\n from CVL, WBC decreasing now that line out, recovering from line\n sepsis, elevated tobra and vanco levels, likely from acute decrease in\n GFR, will reduce doses appropriately\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: LR, kvo once tube feeds restarted\n Consults: General surgery\n Billing Diagnosis: (Respiratory failure), Sepsis\n ICU Care\n Nutrition: restart tube feeds\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Arterial Line - 07:53 AM\n Multi Lumen - 08:14 AM\n 22 Gauge - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 34 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 572124,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ bacteremia, UTI, VAP.\n Chief complaint:\n abd pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n Current medications:\n 1. Magnesium Sulfate IV Sliding Scale Order date: @ 0234\n 2. 1000 mL LR Continuous at 75 ml/hr TF+IVF=90cc/hr, HLIV when TF@ goal\n 90 Order date: @ 1540\n 3. Metoprolol Tartrate 5 mg IV Q4H tachycadia/HTN hold for SBP<100\n HR<60 Order date: @ 0753\n 4. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308\n 5. Miconazole 2% Cream 1 Appl TP yeast rash Order date: @\n 2347\n 6. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139\n 7. Miconazole Powder 2% 1 Appl TP TID:PRN Order date: @ 1255\n 9. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @ 0555\n 10. CloniDINE 0.2 mg PO TID Order date: @ 0751\n 11. Famotidine 20 mg IV Q12H Order date: @ 0419\n 12. Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @ 1209\n 13. Fentanyl Patch 75 mcg/hr TP Q72H Order date: @ 0751\n 14. Potassium Chloride PO Sliding Scale Hold for K > 5 Order date:\n @ 0505\n 15. Haloperidol 2 mg PO TID through G tube Order date: @ 0751\n 16. Potassium Chloride IV Sliding Scale Order date: @ 0526\n 17. Heparin 5000 UNIT SC BID Order date: @ 0139\n 18. Potassium Phosphate IV Sliding Scale Infuse over 6 hours Order\n date: @ 0647\n 19. Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose\n Order date: @ 1234\n 20. Lidocaine 1% 3-5 mL IH Q4-6 HRS PRN Order date: @ 1854\n 21. Lorazepam 2-4 mg IV Q4H:PRN Order date: @ \n 22. Tobramycin 450 mg IV Q24H Order date: @ 1607\n 23. Lorazepam 2-4 mg IV Q30MIN:PRN agitation Order date: @ 0430\n 24. Vancomycin 1000 mg IV Q 12H Order date: @ 1125\n 24 Hour Events:\n weaned off propofol & vent, restarted TF, vanc changed to 1000\"\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Tobramycin - 08:09 PM\n Vancomycin - 08:05 PM\n Piperacillin/Tazobactam (Zosyn) - 11:55 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 12:09 AM\n Heparin Sodium (Prophylaxis) - 06:02 AM\n Famotidine (Pepcid) - 06:03 AM\n Other medications:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.8\nC (98.2\n HR: 71 (71 - 86) bpm\n BP: 101/68(81) {75/47(61) - 123/68(82)} mmHg\n RR: 14 (14 - 29) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 3,563 mL\n 717 mL\n PO:\n Tube feeding:\n 452 mL\n 546 mL\n IV Fluid:\n 2,941 mL\n 171 mL\n Blood products:\n Total out:\n 2,855 mL\n 730 mL\n Urine:\n 2,655 mL\n 730 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 708 mL\n -13 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 369 (265 - 556) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 109\n PIP: 10 cmH2O\n SPO2: 98%\n ABG: ///31/\n Ve: 4.2 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 321 K/uL\n 8.0 g/dL\n 89 mg/dL\n 1.2 mg/dL\n 31 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 103 mEq/L\n 141 mEq/L\n 23.3 %\n 9.4 K/uL\n [image002.jpg]\n 10:00 AM\n 02:41 AM\n 04:11 AM\n 06:00 AM\n 05:27 PM\n 03:29 AM\n 01:30 AM\n 03:00 AM\n 12:31 PM\n 03:18 AM\n WBC\n 12.9\n 15.9\n 14.1\n 9.4\n Hct\n 32.2\n 31.6\n 25.7\n 24.6\n 23.3\n Plt\n 21\n Creatinine\n 0.4\n 0.9\n 1.0\n 1.2\n Troponin T\n <0.01\n TCO2\n 35\n 26\n Glucose\n 105\n 149\n 194\n 158\n 92\n 89\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.4 mmol/L, Albumin:3.6 g/dL, LDH:212 IU/L,\n Ca:9.3 mg/dL, Mg:2.3 mg/dL, PO4:3.7 mg/dL\n Microbiology: blood: neg\n urine: yeast\n MRSA: neg\n PICC tip: neg\n sputum: contam\n sputum: GNR x3, yeast\n bld x2: neg\n C.diff: neg\n sputum: contam\n sputum x2: contam\n bld: coag neg Staph\n urine: yeast >100K\n R SCL CVL tip: GNR\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), INEFFECTIVE COPING, ALTERED MENTAL STATUS (NOT\n DELIRIUM), FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), .H/O\n AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY\n CLEARANCE, COUGH), FUNGAL INFECTION, OTHER, IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, RISK FOR INJURY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ bacteremia, UTI, VAP.\n Neurologic: Pain controlled, Haldol TID & prn. Fentanyl patch. Weaning\n Clonidine.\n Cardiovascular: Beta-blocker, HD stable on Lopressor 5q4h.\n Pulmonary: Trach, Wean to TC today\n Gastrointestinal / Abdomen: TF.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Cr slightly increased & lytes stable.\n Hematology: Hct 31.6 -> 25.7 -> 24.6 -> 23.3. Transfuse one prbc today\n Endocrine: RISS, Goal FS<150.\n Infectious Disease: Check cultures, Continue Vanc/Zosyn/Tobra for\n VAP/bacteremia\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Dry dressings\n Imaging: none\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Sepsis\n ICU Care\n Nutrition: tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:53 AM\n Multi Lumen - 08:14 AM\n 22 Gauge - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570978,
"text": "Hyperglycemia\n Assessment:\n Blood sugar 230-291\n Action:\n Pt started on insulin gtt\n Response:\n Blood sugar down to 264\n Plan:\n Titrate insulin gtt per icu protocol\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on cpap with ps\n Vanco trough back as 11.3\n Action:\n Pt continue on vancomycin and zosyn\n Suctioned pt for thick yellow sputum\n Response:\n Pt tolerating cpap\n Suctioning pt for less sputum this evening\n Plan:\n Continue to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570979,
"text": "Hyperglycemia\n Assessment:\n Blood sugar 230-291\n Action:\n Pt started on insulin gtt\n Response:\n Blood sugar down to 264\n Plan:\n Titrate insulin gtt per icu protocol\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on cpap with ps\n Vanco trough back as 11.3\n Propofol weaned to 10mcg/kg/min\n Continues on Haldol three times per day\n Action:\n Pt continue on vancomycin and zosyn\n Suctioned pt for thick yellow sputum\n Propfol shut off for neuro assessment, pt will open his eyes\n when you call his name, pt will follow commands\n Response:\n Pt tolerating cpap\n Suctioning pt for less sputum this evening\n Plan:\n Continue to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570980,
"text": "Hyperglycemia\n Assessment:\n Blood sugar 230-291\n Action:\n Pt started on insulin gtt\n Response:\n Blood sugar down to 264\n Plan:\n Titrate insulin gtt per icu protocol\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on cpap with ps\n Vanco trough back as 11.3\n Propofol weaned to 10mcg/kg/min\n Continues on Haldol three times per day\n Action:\n Pt continue on vancomycin and zosyn\n Suctioned pt for thick yellow sputum\n Propfol shut off for neuro assessment, pt will open his eyes\n when you call his name, pt will follow commands\n Flexiseal catheter d/c\n Response:\n Pt tolerating cpap\n Suctioning pt for less sputum this evening\n Pt with incontinent of small amt of thick stool\n Plan:\n Continue to monitor\n Pulm. tiolet\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571706,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : T103, increased LFTs/AP, propofol gtt, prophylactic abx\n : weaned to trach collar, R SCL CVL placed, PICC d/c'd, CT abd\n : ERCP\n : started TF\n : HLIV, suctioned q1hr, sputum cx, CXR, heat rash --> miconazole,\n agitation, diaphoretic episodes (afebrile, glucose normal).\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n Impaired Skin Integrity\n Assessment:\n Groin and perianal area errythema, fissure near coccyx between skin\n folds. Incontinent of soft brown stool.\n Action:\n Area washed and dried thoroughly. Turned q2hrs. antifungal barrier\n cream applied.\n Response:\n Scrotal and anal area less red.\n Plan:\n Turn patient\ns position q2hrs. . wound care rn to view areas. Continue\n to apply antifungal barrier cream q 2-4 hrs prn.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Portex trach in place. Suctioned for large amt of thick white sputum.\n Resp rate 15- 30. o2sats 93-100%.\n Action:\n Suctioned q1-2 hrs. for thick white sputum. Head of bed elevated to\n 30-45 degrees. Turned q2hrs. o2sat continuously.\n Response:\n Suctioned for mod to large amt of thick white sputum. O2sat\n maintained > 93%.\n Plan:\n Monitor respiratory status closely.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdomen distended and soft to touch. Passing flatus. Lactate 1.8.\n Action:\n Abdomen palpated. Stool guiac.\n Response:\n Patient nodded no when asked if he had abdominal pain.\n Plan:\n Monitor closely.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571708,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : T103, increased LFTs/AP, propofol gtt, prophylactic abx\n : weaned to trach collar, R SCL CVL placed, PICC d/c'd, CT abd\n : ERCP\n : started TF\n : HLIV, suctioned q1hr, sputum cx, CXR, heat rash --> miconazole,\n agitation, diaphoretic episodes (afebrile, glucose normal).\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n Impaired Skin Integrity\n Assessment:\n Groin and perianal area errythema, fissure near coccyx between skin\n folds. Incontinent of soft brown stool.\n Action:\n Area washed and dried thoroughly. Turned q2hrs. antifungal barrier\n cream applied.\n Response:\n Scrotal and anal area less red.\n Plan:\n Turn patient\ns position q2hrs. . wound care rn to view areas. Continue\n to apply antifungal barrier cream q 2-4 hrs prn.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Portex trach in place. Suctioned for large amt of thick white sputum.\n Resp rate 15- 30. o2sats 93-100%.\n Action:\n Suctioned q1-2 hrs. for thick white sputum. Head of bed elevated to\n 30-45 degrees. Turned q2hrs. o2sat continuously.\n Response:\n Suctioned for mod to large amt of thick white sputum. O2sat\n maintained > 93%.\n Plan:\n Monitor respiratory status closely.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdomen distended and soft to touch. Passing flatus. Lactate 1.8.\n Action:\n Abdomen palpated. Stool guiac.\n Response:\n Patient nodded no when asked if he had abdominal pain.\n Plan:\n Monitor closely.\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-12 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571710,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. 2. 1000 mL NS 3. 1000 mL NS 4. 500 mL NS 5. Acetaminophen 6.\n Bisacodyl 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. CloniDINE 9.\n Famotidine 10. Fentanyl Patch 11. Haloperidol 12. Haloperidol 13.\n Heparin 14. Ibuprofen Suspension 15. Insulin 16. Lidocaine 1% 17.\n Lorazepam 18. Lorazepam 19. Magnesium Sulfate 20. Metoprolol Tartrate\n 21. Miconazole 2% Cream 22. Miconazole Powder 2% 23. Nystatin Oral\n Suspension 24. Phenylephrine 25. Piperacillin-Tazobactam Na 26.\n Potassium Chloride 27. Potassium Phosphate 28. Propofol 29. Sodium\n Chloride 0.9% Flush 30. Tobramycin 31. Vancomycin\n 24 Hour Events:\n PAN CULTURE - At 08:52 AM\n NASAL SWAB - At 10:40 AM\n MRSA\n SPUTUM CULTURE - At 02:41 PM\n first sample with oral flora, resent\n FEVER - 102.6\nF - 08:00 AM\n - hypotensive AM, started on phenylephrine\n - central line site noted to be red, +blood cultures from AM\n - a-line replaced\n Post operative day:\n HD #12, PPD #9\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Tobramycin - 05:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:05 AM\n Vancomycin - 01:17 AM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 02:15 PM\n Famotidine (Pepcid) - 04:30 AM\n Heparin Sodium (Prophylaxis) - 05:31 AM\n Other medications:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.2\nC (102.6\n T current: 38.1\nC (100.6\n HR: 83 (83 - 128) bpm\n BP: 121/79(88) {78/46(54) - 143/99(107)} mmHg\n RR: 21 (16 - 36) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 3,582 mL\n 2,191 mL\n PO:\n Tube feeding:\n 2,160 mL\n 649 mL\n IV Fluid:\n 1,062 mL\n 1,492 mL\n Blood products:\n Total out:\n 1,480 mL\n 235 mL\n Urine:\n 1,480 mL\n 235 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,102 mL\n 1,956 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 351 (324 - 576) mL\n PS : 10 cmH2O\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 120\n PIP: 16 cmH2O\n SPO2: 100%\n ABG: ///32/\n Ve: 9.7 L/min\n Physical Examination\n General Appearance: diaphoretic\n HEENT: PERRL\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Left Extremities: (Edema: 1+), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: 1+), (Pulse - Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 1), (Responds to: Verbal\n stimuli), Moves all extremities, intermittently sedated/agitated\n Labs / Radiology\n 458 K/uL\n 10.5 g/dL\n 158 mg/dL\n 0.9 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 99 mEq/L\n 141 mEq/L\n 31.6 %\n 15.9 K/uL\n [image002.jpg]\n 04:28 AM\n 05:19 AM\n 06:00 AM\n 08:00 AM\n 10:00 AM\n 02:41 AM\n 04:11 AM\n 06:00 AM\n 05:27 PM\n 03:29 AM\n WBC\n 11.3\n 12.9\n 15.9\n Hct\n 31.0\n 32.2\n 31.6\n Plt\n \n Creatinine\n 0.4\n 0.4\n 0.9\n Troponin T\n <0.01\n TCO2\n 34\n 35\n Glucose\n 133\n 130\n 141\n 105\n 149\n 194\n 158\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.8 mmol/L, Albumin:3.6 g/dL, LDH:212 IU/L,\n Ca:9.8 mg/dL, Mg:2.3 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ALTERED MENTAL STATUS (NOT DELIRIUM), FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), FUNGAL INFECTION, OTHER,\n HYPERGLYCEMIA, IMPAIRED SKIN INTEGRITY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction.\n Neurologic: Haldol TID, fentanyl patch, clonidine, was on propofol gtt\n o/n to help with agitation; likely sepsis as cause for agitation with\n new onset bacteremia\n Cardiovascular: Neo for some hypotension, wean as tolerated, will send\n Venous Gas and follow lactate, monitor UOP closely as marker for\n perfusion\n Pulmonary: Trach, (Ventilator mode: CPAP + PS), Wean vent as tolerated;\n CXR has looked OK despite secretions, recheck CVL placement\n Gastrointestinal / Abdomen: LFTs/ammonia wnl, consider CT abd today as\n source of sepsis; continue TF\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Creat stable\n Hematology: Hct stable\n Endocrine: RISS, NPH\n Infectious Disease: Continue Vanco/Zosyn/Tobra. Doiuble covering GNR\n from sputum, Positive GPC from CVL, resite right subclavian central\n line. Consider CT abd if does not defervesce after line removal\n Lines / Tubes / Drains: Foley, G-tube, Trach, d/c right subclavian\n central line (to be resited), Flexiseal, A-line\n Wounds: c/d/i\n Imaging: CT scan abd today,\n Fluids: 75 of LR\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure), Post-op\n hypotension, Pancreatitis\n ICU Care\n Nutrition:\n Replete (Full) - 11:17 PM 90 mL/hour\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571711,
"text": "Hypotension (not Shock)\n Assessment:\n Bp 90\ns -100 syst tonite. Drop in bp to the 80\ns at 0430am. Heart\n rate 90-100 nsr.\n Action:\n Dr notified and in to see patient. Normal saline 500cc iv fluld\n bolus x2 given. Aline inserted. Via right arm.\n Response:\n Bp continued to be in the 80\ns. neo gtt started at 1mcg/kg/min. bp via\n aline 120\ns syst.\n Plan:\n Attempt to wean neo gtt. . continue to monitor bp.\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-12 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571714,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. 2. 1000 mL NS 3. 1000 mL NS 4. 500 mL NS 5. Acetaminophen 6.\n Bisacodyl 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. CloniDINE 9.\n Famotidine 10. Fentanyl Patch 11. Haloperidol 12. Haloperidol 13.\n Heparin 14. Ibuprofen Suspension 15. Insulin 16. Lidocaine 1% 17.\n Lorazepam 18. Lorazepam 19. Magnesium Sulfate 20. Metoprolol Tartrate\n 21. Miconazole 2% Cream 22. Miconazole Powder 2% 23. Nystatin Oral\n Suspension 24. Phenylephrine 25. Piperacillin-Tazobactam Na 26.\n Potassium Chloride 27. Potassium Phosphate 28. Propofol 29. Sodium\n Chloride 0.9% Flush 30. Tobramycin 31. Vancomycin\n 24 Hour Events:\n PAN CULTURE - At 08:52 AM\n NASAL SWAB - At 10:40 AM\n MRSA\n SPUTUM CULTURE - At 02:41 PM\n first sample with oral flora, resent\n FEVER - 102.6\nF - 08:00 AM\n - hypotensive AM, started on phenylephrine\n - central line site noted to be red, +blood cultures from AM\n - a-line replaced\n Post operative day:\n HD #12, PPD #9\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Tobramycin - 05:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:05 AM\n Vancomycin - 01:17 AM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 02:15 PM\n Famotidine (Pepcid) - 04:30 AM\n Heparin Sodium (Prophylaxis) - 05:31 AM\n Other medications:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.2\nC (102.6\n T current: 38.1\nC (100.6\n HR: 83 (83 - 128) bpm\n BP: 121/79(88) {78/46(54) - 143/99(107)} mmHg\n RR: 21 (16 - 36) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 3,582 mL\n 2,191 mL\n PO:\n Tube feeding:\n 2,160 mL\n 649 mL\n IV Fluid:\n 1,062 mL\n 1,492 mL\n Blood products:\n Total out:\n 1,480 mL\n 235 mL\n Urine:\n 1,480 mL\n 235 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,102 mL\n 1,956 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 351 (324 - 576) mL\n PS : 10 cmH2O\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 120\n PIP: 16 cmH2O\n SPO2: 100%\n ABG: ///32/\n Ve: 9.7 L/min\n Physical Examination\n General Appearance: diaphoretic\n HEENT: PERRL\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Left Extremities: (Edema: 1+), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: 1+), (Pulse - Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 1), (Responds to: Verbal\n stimuli), Moves all extremities, intermittently sedated/agitated\n Labs / Radiology\n 458 K/uL\n 10.5 g/dL\n 158 mg/dL\n 0.9 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 99 mEq/L\n 141 mEq/L\n 31.6 %\n 15.9 K/uL\n [image002.jpg]\n 04:28 AM\n 05:19 AM\n 06:00 AM\n 08:00 AM\n 10:00 AM\n 02:41 AM\n 04:11 AM\n 06:00 AM\n 05:27 PM\n 03:29 AM\n WBC\n 11.3\n 12.9\n 15.9\n Hct\n 31.0\n 32.2\n 31.6\n Plt\n \n Creatinine\n 0.4\n 0.4\n 0.9\n Troponin T\n <0.01\n TCO2\n 34\n 35\n Glucose\n 133\n 130\n 141\n 105\n 149\n 194\n 158\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.8 mmol/L, Albumin:3.6 g/dL, LDH:212 IU/L,\n Ca:9.8 mg/dL, Mg:2.3 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ALTERED MENTAL STATUS (NOT DELIRIUM), FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), FUNGAL INFECTION, OTHER,\n HYPERGLYCEMIA, IMPAIRED SKIN INTEGRITY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction.\n Neurologic: Haldol TID, fentanyl patch, clonidine, was on propofol gtt\n o/n to help with agitation; likely sepsis as cause for agitation with\n new onset bacteremia\n Cardiovascular: Neo for some hypotension, wean as tolerated, will place\n a-line and follow ABG and lactate, monitor UOP closely as marker for\n perfusion.\n Pulmonary: Trach, (Ventilator mode: CPAP + PS), Wean vent as tolerated;\n CXR has looked OK despite secretions, repeat after CVL placement\n Gastrointestinal / Abdomen: LFTs/ammonia wnl, consider CT abd today as\n source of sepsis; continue TF\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Creat stable\n Hematology: Hct stable\n Endocrine: RISS, NPH\n Infectious Disease: Continue Vanco/Zosyn/Tobra. Double covering GNR\n from sputum, Positive GPC from CVL, resite right subclavian central\n line. Consider CT abd if does not defervesce after line removal\n Lines / Tubes / Drains: Foley, G-tube, Trach, d/c right subclavian\n central line (to be resited), Flexiseal, A-line\n Wounds: c/d/i\n Imaging: CT scan abd today,\n Fluids: 75 of LR\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure), Post-op\n hypotension, Pancreatitis\n ICU Care\n Nutrition:\n Replete (Full) - 11:17 PM 90 mL/hour\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571885,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation.\n : R-SC CVL discontinues-catheter tip sent fore culture. New L-SC\n CVL placed. Placement confirmed by CRX . CT of ABD with contrast.\n Family updated regarding POC. Plan for family meeting in the next few\n days\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n # 8 portex trach. Trach site clean\n Breath sounds clear in the upper lobes and rhonchus in the lower lobes.\n Resp rate 18-30\n O2sats 96-100%.\n Action:\n Suctioned for copius amts of thick yellow sputum. Dr \n notified.\n Trach care x 4\n On iv vancomycin, tobramycin and unasyn.\n Response:\n Increase in secretitions.\n Plan:\n Aggressive pulmonary toileting\n On cpap with 5peep/ 10 ips.\n Continue on the antibiotics.\n Await results from sputum culture obtained on 5.5/09\n Impaired Skin Integrity\n Assessment:\n Groin and perianal area reddened\n Large amt of flatus\n Incontinent of large amt of golden brown soft stool.\n Action:\n Turned q2hrs.\n Miconazole powder to groin and perianal area.\n Guiac stool.\n Response:\n Perianal and groin less reddened.\n Plan:\n Continue with antifungal barrier cream.\n Turn patient q2hrs.\n Pt\ns sister called for update on brother\ns condition. Sister\n stated she has not heard from the doctors. She is requesting for\n doctor to call her. Sister also stated her mother does not speak\n English and she needs to talk with the doctors and \n interpret. Dr notified and will discuss on am rounds. At the\n change of shift an Email was sent to case manager to\n organize a family meeting.\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-13 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571916,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. Magnesium Sulfate IV Sliding Scale Order date: @ 0234\n 2. Metoprolol Tartrate 5 mg IV Q4H tachycadia/HTN hold for SBP<100\n HR<60 Order date: @ 0753\n 3. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308\n 4. Miconazole 2% Cream 1 Appl TP yeast rash Order date: @\n 2347\n 5. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139\n 6. Miconazole Powder 2% 1 Appl TP TID:PRN Order date: @ 1255\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL Use only if\n patient is on mechanical ventilation. Order date: @ 1119\n 8. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @ 0555\n 9. CloniDINE 0.2 mg PO TID Order date: @ 0751\n 10. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP>65 Order\n date: @ 0551\n 11. Famotidine 20 mg IV Q12H Order date: @ 0419\n 12. Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @ 1209\n 13. Fentanyl Patch 75 mcg/hr TP Q72H Order date: @ 0751\n 14. Potassium Chloride PO Sliding Scale Hold for K > 5 Order date:\n @ 0505\n 15. Haloperidol 2 mg PO TID through G tube Order date: @ 0751\n 16. Potassium Chloride IV Sliding Scale Order date: @ 0526\n 17. Heparin 5000 UNIT SC BID Order date: @ 0139\n 18. Potassium Phosphate IV Sliding Scale Infuse over 6 hours Order\n date: @ 0647\n 19. Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose\n Order date: @ 1234\n 20. Propofol 20-50 mcg/kg/min IV DRIP TITRATE TO adequate sedation\n Order date: @ 1659\n 21. Lidocaine 1% 3-5 mL IH Q4-6 HRS PRN Order date: @ 1854\n 22. Lorazepam 2-4 mg IV Q4H:PRN Order date: @ \n 23. Tobramycin 450 mg IV Q24H Order date: @ 1607\n 24. Lorazepam 2-4 mg IV Q30MIN:PRN agitation Order date: @ 0430\n 25. Vancomycin 750 mg IV Q 8H Order date: @ 1253\n 24 Hour Events:\n MULTI LUMEN - START 08:14 AM\n MULTI LUMEN - STOP 10:42 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Tobramycin - 08:09 PM\n Piperacillin/Tazobactam (Zosyn) - 12:27 AM\n Vancomycin - 01:27 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 06:53 PM\n Metoprolol - 04:13 AM\n Famotidine (Pepcid) - 05:14 AM\n Heparin Sodium (Prophylaxis) - 05:14 AM\n Other medications:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 36.7\nC (98\n HR: 78 (77 - 109) bpm\n BP: 100/51(65) {92/43(61) - 167/91(117)} mmHg\n RR: 20 (12 - 28) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 6,402 mL\n 1,143 mL\n PO:\n Tube feeding:\n 850 mL\n IV Fluid:\n 4,432 mL\n 1,143 mL\n Blood products:\n Total out:\n 1,765 mL\n 1,140 mL\n Urine:\n 1,615 mL\n 940 mL\n NG:\n 150 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n 4,637 mL\n 3 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 395 (347 - 541) mL\n PS : 10 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 63\n PIP: 16 cmH2O\n SPO2: 100%\n ABG: 7.42/39/114/28/1\n Ve: 6.6 L/min\n PaO2 / FiO2: 285\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, PEG\n intact\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: (Responds to: Unresponsive), Moves all extremities, Sedated\n Labs / Radiology\n 347 K/uL\n 9.0 g/dL\n 92 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 20 mg/dL\n 100 mEq/L\n 137 mEq/L\n 25.7 %\n 14.1 K/uL\n [image002.jpg]\n 06:00 AM\n 08:00 AM\n 10:00 AM\n 02:41 AM\n 04:11 AM\n 06:00 AM\n 05:27 PM\n 03:29 AM\n 01:30 AM\n 03:00 AM\n WBC\n 12.9\n 15.9\n 14.1\n Hct\n 32.2\n 31.6\n 25.7\n Plt\n \n Creatinine\n 0.4\n 0.9\n 1.0\n Troponin T\n <0.01\n TCO2\n 35\n 26\n Glucose\n 130\n 141\n 105\n 149\n 194\n 158\n 92\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.4 mmol/L, Albumin:3.6 g/dL, LDH:212 IU/L,\n Ca:9.3 mg/dL, Mg:2.1 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), INEFFECTIVE COPING, ALTERED MENTAL STATUS (NOT\n DELIRIUM), FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), FUNGAL\n INFECTION, OTHER, HYPERGLYCEMIA, IMPAIRED SKIN INTEGRITY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction.\n Neurologic: Pain controlled, Haldol TID & prn, Ativan, fentanyl patch,\n clonidine, propofol\n Cardiovascular: HD Stable\n Pulmonary: (Ventilator mode: CPAP + PS), wean vent to TC\n Gastrointestinal / Abdomen: Continue to hold TF's, G-tube to gravity\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Hct 25.7 down from 31.6. Recheck at noon\n Endocrine: RISS\n Infectious Disease: Check cultures, Cont vanc/Zosyn/tobra, F/U\n cultures, WBC decreasing\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: LR\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress), Sepsis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Arterial Line - 07:53 AM\n Multi Lumen - 08:14 AM\n 22 Gauge - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 572089,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ bacteremia, UTI, VAP.\n Chief complaint:\n abd pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n Current medications:\n 1. Magnesium Sulfate IV Sliding Scale Order date: @ 0234\n 2. 1000 mL LR Continuous at 75 ml/hr TF+IVF=90cc/hr, HLIV when TF@ goal\n 90 Order date: @ 1540\n 3. Metoprolol Tartrate 5 mg IV Q4H tachycadia/HTN hold for SBP<100\n HR<60 Order date: @ 0753\n 4. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308\n 5. Miconazole 2% Cream 1 Appl TP yeast rash Order date: @\n 2347\n 6. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139\n 7. Miconazole Powder 2% 1 Appl TP TID:PRN Order date: @ 1255\n 9. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @ 0555\n 10. CloniDINE 0.2 mg PO TID Order date: @ 0751\n 11. Famotidine 20 mg IV Q12H Order date: @ 0419\n 12. Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @ 1209\n 13. Fentanyl Patch 75 mcg/hr TP Q72H Order date: @ 0751\n 14. Potassium Chloride PO Sliding Scale Hold for K > 5 Order date:\n @ 0505\n 15. Haloperidol 2 mg PO TID through G tube Order date: @ 0751\n 16. Potassium Chloride IV Sliding Scale Order date: @ 0526\n 17. Heparin 5000 UNIT SC BID Order date: @ 0139\n 18. Potassium Phosphate IV Sliding Scale Infuse over 6 hours Order\n date: @ 0647\n 19. Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose\n Order date: @ 1234\n 20. Lidocaine 1% 3-5 mL IH Q4-6 HRS PRN Order date: @ 1854\n 21. Lorazepam 2-4 mg IV Q4H:PRN Order date: @ \n 22. Tobramycin 450 mg IV Q24H Order date: @ 1607\n 23. Lorazepam 2-4 mg IV Q30MIN:PRN agitation Order date: @ 0430\n 24. Vancomycin 1000 mg IV Q 12H Order date: @ 1125\n 24 Hour Events:\n weaned off propofol & vent, restarted TF, vanc changed to 1000\"\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Tobramycin - 08:09 PM\n Vancomycin - 08:05 PM\n Piperacillin/Tazobactam (Zosyn) - 11:55 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 12:09 AM\n Heparin Sodium (Prophylaxis) - 06:02 AM\n Famotidine (Pepcid) - 06:03 AM\n Other medications:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.8\nC (98.2\n HR: 71 (71 - 86) bpm\n BP: 101/68(81) {75/47(61) - 123/68(82)} mmHg\n RR: 14 (14 - 29) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 3,563 mL\n 717 mL\n PO:\n Tube feeding:\n 452 mL\n 546 mL\n IV Fluid:\n 2,941 mL\n 171 mL\n Blood products:\n Total out:\n 2,855 mL\n 730 mL\n Urine:\n 2,655 mL\n 730 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 708 mL\n -13 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 369 (265 - 556) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 109\n PIP: 10 cmH2O\n SPO2: 98%\n ABG: ///31/\n Ve: 4.2 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 321 K/uL\n 8.0 g/dL\n 89 mg/dL\n 1.2 mg/dL\n 31 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 103 mEq/L\n 141 mEq/L\n 23.3 %\n 9.4 K/uL\n [image002.jpg]\n 10:00 AM\n 02:41 AM\n 04:11 AM\n 06:00 AM\n 05:27 PM\n 03:29 AM\n 01:30 AM\n 03:00 AM\n 12:31 PM\n 03:18 AM\n WBC\n 12.9\n 15.9\n 14.1\n 9.4\n Hct\n 32.2\n 31.6\n 25.7\n 24.6\n 23.3\n Plt\n 21\n Creatinine\n 0.4\n 0.9\n 1.0\n 1.2\n Troponin T\n <0.01\n TCO2\n 35\n 26\n Glucose\n 105\n 149\n 194\n 158\n 92\n 89\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.4 mmol/L, Albumin:3.6 g/dL, LDH:212 IU/L,\n Ca:9.3 mg/dL, Mg:2.3 mg/dL, PO4:3.7 mg/dL\n Microbiology: blood: neg\n urine: yeast\n MRSA: neg\n PICC tip: neg\n sputum: contam\n sputum: GNR x3, yeast\n bld x2: neg\n C.diff: neg\n sputum: contam\n sputum x2: contam\n bld: coag neg Staph\n urine: yeast >100K\n R SCL CVL tip: GNR\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), INEFFECTIVE COPING, ALTERED MENTAL STATUS (NOT\n DELIRIUM), FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), .H/O\n AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY\n CLEARANCE, COUGH), FUNGAL INFECTION, OTHER, IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, RISK FOR INJURY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ bacteremia, UTI, VAP.\n Neurologic: Pain controlled, Haldol TID & prn. Fentanyl patch.\n Clonidine.\n Cardiovascular: Beta-blocker, HD stable on Lopressor 5q4h.\n Pulmonary: Trach, Wean to TC, pulm toilet, nebs, abx.\n Gastrointestinal / Abdomen: TF.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Cr & lytes stable.\n Hematology: Hct 31.6 -> 25.7 -> 24.6 -> 23.3. Follow.\n Endocrine: RISS, Goal FS<150.\n Infectious Disease: Check cultures, Continue vanc/Zosyn/tobra for\n VAP/bacteremia/UTI.\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Sepsis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:53 AM\n Multi Lumen - 08:14 AM\n 22 Gauge - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571811,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation.\n : R-SC CVL discontinues-catheter tip sent fore culture. New L-SC\n CVL placed. Placement confirmed by CRX . CT of ABD with contrast.\n Family updated regarding POC. Plan for family meeting in the next few\n days.\n Impaired Skin Integrity\n Assessment:\n -Groin and perianal errythema, fissure near coccyx near skin folds.\n -Incontinent of large formed soft brown stool.\n Action:\n -groin and perianal area cleansed and dried thoroughly.\n -Miconazole cream/Anti-fungal barrier cream applied every 2-4 hours\n PRN.\n -Repositioned Q 2 hours.\n Response:\n -Groin and perianal with decreased errythema.\n Plan:\n -Miconazole cream/Antifungal barrier cream/M q 2-4 hours PRN.\n -Reposition every 2 hours.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n - 8 Portex Trach in place on CPAP/40%/5PEEP/10 PS.\n -Respiratory rate 12-28. Pox: 93-100%.\n -Trach site CDI.\n Action:\n -Suctioned for small to moderate amounts of thick white sputum.\n -HOB maintained between 30-45 degrees.\n -Turned q 2.\n -Mouth care performed q 4.\n -Zosyn/Vancomycin/tobramycin given.\n Response:\n -LS: R+LUL Clear, rhonchus bibasilar.\n -Pox: 93-100%.\n Plan:\n -Aggressive pulmonary hygiene.\n -Titrate vent support as tolerated.\n -Continue Zosyn/Vancomycin/Trobramycin.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n -T-Max: 99.8. Diaphoretic.\n -R-sc CVL line site with errythema at insertion site.\n -Sputum culture results pending.\n Action:\n -R-SC CVL site discontinued. Catheter tip sent for culture.\n -New L-SC CVL line placed and placement confirmed by CXR.\n -Zosyn/Vancomycin/Trobramycin given.\n -MD Legissety notified of Vancomycin trough of 22.1.\n -Trobramycin trough pending.\n Response:\n -Remains afebrile.\n Plan:\n -Continue to follow fever curve and WBC\n -Monitor R-SC CVL site for further errythema. Monitor new L-SC CVL for\n infection.\n -Continue Zosyn/Vancomycin/Trobramycin.\n Supportive care provided to patient and family. Plan is to schedule a\n family meeting in the next few days with MD team and RN to discuss POC.\n Social work consulted.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572008,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n EVENTS:\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation.\n : R-SC CVL discontinued-catheter tip sent fore culture. New L-SC\n CVL placed. Placement confirmed by CRX . CT of ABD with contrast.\n Family updated regarding POC. Plan for family meeting in the next few\n days.\n Impaired Skin Integrity\n Assessment:\n -Groin and perianal errythema, fissure near coccyx near skin folds.\n -Incontinent of small amount of formed brown stool.\n Action:\n -groin and perianal area cleansed and dried thoroughly.\n -Miconazole cream/Anti-fungal barrier cream applied every 2-4 hours\n PRN.\n -Repositioned Q 2 hours.\n Response:\n -Groin and perianal with markedly decreased errythema.\n Plan:\n -Miconazole cream/Antifungal barrier cream/M q 2-4 hours PRN.\n -Reposition every 2 hours.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n -8 Portex Trach in place 40% humidified trach collar. .\n -Respiratory rate 19-22. Pox: 94-100%.\n -Trach site CDI.\n Action:\n -Suctioned for small to moderate amounts of thick white sputum.\n -HOB maintained between 30-45 degrees.\n -Turned q 2.\n -Mouth care performed q 4.\n -Zosyn/Vancomycin/tobramycin given.\n Response:\n -LS: R+LUL Clear, rhonchus bibasilar.\n -Pox: 94-100%.\n Plan:\n -Aggressive pulmonary hygiene.\n -Continue trach collar as tolerated.\n -Continue Zosyn/Vancomycin/Trobramycin.\n Hyperglycemia\n Assessment:\n -FS: 126-144.\n -Continue on NPH and Regular insulin sliding scale.\n -Replete with fiber restarted. Tolerating well with no residuals. Goal\n 90cc.\n Action:\n -BS checked every 6 hours.\n -TF\ns advanced as tolerated.\n Response:\n -Good control of blood sugars on NPH and Regular insulin sliding scale.\n Plan:\n -Hyperglycemia resolved.\n -Refer to Care Plan.\n Risk for Injury\n Assessment:\n -Agitated at times and pulling at lines.\n Action:\n -Sedated with Propofol and Ativan.\n -PO Haldol and Clonidine given with good effect.\n -Bilateral soft hand restraints.\n -Pt frequently reminded not to pull at lines-takes direction well.\n Response:\n -Propofol stopped. Pt A+Ox1-2. Resting comfortably in bed.\n -Bilateral soft hand restraints off.\n Plan:\n -Continue Haldol and Clonidine for agitation.\n -Provide patient with direction PRN.\n -Provide supportive care to patient and family.\n Dr. in to speak with (mother) and (sister) to\n update regarding patient\ns condition and POC. Confirmed is\n patient\ns sister and okay to give condition updates. Per family no\n further need for family meeting at this time. Social work to follow.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-14 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 572072,
"text": "Demographics\n Day of mechanical ventilation: 3\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing, High\n flow demand\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Continue with trach mask trials. Pt went from 1500 to 0100 , 10 hours\n w/o a rest. Reason for continuing current ventilatory support:\n Intolerant of weaning attempts, Cannot manage secretions, Underlying\n illness not resolved\n Respiratory Care Shift Procedures\n Comments: Plan for pt to resume trach mask trials today. Morning RSBI\n was 109\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572029,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n EVENTS:\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation.\n : R-SC CVL discontinued-catheter tip sent fore culture. New L-SC\n CVL placed. Placement confirmed by CRX . CT of ABD with contrast.\n Family updated regarding POC. Plan for family meeting in the next few\n days.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571045,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : T103, increased LFTs/AP, propofol gtt, prophylactic abx\n : weaned to trach collar, R SCL CVL placed, PICC d/c'd, CT abd\n : ERCP\n : started TF\n : HLIV, suctioned q1hr, sputum cx, CXR, heat rash --> miconazole,\n agitation, diaphoretic episodes (afebrile, glucose normal).\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation.\n Fungal Infection, Other\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571170,
"text": "Fungal Infection, Other\n Assessment:\n Pt with yeast infection to sputum and sacrum\n Action:\n Pt on Miconazole powder/cream to affected areas Q12hrs. Was started on\n Fluconazole, but discontinued by primary team.\n Response:\n No change in affected area as yet this shift.\n Plan:\n Continue with application of anti-fungals.\n Turn Q2hrs, keep off back to allow sacrum to heal.\n Hyperglycemia\n Assessment:\n Pt with unstable glucose levels.\n Action:\n On insulin gtt at 6.5units/hr.\n Response:\n Stable glucose levels at present.\n Plan:\n Continue with Insulin gtt, Q2hr finger sticks.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 571601,
"text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Expectorated / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: when pt requires sedation, only propofol is useful therefore\n ventilator requitred.\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-12 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571692,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. 2. 1000 mL NS 3. 1000 mL NS 4. 500 mL NS 5. Acetaminophen 6.\n Bisacodyl 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. CloniDINE 9. Famotidine 10. Fentanyl Patch 11. Haloperidol 12.\n Haloperidol 13. Heparin 14. Ibuprofen Suspension\n 15. Insulin 16. Lidocaine 1% 17. Lorazepam 18. Lorazepam 19. Magnesium\n Sulfate 20. Metoprolol Tartrate\n 21. Miconazole 2% Cream 22. Miconazole Powder 2% 23. Nystatin Oral\n Suspension 24. Phenylephrine 25. Piperacillin-Tazobactam Na\n 26. Potassium Chloride 27. Potassium Phosphate 28. Propofol 29. Sodium\n Chloride 0.9% Flush 30. Tobramycin\n 31. Vancomycin\n 24 Hour Events:\n PAN CULTURE - At 08:52 AM\n NASAL SWAB - At 10:40 AM\n MRSA\n SPUTUM CULTURE - At 02:41 PM\n first sample with oral flora, resent\n FEVER - 102.6\nF - 08:00 AM\n - hypotensive AM, started on phenylephrine\n - central line site noted to be red, +blood cultures from AM\n - a-line replaced\n Post operative day:\n HD #12, PPD #9\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Tobramycin - 05:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:05 AM\n Vancomycin - 01:17 AM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 02:15 PM\n Famotidine (Pepcid) - 04:30 AM\n Heparin Sodium (Prophylaxis) - 05:31 AM\n Other medications:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.2\nC (102.6\n T current: 38.1\nC (100.6\n HR: 83 (83 - 128) bpm\n BP: 121/79(88) {78/46(54) - 143/99(107)} mmHg\n RR: 21 (16 - 36) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 3,582 mL\n 2,191 mL\n PO:\n Tube feeding:\n 2,160 mL\n 649 mL\n IV Fluid:\n 1,062 mL\n 1,492 mL\n Blood products:\n Total out:\n 1,480 mL\n 235 mL\n Urine:\n 1,480 mL\n 235 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,102 mL\n 1,956 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 351 (324 - 576) mL\n PS : 10 cmH2O\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 120\n PIP: 16 cmH2O\n SPO2: 100%\n ABG: ///32/\n Ve: 9.7 L/min\n Physical Examination\n General Appearance: diaphoretic\n HEENT: PERRL\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Left Extremities: (Edema: 1+), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: 1+), (Pulse - Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 1), (Responds to: Verbal\n stimuli), Moves all extremities, intermittently sedated/agitated\n Labs / Radiology\n 458 K/uL\n 10.5 g/dL\n 158 mg/dL\n 0.9 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 99 mEq/L\n 141 mEq/L\n 31.6 %\n 15.9 K/uL\n [image002.jpg]\n 04:28 AM\n 05:19 AM\n 06:00 AM\n 08:00 AM\n 10:00 AM\n 02:41 AM\n 04:11 AM\n 06:00 AM\n 05:27 PM\n 03:29 AM\n WBC\n 11.3\n 12.9\n 15.9\n Hct\n 31.0\n 32.2\n 31.6\n Plt\n \n Creatinine\n 0.4\n 0.4\n 0.9\n Troponin T\n <0.01\n TCO2\n 34\n 35\n Glucose\n 133\n 130\n 141\n 105\n 149\n 194\n 158\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.8 mmol/L, Albumin:3.6 g/dL, LDH:212 IU/L,\n Ca:9.8 mg/dL, Mg:2.3 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ALTERED MENTAL STATUS (NOT DELIRIUM), FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), FUNGAL INFECTION, OTHER,\n HYPERGLYCEMIA, IMPAIRED SKIN INTEGRITY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction.\n Neurologic: Haldol TID, fentanyl patch, clonidine, was on propofol gtt\n o/n to help with agitation, now off; ?infection as cause for agitation\n Cardiovascular: Neo for some hypotension, wean as tolerated\n Pulmonary: Trach, (Ventilator mode: CPAP + PS), Wean vent as tolerated;\n CXR has looked OK despite secretions\n Gastrointestinal / Abdomen: LFTs/ammonia wnl, consider CT abd today;\n continue TF\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Creat stable\n Hematology: Hct stable\n Endocrine: RISS, NPH\n Infectious Disease: Continue Vanco/Zosyn/Tobra. Follow cultures.\n Resite right subclavian central line. Consider CT abd - team to let us\n know.\n Lines / Tubes / Drains: Foley, G-tube, Trach, right subclavian central\n line (to be resited), Flexiseal, A-line\n Wounds:\n Imaging: CT scan abd today, ?\n Fluids: Received some NS boluses for hypotension - team would like to\n continue to wean off neo.\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure), Post-op\n hypotension, Pancreatitis\n ICU Care\n Nutrition:\n Replete (Full) - 11:17 PM 90 mL/hour\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572272,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n EVENTS:\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation.\n : R-SC CVL discontinued-catheter tip sent fore culture. New L-SC\n CVL placed. Placement confirmed by CRX . CT of ABD with contrast.\n Family updated regarding POC. Plan for family meeting in the next few\n days.\n Impaired Physical Mobility\n Assessment:\n Action:\n Response:\n Plan:\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 569950,
"text": "SICU\n HPI:\n pt dx at outside hospital w/pancreatits, s/p pseudocyst\n drainage--culture + for staph, hemodynamically unstable, required\n intubation/pressors. unable to wean off vent, trach'd. admitted to\n sicu, spiking temps tmax-103, increased lft's/alk phos/ r/o\n cholangitiis, currently sedated, prophylactic abx, no pressors\n presently required.\n Chief complaint:\n abdominal pain/pancreatitis/respiratory failure\n PMHx:\n DVT, HTN, Lipidemia, Hx of MI in s/p PTCA\n Current medications:\n 1. 1000 mL LR\n Continuous at 100 ml/hr Order date: @ 0354 8. MetRONIDAZOLE\n (FLagyl) 500 mg IV Q8H Order date: @ 0308\n 2. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308 9.\n Miconazole 2% Cream 1 Appl TP :PRN Order date: @ 0139\n 3. Ampicillin-Sulbactam 3 g IV Q6H Order date: @ 0308 10.\n Pantoprazole 40 mg IV Q24H Order date: @ 0231\n 4. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139 11.\n Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Order date: \n @ 0139\n 5. Fentanyl Patch 50 mcg/hr TP Q72H Order date: @ 0139 12.\n Propofol 5-40 mcg/kg/min IV DRIP INFUSION Order date: @ 0308\n 6. Heparin 5000 UNIT SC BID Order date: @ 0139 13. Vancomycin\n 1000 mg IV Q 12H\n ID Approval will be required for this order in 76 hours. Order date:\n @ 0308\n 7. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0139\n 24 Hour Events:\n PICC LINE - START 11:47 PM\n INVASIVE VENTILATION - START 12:00 AM\n ARTERIAL LINE - START 03:07 AM\n FEVER - 103.5\nF - 11:19 PM\n Allergies:\n Last dose of Antibiotics:\n Metronidazole - 03:27 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 03:27 AM\n Other medications:\n Flowsheet Data as of 04:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.7\nC (103.5\n T current: 38.9\nC (102\n HR: 104 (85 - 116) bpm\n BP: 106/58(72) {88/49(60) - 109/58(72)} mmHg\n RR: 15 (14 - 22) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 0 mL\n 167 mL\n PO:\n Tube feeding:\n IV Fluid:\n 0 mL\n 167 mL\n Blood products:\n Total out:\n 25 mL\n 115 mL\n Urine:\n 25 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n -25 mL\n 52 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 18 cmH2O\n Plateau: 18 cmH2O\n Compliance: 46.2 cmH2O/mL\n SPO2: 98%\n ABG: 7.47/39/155/26/5\n Ve: 10.6 L/min\n PaO2 / FiO2: 388\n Physical Examination\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: b/l)\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Responds to: Tactile stimuli, Noxious stimuli), Moves all\n extremities, Sedated\n Labs / Radiology\n 346 K/uL\n 9.9 g/dL\n 146 mg/dL\n 0.5 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 17 mg/dL\n 102 mEq/L\n 145 mEq/L\n 30.3 %\n 10.6 K/uL\n [image002.jpg]\n 02:36 AM\n 02:55 AM\n WBC\n 10.6\n Hct\n 30.3\n Plt\n 346\n Creatinine\n 0.5\n TCO2\n 29\n Glucose\n 151\n 146\n Other labs: PT / PTT / INR:15.7/27.6/1.4, ALT / AST:204/211, Alk-Phos /\n T bili:353/3.9, Amylase / Lipase:33/22, Differential-Neuts:80.5 %,\n Lymph:15.0 %, Mono:3.0 %, Eos:0.8 %, Lactic Acid:1.1 mmol/L,\n Albumin:3.0 g/dL, Ca:9.5 mg/dL, Mg:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n Assessment and Plan: 42 y/o male w/hx of pancreatits, presents w/septic\n picture, r/o cholangitis\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, sedated on propfol\n and fentanyl gtt\n Cardiovascular: hx of htn, BP stable, no pressors required\n Pulmonary: Trach, (Ventilator mode: CMV), wean vent as tolerated\n Gastrointestinal / Abdomen: stable, Gtube in place\n Nutrition: NPO\n Renal: Foley, u/o 25-30/hr, creatinine stable at 0.5\n Hematology: stable\n Endocrine: RISS, stable\n Infectious Disease: Check cultures, empiric coverage\n w/vanc/zosyn/flagyl, blood cx pending, urine cx pending\n Lines / Tubes / Drains: Foley, G-tube, Trach, left radial a-line\n Wounds: none\n Imaging: CXR today\n Fluids: LR, 100 cc/hr\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure), Sepsis,\n Pancreatitis\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:47 PM\n 20 Gauge - 11:48 PM\n Arterial Line - 03:07 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status:\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-10 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571297,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n abd pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n Current medications:\n 1. Magnesium Sulfate IV Sliding Scale Order date: @ 0234\n 2. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308\n 3. Miconazole 2% Cream 1 Appl TP yeast rash Order date: @\n 2347\n 4. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139\n 5. Miconazole Powder 2% 1 Appl TP TID:PRN Order date: @ 1255\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL Use only if\n patient is on mechanical ventilation. Order date: @ 1119\n 7. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @ 0555\n 8. Famotidine 20 mg IV Q12H Order date: @ 0419\n 9. Phenylephrine 0.5-5 mcg/kg/min IV DRIP INFUSION maintain MAP>60\n Order date: @ 2037\n 10. Fentanyl Patch 50 mcg/hr TP Q72H Order date: @ 0139\n 11. Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @ 1209\n 12. Haloperidol 2 mg PO TID through G tube Order date: @ 0840\n 13. Potassium Chloride PO Sliding Scale Hold for K > 5 Order date:\n @ 0505\n 14. Heparin 5000 UNIT SC BID Order date: @ 0139\n 15. Potassium Phosphate IV Sliding Scale Infuse over 6 hours Order\n date: @ 0647\n 16. Insulin 100 Units/100 ml NS @ 2 UNIT/HR IV DRIP INFUSION\n Fingersticks every hour Order date: @ 1406\n 17. Propofol 5-60 mcg/kg/min IV DRIP INFUSION Order date: @ 2052\n 18. Lidocaine 1% 3-5 mL IH Q4-6 HRS PRN Order date: @ 1854\n 19. Lorazepam 2-4 mg IV Q4H:PRN Order date: @ \n 20. Vancomycin 1000 mg IV Q 8H Order date: @ 1044\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:04 AM\n Weaned to trach collar.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Vancomycin - 12:30 AM\n Infusions:\n Insulin - Regular - 8 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 06:00 PM\n Heparin Sodium (Prophylaxis) - 06:00 PM\n Other medications:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 37.1\nC (98.8\n HR: 94 (70 - 104) bpm\n BP: 129/72(94) {102/59(75) - 143/92(108)} mmHg\n RR: 24 (16 - 33) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 3,714 mL\n 1,080 mL\n PO:\n Tube feeding:\n 2,169 mL\n 656 mL\n IV Fluid:\n 1,435 mL\n 424 mL\n Blood products:\n Total out:\n 2,942 mL\n 300 mL\n Urine:\n 2,942 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 772 mL\n 780 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 384 (384 - 384) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 13 cmH2O\n SPO2: 100%\n ABG: 7.43/49/84./30/6\n Ve: 6.4 L/min\n PaO2 / FiO2: 168\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 424 K/uL\n 10.1 g/dL\n 130\n 0.4 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 102 mEq/L\n 140 mEq/L\n 31.0 %\n 11.3 K/uL\n [image002.jpg]\n 10:45 PM\n 11:59 PM\n 03:59 AM\n 04:11 AM\n 05:35 PM\n 02:48 AM\n 03:27 AM\n 04:28 AM\n 05:19 AM\n 06:00 AM\n WBC\n 20.9\n 25.6\n 12.8\n 10.8\n 11.3\n Hct\n 28.4\n 30.2\n 27.3\n 29.6\n 31.0\n Plt\n 327\n 431\n 344\n 379\n 424\n Creatinine\n 0.5\n 0.5\n 0.4\n 0.4\n 0.4\n 0.4\n TCO2\n 26\n 24\n 34\n Glucose\n 122\n 189\n 180\n \n 130\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:76//<0.01, ALT / AST:32/22, Alk-Phos / T bili:130/0.6, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.8 mmol/L, Albumin:3.1 g/dL, Ca:9.6 mg/dL,\n Mg:2.3 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n FUNGAL INFECTION, OTHER, HYPERGLYCEMIA, DIARRHEA, .H/O RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), .H/O CHOLELITHIASIS, .H/O MYOCARDIAL\n INFARCTION, .H/O PANCREATITIS, ACUTE, .H/O ABDOMINAL PAIN (INCLUDING\n ABDOMINAL TENDERNESS), IMPAIRED SKIN INTEGRITY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction.\n Neurologic: Pain controlled, Fentanyl patch. Haldol TID & prn. Ativan\n prn.\n Cardiovascular: HD stable.\n Pulmonary: Trach, IS, Pulm toilet, nebs, supplemental O2. Stable on\n trach collar.\n Gastrointestinal / Abdomen: TF @ goal.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Cr & lytes stable.\n Hematology: Hct stable.\n Endocrine: Insulin drip, Goal FS<150.\n Infectious Disease: Afebrile, WBC 11.3. Vanc for Staph in pseudocyst\n (OSH culture data) and Zosyn for VAP.\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure), Pancreatitis\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n Arterial Line - 09:27 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 34 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 571474,
"text": "Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Supra-sternal retractions,\n Accessory muscle use\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n :\n Plan/ Comments:\n Pt had difficult night becoming agitated and having frequent coughing\n with copious amount of loose white secretions.\n Nursing and MD tring to titrate right amts of haldol\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 572292,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ UTI, VAP, bacteremia.\n Chief complaint:\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. 2. Acetaminophen 3. Bisacodyl 4. Chlorhexidine Gluconate 0.12% Oral\n Rinse 5. CloniDINE 6. Famotidine\n 7. Fentanyl Patch 8. Haloperidol 9. Heparin 10. Insulin 11. Linezolid\n 12. Lidocaine 1% 13. Lorazepam\n 14. Lorazepam 15. Magnesium Sulfate 16. Metoprolol Tartrate 17.\n Miconazole 2% Cream 18. Miconazole Powder 2%\n 19. Nystatin Oral Suspension 20. Phenylephrine 21.\n Piperacillin-Tazobactam Na 22. Potassium Chloride\n 23. Potassium Chloride 24. Potassium Phosphate 25. Propofol 26. Sodium\n Chloride 0.9% Flush 27. Tobramycin\n 24 Hour Events:\n BLOOD CULTURED - At 05:30 PM\n URINE CULTURE - At 05:30 PM\n - transfused 1 unit RBC\n - decreased Haldol\n - OOB to chair\n - tolerated PMV\n - changed vanco->linezolid (pt with h/o VRE)\n Post operative day:\n HD #15, PPD #12\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:10 AM\n Tobramycin - 05:01 PM\n Linezolid - 08:15 PM\n Piperacillin/Tazobactam (Zosyn) - 11:55 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 05:57 AM\n Heparin Sodium (Prophylaxis) - 05:57 AM\n Other medications:\n Flowsheet Data as of 06:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.9\nC (98.5\n HR: 76 (68 - 79) bpm\n BP: 117/64(83) {101/54(69) - 134/73(94)} mmHg\n RR: 20 (11 - 29) insp/min\n SPO2: 97%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 69 Inch\n Total In:\n 3,556 mL\n 664 mL\n PO:\n Tube feeding:\n 2,095 mL\n 552 mL\n IV Fluid:\n 991 mL\n 111 mL\n Blood products:\n 350 mL\n Total out:\n 1,865 mL\n 415 mL\n Urine:\n 1,865 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,691 mL\n 249 mL\n Respiratory support\n O2 Delivery Device: Trach mask , T-piece\n Ventilator mode: CPAP\n Vt (Spontaneous): 351 (303 - 420) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 114\n PIP: 11 cmH2O\n SPO2: 97%\n ABG: ///28/\n Ve: 10.6 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 315 K/uL\n 9.4 g/dL\n 119 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 24 mg/dL\n 105 mEq/L\n 141 mEq/L\n 27.8 %\n 8.8 K/uL\n [image002.jpg]\n 02:41 AM\n 04:11 AM\n 06:00 AM\n 05:27 PM\n 03:29 AM\n 01:30 AM\n 03:00 AM\n 12:31 PM\n 03:18 AM\n 04:29 AM\n WBC\n 12.9\n 15.9\n 14.1\n 9.4\n 8.8\n Hct\n 32.2\n 31.6\n 25.7\n 24.6\n 23.3\n 27.8\n Plt\n 21\n 315\n Creatinine\n 0.4\n 0.9\n 1.0\n 1.2\n 1.0\n Troponin T\n <0.01\n TCO2\n 35\n 26\n Glucose\n 149\n 194\n 158\n 92\n 89\n 119\n Other labs: PT / PTT / INR:12.4/22.4/1.0, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.4 mmol/L, Albumin:3.6 g/dL, LDH:212 IU/L,\n Ca:9.1 mg/dL, Mg:2.2 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), IMPAIRED PHYSICAL MOBILITY, HYPERGLYCEMIA\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ UTI, VAP, bacteremia,\n improving.\n Neurologic: Pain controlled, Haldol TID, Ativan prn, fentanyl patch,\n clonidine\n Cardiovascular: Beta-blocker, HD stable, on Lopressor 5q6\n Pulmonary: Trach, Trach collar as tolerated, pulm toilet\n Gastrointestinal / Abdomen: TF.\n Nutrition: Tube feeding, NPO\n Renal: Foley, Adequate UO\n Hematology: Hct bumped appropriate after 1 unit blood, continue to\n follow.\n Endocrine: RISS, NPH 60 units SQ \n Infectious Disease: WBC down. U/A neg yesterday, UCx, BCx pending.\n Cont Linezolid/Tobra/Zosyn. ID wants day course from \n (will let us know for sure later). Check tobra trough today.\n Lines / Tubes / Drains: Foley, G-tube, Trach, A-line, left subclavian\n central line, flexiseal\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure), Pancreatitis\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:57 AM 90 mL/hour\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Arterial Line - 07:53 AM\n Multi Lumen - 08:14 AM\n 22 Gauge - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-10 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571324,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n abd pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n Current medications:\n 1. Magnesium Sulfate IV Sliding Scale Order date: @ 0234\n 2. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308\n 3. Miconazole 2% Cream 1 Appl TP yeast rash Order date: @\n 2347\n 4. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139\n 5. Miconazole Powder 2% 1 Appl TP TID:PRN Order date: @ 1255\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL Use only if\n patient is on mechanical ventilation. Order date: @ 1119\n 7. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @ 0555\n 8. Famotidine 20 mg IV Q12H Order date: @ 0419\n 9. Phenylephrine 0.5-5 mcg/kg/min IV DRIP INFUSION maintain MAP>60\n Order date: @ 2037\n 10. Fentanyl Patch 50 mcg/hr TP Q72H Order date: @ 0139\n 11. Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @ 1209\n 12. Haloperidol 2 mg PO TID through G tube Order date: @ 0840\n 13. Potassium Chloride PO Sliding Scale Hold for K > 5 Order date:\n @ 0505\n 14. Heparin 5000 UNIT SC BID Order date: @ 0139\n 15. Potassium Phosphate IV Sliding Scale Infuse over 6 hours Order\n date: @ 0647\n 16. Insulin 100 Units/100 ml NS @ 2 UNIT/HR IV DRIP INFUSION\n Fingersticks every hour Order date: @ 1406\n 17. Propofol 5-60 mcg/kg/min IV DRIP INFUSION Order date: @ 2052\n 18. Lidocaine 1% 3-5 mL IH Q4-6 HRS PRN Order date: @ 1854\n 19. Lorazepam 2-4 mg IV Q4H:PRN Order date: @ \n 20. Vancomycin 1000 mg IV Q 8H Order date: @ 1044\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:04 AM\n Weaned to trach collar.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Vancomycin - 12:30 AM\n Infusions:\n Insulin - Regular - 8 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 06:00 PM\n Heparin Sodium (Prophylaxis) - 06:00 PM\n Other medications:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 37.1\nC (98.8\n HR: 94 (70 - 104) bpm\n BP: 129/72(94) {102/59(75) - 143/92(108)} mmHg\n RR: 24 (16 - 33) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 3,714 mL\n 1,080 mL\n PO:\n Tube feeding:\n 2,169 mL\n 656 mL\n IV Fluid:\n 1,435 mL\n 424 mL\n Blood products:\n Total out:\n 2,942 mL\n 300 mL\n Urine:\n 2,942 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 772 mL\n 780 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 384 (384 - 384) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 13 cmH2O\n SPO2: 100%\n ABG: 7.43/49/84./30/6\n Ve: 6.4 L/min\n PaO2 / FiO2: 168\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 424 K/uL\n 10.1 g/dL\n 130\n 0.4 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 102 mEq/L\n 140 mEq/L\n 31.0 %\n 11.3 K/uL\n [image002.jpg]\n 10:45 PM\n 11:59 PM\n 03:59 AM\n 04:11 AM\n 05:35 PM\n 02:48 AM\n 03:27 AM\n 04:28 AM\n 05:19 AM\n 06:00 AM\n WBC\n 20.9\n 25.6\n 12.8\n 10.8\n 11.3\n Hct\n 28.4\n 30.2\n 27.3\n 29.6\n 31.0\n Plt\n 327\n 431\n 344\n 379\n 424\n Creatinine\n 0.5\n 0.5\n 0.4\n 0.4\n 0.4\n 0.4\n TCO2\n 26\n 24\n 34\n Glucose\n 122\n 189\n 180\n \n 130\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:76//<0.01, ALT / AST:32/22, Alk-Phos / T bili:130/0.6, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.8 mmol/L, Albumin:3.1 g/dL, Ca:9.6 mg/dL,\n Mg:2.3 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n FUNGAL INFECTION, OTHER, HYPERGLYCEMIA, DIARRHEA, .H/O RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), .H/O CHOLELITHIASIS, .H/O MYOCARDIAL\n INFARCTION, .H/O PANCREATITIS, ACUTE, .H/O ABDOMINAL PAIN (INCLUDING\n ABDOMINAL TENDERNESS), IMPAIRED SKIN INTEGRITY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction.\n Neurologic: Pain controlled, Fentanyl patch. Haldol TID & prn.\n Decrease to . Ativan prn.\n Cardiovascular: HD stable.\n Pulmonary: Trach, IS, Pulm toilet, nebs, supplemental O2. Stable on\n trach collar.\n Gastrointestinal / Abdomen: TF @ goal.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Cr & lytes stable.\n Hematology: Hct stable.\n Endocrine: Insulin drip, Goal FS<150. Change to sc regimen\n Infectious Disease: Afebrile, WBC 11.3. Vanc for Staph in pseudocyst\n (OSH culture data) and Zosyn for VAP. D/C vanco. And fluconazole\n Lines / Tubes / Drains: Foley, G-tube, Trach. D/C a-line\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure), Pancreatitis\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n Arterial Line - 09:27 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572065,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n EVENTS:\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation.\n : R-SC CVL discontinued-catheter tip sent fore culture. New L-SC\n CVL placed. Placement confirmed by CRX . CT of ABD with contrast.\n Family updated regarding POC. Plan for family meeting in the next few\n days.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Trached on trach collar\n Sats mid to high 90\n RR in 20\n Patient comfortable and breathing normal.\n Clear upper, diminished lower lung sounds\n Action:\n Suctioned PRN about every 1-2 hrs\n Truned every 2 hrs and PRN\n 30% FIO2\n Response:\n Normal breathing\n Sats in high 90\n Good cough, Productive.\n Plan:\n Continue to assess respiratory status and treat as needed.\n Turn every 2 hrs and as needed\n Impaired Skin Integrity\n Assessment:\n Rash to groin area\n Red, raised.\n Has been there for over a week.\n Action:\n Ointment applied\n Turned every 2 hrs\n Response:\n Tolerated well\n No new skin issues.\n Plan:\n As above, increase nutrition\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572066,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n EVENTS:\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation.\n : R-SC CVL discontinued-catheter tip sent fore culture. New L-SC\n CVL placed. Placement confirmed by CRX . CT of ABD with contrast.\n Family updated regarding POC. Plan for family meeting in the next few\n days.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Trached on trach collar\n Sats mid to high 90\n RR in 20\n Patient comfortable and breathing normal.\n Clear upper, diminished lower lung sounds\n Action:\n Suctioned PRN about every 1-2 hrs\n Truned every 2 hrs and PRN\n 30% FIO2\n Response:\n Normal breathing\n Sats in high 90\n Good cough, Productive.\n Plan:\n Continue to assess respiratory status and treat as needed.\n Turn every 2 hrs and as needed\n Impaired Skin Integrity\n Assessment:\n Rash to groin area\n Red, raised.\n Has been there for over a week.\n Action:\n Ointment applied\n Turned every 2 hrs\n Response:\n Tolerated well\n No new skin issues.\n Plan:\n As above, increase nutrition\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570033,
"text": ".H/O pancreatitis, acute\n Assessment:\n Tmax 101. VSS. Pt becoming more alert as shift progressed. Lungs\n rhonchorous thoroughout. Productive cough for copious amt of oral\n secretions. Abd soft, positive bowel sounds. Pt having frequent loose\n stools.\n Action:\n Aggressive pulmonary toilet. Continues antibiotic therapy. Flexiseal\n placed. PICC line d/c\nd and line sent for culture. New central line\n placed by SICU team. Pt weaned to trach collar.\n Response:\n Presently pt afebrile. Pt consistently following commands. ABG\n acceptable on trach collar.\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 571870,
"text": "Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-09 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571036,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. 2. Acetaminophen 3. Bisacodyl 4. Chlorhexidine Gluconate 0.12% Oral\n Rinse 5. Famotidine 6. Fentanyl Patch\n 7. Haloperidol 8. Heparin 9. Insulin 10. Lidocaine 1% 11. Lorazepam 12.\n Magnesium Sulfate 13. Miconazole 2% Cream\n 14. Miconazole Powder 2% 15. Nystatin Oral Suspension 16. Phenylephrine\n 17. Piperacillin-Tazobactam Na\n 18. Potassium Chloride 19. Potassium Phosphate 20. Propofol 21. Sodium\n Chloride 0.9% Flush 22. Vancomycin\n 24 Hour Events:\n SPUTUM CULTURE - At 08:05 PM\n - started insulin gtt\n Post operative day:\n HD #9, PPD #6 s/p ERCP\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 12:10 AM\n Vancomycin - 12:30 AM\n Infusions:\n Insulin - Regular - 6 units/hour\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 06:11 AM\n Heparin Sodium (Prophylaxis) - 06:11 AM\n Other medications:\n Flowsheet Data as of 05:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.1\nC (98.8\n HR: 77 (73 - 113) bpm\n BP: 128/72(91) {97/45(60) - 152/81(106)} mmHg\n RR: 22 (16 - 47) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 3,872 mL\n 924 mL\n PO:\n Tube feeding:\n 2,193 mL\n 464 mL\n IV Fluid:\n 1,500 mL\n 410 mL\n Blood products:\n Total out:\n 2,105 mL\n 440 mL\n Urine:\n 1,905 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,767 mL\n 484 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 414 (322 - 472) mL\n PS : 8 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 80\n PIP: 16 cmH2O\n SPO2: 99%\n ABG: ///30/\n Ve: 9.3 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 379 K/uL\n 9.8 g/dL\n 108 mg/dL\n 0.4 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 9 mg/dL\n 104 mEq/L\n 141 mEq/L\n 29.6 %\n 10.8 K/uL\n [image002.jpg]\n 01:51 PM\n 03:46 PM\n 05:47 PM\n 10:45 PM\n 11:59 PM\n 03:59 AM\n 04:11 AM\n 05:35 PM\n 02:48 AM\n 03:27 AM\n WBC\n 18.8\n 20.9\n 25.6\n 12.8\n 10.8\n Hct\n 35.8\n 28.4\n 30.2\n 27.3\n 29.6\n Plt\n 44\n 379\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.4\n 0.4\n 0.4\n TCO2\n 30\n 30\n 26\n 24\n Glucose\n 190\n 122\n 189\n 180\n 207\n 108\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:76//<0.01, ALT / AST:39/19, Alk-Phos / T bili:142/0.7, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.8 mmol/L, Albumin:3.1 g/dL, Ca:9.1 mg/dL,\n Mg:2.2 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), FUNGAL INFECTION, OTHER,\n HYPERGLYCEMIA, DIARRHEA, .H/O RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), .H/O CHOLELITHIASIS, .H/O MYOCARDIAL INFARCTION, .H/O\n PANCREATITIS, ACUTE, .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL\n TENDERNESS), IMPAIRED SKIN INTEGRITY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction.\n Neurologic: Pain controlled, Restraints, Wean propofol gtt, Haldol TID\n & prn, Ativan prn, Fentanyl patch, ?clonidine if BP tolerates\n Cardiovascular: HD stable.\n Pulmonary: Trach, (Ventilator mode: CPAP + PS), Wean vent as tolerated.\n Gastrointestinal / Abdomen: Team wants to hold off on repeat liver\n ultrasound for now. Receiving TF's.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Hct stable.\n Endocrine: Insulin drip\n Infectious Disease: On Vanco/Zosyn. Follow up on culture results.\n Vanco trough 11.3, acceptable per team.\n Lines / Tubes / Drains: Foley, G-tube, Trach, A-line, RIJ central line,\n flexiseal\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure), Sepsis,\n Pancreatitis\n ICU Care\n Nutrition:\n Replete (Full) - 03:55 AM 90 mL/hour\n Glycemic Control: Insulin infusion\n Lines:\n Multi Lumen - 08:00 AM\n Arterial Line - 09:27 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-09 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571114,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. 2. Acetaminophen 3. Bisacodyl 4. Chlorhexidine Gluconate 0.12% Oral\n Rinse 5. Famotidine 6. Fentanyl Patch\n 7. Haloperidol 8. Heparin 9. Insulin 10. Lidocaine 1% 11. Lorazepam 12.\n Magnesium Sulfate 13. Miconazole 2% Cream\n 14. Miconazole Powder 2% 15. Nystatin Oral Suspension 16. Phenylephrine\n 17. Piperacillin-Tazobactam Na\n 18. Potassium Chloride 19. Potassium Phosphate 20. Propofol 21. Sodium\n Chloride 0.9% Flush 22. Vancomycin\n 24 Hour Events:\n SPUTUM CULTURE - At 08:05 PM\n - started insulin gtt\n Post operative day:\n HD #9, PPD #6 s/p ERCP\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 12:10 AM\n Vancomycin - 12:30 AM\n Infusions:\n Insulin - Regular - 6 units/hour\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 06:11 AM\n Heparin Sodium (Prophylaxis) - 06:11 AM\n Other medications:\n Flowsheet Data as of 05:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.1\nC (98.8\n HR: 77 (73 - 113) bpm\n BP: 128/72(91) {97/45(60) - 152/81(106)} mmHg\n RR: 22 (16 - 47) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 3,872 mL\n 924 mL\n PO:\n Tube feeding:\n 2,193 mL\n 464 mL\n IV Fluid:\n 1,500 mL\n 410 mL\n Blood products:\n Total out:\n 2,105 mL\n 440 mL\n Urine:\n 1,905 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,767 mL\n 484 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 414 (322 - 472) mL\n PS : 8 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 80\n PIP: 16 cmH2O\n SPO2: 99%\n ABG: ///30/\n Ve: 9.3 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 379 K/uL\n 9.8 g/dL\n 108 mg/dL\n 0.4 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 9 mg/dL\n 104 mEq/L\n 141 mEq/L\n 29.6 %\n 10.8 K/uL\n [image002.jpg]\n 01:51 PM\n 03:46 PM\n 05:47 PM\n 10:45 PM\n 11:59 PM\n 03:59 AM\n 04:11 AM\n 05:35 PM\n 02:48 AM\n 03:27 AM\n WBC\n 18.8\n 20.9\n 25.6\n 12.8\n 10.8\n Hct\n 35.8\n 28.4\n 30.2\n 27.3\n 29.6\n Plt\n 44\n 379\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.4\n 0.4\n 0.4\n TCO2\n 30\n 30\n 26\n 24\n Glucose\n 190\n 122\n 189\n 180\n 207\n 108\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:76//<0.01, ALT / AST:39/19, Alk-Phos / T bili:142/0.7, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.8 mmol/L, Albumin:3.1 g/dL, Ca:9.1 mg/dL,\n Mg:2.2 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), FUNGAL INFECTION, OTHER,\n HYPERGLYCEMIA, DIARRHEA, .H/O RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), .H/O CHOLELITHIASIS, .H/O MYOCARDIAL INFARCTION, .H/O\n PANCREATITIS, ACUTE, .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL\n TENDERNESS), IMPAIRED SKIN INTEGRITY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction.\n Neurologic: Pain controlled, Agitation much improved. Restraints, Wean\n propofol gtt, Haldol TID & prn, Ativan prn, Fentanyl patch,\n Cardiovascular: HD stable.\n Pulmonary: Trach, (Ventilator mode: CPAP + PS), Wean vent as\n tolerated. Try trach collar later.\n Gastrointestinal / Abdomen: Team wants to hold off on repeat liver\n ultrasound for now. Receiving TF's.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Hct stable.\n Endocrine: Insulin drip\n Infectious Disease: On Vanco/Zosyn. Follow up on culture results.\n Vanco trough 11.3, acceptable per team.\n Lines / Tubes / Drains: Foley, G-tube, Trach, A-line, RIJ central line,\n flexiseal\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure), Sepsis,\n Pancreatitis\n ICU Care\n Nutrition:\n Replete (Full) - 03:55 AM 90 mL/hour\n Glycemic Control: Insulin infusion\n Lines:\n Multi Lumen - 08:00 AM\n Arterial Line - 09:27 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 min\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570214,
"text": "Pt dx at outside hospital w/pancreatits, s/p pseudocyst\n drainage--culture + for staph. unable to wean off vent, trach'd.\n transferred here for cholangitis with hemodynamic instability requiring\n intubation/pressors, spiking temps tmax-103, currently on prophylactic\n Abx, no pressors, s/p ERCP done \n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with trach in place. Pt on 40% humidified high flow trach mask. Pt\n continues to have large amounts of oral secretions and has productive\n cough for moderate amounts of clear/white secretions through trach\n Action:\n Pt left on trach collar overnight, did not require vent support this\n shift. Frequent suctioning to clear secretions\n Response:\n Pox maintained at 96-99%, AM ABG drawn which was WNL\n Plan:\n Monitor respiratory status, maintain trach collar ? pass\n muir valve\n .H/O cholelithiasis\n Assessment:\n No c/o pain/discomfort overnight\n Action:\n ERCP done yesterday to clear stones\n Response:\n Pt remains stable, labs work improving\n Plan:\n Monitor labs, assess pt for increased pain\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 571662,
"text": "Demographics\n Day of intubation: Pt back on vent from TM\n Day of mechanical ventilation: 0\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Copious\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571786,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : T103, increased LFTs/AP, propofol gtt, prophylactic abx\n : weaned to trach collar, R SCL CVL placed, PICC d/c'd, CT abd\n : ERCP\n : started TF\n : HLIV, suctioned q1hr, sputum cx, CXR, heat rash --> miconazole,\n agitation, diaphoretic episodes (afebrile, glucose normal).\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation.\n : R-SC CVL discontinues-catheter tip sent fore culture. New L-SC\n CVL placed. Placement confirmed by CRX . CT of ABD with contrast.\n Family updated regarding POC. Plan for family meeting in the next few\n days.\n Impaired Skin Integrity\n Assessment:\n -Groin and perianal errythema, fissure near coccyx near skin folds.\n -Incontinent of large formed soft brown stool.\n Action:\n -groin and perianal area cleansed and dried thoroughly.\n -Miconazole cream/Anti-fungal barrier cream applied every 2-4 hours\n PRN.\n -Repositioned Q 2 hours.\n Response:\n -Groin and perianal with decreased errythema.\n Plan:\n -Miconazole cream/Antifungal barrier cream/M q 2-4 hours PRN.\n -Reposition every 2 hours.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n - 8 Portex Trach in place on CPAP/40%/5PEEP/10 PS.\n -Respiratory rate\n -Trach site CDI.\n Action:\n -Suctioned for small to moderate amounts of thick yellow sputum.\n -Ct PT every 2-4 hours as tolerated.\n -Sputum culture from -pending.\n -Wean to 10 PS.\n -Zosyn/Vancomycin given.\n Response:\n -LS: R+LUL Cear, diminished bibasilar.\n -Pox: 97-98%.\n Plan:\n -Aggressive pulmonary hygiene.\n -Titrate vent support as tolerated.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571792,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : T103, increased LFTs/AP, propofol gtt, prophylactic abx\n : weaned to trach collar, R SCL CVL placed, PICC d/c'd, CT abd\n : ERCP\n : started TF\n : HLIV, suctioned q1hr, sputum cx, CXR, heat rash --> miconazole,\n agitation, diaphoretic episodes (afebrile, glucose normal).\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation.\n : R-SC CVL discontinues-catheter tip sent fore culture. New L-SC\n CVL placed. Placement confirmed by CRX . CT of ABD with contrast.\n Family updated regarding POC. Plan for family meeting in the next few\n days.\n Impaired Skin Integrity\n Assessment:\n -Groin and perianal errythema, fissure near coccyx near skin folds.\n -Incontinent of large formed soft brown stool.\n Action:\n -groin and perianal area cleansed and dried thoroughly.\n -Miconazole cream/Anti-fungal barrier cream applied every 2-4 hours\n PRN.\n -Repositioned Q 2 hours.\n Response:\n -Groin and perianal with decreased errythema.\n Plan:\n -Miconazole cream/Antifungal barrier cream/M q 2-4 hours PRN.\n -Reposition every 2 hours.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n - 8 Portex Trach in place on CPAP/40%/5PEEP/10 PS.\n -Respiratory rate 12-28. Pox: 93-100%.\n -Trach site CDI.\n Action:\n -Suctioned for small to moderate amounts of thick white sputum.\n -HOB maintained between 30-45 degrees.\n -Turned q 2.\n -Mouth care performed q 4.\n -Zosyn/Vancomycin/tobramycin given.\n Response:\n -LS: R+LUL Clear, rhonchus bibasilar.\n -Pox: 93-100%.\n Plan:\n -Aggressive pulmonary hygiene.\n -Titrate vent support as tolerated.\n -Continue Zosyn/Vancomycin/Trobramycin.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n -T-Max: 99.8. Diaphoretic.\n -R-sc CVL line site with errythema at insertion site.\n -Sputum culture results pending.\n Action:\n -R-SC CVL site discontinued. Catheter tip sent for culture.\n -New L-SC CVL line placed and placement confirmed by CXR.\n -Zosyn/Vancomycin/Trobramycin given.\n -Trobramycin trough pending.\n Response:\n -Remains afebrtile.\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571793,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation.\n : R-SC CVL discontinues-catheter tip sent fore culture. New L-SC\n CVL placed. Placement confirmed by CRX . CT of ABD with contrast.\n Family updated regarding POC. Plan for family meeting in the next few\n days.\n Impaired Skin Integrity\n Assessment:\n -Groin and perianal errythema, fissure near coccyx near skin folds.\n -Incontinent of large formed soft brown stool.\n Action:\n -groin and perianal area cleansed and dried thoroughly.\n -Miconazole cream/Anti-fungal barrier cream applied every 2-4 hours\n PRN.\n -Repositioned Q 2 hours.\n Response:\n -Groin and perianal with decreased errythema.\n Plan:\n -Miconazole cream/Antifungal barrier cream/M q 2-4 hours PRN.\n -Reposition every 2 hours.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n - 8 Portex Trach in place on CPAP/40%/5PEEP/10 PS.\n -Respiratory rate 12-28. Pox: 93-100%.\n -Trach site CDI.\n Action:\n -Suctioned for small to moderate amounts of thick white sputum.\n -HOB maintained between 30-45 degrees.\n -Turned q 2.\n -Mouth care performed q 4.\n -Zosyn/Vancomycin/tobramycin given.\n Response:\n -LS: R+LUL Clear, rhonchus bibasilar.\n -Pox: 93-100%.\n Plan:\n -Aggressive pulmonary hygiene.\n -Titrate vent support as tolerated.\n -Continue Zosyn/Vancomycin/Trobramycin.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n -T-Max: 99.8. Diaphoretic.\n -R-sc CVL line site with errythema at insertion site.\n -Sputum culture results pending.\n Action:\n -R-SC CVL site discontinued. Catheter tip sent for culture.\n -New L-SC CVL line placed and placement confirmed by CXR.\n -Zosyn/Vancomycin/Trobramycin given.\n -MD Legissety notified of Vancomycin trough of 22.1.\n -Trobramycin trough pending.\n Response:\n -Remains afebrile.\n Plan:\n -Continue to follow fever curve and WBC\n -Monitor R-SC CVL site for further errythema. Monitor new L-SC CVL for\n infection.\n -Continue Zosyn/Vancomycin/Trobramycin.\n Supportive care provided to patient and family. Plan is to schedule a\n family meeting in the next few days with MD team and RN to discuss POC.\n Social work consulted.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 571989,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments: Pt also suctioned frequently for copious amt of oral\n secretions\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt weaned off sedation this morning then placed on 50% cool\n aerosol TM this afternoon tolerating well\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: plan to continue TM as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572389,
"text": "Impaired Physical Mobility\n Assessment:\n Pt with reduced mobility.\n Action:\n OOB to chair for short time, nursed side to side in bed. PT consult\n in.\n Response:\n Pt able to help with all turns, was able to stand with 2x assist, weak\n gait noted.\n Plan:\n See nursing care plan\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on CPAP/PS. Tolerated well.\n Pt has large amounts of clear white, thin secretions, requiring\n frequent suctioning.\n Action:\n Placed on trach mask at 07:00, speech valve placed also, tolerated\n well.\n Response:\n Less suctioning required during time on speech valve, no removed and\n needing Q1hr suctioning.\n Plan:\n See nursing care plan.\n Hyperglycemia\n Assessment:\n Pt with hyperglycemia.\n Action:\n Treated with standing dose of NPH and sliding scale Regular insulin.\n Response:\n Pt with moderately stable FSG this shift.\n Plan:\n See nursing care plan.\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 572394,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ UTI, VAP, bacteremia.\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. 2. Acetaminophen 3. Bisacodyl 4. Chlorhexidine Gluconate 0.12% Oral\n Rinse 5. CloniDINE 6. Famotidine\n 7. Fentanyl Patch 8. Haloperidol 9. Heparin 10. Insulin 11. Linezolid\n 12. Lidocaine 1% 13. Lorazepam\n 14. Lorazepam 15. Magnesium Sulfate 16. Metoprolol Tartrate 17.\n Miconazole 2% Cream 18. Miconazole Powder 2%\n 19. Nystatin Oral Suspension 20. Phenylephrine 21.\n Piperacillin-Tazobactam Na 22. Potassium Chloride\n 23. Potassium Chloride 24. Potassium Phosphate 25. Propofol 26. Sodium\n Chloride 0.9% Flush 27. Tobramycin\n 24 Hour Events:\n BLOOD CULTURED - At 05:30 PM\n URINE CULTURE - At 05:30 PM\n - transfused 1 unit RBC\n - decreased Haldol\n - OOB to chair\n - tolerated PMV\n - changed vanco->linezolid (pt with h/o VRE)\n Post operative day:\n HD #15, PPD #12\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:10 AM\n Tobramycin - 05:01 PM\n Linezolid - 08:15 PM\n Piperacillin/Tazobactam (Zosyn) - 11:55 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 05:57 AM\n Heparin Sodium (Prophylaxis) - 05:57 AM\n Other medications:\n Flowsheet Data as of 06:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.9\nC (98.5\n HR: 76 (68 - 79) bpm\n BP: 117/64(83) {101/54(69) - 134/73(94)} mmHg\n RR: 20 (11 - 29) insp/min\n SPO2: 97%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 69 Inch\n Total In:\n 3,556 mL\n 664 mL\n PO:\n Tube feeding:\n 2,095 mL\n 552 mL\n IV Fluid:\n 991 mL\n 111 mL\n Blood products:\n 350 mL\n Total out:\n 1,865 mL\n 415 mL\n Urine:\n 1,865 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,691 mL\n 249 mL\n Respiratory support\n O2 Delivery Device: Trach mask , T-piece\n Ventilator mode: CPAP\n Vt (Spontaneous): 351 (303 - 420) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 114\n PIP: 11 cmH2O\n SPO2: 97%\n ABG: ///28/\n Ve: 10.6 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 315 K/uL\n 9.4 g/dL\n 119 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 24 mg/dL\n 105 mEq/L\n 141 mEq/L\n 27.8 %\n 8.8 K/uL\n [image002.jpg]\n 02:41 AM\n 04:11 AM\n 06:00 AM\n 05:27 PM\n 03:29 AM\n 01:30 AM\n 03:00 AM\n 12:31 PM\n 03:18 AM\n 04:29 AM\n WBC\n 12.9\n 15.9\n 14.1\n 9.4\n 8.8\n Hct\n 32.2\n 31.6\n 25.7\n 24.6\n 23.3\n 27.8\n Plt\n 21\n 315\n Creatinine\n 0.4\n 0.9\n 1.0\n 1.2\n 1.0\n Troponin T\n <0.01\n TCO2\n 35\n 26\n Glucose\n 149\n 194\n 158\n 92\n 89\n 119\n Other labs: PT / PTT / INR:12.4/22.4/1.0, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.4 mmol/L, Albumin:3.6 g/dL, LDH:212 IU/L,\n Ca:9.1 mg/dL, Mg:2.2 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), IMPAIRED PHYSICAL MOBILITY, HYPERGLYCEMIA\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ UTI, VAP, bacteremia,\n improving.\n Neurologic: Pain controlled, Haldol TID, Ativan prn, fentanyl patch,\n d/c clonidine now that tapered\n Cardiovascular: Beta-blocker, HD stable, on Lopressor 5q6\n Pulmonary: Trach collar as tolerated, pulm toilet\n needs very frequent\n suctioning, continue to treat for VAP\n Gastrointestinal / Abdomen: TF.\n Nutrition: Tube feeding, swallow eval today\n Renal: Foley, Adequate UO\n creatinine improved.\n Hematology: Hct bumped appropriate after 1 unit blood, continue to\n follow. Monitor daily\n Endocrine: RISS, NPH 60 units SQ \n Infectious Disease: WBC down and afebrile U/A neg yesterday, GPC\n bacteremia, GNR form cath tip, GNR in sputum Cont\n Linezolid/Tobra/Zosyn. ID wants day course from (will let\n us know for sure later). Check tobra trough today.\n Lines / Tubes / Drains: Foley, G-tube, Trach, A-line, left subclavian\n central line, flexiseal\n Imaging: none\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure), Pancreatitis\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:57 AM 90 mL/hour\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Arterial Line - 07:53 AM\n Multi Lumen - 08:14 AM\n 22 Gauge - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 570207,
"text": "TITLE: SICU PROGRESS NOTE\n SICU\n HPI:\n Pt dx at outside hospital w/pancreatits, s/p pseudocyst\n drainage--culture + for staph. unable to wean off vent, trach'd.\n transferred here for cholangitis with hemodynamic instability requiring\n intubation/pressors, spiking temps tmax-103, currently on prophylactic\n Abx, no pressors, s/p ERCP\n Chief complaint:\n no complaints\n PMHx:\n DVT, HTN, Lipidemia, Hx of MI in s/p PTCA\n .\n PSH: PEG/trach\n Current medications:\n 1000 mL LR 3. 1000 mL LR 4. Acetaminophen 5. Ampicillin-Sulbactam 6.\n Bisacodyl 7. Chlorhexidine Gluconate0.12% Oral Rinse 8. Famotidine 9.\n Fentanyl Patch 10. Heparin 11. Insulin 12. Lidocaine 1% 13.\n MetRONIDAZOLE (FLagyl) 14. Miconazole 2% Cream 15. Nystatin Oral\n Suspension 16. Potassium Chloride 17. Propofol 18. Propofol 19. Sodium\n Chloride 0.9% Flush 20. Vancomycin\n 24 Hour Events:\n ERCP - At 08:30 AM\n transferred to on pre procedure for ERCP\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:57 PM\n Ampicillin/Sulbactam (Unasyn) - 04:26 AM\n Metronidazole - 04:27 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 04:00 PM\n Other medications:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 36.8\nC (98.2\n HR: 71 (68 - 90) bpm\n BP: 141/70(94) {114/56(77) - 148/82(107)} mmHg\n RR: 25 (14 - 40) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,474 mL\n 925 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,474 mL\n 925 mL\n Blood products:\n Total out:\n 1,865 mL\n 680 mL\n Urine:\n 1,865 mL\n 680 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,609 mL\n 245 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Aerosol-cool, T-piece\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 432 (432 - 432) mL\n PS : 10 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n SPO2: 97%\n ABG: 7.44/41/86/26/3\n Ve: 9.4 L/min\n PaO2 / FiO2: 215\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 316 K/uL\n 9.8 g/dL\n 135 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 3.1 mEq/L\n 9 mg/dL\n 110 mEq/L\n 145 mEq/L\n 30.2 %\n 7.8 K/uL\n [image002.jpg]\n 02:36 AM\n 02:55 AM\n 05:16 PM\n 02:58 AM\n 03:13 AM\n 02:28 AM\n 06:15 AM\n WBC\n 10.6\n 8.4\n 7.8\n Hct\n 30.3\n 28.7\n 30.2\n Plt\n 346\n 299\n 316\n Creatinine\n 0.5\n 0.3\n 0.4\n TCO2\n 29\n 29\n 25\n 29\n Glucose\n 151\n 146\n 131\n 135\n Other labs: PT / PTT / INR:15.5/24.7/1.4, ALT / AST:205/107, Alk-Phos /\n T bili:325/1.6, Amylase / Lipase:30/21, Differential-Neuts:80.5 %,\n Lymph:15.0 %, Mono:3.0 %, Eos:0.8 %, Lactic Acid:0.6 mmol/L,\n Albumin:3.0 g/dL, Ca:9.2 mg/dL, Mg:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n .H/O CHOLELITHIASIS, .H/O MYOCARDIAL INFARCTION, .H/O PANCREATITIS,\n ACUTE, .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS), IMPAIRED\n SKIN INTEGRITY\n Assessment and Plan: 42M w/ hx of pancreatits, presents w/septic\n picture, cholangitis, now s/p ERCP/stone extraction\n Neurologic: Neuro checks Q: 4 hr, off sedation, fentanyl patch\n Cardiovascular: no issues, HD stable\n Pulmonary: tolerating trach collar\n Gastrointestinal / Abdomen: resolving cholangitis, Tbili improving,\n wean antibiotics\n Nutrition: restart TFs\n Renal: Foley, adequate UOP\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: follow up cultures, wean antibiotics\n Lines / Tubes / Drains: foley, G-tube, trach, left radial a-line, right\n subclavian CVL - could DC if PIVs placed\n Wounds: none\n Imaging: none\n Fluids: LR @ 100, switch to MIVF\n Consults: General surgery\n Billing Diagnosis: Other: cholangitis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:48 PM\n Arterial Line - 03:07 AM\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570210,
"text": ".H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O cholelithiasis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572387,
"text": "Impaired Physical Mobility\n Assessment:\n Pt with reduced mobility.\n Action:\n Response:\n Plan:\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570299,
"text": ".H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt alert/appropriate. Following commands\n Tolerating High flow cool mist neb at 40%. ABG wnl\n Moderate amt of suction required for trach clear/white\n secretions\n Action:\n Turned and repositioned frequently. OOB to chair x 2hrs\n Suctioned approx Q1hr. No resp distress noted/reported\n Trach care per protocol.\n Response:\n Continues to cough up moderate amt of clear/white secretions\n O2 sats stable\n Plan:\n ? Transfer to floor if secretions diminished\n .H/O cholelithiasis\n Assessment:\n NPO. PEG tube clamped\n s/p ERCP on w/ 4mm stone removed from CBD\n No abd pain. ABD soft/distended\n LFTs trending down. Morning K-3.0\n Previous Pseudocyst was drained for 140cc\n Action:\n TF\n Replete w/ fiber started per order. Residuals monitored\n Pain monitored q4hrs . Left arm w/ Fent patch 50mcg\n IVABX admin per order\n Total of 60meqKCL IV administered. Repeat Labs drawn this\n evening\n Response:\n Tolerating TF.\n Afebrile\n No pain\n Plan:\n Continue to monitor labs and replete electrolytes PRN\n Monitor pain and response to pain management\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 570300,
"text": "Respiratory Care Service: Pt appears comfortable on a 50 % T-piece.\n Coughing persists but sxing for thin white secretions. Will monitor\n over night and leave on T-Piece as tolerated and place back on PS 8/5\n PEEP FIO2 .40 as necessary.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 570347,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont trached and on HiFlo as per Metavision. Lung sounds\n rhonchi improved with freq suct and exp mod loose off white sput. Pt\n in NARD but does cough freq. Cont HiFlo via T-piece/pulmonary toilet as\n required.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571271,
"text": "Fungal Infection, Other\n Assessment:\n Afeb, diaphoretic episodes(glucose controlled with insulin gtt),\n Action:\n Freq linen changes, meticulous skin care with antifungals\n Response:\n Continues occasional periods of diaphoresis\n Plan:\n Continue to keep pt dry\n Hyperglycemia\n Assessment:\n Blood sugars 98-198\n Action:\n Titrated insulin gtt per guideline\n Response:\n Blood sugar 130 at 0600\n Plan:\n Continue q1-2hr blood sugars\n Titrate insulin gtt with blood sugar checks\n Impaired Skin Integrity\n Assessment:\n Right elbow slightly reddedned skin intact\n Excoriated buttocks with fissure near coccyx between skin folds\n Action:\n Assessed elbow q 4 hrs\n Assessed and treaedt buttocks with antifungals\n Turned pt side to side, supine only with care as needed\n Response:\n skin remains intact on elbow\n buttocks reddened\n Plan:\n Continue to assess\n Reposition pt q 2 hrs avoid supine position\n Suggest OOB today on rounds\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on trach collar at 40-50% since 11am \n Pt desaturated x 1 with O2sat 88%\n ABG compensated resp acidosis\n Action:\n Trach suction PRN\n CPT q 4 hrs\n Response:\n Trach collar continues at 50%\n Plan:\n Continue trach suction as needed\n Continue CPT q 4 hours\n Trach care q shift and PRN\n Reposition q 2 hrs side to side\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 571780,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt remained on PSV 10/5 all shift tolerating well\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Plan\n Next 24-48 hours: plan to continue current vent support overnight as\n tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1130\n CT abdomen without incident\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571781,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : T103, increased LFTs/AP, propofol gtt, prophylactic abx\n : weaned to trach collar, R SCL CVL placed, PICC d/c'd, CT abd\n : ERCP\n : started TF\n : HLIV, suctioned q1hr, sputum cx, CXR, heat rash --> miconazole,\n agitation, diaphoretic episodes (afebrile, glucose normal).\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation. I\n Impaired Skin Integrity\n Assessment:\n -Groin and peri-anal area errythema and excoriated.\n -Flexi-seal intact with small amount of golden yellow liquid stool.\n Action:\n -Wound Care consult.\n -Miconazole cream/Anti-fungal barrier cream applied every 2-4 hours\n PRN.\n -Repositioned Q 2 from side to side.\n Response:\n -Groin and peri-anal with decreased errythema and excoriation.\n Plan:\n -Miconazole cream/Antifungal barrier cream/M q 2-4 hours PRN.\n -Reposition every 2 hours from side to side.\n -Re-consult Wound Care Nurse PRN.\n -Consider Dermatology consult if no improvement.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n -Trach on CPAP/50%/5PEEP/12 PS.\n -Trach site CDI.\n Action:\n -Suctioned for small to moderate amounts of thick yellow sputum.\n -Ct PT every 2-4 hours as tolerated.\n -Sputum culture from -pending.\n -Wean to 10 PS.\n -Zosyn/Vancomycin given.\n Response:\n -LS: R+LUL Cear, diminished bibasilar.\n -Pox: 97-98%.\n Plan:\n -Aggressive pulmonary hygiene.\n -Titrate vent support as tolerated.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571978,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and question of father with myotonic muscular dystrophy\n disorder (pt has not been tested)\n EVENTS:\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation.\n : R-SC CVL discontinued-catheter tip sent fore culture. New L-SC\n CVL placed. Placement confirmed by CRX . CT of ABD with contrast.\n Family updated regarding POC. Plan for family meeting in the next few\n days.\n Impaired Skin Integrity\n Assessment:\n -Groin and perianal errythema, fissure near coccyx near skin folds.\n -Incontinent of small amount of formed brown stool.\n Action:\n -groin and perianal area cleansed and dried thoroughly.\n -Miconazole cream/Anti-fungal barrier cream applied every 2-4 hours\n PRN.\n -Repositioned Q 2 hours.\n Response:\n -Groin and perianal with markedly decreased errythema.\n Plan:\n -Miconazole cream/Antifungal barrier cream/M q 2-4 hours PRN.\n -Reposition every 2 hours.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n - 8 Portex Trach in place on CPAP/40%/5PEEP/10 PS.\n -Respiratory rate 12-28. Pox: 93-100%.\n -Trach site CDI.\n Action:\n -Suctioned for small to moderate amounts of thick white sputum.\n -HOB maintained between 30-45 degrees.\n -Turned q 2.\n -Mouth care performed q 4.\n -Zosyn/Vancomycin/tobramycin given.\n Response:\n -LS: R+LUL Clear, rhonchus bibasilar.\n -Pox: 93-100%.\n Plan:\n -Aggressive pulmonary hygiene.\n -Titrate vent support as tolerated.\n -Continue Zosyn/Vancomycin/Trobramycin.\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Risk for Injury\n Assessment:\n Action:\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571979,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and question of father with myotonic muscular dystrophy\n disorder (pt has not been tested)\n EVENTS:\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation.\n : R-SC CVL discontinued-catheter tip sent fore culture. New L-SC\n CVL placed. Placement confirmed by CRX . CT of ABD with contrast.\n Family updated regarding POC. Plan for family meeting in the next few\n days.\n Impaired Skin Integrity\n Assessment:\n -Groin and perianal errythema, fissure near coccyx near skin folds.\n -Incontinent of small amount of formed brown stool.\n Action:\n -groin and perianal area cleansed and dried thoroughly.\n -Miconazole cream/Anti-fungal barrier cream applied every 2-4 hours\n PRN.\n -Repositioned Q 2 hours.\n Response:\n -Groin and perianal with markedly decreased errythema.\n Plan:\n -Miconazole cream/Antifungal barrier cream/M q 2-4 hours PRN.\n -Reposition every 2 hours.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n -8 Portex Trach in place 40% humidified trach collar. .\n -Respiratory rate 12-28. Pox: 94-100%.\n -Trach site CDI.\n Action:\n -Suctioned for small to moderate amounts of thick white sputum.\n -HOB maintained between 30-45 degrees.\n -Turned q 2.\n -Mouth care performed q 4.\n -Zosyn/Vancomycin/tobramycin given.\n Response:\n -LS: R+LUL Clear, rhonchus bibasilar.\n -Pox: 93-100%.\n Plan:\n -Aggressive pulmonary hygiene.\n -Titrate vent support as tolerated.\n -Continue Zosyn/Vancomycin/Trobramycin.\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Risk for Injury\n Assessment:\n Action:\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571983,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n EVENTS:\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation.\n : R-SC CVL discontinued-catheter tip sent fore culture. New L-SC\n CVL placed. Placement confirmed by CRX . CT of ABD with contrast.\n Family updated regarding POC. Plan for family meeting in the next few\n days.\n Impaired Skin Integrity\n Assessment:\n -Groin and perianal errythema, fissure near coccyx near skin folds.\n -Incontinent of small amount of formed brown stool.\n Action:\n -groin and perianal area cleansed and dried thoroughly.\n -Miconazole cream/Anti-fungal barrier cream applied every 2-4 hours\n PRN.\n -Repositioned Q 2 hours.\n Response:\n -Groin and perianal with markedly decreased errythema.\n Plan:\n -Miconazole cream/Antifungal barrier cream/M q 2-4 hours PRN.\n -Reposition every 2 hours.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n -8 Portex Trach in place 40% humidified trach collar. .\n -Respiratory rate 19-22. Pox: 94-100%.\n -Trach site CDI.\n Action:\n -Suctioned for small to moderate amounts of thick white sputum.\n -HOB maintained between 30-45 degrees.\n -Turned q 2.\n -Mouth care performed q 4.\n -Zosyn/Vancomycin/tobramycin given.\n Response:\n -LS: R+LUL Clear, rhonchus bibasilar.\n -Pox: 94-100%.\n Plan:\n -Aggressive pulmonary hygiene.\n -Continue trach collar as tolerated.\n -Continue Zosyn/Vancomycin/Trobramycin.\n Hyperglycemia\n Assessment:\n -FS: 126-144.\n -Continue on NPH and Regular insulin sliding scale.\n -Replete with fiber restarted. Tolerating well with no residuals. Goal\n 90cc.\n Action:\n -BS checked every 6 hours.\n -TF\ns advanced as tolerated.\n Response:\n -Good control of blood sugars on NPH and Regular insulin sliding scale.\n Plan:\n -Hyperglycemia resolved.\n -Refer to Care Plan.\n Risk for Injury\n Assessment:\n -Agitated at times and pulling at lines.\n Action:\n -Sedated with Propofol and Ativan.\n -PO Haldol and Clonidine given with good effect.\n -Bilateral soft hand restraints.\n -Pt frequently reminded not to pull at lines-takes direction well.\n Response:\n -Propofol stopped. Pt A+Ox1-2. Resting comfortably in bed.\n -Bilateral soft hand restraints off.\n Plan:\n -Continue Haldol and Clonidine for agitation.\n -Provide patient with direction PRN.\n -Provide supportive care to patient and family.\n Spoke with MD discussed need for family meeting. Social work\n consulted.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571984,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n EVENTS:\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation.\n : R-SC CVL discontinued-catheter tip sent fore culture. New L-SC\n CVL placed. Placement confirmed by CRX . CT of ABD with contrast.\n Family updated regarding POC. Plan for family meeting in the next few\n days.\n Impaired Skin Integrity\n Assessment:\n -Groin and perianal errythema, fissure near coccyx near skin folds.\n -Incontinent of small amount of formed brown stool.\n Action:\n -groin and perianal area cleansed and dried thoroughly.\n -Miconazole cream/Anti-fungal barrier cream applied every 2-4 hours\n PRN.\n -Repositioned Q 2 hours.\n Response:\n -Groin and perianal with markedly decreased errythema.\n Plan:\n -Miconazole cream/Antifungal barrier cream/M q 2-4 hours PRN.\n -Reposition every 2 hours.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n -8 Portex Trach in place 40% humidified trach collar. .\n -Respiratory rate 19-22. Pox: 94-100%.\n -Trach site CDI.\n Action:\n -Suctioned for small to moderate amounts of thick white sputum.\n -HOB maintained between 30-45 degrees.\n -Turned q 2.\n -Mouth care performed q 4.\n -Zosyn/Vancomycin/tobramycin given.\n Response:\n -LS: R+LUL Clear, rhonchus bibasilar.\n -Pox: 94-100%.\n Plan:\n -Aggressive pulmonary hygiene.\n -Continue trach collar as tolerated.\n -Continue Zosyn/Vancomycin/Trobramycin.\n Hyperglycemia\n Assessment:\n -FS: 126-144.\n -Continue on NPH and Regular insulin sliding scale.\n -Replete with fiber restarted. Tolerating well with no residuals. Goal\n 90cc.\n Action:\n -BS checked every 6 hours.\n -TF\ns advanced as tolerated.\n Response:\n -Good control of blood sugars on NPH and Regular insulin sliding scale.\n Plan:\n -Hyperglycemia resolved.\n -Refer to Care Plan.\n Risk for Injury\n Assessment:\n -Agitated at times and pulling at lines.\n Action:\n -Sedated with Propofol and Ativan.\n -PO Haldol and Clonidine given with good effect.\n -Bilateral soft hand restraints.\n -Pt frequently reminded not to pull at lines-takes direction well.\n Response:\n -Propofol stopped. Pt A+Ox1-2. Resting comfortably in bed.\n -Bilateral soft hand restraints off.\n Plan:\n -Continue Haldol and Clonidine for agitation.\n -Provide patient with direction PRN.\n -Provide supportive care to patient and family.\n Spoke with MD discussed need for family meeting.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-09 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 571072,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Supra-sternal retractions\n Assessment of breathing comfort: Pt acknowledges dyspnea\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt having frequent reactive coughing with marked retractions over\n sternal notch\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 570444,
"text": "Respiratory Care Service: Pt remains w/ an 8.0 Portex Trach in place\n and on a 40 % T-Piece. Doing well w/ a RR 20-30 BPM and an SPO2 97-100\n %. Persistent coughing due to lge amts of thin white sputum. Will\n continue to monitor in SICU due to amt of secretions.\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-11 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571443,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n hypotension\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. Acetaminophen 3. Bisacodyl 4. Chlorhexidine Gluconate 0.12% Oral\n Rinse 5. Famotidine 6. Fentanyl Patch\n 7. Haloperidol 8. Haloperidol 9. Heparin 10. Insulin 11. Lidocaine 1%\n 12. Lorazepam 13. Magnesium Sulfate\n 14. Miconazole 2% Cream 15. Miconazole Powder 2% 16. Nystatin Oral\n Suspension 17. Piperacillin-Tazobactam Na 18. Potassium Chloride 19.\n Potassium Phosphate\n 24 Hour Events:\n ARTERIAL LINE - STOP 10:56 AM\n : d/c'd vanc, d/c'd insulin gtt -> NPH 50\" + RISS, d/c'd aline\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:30 AM\n Piperacillin/Tazobactam (Zosyn) - 11:38 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 06:06 PM\n Heparin Sodium (Prophylaxis) - 06:06 PM\n Other medications:\n Flowsheet Data as of 04:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37.1\nC (98.8\n HR: 133 (74 - 133) bpm\n BP: 132/58(78) {82/45(47) - 148/111(116)} mmHg\n RR: 27 (13 - 40) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n Total In:\n 3,211 mL\n 425 mL\n PO:\n Tube feeding:\n 2,189 mL\n 382 mL\n IV Fluid:\n 962 mL\n 42 mL\n Blood products:\n Total out:\n 1,475 mL\n 140 mL\n Urine:\n 1,475 mL\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,736 mL\n 285 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n FiO2: 50%\n SPO2: 98%\n ABG: 7.43/49/84./34/6\n PaO2 / FiO2: 168\n Physical Examination\n General Appearance: Anxious, Cachectic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: at bilateral bases), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: Rash: under arms, (Incision: Clean / Dry / Intact, Erythema)\n Neurologic: (Awake / Alert / Oriented: x 1), (Responds to: Verbal\n stimuli, Tactile stimuli, Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 484 K/uL\n 10.7 g/dL\n 149 mg/dL\n 0.4 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 12 mg/dL\n 99 mEq/L\n 141 mEq/L\n 32.2 %\n 12.9 K/uL\n [image002.jpg]\n 04:11 AM\n 05:35 PM\n 02:48 AM\n 03:27 AM\n 04:28 AM\n 05:19 AM\n 06:00 AM\n 08:00 AM\n 10:00 AM\n 02:41 AM\n WBC\n 12.8\n 10.8\n 11.3\n 12.9\n Hct\n 27.3\n 29.6\n 31.0\n 32.2\n Plt\n 344\n 379\n 424\n 484\n Creatinine\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n TCO2\n 24\n 34\n Glucose\n 180\n 207\n 108\n 133\n 130\n 141\n 105\n 149\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:76//<0.01, ALT / AST:32/22, Alk-Phos / T bili:130/0.6, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.8 mmol/L, Albumin:3.1 g/dL, Ca:9.9 mg/dL,\n Mg:2.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n FUNGAL INFECTION, OTHER, HYPERGLYCEMIA, DIARRHEA, .H/O RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), .H/O CHOLELITHIASIS, .H/O MYOCARDIAL\n INFARCTION, .H/O PANCREATITIS, ACUTE, .H/O ABDOMINAL PAIN (INCLUDING\n ABDOMINAL TENDERNESS), IMPAIRED SKIN INTEGRITY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Haldol TID & prn,\n Ativan, fentanyl patch, pt clearly agitated receiving boluses of ativan\n and haldol\n Cardiovascular: Beta-blocker, sinus tachycardia, searching for\n underlying cause. ecg show sinus tachycardia, drawing cardiac markers,\n increasing sedation, running blood gas\n Pulmonary: Trach, on trach collar, continue pulmonary toilet\n Gastrointestinal / Abdomen: continue tube feeding through Gtube\n Nutrition: Tube feeding, tube feedings are at goal\n Renal: Foley, Adequate UO, Foley, adequate UOP, Cr stable\n Hematology: Serial Hct, hct stable\n Endocrine: RISS, converted to NPH insulin 50units q12h with RISS for\n backup, bs-100-150\n Infectious Disease: Check cultures, f/u cx, Continuing Zosyn\n Lines / Tubes / Drains: Foley, G-tube, Trach, R SCL CVL, Flexiseal\n Wounds: Dry dressings, trach site\n Imaging: CXR today\n Fluids: no ivf\n Consults: General surgery\n Billing Diagnosis: Sepsis\n ICU Care\n Nutrition:\n Replete (Full) - 11:32 PM 90 mL/hour\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571566,
"text": "Altered mental status (not Delirium)\n Assessment:\n restlessness associated with tachycardia and diaphoresis\n no further benzo medications given\n picture complicated by temp to102.8 and diaphoreses associated with\n tylenol and motrin administration\n Action:\n haldol given as ordered\n Tylenol and motrin as ordered\n frequent cold compresses and position changes\n MD Ballrad informed of questionable signs of withdrawal vs restlessness\n Response:\n patient initially calmer, not crawling out of bed or pulling at lines\n followed by restlessness bordering on agitation with legs thrown\n over bed and trying repetitively to sit up\n MD ordered no benzo at this time\n PLAN:\n cont to assess for signs of withdrawal from medications\n haldol around the clock as ordered\n continue to assess restlessness vs withdrawal signs\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n febrile to 102.6 rectally\n diaphoretic\n restless\n tolerating trach collar with minimal secretions\n Action:\n Tylenol given\n ibuprofen given\n pan cultured\n suctioned prn\n Response:\n remains febrile\n diaphoretic\n remains on trach collar\n Plan:\n cont to assess temperature curve\n Tylenol prn\n Question further dosing of motrin if working to suppress temperature\n await culture results\n see nursing care plan\n Fungal Infection, Other\n Assessment:\n pain fungal area to buttocks\n Action:\n moisture barrier cream with nystatin applied\n frequent repositioning\n patient encouraged to stay on side\n Response:\n no worsening of buttocks rash\n Plan:\n cont antifungal barrier cream with nystatin powder\n reposition frequently\n encourage patient to stay on side\n"
},
{
"category": "Rehab Services",
"chartdate": "2140-04-14 00:00:00.000",
"description": "Passy Muir Speaking Valve Eval /Dispense",
"row_id": 572157,
"text": "TITLE: PASSY-MUIR VALVE EVALUATION / DISPENSE\n HISTORY:\n Thank you for referring this 42 year old man who initially presented to\n Hospital with abdominal pain, nausea and vomiting on .\n He was treated with fluid and sent home. He subsequently returned to\n hospital with the same complaint with worsening symptoms.\n Symptoms were worse with eating. CT at and laboratory values\n suggested pancreatitis and OSH records suggest choledocholithiasis on\n initial CT. Pseudocyst was also identified. Hospital course complicated\n with possible over medication with pain medication and subsequent\n intubation, eventually leading to tracheostomy. Hospital course also\n include an episode of atrial flutter. A percutaneous G tube and IR\n drainage of the pancreatic pseudocyst yielding staph species. The\n patient received TPN and then a G tube was placed . Due to\n recurrent fevers and a failure to progress the patient was transferred\n to on . He's now s/p ERCP, sphincterotomy, stone\n extraction, now w/ bacteremia, UTI, VAP. Pt has been tolerating trials\n of trach collar, but remains on vent part time. We were consulted to\n evaluate for Passy Muir Speaking Valve placement. Per discussion with\n RT, plan is for PMV to be tried while on trach collar today.\n PMH\n DVT Right\n NIDDM\n hypertension\n Hyperlipidemia\n CAD ?\n TRACH TYPE:\n Portex #8 blue line, cuffed\n SECRETIONS / ABILITY TO HANDLE CUFF DEFLATION:\n Pt was just suctioned tracheally by RT prior to my arrival in the room,\n as he was transitioned from vent to trach collar. RT deflated cuff and\n pt produced strong cough with return of thick white secretions through\n trach tube. RR stabilized between 25-29 and O2 satable at 96=97%.\n PMV TOLERANCE / VOCAL QUALITY / O2 SATS:\n PMV placed with ease. Tracheal manometer pressures were WNL during\n resting breathing (+/- 10 cm H20). O2 sats stable at 96%+ and RR\n maintained in high 20s. Pt produced weak but audible and clear voicing\n which sounds close to normal per pt. Oriented x3. Follows commands.\n Language fluent but limited by breath support. Pt denied sensation of\n difficulty inhaling/exhaling with PMV in place. No audible rush of air\n on removal.\n SUMMARY:\n Pt tolerating PMV on trach collar without incident. Currently has been\n wearing for 10+ minutes and pt states, \"Can I leave it on?\" when asked\n how he feels about it. Signs posted and PMV left in room for wear at\n RN/RT discretion, per the recommendations below. Please when\n MD team is ready for pt to re-initiate PO diet and green dye swallow\n evaluation can be performed.\n RECOMMENDATIONS:\n 1. ALWAYS DEFLATE CUFF PRIOR TO PLACING THE PASSY-MUIR VALVE!\n 2. Monitor O2 Sats / respiration while valve is in place.\n 3. Do not allow the patient to sleep with the valve in place.\n 4. Once the patient is taking PO's, please deflate the cuff\n and place the PMV for eating and drinking. Keep NPO pending\n green dye swallowing evaluation.\n 5. PMV wear schedule is up to the discretion of the\n nurse and/or respiratory therapist.\n These recommendations were shared with the patient, nurse and medical\n team.\n M.S., CCC-SLP\n Pager # \n Face time: 12:00-12:10\n Total time: 45 minutes\n"
},
{
"category": "Nutrition",
"chartdate": "2140-04-15 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 572351,
"text": "Subjective\n patient in with RN\n Objective\n Pertinent medications: NS @ 10ml/hr, NPH 60 units q 12hrs, RISS, ABX,\n Famotidine, Heparin, SS lytes\n Labs:\n Value\n Date\n Glucose\n 119 mg/dL\n 04:29 AM\n Glucose Finger Stick\n 135\n 10:00 AM\n BUN\n 24 mg/dL\n 04:29 AM\n Creatinine\n 1.0 mg/dL\n 04:29 AM\n Sodium\n 141 mEq/L\n 04:29 AM\n Potassium\n 3.6 mEq/L\n 04:29 AM\n Chloride\n 105 mEq/L\n 04:29 AM\n TCO2\n 28 mEq/L\n 04:29 AM\n PO2 (arterial)\n 114 mm Hg\n 03:00 AM\n PCO2 (arterial)\n 39 mm Hg\n 03:00 AM\n pH (arterial)\n 7.42 units\n 03:00 AM\n pH (urine)\n 7.0 units\n 05:31 PM\n CO2 (Calc) arterial\n 26 mEq/L\n 03:00 AM\n Albumin\n 3.6 g/dL\n 03:29 AM\n Calcium non-ionized\n 9.1 mg/dL\n 04:29 AM\n Phosphorus\n 2.8 mg/dL\n 04:29 AM\n Ionized Calcium\n 1.24 mmol/L\n 04:11 AM\n Magnesium\n 2.2 mg/dL\n 04:29 AM\n ALT\n 30 IU/L\n 03:29 AM\n Alkaline Phosphate\n 136 IU/L\n 03:29 AM\n AST\n 25 IU/L\n 03:29 AM\n Amylase\n 24 IU/L\n 02:48 AM\n Total Bilirubin\n 0.8 mg/dL\n 03:29 AM\n Triglyceride\n 440 mg/dL\n 09:01 PM\n WBC\n 8.8 K/uL\n 04:29 AM\n Hgb\n 9.4 g/dL\n 04:29 AM\n Hematocrit\n 27.8 %\n 04:29 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feeding: Replete with Fiber @ 90ml/hr\n GI: (+) large soft bm \n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropiate:\n Multivitamin / Mineral supplement:\n Check chemistry 10 panel daily\n Comments:\n"
},
{
"category": "Nutrition",
"chartdate": "2140-04-15 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 572353,
"text": "Subjective\n patient in with RN\n Objective\n Pertinent medications: NS @ 10ml/hr, NPH 60 units q 12hrs, RISS, ABX,\n Famotidine, Heparin, SS lytes\n Labs:\n Value\n Date\n Glucose\n 119 mg/dL\n 04:29 AM\n Glucose Finger Stick\n 135\n 10:00 AM\n BUN\n 24 mg/dL\n 04:29 AM\n Creatinine\n 1.0 mg/dL\n 04:29 AM\n Sodium\n 141 mEq/L\n 04:29 AM\n Potassium\n 3.6 mEq/L\n 04:29 AM\n Chloride\n 105 mEq/L\n 04:29 AM\n TCO2\n 28 mEq/L\n 04:29 AM\n PO2 (arterial)\n 114 mm Hg\n 03:00 AM\n PCO2 (arterial)\n 39 mm Hg\n 03:00 AM\n pH (arterial)\n 7.42 units\n 03:00 AM\n pH (urine)\n 7.0 units\n 05:31 PM\n CO2 (Calc) arterial\n 26 mEq/L\n 03:00 AM\n Albumin\n 3.6 g/dL\n 03:29 AM\n Calcium non-ionized\n 9.1 mg/dL\n 04:29 AM\n Phosphorus\n 2.8 mg/dL\n 04:29 AM\n Ionized Calcium\n 1.24 mmol/L\n 04:11 AM\n Magnesium\n 2.2 mg/dL\n 04:29 AM\n ALT\n 30 IU/L\n 03:29 AM\n Alkaline Phosphate\n 136 IU/L\n 03:29 AM\n AST\n 25 IU/L\n 03:29 AM\n Amylase\n 24 IU/L\n 02:48 AM\n Total Bilirubin\n 0.8 mg/dL\n 03:29 AM\n Triglyceride\n 440 mg/dL\n 09:01 PM\n WBC\n 8.8 K/uL\n 04:29 AM\n Hgb\n 9.4 g/dL\n 04:29 AM\n Hematocrit\n 27.8 %\n 04:29 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feeding: Replete with Fiber @ 90ml/hr\n GI: (+) large soft bm \n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n 42 YO male w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH,\n s/p trach/PEG, treated for sepsis cholangitis, s/p ERCP,\n sphincterotomy, stone extraction, now w/ UTI, VAP, bacteremia,\n improving. Tube feeding running at goal via PEG; tolerating well \n RN notes. Patient seen by SLP this AM, recommended NPO and video\n swallow evaluation, patient declined video swallow evaluation. SLP\n plans to follow up next week. BS being managed with 60 units of NPH\n + RISS.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: Continue current tube\n feeding\n Check residuals; hold if greater than 200ml\n Multivitamin / Mineral supplement: via tube feeding\n Check chemistry 10 panel daily\n Continue tight BS management\n Follow up with SLP next week\n Will follow\n page if questions *\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571560,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n febrile to 102.6 rectally\n diaphoretic\n restless\n tolerating trach collar with minimal secretions\n Action:\n Tylenol given\n ibuprofen given\n pan cultured\n suctioned prn\n Response:\n remains febrile\n diaphoretic\n remains on trach collar\n Plan:\n cont to assess temperature curve\n Tylenol prn\n Question further dosing of motrin if working to suppress temperature\n await culture results\n see nursing care plan\n Fungal Infection, Other\n Assessment:\n pain fungal area to buttocks\n Action:\n moisture barrier cream with nystatin applied\n frequent repositioning\n patient encouraged to stay on side\n Response:\n no worsening of buttocks rash\n Plan:\n cont antifungal barrier cream with nystatin powder\n reposition frequently\n encourage patient to stay on side\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 572326,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ UTI, VAP, bacteremia.\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. 2. Acetaminophen 3. Bisacodyl 4. Chlorhexidine Gluconate 0.12% Oral\n Rinse 5. CloniDINE 6. Famotidine\n 7. Fentanyl Patch 8. Haloperidol 9. Heparin 10. Insulin 11. Linezolid\n 12. Lidocaine 1% 13. Lorazepam\n 14. Lorazepam 15. Magnesium Sulfate 16. Metoprolol Tartrate 17.\n Miconazole 2% Cream 18. Miconazole Powder 2%\n 19. Nystatin Oral Suspension 20. Phenylephrine 21.\n Piperacillin-Tazobactam Na 22. Potassium Chloride\n 23. Potassium Chloride 24. Potassium Phosphate 25. Propofol 26. Sodium\n Chloride 0.9% Flush 27. Tobramycin\n 24 Hour Events:\n BLOOD CULTURED - At 05:30 PM\n URINE CULTURE - At 05:30 PM\n - transfused 1 unit RBC\n - decreased Haldol\n - OOB to chair\n - tolerated PMV\n - changed vanco->linezolid (pt with h/o VRE)\n Post operative day:\n HD #15, PPD #12\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:10 AM\n Tobramycin - 05:01 PM\n Linezolid - 08:15 PM\n Piperacillin/Tazobactam (Zosyn) - 11:55 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 05:57 AM\n Heparin Sodium (Prophylaxis) - 05:57 AM\n Other medications:\n Flowsheet Data as of 06:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.9\nC (98.5\n HR: 76 (68 - 79) bpm\n BP: 117/64(83) {101/54(69) - 134/73(94)} mmHg\n RR: 20 (11 - 29) insp/min\n SPO2: 97%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 69 Inch\n Total In:\n 3,556 mL\n 664 mL\n PO:\n Tube feeding:\n 2,095 mL\n 552 mL\n IV Fluid:\n 991 mL\n 111 mL\n Blood products:\n 350 mL\n Total out:\n 1,865 mL\n 415 mL\n Urine:\n 1,865 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,691 mL\n 249 mL\n Respiratory support\n O2 Delivery Device: Trach mask , T-piece\n Ventilator mode: CPAP\n Vt (Spontaneous): 351 (303 - 420) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 114\n PIP: 11 cmH2O\n SPO2: 97%\n ABG: ///28/\n Ve: 10.6 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 315 K/uL\n 9.4 g/dL\n 119 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 24 mg/dL\n 105 mEq/L\n 141 mEq/L\n 27.8 %\n 8.8 K/uL\n [image002.jpg]\n 02:41 AM\n 04:11 AM\n 06:00 AM\n 05:27 PM\n 03:29 AM\n 01:30 AM\n 03:00 AM\n 12:31 PM\n 03:18 AM\n 04:29 AM\n WBC\n 12.9\n 15.9\n 14.1\n 9.4\n 8.8\n Hct\n 32.2\n 31.6\n 25.7\n 24.6\n 23.3\n 27.8\n Plt\n 21\n 315\n Creatinine\n 0.4\n 0.9\n 1.0\n 1.2\n 1.0\n Troponin T\n <0.01\n TCO2\n 35\n 26\n Glucose\n 149\n 194\n 158\n 92\n 89\n 119\n Other labs: PT / PTT / INR:12.4/22.4/1.0, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.4 mmol/L, Albumin:3.6 g/dL, LDH:212 IU/L,\n Ca:9.1 mg/dL, Mg:2.2 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), IMPAIRED PHYSICAL MOBILITY, HYPERGLYCEMIA\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ UTI, VAP, bacteremia,\n improving.\n Neurologic: Pain controlled, Haldol TID, Ativan prn, fentanyl patch,\n d/c clonidine now that tapered\n Cardiovascular: Beta-blocker, HD stable, on Lopressor 5q6\n Pulmonary: Trach collar as tolerated, pulm toilet\n needs very frequent\n suctioning, continue to treat for VAP\n Gastrointestinal / Abdomen: TF.\n Nutrition: Tube feeding, swallow eval today\n Renal: Foley, Adequate UO\n Hematology: Hct bumped appropriate after 1 unit blood, continue to\n follow. Monitor daily\n Endocrine: RISS, NPH 60 units SQ \n Infectious Disease: WBC down and afebrile U/A neg yesterday, GPC\n bacteremia, GNR form cath tip, GNR in sputum Cont\n Linezolid/Tobra/Zosyn. ID wants day course from (will let\n us know for sure later). Check tobra trough today.\n Lines / Tubes / Drains: Foley, G-tube, Trach, A-line, left subclavian\n central line, flexiseal\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure), Pancreatitis\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:57 AM 90 mL/hour\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Arterial Line - 07:53 AM\n Multi Lumen - 08:14 AM\n 22 Gauge - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-11 00:00:00.000",
"description": "Intensivist Note",
"row_id": 571532,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n hypotension\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. Acetaminophen 3. Bisacodyl 4. Chlorhexidine Gluconate 0.12% Oral\n Rinse 5. Famotidine 6. Fentanyl Patch 7. Haloperidol 9. Heparin 10.\n Insulin 11. Lidocaine 1% 12. Lorazepam 13. Magnesium Sulfate 15.\n Miconazole Powder 2% 16. Nystatin Oral Suspension 17.\n Piperacillin-Tazobactam Na\n 24 Hour Events:\n ARTERIAL LINE - STOP 10:56 AM\n : d/c'd vanc, d/c'd insulin gtt -> NPH 50\" + , d/c'd aline\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:30 AM\n Piperacillin/Tazobactam (Zosyn) - 11:38 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 06:06 PM\n Heparin Sodium (Prophylaxis) - 06:06 PM\n Other medications:\n Flowsheet Data as of 04:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37.1\nC (98.8\n HR: 133 (74 - 133) bpm\n BP: 132/58(78) {82/45(47) - 148/111(116)} mmHg\n RR: 27 (13 - 40) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n Total In:\n 3,211 mL\n 425 mL\n PO:\n Tube feeding:\n 2,189 mL\n 382 mL\n IV Fluid:\n 962 mL\n 42 mL\n Blood products:\n Total out:\n 1,475 mL\n 140 mL\n Urine:\n 1,475 mL\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,736 mL\n 285 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n FiO2: 50%\n SPO2: 98%\n ABG: 7.43/49/84 /34/6\n PaO2 / FiO2: 168\n Physical Examination\n General Appearance: Anxious, Cachectic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular),\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral: , Diminished: at bilateral bases)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: Rash: under arms, (Incision: Clean / Dry / Intact, Erythema)\n Neurologic: (Awake / Alert / Oriented: x 1), (Responds to: Verbal\n stimuli, Tactile stimuli, Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 484 K/uL\n 10.7 g/dL\n 149 mg/dL\n 0.4 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 12 mg/dL\n 99 mEq/L\n 141 mEq/L\n 32.2 %\n 12.9 K/uL\n [image002.jpg]\n 04:11 AM\n 05:35 PM\n 02:48 AM\n 03:27 AM\n 04:28 AM\n 05:19 AM\n 06:00 AM\n 08:00 AM\n 10:00 AM\n 02:41 AM\n WBC\n 12.8\n 10.8\n 11.3\n 12.9\n Hct\n 27.3\n 29.6\n 31.0\n 32.2\n Plt\n 344\n 379\n 424\n 484\n Creatinine\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n TCO2\n 24\n 34\n Glucose\n 180\n 207\n 108\n 133\n 130\n 141\n 105\n 149\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:76//<0.01, ALT / AST:32/22, Alk-Phos / T bili:130/0.6, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.8 mmol/L, Albumin:3.1 g/dL, Ca:9.9 mg/dL,\n Mg:2.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n FUNGAL INFECTION, OTHER, HYPERGLYCEMIA, DIARRHEA, .H/O RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), .H/O CHOLELITHIASIS, .H/O MYOCARDIAL\n INFARCTION, .H/O PANCREATITIS, ACUTE, .H/O ABDOMINAL PAIN (INCLUDING\n ABDOMINAL TENDERNESS), IMPAIRED SKIN INTEGRITY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Haldol TID & prn,\n increase fentanyl patch, pt clearly agitated receiving boluses of\n ativan (15 mg total without effect) and haldol, change haldol back to\n previous dose, start clonidine today, check ammonia.\n Cardiovascular: Beta-blocker, sinus tachycardia, searching for\n underlying cause. ecg show sinus tachycardia, drawing cardiac markers,\n increasing sedation, check arterial blood gas, keep prn metoprolol\n Pulmonary: Trach, on trach collar, continue pulmonary toilet, check CXR\n today\n Gastrointestinal / Abdomen: continue tube feeding through Gtube, serial\n abd exams, check ammonia level\n Nutrition: Tube feeding at goal\n Renal: Foley, Adequate UO, Cr stable\n Hematology: Hct relatively unchanged\n Endocrine: , converted to NPH insulin 50units q12h with for\n backup, bs-100-150\n Infectious Disease: Check cultures, Continuing Zosyn, wbc increasing\n but afebrile, may need to restart Vanco, send UA and sputum for culture\n and gram stain today.\n Lines / Tubes / Drains: Foley, G-tube, Trach, R SCL CVL, Flexiseal\n Wounds: Dry dressings, trach site\n Imaging: CXR today\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: Sepsis , Agitation\n ICU Care\n Nutrition:\n Replete (Full) - 11:32 PM 90 mL/hour\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: SICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Nutrition",
"chartdate": "2140-04-12 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 571763,
"text": "Objective\n Current Wt: 84.5kg\n Pertinent medications: Propofol drip, Phenylephrine, lactated ringers\n @100cc/hr, NPH insulin, RISS, ABx, pepcid, heparin, others noted\n Labs:\n Value\n Date\n Glucose\n 158 mg/dL\n 03:29 AM\n Glucose Finger Stick\n 185\n 10:00 AM\n BUN\n 23 mg/dL\n 03:29 AM\n Creatinine\n 0.9 mg/dL\n 03:29 AM\n Sodium\n 141 mEq/L\n 03:29 AM\n Potassium\n 4.0 mEq/L\n 03:29 AM\n Chloride\n 99 mEq/L\n 03:29 AM\n TCO2\n 32 mEq/L\n 03:29 AM\n PO2 (arterial)\n 81. mm Hg\n 04:11 AM\n PCO2 (arterial)\n 50 mm Hg\n 04:11 AM\n pH (arterial)\n 7.44 units\n 04:11 AM\n pH (urine)\n 8.0 units\n 08:05 AM\n CO2 (Calc) arterial\n 35 mEq/L\n 04:11 AM\n Albumin\n 3.6 g/dL\n 03:29 AM\n Calcium non-ionized\n 9.8 mg/dL\n 03:29 AM\n Phosphorus\n 5.0 mg/dL\n 03:29 AM\n Ionized Calcium\n 1.24 mmol/L\n 04:11 AM\n Magnesium\n 2.3 mg/dL\n 03:29 AM\n ALT\n 30 IU/L\n 03:29 AM\n Alkaline Phosphate\n 136 IU/L\n 03:29 AM\n AST\n 25 IU/L\n 03:29 AM\n Amylase\n 24 IU/L\n 02:48 AM\n Total Bilirubin\n 0.8 mg/dL\n 03:29 AM\n Triglyceride\n 440 mg/dL\n 09:01 PM\n Current diet order / nutrition support: Tube Feeds: off\n GI: abdomen soft, +bowel sounds\n Assessment of Nutritional Status\n 42 y.o. M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction. Patient has been receiving tube feeds for nutrition\n support while intubated and sedated on propofol. Tube feeds are\n currently off for abd CT and hypotension. Team would like to hold off\n on tube feeds until patient if weaned off pressor support. Will\n provide recs below for tube feed goals with and without propofol drip\n on.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) If propofol drip continues, rec Tube feed goal of Replete with\n fiber @ 80cc/hr.\n 2) Once propofol is off, rec Replete with fiber @90cc/hr\n (2160kcals, 134g protein) to meet 100% of estimated needs.\n 3) Monitor lytes and replete as needed.\n Following, please page with any questions. #\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-07 00:00:00.000",
"description": "Intensivist Note",
"row_id": 570654,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n respiratory compromise\n PMHx:\n DVT, HTN, hyperlipidemia, CAD s/p MI in \n Current medications:\n . IV access: Temporary central access (ICU) Location: Right Subclavian,\n Date inserted: Order date: @ 0837 18. Lidocaine 1% 3-5\n mL IH Q4-6 HRS PRN Order date: @ 1854\n 2. 1000 mL LR Bolus 1000 ml Over 15 mins Order date: @ 1746 19.\n Lorazepam 1-2 mg IV ONCE Duration: 1 Doses Order date: @ 0503\n 3. 1000 mL LR Bolus 1000 ml Over 15 mins Order date: @ 2126 20.\n Lorazepam 1 mg IV ONCE Duration: 1 Doses Order date: @ 1001\n 4. 1000 mL LR Bolus 1000 ml Over 15 mins Order date: @ 2351 21.\n Lorazepam 1 mg IV ONCE Duration: 1 Doses Order date: @ 1029\n 5. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308 22.\n Lorazepam 2-4 mg IV Q4H:PRN Order date: @ \n 6. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139 23.\n Magnesium Sulfate IV Sliding Scale Order date: @ 0234\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1119 24. Miconazole Powder 2% 1 Appl TP TID:PRN Order date: @\n 1255\n 8. CloniDINE 0.2 mg PO TID Order date: @ 1714 25. Nystatin Oral\n Suspension 5 mL PO QID:PRN Order date: @ 0555\n 9. Famotidine 20 mg IV Q12H Order date: @ 0419 26. Phenylephrine\n 0.5-5 mcg/kg/min IV DRIP INFUSION\n maintain MAP>60 Order date: @ 2037\n 10. Fentanyl Citrate 25-50 mcg IV ONCE Duration: 1 Doses Order date:\n @ 1056 27. Piperacillin-Tazobactam Na 4.5 gm IV ONCE Duration: 1\n Doses Order date: @ 1209\n 11. Fentanyl Citrate 25-100 mcg IV ONCE Duration: 1 Doses Order date:\n @ 28. Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date:\n @ 1209\n 12. Fentanyl Patch 50 mcg/hr TP Q72H Order date: @ 0139 29.\n Potassium Chloride PO Sliding Scale Duration: 24 Hours\n please administer using 20 meq of KCl packets per peg tube. Order\n date: @ 0844\n 13. Haloperidol 1-2 mg IV ONCE Duration: 1 Doses Order date: @\n 0818 30. Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 0647\n 14. Haloperidol 1 mg IV ONCE Duration: 1 Doses Order date: @ 1001\n 31. Propofol 5-60 mcg/kg/min IV DRIP INFUSION Order date: @ 2052\n 15. Haloperidol 2 mg PO TID:PRN\n through G tube Order date: @ 1032 32. Sodium Chloride 0.9% Flush\n 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 0837\n 16. Heparin 5000 UNIT SC BID Order date: @ 0139 33. Vancomycin\n 1000 mg IV ONCE Duration: 1 Doses Order date: @ 1236\n 17. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0139 34. Vancomycin 1000 mg IV\n Q 12H Order date: @ 1746\n 24 Hour Events:\n ARTERIAL LINE - START 04:50 PM\n ARTERIAL LINE - STOP 06:53 PM\n PAN CULTURE - At 09:00 PM\n ARTERIAL LINE - START 09:27 PM\n FEVER - 102.6\nF - 08:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 03:59 AM\n Ampicillin/Sulbactam (Unasyn) - 10:00 AM\n Vancomycin - 09:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 09:20 AM\n Haloperidol (Haldol) - 10:18 AM\n Famotidine (Pepcid) - 06:56 PM\n Heparin Sodium (Prophylaxis) - 06:56 PM\n Fentanyl - 07:45 PM\n Other medications:\n Flowsheet Data as of 04:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.2\nC (102.6\n T current: 38.1\nC (100.6\n HR: 100 (69 - 142) bpm\n BP: 116/58(77) {79/37(46) - 139/77(126)} mmHg\n RR: 15 (12 - 52) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 6,738 mL\n 1,539 mL\n PO:\n Tube feeding:\n 1,774 mL\n 240 mL\n IV Fluid:\n 3,755 mL\n 1,239 mL\n Blood products:\n Total out:\n 1,180 mL\n 1,300 mL\n Urine:\n 1,180 mL\n 900 mL\n NG:\n 400 mL\n Stool:\n Drains:\n Balance:\n 5,558 mL\n 241 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 18 cmH2O\n SPO2: 99%\n ABG: 7.44/34/109/24/0\n Ve: 7.4 L/min\n PaO2 / FiO2: 218\n Physical Examination\n General Appearance: agitated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachy\n Respiratory / Chest: (Breath Sounds: Rhonchorous : b/l), (Sternum:\n Stable )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Sedated\n Labs / Radiology\n 327 K/uL\n 9.6 g/dL\n 122 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 8 mg/dL\n 106 mEq/L\n 140 mEq/L\n 28.4 %\n 20.9 K/uL\n [image002.jpg]\n 04:45 PM\n 03:15 AM\n 12:34 PM\n 04:57 AM\n 01:51 PM\n 03:46 PM\n 05:47 PM\n 10:45 PM\n 11:59 PM\n 04:11 AM\n WBC\n 10.1\n 13.3\n 18.8\n 20.9\n Hct\n 33.6\n 34.7\n 35.8\n 28.4\n Plt\n 27\n Creatinine\n 0.4\n 0.4\n 0.4\n 0.4\n 0.5\n 0.5\n Troponin T\n <0.01\n TCO2\n 30\n 30\n 26\n 24\n Glucose\n 126\n 160\n 151\n 170\n 190\n 122\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:76//<0.01, ALT / AST:72/25, Alk-Phos / T bili:192/1.1, Amylase /\n Lipase:35/31, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.8 mmol/L, Albumin:3.0 g/dL, Ca:8.7 mg/dL,\n Mg:1.7 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n .H/O RESPIRATORY FAILURE, ACUTE (NOT ARDS/), .H/O CHOLELITHIASIS,\n .H/O MYOCARDIAL INFARCTION, .H/O PANCREATITIS, ACUTE, .H/O ABDOMINAL\n PAIN (INCLUDING ABDOMINAL TENDERNESS), IMPAIRED SKIN INTEGRITY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction\n Neurologic: Neuro checks Q: 4 hr, pt currently sedated on low dose\n propofol gtt, continues to be agitated/ CT torso to r/o new\n intrabdominal or pulmonary process--New b/l basilar consolidations,\n left greater than right. no other significant changes\n Cardiovascular: tachycardic, initially hypotensive--fluid given/low\n dose neo. currently off pressor.\n Pulmonary: Trach, (Ventilator mode: CMV), wean to trach mask\n Gastrointestinal / Abdomen: NGT, G tibe\n Nutrition: Replete with fiber Full strength, 90/hr\n Renal: Foley, Adequate UO, creatinine stable at 0.5\n Hematology: stable\n Endocrine: RISS, glc 122\n Infectious Disease: pan cx pending, pt spiked at 102.6\n Lines / Tubes / Drains: Foley, Trach, Foley, G-tube, trach, A-line, R\n SCL CVL\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: LR\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Pancreatitis\n ICU Care\n Nutrition:\n Replete (Full) - 04:10 AM 70 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n Arterial Line - 09:27 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570655,
"text": "Diarrhea\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n .H/O pancreatitis, acute\n Assessment:\n Action:\n Response:\n Plan:\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 572148,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ bacteremia, UTI, VAP.\n Chief complaint:\n abd pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n Current medications:\n 1. Magnesium Sulfate IV Sliding Scale Order date: @ 0234\n 2. 1000 mL LR Continuous at 75 ml/hr TF+IVF=90cc/hr, HLIV when TF@ goal\n 90 Order date: @ 1540\n 3. Metoprolol Tartrate 5 mg IV Q4H tachycadia/HTN hold for SBP<100\n HR<60 Order date: @ 0753\n 4. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308\n 5. Miconazole 2% Cream 1 Appl TP yeast rash Order date: @\n 2347\n 6. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139\n 7. Miconazole Powder 2% 1 Appl TP TID:PRN Order date: @ 1255\n 9. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @ 0555\n 10. CloniDINE 0.2 mg PO TID Order date: @ 0751\n 11. Famotidine 20 mg IV Q12H Order date: @ 0419\n 12. Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @ 1209\n 13. Fentanyl Patch 75 mcg/hr TP Q72H Order date: @ 0751\n 14. Potassium Chloride PO Sliding Scale Hold for K > 5 Order date:\n @ 0505\n 15. Haloperidol 2 mg PO TID through G tube Order date: @ 0751\n 16. Potassium Chloride IV Sliding Scale Order date: @ 0526\n 17. Heparin 5000 UNIT SC BID Order date: @ 0139\n 18. Potassium Phosphate IV Sliding Scale Infuse over 6 hours Order\n date: @ 0647\n 19. Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose\n Order date: @ 1234\n 20. Lidocaine 1% 3-5 mL IH Q4-6 HRS PRN Order date: @ 1854\n 21. Lorazepam 2-4 mg IV Q4H:PRN Order date: @ \n 22. Tobramycin 450 mg IV Q24H Order date: @ 1607\n 23. Lorazepam 2-4 mg IV Q30MIN:PRN agitation Order date: @ 0430\n 24. Vancomycin 1000 mg IV Q 12H Order date: @ 1125\n 24 Hour Events:\n weaned off propofol & vent, restarted TF, vanc changed to 1000\"\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Tobramycin - 08:09 PM\n Vancomycin - 08:05 PM\n Piperacillin/Tazobactam (Zosyn) - 11:55 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 12:09 AM\n Heparin Sodium (Prophylaxis) - 06:02 AM\n Famotidine (Pepcid) - 06:03 AM\n Other medications:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.8\nC (98.2\n HR: 71 (71 - 86) bpm\n BP: 101/68(81) {75/47(61) - 123/68(82)} mmHg\n RR: 14 (14 - 29) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 3,563 mL\n 717 mL\n PO:\n Tube feeding:\n 452 mL\n 546 mL\n IV Fluid:\n 2,941 mL\n 171 mL\n Blood products:\n Total out:\n 2,855 mL\n 730 mL\n Urine:\n 2,655 mL\n 730 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 708 mL\n -13 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 369 (265 - 556) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 109\n PIP: 10 cmH2O\n SPO2: 98%\n ABG: ///31/\n Ve: 4.2 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 321 K/uL\n 8.0 g/dL\n 89 mg/dL\n 1.2 mg/dL\n 31 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 103 mEq/L\n 141 mEq/L\n 23.3 %\n 9.4 K/uL\n [image002.jpg]\n 10:00 AM\n 02:41 AM\n 04:11 AM\n 06:00 AM\n 05:27 PM\n 03:29 AM\n 01:30 AM\n 03:00 AM\n 12:31 PM\n 03:18 AM\n WBC\n 12.9\n 15.9\n 14.1\n 9.4\n Hct\n 32.2\n 31.6\n 25.7\n 24.6\n 23.3\n Plt\n 21\n Creatinine\n 0.4\n 0.9\n 1.0\n 1.2\n Troponin T\n <0.01\n TCO2\n 35\n 26\n Glucose\n 105\n 149\n 194\n 158\n 92\n 89\n Other labs: PT / PTT / INR:15.5/24.7/1.4, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.4 mmol/L, Albumin:3.6 g/dL, LDH:212 IU/L,\n Ca:9.3 mg/dL, Mg:2.3 mg/dL, PO4:3.7 mg/dL\n Microbiology: blood: neg\n urine: yeast\n MRSA: neg\n PICC tip: neg\n sputum: contam\n sputum: GNR x3, yeast\n bld x2: neg\n C.diff: neg\n sputum: contam\n sputum x2: contam\n bld: coag neg Staph\n urine: yeast >100K\n R SCL CVL tip: GNR\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), INEFFECTIVE COPING, ALTERED MENTAL STATUS (NOT\n DELIRIUM), FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), .H/O\n AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY\n CLEARANCE, COUGH), FUNGAL INFECTION, OTHER, IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, RISK FOR INJURY\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ bacteremia, UTI, VAP.\n Neurologic: Pain controlled, Haldol TID & prn. Fentanyl patch. Weaning\n Clonidine.\n Cardiovascular: Beta-blocker, HD stable on Lopressor 5q4h.\n Pulmonary: Trach, Wean to TC today\n Gastrointestinal / Abdomen: TF.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Cr slightly increased.\n Hematology: Hct 31.6 -> 25.7 -> 24.6 -> 23.3. Transfuse one prbc today\n no evidence of active bleeding, cont to follow post-tx Hct.\n Endocrine: RISS, Goal FS<150.\n Infectious Disease: Check cultures, Continue Vanc/Zosyn/Tobra for\n VAP/bacteremia\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Dry dressings\n Imaging: none\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Sepsis\n ICU Care\n Nutrition: tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:53 AM\n Multi Lumen - 08:14 AM\n 22 Gauge - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572232,
"text": "Hypotension (not Shock)\n Assessment:\n Borderline hypotension with SBP 90\ns to low 100\n Action:\n One unit PRBC given\n Lopressor order changed to q 6 hours from q 4 hours\n Response:\n normotenisve\n Plan:\n resolved\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max today 99.2\n Action:\n Pan culture repeated per ID\n Antibiotic regimen changed per ID due to new information\n that patient has VRE\n Around the clock antibiotics given as ordered\n Response:\n No temperature spikes\n Currently normothermic\n Plan:\n resolved\n Fungal Infection, Other\n Assessment:\n Previous urine result showing yeast\n Previously documented rash in peri area appeared to be yeast\n Action:\n Foley changed on \n Miconazole powder utilized on rash\n Response:\n Per skin nurse, peri area / coccyx area has healed\n Plan:\n resolved\n Ineffective Coping\n Assessment:\n Patient today alert and oriented x 3\n Flat affect however smiling and interacting with staff and\n family\n Action:\n Emotional support given\n Passy-muir valve placed and patient was able to speak to\n staff today\n Response:\n Patient appears to be coping appropriately\n Plan:\n Resolved\n Altered mental status (not Delirium)\n Assessment:\n Alert and oriented x3\n Following all commands\n Purposeful movement\n Assisting with care\n Action:\n Discussed plan of care and past events\n Discussed current events and continued to ask orienting\n questions\n Haldol wean in progress\n Response:\n Patient does not appear to have altered mental status\n Plan:\n resolved\n Impaired Skin Integrity\n Assessment:\n Coccyx area, peri area, and elbow abrasion have healed\n Action:\n Frequent repositioning\n Cream and miconazole powder to peri area\n Response:\n Skin impairments have healed per skin nurse\n Plan:\n resolved\n Risk for Injury\n Assessment:\n Patient with previous history of behavior that may cause\n harm to himself, however he has not exhibited any such behavior this\n shift\n Patient is alert and oriented x3\n Assisting with self care\n No restraints needed for > 24 hours\n Action:\n Emotional support\n Q 4 hour assessment of risk for injury\n Response:\n Patient remains safe\n Plan:\n resolved\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Lung sounds rhoncherous\n Patient coughing very frequently, to the point of exhaustion\n Trach site intact\n On ventilator at start of shift\n Action:\n Placed on trach collar\n Passy-muir valve on for a short time only due to secretions\n Suctioned as needed\n Patient encouraged to expectorate and cough\n Frequent trach care as area is almost constantly moist\n Patient instructed on how he can use the suction to clear\n oral secretions and if he wishes to catch and remove sputum from trach.\n OOB to chair\n VAP protocol\n Response:\n Lung sounds much more clear\n Patient is coughing less frequently\n Patient having restful periods without coughing\n Plan:\n Continue suctioning\n Continue to encourage patient to cough and deep breath\n Continue VAP protocol\n Impaired Physical Mobility\n Assessment:\n Patient able to lift and hold all extremities\n Action:\n Slid to stretcher chair\n Encouraged to move arms and legs frequently, exercise\n Response:\n Remains weak however improving\n Plan:\n Continue to increase activity as tolerated\n Continue to encourage patient to participate in care and use\n extremities\n Physical therapy and occupational therapy need to follow\n patient\n Hyperglycemia\n Assessment:\n Blood glucose max today 200 mg/dl\n Tube feeds at goal\n Action:\n NPH and Regular insulin given per standing orders and\n sliding scale\n Response:\n Latest glucose level 149 mg/dl\n Plan:\n Continue to monitor glucose levels\n Continue to administer insulin as ordered.\n ------ Protected Section ------\n Addendum: Patient noted to be in first degree heart block this\n morning, as well as QTc .51, HCT low @ 23.3. SICU team made aware on\n rounds, haldol decreased, one Unit PRBC given, lopressor standing dose\n decreased and all doses held this shift. Continue to monitor.\n ------ Protected Section Addendum Entered By: , RN\n on: 19:26 ------\n"
},
{
"category": "Rehab Services",
"chartdate": "2140-04-15 00:00:00.000",
"description": "Green Dye Swallowing Evaluation",
"row_id": 572338,
"text": "TITLE:\n GREEN DYE BEDSIDE SWALLOWING EVALUATION:\n INTERIM HISTORY:\n Thank you for reconsulting on this 42 year old man with complex medical\n history as reported yesterday in PMV evaluation. Pt has had no major\n changes overnight. Tolerated PMV yesterday for ~2 hours per RT.\n Tolerating trach collar for extended periods of time. We were\n reconsulted today to evaluate oral and pharyngeal swallow function to\n determine the safest diet.\n EVALUATION:\n The examination was performed while the patient was seated upright in\n the bed in SICU.\n Cognition, language, speech, voice:\n Awake, alert, conversant. Follows commands. Answers questions\n appropriately. Language grossly fluent but with flat affect. Speech\n and voice with PMV in place is WFL.\n Teeth: intact in good condition\n Secretions: WNL in oral cavity - coughing white secretions out of trach\n upon cuff deflation.\n ORAL MOTOR EXAM:\n Face grossly symmetrical. Labial, lingual, and buccal tone, strength,\n and ROM were WFL.\n SWALLOWING ASSESSMENT:\n Pt offered ice chips, thin liquid dyed blue (tspn, straw), nectar thick\n liquids dyed blue (tspn, straw), and bites of puree dyed green. Oral\n phase grossly WFL for these limited consistencies. Laryngeal elevation\n reduced to palpation but timely. Pt had overt coughing/throat clear\n with thin liquids, wet vocal quality with nectar thick liquids, and\n sensation of pharyngeal residue with all three consistencies assessed.\n Pt suctioned tracheally by RN (present for entire evaluation) following\n thin liquids and following purees without return of green or blue dyed\n material. Several minutes after PO trials were completed, pt coughed\n and self-yankauered green dyed secretions from oropharynx suggestive of\n pharyngeal residue.\n SUMMARY / IMPRESSION:\n Pt presents with s/sx of aspiration of thin and nectar thick liquids\n and s/sx of pharyngeal residue with purees. Videoswallow study would\n provide more accurate information and might promote initiation of PO\n diet today. However, pt politely declined this evaluation. He states\n a personal feeding goal of returning to steak and , however he\n states this is not urgent and he'd rather await repeat bedside swallow\n in a few days when his overall medical status and strength may have\n improved further. We will f/u early next week for repeat evaluation.\n This swallowing pattern correlates to a Dysphagia Outcome\n Severity Scale (DOSS) rating of 1, unable to tolerate PO.\n RECOMMENDATIONS:\n 1. NPO with no oral meds, no ice chips\n 2. Continue tube feedings and meds via alternative means.\n 3. Repeat green dye swallowing evaluation on Tues/Weds.\n These recommendations were shared with the patient, nurse and medical\n team.\n M.S., CCC-SLP\n Pager # \n Face time:9:35-9:50\n Total time: 45 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571058,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n FamHx: sister and ?father with myotonic muscular dystrophy disorder\n (pt has not been tested)\n EVENTS:\n : T103, increased LFTs/AP, propofol gtt, prophylactic abx\n : weaned to trach collar, R SCL CVL placed, PICC d/c'd, CT abd\n : ERCP\n : started TF\n : HLIV, suctioned q1hr, sputum cx, CXR, heat rash --> miconazole,\n agitation, diaphoretic episodes (a febrile, glucose normal).\n : Very agitated. Hypertensive/ Tachycardia. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation.\n Fungal Infection, Other\n Assessment:\n Yeast in sputum\n Yeast in urine\n Bld cx pending\n WBC elevated\n Low grade fever\n Action:\n Tylenol as ordered\n Zosyn/Vanc\n Turn every 2hrs\n Oral care, excessive secretions\n Response:\n Increased secretions both oral and tracheal\n Frequent suctioning\n ABX as ordered\n Plan:\n Continue with abx and suction as needed. Check cx for organism.\n Hyperglycemia\n Assessment:\n On Insulin gtt\n Glucose has been elevated for over 24 hrs\n Not responding to SQ doses\n Action:\n Gtt started and went up to 6 units/hr per protocol. Currently stable on\n 6 units with finger stick WNL\n Response:\n Glucose has stabilized with gtt\n Plan:\n Continue every hour checks and wean to appropriate dose per protocol.\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1075567,
"text": " 9:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulmonary status\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with trach\n REASON FOR THIS EXAMINATION:\n pulmonary status\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg TUE 11:55 AM\n Interval development of opacity in the retrocardiac space. Low lung volumes\n and simultaneous right basilar atelectasis favors atelectasis instead of\n _____.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old male with tracheotomy. Evaluate pulmonary status.\n\n COMPARISON: .\n\n UPRIGHT AP VIEW OF THE CHEST: Compared to the prior study, there is increased\n opacity in the retrocardiac space. Low lung volumes and simultaneous presence\n of right basilar opacity favors atelectasis instead of infection. The\n tracheostomy tube is in good position. No appreciable pleural effusion or\n pneumothorax is identified. Although evaluation is limited by the\n retrocardiac opacity, the heart size does not appear significantly changed\n compared to prior. Mediastinal and hilar contours are unremarkable. A right\n subclavian catheter is again noted terminating in the lower SVC. There has\n been interval removal of a right PICC line.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1075882,
"text": " 2:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o aspiration\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with trach\n REASON FOR THIS EXAMINATION:\n r/o aspiration\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tracheostomy, to evaluate for aspiration.\n\n FINDINGS: In comparison with the study of , there is a somewhat better\n inspiration. Persistent retrocardiac opacification with air bronchograms.\n This suggests consolidation in the left lower lobe. Probable mild atelectatic\n changes as well.\n\n Tracheostomy tube remains in place. Right subclavian catheter extends to the\n lower portion of the SVC.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1075568,
"text": ", M. SICU-B 9:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulmonary status\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with trach\n REASON FOR THIS EXAMINATION:\n pulmonary status\n ______________________________________________________________________________\n PFI REPORT\n Interval development of opacity in the retrocardiac space. Low lung volumes\n and simultaneous right basilar atelectasis favors atelectasis instead of\n _____.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1075978,
"text": " 4:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: respiratory distress\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with trach\n REASON FOR THIS EXAMINATION:\n respiratory distress\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 1:22 PM\n 1. Stable bibasilar atelectasis and small bilateral pleural effusion.\n\n 2. NG tube terminating at the GE junction with the side hole in the mid\n esophagus.\n\n 3. Tracheostomy tube impinging upon the left aspect of the tracheal wall.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY DATED .\n\n HISTORY: 42-year-old man with a tracheostomy in respiratory distress. The\n cardiomediastinal contour is unchanged in appearance. There is a tracheostomy\n tube which is impinging on the left aspect of the upper trachea. A right\n central venous catheter terminates at the cavoatrial junction. There is\n stable bibasilar atelectasis and bilateral pleural effusions. An NG tube is\n again noted terminating at the GE junction with the side hole well within the\n mid esophagus.\n\n IMPRESSION:\n\n 1. Stable bibasilar atelectasis and small bilateral pleural effusion.\n\n 2. NG tube terminating at the GE junction with the side hole in the mid\n esophagus.\n\n 3. Tracheostomy tube impinging upon the left aspect of the tracheal wall.\n\n These findings were communicated to Dr. on at 10am.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-04-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1075979,
"text": ", M. SICU-B 4:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: respiratory distress\n Admitting Diagnosis: PANCREATITIS;PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with trach\n REASON FOR THIS EXAMINATION:\n respiratory distress\n ______________________________________________________________________________\n PFI REPORT\n 1. Stable bibasilar atelectasis and small bilateral pleural effusion.\n\n 2. NG tube terminating at the GE junction with the side hole in the mid\n esophagus.\n\n 3. Tracheostomy tube impinging upon the left aspect of the tracheal wall.\n\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-16 00:00:00.000",
"description": "Generic Note",
"row_id": 572480,
"text": "TITLE: Pt seen x 3 for trach check. Suctioned for mod amts thick white\n secretions.H20 filled.All equipment present. Remains on t-piece without\n problem. cont to follow.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 572598,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 14\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV: Yes\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572742,
"text": "HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ UTI, VAP, bacteremia.\n Chief complaint:\n respiratory insufficiency, sepsis\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Impaired Physical Mobility\n Assessment:\n Moves from side to side in the bed.\n Legs over the rails and moving down towards the foot of the bed.\n Action:\n Range of motion done.\n Needs assistance with turning in the bed.\n Response:\n Attempts to help when turning and moving in the bed.\n Plan:\n Continue with range of motion, oob to chair prn and provide\n encouragement.\n Altered mental status (not Delirium)\n Assessment:\n Alert and oriented x1 the early part of the shift, following commands\n and visiting with his mother and sister.\n As the shift continued, pt becoming more agitated with attempting to\n climb oob, sitting up in the bed and not following commands.\n Increase in amt to be suctioned.\n Diaphoretic and temp up to 100,.4.\n Action:\n Haldol 1mg via tube tid qtc 0.37 dr notified and in to\n see patient.\n Response:\n Becoming more agitated and ativan 1mg iv given\n Plan:\n Monitor closely.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n On trach collar 50% most ot the shift, being suctioned q 1/2hr for\n thick white sputum. O2sat 95%. Lungs clear in the upper lobes but\n rhonchus in the lower lobes. Temp 99.0 and increasing to 100.4 very\n agitated and moving from side to side not following commands.\n Action:\n Dr notified and in to see patient. Pt back on the ventilatlor\n on c mv 50% 600 20 5. propofol gtt started at 20mcg/kg/min. urine and\n blood culture via peripheral and central obtained, aline inserted via\n right radial .\n Response:\n Pt not tolerating trach collar tonite and placed back on the\n ventilator. Continues to haave copius amt of secretitions. Continues\n on iv tobramycin and iv pipercillin.\n Plan:\n Monitor labs, cultures provide support to mother and sister.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 573040,
"text": ".H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 573042,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ VAP, bacteremia.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on trach collar\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 573044,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ VAP, bacteremia.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on trach collar, 40 % FiO2, RR 20s, O2 sats > 96%. Pt denies\n difficulty breathing. Pt coughs copious amounts of white frothy\n secretions from trach.\n Action:\n Suctioned q 1-2 hrs\n Response:\n Airway clear, remained on trach collar overnight\n Plan:\n Continue to assess respiratory status, suction prn\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 572631,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 14\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV: Yes\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Respiratory Care Service: Pt remains w/ an 8.0 Portex Blue Line Trach\n in place and on the Trach Collar .50 since . Appears comfortable\n w/ a RR 20-24 BPM and an SPO2 of 97 %. Persistent thin white\n secretions. Will c/w Trach Collar as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 573129,
"text": "HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ VAP, intermittent bacteremic\n episodes/agitation.\n Chief complaint:\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Patient alert and orientated follows simple commands, lungs are coarse\n throughout all fields, large amount of frothy white sputum. Afebrile.\n C/O of headache\n Action:\n Frequent suctioning every 2 hours, continues on meropenum and\n linezolid. Liquid Tylenol given for H/A.\n Response:\n Continues on 50% trach mask maintaining 95-100% unlabored. Patient\n c/o of 2 out of 10 pain.\n Plan:\n Continue with current plan of care. Provide comfort and support as\n needed.\n Patient tolerated OOB to chair for 2 hours this am with Pt Stood and\n pivoted to chair.\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-17 00:00:00.000",
"description": "Intensivist Note",
"row_id": 572692,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ UTI, VAP, bacteremia.\n Chief complaint:\n respiratory insufficiency, sepsis\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n Acetaminophen 3. Bisacodyl 4. Chlorhexidine Gluconate 0.12% Oral Rinse\n 5. Famotidine 6. Fentanyl Patch\n 7. Haloperidol 8. Heparin 9. Insulin 10. Linezolid 11. Lidocaine 1% 12.\n Lorazepam 13. Lorazepam\n 14. Magnesium Sulfate 15. Metoprolol Tartrate 16. Miconazole 2% Cream\n 17. Miconazole Powder 2% 18. Nystatin Oral Suspension\n 19. Piperacillin-Tazobactam Na 20. Potassium Chloride 21. Potassium\n Chloride 22. Potassium Phosphate\n 24. Tobramycin\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:10 AM\n Linezolid - 08:15 PM\n Tobramycin - 10:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:55 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 05:47 PM\n Heparin Sodium (Prophylaxis) - 05:47 PM\n Metoprolol - 12:18 AM\n Other medications:\n Flowsheet Data as of 05:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 37.2\nC (99\n HR: 97 (75 - 104) bpm\n BP: 130/84(87) {114/65(51) - 151/91(100)} mmHg\n RR: 38 (17 - 47) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 3,000 mL\n 148 mL\n PO:\n Tube feeding:\n 2,160 mL\n 95 mL\n IV Fluid:\n 840 mL\n 53 mL\n Blood products:\n Total out:\n 2,625 mL\n 480 mL\n Urine:\n 2,625 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 375 mL\n -333 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SPO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bilateral bases)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 349 K/uL\n 10.4 g/dL\n 124 mg/dL\n 0.9 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 21 mg/dL\n 100 mEq/L\n 141 mEq/L\n 30.1 %\n 10.8 K/uL\n [image002.jpg]\n 04:11 AM\n 06:00 AM\n 05:27 PM\n 03:29 AM\n 01:30 AM\n 03:00 AM\n 12:31 PM\n 03:18 AM\n 04:29 AM\n 03:23 AM\n WBC\n 15.9\n 14.1\n 9.4\n 8.8\n 10.8\n Hct\n 31.6\n 25.7\n 24.6\n 23.3\n 27.8\n 30.1\n Plt\n 458\n 347\n 321\n 315\n 349\n Creatinine\n 0.9\n 1.0\n 1.2\n 1.0\n 0.9\n Troponin T\n <0.01\n TCO2\n 35\n 26\n Glucose\n 194\n 158\n 92\n 89\n 119\n 124\n Other labs: PT / PTT / INR:12.4/22.4/1.0, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.4 mmol/L, Albumin:3.6 g/dL, LDH:212 IU/L,\n Ca:10.1 mg/dL, Mg:2.3 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), IMPAIRED PHYSICAL MOBILITY, HYPERGLYCEMIA\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ UTI, VAP, bacteremia.\n Neurologic: Neuro checks Q: hr, Pain controlled, Haldol TID, Ativan\n prn, fentanyl patch\n Cardiovascular: Beta-blocker, HD stable, on Lopressor 5q4\n Pulmonary: Trach, IS, trach collar as tolerated, pulm toilet\n Gastrointestinal / Abdomen: TF, NPO, swallow eval- questionable\n aspiration, reassess on tue\n Nutrition: Tube feeding, Speech and Swallow eval, swallow eval on\n tuesday\n Renal: Foley, Adequate UO\n Hematology: Serial Hct\n Endocrine: RISS, Regular insulin, NPH insulin with RISS, goal FS<150,\n blood sugars well controlled\n Infectious Disease: Check cultures, linezolid/Zosyn/tobra, goal trough\n is <1, ID wants day course (from ), PNA (?Pseudomonas)\n Lines / Tubes / Drains: Foley, G-tube, Trach, L SCL CVL, Flexiseal,\n aline\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Comments: tube feeding\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Multi Lumen - 08:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-18 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 572854,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI done on 0 peep/ 5 ips 79. MDI'S given.\n Reason for continuing current ventilatory support: Cannot manage\n secretions\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-16 00:00:00.000",
"description": "Intensivist Note",
"row_id": 572489,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ UTI, VAP, bacteremia\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. Lorazepam 2-4 mg IV Q30MIN:PRN agitation Order date: @ 0430\n 2. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308\n 3. Magnesium Sulfate IV Sliding Scale Order date: @ 0234\n 4. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139\n 5. Metoprolol Tartrate 5 mg IV Q6H tachycadia/HTN hold for SBP<100\n HR<60 Order date: @ 1218\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL Order\n date: @ 1119\n 7. Miconazole 2% Cream 1 Appl TP yeast rash Order date: @\n 2347\n 8. Famotidine 20 mg IV Q12H Order date: @ 0419\n 9. Miconazole Powder 2% 1 Appl TP TID:PRN Order date: @ 1255\n 10. Fentanyl Patch 75 mcg/hr TP Q72H Order date: @ 0751\n 11. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @ 0555\n 12. Haloperidol 1 mg PO TID through G tube Order date: @ 1014\n 13. Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @ 1209\n 14. Heparin 5000 UNIT SC BID Order date: @ 0139\n 15. Potassium Chloride PO Sliding Scale Hold for K > 5 Order date:\n @ 0505\n 16. Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose\n Order date: @ 1234\n 17. Potassium Chloride IV Sliding Scale Order date: @ 0526\n 18. Linezolid 600 mg PO Q12H Order date: @ 1653\n 19. Potassium Phosphate IV Sliding Scale Infuse over 6 hours Order\n date: @ 0647\n 20. Lidocaine 1% 3-5 mL IH Q4-6 HRS PRN Order date: @ 1854\n 21. Lorazepam 2-4 mg IV Q4H:PRN Order date: @ \n 22. Tobramycin 450 mg IV Q24H Order date: @ 1607\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:51 AM\n Failed swallow eval\n Clonodine D/C'd\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:10 AM\n Linezolid - 08:15 PM\n Tobramycin - 04:12 PM\n Piperacillin/Tazobactam (Zosyn) - 12:24 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 06:00 PM\n Heparin Sodium (Prophylaxis) - 06:00 PM\n Other medications:\n Flowsheet Data as of 04:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.5\n T current: 36.9\nC (98.5\n HR: 78 (70 - 97) bpm\n BP: 124/65(79) {105/60(70) - 144/89(99)} mmHg\n RR: 20 (11 - 32) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 2,981 mL\n 558 mL\n PO:\n Tube feeding:\n 2,161 mL\n 413 mL\n IV Fluid:\n 640 mL\n 146 mL\n Blood products:\n Total out:\n 2,055 mL\n 500 mL\n Urine:\n 2,055 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 926 mL\n 58 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 351 (351 - 351) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 0 cmH2O\n FiO2: 30%\n RSBI: 114\n PIP: 0 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 10.6 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, PEG\n intact\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 315 K/uL\n 9.4 g/dL\n 119 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 24 mg/dL\n 105 mEq/L\n 141 mEq/L\n 27.8 %\n 8.8 K/uL\n [image002.jpg]\n 02:41 AM\n 04:11 AM\n 06:00 AM\n 05:27 PM\n 03:29 AM\n 01:30 AM\n 03:00 AM\n 12:31 PM\n 03:18 AM\n 04:29 AM\n WBC\n 12.9\n 15.9\n 14.1\n 9.4\n 8.8\n Hct\n 32.2\n 31.6\n 25.7\n 24.6\n 23.3\n 27.8\n Plt\n 21\n 315\n Creatinine\n 0.4\n 0.9\n 1.0\n 1.2\n 1.0\n Troponin T\n <0.01\n TCO2\n 35\n 26\n Glucose\n 149\n 194\n 158\n 92\n 89\n 119\n Other labs: PT / PTT / INR:12.4/22.4/1.0, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.4 mmol/L, Albumin:3.6 g/dL, LDH:212 IU/L,\n Ca:9.1 mg/dL, Mg:2.2 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), IMPAIRED PHYSICAL MOBILITY, HYPERGLYCEMIA\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ UTI, VAP, bacteremia.\n Neurologic: Pain controlled, Haldol TID, Ativan prn, fentanyl patch\n Cardiovascular: Beta-blocker, HD stable, on Lopressor 5q4\n Pulmonary: trach collar as tolerated, pulm toilet\n Gastrointestinal / Abdomen: TF, NPO, swallow eval- questionable\n aspiration, reassess on tue\n Nutrition: Tube feeding, NPO\n Renal: Foley, Adequate UO\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: Check cultures, f/u cx, linezolid/Zosyn/tobra\n Lines / Tubes / Drains: G-tube, Trach\n Wounds:\n Imaging:\n Fluids:\n Consults: General surgery, ID dept\n Billing Diagnosis: Sepsis\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:06 AM 89.\n mL/hour\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Multi Lumen - 08:14 AM\n 22 Gauge - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 573185,
"text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt with inability to protect own airway, on trach mask at 50%. Large\n amount of secretions noted throughout shift.\n Action:\n Suctioned Q1-4hrs, pt able to expectorate most secretions. Lasix given\n for goal of negative fluid balance.\n Response:\n Maintained airway. Increased urine output.\n Plan:\n Monitor resp status closely, ? c/o to floor if stable.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-20 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 573290,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ VAP, bacteremia.\n Chief complaint:\n postoperative respiratory insufficiency, hospital acquired pneumonia\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Impaired Physical Mobility\n Assessment:\n seen by PT, weak but able to move in bed\n Action:\n ambulated in with PT, oob to chair, needs to be encouraged to do\n more for himself\n Response:\n weak but slowly improving\n Plan:\n continue PT, ambulate as tolerated, oob to chair\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n trach collar x 48 hrs, coughing and raising large amts thick white\n secretions. Bs clear after coughing\n Action:\n pt using yanker suction to suction his mouth, suctioned q 30-60\n minutes moderate to large amt thick white secretions. Albuterol and\n atrovent given as ordered by resp.\n Response:\n continues to require suctioning frequently, sats stable\n Plan:\n monitor resp parameters, encourage pt to cough and suction himself,\n speech and swallow consult\n Ineffective Coping\n Assessment:\n pt used to having family do a lot for him, Fentanyl patch q 72hrs\n Action:\n seen by psych, haldol changed to qhs\n Response:\n per team, pt is calmer and more cooperative\n Plan:\n continue haldol, encourage pt to participate in his care\n .H/O pancreatitis, acute\n Assessment:\n s/p ERCP on with subsequent sepsis, currently on meropenum iv,\n denies abdominal pain\n Action:\n antibiotics given as ordered, labs followed by sicu team, Fentanyl\n patch for pain\n Response:\n stable at present\n Plan:\n monitor for abdominal pain, monitor labs, continue antibiotics as\n ordered, monitor culture reports\n Aline d/c\nd at 1500. Tf via peg = replete with fiber at 90cc/hr. Pt\n had large formed stool today.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n PANCREATITIS;PSEUDOCYST\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 88.7 kg\n Daily weight:\n 88.2 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Smoker\n CV-PMH: Hypertension, MI\n Additional history: s/p\n mi in 05 with ptca, s/p dvt in past ? date, increased lipids\n pt's father had myotonic muscular dystrophy. this is heriditary and pt\n has not been worked up.\n Surgery / Procedure and date: trache\n g tube placement\n ERCP done w/ sphincterotomy w/ balloon sweep and stone\n extraction.(pt medicated w/ 50mg propofol and 25.6ml of Desflurane for\n procedure)\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:94\n D:76\n Temperature:\n 98.4\n Arterial BP:\n S:169\n D:112\n Respiratory rate:\n 13 insp/min\n Heart Rate:\n 81 bpm\n Heart rhythm:\n 1st AV (First degree AV Block)\n O2 delivery device:\n Trach mask\n O2 saturation:\n 100% %\n O2 flow:\n 10 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 1,857 mL\n 24h total out:\n 1,530 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 03:04 AM\n Potassium:\n 3.9 mEq/L\n 03:04 AM\n Chloride:\n 103 mEq/L\n 03:04 AM\n CO2:\n 28 mEq/L\n 03:04 AM\n BUN:\n 29 mg/dL\n 03:04 AM\n Creatinine:\n 0.8 mg/dL\n 03:04 AM\n Glucose:\n 93 mg/dL\n 03:04 AM\n Hematocrit:\n 28.4 %\n 03:04 AM\n Finger Stick Glucose:\n 128\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: Sicu B\n Transferred to: 905\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2140-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572967,
"text": "Altered Respiratory Function: Impaired Gas Exchange\n Assessment:\n - patient was on CMV yesterday secondary to agitation and\n ineffective respiratory patters\n - this morning patient weaned off CMV to CPAP w/ PS\n - Lung sounds clear bilaterally\n - Trach suctioned for small to moderate amounts of thinning\n white/yellow secretions\n - Pulse oximetry 97-100%\n - Patient denies shortness of breath\n Action:\n - respiratory status improving\n - monitoring respiratory status closely\n - weaned CMV to CPAP\n Response:\n - successfully weaned off of the vent\n - placed on trach collar\n - tolerating well\n Plan:\n - continue to monitor patient\ns respiratory status\n - provide adequate oxygentation\n - monitor for signs and symptoms of respiratory distress\n - monitor VS\n Altered Mental Status: Agitation\n Assessment:\n - patient increasingly anxious and agitated this past weekend\n - placed on propofol gtt for sedation due to preference by\n primary team to avoid benzo\n - this shift patient has been awake and alert, following all\n commands, moving all extremities\n - no neuro deficits shown this shift\n - no anxiety or agitation demonstrated by patient\n Action:\n - weaned patient successfully of propofol gtt\n - started clonidine via PEG tube\n Response:\n - patient remains alert and following all commands this shift\n - successfully able to communicate with RN throughout the day\n Plan:\n - continue to monitor.\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572969,
"text": "Altered Respiratory Function: Impaired Gas Exchange\n Assessment:\n - patient was on CMV yesterday secondary to agitation and\n ineffective respiratory patters\n - this morning patient weaned off CMV to CPAP w/ PS\n - Lung sounds clear bilaterally\n - Trach suctioned for small to moderate amounts of thinning\n white/yellow secretions\n - Pulse oximetry 97-100%\n - Patient denies shortness of breath\n Action:\n - respiratory status improving\n - monitoring respiratory status closely\n - weaned CMV to CPAP\n Response:\n - successfully weaned off of the vent\n - placed on trach collar\n - tolerating well\n Plan:\n - continue to monitor patient\ns respiratory status\n - provide adequate oxygentation\n - monitor for signs and symptoms of respiratory distress\n - monitor VS\n Altered Mental Status: Agitation\n Assessment:\n - patient increasingly anxious and agitated this past weekend\n - placed on propofol gtt for sedation due to preference by\n primary team to avoid benzo\n - this shift patient has been awake and alert, following all\n commands, moving all extremities\n - no neuro deficits shown this shift\n - no anxiety or agitation demonstrated by patient\n Action:\n - weaned patient successfully of propofol gtt\n - started clonidine via PEG tube\n Response:\n - patient remains alert and following all commands this shift\n - successfully able to communicate with RN throughout the day\n Plan:\n - continue to monitor.\n Ineffective Coping\n Assessment:\n - patient\ns family has communication barrier\n - spoke with from social work about arranging\n for interpreter services to assist with translation for a family\n meeting.\n Action:\n - see above\n Response:\n - awaiting plan for family meeting regarding patient\ns plan of\n care\n Plan:\n - keep family and patient informed on plan of care\n - plan for meeting with interpreter to ensure that the family\n understands the plan of care.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-17 00:00:00.000",
"description": "Generic Note",
"row_id": 572676,
"text": "TITLE: Pt remains on t-collar overnight 50%. Suctioned and\n expectorating mod amts frothy white secretions.Unable to tol PMV for\n more than 5 minutes.All equipment present. H20 filled. Will cont to\n monitor resp status.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 573104,
"text": "HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ VAP, intermittent bacteremic\n episodes/agitation.\n Chief complaint:\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Patient alert and orientated follows simple commands, lungs are coarse\n throughout all fields, large amount of frothy white sputum. Afebrile.\n C/O of headache\n Action:\n Frequent suctioning every 2 hours, continues on meropenum and\n linezolid. Liquid Tylenol given for H/A.\n Response:\n Continues on 50% trach mask maintaining 95-100% unlabored. Patient\n c/o of 2 out of 10 pain.\n Plan:\n Continue with current plan of care. Provide comfort and support as\n needed.\n Patient tolerated OOB to chair for 2 hours this am with Pt Stood and\n pivoted\n"
},
{
"category": "Rehab Services",
"chartdate": "2140-04-19 00:00:00.000",
"description": "PMV / Swallow Follow Up",
"row_id": 573107,
"text": "TITLE: PMV / SWALLOW FOLLOW UP\n INTERIM HISTORY\n Returned today for planned repeat green dye swallowing evaluation on\n this patient with trach/PEG. PMV was initially placed while on trach\n collar on and tolerated for approximately 2 hours. On , PMV\n placed and swallow evaluation was performed, however pt had s/sx of\n aspiration of all consistencies and was recommended to remain NPO\n pending repeat evaluation this week. On , RT note indicates PMV\n tolerated for only 5 minutes. Since that time, PMV has not been placed\n copious secretions.\n DEFERRED REPEAT EVALUATIONS\n Given lethargy and secretions, pt is not safe for PMV placement or\n swallow evaluation today. PMV and materials were removed from pt\n room and will be stored in our office pending re-evaluation. Please\n reconsult when pt\ns secretion management has improved such that PMV\n placement might be indicated. Keep pt NPO pending swallowing\n evaluation.\n Whitmill, MS, CCC-SLP\n Pager #\n Total Time: 15 minutes\n"
},
{
"category": "Nutrition",
"chartdate": "2140-04-20 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 573293,
"text": "Subjective RN, patient is tolerating tube feeds well at goal, and\n had a large BM this am.\n Objective\n Current Wt: 88.3 kg ()\n Admit Wt: 88.7 kg\n Weight Change: -0.4kg\n Pertinent medications: Lasix, RISS, NPH, ABx, pepcid, metoprolol\n tartrate\n Labs:\n Value\n Date\n Glucose\n 93 mg/dL\n 03:04 AM\n Glucose Finger Stick\n 128\n 10:00 AM\n BUN\n 29 mg/dL\n 03:04 AM\n Creatinine\n 0.8 mg/dL\n 03:04 AM\n Sodium\n 140 mEq/L\n 03:04 AM\n Potassium\n 3.9 mEq/L\n 03:04 AM\n Chloride\n 103 mEq/L\n 03:04 AM\n TCO2\n 28 mEq/L\n 03:04 AM\n PO2 (arterial)\n 108 mm Hg\n 03:08 AM\n PCO2 (arterial)\n 47 mm Hg\n 03:08 AM\n pH (arterial)\n 7.39 units\n 03:08 AM\n pH (urine)\n 8.0 units\n 06:50 AM\n CO2 (Calc) arterial\n 30 mEq/L\n 03:08 AM\n Albumin\n 3.3 g/dL\n 02:56 AM\n Calcium non-ionized\n 10.0 mg/dL\n 03:04 AM\n Phosphorus\n 3.6 mg/dL\n 03:04 AM\n Ionized Calcium\n 1.24 mmol/L\n 04:11 AM\n Magnesium\n 2.4 mg/dL\n 03:04 AM\n ALT\n 30 IU/L\n 03:29 AM\n Alkaline Phosphate\n 136 IU/L\n 03:29 AM\n AST\n 25 IU/L\n 03:29 AM\n Amylase\n 24 IU/L\n 02:48 AM\n Total Bilirubin\n 0.8 mg/dL\n 03:29 AM\n Triglyceride\n 440 mg/dL\n 09:01 PM\n WBC\n 10.8 K/uL\n 03:04 AM\n Hgb\n 9.6 g/dL\n 03:04 AM\n Hematocrit\n 28.4 %\n 03:04 AM\n Current diet order / nutrition support: NPO/Tube feed Replete with\n Fiber @ 90ml/hr providing 2160 kcal and 134g protein.\n GI: Abd soft, + bowel sounds, large BM ()\n Assessment of Nutritional Status\n 42 year old M with pancreatitis s/p drainage of pseudocyst, s/p ERCP,\n sphincterotomy, stone extraction now with VAP, and respiratory\n insufficiency with trach mask. Patient is currently receiving tube\n feeds of Replete with Fiber at goal rate of 90ml/hr providing 100% of\n estimated needs which have been well tolerated RN. Patient being\n followed by SLP however evaluation deferred increased\n secretions.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Continue with current tube feed regimen at goal\n 2. Monitor tolerance with residual checks q4h, abd exam, and\n bowels\n 3. Daily CHEM 10\n 4. Monitor lytes and BG. Correct with RISS PRN.\n 5. Will follow.\n"
},
{
"category": "Nutrition",
"chartdate": "2140-04-20 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 573294,
"text": "Subjective RN, patient is tolerating tube feeds well at goal, and\n had a large BM this am.\n Objective\n Current Wt: 88.3 kg ()\n Admit Wt: 88.7 kg\n Weight Change: -0.4kg\n Pertinent medications: Lasix, RISS, NPH, ABx, pepcid, metoprolol\n tartrate\n Labs:\n Value\n Date\n Glucose\n 93 mg/dL\n 03:04 AM\n Glucose Finger Stick\n 128\n 10:00 AM\n BUN\n 29 mg/dL\n 03:04 AM\n Creatinine\n 0.8 mg/dL\n 03:04 AM\n Sodium\n 140 mEq/L\n 03:04 AM\n Potassium\n 3.9 mEq/L\n 03:04 AM\n Chloride\n 103 mEq/L\n 03:04 AM\n TCO2\n 28 mEq/L\n 03:04 AM\n PO2 (arterial)\n 108 mm Hg\n 03:08 AM\n PCO2 (arterial)\n 47 mm Hg\n 03:08 AM\n pH (arterial)\n 7.39 units\n 03:08 AM\n pH (urine)\n 8.0 units\n 06:50 AM\n CO2 (Calc) arterial\n 30 mEq/L\n 03:08 AM\n Albumin\n 3.3 g/dL\n 02:56 AM\n Calcium non-ionized\n 10.0 mg/dL\n 03:04 AM\n Phosphorus\n 3.6 mg/dL\n 03:04 AM\n Ionized Calcium\n 1.24 mmol/L\n 04:11 AM\n Magnesium\n 2.4 mg/dL\n 03:04 AM\n ALT\n 30 IU/L\n 03:29 AM\n Alkaline Phosphate\n 136 IU/L\n 03:29 AM\n AST\n 25 IU/L\n 03:29 AM\n Amylase\n 24 IU/L\n 02:48 AM\n Total Bilirubin\n 0.8 mg/dL\n 03:29 AM\n Triglyceride\n 440 mg/dL\n 09:01 PM\n WBC\n 10.8 K/uL\n 03:04 AM\n Hgb\n 9.6 g/dL\n 03:04 AM\n Hematocrit\n 28.4 %\n 03:04 AM\n Current diet order / nutrition support: NPO/Tube feed Replete with\n Fiber @ 90ml/hr providing 2160 kcal and 134g protein.\n GI: Abd soft, + bowel sounds, large BM ()\n Assessment of Nutritional Status\n 42 year old M with pancreatitis s/p drainage of pseudocyst, s/p ERCP,\n sphincterotomy, stone extraction now with VAP, and respiratory\n insufficiency with trach mask. Patient is currently receiving tube\n feeds of Replete with Fiber at goal rate of 90ml/hr providing 100% of\n estimated needs which have been well tolerated RN. Patient being\n followed by SLP however evaluation deferred increased\n secretions.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Continue with current tube feed regimen at goal\n 2. Monitor tolerance with residual checks q4h, abd exam, and\n bowels\n 3. Daily CHEM 10\n 4. Monitor lytes and BG. Correct with RISS PRN.\n 5. Will follow.\n ------ Protected Section ------\n Agree with above note. Please page with questions. #\n ------ Protected Section Addendum Entered By: , RD, \n on: 15:38 ------\n"
},
{
"category": "Nutrition",
"chartdate": "2140-04-20 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 573280,
"text": "Subjective RN, patient is tolerating tube feeds well at goal, and\n had a large BM this am.\n Objective\n Current Wt: 88.3 kg ()\n Admit Wt: 88.7 kg\n Weight Change: -0.4kg\n Pertinent medications: Lasix, RISS, NPH, ABx, pepcid, metoprolol\n tartrate\n Labs:\n Value\n Date\n Glucose\n 93 mg/dL\n 03:04 AM\n Glucose Finger Stick\n 128\n 10:00 AM\n BUN\n 29 mg/dL\n 03:04 AM\n Creatinine\n 0.8 mg/dL\n 03:04 AM\n Sodium\n 140 mEq/L\n 03:04 AM\n Potassium\n 3.9 mEq/L\n 03:04 AM\n Chloride\n 103 mEq/L\n 03:04 AM\n TCO2\n 28 mEq/L\n 03:04 AM\n PO2 (arterial)\n 108 mm Hg\n 03:08 AM\n PCO2 (arterial)\n 47 mm Hg\n 03:08 AM\n pH (arterial)\n 7.39 units\n 03:08 AM\n pH (urine)\n 8.0 units\n 06:50 AM\n CO2 (Calc) arterial\n 30 mEq/L\n 03:08 AM\n Albumin\n 3.3 g/dL\n 02:56 AM\n Calcium non-ionized\n 10.0 mg/dL\n 03:04 AM\n Phosphorus\n 3.6 mg/dL\n 03:04 AM\n Ionized Calcium\n 1.24 mmol/L\n 04:11 AM\n Magnesium\n 2.4 mg/dL\n 03:04 AM\n ALT\n 30 IU/L\n 03:29 AM\n Alkaline Phosphate\n 136 IU/L\n 03:29 AM\n AST\n 25 IU/L\n 03:29 AM\n Amylase\n 24 IU/L\n 02:48 AM\n Total Bilirubin\n 0.8 mg/dL\n 03:29 AM\n Triglyceride\n 440 mg/dL\n 09:01 PM\n WBC\n 10.8 K/uL\n 03:04 AM\n Hgb\n 9.6 g/dL\n 03:04 AM\n Hematocrit\n 28.4 %\n 03:04 AM\n Current diet order / nutrition support: NPO/Tube feed Replete with\n Fiber @ 90ml/hr\n GI: Abd soft, + bowel sounds, large BM ()\n Assessment of Nutritional Status\n 42 year old M with pancreatitis s/p drainage of pseudocyst, s/p ERCP,\n sphincterotomy, stone extraction now with VAP, and respiratory\n insufficiency with trach mask. Patient is currently receiving tube\n feeds of Replete with Fiber at goal rate of 90ml/hr providing 100% of\n estimated needs which have been well tolerated RN. Patient being\n followed by SLP however evaluation deferred increased\n secretions.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Continue with current tube feed regimen at goal\n 2. Monitor tolerance with residual checks q4h, abd exam, and\n bowels\n 3. Monitor lytes and BG. Correct with RISS PRN.\n 4. Will follow.\n"
},
{
"category": "Nutrition",
"chartdate": "2140-04-20 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 573282,
"text": "Subjective RN, patient is tolerating tube feeds well at goal, and\n had a large BM this am.\n Objective\n Current Wt: 88.3 kg ()\n Admit Wt: 88.7 kg\n Weight Change: -0.4kg\n Pertinent medications: Lasix, RISS, NPH, ABx, pepcid, metoprolol\n tartrate\n Labs:\n Value\n Date\n Glucose\n 93 mg/dL\n 03:04 AM\n Glucose Finger Stick\n 128\n 10:00 AM\n BUN\n 29 mg/dL\n 03:04 AM\n Creatinine\n 0.8 mg/dL\n 03:04 AM\n Sodium\n 140 mEq/L\n 03:04 AM\n Potassium\n 3.9 mEq/L\n 03:04 AM\n Chloride\n 103 mEq/L\n 03:04 AM\n TCO2\n 28 mEq/L\n 03:04 AM\n PO2 (arterial)\n 108 mm Hg\n 03:08 AM\n PCO2 (arterial)\n 47 mm Hg\n 03:08 AM\n pH (arterial)\n 7.39 units\n 03:08 AM\n pH (urine)\n 8.0 units\n 06:50 AM\n CO2 (Calc) arterial\n 30 mEq/L\n 03:08 AM\n Albumin\n 3.3 g/dL\n 02:56 AM\n Calcium non-ionized\n 10.0 mg/dL\n 03:04 AM\n Phosphorus\n 3.6 mg/dL\n 03:04 AM\n Ionized Calcium\n 1.24 mmol/L\n 04:11 AM\n Magnesium\n 2.4 mg/dL\n 03:04 AM\n ALT\n 30 IU/L\n 03:29 AM\n Alkaline Phosphate\n 136 IU/L\n 03:29 AM\n AST\n 25 IU/L\n 03:29 AM\n Amylase\n 24 IU/L\n 02:48 AM\n Total Bilirubin\n 0.8 mg/dL\n 03:29 AM\n Triglyceride\n 440 mg/dL\n 09:01 PM\n WBC\n 10.8 K/uL\n 03:04 AM\n Hgb\n 9.6 g/dL\n 03:04 AM\n Hematocrit\n 28.4 %\n 03:04 AM\n Current diet order / nutrition support: NPO/Tube feed Replete with\n Fiber @ 90ml/hr\n GI: Abd soft, + bowel sounds, large BM ()\n Assessment of Nutritional Status\n 42 year old M with pancreatitis s/p drainage of pseudocyst, s/p ERCP,\n sphincterotomy, stone extraction now with VAP, and respiratory\n insufficiency with trach mask. Patient is currently receiving tube\n feeds of Replete with Fiber at goal rate of 90ml/hr providing 100% of\n estimated needs which have been well tolerated RN. Patient being\n followed by SLP however evaluation deferred increased\n secretions.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Continue with current tube feed regimen at goal\n 2. Monitor tolerance with residual checks q4h, abd exam, and\n bowels\n 3. Daily CHEM 10\n 4. Monitor lytes and BG. Correct with RISS PRN.\n 5. Will follow.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572295,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction.\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n EVENTS:\n : Very agitated. Hypertensive/ Tachycardic. Medicated with IVP\n Ativan/Haldolol with minimal effect. sedated on Propofol placed on\n CMV/50%/5 PEEP/RR 12.\n : Liver and bladder US with results pending. Continues on\n Propofol/IVP Ativan and PO Haldolol for agitation.\n : R-SC CVL discontinued-catheter tip sent fore culture. New L-SC\n CVL placed. Placement confirmed by CRX . CT of ABD with contrast.\n Family updated regarding POC. Plan for family meeting in the next few\n days.\n Impaired Physical Mobility\n Assessment:\n Patient on bedrest\n Has gotten oob to chair with assistance\n Able to help with turns and cares\n Normal strength to all extremities\n Action:\n Turned every 2 hrs\n Patient turns himself also\n Uses hands and feet with turns\n Response:\n Patient appears to be in good shape for physical therapy\n Continue to encourage patient to do what he can for himself\n Plan:\n Increase activity as tolerated\n Promote nutrition\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Patient on trach collar most of the night.\n Began to breath faster towards 0200\n Less secretions tonight\n Action:\n Put on CPAP to rest\n Suctioned as needed\n Turned every 2 hrs\n Response:\n Patient had good night\n Less suctioning\n On CPAP for 6 hrs\n Plan:\n Back to trach collar\n Suction as needed\n Oral secretions via yankor\n Hyperglycemia\n Assessment:\n Patient with high glucose during the day\n Is on Q as/HS blood sugars\n Has a fixed dose \n Action:\n Stable glucose tonight\n 6 units regular SC\n 60 units NPH fixed at 2200\n Response:\n O400 =119\n No SS coverage for this result\n Plan:\n Continue to monitor and treat as needed.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-17 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 572823,
"text": "Respiratory Care Service: Pt remains with an 8.0 Blue-Line Portex Trach\n in place. Placed back on mechanical ventilation last night for\n agitation-tachypnea/ need for sedation in setting of fever.\n Currenly on the AC mode 600/14/.40/5 PEEP. ABG stable. Will change to\n PSV as tolerated.\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-20 00:00:00.000",
"description": "Intensivist Note",
"row_id": 573262,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ VAP, bacteremia.\n Chief complaint:\n postoperative respiratory insufficiency, hospital acquired pneumonia\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n Acetaminophen 3. Albuterol Inhaler 4. Bisacodyl 5. Chlorhexidine\n Gluconate 0.12% Oral Rinse\n 6. CloniDINE 7. Famotidine 8. Fentanyl Patch 9. Furosemide 10.\n Haloperidol 11. Heparin 12. Insulin\n 13. Ipratropium Bromide MDI 14. Linezolid 15. Lidocaine 1% 16.\n Magnesium Sulfate 17. Metoprolol Tartrate\n 18. Meropenem 19. Miconazole 2% Cream 20. Miconazole Powder 2% 21.\n Nystatin Oral Suspension 22. Potassium Chloride 23. Potassium Chloride\n 24. Potassium Phosphate\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 09:06 AM\n Tobramycin - 09:26 PM\n Meropenem - 12:00 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 12:00 AM\n Furosemide (Lasix) - 04:05 AM\n Heparin Sodium (Prophylaxis) - 06:02 AM\n Famotidine (Pepcid) - 06:03 AM\n Other medications:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36.7\nC (98\n HR: 72 (69 - 92) bpm\n BP: 107/48(65) {107/48(65) - 142/76(99)} mmHg\n RR: 35 (10 - 35) insp/min\n SPO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 88.2 kg (admission): 88.7 kg\n Height: 69 Inch\n Total In:\n 3,027 mL\n 825 mL\n PO:\n Tube feeding:\n 2,176 mL\n 549 mL\n IV Fluid:\n 640 mL\n 216 mL\n Blood products:\n Total out:\n 2,325 mL\n 910 mL\n Urine:\n 2,325 mL\n 910 mL\n NG:\n Stool:\n Drains:\n Balance:\n 702 mL\n -85 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SPO2: 98%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Rhonchorous : , Diminished: at bases)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli, Noxious stimuli), Moves\n all extremities\n Labs / Radiology\n 373 K/uL\n 9.6 g/dL\n 93 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 29 mg/dL\n 103 mEq/L\n 140 mEq/L\n 28.4 %\n 10.8 K/uL\n [image002.jpg]\n 03:18 AM\n 04:29 AM\n 03:23 AM\n 03:33 AM\n 03:46 PM\n 09:39 PM\n 02:56 AM\n 03:08 AM\n 02:37 AM\n 03:04 AM\n WBC\n 9.4\n 8.8\n 10.8\n 14.2\n 14.0\n 12.4\n 10.8\n Hct\n 23.3\n 27.8\n 30.1\n 33.3\n 27.7\n 28.2\n 28.4\n Plt\n 55\n 371\n 353\n 373\n Creatinine\n 1.2\n 1.0\n 0.9\n 0.9\n 1.0\n 0.8\n 0.8\n TCO2\n 31\n 27\n 30\n Glucose\n 89\n 119\n 124\n 110\n 109\n 103\n 93\n Other labs: PT / PTT / INR:12.4/22.4/1.0, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:79.4 %, Lymph:15.3 %, Mono:3.2 %,\n Eos:1.7 %, Lactic Acid:2.4 mmol/L, Albumin:3.3 g/dL, LDH:212 IU/L,\n Ca:10.0 mg/dL, Mg:2.4 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), IMPAIRED PHYSICAL MOBILITY, HYPERGLYCEMIA\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ VAP, bacteremia.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Haldol qhs,\n clonidine 0.1 TID, fentanyl patch, psych consult done.\n Cardiovascular: Beta-blocker, hemodynamically stable, cont lopressor.\n Dc aline.\n Pulmonary: Trach, TC x 24hrs. will go to passemuir valve. pulm toilet,\n abx\n Gastrointestinal / Abdomen: TF, NPO, swallow eval in near future\n Nutrition: Tube feeding, NPO, TF, NPO, swallow eval in near future\n Renal: Foley, Adequate UO, Cr stable 0.8, KVO'd\n Hematology: Serial Hct, Hct stable at 28.4\n Endocrine: RISS, NPH insulin with RISS, goal FS<150\n blood sugars well controlled\n Infectious Disease: Check cultures, f/u cx, treating for aspiration\n pneumonia, following id recs for length of treatment.\n linezolid()/(. known bacteremia + line infection.\n Lines / Tubes / Drains: Foley, G-tube, Trach, , L SCL CVL, Flexiseal,\n Aline\n Wounds: Dry dressings\n Imaging: none\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Comments: tube feeds\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Multi Lumen - 08:14 AM\n Arterial Line - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 20 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572828,
"text": "Hypotension (not Shock)\n Assessment:\n - low urine outputs\n - sbp decreased to 88-92\n Action:\n - given 500cc LR bolus X 2\n - started on maintenance fluid at 100ml/hr\n Response:\n - urine output increased\n - sbp increased to 100s\n Plan:\n - continue to monitor sbp and urine outputs\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n - fever up to 100\n Action:\n - Antibiotic changed to meropenem\n - Awaiting culture results\n Response:\n - temp decreased to 99.4\n Plan:\n - continue to assess temperature\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n - sedated this morning and mechanically vented on CMV for\n severe agitation overnight\n - pt on 30 of propofol, and continually restless in bed\n - copious amts of oral secretions\n Action:\n - titrated propofol to most comfortable level for pt\n - blood gas was sent\n - sub-glottal suctioned multiple times throughout shift\n - tracheal suctioned as needed\n Response:\n - propofol decreased around 1600, pt became much more alert,\n and calm/cooperative, mouthing words\n - rate decreased after blood gas results returned\n - tracheal suctioned for thin white secretions\n Plan:\n - change vent to CPAP as tolerated by pt\n - continue mild sedation\n - continue to assess respiratory function\n - continue to suction as needed\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-18 00:00:00.000",
"description": "Intensivist Note",
"row_id": 572921,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ UTI, VAP, bacteremia.\n Chief complaint:\n abd pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n Current medications:\n 1. Linezolid 600 mg PO Q12H Order date: @ 1653\n 2. Lidocaine 1% 3-5 mL IH Q4-6 HRS PRN Order date: @ 1854\n 3. Magnesium Sulfate IV Sliding Scale Order date: @ 0234\n 4. 1000 mL LR Continuous at 50 ml/hr Order date: @ 0204\n 5. Metoprolol Tartrate 5 mg IV Q6H tachycadia/HTN hold for SBP<100\n HR<60 Order date: @ 1218\n 6. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308\n 7. Meropenem 500 mg IV Q8H Order date: @ 1448\n 8. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze/SOB Order date: @\n 0815\n 9. Miconazole 2% Cream 1 Appl TP yeast rash Order date: @\n 2347\n 10. Miconazole Powder 2% 1 Appl TP TID:PRN Order date: @ 1255\n 11. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139\n 12. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @ 0555\n 13. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL Use only if\n patient is on mechanical ventilation. Order date: @ 1119\n 14. Potassium Chloride PO Sliding Scale Hold for K > 5 Order date:\n @ 0505\n 15. Famotidine 20 mg IV Q12H Order date: @ 0419\n 16. Potassium Chloride IV Sliding Scale Order date: @ 0526\n 17. Fentanyl Patch 75 mcg/hr TP Q72H Order date: @ 0751\n 18. Potassium Phosphate IV Sliding Scale Infuse over 6 hours Order\n date: @ 0647\n 19. Haloperidol 1 mg PO TID through G tube Order date: @ 1014\n 20. Propofol 20-50 mcg/kg/min IV DRIP TITRATE TO sedation Order date:\n @ 0621\n 21. Heparin 5000 UNIT SC BID Order date: @ 0139\n 22. Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose\n Order date: @ 1234\n 23. Tobramycin 450 mg IV Q24H Order date: @ 1607\n 24. Ipratropium Bromide MDI 2 PUFF IH QID Order date: @ 0815\n 24 Hour Events:\n ARTERIAL LINE - START 08:00 AM\n placed by SICU resident\n Placed back on propofol gtt/vent for agitation. WBC increased. D/c'd\n Ativan. Placed Aline. D/c'd Zosyn, started as per ID. Bolused\n LR 500cc x 2 then started on LR @ 100 -> 50 for low UOP & hypotension.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:55 PM\n Piperacillin - 09:06 AM\n Tobramycin - 09:26 PM\n Meropenem - 11:34 PM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 04:54 AM\n Heparin Sodium (Prophylaxis) - 04:56 AM\n Other medications:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 37.7\nC (99.9\n HR: 72 (70 - 106) bpm\n BP: 134/69(90) {92/46(60) - 151/93(270)} mmHg\n RR: 19 (11 - 23) insp/min\n SPO2: 96%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 69 Inch\n Total In:\n 5,044 mL\n 1,341 mL\n PO:\n Tube feeding:\n 2,160 mL\n 621 mL\n IV Fluid:\n 2,794 mL\n 660 mL\n Blood products:\n Total out:\n 1,475 mL\n 630 mL\n Urine:\n 1,475 mL\n 630 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,569 mL\n 711 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 600) mL\n Vt (Spontaneous): 298 (298 - 298) mL\n PS : 12 cmH2O\n RR (Set): 10\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 74\n PIP: 22 cmH2O\n Plateau: 16 cmH2O\n Compliance: 54.5 cmH2O/mL\n SPO2: 96%\n ABG: 7.39/47/108/28/2\n Ve: 6.2 L/min\n PaO2 / FiO2: 270\n Physical Examination\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : diffusely b/l)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Sedated\n Labs / Radiology\n 371 K/uL\n 9.5 g/dL\n 109 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 32 mg/dL\n 102 mEq/L\n 139 mEq/L\n 27.7 %\n 14.0 K/uL\n [image002.jpg]\n 03:00 AM\n 12:31 PM\n 03:18 AM\n 04:29 AM\n 03:23 AM\n 03:33 AM\n 03:46 PM\n 09:39 PM\n 02:56 AM\n 03:08 AM\n WBC\n 9.4\n 8.8\n 10.8\n 14.2\n 14.0\n Hct\n 24.6\n 23.3\n 27.8\n 30.1\n 33.3\n 27.7\n Plt\n 55\n 371\n Creatinine\n 1.2\n 1.0\n 0.9\n 0.9\n 1.0\n TCO2\n 26\n 31\n 27\n 30\n Glucose\n 89\n 119\n 124\n 110\n 109\n Other labs: PT / PTT / INR:12.4/22.4/1.0, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:79.4 %, Lymph:15.3 %, Mono:3.2 %,\n Eos:1.7 %, Lactic Acid:2.4 mmol/L, Albumin:3.3 g/dL, LDH:212 IU/L,\n Ca:9.3 mg/dL, Mg:2.2 mg/dL, PO4:3.7 mg/dL\n Microbiology: blood: neg\n urine: yeast\n MRSA: neg\n PICC tip: neg\n sputum: E.coli x 2 (S to Ancef, cefepime, ceftaz, ceftriaxone,\n cipro, gent, , Zosyn, tobra, Bactrim), Klebsiella (pan S), yeast\n bld x2: neg\n C.diff: neg\n bld: coag neg Staph\n urine: yeast >100K\n R SCL CVL tip: Klebsiella (pan S)\n urine: neg\n bld x 2: P\n bld x 2: P\n sputum: contam\n mini BAL: P\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), IMPAIRED PHYSICAL MOBILITY, HYPERGLYCEMIA\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ UTI, VAP, bacteremia.\n Neurologic: Pain controlled, Cont to have periods of agitation which\n are difficult to control\n Haldol TID. Wean propofol gtt. Fentanyl\n patch for pain. Restart clonidine if pressure tolerates.\n Cardiovascular: Beta-blocker, Mild hypotension responsive to\n crystalloid resuscitation. On metoprolol 5q6h.\n Pulmonary: Trach, Wean to trach collar today. Pulm toilet. Continue\n abx for VAP.\n Gastrointestinal / Abdomen: Continue TF.\n Nutrition: Tube feeding, NPO\n Renal: Foley, Adequate UO, UOP responded to IVF. Stable Cr & lytes.\n Hematology: Hct 27.7 from 33.3, likely dilutional.\n Endocrine: RISS, Goal FS<150.\n Infectious Disease: Check cultures from yesterday, WBC elevated 14.0.\n On linezolid, , tobra for E.coli PNA & Klebsiella bacteremia. F/u\n ID recs.\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Dry dressings\n Imaging: CXR\n Fluids: KVO IVFs\n Consults: General surgery, ID dept\n Billing Diagnosis: Sepsis, Respiratory failure\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:53 PM 89.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 08:14 AM\n Arterial Line - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds, ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 573098,
"text": "HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ VAP, intermittent bacteremic\n episodes/agitation.\n Chief complaint:\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572884,
"text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572887,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ UTI, VAP, bacteremia.\n Chief complaint:\n respiratory insufficiency, sepsis\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n On propofol gtt at 20mcg/kg/min, remains on ventilator cpap 40% 5/12.\n Suctioned for white sputum via trach and orally.\n Resp rate 15-20\n O2sat 95-100%\n Action:\n Tracheal suctioned prn\n Orally suctioned for copius amts of white sputum.\n Head of bed 30-45 degrees\n Turned q2hrs.\n Abg as md order.\n Propofol gtt iv and titrate.\n Pulmonary toileting.\n Response:\n Tolerating weaning of vent settings.\n Begin to wean propofol gtt to off.\n Plan:\n Monitor resp status closely. \\\n Provide emotional support to patient while weaning from ventilator.\n Continue to provide pulmonary hygiene\n Impaired Skin Integrity\n Assessment:\n Groin, coccyx and buttocks slightly reddened.\n Action:\n Turned q2hrs. micolozole powder applied to area.\n Response:\n Area improved.\n Plan:\n Continue to turn q2hr. oob to chair prn.\n Miconazole powder prn.\n Mother, sister and cousin in to visit. Family asking if they could\n have a meeting with the doctors regarding update of \n condition. Sister asking to have greek interpreter present for her\n mother. emailed on this matter.\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-18 00:00:00.000",
"description": "Intensivist Note",
"row_id": 572898,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ UTI, VAP, bacteremia.\n Chief complaint:\n abd pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n Current medications:\n 1. Linezolid 600 mg PO Q12H Order date: @ 1653\n 2. Lidocaine 1% 3-5 mL IH Q4-6 HRS PRN Order date: @ 1854\n 3. Magnesium Sulfate IV Sliding Scale Order date: @ 0234\n 4. 1000 mL LR Continuous at 50 ml/hr Order date: @ 0204\n 5. Metoprolol Tartrate 5 mg IV Q6H tachycadia/HTN hold for SBP<100\n HR<60 Order date: @ 1218\n 6. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308\n 7. Meropenem 500 mg IV Q8H Order date: @ 1448\n 8. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze/SOB Order date: @\n 0815\n 9. Miconazole 2% Cream 1 Appl TP yeast rash Order date: @\n 2347\n 10. Miconazole Powder 2% 1 Appl TP TID:PRN Order date: @ 1255\n 11. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139\n 12. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @ 0555\n 13. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL Use only if\n patient is on mechanical ventilation. Order date: @ 1119\n 14. Potassium Chloride PO Sliding Scale Hold for K > 5 Order date:\n @ 0505\n 15. Famotidine 20 mg IV Q12H Order date: @ 0419\n 16. Potassium Chloride IV Sliding Scale Order date: @ 0526\n 17. Fentanyl Patch 75 mcg/hr TP Q72H Order date: @ 0751\n 18. Potassium Phosphate IV Sliding Scale Infuse over 6 hours Order\n date: @ 0647\n 19. Haloperidol 1 mg PO TID through G tube Order date: @ 1014\n 20. Propofol 20-50 mcg/kg/min IV DRIP TITRATE TO sedation Order date:\n @ 0621\n 21. Heparin 5000 UNIT SC BID Order date: @ 0139\n 22. Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose\n Order date: @ 1234\n 23. Tobramycin 450 mg IV Q24H Order date: @ 1607\n 24. Ipratropium Bromide MDI 2 PUFF IH QID Order date: @ 0815\n 24 Hour Events:\n ARTERIAL LINE - START 08:00 AM\n placed by SICU resident\n Placed back on propofol gtt/vent for agitation. WBC increased. D/c'd\n Ativan. Placed Aline. D/c'd Zosyn, started as per ID. Bolused\n LR 500cc x 2 then started on LR @ 100 -> 50 for low UOP & hypotension.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:55 PM\n Piperacillin - 09:06 AM\n Tobramycin - 09:26 PM\n Meropenem - 11:34 PM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 04:54 AM\n Heparin Sodium (Prophylaxis) - 04:56 AM\n Other medications:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 37.7\nC (99.9\n HR: 72 (70 - 106) bpm\n BP: 134/69(90) {92/46(60) - 151/93(270)} mmHg\n RR: 19 (11 - 23) insp/min\n SPO2: 96%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 69 Inch\n Total In:\n 5,044 mL\n 1,341 mL\n PO:\n Tube feeding:\n 2,160 mL\n 621 mL\n IV Fluid:\n 2,794 mL\n 660 mL\n Blood products:\n Total out:\n 1,475 mL\n 630 mL\n Urine:\n 1,475 mL\n 630 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,569 mL\n 711 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 600) mL\n Vt (Spontaneous): 298 (298 - 298) mL\n PS : 12 cmH2O\n RR (Set): 10\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 74\n PIP: 22 cmH2O\n Plateau: 16 cmH2O\n Compliance: 54.5 cmH2O/mL\n SPO2: 96%\n ABG: 7.39/47/108/28/2\n Ve: 6.2 L/min\n PaO2 / FiO2: 270\n Physical Examination\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : diffusely b/l)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Sedated\n Labs / Radiology\n 371 K/uL\n 9.5 g/dL\n 109 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 32 mg/dL\n 102 mEq/L\n 139 mEq/L\n 27.7 %\n 14.0 K/uL\n [image002.jpg]\n 03:00 AM\n 12:31 PM\n 03:18 AM\n 04:29 AM\n 03:23 AM\n 03:33 AM\n 03:46 PM\n 09:39 PM\n 02:56 AM\n 03:08 AM\n WBC\n 9.4\n 8.8\n 10.8\n 14.2\n 14.0\n Hct\n 24.6\n 23.3\n 27.8\n 30.1\n 33.3\n 27.7\n Plt\n 55\n 371\n Creatinine\n 1.2\n 1.0\n 0.9\n 0.9\n 1.0\n TCO2\n 26\n 31\n 27\n 30\n Glucose\n 89\n 119\n 124\n 110\n 109\n Other labs: PT / PTT / INR:12.4/22.4/1.0, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:79.4 %, Lymph:15.3 %, Mono:3.2 %,\n Eos:1.7 %, Lactic Acid:2.4 mmol/L, Albumin:3.3 g/dL, LDH:212 IU/L,\n Ca:9.3 mg/dL, Mg:2.2 mg/dL, PO4:3.7 mg/dL\n Microbiology: blood: neg\n urine: yeast\n MRSA: neg\n PICC tip: neg\n sputum: E.coli x 2 (S to Ancef, cefepime, ceftaz, ceftriaxone,\n cipro, gent, , Zosyn, tobra, Bactrim), Klebsiella (pan S), yeast\n bld x2: neg\n C.diff: neg\n bld: coag neg Staph\n urine: yeast >100K\n R SCL CVL tip: Klebsiella (pan S)\n urine: neg\n bld x 2: P\n bld x 2: P\n sputum: contam\n mini BAL: P\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), IMPAIRED PHYSICAL MOBILITY, HYPERGLYCEMIA\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ UTI, VAP, bacteremia.\n Neurologic: Pain controlled, Haldol TID. Wean propofol gtt. Fentanyl\n patch for pain.\n Cardiovascular: Beta-blocker, Resuscitated, now HD stable. On\n metoprolol 5q6h.\n Pulmonary: Trach, Wean to trach collar today. Pulm toilet. Continue\n abx for VAP.\n Gastrointestinal / Abdomen: Continue TF. Swallow eval on Tues.\n Nutrition: Tube feeding, NPO, Speech and Swallow eval\n Renal: Foley, Adequate UO, UOP responded to IVF. HLIV. Stable Cr &\n lytes.\n Hematology: Hct 27.7 from 33.3, likely dilutional.\n Endocrine: RISS, Goal FS<150.\n Infectious Disease: Check cultures, WBC elevated 14.0. On linezolid,\n , tobra for E.coli PNA & Klebsiella bacteremia. F/u ID recs.\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Dry dressings\n Imaging:\n Fluids: LR\n Consults: General surgery, ID dept\n Billing Diagnosis: Sepsis\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:53 PM 89.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 08:14 AM\n Arterial Line - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572912,
"text": "Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-18 00:00:00.000",
"description": "Intensivist Note",
"row_id": 572915,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ UTI, VAP, bacteremia.\n Chief complaint:\n abd pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n : unknown\n Current medications:\n 1. Linezolid 600 mg PO Q12H Order date: @ 1653\n 2. Lidocaine 1% 3-5 mL IH Q4-6 HRS PRN Order date: @ 1854\n 3. Magnesium Sulfate IV Sliding Scale Order date: @ 0234\n 4. 1000 mL LR Continuous at 50 ml/hr Order date: @ 0204\n 5. Metoprolol Tartrate 5 mg IV Q6H tachycadia/HTN hold for SBP<100\n HR<60 Order date: @ 1218\n 6. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308\n 7. Meropenem 500 mg IV Q8H Order date: @ 1448\n 8. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze/SOB Order date: @\n 0815\n 9. Miconazole 2% Cream 1 Appl TP yeast rash Order date: @\n 2347\n 10. Miconazole Powder 2% 1 Appl TP TID:PRN Order date: @ 1255\n 11. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139\n 12. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @ 0555\n 13. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL Use only if\n patient is on mechanical ventilation. Order date: @ 1119\n 14. Potassium Chloride PO Sliding Scale Hold for K > 5 Order date:\n @ 0505\n 15. Famotidine 20 mg IV Q12H Order date: @ 0419\n 16. Potassium Chloride IV Sliding Scale Order date: @ 0526\n 17. Fentanyl Patch 75 mcg/hr TP Q72H Order date: @ 0751\n 18. Potassium Phosphate IV Sliding Scale Infuse over 6 hours Order\n date: @ 0647\n 19. Haloperidol 1 mg PO TID through G tube Order date: @ 1014\n 20. Propofol 20-50 mcg/kg/min IV DRIP TITRATE TO sedation Order date:\n @ 0621\n 21. Heparin 5000 UNIT SC BID Order date: @ 0139\n 22. Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose\n Order date: @ 1234\n 23. Tobramycin 450 mg IV Q24H Order date: @ 1607\n 24. Ipratropium Bromide MDI 2 PUFF IH QID Order date: @ 0815\n 24 Hour Events:\n ARTERIAL LINE - START 08:00 AM\n placed by SICU resident\n Placed back on propofol gtt/vent for agitation. WBC increased. D/c'd\n Ativan. Placed Aline. D/c'd Zosyn, started as per ID. Bolused\n LR 500cc x 2 then started on LR @ 100 -> 50 for low UOP & hypotension.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:55 PM\n Piperacillin - 09:06 AM\n Tobramycin - 09:26 PM\n Meropenem - 11:34 PM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 04:54 AM\n Heparin Sodium (Prophylaxis) - 04:56 AM\n Other medications:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 37.7\nC (99.9\n HR: 72 (70 - 106) bpm\n BP: 134/69(90) {92/46(60) - 151/93(270)} mmHg\n RR: 19 (11 - 23) insp/min\n SPO2: 96%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 69 Inch\n Total In:\n 5,044 mL\n 1,341 mL\n PO:\n Tube feeding:\n 2,160 mL\n 621 mL\n IV Fluid:\n 2,794 mL\n 660 mL\n Blood products:\n Total out:\n 1,475 mL\n 630 mL\n Urine:\n 1,475 mL\n 630 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,569 mL\n 711 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 600) mL\n Vt (Spontaneous): 298 (298 - 298) mL\n PS : 12 cmH2O\n RR (Set): 10\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 74\n PIP: 22 cmH2O\n Plateau: 16 cmH2O\n Compliance: 54.5 cmH2O/mL\n SPO2: 96%\n ABG: 7.39/47/108/28/2\n Ve: 6.2 L/min\n PaO2 / FiO2: 270\n Physical Examination\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : diffusely b/l)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Sedated\n Labs / Radiology\n 371 K/uL\n 9.5 g/dL\n 109 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 32 mg/dL\n 102 mEq/L\n 139 mEq/L\n 27.7 %\n 14.0 K/uL\n [image002.jpg]\n 03:00 AM\n 12:31 PM\n 03:18 AM\n 04:29 AM\n 03:23 AM\n 03:33 AM\n 03:46 PM\n 09:39 PM\n 02:56 AM\n 03:08 AM\n WBC\n 9.4\n 8.8\n 10.8\n 14.2\n 14.0\n Hct\n 24.6\n 23.3\n 27.8\n 30.1\n 33.3\n 27.7\n Plt\n 55\n 371\n Creatinine\n 1.2\n 1.0\n 0.9\n 0.9\n 1.0\n TCO2\n 26\n 31\n 27\n 30\n Glucose\n 89\n 119\n 124\n 110\n 109\n Other labs: PT / PTT / INR:12.4/22.4/1.0, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:79.4 %, Lymph:15.3 %, Mono:3.2 %,\n Eos:1.7 %, Lactic Acid:2.4 mmol/L, Albumin:3.3 g/dL, LDH:212 IU/L,\n Ca:9.3 mg/dL, Mg:2.2 mg/dL, PO4:3.7 mg/dL\n Microbiology: blood: neg\n urine: yeast\n MRSA: neg\n PICC tip: neg\n sputum: E.coli x 2 (S to Ancef, cefepime, ceftaz, ceftriaxone,\n cipro, gent, , Zosyn, tobra, Bactrim), Klebsiella (pan S), yeast\n bld x2: neg\n C.diff: neg\n bld: coag neg Staph\n urine: yeast >100K\n R SCL CVL tip: Klebsiella (pan S)\n urine: neg\n bld x 2: P\n bld x 2: P\n sputum: contam\n mini BAL: P\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), IMPAIRED PHYSICAL MOBILITY, HYPERGLYCEMIA\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ UTI, VAP, bacteremia.\n Neurologic: Pain controlled, Haldol TID. Wean propofol gtt. Fentanyl\n patch for pain. Restart clonidine if pressure tolerates.\n Cardiovascular: Beta-blocker, Resuscitated, now HD stable. On\n metoprolol 5q6h.\n Pulmonary: Trach, Wean to trach collar today. Pulm toilet. Continue\n abx for VAP.\n Gastrointestinal / Abdomen: Continue TF.\n Nutrition: Tube feeding, NPO, Speech and Swallow eval when off vent and\n stable\n Renal: Foley, Adequate UO, UOP responded to IVF. HLIV. Stable Cr &\n lytes.\n Hematology: Hct 27.7 from 33.3, likely dilutional.\n Endocrine: RISS, Goal FS<150.\n Infectious Disease: Check cultures, WBC elevated 14.0. On linezolid,\n , tobra for E.coli PNA & Klebsiella bacteremia. F/u ID recs.\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO IVFs\n Consults: General surgery, ID dept\n Billing Diagnosis: Sepsis\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:53 PM 89.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 08:14 AM\n Arterial Line - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-19 00:00:00.000",
"description": "Daily ICU Note",
"row_id": 573076,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ VAP, intermittent bacteremic\n episodes/agitation.\n Chief complaint:\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. 2. Acetaminophen 3. Albuterol Inhaler 4. Bisacodyl 5. Chlorhexidine\n Gluconate 0.12% Oral Rinse\n 6. CloniDINE 7. Famotidine 8. Fentanyl Patch 9. Haloperidol 10. Heparin\n 11. Insulin 12. Ipratropium Bromide MDI\n 13. Linezolid 14. Lidocaine 1% 15. Magnesium Sulfate 16. Metoprolol\n Tartrate 17. Meropenem 18. Miconazole 2% Cream\n 19. Miconazole Powder 2% 20. Nystatin Oral Suspension 21. Potassium\n Chloride 22. Potassium Chloride\n 23. Potassium Phosphate 24. Propofol 25. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n NASAL SWAB - At 10:00 AM\n - on trach collar\n - agitation improved\n - tobra d/c'd\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:55 PM\n Piperacillin - 09:06 AM\n Tobramycin - 09:26 PM\n Meropenem - 12:14 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 06:00 AM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Metoprolol - 06:00 AM\n Other medications:\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.1\nC (98.8\n HR: 70 (70 - 91) bpm\n BP: 127/68(86) {97/48(63) - 148/92(103)} mmHg\n RR: 20 (13 - 38) insp/min\n SPO2: 99%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 88.2 kg (admission): 88.7 kg\n Height: 69 Inch\n Total In:\n 3,660 mL\n 965 mL\n PO:\n Tube feeding:\n 2,162 mL\n 653 mL\n IV Fluid:\n 1,168 mL\n 223 mL\n Blood products:\n Total out:\n 2,375 mL\n 1,080 mL\n Urine:\n 2,375 mL\n 1,080 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,285 mL\n -115 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 350 (350 - 460) mL\n PS : 5 cmH2O\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 0 cmH2O\n SPO2: 99%\n ABG: ///27/\n Ve: 7.8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities, Able to make\n attempts at communication.\n Labs / Radiology\n 353 K/uL\n 9.8 g/dL\n 103 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 29 mg/dL\n 104 mEq/L\n 141 mEq/L\n 28.2 %\n 12.4 K/uL\n [image002.jpg]\n 12:31 PM\n 03:18 AM\n 04:29 AM\n 03:23 AM\n 03:33 AM\n 03:46 PM\n 09:39 PM\n 02:56 AM\n 03:08 AM\n 02:37 AM\n WBC\n 9.4\n 8.8\n 10.8\n 14.2\n 14.0\n 12.4\n Hct\n 24.6\n 23.3\n 27.8\n 30.1\n 33.3\n 27.7\n 28.2\n Plt\n 55\n 371\n 353\n Creatinine\n 1.2\n 1.0\n 0.9\n 0.9\n 1.0\n 0.8\n TCO2\n 31\n 27\n 30\n Glucose\n 89\n 119\n 124\n 110\n 109\n 103\n Other labs: PT / PTT / INR:12.4/22.4/1.0, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:79.4 %, Lymph:15.3 %, Mono:3.2 %,\n Eos:1.7 %, Lactic Acid:2.4 mmol/L, Albumin:3.3 g/dL, LDH:212 IU/L,\n Ca:9.6 mg/dL, Mg:2.2 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), IMPAIRED PHYSICAL MOBILITY, HYPERGLYCEMIA\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ VAP, intermittent\n bacteremic episodes/agitation.\n Neurologic: Pain controlled, Haldol TID, team would like to avoid\n propofol for sedation. Continue fentanyl patch, clonidine\n Cardiovascular: HD stable\n Pulmonary: Trach, TC as tolerated, pulm toilet\n Gastrointestinal / Abdomen: TF, NPO, ?swallow eval in near future\n Nutrition: Tube feeding, NPO, Speech and Swallow eval\n Renal: Foley, Adequate UO, Creat stable. Goal euvolemia today.\n Hematology: Hct stable.\n Endocrine: RISS, NPH 60 Units \n Infectious Disease: WBC trending down. Linezolid/ x day\n course (starting )\n Lines / Tubes / Drains: Foley, G-tube, Trach, Left subclavian central\n line, flexiseal, a-line\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: General surgery, ID dept\n Billing Diagnosis: (Respiratory distress: Failure), (Pneumonia due to\n procedure), Sepsis\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:02 PM 89.\n mL/hour\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Multi Lumen - 08:14 AM\n Arterial Line - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-19 00:00:00.000",
"description": "Daily ICU Note",
"row_id": 573084,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ VAP, intermittent bacteremic\n episodes/agitation.\n Chief complaint:\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. 2. Acetaminophen 3. Albuterol Inhaler 4. Bisacodyl 5. Chlorhexidine\n Gluconate 0.12% Oral Rinse\n 6. CloniDINE 7. Famotidine 8. Fentanyl Patch 9. Haloperidol 10. Heparin\n 11. Insulin 12. Ipratropium Bromide MDI\n 13. Linezolid 14. Lidocaine 1% 15. Magnesium Sulfate 16. Metoprolol\n Tartrate 17. Meropenem 18. Miconazole 2% Cream\n 19. Miconazole Powder 2% 20. Nystatin Oral Suspension 21. Potassium\n Chloride 22. Potassium Chloride\n 23. Potassium Phosphate 24. Propofol 25. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n NASAL SWAB - At 10:00 AM\n - on trach collar\n - agitation improved\n - tobra d/c'd\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:55 PM\n Piperacillin - 09:06 AM\n Tobramycin - 09:26 PM\n Meropenem - 12:14 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 06:00 AM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Metoprolol - 06:00 AM\n Other medications:\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.1\nC (98.8\n HR: 70 (70 - 91) bpm\n BP: 127/68(86) {97/48(63) - 148/92(103)} mmHg\n RR: 20 (13 - 38) insp/min\n SPO2: 99%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 88.2 kg (admission): 88.7 kg\n Height: 69 Inch\n Total In:\n 3,660 mL\n 965 mL\n PO:\n Tube feeding:\n 2,162 mL\n 653 mL\n IV Fluid:\n 1,168 mL\n 223 mL\n Blood products:\n Total out:\n 2,375 mL\n 1,080 mL\n Urine:\n 2,375 mL\n 1,080 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,285 mL\n -115 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 350 (350 - 460) mL\n PS : 5 cmH2O\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 0 cmH2O\n SPO2: 99%\n ABG: ///27/\n Ve: 7.8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities, Able to make\n attempts at communication.\n Labs / Radiology\n 353 K/uL\n 9.8 g/dL\n 103 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 29 mg/dL\n 104 mEq/L\n 141 mEq/L\n 28.2 %\n 12.4 K/uL\n [image002.jpg]\n 12:31 PM\n 03:18 AM\n 04:29 AM\n 03:23 AM\n 03:33 AM\n 03:46 PM\n 09:39 PM\n 02:56 AM\n 03:08 AM\n 02:37 AM\n WBC\n 9.4\n 8.8\n 10.8\n 14.2\n 14.0\n 12.4\n Hct\n 24.6\n 23.3\n 27.8\n 30.1\n 33.3\n 27.7\n 28.2\n Plt\n 55\n 371\n 353\n Creatinine\n 1.2\n 1.0\n 0.9\n 0.9\n 1.0\n 0.8\n TCO2\n 31\n 27\n 30\n Glucose\n 89\n 119\n 124\n 110\n 109\n 103\n Other labs: PT / PTT / INR:12.4/22.4/1.0, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:79.4 %, Lymph:15.3 %, Mono:3.2 %,\n Eos:1.7 %, Lactic Acid:2.4 mmol/L, Albumin:3.3 g/dL, LDH:212 IU/L,\n Ca:9.6 mg/dL, Mg:2.2 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), IMPAIRED PHYSICAL MOBILITY, HYPERGLYCEMIA\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ VAP, intermittent\n bacteremic episodes/agitation.\n Neurologic: Pain controlled, Decrease Haldol to Daily, team would like\n to avoid propofol for sedation. Continue fentanyl patch, clonidine\n Cardiovascular: HD stable\n Pulmonary: Trach, TC as tolerated, pulm toilet\n Gastrointestinal / Abdomen: TF, NPO, swallow eval in near future\n Nutrition: Tube feeding, NPO, Speech and Swallow eval\n Renal: Foley, Adequate UO, Creat stable. Goal euvolemia today.\n Hematology: Hct stable.\n Endocrine: RISS, NPH 60 Units \n Infectious Disease: WBC trending down. Linezolid/ x day\n course (starting ) for Klebseilla (line, sputum), VRE (OSH\n cultures), E.coli (sputum)\n Lines / Tubes / Drains: Foley, G-tube, Trach, Left subclavian central\n line, flexiseal, a-line\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: General surgery, ID dept\n Billing Diagnosis: (Respiratory distress: Failure), (Pneumonia due to\n procedure), Sepsis\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:02 PM 89.\n mL/hour\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Multi Lumen - 08:14 AM\n Arterial Line - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Rehab Services",
"chartdate": "2140-04-19 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 573086,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: pancreatitis / 577.0\n Reason of referral: Eval & treat\n History of Present Illness / Subjective Complaint: 42 yo M admitted to\n OSH on with abdominal pain and nausea/vomiting, CT showing\n pancreatitis and pseudocyst. Hospital course c/b over-medication with\n pain meds requiring intubation and eventual tracheostomy, G-tube placed\n and cyst drainage revealed + staph, due to recurrent fevers he was\n transferred to on . He has since been treated for sepsis \n cholangitis, and hospital course has also been signifucant for ERCP for\n sphinterotomy and stone extraction, and now with URI, VAP, bacteremia.\n Extubated and tolerating trach mask.\n Past Medical / Surgical History: RLE DVT, NIDDM, HTN, hyperlipidemia,\n CAD s/p MI ' s/p PTCA\n Medications: tylenol, lidocaine, heparin, metoprolol, haloperidol,\n meropenem, albuterol, clonidine\n Radiology: CXR - subtle area of parenchymal opacity with sparse air\n bronchograms that could correspond to aspiration pneumonia. The volume\n of the middle lobe is normal. There is no evidence of pleural\n effusion.\n Labs:\n 28.2\n 9.8\n 353\n 12.4\n [image002.jpg]\n Other labs:\n Activity Orders: OOB with assist\n Social / Occupational History: unknown if patient lives alone, patient\n unable to relate. Patient has sister and mother involved in care.\n Living Environment: unknown\n Prior Functional Status / Activity Level: presumed independent pta.\n Objective Test\n Arousal / Attention / Cognition / Communication: alert, oriented x3,\n unable to verbalize trach, able to mouth words minimally. Makes\n needs known via gestures\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 73\n 118/61\n 100% on TM\n Sit\n /\n Activity\n 84\n 109/68\n 94% on TM\n Stand\n /\n Recovery\n 77\n 99/61\n 98% on TM\n Total distance walked: 0\n Minutes:\n Pulmonary Status: diminished BS bilaterally, on 50% FIO2 via trach\n mask, strong cough.\n Integumentary / Vascular: L subclavian multi-lumen, R radial a-line,\n trach, tele, foley, mod ascites\n Sensory Integrity: grossly intact to light touch, denies parasthesias\n Pain / Limiting Symptoms: denies pain\n Posture: mildly kyphotic posture\n Range of Motion\n Muscle Performance\n B LE's grossly WNL\n B LE's grossly t/o\n Motor Function: no abnormal movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: able to take several small steps from edge of bed to\n chair, unsteady in standing, min c/o fatigue.\n Rolling:\n\n\n\n T\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n T\n\n Transfer:\n\n\n\n T\n\n Sit to Stand:\n\n\n T\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: S static sitting at edge of bed, min/mod A static/dynamic\n standing balance. no gross LOB\n Education / Communication: Reviewed PT and encouraged increased OOB\n time. Communicated with nsg re: status.\n Intervention:\n Other:\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired balance\n 3.\n Impaired endurance\n 4.\n Impaired strength\n Clinical impression / Prognosis: 42 yo M with pancreatitis p/w above\n impairments a/w soft tissue surgery. He is most limited by general\n weakness a/w prolonged icu stay and intubation, and is well below his\n baseline level of function. Would anticipate a good prognosis given\n his age and given his level of function despite >1 mo stay in the\n hospital. He is unsafe for d/c home at this time, however if patient\n remains inpatient for a longer period of time and participates in PT\n daily, he will likely make enough progress to d/c home. PT to\n re-assess d/c plan once on the floor, approx 1 week.\n Goals\n Time frame: 1 week\n 1.\n CG with all mobility\n 2.\n Static/dynamic standing balance with CG\n 3.\n Tolerate OOB >/= 3 hours/day\n 4.\n Tolerate daily UE/LE strengthening\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: daily\n bed mobility, transfers, ambulation, balance, endurance, strengthening,\n education, d/c planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-19 00:00:00.000",
"description": "Daily ICU Note",
"row_id": 573089,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ VAP, intermittent bacteremic\n episodes/agitation.\n Chief complaint:\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. 2. Acetaminophen 3. Albuterol Inhaler 4. Bisacodyl 5. Chlorhexidine\n Gluconate 0.12% Oral Rinse\n 6. CloniDINE 7. Famotidine 8. Fentanyl Patch 9. Haloperidol 10. Heparin\n 11. Insulin 12. Ipratropium Bromide MDI\n 13. Linezolid 14. Lidocaine 1% 15. Magnesium Sulfate 16. Metoprolol\n Tartrate 17. Meropenem 18. Miconazole 2% Cream\n 19. Miconazole Powder 2% 20. Nystatin Oral Suspension 21. Potassium\n Chloride 22. Potassium Chloride\n 23. Potassium Phosphate 24. Propofol 25. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n NASAL SWAB - At 10:00 AM\n - on trach collar\n - agitation improved\n - tobra d/c'd\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:55 PM\n Piperacillin - 09:06 AM\n Tobramycin - 09:26 PM\n Meropenem - 12:14 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 06:00 AM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Metoprolol - 06:00 AM\n Other medications:\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.1\nC (98.8\n HR: 70 (70 - 91) bpm\n BP: 127/68(86) {97/48(63) - 148/92(103)} mmHg\n RR: 20 (13 - 38) insp/min\n SPO2: 99%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 88.2 kg (admission): 88.7 kg\n Height: 69 Inch\n Total In:\n 3,660 mL\n 965 mL\n PO:\n Tube feeding:\n 2,162 mL\n 653 mL\n IV Fluid:\n 1,168 mL\n 223 mL\n Blood products:\n Total out:\n 2,375 mL\n 1,080 mL\n Urine:\n 2,375 mL\n 1,080 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,285 mL\n -115 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 350 (350 - 460) mL\n PS : 5 cmH2O\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 0 cmH2O\n SPO2: 99%\n ABG: ///27/\n Ve: 7.8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities, Able to make\n attempts at communication.\n Labs / Radiology\n 353 K/uL\n 9.8 g/dL\n 103 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 29 mg/dL\n 104 mEq/L\n 141 mEq/L\n 28.2 %\n 12.4 K/uL\n [image002.jpg]\n 12:31 PM\n 03:18 AM\n 04:29 AM\n 03:23 AM\n 03:33 AM\n 03:46 PM\n 09:39 PM\n 02:56 AM\n 03:08 AM\n 02:37 AM\n WBC\n 9.4\n 8.8\n 10.8\n 14.2\n 14.0\n 12.4\n Hct\n 24.6\n 23.3\n 27.8\n 30.1\n 33.3\n 27.7\n 28.2\n Plt\n 55\n 371\n 353\n Creatinine\n 1.2\n 1.0\n 0.9\n 0.9\n 1.0\n 0.8\n TCO2\n 31\n 27\n 30\n Glucose\n 89\n 119\n 124\n 110\n 109\n 103\n Other labs: PT / PTT / INR:12.4/22.4/1.0, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:79.4 %, Lymph:15.3 %, Mono:3.2 %,\n Eos:1.7 %, Lactic Acid:2.4 mmol/L, Albumin:3.3 g/dL, LDH:212 IU/L,\n Ca:9.6 mg/dL, Mg:2.2 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), IMPAIRED PHYSICAL MOBILITY, HYPERGLYCEMIA\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ VAP, intermittent\n bacteremic episodes/agitation.\n Neurologic: Pain controlled, Decrease Haldol to Daily, team would like\n to avoid propofol for sedation. Continue fentanyl patch, clonidine\n Cardiovascular: HD stable\n Pulmonary: Trach, TC as tolerated, pulm toilet\n Gastrointestinal / Abdomen: TF, NPO, swallow eval in near future\n Nutrition: Tube feeding, NPO, Speech and Swallow eval\n Renal: Foley, Adequate UO, Creat stable. Goal euvolemia today.\n Hematology: Stable anemia\n Endocrine: RISS, NPH 60 Units with adequate glucose control. Keep <\n 150\n Infectious Disease: WBC trending down. Linezolid/ x day\n course (starting ) for Klebseilla (line, sputum), VRE (OSH\n cultures), E.coli (sputum)\n Lines / Tubes / Drains: Foley, G-tube, Trach, Left subclavian central\n line, flexiseal, a-line\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: General surgery, ID dept\n Billing Diagnosis: (Respiratory distress: Failure), (Pneumonia due to\n procedure), Sepsis\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:02 PM 89.\n mL/hour\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Multi Lumen - 08:14 AM\n Arterial Line - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 25 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-19 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 573005,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV: Off\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Comments: Pt remained off vent overnoc and did well.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 573063,
"text": "42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ VAP, bacteremia.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on trach collar, 40 % FiO2, RR 20s, O2 sats > 96%. Pt denies\n difficulty breathing. Pt coughs copious amounts of white frothy\n secretions from trach.\n Action:\n Suctioned q 1-2 hrs\n Response:\n Airway clear, remained on trach collar overnight\n Plan:\n Continue to assess respiratory status, suction prn\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-20 00:00:00.000",
"description": "Intensivist Note",
"row_id": 573245,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ VAP, bacteremia.\n Chief complaint:\n postoperative respiratory insufficiency, hospital acquired pneumonia\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n Acetaminophen 3. Albuterol Inhaler 4. Bisacodyl 5. Chlorhexidine\n Gluconate 0.12% Oral Rinse\n 6. CloniDINE 7. Famotidine 8. Fentanyl Patch 9. Furosemide 10.\n Haloperidol 11. Heparin 12. Insulin\n 13. Ipratropium Bromide MDI 14. Linezolid 15. Lidocaine 1% 16.\n Magnesium Sulfate 17. Metoprolol Tartrate\n 18. Meropenem 19. Miconazole 2% Cream 20. Miconazole Powder 2% 21.\n Nystatin Oral Suspension 22. Potassium Chloride 23. Potassium Chloride\n 24. Potassium Phosphate\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 09:06 AM\n Tobramycin - 09:26 PM\n Meropenem - 12:00 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 12:00 AM\n Furosemide (Lasix) - 04:05 AM\n Heparin Sodium (Prophylaxis) - 06:02 AM\n Famotidine (Pepcid) - 06:03 AM\n Other medications:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36.7\nC (98\n HR: 72 (69 - 92) bpm\n BP: 107/48(65) {107/48(65) - 142/76(99)} mmHg\n RR: 35 (10 - 35) insp/min\n SPO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 88.2 kg (admission): 88.7 kg\n Height: 69 Inch\n Total In:\n 3,027 mL\n 825 mL\n PO:\n Tube feeding:\n 2,176 mL\n 549 mL\n IV Fluid:\n 640 mL\n 216 mL\n Blood products:\n Total out:\n 2,325 mL\n 910 mL\n Urine:\n 2,325 mL\n 910 mL\n NG:\n Stool:\n Drains:\n Balance:\n 702 mL\n -85 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SPO2: 98%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Rhonchorous : , Diminished: at bases)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli, Noxious stimuli), Moves\n all extremities\n Labs / Radiology\n 373 K/uL\n 9.6 g/dL\n 93 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 29 mg/dL\n 103 mEq/L\n 140 mEq/L\n 28.4 %\n 10.8 K/uL\n [image002.jpg]\n 03:18 AM\n 04:29 AM\n 03:23 AM\n 03:33 AM\n 03:46 PM\n 09:39 PM\n 02:56 AM\n 03:08 AM\n 02:37 AM\n 03:04 AM\n WBC\n 9.4\n 8.8\n 10.8\n 14.2\n 14.0\n 12.4\n 10.8\n Hct\n 23.3\n 27.8\n 30.1\n 33.3\n 27.7\n 28.2\n 28.4\n Plt\n 55\n 371\n 353\n 373\n Creatinine\n 1.2\n 1.0\n 0.9\n 0.9\n 1.0\n 0.8\n 0.8\n TCO2\n 31\n 27\n 30\n Glucose\n 89\n 119\n 124\n 110\n 109\n 103\n 93\n Other labs: PT / PTT / INR:12.4/22.4/1.0, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:79.4 %, Lymph:15.3 %, Mono:3.2 %,\n Eos:1.7 %, Lactic Acid:2.4 mmol/L, Albumin:3.3 g/dL, LDH:212 IU/L,\n Ca:10.0 mg/dL, Mg:2.4 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), IMPAIRED PHYSICAL MOBILITY, HYPERGLYCEMIA\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ VAP, bacteremia.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Haldol qhs,\n clonidine 0.1 TID, fentanyl patch, psych consult done.\n Cardiovascular: Beta-blocker, hemodynamically stable, cont lopressor.\n Dc aline.\n Pulmonary: Trach, TC x 24hrs. will go to passemuir valve. pulm toilet,\n abx\n Gastrointestinal / Abdomen: TF, NPO, swallow eval in near future\n Nutrition: Tube feeding, NPO, TF, NPO, swallow eval in near future\n Renal: Foley, Adequate UO, Cr stable 0.8, KVO'd\n Hematology: Serial Hct, Hct stable at 28.4\n Endocrine: RISS, NPH insulin with RISS, goal FS<150\n blood sugars well controlled\n Infectious Disease: Check cultures, f/u cx, treating for aspiration\n pneumonia, following id recs for length of treatment.\n linezolid()/(. known bacteremia + line infection.\n Lines / Tubes / Drains: Foley, G-tube, Trach, , L SCL CVL, Flexiseal,\n Aline\n Wounds: Dry dressings\n Imaging: none\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Comments: tube feeds\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Multi Lumen - 08:14 AM\n Arterial Line - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-20 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 573249,
"text": "Impaired Physical Mobility\n Assessment:\n seen by PT, weak but able to move in bed\n Action:\n ambulated in with PT, oob to chair, needs to be encouraged to do\n more for himself\n Response:\n weak but slowly improving\n Plan:\n continue PT, ambulate as tolerated, oob to chair\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n trach collar x 48 hrs, coughing and raising large amts thick white\n secretions. Bs clear after coughing\n Action:\n pt using yanker suction to suction his mouth, suctioned q 30-60\n minutes moderate to large amt thick white secretions. Albuterol and\n atrovent given as ordered by resp.\n Response:\n continues to require suctioning frequently, sats stable\n Plan:\n monitor resp parameters, encourage pt to cough and suction himself,\n speech and swallow consult\n Ineffective Coping\n Assessment:\n pt used to having family do a lot for him, Fentanyl patch q 72hrs\n Action:\n seen by psych, haldol changed to qhs\n Response:\n per team, pt is calmer and more cooperative\n Plan:\n continue haldol, encourage pt to participate in his care\n .H/O pancreatitis, acute\n Assessment:\n s/p ERCP on with subsequent sepsis, currently on meropenum iv,\n denies abdominal pain\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-20 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 573250,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ VAP, bacteremia.\n Chief complaint:\n postoperative respiratory insufficiency, hospital acquired pneumonia\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Impaired Physical Mobility\n Assessment:\n seen by PT, weak but able to move in bed\n Action:\n ambulated in with PT, oob to chair, needs to be encouraged to do\n more for himself\n Response:\n weak but slowly improving\n Plan:\n continue PT, ambulate as tolerated, oob to chair\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n trach collar x 48 hrs, coughing and raising large amts thick white\n secretions. Bs clear after coughing\n Action:\n pt using yanker suction to suction his mouth, suctioned q 30-60\n minutes moderate to large amt thick white secretions. Albuterol and\n atrovent given as ordered by resp.\n Response:\n continues to require suctioning frequently, sats stable\n Plan:\n monitor resp parameters, encourage pt to cough and suction himself,\n speech and swallow consult\n Ineffective Coping\n Assessment:\n pt used to having family do a lot for him, Fentanyl patch q 72hrs\n Action:\n seen by psych, haldol changed to qhs\n Response:\n per team, pt is calmer and more cooperative\n Plan:\n continue haldol, encourage pt to participate in his care\n .H/O pancreatitis, acute\n Assessment:\n s/p ERCP on with subsequent sepsis, currently on meropenum iv,\n denies abdominal pain\n Action:\n antibiotics given as ordered, labs followed by sicu team, Fentanyl\n patch for pain\n Response:\n stable at present\n Plan:\n monitor for abdominal pain, monitor labs, continue antibiotics as\n ordered, monitor culture reports\n"
},
{
"category": "Rehab Services",
"chartdate": "2140-04-20 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 573251,
"text": "Subjective:\n I want to walk (using gestures)\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for patient education\n Updated medical status: no new imaging, called out ot floor.\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n T\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n T\n\n\n Transfer:\n\n\n T\n\n\n Sit to Stand:\n\n T\n\n\n\n Ambulation:\n\n\n T\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 74\n 116/57\n 99% on TM\n Activity\n Sit\n 92\n 144/65\n 100% on TM\n Recovery\n 80\n /\n 99% on TM\n Total distance walked: 125'\n Minutes:\n Gait: mild unsteadiness with gait pushing w/c, limited by fatigue, min\n c/o lightheadedness.\n Balance: S static sitting, CG/min A static/dynamic standing balance.\n No gross LOB with mobility. Impulsive with stand to sit with poor\n eccentric control.\n Education / Communication: Reviewed pacing and deep breathing,\n encouraged OOB >/= 2 hours. Communicated with nsg re: status.\n Other: On 50% FIO2 via trach mask.\n Strong productive cough, using yankouer frequently for oral secretions.\n Denies pain.\n Assessment: 42 yo M with pancreatitis making good progress in PT with\n mobility and endurance, continues to be limited by general fatigue a/w\n prolonged hospitalization/icu stay. He continues to be below his\n baseline but would anticipate continued progress and he may be able to\n return home when medically ready of good supports in place. If minimal\n progress seen, and because he has a new trach, he may benefit from\n rehab upon d/c. Will continue to re-assess.\n Anticipated Discharge: Rehab\n Plan: continue with POC\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-17 00:00:00.000",
"description": "Intensivist Note",
"row_id": 572712,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ UTI, VAP, bacteremia.\n Chief complaint:\n respiratory insufficiency, sepsis\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n Acetaminophen 3. Bisacodyl 4. Chlorhexidine Gluconate 0.12% Oral Rinse\n 5. Famotidine 6. Fentanyl Patch\n 7. Haloperidol 8. Heparin 9. Insulin 10. Linezolid 11. Lidocaine 1% 12.\n Lorazepam 13. Lorazepam\n 14. Magnesium Sulfate 15. Metoprolol Tartrate 16. Miconazole 2% Cream\n 17. Miconazole Powder 2% 18. Nystatin Oral Suspension\n 19. Piperacillin-Tazobactam Na 20. Potassium Chloride 21. Potassium\n Chloride 22. Potassium Phosphate\n 24. Tobramycin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:10 AM\n Linezolid - 08:15 PM\n Tobramycin - 10:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:55 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 05:47 PM\n Heparin Sodium (Prophylaxis) - 05:47 PM\n Metoprolol - 12:18 AM\n Other medications:\n Flowsheet Data as of 05:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 37.2\nC (99\n HR: 97 (75 - 104) bpm\n BP: 130/84(87) {114/65(51) - 151/91(100)} mmHg\n RR: 38 (17 - 47) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 3,000 mL\n 148 mL\n PO:\n Tube feeding:\n 2,160 mL\n 95 mL\n IV Fluid:\n 840 mL\n 53 mL\n Blood products:\n Total out:\n 2,625 mL\n 480 mL\n Urine:\n 2,625 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 375 mL\n -333 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SPO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bilateral bases)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Agitated, Follows simple commands, (Responds to: Verbal\n stimuli), Moves all extremities\n Labs / Radiology\n 349 K/uL\n 10.4 g/dL\n 124 mg/dL\n 0.9 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 21 mg/dL\n 100 mEq/L\n 141 mEq/L\n 30.1 %\n 10.8 K/uL\n [image002.jpg]\n 04:11 AM\n 06:00 AM\n 05:27 PM\n 03:29 AM\n 01:30 AM\n 03:00 AM\n 12:31 PM\n 03:18 AM\n 04:29 AM\n 03:23 AM\n WBC\n 15.9\n 14.1\n 9.4\n 8.8\n 10.8\n Hct\n 31.6\n 25.7\n 24.6\n 23.3\n 27.8\n 30.1\n Plt\n 458\n 347\n 321\n 315\n 349\n Creatinine\n 0.9\n 1.0\n 1.2\n 1.0\n 0.9\n Troponin T\n <0.01\n TCO2\n 35\n 26\n Glucose\n 194\n 158\n 92\n 89\n 119\n 124\n Other labs: PT / PTT / INR:12.4/22.4/1.0, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.4 mmol/L, Albumin:3.6 g/dL, LDH:212 IU/L,\n Ca:10.1 mg/dL, Mg:2.3 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), IMPAIRED PHYSICAL MOBILITY, HYPERGLYCEMIA\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ UTI, VAP, bacteremia.\n Neurologic: Neuro checks Q: hr, Pain controlled, Haldol TID, fentanyl\n patch, propofol for sedation\n Cardiovascular: Beta-blocker, HD stable, on Lopressor 5q4, needs aline\n Pulmonary: Trach, IS, CXRay with Right Middle Lobe infiltrate, send\n Cx\ns, nebulizers, back on ventilator, send mini BAL\n Gastrointestinal / Abdomen: TF, NPO\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, NPH\n Hematology: Serial Hct, daily HCT\n Endocrine: RISS, Regular insulin, NPH insulin with RISS, goal FS<150,\n blood sugars well controlled\n Infectious Disease: Check sputum, urine, blood cxs,\n linezolid/Zosyn/tobra, goal trough is <1, ID wants day course\n (from ), PNA (?Pseudomonas), appears to be septic again, may need\n CT abdomen, sparse yeast in sputum\n may need diflucan\n Lines / Tubes / Drains: Foley, G-tube, Trach, L SCL CVL, Flexiseal,\n aline\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Comments: tube feeding\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Multi Lumen - 08:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572556,
"text": "HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ UTI, VAP, bacteremia\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Impaired Physical Mobility\n Assessment:\n Moving about in the bed side to side. Moves down in the bed and\n attempts to climb oob by placing his legs over the rails.\n Action:\n Turned q2hrs. oob to chair on the day shift.\n Response:\n Range of motion excersises done. Turned q2hrs.\n Plan:\n Monitor closely.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n On trach collar all nite. Suctioned for thick white-yellow sputum.\n O2sats 92-99%.\n Action:\n Hob elevated 45 degrees. Turned q2hrs. suctioned prn.\n Response:\n Tolerated trach collar all nite\n Plan:\n Monitor resp status.\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-17 00:00:00.000",
"description": "Intensivist Note",
"row_id": 572714,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ UTI, VAP, bacteremia.\n Chief complaint:\n respiratory insufficiency, sepsis\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n Acetaminophen 3. Bisacodyl 4. Chlorhexidine Gluconate 0.12% Oral Rinse\n 5. Famotidine 6. Fentanyl Patch\n 7. Haloperidol 8. Heparin 9. Insulin 10. Linezolid 11. Lidocaine 1% 12.\n Lorazepam 13. Lorazepam\n 14. Magnesium Sulfate 15. Metoprolol Tartrate 16. Miconazole 2% Cream\n 17. Miconazole Powder 2% 18. Nystatin Oral Suspension\n 19. Piperacillin-Tazobactam Na 20. Potassium Chloride 21. Potassium\n Chloride 22. Potassium Phosphate\n 24. Tobramycin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:10 AM\n Linezolid - 08:15 PM\n Tobramycin - 10:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:55 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 05:47 PM\n Heparin Sodium (Prophylaxis) - 05:47 PM\n Metoprolol - 12:18 AM\n Other medications:\n Flowsheet Data as of 05:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 37.2\nC (99\n HR: 97 (75 - 104) bpm\n BP: 130/84(87) {114/65(51) - 151/91(100)} mmHg\n RR: 38 (17 - 47) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 3,000 mL\n 148 mL\n PO:\n Tube feeding:\n 2,160 mL\n 95 mL\n IV Fluid:\n 840 mL\n 53 mL\n Blood products:\n Total out:\n 2,625 mL\n 480 mL\n Urine:\n 2,625 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 375 mL\n -333 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SPO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bilateral bases)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Agitated, Follows simple commands, (Responds to: Verbal\n stimuli), Moves all extremities\n Labs / Radiology\n 349 K/uL\n 10.4 g/dL\n 124 mg/dL\n 0.9 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 21 mg/dL\n 100 mEq/L\n 141 mEq/L\n 30.1 %\n 10.8 K/uL\n [image002.jpg]\n 04:11 AM\n 06:00 AM\n 05:27 PM\n 03:29 AM\n 01:30 AM\n 03:00 AM\n 12:31 PM\n 03:18 AM\n 04:29 AM\n 03:23 AM\n WBC\n 15.9\n 14.1\n 9.4\n 8.8\n 10.8\n Hct\n 31.6\n 25.7\n 24.6\n 23.3\n 27.8\n 30.1\n Plt\n 458\n 347\n 321\n 315\n 349\n Creatinine\n 0.9\n 1.0\n 1.2\n 1.0\n 0.9\n Troponin T\n <0.01\n TCO2\n 35\n 26\n Glucose\n 194\n 158\n 92\n 89\n 119\n 124\n Other labs: PT / PTT / INR:12.4/22.4/1.0, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.4 mmol/L, Albumin:3.6 g/dL, LDH:212 IU/L,\n Ca:10.1 mg/dL, Mg:2.3 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), IMPAIRED PHYSICAL MOBILITY, HYPERGLYCEMIA\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ UTI, VAP, bacteremia.\n Neurologic: Neuro checks Q: 2 hr, Pain controlled, Haldol TID,\n fentanyl patch, propofol for sedation\n Cardiovascular: Beta-blocker, HD stable, on Lopressor 5q4, needs a-line\n Pulmonary: Trach, IS, CXRay with Right Middle Lobe infiltrate, send\n Cx\ns, nebulizers, back on ventilator, send mini BAL\n Gastrointestinal / Abdomen: TF, NPO\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, NPH\n Hematology: Serial Hct, daily HCT\n Endocrine: NPH insulin with RISS, goal FS<150, blood sugars well\n controlled\n Infectious Disease: Check sputum, urine, blood cxs,\n linezolid/Zosyn/tobra, goal trough is <1, ID wants day course\n (from ), PNA (?Pseudomonas), appears to be septic again, may need\n CT abdomen, sparse yeast in sputum\n may need diflucan\n Lines / Tubes / Drains: Foley, G-tube, Trach, L SCL CVL, Flexiseal,\n aline\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure); Post-op\n complication\n ICU Care\n Nutrition:\n Comments: tube feeding\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Multi Lumen - 08:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-17 00:00:00.000",
"description": "Generic Note",
"row_id": 572727,
"text": "TITLE: Pt having episodes of agitation changes in mental status. ?\n sepsis increased secretions. Placed back on vent. Sedated with\n propofol. Will cont to monitor resp status.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 573203,
"text": "Demographics\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: 6 mL / Air\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Frothy\n Sputum source/amount: Expectorated / Moderate\n Comments: pt has strong productive cough, no need to suction as he is\n able to expectorate\n Ventilation Assessment\n Level of breathing assistance: unassisted continuous breathing\n Plan\n Next 24-48 hours: continue trach care and administer Meter dose\n inhalers via ambu as ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-20 00:00:00.000",
"description": "Intensivist Note",
"row_id": 573212,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ VAP, bacteremia.\n Chief complaint:\n postoperative respiratory insufficiency, hospital acquired pneumonia\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n Acetaminophen 3. Albuterol Inhaler 4. Bisacodyl 5. Chlorhexidine\n Gluconate 0.12% Oral Rinse\n 6. CloniDINE 7. Famotidine 8. Fentanyl Patch 9. Furosemide 10.\n Haloperidol 11. Heparin 12. Insulin\n 13. Ipratropium Bromide MDI 14. Linezolid 15. Lidocaine 1% 16.\n Magnesium Sulfate 17. Metoprolol Tartrate\n 18. Meropenem 19. Miconazole 2% Cream 20. Miconazole Powder 2% 21.\n Nystatin Oral Suspension 22. Potassium Chloride 23. Potassium Chloride\n 24. Potassium Phosphate\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 09:06 AM\n Tobramycin - 09:26 PM\n Meropenem - 12:00 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 12:00 AM\n Furosemide (Lasix) - 04:05 AM\n Heparin Sodium (Prophylaxis) - 06:02 AM\n Famotidine (Pepcid) - 06:03 AM\n Other medications:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36.7\nC (98\n HR: 72 (69 - 92) bpm\n BP: 107/48(65) {107/48(65) - 142/76(99)} mmHg\n RR: 35 (10 - 35) insp/min\n SPO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 88.2 kg (admission): 88.7 kg\n Height: 69 Inch\n Total In:\n 3,027 mL\n 825 mL\n PO:\n Tube feeding:\n 2,176 mL\n 549 mL\n IV Fluid:\n 640 mL\n 216 mL\n Blood products:\n Total out:\n 2,325 mL\n 910 mL\n Urine:\n 2,325 mL\n 910 mL\n NG:\n Stool:\n Drains:\n Balance:\n 702 mL\n -85 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SPO2: 98%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Rhonchorous : , Diminished: at bases)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli, Noxious stimuli), Moves\n all extremities\n Labs / Radiology\n 373 K/uL\n 9.6 g/dL\n 93 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 29 mg/dL\n 103 mEq/L\n 140 mEq/L\n 28.4 %\n 10.8 K/uL\n [image002.jpg]\n 03:18 AM\n 04:29 AM\n 03:23 AM\n 03:33 AM\n 03:46 PM\n 09:39 PM\n 02:56 AM\n 03:08 AM\n 02:37 AM\n 03:04 AM\n WBC\n 9.4\n 8.8\n 10.8\n 14.2\n 14.0\n 12.4\n 10.8\n Hct\n 23.3\n 27.8\n 30.1\n 33.3\n 27.7\n 28.2\n 28.4\n Plt\n 55\n 371\n 353\n 373\n Creatinine\n 1.2\n 1.0\n 0.9\n 0.9\n 1.0\n 0.8\n 0.8\n TCO2\n 31\n 27\n 30\n Glucose\n 89\n 119\n 124\n 110\n 109\n 103\n 93\n Other labs: PT / PTT / INR:12.4/22.4/1.0, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:79.4 %, Lymph:15.3 %, Mono:3.2 %,\n Eos:1.7 %, Lactic Acid:2.4 mmol/L, Albumin:3.3 g/dL, LDH:212 IU/L,\n Ca:10.0 mg/dL, Mg:2.4 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), IMPAIRED PHYSICAL MOBILITY, HYPERGLYCEMIA\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ VAP, bacteremia.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Haldol qd, clonidine\n TID, fentanyl patch, psych consult\n Cardiovascular: Beta-blocker, hemodynamically stable, cont lopressor\n Pulmonary: Trach, TC as tolerated, pulm toilet, abx\n Gastrointestinal / Abdomen: TF, NPO, ?swallow eval in near future\n Nutrition: Tube feeding, NPO, TF, NPO, ?swallow eval in near future\n Renal: Foley, Adequate UO, Cr stable 0.8, KVO'd\n Hematology: Serial Hct, Hct stable at 28.4\n Endocrine: RISS, NPH insulin with RISS, goal FS<150\n blood sugars well controlled\n Infectious Disease: Check cultures, f/u cx, treating for aspiration\n pneumonia, following id recs for length of treatment:\n linezolid()/(\n Lines / Tubes / Drains: Foley, G-tube, Trach, , L SCL CVL, Flexiseal,\n Aline\n Wounds: Dry dressings\n Imaging: none\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Comments: tube feeds\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Multi Lumen - 08:14 AM\n Arterial Line - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-16 00:00:00.000",
"description": "Intensivist Note",
"row_id": 572547,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ UTI, VAP, bacteremia\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. Lorazepam 2-4 mg IV Q30MIN:PRN agitation Order date: @ 0430\n 2. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308\n 3. Magnesium Sulfate IV Sliding Scale Order date: @ 0234\n 4. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139\n 5. Metoprolol Tartrate 5 mg IV Q6H tachycadia/HTN hold for SBP<100\n HR<60 Order date: @ 1218\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL Order\n date: @ 1119\n 7. Miconazole 2% Cream 1 Appl TP yeast rash Order date: @\n 2347\n 8. Famotidine 20 mg IV Q12H Order date: @ 0419\n 9. Miconazole Powder 2% 1 Appl TP TID:PRN Order date: @ 1255\n 10. Fentanyl Patch 75 mcg/hr TP Q72H Order date: @ 0751\n 11. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @ 0555\n 12. Haloperidol 1 mg PO TID through G tube Order date: @ 1014\n 13. Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @ 1209\n 14. Heparin 5000 UNIT SC BID Order date: @ 0139\n 15. Potassium Chloride PO Sliding Scale Hold for K > 5 Order date:\n @ 0505\n 16. Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose\n Order date: @ 1234\n 17. Potassium Chloride IV Sliding Scale Order date: @ 0526\n 18. Linezolid 600 mg PO Q12H Order date: @ 1653\n 19. Potassium Phosphate IV Sliding Scale Infuse over 6 hours Order\n date: @ 0647\n 20. Lidocaine 1% 3-5 mL IH Q4-6 HRS PRN Order date: @ 1854\n 21. Lorazepam 2-4 mg IV Q4H:PRN Order date: @ \n 22. Tobramycin 450 mg IV Q24H Order date: @ 1607\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:51 AM\n Failed swallow eval\n Clonodine D/C'd\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:10 AM\n Linezolid - 08:15 PM\n Tobramycin - 04:12 PM\n Piperacillin/Tazobactam (Zosyn) - 12:24 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 06:00 PM\n Heparin Sodium (Prophylaxis) - 06:00 PM\n Other medications:\n Flowsheet Data as of 04:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.5\n T current: 36.9\nC (98.5\n HR: 78 (70 - 97) bpm\n BP: 124/65(79) {105/60(70) - 144/89(99)} mmHg\n RR: 20 (11 - 32) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 2,981 mL\n 558 mL\n PO:\n Tube feeding:\n 2,161 mL\n 413 mL\n IV Fluid:\n 640 mL\n 146 mL\n Blood products:\n Total out:\n 2,055 mL\n 500 mL\n Urine:\n 2,055 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 926 mL\n 58 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 351 (351 - 351) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 0 cmH2O\n FiO2: 30%\n RSBI: 114\n PIP: 0 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 10.6 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, PEG\n intact\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 315 K/uL\n 9.4 g/dL\n 119 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 24 mg/dL\n 105 mEq/L\n 141 mEq/L\n 27.8 %\n 8.8 K/uL\n [image002.jpg]\n 02:41 AM\n 04:11 AM\n 06:00 AM\n 05:27 PM\n 03:29 AM\n 01:30 AM\n 03:00 AM\n 12:31 PM\n 03:18 AM\n 04:29 AM\n WBC\n 12.9\n 15.9\n 14.1\n 9.4\n 8.8\n Hct\n 32.2\n 31.6\n 25.7\n 24.6\n 23.3\n 27.8\n Plt\n 21\n 315\n Creatinine\n 0.4\n 0.9\n 1.0\n 1.2\n 1.0\n Troponin T\n <0.01\n TCO2\n 35\n 26\n Glucose\n 149\n 194\n 158\n 92\n 89\n 119\n Other labs: PT / PTT / INR:12.4/22.4/1.0, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.4 mmol/L, Albumin:3.6 g/dL, LDH:212 IU/L,\n Ca:9.1 mg/dL, Mg:2.2 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), IMPAIRED PHYSICAL MOBILITY, HYPERGLYCEMIA\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ UTI, VAP, bacteremia.\n Neurologic: Pain controlled, Haldol TID, Ativan prn, fentanyl patch\n Cardiovascular: Beta-blocker, HD stable, on Lopressor 5q4\n Pulmonary: trach collar as tolerated, pulm toilet\n Gastrointestinal / Abdomen: TF, NPO, swallow eval- questionable\n aspiration, reassess on tue\n Nutrition: Tube feeding, NPO\n Renal: Foley, Adequate UO\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: Check cultures, f/u cx, linezolid/Zosyn/tobra\n Lines / Tubes / Drains: G-tube, Trach\n Wounds: c/d/i\n Imaging: none\n Fluids: kvo\n Consults: General surgery, ID dept\n Billing Diagnosis: Sepsis\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:06 AM 89.\n mL/hour\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Multi Lumen - 08:14 AM\n 22 Gauge - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2140-04-16 00:00:00.000",
"description": "Intensivist Note",
"row_id": 572571,
"text": "SICU\n HPI:\n 42M w/ pancreatitis s/p drainage of pseudocyst (Staph) @ OSH, s/p\n trach/PEG, tx'd for sepsis cholangitis, s/p ERCP, sphincterotomy,\n stone extraction, now w/ UTI, VAP, bacteremia\n Chief complaint:\n Abdominal Pain\n PMHx:\n PMH: DVT, HTN, hyperlipidemia, CAD s/p MI in \n PSH: PEG/trach, PTCA\n Current medications:\n 1. Lorazepam 2-4 mg IV Q30MIN:PRN agitation Order date: @ 0430\n 2. Acetaminophen 650 mg PO Q4H:PRN Order date: @ 0308\n 3. Magnesium Sulfate IV Sliding Scale Order date: @ 0234\n 4. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 0139\n 5. Metoprolol Tartrate 5 mg IV Q6H tachycadia/HTN hold for SBP<100\n HR<60 Order date: @ 1218\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL Order\n date: @ 1119\n 7. Miconazole 2% Cream 1 Appl TP yeast rash Order date: @\n 2347\n 8. Famotidine 20 mg IV Q12H Order date: @ 0419\n 9. Miconazole Powder 2% 1 Appl TP TID:PRN Order date: @ 1255\n 10. Fentanyl Patch 75 mcg/hr TP Q72H Order date: @ 0751\n 11. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @ 0555\n 12. Haloperidol 1 mg PO TID through G tube Order date: @ 1014\n 13. Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @ 1209\n 14. Heparin 5000 UNIT SC BID Order date: @ 0139\n 15. Potassium Chloride PO Sliding Scale Hold for K > 5 Order date:\n @ 0505\n 16. Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose\n Order date: @ 1234\n 17. Potassium Chloride IV Sliding Scale Order date: @ 0526\n 18. Linezolid 600 mg PO Q12H Order date: @ 1653\n 19. Potassium Phosphate IV Sliding Scale Infuse over 6 hours Order\n date: @ 0647\n 20. Lidocaine 1% 3-5 mL IH Q4-6 HRS PRN Order date: @ 1854\n 21. Lorazepam 2-4 mg IV Q4H:PRN Order date: @ \n 22. Tobramycin 450 mg IV Q24H Order date: @ 1607\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:51 AM\n Failed swallow eval\n Clonodine D/C'd\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:10 AM\n Linezolid - 08:15 PM\n Tobramycin - 04:12 PM\n Piperacillin/Tazobactam (Zosyn) - 12:24 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 06:00 PM\n Heparin Sodium (Prophylaxis) - 06:00 PM\n Other medications:\n Flowsheet Data as of 04:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.5\n T current: 36.9\nC (98.5\n HR: 78 (70 - 97) bpm\n BP: 124/65(79) {105/60(70) - 144/89(99)} mmHg\n RR: 20 (11 - 32) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 2,981 mL\n 558 mL\n PO:\n Tube feeding:\n 2,161 mL\n 413 mL\n IV Fluid:\n 640 mL\n 146 mL\n Blood products:\n Total out:\n 2,055 mL\n 500 mL\n Urine:\n 2,055 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 926 mL\n 58 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 351 (351 - 351) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 0 cmH2O\n FiO2: 30%\n RSBI: 114\n PIP: 0 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 10.6 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, PEG\n intact\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 315 K/uL\n 9.4 g/dL\n 119 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 24 mg/dL\n 105 mEq/L\n 141 mEq/L\n 27.8 %\n 8.8 K/uL\n [image002.jpg]\n 02:41 AM\n 04:11 AM\n 06:00 AM\n 05:27 PM\n 03:29 AM\n 01:30 AM\n 03:00 AM\n 12:31 PM\n 03:18 AM\n 04:29 AM\n WBC\n 12.9\n 15.9\n 14.1\n 9.4\n 8.8\n Hct\n 32.2\n 31.6\n 25.7\n 24.6\n 23.3\n 27.8\n Plt\n 21\n 315\n Creatinine\n 0.4\n 0.9\n 1.0\n 1.2\n 1.0\n Troponin T\n <0.01\n TCO2\n 35\n 26\n Glucose\n 149\n 194\n 158\n 92\n 89\n 119\n Other labs: PT / PTT / INR:12.4/22.4/1.0, CK / CK-MB / Troponin\n T:79//<0.01, ALT / AST:30/25, Alk-Phos / T bili:136/0.8, Amylase /\n Lipase:24/19, Differential-Neuts:68.9 %, Lymph:23.5 %, Mono:2.1 %,\n Eos:4.9 %, Lactic Acid:1.4 mmol/L, Albumin:3.6 g/dL, LDH:212 IU/L,\n Ca:9.1 mg/dL, Mg:2.2 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), IMPAIRED PHYSICAL MOBILITY, HYPERGLYCEMIA\n Assessment and Plan: 42M w/ pancreatitis s/p drainage of pseudocyst\n (Staph) @ OSH, s/p trach/PEG, tx'd for sepsis cholangitis, s/p\n ERCP, sphincterotomy, stone extraction, now w/ UTI, VAP, bacteremia.\n Neurologic: Pain controlled, Haldol TID, Ativan prn, fentanyl patch\n Cardiovascular: Beta-blocker, HD stable, on Lopressor 5q4\n Pulmonary: trach collar as tolerated, pulm toilet\n Gastrointestinal / Abdomen: TF, NPO, swallow eval- questionable\n aspiration, reassess on tue\n Nutrition: Tube feeding, NPO\n Renal: Foley, Adequate UO\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: Check cultures, f/u cx, linezolid/Zosyn/tobra\n Lines / Tubes / Drains: G-tube, Trach\n Wounds: c/d/i\n Imaging: none\n Fluids: kvo\n Consults: General surgery, ID dept\n Billing Diagnosis: Sepsis; Respiratory failure.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:06 AM 89.\n mL/hour\n Glycemic Control: Regular insulin sliding scale, NPH\n Lines:\n Multi Lumen - 08:14 AM\n 22 Gauge - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 14 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572642,
"text": ".H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on trach collar on 50%\n Lungs clear but diminished at bases\n pt remains in 1^st degree avb, dr. aware\n Action:\n Pt coughing and raising thin whitish secretions\n Pt suctioned every 2-4 hours for thin whitish secretions\n Pt continue on lopressor 5mg iv every six hours\n Response:\n Pt tolerating trach collar\n Plan:\n Continue to monitor\n Turn and reposition every 2 hours\n Suctioned as needed\n Impaired Physical Mobility\n Assessment:\n Pt moving all over bed\n Range of motion done\n Action:\n Pt pivoted oob to chair, pt able to take a couple of step\n when getting back to bed\n Response:\n Pt tolerated oob to chair\n Plan:\n Continue to monitor\n Range of motion as needed\n Oob to chair\n Altered mental status (not Delirium)\n Assessment:\n Pt alert\n Pt following commands\n At times pt agigated, trying to sit up in bed, putting legs\n over side rails\n Qtc back as .44, dr. aware\n Action:\n Providing reassurance\n Pt continues on haldol 1mg tid\n Response:\n At times less agigated\n Plan:\n Continue to monitor\n Provide reassurance.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-18 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 572983,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments: occasional rhonchi\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments: secretions were thick yellow in AM\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Trache mask as tolerated, place back on vent for\n signs of fatigue. Albuterol and Atrovent MDIs as ordered.\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-04-15 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 572448,
"text": "Respiratory Care Service: Pt remains w/ an 8.0 Blue Line Portex Trach\n in place. Doing well on a 50 % T-Piece. Thin white secretions persist\n but cough is strong.\n"
},
{
"category": "Nursing",
"chartdate": "2140-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572637,
"text": ".H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on trach collar on 50%\n Lungs clear but diminished at bases\n Action:\n Pt coughing and raising thin whitish secretions\n Pt suctioned every 2-4 hours for thin whitish secretions\n Response:\n Plan:\n Continue to monitor\n Turn and reposition every 2 hours\n Impaired Physical Mobility\n Assessment:\n Action:\n Response:\n Plan:\n"
}
] |
|
43,112 | 136,852 | 70 y/o F with severe COPD who presents with hypoxia and respiratory failure, now intubated. . # Resp failure: Patient was intubated on presentation for severe respiratory distress. Was empirically treated for COPD exacerbation and given CXR findings was treated for pneumonia as well. Sputum cultures subsequently grew haemophilus which was treated with a course of ceftriaxone. Patient had difficulty weaning from the vent but was given a trial of extubation after several days of slow improvement. She managed approximately 12-18 hours extubated before she needed to be reintubated for respiratory distress. Following her second intubation patient developed elevated WBC count to 40. Was pan cultured and empirically treated for C. Diff infection. Data subsequently revealed a GNR in the sputum and diagnosis of VAP was made. She was started on doripenem given a history of meropenem resistant isolates in the past. Sensitivities on GNR subsequently revealed a meropenem GNR and after discussion it was determined that patient could be treated with a course of meropenem. Lastly, patient was more than 20L positive on day prior to discharge, but diuresing well. - Meropenem to complete on - Continue to diurese as tolerated with goal 2L negative per day to facilitate weaning from the trach. - If patient not responding clinically to meropenem may require doripenem for coverage. - At time of discharge, tolerating trach collar w/o difficulty. - Tapered steroids down to 10mg prednisone which was pre-admission dose - Continue PCP prophylaxis given steroids . # Hypotension: Likely septic physiology on admission. Treated with stress dose steroids given h/o long standing steroid use, and tapered back to preadmission baseline prior to discharge. Subsequently started on anti-hypertensive regimen of lisinopril and diltiazem. . # CAD/Chest pain: Pt with recent NSTEMI who presented with hypoxia and was denying CP in ED. EKGs with sinus tach in 140s, LBBB and non-specific changes from baseline. Patient did not rule in during hospital stay. Echocardiogram results did no demonstrate significant cardiac pathology. Was restarted on ASA, lipitor, ACE-I. Transiently with atrial fibrillation. Not restarted on anti-coagulation on discharge given acute medical issues and that episode of A. fib was in setting of substantial acute lung pathology. Would reassess need for anticoagulation given episode of a. fib as an outpatient. Continue diltiazem. - Uptitirate lisinopril as tolerated - Recommend repeating electrolytes while actively diuresing patient with lasix and uptitrating lisinopril would follow creatinine regularly. . # Hct drop: Thought to be dilutional. No major bleeding source identified. Patient received 2 units PRBC's during her hospital stay and was trace guaiac positive. - consider outpatient colonoscopy when able. . # Anxiety: started on clonazepam prior to discharge for treatment of anxiety. To use ativan PRN. . # ?Lung Mass: Irregular opacity in R-mid lung noted on chest films that was new from . Recommend obtaining a CT scan of her chest for further evaluation. This was not done during this hospitalization given her other acute medical conditions. . # FEN: PEG placed prior to discharge and started on tube feeds. . # Prophylaxis: heparin sc tid, bowel regimen, PPI . # Access: PICC line placed . # Code: FULL . # Disposition: to rehab for trach care. . # Communication: Niece, patient, (PA) who has been caring for Ms. in her current rehab setting. (Her phone number is ). The patient's niece became involved and visited often. We had several end of life discussions with the patient and she agreed to trach and full code while hospitalized. | Anemia likey from phlebotomy, chronic disease Transfused one unit PRBC , on on - cont to trend . Dropped over course of hospitalization, s/p transfusion again on ; now stabalized. Stage 1 pressure ulcer noted to rt gluteal area. Given acute decompensation without a pre-intubation ABG, suspect a component of hypercarbic resp failure given MS changes & elevated serum bicarb. Given acute decompensation without a pre-intubation ABG, suspect a component of hypercarbic resp failure given MS changes & elevated serum bicarb. Given acute decompensation without a pre-intubation ABG, suspect a component of hypercarbic resp failure given MS changes & elevated serum bicarb. Stage 1 pressure ulcer noted to rt gluteal area. EKGs with sinus tach in 140s, LBBB and non-specific changes from baseline. Aggressive resuscitation with IVF, s/p 10L of IVF on initial presentation. Aggressive resuscitation with IVF, s/p 10L of IVF on initial presentation. Sputum now showing pleomorphic GN coccobacillus (recent sputum cx + HFlu). Sputum now showing pleomorphic GN coccobacillus (recent sputum cx + HFlu). Sputum now showing pleomorphic GN coccobacillus (recent sputum cx + HFlu). Sputum now showing pleomorphic GN coccobacillus (recent sputum cx + HFlu). Stage 1 pressure ulcer noted to rt gluteal area. Stage 1 pressure ulcer noted to rt gluteal area. Aggressive resuscitation with IVF, s/p 10L of IVF on initial presentation. Aggressive resuscitation with IVF, s/p 10L of IVF on initial presentation. Given acute decompensation without a pre-intubation ABG, suspect a component of hypercarbic resp failure given MS changes & elevated serum bicarb. Given acute decompensation without a pre-intubation ABG, suspect a component of hypercarbic resp failure given MS changes & elevated serum bicarb. Anemia likey from phlebotomy, chronic disease Transfused one unit PRBC , on on - cont to trend . Dropped over course of hospitalization, s/p transfusion again on ; now stabalized. Dropped over course of hospitalization, s/p transfusion again on ; now stabalized. # Leukocytosis / Fever has now resolved with treatment of presumed . Anemia likey from phlebotomy, chronic disease Transfused one unit PRBC , now stable - cont to trend . Anemia likey from phlebotomy, chronic disease Transfused one unit PRBC , on on - cont to trend . Dropped over course of hospitalization, s/p transfusion again on ; now stabalized. Events: Bedside trach/PEG by IP and thoracic w/o incident, anesthesia present- sedated w/ Vecuronium, Propofol bolus and gtt- off post procedure. Events: Bedside trach/PEG by IP and thoracic w/o incident, anesthesia present- sedated w/ Vecuronium, Propofol bolus and gtt- off post procedure. - guiac positive - steady drop likely from phlebotomy, will transfuse for Hct <24 - maintain active type & screen . # Disposition: trach and PEG now, case management aware of need for rehab planning - Social work consult placed , PT/OT c/s placed ICU Care Nutrition: Glycemic Control: Lines: PICC Line - 01:30 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: Recent pseudomonas, HFlu in sputum. Recent pseudomonas, HFlu in sputum. Recent pseudomonas, HFlu in sputum. Recent pseudomonas, HFlu in sputum. Recent pseudomonas, HFlu in sputum. Recent pseudomonas, HFlu in sputum. EKGs with sinus tach in 140s, LBBB and non-specific changes from baseline. EKGs with sinus tach in 140s, LBBB and non-specific changes from baseline. She received Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg coccobaccili likely c/w prior sputums of H.Flu. Anemia likey from phlebotomy, chronic disease Transfused one unit PRBC , on on - cont to trend . Dropped over course of hospitalization, s/p transfusion again on ; now stabalized. Given acute decompensation without a pre-intubation ABG, suspect a component of hypercarbic resp failure given MS changes & elevated serum bicarb. She received Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg coccobaccili likely c/w prior sputums of H.Flu. HCt falling- transfused 1 unit RBC-needs post transfusion Hct @ . Action: Skin tears requiring dsg changes Q2hrs. Action: Skin tears requiring dsg changes Q2hrs. Action: Skin tears requiring dsg changes Q2hrs. Blister OTA on LLE. She recd Zofran 4mg IV, followed by Ativan 1mg X 2 with eventual resolution of nausea. Sputum now showing pleomorphic GN coccobacillus (recent sputum cx + HFlu). HCt falling- transfused 1 unit RBC-needs post transfusion Hct @ . Given acute decompensation without a pre-intubation ABG, suspect a component of hypercarbic resp failure given MS changes & elevated serum bicarb. # Prophylaxis: heparin sc tid, bowel regimen, PPI . # Prophylaxis: heparin sc tid, bowel regimen, PPI . Events: Bedside trach/PEG by IP and thoracic w/o incident, anesthesia present- sedated w/ Vecuronium, Propofol bolus and gtt- off post procedure. Anemia likey from phlebotomy, chronic disease Transfused one unit PRBC , on on - cont to trend . Dropped over course of hospitalization, s/p transfusion again on ; now stabalized. # Prophylaxis: heparin sc tid, bowel regimen, PPI . # Prophylaxis: heparin sc tid, bowel regimen, PPI . # Prophylaxis: heparin sc tid, bowel regimen, PPI . # Leukocytosis / Fever has now resolved with treatment of presumed . - guiac positive - steady drop likely from phlebotomy, will transfuse for Hct <24 - maintain active type & screen . Dropped over course of hospitalization, s/p transfusion again on ; now stabalized. Anemia likey from phlebotomy, chronic disease Transfused one unit PRBC , now stable - cont to trend . FINAL REPORT HISTORY: Hypoxia, for NGT placement. IMPRESSION: AP chest compared to 7:12 p.m. Nasogastric tube ends in the upper portion of a nondistended stomach. Prior anteroseptalmyocardial infarction. There is left bundle-branch block and the ischemic appearingT wave abnormalites previously recorded in the anterolateral and apicalareas are now upright, in parallel with an increase in rate, consisentwith pseudonormalization and possible active ischemia. FINDINGS: In comparison with the earlier study of this date, the nasogastric tube is in good position, extending at least to the mid body of the stomach, where it is lost to the bottom of the film. | 263 | [
{
"category": "Physician ",
"chartdate": "2158-02-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443769,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - will need to change doripenem to meropenem 1g q8h for rehab\n - got Trach/PEG\n - hypertensive all day -> started back on home dose dilt and added\n captopril for increased afterload reduction\n PERCUTANEOUS TRACHEOSTOMY - At 01:00 PM\n teach/PEG placement\n TRANSTHORACIC ECHO - At 02:27 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 10:14 AM\n Vancomycin - 03:05 PM\n Infusions:\n Other ICU medications:\n Vecuronium - 12:55 PM\n Propofol - 01:00 PM\n Furosemide (Lasix) - 02:45 PM\n Fentanyl - 06:29 PM\n Lorazepam (Ativan) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.8\nC (98.3\n HR: 77 (68 - 104) bpm\n BP: 118/54(69) {88/40(54) - 170/98(107)} mmHg\n RR: 14 (14 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 56.7 kg (admission): 60.5 kg\n Height: 67 Inch\n Total In:\n 953 mL\n 313 mL\n PO:\n TF:\n 41 mL\n IVF:\n 831 mL\n 233 mL\n Blood products:\n Total out:\n 3,190 mL\n 510 mL\n Urine:\n 3,140 mL\n 510 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n -2,238 mL\n -198 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 405 (340 - 550) mL\n PS : 5 cmH2O\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 11 cmH2O\n SpO2: 95%\n ABG: ///39/\n Ve: 7.2 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 410 K/uL\n 9.8 g/dL\n 81 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 3.9 mEq/L\n 15 mg/dL\n 98 mEq/L\n 139 mEq/L\n 30.3 %\n 15.7 K/uL\n [image002.jpg]\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n 03:54 AM\n 03:56 AM\n 04:00 AM\n WBC\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n 19.7\n 15.9\n 15.7\n Hct\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n 28.7\n 30.0\n 30.3\n Plt\n 258\n 284\n 310\n 349\n 91\n 410\n Cr\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n 0.5\n 0.5\n 0.5\n Glucose\n 106\n 76\n 72\n 135\n 79\n 70\n 90\n 82\n 81\n Other labs: PT / PTT / INR:14.3/34.1/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.2 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:1.7 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443772,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - will need to change doripenem to meropenem 1g q8h for rehab\n - got Trach/PEG\n - hypertensive all day -> started back on home dose dilt and added\n captopril for increased afterload reduction\n PERCUTANEOUS TRACHEOSTOMY - At 01:00 PM\n teach/PEG placement\n TRANSTHORACIC ECHO - At 02:27 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 10:14 AM\n Vancomycin - 03:05 PM\n Infusions:\n Other ICU medications:\n Vecuronium - 12:55 PM\n Propofol - 01:00 PM\n Furosemide (Lasix) - 02:45 PM\n Fentanyl - 06:29 PM\n Lorazepam (Ativan) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.8\nC (98.3\n HR: 77 (68 - 104) bpm\n BP: 118/54(69) {88/40(54) - 170/98(107)} mmHg\n RR: 14 (14 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 56.7 kg (admission): 60.5 kg\n Height: 67 Inch\n Total In:\n 953 mL\n 313 mL\n PO:\n TF:\n 41 mL\n IVF:\n 831 mL\n 233 mL\n Blood products:\n Total out:\n 3,190 mL\n 510 mL\n Urine:\n 3,140 mL\n 510 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n -2,238 mL\n -198 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 405 (340 - 550) mL\n PS : 5 cmH2O\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 11 cmH2O\n SpO2: 95%\n ABG: ///39/\n Ve: 7.2 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic, intubated; not sedated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished: ),\n mild rhonchi diffusedly\n Abdominal: Soft, Non-tender, ND, no hsm, normoactive BS\n Extremities: Right: 2+, Left: 2+, significant BLE edema with skin\n weeping\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, interactive appropriately, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 410 K/uL\n 9.8 g/dL\n 81 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 3.9 mEq/L\n 15 mg/dL\n 98 mEq/L\n 139 mEq/L\n 30.3 %\n 15.7 K/uL\n [image002.jpg]\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n 03:54 AM\n 03:56 AM\n 04:00 AM\n WBC\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n 19.7\n 15.9\n 15.7\n Hct\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n 28.7\n 30.0\n 30.3\n Plt\n 258\n 284\n 310\n 349\n 91\n 410\n Cr\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n 0.5\n 0.5\n 0.5\n Glucose\n 106\n 76\n 72\n 135\n 79\n 70\n 90\n 82\n 81\n Other labs: PT / PTT / INR:14.3/34.1/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.2 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:1.7 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Patient was started on vanc/zosyn. Vanc was d/c\ned once\n it was growth was gram negative. Zosyn was changed to ceftriaxone when\n speciated to H. flu beta-lactamase negative. Patient completed \n day course of HAP and steroid taper when patient passed SBT and was\n extubated. Patient remained extubated for 12 hours and developed sinus\n tachycardia (in the setting of beta blocker withdrawl), tachypnea,\n accessory muscle use and desaturation to low 90s. Patient was given\n trial of nebs and CPAP, patient continued to retain CO2 and patient was\n intubated on . Patient has very poor respiratory reserve and will\n require long-term trach.\n - s/p ceftriaxone course for h.flu; now being treating for pseudomonas\n with vanc/ -> 2 week course from \n - patient to get Trach/PEG as add-on today\n - continue prednisone, now on 40 mg daily for the next three days, and\n will continue taper\n - mouthcare, HOB elevated\n .\n # Leukocytosis / Fever\n developed 4 hours after reintubation. Patient\n was intubated uneventfully and patient was NPO 48 hours prior to\n procedure. Likely , pt improving with decreasing leukocytosis, has\n not spiked since \n - f/u BC, UC, cdiff toxin, mini-BAL, and endobronchial\n aspirate cx (neg gram stain on mini BAL)\n - first c.diff neg, stopped c.diff treatment\n - treating for pseudomonas plus one other GNR yet to be\n speciated with Vanco and doripenem for now, awaiting speciations\n will\n treat 7 days since last fever\n - foley changed secondary to yeast\n .\n # Tachycardia\n similar to previous, could be from infection or\n hypovolemia or anxiety. Could also be MAT given resp problems. \n agents. Responded to fluid boluses , tachy with movement,\n when calm around 80s-90s.\n - Sinus tach on EKG \n - Fluid challenge PRN\n - Hold anti-HTN meds\n .\n # Resolved ARF: Pre-renal from hypovolemia/sepsis, now improved.\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily\n will discuss\n aspirin with thoracic team today.\n - continue to monitor on telemetry, follow EKGs\n - holding all agents at this time; afib responds to metoprolol if\n she goes into it, dilt did not work as well\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF.\n Dropped over course of hospitalization, s/p transfusion again on ;\n now stabalized. Anemia likey from phlebotomy, chronic disease\n Transfused one unit PRBC , on on \n - cont to trend\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # Osteopenia\n was on fosamax as outpatient, in setting of steroid use\n will start Ca/Vit D\n - Ca and Vit D supplementation for now\n - re-start fosamax when respiratory status starts to stabilize\n .\n # FEN: cont TFs, 40cc/hr, running at goal, nutrition following,\n awaiting PEG\n .\n # Prophylaxis: heparin sc BID, PPI\n .\n # Access: Left PIV 18 gauge, PICC\n .\n # Code: FULL\n .\n # Communication\n with patient and niece\n .\n # Disposition: case management aware of need for rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n :\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-12 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 441135,
"text": "Chief Complaint: PNA, Resp Failure\n HPI:\n 70 y/o F with PMHx of severe COPD and recent NSTEMI who was transferred\n in from rehab due to increased SOB over the prior 3-4 days. This am,\n she was noted to have low sats in 70% which did not respond to nebs.\n Her sats came up with high flow O2 in the EMS. Pt denied any cough,\n increased sputum, chest pain or pedal edema. She was notably wheezey\n on presentation and was initially treated as COPD exacerbation.\n .\n In the ED, initial vs were: T 97.6 BP 146/70 HR 147 RR 20 Sats 96% on\n RA. Patient was given solumedrol 125mg, nebs & levofloxacin for LLL\n infiltrate seen on CXR. On re-evaluation, pt was lethargic and\n desatting into the 70s. Pt was intubated for respiratory failure and\n received ceftriaxone and vancomycin for presumed PNA. Pt was noted to\n have sbps in 80s peri-intubation and received a total of 6L of IVF. Pt\n had a Tmax of 103.8 in the ED, though lactate was normal at 1.7. Pt\n was transferred to the ICU on versed/fentanyl and dopamine to maintain\n SBPs.\n .\n On arrival, pt was intubated and sedated though following commands.\n She reported some chest pain but was otherwise comfortable and sating\n 100% on the vent.\n .\n Review of sytems: unable to obtain\n .\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 PM\n Ciprofloxacin - 04:30 PM\n Infusions:\n Dopamine - 3 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 04:00 PM\n Other medications:\n Home medications:\n Aspirin 81mg\n Atorvastatin 40mg\n Xopenex prn\n Tiotropium Daily\n Advair \n Alendronate 70mg weekly\n Colace \n Senna prn\n Mucomyst inhaled\n Vitamin B12\n diltiazem 120mg daily\n Prednisone 10mg daily\n Ativan prn\n Robitussin prn\n Past medical history:\n Family history:\n Social History:\n COPD with severe obstructive defect\n HTN\n CAD s/p NSTEMI\n Carotid Stenosis\n PVD: aortoileac disease, followed by Dr. \n Osteoporosis\n Depression/Anxiety\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Pt has been living in rehab since recent discharge. Smoked for\n about 30 pack years and quit 15yrs ago.\n Review of systems:\n Flowsheet Data as of 05:38 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 101 (93 - 115) bpm\n BP: 126/64(85) {126/64(85) - 126/64(85)} mmHg\n RR: 17 (14 - 17) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 60 Inch\n Total In:\n 7,377 mL\n PO:\n TF:\n IVF:\n 1,377 mL\n Blood products:\n Total out:\n 0 mL\n 360 mL\n Urine:\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 7,017 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 36 cmH2O\n Plateau: 23 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 96%\n ABG: 7.28/55/75//-1\n Ve: 7.7 L/min\n PaO2 / FiO2: 150\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 316 K/uL\n 8.7 g/dL\n 27.6 %\n 19.1 K/uL\n [image002.jpg]\n \n 2:33 A2/8/ 04:47 PM\n \n 10:20 P2/8/ 05:06 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 19.1\n Hct\n 27.6\n Plt\n 316\n TC02\n 27\n Other labs: Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0\n %, Lactic Acid:1.0 mmol/L\n Fluid analysis / Other labs: Lactate:1.7\n .\n Trop-T: 0.01 CK: 28 MB: Notdone\n .\n 138 93 16 188 AGap=13\n --------------\n 4.5 37 0.5\n .\n proBNP: 2952\n .\n WBC 17.0 Hgb 11.2 Hct 34.8 Plts 425 D\n N:89 Band:3 L:5 M:3 E:0 Bas:0\n Hypochr: 2+ Anisocy: 1+ Macrocy: 1+ Polychr: 2+ Stipple: 2+\n Plt-Est: Normal\n .\n PT: 13.6 PTT: 24.4 INR: 1.2\n Imaging: CXR portable reveals left lower lobe hazy opacities\n with blurring of L heart border and R costo phrenic angle opacities\n .\n EKG: sinus tach at 140s with LBBB, no appreciable discordance though\n slightly different from prior tracings\n .\n Repeat EKG at 3pm with sinus rhythm at 100, incomplete LBBB, left\n atrial abnormality, low voltage in limb leads, non-specific lateral\n ST-T wave changes\n .\n ECHO : Suboptimal image quality. Normal left ventricular cavity\n size with mild regional systolic dysfunction most c/w CAD. Mild mitral\n regurgitation. Compared with the prior study (Images reviewed) of\n , the wall motion abnormalities are more extensive (mid-septal\n hypokinesis was suggested on review of the prior study).\n .\n Microbiology: Micro: Urine, Blood pending\n Sputum prelim + 4 PLEOMORPHIC GRAM NEGATIVE COCCOBACILLI.\n Assessment and Plan\n 70 y/o F with severe COPD who presents with hypoxia and respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD and PNA on CXR\n - Vanc, Zosyn, Cipro\n - Xopenex nebs\n - stress dose hydrocortisone 100mg q8hr\n .\n # Hypotension: Etiology unclear, this may have been due to meds\n peri-intubation in setting of hypovolemia.\n - bolus IVF\n - fem line for now\n - foley, monitor UOP goal >30cc/hr\n - art line to be placed\n .\n # Chest pain: Pt with recent NSTEMI who presented with hypoxia and was\n denying CP in ED. EKGs with sinus tach in 140s, LBBB and non-specific\n changes from baseline. First set of CE are negative though pt was\n reporting CP on arrival to ICU. Given the recent history, possible to\n have demand ischemia with tachycardia. Will monitor symptoms and cycle\n cardiac enzymes.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - cycle cardiac enzymes\n - continue to monitor on telemetry, follow EKGs\n - start metoprolol 12.5mg for HR>110s\n .\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - contine Zosyn/Cipro as above\n - f/u urine cultures\n .\n # FEN: NPO for now, will consult nutrition for TFs\n - nutrition consult for TF\n - bolus IVF prn\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, Right femoral line, left PICC\n .\n # Code: FULL\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition: Nutrition consult for TFs\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 01:30 PM\n PICC Line - 01:30 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 04:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-12 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 441131,
"text": "Chief Complaint: PNA, Resp Failure\n HPI:\n 70 y/o F with PMHx of severe COPD and recent NSTEMI who was transferred\n in from rehab due to increased SOB over the prior 3-4 days. This am,\n she was noted to have low sats in 70% which did not respond to nebs.\n Her sats came up with high flow O2 in the EMS. Pt denied any cough,\n increased sputum, chest pain or pedal edema. She was notably wheezey\n on presentation and was initially treated as COPD exacerbation.\n .\n In the ED, initial vs were: T 97.6 BP 146/70 HR 147 RR 20 Sats 96% on\n RA. Patient was given solumedrol 125mg, nebs & levofloxacin for LLL\n infiltrate seen on CXR. On re-evaluation, pt was lethargic and\n desatting into the 70s. Pt was intubated for respiratory failure and\n received ceftriaxone and vancomycin for presumed PNA. Pt was noted to\n have sbps in 80s peri-intubation and received a total of 6L of IVF. Pt\n had a Tmax of 103.8 in the ED, though lactate was normal at 1.7. Pt\n was transferred to the ICU on versed/fentanyl and dopamine to maintain\n SBPs.\n .\n On arrival, pt was intubated and sedated though following commands.\n She reported some chest pain but was otherwise comfortable and sating\n 100% on the vent.\n .\n Review of sytems: unable to obtain\n .\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 PM\n Ciprofloxacin - 04:30 PM\n Infusions:\n Dopamine - 3 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 04:00 PM\n Other medications:\n Home medications:\n Aspirin 81mg\n Atorvastatin 40mg\n Xopenex prn\n Tiotropium Daily\n Advair \n Alendronate 70mg weekly\n Colace \n Senna prn\n Mucomyst inhaled\n Vitamin B12\n diltiazem 120mg daily\n Prednisone 10mg daily\n Ativan prn\n Robitussin prn\n Past medical history:\n Family history:\n Social History:\n COPD with severe obstructive defect\n HTN\n CAD s/p NSTEMI\n Carotid Stenosis\n PVD: aortoileac disease, followed by Dr. \n Osteoporosis\n Depression/Anxiety\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Pt has been living in rehab since recent discharge. Smoked for\n about 30 pack years and quit 15yrs ago.\n Review of systems:\n Flowsheet Data as of 05:38 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 101 (93 - 115) bpm\n BP: 126/64(85) {126/64(85) - 126/64(85)} mmHg\n RR: 17 (14 - 17) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 60 Inch\n Total In:\n 7,377 mL\n PO:\n TF:\n IVF:\n 1,377 mL\n Blood products:\n Total out:\n 0 mL\n 360 mL\n Urine:\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 7,017 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 36 cmH2O\n Plateau: 23 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 96%\n ABG: 7.28/55/75//-1\n Ve: 7.7 L/min\n PaO2 / FiO2: 150\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 316 K/uL\n 8.7 g/dL\n 27.6 %\n 19.1 K/uL\n [image002.jpg]\n \n 2:33 A2/8/ 04:47 PM\n \n 10:20 P2/8/ 05:06 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 19.1\n Hct\n 27.6\n Plt\n 316\n TC02\n 27\n Other labs: Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0\n %, Lactic Acid:1.0 mmol/L\n Fluid analysis / Other labs: Lactate:1.7\n .\n Trop-T: 0.01 CK: 28 MB: Notdone\n .\n 138 93 16 188 AGap=13\n --------------\n 4.5 37 0.5\n .\n proBNP: 2952\n .\n WBC 17.0 Hgb 11.2 Hct 34.8 Plts 425 D\n N:89 Band:3 L:5 M:3 E:0 Bas:0\n Hypochr: 2+ Anisocy: 1+ Macrocy: 1+ Polychr: 2+ Stipple: 2+\n Plt-Est: Normal\n .\n PT: 13.6 PTT: 24.4 INR: 1.2\n Imaging: CXR portable reveals left lower lobe hazy opacities\n with blurring of L heart border and R costo phrenic angle opacities\n .\n EKG: sinus tach at 140s with LBBB, no appreciable discordance though\n slightly different from prior tracings\n .\n Repeat EKG at 3pm with sinus rhythm at 100, incomplete LBBB, left\n atrial abnormality, low voltage in limb leads, non-specific lateral\n ST-T wave changes\n .\n ECHO : Suboptimal image quality. Normal left ventricular cavity\n size with mild regional systolic dysfunction most c/w CAD. Mild mitral\n regurgitation. Compared with the prior study (Images reviewed) of\n , the wall motion abnormalities are more extensive (mid-septal\n hypokinesis was suggested on review of the prior study).\n .\n Microbiology: Micro: Urine, Blood pending\n Sputum prelim + 4 PLEOMORPHIC GRAM NEGATIVE COCCOBACILLI.\n Assessment and Plan\n 70 y/o F with severe COPD who presents with hypoxia and respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD and PNA on CXR\n - Vanc, Zosyn, Cipro\n - Xopenex nebs\n - stress dose hydrocortisone 100mg q8hr\n .\n # Hypotension: Etiology unclear, may be due to meds peri-intubation,\n also clinically dry\n - bolus IVF\n - fem line for now\n - foley, monitor UOP goal >30cc/hr\n - art line to be placed\n .\n # Chest pain: Pt with recent NSTEMI\n .\n # UTI: UA with no epis and >10 WBCs likely most consistent with UTI,\n no prior urine cultures in system.\n - contine Zosyn/Cipro as above\n - f/u urine cultures\n .\n # FEN: NPO for now, will place OG\n - nutrition consult for TF\n - bolus IVF prn\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, Right femoral line, PICC\n .\n # Code: presumed full\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 01:30 PM\n PICC Line - 01:30 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 04:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-12 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 441129,
"text": "Chief Complaint: Respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient with hx of COPD with increased shortness of breath for several\n days. No change in cough; no fever or change in sputum. No chest pain\n or change in edema. Felt to be very wheezy today and more hypoxemic and\n was transferred to .\n In ED given nebs and Levoflox for LLL infiltrate. Became more hypoxemic\n with sats in 70's; lethargic. Was intubated. Antibiotic coverage\n expanded. Post intubation became hypotensive; given 6L of fliuid.\n Lactate 1.7. Started on dopamine. Transferred to MICU.\n On arrival in MICU, was following commands. Patient seemed to be\n indicating that she had some chest pain. An ECG was obtained. No clear\n change from ED although different than . Patient has baseline of\n LBBB.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n COPD - recently growing pseudomonas and H Flu from sputum.\n Hypertension\n s/p NSTEMI\n Carotid stenosis\n Depression\n Anxiety\n Peripheral vascular disease\n Not obtainable\n Occupation:\n Drugs:\n Tobacco: 30 pack years - stopped 15 years ago\n Alcohol:\n Other: Has been in inpatient rehab recently.\n Review of systems:\n Constitutional: Not able to obtain in intubated patient\n Flowsheet Data as of 04:47 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 99 (93 - 115) bpm\n BP: 103/51(64) {79/47(54) - 130/62(6,350)} mmHg\n RR: 14 (14 - 17) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 6,055 mL\n PO:\n TF:\n IVF:\n 55 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,855 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 36 cmH2O\n Plateau: 23 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 97%\n ABG: ////\n Ve: 7.7 L/min\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, No(t)\n Thin, No(t) Anxious, No(t) Diaphoretic, Sedated\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, No(t) NG\n tube, OG tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: No(t) Normal, Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic), Very soft heart sounds\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Breath\n Sounds: No(t) Bronchial: , Wheezes : Prolong exhalation I/E ,\n Diminished: , No(t) Absent : , Rhonchorous: Coarse large airway sounds)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: Absent edema, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Sedated, No(t) Paralyzed, Tone: Not\n assessed\n Labs / Radiology\n 425\n 34.8\n 188\n 0.5\n 16\n 37\n 93\n 4.5\n 138\n 17\n [image002.jpg]\n Other labs: PT / PTT / INR://1.2, Differential-Neuts:89, Band:3, Lactic\n Acid:1.7\n Fluid analysis / Other labs: BNP 1500\n Imaging: CXR: patchy alveolar infiltrate left mid zone and small\n infiltrate right base.\n Assessment and Plan\n ACUTE RESPIRATORY FAILURE\n COPD\n CORONARY ARTERY DISEASE\n PNEUMONIA\n HYPOTENSION\n Patient with hx of infected sputum. Now with evidence of left lung\n pneumonia with possible infiltrate as well at right base. This, on top\n of baseline of severe COPD, has led to respiratory failure. I have\n reduced FIO2 to 0.4 and patient\ns oxygen saturation is holding in the\n low 90\ns. Her serum bicarbonate suggests that she has chronic\n hypercapnia. ABG results are pending. I would ventilate her to maintain\n a pH of 7.30-7.35 to facilitate further compensation by kidney and to\n enable patient\ns minute ventilation requirements to be lower.\n Antibiotics adjusted to address recent sputum cultures. Will send\n another specimen and try to obtain cultures from rehab.\n Patient receiving steroids for COPD and for presumed adrenal\n insufficiency due to chronic steroids.\n Patient complained of some chest pain on admission. Hx of CAD. ECG\n difficult to interpret for acute ischemia with LBBB. Cardiac enzymes\n pending.\n Hypotension post intubation likely related to meds and institution of\n positive pressure breathing and possible adrenal insufficiency. Now\n normotensive. Sepsis seems less likely.\n ICU Care\n Nutrition: NPO\n Glycemic Control: Insulin infusion\n Lines / Intubation:\n Multi Lumen - 01:30 PM\n PICC Line - 01:30 PM\n 18 Gauge - 01:30 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-13 00:00:00.000",
"description": "Generic Note",
"row_id": 441177,
"text": "TITLE:\n 70 y/o F with PMHx of severe COPD and recent NSTEMI who was transferred\n in from rehab with increased SOB over the prior 3-4 days. This am, she\n was noted to have low sats to 70% which did not respond to nebs. Her\n sats came up with high flow O2 in the EMS. Pt denied any cough,\n increased sputum, chest pain or pedal edema. She was notably wheezey\n on presentation and was initially treated as COPD exacerbation.\n .\n In the ED, initial vs were: T 97.6 BP 146/70 HR 147 RR 20 Sats 96% on\n RA. Patient was given solumedrol 125mg, nebs & levofloxacin for LLL\n infiltrate seen on CXR. On re-evaluation, pt was lethargic and\n desatting into the 70s. Pt was intubated for respiratory failure and\n received ceftriaxone and vancomycin for presumed PNA. Pt was noted to\n have sbps in 80s peri-intubation and received a total of 6L of IVF. Pt\n had a Tmax of 103.8 in the ED, though lactate was normal at 1.7. Pt\n was transferred to the ICU on versed/fentanyl and dopamine to maintain\n SBPs.\n .\n On arrival, pt was intubated and sedated though following commands.\n She reported some chest pain but was otherwise comfortable and sating\n 100% on the vent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt\ns LS\ns clear in upper airway, diminished at bases. Vented on AC\n 500x14, FiO2 40%, PEEP 5. O2 sat 94-97%. Suctioned for small to\n moderate amounts of thick tan secretions. Sputum, urine, blood\n cultures sent in ED (including a set off of PICC line). Pt easily\n arousable and following commands, becoming anxious at times and\n reaching for ETT.\n Action:\n Started on Fenta & versed drips. Pt\ns RR ^ed to 16 on the vent after\n ABG . Rec\nd cipro for treatment of pna and will continue on\n vancomycin. Zosyn pending ID approval. CXR done in am.\n Response:\n Pt O2 sat 95 to 97% on current vent settings. Pt appears comfortable\n on ventilator at this time.\n Plan:\n Cont to monitor resp status, wean vent as tolerated.\n Sepsis without organ dysfunction\n Assessment:\n Received pt on Dopamine drip at 2mcg/kg/min. urine output decreased\n .\n Action:\n Total of 2 lits of LR bloused for low urine output. BP WNL ,dopamine\n weaned off at 2245 hrs. .\n Response:\n ABP 95\ns-120\ns/50\ns with MAP >65 on current dose of dopamine. U/O\n decreased again at 2 am, informed Resident, u/o next improved to\n 20 & then to 35 mls.\n Patient positive for a total of 9 lits\n Plan:\n Continue monitoring BP, U/O.\n Alteration in Nutrition\n Assessment:\n Patient received on Pulmonary Nutren at 10 mls/hr , water flushes 30\n mls q 8 hrs. Albumin low, with peripheral edema.\n Action:\n Feeds increased to 30 mls/hr as tolerated by the patient. Glucose\n levels above 150, covered with HISS.\n Response:\n Pending\n Plan:\n Increase to a goal of 40 mls/hr as tolerated. Monitor FS.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple areas of bruising on extremities with 2 skin tears\n noted, 1 to the right elbow and 1 to the right foot. + pedal\n edema. Stage 1 pressure ulcer noted to rt gluteal area.\n Action:\n Skin tears cleaned with NS and covered with adaptic. Rt foot skin tear\n draining small to moderate amounts of serosang drainage. Pt turned and\n repositioned.\n Response:\n Pending\n Plan:\n Continue to monitor for further areas of tearing or breakdown. Turn\n and reposition q2 hours.\n Electrolyte & fluid disorder, other\n Assessment:\n Calcium, ionized calcium ,mag & phos low in pm labs.\n Action:\n Repleted with 4 grams of Calcium, 4 grams of mag sulph, 15 mmol of K\n Phos given\n Response:\n Mag up to 2.8, Ionised calcium 1.15, phos 3.8.\n Plan:\n Continue monitoring labs, replete as per sliding scale.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-12 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 441123,
"text": "Chief Complaint: Respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient with hx of COPD with increased shortness of breath for several\n days. No change in cough; no fever or change in sputum. No chest pain\n or change in edema. Felt to be very wheezy today and more hypoxemic and\n was transferred to .\n In ED given nebs and Levoflox for LLL infiltrate. Became more hypoxemic\n with sats in 70's; lethargic. Was intubated. Antibiotic coverage\n expanded. Post intubation became hypotensive; given 6L of fliuid.\n Lactate 1.7. Started on dopamine. Transferred to MICU.\n On arrival in MICU, was following commands. Patient seemed to be\n indicating that she had some chest pain. An ECG was obtained. No clear\n change from ED although different than . Patient has baseline of\n LBBB.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n COPD - recently growing pseudomonas and H Flu from sputum.\n Hypertension\n s/p NSTEMI\n Carotid stenosis\n Depression\n Anxiety\n Peripheral vascular disease\n Not obtainable\n Occupation:\n Drugs:\n Tobacco: 30 pack years - stopped 15 years ago\n Alcohol:\n Other: Has been in inpatient rehab recently.\n Review of systems:\n Constitutional: Not able to obtain in intubated patient\n Flowsheet Data as of 04:47 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 99 (93 - 115) bpm\n BP: 103/51(64) {79/47(54) - 130/62(6,350)} mmHg\n RR: 14 (14 - 17) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 6,055 mL\n PO:\n TF:\n IVF:\n 55 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,855 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 36 cmH2O\n Plateau: 23 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 97%\n ABG: ////\n Ve: 7.7 L/min\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, No(t)\n Thin, No(t) Anxious, No(t) Diaphoretic, Sedated\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, No(t) NG\n tube, OG tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: No(t) Normal, Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic), Very soft heart sounds\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Breath\n Sounds: No(t) Bronchial: , Wheezes : Prolong exhalation I/E ,\n Diminished: , No(t) Absent : , Rhonchorous: Coarse large airway sounds)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: Absent edema, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Sedated, No(t) Paralyzed, Tone: Not\n assessed\n Labs / Radiology\n 425\n 34.8\n 188\n 0.5\n 16\n 37\n 93\n 4.5\n 138\n 17\n [image002.jpg]\n Other labs: PT / PTT / INR://1.2, Differential-Neuts:89, Band:3, Lactic\n Acid:1.7\n Fluid analysis / Other labs: BNP 1500\n Imaging: CXR: patchy alveolar infiltrate left mid zone and small\n infiltrate right base.\n Assessment and Plan\n ACUTE RESPIRATORY FAILURE\n COPD\n CORONARY ARTERY DISEASE\n PNEUMONIA\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines / Intubation:\n Multi Lumen - 01:30 PM\n PICC Line - 01:30 PM\n 18 Gauge - 01:30 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Nutrition",
"chartdate": "2158-02-13 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 441273,
"text": "Subjective\n Pt intubated/sedated-no family available\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 67\" cm\n 60.5 kg\n 26\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 61.4 Kg kg\n 98%\n Diagnosis: PNA\n PMH :\n COPD - recently growing pseudomonas and H Flu from sputum.\n Hypertension\n s/p NSTEMI\n Carotid stenosis\n Depression\n Anxiety\n Peripheral vascular disease\n Food allergies and intolerances: NKFA\n Pertinent medications: Bowel regimen, HISS, Abx, Heparin, protonix,\n hydrocortisone, Fentanyl gtt, versed gtt, others noted\n Labs:\n Value\n Date\n Glucose\n 158 mg/dL\n 03:20 AM\n Glucose Finger Stick\n 253\n 10:00 AM\n BUN\n 11 mg/dL\n 03:20 AM\n Creatinine\n 0.5 mg/dL\n 03:20 AM\n Sodium\n 139 mEq/L\n 03:20 AM\n Potassium\n 3.8 mEq/L\n 03:20 AM\n Chloride\n 108 mEq/L\n 03:20 AM\n TCO2\n 25 mEq/L\n 03:20 AM\n PO2 (arterial)\n 91 mm Hg\n 03:42 AM\n PCO2 (arterial)\n 47 mm Hg\n 03:42 AM\n pH (arterial)\n 7.31 units\n 03:42 AM\n pH (urine)\n 5.0 units\n 12:48 PM\n CO2 (Calc) arterial\n 25 mEq/L\n 03:42 AM\n Albumin\n 1.9 g/dL\n 04:47 PM\n Calcium non-ionized\n 7.3 mg/dL\n 03:20 AM\n Phosphorus\n 3.8 mg/dL\n 03:20 AM\n Ionized Calcium\n 1.15 mmol/L\n 03:42 AM\n Magnesium\n 2.8 mg/dL\n 03:20 AM\n ALT\n 71 IU/L\n 04:47 PM\n Alkaline Phosphate\n 102 IU/L\n 04:47 PM\n AST\n 113 IU/L\n 04:47 PM\n Total Bilirubin\n 0.4 mg/dL\n 04:47 PM\n WBC\n 15.8 K/uL\n 03:20 AM\n Hgb\n 8.0 g/dL\n 03:20 AM\n Hematocrit\n 25.1 %\n 03:20 AM\n Current diet order / nutrition support: Nutren Pulmonary @40mL/hr (1440\n kcals/65 gr aa)\n GI: Abd: soft/+bs\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1440-1680 (24-32 cal/kg)\n Protein: 65-78 (1-1.3 g/kg)\n Fluid: per team\n Estimation of current intake: Adequate\n Specifics:\n 70 y/o female s/p recent NSTEMI c/ hypoxia and PNA, underlying COPD.\n Pt intubated and sedated. TF\ns started for nutrition via OGT. Pt\n currently tolerating @ 40mL/hr s/ problems. This goal meets 100%\n estimated nutrition needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current nutrition support is appropriate: Continue c/ TF\ns @goal\n Multivitamin / Mineral supplement: multivitamin via TF, would consider\n Ca, Vit D supplementation chronic steroids\n Residual checks q4, hold if >200mL\n BG and lyte management as you are\n Please page c/ ?'s #\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-13 00:00:00.000",
"description": "ICU Attending Note",
"row_id": 441251,
"text": "Clinician: Attending\n Sputum pleomorphic GN coccobacillus (recent sputum cx + HFlu)\n 70 yo woman with severe COPD, recent NSTEMI. Recent pseudomonas, HFlu\n in sputum. Chronic steroids. Intubated when admitted .\n CXR hyperinflation, bilat pleural effu, left pleural opac: loc pleural\n effusion vs infiltrate, left lower lung zone infiltrate increased since\n yest.\n PS 0.4/8/5 RR 18 RSBI 56 7.32/47/91\n Insulin, hep sc, vanc/cipro/zosyn, ppi, asa, statin, hydrocort 100 IV q\n 8, versed 1, fentanyl 25, DA\n Total time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 441259,
"text": "Chief Complaint:\n 24 Hour Events:\n - weaned off of dopamine overnight\n - HCT trending down 34.8 -> 25.1, guaiac neg, hemolysis labs sent\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 PM\n Vancomycin - 08:45 PM\n Ciprofloxacin - 04:00 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 04:45 PM\n Pantoprazole (Protonix) - 05:00 PM\n Heparin Sodium (Prophylaxis) - 05:00 PM\n Fentanyl - 06:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.2\nC (97.1\n HR: 106 (88 - 115) bpm\n BP: 102/67(83) {90/44(58) - 128/68(89)} mmHg\n RR: 16 (14 - 23) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 60 Inch\n Total In:\n 10,259 mL\n 1,062 mL\n PO:\n TF:\n 63 mL\n 161 mL\n IVF:\n 4,136 mL\n 901 mL\n Blood products:\n Total out:\n 648 mL\n 173 mL\n Urine:\n 648 mL\n 173 mL\n NG:\n Stool:\n Drains:\n Balance:\n 9,611 mL\n 889 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 440 (440 - 500) mL\n PS : 8 cmH2O\n RR (Set): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 14 cmH2O\n Plateau: 20 cmH2O\n Compliance: 33.8 cmH2O/mL\n SpO2: 100%\n ABG: 7.31/47/91/25/-2\n Ve: 7.4 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, diffuse\n expiratory wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, +1 pitting edema\n Labs / Radiology\n 288 K/uL\n 8.0 g/dL\n 158 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 108 mEq/L\n 139 mEq/L\n 25.1 %\n 15.8 K/uL\n [image002.jpg]\n 04:47 PM\n 05:06 PM\n 10:44 PM\n 03:20 AM\n 03:42 AM\n WBC\n 19.1\n 15.8\n Hct\n 27.6\n 25.1\n Plt\n 316\n 288\n Cr\n 0.3\n 0.5\n TropT\n <0.01\n <0.01\n TCO2\n 27\n 28\n 25\n Glucose\n 217\n 158\n Other labs: PT / PTT / INR:14.8/30.2/1.3, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.4,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.9 mmol/L, Albumin:1.9 g/dL, LDH:294 IU/L, Ca++:7.3 mg/dL,\n Mg++:2.8 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with hypoxia and respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Given\n acute decompensation without a pre-intubation ABG, suspect a component\n of hypercarbic resp failure given MS changes & elevated serum bicarb.\n Will try to achieve a mild permissive hypercapnea. Received 10L IVF\n yesterday.\n - f/u sputum, blood Cx , Urine legionella (received Levoflox x 1 in ED)\n - broad spectrum Abx with Vanc, Zosyn & Cipro (double coverage for\n pseudomonas until Cx back)\n - MDI while intubated (pt with auto-PEEP), transition to nebs once\n extubated\n - attempt to wean from vent\n - mouthcare, HOB, PPI\n .\n # Hypotension: Etiology unclear, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2months of prednisone use. Aggressive resuscitation with\n IVF, now s/p 10L of IVF.\n - now off dopamine\n - bolus IVF for goal UOP goal >30cc/hr\n - Hydrocortisone 100mg q8hr (stress dose)\n .\n # Chest pain: Pt with recent NSTEMI who presented with hypoxia and was\n denying CP in ED. EKGs with sinus tach in 140s, LBBB and non-specific\n changes from baseline. First set of CE are negative though pt was\n reporting CP on arrival to ICU. Given the recent history, possible to\n have demand ischemia with tachycardia. Will monitor symptoms and cycle\n cardiac enzymes.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - cardiac enzymes negative x2\n - continue to monitor on telemetry, follow EKGs\n - start metoprolol 12.5mg for HR>110s\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s. However, unclear\n etiology to acute drop from baseline.\n - guaic negative\n - hemolysis labs pending\n - maintain active type & screen\n - get rehab records\n - PPI and CVL,PIV, PICC for access\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - contine Zosyn/Cipro as above\n - f/u urine cultures\n .\n # FEN: NPO for now, will consult nutrition for TFs\n - nutrition consult for TF\n - bolus IVF prn\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, Right femoral line, left PICC (plan to d/c\n femoral line in am)\n .\n # Code: FULL\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 07:00 PM 30 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 01:30 PM\n PICC Line - 01:30 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 04:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-13 00:00:00.000",
"description": "ICU Attending Note",
"row_id": 441255,
"text": "Clinician: Attending\n 70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n CXR hyperinflation, bilat pleural effu, left pleural opac: loc pleural\n effusion vs infiltrate, left lower lung zone infiltrate increased since\n yest.\n PS 0.4/8/5 RR 18 RSBI 56 7.32/47/91\n Exam sig for awake, opened eyes, responded to questions with head nod.\n Diffuse exp wheezing. Total PEEP 8 (with ePEEP 5). Right femoral line.\n Distant HS. Abd NABS, soft, NDNT. Extremities cachectic, petechial\n lesions, atrophied. LE pitting edema + bilat. Minimal resp\n secretions.\n BNP 2900 with prior 271.\n Insulin, hep sc, vanc/cipro/zosyn, ppi, asa, statin, hydrocort 100 IV q\n 8, versed 1, fentanyl 25, DA\n BNP in setting of hypovolemia suggests RV strain with cor\n pulmonale/pna/hypoxic vasoconstriction. Received >10L overnight, 6L in\n ED and 4L in MICU, minimal urine output.\n Plan:\n Add atrovent\n d/c fem line\n continue on zosyn/cipro/flagyl until sputum cx obtain\n discuss with Dr \n Total time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441492,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Edema, peripheral\n Assessment:\n + edema to all 4 extremities. Difficult to palpate b/l pedal pulses, +\n b/l radial pulses.\n Action:\n Extremities elevated on pillows.\n Response:\n Plan:\n ? need for lasix\n negative fluid balance goal.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to b/l apices, diminished to b/l bases. Rec\nd on CMV @ 40%/\n 400x14/5+. O2 sats 98-100%. Infreq sxn\ning needed.\n Action:\n Switched to PS of +/40%\n Response:\n Sats 96%, RR 20s\n.unable to draw ABG from aline- team aware.\n Plan:\n Cont to wean vent as tolerated, MDIs.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441371,
"text": "70 y/o F with severe COPD who presented with hypoxia and respiratory\n failure, now intubated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n With severe underlying COPD who p/w fever, hypoxia, leukocytosis and\n infiltrates likely c/w acute PNA. Remains intubated and vented on PS\n 40% 8/5 w/sats at mid to high 90\ns. Bil LS clear, diminished at the\n bases. Small to moderate amnt of blood tinged secretions.\n ABG:7.29/48/107 WBC-24.4, afebrile.\n Action:\n f/u sputum, blood Cx , Urine legionella (received Levoflox x 1 in ED),\n broad spectrum Abx with Vanc, Zosyn & Cipro (double coverage for\n pseudomonas until Cx back), MDI while intubated (pt with auto-PEEP),\n transition to nebs once extubated, mouth care q4hr and prn, VAP\n precautions.\n Response:\n Abg: 7.27/57/106 switched to AC 40% 500x16x5\n Plan:\n Continue w/mechanical ventilation, wean off when able\n Impaired Skin Integrity\n Assessment:\n Skin tears on RT elbow and RT lower extr.\n Action:\n Adaptic dressing applied w/kirlex, , moisture barrier to buttocks and\n sacrum, repositioning q 2hr and prn, nutritional support\n Response:\n pending\n Plan:\n Continue to monitor patient skin status, dressing ASDIR, wound care\n consult if progresses.\n Neuro: sedated on fent/versed however arousable to voice and will\n follow commands. Denies pain.\n Cardio: normotensive. HR at 90-100\ns. Restarted on metoprolol 12.5 TID\n for recent STEMI. Extr edema. Peripheral pulses present.\n GI: abd soft non tender, positive for BS and flatus. No BM this shift.\n OGT in place. Restarted on TF at 40cc/hr. tolerated well, no residuals.\n GU: clear yellow urine via foley, adequate amnt.\n IV access: Left PIV 18 gauge, Right femoral line, left PICC, LT A-line\n Social: patient is a FULL CODE.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-14 00:00:00.000",
"description": "ICU Attending Note",
"row_id": 441473,
"text": "Clinician: Attending\n 70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Switched from PSV to CMV due to resp acidosis.\n Afebrile 88-112. MAP 60-66 off pressors (had been on DA)\n I/O +3L. 800cc urine/24h.\n CMV 0.4/500/16/5 ABG: 7.31/51/106, p/f 265, RSBI 100.\n Versed 2/fent 25.\n Hct stable at 27. lytes nl. Legionella neg. U Cx neg. WBC slightly\n increased. B Cx pending.\n Exam sig for awake, opened eyes, responded to questions with head nod.\n Diffuse exp wheezing. Right femoral line. Distant HS. Abd NABS, soft,\n NDNT. Extremities cachectic, petechial lesions, atrophied. LE pitting\n edema + bilat. Minimal resp secretions.\n Meds: Insulin, hep sc, vanc/cipro/zosyn, ppi, asa, statin, hydrocort\n 100 IV q 8, versed 1, fentanyl 25, DA\n 1. Severe COPD with exacerbation, doubt significant pna\n a. d/c cipro and continue vanc/zosyn\n b. continue high dose steroids for COPD exac\n c. attempt PSV\n 2. RV strain with cor pulmonale/pna/hypoxic\n vasoconstriction\nadmitted with elevated BNP in setting of hypovolemia\n 3. fluid goal even\n Total time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 441474,
"text": "Chief Complaint:\n 24 Hour Events:\n - unable to extubate patient, was on PSV overnight, but gas this\n morning shows primary uncompensated resp acidosis on RR 18 with light\n sedation, so put back on AC to increase RR\n - continues to have femoral line\n - placed nutrition c/s\n - started metoprolol\n - emailed primary, but need to clarify code status\n - replaced OG tube\n - haptoglobin high, no evidence of hemolysis\n - patient stable overnight, did not start doripenem\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:00 PM\n Vancomycin - 08:05 PM\n Piperacillin/Tazobactam (Zosyn) - 12:06 AM\n Ciprofloxacin - 04:38 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Fentanyl - 03:45 PM\n Heparin Sodium (Prophylaxis) - 12:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.7\nC (98.1\n HR: 88 (88 - 112) bpm\n BP: 102/49(66) {72/47(60) - 154/78(99)} mmHg\n RR: 25 (13 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,703 mL\n 674 mL\n PO:\n TF:\n 533 mL\n 225 mL\n IVF:\n 3,050 mL\n 389 mL\n Blood products:\n Total out:\n 803 mL\n 565 mL\n Urine:\n 803 mL\n 565 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,900 mL\n 109 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (374 - 500) mL\n PS : 8 cmH2O\n RR (Set): 16\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 100\n PIP: 23 cmH2O\n Plateau: 16 cmH2O\n Compliance: 62.5 cmH2O/mL\n SpO2: 99%\n ABG: 7.31/51/106/26/-1\n Ve: 9 L/min\n PaO2 / FiO2: 265\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, diffuse\n expiratory wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, +1 pitting edema\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 306 K/uL\n 8.6 g/dL\n 121 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 108 mEq/L\n 140 mEq/L\n 26.7 %\n 24.4 K/uL\n [image002.jpg]\n 04:47 PM\n 05:06 PM\n 10:44 PM\n 03:20 AM\n 03:42 AM\n 07:38 PM\n 07:53 PM\n 03:59 AM\n 04:15 AM\n 06:29 AM\n WBC\n 19.1\n 15.8\n 21.5\n 24.4\n Hct\n 27.6\n 25.1\n 26.5\n 26.7\n Plt\n 06\n Cr\n 0.3\n 0.5\n 1.0\n TropT\n <0.01\n <0.01\n TCO2\n 27\n 28\n 25\n 24\n 27\n 27\n Glucose\n \n Other labs: PT / PTT / INR:14.0/28.0/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.3 mg/dL,\n Mg++:2.6 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with hypoxia and respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Given\n acute decompensation without a pre-intubation ABG, suspect a component\n of hypercarbic resp failure given MS changes & elevated serum bicarb.\n Will try to achieve a mild permissive hypercapnea. Failed PSV 2/10 PM\n primary respiratory acidosis.\n - f/u sputum, blood Cx; Urine legionella (received Levoflox x 1 in ED)\n neg\n - broad spectrum Abx with Vanc, Zosyn until cxs finalized\n - d/c Cipro given lack of evidence of Pseudomonas on sputum cx\n - MDI while intubated (pt with auto-PEEP), transition to nebs once\n extubated\n - attempt to wean from vent\n - mouthcare, HOB elevated\n .\n # Hypotension: Etiology unclear, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2months of prednisone use. Aggressive resuscitation with\n IVF, s/p 10L of IVF on initial presentation. Hypotension now resolved.\n - now off dopamine\n - bolus IVF for goal UOP goal >30cc/hr\n - Hydrocortisone 100mg q8hr (stress dose)\n - goal neutral fluid balance today\n .\n # Chest pain: Pt with recent NSTEMI who presented with hypoxia and was\n denying CP in ED. EKGs with sinus tach in 140s, LBBB and non-specific\n changes from baseline. First set of CE are negative though pt was\n reporting CP on arrival to ICU. Given the recent history, possible to\n have demand ischemia with tachycardia. Will monitor symptoms and cycle\n cardiac enzymes.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - cardiac enzymes negative x2\n - continue to monitor on telemetry, follow EKGs\n - titrate up metoprolol to 25mg \n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s. However, unclear\n etiology to acute drop from baseline.\n - guiaic negative\n - hemolysis labs negative\n - maintain active type & screen\n - get rehab records\n - PPI and CVL,PIV, PICC for access\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - contine Zosyn/Cipro as above\n - f/u urine cultures\n .\n # FEN: NPO for now, will consult nutrition for TFs\n - started TFs\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, Right femoral line, left PICC (plan to d/c\n femoral line today)\n .\n # Code: FULL\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:33 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 01:30 PM\n PICC Line - 01:30 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 01:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-15 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 441686,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment: Erratic exhaled Tidal Volumes\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Mode changed to psv. Toleraing well\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 441784,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - t/b with Dr. regarding recs for trach\n - fem line d/c\n - tolerated PSV 10 PEEP 8\n - back on AC 50%/500/18/8 overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:00 PM\n Ciprofloxacin - 04:38 AM\n Vancomycin - 07:53 PM\n Piperacillin/Tazobactam (Zosyn) - 11:50 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:27 PM\n Midazolam (Versed) - 11:28 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.4\nC (97.6\n HR: 99 (75 - 108) bpm\n BP: 142/81(100) {79/40(53) - 180/81(116)} mmHg\n RR: 20 (13 - 32) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,407 mL\n 433 mL\n PO:\n TF:\n 969 mL\n 274 mL\n IVF:\n 1,048 mL\n 99 mL\n Blood products:\n Total out:\n 3,095 mL\n 450 mL\n Urine:\n 3,095 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -688 mL\n -17 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 457 (457 - 555) mL\n PS : 10 cmH2O\n RR (Set): 18\n PEEP: 8 cmH2O\n RSBI: 63\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 95%\n ABG: 7.39/50/103/32/3\n Ve: 9.9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 302 K/uL\n 7.9 g/dL\n 107 mg/dL\n 1.2 mg/dL\n 32 mEq/L\n 3.1 mEq/L\n 30 mg/dL\n 106 mEq/L\n 146 mEq/L\n 24.1 %\n 17.4 K/uL\n [image002.jpg]\n 07:38 PM\n 07:53 PM\n 03:59 AM\n 04:15 AM\n 06:29 AM\n 03:07 PM\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n WBC\n 21.5\n 24.4\n 20.3\n 17.4\n Hct\n 26.5\n 26.7\n 24.8\n 24.1\n Plt\n 02\n Cr\n 1.0\n 1.1\n 1.2\n TCO2\n 24\n 27\n 27\n 28\n 27\n 31\n Glucose\n 121\n 135\n 107\n Other labs: PT / PTT / INR:14.2/29.8/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 05:07 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Arterial Line - 01:50 AM\n 20 Gauge - 01:36 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 441785,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - t/b with Dr. regarding recs for trach\n - fem line d/c\n - tolerated PSV 10 PEEP 8\n - back on AC 50%/500/18/8 overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:00 PM\n Ciprofloxacin - 04:38 AM\n Vancomycin - 07:53 PM\n Piperacillin/Tazobactam (Zosyn) - 11:50 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:27 PM\n Midazolam (Versed) - 11:28 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.4\nC (97.6\n HR: 99 (75 - 108) bpm\n BP: 142/81(100) {79/40(53) - 180/81(116)} mmHg\n RR: 20 (13 - 32) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,407 mL\n 433 mL\n PO:\n TF:\n 969 mL\n 274 mL\n IVF:\n 1,048 mL\n 99 mL\n Blood products:\n Total out:\n 3,095 mL\n 450 mL\n Urine:\n 3,095 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -688 mL\n -17 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 457 (457 - 555) mL\n PS : 10 cmH2O\n RR (Set): 18\n PEEP: 8 cmH2O\n RSBI: 63\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 95%\n ABG: 7.39/50/103/32/3\n Ve: 9.9 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, diffuse\n expiratory wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, +1 pitting edema, cachectic \n / Radiology\n 302 K/uL\n 7.9 g/dL\n 107 mg/dL\n 1.2 mg/dL\n 32 mEq/L\n 3.1 mEq/L\n 30 mg/dL\n 106 mEq/L\n 146 mEq/L\n 24.1 %\n 17.4 K/uL\n [image002.jpg]\n 07:38 PM\n 07:53 PM\n 03:59 AM\n 04:15 AM\n 06:29 AM\n 03:07 PM\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n WBC\n 21.5\n 24.4\n 20.3\n 17.4\n Hct\n 26.5\n 26.7\n 24.8\n 24.1\n Plt\n 02\n Cr\n 1.0\n 1.1\n 1.2\n TCO2\n 24\n 27\n 27\n 28\n 27\n 31\n Glucose\n 121\n 135\n 107\n Other labs: PT / PTT / INR:14.2/29.8/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 05:07 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Arterial Line - 01:50 AM\n 20 Gauge - 01:36 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 441205,
"text": "Chief Complaint:\n 24 Hour Events:\n - weaned off of dopamine overnight\n - HCT trending down 34.8 -> 25.1, guaiac neg, hemolysis labs sent\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 PM\n Vancomycin - 08:45 PM\n Ciprofloxacin - 04:00 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 04:45 PM\n Pantoprazole (Protonix) - 05:00 PM\n Heparin Sodium (Prophylaxis) - 05:00 PM\n Fentanyl - 06:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.2\nC (97.1\n HR: 106 (88 - 115) bpm\n BP: 102/67(83) {90/44(58) - 128/68(89)} mmHg\n RR: 16 (14 - 23) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 60 Inch\n Total In:\n 10,259 mL\n 1,062 mL\n PO:\n TF:\n 63 mL\n 161 mL\n IVF:\n 4,136 mL\n 901 mL\n Blood products:\n Total out:\n 648 mL\n 173 mL\n Urine:\n 648 mL\n 173 mL\n NG:\n Stool:\n Drains:\n Balance:\n 9,611 mL\n 889 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 440 (440 - 500) mL\n PS : 8 cmH2O\n RR (Set): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 14 cmH2O\n Plateau: 20 cmH2O\n Compliance: 33.8 cmH2O/mL\n SpO2: 100%\n ABG: 7.31/47/91/25/-2\n Ve: 7.4 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, diffuse\n expiratory wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, +1 pitting edema\n Labs / Radiology\n 288 K/uL\n 8.0 g/dL\n 158 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 108 mEq/L\n 139 mEq/L\n 25.1 %\n 15.8 K/uL\n [image002.jpg]\n 04:47 PM\n 05:06 PM\n 10:44 PM\n 03:20 AM\n 03:42 AM\n WBC\n 19.1\n 15.8\n Hct\n 27.6\n 25.1\n Plt\n 316\n 288\n Cr\n 0.3\n 0.5\n TropT\n <0.01\n <0.01\n TCO2\n 27\n 28\n 25\n Glucose\n 217\n 158\n Other labs: PT / PTT / INR:14.8/30.2/1.3, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.4,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.9 mmol/L, Albumin:1.9 g/dL, LDH:294 IU/L, Ca++:7.3 mg/dL,\n Mg++:2.8 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with hypoxia and respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Given\n acute decompensation without a pre-intubation ABG, suspect a component\n of hypercarbic resp failure given MS changes & elevated serum bicarb.\n Repeat ABG 7.28/55/75 on 40% FiO2, 500/5. Awaiting repeat lytes, will\n try to achieve a mild permissive hypercapnea. Received 10L IVF\n yesterday.\n - f/u sputum, blood Cx , Urine legionella (received Levoflox x 1 in ED)\n - broad spectrum Abx with Vanc, Zosyn & Cipro (double coverage for\n pseudomonas until Cx back)\n - Xopenex nebs\n - stress dose hydrocortisone 100mg q8hr\n - aggressive IVFs\n - continue Vent on AC for now, attempt to wean (PS trial)\n - mouthcare, HOB, PPI\n .\n # Hypotension: Etiology unclear, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2months of prednisone use. Aggressive resuscitation with\n IVF, now s/p 10L of IVF.\n - bolus IVF for goal UOP goal >30cc/hr\n - now off dopamine\n - Hydrocortisone 100mg q8hr (stress dose)\n .\n # Chest pain: Pt with recent NSTEMI who presented with hypoxia and was\n denying CP in ED. EKGs with sinus tach in 140s, LBBB and non-specific\n changes from baseline. First set of CE are negative though pt was\n reporting CP on arrival to ICU. Given the recent history, possible to\n have demand ischemia with tachycardia. Will monitor symptoms and cycle\n cardiac enzymes.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - cardiac enzymes negative x2\n - continue to monitor on telemetry, follow EKGs\n - start metoprolol 12.5mg for HR>110s\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s. However, unclear\n etiology to acute drop from baseline.\n - guaic negative\n - hemolysis labs pending\n - maintain active type & screen\n - get rehab records\n - PPI and CVL,PIV, PICC for access\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - contine Zosyn/Cipro as above\n - f/u urine cultures\n .\n # FEN: NPO for now, will consult nutrition for TFs\n - nutrition consult for TF\n - bolus IVF prn\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, Right femoral line, left PICC (plan to d/c\n femoral line in am)\n .\n # Code: FULL\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 07:00 PM 30 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 01:30 PM\n PICC Line - 01:30 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 04:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-13 00:00:00.000",
"description": "Generic Note",
"row_id": 441220,
"text": "TITLE:\n 70 y/o F with PMHx of severe COPD and recent NSTEMI who was transferred\n in from rehab with increased SOB over the prior 3-4 days. This am, she\n was noted to have low sats to 70% which did not respond to nebs. Her\n sats came up with high flow O2 in the EMS. Pt denied any cough,\n increased sputum, chest pain or pedal edema. She was notably wheezey\n on presentation and was initially treated as COPD exacerbation.\n .\n In the ED, initial vs were: T 97.6 BP 146/70 HR 147 RR 20 Sats 96% on\n RA. Patient was given solumedrol 125mg, nebs & levofloxacin for LLL\n infiltrate seen on CXR. On re-evaluation, pt was lethargic and\n desatting into the 70s. Pt was intubated for respiratory failure and\n received ceftriaxone and vancomycin for presumed PNA. Pt was noted to\n have sbps in 80s peri-intubation and received a total of 6L of IVF. Pt\n had a Tmax of 103.8 in the ED, though lactate was normal at 1.7. Pt\n was transferred to the ICU on versed/fentanyl and dopamine to maintain\n SBPs.\n .\n On arrival, pt was intubated and sedated though following commands.\n She reported some chest pain but was otherwise comfortable and sating\n 100% on the vent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt\ns LS\ns clear in upper airway, diminished at bases. Vented on AC\n 500x14, FiO2 40%, PEEP 5. O2 sat 94-97%. Suctioned for small to\n moderate amounts of thick tan secretions. Sputum, urine, blood\n cultures sent in ED (including a set off of PICC line). Pt easily\n arousable and following commands, becoming anxious at times and\n reaching for ETT.\n Action:\n Started on Fenta & versed drips. Pt\ns RR ^ed to 16 on the vent after\n ABG . Rec\nd cipro for treatment of pna and will continue on\n vancomycin. Zosyn pending ID approval. CXR done in am.\n Response:\n Pt O2 sat 95 to 97% on current vent settings. Pt appears comfortable\n on ventilator at this time.\n Plan:\n Cont to monitor resp status, wean vent as tolerated.\n Sepsis without organ dysfunction\n Assessment:\n Received pt on Dopamine drip at 2mcg/kg/min. urine output decreased\n .\n Action:\n Total of 2 lits of LR bloused for low urine output. BP WNL ,dopamine\n weaned off at 2245 hrs. .\n Response:\n ABP 95\ns-120\ns/50\ns with MAP >65 on current dose of dopamine. U/O\n decreased again at 2 am, informed Resident, u/o next improved to\n 20 & then to 35 mls.\n Patient positive for a total of 9 lits\n Plan:\n Continue monitoring BP, U/O.\n Alteration in Nutrition\n Assessment:\n Patient received on Pulmonary Nutren at 10 mls/hr , water flushes 30\n mls q 8 hrs. Albumin low, with peripheral edema.\n Action:\n Feeds increased to 30 mls/hr as tolerated by the patient. Glucose\n levels above 150, covered with HISS.\n Response:\n Pending\n Plan:\n Increase to a goal of 40 mls/hr as tolerated. Monitor FS.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple areas of bruising on extremities with 2 skin tears\n noted, 1 to the right elbow and 1 to the right foot. + pedal\n edema. Stage 1 pressure ulcer noted to rt gluteal area.\n Action:\n Skin tears cleaned with NS and covered with adaptic. Rt foot skin tear\n draining small to moderate amounts of serosang drainage. Pt turned and\n repositioned.\n Response:\n Pending\n Plan:\n Continue to monitor for further areas of tearing or breakdown. Turn\n and reposition q2 hours.\n Electrolyte & fluid disorder, other\n Assessment:\n Calcium, ionized calcium ,mag & phos low in pm labs.\n Action:\n Repleted with 4 grams of Calcium, 4 grams of mag sulph, 15 mmol of K\n Phos given\n Response:\n Mag up to 2.8, Ionised calcium 1.15, phos 3.8.\n Plan:\n Continue monitoring labs, replete as per sliding scale.\n ------ Protected Section ------\n 1 Litre LR bolus started over 2 hours for low urine output at 0515 am.\n Zosyn one time dose given at 0615 am, ID approval pending. Team aware.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:44 ------\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 441410,
"text": "Chief Complaint:\n 24 Hour Events:\n - unable to extubate patient, was on PSV overnight, but gas this\n morning shows primary uncompensated resp acidosis on RR 18 with light\n sedation, so put back on AC to increase RR\n - continues to have femoral line\n - placed nutrition c/s\n - started metoprolol\n - emailed primary, but need to clarify code status\n - replaced OG tube\n - haptoglobin high, no evidence of hemolysis\n - patient stable overnight, did not start doripenem\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:00 PM\n Vancomycin - 08:05 PM\n Piperacillin/Tazobactam (Zosyn) - 12:06 AM\n Ciprofloxacin - 04:38 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Fentanyl - 03:45 PM\n Heparin Sodium (Prophylaxis) - 12:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.7\nC (98.1\n HR: 88 (88 - 112) bpm\n BP: 102/49(66) {72/47(60) - 154/78(99)} mmHg\n RR: 25 (13 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,703 mL\n 674 mL\n PO:\n TF:\n 533 mL\n 225 mL\n IVF:\n 3,050 mL\n 389 mL\n Blood products:\n Total out:\n 803 mL\n 565 mL\n Urine:\n 803 mL\n 565 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,900 mL\n 109 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (374 - 500) mL\n PS : 8 cmH2O\n RR (Set): 16\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 100\n PIP: 23 cmH2O\n Plateau: 16 cmH2O\n Compliance: 62.5 cmH2O/mL\n SpO2: 99%\n ABG: 7.31/51/106/26/-1\n Ve: 9 L/min\n PaO2 / FiO2: 265\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, diffuse\n expiratory wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, +1 pitting edema\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 306 K/uL\n 8.6 g/dL\n 121 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 108 mEq/L\n 140 mEq/L\n 26.7 %\n 24.4 K/uL\n [image002.jpg]\n 04:47 PM\n 05:06 PM\n 10:44 PM\n 03:20 AM\n 03:42 AM\n 07:38 PM\n 07:53 PM\n 03:59 AM\n 04:15 AM\n 06:29 AM\n WBC\n 19.1\n 15.8\n 21.5\n 24.4\n Hct\n 27.6\n 25.1\n 26.5\n 26.7\n Plt\n 06\n Cr\n 0.3\n 0.5\n 1.0\n TropT\n <0.01\n <0.01\n TCO2\n 27\n 28\n 25\n 24\n 27\n 27\n Glucose\n \n Other labs: PT / PTT / INR:14.0/28.0/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.3 mg/dL,\n Mg++:2.6 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with hypoxia and respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Given\n acute decompensation without a pre-intubation ABG, suspect a component\n of hypercarbic resp failure given MS changes & elevated serum bicarb.\n Will try to achieve a mild permissive hypercapnea.\n - f/u sputum, blood Cx , Urine legionella (received Levoflox x 1 in ED)\n - broad spectrum Abx with Vanc, Zosyn & Cipro (double coverage for\n pseudomonas until Cx back)\n - MDI while intubated (pt with auto-PEEP), transition to nebs once\n extubated\n - attempt to wean from vent\n - mouthcare, HOB, PPI\n .\n # Hypotension: Etiology unclear, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2months of prednisone use. Aggressive resuscitation with\n IVF, s/p 10L of IVF on initial presentation.\n - now off dopamine\n - bolus IVF for goal UOP goal >30cc/hr\n - Hydrocortisone 100mg q8hr (stress dose)\n .\n # Chest pain: Pt with recent NSTEMI who presented with hypoxia and was\n denying CP in ED. EKGs with sinus tach in 140s, LBBB and non-specific\n changes from baseline. First set of CE are negative though pt was\n reporting CP on arrival to ICU. Given the recent history, possible to\n have demand ischemia with tachycardia. Will monitor symptoms and cycle\n cardiac enzymes.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - cardiac enzymes negative x2\n - continue to monitor on telemetry, follow EKGs\n - start metoprolol 12.5mg for HR>110s\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s. However, unclear\n etiology to acute drop from baseline.\n - guaic negative\n - hemolysis labs negative\n - maintain active type & screen\n - get rehab records\n - PPI and CVL,PIV, PICC for access\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - contine Zosyn/Cipro as above\n - f/u urine cultures\n .\n # FEN: NPO for now, will consult nutrition for TFs\n - nutrition consult for TF\n - bolus IVF prn\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, Right femoral line, left PICC (plan to d/c\n femoral line in am)\n .\n # Code: FULL\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:33 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 01:30 PM\n PICC Line - 01:30 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 01:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-12 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 441140,
"text": "Chief Complaint: PNA, Resp Failure\n HPI:\n 70 y/o F with PMHx of severe COPD and recent NSTEMI who was transferred\n in from rehab due to increased SOB over the prior 3-4 days. This am,\n she was noted to have low sats in 70% which did not respond to nebs.\n Her sats came up with high flow O2 in the EMS. Pt denied any cough,\n increased sputum, chest pain or pedal edema. She was notably wheezey\n on presentation and was initially treated as COPD exacerbation.\n .\n In the ED, initial vs were: T 97.6 BP 146/70 HR 147 RR 20 Sats 96% on\n RA. Patient was given solumedrol 125mg, nebs & levofloxacin for LLL\n infiltrate seen on CXR. On re-evaluation, pt was lethargic and\n desatting into the 70s. Pt was intubated for respiratory failure and\n received ceftriaxone and vancomycin for presumed PNA. Pt was noted to\n have sbps in 80s peri-intubation and received a total of 6L of IVF. Pt\n had a Tmax of 103.8 in the ED, though lactate was normal at 1.7. Pt\n was transferred to the ICU on versed/fentanyl and dopamine to maintain\n SBPs.\n .\n On arrival, pt was intubated and sedated though following commands.\n She reported some chest pain but was otherwise comfortable and sating\n 100% on the vent.\n .\n Review of sytems: unable to obtain\n .\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 PM\n Ciprofloxacin - 04:30 PM\n Infusions:\n Dopamine - 3 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 04:00 PM\n Other medications:\n Home medications:\n Aspirin 81mg\n Atorvastatin 40mg\n Xopenex prn\n Tiotropium Daily\n Advair \n Alendronate 70mg weekly\n Colace \n Senna prn\n Mucomyst inhaled\n Vitamin B12\n diltiazem 120mg daily\n Prednisone 10mg daily\n Ativan prn\n Robitussin prn\n Past medical history:\n Family history:\n Social History:\n COPD with severe obstructive defect\n HTN\n CAD s/p NSTEMI\n Carotid Stenosis\n PVD: aortoileac disease, followed by Dr. \n Osteoporosis\n Depression/Anxiety\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Pt has been living in rehab since recent discharge. Smoked for\n about 30 pack years and quit 15yrs ago.\n Review of systems:\n Flowsheet Data as of 05:38 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 101 (93 - 115) bpm\n BP: 126/64(85) {126/64(85) - 126/64(85)} mmHg\n RR: 17 (14 - 17) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 60 Inch\n Total In:\n 7,377 mL\n PO:\n TF:\n IVF:\n 1,377 mL\n Blood products:\n Total out:\n 0 mL\n 360 mL\n Urine:\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 7,017 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 36 cmH2O\n Plateau: 23 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 96%\n ABG: 7.28/55/75//-1\n Ve: 7.7 L/min\n PaO2 / FiO2: 150\n Physical Examination\n Vitals: T: 97.5 BP: 103/51 P: 99 R: 14 Sats 100% on AC 500/5/14/100%\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, diffuse\n expiratory wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, +1 pitting edema\n Labs / Radiology\n 316 K/uL\n 8.7 g/dL\n 27.6 %\n 19.1 K/uL\n [image002.jpg]\n \n 2:33 A2/8/ 04:47 PM\n \n 10:20 P2/8/ 05:06 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 19.1\n Hct\n 27.6\n Plt\n 316\n TC02\n 27\n Other labs: Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0\n %, Lactic Acid:1.0 mmol/L\n Fluid analysis / Other labs: Lactate:1.7\n .\n Trop-T: 0.01 CK: 28 MB: Notdone\n .\n 138 93 16 188 AGap=13\n --------------\n 4.5 37 0.5\n .\n proBNP: 2952\n .\n WBC 17.0 Hgb 11.2 Hct 34.8 Plts 425 D\n N:89 Band:3 L:5 M:3 E:0 Bas:0\n Hypochr: 2+ Anisocy: 1+ Macrocy: 1+ Polychr: 2+ Stipple: 2+\n Plt-Est: Normal\n .\n PT: 13.6 PTT: 24.4 INR: 1.2\n Imaging: CXR portable reveals left lower lobe hazy opacities\n with blurring of L heart border and R costo phrenic angle opacities\n .\n EKG: sinus tach at 140s with LBBB, no appreciable discordance though\n slightly different from prior tracings\n .\n Repeat EKG at 3pm with sinus rhythm at 100, incomplete LBBB, left\n atrial abnormality, low voltage in limb leads, non-specific lateral\n ST-T wave changes\n .\n ECHO : Suboptimal image quality. Normal left ventricular cavity\n size with mild regional systolic dysfunction most c/w CAD. Mild mitral\n regurgitation. Compared with the prior study (Images reviewed) of\n , the wall motion abnormalities are more extensive (mid-septal\n hypokinesis was suggested on review of the prior study).\n .\n Microbiology: Micro: Urine, Blood pending\n Sputum prelim + 4 PLEOMORPHIC GRAM NEGATIVE COCCOBACILLI.\n Assessment and Plan\n 70 y/o F with severe COPD who presents with hypoxia and respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD and diffuse infiltrates\n seen on CXR. Fever, hypoxia, leukocytosis and infiltrates likely c/w\n acute PNA. Current sputum with pleomorphic gram neg coccobaccili\n likely c/w prior sputums of H.Flu. However, prior sputums have been\n colonized with serratia, aspergillus, MAC, pseudomonas.\n - broad spectrum Abx with Vanc, Zosyn & Cipro (double coverage for GNR\n until cultures back)\n - Xopenex nebs\n - stress dose hydrocortisone 100mg q8hr\n - aggressive IVFs\n - continue AC for now, attempt to wean overnight (PS trial)\n - RSBI in am\n - mouthcare, HOB, PPI\n .\n # Hypotension: Etiology unclear, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2months of prednisone use. Aggressive resuscitation with\n IVF, now s/p 7L of IVF\n - bolus IVF for goal UOP goal >30cc/hr\n - art line to be placed\n - wean pressors\n - Hydrocortisone 100mg q8hr (stress dose)\n .\n # Chest pain: Pt with recent NSTEMI who presented with hypoxia and was\n denying CP in ED. EKGs with sinus tach in 140s, LBBB and non-specific\n changes from baseline. First set of CE are negative though pt was\n reporting CP on arrival to ICU. Given the recent history, possible to\n have demand ischemia with tachycardia. Will monitor symptoms and cycle\n cardiac enzymes.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - cycle cardiac enzymes\n - continue to monitor on telemetry, follow EKGs\n - start metoprolol 12.5mg for HR>110s\n .\n # Hct drop: Baseline hct in high 30s, down to 27 after 7L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s. However, unclear\n etiology to acute drop from baseline.\n - guaic now\n - maintain active type & screen\n - get rehab records\n - PPI and CVL,PIV, PICC for access\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - contine Zosyn/Cipro as above\n - f/u urine cultures\n .\n # FEN: NPO for now, will consult nutrition for TFs\n - nutrition consult for TF\n - bolus IVF prn\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, Right femoral line, left PICC (plan to d/c\n femoral line in am)\n .\n # Code: FULL\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition: Nutrition consult for TFs\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 01:30 PM\n PICC Line - 01:30 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 04:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-13 00:00:00.000",
"description": "ICU Attending Note",
"row_id": 441308,
"text": "Clinician: Attending\n 70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n CXR hyperinflation, bilat pleural effu, left pleural opac: loc pleural\n effusion vs infiltrate, left lower lung zone infiltrate increased since\n yest.\n PS 0.4/8/5 RR 18 RSBI 56 7.32/47/91\n Exam sig for awake, opened eyes, responded to questions with head nod.\n Diffuse exp wheezing. Total PEEP 8 (with ePEEP 5). Right femoral line.\n Distant HS. Abd NABS, soft, NDNT. Extremities cachectic, petechial\n lesions, atrophied. LE pitting edema + bilat. Minimal resp\n secretions.\n BNP 2900 with prior 271.\n Meds: Insulin, hep sc, vanc/cipro/zosyn, ppi, asa, statin, hydrocort\n 100 IV q 8, versed 1, fentanyl 25, DA\n Severe COPD, pna, with elevated BNP in setting of hypovolemia suggests\n RV strain with cor pulmonale/pna/hypoxic vasoconstriction. Received\n >10L overnight, 6L in ED and 4L in MICU, minimal urine output.\n Plan:\n Add atrovent\n d/c fem line\n continue on zosyn/cipro/vanc until sputum cx obtain\n discuss with Dr \n Total time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441714,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Pt\ns , \n, called this morning. Stated pt is w/o much\n family and believes she is the next of , but is not her HCP. Pt is\n not married, nor does she have any children.\n Alteration in Nutrition\n Assessment:\n Pt cont to tol her TF at goal rate\n Action:\n Check asp ,\n Response:\n Now stooling min asp noted\n Plan:\n Cont to follow for tolerance of TF\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with much less wheezes this am so she was given another PSV trial.\n She remains on the same amt of fentanyl and versed due to her anxiety\n Action:\n Pt placed on PSV of , she cont to be diuresed\n Response:\n Pt tol the PSV for about 4 hours(she had a good ABG ,sats 98%, TV of\n 500, TT 24-30) and then got dysynchronus with the vent and agitated so\n she was placed back on a/c.\n Plan:\n Will rest again overnight, keep comf on vent, get I&O about 1l neg .\n House staff to have discussion with her and neice about long term care\n ?need for trach possible\n Electrolyte & fluid disorder, other\n Assessment:\n Pt still very edamotous\n Action:\n Diuresis cont\n Response:\n 1l u/o rsp so far\n Plan:\n Recheck lytes later and cont with diures\n Social:neice in to visit\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 441882,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-18 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 442098,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont intub with OETT and on mech vent as per Metavision.\n Lung sounds dim suct mod th bld tinged sput. MDI and SVN given as per\n order. Pt in NARD on current settings; no vent changes required\n overnoc. Cont mech vent support.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 441200,
"text": "Chief Complaint:\n 24 Hour Events:\n - weaned off of dopamine overnight\n - HCT trending down 34.8 -> 25.1, guaiac neg, hemolysis labs sent\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 PM\n Vancomycin - 08:45 PM\n Ciprofloxacin - 04:00 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 04:45 PM\n Pantoprazole (Protonix) - 05:00 PM\n Heparin Sodium (Prophylaxis) - 05:00 PM\n Fentanyl - 06:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.2\nC (97.1\n HR: 106 (88 - 115) bpm\n BP: 102/67(83) {90/44(58) - 128/68(89)} mmHg\n RR: 16 (14 - 23) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 60 Inch\n Total In:\n 10,259 mL\n 1,062 mL\n PO:\n TF:\n 63 mL\n 161 mL\n IVF:\n 4,136 mL\n 901 mL\n Blood products:\n Total out:\n 648 mL\n 173 mL\n Urine:\n 648 mL\n 173 mL\n NG:\n Stool:\n Drains:\n Balance:\n 9,611 mL\n 889 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 440 (440 - 500) mL\n PS : 8 cmH2O\n RR (Set): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 14 cmH2O\n Plateau: 20 cmH2O\n Compliance: 33.8 cmH2O/mL\n SpO2: 100%\n ABG: 7.31/47/91/25/-2\n Ve: 7.4 L/min\n PaO2 / FiO2: 228\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 288 K/uL\n 8.0 g/dL\n 158 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 108 mEq/L\n 139 mEq/L\n 25.1 %\n 15.8 K/uL\n [image002.jpg]\n 04:47 PM\n 05:06 PM\n 10:44 PM\n 03:20 AM\n 03:42 AM\n WBC\n 19.1\n 15.8\n Hct\n 27.6\n 25.1\n Plt\n 316\n 288\n Cr\n 0.3\n 0.5\n TropT\n <0.01\n <0.01\n TCO2\n 27\n 28\n 25\n Glucose\n 217\n 158\n Other labs: PT / PTT / INR:14.8/30.2/1.3, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.4,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.9 mmol/L, Albumin:1.9 g/dL, LDH:294 IU/L, Ca++:7.3 mg/dL,\n Mg++:2.8 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 07:00 PM 30 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 01:30 PM\n PICC Line - 01:30 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 04:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 441201,
"text": "Chief Complaint:\n 24 Hour Events:\n - weaned off of dopamine overnight\n - HCT trending down 34.8 -> 25.1, guaiac neg, hemolysis labs sent\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 PM\n Vancomycin - 08:45 PM\n Ciprofloxacin - 04:00 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 04:45 PM\n Pantoprazole (Protonix) - 05:00 PM\n Heparin Sodium (Prophylaxis) - 05:00 PM\n Fentanyl - 06:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.2\nC (97.1\n HR: 106 (88 - 115) bpm\n BP: 102/67(83) {90/44(58) - 128/68(89)} mmHg\n RR: 16 (14 - 23) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 60 Inch\n Total In:\n 10,259 mL\n 1,062 mL\n PO:\n TF:\n 63 mL\n 161 mL\n IVF:\n 4,136 mL\n 901 mL\n Blood products:\n Total out:\n 648 mL\n 173 mL\n Urine:\n 648 mL\n 173 mL\n NG:\n Stool:\n Drains:\n Balance:\n 9,611 mL\n 889 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 440 (440 - 500) mL\n PS : 8 cmH2O\n RR (Set): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 14 cmH2O\n Plateau: 20 cmH2O\n Compliance: 33.8 cmH2O/mL\n SpO2: 100%\n ABG: 7.31/47/91/25/-2\n Ve: 7.4 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, diffuse\n expiratory wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, +1 pitting edema\n Labs / Radiology\n 288 K/uL\n 8.0 g/dL\n 158 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 108 mEq/L\n 139 mEq/L\n 25.1 %\n 15.8 K/uL\n [image002.jpg]\n 04:47 PM\n 05:06 PM\n 10:44 PM\n 03:20 AM\n 03:42 AM\n WBC\n 19.1\n 15.8\n Hct\n 27.6\n 25.1\n Plt\n 316\n 288\n Cr\n 0.3\n 0.5\n TropT\n <0.01\n <0.01\n TCO2\n 27\n 28\n 25\n Glucose\n 217\n 158\n Other labs: PT / PTT / INR:14.8/30.2/1.3, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.4,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.9 mmol/L, Albumin:1.9 g/dL, LDH:294 IU/L, Ca++:7.3 mg/dL,\n Mg++:2.8 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 07:00 PM 30 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 01:30 PM\n PICC Line - 01:30 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 04:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 441203,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use; Comments:\n =m vent support to PSV.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated; Comments:\n RSBI done ~56.\n Reason for continuing current ventilatory support: Underlined illness\n not resolved; PNA.\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 441303,
"text": "Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Tube Type\n ETT:\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n MDIs given as ordered\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt remains on PSV ventilation, tolerating well.\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441350,
"text": "70 y/o F with severe COPD who presented with hypoxia and respiratory\n failure, now intubated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n With severe underlying COPD who p/w fever, hypoxia, leukocytosis and\n infiltrates likely c/w acute PNA. Remains intubated and vented on PS\n 40% 8/5 w/sats at mid to high 90\ns. Bil LS clear, diminished at the\n bases. Small to moderate amnt of blood tinged secretions.\n ABG:7.29/48/107\n Action:\n f/u sputum, blood Cx , Urine legionella (received Levoflox x 1 in ED),\n broad spectrum Abx with Vanc, Zosyn & Cipro (double coverage for\n pseudomonas until Cx back), MDI while intubated (pt with auto-PEEP),\n transition to nebs once extubated, mouth care q4hr and prn, VAP\n precautions.\n Response:\n Abg:\n Plan:\n Continue w/mechanical ventilation, wean off when able\n Impaired Skin Integrity\n Assessment:\n Skin tears on RT elbow and RT lower extr.\n Action:\n Adaptic dressing applied w/kirlex, , moisture barrier to buttocks and\n sacrum, repositioning q 2hr and prn, nutritional support\n Response:\n pending\n Plan:\n Continue to monitor patient skin status, dressing ASDIR, wound care\n consult if progresses.\n Neuro: sedated on fent/versed however arousable to voice and will\n follow commands. Denies pain.\n Cardio: normotensive. HR at 90-100\ns. Restarted on metoprolol 12.5 TID\n for recent STEMI. Extr edema. Peripheral pulses present.\n GI: abd soft non tender, positive for BS and flatus. No BM this shift.\n OGT in place. Restarted on TF at 40cc/hr. tolerated well, no residuals.\n GU: clear yellow urine via foley, adequate amnt.\n IV access: Left PIV 18 gauge, Right femoral line, left PICC, LT A-line\n Social: patient is a FULL CODE.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 441402,
"text": "Chief Complaint:\n 24 Hour Events:\n - unable to extubate patient, was on PSV overnight, but gas this\n morning shows primary uncompensated resp acidosis on RR 18 with light\n sedation, so put back on AC to increase RR\n - continues to have femoral line\n - placed nutrition c/s\n - started metoprolol\n - emailed primary, but need to clarify code status\n - replaced OG tube\n - haptoglobin high, no evidence of hemolysis\n - patient stable overnight, did not start doripenem\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:00 PM\n Vancomycin - 08:05 PM\n Piperacillin/Tazobactam (Zosyn) - 12:06 AM\n Ciprofloxacin - 04:38 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Fentanyl - 03:45 PM\n Heparin Sodium (Prophylaxis) - 12:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.7\nC (98.1\n HR: 88 (88 - 112) bpm\n BP: 102/49(66) {72/47(60) - 154/78(99)} mmHg\n RR: 25 (13 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,703 mL\n 674 mL\n PO:\n TF:\n 533 mL\n 225 mL\n IVF:\n 3,050 mL\n 389 mL\n Blood products:\n Total out:\n 803 mL\n 565 mL\n Urine:\n 803 mL\n 565 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,900 mL\n 109 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (374 - 500) mL\n PS : 8 cmH2O\n RR (Set): 16\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 100\n PIP: 23 cmH2O\n Plateau: 16 cmH2O\n Compliance: 62.5 cmH2O/mL\n SpO2: 99%\n ABG: 7.31/51/106/26/-1\n Ve: 9 L/min\n PaO2 / FiO2: 265\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 306 K/uL\n 8.6 g/dL\n 121 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 108 mEq/L\n 140 mEq/L\n 26.7 %\n 24.4 K/uL\n [image002.jpg]\n 04:47 PM\n 05:06 PM\n 10:44 PM\n 03:20 AM\n 03:42 AM\n 07:38 PM\n 07:53 PM\n 03:59 AM\n 04:15 AM\n 06:29 AM\n WBC\n 19.1\n 15.8\n 21.5\n 24.4\n Hct\n 27.6\n 25.1\n 26.5\n 26.7\n Plt\n 06\n Cr\n 0.3\n 0.5\n 1.0\n TropT\n <0.01\n <0.01\n TCO2\n 27\n 28\n 25\n 24\n 27\n 27\n Glucose\n \n Other labs: PT / PTT / INR:14.0/28.0/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.3 mg/dL,\n Mg++:2.6 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:33 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 01:30 PM\n PICC Line - 01:30 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 01:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441409,
"text": "70 y/o F with severe COPD who presented with hypoxia and respiratory\n failure, now intubated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n With severe underlying COPD who p/w fever, hypoxia, leukocytosis and\n infiltrates likely c/w acute PNA. Remains intubated and vented on PS\n 40% 8/5 w/sats at mid to high 90\ns. Bil LS clear, diminished at the\n bases. Small to moderate amnt of blood tinged secretions.\n ABG:7.29/48/107 WBC-24.4, afebrile.\n Action:\n f/u sputum, blood Cx , Urine legionella (received Levoflox x 1 in ED),\n broad spectrum Abx with Vanc, Zosyn & Cipro (double coverage for\n pseudomonas until Cx back), MDI while intubated (pt with auto-PEEP),\n transition to nebs once extubated, mouth care q4hr and prn, VAP\n precautions.\n Response:\n Abg: 7.27/57/106 switched to AC 40% 500x16x5\n Plan:\n Continue w/mechanical ventilation, wean off when able\n Impaired Skin Integrity\n Assessment:\n Skin tears on RT elbow and RT lower extr.\n Action:\n Adaptic dressing applied w/kirlex, , moisture barrier to buttocks and\n sacrum, repositioning q 2hr and prn, nutritional support\n Response:\n pending\n Plan:\n Continue to monitor patient skin status, dressing ASDIR, wound care\n consult if progresses.\n Neuro: sedated on fent/versed however arousable to voice and will\n follow commands. Denies pain.\n Cardio: normotensive. HR at 90-100\ns. Restarted on metoprolol 12.5 TID\n for recent STEMI. Extr edema. Peripheral pulses present.\n GI: abd soft non tender, positive for BS and flatus. No BM this shift.\n OGT in place. Restarted on TF at 40cc/hr. tolerated well, no residuals.\n GU: clear yellow urine via foley, adequate amnt.\n IV access: Left PIV 18 gauge, Right femoral line, left PICC, LT A-line\n Social: patient is a FULL CODE.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 441871,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - t/b with Dr. regarding recs for trach\n - fem line d/c\n - tolerated PSV 10 PEEP 8\n - back on AC 50%/500/18/8 overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:00 PM\n Ciprofloxacin - 04:38 AM\n Vancomycin - 07:53 PM\n Piperacillin/Tazobactam (Zosyn) - 11:50 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:27 PM\n Midazolam (Versed) - 11:28 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.4\nC (97.6\n HR: 99 (75 - 108) bpm\n BP: 142/81(100) {79/40(53) - 180/81(116)} mmHg\n RR: 20 (13 - 32) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,407 mL\n 433 mL\n PO:\n TF:\n 969 mL\n 274 mL\n IVF:\n 1,048 mL\n 99 mL\n Blood products:\n Total out:\n 3,095 mL\n 450 mL\n Urine:\n 3,095 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -688 mL\n -17 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 457 (457 - 555) mL\n PS : 10 cmH2O\n RR (Set): 18\n PEEP: 8 cmH2O\n RSBI: 63\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 95%\n ABG: 7.39/50/103/32/3\n Ve: 9.9 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, +2 pitting edema, cachectic \n / Radiology\n 302 K/uL\n 7.9 g/dL\n 107 mg/dL\n 1.2 mg/dL\n 32 mEq/L\n 3.1 mEq/L\n 30 mg/dL\n 106 mEq/L\n 146 mEq/L\n 24.1 %\n 17.4 K/uL\n [image002.jpg]\n 07:38 PM\n 07:53 PM\n 03:59 AM\n 04:15 AM\n 06:29 AM\n 03:07 PM\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n WBC\n 21.5\n 24.4\n 20.3\n 17.4\n Hct\n 26.5\n 26.7\n 24.8\n 24.1\n Plt\n 02\n Cr\n 1.0\n 1.1\n 1.2\n TCO2\n 24\n 27\n 27\n 28\n 27\n 31\n Glucose\n 121\n 135\n 107\n Other labs: PT / PTT / INR:14.2/29.8/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n y/o F with severe COPD who presents with hypoxia and respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Given\n acute decompensation without a pre-intubation ABG, suspect a component\n of hypercarbic resp failure given MS changes & elevated serum bicarb.\n Will try to achieve a mild permissive hypercapnea. Failed PSV 2/10 PM\n primary respiratory acidosis.\n - sputum -> moderate H. flu, blood Cx pending; Urine legionella\n (received Levoflox x 1 in ED) neg\n - d/c Vanc, cont Zosyn for H. flu\n - MDI while intubated (pt with auto-PEEP), transition to nebs once\n extubated\n - unlikely to be weaned from vent soon, will consider trach -> will d/w\n pt/family/Dr. \n - goal 1L neg today\n - mouthcare, HOB elevated\n .\n # Hypotension: Etiology unclear, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2months of prednisone use. Aggressive resuscitation with\n IVF, s/p 10L of IVF on initial presentation. Hypotension now resolved.\n - Hydrocortisone 100mg q8hr (stress dose)\n - goal 1L neg today\n .\n # ARF\n pre-renal from lasix administration\n .\n # Chest pain: Pt with recent NSTEMI who presented with hypoxia and was\n denying CP in ED. EKGs with sinus tach in 140s, LBBB and non-specific\n changes from baseline. First set of CE are negative though pt was\n reporting CP on arrival to ICU. Given the recent history, possible to\n have demand ischemia with tachycardia. Will monitor symptoms and cycle\n cardiac enzymes.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - cardiac enzymes negative x3\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg \n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s. However, unclear\n etiology to acute drop from baseline.\n - transfusing one unit PRBC now\n - guiaic negative\n - hemolysis labs negative\n - maintain active type & screen\n - get rehab records\n - PPI and CVL,PIV, PICC for access\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative\n .\n # FEN: NPO for now, will consult nutrition for TFs\n - cont TFs\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, Right femoral line, left PICC (plan to d/c\n femoral line today)\n .\n # Code: FULL\n .\n # Disposition: pending above\n - SW c/s\n - Will discuss with niece re trach, spoke to family\n today\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 05:07 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Arterial Line - 01:50 AM\n 20 Gauge - 01:36 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441873,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441349,
"text": "70 y/o F with severe COPD who presented with hypoxia and respiratory\n failure, now intubated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n With severe underlying COPD who p/w fever, hypoxia, leukocytosis and\n infiltrates likely c/w acute PNA. Remains intubated and vented on PS\n 40% 8/5 w/sats at mid to high 90\ns. Bil LS clear, diminished at the\n bases. Small to moderate amnt of blood tinged secretions.\n ABG:7.29/48/107\n Action:\n f/u sputum, blood Cx , Urine legionella (received Levoflox x 1 in ED),\n broad spectrum Abx with Vanc, Zosyn & Cipro (double coverage for\n pseudomonas until Cx back), MDI while intubated (pt with auto-PEEP),\n transition to nebs once extubated, mouth care q4hr and prn, VAP\n precautions.\n Response:\n Abg:\n Plan:\n Continue w/mechanical ventilation, wean off when able\n Impaired Skin Integrity\n Assessment:\n Skin tears on RT elbow and RT lower extr.\n Action:\n Adaptic dressing applied w/kirlex, , moisture barrier to buttocks and\n sacrum, repositioning q 2hr and prn, nutritional support\n Response:\n pending\n Plan:\n Continue to monitor patient skin status, dressing ASDIR, wound care\n consult if progresses.\n Neuro: sedated on fent/versed however arousable to voice and will\n follow commands. Denies pain.\n Cardio: normotensive. HR at 90-100\ns. Restarted on metoprolol 12.5 TID\n for recent STEMI. Extr edema. Peripheral pulses present.\n GI: abd soft non tender, positive for BS and flatus. No BM this shift.\n OGT in place. Restarted on TF at 30cc/hr. tolerated well, no residuals.\n GU: clear yellow urine via foley, adequate amnt.\n IV access: Left PIV 18 gauge, Right femoral line, left PICC, LT A-line\n Social: patient is a FULL CODE.\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 441400,
"text": "Demographics\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments: xopenex/atrovent/flovent given as ordered.\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Mornring abg revealed a worsening resp acidosis. Changed to a/c\n 500x16.Will wean back to psv when able. Pt become very bronchospastic\n with any movement with + auto peep.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 441406,
"text": "Chief Complaint:\n 24 Hour Events:\n - unable to extubate patient, was on PSV overnight, but gas this\n morning shows primary uncompensated resp acidosis on RR 18 with light\n sedation, so put back on AC to increase RR\n - continues to have femoral line\n - placed nutrition c/s\n - started metoprolol\n - emailed primary, but need to clarify code status\n - replaced OG tube\n - haptoglobin high, no evidence of hemolysis\n - patient stable overnight, did not start doripenem\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:00 PM\n Vancomycin - 08:05 PM\n Piperacillin/Tazobactam (Zosyn) - 12:06 AM\n Ciprofloxacin - 04:38 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Fentanyl - 03:45 PM\n Heparin Sodium (Prophylaxis) - 12:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.7\nC (98.1\n HR: 88 (88 - 112) bpm\n BP: 102/49(66) {72/47(60) - 154/78(99)} mmHg\n RR: 25 (13 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,703 mL\n 674 mL\n PO:\n TF:\n 533 mL\n 225 mL\n IVF:\n 3,050 mL\n 389 mL\n Blood products:\n Total out:\n 803 mL\n 565 mL\n Urine:\n 803 mL\n 565 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,900 mL\n 109 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (374 - 500) mL\n PS : 8 cmH2O\n RR (Set): 16\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 100\n PIP: 23 cmH2O\n Plateau: 16 cmH2O\n Compliance: 62.5 cmH2O/mL\n SpO2: 99%\n ABG: 7.31/51/106/26/-1\n Ve: 9 L/min\n PaO2 / FiO2: 265\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, diffuse\n expiratory wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, +1 pitting edema\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 306 K/uL\n 8.6 g/dL\n 121 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 108 mEq/L\n 140 mEq/L\n 26.7 %\n 24.4 K/uL\n [image002.jpg]\n 04:47 PM\n 05:06 PM\n 10:44 PM\n 03:20 AM\n 03:42 AM\n 07:38 PM\n 07:53 PM\n 03:59 AM\n 04:15 AM\n 06:29 AM\n WBC\n 19.1\n 15.8\n 21.5\n 24.4\n Hct\n 27.6\n 25.1\n 26.5\n 26.7\n Plt\n 06\n Cr\n 0.3\n 0.5\n 1.0\n TropT\n <0.01\n <0.01\n TCO2\n 27\n 28\n 25\n 24\n 27\n 27\n Glucose\n \n Other labs: PT / PTT / INR:14.0/28.0/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.3 mg/dL,\n Mg++:2.6 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:33 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 01:30 PM\n PICC Line - 01:30 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 01:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 441517,
"text": "Demographics\n Day of mechanical ventilation: 0\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Exp Wheeze\n Comments: xopenex nebs and atrovent MDI given as documented\n Secretions\n Sputum color / consistency: Bloody / Plug\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: attempted PSV wean but ABG revealed resp acidosis, pt placed\n back on A/C.\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441877,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Orally intubated, respiratory effort unlabored. Expiratory wheezes\n noted on auscultation. 02 sat 94%\n Action:\n Suctioned for thick tan secretions, IV antibiotics for pneumonia per\n . ICU team spoke with family re: Pt condition.\n Response:\n Appears comfortable, 02 sat stable\n Plan:\n Continue ventilator support, family meeting planned for tomorrow\n Electrolyte & fluid disorder, other\n Assessment:\n Hct 24.1, K 3.1 Hemodynamically stable with no ectopy. Uo 30+cc/hr\n Action:\n Transfused one unit packed red blood cells. 20meq KCL IVPB x 2\n Response:\n Post transfusion hct 30.4, K level 4, uo 20cc last hour\n Plan:\n Follow Hct and lytes, monitor for any frank bleeding. Hourly urine\n output, consider diuresis as indicated.\n Impaired Skin Integrity\n Assessment:\n Multiple areas of friable weeping skin on extremities. + edema of\n hands and feet. Pedal pulses by Doppler, skin warm to touch.\n Action:\n Repostioned q2hrs, barrier cream to heels and waffle boots applied.\n Weeping areas of upper extremities covered with absorbent dressings.\n Skin tear at right upper extremity covered with adaptic dressing.\n Response:\n All procedures tolerated well, weeping areas of upper extremities with\n less drainage.\n Plan:\n Continue nutrition, meticulous skin and frequent turns. Observe for any\n areas of break down. Consider specialty mattress as indicated.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441931,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Edema, peripheral\n Assessment:\n General dependant edema, TBB LOS urine output qs\n Action:\n Skin care to prevent injury, change position of pt, elevate\n extremities\n Response:\n Unchanged from prev exam\n Plan:\n Prevent skin impairment, may consider lasix today\n Alteration in Nutrition\n Assessment:\n Goal tf nutren pulm fs at 40 cc hr, good bowel tones, stool drk brwn x1\n loose\n Action:\n Cont. tube feeds, bowel program,\n Response:\n Stooling, no residuals tol. TF well\n Plan:\n Cont. tube feedings. discuss peg placement as pt. has cont. need\n for nutrition\n Impaired Skin Integrity\n Assessment:\n Multiple skin abrasions, tears, bruises primary on legs and arms,\n coccyx light pink, perineum swollen red and some clusters, weeping from\n wound on arms\n Action:\n Skin tears on leg and upper right arm drsg , turning /s,\n barrier cream , antifungal cream to perineum\n Response:\n Increase in perianal rash\n Plan:\n Meticulous skin cares, apply barrier cream to coccyx, heels, cont.\n waffles on legs, keep perineum dry apply barrier cream\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on full vent. 40% sats good. Secretioins thick tan mod amt.\n , lung fields clear bil. Min oral clear secretions. Bronchospastic with\n cough\n Action:\n Pulm. Toilet, suction prn, wean to ext. or discussion with family/pt\n today regarding long term plan e.g. trach vs extubation\n Response:\n stable\n Plan:\n Supportive care, discussion with family/pt over long term plan\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442037,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Significant Events: pt and family met w/ team as well as pt\ns primary\n pulmonologist r/t trach vs extubation.\n Alteration in Nutrition\n Assessment:\n Goal tf nutren pulm fs at 40 cc hr, good bowel tones, stool drk brwn x1\n loose\n Action:\n Cont. tube feeds, bowel program, discussed possibility of PEG placement\n along w/ trach if needed.\n Response:\n Stooling, no residuals tol. TF well, pt agrees to PEG if needed.\n Plan:\n Cont. tube feedings. Peg placement w/ trach if needed sometime next\n week.\n Impaired Skin Integrity\n Assessment:\n Multiple skin abrasions, tears, bruises primary on legs and arms,\n coccyx light pink, perineum swollen red and some clusters, weeping from\n wound on arms\n Action:\n Skin tears on leg and upper right arm drsg , turning /s,\n barrier cream , antifungal cream to perineum\n Response:\n Increase in perianal rash\n Plan:\n Meticulous skin cares, apply barrier cream to coccyx, heels, cont.\n waffles on legs, keep perineum dry apply barrier cream\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on AC 500x 18, 40%, PEEP 8. sats good. Secretions thick tan/\n bld tinged mod amt. , lung fields clear bil.w/ dim bases Bronchospastic\n with cough, remains on fentanyl 25mcg/hr and midazolam 2mg/hr tol well.\n Action:\n Pulm. Toilet, suction prn, wean to ext. or discussion with family/pt\n today regarding long term plan e.g. trach vs extubation\n Response:\n Pt states she would like to con to att to wean/ extubate but if unable\n to wean would want trach.\n Plan:\n Supportive care, wean vent as tol, w/ plan to trach sometime next week\n if unable to extubate.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441515,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Pt\ns , \n, called this morning. Stated pt is w/o much\n family and believes she is the next of , but is not her HCP. Pt is\n not married, nor does she have any children.\n Edema, peripheral\n Assessment:\n 2+-3+ edema to all 4 extremities. Pedal pulses palpable. Fluid\n balance running close to even at this time. UOP adequate.\n Action:\n Extremities elevated on pillows.\n Response:\n Plan:\n ? need for lasix for negative fluid balance goal, monitor closely.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to b/l apices, diminished to b/l bases. Rec\nd on CMV @ 40%/\n 400x14/5+. O2 sats 98-100%. Infreq sxn\ning for white thick sputum.\n Action:\n Switched to PS of +/40% this afternoon\n Response:\n Sats on PS 96-98%, RR 20s-mid 30s, MV 9.1, TV high 200s-400. ABG\n drawn- increasingly acidotic 7.28/58/93- team aware. Placed back on\n CMV 40%/18x400/5+.\n Plan:\n Cont to wean vent as tolerated, MDIs/neb txs\n Sepsis without organ dysfunction\n Assessment:\n Pt cont off of pressors, ABP 90s-160s systolic. Afebrile, but w/ a\n slightly increased wbc. Cont on 25mcg fent and 2mg versed.\n Action:\n Lopressor increased to 25mg po..but held this afternoon for SBP in the\n 90s. Given aspirin and high dose steroids . Cefepime d/c\nd, but cont\n on vanco and zosyn. Cxs neg to date.\n Response:\n No change.\n Plan:\n Cont to monitor labs, blood sugars, monitor BP and UOP closely, f/u on\n cx\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-17 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 442031,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Comments: Pt remains on full support with no changes made to parameter\n settings. Xopenex given inline through the vent.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442091,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Social Work",
"chartdate": "2158-02-17 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 442022,
"text": "Family Information\n Next of : -- \n Health Care Proxy appointed: Proxy\n Family Spokesperson designated: \n Communication or visitation restriction:\n Patient Information:\n Previous living situation:\n Previous level of functioning: Independent\n Previous or other hospital admissions:\n Past psychiatric history:\n Past addictions history:\n Employment status: Retired\n Legal involvement:\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment: Patient is a 70 year old woman who is\n estranged from many family members and only has one that she is\n close to. , , has been at the hospital all day. Patient has a\n HX of emphizema and lung infections and currently is very ill with a\n bad pneumonia. Patient is intubated and was told today that medical\n team has been unable to wean her from the breathing tube. Patient will\n need to make a decision soon as to whether she would like to have the\n tube removed and be treched or have the tube removed and be made CMO.\n It is difficult for patient to communicate her wishes other than\n nodding her head yes or no. Patient appears sad and frustrated that she\n can not talk and keeps trying to reach up and yank on her breathing\n tube. Patient was previously a very independent woman living on her own\n and this situation is very hard for her. Patient\ns is visiting\n and is the only family member that patient will allow to participate in\n her care. This SW and medical team was able to gather from patient\n head nods that she does want to continue treatment for her pneumonia\n and will most likely give consent to be treched. Patient requested to\n speak with her PCP who she had know for a long time. He will be coming\n to visit patient this afternoon. Both options of care were carefully\n and clearly explained to the patient by Dr. with both this SW and\n patient\ns in the room. Patient became tearful several times but\n clearly wanted to keep trying to communicate by trying to wrote down\n letters, though her hand writing could not be deciphered. SW will\n continue to support patient and her as they make decisions about\n her plan of care. Please page with questions. , LCSW \n Clergy Contact:\n Communication with Team:\n Plan / Follow up:\n Continuing issues to be addressed: Supporting patient's inability to\n communicate verbally and addressing end of life issues.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441493,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Edema, peripheral\n Assessment:\n + edema to all 4 extremities. Difficult to palpate b/l pedal pulses, +\n b/l radial pulses.\n Action:\n Extremities elevated on pillows.\n Response:\n Plan:\n ? need for lasix\n negative fluid balance goal.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to b/l apices, diminished to b/l bases. Rec\nd on CMV @ 40%/\n 400x14/5+. O2 sats 98-100%. Infreq sxn\ning needed.\n Action:\n Switched to PS of +/40%\n Response:\n Sats 96%, RR 20s\n.unable to draw ABG from aline- team aware.\n Plan:\n Cont to wean vent as tolerated, MDIs.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441500,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Pt\ns , \n, called this morning. Stated pt is w/o much\n family and believes she is the next of , but is not her HCP. Pt is\n not married, nor does she have any children.\n Edema, peripheral\n Assessment:\n 2+-3+ edema to all 4 extremities. Pedal pulses palpable. Fluid\n balance running close to even at this time. UOP adequate.\n Action:\n Extremities elevated on pillows.\n Response:\n Plan:\n ? need for lasix\n negative fluid balance goal.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to b/l apices, diminished to b/l bases. Rec\nd on CMV @ 40%/\n 400x14/5+. O2 sats 98-100%. Infreq sxn\ning needed.\n Action:\n Switched to PS of +/40%\n Response:\n Sats 96%, RR 20s\n.unable to draw ABG from aline- team aware.\n Plan:\n Cont to wean vent as tolerated, MDIs.\n Sepsis without organ dysfunction\n Assessment:\n Pt cont off of pressors, ABP 90s-160s systolic. Afebrile, but w/ a\n slightly increased wbc. Cont on 25mcg fent and 2mg versed.\n Action:\n Lopressor increased to 25mg po. Given aspirin and high dose steroids .\n Cefepime d/c\nd, but cont on vanco and zosyn. Cxs neg to date.\n Response:\n No change.\n Plan:\n Cont to monitor labs, blood sugars, monitor BP and UOP closely.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442137,
"text": "Chief Complaint:\n 24 Hour Events:\n - niece came and had meeting with pt and Dr. , decided that\n she wanted to go ahead with a trach\n - changed abx to ceftriaxone per pharm recommendation\n - plan to call IP for trach eval\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Ceftriaxone - 10:19 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 76 (68 - 95) bpm\n BP: 101/46(60) {101/46(60) - 166/86(96)} mmHg\n RR: 18 (13 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,858 mL\n 395 mL\n PO:\n TF:\n 1,128 mL\n 268 mL\n IVF:\n 398 mL\n 97 mL\n Blood products:\n 212 mL\n Total out:\n 1,190 mL\n 270 mL\n Urine:\n 1,190 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n 668 mL\n 125 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 17\n PIP: 30 cmH2O\n Plateau: 19 cmH2O\n Compliance: 62.5 cmH2O/mL\n SpO2: 98%\n ABG: ///35/\n Ve: 10.9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 279 K/uL\n 9.7 g/dL\n 102 mg/dL\n 0.9 mg/dL\n 35 mEq/L\n 3.7 mEq/L\n 32 mg/dL\n 108 mEq/L\n 148 mEq/L\n 29.8 %\n 20.7 K/uL\n [image002.jpg]\n 04:15 AM\n 06:29 AM\n 03:07 PM\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n Plt\n 79\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n TCO2\n 27\n 27\n 28\n 27\n 31\n Glucose\n 135\n 107\n 119\n 102\n Other labs: PT / PTT / INR:13.3/32.1/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.8 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:41 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 01:36 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442143,
"text": "Chief Complaint:\n 24 Hour Events:\n - niece came and had meeting with pt and Dr. , decided that\n she wanted to go ahead with a trach\n - changed abx to ceftriaxone per pharm recommendation\n - plan to call IP for trach eval\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Ceftriaxone - 10:19 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 76 (68 - 95) bpm\n BP: 101/46(60) {101/46(60) - 166/86(96)} mmHg\n RR: 18 (13 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,858 mL\n 395 mL\n PO:\n TF:\n 1,128 mL\n 268 mL\n IVF:\n 398 mL\n 97 mL\n Blood products:\n 212 mL\n Total out:\n 1,190 mL\n 270 mL\n Urine:\n 1,190 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n 668 mL\n 125 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 17\n PIP: 30 cmH2O\n Plateau: 19 cmH2O\n Compliance: 62.5 cmH2O/mL\n SpO2: 98%\n ABG: ///35/\n Ve: 10.9 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 279 K/uL\n 9.7 g/dL\n 102 mg/dL\n 0.9 mg/dL\n 35 mEq/L\n 3.7 mEq/L\n 32 mg/dL\n 108 mEq/L\n 148 mEq/L\n 29.8 %\n 20.7 K/uL\n [image002.jpg]\n 04:15 AM\n 06:29 AM\n 03:07 PM\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n Plt\n 79\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n TCO2\n 27\n 27\n 28\n 27\n 31\n Glucose\n 135\n 107\n 119\n 102\n Other labs: PT / PTT / INR:13.3/32.1/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.8 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with hypoxia and respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. MDI while intubated. Patient was able to tolerate\n PS10/PEEP8 yesterday for approx 2 hrs . Sputum showed moderate H.\n flu beta-lactamase negative, changed to ceftriaxone. Initally, vanc was\n d/c\ned and patient was kept on Zosyn until found to be flu\n beta-lactamase negative.\n - continue ceftriaxone\n - family meeting with Dr. , plan for trach\n - mouthcare, HOB elevated\n .\n # ARF: pre-renal from lasix administration\n .\n # Hypotension: Resolved, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2 months of prednisone use and patient had initially\n been given Hydrocortisone. Aggressive resuscitation with IVF, s/p 10L\n of IVF on initial presentation. Hypotension now resolved.\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg \n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - guiaic negative\n - maintain active type & screen\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative\n .\n # FEN: cont TFs, nutrition following\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n # Code: FULL\n .\n # Disposition: pending family meeting and goals of care, trach vs.\n terminal extubation\n - Social work consult placed \n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:41 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 01:36 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441494,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Edema, peripheral\n Assessment:\n 2+-3+ edema to all 4 extremities. Pedal pulses palpable. Fluid\n balance running close to even at this time. UOP adequate.\n Action:\n Extremities elevated on pillows.\n Response:\n Plan:\n ? need for lasix\n negative fluid balance goal.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to b/l apices, diminished to b/l bases. Rec\nd on CMV @ 40%/\n 400x14/5+. O2 sats 98-100%. Infreq sxn\ning needed.\n Action:\n Switched to PS of +/40%\n Response:\n Sats 96%, RR 20s\n.unable to draw ABG from aline- team aware.\n Plan:\n Cont to wean vent as tolerated, MDIs.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441496,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Edema, peripheral\n Assessment:\n 2+-3+ edema to all 4 extremities. Pedal pulses palpable. Fluid\n balance running close to even at this time. UOP adequate.\n Action:\n Extremities elevated on pillows.\n Response:\n Plan:\n ? need for lasix\n negative fluid balance goal.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to b/l apices, diminished to b/l bases. Rec\nd on CMV @ 40%/\n 400x14/5+. O2 sats 98-100%. Infreq sxn\ning needed.\n Action:\n Switched to PS of +/40%\n Response:\n Sats 96%, RR 20s\n.unable to draw ABG from aline- team aware.\n Plan:\n Cont to wean vent as tolerated, MDIs.\n Sepsis without organ dysfunction\n Assessment:\n Pt cont off of pressors, ABP 90s-160s systolic. Cont on 25mcg fent\n and 2mg versed.\n Action:\n Lopressor increased to 25mg po. Given aspirin dose. Cefepime d/c\n but cont on vanco and zosyn. Cxs neg to date.\n Response:\n No change.\n Plan:\n Cont to monitor labs, monitor BP and UOP closely.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441498,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Pt\ns , \n, called this morning. Stated pt is w/o much\n family and believes she is the next of , but is not her HCP. Pt is\n not married, nor does she have any children.\n Edema, peripheral\n Assessment:\n 2+-3+ edema to all 4 extremities. Pedal pulses palpable. Fluid\n balance running close to even at this time. UOP adequate.\n Action:\n Extremities elevated on pillows.\n Response:\n Plan:\n ? need for lasix\n negative fluid balance goal.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to b/l apices, diminished to b/l bases. Rec\nd on CMV @ 40%/\n 400x14/5+. O2 sats 98-100%. Infreq sxn\ning needed.\n Action:\n Switched to PS of +/40%\n Response:\n Sats 96%, RR 20s\n.unable to draw ABG from aline- team aware.\n Plan:\n Cont to wean vent as tolerated, MDIs.\n Sepsis without organ dysfunction\n Assessment:\n Pt cont off of pressors, ABP 90s-160s systolic. Afebrile, but w/ a\n slightly increased wbc. Cont on 25mcg fent and 2mg versed.\n Action:\n Lopressor increased to 25mg po. Given aspirin and high dose steroids .\n Cefepime d/c\nd, but cont on vanco and zosyn. Cxs neg to date.\n Response:\n No change.\n Plan:\n Cont to monitor labs, monitor BP and UOP closely.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442139,
"text": "Chief Complaint:\n 24 Hour Events:\n - niece came and had meeting with pt and Dr. , decided that\n she wanted to go ahead with a trach\n - changed abx to ceftriaxone per pharm recommendation\n - plan to call IP for trach eval\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Ceftriaxone - 10:19 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 76 (68 - 95) bpm\n BP: 101/46(60) {101/46(60) - 166/86(96)} mmHg\n RR: 18 (13 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,858 mL\n 395 mL\n PO:\n TF:\n 1,128 mL\n 268 mL\n IVF:\n 398 mL\n 97 mL\n Blood products:\n 212 mL\n Total out:\n 1,190 mL\n 270 mL\n Urine:\n 1,190 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n 668 mL\n 125 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 17\n PIP: 30 cmH2O\n Plateau: 19 cmH2O\n Compliance: 62.5 cmH2O/mL\n SpO2: 98%\n ABG: ///35/\n Ve: 10.9 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 279 K/uL\n 9.7 g/dL\n 102 mg/dL\n 0.9 mg/dL\n 35 mEq/L\n 3.7 mEq/L\n 32 mg/dL\n 108 mEq/L\n 148 mEq/L\n 29.8 %\n 20.7 K/uL\n [image002.jpg]\n 04:15 AM\n 06:29 AM\n 03:07 PM\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n Plt\n 79\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n TCO2\n 27\n 27\n 28\n 27\n 31\n Glucose\n 135\n 107\n 119\n 102\n Other labs: PT / PTT / INR:13.3/32.1/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.8 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:41 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 01:36 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-19 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 442291,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont intub with OETT and on mech vent as per Metavision.\n Lung sounds dim suct mod th bld tinged sput. MDI and SVN given as per\n order. Pt in NARD on current settings; no vent changes required\n overnoc. Cont mech vent support.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442364,
"text": "Chief Complaint:\n 24 Hour Events:\n - brief episode of SVT, EKG with no significant changes\n - IP to trach/PEG Tuesday\n - spoke with case mgmt re: rehab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Ceftriaxone - 10:44 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 04:15 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Lorazepam (Ativan) - 04:20 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98.1\n HR: 73 (72 - 102) bpm\n BP: 137/51(72) {110/45(61) - 157/69(91)} mmHg\n RR: 18 (18 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,196 mL\n 899 mL\n PO:\n TF:\n 889 mL\n 271 mL\n IVF:\n 498 mL\n 348 mL\n Blood products:\n Total out:\n 993 mL\n 255 mL\n Urine:\n 993 mL\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,203 mL\n 644 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 29 cmH2O\n Plateau: 20 cmH2O\n SpO2: 97%\n ABG: ///35/\n Ve: 10.2 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 251 K/uL\n 8.5 g/dL\n 102 mg/dL\n 0.8 mg/dL\n 35 mEq/L\n 4.1 mEq/L\n 32 mg/dL\n 108 mEq/L\n 147 mEq/L\n 26.2 %\n 16.7 K/uL\n [image002.jpg]\n 03:07 PM\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n 16.7\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n Plt\n 79\n 251\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n TCO2\n 28\n 27\n 31\n Glucose\n 135\n 107\n 119\n 102\n 160\n 102\n Other labs: PT / PTT / INR:13.5/31.7/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.7 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. MDI while intubated. Patient was able to tolerate\n PS10/PEEP8 yesterday for approx 2 hrs . Sputum showed moderate H.\n flu beta-lactamase negative, changed to ceftriaxone. Initally, vanc was\n d/c\ned and patient was kept on Zosyn until found to be flu\n beta-lactamase negative.\n - continue ceftriaxone for total of 14 days\n - plan for trach and PEG on Tuesday per IP\n - mouthcare, HOB elevated\n .\n # ARF: pre-renal from lasix administration -> holding lasix for now,\n increase free water flushes to 250cc q4h\n .\n # Hypotension: Resolved, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2 months of prednisone use and patient had initially\n been given Hydrocortisone. Aggressive resuscitation with IVF, s/p 10L\n of IVF on initial presentation.\n - Hypotension now resolved\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg \n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - guiaic negative\n - maintain active type & screen\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative\n .\n # FEN: cont TFs, nutrition following, PEG to be placed Tuesday\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n # Code: FULL\n .\n # Disposition: trach and PEG Tuesday, case management aware of need for\n rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 07:28 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442285,
"text": "PMH: 70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic\n resp failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN cocci. Chronic steroids. Intubated when admitted ,\n now failure to wean with plan to trach/PEG by IP.\n Events: Pt follows commands, MAEs, PERRL. Pt anxious at bedtime\n (2200), 1 mg ativan given w/ good effect. Pt able to sleep through\n most of night. Pt consistently denies pain, SOB. Pt communicates by\n mouthing words and using writing tablet. Mushroom cath in place, foley\n in place and UOP 30-40 ml/hr.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 40%/500/18/8. Sp02 approx 98%. LS course to clear\n throughout night and dim at bases. Pt sux\ned for min amts tan, blood\n tinged sputum.\n Action:\n No vent changes overnight.\n Response:\n Resp status remains unchanged.\n Plan:\n Cont w/ plan for trach/peg placement tues .\n Impaired Skin Integrity\n Assessment:\n Pt has very fragile skin, thin, weeping, w/ mult skin tears at all\n extremities. Pt denies pain when asked.\n Action:\n Freq repositioning, extremities elevated on pillows. Bilat UEs dressed\n w/ softsorb, RLE dressed w/ adaptic and gauze. Blister OTA on LLE.\n Barrier cream applied to coccyx, moisturizer applied liberally.\n Response:\n Skin remains unchanged.\n Plan:\n Vigilent skin care.\n Electrolyte & fluid disorder, other\n Assessment:\n Na 148\n Action:\n FWB at 250 ml q 6 h\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442496,
"text": "PMH: 70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic\n resp failure and pneumonia. Recent pseudomonas, H Flu in sputum. Sputum\n now showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin\n with multiple tears, weeping. Intubated on admit, now failure to\n wean with plan to trach/PEG by IP, prep for rehab.\n Events: Uneventful night, pt slept intermittently. Cont w/ Ativan PRN\n for anxiety, Zofran PRN for nausea. Fentanyl patch in place on L\n shoulder, pt consistently denies pain. Replete lytes per sliding\n scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 40%/500/18/5. Sp02 94-98%, SRR to 20 when pt is\n awake. Pt is not sedated, not restrained. LS clear and dim at bases\n bilat. Mod amts thick, tan, blood tinged sputum w/ sux.\n Action:\n Nebulizers given, freq oral care. Suction as needed. ABX for PNA.\n Response:\n Sp02 currently 97%. Pt in no acute distress.\n Plan:\n Plan for trach/PEG , family and pt aware.\n Impaired Skin Integrity\n Assessment:\n Pt has mult skin tears, very fragile, thin skin. Generalized and\n weeping edema. Lg sanguinous blister at medial aspect LLE, OTA.\n Adaptic dressing on L inner thigh, R shin. Reddened area at coccyx.\n Action:\n Reposition as tol, dressings to UEs and LEs changed as needed. Barrier\n cream, moisturizers applied liberally.\n Response:\n Skin integrity remains impaired.\n Plan:\n Cont vigilant skin care.\n Hypernatremia (high sodium)\n Assessment:\n Na has been elevated 148-147 for several days.\n Action:\n 250 ml FWB increased from q 6 h to q 4 h.\n Response:\n Na normalizing, this AM is 143.\n Plan:\n Cont to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-13 00:00:00.000",
"description": "Generic Note",
"row_id": 441168,
"text": "TITLE:\n 70 y/o F with PMHx of severe COPD and recent NSTEMI who was transferred\n in from rehab with increased SOB over the prior 3-4 days. This am, she\n was noted to have low sats to 70% which did not respond to nebs. Her\n sats came up with high flow O2 in the EMS. Pt denied any cough,\n increased sputum, chest pain or pedal edema. She was notably wheezey\n on presentation and was initially treated as COPD exacerbation.\n .\n In the ED, initial vs were: T 97.6 BP 146/70 HR 147 RR 20 Sats 96% on\n RA. Patient was given solumedrol 125mg, nebs & levofloxacin for LLL\n infiltrate seen on CXR. On re-evaluation, pt was lethargic and\n desatting into the 70s. Pt was intubated for respiratory failure and\n received ceftriaxone and vancomycin for presumed PNA. Pt was noted to\n have sbps in 80s peri-intubation and received a total of 6L of IVF. Pt\n had a Tmax of 103.8 in the ED, though lactate was normal at 1.7. Pt\n was transferred to the ICU on versed/fentanyl and dopamine to maintain\n SBPs.\n .\n On arrival, pt was intubated and sedated though following commands.\n She reported some chest pain but was otherwise comfortable and sating\n 100% on the vent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt\ns LS\ns clear in upper airway, diminished at bases. Vented on AC\n 500x14, FiO2 40%, PEEP 5. O2 sat 94-97%. ABG 7.27-55-75-21.\n Suctioned for large amounts of thick tan secretions. Sputum, urine,\n blood cultures sent in ED (including a set off of PICC line). Pt\n easily arousable and following commands, becoming anxious at times and\n reaching for ETT.\n Action:\n Started on Fenta & versed drips. Pt\ns RR ^ed to 16 on the vent after\n ABG . Rec\nd cipro and zosyn for treatment of pna and will continue\n on vancomycin.\n Response:\n Pt O2 sat 95 to 97% on current vent settings. Pt appears comfortable\n on ventilator at this time.\n Plan:\n Cont to monitor resp status.\n Sepsis without organ dysfunction\n Assessment:\n Received pt on Dopamine drip at 2mcg/kg/min. urine output decreased\n .\n Action:\n Total of 2 lits of LR bloused for low urine output. BP WNL ,dopamine\n weaned off at 2245 hrs. .\n Response:\n ABP 95\ns-120\ns/50\ns with MAP >65 on current dose of dopamine. U/O\n decreased again at 2 am, informed Resident, will monitor u/o\n Patient\n positive for a total of 9 lits at 0230 am.\n Plan:\n Continue monitoring BP, U/O,\n Alteration in Nutrition\n Assessment:\n Patient received on Pulmonary Nutren at 10 mls/hr , water flushes 30\n mls q 8 hrs. Albumin low, with peripheral edema.\n Action:\n Feeds increased to 30 mls/hr as tolerated by the patient.\n Response:\n Pending\n Plan:\n Increase to a goal of 40 mls/hr as tolerated.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple areas of bruising on extremities with 2 skin tears\n noted, 1 to the right elbow and 1 to the right foot. + pedal\n edema. Stage 1 pressure ulcer noted to rt gluteal area.\n Action:\n Skin tears cleaned with NS and covered with adaptic. Rt foot skin tear\n draining small to moderate amounts of serosang drainage. Pt turned and\n repositioned.\n Response:\n Pending\n Plan:\n Continue to monitor for further areas of tearing or breakdown. Turn\n and reposition q2 hours.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442613,
"text": "70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n Impaired Skin Integrity\n Assessment:\n Multiple skin tears weeping serosang fluid. Blister to left inner\n medial shin- intact. Poor skin likely d/t long term steroid use. Stage\n 1 to rt gluteal fold unchanged- skin intact.\n Action:\n Adaptic w/ soft sorb and kerlix applied to skin tears changed x 2\n today.\n Response:\n Unchanged.\n Plan:\n Cont w/ skin care, frequent repositioning.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to b/l apices, diminished to b/l bases. Rec\nd on CMV\n 40%/500x18/5+. Sats 99-100%. Pt in no acute distress. Suctioned\n frequently for thick yellow sputum.\n Action:\n Pt currently on 12 PS, 40%, 8 peep. Given MDIs.\n Response:\n ABG pending. RR teens to 20s, sats 97-98%.\n Plan:\n Plan for trach and peg tomorrow- pt on add on list.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442615,
"text": "70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n Impaired Skin Integrity\n Assessment:\n Multiple skin tears weeping serosang fluid. Blister to left inner\n medial shin- intact. Poor skin likely d/t long term steroid use. Stage\n 1 to rt gluteal fold unchanged- skin intact.\n Action:\n Adaptic w/ soft sorb and kerlix applied to skin tears changed x 2\n today.\n Response:\n Unchanged.\n Plan:\n Cont w/ skin care, frequent repositioning.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to b/l apices, diminished to b/l bases. Rec\nd on CMV\n 40%/500x18/5+. Sats 99-100%. Pt in no acute distress. Suctioned\n frequently for thick yellow sputum.\n Action:\n Pt currently on 12 PS, 40%, 8 peep. Given MDIs.\n Response:\n ABG pending. RR teens to 20s, sats 97-98%.\n Plan:\n Plan for trach and peg tomorrow- pt on add on list.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442619,
"text": "70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n -Pt seen by Case mgmt today for rehab placement in near future.\n -Given ativan IV x 2 today 0.5mg doses for increased anxiety. Given\n Zofran x 1 for nausea\n..no vomiting.\n Impaired Skin Integrity\n Assessment:\n Multiple skin tears weeping serosang fluid. Fragile, thin skin.\n Reddened area to rt gluteal fold unchanged- skin intact. Lg sanguinous\n blister at medial aspect LLE, OTA. Pedal edema- dopplerable pulses.\n Action:\n Adaptic w/ soft sorb and kerlix applied to skin tears changed x 2\n today.\n Response:\n No change\n Plan:\n Cont w/ skin care, frequent repositioning.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to b/l apices, diminished to b/l bases. Rec\nd on CMV\n 40%/500x18/5+. Sats 99-100%. Pt in no acute distress. Suctioned\n frequently for thick yellow sputum.\n Action:\n Pt currently on 12 PS, 40%, 8 peep. Given MDIs. OOB to chair today\n for approx 4 hrs.\n Response:\n VBG on PS 7.41/54/172/35. RR teens to 20s, sats 97-98%.\n Plan:\n Plan for trach and peg tomorrow- pt on add on list, pt and family\n aware.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-13 00:00:00.000",
"description": "Generic Note",
"row_id": 441170,
"text": "TITLE:\n 70 y/o F with PMHx of severe COPD and recent NSTEMI who was transferred\n in from rehab with increased SOB over the prior 3-4 days. This am, she\n was noted to have low sats to 70% which did not respond to nebs. Her\n sats came up with high flow O2 in the EMS. Pt denied any cough,\n increased sputum, chest pain or pedal edema. She was notably wheezey\n on presentation and was initially treated as COPD exacerbation.\n .\n In the ED, initial vs were: T 97.6 BP 146/70 HR 147 RR 20 Sats 96% on\n RA. Patient was given solumedrol 125mg, nebs & levofloxacin for LLL\n infiltrate seen on CXR. On re-evaluation, pt was lethargic and\n desatting into the 70s. Pt was intubated for respiratory failure and\n received ceftriaxone and vancomycin for presumed PNA. Pt was noted to\n have sbps in 80s peri-intubation and received a total of 6L of IVF. Pt\n had a Tmax of 103.8 in the ED, though lactate was normal at 1.7. Pt\n was transferred to the ICU on versed/fentanyl and dopamine to maintain\n SBPs.\n .\n On arrival, pt was intubated and sedated though following commands.\n She reported some chest pain but was otherwise comfortable and sating\n 100% on the vent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt\ns LS\ns clear in upper airway, diminished at bases. Vented on AC\n 500x14, FiO2 40%, PEEP 5. O2 sat 94-97%. ABG 7.27-55-75-21.\n Suctioned for large amounts of thick tan secretions. Sputum, urine,\n blood cultures sent in ED (including a set off of PICC line). Pt\n easily arousable and following commands, becoming anxious at times and\n reaching for ETT.\n Action:\n Started on Fenta & versed drips. Pt\ns RR ^ed to 16 on the vent after\n ABG . Rec\nd cipro and zosyn for treatment of pna and will continue\n on vancomycin.\n Response:\n Pt O2 sat 95 to 97% on current vent settings. Pt appears comfortable\n on ventilator at this time.\n Plan:\n Cont to monitor resp status.\n Sepsis without organ dysfunction\n Assessment:\n Received pt on Dopamine drip at 2mcg/kg/min. urine output decreased\n .\n Action:\n Total of 2 lits of LR bloused for low urine output. BP WNL ,dopamine\n weaned off at 2245 hrs. .\n Response:\n ABP 95\ns-120\ns/50\ns with MAP >65 on current dose of dopamine. U/O\n decreased again at 2 am, informed Resident, will monitor u/o\n Patient\n positive for a total of 9 lits at 0230 am.\n Plan:\n Continue monitoring BP, U/O,\n Alteration in Nutrition\n Assessment:\n Patient received on Pulmonary Nutren at 10 mls/hr , water flushes 30\n mls q 8 hrs. Albumin low, with peripheral edema.\n Action:\n Feeds increased to 30 mls/hr as tolerated by the patient.\n Response:\n Pending\n Plan:\n Increase to a goal of 40 mls/hr as tolerated.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple areas of bruising on extremities with 2 skin tears\n noted, 1 to the right elbow and 1 to the right foot. + pedal\n edema. Stage 1 pressure ulcer noted to rt gluteal area.\n Action:\n Skin tears cleaned with NS and covered with adaptic. Rt foot skin tear\n draining small to moderate amounts of serosang drainage. Pt turned and\n repositioned.\n Response:\n Pending\n Plan:\n Continue to monitor for further areas of tearing or breakdown. Turn\n and reposition q2 hours.\n Electrolyte & fluid disorder, other\n Assessment:\n PM labs off normal .\n Action:\n Repleted with 4 grams of Calcium, 4 grams of mag sulph, 15 mmol of K\n Phos given\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442666,
"text": "PMH: 70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic\n resp failure and pneumonia. Recent pseudomonas, H Flu in sputum. Sputum\n now showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin\n with multiple tears, weeping. Intubated on admit, now failure to\n wean with plan to trach/PEG by IP. Pt seen by case management\n to eval for rehab.\n Events: TF stopped at MN for surgery tomorrow (T / P). Pt expressed\n anxiety for tomorrow, ambien 5 mg / ativan given as ordered. Pt not\n sleeping well throughout night, spent some time talking w/ patient,\n explaining procedure. Hct and WBC stable. K elevated to 5.3 (4.2\n yesterday).\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CPAP 40%/. SRR 21-24, Sp02 97-99%. Pt sux\ned for\n copious amts thick, blood tinged sputum. LS clear and dim at bases.\n Pt mentating well, communicating by mouthing words, writing. Pt\n afebrile T max 98.8 oral.\n Action:\n Pt remains on CPAP, neb tx\ns given as ordered. ET tube lavaged to\n improve ability to sux out sputum and secretions.\n Response:\n Pt tolerating CPAP w/o incident, Sp02 remains 97-99%, no tachypnea or\n increased WOB noted.\n Plan:\n Pt consented by surgery and anesthesia for trach and PEG today.\n Impaired Skin Integrity\n Assessment:\n Mult skin tears at all extremities. Mult hematomas, thin fragile skin,\n weeping edema. Lg sanguinous blister at L LE.\n Action:\n Requested wound care consult from team as this RN worries skin\n breakdown may become source of infection. Softsorb, adaptic, and\n dressing changes as needed. Prednisone dose decreased.\n Response:\n Skin is not improved.\n Plan:\n Cont vigilant skin care.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 441603,
"text": "Chief Complaint:\n 24 Hour Events:\n - cipro d/c'ed as no longer need double coverage for pseudomonas\n - PS trial failed with gas 7.28 / 58 / 93; placed back no AC\n - fem line pulled\n - IV lasix 20 mg x1 for slightly positive fluid status\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:00 PM\n Ciprofloxacin - 04:38 AM\n Vancomycin - 07:53 PM\n Piperacillin/Tazobactam (Zosyn) - 12:38 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:15 PM\n Heparin Sodium (Prophylaxis) - 12:38 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.6\n HR: 91 (74 - 102) bpm\n BP: 153/72(101) {88/43(59) - 164/77(109)} mmHg\n RR: 19 (16 - 28) insp/min\n SpO2: 20%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,484 mL\n 753 mL\n PO:\n TF:\n 925 mL\n 274 mL\n IVF:\n 1,339 mL\n 299 mL\n Blood products:\n Total out:\n 1,604 mL\n 960 mL\n Urine:\n 1,604 mL\n 960 mL\n NG:\n Stool:\n Drains:\n Balance:\n 880 mL\n -207 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 491 (491 - 491) mL\n PS : 10 cmH2O\n RR (Set): 18\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 74\n PIP: 23 cmH2O\n Plateau: 18 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 20%\n ABG: 7.40/42/112/29/1\n Ve: 10.5 L/min\n PaO2 / FiO2: 280\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 320 K/uL\n 8.2 g/dL\n 135 mg/dL\n 1.1 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 22 mg/dL\n 104 mEq/L\n 140 mEq/L\n 24.8 %\n 20.3 K/uL\n [image002.jpg]\n 03:20 AM\n 03:42 AM\n 07:38 PM\n 07:53 PM\n 03:59 AM\n 04:15 AM\n 06:29 AM\n 03:07 PM\n 05:40 PM\n 02:50 AM\n WBC\n 15.8\n 21.5\n 24.4\n 20.3\n Hct\n 25.1\n 26.5\n 26.7\n 24.8\n Plt\n 288\n 301\n 306\n 320\n Cr\n 0.5\n 1.0\n 1.1\n TropT\n <0.01\n TCO2\n 25\n 24\n 27\n 27\n 28\n 27\n Glucose\n 158\n 121\n 135\n Other labs: PT / PTT / INR:14.0/29.4/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.0 mg/dL,\n Mg++:2.4 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 05:16 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 01:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 441605,
"text": "Chief Complaint:\n 24 Hour Events:\n - cipro d/c'ed as no longer need double coverage for pseudomonas\n - PS trial failed with gas 7.28 / 58 / 93; placed back no AC\n - fem line pulled\n - IV lasix 20 mg x1 for slightly positive fluid status\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:00 PM\n Ciprofloxacin - 04:38 AM\n Vancomycin - 07:53 PM\n Piperacillin/Tazobactam (Zosyn) - 12:38 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:15 PM\n Heparin Sodium (Prophylaxis) - 12:38 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.6\n HR: 91 (74 - 102) bpm\n BP: 153/72(101) {88/43(59) - 164/77(109)} mmHg\n RR: 19 (16 - 28) insp/min\n SpO2: 20%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,484 mL\n 753 mL\n PO:\n TF:\n 925 mL\n 274 mL\n IVF:\n 1,339 mL\n 299 mL\n Blood products:\n Total out:\n 1,604 mL\n 960 mL\n Urine:\n 1,604 mL\n 960 mL\n NG:\n Stool:\n Drains:\n Balance:\n 880 mL\n -207 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 491 (491 - 491) mL\n PS : 10 cmH2O\n RR (Set): 18\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 74\n PIP: 23 cmH2O\n Plateau: 18 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 20%\n ABG: 7.40/42/112/29/1\n Ve: 10.5 L/min\n PaO2 / FiO2: 280\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, diffuse\n expiratory wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, +1 pitting edema\n Labs / Radiology\n 320 K/uL\n 8.2 g/dL\n 135 mg/dL\n 1.1 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 22 mg/dL\n 104 mEq/L\n 140 mEq/L\n 24.8 %\n 20.3 K/uL\n [image002.jpg]\n 03:20 AM\n 03:42 AM\n 07:38 PM\n 07:53 PM\n 03:59 AM\n 04:15 AM\n 06:29 AM\n 03:07 PM\n 05:40 PM\n 02:50 AM\n WBC\n 15.8\n 21.5\n 24.4\n 20.3\n Hct\n 25.1\n 26.5\n 26.7\n 24.8\n Plt\n 288\n 301\n 306\n 320\n Cr\n 0.5\n 1.0\n 1.1\n TropT\n <0.01\n TCO2\n 25\n 24\n 27\n 27\n 28\n 27\n Glucose\n 158\n 121\n 135\n Other labs: PT / PTT / INR:14.0/29.4/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.0 mg/dL,\n Mg++:2.4 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 05:16 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 01:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 441608,
"text": "Chief Complaint:\n 24 Hour Events:\n - cipro d/c'ed as no longer need double coverage for pseudomonas\n - PS trial failed with gas 7.28 / 58 / 93; placed back no AC\n - fem line pulled\n - IV lasix 20 mg x1 for slightly positive fluid status\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:00 PM\n Ciprofloxacin - 04:38 AM\n Vancomycin - 07:53 PM\n Piperacillin/Tazobactam (Zosyn) - 12:38 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:15 PM\n Heparin Sodium (Prophylaxis) - 12:38 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.6\n HR: 91 (74 - 102) bpm\n BP: 153/72(101) {88/43(59) - 164/77(109)} mmHg\n RR: 19 (16 - 28) insp/min\n SpO2: 20%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,484 mL\n 753 mL\n PO:\n TF:\n 925 mL\n 274 mL\n IVF:\n 1,339 mL\n 299 mL\n Blood products:\n Total out:\n 1,604 mL\n 960 mL\n Urine:\n 1,604 mL\n 960 mL\n NG:\n Stool:\n Drains:\n Balance:\n 880 mL\n -207 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 491 (491 - 491) mL\n PS : 10 cmH2O\n RR (Set): 18\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 74\n PIP: 23 cmH2O\n Plateau: 18 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 20%\n ABG: 7.40/42/112/29/1\n Ve: 10.5 L/min\n PaO2 / FiO2: 280\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, diffuse\n expiratory wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, +1 pitting edema, cachectic \n / Radiology\n 320 K/uL\n 8.2 g/dL\n 135 mg/dL\n 1.1 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 22 mg/dL\n 104 mEq/L\n 140 mEq/L\n 24.8 %\n 20.3 K/uL\n [image002.jpg]\n 03:20 AM\n 03:42 AM\n 07:38 PM\n 07:53 PM\n 03:59 AM\n 04:15 AM\n 06:29 AM\n 03:07 PM\n 05:40 PM\n 02:50 AM\n WBC\n 15.8\n 21.5\n 24.4\n 20.3\n Hct\n 25.1\n 26.5\n 26.7\n 24.8\n Plt\n 288\n 301\n 306\n 320\n Cr\n 0.5\n 1.0\n 1.1\n TropT\n <0.01\n TCO2\n 25\n 24\n 27\n 27\n 28\n 27\n Glucose\n 158\n 121\n 135\n Other labs: PT / PTT / INR:14.0/29.4/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.0 mg/dL,\n Mg++:2.4 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with hypoxia and respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Given\n acute decompensation without a pre-intubation ABG, suspect a component\n of hypercarbic resp failure given MS changes & elevated serum bicarb.\n Will try to achieve a mild permissive hypercapnea. Failed PSV 2/10 PM\n primary respiratory acidosis.\n - sputum -> moderate H. flu, blood Cx pending; Urine legionella\n (received Levoflox x 1 in ED) neg\n - d/c Vanc, cont Zosyn for H. flu\n - MDI while intubated (pt with auto-PEEP), transition to nebs once\n extubated\n - attempt to wean from vent\n - mouthcare, HOB elevated\n .\n # Hypotension: Etiology unclear, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2months of prednisone use. Aggressive resuscitation with\n IVF, s/p 10L of IVF on initial presentation. Hypotension now resolved.\n - now off dopamine\n - bolus IVF for goal UOP goal >30cc/hr\n - Hydrocortisone 100mg q8hr (stress dose)\n - goal neutral fluid balance today\n .\n # Chest pain: Pt with recent NSTEMI who presented with hypoxia and was\n denying CP in ED. EKGs with sinus tach in 140s, LBBB and non-specific\n changes from baseline. First set of CE are negative though pt was\n reporting CP on arrival to ICU. Given the recent history, possible to\n have demand ischemia with tachycardia. Will monitor symptoms and cycle\n cardiac enzymes.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - cardiac enzymes negative x3\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg \n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s. However, unclear\n etiology to acute drop from baseline.\n - guiaic negative\n - hemolysis labs negative\n - maintain active type & screen\n - get rehab records\n - PPI and CVL,PIV, PICC for access\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative\n .\n # FEN: NPO for now, will consult nutrition for TFs\n - cont TFs\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, Right femoral line, left PICC (plan to d/c\n femoral line today)\n .\n # Code: FULL\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 05:16 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 01:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 442610,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: 6 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-14 00:00:00.000",
"description": "ICU Attending Note",
"row_id": 441438,
"text": "Clinician: Attending\n 70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n CXR hyperinflation, bilat pleural effu, left pleural opac: loc pleural\n effusion vs infiltrate, left lower lung zone infiltrate increased since\n yest.\n PS 0.4/8/5 RR 18 RSBI 56 7.32/47/91\n Exam sig for awake, opened eyes, responded to questions with head nod.\n Diffuse exp wheezing. Total PEEP 8 (with ePEEP 5). Right femoral line.\n Distant HS. Abd NABS, soft, NDNT. Extremities cachectic, petechial\n lesions, atrophied. LE pitting edema + bilat. Minimal resp\n secretions.\n BNP 2900 with prior 271.\n Meds: Insulin, hep sc, vanc/cipro/zosyn, ppi, asa, statin, hydrocort\n 100 IV q 8, versed 1, fentanyl 25, DA\n Severe COPD, pna, with elevated BNP in setting of hypovolemia suggests\n RV strain with cor pulmonale/pna/hypoxic vasoconstriction. Received\n >10L overnight, 6L in ED and 4L in MICU, minimal urine output.\n Plan:\n Add atrovent\n d/c fem line\n continue on zosyn/cipro/vanc until sputum cx obtain\n discuss with Dr \n Total time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-12 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 441152,
"text": "Chief Complaint: PNA, Resp Failure\n HPI:\n 70 y/o F with PMHx of severe COPD and recent NSTEMI who was transferred\n in from rehab due to increased SOB over the prior 3-4 days. This am,\n she was noted to have low sats in 70% which did not respond to nebs.\n Her sats came up with high flow O2 in the EMS. Pt denied any cough,\n increased sputum, chest pain or pedal edema. She was notably wheezey\n on presentation and was initially treated as COPD exacerbation.\n .\n In the ED, initial vs were: T 97.6 BP 146/70 HR 147 RR 20 Sats 96% on\n RA. Patient was given solumedrol 125mg, nebs & levofloxacin for LLL\n infiltrate seen on CXR. On re-evaluation, pt was lethargic and\n desatting into the 70s. Pt was intubated for respiratory failure and\n received ceftriaxone and vancomycin for presumed PNA. Pt was noted to\n have sbps in 80s peri-intubation and right femoral CVL was placed. Pt\n received a total of 6L of IVF and HR trended down to 90s. Pt had a\n Tmax of 103.8 in the ED, though lactate was normal at 1.7. On transfer,\n pt was on versed/fentanyl and dopamine to maintain SBPs.\n .\n On arrival, pt was intubated and sedated though following commands.\n She reported some chest pain but was otherwise comfortable and sating\n 100% on the vent.\n .\n Review of sytems: unable to obtain\n .\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 PM\n Ciprofloxacin - 04:30 PM\n Infusions:\n Dopamine - 3 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 04:00 PM\n Other medications:\n Home medications:\n Aspirin 81mg\n Atorvastatin 40mg\n Xopenex prn\n Tiotropium Daily\n Advair \n Alendronate 70mg weekly\n Colace \n Senna prn\n Mucomyst inhaled\n Vitamin B12\n diltiazem 120mg daily\n Prednisone 10mg daily\n Ativan prn\n Robitussin prn\n Past medical history:\n Family history:\n Social History:\n COPD with severe obstructive defect\n HTN\n CAD s/p NSTEMI\n Carotid Stenosis\n PVD: aortoileac disease, followed by Dr. \n Osteoporosis\n Depression/Anxiety\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Pt has been living in rehab since recent discharge. Smoked for\n about 30 pack years and quit 15yrs ago.\n Flowsheet Data as of 05:38 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 101 (93 - 115) bpm\n BP: 126/64(85) {126/64(85) - 126/64(85)} mmHg\n RR: 17 (14 - 17) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 60 Inch\n Total In:\n 7,377 mL\n PO:\n TF:\n IVF:\n 1,377 mL\n Blood products:\n Total out:\n 0 mL\n 360 mL\n Urine:\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 7,017 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 36 cmH2O\n Plateau: 23 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 96%\n ABG: 7.28/55/75//-1\n Ve: 7.7 L/min\n PaO2 / FiO2: 150\n Physical Examination\n Vitals: T: 97.5 BP: 103/51 P: 99 R: 14 Sats 100% on AC 500/5/14/100%\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, diffuse\n expiratory wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, +1 pitting edema\n Labs / Radiology\n 316 K/uL\n 8.7 g/dL\n 27.6 %\n 19.1 K/uL\n [image002.jpg]\n \n 2:33 A2/8/ 04:47 PM\n \n 10:20 P2/8/ 05:06 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 19.1\n Hct\n 27.6\n Plt\n 316\n TC02\n 27\n Other labs: Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0\n %, Lactic Acid:1.0 mmol/L\n Fluid analysis / Other labs: Lactate:1.7\n .\n Trop-T: 0.01 CK: 28 MB: Notdone\n .\n 138 93 16 188 AGap=13\n --------------\n 4.5 37 0.5\n .\n proBNP: 2952\n .\n WBC 17.0 Hgb 11.2 Hct 34.8 Plts 425 D\n N:89 Band:3 L:5 M:3 E:0 Bas:0\n Hypochr: 2+ Anisocy: 1+ Macrocy: 1+ Polychr: 2+ Stipple: 2+\n Plt-Est: Normal\n .\n PT: 13.6 PTT: 24.4 INR: 1.2\n Imaging: CXR portable reveals left lower lobe hazy opacities\n with blurring of L heart border and R costo phrenic angle opacities\n .\n EKG: sinus tach at 140s with LBBB, no appreciable discordance though\n slightly different from prior tracings\n .\n Repeat EKG at 3pm with sinus rhythm at 100, incomplete LBBB, left\n atrial abnormality, low voltage in limb leads, non-specific lateral\n ST-T wave changes\n .\n ECHO : Suboptimal image quality. Normal left ventricular cavity\n size with mild regional systolic dysfunction most c/w CAD. Mild mitral\n regurgitation. Compared with the prior study (Images reviewed) of\n , the wall motion abnormalities are more extensive (mid-septal\n hypokinesis was suggested on review of the prior study).\n .\n Microbiology: Micro: Urine, Blood pending\n Sputum prelim + 4 PLEOMORPHIC GRAM NEGATIVE COCCOBACILLI.\n Assessment and Plan\n 70 y/o F with severe COPD who presents with hypoxia and respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Given\n acute decompensation without a pre-intubation ABG, suspect a component\n of hypercarbic resp failure given MS changes & elevated serum bicarb.\n Repeat ABG 7.28/55/75 on 40% FiO2, 500/5. Awaiting repeat lytes, will\n try to achieve a mild permissive hypercapnea\n - f/u sputum, blood Cx , Urine legionella (received Levoflox x 1 in ED)\n - broad spectrum Abx with Vanc, Zosyn & Cipro (double coverage for\n pseudomonas until Cx back)\n - Xopenex nebs\n - stress dose hydrocortisone 100mg q8hr\n - aggressive IVFs\n - continue Vent on AC for now, attempt to wean overnight (PS trial)\n - RSBI in am\n - mouthcare, HOB, PPI\n .\n # Hypotension: Etiology unclear, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2months of prednisone use. Aggressive resuscitation with\n IVF, now s/p 7L of IVF\n - bolus IVF for goal UOP goal >30cc/hr\n - art line to be placed\n - wean pressors\n - Hydrocortisone 100mg q8hr (stress dose)\n .\n # Chest pain: Pt with recent NSTEMI who presented with hypoxia and was\n denying CP in ED. EKGs with sinus tach in 140s, LBBB and non-specific\n changes from baseline. First set of CE are negative though pt was\n reporting CP on arrival to ICU. Given the recent history, possible to\n have demand ischemia with tachycardia. Will monitor symptoms and cycle\n cardiac enzymes.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - cycle cardiac enzymes\n - continue to monitor on telemetry, follow EKGs\n - start metoprolol 12.5mg for HR>110s\n .\n # Hct drop: Baseline hct in high 30s, down to 27 after 7L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s. However, unclear\n etiology to acute drop from baseline.\n - guaic now, add on hemolysis labs\n - maintain active type & screen\n - get rehab records\n - PPI and CVL,PIV, PICC for access\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - contine Zosyn/Cipro as above\n - f/u urine cultures\n .\n # FEN: NPO for now, will consult nutrition for TFs\n - nutrition consult for TF\n - bolus IVF prn\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, Right femoral line, left PICC (plan to d/c\n femoral line in am)\n .\n # Code: FULL\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition: Nutrition consult for TFs\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 01:30 PM\n PICC Line - 01:30 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 04:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 442660,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: 6 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont intub with OETT and on mech vent as per Metavision.\n Lung sounds ess clear after suct mod bld tinged sput. MDI and SVN given\n as per order. Pt in NARD on PSV; no vent changes required overnoc. Cont\n PSV/? OR for trach and peg today.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441728,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Pt\ns , \n, called this morning. Stated pt is w/o much\n family and believes she is the next of , but is not her HCP. Pt is\n not married, nor does she have any children.\n Edema, peripheral\n Assessment:\n General anasarca TBB +12, urine light colored qs\n Action:\n Monitor urine out, vs and gave skin care to skin tears on right arm and\n foot, drsg for mod sang. Drainage from stick sites\n Response:\n Stable with adequate output of over 50 cc hr\n Plan:\n Consider lasix, change drsg least 1 day or more as needed for\n drainage\n Impaired Skin Integrity\n Assessment:\n Skin tears healing on right arm and right leg, buttocks red in peri\n area and coccyx, barrier cream on\n Action:\n Drsg . Replaced with adaptic and kerlix\n Response:\n Healing wounds\n Plan:\n Daily and prn drsg to . Compression stocking off for the\n night\n Respiratory failure, acute (not ARDS/)\n Assessment:\n No vent sets changes, thick tan mucous suctioned, bronchospastic, min.\n oral secretions, vanco dc, cont. pipercillin\n Action:\n No changes in vent. Cont. pulm supportive care, oral care\n Response:\n Cont. need for vent support.\n Plan:\n Supportive care, wean to extubate if possible or discuss trach with\n neice and pt\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441782,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Pt\ns , \n, called this morning. Stated pt is w/o much\n family and believes she is the next of , but is not her HCP. Pt is\n not married, nor does she have any children.\n Edema, peripheral\n Assessment:\n General anasarca TBB +12, urine light colored qs\n Action:\n Monitor urine out, vs and gave skin care to skin tears on right arm and\n foot, drsg for mod sang. Drainage from stick sites\n Response:\n Stable with adequate output of over 50 cc hr\n Plan:\n Consider lasix, change drsg least 1 day or more as needed for\n drainage\n Impaired Skin Integrity\n Assessment:\n Skin tears healing on right arm and right leg, buttocks red in peri\n area and coccyx, barrier cream on\n Action:\n Drsg . Replaced with adaptic and kerlix\n Response:\n Healing wounds\n Plan:\n Daily and prn drsg to . Compression stocking off for the\n night\n Respiratory failure, acute (not ARDS/)\n Assessment:\n No vent sets changes, thick tan mucous suctioned, bronchospastic, min.\n oral secretions, vanco dc, cont. pipercillin\n Action:\n No changes in vent. Cont. pulm supportive care, oral care\n Response:\n Cont. need for vent support.\n Plan:\n Supportive care, wean to extubate if possible or discuss trach with\n neice and pt\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.1 this am phos 2.5, noted to HO\n Action:\n Discussed and awaiting orders for repletion of K+ sliding scale for\n phos\n Response:\n No able to assess\n Plan:\n Monitor K+ after repletion.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 441788,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - t/b with Dr. regarding recs for trach\n - fem line d/c\n - tolerated PSV 10 PEEP 8\n - back on AC 50%/500/18/8 overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:00 PM\n Ciprofloxacin - 04:38 AM\n Vancomycin - 07:53 PM\n Piperacillin/Tazobactam (Zosyn) - 11:50 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:27 PM\n Midazolam (Versed) - 11:28 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.4\nC (97.6\n HR: 99 (75 - 108) bpm\n BP: 142/81(100) {79/40(53) - 180/81(116)} mmHg\n RR: 20 (13 - 32) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,407 mL\n 433 mL\n PO:\n TF:\n 969 mL\n 274 mL\n IVF:\n 1,048 mL\n 99 mL\n Blood products:\n Total out:\n 3,095 mL\n 450 mL\n Urine:\n 3,095 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -688 mL\n -17 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 457 (457 - 555) mL\n PS : 10 cmH2O\n RR (Set): 18\n PEEP: 8 cmH2O\n RSBI: 63\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 95%\n ABG: 7.39/50/103/32/3\n Ve: 9.9 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, diffuse\n expiratory wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, +1 pitting edema, cachectic \n / Radiology\n 302 K/uL\n 7.9 g/dL\n 107 mg/dL\n 1.2 mg/dL\n 32 mEq/L\n 3.1 mEq/L\n 30 mg/dL\n 106 mEq/L\n 146 mEq/L\n 24.1 %\n 17.4 K/uL\n [image002.jpg]\n 07:38 PM\n 07:53 PM\n 03:59 AM\n 04:15 AM\n 06:29 AM\n 03:07 PM\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n WBC\n 21.5\n 24.4\n 20.3\n 17.4\n Hct\n 26.5\n 26.7\n 24.8\n 24.1\n Plt\n 02\n Cr\n 1.0\n 1.1\n 1.2\n TCO2\n 24\n 27\n 27\n 28\n 27\n 31\n Glucose\n 121\n 135\n 107\n Other labs: PT / PTT / INR:14.2/29.8/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n y/o F with severe COPD who presents with hypoxia and respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Given\n acute decompensation without a pre-intubation ABG, suspect a component\n of hypercarbic resp failure given MS changes & elevated serum bicarb.\n Will try to achieve a mild permissive hypercapnea. Failed PSV 2/10 PM\n primary respiratory acidosis.\n - sputum -> moderate H. flu, blood Cx pending; Urine legionella\n (received Levoflox x 1 in ED) neg\n - d/c Vanc, cont Zosyn for H. flu\n - MDI while intubated (pt with auto-PEEP), transition to nebs once\n extubated\n - unlikely to be weaned from vent soon, will consider trach -> will d/w\n pt/family/Dr. \n - goal 1L neg today\n - mouthcare, HOB elevated\n .\n # Hypotension: Etiology unclear, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2months of prednisone use. Aggressive resuscitation with\n IVF, s/p 10L of IVF on initial presentation. Hypotension now resolved.\n - now off dopamine\n - Hydrocortisone 100mg q8hr (stress dose)\n - goal 1L neg today\n .\n # Chest pain: Pt with recent NSTEMI who presented with hypoxia and was\n denying CP in ED. EKGs with sinus tach in 140s, LBBB and non-specific\n changes from baseline. First set of CE are negative though pt was\n reporting CP on arrival to ICU. Given the recent history, possible to\n have demand ischemia with tachycardia. Will monitor symptoms and cycle\n cardiac enzymes.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - cardiac enzymes negative x3\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg \n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s. However, unclear\n etiology to acute drop from baseline.\n - guiaic negative\n - hemolysis labs negative\n - maintain active type & screen\n - get rehab records\n - PPI and CVL,PIV, PICC for access\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative\n .\n # FEN: NPO for now, will consult nutrition for TFs\n - cont TFs\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, Right femoral line, left PICC (plan to d/c\n femoral line today)\n .\n # Code: FULL\n .\n # Disposition: pending above\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 05:07 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Arterial Line - 01:50 AM\n 20 Gauge - 01:36 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 441145,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441147,
"text": "70 y/o F with PMHx of severe COPD and recent NSTEMI who was transferred\n in from rehab with increased SOB over the prior 3-4 days. This am, she\n was noted to have low sats to 70% which did not respond to nebs. Her\n sats came up with high flow O2 in the EMS. Pt denied any cough,\n increased sputum, chest pain or pedal edema. She was notably wheezey\n on presentation and was initially treated as COPD exacerbation.\n .\n In the ED, initial vs were: T 97.6 BP 146/70 HR 147 RR 20 Sats 96% on\n RA. Patient was given solumedrol 125mg, nebs & levofloxacin for LLL\n infiltrate seen on CXR. On re-evaluation, pt was lethargic and\n desatting into the 70s. Pt was intubated for respiratory failure and\n received ceftriaxone and vancomycin for presumed PNA. Pt was noted to\n have sbps in 80s peri-intubation and received a total of 6L of IVF. Pt\n had a Tmax of 103.8 in the ED, though lactate was normal at 1.7. Pt\n was transferred to the ICU on versed/fentanyl and dopamine to maintain\n SBPs.\n .\n On arrival, pt was intubated and sedated though following commands.\n She reported some chest pain but was otherwise comfortable and sating\n 100% on the vent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt\ns LS\ns clear in upper airway, diminished at bases. Vented on AC\n 500x14, FiO2 40%, PEEP 5. O2 sat 94-97%. ABG 7.27-55-75-21.\n Suctioned for large amounts of thick tan secretions. Sputum, urine,\n blood cultures sent in ED (including a set off of PICC line). Pt\n easily arousable and following commands, becoming anxious at times and\n reaching for ETT.\n Action:\n Pt\ns O2 weaned to 40% from 100%. Pt sedated with boluses of fentanyl\n and versed with fair effect. Rec\nd cipro and zosyn for treatment of\n pna and will continue on vancomycin.\n Response:\n Pt O2 sat 97% on current vent settings. Pt appears comfortable on\n ventilator at this time.\n Plan:\n Cont to monitor resp status. Consider continuous infusion of sedation\n if needed.\n Sepsis without organ dysfunction\n Assessment:\n Pt hypotensive in the ED requiring fluid boluses and initiation of\n dopamine drip which is currently infusing at 2mcg/kg/min. U/o\n 35-85cc/hour. PM HCT 27.6.\n Action:\n Aline placed on arrival to unit. Attempted to wean dopamine off after\n pt rec\nd add\nl 1L NS fluid bolus, but required restart for persistent\n hypotension. T&S sent to blood bank.\n Response:\n ABP 90\ns-100\ns/50\ns with MAP >60 on current dose of dopamine. U/O\n adequate.\n Plan:\n Cont to attempt to wean dopamine. Monitor labs, my need transfusion of\n PRBC in order to wean dopamine.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441149,
"text": "70 y/o F with PMHx of severe COPD and recent NSTEMI who was transferred\n in from rehab with increased SOB over the prior 3-4 days. This am, she\n was noted to have low sats to 70% which did not respond to nebs. Her\n sats came up with high flow O2 in the EMS. Pt denied any cough,\n increased sputum, chest pain or pedal edema. She was notably wheezey\n on presentation and was initially treated as COPD exacerbation.\n .\n In the ED, initial vs were: T 97.6 BP 146/70 HR 147 RR 20 Sats 96% on\n RA. Patient was given solumedrol 125mg, nebs & levofloxacin for LLL\n infiltrate seen on CXR. On re-evaluation, pt was lethargic and\n desatting into the 70s. Pt was intubated for respiratory failure and\n received ceftriaxone and vancomycin for presumed PNA. Pt was noted to\n have sbps in 80s peri-intubation and received a total of 6L of IVF. Pt\n had a Tmax of 103.8 in the ED, though lactate was normal at 1.7. Pt\n was transferred to the ICU on versed/fentanyl and dopamine to maintain\n SBPs.\n .\n On arrival, pt was intubated and sedated though following commands.\n She reported some chest pain but was otherwise comfortable and sating\n 100% on the vent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt\ns LS\ns clear in upper airway, diminished at bases. Vented on AC\n 500x14, FiO2 40%, PEEP 5. O2 sat 94-97%. ABG 7.27-55-75-21.\n Suctioned for large amounts of thick tan secretions. Sputum, urine,\n blood cultures sent in ED (including a set off of PICC line). Pt\n easily arousable and following commands, becoming anxious at times and\n reaching for ETT.\n Action:\n Pt\ns O2 weaned to 40% from 100%. Pt sedated with boluses of fentanyl\n and versed with fair effect. Rec\nd cipro and zosyn for treatment of\n pna and will continue on vancomycin.\n Response:\n Pt O2 sat 97% on current vent settings. Pt appears comfortable on\n ventilator at this time.\n Plan:\n Cont to monitor resp status. Consider continuous infusion of sedation\n if needed.\n Sepsis without organ dysfunction\n Assessment:\n Pt hypotensive in the ED requiring fluid boluses and initiation of\n dopamine drip which is currently infusing at 2mcg/kg/min. U/o\n 35-85cc/hour. PM HCT 27.6.\n Action:\n Aline placed on arrival to unit. Attempted to wean dopamine off after\n pt rec\nd add\nl 1L NS fluid bolus, but required restart for persistent\n hypotension. T&S sent to blood bank.\n Response:\n ABP 90\ns-100\ns/50\ns with MAP >60 on current dose of dopamine. U/O\n adequate.\n Plan:\n Cont to attempt to wean dopamine. Monitor labs, my need transfusion of\n PRBC in order to wean dopamine.\n Alteration in Nutrition\n Assessment:\n Pt appears to be in a state of poor nutirition. BUN 10, crea 0.3\n Action:\n OGT placed in ED and confirmed in stomach by x-ray\n Response:\n Pending\n Plan:\n Start TF\ns and nutrition to be consulted in the am.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple areas of bruising on extremities with 2 skin tears\n noted, 1 to the right elbow and 1 to the right foot. + pedal\n edema. Stage 1 pressure ulcer noted to rt gluteal area.\n Action:\n Skin tears cleaned with NS and covered with adaptic. Rt foot skin tear\n draining small to moderate amounts of serosang drainage. Pt turned and\n repositioned.\n Response:\n Pending\n Plan:\n Continue to monitor for further areas of tearing or breakdown. Turn\n and reposition q2 hours.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441314,
"text": "70 y/o F with PMHx of severe COPD and recent NSTEMI who was transferred\n in from rehab with increased SOB over the prior 3-4 days. This am, she\n was noted to have low sats to 70% which did not respond to nebs. Her\n sats came up with high flow O2 in the EMS. Pt denied any cough,\n increased sputum, chest pain or pedal edema. She was notably wheezey\n on presentation and was initially treated as COPD exacerbation.\n .\n In the ED, initial vs were: T 97.6 BP 146/70 HR 147 RR 20 Sats 96% on\n RA. Patient was given solumedrol 125mg, nebs & levofloxacin for LLL\n infiltrate seen on CXR. On re-evaluation, pt was lethargic and\n desatting into the 70s. Pt was intubated for respiratory failure and\n received ceftriaxone and vancomycin for presumed PNA. Pt was noted to\n have sbps in 80s peri-intubation and received a total of 6L of IVF. Pt\n had a Tmax of 103.8 in the ED, though lactate was normal at 1.7. Pt\n was transferred to the ICU on versed/fentanyl and dopamine to maintain\n SBPs.\n .\n On arrival, pt was intubated and sedated though following commands.\n She reported some chest pain but was otherwise comfortable and sating\n 100% on the vent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n pt on CPAP 8/5 Fi0240% sat 94-97%. Suctioned for small to\n moderate amounts of thick tan secretions. Sputum, urine, blood\n cultures sent in ED .Pt easily arousable and following commands, pt\n anxious at times, requiring boluses of Versed/Fent HR 100-110\ns with\n agitation\n Action:\n Cont on Fent/Versed gtt.\n Response:\n Pt O2 sat 95 to 97% Pt appears comfortable on CPAP at this time.\n Plan:\n Cont to monitor resp status, wean as tolerated, cont with IV abx\n Sepsis without organ dysfunction\n Assessment:\n Pt off Dopamine since 2200 .Urinary output remains 35-40cc/hr,\n ABP\ns up in 160-170\ns this am\n Action:\n Pt started on Metoprolol 12.5mg q8 Pt bloused with 250NS for BP in 70\n to Fent bolus .\n Response:\n ABP 130\ns, waveform dampened at time/positional\n Plan:\n Continue monitoring BP, U/O.\n Alteration in Nutrition\n Assessment:\n Patient received on Pulmonary Nutren at 40 mls/hr water flushes 30\n mls q 8 hrs. Albumin low, with peripheral edema. Pt pulled OGT@ 1700,\n FBS range 250-150\n Action:\n TF on hold pending xray, will restart . covered with SSI\n Response:\n No residuals\n Plan:\n residuals, cont TF as ordered. Monitor FS.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple areas of bruising on extremities with 2 skin tears\n noted, 1 to the right elbow and 1 to the right foot. + pedal\n edema. Stage 1 pressure ulcer noted to rt gluteal area.\n Action:\n Skin tears cleaned with NS and covered with adaptic. Rt foot skin tear\n draining small to moderate amounts of serosang drainage. Pt turned and\n repositioned.\n Response:\n Pending\n Plan:\n Continue to monitor for further areas of tearing or breakdown. Turn\n and reposition q2 hours.\n Electrolyte & fluid disorder, other\n Assessment:\n .\n Action:\n Response:\n Plan:\n Continue monitoring labs, replete as per sliding scale.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441529,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Pt\ns , \n, called this morning. Stated pt is w/o much\n family and believes she is the next of , but is not her HCP. Pt is\n not married, nor does she have any children.\n Edema, peripheral\n Assessment:\n 2+-3+ edema to all 4 extremities. Pedal pulses palpable. Fluid\n balance running close to even at this time. UOP adequate.\n Action:\n Extremities elevated on pillows.\n Response:\n Plan:\n ? need for lasix for negative fluid balance goal, monitor closely.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to b/l apices, diminished to b/l bases. Rec\nd on CMV @ 40%/\n 400x14/5+. O2 sats 98-100%. Infreq sxn\ning for white thick sputum.\n Action:\n Switched to PS of +/40% this afternoon\n Response:\n Sats on PS 96-98%, RR 20s-mid 30s, MV 9.1, TV high 200s-400. ABG\n drawn- increasingly acidotic 7.28/58/93- team aware. Placed back on\n CMV 40%/18x400/5+.\n Plan:\n Cont to wean vent as tolerated, MDIs/neb txs\n Sepsis without organ dysfunction\n Assessment:\n Pt cont off of pressors, ABP 90s-160s systolic. Afebrile, but w/ a\n slightly increased wbc. Cont on 25mcg fent and 2mg versed.\n Action:\n Lopressor increased to 25mg po..but held this afternoon for SBP in the\n 90s. Given aspirin and high dose steroids . Cefepime d/c\nd, but cont\n on vanco and zosyn. Cxs neg to date.\n Response:\n No change.\n Plan:\n Cont to monitor labs, blood sugars, monitor BP and UOP closely, f/u on\n cx\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443873,
"text": "70 y/o woman with severe COPD who initially presented with acute\n hypoxic respiratory failure. Her course in the MICU has been c/b fevers\n with +leukocytosis most likely r/t vap. She was briefly extubated on\n and reintubated the following day for hypoxia and hypercarbia.\n A bedside trach/peg was performed on without incident\n EVENTS\n..screened for rehab, received lasix 20mgs aim neg balance 2l,\n D/C vanc, OOB with PT, feed recommenced via new PEG tube\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on p/s 5/s5 via new trach TV at 450 sats @ 94-97@, sx fo0r\n blood tinged secretions, lungs relatively clear\n Action:\n Patient received 20mgs lasix for overall pos balance ans commenced on\n klonipin po for anxiety\n Response:\n Patient 1l neg for the day [ aim is 2l] patient calm co-operative this\n afternoon and went to trach mask at 1600hrs for which she is tolerating\n well with stas @ 98% RR 15-20\n Plan:\n Continue trach mask as tolerated ? back to P/S for overnight ? to\n receive further dose lasix for neg balance\n Impaired Skin Integrity\n Assessment:\n Numerous skin tears LUE, inner thighs, RT /LT lower extrems, red\n sacrum\n.received on kinair bed\n Action:\n All dressings re-done with adpatic/sofsorb, barrier cream to sacrum\n Response:\n Re-done this pm\n Plan:\n Await wound care review, new waffle boots applied, frequent\n re-positioning turns/skin care/kinair\n Alteration in Nutrition\n Assessment:\n Patient received with PEG to gravity, meds only as per CT\n Action:\n Patient remained NPO for 24hrs as instructed, then commenced feed at\n 1700hrs\n Response:\n Commenced at 20cc/hr with flush q6, check residuals q4\n Plan:\n Increase feed as tolerated to total of 40cc hr checking residuals q6\n"
},
{
"category": "Rehab Services",
"chartdate": "2158-03-01 00:00:00.000",
"description": "PMV Evaluation",
"row_id": 444007,
"text": "TITLE: PMV Consult\nWe received consult and arrived to unit this pm. Patient was\nplaced back on the vent and is actively leaving for rehab at this\ntime. Recommend Passy-Muir Speaking Valve (PMV) evaluation be\nperformed at rehab as appropriate.\n"
},
{
"category": "Nursing",
"chartdate": "2158-03-01 00:00:00.000",
"description": "Generic Note",
"row_id": 443915,
"text": "TITLE:\n Events : IV Lasix 20 mgs given at midnight .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient on Trach mask sats @ 94-97@, sx for copious to\n moderate blood tinged thin secretions, lungs rhonchorous to clear\n with diminished bases.\n Action:\n Patient received 20mgs iv lasix after midnight to improve urine output\n as BP remained WNL. Achieved a negative balance of 2314 mls by 2300\n hrs- Patient connected back to CPAP on the vent overnight.\n Response:\n Diuresing well post Lasix.\n Plan:\n Will continue with trach mask in am as tolerated.\n Impaired Skin Integrity\n Assessment:\n Numerous skin tears LUE, inner thighs, RT /LT lower extrems, red\n sacrum\n.received on kinair bed\n Action:\n All dressings re-done with adpatic/sofsorb, barrier cream to sacrum.\n Patient wanted the waffle boots off for the night, BLE elevated &\n cushioned on soft pillows.\n Response:\n Dressings changed this am.\n Plan:\n Await wound care review, continue with waffle bootsas tolerated,\n frequent re-positioning turns/skin care/kinair\n Alteration in Nutrition\n Assessment:\n Patient received with PEG tube , feeds with Nutren Pulmonary @ 20\n mls/hr.\n Action:\n Feeds increased to 30 mls/hr, Goal rate of 40 mls/hr.\n Response:\n check residuals q4\n Plan:\n Increase feed as tolerated to total of 40cc hr ,checking residuals q4\n"
},
{
"category": "General",
"chartdate": "2158-03-01 00:00:00.000",
"description": "Generic Note",
"row_id": 443984,
"text": "TITLE: Critical Care\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan.\n 2+L diuresis overnight.\n More alert, comfortable, breathing on trache collar.\n Gradually weaning prednisone down to 10 mg\n Completing 14 d course of abx\n Has bed at rehab\n Time spent 30 min\n"
},
{
"category": "Nursing",
"chartdate": "2158-03-01 00:00:00.000",
"description": "Generic Note",
"row_id": 443954,
"text": "TITLE:\n Events : IV Lasix 20 mgs given at midnight .\n K+ 3.7 in am labs, started 20 meq KCL in 50 mls over 1 hour.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient on Trach mask sats @ 94-97@, sx for copious to\n moderate blood tinged thin secretions, lungs rhonchorous to clear\n with diminished bases.\n Action:\n Patient received 20mgs iv lasix after midnight to improve urine output\n as BP remained WNL. Achieved a negative balance of 2314 mls by 2300\n hrs- Patient connected to CPAP on the vent overnight, changed back to\n Trach mask in am.\n Response:\n Diuresing well post Lasix.\n Plan:\n Will continue with trach mask in am as tolerated.\n Impaired Skin Integrity\n Assessment:\n Numerous skin tears LUE, inner thighs, RT /LT lower extrems, red\n sacrum\n.received on kinair bed\n Action:\n All dressings re-done with adpatic/sofsorb, barrier cream to sacrum.\n Patient wanted the waffle boots off for the night, BLE elevated &\n cushioned on soft pillows.\n Response:\n Dressings changed this am.\n Plan:\n Await wound care review, continue with waffle boots as tolerated,\n frequent re-positioning turns/skin care/kinair\n Alteration in Nutrition\n Assessment:\n Patient received with PEG tube , feeds with Nutren Pulmonary @ 20\n mls/hr.\n Action:\n Feeds increased to Goal rate of 40 mls/hr.\n Response:\n At Goal. check residuals q4\n Plan:\n Monitor residuals q4.\n"
},
{
"category": "Physician ",
"chartdate": "2158-03-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443957,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n d/ced vanco\n given IV lasix 20 x3\n tapered prednisone from 20 to 10mg PO daily\n started clonazepam standing\n successful of trach mask\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 10:14 AM\n Vancomycin - 03:05 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:49 AM\n Furosemide (Lasix) - 12:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.6\nC (97.9\n HR: 85 (69 - 98) bpm\n BP: 123/45(63) {91/41(54) - 158/70(90)} mmHg\n RR: 15 (12 - 19) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 56.7 kg (admission): 60.5 kg\n Height: 67 Inch\n Total In:\n 885 mL\n 599 mL\n PO:\n TF:\n 185 mL\n 231 mL\n IVF:\n 451 mL\n 118 mL\n Blood products:\n Total out:\n 3,115 mL\n 975 mL\n Urine:\n 3,115 mL\n 975 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,230 mL\n -376 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: Standby\n Vt (Spontaneous): 315 (315 - 419) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 10 cmH2O\n SpO2: 97%\n ABG: ///40/\n Ve: 5.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 422 K/uL\n 10.3 g/dL\n 95 mg/dL\n 0.5 mg/dL\n 40 mEq/L\n 3.7 mEq/L\n 15 mg/dL\n 92 mEq/L\n 139 mEq/L\n 31.1 %\n 15.3 K/uL\n [image002.jpg]\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n 03:54 AM\n 03:56 AM\n 04:00 AM\n 03:05 AM\n WBC\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n 19.7\n 15.9\n 15.7\n 15.3\n Hct\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n 28.7\n 30.0\n 30.3\n 31.1\n Plt\n 10\n 422\n Cr\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n 0.5\n 0.5\n 0.5\n 0.5\n Glucose\n 76\n 72\n 135\n 79\n 70\n 90\n 82\n 81\n 95\n Other labs: PT / PTT / INR:13.8/35.1/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.2 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:1.8 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:04 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-03-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443958,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n d/ced vanco\n given IV lasix 20 x3\n tapered prednisone from 20 to 10mg PO daily\n started clonazepam standing\n successful of trach mask\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 10:14 AM\n Vancomycin - 03:05 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:49 AM\n Furosemide (Lasix) - 12:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.6\nC (97.9\n HR: 85 (69 - 98) bpm\n BP: 123/45(63) {91/41(54) - 158/70(90)} mmHg\n RR: 15 (12 - 19) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 56.7 kg (admission): 60.5 kg\n Height: 67 Inch\n Total In:\n 885 mL\n 599 mL\n PO:\n TF:\n 185 mL\n 231 mL\n IVF:\n 451 mL\n 118 mL\n Blood products:\n Total out:\n 3,115 mL\n 975 mL\n Urine:\n 3,115 mL\n 975 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,230 mL\n -376 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: Standby\n Vt (Spontaneous): 315 (315 - 419) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 10 cmH2O\n SpO2: 97%\n ABG: ///40/\n Ve: 5.6 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic, new trach in place, slight\n amount of dried blood, otherwise clean\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished: ),\n mild rhonchi diffusedly\n Abdominal: Soft, Non-tender, ND, no hsm, normoactive BS\n Extremities: Right: 2+, Left: 2+, significant BLE edema with skin\n weeping\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, interactive appropriately, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 422 K/uL\n 10.3 g/dL\n 95 mg/dL\n 0.5 mg/dL\n 40 mEq/L\n 3.7 mEq/L\n 15 mg/dL\n 92 mEq/L\n 139 mEq/L\n 31.1 %\n 15.3 K/uL\n [image002.jpg]\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n 03:54 AM\n 03:56 AM\n 04:00 AM\n 03:05 AM\n WBC\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n 19.7\n 15.9\n 15.7\n 15.3\n Hct\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n 28.7\n 30.0\n 30.3\n 31.1\n Plt\n 10\n 422\n Cr\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n 0.5\n 0.5\n 0.5\n 0.5\n Glucose\n 76\n 72\n 135\n 79\n 70\n 90\n 82\n 81\n 95\n Other labs: PT / PTT / INR:13.8/35.1/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.2 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:1.8 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:04 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-03-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443959,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n d/ced vanco\n given IV lasix 20 x3\n tapered prednisone from 20 to 10mg PO daily\n started clonazepam standing\n successful of trach mask\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 10:14 AM\n Vancomycin - 03:05 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:49 AM\n Furosemide (Lasix) - 12:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.6\nC (97.9\n HR: 85 (69 - 98) bpm\n BP: 123/45(63) {91/41(54) - 158/70(90)} mmHg\n RR: 15 (12 - 19) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 56.7 kg (admission): 60.5 kg\n Height: 67 Inch\n Total In:\n 885 mL\n 599 mL\n PO:\n TF:\n 185 mL\n 231 mL\n IVF:\n 451 mL\n 118 mL\n Blood products:\n Total out:\n 3,115 mL\n 975 mL\n Urine:\n 3,115 mL\n 975 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,230 mL\n -376 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: Standby\n Vt (Spontaneous): 315 (315 - 419) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 10 cmH2O\n SpO2: 97%\n ABG: ///40/\n Ve: 5.6 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic, new trach in place, slight\n amount of dried blood, otherwise clean\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished: ),\n mild rhonchi diffusedly\n Abdominal: Soft, Non-tender, ND, no hsm, normoactive BS\n Extremities: Right: 2+, Left: 2+, significant BLE edema with skin\n weeping\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, interactive appropriately, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 422 K/uL\n 10.3 g/dL\n 95 mg/dL\n 0.5 mg/dL\n 40 mEq/L\n 3.7 mEq/L\n 15 mg/dL\n 92 mEq/L\n 139 mEq/L\n 31.1 %\n 15.3 K/uL\n [image002.jpg]\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n 03:54 AM\n 03:56 AM\n 04:00 AM\n 03:05 AM\n WBC\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n 19.7\n 15.9\n 15.7\n 15.3\n Hct\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n 28.7\n 30.0\n 30.3\n 31.1\n Plt\n 10\n 422\n Cr\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n 0.5\n 0.5\n 0.5\n 0.5\n Glucose\n 76\n 72\n 135\n 79\n 70\n 90\n 82\n 81\n 95\n Other labs: PT / PTT / INR:13.8/35.1/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.2 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:1.8 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Patient was started on vanc/zosyn. Vanc was d/c\ned once\n it was growth was gram negative. Zosyn was changed to ceftriaxone when\n speciated to H. flu beta-lactamase negative. Patient completed \n day course of HAP and steroid taper when patient passed SBT and was\n extubated. Patient remained extubated for 12 hours and developed sinus\n tachycardia (in the setting of beta blocker withdrawl), tachypnea,\n accessory muscle use and desaturation to low 90s. Patient was given\n trial of nebs and CPAP, patient continued to retain CO2 and patient was\n intubated on . Patient has very poor respiratory reserve and will\n require long-term trach.\n - trach and peg placed , in place and doing well\n - did not tolerate trach mask trial secondary to anxiety and feeling\n SOB, will continue with PS 5/5 and do trials as tolerated\n - s/p ceftriaxone course for h.flu; now being treating for pseudomonas\n with -> 2 week course from , plan on switching to\n meropenem 1 gm q 8 hr when goes to rehab\n - stopped vanco today\n - continue prednisone, now on 30 mg from 40 mg, and will continue\n taper; goal to get to 10 mg for baseline and continue on 10 for the\n long term\n - mouthcare, HOB elevated\n .\n # Leukocytosis / Fever\n has now resolved with treatment of presumed\n . developed 4 hours after reintubation. Patient was intubated\n uneventfully and patient was NPO 48 hours prior to procedure. Likely\n , pt improving with decreasing leukocytosis, has not spiked since\n \n - growing pseudomonas, to ; responding to doripenem and plan\n on continuing until transfer to rehab\n .\n # Anxiety\n has underlying anxiety, was receiving boluses of ativan as\n needed\n - adding clonapin for longer acting antianxietolytic\n .\n # HTN - running slightly hypertensive now that is resolving, could\n be secondary to anxiety vs. essential hypertension\n - added home dilt back on\n - captopril added as well, getting good effects, can titrate as needed\n .\n # Resolved ARF: Pre-renal from hypovolemia/sepsis, now improved.\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily\n - tolerated BB for rate control, but using dilt if we can due to\n potential bronchospastic properties\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF.\n Dropped over course of hospitalization, s/p transfusion again on ;\n now stabalized. Anemia likey from phlebotomy, chronic disease\n Transfused one unit PRBC , now stable\n - cont to trend\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # Osteopenia\n was on fosamax as outpatient, in setting of steroid use\n will start Ca/Vit D\n - Ca and Vit D supplementation for now\n - re-start fosamax when respiratory status starts to stabilize\n .\n # FEN: PEG placed, doing well, restarting TFs today after thoracic\n evaluates\n .\n # Prophylaxis: heparin sc BID, PPI\n .\n # Access: Left PIV 18 gauge, PICC\n .\n # Code: FULL\n .\n # Communication\n with patient and niece\n .\n # Disposition: case management aware of need for rehab planning\n - Social work consult placed , PT/OT c/s placed \n - Likely to rehab later this week\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:04 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n :\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 443391,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing,\n Accessory muscle use\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Remains on psv/cpap, tolerating t/out shift. Bronchodilators as\n ordered.\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 443453,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Cuff volume: 10 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Respiratory Care Shift Procedures\n Bedside Procedures: No morning abg results at this time. RSBI = 50 on\n 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443457,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - stopped cipro\n - NG tube replaced\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Vancomycin - 08:19 PM\n Metronidazole - 04:10 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:11 PM\n Pantoprazole (Protonix) - 04:29 PM\n Labetalol - 06:35 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.2\nC (97.2\n HR: 97 (75 - 135) bpm\n BP: 149/94(107) {111/47(63) - 188/94(108)} mmHg\n RR: 18 (13 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,012 mL\n 533 mL\n PO:\n TF:\n 682 mL\n 266 mL\n IVF:\n 900 mL\n 167 mL\n Blood products:\n Total out:\n 1,920 mL\n 750 mL\n Urine:\n 1,920 mL\n 750 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,092 mL\n -217 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 499 (412 - 537) mL\n PS : 8 cmH2O\n RR (Spontaneous): 19\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 17 cmH2O\n SpO2: 94%\n ABG: ///32/\n Ve: 10.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 381 K/uL\n 9.5 g/dL\n 90 mg/dL\n 0.5 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 102 mEq/L\n 138 mEq/L\n 28.7 %\n 19.7 K/uL\n [image002.jpg]\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n 03:54 AM\n WBC\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n 19.7\n Hct\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n 28.7\n Plt\n \n 301\n 381\n Cr\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n 0.5\n Glucose\n 160\n 102\n 106\n 76\n 72\n 135\n 79\n 70\n 90\n Other labs: PT / PTT / INR:13.7/28.5/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.2 g/dL, LDH:315 IU/L, Ca++:6.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:05 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443458,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - stopped cipro\n - NG tube replaced\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Vancomycin - 08:19 PM\n Metronidazole - 04:10 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:11 PM\n Pantoprazole (Protonix) - 04:29 PM\n Labetalol - 06:35 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.2\nC (97.2\n HR: 97 (75 - 135) bpm\n BP: 149/94(107) {111/47(63) - 188/94(108)} mmHg\n RR: 18 (13 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,012 mL\n 533 mL\n PO:\n TF:\n 682 mL\n 266 mL\n IVF:\n 900 mL\n 167 mL\n Blood products:\n Total out:\n 1,920 mL\n 750 mL\n Urine:\n 1,920 mL\n 750 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,092 mL\n -217 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 499 (412 - 537) mL\n PS : 8 cmH2O\n RR (Spontaneous): 19\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 17 cmH2O\n SpO2: 94%\n ABG: ///32/\n Ve: 10.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 381 K/uL\n 9.5 g/dL\n 90 mg/dL\n 0.5 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 102 mEq/L\n 138 mEq/L\n 28.7 %\n 19.7 K/uL\n [image002.jpg]\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n 03:54 AM\n WBC\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n 19.7\n Hct\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n 28.7\n Plt\n \n 301\n 381\n Cr\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n 0.5\n Glucose\n 160\n 102\n 106\n 76\n 72\n 135\n 79\n 70\n 90\n Other labs: PT / PTT / INR:13.7/28.5/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.2 g/dL, LDH:315 IU/L, Ca++:6.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Patient was started on vanc/zosyn. Vanc was d/c\ned once\n it was growth was gram negative. Zosyn was changed to ceftriaxone when\n speciated to H. flu beta-lactamase negative. Patient completed \n day course of HAP and steroid taper when patient passed SBT and was\n extubated. Patient remained extubated for 12 hours and developed sinus\n tachycardia (in the setting of beta blocker withdrawl), tachypnea,\n accessory muscle use and desaturation to low 90s. Patient was given\n trial of nebs and CPAP, patient continued to retain CO2 and patient was\n intubated on . Patient has very poor respiratory reserve and will\n require long-term trach.\n - patient to get Trach/PEG on Monday\n - continue prednisone 60mg PO and will taper to 40mg in tomorrow\n - mouthcare, HOB elevated\n .\n # Leukocytosis / Fever\n developed 4 hours after reintubation. Patient\n was intubated uneventfully and patient was NPO 48 hours prior to\n procedure. Differential includes VAP vs. aspiration PNA vs aspiration\n pneumonitis. Leukocytosis also in the setting diarrhea and prolonged\n hospitalization could be consistent with c diff.\n - f/u BC, UC, cdiff toxin, mini-BAL, and endobronchial\n aspirate cx (neg gram stain on mini BAL)\n - treating c diff with IV Flagyl and PO vanc , placed on\n contact precautions (started ), first c diff negative, if second\n negative, will stop tx for c diff\n - treating VAP with IV vanc, doripenem and cipro (started\n , cipro to dbl cover pseudomonas), will stop VAP abx on if\n cultures negative, sputum cx showing GNR, pending speciation\n - yeast in urine, if foley >3d old will change foley\n .\n # Tachycardia\n similar to previous, could be from infection or\n hypovolemia. Could also be MAT given resp problems. \n agents. Responded to fluid boluses .\n - Sinus tach on EKG \n - Fluid challenge PRN\n - Hold anti-HTN meds\n .\n # Resolved ARF: Pre-renal from hypovolemia/sepsis, now improved.\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg ; will consider changing as is possible to\n cause bronchospasm, could try diltiazem\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - will transfuse 1U PRBC today\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # Osteopenia\n was on fosamax as outpatient, in setting of steroid use\n will start Ca/Vit D\n - Ca and Vit D supplementation for now\n - re-start fosamax when respiratory status starts to stabilize\n .\n # FEN: cont TFs, 40cc/hr, running at goal, nutrition following,\n awaiting PEG\n .\n # Prophylaxis: heparin sc BID, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n .\n # Code: FULL\n .\n # Communication\n with patient and niece\n .\n # Disposition: case management aware of need for rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:05 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "General",
"chartdate": "2158-02-27 00:00:00.000",
"description": "Generic Note",
"row_id": 443633,
"text": "TITLE: Critical Care\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan.\n Alert, comfortable.\n Chest\n diffuse prolonged exhalation\n WBC\n down further to 16k\n No new cx data\n Trache today. She is still 23L pos LOS. Will weigh today. Check echo.\n Begin to try to diurese by accepting lower BP. benefit from lasix\n gtt. Will complete course of Dory and Vanco\n Time spent 35 min\n Critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443638,
"text": "Chief Complaint:\n 24 Hour Events:\n - d/c'ed c.diff antibiotics\n - plan for 7 day course of since last fever on \n - requested for her pseudomonas\n - plan for trach/peg on monday as add on\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Metronidazole - 10:14 AM\n Vancomycin - 08:51 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 05:03 PM\n Heparin Sodium (Prophylaxis) - 08:01 PM\n Lorazepam (Ativan) - 11:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.6\nC (96\n HR: 82 (73 - 116) bpm\n BP: 132/60(76) {106/44(61) - 181/84(107)} mmHg\n RR: 17 (14 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,439 mL\n 207 mL\n PO:\n TF:\n 959 mL\n 41 mL\n IVF:\n 1,050 mL\n 166 mL\n Blood products:\n Total out:\n 2,590 mL\n 550 mL\n Urine:\n 2,590 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -151 mL\n -343 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 545 (462 - 545) mL\n PS : 8 cmH2O\n RR (Spontaneous): 16\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 17 cmH2O\n SpO2: 97%\n ABG: ///34/\n Ve: 9 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic, intubated; not sedated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished: ),\n mild rhonchi diffusedly\n Abdominal: Soft, Non-tender, ND, no hsm, normoactive BS\n Extremities: Right: 2+, Left: 2+, significant BLE edema with skin\n weeping\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, interactive appropriately, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 391 K/uL\n 9.6 g/dL\n 82 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 16 mg/dL\n 101 mEq/L\n 139 mEq/L\n 30.0 %\n 15.9 K/uL\n [image002.jpg]\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n 03:54 AM\n 03:56 AM\n WBC\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n 19.7\n 15.9\n Hct\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n 28.7\n 30.0\n Plt\n \n \n Cr\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n 0.5\n 0.5\n Glucose\n 102\n 106\n 76\n 72\n 135\n 79\n 70\n 90\n 82\n Other labs: PT / PTT / INR:14.0/29.9/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.2 g/dL, LDH:315 IU/L, Ca++:7.9 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Patient was started on vanc/zosyn. Vanc was d/c\ned once\n it was growth was gram negative. Zosyn was changed to ceftriaxone when\n speciated to H. flu beta-lactamase negative. Patient completed \n day course of HAP and steroid taper when patient passed SBT and was\n extubated. Patient remained extubated for 12 hours and developed sinus\n tachycardia (in the setting of beta blocker withdrawl), tachypnea,\n accessory muscle use and desaturation to low 90s. Patient was given\n trial of nebs and CPAP, patient continued to retain CO2 and patient was\n intubated on . Patient has very poor respiratory reserve and will\n require long-term trach.\n - s/p ceftriaxone course for h.flu; now being treating for pseudomonas\n with vanc/ -> 2 week course from \n - patient to get Trach/PEG as add-on today\n - continue prednisone, now on 40 mg daily for the next three days, and\n will continue taper\n - mouthcare, HOB elevated\n .\n # Leukocytosis / Fever\n developed 4 hours after reintubation. Patient\n was intubated uneventfully and patient was NPO 48 hours prior to\n procedure. Likely , pt improving with decreasing leukocytosis, has\n not spiked since \n - f/u BC, UC, cdiff toxin, mini-BAL, and endobronchial\n aspirate cx (neg gram stain on mini BAL)\n - first c.diff neg, stopped c.diff treatment\n - treating for pseudomonas plus one other GNR yet to be\n speciated with Vanco and for now, awaiting speciations\n will\n treat 7 days since last fever\n - foley changed secondary to yeast\n .\n # Tachycardia\n similar to previous, could be from infection or\n hypovolemia or anxiety. Could also be MAT given resp problems. \n agents. Responded to fluid boluses , tachy with movement,\n when calm around 80s-90s.\n - Sinus tach on EKG \n - Fluid challenge PRN\n - Hold anti-HTN meds\n .\n # Resolved ARF: Pre-renal from hypovolemia/sepsis, now improved.\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily\n will discuss\n aspirin with thoracic team today.\n - continue to monitor on telemetry, follow EKGs\n - holding all agents at this time; afib responds to metoprolol if\n she goes into it, dilt did not work as well\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF.\n Dropped over course of hospitalization, s/p transfusion again on ;\n now stabalized. Anemia likey from phlebotomy, chronic disease\n Transfused one unit PRBC , on on \n - cont to trend\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # Osteopenia\n was on fosamax as outpatient, in setting of steroid use\n will start Ca/Vit D\n - Ca and Vit D supplementation for now\n - re-start fosamax when respiratory status starts to stabilize\n .\n # FEN: cont TFs, 40cc/hr, running at goal, nutrition following,\n awaiting PEG\n .\n # Prophylaxis: heparin sc BID, PPI\n .\n # Access: Left PIV 18 gauge, PICC\n .\n # Code: FULL\n .\n # Communication\n with patient and niece\n .\n # Disposition: case management aware of need for rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n :\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443459,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - stopped cipro\n - NG tube replaced\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Vancomycin - 08:19 PM\n Metronidazole - 04:10 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:11 PM\n Pantoprazole (Protonix) - 04:29 PM\n Labetalol - 06:35 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.2\nC (97.2\n HR: 97 (75 - 135) bpm\n BP: 149/94(107) {111/47(63) - 188/94(108)} mmHg\n RR: 18 (13 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,012 mL\n 533 mL\n PO:\n TF:\n 682 mL\n 266 mL\n IVF:\n 900 mL\n 167 mL\n Blood products:\n Total out:\n 1,920 mL\n 750 mL\n Urine:\n 1,920 mL\n 750 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,092 mL\n -217 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 499 (412 - 537) mL\n PS : 8 cmH2O\n RR (Spontaneous): 19\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 17 cmH2O\n SpO2: 94%\n ABG: ///32/\n Ve: 10.1 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished: )\n Abdominal: Soft, Non-tender\n Extremities: Right: 2+, Left: 2+, significant BLE edema with skin\n weeping\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 381 K/uL\n 9.5 g/dL\n 90 mg/dL\n 0.5 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 102 mEq/L\n 138 mEq/L\n 28.7 %\n 19.7 K/uL\n [image002.jpg]\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n 03:54 AM\n WBC\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n 19.7\n Hct\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n 28.7\n Plt\n \n 301\n 381\n Cr\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n 0.5\n Glucose\n 160\n 102\n 106\n 76\n 72\n 135\n 79\n 70\n 90\n Other labs: PT / PTT / INR:13.7/28.5/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.2 g/dL, LDH:315 IU/L, Ca++:6.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Patient was started on vanc/zosyn. Vanc was d/c\ned once\n it was growth was gram negative. Zosyn was changed to ceftriaxone when\n speciated to H. flu beta-lactamase negative. Patient completed \n day course of HAP and steroid taper when patient passed SBT and was\n extubated. Patient remained extubated for 12 hours and developed sinus\n tachycardia (in the setting of beta blocker withdrawl), tachypnea,\n accessory muscle use and desaturation to low 90s. Patient was given\n trial of nebs and CPAP, patient continued to retain CO2 and patient was\n intubated on . Patient has very poor respiratory reserve and will\n require long-term trach.\n - patient to get Trach/PEG on Monday\n - continue prednisone 60mg PO and will taper to 40mg in tomorrow\n - mouthcare, HOB elevated\n .\n # Leukocytosis / Fever\n developed 4 hours after reintubation. Patient\n was intubated uneventfully and patient was NPO 48 hours prior to\n procedure. Differential includes VAP vs. aspiration PNA vs aspiration\n pneumonitis. Leukocytosis also in the setting diarrhea and prolonged\n hospitalization could be consistent with c diff.\n - f/u BC, UC, cdiff toxin, mini-BAL, and endobronchial\n aspirate cx (neg gram stain on mini BAL)\n - treating c diff with IV Flagyl and PO vanc , placed on\n contact precautions (started ), first c diff negative, if second\n negative, will stop tx for c diff\n - treating VAP with IV vanc, doripenem and cipro (started\n , cipro to dbl cover pseudomonas), will stop VAP abx on if\n cultures negative, sputum cx showing GNR, pending speciation\n - yeast in urine, if foley >3d old will change foley\n .\n # Tachycardia\n similar to previous, could be from infection or\n hypovolemia. Could also be MAT given resp problems. \n agents. Responded to fluid boluses .\n - Sinus tach on EKG \n - Fluid challenge PRN\n - Hold anti-HTN meds\n .\n # Resolved ARF: Pre-renal from hypovolemia/sepsis, now improved.\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg ; will consider changing as is possible to\n cause bronchospasm, could try diltiazem\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - will transfuse 1U PRBC today\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # Osteopenia\n was on fosamax as outpatient, in setting of steroid use\n will start Ca/Vit D\n - Ca and Vit D supplementation for now\n - re-start fosamax when respiratory status starts to stabilize\n .\n # FEN: cont TFs, 40cc/hr, running at goal, nutrition following,\n awaiting PEG\n .\n # Prophylaxis: heparin sc BID, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n .\n # Code: FULL\n .\n # Communication\n with patient and niece\n .\n # Disposition: case management aware of need for rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:05 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443461,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit. Failure to wean with\n original plan to trach/PEG by IP. Pt did well on RSBI (score\n 50), and passed SBT so extubated at 1400. Patient reintubated at\n at 0200. Pt now awaiting Trach./PEG scheduled for Monday .\n EVENTS: CXR for NGT placement confirmation, and it is OK to use and TF\n started .\n Ativan 1mg at 0430hrs after dressing change\n SBP 110-140mmhg, no interventions\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient sitting on the chair, vented PSV 8/8 and O2 40%.\n Bilateral lung sounds rhonchorous and diminished bases. O2 sats 96-98%\n Action:\n No vent changes , suction PRN, MDI\ns as ordered\n Response:\n Stable overnight, moderate thick yellow secretions with suction\n Plan:\n Awaiting trach/PEG on Monday\n Impaired Skin Integrity\n Assessment:\n Multiple skin tear sites. Pt has very fragile skin secondary to\n chronic steroid use. Generalized edema throughout body.+2-+4mm. Skin\n weeping large amounts of serous/ serosanguinous fluid continueously.\n Left lower leg hematoma burst today causing skin tear.\n Action:\n Dressing changes as needed secondary to weeping, done at 0400\n Response:\n Weeping serosanguious fluid from multiple ares of broken skin ,\n patient refusing position changes some times\n Plan:\n Skin care consults on Monday. Frequent dressing changes to keep clean\n and dry\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443586,
"text": "Chief Complaint:\n 24 Hour Events:\n - d/c'ed c.diff antibiotics\n - plan for 7 day course of VAP since last fever on \n - requested for her pseudomonas\n - plan for trach/peg on monday as add on\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Metronidazole - 10:14 AM\n Vancomycin - 08:51 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 05:03 PM\n Heparin Sodium (Prophylaxis) - 08:01 PM\n Lorazepam (Ativan) - 11:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.6\nC (96\n HR: 82 (73 - 116) bpm\n BP: 132/60(76) {106/44(61) - 181/84(107)} mmHg\n RR: 17 (14 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,439 mL\n 207 mL\n PO:\n TF:\n 959 mL\n 41 mL\n IVF:\n 1,050 mL\n 166 mL\n Blood products:\n Total out:\n 2,590 mL\n 550 mL\n Urine:\n 2,590 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -151 mL\n -343 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 545 (462 - 545) mL\n PS : 8 cmH2O\n RR (Spontaneous): 16\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 17 cmH2O\n SpO2: 97%\n ABG: ///34/\n Ve: 9 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic, intubated; not sedated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished: ),\n mild rhonchi diffusedly\n Abdominal: Soft, Non-tender, ND, no hsm, normoactive BS\n Extremities: Right: 2+, Left: 2+, significant BLE edema with skin\n weeping\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, interactive appropriately, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 391 K/uL\n 9.6 g/dL\n 82 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 16 mg/dL\n 101 mEq/L\n 139 mEq/L\n 30.0 %\n 15.9 K/uL\n [image002.jpg]\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n 03:54 AM\n 03:56 AM\n WBC\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n 19.7\n 15.9\n Hct\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n 28.7\n 30.0\n Plt\n \n \n Cr\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n 0.5\n 0.5\n Glucose\n 102\n 106\n 76\n 72\n 135\n 79\n 70\n 90\n 82\n Other labs: PT / PTT / INR:14.0/29.9/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.2 g/dL, LDH:315 IU/L, Ca++:7.9 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443587,
"text": "Chief Complaint:\n 24 Hour Events:\n - d/c'ed c.diff antibiotics\n - plan for 7 day course of since last fever on \n - requested for her pseudomonas\n - plan for trach/peg on monday as add on\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Metronidazole - 10:14 AM\n Vancomycin - 08:51 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 05:03 PM\n Heparin Sodium (Prophylaxis) - 08:01 PM\n Lorazepam (Ativan) - 11:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.6\nC (96\n HR: 82 (73 - 116) bpm\n BP: 132/60(76) {106/44(61) - 181/84(107)} mmHg\n RR: 17 (14 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,439 mL\n 207 mL\n PO:\n TF:\n 959 mL\n 41 mL\n IVF:\n 1,050 mL\n 166 mL\n Blood products:\n Total out:\n 2,590 mL\n 550 mL\n Urine:\n 2,590 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -151 mL\n -343 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 545 (462 - 545) mL\n PS : 8 cmH2O\n RR (Spontaneous): 16\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 17 cmH2O\n SpO2: 97%\n ABG: ///34/\n Ve: 9 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic, intubated; not sedated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished: ),\n mild rhonchi diffusedly\n Abdominal: Soft, Non-tender, ND, no hsm, normoactive BS\n Extremities: Right: 2+, Left: 2+, significant BLE edema with skin\n weeping\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, interactive appropriately, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 391 K/uL\n 9.6 g/dL\n 82 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 16 mg/dL\n 101 mEq/L\n 139 mEq/L\n 30.0 %\n 15.9 K/uL\n [image002.jpg]\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n 03:54 AM\n 03:56 AM\n WBC\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n 19.7\n 15.9\n Hct\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n 28.7\n 30.0\n Plt\n \n \n Cr\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n 0.5\n 0.5\n Glucose\n 102\n 106\n 76\n 72\n 135\n 79\n 70\n 90\n 82\n Other labs: PT / PTT / INR:14.0/29.9/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.2 g/dL, LDH:315 IU/L, Ca++:7.9 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Patient was started on vanc/zosyn. Vanc was d/c\ned once\n it was growth was gram negative. Zosyn was changed to ceftriaxone when\n speciated to H. flu beta-lactamase negative. Patient completed \n day course of HAP and steroid taper when patient passed SBT and was\n extubated. Patient remained extubated for 12 hours and developed sinus\n tachycardia (in the setting of beta blocker withdrawl), tachypnea,\n accessory muscle use and desaturation to low 90s. Patient was given\n trial of nebs and CPAP, patient continued to retain CO2 and patient was\n intubated on . Patient has very poor respiratory reserve and will\n require long-term trach.\n - s/p ceftriaxone course for h.flu; now being treating for pseudomonas\n with vanc/ -> 2 week course from \n - patient to get Trach/PEG as add-on today\n - continue prednisone, now on 40 mg daily for the next three days, and\n will continue taper\n - mouthcare, HOB elevated\n .\n # Leukocytosis / Fever\n developed 4 hours after reintubation. Patient\n was intubated uneventfully and patient was NPO 48 hours prior to\n procedure. Likely , pt improving with decreasing leukocytosis, has\n not spiked since \n - f/u BC, UC, cdiff toxin, mini-BAL, and endobronchial\n aspirate cx (neg gram stain on mini BAL)\n - first c.diff neg, stopped c.diff treatment\n - treating for pseudomonas plus one other GNR yet to be\n speciated with Vanco and for now, awaiting speciations\n will\n treat 7 days since last fever\n - foley changed secondary to yeast\n .\n # Tachycardia\n similar to previous, could be from infection or\n hypovolemia or anxiety. Could also be MAT given resp problems. \n agents. Responded to fluid boluses , tachy with movement,\n when calm around 80s-90s.\n - Sinus tach on EKG \n - Fluid challenge PRN\n - Hold anti-HTN meds\n .\n # Resolved ARF: Pre-renal from hypovolemia/sepsis, now improved.\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily\n will discuss\n aspirin with thoracic team today.\n - continue to monitor on telemetry, follow EKGs\n - holding all agents at this time; afib responds to metoprolol if\n she goes into it, dilt did not work as well\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF.\n Dropped over course of hospitalization, s/p transfusion again on ;\n now stabalized. Anemia likey from phlebotomy, chronic disease\n Transfused one unit PRBC , on on \n - cont to trend\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # Osteopenia\n was on fosamax as outpatient, in setting of steroid use\n will start Ca/Vit D\n - Ca and Vit D supplementation for now\n - re-start fosamax when respiratory status starts to stabilize\n .\n # FEN: cont TFs, 40cc/hr, running at goal, nutrition following,\n awaiting PEG, npo at midnight for procedure tomorrow\n .\n # Prophylaxis: heparin sc BID, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n .\n # Code: FULL\n .\n # Communication\n with patient and niece\n .\n # Disposition: case management aware of need for rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n :\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442811,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit, now failure to wean\n with plan to trach/PEG by IP, prep for rehab.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on vent settings CPAP/PS 40% 12/+8 with RR 16-24 and regular. O2\n sat 97-100%. Pt denied SOB, C/O claustrophobia. Lung sounds\n rhonchorous, diminished in bases. Suctioned for mod\ncopious amts\n blood-tinged, thick, tan secretions. Afebrile. Fentnayl patch in\n place.\n Action:\n Pt rec\nd Ativan 1mg Q4hrs. Suctioned PRN.\n Response:\n Pt remains stable. She reports fair relief from Ativan.\n Plan:\n Cont PRN Ativan for anxiety, nausea. PO calcium ONLY for repletion. For\n trach/PEG in Am. Cont prep for transfer to rehab.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple skintears, blisters, hematomas on all extremeties,\n with decreasing amts yellow fluid leaking from all limbs. Pt denies\n pain, rec\ning Fentanyl patch for comfort.\n Action:\n Skin tears requiring dsg changes Q2-4hrs. Pt turned freq STS. Heels\n elevated off bed or waffle boots in place. Compression stockings off\n D/T blisters, skin tears on legs.\n Response:\n Weeping cont from impaired skin.\n Plan:\n Cont vigilent skin care. Wound care nurse consulted.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443585,
"text": "Chief Complaint:\n 24 Hour Events:\n - d/c'ed c.diff antibiotics\n - plan for 7 day course of VAP since last fever on \n - requested for her pseudomonas\n - plan for trach/peg on monday as add on\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Metronidazole - 10:14 AM\n Vancomycin - 08:51 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 05:03 PM\n Heparin Sodium (Prophylaxis) - 08:01 PM\n Lorazepam (Ativan) - 11:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.6\nC (96\n HR: 82 (73 - 116) bpm\n BP: 132/60(76) {106/44(61) - 181/84(107)} mmHg\n RR: 17 (14 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,439 mL\n 207 mL\n PO:\n TF:\n 959 mL\n 41 mL\n IVF:\n 1,050 mL\n 166 mL\n Blood products:\n Total out:\n 2,590 mL\n 550 mL\n Urine:\n 2,590 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -151 mL\n -343 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 545 (462 - 545) mL\n PS : 8 cmH2O\n RR (Spontaneous): 16\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 17 cmH2O\n SpO2: 97%\n ABG: ///34/\n Ve: 9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 391 K/uL\n 9.6 g/dL\n 82 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 16 mg/dL\n 101 mEq/L\n 139 mEq/L\n 30.0 %\n 15.9 K/uL\n [image002.jpg]\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n 03:54 AM\n 03:56 AM\n WBC\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n 19.7\n 15.9\n Hct\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n 28.7\n 30.0\n Plt\n \n \n Cr\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n 0.5\n 0.5\n Glucose\n 102\n 106\n 76\n 72\n 135\n 79\n 70\n 90\n 82\n Other labs: PT / PTT / INR:14.0/29.9/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.2 g/dL, LDH:315 IU/L, Ca++:7.9 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443738,
"text": "70 y/o woman with severe COPD who initially presented with acute\n hypoxic respiratory failure. Her course in the MICU has been c/b fevers\n with +leukocytosis most likely r/t vap. She was briefly extubated on\n and reintubated the following day for hypoxia and hypercarbia.\n A bedside trach/peg was performed on without incident.\n Alteration in Nutrition\n Assessment:\n The pt has been npo except for meds overnight. Her peg was placed to\n gravity intermittently.\n Action:\n NPO per thorasic team s/p peg placement.\n Response:\n Pt tolerating meds/sterile water flushes with minimal drainage.\n Plan:\n Resume tube feedings later today.\n Impaired Skin Integrity\n Assessment:\n Multiple skin tears over the pt\ns arms and legs weeping moderate amts\n of serous or serosanguinous drainage.\n Action:\n Affected areas were cleansed with ns then redressed with aquaphor and\n softsorb pads.\n Response:\n Unchanged.\n Plan:\n Continue skin care as described. Change dressings as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is trached and vented on psv5/peep5 with o2 40%. RR teens with mv\n ~8-9 liters. Suctioned ~q4hrs for small amts of thick, blood tinged\n sputum. Trach site also with a small amt of bloody discharge.\n Action:\n Rested on psv overnight. Received ativan x3 for anxiety w/ tachypnea\n and hypertension.\n Response:\n Pt slept for several hours with improved respiratory rate and bp.\n Plan:\n Continue pulmonary toilet. Check rsbi this morning and anticipate\n transition to trach mask this morning.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443689,
"text": "Events: Bedside trach/PEG by IP and thoracic w/o incident, anesthesia\n present- sedated w/ Vecuronium, Propofol bolus and gtt- off post\n procedure. NO further sedation w/ PRN anxiety of hospitalization and\n trach. Niece @ bedside throughout most of day. Plan for 24hrs on PEG\n draining to gravity- to be cleared by for tube feeding-\n may give meds and needs sterile H2O flush Q6hrs. Starting diuretic\n therapy for + 16 L LOS/anasarca. Bedside echo: EF preserved. Needs\n large amount fo emotional support. Wound care.\n Edema, peripheral\n Assessment:\n 3+ pitting/weeping bilat arms, legs, feet, and dependent areas-\n specific area listed in wound care\n Action:\n 20mg IVP Lasix\n Response:\n 900cc/1hrs- then 300cc, awaiting tapering dose\n Plan:\n Goal neg 500-1L, ? additional therapy pending output, BP,\n Impaired Skin Integrity\n Assessment:\n Mult skin tears, bruising throughout body, large bruise on abd,\n Action:\n On air bed, turning as frequently as pt tolerated, large amount of\n encouragement to turn, barrier cream peri-wound and @ risk areas,\n coccyx sm pink area slightly blanching, in waffle boots, cool\n extremities w/ + edema, R arm large skin tear ? burst blister- weeping\n w/ red/bleeding center, left calf - hematoma, lateral side large skin\n tear large amount weeping-covered in Aquacel, abd, sorftsorb and\n Kerlex, R calf anterior mod skin tear- large amount weaping- covered q/\n Aquacel, abd, softworb, and kerlex, other than weeping areas general\n dry, think fragile skin\n Response:\n Wound care/weeping care-see metavision,\n Plan:\n Cont kinair bed, resume nutrition when cleared, starting diuretic\n therapy, frequent turning as tolerated, heals and arms elevated w/\n barrier cream to @ risk areas, pt thin, cechetic @ risk for breakdown\n over bony areas\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear bilat upper lobes w/ mild exp wheeze, slightly diminished\n bilat lower lobes, toerlating CPAP+PSV 8/+8 then 8/+5 before trach\n Action:\n Suctioned PRN, bedside trach, toerlating 8/+8- attempted trach mask but\n increase in pt anxiety\n Response:\n Sat >95% throughout day w/ vent changes, trach, post trach large amout\n of thick pink secretions-pt able to bring up some of own secretions\n Plan:\n Suction PRN, nebs, chest PT, pulm toilet, emotional support and anxiety\n relief, wean as tolerated\n Alteration in Nutrition\n Assessment:\n NPO throughout day- to restart TF when PEG cleared by , \n family s/s 10 lbs recent weight loss @ OSH, pt cechectic appearing\n Action:\n Cont NPO, awaiting clearance, electrolyte repletion\n Response:\n No acute change\n Plan:\n Resume TF when cleared ? supplemental nutrition, electrolyte repletion\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443675,
"text": "Events: Bedside trach/PEG by IP and thoracic w/o incident, anesthesia\n present- sedated w/ Vecuronium, Propofol bolus and gtt- off post\n procedure. NO further sedation w/ PRN anxiety of hospitalization and\n trach. Niece @ bedside throughout most of day. Plan for 24hrs on PEG\n draining to gravity- to be cleared by for tube feeding-\n may give meds and needs sterile H2O flush Q6hrs. Starting diuretic\n therapy for + 16 L LOS/anasarca. Bedside echo:\n Edema, peripheral\n Assessment:\n 3+ pitting/weeping bilat arms, legs, feet, and dependent areas-\n specific area listed in wound care\n Action:\n 20mg IVP Lasix\n Response:\n 900cc/1hrs- then 300cc, awaiting tapering dose\n Plan:\n Goal neg 500-1L, ? additional therapy pending output, BP,\n Impaired Skin Integrity\n Assessment:\n Mult skin tears, bruising throughout body, large bruise on abd,\n Action:\n On air bed, turning as frequently as pt tolerated, large amount of\n encouragement to turn, barrier cream peri-wound and @ risk areas,\n coccyx sm pink area slightly blanching, in waffle boots, cool\n extremities w/ + edema, R arm large skin tear ? burst blister- weeping\n w/ red/bleeding center, left calf - hematoma, lateral side large skin\n tear large amount weeping-covered in Aquacel, abd, sorftsorb and\n Kerlex, R calf anterior mod skin tear- large amount weaping- covered q/\n Aquacel, abd, softworb, and kerlex, other than weeping areas general\n dry, think fragile skin\n Response:\n Wound care/weeping care-see metavision,\n Plan:\n Cont kinair bed, resume nutrition when cleared, starting diuretic\n therapy, frequent turning as tolerated, heals and arms elevated w/\n barrier cream to @ risk areas, pt thin, cechetic @ risk for breakdown\n over bony areas\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear bilat upper lobes w/ mild exp wheeze, slightly diminished\n bilat lower lobes, toerlating CPAP+PSV 8/+8 then 8/+5 before trach\n Action:\n Suctioned PRN, bedside trach, toerlating 8/+8- attempted trach mask but\n increase in pt anxiety\n Response:\n Sat >95% throughout day w/ vent changes, trach, post trach large amout\n of thick pink secretions-pt able to bring up some of own secretions\n Plan:\n Suction PRN, nebs, chest PT, pulm toilet, emotional support and anxiety\n relief, wean as tolerated\n Alteration in Nutrition\n Assessment:\n NPO throughout day- to restart TF when PEG cleared by , \n family s/s 10 lbs recent weight loss @ OSH, pt cechectic appearing\n Action:\n Cont NPO, awaiting clearance, electrolyte repletion\n Response:\n No acute change\n Plan:\n Resume TF when cleared ? supplemental nutrition, electrolyte repletion\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442810,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442848,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - Trach/PEG re-scheduled for \n - taper prednisone 60, 40, 30, 20 in 4 day intervals, so that within 2\n wks or so she is down to 10mg (per Dr. \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 05:00 PM\n Heparin Sodium (Prophylaxis) - 09:34 PM\n Lorazepam (Ativan) - 03:12 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.3\n HR: 92 (73 - 99) bpm\n BP: 153/58(81) {121/42(62) - 161/78(95)} mmHg\n RR: 24 (16 - 25) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 435 mL\n 442 mL\n PO:\n TF:\n IVF:\n 270 mL\n 442 mL\n Blood products:\n Total out:\n 1,295 mL\n 360 mL\n Urine:\n 1,295 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n -860 mL\n 82 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 505 (347 - 529) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n SpO2: 96%\n ABG: ///37/\n Ve: 9.7 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 310 K/uL\n 8.1 g/dL\n 72 mg/dL\n 0.6 mg/dL\n 37 mEq/L\n 3.7 mEq/L\n 21 mg/dL\n 100 mEq/L\n 140 mEq/L\n 25.0 %\n 19.5 K/uL\n [image002.jpg]\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n WBC\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n Hct\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n Plt\n \n 310\n Cr\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n TCO2\n 31\n Glucose\n 107\n 119\n 102\n 160\n 102\n 106\n 76\n 72\n Other labs: PT / PTT / INR:13.2/38.8/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.0 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-24 00:00:00.000",
"description": "Generic Note",
"row_id": 443071,
"text": "TITLE:\n Events:\n SBP in 80\ns at hrs , 250 mls fluid bolus given with good effect.\n Feed restarted at hrs, held at midnight for ? procedures in am.\n Impaired Skin Integrity\n Assessment:\n General thin fragile skin w/ mult skin tears bilat legs, mild\n maceration in bilat legs sm amt cont weeping edema, on coccyx sm\n pink area-blanching\n Action:\n Barrier cream to bilat legs- adaptic on bilat calves and covered w/\n ABD, barrier cream to elbows\npt think and @ risk for mult pressure\n ulcers on bony areas\n Response:\n Pt weeping through bilat leg dressings x1 and weeping to saturate pink\n pad\n Plan:\n ? order specialized bed, frequent turning, barrier cream, wound care\n Sepsis without organ dysfunction\n Assessment:\n No fever till time noted, BP dropped at hrs to SBP 80\ns, maps of\n 40\n Action:\n Given total of 250 mls of NS, continued on broad coverage ABX-PO and IV\n Response:\n BP improved to SBP 120\ns to 130\ns, MAP of 60\n Plan:\n Follow cultures, monitor temp curve, cont IV and PO ABX\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS very tight/diminished, mild wheezy bilat, sat 97-10%, RR 20\n Action:\n Continued neb treatment by resp, no vent changes\n Response:\n No acute change\n Plan:\n Cont vent settings, monitor O2 sat, nebs for severe COPD\n"
},
{
"category": "Nutrition",
"chartdate": "2158-02-24 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 443158,
"text": "Objective\n Pertinent medications: Docusate, protonix, prednisone, CaCo3 Vit D,\n HISS, abx, SS lytes, others noted\n Labs:\n Value\n Date\n Glucose\n 79 mg/dL\n 03:22 AM\n Glucose Finger Stick\n 168\n 10:00 AM\n BUN\n 13 mg/dL\n 03:22 AM\n Creatinine\n 0.7 mg/dL\n 03:22 AM\n Sodium\n 139 mEq/L\n 03:22 AM\n Potassium\n 3.5 mEq/L\n 03:22 AM\n Chloride\n 102 mEq/L\n 03:22 AM\n TCO2\n 30 mEq/L\n 03:22 AM\n Calcium non-ionized\n 6.7 mg/dL\n 03:22 AM\n Phosphorus\n 2.6 mg/dL\n 03:22 AM\n Ionized Calcium\n 1.10 mmol/L\n 07:35 AM\n Magnesium\n 1.9 mg/dL\n 03:22 AM\n WBC\n 31.2 K/uL\n 03:22 AM\n Hgb\n 7.3 g/dL\n 03:22 AM\n Hematocrit\n 22.4 %\n 03:22 AM\n Current diet order / nutrition support: Nutren Pulmonary @40mL/hr (1440\n kcals/65 gr aa) on hold\n GI: Abd: soft/+bs\n Assessment of Nutritional Status\n Specifics:\n Pt has yet to receive trach and PEG. Initially this was because pt had\n extubation trial, now this d/t leukocytosis. Trach and PEG rescheduled\n for Monday. Pt has received minimal nutrition since midnight ,\n however, dW RN TF\ns to resume shortly via NGT. Ca and Vit D\n supplementation added d/t chronic steroids use. Low PO4 noted. PT on\n SS Phos, but will not receive repletion until PO4 <2.4. Can give po\n repletion in effore to avoid needing IV.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: add 5mL liquid multivit\n Tube feeding recommendations: Resume TF's as ordered\n 2 packets neutraphos\n BG management as you are\n Please page c/ ?'s #\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443731,
"text": "70 y/o woman with severe COPD who initially presented with acute\n hypoxic respiratory failure. Her course in the MICU has been c/b fevers\n with +leukocytosis most likely r/t vap. She was briefly extubated on\n and reintubated the following day for hypoxia and hypercarbia.\n A bedside trach/peg was performed on without incident.\n Alteration in Nutrition\n Assessment:\n The pt has been npo except for meds overnight. Her peg was placed to\n gravity intermittently.\n Action:\n NPO per thorasic team s/p peg placement.\n Response:\n Pt tolerating meds/sterile water flushes with minimal drainage.\n Plan:\n Resume tube feedings later today.\n Impaired Skin Integrity\n Assessment:\n Multiple skin tears over the pt\ns arms and legs weeping moderate amts\n of serous or serosanguinous drainage.\n Action:\n Affected areas were cleansed with ns then redressed with aquaphor and\n softsorb pads.\n Response:\n Unchanged.\n Plan:\n Continue skin care as described. Change dressings as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt was rested on psv5/peep5 with o2 40%. RR teens with mv ~8-9 liters.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442850,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - Trach/PEG re-scheduled for \n - taper prednisone 60, 40, 30, 20 in 4 day intervals, so that within 2\n wks or so she is down to 10mg (per Dr. \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 05:00 PM\n Heparin Sodium (Prophylaxis) - 09:34 PM\n Lorazepam (Ativan) - 03:12 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.3\n HR: 92 (73 - 99) bpm\n BP: 153/58(81) {121/42(62) - 161/78(95)} mmHg\n RR: 24 (16 - 25) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 435 mL\n 442 mL\n PO:\n TF:\n IVF:\n 270 mL\n 442 mL\n Blood products:\n Total out:\n 1,295 mL\n 360 mL\n Urine:\n 1,295 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n -860 mL\n 82 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 505 (347 - 529) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n SpO2: 96%\n ABG: ///37/\n Ve: 9.7 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 310 K/uL\n 8.1 g/dL\n 72 mg/dL\n 0.6 mg/dL\n 37 mEq/L\n 3.7 mEq/L\n 21 mg/dL\n 100 mEq/L\n 140 mEq/L\n 25.0 %\n 19.5 K/uL\n [image002.jpg]\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n WBC\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n Hct\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n Plt\n \n 310\n Cr\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n TCO2\n 31\n Glucose\n 107\n 119\n 102\n 160\n 102\n 106\n 76\n 72\n Other labs: PT / PTT / INR:13.2/38.8/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.0 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442851,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - Trach/PEG re-scheduled for \n - taper prednisone 60, 40, 30, 20 in 4 day intervals, so that within 2\n wks or so she is down to 10mg (per Dr. \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 05:00 PM\n Heparin Sodium (Prophylaxis) - 09:34 PM\n Lorazepam (Ativan) - 03:12 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.3\n HR: 92 (73 - 99) bpm\n BP: 153/58(81) {121/42(62) - 161/78(95)} mmHg\n RR: 24 (16 - 25) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 435 mL\n 442 mL\n PO:\n TF:\n IVF:\n 270 mL\n 442 mL\n Blood products:\n Total out:\n 1,295 mL\n 360 mL\n Urine:\n 1,295 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n -860 mL\n 82 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 505 (347 - 529) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n SpO2: 96%\n ABG: ///37/\n Ve: 9.7 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 310 K/uL\n 8.1 g/dL\n 72 mg/dL\n 0.6 mg/dL\n 37 mEq/L\n 3.7 mEq/L\n 21 mg/dL\n 100 mEq/L\n 140 mEq/L\n 25.0 %\n 19.5 K/uL\n [image002.jpg]\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n WBC\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n Hct\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n Plt\n \n 310\n Cr\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n TCO2\n 31\n Glucose\n 107\n 119\n 102\n 160\n 102\n 106\n 76\n 72\n Other labs: PT / PTT / INR:13.2/38.8/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.0 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Initally, vanc was d/c\ned and patient was kept on Zosyn\n until found to be flu beta-lactamase negative. Sputum showed moderate\n H. flu beta-lactamase negative, changed to ceftriaxone. Patient was\n able to tolerate PS12/PEEP8 for approx 2 hrs \n - will check VBG before and after PS trials\n - continue ceftriaxone for total of 14 days (d/c calcium SS given\n potential interaction)\n - plan for trach and PEG today\n - continue prednisone 40mg daily\n - mouthcare, HOB elevated\n .\n # ARF: pre-renal from lasix administration -> holding lasix for now,\n free water flushes at 250cc q4h (hyper NA improved)\n .\n # Hypotension: Resolved, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2 months of prednisone use and patient had initially\n been given Hydrocortisone. Aggressive resuscitation with IVF, s/p 10L\n of IVF on initial presentation.\n - Hypotension now resolved\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg \n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - guiaic negative\n - maintain active type & screen\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative\n .\n # FEN: cont TFs, nutrition following, PEG to be placed Tuesday\n .\n # Prophylaxis: heparin sc TID will change to 2.2 PTT 41 today,\n bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n # Code: FULL\n .\n # Disposition: trach and PEG now, case management aware of need for\n rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442689,
"text": "Chief Complaint:\n 24 Hour Events:\n - had PS trial and did well - on PS with improved oxygenation on\n this setting - ABG 7.41/54/172\n - plan for trach and peg tomorrow\n - trouble sleeping, treated with ambien\n - one guaiac positive brown stool, Hct stable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 04:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Lorazepam (Ativan) - 02:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.1\nC (98.8\n HR: 79 (70 - 86) bpm\n BP: 118/44(61) {117/44(61) - 154/68(88)} mmHg\n RR: 23 (16 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,490 mL\n 15 mL\n PO:\n TF:\n 865 mL\n IVF:\n 210 mL\n Blood products:\n Total out:\n 1,430 mL\n 385 mL\n Urine:\n 1,410 mL\n 385 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,060 mL\n -370 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 525 (421 - 525) mL\n PS : 12 cmH2O\n RR (Set): 18\n RR (Spontaneous): 25\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 22 cmH2O\n Plateau: 24 cmH2O\n Compliance: 31.3 cmH2O/mL\n SpO2: 96%\n ABG: ///35/\n Ve: 11.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 284 K/uL\n 8.4 g/dL\n 76 mg/dL\n 0.7 mg/dL\n 35 mEq/L\n 5.3 mEq/L\n 26 mg/dL\n 102 mEq/L\n 142 mEq/L\n 25.8 %\n 17.5 K/uL\n [image002.jpg]\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n Plt\n 79\n 251\n 258\n 284\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n TCO2\n 31\n Glucose\n 135\n 107\n 119\n 102\n 160\n 102\n 106\n 76\n Other labs: PT / PTT / INR:13.1/38.5/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:6.6 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442690,
"text": "Chief Complaint:\n 24 Hour Events:\n - had PS trial and did well - on PS with improved oxygenation on\n this setting - ABG 7.41/54/172\n - plan for trach and peg tomorrow\n - trouble sleeping, treated with ambien\n - one guaiac positive brown stool, Hct stable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 04:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Lorazepam (Ativan) - 02:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.1\nC (98.8\n HR: 79 (70 - 86) bpm\n BP: 118/44(61) {117/44(61) - 154/68(88)} mmHg\n RR: 23 (16 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,490 mL\n 15 mL\n PO:\n TF:\n 865 mL\n IVF:\n 210 mL\n Blood products:\n Total out:\n 1,430 mL\n 385 mL\n Urine:\n 1,410 mL\n 385 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,060 mL\n -370 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 525 (421 - 525) mL\n PS : 12 cmH2O\n RR (Set): 18\n RR (Spontaneous): 25\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 22 cmH2O\n Plateau: 24 cmH2O\n Compliance: 31.3 cmH2O/mL\n SpO2: 96%\n ABG: ///35/\n Ve: 11.1 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 284 K/uL\n 8.4 g/dL\n 76 mg/dL\n 0.7 mg/dL\n 35 mEq/L\n 5.3 mEq/L\n 26 mg/dL\n 102 mEq/L\n 142 mEq/L\n 25.8 %\n 17.5 K/uL\n [image002.jpg]\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n Plt\n 79\n 251\n 258\n 284\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n TCO2\n 31\n Glucose\n 135\n 107\n 119\n 102\n 160\n 102\n 106\n 76\n Other labs: PT / PTT / INR:13.1/38.5/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:6.6 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442691,
"text": "Chief Complaint:\n 24 Hour Events:\n - had PS trial and did well - on PS with improved oxygenation on\n this setting - ABG 7.41/54/172\n - plan for trach and peg tomorrow\n - trouble sleeping, treated with ambien\n - one guaiac positive brown stool, Hct stable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 04:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Lorazepam (Ativan) - 02:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.1\nC (98.8\n HR: 79 (70 - 86) bpm\n BP: 118/44(61) {117/44(61) - 154/68(88)} mmHg\n RR: 23 (16 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,490 mL\n 15 mL\n PO:\n TF:\n 865 mL\n IVF:\n 210 mL\n Blood products:\n Total out:\n 1,430 mL\n 385 mL\n Urine:\n 1,410 mL\n 385 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,060 mL\n -370 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 525 (421 - 525) mL\n PS : 12 cmH2O\n RR (Set): 18\n RR (Spontaneous): 25\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 22 cmH2O\n Plateau: 24 cmH2O\n Compliance: 31.3 cmH2O/mL\n SpO2: 96%\n ABG: ///35/\n Ve: 11.1 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 284 K/uL\n 8.4 g/dL\n 76 mg/dL\n 0.7 mg/dL\n 35 mEq/L\n 5.3 mEq/L\n 26 mg/dL\n 102 mEq/L\n 142 mEq/L\n 25.8 %\n 17.5 K/uL\n [image002.jpg]\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n Plt\n 79\n 251\n 258\n 284\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n TCO2\n 31\n Glucose\n 135\n 107\n 119\n 102\n 160\n 102\n 106\n 76\n Other labs: PT / PTT / INR:13.1/38.5/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:6.6 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Initally, vanc was d/c\ned and patient was kept on Zosyn\n until found to be flu beta-lactamase negative. Sputum showed moderate\n H. flu beta-lactamase negative, changed to ceftriaxone. Patient was\n able to tolerate PS12/PEEP8 for approx 2 hrs \n - will check VBG before and after PS trials\n - continue ceftriaxone for total of 14 days\n - plan for trach and PEG today\n - continue prednisone 40mg daily\n - mouthcare, HOB elevated\n .\n # ARF: pre-renal from lasix administration -> holding lasix for now,\n free water flushes at 250cc q4h (hyper NA improved)\n .\n # Hypotension: Resolved, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2 months of prednisone use and patient had initially\n been given Hydrocortisone. Aggressive resuscitation with IVF, s/p 10L\n of IVF on initial presentation.\n - Hypotension now resolved\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg \n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - guiaic negative\n - maintain active type & screen\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative\n .\n # FEN: cont TFs, nutrition following, PEG to be placed Tuesday\n .\n # Prophylaxis: heparin sc TID will change to 2.2 PTT 41 today,\n bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n # Code: FULL\n .\n # Disposition: trach and PEG now, case management aware of need for\n rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443150,
"text": "Chief Complaint:\n 24 Hour Events:\n - started IV flagyl/PO vanco for possible c.diff; IV vanco, doripenem,\n cipro for possible HAP\n - stop VAP ABX on Monday if cxs negative****\n - OG pulled out; placed new NG tube\n - had chest/epigastic pain, EKG unchanged; responded to zofran and\n started feeling better\n - moderately hypotensive to SBPs in 80s most of afternoon; would\n transiently respond to 500 cc boluses\n - BPs stabalized overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Ciprofloxacin - 09:00 PM\n Vancomycin - 12:00 AM\n Metronidazole - 02:04 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Lorazepam (Ativan) - 05:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 36.9\nC (98.4\n HR: 87 (71 - 112) bpm\n BP: 108/51(65) {76/34(44) - 159/61(83)} mmHg\n RR: 21 (16 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 6,218 mL\n 359 mL\n PO:\n TF:\n 160 mL\n IVF:\n 6,058 mL\n 319 mL\n Blood products:\n Total out:\n 1,060 mL\n 360 mL\n Urine:\n 1,060 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,158 mL\n -2 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 58\n PIP: 19 cmH2O\n Plateau: 21 cmH2O\n Compliance: 49.5 cmH2O/mL\n SpO2: 96%\n ABG: ///30/\n Ve: 9.9 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished: )\n Abdominal: Soft, Non-tender\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 314 K/uL\n 7.3 g/dL\n 79 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 102 mEq/L\n 139 mEq/L\n 22.4 %\n 31.2 K/uL\n [image002.jpg]\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n WBC\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n Hct\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n Plt\n 255\n 279\n 251\n 258\n 14\n Cr\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n Glucose\n 119\n 102\n 160\n 102\n 106\n 76\n 72\n 135\n 79\n Other labs: PT / PTT / INR:15.9/33.9/1.4, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:6.7 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Patient was started on vanc/zosyn. Vanc was d/c\ned once\n it was growth was gram negative. Zosyn was changed to ceftriaxone when\n speciated to H. flu beta-lactamase negative. Patient completed \n day course of HAP and steroid taper when patient passed SBT and was\n extubated. Patient remained extubated for 12 hours and developed sinus\n tachycardia (in the setting of beta blocker withdrawl), tachypnea,\n accessory muscle use and desaturation to low 90s. Patient was given\n trial of nebs and CPAP, patient continued to retain CO2 and patient was\n intubated on . Patient has very poor respiratory reserve and will\n require long-term trach.\n - patient to get Trach/PEG on Monday\n - continue prednisone 60mg PO and will taper to 40mg in tomorrow\n - mouthcare, HOB elevated\n .\n # Leukocytosis / Fever\n developed 4 hours after reintubation. Patient\n was intubated uneventfully and patient was NPO 48 hours prior to\n procedure. Differential includes VAP vs. aspiration PNA vs aspiration\n pneumonitis. Leukocytosis also in the setting diarrhea and prolonged\n hospitalization could be consistent with c diff.\n - f/u BC, UC, cdiff toxin, mini-BAL, and endobronchial\n aspirate cx (neg gram stain on mini BAL)\n - treating c diff with IV Flagyl and PO vanc , placed on\n contact precautions (started )\n - treating VAP with IV vanc, doripenem and cipro (started\n , cipro to dbl cover pseudomonas), will stop VAP abx on if\n cultures negative\n .\n # Tachycardia\n similar to previous, could be from infection or\n hypovolemia. Could also be MAT given resp problems. \n agents. Responded to fluid boluses .\n - Sinus tach on EKG \n - Fluid challenge PRN\n - Hold anti-HTN meds\n .\n # Resolved ARF: Pre-renal from hypovolemia/sepsis, now improved.\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg ; will consider changing as is possible to\n cause bronchospasm, could try diltiazem\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - will transfuse 1U PRBC today\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # Osteopenia\n was on fosamax as outpatient, in setting of steroid use\n will start Ca/Vit D\n - Ca and Vit D supplementation for now\n - re-start fosamax when respiratory status starts to stabilize\n .\n # FEN: cont TFs, nutrition following, awaiting PEG\n .\n # Prophylaxis: heparin sc BID, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n .\n # Code: FULL\n .\n # Communication\n with patient and niece\n .\n # Disposition: case management aware of need for rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-25 00:00:00.000",
"description": "Generic Note",
"row_id": 443258,
"text": "TITLE:\n 70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit. Failure to wean with\n original plan to trach/PEG by IP. Pt did well on RSBI (score\n 50), and passed SBT so extubated at 1400.\n Pt became tachycardic, tachypnic, increased BP at MN on . VBG\n indicated elevated CO2, pt originally not responsive to IV diltiazem,\n responsive to IV labetolol IVP 10 mg x 2 to control HR/BP. However\n resp status not improved, pt re-intubated at 0200. Labetolol gtt\n started for rate / BP control but \nt s/p intubation as SBP\n dropped to 84/38 (51). ET tube / OG tube placement confirmed.\n Pt is being followe by case mgt for rehab.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-25 00:00:00.000",
"description": "Generic Note",
"row_id": 443260,
"text": "TITLE:\n 70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit. Failure to wean with\n original plan to trach/PEG by IP. Pt did well on RSBI (score\n 50), and passed SBT so extubated at 1400.\n Pt became tachycardic, tachypnic, increased BP at MN on . VBG\n indicated elevated CO2, pt originally not responsive to IV diltiazem,\n responsive to IV labetolol IVP 10 mg x 2 to control HR/BP. However\n resp status not improved, pt re-intubated at 0200. Labetolol gtt\n started for rate / BP control but \nt s/p intubation as SBP\n dropped to 84/38 (51). ET tube / OG tube placement confirmed.\n Pt is being followe by case mgt for rehab.\n Edema, peripheral\n Assessment:\n Generalized edema + bilat legs and pedal, no hand edema, coccyx and\n dependent edema-continuously weeping- through total 3 pink pads/2\n sheets, thin fragile skin likely chronic steroid therapy, mult sm\n bruising throughout body, blanching borderline stage I on gleut- pt\n very thin and @ risk for ulcerations on bony areas\n Action:\n Barrier cream to protect maceration, turning, OOB to chair, supportive\n care, now on Kinair bed\n Response:\n Cont weeping large amounts serous fluids\n Plan:\n Tuning/OOB to chair-activity, skin care, BP stabilizing and ? diuretic\n therapy in future\n Alteration in Nutrition\n Assessment:\n TF Nutren Pulmonary @ goal 40cc/hr, 250cc free water flush Q4hrs\n Action:\n none\n Response:\n Tolerating tf well.\n Plan:\n Cont TF . NPO @ MN Sunday night for trach/PEG Monday\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS tight/diminished\nless secretions than previous day, on PSV\n Action:\n CPAP+PSV 8/+8/40%,\n Response:\n O2 sats 91 to 96\n Plan:\n Cont PSV as tolerated , possible slow wean over weekend.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442676,
"text": "PMH: 70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic\n resp failure and pneumonia. Recent pseudomonas, H Flu in sputum. Sputum\n now showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin\n with multiple tears, weeping. Intubated on admit, now failure to\n wean with plan to trach/PEG by IP. Pt seen by case management\n to eval for rehab.\n Events: TF stopped at MN for surgery tomorrow (T / P). Pt expressed\n anxiety for tomorrow, ambien 5 mg / ativan given as ordered. Pt not\n sleeping well throughout night, spent some time talking w/ patient,\n explaining procedure. Hct and WBC stable. K elevated to 5.3 (4.2\n yesterday). UOP 30-50 ml/hr.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CPAP 40%/. SRR 21-24, Sp02 97-99%. Pt sux\ned for\n copious amts thick, blood tinged sputum. LS clear and dim at bases.\n Pt mentating well, communicating by mouthing words, writing. Pt\n afebrile T max 98.8 oral.\n Action:\n Pt remains on CPAP, neb tx\ns given as ordered. ET tube lavaged to\n improve ability to sux out sputum and secretions.\n Response:\n Pt tolerating CPAP w/o incident, Sp02 remains 97-99%, no tachypnea or\n increased WOB noted.\n Plan:\n Pt consented by surgery and anesthesia for trach and PEG today.\n Impaired Skin Integrity\n Assessment:\n Mult skin tears at all extremities. Mult hematomas, thin fragile skin,\n weeping edema. Lg sanguinous blister at L LE.\n Action:\n Requested wound care consult from team as this RN worries skin\n breakdown may become source of infection. Softsorb, adaptic, and\n dressing changes as needed. Prednisone dose decreased.\n Response:\n Skin is not improved.\n Plan:\n Cont vigilant skin care.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442788,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit, now failure to wean\n with plan to trach/PEG by IP, prep for rehab.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on vent settings CPAP/PS 40% 12/+8 with RR regular. O2 sat\n 95-98%. Pt denied SOB. Lung snds clear, diminished in bases.\n Suctionned for scant amts blood-tinged, thick, tan secretions. Other VS\n generally stable with HR 78-97SR without VEA, BP 124/50-177/63.\n Afebrile. Rec\nd on Fentanyl 25mcg/hr.\n Action:\n Pt OOB to chair for several hrs in AM. Vent settings changed to PS\n 12/+8/40%. Fentanyl qtt stopped, Fentanyl patch in place.\n Response:\n Pt C/O nausea after moved to chair. She rec\nd Ativan 0.5mg with\n eventual resolution of nausea. After 11/2 hrs on PS, pt C/O feeling\n anxious with RR inc\nd to mid 20\ns and SBP to 170\ns. Pt rec\nd Ativan 1mg\n IV without resolution of symptoms, and vent settngs returned to AC. Pt\n again C/O abd discomfort @ 1600, and rec\nd Zofran 4mg IV with good\n resolution. Pt consented for trach/PEG by IP.\n Plan:\n Cont PRN Ativan for anxiety, nausea. Zofran also available PRN. Cont\n prep for transfer to rehab, with trach/PEG planned for by IP.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple skintear, blisters, hematomas on all extremeties, with\n copious amts yellow fluid leaking from all limbs. Pt denies pain,\n rec\ning Fentanyl for comfort.\n Action:\n Skin tears requiring dsg changes Q2hrs. Pt OOB to chair, and turned\n freq STS. Heels elevated off bed or waffle boots in place. Compression\n stockings off D/T blisters, skin tears on legs.\n Response:\n Increased amt weeping from impaired skin.\n Plan:\n Cont vigilent skin care.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442795,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit, now failure to wean\n with plan to trach/PEG by IP, prep for rehab.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on vent settings CPAP/PS 40% 12/+8 with RR 16-24 and regular. O2\n sat 97-100%. Pt denied SOB, but requesting Ativan Q4hrs and C/O\n claustrophobia. Lung snds rhonchorous, diminished in bases. Suctionned\n for mod -copiousamts blood-tinged, thick, tan secretions. Other VS\n stable with HR 73-89SR without VEA, BP 121/49-159/68. Afebrile.\n Fentnayl patch in place.\n Action:\n Pt rec\nd Ativan 1mg Q4hrs. Suctioned PRN. Calcium repleted in am, but\n noted to be not compatible with Ceftriaxone.\n Response:\n Pt remains stable. She reports fair relief from Ativan. Niece @\n bedside.\n Plan:\n Cont PRN Ativan for anxiety, nausea. PO calcium ONLY for repletion. OR\n reported @ 1800 that pt may still go for trach/PEG tonight. Cont prep\n for transfer to rehab.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple skintears, blisters, hematomas on all extremeties,\n with decreasing amts yellow fluid leaking from all limbs. Pt denies\n pain, rec\ning Fentanyl patch for comfort.\n Action:\n Skin tears requiring dsg changes Q2-4hrs. Pt turned freq STS. Heels\n elevated off bed or waffle boots in place. Compression stockings off\n D/T blisters, skin tears on legs.\n Response:\n Weeping cont from impaired skin.\n Plan:\n Cont vigilent skin care. Wound care nurse consulted.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 442992,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Extubated after successful SBT.\n Tired and reintubated early this morning.\n HR/BP control with beta blockers/labetalol\n Spiked fever this morning, with substantial leucocytosis\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Labetalol - 01:45 AM\n Lorazepam (Ativan) - 02:00 AM\n Fentanyl - 03:35 AM\n Diltiazem - 06:45 AM\n Other medications:\n colace, PPI, ASA, statin, xoponex, CHG, nebs, SQI, ceftriaxone 1g IV\n q24, duragesic, SQH, vit D, calcium oral, pred @ 30, dilt 10 mg IV q 6\n hours\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 36.9\nC (98.4\n HR: 95 (80 - 124) bpm\n BP: 97/42(54) {82/39(48) - 190/100(114)} mmHg\n RR: 19 (19 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,852 mL\n 1,054 mL\n PO:\n TF:\n IVF:\n 1,792 mL\n 1,054 mL\n Blood products:\n Total out:\n 2,340 mL\n 410 mL\n Urine:\n 2,340 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -488 mL\n 644 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 373\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 27 cmH2O\n Plateau: 18 cmH2O\n SpO2: 100%\n ABG: ///34/\n Ve: 9.9 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished: )\n Abdominal: Soft, Non-tender\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.2 g/dL\n 349 K/uL\n 135 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 4.7 mEq/L\n 15 mg/dL\n 98 mEq/L\n 138 mEq/L\n 28.0 %\n 41.1 K/uL\n [image002.jpg]\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n WBC\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n Hct\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n Plt\n \n 310\n 349\n Cr\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n Glucose\n 107\n 119\n 102\n 160\n 102\n 106\n 76\n 72\n 135\n Other labs: PT / PTT / INR:13.8/26.3/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Imaging: CXR with no obvious new infiltrate.\n Assessment and Plan\n 70-year-old woman with severe COPD now with acute respiratory failure\n in the setting of Haemophilus influenza infection.\n Respiratory failure\n Trial of extubation after successful SBT but tired and\n reintubated\n Seems reasonable to pursue tracheostomy; will hold off until\n fever/leucocytosis fully evaluated\n Bronchodilators\n Continue present steroids for now\n assess resistance on\n ventilator and consider increase of steroids\n Fever/leucocytosis\n Meets criteria for sepsis but not severe sepsis\n Etiology is not clear: will evaluate for VAP, BSI (doubt),\n and C diff (probable)\n Treat empirically for C diff\n Treat empirically for HAP\n Tachycardia\n Check 12 lead to ensure sinus mechanism\n Trial of volume challenge if persists\n Hold antihypertensives given borderline BP, assuming sinus\n mechanism\n Other issues per ICU team note\n ICU Care\n Nutrition: resume tube feeds\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443000,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 02:33 PM\n events:\n - patient was extubated in the afternoon and metoprolol was dc'ed\n around midnight, patient became more tachypenic, RR 25-35, accessory\n muscle use, retaining CO2 despite CPAP, multiple suctionings and nebs,\n intubated at 3am by anesthesia. given bolus fen/versed sedation.\n per Dr. recs, significant steroid taper (will give\n solumedrol if not taking PO meds)\n - for afib not not responsive to dilt, gave labetalol bolus and started\n on labetalol drip, switched to esmolol drip because relative\n hypotension\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Diltiazem - 01:00 AM\n Labetalol - 01:45 AM\n Lorazepam (Ativan) - 02:00 AM\n Fentanyl - 03:35 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.3\nC (99.1\n HR: 95 (80 - 124) bpm\n BP: 97/42(54) {82/39(48) - 190/100(114)} mmHg\n RR: 19 (19 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,852 mL\n 1,035 mL\n PO:\n TF:\n IVF:\n 1,792 mL\n 1,035 mL\n Blood products:\n Total out:\n 2,340 mL\n 410 mL\n Urine:\n 2,340 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -488 mL\n 625 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 400 (400 - 400) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 373\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 33 cmH2O\n Plateau: 23 cmH2O\n SpO2: 100%\n ABG: ///34/\n Ve: 7.4 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 349 K/uL\n 9.2 g/dL\n 135 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 4.7 mEq/L\n 15 mg/dL\n 98 mEq/L\n 138 mEq/L\n 28.0 %\n 41.1 K/uL\n [image002.jpg]\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n WBC\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n Hct\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n Plt\n \n 310\n 349\n Cr\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n Glucose\n 107\n 119\n 102\n 160\n 102\n 106\n 76\n 72\n 135\n Other labs: PT / PTT / INR:13.8/26.3/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Patient was started on vanc/zosyn. Vanc was d/c\ned once\n it was growth was gram negative. Zosyn was changed to ceftriaxone when\n speciated to H. flu beta-lactamase negative. Patient completed \n day course of HAP and steroid taper when patient passed SBT and was\n extubated. Patient remained extubated for 12 hours and developed sinus\n tachycardia (in the setting of beta blocker withdrawl), tachypnea,\n accessory muscle use and desaturation to low 90s. Patient was given\n trial of nebs and CPAP, patient continued to retain CO2 and patient was\n intubated on . Patient has very poor respiratory reserve and will\n require long-term trach.\n - patient to get trach and peg \n - stopped steroid taper and kept on prednisone 40mg PO daily for now\n - mouthcare, HOB elevated\n # Leukocytosis / fever\n developed 4 hours after reintubation. Patient\n was intubated uneventfully and patient was NPO 48 hours prior to\n procedure. Differential includes VAP vs. aspiration PNA vs aspiration\n pneumonitis. Leukocytosis also in the setting diarrhea and prolonged\n hospitalization could be consistent with c diff.\n - sent BC, UC, cdiff toxin, mini-BAL, and endobronchial\n aspirate cx\n - treating c diff with IV Flagyl and PO vanc , placed on\n contact precautions (started )\n - treating VAP with IV vanc, meropenem/doripenem, and cipro\n (started , cipro to dbl cover pseudomonas), will stop VAP abx on\n if cultures negative\n # tachycardia\n similar to previous, could be from infection or\n hypovolemia. Could also be MAT given resp problems. \n agents.\n - check urine lytes give NS 500cc bolus and recheck lytes\n -\n # Resolved ARF: pre-renal from lasix administration\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg ; will consider changing as is possible to\n cause bronchospasm, could try diltiazem\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # Osteopenia\n was on fosamax as outpatient, in setting of steroid use\n will start ca/vit D\n - ca and vit d supplementation for now\n - consider fosamax when respiratory status starts to stabilize\n .\n # FEN: cont TFs, nutrition following, PEG to be placed Tuesday\n .\n # Prophylaxis: heparin sc TID will change to 2.2 PTT 41 today,\n bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n .\n # Code: FULL\n .\n # Communication\n with patient and niece\n .\n # Disposition: trach and PEG now, case management aware of need for\n rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443001,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 02:33 PM\n events:\n - patient was extubated in the afternoon and metoprolol was dc'ed\n around midnight, patient became more tachypenic, RR 25-35, accessory\n muscle use, retaining CO2 despite CPAP, multiple suctionings and nebs,\n intubated at 3am by anesthesia. given bolus fen/versed sedation.\n per Dr. recs, significant steroid taper (will give\n solumedrol if not taking PO meds)\n - for afib not not responsive to dilt, gave labetalol bolus and started\n on labetalol drip, switched to esmolol drip because relative\n hypotension\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Diltiazem - 01:00 AM\n Labetalol - 01:45 AM\n Lorazepam (Ativan) - 02:00 AM\n Fentanyl - 03:35 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.3\nC (99.1\n HR: 95 (80 - 124) bpm\n BP: 97/42(54) {82/39(48) - 190/100(114)} mmHg\n RR: 19 (19 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,852 mL\n 1,035 mL\n PO:\n TF:\n IVF:\n 1,792 mL\n 1,035 mL\n Blood products:\n Total out:\n 2,340 mL\n 410 mL\n Urine:\n 2,340 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -488 mL\n 625 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 400 (400 - 400) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 373\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 33 cmH2O\n Plateau: 23 cmH2O\n SpO2: 100%\n ABG: ///34/\n Ve: 7.4 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 349 K/uL\n 9.2 g/dL\n 135 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 4.7 mEq/L\n 15 mg/dL\n 98 mEq/L\n 138 mEq/L\n 28.0 %\n 41.1 K/uL\n [image002.jpg]\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n WBC\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n Hct\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n Plt\n \n 310\n 349\n Cr\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n Glucose\n 107\n 119\n 102\n 160\n 102\n 106\n 76\n 72\n 135\n Other labs: PT / PTT / INR:13.8/26.3/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Patient was started on vanc/zosyn. Vanc was d/c\ned once\n it was growth was gram negative. Zosyn was changed to ceftriaxone when\n speciated to H. flu beta-lactamase negative. Patient completed \n day course of HAP and steroid taper when patient passed SBT and was\n extubated. Patient remained extubated for 12 hours and developed sinus\n tachycardia (in the setting of beta blocker withdrawl), tachypnea,\n accessory muscle use and desaturation to low 90s. Patient was given\n trial of nebs and CPAP, patient continued to retain CO2 and patient was\n intubated on . Patient has very poor respiratory reserve and will\n require long-term trach.\n - patient to get trach and peg \n - stopped steroid taper and kept on prednisone 40mg PO daily for now\n - mouthcare, HOB elevated\n # Leukocytosis / fever\n developed 4 hours after reintubation. Patient\n was intubated uneventfully and patient was NPO 48 hours prior to\n procedure. Differential includes VAP vs. aspiration PNA vs aspiration\n pneumonitis. Leukocytosis also in the setting diarrhea and prolonged\n hospitalization could be consistent with c diff.\n - sent BC, UC, cdiff toxin, mini-BAL, and endobronchial\n aspirate cx\n - treating c diff with IV Flagyl and PO vanc , placed on\n contact precautions (started )\n - treating VAP with IV vanc, meropenem/doripenem, and cipro\n (started , cipro to dbl cover pseudomonas), will stop VAP abx on\n if cultures negative\n # tachycardia\n similar to previous, could be from infection or\n hypovolemia. Could also be MAT given resp problems. \n agents.\n - check urine lytes give NS 500cc bolus and recheck lytes\n -\n # Resolved ARF: pre-renal from lasix administration\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg ; will consider changing as is possible to\n cause bronchospasm, could try diltiazem\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # Osteopenia\n was on fosamax as outpatient, in setting of steroid use\n will start ca/vit D\n - ca and vit d supplementation for now\n - consider fosamax when respiratory status starts to stabilize\n .\n # FEN: cont TFs, nutrition following, PEG to be placed Tuesday\n .\n # Prophylaxis: heparin sc TID will change to 2.2 PTT 41 today, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n .\n # Code: FULL\n .\n # Communication\n with patient and niece\n .\n # Disposition: trach and PEG today, case management aware of need for\n rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-03-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 443947,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n :\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Cuff volume: 10 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thin\n Sputum source/amount: Suctioned / Copious\n Comments:\n :\n Comments: Remained off the vent yesterday afternoon. Put on cpap\n overnight to rest but taken off at 6a.m., Currently on a 40% trach\n collar and appears comfortable.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-22 00:00:00.000",
"description": "ICU Attending",
"row_id": 442920,
"text": "CRITICAL CARE STAFF ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n ICU team note from today, including the assessment and plan. I would\n emphasize and add the following points: 70-year-old woman with severe\n COPD now with acute respiratory failure in the setting of Haemophilus\n influenza infection. On exam, she is comfortable on PSV 12/8/.4\n mid 20s. With decrease of PSV to 5/0, she continued to look\n comfortable, with RSBI mid-50s. Breath sounds without wheezes. WBC\n stably elevated; anemia is stable. Bicarb is rising.\n Meds reviewed from .\n Assessment and Plan\n 70-year-old woman with severe COPD, H. flu pneumonia, and respiratory\n failure.\n Although she was planned for trach/PEG today, her RSBI\n suggested that she might do well with SBT. We therefore proceeded with\n SBT. She tolerated SBT x 90 minutes. She has moderate secretions,\n which may limit After discussion with her and her family, we proceeded\n with extubation.\n Continue ceftriaxone for H. flu\n Bronchodilators\n Prednisone taper\n Other issues as per ICU team note above.\n She is critically ill\n 50 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443060,
"text": "Events: Am temp 101.3PO - pan cultured, currently afebrile. D/C\n Ceftriaxone and started on IV Vanco, IV Cipro, IV Doripenem for broad\n coverage, PO Vanco and IV Flagyl for ? CDiff. Increased\n steroids.Contact precautions for CDiff. In early afternoon c/o vague\n pain/anxiety BP 90-100\ns/ drifing down and started fluid bolus- EKG\n neg, given 4mg IV Zofran, 1mg IV pt pulled out OG tube, then\n persistently hypotensive given 3L NS in 500cc NS bolus w/ transient\n trend up @ 1600 to 120\ns/- then down to low 80\ns and received another\n 50cc ND bolus, given NG tube for PO ABX. Friend @ bedside to\n visit-updated. Plan for OR trach/PEG in AM. Needs anesthesia consent.\n NPO @ MD. @ 1800 changed to IV instead of PO Flagyl. CXR for\n confirmation of NG tube.\n Edema, peripheral\n Assessment:\n Mild generalized edema and dependent edema 2+\n Action:\n BP tending down- per team pt dry and new septic shock, turning,\n elevated arms and legs on pillows\n Response:\n No acute change\n Plan:\n Cont to monitor- getting fluid bolus, frequent turning, elevate limbs\n on pillows\n Alteration in Nutrition\n Assessment:\n In Am started of Nutren Pulmonary @ 10cc/hr\n Action:\n Unable to continue-[pt pulled out OG tube, restrained, NG tube back and\n awaiting confirmation via CXR to begin feeding\n Response:\n Plan:\n Start TF- NPO @ pt not fed x 2days\n Impaired Skin Integrity\n Assessment:\n General thin fragile skin w/ mult skin tears bilat legs, mild\n maceration in bilat legs sm amt cont weeping edema\n Action:\n Barrier cream to bilat legs- adaptic on bilat calves and covered w/\n ABD, barrier cream to elbows\npt think and @ risk for mult pressure\n olcers on bony areas\n Response:\n Pt weeping through bilat leg dressings x1 and weeping to saturate pink\n pad\n Plan:\n ? specialized bed, frequent turning\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443061,
"text": "Events: Am temp 101.3PO - pan cultured, currently afebrile. D/C\n Ceftriaxone and started on IV Vanco, IV Cipro, IV Doripenem for broad\n coverage, PO Vanco and IV Flagyl for ? CDiff. Increased steroids.\n Contact precautions for CDiff. In early afternoon c/o vague\n pain/anxiety BP 90-100\ns/ drifting down and started fluid bolus- EKG\n neg, given 4mg IV Zofran, 1mg IV pt pulled out OG tube, then\n persistently hypotensive given 3L NS in 500cc NS bolus w/ transient\n trend up @ 1600 to 120\ns/- then down to low 80\ns and received another\n 50cc ND bolus, given NG tube for PO ABX. Friend @ bedside to\n visit-updated. Plan for OR trach/PEG in AM. Needs anesthesia consent.\n NPO @ MD. @ 1800 changed to IV instead of PO Flagyl. CXR for\n confirmation of NG tube.\n Edema, peripheral\n Assessment:\n Mild generalized edema and dependent edema 2+\n Action:\n BP tending down- per team pt dry and new septic shock, turning,\n elevated arms and legs on pillows\n Response:\n No acute change\n Plan:\n Cont to monitor- getting fluid bolus, frequent turning, elevate limbs\n on pillows\n Alteration in Nutrition\n Assessment:\n In Am started of Nutren Pulmonary @ 10cc/hr\n Action:\n Unable to continue-[pt pulled out OG tube, restrained, NG tube back and\n awaiting confirmation via CXR to begin feeding\n Response:\n Plan:\n Start TF- NPO @ pt not fed x 2days\n Impaired Skin Integrity\n Assessment:\n General thin fragile skin w/ mult skin tears bilat legs, mild\n maceration in bilat legs sm amt cont weeping edema, on coccyx sm\n pink area-blanching\n Action:\n Barrier cream to bilat legs- adaptic on bilat calves and covered w/\n ABD, barrier cream to elbows\npt think and @ risk for mult pressure\n ulcers on bony areas\n Response:\n Pt weeping through bilat leg dressings x1 and weeping to saturate pink\n pad\n Plan:\n ? order specialized bed, frequent turning, barrier cream, wound care\n Sepsis without organ dysfunction\n Assessment:\n Fever spike/hypotensive\n Action:\n Given total 3.5L throughout day, broad coverage ABX-PO and IV, pan\n cultures\n Response:\n Currently afebrile\n Plan:\n Follow cultures, monitor temp curve, cont IV and PO ABX\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS very tight/diminished, mild wheezy bilat, sat 97-10%, RR 20\n Action:\n In AM changed to 40% FIo2 (60%)- nebs by resp, no further vent changes\n Response:\n No acute change\n Plan:\n Cont vent settings, monitor O2 sat, nebs for severe COPD\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443118,
"text": "Chief Complaint:\n 24 Hour Events:\n - started IV flagyl/PO vanco for possible c.diff; IV vanco, doripenem,\n cipro for possible HAP\n - stop VAP ABX on Monday if cxs negative****\n - OG pulled out; placed new NG tube\n - had chest/epigastic pain, EKG unchanged; responded to zofran and\n started feeling better\n - moderately hypotensive to SBPs in 80s most of afternoon; would\n transiently respond to 500 cc boluses\n - BPs stabalized overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Ciprofloxacin - 09:00 PM\n Vancomycin - 12:00 AM\n Metronidazole - 02:04 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Lorazepam (Ativan) - 05:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 36.9\nC (98.4\n HR: 87 (71 - 112) bpm\n BP: 108/51(65) {76/34(44) - 159/61(83)} mmHg\n RR: 21 (16 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 6,218 mL\n 359 mL\n PO:\n TF:\n 160 mL\n IVF:\n 6,058 mL\n 319 mL\n Blood products:\n Total out:\n 1,060 mL\n 360 mL\n Urine:\n 1,060 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,158 mL\n -2 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 58\n PIP: 19 cmH2O\n Plateau: 21 cmH2O\n Compliance: 49.5 cmH2O/mL\n SpO2: 96%\n ABG: ///30/\n Ve: 9.9 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished: )\n Abdominal: Soft, Non-tender\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 314 K/uL\n 7.3 g/dL\n 79 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 102 mEq/L\n 139 mEq/L\n 22.4 %\n 31.2 K/uL\n [image002.jpg]\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n WBC\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n Hct\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n Plt\n 255\n 279\n 251\n 258\n 14\n Cr\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n Glucose\n 119\n 102\n 160\n 102\n 106\n 76\n 72\n 135\n 79\n Other labs: PT / PTT / INR:15.9/33.9/1.4, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:6.7 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-23 00:00:00.000",
"description": "Generic Note",
"row_id": 443064,
"text": "TITLE:\n Events:\n sBp in 80\ns at hrs , 250 mls fluid bolus given with good effect.\n Feed restarted at hrs, will be held t midnight for ? procedures in\n am.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443416,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit. Failure to wean with\n original plan to trach/PEG by IP. Pt did well on RSBI (score\n 50), and passed SBT so extubated at 1400. Patient reintubated at\n at 0200. Pt now awaiting Trach./PEG scheduled for Monday .\n EVENTS: CXR for NGT placement confirmation, and it is OK to use and TF\n started .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Multiple skin tear sites. Pt has very fragile skin secondary to\n chronic steroid use. Generalized edema throughout body.+2-+4mm. Skin\n weeping large amounts of serous/ serosanguinous fluid continueously.\n Left lower leg hematoma burst today causing skin tear.\n Action:\n Dressing changes as needed secondary to weeping\n Response:\n Weeping serosanguious fluid from multiple ares of broken skin\n Plan:\n Skin care consults on Monday. Frequent dressing changes to keep clean\n and dry\n"
},
{
"category": "Rehab Services",
"chartdate": "2158-02-28 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 443851,
"text": "Subjective:\n Objective:\n Follow up PT visit to address goals of: .\n Updated medical status: s/p trach/PEG\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n C Rail\n\n\n\n\n\n T\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 82\n 114/38\n 12\n 98%\n Activity\n Sit\n 96\n 105/50\n 16\n 96%\n Recovery\n Sit\n 90\n 102/52\n 16\n 97%\n Total distance walked:\n Minutes:\n Tranfer: Pt was total A for slideboard to stretcher chair.\n Balance: Min A for unsupported sitting. Able to tolerate 2min x3Reps,\n limited by c/o fatigue.\n Education / Communication: c RN RE Pt Status\n Pt RE Importance of OOB\n Other: Pulm: CPAP FiO2 40%. PEEP 5. PSupp 5. TV .475(Supine)\n .515(Seated)\n Diminished at bases.\n Assessment: Pt is a 70F c COPD/Respiratory failure p/w continued\n limitations in functional mobility. Pt was limited today by c/o fatigue\n deconditioning. Pt tolerated one hour in chair but was assisted\n back to bed by RN hypotension. Pt will require STR at D/C.\n Anticipated Discharge: Rehab\n Plan: Progress tolerance for unsupported sitting\n Asses functional transfer.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442918,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt extubated\n Action:\n Pt placed on SBT ps 5 peep 0 40%, tolerated well, VBG sent\n Extubated at ~1400 trache/peg currently on hold\n Placed on high flow face tent with o2 sats >90%\n Pt with weak cough, unable to vocalize at this time, and unable to\n tolerate po\n Pt anxious, med with ativan 1mg iv x2 with good effect, niece in to\n visit\n Response:\n Exutbated\n Plan:\n Speech and swallow eval ordered for \n Enc cough deep breathing to clear secretions\n Ativan prn for anxiety\n Case managewment following, being screened for rehab\n Impaired Skin Integrity\n Assessment:\n Multiple skin tears\n Action:\n Pt with skin tears on 3 out of 4 extremites, weeping mod amounts serous\n fluid, dressing changed x2, softsorb and adaptic applied to sites,\n allevyne applied to right elbow\n Pt with multiple ecchymotic areas all over body\n Response:\n Multiple skin issues\n Plan:\n Dressing changes prn\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442972,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 02:33 PM\n events:\n - patient was extubated in the afternoon and metoprolol was dc'ed\n around midnight, patient became more tachypenic, RR 25-35, accessory\n muscle use, retaining CO2 despite CPAP, multiple suctionings and nebs,\n intubated at 3am by anesthesia. given bolus fen/versed sedation.\n per Dr. recs, significant steroid taper (will give\n solumedrol if not taking PO meds)\n - for afib not not responsive to dilt, gave labetalol bolus and started\n on labetalol drip, switched to esmolol drip because relative\n hypotension\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Diltiazem - 01:00 AM\n Labetalol - 01:45 AM\n Lorazepam (Ativan) - 02:00 AM\n Fentanyl - 03:35 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.3\nC (99.1\n HR: 95 (80 - 124) bpm\n BP: 97/42(54) {82/39(48) - 190/100(114)} mmHg\n RR: 19 (19 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,852 mL\n 1,035 mL\n PO:\n TF:\n IVF:\n 1,792 mL\n 1,035 mL\n Blood products:\n Total out:\n 2,340 mL\n 410 mL\n Urine:\n 2,340 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -488 mL\n 625 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 400 (400 - 400) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 373\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 33 cmH2O\n Plateau: 23 cmH2O\n SpO2: 100%\n ABG: ///34/\n Ve: 7.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 349 K/uL\n 9.2 g/dL\n 135 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 4.7 mEq/L\n 15 mg/dL\n 98 mEq/L\n 138 mEq/L\n 28.0 %\n 41.1 K/uL\n [image002.jpg]\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n WBC\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n Hct\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n Plt\n \n 310\n 349\n Cr\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n Glucose\n 107\n 119\n 102\n 160\n 102\n 106\n 76\n 72\n 135\n Other labs: PT / PTT / INR:13.8/26.3/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442975,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 02:33 PM\n events:\n - patient was extubated in the afternoon and metoprolol was dc'ed\n around midnight, patient became more tachypenic, RR 25-35, accessory\n muscle use, retaining CO2 despite CPAP, multiple suctionings and nebs,\n intubated at 3am by anesthesia. given bolus fen/versed sedation.\n per Dr. recs, significant steroid taper (will give\n solumedrol if not taking PO meds)\n - for afib not not responsive to dilt, gave labetalol bolus and started\n on labetalol drip, switched to esmolol drip because relative\n hypotension\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Diltiazem - 01:00 AM\n Labetalol - 01:45 AM\n Lorazepam (Ativan) - 02:00 AM\n Fentanyl - 03:35 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.3\nC (99.1\n HR: 95 (80 - 124) bpm\n BP: 97/42(54) {82/39(48) - 190/100(114)} mmHg\n RR: 19 (19 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,852 mL\n 1,035 mL\n PO:\n TF:\n IVF:\n 1,792 mL\n 1,035 mL\n Blood products:\n Total out:\n 2,340 mL\n 410 mL\n Urine:\n 2,340 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -488 mL\n 625 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 400 (400 - 400) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 373\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 33 cmH2O\n Plateau: 23 cmH2O\n SpO2: 100%\n ABG: ///34/\n Ve: 7.4 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 349 K/uL\n 9.2 g/dL\n 135 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 4.7 mEq/L\n 15 mg/dL\n 98 mEq/L\n 138 mEq/L\n 28.0 %\n 41.1 K/uL\n [image002.jpg]\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n WBC\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n Hct\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n Plt\n \n 310\n 349\n Cr\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n Glucose\n 107\n 119\n 102\n 160\n 102\n 106\n 76\n 72\n 135\n Other labs: PT / PTT / INR:13.8/26.3/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442978,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 02:33 PM\n events:\n - patient was extubated in the afternoon and metoprolol was dc'ed\n around midnight, patient became more tachypenic, RR 25-35, accessory\n muscle use, retaining CO2 despite CPAP, multiple suctionings and nebs,\n intubated at 3am by anesthesia. given bolus fen/versed sedation.\n per Dr. recs, significant steroid taper (will give\n solumedrol if not taking PO meds)\n - for afib not not responsive to dilt, gave labetalol bolus and started\n on labetalol drip, switched to esmolol drip because relative\n hypotension\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Diltiazem - 01:00 AM\n Labetalol - 01:45 AM\n Lorazepam (Ativan) - 02:00 AM\n Fentanyl - 03:35 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.3\nC (99.1\n HR: 95 (80 - 124) bpm\n BP: 97/42(54) {82/39(48) - 190/100(114)} mmHg\n RR: 19 (19 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,852 mL\n 1,035 mL\n PO:\n TF:\n IVF:\n 1,792 mL\n 1,035 mL\n Blood products:\n Total out:\n 2,340 mL\n 410 mL\n Urine:\n 2,340 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -488 mL\n 625 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 400 (400 - 400) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 373\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 33 cmH2O\n Plateau: 23 cmH2O\n SpO2: 100%\n ABG: ///34/\n Ve: 7.4 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 349 K/uL\n 9.2 g/dL\n 135 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 4.7 mEq/L\n 15 mg/dL\n 98 mEq/L\n 138 mEq/L\n 28.0 %\n 41.1 K/uL\n [image002.jpg]\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n WBC\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n Hct\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n Plt\n \n 310\n 349\n Cr\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n Glucose\n 107\n 119\n 102\n 160\n 102\n 106\n 76\n 72\n 135\n Other labs: PT / PTT / INR:13.8/26.3/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Initally, vanc was d/c\ned and patient was kept on Zosyn\n until found to be flu beta-lactamase negative. Sputum showed moderate\n H. flu beta-lactamase negative, changed to ceftriaxone.\n - did well on pressure support trials, RISBI in 50s today, doing a SBT\n trial to see if extubation prior to ? trach should be tried, per resp\n therapy, may have a hard time with secretions; likely will get trach\n and peg today\n - continue ceftriaxone for total of 14 days, day today\n - plan for trach and PEG today if fails SBT\n - will quickly taper prednisone\n 40 mg today, 30 tomorrow, 20 the\n next, then 10 daily for basal dosing\n - mouthcare, HOB elevated\n .\n # ARF: pre-renal from lasix administration -> holding lasix for now,\n free water flushes at 250cc q4h\n - normal Na\n - ARF resolved\n .\n # Hypotension: Resolved, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2 months of prednisone use and patient had initially\n been given Hydrocortisone. Aggressive resuscitation with IVF, s/p 10L\n of IVF on initial presentation.\n - Hypotension now resolved\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg ; will consider changing as is possible to\n cause bronchospasm, could try diltiazem\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - guiac positive\n - steady drop likely from phlebotomy, will transfuse for Hct <24\n - maintain active type & screen\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative, no tx needed\n .\n # Osteopenia\n was on fosamax as outpatient, in setting of steroid use\n will start ca/vit D\n - ca and vit d supplementation for now\n - consider fosamax when respiratory status starts to stabilize\n .\n # FEN: cont TFs, nutrition following, PEG to be placed Tuesday\n .\n # Prophylaxis: heparin sc TID will change to 2.2 PTT 41 today,\n bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n .\n # Code: FULL\n .\n # Communication\n with patient and niece\n .\n # Disposition: trach and PEG now, case management aware of need for\n rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443120,
"text": "Chief Complaint:\n 24 Hour Events:\n - started IV flagyl/PO vanco for possible c.diff; IV vanco, doripenem,\n cipro for possible HAP\n - stop VAP ABX on Monday if cxs negative****\n - OG pulled out; placed new NG tube\n - had chest/epigastic pain, EKG unchanged; responded to zofran and\n started feeling better\n - moderately hypotensive to SBPs in 80s most of afternoon; would\n transiently respond to 500 cc boluses\n - BPs stabalized overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Ciprofloxacin - 09:00 PM\n Vancomycin - 12:00 AM\n Metronidazole - 02:04 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Lorazepam (Ativan) - 05:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 36.9\nC (98.4\n HR: 87 (71 - 112) bpm\n BP: 108/51(65) {76/34(44) - 159/61(83)} mmHg\n RR: 21 (16 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 6,218 mL\n 359 mL\n PO:\n TF:\n 160 mL\n IVF:\n 6,058 mL\n 319 mL\n Blood products:\n Total out:\n 1,060 mL\n 360 mL\n Urine:\n 1,060 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,158 mL\n -2 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 58\n PIP: 19 cmH2O\n Plateau: 21 cmH2O\n Compliance: 49.5 cmH2O/mL\n SpO2: 96%\n ABG: ///30/\n Ve: 9.9 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished: )\n Abdominal: Soft, Non-tender\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 314 K/uL\n 7.3 g/dL\n 79 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 102 mEq/L\n 139 mEq/L\n 22.4 %\n 31.2 K/uL\n [image002.jpg]\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n WBC\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n Hct\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n Plt\n 255\n 279\n 251\n 258\n 14\n Cr\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n Glucose\n 119\n 102\n 160\n 102\n 106\n 76\n 72\n 135\n 79\n Other labs: PT / PTT / INR:15.9/33.9/1.4, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:6.7 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Patient was started on vanc/zosyn. Vanc was d/c\ned once\n it was growth was gram negative. Zosyn was changed to ceftriaxone when\n speciated to H. flu beta-lactamase negative. Patient completed \n day course of HAP and steroid taper when patient passed SBT and was\n extubated. Patient remained extubated for 12 hours and developed sinus\n tachycardia (in the setting of beta blocker withdrawl), tachypnea,\n accessory muscle use and desaturation to low 90s. Patient was given\n trial of nebs and CPAP, patient continued to retain CO2 and patient was\n intubated on . Patient has very poor respiratory reserve and will\n require long-term trach.\n - patient to get Trach/PEG when leukocytosis/fever further evaluated\n - continue prednisone 60mg PO and will taper to 40mg in two days\n - mouthcare, HOB elevated\n .\n # Leukocytosis / Fever\n developed 4 hours after reintubation. Patient\n was intubated uneventfully and patient was NPO 48 hours prior to\n procedure. Differential includes VAP vs. aspiration PNA vs aspiration\n pneumonitis. Leukocytosis also in the setting diarrhea and prolonged\n hospitalization could be consistent with c diff.\n - f/u BC, UC, cdiff toxin, mini-BAL, and endobronchial\n aspirate cx\n - treating c diff with IV Flagyl and PO vanc , placed on\n contact precautions (started )\n - treating VAP with IV vanc, doripenem and cipro (started\n , cipro to dbl cover pseudomonas), will stop VAP abx on if\n cultures negative\n .\n # Tachycardia\n similar to previous, could be from infection or\n hypovolemia. Could also be MAT given resp problems. \n agents. Responded to fluid boluses .\n - Sinus tach on EKG \n - Fluid challenge PRN\n - Hold anti-HTN meds\n .\n # Resolved ARF: Pre-renal from hypovolemia/sepsis, now improved.\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg ; will consider changing as is possible to\n cause bronchospasm, could try diltiazem\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # Osteopenia\n was on fosamax as outpatient, in setting of steroid use\n will start Ca/Vit D\n - Ca and Vit D supplementation for now\n - re-start fosamax when respiratory status starts to stabilize\n .\n # FEN: cont TFs, nutrition following, awaiting PEG\n .\n # Prophylaxis: heparin sc BID, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n .\n # Code: FULL\n .\n # Communication\n with patient and niece\n .\n # Disposition: case management aware of need for rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443121,
"text": "Chief Complaint:\n 24 Hour Events:\n - started IV flagyl/PO vanco for possible c.diff; IV vanco, doripenem,\n cipro for possible HAP\n - stop VAP ABX on Monday if cxs negative****\n - OG pulled out; placed new NG tube\n - had chest/epigastic pain, EKG unchanged; responded to zofran and\n started feeling better\n - moderately hypotensive to SBPs in 80s most of afternoon; would\n transiently respond to 500 cc boluses\n - BPs stabalized overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Ciprofloxacin - 09:00 PM\n Vancomycin - 12:00 AM\n Metronidazole - 02:04 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Lorazepam (Ativan) - 05:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 36.9\nC (98.4\n HR: 87 (71 - 112) bpm\n BP: 108/51(65) {76/34(44) - 159/61(83)} mmHg\n RR: 21 (16 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 6,218 mL\n 359 mL\n PO:\n TF:\n 160 mL\n IVF:\n 6,058 mL\n 319 mL\n Blood products:\n Total out:\n 1,060 mL\n 360 mL\n Urine:\n 1,060 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,158 mL\n -2 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 58\n PIP: 19 cmH2O\n Plateau: 21 cmH2O\n Compliance: 49.5 cmH2O/mL\n SpO2: 96%\n ABG: ///30/\n Ve: 9.9 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished: )\n Abdominal: Soft, Non-tender\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 314 K/uL\n 7.3 g/dL\n 79 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 102 mEq/L\n 139 mEq/L\n 22.4 %\n 31.2 K/uL\n [image002.jpg]\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n WBC\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n Hct\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n Plt\n 255\n 279\n 251\n 258\n 14\n Cr\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n Glucose\n 119\n 102\n 160\n 102\n 106\n 76\n 72\n 135\n 79\n Other labs: PT / PTT / INR:15.9/33.9/1.4, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:6.7 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Patient was started on vanc/zosyn. Vanc was d/c\ned once\n it was growth was gram negative. Zosyn was changed to ceftriaxone when\n speciated to H. flu beta-lactamase negative. Patient completed \n day course of HAP and steroid taper when patient passed SBT and was\n extubated. Patient remained extubated for 12 hours and developed sinus\n tachycardia (in the setting of beta blocker withdrawl), tachypnea,\n accessory muscle use and desaturation to low 90s. Patient was given\n trial of nebs and CPAP, patient continued to retain CO2 and patient was\n intubated on . Patient has very poor respiratory reserve and will\n require long-term trach.\n - patient to get Trach/PEG when leukocytosis/fever further evaluated\n - continue prednisone 60mg PO and will taper to 40mg in two days\n - mouthcare, HOB elevated\n .\n # Leukocytosis / Fever\n developed 4 hours after reintubation. Patient\n was intubated uneventfully and patient was NPO 48 hours prior to\n procedure. Differential includes VAP vs. aspiration PNA vs aspiration\n pneumonitis. Leukocytosis also in the setting diarrhea and prolonged\n hospitalization could be consistent with c diff.\n - f/u BC, UC, cdiff toxin, mini-BAL, and endobronchial\n aspirate cx (neg gram stain on mini BAL)\n - treating c diff with IV Flagyl and PO vanc , placed on\n contact precautions (started )\n - treating VAP with IV vanc, doripenem and cipro (started\n , cipro to dbl cover pseudomonas), will stop VAP abx on if\n cultures negative\n .\n # Tachycardia\n similar to previous, could be from infection or\n hypovolemia. Could also be MAT given resp problems. \n agents. Responded to fluid boluses .\n - Sinus tach on EKG \n - Fluid challenge PRN\n - Hold anti-HTN meds\n .\n # Resolved ARF: Pre-renal from hypovolemia/sepsis, now improved.\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg ; will consider changing as is possible to\n cause bronchospasm, could try diltiazem\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # Osteopenia\n was on fosamax as outpatient, in setting of steroid use\n will start Ca/Vit D\n - Ca and Vit D supplementation for now\n - re-start fosamax when respiratory status starts to stabilize\n .\n # FEN: cont TFs, nutrition following, awaiting PEG\n .\n # Prophylaxis: heparin sc BID, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n .\n # Code: FULL\n .\n # Communication\n with patient and niece\n .\n # Disposition: case management aware of need for rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-24 00:00:00.000",
"description": "ICU attending",
"row_id": 443142,
"text": "CRITICAL CARE STAFF ADDENDUM\n 10:25 a\n I saw and examined Ms. with the ICU team, whose note from today\n reflects my input. I would add/emphasize that she responded to volume\n challenge with improved blood pressure. Fever and WBC have both\n improved, though she still has marked leucocytosis. She is comfortable\n on PSV. Breaths sounds are distant but clear, heart is regular, and\n abdomen is soft. WBC is 31; Hct is 22. CXR is essentially unchanged.\n A/P\n 70-year-old woman with severe COPD now with acute respiratory failure\n in the setting of Haemophilus influenza infection. Main intercurrent\n issue was failed trial of extubation followed by fever/leucocytosis.\n Respiratory failure\n Trial of extubation after successful SBT but tired and\n reintubated\n Seems reasonable to pursue tracheostomy; will try to get her\n on the schedule today\n Bronchodilators\n Steroid taper\n Fever/leucocytosis\n Etiology is not clear: following cx for VAP, BSI (doubt),\n and C diff (probable)\n Treating empirically for C diff\n Treating empirically for HAP\n If cx negative on Monday, d/c ABX\n Tachycardia\n Appears to have been largely hypovolemic.\n Anemia\n Will transfuse at Hct of 22 since planned for operative\n intervention today\n Other issues per ICU team note\n She is critically ill: 35 min\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443116,
"text": "Chief Complaint:\n 24 Hour Events:\n - started IV flagyl/PO vanco for possible c.diff; IV vanco, doripenem,\n cipro for possible HAP\n - stop VAP ABX on Monday if cxs negative****\n - OG pulled out; placed new NG tube\n - had chest/epigastic pain, EKG unchanged; responded to zofran and\n started feeling better\n - moderately hypotensive to SBPs in 80s most of afternoon; would\n transiently respond to 500 cc boluses\n - BPs stabalized overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Ciprofloxacin - 09:00 PM\n Vancomycin - 12:00 AM\n Metronidazole - 02:04 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Lorazepam (Ativan) - 05:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 36.9\nC (98.4\n HR: 87 (71 - 112) bpm\n BP: 108/51(65) {76/34(44) - 159/61(83)} mmHg\n RR: 21 (16 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 6,218 mL\n 359 mL\n PO:\n TF:\n 160 mL\n IVF:\n 6,058 mL\n 319 mL\n Blood products:\n Total out:\n 1,060 mL\n 360 mL\n Urine:\n 1,060 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,158 mL\n -2 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 58\n PIP: 19 cmH2O\n Plateau: 21 cmH2O\n Compliance: 49.5 cmH2O/mL\n SpO2: 96%\n ABG: ///30/\n Ve: 9.9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 314 K/uL\n 7.3 g/dL\n 79 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 102 mEq/L\n 139 mEq/L\n 22.4 %\n 31.2 K/uL\n [image002.jpg]\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n WBC\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n Hct\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n Plt\n 255\n 279\n 251\n 258\n 14\n Cr\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n Glucose\n 119\n 102\n 160\n 102\n 106\n 76\n 72\n 135\n 79\n Other labs: PT / PTT / INR:15.9/33.9/1.4, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:6.7 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443413,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit. Failure to wean with\n original plan to trach/PEG by IP. Pt did well on RSBI (score\n 50), and passed SBT so extubated at 1400. Patient reintubated at\n at 0200. Pt now awaiting Trach./PEG scheduled for Monday .\n EVENTS: CXR for NGT placement confirmation, and it is OK to use and TF\n started .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443551,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit. Failure to wean with\n original plan to trach/PEG by IP. Pt did well on RSBI (score\n 50), and passed SBT so extubated at 1400. Patient reintubated at\n at 0200. Pt now awaiting Trach./PEG scheduled for Monday .\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443552,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit. Failure to wean with\n original plan to trach/PEG by IP. Pt did well on RSBI (score\n 50), and passed SBT so extubated at 1400. Patient reintubated at\n at 0200. Pt now awaiting Trach./PEG scheduled for Monday .\n Impaired Skin Integrity\n Assessment:\n Multiple skin tears. Fragile skin secondary to chronic steroid use. .\n Action:\n Dressings changed as needed q 4 hours.\n Response:\n No change. Large amount of weeping from skin throughout the day\n Plan:\n Skin care consult in am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on PSV 8/8 @40% LS diminished at bases. Large amount of\n secretions suctioned Pt remains on antibx coverage for pseudomonas.\n Action:\n No change in plan of care. Awaiting trach in am.\n Response:\n Unchanged\n Plan:\n Trach and PEG tomorrow. Pt on OR schedule as add on. NPO after midnoc\n for procedure tomorrow.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442965,
"text": "PMH: 70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic\n resp failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum\n now showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin\n with multiple tears, weeping. Intubated on admit. Failure to wean\n with original plan to trach/PEG by IP. Pt did well on RSBI \n (score 50), and passed SBT so extubated at 1400. Pt is being\n followe by case mgt for rehab.\n Events: Pt became tachycardic, tachypnic, increased BP at MN on .\n VBG indicated elevated CO2, pt originally not responsive to IV\n diltiazem, responsive to IV labetolol IVP 10 mg x 2 to control HR/BP.\n However resp status not improved, pt re-intubated at 0200. Labetolol\n gtt started for rate / BP control but \nt s/p intubation as SBP\n dropped to 84/38 (51). ET tube / OG tube placement confirmed.\n Of note pt\ns WBC elevated this AM to 41.1 from 19.5 o , intern\n notified. T max overnight 99.1 F oral.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt appeared comfortable early in evening, then decompensated as above.\n HR to 120s, SBP to 170s, tachypnic to 30 w/ Sp02 dropping to 87% face\n tent 70% Fi02.\n Action:\n Attempted bipap w/o improvement, pt re-intubated as above: AC\n 60%/500/18/8.\n Response:\n Sp02 98-100%, RR 18-19, VBG shows pC02 of 62 and improved.\n Plan:\n Monitor resp status, re-introduce trach/PEG plan.\n Impaired Skin Integrity\n Assessment:\n Pt w/ mult skin tears all extremities, weeping anasarca. Coccyx w/\n reddened area on R, skin intact.\n Action:\n Dressings changed PRN to bilat LEs, L medial thigh. Mushroom cath\n replaced. Steroid taper.\n Response:\n Skin integrity remains impaired.\n Plan:\n Maintain vigilant skin care.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443048,
"text": "Events: Am temp 101.3PO - pan cultured. D/C\nd Ceftriaxone and started\n on IV Vanco, IV Cipro, IV Doripenem for broad coverade, PO Vanco and IV\n Flagyl for ? CDiff. In early afternoon c/o vague pain/anxiety BP\n 90-100\ns/ drifing down and started fluid bolus- EKG neg, given 4mg IV\n Zofran, 1mg IV pt pulled out OG tube, then persistently\n hypotensive given 3L NS in 500cc NS bolus w/ transient trend up @ 1600\n to 120\ns/- then down to low 80\ns and received another 50cc ND bolus,\n given NG tube for PO ABX. Friend\n Edema, peripheral\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-24 00:00:00.000",
"description": "Generic Note",
"row_id": 443107,
"text": "TITLE:\n Events:\n SBP in 80\ns at hrs , 250 mls fluid bolus given with good effect.\n Feed restarted at hrs, held at midnight for ? trach & Peg in am.\n HCT down to 22 in am labs, ? Dilutional to fluid boluses. awaiting\n orders.\n Patient requested for antianxiety med at 0515 am- given 0.5 mgs iv\n Ativan.\n K + 3.5 in am labs- Repleted 20 meq KCL in 50 mls over 1 hour via Picc.\n Glucose in am lab was 79, Fingerstick to be monitored closely as\n patient is NPO.\n Impaired Skin Integrity\n Assessment:\n General thin fragile skin w/ mult skin tears bilat legs, mild\n maceration in bilat legs sm amt cont weeping edema, on coccyx sm\n pink area-blanching\n Action:\n Barrier cream to bilat legs- adaptic on bilat calves and covered w/\n ABD, barrier cream to elbows\npt @ risk for multi pressure ulcers on\n bony areas, PAtienr refused to be turned couple of times during the\n night, after much encouragement & explanations patient agreed to be\n turned each time, she refused for a full bath, agreed for back care,\n bilateral lower extremity care & for the bottom sheet & pad to be\n changed at 5 am.\n Response:\n Pt weeping through bilat leg dressings x1 and weeping to saturate pink\n pad\n Plan:\n Will need to be placed on AIR bed, frequent turning, barrier cream,\n wound care\n Sepsis without organ dysfunction\n Assessment:\n No fever till time noted, BP dropped at hrs to SBP 80\ns, maps of\n 40\n Action:\n Given total of 250 mls of NS, continued on broad coverage ABX-PO and\n IV, endotracheal secretions sent for cultures in am.\n Response:\n BP improved to SBP 120\ns to 130\ns, MAP of 60\ns. WBC in am labs 31.2 (\n 41.1 yesterday)\n Plan:\n Follow cultures, monitor temp curve, cont IV and PO ABX,\n To discuss about replacing the current invasive lines & catheters( the\n Picc is from Outside facility ).\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS very tight/diminished, mild wheezy bilat, sat 97-10%, RR 20\n Action:\n Continued neb treatment by resp, no vent changes\n Response:\n No acute change\n Plan:\n Cont vent settings, monitor O2 sat, nebs for severe COPD\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 443330,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n COPD flare, persistent resp failure\n trach and peg scheduled for monday\n 24 Hour Events:\n Stable on vent\n History obtained from HO\n Patient unable to provide history: intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Ciprofloxacin - 10:00 PM\n Vancomycin - 07:45 AM\n Metronidazole - 10:57 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 04:00 PM\n Lorazepam (Ativan) - 08:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 109 (76 - 109) bpm\n BP: 143/60(81) {111/40(62) - 161/82(100)} mmHg\n RR: 19 (15 - 25) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 2,615 mL\n 1,934 mL\n PO:\n TF:\n 180 mL\n 467 mL\n IVF:\n 1,750 mL\n 567 mL\n Blood products:\n 375 mL\n Total out:\n 1,580 mL\n 795 mL\n Urine:\n 1,530 mL\n 795 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,035 mL\n 1,139 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 443 (430 - 537) mL\n PS : 8 cmH2O\n RR (Spontaneous): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 41\n PIP: 17 cmH2O\n SpO2: 91%\n ABG: ///31/\n Ve: 8.9 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished, no wheezes\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 8.4 g/dL\n 301 K/uL\n 70 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 102 mEq/L\n 135 mEq/L\n 25.6 %\n 25.0 K/uL\n [image002.jpg]\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n WBC\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n Hct\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n Plt\n 279\n 251\n 258\n 01\n Cr\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n Glucose\n 102\n 160\n 102\n 106\n 76\n 72\n 135\n 79\n 70\n Other labs: PT / PTT / INR:14.4/32.5/1.3, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.2 g/dL, LDH:315 IU/L, Ca++:6.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.5 mg/dL\n Microbiology: UA neg\n CDiff neg\n Assessment and Plan\n ALTERATION IN NUTRITION - g-tube scheduled for monday\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) - related to COPD and VAP,\n trach scheduled, wean prednisone, cont bronchodilators\n VAP - continue abx, stop on monday if stabe\n diarrhea - on treatment for CDiff for now, repeat\n CAD - continue current regimen\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 05:30 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443399,
"text": "Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443406,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit. Failure to wean with\n original plan to trach/PEG by IP. Pt did well on RSBI (score\n 50), and passed SBT so extubated at 1400. Patient reintubated at\n at 0200. Pt now awaiting Trach./PEG scheduled for Monday .\n EVENTS:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443702,
"text": "Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443403,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit. Failure to wean with\n original plan to trach/PEG by IP. Pt did well on RSBI (score\n 50), and passed SBT so extubated at 1400.\n Pt became tachycardic, tachypnic, increased BP at MN on . VBG\n indicated elevated CO2, pt originally not responsive to IV diltiazem,\n responsive to IV labetolol IVP 10 mg x 2 to control HR/BP. However\n resp status not improved, pt re-intubated at 0200. Labetolol gtt\n started for rate / BP control but \nt s/p intubation as SBP .\n Pt now awaiting Trach./PEG scheduled for Monday .\n Impaired Skin Integrity\n Assessment:\n Multiple skin tear sites. Pt has very fragile skin secondary to\n chronic steroid use. Generalized edema throughout body.+2-+4mm. Skin\n weeping large amounts of serous/ serosanguinous fluid continueously.\n Left lower leg hematoma burst today causing skin tear. Site worsening\n in appearance as day passed. Site seen by MD. . Pt needed\n encouragement to allow/participate in care today.\n Action:\n Skin sites change multiple times today secondary to weeping.\n Response:\n Left lower extremity worsening in appearance. New rt wrist skin tear\n draining serosanguinous fluid\n Plan:\n Skin care consult on Monday.\n Alteration in Nutrition\n Assessment:\n Pt on nutren FS. Tolerating TF without high residuals. At 1700, NG\n tube noted to be further out of nose. Tube advanced but unable to\n auscultate with air or get residuals. ? if pt could have aspirated\n TF. Team aware\n Action:\n Attempted to readvance tube\n Response:\n Unsure if tube is in place. Xray ordered\n Plan:\n Check Xray when completed to see if ng tube is in place. ? restarting\n TF\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remained on PS @40%. Sxned for copious thick secretions q 2-4\n hours today. LS diminished @ bases. VSS throughout day although pt\n had one episode of increase HR to 130\ns and BP 180\ns. Pt given\n labetolol which pt tolerated well.\n Action:\n Labetolol 10mg given for tachycardia and hypertension. Sxned and nebs\n for resp. status. NO vent changes made today.\n Response:\n Post labetolol HER 85 and bp 113/54.\n Plan:\n Trach and peg Monday. Continue to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443405,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 443755,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Cuff volume: 10 mL /\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Periodic SBT's for conditioning\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Bedside Procedures: No morning abg results at this time. Receiving\n xopenex nebulizers q4 and atrovent mdi in-line. Sx\nd for blood-tinged\n sputum.\n RSBI = 38 on 0-PEEP and 5 cm PSV>\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 443884,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Cuff volume: 10 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt placed on TM this afternoon tolerated well\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: continue TM trials as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 443190,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 29 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments: ETT advanced and 12cc of air taken out of\n cuff cuff pressure from 100 to 29\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Trach planned for monday\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443326,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - plan for Trach/PEG on Monday\n - received 1U PRBC\n - tolerated PSV 8/8 for majority of day\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Ciprofloxacin - 10:00 PM\n Metronidazole - 01:49 AM\n Vancomycin - 05:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:21 AM\n Pantoprazole (Protonix) - 04:00 PM\n Lorazepam (Ativan) - 08:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.4\nC (97.5\n HR: 88 (76 - 102) bpm\n BP: 125/57(74) {93/40(53) - 150/70(84)} mmHg\n RR: 17 (15 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,615 mL\n 1,140 mL\n PO:\n TF:\n 180 mL\n 288 mL\n IVF:\n 1,750 mL\n 322 mL\n Blood products:\n 375 mL\n Total out:\n 1,580 mL\n 295 mL\n Urine:\n 1,530 mL\n 295 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,035 mL\n 845 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 437 (430 - 437) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 41\n PIP: 17 cmH2O\n SpO2: 93%\n ABG: ///31/\n Ve: 10.4 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished: )\n Abdominal: Soft, Non-tender\n Extremities: Right: 2+, Left: 2+, significant BLE edema with skin\n weeping\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 301 K/uL\n 8.4 g/dL\n 70 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 102 mEq/L\n 135 mEq/L\n 25.6 %\n 25.0 K/uL\n [image002.jpg] UA neg, cdiff negx1, sputum GNR, foley - yeast\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n WBC\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n Hct\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n Plt\n 279\n 251\n 258\n 01\n Cr\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n Glucose\n 102\n 160\n 102\n 106\n 76\n 72\n 135\n 79\n 70\n Other labs: PT / PTT / INR:14.4/32.5/1.3, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:6.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Patient was started on vanc/zosyn. Vanc was d/c\ned once\n it was growth was gram negative. Zosyn was changed to ceftriaxone when\n speciated to H. flu beta-lactamase negative. Patient completed \n day course of HAP and steroid taper when patient passed SBT and was\n extubated. Patient remained extubated for 12 hours and developed sinus\n tachycardia (in the setting of beta blocker withdrawl), tachypnea,\n accessory muscle use and desaturation to low 90s. Patient was given\n trial of nebs and CPAP, patient continued to retain CO2 and patient was\n intubated on . Patient has very poor respiratory reserve and will\n require long-term trach.\n - patient to get Trach/PEG on Monday\n - continue prednisone 60mg PO and will taper to 40mg in tomorrow\n - mouthcare, HOB elevated\n .\n # Leukocytosis / Fever\n developed 4 hours after reintubation. Patient\n was intubated uneventfully and patient was NPO 48 hours prior to\n procedure. Differential includes VAP vs. aspiration PNA vs aspiration\n pneumonitis. Leukocytosis also in the setting diarrhea and prolonged\n hospitalization could be consistent with c diff.\n - f/u BC, UC, cdiff toxin, mini-BAL, and endobronchial\n aspirate cx (neg gram stain on mini BAL)\n - treating c diff with IV Flagyl and PO vanc , placed on\n contact precautions (started ), first c diff negative, if second\n negative, will stop tx for c diff\n - treating VAP with IV vanc, doripenem and cipro (started\n , cipro to dbl cover pseudomonas), will stop VAP abx on if\n cultures negative, sputum cx showing GNR, pending speciation\n - yeast in urine, if foley >3d old will change foley\n .\n # Tachycardia\n similar to previous, could be from infection or\n hypovolemia. Could also be MAT given resp problems. \n agents. Responded to fluid boluses .\n - Sinus tach on EKG \n - Fluid challenge PRN\n - Hold anti-HTN meds\n .\n # Resolved ARF: Pre-renal from hypovolemia/sepsis, now improved.\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg ; will consider changing as is possible to\n cause bronchospasm, could try diltiazem\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - will transfuse 1U PRBC today\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # Osteopenia\n was on fosamax as outpatient, in setting of steroid use\n will start Ca/Vit D\n - Ca and Vit D supplementation for now\n - re-start fosamax when respiratory status starts to stabilize\n .\n # FEN: cont TFs, 40cc/hr, running at goal, nutrition following,\n awaiting PEG\n .\n # Prophylaxis: heparin sc BID, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n .\n # Code: FULL\n .\n # Communication\n with patient and niece\n .\n # Disposition: case management aware of need for rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 05:30 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 443493,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n cipro stopped\n NG tube replaced\n stable on vent\n WBC improving\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Metronidazole - 04:10 AM\n Vancomycin - 07:40 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 04:29 PM\n Labetalol - 06:35 PM\n Lorazepam (Ativan) - 08:16 AM\n Other medications:\n ASA\n prednisone\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 98 (75 - 135) bpm\n BP: 154/73(92) {111/47(63) - 188/94(108)} mmHg\n RR: 19 (13 - 24) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 3,012 mL\n 1,001 mL\n PO:\n TF:\n 682 mL\n 400 mL\n IVF:\n 900 mL\n 401 mL\n Blood products:\n Total out:\n 1,920 mL\n 1,330 mL\n Urine:\n 1,920 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,092 mL\n -329 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 462 (412 - 515) mL\n PS : 8 cmH2O\n RR (Spontaneous): 20s\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 17 cmH2O\n SpO2: 97%\n ABG: ///32/\n Ve: 9.9 L/min\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.5 g/dL\n 381 K/uL\n 90 mg/dL\n 0.5 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 102 mEq/L\n 138 mEq/L\n 28.7 %\n 19.7 K/uL\n [image002.jpg]\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n 03:54 AM\n WBC\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n 19.7\n Hct\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n 28.7\n Plt\n \n 301\n 381\n Cr\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n 0.5\n Glucose\n 160\n 102\n 106\n 76\n 72\n 135\n 79\n 70\n 90\n Other labs: PT / PTT / INR:13.7/28.5/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.2 g/dL, LDH:315 IU/L, Ca++:6.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION - g-tube scheduled for monday\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) - related to COPD and VAP,\n trach scheduled, wean prednisone, cont bronchodilators\n pseudomonas VAP - continue abx, complete 7 day course\n diarrhea - improved, on treatment for , stop\n CAD - continue current regimen\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:05 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 443500,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n cipro stopped\n NG tube replaced\n stable on vent\n WBC improving\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Metronidazole - 04:10 AM\n Vancomycin - 07:40 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 04:29 PM\n Labetalol - 06:35 PM\n Lorazepam (Ativan) - 08:16 AM\n Other medications:\n ASA\n prednisone\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 98 (75 - 135) bpm\n BP: 154/73(92) {111/47(63) - 188/94(108)} mmHg\n RR: 19 (13 - 24) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 3,012 mL\n 1,001 mL\n PO:\n TF:\n 682 mL\n 400 mL\n IVF:\n 900 mL\n 401 mL\n Blood products:\n Total out:\n 1,920 mL\n 1,330 mL\n Urine:\n 1,920 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,092 mL\n -329 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 462 (412 - 515) mL\n PS : 8 cmH2O\n RR (Spontaneous): 20s\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 17 cmH2O\n SpO2: 97%\n ABG: ///32/\n Ve: 9.9 L/min\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive,\n Labs / Radiology\n 9.5 g/dL\n 381 K/uL\n 90 mg/dL\n 0.5 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 102 mEq/L\n 138 mEq/L\n 28.7 %\n 19.7 K/uL\n [image002.jpg]\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n 03:54 AM\n WBC\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n 19.7\n Hct\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n 28.7\n Plt\n \n 301\n 381\n Cr\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n 0.5\n Glucose\n 160\n 102\n 106\n 76\n 72\n 135\n 79\n 70\n 90\n Other labs: PT / PTT / INR:13.7/28.5/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.2 g/dL, LDH:315 IU/L, Ca++:6.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION - g-tube scheduled for monday\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) - related to COPD and VAP,\n trach scheduled, wean prednisone, cont bronchodilators\n pseudomonas VAP - continue abx, complete 7 day course\n diarrhea - improved, on treatment for , stop\n CAD - continue current regimen\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:05 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443504,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - stopped cipro\n - NG tube replaced\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Vancomycin - 08:19 PM\n Metronidazole - 04:10 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:11 PM\n Pantoprazole (Protonix) - 04:29 PM\n Labetalol - 06:35 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.2\nC (97.2\n HR: 97 (75 - 135) bpm\n BP: 149/94(107) {111/47(63) - 188/94(108)} mmHg\n RR: 18 (13 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,012 mL\n 533 mL\n PO:\n TF:\n 682 mL\n 266 mL\n IVF:\n 900 mL\n 167 mL\n Blood products:\n Total out:\n 1,920 mL\n 750 mL\n Urine:\n 1,920 mL\n 750 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,092 mL\n -217 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 499 (412 - 537) mL\n PS : 8 cmH2O\n RR (Spontaneous): 19\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 17 cmH2O\n SpO2: 94%\n ABG: ///32/\n Ve: 10.1 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic, intubated; not sedated\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished: ),\n mild rhonchi diffusedly\n Abdominal: Soft, Non-tender, ND, no hsm, normoactive BS\n Extremities: Right: 2+, Left: 2+, significant BLE edema with skin\n weeping\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, interactive appropriately, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 381 K/uL\n 9.5 g/dL\n 90 mg/dL\n 0.5 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 102 mEq/L\n 138 mEq/L\n 28.7 %\n 19.7 K/uL\n [image002.jpg]\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n 03:54 AM\n WBC\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n 19.7\n Hct\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n 28.7\n Plt\n \n 301\n 381\n Cr\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n 0.5\n Glucose\n 160\n 102\n 106\n 76\n 72\n 135\n 79\n 70\n 90\n Other labs: PT / PTT / INR:13.7/28.5/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.2 g/dL, LDH:315 IU/L, Ca++:6.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Patient was started on vanc/zosyn. Vanc was d/c\ned once\n it was growth was gram negative. Zosyn was changed to ceftriaxone when\n speciated to H. flu beta-lactamase negative. Patient completed \n day course of HAP and steroid taper when patient passed SBT and was\n extubated. Patient remained extubated for 12 hours and developed sinus\n tachycardia (in the setting of beta blocker withdrawl), tachypnea,\n accessory muscle use and desaturation to low 90s. Patient was given\n trial of nebs and CPAP, patient continued to retain CO2 and patient was\n intubated on . Patient has very poor respiratory reserve and will\n require long-term trach.\n - s/p ceftriaxone course for h.flu; now being treating for pseudomonas\n \n - patient to get Trach/PEG on Monday\n - continue prednisone, now on 40 mg daily for the next three days, and\n will continue taper\n - mouthcare, HOB elevated\n .\n # Leukocytosis / Fever\n developed 4 hours after reintubation. Patient\n was intubated uneventfully and patient was NPO 48 hours prior to\n procedure. Likely , pt improving with decreasing leukocytosis, has\n not spiked since \n - f/u BC, UC, cdiff toxin, mini-BAL, and endobronchial\n aspirate cx (neg gram stain on mini BAL)\n - first c.diff neg, stopped c.diff treatment\n - treating for pseudomonas plus one other GNR yet to be\n speciated with Vanco and doripenem for now, awaiting speciations\n will\n treat 7 days since last fever\n - foley changed secondary to yeast\n .\n # Tachycardia\n similar to previous, could be from infection or\n hypovolemia v.anxiety. Could also be MAT given resp problems. \n agents. Responded to fluid boluses , tachy with movement,\n when calm around 80s-90s.\n - Sinus tach on EKG \n - Fluid challenge PRN\n - Hold anti-HTN meds\n .\n # Resolved ARF: Pre-renal from hypovolemia/sepsis, now improved.\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily\n will discuss\n aspirin with thoracic team today.\n - continue to monitor on telemetry, follow EKGs\n - holding all agents at this time; afib responds to metoprolol if\n she goes into it, dilt did not work as well\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF.\n Dropped over course of hospitalization, s/p transfusion again on ;\n now stabalized. Anemia likey from phlebotomy, chronic disease\n Transfused one unit PRBC , on on \n - cont to trend\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # Osteopenia\n was on fosamax as outpatient, in setting of steroid use\n will start Ca/Vit D\n - Ca and Vit D supplementation for now\n - re-start fosamax when respiratory status starts to stabilize\n .\n # FEN: cont TFs, 40cc/hr, running at goal, nutrition following,\n awaiting PEG, npo at midnight for procedure tomorrow\n .\n # Prophylaxis: heparin sc BID, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n .\n # Code: FULL\n .\n # Communication\n with patient and niece\n .\n # Disposition: case management aware of need for rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:05 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n :\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443297,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - plan for Trach/PEG on Monday\n - received 1U PRBC\n - tolerated PSV 8/8 for majority of day\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Ciprofloxacin - 10:00 PM\n Metronidazole - 01:49 AM\n Vancomycin - 05:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:21 AM\n Pantoprazole (Protonix) - 04:00 PM\n Lorazepam (Ativan) - 08:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.4\nC (97.5\n HR: 88 (76 - 102) bpm\n BP: 125/57(74) {93/40(53) - 150/70(84)} mmHg\n RR: 17 (15 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,615 mL\n 1,140 mL\n PO:\n TF:\n 180 mL\n 288 mL\n IVF:\n 1,750 mL\n 322 mL\n Blood products:\n 375 mL\n Total out:\n 1,580 mL\n 295 mL\n Urine:\n 1,530 mL\n 295 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,035 mL\n 845 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 437 (430 - 437) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 41\n PIP: 17 cmH2O\n SpO2: 93%\n ABG: ///31/\n Ve: 10.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 301 K/uL\n 8.4 g/dL\n 70 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 102 mEq/L\n 135 mEq/L\n 25.6 %\n 25.0 K/uL\n [image002.jpg]\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n WBC\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n Hct\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n Plt\n 279\n 251\n 258\n 01\n Cr\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n Glucose\n 102\n 160\n 102\n 106\n 76\n 72\n 135\n 79\n 70\n Other labs: PT / PTT / INR:14.4/32.5/1.3, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:6.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 05:30 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443298,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - plan for Trach/PEG on Monday\n - received 1U PRBC\n - tolerated PSV 8/8 for majority of day\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Ciprofloxacin - 10:00 PM\n Metronidazole - 01:49 AM\n Vancomycin - 05:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:21 AM\n Pantoprazole (Protonix) - 04:00 PM\n Lorazepam (Ativan) - 08:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.4\nC (97.5\n HR: 88 (76 - 102) bpm\n BP: 125/57(74) {93/40(53) - 150/70(84)} mmHg\n RR: 17 (15 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,615 mL\n 1,140 mL\n PO:\n TF:\n 180 mL\n 288 mL\n IVF:\n 1,750 mL\n 322 mL\n Blood products:\n 375 mL\n Total out:\n 1,580 mL\n 295 mL\n Urine:\n 1,530 mL\n 295 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,035 mL\n 845 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 437 (430 - 437) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 41\n PIP: 17 cmH2O\n SpO2: 93%\n ABG: ///31/\n Ve: 10.4 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished: )\n Abdominal: Soft, Non-tender\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 301 K/uL\n 8.4 g/dL\n 70 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 102 mEq/L\n 135 mEq/L\n 25.6 %\n 25.0 K/uL\n [image002.jpg]\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n WBC\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n Hct\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n Plt\n 279\n 251\n 258\n 01\n Cr\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n Glucose\n 102\n 160\n 102\n 106\n 76\n 72\n 135\n 79\n 70\n Other labs: PT / PTT / INR:14.4/32.5/1.3, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:6.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 05:30 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443299,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - plan for Trach/PEG on Monday\n - received 1U PRBC\n - tolerated PSV 8/8 for majority of day\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Ciprofloxacin - 10:00 PM\n Metronidazole - 01:49 AM\n Vancomycin - 05:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:21 AM\n Pantoprazole (Protonix) - 04:00 PM\n Lorazepam (Ativan) - 08:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.4\nC (97.5\n HR: 88 (76 - 102) bpm\n BP: 125/57(74) {93/40(53) - 150/70(84)} mmHg\n RR: 17 (15 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,615 mL\n 1,140 mL\n PO:\n TF:\n 180 mL\n 288 mL\n IVF:\n 1,750 mL\n 322 mL\n Blood products:\n 375 mL\n Total out:\n 1,580 mL\n 295 mL\n Urine:\n 1,530 mL\n 295 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,035 mL\n 845 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 437 (430 - 437) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 41\n PIP: 17 cmH2O\n SpO2: 93%\n ABG: ///31/\n Ve: 10.4 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished: )\n Abdominal: Soft, Non-tender\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 301 K/uL\n 8.4 g/dL\n 70 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 102 mEq/L\n 135 mEq/L\n 25.6 %\n 25.0 K/uL\n [image002.jpg]\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n WBC\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n Hct\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n Plt\n 279\n 251\n 258\n 01\n Cr\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n Glucose\n 102\n 160\n 102\n 106\n 76\n 72\n 135\n 79\n 70\n Other labs: PT / PTT / INR:14.4/32.5/1.3, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:6.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Patient was started on vanc/zosyn. Vanc was d/c\ned once\n it was growth was gram negative. Zosyn was changed to ceftriaxone when\n speciated to H. flu beta-lactamase negative. Patient completed \n day course of HAP and steroid taper when patient passed SBT and was\n extubated. Patient remained extubated for 12 hours and developed sinus\n tachycardia (in the setting of beta blocker withdrawl), tachypnea,\n accessory muscle use and desaturation to low 90s. Patient was given\n trial of nebs and CPAP, patient continued to retain CO2 and patient was\n intubated on . Patient has very poor respiratory reserve and will\n require long-term trach.\n - patient to get Trach/PEG on Monday\n - continue prednisone 60mg PO and will taper to 40mg in tomorrow\n - mouthcare, HOB elevated\n .\n # Leukocytosis / Fever\n developed 4 hours after reintubation. Patient\n was intubated uneventfully and patient was NPO 48 hours prior to\n procedure. Differential includes VAP vs. aspiration PNA vs aspiration\n pneumonitis. Leukocytosis also in the setting diarrhea and prolonged\n hospitalization could be consistent with c diff.\n - f/u BC, UC, cdiff toxin, mini-BAL, and endobronchial\n aspirate cx (neg gram stain on mini BAL)\n - treating c diff with IV Flagyl and PO vanc , placed on\n contact precautions (started )\n - treating VAP with IV vanc, doripenem and cipro (started\n , cipro to dbl cover pseudomonas), will stop VAP abx on if\n cultures negative\n .\n # Tachycardia\n similar to previous, could be from infection or\n hypovolemia. Could also be MAT given resp problems. \n agents. Responded to fluid boluses .\n - Sinus tach on EKG \n - Fluid challenge PRN\n - Hold anti-HTN meds\n .\n # Resolved ARF: Pre-renal from hypovolemia/sepsis, now improved.\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg ; will consider changing as is possible to\n cause bronchospasm, could try diltiazem\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - will transfuse 1U PRBC today\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # Osteopenia\n was on fosamax as outpatient, in setting of steroid use\n will start Ca/Vit D\n - Ca and Vit D supplementation for now\n - re-start fosamax when respiratory status starts to stabilize\n .\n # FEN: cont TFs, nutrition following, awaiting PEG\n .\n # Prophylaxis: heparin sc BID, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n .\n # Code: FULL\n .\n # Communication\n with patient and niece\n .\n # Disposition: case management aware of need for rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 05:30 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 443317,
"text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n COPD flare, persistent resp failure\n trach and peg scheduled for monday\n 24 Hour Events:\n History obtained from HO\n Patient unable to provide history: intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Ciprofloxacin - 10:00 PM\n Vancomycin - 07:45 AM\n Metronidazole - 10:57 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 04:00 PM\n Lorazepam (Ativan) - 08:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 109 (76 - 109) bpm\n BP: 143/60(81) {111/40(62) - 161/82(100)} mmHg\n RR: 19 (15 - 25) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 2,615 mL\n 1,934 mL\n PO:\n TF:\n 180 mL\n 467 mL\n IVF:\n 1,750 mL\n 567 mL\n Blood products:\n 375 mL\n Total out:\n 1,580 mL\n 795 mL\n Urine:\n 1,530 mL\n 795 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,035 mL\n 1,139 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 443 (430 - 537) mL\n PS : 8 cmH2O\n RR (Spontaneous): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 41\n PIP: 17 cmH2O\n SpO2: 91%\n ABG: ///31/\n Ve: 8.9 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 8.4 g/dL\n 301 K/uL\n 70 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 102 mEq/L\n 135 mEq/L\n 25.6 %\n 25.0 K/uL\n [image002.jpg]\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n WBC\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n Hct\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n Plt\n 279\n 251\n 258\n 01\n Cr\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n Glucose\n 102\n 160\n 102\n 106\n 76\n 72\n 135\n 79\n 70\n Other labs: PT / PTT / INR:14.4/32.5/1.3, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.2 g/dL, LDH:315 IU/L, Ca++:6.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.5 mg/dL\n Microbiology: UA neg\n CDiff neg\n Assessment and Plan\n ALTERATION IN NUTRITION - g-tube scheduled for monday\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) - related to COPD and VAP,\n trach scheduled, wean prednisone, cont bronchodilators\n VAP - continue abx, stop on monday if stabe\n diarrhea - on treatment for CDiff for now, repeat\n CAD - continue current regimen\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 05:30 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 07:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nutrition",
"chartdate": "2158-02-21 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 442734,
"text": "Objective\n Pertinent medications: Insulin SS, docusate, protonix, abx, prednisone,\n others noted\n Labs:\n Value\n Date\n Glucose\n 76 mg/dL\n 01:55 AM\n Glucose Finger Stick\n 174\n 10:00 AM\n BUN\n 26 mg/dL\n 01:55 AM\n Creatinine\n 0.7 mg/dL\n 01:55 AM\n Sodium\n 142 mEq/L\n 01:55 AM\n Potassium\n 3.9 mEq/L\n 07:30 AM\n Chloride\n 102 mEq/L\n 01:55 AM\n TCO2\n 35 mEq/L\n 01:55 AM\n Calcium non-ionized\n 6.6 mg/dL\n 01:55 AM\n Phosphorus\n 3.7 mg/dL\n 01:55 AM\n Ionized Calcium\n 1.10 mmol/L\n 07:35 AM\n Magnesium\n 1.9 mg/dL\n 01:55 AM\n WBC\n 17.5 K/uL\n 01:55 AM\n Hgb\n 8.4 g/dL\n 01:55 AM\n Hematocrit\n 25.8 %\n 01:55 AM\n Current diet order / nutrition support: NUtren Pulmonary @40mL/hr\n (1440 kcals/65 gr aa)\n GI: Abd: soft/+bs\n Assessment of Nutritional Status\n Specifics:\n TF\ns on hold for trach and PEG today. Pt previously tolerating TF\n goal, meeting 100% estimated nutrition needs. Na WNL c/ increase of\n FWB. BG\ns slightly elevated on steroids. No recent weight available.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: 5 mL liquid multivitamin, consider\n Ca and Vitamin D supplements d/t chronic steroids\n Tube feeding / TPN recommendations: Resume TF's p/ PEG when able\n Decrease FWB as able\n Please check weight\n BG and llyte managements as you are\n Please page c/ ?'s #\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441574,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Pt\ns , \n, called this morning. Stated pt is w/o much\n family and believes she is the next of , but is not her HCP. Pt is\n not married, nor does she have any children.\n Edema, peripheral\n Assessment:\n Anasarca, right leg/foot with less edema than left.\n Action:\n Lasix 20 mgm IV given\n Response:\n 500cc for 1 hr response clear urine\n Plan:\n Cont. to monitor I/O , diures as tol, meticulous skin care\n Alteration in Nutrition\n Assessment:\n Abd soft, rounded, BT active, TF Nutren Pulm. At goal 40 cc hr with min\n . residuals, no stools this shift did give stool softner and senna\n Action:\n Cont. tf at goal rate, flush 30 cc q 8 hr\n Response:\n No stool. Tol. Tf well\n Plan:\n Cont. tube feeding at goal, bowel program\n Impaired Skin Integrity\n Assessment:\n Multiple bruises, red areas on extremities, skin tear on right ankle\n and right arm healing, redressed\n Action:\n Redress wounds, barrier cream on ext., turning schedule\n Response:\n No further progression of wounds, currently clean and dry\n Plan:\n Turning schedule, wound care, barrier cream to ext.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On fentanyl 25 mcq/versed at 2 mgm with few bolus for sitting up in\n bed. Suction thick sputum, little in oral cavity, breath sounds\n clear, appears comfortable on current settings. Sats 100%\n Action:\n Pulm. Care, turning, supportive care given. Maintain current levels of\n sedation /analgesia\n Response:\n stable\n Plan:\n Rsbi improved this am. Wbc dropping although 20, wean to extubate\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.5 after lasix, CA 7.0, phos low\n Action:\n Call HO, for orders to replete K+, sliding scale for calcium and phos\n in place\n Response:\n Unknown until repleteion and recheck labs\n Plan:\n Recheck elect. Today, replete as needed\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442654,
"text": "PMH: 70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic\n resp failure and pneumonia. Recent pseudomonas, H Flu in sputum. Sputum\n now showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin\n with multiple tears, weeping. Intubated on admit, now failure to\n wean with plan to trach/PEG by IP. Pt seen by case management\n to eval for rehab.\n Events: TF stopped at MN for surgery tomorrow (T / P). Pt expressed\n anxiety for tomorrow, ambien 5 mg / ativan given as ordered. Pt not\n sleeping well throughout night.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CPAP 40%/. SRR 21-24, Sp02 97-99%. Pt sux\ned for\n copious amts thick, blood tinged sputum. LS clear and dim at bases.\n Pt mentating well, communicating by mouthing words, writing. Pt\n afebrile T max 98.4 oral.\n Action:\n Pt remains on CPAP, neb tx\ns given as ordered. ET tube lavaged to\n improve ability to sux out sputum and secretions.\n Response:\n Pt tolerating CPAP w/o incident, Sp02 remains 97-99%, no tachypnea or\n increased WOB noted.\n Plan:\n Pt consented by surgery and anesthesia for trach and PEG today.\n Impaired Skin Integrity\n Assessment:\n Mult skin tears at all extremities. Mult hematomas, thin fragile skin,\n weeping edema. Lg sanguinous blister at L LE.\n Action:\n Requested wound care consult from team as this RN worries skin\n breakdown may become source of infection. Softsorb, adaptic, and\n dressing changes as needed. Prednisone dose decreased.\n Response:\n Skin is not improved.\n Plan:\n Cont vigilant skin care.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442819,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit, now failure to wean\n with plan to trach/PEG by IP, prep for rehab.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on vent settings CPAP/PS 40% 12/+8 with RR 16-24 and regular. O2\n sat 97-100%. Pt denied SOB, C/O claustrophobia. Lung sounds\n rhonchorous, diminished in bases. Suctioned for mod\ncopious amts\n blood-tinged, thick, tan secretions. Afebrile. Fentnayl patch in\n place.\n Action:\n Pt rec\nd Ativan 1mg Q4hrs PRN. Suctioned PRN. No vent changes\n overnight, NPO for procedure in AM and started D51/2NS 75ml/hr.\n Response:\n Pt remains stable. She reports fair relief from Ativan.\n Plan:\n Cont PRN Ativan for anxiety, nausea. PO calcium ONLY for repletion. For\n trach/PEG in Am. NPO after midnight, Cont prep for transfer to rehab.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple skintears, blisters, hematomas on all extremeties,\n with decreasing amts yellow fluid leaking from all limbs. Pt denies\n pain, rec\ning Fentanyl patch for comfort.\n Action:\n Skin tears requiring dsg changes Q2-4hrs. Pt turned freq STS. Heels\n elevated off bed or waffle boots in place. Compression stockings off\n D/T blisters, skin tears on legs.\n Response:\n Weeping cont from impaired skin.\n Plan:\n Cont vigilent skin care. Wound care nurse consulted.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442737,
"text": "Chief Complaint:\n 24 Hour Events:\n - had PS trial and did well - on PS with improved oxygenation on\n this setting - ABG 7.41/54/172\n - plan for trach and peg tomorrow\n - trouble sleeping, treated with ambien\n - one guaiac positive brown stool, Hct stable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 04:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Lorazepam (Ativan) - 02:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.1\nC (98.8\n HR: 79 (70 - 86) bpm\n BP: 118/44(61) {117/44(61) - 154/68(88)} mmHg\n RR: 23 (16 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,490 mL\n 15 mL\n PO:\n TF:\n 865 mL\n IVF:\n 210 mL\n Blood products:\n Total out:\n 1,430 mL\n 385 mL\n Urine:\n 1,410 mL\n 385 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,060 mL\n -370 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 525 (421 - 525) mL\n PS : 12 cmH2O\n RR (Set): 18\n RR (Spontaneous): 25\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 22 cmH2O\n Plateau: 24 cmH2O\n Compliance: 31.3 cmH2O/mL\n SpO2: 96%\n ABG: ///35/\n Ve: 11.1 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 284 K/uL\n 8.4 g/dL\n 76 mg/dL\n 0.7 mg/dL\n 35 mEq/L\n 5.3 mEq/L\n 26 mg/dL\n 102 mEq/L\n 142 mEq/L\n 25.8 %\n 17.5 K/uL\n [image002.jpg]\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n Plt\n 79\n 251\n 258\n 284\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n TCO2\n 31\n Glucose\n 135\n 107\n 119\n 102\n 160\n 102\n 106\n 76\n Other labs: PT / PTT / INR:13.1/38.5/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:6.6 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Initally, vanc was d/c\ned and patient was kept on Zosyn\n until found to be flu beta-lactamase negative. Sputum showed moderate\n H. flu beta-lactamase negative, changed to ceftriaxone. Patient was\n able to tolerate PS12/PEEP8 for approx 2 hrs \n - will check VBG before and after PS trials\n - continue ceftriaxone for total of 14 days (d/c calcium SS given\n potential interaction)\n - plan for trach and PEG today\n - continue prednisone 40mg daily\n - mouthcare, HOB elevated\n .\n # ARF: pre-renal from lasix administration -> holding lasix for now,\n free water flushes at 250cc q4h (hyper NA improved)\n .\n # Hypotension: Resolved, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2 months of prednisone use and patient had initially\n been given Hydrocortisone. Aggressive resuscitation with IVF, s/p 10L\n of IVF on initial presentation.\n - Hypotension now resolved\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg \n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - guiaic negative\n - maintain active type & screen\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative\n .\n # FEN: cont TFs, nutrition following, PEG to be placed Tuesday\n .\n # Prophylaxis: heparin sc TID will change to 2.2 PTT 41 today,\n bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n # Code: FULL\n .\n # Disposition: trach and PEG now, case management aware of need for\n rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 443527,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Cuff volume: 10 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Tracheostomy planned\n Reason for continuing current ventilatory support: Pending procedure /\n OR\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-15 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 441573,
"text": "Demographics\n Day of mechanical ventilation: 4\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:xopenex/atro /flovent given as ordered.\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Pt rested overnight on a/c. Rsbi better this am. Still with significant\n bronchospasm and autopeep.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 441649,
"text": "Chief Complaint:\n 24 Hour Events:\n - cipro d/c'ed as no longer need double coverage for pseudomonas\n - PS trial failed with gas 7.28 / 58 / 93; placed back no AC\n - fem line pulled\n - IV lasix 20 mg x1 for slightly positive fluid status\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:00 PM\n Ciprofloxacin - 04:38 AM\n Vancomycin - 07:53 PM\n Piperacillin/Tazobactam (Zosyn) - 12:38 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:15 PM\n Heparin Sodium (Prophylaxis) - 12:38 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.6\n HR: 91 (74 - 102) bpm\n BP: 153/72(101) {88/43(59) - 164/77(109)} mmHg\n RR: 19 (16 - 28) insp/min\n SpO2: 20%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,484 mL\n 753 mL\n PO:\n TF:\n 925 mL\n 274 mL\n IVF:\n 1,339 mL\n 299 mL\n Blood products:\n Total out:\n 1,604 mL\n 960 mL\n Urine:\n 1,604 mL\n 960 mL\n NG:\n Stool:\n Drains:\n Balance:\n 880 mL\n -207 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 491 (491 - 491) mL\n PS : 10 cmH2O\n RR (Set): 18\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 74\n PIP: 23 cmH2O\n Plateau: 18 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 20%\n ABG: 7.40/42/112/29/1\n Ve: 10.5 L/min\n PaO2 / FiO2: 280\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, diffuse\n expiratory wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, +1 pitting edema, cachectic \n / Radiology\n 320 K/uL\n 8.2 g/dL\n 135 mg/dL\n 1.1 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 22 mg/dL\n 104 mEq/L\n 140 mEq/L\n 24.8 %\n 20.3 K/uL\n [image002.jpg]\n 03:20 AM\n 03:42 AM\n 07:38 PM\n 07:53 PM\n 03:59 AM\n 04:15 AM\n 06:29 AM\n 03:07 PM\n 05:40 PM\n 02:50 AM\n WBC\n 15.8\n 21.5\n 24.4\n 20.3\n Hct\n 25.1\n 26.5\n 26.7\n 24.8\n Plt\n 288\n 301\n 306\n 320\n Cr\n 0.5\n 1.0\n 1.1\n TropT\n <0.01\n TCO2\n 25\n 24\n 27\n 27\n 28\n 27\n Glucose\n 158\n 121\n 135\n Other labs: PT / PTT / INR:14.0/29.4/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.0 mg/dL,\n Mg++:2.4 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with hypoxia and respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Given\n acute decompensation without a pre-intubation ABG, suspect a component\n of hypercarbic resp failure given MS changes & elevated serum bicarb.\n Will try to achieve a mild permissive hypercapnea. Failed PSV 2/10 PM\n primary respiratory acidosis.\n - sputum -> moderate H. flu, blood Cx pending; Urine legionella\n (received Levoflox x 1 in ED) neg\n - d/c Vanc, cont Zosyn for H. flu\n - MDI while intubated (pt with auto-PEEP), transition to nebs once\n extubated\n - unlikely to be weaned from vent soon, will consider trach -> will d/w\n pt/family/Dr. \n - goal 1L neg today\n - mouthcare, HOB elevated\n .\n # Hypotension: Etiology unclear, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2months of prednisone use. Aggressive resuscitation with\n IVF, s/p 10L of IVF on initial presentation. Hypotension now resolved.\n - now off dopamine\n - Hydrocortisone 100mg q8hr (stress dose)\n - goal 1L neg today\n .\n # Chest pain: Pt with recent NSTEMI who presented with hypoxia and was\n denying CP in ED. EKGs with sinus tach in 140s, LBBB and non-specific\n changes from baseline. First set of CE are negative though pt was\n reporting CP on arrival to ICU. Given the recent history, possible to\n have demand ischemia with tachycardia. Will monitor symptoms and cycle\n cardiac enzymes.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - cardiac enzymes negative x3\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg \n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s. However, unclear\n etiology to acute drop from baseline.\n - guiaic negative\n - hemolysis labs negative\n - maintain active type & screen\n - get rehab records\n - PPI and CVL,PIV, PICC for access\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative\n .\n # FEN: NPO for now, will consult nutrition for TFs\n - cont TFs\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, Right femoral line, left PICC (plan to d/c\n femoral line today)\n .\n # Code: FULL\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 05:16 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 01:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441712,
"text": "Alteration in Nutrition\n Assessment:\n Pt cont to tol her TF at goal rate\n Action:\n Check asp ,\n Response:\n Now stooling\n Plan:\n Cont to follow for tolerance of TF\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with much less wheezes this am so she was given another PSV trial.\n She remains on the same amt of fentanyl and versed due to her anxiety\n Action:\n Pt placed on PSV of , she cont to be diuresed\n Response:\n Pt tol the PSV for about 4 hours(she had a good ABG ,sats 98%, TV of\n 500, TT 24-30) and then got dysynchronus with the vent and agitated so\n she was placed back on a/c.\n Plan:\n Will rest again overnight, keep comf on vent, get I&O about 1l neg .\n House staff to have discussion with her and neice about long term care\n ?need for trach possible\n Electrolyte & fluid disorder, other\n Assessment:\n Pt still very edamotous\n Action:\n Diuresis cont\n Response:\n 1l u/o rsp so far\n Plan:\n Recheck lytes later and cont with diures\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-21 00:00:00.000",
"description": "Resident / Attending Notes",
"row_id": 442747,
"text": "Chief Complaint:\n 24 Hour Events:\n - had PS trial and did well - on PS with improved oxygenation on\n this setting - ABG 7.41/54/172\n - plan for trach and peg tomorrow\n - trouble sleeping, treated with ambien\n - one guaiac positive brown stool, Hct stable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 04:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Lorazepam (Ativan) - 02:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.1\nC (98.8\n HR: 79 (70 - 86) bpm\n BP: 118/44(61) {117/44(61) - 154/68(88)} mmHg\n RR: 23 (16 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,490 mL\n 15 mL\n PO:\n TF:\n 865 mL\n IVF:\n 210 mL\n Blood products:\n Total out:\n 1,430 mL\n 385 mL\n Urine:\n 1,410 mL\n 385 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,060 mL\n -370 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 525 (421 - 525) mL\n PS : 12 cmH2O\n RR (Set): 18\n RR (Spontaneous): 25\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 22 cmH2O\n Plateau: 24 cmH2O\n Compliance: 31.3 cmH2O/mL\n SpO2: 96%\n ABG: ///35/\n Ve: 11.1 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 284 K/uL\n 8.4 g/dL\n 76 mg/dL\n 0.7 mg/dL\n 35 mEq/L\n 5.3 mEq/L\n 26 mg/dL\n 102 mEq/L\n 142 mEq/L\n 25.8 %\n 17.5 K/uL\n [image002.jpg]\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n Plt\n 79\n 251\n 258\n 284\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n TCO2\n 31\n Glucose\n 135\n 107\n 119\n 102\n 160\n 102\n 106\n 76\n Other labs: PT / PTT / INR:13.1/38.5/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:6.6 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Initally, vanc was d/c\ned and patient was kept on Zosyn\n until found to be flu beta-lactamase negative. Sputum showed moderate\n H. flu beta-lactamase negative, changed to ceftriaxone. Patient was\n able to tolerate PS12/PEEP8 for approx 2 hrs \n - will check VBG before and after PS trials\n - continue ceftriaxone for total of 14 days (d/c calcium SS given\n potential interaction)\n - plan for trach and PEG today\n - continue prednisone 40mg daily\n - mouthcare, HOB elevated\n .\n # ARF: pre-renal from lasix administration -> holding lasix for now,\n free water flushes at 250cc q4h (hyper NA improved)\n .\n # Hypotension: Resolved, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2 months of prednisone use and patient had initially\n been given Hydrocortisone. Aggressive resuscitation with IVF, s/p 10L\n of IVF on initial presentation.\n - Hypotension now resolved\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg \n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - guiaic negative\n - maintain active type & screen\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative\n .\n # FEN: cont TFs, nutrition following, PEG to be placed Tuesday\n .\n # Prophylaxis: heparin sc TID will change to 2.2 PTT 41 today,\n bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n # Code: FULL\n .\n # Disposition: trach and PEG now, case management aware of need for\n rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 70-year-old woman with severe COPD now with\n acute respiratory failure in the setting of Haemophilus influenza\n infection. On exam, she is comfortable on PSV 12/8/.4\n RR mid 20s.\n Breath sounds without wheezes. WBC stably elevated; anemia is stable.\n Meds reviewed from .\n Labs / Radiology\n 284 K/uL\n 8.4 g/dL\n 76 mg/dL\n 0.7 mg/dL\n 35 mEq/L\n 5.3 mEq/L\n 26 mg/dL\n 102 mEq/L\n 142 mEq/L\n 25.8 %\n 17.5 K/uL\n [image002.jpg]\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n Plt\n 79\n 251\n 258\n 284\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n TCO2\n 31\n Glucose\n 135\n 107\n 119\n 102\n 160\n 102\n 106\n 76\n Other labs: PT / PTT / INR:13.1/38.5/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:6.6 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.7 mg/dL\n We will plan\n Ceftriaxone for H. flu\n Bronchodilators\n Prednisone taper (slow)\n Ongoing ventilatory support with weaning trials as tolerated\n Trach/PEG (now approaching day 10 with plateau in weaning,\n not approaching extubation at present)\n Other issues as per ICU team note above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 01:32 PM ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 442944,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 0\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: MICU6\n Reason: Re-intubation\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: 10 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot manage\n secretions, Underlying illness not resolved\n Comments: Pt was extubated in the evening . Pt stayed on HI- 60%\n until 1:30 when HR increased, RR slightly increased, sats in low 90\n and slight WOB increase. Pt placed on NIV 60%. Pt. tolerated at\n first and RR and sats improved. However, pt later began refusing mask.\n Pt re-intubated 0300 with increasing WOB, decreased sats, and\n increasing VBG CO2 levels. Pt re-intubated without incident and\n tolerating well.\n"
},
{
"category": "Rehab Services",
"chartdate": "2158-02-24 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 443177,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: COPD / 493.20\n Reason of referral: Eval & tx\n History of Present Illness / Subjective Complaint: 70 yo F with h/o\n COPD admitted with increasing SOB over several days, in ED found to be\n increasingly lethargic and hypoxemic, was intubated and transferred to\n MICU, found to have infiltrates c/w acute pneumonia. Once extubated\n patient became hypercarbic and required re-intubation on , now\n scheduled for trach/peg on . Course has also been c/w leukocytosis\n and tachycardia.\n Past Medical / Surgical History: COPD with recent pseudomonas and h.\n flu, HTN, recent NSTEMI, carotid stenosis, depression, anxiety, PVD\n Medications: aspirin, fentanyl, lorazepam, heparin, midazolam,\n ciprofloxacin, prednisone, flagyl\n Radiology: CXR - Hyperexpansion of the lungs, area of increased\n opacification in the left mid zone laterally, continued bilateral\n pleural effusions or pleural thickening.\n Labs:\n 22.4\n 7.3\n 314\n 31.2\n [image002.jpg]\n Other labs:\n Activity Orders: Out of bed with assist\n Social / Occupational History: lives alone, supportive neice at bedside\n Living Environment: lives in apartment with elevator access\n Prior Functional Status / Activity Level: I pta, no DME\n Objective Test\n Arousal / Attention / Cognition / Communication: a&o x3, orally\n intubated but makes needs met by writing & gestures. Follows all\n commands.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 92\n 148/63\n 95% on CPAP\n Sit\n /\n Activity\n 104\n 160/68\n 92% on CPAP\n Stand\n /\n Recovery\n 100\n 149/56\n 92% on CPAP\n Total distance walked: 0\n Minutes:\n Pulmonary Status: lung sounds diminished t/o, on CPAP 8/8 PEEP/PS, 40%\n FIO2, TV 300-400. Occ thin oral secretions.\n Integumentary / Vascular: 3+ peripheral edema all extremities with\n weeping, R PICC, R PIV, foley, rectal tube, OG tube, B LE with\n gauze/dressing intact\n Sensory Integrity: grossly intact to light touch\n Pain / Limiting Symptoms: denies pain, reports some abdominal\n discomfort/nausea\n Posture: kyphotic posture in sitting\n Range of Motion\n Muscle Performance\n B LE\"s grossly WNL, B ankles to neutral\n B LE's grossly 3+ to \n B UE's grossly , fair grip R>L\n Motor Function: moves all extremities volitionally, no abnormal\n movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: tolerated slide transfer to stretcher chair with\n total assist.\n Rolling:\n\n\n\n\n T\n\n Supine /\n Sidelying to Sit:\n\n\n\n X2\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Maintains static sitting S, dynamic activities with CG.\n Standing balance not assessed.\n Education / Communication: Reviewed PT role and POC, encouraged OOB for\n skin integrity and pulmonary hygeine. COmmunicated with nsg re: status\n Intervention:\n Other:\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired balance\n 3.\n Impaired endurance\n 4.\n Decreased strength\n Clinical impression / Prognosis: 70 yo F with COPD p/w above\n impairments a/w ventilatory pump dysfunction. She is currently orally\n intubated and will likely be able to participate in more mobility when\n intubated via trachea or when on trach mask. She is well below her\n baseline and has some general weakness a/w prolonged hospital stay,\n however would anticipate good prognosis given her ability to\n participate in mobility. She is a good rehab candidate and will\n benefit from daily PT.\n Goals\n Time frame: 1 week\n 1.\n Mod A with bed mobiltiy, transfers\n 2.\n Assess ambulation\n 3.\n No LOB with mobility/gait\n 4.\n Tolerate daily OOB and PT\n 5.\n Tolerate daily strengthening\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n mobility, transfers, ambulation, balance, strengthening,\n endurance, education, d/c planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443523,
"text": "Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442265,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN cocci. Chronic steroids. Intubated when admitted ,\n now failure to wean with plan to trach/PEG by IP.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on vent settings AC 40%/18 X 500/+8 with SRR to 22 and regular.\n O2 sat 95-98%. Pt denied SOB. Lung snds clear, diminished in bases.\n Suctionned for scant amts blood-tinged, thick. Other VS generally\n stable with HR 75-93SR without VEA, BP 110/50-157/68. Afebrile. Rec\n on Versed @ 2mg/hr, Fentanyl 25mcg/hr.\n Action:\n Pt OOB to chair for several hrs. Versed stopped, Fentanyl patch added.\n Response:\n Pt C/O nausea after moved to chair. She rec\nd Zofran 4mg IV, followed\n by Ativan 1mg X 2 with eventual resolution of nausea. Pt had burst SVT\n @ 1700, and was returned to bed and EKG done. MD aware. Lytes pndg.\n Plan:\n D/C Fentanyl after patch established. Cont PRN Ativan for anxiety,\n nausea. Zofran also available PRN. Replete lytes as necessary. Cont\n prep for transfer to rehab, with trach/PEG planned for by IP.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple skintear, blisters, hematomas on all extremeties, with\n fluid leaking from all limbs. Pt denies pain, but rec\ning Fentanyl for\n comfort. Pt occas teary, writing\nI can\nt do this anymore.\n Action:\n Skin tears cleaned and dressed freq. Pt OOB to chair, and turned freq\n STS. Heels elevated off bed or waffle boots in place. Compression\n stockings off D/T blisters, skin tears on legs.\n Response:\n Unchanged.\n Plan:\n Cont aggressive skin care.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442316,
"text": "PMH: 70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic\n resp failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN cocci. Chronic steroids. Intubated when admitted ,\n now failure to wean with plan to trach/PEG by IP.\n Events: Pt follows commands, MAEs, PERRL. Afebrile. Pt anxious at\n bedtime (2200), 1 mg ativan given w/ good effect. Pt able to sleep\n through most of night. Pt consistently denies pain, SOB. Pt\n communicates by mouthing words and using writing tablet. Mushroom cath\n in place, foley in place and UOP 30-40 ml/hr. Hct dropped again to\n 26.2, team aware and plan to monitor.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 40%/500/18/8. Sp02 approx 98%. LS course to clear\n throughout night and dim at bases. Pt sux\ned for min amts tan, blood\n tinged sputum.\n Action:\n No vent changes overnight.\n Response:\n Resp status remains unchanged.\n Plan:\n Cont w/ plan for trach/peg placement tues .\n Impaired Skin Integrity\n Assessment:\n Pt has very fragile skin, thin, weeping, w/ mult skin tears at all\n extremities. Pt denies pain when asked.\n Action:\n Freq repositioning, extremities elevated on pillows. Bilat UEs dressed\n w/ softsorb, RLE dressed w/ adaptic and gauze. Blister OTA on LLE.\n Barrier cream applied to coccyx, moisturizer applied liberally.\n Response:\n Skin remains unchanged.\n Plan:\n Vigilent skin care.\n Electrolyte & fluid disorder, other\n Assessment:\n Na 147 down from 148. Ionized Ca and K low.\n Action:\n Cont FWB at 250 ml q 6 h. Repleted lytes.\n Response:\n Plan:\n Follow lyte / fluid status.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-15 00:00:00.000",
"description": "ICU Attending Note",
"row_id": 441650,
"text": "Clinician: Attending\n I saw and examined the patient, and was physically present with the ICU\n resident, Dr , for key portions of the services provided. I agree\n with his note, including assessment and plan.\n Key Points:\n 70 yo woman with severe COPD, and pneumonia. recent NSTEMI. Intubated\n when admitted .\n Yesterday, attempted PSV but dev resp acidosis.\n Sputum grew HFlu\n Right femoral line removed.\n Afebrile, hemodynamically stable.\n CMV vent, RSBI 74.\n Versed 2/fent 25.\n Exam sig for awake, opened eyes, responded to questions with head nod.\n Diffuse exp wheezing. Distant HS. Abd NABS, soft, NDNT. Extremities\n cachectic, petechial and purpuric lesions, atrophied. LE pitting edema\n + bilat. Minimal resp secretions.\n Meds: Insulin, hep sc, vanc/cipro/zosyn, ppi, asa, statin, hydrocort\n 100 IV q 8, versed 1, fentanyl 25, DA\n 1. Severe COPD with exacerbation-- continue high dose steroids\n for COPD exac\nhas been on hydrocort but will change to prednisone 60mg\n PO qd, taper to 40 in a couple of days.\n 2. sputum with Hflu, d/c vanc and continue zosyn\n 3. RV strain with cor pulmonale/pna/hypoxic vasoconstriction\n 4. diuresis\n 5. TF, heparin, PPI, bowel reg\n Total time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441711,
"text": "Alteration in Nutrition\n Assessment:\n Pt cont to tol her TF at goal rate\n Action:\n Check asp ,\n Response:\n Now stooling\n Plan:\n Cont to follow for tolerance of TF\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with much less wheezes this am so she was given another PSV trial.\n She remains on the same amt of fentanyl and versed due to her anxiety\n Action:\n Pt placed on PSV of , she cont to be diuresed\n Response:\n Pt tol the PSV for about 4 hours(she had a good ABG ,sats 98%, TV of\n 500, TT 24-30) and then got dysynchronus with the vent and agitated so\n she was placed back on a/c.\n Plan:\n Will rest again overnight, keep comf on vent, get I&O about 1l neg .\n House staff to have discussion with her and neice about long term care\n ?need for trach possible\n Electrolyte & fluid disorder, other\n Assessment:\n Pt still very edamotous\n Action:\n Diuresis cont\n Response:\n 1l u/o rsp so far\n Plan:\n Recheck lytes later and cont with diures\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441713,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Pt\ns , \n, called this morning. Stated pt is w/o much\n family and believes she is the next of , but is not her HCP. Pt is\n not married, nor does she have any children.\n Alteration in Nutrition\n Assessment:\n Pt cont to tol her TF at goal rate\n Action:\n Check asp ,\n Response:\n Now stooling min asp noted\n Plan:\n Cont to follow for tolerance of TF\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with much less wheezes this am so she was given another PSV trial.\n She remains on the same amt of fentanyl and versed due to her anxiety\n Action:\n Pt placed on PSV of , she cont to be diuresed\n Response:\n Pt tol the PSV for about 4 hours(she had a good ABG ,sats 98%, TV of\n 500, TT 24-30) and then got dysynchronus with the vent and agitated so\n she was placed back on a/c.\n Plan:\n Will rest again overnight, keep comf on vent, get I&O about 1l neg .\n House staff to have discussion with her and neice about long term care\n ?need for trach possible\n Electrolyte & fluid disorder, other\n Assessment:\n Pt still very edamotous\n Action:\n Diuresis cont\n Response:\n 1l u/o rsp so far\n Plan:\n Recheck lytes later and cont with diures\n Social:neice in to visit\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443223,
"text": "Events: A-febrile in AM but trach/PEG differed until Monday. Awake,\n alert and interactive. Tolerating CPAP+PSV 8/+8 x 6 +hrs. Seen by PT-\n OOB to chair, given AIR bed. Restarted TF. HCt falling- transfused\n 1 unit RBC-needs post transfusion Hct @ . Intermittently refusing\n care-movement/turning/oob/ subglottal suctioning and oral care- w/\n support and education pt tolerating procedures. Niece visiting @\n bedside for support..\n Edema, peripheral\n Assessment:\n Generalized edema + bilat legs and pedal, no hand edema, coccyx and\n dependent edema-continuously weeping- through total 3 pink pads/2\n sheets, thin fragile skin likely chronic steroid therapy, mult sm\n bruising throughout body, blanching borderline stage I on gleut- pt\n very thin and @ risk for ulcerations on bony areas\n Action:\n Barrier cream to protect maceration, turning, OOB to chair, supportive\n care, now on Kinair bed\n Response:\n Cont weeping large amounts serous fluids\n Plan:\n Tuning/OOB to chair-activity, skin care, BP stabilizing and ? diuretic\n therapy in future\n Alteration in Nutrition\n Assessment:\n NPO until afternoon, then restarting TF Nutren Pulmonary @ 20cc/hr w/\n goal 40cc/hr\n Action:\n Restarted, 250cc free water flush Q4hrs\n Response:\n tolerating\n Plan:\n Cont TF and increase to goal- NPO @ MD Sunday night for trach/PEG\n Monday\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS tight/diminished\nless secretions than previous day, sat 96-99% on\n PSV\n Action:\n AC changed to CPAP+PSV 8/+8/40%,\n Response:\n No acute change\n Plan:\n Cont PSV as tolerated then return to AC, possible slow wean over\n weekend- BAL negative- awaiting culture growth if no growth then needs\n ABX tailoring Monday\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443437,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit. Failure to wean with\n original plan to trach/PEG by IP. Pt did well on RSBI (score\n 50), and passed SBT so extubated at 1400. Patient reintubated at\n at 0200. Pt now awaiting Trach./PEG scheduled for Monday .\n EVENTS: CXR for NGT placement confirmation, and it is OK to use and TF\n started .\n Ativan 1mg at 0430hrs after dressing change\n SBP 110-140mmhg, no interventions\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient sitting on the chair, vented PSV 8/8 and O2 40%.\n Bilateral lung sounds rhonchorous and diminished bases. O2 sats 96-98%\n Action:\n No vent changes , suction PRN, MDI\ns as ordered\n Response:\n Stable overnight, moderate thick yellow secretions with suction\n Plan:\n Awaiting trach/PEG on Monday\n Impaired Skin Integrity\n Assessment:\n Multiple skin tear sites. Pt has very fragile skin secondary to\n chronic steroid use. Generalized edema throughout body.+2-+4mm. Skin\n weeping large amounts of serous/ serosanguinous fluid continueously.\n Left lower leg hematoma burst today causing skin tear.\n Action:\n Dressing changes as needed secondary to weeping, done at 0400\n Response:\n Weeping serosanguious fluid from multiple ares of broken skin ,\n patient refusing position changes some times\n Plan:\n Skin care consults on Monday. Frequent dressing changes to keep clean\n and dry\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443524,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit. Failure to wean with\n original plan to trach/PEG by IP. Pt did well on RSBI (score\n 50), and passed SBT so extubated at 1400. Patient reintubated at\n at 0200. Pt now awaiting Trach./PEG scheduled for Monday .\n No major events today.\n Impaired Skin Integrity\n Assessment:\n Multiple skin tears. Fragile skin secondary to chronic steroid use. .\n Action:\n Dressings changed as needed q 4 hours.\n Response:\n No change. Large amount of weeping from skin throughout the day\n Plan:\n Skin care consult in am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n No change in vent status today. Pt remains on PSV 8/8 @40% LS\n diminished at bases. Large amount of secretions suctioned today. Pt\n remains on antibx coverage for pseudomonas.\n Action:\n No change in plan of care. Awaiting trach in am.\n Response:\n Plan:\n Trach and PEG tomorrow. Pt on OR schedule as add on. Please make NPO\n after midnoc for procedure tomorrow.\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 443569,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Cuff volume: 10 mL /\n Airway problems:\n sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Tracheostomy planned\n Respiratory Care Shift Procedures\n Bedside Procedures: No abg results at this time. RSBI not measured\n due to planned tracheostomy today.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442392,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit, now failure to wean\n with plan to trach/PEG by IP, prep for rehab.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on vent settings AC 40%/18 X 500/+8 with SRR to 19 and regular.\n O2 sat 95-98%. Pt denied SOB. Lung snds clear, diminished in bases.\n Suctionned for scant amts blood-tinged, thick, tan secretions. Other VS\n generally stable with HR 78-97SR without VEA, BP 124/50-177/63.\n Afebrile. Rec\nd on Fentanyl 25mcg/hr.\n Action:\n Pt OOB to chair for several hrs in AM. Vent settings changed to PS\n 12/+8/40%. Fentanyl qtt stopped, Fentanyl patch in place.\n Response:\n Pt C/O nausea after moved to chair. She rec\nd Ativan 0.5mg with\n eventual resolution of nausea. After 11/2 hrs on PS, pt C/O feeling\n anxious with RR inc\nd to mid 20\ns and SBP to 170\ns. Pt rec\nd Ativan 1mg\n IV without resolution of symptoms, and vent settngs returned to AC. Pt\n consented for trach/PEG by IP.\n Plan:\n Cont PRN Ativan for anxiety, nausea. Zofran also available PRN. Cont\n prep for transfer to rehab, with trach/PEG planned for by IP.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple skintear, blisters, hematomas on all extremeties, with\n copious amts yellow fluid leaking from all limbs. Pt denies pain,\n rec\ning Fentanyl for comfort.\n Action:\n Skin tears requiring dsg changes Q2hrs. Pt OOB to chair, and turned\n freq STS. Heels elevated off bed or waffle boots in place. Compression\n stockings off D/T blisters, skin tears on legs.\n Response:\n Increased amt weeping from impaired skin.\n Plan:\n Cont vigilent skin care.\n Hypernatremia (high sodium)\n Assessment:\n AM Na 147, down from 148 yesterday. Pt rec\ning FWB of 250ml Q6hrs. TF\n residuals <5ml. Pt intermit C/O vague stomach discomfort. Abd soft with\n +BS, and mushroom cath draining small amt loose brown stool.\n Action:\n FWB inc\nd to 250ml Q4hrs.\n Response:\n Residuals cont scant. Na level to follow.\n Plan:\n Cont to monitor Na level.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-16 00:00:00.000",
"description": "ICU Attending Note",
"row_id": 441865,
"text": "Clinician: Attending\n Problems: Respiratory failure, pneumonia, COPD\n 70 year old woman with end stage COPD, Hflu pneumonia, recent NSTEMI.\n Events: tolerated brief period of reducing vent support to PS8/PEEP5.\n -700cc with diuresis.\n Exam sig for anasarca, coarse breath sounds, decreased wheezing,\n prolonged exp phase, abd soft, affect very depressed but awake and\n responds to questions with nodding. A-line not correlating with cuff\n pressure\nnormotensive SBP 115 when aline SBP was 70.\n plan\n * Hflu pneumonia, continue zosyn\n * COPD, continue steroids, MDI\n * need to discuss end-stage disease with pt and niece, who can help\n us determine who is HCP\n \n Ms successfully\n extubating, so we need to determine trach and chronic vent facility\n or terminally extubate knowing end stage disease.\n Total time spent: 40 minutes\n Patient is critically ill.\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 443074,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 0\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Cuff volume: 10 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Tracheostomy planned\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 443268,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Cuff volume: 10 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Bedside Procedures: Patient was moved without incident from to\n . Remains on CPAP/PSV with no parameter changes noted.\n RSBI = 41 on 0-PEEP and 5 cm PSV. Please Note: It took the patient\n several moments before returning to a stable SPO2.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443570,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit. Failure to wean with\n original plan to trach/PEG by IP. Pt did well on RSBI (score\n 50), and passed SBT so extubated at 1400. Patient reintubated at\n at 0200. Pt now awaiting Trach./PEG scheduled for Monday .\n No significant events, for Trach/PEG in am\n Impaired Skin Integrity\n Assessment:\n Multiple skin tears. Fragile skin secondary to chronic steroid use. .\n Action:\n Dressings changed as needed q 4 hours.\n Response:\n No change. Large amount of weeping from skin throughout the day\n Plan:\n Skin care consult in am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on PSV 8/8 @40% LS diminished at bases. Large amount of\n secretions suctioned Pt remains on antibx coverage for pseudomonas.\n Action:\n No change in plan of care. Awaiting trach in am.\n Response:\n Unchanged\n Plan:\n Trach and PEG tomorrow. Pt on OR schedule as add on. NPO after midnoc\n for procedure tomorrow.\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-18 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 442254,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged /\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442389,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit, now failure to wean\n with plan to trach/PEG by IP, prep for rehab.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on vent settings AC 40%/18 X 500/+8 with SRR to 19 and regular.\n O2 sat 95-98%. Pt denied SOB. Lung snds clear, diminished in bases.\n Suctionned for scant amts blood-tinged, thick, tan secretions. Other VS\n generally stable with HR 78-97SR without VEA, BP 124/50-177/63.\n Afebrile. Rec\nd on Fentanyl 25mcg/hr.\n Action:\n Pt OOB to chair for several hrs in AM. Vent settings changed to PS\n 12/+8/40%. Fentanyl qtt stopped, Fentanyl patch in place.\n Response:\n Pt C/O nausea after moved to chair. She rec\nd Ativan 0.5mg with\n eventual resolution of nausea. After 11/2 hrs on PS, pt C/O feeling\n anxious with RR inc\nd to mid 20\ns and SBP to 170\ns. Pt rec\nd Ativan 1mg\n IV without resolution of symptoms, and vent settngs returned to AC. Pt\n consented for trach/PEG by IP.\n Plan:\n Cont PRN Ativan for anxiety, nausea. Zofran also available PRN. Cont\n prep for transfer to rehab, with trach/PEG planned for by IP.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple skintear, blisters, hematomas on all extremeties, with\n copious amts yellow fluid leaking from all limbs. Pt denies pain,\n rec\ning Fentanyl for comfort.\n Action:\n Skin tears requiring dsg changes Q2hrs. Pt OOB to chair, and turned\n freq STS. Heels elevated off bed or waffle boots in place. Compression\n stockings off D/T blisters, skin tears on legs.\n Response:\n Increased amt weeping from impaired skin.\n Plan:\n Cont vigilent skin care.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442390,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit, now failure to wean\n with plan to trach/PEG by IP, prep for rehab.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on vent settings AC 40%/18 X 500/+8 with SRR to 19 and regular.\n O2 sat 95-98%. Pt denied SOB. Lung snds clear, diminished in bases.\n Suctionned for scant amts blood-tinged, thick, tan secretions. Other VS\n generally stable with HR 78-97SR without VEA, BP 124/50-177/63.\n Afebrile. Rec\nd on Fentanyl 25mcg/hr.\n Action:\n Pt OOB to chair for several hrs in AM. Vent settings changed to PS\n 12/+8/40%. Fentanyl qtt stopped, Fentanyl patch in place.\n Response:\n Pt C/O nausea after moved to chair. She rec\nd Ativan 0.5mg with\n eventual resolution of nausea. After 11/2 hrs on PS, pt C/O feeling\n anxious with RR inc\nd to mid 20\ns and SBP to 170\ns. Pt rec\nd Ativan 1mg\n IV without resolution of symptoms, and vent settngs returned to AC. Pt\n consented for trach/PEG by IP.\n Plan:\n Cont PRN Ativan for anxiety, nausea. Zofran also available PRN. Cont\n prep for transfer to rehab, with trach/PEG planned for by IP.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple skintear, blisters, hematomas on all extremeties, with\n copious amts yellow fluid leaking from all limbs. Pt denies pain,\n rec\ning Fentanyl for comfort.\n Action:\n Skin tears requiring dsg changes Q2hrs. Pt OOB to chair, and turned\n freq STS. Heels elevated off bed or waffle boots in place. Compression\n stockings off D/T blisters, skin tears on legs.\n Response:\n Increased amt weeping from impaired skin.\n Plan:\n Cont vigilent skin care.\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-15 00:00:00.000",
"description": "ICU Attending Note",
"row_id": 441643,
"text": "Clinician: Attending\n ATTENDING ADDENDUM:\n I saw and examined the patient, and was physically present with the ICU\n resident, Dr , for key portions of the services provided. I agree\n with his note above, including assessment and plan.\n Key Points:\n 70 yo woman with severe COPD, and pneumonia. recent NSTEMI. Intubated\n when admitted . Attempted PSV but dev resp acidosis.\n Sputum grew HFlu\n Fent 25/versed 2\n ppi\n Afebrile 88-112. MAP 60-66 off pressors (had been on DA)\n I/O +3L. 800cc urine/24h.\n CMV 0.4/500/16/5 ABG: 7.31/51/106, RSBI 74.\n Versed 2/fent 25.\n Exam sig for awake, opened eyes, responded to questions with head nod.\n Diffuse exp wheezing. Right femoral line. Distant HS. Abd NABS, soft,\n NDNT. Extremities cachectic, petechial lesions, atrophied. LE pitting\n edema + bilat. Minimal resp secretions.\n Meds: Insulin, hep sc, vanc/cipro/zosyn, ppi, asa, statin, hydrocort\n 100 IV q 8, versed 1, fentanyl 25, DA\n 1. Severe COPD with exacerbation-- continue high dose steroids\n for COPD exac\n 2. sputum with Hflu, d/c vanc and continue zosyn\n 3. RV strain with cor pulmonale/pna/hypoxic\n vasoconstriction\nadmitted with elevated BNP in setting of hypovolemia\n 4. diuresis\n 5. TF, heparin, PPI, bowel reg\n Total time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441920,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Edema, peripheral\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 443022,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: ICU\n Reason: Re-intubation\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments: Nebs/MDIs given as documented\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt remains on A/C ventilation w/ PIP/Pplat = 25/20. Mini BAL\n performed at bedside w/out complication; spec sent to lab - results\n pending.\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: maintain support; ? tracheostomy\n Respiratory Care Shift Procedures\n Bedside Procedures:\n mini BAL (0900)\n Comments: no complications, pt tolerated well; spec sent to lab.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-17 00:00:00.000",
"description": "Attending Note",
"row_id": 441999,
"text": "TITLE: Attending Note\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan. 70 year old woman with\n end stage COPD, Hflu pneumonia, recent NSTEMI.\n Events:\n Pt\ns niece felt pt would not want to be trached. Ongoing process of\n determining HCP status.\n CMV 0.4/500/18/8.\n Tolerated PS10/PEEP8 yesterday for approx 2 hrs.\n Art line removed.\n Exam sig for anasarca, coarse breath sounds, increased wheezing,\n prolonged exp phase, abd soft, affect very depressed but awake and\n responds to questions with nodding.\n plan\n * Hflu pneumonia, beta-lactamase negative, change to ampicillin after\n confirm with lab\n * COPD, continue steroids, MDI\n * Family meeting today\n Total time spent: 30 minutes\n Patient is critically ill.\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-17 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 441921,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont intub with OETT and on mech vent as per Metavision.\n Lung sounds dim suct mod th yellow sput. MDI and SVN given as per\n order. Pt in NARD on current settings; no vent changes required\n overnoc. Cont mech vent support.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442007,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 01:08 PM\n Events:\n - discussion with niece and other family member re trach\n - placed s/w c/s\n - transfused 1u PRBC\n - family meeting today re trach and code status\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:53 PM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.1\nC (97\n HR: 80 (68 - 100) bpm\n BP: 130/56(73) {96/42(57) - 168/80(102)} mmHg\n RR: 19 (17 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,038 mL\n 496 mL\n PO:\n TF:\n 970 mL\n 277 mL\n IVF:\n 798 mL\n 99 mL\n Blood products:\n Total out:\n 1,230 mL\n 430 mL\n Urine:\n 1,230 mL\n 430 mL\n NG:\n Stool:\n Drains:\n Balance:\n 808 mL\n 66 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 84\n PIP: 31 cmH2O\n Plateau: 20 cmH2O\n SpO2: 95%\n ABG: ///34/\n Ve: 10.3 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, +2 pitting edema, cachectic \n / Radiology\n 255 K/uL\n 9.1 g/dL\n 119 mg/dL\n 1.1 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 33 mg/dL\n 107 mEq/L\n 146 mEq/L\n 26.5 %\n 19.4 K/uL\n [image002.jpg]\n 03:59 AM\n 04:15 AM\n 06:29 AM\n 03:07 PM\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n WBC\n 24.4\n 20.3\n 17.4\n 19.4\n Hct\n 26.7\n 24.8\n 24.1\n 30.9\n 26.5\n Plt\n 55\n Cr\n 1.0\n 1.1\n 1.2\n 1.1\n TCO2\n 27\n 27\n 28\n 27\n 31\n Glucose\n 121\n 135\n 107\n 119\n Other labs: PT / PTT / INR:13.4/32.1/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.2 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with hypoxia and respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. MDI while intubated. Patient was able to tolerate\n PS10/PEEP8 yesterday for approx 2 hrs yesterday. Sputum showed moderate\n H. flu beta-lactamase negative, change to ampicillin after confirm with\n lab. Initally, vanc was d/c\ned and patient was kept on Zosyn until\n found to be flu beta-lactamase negative. Dr. had seen the\n patient one week prior and discusses patient wishes with family.\n - family meeting today to determine if patient should be trached.\n - mouthcare, HOB elevated\n .\n # ARF\n pre-renal from lasix administration\n .\n # Hypotension: Resolved, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2 months of prednisone use and patient had initially\n been given Hydrocortisone. Aggressive resuscitation with IVF, s/p 10L\n of IVF on initial presentation. Hypotension now resolved.\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg \n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - guiaic negative\n - maintain active type & screen\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative\n .\n # FEN: cont TFs, nutrition following\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, Right femoral line, left PICC (plan to d/c\n femoral line today)\n .\n # Code: FULL\n .\n # Disposition: pending family meeting and goals of care, trach vs.\n terminal extubation\n - Social work consult placed \n - Will discuss with niece re trach, family meeting today\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:49 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 01:36 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Pt\ns niece felt pt would not want to be trached. Ongoing process of\n determining HCP status.\n CMV 0.4/500/18/8.\n Tolerated PS10/PEEP8 yesterday for approx 2 hrs.\n Art line removed.\n Exam sig for anasarca, coarse breath sounds, increased wheezing,\n prolonged exp phase, abd soft, affect very depressed but awake and\n responds to questions with nodding.\n plan\n * Hflu pneumonia,\n * COPD, continue steroids, MDI\n * Family meeting today\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-24 00:00:00.000",
"description": "Generic Note",
"row_id": 443072,
"text": "TITLE:\n Events:\n SBP in 80\ns at hrs , 250 mls fluid bolus given with good effect.\n Feed restarted at hrs, held at midnight for ? procedures in am.\n Patient refused to be turned at midnight , after much explanations &\n encouragement, patient turned & back care given, patient refused a\n bath at this time.\n Impaired Skin Integrity\n Assessment:\n General thin fragile skin w/ mult skin tears bilat legs, mild\n maceration in bilat legs sm amt cont weeping edema, on coccyx sm\n pink area-blanching\n Action:\n Barrier cream to bilat legs- adaptic on bilat calves and covered w/\n ABD, barrier cream to elbows\npt @ risk for multi pressure ulcers on\n bony areas\n Response:\n Pt weeping through bilat leg dressings x1 and weeping to saturate pink\n pad\n Plan:\n Will need to be placed on AIR bed, frequent turning, barrier cream,\n wound care\n Sepsis without organ dysfunction\n Assessment:\n No fever till time noted, BP dropped at hrs to SBP 80\ns, maps of\n 40\n Action:\n Given total of 250 mls of NS, continued on broad coverage ABX-PO and IV\n Response:\n BP improved to SBP 120\ns to 130\ns, MAP of 60\n Plan:\n Follow cultures, monitor temp curve, cont IV and PO ABX\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS very tight/diminished, mild wheezy bilat, sat 97-10%, RR 20\n Action:\n Continued neb treatment by resp, no vent changes\n Response:\n No acute change\n Plan:\n Cont vent settings, monitor O2 sat, nebs for severe COPD\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443219,
"text": "Events: A-febrile in AM but trach/PEG differed until Monday. Awake,\n alert and interactive. Tolerating CPAP+PSV 8/+8 x 6 +hrs. Seen by PT-\n OOB to chair, given AIR bed. Restarted TF. HCt falling- transfused\n 1 unit RBC-needs post transfusion Hct @ . Intermittently refusing\n care-movement/turning/oob/ subglottal suctioning and oral care- w/\n support and education pt tolerating procedures.\n Edema, peripheral\n Assessment:\n Generalized edema + bilat legs and pedal, no hand edema, coccyx and\n dependent edema-continuously weeping- through total 3 pink pads/2\n sheets, thin fragile skin likely chronic steroid therapy, mult sm\n bruising throughout body, blanching borderline stage I on gleut- pt\n very thin and @ risk for ulcerations on bony areas\n Action:\n Barrier cream to protect maceration, turning, OOB to chair, supportive\n care, now on Kinair bed\n Response:\n Cont weeping large amounts serous fluids\n Plan:\n Tuning/OOB to chair-activity, skin care, BP stabilizing and ? diuretic\n therapy in future\n Alteration in Nutrition\n Assessment:\n NPO until afternoon, then restarting TF Nutren Pulmonary @ 200cc/hr w/\n goal 40cc/hr\n Action:\n Restarted, 250cc free water flush Q4hrs\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442383,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit, now failure to wean\n with plan to trach/PEG by IP, prep for rehab.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on vent settings AC 40%/18 X 500/+8 with SRR to 19 and regular.\n O2 sat 95-98%. Pt denied SOB. Lung snds clear, diminished in bases.\n Suctionned for scant amts blood-tinged, thick, tan secretions. Other VS\n generally stable with HR 78-97SR without VEA, BP 124/50-177/63.\n Afebrile. Rec\nd on Fentanyl 25mcg/hr.\n Action:\n Pt OOB to chair for several hrs in AM. Vent settings changed to PS\n 12/+8/40%. Fentanyl qtt stopped, Fentanyl patch in place.\n Response:\n Pt C/O nausea after moved to chair. She rec\nd Ativan 0.5mg with\n eventual resolution of nausea. After 11/2 hrs on PS, pt C/O feeling\n anxious with RR inc\nd to mid 20\ns and SBP to 170\ns. Pt rec\nd Ativan 1mg\n IV without resolution of symptoms, and vent settngs returned to AC.\n Plan:\n Cont PRN Ativan for anxiety, nausea. Zofran also available PRN. Replete\n lytes as necessary. Cont prep for transfer to rehab, with trach/PEG\n planned for by IP.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple skintear, blisters, hematomas on all extremeties, with\n fluid leaking from all limbs. Pt denies pain, but rec\ning Fentanyl for\n comfort. Pt occas teary, writing\nI can\nt do this anymore.\n Action:\n Skin tears cleaned and dressed freq. Pt OOB to chair, and turned freq\n STS. Heels elevated off bed or waffle boots in place. Compression\n stockings off D/T blisters, skin tears on legs.\n Response:\n Unchanged.\n Plan:\n Cont aggressive skin care.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443169,
"text": "Events: Afebrile in AM but trach/PEG deffered until Monday. Awake,\n alert and interactive. Tolerating CPAP+PSV 8/+8 x _hrs. Seen by PT-\n OOB to chair, given AIR bed.\n Edema, peripheral\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442435,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit, now failure to wean\n with plan to trach/PEG by IP, prep for rehab.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on vent settings AC 40%/18 X 500/+8 with SRR to 19 and regular.\n O2 sat 95-98%. Pt denied SOB. Lung snds clear, diminished in bases.\n Suctionned for scant amts blood-tinged, thick, tan secretions. Other VS\n generally stable with HR 78-97SR without VEA, BP 124/50-177/63.\n Afebrile. Rec\nd on Fentanyl 25mcg/hr.\n Action:\n Pt OOB to chair for several hrs in AM. Vent settings changed to PS\n 12/+8/40%. Fentanyl qtt stopped, Fentanyl patch in place.\n Response:\n Pt C/O nausea after moved to chair. She rec\nd Ativan 0.5mg with\n eventual resolution of nausea. After 11/2 hrs on PS, pt C/O feeling\n anxious with RR inc\nd to mid 20\ns and SBP to 170\ns. Pt rec\nd Ativan 1mg\n IV without resolution of symptoms, and vent settngs returned to AC. Pt\n again C/O abd discomfort @ 1600, and rec\nd Zofran 4mg IV with good\n resolution. Pt consented for trach/PEG by IP.\n Plan:\n Cont PRN Ativan for anxiety, nausea. Zofran also available PRN. Cont\n prep for transfer to rehab, with trach/PEG planned for by IP.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple skintear, blisters, hematomas on all extremeties, with\n copious amts yellow fluid leaking from all limbs. Pt denies pain,\n rec\ning Fentanyl for comfort.\n Action:\n Skin tears requiring dsg changes Q2hrs. Pt OOB to chair, and turned\n freq STS. Heels elevated off bed or waffle boots in place. Compression\n stockings off D/T blisters, skin tears on legs.\n Response:\n Increased amt weeping from impaired skin.\n Plan:\n Cont vigilent skin care.\n Hypernatremia (high sodium)\n Assessment:\n AM Na 147, down from 148 yesterday. Pt rec\ning FWB of 250ml Q6hrs. TF\n residuals <5ml. Pt intermit C/O vague stomach discomfort. Abd soft with\n +BS, and mushroom cath draining small amt loose brown stool.\n Action:\n FWB inc\nd to 250ml Q4hrs.\n Response:\n Residuals cont scant. Na level to follow.\n Plan:\n Cont to monitor Na level.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441559,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Pt\ns , \n, called this morning. Stated pt is w/o much\n family and believes she is the next of , but is not her HCP. Pt is\n not married, nor does she have any children.\n Edema, peripheral\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "General",
"chartdate": "2158-02-16 00:00:00.000",
"description": "ICU Event Note",
"row_id": 441840,
"text": "Clinician: Resident\n I spoke to Ms. , . She is the closest\n relative that Ms. actually talks to. She is estranged from her\n sister mother). Pt also has a friend who knows her very well.\n Formal HCP status has never been designated to any individual. Ms.\n has always been highly private and appears to only have been in\n contact with and 2 other friends.\n We discussed her long term prognosis, need for trach, and inability to\n come off the vent. will d/w Ms. friend tonight to see if\n they had ever discussed such issues. will be in tomorrow ()\n at 1PM for further discussion regarding goals of care. did\n express that Ms. would \"go nuts\" if she had to be chronically\n vented and not able to live independently. Further discussion tomorrow\n after has spoken to pts friend.\n Total time spent: 15 minutes\n Patient is critically ill.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 441972,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 01:08 PM\n Events:\n - discussion with niece and other family member re trach\n - placed s/w c/s\n - transfused 1u PRBC\n - family meeting today re trach and code status\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:53 PM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.1\nC (97\n HR: 80 (68 - 100) bpm\n BP: 130/56(73) {96/42(57) - 168/80(102)} mmHg\n RR: 19 (17 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,038 mL\n 496 mL\n PO:\n TF:\n 970 mL\n 277 mL\n IVF:\n 798 mL\n 99 mL\n Blood products:\n Total out:\n 1,230 mL\n 430 mL\n Urine:\n 1,230 mL\n 430 mL\n NG:\n Stool:\n Drains:\n Balance:\n 808 mL\n 66 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 84\n PIP: 31 cmH2O\n Plateau: 20 cmH2O\n SpO2: 95%\n ABG: ///34/\n Ve: 10.3 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 255 K/uL\n 9.1 g/dL\n 119 mg/dL\n 1.1 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 33 mg/dL\n 107 mEq/L\n 146 mEq/L\n 26.5 %\n 19.4 K/uL\n [image002.jpg]\n 03:59 AM\n 04:15 AM\n 06:29 AM\n 03:07 PM\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n WBC\n 24.4\n 20.3\n 17.4\n 19.4\n Hct\n 26.7\n 24.8\n 24.1\n 30.9\n 26.5\n Plt\n 55\n Cr\n 1.0\n 1.1\n 1.2\n 1.1\n TCO2\n 27\n 27\n 28\n 27\n 31\n Glucose\n 121\n 135\n 107\n 119\n Other labs: PT / PTT / INR:13.4/32.1/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.2 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:49 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 01:36 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 441973,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 01:08 PM\n Events:\n - discussion with niece and other family member re trach\n - placed s/w c/s\n - transfused 1u PRBC\n - family meeting today re trach and code status\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:53 PM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.1\nC (97\n HR: 80 (68 - 100) bpm\n BP: 130/56(73) {96/42(57) - 168/80(102)} mmHg\n RR: 19 (17 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,038 mL\n 496 mL\n PO:\n TF:\n 970 mL\n 277 mL\n IVF:\n 798 mL\n 99 mL\n Blood products:\n Total out:\n 1,230 mL\n 430 mL\n Urine:\n 1,230 mL\n 430 mL\n NG:\n Stool:\n Drains:\n Balance:\n 808 mL\n 66 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 84\n PIP: 31 cmH2O\n Plateau: 20 cmH2O\n SpO2: 95%\n ABG: ///34/\n Ve: 10.3 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, +2 pitting edema, cachectic \n / Radiology\n 255 K/uL\n 9.1 g/dL\n 119 mg/dL\n 1.1 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 33 mg/dL\n 107 mEq/L\n 146 mEq/L\n 26.5 %\n 19.4 K/uL\n [image002.jpg]\n 03:59 AM\n 04:15 AM\n 06:29 AM\n 03:07 PM\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n WBC\n 24.4\n 20.3\n 17.4\n 19.4\n Hct\n 26.7\n 24.8\n 24.1\n 30.9\n 26.5\n Plt\n 55\n Cr\n 1.0\n 1.1\n 1.2\n 1.1\n TCO2\n 27\n 27\n 28\n 27\n 31\n Glucose\n 121\n 135\n 107\n 119\n Other labs: PT / PTT / INR:13.4/32.1/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.2 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:49 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 01:36 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 441974,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 01:08 PM\n Events:\n - discussion with niece and other family member re trach\n - placed s/w c/s\n - transfused 1u PRBC\n - family meeting today re trach and code status\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:53 PM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.1\nC (97\n HR: 80 (68 - 100) bpm\n BP: 130/56(73) {96/42(57) - 168/80(102)} mmHg\n RR: 19 (17 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,038 mL\n 496 mL\n PO:\n TF:\n 970 mL\n 277 mL\n IVF:\n 798 mL\n 99 mL\n Blood products:\n Total out:\n 1,230 mL\n 430 mL\n Urine:\n 1,230 mL\n 430 mL\n NG:\n Stool:\n Drains:\n Balance:\n 808 mL\n 66 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 84\n PIP: 31 cmH2O\n Plateau: 20 cmH2O\n SpO2: 95%\n ABG: ///34/\n Ve: 10.3 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, +2 pitting edema, cachectic \n / Radiology\n 255 K/uL\n 9.1 g/dL\n 119 mg/dL\n 1.1 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 33 mg/dL\n 107 mEq/L\n 146 mEq/L\n 26.5 %\n 19.4 K/uL\n [image002.jpg]\n 03:59 AM\n 04:15 AM\n 06:29 AM\n 03:07 PM\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n WBC\n 24.4\n 20.3\n 17.4\n 19.4\n Hct\n 26.7\n 24.8\n 24.1\n 30.9\n 26.5\n Plt\n 55\n Cr\n 1.0\n 1.1\n 1.2\n 1.1\n TCO2\n 27\n 27\n 28\n 27\n 31\n Glucose\n 121\n 135\n 107\n 119\n Other labs: PT / PTT / INR:13.4/32.1/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.2 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with hypoxia and respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Given\n acute decompensation without a pre-intubation ABG, suspect a component\n of hypercarbic resp failure given MS changes & elevated serum bicarb.\n Will try to achieve a mild permissive hypercapnea. Failed PSV 2/10 PM\n primary respiratory acidosis.\n - sputum -> moderate H. flu, blood Cx pending; Urine legionella\n (received Levoflox x 1 in ED) neg\n - d/c Vanc, cont Zosyn for H. flu\n - MDI while intubated (pt with auto-PEEP), transition to nebs once\n extubated\n - unlikely to be weaned from vent soon, will consider trach -> will d/w\n pt/family/Dr. \n - goal 1L neg today\n - mouthcare, HOB elevated\n .\n # Hypotension: Etiology unclear, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2months of prednisone use. Aggressive resuscitation with\n IVF, s/p 10L of IVF on initial presentation. Hypotension now resolved.\n - Hydrocortisone 100mg q8hr (stress dose)\n - goal 1L neg today\n .\n # ARF\n pre-renal from lasix administration\n .\n # Chest pain: Pt with recent NSTEMI who presented with hypoxia and was\n denying CP in ED. EKGs with sinus tach in 140s, LBBB and non-specific\n changes from baseline. First set of CE are negative though pt was\n reporting CP on arrival to ICU. Given the recent history, possible to\n have demand ischemia with tachycardia. Will monitor symptoms and cycle\n cardiac enzymes.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - cardiac enzymes negative x3\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg \n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s. However, unclear\n etiology to acute drop from baseline.\n - transfusing one unit PRBC now\n - guiaic negative\n - hemolysis labs negative\n - maintain active type & screen\n - get rehab records\n - PPI and CVL,PIV, PICC for access\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative\n .\n # FEN: NPO for now, will consult nutrition for TFs\n - cont TFs\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, Right femoral line, left PICC (plan to d/c\n femoral line today)\n .\n # Code: FULL\n .\n # Disposition: pending above\n - SW c/s\n - Will discuss with niece re trach, spoke to family\n today\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:49 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 01:36 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-25 00:00:00.000",
"description": "Generic Note",
"row_id": 443262,
"text": "TITLE:\n 70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit. Failure to wean with\n original plan to trach/PEG by IP. Pt did well on RSBI (score\n 50), and passed SBT so extubated at 1400.\n Pt became tachycardic, tachypnic, increased BP at MN on . VBG\n indicated elevated CO2, pt originally not responsive to IV diltiazem,\n responsive to IV labetolol IVP 10 mg x 2 to control HR/BP. However\n resp status not improved, pt re-intubated at 0200. Labetolol gtt\n started for rate / BP control but \nt s/p intubation as SBP\n dropped to 84/38 (51). ET tube / OG tube placement confirmed.\n Pt is being followe by case mgt for rehab.\n Edema, peripheral\n Assessment:\n Generalized edema + bilat legs and pedal, no hand edema, coccyx and\n dependent edema-continuously weeping- through total 3 pink pads/2\n sheets, thin fragile skin likely chronic steroid therapy, mult sm\n bruising throughout body, blanching borderline stage I on gleut- pt\n very thin and @ risk for ulcerations on bony areas\n Action:\n Barrier cream to protect maceration, turning, OOB to chair, supportive\n care, now on Kinair bed\n Response:\n Cont weeping large amounts serous fluids\n Plan:\n Tuning/OOB to chair-activity, skin care, BP stabilizing and ? diuretic\n therapy in future\n Alteration in Nutrition\n Assessment:\n TF Nutren Pulmonary @ goal 40cc/hr, 250cc free water flush Q4hrs\n Action:\n none\n Response:\n Tolerating tf well.\n Plan:\n Cont TF . NPO @ MN Sunday night for trach/PEG Monday\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS tight/diminished\nless secretions than previous day, on PSV\n Action:\n CPAP+PSV 8/+8/40%,\n Response:\n O2 sats 91 to 96\n Plan:\n Cont PSV as tolerated , possible slow wean over weekend.\n K + 3.6\n repleted with 20 meq of KCL over 1 hour via PICC.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443661,
"text": "Events: Bedside trach/PEG by IP and thoracic w/o incident, anesthesia\n present- sedated w/ Vecuronium, Propofol bolus and gtt- off post\n procedure. NO further sedation w/ PRN anxiety of hospitalization and\n trach. Niece @ bedside throughout most of day. Plan for 24hrs on PEG\n draining to gravity- to be cleared by thorasics for tube feeding-\n may give meds and needs sterile H2O flush Q6hrs. Starting diuretic\n therapy for + 16 L LOS/anasarca. Bedside echo:\n Edema, peripheral\n Assessment:\n 3+ pitting/weeping bilat arms, legs, feet, and dependent areas-\n specific area\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Mult skin tears, bruising throughout body, large bruise on abd,\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442834,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit, now failure to wean\n with plan to trach/PEG by IP, prep for rehab.\n No significant events overnight, for trach/peg in AM\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on vent settings CPAP/PS 40% 12/+8 with RR 16-24 and regular. O2\n sat 97-100%. Pt denied SOB, C/O claustrophobia. Lung sounds\n rhonchorous, diminished in bases. Suctioned for mod\ncopious amts\n blood-tinged, thick, tan secretions. Afebrile. Fentnayl patch in\n place.\n Action:\n Pt rec\nd Ativan 1mg Q4hrs PRN. Suctioned PRN. No vent changes\n overnight, NPO for procedure in AM and started D51/2NS 75ml/hr.\n Response:\n Pt remains stable. She reports fair relief from Ativan.\n Plan:\n Cont PRN Ativan for anxiety, nausea. PO calcium ONLY for repletion. For\n trach/PEG in Am. NPO after midnight, Cont prep for transfer to rehab.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple skintears, blisters, hematomas on all extremeties,\n with decreasing amts yellow fluid leaking from all limbs. Pt denies\n pain, rec\ning Fentanyl patch for comfort.\n Action:\n Skin tears requiring dsg changes Q2-4hrs. Pt turned freq STS. Heels\n elevated off bed or waffle boots in place. Compression stockings off\n D/T blisters, skin tears on legs.\n Response:\n Weeping cont from impaired skin.\n Plan:\n Cont vigilent skin care. Wound care nurse consulted.\n"
},
{
"category": "Nutrition",
"chartdate": "2158-02-16 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 441825,
"text": "Subjective\n pt intubated/sedated\n Objective\n Pertinent medications: SS Ca, SS K, SS NaPo4, SS Mg, HISS, prednisone,\n protonix, bowel meds, lasix x1, others noted\n Labs:\n Value\n Date\n Glucose\n 107 mg/dL\n 02:05 AM\n Glucose Finger Stick\n 164\n 10:00 AM\n BUN\n 30 mg/dL\n 02:05 AM\n Creatinine\n 1.2 mg/dL\n 02:05 AM\n Sodium\n 146 mEq/L\n 02:05 AM\n Potassium\n 3.1 mEq/L\n 02:05 AM\n Chloride\n 106 mEq/L\n 02:05 AM\n TCO2\n 32 mEq/L\n 02:05 AM\n Calcium non-ionized\n 7.5 mg/dL\n 02:05 AM\n Phosphorus\n 2.5 mg/dL\n 02:05 AM\n Magnesium\n 2.2 mg/dL\n 02:05 AM\n WBC\n 17.4 K/uL\n 02:05 AM\n Hgb\n 7.9 g/dL\n 02:05 AM\n Hematocrit\n 24.1 %\n 02:05 AM\n Current diet order / nutrition support: Nutren Pulmonary @40mL/hr (1440\n kcals/65 gr aa)\n GI: Abd: soft/+bs\n Assessment of Nutritional Status\n Specifics:\n Pt continues on TF\ns for full nutrition support, meeting 100% estimated\n nutrition needs. TF\ns well tolerated RN. Na trending up, will\n need to increase FWB. K, Ca, and Po4 repletions noted. Bg\ns elevated\n on prednisone. Noted possible trach.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: multivit via TF, consider Ca and vit\n D d/t long term steroids\n Continue TF's @goal, increase FWB to 100 q4 hr\n Consider switching from HISS to RISS for more consistent coverage on\n continuous feeds\n Lyte management as you are\n Please page c/ ?'s #\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441556,
"text": "Edema, peripheral\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-15 00:00:00.000",
"description": "ICU Attending Note",
"row_id": 441621,
"text": "Clinician: Attending\n 70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Switched from PSV to CMV due to resp acidosis.\n Afebrile 88-112. MAP 60-66 off pressors (had been on DA)\n I/O +3L. 800cc urine/24h.\n CMV 0.4/500/16/5 ABG: 7.31/51/106, p/f 265, RSBI 100.\n Versed 2/fent 25.\n Hct stable at 27. lytes nl. Legionella neg. U Cx neg. WBC slightly\n increased. B Cx pending.\n Exam sig for awake, opened eyes, responded to questions with head nod.\n Diffuse exp wheezing. Right femoral line. Distant HS. Abd NABS, soft,\n NDNT. Extremities cachectic, petechial lesions, atrophied. LE pitting\n edema + bilat. Minimal resp secretions.\n Meds: Insulin, hep sc, vanc/cipro/zosyn, ppi, asa, statin, hydrocort\n 100 IV q 8, versed 1, fentanyl 25, DA\n 1. Severe COPD with exacerbation, doubt significant pna\n a. d/c cipro and continue vanc/zosyn\n b. continue high dose steroids for COPD exac\n c. attempt PSV\n 2. RV strain with cor pulmonale/pna/hypoxic\n vasoconstriction\nadmitted with elevated BNP in setting of hypovolemia\n 3. fluid goal even\n Total time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442120,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. (See Dr\n \ns note for list of multiple + sputum cx). Sputum now showing\n pleomorphic GN coccobacillus (recent sputum cx + HFlu). Chronic\n steroids. Intubated when admitted .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated on AC40%/500/18/+8. Lungs clear diminished at\n bases. Suctioned A 3 hours for moderate amounts of yellow blood tinged\n secretions. Sats 94-97%. Continues on MDI\ns & nebs\n Action:\n No vent changes made overnight, Zoysn changed to ceftriaxone\n Response:\n Pt with stable respiratory status overnight\n Plan:\n Continue to wean from vent as tolerated, ? trach some time next week\n Impaired Skin Integrity\n Assessment:\n Pt with multiple skin tears to upper extremities & R shin. Perineum\n red\n Action:\n Skin tears dressed with adaptic & DSD or DSD\ns. Criticad cream applied\n to perineium\n Response:\n Skin status remains unchanged\n Plan:\n Continue with meticulous skin care, frequent turns\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 442773,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n ETT:\n Route: oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: 6 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot manage\n secretions\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441557,
"text": "Edema, peripheral\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 441558,
"text": "Edema, peripheral\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442334,
"text": "Chief Complaint:\n 24 Hour Events:\n - brief episode of SVT, EKG with no significant changes\n - IP to trach/PEG Tuesday\n - spoke with case mgmt re: rehab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Ceftriaxone - 10:44 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 04:15 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Lorazepam (Ativan) - 04:20 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98.1\n HR: 73 (72 - 102) bpm\n BP: 137/51(72) {110/45(61) - 157/69(91)} mmHg\n RR: 18 (18 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,196 mL\n 899 mL\n PO:\n TF:\n 889 mL\n 271 mL\n IVF:\n 498 mL\n 348 mL\n Blood products:\n Total out:\n 993 mL\n 255 mL\n Urine:\n 993 mL\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,203 mL\n 644 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 29 cmH2O\n Plateau: 20 cmH2O\n SpO2: 97%\n ABG: ///35/\n Ve: 10.2 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 251 K/uL\n 8.5 g/dL\n 102 mg/dL\n 0.8 mg/dL\n 35 mEq/L\n 4.1 mEq/L\n 32 mg/dL\n 108 mEq/L\n 147 mEq/L\n 26.2 %\n 16.7 K/uL\n [image002.jpg]\n 03:07 PM\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n 16.7\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n Plt\n 79\n 251\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n TCO2\n 28\n 27\n 31\n Glucose\n 135\n 107\n 119\n 102\n 160\n 102\n Other labs: PT / PTT / INR:13.5/31.7/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.7 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 07:28 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442335,
"text": "Chief Complaint:\n 24 Hour Events:\n - brief episode of SVT, EKG with no significant changes\n - IP to trach/PEG Tuesday\n - spoke with case mgmt re: rehab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Ceftriaxone - 10:44 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 04:15 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Lorazepam (Ativan) - 04:20 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98.1\n HR: 73 (72 - 102) bpm\n BP: 137/51(72) {110/45(61) - 157/69(91)} mmHg\n RR: 18 (18 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,196 mL\n 899 mL\n PO:\n TF:\n 889 mL\n 271 mL\n IVF:\n 498 mL\n 348 mL\n Blood products:\n Total out:\n 993 mL\n 255 mL\n Urine:\n 993 mL\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,203 mL\n 644 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 29 cmH2O\n Plateau: 20 cmH2O\n SpO2: 97%\n ABG: ///35/\n Ve: 10.2 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 251 K/uL\n 8.5 g/dL\n 102 mg/dL\n 0.8 mg/dL\n 35 mEq/L\n 4.1 mEq/L\n 32 mg/dL\n 108 mEq/L\n 147 mEq/L\n 26.2 %\n 16.7 K/uL\n [image002.jpg]\n 03:07 PM\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n 16.7\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n Plt\n 79\n 251\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n TCO2\n 28\n 27\n 31\n Glucose\n 135\n 107\n 119\n 102\n 160\n 102\n Other labs: PT / PTT / INR:13.5/31.7/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.7 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 07:28 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442337,
"text": "Chief Complaint:\n 24 Hour Events:\n - brief episode of SVT, EKG with no significant changes\n - IP to trach/PEG Tuesday\n - spoke with case mgmt re: rehab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Ceftriaxone - 10:44 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 04:15 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Lorazepam (Ativan) - 04:20 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98.1\n HR: 73 (72 - 102) bpm\n BP: 137/51(72) {110/45(61) - 157/69(91)} mmHg\n RR: 18 (18 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,196 mL\n 899 mL\n PO:\n TF:\n 889 mL\n 271 mL\n IVF:\n 498 mL\n 348 mL\n Blood products:\n Total out:\n 993 mL\n 255 mL\n Urine:\n 993 mL\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,203 mL\n 644 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 29 cmH2O\n Plateau: 20 cmH2O\n SpO2: 97%\n ABG: ///35/\n Ve: 10.2 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 251 K/uL\n 8.5 g/dL\n 102 mg/dL\n 0.8 mg/dL\n 35 mEq/L\n 4.1 mEq/L\n 32 mg/dL\n 108 mEq/L\n 147 mEq/L\n 26.2 %\n 16.7 K/uL\n [image002.jpg]\n 03:07 PM\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n 16.7\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n Plt\n 79\n 251\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n TCO2\n 28\n 27\n 31\n Glucose\n 135\n 107\n 119\n 102\n 160\n 102\n Other labs: PT / PTT / INR:13.5/31.7/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.7 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with hypoxia and respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. MDI while intubated. Patient was able to tolerate\n PS10/PEEP8 yesterday for approx 2 hrs . Sputum showed moderate H.\n flu beta-lactamase negative, changed to ceftriaxone. Initally, vanc was\n d/c\ned and patient was kept on Zosyn until found to be flu\n beta-lactamase negative.\n - continue ceftriaxone\n - plan for trach and PEG on Tuesday per IP\n - mouthcare, HOB elevated\n .\n # ARF: pre-renal from lasix administration\n .\n # Hypotension: Resolved, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2 months of prednisone use and patient had initially\n been given Hydrocortisone. Aggressive resuscitation with IVF, s/p 10L\n of IVF on initial presentation.\n - Hypotension now resolved\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg \n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - guiaic negative\n - maintain active type & screen\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative\n .\n # FEN: cont TFs, nutrition following, PEG to be placed Tuesday\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n # Code: FULL\n .\n # Disposition: trach and PEG Tuesday, case management aware of need for\n rehab planning\n - Social work consult placed \n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 07:28 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443418,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit. Failure to wean with\n original plan to trach/PEG by IP. Pt did well on RSBI (score\n 50), and passed SBT so extubated at 1400. Patient reintubated at\n at 0200. Pt now awaiting Trach./PEG scheduled for Monday .\n EVENTS: CXR for NGT placement confirmation, and it is OK to use and TF\n started .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient sitting on the chair, vented PSV 8/8 and O2 40%.\n Bilateral lung sounds rhonchorous and diminished bases. O2 sats 96-98%\n Action:\n No vent changes , suction PRN, MDI\ns as ordered\n Response:\n Plan:\n Awaiting trach/PEG on Monday\n Impaired Skin Integrity\n Assessment:\n Multiple skin tear sites. Pt has very fragile skin secondary to\n chronic steroid use. Generalized edema throughout body.+2-+4mm. Skin\n weeping large amounts of serous/ serosanguinous fluid continueously.\n Left lower leg hematoma burst today causing skin tear.\n Action:\n Dressing changes as needed secondary to weeping\n Response:\n Weeping serosanguious fluid from multiple ares of broken skin\n Plan:\n Skin care consults on Monday. Frequent dressing changes to keep clean\n and dry\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 443657,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Cuffed, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Cuff volume: 10 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Copious\n Comments: blood tinged secretions post trach placeemtn tan/yellow prior\n to trach\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: attempted to wean pt to Tm this afternoon, pt appeared\n comfortable hopwever complained of sob ? anxiety factor plan to attempt\n again tomorrow with family present\n Assessment of breathing comfort: Pt acknowledges dyspnea\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Bedside tracheostomy (1300)\n Comments: pt trached at bedside with 8.0 portex without incident\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443770,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - will need to change doripenem to meropenem 1g q8h for rehab\n - got Trach/PEG\n - hypertensive all day -> started back on home dose dilt and added\n captopril for increased afterload reduction\n PERCUTANEOUS TRACHEOSTOMY - At 01:00 PM\n teach/PEG placement\n TRANSTHORACIC ECHO - At 02:27 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 10:14 AM\n Vancomycin - 03:05 PM\n Infusions:\n Other ICU medications:\n Vecuronium - 12:55 PM\n Propofol - 01:00 PM\n Furosemide (Lasix) - 02:45 PM\n Fentanyl - 06:29 PM\n Lorazepam (Ativan) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.8\nC (98.3\n HR: 77 (68 - 104) bpm\n BP: 118/54(69) {88/40(54) - 170/98(107)} mmHg\n RR: 14 (14 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 56.7 kg (admission): 60.5 kg\n Height: 67 Inch\n Total In:\n 953 mL\n 313 mL\n PO:\n TF:\n 41 mL\n IVF:\n 831 mL\n 233 mL\n Blood products:\n Total out:\n 3,190 mL\n 510 mL\n Urine:\n 3,140 mL\n 510 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n -2,238 mL\n -198 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 405 (340 - 550) mL\n PS : 5 cmH2O\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 11 cmH2O\n SpO2: 95%\n ABG: ///39/\n Ve: 7.2 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 410 K/uL\n 9.8 g/dL\n 81 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 3.9 mEq/L\n 15 mg/dL\n 98 mEq/L\n 139 mEq/L\n 30.3 %\n 15.7 K/uL\n [image002.jpg]\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n 03:54 AM\n 03:56 AM\n 04:00 AM\n WBC\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n 19.7\n 15.9\n 15.7\n Hct\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n 28.7\n 30.0\n 30.3\n Plt\n 258\n 284\n 310\n 349\n 91\n 410\n Cr\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n 0.5\n 0.5\n 0.5\n Glucose\n 106\n 76\n 72\n 135\n 79\n 70\n 90\n 82\n 81\n Other labs: PT / PTT / INR:14.3/34.1/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.2 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:1.7 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Patient was started on vanc/zosyn. Vanc was d/c\ned once\n it was growth was gram negative. Zosyn was changed to ceftriaxone when\n speciated to H. flu beta-lactamase negative. Patient completed \n day course of HAP and steroid taper when patient passed SBT and was\n extubated. Patient remained extubated for 12 hours and developed sinus\n tachycardia (in the setting of beta blocker withdrawl), tachypnea,\n accessory muscle use and desaturation to low 90s. Patient was given\n trial of nebs and CPAP, patient continued to retain CO2 and patient was\n intubated on . Patient has very poor respiratory reserve and will\n require long-term trach.\n - s/p ceftriaxone course for h.flu; now being treating for pseudomonas\n with vanc/ -> 2 week course from \n - patient to get Trach/PEG as add-on today\n - continue prednisone, now on 40 mg daily for the next three days, and\n will continue taper\n - mouthcare, HOB elevated\n .\n # Leukocytosis / Fever\n developed 4 hours after reintubation. Patient\n was intubated uneventfully and patient was NPO 48 hours prior to\n procedure. Likely , pt improving with decreasing leukocytosis, has\n not spiked since \n - f/u BC, UC, cdiff toxin, mini-BAL, and endobronchial\n aspirate cx (neg gram stain on mini BAL)\n - first c.diff neg, stopped c.diff treatment\n - treating for pseudomonas plus one other GNR yet to be\n speciated with Vanco and doripenem for now, awaiting speciations\n will\n treat 7 days since last fever\n - foley changed secondary to yeast\n .\n # Tachycardia\n similar to previous, could be from infection or\n hypovolemia or anxiety. Could also be MAT given resp problems. \n agents. Responded to fluid boluses , tachy with movement,\n when calm around 80s-90s.\n - Sinus tach on EKG \n - Fluid challenge PRN\n - Hold anti-HTN meds\n .\n # Resolved ARF: Pre-renal from hypovolemia/sepsis, now improved.\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily\n will discuss\n aspirin with thoracic team today.\n - continue to monitor on telemetry, follow EKGs\n - holding all agents at this time; afib responds to metoprolol if\n she goes into it, dilt did not work as well\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF.\n Dropped over course of hospitalization, s/p transfusion again on ;\n now stabalized. Anemia likey from phlebotomy, chronic disease\n Transfused one unit PRBC , on on \n - cont to trend\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # Osteopenia\n was on fosamax as outpatient, in setting of steroid use\n will start Ca/Vit D\n - Ca and Vit D supplementation for now\n - re-start fosamax when respiratory status starts to stabilize\n .\n # FEN: cont TFs, 40cc/hr, running at goal, nutrition following,\n awaiting PEG\n .\n # Prophylaxis: heparin sc BID, PPI\n .\n # Access: Left PIV 18 gauge, PICC\n .\n # Code: FULL\n .\n # Communication\n with patient and niece\n .\n # Disposition: case management aware of need for rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n :\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "General",
"chartdate": "2158-02-28 00:00:00.000",
"description": "Generic Note",
"row_id": 443826,
"text": "TITLE: Critical Care\n Present for key portions of resident\ns history and exam. Agree\n substantially with assessment and plan as outlined.\n Episodes of anxiety yesterday\n iv Ativan\n Trache and PEG done.\n I&O neg 1.8L over day yesterday remains pos 20L LOS\n Creat remains 0.5.\n We are adding standing anxiolytic, continuing aggressive diuresis, will\n start to wean vent as tolerated\n try in PSV now. Completing course of\n abx.\n Time spent 40 min\n Critically ill\n"
},
{
"category": "Social Work",
"chartdate": "2158-02-22 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 442904,
"text": "Social Work:\n Met with pt and her , \n (c: ), at bedside\n in MICU. Pt was extubated this afternoon and presents as sitting up in\n bed visiting with . Pt is not able to speak at this time, though\n she mouths that she feels\nokay.\n speaks of the unexpected but\n good news that pt has been extubated and raises questions about what\n this means for discharge plans. Discussed how, at this time, focus is\n on watching to assess how pt is doing in the next 24 hours while she\n remains in the MICU. Confirmed that if pt continues to make progress\n and remains stable, she may either be transferred to the floor and be\n screened for rehab facilities then or possibly be screened for rehab\n from the MICU. Deferred her specific questions about rehab and\n discharge planning to RNCM. Ultimately, empathized with \ns wish\n for clarity around what to expect as she acknowledges that uncertainty\n increases her anxiety, and encouraged focus on present as much as\n possible.\n states that if pt does well in the next couple of days, she plans\n to return to VT where she is vacationing this week. She provides\n contact information for a friend, (c: , w:\n ), who can be reached if she is not available, though she\n also emphasizes that she intends to remain available by phone, whether\n here or in VT.\n Pt/ seem to be coping well at this time. SW will remain available\n to them for ongoing emotional support as needed during\n hospitalization. Please page with any questions or concerns.\n , LICSW, #\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 441736,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Comments:\n Plan\n Next 24-48 hours: wean to ext if possible or discuss trach\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-18 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 442201,
"text": "Chief Complaint:\n 24 Hour Events:\n - niece came and had meeting with pt and Dr. , decided that\n she wanted to go ahead with a trach\n - changed abx to ceftriaxone per pharm recommendation\n - plan to call IP for trach eval\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Ceftriaxone - 10:19 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 76 (68 - 95) bpm\n BP: 101/46(60) {101/46(60) - 166/86(96)} mmHg\n RR: 18 (13 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,858 mL\n 395 mL\n PO:\n TF:\n 1,128 mL\n 268 mL\n IVF:\n 398 mL\n 97 mL\n Blood products:\n 212 mL\n Total out:\n 1,190 mL\n 270 mL\n Urine:\n 1,190 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n 668 mL\n 125 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 17\n PIP: 30 cmH2O\n Plateau: 19 cmH2O\n Compliance: 62.5 cmH2O/mL\n SpO2: 98%\n ABG: ///35/\n Ve: 10.9 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 279 K/uL\n 9.7 g/dL\n 102 mg/dL\n 0.9 mg/dL\n 35 mEq/L\n 3.7 mEq/L\n 32 mg/dL\n 108 mEq/L\n 148 mEq/L\n 29.8 %\n 20.7 K/uL\n [image002.jpg]\n 04:15 AM\n 06:29 AM\n 03:07 PM\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n Plt\n 79\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n TCO2\n 27\n 27\n 28\n 27\n 31\n Glucose\n 135\n 107\n 119\n 102\n Other labs: PT / PTT / INR:13.3/32.1/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.8 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with hypoxia and respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. MDI while intubated. Patient was able to tolerate\n PS10/PEEP8 yesterday for approx 2 hrs . Sputum showed moderate H.\n flu beta-lactamase negative, changed to ceftriaxone. Initally, vanc was\n d/c\ned and patient was kept on Zosyn until found to be flu\n beta-lactamase negative.\n - continue ceftriaxone\n - plan for trach and PEG on Tuesday per IP\n - mouthcare, HOB elevated\n .\n # ARF: pre-renal from lasix administration\n .\n # Hypotension: Resolved, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2 months of prednisone use and patient had initially\n been given Hydrocortisone. Aggressive resuscitation with IVF, s/p 10L\n of IVF on initial presentation.\n - Hypotension now resolved\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg \n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - guiaic negative\n - maintain active type & screen\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative\n .\n # FEN: cont TFs, nutrition following, PEG to be placed Tuesday\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n # Code: FULL\n .\n # Disposition: trach and PEG today, will talk to case management re:\n rehab\n - Social work consult placed \n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:41 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 01:36 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 70F COPD c/b respiratory failure x7 days.\n Sputum + H. flu. Plan for trach and feeding tube.\n Exam notable for Tm 36.8 BP 110/50 HR 73 RR 20 with sat 99 on VAC\n 500x18 8 0.4. Tearful but denies pain. Distant BS B. RRR s1s2. Soft\n +BS. 2+ edema. Labs notable for WBC 20K, HCT 30, Na 148, K+ 3.7,\n Cr 0.9. CXR with , EKG .\n Agree with plan to manage severe COPD c/b H. flu pneumonia with ongoing\n vent support, CTX, prednisone taper and plan for T+G. Will transition\n off gtt sedation and start fent patch with ativan for breakthrough.\n Will increase FWB for FW depletion and hypernatremia. Continue\n remainder of supportive care as outlined. Remainder of plan as outlined\n above.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 01:40 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442405,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit, now failure to wean\n with plan to trach/PEG by IP, prep for rehab.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on vent settings AC 40%/18 X 500/+8 with SRR to 19 and regular.\n O2 sat 95-98%. Pt denied SOB. Lung snds clear, diminished in bases.\n Suctionned for scant amts blood-tinged, thick, tan secretions. Other VS\n generally stable with HR 78-97SR without VEA, BP 124/50-177/63.\n Afebrile. Rec\nd on Fentanyl 25mcg/hr.\n Action:\n Pt OOB to chair for several hrs in AM. Vent settings changed to PS\n 12/+8/40%. Fentanyl qtt stopped, Fentanyl patch in place.\n Response:\n Pt C/O nausea after moved to chair. She rec\nd Ativan 0.5mg with\n eventual resolution of nausea. After 11/2 hrs on PS, pt C/O feeling\n anxious with RR inc\nd to mid 20\ns and SBP to 170\ns. Pt rec\nd Ativan 1mg\n IV without resolution of symptoms, and vent settngs returned to AC. Pt\n again C/O abd discomfort @ 1600, and rec\nd Zofran 4mg IV with good\n resolution. Pt consented for trach/PEG by IP.\n Plan:\n Cont PRN Ativan for anxiety, nausea. Zofran also available PRN. Cont\n prep for transfer to rehab, with trach/PEG planned for by IP.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple skintear, blisters, hematomas on all extremeties, with\n copious amts yellow fluid leaking from all limbs. Pt denies pain,\n rec\ning Fentanyl for comfort.\n Action:\n Skin tears requiring dsg changes Q2hrs. Pt OOB to chair, and turned\n freq STS. Heels elevated off bed or waffle boots in place. Compression\n stockings off D/T blisters, skin tears on legs.\n Response:\n Increased amt weeping from impaired skin.\n Plan:\n Cont vigilent skin care.\n Hypernatremia (high sodium)\n Assessment:\n AM Na 147, down from 148 yesterday. Pt rec\ning FWB of 250ml Q6hrs. TF\n residuals <5ml. Pt intermit C/O vague stomach discomfort. Abd soft with\n +BS, and mushroom cath draining small amt loose brown stool.\n Action:\n FWB inc\nd to 250ml Q4hrs.\n Response:\n Residuals cont scant. Na level to follow.\n Plan:\n Cont to monitor Na level.\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442197,
"text": "Chief Complaint:\n 24 Hour Events:\n - niece came and had meeting with pt and Dr. , decided that\n she wanted to go ahead with a trach\n - changed abx to ceftriaxone per pharm recommendation\n - plan to call IP for trach eval\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Ceftriaxone - 10:19 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 76 (68 - 95) bpm\n BP: 101/46(60) {101/46(60) - 166/86(96)} mmHg\n RR: 18 (13 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,858 mL\n 395 mL\n PO:\n TF:\n 1,128 mL\n 268 mL\n IVF:\n 398 mL\n 97 mL\n Blood products:\n 212 mL\n Total out:\n 1,190 mL\n 270 mL\n Urine:\n 1,190 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n 668 mL\n 125 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 17\n PIP: 30 cmH2O\n Plateau: 19 cmH2O\n Compliance: 62.5 cmH2O/mL\n SpO2: 98%\n ABG: ///35/\n Ve: 10.9 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 279 K/uL\n 9.7 g/dL\n 102 mg/dL\n 0.9 mg/dL\n 35 mEq/L\n 3.7 mEq/L\n 32 mg/dL\n 108 mEq/L\n 148 mEq/L\n 29.8 %\n 20.7 K/uL\n [image002.jpg]\n 04:15 AM\n 06:29 AM\n 03:07 PM\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n Plt\n 79\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n TCO2\n 27\n 27\n 28\n 27\n 31\n Glucose\n 135\n 107\n 119\n 102\n Other labs: PT / PTT / INR:13.3/32.1/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.8 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with hypoxia and respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. MDI while intubated. Patient was able to tolerate\n PS10/PEEP8 yesterday for approx 2 hrs . Sputum showed moderate H.\n flu beta-lactamase negative, changed to ceftriaxone. Initally, vanc was\n d/c\ned and patient was kept on Zosyn until found to be flu\n beta-lactamase negative.\n - continue ceftriaxone\n - plan for trach and PEG on Tuesday per IP\n - mouthcare, HOB elevated\n .\n # ARF: pre-renal from lasix administration\n .\n # Hypotension: Resolved, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2 months of prednisone use and patient had initially\n been given Hydrocortisone. Aggressive resuscitation with IVF, s/p 10L\n of IVF on initial presentation.\n - Hypotension now resolved\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg \n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - guiaic negative\n - maintain active type & screen\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative\n .\n # FEN: cont TFs, nutrition following, PEG to be placed Tuesday\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n # Code: FULL\n .\n # Disposition: trach and PEG today, will talk to case management re:\n rehab\n - Social work consult placed \n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:41 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 01:36 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-19 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 442409,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n :\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea); Comments: htn,\n anxious after 1-2 hrs of psv, not clear if respiratory in origin\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n :\n Comments:\n Refer to comments in above section\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442465,
"text": "PMH: 70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic\n resp failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum\n now showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin\n with multiple tears, weeping. Intubated on admit, now failure to\n wean with plan to trach/PEG by IP, prep for rehab.\n Events:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 40%/500/18/5. Sp02 94-98%, SRR to 20 when pt is\n awake. Pt is not sedated. LS clear and dim at bases bilat. Mod amts\n thick, tan, blood tinged sputum w/ sux.\n Action:\n Nebulizers given, freq oral care. Suction as needed. ABX for PNA.\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442470,
"text": "PMH: 70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic\n resp failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum\n now showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin\n with multiple tears, weeping. Intubated on admit, now failure to\n wean with plan to trach/PEG by IP, prep for rehab.\n Events:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 40%/500/18/5. Sp02 94-98%, SRR to 20 when pt is\n awake. Pt is not sedated, not restrained. LS clear and dim at bases\n bilat. Mod amts thick, tan, blood tinged sputum w/ sux.\n Action:\n Nebulizers given, freq oral care. Suction as needed. ABX for PNA.\n Response:\n Sp02 currently 97%. Pt in no acute distress.\n Plan:\n Plan for trach/PEG , family and pt aware.\n Impaired Skin Integrity\n Assessment:\n Pt has mult skin tears, very fragile, thin skin. Generalized and\n weeping edema. Lg sanguinous blister at L medial\n Action:\n Reposition as tol, dressings to LEs changed as needed.\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442560,
"text": "Chief Complaint:\n 24 Hour Events:\n - changed free water boluses thru feeding tube to reduce hyperNa\n - d/c fent drip\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 03:52 PM\n Lorazepam (Ativan) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.3\nC (99.1\n HR: 79 (67 - 97) bpm\n BP: 138/52(73) {121/48(65) - 177/71(97)} mmHg\n RR: 18 (18 - 20) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,080 mL\n 892 mL\n PO:\n TF:\n 953 mL\n 271 mL\n IVF:\n 737 mL\n 106 mL\n Blood products:\n Total out:\n 1,382 mL\n 330 mL\n Urine:\n 1,132 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,698 mL\n 562 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (455 - 500) mL\n PS : 12 cmH2O\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 31 cmH2O\n Plateau: 19 cmH2O\n SpO2: 92%\n ABG: ///34/\n Ve: 9.2 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 258 K/uL\n 8.1 g/dL\n 106 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 105 mEq/L\n 143 mEq/L\n 25.6 %\n 17.7 K/uL\n [image002.jpg]\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n Plt\n 79\n 251\n 258\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n TCO2\n 27\n 31\n Glucose\n 135\n 107\n 119\n 102\n 160\n 102\n 106\n Other labs: PT / PTT / INR:13.2/41.4/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. MDI while intubated. Patient was able to tolerate\n PS10/PEEP8 yesterday for approx 2 hrs . Sputum showed moderate H.\n flu beta-lactamase negative, changed to ceftriaxone. Initally, vanc was\n d/c\ned and patient was kept on Zosyn until found to be flu\n beta-lactamase negative.\n - will check VBG before and after PS trials\n - continue ceftriaxone for total of 14 days\n - plan for trach and PEG on Tuesday per IP\n - begin to taper prednisone, 40mg daily today\n - mouthcare, HOB elevated\n .\n # ARF: pre-renal from lasix administration -> holding lasix for now,\n free water flushes at 250cc q4h (hyper NA improved)\n .\n # Hypotension: Resolved, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2 months of prednisone use and patient had initially\n been given Hydrocortisone. Aggressive resuscitation with IVF, s/p 10L\n of IVF on initial presentation.\n - Hypotension now resolved\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg \n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - guiaic negative\n - maintain active type & screen\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative\n .\n # FEN: cont TFs, nutrition following, PEG to be placed Tuesday\n .\n # Prophylaxis: heparin sc TID will change to 2.2 PTT 41 today,\n bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n # Code: FULL\n .\n # Disposition: trach and PEG Tuesday, case management aware of need for\n rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 08:38 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-20 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 442581,
"text": "Chief Complaint:\n 24 Hour Events:\n - changed free water boluses thru feeding tube to reduce hyperNa\n - d/c fent drip\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 03:52 PM\n Lorazepam (Ativan) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.3\nC (99.1\n HR: 79 (67 - 97) bpm\n BP: 138/52(73) {121/48(65) - 177/71(97)} mmHg\n RR: 18 (18 - 20) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,080 mL\n 892 mL\n PO:\n TF:\n 953 mL\n 271 mL\n IVF:\n 737 mL\n 106 mL\n Blood products:\n Total out:\n 1,382 mL\n 330 mL\n Urine:\n 1,132 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,698 mL\n 562 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (455 - 500) mL\n PS : 12 cmH2O\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 31 cmH2O\n Plateau: 19 cmH2O\n SpO2: 92%\n ABG: ///34/\n Ve: 9.2 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 258 K/uL\n 8.1 g/dL\n 106 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 105 mEq/L\n 143 mEq/L\n 25.6 %\n 17.7 K/uL\n [image002.jpg]\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n Plt\n 79\n 251\n 258\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n TCO2\n 27\n 31\n Glucose\n 135\n 107\n 119\n 102\n 160\n 102\n 106\n Other labs: PT / PTT / INR:13.2/41.4/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. MDI while intubated. Patient was able to tolerate\n PS10/PEEP8 yesterday for approx 2 hrs . Sputum showed moderate H.\n flu beta-lactamase negative, changed to ceftriaxone. Initally, vanc was\n d/c\ned and patient was kept on Zosyn until found to be flu\n beta-lactamase negative.\n - will check VBG before and after PS trials\n - continue ceftriaxone for total of 14 days\n - plan for trach and PEG on Tuesday per IP\n - begin to taper prednisone, 40mg daily today\n - mouthcare, HOB elevated\n .\n # ARF: pre-renal from lasix administration -> holding lasix for now,\n free water flushes at 250cc q4h (hyper NA improved)\n .\n # Hypotension: Resolved, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2 months of prednisone use and patient had initially\n been given Hydrocortisone. Aggressive resuscitation with IVF, s/p 10L\n of IVF on initial presentation.\n - Hypotension now resolved\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg \n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - guiaic negative\n - maintain active type & screen\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative\n .\n # FEN: cont TFs, nutrition following, PEG to be placed Tuesday\n .\n # Prophylaxis: heparin sc TID will change to 2.2 PTT 41 today,\n bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n # Code: FULL\n .\n # Disposition: trach and PEG Tuesday, case management aware of need for\n rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 08:38 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 70F severe COPD c/b respiratory failure x8\n days. Sputum + H. flu. Plan for trach and feeding tube on Tuesday.\n Increased FWB, off gtt sedation, tol PSV for a few hours.\n Exam notable for Tm 99.8 BP 130/50 HR 60-90 RR 20 with sat 99 on VAC\n 500x18 8 0.4. Comfortable, denies pain. Distant BS B. RRR s1s2. Soft\n +BS. 2+ edema. Labs notable for WBC 17K, HCT 25, Na 143, K+ 4.2,\n Cr 0.7.\n Agree with plan to manage severe COPD c/b H. flu pneumonia with ongoing\n vent support, including PSV trials today with VBG pre/post. Will\n continue CTX (day ) via PICC, slow prednisone taper (down to 40\n today) and plan for T+G. Will continue FWB to 250 q4h for resolving\n hypernatremia. Needs PT and OT eval. Continue remainder of supportive\n care as outlined. Remainder of plan as outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 12:57 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443706,
"text": "70 y/o woman with severe COPD who initially presented with acute\n hypoxic respiratory failure. Her course in the MICU has been c/b fevers\n with +leukocytosis most likely r/t vap. She was briefly extubated on\n and reintubated the following day for hypoxia and hypercarbia.\n A bedside trach/peg was performed on without incident.\n Alteration in Nutrition\n Assessment:\n The pt has been npo except for meds overnight. Her peg was placed to\n gravity intermittently.\n Action:\n NPO per thorasic team s/p peg placement.\n Response:\n Pt tolerating meds/sterile water flushes with minimal drainage.\n Plan:\n Resume tube feedings later today.\n Impaired Skin Integrity\n Assessment:\n Multiple skin tears over the pt\ns arms and legs weeping moderate amts\n of serous or serosanguinous drainage.\n Action:\n Affected areas were cleansed with ns then redressed with aquaphor and\n softsorb pads.\n Response:\n Unchanged.\n Plan:\n Continue skin care as described. Change dressings as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt was rested on psv5/peep5 with o2 40%. RR teens with mv ~8-9 liters.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Rehab Services",
"chartdate": "2158-02-22 00:00:00.000",
"description": "Generic Note",
"row_id": 442887,
"text": "TITLE:\n Consult received and appreciated. Attempted to see patient for\n evaluation today. After discussing patients\n status with RN it was\n decided to hold evaluation at this time. Patient is currently\n undergoing SBT, and may go for trach later today depending outcome. We\n will f/u for evaluation as appropriate. Please call with questions.\n PT pg \n"
},
{
"category": "Physician ",
"chartdate": "2158-02-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442889,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - Trach/PEG re-scheduled for \n - taper prednisone 60, 40, 30, 20 in 4 day intervals, so that within 2\n wks or so she is down to 10mg (per Dr. \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 05:00 PM\n Heparin Sodium (Prophylaxis) - 09:34 PM\n Lorazepam (Ativan) - 03:12 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.3\n HR: 92 (73 - 99) bpm\n BP: 153/58(81) {121/42(62) - 161/78(95)} mmHg\n RR: 24 (16 - 25) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 435 mL\n 442 mL\n PO:\n TF:\n IVF:\n 270 mL\n 442 mL\n Blood products:\n Total out:\n 1,295 mL\n 360 mL\n Urine:\n 1,295 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n -860 mL\n 82 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 505 (347 - 529) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n SpO2: 96%\n ABG: ///37/\n Ve: 9.7 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 310 K/uL\n 8.1 g/dL\n 72 mg/dL\n 0.6 mg/dL\n 37 mEq/L\n 3.7 mEq/L\n 21 mg/dL\n 100 mEq/L\n 140 mEq/L\n 25.0 %\n 19.5 K/uL\n [image002.jpg]\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n 01:55 AM\n 03:55 AM\n WBC\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n 17.5\n 19.5\n Hct\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n 25.8\n 25.0\n Plt\n \n 310\n Cr\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n 0.7\n 0.6\n TCO2\n 31\n Glucose\n 107\n 119\n 102\n 160\n 102\n 106\n 76\n 72\n Other labs: PT / PTT / INR:13.2/38.8/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.0 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Initally, vanc was d/c\ned and patient was kept on Zosyn\n until found to be flu beta-lactamase negative. Sputum showed moderate\n H. flu beta-lactamase negative, changed to ceftriaxone.\n - did well on pressure support trials, RISBI in 50s today, doing a SBT\n trial to see if extubation prior to ? trach should be tried, per resp\n therapy, may have a hard time with secretions; likely will get trach\n and peg today\n - continue ceftriaxone for total of 14 days, day today\n - plan for trach and PEG today if fails SBT\n - will quickly taper prednisone\n 40 mg today, 30 tomorrow, 20 the\n next, then 10 daily for basal dosing\n - mouthcare, HOB elevated\n .\n # ARF: pre-renal from lasix administration -> holding lasix for now,\n free water flushes at 250cc q4h\n - normal Na\n - ARF resolved\n .\n # Hypotension: Resolved, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2 months of prednisone use and patient had initially\n been given Hydrocortisone. Aggressive resuscitation with IVF, s/p 10L\n of IVF on initial presentation.\n - Hypotension now resolved\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg ; will consider changing as is possible to\n cause bronchospasm, could try diltiazem\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - guiac positive\n - steady drop likely from phlebotomy, will transfuse for Hct <24\n - maintain active type & screen\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative, no tx needed\n .\n # Osteopenia\n was on fosamax as outpatient, in setting of steroid use\n will start ca/vit D\n - ca and vit d supplementation for now\n - consider fosamax when respiratory status starts to stabilize\n .\n # FEN: cont TFs, nutrition following, PEG to be placed Tuesday\n .\n # Prophylaxis: heparin sc TID will change to 2.2 PTT 41 today,\n bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n .\n # Code: FULL\n .\n # Communication\n with patient and niece\n .\n # Disposition: trach and PEG now, case management aware of need for\n rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2158-02-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 442823,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: 6 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont intub with OETT and on mech vent as per Metavision.\n Lung sounds ess clear after suct mod bld tinged sput. MDI and SVN given\n as per order. Pt in NARD on PSV; no vent changes required overnoc. Cont\n PSV/? OR for trach and peg today.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443228,
"text": "Events: A-febrile in AM and throughout day but trach/PEG differed until\n Monday. Awake, alert and interactive. Tolerating CPAP+PSV 8/+8 x 6\n +hrs. Seen by PT- OOB to chair, given AIR bed. Restarted TF. HCt\n falling- transfused 1 unit RBC-needs post transfusion Hct @ .\n Intermittently refusing care-movement/turning/OOB/ subglottal\n suctioning and oral care- w/ support and education pt tolerating\n procedures. Niece visiting @ bedside for support..\n Edema, peripheral\n Assessment:\n Generalized edema + bilat legs and pedal, no hand edema, coccyx and\n dependent edema-continuously weeping- through total 3 pink pads/2\n sheets, thin fragile skin likely chronic steroid therapy, mult sm\n bruising throughout body, blanching borderline stage I on gleut- pt\n very thin and @ risk for ulcerations on bony areas\n Action:\n Barrier cream to protect maceration, turning, OOB to chair, supportive\n care, now on Kinair bed\n Response:\n Cont weeping large amounts serous fluids\n Plan:\n Tuning/OOB to chair-activity, skin care, BP stabilizing and ? diuretic\n therapy in future\n Alteration in Nutrition\n Assessment:\n NPO until afternoon, then restarting TF Nutren Pulmonary @ 20cc/hr w/\n goal 40cc/hr\n Action:\n Restarted, 250cc free water flush Q4hrs\n Response:\n tolerating\n Plan:\n Cont TF and increase to goal- NPO @ MD Sunday night for trach/PEG\n Monday\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS tight/diminished\nless secretions than previous day, sat 96-99% on\n PSV\n Action:\n AC changed to CPAP+PSV 8/+8/40%,\n Response:\n No acute change\n Plan:\n Cont PSV as tolerated then return to AC, possible slow wean over\n weekend- BAL negative- awaiting culture growth if no growth then needs\n ABX tailoring Monday\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-19 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 442403,
"text": "Chief Complaint:\n 24 Hour Events:\n - brief episode of SVT, EKG with no significant changes\n - IP to trach/PEG Tuesday\n - spoke with case mgmt re: rehab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Ceftriaxone - 10:44 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 04:15 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Lorazepam (Ativan) - 04:20 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98.1\n HR: 73 (72 - 102) bpm\n BP: 137/51(72) {110/45(61) - 157/69(91)} mmHg\n RR: 18 (18 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 2,196 mL\n 899 mL\n PO:\n TF:\n 889 mL\n 271 mL\n IVF:\n 498 mL\n 348 mL\n Blood products:\n Total out:\n 993 mL\n 255 mL\n Urine:\n 993 mL\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,203 mL\n 644 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 29 cmH2O\n Plateau: 20 cmH2O\n SpO2: 97%\n ABG: ///35/\n Ve: 10.2 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 251 K/uL\n 8.5 g/dL\n 102 mg/dL\n 0.8 mg/dL\n 35 mEq/L\n 4.1 mEq/L\n 32 mg/dL\n 108 mEq/L\n 147 mEq/L\n 26.2 %\n 16.7 K/uL\n [image002.jpg]\n 03:07 PM\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n 16.7\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n Plt\n 79\n 251\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n TCO2\n 28\n 27\n 31\n Glucose\n 135\n 107\n 119\n 102\n 160\n 102\n Other labs: PT / PTT / INR:13.5/31.7/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:7.7 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. MDI while intubated. Patient was able to tolerate\n PS10/PEEP8 yesterday for approx 2 hrs . Sputum showed moderate H.\n flu beta-lactamase negative, changed to ceftriaxone. Initally, vanc was\n d/c\ned and patient was kept on Zosyn until found to be flu\n beta-lactamase negative.\n - continue ceftriaxone for total of 14 days\n - plan for trach and PEG on Tuesday per IP\n - mouthcare, HOB elevated\n .\n # ARF: pre-renal from lasix administration -> holding lasix for now,\n increase free water flushes to 250cc q4h\n .\n # Hypotension: Resolved, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2 months of prednisone use and patient had initially\n been given Hydrocortisone. Aggressive resuscitation with IVF, s/p 10L\n of IVF on initial presentation.\n - Hypotension now resolved\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg \n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - guiaic negative\n - maintain active type & screen\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative\n .\n # FEN: cont TFs, nutrition following, PEG to be placed Tuesday\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n # Code: FULL\n .\n # Disposition: trach and PEG Tuesday, case management aware of need for\n rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 07:28 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 70F severe COPD c/b respiratory failure x8\n days. Sputum + H. flu. Plan for trach and feeding tube on Tuesday. SVT\n yesterday\n Exam notable for Tm 99.1 BP 150/50 HR 73-90 RR 20 with sat 99 on VAC\n 500x18 8 0.4. Comfortable, denies pain. Distant BS B. RRR s1s2. Soft\n +BS. 2+ edema. Labs notable for WBC 16K, HCT 26, Na 147, K+ 4.1,\n Cr 0.8.\n Agree with plan to manage severe COPD c/b H. flu pneumonia with ongoing\n vent support, including PSV trials today, in addition to CTX (day )\n via PICC, prednisone taper and plan for T+G. Will transition off gtt\n sedation and start fent patch with ativan for breakthrough. Will\n increase FWB to 250 q4h for FW depletion and hypernatremia. Needs PT\n and OT eval. Continue remainder of supportive care as outlined.\n Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 05:11 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 442464,
"text": "70 yo woman with severe COPD, recent NSTEMI admitted with hypoxic resp\n failure and pneumonia. Recent pseudomonas, HFlu in sputum. Sputum now\n showing pleomorphic GN cocci. Chronic steroids\nvery fragile skin with\n multiple tears, weeping. Intubated on admit, now failure to wean\n with plan to trach/PEG by IP, prep for rehab.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442518,
"text": "Chief Complaint:\n 24 Hour Events:\n - changed free water boluses thru feeding tube to reduce hyperNa\n - d/c fent drip\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 03:52 PM\n Lorazepam (Ativan) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.3\nC (99.1\n HR: 79 (67 - 97) bpm\n BP: 138/52(73) {121/48(65) - 177/71(97)} mmHg\n RR: 18 (18 - 20) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,080 mL\n 892 mL\n PO:\n TF:\n 953 mL\n 271 mL\n IVF:\n 737 mL\n 106 mL\n Blood products:\n Total out:\n 1,382 mL\n 330 mL\n Urine:\n 1,132 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,698 mL\n 562 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (455 - 500) mL\n PS : 12 cmH2O\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 31 cmH2O\n Plateau: 19 cmH2O\n SpO2: 92%\n ABG: ///34/\n Ve: 9.2 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 258 K/uL\n 8.1 g/dL\n 106 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 105 mEq/L\n 143 mEq/L\n 25.6 %\n 17.7 K/uL\n [image002.jpg]\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n Plt\n 79\n 251\n 258\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n TCO2\n 27\n 31\n Glucose\n 135\n 107\n 119\n 102\n 160\n 102\n 106\n Other labs: PT / PTT / INR:13.2/41.4/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 08:38 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442519,
"text": "Chief Complaint:\n 24 Hour Events:\n - changed free water boluses thru feeding tube to reduce hyperNa\n - d/c fent drip\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 03:52 PM\n Lorazepam (Ativan) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.3\nC (99.1\n HR: 79 (67 - 97) bpm\n BP: 138/52(73) {121/48(65) - 177/71(97)} mmHg\n RR: 18 (18 - 20) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,080 mL\n 892 mL\n PO:\n TF:\n 953 mL\n 271 mL\n IVF:\n 737 mL\n 106 mL\n Blood products:\n Total out:\n 1,382 mL\n 330 mL\n Urine:\n 1,132 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,698 mL\n 562 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (455 - 500) mL\n PS : 12 cmH2O\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 31 cmH2O\n Plateau: 19 cmH2O\n SpO2: 92%\n ABG: ///34/\n Ve: 9.2 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 258 K/uL\n 8.1 g/dL\n 106 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 105 mEq/L\n 143 mEq/L\n 25.6 %\n 17.7 K/uL\n [image002.jpg]\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n Plt\n 79\n 251\n 258\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n TCO2\n 27\n 31\n Glucose\n 135\n 107\n 119\n 102\n 160\n 102\n 106\n Other labs: PT / PTT / INR:13.2/41.4/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ELECTROLYTE & FLUID DISORDER, OTHER\n EDEMA, PERIPHERAL\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 08:38 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 442521,
"text": "Chief Complaint:\n 24 Hour Events:\n - changed free water boluses thru feeding tube to reduce hyperNa\n - d/c fent drip\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 03:52 PM\n Lorazepam (Ativan) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.3\nC (99.1\n HR: 79 (67 - 97) bpm\n BP: 138/52(73) {121/48(65) - 177/71(97)} mmHg\n RR: 18 (18 - 20) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,080 mL\n 892 mL\n PO:\n TF:\n 953 mL\n 271 mL\n IVF:\n 737 mL\n 106 mL\n Blood products:\n Total out:\n 1,382 mL\n 330 mL\n Urine:\n 1,132 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,698 mL\n 562 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (455 - 500) mL\n PS : 12 cmH2O\n RR (Set): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 31 cmH2O\n Plateau: 19 cmH2O\n SpO2: 92%\n ABG: ///34/\n Ve: 9.2 L/min\n Physical Examination\n General: Intubated, sedated, following commands\n HEENT: dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: diffuse rhonchi apprec at LLL base, not moving air well, no\n wheezes, prolonged exp phase\n CV: RRR, normal S1/S2, diff to apprec murmur due to lung sounds\n Abdomen: soft, NTTP, non-distended, NABS, no rebound tenderness or\n guarding, no organomegaly\n Ext: thin skin with tears, 1+ pulses, 2+ pitting edema, cachectic \n / Radiology\n 258 K/uL\n 8.1 g/dL\n 106 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 105 mEq/L\n 143 mEq/L\n 25.6 %\n 17.7 K/uL\n [image002.jpg]\n 05:40 PM\n 02:50 AM\n 03:36 PM\n 02:05 AM\n 03:53 PM\n 02:44 AM\n 03:32 AM\n 05:20 PM\n 03:01 AM\n 03:13 AM\n WBC\n 20.3\n 17.4\n 19.4\n 20.7\n 16.7\n 17.7\n Hct\n 24.8\n 24.1\n 30.9\n 26.5\n 29.8\n 26.2\n 25.6\n Plt\n 79\n 251\n 258\n Cr\n 1.1\n 1.2\n 1.1\n 0.9\n 0.9\n 0.8\n 0.7\n TCO2\n 27\n 31\n Glucose\n 135\n 107\n 119\n 102\n 160\n 102\n 106\n Other labs: PT / PTT / INR:13.2/41.4/1.1, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.6 %, Lymph:2.3 %, Mono:1.6 %, Eos:0.0 %, Lactic\n Acid:0.7 mmol/L, Albumin:1.9 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. MDI while intubated. Patient was able to tolerate\n PS10/PEEP8 yesterday for approx 2 hrs . Sputum showed moderate H.\n flu beta-lactamase negative, changed to ceftriaxone. Initally, vanc was\n d/c\ned and patient was kept on Zosyn until found to be flu\n beta-lactamase negative.\n - continue ceftriaxone for total of 14 days\n - plan for trach and PEG on Tuesday per IP\n - mouthcare, HOB elevated\n .\n # ARF: pre-renal from lasix administration -> holding lasix for now,\n increase free water flushes to 250cc q4h\n .\n # Hypotension: Resolved, this may have been due to meds given\n peri-intubation in setting of hypovolemia. Sepsis also possible given\n fever, leukocytosis and infiltrate on CXR. Adrenal insufficiency also\n possible given 2 months of prednisone use and patient had initially\n been given Hydrocortisone. Aggressive resuscitation with IVF, s/p 10L\n of IVF on initial presentation.\n - Hypotension now resolved\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily.\n - continue to monitor on telemetry, follow EKGs\n - cont metoprolol to 25mg \n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF. Pt\n was clinically hypovolemic on admission with HR 140s.\n Transfused one unit PRBC .\n - guiaic negative\n - maintain active type & screen\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # UTI: UA with no epis and >10 WBCs consistent with UTI, no prior\n urine cultures in system.\n - urine cxs negative\n .\n # FEN: cont TFs, nutrition following, PEG to be placed Tuesday\n .\n # Prophylaxis: heparin sc tid, bowel regimen, PPI\n .\n # Access: Left PIV 18 gauge, left PICC\n # Code: FULL\n .\n # Disposition: trach and PEG Tuesday, case management aware of need for\n rehab planning\n - Social work consult placed , PT/OT c/s placed \n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 08:38 PM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Case Management ",
"chartdate": "2158-02-20 00:00:00.000",
"description": "Discharge Planning Note",
"row_id": 442589,
"text": "TITLE: Discharge Planning\n NCM met with the patient who communicated with a clipboard & pen as\n well as head/hand motions. Pt. has expressed a strong preference for\n Rehab for her vent weaning. She does not want to go to NE \n under any circumstances. She also agreed to referrals to \n and as back-ups in the event does not have a bed\n on the MACU when she is ready for discharge.\n NCM made referrals to all three facilities anticipating that the\n patient will be ready for transfer . Please page for any\n questions. NCM will continue to follow the patient.\n"
},
{
"category": "Nursing",
"chartdate": "2158-02-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 443840,
"text": "70 y/o woman with severe COPD who initially presented with acute\n hypoxic respiratory failure. Her course in the MICU has been c/b fevers\n with +leukocytosis most likely r/t vap. She was briefly extubated on\n and reintubated the following day for hypoxia and hypercarbia.\n A bedside trach/peg was performed on without incident\n EVENTS\n..screened for rehab, received lasix 20mgs aim neg balance 2l,\n D/C vanc, OOB with PT, feed recommenced via new PEG tube\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2158-02-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 443841,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - will need to change doripenem to meropenem 1g q8h for rehab\n - got Trach/PEG\n - hypertensive all day -> started back on home dose dilt and added\n captopril for increased afterload reduction\n PERCUTANEOUS TRACHEOSTOMY - At 01:00 PM\n teach/PEG placement\n TRANSTHORACIC ECHO - At 02:27 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 10:14 AM\n Vancomycin - 03:05 PM\n Infusions:\n Other ICU medications:\n Vecuronium - 12:55 PM\n Propofol - 01:00 PM\n Furosemide (Lasix) - 02:45 PM\n Fentanyl - 06:29 PM\n Lorazepam (Ativan) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.8\nC (98.3\n HR: 77 (68 - 104) bpm\n BP: 118/54(69) {88/40(54) - 170/98(107)} mmHg\n RR: 14 (14 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 56.7 kg (admission): 60.5 kg\n Height: 67 Inch\n Total In:\n 953 mL\n 313 mL\n PO:\n TF:\n 41 mL\n IVF:\n 831 mL\n 233 mL\n Blood products:\n Total out:\n 3,190 mL\n 510 mL\n Urine:\n 3,140 mL\n 510 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n -2,238 mL\n -198 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 405 (340 - 550) mL\n PS : 5 cmH2O\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 11 cmH2O\n SpO2: 95%\n ABG: ///39/\n Ve: 7.2 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic, new trach in place, slight\n amount of dried blood, otherwise clean\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished: ),\n mild rhonchi diffusedly\n Abdominal: Soft, Non-tender, ND, no hsm, normoactive BS\n Extremities: Right: 2+, Left: 2+, significant BLE edema with skin\n weeping\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, interactive appropriately, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 410 K/uL\n 9.8 g/dL\n 81 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 3.9 mEq/L\n 15 mg/dL\n 98 mEq/L\n 139 mEq/L\n 30.3 %\n 15.7 K/uL\n [image002.jpg]\n 03:13 AM\n 01:55 AM\n 03:55 AM\n 03:16 AM\n 03:22 AM\n 08:21 PM\n 03:10 AM\n 03:54 AM\n 03:56 AM\n 04:00 AM\n WBC\n 17.7\n 17.5\n 19.5\n 41.1\n 31.2\n 25.0\n 19.7\n 15.9\n 15.7\n Hct\n 25.6\n 25.8\n 25.0\n 28.0\n 22.4\n 30.2\n 25.6\n 28.7\n 30.0\n 30.3\n Plt\n 258\n 284\n 310\n 349\n 91\n 410\n Cr\n 0.7\n 0.7\n 0.6\n 0.7\n 0.7\n 0.6\n 0.5\n 0.5\n 0.5\n Glucose\n 106\n 76\n 72\n 135\n 79\n 70\n 90\n 82\n 81\n Other labs: PT / PTT / INR:14.3/34.1/1.2, CK / CKMB /\n Troponin-T:29//<0.01, ALT / AST:71/113, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:95.8 %, Lymph:1.6 %, Mono:2.3 %, Eos:0.3 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.2 g/dL, LDH:315 IU/L, Ca++:8.0 mg/dL,\n Mg++:1.7 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Assessment and Plan\n 70 y/o F with severe COPD who presents with acute hypoxic respiratory\n failure, now intubated.\n .\n # Resp failure: Pt with severe underlying COPD who p/w fever, hypoxia,\n leukocytosis and infiltrates likely c/w acute PNA. She received\n Ceftriaxone/Levo in ED though current sputum with pleomorphic gram neg\n coccobaccili likely c/w prior sputums of H.Flu. Prior sputums have\n been colonized with serratia, aspergillus, MAC, pseudomonas. Patient\n had a component of hypercarbic resp failure given MS changes & elevated\n serum bicarb. Patient was started on vanc/zosyn. Vanc was d/c\ned once\n it was growth was gram negative. Zosyn was changed to ceftriaxone when\n speciated to H. flu beta-lactamase negative. Patient completed \n day course of HAP and steroid taper when patient passed SBT and was\n extubated. Patient remained extubated for 12 hours and developed sinus\n tachycardia (in the setting of beta blocker withdrawl), tachypnea,\n accessory muscle use and desaturation to low 90s. Patient was given\n trial of nebs and CPAP, patient continued to retain CO2 and patient was\n intubated on . Patient has very poor respiratory reserve and will\n require long-term trach.\n - trach and peg placed , in place and doing well\n - did not tolerate trach mask trial secondary to anxiety and feeling\n SOB, will continue with PS 5/5 and do trials as tolerated\n - s/p ceftriaxone course for h.flu; now being treating for pseudomonas\n with -> 2 week course from , plan on switching to\n meropenem 1 gm q 8 hr when goes to rehab\n - stopped vanco today\n - continue prednisone, now on 30 mg from 40 mg, and will continue\n taper; goal to get to 10 mg for baseline and continue on 10 for the\n long term\n - mouthcare, HOB elevated\n .\n # Leukocytosis / Fever\n has now resolved with treatment of presumed\n . developed 4 hours after reintubation. Patient was intubated\n uneventfully and patient was NPO 48 hours prior to procedure. Likely\n , pt improving with decreasing leukocytosis, has not spiked since\n \n - growing pseudomonas, to ; responding to doripenem and plan\n on continuing until transfer to rehab\n .\n # Anxiety\n has underlying anxiety, was receiving boluses of ativan as\n needed\n - adding clonapin for longer acting antianxietolytic\n .\n # HTN - running slightly hypertensive now that is resolving, could\n be secondary to anxiety vs. essential hypertension\n - added home dilt back on\n - captopril added as well, getting good effects, can titrate as needed\n .\n # Resolved ARF: Pre-renal from hypovolemia/sepsis, now improved.\n .\n # s/p recent NSTEMI - Denied CP in ED. EKGs with sinus tach in 140s,\n LBBB and non-specific changes from baseline. Cardiac enzymes negative.\n - continue Aspirin 325mg & Atorvastatin 40mg daily\n - tolerated BB for rate control, but using dilt if we can due to\n potential bronchospastic properties\n .\n # Hct drop: Baseline hct in high 30s, down to 25 after 10L of IVF.\n Dropped over course of hospitalization, s/p transfusion again on ;\n now stabalized. Anemia likey from phlebotomy, chronic disease\n Transfused one unit PRBC , now stable\n - cont to trend\n .\n # Depression\n Celexa 10mg PO daily started for passive SI\n .\n # Osteopenia\n was on fosamax as outpatient, in setting of steroid use\n will start Ca/Vit D\n - Ca and Vit D supplementation for now\n - re-start fosamax when respiratory status starts to stabilize\n .\n # FEN: PEG placed, doing well, restarting TFs today after thoracic\n evaluates\n .\n # Prophylaxis: heparin sc BID, PPI\n .\n # Access: Left PIV 18 gauge, PICC\n .\n # Code: FULL\n .\n # Communication\n with patient and niece\n .\n # Disposition: case management aware of need for rehab planning\n - Social work consult placed , PT/OT c/s placed \n - Likely to rehab later this week\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n :\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Echo",
"chartdate": "2158-02-27 00:00:00.000",
"description": "Report",
"row_id": 98782,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pneumonia. Volume overload.\nWeight (lb): 133\nBP (mm Hg): 127/52\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 15:32\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically ventilated.\nCannot assess RA pressure.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thickness, cavity size, and global systolic function are normal\n(LVEF>55%). Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. Right ventricular chamber size and free\nwall motion are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. Trace aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen.\nThere is mild pulmonary artery systolic hypertension.\n\nCompared with the prior study (images reviewed) of , regional and\nglobal left ventricular systolic function are improved. The estimated\npulmonary artery systolic pressure is now slightly higher.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-02-24 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1063826,
"text": " 11:36 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ?placement of ETT\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p ETT adjustment\n REASON FOR THIS EXAMINATION:\n ?placement of ETT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld 12:15 PM\n PFI: ET tube tip is 4.7 cm above the carina.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess ET tube.\n\n ET tube tip is 4.7 cm above the carina otherwise unchanged from prior study\n performed three hours earlier.\n\n jr\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2158-02-24 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1063827,
"text": ", MED MICU 11:36 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ?placement of ETT\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p ETT adjustment\n REASON FOR THIS EXAMINATION:\n ?placement of ETT\n ______________________________________________________________________________\n PFI REPORT\n PFI: ET tube tip is 4.7 cm above the carina.\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-02-25 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1064051,
"text": " 8:36 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: NG tube location\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with NG tube replacement\n REASON FOR THIS EXAMINATION:\n NG tube location\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:38 P.M.\n\n HISTORY: NG tube placement, check location.\n\n IMPRESSION: AP chest compared to 7:12 p.m.\n\n Nasogastric tube ends in the upper portion of a nondistended stomach. Although\n the tip of the ET tube is less than 2 cm from the carina and the chin is down,\n this is only 1 cm below optimal placement. Right PIC line ends at the\n junction of the brachiocephalic veins. Residual of pneumonia in the left mid\n lung has been stable for several days. Small bilateral pleural effusion has\n increased slightly since earlier in the day, and there is pulmonary vascular\n redistribution but no edema. Heart size is normal. Thoracic configuration\n indicates COPD.\n\n A region of scar-like opacity in the axillary portion of the right mid lung is\n more radiodense than it was earlier in and largely new since . This could also be post-inflammatory, but is concerning for possible\n malignancy. Followup is advised clinically indicated, with chest CT, which\n can be compared to the CTPA on . Dr. and I discussed\n these findings at the time of dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-02-12 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1061521,
"text": " 10:38 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p ett check placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with ett\n REASON FOR THIS EXAMINATION:\n s/p ett check placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old woman, check ETT placement.\n\n COMPARISON: Chest radiograph of approximately 40 minutes earlier.\n\n SINGLE SUPINE VIEW OF THE CHEST AT 10:45 A.M.: There has been interval\n placement of an endotracheal tube, which terminates at the thoracic inlet,\n approximately 7 cm from the carina. An enteric tube extends below the\n diaphragm, and its tip is not visualized, although the side port is positioned\n below the diaphragm. A right PICC is stable, terminating in the mid SVC.\n\n Again, lungs are hyperinflated with changes of emphysema, and superimposed\n focal consolidation at the left peripheral mid lung. There may be small\n bilateral pleural effusions, now layering. There is no pneumothorax.\n\n IMPRESSION: ETT at thoracic inlet. NGT below the diaphragm. Stable\n appearance of lungs with new consolidative opacity in the left peripheral mid\n lung consistent with pneumonia. Followup to resolution is recommended,\n following appropriate therapy.\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-02-13 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1061779,
"text": " 5:36 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please assess NGT\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with hypoxia\n REASON FOR THIS EXAMINATION:\n please assess NGT\n ______________________________________________________________________________\n WET READ: DMFj MON 6:26 PM\n NG tube tip beyond edge of film, in good position.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxia, for NGT placement.\n\n FINDINGS: In comparison with the earlier study of this date, the nasogastric\n tube is in good position, extending at least to the mid body of the stomach,\n where it is lost to the bottom of the film. Otherwise, little change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-02-27 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1064317,
"text": " 1:59 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: trach placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with new trach/peg\n REASON FOR THIS EXAMINATION:\n trach placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 5:36 PM\n Hyperinflation of the ET tube cuff. The ET tube tip 6 cm above the carina.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of tracheal placement.\n\n Portable AP chest radiograph was compared to obtained at\n 0308 a.m.\n\n The ET tube tip has been replaced by the tracheostomy with its tip currently\n being 6 cm above the carina. The tracheostomy cuff is slightly overinflated.\n The right PICC line tip is in mid SVC. The cardiomediastinal silhouette is\n stable. The lungs are hyperinflated with no significant interval change in\n extensive areas of scarring and consolidation. No pneumothorax or\n pneumomediastinum demonstrated. Severe emphysema is present.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-02-27 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1064318,
"text": ", MED MICU 1:59 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: trach placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with new trach/peg\n REASON FOR THIS EXAMINATION:\n trach placement\n ______________________________________________________________________________\n PFI REPORT\n Hyperinflation of the ET tube cuff. The ET tube tip 6 cm above the carina.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-02-25 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1064041,
"text": " 7:05 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: NG tube placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with NG tube replacement\n REASON FOR THIS EXAMINATION:\n NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:12 P.M., \n\n HISTORY: Check NG tube placement.\n\n IMPRESSION: AP chest compared to and , 4:05 a.m.:\n\n Nasogastric tube ends just above the GE junction and should be advanced to at\n least 10 cm to move all the side ports into the stomach. ET tube in standard\n placement. Hyperinflation indicates COPD. Small bilateral pleural effusions\n have increased. Opacity in the left mid lung is residual from acute\n pneumonia. An irregular opacity in the right mid lung has a scar-like\n appearance, but is new over 18 months and needs to be followed to exclude\n malignancy. Findings discussed with the physician caregiver at the time of\n dictation of radiograph obtained subsequently on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-02-23 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1063682,
"text": " 6:29 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: check NG tube placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with PNA on vent, new NG tube\n REASON FOR THIS EXAMINATION:\n check NG tube placement\n ______________________________________________________________________________\n WET READ: 10:12 PM\n NG tube in good position.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess NG tube.\n\n NG tube tip is in the stomach in good position. No other interval change from\n prior study performed the same day earlier in the morning.\n\n jr\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-02-13 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1061771,
"text": " 4:45 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: OG tube placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with OG tube replacement\n REASON FOR THIS EXAMINATION:\n OG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of orogastric tube placement.\n\n Portable AP chest radiograph was reviewed in comparison to prior study\n obtained the same day earlier at 03:38 a.m.\n\n The NG tube tip passes below the diaphragm with its tip most likely\n terminating in the stomach. The ET tube tip is approximately 4.5 cm above the\n carina. The right internal jugular line tip is in mid SVC. There is no\n significant change in widespread bilateral opacities and lung hyperinflation,\n findings that are suspicious for multifocal infection in the presence of\n severe emphysema.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2158-02-12 00:00:00.000",
"description": "Report",
"row_id": 288148,
"text": "Sinus rhythm with slowing of the rate as compared with prior tracing of .\nLow limb lead voltage. Left bundle-branch block. Prior anteroseptal\nmyocardial infarction. Compared to the previous tracing of the\nrate has slowed and the ST-T wave abnormalities have improved. Otherwise,\nno diagnostic interim change. Clinical correlation is suggested.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2158-02-12 00:00:00.000",
"description": "Report",
"row_id": 288149,
"text": "Sinus tachycardia. The previously mentioned multiple abnormalities persist\nwithout diagnostic interim change. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2158-02-12 00:00:00.000",
"description": "Report",
"row_id": 288150,
"text": "Sinus tachycardia. Peaked P waves with rightward P wave axis as recorded\non which is consistent with right atrial enlargement and pulmonary\npathology. There is left bundle-branch block and the ischemic appearing\nT wave abnormalites previously recorded in the anterolateral and apical\nareas are now upright, in parallel with an increase in rate, consisent\nwith pseudonormalization and possible active ischemia. Followup and clinical\ncorrelation are suggested. Rule out myocardial infarction.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2158-02-23 00:00:00.000",
"description": "Report",
"row_id": 288145,
"text": "Sinus rhythm. Left bundle-branch block with secondary repolarization\nabnormaliites. Compared to the previous tracing of no diagnostic\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2158-02-17 00:00:00.000",
"description": "Report",
"row_id": 288146,
"text": "Sinus rhythm. Short P-R interval. Intraventricular conduction delay of left\nbundle-branch block type. ST-T wave abnormalities. Since the previous tracing\nof the rate has decreased.\n\n"
},
{
"category": "ECG",
"chartdate": "2158-02-13 00:00:00.000",
"description": "Report",
"row_id": 288147,
"text": "Sinus tachycardia. Intraventricular conduction delay. Compared to the\nprevious tracing of no change.\n\n"
}
] |
59,266 | 161,969 | Surgery evaluated the patient in the ED. | If any, there is a small left pleural effusion. SINGLE FRONTAL VIEW OF THE CHEST: A left-sided central venous line is seen which does not cross midline and ends somewhat low to be within the brachiocephalic. Intra-abdominal loops of bowel are within normal limits. Moderate (2+) mitral regurgitation is seen. IMPRESSION: Left central venous line does not cross midline. Mild PA systolic hypertension.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:Suboptimal image quality. The intrapelvic loops of bowel are within normal limits. Cardiomediastinal silhouette is within normal limits given low lung volumes. Non-contrast appearance of the adrenal glands, stomach, and intra-abdominal loops of bowel are within normal limits. Moderate [2+] tricuspidregurgitation is seen. Evaluation limited by lack of IV contrast. Consider prior inferior myocardial infarction, althoughit is non-diagnostic. The diameters of aorta at the sinus, ascending and arch levelsare normal. The aortic valve leaflets (3) are mildly thickened but aorticstenosis is not present. There is mild pulmonary artery systolic hypertension.There is an anterior space which most likely represents a prominent fat pad. Evaluation limited by the lack of IV contrast. 2.6 cm calcified rounded density in the epigatric region of unclear etiology. There are low lung volumes. The non-contrast appearance of the liver is within normal limits. Mild bronchiectasis is noted at the right lung base. The left ventricular cavity size is normal. Trace aortic regurgitation is seen. The rectum and uterus are within normal limits. The right ventricular cavity is dilated with normal free wallcontractility. calcified lymph node? Left ventricular wallthicknesses are normal. Rounded 2.6 cm calcified density in the epigastric region of unclear etiology. A small calcification is noted at the posterior aspect of the right lobe, which also may represent a calcified granuloma. Normal LV cavity size. Moderate (2+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Lung volumes are low. The left cephalic vein was not visualized. Cholelithiasis. Cholelithiasis. Normal RV systolic function.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Generalized low voltages are non-specific. Moderate[2+] TR. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. IMPRESSION: Technically limited study, no DVT seen in the left upper extremity. Cardiomediastinal contours are normal. FINDINGS: CT OF THE ABDOMEN WITHOUT CONTRAST: Lung bases demonstrate bilateral small pleural effusions with adjacent atelectasis. IMPRESSION: No evidence of left upper extremity arterial obstruction. The left subclavian catheter tip is in the lower SVC. Atrial fibrillation. PATIENT/TEST INFORMATION:Indication: Atrial fibrillation.Height: (in) 59Weight (lb): 220BSA (m2): 1.92 m2BP (mm Hg): 112/53HR (bpm): 89Status: InpatientDate/Time: at 11:15Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Elongated LA.LEFT VENTRICLE: Normal LV wall thickness. There is a 2.6 x 2.3 cm calcified rounded density adjacent to the left lobe of the liver near the epigastric region (2:18) of unclear etiology. Thetricuspid valve leaflets are mildly thickened. Catheter is noted within a decompressed bladder. CT OF THE PELVIS WITHOUT CONTRAST: Inspissated barium is noted within multiple diverticula throughout the colon. No AS. The left atrium is elongated. Suboptimaltechnical quality, a focal LV wall motion abnormality cannot be fullyexcluded. Diverticulosis wihtout diverticulitis. TECHNIQUE: Axially-acquired images were obtained from the lung bases to the pubic symphysis without contrast. There is minimal fat stranding surrounding the pancreas, which may be the result of patient's known pancreatitis. The lungs are grossly clear. The left subclavian, left axillary and left brachial waveforms are all triphasic with velocities ranging from 45 to 86 cm/sec. FINDINGS: This was a technically limited study due to patient body habitus and edema. IMPRESSION: 1. The heart size is normal. FINDINGS: The left upper extremity arterial circulation was evaluated. Consider venous exam if the main complaint is swelling. Overall normal LVEF (>55%).RIGHT VENTRICLE: Dilated RV cavity. The mitral valveleaflets are mildly thickened. COMPARISON: None. COMPARISON: None. Clinicalcorrelation is suggested. No TS. The line may end in the hemiazygous or intercostal vein. No thrombus was seen in the visualized portions of the left jugular, left subclavian, left axillary, left brachial and left basilic veins. Mild fat stading around the head of the pancreas whic may reflect known pancreatitiss. No MS. There (Over) 5:36 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: eval abdominal catastrophy FINAL REPORT (Cont) is no pelvic or inguinal lymphadenopathy. The gallbladder contains multiple small calcified gallstones. Due tosuboptimal technical quality, a focal wall motion abnormality cannot be fullyexcluded. Overall left ventricular systolic function is probably normal(LVEF>50%). free stone? Extensive coronary artery calcifications are noted. There is no free fluid. There is no pneumothorax. There is no pneumothorax. Multiple calcifications are noted within the spleen, likely calcified granulomas. There is no focal consolidation. 2. 2. 4. There is no free fluid or air. 3. 3. BONE WINDOWS: No concerning osseous lesions are identified. Evaluate for abdominal catastrophe. 5. 2:49 AM CHEST PORT. Evaluate central line placement. Coronal and sagittal reformatted images were also displayed. Lateral chest radiograph could be performed for further evaluation. The left radial and ulnar arteries are also patent with triphasic waveforms and velocities from 40 to 63 cm/sec. | 7 | [
{
"category": "Radiology",
"chartdate": "2120-09-06 00:00:00.000",
"description": "ART DUP EXT UP UNI OR LMTD",
"row_id": 1145728,
"text": " 12:59 PM\n ART DUP EXT UP UNI OR LMTD Clip # \n Reason: please evaluate for arterial flow in bilateral upper extremi\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with LUE swelling after L IJ line placement\n REASON FOR THIS EXAMINATION:\n please evaluate for arterial flow in bilateral upper extremities\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 89-year-old female with left upper extremity after left IJ\n venous line placement.\n\n FINDINGS: The left upper extremity arterial circulation was evaluated. The\n left subclavian, left axillary and left brachial waveforms are all triphasic\n with velocities ranging from 45 to 86 cm/sec. The left radial and ulnar\n arteries are also patent with triphasic waveforms and velocities from 40 to 63\n cm/sec.\n\n IMPRESSION: No evidence of left upper extremity arterial obstruction.\n Consider venous exam if the main complaint is swelling.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-09-06 00:00:00.000",
"description": "R UNILAT UP EXT VEINS US RIGHT",
"row_id": 1145729,
"text": " 12:59 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: evaluate for flow or DVT in B upper extremities\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with LUE swelling after L IJ line placement\n REASON FOR THIS EXAMINATION:\n evaluate for flow or DVT in B upper extremities\n ______________________________________________________________________________\n FINAL REPORT\n LEFT UPPER EXTREMITY VENOUS ULTRASOUND WITH DOPPLER\n\n HISTORY: 89-year-old woman with left upper extremity swelling after left IJ\n line placement.\n\n No prior studies for comparison.\n\n FINDINGS: This was a technically limited study due to patient body habitus\n and edema. No thrombus was seen in the visualized portions of the left\n jugular, left subclavian, left axillary, left brachial and left basilic veins.\n The left cephalic vein was not visualized.\n\n IMPRESSION: Technically limited study, no DVT seen in the left upper\n extremity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-09-05 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1145515,
"text": " 5:36 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval abdominal catastrophy\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with gallstone pancreatitis\n REASON FOR THIS EXAMINATION:\n eval abdominal catastrophy\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 6:38 AM\n 1. Evaluation limited by lack of IV contrast.\n 2. Cholelithiasis.\n 3. Mild fat stading around the head of the pancreas whic may reflect known\n pancreatitiss.\n 4. Diverticulosis wihtout diverticulitis.\n 5. 2.6 cm calcified rounded density in the epigatric region of unclear\n etiology. free stone? calcified lymph node?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 89-year-old woman with gallstone pancreatitis. Evaluate for\n abdominal catastrophe.\n\n COMPARISON: None.\n\n TECHNIQUE: Axially-acquired images were obtained from the lung bases to the\n pubic symphysis without contrast. Coronal and sagittal reformatted images\n were also displayed.\n\n FINDINGS:\n CT OF THE ABDOMEN WITHOUT CONTRAST: Lung bases demonstrate bilateral small\n pleural effusions with adjacent atelectasis. Mild bronchiectasis is noted at\n the right lung base. The heart size is normal. Extensive coronary artery\n calcifications are noted. Multiple calcifications are noted within the\n spleen, likely calcified granulomas. Non-contrast appearance of the adrenal\n glands, stomach, and intra-abdominal loops of bowel are within normal limits.\n There is a 2.6 x 2.3 cm calcified rounded density adjacent to the left lobe of\n the liver near the epigastric region (2:18) of unclear etiology.\n\n The non-contrast appearance of the liver is within normal limits. A small\n calcification is noted at the posterior aspect of the right lobe, which also\n may represent a calcified granuloma.\n\n The gallbladder contains multiple small calcified gallstones. There is\n minimal fat stranding surrounding the pancreas, which may be the result of\n patient's known pancreatitis. There is no free fluid or air.\n\n Intra-abdominal loops of bowel are within normal limits.\n\n CT OF THE PELVIS WITHOUT CONTRAST: Inspissated barium is noted within\n multiple diverticula throughout the colon. The rectum and uterus are within\n normal limits. Catheter is noted within a decompressed bladder. There is no\n free fluid. The intrapelvic loops of bowel are within normal limits. There\n (Over)\n\n 5:36 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval abdominal catastrophy\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n is no pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: No concerning osseous lesions are identified. Again seen are\n extensive degenerative changes throughout the visualized spine.\n\n IMPRESSION:\n 1. Evaluation limited by the lack of IV contrast.\n\n 2. Rounded 2.6 cm calcified density in the epigastric region of unclear\n etiology.\n\n 3. Cholelithiasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-09-05 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1145507,
"text": " 2:49 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Eval central line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with gallstone pancreatitis\n REASON FOR THIS EXAMINATION:\n Eval central line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 89-year-old woman with gallstone pancreatitis. Evaluate central\n line placement.\n\n COMPARISON: None.\n\n SINGLE FRONTAL VIEW OF THE CHEST: A left-sided central venous line is seen\n which does not cross midline and ends somewhat low to be within the\n brachiocephalic. There is no pneumothorax. Lung volumes are low. There is\n no focal consolidation. Cardiomediastinal silhouette is within normal limits\n given low lung volumes.\n\n IMPRESSION: Left central venous line does not cross midline. The line may end\n in the hemiazygous or intercostal vein. Lateral chest radiograph could be\n performed for further evaluation. Discussion with Dr. at 5am\n on confirms venous return.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-09-05 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1145554,
"text": " 10:26 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate CVL in subclavian\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with pancreatitis, new subclavian line\n REASON FOR THIS EXAMINATION:\n evaluate CVL in subclavian\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Evaluate left subclavian catheter.\n\n The left subclavian catheter tip is in the lower SVC. There is no\n pneumothorax. There are low lung volumes. Cardiomediastinal contours are\n normal. The lungs are grossly clear. If any, there is a small left pleural\n effusion.\n\n"
},
{
"category": "Echo",
"chartdate": "2120-09-06 00:00:00.000",
"description": "Report",
"row_id": 89834,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation.\nHeight: (in) 59\nWeight (lb): 220\nBSA (m2): 1.92 m2\nBP (mm Hg): 112/53\nHR (bpm): 89\nStatus: Inpatient\nDate/Time: at 11:15\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Dilated RV cavity. Normal RV systolic function.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Moderate (2+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Moderate\n[2+] TR. Mild PA systolic hypertension.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nSuboptimal image quality. The left atrium is elongated. Left ventricular wall\nthicknesses are normal. The left ventricular cavity size is normal. Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Overall left ventricular systolic function is probably normal\n(LVEF>50%). The right ventricular cavity is dilated with normal free wall\ncontractility. The diameters of aorta at the sinus, ascending and arch levels\nare normal. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. Trace aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The\ntricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\nThere is an anterior space which most likely represents a prominent fat pad.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2120-09-05 00:00:00.000",
"description": "Report",
"row_id": 236122,
"text": "Atrial fibrillation. Consider prior inferior myocardial infarction, although\nit is non-diagnostic. Generalized low voltages are non-specific. Clinical\ncorrelation is suggested. No previous tracing available for comparison.\n\n"
}
] |
160 | 161,672 | 49 yo male with past medical history significant for hyperlipidemia transferred from OSH with inferior STEMI, found to have mid-RCA lesion, and now s/p BMS and chest pain free. . 1. Coronary artery disease At cardiac catheterization, patient found to have a 95% thrombotic lesion of mid-RCA with BMS placed. Patient was chest pain free for the duration of her hospitalization after cardiac cath. Her course was complicated by formation of large ecchymoses at the site of cardiac cath. She was noted to have a right femoral bruit both before her catheterization and remained stable after her catheterizations. She was started on aspirin 325mg, plavix 75mg, atorvastatin 80mg, and was converted to Toprol XL 25mg PO daily. Given that patient's EF was not diminished, patient was not started on ACE inhibitor. Patient was evaluated by physical therapy during this admission who cleared patient to be discharged home. Patient was discharged home with cardiology follow-up with Dr. . . 2. Hyperlipidemia Patient reports a history of hyperlipidemia and was started on high dose atorvastatin during this admisison. | Resting regional wallmotion abnormalities include basal and mid inferior and inferoseptal akinesiswith apical inferior hypokinesis.3.Right ventricular chamber size is normal. Normal ascending aorta diameter. S/P stent mid RCA.Height: (in) 67Weight (lb): 129BSA (m2): 1.68 m2BP (mm Hg): 115/63HR (bpm): 67Status: InpatientDate/Time: at 08:30Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. Normal RVsystolic function.AORTA: Normal aortic root diameter. Moderate (2+) MR.PERICARDIUM: No pericardial effusion.Conclusions:1. ]LV WALL MOTION: Regional LV wall motion abnormalities include: basalinferoseptal - akinetic; mid inferoseptal - akinetic; basal inferior -akinetic; mid inferior - akinetic; inferior apex - hypo;RIGHT VENTRICLE: Normal RV wall thickness. rr- reg bs-clgi: tol po's abd soft non tender. los + 596. bun creat wnl will d/c foley in am as condition warrents.skin: r groin c/d, but ecchymotic. Right ventricular function. The left ventricular cavitysize is normal. Overall left ventricular systolic function is mildlydepressed. ecchymotic area in l ac likley from blood draws.neuro: a/o mae intact. follows all commadsid: afebrile wbc wnllabs: wnlaccess: piv's x2 intact/patent completed post procedure fluidscomfort: c/o back pain d/t br percocet x2 tabs and back reub/reposition w relief. Right ventricular systolicfunction is normal.4.The aortic valve leaflets (3) appear structurally normal with good leafletexcursion. pt remains pain free, cardiac cath site right femoral area with eccymotic area. Normal LV cavity size. Moderate (2+) mitralregurgitation is seen.6.There is no pericardial effusion. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mildlydepressed LVEF. No aortic regurgitation is seen.5.The mitral valve leaflets are mildly thickened. d/c foley in am. Normalaortic arch diameter.AORTIC VALVE: Normal aortic valve leaflets (3). Left ventricular wall thicknesses are normal. The left atrium is normal in size.2. Sinus rhythmPoor R wave progression - consider anteroseptal myocardial infarction - ageindeterminateNo previous tracing available for comparison Sinus rhythmConsider septal infarct - age indeterminateSince previous tracing, no significant change PATIENT/TEST INFORMATION:Indication: Left ventricular function. ft wrm. Since the previous tracing of positionalchanges are noted over the lateral precordium. ccu nursing addendumpt noted to have approx 5x10 cm hematoma/ecchymotic area on l posterior rib area - area marked - has not extended, appears on ewhere defib pads were placed for transport, pt remains on integrellin 2mcgs until 2200; house staff notified. "THE LEFT SIDE OF MY BACK HURTS BUT MY CHEST PAIN IS GONE."O. [Intrinsic left ventricular systolic function is likely moredepressed given the severity of valvular regurgitation.] Sinus rhythmInferior T wave changes may be due to myocardial ischemiaPoor R wave progressionNo previous tracing available for comparison nursing transfer note intitiated. no stool overnoc.gu: foley draining cl yellow. follow ck's. [Intrinsic LV systolic function likely depressed given theseverity of valvular regurgitation. ccu npns: " I would like to get out of bed soon"cv: remains in nsr w hr 60-70. sbp 90-120, map's >60 ck 327,270 mb 39,31. started on lipitor. has ecchymotic area upper l back ? Normal RV chamber size. CCU NURSING PROGRESS NOTE 0700-1900S. Area has increased in size but very softpt denies pain in that area but sltly tender during palpation.started on lopressor today, tolerated 12.5, bp 97/55-- 117/60hr 60-70, pt also started on lipitor.neuro- OX3, moves all extrem, ambulates, converses.cv- SR on monitor, no ectopy, denies CP.respiratory: lungs clear on ra sat 97 percent.GI- + flatus, no bm on colace, eating cardiac diet.GU- putting out 2700 cc urine last 12 hours. Foley dc'd at 6 pm and pt is due to void.A: pt sp inferior MI, echo done today, results pending, starting to get oob, ambul pain free, continues on asa, metoprolol, plavix, called out to floor.p: med teaching, continue activity, monitor cv status, resp status,keep pt and family updated on POC as discussed on multidiciplanary rounds. u/o > 100cc/hr. tender, but denies pain @ site. denies sob. pulses 3+/2+ bilat. Sinus rhythm, rate 60. integrelin d/cd @ 2200. denies cp/sobresp: ra sats 97-98%. source. appears comfortable. Doing well today, walked with physical therapy, OOB to chair off and on today. Pt is called out to tele floor, please see transfer note. needs teaching regarding meds/ lipitor and cardiac rehab family and pt updated on poc and expectations for day shift.a/p: possible c/o today. ambien given w some effectsocial: daughter called on eves. soft to touch. advance activity as tol. pt was able to speak to her. NPN 7 AM-7 PMS: " I quit smoking yesterday"o: please see careview for vitals and other objective dataPT sp inf MI, cpk trending down, pt had stent to 95 percent occludedRCa yesterday. Med teaching started and cardiac teaching, pt has MI and cardiac booklets, asking questions and showing initiative to lifestyle changes. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA SEE ICU ADMISSION NOTE FOR COMPLETE PMHX/HPICV: BRIEFLY, THIS 49 YO WOMAN WAS ADMITTED VIA OSH TO CATH LAB W/STEMI - INF AFTER WEEK HX INCREASEING CP; RCA LESION STENTED W/O DIFFICULTY - TRANSFERRED TO CCU @000 W/RFA/RFV SHEATHS IN PLACE, INTEGRELLIN AT 2MCGS/KG/MIN INFUSING X 12 HOURS; NO FURTHER CP SINCE ADMISSION, C/O L LOWER BACK PAIN (HAS CHRONIC CONDITION) RECEIVED 2 PERCOCET W/GOOD EFFECT; TURNED/BACK RUB ALSO HELPFUL, HR 60-70'S SR RARE PVC, BP 108-120'S/50-60; R GROIN SHEATHS D/C'D - INITIAL SM-MOD HEMATOMA NOW STABLE, PULSES 3+/2+ BILAT; CPK POST-PROCEDUR 80RESP: LUNGS CLEAR, SATS 98-100% ON 2L NCGI: TOLERATING SIPS WATER, CARDIAC DIET IN SM AMTS, NO STOOLGU: FOELY PLACED POST-PROCEDURE SECONDARY TO UNABLE TO VOID - INITIAL 670 CC CLEAR U/O, CONT TO PRODUCE GD AMT URINE, I/O'S EVENSOCIAL: HUSBAND, SON, DAUGHTER IN TO VISIT TODAY, ALSO CALLED LATER IN DAYNEURO/MS: ALERT AND ORIENTED X3, APPROPRIATELY ANXIOUS INITIALLY, CALM AND COOPERATIVE, TEACHING W/PT/FAMILY REGARDING MI/ICU CARE/NEED FOR RISK FACTOR MODIFICATION, AND REINFORCED NEED TO CALL AMBULANCE FOR SEVERE CP IN FUTUREA: STABLE POST STENT PLACEMENTP: MONITOR HR/RHYTHM, FOLOW CPK'S, LYTES, FREQUENT R GROIN CHECKS, FOLLOW PERIPH PULSES, CONT REINFORCE TEACHING, BEGIN CARDIAC REHAB IN AM W/INCREASE ACTIVITY; CONT KEEP PT FAMILY INFORMED OF CONDITION, PLAN OF CARE/EMOTIONAL SUPPORT. | 9 | [
{
"category": "Echo",
"chartdate": "2174-11-07 00:00:00.000",
"description": "Report",
"row_id": 82091,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. S/P stent mid RCA.\nHeight: (in) 67\nWeight (lb): 129\nBSA (m2): 1.68 m2\nBP (mm Hg): 115/63\nHR (bpm): 67\nStatus: Inpatient\nDate/Time: at 08:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mildly\ndepressed LVEF. [Intrinsic LV systolic function likely depressed given the\nseverity of valvular regurgitation.]\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - akinetic; mid inferoseptal - akinetic; basal inferior -\nakinetic; mid inferior - akinetic; inferior apex - hypo;\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\naortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. The left atrium is normal in size.\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Overall left ventricular systolic function is mildly\ndepressed. [Intrinsic left ventricular systolic function is likely more\ndepressed given the severity of valvular regurgitation.] Resting regional wall\nmotion abnormalities include basal and mid inferior and inferoseptal akinesis\nwith apical inferior hypokinesis.\n3.Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4.The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion. No aortic regurgitation is seen.\n5.The mitral valve leaflets are mildly thickened. Moderate (2+) mitral\nregurgitation is seen.\n6.There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2174-11-06 00:00:00.000",
"description": "Report",
"row_id": 206082,
"text": "Sinus rhythm\nConsider septal infarct - age indeterminate\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2174-11-08 00:00:00.000",
"description": "Report",
"row_id": 206079,
"text": "Sinus rhythm, rate 60. Since the previous tracing of positional\nchanges are noted over the lateral precordium.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2174-11-07 00:00:00.000",
"description": "Report",
"row_id": 206080,
"text": "Sinus rhythm\nInferior T wave changes may be due to myocardial ischemia\nPoor R wave progression\nNo previous tracing available for comparison\n\n"
},
{
"category": "ECG",
"chartdate": "2174-11-06 00:00:00.000",
"description": "Report",
"row_id": 206081,
"text": "Sinus rhythm\nPoor R wave progression - consider anteroseptal myocardial infarction - age\nindeterminate\nNo previous tracing available for comparison\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-11-07 00:00:00.000",
"description": "Report",
"row_id": 1262535,
"text": "NPN 7 AM-7 PM\n\nS: \" I quit smoking yesterday\"\n\no: please see careview for vitals and other objective data\n\nPT sp inf MI, cpk trending down, pt had stent to 95 percent occluded\nRCa yesterday. Doing well today, walked with physical therapy, OOB to chair off and on today. Med teaching started and cardiac teaching, pt has MI and cardiac booklets, asking questions and showing initiative to lifestyle changes. Pt is called out to tele floor, please see transfer note. pt remains pain free, cardiac cath site right femoral area with eccymotic area. Area has increased in size but very soft\npt denies pain in that area but sltly tender during palpation.\nstarted on lopressor today, tolerated 12.5, bp 97/55-- 117/60\nhr 60-70, pt also started on lipitor.\n\nneuro- OX3, moves all extrem, ambulates, converses.\n\ncv- SR on monitor, no ectopy, denies CP.\n\nrespiratory: lungs clear on ra sat 97 percent.\n\nGI- + flatus, no bm on colace, eating cardiac diet.\n\nGU- putting out 2700 cc urine last 12 hours. Foley dc'd at 6 pm and\n pt is due to void.\n\nA: pt sp inferior MI, echo done today, results pending, starting to get oob, ambul pain free, continues on asa, metoprolol, plavix, called out to floor.\n\np: med teaching, continue activity, monitor cv status, resp status,\nkeep pt and family updated on POC as discussed on multidiciplanary rounds.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-11-06 00:00:00.000",
"description": "Report",
"row_id": 1262532,
"text": "CCU NURSING PROGRESS NOTE 0700-1900\nS. \"THE LEFT SIDE OF MY BACK HURTS BUT MY CHEST PAIN IS GONE.\"\n\nO. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\n SEE ICU ADMISSION NOTE FOR COMPLETE PMHX/HPI\n\nCV: BRIEFLY, THIS 49 YO WOMAN WAS ADMITTED VIA OSH TO CATH LAB W/STEMI - INF AFTER WEEK HX INCREASEING CP; RCA LESION STENTED W/O DIFFICULTY - TRANSFERRED TO CCU @000 W/RFA/RFV SHEATHS IN PLACE, INTEGRELLIN AT 2MCGS/KG/MIN INFUSING X 12 HOURS; NO FURTHER CP SINCE ADMISSION, C/O L LOWER BACK PAIN (HAS CHRONIC CONDITION) RECEIVED 2 PERCOCET W/GOOD EFFECT; TURNED/BACK RUB ALSO HELPFUL, HR 60-70'S SR RARE PVC, BP 108-120'S/50-60; R GROIN SHEATHS D/C'D - INITIAL SM-MOD HEMATOMA NOW STABLE, PULSES 3+/2+ BILAT; CPK POST-PROCEDUR 80\n\nRESP: LUNGS CLEAR, SATS 98-100% ON 2L NC\n\nGI: TOLERATING SIPS WATER, CARDIAC DIET IN SM AMTS, NO STOOL\n\nGU: FOELY PLACED POST-PROCEDURE SECONDARY TO UNABLE TO VOID - INITIAL 670 CC CLEAR U/O, CONT TO PRODUCE GD AMT URINE, I/O'S EVEN\n\nSOCIAL: HUSBAND, SON, DAUGHTER IN TO VISIT TODAY, ALSO CALLED LATER IN DAY\n\nNEURO/MS: ALERT AND ORIENTED X3, APPROPRIATELY ANXIOUS INITIALLY, CALM AND COOPERATIVE, TEACHING W/PT/FAMILY REGARDING MI/ICU CARE/NEED FOR RISK FACTOR MODIFICATION, AND REINFORCED NEED TO CALL AMBULANCE FOR SEVERE CP IN FUTURE\n\nA: STABLE POST STENT PLACEMENT\n\nP: MONITOR HR/RHYTHM, FOLOW CPK'S, LYTES, FREQUENT R GROIN CHECKS, FOLLOW PERIPH PULSES, CONT REINFORCE TEACHING, BEGIN CARDIAC REHAB IN AM W/INCREASE ACTIVITY; CONT KEEP PT FAMILY INFORMED OF CONDITION, PLAN OF CARE/EMOTIONAL SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-11-06 00:00:00.000",
"description": "Report",
"row_id": 1262533,
"text": "ccu nursing addendum\npt noted to have approx 5x10 cm hematoma/ecchymotic area on l posterior rib area - area marked - has not extended, appears on ewhere defib pads were placed for transport, pt remains on integrellin 2mcgs until 2200; house staff notified.\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-11-07 00:00:00.000",
"description": "Report",
"row_id": 1262534,
"text": "ccu npn\n\ns: \" I would like to get out of bed soon\"\n\ncv: remains in nsr w hr 60-70. sbp 90-120, map's >60 ck 327,270 mb 39,31. started on lipitor. integrelin d/cd @ 2200. denies cp/sob\n\nresp: ra sats 97-98%. appears comfortable. denies sob. rr- reg bs-cl\n\ngi: tol po's abd soft non tender. no stool overnoc.\n\ngu: foley draining cl yellow. u/o > 100cc/hr. los + 596. bun creat wnl will d/c foley in am as condition warrents.\n\nskin: r groin c/d, but ecchymotic. soft to touch. tender, but denies pain @ site. pulses 3+/2+ bilat. ft wrm. has ecchymotic area upper l back ? source. ecchymotic area in l ac likley from blood draws.\n\nneuro: a/o mae intact. follows all commads\n\nid: afebrile wbc wnl\n\nlabs: wnl\n\naccess: piv's x2 intact/patent completed post procedure fluids\n\ncomfort: c/o back pain d/t br percocet x2 tabs and back reub/reposition w relief. difficulty sleeping. ambien given w some effect\n\nsocial: daughter called on eves. pt was able to speak to her. family and pt updated on poc and expectations for day shift.\n\na/p: possible c/o today. follow ck's. d/c foley in am. advance activity as tol. nursing transfer note intitiated. needs teaching regarding meds/ lipitor and cardiac rehab\n\n"
}
] |
3,199 | 112,969 | 72 yo f with h/o htn & cad admitted for stenting of asymptomatic carotid stenosis. -Pt underwent successful stenting of R carotid on . During procedure pt became asystolic, which was reversed with atropine. Post-procedure course was uncomplicated. Her SBP was maintained b/t 110-170mmHG with neosynephrine drip, which was weaned of . Pt did exhibit signs of "sun-downing" ON with some disorientation to place & people. This resolved after two days. However, her post-procedure neuro exam remained normal. Pt was weaned off of neo gtt without complication. SBP increased appropriately, though her home anti-hypertensives medications were held during the hospitalization. She was started on aspirin & plavix, and continued on atorvastatin. | 1/2NS@75cc/hr.PLAN: Goal SBP 110-170s titrate NEOSYNEPHRINE as tolerated. pt was briefly asystolic post stent deployment resolved w/ atropine. then hypotensive to SBP 60s - placed on NEO - currently at 1.48mcg/k/min. on arrival BP 230-260s/72-100. Consent signed.Resp: lungs with few crackles in the bases this am. Abdomen soft, + BS.GU: foley in place u/o as above. Equal strenght bilaterally.ID: T max 98.6 po. SBP now 98-110 via cuff. pt was slightly confused, easily re-oriented this morning. Restarted NEO at 1mcg/k/min then assisted back to bed.. after 5 min BP returned to 150s.. weaned back off gtt. Weaned off NEO this afternoon. Weaned off NEO this afternoon. On Neo 1mcg/k/min this morning. AM Hct 23.8 (28.7). ?repeat fluid bolus only per Dr for BP/u/o. Mental status improved but still not at baseline.P: transfuse 2 U PRBC when blood is available. sats 99%.GI/GU: foley patent. BUN 14 (13), CR 0.9(0.8).Neuro: according to daughter-in-law, patient is oriented . R groin sheaths d/c'd - brought to CCU. BP 104-129/31-44. CCU NSG PROGRESS NOTE 7P-7A/ S/P CAROTID STENT PT DENIES HEADACHE, DIZZINESS, PAINO- SEE FLOWSHEET FOR OBJECTIVE DATA PT S/P CAROTID STENT WITH RT FEMORAL SHEATHS D/C IN LAB 6PM.REMAINS ON NEO GTT FOR BP CONTROL AT GOAL SBP 110/OVERALL, REMAINS HEMODYNAMICALLY STABLE WITHOUT NEURO SYMPTOMS.HR- 90'S ST, BP- 110/45-130/60 VIA DYNAMAP.ABLE TO WEAN NEO FROM 1.48 TO 1 MCG/KG THIS SHIFT.RECEIVED 1 NS BOLUS 250 CC- PER DR .RT GROIN SITE STABLE, PULSES PRESENT, FEET COOL.RESP- CLEAR LUNGS, COMFORTABLE ON ROOM AIR, NO ISSUES.GU- FOLEY CATHETER IN PLACE- 30-40CC/HOUR CLEAR YELLOW URINE.I/O CLOSE TO EVEN AS OF MN. Goal SBP >100. ~ 2L positive as of midnight. abd soft +BS. DR NOTIFIED BY TEAM- TO GIVE 0.5 HALDOL, BUT PT CALM, NOT AGITATED AND DAUGHTER DECLINED PRESENTLY- TEAM AWARE. is still not at baseline neurologically, but feels she is better than the previous night.O: see CCU flow sheet for complete objective dataCV: HR 55-64 SB/NSR. OVER COURSE OF EARLY MORNING, PT FAMILY MEMBER STATES PT IS MUCH CLEARER MENTALLY.OVERALL, NO HEADACHE/DIZZINESS/NEURO SYMPTOMS. bolus given this evening - reeval tonite - ?repeat bolus only per Dr . Monitor BP and U/O. U/O 10-25 cc/hour. re-eval if urine output increased with BP and discuss w/ Dr if not improvement for additional boluses if necessary.NEURO: A+Ox3. OOB to commode, SBP 140. Dr aware. SOME " HEAVINESS" IN HEAD AT ARRIVAL TO CCU, RESOLVING, TEAM AWARE AS WELL.PT DOING WELL WITH STRICT BEDREST X 6 HOURS.LINES- CURRENTLY 2 PERIPHERAL PATENT LINES. GOAL SBP- >110/.PLAN- AM FLUID BOLUSES, CONTINUE TO WEAN NEO, INCREASE ACTIVITY IN LIGHT OF DAY.KEEP PT AND FAMILY AWARE OF PLAN OF CARE/PROGRESS.AM LABS, REPLETE LYTES AS NEEDED. R groin D+I. Confustion much improved by late morning and rest of day. WBC 8 (10.2).Skin: intact. NS boluses 300cc x 2 given this morning per Dr .. and 250cc NS bolus given this evening per Dr . Dr and CCu team aware. etio. Remains off NEO this evening.RESP: LS clear, dim. Family at bedside all day to assist w/ translation - pt speaks some very accented english.CARDIAC: SB/SR 38-70s. strict bedrest until 12am. Pt did become dizzy (after Neo weaned off 1st time) after washing up and standing beside chair putting on petticoat - sat back down in chair SBP 60s-70s. Patient moving freely in bed.A: decrease Hct, ? Sinus bradycardiaLeft ventricular hypertrophy with ST-T abnormalitiesNo previous tracing available for comparison Sinus bradycardiaProlonged QT intervalLVH with secondary repolarization abnormalitySeptal ST elevation - cannot rule out myocardial injury but may be related toleft ventricular hypertrophyQT interval prolonged for rateExtensive ST-T changes may be due to hypertrophy, ischemia metabolicderangements, central nervous system eventSince previous tracing, QT increased, T wave inversion new - clinicalcorrelation is suggested Given 250 cc NS over 1 hour. diminished u/o this evening. vegetarian diet.PLAN: monitor VS. goal SBP >100 as long as asymptomatic. CCU admit note 6p-7pAdmitted from cath holding area s/p R carotid stent placement.HPI: pt admitted w/ RCA disease - sent to cath for stent. OOB to chair multiple times during the day. family in all day for assist with translating - pt does speak minimal accented english. No dizziness with being OOB. O2 sats 97-100% on room air.GI: Large soft OB negative stool. 2PIV. CCU progress note 7a-7p71yo female s/p R carotid stent. given total of 3 NS boluses today, last bolus of 250cc NS going thru now. ?d/c home tomorrow. monitor for neuro changes. BP and U/O decrease is secondary to fall in Hct. Right femoral site without oozing, transparent dressing with gauze in place. palpable pedal pulses. CCU Nursing Progress Note 1900-0700S: daughter-in-law (pediatrician) states that pt. MAE. to receive 2 U PRBC over 4 hours each. Type and Screen sent. ? Family at bedside to provide emotional support and translation. family planning to continue taking turns staying w/ patient at bedside to assist w/ translation. Distal pulses palpable, feet warm with good movement. room air. PERLA, no neuro defecits noted. PT ATE FULL DINNER, GOOD APPETITE, (+) BOWEL SOUNDS,NO STOOL THIS SHIFT.A/ PT S/P CAROTID STENT EXPERIENCING SOME MILD DELIRIUM, OTHERWISE TOLERATING GRADUAL NEO WEAN.CONTINUE TO CLOSELY WATCH FOR ANY NEURO EVENTS, NOTIFY HO AND DR IF SO. PT SLEEPING MOST OF SHIFT WITH DAUGHTER PRESENT AS TRANSLATOR.OVER COURSE OF EVE, PT DAUGHTER STATING PT IS DELIRIOUS, HALLUCINATING, BUT ABLE TO REORIENT. Continue to assess for source of blood loss. no BM. taking meals well. | 6 | [
{
"category": "ECG",
"chartdate": "2151-06-29 00:00:00.000",
"description": "Report",
"row_id": 201694,
"text": "Sinus bradycardia\nProlonged QT interval\nLVH with secondary repolarization abnormality\nSeptal ST elevation - cannot rule out myocardial injury but may be related to\nleft ventricular hypertrophy\nQT interval prolonged for rate\nExtensive ST-T changes may be due to hypertrophy, ischemia metabolic\nderangements, central nervous system event\nSince previous tracing, QT increased, T wave inversion new - clinical\ncorrelation is suggested\n\n"
},
{
"category": "ECG",
"chartdate": "2151-06-28 00:00:00.000",
"description": "Report",
"row_id": 201695,
"text": "Sinus bradycardia\nLeft ventricular hypertrophy with ST-T abnormalities\nNo previous tracing available for comparison\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-06-28 00:00:00.000",
"description": "Report",
"row_id": 1303419,
"text": "CCU admit note 6p-7p\nAdmitted from cath holding area s/p R carotid stent placement.\n\nHPI: pt admitted w/ RCA disease - sent to cath for stent. on arrival BP 230-260s/72-100. pt was briefly asystolic post stent deployment resolved w/ atropine. then hypotensive to SBP 60s - placed on NEO - currently at 1.48mcg/k/min. R groin sheaths d/c'd - brought to CCU. strict bedrest until 12am. R groin D+I. palpable pedal pulses. Family at bedside to provide emotional support and translation. 1/2NS@75cc/hr.\n\nPLAN: Goal SBP 110-170s titrate NEOSYNEPHRINE as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-06-29 00:00:00.000",
"description": "Report",
"row_id": 1303420,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P CAROTID STENT\n\n PT DENIES HEADACHE, DIZZINESS, PAIN\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT S/P CAROTID STENT WITH RT FEMORAL SHEATHS D/C IN LAB 6PM.\nREMAINS ON NEO GTT FOR BP CONTROL AT GOAL SBP 110/\nOVERALL, REMAINS HEMODYNAMICALLY STABLE WITHOUT NEURO SYMPTOMS.\nHR- 90'S ST, BP- 110/45-130/60 VIA DYNAMAP.\nABLE TO WEAN NEO FROM 1.48 TO 1 MCG/KG THIS SHIFT.\nRECEIVED 1 NS BOLUS 250 CC- PER DR .\nRT GROIN SITE STABLE, PULSES PRESENT, FEET COOL.\n\n\nRESP- CLEAR LUNGS, COMFORTABLE ON ROOM AIR, NO ISSUES.\n\nGU- FOLEY CATHETER IN PLACE- 30-40CC/HOUR CLEAR YELLOW URINE.\nI/O CLOSE TO EVEN AS OF MN.\n\n PT SLEEPING MOST OF SHIFT WITH DAUGHTER PRESENT AS TRANSLATOR.\nOVER COURSE OF EVE, PT DAUGHTER STATING PT IS DELIRIOUS, HALLUCINATING, BUT ABLE TO REORIENT. DR NOTIFIED BY TEAM- TO GIVE 0.5 HALDOL, BUT PT CALM, NOT AGITATED AND DAUGHTER DECLINED PRESENTLY- TEAM AWARE. OVER COURSE OF EARLY MORNING, PT FAMILY MEMBER STATES PT IS MUCH CLEARER MENTALLY.\nOVERALL, NO HEADACHE/DIZZINESS/NEURO SYMPTOMS. SOME \" HEAVINESS\" IN HEAD AT ARRIVAL TO CCU, RESOLVING, TEAM AWARE AS WELL.\nPT DOING WELL WITH STRICT BEDREST X 6 HOURS.\n\nLINES- CURRENTLY 2 PERIPHERAL PATENT LINES.\n\n PT ATE FULL DINNER, GOOD APPETITE, (+) BOWEL SOUNDS,\nNO STOOL THIS SHIFT.\n\nA/ PT S/P CAROTID STENT EXPERIENCING SOME MILD DELIRIUM, OTHERWISE TOLERATING GRADUAL NEO WEAN.\n\nCONTINUE TO CLOSELY WATCH FOR ANY NEURO EVENTS, NOTIFY HO AND DR IF SO. GOAL SBP- >110/.\nPLAN- AM FLUID BOLUSES, CONTINUE TO WEAN NEO, INCREASE ACTIVITY IN LIGHT OF DAY.\nKEEP PT AND FAMILY AWARE OF PLAN OF CARE/PROGRESS.\nAM LABS, REPLETE LYTES AS NEEDED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-06-29 00:00:00.000",
"description": "Report",
"row_id": 1303421,
"text": "CCU progress note 7a-7p\n\n71yo female s/p R carotid stent. Weaned off NEO this afternoon. given total of 3 NS boluses today, last bolus of 250cc NS going thru now. Dr aware. Goal SBP >100. Family at bedside all day to assist w/ translation - pt speaks some very accented english.\n\nCARDIAC: SB/SR 38-70s. Weaned off NEO this afternoon. SBP now 98-110 via cuff. 2PIV. NS boluses 300cc x 2 given this morning per Dr .. and 250cc NS bolus given this evening per Dr . re-eval if urine output increased with BP and discuss w/ Dr if not improvement for additional boluses if necessary.\n\nNEURO: A+Ox3. pt was slightly confused, easily re-oriented this morning. PERLA, no neuro defecits noted. On Neo 1mcg/k/min this morning. Confustion much improved by late morning and rest of day. family in all day for assist with translating - pt does speak minimal accented english. OOB to chair multiple times during the day. Pt did become dizzy (after Neo weaned off 1st time) after washing up and standing beside chair putting on petticoat - sat back down in chair SBP 60s-70s. Restarted NEO at 1mcg/k/min then assisted back to bed.. after 5 min BP returned to 150s.. weaned back off gtt. Remains off NEO this evening.\n\nRESP: LS clear, dim. room air. sats 99%.\n\nGI/GU: foley patent. diminished u/o this evening. Dr and CCu team aware. bolus given this evening - reeval tonite - ?repeat bolus only per Dr . abd soft +BS. no BM. taking meals well. vegetarian diet.\n\nPLAN: monitor VS. goal SBP >100 as long as asymptomatic. monitor for neuro changes. ?repeat fluid bolus only per Dr for BP/u/o. family planning to continue taking turns staying w/ patient at bedside to assist w/ translation. ?d/c home tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-06-30 00:00:00.000",
"description": "Report",
"row_id": 1303422,
"text": "CCU Nursing Progress Note 1900-0700\nS: daughter-in-law (pediatrician) states that pt. is still not at baseline neurologically, but feels she is better than the previous night.\n\nO: see CCU flow sheet for complete objective data\n\nCV: HR 55-64 SB/NSR. BP 104-129/31-44. OOB to commode, SBP 140. No dizziness with being OOB. U/O 10-25 cc/hour. Given 250 cc NS over 1 hour. ~ 2L positive as of midnight. Right femoral site without oozing, transparent dressing with gauze in place. Distal pulses palpable, feet warm with good movement. AM Hct 23.8 (28.7). Type and Screen sent. to receive 2 U PRBC over 4 hours each. Consent signed.\n\nResp: lungs with few crackles in the bases this am. O2 sats 97-100% on room air.\n\nGI: Large soft OB negative stool. Abdomen soft, + BS.\n\nGU: foley in place u/o as above. BUN 14 (13), CR 0.9(0.8).\n\nNeuro: according to daughter-in-law, patient is oriented . Son did express he was concerned his mother not at baseline \"she thought she saw something coming from the ceiling.\" MAE. Equal strenght bilaterally.\n\nID: T max 98.6 po. WBC 8 (10.2).\n\nSkin: intact. Patient moving freely in bed.\n\nA: decrease Hct, ? etio. ? BP and U/O decrease is secondary to fall in Hct. Mental status improved but still not at baseline.\n\nP: transfuse 2 U PRBC when blood is available. Continue to assess for source of blood loss. Monitor BP and U/O.\n\n\n\n\n\n\n\n\n"
}
] |
19,356 | 137,859 | The patient was directed admitted to Dr. service from home. On admission, she was underwent bronchoscopy in conjuncition with the IP service, who also knows her. Due to marked cord edema, she was transferred to the CSRU and was maintatined on Heliox and CPAP mask. After her first night, she was doing much better and was able to be weaned off her heliox/mask. GI was consulted who adjusted her antiacid therapy, which seemed to help. She will undergo futher work up as an outpaient. She was tranferred to the floor once more stable. On HD4 her breathing was much better and she was dischared home on her modifed regimen, to recieve more extensive outpatient workup. | Hx of GERD with return of symptoms. recieving racemic epi nebs q4h and albuteral. slight exp wheezes noted. After stridor resolved, pt. INDICATION: Acute shortness of breath. c/o thirst/dry mouth.integ. c/o nausea x 1 med w reglan ivp good effect. Consider old chronic malformations possibly with bronchiectasis. Sinus rhythm. mouth swabs given . Resp Care: Pt trans from floor in resp distress d/t stridor, increased wob with prolonged insp, marked effort with paradoxical breathing >> placed on bipap 12/8 with heliox bled in after failing to respond to either rx alone with some improvement, voice change noted signifying heliox effect, subsequently removed from bipap d/t nausea and placed on nasal o2 with heliox maintaining adequate spo2 with acceptable wob; rx with epi/albuterol/atrovent as ordered, bs diminished throughout with episodic stridor, will cont bipap/heliox/bronchodilator/o2 as needed. Late transition which is difficult toevaluate in the presence of the baseline artifact. These changes which basically consist of a crowded vasculature in this area remains unchanged. has collasped vocal cords causing stridor requiring bipap/heliox rx.neuro: alert and oriented. Strict npo. Compared to the previoustracing probably no significant change. bp stable. reflux of acid ontyo vocal cords.Pt. Baseline artifact. pt. Skin intact no skin issues.plan: Monitor resp status closley, Rx stridor w meds/ nebs/ and bipap and/or heliox. The pulmonary vasculature is within normal limits without evidence of congestion, interstitial or alveolar edema. At first, pt. Available for comparison is a previous chest examination of as well as . IMPRESSION: No evidence of CHF or new acute parenchymal infiltrates. Evaluate for acute pulmonary process. ? good effect. FINDINGS: AP single view of the chest obtained with the patient in upright position demonstrates the heart size to be in normal limits. switched over to heliox by mask and tol well. Monitor o2 status. Thoracic aorta is moderately widened and elongated but no local contour abnormalities are identified. From these studies, right lower lobe opacities have been identified and are suspicious for pneumonia. It is therefore unlikely that that they represent an acute infectious process. did not tolerate heliox because she still had significant stridor. Slightly anxious and expressing that she does not want to be intubated. med with ativan .5mg ivp for insomnia(good effect)cv/resp hr 60's-70's nsr no ectopy. On the left base, a thin plate peripheral atelectasis has developed but no other significant pulmonary abnormalities are identified. See resp care flow sheet for specific modes of therapy. med x 2 with 2mg ivp mso4 for mod-severe substernal pain. Pt arrived from 2 last eve with resp distress/increased work of breathing. arrived to csru and continued on bipap that she was getting on the floor. o2 sats 92-98 range at all times.gi/gu Foley inserted shortly after arrival (pt had not voided) good initial uop of 400cc. no stools. 12:41 PM CHEST (PORTABLE AP) Clip # Reason: eval for acute process Admitting Diagnosis: SHORTNESS OF BREATH MEDICAL CONDITION: 70 year old woman with acute sob REASON FOR THIS EXAMINATION: eval for acute process FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view. | 4 | [
{
"category": "Nursing/other",
"chartdate": "2144-05-29 00:00:00.000",
"description": "Report",
"row_id": 1517800,
"text": "Pt arrived from 2 last eve with resp distress/increased work of breathing. Hx of GERD with return of symptoms. ? reflux of acid ontyo vocal cords.\nPt. has collasped vocal cords causing stridor requiring bipap/heliox rx.\nneuro: alert and oriented. Slightly anxious and expressing that she does not want to be intubated. med x 2 with 2mg ivp mso4 for mod-severe substernal pain. med with ativan .5mg ivp for insomnia(good effect)\ncv/resp hr 60's-70's nsr no ectopy. bp stable. See resp care flow sheet for specific modes of therapy. arrived to csru and continued on bipap that she was getting on the floor. At first, pt. did not tolerate heliox because she still had significant stridor. After stridor resolved, pt. switched over to heliox by mask and tol well. slight exp wheezes noted. recieving racemic epi nebs q4h and albuteral. good effect. o2 sats 92-98 range at all times.\ngi/gu Foley inserted shortly after arrival (pt had not voided) good initial uop of 400cc. Strict npo. no stools. c/o nausea x 1 med w reglan ivp good effect. mouth swabs given . pt. c/o thirst/dry mouth.\ninteg. Skin intact no skin issues.\nplan: Monitor resp status closley, Rx stridor w meds/ nebs/ and bipap and/or heliox. Monitor o2 status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-05-29 00:00:00.000",
"description": "Report",
"row_id": 1517801,
"text": "Resp Care: Pt trans from floor in resp distress d/t stridor, increased wob with prolonged insp, marked effort with paradoxical breathing >> placed on bipap 12/8 with heliox bled in after failing to respond to either rx alone with some improvement, voice change noted signifying heliox effect, subsequently removed from bipap d/t nausea and placed on nasal o2 with heliox maintaining adequate spo2 with acceptable wob; rx with epi/albuterol/atrovent as ordered, bs diminished throughout with episodic stridor, will cont bipap/heliox/bronchodilator/o2 as needed.\n"
},
{
"category": "ECG",
"chartdate": "2144-05-28 00:00:00.000",
"description": "Report",
"row_id": 184813,
"text": "Baseline artifact. Sinus rhythm. Late transition which is difficult to\nevaluate in the presence of the baseline artifact. Compared to the previous\ntracing probably no significant change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-05-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 912449,
"text": " 12:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute process\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with acute sob\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Acute shortness of breath. Evaluate for acute pulmonary process.\n\n FINDINGS: AP single view of the chest obtained with the patient in upright\n position demonstrates the heart size to be in normal limits. Thoracic aorta\n is moderately widened and elongated but no local contour abnormalities are\n identified. No mediastinal masses are seen. The pulmonary vasculature is\n within normal limits without evidence of congestion, interstitial or alveolar\n edema. Available for comparison is a previous chest examination of as well as . From these studies, right lower lobe opacities\n have been identified and are suspicious for pneumonia. These changes which\n basically consist of a crowded vasculature in this area remains unchanged. It\n is therefore unlikely that that they represent an acute infectious process.\n Consider old chronic malformations possibly with bronchiectasis. On the left\n base, a thin plate peripheral atelectasis has developed but no other\n significant pulmonary abnormalities are identified.\n\n IMPRESSION: No evidence of CHF or new acute parenchymal infiltrates.\n\n\n"
}
] |
11,116 | 117,842 | # Abdominal pain: According to past records from and from , the patient has a long history of admissions and ED visits for abdominal pain, as well as a history of narcotic-seeking behavior. He has a history of HCV cirrhosis. The differential diagnosis of his pain was broad, and included pancreatitis (although amylase, lipase, and CT findings argue against this), SBP (paracentesis results were negative), colitis (some chronic changes noted on CT, no change from prior), and gastritis. The patient did have an elevated bilirubin, but RUQ ultrasound was unrevealing, other than his known cirrhosis. Chronic mild elevation of LFTs was felt to be secondary to HCV and EtOH. The patient was initially kept NPO and given IV fluids and PPI. Due to his somnolence on admission, narcotics were initially avoided. Later in the hospital course, the patient was given PO opiates only, due to his hypercarbic respiratory failure (see below). The patient was very demanding and constantly requested IV pain medications. He also frequently refused all PO medications. At time of discharge he was on tramadol po only and is eating well without significant abdominal pain. The patient does claim to have a history of chronic pancreatitis as the etiology of his pain, so to make a definitive diagnosis he could be referred for a secretin test. This can be consider as an outpatient. . # Groin hematoma: Following placement of a femoral venous catheter for IV access, the patient developed a hematoma and became hypotensive. He was taken to the OR on given concern for an AVM. No AVM was found, but a large hematoma was evacuated. A JP was left in place, but on the patient pulled this out. At that time the had still been draining 600-700cc/day. Serosanguinous fluid continued to from the site of the JP , vascular surgery recommended placement of an ostomy bag over the site to collect the fluid and monitor its volume, as well as to protect the patient's skin. The patient's hematocrit remained stable. Lasix was also restarted in the hopes that treating the patient's peripheral edema would help to prevent reaccumulation of fluid in the groin site. (though albumin is quite low so this may not be successful) The patient had apparently been on diuretics as an outpatient as well, but adherence was not certain. Needs follow up with vascular surgery. . #HCV/EtOH Cirrohsis - Now closer to euvolemic. Continue on lasix 40 po bid and spironolactone. Also on lactulose and rifimaxin with improvement of mental status. Will restart bactrium SBP prophylaxis. Paracentesis neg for SBP. . #Scrotal cellulitis - Has prior hx of scrotal edema and bilateral varicoceles per records from . This admission was noted to have scrotal erythema and TTP. Started on treated with levofloxacin and vancomycin when not taking PO. Now will take a 10d course of cipro. . # Hypercarbic respiratory failure: The patient was first noted to be somnolent in the PACU following evacuation of his groin hematoma on . ABGs over time were 7.19/69/135 -> 7.23/55/170. He received 2 doses of narcan with some response, but the response waned quickly. He was re-intubated in the PACU and transferred to the MICU for further management. He was extubated on and transferred back to the floor. However, overnight he again became somnolent with a decreased RR and ABG 7.15/63/80. He had received morphine 2mg IV ~12 hours earlier. He was again given narcan, after which his RR increased to 24 and he became acutely wheezy and tachycardic to the 140s. He was transferred to the MICU, but did not need to be re-intubated at that time. No further intervention was needed, and he was again transferred to the floor. From that time onward, sedating medications were kept to a minimum, and IV opiates were avoided entirely. As mentioned above, the patient tended to refuse PO medications, so he received relatively small amounts of narcotics. He was noted to have a persistent LLL opacity on serial CXR, but as he was afebrile and it was not felt that he had a pneumonia clinicially, he was not treated with antibiotics. . # altered mental status: On admission this was secondary to EtOH withdrawal/intoxication (see below). There was also concern for a head bleed given a history of possible head trauma, but head CT was negative for bleed. EtOH abuse was treated as below. The patient remained very agitated, combative, and uncooperative throughout his admission. As above, he pulled out a JP from his groin following hematoma evacuation, and at another time he pulled out a R IJ central venous line. He required a 1:1 sitter for his own safety and that of others, as he threatened to harm staff members and to jump out a window. At the time of discharge mental status has cleared and he had no active suicidal ideation. . # ETOH abuse: The patient was intoxicated on admission, and he does have a history of withdrawal and DTs. He was kept on a CIWA scale with ativan. He was given a banana bag on admission and was also continued on PO thiamine, folate, MVI. There was no evidence for acute alcoholic hepatitis on admission. . # hypoxia: On admission the patient was found to be hypoxic. As mentioned above, it was not felt that he had pneumonia. Given that he was also tachycardia, there was also concern for PE. This was ruled out with CTA of the chest. He was give albuterol and atrovent nebs as well, given his history of asthma/COPD His hypoxia has now resolved. . # leg pain: The patient had this complaint on admissin. X-rays were negative for fracture. | Sinus tachycardia.Normal ECG except for rateSince previous tracing of , ventricular ectopy absent Sinus tachycardiaVentricular premature complexOtherwise normal ECGNo previous tracing available for comparison Per vascular us pt has right fem av fistula. Small amount of perihepatic ascites which tracks into right paracolic gutter. Ultrasound confirmed the right basilic vein was patent and compressible. right femoral tlcl placed in ed d/t poor piv access, piv placed tlcl removed. Cirrhosis with small amount of perihepatic ascites tracking into the right paracolic gutter. right fem site covered w/ dsd eccymotic areas noted on the inner right thigh and testicles swollen and eccymotic.gi: abd soft tender on right side bs+ no stool this shift. urine lytes sentskin: right femoral site covered w/ dsd. In the visualized abdomen, the liver appears nodular consistent with the history of cirrhosis. 12:06 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: EPIGASTIC PAIN S/P ETOH INGESTION. Nodular liver consistent with a cirrhotic liver, associated small amount of ascites, and likely reactive lymph node at the gastroesophageal junction. The pt is a Full Code.The pt has the following documented allergies; Compazine & Unasyn.MS: Pt re-admitted to MICU WEST somnolent but AAO times one, MAE and c/o pain. (Over) 12:06 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: EPIGASTIC PAIN S/P ETOH INGESTION. to or for evacuation of hematoma. The liver is nodular consistent with cirrhosis. After the inner dilator was removed, a single lumen PICC line was placed over the wire under fluoroscopic guidance with the tip in the superior vena cava. CT ABDOMEN BEFORE AND AFTER IV CONTRAST: The liver contour is markedly nodular and coarse, with a hypertrophied left lobe. Vent checked and lalarms functioning. Gynecomastia is noted. The airways are patent to the level of the segmental bronchi bilaterally. There is calcification of the right pectoralis major muscle, suggestive of prior hematoma in this region. Old compression deformity of a mid thoracic vertebral body. After surgery the pts became apneic c significantly altered ABG values requiring emergent intubation/MV support. There are tiny bilateral pleural effusions, with associated atelectasis. Calcification along the right pectoralis major muscle is suggestive of a prior hematoma in this region. Coronal and sagittal reconstructions were performed. (Over) 9:39 AM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: please eval for PE vs infiltrate Admitting Diagnosis: CHRONIC PANCREATITIS Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) IMPRESSION: Successful placement of a 37 cm, single lumen PICC line through right basilic vein with the tip in the superior vena cava. A slight bowel wall thickening is probably due to ascites. Evaluation of the solid abdominal organs is limited by the noncontrast technique. Pt MS was then somnolent and he was transferred to MICU WEST 6 for possible CPAP/PS non-invasive MV support. There is a right femoral vascular line. The osseous structures demonstrate a compression deformity of a mid thoracic vertebral body which was also seen in . Bowel loops are within normal limits. 03:00 Pan labs essentially WNL c stable HCT. A 0.018 guidewire was placed through the needle under fluoroscopic guidance with the tip in the superior vena cava. Nodular liver consistent with cirrhosis. CT PELVIS WITH IV CONTRAST: There is a Foley in the bladder. Please also quantify ascites, and mark for paracentesis if appropriate. CT OF THE ABDOMEN WITHOUT IV CONTRAST: The visualized lung bases are clear. COMPARISON: CT abdomen, . The patient is status post cholecystectomy and splenectomy. Bilateral tiny pleural effusions. PLAN: Pt to remain vented O/noc for pain management. TECHNIQUE: MDCT continuously acquired axial images of the abdomen and pelvis were obtained after oral contrast, but no IV contrast due to infiltration of the antecubital intravenous access. The right arm was prepped and draped in the standard sterile fashion. admitted on intoxicated c/o epigastric and abd pain. Bowel loops appear normal. atrial flutterBorderline left axis deviation - is nonspecificNo previous tracing available for comparison The portal veins and hepatic veins are patent with appropriate waveforms. There is a small amount of ascites surrounding the liver in the right upper quadrant. There is a small amount of ascites mostly around the liver and tracking into the right colic gutter. (Over) 3:02 PM CT ABD W&W/O C; CT PELVIS W&W/O C Clip # CT 150CC NONIONIC CONTRAST Reason: please evaluate hepatobiliary tree ?cholangitis Admitting Diagnosis: CHRONIC PANCREATITIS Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) The responded to IVP Narcan and was able to expectorate a large mucus plug. Perihepatic ascites. IV contrast-enhanced images in the arterial and portal venous phases were obtained in the same field of view, followed by delayed phase images through the abdomen and pelvis (so-called liver triple scan). Fatty cirrhotic liver without enhancing lesions identified. Comparison with non-IV contrast scan, also compared with CT and . Respiratory Care Pt received from PACU intubated and vented as documented. suctioned minimal yellow/tan secretionscv: tele sr 80s sbp 120-140s hrt sounds s1s2 pedal pulses +3 post tibs +3 bilat lower extrem warm and dry. | 15 | [
{
"category": "Radiology",
"chartdate": "2107-06-16 00:00:00.000",
"description": "CT 100CC NON IONIC CONTRAST",
"row_id": 913385,
"text": " 9:39 AM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: please eval for PE vs infiltrate\n Admitting Diagnosis: CHRONIC PANCREATITIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with alcohol intoxication p/w N/V, also tachycardic & hypoxic,\n CXR appears fairly clear\n REASON FOR THIS EXAMINATION:\n please eval for PE vs infiltrate\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia, nausea, vomiting, and tachycardia, assess for pulmonary\n embolism.\n\n COMPARISON: Chest x-ray from as well as abdominal CT from one\n day prior.\n\n TECHNIQUE: Multidetector CT scanning of the chest was performed after the\n administration of intravenous contrast. Multiplanar reformations were\n obtained.\n\n CT OF THE CHEST: The heart, pericardium, and great vessels appear\n unremarkable. No central or segmental filling defects are identified within\n the pulmonary arteries. The thoracic aorta is normal in caliber and contour\n throughout. The airways are patent to the level of the segmental bronchi\n bilaterally. No axillary, mediastinal, or hilar lymphadenopathy is\n identified. There is a 1.5-cm lymph node in the region of the\n gastroesophageal junction. The lungs are clear apart from some dependent\n changes. No pleural effusions or pneumothoraces are identified. There is\n calcification of the right pectoralis major muscle, suggestive of prior\n hematoma in this region.\n\n In the visualized abdomen, the liver appears nodular consistent with the\n history of cirrhosis. There is a small amount of ascites surrounding the\n liver in the right upper quadrant.\n\n The osseous structures demonstrate a compression deformity of a mid thoracic\n vertebral body which was also seen in .\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism. No consolidation within the lungs.\n 2. Old compression deformity of a mid thoracic vertebral body.\n 3. Nodular liver consistent with a cirrhotic liver, associated small amount\n of ascites, and likely reactive lymph node at the gastroesophageal junction.\n 4. Calcification along the right pectoralis major muscle is suggestive of a\n prior hematoma in this region.\n\n (Over)\n\n 9:39 AM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: please eval for PE vs infiltrate\n Admitting Diagnosis: CHRONIC PANCREATITIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-06-16 00:00:00.000",
"description": "CT PELVIS W/O CONTRAST",
"row_id": 913339,
"text": " 12:06 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: EPIGASTIC PAIN S/P ETOH INGESTION.\n Admitting Diagnosis: CHRONIC PANCREATITIS\n Field of view: 38\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with epigastric pain s/p alcohol ingestion\n REASON FOR THIS EXAMINATION:\n eval for pancreatitis,\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 4:50 AM\n Shrunken nodular liver c/w cirrhosis. Small amount of perihepatic ascites\n which tracks into right paracolic gutter. Extensive wall thickening of\n ascending and transverse colon indicating colitis, etilogy indeterminate,\n possibly infectious, inflammatory or less likely ischemic. No obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old male with epigastric pain after alcohol.\n\n TECHNIQUE: MDCT continuously acquired axial images of the abdomen and pelvis\n were obtained after oral contrast, but no IV contrast due to infiltration of\n the antecubital intravenous access. Coronal and sagittal reconstructions were\n performed.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: The visualized lung bases are clear.\n Evaluation of the solid abdominal organs is limited by the noncontrast\n technique. The liver has a nodular appearance with areas of fatty\n replacement consistent with cirrhosis. An underlying hepatic mass cannot be\n excluded. There is a small amount of ascites mostly around the\n liver and tracking into the right colic gutter. The patient is status post\n cholecystectomy and splenectomy. The adrenal glands, kidneys, stomach and\n duodenum are unremarkable. There is no inflammatory stranding or fluid\n collection around the pancreas to suggest pancreatitis. There is extensive\n wall thickening of the ascending and transverse colon indicating colitis of\n indeterminant etiology, possibly secondary to liver failure. There is no\n evidence of obstruction. There is no free intraabdominal air.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum, urinary bladder, prostate\n gland, and seminal vesicles are unremarkable. No pelvic lymphadenopathy.\n\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are\n identified.\n\n IMPRESSION:\n 1. Cirrhosis with small amount of perihepatic ascites tracking into the right\n paracolic gutter.\n 2. Extensive wall thickening of the ascending and transverse colon indicating\n colitis of indeterminant etiology, possibly secondary to liver failure.\n 3. No evidence of pancreatitis.\n\n ER dashboard wet read at 4:45 a.m., .\n (Over)\n\n 12:06 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: EPIGASTIC PAIN S/P ETOH INGESTION.\n Admitting Diagnosis: CHRONIC PANCREATITIS\n Field of view: 38\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "ECG",
"chartdate": "2107-06-26 00:00:00.000",
"description": "Report",
"row_id": 299607,
"text": "Sinus tachycardia.\nNormal ECG except for rate\nSince previous tracing of , ventricular ectopy absent\n\n"
},
{
"category": "ECG",
"chartdate": "2107-06-15 00:00:00.000",
"description": "Report",
"row_id": 299608,
"text": "atrial flutter\nBorderline left axis deviation - is nonspecific\nNo previous tracing available for comparison\n\n"
},
{
"category": "ECG",
"chartdate": "2107-06-16 00:00:00.000",
"description": "Report",
"row_id": 299609,
"text": "Sinus tachycardia\nVentricular premature complex\nOtherwise normal ECG\nNo previous tracing available for comparison\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-06-17 00:00:00.000",
"description": "CT PELVIS W&W/O C",
"row_id": 913599,
"text": " 3:02 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: please evaluate hepatobiliary tree ?cholangitis\n Admitting Diagnosis: CHRONIC PANCREATITIS\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with epigastric pain, distention, transaminitis, please\n evaluate hepatobiliary tree\n REASON FOR THIS EXAMINATION:\n please evaluate hepatobiliary tree ?cholangitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Epigastric pain and distention. Transaminitis.\n\n TECHNIQUE: After administration of oral contrast, MDCT was used to obtain\n contiguous axial images through the liver. IV contrast-enhanced images in the\n arterial and portal venous phases were obtained in the same field of view,\n followed by delayed phase images through the abdomen and pelvis (so-called\n liver triple scan). Comparison with non-IV contrast scan, also\n compared with CT and .\n\n CT ABDOMEN BEFORE AND AFTER IV CONTRAST: The liver contour is markedly\n nodular and coarse, with a hypertrophied left lobe. However, no enhancing\n lesions are identified within the liver. Portal veins remain patent. Normal\n hepatic arterial anatomy appears to be maintained. The splenic vein appears\n small, however, the spleen is not identified. The gallbladder is also absent.\n\n There are tiny bilateral pleural effusions, with associated atelectasis. No\n pericardial effusion is seen. There is a moderate amount of ascites\n especially around the liver. Gynecomastia is noted. There are small\n retroperitoneal and periportal lymph nodes, however, none of them meet\n criteria for pathologic enlargement. Bowel loops appear normal. Kidneys are\n normal.\n\n CT PELVIS WITH IV CONTRAST: There is a Foley in the bladder. Bowel loops are\n within normal limits. A slight bowel wall thickening is probably due to\n ascites. Prostate and seminal vesicles are normal. There is a right femoral\n vascular line.\n\n Bone windows show no suspicious sclerotic or lytic lesions. There is evidence\n of previous instrumentation of the left iliac bone.\n\n IMPRESSION:\n\n 1. Fatty cirrhotic liver without enhancing lesions identified. Perihepatic\n ascites.\n\n 2. Bilateral tiny pleural effusions.\n\n Findings were discussed with Dr. at time of interpretation.\n (Over)\n\n 3:02 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: please evaluate hepatobiliary tree ?cholangitis\n Admitting Diagnosis: CHRONIC PANCREATITIS\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-06-23 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 914285,
"text": " 12:56 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Please perform RUQ U/S to evaluate for etiology of abd pain,\n Admitting Diagnosis: CHRONIC PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with Hep C cirrhosis presents with abdominal pain, slowly\n rising bili. Please evaluate biliary tree, ascites.\n REASON FOR THIS EXAMINATION:\n Please perform RUQ U/S to evaluate for etiology of abd pain, rising bili.\n Please also quantify ascites, and mark for paracentesis if appropriate.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with hepatitis C, presents with abdominal pain\n and rising bilirubin.\n\n COMPARISON: CT abdomen, .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The gallbladder is not visualized consistent\n with the patient's history of cholecystectomy. The liver is nodular\n consistent with cirrhosis. The portal veins and hepatic veins are patent with\n appropriate waveforms. There is a moderate amount of ascites.\n\n IMPRESSION:\n 1. Nodular liver consistent with cirrhosis.\n 2. Moderate amount of ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-06-15 00:00:00.000",
"description": "R TIB/FIB (AP & LAT) RIGHT",
"row_id": 913320,
"text": " 9:00 PM\n ANKLE (AP, MORTISE & LAT) RIGHT; TIB/FIB (AP & LAT) RIGHT Clip # \n Reason: eval for fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with ? of fracture\n REASON FOR THIS EXAMINATION:\n eval for fracture\n ______________________________________________________________________________\n FINAL REPORT\n 53-year-old male with right leg pain and concern for fracture.\n\n TWO VIEWS OF THE RIGHT FIBULA AND TIBIA AND THREE VIEWS OF THE RIGHT ANKLE:\n There is no evidence of acute fracture or dislocation. There is old fracture\n deformity of the right fibula. The mortise is congruent and the talar dome is\n smooth. Regional soft tissues are unremarkable. There is no ankle effusion.\n\n IMPRESSION: No acute fracture.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-06-17 00:00:00.000",
"description": "FLUOR GUID PLCT/REPLCT/REMOVE",
"row_id": 913586,
"text": " 1:49 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC\n Admitting Diagnosis: CHRONIC PANCREATITIS\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with abd pain, EtOH w/drawal, currently w/ femoral CVL, needs\n IV abx\n REASON FOR THIS EXAMINATION:\n please place PICC\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 53-year-old man with abdominal pain, needs PICC line\n placement for IV antibiotics.\n\n PROCEDURE/FINDINGS: The procedure was performed by Dr. and Dr.\n . Dr. , the attending radiologist, was present and supervising\n throughout the procedure.\n\n The patient was placed supine on the angiographic table. The right arm was\n prepped and draped in the standard sterile fashion. Ultrasound confirmed the\n right basilic vein was patent and compressible. 5 cc of 1% lidocaine was\n applied for local anesthesia. Under ultrasonographic guidance, a 21-gauge\n needle was used to access the right basilic vein. A 0.018 guidewire was\n placed through the needle under fluoroscopic guidance with the tip in the\n superior vena cava. The needle was exchanged for a 4-French peel-away sheath.\n The length of the PICC line was measured at 37 cm depending on the mark on the\n wire. After the inner dilator was removed, a single lumen PICC line was\n placed over the wire under fluoroscopic guidance with the tip in the superior\n vena cava. The peel-away sheath and the wire were removed. The lumen was\n flushed and the line was secured with skin with StatLock. The patient\n tolerated the procedure well. There were no immediate complications.\n\n IMPRESSION: Successful placement of a 37 cm, single lumen PICC line through\n right basilic vein with the tip in the superior vena cava. The line is ready\n to use.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-06-18 00:00:00.000",
"description": "Report",
"row_id": 1408405,
"text": "Respiratory Care\n\n Pt received from PACU intubated and vented as documented. PLAN: Pt to remain vented O/noc for pain management. B/S scatt rhonchi, sx'ing sm thick white. Will follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-06-18 00:00:00.000",
"description": "Report",
"row_id": 1408406,
"text": "Nursing progress notes\n\n53 yr old male w/ hx of self reported pancreatitis, hep c cirrosis, polysubstance abuse (ethoh hx of dt's, smoker, drg seeking behavior past ivda) depression w/ suicide attempts asthma, s/p chole, s/p splenectopmy, s/t spinal fusion surgeries. admitted on intoxicated c/o epigastric and abd pain. hosp course. admit to floor placed on ciwa scale receiving ativan last dose 5/27 at 0400 and received 4mg iv ativan. right femoral tlcl placed in ed d/t poor piv access, piv placed tlcl removed. bled into testicles and thigh. Per vascular us pt has right fem av fistula. to or for evacuation of hematoma. during or pt hct dropped from 33 to 24 received 4 u prbc repeat hct at 1600 27.9. pt sedated and paralyzed during or and was extubated. In pacu he was difficult to arose and became hypercarbnic and acidotic. pt reintubated and tx to micu.\n\nreview of systems:\n\nneuro: pt arousable upon admission and at present he is very angry banging side rails wanting ett out. mae, follows commands. pt c/o of pain pointing to right fem site. ms 4mg ivp given at 1530 pt fell asleep for a short time than woke up banging on side rails, c/o pain\nms 2mg ivp given at 1630 w/ some effect. at 1800 pt wide awake banging side rails asking for tube to come out and requesting diludid for pain micu team aware. and ordered ms 4mg ivp (given at 1900) ciwa scale 6\n\nresp: pt intubated vented on ac rate 12 breathing over rr 18-40\nls clear w/ diminished bases. suctioned minimal yellow/tan secretions\n\n\ncv: tele sr 80s sbp 120-140s hrt sounds s1s2 pedal pulses +3 post tibs +3 bilat lower extrem warm and dry. k+ 3.6 repleated w/ 20meq kcl iv, mag 1.6 2gms of mag in 100cc. right fem site covered w/ dsd eccymotic areas noted on the inner right thigh and testicles swollen and eccymotic.\n\ngi: abd soft tender on right side bs+ no stool this shift. no ogt d/t will extubate this pm or in am.\n\ngu: pt foley cath draining amber urine. pt has had low uop 15cc/hr received 1500cc total of ns boluses. w/ slight improvement. urine lytes sent\n\nskin: right femoral site covered w/ dsd. right post forearm has a 2x2\" abrasion covered w/ antibx oint and 2x2\n\nsocial: pt has sister. social worker left message on her voice mail on admission. he also has a son and a daughter.\n\naccess: right ij tlcl, right picc line, left aline.\n\ncode: full\n\nplan:\nfollow hct q 8hrs\ncont to assess lower extrem and right fem site.\n? extubate tonight or in am.\ncont to keep right knee staight w/ knee immobilizer.\nmonitor uo\nciwa scale\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-06-19 00:00:00.000",
"description": "Report",
"row_id": 1408407,
"text": "npn 7p-7a (see also carevue flow notes for objective data)\n\ndx: ETOH w/drawal; POD 1 for evacuation Rt fem hematoma\n\n53 yo pt w/ PMHx of ETOH cirrhosis, hx w/drawla DT's, IVDA, PSA;\ncame to ER for c/o abdominal pain--stated he had pancreatitis, +ETOH;\nRt fem cvl placed, developed hematoma requiring surgical intervention/evacuation of hematoma ; testicles significantly enlarged d/t bleeding into, also Rt thigh swollen d/t bleeding; hct dropped from 33 to 24, received 4 units PRBC's;\n\n is 'day 3' post last drink, anticipated pt would go into w/drawal/DT's;\n\nPt returned from OR approx 12:30; over the afternoon and evening, pt becoming increasingly aggitated, banging on siderails; hypertensive, mildly tachycardic, very anxious;\npt banging wrists on siderails--new reddish bruising on wrists/hands d/t pt banging hands/wrists on siderails;\n\nbecause of w/drawal, versed and fentanyl gtts started at approx 21:00, with hope of weaning and possible extubation ;\n\npt aggitation, vs, anxiousness, required dosages of versed up to 10 mg/hr, and fentanyl 100 mcgs/hr, yet still with prn bolus as ordered;\n\npost-op sugical issues--rt groin J-P drain output was approx 50cc per hr red bloody appearing drainage, MICU MD team made aware; Rt knee in immobilizer to prevent pt from bending Rt groin;\n urine output also low; received 500 cc NS IV bolus x3 yesterday eve (x2 prior to this 12 hr shift, 3rd this shift approx 23:00);\n 23:00 hct down approx 1.5 pts from 15:00; other lab values confirm decrease is not dilutional; pt received 1mg IV Vit K over 30 minutes;\n serum K+ at 23:00 also down from 16:00; received 20 more mEq KCL at approx 04:30.\n surgical team MD up to assess pt at 02:00;\n\nO2 sat 98-100% all night, on current vent settings (A/C 12x600, peep 5, FIO2 0.40); required infrequent suctioning during the night;\n\nabd obese; pt NPO; q 6 hr FS's wnls;\n\nabx's dc'd d/t CT and labs do not confirm/support dx of pancreatitis;\n\naccess:\nRt neck EJ;\nLt wrist a-line (slightly positional);\n\nsocial:\n?pt homeless\nSW attempting to reach pt's sister\n\nPLAN:\n1) post-op extubation complicated by ETOH w/drawal and CIWA sedation issues/needs;\n2) check a.m. labs at 06:00 d/t previous labs drawn 23:00;\n3) follow exam dependent areas of Rt fem hemmorhage (testicles, rt thigh)\n4) SW page #--for discharge planning, please pg for imminent d/c\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-06-19 00:00:00.000",
"description": "Report",
"row_id": 1408408,
"text": "Respiratory care:\nPaitient remains intubated and mechanically vented. Vent checked and lalarms functioning. Current settings: A/C 600*12 40% with r peep. Breathsounds are decreased at bases. Please see respiratory section of crarevue for further data.\nPlan: Continue mechanical ventilation. No ABG's drawn this shift.\nWean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-06-20 00:00:00.000",
"description": "Report",
"row_id": 1408409,
"text": "Nursing Progress/Admission Note.\n\nBriefly, this is a 53 yr old male admitted to ER on in an intoxicated state (ETOH) c c/o abd pain. PMH includes; chronic Pancreatitis, chronic pain syndrome, Depression c suicide attempts & ideation, polysubstance abuse/IVDA, DT's, Asthma, Cigs, Hepatitis C, Cirrhosis and is s/p colecystectomy, splenectomy, & spinal fusion surgery. The pts hosp coarse has been complicated by a large R Fem hematoma (s/p R fem trauma line removal) requiring OR evacuation which was c/b 10 point HCT drop (s/p 4 units PRBC transfusions). After surgery the pts became apneic c significantly altered ABG values requiring emergent intubation/MV support. The pt required a short stay in the MICU (West 6) before transfer to the floor on . Unfortunately the pt was found @ MN unresponsive to noxious stimuli c low sats and poor ABG values. The responded to IVP Narcan and was able to expectorate a large mucus plug. Pt MS was then somnolent and he was transferred to MICU WEST 6 for possible CPAP/PS non-invasive MV support. The pt is a Full Code.\n\nThe pt has the following documented allergies; Compazine & Unasyn.\n\nMS: Pt re-admitted to MICU WEST somnolent but AAO times one, MAE and c/o pain. Pt now AAO times three though he does not consistently follow commands. Pt currently reporting abd pain. Team feels hypoventilation episode prior to transfer was 2nd pts last dose of IV Morphine SO4 @ 14:00 on 2nd positive responce to IVP Narcan. The pt is @ risk of developing DT's and will re-institute CIWA scale.\nSwollen scrotum elevated for comfort.\n\nRESP: Pt now on 2LNCO2 c nl sats, RR and resp effort @ rest. 03:15 ABG values; 7.39-33-81. LS are fairly clear to auscultation. Good cough reflex noted. CXR performed @ 03:15 c no new changes.\n\nCV: Hemodynamically stable and afebrile. NSR c no VEA. 03:00 Pan labs essentially WNL c stable HCT. RLE Leg brace in place to keep pt from bending R hip. R Hip staples are clean and intact, drain c 100ml of thin serosanguineous output overnight. DSD applied to R hip staples @ 06:00. Foley cath in place c adequate (>30ml/hr) hourly urinary output.\n\nGI: Pt is NPO but expect to adv diet this AM. Abd is obese, soft c +BS appreciated.\n\nSOC: No calls/visitors received overnight.\n\nOTHER: Please see CareVue for additional pt care data/comments. Univ isolation precautions in place.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-06-20 00:00:00.000",
"description": "Report",
"row_id": 1408410,
"text": "Nursing Progress Note 0700-1400\n\nUneventful shaift. Please see Nursing Transfer Note for review of systems. Pt. transferred to 710 in stable condition.\n"
}
] |
30,134 | 118,998 | 73 yo man with HTN, diet-controlled DM2, mild Alzheimer's and mild Parkinson's disease presented after a fall that led to traumatic subdural and subarachnoid hemorrhages. | CT OF THE ABDOMEN WITHOUT IV CONTRAST: A nasogastric tube terminates in the lower esophagus. Re- demonstrated is the low density round lesion of the left adrenal gland, which measures 18 mm and has Hounsfield unit compatible with adenoma. Left adrenal adenoma. Left adrenal adenoma. Bifrontal extra-axial hematomas have evolved and now are slightly hypodense compared to the prior study. Scattered linear foci of hyperdensity within the sulci are again seen, consistent with subarachnoid hemorrhage in a non-aneurysmal distribution. TECHNIQUE: MDCT non-contrast axial images of the abdomen. No MS.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Probable tiny right sided pleural effusion. FINDINGS: Again seen is parafalcine subdural hematoma. Left ventricular wall thicknesses arenormal. PATIENT/TEST INFORMATION:Indication: Shortness of breathHeight: (in) 71Weight (lb): 156BSA (m2): 1.90 m2BP (mm Hg): 163/78HR (bpm): 98Status: InpatientDate/Time: at 10:00Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Normal LV wall thickness. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets. FINDINGS: Single bedside AP examination of the chest, quite limited by exposure and the trauma board, with the lateral aspect of the right hemithorax excluded from the film, and the patient significantly rotated to his right. Right basilar opacity and small pleural effusions are unchanged since the recent radiograph. S-shaped thoracolumbar scoliosis identified. Minimal subarachnoid hemorrhage is unchanged. A 1.7 cm rounded low-attenuation lesion consistent with an adenoma is seen in the left adrenal gland. The nasogastric tube has been removed. There is stable hemorrhage along the tentorial reflection. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Moderately dilated aortic sinus. Small simple bilateral pleural effusions. Allowing for factors above, there is smooth, rounded prominence of the right paratracheal soft tissues, likely representing ectatic brachiocephalic vessels. The right PICC line has been repositioned in the interim, now terminating within the mid superior vena cava. A right PICC terminates in the mid SVC. There is a thoracic levoscoliosis, but no acute skeletal abnormality. It demonstrates a nasogastric tube with the tip terminating several centimeters proximal to the thoracoabdominal junction. The cardiac shadow is at the upper limit of normal. Evaluation of the solid abdominal organs is limited without IV contrast. Status post distal gastrectomy. There is no mitral valve prolapse.The tricuspid valve leaflets are mildly thickened. Small right pleural effusion and a trace left pleural effusion measure simple fluid density. There is a small fluid level in the left maxillary sinus which appears new. IMPRESSION: Gastric remnant fills with contrast with slow passage into small bowel. Normal main PA. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - ventilator.Conclusions:The left atrium is normal in size. TECHNIQUE: Non-contrast head CT scan. Multiple calcified mediastinal and hilar lymph nodes are unchanged since without evidence of pathological enlargement. Normal PA systolicpressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. dependant edemaRESP: RLL diminished, able to ausc. Peripheral pulses strongly palpable; 2+ pre-tibial edema. mouth dry.GU/GI: foley qs, noted to have uti earlier in weak. NPO, F/U hematuria. lethargic, opens eyes to tactile stim. will open eyes to voice, pt is lethargic. No LOS; transfered to from head CT reveal of SAH/SDH w/ 3mm shift. +BS noted. Duoderm to coccyx c/d/i.I-D: Temp max 99.6 po. Again, findings consistent with sinusitis. +mae noted, L sided weakness (baseline). npoENDO: bs 120's with q 6 hr FSBS and sliding scale coverage. On hydralazine for BP control (goal SBP <160).Resp: LS coarse throughout and diminished bibasilar. +nonprod cough. In the interim, a right PICC line has been placed that terminates beyond the superior margin of the film in the internal jugular vein. pt now afebrile. cipro for UTI, vanco, flagyl.ACCESS: two PIV intact, art line with good trace correlatesSKIN: ext. BS essentially CTA throughout, diminished bases. Surrounding osseous structures again demonstrate minimal ethmoid sinus mucosal thickening. pitting edema in right foot only, bil. Tetanus and dilantin load given in ER. +perrla noted. Minimal left maxillary sinus mucosal thickening is partially imaged. febrile tmax 100.8 ax. with rigors, does respond to rectal tylenol. nebs given. soft hypoactive BT. COMPARISON: CT head . Nebs with good effect.Cv: A fib, without ectopy, continued on iv lopresssor and SBP 100-150's controlled with hudralazine iv. art line placed in left radial with good trace.SKIN: on admit noted sm. Multiple areas multi-stage bruises over extremities and back.Endo: RISS, doses needs to be increased.ID: Tmax 99.9 po; no antibx. abd soft, no BT notedSKIN: dry skinACCESS: 2 pivSOCIAL: large familyPLAN: supportive care. sm skin break on coccyx. IMPRESSION: Slightly worsening right lower lobe atelectasis and effusion. to commands, L<R ,CV: sinus tach, bp 140's, urine out qs, rigorous and febrile. rr 36, am incease volume and rate now 24-28. no cough spont. There is a persistent small right pleural effusion. cough intact, gag impaired. HR NSR/ST. Code status DNR/DNI. PERRLA, intact cough and gag. Plan to wean niv as tolerated. H/O HTN. Cervical spondylosis as described. Sinus rhythm. Cardiac, mediastinal, and hilar contours are unchanged. J collar placed upon arrival to TSICU.Neuro: exam q 1 hr overnoc (w/ Portuguese interpreter prn) essentially unchanged. apsiration PNA or hosp. febile required tylenol supp. Developed Uti this admit, cipro started, today decreased LOC, increased RR, decreased sats requiring 100% NRB.Family decision DNR/DNI prior to transfer. portugese speakingCV: sinus tach, sys 140-160. urine out qs. Again, there are scattered hyperdense sulci bilaterally consistent with subarachnoid blood overall not significantly changed compared to the recent prior. PRN labetolol to maintain SBP<140. Arrived stable, NAD. Large healing areas of ecchymosis/abrasions left posterior flank. 10:54 AM CT HEAD W/O CONTRAST Clip # Reason: progression of SDH? | 34 | [
{
"category": "Radiology",
"chartdate": "2163-03-15 00:00:00.000",
"description": "UGI AIR W/KUB",
"row_id": 1002951,
"text": " 3:43 PM\n UGI AIR W/KUB Clip # \n Reason: please eval for pathology\n Admitting Diagnosis: SUBDURAL HEMORRHAGE;SUBARACHNOID HEMATOMA;FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with need for feeding tube, chronic aspirator\n REASON FOR THIS EXAMINATION:\n please eval for pathology\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old male with chronic aspiration in need of feeding tube.\n\n COMPARISON: CT torso, , and CT abdomen, .\n\n SINGLE CONTRAST UPPER GI EVALUATION: The initial scout radiograph\n demonstrates retained contrast throughout the colon, limiting subsequent\n evaluation. Under fluoroscopic guidance, Conray contrast was administered\n through a nasogastric tube. This demonstrated filling of the gastric remnant,\n which is surrounded by contrast- filled loops of colon including the splenic\n flexure in the left upper quadrant. There is slow passage of contrast into\n loops of small bowel and at the end of the study most of the administered\n contrast was retained within the gastric remnant.\n\n IMPRESSION: Gastric remnant fills with contrast with slow passage into\n small bowel.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-02-28 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1000679,
"text": " 5:36 PM\n CHEST (PA & LAT) Clip # \n Reason: r/p pneumonia\n Admitting Diagnosis: SUBDURAL HEMORRHAGE;SUBARACHNOID HEMATOMA;FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with bifrontal SDH\n REASON FOR THIS EXAMINATION:\n r/p pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: Bifrontal subdural hemorrhage.\n\n Cardiac size is top normal. The aorta is tortuous. There is elevation of the\n left hemidiaphragm due to distended colon. There are mild bibasilar\n atelectases greater on the left side. Bilateral pleural effusions are small.\n There is no pneumothorax.\n\n IMPRESSION: Aside from minimal bibasilar atelectasis, the lungs are clear,\n with no evidence of pneumonia or CHF.\n\n jr\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2163-03-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1001157,
"text": " 2:03 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please eval for interval change.\n Admitting Diagnosis: SUBDURAL HEMORRHAGE;SUBARACHNOID HEMATOMA;FALL\n Field of view: 25\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with recent subdural and subarachnoid hemorrhage now with\n worsening mental status.\n REASON FOR THIS EXAMINATION:\n Please eval for interval change.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n ROUTINE UNENHANCED CT HEAD\n\n Comparison is made with .\n\n Bifrontal extra-axial hematomas have evolved and now are slightly hypodense\n compared to the prior study. There is no significant mass effect on the\n underlying brain. Collections appear to have mildly increased in size\n compared to the prior study and measure approximately 7-9 mm in greatest\n dimension compared to prior measurements of mm.\n\n There is stable hemorrhage along the tentorial reflection. Previously noted\n biparietal subdural hematomas have evolved in density but are stable to\n minimally decreased in size. There is stable mild midline shift to the left.\n\n No new hematomas are seen.\n\n Minimal subarachnoid hemorrhage is unchanged. There is a small fluid level in\n the left maxillary sinus which appears new. Right-sided sphenoid sinus\n inflammatory disease has improved.\n\n IMPRESSION:\n\n Interval evolution of bifrontal subdural hematomas which have slightly\n increased in size, without significant mass effect on the underlying brain.\n\n Interval evolution of biparietal subdural hematomas which are essentially\n stable in size.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-03-12 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1002491,
"text": " 1:26 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: confirm picc tip post repositioning\n Admitting Diagnosis: SUBDURAL HEMORRHAGE;SUBARACHNOID HEMATOMA;FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with poor access requring iv antibx ; s/p SAH/SDH\n REASON FOR THIS EXAMINATION:\n confirm picc tip post repositioning\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: PICC line repositioning.\n\n FINDINGS: A single portable image of the chest was obtained and compared to\n the prior examination the same day at 11:35 a.m. The right PICC line has been\n repositioned in the interim, now terminating within the mid superior vena\n cava. Otherwise, no significant interval change since the prior examination\n earlier the same day.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-02-25 00:00:00.000",
"description": "TRAUMA #3 (PORT CHEST ONLY)",
"row_id": 1000381,
"text": " 7:43 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma.\n\n FINDINGS: Single bedside AP examination of the chest, quite limited by\n exposure and the trauma board, with the lateral aspect of the right hemithorax\n excluded from the film, and the patient significantly rotated to his right.\n The included portion of the lungs is grossly clear, with no supine evidence of\n pneumothorax or pleural effusion. Allowing for factors above, there is\n smooth, rounded prominence of the right paratracheal soft tissues, likely\n representing ectatic brachiocephalic vessels. The thoracic aortic contour is\n grossly unremarkable. There is a thoracic levoscoliosis, but no acute\n skeletal abnormality.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-03-10 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1002148,
"text": " 12:07 PM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: Dysphagia and aspiration. Unable to place gastrostomy under\n Admitting Diagnosis: SUBDURAL HEMORRHAGE;SUBARACHNOID HEMATOMA;FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with intracranial hemorrhage\n REASON FOR THIS EXAMINATION:\n Dysphagia and aspiration. Unable to place gastrostomy under fluoro due to\n gastric surgery and interposing bowel loops.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old male with traumatic intracranial hemorrhage, now with\n dysphagia and aspiration referred for placement of percutaneous gastrostomy\n tube for nutrition and medication administration.\n\n COMPARISON: Attempted percutaneous gastrostomy placement via fluoroscopy\n , CTA chest , and CT torso , chest radiograph\n .\n\n TECHNIQUE: MDCT non-contrast axial images of the abdomen.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: A nasogastric tube terminates in the\n lower esophagus. The visualized lung bases demonstrate consolidation of the\n dependent right lower lobe with previously administered oral contrast present\n within the right lower lobe airways. There are small bilateral pleural\n effusions and dependent atelectasis of the left lower lobe. The patient is\n status post distal gastrectomy and gastrojejunal anastomosis. Loops of jejunum\n and colon are interposed between the anterior abdominal wall and the stomach.\n Previously administered oral contrast is present throughout the colon. The\n stomach and proximal jejunum are mildly distended with gas. Evaluation of the\n solid abdominal organs is limited without IV contrast. Non-contrast view of\n the liver, spleen, pancreas, and right adrenal gland is unremarkable. Re-\n demonstrated is the low density round lesion of the left adrenal gland, which\n measures 18 mm and has Hounsfield unit compatible with adenoma. Previously\n administered IV contrast is noted within the renal collecting systems. The\n kidneys are otherwise unremarkable. There is no ascites. Again seen is a\n large sludge ball or noncalcified stone of the gallbladder without CT evidence\n of acute cholecystitis. Bone windows demonstrate multiple nondisplaced rib\n fractures, more numerous on the right, unchanged from the recent CT torso.\n\n Based upon these diagnostic findings, a decision was made to attempt\n percutaneous jejunostomy placement after consultation with the referring\n physician, . . Written informed consent had been previously\n obtained from the patient's proxy, after discussion of risks and benefits. A\n preprocedure timeout was performed to verify the patient's identity and\n indication for the procedure. The patient was placed supine on the CT table\n and the abdomen prepped and draped in sterile fashion. However, prior to\n performing any intervention, the patient suddenly became hypoxic, thought\n secondary to aspiration. Oxygen was supplied by facemask. Dr. and\n respiratory therapy were called and promptly arrived at the CT suite. The\n respiratory therapist then performed suction of the patient's airways with\n (Over)\n\n 12:07 PM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: Dysphagia and aspiration. Unable to place gastrostomy under\n Admitting Diagnosis: SUBDURAL HEMORRHAGE;SUBARACHNOID HEMATOMA;FALL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n improvement in oxygenation. The patient was observed in the radiology holding\n area until his respiratory status stabilized. Dr. then escorted the\n patient back to his room for further care.\n\n IMPRESSION:\n 1. Percutaneous gastrojejunostomy not performed due to patient aspiration and\n respiratory compromise. The referring physician, . and\n respiratory therapy were consulted and after the patient's respiratory status\n stabilized, he was transferred back to his room for further care.\n\n 2. CT evidence of prior aspiration with previously administered oral contrast\n present in the airways of the right lower lobe.\n\n 3. Left adrenal adenoma.\n\n 4. Status post distal gastrectomy.\n\n 5. Nondisplaced rib fractures, similar to the prior CT torso study.\n\n 6. Large sludge ball or noncalcified gallstone within the gallbladder without\n CT evidence of acute cholecystitis.\n\n These findings were discussed with Dr. on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-03-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1002178,
"text": " 2:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o aspiration\n Admitting Diagnosis: SUBDURAL HEMORRHAGE;SUBARACHNOID HEMATOMA;FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with\n REASON FOR THIS EXAMINATION:\n r/o aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 73-year-old man. Question aspiration.\n\n CHEST, SEMI-UPRIGHT AP: Comparison is made to the prior day. The nasogastric\n tube has been removed. There is increased patchy density in the right\n costophrenic angle, which may reflect suspected aspiration. Minimally\n displaced lateral fractures of the seventh and eighth ribs are unchanged. A\n small right- sided pleural effusion is also similar.\n\n IMPRESSION: Increased density in the right cardiophrenic angle, which could\n reflect clinically suspected aspiration.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-03-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1002026,
"text": " 4:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls evaluate NGT placement\n Admitting Diagnosis: SUBDURAL HEMORRHAGE;SUBARACHNOID HEMATOMA;FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with NGT placement\n REASON FOR THIS EXAMINATION:\n pls evaluate NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE RADIOGRAPH DATED \n\n COMPARISON: .\n\n INDICATION: Nasogastric tube placement.\n\n A portable radiograph centered at the thoracoabdominal junction was obtained\n for nasogastric tube assessment. It demonstrates a nasogastric tube with the\n tip terminating several centimeters proximal to the thoracoabdominal junction.\n Right basilar opacity and small pleural effusions are unchanged since the\n recent radiograph. Mildly distended loops of bowel are present in the imaged\n portion of the abdomen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-02-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1000383,
"text": " 7:50 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with fall down stairs, trauma trasfer, SDH, SAH\n REASON FOR THIS EXAMINATION:\n eval ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KCLd FRI 9:49 PM\n subdural and subarachnoid hemorrhage, minimal rightward shift.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old man status post fall with intracranial hemorrhage.\n\n COMPARISON: Comparison is made to an outside study performed at at approximately 5:30 p.m., , two and half hours\n before the current study.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n FINDINGS: Again seen is parafalcine subdural hematoma. Subdural hematoma is\n also again seen layering over the entire left convexity, as well as subjacent\n to both occipital lobes, above the tentorium. This appears slightly thicker at\n the vertex when compared to prior study, where it measures approximately 7 mm\n in greatest thickness. There is approximately 3 mm rightward shift of the\n septum pellucidum. Subdural hematoma also seen layering along the posterior\n right parietal region. Scattered linear foci of hyperdensity within the sulci\n are again seen, consistent with subarachnoid hemorrhage in a non-aneurysmal\n distribution. There is no evidence of intraparenchymal hemorrhage or\n contusion. Ventricles and cisterns appear within normal limits.\n\n There is no skull fracture. Moderate mucosal thickening is seen within the\n frontal and ethmoid sinuses. Mucosal thickening with fluid levels in the left\n greater than right maxillary sinus are noted. Severe mucosal thickening also\n is seen in the right sphenoid sinus.\n\n IMPRESSION:\n 1. Post-traumatic subdural and subarachnoid hemorrhage as described with 3 mm\n rightward shift of the septum pellucidum, but no significant mass effect or\n evidence of herniation.\n 2. Findings consistent with sinusitis.\n\n COMMENT: Findings reviewed with Drs. (Neurosurgery service) and \n (Trauma Surgery service) houseofficers.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-02-25 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1000384,
"text": " 7:51 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for intrabdominal injury, please do spine recons. \n Field of view: 42\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with fall down stairs, trauma trasfer\n REASON FOR THIS EXAMINATION:\n eval for intrabdominal injury, please do spine recons. Lumbar spine\n tendernessOSH Cre 1.1\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KCLd FRI 9:49 PM\n nondisplaced fractures of right 2, 5, 6, 7, 8, and left 4 ribs.\n\n right flank contusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old man with fall down stairs, evaluate for intra-\n abdominal injury. Lumbar spine tenderness.\n\n COMPARISONS: None.\n\n TECHNIQUE: MDCT acquired axial images of the chest, abdomen and pelvis were\n obtained with IV contrast. Multiplanar reformatted images were also\n displayed.\n\n CT OF THE CHEST WITH IV CONTRAST: There is no evidence of acute aortic\n injury. The heart and great vessels appear unremarkable. There is no\n pericardial effusion.\n\n Multiple calcified mediastinal and hilar lymph nodes are identified. No\n pathologically enlarged mediastinal or hilar lymph nodes identified.\n\n Patchy opacity seen at the left upper lobe consistent with small contusion.\n Pleural thickening noted at the right lung apex. There is no evidence of\n pneumothorax.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The liver appears unremarkable. A large\n sludge ball versus stone is seen within the gallbladder. The pancreas is\n largely fatty replaced. The spleen and splenule appear unremarkable. Right\n adrenal gland is unremarkable. A 1.7 cm rounded low-attenuation lesion\n consistent with an adenoma is seen in the left adrenal gland. The kidneys\n enhance symmetrically and excrete contrast bilaterally. There is no free air\n or free fluid within the abdomen. No abnormally dilated loops of bowel are\n seen.\n\n CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid, and prostate appear\n unremarkable. A Foley catheter is seen within the bladder. No fluid\n identified within the pelvis. Subcutaneous stranding is seen in the right\n flank soft tissues, consistent with contusion.\n\n (Over)\n\n 7:51 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for intrabdominal injury, please do spine recons. \n Field of view: 42\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n BONE WINDOWS: Nondisplaced fractures of the right second, fifth, six, seventh\n and eighth ribs identified. Likely nondisplaced fracture of the left fourth\n rib also identified.\n\n The patient is status post L4 and L5 laminectomy. Vertebral body heights\n appear maintained. No evidence of acute compression fracture. Small\n irregular likely heterotopic bone seen arising from left iliac bone.\n\n S-shaped thoracolumbar scoliosis identified.\n\n IMPRESSION:\n 1. Non-displaced fractures of the right second, fifth, sixth, seventh and\n eighth and left fourth ribs. Opacity in the left upper lobe consistent with\n small contusion. No pneumothorax or hemothorax.\n 2. No thoracolumbar spine fracture.\n 3. Right flank soft tissue contusion.\n 4. Large gallstone/sludge ball within the gallbladder.\n 5. Left adrenal adenoma.\n 6. Calcified lymph nodes and pleural thickening suggesting old granulomatous\n disease.\n\n COMMENT: Findings reviewed in-person with Dr. (Trauma Surgery) at\n time of study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-03-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1003579,
"text": " 12:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for new infiltrate, volume overload\n Admitting Diagnosis: SUBDURAL HEMORRHAGE;SUBARACHNOID HEMATOMA;FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with SAH/SDH and h/o aspiration now with worsening lung sounds\n REASON FOR THIS EXAMINATION:\n please eval for new infiltrate, volume overload\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 73-year-old man with intracranial hemorrhage. Now with history of\n aspiration.\n\n FINDINGS: Comparison is made to previous study from .\n\n There is again noted a right middle lobe opacity, which is stable. There is\n atelectasis at the lung bases. There is cardiomegaly. Overall, the lung\n findings are stable. There is again seen retained contrast material\n throughout the colon, and the colonic loops are prominent.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-03-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1003147,
"text": " 9:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: SUBDURAL HEMORRHAGE;SUBARACHNOID HEMATOMA;FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with parkinson's disease, SDH, recurrent aspiration now s/p\n J-tube placement and unresponsive.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Parkinson's disease, recurrent aspiration, unresponsive.\n\n Portable AP view of the chest dated is compared to the prior from\n and . A right PICC terminates in the mid SVC. The lung volumes\n are low. The heart size is normal. There is no pulmonary vascular\n congestion. The lung fields show opacity in the right middle lobe which\n likely represents atelectasis versus aspiration. Plate-like atelectasis is\n seen at the bilateral lung bases. There is no large pleural effusion. There\n is no pneumothorax. The surrounding soft tissue structures show barium\n contrast within the large bowel.\n\n IMPRESSION:\n 1. Right middle lobe atelectasis/aspiration is new.\n 2. PICC terminating in the mid SVC.\n\n\n DL\n\n"
},
{
"category": "Echo",
"chartdate": "2163-03-04 00:00:00.000",
"description": "Report",
"row_id": 84875,
"text": "PATIENT/TEST INFORMATION:\nIndication: Shortness of breath\nHeight: (in) 71\nWeight (lb): 156\nBSA (m2): 1.90 m2\nBP (mm Hg): 163/78\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 10:00\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Small LV cavity. Hyperdynamic LVEF\n>75%. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic sinus. Focal calcifications in aortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Physiologic TR. Normal PA systolic\npressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - ventilator.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is unusually small. Left ventricular\nsystolic function is hyperdynamic (EF 80%). There is no ventricular septal\ndefect. Right ventricular chamber size and free wall motion are normal. The\naortic root is moderately dilated at the sinus level. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. The\nmitral valve leaflets are mildly thickened. There is no mitral valve prolapse.\nThe tricuspid valve leaflets are mildly thickened. The estimated pulmonary\nartery systolic pressure is normal. There is no pericardial effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-03-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1001187,
"text": " 4:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? aspiration vs. pulmonary edema vs. pna\n Admitting Diagnosis: SUBDURAL HEMORRHAGE;SUBARACHNOID HEMATOMA;FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with hypoxemia after CT scan and fluid recussitation this AM.\n REASON FOR THIS EXAMINATION:\n ? aspiration vs. pulmonary edema vs. pna\n ______________________________________________________________________________\n WET READ: 9:27 PM\n Limited exam secondary to pt rotation and motion. Probable tiny right sided\n pleural effusion. Otherwise, clear lungs.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with hypoxemia after fluid\n resuscitation.\n\n Portable AP chest radiograph compared to obtained at 00:42\n a.m.\n\n The technique of the current radiograph is suboptimal due to motion artifacts.\n The patient is significantly rotated. Within the limitation of the study\n there is no significant change in mediastinal contour and bibasilar\n atelectasis. No overt pulmonary edema is demonstrated.\n\n\n DL\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-03-03 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1001087,
"text": " 8:45 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE\n Admitting Diagnosis: SUBDURAL HEMORRHAGE;SUBARACHNOID HEMATOMA;FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with tachycardia, tachpnea and fevers\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n CLINICAL INDICATION: 73-year-old man with tachycardia, tachypnea, fevers,\n rule out PE.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT-acquired images were obtained through the chest after the\n uneventful administration of 90 cc of IV Visipaque contrast. Multiplanar\n reformats were reviewed.\n\n CTA CHEST: There is no PE or aortic dissection. Heart size is top\n normal. There is trace pericardial effusion. Small right pleural effusion\n and a trace left pleural effusion measure simple fluid density. Multiple\n calcified mediastinal and hilar lymph nodes are unchanged since \n without evidence of pathological enlargement.\n\n Although this exam was not optimized for subdiaphragmatic diagnosis the imaged\n abdominal organs are unremarkable.\n\n Bone windows demonstrate non-displaced fractures of the right fifth, sixth and\n seventh ribs and non-displaced fracture of the left fourth rib, unchanged\n since .\n\n IMPRESSION:\n\n 1. No PE.\n\n 2. Small simple bilateral pleural effusions.\n\n 3. Multiple non-displaced rib fractures, unchanged since .\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-03-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1000862,
"text": " 12:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate/pna\n Admitting Diagnosis: SUBDURAL HEMORRHAGE;SUBARACHNOID HEMATOMA;FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with fever\n REASON FOR THIS EXAMINATION:\n eval for infiltrate/pna\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: chest radiograph.\n\n HISTORY: 73-year-old man with fever, evaluate for infiltrate/pneumonia.\n\n FINDINGS: Persistent low lung volume with bibasilar atelectasis. The cardiac\n shadow is at the upper limit of normal. The aorta is tortuous.\n\n IMPRESSION: Persistent low lung volume with bibasilar atelectasis and no\n evidence of pneumonia or heart failure.\n\n\n DL\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-03-10 00:00:00.000",
"description": "FLUORO 1 HR W/RADIOLOGIST",
"row_id": 1002094,
"text": " 7:08 AM\n PERC G/G-J TUBE PLMT Clip # \n Reason: Please place PEG tube\n Admitting Diagnosis: SUBDURAL HEMORRHAGE;SUBARACHNOID HEMATOMA;FALL\n ********************************* CPT Codes ********************************\n * FLUORO 1 HR W/RADIOLOGIST *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with recent fall with SDH and SAH, now unable to swallow\n safely. Needs PEG for nutrition/meds\n REASON FOR THIS EXAMINATION:\n Please place PEG tube\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old male with traumatic intracranial hemorrhage now with\n dysphagia and aspiration referred for placement of percutaneous gastrostomy\n tube for nutrition and medication administration.\n\n COMPARISON: CT of the torso , CTA chest , and chest\n radiograph .\n\n RADIOLOGISTS: Drs. and performed the procedure. Dr.\n , the attending radiologist, was present and supervised throughout.\n\n PROCEDURE AND FINDINGS: After the risks and benefits of the procedure were\n explained to the patient's proxy, written informed consent was obtained and a\n preprocedure timeout performed to verify the patient's identity and the\n indication for the procedure. The patient was placed supine on the\n angiographic table and the abdomen was prepped and draped in the usual sterile\n fashion. Initial AP and oblique scout fluoroscopic spot images of the abdomen\n demonstrate loops of colon and small bowel interposed between the stomach and\n anterior abdominal wall. Previously administered oral contrast is noted\n throughout the colon. Given the presence of the bowel loops anterior to the\n stomach, percutaneous gastrostomy placement by fluoroscopy was not deemed to\n be safe. Dr. was consulted and a decision was made to attempt to\n place a gastrostomy under CT guidance, and so the fluoroscopic procedure was\n aborted prematurely.\n\n IMPRESSION: Interposition of multiple loops of colon and small bowel between\n the anterior abdominal wall and stomach interfere with percutaneous placement\n of gastrostomy tube by fluoroscopy and thus this was not attempted.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-03-12 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1002480,
"text": " 11:16 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: SL PICC inserted 55 cm to R basilic. Pls confirm tip placeme\n Admitting Diagnosis: SUBDURAL HEMORRHAGE;SUBARACHNOID HEMATOMA;FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with subdural hemmorhage\n REASON FOR THIS EXAMINATION:\n SL PICC inserted 55 cm to R basilic. Pls confirm tip placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n CLINICAL INDICATION: Assess for line placement.\n\n FINDINGS: A single portable image of the chest was obtained and compared to\n the prior examination dated . In the interim, a right PICC line has\n been placed that terminates beyond the superior margin of the film in the\n internal jugular vein. Otherwise, no significant interval change. An opacity\n at the right cardiophrenic angle is again noted, may be secondary to\n underlying aspiration. There is a persistent small right pleural effusion.\n Right lateral rib fractures are again seen. The left hemithorax is clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-03-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1001233,
"text": " 4:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SUBDURAL HEMORRHAGE;SUBARACHNOID HEMATOMA;FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with new onset hypoxia, SOB\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New onset shortness of breath.\n\n CHEST, ONE VIEW: Comparison with exam , 17:27 and , 00:42.\n Right lower lobe atelectasis and small pleural effusion are slightly worse.\n Pulmonary vasculature is prominent, but there is no evidence of CHF. Left\n lung has minor lower lobe atelectasis. Cardiac, mediastinal, and hilar\n contours are unchanged. Osseous structures are also similar to the previous\n study.\n\n IMPRESSION: Slightly worsening right lower lobe atelectasis and effusion.\n\n jr\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-02-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1000434,
"text": " 10:54 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: progression of SDH? shift?\n Admitting Diagnosis: SUBDURAL HEMORRHAGE;SUBARACHNOID HEMATOMA;FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with fall down 15 stairs. SAH/SDH progressed since OSH scan.\n Re-eval for further progression.,\n REASON FOR THIS EXAMINATION:\n progression of SDH? shift?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old male with trauma and subarachnoid/subdural\n hemorrhage. Evaluate for progression of intracranial hemorrhage.\n\n COMPARISON: CT head .\n\n TECHNIQUE: Non-contrast axial images of the head are obtained with 5-mm\n section thickness.\n\n CT HEAD WITHOUT CONTRAST: Again a parafalcine subdural hematoma as well as\n subdural hematoma layering along the entire left convexity is identified, not\n significantly changed compared with a prior measuring approximately 7 mm in\n greatest width. There is 2 mm rightward shift of the septum pellucidum.\n Subdural blood layering along the tentorium persists. Again, there are\n scattered hyperdense sulci bilaterally consistent with subarachnoid blood\n overall not significantly changed compared to the recent prior. There is no\n evidence of an acute major vascular territorial infarct. Atherosclerotic\n calcification of the cavernous carotids is noted bilaterally.\n\n Surrounding osseous structures again demonstrate minimal ethmoid sinus mucosal\n thickening. Severe sphenoid sinus mucosal thickening.\n\n IMPRESSION:\n 1. No significant change in the extent of subdural and subarachnoid\n hemorrhage as described with 3 mm rightward shift of the septum pellucidum.\n 2. Again, findings consistent with sinusitis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-02-26 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1000435,
"text": " 10:56 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: Please evaluate for any further fx\n Admitting Diagnosis: SUBDURAL HEMORRHAGE;SUBARACHNOID HEMATOMA;FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with C7 spinous process fx\n REASON FOR THIS EXAMINATION:\n Please evaluate for any further fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: C7 spinous process fracture. Evaluate for any further osseous\n injury.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast axial images of the cervical spine were obtained with\n multiplanar reformatted images.\n\n CT CERVICAL SPINE: A non-displaced fracture of the spinous process of C7 is\n identified. No other definite fracture is identified. The atlanto-occipital\n and atlantoaxial articulations are maintained. Vertebral body heights and\n alignment are maintained. There is multilevel degenerative change with the\n most severe disc height loss at C5/6. Moderate degenerative neural foramen\n narrowing is present at C4/5 and C5/6 bilaterally. Minimal left maxillary\n sinus mucosal thickening is partially imaged. Emphysematous changes noted at\n the lung apices bilaterally.\n\n IMPRESSION:\n\n 1. Non-displaced fracture of the C7 spinous process without other fractures\n identified.\n\n 2. Cervical spondylosis as described.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-03-05 00:00:00.000",
"description": "Report",
"row_id": 1650989,
"text": "1900-0700 NPN\nNEURO: awake and alert MAE, left sided weakness baseline. perl at 2 cm. portugese speaking\n\nCV: sinus tach, sys 140-160. urine out qs. warm extremities. pp intact. febile required tylenol supp. small amt. dependant edema\n\nRESP: RLL diminished, able to ausc. breath sounds. diminished early. rr 36, am incease volume and rate now 24-28. no cough spont. , gag impaired. titrating oxygen to maintain sats mid 90's. now on 40% face mask.\n\nGU/GI: foley clear yellow, abd. soft hypoactive BT. no stool, smear of stool only.\n\nID: cont. cipro for UTI, vanco, flagyl.\n\nACCESS: two PIV intact, art line with good trace correlates\n\nSKIN: ext. warm, dusky. sm skin break on coccyx. cleansed, duoderm on, waffle boots in place.\n\nENDO: sliding scale, requiring insulin for FSBS 145.\n\nSOCIAL: family actively grieving. updated on plan to not use mask ventilation. supportive care, cont. antibiotics, use of morphine in sparing amts for comfort.\n\nPLAN: cv monitoring, maintain sats mid 90's, pulm toilet, frequent position changes, keep off back due to skin. mobilize, cont. antibiotics. support pt and family emotionally. may transfer to floor later today if remain s stable, replete electrolytes as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-03-05 00:00:00.000",
"description": "Report",
"row_id": 1650990,
"text": "Neuro: Somnolent this shift, arouses to stimuli and follows commands. +mae noted, L sided weakness (baseline). cough intact, gag impaired. +perrla noted. + tremors noted (hx Parkinsons's). c/o head pain in am, morphine given x2 with +effect. Primary language is portugese but understands some english, family states pt is a+ox3. No seizure activity noted.\nCV: Monitor shows Afib with occ pvc's noted. HR ^ to 150's, started on IV lopressor Q4hr. On hydralazine for BP control (goal SBP <160).\nResp: LS coarse throughout and diminished bibasilar. +nonprod cough. Denies sob or resp distress. 40% face mask.\nGI: Abd soft and distended. +BS noted. No stools this shift. NPO.\nGU: Foley intact and patent draining yellow urine with no sedimentation noted.\nSKIN: Multiple eccymotic areas noted on back, legs and arms. Duoderm to coccyx c/d/i.\nI-D: Temp max 99.6 po. Remains on Flagyl, Vanco and Cipro.\nPsy-Soc: Pt has large supportive family, updated on status and plan of care by this rn and Dr. . Code status DNR/DNI.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-03-06 00:00:00.000",
"description": "Report",
"row_id": 1650991,
"text": "MICU NPN 1900-0700\nReview carevue for all additional data\n\nNo significant events overnight\n\nNeuro: Alert, portugese speaking, understand some english,unable to assess for orientation, following commands with family.Rt hand lift and holds, all other extrimities moves on bed. Pupils 2mm and reacting to light. Cough intact/gag impaired.\n\nresp: continue to be on cool neb 40%, O2 sats 95-98%, RR unlaboured, congested cough not productive. Breath sounds coarse, bibasilar diminished. Nebs with good effect.\n\nCv: A fib, without ectopy, continued on iv lopresssor and SBP 100-150's controlled with hudralazine iv. A febrile, continued on antibiotics.\n\nGi/Gu: NPO, abd soft distended , no BM this shift, UO 40-100ml/hr\nSkin: Duaderm intac in coccyx, multiple echymotic area.\n\nSocial: Family at bed side in the evening, and telephoned this AM.\n\nPlan: Reassess code status\n monitor resp status/CPT/pul toilet\n ? Nutrition management\n frequent position changes\n Routine care/support to patient and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-03-04 00:00:00.000",
"description": "Report",
"row_id": 1650987,
"text": "2200-0700 NPN\nNEURO: pt. lethargic, opens eyes to tactile stim. or voice. noted weakness on Left side, does mae to command inconsistantly. Portugese speaking pt. does understand some spanish, PERL sluggish.\n\nCV: hr 130 early even then now 110 after bolus ns 1000cc, sys 180's now 140-150's, no ectopy noted. febrile tmax 100.8 ax. with rigors, does respond to rectal tylenol. urine clear qs, skin pink warm and dry. pp intact and robust\n\nRESP: rec'd on 100% NRB, lethargic tachypneic, placed on 100% bipap with rapid improvement in oxygenation. decreased to 50% bipap. with sats in mid 90's. able to place on 10 liter nc for mouth care, found partial plate in mouth and removed. lots of needed mouth care done. nasal trumpet placed and suction repeatedly for copious amt thick yellow to tan sputum. spec sent. gag impaired, poor cough effort, no spont cough. lung fields coarse, no bs heard in right base.\n\nGu/GI: foley qs, abd soft, passing flatus, no stool BT hypoactive. npo\n\nENDO: bs 120's with q 6 hr FSBS and sliding scale coverage. npo, no ngt in.\n\nID: hx Cdiff, contact precautions in place, sputum culture pending, pt noted to have UTI earlier in week. On Cipro, flagyl, vanco.\n\nACCESS: 2 PIV in place. art line placed in left radial with good trace.\n\nSKIN: on admit noted sm. skin tear on coccyx. cleansed, light duoderm on and pt to be off back at all times. will order foam boots for heal protection.\n\nSOCIAL: huge family here, active grieving as pt is now DNR/DNI. pt did respond appropriately to wife and children. Son will be spokesperson for group, wife is HCP>\n\nPLAN: pulm toilet including nt suction, bipap and positioning. antibiotics, anticipate vanco level prior to 3rd dose. replete electrolytes. mobilize when able. meticulus skin care, nutrition consult. foam boots. support pt and family emotionally.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-03-04 00:00:00.000",
"description": "Report",
"row_id": 1650988,
"text": "Micu progress Note 0700-1900\nPt was admitted last night from floor, ? apsiration PNA or hosp. accquired PNA.\n\nEvents: bipap changed to ventimask 70%, pt has been NSR to sinus tach, Goal is to keep SBP in 160's, pt went as high as 180's, 10mg hydralazine x2 given.\n\nNeuro: pt is able to answer orientation questions per family, seems oriented x3, will follow commands. will open eyes to voice, pt is lethargic. pupils 2mm, equal/reactive to light but sluggish.\n\nResp: pt RR 25-30, team aware pt seems to have harder time breathing, lung sounds clear/diminished, 1mg total of morphine given to try to help pt with breathing and for back pain. nebs given. Team aware of breathing and last ABG, see last ABG in care view, no changes made. oral care and oral sx done.\n\nCardio: SBP to keep in 160's, pt has had x2 10mg doses of hydralizine for SBP in 180's. HR NSR/ST. pt also developed parkinsons tremors for a while in left arm, but seems to be gone now. pt now afebrile. pitting edema in right foot only, bil. arms look mottled, seems to be warm and good peripheral pulses through out, team aware of all of this.\n\nGI/GU: foley, pt has decent urine output 40-60ml/hr. Pt passing small smear of stool, gave tylonol at 1100 for pain/fever. NPO. no nurtition started.\n\nPlan: pt needs replacement K, waiting for it from pharmacy, monitor labs, monitor SBP keep in 160's per team. Family cont to keep pt DNR/DNI, team talked to family about his worsening resp issues.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-02-26 00:00:00.000",
"description": "Report",
"row_id": 1650984,
"text": "Admission and ROS, 2215-0700\n72 y/o Portuguese-speaking male w/ acute fall down ? 4+ stairs at home. No LOS; transfered to from head CT reveal of SAH/SDH w/ 3mm shift. Arrived stable, NAD. Exam revealed large soft hematoma over right renal flank; large older ecchymosis and healing abrasions over left flank, lower back. Multiple areas new and old bruises over extremities and back. Torso CT reveals C7 SP fx, 5 non-displaced posterior rib fxs right, 2 non-displaced rib fxs left. Per wife, pt has been falling frequently and refusing to tell family or seek medical attention. Recently diagnosed w/ Alzheimer's and Parkinson's, started on arricept and sinemet. H/O HTN. Tetanus and dilantin load given in ER. J collar placed upon arrival to TSICU.\n\nNeuro: exam q 1 hr overnoc (w/ Portuguese interpreter prn) essentially unchanged. AAO x (forgets name of hospital); calm and cooperative. No focal deficits; strength + x 4 extremities. PERRLA, intact cough and gag. Adamantly denies any pain, but grimaces w/ turns and admits to back \"soreness\". Pt was able to sleep soundly between exams, so narcotic analgesia not administered.\n\nCV: NSR, no ectopy. Peripheral pulses strongly palpable; 2+ pre-tibial edema. Pboots DVT prophy.\n\nPulm: RA sats 92-93 while asleep; NP @ 2liters, sats>95%. BS essentially CTA throughout, diminished bases. IS to 1500cc w/ coaching. Dry cough.\n\nGI: abd soft, non-tender; BS hypoactive, no stool. NPO.\n\nGU: F/C urine clear yellow throughout noc w/ single episode bright sanguinous flush followed by several small bright clots ~ 0300. Urine clear since; OP adequate. Chemisties all WNL except BG. D5.45/20KcL @ 100cc overnoc.\n\nSkin: no pressue areas; coccyx slightly pink, intact. Large soft dark purple hematoma over right renal flank. Large healing areas of ecchymosis/abrasions left posterior flank. Multiple areas multi-stage bruises over extremities and back.\n\nEndo: RISS, doses needs to be increased.\n\nID: Tmax 99.9 po; no antibx. WBC wnl.\n\nHeme: Hct 31 from 35, probaly dilutional; platelets stable\n\nPsychosocial: very supportive extended family; wife in wheelchair accompanied by 2 , 2 sons and spouses. Pt and wife live in apartement below elder daughter. both expressed deep concern about teh need for hospital/rehab care for pt.since his many recent falls, about which they were unaware.\n\nP: repeat head CT. Cont q 1 hr neuro exam. NPO, F/U hematuria. Maintain c-collar at all times. PRN labetolol to maintain SBP<140. PRN interpreter, family at bedside prn as able.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-03-03 00:00:00.000",
"description": "Report",
"row_id": 1650985,
"text": "1900-0700 transfer into MICU 6\nPt. transfered from 7 , prev admit on from OSH after fall resulting in SDH, SAH on Left side. Hx parkinsons, baseline left weakness. Developed Uti this admit, cipro started, today decreased LOC, increased RR, decreased sats requiring 100% NRB.\nFamily decision DNR/DNI prior to transfer. Portguese speaking only. family large, able to assist with translation.\n\nADMIT NEURO: opens eyes to voice, perl sluggish, moves all ext. to commands, L<R ,\n\nCV: sinus tach, bp 140's, urine out qs, rigorous and febrile. warm to touch, pp intact. rec'd 1500cc bolus prior to transfer\n\nRESP: tachypneic, BS diminished throughout, no cough no gag, sats 88-90% on 100% NRB. mouth dry.\n\nGU/GI: foley qs, noted to have uti earlier in weak. abd soft, no BT noted\n\nSKIN: dry skin\n\nACCESS: 2 piv\n\nSOCIAL: large family\n\nPLAN: supportive care. labs aline\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-03-04 00:00:00.000",
"description": "Report",
"row_id": 1650986,
"text": "Resp: pt on NRB tranferred from floors following resp trigger. Placed on NIV psv 10/10/100% then weaned down to 50%. 02 sats @ 95%. Suctioning for large amounts of thick tannish secretions and sample sent. Plan to wean niv as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-03-06 00:00:00.000",
"description": "Report",
"row_id": 1650992,
"text": "Please see nursing transfer note. Pt has bed on 7, transfer note done, floor will take pt after 7pm.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-03-06 00:00:00.000",
"description": "Report",
"row_id": 1650993,
"text": "NPN \nTransfering patient to 10, A line d/ced.\n"
},
{
"category": "ECG",
"chartdate": "2163-03-03 00:00:00.000",
"description": "Report",
"row_id": 213364,
"text": "Sinus tachycardia. Right bundle-branch block. Compared to the previous\ntracing the rate is faster.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2163-03-03 00:00:00.000",
"description": "Report",
"row_id": 213365,
"text": "Sinus tachycardia. Right bundle-branch block. T wave abnormalities.\nCompared to the previous tracing earlier on the rate has increased.\nT wave abnormalities are more prominent.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2163-03-03 00:00:00.000",
"description": "Report",
"row_id": 213366,
"text": "Sinus rhythm. Right bundle-branch block. No previous tracing available for\ncomparison.\n\n"
}
] |
49,840 | 178,877 | 54yo M with PMHx of chronic RLE pain and lymphedema, pAfib, morbid obesity s/p gastric bypass, HTN, and depression who presents with complaints of melena vs. BRBPR also found to be in atrial fibrillation. | Non-specific ST-T wavechanges, likely related to rapid rate. Compared tothe previous tracing of there is diffuse slight ST segment elevation inthe context of the appearance of sinus rhythm. Sinus rhythm and occasional atrial ectopy. Diffuse non-specific ST-T wave abnormalities whichmight be related to rate. Compared to tracing #1 the ventricular rate hasdecreased.TRACING #2 Compared to the previous tracingof atrial fibrillation has replaced sinus bradycardia, non-specificST-T wave abnormalities are now noted at a much faster heart rate.TRACING #1 Atrial fibrillation with rapid ventricular rate. Non-specific inferior andanterolateral ST-T wave changes. Compared to the previous tracing of QRS voltage in the limb and precordial leads have increased, ventricularresponse has decreased. Atrial fibrillation with rapid ventricular response. Atrial fibrillation with rapid ventricular response. Low QRS voltage, mostnotable in the limb leads, raises the possibility of pericardial effusionversus myocardial disease. However, similar ST segmentrecording is noted on the previous tracing of in sinus rhythm. Noapparent diagnostic interim change. | 4 | [
{
"category": "ECG",
"chartdate": "2165-07-09 00:00:00.000",
"description": "Report",
"row_id": 296172,
"text": "Sinus rhythm and occasional atrial ectopy. Low limb lead voltage. Compared to\nthe previous tracing of there is diffuse slight ST segment elevation in\nthe context of the appearance of sinus rhythm. However, similar ST segment\nrecording is noted on the previous tracing of in sinus rhythm. No\napparent diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2165-06-28 00:00:00.000",
"description": "Report",
"row_id": 296173,
"text": "Atrial fibrillation with rapid ventricular response. Non-specific inferior and\nanterolateral ST-T wave changes. Compared to the previous tracing of \nQRS voltage in the limb and precordial leads have increased, ventricular\nresponse has decreased.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2165-06-25 00:00:00.000",
"description": "Report",
"row_id": 296174,
"text": "Atrial fibrillation with rapid ventricular response. Low QRS voltage, most\nnotable in the limb leads, raises the possibility of pericardial effusion\nversus myocardial disease. Diffuse non-specific ST-T wave abnormalities which\nmight be related to rate. Compared to tracing #1 the ventricular rate has\ndecreased.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2165-06-24 00:00:00.000",
"description": "Report",
"row_id": 296175,
"text": "Atrial fibrillation with rapid ventricular rate. Non-specific ST-T wave\nchanges, likely related to rapid rate. Compared to the previous tracing\nof atrial fibrillation has replaced sinus bradycardia, non-specific\nST-T wave abnormalities are now noted at a much faster heart rate.\nTRACING #1\n\n"
}
] |
57,507 | 108,029 | 29 yo M w/ no significant PMH presented with pleuritic chest pain and syncope (likely vasovagal) and was found to have a pericardial effusion with a Pulsus of 12 and early tamponade physiology on TTE who underwent successful pericardiocentesis with improved chest pressure. #Pericardial effusion- etiology is unclear. Cytology is still pending. Given that the most common cause is pericarditis, he was started on colchicine and ibuprofen in house and will continue these as an outpatient. He has multiple labs on the pericardial fluid still pending at the time of discharge. As he had a significant effusion it was decided to drain it rather than monitor with serial TTE. He will require f/u with TTE with Dr. on . He will continue on colchicine and ibuprofen until then, and will be directed by Dr. when to stop the colchicine. He was instructed what to look out for in terms of signs of tamponade or worsening effusion. -discharged on colchicine and ibuprofen -will f/u with Dr. of cardiology to determine course of treatment -Multiple pericarld fluid studies are still pending #Syncope- patient had syncope on admission and it was in teh setting of pain, and therefore likely due to a vasovagal event as opposed to his pericardial effusion. | Normal main PA. No Doppler evidence for PDAPERICARDIUM: Moderate pericardial effusion. Normal ascending aortadiameter. Normal PA systolic pressure.PERICARDIUM: No pericardial effusion.Conclusions:FOCUSED STUDY POST-PERICARDIOCENTESIS: Regional left ventricular wall motionis normal. Low normalLVEF.MITRAL VALVE: Mild MVP.PERICARDIUM: No pericardial effusion.Conclusions:Left ventricular wall thicknesses are normal. Normal aortic arch diameter. Thereis brief right atrial diastolic collapse. Significant, accentuated respiratory variation inmitral/tricuspid valve inflows, c/w impaired ventricular filling.Conclusions:The left atrium is normal in size. The left ventricular cavity sizeis normal. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Normal PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. The mitral valve leaflets are mildly thickened.Trivial mitral regurgitation is seen. Normal tricuspid valve supporting structures. Focal right ventriculardiastolic compression is seen in the subcostal view but is not present in theapical and parasternal views (this may represent focal/early tamponade). Brief RA diastoliccollapse. Normal mitral valvesupporting structures. SyncopeHeight: (in) 72Weight (lb): 195BSA (m2): 2.11 m2BP (mm Hg): 127/79HR (bpm): 91Status: InpatientDate/Time: at 09:18Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolicfunction (LVEF>55%). No RA orRV diastolic collapse. of the mitral chordae (normal variant). There is a moderatesized pericardial effusion. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. There is nopericardial effusion.Compared with the findings of the prior study (images reviewed) of , a pericardial effusion is no longer present. The aortic valve leaflets (3)appear structurally normal with good leaflet excursion and no aortic stenosisor aortic regurgitation. Theestimated pulmonary artery systolic pressure is normal. Theestimated pulmonary artery systolic pressure is normal. Assess for residual effusion from o/n.Height: (in) 72Weight (lb): 195BSA (m2): 2.11 m2BP (mm Hg): 131/71HR (bpm): 93Status: InpatientDate/Time: at 08:30Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Normal regional LV systolic function. There is mild posterior leaflet mitral valve prolapse. There is significant,accentuated respiratory variation in mitral/tricuspid valve inflows,consistent with impaired ventricular filling, although frank cardiac tamponadeis not present.Compared with the findings of the prior study (images reviewed) of , the findings are similar. Right ventricularchamber size and free wall motion are normal. PATIENT/TEST INFORMATION:Indication: Echo s/p pericardial tap of 320cc to assess for residual effusionHeight: (in) 72Weight (lb): 195BSA (m2): 2.11 m2BP (mm Hg): 135/86HR (bpm): 95Status: InpatientDate/Time: at 18:09Test: Portable TTE (Focused views)Doppler: No DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT VENTRICLE: Normal LV wall thickness. Cardiac silhouette is at the upper limits of normal or mildly enlarged. Normal LV cavity size. There is asmall to moderate sized pericardial effusion. Tamponade.Height: (in) 72Weight (lb): 195BSA (m2): 2.11 m2BP (mm Hg): 102/82HR (bpm): 97Status: InpatientDate/Time: at 17:14Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT VENTRICLE: Overall normal LVEF (>55%).PERICARDIUM: Small to moderate pericardial effusion. No 2D or Doppler evidence of distalarch coarctation.AORTIC VALVE: Normal aortic valve leaflets (3). Overall left ventricular systolic function is low normal (LVEF50%). Overall normal LVEF(>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTIC VALVE: Normal aortic valve leaflets (3).TRICUSPID VALVE: Normal tricuspid valve leaflets. On the lateral view, there appears to be bilateral small pleural effusions. No rightatrial or right ventricular diastolic collapse is seen. There is nopericardial effusion.Compared with the prior study (images reviewed) of , left ventricularfunction appears more vigorous. Trivial MR.TRICUSPID VALVE: TVP. No TS.Physiologic TR. Left ventricular wall thickness, cavitysize, and global systolic function are normal (LVEF 60%). There is variation in precordial lead placement.Otherwise, no diagnostic interim change.TRACING #2 Overall left ventricular systolic function is normal (LVEF>55%).Right ventricular chamber size and free wall motion are normal. The effusion appears circumferential. Tricuspid valve prolapse is present. PATIENT/TEST INFORMATION:Indication: Pericardial effusion. There is significant, accentuatedrespiratory variation in mitral/tricuspid valve inflows, consistent withimpaired ventricular filling.IMPRESSION: Early/focal tamponade suggested. Pericarditis. No definite vascular congestion or acute pneumonia. FINDINGS: No previous images. No PS.Physiologic PR. Diffuse ST segment elevation and PR segment depression whichmay represent pericardial process. Sinus rhythm. Sinus rhythm. The aorticvalve leaflets (3) appear structurally normal with good leaflet excursion. No restingLVOT gradient. No AS. Effusion circumferential. However, there is also delayed precordialR wave progression and QS deflection in lead V3 consistent with prioranteroseptal myocardial infarction. Syncope. Significant, accentuated respiratory variation in mitral/tricuspidvalve inflows, c/w impaired ventricular filling.GENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.Results were reviewed with the Cardiology Fellow involved with the patient'scare.Conclusions:Overall left ventricular systolic function is normal (LVEF>55%). Followup and clinical correlation aresuggested. Clinical correlation suggested. No MS. No previous tracing available for comparison.TRACING #1 PATIENT/TEST INFORMATION:Indication: Focused study after pericardiocentesis. There is no evidence of post-procedure pneumothorax. The previously mentioned multiple abnormalities recordedon persist. PATIENT/TEST INFORMATION:Indication: Chest pain. | 7 | [
{
"category": "Echo",
"chartdate": "2117-07-13 00:00:00.000",
"description": "Report",
"row_id": 104096,
"text": "PATIENT/TEST INFORMATION:\nIndication: Echo s/p pericardial tap of 320cc to assess for residual effusion\nHeight: (in) 72\nWeight (lb): 195\nBSA (m2): 2.11 m2\nBP (mm Hg): 135/86\nHR (bpm): 95\nStatus: Inpatient\nDate/Time: at 18:09\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Low normal\nLVEF.\n\nMITRAL VALVE: Mild MVP.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. Overall left ventricular systolic function is low normal (LVEF\n50%). There is mild posterior leaflet mitral valve prolapse. There is no\npericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , a pericardial effusion is no longer present.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2117-07-12 00:00:00.000",
"description": "Report",
"row_id": 104210,
"text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain. Pericarditis. Syncope. Tamponade.\nHeight: (in) 72\nWeight (lb): 195\nBSA (m2): 2.11 m2\nBP (mm Hg): 102/82\nHR (bpm): 97\nStatus: Inpatient\nDate/Time: at 17:14\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nPERICARDIUM: Small to moderate pericardial effusion. Brief RA diastolic\ncollapse. Significant, accentuated respiratory variation in mitral/tricuspid\nvalve inflows, c/w impaired ventricular filling.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\nResults were reviewed with the Cardiology Fellow involved with the patient's\ncare.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). There is a\nsmall to moderate sized pericardial effusion. Focal right ventricular\ndiastolic compression is seen in the subcostal view but is not present in the\napical and parasternal views (this may represent focal/early tamponade). There\nis brief right atrial diastolic collapse. There is significant, accentuated\nrespiratory variation in mitral/tricuspid valve inflows, consistent with\nimpaired ventricular filling.\n\nIMPRESSION: Early/focal tamponade suggested. Clinical correlation suggested.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2117-07-14 00:00:00.000",
"description": "Report",
"row_id": 104106,
"text": "PATIENT/TEST INFORMATION:\nIndication: Focused study after pericardiocentesis. Assess for residual effusion from o/n.\nHeight: (in) 72\nWeight (lb): 195\nBSA (m2): 2.11 m2\nBP (mm Hg): 131/71\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 08:30\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets (3).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nFOCUSED STUDY POST-PERICARDIOCENTESIS: Regional left ventricular wall motion\nis normal. Overall left ventricular systolic function is normal (LVEF>55%).\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion. The\nestimated pulmonary artery systolic pressure is normal. There is no\npericardial effusion.\n\nCompared with the prior study (images reviewed) of , left ventricular\nfunction appears more vigorous.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2117-07-13 00:00:00.000",
"description": "Report",
"row_id": 104107,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Syncope\nHeight: (in) 72\nWeight (lb): 195\nBSA (m2): 2.11 m2\nBP (mm Hg): 127/79\nHR (bpm): 91\nStatus: Inpatient\nDate/Time: at 09:18\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. No 2D or Doppler evidence of distal\narch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Normal mitral valve\nsupporting structures. of the mitral chordae (normal variant). No resting\nLVOT gradient. No MS. Trivial MR.\n\nTRICUSPID VALVE: TVP. Normal tricuspid valve supporting structures. No TS.\nPhysiologic TR. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: Moderate pericardial effusion. Effusion circumferential. No RA or\nRV diastolic collapse. Significant, accentuated respiratory variation in\nmitral/tricuspid valve inflows, c/w impaired ventricular filling.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and global systolic function are normal (LVEF 60%). Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion and no aortic stenosis\nor aortic regurgitation. The mitral valve leaflets are mildly thickened.\nTrivial mitral regurgitation is seen. Tricuspid valve prolapse is present. The\nestimated pulmonary artery systolic pressure is normal. There is a moderate\nsized pericardial effusion. The effusion appears circumferential. No right\natrial or right ventricular diastolic collapse is seen. There is significant,\naccentuated respiratory variation in mitral/tricuspid valve inflows,\nconsistent with impaired ventricular filling, although frank cardiac tamponade\nis not present.\n\nCompared with the findings of the prior study (images reviewed) of , the findings are similar.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-07-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1244272,
"text": " 1:41 PM\n CHEST (PA & LAT) Clip # \n Reason: pneumothorax\n Admitting Diagnosis: PERICARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man with pericardial effusion s/p pericardiocentesis\n REASON FOR THIS EXAMINATION:\n pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pericardial effusion after pericardiocentesis, to assess for\n pneumothorax.\n\n FINDINGS: No previous images. There is no evidence of post-procedure\n pneumothorax. Cardiac silhouette is at the upper limits of normal or mildly\n enlarged. No definite vascular congestion or acute pneumonia.\n\n On the lateral view, there appears to be bilateral small pleural effusions.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2117-07-13 00:00:00.000",
"description": "Report",
"row_id": 306195,
"text": "Sinus rhythm. The previously mentioned multiple abnormalities recorded\non persist. There is variation in precordial lead placement.\nOtherwise, no diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2117-07-12 00:00:00.000",
"description": "Report",
"row_id": 306196,
"text": "Sinus rhythm. Diffuse ST segment elevation and PR segment depression which\nmay represent pericardial process. However, there is also delayed precordial\nR wave progression and QS deflection in lead V3 consistent with prior\nanteroseptal myocardial infarction. Followup and clinical correlation are\nsuggested. No previous tracing available for comparison.\nTRACING #1\n\n\n"
}
] |
16,296 | 152,081 | 1st NEURO ICU COURSE: 86 year-old woman with CAD s/p CABG, HTN, HL, R retinal vein occlusion and recently dx. colon cancer, s/p colectomy c/b C.Diff coilitis who now presented from NH with two episodes of GTC seizures. She was loaded with Keppra IV and was transferred to . At upon evaluation in the ED, she was found to be "obtunded" s/p Keppra load and given multiple hospitalizations, WBC and seizure, she was felt to be at risk for meningitis, thus was treated with Vancomycin IV, Bactrim IV and Acyclovir IV for possible meningitis. LP couldn not be performed due to requirement of remaining on coumadin and INR of 2.6. There was also concern for top of the basilar syndrome, thus she underwent a CTA of the neck, showing severe atherosclerotic narrowing of the distal right vertebral artery and moderate-to-severe narrowing of both cavernous internal carotid arteries along w/ a small calcification in the basilar artery. She was transfered out of neuro ICU on for further care. On HD#1 patient was noted to be arousable to voice, oriented to hospital and following simple appendicular and axial commands. Given sudden improvement and no menigismus the antibiotics were discontinued. She continued to improve in her mental status. The detailed neuro exam after she came back to Neuro floor showed subtle weakness on the left side and absent reflexes. To assess the etiology of the seizure (stroke vs. metastatic mass), pt. underwent an of the head w/ and w/o contrast. Unfortunately she was agitated and was unable to complete the sequences with contrast. The Non contrast showed a lesion in right parietal area, possibly infarct with hemorrhagic conversion, although mass or AVM could not be ruled out due to lack of contrast administration. Initially there was concern for endocarditis, TTE was performed and showed no vegetations. CV. s/p CABG and AV valvuloplasty. Patient was noted to have episodes of hypotension in setting of her home BB dose, this was decreased to 1/2 dose and her lasix was held x 1 day in this setting. TTE revealed EF of > 60%, LVH, mild LVOT and aortic valve leaflets are severely thickened/deformed as well as "significant aortic stenosis." She was continued on the remainder of her NH medications. We held lasix after transfer to floor as there was concerns about lowering her blood pressure in setting of possible ischemic stroke. PULM. Mild oxygen requirement in setting of b/l pleural effusions and mild volume overload, likely due to diastolic dysfunction. In setting of hypotension, the lasix was temporarily held but shortly resumed after concern for her tenuous fluid balance. GI. C. Diff infection. Per discussion w/ NH, it appears that the loose stools have been declining and the plan was to d/c Flagyl/Vanco on day of transfer. She has not had any more loose stools while in the SICU and last C.diff was at NH and was neg. These were discontinued. 1st CCU COURSE: Pt was found to be in Afib with RVR on admission secondary to missing several doses of metoprolol on the floor. She was also found to be in acute pulmonary edema likely secondary to combination of afib with RVR and missing lasix doses. CXR also showed RLL lung collapse. She was febrile to 100.3 and given her worsened lung exam and MS it was thought that she had additional experienced silent aspiration. She was initially kept NP her depressed mental status and her Afib with RVR was rate controlled with IV metoprolol. As her sensorium cleared she was transitioned to p.o metoprolol with effect. She was treated for HAP aspiration pneumonia with vanc/falgyll/cefepime. On ICU day 3 she spiked to 102 and was pancultured with urine analysis showing pyuria and positive leuk esterase. She was kept on broad spectrum coverage with culture data pending. She was noted to have some new anisocoria on exam on hospital day three felt likely nebulizer treatment, given that her was still overall improved but should be followed with serial exam. The neurology service had recommended with gadollinium once medically stable to evaluate hyperdensity noted on prior imaging. Currently this is believed to be in nature (infarct) although metastatic disease cannot be ruled out given her history of colon cancer. Her INR was supratherapeutic on CCU admission, is now 1.4 with neurology recommending restarting low dose coumadin. Given her AS she was being judiciously diuresed with lasix drip, was running negative and was switched to her home lasix p.o dosing. Discussion is underway with Dr regarding percutaneous Aortic valve replacement once she is medically stable. Oral vancomycin suppression for c.diff infection has been discontinued following a negative c.diff and the fact that she has not had any further diarrhea. She was seen by speech and swallow with recommendation made for tube feeding and an NGT was placed. As her mental status was not improving, she was started on continuous EEG monitoring. On the evening of the patient was found to be in NCSE with generalized spikes in all leads at 2Hz on EEG. She was given ativan 0.5 mg x1, continued on keppra 1g and loaded with dilantin and was no longer in status. She was transferred to the neuro ICU for further care. 2nd NEURO ICU COURSE: Neurology; The patient remained on continuous video EEG monitoring. Her EEG remained active with generalized sharp waves at a rate of approximately 2 Hz, and on was found to be back in subclinical status. Her keppra was increased to 1500 mg and her dilantin was adjusted for goal levels 15-20. Her EEG remained active on AM. She also had worsening renal function. Therefore, she was given ativan 1 mg x1, her keppra was decreased to 500 mg q12h, and she was loaded with phenobarbital at 15 mg/kg with maintenance dose of 1 mg/kg. An with and without contrast was unable to be performed due to the patient's instability. Her EEG has slowly become less active, currently consistent with encephalopathy and occasional GPEDs with less sharp activity. Her keppra was discontinued , and phenobarbital was decreased to 60 mg . Her phenytoin is continued with goal level of 8 (which corresponds to free dilantin level 1.9 as per draw). Trough levels are requested for dilantin and free dilantin levels on . Clinically, she does not open eyes to noxious stimuli or follow any commands. Respiratory; The patient had worsening respiratory status , requiring intubation. ID; The patient completed a seven-day course of vancomycin and cefepime for a presumed pneumonia. She spiked a low grade fever and urinalysis revealed a likely UTI, but culture grew yeast. She received a three-day course of ciprofloxacin. CV; The patient continued to have a tenuous fluid balance. She was continued on aspirin, lasix, digoxin, lopressor, and statin. She required pressors to maintain her SBP (phenylephrine). A bedside TTE showed an aortic valve area of 0.6 cm2. She is on coumadin for goal INR . Renal; The patient has had worsening renal failure with minimal urine output. This was presumed to be due to cardiorenal syndrome. She is being followed by nephrology and is considered to be a poor dialysis candidate. Goals of care; multiple family meetings have been held regarding goals of care. The patient's husband and son still wish for all aggressive measures at this time. 2nd CCU COURSE: The patient was transferred back to the CCU service on . At this time, she was intubated and unresponsive. She was also grossly fluid overloaded and in renal failure. Attempts at diuresis with IV lasix, diuril, and bumex were all unsuccessful. On transfer to the CCU service, the patient was on pressors; however, these were able to be weaned off. The neurology service continued to follow the patient and provided recommendations for weaning down her phenobarbital and dilantin. Per neurology recommendations, the patient underwent of his head, which did not reveal any acute changes from prior MRIs. The patient was continued on EEG monitoring, which did not reveal any active seizure activity. The prospect of dialysis was brought up; however, it was felt that the patient was not a candidate for dialysis at that time. After multiple family meetings, the patient's family decided that she was unlikely to awaken from her coma. They decided to make the patient DNR/DNI with a focus on comfort. They decided not to escalate the patient's care any further but also not to deescalate. The patient remained stable until when she started to desat and look dusky. The family was notified of her clinical deterioration. On the patient expired. | # MS: initially noted to have anisocoria. Dilantin amd Keppra for seziure prophylaxis, f/u AM level. Admitted after seizure which stopped with ativan and keppra. Admitted after seizure which stopped with ativan and keppra. Admitted after seizure which stopped with ativan and keppra. Admitted after seizure which stopped with ativan and keppra. Pt has severe AS, is in A Fib, on Coumadin, has hx HTN. Pt has severe AS, is in A Fib, on Coumadin, has hx HTN. On ASA -- CAD s/p CABG , diastolic dysfunction. # MS: initially noted to have anisocoria. # MS: initially noted to have anisocoria. Dilantin and Keppra for seziure prophylaxis, f/u AM level. Pt remains somulent Plan: Aortic stenosis Assessment: Tele AF 70s-90 Lasix drip off. Nystatin Oral Suspension 29. Nystatin Oral Suspension 29. Nystatin Oral Suspension 29. Aortic stenosis Assessment: Tele AF 70s-90 Lasix drip off. Dilantin for seziure prophylaxis, f/u AM level. Dilantin for seziure prophylaxis, f/u AM level. Aortic stenosis Assessment: Tele AF 70s-90 Lasix drip off. Nystatin Oral Suspension 29. After MRI on she triggered for AMS and lethargy. After MRI on she triggered for AMS and lethargy. Dilantin for seziure prophylaxis, f/u AM level. Albuterol 0.083% Neb Soln 7. Albuterol 0.083% Neb Soln 7. Albuterol 0.083% Neb Soln 7. Nystatin Oral Suspension 39. On ASA -- CAD s/p CABG , diastolic dysfunction. On ASA -- CAD s/p CABG , diastolic dysfunction. On ASA -- CAD s/p CABG , diastolic dysfunction. Abg on eves (likely venous) Action: Aggressive C&DB Started on IS Received Cefipime/Flagyl iv MD notifed on ^ temp (last pan cult ) Tylenol 650mg PR Gentle CPT Repositioning q2/hr Hob ^ 45/degrees Has remained NPO. Dilantin and Keppra for seziure prophylaxis, f/u AM level. Dilantin Trough before next dose Apnea noted w/ RSBI Plan: Neuro checks Q2hrs, EEG, ? Action: INR was reversed today with FFP for a bedside trach and PEG. Dilantin amd Keppra for seziure prophylaxis, f/u AM level. On ASA -- CAD s/p CABG , diastolic dysfunction. After MRI on she triggered for AMS and lethargy. After MRI on she triggered for AMS and lethargy. After MRI on she triggered for AMS and lethargy. After MRI on she triggered for AMS and lethargy. After MRI on she triggered for AMS and lethargy. After MRI on she triggered for AMS and lethargy. After MRI on she triggered for AMS and lethargy. After MRI on she triggered for AMS and lethargy. # Acute Renal Failure: Per previous notes, renal believes that this is ATN. # Acute Renal Failure: Per previous notes, renal believes that this is ATN. # Respiratory Failure: Now, intubated with plans to trach pt on . # Respiratory Failure: Now, intubated with plans to trach pt on . # Respiratory Failure: Now, s/p trach. On ASA -- CAD s/p CABG , diastolic dysfunction. On ASA -- CAD s/p CABG , diastolic dysfunction. ECHO ordered to r/o endocarditis. Nystatin Oral Suspension 39. Aortic stenosis Assessment: Tele AF 70s-90 Lasix drip off. -- Critical AS (valve area pre-valvuloplasty 0.8cm2, post vavluloplasty). On ASA -- CAD s/p CABG , diastolic dysfunction. Pt has severe AS, is in A Fib, on Coumadin, has hx HTN. ECHO ordered to r/o endocarditis. Tortuosity of the basilar artery, consistent with dolichoectasia, previously described by CTA on . Off Phenobarbital and Dilantin is subtherapeutic (3.3). - Continue bumex and metolazone with goal of net negative 1.5L today - No further escalations # Respiratory Failure and Intubation - Preserve for now given mental status and edema # Atrial Fibrillation Pt has good control of HR on beta blockade and digoxin. - Continue bumex and metolazone with goal of net negative 1.5L today - No further escalations # Respiratory Failure and Intubation - Preserve for now given mental status and edema # Atrial Fibrillation Pt has good control of HR on beta blockade and digoxin. Per previous notes, is ATN - Will attempt diuresis with bumex/metolazone, as above - Appreciate renal recs. # Respiratory Failure: Now, intubated with plans to trach pt on . # Respiratory Failure: Now, intubated with plans to trach pt on . - Continue bumex and metolazone with goal of net negative 1.5L today - No further escalations # Respiratory Failure and Intubation - Preserve for now given mental status and edema # Atrial Fibrillation Pt has good control of HR on beta blockade and digoxin. # Respiratory Failure: Now, s/p trach. Now, holding coumading in case pt undergoes valvuloplasty. Now, holding coumading in case pt undergoes valvuloplasty. Now, holding coumading in case pt undergoes valvuloplasty. Now, holding coumading in case pt undergoes valvuloplasty. Plan: Monitor uo and bun and creatinine Respiratory failure, acute (not ARDS/) Assessment: Occ wheezes noted. Per previous notes, is ATN - Will attempt diuresis with bumex/metolazone, as above - Appreciate renal recs. # Respiratory Failure: Now, s/p trach. - Continue bumex and metolazone - No further escalations # Respiratory Failure and Intubation - Preserve for now given mental status and edema # Atrial Fibrillation Pt has good control of HR on beta blockade and digoxin. Action: Dilantin given as ordered- neuro checks q4hrs. -- Critical AS (valve area pre-valvuloplasty 0.8cm2, post vavluloplasty). On ASA -- CAD s/p CABG , diastolic dysfunction. Continues on Coumadin/Digoxin/Metoprolol. cultures p, last dose 3/16, Redo UA c/w Bact no need for Antibiotics now f/up Cx Hematology: --Hct slowly decreasing, 25.8--> tx 2u prbcs on ->29.7-->30.4 () --ASA, coumadin (2/5/5/3/2) Hold coumadin today INR level 3.4 - A. Fib anticoagulation with coumadin, INR 3.4 (goal ) Endocrine: --RISS, Hgb A1C 5.9 --Synthroid 75 mcg for hypothyroidism, previous TSH was 6.8 ID: --Wbc 9.4-->10.4 --Treated for PNA with cefepime/vanc (?aspiration) total course should be 7 days (ending ). On ASA -- CAD s/p CABG , diastolic dysfunction. Per previous notes, is ATN - Will attempt diuresis with bumex/metolazone, as above - Appreciate renal recs. Per previous notes, is ATN - Will attempt diuresis with bumex/metolazone, as above - Appreciate renal recs. Latanoprost 0.005% Ophth. | 355 | [
{
"category": "General",
"chartdate": "2196-02-15 00:00:00.000",
"description": "Generic Note",
"row_id": 404687,
"text": "TITLE: Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 04:00 PM\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Furosemide (Lasix) - 09:22 PM\n Dilantin - 04:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.3\nC (99.2\n HR: 97 (80 - 99) bpm\n BP: 120/57(80) {106/47(68) - 144/62(90)} mmHg\n RR: 17 (17 - 29) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 96.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 15 (10 - 17)mmHg\n Total In:\n 2,106 mL\n 176 mL\n PO:\n TF:\n 842 mL\n 2 mL\n IVF:\n 1,263 mL\n 174 mL\n Blood products:\n Total out:\n 224 mL\n 366 mL\n Urine:\n 124 mL\n 66 mL\n NG:\n Stool:\n 100 mL\n 300 mL\n Drains:\n Balance:\n 1,882 mL\n -190 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 505 (357 - 505) mL\n PS : 18 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 145\n PIP: 24 cmH2O\n SpO2: 98%\n ABG: 7.36/38/81./21/-3\n Ve: 8.3 L/min\n PaO2 / FiO2: 205\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: ET tube in place; JVD noted.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n Radiated to carotids.\n LUNGS: Ventilated breath sounds.\n ABDOMEN: Obese, S/NT/ND, BS present\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal or painful stimuli.\n Labs / Radiology\n 399 K/uL\n 8.3 g/dL\n 122 mg/dL\n 3.2 mg/dL\n 21 mEq/L\n 4.5 mEq/L\n 99 mg/dL\n 103 mEq/L\n 136 mEq/L\n 27.8 %\n 9.7 K/uL\n [image002.jpg]\n 06:10 PM\n 08:30 PM\n 10:18 PM\n 11:21 PM\n 03:29 AM\n 03:47 AM\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n WBC\n 10.8\n 9.7\n Hct\n 27.8\n 27.8\n Plt\n 434\n 399\n Cr\n 3.1\n 3.2\n TCO2\n 21\n 24\n 23\n 22\n 26\n 23\n 24\n 22\n Glucose\n 137\n 133\n 124\n 116\n 122\n Other labs: PT / PTT / INR:26.2/31.5/2.5, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine. Being\n transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU and appears very\n fluid overloaded on physical exam.\n - pt did not put out well to IV diuresis last night; will hold off on\n further diuresis or fluid at this time\n - continue to closely monitor volume status\n .\n # Atrial Fibrillation: Per previous notes, pt has good control of HR on\n beta blockade and digoxin.\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - coumadin was being held for ?supratherapeutic INR; INR in therapeutic\n range this morning; can restart coumadin after trach\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol.\n - continue phenytoin and phenobarbital\n - appreciate neuro recs\n .\n # Respiratory Failure: Now, intubated with plans to trach pt on .\n - NPO p MN for trach\n - plan for trach placement tomorrow\n - will need FFP prior to trach supratherapeutic INR\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Etiology unclear.\n - need to investigate prior work-up\n .\n # Acute Renal Failure: Per previous notes, renal believes that this is\n ATN. Recommend to not diurese or give IVF's.\n - holding on further diuresis, as above\n - continue to monitor fluid status otherwise\n .\n # Hypothyroidism:\n - continue synthroid 75 mcg daily\n .\n # Fevers: Per notes, pt completed vanc/cefepime 7 day course for\n pneumonia as well as 3 days course of abx for positive UA.\n - f/u cx data\n - follow fever curve\n - stool for c.diff\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin (on hold))\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU (transfer to LTAC soon)\n"
},
{
"category": "Physician ",
"chartdate": "2196-01-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402780,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.8\nF - 10:00 PM\n -TEE performed showing No vegetations on valves or RV/RA wires. Mild to\n moderate mitral regurgitation.\n -dental consulted recommended oral surgery consult for tooth\n extractions (loose incisors).\n -PA catheter pulled,tip not sent.\n -Last swan numbers:35, 13, 5.7, 2.8, 841.\n Labs showed worsening metabolic alkalosis, stable respiratory\n alkalosis. Started on acetazolamide x 2 doses in addition to K/Phos\n repletions, with ABG this morning showing: *****\n Lasix held given hypotension in afternoon to 60s systolic after\n diuresing two litres. Dobutamin considered but given that C.O\n normalized (and dobutamine would have helped by augmenting CO, and has\n mild vasodilatory pressures so would potentially worsen pressures if it\n doesn't augment her C.O), so started vasopressin instead. BP's\n normalized, restarted lasix with UOP ~ 200cc/hr achieved with lasix\n drip at 10cc/hr.\n 5am had 32 beat run of VT, with K of 2.9, agitated.\n K repleted.\n Continued diarrhea. Cdiff\nve x1. Guaic +ve. With crit drop this am to\n 27 from 30.\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:11 AM\n Acyclovir - 04:42 PM\n Vancomycin - 06:40 PM\n Cefipime - 08:00 PM\n Metronidazole - 05:57 AM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Famotidine (Pepcid) - 08:28 PM\n Metoprolol - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 36.5\nC (97.7\n HR: 87 (85 - 128) bpm\n BP: 103/51(65) {96/42(58) - 129/66(80)} mmHg\n RR: 21 (18 - 29) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 86 kg (admission): 80.1 kg\n Total In:\n 628 mL\n 300 mL\n PO:\n TF:\n IVF:\n 628 mL\n 300 mL\n Blood products:\n Total out:\n 1,190 mL\n 270 mL\n Urine:\n 1,190 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n -562 mL\n 30 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 95%\n ABG: 7.42/51/51/31/6\n PaO2 / FiO2: 73\n Physical Examination\n Neuro: responds to voice, moves extremities spontaneously, tracks,\n unable to follow commands\n CVS: RRR\n Lung: improved, less ronchorous\n Abd: +bs, soft, nt, nd\n Skin: appears slightly yellowed but no scleral icterus\n Ext:1+ edema to upper thigh, improved.\n warm extremities, weak peripheral pulses\n Labs / Radiology\n 430 K/uL\n 8.8 g/dL\n 87 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 100 mEq/L\n 141 mEq/L\n 30.6 %\n 9.9 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n WBC\n 11.7\n 9.9\n Hct\n 34.7\n 30.6\n Plt\n 500\n 430\n Cr\n 0.8\n 1.0\n TropT\n 0.02\n TCO2\n 34\n Glucose\n 107\n 87\n Other labs: PT / PTT / INR:28.2/41.5/2.8, CK / CKMB /\n Troponin-T:15//0.02, ALT / AST:, Alk Phos / T Bili:62/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.0\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n PNEUMONIA, ASPIRATION\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 63 y/o F w/ decompensated Stage IV CHF admitted for inotropic-assisted\n diuresis with superimposed sepsis, now intubated for hypercarbic\n respiratory failure/airway protection.\n .\n # CHF: Continued evidence CHF with peripheral edema, crackles on lung\n exam. Continued ionotrope assisted diuresis for decompensated CHF.\n Swan ganz dc'd yesterday. Continue diuresis given cardiogenic shock\n picture CHF.\n Continue lasix drip with lasix bolus's PRN goal negative 1L/day.Renal\n fx tolerating with Cr stable at 1.0\n -Continue pressor support PRN to achieve goal. Wean neo as tolerated,\n d'c vasopressin when able.\n - lyte checks.\n .\n Sepsis: Continues to have low grade fever but no white count, swan\n numbers prior to DC arguing against current ongoing sepsis. No\n vegetation evidenced on TEE to suggest endocarditis. MRSA cultured from\n sputum,blood-vanc sensitive. Sparse growth proteus mirabilis from\n sputum sensitive to cefepime.\n Dental consulted given poor dentition.\n Continue vanc/cefepime with Dose vanc by troughs.\n - Consider d/c flagyll.\n -Per dental recs consult oral surgery for tooth extraction. Unstable\n for panorex.\n Appreciate ID recs.\n d/c surveillance blood cx.\n -f/u wound cultures.\n .\n # Respiratory failure: Intubated for worsening\n hypercarbia/mental status. Respiratory failure likely multifactorial,\n with some component of heart failure/fluid overload as well as some\n pneumonia component. Pt has thus far failed SBTs.RISBI this am\n Barriers to extubation and MS dependence for respiratory\n support. Off sedation almost 72 hours MS slowly improving.\n -daily SBTs.\n -acetazolamide/K/Phos repletions for metabolic alkalosis.\n -K/phos repletions\n -continue abx.\n .\n # PUMP: Acute on chronic right and left-sided systolic heart failure.\n Currently holding lasix drip as was hypotensive to low 80\ns this am,\n with UOP continued at 200-300cc/hr.\n Titrate lasix to maintain UOP as bp tolerates. Goal negative\n -continue digoxin\n Wean neo as tolerated.\n .\n # CORONARIES: CTO of proximal LAD. CE's negative at OSH.\n - continue aspirin 81mg daily\n - continue zocor\n - holding on beta blocker and ACEi due to pressor requirement\n .\n # RHYTHM: Hx cardiomyopathy s/p ICD placement. TEE estimates EF at 55%,\n more accurate than TTE with EF 30%. Also with hx afib. Currently in\n sinus with frequent ectopy. Holding metoprolol in setting of\n hypotension. Had episode of VT o/n in setting of low K+.\n -continue telemetry\n -electrolyte repletions PRN.\n -heparin GTT for Afib. Had some bleeding with TEE now Guaic +Ve stools,\n Crit drop. PTTs in 70s, stable\n -consider holding heparin temporarily, repeat crit, maintain active T\n and S.\n -Hold Coumadin until medically stable.\n -serial EKGs.\n # MS: initially noted to have anisocoria. Now PERRLA but still sluggish\n MS. been off sedation 72 hours although did get versed/fentanyl x1\n for TEE yesterday. Non con CT head showing extensive paranasal sinus\n disease, ? NP hydrocephalus, small radiolucent focus in Left frontal\n bone.\n f/u ? intracranial process as o/p with further imaging\n -continue pressors to maintain CO/cerebral perfusion.\n -daily neuro exams.\n -electrolytes PRN.\n - f/u ? NP hydrocephalus and focal lesion as o/p\n .\n # Hypervolemic hyponatremia: likely secondary to CHF.\n Resolved with Na 139\n -continue to trend.\n .\n # Elevated lactate: Likely secondary to hypoperfusion. Trending down.\n - continue hemodynamic support with pressors\n -continue to trend.\n .\n # Hypothyroidism:\n - continue Synthroid\n .\n # Cardiac Risk Factors: LDL 69. HbA1c 6.6.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full)\n continue tube feeds.\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:00 PM\n Multi Lumen - 09:05 PM\n .\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Communication: Comments: Brother is HCP (contact info in chart)\n Code status: Full code\n Disposition: CCU for now\n ICU Care\n Nutrition:\n Nutren 2.0 (Full)\n continue tube feeds.\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:00 PM\n Multi Lumen - 09:05 PM\n .\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Communication: Comments: Brother is HCP (contact info in chart)\n Code status: Full code\n Disposition: CCU for now\n"
},
{
"category": "Echo",
"chartdate": "2196-02-08 00:00:00.000",
"description": "Report",
"row_id": 95094,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic stenosis. Congestive heart failure. Atrial fibrillation.\nHeight: (in) 63\nWeight (lb): 193\nBSA (m2): 1.91 m2\nBP (mm Hg): 86/37\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 15:03\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement. No LA mass/thrombus (best excluded by\nTEE).\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Moderate global RV free wall\nhypokinesis.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Critical AS\n(area <0.8cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Severe mitral annular\ncalcification. No MS. Mild to moderate (+) MR. [Due to acoustic shadowing,\nthe severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left and right atria are moderately dilated. No left atrial mass/thrombus\nseen (best excluded by transesophageal echocardiography). There is mild\nsymmetric left ventricular hypertrophy with normal cavity size and\nregional/global systolic function (LVEF>55%). The right ventricular cavity is\nmoderately dilated with moderate global free wall hypokinesis. The diameters\nof aorta at the sinus, ascending and arch levels are normal. The aortic valve\nleaflets are severely thickened/deformed. There is critical aortic valve\nstenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is severe mitral annular\ncalcification. There is no mitral stenosis. Mild to moderate (+) mitral\nregurgitation is seen. [Due to acoustic shadowing, the severity of mitral\nregurgitation may be significantly UNDERestimated.] The tricuspid valve\nleaflets are mildly thickened. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Critical aortic valve stenosis. Pulmonary artery hypertension.\nRight ventricular cavity enlargement with free wall hypokinesis. Mild\nsymmetric left ventricular hypertrophy with preserved global and regional\nsystolic function.\nCompared with the prior study (images reviewed) of , the gradient\nacross the aortic valve has increased and the right ventricular cavity is now\ndilated with free wall hypokinesis. The estimated PA systolic pressure and\nseverity of mitral regurgitation are similar.\n\nCLINICAL IMPLICATIONS:\nThe patient has severe aortic stenosis. Based on ACC/AHA Valvular Heart\nDisease Guidelines, if the patient is symptomatic (angina, syncope, CHF) and a\nsurgical candidate, surgical intervention has been shown to be beneficial.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2196-01-27 00:00:00.000",
"description": "Report",
"row_id": 95095,
"text": "PATIENT/TEST INFORMATION:\nIndication: Mental status change. ?Thromboembolic event. ?Endocarditis.\nHeight: (in) 67\nWeight (lb): 193\nBSA (m2): 1.99 m2\nBP (mm Hg): 105/56\nHR (bpm): 92\nStatus: Inpatient\nDate/Time: at 11:38\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Dilated LA.\n\nLEFT VENTRICLE: Symmetric LVH. Normal LV cavity size. Mild resting LVOT\ngradient.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Significant\nAS is present (not quantified) Trace AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral\nannular calcification. Mild thickening of mitral valve chordae. Trivial MR.\n[Due to acoustic shadowing, the severity of MR may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is dilated. There is symmetric left ventricular hypertrophy.\nThe left ventricular cavity size is normal. There is a mild resting left\nventricular outflow tract obstruction. The aortic valve leaflets are severely\nthickened/deformed. Significant aortic stenosis is present (not quantified).\nTrace aortic regurgitation is seen. The mitral valve leaflets are moderately\nthickened. Trivial mitral regurgitation is seen. [Due to acoustic shadowing,\nthe severity of mitral regurgitation may be significantly UNDERestimated.] The\ntricuspid valve leaflets are mildly thickened. There is mild pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nNo vegetation seen (cannot definitively exclude).\n\nCompared with the prior study (images reviewed) of , a mild left\nventricular outflow gradient is now detected.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2196-01-30 00:00:00.000",
"description": "Report",
"row_id": 252336,
"text": "Atrial fibrillation. Left axis deviation. Left anterior fascicular block.\nNon-specific ST-T wave changes. Compared to the previous tracing the rate is\nslower.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2196-01-29 00:00:00.000",
"description": "Report",
"row_id": 252337,
"text": "Atrial fibrillation with a rapid ventricular response. Left axis deviation.\nLeft anterior fascicular block. Non-specific ST-T wave changes. Compared to\nthe previous tracing there is no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2196-01-26 00:00:00.000",
"description": "Report",
"row_id": 252338,
"text": "Atrial fibrillation with rapid ventricular response and occasional\nventricular ectopy. Left axis deviation. Left ventricular hypertrophy.\nNon-specific ST-T wave changes. Compared to the previous tracing of \nno diagnostic interim change.\n\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404036,
"text": "TITLE:\n Seizure, without status epilepticus\n Assessment:\n Remains on cont eeg, no observable seizures. Remains on keppra and\n dilantin.\n Neuro- minimally responsive to nox stim. Spont moves bilat upper\n extrems to nox stim., min withdraws lower extrems to nox stim.\n Temp spike to 101.5\n Action:\n Neuro exam q2h pupils unequal at times. Spont movement upper extrems\n ,no spont movement to lower extrems.Does not open eyes to loud voice or\n nox stim.\n Pan cultured, stool for c diff sent, (2 bld and urine cult) . + u/a ->\n started on cipro iv.\n PR Tylenol given\n Response:\n Neuro unchanged, no signs of activity. Cont eeg.Defervesced to\n 100.4 Temp oral.\n Plan:\n Cont w keppra and dilantin as ordered.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated on 50 % cmv tv 450 rr 18 peep 5. Lungs rhonchorous and lt\n side diminished.Desats to hight 80\ns while bathing and\n turning/repositioning.\n Action:\n Preoxy lavage and suct x 3 w only small results of thick tan\n secretions. MDI puffs via vent. DR &\n RT here to eval\n Pcxr done\n Peep increased to 8cm and fio2 increased to 70% w improving sats.\n Fio2 weaned back down to 50% w adeq sats ~ 98%\n Response:\n ? pulm process rll per HO.\n O2 sats improved w increased peep\n Plan:\n ? place on wet circuit to help w secretions.\n Check for results of sput cult sent 3/14 days.\n Pulm hygiene.\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402914,
"text": "86 yr. old woman with severe AS (critical AS-> s/p valvuloplasty\n ), CAD s/p CABG (lima-lad, svg-om), dCHF, & AF. Multiple\n recent hospitalizations ( valvuloplasty, hemicolectomy for\n adenoCA, c diff colitis, diverticulitis. Admitted after seizure\n which stopped with ativan and keppra. Diuretics were held on admission.\n She was treated initially for meningitis. CTA was negative for CVA. MRI\n w/ pre-MRI sedation to head with high signal intensity in the R\n superior parietal lobe. After MRI on she triggered for AMS and\n lethargy. Her HR was in the 130s and her SBP was in the 80s. Her ABG\n was notable for pCO2 65. She was given lasix 10mg IV then 30mg and 5mg\n IV metoprolol without significant improvement.\n Impaired Skin Integrity\n Assessment:\n LE wounds clean, w/o significant changes\n Action:\n Bilat LE ulcers x 2 years per family\n cleansed and redressed \n wound RN consultation, sites look clean, sm sero-sanguinous drainage,\n OOB to chair x 2 hours with position shift after 1 hour, heels off bed,\n waffle boots on, turned q 2hrs while in bed\n Response:\n Family states ulcers have healed significantly\n Plan:\n Cont wound care/dressings per consult; waffle boots, keep heels\n elevated off bed\n Pneumonia, aspiration\n Assessment:\n O2 sats significantly improved on decreasing oxygen\n Increased congested cough\n expectorating small amounts thick tan\n Action:\n O2 down to 2l nasal cannula with sats 95-100%, sats into high 80\n while off O2\n Albuterol neb x1, Atrovent nebs Q6hrs\n Robitussin ordered and given for cough\n Antibx x 3 continue\n C+DB frequently, attempting CPT but not tolerating well\n Response:\n Lungs remain wheezy with crackles at bases bilaterally\n slight improvement in frequency of coughing after Robitussin given\n afeb to low grade temp, WBC 8\n Plan:\n Cont antibx, frequent lung exam, follow temps, WBC, follow sats and\n wean )2 as tolerated\n Seizure, without status epilepticus\n Assessment:\n No evidence of seizure activity\n Action:\n Continues on IV Keppra\n Response:\n No further seizures noted since ED\n Plan:\n Cont meds and follow for seizure activity, other changes in mental\n status\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402915,
"text": "86 yr. old woman with severe AS (critical AS-> s/p valvuloplasty\n ), CAD s/p CABG (lima-lad, svg-om), dCHF, & AF. Multiple\n recent hospitalizations ( valvuloplasty, hemicolectomy for\n adenoCA, c diff colitis, diverticulitis. Admitted after seizure\n which stopped with ativan and keppra. Diuretics were held on admission.\n She was treated initially for meningitis. CTA was negative for CVA. MRI\n w/ pre-MRI sedation to head with high signal intensity in the R\n superior parietal lobe. After MRI on she triggered for AMS and\n lethargy. Her HR was in the 130s and her SBP was in the 80s. Her ABG\n was notable for pCO2 65. She was given lasix 10mg IV then 30mg and 5mg\n IV metoprolol without significant improvement.\n Impaired Skin Integrity\n Assessment:\n LE wounds clean, w/o significant changes\n Action:\n Bilat LE ulcers x 2 years per family\n cleansed and redressed \n wound RN consultation, sites look clean, sm sero-sanguinous drainage,\n OOB to chair x 2 hours with position shift after 1 hour, heels off bed,\n waffle boots on, turned q 2hrs while in bed\n Response:\n Family states ulcers have healed significantly\n Plan:\n Cont wound care/dressings per consult; waffle boots, keep heels\n elevated off bed\n Pneumonia, aspiration\n Assessment:\n O2 sats significantly improved on decreasing oxygen\n Increased congested cough\n expectorating small amounts thick tan\n Action:\n O2 down to 2l nasal cannula with sats 95-100%, sats into high 80\n while off O2\n Albuterol neb x1, Atrovent nebs Q6hrs\n Robitussin ordered and given for cough\n Antibx x 3 continue\n C+DB frequently, attempting CPT but not tolerating well\n Response:\n Lungs remain wheezy with crackles at bases bilaterally\n slight improvement in frequency of coughing after Robitussin given\n afeb to low grade temp, WBC 8\n Plan:\n Cont antibx, frequent lung exam, follow temps, WBC, follow sats and\n wean )2 as tolerated\n Seizure, without status epilepticus\n Assessment:\n No evidence of seizure activity\n Action:\n Continues on IV Keppra\n Response:\n No further seizures noted since ED\n Plan:\n Cont meds and follow for seizure activity, other changes in mental\n status\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402917,
"text": "86 yr. old woman with severe AS (critical AS-> s/p valvuloplasty\n ), CAD s/p CABG (lima-lad, svg-om), dCHF, & AF. Multiple\n recent hospitalizations ( valvuloplasty, hemicolectomy for\n adenoCA, c diff colitis, diverticulitis. Admitted after seizure\n which stopped with ativan and keppra. Diuretics were held on admission.\n She was treated initially for meningitis. CTA was negative for CVA. MRI\n w/ pre-MRI sedation to head with high signal intensity in the R\n superior parietal lobe. After MRI on she triggered for AMS and\n lethargy. Her HR was in the 130s and her SBP was in the 80s. Her ABG\n was notable for pCO2 65. She was given lasix 10mg IV then 30mg and 5mg\n IV metoprolol without significant improvement.\n Impaired Skin Integrity\n Assessment:\n LE wounds clean, w/o significant changes\n Action:\n Bilat LE ulcers x 2 years per family\n cleansed and redressed \n wound RN consultation, sites look clean, sm sero-sanguinous drainage,\n OOB to chair x 2 hours with position shift after 1 hour, heels off bed,\n waffle boots on, turned q 2hrs while in bed\n Response:\n Family states ulcers have healed significantly\n Plan:\n Cont wound care/dressings per consult; waffle boots, keep heels\n elevated off bed\n Pneumonia, aspiration\n Assessment:\n O2 sats significantly improved on decreasing oxygen\n Increased congested cough\n expectorating small amounts thick tan\n Action:\n O2 down to 2l nasal cannula with sats 95-100%, sats into high 80\n while off O2\n Albuterol neb x1, Atrovent nebs Q6hrs\n Robitussin ordered and given for cough\n Antibx x 3 continue\n C+DB frequently, attempting CPT but not tolerating well\n Response:\n Lungs remain wheezy with crackles at bases bilaterally\n slight improvement in frequency of coughing after Robitussin given\n afeb to low grade temp, WBC 8\n Plan:\n Cont antibx, frequent lung exam, follow temps, WBC, follow sats and\n wean )2 as tolerated\n Seizure, without status epilepticus\n Assessment:\n No evidence of seizure activity\n Action:\n Continues on IV Keppra\n Response:\n No further seizures noted since ED\n Plan:\n Cont meds and follow for seizure activity, other changes in mental\n status\n Aortic stenosis\n Assessment:\n BP 90\ns to 117/40\ns-50\ns; Hr 100-115\n Action:\n after Lopressor 75 mg in AM, HR to 88-90\ns; BP marginal\n Lasix gtt at 5MG IN am WITH GOAL\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402921,
"text": "86 yr. old woman with severe AS (critical AS-> s/p valvuloplasty\n ), CAD s/p CABG (lima-lad, svg-om), dCHF, & AF. Multiple\n recent hospitalizations ( valvuloplasty, hemicolectomy for\n adenoCA, c diff colitis, diverticulitis. Admitted after seizure\n which stopped with ativan and keppra. Diuretics were held on admission.\n She was treated initially for meningitis. CTA was negative for CVA. MRI\n w/ pre-MRI sedation to head with high signal intensity in the R\n superior parietal lobe. After MRI on she triggered for AMS and\n lethargy. Her HR was in the 130s and her SBP was in the 80s. Her ABG\n was notable for pCO2 65. She was given lasix 10mg IV then 30mg and 5mg\n IV metoprolol without significant improvement.\n Impaired Skin Integrity\n Assessment:\n LE wounds clean, w/o significant changes\n Action:\n Bilat LE ulcers x 2 years per family\n cleansed and redressed \n wound RN consultation, sites look clean, sm sero-sanguinous drainage,\n OOB to chair x 2 hours with position shift after 1 hour, heels off bed,\n waffle boots on, turned q 2hrs while in bed\n Response:\n Family states ulcers have healed significantly\n Plan:\n Cont wound care/dressings per consult; waffle boots, keep heels\n elevated off bed\n Pneumonia, aspiration\n Assessment:\n O2 sats significantly improved on decreasing oxygen\n Increased congested cough\n expectorating small amounts thick tan\n Action:\n O2 down to 2l nasal cannula with sats 95-100%, sats into high 80\n while off O2\n Albuterol neb x1, Atrovent nebs Q6hrs\n Robitussin ordered and given for cough\n Antibx x 3 continue\n C+DB frequently, attempting CPT but not tolerating well\n Response:\n Lungs remain wheezy with crackles at bases bilaterally\n slight improvement in frequency of coughing after Robitussin given\n afeb to low grade temp, WBC 8\n Plan:\n Cont antibx, frequent lung exam, follow temps, WBC, follow sats and\n wean )2 as tolerated\n Seizure, without status epilepticus\n Assessment:\n No evidence of seizure activity\n Action:\n Continues on IV Keppra\n Response:\n No further seizures noted since ED\n Plan:\n Cont meds and follow for seizure activity, other changes in mental\n status\n Aortic stenosis\n Assessment:\n Pt with AS and fluid overload on Lasix gtt\n Action:\n BP 90\ns to 117/40\ns-50\ns; Hr 100-115, after Lopressor 75 mg in AM, HR\n to 88-90\ns; BP marginal\n Lasix gtt at 5MG IN am WITH GOAL 500cc negative\n increased to 7mg then\n 10mg/hr at 12 noon\n Response:\n Initially urine output decreased then at 1600 pt with increased urine\n light yellow ~100cc/hr\n Cr from 1.0 to 1.2\n Plan:\n Continue gently diuresis with Lasix gtt as long as BP tolerates to goal\n 500cc negative today\n Replace lytes as needed\n Follow BUN/CR\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402923,
"text": "86 yr. old woman with severe AS (critical AS-> s/p valvuloplasty\n ), CAD s/p CABG (lima-lad, svg-om), dCHF, & AF. Multiple\n recent hospitalizations ( valvuloplasty, hemicolectomy for\n adenoCA, c diff colitis, diverticulitis. Admitted after seizure\n which stopped with ativan and keppra. Diuretics were held on admission.\n She was treated initially for meningitis. CTA was negative for CVA. MRI\n w/ pre-MRI sedation to head with high signal intensity in the R\n superior parietal lobe. After MRI on she triggered for AMS and\n lethargy. Her HR was in the 130s and her SBP was in the 80s. Her ABG\n was notable for pCO2 65. She was given lasix 10mg IV then 30mg and 5mg\n IV metoprolol without significant improvement.\n Impaired Skin Integrity\n Assessment:\n LE wounds clean, w/o significant changes\n Action:\n Bilat LE ulcers x 2 years per family\n cleansed and redressed \n wound RN consultation, sites look clean, sm sero-sanguinous drainage,\n OOB to chair x 2 hours with position shift after 1 hour, heels off bed,\n waffle boots on, turned q 2hrs while in bed\n Response:\n Family states ulcers have healed significantly\n Plan:\n Cont wound care/dressings per consult; waffle boots, keep heels\n elevated off bed\n Pneumonia, aspiration\n Assessment:\n O2 sats significantly improved on decreasing oxygen\n Increased congested cough\n expectorating small amounts thick tan\n Action:\n O2 down to 2l nasal cannula with sats 95-100%, sats into high 80\n while off O2\n Albuterol neb x1, Atrovent nebs Q6hrs\n Robitussin ordered and given for cough\n Antibx x 3 continue\n C+DB frequently, attempting CPT but not tolerating well\n Response:\n Lungs remain wheezy with crackles at bases bilaterally\n slight improvement in frequency of coughing after Robitussin given\n afeb to low grade temp, WBC 8\n Plan:\n Cont antibx, frequent lung exam, follow temps, WBC, follow sats and\n wean )2 as tolerated\n Seizure, without status epilepticus\n Assessment:\n No evidence of seizure activity\n Action:\n Continues on IV Keppra\n Response:\n No further seizures noted since ED\n Plan:\n Cont meds and follow for seizure activity, other changes in mental\n status\n Aortic stenosis\n Assessment:\n Pt with AS and fluid overload on Lasix gtt\n Action:\n BP 90\ns to 117/40\ns-50\ns; Hr 100-115, after Lopressor 75 mg in AM, HR\n to 88-90\ns; BP marginal\n Lasix gtt at 5MG IN am WITH GOAL 500cc negative\n increased to 7mg then\n 10mg/hr at 12 noon\n Response:\n Initially urine output decreased then at 1600 pt with increased urine\n light yellow ~100cc/hr\n Cr from 1.0 to 1.2\n Plan:\n Continue gently diuresis with Lasix gtt as long as BP tolerates to goal\n 500cc negative today\n Replace lytes as needed\n Follow BUN/CR\n Knowledge Deficit\n Assessment:\n Patients family with questions regarding patients condition, MRI\n results\n Action:\n Family visiting, spoke with CCU resident Dr as well as this RN\n Response:\n Pt\ns family without further questions at this time\n Plan:\n Keep patient and family updated regarding condition and plan of care as\n discussed in multidisciplinary rounds\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402929,
"text": "86 yr. old woman with severe AS (critical AS-> s/p valvuloplasty\n ), CAD s/p CABG (lima-lad, svg-om), dCHF, & AF. Multiple\n recent hospitalizations ( valvuloplasty, hemicolectomy for\n adenoCA, c diff colitis, diverticulitis. Admitted after seizure\n which stopped with ativan and keppra. Diuretics were held on admission.\n She was treated initially for meningitis. CTA was negative for CVA. MRI\n w/ pre-MRI sedation to head with high signal intensity in the R\n superior parietal lobe. After MRI on she triggered for AMS and\n lethargy; HR 130s and her SBP was in the 80s. Her ABG was notable for\n pCO2 65. She was given lasix 10mg IV then 30mg and 5mg IV metoprolol\n without significant improvement.\n Impaired Skin Integrity\n Assessment:\n LE wounds clean, w/o significant changes\n Action:\n Bilat LE ulcers x 2 years per family\n cleansed and redressed \n wound RN consultation, sites look clean, sm sero-sanguinous drainage,\n OOB to chair x 2 hours with position shift after 1 hour, heels off bed,\n waffle boots on, turned q 2hrs while in bed\n Response:\n Family states ulcers have healed significantly\n Plan:\n Cont wound care/dressings per consult; waffle boots, keep heels\n elevated off bed\n Pneumonia, aspiration\n Assessment:\n O2 sats significantly improved on decreasing oxygen\n Increased congested cough\n expectorating small amounts thick tan\n Tolerating crushed meds in applesauce w/o evidence aspiration\n Action:\n O2 down to 2l nasal cannula with sats 95-100%, sats into high 80\n while off O2\n Albuterol neb x1, Atrovent nebs Q6hrs\n Robitussin ordered and given for cough\n Antibx x 3 continue\n C+DB frequently, attempting CPT but not tolerating well\n NPO changed to soft solid/thickened liq with aspiration precautions\n when awake and alert\n Response:\n Lungs remain wheezy with crackles at bases bilaterally\n slight improvement in frequency of coughing after Robitussin given\n afeb to low grade temp, WBC 8\n tolerated Ensure pudding\n Plan:\n Cont antibx, frequent lung exam, follow temps, WBC, follow sats and\n wean as tolerated\n Soft solids WITH ASPIRATION PRECAUTIONS\n speech and swallow study in\n am\n Seizure, without status epilepticus\n Assessment:\n No evidence of seizure activity\n Action:\n Continues on IV Keppra\n Response:\n No further seizures noted since ED\n Plan:\n Cont meds and follow for seizure activity, other changes in mental\n status\n Aortic stenosis\n Assessment:\n Pt with AS and fluid overload on Lasix gtt\n Action:\n BP 90\ns to 117/40\ns-50\ns; Hr 100-115, after Lopressor 75 mg in AM, HR\n to 88-90\ns; BP marginal\n Lasix gtt at 5MG IN am WITH GOAL 500cc negative\n increased to 7mg then\n 10mg/hr at 12 noon\n Response:\n Initially urine output decreased then at 1600 pt with increased urine\n light yellow ~100cc/hr\n Cr from 1.0 to 1.2\n Plan:\n Continue gently diuresis with Lasix gtt as long as BP tolerates to goal\n 500cc negative today\n Replace lytes as needed\n Follow BUN/CR\n Knowledge Deficit\n Assessment:\n Patients family with questions regarding patients condition, MRI\n results\n Action:\n Family visiting, spoke with CCU resident Dr as well as this RN\n Response:\n Pt\ns family without further questions at this time\n Plan:\n Keep patient and family updated regarding condition and plan of care as\n discussed in multidisciplinary rounds\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402903,
"text": "Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402932,
"text": "86 yr. old woman with severe AS (critical AS-> s/p valvuloplasty\n ), CAD s/p CABG (lima-lad, svg-om), dCHF, & AF. Multiple\n recent hospitalizations ( valvuloplasty, hemicolectomy for\n adenoCA, c diff colitis, diverticulitis. Admitted after seizure\n which stopped with ativan and keppra. Diuretics were held on admission.\n She was treated initially for meningitis. CTA was negative for CVA. MRI\n w/ pre-MRI sedation to head with high signal intensity in the R\n superior parietal lobe. After MRI on she triggered for AMS and\n lethargy; HR 130s and her SBP was in the 80s. Her ABG was notable for\n pCO2 65. She was given lasix 10mg IV then 30mg and 5mg IV metoprolol\n without significant improvement.\n Impaired Skin Integrity\n Assessment:\n LE wounds clean, w/o significant changes\n Action:\n Bilat LE ulcers x 2 years per family\n cleansed and redressed \n wound RN consultation, sites look clean, sm sero-sanguinous drainage,\n OOB to chair x 2 hours with position shift after 1 hour, heels off bed,\n waffle boots on, turned q 2hrs while in bed\n Response:\n Family states ulcers have healed significantly\n Plan:\n Cont wound care/dressings per consult; waffle boots, keep heels\n elevated off bed\n Pneumonia, aspiration\n Assessment:\n O2 sats significantly improved on decreasing oxygen\n Increased congested cough\n expectorating small amounts thick tan\n Tolerating crushed meds in applesauce w/o evidence aspiration\n Action:\n O2 down to 2l nasal cannula with sats 95-100%, sats into high 80\n while off O2\n Albuterol neb x1, Atrovent nebs Q6hrs\n Robitussin ordered and given for cough\n Antibx x 3 continue\n C+DB frequently, attempting CPT but not tolerating well\n NPO changed to soft solid/thickened liq with aspiration precautions\n when awake and alert\n Response:\n Lungs remain wheezy with crackles at bases bilaterally\n slight improvement in frequency of coughing after Robitussin given\n afeb to low grade temp, WBC 8\n tolerated Ensure pudding\n Plan:\n Cont antibx, frequent lung exam, follow temps, WBC, follow sats and\n wean as tolerated\n Soft solids WITH ASPIRATION PRECAUTIONS\n speech and swallow study in\n am\n Seizure, without status epilepticus\n Assessment:\n No evidence of seizure activity\n Action:\n Continues on IV Keppra\n Response:\n No further seizures noted since ED\n Plan:\n Cont meds and follow for seizure activity, other changes in mental\n status\n Aortic stenosis\n Assessment:\n Pt with AS and fluid overload on Lasix gtt\n Action:\n BP 90\ns to 117/40\ns-50\ns; Hr 100-115, after Lopressor 75 mg in AM, HR\n to 88-90\ns; BP marginal\n Lasix gtt at 5MG IN am WITH GOAL 500cc negative\n increased to 7mg then\n 10mg/hr at 12 noon\n Response:\n Initially urine output decreased then at 1600 pt with increased urine\n light yellow ~100cc/hr\n Cr from 1.0 to 1.2\n Plan:\n Continue gently diuresis with Lasix gtt as long as BP tolerates to goal\n 500cc negative today\n Replace lytes as needed\n Follow BUN/CR\n Knowledge Deficit\n Assessment:\n Patients family with questions regarding patients condition, MRI\n results\n Action:\n Family visiting, spoke with CCU resident Dr as well as this RN\n Response:\n Pt\ns family without further questions at this time\n Plan:\n Keep patient and family updated regarding condition and plan of care as\n discussed in multidisciplinary rounds\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402939,
"text": "86 yr. old woman with severe AS (critical AS-> s/p valvuloplasty\n ), CAD s/p CABG (lima-lad, svg-om), dCHF, & AF. Multiple\n recent hospitalizations ( valvuloplasty, hemicolectomy for\n adenoCA, c diff colitis, diverticulitis. Admitted after seizure\n which stopped with ativan and keppra. Diuretics were held on admission.\n She was treated initially for meningitis. CTA was negative for CVA. MRI\n w/ pre-MRI sedation to head with high signal intensity in the R\n superior parietal lobe. After MRI on she triggered for AMS and\n lethargy; HR 130s and her SBP was in the 80s. Her ABG was notable for\n pCO2 65. She was given lasix 10mg IV then 30mg and 5mg IV metoprolol\n without significant improvement.\n Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n a/o x2. follows all commands. Lifts and hold ^ ext. moves lower ext on\n bed. Pupils 3mm/brisk bilat. No seizure act noted. Open\ns eyes to\n voice command. Some periods where she is alert. Smiles appropriately,\n but does not initiate conversation. Will answer questions\n appropriately.\n Action:\n Con\nt on Keppra iv\n Neuro checks q2-4hrs\n Response:\n No Seizure act noted\n Currently stable\n Plan:\n Con\nt Keppra\n Follow neuro status for chgs\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Perianal area red w small raised rash area noted in L groin. Lower ext\n dsg sites c&d. + DP/Pt via Doppler noted. Ft and lower ext warm to\n touch. L heel has pea size open area noted, appears to be drying w no\n drainage noted. Toes on both feet w dry flaking skin. Coccyx intact,\n pink area noted, but blanches w pressure\n Action:\n Dsg chg to lower ext\ns qd- wound care following ,using\n Collagenase qd w dsd\n Mycostatin powder to perianal areas\n Waffle boots and heels ^ off bed\n Turned q2/hr\n Aloe vista to back and bony areas\n Response:\n Perianal area less red\n No further skin breakdown noted\n Plan:\n Con\nt qd dsg chg to lower ext\n Consult wound care for further chg\n Reposition for max comfort and to prevent further brkdown\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402946,
"text": "86 yr. old woman with severe AS (critical AS-> s/p valvuloplasty\n ), CAD s/p CABG (lima-lad, svg-om), dCHF, & AF. Multiple\n recent hospitalizations ( valvuloplasty, hemicolectomy for\n adenoCA, c diff colitis, diverticulitis. Admitted after seizure\n which stopped with ativan and keppra. Diuretics were held on admission.\n She was treated initially for meningitis. CTA was negative for CVA. MRI\n w/ pre-MRI sedation to head with high signal intensity in the R\n superior parietal lobe. After MRI on she triggered for AMS and\n lethargy; HR 130s and her SBP was in the 80s. Her ABG was notable for\n pCO2 65. She was given lasix 10mg IV then 30mg and 5mg IV metoprolol\n without significant improvement.\n Pneumonia, aspiration\n Assessment:\n RR-20-24. Cough becoming stronger, although con\nt to have difficulty\n expectorating. Usually swallows secretions. Congested cough. O2 sats\n improving however. @ 1-2L np sats 96-99%. Has periods of con\n coughing triggered by repositioning. BS bilbasilar exp wheezes and\n crackles @ the bases. Pt will deny sob, but becomes tachypnic w\n repositioning. Temp max 101 R.\n Action:\n Takes meds crushed in applesauce\n Thickened liquids only\n Hob maintained 45-90/degrees\n Gentle CPT, C&DB and IS\n Maintain o2 @ 2L w sleep and 1 L w/a\n Atrovent q6/hr\n Robitussin po for cough\n Received vanco, flagyl and iv\n MD aware of ^ temp\n Tylenol given PR\n Bld cult completed, ua c&s completed\n Response:\n Robitussin w good effect\n Atrovent instrumental in quieting cough\n UTI evident MD\n Temp down to 99.8 R pt appears more comfortable\n Plan:\n Con\nt asp precautions\n Speech and swallow study likely today\n Repeat cxr today\n Bld cult pending\n Con\nt aggressive pulm hygiene\n Seizure, without status epilepticus\n Assessment:\n a/o x2. follows all commands. Lifts and hold ^ ext. moves lower ext on\n bed. Pupils 3mm/brisk bilat. No seizure act noted. Open\ns eyes to\n voice command. Some periods where she is alert. Smiles appropriately,\n but does not initiate conversation. Will answer questions\n appropriately.\n Action:\n Con\nt on Keppra iv\n Neuro checks q2-4hrs\n Response:\n No Seizure act noted\n Currently stable\n Plan:\n Con\nt Keppra\n Follow neuro status for chgs\n Aortic stenosis\n Assessment:\n Remains in a-fib w hr 75-90. sbp 100-120 w map\ns > 60. bilat leg edema\n noted thigh to knee. 2-3mm, also has ^ ext edema noted. Denies cp/sob.\n Received pt on lasix 10mg. u/o marginal. Goal is to be 500cc neg. u/o\n dropping off to 20cc/hr-25cc/hr. k+ 3.8.\n Action:\n Con\nt on po Metoprolol 75mg crushed in applesauce.\n Lasix gtt ^ 15mg per protocol\n Received kcl 20meq iv\n Response:\n No significant chg in u/o w ^ lasix\n Lasix ^ 20mg/hr, u/o improving slightly, md notified of ^\n Plan:\n Con\nt on daily dose digoxin\n Con\nt BB as bp tolerates\n Check daily lytes\n Con\nt on lasix w goal 500cc neg\n Impaired Skin Integrity\n Assessment:\n Perianal area red w small raised rash area noted in L groin. Lower ext\n dsg sites c&d. + DP/Pt via Doppler noted. Ft and lower ext warm to\n touch. L heel has pea size open area noted, appears to be drying w no\n drainage noted. Toes on both feet w dry flaking skin. Coccyx intact,\n pink area noted, but blanches w pressure\n Action:\n Dsg chg to lower ext\ns qd- wound care following ,using\n Collagenase qd w dsd\n Mycostatin powder to perianal areas\n Waffle boots and heels ^ off bed\n Turned q2/hr\n Aloe vista to back and bony areas\n Response:\n Perianal area less red\n No further skin breakdown noted\n Plan:\n Con\nt qd dsg chg to lower ext\n Consult wound care for further chg\n Reposition for max comfort and to prevent further brkdown\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-07 00:00:00.000",
"description": "Intensivist Note",
"row_id": 403943,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. At time of SICU admission, she\n responded only to painful stimuli.\n Chief complaint:\n Seizures\n .\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n 1. 2. 3. 4. 5. 500 mL LR 6. Acetaminophen 7. Albuterol 0.083% Neb Soln\n 8. Aspirin 9. Atorvastatin 10. Bacitracin-Polymyxin Ointment 11.\n Calcium Gluconate 12. CefePIME 13. Collagenase Ointment 14.\n Cosyntropin 15. Dextrose 50% 16. Digoxin 17. FoLIC Acid 18. Furosemide\n 19. Gabapentin 20. Glucagon 21. Heparin 22. Insulin 23. Ipratropium\n Bromide Neb 24. Latanoprost 0.005% Ophth. Soln. 25. Levothyroxine\n Sodium 26. LeVETiracetam 27. Lidocaine 5% Patch 28. Lorazepam 29.\n Magnesium Sulfate 30. Metoprolol Tartrate\n 31. Miconazole Powder 2% 32. Nystatin Oral Suspension 33. Phenytoin\n Sodium (IV) 34. Phenylephrine 35. Phenytoin Sodium (IV) 36. Phenytoin\n Sodium (IV) 37. Potassium Chloride 38. Sodium Chloride 0.9% Flush\n 39. Sodium Chloride 0.9% Flush 40. Sodium Chloride 0.9% Flush 41.\n Timolol Maleate 0.5% 42. Vancomycin\n 43. Warfarin\n 24 Hour Events:\n : MRI brain on hold for now by Neurology, Bolus of dilantin 200\n given\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Cefipime - 10:00 PM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:07 PM\n Dilantin - 11:58 PM\n Other medications:\n Flowsheet Data as of 05:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 36.8\nC (98.2\n HR: 94 (83 - 103) bpm\n BP: 106/45(70) {97/45(64) - 133/59(87)} mmHg\n RR: 29 (20 - 31) insp/min\n SPO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 87.5 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 3,985 mL\n 154 mL\n PO:\n Tube feeding:\n 3,290 mL\n 154 mL\n IV Fluid:\n 474 mL\n Blood products:\n Total out:\n 832 mL\n 87 mL\n Urine:\n 832 mL\n 87 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,153 mL\n 67 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 100%\n ABG: 7.40/49/65/30/3\n PaO2 / FiO2: 65\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : bilateral)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Responds to: Tactile stimuli), Moves all extremities, non\n purposful\n Labs / Radiology\n 372 K/uL\n 8.5 g/dL\n 119 mg/dL\n 1.5 mg/dL\n 30 mEq/L\n 4.3 mEq/L\n 40 mg/dL\n 110 mEq/L\n 146 mEq/L\n 30.4 %\n 10.5 K/uL\n [image002.jpg]\n 06:37 PM\n 03:07 AM\n 04:56 PM\n 03:35 AM\n 03:52 AM\n 11:58 AM\n 08:32 PM\n 02:19 AM\n 10:32 AM\n 03:49 AM\n WBC\n 8.9\n 9.9\n 11.1\n 10.5\n Hct\n 30.6\n 30.5\n 30.6\n 30.4\n Plt\n 72\n Creatinine\n 1.3\n 1.3\n 1.3\n 1.2\n 1.2\n 1.5\n Troponin T\n 0.03\n TCO2\n 35\n 32\n 30\n 31\n Glucose\n 146\n 121\n 122\n 136\n 119\n Other labs: PT / PTT / INR:15.7/32.3/1.4, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:62/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca:7.8 mg/dL, Mg:2.2 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n KNOWLEDGE DEFICIT, IMPAIRED SKIN INTEGRITY, PNEUMONIA, ASPIRATION,\n AORTIC STENOSIS, SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD\n Neurologic:\n -- Patient with seizures, loaded with dilantin and ativan prior to\n admission with poor mental status. Dilantin amd Keppra for seziure\n prophylaxis, f/u AM level.\n --Follow up 24hr video EEG. Initial EEG - no seizures\n -- Continue neurontin for chronic pain well controlled on current\n medication.\n -- MRI brain w/ and w/o ordered for when pt is stable to transport\n Cardiovascular:\n -- PAF with good control of HR on beta blockade and digoxin.\n -- Multiple medical cardiovascular problems. CAD s/p CABG but\n still diastolic dysfunction. She had AS (valve area 0.8cm2 on previous\n echo) but underwent valvuloplasty\n no gradient estimation after\n procedure.\n -- Anticoagulation for A. Fib: On ASA and atorvastatin. Coumadin 2\n start pm\n --\n -- Cortisol stim test negative\n -- Begin midodrine\n Pulmonary:\n --Treated empirically for aspiration pneumonia with /Cefepime but\n cultures are negative. We will continue treatment for full 7 days (to\n )\n -- lasix 40 daily. Hold .\n --Chest PT and inhalers\n --Likely aspirating secretions, may need trach. To be discussed with\n family.\n Gastrointestinal / Abdomen:\n --Resume TFs, consider PEG tube placement.\n --CDiff x 2 has been negative and diarrhea has stopped, PO vanc has\n been stopped.\n Nutrition: --TF restarted via Dobhoff\n Renal:\n --Lasix dependent, continue Lasix 40 (decreased from 60 given Cr 1.5)\n PO/NG daily; was previously on lasix gtt, will continue to monitor\n --Increasing Cr, 0.8 on admission, currently 1.5. Fe urea = 27.65\n Hematology:\n --Hct stable\n --ASA, SQH\n --Coumadin 2mg x1 PO INR 1.4\n Endocrine:\n --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg for hypothyroidism, previous TSH was 6.8\n Infectious Disease:\n --Wbc 8.8->9.9->11.1-->10.5 afebrile\n --Being treated for PNA with cefepime/vanc (?aspiration) total course\n should be 7 days (ending )\n --Vanc trough 20.6 , dose decreased to 500mg IV q24hrs from 750\n --Follow cultures (NGTD except yeast in urine)\n --CDF X2 negative\n Lines / Tubes / Drains: PIV, Foley, PICC\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: Seizure\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:00 AM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 06:03 PM\n Arterial Line - 04:39 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403869,
"text": "Seizure, without status epilepticus\n Assessment:\n Patient continues to be minimally responsive today; she will open her\n eyes intermittently when her name is called. She does not move to\n command but she will move her right upper extremity randomly. Her\n pupils remain 2 to 3 MM and are round and reactive. She does not\n appear to be seizing when observed subjectively, however, neurology\n feels she is seizing subclinically.\n Action:\n Bolus with additional 200 mg phenytoin this morning. She was\n re-started on warfarin PO this evening. She required insulin this\n afternoon. MRI was cancelled for today given that it will not change\n medical management at all. She continues to have a very poor cough and\n impaired gag, for which she has been turned and repositioned\n frequently. Sent stool sample for c-dif.\n Response:\n She has tolerated all of the above interventions well.\n Plan:\n Plan to continue to provide supportive care. Continue to give\n anti-seizure meds as ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2196-01-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402789,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.8\nF - 10:00 PM\n Overnight events:\n Initially continued to be tachycardic in low 100s. Started on schedule\n of lopressor 15mg IV q4 with HR mostly in 90s in afib.\n AM CXR read as RLL collapse, stable Left pleural effusion, no PNA or\n CHF. Planned for CT chest ? etiology with DD lung collapse including\n aspiration, mucous plugging, pna, malignancy. Started to desat around\n 5pm to mid 80s on 4% NC, improved on 40% shovel mask. ABG obtained at\n that time showed 7.42/51/51/34 from 7.35/63/72/36, more consistent with\n venous gas. Started on abx coverage for hospital acquired PNA with\n aspiration coverage with vanc/cefepime/flagyll. Continued to have low\n grade temp 99.8 then spiked temp around 9pm to 102, defervesced with\n tylenol and congested cough but unable to clear secretions for sputum\n cx. Continued to congestion on lung exam, although did not appear very\n uncomfortable, not using accessory muscles. 02 sat's improved on shovel\n mask/suctioning, although intermittently desaturated, with multiple neb\n treatments, uptitration to 100% shovel mask by respiratory therapy with\n sat's in mid to low 90s. Repeat ABG was deferred given no contribution\n to management, management guided by clinical status. Initially held\n lasix drip but UOP started to drop off and BP's were in the one teens,\n although 02 sats at this point stable in the low 90s. Restarted lasix\n drip to run negative.\n 8 beat run of NSVT at 3:30am.\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:11 AM\n Acyclovir - 04:42 PM\n Vancomycin - 06:40 PM\n Cefipime - 08:00 PM\n Metronidazole - 05:57 AM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Famotidine (Pepcid) - 08:28 PM\n Metoprolol - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 36.5\nC (97.7\n HR: 87 (85 - 128) bpm\n BP: 103/51(65) {96/42(58) - 129/66(80)} mmHg\n RR: 21 (18 - 29) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 86 kg (admission): 80.1 kg\n Total In:\n 628 mL\n 300 mL\n PO:\n TF:\n IVF:\n 628 mL\n 300 mL\n Blood products:\n Total out:\n 1,190 mL\n 270 mL\n Urine:\n 1,190 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n -562 mL\n 30 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 95%\n ABG: 7.42/51/51/31/6\n PaO2 / FiO2: 73\n Physical Examination\n Neuro: AO to Person, time, disoriented to place\n CVS:irregularly irregular, SEM\n Lung: improved, less ronchorous, less wheeze, JVP ~ 7cm\n Abd: +bs, soft, nt, nd\n Ext : WWP, 1+ edema below knee, mid shin bandages in place.\n warm extremities, weak peripheral pulses\n Labs / Radiology\n 430 K/uL\n 8.8 g/dL\n 87 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 100 mEq/L\n 141 mEq/L\n 30.6 %\n 9.9 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n WBC\n 11.7\n 9.9\n Hct\n 34.7\n 30.6\n Plt\n 500\n 430\n Cr\n 0.8\n 1.0\n TropT\n 0.02\n TCO2\n 34\n Glucose\n 107\n 87\n Other labs: PT / PTT / INR:28.2/41.5/2.8, CK / CKMB /\n Troponin-T:15//0.02, ALT / AST:, Alk Phos / T Bili:62/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.0\n mg/dL, PO4:3.1 mg/dL\n ASSESSMENT AND PLAN\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures on who had MS\n change first noted following MRI. Pt was lying flat for some time\n during MRI following which she was noted to have MS change, and was\n subsequently febrile to 101 which altogether suggests an aspiration\n event. She subsequently had a CXR which showed RLL lung collapse which\n may have been secondary to mucous plugging following aspiration, vs \n hospital acquired pneumonia, less likely malignancy and on CXR does not\n look like pneumothorax. Her Afib going into RVR appears to have been\n precipirated by missing some metoprolol doses while she was NPO with ?\n aspiration, and this could have caused her to flash and at the same\n time her lasix was being held in order to allow for cerebral perfusion,\n but CXR was not consistent with acute pulm edema and her peripheral\n edema was more consistent with chronic CHF.\n .\n Afib: Pt in Afib with RVR on arrival. Had been NPO for some time on the\n floor, had been on p.o metoprolol on am then changed to IV at 5-10\n Q4 on 3/3pm but didn't get any on although written, ? low SBPs.\n On arrival to floor received IV metoprolol 2.5 with improvement rate to\n 80's from 128.\n Continue metoprolol IV 15mg Q4. Down titrate if HR allows, switch to\n p.o if pt becomes more alert, able to take p.o\n -am EKG.\n .\n Respiratory distress: ? asp/HAP\n # Flash Pulmonary Edema: CAD s/p CABG 86F with CAD s/p CABG \n (SVG-OM, LIMA-LAD)\n -Given AS pt very sensitive to fluid shifts, had been lying down for a\n long time at MRI and lasix was being held on floor to prevent cerebral\n hypoperfusion with subsequent flash.\n On arrival to ICU received IV lasix bolus 60mg IV and started on lasix\n drip.\n Continue lasix drip, titrating based on clinical appearance/respiratory\n status.\n -On digoxin chronically, typically not preferred in setting of normal\n EF, will continue for now. Dig level 0.9 (range 0.9-2)\n -repeat CXR in am.\n -trend fever curve\n .\n #AS: AS s/p valvuloplasty .Severe AS on Echo with valve\n area not quantified but LVOT of 12 noted which was not noted on Echo of\n but valve area of 0.8. EF stable at 60%. AS known critical, unclear\n if worsened AS since as valve area not quantified but known to be\n critical. Pt poor surgical candidate thus had not received AVR.\n -Consideration being given for minimally invasive percutaneous valve\n replacement.\n -f/u with ICU fellow/Dr \n diuresis given evolving clinical picture more consistent with\n pneumonia/pneumonitis.\n .\n # MS Change: Likely multifactorial related to benzodiazepine pre MRI\n although only received 0.5mg, C02 retention fatigue with mildly\n elevated C02 of 63 on ABG, and low CO with CHF. MS improved this am\n Did have on CTA and has new, subtle LUE/LLE weakness and no\n reflexes on LLE which is new per neuro consistent with lesion on right.\n This lesion is most likely vascular in nature, either a small infarct\n which converted to a bleed, versus less likely malignant ? metastatic\n colon cancer. Once medically stable neuro recommends MRI with\n gadolinium to asses lesion. If does not enhance, likely bleed.\n -appreciate neuro recs\n -ASA 81mg\n -serial neuro exams.\n -keppra for seizure prophylaxis.\n -avoid benzos\n -follow resp status, serial ABGs.\n -continue gentle diureis\n .\n # Hx Diarrhea:\n hx C.diff on chronic suppression therapy with p.o vanc/flagyll with\n last cx at rehab on negative but abx were continued to\n continued diarrhea. However diarrhea has stopped so c.diff directed abx\n stopped this hospitalization.\n -judicious use abx given hx c.diff\n -cx if diarrhea.\n .\n #hx GI bleed: s/p hemicolectomy following which she presented to \n rehab.\n Baseline Hct ~ 30, 35 on now 32.2\n Continue to trend daily.\n Guiac all stools\n active type and screen.\n .\n FEN: NPO for now. Speech and swallow initially consulted but became\n unresponsive. Reconsult when pt alert. RISS, GFS.\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx: holding given INR 5.0. Trend INR.\n .\n -Pain management with tylenol/gabapentin\n -Bowel regimen: hold\n .\n Lines:\n PICC Line - 11:01 AM\n 20 Gauge - 11:02 AM\n Stress ulcer: none\n VAP:\n DISPO: CCU for now\n COMM: , : \n Code: Full\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx: holding given INR 5.0. Trend INR.\n .\n -Pain management with tylenol/gabapentin\n -Bowel regimen: hold\n .\n Lines:\n PICC Line - 11:01 AM\n 20 Gauge - 11:02 AM\n Stress ulcer: none\n VAP:\n DISPO: CCU for now\n COMM: , : \n Code: Full\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402905,
"text": "86 yr. old woman with severe AS (critical AS-> s/p valvuloplasty\n ), CAD s/p CABG (lima-lad, svg-om), dCHF, & AF. Multiple\n recent hospitalizations ( valvuloplasty, hemicolectomy for\n adenoCA, c diff colitis, diverticulitis. Admitted after seizure\n which stopped with ativan and keppra. Diuretics were held on admission.\n She was treated initially for meningitis. CTA was negative for CVA. MRI\n w/ pre-MRI sedation to head with high signal intensity in the R\n superior parietal lobe. After MRI on she triggered for AMS and\n lethargy. Her HR was in the 130s and her SBP was in the 80s. Her ABG\n was notable for pCO2 65. She was given lasix 10mg IV then 30mg and 5mg\n IV metoprolol without significant improvement.\n Impaired Skin Integrity\n Assessment:\n LE wounds clean, w/o significant changes\n Action:\n Bilat LE ulcers x 2 years per family\n cleansed and redressed \n wound RN consultation, sites look clean, sm sero-sanguinous drainage\n Response:\n Family states ulcers have healed significantly\n Plan:\n Cont wound care/dressings per consult; waffle boots, keep heels\n elevated off bed\n Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404031,
"text": "Demographics\n Day of intubation: 2\n Day of mechanical ventilation: 2\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Re-intubation\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt frequently has wheezing, now on atrovent MDI Q 6, Alb Q4 prn\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-08 00:00:00.000",
"description": "Intensivist Note",
"row_id": 404032,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. At time of SICU admission, she\n responded only to painful stimuli.\n Chief complaint:\n Seizures\n PMHx:\n CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Albumin 5% (12.5g /\n 250mL) 8. Albuterol Inhaler\n 9. Albumin 5% (12.5g / 250mL) 10. Aspirin 11. Atorvastatin 12.\n Bacitracin-Polymyxin Ointment 13. Calcium Gluconate\n 14. CefePIME 15. Chlorhexidine Gluconate 0.12% Oral Rinse 16.\n Ciprofloxacin 17. Ciprofloxacin 18. Collagenase Ointment\n 19. Dextrose 50% 20. Digoxin 21. Etomidate 22. Famotidine 23. Fentanyl\n Citrate 24. Fentanyl Citrate\n 25. FoLIC Acid 26. Furosemide 27. Furosemide 28. Gabapentin 29.\n Glucagon 30. Heparin 31. Insulin\n 32. Ipratropium Bromide MDI 33. Ipratropium Bromide Neb 34. Latanoprost\n 0.005% Ophth. Soln. 35. Levothyroxine Sodium\n 36. LeVETiracetam 37. Lidocaine 5% Patch 38. Lorazepam 39. Magnesium\n Sulfate 40. Metoprolol Tartrate\n 41. Miconazole Powder 2% 42. Midodrine 43. Nystatin Oral Suspension 44.\n Phenytoin Sodium (IV) 45. Phenylephrine\n 46. Potassium Chloride 47. Sodium Chloride 0.9% Flush 48. Sodium\n Chloride 0.9% Flush 49. Sodium Chloride 0.9% Flush\n 50. Succinylcholine 51. Timolol Maleate 0.5% 52. Vancomycin 53.\n Warfarin\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 11:30 AM\n INTUBATION - At 02:30 PM\n NON-INVASIVE VENTILATION - STOP 02:30 PM\n INVASIVE VENTILATION - START 02:35 PM\n BLOOD CULTURED - At 09:00 PM\n URINE CULTURE - At 09:00 PM\n FEVER - 101.5\nF - 08:00 PM\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 10:15 PM\n Ciprofloxacin - 11:35 PM\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Other ICU medications:\n Dilantin - 04:23 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Flowsheet Data as of 04:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.5\n T current: 38\nC (100.4\n HR: 82 (78 - 106) bpm\n BP: 115/47(71) {78/36(51) - 144/65(95)} mmHg\n RR: 21 (13 - 33) insp/min\n SPO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 87.5 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 2,078 mL\n 545 mL\n PO:\n Tube feeding:\n 917 mL\n 160 mL\n IV Fluid:\n 621 mL\n 75 mL\n Blood products:\n 250 mL\n 250 mL\n Total out:\n 286 mL\n 50 mL\n Urine:\n 286 mL\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,792 mL\n 495 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 200 (200 - 295) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 175\n PIP: 24 cmH2O\n Plateau: 21 cmH2O\n Compliance: 28.1 cmH2O/mL\n SPO2: 97%\n ABG: 7.38/49/99.//2\n Ve: 9.3 L/min\n PaO2 / FiO2: 198\n Physical Examination\n General Appearance: Intubated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Breath Sounds: Crackles : bibasilar, Rhonchorous\n : , Diminished: bibasilar)\n Abdominal: Soft, Non-distended, Non-tender, Obese\n Left Extremities: (Edema: 1+, No(t) 2+), (Temperature: Warm), (Pulse -\n Dorsalis pedis: No(t) Present, Diminished)\n Right Extremities: (Edema: No(t) Trace, 1+), (Temperature: Warm),\n (Pulse - Dorsalis pedis: Diminished)\n Neurologic: Moves all extremities, MAE to painful stimuli, sometimes\n purposefully\n Labs / Radiology\n 430 K/uL\n 7.8 g/dL\n 119 mg/dL\n 1.5 mg/dL\n 30 mEq/L\n 4.3 mEq/L\n 40 mg/dL\n 110 mEq/L\n 146 mEq/L\n 26.9 %\n 11.3 K/uL\n [image002.jpg]\n 11:58 AM\n 08:32 PM\n 02:19 AM\n 10:32 AM\n 03:49 AM\n 10:50 AM\n 01:08 PM\n 04:35 PM\n 06:36 PM\n 03:33 AM\n WBC\n 11.1\n 10.5\n 11.3\n Hct\n 30.6\n 30.4\n 26.9\n Plt\n \n Creatinine\n 1.2\n 1.2\n 1.5\n TCO2\n 30\n 31\n 31\n 30\n 29\n 30\n Glucose\n 136\n 119\n Other labs: PT / PTT / INR:18.0/42.2/1.6, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:62/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca:7.8 mg/dL, Mg:2.2 mg/dL, PO4:3.4 mg/dL\n Imaging: CT head: No acute ICH. Small ovoid hypodensity in R\n parietal lobe corresponds to area demonstrating old blood products seen\n on MRI of . New opacification of L anterior ethmoid air cells and\n increased opacification of L mastoid air cells.\n CXR: Cardiomegaly, prominent pulmonary vasculature, and bibasilar\n atelectasis is unchanged.\n MR: Focal area w/high signal intensity @ R sup parietal lobule, no\n mass effect and may represent a chronic hemorrhagic area. Subcortical\n areas w/high signal intensity on T2 and FLAIR c/w chronic microvascular\n ischemic changes. Tortuosity of basilar artery, cw dolichoectasia\n Echo: EF >= 60%, Symmetric LVH, Significant AS, Trivial MR (may be\n significantly UNDERestimated), Mild [1+] TR. Mild PA systolic HTN\n CTA: No acute infarctor hemorrhage. Severe atherosclerotic\n narrowing of distal R vertebral art and moderate-to-severe narrowing of\n both cavernous ICAs. Small focus of calcification in Basilar A. close\n to the tip. Moderate microangiopathic ischemic white matter dz\n Microbiology: UCx: Yeast, >100,000\n BCx x2 neg\n BCx x2 p\n UCx: Yeast 10-100,000\n & Cdiff: Neg\n Sp Cx: 1+ Yeast\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), KNOWLEDGE DEFICIT, IMPAIRED\n SKIN INTEGRITY, PNEUMONIA, ASPIRATION, AORTIC STENOSIS, SEIZURE,\n WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD, now w/respiratory acidosis and\n failure resulting in intubation ().\n Neurologic: -- Patient sedtaed with fentanyl. Unsatisfactory mental\n status.\n -- Patient with seizures, loaded with dilantin and ativan prior to\n admission with poor mental status. Despite loading dose continued to\n have seziures according to EEG (). Medication regiment\n changed. Currently on phenytoin and lorazepam.MRI brain w/ and w/o\n ordered for when pt is stable to transport to evaluate to source of\n bleed in parietal lobe.\n --Continue neurontin for chronic pain well controlled on current\n medication.\n Cardiovascular: -- PAF with good control of HR on beta blockade and\n digoxin. Anticoagulation started with coumadin. INR subtherapeutic. No\n heparin bridge for risk of rebleed. On ASA\n -- CAD s/p CABG , diastolic dysfunction. On b-blockade,\n furosemide, ASA, and statin.\n -- Critical AS (valve area on pre-valvuloplasty 0.8cm2, post\n vavluloplasty). On ICU-based ECHO estimated area is 0.6cm2. Not\n eligible for open valve replacement. Family is discussing this issue\n with another cardiologist.\n -- Neosynephrine weaning off, started midodrine (renal clearance)\n -- Cortisol stim test negative\n Pulmonary: --Treated empirically for aspiration pneumonia with\n Vanc/Cefepime, and massive amount of copious sputum. Cultures are\n negative. We will continue treatment for full 7 days despite negative\n cultures (to )\n --After long d/w family, pt intubated w/worsening resp acidosis despite\n CPAP. Family discussion included trach, which they most likely will\n agree to.\n --albuterol/atrovent PRN\n --Chest PT\n Gastrointestinal / Abdomen: --Resume TFs, consider PEG tube placement.\n --CDiff x 2 have been negative and diarrhea has stopped, PO vanc has\n been stopped.\n Nutrition: --TF restarted via Dobhoff\n Renal: -- On home dose of Lasix\n -- Diminished urine output, received albumin x2 overnight\n -- Cipro for UTI, started , cultures pending\n Hematology: --Hct stable, 26.9\n --ASA, SQH\n Endocrine: --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg for hypothyroidism, previous TSH was 6.8\n Infectious Disease: --Wbc 8.8->9.9->11.1->10.5->11.3. febrile \n --Being treated for PNA with cefepime/vanc (?aspiration) total course\n should be 7 days (ending ). Vanc trough 20.6 , dose decreased\n to 500mg IV q24hrs from 750; vanc trough , held , decreased to\n 500\n --Follow cultures (NGTD except yeast in urine, sputum), resent \n (temp 101.5). +U/A, cipro started on \n Lines / Tubes / Drains: PIV, Foley, PICC\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: Other: status epilepticus, respiratory failure, UTI\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 06:03 PM\n Arterial Line - 04:39 PM\n Prophylaxis:\n DVT: SQ UF Heparin (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2196-01-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402798,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.8\nF - 10:00 PM\n Overnight events:\n Initially continued to be tachycardic in low 100s. Started on schedule\n of lopressor 15mg IV q4 with HR mostly in 90s in afib.\n AM CXR read as RLL collapse, stable Left pleural effusion, no PNA or\n CHF. Planned for CT chest ? etiology with DD lung collapse including\n aspiration, mucous plugging, pna, malignancy. Started to desat around\n 5pm to mid 80s on 4% NC, improved on 40% shovel mask. ABG obtained at\n that time showed 7.42/51/51/34 from 7.35/63/72/36, more consistent with\n venous gas. Started on abx coverage for hospital acquired PNA with\n aspiration coverage with vanc/cefepime/flagyll. Continued to have low\n grade temp 99.8 then spiked temp around 9pm to 102, defervesced with\n tylenol and congested cough but unable to clear secretions for sputum\n cx. Continued to congestion on lung exam, although did not appear very\n uncomfortable, not using accessory muscles. 02 sat's improved on shovel\n mask/suctioning, although intermittently desaturated, with multiple neb\n treatments, uptitration to 100% shovel mask by respiratory therapy with\n sat's in mid to low 90s. Repeat ABG was deferred given no contribution\n to management, management guided by clinical status. Initially held\n lasix drip but UOP started to drop off and BP's were in the one teens,\n although 02 sats at this point stable in the low 90s. Restarted lasix\n drip to run negative.\n 8 beat run of NSVT at 3:30am.\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:11 AM\n Acyclovir - 04:42 PM\n Vancomycin - 06:40 PM\n Cefipime - 08:00 PM\n Metronidazole - 05:57 AM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Famotidine (Pepcid) - 08:28 PM\n Metoprolol - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 36.5\nC (97.7\n HR: 87 (85 - 128) bpm\n BP: 103/51(65) {96/42(58) - 129/66(80)} mmHg\n RR: 21 (18 - 29) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 86 kg (admission): 80.1 kg\n Total In:\n 628 mL\n 300 mL\n PO:\n TF:\n IVF:\n 628 mL\n 300 mL\n Blood products:\n Total out:\n 1,190 mL\n 270 mL\n Urine:\n 1,190 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n -562 mL\n 30 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 95%\n ABG: 7.42/51/51/31/6\n PaO2 / FiO2: 73\n Physical Examination\n Neuro: AO to Person, time, disoriented to place\n CVS:irregularly irregular, SEM\n Lung: improved, less ronchorous, less wheeze, JVP ~ 7cm\n Abd: +bs, soft, nt, nd\n Ext : WWP, 1+ edema below knee, mid shin bandages in place.\n warm extremities, weak peripheral pulses\n Labs / Radiology\n 430 K/uL\n 8.8 g/dL\n 87 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 100 mEq/L\n 141 mEq/L\n 30.6 %\n 9.9 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n WBC\n 11.7\n 9.9\n Hct\n 34.7\n 30.6\n Plt\n 500\n 430\n Cr\n 0.8\n 1.0\n TropT\n 0.02\n TCO2\n 34\n Glucose\n 107\n 87\n ASSESSMENT AND PLAN\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures on who had MS\n change first noted following MRI, who subsequently flashed on the floor\n in the setting of holding lasix.\n .\n Afib: Pt in Afib with RVR on arrival. Had been NPO for some time on the\n floor, had been on p.o metoprolol on am then changed to IV at 5-10\n Q4 on 3/3pm but didn't get any on although written, ? low SBPs.\n On arrival to floor received IV metoprolol 2.5 with improvement rate to\n 80's from 128.\n Uptitrated metoprolol to 15mg IV q4 (conversion 2.5:1 IV to p.o)\n -continue metoprolol IV.\n As becomes more alert, able to tolerate pills convert to p.o.\n -am EKG.\n # Flash Pulmonary Edema: CAD s/p CABG 86F with CAD s/p CABG \n (SVG-OM, LIMA-LAD)\n -Given AS pt very sensitive to fluid shifts, had been lying down for a\n long time at MRI and lasix was being held on floor to prevent cerebral\n hypoperfusion with subsequent flash.\n On arrival to ICU received IV lasix bolus 60mg IV and started on lasix\n drip.\n Continue lasix drip, titrating based on clinical appearance/respiratory\n status.\n -On digoxin chronically, typically not preferred in setting of normal\n EF, will continue for now. Dig level 0.9 (range 0.9-2)\n -repeat ABG this pm\n -repeat CXR in am.\n .\n #AS: AS s/p valvuloplasty .Severe AS on Echo with valve\n area not quantified but LVOT of 12 noted which was not noted on Echo of\n but valve area of 0.8. EF stable at 60%. AS known critical,\n unclear if worsened AS since as valve area not quantified but known\n to be critical. Pt poor surgical candidate thus had not received AVR.\n -Consideration being given for minimally invasive percutaneous valve\n replacement.\n -f/u with ICU fellow/Dr \n cautious diruesis in setting critical AS.\n .\n # MS Change: Likely multifactorial related to benzodiazepine pre MRI\n although only received 0.5mg, C02 retention fatigue with mildly\n elevated C02 of 63 on ABG, and low CO with CHF.\n Did have on CTA and has new, subtle LUE/LLE weakness and no\n reflexes on LLE which is new per neuro consistent with lesion on right.\n This lesion is most likely vascular in nature, either a small infarct\n which converted to a bleed, versus less likely malignant ? metastatic\n colon cancer. Once medically stable neuro recommends MRI with\n gadolinium to asses lesion. If does not enhance, likely bleed.\n -appreciate neuro recs\n -ASA 81mg\n -serial neuro exams.\n -keppra for seizure prophylaxis.\n -gentle diuresis\n -avoid benzos\n -follow resp status, serial ABGs.\n -diuresis\n .\n # ? Infection: Pt low grade temp to 100.3.\n Had been lying flat at MRI y/d, possible aspiration pneumonitis.\n If spikes temp, white count, institute Abx coverage with cipro.\n f/u with ? chronic suppression with vanc for c.diff\n Blood cx drawn with initial question of meningitis on presentation with\n seizures have been negative x 3. Urine cx negative x1, repeat drawn on\n pending.\n -f/u final urine cx\n -trend WBC, fever curve.\n .\n # Hx Diarrhea:\n hx C.diff on chronic suppression therapy with p.o vanc/flagyll with\n last cx at rehab on negative but abx were continued to\n continued diarrhea. However diarrhea has stopped so abx stopped this\n hospitalization.\n Continue to monitor.\n .\n #hx GI bleed: s/p hemicolectomy following which she presented to \n rehab.\n Baseline Hct ~ 30, 35 on now 32.2\n Continue to trend daily.\n Guiac all stools\n active type and screen.\n .\n FEN: NPO currently. Speech and swallow initially consulted but became\n unresponsive. Reconsult when pt alert.\n Continue RISS, finger sticks.\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx: holding given INR 5.0\n -Pain management with tylenol/gabapentin\n -Bowel regimen: hold\n .\n CODE: FULL\n .\n COMM: , : \n .\n DISPO: CCU for now\n"
},
{
"category": "Physician ",
"chartdate": "2196-01-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402802,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.8\nF - 10:00 PM\n Overnight events:\n Initially continued to be tachycardic in low 100s. Started on schedule\n of lopressor 15mg IV q4 with HR mostly in 90s in afib.\n AM CXR read as RLL collapse, stable Left pleural effusion, no PNA or\n CHF. Planned for CT chest ? etiology with DD lung collapse including\n aspiration, mucous plugging, pna, malignancy. Started to desat around\n 5pm to mid 80s on 4% NC, improved on 40% shovel mask. ABG obtained at\n that time showed 7.42/51/51/34 from 7.35/63/72/36, more consistent with\n venous gas. Started on abx coverage for hospital acquired PNA with\n aspiration coverage with vanc/cefepime/flagyll. Continued to have low\n grade temp 99.8 then spiked temp around 9pm to 102, defervesced with\n tylenol and congested cough but unable to clear secretions for sputum\n cx. Continued to congestion on lung exam, although did not appear very\n uncomfortable, not using accessory muscles. 02 sat's improved on shovel\n mask/suctioning, although intermittently desaturated, with multiple neb\n treatments, uptitration to 100% shovel mask by respiratory therapy with\n sat's in mid to low 90s. Repeat ABG was deferred given no contribution\n to management, management guided by clinical status. Initially held\n lasix drip but UOP started to drop off and BP's were in the one teens,\n although 02 sats at this point stable in the low 90s. Restarted lasix\n drip to run negative.\n 8 beat run of NSVT at 3:30am.\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:11 AM\n Acyclovir - 04:42 PM\n Vancomycin - 06:40 PM\n Cefipime - 08:00 PM\n Metronidazole - 05:57 AM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Famotidine (Pepcid) - 08:28 PM\n Metoprolol - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 36.5\nC (97.7\n HR: 87 (85 - 128) bpm\n BP: 103/51(65) {96/42(58) - 129/66(80)} mmHg\n RR: 21 (18 - 29) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 86 kg (admission): 80.1 kg\n Total In:\n 628 mL\n 300 mL\n PO:\n TF:\n IVF:\n 628 mL\n 300 mL\n Blood products:\n Total out:\n 1,190 mL\n 270 mL\n Urine:\n 1,190 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n -562 mL\n 30 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 95%\n ABG: 7.42/51/51/31/6\n PaO2 / FiO2: 73\n Physical Examination\n Neuro: AO to Person, time, disoriented to place\n CVS:irregularly irregular, SEM\n Lung: improved, less ronchorous, less wheeze, JVP ~ 7cm\n Abd: +bs, soft, nt, nd\n Ext : WWP, 1+ edema below knee, mid shin bandages in place.\n warm extremities, weak peripheral pulses\n Labs / Radiology\n 430 K/uL\n 8.8 g/dL\n 87 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 100 mEq/L\n 141 mEq/L\n 30.6 %\n 9.9 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n WBC\n 11.7\n 9.9\n Hct\n 34.7\n 30.6\n Plt\n 500\n 430\n Cr\n 0.8\n 1.0\n TropT\n 0.02\n TCO2\n 34\n Glucose\n 107\n 87\n ASSESSMENT AND PLAN\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures on who had MS\n change first noted following MRI, who subsequently flashed on the floor\n in the setting of holding lasix.\n .\n Afib: Pt in Afib with RVR on arrival. Had been NPO for some time on the\n floor, had been on p.o metoprolol on am then changed to IV at 5-10\n Q4 on 3/3pm but didn't get any on although written, ? low SBPs.\n On arrival to floor received IV metoprolol 2.5 with improvement rate to\n 80's from 128.\n Uptitrated metoprolol to 15mg IV q4 (conversion 2.5:1 IV to p.o)\n -continue metoprolol IV.\n As becomes more alert, able to tolerate pills convert to p.o.\n -am EKG.\n # Flash Pulmonary Edema: CAD s/p CABG 86F with CAD s/p CABG \n (SVG-OM, LIMA-LAD)\n -Given AS pt very sensitive to fluid shifts, had been lying down for a\n long time at MRI and lasix was being held on floor to prevent cerebral\n hypoperfusion with subsequent flash.\n On arrival to ICU received IV lasix bolus 60mg IV and started on lasix\n drip.\n Continue lasix drip, titrating based on clinical appearance/respiratory\n status.\n -On digoxin chronically, typically not preferred in setting of normal\n EF, will continue for now. Dig level 0.9 (range 0.9-2)\n -repeat ABG this pm\n -repeat CXR in am.\n .\n #AS: AS s/p valvuloplasty .Severe AS on Echo with valve\n area not quantified but LVOT of 12 noted which was not noted on Echo of\n but valve area of 0.8. EF stable at 60%. AS known critical,\n unclear if worsened AS since as valve area not quantified but known\n to be critical. Pt poor surgical candidate thus had not received AVR.\n -Consideration being given for minimally invasive percutaneous valve\n replacement.\n -f/u with ICU fellow/Dr \n cautious diruesis in setting critical AS.\n .\n # MS Change: Likely multifactorial related to benzodiazepine pre MRI\n although only received 0.5mg, C02 retention fatigue with mildly\n elevated C02 of 63 on ABG, and low CO with CHF.\n Did have on CTA and has new, subtle LUE/LLE weakness and no\n reflexes on LLE which is new per neuro consistent with lesion on right.\n This lesion is most likely vascular in nature, either a small infarct\n which converted to a bleed, versus less likely malignant ? metastatic\n colon cancer. Once medically stable neuro recommends MRI with\n gadolinium to asses lesion. If does not enhance, likely bleed.\n -appreciate neuro recs\n -ASA 81mg\n -serial neuro exams.\n -keppra for seizure prophylaxis.\n -gentle diuresis\n -avoid benzos\n -follow resp status, serial ABGs.\n -diuresis\n .\n # ? Infection: Pt low grade temp to 100.3.\n Had been lying flat at MRI y/d, possible aspiration pneumonitis.\n If spikes temp, white count, institute Abx coverage with cipro.\n f/u with ? chronic suppression with vanc for c.diff\n Blood cx drawn with initial question of meningitis on presentation with\n seizures have been negative x 3. Urine cx negative x1, repeat drawn on\n pending.\n -f/u final urine cx\n -trend WBC, fever curve.\n .\n # Hx Diarrhea:\n hx C.diff on chronic suppression therapy with p.o vanc/flagyll with\n last cx at rehab on negative but abx were continued to\n continued diarrhea. However diarrhea has stopped so abx stopped this\n hospitalization.\n Continue to monitor.\n .\n #hx GI bleed: s/p hemicolectomy following which she presented to \n rehab.\n Baseline Hct ~ 30, 35 on now 32.2\n Continue to trend daily.\n Guiac all stools\n active type and screen.\n .\n FEN: NPO currently. Speech and swallow initially consulted but became\n unresponsive. Reconsult when pt alert.\n Continue RISS, finger sticks.\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx: holding given INR 5.0\n -Pain management with tylenol/gabapentin\n -Bowel regimen: hold\n .\n CODE: FULL\n .\n COMM: , : \n .\n DISPO: CCU for now\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n Per Housestaff\n nothing to add\n Physical Examination\n Per housestaff\n nothing to add\n Medical Decision Making\n Per housestaff\n nothing to add\n Above discussed extensively with patient.\n Total time spent on patient care: 60 minutes.\n Additional comments:\n Improving\n Continue diuresis\n Rate is better controlled\n Sit up to improve respiratory function\n ------ Protected Section Addendum Entered By: ,MD\n on: 10:22 ------\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402425,
"text": "HPI:\n 86F s/p witnessed tonic clonic/sz activity @ Rehab no hx of\n seizures; the seizure lasted only about 5 minutes at the rehabilitation\n facility, and then resolved spontaneously. Her daughter and husband\n were visiting her and they noticed a self-limitted 5 minutes seizure,\n described as acute onset of LOC, followed by whole body stiffens and\n later shaking. She was brought to the ED, and during her\n observation in the ED she another 30 seconds GTC seizure. To stop the\n cluster she received Ativan IV and later she was loaded with 1000mg of\n IV Keppra. No further seizures in the ED.\n .\n She had a valvuloplasty performed for AS; she was then admitted\n from 1/11-20/10 for right hemicolectomy for colon cancer. Her hospital\n course was complicated by hypercarbia requiring intubation and fluid\n overload requiring diuresis. Subsequent to this she developed C.\n difficile colitis, for which she has been on IV vancomycin since; she\n continues to complain of abdominal pain, although she has had a recent\n followup abdominal CT after her partial colectomy, which per the\n patient's family was unremarkable\n Assessment:\n Pt admitted to SICU B from the ED s/p seizure. Neuro exam intact,\n although pt speaking in grunts and\n occasional\n one word response to questions. WBC 12.1, ? meningitis as\n per neuro-med team.\n Pt has severe AS, is in A Fib, on Coumadin, has hx HTN.\n On O2 at 2-4 l, congested cough. Sats 93-99.\n Foley in place, u/o 25-40 cc/hr.\n Small amts green stool per rectum.\n Pt has chronic bilat venous ulcerations on lower legs.\n Action:\n Antibiotics for possible CNS infection\n Q2 hr neuro checks\n Coumadin as ordered qd at 1600, monitor INR\n Rate control with Metoprolol for AF, cardiac echo to r/o endocarditis\n Continue O2 as needed to support sats >95%\n Lasix \n Lower leg dsgs changed\ntelfa and kerlix applied\n Response:\n Pt has no signs of seizure since admission, Neuro stable\n O2 at 4 l, pt coughing and a bit congested\n Antibiotics given as ordered\n Metoprolol held at 0200 due to borderline blood pressure 102/70\n Venodynes ordered but not applied due to open venous ulcers on legs.\n Plan:\n Continue Neuro checks q 2\n Monitor for sx of seizure\n Echo in AM\n Metoprolol if bp tolerates\n Coumadin qd\n Encourage coughing and deep breathing, IS q 1-2 hrs when awake\n Antibiotics as ordered\n Check labs this am.\n Change dsd on lower legs , keep heels off bed to prevent further\n skin issues.\n"
},
{
"category": "Physician ",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402862,
"text": "Chief Complaint:\n 24 Hour Events:\n - got an ABG, which was stable\n - stopped lasix gtt temporarily because she was hypotensive, restarted\n when BP's improved\n - allowed her to get some applesauce\n - changed metoprolol to PO\n - all Cx NGTD\n - sent stool for C.diff\n - wound care: rheum should be consulted when patients condition\n improves (for leg ulcers) - refer to wound care note for furhter\n details\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 08:00 PM\n Metronidazole - 11:00 PM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:45 AM\n Metoprolol - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 35.9\nC (96.7\n HR: 93 (82 - 99) bpm\n BP: 115/52(66) {82/38(49) - 119/62(73)} mmHg\n RR: 22 (16 - 28) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 86 kg (admission): 80.1 kg\n Total In:\n 1,523 mL\n 104 mL\n PO:\n TF:\n IVF:\n 1,523 mL\n 104 mL\n Blood products:\n Total out:\n 1,215 mL\n 475 mL\n Urine:\n 1,215 mL\n 475 mL\n NG:\n Stool:\n Drains:\n Balance:\n 308 mL\n -371 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.36/60/73.//5\n PaO2 / FiO2: 104\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 354 K/uL\n 8.8 g/dL\n 85 mg/dL\n 1.0 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 20 mg/dL\n 101 mEq/L\n 142 mEq/L\n 30.0 %\n 8.2 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n 02:18 PM\n 05:28 AM\n WBC\n 11.7\n 9.9\n 8.2\n Hct\n 34.7\n 30.6\n 30.0\n Plt\n \n Cr\n 0.8\n 1.0\n 1.0\n TropT\n 0.02\n TCO2\n 34\n 35\n Glucose\n 107\n 87\n 85\n Other labs: PT / PTT / INR:55.1/41.5/6.1, CK / CKMB /\n Troponin-T:15//0.02, ALT / AST:, Alk Phos / T Bili:62/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca++:8.1 mg/dL, Mg++:1.8\n mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n PNEUMONIA, ASPIRATION\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:01 AM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Possible transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402863,
"text": "Chief Complaint:\n 24 Hour Events:\n - got an ABG, which was stable\n - stopped lasix gtt temporarily because she was hypotensive, restarted\n when BP's improved\n - allowed her to get some applesauce\n - changed metoprolol to PO\n - all Cx NGTD\n - sent stool for C.diff\n - wound care: rheum should be consulted when patients condition\n improves (for leg ulcers) - refer to wound care note for furhter\n details\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 08:00 PM\n Metronidazole - 11:00 PM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:45 AM\n Metoprolol - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 35.9\nC (96.7\n HR: 93 (82 - 99) bpm\n BP: 115/52(66) {82/38(49) - 119/62(73)} mmHg\n RR: 22 (16 - 28) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 86 kg (admission): 80.1 kg\n Total In:\n 1,523 mL\n 104 mL\n PO:\n TF:\n IVF:\n 1,523 mL\n 104 mL\n Blood products:\n Total out:\n 1,215 mL\n 475 mL\n Urine:\n 1,215 mL\n 475 mL\n NG:\n Stool:\n Drains:\n Balance:\n 308 mL\n -371 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.36/60/73.//5\n PaO2 / FiO2: 104\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 354 K/uL\n 8.8 g/dL\n 85 mg/dL\n 1.0 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 20 mg/dL\n 101 mEq/L\n 142 mEq/L\n 30.0 %\n 8.2 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n 02:18 PM\n 05:28 AM\n WBC\n 11.7\n 9.9\n 8.2\n Hct\n 34.7\n 30.6\n 30.0\n Plt\n \n Cr\n 0.8\n 1.0\n 1.0\n TropT\n 0.02\n TCO2\n 34\n 35\n Glucose\n 107\n 87\n 85\n Other labs: PT / PTT / INR:55.1/41.5/6.1, CK / CKMB /\n Troponin-T:15//0.02, ALT / AST:, Alk Phos / T Bili:62/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca++:8.1 mg/dL, Mg++:1.8\n mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures on who had MS\n change first noted following MRI, who subsequently flashed on the floor\n in the setting of holding lasix.\n .\n Afib: Pt in Afib with RVR on arrival. Had been NPO for some time on the\n floor, had been on p.o metoprolol on am then changed to IV at 5-10\n Q4 on 3/3pm but didn't get any on although written, ? low SBPs.\n On arrival to floor received IV metoprolol 2.5 with improvement rate to\n 80's from 128.\n Uptitrated metoprolol to 15mg IV q4 (conversion 2.5:1 IV to p.o)\n -continue metoprolol IV.\n As becomes more alert, able to tolerate pills convert to p.o.\n -am EKG.\n # Flash Pulmonary Edema: CAD s/p CABG 86F with CAD s/p CABG \n (SVG-OM, LIMA-LAD)\n -Given AS pt very sensitive to fluid shifts, had been lying down for a\n long time at MRI and lasix was being held on floor to prevent cerebral\n hypoperfusion with subsequent flash.\n On arrival to ICU received IV lasix bolus 60mg IV and started on lasix\n drip.\n Continue lasix drip, titrating based on clinical appearance/respiratory\n status.\n -On digoxin chronically, typically not preferred in setting of normal\n EF, will continue for now. Dig level 0.9 (range 0.9-2)\n -repeat ABG this pm\n -repeat CXR in am.\n .\n #AS: AS s/p valvuloplasty .Severe AS on Echo with valve\n area not quantified but LVOT of 12 noted which was not noted on Echo of\n but valve area of 0.8. EF stable at 60%. AS known critical,\n unclear if worsened AS since as valve area not quantified but known\n to be critical. Pt poor surgical candidate thus had not received AVR.\n -Consideration being given for minimally invasive percutaneous valve\n replacement.\n -f/u with ICU fellow/Dr \n cautious diruesis in setting critical AS.\n .\n # MS Change: Likely multifactorial related to benzodiazepine pre MRI\n although only received 0.5mg, C02 retention fatigue with mildly\n elevated C02 of 63 on ABG, and low CO with CHF.\n Did have on CTA and has new, subtle LUE/LLE weakness and no\n reflexes on LLE which is new per neuro consistent with lesion on right.\n This lesion is most likely vascular in nature, either a small infarct\n which converted to a bleed, versus less likely malignant ? metastatic\n colon cancer. Once medically stable neuro recommends MRI with\n gadolinium to asses lesion. If does not enhance, likely bleed.\n -appreciate neuro recs\n -ASA 81mg\n -serial neuro exams.\n -keppra for seizure prophylaxis.\n -gentle diuresis\n -avoid benzos\n -follow resp status, serial ABGs.\n -diuresis\n .\n # ? Infection: Pt low grade temp to 100.3.\n Had been lying flat at MRI y/d, possible aspiration pneumonitis.\n If spikes temp, white count, institute Abx coverage with cipro.\n f/u with ? chronic suppression with vanc for c.diff\n Blood cx drawn with initial question of meningitis on presentation with\n seizures have been negative x 3. Urine cx negative x1, repeat drawn on\n pending.\n -f/u final urine cx\n -trend WBC, fever curve.\n .\n # Hx Diarrhea:\n hx C.diff on chronic suppression therapy with p.o vanc/flagyll with\n last cx at rehab on negative but abx were continued to\n continued diarrhea. However diarrhea has stopped so abx stopped this\n hospitalization.\n Continue to monitor.\n .\n #hx GI bleed: s/p hemicolectomy following which she presented to \n rehab.\n Baseline Hct ~ 30, 35 on now 32.2\n Continue to trend daily.\n Guiac all stools\n active type and screen.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:01 AM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Possible transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402864,
"text": "Chief Complaint:\n 24 Hour Events:\n - got an ABG, which was stable\n - stopped lasix gtt temporarily because she was hypotensive, restarted\n when BP's improved\n - allowed her to get some applesauce\n - changed metoprolol to PO\n - all Cx NGTD\n - sent stool for C.diff\n - wound care: rheum should be consulted when patients condition\n improves (for leg ulcers) - refer to wound care note for furhter\n details\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 08:00 PM\n Metronidazole - 11:00 PM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:45 AM\n Metoprolol - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 35.9\nC (96.7\n HR: 93 (82 - 99) bpm\n BP: 115/52(66) {82/38(49) - 119/62(73)} mmHg\n RR: 22 (16 - 28) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 86 kg (admission): 80.1 kg\n Total In:\n 1,523 mL\n 104 mL\n PO:\n TF:\n IVF:\n 1,523 mL\n 104 mL\n Blood products:\n Total out:\n 1,215 mL\n 475 mL\n Urine:\n 1,215 mL\n 475 mL\n NG:\n Stool:\n Drains:\n Balance:\n 308 mL\n -371 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.36/60/73.//5\n PaO2 / FiO2: 104\n Physical Examination\n Neuro: AO to Person, time, disoriented to place\n CVS:irregularly irregular, SEM\n Lung: improved, less ronchorous, less wheeze, JVP ~ 7cm\n Abd: +bs, soft, nt, nd\n Ext : WWP, 1+ edema below knee, mid shin bandages in place.\n warm extremities, weak peripheral pulses\n Labs / Radiology\n 354 K/uL\n 8.8 g/dL\n 85 mg/dL\n 1.0 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 20 mg/dL\n 101 mEq/L\n 142 mEq/L\n 30.0 %\n 8.2 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n 02:18 PM\n 05:28 AM\n WBC\n 11.7\n 9.9\n 8.2\n Hct\n 34.7\n 30.6\n 30.0\n Plt\n \n Cr\n 0.8\n 1.0\n 1.0\n TropT\n 0.02\n TCO2\n 34\n 35\n Glucose\n 107\n 87\n 85\n Other labs: PT / PTT / INR:55.1/41.5/6.1, CK / CKMB /\n Troponin-T:15//0.02, ALT / AST:, Alk Phos / T Bili:62/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca++:8.1 mg/dL, Mg++:1.8\n mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures on who had MS\n change first noted following MRI, who subsequently flashed on the floor\n in the setting of holding lasix.\n .\n Afib: Pt in Afib with RVR on arrival. Had been NPO for some time on the\n floor, had been on p.o metoprolol on am then changed to IV at 5-10\n Q4 on 3/3pm but didn't get any on although written, ? low SBPs.\n On arrival to floor received IV metoprolol 2.5 with improvement rate to\n 80's from 128.\n Uptitrated metoprolol to 15mg IV q4 (conversion 2.5:1 IV to p.o)\n -continue metoprolol IV.\n As becomes more alert, able to tolerate pills convert to p.o.\n -am EKG.\n # Flash Pulmonary Edema: CAD s/p CABG 86F with CAD s/p CABG \n (SVG-OM, LIMA-LAD)\n -Given AS pt very sensitive to fluid shifts, had been lying down for a\n long time at MRI and lasix was being held on floor to prevent cerebral\n hypoperfusion with subsequent flash.\n On arrival to ICU received IV lasix bolus 60mg IV and started on lasix\n drip.\n Continue lasix drip, titrating based on clinical appearance/respiratory\n status.\n -On digoxin chronically, typically not preferred in setting of normal\n EF, will continue for now. Dig level 0.9 (range 0.9-2)\n -repeat ABG this pm\n -repeat CXR in am.\n .\n #AS: AS s/p valvuloplasty .Severe AS on Echo with valve\n area not quantified but LVOT of 12 noted which was not noted on Echo of\n but valve area of 0.8. EF stable at 60%. AS known critical,\n unclear if worsened AS since as valve area not quantified but known\n to be critical. Pt poor surgical candidate thus had not received AVR.\n -Consideration being given for minimally invasive percutaneous valve\n replacement.\n -f/u with ICU fellow/Dr \n cautious diruesis in setting critical AS.\n .\n # MS Change: Likely multifactorial related to benzodiazepine pre MRI\n although only received 0.5mg, C02 retention fatigue with mildly\n elevated C02 of 63 on ABG, and low CO with CHF.\n Did have on CTA and has new, subtle LUE/LLE weakness and no\n reflexes on LLE which is new per neuro consistent with lesion on right.\n This lesion is most likely vascular in nature, either a small infarct\n which converted to a bleed, versus less likely malignant ? metastatic\n colon cancer. Once medically stable neuro recommends MRI with\n gadolinium to asses lesion. If does not enhance, likely bleed.\n -appreciate neuro recs\n -ASA 81mg\n -serial neuro exams.\n -keppra for seizure prophylaxis.\n -gentle diuresis\n -avoid benzos\n -follow resp status, serial ABGs.\n -diuresis\n .\n # ? Infection: Pt low grade temp to 100.3.\n Had been lying flat at MRI y/d, possible aspiration pneumonitis.\n If spikes temp, white count, institute Abx coverage with cipro.\n f/u with ? chronic suppression with vanc for c.diff\n Blood cx drawn with initial question of meningitis on presentation with\n seizures have been negative x 3. Urine cx negative x1, repeat drawn on\n pending.\n -f/u final urine cx\n -trend WBC, fever curve.\n .\n # Hx Diarrhea:\n hx C.diff on chronic suppression therapy with p.o vanc/flagyll with\n last cx at rehab on negative but abx were continued to\n continued diarrhea. However diarrhea has stopped so abx stopped this\n hospitalization.\n Continue to monitor.\n .\n #hx GI bleed: s/p hemicolectomy following which she presented to \n rehab.\n Baseline Hct ~ 30, 35 on now 32.2\n Continue to trend daily.\n Guiac all stools\n active type and screen.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:01 AM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Possible transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402865,
"text": "Chief Complaint:\n 24 Hour Events:\n - got an ABG, which was stable\n - stopped lasix gtt temporarily because she was hypotensive, restarted\n when BP's improved\n - allowed her to get some applesauce\n - changed metoprolol to PO\n - all Cx NGTD\n - sent stool for C.diff\n - wound care: rheum should be consulted when patients condition\n improves (for leg ulcers) - refer to wound care note for furhter\n details\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 08:00 PM\n Metronidazole - 11:00 PM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:45 AM\n Metoprolol - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 35.9\nC (96.7\n HR: 93 (82 - 99) bpm\n BP: 115/52(66) {82/38(49) - 119/62(73)} mmHg\n RR: 22 (16 - 28) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 86 kg (admission): 80.1 kg\n Total In:\n 1,523 mL\n 104 mL\n PO:\n TF:\n IVF:\n 1,523 mL\n 104 mL\n Blood products:\n Total out:\n 1,215 mL\n 475 mL\n Urine:\n 1,215 mL\n 475 mL\n NG:\n Stool:\n Drains:\n Balance:\n 308 mL\n -371 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.36/60/73.//5\n PaO2 / FiO2: 104\n Physical Examination\n Neuro: AO to Person, time, disoriented to place\n CVS:irregularly irregular, SEM\n Lung: improved, less ronchorous, less wheeze, JVP ~ 7cm\n Abd: +bs, soft, nt, nd\n Ext : WWP, 1+ edema below knee, mid shin bandages in place.\n warm extremities, weak peripheral pulses\n Labs / Radiology\n 354 K/uL\n 8.8 g/dL\n 85 mg/dL\n 1.0 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 20 mg/dL\n 101 mEq/L\n 142 mEq/L\n 30.0 %\n 8.2 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n 02:18 PM\n 05:28 AM\n WBC\n 11.7\n 9.9\n 8.2\n Hct\n 34.7\n 30.6\n 30.0\n Plt\n \n Cr\n 0.8\n 1.0\n 1.0\n TropT\n 0.02\n TCO2\n 34\n 35\n Glucose\n 107\n 87\n 85\n Other labs: PT / PTT / INR:55.1/41.5/6.1, CK / CKMB /\n Troponin-T:15//0.02, ALT / AST:, Alk Phos / T Bili:62/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca++:8.1 mg/dL, Mg++:1.8\n mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures on who had MS\n change first noted following MRI, who subsequently flashed on the floor\n in the setting of holding lasix.\n # Pulmonary Edema:\n Afib: Pt in Afib with RVR on arrival. Had been NPO for some time on the\n floor, had been on p.o metoprolol on am then changed to IV at 5-10\n Q4 on 3/3pm but didn't get any on although written, ? low SBPs.\n On arrival to floor received IV metoprolol 2.5 with improvement rate to\n 80's from 128.\n Uptitrated metoprolol to 15mg IV q4 (conversion 2.5:1 IV to p.o)\n -continue metoprolol IV.\n As becomes more alert, able to tolerate pills convert to p.o.\n -am EKG.\n # Flash Pulmonary Edema: CAD s/p CABG 86F with CAD s/p CABG \n (SVG-OM, LIMA-LAD)\n -Given AS pt very sensitive to fluid shifts, had been lying down for a\n long time at MRI and lasix was being held on floor to prevent cerebral\n hypoperfusion with subsequent flash.\n On arrival to ICU received IV lasix bolus 60mg IV and started on lasix\n drip.\n Continue lasix drip, titrating based on clinical appearance/respiratory\n status.\n -On digoxin chronically, typically not preferred in setting of normal\n EF, will continue for now. Dig level 0.9 (range 0.9-2)\n -repeat ABG this pm\n -repeat CXR in am.\n .\n #AS: AS s/p valvuloplasty .Severe AS on Echo with valve\n area not quantified but LVOT of 12 noted which was not noted on Echo of\n but valve area of 0.8. EF stable at 60%. AS known critical,\n unclear if worsened AS since as valve area not quantified but known\n to be critical. Pt poor surgical candidate thus had not received AVR.\n -Consideration being given for minimally invasive percutaneous valve\n replacement.\n -f/u with ICU fellow/Dr \n cautious diruesis in setting critical AS.\n .\n # MS Change: Likely multifactorial related to benzodiazepine pre MRI\n although only received 0.5mg, C02 retention fatigue with mildly\n elevated C02 of 63 on ABG, and low CO with CHF.\n Did have on CTA and has new, subtle LUE/LLE weakness and no\n reflexes on LLE which is new per neuro consistent with lesion on right.\n This lesion is most likely vascular in nature, either a small infarct\n which converted to a bleed, versus less likely malignant ? metastatic\n colon cancer. Once medically stable neuro recommends MRI with\n gadolinium to asses lesion. If does not enhance, likely bleed.\n -appreciate neuro recs\n -ASA 81mg\n -serial neuro exams.\n -keppra for seizure prophylaxis.\n -gentle diuresis\n -avoid benzos\n -follow resp status, serial ABGs.\n -diuresis\n .\n # ? Infection: Pt low grade temp to 100.3.\n Had been lying flat at MRI y/d, possible aspiration pneumonitis.\n If spikes temp, white count, institute Abx coverage with cipro.\n f/u with ? chronic suppression with vanc for c.diff\n Blood cx drawn with initial question of meningitis on presentation with\n seizures have been negative x 3. Urine cx negative x1, repeat drawn on\n pending.\n -f/u final urine cx\n -trend WBC, fever curve.\n .\n # Hx Diarrhea:\n hx C.diff on chronic suppression therapy with p.o vanc/flagyll with\n last cx at rehab on negative but abx were continued to\n continued diarrhea. However diarrhea has stopped so abx stopped this\n hospitalization.\n Continue to monitor.\n .\n #hx GI bleed: s/p hemicolectomy following which she presented to \n rehab.\n Baseline Hct ~ 30, 35 on now 32.2\n Continue to trend daily.\n Guiac all stools\n active type and screen.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:01 AM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Possible transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2196-01-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402775,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.8\nF - 10:00 PM\n -TEE performed showing No vegetations on valves or RV/RA wires. Mild to\n moderate mitral regurgitation.\n -dental consulted recommended oral surgery consult for tooth\n extractions (loose incisors).\n -PA catheter pulled,tip not sent.\n -Last swan numbers:35, 13, 5.7, 2.8, 841.\n Labs showed worsening metabolic alkalosis, stable respiratory\n alkalosis. Started on acetazolamide x 2 doses in addition to K/Phos\n repletions, with ABG this morning showing: *****\n Lasix held given hypotension in afternoon to 60s systolic after\n diuresing two litres. Dobutamin considered but given that C.O\n normalized (and dobutamine would have helped by augmenting CO, and has\n mild vasodilatory pressures so would potentially worsen pressures if it\n doesn't augment her C.O), so started vasopressin instead. BP's\n normalized, restarted lasix with UOP ~ 200cc/hr achieved with lasix\n drip at 10cc/hr.\n 5am had 32 beat run of VT, with K of 2.9, agitated.\n K repleted.\n Continued diarrhea. Cdiff\nve x1. Guaic +ve. With crit drop this am to\n 27 from 30.\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:11 AM\n Acyclovir - 04:42 PM\n Vancomycin - 06:40 PM\n Cefipime - 08:00 PM\n Metronidazole - 05:57 AM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Famotidine (Pepcid) - 08:28 PM\n Metoprolol - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 36.5\nC (97.7\n HR: 87 (85 - 128) bpm\n BP: 103/51(65) {96/42(58) - 129/66(80)} mmHg\n RR: 21 (18 - 29) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 86 kg (admission): 80.1 kg\n Total In:\n 628 mL\n 300 mL\n PO:\n TF:\n IVF:\n 628 mL\n 300 mL\n Blood products:\n Total out:\n 1,190 mL\n 270 mL\n Urine:\n 1,190 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n -562 mL\n 30 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 95%\n ABG: 7.42/51/51/31/6\n PaO2 / FiO2: 73\n Physical Examination\n Neuro: responds to voice, moves extremities spontaneously, tracks,\n unable to follow commands\n CVS: RRR\n Lung: improved, less ronchorous\n Abd: +bs, soft, nt, nd\n Skin: appears slightly yellowed but no scleral icterus\n Ext:1+ edema to upper thigh, improved.\n warm extremities, weak peripheral pulses\n Labs / Radiology\n 430 K/uL\n 8.8 g/dL\n 87 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 100 mEq/L\n 141 mEq/L\n 30.6 %\n 9.9 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n WBC\n 11.7\n 9.9\n Hct\n 34.7\n 30.6\n Plt\n 500\n 430\n Cr\n 0.8\n 1.0\n TropT\n 0.02\n TCO2\n 34\n Glucose\n 107\n 87\n Other labs: PT / PTT / INR:28.2/41.5/2.8, CK / CKMB /\n Troponin-T:15//0.02, ALT / AST:, Alk Phos / T Bili:62/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.0\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n PNEUMONIA, ASPIRATION\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 63 y/o F w/ decompensated Stage IV CHF admitted for inotropic-assisted\n diuresis with superimposed sepsis, now intubated for hypercarbic\n respiratory failure/airway protection.\n .\n # CHF: Continued evidence CHF with peripheral edema, crackles on lung\n exam. Continued ionotrope assisted diuresis for decompensated CHF.\n Swan ganz dc'd yesterday. Continue diuresis given cardiogenic shock\n picture CHF.\n Continue lasix drip with lasix bolus's PRN goal negative 1L/day.Renal\n fx tolerating with Cr stable at 1.0\n -Continue pressor support PRN to achieve goal. Wean neo as tolerated,\n d'c vasopressin when able.\n - lyte checks.\n .\n Sepsis: Continues to have low grade fever but no white count, swan\n numbers prior to DC arguing against current ongoing sepsis. No\n vegetation evidenced on TEE to suggest endocarditis. MRSA cultured from\n sputum,blood-vanc sensitive. Sparse growth proteus mirabilis from\n sputum sensitive to cefepime.\n Dental consulted given poor dentition.\n Continue vanc/cefepime with Dose vanc by troughs.\n - Consider d/c flagyll.\n -Per dental recs consult oral surgery for tooth extraction. Unstable\n for panorex.\n Appreciate ID recs.\n d/c surveillance blood cx.\n -f/u wound cultures.\n .\n # Respiratory failure: Intubated for worsening\n hypercarbia/mental status. Respiratory failure likely multifactorial,\n with some component of heart failure/fluid overload as well as some\n pneumonia component. Pt has thus far failed SBTs.RISBI this am\n Barriers to extubation and MS dependence for respiratory\n support. Off sedation almost 72 hours MS slowly improving.\n -daily SBTs.\n -acetazolamide/K/Phos repletions for metabolic alkalosis.\n -K/phos repletions\n -continue abx.\n .\n # PUMP: Acute on chronic right and left-sided systolic heart failure,\n Continue lasix drip.\n -continue digoxin\n Wean neo as tolerated.\n .\n # CORONARIES: CTO of proximal LAD. CE's negative at OSH.\n - continue aspirin 81mg daily\n - continue zocor\n - holding on beta blocker and ACEi due to pressor requirement\n .\n # RHYTHM: Hx cardiomyopathy s/p ICD placement. TEE estimates EF at 55%,\n more accurate than TTE with EF 30%. Also with hx afib. Currently in\n sinus with frequent ectopy. Holding metoprolol in setting of\n hypotension. Had episode of VT o/n in setting of low K+.\n -continue telemetry\n -electrolyte repletions PRN.\n -heparin GTT for Afib. Had some bleeding with TEE now Guaic +Ve stools,\n Crit drop. PTTs in 70s, stable\n -consider holding heparin temporarily, repeat crit, maintain active T\n and S.\n -Hold Coumadin until medically stable.\n -serial EKGs.\n # MS: initially noted to have anisocoria. Now PERRLA but still sluggish\n MS. been off sedation 72 hours although did get versed/fentanyl x1\n for TEE yesterday. Non con CT head showing extensive paranasal sinus\n disease, ? NP hydrocephalus, small radiolucent focus in Left frontal\n bone.\n f/u ? intracranial process as o/p with further imaging\n -continue pressors to maintain CO/cerebral perfusion.\n -daily neuro exams.\n -electrolytes PRN.\n - f/u ? NP hydrocephalus and focal lesion as o/p\n .\n # Hypervolemic hyponatremia: likely secondary to CHF.\n Resolved with Na 139\n -continue to trend.\n .\n # Elevated lactate: Likely secondary to hypoperfusion. Trending down.\n - continue hemodynamic support with pressors\n -continue to trend.\n .\n # Hypothyroidism:\n - continue Synthroid\n .\n # Cardiac Risk Factors: LDL 69. HbA1c 6.6.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full)\n continue tube feeds.\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:00 PM\n Multi Lumen - 09:05 PM\n .\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Communication: Comments: Brother is HCP (contact info in chart)\n Code status: Full code\n Disposition: CCU for now\n ICU Care\n Nutrition:\n Nutren 2.0 (Full)\n continue tube feeds.\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:00 PM\n Multi Lumen - 09:05 PM\n .\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Communication: Comments: Brother is HCP (contact info in chart)\n Code status: Full code\n Disposition: CCU for now\n"
},
{
"category": "Physician ",
"chartdate": "2196-01-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402778,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.8\nF - 10:00 PM\n -TEE performed showing No vegetations on valves or RV/RA wires. Mild to\n moderate mitral regurgitation.\n -dental consulted recommended oral surgery consult for tooth\n extractions (loose incisors).\n -PA catheter pulled,tip not sent.\n -Last swan numbers:35, 13, 5.7, 2.8, 841.\n Labs showed worsening metabolic alkalosis, stable respiratory\n alkalosis. Started on acetazolamide x 2 doses in addition to K/Phos\n repletions, with ABG this morning showing: *****\n Lasix held given hypotension in afternoon to 60s systolic after\n diuresing two litres. Dobutamin considered but given that C.O\n normalized (and dobutamine would have helped by augmenting CO, and has\n mild vasodilatory pressures so would potentially worsen pressures if it\n doesn't augment her C.O), so started vasopressin instead. BP's\n normalized, restarted lasix with UOP ~ 200cc/hr achieved with lasix\n drip at 10cc/hr.\n 5am had 32 beat run of VT, with K of 2.9, agitated.\n K repleted.\n Continued diarrhea. Cdiff\nve x1. Guaic +ve. With crit drop this am to\n 27 from 30.\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:11 AM\n Acyclovir - 04:42 PM\n Vancomycin - 06:40 PM\n Cefipime - 08:00 PM\n Metronidazole - 05:57 AM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Famotidine (Pepcid) - 08:28 PM\n Metoprolol - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 36.5\nC (97.7\n HR: 87 (85 - 128) bpm\n BP: 103/51(65) {96/42(58) - 129/66(80)} mmHg\n RR: 21 (18 - 29) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 86 kg (admission): 80.1 kg\n Total In:\n 628 mL\n 300 mL\n PO:\n TF:\n IVF:\n 628 mL\n 300 mL\n Blood products:\n Total out:\n 1,190 mL\n 270 mL\n Urine:\n 1,190 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n -562 mL\n 30 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 95%\n ABG: 7.42/51/51/31/6\n PaO2 / FiO2: 73\n Physical Examination\n Neuro: responds to voice, moves extremities spontaneously, tracks,\n unable to follow commands\n CVS: RRR\n Lung: improved, less ronchorous\n Abd: +bs, soft, nt, nd\n Skin: appears slightly yellowed but no scleral icterus\n Ext:1+ edema to upper thigh, improved.\n warm extremities, weak peripheral pulses\n Labs / Radiology\n 430 K/uL\n 8.8 g/dL\n 87 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 100 mEq/L\n 141 mEq/L\n 30.6 %\n 9.9 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n WBC\n 11.7\n 9.9\n Hct\n 34.7\n 30.6\n Plt\n 500\n 430\n Cr\n 0.8\n 1.0\n TropT\n 0.02\n TCO2\n 34\n Glucose\n 107\n 87\n Other labs: PT / PTT / INR:28.2/41.5/2.8, CK / CKMB /\n Troponin-T:15//0.02, ALT / AST:, Alk Phos / T Bili:62/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.0\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n PNEUMONIA, ASPIRATION\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 63 y/o F w/ decompensated Stage IV CHF admitted for inotropic-assisted\n diuresis with superimposed sepsis, now intubated for hypercarbic\n respiratory failure/airway protection.\n .\n # CHF: Continued evidence CHF with peripheral edema, crackles on lung\n exam. Continued ionotrope assisted diuresis for decompensated CHF.\n Swan ganz dc'd yesterday. Continue diuresis given cardiogenic shock\n picture CHF.\n Continue lasix drip with lasix bolus's PRN goal negative 1L/day.Renal\n fx tolerating with Cr stable at 1.0\n -Continue pressor support PRN to achieve goal. Wean neo as tolerated,\n d'c vasopressin when able.\n - lyte checks.\n .\n Sepsis: Continues to have low grade fever but no white count, swan\n numbers prior to DC arguing against current ongoing sepsis. No\n vegetation evidenced on TEE to suggest endocarditis. MRSA cultured from\n sputum,blood-vanc sensitive. Sparse growth proteus mirabilis from\n sputum sensitive to cefepime.\n Dental consulted given poor dentition.\n Continue vanc/cefepime with Dose vanc by troughs.\n - Consider d/c flagyll.\n -Per dental recs consult oral surgery for tooth extraction. Unstable\n for panorex.\n Appreciate ID recs.\n d/c surveillance blood cx.\n -f/u wound cultures.\n .\n # Respiratory failure: Intubated for worsening\n hypercarbia/mental status. Respiratory failure likely multifactorial,\n with some component of heart failure/fluid overload as well as some\n pneumonia component. Pt has thus far failed SBTs.RISBI this am\n Barriers to extubation and MS dependence for respiratory\n support. Off sedation almost 72 hours MS slowly improving.\n -daily SBTs.\n -acetazolamide/K/Phos repletions for metabolic alkalosis.\n -K/phos repletions\n -continue abx.\n .\n # PUMP: Acute on chronic right and left-sided systolic heart failure.\n Currently holding lasix drip as was hypotensive to low 80\ns this am,\n with UOP continued at 200-300cc/hr.\n Titrate lasix to maintain UOP as bp tolerates. Goal negative\n -continue digoxin\n Wean neo as tolerated.\n .\n # CORONARIES: CTO of proximal LAD. CE's negative at OSH.\n - continue aspirin 81mg daily\n - continue zocor\n - holding on beta blocker and ACEi due to pressor requirement\n .\n # RHYTHM: Hx cardiomyopathy s/p ICD placement. TEE estimates EF at 55%,\n more accurate than TTE with EF 30%. Also with hx afib. Currently in\n sinus with frequent ectopy. Holding metoprolol in setting of\n hypotension. Had episode of VT o/n in setting of low K+.\n -continue telemetry\n -electrolyte repletions PRN.\n -heparin GTT for Afib. Had some bleeding with TEE now Guaic +Ve stools,\n Crit drop. PTTs in 70s, stable\n -consider holding heparin temporarily, repeat crit, maintain active T\n and S.\n -Hold Coumadin until medically stable.\n -serial EKGs.\n # MS: initially noted to have anisocoria. Now PERRLA but still sluggish\n MS. been off sedation 72 hours although did get versed/fentanyl x1\n for TEE yesterday. Non con CT head showing extensive paranasal sinus\n disease, ? NP hydrocephalus, small radiolucent focus in Left frontal\n bone.\n f/u ? intracranial process as o/p with further imaging\n -continue pressors to maintain CO/cerebral perfusion.\n -daily neuro exams.\n -electrolytes PRN.\n - f/u ? NP hydrocephalus and focal lesion as o/p\n .\n # Hypervolemic hyponatremia: likely secondary to CHF.\n Resolved with Na 139\n -continue to trend.\n .\n # Elevated lactate: Likely secondary to hypoperfusion. Trending down.\n - continue hemodynamic support with pressors\n -continue to trend.\n .\n # Hypothyroidism:\n - continue Synthroid\n .\n # Cardiac Risk Factors: LDL 69. HbA1c 6.6.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full)\n continue tube feeds.\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:00 PM\n Multi Lumen - 09:05 PM\n .\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Communication: Comments: Brother is HCP (contact info in chart)\n Code status: Full code\n Disposition: CCU for now\n ICU Care\n Nutrition:\n Nutren 2.0 (Full)\n continue tube feeds.\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:00 PM\n Multi Lumen - 09:05 PM\n .\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Communication: Comments: Brother is HCP (contact info in chart)\n Code status: Full code\n Disposition: CCU for now\n"
},
{
"category": "Physician ",
"chartdate": "2196-01-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402782,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.8\nF - 10:00 PM\n -TEE performed showing No vegetations on valves or RV/RA wires. Mild to\n moderate mitral regurgitation.\n -dental consulted recommended oral surgery consult for tooth\n extractions (loose incisors).\n -PA catheter pulled,tip not sent.\n -Last swan numbers:35, 13, 5.7, 2.8, 841.\n Labs showed worsening metabolic alkalosis, stable respiratory\n alkalosis. Started on acetazolamide x 2 doses in addition to K/Phos\n repletions, with ABG this morning showing: *****\n Lasix held given hypotension in afternoon to 60s systolic after\n diuresing two litres. Dobutamin considered but given that C.O\n normalized (and dobutamine would have helped by augmenting CO, and has\n mild vasodilatory pressures so would potentially worsen pressures if it\n doesn't augment her C.O), so started vasopressin instead. BP's\n normalized, restarted lasix with UOP ~ 200cc/hr achieved with lasix\n drip at 10cc/hr.\n 5am had 32 beat run of VT, with K of 2.9, agitated.\n K repleted.\n Continued diarrhea. Cdiff\nve x1. Guaic +ve. With crit drop this am to\n 27 from 30.\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:11 AM\n Acyclovir - 04:42 PM\n Vancomycin - 06:40 PM\n Cefipime - 08:00 PM\n Metronidazole - 05:57 AM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Famotidine (Pepcid) - 08:28 PM\n Metoprolol - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 36.5\nC (97.7\n HR: 87 (85 - 128) bpm\n BP: 103/51(65) {96/42(58) - 129/66(80)} mmHg\n RR: 21 (18 - 29) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 86 kg (admission): 80.1 kg\n Total In:\n 628 mL\n 300 mL\n PO:\n TF:\n IVF:\n 628 mL\n 300 mL\n Blood products:\n Total out:\n 1,190 mL\n 270 mL\n Urine:\n 1,190 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n -562 mL\n 30 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 95%\n ABG: 7.42/51/51/31/6\n PaO2 / FiO2: 73\n Physical Examination\n Neuro: responds to voice, moves extremities spontaneously, tracks,\n unable to follow commands\n CVS: RRR\n Lung: improved, less ronchorous\n Abd: +bs, soft, nt, nd\n Skin: appears slightly yellowed but no scleral icterus\n Ext:1+ edema to upper thigh, improved.\n warm extremities, weak peripheral pulses\n Labs / Radiology\n 430 K/uL\n 8.8 g/dL\n 87 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 100 mEq/L\n 141 mEq/L\n 30.6 %\n 9.9 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n WBC\n 11.7\n 9.9\n Hct\n 34.7\n 30.6\n Plt\n 500\n 430\n Cr\n 0.8\n 1.0\n TropT\n 0.02\n TCO2\n 34\n Glucose\n 107\n 87\n Other labs: PT / PTT / INR:28.2/41.5/2.8, CK / CKMB /\n Troponin-T:15//0.02, ALT / AST:, Alk Phos / T Bili:62/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.0\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n PNEUMONIA, ASPIRATION\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 63 y/o F w/ decompensated Stage IV CHF admitted for inotropic-assisted\n diuresis with superimposed sepsis, now intubated for hypercarbic\n respiratory failure/airway protection.\n .\n # CHF: Continued evidence CHF with peripheral edema, crackles on lung\n exam. Continued ionotrope assisted diuresis for decompensated CHF.\n Swan ganz dc'd yesterday. Continue diuresis given cardiogenic shock\n picture CHF.\n Continue lasix drip with lasix bolus's PRN goal negative 1L/day.Renal\n fx tolerating with Cr stable at 1.0\n -Continue pressor support PRN to achieve goal. Wean neo as tolerated,\n d'c vasopressin when able.\n - lyte checks.\n .\n Sepsis: Continues to have low grade fever but no white count, swan\n numbers prior to DC arguing against current ongoing sepsis. No\n vegetation evidenced on TEE to suggest endocarditis. MRSA cultured from\n sputum,blood-vanc sensitive. Sparse growth proteus mirabilis from\n sputum sensitive to cefepime.\n Dental consulted given poor dentition.\n Continue vanc/cefepime with Dose vanc by troughs.\n - Consider d/c flagyll.\n -Per dental recs consult oral surgery for tooth extraction. Unstable\n for panorex.\n Appreciate ID recs.\n d/c surveillance blood cx.\n -f/u wound cultures.\n .\n # Respiratory failure: Intubated for worsening\n hypercarbia/mental status. Respiratory failure likely multifactorial,\n with some component of heart failure/fluid overload as well as some\n pneumonia component. Pt has thus far failed SBTs.RISBI this am\n Barriers to extubation and MS dependence for respiratory\n support. Off sedation almost 72 hours MS slowly improving.\n -daily SBTs.\n -acetazolamide/K/Phos repletions for metabolic alkalosis.\n -K/phos repletions\n -continue abx.\n .\n # PUMP: Acute on chronic right and left-sided systolic heart failure.\n Currently holding lasix drip as was hypotensive to low 80\ns this am,\n with UOP continued at 200-300cc/hr.\n Titrate lasix to maintain UOP as bp tolerates. Goal negative\n -continue digoxin\n Wean neo as tolerated.\n .\n # CORONARIES: CTO of proximal LAD. CE's negative at OSH.\n - continue aspirin 81mg daily\n - continue zocor\n - holding on beta blocker and ACEi due to pressor requirement\n .\n # RHYTHM: Hx cardiomyopathy s/p ICD placement. TEE estimates EF at 55%,\n more accurate than TTE with EF 30%. Also with hx afib. Currently in\n sinus with frequent ectopy. Holding metoprolol in setting of\n hypotension. Had episode of VT o/n in setting of low K+.\n -continue telemetry\n -electrolyte repletions PRN.\n -heparin GTT for Afib. Had some bleeding with TEE now Guaic +Ve stools,\n Crit drop. PTTs in 70s, stable\n -consider holding heparin temporarily, repeat crit, maintain active T\n and S.\n -Hold Coumadin until medically stable.\n -serial EKGs.\n # MS: initially noted to have anisocoria. Now PERRLA but still sluggish\n MS. been off sedation 72 hours although did get versed/fentanyl x1\n for TEE yesterday. Non con CT head showing extensive paranasal sinus\n disease, ? NP hydrocephalus, small radiolucent focus in Left frontal\n bone.\n f/u ? intracranial process as o/p with further imaging\n -continue pressors to maintain CO/cerebral perfusion.\n -daily neuro exams.\n -electrolytes PRN.\n - f/u ? NP hydrocephalus and focal lesion as o/p\n .\n # Hypervolemic hyponatremia: likely secondary to CHF.\n Resolved with Na 139\n -continue to trend.\n .\n # Elevated lactate: Likely secondary to hypoperfusion. Trending down.\n - continue hemodynamic support with pressors\n -continue to trend.\n .\n # Hypothyroidism:\n - continue Synthroid\n .\n # Cardiac Risk Factors: LDL 69. HbA1c 6.6.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full)\n continue tube feeds.\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:00 PM\n Multi Lumen - 09:05 PM\n .\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Communication: Comments: Brother is HCP (contact info in chart)\n Code status: Full code\n Disposition: CCU for now\n ICU Care\n Nutrition:\n Nutren 2.0 (Full)\n continue tube feeds.\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:00 PM\n Multi Lumen - 09:05 PM\n .\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Communication: Comments: Brother is HCP (contact info in chart)\n Code status: Full code\n Disposition: CCU for now\n"
},
{
"category": "General",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Generic Note",
"row_id": 402888,
"text": "TITLE:\n Cardiology attending addendum to Dr \ns note\n 45 minutes\n History and exam as described in his note.\n Continued to diurese over night. Metoprolol changed to PO from IV\n Heart rate 80s in AF.\n Saturating 90% on 3l NC\n She remains mildly confused but no evidence of seizures or progressive\n neurological decline.\n Plan for today is to continue to diurese slowly.\n INR is 6\n will monitor closely and administer small dose of vitamin K\n if rises further.\n"
},
{
"category": "Physician ",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402897,
"text": "Chief Complaint:\n 24 Hour Events:\n - got an ABG, which was stable\n - stopped lasix gtt temporarily because she was hypotensive, restarted\n when BP's improved\n - allowed her to get some applesauce\n - changed metoprolol to PO\n - all Cx NGTD\n - sent stool for C.diff\n - wound care: rheum should be consulted when patients condition\n improves (for leg ulcers) - refer to wound care note for furhter\n details\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 08:00 PM\n Metronidazole - 11:00 PM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:45 AM\n Metoprolol - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 35.9\nC (96.7\n HR: 93 (82 - 99) bpm\n BP: 115/52(66) {82/38(49) - 119/62(73)} mmHg\n RR: 22 (16 - 28) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 86 kg (admission): 80.1 kg\n Total In:\n 1,523 mL\n 104 mL\n PO:\n TF:\n IVF:\n 1,523 mL\n 104 mL\n Blood products:\n Total out:\n 1,215 mL\n 475 mL\n Urine:\n 1,215 mL\n 475 mL\n NG:\n Stool:\n Drains:\n Balance:\n 308 mL\n -371 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.36/60/73.//5\n PaO2 / FiO2: 104\n Physical Examination\n Gen: Alert; NAD; Oriented to person (disoriented to place and time)\n HEENT: EOMI, PERRL, OP clear\n CV: Irregular rhythm; holosystolic murmur heard throughout\n Lungs: significant for wet cough; wheezes and rhonchi throughout\n Abd: S/NT/ND; BS present\n Ext : WWP; waffle boots in place\n Labs / Radiology\n 354 K/uL\n 8.8 g/dL\n 85 mg/dL\n 1.0 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 20 mg/dL\n 101 mEq/L\n 142 mEq/L\n 30.0 %\n 8.2 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n 02:18 PM\n 05:28 AM\n WBC\n 11.7\n 9.9\n 8.2\n Hct\n 34.7\n 30.6\n 30.0\n Plt\n \n Cr\n 0.8\n 1.0\n 1.0\n TropT\n 0.02\n TCO2\n 34\n 35\n Glucose\n 107\n 87\n 85\n Other labs: PT / PTT / INR:55.1/41.5/6.1, CK / CKMB /\n Troponin-T:15//0.02, ALT / AST:, Alk Phos / T Bili:62/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca++:8.1 mg/dL, Mg++:1.8\n mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures on who had MS\n change first noted following MRI, who subsequently flashed on the floor\n in the setting of holding lasix.\n # Pulmonary Edema: The patient has a history of severe AS and developed\n pulmonary edema in the setting of having her diuretics held on\n admission. She is currently on a lasix gtt. Her respiratory status\n has improved greatly since transfer to the CCU. ABG yesterday was\n stable with priors.\n - continue lasix drip, titrating as needed\n - consider repeat CXR today\n # Possibly Aspiration PNA: Pt noted to have a fever 2 nights ago.\n Afebrile overnight tonight without leukocytosis. Of note, however, MS\n change occurred in the setting of laying flat for an MRI and could\n represent an aspiration event.\n - continue vanc/cefepime/zosyn for now; can stop if CXR does not show\n any new infiltrate though\n - trend WBC and fever curves\n - f/u micro data\n # Afib: Pt in Afib with RVR on arrival, in the setting of not receiving\n her metoprolol. Restarted on IV metoprolol on arrival to the CCU. Now\n s/p transition to PO metprolol.\n - no episodes RVR overnight\n - continue to monitor on telemetry\n # AS: AS s/p valvuloplasty .Severe AS on Echo . AS known\n critical, unclear if worsened AS since as valve area not quantified\n but known to be critical. Pt poor surgical candidate thus had not\n received AVR.\n - consideration being given for minimally invasive percutaneous valve\n replacement\n # MS Change: Likely multifactorial related to benzodiazepine,\n infection, ?stroke.\n - ASA 81mg\n - serial neuro exams.\n - keppra for seizure prophylaxis.\n - avoid benzos\n - follow resp status, serial ABGs.\n - diuresis and antibiotics as above\n - MRI when stable, per neuro recs\n # Hx Diarrhea: Hx C.diff on chronic suppression therapy with p.o\n vanc/flagyl with last cx at rehab on negative. At that\n time, antibiotics were continued. However diarrhea has stopped so abx\n stopped this hospitalization.\n - can continue to monitor\n - f/u stool studies sent yesterday\n # hx GI bleed: Hematocrit stable this morning\n - continue to trend hematocrit\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:01 AM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Possible transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 402521,
"text": "86F s/p witnessed tonic clonic/sz activity @ Rehab no hx of\n seizures; the seizure lasted only about 5 minutes at the rehabilitation\n facility, and then resolved spontaneously. Her daughter and husband\n were visiting her and they noticed a self-limitted 5 minutes seizure,\n described as acute onset of LOC, followed by whole body stiffens and\n later shaking. She was brought to the ED, and during her\n observation in the ED she another 30 seconds GTC seizure. To stop the\n cluster she received Ativan IV and later she was loaded with 1000mg of\n IV Keppra. No further seizures in the ED.\n .\n She had a valvuloplasty performed for AS;she was then admitted\n from 1/11-20/10 for right hemicolectomy for cancer. Her hospital\n course was complicated by hypercarbia requiring intubation and fluid\n overload requiring diuresis. Subsequent to this she developed C.\n difficile colitis, for which she has been on IV vancomycin since; she\n continues to complain of abdominal pain, although she has had a recent\n followup abdominal CT after her partial colectomy, which per the\n patient's family was unremarkable\n PMHx:\n . CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Cancer\n Pt admitted to SICU B from the ED s/p seizure. Neuro exam intact,\n although pt speaking in grunts and\n occasional\n one word response to questions. WBC 12.1, ? meningitis as per\n neuro-med team.\n Pt has severe AS, is in A Fib, on Coumadin, has hx HTN.\n On O2 at 2-4 l, congested cough. Sats 93-99.\n Foley in place, u/o 25-40 cc/hr.\n Small amts green stool per rectum.\n Pt has chronic bilat venous ulcerations on lower legs.\n Action:\n Antibiotics for possible CNS infection\n Q2 hr neuro checks\n Coumadin as ordered qd at 1600, monitor INR\n Rate control with Metoprolol for AF, cardiac echo to r/o endocarditis\n Continue O2 as needed to support sats >95%\n Lasix \n Lower leg dsgs changed\ntelfa and kerlix applied\n Response:\n Pt has no signs of seizure since admission, Neuro stable\n O2 at 4 l, pt coughing and a bit congested\n Antibiotics given as ordered\n Metoprolol held at 0200 due to borderline blood pressure 102/70\n Venodynes ordered but not applied due to open venous ulcers on legs.\n Plan:\n Continue Neuro checks q 2\n Monitor for sx of seizure\n Echo in AM\n Metoprolol if bp tolerates\n Coumadin qd\n Encourage coughing and deep breathing, IS q 1-2 hrs when awake\n Antibiotics as ordered\n Check labs this am.\n Change dsd on lower legs , keep heels off bed to prevent further\n skin issues.\n Seizure, without status epilepticus\n Assessment:\n No further seizures noted..lethargic but easily aroused..follows\n commands..equal strength both arms..unable to move legs due to\n arthritis per patient..is able to wiggle toes to command..pupils equal\n & react to light\n oriented x2 to person & occ place\n Action:\n Cardiac echo & EEG done..attempted po liquids\nantibiotics dc\nd per\n neuro\n Response:\n ? Aspirated h2o but does well with soft solids(will take pills with\n apple sauce)\n Plan:\n Transfer to floor\nneuro checks Q 4h\nPT consult to increase activity\n Demographics\n Attending MD:\n \n Admit diagnosis:\n SEIZURE\n Code status:\n Height:\n Admission weight:\n 80.1 kg\n Daily weight:\n 80.1 kg\n Allergies/Reactions:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Precautions:\n PMH:\n CV-PMH: Arrhythmias, Hypertension\n Additional history: PMH: 1. CAD s/p CABG for LM disease (LIMA\n to LAD and saphenous vein graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 15. Cancer s/p hemicolectomy on \n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:103\n D:58\n Temperature:\n 97.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 98 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 3,067 mL\n 24h total out:\n 994 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 04:27 AM\n Potassium:\n 4.0 mEq/L\n 04:27 AM\n Chloride:\n 101 mEq/L\n 04:27 AM\n CO2:\n 33 mEq/L\n 04:27 AM\n BUN:\n 21 mg/dL\n 04:27 AM\n Creatinine:\n 0.8 mg/dL\n 04:27 AM\n Glucose:\n 107 mg/dL\n 04:27 AM\n Hematocrit:\n 34.7 %\n 04:27 AM\n Finger Stick Glucose:\n 98\n 04:00 PM\n Valuables / Signature\n Patient valuables: NONE\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 11\n Date & time of Transfer: \n"
},
{
"category": "Physician ",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402867,
"text": "Chief Complaint:\n 24 Hour Events:\n - got an ABG, which was stable\n - stopped lasix gtt temporarily because she was hypotensive, restarted\n when BP's improved\n - allowed her to get some applesauce\n - changed metoprolol to PO\n - all Cx NGTD\n - sent stool for C.diff\n - wound care: rheum should be consulted when patients condition\n improves (for leg ulcers) - refer to wound care note for furhter\n details\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 08:00 PM\n Metronidazole - 11:00 PM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:45 AM\n Metoprolol - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 35.9\nC (96.7\n HR: 93 (82 - 99) bpm\n BP: 115/52(66) {82/38(49) - 119/62(73)} mmHg\n RR: 22 (16 - 28) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 86 kg (admission): 80.1 kg\n Total In:\n 1,523 mL\n 104 mL\n PO:\n TF:\n IVF:\n 1,523 mL\n 104 mL\n Blood products:\n Total out:\n 1,215 mL\n 475 mL\n Urine:\n 1,215 mL\n 475 mL\n NG:\n Stool:\n Drains:\n Balance:\n 308 mL\n -371 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.36/60/73.//5\n PaO2 / FiO2: 104\n Physical Examination\n Neuro: AO to Person, time, disoriented to place\n CVS:irregularly irregular, SEM\n Lung: improved, less ronchorous, less wheeze, JVP ~ 7cm\n Abd: +bs, soft, nt, nd\n Ext : WWP, 1+ edema below knee, mid shin bandages in place.\n warm extremities, weak peripheral pulses\n Labs / Radiology\n 354 K/uL\n 8.8 g/dL\n 85 mg/dL\n 1.0 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 20 mg/dL\n 101 mEq/L\n 142 mEq/L\n 30.0 %\n 8.2 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n 02:18 PM\n 05:28 AM\n WBC\n 11.7\n 9.9\n 8.2\n Hct\n 34.7\n 30.6\n 30.0\n Plt\n \n Cr\n 0.8\n 1.0\n 1.0\n TropT\n 0.02\n TCO2\n 34\n 35\n Glucose\n 107\n 87\n 85\n Other labs: PT / PTT / INR:55.1/41.5/6.1, CK / CKMB /\n Troponin-T:15//0.02, ALT / AST:, Alk Phos / T Bili:62/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca++:8.1 mg/dL, Mg++:1.8\n mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures on who had MS\n change first noted following MRI, who subsequently flashed on the floor\n in the setting of holding lasix.\n # Pulmonary Edema: The patient has a history of severe AS and developed\n pulmonary edema in the setting of having her diuretics held on\n admission. She is currently on a lasix gtt. Her respiratory status\n has improved greatly since transfer to the CCU. ABG yesterday was\n stable with priors.\n - continue lasix drip, titrating as needed\n - continue digoxin\n - consider repeat CXR today\n Afib: Pt in Afib with RVR on arrival. Had been NPO for some time on the\n floor, had been on p.o metoprolol on am then changed to IV at 5-10\n Q4 on 3/3pm but didn't get any on although written, ? low SBPs.\n On arrival to floor received IV metoprolol 2.5 with improvement rate to\n 80's from 128.\n Uptitrated metoprolol to 15mg IV q4 (conversion 2.5:1 IV to p.o)\n -continue metoprolol IV.\n As becomes more alert, able to tolerate pills convert to p.o.\n -am EKG.\n # Flash Pulmonary Edema: CAD s/p CABG 86F with CAD s/p CABG \n (SVG-OM, LIMA-LAD)\n -Given AS pt very sensitive to fluid shifts, had been lying down for a\n long time at MRI and lasix was being held on floor to prevent cerebral\n hypoperfusion with subsequent flash.\n On arrival to ICU received IV lasix bolus 60mg IV and started on lasix\n drip.\n .\n #AS: AS s/p valvuloplasty .Severe AS on Echo with valve\n area not quantified but LVOT of 12 noted which was not noted on Echo of\n but valve area of 0.8. EF stable at 60%. AS known critical,\n unclear if worsened AS since as valve area not quantified but known\n to be critical. Pt poor surgical candidate thus had not received AVR.\n -Consideration being given for minimally invasive percutaneous valve\n replacement.\n -f/u with ICU fellow/Dr \n cautious diruesis in setting critical AS.\n .\n # MS Change: Likely multifactorial related to benzodiazepine pre MRI\n although only received 0.5mg, C02 retention fatigue with mildly\n elevated C02 of 63 on ABG, and low CO with CHF.\n Did have on CTA and has new, subtle LUE/LLE weakness and no\n reflexes on LLE which is new per neuro consistent with lesion on right.\n This lesion is most likely vascular in nature, either a small infarct\n which converted to a bleed, versus less likely malignant ? metastatic\n colon cancer. Once medically stable neuro recommends MRI with\n gadolinium to asses lesion. If does not enhance, likely bleed.\n -appreciate neuro recs\n -ASA 81mg\n -serial neuro exams.\n -keppra for seizure prophylaxis.\n -gentle diuresis\n -avoid benzos\n -follow resp status, serial ABGs.\n -diuresis\n .\n # ? Infection: Pt low grade temp to 100.3.\n Had been lying flat at MRI y/d, possible aspiration pneumonitis.\n If spikes temp, white count, institute Abx coverage with cipro.\n f/u with ? chronic suppression with vanc for c.diff\n Blood cx drawn with initial question of meningitis on presentation with\n seizures have been negative x 3. Urine cx negative x1, repeat drawn on\n pending.\n -f/u final urine cx\n -trend WBC, fever curve.\n .\n # Hx Diarrhea:\n hx C.diff on chronic suppression therapy with p.o vanc/flagyll with\n last cx at rehab on negative but abx were continued to\n continued diarrhea. However diarrhea has stopped so abx stopped this\n hospitalization.\n Continue to monitor.\n .\n #hx GI bleed: s/p hemicolectomy following which she presented to \n rehab.\n Baseline Hct ~ 30, 35 on now 32.2\n Continue to trend daily.\n Guiac all stools\n active type and screen.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:01 AM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Possible transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402872,
"text": "Chief Complaint:\n 24 Hour Events:\n - got an ABG, which was stable\n - stopped lasix gtt temporarily because she was hypotensive, restarted\n when BP's improved\n - allowed her to get some applesauce\n - changed metoprolol to PO\n - all Cx NGTD\n - sent stool for C.diff\n - wound care: rheum should be consulted when patients condition\n improves (for leg ulcers) - refer to wound care note for furhter\n details\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 08:00 PM\n Metronidazole - 11:00 PM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:45 AM\n Metoprolol - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 35.9\nC (96.7\n HR: 93 (82 - 99) bpm\n BP: 115/52(66) {82/38(49) - 119/62(73)} mmHg\n RR: 22 (16 - 28) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 86 kg (admission): 80.1 kg\n Total In:\n 1,523 mL\n 104 mL\n PO:\n TF:\n IVF:\n 1,523 mL\n 104 mL\n Blood products:\n Total out:\n 1,215 mL\n 475 mL\n Urine:\n 1,215 mL\n 475 mL\n NG:\n Stool:\n Drains:\n Balance:\n 308 mL\n -371 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.36/60/73.//5\n PaO2 / FiO2: 104\n Physical Examination\n Neuro: AO to Person, time, disoriented to place\n CVS:irregularly irregular, SEM\n Lung: improved, less ronchorous, less wheeze, JVP ~ 7cm\n Abd: +bs, soft, nt, nd\n Ext : WWP, 1+ edema below knee, mid shin bandages in place.\n warm extremities, weak peripheral pulses\n Labs / Radiology\n 354 K/uL\n 8.8 g/dL\n 85 mg/dL\n 1.0 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 20 mg/dL\n 101 mEq/L\n 142 mEq/L\n 30.0 %\n 8.2 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n 02:18 PM\n 05:28 AM\n WBC\n 11.7\n 9.9\n 8.2\n Hct\n 34.7\n 30.6\n 30.0\n Plt\n \n Cr\n 0.8\n 1.0\n 1.0\n TropT\n 0.02\n TCO2\n 34\n 35\n Glucose\n 107\n 87\n 85\n Other labs: PT / PTT / INR:55.1/41.5/6.1, CK / CKMB /\n Troponin-T:15//0.02, ALT / AST:, Alk Phos / T Bili:62/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca++:8.1 mg/dL, Mg++:1.8\n mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures on who had MS\n change first noted following MRI, who subsequently flashed on the floor\n in the setting of holding lasix.\n # Pulmonary Edema: The patient has a history of severe AS and developed\n pulmonary edema in the setting of having her diuretics held on\n admission. She is currently on a lasix gtt. Her respiratory status\n has improved greatly since transfer to the CCU. ABG yesterday was\n stable with priors.\n - continue lasix drip, titrating as needed\n - continue digoxin\n - consider repeat CXR today\n # Possibly Aspiration PNA: Pt noted to have a fever 2 nights ago.\n Afebrile overnight tonight without leukocytosis. Of note, however, MS\n change occurred in the setting of laying flat for an MRI and could\n represent an aspiration event.\n - continue vanc/cefepime/zosyn for now\n - trend WBC and fever curves\n - f/u micro data\n # Afib: Pt in Afib with RVR on arrival, in the setting of not receiving\n her metoprolol. Restarted on IV metoprolol on arrival to the CCU. Now\n s/p transition to PO metprolol.\n - no episodes RVR overnight\n - continue to monitor on telemetry\n # AS: AS s/p valvuloplasty .Severe AS on Echo . AS known\n critical, unclear if worsened AS since as valve area not quantified\n but known to be critical. Pt poor surgical candidate thus had not\n received AVR.\n - consideration being given for minimally invasive percutaneous valve\n replacement\n # MS Change: Likely multifactorial related to benzodiazepine pre MRI\n although only received 0.5mg, C02 retention fatigue with mildly\n elevated C02 of 63 on ABG, and low CO with CHF. Did have on\n CTA and has new, subtle LUE/LLE weakness and no reflexes on LLE which\n is new per neuro consistent with lesion on right. This lesion is most\n likely vascular in nature, either a small infarct which converted to a\n bleed, versus less likely malignant ? metastatic colon cancer. Once\n medically stable neuro recommends MRI with gadolinium to asses lesion.\n If does not enhance, likely bleed. Also could be related to aspiration\n event.\n -appreciate neuro recs\n -ASA 81mg\n -serial neuro exams.\n -keppra for seizure prophylaxis.\n -gentle diuresis\n -avoid benzos\n -follow resp status, serial ABGs.\n -diuresis as above\n - antibiotics as above\n # Hx Diarrhea: Hx C.diff on chronic suppression therapy with p.o\n vanc/flagyl with last cx at rehab on negative. At that\n time, antibiotics were continued. However diarrhea has stopped so abx\n stopped this hospitalization.\n - can continue to monitor\n - f/u stool studies sent yesterday\n # hx GI bleed: Hematocrit stable this morning\n - continue to trend hematocrit\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:01 AM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Possible transfer to floor\n"
},
{
"category": "Nutrition",
"chartdate": "2196-02-01 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 403007,
"text": "Subjective\n per patient's husband she barely ate anything in rehab resulting in wt\n loss unsure amount\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 80.1 kg\n 82 kg ( 08:00 AM)\n 28.4\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 59 kg\n 136%\n 64.3 kg\n kg\n %\n Diagnosis: seizure\n PMHx: CAD s/p CABG for LM disease (LIMA to LAD and saphenous\n vein graft to the OM\n Severe AS s/p valvuloplasty in \n AFib on coumadin\n HTN\n Hyperlipidemia\n OA, s/p R THR and spinal stenosis\n Squamous cell carcinoma\n Chronic venous stasis with ulcerations\n Hypothyroidism\n Peripheral neurophathy\n Raynaud\ns syndrome\n R Retinal VA clot, w/ mild loss of vision\n Chronic Diastolic heart failure\n Shingles \n Colon Cancer s/p hemicolectomy on course complicated by C.diff.\n Currently negative C. diff.\n Food allergies and intolerances: lactose\n Pertinent medications:\n Labs:\n Value\n Date\n Glucose\n 109 mg/dL\n 04:56 AM\n Glucose Finger Stick\n 107\n 12:00 PM\n BUN\n 22 mg/dL\n 04:56 AM\n Creatinine\n 1.1 mg/dL\n 04:56 AM\n Sodium\n 141 mEq/L\n 04:56 AM\n Potassium\n 3.9 mEq/L\n 04:56 AM\n Chloride\n 101 mEq/L\n 04:56 AM\n TCO2\n 36 mEq/L\n 04:56 AM\n PO2 (arterial)\n 73. mm Hg\n 02:18 PM\n PCO2 (arterial)\n 60 mm Hg\n 02:18 PM\n pH (arterial)\n 7.36 units\n 02:18 PM\n pH (urine)\n 5.0 units\n 09:34 PM\n CO2 (Calc) arterial\n 35 mEq/L\n 02:18 PM\n Calcium non-ionized\n 8.2 mg/dL\n 04:56 AM\n Phosphorus\n 2.7 mg/dL\n 04:56 AM\n Magnesium\n 2.1 mg/dL\n 04:56 AM\n ALT\n 6 IU/L\n 04:27 AM\n Alkaline Phosphate\n 62 IU/L\n 04:27 AM\n AST\n 18 IU/L\n 04:27 AM\n Total Bilirubin\n 0.2 mg/dL\n 04:27 AM\n Triglyceride\n 98 mg/dL\n 04:27 AM\n WBC\n 7.0 K/uL\n 04:56 AM\n Hgb\n 8.7 g/dL\n 04:56 AM\n Hematocrit\n 30.7 %\n 04:56 AM\n Current diet order / nutrition support: Nutren 2.0@ 50 ml/hr= 2400\n kcals/ 96 g protein\n GI: soft, positive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO / hypocaloric diet, wt loss\n Estimated Nutritional Needs\n Calories: 1608- (BEE x or / 25-30 cal/kg)\n Protein: 77-96 (1.2-1.5 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: Inadequate per patient\ns husband\n Estimation of current intake: Inadequate\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402873,
"text": "86 yr. old woman with severe AS (critical AS-> s/p valvuloplasty\n ), CAD s/p CABG (lima-lad, svg-om), dCHF, & AF. Multiple\n recent hospitalizations ( valvuloplasty, hemicolectomy for\n adenoCA, c diff colitis, diverticulitis. Admitted after seizure\n which stopped with ativan and keppra. Diuretics were held on admission.\n She was treated initially for meningitis. CTA was negative for CVA. MRI\n head with high signal intensity in the R superior parietal lobe. After\n MRI on she triggered for AMS and lethargy. Her HR was in the\n 130s and her SBP was in the 80s. Her ABG was notable for pCO2 65. She\n was given lasix 10mg IV then 30mg and 5mg IV metoprolol without\n significant improvement.\n Pneumonia, aspiration\n Assessment:\n O2 70% OFT & 4L NP. O2 sat 98-100%\n BS clear with crackles at bases.\n C&R thick tan secretions.\n Action:\n Cont. to receive IV vanco, flagyl & cefepime.\n O2 weaned to 3l NP.\n Encourage pt to C&DB.\n Response:\n O2 sats 95-100% on 3l NP.\n Plan:\n Cont. to be vigilant with pulmonary toilet.\n Seizure, without status epilepticus\n Assessment:\n Lethargic, but easily arousable.\n PERL.\n Moves all extremities, but extremely deconditioned.\n Follows commands & engages in conversation.\n Action:\n Keppra \n Response:\n No seizure activity noted since admission to ccu.\n Plan:\n Cont. with Keppra.\n Cont. to monitor neuro signs,\n Aortic stenosis\n Assessment:\n HR 80-90\ns AF with rare PVC.\n BP 91-121/40-50\n Cont. with LE edema.\n Lasix gtt held at 1800 D/T mild hypotension.\n U/O dropped to 15cc/hr x2hrs.\n K 3.6, Mg 1.8\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402875,
"text": "86 yr. old woman with severe AS (critical AS-> s/p valvuloplasty\n ), CAD s/p CABG (lima-lad, svg-om), dCHF, & AF. Multiple\n recent hospitalizations ( valvuloplasty, hemicolectomy for\n adenoCA, c diff colitis, diverticulitis. Admitted after seizure\n which stopped with ativan and keppra. Diuretics were held on admission.\n She was treated initially for meningitis. CTA was negative for CVA. MRI\n head with high signal intensity in the R superior parietal lobe. After\n MRI on she triggered for AMS and lethargy. Her HR was in the\n 130s and her SBP was in the 80s. Her ABG was notable for pCO2 65. She\n was given lasix 10mg IV then 30mg and 5mg IV metoprolol without\n significant improvement.\n Pneumonia, aspiration\n Assessment:\n O2 70% OFT & 4L NP. O2 sat 98-100%\n BS clear with crackles at bases.\n C&R thick tan secretions.\n Action:\n Cont. to receive IV vanco, flagyl & cefepime.\n O2 weaned to 3l NP.\n Encourage pt to C&DB.\n Response:\n O2 sats 95-100% on 3l NP.\n Plan:\n Cont. to be vigilant with pulmonary toilet.\n Seizure, without status epilepticus\n Assessment:\n Lethargic, but easily arousable.\n PERL.\n Moves all extremities, but extremely deconditioned.\n Follows commands & engages in conversation.\n Action:\n Keppra \n Response:\n No seizure activity noted since admission to ccu.\n Plan:\n Cont. with Keppra.\n Cont. to monitor neuro signs,\n Aortic stenosis\n Assessment:\n HR 80-90\ns AF with rare PVC.\n BP 91-121/40-50\n Cont. with LE edema.\n Lasix gtt held at 1800 D/T mild hypotension.\n U/O dropped to 15cc/hr x2hrs.\n K 3.6, Mg 1.8\n Action:\n Lasix gtt restarted 5mg/hr.\n Receiving po metoprolol & dig.\n KCL 40meq PB & MgSo4 2 Gms PB given.\n Cont. to hold Coumadin D/T elevated INR.\n Response:\n U/O 25-120cc/hr.\n + 1.6L for LOS.\n Plan:\n Cont. with lasix gtt.\n Replete lytes as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403214,
"text": "Pneumonia, aspiration\n Assessment:\n Lungs rhonchi with crackles.\n O2 sats > 95% on 2l.,\n Less frequent coughing although cough remains very congested.\n Action:\n Conts on Vancomycin. Flagyl & Cefipeme\n Strict NPO for aspiration precautions.\n Conts on TF at goal rate.\n Atrovent Q6hrs.\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n No seizures noted.\n Pt lethargic but arousable to voice.\n Able to follow commands.\n MAE.\n Action:\n Kepra ^\nd to 1000mg .\n Monitor neuro status.\n Response:\n No seizures noted.\n Pt remains somulent\n Plan:\n Aortic stenosis\n Assessment:\n Tele AF 70\ns-90\n Lasix drip off.\n Action:\n Lasix 60mg daily.\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nutrition",
"chartdate": "2196-02-01 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 403014,
"text": "Subjective\n per patient's husband she barely ate anything in rehab resulting in wt\n loss unsure amount\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 80.1 kg\n 82 kg ( 08:00 AM)\n 28.4\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 59 kg\n 136%\n 64.3 kg\n Diagnosis: seizure\n PMHx: CAD s/p CABG for LM disease (LIMA to LAD and saphenous\n vein graft to the OM\n Severe AS s/p valvuloplasty in \n AFib on coumadin\n HTN\n Hyperlipidemia\n OA, s/p R THR and spinal stenosis\n Squamous cell carcinoma\n Chronic venous stasis with ulcerations\n Hypothyroidism\n Peripheral neurophathy\n Raynaud\ns syndrome\n R Retinal VA clot, w/ mild loss of vision\n Chronic Diastolic heart failure\n Shingles \n Colon Cancer s/p hemicolectomy on course complicated by C.diff.\n Currently negative C. diff.\n Food allergies and intolerances: lactose\n Pertinent medications: heparin, RISS, folic acid, famotidine, Potassium\n Chloride (20 mEq repletion), others noted\n Labs:\n Value\n Date\n Glucose\n 109 mg/dL\n 04:56 AM\n Glucose Finger Stick\n 107\n 12:00 PM\n BUN\n 22 mg/dL\n 04:56 AM\n Creatinine\n 1.1 mg/dL\n 04:56 AM\n Sodium\n 141 mEq/L\n 04:56 AM\n Potassium\n 3.9 mEq/L\n 04:56 AM\n Chloride\n 101 mEq/L\n 04:56 AM\n TCO2\n 36 mEq/L\n 04:56 AM\n PO2 (arterial)\n 73. mm Hg\n 02:18 PM\n PCO2 (arterial)\n 60 mm Hg\n 02:18 PM\n pH (arterial)\n 7.36 units\n 02:18 PM\n pH (urine)\n 5.0 units\n 09:34 PM\n CO2 (Calc) arterial\n 35 mEq/L\n 02:18 PM\n Calcium non-ionized\n 8.2 mg/dL\n 04:56 AM\n Phosphorus\n 2.7 mg/dL\n 04:56 AM\n Magnesium\n 2.1 mg/dL\n 04:56 AM\n ALT\n 6 IU/L\n 04:27 AM\n Alkaline Phosphate\n 62 IU/L\n 04:27 AM\n AST\n 18 IU/L\n 04:27 AM\n Total Bilirubin\n 0.2 mg/dL\n 04:27 AM\n Triglyceride\n 98 mg/dL\n 04:27 AM\n WBC\n 7.0 K/uL\n 04:56 AM\n Hgb\n 8.7 g/dL\n 04:56 AM\n Hematocrit\n 30.7 %\n 04:56 AM\n Current diet order / nutrition support: Nutren 2.0@ 50 ml/hr= 2400\n kcals/ 96 g protein\n GI: soft, positive bowel sounds\n Skin:left heel unstageable\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO / hypocaloric diet, wt loss\n Estimated Nutritional Needs\n Calories: 1608- (BEE x or / 25-30 cal/kg)\n Protein: 77-96 (1.2-1.5 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: Inadequate per patient\ns husband\n Estimation of current intake: Inadequate\n Specifics: 86 year old female s/p winressed tonic seizure at \n rehab lasted about 5 minutes brought to ED had 30 seconds GTC seizure.\n Patient transferred to CCU after AMS and lethargy after MRI. Received\n consult for tube feeding recommendations. SLP recommended patient be\n NPO this morning, NGT placed. Patient with extra fluid per patient\n husband plan to diurese.\n Medical Nutrition Therapy Plan - Recommend the Following:\n 1. Tube feeding recommendations Nutren Pulmonary @ 15 ml/hr\n advance to goal of 45 ml/hr with 21 g beneprotein to provide 1695\n kcals/ 81 g protein\n 2. Check residuals hold if greater than 200 ml\n 3. At high risk of refeeding syndrome monitor and replete K, Mg,\n Phos\n 4. Will follow page with questions\n"
},
{
"category": "Rehab Services",
"chartdate": "2196-02-01 00:00:00.000",
"description": "Bedside Swallowing Evaluation",
"row_id": 403020,
"text": "TITLE: BEDSIDE SWALLOWING EVALUATION:\nHISTORY:Thank you for consulting on this 86 y/o woman with\ncomplex medical history which includes CAD s\\p CABG in ,\nvalvuloplasty and recent laparoscopy with right\nhemicolectomy in , complicated by ongoing C. Diff\ninfection. She has been living in the \nCenter and for the past 5 weeks her family has noted that she is\nslightly confused and more somnolent. Her daughter and husband\nwere visiting her and they noticed a self-limited 5 minutes\nseizure, described as acute onset of LOC, followed by whole body\nstiffness and later, shaking. She was brought to the ED on\n, and during her observation in the ED she another 30\nseconds GTC seizure. To stop the cluster she received Ativan and\nKeppra. No further seizures. CXR on showed mild pulmonary\nedema and opacity in the left lower lobe which might represent\natelectasis or infection. Patient was transferred to Neuro ICU.\nWe were consulted to evaluate the pt for oral and pharyngeal\ndysphagia. Patient was initially ordered for nectar thick liquids\nand ground solids, but was made NPO on . We attempted to\nsee the patient on , but patient triggered on for\naltered mental status and lethargy, so evaluation was deferred.\nPatient was transferred to CCU for further management. We\nreturned today to re-attempt the bedside swallow evaluation. RN\nreported that patient is more alert today and was given meds with\napplesauce over the weekend, but otherwise remained NPO.\nPMH:\n1. CAD status post CABG \n2. Severe aortic stenosis, s\\p recent valvuloplasty.\n3. AFib on coumadin\n4. HTN\n5. Hyperlipidemia\n6. Osteoarthritis - hip replacement spinal stenosis\n7. Squamous cell carcinoma\n8. Chronic venous stasis with ulceration\n9. Hypothyroidism\n10. peripheral neuropathy\n11. Raynaud's synd\n12. Right retinal vein clot with mild loss of vision\n13. Diastolic heart failure\n14. Shingles in \n15. Status post right hemicolectomy in \nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed in the CCU.\nCognition, language, speech, voice:\nPatient was awake and alert when stimulated. Oriented to name.\nOriented to year and location when given two choices. Patient\nfollowed most basic commands. Speech output was somewhat\nintelligible but limited, so it was difficult to assess fluency.\nVoice was very hoarse and quiet.\nTeeth: Intact\nSecretions: Normal oral secretions. Persistent, weak, baseline\ncongested cough, non-productive.\nORAL MOTOR EXAM:\nTongue protruded midline. Reduced lingual strength and ROM.\nAdequate labial strength and ROM. Reduced buccal tone.\nSymmetrical palatal elevation. Mild gag upon Yankauer\nsuctioning.\nSWALLOWING ASSESSMENT:\nPO trials included ice chip, thin liquid (tsp), nectar-thick\nliquid (tsp), honey-thick liquid (tsp), and puree. Patient\nformed adequate labial seal w/ no anterior spill. Mastication\nnot assessed, as no solids were given. Oral transit was timely.\nNo oral residue following POs. Swallow trigger present.\nLaryngeal elevation adequate to palpation. Wet change in vocal\nquality following all liquids. Consistent congested coughing\nfollowing all POs. Weak baseline coughing persisted for several\nminutes after each PO trial, and following evaluation. O2 sats\nremained stable at 98-100%.\nSUMMARY / IMPRESSION:\nMs. presents with significant generalized weakness,\nsignificant baseline congested cough w/ difficulty managing\nsecretions, and s/sx of aspiration on liquids and purees,\nincluding consistent congested coughing and wet change in vocal\nquality. At this time, recommend that patient remain NPO.\nRecommend tube feeds as primary means of much-needed nutrition,\nhydration, and medication. We will follow-up later on this week\nto repeat the bedside evaluation to determine if patient is ready\nfor a PO diet, with improvement in strength and nutritional\nstatus.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of 1, NPO.\nRECOMMENDATIONS:\n1. Tube feeds as primary means of nutrition, hydration, and\nmedication.\n2. We will follow-up later on this week to repeat the bedside\nevaluation to determine if patient is ready for a PO diet, with\nimprovement in strength and nutritional status.\n3. Q4 oral care\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\nRamya B.A, SLP/S\nPager#\n____________________________________\n M.S., CCC-SLP\nPager #\nFace time: 1145-1215\nTotal time: 80 minutes\n"
},
{
"category": "Rehab Services",
"chartdate": "2196-02-04 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 403537,
"text": "Re-consult received and appreciated, spoke with nursing and patient is\n medically not appropriate for PT eval at this time. We will continue\n to check in and will evaluate when medically stable.\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-04 00:00:00.000",
"description": "Physician Surgical Admission Note",
"row_id": 403623,
"text": "Chief Complaint: Seizures\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from 1/11-20/10 for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. Currently, she responds only to\n painful stimuli.\n Post operative day:\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:47 PM\n Cefipime - 08:19 PM\n Metronidazole - 10:21 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family / Social history:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n rehab for 5 weeks.\n -Tobacco history:none\n -ETOH:none\n -Illicit drugs:none\n -uses walker/wheelchair at home, poor candidate for knee replacement.\n Flowsheet Data as of 06:52 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 80 (80 - 82) bpm\n BP: 94/74(78) {94/59(69) - 104/74(78)} mmHg\n RR: 26 (22 - 27) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 80.6 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 841 mL\n PO:\n TF:\n 501 mL\n IVF:\n 190 mL\n Blood products:\n Total out:\n 1,385 mL\n 0 mL\n Urine:\n 1,385 mL\n NG:\n Stool:\n Drains:\n Balance:\n -544 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese, Minimally responsive\n Eyes / Conjunctiva: R pupil 3.5 mm, L 4 mm-->2 b/l, equally responsive\n Head, Ears, Nose, Throat: NG tube, Dry MM, thick secretions\n Cardiovascular: (S2: Normal), (Murmur: Systolic), AF\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished),\n venous stasis ulcers\n Respiratory / Chest: (Breath Sounds: Crackles : , Diminished: ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Obese\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, venous stasis ulcers\n Skin: Warm\n Neurologic: No(t) Follows simple commands, Responds to: Noxious\n stimuli, Movement: Purposeful, Tone: Normal, sedated with ativan prior\n to admission\n Labs / Radiology\n 307 K/uL\n 9.2 g/dL\n 98 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 23 mg/dL\n 102 mEq/L\n 145 mEq/L\n 32.7 %\n 7.1 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n 02:18 PM\n 05:28 AM\n 02:25 PM\n 09:34 PM\n 04:56 AM\n 06:05 AM\n WBC\n 11.7\n 9.9\n 8.2\n 7.0\n 7.1\n Hct\n 34.7\n 30.6\n 30.0\n 30.7\n 32.7\n Plt\n 23\n 307\n Cr\n 0.8\n 1.0\n 1.0\n 1.0\n 1.2\n 1.1\n 1.1\n 1.1\n TropT\n 0.02\n TCO2\n 34\n 35\n Glucose\n 107\n 87\n 85\n 113\n 137\n 153\n 109\n 98\n Other labs: PT / PTT / INR:14.3/29.6/1.2, CK / CKMB /\n Troponin-T:15//0.02, ALT / AST:, Alk Phos / T Bili:62/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:2.6 mg/dL\n Imaging:\n IMAGING:\n CXR: Cardiomegaly, prominent pulmonary vasculature, and bibasilar\n atelectasis is unchanged.\n MR: Focal area w/high signal intensity @ R sup parietal lobule, no\n mass effect and may represent a chronic hemorrhagic area. Subcortical\n areas w/high signal intensity on T2 and FLAIR c/w chronic microvascular\n ischemic changes. Tortuosity of basilar artery, cw dolichoectasia\n Echo: EF >= 60%, Symmetric LVH, Significant AS, Trivial MR (may be\n significantly UNDERestimated), Mild [1+] TR. Mild PA systolic HTN\n CTA: No acute infarction or hemorrhage. Severe atherosclerotic\n narrowing of distal R vertebral art and moderate-to-severe narrowing of\n both cavernous internal carotid arteries. Small focus of calcification\n in the Basilar A. close to the tip. Moderate microangiopathic ischemic\n white matter disease\n Microbiology: UCx: Yeast, >100,000\n BCx x2 P\n .\n Assessment and Plan\n KNOWLEDGE DEFICIT\n IMPAIRED SKIN INTEGRITY\n PNEUMONIA, ASPIRATION\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment And Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD\n Neurologic: --subclinical seizures, loaded with dilantin and ativan\n prior to admission with poor mental status\n --r/o underlying mass or avm/cavernoma prior to restarting\n anticoagulation for her paroxismal AF (she underwent MRI of the brain\n without contrast (2 sets) w/a bleed in RIGHT posterior temporo-parietal\n area).\n --f/u 24 h EEG\n --f/u MRI/A with contrast\n --Keppra for seizure prophylaxis\n --Cont neurontin, Tylenol for pain/fever\n Cardiovascular: --CAD s/p CABG , Severe AS s/p valvuloplasty in\n , AF previously coumadin, HTN, Chronic Diastolic heart failure\n -ASA, atorvastatin\n --Rate control for AF with metoprolol 75 mg PO/NG TID , Digoxin\n --Resume anticoagulation after underlying mass, avm r/o\n Pulmonary: Albuterol/Atrovent nebs PRN\n --Significant Chest PT\n --Being treated for PNA with cefepime/\n Gastrointestinal: --TFs@goal prior to admission, will hold given\n worsening pulmonary status. Considering PEG tube placement.\n --CDiff has been negative and diarrhea has stopped, PO has been\n stopped.\n Renal: --Lasix dependant, continue Lasix 40 (decreased from 60 given Cr\n 1.3) PO/NG daily; was previously on lasix gtt, will continue to monitor\n --Increasing Cr, 0.8 on admission, currently 1.3 from 1.1\n --Hypernatremia, Na 146\n Hematology: --Hct 31.8\n --ASA, SQH\n --Resume anticoagulation after underlying mass, avm r/o\n Infectious Disease: --Wbc 8.8\n --Being treated for PNA with cefepime/, consider d/c'ing as\n most likely aspiration pna\n Endocrine: --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg\n Fluids: D5 1/2 NS + 20 KCL@40\n Electrolytes: pending\n Nutrition: NPO\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 06:03 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed in detail. Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 403624,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. Currently, she responds only to\n painful stimuli.\n Chief complaint:\n seizures\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS 6. 250 mL NS 7. 500 mL\n NS 8. Acetaminophen\n 9. Albuterol 0.083% Neb Soln 10. Aspirin 11. Atorvastatin 12.\n Bacitracin-Polymyxin Ointment 13. CefePIME\n 14. Collagenase Ointment 15. Digoxin 16. FoLIC Acid 17. Furosemide 18.\n Gabapentin 19. Heparin 20. Ipratropium Bromide Neb\n 21. Latanoprost 0.005% Ophth. Soln. 22. Levothyroxine Sodium 23.\n LeVETiracetam 24. Lidocaine 5% Patch\n 25. Lorazepam 26. Metoprolol Tartrate 27. Miconazole Powder 2% 28.\n Nystatin Oral Suspension 29. Phenytoin Sodium (IV)\n 30. Sodium Chloride 0.9% Flush 31. Sodium Chloride 0.9% Flush 32.\n Sodium Chloride 0.9% Flush 33. Timolol Maleate 0.5%\n 34. Vancomycin\n 24 Hour Events:\n EEG - At 06:00 PM\n continuous\n PICC LINE - START 06:03 PM\n Admitted, mild hypotension, 250 x2 NS given with good effect\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Metronidazole - 10:21 PM\n Vancomycin - 09:09 PM\n Cefipime - 10:15 PM\n Infusions:\n Other ICU medications:\n Dilantin - 12:24 AM\n Other medications:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.3\nC (97.3\n T current: 35.6\nC (96\n HR: 74 (66 - 82) bpm\n BP: 79/39(47) {79/30(45) - 105/74(78)} mmHg\n RR: 15 (14 - 27) insp/min\n SPO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 80.6 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 1,340 mL\n 738 mL\n PO:\n Tube feeding:\n IV Fluid:\n 540 mL\n 738 mL\n Blood products:\n Total out:\n 750 mL\n 116 mL\n Urine:\n 750 mL\n 116 mL\n NG:\n Stool:\n Drains:\n Balance:\n 590 mL\n 622 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SPO2: 99%\n ABG: ///34/\n Physical Examination\n General Appearance: Minimally reactive/interactive.\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous : ,\n Diminished: bibasilar)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: No(t) Present, Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Skin: b/l venous stasis ulcers\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities\n Labs / Radiology\n 302 K/uL\n 8.9 g/dL\n 121 mg/dL\n 1.3 mg/dL\n 34 mEq/L\n 3.2 mEq/L\n 33 mg/dL\n 106 mEq/L\n 144 mEq/L\n 30.6 %\n 8.9 K/uL\n [image002.jpg]\n 09:22 PM\n 05:40 AM\n 02:18 PM\n 05:28 AM\n 02:25 PM\n 09:34 PM\n 04:56 AM\n 06:05 AM\n 06:37 PM\n 03:07 AM\n WBC\n 9.9\n 8.2\n 7.0\n 7.1\n 8.9\n Hct\n 30.6\n 30.0\n 30.7\n 32.7\n 30.6\n Plt\n 07\n 302\n Creatinine\n 1.0\n 1.0\n 1.0\n 1.2\n 1.1\n 1.1\n 1.1\n 1.3\n 1.3\n TCO2\n 35\n Glucose\n 87\n 85\n 113\n 137\n 153\n 109\n 98\n 146\n 121\n Other labs: PT / PTT / INR:14.9/36.6/1.3, CK / CK-MB / Troponin\n T:15//0.02, ALT / AST:, Alk-Phos / T bili:62/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Albumin:2.4 g/dL, LDH:202 IU/L, Ca:7.5\n mg/dL, Mg:1.9 mg/dL, PO4:2.4 mg/dL\n Imaging: CXR: Cardiomegaly, prominent pulmonary vasculature, and\n bibasilar\n atelectasis is unchanged.\n MR: Focal area w/high signal intensity @ R sup parietal lobule, no\n mass effect and may represent a chronic hemorrhagic area. Subcortical\n areas w/high signal intensity on T2 and FLAIR c/w chronic microvascular\n ischemic changes. Tortuosity of basilar artery, cw dolichoectasia\n Echo: EF >= 60%, Symmetric LVH, Significant AS, Trivial MR (may be\n significantly UNDERestimated), Mild [1+] TR. Mild PA systolic HTN\n CTA: No acute infarction or hemorrhage. Severe atherosclerotic\n narrowing of distal R vertebral art and moderate-to-severe narrowing of\n both cavernous internal carotid arteries. Small focus of calcification\n in the Basilar A. close to the tip. Moderate microangiopathic ischemic\n white matter disease\n Microbiology: UCx: Yeast, >100,000\n BCx x2 P\n Assessment and Plan\n KNOWLEDGE DEFICIT, IMPAIRED SKIN INTEGRITY, PNEUMONIA, ASPIRATION,\n AORTIC STENOSIS, SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD\n Neurologic:\n Patient with subclinical seizures, loaded with dilantin and\n ativan prior to admission with poor mental status. Dilantin level is\n 12.0 (therapeutic). Follow up on EEG -> no seizures. She needs MRI in\n to exclude underlying mass or AVM since they can affect the decision to\n restart anticoagulation for PAF and overall prognosis. There is a bleed\n detected on the prior MRI in the right posterior temporo-parietal area.\n Continue neurontin for chronic pain\n Pain well controlled on current medication.\n Cardiovascular:\n PAF with good control of HR on beta blockade and digoxin.\n Restart anticoagulation after MRI of the brain.\n Multiple medical cardiovascular problems. CAD s/p CABG\n but still diastolic dysfunction. She had AS (valve area 0.8cm2)\n but underwent valvuloplasty\n no gradient estimation after procedure.\n On ASA and atrovastatin. We will contact NEURO service in respect to\n the need for anti-platelets therapy.\n Restart all home medications. Digoxin levels 0.8.\n Pulmonary:\n Treated empirically for aspiration pneumonia with\n /Cefepime but cultures are negative. We will continue treatment for\n full 7 days considering that she is very advanced in her empirical\n treatment.\n Chest PT and inhalers.\n Gastrointestinal / Abdomen:\n Diarrhea resolved. C.diff toxin negative. PO has been\n stopped.\n Consideration for DHT/PEG placement since patient aspirated\n on TF.\n H/O colon cancer;\n Nutrition:\n TFs held currently\n Renal:\n secondary to pre-renal factors and Lasix intake. Lasix\n decrease -> monitor.\n Hypernatremia resolved today\n Hematology:\n Stable post-op anemia\n On ASA & SQH. Resume anticoagulation depending on MRI\n results.\n Endocrine:\n RISS with adequate BG control. Hg1ac = 5.9\n On Synthroid 75 mcg. TSH=6.8. T3=5.2; fT4=1.1. Sick\n euthyroid syndrome.\n Infectious Disease:\n - Finish course of empiric ABX. Check Vancomycin levels.\n Lines / Tubes / Drains: PIV, Foley, PICC\n Wounds:\n Imaging: CXR today\n Fluids: D5 1/2 NS + 20 KCL@40--increased to 60\n Consults: Neurology\n Billing Diagnosis: Other: status epilepticus\n ICU Care\n Lines:\n PICC Line - 06:03 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403208,
"text": "Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "General",
"chartdate": "2196-02-02 00:00:00.000",
"description": "Generic Note",
"row_id": 403185,
"text": "TITLE:\n Cardiology attending progress note\n Exam and plan discussed on attending rounds\n 60 minutes\n Continuous aspiration\n Doubt she is a candidate for percutaneous valve at this point\n Need to discuss options with family\n may require peg if family wishes\n aggressive ongoing management\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403500,
"text": "TITLE: 86F initially admitted with new onset seizures @ \n Rehab. She was subsequently transferred to the floor in stable\n condition, and was readmitted on again with subclinical seizures\n found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. Currently, she responds only to\n painful stimuli.\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403737,
"text": "Pneumonia, aspiration\n Assessment:\n Patient continues to have a weakened cough today. She is maintaining\n her O2 sat above 90% consistently. She is turned and repositioned\n frequently and chest PT has been given frequently.\n Action:\n She coughs intermittently and is requiring chest PT, continues with\n empiric antibiotics.\n Response:\n Tolerating well.\n Plan:\n Seizure, without status epilepticus\n Assessment:\n One short episode of what appeared to be a seizure this afternoon, with\n approximately 30 second duration this afternoon.\n Action:\n Recorded seizure, did not administer ativan as the seizure stopped with\n out intervention.\n Response:\n She continues to receive keppra/dilantin as ordered.\n Plan:\n Continue to monitor patient for seizures and plan for MRI to look for\n possible AVM or tumor as source of bleeding, causing seizures.\n Impaired Skin Integrity\n Assessment:\n Continues to have large ulcers on lower extremities.\n Action:\n Wound RN to see patient and manage dressings.\n Response:\n Wounds subjectively appear improved.\n Plan:\n Plan to continue to redress patient\ns wounds as appropriate.\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 403194,
"text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n Seen by speech and swallow with overt aspiration noted with liquids and\n purees. NPO recommended. NGT placed, tube feeds started.\n Neuro recs: 1. Anticoagulate after mass/AVM ruled out with MRI/MRA. 2.\n Increase keppra to 1000mg (done). 3. d/c meds (including flagyl)\n that lower seizure thresh. Flagyl continued.\n Per neuro recheck INR, if below 2 and restart coumadin low dose.\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:47 PM\n Cefipime - 08:19 PM\n Metronidazole - 10:21 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 05:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.4\nC (97.6\n HR: 88 (75 - 98) bpm\n BP: 107/58(71) {93/33(58) - 137/86(100)} mmHg\n RR: 24 (15 - 26) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 80.6 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 1,461 mL\n 367 mL\n PO:\n 50 mL\n TF:\n 99 mL\n 249 mL\n IVF:\n 1,252 mL\n 118 mL\n Blood products:\n Total out:\n 2,625 mL\n 505 mL\n Urine:\n 2,625 mL\n 505 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,164 mL\n -138 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n Gen: Lying in bed. NAD. Responds to yes/no questions and commands to\n move extremities.\n CV: 4/6 SEM heard best at RUSB, radiating throughout precordium, S1 S2\n clear\n Resp: Rhonchorous breath sounds throughout.\n Abd: +bs, soft, NT, ND\n Ext: WWP, 2+ distal pulses, Venous stasis ulcers with bandaging to mid\n shin/C/DI\n Neuro: CN II-XII intact, mental status as above.\n Labs / Radiology\n 307 K/uL\n 9.2 g/dL\n 109 mg/dL\n 1.1 mg/dL\n 36 mEq/L\n 4.0 mEq/L\n 22 mg/dL\n 101 mEq/L\n 141 mEq/L\n 32.7 %\n 7.1 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n 02:18 PM\n 05:28 AM\n 02:25 PM\n 09:34 PM\n 04:56 AM\n 06:05 AM\n WBC\n 11.7\n 9.9\n 8.2\n 7.0\n 7.1\n Hct\n 34.7\n 30.6\n 30.0\n 30.7\n 32.7\n Plt\n 23\n 307\n Cr\n 0.8\n 1.0\n 1.0\n 1.0\n 1.2\n 1.1\n 1.1\n TropT\n 0.02\n TCO2\n 34\n 35\n Glucose\n 107\n 87\n 85\n 113\n 137\n 153\n 109\n Other labs: PT / PTT / INR:14.3/29.6/1.2, CK / CKMB /\n Troponin-T:15//0.02, ALT / AST:, Alk Phos / T Bili:62/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca++:8.2 mg/dL, Mg++:1.9\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic C.diff,\n admitted with new onset tonic clonic seizures on . Patient had MS\n change first noted following MRI, likely having suffered an aspiration\n event, who subsequently went into Afib and flashed on the floor in the\n setting of holding her metoprolol and Lasix.\n # Volume overload: The patient has a history of severe AS and developed\n pulmonary edema in the setting of having her diuretics held on\n admission. Also noted to have RLL collapse on CXR. Overall her\n respiratory status has improved greatly since transfer to the CCU\n initially requiring humidified face mask, now on 2L NC o/n. UOP has\n been guiding diuresis, goal had been set to diurese 500cc. Initially\n required Lasix gtt for diuresis, but Lasix has now been transitioned to\n PO.\n -Wean 02 as tolerated (satting well on 2L)\n -lasix 60 mg PO daily\n -Continue atrovent nebs, with dextromorphan PRN cough\n -Goal net negative 500cc/day\n - lytes\n # Possibly Aspiration PNA: Had fever to 101 on the evening of ,\n but patient is now afebrile. Was pan cultured. UA showed pyuria. No\n positive culture data. Currently on vanc/cefepime/flagyl.\n -continue vanc/cefepime/flagyl\n -trend WBC and fever curves\n -f/u pending cultures\n # Afib: Pt in Afib with RVR on arrival, in the setting of not receiving\n her metoprolol. Restarted on IV metoprolol on arrival to the CCU. Now\n s/p transition to PO metprolol.\n -continue PO metoprolol\n -continue to monitor on telemetry\n # AS: AS s/p valvuloplasty .Severe AS on Echo . AS known\n critical, unclear if worsened AS since as valve area not quantified\n but known to be critical. Pt poor surgical candidate thus had not\n received AVR.\n - consideration being given for minimally invasive percutaneous valve\n replacement once medically stable, although it is not clear that the\n patient will be a candidate for this.\n # Altered mental status: Likely toxic/metabolic, although patient does\n have a focal lesion on head imaging.\n - ASA 81mg\n - f/u neuro recs\n - keppra for seizure prophylaxis.\n - avoid sedating meds\n - MRI when stable, per neuro recs\n # Seizure: be related to focal lesion identified on MRI.\n - f/u neuro recs\n - further head imagingn per neuro recs\n # Hx Diarrhea: Hx C.diff on chronic suppression therapy with p.o\n vanc/flagyl with last cx at rehab on negative. At that\n time, antibiotics were continued. However diarrhea has stopped so abx\n stopped this hospitalization.\n - c.diff negative\n - continue to monitor\n # hx GI bleed: Hematocrit stable this morning\n - continue to trend hematocrit\n #Leg Ulcers: per wound care, ? if venous stasis vs. autoimmune\n - rheum consult following ICU stabilization\n #Dysphagia: Aspirated liquids and purees during speech and swallow\n evaluation.\n - tube feeds\n - speech and swallow to reevaluate later this week\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 06:13 AM 45 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:01 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Likely transfer to medicine floor\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-02 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 403250,
"text": "PMH\n. CAD status post CABG \n2. Severe aortic stenosis, s\\p recent valvuloplasty.\n3. AFib on coumadin\n4. HTN\n5. Hyperlipidemia\n6. Osteoarthritis - hip replacement spinal stenosis\n7. Squamous cell carcinoma\n8. Chronic venous stasis with ulceration\n9. Hypothyroidism\n10. peripheral neuropathy\n11. Raynaud's synd\n12. Right retinal vein clot with mild loss of vision\n13. Diastolic heart failure\n14. Shingles in \n15. Status post right hemicolectomy in \n"
},
{
"category": "Nursing",
"chartdate": "2196-02-02 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 403251,
"text": "PMH\n. CAD status post CABG \n2. Severe aortic stenosis, s\\p recent valvuloplasty.\n3. AFib on coumadin\n4. HTN\n5. Hyperlipidemia\n6. Osteoarthritis - hip replacement spinal stenosis\n7. Squamous cell carcinoma\n8. Chronic venous stasis with ulceration\n9. Hypothyroidism\n10. peripheral neuropathy\n11. Raynaud's synd\n12. Right retinal vein clot with mild loss of vision\n13. Diastolic heart failure\n14. Shingles in \n15. Status post right hemicolectomy in \n86 yo women admitted to ED from rehab after witnessed seizure. Started on Kepra\nand transferred to 11 Cardiac meds held. Pt became hypoxic with increase so\nmulence after ativan. To CCU on . Pt febrile found to have UTI and aspiration\n PNA. Speech & swallow. Pt strict NPO\ns. NTG passed as pt high risk for aspirati\non. TF at goal rate.\nPt has husband and 2 children who are very involved in care. Pt is full code.\n Pneumonia, aspiration\n Assessment:\n Lungs rhonchi with crackles.\n O2 sats > 95% on 2l.,\n Less frequent coughing although cough remains very congested.\n Action:\n Conts on Vancomycin. Flagyl & Cefipeme\n Strict NPO for aspiration precautions.\n TF at goal rate.\n Atrovent Q6hrs.\n Response:\n Good O2 sats on minimal O2. conts to desat without O2\n Plan:\n Cont with antibiotics.\n Check vanco level this pm. Dose decreased to 750mg daily.\n Seizure, without status epilepticus\n Assessment:\n No seizures noted.\n Pt lethargic but arousable to voice.\n Able to follow commands.\n MAE.\n Action:\n Kepra ^\nd to 1000mg .\n Monitor neuro status.\n Response:\n No seizures noted.\n Pt remains somulent although more responsive this pm.\n Plan:\n EEG in am.\n Aortic stenosis\n Assessment:\n Tele AF 70\ns-90\n Lasix drip off.\n Action:\n Lasix 60mg daily.\n Response:\n Good urine output today.\n Plan:\n Cont with gentle diuresis.\n Check lytes.\n Impaired Skin Integrity\n Assessment:\n Pt with h/o BLL ulcers per family for several yrs.\n Action:\n Dsg changed this am per skin care recs.\n Frequent turning and repositioning with aloe vesta.\n Response:\n R Leg draining more than L.\n Plan:\n Cont with POC.\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 403510,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. Currently, she responds only to\n painful stimuli.\n Chief complaint:\n seizures\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS 6. 250 mL NS 7. 500 mL\n NS 8. Acetaminophen\n 9. Albuterol 0.083% Neb Soln 10. Aspirin 11. Atorvastatin 12.\n Bacitracin-Polymyxin Ointment 13. CefePIME\n 14. Collagenase Ointment 15. Digoxin 16. FoLIC Acid 17. Furosemide 18.\n Gabapentin 19. Heparin 20. Ipratropium Bromide Neb\n 21. Latanoprost 0.005% Ophth. Soln. 22. Levothyroxine Sodium 23.\n LeVETiracetam 24. Lidocaine 5% Patch\n 25. Lorazepam 26. Metoprolol Tartrate 27. Miconazole Powder 2% 28.\n Nystatin Oral Suspension 29. Phenytoin Sodium (IV)\n 30. Sodium Chloride 0.9% Flush 31. Sodium Chloride 0.9% Flush 32.\n Sodium Chloride 0.9% Flush 33. Timolol Maleate 0.5%\n 34. Vancomycin\n 24 Hour Events:\n EEG - At 06:00 PM\n continuous\n PICC LINE - START 06:03 PM\n Admitted, mild hypotension, 250 x2 NS given with good effect\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Metronidazole - 10:21 PM\n Vancomycin - 09:09 PM\n Cefipime - 10:15 PM\n Infusions:\n Other ICU medications:\n Dilantin - 12:24 AM\n Other medications:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.3\nC (97.3\n T current: 35.6\nC (96\n HR: 74 (66 - 82) bpm\n BP: 79/39(47) {79/30(45) - 105/74(78)} mmHg\n RR: 15 (14 - 27) insp/min\n SPO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 80.6 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 1,340 mL\n 738 mL\n PO:\n Tube feeding:\n IV Fluid:\n 540 mL\n 738 mL\n Blood products:\n Total out:\n 750 mL\n 116 mL\n Urine:\n 750 mL\n 116 mL\n NG:\n Stool:\n Drains:\n Balance:\n 590 mL\n 622 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SPO2: 99%\n ABG: ///34/\n Physical Examination\n General Appearance: Minimally reactive/interactive.\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous : ,\n Diminished: bibasilar)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: No(t) Present, Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Skin: b/l venous stasis ulcers\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities\n Labs / Radiology\n 302 K/uL\n 8.9 g/dL\n 121 mg/dL\n 1.3 mg/dL\n 34 mEq/L\n 3.2 mEq/L\n 33 mg/dL\n 106 mEq/L\n 144 mEq/L\n 30.6 %\n 8.9 K/uL\n [image002.jpg]\n 09:22 PM\n 05:40 AM\n 02:18 PM\n 05:28 AM\n 02:25 PM\n 09:34 PM\n 04:56 AM\n 06:05 AM\n 06:37 PM\n 03:07 AM\n WBC\n 9.9\n 8.2\n 7.0\n 7.1\n 8.9\n Hct\n 30.6\n 30.0\n 30.7\n 32.7\n 30.6\n Plt\n 07\n 302\n Creatinine\n 1.0\n 1.0\n 1.0\n 1.2\n 1.1\n 1.1\n 1.1\n 1.3\n 1.3\n TCO2\n 35\n Glucose\n 87\n 85\n 113\n 137\n 153\n 109\n 98\n 146\n 121\n Other labs: PT / PTT / INR:14.9/36.6/1.3, CK / CK-MB / Troponin\n T:15//0.02, ALT / AST:, Alk-Phos / T bili:62/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Albumin:2.4 g/dL, LDH:202 IU/L, Ca:7.5\n mg/dL, Mg:1.9 mg/dL, PO4:2.4 mg/dL\n Imaging: CXR: Cardiomegaly, prominent pulmonary vasculature, and\n bibasilar\n atelectasis is unchanged.\n MR: Focal area w/high signal intensity @ R sup parietal lobule, no\n mass effect and may represent a chronic hemorrhagic area. Subcortical\n areas w/high signal intensity on T2 and FLAIR c/w chronic microvascular\n ischemic changes. Tortuosity of basilar artery, cw dolichoectasia\n Echo: EF >= 60%, Symmetric LVH, Significant AS, Trivial MR (may be\n significantly UNDERestimated), Mild [1+] TR. Mild PA systolic HTN\n CTA: No acute infarction or hemorrhage. Severe atherosclerotic\n narrowing of distal R vertebral art and moderate-to-severe narrowing of\n both cavernous internal carotid arteries. Small focus of calcification\n in the Basilar A. close to the tip. Moderate microangiopathic ischemic\n white matter disease\n Microbiology: UCx: Yeast, >100,000\n BCx x2 P\n Assessment and Plan\n KNOWLEDGE DEFICIT, IMPAIRED SKIN INTEGRITY, PNEUMONIA, ASPIRATION,\n AORTIC STENOSIS, SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD\n Neurologic:\n Patient with subclinical seizures, loaded with dilantin and\n ativan prior to admission with poor mental status. Follow up on EEG. He\n need MTI in a future to exclude underlying mass or AVM since they can\n affect the decision to restart anticoagulation for PAF. There is a\n bleed detected on the prior MRI in the right posterior\n temproro-parietal area.\n Continue neurontin for chronic pain\n Pain well controlled on current medication.\n Cardiovascular:\n PAF with good control of HR on beta blockade and digoxin.\n Restart anticoagulation after MRI of the brain.\n Multiple medical cardiovascular problems. CAD s/p CABG\n but still diastolic dysfunction.she had AS (valve area 0.8cm2)\n but underwent valvuloplasty\n no gradient estimation after procedure.\n On ASA and atrovastatin.\n Pulmonary:\n Treated empirically for aspiration pneumonia with\n /Cefepime but cultures are negative. To be discontinued.\n Chest PT and inhalers.\n Gastrointestinal / Abdomen:\n Diarrhea resolved. C.diff toxin negative. PO vanc has been\n stopped.\n Consideration for PEG placement since patient aspirated on\n TF.\n Nutrition:\n TFs held currently\n Renal:\n secondary to pre-renal factors and Lasix intake. Lasix\n decrease -> monitor.\n Hypernatremia resolved today\n Hematology:\n Stable post-op anemia\n On ASA & SQH. Resume anticoagulation after underlying mass,\n avm r/o\n Endocrine:\n RISS with adequate BG control. Hg1ac = 5.9\n Synthroid 75 mcg. No TSH.\n Infectious Disease:\n - no overt sign of infection. DC ABX\n Lines / Tubes / Drains: PIV, Foley, PICC\n Wounds:\n Imaging: CXR today\n Fluids: D5 1/2 NS + 20 KCL@40--increased to 60\n Consults: Neurology\n Billing Diagnosis: Other: status epilepticus\n ICU Care\n Lines:\n PICC Line - 06:03 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403530,
"text": "TITLE: 86F initially admitted with new onset seizures @ \n Rehab. She was subsequently transferred to the floor in stable\n condition, and was readmitted on again with subclinical seizures\n found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. Currently, she responds only to\n painful stimuli.\n Seizure, without status epilepticus\n Assessment:\n Neuro exam- pupils unequal brisk reactive, nonresponsive to minimally\n responsive. Spont movement of bue and withdraws to nailbed pressure\n upper extrems, flexion lt lower extremety only.\n Dilantin load completed at ,keppra per ngt.\n Continuous eeg monitoring. No observable signs of seizures.\n Action:\n Dilantin 2hr post load drawn & dilantin 100mg iv q8hr.\n Hob 45\n Response:\n Dilantin level 13. Increasingly responsive after 0615, Moaning and\n making incomprehensible sounds. Still not following commands.Spont\n moving upper extrems nonpurposefully.\n Plan:\n Cont neuro exam q2h.\n Maintain hob 45 for asp precautions\n Pneumonia, aspiration\n Assessment:\n BBS rhonchorous to exp wheezes w dim bibasilar brth snds.OFM at 100% w\n sats 98-100%\n Action:\n Bcpt and albut/atrovent neb. Nts for thick tan secretions. Desats to\n low 90\ns on OFM-> switched to closed face mask w sats improving to >\n 95%\n AM pcxr done\n Antibx as ordered cefepime and vanco iv given.\n Response:\n Brth snds slight improved audibility, cont to have exp wheezes and dim\n brth snds.O2 sats improved on closed face mask and after albut/atrov\n neb.\n Plan:\n Cont aggressive pulm toilet and atrovent/albut nebs. Monitor for signs\n of resp distress.\n"
},
{
"category": "Rehab Services",
"chartdate": "2196-02-04 00:00:00.000",
"description": "Swallowing Follow-Up",
"row_id": 403532,
"text": "TITLE: SWALLOWING FOLLOW-UP\nWe returned to follow-up with patient regarding swallowing.\nPatient was last seen on and recommended to remain NPO.\nShe has since been transferred to the floor and then returned to\nthe ICU seizure activity. Spoke with RN. Patient not\nappropriate for PO trials at this time. Please reconsult when\npatient is stable and appropriate for POs and we will be happy to\nreturn.\n_______________________________\n , MS, CCC-SLP\n Pager #\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 403534,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. Currently, she responds only to\n painful stimuli.\n Chief complaint:\n seizures\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS 6. 250 mL NS 7. 500 mL\n NS 8. Acetaminophen\n 9. Albuterol 0.083% Neb Soln 10. Aspirin 11. Atorvastatin 12.\n Bacitracin-Polymyxin Ointment 13. CefePIME\n 14. Collagenase Ointment 15. Digoxin 16. FoLIC Acid 17. Furosemide 18.\n Gabapentin 19. Heparin 20. Ipratropium Bromide Neb\n 21. Latanoprost 0.005% Ophth. Soln. 22. Levothyroxine Sodium 23.\n LeVETiracetam 24. Lidocaine 5% Patch\n 25. Lorazepam 26. Metoprolol Tartrate 27. Miconazole Powder 2% 28.\n Nystatin Oral Suspension 29. Phenytoin Sodium (IV)\n 30. Sodium Chloride 0.9% Flush 31. Sodium Chloride 0.9% Flush 32.\n Sodium Chloride 0.9% Flush 33. Timolol Maleate 0.5%\n 34. Vancomycin\n 24 Hour Events:\n EEG - At 06:00 PM\n continuous\n PICC LINE - START 06:03 PM\n Admitted, mild hypotension, 250 x2 NS given with good effect\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Metronidazole - 10:21 PM\n Vancomycin - 09:09 PM\n Cefipime - 10:15 PM\n Infusions:\n Other ICU medications:\n Dilantin - 12:24 AM\n Other medications:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.3\nC (97.3\n T current: 35.6\nC (96\n HR: 74 (66 - 82) bpm\n BP: 79/39(47) {79/30(45) - 105/74(78)} mmHg\n RR: 15 (14 - 27) insp/min\n SPO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 80.6 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 1,340 mL\n 738 mL\n PO:\n Tube feeding:\n IV Fluid:\n 540 mL\n 738 mL\n Blood products:\n Total out:\n 750 mL\n 116 mL\n Urine:\n 750 mL\n 116 mL\n NG:\n Stool:\n Drains:\n Balance:\n 590 mL\n 622 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SPO2: 99%\n ABG: ///34/\n Physical Examination\n General Appearance: Minimally reactive/interactive.\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous : ,\n Diminished: bibasilar)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: No(t) Present, Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Skin: b/l venous stasis ulcers\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities\n Labs / Radiology\n 302 K/uL\n 8.9 g/dL\n 121 mg/dL\n 1.3 mg/dL\n 34 mEq/L\n 3.2 mEq/L\n 33 mg/dL\n 106 mEq/L\n 144 mEq/L\n 30.6 %\n 8.9 K/uL\n [image002.jpg]\n 09:22 PM\n 05:40 AM\n 02:18 PM\n 05:28 AM\n 02:25 PM\n 09:34 PM\n 04:56 AM\n 06:05 AM\n 06:37 PM\n 03:07 AM\n WBC\n 9.9\n 8.2\n 7.0\n 7.1\n 8.9\n Hct\n 30.6\n 30.0\n 30.7\n 32.7\n 30.6\n Plt\n 07\n 302\n Creatinine\n 1.0\n 1.0\n 1.0\n 1.2\n 1.1\n 1.1\n 1.1\n 1.3\n 1.3\n TCO2\n 35\n Glucose\n 87\n 85\n 113\n 137\n 153\n 109\n 98\n 146\n 121\n Other labs: PT / PTT / INR:14.9/36.6/1.3, CK / CK-MB / Troponin\n T:15//0.02, ALT / AST:, Alk-Phos / T bili:62/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Albumin:2.4 g/dL, LDH:202 IU/L, Ca:7.5\n mg/dL, Mg:1.9 mg/dL, PO4:2.4 mg/dL\n Imaging: CXR: Cardiomegaly, prominent pulmonary vasculature, and\n bibasilar\n atelectasis is unchanged.\n MR: Focal area w/high signal intensity @ R sup parietal lobule, no\n mass effect and may represent a chronic hemorrhagic area. Subcortical\n areas w/high signal intensity on T2 and FLAIR c/w chronic microvascular\n ischemic changes. Tortuosity of basilar artery, cw dolichoectasia\n Echo: EF >= 60%, Symmetric LVH, Significant AS, Trivial MR (may be\n significantly UNDERestimated), Mild [1+] TR. Mild PA systolic HTN\n CTA: No acute infarction or hemorrhage. Severe atherosclerotic\n narrowing of distal R vertebral art and moderate-to-severe narrowing of\n both cavernous internal carotid arteries. Small focus of calcification\n in the Basilar A. close to the tip. Moderate microangiopathic ischemic\n white matter disease\n Microbiology: UCx: Yeast, >100,000\n BCx x2 P\n Assessment and Plan\n KNOWLEDGE DEFICIT, IMPAIRED SKIN INTEGRITY, PNEUMONIA, ASPIRATION,\n AORTIC STENOSIS, SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD\n Neurologic:\n Patient with subclinical seizures, loaded with dilantin and\n ativan prior to admission with poor mental status. Dilantin level is\n 12.0 (therapeutic). Follow up on EEG -> no seizures. She needs MRI in\n to exclude underlying mass or AVM since they can affect the decision to\n restart anticoagulation for PAF and overall prognosis. There is a bleed\n detected on the prior MRI in the right posterior temporo-parietal area.\n Continue neurontin for chronic pain\n Pain well controlled on current medication.\n Cardiovascular:\n PAF with good control of HR on beta blockade and digoxin.\n Restart anticoagulation after MRI of the brain.\n Multiple medical cardiovascular problems. CAD s/p CABG\n but still diastolic dysfunction. She had AS (valve area 0.8cm2)\n but underwent valvuloplasty\n no gradient estimation after procedure.\n On ASA and atrovastatin. We will contact NEURO service in respect to\n the need for anti-platelets therapy.\n Restart all home medications. Digoxin levels 0.8.\n Pulmonary:\n Treated empirically for aspiration pneumonia with\n /Cefepime but cultures are negative. We will continue treatment for\n full 7 days considering that she is very advanced in her empirical\n treatment.\n Chest PT and inhalers.\n Gastrointestinal / Abdomen:\n Diarrhea resolved. C.diff toxin negative. PO vanc has been\n stopped.\n Consideration for DHT/PEG placement since patient aspirated\n on TF.\n H/O colon cancer;\n Nutrition:\n TFs held currently\n Renal:\n secondary to pre-renal factors and Lasix intake. Lasix\n decrease -> monitor.\n Hypernatremia resolved today\n Hematology:\n Stable post-op anemia\n On ASA & SQH. Resume anticoagulation depending on MRI\n results.\n Endocrine:\n RISS with adequate BG control. Hg1ac = 5.9\n On Synthroid 75 mcg. TSH=6.8. T3=5.2; fT4=1.1. Sick\n euthyroid syndrome.\n Infectious Disease:\n - Finish course of empiric ABX. Check Vancomycin levels.\n Lines / Tubes / Drains: PIV, Foley, PICC\n Wounds:\n Imaging: CXR today\n Fluids: D5 1/2 NS + 20 KCL@40--increased to 60\n Consults: Neurology\n Billing Diagnosis: Other: status epilepticus\n ICU Care\n Lines:\n PICC Line - 06:03 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-06 00:00:00.000",
"description": "Intensivist Note",
"row_id": 403793,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. At time of SICU admission, she\n responded only to painful stimuli.\n Chief complaint:\n Seizures\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n 1. IV access: Peripheral line Location: Right Order date: @ \n 19. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS Order date:\n @ \n 2. IV access: Peripheral line Order date: @ 20.\n Levothyroxine Sodium 75 mcg PO/NG DAILY Order date: @ \n 3. IV access: PICC, non-heparin dependent Location: Right Brachial,\n Date inserted: Order date: @ 21. LeVETiracetam 1000\n mg PO/NG Order date: @ \n 4. IV access: None Order date: @ 22. Lidocaine 5% Patch 2\n PTCH TD DAILY\n 12 h on 12 h off; apply one patch to each knee Order date: @\n \n 5. Acetaminophen 650 mg PR Q6H:PRN fever/pain\n please do not exceed 3000mg/day Order date: @ 23. Lorazepam\n 0.5-1 mg IV HS PRN Sz\n prolonged Sz > 3 minutes; Pls page neurology resident prior\n administering. Order date: @ 2213\n 6. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing Order date:\n @ 24. Magnesium Sulfate IV Sliding Scale Order date: \n @ 0638\n 7. Aspirin 81 mg PO/NG DAILY Order date: @ 25. Metoprolol\n Tartrate 25 mg PO/NG TID\n hold for HR<60 or BP<100 Order date: @ 0923\n 8. Atorvastatin 40 mg PO/NG DAILY Order date: @ 26.\n Miconazole Powder 2% 1 Appl TP PRN fungal infection Order date: \n @ \n 9. Bacitracin-Polymyxin Ointment 1 Appl TP Q6H:PRN wound Order date:\n @ 27. Neutra-Phos 2 PKT PO/NG Duration: 2 Days Order\n date: @ 2236\n 10. Calcium Gluconate IV Sliding Scale Order date: @ 0638 28.\n Nystatin Oral Suspension 5 mL PO QID:PRN \n swish and swallow Order date: @ \n 11. CefePIME 2 g IV Q24H\n Stop Order date: @ 0948 29. Phenytoin Sodium (IV) 100 mg\n IV Q8H Order date: @ 2157\n 12. Collagenase Ointment 1 Appl TP DAILY Order date: @ 30.\n Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAPs >60 Order date:\n @ 1434\n 13. Digoxin 0.0625 mg PO/NG DAILY Order date: @ 31.\n Potassium Chloride IV Sliding Scale Order date: @ 0638\n 14. FoLIC Acid 1 mg PO/NG DAILY Order date: @ 32. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ \n 15. Furosemide 40 mg PO/NG DAILY\n hold for BP <100 Order date: @ 33. Sodium Chloride 0.9%\n Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ \n 16. Gabapentin 100 mg PO/NG Order date: @ 34. Sodium\n Chloride 0.9% Flush 10 mL IV PRN line flush\n PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and\n PRN per lumen. Order date: @ \n 17. Heparin 5000 UNIT SC TID Order date: @ 35. Timolol\n Maleate 0.5% 1 DROP BOTH EYES DAILY Order date: @ \n 18. Ipratropium Bromide Neb 1 NEB IH Q6H Order date: @ 36.\n Vancomycin 750 mg IV Q 24H Start: when due pm of \n Stop Order date: @ 0949\n 24 Hour Events:\n Awaiting MRI, stable, family wishes to pursue aggressive treatment\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Dilantin - 12:05 AM\n Other medications:\n Flowsheet Data as of 06:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.1\nC (97\n HR: 97 (86 - 100) bpm\n BP: 109/47(71) {89/47(66) - 130/60(86)} mmHg\n RR: 23 (16 - 31) insp/min\n SPO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 87 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 5,747 mL\n 329 mL\n PO:\n Tube feeding:\n 4,677 mL\n 268 mL\n IV Fluid:\n 870 mL\n 62 mL\n Blood products:\n Total out:\n 940 mL\n 340 mL\n Urine:\n 940 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,807 mL\n -11 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 98%\n ABG: 7.35/53/87./30/1\n PaO2 / FiO2: 176\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Wheezes : , Crackles : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent, 2+)\n Right Extremities: (Edema: Absent, 2+)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Follows simple commands, (Responds to: Noxious\n stimuli), Moves all extremities\n Labs / Radiology\n 401 K/uL\n 8.9 g/dL\n 136 mg/dL\n 1.2 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 33 mg/dL\n 108 mEq/L\n 146 mEq/L\n 30.6 %\n 11.1 K/uL\n [image002.jpg]\n 04:56 AM\n 06:05 AM\n 06:37 PM\n 03:07 AM\n 04:56 PM\n 03:35 AM\n 03:52 AM\n 11:58 AM\n 08:32 PM\n 02:19 AM\n WBC\n 7.0\n 7.1\n 8.9\n 9.9\n 11.1\n Hct\n 30.7\n 32.7\n 30.6\n 30.5\n 30.6\n Plt\n 76\n 401\n Creatinine\n 1.1\n 1.1\n 1.3\n 1.3\n 1.3\n 1.2\n 1.2\n Troponin T\n 0.03\n TCO2\n 35\n 32\n 30\n Glucose\n 109\n 98\n 146\n 121\n 122\n 136\n Other labs: PT / PTT / INR:17.3/31.6/1.6, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:62/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:202 IU/L, Ca:7.4 mg/dL, Mg:1.8 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n KNOWLEDGE DEFICIT, IMPAIRED SKIN INTEGRITY, PNEUMONIA, ASPIRATION,\n AORTIC STENOSIS, SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD\n .\n Neurologic:\n -- Patient with seizures, loaded with dilantin and ativan prior to\n admission with poor mental status. Dilantin and Keppra for seziure\n prophylaxis, f/u AM level.\n --Follow up 24hr video EEG. Initial EEG - no seizures\n -- Continue neurontin for chronic pain well controlled on current\n medication.\n -- MRI brain w/ and w/o ordered for when pt is stable to transport\n Cardiovascular:\n -- PAF with good control of HR on beta blockade and digoxin.\n -- Multiple medical cardiovascular problems. CAD s/p CABG but\n still diastolic dysfunction. She had AS (valve area 0.8cm2 on previous\n echo) but underwent valvuloplasty\n no gradient estimation after\n procedure.\n -- anticoagulation for A. Fib: On ASA and atorvastatin. No\n anticoagulation for now\n -- Neosynephrine 0.5\n Pulmonary:\n --Treated empirically for aspiration pneumonia with Vanc/Cefepime but\n cultures are negative. We will continue treatment for full 7 days (to\n )\n --CXR stable on lasix 40 daily.\n --Chest PT and inhalers\n --CXRs daily\n Gastrointestinal / Abdomen:\n --TFs@goal prior to admission, will hold given worsening pulmonary\n status. In future consider PEG tube placement.\n --CDiff has been negative and diarrhea has stopped, PO vanc has been\n stopped.\n Nutrition:\n --TF restarted via Dobhoff\n Renal:\n --Lasix dependent, continue Lasix 40 (decreased from 60 given Cr 1.3)\n PO/NG daily; was previously on lasix gtt, will continue to monitor\n --Increasing Cr, 0.8 on admission, currently 1.3. Fe urea = 27.65\n Hematology:\n --Hct stable\n --ASA, SQH\n -- D/w neurology when to resume anticoagulation after underlying mass,\n AVM are ruled out\n Endocrine:\n --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg for hypothyroidism, previous TSH was 6.8\n ID:\n --Wbc 8.8->9.9->11.1 afebrile\n --Being treated for PNA with cefepime/vanc (?aspiration) total course\n should be 7 days (ending )\n --Vanc trough 20.6 , dose decreased to 500mg IV q24hrs from 750\n --Follow cultures (NGTD except yeast in urine)\n T/L/D: PIV, Foley, PICC\n Wounds: none\n Imaging: CXR\n Fluids:\n Consults:\n Billing Diagnosis: status epilepticus\n Prophylaxis:\n DVT: SQH\n Stress ulcer: H2B\n VAP bundle: +\n Comments:\n Communication: ICU consent done\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-02 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 403254,
"text": "PMH\n. CAD status post CABG \n2. Severe aortic stenosis, s\\p recent valvuloplasty.\n3. AFib on coumadin\n4. HTN\n5. Hyperlipidemia\n6. Osteoarthritis - hip replacement spinal stenosis\n7. Squamous cell carcinoma\n8. Chronic venous stasis with ulceration\n9. Hypothyroidism\n10. peripheral neuropathy\n11. Raynaud's synd\n12. Right retinal vein clot with mild loss of vision\n13. Diastolic heart failure\n14. Shingles in \n15. Status post right hemicolectomy in \n86 yo women admitted to ED from rehab after witnessed seizure. Started on Kepra\nand transferred to 11 Cardiac meds held. Pt became hypoxic with increase so\nmulence after ativan. To CCU on . Pt febrile found to have UTI and aspiration\n PNA. Speech & swallow. Pt strict NPO\ns. NTG passed as pt high risk for aspirati\non. TF at goal rate.\nPt has husband and 2 children who are very involved in care. Pt is full code.\n Pneumonia, aspiration\n Assessment:\n Lungs rhonchi with crackles.\n O2 sats > 95% on 2l.,\n Less frequent coughing although cough remains very congested.\n Action:\n Conts on Vancomycin. Flagyl & Cefipeme\n Strict NPO for aspiration precautions.\n TF at goal rate.\n Atrovent Q6hrs.\n Response:\n Good O2 sats on minimal O2. conts to desat without O2\n Plan:\n Cont with antibiotics.\n Check vanco level this pm. Dose decreased to 750mg daily.\n Seizure, without status epilepticus\n Assessment:\n No seizures noted.\n Pt lethargic but arousable to voice.\n Able to follow commands.\n MAE.\n Action:\n Kepra ^\nd to 1000mg .\n Monitor neuro status.\n Response:\n No seizures noted.\n Pt remains somulent although more responsive this pm.\n Plan:\n EEG in am.\n Aortic stenosis\n Assessment:\n Tele AF 70\ns-90\n Lasix drip off.\n Action:\n Lasix 60mg daily.\n Response:\n Good urine output today.\n Plan:\n Cont with gentle diuresis.\n Check lytes.\n Impaired Skin Integrity\n Assessment:\n Pt with h/o BLL ulcers per family for several yrs.\n Action:\n Dsg changed this am per skin care recs.\n Frequent turning and repositioning with aloe vesta.\n Response:\n R Leg draining more than L.\n Plan:\n Cont with POC.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n SEIZURE\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 80.1 kg\n Daily weight:\n 80.6 kg\n Allergies/Reactions:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Precautions:\n PMH:\n CV-PMH: Arrhythmias, Hypertension\n Additional history: PMH: 1. CAD s/p CABG for LM disease (LIMA\n to LAD and saphenous vein graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 15. Colon Cancer s/p hemicolectomy on \n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:99\n D:49\n Temperature:\n 100.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 28 insp/min\n Heart Rate:\n 85 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 70% %\n 24h total in:\n 841 mL\n 24h total out:\n 1,385 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 06:05 AM\n Potassium:\n 3.9 mEq/L\n 06:05 AM\n Chloride:\n 102 mEq/L\n 06:05 AM\n CO2:\n 33 mEq/L\n 06:05 AM\n BUN:\n 23 mg/dL\n 06:05 AM\n Creatinine:\n 1.1 mg/dL\n 06:05 AM\n Glucose:\n 98 mg/dL\n 06:05 AM\n Hematocrit:\n 32.7 %\n 06:05 AM\n Finger Stick Glucose:\n 106\n 12:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: ccu\n Transferred to: cc7\n Date & time of Transfer: \n"
},
{
"category": "Physician ",
"chartdate": "2196-02-05 00:00:00.000",
"description": "Intensivist Note",
"row_id": 403704,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. Currently, she responds only to\n painful stimuli.\n Chief complaint:\n Seizures\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS 6. 250 mL NS 7. 250 mL NS\n 8. Acetaminophen\n 9. Albuterol 0.083% Neb Soln 10. Albumin 25% (12.5g / 50mL) 11. Aspirin\n 12. Atorvastatin 13. Bacitracin-Polymyxin Ointment\n 14. Calcium Gluconate 15. CefePIME 16. Collagenase Ointment 17. Digoxin\n 18. FoLIC Acid 19. Furosemide\n 20. Gabapentin 21. Heparin 22. Ipratropium Bromide Neb 23. Latanoprost\n 0.005% Ophth. Soln. 24. Levothyroxine Sodium\n 25. LeVETiracetam 26. Lidocaine 5% Patch 27. Lorazepam 28. Magnesium\n Sulfate 29. Metoprolol Tartrate\n 30. Metoclopramide 31. Miconazole Powder 2% 32. Neutra-Phos 33.\n Nystatin Oral Suspension 34. Phenytoin Sodium (IV)\n 35. Phenylephrine 36. Potassium Chloride 37. Sodium Chloride 0.9% Flush\n 38. Sodium Chloride 0.9% Flush\n 39. Sodium Chloride 0.9% Flush 40. Timolol Maleate 0.5% 41. Vancomycin\n 24 Hour Events:\n URINE CULTURE - At 09:52 AM\n ARTERIAL LINE - START 04:39 PM\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Cefipime - 10:16 PM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Dilantin - 12:15 AM\n Other medications:\n Flowsheet Data as of 05:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36\nC (96.8\n HR: 81 (70 - 92) bpm\n BP: 106/46(68) {95/44(62) - 165/82(114)} mmHg\n RR: 15 (14 - 22) insp/min\n SPO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 80.6 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 2,656 mL\n 516 mL\n PO:\n Tube feeding:\n 83 mL\n IV Fluid:\n 2,566 mL\n 383 mL\n Blood products:\n Total out:\n 847 mL\n 170 mL\n Urine:\n 847 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,809 mL\n 346 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 95%\n ABG: 7.35/56/90./31/3\n PaO2 / FiO2: 180\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : bilat)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n moves some spontaneuously, and responds to noxious stim\n Labs / Radiology\n 376 K/uL\n 8.5 g/dL\n 122 mg/dL\n 1.3 mg/dL\n 31 mEq/L\n 4.0 mEq/L\n 33 mg/dL\n 107 mEq/L\n 143 mEq/L\n 30.5 %\n 9.9 K/uL\n [image002.jpg]\n 05:28 AM\n 02:25 PM\n 09:34 PM\n 04:56 AM\n 06:05 AM\n 06:37 PM\n 03:07 AM\n 04:56 PM\n 03:35 AM\n 03:52 AM\n WBC\n 8.2\n 7.0\n 7.1\n 8.9\n 9.9\n Hct\n 30.0\n 30.7\n 32.7\n 30.6\n 30.5\n Plt\n 354\n 323\n 307\n 302\n 376\n Creatinine\n 1.0\n 1.2\n 1.1\n 1.1\n 1.1\n 1.3\n 1.3\n 1.3\n Troponin T\n 0.03\n TCO2\n 35\n 32\n Glucose\n 113\n 137\n 153\n 109\n 98\n 146\n 121\n 122\n Other labs: PT / PTT / INR:16.1/35.1/1.4, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:62/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:202 IU/L, Ca:7.6 mg/dL, Mg:1.8 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n KNOWLEDGE DEFICIT, IMPAIRED SKIN INTEGRITY, PNEUMONIA, ASPIRATION,\n AORTIC STENOSIS, SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD\n Neurologic:\n -- Patient with subclinical seizures, loaded with dilantin and ativan\n prior to admission with poor mental status. Dilantin for seziure\n prophylaxis, f/u AM level. Follow up on EEG -> no seizures. CT\n performed to exclude underlying mass or AVM since they can affect\n the decision to restart anticoagulation for PAF and overall prognosis.\n There is a bleed detected on the prior MRI in the right posterior\n temporo-parietal area. F/U CT head results\n -- Continue neurontin for chronic pain well controlled on current\n medication.\n Cardiovascular:\n --PAF with good control of HR on beta blockade and digoxin.\n -- Multiple medical cardiovascular problems. CAD s/p CABG but\n still diastolic dysfunction. She had AS (valve area 0.8-0.6cm2 on\n previous echo) but underwent valvuloplasty\n no gradient estimation\n after procedure. Critical stenosis with very tenuous cardiac status.\n -- anticoagulation for A. Fib: On ASA and atrovastatin. No\n anticoagulation for now, will reassess today\n -- required low dose phenylephrine for MAPs>60, ?low SVR state as pt is\n clinically volume overloaded\n Pulmonary: Treated empirically for aspiration pneumonia with\n /Cefepime but cultures are negative. We will continue treatment for\n full 7 days considering that she is very advanced in her empirical\n treatment.\n -- Chest PT and inhalers\n Gastrointestinal / Abdomen: --TFs@goal prior to admission, will hold\n given worsening pulmonary status. In future consider PEG tube\n placement.\n --CDiff has been negative and diarrhea has stopped, PO vanc has been\n stopped.\n Nutrition: --TF restarted via Dobhoff\n Renal: --Lasix dependent, continue Lasix 40 (decreased from 60 given Cr\n 1.3) PO/NG daily; was previously on lasix gtt, will continue to monitor\n --Increasing Cr, 0.8 on admission, currently 1.3\n Hematology:\n --Hct stable\n --ASA, SQH\n -- D/w neurology when to resume anticoagulation after underlying mass,\n avm r/o\n Endocrine: --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg for hypothyroidism\n Infectious Disease: --Wbc 8.8->9.9 afebrile\n --Being treated for PNA with cefepime/vanc (?aspiration) total course\n should be 7 days (ending )\n --Vanc trough 20.6, dose decreased to 500mg IV q24hrs from 750\n Lines / Tubes / Drains: PIV, Foley, PICC\n Consults: neuromed\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:30 AM 25 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 06:03 PM\n Arterial Line - 04:39 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent: 33 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-03 00:00:00.000",
"description": "Physician Surgical Admission Note",
"row_id": 403435,
"text": "Chief Complaint: Seizures\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from 1/11-20/10 for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. Currently, she responds only to\n painful stimuli.\n Post operative day:\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:47 PM\n Cefipime - 08:19 PM\n Metronidazole - 10:21 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family / Social history:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n rehab for 5 weeks.\n -Tobacco history:none\n -ETOH:none\n -Illicit drugs:none\n -uses walker/wheelchair at home, poor candidate for knee replacement.\n Flowsheet Data as of 06:52 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 80 (80 - 82) bpm\n BP: 94/74(78) {94/59(69) - 104/74(78)} mmHg\n RR: 26 (22 - 27) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 80.6 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 841 mL\n PO:\n TF:\n 501 mL\n IVF:\n 190 mL\n Blood products:\n Total out:\n 1,385 mL\n 0 mL\n Urine:\n 1,385 mL\n NG:\n Stool:\n Drains:\n Balance:\n -544 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese, Minimally responsive\n Eyes / Conjunctiva: R pupil 3.5 mm, L 4 mm-->2 b/l, equally responsive\n Head, Ears, Nose, Throat: NG tube, Dry MM, thick secretions\n Cardiovascular: (S2: Normal), (Murmur: Systolic), AF\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished),\n venous stasis ulcers\n Respiratory / Chest: (Breath Sounds: Crackles : , Diminished: ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Obese\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, venous stasis ulcers\n Skin: Warm\n Neurologic: No(t) Follows simple commands, Responds to: Noxious\n stimuli, Movement: Purposeful, Tone: Normal, sedated with ativan prior\n to admission\n Labs / Radiology\n 307 K/uL\n 9.2 g/dL\n 98 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.5 mEq/L\n 23 mg/dL\n 102 mEq/L\n 145 mEq/L\n 32.7 %\n 7.1 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n 02:18 PM\n 05:28 AM\n 02:25 PM\n 09:34 PM\n 04:56 AM\n 06:05 AM\n WBC\n 11.7\n 9.9\n 8.2\n 7.0\n 7.1\n Hct\n 34.7\n 30.6\n 30.0\n 30.7\n 32.7\n Plt\n 23\n 307\n Cr\n 0.8\n 1.0\n 1.0\n 1.0\n 1.2\n 1.1\n 1.1\n 1.1\n TropT\n 0.02\n TCO2\n 34\n 35\n Glucose\n 107\n 87\n 85\n 113\n 137\n 153\n 109\n 98\n Other labs: PT / PTT / INR:14.3/29.6/1.2, CK / CKMB /\n Troponin-T:15//0.02, ALT / AST:, Alk Phos / T Bili:62/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:2.6 mg/dL\n Imaging:\n IMAGING:\n CXR: Cardiomegaly, prominent pulmonary vasculature, and bibasilar\n atelectasis is unchanged.\n MR: Focal area w/high signal intensity @ R sup parietal lobule, no\n mass effect and may represent a chronic hemorrhagic area. Subcortical\n areas w/high signal intensity on T2 and FLAIR c/w chronic microvascular\n ischemic changes. Tortuosity of basilar artery, cw dolichoectasia\n Echo: EF >= 60%, Symmetric LVH, Significant AS, Trivial MR (may be\n significantly UNDERestimated), Mild [1+] TR. Mild PA systolic HTN\n CTA: No acute infarction or hemorrhage. Severe atherosclerotic\n narrowing of distal R vertebral art and moderate-to-severe narrowing of\n both cavernous internal carotid arteries. Small focus of calcification\n in the Basilar A. close to the tip. Moderate microangiopathic ischemic\n white matter disease\n Microbiology: UCx: Yeast, >100,000\n BCx x2 P\n .\n Assessment and Plan\n KNOWLEDGE DEFICIT\n IMPAIRED SKIN INTEGRITY\n PNEUMONIA, ASPIRATION\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment And Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD\n Neurologic: --subclinical seizures, loaded with dilantin and ativan\n prior to admission with poor mental status\n --r/o underlying mass or avm/cavernoma prior to restarting\n anticoagulation for her paroxismal AF (she underwent MRI of the brain\n without contrast (2 sets) w/a bleed in RIGHT posterior temporo-parietal\n area).\n --f/u 24 h EEG\n --f/u MRI/A with contrast\n --Keppra for seizure prophylaxis\n --Cont neurontin, Tylenol for pain/fever\n Cardiovascular: --CAD s/p CABG , Severe AS s/p valvuloplasty in\n , AF previously coumadin, HTN, Chronic Diastolic heart failure\n -ASA, atorvastatin\n --Rate control for AF with metoprolol 75 mg PO/NG TID , Digoxin\n --Resume anticoagulation after underlying mass, avm r/o\n Pulmonary: Albuterol/Atrovent nebs PRN\n --Significant Chest PT\n --Being treated for PNA with cefepime/\n Gastrointestinal: --TFs@goal prior to admission, will hold given\n worsening pulmonary status. Considering PEG tube placement.\n --CDiff has been negative and diarrhea has stopped, PO has been\n stopped.\n Renal: --Lasix dependant, continue Lasix 40 (decreased from 60 given Cr\n 1.3) PO/NG daily; was previously on lasix gtt, will continue to monitor\n --Increasing Cr, 0.8 on admission, currently 1.3 from 1.1\n --Hypernatremia, Na 146\n Hematology: --Hct 31.8\n --ASA, SQH\n --Resume anticoagulation after underlying mass, avm r/o\n Infectious Disease: --Wbc 8.8\n --Being treated for PNA with cefepime/, consider d/c'ing as\n most likely aspiration pna\n Endocrine: --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg\n Fluids: D5 1/2 NS + 20 KCL@40\n Electrolytes: pending\n Nutrition: NPO\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 06:03 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402746,
"text": "86F severe AS (critical AS s/p valvuloplasty ), CAD s/p CABG \n (lima-lad, svg-om), dCHF, AF with multiple recent hospitalizations\n ( valvuloplasty, hemicolectomy for adenoCA, c diff colitis,\n diverticulitis. Admitted after seizure which stopped with ativan\n and keppra. Diuretics were held on admission. She was treated initially\n for meningitis. CTA was negative for CVA. MRI head with high signal\n intensity in the R superior parietal lobe. After MRI on she\n triggered for AMS and lethargy. Her HR was in the 130s and her SBP was\n in the 80s. Her ABG was notable for pCO2 65. She was given lasix 10mg\n IV then 30mg and 5mg IV metoprolol without significant improvement.\n Aortic stenosis\n Assessment:\n Tele AF 80\ns-120\n SBP 90\ns-120\n Lungs with crackles throughout with exp wheezes.\n O2 sats 85-92%.\n Action:\n Given Lasix bolus and Lasix drip at 5mg/hr.\n Lopressor 5mg Q4hrs.\n Atrovent Q6hrs.\n With turning pt has desaturated.\n Response:\n Better rate control with lopressor.\n Moderate diuresis from Lasix.\n Pt slow to recover from desaturation. House staff aware.\n Plan:\n Placed on 40% face mask.\n Chest CT tonite.\n Encourage pulmonary toilet.\n Cont with gentle diuresis.\n Seizure, without status epilepticus\n Assessment:\n Recent h/o seizures.\n No seizures noted since started on Kepra\n Somulent upon arrival to CCU.\n Responding to painful stimuli only.\n Action:\n Kepra .\n Monitor neuro status.\n EEG this am.\n Response:\n Stable.\n More responsive this pm.\n Able to follow a few commands.\n Cooperative with care.\n Plan:\n Cont to monitor for seizures.\n Monitor neuro status.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403779,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. Currently, she responds only to\n painful stimuli.\n Chief complaint:\n Seizures\n Seizure, without status epilepticus\n Assessment:\n Patient opens eyes to pain continous EEG withdraws to pain pupils\n brisk withdraws to pain moans some non purposeful movements noted\n lungs with rhonchi throughout all fields on 50% open face tent\n suctioned orally for secretions heart rate 80-90\ns afib systolic b/p\n 90-100\n over 70\ns + bowel sounds + flatus\n Action:\n ABG drawn PCO2 53 resident aware\n Response:\n Patient condition remains unchanged\n Plan:\n MRI in am notify team of any changes provide comfort and support as\n needed.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403787,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent follow-up abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and A Fib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. Currently, she responds only to\n painful stimuli.\n Chief complaint:\n Seizures\n Seizure, without status epilepticus\n Assessment:\n Patient opens eyes to pain continuous EEG withdraws to pain pupils\n brisk withdraws to pain moans some non purposeful movements noted\n lungs with rhonchi throughout all fields on 50% open face tent\n suctioned orally for secretions heart rate 80-90\ns a fib systolic b/p\n 90-100\n over 70\ns + bowel sounds + flatus\n Action:\n ABG drawn PCO2 53 resident aware\n Response:\n Patient condition remains unchanged\n Plan:\n MRI in am notify team of any changes provides comfort and support as\n needed.\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 403487,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. Currently, she responds only to\n painful stimuli.\n Chief complaint:\n seizures\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS 6. 250 mL NS 7. 500 mL\n NS 8. Acetaminophen\n 9. Albuterol 0.083% Neb Soln 10. Aspirin 11. Atorvastatin 12.\n Bacitracin-Polymyxin Ointment 13. CefePIME\n 14. Collagenase Ointment 15. Digoxin 16. FoLIC Acid 17. Furosemide 18.\n Gabapentin 19. Heparin 20. Ipratropium Bromide Neb\n 21. Latanoprost 0.005% Ophth. Soln. 22. Levothyroxine Sodium 23.\n LeVETiracetam 24. Lidocaine 5% Patch\n 25. Lorazepam 26. Metoprolol Tartrate 27. Miconazole Powder 2% 28.\n Nystatin Oral Suspension 29. Phenytoin Sodium (IV)\n 30. Sodium Chloride 0.9% Flush 31. Sodium Chloride 0.9% Flush 32.\n Sodium Chloride 0.9% Flush 33. Timolol Maleate 0.5%\n 34. Vancomycin\n 24 Hour Events:\n EEG - At 06:00 PM\n continuous\n PICC LINE - START 06:03 PM\n Admitted, mild hypotension, 250 x2 NS given with good effect\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Metronidazole - 10:21 PM\n Vancomycin - 09:09 PM\n Cefipime - 10:15 PM\n Infusions:\n Other ICU medications:\n Dilantin - 12:24 AM\n Other medications:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.3\nC (97.3\n T current: 35.6\nC (96\n HR: 74 (66 - 82) bpm\n BP: 79/39(47) {79/30(45) - 105/74(78)} mmHg\n RR: 15 (14 - 27) insp/min\n SPO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 80.6 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 1,340 mL\n 738 mL\n PO:\n Tube feeding:\n IV Fluid:\n 540 mL\n 738 mL\n Blood products:\n Total out:\n 750 mL\n 116 mL\n Urine:\n 750 mL\n 116 mL\n NG:\n Stool:\n Drains:\n Balance:\n 590 mL\n 622 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SPO2: 99%\n ABG: ///34/\n Physical Examination\n General Appearance: Minimally reactive/interactive.\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous : ,\n Diminished: bibasilar)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: No(t) Present, Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Skin: b/l venous stasis ulcers\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities\n Labs / Radiology\n 302 K/uL\n 8.9 g/dL\n 121 mg/dL\n 1.3 mg/dL\n 34 mEq/L\n 3.2 mEq/L\n 33 mg/dL\n 106 mEq/L\n 144 mEq/L\n 30.6 %\n 8.9 K/uL\n [image002.jpg]\n 09:22 PM\n 05:40 AM\n 02:18 PM\n 05:28 AM\n 02:25 PM\n 09:34 PM\n 04:56 AM\n 06:05 AM\n 06:37 PM\n 03:07 AM\n WBC\n 9.9\n 8.2\n 7.0\n 7.1\n 8.9\n Hct\n 30.6\n 30.0\n 30.7\n 32.7\n 30.6\n Plt\n 07\n 302\n Creatinine\n 1.0\n 1.0\n 1.0\n 1.2\n 1.1\n 1.1\n 1.1\n 1.3\n 1.3\n TCO2\n 35\n Glucose\n 87\n 85\n 113\n 137\n 153\n 109\n 98\n 146\n 121\n Other labs: PT / PTT / INR:14.9/36.6/1.3, CK / CK-MB / Troponin\n T:15//0.02, ALT / AST:, Alk-Phos / T bili:62/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Albumin:2.4 g/dL, LDH:202 IU/L, Ca:7.5\n mg/dL, Mg:1.9 mg/dL, PO4:2.4 mg/dL\n Imaging: CXR: Cardiomegaly, prominent pulmonary vasculature, and\n bibasilar\n atelectasis is unchanged.\n MR: Focal area w/high signal intensity @ R sup parietal lobule, no\n mass effect and may represent a chronic hemorrhagic area. Subcortical\n areas w/high signal intensity on T2 and FLAIR c/w chronic microvascular\n ischemic changes. Tortuosity of basilar artery, cw dolichoectasia\n Echo: EF >= 60%, Symmetric LVH, Significant AS, Trivial MR (may be\n significantly UNDERestimated), Mild [1+] TR. Mild PA systolic HTN\n CTA: No acute infarction or hemorrhage. Severe atherosclerotic\n narrowing of distal R vertebral art and moderate-to-severe narrowing of\n both cavernous internal carotid arteries. Small focus of calcification\n in the Basilar A. close to the tip. Moderate microangiopathic ischemic\n white matter disease\n Microbiology: UCx: Yeast, >100,000\n BCx x2 P\n Assessment and Plan\n KNOWLEDGE DEFICIT, IMPAIRED SKIN INTEGRITY, PNEUMONIA, ASPIRATION,\n AORTIC STENOSIS, SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD\n Neurologic: --subclinical seizures, loaded with dilantin and ativan\n prior to admission with poor mental status\n --r/o underlying mass or avm/cavernoma prior to restarting\n anticoagulation for her paroxismal AF (she underwent MRI of the brain\n without contrast (2 sets) w/a bleed in RIGHT posterior temporo-parietal\n area).\n --f/u 24 h EEG\n --f/u MRI with contrast in future\n --Keppra and Dilantin for seizure prophylaxis\n --Cont neurontin, Tylenol for pain/fever\n Cardiovascular: --CAD s/p CABG , Severe AS s/p valvuloplasty in\n , AF previously coumadin, HTN, Chronic Diastolic heart failure\n -ASA, atorvastatin\n --Rate control for AF with metoprolol 75 mg PO/NG TID , Digoxin\n --Resume anticoagulation after underlying mass, avm r/o\n --250 x2 NS given with good effect\n Pulmonary: --Albuterol/Atrovent nebs PRN\n --Significant Chest PT\n --Being treated for PNA with cefepime/\n Gastrointestinal / Abdomen: --TFs@goal prior to admission, will hold\n given worsening pulmonary status. Considering PEG tube placement.\n --CDiff has been negative and diarrhea has stopped, PO has been\n stopped.\n Nutrition: TFs held currently\n Renal: --Lasix dependant, continue Lasix 40 (decreased from 60 given Cr\n 1.3) PO/NG daily; was previously on lasix gtt, will continue to monitor\n --Increasing Cr, 0.8 on admission, currently 1.3 from 1.1\n --Hypernatremia, Na 146\n Hematology: --Hct 31.8\n --ASA, SQH\n --Resume anticoagulation after underlying mass, avm r/o\n Endocrine: --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg\n Infectious Disease: --Wbc 8.8-8.9\n --Being treated for PNA with cefepime/, consider d/c'ing as\n most likely aspiration pna\n Lines / Tubes / Drains: PIV, Foley, PICC\n Wounds:\n Imaging: CXR today\n Fluids: D5 1/2 NS + 20 KCL@40--increased to 60\n Consults: Neurology\n Billing Diagnosis: Other: status epilepticus\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 06:03 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402745,
"text": "86F severe AS (critical AS s/p valvuloplasty ), CAD s/p CABG \n (lima-lad, svg-om), dCHF, AF with multiple recent hospitalizations\n ( valvuloplasty, hemicolectomy for adenoCA, c diff colitis,\n diverticulitis. Admitted after seizure which stopped with ativan\n and keppra. Diuretics were held on admission. She was treated initially\n for meningitis. CTA was negative for CVA. MRI head with high signal\n intensity in the R superior parietal lobe. After MRI on she\n triggered for AMS and lethargy. Her HR was in the 130s and her SBP was\n in the 80s. Her ABG was notable for pCO2 65. She was given lasix 10mg\n IV then 30mg and 5mg IV metoprolol without significant improvement.\n Aortic stenosis\n Assessment:\n Tele AF 80\ns-120\n SBP 90\ns-120\n Lungs with crackles throughout with exp wheezes.\n O2 sats 85-92%.\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403659,
"text": "Aortic stenosis\n Assessment:\n BP\ns 80\ns-100\ns/40\ns-60\ns. Afib with ectopy. Lungs With crackles\n throughout bilaterally. 2+ edema in LE\ns to knees. U/O 25-80 CC/HR.\n Action:\n Neo gtt continued. O.25-0.5 mcg/kg/min\n Response:\n MAP > 60 with neo @..5\n Plan:\n continue Neo for MAP>60, monitor U/O\n PO Lasix daily.\n Seizure, without status epilepticus\n Assessment:\n no seizure activity noted. some slight tremulousness noted at times..\n EEG at bedside\n Action:\n dilantin IV TID, keppra \n Q2 neuro checks.\n Response:\n no seizure activity noted\n dilantin level\n Plan:\n continue to monitor\n Pneumonia, aspiration\n Assessment:\n LS coarse with crackles throughout. A-febrile during the day. Sats WNL,\n ABG PCO2 56. O2.\n Non-productive, congested cough.\n WBC 9.9\n Action:\n chest pt done\n combivent nebs q6\n chest xray am\n O2 changed to 50% open FM, 5L\n Response:\n sats WNL\n Plan:\n pulmonary toileting, monitor sats, continue IV abx\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-05 00:00:00.000",
"description": "Intensivist Note",
"row_id": 403665,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. Currently, she responds only to\n painful stimuli.\n Chief complaint:\n Seizures\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS 6. 250 mL NS 7. 250 mL NS\n 8. Acetaminophen\n 9. Albuterol 0.083% Neb Soln 10. Albumin 25% (12.5g / 50mL) 11. Aspirin\n 12. Atorvastatin 13. Bacitracin-Polymyxin Ointment\n 14. Calcium Gluconate 15. CefePIME 16. Collagenase Ointment 17. Digoxin\n 18. FoLIC Acid 19. Furosemide\n 20. Gabapentin 21. Heparin 22. Ipratropium Bromide Neb 23. Latanoprost\n 0.005% Ophth. Soln. 24. Levothyroxine Sodium\n 25. LeVETiracetam 26. Lidocaine 5% Patch 27. Lorazepam 28. Magnesium\n Sulfate 29. Metoprolol Tartrate\n 30. Metoclopramide 31. Miconazole Powder 2% 32. Neutra-Phos 33.\n Nystatin Oral Suspension 34. Phenytoin Sodium (IV)\n 35. Phenylephrine 36. Potassium Chloride 37. Sodium Chloride 0.9% Flush\n 38. Sodium Chloride 0.9% Flush\n 39. Sodium Chloride 0.9% Flush 40. Timolol Maleate 0.5% 41. Vancomycin\n 24 Hour Events:\n URINE CULTURE - At 09:52 AM\n ARTERIAL LINE - START 04:39 PM\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Cefipime - 10:16 PM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Dilantin - 12:15 AM\n Other medications:\n Flowsheet Data as of 05:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36\nC (96.8\n HR: 81 (70 - 92) bpm\n BP: 106/46(68) {95/44(62) - 165/82(114)} mmHg\n RR: 15 (14 - 22) insp/min\n SPO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 80.6 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 2,656 mL\n 516 mL\n PO:\n Tube feeding:\n 83 mL\n IV Fluid:\n 2,566 mL\n 383 mL\n Blood products:\n Total out:\n 847 mL\n 170 mL\n Urine:\n 847 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,809 mL\n 346 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 95%\n ABG: 7.35/56/90./31/3\n PaO2 / FiO2: 180\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : bilat)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n moves some spontaneuously, and responds to noxious stim\n Labs / Radiology\n 376 K/uL\n 8.5 g/dL\n 122 mg/dL\n 1.3 mg/dL\n 31 mEq/L\n 4.0 mEq/L\n 33 mg/dL\n 107 mEq/L\n 143 mEq/L\n 30.5 %\n 9.9 K/uL\n [image002.jpg]\n 05:28 AM\n 02:25 PM\n 09:34 PM\n 04:56 AM\n 06:05 AM\n 06:37 PM\n 03:07 AM\n 04:56 PM\n 03:35 AM\n 03:52 AM\n WBC\n 8.2\n 7.0\n 7.1\n 8.9\n 9.9\n Hct\n 30.0\n 30.7\n 32.7\n 30.6\n 30.5\n Plt\n 354\n 323\n 307\n 302\n 376\n Creatinine\n 1.0\n 1.2\n 1.1\n 1.1\n 1.1\n 1.3\n 1.3\n 1.3\n Troponin T\n 0.03\n TCO2\n 35\n 32\n Glucose\n 113\n 137\n 153\n 109\n 98\n 146\n 121\n 122\n Other labs: PT / PTT / INR:16.1/35.1/1.4, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:62/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:202 IU/L, Ca:7.6 mg/dL, Mg:1.8 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n KNOWLEDGE DEFICIT, IMPAIRED SKIN INTEGRITY, PNEUMONIA, ASPIRATION,\n AORTIC STENOSIS, SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD\n Neurologic: -- Patient with subclinical seizures, loaded with dilantin\n and ativan prior to admission with poor mental status. Dilantin for\n seziure prophylaxis, f/u AM level. Follow up on EEG -> no seizures. CT\n performed to exclude underlying mass or AVM since they can affect\n the decision to restart anticoagulation for PAF and overall prognosis.\n There is a bleed detected on the prior MRI in the right posterior\n temporo-parietal area. F/U CT head results\n -- Continue neurontin for chronic pain well controlled on current\n medication.\n Cardiovascular: --PAF with good control of HR on beta blockade and\n digoxin.\n -- Multiple medical cardiovascular problems. CAD s/p CABG but\n still diastolic dysfunction. She had AS (valve area 0.8cm2 on previous\n echo) but underwent valvuloplasty\n no gradient estimation after\n procedure.\n -- anticoagulation for A. Fib: On ASA and atrovastatin. No\n anticoagulation for now, will reassess today\n -- required low dose phenylephrine for MAPs>60, ?low SVR state as pt is\n clinically volume overloaded\n Pulmonary: Treated empirically for aspiration pneumonia with\n /Cefepime but cultures are negative. We will continue treatment for\n full 7 days considering that she is very advanced in her empirical\n treatment.\n -- Chest PT and inhalers\n Gastrointestinal / Abdomen: --TFs@goal prior to admission, will hold\n given worsening pulmonary status. In future consider PEG tube\n placement.\n --CDiff has been negative and diarrhea has stopped, PO vanc has been\n stopped.\n Nutrition: --TF restarted via Dobhoff\n Renal: --Lasix dependent, continue Lasix 40 (decreased from 60 given Cr\n 1.3) PO/NG daily; was previously on lasix gtt, will continue to monitor\n --Increasing Cr, 0.8 on admission, currently 1.3\n Hematology: --Hct stable\n --ASA, SQH\n -- D/w neurology when to resume anticoagulation after underlying mass,\n avm r/o\n Endocrine: --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg for hypothyroidism\n Infectious Disease: --Wbc 8.8->9.9 afebrile\n --Being treated for PNA with cefepime/vanc (?aspiration) total course\n should be 7 days (ending )\n --Vanc trough 20.6, dose decreased to 500mg IV q24hrs from 750\n Lines / Tubes / Drains: PIV, Foley, PICC\n Wounds:\n Imaging:\n Fluids:\n Consults: neuromed\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:30 AM 25 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 06:03 PM\n Arterial Line - 04:39 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent: 33 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402535,
"text": "Patient A+Ox3, denies pain. MAE to command. LS clear upper crackles\n bases. Lasix 20mg IV given as ordered. Report given to Nurse \n on 11. Transfering patient shortly. No personal belongings noted\n in room.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403769,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. Currently, she responds only to\n painful stimuli.\n Chief complaint:\n Seizures\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403772,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. Currently, she responds only to\n painful stimuli.\n Chief complaint:\n Seizures\n Seizure, without status epilepticus\n Assessment:\n Patient opens eyes to pain continous EEG withdraws to pain pupils\n brisk withdraws to pain moans some non purposeful movements noted\n lungs with rhonchi throughout all fields on 50% open face tnet\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403778,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. Currently, she responds only to\n painful stimuli.\n Chief complaint:\n Seizures\n Seizure, without status epilepticus\n Assessment:\n Patient opens eyes to pain continous EEG withdraws to pain pupils\n brisk withdraws to pain moans some non purposeful movements noted\n lungs with rhonchi throughout all fields on 50% open face tent suctioen\n orally for secretions heart rate 80-90\ns afib\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nutrition",
"chartdate": "2196-02-08 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 404095,
"text": "Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 122 mg/dL\n 03:33 AM\n Glucose Finger Stick\n 146\n 04:00 PM\n BUN\n 51 mg/dL\n 03:33 AM\n Creatinine\n 1.7 mg/dL\n 03:33 AM\n Sodium\n 147 mEq/L\n 03:33 AM\n Potassium\n 4.0 mEq/L\n 03:33 AM\n Chloride\n 111 mEq/L\n 03:33 AM\n TCO2\n 28 mEq/L\n 03:33 AM\n PO2 (arterial)\n 114 mm Hg\n 09:41 AM\n PCO2 (arterial)\n 45 mm Hg\n 09:41 AM\n pH (arterial)\n 7.41 units\n 09:41 AM\n CO2 (Calc) arterial\n 30 mEq/L\n 09:41 AM\n Albumin\n 2.7 g/dL\n 03:33 AM\n Calcium non-ionized\n 7.6 mg/dL\n 03:33 AM\n Phosphorus\n 2.3 mg/dL\n 03:33 AM\n Magnesium\n 2.1 mg/dL\n 03:33 AM\n ALT\n 5 IU/L\n 03:33 AM\n Alkaline Phosphate\n 60 IU/L\n 03:33 AM\n AST\n 28 IU/L\n 03:33 AM\n Total Bilirubin\n 0.2 mg/dL\n 03:33 AM\n Phenytoin (Dilantin)\n 9.3 ug/mL\n 03:33 AM\n WBC\n 11.3 K/uL\n 03:33 AM\n Hgb\n 7.8 g/dL\n 03:33 AM\n Hematocrit\n 26.9 %\n 03:33 AM\n Current diet order / nutrition support: Nutren Pulmonary w/ 21 gr\n beneprotein @45mLhr (1695 kcals/81 gr protein)\n GI: Abd:obese/nbs\n Assessment of Nutritional Status\n Specifics:\n Nutrition called by team requesting more concentrated tube feed\n formula. Patient is already receiving semi-concentrated formula which\n provides 1080 mL\ns/day. Given patient already hypernatremic, with ~2L\n calculated free water deficit (using admit wt of 80kg), would continue\n w/ current Rx. Changing to even more volume restricted formula will\n require further increase in free water flushes. Low P noted.\n Medical Nutrition Therapy Plan - Recommend the Following\n Would continue w/ current tube feed formula, however, if\n team wishes to further fluid restrict, can change to NUtren 2.0 @\n 35mL/hr w/ 21 gr beneprotein (1755 kcals/85 gr protein)\n IF Na remains elevated on repeat chem. 10 this afternoon,\n Increase free water flushes to 200ml q6 hr until Na WNL- will need to\n monitor Na and continue to adjust water flushes prn\n Replete P now\n Glucose management as you are\n Following #\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404279,
"text": "Ineffective Coping\n Assessment:\n Received pt @ 1300, husband & son in room, neuro resident in to speak\n with family, update given, poor prognosis given but family told pt has\n a slight chance of improvement, family wishes to keep pt full code &\n is planning for trach/peg but will still need more time to make final\n trach/peg decision, husband expressed his extreme sadness,\n \n know what to do without her\n, he has not been able to eat & is worried\n about living alone, pt/husband have been living in own home without\n services, son lives close by, pt does have life alert button for\n herself but husband does not\n Action:\n Support given, encouraged husband to wear wife\ns life alert button now\n that he is living alone, social work consult placed for family coping &\n husbands concern for caring for himself, husband also encouraged to at\n least take liquids if not able to have solids @ this time\n Response:\n Family happy to know social work will be available for them\n Plan:\n Continue to assess family coping, offer support/services as needed\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404651,
"text": "Seizure, without status epilepticus\n Assessment:\n Pt remains intubated, no sedation\n Pt slightly withdraws extremities to deep nailbed pressure,\n pupils equal and reactive, weak cough, no gag, does not open eyes, no\n spontaneous movement\n EEG continues\n Pt remains on neo gtt to keep SBP >120\n Remains oliguric, BUN 99 Cr 3.2\n No vent changes made\n Thick yellow sputum\n Tmax 101.2\n Action:\n Pt transferred to CCU service\n Neuro checks Q2hrs\n Neo gtt to keep SBP >120\n Lasix given x1\n Dilantin bolus given for sub-therapeutic level\n Suctioned prn\n Monitor o/u\n Monitor ABGs\n Pt turned Q2 hrs\n NPO after MN\n Response:\n No change in neuro exam\n No response to IVP Lasix\n No change in resp status\n Plan:\n Trach and PEG on Monday per family\n Continue to monitor neuro exam, outputs/renal function\n Wean vent as tolerated\n Keep SBP>120\n Pt continues to be a full code\n Provide pt and family with emotional support\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405016,
"text": "86F with CAD s/p CABG (SVG-OM, LIMA-LAD), AS s/p valvuloplasty\n , diastolic CHF, AF on coumadin, s/p R colectomy who was\n initially admitted to the neurology service with generalized tonic\n clonic seizure on . Then, on evening of , the patient\n triggered for altered mental status and lethargy following a head MRI.\n At that time, it was unclear whether this was related to flash\n pulmonary edema in the setting of having her lasix held versus an\n aspiration event while she was lying flat for her MRI. She was also\n having episodes of Afib with RVR secondary to missing metoprolol doses\n while she was on the floor. She was transferred to the CCU for further\n management. After she was diuresed and her afib was better controlled,\n the patient was transferred to the medical service. However, on the\n medical floor, the patient was noted to be in NCSE on EEG. She was then\n transferred to the neuro ICU for further care.\n .\n Now, at the patient's family's request, she is being transferred to the\n CCU service for further management. Her course up to this transfer has\n been complicated by subclinical seizures and deteriorating mental\n status, aspiration pneumonia, respiratory acidosis and failure\n resulting in intubation (), ARF, hypotension requiring\n phenylephrine.\n She was trached and peg EEG continuous monitoring resumed,\n phenobarb decreased to 30mg , Dilantin increased to 125mg q 8.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n urine output 10cc\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n eeg monitoring in place, no sz activity noted. Pupils equal and\n reactive, UE withdrawal to very painful stimuli, LE responding to\n light noxious stimuli.\n Action:\n given Dilantin as ordered, monitor neuro signs and signs sz activity\n Response:\n no sz activity\n Plan:\n MRI today call eeg to remove from eeg machine the electrodes are\n compatible, ? LP to r/o infectious process\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405152,
"text": "Pt transferred from SICU B to CCU for continued care by CCU team.\n Please see SICU RN note from today. Pt arrived at 1600, vital signs\n stable. Cont plan of care.\n Seizure, without status epilepticus\n Assessment:\n EEG monitoring in place, no twitching, tonic clonic movements noted. Pt\n unarrousable, sl. Grimace with mouth care, no gag, weak cough.\n Action:\n Given Dilantin load of 800mg.\n Response:\n unchanged\n Plan:\n Decreasing phenobarb dosing and cont on Dilantin, cont to follow neuro\n exam.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Arrived to CCU on PS 15/5 Peep 50%. Difficult to pick up sat, place on\n ear lobe and adequate pleth obtained. Sats initially 95%, then sats\n dropping to 80\ns, only minimal thick tan secretions.\n Action:\n Suctioned and placed on 100%, sats come up on higher FIO2, left on 100%\n and Resp therapy to come by to assess. Turned to L side, sats up to\n 98%.\n Response:\n Sat improved with increased FIO2 and then even better with position\n change. Pt has been unresponsive to diuresis.\n Plan:\n Resp therapy to follow up and adjust , increase peep per team.\n Cont pul toilet. Wean FIO2 as able. Possibly increase PEEP.\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-10 00:00:00.000",
"description": "Intensivist Note",
"row_id": 404267,
"text": "SICU\n HPI:\n Seizures\n Chief complaint:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. At time of SICU admission, she\n responded only to painful stimuli.\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n 1. IV access: Peripheral line Location: Right Order date: @ \n 25. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1707\n 2. IV access: Peripheral line Order date: @ 26. Ipratropium\n Bromide MDI 2 PUFF IH Q6H wheezing\n MDI while on vent Order date: @ 2059\n 3. IV access: PICC, non-heparin dependent Location: Right Brachial,\n Date inserted: Order date: @ 27. Ipratropium\n Bromide Neb 1 NEB IH Q6H\n Use MDI/inhaler while pt in intubated, on vent Order date: @\n 2059\n 4. IV access: None Order date: @ 28. Latanoprost 0.005%\n Ophth. Soln. 1 DROP BOTH EYES HS Order date: @ \n 5. OK to use line Order date: @ 1549 29. Levothyroxine Sodium 75\n mcg PO/NG DAILY Order date: @ \n 6. Acetaminophen 325-650 mg PO/NG Q6H:PRN fever Order date: @\n 1054 30. LeVETiracetam 500 mg PO/NG Order date: @ 1002\n 7. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing Order date:\n @ 31. Lidocaine 5% Patch 2 PTCH TD DAILY\n 12 h on 12 h off; apply one patch to each knee Order date: @\n \n 8. Albuterol Inhaler PUFF IH Q4H:PRN wheezing\n while intubated ,on vent Order date: @ 2059 32. Lorazepam 0.5-1\n mg IV HS PRN Sz\n prolonged Sz > 3 minutes; Pls page neurology resident prior\n administering. Order date: @ 2213\n 9. Aspirin 81 mg PO/NG DAILY Order date: @ 33. Magnesium\n Sulfate IV Sliding Scale Order date: @ 0638\n 10. Atorvastatin 40 mg PO/NG DAILY Order date: @ 34.\n Metoprolol Tartrate 25 mg PO/NG TID\n hold for HR<60 or BP<100 Order date: @ 0923\n 11. Bacitracin-Polymyxin Ointment 1 Appl TP Q6H:PRN wound Order date:\n @ 35. Miconazole Powder 2% 1 Appl TP PRN fungal infection\n Order date: @ \n 12. Calcium Gluconate IV Sliding Scale Order date: @ 0638 36.\n Nystatin Oral Suspension 5 mL PO QID:PRN \n swish and swallow Order date: @ \n 13. CefePIME 2 g IV Q24H Duration: 1 Doses\n Stop Order date: @ 0827 37. PHENObarbital 90 mg PO/NG \n start with PM dose 3/15 Order date: @ 1002\n 14. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1754 38. Phenytoin Sodium (IV) 100 mg IV Q8H Order date: @ 2157\n 15. Ciprofloxacin 400 mg IV ONCE Duration: 1 Doses Order date: @\n 0827 39. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAPs >60\n Order date: @ 1434\n 16. Collagenase Ointment 1 Appl TP DAILY Order date: @ 40.\n Phenytoin Sodium (IV) 250 mg IV ONCE Duration: 1 Doses Order date:\n @ 1056\n 17. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date:\n @ 1707 41. Phenytoin Sodium (IV) 500 mg IV ONCE Duration: 1 Doses\n Order date: @ 2124\n 18. Digoxin 0.0625 mg PO/NG DAILY Order date: @ 42.\n Potassium Chloride IV Sliding Scale Order date: @ 0638\n 19. Famotidine 20 mg IV Q24H Order date: @ 1817 43. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ \n 20. Fentanyl Citrate 12.5-100 mcg IV Q2H:PRN agitation, for sedation\n Order date: @ 1508 44. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN\n line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ \n 21. FoLIC Acid 1 mg PO/NG DAILY Order date: @ 45. Sodium\n Chloride 0.9% Flush 10 mL IV PRN line flush\n PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and\n PRN per lumen. Order date: @ \n 22. Furosemide 40 mg PO/NG DAILY\n hold for BP <100 Order date: @ 46. Timolol Maleate 0.5% 1\n DROP BOTH EYES DAILY Order date: @ \n 23. Gabapentin 100 mg PO/NG Order date: @ 47.\n Vancomycin 500 mg IV Q 24H Duration: 1 Doses Start: In am\n Stop Hold please Order date: @ 0827\n 24. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1707\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:09 AM\n MULTI LUMEN - START 01:49 PM\n WOUND CULTURE - At 05:30 PM\n PICC tip\n PICC LINE - STOP 05:42 PM\n Post operative day:\n N/A\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Cefipime - 10:00 PM\n Vancomycin - 08:23 PM\n Ciprofloxacin - 12:02 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 01:40 PM\n Famotidine (Pepcid) - 08:22 PM\n Dilantin - 01:30 AM\n Other medications:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.6\nC (99.6\n HR: 82 (68 - 84) bpm\n BP: 109/51(72) {101/38(62) - 118/65(81)} mmHg\n RR: 18 (12 - 19) insp/min\n SPO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 95.2 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 2,555 mL\n 564 mL\n PO:\n Tube feeding:\n 822 mL\n 216 mL\n IV Fluid:\n 692 mL\n 348 mL\n Blood products:\n 631 mL\n Total out:\n 448 mL\n 40 mL\n Urine:\n 148 mL\n 40 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 2,107 mL\n 524 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 24 cmH2O\n Plateau: 22 cmH2O\n Compliance: 32.1 cmH2O/mL\n SPO2: 98%\n ABG: 7.37/37/142/24/-3\n Ve: 6.6 L/min\n PaO2 / FiO2: 284\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: (Responds to: Unresponsive), Moves all extremities\n Labs / Radiology\n 381 K/uL\n 9.0 g/dL\n 107 mg/dL\n 2.2 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 59 mg/dL\n 106 mEq/L\n 138 mEq/L\n 29.7 %\n 9.7 K/uL\n [image002.jpg]\n 01:08 PM\n 04:35 PM\n 06:36 PM\n 03:33 AM\n 09:41 AM\n 04:39 PM\n 04:06 AM\n 06:15 PM\n 02:54 AM\n 03:18 AM\n WBC\n 11.3\n 10.4\n 9.7\n 9.7\n Hct\n 26.9\n 25.8\n 30.1\n 29.7\n Plt\n 81\n Creatinine\n 1.7\n 2.0\n 2.1\n 2.2\n 2.2\n TCO2\n 30\n 29\n 30\n 30\n 22\n Glucose\n 122\n 116\n 121\n 107\n Other labs: PT / PTT / INR:28.3/35.5/2.8, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:60/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca:7.6 mg/dL, Mg:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), KNOWLEDGE DEFICIT, IMPAIRED\n SKIN INTEGRITY, PNEUMONIA, ASPIRATION, AORTIC STENOSIS, SEIZURE,\n WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension requiring\n phenylephrine.\n Neurologic:\n -- Patient sedated with fentanyl prn.\n -- Patient with seizures, loaded with dilantin and ativan PRN prior to\n admission with poor mental status. Despite loading dose continued to\n have sub clinical seziures on EEG. Medication regimen changed,\n currently on phenytoin (Goal 15-20), Keppra and now phenobarbitol.\n --MRI brain w/ and w/o ordered for when pt is stable to transport to\n evaluate to source of bleed in parietal lobe.\n --Continue neurontin for chronic pain well controlled on current\n medication.\n --Withdraws to pain in all extremities\n Cardiovascular:\n -- PAF with good control of HR on beta blockade and digoxin.\n Anticoagulation started with coumadin. With INR being therapeutics. On\n ASA.\n -- CAD s/p CABG , diastolic dysfunction. On b-blockade,\n furosemide, ASA, and statin.\n -- Critical AS (valve area pre-valvuloplasty 0.8cm2, post\n vavluloplasty). On ICU-based ECHO estimated area is 0.6cm2. Likely not\n eligible for open valve replacement. Family is discussing this issue\n with another cardiologist.\n -- Pt still requires neosynephrine for MAPs > 60\n Pulmonary:\n --Treated empirically for HAP with Vanc/Cefepime, cultures negative,\n finished 7 day course\n --albuterol/atrovent PRN\n Gastrointestinal / Abdomen:\n --TFs at goal, consider PEG tube placement in future if clinical\n picture warrants\n Nutrition:\n --TFs at goal, consider PEG tube placement in future if clinical\n picture warrants\n Renal:\n -- On home dose of Lasix\n -- Diminished urine output, received albumin x2 overnight, Creatinine\n increasing 1.5-1.7->2.1. Prerenal in nature\n we will increase dose of\n the neosyneprine to support better perfusion pressure since other\n indices suggest increased preload on left side.\n -- Cipro for UTI, started . cultures p, last dose 3/16\n Hematology: --Hct slowly decreasing, 25.8--> tx 2u prbcs on ->29.7\n --ASA, coumadin (2/5/5/3\n - A. Fib anticoagulation with coumadin, INR 2.0 (goal ), dose\n decreased to 3mg\n Endocrine:\n --RISS, Hgb A1C 5.9. Satisfactor blood pressure control\n --Synthroid 75 mcg for hypothyroidism, previous TSH was 6.8\n Infectious Disease: --Wbc down to 9.7\n --Treated for PNA with cefepime/vanc (?aspiration) total course should\n be 7 days (ending ).\n --Follow cultures\n Lines / Tubes / Drains: PIV, Foley, CVL ()\n Wounds: none\n Imaging: CXR\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 10:37 PM 35 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-09 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404166,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n :\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n :\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue on current settings.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404168,
"text": "Seizure, without status epilepticus\n Assessment:\n Pt with eyes closed, pupils 3-4mm bilaterally, briskly\n reactive to light.\n Withdraws arms L>R to nailbed pressure, moves feet to\n nailbed pressure, very rare spontaneous movement of R foot and\n shoulders observed. No perceptible gag, weak cough.\n Cont EEG in place- no seizure activity observed, cont\n phenobarbitol/keppra/dilantin\n AM dilantin level 8-> albumin corrected for 12.5, phenobarb\n level 16.9\n Phenylephrine to maintain SBP> 100, MAP >60\n Loud systolic murmur, rhythm remains AFib\n AM H/H decreased\n UO 10-20mL/2hrs, SICU and primary teams aware\n Tmax 100.6F this shift\n TF at goal\n Action:\n Dilantin bolus given to maintain level 15-20\n Bedside TTE by cardiology\n 2 Units PRBC given to improve preload, H/H\n Standing dose lasix given per Dr. despite rising\n BUN/Crt\n LIJ central line placed, xray completed and reviewed\n Family met with NMED and SICU attending re: plan of care\n Response:\n Neuro exam remains as above.\n Weaning neo slowly\n UO remains scant\n Plan:\n Continue Q2hr neuro exams, continuous EEG monitoring\n Recheck dilantin level, CBC, Chems at 1900\n Wean neo as tolerated for SBP>100, MAP> 60\n Consider milrinone per rounds for improved CO\n D/C PICC, send tip for culture\n Reassess code status, plan of care on Friday with family,\n esp RE: PEG/Trach\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-11 00:00:00.000",
"description": "Intensivist Note",
"row_id": 404342,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. At time of SICU admission, she\n responded only to painful stimuli.\n Chief complaint:\n Seizures\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n 1. 2. 3. 4. 5. Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Albuterol\n Inhaler 8. Aspirin 9. Atorvastatin 10. Bacitracin-Polymyxin Ointment\n 11. Calcium Gluconate 12. Chlorhexidine Gluconate 0.12% Oral Rinse 13.\n Collagenase Ointment 14. Dextrose 50% 15. Digoxin 16. Famotidine 17.\n Fentanyl Citrate 18. FoLIC Acid 19. Furosemide 20. Gabapentin 21.\n Glucagon 22. 23. Insulin 24. Ipratropium Bromide MDI 25. Ipratropium\n Bromide Neb 26. Latanoprost 0.005% Ophth. Soln. 27. Levothyroxine\n Sodium 28. LeVETiracetam 29. Lidocaine 5% Patch 30. Lorazepam 31.\n Magnesium Sulfate 32. Metoprolol Tartrate 33. Miconazole Powder 2% 34.\n Nystatin Oral Suspension 35. PHENObarbital 36. PHENObarbital 37.\n Phenytoin Sodium (IV) 38. Phenylephrine 39. Potassium Chloride\n 40. Sodium Chloride 0.9% Flush 41. Sodium Chloride 0.9% Flush 42.\n Sodium Chloride 0.9% Flush 43. Timolol Maleate 0.5%\n 44. Warfarin\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:09 AM\n MULTI LUMEN - START 01:49 PM\n WOUND CULTURE - At 05:30 PM\n PICC tip\n PICC LINE - STOP 05:42 PM\n coumadin 2mg. Fe urea, u/a. increased phenylephrine, UA positive\n Foley changed , Phenobarb bolus 200mg IV x1 given, no evidence of\n seizure\n .\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Cefipime - 10:00 PM\n Vancomycin - 08:23 PM\n Ciprofloxacin - 12:02 AM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Dilantin - 10:30 AM\n Famotidine (Pepcid) - 08:30 PM\n Other medications:\n Flowsheet Data as of 03:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.5\n T current: 37.9\nC (100.2\n HR: 83 (77 - 90) bpm\n BP: 117/50(73) {96/41(60) - 143/65(89)} mmHg\n RR: 20 (12 - 21) insp/min\n SPO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 95.2 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 1,765 mL\n 222 mL\n PO:\n Tube feeding:\n 840 mL\n 122 mL\n IV Fluid:\n 715 mL\n 100 mL\n Blood products:\n Total out:\n 581 mL\n 244 mL\n Urine:\n 156 mL\n 44 mL\n NG:\n Stool:\n 300 mL\n 200 mL\n Drains:\n Balance:\n 1,184 mL\n -22 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 23 cmH2O\n Plateau: 22 cmH2O\n Compliance: 32.1 cmH2O/mL\n SPO2: 98%\n ABG: ////\n Ve: 7.7 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Breath Sounds: Crackles : bilateral, Rhonchorous\n : bilateral)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: Chemically paralyzed\n Labs / Radiology\n 368 K/uL\n 9.2 g/dL\n 107 mg/dL\n 2.2 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 59 mg/dL\n 106 mEq/L\n 138 mEq/L\n 30.4 %\n 10.4 K/uL\n [image002.jpg]\n 04:35 PM\n 06:36 PM\n 03:33 AM\n 09:41 AM\n 04:39 PM\n 04:06 AM\n 06:15 PM\n 02:54 AM\n 03:18 AM\n 02:38 AM\n WBC\n 11.3\n 10.4\n 9.7\n 9.7\n 10.4\n Hct\n 26.9\n 25.8\n 30.1\n 29.7\n 30.4\n Plt\n 81\n 368\n Creatinine\n 1.7\n 2.0\n 2.1\n 2.2\n 2.2\n TCO2\n 29\n 30\n 30\n 22\n Glucose\n 122\n 116\n 121\n 107\n Other labs: PT / PTT / INR:33.5/35.4/3.4, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:60/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca:7.6 mg/dL, Mg:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n KNOWLEDGE DEFICIT, IMPAIRED SKIN INTEGRITY, PNEUMONIA, ASPIRATION,\n AORTIC STENOSIS, SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension requiring\n phenylephrine.\n Neurologic:\n -- Patient sedated with fentanyl prn.\n -- Patient with seizures, loaded with dilantin and ativan PRN prior to\n admission with poor mental status. Despite loading dose continued to\n have sub clinical seziures on EEG. Medication regimen changed,\n currently on phenytoin (Goal 15-20), Keppra and now phenobarbitol.\n --MRI brain w/ and w/o ordered for when pt is stable to transport to\n evaluate to source of bleed in parietal lobe.\n --Continue neurontin for chronic pain well controlled on current\n medication.\n --Delayed Withdraws to pain in all extremities\n -- F/U Am pehnobarb and dilantin levels\n Cardiovascular:\n -- PAF with good control of HR on beta blockade and digoxin.\n Anticoagulation started with coumadin. No heparin bridge for risk of\n rebleed. On ASA\n -- CAD s/p CABG , diastolic dysfunction. On b-blockade,\n furosemide, ASA, and statin.\n -- Critical AS (valve area pre-valvuloplasty 0.8cm2, post\n vavluloplasty). On ICU-based ECHO estimated area is 0.6cm2. Likely not\n eligible for open valve replacement. Family is discussing this issue\n with another cardiologist.\n -- Pt still requires neosynephrine for MAPs > 65\n -- tx 2u prbcs with Hct 25.8 on \n Pulmonary:\n --Treated empirically for HAP with Vanc/Cefepime, cultures negative,\n finished 7 day course \n --albuterol/atrovent PRN\n --Family considering trach\n Gastrointestinal / Abdomen:\n --TFs at goal, consider PEG tube placement in future if clinical\n picture warrants\n Nutrition:\n --TF continued\n Renal:\n -- On home dose of Lasix\n -- Diminished urine output, received albumin x2 overnight, Creatinine\n increasing 1.5-1.7->2.1.-->2.2 Fe urea 14.5. Repeat labs, obtain renal\n ultrasound. Consider renal consult. Low UOP secondary to pre-renal\n failure.\n -- Cipro for UTI, started . cultures p, last dose 3/16, Redo UA c/w\n Bact no need for Antibiotics now f/up Cx\n Hematology:\n --Hct slowly decreasing, 25.8--> tx 2u prbcs on ->29.7-->30.4\n ()\n --ASA, coumadin (2/5/5/3/2) Hold coumadin today INR level 3.4\n - A. Fib anticoagulation with coumadin, INR 3.4 (goal )\n Endocrine:\n --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg for hypothyroidism, previous TSH was 6.8\n ID:\n --Wbc 9.4-->10.4. No issues.\n T/L/D: PIV, Foley, CVL ()\n Wounds: none\n Imaging: CXR\n Fluids: KVO\n Consults:\n Billing Diagnosis: status epilepticus, respiratory failure\n Prophylaxis:\n DVT: ASA, coumadin\n Stress ulcer: H2B\n VAP bundle: +\n Comments:\n Communication: ICU consent done\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-11 00:00:00.000",
"description": "Intensivist Note",
"row_id": 404344,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. At time of SICU admission, she\n responded only to painful stimuli.\n Chief complaint:\n Seizures\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n 1. 2. 3. 4. 5. Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Albuterol\n Inhaler 8. Aspirin 9. Atorvastatin 10. Bacitracin-Polymyxin Ointment\n 11. Calcium Gluconate 12. Chlorhexidine Gluconate 0.12% Oral Rinse 13.\n Collagenase Ointment 14. Dextrose 50% 15. Digoxin 16. Famotidine 17.\n Fentanyl Citrate 18. FoLIC Acid 19. Furosemide 20. Gabapentin 21.\n Glucagon 22. 23. Insulin 24. Ipratropium Bromide MDI 25. Ipratropium\n Bromide Neb 26. Latanoprost 0.005% Ophth. Soln. 27. Levothyroxine\n Sodium 28. LeVETiracetam 29. Lidocaine 5% Patch 30. Lorazepam 31.\n Magnesium Sulfate 32. Metoprolol Tartrate 33. Miconazole Powder 2% 34.\n Nystatin Oral Suspension 35. PHENObarbital 36. PHENObarbital 37.\n Phenytoin Sodium (IV) 38. Phenylephrine 39. Potassium Chloride\n 40. Sodium Chloride 0.9% Flush 41. Sodium Chloride 0.9% Flush 42.\n Sodium Chloride 0.9% Flush 43. Timolol Maleate 0.5%\n 44. Warfarin\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:09 AM\n MULTI LUMEN - START 01:49 PM\n WOUND CULTURE - At 05:30 PM\n PICC tip\n PICC LINE - STOP 05:42 PM\n coumadin 2mg. Fe urea, u/a. increased phenylephrine, UA positive\n Foley changed , Phenobarb bolus 200mg IV x1 given, no evidence of\n seizure\n .\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Cefipime - 10:00 PM\n Vancomycin - 08:23 PM\n Ciprofloxacin - 12:02 AM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Dilantin - 10:30 AM\n Famotidine (Pepcid) - 08:30 PM\n Other medications:\n Flowsheet Data as of 03:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.5\n T current: 37.9\nC (100.2\n HR: 83 (77 - 90) bpm\n BP: 117/50(73) {96/41(60) - 143/65(89)} mmHg\n RR: 20 (12 - 21) insp/min\n SPO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 95.2 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 1,765 mL\n 222 mL\n PO:\n Tube feeding:\n 840 mL\n 122 mL\n IV Fluid:\n 715 mL\n 100 mL\n Blood products:\n Total out:\n 581 mL\n 244 mL\n Urine:\n 156 mL\n 44 mL\n NG:\n Stool:\n 300 mL\n 200 mL\n Drains:\n Balance:\n 1,184 mL\n -22 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 23 cmH2O\n Plateau: 22 cmH2O\n Compliance: 32.1 cmH2O/mL\n SPO2: 98%\n ABG: ////\n Ve: 7.7 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Breath Sounds: Crackles : bilateral, Rhonchorous\n : bilateral)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: Chemically paralyzed\n Labs / Radiology\n 368 K/uL\n 9.2 g/dL\n 107 mg/dL\n 2.2 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 59 mg/dL\n 106 mEq/L\n 138 mEq/L\n 30.4 %\n 10.4 K/uL\n [image002.jpg]\n 04:35 PM\n 06:36 PM\n 03:33 AM\n 09:41 AM\n 04:39 PM\n 04:06 AM\n 06:15 PM\n 02:54 AM\n 03:18 AM\n 02:38 AM\n WBC\n 11.3\n 10.4\n 9.7\n 9.7\n 10.4\n Hct\n 26.9\n 25.8\n 30.1\n 29.7\n 30.4\n Plt\n 81\n 368\n Creatinine\n 1.7\n 2.0\n 2.1\n 2.2\n 2.2\n TCO2\n 29\n 30\n 30\n 22\n Glucose\n 122\n 116\n 121\n 107\n Other labs: PT / PTT / INR:33.5/35.4/3.4, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:60/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca:7.6 mg/dL, Mg:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n KNOWLEDGE DEFICIT, IMPAIRED SKIN INTEGRITY, PNEUMONIA, ASPIRATION,\n AORTIC STENOSIS, SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension requiring\n phenylephrine.\n Neurologic:\n -- Patient sedated with fentanyl prn.\n -- Patient with seizures, loaded with dilantin and ativan PRN prior to\n admission with poor mental status. Despite loading dose continued to\n have sub clinical seziures on EEG. Medication regimen changed,\n currently on phenytoin (Goal 15-20), Keppra and now phenobarbitol.\n --MRI brain w/ and w/o ordered for when pt is stable to transport to\n evaluate to source of bleed in parietal lobe.\n --Continue neurontin for chronic pain well controlled on current\n medication.\n --Delayed Withdraws to pain in all extremities\n -- F/U Am pehnobarb and dilantin levels\n Cardiovascular:\n -- PAF with good control of HR on beta blockade and digoxin.\n Anticoagulation started with coumadin. No heparin bridge for risk of\n rebleed. On ASA\n -- CAD s/p CABG , diastolic dysfunction. On b-blockade,\n furosemide, ASA, and statin.\n -- Critical AS (valve area pre-valvuloplasty 0.8cm2, post\n vavluloplasty). On ICU-based ECHO estimated area is 0.6cm2. Likely not\n eligible for open valve replacement. Family is discussing this issue\n with another cardiologist.\n -- Pt still requires neosynephrine for MAPs > 65\n -- tx 2u prbcs with Hct 25.8 on \n Pulmonary:\n --Treated empirically for HAP with Vanc/Cefepime, cultures negative,\n finished 7 day course \n --albuterol/atrovent PRN\n --Family considering trach\n Gastrointestinal / Abdomen:\n --TFs at goal, consider PEG tube placement in future if clinical\n picture warrants\n Nutrition:\n --TF continued\n Renal:\n -- On home dose of Lasix\n -- Diminished urine output, received albumin x2 overnight, Creatinine\n increasing 1.5-1.7->2.1.-->2.2 Fe urea 14.5. Repeat labs, obtain renal\n ultrasound. Consider renal consult. Low UOP secondary to pre-renal\n failure.\n -- Cipro for UTI, started . cultures p, last dose 3/16, Redo UA c/w\n Bact no need for Antibiotics now f/up Cx\n Hematology:\n --Hct slowly decreasing, 25.8--> tx 2u prbcs on ->29.7-->30.4\n ()\n --ASA, coumadin (2/5/5/3/2) Hold coumadin today INR level 3.4\n - A. Fib anticoagulation with coumadin, INR 3.4 (goal )\n Endocrine:\n --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg for hypothyroidism, previous TSH was 6.8\n ID:\n --Wbc 9.4-->10.4. No issues.\n T/L/D: PIV, Foley, CVL ()\n Wounds: none\n Imaging: CXR\n Fluids: KVO\n Consults:\n Billing Diagnosis: status epilepticus, respiratory failure\n Prophylaxis:\n DVT: ASA, coumadin\n Stress ulcer: H2B\n VAP bundle: +\n Comments:\n Communication: ICU consent done\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404585,
"text": "Demographics\n Day of intubation: 7\n Day of mechanical ventilation: 7\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 18 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Tracheostomy planned\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt remains on Mechanical ventilation: now on PSV 5/5/@ 40%, RR = 32; MV\n = 10.1L; HR = 109; BP = 125/55;\n O2 Sat = 95%. Still not opening eyes.\n, RRT 17:31\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-15 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 404652,
"text": "Chief Complaint: CRITICAL AS\n HPI:\n 86F with CAD s/p CABG (SVG-OM, LIMA-LAD), AS s/p valvuloplasty\n , diastolic CHF, AF on coumadin, s/p R colectomy who was\n initially admitted to the neurology service with generalized tonic\n clonic seizure on . Then, on evening of , the patient\n triggered for altered mental status and lethargy following a head MRI.\n At that time, it was unclear whether this was related to flash\n pulmonary edema in the setting of having her lasix held versus an\n aspiration event while she was lying flat for her MRI. She was also\n having episodes of Afib with RVR secondary to missing metoprolol doses\n while she was on the floor. She was transferred to the CCU for further\n management. After she was diuresed and her afib was better controlled,\n the patient was transferred to the medical service. However, on the\n medical floor, the patient was noted to be in NCSE on EEG. She was then\n transferred to the neuro ICU for further care.\n .\n Now, at the patient's family's request, she is being transferred to the\n CCU service for further management. Her course up to this transfer has\n been complicated by subclinical seizures and deteriorating mental\n status, aspiration pneumonia, respiratory acidosis and failure\n resulting in intubation (), ARF, hypotension requiring\n phenylephrine.\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Furosemide (Lasix) - 09:22 PM\n Dilantin - 09:22 PM\n Other medications:\n HOME MEDICATIONS:\n 1. Furosemide 60mg daily\n 2. Levothyroxine 75mg daily\n 3.Latanoprost 0.005% drop daily\n 4. Timoptic 0.5% drop daily\n 5. Lipitor 40mg daily\n 6. Gabapentin 300mg \n 7. Coumadin 4mg \n Past medical history:\n Family history:\n Social History:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on course complicated by\n C.diff. Currently negative C. diff.\n No family history of early MI, arrhythmia, cardiomyopathies, or sudden\n cardiac death; otherwise non-contributory.\n Occupation:\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other: -uses walker/wheelchair at home, poor candidate for knee\n replacement.\n Review of systems:\n Flowsheet Data as of 04:06 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 38.4\nC (101.1\n HR: 95 (80 - 99) bpm\n BP: 137/59(86) {106/47(68) - 144/62(90)} mmHg\n RR: 22 (18 - 29) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 96.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 13 (9 - 17)mmHg\n Total In:\n 2,106 mL\n 131 mL\n PO:\n TF:\n 842 mL\n 2 mL\n IVF:\n 1,263 mL\n 129 mL\n Blood products:\n Total out:\n 224 mL\n 341 mL\n Urine:\n 124 mL\n 41 mL\n NG:\n Stool:\n 100 mL\n 300 mL\n Drains:\n Balance:\n 1,882 mL\n -210 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 425 (357 - 444) mL\n PS : 18 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 24 cmH2O\n SpO2: 98%\n ABG: 7.36/38/81./21/-3\n Ve: 8.9 L/min\n PaO2 / FiO2: 205\n Physical Examination\n VS: T=100.0 BP=129/53 HR= 91 RR= 18 O2 sat= 99% on ventilator\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: ET tube in place; JVD noted.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n Radiated to carotids.\n LUNGS: Ventilated breath sounds.\n ABDOMEN: Obese, S/NT/ND, BS present\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal or painful stimuli.\n Labs / Radiology\n 399 K/uL\n 8.3 g/dL\n 122 mg/dL\n 3.2 mg/dL\n 99 mg/dL\n 21 mEq/L\n 103 mEq/L\n 4.5 mEq/L\n 136 mEq/L\n 27.8 %\n 9.7 K/uL\n [image002.jpg]\n \n 2:33 A3/20/ 06:10 PM\n \n 10:20 P3/20/ 08:30 PM\n \n 1:20 P3/20/ 10:18 PM\n \n 11:50 P3/20/ 11:21 PM\n \n 1:20 A3/21/ 03:29 AM\n \n 7:20 P3/21/ 03:47 AM\n 1//11/006\n 1:23 P3/21/ 05:57 AM\n \n 1:20 P3/21/ 05:45 PM\n \n 11:20 P3/22/ 02:19 AM\n \n 4:20 P3/22/ 02:38 AM\n WBC\n 10.8\n 9.7\n Hct\n 27.8\n 27.8\n Plt\n 434\n 399\n Cr\n 3.1\n 3.2\n TC02\n 21\n 24\n 23\n 22\n 26\n 23\n 24\n 22\n Glucose\n 137\n 133\n 124\n 116\n 122\n Other labs: PT / PTT / INR:26.2/31.5/2.5, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:2.4 mg/dL\n Imaging: CARDIAC CATH: - COMMENTS:\n 1) Coronary angiography in this right dominant system demonstrated two\n vessel disease. The LMCA was heavily calcified and had a 50-60%\n stenosis. The LAD was calcified and had a proximal 70% stenosis. The\n LCx was calcified and had a proximal 50% stenosis. The RCA had mild\n lunen irregularities.\n 2) Arterial conduit angiography revealed the LIMA to be widely patent.\n The SVG-OM1 had and 80% stenosis mid graft with TIMI 3 flow into the\n distal vessel.\n 3) Resting hemodynamics revealed elvated right and left sided filling\n pressures with an RVEDP of 24 and LVEDP of 35mmHg. There was moderate\n to severe pulmonary arterial systolic hypertension with PASP of 68mmHg.\n The cardiac index was preserved at 3.26 l/min/m2. There was normal\n systemic arterial pressure with a BP of 136/73, mean 97mmHg.\n 4) There was severe aortic stenosis with a peak to peak gradient of\n 56mmHg and a calculated of 0.56cm2. Following the Valvuloplasty the\n calculated improved to 0.98cm2.\n 5) Successful Aortic ballon valvuloplasty with a 20mm Tyshak balloon.\n (see PTCA comments for details)\n 6) Unsuccessful Preclose of right femoral arteriotomy site.\n 7) Successful closure of the right femoral arteriotomy site with an 8\n French Angioseal.\n FINAL DIAGNOSIS:\n 1. Two vessel coronary artery disease.\n 2. Severe aortic stenosis with a calculated 0.56cm2\n 3. Diseased SVG to OMB for staged PCI.\n 4. Successful aortic balloon valvuloplasty to 0.98cm2 .\n 5. Unsuccessful closure with a Pre-close device.\n 6. Successful closure with an Angioseal device.\n .\n HEAD MRI - IMPRESSION:\n 1. Focal area with high signal intensity is demonstrated at the right\n superior parietal lobule, with no significant mass effect and may\n represent a chronic hemorrhagic area.\n 2. Subcortical areas with high signal intensity are identified on T2\n and FLAIR sequences, likely consistent with chronic microvascular\n ischemic changes.\n 3. Tortuosity of the basilar artery, consistent with dolichoectasia,\n previously described by CTA on .\n .\n CT HEAD () - IMPRESSION:\n 1. No acute intracranial hemorrhage seen. Small ovoid hypodensity in\n right parietal lobe corresponds to area demonstrating old blood\n products seen on MRI of .\n 2. New opacification of left anterior ethmoid air cells and increased\n opacification of left mastoid air cells.\n .\n ECHO () - The left and right atria are moderately dilated. No\n left atrial mass/thrombus seen (best excluded by transesophageal\n echocardiography). There is mild symmetric left ventricular hypertrophy\n with normal cavity size and regional/global systolic function\n (LVEF>55%). The right ventricular cavity is moderately dilated with\n moderate global free wall hypokinesis. The diameters of aorta at the\n sinus, ascending and arch levels are normal. The aortic valve leaflets\n are severely thickened/deformed. There is critical aortic valve\n stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen.\n The mitral valve leaflets are mildly thickened. There is severe mitral\n annular calcification. There is no mitral stenosis. Mild to moderate\n (+) mitral regurgitation is seen. [Due to acoustic shadowing, the\n severity of mitral regurgitation may be significantly UNDERestimated.]\n The tricuspid valve leaflets are mildly thickened. There is moderate\n pulmonary artery systolic hypertension. There is no pericardial\n effusion.\n IMPRESSION: Critical aortic valve stenosis. Pulmonary artery\n hypertension. Right ventricular cavity enlargement with free wall\n hypokinesis. Mild symmetric left ventricular hypertrophy with preserved\n global and regional systolic function.\n Compared with the prior study (images reviewed) of , the\n gradient across the aortic valve has increased and the right\n ventricular cavity is now dilated with free wall hypokinesis. The\n estimated PA systolic pressure and severity of mitral regurgitation are\n similar.\n .\n CXR () - As compared to the previous radiograph, the extent of\n the bilateral areas of atelectasis, presumably caused by the bilateral\n relatively extensive pleural effusions, is unchanged. No newly appeared\n focal parenchymal opacities in the interval. Unchanged moderate\n cardiomegaly, unchanged course and position of the monitoring and\n support devices.\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine. Being\n transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU and appears very\n fluid overloaded on physical exam.\n - will give 60 mg IV lasix now for diuresis\n - continue to closely monitor volume status\n .\n # Atrial Fibrillation: Per previous notes, pt has good control of HR on\n beta blockade and digoxin.\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - coumadin was being held for ?supratherapeutic INR; INR in therapeutic\n range this morning; can restart coumadin after trach\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol.\n - continue phenytoin and phenobarbital\n - appreciate neuro recs\n .\n # Respiratory Failure: Now, intubated with plans to trach pt on .\n - NPO p MN for trach\n - plan for trach placement tomorrow\n - continue albuterol/atrovent PRN\n .\n # Acute Renal Failure: Per previous notes, renal believes that this is\n ATN. Recommend to not diurese or give IVF's.\n - small lasix bolus as above\n - continue to monitor fluid status otherwise\n .\n # Hypothyroidism:\n - continue synthroid 75 mcg daily\n .\n # Fevers: Per notes, pt completed vanc/cefepime 7 day course for\n pneumonia as well as 3 days course of abx for positive UA.\n - f/u cx data\n - follow fever curve\n .\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin (on hold))\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU (transfer to LTAC)\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405011,
"text": "86F with CAD s/p CABG (SVG-OM, LIMA-LAD), AS s/p valvuloplasty\n , diastolic CHF, AF on coumadin, s/p R colectomy who was\n initially admitted to the neurology service with generalized tonic\n clonic seizure on . Then, on evening of , the patient\n triggered for altered mental status and lethargy following a head MRI.\n At that time, it was unclear whether this was related to flash\n pulmonary edema in the setting of having her lasix held versus an\n aspiration event while she was lying flat for her MRI. She was also\n having episodes of Afib with RVR secondary to missing metoprolol doses\n while she was on the floor. She was transferred to the CCU for further\n management. After she was diuresed and her afib was better controlled,\n the patient was transferred to the medical service. However, on the\n medical floor, the patient was noted to be in NCSE on EEG. She was then\n transferred to the neuro ICU for further care.\n .\n Now, at the patient's family's request, she is being transferred to the\n CCU service for further management. Her course up to this transfer has\n been complicated by subclinical seizures and deteriorating mental\n status, aspiration pneumonia, respiratory acidosis and failure\n resulting in intubation (), ARF, hypotension requiring\n phenylephrine.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404137,
"text": "Seizure, without status epilepticus\n Assessment:\n Not opeining eyes, pupils equal in size (3-4mm) and reactivity (brisk).\n Not moving upper extremities to painful stimuli.\n Small spontaneous movement of rt foot, moves left foot to painful\n stimuli.\\\n Cont on NEO gtt to maintain MAP >60.\n Remains ventilated on CMV.\n Minimal urine output.\n Temp max 100.8\n Action:\n Continued regimen of Phenobarbital , keppra and dilantin.\n Antibiotics continued.\n Continuous EEG monitoring.\n Tylenol 650mg given.\n Response:\n Neuro exam flat.\n U/O remains scant.\n MAP maintained > 60.\n Afebrile this am.\n Plan:\n Repeat albumin challenge this am.\n Cont EEG monitoring.\n Monitor hemodynamics.\n Monitor renal status.\n Continue update, educate and support pt\ns family.\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-10 00:00:00.000",
"description": "Intensivist Note",
"row_id": 404274,
"text": "SICU\n HPI:\n Seizures\n Chief complaint:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. At time of SICU admission, she\n responded only to painful stimuli.\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n Levothyroxine Sodium 75 mcg PO/NG DAILY Order date: @ \n Acetaminophen 325-650 mg PO/NG Q6H:PRN fever Order date: @ 1054\n LeVETiracetam 500 mg PO/NG Order date: @ 1002\n Lorazepam 0.5-1 mg IV HS PRN Sz\n 9. Aspirin 81 mg PO/NG DAILY\n 10. Atorvastatin 40 mg PO/NG DAILY Order date: @ \n 34. Metoprolol Tartrate 25 mg PO/NG TID\n 13. CefePIME 2 g IV Q24H Duration: 1 Doses\n 37. PHENObarbital 90 mg PO/NG \n 14. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n . Phenytoin Sodium (IV) 100 mg IV Q8H Order date: @ 2157\n 15. Ciprofloxacin 400 mg IV ONCE Duration: 1 Doses Order date: @\n 0827 39. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAPs >60\n 18. Digoxin 0.0625 mg PO/NG DAILY Order date: @ \n 19. Famotidine 20 mg IV Q24H Order date: @ 1817\n 20. Fentanyl Citrate 12.5-100 mcg IV Q2H:PRN agitation, for sedation\n 21. FoLIC Acid 1 mg PO/NG DAILY\n 22. Furosemide 40 mg PO/NG DAILY\n 23. Gabapentin 100 mg PO/NG Order date: @ \n 47. Vancomycin 500 mg IV Q 24H Duration: 1 Doses Start: In am\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:09 AM\n MULTI LUMEN - START 01:49 PM\n WOUND CULTURE - At 05:30 PM\n PICC tip\n PICC LINE - STOP 05:42 PM\n Post operative day:\n N/A\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Cefipime - 10:00 PM\n Vancomycin - 08:23 PM\n Ciprofloxacin - 12:02 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 01:40 PM\n Famotidine (Pepcid) - 08:22 PM\n Dilantin - 01:30 AM\n Other medications:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.6\nC (99.6\n HR: 82 (68 - 84) bpm\n BP: 109/51(72) {101/38(62) - 118/65(81)} mmHg\n RR: 18 (12 - 19) insp/min\n SPO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 95.2 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 2,555 mL\n 564 mL\n PO:\n Tube feeding:\n 822 mL\n 216 mL\n IV Fluid:\n 692 mL\n 348 mL\n Blood products:\n 631 mL\n Total out:\n 448 mL\n 40 mL\n Urine:\n 148 mL\n 40 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 2,107 mL\n 524 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 24 cmH2O\n Plateau: 22 cmH2O\n Compliance: 32.1 cmH2O/mL\n SPO2: 98%\n ABG: 7.37/37/142/24/-3\n Ve: 6.6 L/min\n PaO2 / FiO2: 284\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: (Responds to: Unresponsive), Moves all extremities\n Labs / Radiology\n 381 K/uL\n 9.0 g/dL\n 107 mg/dL\n 2.2 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 59 mg/dL\n 106 mEq/L\n 138 mEq/L\n 29.7 %\n 9.7 K/uL\n [image002.jpg]\n 01:08 PM\n 04:35 PM\n 06:36 PM\n 03:33 AM\n 09:41 AM\n 04:39 PM\n 04:06 AM\n 06:15 PM\n 02:54 AM\n 03:18 AM\n WBC\n 11.3\n 10.4\n 9.7\n 9.7\n Hct\n 26.9\n 25.8\n 30.1\n 29.7\n Plt\n 81\n Creatinine\n 1.7\n 2.0\n 2.1\n 2.2\n 2.2\n TCO2\n 30\n 29\n 30\n 30\n 22\n Glucose\n 122\n 116\n 121\n 107\n Other labs: PT / PTT / INR:28.3/35.5/2.8, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:60/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca:7.6 mg/dL, Mg:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), KNOWLEDGE DEFICIT, IMPAIRED\n SKIN INTEGRITY, PNEUMONIA, ASPIRATION, AORTIC STENOSIS, SEIZURE,\n WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension requiring\n phenylephrine.\n Neurologic:\n -- Patient sedated with fentanyl prn.\n -- Patient with seizures, loaded with dilantin and ativan PRN prior to\n admission with poor mental status. Despite loading dose continued to\n have sub clinical seziures on EEG. Medication regimen changed,\n currently on phenytoin (Goal 15-20), Keppra and now phenobarbitol.\n --MRI brain w/ and w/o ordered for when pt is stable to transport to\n evaluate to source of bleed in parietal lobe.\n --Continue neurontin for chronic pain well controlled on current\n medication.\n --Withdraws to pain in all extremities\n Cardiovascular:\n -- PAF with good control of HR on beta blockade and digoxin.\n Anticoagulation started with coumadin. With INR being therapeutics. On\n ASA.\n -- CAD s/p CABG , diastolic dysfunction. On b-blockade,\n furosemide, ASA, and statin.\n -- Critical AS (valve area pre-valvuloplasty 0.8cm2, post\n vavluloplasty). On ICU-based ECHO estimated area is 0.6cm2. Likely not\n eligible for open valve replacement. Family is discussing this issue\n with another cardiologist.\n -- Pt still requires neosynephrine for MAPs > 60\n Pulmonary:\n --Treated empirically for HAP with Vanc/Cefepime, cultures negative,\n finished 7 day course\n --albuterol/atrovent PRN\n Gastrointestinal / Abdomen:\n --TFs at goal, consider PEG tube placement in future if clinical\n picture warrants\n Nutrition:\n --TFs at goal, consider PEG tube placement in future if clinical\n picture warrants\n Renal:\n -- On home dose of Lasix\n -- Diminished urine output, received albumin x2 overnight, Creatinine\n increasing 1.5-1.7->2.1. Prerenal in nature\n we will increase dose of\n the neosyneprine to support better perfusion pressure since other\n indices suggest increased preload on left side.\n -- Cipro for UTI, started . cultures p, last dose 3/16\n Hematology: --Hct slowly decreasing, 25.8--> tx 2u prbcs on ->29.7\n --ASA, coumadin (2/5/5/3\n - A. Fib anticoagulation with coumadin, INR 2.0 (goal ), dose\n decreased to 3mg\n Endocrine:\n --RISS, Hgb A1C 5.9. Satisfactor blood pressure control\n --Synthroid 75 mcg for hypothyroidism, previous TSH was 6.8\n Infectious Disease: --Wbc down to 9.7\n --Treated for PNA with cefepime/vanc (?aspiration) total course should\n be 7 days (ending ).\n --Follow cultures\n Lines / Tubes / Drains: PIV, Foley, CVL ()\n Wounds: none\n Imaging: CXR\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 10:37 PM 35 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404427,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output diminished\n Neo drip to maintain sbp > 120\n Action:\n Neo weanes very slowly as bp tolerated, presently at 0.75 mcg/kg/min\n Resident aware of low u/o\n no treatment at this time\n Response:\n BUN 74, creatinine 2.7 this am\n Plan:\n Monitor bp and u/o.\n Continue to wean neo if tolerated\n Seizure, without status epilepticus\n Assessment:\n Neuro signs q 2 hrs\n Pupils unequal at times, then equal again\n Withdraws to painful nailbed stim, more briskly on left than right\n No evidence of seizures noted\n Action:\n Resident aware of unequal pupils\n Continuous EEG\n Response:\n Pupils back to equal this am\n Plan:\n Continue to monitor NS q 2 hrs\n EEG continuously\n Trach and peg on Monday\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-12 00:00:00.000",
"description": "Intensivist Note",
"row_id": 404436,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. At time of SICU admission, she\n responded only to painful stimuli.\n Chief complaint:\n Seizures\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n Acetaminophen 7. Albuterol 0.083% Neb Soln 8. Albuterol Inhaler 9.\n Aspirin\n 10. Atorvastatin 11. Bacitracin-Polymyxin Ointment 12. Calcium\n Gluconate 13. Chlorhexidine Gluconate 0.12% Oral Rinse\n 14. Collagenase Ointment 15. Dextrose 50% 16. Digoxin 17. Famotidine\n 18. Fentanyl Citrate 19. FoLIC Acid\n 21. Gabapentin 22. Glucagon 23. 24. Insulin 25. Ipratropium Bromide MDI\n 26. Ipratropium Bromide Neb\n 27. Latanoprost 0.005% Ophth. Soln. 28. Levothyroxine Sodium 29.\n LeVETiracetam 30. Lidocaine 5% Patch\n 31. Lorazepam 32. Magnesium Sulfate 33. Metoprolol Tartrate 34.\n Miconazole Powder 2% 35. Nystatin Oral Suspension\n 36. PHENObarbital 37. Phenytoin Sodium (IV) 38. Phenytoin Sodium (IV)\n 39. Phenylephrine 40. Potassium Chloride\n 41. Sodium Chloride 0.9% Flush 42. Sodium Chloride 0.9% Flush 43.\n Sodium Chloride 0.9% Flush 44. Sodium Chloride 0.9% Flush\n 45. Timolol Maleate 0.5%\n 24 Hour Events:\n Cont oliguria in spite of albumin. Renal consult called. Ultrasound\n obtained (WNL). INR supratherapeutic. keppra 250\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:23 PM\n Ciprofloxacin - 12:02 AM\n Infusions:\n Phenylephrine - 0.9 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Dilantin - 12:45 AM\n Other medications:\n Flowsheet Data as of 03:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 36.9\nC (98.5\n HR: 89 (75 - 93) bpm\n BP: 127/56(81) {108/49(69) - 139/64(92)} mmHg\n RR: 21 (17 - 21) insp/min\n SPO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 96.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 14 (13 - 21) mmHg\n Total In:\n 1,986 mL\n 214 mL\n PO:\n Tube feeding:\n 842 mL\n 119 mL\n IV Fluid:\n 984 mL\n 95 mL\n Blood products:\n 100 mL\n Total out:\n 389 mL\n 41 mL\n Urine:\n 189 mL\n 41 mL\n NG:\n Stool:\n 200 mL\n Drains:\n Balance:\n 1,597 mL\n 173 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 27 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 8.7 L/min\n Physical Examination\n General Appearance: Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), + murmur\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous : ,\n Diminished: )\n Abdominal: Soft, Non-distended, Obese\n Left Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n delayed response to noxious stimuli\n Labs / Radiology\n 368 K/uL\n 9.2 g/dL\n 120 mg/dL\n 2.5 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 70 mg/dL\n 105 mEq/L\n 140 mEq/L\n 30.4 %\n 10.4 K/uL\n [image002.jpg]\n 06:36 PM\n 03:33 AM\n 09:41 AM\n 04:39 PM\n 04:06 AM\n 06:15 PM\n 02:54 AM\n 03:18 AM\n 02:38 AM\n 10:24 AM\n WBC\n 11.3\n 10.4\n 9.7\n 9.7\n 10.4\n Hct\n 26.9\n 25.8\n 30.1\n 29.7\n 30.4\n Plt\n 81\n 368\n Creatinine\n 1.7\n 2.0\n 2.1\n 2.2\n 2.2\n 2.5\n 2.5\n TCO2\n 30\n 30\n 22\n Glucose\n 122\n 116\n 121\n 107\n 120\n Other labs: PT / PTT / INR:33.5/35.4/3.4, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:60/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca:7.7 mg/dL, Mg:2.0 mg/dL, PO4:2.2 mg/dL\n Imaging: Renal US: no hydronephrosis. mild ascites\n CT head: No acute ICH. Small ovoid hypodensity in R parietal lobe\n corresponds to area demonstrating old blood seen on MRI of . New\n opacification of L anterior ethmoid air cells and increased\n opacification of L mastoid air cells.\n CXR: Cardiomegaly, prominent pulmonary vasculature, and bibasilar\n atelectasis is unchanged.\n MR: Focal area w/high signal intensity @ R sup parietal lobule, no\n mass effect and may represent a chronic hemorrhagic area. Subcortical\n areas w/high signal intensity on T2 and FLAIR c/w chronic microvascular\n ischemic changes. Tortuosity of basilar artery, cw dolichoectasia\n Echo: EF >= 60%, Symmetric LVH, Significant AS, Trivial MR (may be\n significantly UNDERestimated), Mild [1+] TR. Mild PA systolic HTN\n CTA: No acute infarct or hemorrhage. Severe atherosclerotic\n narrowing of distal R vertebral art and moderate-to-severe narrowing of\n b/l cavernous ICAs. Small focus of calcification in Basilar A. close to\n the tip. Moderate microangiopathic ischemic white matter dz\n Microbiology: UCx: Yeast, >100,000\n BCx x2 neg\n BCx x2 p\n UCx: Yeast 10-100,000\n & Cdiff: Neg\n Sp Cx: 1+ Yeast\n Assessment and Plan\n INEFFECTIVE COPING, RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n KNOWLEDGE DEFICIT, IMPAIRED SKIN INTEGRITY, PNEUMONIA, ASPIRATION,\n AORTIC STENOSIS, SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension requiring\n phenylephrine.\n Neurologic:\n -- Patient sedated with minimal doses intermittent fentanyl prn.\n -- Patient with seizures, loaded with dilantin and ativan PRN prior to\n admission with poor mental status. Despite loading dose continued to\n have sub clinical seziures on EEG. Medication regimen adjusted,\n currently on phenytoin (Goal 15-20), Keppra->lowered and now\n phenobarbitol. No seizure yesterday but occasional sharp waves.\n --Continue neurontin for chronic pain well controlled on current\n medication -> stop b/o ATN.\n --Delayed Withdraws to pain in all extremities\n Cardiovascular:\n -- PAF with good control of HR on beta blockade and digoxin.\n Anticoagulation started with coumadin. No heparin bridge for risk of\n rebleed. On ASA\n -- CAD s/p CABG , diastolic dysfunction. On b-blockade,\n furosemide, ASA, and statin.\n -- Critical AS (valve area pre-valvuloplasty 0.8cm2, post\n vavluloplasty). On ICU-based ECHO estimated area is 0.6cm2. Likely not\n eligible for open valve replacement. Family is discussing this issue\n with another cardiologist\n Pulmonary:\n --lower FiO2 and PEEP to minimal settings if possible\n --albuterol/atrovent PRN\n -- Trach & PEG on Monday\n Gastrointestinal / Abdomen:\n --TFs at goal, PEG \n Nutrition:\n --Tube feeding\n Renal: -- Lasix held\n -- ATN (muddy brown casts), would not diurese, or give IVF; do not\n oliguria. need dialysis in future (gentle CVVH).\n Hematology:\n --Transfuse to the Hct of 25%\n --ASA, coumadin (2/5/5/3/1) Hold coumadin and when INR below 2.0 then\n switch to heparin.\n - A. Fib anticoagulation with coumadin, INR 3.4 (goal ), last dose\n , will start hep gtt to bridge for trach/PEG Monday (have\n contact Dr. \n Endocrine:\n --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg for hypothyroidism\n Infectious Disease:\n --No issues\n Lines / Tubes / Drains: PIV, Foley, CVL (), ETT, NGT\n Imaging: none\n Fluids: KVO\n Consults: Neurology, Nephrology\n Billing Diagnosis: Other: status epilepticus, respiratory failure, ATN\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 07:52 PM 35 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: Boots (Supratherapeutic with coumadin, plan for hep gtt once INR\n decreases)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-12 00:00:00.000",
"description": "Intensivist Note",
"row_id": 404437,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. At time of SICU admission, she\n responded only to painful stimuli.\n Chief complaint:\n Seizures\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n Acetaminophen 7. Albuterol 0.083% Neb Soln 8. Albuterol Inhaler 9.\n Aspirin\n 10. Atorvastatin 11. Bacitracin-Polymyxin Ointment 12. Calcium\n Gluconate 13. Chlorhexidine Gluconate 0.12% Oral Rinse\n 14. Collagenase Ointment 15. Dextrose 50% 16. Digoxin 17. Famotidine\n 18. Fentanyl Citrate 19. FoLIC Acid\n 21. Gabapentin 22. Glucagon 23. 24. Insulin 25. Ipratropium Bromide MDI\n 26. Ipratropium Bromide Neb\n 27. Latanoprost 0.005% Ophth. Soln. 28. Levothyroxine Sodium 29.\n LeVETiracetam 30. Lidocaine 5% Patch\n 31. Lorazepam 32. Magnesium Sulfate 33. Metoprolol Tartrate 34.\n Miconazole Powder 2% 35. Nystatin Oral Suspension\n 36. PHENObarbital 37. Phenytoin Sodium (IV) 38. Phenytoin Sodium (IV)\n 39. Phenylephrine 40. Potassium Chloride\n 41. Sodium Chloride 0.9% Flush 42. Sodium Chloride 0.9% Flush 43.\n Sodium Chloride 0.9% Flush 44. Sodium Chloride 0.9% Flush\n 45. Timolol Maleate 0.5%\n 24 Hour Events:\n Cont oliguria in spite of albumin. Renal consult called. Ultrasound\n obtained (WNL). INR supratherapeutic. keppra 250\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:23 PM\n Ciprofloxacin - 12:02 AM\n Infusions:\n Phenylephrine - 0.9 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Dilantin - 12:45 AM\n Other medications:\n Flowsheet Data as of 03:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 36.9\nC (98.5\n HR: 89 (75 - 93) bpm\n BP: 127/56(81) {108/49(69) - 139/64(92)} mmHg\n RR: 21 (17 - 21) insp/min\n SPO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 96.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 14 (13 - 21) mmHg\n Total In:\n 1,986 mL\n 214 mL\n PO:\n Tube feeding:\n 842 mL\n 119 mL\n IV Fluid:\n 984 mL\n 95 mL\n Blood products:\n 100 mL\n Total out:\n 389 mL\n 41 mL\n Urine:\n 189 mL\n 41 mL\n NG:\n Stool:\n 200 mL\n Drains:\n Balance:\n 1,597 mL\n 173 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 27 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 8.7 L/min\n Physical Examination\n General Appearance: Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), + murmur\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous : ,\n Diminished: )\n Abdominal: Soft, Non-distended, Obese\n Left Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n delayed response to noxious stimuli\n Labs / Radiology\n 368 K/uL\n 9.2 g/dL\n 120 mg/dL\n 2.5 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 70 mg/dL\n 105 mEq/L\n 140 mEq/L\n 30.4 %\n 10.4 K/uL\n [image002.jpg]\n 06:36 PM\n 03:33 AM\n 09:41 AM\n 04:39 PM\n 04:06 AM\n 06:15 PM\n 02:54 AM\n 03:18 AM\n 02:38 AM\n 10:24 AM\n WBC\n 11.3\n 10.4\n 9.7\n 9.7\n 10.4\n Hct\n 26.9\n 25.8\n 30.1\n 29.7\n 30.4\n Plt\n 81\n 368\n Creatinine\n 1.7\n 2.0\n 2.1\n 2.2\n 2.2\n 2.5\n 2.5\n TCO2\n 30\n 30\n 22\n Glucose\n 122\n 116\n 121\n 107\n 120\n Other labs: PT / PTT / INR:33.5/35.4/3.4, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:60/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca:7.7 mg/dL, Mg:2.0 mg/dL, PO4:2.2 mg/dL\n Imaging: Renal US: no hydronephrosis. mild ascites\n CT head: No acute ICH. Small ovoid hypodensity in R parietal lobe\n corresponds to area demonstrating old blood seen on MRI of . New\n opacification of L anterior ethmoid air cells and increased\n opacification of L mastoid air cells.\n CXR: Cardiomegaly, prominent pulmonary vasculature, and bibasilar\n atelectasis is unchanged.\n MR: Focal area w/high signal intensity @ R sup parietal lobule, no\n mass effect and may represent a chronic hemorrhagic area. Subcortical\n areas w/high signal intensity on T2 and FLAIR c/w chronic microvascular\n ischemic changes. Tortuosity of basilar artery, cw dolichoectasia\n Echo: EF >= 60%, Symmetric LVH, Significant AS, Trivial MR (may be\n significantly UNDERestimated), Mild [1+] TR. Mild PA systolic HTN\n CTA: No acute infarct or hemorrhage. Severe atherosclerotic\n narrowing of distal R vertebral art and moderate-to-severe narrowing of\n b/l cavernous ICAs. Small focus of calcification in Basilar A. close to\n the tip. Moderate microangiopathic ischemic white matter dz\n Microbiology: UCx: Yeast, >100,000\n BCx x2 neg\n BCx x2 p\n UCx: Yeast 10-100,000\n & Cdiff: Neg\n Sp Cx: 1+ Yeast\n Assessment and Plan\n INEFFECTIVE COPING, RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n KNOWLEDGE DEFICIT, IMPAIRED SKIN INTEGRITY, PNEUMONIA, ASPIRATION,\n AORTIC STENOSIS, SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension requiring\n phenylephrine.\n Neurologic:\n -- Patient sedated with minimal doses intermittent fentanyl prn.\n -- Patient with seizures, loaded with dilantin and ativan PRN prior to\n admission with poor mental status. Despite loading dose continued to\n have sub clinical seziures on EEG. Medication regimen adjusted,\n currently on phenytoin (Goal 15-20), Keppra->lowered and now\n phenobarbitol. No seizure yesterday but occasional sharp waves.\n --Continue neurontin for chronic pain well controlled on current\n medication -> stop b/o ATN.\n --Delayed Withdraws to pain in all extremities\n Cardiovascular:\n -- PAF with good control of HR on beta blockade and digoxin.\n Anticoagulation started with coumadin. No heparin bridge for risk of\n rebleed. On ASA\n -- CAD s/p CABG , diastolic dysfunction. On b-blockade,\n furosemide, ASA, and statin.\n -- Critical AS (valve area pre-valvuloplasty 0.8cm2, post\n vavluloplasty). On ICU-based ECHO estimated area is 0.6cm2. Likely not\n eligible for open valve replacement. Family is discussing this issue\n with another cardiologist\n Pulmonary:\n --lower FiO2 and PEEP to minimal settings if possible\n --albuterol/atrovent PRN\n -- Trach & PEG on Monday\n Gastrointestinal / Abdomen:\n --TFs at goal, PEG \n Nutrition:\n --Tube feeding\n Renal: -- Lasix held\n -- ATN (muddy brown casts), would not diurese, or give IVF; do not\n oliguria. need dialysis in future (gentle CVVH).\n Hematology:\n --Transfuse to the Hct of 25%\n --ASA, coumadin (2/5/5/3/1) Hold coumadin and when INR below 2.0 then\n switch to heparin.\n - A. Fib anticoagulation with coumadin, INR 3.4 (goal ), last dose\n , will start hep gtt to bridge for trach/PEG Monday (have\n contact Dr. \n Endocrine:\n --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg for hypothyroidism\n Infectious Disease:\n --No issues\n Lines / Tubes / Drains: PIV, Foley, CVL (), ETT, NGT\n Imaging: none\n Fluids: KVO\n Consults: Neurology, Nephrology\n Billing Diagnosis: Other: status epilepticus, respiratory failure, ATN\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 07:52 PM 35 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: Boots (Supratherapeutic with coumadin, plan for hep gtt once INR\n decreases)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held yesterday. Family expressed desire to continue aggressive\n care. and to proceed with Trach and PEG , ICU consent signed\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-17 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404891,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Wean PS as tol\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Hemodynimic instability, Underlying illness not\n resolved\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-05 00:00:00.000",
"description": "Intensivist Note",
"row_id": 403759,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. Currently, she responds only to\n painful stimuli.\n Chief complaint:\n Seizures\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS 6. 250 mL NS 7. 250 mL NS\n 8. Acetaminophen\n 9. Albuterol 0.083% Neb Soln 10. Albumin 25% (12.5g / 50mL) 11. Aspirin\n 12. Atorvastatin 13. Bacitracin-Polymyxin Ointment\n 14. Calcium Gluconate 15. CefePIME 16. Collagenase Ointment 17. Digoxin\n 18. FoLIC Acid 19. Furosemide\n 20. Gabapentin 21. Heparin 22. Ipratropium Bromide Neb 23. Latanoprost\n 0.005% Ophth. Soln. 24. Levothyroxine Sodium\n 25. LeVETiracetam 26. Lidocaine 5% Patch 27. Lorazepam 28. Magnesium\n Sulfate 29. Metoprolol Tartrate\n 30. Metoclopramide 31. Miconazole Powder 2% 32. Neutra-Phos 33.\n Nystatin Oral Suspension 34. Phenytoin Sodium (IV)\n 35. Phenylephrine 36. Potassium Chloride 37. Sodium Chloride 0.9% Flush\n 38. Sodium Chloride 0.9% Flush\n 39. Sodium Chloride 0.9% Flush 40. Timolol Maleate 0.5% 41. Vancomycin\n 24 Hour Events:\n URINE CULTURE - At 09:52 AM\n ARTERIAL LINE - START 04:39 PM\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Cefipime - 10:16 PM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Dilantin - 12:15 AM\n Other medications:\n Flowsheet Data as of 05:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36\nC (96.8\n HR: 81 (70 - 92) bpm\n BP: 106/46(68) {95/44(62) - 165/82(114)} mmHg\n RR: 15 (14 - 22) insp/min\n SPO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 80.6 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 2,656 mL\n 516 mL\n PO:\n Tube feeding:\n 83 mL\n IV Fluid:\n 2,566 mL\n 383 mL\n Blood products:\n Total out:\n 847 mL\n 170 mL\n Urine:\n 847 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,809 mL\n 346 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 95%\n ABG: 7.35/56/90./31/3\n PaO2 / FiO2: 180\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : bilat)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n moves some spontaneuously, and responds to noxious stim\n Labs / Radiology\n 376 K/uL\n 8.5 g/dL\n 122 mg/dL\n 1.3 mg/dL\n 31 mEq/L\n 4.0 mEq/L\n 33 mg/dL\n 107 mEq/L\n 143 mEq/L\n 30.5 %\n 9.9 K/uL\n [image002.jpg]\n 05:28 AM\n 02:25 PM\n 09:34 PM\n 04:56 AM\n 06:05 AM\n 06:37 PM\n 03:07 AM\n 04:56 PM\n 03:35 AM\n 03:52 AM\n WBC\n 8.2\n 7.0\n 7.1\n 8.9\n 9.9\n Hct\n 30.0\n 30.7\n 32.7\n 30.6\n 30.5\n Plt\n 354\n 323\n 307\n 302\n 376\n Creatinine\n 1.0\n 1.2\n 1.1\n 1.1\n 1.1\n 1.3\n 1.3\n 1.3\n Troponin T\n 0.03\n TCO2\n 35\n 32\n Glucose\n 113\n 137\n 153\n 109\n 98\n 146\n 121\n 122\n Other labs: PT / PTT / INR:16.1/35.1/1.4, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:62/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:202 IU/L, Ca:7.6 mg/dL, Mg:1.8 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n KNOWLEDGE DEFICIT, IMPAIRED SKIN INTEGRITY, PNEUMONIA, ASPIRATION,\n AORTIC STENOSIS, SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD\n Neurologic:\n -- Patient with subclinical seizures, loaded with dilantin and ativan\n prior to admission with poor mental status. Dilantin for seziure\n prophylaxis, f/u AM level. Follow up on EEG -> no seizures. CT\n performed to exclude underlying mass or AVM since they can affect\n the decision to restart anticoagulation for PAF and overall prognosis.\n There is a bleed detected on the prior MRI in the right posterior\n temporo-parietal area. F/U CT head results\n -- Continue neurontin for chronic pain well controlled on current\n medication.\n Cardiovascular:\n --PAF with good control of HR on beta blockade and digoxin.\n -- Multiple medical cardiovascular problems. CAD s/p CABG but\n still diastolic dysfunction. She had AS (valve area 0.8-0.6cm2 on\n previous echo) but underwent valvuloplasty\n no gradient estimation\n after procedure. Critical stenosis with very tenuous cardiac status.\n -- anticoagulation for A. Fib: On ASA and atrovastatin. No\n anticoagulation for now, will reassess today\n -- required low dose phenylephrine for MAPs>60, ?low SVR state as pt is\n clinically volume overloaded\n Pulmonary: Treated empirically for aspiration pneumonia with\n /Cefepime but cultures are negative. We will continue treatment for\n full 7 days considering that she is very advanced in her empirical\n treatment.\n -- Chest PT and inhalers\n Gastrointestinal / Abdomen: --TFs@goal prior to admission, will hold\n given worsening pulmonary status. In future consider PEG tube\n placement.\n --CDiff has been negative and diarrhea has stopped, PO vanc has been\n stopped.\n Nutrition: --TF restarted via Dobhoff\n Renal: --Lasix dependent, continue Lasix 40 (decreased from 60 given Cr\n 1.3) PO/NG daily; was previously on lasix gtt, will continue to monitor\n --Increasing Cr, 0.8 on admission, currently 1.3\n Hematology:\n --Hct stable\n --ASA, SQH\n -- D/w neurology when to resume anticoagulation after underlying mass,\n avm r/o\n Endocrine: --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg for hypothyroidism\n Infectious Disease: --Wbc 8.8->9.9 afebrile\n --Being treated for PNA with cefepime/vanc (?aspiration) total course\n should be 7 days (ending )\n --Vanc trough 20.6, dose decreased to 500mg IV q24hrs from 750\n Lines / Tubes / Drains: PIV, Foley, PICC\n Consults: neuromed\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:30 AM 25 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 06:03 PM\n Arterial Line - 04:39 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent: 33 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-19 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 405079,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 13\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt recieved on PSV 15/5 as noted with no vent changes this\n shift.\n Assessment of breathing comfort: No claim of dyspnea\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Plan to continue on current settings at this time.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n MRI\n 10:30a\n Transport was without incident.\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-09 00:00:00.000",
"description": "Intensivist Note",
"row_id": 404134,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG\n Chief complaint:\n Seizures\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Albuterol Inhaler 8.\n Albumin 5% (12.5g / 250mL)\n 9. Aspirin 10. Atorvastatin 11. Bacitracin-Polymyxin Ointment 12.\n Calcium Gluconate 13. CefePIME\n 14. Chlorhexidine Gluconate 0.12% Oral Rinse 15. Ciprofloxacin 16.\n Collagenase Ointment 17. Dextrose 50%\n 18. Digoxin 19. Famotidine 20. Fentanyl Citrate 21. FoLIC Acid 22.\n Furosemide 23. Gabapentin 24. Glucagon\n 25. Heparin 26. Insulin 27. Ipratropium Bromide MDI 28. Ipratropium\n Bromide Neb 29. Latanoprost 0.005% Ophth. Soln.\n 30. Levothyroxine Sodium 31. LeVETiracetam 32. Lidocaine 5% Patch 33.\n Lorazepam 34. Lorazepam 35. Magnesium Sulfate\n 36. Metoprolol Tartrate 37. Miconazole Powder 2% 38. Nystatin Oral\n Suspension 39. PHENObarbital 40. PHENObarbital\n 41. Phenytoin Sodium (IV) 42. Phenylephrine 43. Potassium Chloride 44.\n Sodium Chloride 0.9% Flush\n 45. Sodium Chloride 0.9% Flush 46. Sodium Chloride 0.9% Flush 47.\n Timolol Maleate 0.5% 48. Vancomycin\n 49. Warfarin\n 24 Hour Events:\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Ciprofloxacin - 11:59 PM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 11:46 AM\n Heparin Sodium (Prophylaxis) - 04:48 PM\n Famotidine (Pepcid) - 09:00 PM\n Dilantin - 11:59 PM\n Other medications:\n Flowsheet Data as of 05:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 36.9\nC (98.5\n HR: 82 (71 - 90) bpm\n BP: 109/45(68) {65/38(53) - 130/58(84)} mmHg\n RR: 18 (18 - 23) insp/min\n SPO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 88.7 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 3,130 mL\n 290 mL\n PO:\n Tube feeding:\n 961 mL\n 185 mL\n IV Fluid:\n 1,369 mL\n 105 mL\n Blood products:\n 500 mL\n Total out:\n 187 mL\n 29 mL\n Urine:\n 187 mL\n 29 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,943 mL\n 261 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 18\n RR (Spontaneous): 3\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Elevated ICP\n PIP: 24 cmH2O\n Plateau: 21 cmH2O\n SPO2: 99%\n ABG: 7.41/45/114/28/3\n Ve: 7.5 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Neurologic: (Responds to: Noxious stimuli), No(t) Moves all\n extremities, (RUE: No movement), (LUE: No movement)\n Labs / Radiology\n 381 K/uL\n 7.5 g/dL\n 121 mg/dL\n 2.1 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 57 mg/dL\n 107 mEq/L\n 143 mEq/L\n 25.8 %\n 10.4 K/uL\n [image002.jpg]\n 10:32 AM\n 03:49 AM\n 10:50 AM\n 01:08 PM\n 04:35 PM\n 06:36 PM\n 03:33 AM\n 09:41 AM\n 04:39 PM\n 04:06 AM\n WBC\n 10.5\n 11.3\n 10.4\n Hct\n 30.4\n 26.9\n 25.8\n Plt\n 372\n 430\n 381\n Creatinine\n 1.5\n 1.7\n 2.0\n 2.1\n TCO2\n 31\n 31\n 30\n 29\n 30\n 30\n Glucose\n 119\n 122\n 116\n 121\n Other labs: PT / PTT / INR:21.6/46.0/2.0, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:60/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca:7.4 mg/dL, Mg:2.2 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), KNOWLEDGE DEFICIT, IMPAIRED\n SKIN INTEGRITY, PNEUMONIA, ASPIRATION, AORTIC STENOSIS, SEIZURE,\n WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD, now w/respiratory acidosis and\n failure resulting in intubation ().\n Neurologic: -- Patient sedtaed with fentanyl prn.\n -- Patient with seizures, loaded with dilantin and ativan PRN prior to\n admission with poor mental status. Despite loading dose continued to\n have sub clinical seziures on EEG. Medication regiment changed.\n Currently on phenytoin and Keppra and now phenobarbitol.MRI brain w/\n and w/o ordered for when pt is stable to transport to evaluate to\n source of bleed in parietal lobe.\n --Continue neurontin for chronic pain well controlled on current\n medication.\n Cardiovascular: -- PAF with good control of HR on beta blockade and\n digoxin. Anticoagulation started with coumadin. No heparin bridge for\n risk of rebleed. On ASA\n -- CAD s/p CABG , diastolic dysfunction. On b-blockade,\n furosemide, ASA, and statin.\n -- Critical AS (valve area pre-valvuloplasty 0.8cm2, post\n vavluloplasty). On ICU-based ECHO estimated area is 0.6cm2. Likely not\n eligible for open valve replacement. Family is discussing this issue\n with another cardiologist.\n -- Pt still requires neosynephrine for MAPs > 60\n -- albmunin bolus x2 for low MAPS and poor UOP\n Pulmonary: --Treated empirically for HAP with Vanc/Cefepime, Cultures\n are negative so far. We will continue treatment for full 7 days despite\n negative cultures ending today\n --albuterol/atrovent PRN\n Gastrointestinal / Abdomen: --Resume TFs, consider PEG tube placement\n in future if clinical picture warrants\n Nutrition: --TF continued\n Renal: -- On home dose of Lasix\n -- Diminished urine output, received albumin x2 overnight, Creatinine\n increasing 1.5-1.7->2.1\n -- Cipro for UTI, started . cultures p, last dose today\n Hematology: --Hct slowly decreasing, 25.8\n --ASA, SQH\n - A. Fib anticoagulation with coumadin, INR 2.0 (goal ), dose\n decreased to 3mg\n Endocrine: --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg for hypothyroidism, previous TSH was 6.8\n Infectious Disease: --Wbc down slightly to 10.4\n --Being treated for PNA with cefepime/vanc (?aspiration) total course\n should be 7 days (ending ).\n --Follow cultures\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults: neuromed\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:59 PM 35 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 06:03 PM\n Arterial Line - 04:39 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent: 33 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404420,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 21cm at teeth\n Route: po\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments/Plan\n No changes made overnight, remains on AC mode. No RSBI secondary to no\n spont. RR. See flowsheet for further pt data. Will follow.\n 05:59\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404997,
"text": "Seizure, without status epilepticus\n Assessment:\n Pt intermittingly to deep nail bed stimulation. Opened eyes x1 to nail\n bed. Grimacing. PERRLA.\n Non-purposeful mvt. Moving only LE\ns to stimuli.\n Weak cough, no gag.\n Continued on EEG.\n U/O 10cc/hr.\n BUN 111\n Creat 3.6\n MAP requirement lowered to >65 by MD . Continues to be in Afib\n without ectopy.\n Awaiting MRI.\n Action:\n Family mtg @ bedside with MD . Husband, and Daughter.\n Neo weaned off.\n Chlorothiazide 500mg and Lasix 200mg as ordered.\n Dilantin continued as ordered.\n Phenobarbital decreased to 30 mg .\n Response:\n Family continues to want aggressive treatment. Requesting anti-sz meds\n be removed to see if pt wakes up.\n No change in urine output.\n MAP maintained >65.\n Plan:\n Continue aggressive treatment including full code status.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405146,
"text": "Pt transferred from SICU B to CCU for continued care by CCU team.\n Please see SICU RN note from today. Pt arrived at 1600, vital signs\n stable. Cont plan of care.\n Seizure, without status epilepticus\n Assessment:\n EEG monitoring in place, no twitching, tonic clonic movements noted. Pt\n unarrousable, sl. Grimace with mouth care, no gag, weak cough.\n Action:\n Given Dilantin load of 800mg.\n Response:\n unchanged\n Plan:\n Decreasing phenobarb dosing and cont on Dilantin, cont to follow neuro\n exam.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404810,
"text": "Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404816,
"text": "Seizure, without status epilepticus\n Assessment:\n Patient is unresponsive, not on sedation, still on neo gtt tp keep MAP\n >70, pupils equal and reactive to light, withdrawing all extremities\n very slightly to deep painful stimuli only, not opening eyes or\n following commands. Absent gag and cough.\n Action:\n Q4H neuro checks, continued with neo gtt to keep MAP >70, HOB >30*, TF\n continued, wound care for venous ulcer on both LE,\n Response:\n Unchanged neuro status, no seizure activities noted.\n Plan:\n Cont to monitor , neuro checks q4h, cont neo to keep MAP>70, support\n to pt and family.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403635,
"text": "Aortic stenosis\n Assessment:\n BP\ns 80\ns-100\ns/40\ns-60\ns. Lungs With crackles throughout bilaterally.\n 2+ edema in LE\ns to knees. U/O 25-80 CC/HR.\n Action:\n Bedside echo done\n Neo gtt started\n IV albumin x1\n 250 cc NS bolus\n PO lasix given\n Response:\n MAP > 60 with neo @..5\n Plan:\n continue Neo for MAP>60, monitor U/O\n Seizure, without status epilepticus\n Assessment:\n no seizure activity noted. some slight tremulousness noted at times..\n EEG at bedside\n Action:\n head CT done\n dilantin IV TID, keppra \n Response:\n no seizure activity noted\n dilantin level 10\n Plan:\n continue to monitor\n Pneumonia, aspiration\n Assessment:\n LS coarse with crackles throughout. A-febrile during the day. Sats WNL\n on 100% FM\n Action:\n chest pt done\n combivent nebs q6\n chest xray done\n Response:\n sats WNL\n Plan:\n pulmonary toileting, monitor sats, continue IV abx\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-10 00:00:00.000",
"description": "Intensivist Note",
"row_id": 404210,
"text": "SICU\n HPI:\n Seizures\n Chief complaint:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. At time of SICU admission, she\n responded only to painful stimuli.\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n 1. IV access: Peripheral line Location: Right Order date: @ \n 25. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1707\n 2. IV access: Peripheral line Order date: @ 26. Ipratropium\n Bromide MDI 2 PUFF IH Q6H wheezing\n MDI while on vent Order date: @ 2059\n 3. IV access: PICC, non-heparin dependent Location: Right Brachial,\n Date inserted: Order date: @ 27. Ipratropium\n Bromide Neb 1 NEB IH Q6H\n Use MDI/inhaler while pt in intubated, on vent Order date: @\n 2059\n 4. IV access: None Order date: @ 28. Latanoprost 0.005%\n Ophth. Soln. 1 DROP BOTH EYES HS Order date: @ \n 5. OK to use line Order date: @ 1549 29. Levothyroxine Sodium 75\n mcg PO/NG DAILY Order date: @ \n 6. Acetaminophen 325-650 mg PO/NG Q6H:PRN fever Order date: @\n 1054 30. LeVETiracetam 500 mg PO/NG Order date: @ 1002\n 7. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing Order date:\n @ 31. Lidocaine 5% Patch 2 PTCH TD DAILY\n 12 h on 12 h off; apply one patch to each knee Order date: @\n \n 8. Albuterol Inhaler PUFF IH Q4H:PRN wheezing\n while intubated ,on vent Order date: @ 2059 32. Lorazepam 0.5-1\n mg IV HS PRN Sz\n prolonged Sz > 3 minutes; Pls page neurology resident prior\n administering. Order date: @ 2213\n 9. Aspirin 81 mg PO/NG DAILY Order date: @ 33. Magnesium\n Sulfate IV Sliding Scale Order date: @ 0638\n 10. Atorvastatin 40 mg PO/NG DAILY Order date: @ 34.\n Metoprolol Tartrate 25 mg PO/NG TID\n hold for HR<60 or BP<100 Order date: @ 0923\n 11. Bacitracin-Polymyxin Ointment 1 Appl TP Q6H:PRN wound Order date:\n @ 35. Miconazole Powder 2% 1 Appl TP PRN fungal infection\n Order date: @ \n 12. Calcium Gluconate IV Sliding Scale Order date: @ 0638 36.\n Nystatin Oral Suspension 5 mL PO QID:PRN \n swish and swallow Order date: @ \n 13. CefePIME 2 g IV Q24H Duration: 1 Doses\n Stop Order date: @ 0827 37. PHENObarbital 90 mg PO/NG \n start with PM dose 3/15 Order date: @ 1002\n 14. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1754 38. Phenytoin Sodium (IV) 100 mg IV Q8H Order date: @ 2157\n 15. Ciprofloxacin 400 mg IV ONCE Duration: 1 Doses Order date: @\n 0827 39. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAPs >60\n Order date: @ 1434\n 16. Collagenase Ointment 1 Appl TP DAILY Order date: @ 40.\n Phenytoin Sodium (IV) 250 mg IV ONCE Duration: 1 Doses Order date:\n @ 1056\n 17. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date:\n @ 1707 41. Phenytoin Sodium (IV) 500 mg IV ONCE Duration: 1 Doses\n Order date: @ 2124\n 18. Digoxin 0.0625 mg PO/NG DAILY Order date: @ 42.\n Potassium Chloride IV Sliding Scale Order date: @ 0638\n 19. Famotidine 20 mg IV Q24H Order date: @ 1817 43. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ \n 20. Fentanyl Citrate 12.5-100 mcg IV Q2H:PRN agitation, for sedation\n Order date: @ 1508 44. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN\n line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ \n 21. FoLIC Acid 1 mg PO/NG DAILY Order date: @ 45. Sodium\n Chloride 0.9% Flush 10 mL IV PRN line flush\n PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and\n PRN per lumen. Order date: @ \n 22. Furosemide 40 mg PO/NG DAILY\n hold for BP <100 Order date: @ 46. Timolol Maleate 0.5% 1\n DROP BOTH EYES DAILY Order date: @ \n 23. Gabapentin 100 mg PO/NG Order date: @ 47.\n Vancomycin 500 mg IV Q 24H Duration: 1 Doses Start: In am\n Stop Hold please Order date: @ 0827\n 24. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1707\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:09 AM\n MULTI LUMEN - START 01:49 PM\n WOUND CULTURE - At 05:30 PM\n PICC tip\n PICC LINE - STOP 05:42 PM\n Post operative day:\n N/A\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Cefipime - 10:00 PM\n Vancomycin - 08:23 PM\n Ciprofloxacin - 12:02 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 01:40 PM\n Famotidine (Pepcid) - 08:22 PM\n Dilantin - 01:30 AM\n Other medications:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.6\nC (99.6\n HR: 82 (68 - 84) bpm\n BP: 109/51(72) {101/38(62) - 118/65(81)} mmHg\n RR: 18 (12 - 19) insp/min\n SPO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 95.2 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 2,555 mL\n 564 mL\n PO:\n Tube feeding:\n 822 mL\n 216 mL\n IV Fluid:\n 692 mL\n 348 mL\n Blood products:\n 631 mL\n Total out:\n 448 mL\n 40 mL\n Urine:\n 148 mL\n 40 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 2,107 mL\n 524 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 24 cmH2O\n Plateau: 22 cmH2O\n Compliance: 32.1 cmH2O/mL\n SPO2: 98%\n ABG: 7.37/37/142/24/-3\n Ve: 6.6 L/min\n PaO2 / FiO2: 284\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: (Responds to: Unresponsive), Moves all extremities\n Labs / Radiology\n 381 K/uL\n 9.0 g/dL\n 107 mg/dL\n 2.2 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 59 mg/dL\n 106 mEq/L\n 138 mEq/L\n 29.7 %\n 9.7 K/uL\n [image002.jpg]\n 01:08 PM\n 04:35 PM\n 06:36 PM\n 03:33 AM\n 09:41 AM\n 04:39 PM\n 04:06 AM\n 06:15 PM\n 02:54 AM\n 03:18 AM\n WBC\n 11.3\n 10.4\n 9.7\n 9.7\n Hct\n 26.9\n 25.8\n 30.1\n 29.7\n Plt\n 81\n Creatinine\n 1.7\n 2.0\n 2.1\n 2.2\n 2.2\n TCO2\n 30\n 29\n 30\n 30\n 22\n Glucose\n 122\n 116\n 121\n 107\n Other labs: PT / PTT / INR:28.3/35.5/2.8, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:60/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca:7.6 mg/dL, Mg:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), KNOWLEDGE DEFICIT, IMPAIRED\n SKIN INTEGRITY, PNEUMONIA, ASPIRATION, AORTIC STENOSIS, SEIZURE,\n WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension requiring\n phenylephrine.\n Neurologic: -- Patient sedated with fentanyl prn.\n -- Patient with seizures, loaded with dilantin and ativan PRN prior to\n admission with poor mental status. Despite loading dose continued to\n have sub clinical seziures on EEG. Medication regimen changed,\n currently on phenytoin (Goal 15-20), Keppra and now phenobarbitol.\n --MRI brain w/ and w/o ordered for when pt is stable to transport to\n evaluate to source of bleed in parietal lobe.\n --Continue neurontin for chronic pain well controlled on current\n medication.\n --Withdraws to pain in all extremities\n Cardiovascular: -- PAF with good control of HR on beta blockade and\n digoxin. Anticoagulation started with coumadin. No heparin bridge for\n risk of rebleed. On ASA\n -- CAD s/p CABG , diastolic dysfunction. On b-blockade,\n furosemide, ASA, and statin.\n -- Critical AS (valve area pre-valvuloplasty 0.8cm2, post\n vavluloplasty). On ICU-based ECHO estimated area is 0.6cm2. Likely not\n eligible for open valve replacement. Family is discussing this issue\n with another cardiologist.\n -- Pt still requires neosynephrine for MAPs > 60\n -- tx 2u prbcs with Hct 25.8 on \n Pulmonary: --Treated empirically for HAP with Vanc/Cefepime, cultures\n negative, finished 7 day course\n --albuterol/atrovent PRN\n Gastrointestinal / Abdomen: --TFs at goal, consider PEG tube placement\n in future if clinical picture warrants\n Nutrition: --TFs at goal, consider PEG tube placement in future if\n clinical picture warrants\n Renal: -- On home dose of Lasix\n -- Diminished urine output, received albumin x2 overnight, Creatinine\n increasing 1.5-1.7->2.1\n -- Cipro for UTI, started . cultures p, last dose 3/16\n Hematology: --Hct slowly decreasing, 25.8--> tx 2u prbcs on ->29.7\n --ASA, coumadin (2/5/5/3\n - A. Fib anticoagulation with coumadin, INR 2.0 (goal ), dose\n decreased to 3mg\n Endocrine: --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg for hypothyroidism, previous TSH was 6.8\n Infectious Disease: --Wbc down to 9.7\n --Treated for PNA with cefepime/vanc (?aspiration) total course should\n be 7 days (ending ).\n --Follow cultures\n Lines / Tubes / Drains: PIV, Foley, CVL ()\n Wounds: none\n Imaging: CXR\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 10:37 PM 35 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-13 00:00:00.000",
"description": "Intensivist Note",
"row_id": 404546,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. At time of SICU admission, she\n responded only to painful stimuli\n Chief complaint:\n Seizures\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n Acetaminophen 7. Albuterol 0.083% Neb Soln 8. Albuterol Inhaler 9.\n Aspirin\n 10. Atorvastatin 11. Bacitracin-Polymyxin Ointment 12. Calcium\n Gluconate 13. Chlorhexidine Gluconate 0.12% Oral Rinse\n 14. Collagenase Ointment 15. Dextrose 50% 16. Digoxin 17. Famotidine\n 18. Fentanyl Citrate 19. FoLIC Acid\n 20. Glucagon 21. 22. Insulin 23. Ipratropium Bromide MDI 24.\n Ipratropium Bromide Neb 25. Latanoprost 0.005% Ophth. Soln.\n 26. Levothyroxine Sodium 27. LeVETiracetam 28. Lidocaine 5% Patch 29.\n Lorazepam 30. Magnesium Sulfate\n 31. Metoprolol Tartrate 32. Miconazole Powder 2% 33. Nystatin Oral\n Suspension 34. PHENObarbital 35. Phenytoin Sodium (IV)\n 36. Phenylephrine 37. Phenytoin Sodium (IV) 38. Potassium Chloride 39.\n Sodium Chloride 0.9% Flush\n 40. Sodium Chloride 0.9% Flush 41. Sodium Chloride 0.9% Flush 42.\n Sodium Chloride 0.9% Flush 43. Timolol Maleate 0.5%\n 24 Hour Events:\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Dilantin - 02:09 AM\n Other medications:\n Flowsheet Data as of 04:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 37.6\nC (99.7\n HR: 89 (80 - 93) bpm\n BP: 136/58(87) {107/46(66) - 136/58(87)} mmHg\n RR: 21 (18 - 33) insp/min\n SPO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 96.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 16 (10 - 16) mmHg\n Total In:\n 1,928 mL\n 319 mL\n PO:\n Tube feeding:\n 840 mL\n 144 mL\n IV Fluid:\n 858 mL\n 175 mL\n Blood products:\n Total out:\n 177 mL\n 30 mL\n Urine:\n 177 mL\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,751 mL\n 289 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 21 cmH2O\n Plateau: 20 cmH2O\n SPO2: 94%\n ABG: 7.35/44/80./22/-1\n Ve: 7.7 L/min\n PaO2 / FiO2: 200\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Neurologic: (Responds to: Noxious stimuli), No(t) Moves all\n extremities, (RUE: No movement), (LUE: No movement), (RLE: Weakness),\n (LLE: Weakness), withdraws lowers to pain\n Labs / Radiology\n 393 K/uL\n 9.0 g/dL\n 124 mg/dL\n 3.0 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 81 mg/dL\n 103 mEq/L\n 137 mEq/L\n 30.3 %\n 10.1 K/uL\n [image002.jpg]\n 06:15 PM\n 02:54 AM\n 03:18 AM\n 02:38 AM\n 10:24 AM\n 03:06 AM\n 03:29 AM\n 12:15 PM\n 02:20 AM\n 02:31 AM\n WBC\n 9.7\n 9.7\n 10.4\n 10.4\n 10.1\n Hct\n 30.1\n 29.7\n 30.4\n 30.2\n 30.3\n Plt\n 382\n 381\n 368\n 428\n 393\n Creatinine\n 2.2\n 2.2\n 2.5\n 2.5\n 2.7\n 3.0\n TCO2\n 22\n 25\n 22\n 25\n Glucose\n 107\n 120\n 112\n 124\n Other labs: PT / PTT / INR:29.5/33.7/2.9, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:60/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca:7.8 mg/dL, Mg:1.9 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), INEFFECTIVE COPING,\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), KNOWLEDGE DEFICIT, IMPAIRED\n SKIN INTEGRITY, PNEUMONIA, ASPIRATION, AORTIC STENOSIS, SEIZURE,\n WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension requiring\n phenylephrine.\n Neurologic: -- Patient sedated with minimal doses intermittent fentanyl\n prn.\n -- Patient with seizures, loaded with dilantin and ativan PRN prior to\n admission with poor mental status. Despite loading dose continued to\n have sub clinical seziures on EEG. Medication regimen changed,\n currently on phenytoin (Goal 15-20), Keppra and phenobarbitol.\n --Delayed Withdrawal to pain in all extremities\n -- f/u AM dilantin level given load yesterday\n Cardiovascular: -- PAF with good control of HR on beta blockade and\n digoxin. Anticoagulation started with coumadin. Coumadin held for now\n given elevated INR, will bridge with heparin once INR<2.0. On ASA\n -- CAD s/p CABG , diastolic dysfunction. On b-blockade, ASA, and\n statin.\n -- Critical AS (valve area pre-valvuloplasty 0.8cm2, post\n vavluloplasty). On ICU-based ECHO estimated area is 0.6cm2. Likely not\n eligible for open valve replacement. Family is discussing this issue\n with another cardiologist.\n --Cont phenylephrine as needed, goal SBP>120, MAP>70\n Pulmonary: --albuterol/atrovent PRN\n --plan for trach \n --wean vent as tolerated. Try PSV\n Gastrointestinal / Abdomen: --TFs at goal,plan for PEG \n Nutrition: --TF continued\n Renal: -- Lasix held\n -- Pt still requires neosynephrine for MAPs > 65\n -- Cr increasing: now at 3, renal believes it is ATN (muddy brown\n casts), would not diurese, or give IVF; do not oliguria.\n Hematology: --ASA. Hold coumadin given elevated INR\n - A. Fib anticoagulation with coumadin, INR goal , f/u daily INR and\n start heparin drip once INR < 2 as pt is planned for trach/peg on\n monday (2.9 today)\n Endocrine: --RISS with adequate glucose control\n --Synthroid 75 mcg for hypothyroidism\n Infectious Disease: --completed cefepime vanc 7 day course for\n pneumonia\n --UA positive foley changed patient received 3 days cours of\n antibiotics last dose 03/16\n Lines / Tubes / Drains: PIV, Foley, CVL (), ETT, Dobhoff\n Consults: neuromed, renal\n Billing Diagnosis: ARF\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:37 PM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle: All\n Comments: coumadin held, INR theraputic\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 33 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404640,
"text": "86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeding.\n Unresponsive except for withdraw of right leg with nailbed, + cough\n intermittently\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n <17 ml q 2 hour uo, yellow with sediment\n cloudy at 1800\n Action:\n Urine monitored, ua+c+s obtained.\n Response:\n Uo remains unchanged = awaiting ccu transfer orders.\n Plan:\n Monitor uo as per orders.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated cpap 18/5 , rr 20\ns to 30\n Action:\n suctioned for small to moderate amounts of thick white tan sputum. abg\n Response:\n Abg per flow . awaiting ccu orders\n Plan:\n Monitor respiratory status, as per orders. Npo after mn for ? trache\n and peg\n Seizure, without status epilepticus\n Assessment:\n No seizure activity noted, neuro status unchanged, left leg withdraws\n with nailbed, dilantin level subtherapuetic, phenobarb\n therapeutic,per;l, + intermittent cough when suctioned\n Action:\n Neuro monitored q2hr. awaiting ccu resident to address dilantin level\n Response:\n No seizure activity\n Plan:\n Monitor neuro status, eeg continues\n Temp max 101.2- blood cultures and urine culture sent. Temp at 1800m\n 100. sr=st with pvc\ns noted, k 4.5. sbp requiring neo attempt to wean\n with sbp 100-map high 50\ns therefore continues on 2 mcq neo. Husband\n and son into visit and updated.\n Pressure ulcer butterfly in nature coccyx with blister, cleansed and\n ota, repositioned q 2hr. please see flow.\n AS per orders.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404881,
"text": "Seizure, without status epilepticus\n Assessment:\n Remains unresponsive although did slightly open left eye and move head\n to husband\ns voice. Perrl. Minimally flex/withdraws at times to deep\n nailbed pressure. No other spont movement. Con\nt eeg on. Remains vented\n on cpap. Remains in afib. Neo on. Abd soft/nt. +bs. + stool via\n flexiseal. Con\nt with min u/o via foley. Con\nt with impaired skin.\n Action:\n Neuro checks. Con\nt eeg on. No vent changes. Skin care. Neo gtt to keep\n map>70.\n Response:\n No change in neuro status. u/o remains min with rising bun/creat. Skin\n unchanged.\n Plan:\n Con\nt with current plan. Monitor for changes. Wean pressor as tol. skin\n care.\n"
},
{
"category": "Nutrition",
"chartdate": "2196-02-04 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 403552,
"text": "Objective\n Pertinent medications: lasix, synthroid, folic acid, keppra, dilantin,\n heparin, others noted\n Labs:\n Value\n Date\n Glucose\n 121 mg/dL\n 03:07 AM\n Glucose Finger Stick\n 143\n 10:00 AM\n BUN\n 33 mg/dL\n 03:07 AM\n Creatinine\n 1.3 mg/dL\n 03:07 AM\n Sodium\n 144 mEq/L\n 03:07 AM\n Potassium\n 3.2 mEq/L\n 03:07 AM\n Chloride\n 106 mEq/L\n 03:07 AM\n TCO2\n 34 mEq/L\n 03:07 AM\n pH (urine)\n 5.0 units\n 06:38 AM\n Albumin\n 2.4 g/dL\n 03:07 AM\n Calcium non-ionized\n 7.5 mg/dL\n 03:07 AM\n Corrected Ca\n 8.78\n calculated\n Phosphorus\n 2.4 mg/dL\n 03:07 AM\n Magnesium\n 1.9 mg/dL\n 03:07 AM\n Phenytoin (Dilantin)\n 12.0 ug/mL\n 03:07 AM\n WBC\n 8.9 K/uL\n 03:07 AM\n Hgb\n 8.9 g/dL\n 03:07 AM\n Hematocrit\n 30.6 %\n 03:07 AM\n Current diet order / nutrition support: NPO; tube feeds discontinued\n last pm\n GI: Abd: soft/distended/nbs\n Assessment of Nutritional Status\n Specifics:\n 86 year old female presented w/ new onset seizures, transferred to\n floor, now back in unit w/ seizure activity. Patient was tolerating\n tube feeds at goal, w/o residuals- discontinued last pm. Plan is for\n dobhoff placement now to resume feeds. K repletion noted. Low P as\n well-no repletion ordered.\n Medical Nutrition Therapy Plan - Recommend the Following\n Once FT replaced and checked- resume tube feeds- Nutren\n Pulmonary /w 21 gr Beneprotein @ 15mL/hr to increase 10mL q6 hr to goal\n of 45mL/hr (1695 kcals/81 gr protein)\n 2 packets neutraphos for low P\n Glucose management as you are\n Monitor dilantin levels on tube feeds\n Following #\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-14 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404641,
"text": "Demographics\n Day of intubation: 8\n Day of mechanical ventilation: 8\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Tracheostomy planned\n Reason for continuing current ventilatory support: Pending procedure /\n OR, Cannot protect airway; Comments: Pt has been changed to CCU SERVICE\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n NO CHANGES since the PS increased to 18cms.\n, RRT 18:54\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404572,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient remains oliguric today. She has been producing approximately\n 10 to 15 cc\ns per hour. She remains unarousable and will withdraw to\n painful stimuli in a delayed fashion. She does not open her eyes to\n voice or noxious stimuli.\n Action:\n She was transitioned from CMV to CPAP today. Extensive family meeting\n occurred today with the neurology service and the cardiology service\n and the family.\n Response:\n She has tolerated being moved to CPAP well.\n Plan:\n Plan for trach and peg placement on Monday. Plan for diuresis.\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 404986,
"text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n EEG - At 11:30 AM\n continuous eeg placed\n - stopped coumadin today, as pt's INR went from 1.8 to 2.7 after\n getting 1 mg x 1 day yesterday\n - spoke with neuro: previous head bleed not an active issue and not\n likely causing pt's current symptoms; anticoagulation not likely a\n problem in the setting of this previous bleed; neuro does feel that\n there is a change in her exam (she lost her doll's eye reflex) and\n there is concern that there could be a pons lesion, therefore they are\n recommending MRI; they are also recommending LP to look for partially\n treated meningitis as possible cause for patient's AMS\n - per neuro recs, phenobarbital decreased to 45 mg , gave 300 mg IV\n bolus of phenytoin and increased dose to 125 mg TID; ordered MRI; put\n in for daily dilantin level\n - spoke with Dr. and he felt we should try more diuresis; wrote\n for 120 mg IV lasix\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Furosemide (Lasix) - 08:30 PM\n Dilantin - 09:36 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37\nC (98.6\n HR: 95 (82 - 98) bpm\n BP: 148/66(97) {93/44(60) - 148/69(97)} mmHg\n RR: 24 (17 - 29) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 104.2 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 14 (12 - 19)mmHg\n Total In:\n 1,277 mL\n 284 mL\n PO:\n 150 mL\n 30 mL\n TF:\n 840 mL\n 244 mL\n IVF:\n 156 mL\n 10 mL\n Blood products:\n Total out:\n 190 mL\n 80 mL\n Urine:\n 190 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,087 mL\n 204 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 228 (228 - 376) mL\n PS : 15 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 136\n PIP: 21 cmH2O\n SpO2: 97%\n ABG: ///19/\n Ve: 7.4 L/min\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. late-peaking high-pitched crescendo/decrescendo\n murmur loudest at RUSB.\n LUNGS: Ventilated breath sounds.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal stimuli. Minimal response to\n painful stimuli. PERRL. No oculovestibular reflex.\n Labs / Radiology\n 469 K/uL\n 8.4 g/dL\n 132 mg/dL\n 3.6 mg/dL\n 19 mEq/L\n 5.0 mEq/L\n 110 mg/dL\n 102 mEq/L\n 136 mEq/L\n 26.1 %\n 7.4 K/uL\n [image002.jpg]\n 11:21 PM\n 03:29 AM\n 03:47 AM\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n 02:12 AM\n 02:44 AM\n 02:34 AM\n WBC\n 10.8\n 9.7\n 8.1\n 7.4\n 7.4\n Hct\n 27.8\n 27.8\n 25.3\n 25.6\n 26.1\n Plt\n 36\n 469\n Cr\n 3.1\n 3.2\n 3.3\n 3.6\n 3.6\n TCO2\n 22\n 26\n 23\n 24\n 22\n Glucose\n 133\n 124\n 116\n 122\n 89\n 96\n 132\n Other labs: PT / PTT / INR:23.5/29.4/2.2, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU. Continues to be\n severely fluid overloaded and oliguric. Does not respond well to lasix.\n - attempt to diurese with Lasix 200 mg IV + Diuril 500 mg IV\n - monitor volume status\n - likely repeat valvuloplasty on Monday\n .\n # Atrial Fibrillation: Pt has good control of HR on beta blockade and\n digoxin. Coumadin was being held before for trach/PEG; restarted\n yesterday and INR went from 1.8 to 2.7.\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - holding Coumadin for possible procedure. INR currently therapeutic.\n Will need heparin gtt when subtherapeutic.\n - will d/w neurology and rest of CCU team risks and benefits of\n Coumadin in this pt\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol. Neuro not sure what is causing continued depressed\n mental status, states she is not having active seizures on EEG.\n - continue phenytoin and Phenobarbital, adjusting per neuro recs: Will\n wean phenobarbital to 30 mg today\n - appreciate neuro recs: recommending LP and MRI\n .\n # Respiratory Failure: Now, s/p trach.\n - trach in place\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Etiology unclear. Likely cardiogenic in setting\n of tight AS, but will need to consider sepsis if patient begins to\n spike fevers. Currently without fever or luekocytosis.\n - will lower MAP goal to 65 to try to keep pt off of pressors\n .\n # Acute Renal Failure: Still worsening. Per previous notes, renal\n believes that this is ATN. Recommend to not diurese or give IVF's.\n - holding on further diuresis, as above\n - continue to monitor fluid status otherwise\n .\n # Hypothyroidism:\n - continue synthroid 75 mcg daily\n .\n # Fevers: Per notes, pt completed vanc/cefepime 7 day course for\n pneumonia as well as 3 days course of abx for positive UA. Afebrile\n overnight.\n - f/u cx data\n - follow fever curve\n - stool for c.diff\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 12:29 AM 35 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 404988,
"text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n EEG - At 11:30 AM\n continuous eeg placed\n - stopped coumadin today, as pt's INR went from 1.8 to 2.7 after\n getting 1 mg x 1 day yesterday\n - spoke with neuro: previous head bleed not an active issue and not\n likely causing pt's current symptoms; anticoagulation not likely a\n problem in the setting of this previous bleed; neuro does feel that\n there is a change in her exam (she lost her doll's eye reflex) and\n there is concern that there could be a pons lesion, therefore they are\n recommending MRI; they are also recommending LP to look for partially\n treated meningitis as possible cause for patient's AMS\n - per neuro recs, phenobarbital decreased to 45 mg , gave 300 mg IV\n bolus of phenytoin and increased dose to 125 mg TID; ordered MRI; put\n in for daily dilantin level\n - spoke with Dr. and he felt we should try more diuresis; wrote\n for 120 mg IV lasix\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Furosemide (Lasix) - 08:30 PM\n Dilantin - 09:36 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37\nC (98.6\n HR: 95 (82 - 98) bpm\n BP: 148/66(97) {93/44(60) - 148/69(97)} mmHg\n RR: 24 (17 - 29) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 104.2 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 14 (12 - 19)mmHg\n Total In:\n 1,277 mL\n 284 mL\n PO:\n 150 mL\n 30 mL\n TF:\n 840 mL\n 244 mL\n IVF:\n 156 mL\n 10 mL\n Blood products:\n Total out:\n 190 mL\n 80 mL\n Urine:\n 190 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,087 mL\n 204 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 228 (228 - 376) mL\n PS : 15 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 136\n PIP: 21 cmH2O\n SpO2: 97%\n ABG: ///19/\n Ve: 7.4 L/min\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. late-peaking high-pitched crescendo/decrescendo\n murmur loudest at RUSB.\n LUNGS: Ventilated breath sounds.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal stimuli. Minimal response to\n painful stimuli. PERRL. No oculovestibular reflex.\n Labs / Radiology\n 469 K/uL\n 8.4 g/dL\n 132 mg/dL\n 3.6 mg/dL\n 19 mEq/L\n 5.0 mEq/L\n 110 mg/dL\n 102 mEq/L\n 136 mEq/L\n 26.1 %\n 7.4 K/uL\n [image002.jpg]\n 11:21 PM\n 03:29 AM\n 03:47 AM\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n 02:12 AM\n 02:44 AM\n 02:34 AM\n WBC\n 10.8\n 9.7\n 8.1\n 7.4\n 7.4\n Hct\n 27.8\n 27.8\n 25.3\n 25.6\n 26.1\n Plt\n 36\n 469\n Cr\n 3.1\n 3.2\n 3.3\n 3.6\n 3.6\n TCO2\n 22\n 26\n 23\n 24\n 22\n Glucose\n 133\n 124\n 116\n 122\n 89\n 96\n 132\n Other labs: PT / PTT / INR:23.5/29.4/2.2, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU. Continues to be\n severely fluid overloaded and oliguric. Does not respond well to lasix.\n - attempt to diurese with Lasix 200 mg IV + Diuril 500 mg IV\n - monitor volume status\n - likely repeat valvuloplasty on Monday\n .\n # Atrial Fibrillation: Pt has good control of HR on beta blockade and\n digoxin. Coumadin was being held before for trach/PEG; restarted\n yesterday and INR went from 1.8 to 2.7.\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - holding Coumadin for possible procedure. INR currently therapeutic.\n Will need heparin gtt when subtherapeutic.\n - will d/w neurology and rest of CCU team risks and benefits of\n Coumadin in this pt\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol. Neuro not sure what is causing continued depressed\n mental status, states she is not having active seizures on EEG.\n - continue phenytoin and Phenobarbital, adjusting per neuro recs: Will\n wean phenobarbital to 30 mg today\n - appreciate neuro recs: recommending LP and MRI\n .\n # Respiratory Failure: Now, s/p trach.\n - trach in place\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Etiology unclear. Likely cardiogenic in setting\n of tight AS, but will need to consider sepsis if patient begins to\n spike fevers. Currently without fever or luekocytosis.\n - will lower MAP goal to 65 to try to keep pt off of pressors\n .\n # Acute Renal Failure: Creatinine stable today. Per previous notes,\n renal believes that this is ATN. Recommend to not diurese or give\n IVF's.\n - will attempt diuresis with Lasix + metolozone, although this may not\n be successful\n - continue to monitor fluid status otherwise\n .\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n .\n # Fevers: Per notes, pt completed vanc/cefepime 7 day course for\n pneumonia as well as 3 days course of abx for positive UA. Afebrile\n overnight.\n - f/u cx data\n - follow fever curve\n - stool for c.diff\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 12:29 AM 35 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 404989,
"text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n EEG - At 11:30 AM\n continuous eeg placed\n - stopped coumadin today, as pt's INR went from 1.8 to 2.7 after\n getting 1 mg x 1 day yesterday\n - spoke with neuro: previous head bleed not an active issue and not\n likely causing pt's current symptoms; anticoagulation not likely a\n problem in the setting of this previous bleed; neuro does feel that\n there is a change in her exam (she lost her doll's eye reflex) and\n there is concern that there could be a pons lesion, therefore they are\n recommending MRI; they are also recommending LP to look for partially\n treated meningitis as possible cause for patient's AMS\n - per neuro recs, phenobarbital decreased to 45 mg , gave 300 mg IV\n bolus of phenytoin and increased dose to 125 mg TID; ordered MRI; put\n in for daily dilantin level\n - spoke with Dr. and he felt we should try more diuresis; wrote\n for 120 mg IV lasix\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Furosemide (Lasix) - 08:30 PM\n Dilantin - 09:36 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37\nC (98.6\n HR: 95 (82 - 98) bpm\n BP: 148/66(97) {93/44(60) - 148/69(97)} mmHg\n RR: 24 (17 - 29) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 104.2 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 14 (12 - 19)mmHg\n Total In:\n 1,277 mL\n 284 mL\n PO:\n 150 mL\n 30 mL\n TF:\n 840 mL\n 244 mL\n IVF:\n 156 mL\n 10 mL\n Blood products:\n Total out:\n 190 mL\n 80 mL\n Urine:\n 190 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,087 mL\n 204 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 228 (228 - 376) mL\n PS : 15 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 136\n PIP: 21 cmH2O\n SpO2: 97%\n ABG: ///19/\n Ve: 7.4 L/min\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. late-peaking high-pitched crescendo/decrescendo\n murmur loudest at RUSB.\n LUNGS: Ventilated breath sounds.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal stimuli. Minimal response to\n painful stimuli. PERRL. No oculovestibular reflex.\n Labs / Radiology\n 469 K/uL\n 8.4 g/dL\n 132 mg/dL\n 3.6 mg/dL\n 19 mEq/L\n 5.0 mEq/L\n 110 mg/dL\n 102 mEq/L\n 136 mEq/L\n 26.1 %\n 7.4 K/uL\n [image002.jpg]\n 11:21 PM\n 03:29 AM\n 03:47 AM\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n 02:12 AM\n 02:44 AM\n 02:34 AM\n WBC\n 10.8\n 9.7\n 8.1\n 7.4\n 7.4\n Hct\n 27.8\n 27.8\n 25.3\n 25.6\n 26.1\n Plt\n 36\n 469\n Cr\n 3.1\n 3.2\n 3.3\n 3.6\n 3.6\n TCO2\n 22\n 26\n 23\n 24\n 22\n Glucose\n 133\n 124\n 116\n 122\n 89\n 96\n 132\n Other labs: PT / PTT / INR:23.5/29.4/2.2, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU. Continues to be\n severely fluid overloaded and oliguric. Does not respond well to lasix.\n - attempt to diurese with Lasix 200 mg IV + Diuril 500 mg IV\n - monitor volume status\n - likely repeat valvuloplasty on Monday\n .\n # Atrial Fibrillation: Pt has good control of HR on beta blockade and\n digoxin. Coumadin was being held before for trach/PEG; restarted\n yesterday and INR went from 1.8 to 2.7.\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - holding Coumadin for possible procedure. INR currently therapeutic.\n Will need heparin gtt when subtherapeutic.\n - will d/w neurology and rest of CCU team risks and benefits of\n Coumadin in this pt\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol. Neuro not sure what is causing continued depressed\n mental status, states she is not having active seizures on EEG.\n - continue phenytoin and Phenobarbital, adjusting per neuro recs: Will\n wean phenobarbital to 30 mg today\n - appreciate neuro recs: recommending LP and MRI\n .\n # Respiratory Failure: Now, s/p trach.\n - trach in place\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Etiology unclear. Likely cardiogenic in setting\n of tight AS, but will need to consider sepsis if patient begins to\n spike fevers. Currently without fever or luekocytosis.\n - will lower MAP goal to 65 to try to keep pt off of pressors\n .\n # Acute Renal Failure: Creatinine stable today. Per previous notes,\n renal believes that this is ATN. Recommend to not diurese or give\n IVF's.\n - will attempt diuresis with Lasix + metolozone, although this may not\n be successful\n - continue to monitor fluid status otherwise\n .\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n .\n # Fevers: Afebrile x 4 days. Per notes, pt completed vanc/cefepime 7\n day course for pneumonia as well as 3 days course of abx for positive\n UA.\n - f/u cx data\n - follow fever curve\n - f/u stool for c.diff\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 12:29 AM 35 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: therapeutic INR\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: Dr. to speak with family today.\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-18 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404992,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Wean PS as tol\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403908,
"text": "Seizure, without status epilepticus\n Assessment:\n Patient is still on continuous EEG, no sz activities noted,\n responding to pain only, not opening eyes or following commands,\n withdrawing all extremities to pain. no gag, weak cough\n Action:\n Neuro checks q2h, Dilantin level checked at night 10.6,200mg dilantin\n x 1 given, seen by neurology, Cont with EEG, oral suction prn done,\n NT suction x1 with moderate amt yellow thick secretion\n Response:\n No seizure activities noted, stable VS, OFF neo now.\n Plan:\n Cont to monitor, Neuro checks q2h, support to pt and family. Cont pulm\n toilet\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402761,
"text": "86F severe AS (critical AS s/p valvuloplasty ), CAD s/p CABG \n (lima-lad, svg-om), dCHF, AF with multiple recent hospitalizations\n ( valvuloplasty, hemicolectomy for adenoCA, c diff colitis,\n diverticulitis. Admitted after seizure which stopped with ativan\n and keppra. Diuretics were held on admission. She was treated initially\n for meningitis. CTA was negative for CVA. MRI head with high signal\n intensity in the R superior parietal lobe. After MRI on she\n triggered for AMS and lethargy. Her HR was in the 130s and her SBP was\n in the 80s. Her ABG was notable for pCO2 65. She was given lasix 10mg\n IV then 30mg and 5mg IV metoprolol without significant improvement.\n Aortic stenosis\n Assessment:\n remains in a-fib w hr 86-100. Occassional pvc\ns noted. @ 03:30 had 8\n beat run of VT. Sbp 98-115 w maps 58-67. Bilat lower ext edema noted\n thighs to knee @ 2mm. Initialy received pt on open humidified face\n mask 40%. Sats 89%. RR 20\ns. k+ 3.8. drops sats (pt pulling off FM) RA\n sats 88%. u/o 40-100cc/hr\n Action:\n On lasix gtt initially @ 5mg/hr (gentle diuresis in light of\n AS)\n @ 2300 lasix gtt to off d/t sbp down to 90)\n Resumed lasix gtt @ 0300 for u/o 20-25cc/hr\n K+ repleted w 20meq kcl\n Receiving Metoprolol iv 15mg Q 4/hr (unable to take po\n Mask chg to closed FM , Fio2 ^ 100%, than titrated down to\n 70%\n Response:\n Improving HR after Metoprolol dosing\n Improving sats after ^ fio2\n u/o back to 50cc/hr after resuming Lasix gtt\n creat 1.0\n Plan:\n Con\nt lasix gtt\n Cxr today\n Seizure, without status epilepticus\n Assessment:\n No obvious seizure activity noted. Pt is arousable to voice. Oriented\n x1-2. Following all commands. Pupils 2mm/brisk and equal. Attempting to\n pull off mask.\n Action:\n Received Levetiracetam 750mg iv\n Feq neuro s/s\n Re-oreint as needed\n Soft wrist restraints order and applied.\n Released per protocol.\n Freq reminders to leave mask on face\n Response:\n No seizure activity noted\n Plan:\n Con\nt Keppra\n Monitor freq neuro checks.\n Pneumonia, aspiration\n Assessment:\n temp max 101.8 R. Pt has congested cough. BS rhonchi bilat in ^ fields.\n Crackles and exp wheezes noted in lower bases. WOB ^ w repositioning\n and coughing. Pt denies sob and RR back to baseline after resting.\n Cough becoming stronger, however pt unable to raise secretions. Able to\n cough and raise x1 but spit secretions on mask. Raising thick tan\n secretion. (unable to get spec). Drops sats on RA (pulled off mask) to\n 88%. Abg on eves (likely venous)\n Action:\n Aggressive C&DB\n Started on IS\n Received Cefipime/Flagyl iv\n MD notifed on ^ temp (last pan cult )\n Tylenol 650mg PR\n Gentle CPT\n Repositioning q2/hr\n Hob ^ 45/degrees\n Has remained NPO. Held po meds md order\n Open FM chg to closed humidified mask.\n Fio2 ^ from 40% to 70%\n Alb/Atrovent nebs q/6/hr\n Response:\n Cough becoming stronger\n Sats improved w ^ fio2 and pulm hygiene\n Plan:\n Needs speech/swallow study\n Needs sputum culture\n Con\nt pulm hygiene\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402762,
"text": "86F severe AS (critical AS s/p valvuloplasty ), CAD s/p CABG \n (lima-lad, svg-om), dCHF, AF with multiple recent hospitalizations\n ( valvuloplasty, hemicolectomy for adenoCA, c diff colitis,\n diverticulitis. Admitted after seizure which stopped with ativan\n and keppra. Diuretics were held on admission. She was treated initially\n for meningitis. CTA was negative for CVA. MRI head with high signal\n intensity in the R superior parietal lobe. After MRI on she\n triggered for AMS and lethargy. Her HR was in the 130s and her SBP was\n in the 80s. Her ABG was notable for pCO2 65. She was given lasix 10mg\n IV then 30mg and 5mg IV metoprolol without significant improvement.\n Aortic stenosis\n Assessment:\n remains in a-fib w hr 86-100. Occassional pvc\ns noted. @ 03:30 had 8\n beat run of VT. Sbp 98-115 w maps 58-67. Bilat lower ext edema noted\n thighs to knee @ 2mm. Initialy received pt on open humidified face\n mask 40%. Sats 89%. RR 20\ns. k+ 3.8. drops sats (pt pulling off FM) RA\n sats 88%. u/o 40-100cc/hr\n Action:\n On lasix gtt initially @ 5mg/hr (gentle diuresis in light of\n AS)\n @ 2300 lasix gtt to off d/t sbp down to 90)\n Resumed lasix gtt @ 0300 for u/o 20-25cc/hr\n K+ repleted w 20meq kcl\n Receiving Metoprolol iv 15mg Q 4/hr (unable to take po\n Mask chg to closed FM , Fio2 ^ 100%, than titrated down to\n 70%\n Response:\n Improving HR after Metoprolol dosing\n Improving sats after ^ fio2\n u/o back to 50cc/hr after resuming Lasix gtt\n creat 1.0\n Plan:\n Con\nt lasix gtt\n Cxr today\n Seizure, without status epilepticus\n Assessment:\n No obvious seizure activity noted. Pt is arousable to voice. Oriented\n x1-2. Following all commands. Pupils 2mm/brisk and equal. Attempting to\n pull off mask.\n Action:\n Received Levetiracetam 750mg iv\n Feq neuro s/s\n Re-oreint as needed\n Soft wrist restraints order and applied.\n Released per protocol.\n Freq reminders to leave mask on face\n Response:\n No seizure activity noted\n Plan:\n Con\nt Keppra\n Monitor freq neuro checks.\n Pneumonia, aspiration\n Assessment:\n temp max 101.8 R. Pt has congested cough. BS rhonchi bilat in ^ fields.\n Crackles and exp wheezes noted in lower bases. WOB ^ w repositioning\n and coughing. Pt denies sob and RR back to baseline after resting.\n Cough becoming stronger, however pt unable to raise secretions. Able to\n cough and raise x1 but spit secretions on mask. Raising thick tan\n secretion. (unable to get spec). Drops sats on RA (pulled off mask) to\n 88%. Abg on eves (likely venous)\n Action:\n Aggressive C&DB\n Started on IS\n Received Cefipime/Flagyl iv\n MD notifed on ^ temp (last pan cult )\n Tylenol 650mg PR\n Gentle CPT\n Repositioning q2/hr\n Hob ^ 45/degrees\n Has remained NPO. Held po meds md order\n Open FM chg to closed humidified mask.\n Fio2 ^ from 40% to 70%\n Alb/Atrovent nebs q/6/hr\n Response:\n Cough becoming stronger\n Sats improved w ^ fio2 and pulm hygiene\n Plan:\n Needs speech/swallow study\n Needs sputum culture\n Con\nt pulm hygiene\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405305,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with anasarca, oliguric. Elevated BUN/Cr, K. metabolic acidocis.\n Action:\n Monitored, BUN/Cr, pt receiving zaroxalyn, bumex.\n Response:\n Minimal response to diuretics. Remains with low u/o.\n Plan:\n Continue to monitor. Team aware of low urine output.\n Seizure, without status epilepticus\n Assessment:\n No sz activity noted this shift. Pt unresponsive to nailbed pressure\n does not withdraw. PERRL. No spontaneous movement. +corneals. Noted\n to grimace with oral care and pt refuses to open mouth.\n Action:\n Monitored, neuro assessments, dilantin as ordered. Heparin gtt on hold\n today for LP to be done this afternoon.\n Response:\n No sz activity noted. Pt appears comfortable at rest.\n Plan:\n Continue to monitor, continue neuro assess and anticonvulsants as\n ordered. Neuro on consult. Plan for reassessment of neuro status on\n wed\n family meeting regarding plan of care wed.\n Aortic stenosis\n Assessment:\n Pt in a fib with rare PVC noted. Sbp 90\ns-130. tolerating lopressor\n dose. Poor response to diuretics. Continues on heparin gtt. Remains\n vented on AC today. Low 90% sats. Sx tan secretions.\n Action:\n Heparin gtt on hold this afternoon\n awaiting LP for this afternoon.\n Response:\n LP not done this afternoon/evening\n Heparin restarted at 1350units/hr.\n Plan:\n Recheck PTT at 1am.\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-12 00:00:00.000",
"description": "Intensivist Note",
"row_id": 404405,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. At time of SICU admission, she\n responded only to painful stimuli.\n Chief complaint:\n Seizures\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n Acetaminophen 7. Albuterol 0.083% Neb Soln 8. Albuterol Inhaler 9.\n Aspirin\n 10. Atorvastatin 11. Bacitracin-Polymyxin Ointment 12. Calcium\n Gluconate 13. Chlorhexidine Gluconate 0.12% Oral Rinse\n 14. Collagenase Ointment 15. Dextrose 50% 16. Digoxin 17. Famotidine\n 18. Fentanyl Citrate 19. FoLIC Acid\n 21. Gabapentin 22. Glucagon 23. 24. Insulin 25. Ipratropium Bromide MDI\n 26. Ipratropium Bromide Neb\n 27. Latanoprost 0.005% Ophth. Soln. 28. Levothyroxine Sodium 29.\n LeVETiracetam 30. Lidocaine 5% Patch\n 31. Lorazepam 32. Magnesium Sulfate 33. Metoprolol Tartrate 34.\n Miconazole Powder 2% 35. Nystatin Oral Suspension\n 36. PHENObarbital 37. Phenytoin Sodium (IV) 38. Phenytoin Sodium (IV)\n 39. Phenylephrine 40. Potassium Chloride\n 41. Sodium Chloride 0.9% Flush 42. Sodium Chloride 0.9% Flush 43.\n Sodium Chloride 0.9% Flush 44. Sodium Chloride 0.9% Flush\n 45. Timolol Maleate 0.5%\n 24 Hour Events:\n Cont oliguria in spite of albumin. Renal consult called. Ultrasound\n obtained (WNL). INR supratherapeutic. keppra 250\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:23 PM\n Ciprofloxacin - 12:02 AM\n Infusions:\n Phenylephrine - 0.9 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Dilantin - 12:45 AM\n Other medications:\n Flowsheet Data as of 03:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 36.9\nC (98.5\n HR: 89 (75 - 93) bpm\n BP: 127/56(81) {108/49(69) - 139/64(92)} mmHg\n RR: 21 (17 - 21) insp/min\n SPO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 96.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 14 (13 - 21) mmHg\n Total In:\n 1,986 mL\n 214 mL\n PO:\n Tube feeding:\n 842 mL\n 119 mL\n IV Fluid:\n 984 mL\n 95 mL\n Blood products:\n 100 mL\n Total out:\n 389 mL\n 41 mL\n Urine:\n 189 mL\n 41 mL\n NG:\n Stool:\n 200 mL\n Drains:\n Balance:\n 1,597 mL\n 173 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 27 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 8.7 L/min\n Physical Examination\n General Appearance: Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), + murmur\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous : ,\n Diminished: )\n Abdominal: Soft, Non-distended, Obese\n Left Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n delayed response to noxious stimuli\n Labs / Radiology\n 368 K/uL\n 9.2 g/dL\n 120 mg/dL\n 2.5 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 70 mg/dL\n 105 mEq/L\n 140 mEq/L\n 30.4 %\n 10.4 K/uL\n [image002.jpg]\n 06:36 PM\n 03:33 AM\n 09:41 AM\n 04:39 PM\n 04:06 AM\n 06:15 PM\n 02:54 AM\n 03:18 AM\n 02:38 AM\n 10:24 AM\n WBC\n 11.3\n 10.4\n 9.7\n 9.7\n 10.4\n Hct\n 26.9\n 25.8\n 30.1\n 29.7\n 30.4\n Plt\n 81\n 368\n Creatinine\n 1.7\n 2.0\n 2.1\n 2.2\n 2.2\n 2.5\n 2.5\n TCO2\n 30\n 30\n 22\n Glucose\n 122\n 116\n 121\n 107\n 120\n Other labs: PT / PTT / INR:33.5/35.4/3.4, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:60/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca:7.7 mg/dL, Mg:2.0 mg/dL, PO4:2.2 mg/dL\n Imaging: Renal US: no hydronephrosis. mild ascites\n CT head: No acute ICH. Small ovoid hypodensity in R parietal lobe\n corresponds to area demonstrating old blood seen on MRI of . New\n opacification of L anterior ethmoid air cells and increased\n opacification of L mastoid air cells.\n CXR: Cardiomegaly, prominent pulmonary vasculature, and bibasilar\n atelectasis is unchanged.\n MR: Focal area w/high signal intensity @ R sup parietal lobule, no\n mass effect and may represent a chronic hemorrhagic area. Subcortical\n areas w/high signal intensity on T2 and FLAIR c/w chronic microvascular\n ischemic changes. Tortuosity of basilar artery, cw dolichoectasia\n Echo: EF >= 60%, Symmetric LVH, Significant AS, Trivial MR (may be\n significantly UNDERestimated), Mild [1+] TR. Mild PA systolic HTN\n CTA: No acute infarct or hemorrhage. Severe atherosclerotic\n narrowing of distal R vertebral art and moderate-to-severe narrowing of\n b/l cavernous ICAs. Small focus of calcification in Basilar A. close to\n the tip. Moderate microangiopathic ischemic white matter dz\n Microbiology: UCx: Yeast, >100,000\n BCx x2 neg\n BCx x2 p\n UCx: Yeast 10-100,000\n & Cdiff: Neg\n Sp Cx: 1+ Yeast\n Assessment and Plan\n INEFFECTIVE COPING, RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n KNOWLEDGE DEFICIT, IMPAIRED SKIN INTEGRITY, PNEUMONIA, ASPIRATION,\n AORTIC STENOSIS, SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension requiring\n phenylephrine.\n Neurologic: -- Patient sedated with minimal doses intermittent fentanyl\n prn.\n -- Patient with seizures, loaded with dilantin and ativan PRN prior to\n admission with poor mental status. Despite loading dose continued to\n have sub clinical seziures on EEG. Medication regimen changed,\n currently on phenytoin (Goal 15-20), Keppra and now phenobarbitol.\n --Continue neurontin for chronic pain well controlled on current\n medication.\n --Delayed Withdraws to pain in all extremities\n -- phenobarb and phenytoin levels are theraputic\n Cardiovascular: -- PAF with good control of HR on beta blockade and\n digoxin. Anticoagulation started with coumadin. No heparin bridge for\n risk of rebleed. On ASA\n -- CAD s/p CABG , diastolic dysfunction. On b-blockade,\n furosemide, ASA, and statin.\n -- Critical AS (valve area pre-valvuloplasty 0.8cm2, post\n vavluloplasty). On ICU-based ECHO estimated area is 0.6cm2. Likely not\n eligible for open valve replacement. Family is discussing this issue\n with another cardiologist\n Pulmonary: --albuterol/atrovent PRN\n -- trach \n Gastrointestinal / Abdomen: --TFs at goal, PEG \n Nutrition: Tube feeding\n Renal: -- Lasix held\n -- Creatinine increasing 1.5-1.7->2.1.->2.2->2.5\n -- Cipro for UTI, started , f/up repeat Cx\n -- Fe urea - 16.3%\n -- Pt still requires neosynephrine for MAPs > 65\n -- Albumin given w/no improvement in urine output\n -- renal recs: ATN (muddy brown casts), would not diurese, or give IVF;\n do not oliguria. need dialysis in future (gentle CVVH).\n Hematology: --Hct slowly decreasing, 25.8--> tx 2u prbcs on\n ->29.7->30.4-> P\n --ASA, coumadin (2/5/5/3/1) Hold coumadin today INR level 3.4\n - A. Fib anticoagulation with coumadin, INR 3.4 (goal ), last dose\n , will start hep gtt to bridge for trach/PEG Monday (have\n contact Dr. \n Endocrine: --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg for hypothyroidism\n Infectious Disease: --Wbc 9.4-->10.4--> P\n --completed cefepime vanc 7 day course\n --UA positive foley changed patient received 3 days cours of\n antibiotics last dose 03/16\n --Follow cultures\n Lines / Tubes / Drains: PIV, Foley, CVL (), ETT, NGT\n Wounds:\n Imaging: none\n Fluids: KVO\n Consults: Neurology, Nephrology\n Billing Diagnosis: Other: status epilepticus, respiratory failure, ATN\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 07:52 PM 35 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: Boots (Supratherapeutic with coumadin, plan for hep gtt once INR\n decreases)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-15 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404714,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: pt had a 3 8.0 percutaneous trach placed this PM @ ~\n 1500hrs\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Bedside tracheostomy (1500hrs)\n Comments:\n Pt trached today and is presently in the recovery period to allow the\n sedation and paralytics to wear off. Should go back to\n PSV soon..\n, RRT 17:16\n"
},
{
"category": "General",
"chartdate": "2196-02-20 00:00:00.000",
"description": "Generic Note",
"row_id": 405122,
"text": "TITLE:\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr. \n I would add the following remarks:\n History\n Pupils reactive to light; opens eyes to deep stimulation\n Marked peripheral edema but creatinine steady at 3.7.\n Poor response to diuretics\n Medical Decision Making\n Trial of bumex 2 mg\n Reduce dosage of Phenobarbital to 15 mg today then off on Monday\n No acute need for dialysis\n Above discussed extensively with family member, next of or health\n care proxy.\n Total time spent on patient care: 30 minutes of critical care time.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404003,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n This am on open face mask, FiO2 70%, 10L.\n O2 SATs 90-94%.\n Pt with RR in the 30\ns and 40\n Shallow, abdominal breathing.\n Rhonchi throughout. Nasal Suctioned for moderate thick yellow\n secretions.\n ABG pH 7.30/ CO2 61.\n Pt mildly responsive only to painful stimuli.\n U/O very minimal < 10 cc/hr.\n MD aware and at bedside throughout events.\n Action:\n Bipap initiated.\n Pt continues in RR 30-40\ns, O2 SAT 99-100%,\n With family at bedside, SICU Resident, Neurology Resident and RN\n explain the need for intubation. Family asked to decide what pt would\n want given current status.\n Pt intubated, anesthesia intubates and sedates.\n Response:\n ABG s/p 7.31, CO2 55.\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404004,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n This am on open face mask, FiO2 70%, 10L.\n O2 SATs 90-94%.\n Pt with RR in the 30\ns and 40\n Shallow, abdominal breathing.\n Rhonchi throughout. Nasal Suctioned for moderate thick yellow\n secretions.\n ABG pH 7.30/ CO2 61.\n Pt mildly responsive only to painful stimuli.\n U/O very minimal < 10 cc/hr.\n MD aware and at bedside throughout events.\n Action:\n Pap initiated.\n Pt continues in RR 30-40\ns, O2 SAT 99-100%,\n With family at bedside, SICU Resident, Neurology Resident and RN\n explain the need for intubation. Family asked to decide what pt would\n want given current status.\n Pt intubated, anesthesia intubates and sedates.\n Neo initiated r/t BP drop s/p sedation.\n AM PO lasix held r/t elevated BUN/Creat. And low SBP.\n Albumin as ordered.\n AM Lasix given @ 1600 MD .\n Response:\n ABG s/p 7.31, CO2 55.\n Pt more responsive to tactile stimuli.\n Regular respirations.\n Plan:\n Continue to monitor ABG\n Chest PT.\n Continue strict I&O\ns. Wean Neo off. ? Fluid boluses.\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 403005,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 10:12 PM\n temp 101 R\n URINE CULTURE - At 10:12 PM\n temp 101 R,blood and urine cultures sent, defervesced to 99.\n Pyuria noted on UA. culture data pending.\n Continues on vanc/cefepime/flagyl started for aspiration PNA.\n Diarrhrea?\n -C. diff toxin negative\n -She continues on a lasix drip for diuresis which was uptitrated from\n to with goal UOP 500cc which she did not achieve, putting out approx\n /hr\n and ended up running even. She was able to maintain her BP's in the low\n 100's systolic and remained rate controlled for her afib.\n -\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Cefipime - 08:13 PM\n Vancomycin - 08:47 PM\n Metronidazole - 05:30 AM\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.2\nC (99\n HR: 85 (75 - 107) bpm\n BP: 113/55(70) {95/39(53) - 145/74(96)} mmHg\n RR: 17 (12 - 27) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 81.2 kg (admission): 80.1 kg\n Total In:\n 1,770 mL\n 421 mL\n PO:\n 400 mL\n 50 mL\n TF:\n IVF:\n 1,370 mL\n 371 mL\n Blood products:\n Total out:\n 1,730 mL\n 650 mL\n Urine:\n 1,730 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 40 mL\n -229 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///36/\n Physical Examination\n Gen:comfortable\n CVS: 4/6 SEM heard best at RUSB, radiating throughout precordium, S1 S2\n clear\n Resp Mouth breathes, but no longer retracting, bilateral crackles,\n moderately improved, no wheeze, wet cough, unable to clear\n Abd: +bs, soft, NT, nD\n Ext: WWP, 2+ distal pulses,\n Neuro: new anisicoria, with R from and L from with light, left\n sided weakness stable\n Able to follow commands, Alert and oriented to person and place,\n disoriented to time, overall improved.\n Venous stasis ulcers with bandaging to mid shin/C/DI\n Labs / Radiology\n 323 K/uL\n 8.7 g/dL\n 109 mg/dL\n 1.1 mg/dL\n 36 mEq/L\n 3.9 mEq/L\n 22 mg/dL\n 101 mEq/L\n 141 mEq/L\n 30.7 %\n 7.0 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n 02:18 PM\n 05:28 AM\n 02:25 PM\n 09:34 PM\n 04:56 AM\n WBC\n 11.7\n 9.9\n 8.2\n 7.0\n Hct\n 34.7\n 30.6\n 30.0\n 30.7\n Plt\n 23\n Cr\n 0.8\n 1.0\n 1.0\n 1.0\n 1.2\n 1.1\n 1.1\n TropT\n 0.02\n TCO2\n 34\n 35\n Glucose\n 107\n 87\n 85\n 113\n 137\n 153\n 109\n Other labs: PT / PTT / INR:15.9/32.2/1.4, CK / CKMB /\n Troponin-T:15//0.02, ALT / AST:, Alk Phos / T Bili:62/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca++:8.2 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n KNOWLEDGE DEFICIT\n IMPAIRED SKIN INTEGRITY\n PNEUMONIA, ASPIRATION\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures on who had MS\n change first noted following MRI, likely having suffered an aspiration\n event, who subsequently went into afib and flashed on the floor in the\n setting of holding her metoprolol and Lasix.\n # Pulmonary Edema: The patient has a history of severe AS and developed\n pulmonary edema in the setting of having her diuretics held on\n admission. Also noted to have RLL collapse on CXR Overall her\n respiratory status has improved greatly since transfer to the CCU\n initially requiring humidified face mask, now on 2L NC o/n. UOP has\n been guiding diuresis, goal had been set to diurese 500cc y,d with\n Lasix gtt uptitrated from 10- 20, running mostly even, over last few\n hours has now been negative ~200cc, now responding. Continues to need\n diuresis given respiratory exam, LE edema both of which improved and\n her renal function in tolerating diuresis. Unable to obtain sputum cx\n as pt cannot clear cough.\n -Wean 02 as tolerated.\n - continue lasix drip, titrating as needed\n -continue atrovent nebs, with dextromorphan PRN cough\n -Goal UOP 500cc/day\n - repeat CXR today\n - lytes.\n # Possibly Aspiration PNA: Low grade fever to 100.3 on admission, now\n febrile to 101 o/n. Was pan cultured. UA showed pyuria. Currently on\n vanc/cefepime/flagyll. consider adding zosyn.\n - continue vanc/cefepime/flagyll\n -repeat CXR\n -f/u UCx with s/s\n - trend WBC and fever curves\n -f/u blood cx.\n # Afib: Pt in Afib with RVR on arrival, in the setting of not receiving\n her metoprolol. Restarted on IV metoprolol on arrival to the CCU. Now\n s/p transition to PO metprolol.\n -In fib with rate well controlled in 80s\n - continue to monitor on telemetry\n # AS: AS s/p valvuloplasty .Severe AS on Echo . AS known\n critical, unclear if worsened AS since as valve area not quantified\n but known to be critical. Pt poor surgical candidate thus had not\n received AVR.\n - consideration being given for minimally invasive\n percutaneous valve replacement once medically stable.\n -\n # MS Change: Likely multifactorial related to benzodiazepine, ?stroke,\n respiratory status/hypercarbia on admission. Anisicoria noted on exam\n today, may be recent neb treatment.\n - ASA 81mg\n -In fib with rate contro serial neuro exams.\n -f/u with neuro continued consultation.\n - keppra for seizure prophylaxis.\n - avoid benzos\n - follow resp status, serial ABGs.\n - diuresis and antibiotics as above\n - MRI when stable, per neuro recs\n # Hx Diarrhea: Hx C.diff on chronic suppression therapy with p.o\n vanc/flagyl with last cx at rehab on negative. At that\n time, antibiotics were continued. However diarrhea has stopped so abx\n stopped this hospitalization.\n -c.diff negative.\n can continue to monitor\n # hx GI bleed: Hematocrit stable this morning\n - continue to trend hematocrit\n #Leg Ulcers: per wound care, ? if venous stasis vs autoimmune\n -rheum consult following ICU stabilization.\n # Nutrition: Pt now on crushed meds with apple sauce, nectar thickened\n liquids, lactose intolerant.\n -consult speech and swallow today re p.o intake now that MS improved.\n L\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:01 AM\n Prophylaxis:\n DVT: TEDS/OOB and amb.\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Possible transfer to floor\n ------ Protected Section ------\n Chart reviewed. Patient interviewed and examined. Discussed on CCU\n rounds with team. I agree with Dr. \ns H+P, A+P. ICU level\n care due to severe AS, PNA, compromised respiratory status and\n intermittent hypotension. Total time on ICD level care: 45 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 14:30 ------\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404202,
"text": "Seizure w/ status epilepticus\n Assessment:\n Pt unarouseable w/ eyes closed, pupils 3-4mm equal/brickly\n reactive\n MAE to nailbed pressure. Grimacing noticed and moving of\n head. Occassional spontaneous movement of right foot\n Intubated on CMV w/o sedation\n Cont EEG. No seizures noted. Evening Dilantin level 8.2\n Phenylephrine gtt titrated to goal of SBP >100 MAP >60\n Tele in A-fib w/ occasional PVCs. Systolic murmur\n loud/audible. Continues on Coumadin/Digoxin/Metoprolol\n Received 2uPRBC on day shift to assist w/ preload and HCT\n bumped accordingly\n u/o . SICU made aware. Evening lytes wnl and Cr 2.2.\n Received home dose of Lasix on day shift\n Right nare dobhoff w/ Nutren 2.0 Full w/ Benepro @35cc/hr\n Generalized edema noted\n Blood cx pending last pan cx . PICC d/c\nd and tip\n sent for cx. RIJ oozing team aware on Coumadin\n Action:\n Neuro checks Q2hrs\n Dilantin 500mg IV given to assist w/ goal of 15-20\n EEG reviewed my N-med overnoc\n Completed IVABX for Asp PNA.\n Response:\n Neuro checks w/o change\n Unable to wean Neo gtt requires 0.5-0.6mcg/kg/min\n Dilantin level 10.7 and Phenobarb 18.1 Neuro-med aware.\n Dilantin Trough before next dose\n Apnea noted w/ RSBI\n Plan:\n Neuro checks Q2hrs, EEG, ? MRI once off EEG\n Wean Neo as tolerated\n CXR pending\n Reassess code status/plan of care (Trach/PEG) on Friday\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404311,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments/Plan\n No vent changes overnight, remains supported on PSV/CPAP. No\n spontaneous RR w/ RSBI. See flowsheet for further pt data. Will\n follow.\n 04:42\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404713,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient continues to be minimally responsive today. She will withdraw\n her upper extremities to painful stimuli. She continues to be on a neo\n infusion to support her blood pressure. She continues to be oliguric\n and her serum creat. Is 3.2 today.\n Action:\n INR was reversed today with FFP for a bedside trach and PEG. Trach and\n PEG were placed.\n Response:\n She appeared to tolerate the procedure well.\n Plan:\n Leave patient NPO until tomorrow. Continue to provide supportive care\n as antiseizure meds are weaned.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-20 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 405124,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405125,
"text": "Chief Complaint:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 10:40 AM\n MRI of head\n -Per neuro, amount of phenytoin is so low, would not contribute to\n seizures. Given had seizures this admit, loaded her with phenytoin\n 800mg x1 and continue maintenance dose 30 mg , and check levels\n daily starting tomorrow. Neuro said MRI unremarkable, stable blood\n products seen before. Recommend LP for ? paraneoplastic syndrome ? vs\n carcinomatous meningitis (that could trigger a cortical vein bleed:\n there is a known bleed since initial MRI at admission).\n -Did not respond to diuretics y/d, started lasix drip with one-time\n dose of metolazone given, Cr worsened from 3.6 to 3.8 UOP 17 cc/hr by\n 7pm (no different than before Lasix gtt); Lasix drip was stopped\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:15 PM\n Dilantin - 06:41 PM\n Famotidine (Pepcid) - 07:27 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 94 (83 - 99) bpm\n BP: 121/56(80) {93/43(61) - 132/63(89)} mmHg\n RR: 23 (17 - 27) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 104.8 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 12 (8 - 18)mmHg\n Total In:\n 1,550 mL\n 519 mL\n PO:\n TF:\n 845 mL\n 241 mL\n IVF:\n 386 mL\n 148 mL\n Blood products:\n Total out:\n 466 mL\n 144 mL\n Urine:\n 466 mL\n 144 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,084 mL\n 375 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 368 (325 - 392) mL\n PS : 15 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 192\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: 7.34/40/147/19/-3\n Ve: 7.4 L/min\n PaO2 / FiO2: 294\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n LUNGS: Ventilated breath sounds. Unable to hear good breath sounds at\n the bases.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal stimuli. Minimal response to\n painful stimuli. PERRL. No oculovestibular reflex.\n Labs / Radiology\n 402 K/uL\n 8.2 g/dL\n 122\n 3.7 mg/dL\n 19 mEq/L\n 4.8 mEq/L\n 115 mg/dL\n 103 mEq/L\n 136 mEq/L\n 26.8 %\n 6.7 K/uL\n [image002.jpg]\n 02:44 AM\n 02:34 AM\n 02:04 PM\n 02:23 PM\n 03:16 AM\n 05:36 PM\n 10:00 PM\n 01:52 AM\n 04:00 AM\n 04:07 AM\n WBC\n 7.4\n 7.4\n 6.8\n 6.7\n Hct\n 25.6\n 26.1\n 26.1\n 26.8\n Plt\n 436\n 469\n 472\n 402\n Cr\n 3.6\n 3.6\n 3.6\n 3.6\n 3.8\n 3.7\n TCO2\n 21\n 23\n Glucose\n 96\n 132\n 130\n 108\n 136\n 98\n 105\n 122\n Other labs: PT / PTT / INR:18.3/64.1/1.7, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU. Continues to be\n severely fluid overloaded and oliguric, positive 30L Los. She does not\n respond well to lasix/diuril but is also not a candidate for HD.\n -will try 2mg bumex to see if pt puts out urine to this\n - lytes\n -monitor volume status, UOP.\n -holding off on valvuloplasty at this point\n .\n # Atrial Fibrillation: Pt has good control of HR on beta blockade and\n digoxin. Coumadin was being held before for trach/PEG. Now, holding\n coumading in case pt undergoes valvuloplasty. Now on heparin gtt while\n INR subtherapeutic.\n - continue heparin gtt\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - trend coags\n .\n # Acute Renal Failure: Creatinine 3.7 today. Per previous notes, renal\n believes that this is ATN\n - will attempt diuresis with bumex, as above\n - appreciate renal recs.\n - continue to monitor fluid status otherwise\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol. Neuro not sure what is causing continued depressed\n mental status, states she is not having active seizures on EEG. MRI did\n not show any acute changes.\n - continue phenytoin and Phenobarbital, adjusting per neuro recs\n - Decrease phenobarbital to 15 mg today, decrease to further in 2\n days.\n - appreciate neuro recs\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Respiratory Failure: Now, s/p trach.\n - trach in place\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Pt weaned off of pressors.\n .\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n .\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - f/u cx data\n - follow fever curve\n - f/u stool for c.diff\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:34 AM 35 mL/hour\n Glycemic Control: Comments: ISS\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-20 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 405126,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt creatinine 3.6, stabilized. Urine output 15-25 per hour. Remains\n grossly generally edematous. Serum lytes WNL. 200 mg lasix bolus given\n yesterday, gtt started without success.\n Action:\n Administered bumex to attempt more successful diuresis than lasix. Dose\n administered 2 mg, which is equivalent to 80 mg of lasix.\n Response:\n Awaiting pt response to bumex.\n Plan:\n Hold HD for now, until prognosis of pt\ns neuro status more clear\n Impaired Skin Integrity *PT ALLERGIC TO ADAPTIC*\n Assessment:\n Pt has multiple areas of skin integrity issues. This is a long \n problem as pt has been seen by visiting nurse for various venous stasis\n ulcers long term; pts acute edema has worsened her preexisting skin\n issues. See metavision for more substantial details. In summary:\n - DTI on coccyx and LLE. Coccyx is red but blanchable\n throughout it. Flexiseal in place for stool mgmt\n - Bilat LE venous ulcers\n - Excoriated areas beneath abdominal pannus\n - Healing area of impaired skin next to PEG site\n attempted PEG site\n - Eschar covered abrasion on R 1^st toe\n Action:\n - See metavision for specific treatments. One change this writer\n instituted was to add aquacel to her venous stasis dsgs. Waffle boots\n maintained on, heels have no pressure to them whatsoever. Frequent skin\n checks\n Response:\n - Skin unchanged.\n Plan:\n - Continue skin assessment and treatments.\n Seizure, without status epilepticus\n Assessment:\n Pt without seizure activity X 4 days per neuro. Dilantin loaded\n overnight. Dilantin level low so plan to reload this afternoon. Pt\n unresponsive except occasional flickering of eyes to voice, flexion to\n pain in all extremities, PERRL. + corneals. No s/s seizure activity\n noted\n Action:\n Team wrote to lower phenobarb today to 15\n first dose at that amount\n to be administered this evening. Sunday she will get 15 then it\n shall be discontinued Monday.\n Response:\n Pt remains without seizure activity thus far\n Plan:\n Continue to monitor pt, cont EEG. Will have better picture of pts true\n neuro status once phenobarb clears\n Aortic stenosis\n Assessment:\n Heparin gtt within therapeutic range. Metoprolol ATC as ordered.\n Remains in afib 70-90, few PVCs noted.\n Action:\n Medications as ordered.\n Response:\n Pt clinical assessment unchanged\n Plan:\n Valvuloplasty tentatively planned for Monday in interventional\n radiology.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt 30L total body balance positive, Lung sounds clear, diminished in\n bases. Trached 38 portex. Remains on CPAP 15/5. 50% Fi02, minimal\n secretions via suctioning. + cough but impaired/absent gag. Trach site\n with sutures intact, site looks clean/minimal drainage. RR 17-22, sats\n >97%\n Action:\n Monitored patient, administered bumex to attempt to remove fluid, trach\n care\n Response:\n Pt remains on vent settings.\n Plan:\n Attempt to remove fluid before attempt to wean pressure support.\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405171,
"text": "Chief Complaint:\n 24 Hour Events:\n Overnight Events:\n - decreased phenobarb to 15 \n - neuro recommended 800 bolus of dilantin again and to check level in\n AM\n - gave bumex with no effect on UOP\n - moved to CCU\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.1\nC (96.9\n HR: 97 (81 - 103) bpm\n BP: 123/66(87) {99/48(66) - 144/70(97)} mmHg\n RR: 26 (10 - 30) insp/min\n SpO2: 89%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 104.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 24 (8 - 24)mmHg\n Total In:\n 1,667 mL\n 365 mL\n PO:\n TF:\n 841 mL\n 226 mL\n IVF:\n 566 mL\n 139 mL\n Blood products:\n Total out:\n 1,121 mL\n 105 mL\n Urine:\n 471 mL\n 105 mL\n NG:\n Stool:\n Drains:\n Balance:\n 546 mL\n 260 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 366 (366 - 421) mL\n PS : 15 cmH2O\n RR (Spontaneous): 22\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 24 cmH2O\n SpO2: 89%\n ABG: 7.33/38/133/20/-5\n Ve: 7.7 L/min\n PaO2 / FiO2: 266\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 462 K/uL\n 8.2 g/dL\n 126\n 3.8 mg/dL\n 20 mEq/L\n 4.7 mEq/L\n 120 mg/dL\n 102 mEq/L\n 136 mEq/L\n 26.6 %\n 7.4 K/uL\n [image002.jpg]\n 10:00 PM\n 01:52 AM\n 04:00 AM\n 04:07 AM\n 03:09 PM\n 09:07 PM\n 11:05 PM\n 03:53 AM\n 04:00 AM\n 04:12 AM\n WBC\n 6.7\n 7.4\n Hct\n 26.8\n 26.6\n Plt\n 402\n 462\n Cr\n 3.7\n 3.9\n 3.8\n TCO2\n 23\n 21\n 20\n 21\n Glucose\n 98\n 105\n 122\n 128\n 126\n 126\n Other labs: PT / PTT / INR:18.3/60.0/1.7, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:7.9 mg/dL, Mg++:2.4 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n INEFFECTIVE COPING\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n KNOWLEDGE DEFICIT\n IMPAIRED SKIN INTEGRITY\n PNEUMONIA, ASPIRATION\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 09:33 PM 35 mL/hour\n Glycemic Control: Comments: ISS\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-06 00:00:00.000",
"description": "Intensivist Note",
"row_id": 403824,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. At time of SICU admission, she\n responded only to painful stimuli.\n Chief complaint:\n Seizures\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n 1. IV access: Peripheral line Location: Right Order date: @ \n 19. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS Order date:\n @ \n 2. IV access: Peripheral line Order date: @ 20.\n Levothyroxine Sodium 75 mcg PO/NG DAILY Order date: @ \n 3. IV access: PICC, non-heparin dependent Location: Right Brachial,\n Date inserted: Order date: @ 21. LeVETiracetam 1000\n mg PO/NG Order date: @ \n 4. IV access: None Order date: @ 22. Lidocaine 5% Patch 2\n PTCH TD DAILY\n 12 h on 12 h off; apply one patch to each knee Order date: @\n \n 5. Acetaminophen 650 mg PR Q6H:PRN fever/pain\n please do not exceed 3000mg/day Order date: @ 23. Lorazepam\n 0.5-1 mg IV HS PRN Sz\n prolonged Sz > 3 minutes; Pls page neurology resident prior\n administering. Order date: @ 2213\n 6. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing Order date:\n @ 24. Magnesium Sulfate IV Sliding Scale Order date: \n @ 0638\n 7. Aspirin 81 mg PO/NG DAILY Order date: @ 25. Metoprolol\n Tartrate 25 mg PO/NG TID\n hold for HR<60 or BP<100 Order date: @ 0923\n 8. Atorvastatin 40 mg PO/NG DAILY Order date: @ 26.\n Miconazole Powder 2% 1 Appl TP PRN fungal infection Order date: \n @ \n 9. Bacitracin-Polymyxin Ointment 1 Appl TP Q6H:PRN wound Order date:\n @ 27. Neutra-Phos 2 PKT PO/NG Duration: 2 Days Order\n date: @ 2236\n 10. Calcium Gluconate IV Sliding Scale Order date: @ 0638 28.\n Nystatin Oral Suspension 5 mL PO QID:PRN \n swish and swallow Order date: @ \n 11. CefePIME 2 g IV Q24H\n Stop Order date: @ 0948 29. Phenytoin Sodium (IV) 100 mg\n IV Q8H Order date: @ 2157\n 12. Collagenase Ointment 1 Appl TP DAILY Order date: @ 30.\n Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAPs >60 Order date:\n @ 1434\n 13. Digoxin 0.0625 mg PO/NG DAILY Order date: @ 31.\n Potassium Chloride IV Sliding Scale Order date: @ 0638\n 14. FoLIC Acid 1 mg PO/NG DAILY Order date: @ 32. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ \n 15. Furosemide 40 mg PO/NG DAILY\n hold for BP <100 Order date: @ 33. Sodium Chloride 0.9%\n Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ \n 16. Gabapentin 100 mg PO/NG Order date: @ 34. Sodium\n Chloride 0.9% Flush 10 mL IV PRN line flush\n PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and\n PRN per lumen. Order date: @ \n 17. Heparin 5000 UNIT SC TID Order date: @ 35. Timolol\n Maleate 0.5% 1 DROP BOTH EYES DAILY Order date: @ \n 18. Ipratropium Bromide Neb 1 NEB IH Q6H Order date: @ 36.\n Vancomycin 750 mg IV Q 24H Start: when due pm of \n Stop Order date: @ 0949\n 24 Hour Events:\n Awaiting MRI, stable, family wishes to pursue aggressive treatment\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Dilantin - 12:05 AM\n Other medications:\n Flowsheet Data as of 06:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.1\nC (97\n HR: 97 (86 - 100) bpm\n BP: 109/47(71) {89/47(66) - 130/60(86)} mmHg\n RR: 23 (16 - 31) insp/min\n SPO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 87 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 5,747 mL\n 329 mL\n PO:\n Tube feeding:\n 4,677 mL\n 268 mL\n IV Fluid:\n 870 mL\n 62 mL\n Blood products:\n Total out:\n 940 mL\n 340 mL\n Urine:\n 940 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,807 mL\n -11 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 98%\n ABG: 7.35/53/87./30/1\n PaO2 / FiO2: 176\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Wheezes : , Crackles : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent, 2+)\n Right Extremities: (Edema: Absent, 2+)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Follows simple commands, (Responds to: Noxious\n stimuli), Moves all extremities\n Labs / Radiology\n 401 K/uL\n 8.9 g/dL\n 136 mg/dL\n 1.2 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 33 mg/dL\n 108 mEq/L\n 146 mEq/L\n 30.6 %\n 11.1 K/uL\n [image002.jpg]\n 04:56 AM\n 06:05 AM\n 06:37 PM\n 03:07 AM\n 04:56 PM\n 03:35 AM\n 03:52 AM\n 11:58 AM\n 08:32 PM\n 02:19 AM\n WBC\n 7.0\n 7.1\n 8.9\n 9.9\n 11.1\n Hct\n 30.7\n 32.7\n 30.6\n 30.5\n 30.6\n Plt\n 76\n 401\n Creatinine\n 1.1\n 1.1\n 1.3\n 1.3\n 1.3\n 1.2\n 1.2\n Troponin T\n 0.03\n TCO2\n 35\n 32\n 30\n Glucose\n 109\n 98\n 146\n 121\n 122\n 136\n Other labs: PT / PTT / INR:17.3/31.6/1.6, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:62/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:202 IU/L, Ca:7.4 mg/dL, Mg:1.8 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n KNOWLEDGE DEFICIT, IMPAIRED SKIN INTEGRITY, PNEUMONIA, ASPIRATION,\n AORTIC STENOSIS, SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD\n .\n Neurologic:\n -- Patient with seizures, loaded with dilantin and ativan prior to\n admission with poor mental status. Dilantin and Keppra for seziure\n prophylaxis, f/u AM level.\n --Follow up 24hr video EEG. Initial EEG - no seizures\n -- Continue neurontin for chronic pain well controlled on current\n medication.\n -- MRI brain w/ and w/o ordered for when pt is stable to transport.\n Concern about stability for this today.\n Cardiovascular:\n -- PAF with good control of HR on beta blockade and digoxin.\n -- Multiple medical cardiovascular problems. CAD s/p CABG but\n still diastolic dysfunction. She had AS (valve area 0.8cm2 on previous\n echo) but underwent valvuloplasty\n no gradient estimation after\n procedure.\n -- anticoagulation for A. Fib: On ASA and atorvastatin. No\n anticoagulation for now\n -- Neosynephrine 0.5 Will stim test . If negative, start\n midodrine.\n Pulmonary:\n --Treated empirically for aspiration pneumonia with Vanc/Cefepime but\n cultures are negative. We will continue treatment for full 7 days (to\n )\n --CXR stable on lasix 40 daily.\n --Chest PT and inhalers\n Poor airway protection- ? consider trach\n Gastrointestinal / Abdomen:\n --TFs@goal prior to admission, will hold given worsening pulmonary\n status. In future consider PEG tube placement.\n --CDiff has been negative and diarrhea has stopped, PO vanc has been\n stopped.\n Nutrition:\n --TF restarted via Dobhoff\n Renal:\n --Lasix dependent, continue Lasix 40 (decreased from 60 given Cr 1.3)\n PO/NG daily; was previously on lasix gtt, will continue to monitor\n --Increasing Cr, 0.8 on admission, currently 1.3. Fe urea = 27.65\n Hematology:\n --Hct stable\n --ASA, SQH\n -- D/w neurology when to resume anticoagulation after underlying mass,\n AVM are ruled out\n Endocrine:\n --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg for hypothyroidism, previous TSH was 6.8\n ID:\n --Wbc 8.8->9.9->11.1 afebrile\n --Being treated for PNA with cefepime/vanc (?aspiration) total course\n should be 7 days (ending )\n --Vanc trough 20.6 , dose decreased to 500mg IV q24hrs from 750\n --Follow cultures (NGTD except yeast in urine)\n T/L/D: PIV, Foley, PICC\n Wounds: none\n Imaging: CXR\n Fluids:\n Consults:\n Billing Diagnosis: status epilepticus\n Prophylaxis:\n DVT: SQH\n Stress ulcer: H2B\n VAP bundle: +\n Comments:\n Communication: ICU consent done\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404792,
"text": "Seizure, without status epilepticus\n Assessment:\n Patient remains unresponsive today. She continues to withdraw to\n painful stimuli and will breathe independently. Her renal failure\n continues to worsen, she remains oliguric.\n Action:\n Continue to use neo to support blood pressure. Continue to provide\n supportive care.\n Response:\n Blood pressure remains stable on neo.\n Plan:\n Plan to continue with supportive care and continue to wean anti seizure\n medication.\n"
},
{
"category": "Nutrition",
"chartdate": "2196-02-19 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 405053,
"text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 80.1 kg\n 104.8 kg ( 10:00 PM)\n 28.4\n Pertinent medications: RISS, digoxin, folic acid, famotidine, others\n noted\n Labs:\n Value\n Date\n Glucose\n 108 mg/dL\n 03:16 AM\n Glucose Finger Stick\n 155\n 10:00 AM\n BUN\n 114 mg/dL\n 03:16 AM\n Creatinine\n 3.6 mg/dL\n 03:16 AM\n Sodium\n 135 mEq/L\n 03:16 AM\n Potassium\n 5.0 mEq/L\n 03:16 AM\n Chloride\n 103 mEq/L\n 03:16 AM\n TCO2\n 17 mEq/L\n 03:16 AM\n PO2 (arterial)\n 99. mm Hg\n 02:23 PM\n PCO2 (arterial)\n 36 mm Hg\n 02:23 PM\n pH (arterial)\n 7.36 units\n 02:23 PM\n pH (urine)\n 5.0 units\n 05:33 PM\n CO2 (Calc) arterial\n 21 mEq/L\n 02:23 PM\n Albumin\n 2.7 g/dL\n 06:39 PM\n Calcium non-ionized\n 7.9 mg/dL\n 03:16 AM\n Phosphorus\n 4.8 mg/dL\n 03:16 AM\n Ionized Calcium\n 1.12 mmol/L\n 02:38 AM\n Magnesium\n 2.2 mg/dL\n 03:16 AM\n ALT\n 5 IU/L\n 03:33 AM\n Alkaline Phosphate\n 60 IU/L\n 03:33 AM\n AST\n 28 IU/L\n 03:33 AM\n Total Bilirubin\n 0.2 mg/dL\n 03:33 AM\n Triglyceride\n 98 mg/dL\n 04:27 AM\n Phenytoin (Free)\n 1.9 ug/mL\n 04:39 PM\n Phenytoin (Dilantin)\n 2.3 ug/mL\n 02:34 AM\n WBC\n 6.8 K/uL\n 03:16 AM\n Hgb\n 8.0 g/dL\n 03:16 AM\n Hematocrit\n 26.1 %\n 03:16 AM\n Current diet order / nutrition support: Tube Feed: Nutren 2.0 @ 35mL/hr\n (1680kcals, 67g protein)\n GI: PEG in place, abd soft, obese, bowel sounds present\n Assessment of Nutritional Status\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n Patient was trached and PEG\nd . Current tube feeds meet 100% of\n estimated needs, but a renal formula would be more appropriate given\n worsening renal failure.\n Medical Nutrition Therapy Plan - Recommend the Following\n Recommend change tube feed goal to Novasource Renal @\n 35mL/hr (1680kcals, 62g protein)\n If HD is started, recommend adding 21g Beneprotien to above\n tube feed. (1755kcals, 80g protein)\n Following - #\n 10:50\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405112,
"text": "Chief Complaint:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 10:40 AM\n MRI of head\n -Renal curbsided , recommended ethics consult.\n -Per neuro, amount of phenytoin is so low, would not contribute to\n seizures. Given had seizures this admit, loaded her with phenytoin\n 800mg x1 and continue maintenance dose 30 mg , and check levels\n daily starting tomorrow. Neuro said MRI unremarkable, stable blood\n products seen before. Recommend LP for ? paraneoplastic syndrome ? vs\n carcinomatous meningitis (that could trigger a cortical vein bleed:\n there is a known bleed since initial MRI at admission).\n -Did not respond to diuretics y/d, started lasix drip with one-time\n dose of metolazone given, Cr worsened from 3.6 to 3.8 UOP 17 cc/hr by\n 7pm (no different than before Lasix gtt); Lasix drip was stopped\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:15 PM\n Dilantin - 06:41 PM\n Famotidine (Pepcid) - 07:27 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 94 (83 - 99) bpm\n BP: 121/56(80) {93/43(61) - 132/63(89)} mmHg\n RR: 23 (17 - 27) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 104.8 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 12 (8 - 18)mmHg\n Total In:\n 1,550 mL\n 519 mL\n PO:\n TF:\n 845 mL\n 241 mL\n IVF:\n 386 mL\n 148 mL\n Blood products:\n Total out:\n 466 mL\n 144 mL\n Urine:\n 466 mL\n 144 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,084 mL\n 375 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 368 (325 - 392) mL\n PS : 15 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 192\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: 7.34/40/147/19/-3\n Ve: 7.4 L/min\n PaO2 / FiO2: 294\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 402 K/uL\n 8.2 g/dL\n 122\n 3.7 mg/dL\n 19 mEq/L\n 4.8 mEq/L\n 115 mg/dL\n 103 mEq/L\n 136 mEq/L\n 26.8 %\n 6.7 K/uL\n [image002.jpg]\n 02:44 AM\n 02:34 AM\n 02:04 PM\n 02:23 PM\n 03:16 AM\n 05:36 PM\n 10:00 PM\n 01:52 AM\n 04:00 AM\n 04:07 AM\n WBC\n 7.4\n 7.4\n 6.8\n 6.7\n Hct\n 25.6\n 26.1\n 26.1\n 26.8\n Plt\n 436\n 469\n 472\n 402\n Cr\n 3.6\n 3.6\n 3.6\n 3.6\n 3.8\n 3.7\n TCO2\n 21\n 23\n Glucose\n 96\n 132\n 130\n 108\n 136\n 98\n 105\n 122\n Other labs: PT / PTT / INR:18.3/64.1/1.7, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n INEFFECTIVE COPING\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n KNOWLEDGE DEFICIT\n IMPAIRED SKIN INTEGRITY\n PNEUMONIA, ASPIRATION\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:34 AM 35 mL/hour\n Glycemic Control: Comments: ISS\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405113,
"text": "Chief Complaint:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 10:40 AM\n MRI of head\n -Renal curbsided , recommended ethics consult.\n -Per neuro, amount of phenytoin is so low, would not contribute to\n seizures. Given had seizures this admit, loaded her with phenytoin\n 800mg x1 and continue maintenance dose 30 mg , and check levels\n daily starting tomorrow. Neuro said MRI unremarkable, stable blood\n products seen before. Recommend LP for ? paraneoplastic syndrome ? vs\n carcinomatous meningitis (that could trigger a cortical vein bleed:\n there is a known bleed since initial MRI at admission).\n -Did not respond to diuretics y/d, started lasix drip with one-time\n dose of metolazone given, Cr worsened from 3.6 to 3.8 UOP 17 cc/hr by\n 7pm (no different than before Lasix gtt); Lasix drip was stopped\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:15 PM\n Dilantin - 06:41 PM\n Famotidine (Pepcid) - 07:27 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 94 (83 - 99) bpm\n BP: 121/56(80) {93/43(61) - 132/63(89)} mmHg\n RR: 23 (17 - 27) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 104.8 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 12 (8 - 18)mmHg\n Total In:\n 1,550 mL\n 519 mL\n PO:\n TF:\n 845 mL\n 241 mL\n IVF:\n 386 mL\n 148 mL\n Blood products:\n Total out:\n 466 mL\n 144 mL\n Urine:\n 466 mL\n 144 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,084 mL\n 375 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 368 (325 - 392) mL\n PS : 15 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 192\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: 7.34/40/147/19/-3\n Ve: 7.4 L/min\n PaO2 / FiO2: 294\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. late-peaking high-pitched crescendo/decrescendo\n murmur loudest at RUSB.\n LUNGS: Ventilated breath sounds.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal stimuli. Minimal response to\n painful stimuli. PERRL. No oculovestibular reflex.\n Labs / Radiology\n 402 K/uL\n 8.2 g/dL\n 122\n 3.7 mg/dL\n 19 mEq/L\n 4.8 mEq/L\n 115 mg/dL\n 103 mEq/L\n 136 mEq/L\n 26.8 %\n 6.7 K/uL\n [image002.jpg]\n 02:44 AM\n 02:34 AM\n 02:04 PM\n 02:23 PM\n 03:16 AM\n 05:36 PM\n 10:00 PM\n 01:52 AM\n 04:00 AM\n 04:07 AM\n WBC\n 7.4\n 7.4\n 6.8\n 6.7\n Hct\n 25.6\n 26.1\n 26.1\n 26.8\n Plt\n 436\n 469\n 472\n 402\n Cr\n 3.6\n 3.6\n 3.6\n 3.6\n 3.8\n 3.7\n TCO2\n 21\n 23\n Glucose\n 96\n 132\n 130\n 108\n 136\n 98\n 105\n 122\n Other labs: PT / PTT / INR:18.3/64.1/1.7, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n INEFFECTIVE COPING\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n KNOWLEDGE DEFICIT\n IMPAIRED SKIN INTEGRITY\n PNEUMONIA, ASPIRATION\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:34 AM 35 mL/hour\n Glycemic Control: Comments: ISS\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405114,
"text": "Chief Complaint:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 10:40 AM\n MRI of head\n -Renal curbsided , recommended ethics consult.\n -Per neuro, amount of phenytoin is so low, would not contribute to\n seizures. Given had seizures this admit, loaded her with phenytoin\n 800mg x1 and continue maintenance dose 30 mg , and check levels\n daily starting tomorrow. Neuro said MRI unremarkable, stable blood\n products seen before. Recommend LP for ? paraneoplastic syndrome ? vs\n carcinomatous meningitis (that could trigger a cortical vein bleed:\n there is a known bleed since initial MRI at admission).\n -Did not respond to diuretics y/d, started lasix drip with one-time\n dose of metolazone given, Cr worsened from 3.6 to 3.8 UOP 17 cc/hr by\n 7pm (no different than before Lasix gtt); Lasix drip was stopped\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:15 PM\n Dilantin - 06:41 PM\n Famotidine (Pepcid) - 07:27 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 94 (83 - 99) bpm\n BP: 121/56(80) {93/43(61) - 132/63(89)} mmHg\n RR: 23 (17 - 27) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 104.8 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 12 (8 - 18)mmHg\n Total In:\n 1,550 mL\n 519 mL\n PO:\n TF:\n 845 mL\n 241 mL\n IVF:\n 386 mL\n 148 mL\n Blood products:\n Total out:\n 466 mL\n 144 mL\n Urine:\n 466 mL\n 144 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,084 mL\n 375 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 368 (325 - 392) mL\n PS : 15 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 192\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: 7.34/40/147/19/-3\n Ve: 7.4 L/min\n PaO2 / FiO2: 294\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. late-peaking high-pitched crescendo/decrescendo\n murmur loudest at RUSB.\n LUNGS: Ventilated breath sounds.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal stimuli. Minimal response to\n painful stimuli. PERRL. No oculovestibular reflex.\n Labs / Radiology\n 402 K/uL\n 8.2 g/dL\n 122\n 3.7 mg/dL\n 19 mEq/L\n 4.8 mEq/L\n 115 mg/dL\n 103 mEq/L\n 136 mEq/L\n 26.8 %\n 6.7 K/uL\n [image002.jpg]\n 02:44 AM\n 02:34 AM\n 02:04 PM\n 02:23 PM\n 03:16 AM\n 05:36 PM\n 10:00 PM\n 01:52 AM\n 04:00 AM\n 04:07 AM\n WBC\n 7.4\n 7.4\n 6.8\n 6.7\n Hct\n 25.6\n 26.1\n 26.1\n 26.8\n Plt\n 436\n 469\n 472\n 402\n Cr\n 3.6\n 3.6\n 3.6\n 3.6\n 3.8\n 3.7\n TCO2\n 21\n 23\n Glucose\n 96\n 132\n 130\n 108\n 136\n 98\n 105\n 122\n Other labs: PT / PTT / INR:18.3/64.1/1.7, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.3 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU. Continues to be\n severely fluid overloaded and oliguric, positive 28L Los. She does not\n respond well to lasix/diuril but is also not a candidate for HD.\n -start lasix gtt\n - lytes.\n -monitor volume status, UOP.\n - likely repeat valvuloplasty on Monday\n .\n # Atrial Fibrillation: Pt has good control of HR on beta blockade and\n digoxin. Coumadin was being held before for trach/PEG; restarted\n yesterday and INR went from 1.8 to 2.7. Currently INR 1.9. will d/w\n neurology and rest of CCU team risks and benefits of Coumadin in this\n pt\n -Restart coumadin with heparin bridge. Valvuloplasty not until Monday.\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n .\n # Acute Renal Failure: Creatinine stable today. Per previous notes,\n renal believes that this is ATN\n - will attempt diuresis with Lasix gtt+\n -appreciate renal recs.\n - continue to monitor fluid status otherwise\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol. Neuro not sure what is causing continued depressed\n mental status, states she is not having active seizures on EEG.\n - continue phenytoin and Phenobarbital, adjusting per neuro recs:\n Maintain at phenobarbital at 30 mg today, decrease to 15mg \n tomorrow.\n - appreciate neuro recs: recommending LP and MRI\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Respiratory Failure: Now, s/p trach.\n - trach in place\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Etiology unclear. Likely cardiogenic in setting\n of tight AS, but will need to consider sepsis if patient begins to\n spike fevers. Currently without fever or luekocytosis.\n - MAP goal is 65 to try to keep pt off of pressors\n .\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n .\n # Fevers: Afebrile x 5 days. Per notes, pt completed vanc/cefepime 7\n day course for pneumonia as well as 3 days course of abx for positive\n UA.\n - f/u cx data\n - follow fever curve\n - f/u stool for c.diff\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:34 AM 35 mL/hour\n Glycemic Control: Comments: ISS\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405172,
"text": "Chief Complaint:\n 24 Hour Events:\n Overnight Events:\n - decreased phenobarb to 15 \n - neuro recommended 800 bolus of dilantin again and to check level in\n AM\n - gave bumex with no effect on UOP\n - moved to CCU\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.1\nC (96.9\n HR: 97 (81 - 103) bpm\n BP: 123/66(87) {99/48(66) - 144/70(97)} mmHg\n RR: 26 (10 - 30) insp/min\n SpO2: 89%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 104.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 24 (8 - 24)mmHg\n Total In:\n 1,667 mL\n 365 mL\n PO:\n TF:\n 841 mL\n 226 mL\n IVF:\n 566 mL\n 139 mL\n Blood products:\n Total out:\n 1,121 mL\n 105 mL\n Urine:\n 471 mL\n 105 mL\n NG:\n Stool:\n Drains:\n Balance:\n 546 mL\n 260 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 366 (366 - 421) mL\n PS : 15 cmH2O\n RR (Spontaneous): 22\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 24 cmH2O\n SpO2: 89%\n ABG: 7.33/38/133/20/-5\n Ve: 7.7 L/min\n PaO2 / FiO2: 266\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 462 K/uL\n 8.2 g/dL\n 126\n 3.8 mg/dL\n 20 mEq/L\n 4.7 mEq/L\n 120 mg/dL\n 102 mEq/L\n 136 mEq/L\n 26.6 %\n 7.4 K/uL\n [image002.jpg]\n 10:00 PM\n 01:52 AM\n 04:00 AM\n 04:07 AM\n 03:09 PM\n 09:07 PM\n 11:05 PM\n 03:53 AM\n 04:00 AM\n 04:12 AM\n WBC\n 6.7\n 7.4\n Hct\n 26.8\n 26.6\n Plt\n 402\n 462\n Cr\n 3.7\n 3.9\n 3.8\n TCO2\n 23\n 21\n 20\n 21\n Glucose\n 98\n 105\n 122\n 128\n 126\n 126\n Other labs: PT / PTT / INR:18.3/60.0/1.7, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:7.9 mg/dL, Mg++:2.4 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU. Continues to be\n severely fluid overloaded and oliguric, positive 30L Los. She does not\n respond well to lasix/diuril but is also not a candidate for HD.\n -will try 2mg bumex to see if pt puts out urine to this\n - lytes\n -monitor volume status, UOP.\n -holding off on valvuloplasty at this point\n .\n # Atrial Fibrillation: Pt has good control of HR on beta blockade and\n digoxin. Coumadin was being held before for trach/PEG. Now, holding\n coumading in case pt undergoes valvuloplasty. Now on heparin gtt while\n INR subtherapeutic.\n - continue heparin gtt\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - trend coags\n .\n # Acute Renal Failure: Creatinine 3.7 today. Per previous notes, renal\n believes that this is ATN\n - will attempt diuresis with bumex, as above\n - appreciate renal recs.\n - continue to monitor fluid status otherwise\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol. Neuro not sure what is causing continued depressed\n mental status, states she is not having active seizures on EEG. MRI did\n not show any acute changes.\n - continue phenytoin and Phenobarbital, adjusting per neuro recs\n - Decrease phenobarbital to 15 mg today, decrease to further in 2\n days.\n - appreciate neuro recs\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Respiratory Failure: Now, s/p trach.\n - trach in place\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Pt weaned off of pressors.\n .\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n .\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - f/u cx data\n - follow fever curve\n - f/u stool for c.diff\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 09:33 PM 35 mL/hour\n Glycemic Control: Comments: ISS\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405173,
"text": "Chief Complaint:\n 24 Hour Events:\n Overnight Events:\n - decreased phenobarb to 15 \n - neuro recommended 800 bolus of dilantin again and to check level in\n AM\n - gave bumex with no effect on UOP\n - moved to CCU\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.1\nC (96.9\n HR: 97 (81 - 103) bpm\n BP: 123/66(87) {99/48(66) - 144/70(97)} mmHg\n RR: 26 (10 - 30) insp/min\n SpO2: 89%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 104.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 24 (8 - 24)mmHg\n Total In:\n 1,667 mL\n 365 mL\n PO:\n TF:\n 841 mL\n 226 mL\n IVF:\n 566 mL\n 139 mL\n Blood products:\n Total out:\n 1,121 mL\n 105 mL\n Urine:\n 471 mL\n 105 mL\n NG:\n Stool:\n Drains:\n Balance:\n 546 mL\n 260 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 366 (366 - 421) mL\n PS : 15 cmH2O\n RR (Spontaneous): 22\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 24 cmH2O\n SpO2: 89%\n ABG: 7.33/38/133/20/-5\n Ve: 7.7 L/min\n PaO2 / FiO2: 266\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n LUNGS: Ventilated breath sounds. Unable to hear good breath sounds at\n the bases.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal stimuli. Minimal response to\n painful stimuli. PERRL. No oculovestibular reflex.\n Labs / Radiology\n 462 K/uL\n 8.2 g/dL\n 126\n 3.8 mg/dL\n 20 mEq/L\n 4.7 mEq/L\n 120 mg/dL\n 102 mEq/L\n 136 mEq/L\n 26.6 %\n 7.4 K/uL\n [image002.jpg]\n 10:00 PM\n 01:52 AM\n 04:00 AM\n 04:07 AM\n 03:09 PM\n 09:07 PM\n 11:05 PM\n 03:53 AM\n 04:00 AM\n 04:12 AM\n WBC\n 6.7\n 7.4\n Hct\n 26.8\n 26.6\n Plt\n 402\n 462\n Cr\n 3.7\n 3.9\n 3.8\n TCO2\n 23\n 21\n 20\n 21\n Glucose\n 98\n 105\n 122\n 128\n 126\n 126\n Other labs: PT / PTT / INR:18.3/60.0/1.7, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:7.9 mg/dL, Mg++:2.4 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU. Continues to be\n severely fluid overloaded and oliguric, positive 30L Los. She does not\n respond well to lasix/diuril but is also not a candidate for HD.\n -will try 2mg bumex to see if pt puts out urine to this\n - lytes\n -monitor volume status, UOP.\n -holding off on valvuloplasty at this point\n .\n # Atrial Fibrillation: Pt has good control of HR on beta blockade and\n digoxin. Coumadin was being held before for trach/PEG. Now, holding\n coumading in case pt undergoes valvuloplasty. Now on heparin gtt while\n INR subtherapeutic.\n - continue heparin gtt\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - trend coags\n .\n # Acute Renal Failure: Creatinine 3.7 today. Per previous notes, renal\n believes that this is ATN\n - will attempt diuresis with bumex, as above\n - appreciate renal recs.\n - continue to monitor fluid status otherwise\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol. Neuro not sure what is causing continued depressed\n mental status, states she is not having active seizures on EEG. MRI did\n not show any acute changes.\n - continue phenytoin and Phenobarbital, adjusting per neuro recs\n - Decrease phenobarbital to 15 mg today, decrease to further in 2\n days.\n - appreciate neuro recs\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Respiratory Failure: Now, s/p trach.\n - trach in place\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Pt weaned off of pressors.\n .\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n .\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - f/u cx data\n - follow fever curve\n - f/u stool for c.diff\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 09:33 PM 35 mL/hour\n Glycemic Control: Comments: ISS\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404109,
"text": "86F w/subclinical seizures and deteriorating mental status, aspiration\n pneumonia with a complicated PMHx including severe AS s/p\n valvuloplasty, AF, CAD, now w/respiratory acidosis and failure\n resulting in intubation ().\n Seizure, without status epilepticus\n Assessment:\n Pt remains with eyes closed. Moves upper ext spontaneously and\n intermittingly. MAE\ns to painful stimuli.\n PERRLA 2-4mm. Continuous EEG monitoring.\n Cont on NEO gtt to maintain MAP >60.\n TMAX 100.8\n Remains ventilated on CMV.\n BUN/Creat continues to elevate. U/O < 10 cc/hr.\n Action:\n Ativan 1 mg x1. EEG button activated immediately following dose.\n Phenobarbital loading dose 1300mg x1.\n Keppra level decreased r/t kidney function.\n MD aware of u/o and BUN/Creat levels. Albumin as ordered.\n Antibiotics to be d/c\ns tomorrow.\n Response:\n Pt more sedate s/p ativan and phenobarb boluses.\n U/O remains scant.\n MAP maintained > 60, currently 1.0 mcg/kg/hr.\n Plan:\n Cont EEG monitoring.\n Monitor hemodynamically.\n Closely follow renal status.\n Continue update, educate and support pt\ns family.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403892,
"text": "Seizure, without status epilepticus\n Assessment:\n Patient is still on continuous EEG, no sz activities noted,\n responding to pain only, not opening eyes or following commands,\n withdrawing all extremities to pain.\n Action:\n Neuro checks q2h, Dilantin level checked at night 10.6,200mg dilantin\n x 1 given, seen by neurology, Cont with EEG\n Response:\n No seizure activities noted, stable VS, OFF neo now.\n Plan:\n Cont to monitor, Neuro checks q2h, support to pt and family.\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 403999,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Elective; Comments: hypercarbic resp. failure\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403003,
"text": "86F severe AS (critical AS s/p valvuloplasty ), CAD s/p CABG \n (lima-lad, svg-om), dCHF, AF with multiple recent hospitalizations\n ( valvuloplasty, hemicolectomy for adenoCA, c diff colitis,\n diverticulitis. Admitted after seizure which stopped with ativan\n and keppra. Diuretics were held on admission. She was treated initially\n for meningitis. CTA was negative for CVA. MRI head with high signal\n intensity in the R superior parietal lobe. After MRI on she\n triggered for AMS and lethargy. Her HR was in the 130s and her SBP was\n in the 80s. Her ABG was notable for pCO2 65. She was given lasix 10mg\n IV then 30mg and 5mg IV metoprolol without significant improvement.\n Impaired Skin Integrity\n Assessment:\n Pt remains NPO x pills.\n Failed speech & swallow exam.\n Pt with limited moblilty.\n Bilateral LE open areas.\n Action:\n NG tube passes.\n Frequent turning and repositioning .\n Aloe vesta prn.\n LE dressings changed per skin care nurse.\n Response:\n LE open areas are unchanged.\n Plan:\n To start on TF per nutrition this pm.\n Maintain strict NPO.\n Aortic stenosis\n Assessment:\n Tele AF.\n Lungs inspiratory wheezes and crackles throughout.\n O2 sats > 95%.\n Lasix drip at 20mg/hr.\n Action:\n Cont to diuresis.\n Response:\n Improved urine output today.\n Plan:\n Check lytes. Monitor I&O.\n Pneumonia, aspiration\n Assessment:\n O2 sat much improved on 2l NP.\n Pt having periods of apnea\n Weak congested nonproductive cough.\n CXR PNA.\n Lungs with expiratory wheezes & crackles.\n Action:\n Conts on Vancomycin, Cefipeme and flagyl.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404305,
"text": "Seizure\n Assessment:\n Pt unarouseable w/ eyes closed, pupils 3-4mm equal/brickly\n reactive\n MAE to nailbed pressure. UE\ns respond less than LE. Response\n is delayed. Grimacing noticed and moving of head. Occassional\n spontaneous movement of right foot\n Intubated on CMV w/o sedation\n Cont EEG. No seizures noted. Kepra/Dilantin/Phenobarb for\n seizure prophylaxis. Goal Dilantin level corrected w/ albumin 15-20 or\n w/o correction.\n Morning Dilantin level 8.4 Phenobarb 18.1\n Phenylephrine gtt titrated to goal of SBP >120 MAP >65.\n Parameters increased to help w/ prerenal perfusion and to see if u/o\n would increase\n Tele in A-fib w/ occasional PVCs. Systolic murmur\n loud/audible. Continues on Coumadin/Digoxin/Metoprolol. Received2mg\n Coumadin on day shift . Goal INR \n Received 2uPRBC on day shift to assist w/ preload and HCT\n bumped accordingly\n u/o . SICU aware no change over 24hrs. No lytes drawn\n last eve per SICU. Received home dose of Lasix on day shift\n Right nare dobhoff w/ Nutren 2.0 Full w/ Benepro @35cc/hr\n Generalized edema noted\n Blood cx pending last pan cx . PICC d/c\nd and tip\n sent for cx. Completed IVABX for asp PNA/UTI on . Foley switched\n out by day staff\n Action:\n Neuro checks Q2hrs\n Phenobarb 200mg IV bolus x1\n Low grade temps 99.9-100.5. Per SICU Cx if >100.5\n EEG w/ subclinical seizures per Neuromed notes\n BLE stasis ulcer dressings change per wound care\n recommendations\n Response:\n Neuro checks w/o change\n Neo gtt 0.9-1.1mcg/kg/min\n Plan:\n Neuro checks Q2hrs, EEG, ? MRI in future\n CXR\n Reassess code status/plan of care (Trach/PEG) on Friday\n SW to consult to assist son/husband w/ coping\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404307,
"text": "Seizure\n Assessment:\n Pt unarouseable w/ eyes closed, pupils 3-4mm equal/brickly\n reactive\n MAE to nailbed pressure. UE\ns respond less than LE. Response\n is delayed. Grimacing noticed and moving of head. Occassional\n spontaneous movement of right foot\n Intubated on CMV w/o sedation\n Cont EEG. No seizures noted. Kepra/Dilantin/Phenobarb for\n seizure prophylaxis. Goal Dilantin level corrected w/ albumin 15-20 or\n w/o correction.\n Morning Dilantin level 8.4 Phenobarb 18.1\n Phenylephrine gtt titrated to goal of SBP >120 MAP >65.\n Parameters increased to help w/ prerenal perfusion and to see if u/o\n would increase\n Tele in A-fib w/ occasional PVCs. Systolic murmur\n loud/audible. Continues on Coumadin/Digoxin/Metoprolol. Received2mg\n Coumadin on day shift . Goal INR \n Received 2uPRBC on day shift to assist w/ preload and HCT\n bumped accordingly\n u/o 10-17q 2hrs. SICU aware no change over 24hrs. No lytes\n drawn last eve per SICU. Received home dose of Lasix on day shift\n Right nare dobhoff w/ Nutren 2.0 Full w/ Benepro @35cc/hr\n Generalized edema noted\n Blood cx pending last pan cx . PICC d/c\nd and tip\n sent for cx. Completed IVABX for asp PNA/UTI on . Foley switched\n out by day staff\n Action:\n Neuro checks Q2hrs\n Phenobarb 200mg IV bolus x1\n Low grade temps 99.9-100.5. Per SICU Cx if >100.5\n EEG w/ subclinical seizures per Neuromed notes\n BLE stasis ulcer dressings change per wound care\n recommendations\n u/o monitored\n Response:\n Neuro checks w/o change\n Neo gtt 0.9-1.1mcg/kg/min\n Morning Dilantin trough 5.9 w/ Albumin of 2.4. Per Neuromed\n Dilantin 500mg IV x1 admin\n Remains oliguric and Cr up 2.5\n Plan:\n Neuro checks Q2hrs, EEG, ? MRI in future\n Dilantin level 2hrs post bolus and trough prior next\n scheduled dose. Phenobarb trough due at 0700\n CXR pending\n Reassess code status/plan of care (Trach/PEG) on Friday\n SW to consult to assist son/husband w/ coping\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404941,
"text": "Seizure, without status epilepticus\n Assessment:\n Patient remains unresponsive, not following any commands, not opening\n eyes, minimal withdrawal to deep pain, PERL, On cont EEG monitoring\n on, no sz activities noted,\n Action:\n Q4h neuro checks, dilantin 300mg x1 given and dose increased to 125mg\n TID by cardiology team, 120mg lasix x1 , MRI ordered, check list sent\n down to dept.\n Response:\n No changes in neuro status, very minimal UO, no change in UO after\n lasix t, cont with EEG\n Plan:\n Cont to monitor, pulm hygiene, neuro checks, for MRI toady, no time\n yet, support to pt and family.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405023,
"text": "86F with CAD s/p CABG (SVG-OM, LIMA-LAD), AS s/p valvuloplasty\n , diastolic CHF, AF on coumadin, s/p R colectomy who was\n initially admitted to the neurology service with generalized tonic\n clonic seizure on . Then, on evening of , the patient\n triggered for altered mental status and lethargy following a head MRI.\n At that time, it was unclear whether this was related to flash\n pulmonary edema in the setting of having her lasix held versus an\n aspiration event while she was lying flat for her MRI. She was also\n having episodes of Afib with RVR secondary to missing metoprolol doses\n while she was on the floor. She was transferred to the CCU for further\n management. After she was diuresed and her afib was better controlled,\n the patient was transferred to the medical service. However, on the\n medical floor, the patient was noted to be in NCSE on EEG. She was then\n transferred to the neuro ICU for further care.\n .\n Now, at the patient's family's request, she is being transferred to the\n CCU service for further management. Her course up to this transfer has\n been complicated by subclinical seizures and deteriorating mental\n status, aspiration pneumonia, respiratory acidosis and failure\n resulting in intubation (), ARF, hypotension requiring\n phenylephrine.\n She was trached and peg EEG continuous monitoring resumed,\n phenobarb decreased to 30mg , Dilantin increased to 125mg q 8.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n urine output 10cc\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n eeg monitoring in place, no sz activity noted. Pupils equal and\n reactive, UE withdrawal to very painful stimuli, LE responding to\n light noxious stimuli.\n Action:\n given Dilantin as ordered, monitor neuro signs and signs sz activity\n Response:\n no sz activity\n Plan:\n MRI today call eeg to remove from eeg machine the electrodes are\n compatible, ? LP to r/o infectious process\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405024,
"text": "86F with CAD s/p CABG (SVG-OM, LIMA-LAD), AS s/p valvuloplasty\n , diastolic CHF, AF on coumadin, s/p R colectomy who was\n initially admitted to the neurology service with generalized tonic\n clonic seizure on . Then, on evening of , the patient\n triggered for altered mental status and lethargy following a head MRI.\n At that time, it was unclear whether this was related to flash\n pulmonary edema in the setting of having her lasix held versus an\n aspiration event while she was lying flat for her MRI. She was also\n having episodes of Afib with RVR secondary to missing metoprolol doses\n while she was on the floor. She was transferred to the CCU for further\n management. After she was diuresed and her afib was better controlled,\n the patient was transferred to the medical service. However, on the\n medical floor, the patient was noted to be in NCSE on EEG. She was then\n transferred to the neuro ICU for further care.\n .\n Now, at the patient's family's request, she is being transferred to the\n CCU service for further management. Her course up to this transfer has\n been complicated by subclinical seizures and deteriorating mental\n status, aspiration pneumonia, respiratory acidosis and failure\n resulting in intubation (), ARF, hypotension requiring\n phenylephrine.\n She was trached and peg EEG continuous monitoring resumed,\n phenobarb decreased to 30mg , Dilantin increased to 125mg q 8.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n urine output 10cc-20cc q hr bun 117 cr 3.7 K+5.0 given lasix 200mg IV\n and diuril 500mg IV on days without effect. Patient is 28,000+ for LOS.\n SBP>100/ off of neo\n Action:\n continue to monitor\n Response:\n poor response to diuretics\n Plan:\n renal status continues to decline, renal feeling patient is not a good\n HD candidate\n Seizure, without status epilepticus\n Assessment:\n eeg monitoring in place, no sz activity noted. Pupils equal and\n reactive, UE withdrawal to very painful stimuli, LE responding to\n light noxious stimuli.\n Action:\n given Dilantin as ordered, monitor neuro signs and signs sz activity\n Response:\n no sz activity\n Plan:\n MRI today call eeg to remove from eeg machine the electrodes are\n compatible, ? LP to r/o infectious process\n Respiratory failure, acute (not ARDS/)\n Assessment:\n lungs crackles bases o2 sats > 95% cpap and ps.\n Action:\n suctioned RT nebs given\n Response:\n moderate amt of thick yellow sputum\n Plan:\n continue vigorous pulm toliet\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404874,
"text": "Seizure, without status epilepticus\n Assessment:\n Remains unresponsive. Perrl. Minimally flex/withdraws at times to deep\n nailbed pressure. No spont movement. Con\nt eeg on. Remains vented on\n cpap. Remains in afib. Neo on. Abd soft/nt. +bs. + stool via flexiseal.\n Con\nt with min u/o via foley. Con\nt with impaired skin.\n Action:\n Neuro checks. Con\nt eeg on. No vent changes. Skin care. Neo gtt to keep\n map>70.\n Response:\n No change in neuro status. u/o remains min with rising bun/creat. Skin\n unchanged.\n Plan:\n Con\nt with current plan. Monitor for changes. Wean pressor as tol. skin\n care.\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 404949,
"text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n EEG - At 11:30 AM\n continuous eeg placed\n - stopped coumadin today, as pt's INR went from 1.8 to 2.7 after\n getting 1 mg x 1 day yesterday\n - spoke with neuro: previous head bleed not an active issue and not\n likely causing pt's current symptoms; anticoagulation not likely a\n problem in the setting of this previous bleed; neuro does feel that\n there is a change in her exam (she lost her doll's eye reflex) and\n there is concern that there could be a pons lesion, therefore they are\n recommending MRI; they are also recommending LP to look for partially\n treated meningitis as possible cause for patient's AMS\n - per neuro recs, phenobarbital decreased to 45 mg , gave 300 mg IV\n bolus of phenytoin and increased dose to 125 mg TID; ordered MRI; put\n in for daily dilantin level\n - spoke with Dr. and he felt we should try more diuresis; wrote\n for 120 mg IV lasix\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Furosemide (Lasix) - 08:30 PM\n Dilantin - 09:36 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37\nC (98.6\n HR: 95 (82 - 98) bpm\n BP: 148/66(97) {93/44(60) - 148/69(97)} mmHg\n RR: 24 (17 - 29) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 104.2 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 14 (12 - 19)mmHg\n Total In:\n 1,277 mL\n 284 mL\n PO:\n 150 mL\n 30 mL\n TF:\n 840 mL\n 244 mL\n IVF:\n 156 mL\n 10 mL\n Blood products:\n Total out:\n 190 mL\n 80 mL\n Urine:\n 190 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,087 mL\n 204 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 228 (228 - 376) mL\n PS : 15 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 136\n PIP: 21 cmH2O\n SpO2: 97%\n ABG: ///19/\n Ve: 7.4 L/min\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n Radiates to carotids.\n LUNGS: Ventilated breath sounds. Decreased in L lower lung (?\n Positional).\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal or painful stimuli.\n Labs / Radiology\n 469 K/uL\n 8.4 g/dL\n 132 mg/dL\n 3.6 mg/dL\n 19 mEq/L\n 5.0 mEq/L\n 110 mg/dL\n 102 mEq/L\n 136 mEq/L\n 26.1 %\n 7.4 K/uL\n [image002.jpg]\n 11:21 PM\n 03:29 AM\n 03:47 AM\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n 02:12 AM\n 02:44 AM\n 02:34 AM\n WBC\n 10.8\n 9.7\n 8.1\n 7.4\n 7.4\n Hct\n 27.8\n 27.8\n 25.3\n 25.6\n 26.1\n Plt\n 36\n 469\n Cr\n 3.1\n 3.2\n 3.3\n 3.6\n 3.6\n TCO2\n 22\n 26\n 23\n 24\n 22\n Glucose\n 133\n 124\n 116\n 122\n 89\n 96\n 132\n Other labs: PT / PTT / INR:23.5/29.4/2.2, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU. Continues to be\n severely fluid overloaded and oliguric. Does not respond well to lasix.\n - holding on further diuresis\n - continue to closely monitor volume status\n .\n # Atrial Fibrillation: Pt has good control of HR on beta blockade and\n digoxin. Coumadin was being held before for trach/PEG; restarted\n yesterday and INR went from 1.8 to 2.7.\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - stopping Coumadin at this time\n - will d/w neurology and rest of CCU team risks and benefits of\n Coumadin in this pt.\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol. Neuro not sure what is causing continued depressed\n mental status, states she is not having active seizures on EEG.\n - continue phenytoin and Phenobarbital, adjusting per neuro recs\n - appreciate neuro recs: recommending LP and MRI\n .\n # Respiratory Failure: Now, s/p trach.\n - trach in place\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Etiology unclear.\n - will lower MAP goal to try to keep pt off of pressors\n - need to review what has been done to look for source of hypotension\n .\n # Acute Renal Failure: Still worsening. Per previous notes, renal\n believes that this is ATN. Recommend to not diurese or give IVF's.\n - holding on further diuresis, as above\n - continue to monitor fluid status otherwise\n .\n # Hypothyroidism:\n - continue synthroid 75 mcg daily\n .\n # Fevers: Per notes, pt completed vanc/cefepime 7 day course for\n pneumonia as well as 3 days course of abx for positive UA. Afebrile\n overnight.\n - f/u cx data\n - follow fever curve\n - stool for c.diff\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 12:29 AM 35 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-07 00:00:00.000",
"description": "Intensivist Note",
"row_id": 403895,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. At time of SICU admission, she\n responded only to painful stimuli.\n Chief complaint:\n Seizures\n .\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n 1. 2. 3. 4. 5. 500 mL LR 6. Acetaminophen 7. Albuterol 0.083% Neb Soln\n 8. Aspirin 9. Atorvastatin 10. Bacitracin-Polymyxin Ointment 11.\n Calcium Gluconate 12. CefePIME 13. Collagenase Ointment 14. Cosyntropin\n 15. Dextrose 50% 16. Digoxin 17. FoLIC Acid 18. Furosemide 19.\n Gabapentin 20. Glucagon 21. Heparin 22. Insulin 23. Ipratropium\n Bromide Neb 24. Latanoprost 0.005% Ophth. Soln. 25. Levothyroxine\n Sodium 26. LeVETiracetam 27. Lidocaine 5% Patch 28. Lorazepam 29.\n Magnesium Sulfate 30. Metoprolol Tartrate\n 31. Miconazole Powder 2% 32. Nystatin Oral Suspension 33. Phenytoin\n Sodium (IV) 34. Phenylephrine 35. Phenytoin Sodium (IV) 36. Phenytoin\n Sodium (IV) 37. Potassium Chloride 38. Sodium Chloride 0.9% Flush\n 39. Sodium Chloride 0.9% Flush 40. Sodium Chloride 0.9% Flush 41.\n Timolol Maleate 0.5% 42. Vancomycin\n 43. Warfarin\n 24 Hour Events:\n : MRI brain on hold for now by Neurology, Bolus of dilantin 200\n given\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Cefipime - 10:00 PM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:07 PM\n Dilantin - 11:58 PM\n Other medications:\n Flowsheet Data as of 05:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 36.8\nC (98.2\n HR: 94 (83 - 103) bpm\n BP: 106/45(70) {97/45(64) - 133/59(87)} mmHg\n RR: 29 (20 - 31) insp/min\n SPO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 87.5 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 3,985 mL\n 154 mL\n PO:\n Tube feeding:\n 3,290 mL\n 154 mL\n IV Fluid:\n 474 mL\n Blood products:\n Total out:\n 832 mL\n 87 mL\n Urine:\n 832 mL\n 87 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,153 mL\n 67 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 100%\n ABG: 7.40/49/65/30/3\n PaO2 / FiO2: 65\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : bilateral)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Responds to: Tactile stimuli), Moves all extremities, non\n purposful\n Labs / Radiology\n 372 K/uL\n 8.5 g/dL\n 119 mg/dL\n 1.5 mg/dL\n 30 mEq/L\n 4.3 mEq/L\n 40 mg/dL\n 110 mEq/L\n 146 mEq/L\n 30.4 %\n 10.5 K/uL\n [image002.jpg]\n 06:37 PM\n 03:07 AM\n 04:56 PM\n 03:35 AM\n 03:52 AM\n 11:58 AM\n 08:32 PM\n 02:19 AM\n 10:32 AM\n 03:49 AM\n WBC\n 8.9\n 9.9\n 11.1\n 10.5\n Hct\n 30.6\n 30.5\n 30.6\n 30.4\n Plt\n 72\n Creatinine\n 1.3\n 1.3\n 1.3\n 1.2\n 1.2\n 1.5\n Troponin T\n 0.03\n TCO2\n 35\n 32\n 30\n 31\n Glucose\n 146\n 121\n 122\n 136\n 119\n Other labs: PT / PTT / INR:15.7/32.3/1.4, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:62/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca:7.8 mg/dL, Mg:2.2 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n KNOWLEDGE DEFICIT, IMPAIRED SKIN INTEGRITY, PNEUMONIA, ASPIRATION,\n AORTIC STENOSIS, SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD\n Neurologic:\n -- Patient with seizures, loaded with dilantin and ativan prior to\n admission with poor mental status. Dilantin amd Keppra for seziure\n prophylaxis, f/u AM level.\n --Follow up 24hr video EEG. Initial EEG - no seizures\n -- Continue neurontin for chronic pain well controlled on current\n medication.\n -- MRI brain w/ and w/o ordered for when pt is stable to transport\n Cardiovascular:\n -- PAF with good control of HR on beta blockade and digoxin.\n -- Multiple medical cardiovascular problems. CAD s/p CABG but\n still diastolic dysfunction. She had AS (valve area 0.8cm2 on previous\n echo) but underwent valvuloplasty\n no gradient estimation after\n procedure.\n -- Anticoagulation for A. Fib: On ASA and atorvastatin. Coumadin 2\n start pm\n -- Neosynephrine 0.5\n -- Cortisol stim test negative\n -- Consider midodrine\n Pulmonary:\n --Treated empirically for aspiration pneumonia with /Cefepime but\n cultures are negative. We will continue treatment for full 7 days (to\n )\n -- lasix 40 daily.\n --Chest PT and inhalers\n --Likely aspirating secretions, may need trach. To be discussed with\n family.\n Gastrointestinal / Abdomen:\n --Resume TFs, consider PEG tube placement.\n --CDiff x 2 has been negative and diarrhea has stopped, PO vanc has\n been stopped.\n Nutrition: --TF restarted via Dobhoff\n Renal:\n --Lasix dependent, continue Lasix 40 (decreased from 60 given Cr 1.5)\n PO/NG daily; was previously on lasix gtt, will continue to monitor\n --Increasing Cr, 0.8 on admission, currently 1.5. Fe urea = 27.65\n Hematology:\n --Hct stable\n --ASA, SQH\n --Coumadin 2mg x1 PO INR 1.4\n Endocrine:\n --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg for hypothyroidism, previous TSH was 6.8\n Infectious Disease:\n --Wbc 8.8->9.9->11.1-->10.5 afebrile\n --Being treated for PNA with cefepime/vanc (?aspiration) total course\n should be 7 days (ending )\n --Vanc trough 20.6 , dose decreased to 500mg IV q24hrs from 750\n --Follow cultures (NGTD except yeast in urine)\n --CDF X2 negative\n Lines / Tubes / Drains: PIV, Foley, PICC\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: Seizure\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:00 AM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 06:03 PM\n Arterial Line - 04:39 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402756,
"text": "86F severe AS (critical AS s/p valvuloplasty ), CAD s/p CABG \n (lima-lad, svg-om), dCHF, AF with multiple recent hospitalizations\n ( valvuloplasty, hemicolectomy for adenoCA, c diff colitis,\n diverticulitis. Admitted after seizure which stopped with ativan\n and keppra. Diuretics were held on admission. She was treated initially\n for meningitis. CTA was negative for CVA. MRI head with high signal\n intensity in the R superior parietal lobe. After MRI on she\n triggered for AMS and lethargy. Her HR was in the 130s and her SBP was\n in the 80s. Her ABG was notable for pCO2 65. She was given lasix 10mg\n IV then 30mg and 5mg IV metoprolol without significant improvement.\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402757,
"text": "86F severe AS (critical AS s/p valvuloplasty ), CAD s/p CABG \n (lima-lad, svg-om), dCHF, AF with multiple recent hospitalizations\n ( valvuloplasty, hemicolectomy for adenoCA, c diff colitis,\n diverticulitis. Admitted after seizure which stopped with ativan\n and keppra. Diuretics were held on admission. She was treated initially\n for meningitis. CTA was negative for CVA. MRI head with high signal\n intensity in the R superior parietal lobe. After MRI on she\n triggered for AMS and lethargy. Her HR was in the 130s and her SBP was\n in the 80s. Her ABG was notable for pCO2 65. She was given lasix 10mg\n IV then 30mg and 5mg IV metoprolol without significant improvement.\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 403161,
"text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n Seen by speech and swallow with overt aspiration noted with liquids and\n purees. NPO recommended. NGT placed, tube feeds started.\n Neuro recs: 1. Anticoagulate after mass/AVM ruled out with MRI/MRA. 2.\n Increase keppra to 1000mg (done). 3. d/c meds (including flagyl)\n that lower seizure thresh. Flagyl continued.\n Per neuro recheck INR, if below 2 and restart coumadin low dose.\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:47 PM\n Cefipime - 08:19 PM\n Metronidazole - 10:21 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 05:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.4\nC (97.6\n HR: 88 (75 - 98) bpm\n BP: 107/58(71) {93/33(58) - 137/86(100)} mmHg\n RR: 24 (15 - 26) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 80.6 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 1,461 mL\n 367 mL\n PO:\n 50 mL\n TF:\n 99 mL\n 249 mL\n IVF:\n 1,252 mL\n 118 mL\n Blood products:\n Total out:\n 2,625 mL\n 505 mL\n Urine:\n 2,625 mL\n 505 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,164 mL\n -138 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n Gen:comfortable\n CVS: 4/6 SEM heard best at RUSB, radiating throughout precordium, S1 S2\n clear\n Resp Mouth breathes, but no longer retracting, bilateral crackles,\n moderately improved, no wheeze, wet cough, unable to clear\n Abd: +bs, soft, NT, nD\n Ext: WWP, 2+ distal pulses,\n Neuro: new anisicoria, with R from and L from with light, left\n sided weakness stable\n Able to follow commands, Alert and oriented to person and place,\n disoriented to time, overall improved.\n Venous stasis ulcers with bandaging to mid shin/C/DI\n Labs / Radiology\n 307 K/uL\n 9.2 g/dL\n 109 mg/dL\n 1.1 mg/dL\n 36 mEq/L\n 4.0 mEq/L\n 22 mg/dL\n 101 mEq/L\n 141 mEq/L\n 32.7 %\n 7.1 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n 02:18 PM\n 05:28 AM\n 02:25 PM\n 09:34 PM\n 04:56 AM\n 06:05 AM\n WBC\n 11.7\n 9.9\n 8.2\n 7.0\n 7.1\n Hct\n 34.7\n 30.6\n 30.0\n 30.7\n 32.7\n Plt\n 23\n 307\n Cr\n 0.8\n 1.0\n 1.0\n 1.0\n 1.2\n 1.1\n 1.1\n TropT\n 0.02\n TCO2\n 34\n 35\n Glucose\n 107\n 87\n 85\n 113\n 137\n 153\n 109\n Other labs: PT / PTT / INR:14.3/29.6/1.2, CK / CKMB /\n Troponin-T:15//0.02, ALT / AST:, Alk Phos / T Bili:62/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca++:8.2 mg/dL, Mg++:1.9\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic C.diff,\n admitted with new onset tonic clonic seizures on . Patient had MS\n change first noted following MRI, likely having suffered an aspiration\n event, who subsequently went into Afib and flashed on the floor in the\n setting of holding her metoprolol and Lasix.\n # Pulmonary Edema: The patient has a history of severe AS and developed\n pulmonary edema in the setting of having her diuretics held on\n admission. Also noted to have RLL collapse on CXR. Overall her\n respiratory status has improved greatly since transfer to the CCU\n initially requiring humidified face mask, now on 2L NC o/n. UOP has\n been guiding diuresis, goal had been set to diurese 500cc per day with\n Lasix gtt uptitrated from 10- 20, running mostly even, over last few\n hours has now been negative ~200cc, now responding. Continues to need\n diuresis given respiratory exam, LE edema both of which improved and\n her renal function in tolerating diuresis. Unable to obtain sputum cx\n as pt cannot clear cough.\n -Wean 02 as tolerated\n -continue lasix drip, titrating as needed\n -continue atrovent nebs, with dextromorphan PRN cough\n -Goal net negative 500cc/day\n -repeat CXR today\n - lytes\n # Possibly Aspiration PNA: Low grade fever to 100.3 on admission, now\n febrile to 101 o/n. Was pan cultured. UA showed pyuria. Currently on\n vanc/cefepime/flagyll. consider adding zosyn.\n -continue vanc/cefepime/flagyll\n -repeat CXR\n -f/u UCx with s/s\n -trend WBC and fever curves\n -f/u blood cx.\n # Afib: Pt in Afib with RVR on arrival, in the setting of not receiving\n her metoprolol. Restarted on IV metoprolol on arrival to the CCU. Now\n s/p transition to PO metprolol.\n -In fib with rate well controlled in 80s\n -continue to monitor on telemetry\n # AS: AS s/p valvuloplasty .Severe AS on Echo . AS known\n critical, unclear if worsened AS since as valve area not quantified\n but known to be critical. Pt poor surgical candidate thus had not\n received AVR.\n - consideration being given for minimally invasive percutaneous valve\n replacement once medically stable.\n # MS Change: Likely multifactorial related to benzodiazepine, ?stroke,\n respiratory status/hypercarbia on admission. Anisicoria noted on exam\n today, may be recent neb treatment.\n -ASA 81mg\n -In fib with rate contro serial neuro exams.\n -f/u with neuro continued consultation.\n -keppra for seizure prophylaxis.\n -avoid benzos\n -follow resp status, serial ABGs.\n -diuresis and antibiotics as above\n -MRI when stable, per neuro recs\n # Hx Diarrhea: Hx C.diff on chronic suppression therapy with p.o\n vanc/flagyl with last cx at rehab on negative. At that\n time, antibiotics were continued. However diarrhea has stopped so abx\n stopped this hospitalization.\n -c.diff negative\n -can continue to monitor\n # hx GI bleed: Hematocrit stable this morning\n -continue to trend hematocrit\n #Leg Ulcers: per wound care, ? if venous stasis vs. autoimmune\n -rheum consult following ICU stabilization\n #Dysphagia: Aspirated liquids and purees during speech and swallow\n evaluation.\n - tube feeds\n - speech and swallow to reevaluated later this week\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 06:13 AM 45 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:01 AM\n Prophylaxis:\n DVT: TEDS/OOB and amb.\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Possible transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 404623,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. At time of SICU admission, she\n responded only to painful stimuli.\n Chief complaint:\n Seizures, ARF\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n 1. 2. 3. 4. 5. 6. Acetaminophen 7. Albuterol 0.083% Neb Soln 8.\n Albuterol Inhaler 9. Aspirin\n 10. Atorvastatin 11. Bacitracin-Polymyxin Ointment 12. Calcium\n Gluconate 13. Chlorhexidine Gluconate 0.12% Oral Rinse\n 14. Collagenase Ointment 15. Dextrose 50% 16. Digoxin 17. Famotidine\n 18. Fentanyl Citrate 19. FoLIC Acid\n 20. Glucagon 21. 22. Insulin 23. Ipratropium Bromide MDI 24.\n Ipratropium Bromide Neb 25. Latanoprost 0.005% Ophth. Soln.\n 26. Levothyroxine Sodium 27. Lidocaine 5% Patch 28. Lorazepam 29.\n Magnesium Sulfate 30. Metoprolol Tartrate\n 31. Miconazole Powder 2% 32. Nystatin Oral Suspension 33. PHENObarbital\n 34. Phenytoin Sodium (IV)\n 35. Phenylephrine 36. Potassium Chloride 37. Sodium Chloride 0.9% Flush\n 38. Sodium Chloride 0.9% Flush\n 39. Sodium Chloride 0.9% Flush 40. Sodium Chloride 0.9% Flush 41.\n Timolol Maleate 0.5%\n 24 Hour Events:\n : Family meeting held still full code, cardiology will take the\n patient to CCU in am. Keppra D/C.\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 2.5 mcg/Kg/min\n Other ICU medications:\n Dilantin - 06:00 PM\n Famotidine (Pepcid) - 08:25 PM\n Other medications:\n Flowsheet Data as of 03:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (101\n T current: 37.6\nC (99.6\n HR: 89 (83 - 109) bpm\n BP: 132/55(82) {105/45(66) - 146/57(89)} mmHg\n RR: 26 (18 - 31) insp/min\n SPO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 96.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 14 (4 - 14) mmHg\n Total In:\n 2,075 mL\n 316 mL\n PO:\n Tube feeding:\n 844 mL\n 117 mL\n IV Fluid:\n 1,112 mL\n 199 mL\n Blood products:\n Total out:\n 162 mL\n 11 mL\n Urine:\n 162 mL\n 11 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,913 mL\n 305 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 450) mL\n Vt (Spontaneous): 439 (315 - 656) mL\n PS : 18 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 79\n RSBI Deferred: RR >35\n PIP: 24 cmH2O\n Plateau: 22 cmH2O\n SPO2: 96%\n ABG: 7.34/39/82.//-4\n Ve: 10.5 L/min\n PaO2 / FiO2: 207\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : At the base,\n Rhonchorous : Bilateral)\n Abdominal: Soft, Bowel sounds present, Distended\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: (Responds to: Noxious stimuli), Delay response to noxious\n stimili\n Labs / Radiology\n 10:24 AM\n 03:06 AM\n 03:29 AM\n 12:15 PM\n 02:20 AM\n 02:31 AM\n 06:10 PM\n 08:30 PM\n 10:18 PM\n 11:21 PM\n WBC\n 10.4\n 10.1\n Hct\n 30.2\n 30.3\n Plt\n 428\n 393\n Creatinine\n 2.5\n 2.7\n 3.0\n TCO2\n 25\n 22\n 25\n 21\n 24\n 23\n 22\n Glucose\n 112\n 124\n 137\n Other labs: PT / PTT / INR:29.5/33.7/2.9, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:60/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca:7.8 mg/dL, Mg:1.9 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), INEFFECTIVE COPING,\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), KNOWLEDGE DEFICIT, IMPAIRED\n SKIN INTEGRITY, PNEUMONIA, ASPIRATION, AORTIC STENOSIS, SEIZURE,\n WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension requiring\n phenylephrine. Being transferred to CCU at request of family and\n consulting cardiologist\n Neurologic:\n -- Patient sedated with minimal doses intermittent fentanyl prn.\n -- Patient with seizures, loaded with dilantin and ativan PRN prior to\n admission with poor mental status. Despite loading dose continued to\n have sub clinical seziures on EEG. Medication regimen changed,\n currently on phenytoin (Goal 15-20), and phenobarbitol. (Keppra d/c\n 0./20)\n --Delayed Withdrawal to pain in all extremities\n -- AM dilantin level - , phenobarb ->\n Cardiovascular:\n -- PAF with good control of HR on beta blockade and digoxin.\n Anticoagulation started with coumadin. Coumadin held for now given\n elevated INR, will bridge with heparin once INR<2.0. On ASA\n -- CAD s/p CABG , diastolic dysfunction. On b-blockade, ASA, and\n statin.\n -- Critical AS (valve area pre-valvuloplasty 0.8cm2, post\n vavluloplasty). On ICU-based ECHO estimated area is 0.6cm2. Likely not\n eligible for open valve replacement. Family is discussing this issue\n with another cardiologist.\n --Cont phenylephrine as needed, goal SBP>120, MAP>70\n Pulmonary:\n --albuterol/atrovent PRN\n --plan for trach \n --CPAP 5/5\n Gastrointestinal / Abdomen:\n --TFs at goal,plan for PEG \n Nutrition:\n --TF continued\n Renal:\n -- Lasix held\n -- Pt still requires neosynephrine for MAPs > 65\n -- Cr increasing: now at , renal believes it is ATN (muddy brown\n casts), would not diurese, or give IVF; do not oliguria.\n Hematology:\n --ASA. Hold coumadin given elevated INR\n - A. Fib anticoagulation with Coumadin now on hold for procedure, INR\n goal , f/u daily INR and start heparin drip once INR < 2 as pt is\n planned for trach/peg on Monday\n Endocrine:\n --RISS with adequate glucose control\n --Synthroid 75 mcg for hypothyroidism\n ID:\n --completed cefepime vanc 7 day course for pneumonia\n --UA positive foley changed patient received 3 days course of\n antibiotics last dose 03/16\n --Follow cultures\n T/L/D: PIV, Foley, CVL (), ETT, Dobhoff\n Wounds: none\n Imaging: none\n Fluids: KVO\n Consults:\n Billing Diagnosis: status epilepticus, respiratory failure, ATN\n Prophylaxis:\n DVT: ASA, coumadin (held)\n Stress ulcer: H2B\n VAP bundle: +\n Communication: ICU consent done\n Code status: Full\n Disposition: SICU\n Time spent: 15\n"
},
{
"category": "General",
"chartdate": "2196-02-14 00:00:00.000",
"description": "Generic Note",
"row_id": 404632,
"text": "TITLE: Cardiology fellow CCU admit note\n 86F with CAD s/p CABG (SVG-OM, LIMA-LAD), AS s/p valvuloplasty\n , diastolic CHF, AF on coumadin, s/p R colectomy admitted\n with generalized tonic-clonic seizure who has remained persistently\n nearly unresponsive. She is being transferred to the CCU for continued\n care.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404702,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient continues to be minimally responsive today. She will withdraw\n her upper extremities to painful stimuli. She continues to be on a neo\n infusion to support her blood pressure. She is\n Action:\n Response:\n Plan:\n"
},
{
"category": "General",
"chartdate": "2196-02-15 00:00:00.000",
"description": "Generic Note",
"row_id": 404709,
"text": "TITLE: Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 04:00 PM\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Furosemide (Lasix) - 09:22 PM\n Dilantin - 04:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.3\nC (99.2\n HR: 97 (80 - 99) bpm\n BP: 120/57(80) {106/47(68) - 144/62(90)} mmHg\n RR: 17 (17 - 29) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 96.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 15 (10 - 17)mmHg\n Total In:\n 2,106 mL\n 176 mL\n PO:\n TF:\n 842 mL\n 2 mL\n IVF:\n 1,263 mL\n 174 mL\n Blood products:\n Total out:\n 224 mL\n 366 mL\n Urine:\n 124 mL\n 66 mL\n NG:\n Stool:\n 100 mL\n 300 mL\n Drains:\n Balance:\n 1,882 mL\n -190 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 505 (357 - 505) mL\n PS : 18 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 145\n PIP: 24 cmH2O\n SpO2: 98%\n ABG: 7.36/38/81./21/-3\n Ve: 8.3 L/min\n PaO2 / FiO2: 205\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: ET tube in place; JVD noted.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n Radiated to carotids.\n LUNGS: Ventilated breath sounds.\n ABDOMEN: Obese, S/NT/ND, BS present\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal or painful stimuli.\n Labs / Radiology\n 399 K/uL\n 8.3 g/dL\n 122 mg/dL\n 3.2 mg/dL\n 21 mEq/L\n 4.5 mEq/L\n 99 mg/dL\n 103 mEq/L\n 136 mEq/L\n 27.8 %\n 9.7 K/uL\n [image002.jpg]\n 06:10 PM\n 08:30 PM\n 10:18 PM\n 11:21 PM\n 03:29 AM\n 03:47 AM\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n WBC\n 10.8\n 9.7\n Hct\n 27.8\n 27.8\n Plt\n 434\n 399\n Cr\n 3.1\n 3.2\n TCO2\n 21\n 24\n 23\n 22\n 26\n 23\n 24\n 22\n Glucose\n 137\n 133\n 124\n 116\n 122\n Other labs: PT / PTT / INR:26.2/31.5/2.5, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine. Being\n transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU and appears very\n fluid overloaded on physical exam.\n - pt did not put out well to IV diuresis last night; will hold off on\n further diuresis or fluid at this time\n - continue to closely monitor volume status\n .\n # Atrial Fibrillation: Per previous notes, pt has good control of HR on\n beta blockade and digoxin.\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - coumadin was being held for ?supratherapeutic INR; INR in therapeutic\n range this morning; can restart coumadin after trach\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol.\n - continue phenytoin and phenobarbital\n - appreciate neuro recs\n .\n # Respiratory Failure: Now, intubated with plans to trach pt on .\n - NPO p MN for trach\n - plan for trach placement tomorrow\n - will need FFP prior to trach supratherapeutic INR\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Etiology unclear.\n - need to investigate prior work-up\n .\n # Acute Renal Failure: Per previous notes, renal believes that this is\n ATN. Recommend to not diurese or give IVF's.\n - holding on further diuresis, as above\n - continue to monitor fluid status otherwise\n .\n # Hypothyroidism:\n - continue synthroid 75 mcg daily\n .\n # Fevers: Per notes, pt completed vanc/cefepime 7 day course for\n pneumonia as well as 3 days course of abx for positive UA.\n - f/u cx data\n - follow fever curve\n - stool for c.diff\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin (on hold))\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU (transfer to LTAC soon)\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n have seen and examined the patient. I have reviewed the above note\n and plans.\n I have also reviewed the notes of Dr(s). dated .\n I would add the following remarks:\n Medical Decision Making\n Trach and PEG today. Discharge planning. 20 minutes patient care.\n ------ Protected Section Addendum Entered By: , MD\n on: 16:51 ------\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405032,
"text": "Chief Complaint:\n 24 Hour Events:\n per Dr. , plan is for valvuloplasty on Monday\n -Dr. met with family\n -ordered SW consult\n -attempted diruesis with Diuril 500 mg IV and Lasix 20 mg IV: Patient\n put out 20 cc/hr of urine to this\n -renal recs: kidneys poorly perfused; very poor candidate for HD\n -FE urea 24%\n -decreased phenobarbital to 30 mg . Per neuro, will decrease dose by\n 15 mg every 2 days\n -weaned phenylephrine\n -held Coumadin, did not start heparin gtt as INR was therapeutic; will\n need to restart once INR<2\n -ordered for head MRI, but this was not done yet\n -may do LP: will get MRI first\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:30 AM\n Dilantin - 04:16 PM\n Famotidine (Pepcid) - 09:38 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 35.8\nC (96.5\n HR: 91 (85 - 101) bpm\n BP: 109/58(77) {86/48(67) - 133/88(97)} mmHg\n RR: 22 (20 - 30) insp/min\n SpO2: 92%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 104.8 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 15 (12 - 23)mmHg\n Total In:\n 1,184 mL\n 206 mL\n PO:\n 30 mL\n TF:\n 861 mL\n 206 mL\n IVF:\n 113 mL\n Blood products:\n Total out:\n 973 mL\n 105 mL\n Urine:\n 373 mL\n 105 mL\n NG:\n Stool:\n Drains:\n Balance:\n 211 mL\n 101 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 368 (349 - 394) mL\n PS : 15 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 200\n PIP: 21 cmH2O\n SpO2: 92%\n ABG: 7.36/36/99./17/-4\n Ve: 8.6 L/min\n PaO2 / FiO2: 250\n Physical Examination\n Labs / Radiology\n 472 K/uL\n 8.0 g/dL\n 108 mg/dL\n 3.6 mg/dL\n 17 mEq/L\n 5.0 mEq/L\n 114 mg/dL\n 103 mEq/L\n 135 mEq/L\n 26.1 %\n 6.8 K/uL\n [image002.jpg]\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n 02:12 AM\n 02:44 AM\n 02:34 AM\n 02:04 PM\n 02:23 PM\n 03:16 AM\n WBC\n 9.7\n 8.1\n 7.4\n 7.4\n 6.8\n Hct\n 27.8\n 25.3\n 25.6\n 26.1\n 26.1\n Plt\n 399\n 367\n 436\n 469\n 472\n Cr\n 3.2\n 3.3\n 3.6\n 3.6\n 3.6\n 3.6\n TCO2\n 23\n 24\n 22\n 21\n Glucose\n 124\n 116\n 122\n 89\n 96\n 132\n 130\n 108\n Other labs: PT / PTT / INR:20.3/27.8/1.9, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n INEFFECTIVE COPING\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n KNOWLEDGE DEFICIT\n IMPAIRED SKIN INTEGRITY\n PNEUMONIA, ASPIRATION\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405033,
"text": "Chief Complaint:\n 24 Hour Events:\n per Dr. , plan is for valvuloplasty on Monday\n -Dr. met with family\n -ordered SW consult\n -attempted diruesis with Diuril 500 mg IV and Lasix 20 mg IV: Patient\n put out 20 cc/hr of urine to this\n -renal recs: kidneys poorly perfused; very poor candidate for HD\n -FE urea 24%\n -decreased phenobarbital to 30 mg . Per neuro, will decrease dose by\n 15 mg every 2 days\n -weaned phenylephrine\n -held Coumadin, did not start heparin gtt as INR was therapeutic; will\n need to restart once INR<2\n -ordered for head MRI, but this was not done yet\n -may do LP: will get MRI first\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:30 AM\n Dilantin - 04:16 PM\n Famotidine (Pepcid) - 09:38 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 35.8\nC (96.5\n HR: 91 (85 - 101) bpm\n BP: 109/58(77) {86/48(67) - 133/88(97)} mmHg\n RR: 22 (20 - 30) insp/min\n SpO2: 92%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 104.8 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 15 (12 - 23)mmHg\n Total In:\n 1,184 mL\n 206 mL\n PO:\n 30 mL\n TF:\n 861 mL\n 206 mL\n IVF:\n 113 mL\n Blood products:\n Total out:\n 973 mL\n 105 mL\n Urine:\n 373 mL\n 105 mL\n NG:\n Stool:\n Drains:\n Balance:\n 211 mL\n 101 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 368 (349 - 394) mL\n PS : 15 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 200\n PIP: 21 cmH2O\n SpO2: 92%\n ABG: 7.36/36/99./17/-4\n Ve: 8.6 L/min\n PaO2 / FiO2: 250\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. late-peaking high-pitched crescendo/decrescendo\n murmur loudest at RUSB.\n LUNGS: Ventilated breath sounds.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal stimuli. Minimal response to\n painful stimuli. PERRL. No oculovestibular reflex.\n Labs / Radiology\n 472 K/uL\n 8.0 g/dL\n 108 mg/dL\n 3.6 mg/dL\n 17 mEq/L\n 5.0 mEq/L\n 114 mg/dL\n 103 mEq/L\n 135 mEq/L\n 26.1 %\n 6.8 K/uL\n [image002.jpg]\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n 02:12 AM\n 02:44 AM\n 02:34 AM\n 02:04 PM\n 02:23 PM\n 03:16 AM\n WBC\n 9.7\n 8.1\n 7.4\n 7.4\n 6.8\n Hct\n 27.8\n 25.3\n 25.6\n 26.1\n 26.1\n Plt\n 399\n 367\n 436\n 469\n 472\n Cr\n 3.2\n 3.3\n 3.6\n 3.6\n 3.6\n 3.6\n TCO2\n 23\n 24\n 22\n 21\n Glucose\n 124\n 116\n 122\n 89\n 96\n 132\n 130\n 108\n Other labs: PT / PTT / INR:20.3/27.8/1.9, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n INEFFECTIVE COPING\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n KNOWLEDGE DEFICIT\n IMPAIRED SKIN INTEGRITY\n PNEUMONIA, ASPIRATION\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402837,
"text": "86F severe AS (critical AS s/p valvuloplasty ), CAD s/p CABG \n (lima-lad, svg-om), dCHF, AF with multiple recent hospitalizations\n ( valvuloplasty, hemicolectomy for adenoCA, c diff colitis,\n diverticulitis. Admitted after seizure which stopped with ativan\n and keppra. Diuretics were held on admission. She was treated initially\n for meningitis. CTA was negative for CVA. MRI head with high signal\n intensity in the R superior parietal lobe. After MRI on she\n triggered for AMS and lethargy. Her HR was in the 130s and her SBP was\n in the 80s. Her ABG was notable for pCO2 65. She was given lasix 10mg\n IV then 30mg and 5mg IV metoprolol without significant improvement.\n Pneumonia, aspiration\n Assessment:\n LS: Rhonchi/ rales/ exp wheezes throughout. SPO2 >90% closed,\n humidified aerosol mask w/ FiO2 70%/ 10L. Strong cough productive of\n thick, tan sputum.\n Action:\n IV anbx: vanco/ cefepime/ flagyl\n Pulm toilet: chest PT, Nebs q 6 hrs, C&DB\n Changed O2 to 4LNC w/ face tent 70% FiO2\n OOB to stretcher chair x 2 hours\n Sputum cx sent\n Speech and swallow consult ordered to evaluate for\n aspiration- not available today. Pt maintained NPO until 1600, when\n sitting in chair and more alert MS. w/ no s/s\n aspiration. Given daily PO meds crushed in .\n Response:\n Pt expectorating small amts thick, tan sputum frequently. Needs\n reminders for C&DB. SPO2>94% on above O2 requirement. Drops to 80s when\n she removes mask. Improved oxygenation and coughing when sitting in\n chair.\n Plan:\n Continue to monitor resp status. Cont IV anbx. S&S consult when able-\n NPO except meds in appleasauce for now w/ HOB @ 90 degrees and pt\n alert. Encourage activity as tolerated. OOB-chair at least daily. Needs\n PT consult.\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Impaired skin.\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402839,
"text": "86F severe AS (critical AS s/p valvuloplasty ), CAD s/p CABG \n (lima-lad, svg-om), dCHF, AF with multiple recent hospitalizations\n ( valvuloplasty, hemicolectomy for adenoCA, c diff colitis,\n diverticulitis. Admitted after seizure which stopped with ativan\n and keppra. Diuretics were held on admission. She was treated initially\n for meningitis. CTA was negative for CVA. MRI head with high signal\n intensity in the R superior parietal lobe. After MRI on she\n triggered for AMS and lethargy. Her HR was in the 130s and her SBP was\n in the 80s. Her ABG was notable for pCO2 65. She was given lasix 10mg\n IV then 30mg and 5mg IV metoprolol without significant improvement.\n Pneumonia, aspiration\n Assessment:\n LS: Rhonchi/ rales/ exp wheezes throughout. SPO2 >90% closed,\n humidified aerosol mask w/ FiO2 70%/ 10L. Strong cough productive of\n thick, tan sputum. Tmax 99.6 PO.\n Action:\n IV anbx: vanco/ cefepime/ flagyl\n Pulm toilet: chest PT, Nebs q 6 hrs, C&DB\n Changed O2 to 4LNC w/ face tent 70% FiO2\n OOB to stretcher chair x 2 hours\n Sputum cx sent\n ABG unchanged from prior assessment.\n Speech and swallow consult ordered to evaluate for\n aspiration- not available today. Pt maintained NPO until 1600, when\n sitting in chair and more alert MS. w/ no s/s\n aspiration. Given daily PO meds crushed in .\n Response:\n Pt expectorating small amts thick, tan sputum frequently. Needs\n reminders for C&DB. SPO2>94% on above O2 requirement. Drops to 80s when\n she removes mask. Improved oxygenation and coughing when sitting in\n chair.\n Plan:\n Continue to monitor resp status. Cont IV anbx. S&S consult when able-\n NPO except meds in appleasauce for now w/ HOB @ 90 degrees and pt\n alert. Encourage activity as tolerated. OOB-chair at least daily. Needs\n PT consult.\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n No seizure activity noted. Pt initially sleepy, but rousable. Oriented\n to self/ month/ year. Pupils @ 3mm bilat, brisk response to light. MAE\n in bed- very deconditioned. Following commands. Frequently removing\n her face mask, needing reminders to leave in place.\n Action:\n IV keppra \n Freq neuro s/s\n Re-oreint as needed\n Freq reminders to leave mask on face\n Response:\n No seizure activity noted\n Plan:\n Con\nt Keppra\n Monitor freq neuro checks.\n Impaired skin.: stool/ wounds/ nutrition\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402840,
"text": "86F severe AS (critical AS s/p valvuloplasty ), CAD s/p CABG \n (lima-lad, svg-om), dCHF, AF with multiple recent hospitalizations\n ( valvuloplasty, hemicolectomy for adenoCA, c diff colitis,\n diverticulitis. Admitted after seizure which stopped with ativan\n and keppra. Diuretics were held on admission. She was treated initially\n for meningitis. CTA was negative for CVA. MRI head with high signal\n intensity in the R superior parietal lobe. After MRI on she\n triggered for AMS and lethargy. Her HR was in the 130s and her SBP was\n in the 80s. Her ABG was notable for pCO2 65. She was given lasix 10mg\n IV then 30mg and 5mg IV metoprolol without significant improvement.\n Pneumonia, aspiration\n Assessment:\n LS: Rhonchi/ rales/ exp wheezes throughout. SPO2 >90% closed,\n humidified aerosol mask w/ FiO2 70%/ 10L. Strong cough productive of\n thick, tan sputum. Tmax 99.6 PO.\n Action:\n IV anbx: vanco/ cefepime/ flagyl\n Pulm toilet: chest PT, Nebs q 6 hrs, C&DB\n Changed O2 to 4LNC w/ face tent 70% FiO2\n OOB to stretcher chair x 2 hours\n Sputum cx sent\n ABG unchanged from prior assessment.\n Speech and swallow consult ordered to evaluate for\n aspiration- not available today. Pt maintained NPO until 1600, when\n sitting in chair and more alert MS. w/ no s/s\n aspiration. Given daily PO meds crushed in .\n Response:\n Pt expectorating small amts thick, tan sputum frequently. Needs\n reminders for C&DB. SPO2>94% on above O2 requirement. Drops to 80s when\n she removes mask. Improved oxygenation and coughing when sitting in\n chair.\n Plan:\n Continue to monitor resp status. Cont IV anbx. S&S consult when able-\n NPO except meds in appleasauce for now w/ HOB @ 90 degrees and pt\n alert. Encourage activity as tolerated. OOB-chair at least daily. Needs\n PT consult.\n Aortic stenosis\n Assessment:\n Remains in a-fib w hr 86-100s, occas PVCs w rare bts Vt noted. BP\n 90s-120s/ 60s. Bilat lower ext edema noted thighs to knee @ 2mm. Resp\n status as above. Rec\nd on lasix gtt @ 5mg/hr w/ 50+ml UOP/hr.\n Action:\n On lasix gtt @ 5mg/hr (gentle diuresis in light of AS)\n @ 2300 lasix gtt to off d/t sbp down to 90)\n Rec\nd Metoprolol IV 15mg Q 4/hr\n changed to PO at 1600.\n Also given digoxin at that time.\n Response:\n Improving HR after Metoprolol and digoxin dosing\n SBP down high 70s, low 80s at 1800 when back to bed. Team\n alerted. Lasix gtt DC\n Adequate UOP response to lasix gtt- monitor now that lasix\n on hold\n Plan:\n Continue to monitor resp status.\n Seizure, without status epilepticus\n Assessment:\n No seizure activity noted. Pt initially sleepy, but rousable. Oriented\n to self/ month/ year. Pupils @ 3mm bilat, brisk response to light. MAE\n in bed- very deconditioned. Following commands. Frequently removing\n her face mask, needing reminders to leave in place.\n Action:\n IV keppra \n Freq neuro s/s\n Re-oreint as needed\n Freq reminders to leave mask on face\n Response:\n No seizure activity noted\n Plan:\n Con\nt Keppra\n Monitor freq neuro checks.\n Impaired skin.: stool/ wounds/ nutrition/ thrush/ groin\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402845,
"text": "86 yr. old woman with severe AS (critical AS-> s/p valvuloplasty\n ), CAD s/p CABG (lima-lad, svg-om), dCHF, & AF. Multiple\n recent hospitalizations ( valvuloplasty, hemicolectomy for\n adenoCA, c diff colitis, diverticulitis. Admitted after seizure\n which stopped with ativan and keppra. Diuretics were held on admission.\n She was treated initially for meningitis. CTA was negative for CVA. MRI\n head with high signal intensity in the R superior parietal lobe. After\n MRI on she triggered for AMS and lethargy. Her HR was in the\n 130s and her SBP was in the 80s. Her ABG was notable for pCO2 65. She\n was given lasix 10mg IV then 30mg and 5mg IV metoprolol without\n significant improvement.\n Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403157,
"text": "86F severe AS (critical AS s/p valvuloplasty ), CAD s/p CABG \n (lima-lad, svg-om), dCHF, AF with multiple recent hospitalizations\n ( valvuloplasty, hemicolectomy for adenoCA, c diff colitis,\n diverticulitis. Admitted after seizure which stopped with ativan\n and keppra. Diuretics were held on admission. She was treated initially\n for meningitis. CTA was negative for CVA. MRI head with high signal\n intensity in the R superior parietal lobe. After MRI on she\n triggered for AMS and lethargy. Her HR was in the 130s and her SBP was\n in the 80s. Her ABG was notable for pCO2 65. She was given lasix 10mg\n IV then 30mg and 5mg IV metoprolol without significant improvement.\n Pneumonia, aspiration\n Assessment:\n O2 at 2lnp with sats in the upper 90\ns to 100%. Conts to have very\n congested cough that is not productive. Lungs with scattered\n rhonci/wheezes throughout, also noted for crackles. Lasix gtt conts at\n 10mg/hr. Conts on iv antibx. Tube feeds at 10cc/hr initially.\n Action:\n Rec\ning Atrovent nebs q 6hours. CPT to R lobes. Attempted to orally\n sxn for presumed secretions. No change made in lasix gtt, goal to\n maintain even. Increased tube feeds to 45cc/hr (goal) at 4:30.\n Response:\n conts to have very congested cough, at times cough is continuous. Sats\n have remained good. Approx even so far. Having no residuals with\n increase in tube feed rate. Determined to stop lasix gtt and restart\n home regimen of lasix po.\n Plan:\n cont with cpt/nebs. Follow oxygenation. Cont to check residuals.\n Maintain strict NPO.\n Seizure, without status epilepticus\n Assessment:\n She is alert and oriented x 2 (person/time). Slightly lethargic,\n awakens easily but falls back to sleep. Able to follow simple\n commands. No seizures noted.\n Action:\n Keppra given, to have increased dose at 8am\n Response:\n no change in neuro status\n Plan:\n give increased dose of keppra, cont to follow neuro status\n Aortic stenosis\n Assessment:\n Hr 80-90\ns afib with occ pvc. Bp stable 90-120\n Action:\n conts on lopressor 75mg\n Response:\n tolerating cardiac meds, conts on lasix gtt\n Plan:\n cont to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405098,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO via foley clear,yellow. Pt in beginning of shift on lasix gtt for\n goal of 100cc/hr of urine\n Action\n Hourly urine output checks, lasix gtt shut off around 2100 per CCU\n team, lytes sent with am labs,\n Response:\n Urine output approx 15-20cc/hr-not much difference on or off lasix gtt,\n BUN/Creat 115/3.7, lytes wnl\n Plan:\n Cont to assess hourly urine outputs, ? another renal consult to ? HD\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear bilat upper lobes and dim bilat lower lobes, # 8 portex\n Action:\n Pt remains on CPAP 15/5/50%-no changes throughout night, sxn\nd as\n needed\n Response:\n Sxning small amt of white, thin secretions, pt ventilating well\n Plan:\n Cont to assess respiratory status, wean vent as tolerated\n Seizure, without status epilepticus\n Assessment:\n Pt w/d to pain in bilat LE\ns, and occasionally w/d to pain in bilat\n UE\ns, no opening of eyes, pupils equal and reactive bilat, no following\n of commands, impaired to absent gag, impaired cough, positive corneals\n Action:\n Monitored for seizure activity, pt hooked up to cont EEG. Dilantin load\n given at change of shift, dilantin level sent with am labs, q 4 hour\n neuro checks\n Response:\n No s/s of seizures, dilantin level still low at 3.8-? from renal status\n Plan:\n Cont with EEG to monitior for seizures, reload pt with dilantin?\n Aortic stenosis\n Assessment:\n Pt has hx of severe AS, pt with HR in the 80\ns- afib with occasional\n PVC\n Action:\n Pt on heparin gtt- titrating gtt to goal PTT of 60-80, pt given her\n ordered ATC lopressor\n Response:\n Pt at goal PTT of 64.1 on 1150 Units/hr of heparin, pt remains in afib\n with a controlled rate in the 80\n Plan:\n Pt on CCU service-? Transfer to their floor if beds available, pt\n planned for a valvuloplasty on Monday\n Impaired Skin Integrity\n Assessment:\n Pt has generalized edema and many skin impairments-see metavision for\n details\n Action:\n Q 4 hour skin assessments, pt turned q 2-3 hours, pt at goal for\n tubefeeds, changed dressings as ordered/prn\n Response:\n No changes in skin integrity\n Plan:\n Cont to assess skin for s/s of impairments.\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 405101,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 14\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont trached and on mech vent as per Metavision. Lung\n sounds rhonchi suct mod th off white sput. ABGs stable on current\n settings; no vent changes required overnoc. Cont PSV.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405035,
"text": "86F with CAD s/p CABG (SVG-OM, LIMA-LAD), AS s/p valvuloplasty\n , diastolic CHF, AF on coumadin, s/p R colectomy who was\n initially admitted to the neurology service with generalized tonic\n clonic seizure on . Then, on evening of , the patient\n triggered for altered mental status and lethargy following a head MRI.\n At that time, it was unclear whether this was related to flash\n pulmonary edema in the setting of having her lasix held versus an\n aspiration event while she was lying flat for her MRI. She was also\n having episodes of Afib with RVR secondary to missing metoprolol doses\n while she was on the floor. She was transferred to the CCU for further\n management. After she was diuresed and her afib was better controlled,\n the patient was transferred to the medical service. However, on the\n medical floor, the patient was noted to be in NCSE on EEG. She was then\n transferred to the neuro ICU for further care.\n .\n Now, at the patient's family's request, she is being transferred to the\n CCU service for further management. Her course up to this transfer has\n been complicated by subclinical seizures and deteriorating mental\n status, aspiration pneumonia, respiratory acidosis and failure\n resulting in intubation (), ARF, hypotension requiring\n phenylephrine.\n She was trached and peg EEG continuous monitoring resumed,\n phenobarb decreased to 30mg , Dilantin increased to 125mg q 8.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n urine output 10cc-20cc q hr bun 117 cr 3.7 K+5.0 given lasix 200mg IV\n and diuril 500mg IV on days without effect. Patient is 28,000+ for LOS.\n SBP>100/ off of neo\n Action:\n continue to monitor\n Response:\n poor response to diuretics\n Plan:\n renal status continues to decline, renal feeling patient is not a good\n HD candidate\n Seizure, without status epilepticus\n Assessment:\n eeg monitoring in place, no sz activity noted. Pupils equal and\n reactive, UE withdrawal to very painful stimuli, LE responding to\n light noxious stimuli.\n Action:\n given Dilantin as ordered, monitor neuro signs and signs sz activity\n Response:\n no sz activity\n Plan:\n MRI today call eeg to remove from eeg machine the electrodes are\n compatible, ? LP to r/o infectious process\n Respiratory failure, acute (not ARDS/)\n Assessment:\n lungs crackles bases o2 sats > 95% cpap and ps.\n Action:\n suctioned RT nebs given\n Response:\n moderate amt of thick yellow sputum\n Plan:\n continue vigorous pulm toliet\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405036,
"text": "Chief Complaint:\n 24 Hour Events:\n Dr met with family. Plan currently is to attempt diuresis with\n plan for valvuloplasty on Monday.\n Pt received diuril 500mg X1, and lasix 200mg IV x1, with total UOP over\n 24 hours of 373 cc, approx 15 cc/hr\n Seen by renal with assessment that she her kidney\ns are being poorly\n perfused, as indicated by an FE Urea 24%, and that she is a poor\n candidate for HD.\n Her MRI was deferred to today, with phenobarb down titrated from 45mg\n to 30mg . Per neuro plan is to decrease dose by 15mg every 2\n days.\n LP being deferred until after MRI.\n Held heparin GTT y/d and held Coumadin as INR therapeutic then.\n -held Coumadin, did not start heparin gtt as INR was therapeutic; will\n need to restart once INR<2\n -ordered for head MRI, but this was not done yet\n -may do LP: will get MRI first\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:30 AM\n Dilantin - 04:16 PM\n Famotidine (Pepcid) - 09:38 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 35.8\nC (96.5\n HR: 91 (85 - 101) bpm\n BP: 109/58(77) {86/48(67) - 133/88(97)} mmHg\n RR: 22 (20 - 30) insp/min\n SpO2: 92%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 104.8 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 15 (12 - 23)mmHg\n Total In:\n 1,184 mL\n 206 mL\n PO:\n 30 mL\n TF:\n 861 mL\n 206 mL\n IVF:\n 113 mL\n Blood products:\n Total out:\n 973 mL\n 105 mL\n Urine:\n 373 mL\n 105 mL\n NG:\n Stool:\n LOS\n +28,8L\n Balance:\n 211 mL\n 101 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 368 (349 - 394) mL\n PS : 15 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 200\n PIP: 21 cmH2O\n SpO2: 92%\n ABG: 7.36/36/99./17/-4\n Ve: 8.6 L/min\n PaO2 / FiO2: 250\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. late-peaking high-pitched crescendo/decrescendo\n murmur loudest at RUSB.\n LUNGS: Ventilated breath sounds.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal stimuli. Minimal response to\n painful stimuli. PERRL. No oculovestibular reflex.\n Labs / Radiology\n 472 K/uL\n 8.0 g/dL\n 108 mg/dL\n 3.6 mg/dL\n 17 mEq/L\n 5.0 mEq/L\n 114 mg/dL\n 103 mEq/L\n 135 mEq/L\n 26.1 %\n 6.8 K/uL\n [image002.jpg]\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n 02:12 AM\n 02:44 AM\n 02:34 AM\n 02:04 PM\n 02:23 PM\n 03:16 AM\n WBC\n 9.7\n 8.1\n 7.4\n 7.4\n 6.8\n Hct\n 27.8\n 25.3\n 25.6\n 26.1\n 26.1\n Plt\n 399\n 367\n 436\n 469\n 472\n Cr\n 3.2\n 3.3\n 3.6\n 3.6\n 3.6\n 3.6\n TCO2\n 23\n 24\n 22\n 21\n Glucose\n 124\n 116\n 122\n 89\n 96\n 132\n 130\n 108\n Other labs: PT / PTT / INR:20.3/27.8/1.9, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n INEFFECTIVE COPING\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n KNOWLEDGE DEFICIT\n IMPAIRED SKIN INTEGRITY\n PNEUMONIA, ASPIRATION\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU. Continues to be\n severely fluid overloaded and oliguric, positive 28L Los. She does not\n respond well to lasix/diuril but is also not a candidate for HD. Given\n the extent of her volume overload, her organs are likely to be quite\n edematous, thus torsemide might be considered over lasix. Torsemide\n () can be given 10-20mg IV/day versus loading dose 20mg IV then drip\n 5-20mg/hr.\n Metolazone only oral, thus not an option. Equivalence of torsemide to\n lasix ?\n - monitor volume status\n - likely repeat valvuloplasty on Monday\n .\n # Atrial Fibrillation: Pt has good control of HR on beta blockade and\n digoxin. Coumadin was being held before for trach/PEG; restarted\n yesterday and INR went from 1.8 to 2.7. Currently INR 1.9. will d/w\n neurology and rest of CCU team risks and benefits of Coumadin in this\n pt\n -Restart coumadin with heparin bridge. Valvuloplasty not until Monday.\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n .\n # Acute Renal Failure: Creatinine stable today. Per previous notes,\n renal believes that this is ATN. Recommend to not diurese or give\n IVF's.\n - will attempt diuresis with Lasix + metolozone, although this may not\n be successful\n - continue to monitor fluid status otherwise\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol. Neuro not sure what is causing continued depressed\n mental status, states she is not having active seizures on EEG.\n - continue phenytoin and Phenobarbital, adjusting per neuro recs:\n Maintain at phenobarbital at 30 mg today, decrease to 15mg \n tomorrow.\n - appreciate neuro recs: recommending LP and MRI\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Respiratory Failure: Now, s/p trach.\n - trach in place\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Etiology unclear. Likely cardiogenic in setting\n of tight AS, but will need to consider sepsis if patient begins to\n spike fevers. Currently without fever or luekocytosis.\n - MAP goal is 65 to try to keep pt off of pressors\n .\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n .\n # Fevers: Afebrile x 5 days. Per notes, pt completed vanc/cefepime 7\n day course for pneumonia as well as 3 days course of abx for positive\n UA.\n - f/u cx data\n - follow fever curve\n - f/u stool for c.diff\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 12:29 AM 35 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: subtherapeutic INR, restart hep gtt, coumadin today\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: Family\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 405164,
"text": "Demographics\n Day of intubation: 15\n Day of mechanical ventilation: 15\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated, Increase\n ventilatory support at night\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405165,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output med-light yellow w/ some white sediment\n Action:\n Pt s/p attempts at lasix gtt, s/p bumex of yesterday\n Received no diuretics this 12 hours\n Response:\n Pt w/ low urine volumes via patent foley\n a.m. creatinine drawn, pending, previous\nstable\n level 3.6\n Plan:\n Cont to follow urine outputs, check results a.m. serum creatinine\n Respiratory failure, acute (not ARDS/)\n Assessment:\n difficulty getting good pleth for finger or ear lobe O2 sat probe sats,\n readings in 80\n Action:\n ABG obtained; pt placed on a/c 18 per resp therapist, ABG obtained to\n check difference\n Response:\n ABG showed a/c mode not needed to maintain adequate pO2, and did not\n help pH/metabolic acidosis\n Pt returned to CPAP mode, at 50%, which previous ABG showed pO2 of 100%\n Plan:\n Check results a.m. ABG drawn w/ 4a labs\n Seizure, without status epilepticus\n Assessment:\n Pt remains w/ EEG monitor/leads attached to head for continued EEG\n monitoring\n Action:\n No seizure activity observed by nurse, though some mild jaw movements\n noted during po hygiene cares\n Pt also received dilantin load yesterday, and adjustment of dilantin\n dose\n Response:\n -----\n Plan:\n a.m. dilantin level drawn this a.m., results pending\n Aortic stenosis\n Assessment:\n Pt on hep gtt for AS, has been on 1150 units/hr;\n Action:\n PTT drawn at 20:30 result was approx 62, was 73 previous draw;\n Response:\n PTT stable, adjustment not needed; PTT drawn again w/ 4a labs, pending\n at this time\n Plan:\n Lopressor as ordered\n Cont card monitorting\n ?valvuloplasty Mon\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405269,
"text": "Chief Complaint: CHIEF COMPLAINT: CRITICAL AS\n 24 Hour Events:\n Notes from on call intern:\n \n Neuro recs:\n -phenytoin 300 mg IV bolus now\n -phenytoin 125 mg PO TID\n -check EEG in a.m.\n -phenytoin and free phenytoin tonight\n -do not wean phenobarb tonight (give one more dose tonight)\n -ordered metolazone + bumetanide. Patient did not diurese.\n -gave 1-time dose of phenobarbital in p.m. per neuro recs (had d/c'ed\n on rounds, but neuro felt this was too abrupt). Per neuro, patient will\n not need further doses of phenobarb.\n -1 a.m., noted to be hypoxemic 7.30/42/64 on FiO2 50%. Ventillation\n mode changed to AC and FiO2 increased to 100% with gas subsequently\n 7.35/35/249. CXR unchanged.\n -weaned FiO2\n However, per Neurology this a.m.:\n - Do not stop Phenobarbital precipitously\n may result in\n seizure.\n - Per Neurology, unlikely AEDs causing mental status changes,\n therefore need to proceed with LP to ensure no\n carcinomatosis/paraneoplastic syndrome.\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,350 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:02 PM\n Dilantin - 03:42 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 95 (91 - 108) bpm\n BP: 96/50(67) {90/50(64) - 138/70(96)} mmHg\n RR: 5 (0 - 27) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 103.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 18 (18 - 25)mmHg\n Total In:\n 1,622 mL\n 478 mL\n PO:\n TF:\n 840 mL\n 265 mL\n IVF:\n 591 mL\n 182 mL\n Blood products:\n Total out:\n 315 mL\n 85 mL\n Urine:\n 315 mL\n 85 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,307 mL\n 393 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 362 (320 - 374) mL\n PS : 15 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 118\n RSBI Deferred: FiO2 > 60%, Hemodynamic Instability\n PIP: 25 cmH2O\n SpO2: 95%\n ABG: 7.32/38/102/18/-5\n Ve: 7.9 L/min\n PaO2 / FiO2: 204\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 422 K/uL\n 7.6 g/dL\n 137 mg/dL\n 3.7 mg/dL\n 18 mEq/L\n 4.8 mEq/L\n 123 mg/dL\n 103 mEq/L\n 137 mEq/L\n 24.7 %\n 7.0 K/uL\n [image002.jpg]\n 03:53 AM\n 04:00 AM\n 04:12 AM\n 02:26 PM\n 11:27 PM\n 11:51 PM\n 01:04 AM\n 02:02 AM\n 04:44 AM\n 05:08 AM\n WBC\n 7.4\n 7.0\n Hct\n 26.6\n 24.7\n Plt\n 462\n 422\n Cr\n 3.8\n 3.7\n TCO2\n 21\n 23\n 21\n 21\n 20\n 20\n Glucose\n 126\n 126\n 120\n 137\n Other labs: PT / PTT / INR:15.0/65.8/1.3, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:5.1 mg/dL\n Fluid analysis / Other labs: .\n Imaging: CXR from this a.m.\n Microbiology: Yeast in urine and sputum.\n ECG: .\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU. Continues to be\n severely fluid overloaded and oliguric, positive ~30L Los. She does not\n respond well to lasix/diuril/bumex but is also not a candidate for HD.\n -will try PO bumex and metolazone to try to get some diuresis\n - lytes\n -monitor volume status, UOP.\n -holding off on valvuloplasty at this point\n .\n # Atrial Fibrillation: Pt has good control of HR on beta blockade and\n digoxin. Coumadin was being held before for trach/PEG. Now, holding\n coumading in case pt undergoes valvuloplasty. Now on heparin gtt while\n INR subtherapeutic.\n - continue heparin gtt\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - trend coags\n .\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, renal\n believes that this is ATN\n - will attempt diuresis with bumex/metolazone, as above\n - appreciate renal recs.\n - continue to monitor fluid status otherwise\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin boluses and\n phenobarbitol taper. Neuro not sure what is causing continued depressed\n mental status, states she is not having active seizures on EEG. MRI did\n not show any acute changes.\n - continue phenytoin; need to readdress dosing with neuro\n - stopping phenobarbital\n - appreciate neuro input\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Respiratory Failure: Now, s/p trach.\n - trach in place\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Pt weaned off of pressors.\n .\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n .\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - f/u cx data\n - follow fever curve\n - f/u stool for c.diff\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 03:27 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405271,
"text": "Chief Complaint: CHIEF COMPLAINT: CRITICAL AS\n 24 Hour Events:\n Notes from on call intern:\n \n Neuro recs:\n -phenytoin 300 mg IV bolus now\n -phenytoin 125 mg PO TID\n -check EEG in a.m.\n -phenytoin and free phenytoin tonight\n -do not wean phenobarb tonight (give one more dose tonight)\n -ordered metolazone + bumetanide. Patient did not diurese.\n -gave 1-time dose of phenobarbital in p.m. per neuro recs (had d/c'ed\n on rounds, but neuro felt this was too abrupt). Per neuro, patient will\n not need further doses of phenobarb.\n -1 a.m., noted to be hypoxemic 7.30/42/64 on FiO2 50%. Ventillation\n mode changed to AC and FiO2 increased to 100% with gas subsequently\n 7.35/35/249. CXR unchanged.\n -weaned FiO2\n However, per Neurology this a.m.:\n - Do not stop Phenobarbital precipitously\n may result in\n seizure.\n - Per Neurology, unlikely AEDs causing mental status changes,\n therefore need to proceed with LP to ensure no\n carcinomatosis/paraneoplastic syndrome.\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,350 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:02 PM\n Dilantin - 03:42 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 95 (91 - 108) bpm\n BP: 96/50(67) {90/50(64) - 138/70(96)} mmHg\n RR: 5 (0 - 27) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 103.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 18 (18 - 25)mmHg\n Total In:\n 1,622 mL\n 478 mL\n PO:\n TF:\n 840 mL\n 265 mL\n IVF:\n 591 mL\n 182 mL\n Blood products:\n Total out:\n 315 mL\n 85 mL\n Urine:\n 315 mL\n 85 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,307 mL\n 393 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 362 (320 - 374) mL\n PS : 15 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 118\n RSBI Deferred: FiO2 > 60%, Hemodynamic Instability\n PIP: 25 cmH2O\n SpO2: 95%\n ABG: 7.32/38/102/18/-5\n Ve: 7.9 L/min\n PaO2 / FiO2: 204\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n LUNGS: Ventilated breath sounds. Unable to hear good breath sounds at\n the bases.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Comatose (GCS 3), no plantar response on left and small upgoing\n on right. Jaw jerk hyperactive, glalbella tap present, corneals WNLs\n bilaterally. No doll\ns eyes to lateral head roll. PERRL.\n Labs / Radiology\n 422 K/uL\n 7.6 g/dL\n 137 mg/dL\n 3.7 mg/dL\n 18 mEq/L\n 4.8 mEq/L\n 123 mg/dL\n 103 mEq/L\n 137 mEq/L\n 24.7 %\n 7.0 K/uL\n [image002.jpg]\n 03:53 AM\n 04:00 AM\n 04:12 AM\n 02:26 PM\n 11:27 PM\n 11:51 PM\n 01:04 AM\n 02:02 AM\n 04:44 AM\n 05:08 AM\n WBC\n 7.4\n 7.0\n Hct\n 26.6\n 24.7\n Plt\n 462\n 422\n Cr\n 3.8\n 3.7\n TCO2\n 21\n 23\n 21\n 21\n 20\n 20\n Glucose\n 126\n 126\n 120\n 137\n Other labs: PT / PTT / INR:15.0/65.8/1.3, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:5.1 mg/dL\n Fluid analysis / Other labs: .\n Imaging: CXR from this a.m.\n Microbiology: Yeast in urine and sputum.\n ECG: .\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures (now none for a week on EEG) and deteriorating\n mental status, aspiration pneumonia, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension requiring\n phenylephrine. Transferred to CCU at request of family and consulting\n cardiologist.\n # Coma, seizures, Goals of Care\n Comatose with some brainstem reflexes. No seizures for some time. No\n evidence of cortical function. BUN 123 and patient has been\n intermittently hypotensive. Therefore differential includes (also\n possible multifactorial) uremia, anoxic brain injury and\n carcinoatosis/paraneoplastic encephalopathy. Not likely related to\n presently low levels of AEDs. Given this state, we need to aggressively\n treat reversible causes, if present, then determine whether further\n cardiac interventions are warranted This will require some further\n investigations and discussion with Dr , Neurology, the family.\n - Attending and family keen to stop AEDs, so will need to check with\n them prior to giving phenobarbital\n - LP today for cytology\n - Continue phenytoin\n # Aortic Stenosis\n Treatment of this is deferred pending decision about the above.\n Valvuloplasty will need to be repeated (if this is compatible with\n goals of care). Pt with known severe aortic stenosis s/p valvuloplasty\n in . She was initially on the CCU service early in her\n hospitalization in the setting of flash pulmonary edema when her lasix\n were held. Now, she is intubated in the ICU. Continues to be severely\n fluid overloaded and oliguric, positive ~30L Los. She does not respond\n well to lasix/diuril/bumex but is also not a candidate for HD.\n - Continue bumex and metolazone with goal of net negative 1.5L today\n - lytes\n - Monitor volume status, UOP.\n - Holding off on valvuloplasty at this point\n # Respiratory Failure and Intubation\n - Preserve for now given mental status and edema\n # Atrial Fibrillation\n Pt has good control of HR on beta blockade and digoxin. Coumadin was\n being held before for trach/PEG. Now, holding coumading in case pt\n undergoes valvuloplasty. Now on heparin gtt while INR subtherapeutic.\n - Stop heparin this a.m. for LP this afternoon\n - Continue metoprolol tartrate 25 mg TID\n - Continue digoxin 0.0625 mg daily\n - Trend coags\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, is ATN\n - Will attempt diuresis with bumex/metolazone, as above\n - Appreciate renal recs.\n - Continue to monitor fluid status otherwise\n # Coronary Artery Disease: Pt is s/p CABG /.\n - Continue metoprolol as above\n - Continue aspirin 81 mg daily, atorvastatin 40 mg daily\n # Respiratory Failure: Now, s/p trach.\n - Trach in place\n - Continue albuterol/atrovent PRN\n # Pressor Requirement: Pt weaned off of pressors.\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - f/u cx data\n - follow fever curve\n - f/u stool for c.diff\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 03:27 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404102,
"text": "86F w/subclinical seizures and deteriorating mental status, aspiration\n pneumonia with a complicated PMHx including severe AS s/p\n valvuloplasty, AF, CAD, now w/respiratory acidosis and failure\n resulting in intubation ().\n Seizure, without status epilepticus\n Assessment:\n Pt remains with eyes closed. Moves upper ext spontaneously and\n intermittingly. MAE\ns to painful stimuli.\n PERRLA 2-4mm. Continuous EEG monitoring.\n Action:\n Ativan 1 mg x1. EEG button activated immediately following dose.\n Phenobarbital loading dose 1300mg x1.\n Keppra level decreased r/t kidney function.\n Response:\n Pt more sedate s/p ativan and phenobarb boluses.\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404286,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402841,
"text": "86F severe AS (critical AS s/p valvuloplasty ), CAD s/p CABG \n (lima-lad, svg-om), dCHF, AF with multiple recent hospitalizations\n ( valvuloplasty, hemicolectomy for adenoCA, c diff colitis,\n diverticulitis. Admitted after seizure which stopped with ativan\n and keppra. Diuretics were held on admission. She was treated initially\n for meningitis. CTA was negative for CVA. MRI head with high signal\n intensity in the R superior parietal lobe. After MRI on she\n triggered for AMS and lethargy. Her HR was in the 130s and her SBP was\n in the 80s. Her ABG was notable for pCO2 65. She was given lasix 10mg\n IV then 30mg and 5mg IV metoprolol without significant improvement.\n Pneumonia, aspiration\n Assessment:\n LS: Rhonchi/ rales/ exp wheezes throughout. SPO2 >90% closed,\n humidified aerosol mask w/ FiO2 70%/ 10L. Strong cough productive of\n thick, tan sputum. Tmax 99.6 PO.\n Action:\n IV anbx: vanco/ cefepime/ flagyl\n Pulm toilet: chest PT, Nebs q 6 hrs, C&DB\n Changed O2 to 4LNC w/ face tent 70% FiO2\n OOB to stretcher chair x 2 hours\n Sputum cx sent\n ABG unchanged from prior assessment.\n Speech and swallow consult ordered to evaluate for\n aspiration- not available today. Pt maintained NPO until 1600, when\n sitting in chair and more alert MS. w/ no s/s\n aspiration. Given daily PO meds crushed in .\n Response:\n Pt expectorating small amts thick, tan sputum frequently. Needs\n reminders for C&DB. SPO2>94% on above O2 requirement. Drops to 80s when\n she removes mask. Improved oxygenation and coughing when sitting in\n chair.\n Plan:\n Continue to monitor resp status. Cont IV anbx. S&S consult when able-\n NPO except meds in appleasauce for now w/ HOB @ 90 degrees and pt\n alert. Encourage activity as tolerated. OOB-chair at least daily. Needs\n PT consult.\n Aortic stenosis\n Assessment:\n Remains in a-fib w hr 86-100s, occas PVCs w rare bts Vt noted. BP\n 90s-120s/ 60s. Bilat lower ext edema noted thighs to knee @ 2mm. Resp\n status as above. Rec\nd on lasix gtt @ 5mg/hr w/ 50+ml UOP/hr.\n Action:\n On lasix gtt @ 5mg/hr (gentle diuresis in light of AS)\n @ 2300 lasix gtt to off d/t sbp down to 90)\n Rec\nd Metoprolol IV 15mg Q 4/hr\n changed to PO at 1600.\n Also given digoxin at that time.\n Response:\n Improving HR after Metoprolol and digoxin dosing\n SBP down high 70s, low 80s at 1800 when back to bed. Team\n alerted. Lasix gtt DC\n Adequate UOP response to lasix gtt- monitor now that lasix\n on hold\n Plan:\n Continue to monitor resp status.\n Seizure, without status epilepticus\n Assessment:\n No seizure activity noted. Pt initially sleepy, but rousable. Oriented\n to self/ month/ year. Pupils @ 3mm bilat, brisk response to light. MAE\n in bed- very deconditioned. Following commands. Frequently removing\n her face mask, needing reminders to leave in place.\n Action:\n IV keppra \n Freq neuro s/s\n Re-oreint as needed\n Freq reminders to leave mask on face\n Response:\n No seizure activity noted\n Plan:\n Con\nt Keppra\n Monitor freq neuro checks.\n Impaired Skin Integrity\n Assessment:\n BLE w/ ulcers previously documented as venous wounds.\n No significant PO intake x several days\n Mouth w/ healing thrush; Bilat groin folds w/ yeast-like\n rash\n Loose green stool x 3 today.\n Action:\n Seen by wound RN for BLE ulcers please see note in careweb. Dsgs\n changed per wound care recs w/ collagenase ointment and DSD. Nystatin\n swish and swallow PRN. Miconazole powder to groin. Oral care q 4 hours.\n Turned and repositioned q 2 hours. OOB to chair today. C-diff sent-\n negative at rehab.\n Response:\n Resolving thrush. Stable ulcers. Did take PO meds w/ .\n Plan:\n Continue meticulous skin care. Readdress nutritional status tomorrow-\n S&S evaluation if available.\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402844,
"text": "Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402969,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 10:12 PM\n temp 101 R\n URINE CULTURE - At 10:12 PM\n temp 101 R,blood and urine cultures sent, defervesced to 99.\n Pyuria noted on UA. culture data pending.\n Continues on vanc/cefepime/flagyl started for aspiration PNA.\n Diarrhrea?\n -C. diff toxin negative\n -She continues on a lasix drip for diuresis which was uptitrated from\n to with goal UOP 500cc which she did not achieve, putting out approx\n /hr\n and ended up running even. She was able to maintain her BP's in the low\n 100's systolic and remained rate controlled for her afib.\n -\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Cefipime - 08:13 PM\n Vancomycin - 08:47 PM\n Metronidazole - 05:30 AM\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.2\nC (99\n HR: 85 (75 - 107) bpm\n BP: 113/55(70) {95/39(53) - 145/74(96)} mmHg\n RR: 17 (12 - 27) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 81.2 kg (admission): 80.1 kg\n Total In:\n 1,770 mL\n 421 mL\n PO:\n 400 mL\n 50 mL\n TF:\n IVF:\n 1,370 mL\n 371 mL\n Blood products:\n Total out:\n 1,730 mL\n 650 mL\n Urine:\n 1,730 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 40 mL\n -229 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///36/\n Physical Examination\n Gen:comfortable\n CVS: 4/6 SEM heard best at RUSB, radiating throughout precordium, S1 S2\n clear\n Resp Mouth breathes, but no longer retracting, bilateral crackles,\n moderately improved, no wheeze, wet cough, unable to clear\n Abd: +bs, soft, NT, nD\n Ext: WWP, 2+ distal pulses,\n Neuro: new anisicoria, with R from and L from with light, left\n sided weakness stable\n Able to follow commands, Alert and oriented to person and place,\n disoriented to time, overall improved.\n Venous stasis ulcers with bandaging to mid shin/C/DI\n Labs / Radiology\n 323 K/uL\n 8.7 g/dL\n 109 mg/dL\n 1.1 mg/dL\n 36 mEq/L\n 3.9 mEq/L\n 22 mg/dL\n 101 mEq/L\n 141 mEq/L\n 30.7 %\n 7.0 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n 02:18 PM\n 05:28 AM\n 02:25 PM\n 09:34 PM\n 04:56 AM\n WBC\n 11.7\n 9.9\n 8.2\n 7.0\n Hct\n 34.7\n 30.6\n 30.0\n 30.7\n Plt\n 23\n Cr\n 0.8\n 1.0\n 1.0\n 1.0\n 1.2\n 1.1\n 1.1\n TropT\n 0.02\n TCO2\n 34\n 35\n Glucose\n 107\n 87\n 85\n 113\n 137\n 153\n 109\n Other labs: PT / PTT / INR:15.9/32.2/1.4, CK / CKMB /\n Troponin-T:15//0.02, ALT / AST:, Alk Phos / T Bili:62/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca++:8.2 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n KNOWLEDGE DEFICIT\n IMPAIRED SKIN INTEGRITY\n PNEUMONIA, ASPIRATION\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures on who had MS\n change first noted following MRI, likely having suffered an aspiration\n event, who subsequently went into afib and flashed on the floor in the\n setting of holding her metoprolol and Lasix.\n # Pulmonary Edema: The patient has a history of severe AS and developed\n pulmonary edema in the setting of having her diuretics held on\n admission. Also noted to have RLL collapse on CXR Overall her\n respiratory status has improved greatly since transfer to the CCU\n initially requiring humidified face mask, now on 2L NC o/n. UOP has\n been guiding diuresis, goal had been set to diurese 500cc y,d with\n Lasix gtt uptitrated from 10- 20, running mostly even, over last few\n hours has now been negative ~200cc, now responding. Continues to need\n diuresis given respiratory exam, LE edema both of which improved and\n her renal function in tolerating diuresis. Unable to obtain sputum cx\n as pt cannot clear cough.\n -Wean 02 as tolerated.\n - continue lasix drip, titrating as needed\n -continue atrovent nebs, with dextromorphan PRN cough\n -Goal UOP 500cc/day\n - repeat CXR today\n - lytes.\n # Possibly Aspiration PNA: Low grade fever to 100.3 on admission, now\n febrile to 101 o/n. Was pan cultured. UA showed pyuria. Currently on\n vanc/cefepime/flagyll. consider adding zosyn.\n - continue vanc/cefepime/flagyll\n -repeat CXR\n -f/u UCx with s/s\n - trend WBC and fever curves\n -f/u blood cx.\n # Afib: Pt in Afib with RVR on arrival, in the setting of not receiving\n her metoprolol. Restarted on IV metoprolol on arrival to the CCU. Now\n s/p transition to PO metprolol.\n -In fib with rate well controlled in 80s\n - continue to monitor on telemetry\n # AS: AS s/p valvuloplasty .Severe AS on Echo . AS known\n critical, unclear if worsened AS since as valve area not quantified\n but known to be critical. Pt poor surgical candidate thus had not\n received AVR.\n - consideration being given for minimally invasive\n percutaneous valve replacement once medically stable.\n -\n # MS Change: Likely multifactorial related to benzodiazepine, ?stroke,\n respiratory status/hypercarbia on admission. Anisicoria noted on exam\n today, may be recent neb treatment.\n - ASA 81mg\n -In fib with rate contro serial neuro exams.\n -f/u with neuro continued consultation.\n - keppra for seizure prophylaxis.\n - avoid benzos\n - follow resp status, serial ABGs.\n - diuresis and antibiotics as above\n - MRI when stable, per neuro recs\n # Hx Diarrhea: Hx C.diff on chronic suppression therapy with p.o\n vanc/flagyl with last cx at rehab on negative. At that\n time, antibiotics were continued. However diarrhea has stopped so abx\n stopped this hospitalization.\n -c.diff negative.\n can continue to monitor\n # hx GI bleed: Hematocrit stable this morning\n - continue to trend hematocrit\n #Leg Ulcers: per wound care, ? if venous stasis vs autoimmune\n -rheum consult following ICU stabilization.\n # Nutrition: Pt now on crushed meds with apple sauce, nectar thickened\n liquids, lactose intolerant.\n -consult speech and swallow today re p.o intake now that MS improved.\n L\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:01 AM\n Prophylaxis:\n DVT: TEDS/OOB and amb.\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Possible transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402981,
"text": "Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402982,
"text": "86F severe AS (critical AS s/p valvuloplasty ), CAD s/p CABG \n (lima-lad, svg-om), dCHF, AF with multiple recent hospitalizations\n ( valvuloplasty, hemicolectomy for adenoCA, c diff colitis,\n diverticulitis. Admitted after seizure which stopped with ativan\n and keppra. Diuretics were held on admission. She was treated initially\n for meningitis. CTA was negative for CVA. MRI head with high signal\n intensity in the R superior parietal lobe. After MRI on she\n triggered for AMS and lethargy. Her HR was in the 130s and her SBP was\n in the 80s. Her ABG was notable for pCO2 65. She was given lasix 10mg\n IV then 30mg and 5mg IV metoprolol without significant improvement.\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402983,
"text": "86F severe AS (critical AS s/p valvuloplasty ), CAD s/p CABG \n (lima-lad, svg-om), dCHF, AF with multiple recent hospitalizations\n ( valvuloplasty, hemicolectomy for adenoCA, c diff colitis,\n diverticulitis. Admitted after seizure which stopped with ativan\n and keppra. Diuretics were held on admission. She was treated initially\n for meningitis. CTA was negative for CVA. MRI head with high signal\n intensity in the R superior parietal lobe. After MRI on she\n triggered for AMS and lethargy. Her HR was in the 130s and her SBP was\n in the 80s. Her ABG was notable for pCO2 65. She was given lasix 10mg\n IV then 30mg and 5mg IV metoprolol without significant improvement.\n Impaired Skin Integrity\n Assessment:\n Pt remains NPO x pills.\n Action:\n Response:\n Plan:\n Aortic stenosis\n Assessment:\n Tele AF.\n Lungs inspiratory wheezes and crackles throughout.\n O2 sats > 95%.\n Lasix drip at 20mg/hr.\n Action:\n Response:\n Plan:\n Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 404746,
"text": "Chief Complaint:\n 24 Hour Events:\n PERCUTANEOUS TRACHEOSTOMY - At 03:10 PM\n PEG INSERTION - At 04:01 PM\n Overnight Events:\n -per neurosurg recs, decreased phenobarbital dose to 60 mg and\n checked Dilantin and free Dilantin troughs\n -converted metoprolol to IV as patient was not taking PO's\n -gave FFP prior to trach/PEG\n -patient got trach/PEG\n -gradually decreased dose of phenylephrine\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Vecuronium - 03:03 PM\n Midazolam (Versed) - 04:03 PM\n Fentanyl - 04:03 PM\n Famotidine (Pepcid) - 08:27 PM\n Dilantin - 04:10 AM\n Metoprolol - 06:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 37.4\nC (99.3\n HR: 96 (78 - 102) bpm\n BP: 113/56(76) {104/48(68) - 150/71(101)} mmHg\n RR: 19 (13 - 31) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 96.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 19 (13 - 326)mmHg\n Total In:\n 1,423 mL\n 14 mL\n PO:\n TF:\n 2 mL\n IVF:\n 509 mL\n 14 mL\n Blood products:\n 882 mL\n Total out:\n 460 mL\n 160 mL\n Urine:\n 160 mL\n 60 mL\n NG:\n 100 mL\n Stool:\n 300 mL\n Drains:\n Balance:\n 963 mL\n -146 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 312 (312 - 469) mL\n PS : 15 cmH2O\n RR (Set): 14\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 110\n PIP: 21 cmH2O\n SpO2: 96%\n ABG: ///16/\n Ve: 7.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 367 K/uL\n 7.7 g/dL\n 89 mg/dL\n 3.3 mg/dL\n 16 mEq/L\n 4.7 mEq/L\n 100 mg/dL\n 104 mEq/L\n 136 mEq/L\n 25.3 %\n 8.1 K/uL\n [image002.jpg]\n 08:30 PM\n 10:18 PM\n 11:21 PM\n 03:29 AM\n 03:47 AM\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n 02:12 AM\n WBC\n 10.8\n 9.7\n 8.1\n Hct\n 27.8\n 27.8\n 25.3\n Plt\n \n Cr\n 3.1\n 3.2\n 3.3\n TCO2\n 24\n 23\n 22\n 26\n 23\n 24\n 22\n Glucose\n 137\n 133\n 124\n 116\n 122\n 89\n Other labs: PT / PTT / INR:19.6/29.0/1.8, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:7.9 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n INEFFECTIVE COPING\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n KNOWLEDGE DEFICIT\n IMPAIRED SKIN INTEGRITY\n PNEUMONIA, ASPIRATION\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n Glycemic Control: Comments: Insulin Sliding Scale\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU; Ultimately transfer to LTAC\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 404747,
"text": "Chief Complaint:\n 24 Hour Events:\n PERCUTANEOUS TRACHEOSTOMY - At 03:10 PM\n PEG INSERTION - At 04:01 PM\n Overnight Events:\n -per neurosurg recs, decreased phenobarbital dose to 60 mg and\n checked Dilantin and free Dilantin troughs\n -converted metoprolol to IV as patient was not taking PO's\n -gave FFP prior to trach/PEG\n -patient got trach/PEG\n -gradually decreased dose of phenylephrine\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Vecuronium - 03:03 PM\n Midazolam (Versed) - 04:03 PM\n Fentanyl - 04:03 PM\n Famotidine (Pepcid) - 08:27 PM\n Dilantin - 04:10 AM\n Metoprolol - 06:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 37.4\nC (99.3\n HR: 96 (78 - 102) bpm\n BP: 113/56(76) {104/48(68) - 150/71(101)} mmHg\n RR: 19 (13 - 31) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 96.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 19 (13 - 326)mmHg\n Total In:\n 1,423 mL\n 14 mL\n PO:\n TF:\n 2 mL\n IVF:\n 509 mL\n 14 mL\n Blood products:\n 882 mL\n Total out:\n 460 mL\n 160 mL\n Urine:\n 160 mL\n 60 mL\n NG:\n 100 mL\n Stool:\n 300 mL\n Drains:\n Balance:\n 963 mL\n -146 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 312 (312 - 469) mL\n PS : 15 cmH2O\n RR (Set): 14\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 110\n PIP: 21 cmH2O\n SpO2: 96%\n ABG: ///16/\n Ve: 7.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 367 K/uL\n 7.7 g/dL\n 89 mg/dL\n 3.3 mg/dL\n 16 mEq/L\n 4.7 mEq/L\n 100 mg/dL\n 104 mEq/L\n 136 mEq/L\n 25.3 %\n 8.1 K/uL\n [image002.jpg]\n 08:30 PM\n 10:18 PM\n 11:21 PM\n 03:29 AM\n 03:47 AM\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n 02:12 AM\n WBC\n 10.8\n 9.7\n 8.1\n Hct\n 27.8\n 27.8\n 25.3\n Plt\n \n Cr\n 3.1\n 3.2\n 3.3\n TCO2\n 24\n 23\n 22\n 26\n 23\n 24\n 22\n Glucose\n 137\n 133\n 124\n 116\n 122\n 89\n Other labs: PT / PTT / INR:19.6/29.0/1.8, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:7.9 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine. Being\n transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU and appears very\n fluid overloaded on physical exam.\n - pt did not put out well to IV diuresis last night; will hold off on\n further diuresis or fluid at this time\n - continue to closely monitor volume status\n .\n # Atrial Fibrillation: Per previous notes, pt has good control of HR on\n beta blockade and digoxin.\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - coumadin was being held for ?supratherapeutic INR; INR in therapeutic\n range this morning; can restart coumadin after trach\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol.\n - continue phenytoin and phenobarbital\n - appreciate neuro recs\n .\n # Respiratory Failure: Now, intubated with plans to trach pt on .\n - NPO p MN for trach\n - plan for trach placement tomorrow\n - will need FFP prior to trach supratherapeutic INR\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Etiology unclear.\n - need to investigate prior work-up\n .\n # Acute Renal Failure: Per previous notes, renal believes that this is\n ATN. Recommend to not diurese or give IVF's.\n - holding on further diuresis, as above\n - continue to monitor fluid status otherwise\n .\n # Hypothyroidism:\n - continue synthroid 75 mcg daily\n .\n # Fevers: Per notes, pt completed vanc/cefepime 7 day course for\n pneumonia as well as 3 days course of abx for positive UA.\n - f/u cx data\n - follow fever curve\n - stool for c.diff\n ICU Care\n Nutrition:\n Glycemic Control: Comments: Insulin Sliding Scale\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU; Ultimately transfer to LTAC\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 404748,
"text": "Chief Complaint:\n 24 Hour Events:\n PERCUTANEOUS TRACHEOSTOMY - At 03:10 PM\n PEG INSERTION - At 04:01 PM\n Overnight Events:\n -per neurosurg recs, decreased phenobarbital dose to 60 mg and\n checked Dilantin and free Dilantin troughs\n -converted metoprolol to IV as patient was not taking PO's\n -gave FFP prior to trach/PEG\n -patient got trach/PEG\n -gradually decreased dose of phenylephrine\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Vecuronium - 03:03 PM\n Midazolam (Versed) - 04:03 PM\n Fentanyl - 04:03 PM\n Famotidine (Pepcid) - 08:27 PM\n Dilantin - 04:10 AM\n Metoprolol - 06:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 37.4\nC (99.3\n HR: 96 (78 - 102) bpm\n BP: 113/56(76) {104/48(68) - 150/71(101)} mmHg\n RR: 19 (13 - 31) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 96.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 19 (13 - 326)mmHg\n Total In:\n 1,423 mL\n 14 mL\n PO:\n TF:\n 2 mL\n IVF:\n 509 mL\n 14 mL\n Blood products:\n 882 mL\n Total out:\n 460 mL\n 160 mL\n Urine:\n 160 mL\n 60 mL\n NG:\n 100 mL\n Stool:\n 300 mL\n Drains:\n Balance:\n 963 mL\n -146 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 312 (312 - 469) mL\n PS : 15 cmH2O\n RR (Set): 14\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 110\n PIP: 21 cmH2O\n SpO2: 96%\n ABG: ///16/\n Ve: 7.5 L/min\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: ET tube in place; JVD noted.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n Radiated to carotids.\n LUNGS: Ventilated breath sounds.\n ABDOMEN: Obese, S/NT/ND, BS present\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal or painful stimuli.\n Labs / Radiology\n 367 K/uL\n 7.7 g/dL\n 89 mg/dL\n 3.3 mg/dL\n 16 mEq/L\n 4.7 mEq/L\n 100 mg/dL\n 104 mEq/L\n 136 mEq/L\n 25.3 %\n 8.1 K/uL\n [image002.jpg]\n 08:30 PM\n 10:18 PM\n 11:21 PM\n 03:29 AM\n 03:47 AM\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n 02:12 AM\n WBC\n 10.8\n 9.7\n 8.1\n Hct\n 27.8\n 27.8\n 25.3\n Plt\n \n Cr\n 3.1\n 3.2\n 3.3\n TCO2\n 24\n 23\n 22\n 26\n 23\n 24\n 22\n Glucose\n 137\n 133\n 124\n 116\n 122\n 89\n Other labs: PT / PTT / INR:19.6/29.0/1.8, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:7.9 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine. Being\n transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU and appears very\n fluid overloaded on physical exam.\n - pt did not put out well to IV diuresis last night; will hold off on\n further diuresis or fluid at this time\n - continue to closely monitor volume status\n .\n # Atrial Fibrillation: Per previous notes, pt has good control of HR on\n beta blockade and digoxin.\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - coumadin was being held for ?supratherapeutic INR; INR in therapeutic\n range this morning; can restart coumadin after trach\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol.\n - continue phenytoin and phenobarbital\n - appreciate neuro recs\n .\n # Respiratory Failure: Now, intubated with plans to trach pt on .\n - NPO p MN for trach\n - plan for trach placement tomorrow\n - will need FFP prior to trach supratherapeutic INR\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Etiology unclear.\n - need to investigate prior work-up\n .\n # Acute Renal Failure: Per previous notes, renal believes that this is\n ATN. Recommend to not diurese or give IVF's.\n - holding on further diuresis, as above\n - continue to monitor fluid status otherwise\n .\n # Hypothyroidism:\n - continue synthroid 75 mcg daily\n .\n # Fevers: Per notes, pt completed vanc/cefepime 7 day course for\n pneumonia as well as 3 days course of abx for positive UA.\n - f/u cx data\n - follow fever curve\n - stool for c.diff\n ICU Care\n Nutrition:\n Glycemic Control: Comments: Insulin Sliding Scale\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU; Ultimately transfer to LTAC\n"
},
{
"category": "Nutrition",
"chartdate": "2196-02-16 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 404774,
"text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 80.1 kg\n 96.5 kg ( 04:00 AM)\n 28.4\n Pertinent medications: Phenylephrine, RISS, famotidine, folic acid,\n others noted\n Labs:\n Value\n Date\n Glucose\n 89 mg/dL\n 02:12 AM\n Glucose Finger Stick\n 102\n 10:00 AM\n BUN\n 100 mg/dL\n 02:12 AM\n Creatinine\n 3.3 mg/dL\n 02:12 AM\n Sodium\n 136 mEq/L\n 02:12 AM\n Potassium\n 4.7 mEq/L\n 02:12 AM\n Chloride\n 104 mEq/L\n 02:12 AM\n TCO2\n 16 mEq/L\n 02:12 AM\n PO2 (arterial)\n 81. mm Hg\n 02:38 AM\n PCO2 (arterial)\n 38 mm Hg\n 02:38 AM\n pH (arterial)\n 7.36 units\n 02:38 AM\n pH (urine)\n 5.0 units\n 05:33 PM\n CO2 (Calc) arterial\n 22 mEq/L\n 02:38 AM\n Albumin\n 2.7 g/dL\n 06:39 PM\n Calcium non-ionized\n 7.9 mg/dL\n 02:12 AM\n Phosphorus\n 3.5 mg/dL\n 02:12 AM\n Ionized Calcium\n 1.12 mmol/L\n 02:38 AM\n Magnesium\n 1.9 mg/dL\n 02:12 AM\n ALT\n 5 IU/L\n 03:33 AM\n Alkaline Phosphate\n 60 IU/L\n 03:33 AM\n AST\n 28 IU/L\n 03:33 AM\n Total Bilirubin\n 0.2 mg/dL\n 03:33 AM\n Triglyceride\n 98 mg/dL\n 04:27 AM\n Phenytoin (Free)\n 1.9 ug/mL\n 04:39 PM\n Phenytoin (Dilantin)\n 1.5 ug/mL\n 06:39 PM\n WBC\n 8.1 K/uL\n 02:12 AM\n Hgb\n 7.7 g/dL\n 02:12 AM\n Hematocrit\n 25.3 %\n 02:12 AM\n Current diet order / nutrition support: Tube Feeds: Nutren 2.0 @\n 35mL/hr + 21g Beneprotein) = 1755kcals, 85g protien\n GI: abd soft, PEG in place\n Assessment of Nutritional Status\n 86 y.o Female w/ subclinical seizures and deteriorating mental status,\n aspiration pneumonia with a complicated PMHx, now w/ respiratory\n acidosis and failure resulting in intubation (), ARF, hypotension\n requiring phenylephrine drip. Patient remains intubated, unarousable,\n on tube feeds for nutrition, which meet 100% of estimated needs. Renal\n is recommending no dialysis right now given extensive cardiac issues.\n Recommend changing to a renal formula at this time given worsening\n renal function and elevating lytes. Noted deep tissue injury on\n coccyx.\n Medical Nutrition Therapy Plan - Recommend the Following\n Recommend change tube feed goal to Novasource Renal @\n 35mL/hr + 21g Beneprotein (1775kcals, 80g protein) to meet 100% of\n estimated calorie needs and 1.25g protein/kg adjusted wt.\n Will follow plan/progress. #\n 12:37\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 404776,
"text": "Chief Complaint:\n 24 Hour Events:\n PERCUTANEOUS TRACHEOSTOMY - At 03:10 PM\n PEG INSERTION - At 04:01 PM\n Overnight Events:\n -per neurosurg recs, decreased phenobarbital dose to 60 mg and\n checked Dilantin and free Dilantin troughs\n -converted metoprolol to IV as patient was not taking PO's\n -gave FFP prior to trach/PEG\n -patient got trach/PEG\n -gradually decreased dose of phenylephrine\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Vecuronium - 03:03 PM\n Midazolam (Versed) - 04:03 PM\n Fentanyl - 04:03 PM\n Famotidine (Pepcid) - 08:27 PM\n Dilantin - 04:10 AM\n Metoprolol - 06:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 37.4\nC (99.3\n HR: 96 (78 - 102) bpm\n BP: 113/56(76) {104/48(68) - 150/71(101)} mmHg\n RR: 19 (13 - 31) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 96.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 19 (13 - 326)mmHg\n Total In:\n 1,423 mL\n 14 mL\n PO:\n TF:\n 2 mL\n IVF:\n 509 mL\n 14 mL\n Blood products:\n 882 mL\n Total out:\n 460 mL\n 160 mL\n Urine:\n 160 mL\n 60 mL\n NG:\n 100 mL\n Stool:\n 300 mL\n Drains:\n Balance:\n 963 mL\n -146 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 312 (312 - 469) mL\n PS : 15 cmH2O\n RR (Set): 14\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 110\n PIP: 21 cmH2O\n SpO2: 96%\n ABG: ///16/\n Ve: 7.5 L/min\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n Radiates to carotids.\n LUNGS: Ventilated breath sounds.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal or painful stimuli.\n Labs / Radiology\n 367 K/uL\n 7.7 g/dL\n 89 mg/dL\n 3.3 mg/dL\n 16 mEq/L\n 4.7 mEq/L\n 100 mg/dL\n 104 mEq/L\n 136 mEq/L\n 25.3 %\n 8.1 K/uL\n [image002.jpg]\n 08:30 PM\n 10:18 PM\n 11:21 PM\n 03:29 AM\n 03:47 AM\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n 02:12 AM\n WBC\n 10.8\n 9.7\n 8.1\n Hct\n 27.8\n 27.8\n 25.3\n Plt\n \n Cr\n 3.1\n 3.2\n 3.3\n TCO2\n 24\n 23\n 22\n 26\n 23\n 24\n 22\n Glucose\n 137\n 133\n 124\n 116\n 122\n 89\n Other labs: PT / PTT / INR:19.6/29.0/1.8, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:7.9 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine. Being\n transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU and appears very\n fluid overloaded on physical exam. Pt has not responded to IV lasix.\n - holding on further diuresis\n - continue to closely monitor volume status\n .\n # Atrial Fibrillation: Pt has good control of HR on beta blockade and\n digoxin.\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - coumadin was being held for ?supratherapeutic INR; INR subtherapeutic\n this AM; restart heparin gtt and coumadin\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol.\n - continue phenytoin and Phenobarbital, adjusting per neuro recs\n - appreciate neuro recs\n .\n # Respiratory Failure: Now, s/p trach.\n - trach in place\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Able to wean down this morning.\n - will lower MAP goal to try to keep pt off of pressors\n .\n # Acute Renal Failure: Still worsening. Per previous notes, renal\n believes that this is ATN. Recommend to not diurese or give IVF's.\n - holding on further diuresis, as above\n - continue to monitor fluid status otherwise\n .\n # Hypothyroidism:\n - continue synthroid 75 mcg daily\n .\n # Fevers: Per notes, pt completed vanc/cefepime 7 day course for\n pneumonia as well as 3 days course of abx for positive UA. Afebrile\n overnight.\n - f/u cx data\n - follow fever curve\n - stool for c.diff\n ICU Care\n Nutrition:\n Glycemic Control: Comments: Insulin Sliding Scale\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU; Ultimately transfer to LTAC\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 404777,
"text": "Chief Complaint:\n 24 Hour Events:\n PERCUTANEOUS TRACHEOSTOMY - At 03:10 PM\n PEG INSERTION - At 04:01 PM\n Overnight Events:\n -per neurosurg recs, decreased phenobarbital dose to 60 mg and\n checked Dilantin and free Dilantin troughs\n -converted metoprolol to IV as patient was not taking PO's\n -gave FFP prior to trach/PEG\n -patient got trach/PEG\n -gradually decreased dose of phenylephrine\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Vecuronium - 03:03 PM\n Midazolam (Versed) - 04:03 PM\n Fentanyl - 04:03 PM\n Famotidine (Pepcid) - 08:27 PM\n Dilantin - 04:10 AM\n Metoprolol - 06:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 37.4\nC (99.3\n HR: 96 (78 - 102) bpm\n BP: 113/56(76) {104/48(68) - 150/71(101)} mmHg\n RR: 19 (13 - 31) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 96.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 19 (13 - 326)mmHg\n Total In:\n 1,423 mL\n 14 mL\n PO:\n TF:\n 2 mL\n IVF:\n 509 mL\n 14 mL\n Blood products:\n 882 mL\n Total out:\n 460 mL\n 160 mL\n Urine:\n 160 mL\n 60 mL\n NG:\n 100 mL\n Stool:\n 300 mL\n Drains:\n Balance:\n 963 mL\n -146 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 312 (312 - 469) mL\n PS : 15 cmH2O\n RR (Set): 14\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 110\n PIP: 21 cmH2O\n SpO2: 96%\n ABG: ///16/\n Ve: 7.5 L/min\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n Radiates to carotids.\n LUNGS: Ventilated breath sounds.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal or painful stimuli.\n Labs / Radiology\n 367 K/uL\n 7.7 g/dL\n 89 mg/dL\n 3.3 mg/dL\n 16 mEq/L\n 4.7 mEq/L\n 100 mg/dL\n 104 mEq/L\n 136 mEq/L\n 25.3 %\n 8.1 K/uL\n [image002.jpg]\n 08:30 PM\n 10:18 PM\n 11:21 PM\n 03:29 AM\n 03:47 AM\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n 02:12 AM\n WBC\n 10.8\n 9.7\n 8.1\n Hct\n 27.8\n 27.8\n 25.3\n Plt\n \n Cr\n 3.1\n 3.2\n 3.3\n TCO2\n 24\n 23\n 22\n 26\n 23\n 24\n 22\n Glucose\n 137\n 133\n 124\n 116\n 122\n 89\n Other labs: PT / PTT / INR:19.6/29.0/1.8, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:7.9 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine. Being\n transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU and appears very\n fluid overloaded on physical exam. Pt has not responded to IV lasix.\n - holding on further diuresis\n - continue to closely monitor volume status\n .\n # Atrial Fibrillation: Pt has good control of HR on beta blockade and\n digoxin.\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - coumadin was being held for ?supratherapeutic INR; INR subtherapeutic\n this AM; restart heparin gtt and coumadin\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol.\n - continue phenytoin and Phenobarbital, adjusting per neuro recs\n - appreciate neuro recs\n .\n # Respiratory Failure: Now, s/p trach.\n - trach in place\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Able to wean down this morning.\n - will lower MAP goal to try to keep pt off of pressors\n .\n # Acute Renal Failure: Still worsening. Per previous notes, renal\n believes that this is ATN. Recommend to not diurese or give IVF's.\n - holding on further diuresis, as above\n - continue to monitor fluid status otherwise\n .\n # Hypothyroidism:\n - continue synthroid 75 mcg daily\n .\n # Fevers: Per notes, pt completed vanc/cefepime 7 day course for\n pneumonia as well as 3 days course of abx for positive UA. Afebrile\n overnight.\n - f/u cx data\n - follow fever curve\n - stool for c.diff\n ICU Care\n Nutrition:\n Glycemic Control: Comments: Insulin Sliding Scale\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU; Ultimately transfer to LTAC\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 404778,
"text": "Chief Complaint:\n 24 Hour Events:\n PERCUTANEOUS TRACHEOSTOMY - At 03:10 PM\n PEG INSERTION - At 04:01 PM\n Overnight Events:\n -per neurosurg recs, decreased phenobarbital dose to 60 mg and\n checked Dilantin and free Dilantin troughs\n -converted metoprolol to IV as patient was not taking PO's\n -gave FFP prior to trach/PEG\n -patient got trach/PEG\n -gradually decreased dose of phenylephrine\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Vecuronium - 03:03 PM\n Midazolam (Versed) - 04:03 PM\n Fentanyl - 04:03 PM\n Famotidine (Pepcid) - 08:27 PM\n Dilantin - 04:10 AM\n Metoprolol - 06:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 37.4\nC (99.3\n HR: 96 (78 - 102) bpm\n BP: 113/56(76) {104/48(68) - 150/71(101)} mmHg\n RR: 19 (13 - 31) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 96.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 19 (13 - 326)mmHg\n Total In:\n 1,423 mL\n 14 mL\n PO:\n TF:\n 2 mL\n IVF:\n 509 mL\n 14 mL\n Blood products:\n 882 mL\n Total out:\n 460 mL\n 160 mL\n Urine:\n 160 mL\n 60 mL\n NG:\n 100 mL\n Stool:\n 300 mL\n Drains:\n Balance:\n 963 mL\n -146 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 312 (312 - 469) mL\n PS : 15 cmH2O\n RR (Set): 14\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 110\n PIP: 21 cmH2O\n SpO2: 96%\n ABG: ///16/\n Ve: 7.5 L/min\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n Radiates to carotids.\n LUNGS: Ventilated breath sounds.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal or painful stimuli.\n Labs / Radiology\n 367 K/uL\n 7.7 g/dL\n 89 mg/dL\n 3.3 mg/dL\n 16 mEq/L\n 4.7 mEq/L\n 100 mg/dL\n 104 mEq/L\n 136 mEq/L\n 25.3 %\n 8.1 K/uL\n [image002.jpg]\n 08:30 PM\n 10:18 PM\n 11:21 PM\n 03:29 AM\n 03:47 AM\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n 02:12 AM\n WBC\n 10.8\n 9.7\n 8.1\n Hct\n 27.8\n 27.8\n 25.3\n Plt\n \n Cr\n 3.1\n 3.2\n 3.3\n TCO2\n 24\n 23\n 22\n 26\n 23\n 24\n 22\n Glucose\n 137\n 133\n 124\n 116\n 122\n 89\n Other labs: PT / PTT / INR:19.6/29.0/1.8, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:7.9 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine. Being\n transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU and appears very\n fluid overloaded on physical exam. Pt has not responded to IV lasix.\n - holding on further diuresis\n - continue to closely monitor volume status\n .\n # Atrial Fibrillation: Pt has good control of HR on beta blockade and\n digoxin.\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - coumadin was being held for ?supratherapeutic INR; INR subtherapeutic\n this AM; restart heparin gtt and coumadin\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol.\n - continue phenytoin and Phenobarbital, adjusting per neuro recs\n - appreciate neuro recs\n .\n # Respiratory Failure: Now, s/p trach.\n - trach in place\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Able to wean down this morning.\n - will lower MAP goal to try to keep pt off of pressors\n .\n # Acute Renal Failure: Still worsening. Per previous notes, renal\n believes that this is ATN. Recommend to not diurese or give IVF's.\n - holding on further diuresis, as above\n - continue to monitor fluid status otherwise\n .\n # Hypothyroidism:\n - continue synthroid 75 mcg daily\n .\n # Fevers: Per notes, pt completed vanc/cefepime 7 day course for\n pneumonia as well as 3 days course of abx for positive UA. Afebrile\n overnight.\n - f/u cx data\n - follow fever curve\n - stool for c.diff\n ICU Care\n Nutrition:\n Glycemic Control: Comments: Insulin Sliding Scale\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU; Ultimately transfer to LTAC\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n History\n Had trach and PEG placed yesterday.\n Remains unreponsive.\n Continues with oliguric renal failure BUN 100 Cr 3.3.\n Mostly off pressors today.\n Medical Decision Making\n Prognosis terrible.\n Renal failure may be terminal event in near future.\n Total time spent on patient care: 30 minutes of critical care time.\n ------ Protected Section Addendum Entered By: , MD\n on: 02:34 PM ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 405244,
"text": "Demographics\n Day of intubation: 16\n Day of mechanical ventilation: 16\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Copious\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Increase ventilatory support at night\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot manage secretions, Underlying illness not\n resolved\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405248,
"text": "TITLE: PHYSICIAN RESIDENT INTERN NOTE\n Chief Complaint:\n 24 Hour Events:\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,350 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:02 PM\n Dilantin - 03:42 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 95 (91 - 108) bpm\n BP: 96/50(67) {90/50(64) - 138/70(96)} mmHg\n RR: 5 (0 - 27) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 103.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 18 (18 - 25)mmHg\n Total In:\n 1,622 mL\n 460 mL\n PO:\n TF:\n 840 mL\n 255 mL\n IVF:\n 591 mL\n 175 mL\n Blood products:\n Total out:\n 315 mL\n 85 mL\n Urine:\n 315 mL\n 85 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,307 mL\n 375 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 362 (320 - 374) mL\n PS : 15 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 118\n RSBI Deferred: FiO2 > 60%, Hemodynamic Instability\n PIP: 25 cmH2O\n SpO2: 95%\n ABG: 7.32/38/102/18/-5\n Ve: 7.9 L/min\n PaO2 / FiO2: 204\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 422 K/uL\n 7.6 g/dL\n 137 mg/dL\n 3.7 mg/dL\n 18 mEq/L\n 4.8 mEq/L\n 123 mg/dL\n 103 mEq/L\n 137 mEq/L\n 24.7 %\n 7.0 K/uL\n [image002.jpg]\n 03:53 AM\n 04:00 AM\n 04:12 AM\n 02:26 PM\n 11:27 PM\n 11:51 PM\n 01:04 AM\n 02:02 AM\n 04:44 AM\n 05:08 AM\n WBC\n 7.4\n 7.0\n Hct\n 26.6\n 24.7\n Plt\n 462\n 422\n Cr\n 3.8\n 3.7\n TCO2\n 21\n 23\n 21\n 21\n 20\n 20\n Glucose\n 126\n 126\n 120\n 137\n Other labs: PT / PTT / INR:15.0/65.8/1.3, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 03:27 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405254,
"text": "Chief Complaint: Reason for admission: ulcer debridement\n Reason for transfer to CCU: HF and afib\n 24 Hour Events:\n \n - changed PPI to PO\n - started insulin gtt for hyperglycemia\n - transfused 1 units PRBCs\n - attempted diuresis with Lasix + Diuril\n - renal recs: If diuresis does not work, CVVH is unlikely to succeed.\n Could consider inotrope-assisted diuresis.\n - thick secretions (?tube feeds) suctioned from ET tube. Tube feeds\n stopped for night3/28/10\n - changed PPI to PO\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,350 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:02 PM\n Dilantin - 03:42 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 95 (91 - 108) bpm\n BP: 96/50(67) {90/50(64) - 138/70(96)} mmHg\n RR: 5 (0 - 27) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 103.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 18 (18 - 25)mmHg\n Total In:\n 1,622 mL\n 468 mL\n PO:\n TF:\n 840 mL\n 260 mL\n IVF:\n 591 mL\n 178 mL\n Blood products:\n Total out:\n 315 mL\n 85 mL\n Urine:\n 315 mL\n 85 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,307 mL\n 383 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 362 (320 - 374) mL\n PS : 15 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 118\n RSBI Deferred: FiO2 > 60%, Hemodynamic Instability\n PIP: 25 cmH2O\n SpO2: 95%\n ABG: 7.32/38/102/18/-5\n Ve: 7.9 L/min\n PaO2 / FiO2: 204\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 422 K/uL\n 7.6 g/dL\n 137 mg/dL\n 3.7 mg/dL\n 18 mEq/L\n 4.8 mEq/L\n 123 mg/dL\n 103 mEq/L\n 137 mEq/L\n 24.7 %\n 7.0 K/uL\n [image002.jpg]\n 03:53 AM\n 04:00 AM\n 04:12 AM\n 02:26 PM\n 11:27 PM\n 11:51 PM\n 01:04 AM\n 02:02 AM\n 04:44 AM\n 05:08 AM\n WBC\n 7.4\n 7.0\n Hct\n 26.6\n 24.7\n Plt\n 462\n 422\n Cr\n 3.8\n 3.7\n TCO2\n 21\n 23\n 21\n 21\n 20\n 20\n Glucose\n 126\n 126\n 120\n 137\n Other labs: PT / PTT / INR:15.0/65.8/1.3, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:5.1 mg/dL\n Fluid analysis / Other labs: .\n Imaging: PORTABLE CHEST OF \n COMPARISON: .\n INDICATION: Pneumonia and heart failure.\n FINDINGS: Support and monitoring devices are unchanged in position.\n Cardiac\n silhouette remains enlarged, and there is persistent congestive heart\n failure.\n More confluent areas of opacity in the right upper and both lower lobes\n probably represent pneumonia, and appear slightly worse in the right\n upper\n lobe and slightly better in the left lower lobe. Moderate right and\n small\n left pleural effusion are unchanged.\n Microbiology: albicans in blood culture , subsequent\n cultures without growth so far.\n ECG: , G M 66 \n Cardiology Report ECG Study Date of 12:44:48 PM\n Baseline artifact. Probable sinus rhythm with atrial premature beat and\n ventricular premature beats. Left atrial abnormality. Low limb lead\n QRS voltage. Right bundle-branch block. Indeterminate axis. ST-T wave\n changes\n may be primary. Baseline artifact makes assessment difficult. Since the\n previous tracing of there may be no significant change but\n baseline\n artifact makes comparison difficult.\n Read by: , W.\n Intervals Axes\n Rate PR QRS QT/QTc P QRS T\n 81 0 162 430/466 0 0 118\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 03:27 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405255,
"text": "Chief Complaint: Reason for admission: ulcer debridement\n Reason for transfer to CCU: HF and afib\n 24 Hour Events:\n \n - changed PPI to PO\n - started insulin gtt for hyperglycemia\n - transfused 1 units PRBCs\n - attempted diuresis with Lasix + Diuril\n - renal recs: If diuresis does not work, CVVH is unlikely to succeed.\n Could consider inotrope-assisted diuresis.\n - thick secretions (?tube feeds) suctioned from ET tube. Tube feeds\n stopped for night3/28/10\n - changed PPI to PO\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,350 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:02 PM\n Dilantin - 03:42 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 95 (91 - 108) bpm\n BP: 96/50(67) {90/50(64) - 138/70(96)} mmHg\n RR: 5 (0 - 27) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 103.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 18 (18 - 25)mmHg\n Total In:\n 1,622 mL\n 468 mL\n PO:\n TF:\n 840 mL\n 260 mL\n IVF:\n 591 mL\n 178 mL\n Blood products:\n Total out:\n 315 mL\n 85 mL\n Urine:\n 315 mL\n 85 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,307 mL\n 383 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 362 (320 - 374) mL\n PS : 15 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 118\n RSBI Deferred: FiO2 > 60%, Hemodynamic Instability\n PIP: 25 cmH2O\n SpO2: 95%\n ABG: 7.32/38/102/18/-5\n Ve: 7.9 L/min\n PaO2 / FiO2: 204\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 422 K/uL\n 7.6 g/dL\n 137 mg/dL\n 3.7 mg/dL\n 18 mEq/L\n 4.8 mEq/L\n 123 mg/dL\n 103 mEq/L\n 137 mEq/L\n 24.7 %\n 7.0 K/uL\n [image002.jpg]\n 03:53 AM\n 04:00 AM\n 04:12 AM\n 02:26 PM\n 11:27 PM\n 11:51 PM\n 01:04 AM\n 02:02 AM\n 04:44 AM\n 05:08 AM\n WBC\n 7.4\n 7.0\n Hct\n 26.6\n 24.7\n Plt\n 462\n 422\n Cr\n 3.8\n 3.7\n TCO2\n 21\n 23\n 21\n 21\n 20\n 20\n Glucose\n 126\n 126\n 120\n 137\n Other labs: PT / PTT / INR:15.0/65.8/1.3, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:5.1 mg/dL\n Fluid analysis / Other labs: .\n Imaging: PORTABLE CHEST OF \n COMPARISON: .\n INDICATION: Pneumonia and heart failure.\n FINDINGS: Support and monitoring devices are unchanged in position.\n Cardiac\n silhouette remains enlarged, and there is persistent congestive heart\n failure.\n More confluent areas of opacity in the right upper and both lower lobes\n probably represent pneumonia, and appear slightly worse in the right\n upper\n lobe and slightly better in the left lower lobe. Moderate right and\n small\n left pleural effusion are unchanged.\n Microbiology: albicans in blood culture , subsequent\n cultures without growth so far.\n ECG: , G M 66 \n Cardiology Report ECG Study Date of 12:44:48 PM\n Baseline artifact. Probable sinus rhythm with atrial premature beat and\n ventricular premature beats. Left atrial abnormality. Low limb lead\n QRS voltage. Right bundle-branch block. Indeterminate axis. ST-T wave\n changes\n may be primary. Baseline artifact makes assessment difficult. Since the\n previous tracing of there may be no significant change but\n baseline\n artifact makes comparison difficult.\n Read by: , W.\n Intervals Axes\n Rate PR QRS QT/QTc P QRS T\n 81 0 162 430/466 0 0 118\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU. Continues to be\n severely fluid overloaded and oliguric, positive ~30L Los. She does not\n respond well to lasix/diuril/bumex but is also not a candidate for HD.\n -will try PO bumex and metolazone to try to get some diuresis\n - lytes\n -monitor volume status, UOP.\n -holding off on valvuloplasty at this point\n .\n # Atrial Fibrillation: Pt has good control of HR on beta blockade and\n digoxin. Coumadin was being held before for trach/PEG. Now, holding\n coumading in case pt undergoes valvuloplasty. Now on heparin gtt while\n INR subtherapeutic.\n - continue heparin gtt\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - trend coags\n .\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, renal\n believes that this is ATN\n - will attempt diuresis with bumex/metolazone, as above\n - appreciate renal recs.\n - continue to monitor fluid status otherwise\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin boluses and\n phenobarbitol taper. Neuro not sure what is causing continued depressed\n mental status, states she is not having active seizures on EEG. MRI did\n not show any acute changes.\n - continue phenytoin; need to readdress dosing with neuro\n - stopping phenobarbital\n - appreciate neuro input\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Respiratory Failure: Now, s/p trach.\n - trach in place\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Pt weaned off of pressors.\n .\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n .\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - f/u cx data\n - follow fever curve\n - f/u stool for c.diff\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 03:27 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405256,
"text": "Chief Complaint: CHIEF COMPLAINT: CRITICAL AS\n 24 Hour Events:\n \n Neuro recs:\n -phenytoin 300 mg IV bolus now\n -phenytoin 125 mg PO TID\n -check EEG in a.m.\n -phenytoin and free phenytoin tonight\n -do not wean phenobarb tonight (give one more dose tonight)\n -ordered metolazone + bumetanide. Patient did not diurese.\n -gave 1-time dose of phenobarbital in p.m. per neuro recs (had d/c'ed\n on rounds, but neuro felt this was too abrupt). Per neuro, patient will\n not need further doses of phenobarb.\n -1 a.m., noted to be hypoxemic 7.30/42/64 on FiO2 50%. Ventillation\n mode changed to AC and FiO2 increased to 100% with gas subsequently\n 7.35/35/249. CXR unchanged.\n -weaned FiO2\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,350 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:02 PM\n Dilantin - 03:42 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 95 (91 - 108) bpm\n BP: 96/50(67) {90/50(64) - 138/70(96)} mmHg\n RR: 5 (0 - 27) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 103.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 18 (18 - 25)mmHg\n Total In:\n 1,622 mL\n 478 mL\n PO:\n TF:\n 840 mL\n 265 mL\n IVF:\n 591 mL\n 182 mL\n Blood products:\n Total out:\n 315 mL\n 85 mL\n Urine:\n 315 mL\n 85 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,307 mL\n 393 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 362 (320 - 374) mL\n PS : 15 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 118\n RSBI Deferred: FiO2 > 60%, Hemodynamic Instability\n PIP: 25 cmH2O\n SpO2: 95%\n ABG: 7.32/38/102/18/-5\n Ve: 7.9 L/min\n PaO2 / FiO2: 204\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 422 K/uL\n 7.6 g/dL\n 137 mg/dL\n 3.7 mg/dL\n 18 mEq/L\n 4.8 mEq/L\n 123 mg/dL\n 103 mEq/L\n 137 mEq/L\n 24.7 %\n 7.0 K/uL\n [image002.jpg]\n 03:53 AM\n 04:00 AM\n 04:12 AM\n 02:26 PM\n 11:27 PM\n 11:51 PM\n 01:04 AM\n 02:02 AM\n 04:44 AM\n 05:08 AM\n WBC\n 7.4\n 7.0\n Hct\n 26.6\n 24.7\n Plt\n 462\n 422\n Cr\n 3.8\n 3.7\n TCO2\n 21\n 23\n 21\n 21\n 20\n 20\n Glucose\n 126\n 126\n 120\n 137\n Other labs: PT / PTT / INR:15.0/65.8/1.3, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:5.1 mg/dL\n Fluid analysis / Other labs: .\n Imaging: CXR from this a.m.\n Microbiology: Yeast in urine and sputum.\n ECG: .\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 03:27 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405257,
"text": "Chief Complaint: CHIEF COMPLAINT: CRITICAL AS\n 24 Hour Events:\n \n Neuro recs:\n -phenytoin 300 mg IV bolus now\n -phenytoin 125 mg PO TID\n -check EEG in a.m.\n -phenytoin and free phenytoin tonight\n -do not wean phenobarb tonight (give one more dose tonight)\n -ordered metolazone + bumetanide. Patient did not diurese.\n -gave 1-time dose of phenobarbital in p.m. per neuro recs (had d/c'ed\n on rounds, but neuro felt this was too abrupt). Per neuro, patient will\n not need further doses of phenobarb.\n -1 a.m., noted to be hypoxemic 7.30/42/64 on FiO2 50%. Ventillation\n mode changed to AC and FiO2 increased to 100% with gas subsequently\n 7.35/35/249. CXR unchanged.\n -weaned FiO2\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,350 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:02 PM\n Dilantin - 03:42 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 95 (91 - 108) bpm\n BP: 96/50(67) {90/50(64) - 138/70(96)} mmHg\n RR: 5 (0 - 27) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 103.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 18 (18 - 25)mmHg\n Total In:\n 1,622 mL\n 478 mL\n PO:\n TF:\n 840 mL\n 265 mL\n IVF:\n 591 mL\n 182 mL\n Blood products:\n Total out:\n 315 mL\n 85 mL\n Urine:\n 315 mL\n 85 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,307 mL\n 393 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 362 (320 - 374) mL\n PS : 15 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 118\n RSBI Deferred: FiO2 > 60%, Hemodynamic Instability\n PIP: 25 cmH2O\n SpO2: 95%\n ABG: 7.32/38/102/18/-5\n Ve: 7.9 L/min\n PaO2 / FiO2: 204\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 422 K/uL\n 7.6 g/dL\n 137 mg/dL\n 3.7 mg/dL\n 18 mEq/L\n 4.8 mEq/L\n 123 mg/dL\n 103 mEq/L\n 137 mEq/L\n 24.7 %\n 7.0 K/uL\n [image002.jpg]\n 03:53 AM\n 04:00 AM\n 04:12 AM\n 02:26 PM\n 11:27 PM\n 11:51 PM\n 01:04 AM\n 02:02 AM\n 04:44 AM\n 05:08 AM\n WBC\n 7.4\n 7.0\n Hct\n 26.6\n 24.7\n Plt\n 462\n 422\n Cr\n 3.8\n 3.7\n TCO2\n 21\n 23\n 21\n 21\n 20\n 20\n Glucose\n 126\n 126\n 120\n 137\n Other labs: PT / PTT / INR:15.0/65.8/1.3, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:5.1 mg/dL\n Fluid analysis / Other labs: .\n Imaging: CXR from this a.m.\n Microbiology: Yeast in urine and sputum.\n ECG: .\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU. Continues to be\n severely fluid overloaded and oliguric, positive ~30L Los. She does not\n respond well to lasix/diuril/bumex but is also not a candidate for HD.\n -will try PO bumex and metolazone to try to get some diuresis\n - lytes\n -monitor volume status, UOP.\n -holding off on valvuloplasty at this point\n .\n # Atrial Fibrillation: Pt has good control of HR on beta blockade and\n digoxin. Coumadin was being held before for trach/PEG. Now, holding\n coumading in case pt undergoes valvuloplasty. Now on heparin gtt while\n INR subtherapeutic.\n - continue heparin gtt\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - trend coags\n .\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, renal\n believes that this is ATN\n - will attempt diuresis with bumex/metolazone, as above\n - appreciate renal recs.\n - continue to monitor fluid status otherwise\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin boluses and\n phenobarbitol taper. Neuro not sure what is causing continued depressed\n mental status, states she is not having active seizures on EEG. MRI did\n not show any acute changes.\n - continue phenytoin; need to readdress dosing with neuro\n - stopping phenobarbital\n - appreciate neuro input\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Respiratory Failure: Now, s/p trach.\n - trach in place\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Pt weaned off of pressors.\n .\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n .\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - f/u cx data\n - follow fever curve\n - f/u stool for c.diff\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 03:27 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2196-02-11 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 404356,
"text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 80.1 kg\n 96.5 kg ( 04:00 AM)\n 28.4\n Pertinent medications: RISS, folic acid, lasix, famotidine,\n phenobarbital, cipro, warfarin, others noted\n Labs:\n Value\n Date\n Glucose\n 120 mg/dL\n 02:38 AM\n Glucose Finger Stick\n 160\n 10:00 AM\n BUN\n 70 mg/dL\n 10:24 AM\n Creatinine\n 2.5 mg/dL\n 10:24 AM\n Sodium\n 140 mEq/L\n 02:38 AM\n Potassium\n 4.0 mEq/L\n 02:38 AM\n Chloride\n 105 mEq/L\n 02:38 AM\n TCO2\n 23 mEq/L\n 02:38 AM\n PO2 (arterial)\n 142 mm Hg\n 03:18 AM\n PCO2 (arterial)\n 37 mm Hg\n 03:18 AM\n pH (arterial)\n 7.37 units\n 03:18 AM\n pH (urine)\n 5.0 units\n 02:03 PM\n CO2 (Calc) arterial\n 22 mEq/L\n 03:18 AM\n Albumin\n 2.4 g/dL\n 02:38 AM\n Calcium non-ionized\n 7.7 mg/dL\n 02:38 AM\n Phosphorus\n 2.2 mg/dL\n 02:38 AM\n Ionized Calcium\n 1.10 mmol/L\n 03:18 AM\n Magnesium\n 2.0 mg/dL\n 02:38 AM\n ALT\n 5 IU/L\n 03:33 AM\n Alkaline Phosphate\n 60 IU/L\n 03:33 AM\n AST\n 28 IU/L\n 03:33 AM\n Total Bilirubin\n 0.2 mg/dL\n 03:33 AM\n Triglyceride\n 98 mg/dL\n 04:27 AM\n Phenytoin (Free)\n 1.9 ug/mL\n 04:39 PM\n Phenytoin (Dilantin)\n 8.6 ug/mL\n 08:00 AM\n WBC\n 10.4 K/uL\n 02:38 AM\n Hgb\n 9.2 g/dL\n 02:38 AM\n Hematocrit\n 30.4 %\n 02:38 AM\n Current diet order / nutrition support: Tube Feeds: Nutren 2.0 @\n 35mL/hr + 21g Beneprotein (1755kcals, 85g protein)\n GI: abd soft, obese, bowel sounds present, liquid brown stool via\n flexiseal\n Assessment of Nutritional Status\n 86 y.o Female w/ subclinical seizures and deteriorating mental status,\n aspiration pneumonia with a complicated PMHx, now w/ respiratory\n acidosis and failure resulting in intubation (), ARF, hypotension\n requiring phenylephrine drip. Patient remains intubated, unarousable,\n on tube feeds for nutrition, which meets 100% of estimated needs.\n Patient is tolerating tube feeds at goal. Noted plan for family\n meeting to address plan of care and code status .\n Medical Nutrition Therapy Plan - Recommend the Following\n Recommend continue with tube feeds at goal.\n Will follow plan/progress.\n #\n 12:14 PM\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402966,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 10:12 PM\n temp 101 R\n URINE CULTURE - At 10:12 PM\n temp 101 R,blood and urine cultures sent, defervesced to 99.\n Pyuria noted on UA. culture data pending.\n Continues on vanc/cefepime/flagyl started for aspiration PNA.\n Diarrhrea?\n -C. diff toxin negative\n -She continues on a lasix drip for diuresis which was uptitrated from\n to with goal UOP 500cc which she did not achieve, putting out approx\n /hr\n and ended up running even. She was able to maintain her BP's in the low\n 100's systolic and remained rate controlled for her afib.\n -\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Cefipime - 08:13 PM\n Vancomycin - 08:47 PM\n Metronidazole - 05:30 AM\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.2\nC (99\n HR: 85 (75 - 107) bpm\n BP: 113/55(70) {95/39(53) - 145/74(96)} mmHg\n RR: 17 (12 - 27) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 81.2 kg (admission): 80.1 kg\n Total In:\n 1,770 mL\n 421 mL\n PO:\n 400 mL\n 50 mL\n TF:\n IVF:\n 1,370 mL\n 371 mL\n Blood products:\n Total out:\n 1,730 mL\n 650 mL\n Urine:\n 1,730 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 40 mL\n -229 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///36/\n Physical Examination\n Gen:comfortable\n CVS: 4/6 SEM heard best at RUSB, radiating throughout precordium, S1 S2\n clear\n Resp Mouth breathes, but no longer retracting, bilateral crackles,\n moderately improved, no wheeze, wet cough, unable to clear\n Abd: +bs, soft, NT, nD\n Ext: WWP, 2+ distal pulses,\n Neuro: new anisicoria, with R from and L from with light, left\n sided weakness stable\n Able to follow commands, Alert and oriented to person and place,\n disoriented to time, overall improved.\n Venous stasis ulcers with bandaging to mid shin/C/DI\n Labs / Radiology\n 323 K/uL\n 8.7 g/dL\n 109 mg/dL\n 1.1 mg/dL\n 36 mEq/L\n 3.9 mEq/L\n 22 mg/dL\n 101 mEq/L\n 141 mEq/L\n 30.7 %\n 7.0 K/uL\n [image002.jpg]\n 04:27 AM\n 07:42 PM\n 09:22 PM\n 05:40 AM\n 02:18 PM\n 05:28 AM\n 02:25 PM\n 09:34 PM\n 04:56 AM\n WBC\n 11.7\n 9.9\n 8.2\n 7.0\n Hct\n 34.7\n 30.6\n 30.0\n 30.7\n Plt\n 23\n Cr\n 0.8\n 1.0\n 1.0\n 1.0\n 1.2\n 1.1\n 1.1\n TropT\n 0.02\n TCO2\n 34\n 35\n Glucose\n 107\n 87\n 85\n 113\n 137\n 153\n 109\n Other labs: PT / PTT / INR:15.9/32.2/1.4, CK / CKMB /\n Troponin-T:15//0.02, ALT / AST:, Alk Phos / T Bili:62/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca++:8.2 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n KNOWLEDGE DEFICIT\n IMPAIRED SKIN INTEGRITY\n PNEUMONIA, ASPIRATION\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:01 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Social Work",
"chartdate": "2196-02-01 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 403051,
"text": "SOCIAL WORK: Pt referred to SW by RN to support pt and family coping.\n Pt is an 86yo married woman with a complex past medical history\n recently treated for colon cancer, s/p colectomy in . She\n has subsequently been in rehab and readmitted s/p seizure, currently on\n CCU. RN, pt is full code. SW met with pt\ns husband, and son\n in her room, pt somnolent, but appears distressed. Family seeming to\n quietly sit vigil, husb and son report pt seems improved over\n yesterday, whereas, feels she is worse. Role of SW explained,\n including availability to provide emotional support and assist in\n facilitating communication with team or helping to coordinate family\n meetings if needed. Family receptive to SW involvement. SW will\n follow with CCU team.\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 404839,
"text": "Chief Complaint:\n 24 Hour Events:\n Overnight Events:\n - spoke with neuro: recommended resuming EEG; concerned that patient\n has not woken up yet (as she is not having active seizures on EEG) and\n recommending LP to look for infectious etiology as well as MRI to look\n for watershed infarct. EEG ordered. LP to be performed (? goals of\n care)\n - back on pressors (neo)in afternoon\n - restarted coumadin at 1mg\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 12:02 PM\n Coumadin (Warfarin) - 04:46 PM\n Famotidine (Pepcid) - 08:00 PM\n Dilantin - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.2\nC (99\n HR: 94 (90 - 107) bpm\n BP: 110/49(71) {101/49(69) - 128/62(86)} mmHg\n RR: 27 (12 - 30) insp/min\n SpO2: 80%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 102.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 12 (12 - 21)mmHg\n Total In:\n 718 mL\n 291 mL\n PO:\n 90 mL\n 30 mL\n TF:\n 526 mL\n 243 mL\n IVF:\n 102 mL\n 17 mL\n Blood products:\n Total out:\n 219 mL\n 60 mL\n Urine:\n 119 mL\n 60 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 499 mL\n 231 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 373 (300 - 373) mL\n PS : 15 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 21 cmH2O\n SpO2: 80%\n ABG: ///19/\n Ve: 10.9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 436 K/uL\n 7.9 g/dL\n 96 mg/dL\n 3.6 mg/dL\n 19 mEq/L\n 5.1 mEq/L\n 107 mg/dL\n 102 mEq/L\n 136 mEq/L\n 25.6 %\n 7.4 K/uL\n [image002.jpg]\n 10:18 PM\n 11:21 PM\n 03:29 AM\n 03:47 AM\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n 02:12 AM\n 02:44 AM\n WBC\n 10.8\n 9.7\n 8.1\n 7.4\n Hct\n 27.8\n 27.8\n 25.3\n 25.6\n Plt\n 36\n Cr\n 3.1\n 3.2\n 3.3\n 3.6\n TCO2\n 23\n 22\n 26\n 23\n 24\n 22\n Glucose\n 133\n 124\n 116\n 122\n 89\n 96\n Other labs: PT / PTT / INR:27.7/31.9/2.7, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:72.6 %, Lymph:14.7 %, Mono:6.6 %,\n Eos:5.9 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.1 mg/dL, Mg++:2.1 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n INEFFECTIVE COPING\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n KNOWLEDGE DEFICIT\n IMPAIRED SKIN INTEGRITY\n PNEUMONIA, ASPIRATION\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:39 AM 35 mL/hour\n Glycemic Control: Comments: ISS\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 404840,
"text": "Chief Complaint:\n 24 Hour Events:\n Overnight Events:\n - spoke with neuro: recommended resuming EEG; concerned that patient\n has not woken up yet (as she is not having active seizures on EEG) and\n recommending LP to look for infectious etiology as well as MRI to look\n for watershed infarct. EEG ordered. LP to be performed (? goals of\n care)\n - back on pressors (neo)in afternoon\n - restarted coumadin at 1mg\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 12:02 PM\n Coumadin (Warfarin) - 04:46 PM\n Famotidine (Pepcid) - 08:00 PM\n Dilantin - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.2\nC (99\n HR: 94 (90 - 107) bpm\n BP: 110/49(71) {101/49(69) - 128/62(86)} mmHg\n RR: 27 (12 - 30) insp/min\n SpO2: 80%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 102.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 12 (12 - 21)mmHg\n Total In:\n 718 mL\n 291 mL\n PO:\n 90 mL\n 30 mL\n TF:\n 526 mL\n 243 mL\n IVF:\n 102 mL\n 17 mL\n Blood products:\n Total out:\n 219 mL\n 60 mL\n Urine:\n 119 mL\n 60 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 499 mL\n 231 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 373 (300 - 373) mL\n PS : 15 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 21 cmH2O\n SpO2: 80%\n ABG: ///19/\n Ve: 10.9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 436 K/uL\n 7.9 g/dL\n 96 mg/dL\n 3.6 mg/dL\n 19 mEq/L\n 5.1 mEq/L\n 107 mg/dL\n 102 mEq/L\n 136 mEq/L\n 25.6 %\n 7.4 K/uL\n [image002.jpg]\n 10:18 PM\n 11:21 PM\n 03:29 AM\n 03:47 AM\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n 02:12 AM\n 02:44 AM\n WBC\n 10.8\n 9.7\n 8.1\n 7.4\n Hct\n 27.8\n 27.8\n 25.3\n 25.6\n Plt\n 36\n Cr\n 3.1\n 3.2\n 3.3\n 3.6\n TCO2\n 23\n 22\n 26\n 23\n 24\n 22\n Glucose\n 133\n 124\n 116\n 122\n 89\n 96\n Other labs: PT / PTT / INR:27.7/31.9/2.7, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:72.6 %, Lymph:14.7 %, Mono:6.6 %,\n Eos:5.9 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.1 mg/dL, Mg++:2.1 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine. Being\n transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU and appears very\n fluid overloaded on physical exam. Pt has not responded to IV lasix.\n - holding on further diuresis\n - continue to closely monitor volume status\n .\n # Atrial Fibrillation: Pt has good control of HR on beta blockade and\n digoxin.\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - coumadin was being held for ?supratherapeutic INR; INR subtherapeutic\n this AM; restart heparin gtt and coumadin\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol.\n - continue phenytoin and Phenobarbital, adjusting per neuro recs\n - appreciate neuro recs\n .\n # Respiratory Failure: Now, s/p trach.\n - trach in place\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Able to wean down this morning.\n - will lower MAP goal to try to keep pt off of pressors\n .\n # Acute Renal Failure: Still worsening. Per previous notes, renal\n believes that this is ATN. Recommend to not diurese or give IVF's.\n - holding on further diuresis, as above\n - continue to monitor fluid status otherwise\n .\n # Hypothyroidism:\n - continue synthroid 75 mcg daily\n .\n # Fevers: Per notes, pt completed vanc/cefepime 7 day course for\n pneumonia as well as 3 days course of abx for positive UA. Afebrile\n overnight.\n - f/u cx data\n - follow fever curve\n - stool for c.diff\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:39 AM 35 mL/hour\n Glycemic Control: Comments: ISS\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 404841,
"text": "Chief Complaint:\n 24 Hour Events:\n Overnight Events:\n - spoke with neuro: recommended resuming EEG; concerned that patient\n has not woken up yet (as she is not having active seizures on EEG) and\n recommending LP to look for infectious etiology as well as MRI to look\n for watershed infarct. EEG ordered. LP to be performed (? goals of\n care)\n - back on pressors (neo)in afternoon\n - restarted coumadin at 1mg\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 12:02 PM\n Coumadin (Warfarin) - 04:46 PM\n Famotidine (Pepcid) - 08:00 PM\n Dilantin - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.2\nC (99\n HR: 94 (90 - 107) bpm\n BP: 110/49(71) {101/49(69) - 128/62(86)} mmHg\n RR: 27 (12 - 30) insp/min\n SpO2: 80%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 102.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 12 (12 - 21)mmHg\n Total In:\n 718 mL\n 291 mL\n PO:\n 90 mL\n 30 mL\n TF:\n 526 mL\n 243 mL\n IVF:\n 102 mL\n 17 mL\n Blood products:\n Total out:\n 219 mL\n 60 mL\n Urine:\n 119 mL\n 60 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 499 mL\n 231 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 373 (300 - 373) mL\n PS : 15 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 21 cmH2O\n SpO2: 80%\n ABG: ///19/\n Ve: 10.9 L/min\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n Radiates to carotids.\n LUNGS: Ventilated breath sounds.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal or painful stimuli.\n Labs / Radiology\n 436 K/uL\n 7.9 g/dL\n 96 mg/dL\n 3.6 mg/dL\n 19 mEq/L\n 5.1 mEq/L\n 107 mg/dL\n 102 mEq/L\n 136 mEq/L\n 25.6 %\n 7.4 K/uL\n [image002.jpg]\n 10:18 PM\n 11:21 PM\n 03:29 AM\n 03:47 AM\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n 02:12 AM\n 02:44 AM\n WBC\n 10.8\n 9.7\n 8.1\n 7.4\n Hct\n 27.8\n 27.8\n 25.3\n 25.6\n Plt\n 36\n Cr\n 3.1\n 3.2\n 3.3\n 3.6\n TCO2\n 23\n 22\n 26\n 23\n 24\n 22\n Glucose\n 133\n 124\n 116\n 122\n 89\n 96\n Other labs: PT / PTT / INR:27.7/31.9/2.7, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:72.6 %, Lymph:14.7 %, Mono:6.6 %,\n Eos:5.9 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.1 mg/dL, Mg++:2.1 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine. Being\n transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU and appears very\n fluid overloaded on physical exam. Pt has not responded to IV lasix.\n - holding on further diuresis\n - continue to closely monitor volume status\n .\n # Atrial Fibrillation: Pt has good control of HR on beta blockade and\n digoxin.\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - coumadin was being held for ?supratherapeutic INR; INR subtherapeutic\n this AM; restart heparin gtt and coumadin\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol.\n - continue phenytoin and Phenobarbital, adjusting per neuro recs\n - appreciate neuro recs\n .\n # Respiratory Failure: Now, s/p trach.\n - trach in place\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Able to wean down this morning.\n - will lower MAP goal to try to keep pt off of pressors\n .\n # Acute Renal Failure: Still worsening. Per previous notes, renal\n believes that this is ATN. Recommend to not diurese or give IVF's.\n - holding on further diuresis, as above\n - continue to monitor fluid status otherwise\n .\n # Hypothyroidism:\n - continue synthroid 75 mcg daily\n .\n # Fevers: Per notes, pt completed vanc/cefepime 7 day course for\n pneumonia as well as 3 days course of abx for positive UA. Afebrile\n overnight.\n - f/u cx data\n - follow fever curve\n - stool for c.diff\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:39 AM 35 mL/hour\n Glycemic Control: Comments: ISS\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-19 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 405021,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 13\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont trached and on mech vent as per Metavision. Lung\n sounds rhonchi suct sm th tan sput. Pt in NARD on current settings; no\n vent changes required overnoc. Cont PSV.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405237,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405314,
"text": "Chief Complaint: CHIEF COMPLAINT: CRITICAL AS\n 24 Hour Events:\n Notes from on call intern:\n \n Neuro recs:\n -phenytoin 300 mg IV bolus now\n -phenytoin 125 mg PO TID\n -check EEG in a.m.\n -phenytoin and free phenytoin tonight\n -do not wean phenobarb tonight (give one more dose tonight)\n -ordered metolazone + bumetanide. Patient did not diurese.\n -gave 1-time dose of phenobarbital in p.m. per neuro recs (had d/c'ed\n on rounds, but neuro felt this was too abrupt). Per neuro, patient will\n not need further doses of phenobarb.\n -1 a.m., noted to be hypoxemic 7.30/42/64 on FiO2 50%. Ventillation\n mode changed to AC and FiO2 increased to 100% with gas subsequently\n 7.35/35/249. CXR unchanged.\n -weaned FiO2\n However, per Neurology this a.m.:\n - Do not stop Phenobarbital precipitously\n may result in\n seizure.\n - Per Neurology, unlikely AEDs causing mental status changes,\n therefore need to proceed with LP to ensure no\n carcinomatosis/paraneoplastic syndrome.\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,350 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:02 PM\n Dilantin - 03:42 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 95 (91 - 108) bpm\n BP: 96/50(67) {90/50(64) - 138/70(96)} mmHg\n RR: 5 (0 - 27) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 103.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 18 (18 - 25)mmHg\n Total In:\n 1,622 mL\n 478 mL\n PO:\n TF:\n 840 mL\n 265 mL\n IVF:\n 591 mL\n 182 mL\n Blood products:\n Total out:\n 315 mL\n 85 mL\n Urine:\n 315 mL\n 85 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,307 mL\n 393 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 362 (320 - 374) mL\n PS : 15 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 118\n RSBI Deferred: FiO2 > 60%, Hemodynamic Instability\n PIP: 25 cmH2O\n SpO2: 95%\n ABG: 7.32/38/102/18/-5\n Ve: 7.9 L/min\n PaO2 / FiO2: 204\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n LUNGS: Ventilated breath sounds. Unable to hear good breath sounds at\n the bases.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Comatose (GCS 3), no plantar response on left and small upgoing\n on right. Jaw jerk hyperactive, glalbella tap present, corneals WNLs\n bilaterally. No doll\ns eyes to lateral head roll. PERRL.\n Labs / Radiology\n 422 K/uL\n 7.6 g/dL\n 137 mg/dL\n 3.7 mg/dL\n 18 mEq/L\n 4.8 mEq/L\n 123 mg/dL\n 103 mEq/L\n 137 mEq/L\n 24.7 %\n 7.0 K/uL\n [image002.jpg]\n 03:53 AM\n 04:00 AM\n 04:12 AM\n 02:26 PM\n 11:27 PM\n 11:51 PM\n 01:04 AM\n 02:02 AM\n 04:44 AM\n 05:08 AM\n WBC\n 7.4\n 7.0\n Hct\n 26.6\n 24.7\n Plt\n 462\n 422\n Cr\n 3.8\n 3.7\n TCO2\n 21\n 23\n 21\n 21\n 20\n 20\n Glucose\n 126\n 126\n 120\n 137\n Other labs: PT / PTT / INR:15.0/65.8/1.3, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:5.1 mg/dL\n Fluid analysis / Other labs: .\n Imaging: CXR from this a.m.\n Microbiology: Yeast in urine and sputum.\n ECG: .\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures (now none for a week on EEG) and deteriorating\n mental status, aspiration pneumonia, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension requiring\n phenylephrine. Transferred to CCU at request of family and consulting\n cardiologist.\n # Coma, seizures, Goals of Care\n Comatose with some brainstem reflexes. No seizures for some time. No\n evidence of cortical function. BUN 123 and patient has been\n intermittently hypotensive. Therefore differential includes (also\n possible multifactorial) uremia, anoxic brain injury and\n carcinoatosis/paraneoplastic encephalopathy. Not likely related to\n presently low levels of AEDs. Given this state, we need to aggressively\n treat reversible causes, if present, then determine whether further\n cardiac interventions are warranted This will require some further\n investigations and discussion with Dr , Neurology, the family.\n - Attending and family keen to stop AEDs, so will need to check with\n them prior to giving phenobarbital\n - LP today for cytology\n - Continue phenytoin\n # Aortic Stenosis\n Treatment of this is deferred pending decision about the above.\n Valvuloplasty will need to be repeated (if this is compatible with\n goals of care). Pt with known severe aortic stenosis s/p valvuloplasty\n in . She was initially on the CCU service early in her\n hospitalization in the setting of flash pulmonary edema when her lasix\n were held. Now, she is intubated in the ICU. Continues to be severely\n fluid overloaded and oliguric, positive ~30L Los. She does not respond\n well to lasix/diuril/bumex but is also not a candidate for HD.\n - Continue bumex and metolazone with goal of net negative 1.5L today\n - lytes\n - Monitor volume status, UOP.\n - Holding off on valvuloplasty at this point\n # Respiratory Failure and Intubation\n - Preserve for now given mental status and edema\n # Atrial Fibrillation\n Pt has good control of HR on beta blockade and digoxin. Coumadin was\n being held before for trach/PEG. Now, holding coumading in case pt\n undergoes valvuloplasty. Now on heparin gtt while INR subtherapeutic.\n - Stop heparin this a.m. for LP this afternoon\n - Continue metoprolol tartrate 25 mg TID\n - Continue digoxin 0.0625 mg daily\n - Trend coags\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, is ATN\n - Will attempt diuresis with bumex/metolazone, as above\n - Appreciate renal recs.\n - Continue to monitor fluid status otherwise\n # Coronary Artery Disease: Pt is s/p CABG /.\n - Continue metoprolol as above\n - Continue aspirin 81 mg daily, atorvastatin 40 mg daily\n # Respiratory Failure: Now, s/p trach.\n - Trach in place\n - Continue albuterol/atrovent PRN\n # Pressor Requirement: Pt weaned off of pressors.\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - f/u cx data\n - follow fever curve\n - f/u stool for c.diff\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 03:27 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the note by Dr. today and I agree with\n the plan.\n I would add the following remarks:\n History\n Still poorly responsive to verbal stimuli and pain.\n Medical Decision Making\n Will continue to taper phenobarbital in an effort to reverse metabolic\n encephalopathy.\n Family meeting to discuss options is scheduled for Wednesday.\n Above discussed extensively with family member, next of or health\n care proxy.\n Total time spent on patient care: 30 minutes of critical care time\n ------ Protected Section Addendum Entered By: , MD\n on: 21:06 ------\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405239,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with anasarca, oliguric. Elevated BUN/Cr, K. metabolic acidocis.\n Action:\n Monitored, BUN/Cr, pt receiving zaroxalyn, bumex.\n Response:\n No response to diuretics, continues with oliguria.\n Plan:\n Continue to monitor. Team aware of low urine output.\n Seizure, without status epilepticus\n Assessment:\n No sz activity noted this shift. Pt unresponsive to nailbed pressure.\n PERRL. No spontaneous movement. +corneals. Noted to grimace once\n during care.\n Action:\n Monitored, neuro assessments, dilantin and\n Response:\n Plan:\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404100,
"text": "Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-13 00:00:00.000",
"description": "Intensivist Note",
"row_id": 404511,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. At time of SICU admission, she\n responded only to painful stimuli\n Chief complaint:\n Seizures\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n Acetaminophen 7. Albuterol 0.083% Neb Soln 8. Albuterol Inhaler 9.\n Aspirin\n 10. Atorvastatin 11. Bacitracin-Polymyxin Ointment 12. Calcium\n Gluconate 13. Chlorhexidine Gluconate 0.12% Oral Rinse\n 14. Collagenase Ointment 15. Dextrose 50% 16. Digoxin 17. Famotidine\n 18. Fentanyl Citrate 19. FoLIC Acid\n 20. Glucagon 21. 22. Insulin 23. Ipratropium Bromide MDI 24.\n Ipratropium Bromide Neb 25. Latanoprost 0.005% Ophth. Soln.\n 26. Levothyroxine Sodium 27. LeVETiracetam 28. Lidocaine 5% Patch 29.\n Lorazepam 30. Magnesium Sulfate\n 31. Metoprolol Tartrate 32. Miconazole Powder 2% 33. Nystatin Oral\n Suspension 34. PHENObarbital 35. Phenytoin Sodium (IV)\n 36. Phenylephrine 37. Phenytoin Sodium (IV) 38. Potassium Chloride 39.\n Sodium Chloride 0.9% Flush\n 40. Sodium Chloride 0.9% Flush 41. Sodium Chloride 0.9% Flush 42.\n Sodium Chloride 0.9% Flush 43. Timolol Maleate 0.5%\n 24 Hour Events:\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Dilantin - 02:09 AM\n Other medications:\n Flowsheet Data as of 04:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 37.6\nC (99.7\n HR: 89 (80 - 93) bpm\n BP: 136/58(87) {107/46(66) - 136/58(87)} mmHg\n RR: 21 (18 - 33) insp/min\n SPO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 96.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 16 (10 - 16) mmHg\n Total In:\n 1,928 mL\n 319 mL\n PO:\n Tube feeding:\n 840 mL\n 144 mL\n IV Fluid:\n 858 mL\n 175 mL\n Blood products:\n Total out:\n 177 mL\n 30 mL\n Urine:\n 177 mL\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,751 mL\n 289 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 21 cmH2O\n Plateau: 20 cmH2O\n SPO2: 94%\n ABG: 7.35/44/80./22/-1\n Ve: 7.7 L/min\n PaO2 / FiO2: 200\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Neurologic: (Responds to: Noxious stimuli), No(t) Moves all\n extremities, (RUE: No movement), (LUE: No movement), (RLE: Weakness),\n (LLE: Weakness), withdraws lowers to pain\n Labs / Radiology\n 393 K/uL\n 9.0 g/dL\n 124 mg/dL\n 3.0 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 81 mg/dL\n 103 mEq/L\n 137 mEq/L\n 30.3 %\n 10.1 K/uL\n [image002.jpg]\n 06:15 PM\n 02:54 AM\n 03:18 AM\n 02:38 AM\n 10:24 AM\n 03:06 AM\n 03:29 AM\n 12:15 PM\n 02:20 AM\n 02:31 AM\n WBC\n 9.7\n 9.7\n 10.4\n 10.4\n 10.1\n Hct\n 30.1\n 29.7\n 30.4\n 30.2\n 30.3\n Plt\n 382\n 381\n 368\n 428\n 393\n Creatinine\n 2.2\n 2.2\n 2.5\n 2.5\n 2.7\n 3.0\n TCO2\n 22\n 25\n 22\n 25\n Glucose\n 107\n 120\n 112\n 124\n Other labs: PT / PTT / INR:29.5/33.7/2.9, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:60/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca:7.8 mg/dL, Mg:1.9 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), INEFFECTIVE COPING,\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), KNOWLEDGE DEFICIT, IMPAIRED\n SKIN INTEGRITY, PNEUMONIA, ASPIRATION, AORTIC STENOSIS, SEIZURE,\n WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension requiring\n phenylephrine.\n Neurologic: -- Patient sedated with minimal doses intermittent fentanyl\n prn.\n -- Patient with seizures, loaded with dilantin and ativan PRN prior to\n admission with poor mental status. Despite loading dose continued to\n have sub clinical seziures on EEG. Medication regimen changed,\n currently on phenytoin (Goal 15-20), Keppra and phenobarbitol.\n --Delayed Withdrawal to pain in all extremities\n -- f/u AM dilantin level given load yesterday\n Cardiovascular: -- PAF with good control of HR on beta blockade and\n digoxin. Anticoagulation started with coumadin. Coumadin held for now\n given elevated INR, will bridge with heparin once INR<2.0. On ASA\n -- CAD s/p CABG , diastolic dysfunction. On b-blockade, ASA, and\n statin.\n -- Critical AS (valve area pre-valvuloplasty 0.8cm2, post\n vavluloplasty). On ICU-based ECHO estimated area is 0.6cm2. Likely not\n eligible for open valve replacement. Family is discussing this issue\n with another cardiologist.\n --Cont phenylephrine as needed, goal SBP>120, MAP>70\n Pulmonary: --albuterol/atrovent PRN\n --pan for trach \n --wean vent as tolerated\n Gastrointestinal / Abdomen: --TFs at goal,plan for PEG \n Nutrition: --TF continued\n Renal: -- Lasix held\n -- Pt still requires neosynephrine for MAPs > 65\n -- Cr increasing: now at 3, renal believes it is ATN (muddy brown\n casts), would not diurese, or give IVF; do not oliguria.\n Hematology: --ASA. Hold coumadin given elevated INR\n - A. Fib anticoagulation with coumadin, INR goal , f/u daily INR and\n start heparin drip once INR < 2 as pt is planned for trach/peg on\n monday (2.9 today)\n Endocrine: --RISS with adequate glucose control\n --Synthroid 75 mcg for hypothyroidism\n Infectious Disease: --completed cefepime vanc 7 day course for\n pneumonia\n --UA positive foley changed patient received 3 days cours of\n antibiotics last dose 03/16\n Lines / Tubes / Drains: PIV, Foley, CVL (), ETT, Dobhoff\n Wounds:\n Imaging:\n Fluids:\n Consults: neuromed, renal\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:37 PM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments: coumadin held, INR theraputic\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent: 33 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403046,
"text": "86F severe AS (critical AS s/p valvuloplasty ), CAD s/p CABG \n (lima-lad, svg-om), dCHF, AF with multiple recent hospitalizations\n ( valvuloplasty, hemicolectomy for adenoCA, c diff colitis,\n diverticulitis. Admitted after seizure which stopped with ativan\n and keppra. Diuretics were held on admission. She was treated initially\n for meningitis. CTA was negative for CVA. MRI head with high signal\n intensity in the R superior parietal lobe. After MRI on she\n triggered for AMS and lethargy. Her HR was in the 130s and her SBP was\n in the 80s. Her ABG was notable for pCO2 65. She was given lasix 10mg\n IV then 30mg and 5mg IV metoprolol without significant improvement.\n Impaired Skin Integrity\n Assessment:\n Pt remains NPO x pills.\n Failed speech & swallow exam.\n Pt with limited moblilty.\n Bilateral LE open areas.\n Action:\n NG tube passed.\n Frequent turning and repositioning .\n Aloe vesta prn.\n LE dressings changed per skin care nurse.\n Response:\n LE open areas are unchanged.\n Plan:\n To start on TF per nutrition this pm.\n Maintain strict NPO.\n Aortic stenosis\n Assessment:\n Tele AF.\n Lungs inspiratory wheeze and crackles throughout.\n O2 sats > 95%.\n Lasix drip at 20mg/hr.\n Action:\n Cont to diuresis.\n Lasix decreased to 10mg/hr.\n Response:\n Improved urine output today.\n Plan:\n Check lytes. Monitor I&O.\n Pneumonia, aspiration\n Assessment:\n O2 sat much improved on 2l NP.\n Pt having periods of apnea\n Weak congested nonproductive cough.\n CXR PNA.\n Lungs with expiratory wheezes & crackles.\n Action:\n Conts on Vancomycin, Cefipeme and flagyl.\n Response:\n Cough slightly improved this pm.\n Plan:\n Cont with pulmonary toilet.\n Cont with coarse of antibiotics.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403240,
"text": "Pneumonia, aspiration\n Assessment:\n Lungs rhonchi with crackles.\n O2 sats > 95% on 2l.,\n Less frequent coughing although cough remains very congested.\n Action:\n Conts on Vancomycin. Flagyl & Cefipeme\n Strict NPO for aspiration precautions.\n TF at goal rate.\n Atrovent Q6hrs.\n Response:\n Good O2 sats on minimal O2. conts to desat without O2\n Plan:\n Cont with antibiotics.\n Check vanco level this pm. Dose decreased to 750mg daily.\n Seizure, without status epilepticus\n Assessment:\n No seizures noted.\n Pt lethargic but arousable to voice.\n Able to follow commands.\n MAE.\n Action:\n Kepra ^\nd to 1000mg .\n Monitor neuro status.\n Response:\n No seizures noted.\n Pt remains somulent although more responsive this pm.\n Plan:\n EEG in am.\n Aortic stenosis\n Assessment:\n Tele AF 70\ns-90\n Lasix drip off.\n Action:\n Lasix 60mg daily.\n Response:\n Good urine output today.\n Plan:\n Cont with gentle diuresis.\n Check lytes.\n Impaired Skin Integrity\n Assessment:\n Pt with h/o BLL ulcers per family for several yrs.\n Action:\n Dsg changed this am per skin care recs.\n Frequent turning and repositioning with aloe vesta.\n Response:\n R Leg draining more than L.\n Plan:\n Cont with POC.\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-18 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404930,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: wean PS as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-09 00:00:00.000",
"description": "Intensivist Note",
"row_id": 404147,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG\n Chief complaint:\n Seizures\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Albuterol Inhaler 8.\n Albumin 5% (12.5g / 250mL) 9. Aspirin 10. Atorvastatin 11.\n Bacitracin-Polymyxin Ointment 12. Calcium Gluconate 13. CefePIME 14.\n Chlorhexidine Gluconate 0.12% Oral Rinse 15. Ciprofloxacin 16.\n Collagenase Ointment 17. Dextrose 50%\n 18. Digoxin 19. Famotidine 20. Fentanyl Citrate 21. FoLIC Acid 22.\n Furosemide 23. Gabapentin 24. Glucagon 26. Insulin 27. Ipratropium\n Bromide MDI 28. Ipratropium Bromide Neb 29. Latanoprost 0.005% Ophth.\n Soln.\n 30. Levothyroxine Sodium 31. LeVETiracetam 32. Lidocaine 5% Patch 33.\n Lorazepam 34. Lorazepam 35. Magnesium Sulfate 36. Metoprolol Tartrate\n 37. Miconazole Powder 2% 38. Nystatin Oral Suspension 39. PHENObarbital\n 40. PHENObarbital 41. Phenytoin Sodium (IV) 42. Phenylephrine 48.\n Vancomycin\n 49. Warfarin\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Ciprofloxacin - 11:59 PM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 11:46 AM\n Heparin Sodium (Prophylaxis) - 04:48 PM\n Famotidine (Pepcid) - 09:00 PM\n Dilantin - 11:59 PM\n Other medications:\n Flowsheet Data as of 05:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 36.9\nC (98.5\n HR: 82 (71 - 90) bpm\n BP: 109/45(68) {65/38(53) - 130/58(84)} mmHg\n RR: 18 (18 - 23) insp/min\n SPO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 88.7 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 3,130 mL\n 290 mL\n PO:\n Tube feeding:\n 961 mL\n 185 mL\n IV Fluid:\n 1,369 mL\n 105 mL\n Blood products:\n 500 mL\n Total out:\n 187 mL\n 29 mL\n Urine:\n 187 mL\n 29 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,943 mL\n 261 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 18\n RR (Spontaneous): 3\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Elevated ICP\n PIP: 24 cmH2O\n Plateau: 21 cmH2O\n SPO2: 99%\n ABG: 7.41/45/114/28/3\n Ve: 7.5 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Neurologic: (Responds to: Noxious stimuli), No(t) Moves all\n extremities, (RUE: No movement), (LUE: No movement)\n Labs / Radiology\n 381 K/uL\n 7.5 g/dL\n 121 mg/dL\n 2.1 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 57 mg/dL\n 107 mEq/L\n 143 mEq/L\n 25.8 %\n 10.4 K/uL\n [image002.jpg]\n 10:32 AM\n 03:49 AM\n 10:50 AM\n 01:08 PM\n 04:35 PM\n 06:36 PM\n 03:33 AM\n 09:41 AM\n 04:39 PM\n 04:06 AM\n WBC\n 10.5\n 11.3\n 10.4\n Hct\n 30.4\n 26.9\n 25.8\n Plt\n 372\n 430\n 381\n Creatinine\n 1.5\n 1.7\n 2.0\n 2.1\n TCO2\n 31\n 31\n 30\n 29\n 30\n 30\n Glucose\n 119\n 122\n 116\n 121\n Other labs: PT / PTT / INR:21.6/46.0/2.0, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:60/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca:7.4 mg/dL, Mg:2.2 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), KNOWLEDGE DEFICIT, IMPAIRED\n SKIN INTEGRITY, PNEUMONIA, ASPIRATION, AORTIC STENOSIS, SEIZURE,\n WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD, now w/respiratory acidosis and\n failure resulting in intubation ().\n Neurologic: -- Patient sedtaed with fentanyl prn.\n -- Patient with seizures, loaded with dilantin and ativan PRN prior to\n admission with poor mental status. Despite loading dose continued to\n have sub clinical seziures on EEG. Medication regiment changed.\n Currently on phenytoin and Keppra and now phenobarbitol.MRI brain w/\n and w/o ordered for when pt is stable to transport to evaluate to\n source of bleed in parietal lobe.\n --Continue neurontin for chronic pain well controlled on current\n medication.\n Cardiovascular: -- PAF with good control of HR on beta blockade and\n digoxin. Anticoagulation started with coumadin. No heparin bridge for\n risk of rebleed. On ASA\n -- CAD s/p CABG , diastolic dysfunction. On b-blockade,\n furosemide, ASA, and statin.\n -- Critical AS (valve area pre-valvuloplasty 0.8cm2, post\n vavluloplasty). On ICU-based ECHO estimated area is 0.6cm2. Likely not\n eligible for open valve replacement. Family is discussing this issue\n with another cardiologist.\n -- Pt still requires neosynephrine for MAPs > 60\n -- Albmunin bolus x2 for low MAPS and poor UOP\n Pulmonary: --Treated empirically for HAP with Vanc/Cefepime, Cultures\n are negative so far. We will continue treatment for full 7 days despite\n negative cultures ending today\n --albuterol/atrovent PRN\n Gastrointestinal / Abdomen: --Resume TFs, consider PEG tube placement\n in future if clinical picture warrants\n Nutrition: --TF continued\n Renal: -- On home dose of Lasix\n -- Diminished urine output, received albumin x2 overnight, Creatinine\n increasing 1.5-1.7->2.1\n -- Cipro for UTI, started . cultures p, last dose today\n Hematology: --Hct slowly decreasing, 25.8 . TransfusePC X2\n --ASA, SQH\n - A. Fib anticoagulation with coumadin, INR 2.0 (goal ), dose\n decreased to 3mg\n Endocrine: --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg for hypothyroidism, previous TSH was 6.8\n Infectious Disease: --Wbc down slightly to 10.4\n --Being treated for PNA with cefepime/vanc (?aspiration) total course\n should be 7 days (ending ).\n --Follow cultures\n Lines / Tubes / Drains:\n Fluids: KVO\n Consults: neuromed\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:59 PM 35 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 06:03 PM\n Arterial Line - 04:39 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle: ALL\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 33 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405241,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with anasarca, oliguric. Elevated BUN/Cr, K. metabolic acidocis.\n Action:\n Monitored, BUN/Cr, pt receiving zaroxalyn, bumex.\n Response:\n No response to diuretics, continues with oliguria.\n Plan:\n Continue to monitor. Team aware of low urine output.\n Seizure, without status epilepticus\n Assessment:\n No sz activity noted this shift. Pt unresponsive to nailbed pressure.\n PERRL. No spontaneous movement. +corneals. Noted to grimace once\n during care.\n Action:\n Monitored, neuro assessments, dilantin and phenobarb admin. As\n ordered. Dilantin level sent in eve after first recurring dose admin.\n Pain treated with acetamin.\n Response:\n No sz activity noted. Pt appears comfortable at rest. Dilantin level\n 3.5 team notified.\n Plan:\n Continue to monitor, continue neuro assess and anticonvulsants as\n ordered.\n Aortic stenosis\n Assessment:\n Pt in a fib with rare PVC noted. Sbp 90\ns-130. tolerating lopressor\n dose. No response to diuretics. Continues on heparin gtt.\n Action:\n Monitored\n Response:\n Stable hemodynamics. PTT therapeutic x1.\n Plan:\n Continue to monitor, PTT pending. Plan for ?valvulopoasty if neuro\n status improves.\n Resp. Failure\n Assessment: pt received on cpap . resps shallow, good VT. Sats\n ranging from 88-93% with ?unreliable sat probe. Pao2 on abg 80.\n through evening increased incidence of desaturation with associated\n tachycardia up to 120\ns, transient hypotension.\n Action: abg re-checked; at time of desat to 80% on monitor, pao2 64.\n pt returned to cmv, fio2 increased to 100%. Suctioned for moderate\n amounts thick tan sputum.\n Response: repeat abg shows good oxygenation, improvement of acidocis.\n Hemodynamically stable. WBC pending in AM labs. Currently weaning\n fio2.\n Plan: continue vent wean as tolerated, continue to monitor abg. Cpap\n as tolerated.\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404090,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum source/amount: / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt on the vent no changes made tol well. See respiratory page of meta\n vision for more information.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405242,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with anasarca, oliguric. Elevated BUN/Cr, K. metabolic acidocis.\n Action:\n Monitored, BUN/Cr, pt receiving zaroxalyn, bumex.\n Response:\n No response to diuretics, continues with oliguria.\n Plan:\n Continue to monitor. Team aware of low urine output.\n Seizure, without status epilepticus\n Assessment:\n No sz activity noted this shift. Pt unresponsive to nailbed pressure.\n PERRL. No spontaneous movement. +corneals. Noted to grimace once\n during care.\n Action:\n Monitored, neuro assessments, dilantin and phenobarb admin. As\n ordered. Dilantin level sent in eve after first recurring dose admin.\n Pain treated with acetamin.\n Response:\n No sz activity noted. Pt appears comfortable at rest. Dilantin level\n 3.5 team notified.\n Plan:\n Continue to monitor, continue neuro assess and anticonvulsants as\n ordered.\n Aortic stenosis\n Assessment:\n Pt in a fib with rare PVC noted. Sbp 90\ns-130. tolerating lopressor\n dose. No response to diuretics. Continues on heparin gtt.\n Action:\n Monitored\n Response:\n Stable hemodynamics. PTT therapeutic x2.\n Plan:\n Continue to monitor, PTT q day. Plan for ?valvulopoasty if neuro\n status improves.\n Resp. Failure\n Assessment: pt received on cpap . resps shallow, good VT. Sats\n ranging from 88-93% with ?unreliable sat probe. Pao2 on abg 80.\n through evening increased incidence of desaturation with associated\n tachycardia up to 120\ns, transient hypotension.\n Action: abg re-checked; at time of desat to 80% on monitor, pao2 64.\n pt returned to cmv, fio2 increased to 100%. Suctioned for moderate\n amounts thick tan sputum.\n Response: repeat abg shows good oxygenation, improvement of acidocis.\n Hemodynamically stable. WBC wnl this AM. Currently weaning fio2.\n Plan: continue vent wean as tolerated, continue to monitor abg. Cpap\n as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404515,
"text": "Seizure, without status epilepticus\n Assessment:\n Pt remains intubated, no sedation\n Pt slightly withdraws extremities to deep nailbed pressure,\n pupils equal and reactive, weak cough, impaired gag, does not open\n eyes, no spontaneous movement\n EEG continues\n Pt remains on neo gtt to keep SBP >120\n Remains oliguric, BUN 81Cr 3\n No vent changes over night, PaO2 80, O2 sat 93-97%\n Action:\n Neuro checks Q2hrs\n Neo gtt to keep SBP >120\n Monitor o/u\n Wean vent as tolerated\n Response:\n No change in pt\ns condition\n Plan:\n ? Family meeting again to discuss pt\ns prognosis and POC\n Trach and PEG on Monday per family\n Continue to monitor neuro exam, outputs/renal function\n Keep SBP>120\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403126,
"text": "86F severe AS (critical AS s/p valvuloplasty ), CAD s/p CABG \n (lima-lad, svg-om), dCHF, AF with multiple recent hospitalizations\n ( valvuloplasty, hemicolectomy for adenoCA, c diff colitis,\n diverticulitis. Admitted after seizure which stopped with ativan\n and keppra. Diuretics were held on admission. She was treated initially\n for meningitis. CTA was negative for CVA. MRI head with high signal\n intensity in the R superior parietal lobe. After MRI on she\n triggered for AMS and lethargy. Her HR was in the 130s and her SBP was\n in the 80s. Her ABG was notable for pCO2 65. She was given lasix 10mg\n IV then 30mg and 5mg IV metoprolol without significant improvement.\n Pneumonia, aspiration\n Assessment:\n O2 at 2lnp with sats in the upper 90\ns to 100%. Conts to have very\n congested cough that is not productive. Lungs with scattered\n rhonci/wheezes throughout, also noted for crackles. Lasix gtt conts at\n 10mg/hr. Conts on iv antibx. Tube feeds at 10cc/hr initially.\n Action:\n Rec\ning Atrovent nebs q 6hours. CPT to R lobes. Attempted to orally\n sxn for presumed secretions. No change made in lasix gtt, goal to\n maintain even. Increased tubefeeds to 45cc/hr (goal) at 4:30.\n Response:\n conts to have very congested cough, at times cough is continuous. Sats\n have remained good. Approx even so far. Having no residuals with\n increase in tubefeed rate.\n Plan:\n cont with cpt/nebs. Follow oxygenation. Cont to check residuals.\n Maintain strict NPO.\n Seizure, without status epilepticus\n Assessment:\n She is alert and oriented x 2 (person/time). Slightly lethargic,\n awakens easily but falls back to sleep. Able to follow simple\n commands. No seizures noted.\n Action:\n Keppra given, to have increased dose at 8am\n Response:\n no change in neuro status\n Plan:\n give increased dose of keppra, cont to follow neuro status\n Aortic stenosis\n Assessment:\n Hr 80-90\ns afib with occ pvc. Bp stable 90-120\n Action:\n conts on lopressor 75mg\n Response:\n tolerating cardiac meds, conts on lasix gtt\n Plan:\n cont to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404833,
"text": "Seizure, without status epilepticus\n Assessment:\n Patient is unresponsive, not on sedation, still on neo gtt tp keep MAP\n >70, pupils equal and reactive to light, withdrawing all extremities\n very slightly to deep painful stimuli only, not opening eyes or\n following commands. Absent gag and cough.\n Action:\n Q4H neuro checks, continued with neo gtt to keep MAP >70, HOB >30*, TF\n continued, wound care for venous ulcer on both LE,\n Response:\n Unchanged neuro status, no seizure activities noted.\n Plan:\n Cont to monitor , neuro checks q4h, cont neo to keep MAP>70, support\n to pt and family.\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405082,
"text": "Chief Complaint:\n 24 Hour Events:\n Dr met with family. Plan currently is to attempt diuresis with\n plan for valvuloplasty on Monday.\n Pt received diuril 500mg X1, and lasix 200mg IV x1, with total UOP over\n 24 hours of 373 cc, approx 15 cc/hr\n Seen by renal with assessment that she her kidney\ns are being poorly\n perfused, as indicated by an FE Urea 24%, and that she is a poor\n candidate for HD.\n Her MRI was deferred to today, with phenobarb down titrated from 45mg\n to 30mg . Per neuro plan is to decrease dose by 15mg every 2\n days.\n LP being deferred until after MRI.\n Held heparin GTT y/d and held Coumadin as INR therapeutic then.\n -held Coumadin, did not start heparin gtt as INR was therapeutic; will\n need to restart once INR<2\n -ordered for head MRI, but this was not done yet\n -may do LP: will get MRI first\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:30 AM\n Dilantin - 04:16 PM\n Famotidine (Pepcid) - 09:38 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 35.8\nC (96.5\n HR: 91 (85 - 101) bpm\n BP: 109/58(77) {86/48(67) - 133/88(97)} mmHg\n RR: 22 (20 - 30) insp/min\n SpO2: 92%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 104.8 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 15 (12 - 23)mmHg\n Total In:\n 1,184 mL\n 206 mL\n PO:\n 30 mL\n TF:\n 861 mL\n 206 mL\n IVF:\n 113 mL\n Blood products:\n Total out:\n 973 mL\n 105 mL\n Urine:\n 373 mL\n 105 mL\n NG:\n Stool:\n LOS\n +28,8L\n Balance:\n 211 mL\n 101 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 368 (349 - 394) mL\n PS : 15 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 200\n PIP: 21 cmH2O\n SpO2: 92%\n ABG: 7.36/36/99./17/-4\n Ve: 8.6 L/min\n PaO2 / FiO2: 250\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. late-peaking high-pitched crescendo/decrescendo\n murmur loudest at RUSB.\n LUNGS: Ventilated breath sounds.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal stimuli. Minimal response to\n painful stimuli. PERRL. No oculovestibular reflex.\n Labs / Radiology\n 472 K/uL\n 8.0 g/dL\n 108 mg/dL\n 3.6 mg/dL\n 17 mEq/L\n 5.0 mEq/L\n 114 mg/dL\n 103 mEq/L\n 135 mEq/L\n 26.1 %\n 6.8 K/uL\n [image002.jpg]\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n 02:12 AM\n 02:44 AM\n 02:34 AM\n 02:04 PM\n 02:23 PM\n 03:16 AM\n WBC\n 9.7\n 8.1\n 7.4\n 7.4\n 6.8\n Hct\n 27.8\n 25.3\n 25.6\n 26.1\n 26.1\n Plt\n 399\n 367\n 436\n 469\n 472\n Cr\n 3.2\n 3.3\n 3.6\n 3.6\n 3.6\n 3.6\n TCO2\n 23\n 24\n 22\n 21\n Glucose\n 124\n 116\n 122\n 89\n 96\n 132\n 130\n 108\n Other labs: PT / PTT / INR:20.3/27.8/1.9, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n INEFFECTIVE COPING\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n KNOWLEDGE DEFICIT\n IMPAIRED SKIN INTEGRITY\n PNEUMONIA, ASPIRATION\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU. Continues to be\n severely fluid overloaded and oliguric, positive 28L Los. She does not\n respond well to lasix/diuril but is also not a candidate for HD.\n -start lasix gtt\n - lytes.\n -monitor volume status, UOP.\n - likely repeat valvuloplasty on Monday\n .\n # Atrial Fibrillation: Pt has good control of HR on beta blockade and\n digoxin. Coumadin was being held before for trach/PEG; restarted\n yesterday and INR went from 1.8 to 2.7. Currently INR 1.9. will d/w\n neurology and rest of CCU team risks and benefits of Coumadin in this\n pt\n -Restart coumadin with heparin bridge. Valvuloplasty not until Monday.\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n .\n # Acute Renal Failure: Creatinine stable today. Per previous notes,\n renal believes that this is ATN\n - will attempt diuresis with Lasix gtt+\n -appreciate renal recs.\n - continue to monitor fluid status otherwise\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol. Neuro not sure what is causing continued depressed\n mental status, states she is not having active seizures on EEG.\n - continue phenytoin and Phenobarbital, adjusting per neuro recs:\n Maintain at phenobarbital at 30 mg today, decrease to 15mg \n tomorrow.\n - appreciate neuro recs: recommending LP and MRI\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Respiratory Failure: Now, s/p trach.\n - trach in place\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Etiology unclear. Likely cardiogenic in setting\n of tight AS, but will need to consider sepsis if patient begins to\n spike fevers. Currently without fever or luekocytosis.\n - MAP goal is 65 to try to keep pt off of pressors\n .\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n .\n # Fevers: Afebrile x 5 days. Per notes, pt completed vanc/cefepime 7\n day course for pneumonia as well as 3 days course of abx for positive\n UA.\n - f/u cx data\n - follow fever curve\n - f/u stool for c.diff\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 12:29 AM 35 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: subtherapeutic INR, restart hep gtt, coumadin today\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: Family\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "General",
"chartdate": "2196-01-29 00:00:00.000",
"description": "CCU Fellow Admit Note",
"row_id": 402719,
"text": "TITLE: CCU Fellow Admit Note\n 86F severe AS (critical AS s/p valvuloplasty ), CAD s/p CABG \n (lima-lad, svg-om), dCHF, AF with multiple recent hospitalizations\n ( valvuloplasty, hemicolectomy for adenoCA, c diff colitis,\n diverticulitis. Admitted after seizure which stopped with ativan\n and keppra. Diuretics were held on admission. She was treated initially\n for meningitis. CTA was negative for CVA. MRI head with high signal\n intensity in the R superior parietal lobe. After MRI on she\n triggered for AMS and lethargy. Her HR was in the 130s and her SBP was\n in the 80s. Her ABG was notable for pCO2 65. She was given lasix 10mg\n IV then 30mg and 5mg IV metoprolol without significant improvement.\n VS: 100.2 129/59 128 90% 4L\n Somnolent and difficult to arouse\n S1, no A2, late peaking systolic CDC murmur, tachy\n Crackles lower lung fields\n Abd soft nt/nd\n 2+\n and studies: reviewed in OMR.\n A/P: 86F with severe AS, CAD, AF, dCHF presenting with hypoxia and\n volume overload. Likely CHF in the setting of holding diuretics and\n diastolic dysfxn due to tachycardia.\n Hypoxia:\n -IV lasix (consider gtt)\n -start metoprolol for AF control and AS mgmt\n -no need for abx at this time given no PNA on cxr\n Fever:\n -f/u cx\n -no abx now as no clear source of infection\n"
},
{
"category": "Physician ",
"chartdate": "2196-01-27 00:00:00.000",
"description": "Intensivist Note",
"row_id": 402516,
"text": "SICU\n HPI:\n 86F s/p witnessed tonic clonic/sz activity @ Rehab no hx of\n seizures; the seizure lasted only about 5 minutes at the rehabilitation\n facility, and then resolved spontaneously. Her daughter and husband\n were visiting her and they noticed a self-limitted 5 minutes seizure,\n described as acute onset of LOC, followed by whole body stiffens and\n later shaking. She was brought to the ED, and during her\n observation in the ED she another 30 seconds GTC seizure. To stop the\n cluster she received Ativan IV and later she was loaded with 1000mg of\n IV Keppra. No further seizures in the ED.\n .\n She had a valvuloplasty performed for AS;she was then admitted\n from 1/11-20/10 for right hemicolectomy for colon cancer. Her hospital\n course was complicated by hypercarbia requiring intubation and fluid\n overload requiring diuresis. Subsequent to this she developed C.\n difficile colitis, for which she has been on IV vancomycin since; she\n continues to complain of abdominal pain, although she has had a recent\n followup abdominal CT after her partial colectomy, which per the\n patient's family was unremarkable\n Chief complaint:\n seizure\n PMHx:\n . CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n Acetaminophen 4. Acyclovir 5. Atorvastatin 6. Ciprofloxacin 7.\n Ciprofloxacin\n 8. Dextrose 50% 9. Famotidine 10. Furosemide 11. Gabapentin 12.\n Glucagon 13. Heparin 14. Insulin 15. Latanoprost 0.005% Ophth. Soln.\n 16. Levothyroxine Sodium 17. Metoprolol Tartrate 18. Miconazole Powder\n 2% 19. Sodium Chloride 0.9% Flush 20. Sulfameth/Trimethoprim 21.\n Timolol Maleate 0.5% 22. Vancomycin 23. Warfarin\n 24 Hour Events:\n : Admitted\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 12:43 AM\n Acyclovir - 12:44 AM\n Ciprofloxacin - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 36.2\nC (97.2\n HR: 101 (90 - 104) bpm\n BP: 125/113(116) {86/41(54) - 125/113(116)} mmHg\n RR: 14 (14 - 22) insp/min\n SPO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 80.1 kg (admission): 80.1 kg\n Total In:\n 123 mL\n 1,360 mL\n PO:\n Tube feeding:\n IV Fluid:\n 123 mL\n 1,360 mL\n Blood products:\n Total out:\n 75 mL\n 210 mL\n Urine:\n 75 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 48 mL\n 1,150 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 95%\n ABG: ///33/\n Physical Examination\n Labs / Radiology\n 500 K/uL\n 9.8 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 101 mEq/L\n 142 mEq/L\n 34.7 %\n 11.7 K/uL\n [image002.jpg]\n 04:27 AM\n WBC\n 11.7\n Hct\n 34.7\n Plt\n 500\n Creatinine\n 0.8\n Troponin T\n 0.02\n Glucose\n 107\n Other labs: PT / PTT / INR:28.2/30.6/2.8, CK / CK-MB / Troponin\n T:15//0.02, ALT / AST:, Alk-Phos / T bili:62/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca:8.0 mg/dL, Mg:1.8\n mg/dL, PO4:3.4 mg/dL\n Imaging: CT Head: No bleed or mass effect\n CTA: Extensive motion artifact limits noncon images. Dolichoectasia\n of R vertebral artery (V4). Extensive vascular calcification with\n stenosis of R vertebral aa (4,33) although contrast seen distally. No\n thrombosis or large aneurysm. Basilar tip coarse calcification.\n Microbiology: UCx: P\n BCx: P\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/new onset seizures in the setting of ongoing\n treatment with IV abx for C. difficile colitis.\n Neurologic:\n Patient with AMS\n unclear reason.\n New onset seizures, currently post-ictal with non-focal;\n neuro-exam.\n o EEG\n o LP vs MRA/MRI (infection vs thrombosis vs medication\n ciprofloxacin)\n o Treated for meningitis empirically.\n o We will talk to neurology about long-term anti-seziure\n medications.\n Pain well controlled.\n Cardiovascular:\n H/O CABG secondary to CAD complicated by AF and diastolic\n dysfunction.\n Continue coumadin for INR and control HR below 80 and lasix\n for diastolic dysfunction.\n ECHO ordered to r/o endocarditis.\n Restart all home medication if stable medically after\n converting to iv since patient unable to swallow.\n Pulmonary:\n Wean oxygen by NC as tolerated\n IS\n Gastrointestinal / Abdomen:\n o Treated for pre-existing C.Difficille on metronidzole\n o Unclear reason for RUQ\n we will continue the primary team\n Nutrition: NPO\n Renal:\n o Stable.\n Hematology:\n o Slight anemia\n o INR therapeutic for now.\n Endocrine:\n o Sliding scale of insulin with good blood glucose control.\n o On synthroid 75 mcg\n Infectious Disease:\n o On ABX for empiric meningitis.\n o BC pending\n o C.difficile\n treated but we repeat toxins assay and\n cultures.\n o Oral candidiosis\n we will add anti-fungal medication.\n Lines / Tubes / Drains: Foley\n Fluids: D5 1/2NS @ 70\n Consults: Neurology\n Billing Diagnosis: Seizure\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 10:31 PM\n 22 Gauge - 12:42 AM\n Prophylaxis:\n DVT: INR\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU -> transfer to the floor per neur\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402406,
"text": "HPI:\n 86F s/p witnessed tonic clonic/sz activity @ Rehab no hx of\n seizures; the seizure lasted only about 5 minutes at the rehabilitation\n facility, and then resolved spontaneously. Her daughter and husband\n were visiting her and they noticed a self-limitted 5 minutes seizure,\n described as acute onset of LOC, followed by whole body stiffens and\n later shaking. She was brought to the ED, and during her\n observation in the ED she another 30 seconds GTC seizure. To stop the\n cluster she received Ativan IV and later she was loaded with 1000mg of\n IV Keppra. No further seizures in the ED.\n .\n She had a valvuloplasty performed for AS; she was then admitted\n from 1/11-20/10 for right hemicolectomy for colon cancer. Her hospital\n course was complicated by hypercarbia requiring intubation and fluid\n overload requiring diuresis. Subsequent to this she developed C.\n difficile colitis, for which she has been on IV vancomycin since; she\n continues to complain of abdominal pain, although she has had a recent\n followup abdominal CT after her partial colectomy, which per the\n patient's family was unremarkable\n"
},
{
"category": "Physician ",
"chartdate": "2196-01-26 00:00:00.000",
"description": "Physician Surgical Admission Note",
"row_id": 402401,
"text": "Chief Complaint: Seizure\n HPI:\n 86F s/p witnessed tonic clonic/sz activity @ Rehab no hx of\n seizures; the seizure lasted only about 5 minutes at the rehabilitation\n facility, and then resolved spontaneously. Her daughter and husband\n were visiting her and they noticed a self-limitted 5 minutes seizure,\n described as acute onset of LOC, followed by whole body stiffens and\n later shaking. She was brought to the ED, and during her\n observation in the ED she another 30 seconds GTC seizure. To stop the\n cluster she received Ativan IV and later she was loaded with 1000mg of\n IV Keppra. No further seizures in the ED.\n .\n She had a valvuloplasty performed for AS;she was then admitted\n from 1/11-20/10 for right hemicolectomy for colon cancer. Her hospital\n course was complicated by hypercarbia requiring intubation and fluid\n overload requiring diuresis. Subsequent to this she developed C.\n difficile colitis, for which she has been on IV vancomycin since; she\n continues to complain of abdominal pain, although she has had a recent\n followup abdominal CT after her partial colectomy, which per the\n patient's family was unremarkable\n Post operative day:\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family / Social history:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Home: Lives with husband usually but has been staying at \n Rehab since discharge\n Occupation: previously managed a store with her husband\n EtOH: Denies\n Drugs: Denies\n Tobacco: Denies\n Flowsheet Data as of 10:21 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36.1\nC (96.9\n HR: 96 (96 - 101) bpm\n BP: 112/50(67) {112/50(67) - 112/50(67)} mmHg\n RR: 18 (18 - 18) insp/min\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4 mL\n PO:\n TF:\n IVF:\n 4 mL\n Blood products:\n Total out:\n 0 mL\n 45 mL\n Urine:\n 45 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -41 mL\n Respiratory support\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese, Responsive but falls asleep\n during exam\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (Murmur: Systolic), harsh systolic murmur\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bibasilar)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: b/l venous stasis ulcers, erythema\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: CT Head: No bleed or mass effect\n CTA: Extensive motion artifact limits noncon images. Dolichoectasia\n of R vertebral artery (V4). Extensive vascular calcification with\n stenosis of R vertebral aa (4,33) although contrast seen distally. No\n thrombosis or large aneurysm. Basilar tip coarse calcification.\n Microbiology: UCx: P\n BCx: P\n Assessment and Plan\n Assessment And Plan: 86F w/new onset seizures in the setting of ongoing\n treatment with IV abx for C. difficile colitis.\n Neurologic: New onset seizures, currently post ictal, but nonfocal\n neurologic exam, intact\n --EEG\n --flow imagings from the brain rec'd by neuro.\n --empiric abx for possible CNS infection\n --Cont neurontin, Tylenol for pain/fever\n Cardiovascular: --CAD s/p CABG , Severe AS s/p valvuloplasty in\n , AF on coumadin, HTN, Chronic Diastolic heart failure\n -cont coumadin 4 mg daily, monitor INR\n -Rate control for AF\n --Echo ordered to r/o endocarditis\n Pulmonary: stable, IS\n -Wean oxygen by NC as tolerated\n Gastrointestinal: NPO\n Renal: stable, will monitor uop; Furosemide 40 mg IV BID. Cr 0.8\n Hematology: Hct 36.4; INR: 2.6\n -cont coumadin 4 mg daily, monitor INR\n Infectious Disease: Wbc 12.1, empiric abx for possible CNS infection\n --vanc, Acyclovir\n Endocrine: RISS\n --Synthroid 75 mcg\n Fluids: D5 1/2NS @ 70\n Electrolytes: WNL\n Nutrition: NPO\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 402500,
"text": "86F s/p witnessed tonic clonic/sz activity @ Rehab no hx of\n seizures; the seizure lasted only about 5 minutes at the rehabilitation\n facility, and then resolved spontaneously. Her daughter and husband\n were visiting her and they noticed a self-limitted 5 minutes seizure,\n described as acute onset of LOC, followed by whole body stiffens and\n later shaking. She was brought to the ED, and during her\n observation in the ED she another 30 seconds GTC seizure. To stop the\n cluster she received Ativan IV and later she was loaded with 1000mg of\n IV Keppra. No further seizures in the ED.\n .\n She had a valvuloplasty performed for AS;she was then admitted\n from 1/11-20/10 for right hemicolectomy for colon cancer. Her hospital\n course was complicated by hypercarbia requiring intubation and fluid\n overload requiring diuresis. Subsequent to this she developed C.\n difficile colitis, for which she has been on IV vancomycin since; she\n continues to complain of abdominal pain, although she has had a recent\n followup abdominal CT after her partial colectomy, which per the\n patient's family was unremarkable\n PMHx:\n . CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 402502,
"text": "86F s/p witnessed tonic clonic/sz activity @ Rehab no hx of\n seizures; the seizure lasted only about 5 minutes at the rehabilitation\n facility, and then resolved spontaneously. Her daughter and husband\n were visiting her and they noticed a self-limitted 5 minutes seizure,\n described as acute onset of LOC, followed by whole body stiffens and\n later shaking. She was brought to the ED, and during her\n observation in the ED she another 30 seconds GTC seizure. To stop the\n cluster she received Ativan IV and later she was loaded with 1000mg of\n IV Keppra. No further seizures in the ED.\n .\n She had a valvuloplasty performed for AS;she was then admitted\n from 1/11-20/10 for right hemicolectomy for cancer. Her hospital\n course was complicated by hypercarbia requiring intubation and fluid\n overload requiring diuresis. Subsequent to this she developed C.\n difficile colitis, for which she has been on IV vancomycin since; she\n continues to complain of abdominal pain, although she has had a recent\n followup abdominal CT after her partial colectomy, which per the\n patient's family was unremarkable\n PMHx:\n . CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Cancer\n Pt admitted to SICU B from the ED s/p seizure. Neuro exam intact,\n although pt speaking in grunts and\n occasional\n one word response to questions. WBC 12.1, ? meningitis as per\n neuro-med team.\n Pt has severe AS, is in A Fib, on Coumadin, has hx HTN.\n On O2 at 2-4 l, congested cough. Sats 93-99.\n Foley in place, u/o 25-40 cc/hr.\n Small amts green stool per rectum.\n Pt has chronic bilat venous ulcerations on lower legs.\n Action:\n Antibiotics for possible CNS infection\n Q2 hr neuro checks\n Coumadin as ordered qd at 1600, monitor INR\n Rate control with Metoprolol for AF, cardiac echo to r/o endocarditis\n Continue O2 as needed to support sats >95%\n Lasix \n Lower leg dsgs changed\ntelfa and kerlix applied\n Response:\n Pt has no signs of seizure since admission, Neuro stable\n O2 at 4 l, pt coughing and a bit congested\n Antibiotics given as ordered\n Metoprolol held at 0200 due to borderline blood pressure 102/70\n Venodynes ordered but not applied due to open venous ulcers on legs.\n Plan:\n Continue Neuro checks q 2\n Monitor for sx of seizure\n Echo in AM\n Metoprolol if bp tolerates\n Coumadin qd\n Encourage coughing and deep breathing, IS q 1-2 hrs when awake\n Antibiotics as ordered\n Check labs this am.\n Change dsd on lower legs , keep heels off bed to prevent further\n skin issues.\n Seizure, without status epilepticus\n Assessment:\n No further seizures noted..lethargic but easily aroused..follows\n commands..equal strength both arms..unable to move legs due to\n arthritis per patient..is able to wiggle toes to command..pupils equal\n & react to light\n oriented x2 to person & occ place\n Action:\n Cardiac echo & EEG done..attempted po liquids\nantibiotics dc\nd per\n neuro\n Response:\n Aspirated h2o so will keep NPO today\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2196-01-27 00:00:00.000",
"description": "Intensivist Note",
"row_id": 402492,
"text": "SICU\n HPI:\n 86F s/p witnessed tonic clonic/sz activity @ Rehab no hx of\n seizures; the seizure lasted only about 5 minutes at the rehabilitation\n facility, and then resolved spontaneously. Her daughter and husband\n were visiting her and they noticed a self-limitted 5 minutes seizure,\n described as acute onset of LOC, followed by whole body stiffens and\n later shaking. She was brought to the ED, and during her\n observation in the ED she another 30 seconds GTC seizure. To stop the\n cluster she received Ativan IV and later she was loaded with 1000mg of\n IV Keppra. No further seizures in the ED.\n .\n She had a valvuloplasty performed for AS;she was then admitted\n from 1/11-20/10 for right hemicolectomy for colon cancer. Her hospital\n course was complicated by hypercarbia requiring intubation and fluid\n overload requiring diuresis. Subsequent to this she developed C.\n difficile colitis, for which she has been on IV vancomycin since; she\n continues to complain of abdominal pain, although she has had a recent\n followup abdominal CT after her partial colectomy, which per the\n patient's family was unremarkable\n Chief complaint:\n seizure\n PMHx:\n . CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n Acetaminophen 4. Acyclovir 5. Atorvastatin 6. Ciprofloxacin 7.\n Ciprofloxacin\n 8. Dextrose 50% 9. Famotidine 10. Furosemide 11. Gabapentin 12.\n Glucagon 13. Heparin 14. Insulin 15. Latanoprost 0.005% Ophth. Soln.\n 16. Levothyroxine Sodium 17. Metoprolol Tartrate 18. Miconazole Powder\n 2% 19. Sodium Chloride 0.9% Flush 20. Sulfameth/Trimethoprim 21.\n Timolol Maleate 0.5% 22. Vancomycin 23. Warfarin\n 24 Hour Events:\n : Admitted\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 12:43 AM\n Acyclovir - 12:44 AM\n Ciprofloxacin - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 36.2\nC (97.2\n HR: 101 (90 - 104) bpm\n BP: 125/113(116) {86/41(54) - 125/113(116)} mmHg\n RR: 14 (14 - 22) insp/min\n SPO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 80.1 kg (admission): 80.1 kg\n Total In:\n 123 mL\n 1,360 mL\n PO:\n Tube feeding:\n IV Fluid:\n 123 mL\n 1,360 mL\n Blood products:\n Total out:\n 75 mL\n 210 mL\n Urine:\n 75 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 48 mL\n 1,150 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 95%\n ABG: ///33/\n Physical Examination\n Labs / Radiology\n 500 K/uL\n 9.8 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 101 mEq/L\n 142 mEq/L\n 34.7 %\n 11.7 K/uL\n [image002.jpg]\n 04:27 AM\n WBC\n 11.7\n Hct\n 34.7\n Plt\n 500\n Creatinine\n 0.8\n Troponin T\n 0.02\n Glucose\n 107\n Other labs: PT / PTT / INR:28.2/30.6/2.8, CK / CK-MB / Troponin\n T:15//0.02, ALT / AST:, Alk-Phos / T bili:62/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca:8.0 mg/dL, Mg:1.8\n mg/dL, PO4:3.4 mg/dL\n Imaging: CT Head: No bleed or mass effect\n CTA: Extensive motion artifact limits noncon images. Dolichoectasia\n of R vertebral artery (V4). Extensive vascular calcification with\n stenosis of R vertebral aa (4,33) although contrast seen distally. No\n thrombosis or large aneurysm. Basilar tip coarse calcification.\n Microbiology: UCx: P\n BCx: P\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/new onset seizures in the setting of ongoing\n treatment with IV abx for C. difficile colitis.\n Neurologic:\n Patient with AMS\n unclear reason.\n New onset seizures, currently post-ictal with non-focal;\n neuro-exam.\n o EEG\n o LP vs MRA/MRI (infection vs thrombosis vs medication\n ciprofloxacin)\n o Treated for meningitis empirically.\n o We will talk to neurology about long-term anti-seziure\n medications.\n Pain well controlled.\n Cardiovascular:\n H/O CABG secondary to CAD complicated by AF and diastolic\n dysfunction.\n Continue coumadin for INR and control HR below 80 and lasix\n for diastolic dysfunction.\n ECHO ordered to r/o endocarditis.\n Restart all home medication if stable medically after\n converting to iv since patient unable to swallow.\n Pulmonary:\n Wean oxygen by NC as tolerated\n IS\n Gastrointestinal / Abdomen:\n o Treated for pre-existing C.Difficille on metronidzole\n o Unclear reason for RUQ\n we will continue the primary team\n Nutrition: NPO\n Renal:\n o Stable.\n Hematology:\n o Slight anemia\n o INR therapeutic for now.\n Endocrine:\n o Sliding scale of insulin with good blood glucose control.\n o On synthroid 75 mcg\n Infectious Disease:\n o On ABX for empiric meningitis.\n o BC pending\n o C.difficile\n treated but we repeat toxins assay and\n cultures.\n o Oral candidiosis\n we will add anti-fungal medication.\n Lines / Tubes / Drains: Foley\n Fluids: D5 1/2NS @ 70\n Consults: Neurology\n Billing Diagnosis: Seizure\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 10:31 PM\n 22 Gauge - 12:42 AM\n Prophylaxis:\n DVT: INR\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU -> transfer to the floor per neur\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Social Work",
"chartdate": "2196-01-27 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 402474,
"text": "Pt is an 86 yr old married woman who is admitted from Rehab. Pt\n was d/c'ed to Rehab following her recent d/c from . Per\n daughter , pt was in bed and had a seizure, had a second seizure here\n in the , pt has no hx of seizures. Pt does have a long medical HX and\n is closely monitored by cardiology and vascular medicine. Pt is easily\n arousable, asks for the date as she is anticipating being asked by the\n medical team and wants to be prepared with the right answer, is able to\n laugh about this. Per daughter pt's baseline functioning has been\n independent at home with her husband. Daughter reports that the pt as\n VNS who are monitoring her legs that have multiple area of wounds\n secondary to venous stasis. husband helps to wrap here legs and\n per the daughter pt's legs are much improved. Over the last 2 weeks\n pt's daughter reports that the pt has been more tearful, decreased\n appetite and reports feeling depressed . Pt told daughter \"I don't want\n this\", daughter states that pt is referring to being bed bound and in\n diapers. Daughter states that he pt was seen by psychiatry at \n rehab and was dx with situational depression and received no treatment.\n Daughter advocating that this issue be addressed during this admission.\n husband's health is declining, he is moving toward needing\n hemodialysis. Per daughter he continues to be active and able to care\n for wife and self. Pt would like to talk more at a later time, will\n assess pt's depression and advocate treatment if appropriate.\n"
},
{
"category": "General",
"chartdate": "2196-01-29 00:00:00.000",
"description": "CCU Fellow Admit Note",
"row_id": 402740,
"text": "TITLE: CCU Fellow Admit Note\n 86F severe AS (critical AS s/p valvuloplasty ), CAD s/p CABG \n (lima-lad, svg-om), dCHF, AF with multiple recent hospitalizations\n ( valvuloplasty, hemicolectomy for adenoCA, c diff colitis,\n diverticulitis. Admitted after seizure which stopped with ativan\n and keppra. Diuretics were held on admission. She was treated initially\n for meningitis. CTA was negative for CVA. MRI head with high signal\n intensity in the R superior parietal lobe. After MRI on she\n triggered for AMS and lethargy. Her HR was in the 130s and her SBP was\n in the 80s. Her ABG was notable for pCO2 65. She was given lasix 10mg\n IV then 30mg and 5mg IV metoprolol without significant improvement.\n VS: 100.2 129/59 128 90% 4L\n Somnolent and difficult to arouse\n S1, no A2, late peaking systolic CDC murmur, tachy\n Crackles lower lung fields\n Abd soft nt/nd\n 2+\n and studies: reviewed in OMR.\n A/P: 86F with severe AS, CAD, AF, dCHF presenting with hypoxia and\n volume overload. Likely CHF in the setting of holding diuretics and\n diastolic dysfxn due to tachycardia.\n Hypoxia:\n -IV lasix (consider gtt)\n -start metoprolol for AF control and AS mgmt\n -no need for abx at this time given no PNA on cxr\n Fever:\n -f/u cx\n -no abx now as no clear source of infection\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n Per fellow\n nothing to add\n Physical Examination\n per fellow\n nothing to add\n Medical Decision Making\n per fellow\n nothing to add\n Above discussed extensively with family member, next of or health\n care proxy.\n Total time spent on patient care: 60 minutes.\n Additional comments:\n admitted with chf exacerbation in setting of tight aortic stenosis and\n possible infection.\n plan for rate control and diuresis\n ------ Protected Section Addendum Entered By: ,MD\n on: 17:11 ------\n"
},
{
"category": "Physician ",
"chartdate": "2196-01-27 00:00:00.000",
"description": "Intensivist Note",
"row_id": 402454,
"text": "SICU\n HPI:\n 86F s/p witnessed tonic clonic/sz activity @ Rehab no hx of\n seizures; the seizure lasted only about 5 minutes at the rehabilitation\n facility, and then resolved spontaneously. Her daughter and husband\n were visiting her and they noticed a self-limitted 5 minutes seizure,\n described as acute onset of LOC, followed by whole body stiffens and\n later shaking. She was brought to the ED, and during her\n observation in the ED she another 30 seconds GTC seizure. To stop the\n cluster she received Ativan IV and later she was loaded with 1000mg of\n IV Keppra. No further seizures in the ED.\n .\n She had a valvuloplasty performed for AS;she was then admitted\n from 1/11-20/10 for right hemicolectomy for colon cancer. Her hospital\n course was complicated by hypercarbia requiring intubation and fluid\n overload requiring diuresis. Subsequent to this she developed C.\n difficile colitis, for which she has been on IV vancomycin since; she\n continues to complain of abdominal pain, although she has had a recent\n followup abdominal CT after her partial colectomy, which per the\n patient's family was unremarkable\n Chief complaint:\n seizure\n PMHx:\n . CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n Acetaminophen 4. Acyclovir 5. Atorvastatin 6. Ciprofloxacin 7.\n Ciprofloxacin\n 8. Dextrose 50% 9. Famotidine 10. Furosemide 11. Gabapentin 12.\n Glucagon 13. Heparin 14. Insulin\n 15. Latanoprost 0.005% Ophth. Soln. 16. Levothyroxine Sodium 17.\n Metoprolol Tartrate 18. Miconazole Powder 2%\n 19. Sodium Chloride 0.9% Flush 20. Sulfameth/Trimethoprim 21. Timolol\n Maleate 0.5% 22. Vancomycin\n 23. Warfarin\n 24 Hour Events:\n : Admitted\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 12:43 AM\n Acyclovir - 12:44 AM\n Ciprofloxacin - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 36.2\nC (97.2\n HR: 101 (90 - 104) bpm\n BP: 125/113(116) {86/41(54) - 125/113(116)} mmHg\n RR: 14 (14 - 22) insp/min\n SPO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 80.1 kg (admission): 80.1 kg\n Total In:\n 123 mL\n 1,360 mL\n PO:\n Tube feeding:\n IV Fluid:\n 123 mL\n 1,360 mL\n Blood products:\n Total out:\n 75 mL\n 210 mL\n Urine:\n 75 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 48 mL\n 1,150 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 95%\n ABG: ///33/\n Physical Examination\n Labs / Radiology\n 500 K/uL\n 9.8 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 101 mEq/L\n 142 mEq/L\n 34.7 %\n 11.7 K/uL\n [image002.jpg]\n 04:27 AM\n WBC\n 11.7\n Hct\n 34.7\n Plt\n 500\n Creatinine\n 0.8\n Troponin T\n 0.02\n Glucose\n 107\n Other labs: PT / PTT / INR:28.2/30.6/2.8, CK / CK-MB / Troponin\n T:15//0.02, ALT / AST:, Alk-Phos / T bili:62/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca:8.0 mg/dL, Mg:1.8\n mg/dL, PO4:3.4 mg/dL\n Imaging: CT Head: No bleed or mass effect\n CTA: Extensive motion artifact limits noncon images. Dolichoectasia\n of R vertebral artery (V4). Extensive vascular calcification with\n stenosis of R vertebral aa (4,33) although contrast seen distally. No\n thrombosis or large aneurysm. Basilar tip coarse calcification.\n Microbiology: UCx: P\n BCx: P\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/new onset seizures in the setting of ongoing\n treatment with IV abx for C. difficile colitis.\n Neurologic: New onset seizures, currently post ictal, but nonfocal\n neurologic exam, intact\n --CTA brain and neck (f/u final read)\n --EEG\n --flow imagings from the brain rec'd by neuro for basilar art\n abnormalities.\n --empiric abx for possible CNS infection\n --Cont neurontin, Tylenol for pain/fever\n Cardiovascular: --CAD s/p CABG , Severe AS s/p valvuloplasty in\n , AF on coumadin, HTN, Chronic Diastolic heart failure\n -cont coumadin 4 mg daily, monitor INR\n -Rate control for AF\n --Echo ordered to r/o endocarditis\n Pulmonary: -Wean oxygen by NC as tolerated\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO\n Renal: stable, will monitor uop; Furosemide 40 mg IV BID\n Hematology: Hct 36.4; INR: 2.6\n -cont coumadin 4 mg daily, monitor INR\n Endocrine: RISS\n --Synthroid 75 mcg\n Infectious Disease: Wbc 12.1, empiric abx for possible CNS infection\n --vanc, Acyclovir, cipro, Bactrim\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: D5 1/2NS @ 70\n Consults: Neurology\n Billing Diagnosis: Seizure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 10:31 PM\n 22 Gauge - 12:42 AM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402722,
"text": "Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2196-01-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402736,
"text": "Chief Complaint: CHF/Afib with RVR\n 24 Hour Events:\n PICC LINE - START 11:01 AM\n HISTORY OF PRESENTING ILLNESS: The patient is an 86y/o F with a PMH of\n CAD s/p CABG 86F with CAD s/p CABG (SVG-OM, LIMA-LAD), AS s/p\n valvuloplasty , diastolic CHF, AF on coumadin, s/p R colectomy\n admitted with generalized tonic clonic seizure now transferred to\n the CCU for management of AF w/ RVR and pulmonary edema. Her recent\n past medical history inculdes an admission for a history of\n worsening DOE with AS with valve area of 0.56cm2. She underwent\n valvuloplasty with subsequent diameter of 0.98cm2. Her course was\n complicated by LGI bleed and on colonoscopy a precancerous 2cm cecal\n polyp was found. She was then admitted from 1/11-20/10 for right\n hemicolectomy. Low-grade T2N0M0 well or moderately\n differentiatedadenocarcinoma. Her hospital course (- )\n was complicated by hypercarbia requiring intubation and fluid overload\n requiring diuresis. Subsequent to this she developed C.\n difficile colitis, for which she has been on PO vancomycin since;\n she continued to complain of abdominal pain, with fevers post op\n and had a CT in , that revealed slight increased fat\n stranding in the region of the sigmoid colon at sites of diverticula,\n representing a mild case of uncomplicated diverticulitis.\n .\n The patient was admitted on to Neurology service after tonic clonic\n seizure activity which resolved spontaneously. Her daughter and husband\n were visiting her and they noticed a self-limitted 5 minutes seizure,\n described as acute onset of LOC, followed by whole body stiffens and\n later shaking. She was brought to the ED, and during her\n observation in the ED she another 30 seconds GTC seizure. To stop the\n cluster she received Ativan IV and later she was loaded with 1000mg of\n IV Keppra. No further seizures in the ED. She was admitted to the Neuro\n ICU for further management. She was initially treated with broad\n spectrum abx including vancomycin/cipro/bactrim and acyclovir for\n concern for meningitis/encephalitis. These were stopped after approx 24\n hours. LP was not pursued given elevated INR on coumadin. CTA negative\n for CVA. She had no further seizure activity. MRI head demonstrated a\n focal area with high signal intensity in the right superior parietal\n lobule.\n .\n On evening of the patient triggered for altered mental status and\n lethargy following head MRI. O2 sat found to be 84% and HR 130s, SBPs\n in 80s. Lasix 10mg IV given with no improvement. ABG 7.32/65/89/35.\n MICU consult was called and an additional 30mg IV lasix given with\n metoprolol 5mg IV. AMS felt most likely secondary to ativan given for\n head MRI. Repeat ABG this am 7.35/63/72/36. Given continued tachypnea\n and hypoxia requiring 4-5L NC, the patient was transferred to the CCU\n for further managment. Temp spiked to 101 and cultures sent.\n .\n .\n PAST MEDICAL HISTORY:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on course complicated by\n C.diff. Currently negative C. diff.\n .\n HOME MEDICATIONS:\n 1. Furosemide 60mg daily\n 2. Levothyroxine 75mg daily\n 3.Latanoprost 0.005% drop daily\n 4. Timoptic 0.5% drop daily\n 5. Lipitor 40mg daily\n 6. Gabapentin 300mg \n 7. Coumadin 4mg \n .\n MEDICATIONS ON TRANSFER:\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol\n Insulin SC (per Insulin Flowsheet)\n Acetaminophen 325-650 mg PO/NG Q6H:PRN pain\\fever\n Ipratropium Bromide Neb 1 NEB IH Q6H\n Aspirin 81 mg PO/NG DAILY\n Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS\n Atorvastatin 40 mg PO/NG DAILY\n Levothyroxine Sodium 75 mcg PO/NG DAILY\n Bacitracin-Polymyxin Ointment 1 Appl TP Q6H:PRN wound\n LeVETiracetam 750 mg IV Q12H\n Collagenase Ointment 1 Appl TP DAILY\n Lidocaine 5% Patch 1 PTCH TD DAILY\n Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol\n Digoxin 0.0625 mg PO/NG DAILY\n Metoprolol Tartrate 25 mg PO/NG TID\n Famotidine 20 mg IV Q24H\n FoLIC Acid 1 mg PO/NG DAILY\n Nystatin Oral Suspension 5 mL PO QID:PRN \n Gabapentin 100 mg PO/NG \n Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY\n .\n ALLERGIES: penicillin and erythromycin with rash and GI upset\n from Motrin\n .\n SOCIAL HISTORY\n rehab for 5 weeks.\n -Tobacco history:none\n -ETOH:none\n -Illicit drugs:none\n -uses walker/wheelchair at home, poor candidate for knee replacement.\n .\n FAMILY HISTORY:\n No family history of early MI, arrhythmia, cardiomyopathies, or sudden\n cardiac death; otherwise non-contributory.\n .\n PHYSICAL EXAMINATION:\n VS: T=100.2 BP=123/66 HR= 87 RR= 21 O2 sat=95% on 4LNC\n GENERAL: responds to voice and painful stimuli, unable to follow\n commands.\n OPC/NC/AT/no LAD\n NECK: Supple with JVP of cm in mid neck)\n CARDIAC: iirregularly irregular, late peaking SEM heard, hear both\n S1 and S2 clearly, S2 may be fainter, throughout precordium, radiating\n to carotids.\n LUNGS: diffusely ronchorous, wheezing.\n ABDOMEN:+bs, soft, NT, obese.\n EXTREMITIES: 1+ pitting edema up to mid calf, bandages in place\n bilaterally in mid shin at site of presumed venous stasis ulcers.\n R/L DP/PT pulses weak,palpable, extremities WWP, good cap refill, skin\n turgor.\n .\n LABS/STUDIES\n EKG: in afib with rate varying between 100-150, nl axis. LVH:\n biphasic T waves in I, aVL. No waves seen.\n .\n 2D-ECHOCARDIOGRAM: - The left atrium is dilated. There is\n symmetric left ventricular hypertrophy. The left ventricular cavity\n size is normal. There is a mild resting left ventricular outflow tract\n obstruction. The aortic valve leaflets are severely thickened/deformed.\n Significant aortic stenosis is present (not quantified). Trace aortic\n regurgitation is seen. The mitral valve leaflets are moderately\n thickened. Trivial mitral regurgitation is seen. [Due to acoustic\n shadowing, the severity of mitral regurgitation may be significantly\n UNDERestimated.] The tricuspid valve leaflets are mildly thickened.\n There is mild pulmonary artery systolic hypertension. There is no\n pericardial effusion.\n No vegetation seen (cannot definitively exclude).\n Compared with the prior study (images reviewed) of , a mild\n left ventricular outflow gradient is now detected.\n .\n CARDIAC CATH: - COMMENTS: 1) Coronary angiography in this\n right dominant system demonstrated two vessel disease. The LMCA was\n heavily calcified and had a 50-60% stenosis. The LAD was calcified and\n had a proximal 70% stenosis. The LCx was calcified and had a proximal\n 50% stenosis. The RCA had mild lunen irregularities.\n 2) Arterial conduit angiography revealed the LIMA to be widely patent.\n The SVG-OM1 had and 80% stenosis mid graft with TIMI 3 flow into the\n distal vessel.\n 3) Resting hemodynamics revealed elvated right and left sided filling\n pressures with an RVEDP of 24 and LVEDP of 35mmHg. There was moderate\n to severe pulmonary arterial systolic hypertension with PASP of 68mmHg.\n The cardiac index was preserved at 3.26 l/min/m2. There was normal\n systemic arterial pressure with a BP of 136/73, mean 97mmHg.\n 4) There was severe aortic stenosis with a peak to peak gradient of\n 56mmHg and a calculated of 0.56cm2. Following the Valvuloplasty the\n calculated improved to 0.98cm2.\n 5) Successful Aortic ballon valvuloplasty with a 20mm Tyshak balloon.\n (see PTCA comments for details)\n 6) Unsuccessful Preclose of right femoral arteriotomy site.\n 7) Successful closure of the right femoral arteriotomy site with an 8\n French Angioseal.\n FINAL DIAGNOSIS:\n 1. Two vessel coronary artery disease.\n 2. Severe aortic stenosis with a calculated 0.56cm2\n 3. Diseased SVG to OMB for staged PCI.\n 4. Successful aortic balloon valvuloplasty to 0.98cm2 .\n 5. Unsuccessful closure with a Pre-close device.\n 6. Successful closure with an Angioseal device.\n .\n RADIOLOGY: CXR - Unchanged cardiomegaly with increased opacity in\n the left lower lobe concerning for pneumonia versus atelectasis. There\n is a small left pleural effusion unchanged. Fractures of the sternal\n wires are known and unchanged with no migration evident. The prior\n noted interstitial edema has now improved. There is persistent\n prominence of the bilateral pulmonary vasculature.\n IMPRESSION: Left lower lobe opacification may represent atelectasis\n versus pneumonia. Recommend clinical correlation.\n .\n HEAD MRI - IMPRESSION: 1. Focal area with high signal intensity\n is demonstrated at the right superior parietal lobule, with no\n significant mass effect and may represent a chronic hemorrhagic area.\n 2. Subcortical areas with high signal intensity are identified on T2\n and FLAIR sequences, likely consistent with chronic microvascular\n ischemic changes.\n 3. Tortuosity of the basilar artery, consistent with dolichoectasia,\n previously described by CTA on .\n .\n EEG - This is an abnormal routine EEG in the waking and sleeping\n states due to a mildly slow and disorganized background as well as\n focal mild right temporal slowing throughout the recording. This\n background is consistent with a mild encephalopathy with focal\n dysfunction in the right temporal region. There were no epileptiform\n features noted\n .\n CTA HEAD - 1. No acute infarction or hemorrhage.\n 2. Severe atherosclerotic narrowing of the distal right vertebral\n artery and moderate-to-severe narrowing of both cavernous internal\n carotid arteries. Small focus of calcification in the Basilar A. close\n to ithe tip. Given the extent of disease in the dominant right\n vertebral artery, associated vertebrobasilar insufficiency cannot be\n excluded. Further evlauation with MRA Neck with Gado can be considered\n for temporal info regarding the direction of flow, if there is no\n contra-indication to MRI.\n 3. Moderate microangiopathic ischemic white matter disease\n .\n LABORATORY DATA:\n See below.\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Ciprofloxacin - 02:00 AM\n Vancomycin - 09:00 AM\n Bactrim (SMX/TMP) - 09:11 AM\n Acyclovir - 04:42 PM\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Metoprolol - 02:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:47 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.6\nC (99.6\n HR: 98 (98 - 128) bpm\n BP: 106/61(70) {106/54(70) - 129/66(80)} mmHg\n RR: 22 (21 - 28) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 86 kg (admission): 80.1 kg\n Total In:\n 74 mL\n PO:\n TF:\n IVF:\n 74 mL\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -426 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 500 K/uL\n 9.8 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 101 mEq/L\n 142 mEq/L\n 34.7 %\n 11.7 K/uL\n [image002.jpg]\n 04:27 AM\n WBC\n 11.7\n Hct\n 34.7\n Plt\n 500\n Cr\n 0.8\n TropT\n 0.02\n Glucose\n 107\n Other labs: PT / PTT / INR:28.2/30.6/2.8, CK / CKMB /\n Troponin-T:15//0.02, ALT / AST:, Alk Phos / T Bili:62/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:1.8\n mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ASSESSMENT AND PLAN\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures on who had MS\n change first noted following MRI, who subsequently flashed on the floor\n in the setting of holding lasix.\n .\n Afib: Pt in Afib with RVR on arrival. Had been NPO for some time on the\n floor, had been on p.o metoprolol on am then changed to IV at 5-10\n Q4 on 3/3pm but didn't get any on although written, ? low SBPs.\n On arrival to floor received IV metoprolol 2.5 with improvement rate to\n 80's from 128.\n Uptitrated metoprolol to 15mg IV q4 (conversion 2.5:1 IV to p.o)\n -continue metoprolol IV.\n As becomes more alert, able to tolerate pills convert to p.o.\n -am EKG.\n # Flash Pulmonary Edema: CAD s/p CABG 86F with CAD s/p CABG \n (SVG-OM, LIMA-LAD)\n -Given AS pt very sensitive to fluid shifts, had been lying down for a\n long time at MRI and lasix was being held on floor to prevent cerebral\n hypoperfusion with subsequent flash.\n On arrival to ICU received IV lasix bolus 60mg IV and started on lasix\n drip.\n Continue lasix drip, titrating based on clinical appearance/respiratory\n status.\n -On digoxin chronically, typically not preferred in setting of normal\n EF, will continue for now. Dig level 0.9 (range 0.9-2)\n -repeat ABG this pm\n -repeat CXR in am.\n .\n #AS: AS s/p valvuloplasty .Severe AS on Echo with valve\n area not quantified but LVOT of 12 noted which was not noted on Echo of\n but valve area of 0.8. EF stable at 60%. AS known critical, unclear\n if worsened AS since as valve area not quantified but known to be\n critical. Pt poor surgical candidate thus had not received AVR.\n -Consideration being given for minimally invasive percutaneous valve\n replacement.\n -f/u with ICU fellow/Dr \n cautious diruesis in setting critical AS.\n .\n # MS Change: Likely multifactorial related to benzodiazepine pre MRI\n although only received 0.5mg, C02 retention fatigue with mildly\n elevated C02 of 63 on ABG, and low CO with CHF.\n Did have on CTA and has new, subtle LUE/LLE weakness and no\n reflexes on LLE which is new per neuro consistent with lesion on right.\n This lesion is most likely vascular in nature, either a small infarct\n which converted to a bleed, versus less likely malignant ? metastatic\n colon cancer. Once medically stable neuro recommends MRI with\n gadolinium to asses lesion. If does not enhance, likely bleed.\n -appreciate neuro recs\n -ASA 81mg\n -serial neuro exams.\n -keppra for seizure prophylaxis.\n -gentle diuresis\n -avoid benzos\n -follow resp status, serial ABGs.\n -diuresis\n .\n # ? Infection: Pt low grade temp to 100.3.\n Had been lying flat at MRI y/d, possible aspiration pneumonitis.\n If spikes temp, white count, institute Abx coverage with cipro.\n f/u with ? chronic suppression with vanc for c.diff\n Blood cx drawn with initial question of meningitis on presentation with\n seizures have been negative x 3. Urine cx negative x1, repeat drawn on\n pending.\n -f/u final urine cx\n -trend WBC, fever curve.\n .\n # Hx Diarrhea:\n hx C.diff on chronic suppression therapy with p.o vanc/flagyll with\n last cx at rehab on negative but abx were continued to\n continued diarrhea. However diarrhea has stopped so abx stopped this\n hospitalization.\n Continue to monitor.\n .\n #hx GI bleed: s/p hemicolectomy following which she presented to \n rehab.\n Baseline Hct ~ 30, 35 on now 32.2\n Continue to trend daily.\n Guiac all stools\n active type and screen.\n .\n FEN:\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx: holding given INR 5.0\n -Pain management with tylenol/gabapentin\n -Bowel regimen: hold\n .\n CODE: FULL\n .\n COMM: , : \n .\n DISPO: CCU for now\n ICU Care\n Nutrition: NPO currently. Speech and swallow initially consulted but\n became unresponsive. Reconsult when pt alert.\n Continue RISS, finger sticks.\n Glycemic Control: RISS\n Lines:\n PICC Line - 11:01 AM\n 20 Gauge - 11:02 AM\n Prophylaxis:\n DVT: holding coumadin given INR 5\n Stress ulcer: none\n VAP:\n Comments:\n Communication: Comments: COMM: , : \n .\n DISPO: CCU for now\n Code status: Full Code\n Disposition:ICU for now\n"
},
{
"category": "Nursing",
"chartdate": "2196-01-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402723,
"text": "86F severe AS (critical AS s/p valvuloplasty ), CAD s/p CABG \n (lima-lad, svg-om), dCHF, AF with multiple recent hospitalizations\n ( valvuloplasty, hemicolectomy for adenoCA, c diff colitis,\n diverticulitis. Admitted after seizure which stopped with ativan\n and keppra. Diuretics were held on admission. She was treated initially\n for meningitis. CTA was negative for CVA. MRI head with high signal\n intensity in the R superior parietal lobe. After MRI on she\n triggered for AMS and lethargy. Her HR was in the 130s and her SBP was\n in the 80s. Her ABG was notable for pCO2 65. She was given lasix 10mg\n IV then 30mg and 5mg IV metoprolol without significant improvement.\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-08 00:00:00.000",
"description": "Intensivist Note",
"row_id": 404063,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. At time of SICU admission, she\n responded only to painful stimuli.\n Chief complaint:\n Seizures\n PMHx:\n CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Albumin 5% (12.5g /\n 250mL) 8. Albuterol Inhaler 9. Albumin 5% (12.5g / 250mL) 10. Aspirin\n 11. Atorvastatin 12. Bacitracin-Polymyxin Ointment 13. Calcium\n Gluconate 14. CefePIME 15. Chlorhexidine Gluconate 0.12% Oral Rinse 16.\n Ciprofloxacin 17. Ciprofloxacin 20. Digoxin 21. Etomidate 22.\n Famotidine 23. Fentanyl Citrate 25. FoLIC Acid 26. Furosemide 27.\n Furosemide 28. Gabapentin 29. Glucagon 30. Heparin 31. Insulin 32.\n Ipratropium Bromide MDI. 35. Levothyroxine Sodium\n 36. LeVETiracetam 40. Metoprolol Tartrate 41. Miconazole Powder 2% 43.\n Nystatin Oral Suspension 44. Phenytoin Sodium (IV) 45. Phenylephrine\n 51. Timolol Maleate 0.5% 52. Vancomycin 53. Warfarin\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 11:30 AM\n INTUBATION - At 02:30 PM\n NON-INVASIVE VENTILATION - STOP 02:30 PM\n INVASIVE VENTILATION - START 02:35 PM\n BLOOD CULTURED - At 09:00 PM\n URINE CULTURE - At 09:00 PM\n FEVER - 101.5\nF - 08:00 PM\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 10:15 PM\n Ciprofloxacin - 11:35 PM\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Other ICU medications:\n Dilantin - 04:23 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Flowsheet Data as of 04:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.5\n T current: 38\nC (100.4\n HR: 82 (78 - 106) bpm\n BP: 115/47(71) {78/36(51) - 144/65(95)} mmHg\n RR: 21 (13 - 33) insp/min\n SPO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 87.5 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 2,078 mL\n 545 mL\n PO:\n Tube feeding:\n 917 mL\n 160 mL\n IV Fluid:\n 621 mL\n 75 mL\n Blood products:\n 250 mL\n 250 mL\n Total out:\n 286 mL\n 50 mL\n Urine:\n 286 mL\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,792 mL\n 495 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 200 (200 - 295) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 175\n PIP: 24 cmH2O\n Plateau: 21 cmH2O\n Compliance: 28.1 cmH2O/mL\n SPO2: 97%\n ABG: 7.38/49/99.//2\n Ve: 9.3 L/min\n PaO2 / FiO2: 198\n Physical Examination\n General Appearance: Intubated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Breath Sounds: Crackles : bibasilar, Rhonchorous\n : , Diminished: bibasilar)\n Abdominal: Soft, Non-distended, Non-tender, Obese\n Left Extremities: (Edema: 1+, No(t) 2+), (Temperature: Warm), (Pulse -\n Dorsalis pedis: No(t) Present, Diminished)\n Right Extremities: (Edema: No(t) Trace, 1+), (Temperature: Warm),\n (Pulse - Dorsalis pedis: Diminished)\n Neurologic: Moves all extremities, MAE to painful stimuli, sometimes\n purposefully\n Labs / Radiology\n 430 K/uL\n 7.8 g/dL\n 119 mg/dL\n 1.5 mg/dL\n 30 mEq/L\n 4.3 mEq/L\n 40 mg/dL\n 110 mEq/L\n 146 mEq/L\n 26.9 %\n 11.3 K/uL\n [image002.jpg]\n 11:58 AM\n 08:32 PM\n 02:19 AM\n 10:32 AM\n 03:49 AM\n 10:50 AM\n 01:08 PM\n 04:35 PM\n 06:36 PM\n 03:33 AM\n WBC\n 11.1\n 10.5\n 11.3\n Hct\n 30.6\n 30.4\n 26.9\n Plt\n \n Creatinine\n 1.2\n 1.2\n 1.5\n TCO2\n 30\n 31\n 31\n 30\n 29\n 30\n Glucose\n 136\n 119\n Other labs: PT / PTT / INR:18.0/42.2/1.6, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:62/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca:7.8 mg/dL, Mg:2.2 mg/dL, PO4:3.4 mg/dL\n Imaging: CT head: No acute ICH. Small ovoid hypodensity in R\n parietal lobe corresponds to area demonstrating old blood products seen\n on MRI of . New opacification of L anterior ethmoid air cells and\n increased opacification of L mastoid air cells.\n CXR: Cardiomegaly, prominent pulmonary vasculature, and bibasilar\n atelectasis is unchanged.\n MR: Focal area w/high signal intensity @ R sup parietal lobule, no\n mass effect and may represent a chronic hemorrhagic area. Subcortical\n areas w/high signal intensity on T2 and FLAIR c/w chronic microvascular\n ischemic changes. Tortuosity of basilar artery, cw dolichoectasia\n Echo: EF >= 60%, Symmetric LVH, Significant AS, Trivial MR (may be\n significantly UNDERestimated), Mild [1+] TR. Mild PA systolic HTN\n CTA: No acute infarctor hemorrhage. Severe atherosclerotic\n narrowing of distal R vertebral art and moderate-to-severe narrowing of\n both cavernous ICAs. Small focus of calcification in Basilar A. close\n to the tip. Moderate microangiopathic ischemic white matter dz\n Microbiology: UCx: Yeast, >100,000\n BCx x2 neg\n BCx x2 p\n UCx: Yeast 10-100,000\n & Cdiff: Neg\n Sp Cx: 1+ Yeast\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), KNOWLEDGE DEFICIT, IMPAIRED\n SKIN INTEGRITY, PNEUMONIA, ASPIRATION, AORTIC STENOSIS, SEIZURE,\n WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD, now w/respiratory acidosis and\n failure resulting in intubation ().\n Neurologic: -- Patient sedtaed with fentanyl. Unsatisfactory mental\n status.\n -- Patient with seizures, loaded with dilantin and ativan prior to\n admission with poor mental status. Despite loading dose continued to\n have seziures according to EEG (). Medication regiment\n changed. Currently on phenytoin and kepra. MRI brain w/ and w/o ordered\n for when pt is stable to transport to evaluate to source of bleed in\n parietal lobe.\n --Continue neurontin for chronic pain well controlled on current\n medication.\n Cardiovascular: -- PAF with good control of HR on beta blockade and\n digoxin. Anticoagulation started with coumadin. INR subtherapeutic. No\n heparin bridge for risk of rebleed. On ASA\n -- CAD s/p CABG , diastolic dysfunction. On b-blockade,\n furosemide, ASA, and statin.\n -- Critical AS (valve area on pre-valvuloplasty 0.8cm2). On ICU-based\n ECHO estimated area is 0.6cm2. Not eligible for open valve replacement.\n Family is discussing this issue with another cardiologist.\n -- Neosynephrine weaning off\n -- Cortisol stim test negative\n Pulmonary: --Treated empirically for pneumonia with Vanc/Cefepime, and\n massive amount of copious sputum. Cultures are negative. We will\n continue treatment for full 7 days despite negative cultures (to )\n --After long d/w family, pt intubated w/worsening resp acidosis despite\n CPAP. Family discussion included trach, which they most likely will\n agree to.\n --albuterol/atrovent PRN\n --Chest PT\n Gastrointestinal / Abdomen: --Resume TFs, consider PEG tube placement.\n --CDiff x 2 have been negative and diarrhea has stopped, PO vanc has\n been stopped.\n Nutrition: --TF restarted via Dobhoff\n Renal: -- On home dose of Lasix\n -- Diminished urine output, received albumin x2 overnight\n -- Cipro for UTI, started , cultures pending\n Hematology: --Hct stable, 26.9\n --ASA, SQH\n Endocrine: --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg for hypothyroidism, previous TSH was 6.8\n Infectious Disease: --Wbc 8.8->9.9->11.1->10.5->11.3. febrile \n --Being treated for PNA with cefepime/vanc (?aspiration) total course\n should be 7 days (ending ). Vanc trough 20.6 , dose decreased\n to 500mg IV q24hrs from 750; vanc trough , held , decreased to\n 500\n --Follow cultures (NGTD except yeast in urine, sputum), resent \n (temp 101.5). +U/A, cipro started on \n Lines / Tubes / Drains: PIV, Foley, PICC\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: Other: status epilepticus, respiratory failure, UTI\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 06:03 PM\n Arterial Line - 04:39 PM\n Prophylaxis:\n DVT: SQ UF Heparin (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 405357,
"text": "Demographics\n Day of intubation: 17\n Day of mechanical ventilation: 17\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Pending procedure /\n OR (Possible valvuloplasty if neuro status improves) Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405432,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now w/respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urinary output remains low-> 10-15cc/hr- BUN 124 Crea 3.8- worsening\n metabolic acidosis- (+) anasarca- weight trending up (107.1 kg)\n Action:\n Metolazone and bumex given as ordered.\n Response:\n No increase in U/O.\n Plan:\n Con\nt to follow labs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n CMV 400x14 50% P5 via trach\n Action:\n ABG 7.27-41-119-20 98%- suctioned scant-small amt thick tan colored\n mucous- resp rx given as ordered- RR increased to 18 on vent.\n Response:\n Repeat ABG 7.30-41-112-21 96%\n Plan:\n Con\nt vent support- maintain VAP protocol.\n Seizure, without status epilepticus\n Assessment:\n Remains unresponsive- unable to follow command- no spontaneous\n movement noted- resists mouth care by clenching teeth- PERL- ?\n attempted to open eyes when husband called her name, but was unable to.\n Action:\n Dilantin given as ordered- neuro status monitored.\n Response:\n No seizure activity noted- neuro status unchanged.\n Plan:\n Con\nt to monitor- follow dilantin levels- notify HO of any seizure\n activity.\n Impaired Skin Integrity\n Assessment:\n Bilateral leg dsgs intact, mepilex dsg on coccyx intact- abd folds w/\n redness/crack skin- (+) anasarca\n Action:\n Foam cleanser and miconazole powder PRN- see metavision for details of\n skin integrity- frequent repositioning and skin care.\n Response:\n Unchanged.\n Plan:\n Con\nt present management.\n Heparin gtt (Afib) @ 1350u/hr- PTT 100.5 on 1500u/hr- repeat PTT\n pending- hemodynamically stable- TF @ goal 35cc/hr.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405430,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now w/respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urinary output remains low-> 10-15cc/hr- BUN 124 Crea 3.8- worsening\n metabolic acidosis- (+) anasarca- weight trending up (107.1 kg)\n Action:\n Metolazone and bumex given as ordered.\n Response:\n No increase in U/O.\n Plan:\n Con\nt to follow labs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n CMV 400x14 50% P5 via trach\n Action:\n ABG 7.27-41-119-20 98%- suctioned scant-small amt thick tan colored\n mucous- resp rx given as ordered- RR increased to 18 on vent.\n Response:\n Repeat ABG 7.30-41-112-21 96%\n Plan:\n Con\nt vent support- maintain VAP protocol.\n Seizure, without status epilepticus\n Assessment:\n Remains unresponsive- unable to follow command- no spontaneous\n movement noted- resists mouth care by clenching teeth- PERL- ?\n attempted to open eyes when husband called her name, but was unable to.\n Action:\n Dilantin given as ordered- neuro status monitored.\n Response:\n No seizure activity noted- neuro status unchanged.\n Plan:\n Con\nt to monitor- follow dilantin levels- notify HO of any seizure\n activity.\n Impaired Skin Integrity\n Assessment:\n Bilateral leg dsgs intact, mepilex dsg on coccyx intact- abd folds w/\n redness/crack skin- (+) anasarca\n Action:\n Foam cleanser and miconazole powder PRN- see metavision for details of\n skin integrity- frequent repositioning and skin care.\n Response:\n Unchanged.\n Plan:\n Con\nt present management.\n Heparin gtt (Afib) @ 1350u/hr- PTT 100.1 on 1500u/hr- repeat PTT\n pending- hemodynamically stabe.\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405502,
"text": "Chief Complaint: Critical AS, with failed repair, subsequent\n intraparenchymal cerebral hemorrhage, seizure, family requested Tx to\n CCU where mental status have continued to deteriorate.\n 24 Hour Events:\n \n RT went up on ventalator rate and acidosis improved somewhat\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,350 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Dilantin - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 89 (80 - 98) bpm\n BP: 106/50(71) {100/45(68) - 132/63(89)} mmHg\n RR: 14 (10 - 31) insp/min\n SpO2: 92%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 107.1 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 16 (16 - 22)mmHg\n Total In:\n 1,341 mL\n 618 mL\n PO:\n TF:\n 682 mL\n 256 mL\n IVF:\n 630 mL\n 172 mL\n Blood products:\n Total out:\n 380 mL\n 125 mL\n Urine:\n 280 mL\n 125 mL\n NG:\n Stool:\n Drains:\n Balance:\n 961 mL\n 493 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 64\n PIP: 24 cmH2O\n Plateau: 17 cmH2O\n SpO2: 92%\n ABG: 7.30/41/112/18/-5\n Ve: 8.1 L/min\n PaO2 / FiO2: 224\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n LUNGS: Ventilated breath sounds. Unable to hear good breath sounds at\n the bases.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Comatose (GCS 3), no plantar response on left and small upgoing\n on right. Jaw jerk hyperactive, glalbella tap present, corneals WNLs\n bilaterally. No doll\ns eyes to lateral head roll. PERRL.\n Labs / Radiology\n 357 K/uL\n 7.3 g/dL\n 124 mg/dL\n 3.8 mg/dL\n 18 mEq/L\n 4.5 mEq/L\n 124 mg/dL\n 102 mEq/L\n 137 mEq/L\n 25.4 %\n 7.6 K/uL\n 11:51 PM\n 01:04 AM\n 02:02 AM\n 04:44 AM\n 05:08 AM\n 09:16 PM\n 04:32 AM\n 08:40 AM\n 06:02 PM\n 04:16 AM\n WBC\n 7.0\n 7.1\n 7.6\n Hct\n 24.7\n 25.5\n 25.4\n Plt\n 422\n 381\n 357\n Cr\n 3.7\n 3.7\n 3.8\n 3.8\n TCO2\n 21\n 21\n 20\n 20\n 20\n 21\n Glucose\n 137\n 127\n 122\n 119\n 124\n Other labs: PT / PTT / INR:13.2/76.4/1.1, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL, PO4:5.4 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: CXR portable :\n Portable AP chest radiograph was compared to .\n The tracheostomy is at the midline with its tip being 4.5 cm above the\n carina.\n The left internal jugular line tip is at the level of mid SVC. There is\n no\n change in the cardiomediastinal silhouette. There is interval\n improvement in\n pulmonary edema. The left pleural effusion is present as well as left\n retrocardiac atelectasis. The right lateral chest was not included in\n the\n field of view preventing evaluation of the right pleural effusion.\n Broken sternal wires are unchanged. The gastrostomy is projecting over\n the\n stomach.\n Microbiology: Yeast in urine and sputum. No other significant findings.\n Electrrphysiology:\n ECG:\n EEG:\n BACKGROUND: Is diffusely slow and disorganized consisting of mixed\n theta and delta frequencies and occasional periods of diffuse global\n suppression of the background. There were rare bursts of generalized\n slowing and rare generalized sharps occurring in isolation. There were\n no electrographic seizures and there were no periodic discharges.\n HYPERVENTILATION: Could not be performed secondary to history of\n intracranial hemorrhage.\n INTERMITTENT PHOTIC STIMULATION: Could not be performed secondary to\n the portable nature of this study.\n SLEEP: No normal sleep morphology was seen on this recording.\n CARDIAC MONITOR: Showed an irregularly irregular rhythm with occasional\n wide complex ectopic beats.\n IMPRESSION: This is a severely abnormal extended routine EEG due to a\n diffusely slow and disorganized background consisting of mixed theta\n and\n delta frequencies marked by occasional generalized bursts of slowing,\n rare generalized sharps occurring in isolation and occasional brief\n suppressive bursts of the background. There were no periodic discharges\n and there were no electrographic seizures. Overall, this background is\n suggestive of a severe encephalopathy. Amongst the most common causes\n of encephalopathy are medications, infection, metabolic derangements,\n and anoxia.\n INTERPRETED BY: , L.\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures (now none for a week on EEG) and deteriorating\n mental status, aspiration pneumonia, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension required\n phenylephrine. Transferred to CCU at request of family and consulting\n cardiologist.\n # Coma, seizures, Goals of Care\n Comatose with some brainstem reflexes. No seizures for some time. No\n evidence of cortical function. BUN 124 and patient has been\n intermittently hypotensive. Therefore differential includes (also\n possible multifactorial) uremia, anoxic brain injury and\n carcinoatosis/paraneoplastic encephalopathy (although very unlikely).\n Dr. has discussed issue of Phenobarbital with Dr. \n (neurology) and decision made to not restart phenobarbital.\n - No need for LP given carcinomatosis is an extremely unlikely cause of\n coma and metabolic toxicities (many different sources) seem more\n likely.\n - Will consider stopping AEDs, given possible contribution to mental\n status\n # Acidemia\n ABG slightly improved today - 7.30/41/112/18/-5. Lactate was not\n elevated at 1.0 making metabolic acidosis from renal failure or uremia\n more likely. Pt not a candidate for HD.\n - increase ventilation rate for respiratory compensation of\n metabolic acidosis\n - will hold off on bicarb/fluids\n # Aortic Stenosis\n Treatment of this is deferred pending decision about the above.\n Valvuloplasty will need to be repeated (if this is compatible with\n goals of care). Pt with known severe aortic stenosis s/p valvuloplasty\n in . She was initially on the CCU service early in her\n hospitalization in the setting of flash pulmonary edema when her lasix\n were held. Now, she is intubated in the ICU. Continues to be severely\n fluid overloaded and oliguric, positive ~30L Los. She does not respond\n well to lasix/diuril/bumex but is also not a candidate for HD.\n - Continue bumex and metolazone with goal of net negative 1.5L today\n - lytes\n - Monitor volume status, UOP.\n - Holding off on valvuloplasty at this point\n # Respiratory Failure and Intubation\n - Preserve for now given mental status and edema\n # Atrial Fibrillation\n Pt has good control of HR on beta blockade and digoxin. Coumadin was\n being held before for trach/PEG. Now, holding coumading in case pt\n undergoes valvuloplasty. Now on heparin gtt while INR subtherapeutic.\n - Continue metoprolol tartrate 25 mg TID\n - Continue digoxin 0.0625 mg daily\n - Trend coags\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, is ATN\n - Will attempt diuresis with bumex/metolazone, as above\n - Appreciate renal recs.\n - Continue to monitor fluid status otherwise\n # Coronary Artery Disease: Pt is s/p CABG /.\n - Continue metoprolol as above\n - Continue aspirin 81 mg daily, atorvastatin 40 mg daily\n # Respiratory Failure: Now, s/p trach.\n - Trach in place\n - Continue albuterol/atrovent PRN\n # Pressor Requirement: Pt weaned off of pressors.\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - f/u cx data\n - follow fever curve\n - f/u stool for c.diff\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:56 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n TITLE: CCU Attending Cardiology Progress Note\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the note by Dr. today and I agree with\n the plan.\n I would add the following remarks:\n History\n Smiled and opened eyes to husband\ns voice. Off Phenobarbital and\n Dilantin is subtherapeutic (3.3).\n Is increasing her ventilatory requirements on higher degrees of FIO2.\n Still fluid overloaded.\n Medical Decision Making\n Given the finding of her responsiveness to her husband, will temporize\n with supportive care for the next day and reassess supportive measures\n in one day.\n Total time spent on patient care: 30 minutes of critical care time\n ------ Protected Section Addendum Entered By: , MD\n on: 16:45 ------\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405496,
"text": "Chief Complaint: Critical AS, with failed repair, subsequent\n intraparenchymal cerebral hemorrhage, seizure, family requested Tx to\n CCU where mental status have continued to deteriorate.\n 24 Hour Events:\n \n RT went up on ventalator rate and acidosis improved somewhat\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,350 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Dilantin - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 89 (80 - 98) bpm\n BP: 106/50(71) {100/45(68) - 132/63(89)} mmHg\n RR: 14 (10 - 31) insp/min\n SpO2: 92%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 107.1 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 16 (16 - 22)mmHg\n Total In:\n 1,341 mL\n 618 mL\n PO:\n TF:\n 682 mL\n 256 mL\n IVF:\n 630 mL\n 172 mL\n Blood products:\n Total out:\n 380 mL\n 125 mL\n Urine:\n 280 mL\n 125 mL\n NG:\n Stool:\n Drains:\n Balance:\n 961 mL\n 493 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 64\n PIP: 24 cmH2O\n Plateau: 17 cmH2O\n SpO2: 92%\n ABG: 7.30/41/112/18/-5\n Ve: 8.1 L/min\n PaO2 / FiO2: 224\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n LUNGS: Ventilated breath sounds. Unable to hear good breath sounds at\n the bases.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Comatose (GCS 3), no plantar response on left and small upgoing\n on right. Jaw jerk hyperactive, glalbella tap present, corneals WNLs\n bilaterally. No doll\ns eyes to lateral head roll. PERRL.\n Labs / Radiology\n 357 K/uL\n 7.3 g/dL\n 124 mg/dL\n 3.8 mg/dL\n 18 mEq/L\n 4.5 mEq/L\n 124 mg/dL\n 102 mEq/L\n 137 mEq/L\n 25.4 %\n 7.6 K/uL\n [image002.jpg]\n 11:51 PM\n 01:04 AM\n 02:02 AM\n 04:44 AM\n 05:08 AM\n 09:16 PM\n 04:32 AM\n 08:40 AM\n 06:02 PM\n 04:16 AM\n WBC\n 7.0\n 7.1\n 7.6\n Hct\n 24.7\n 25.5\n 25.4\n Plt\n 422\n 381\n 357\n Cr\n 3.7\n 3.7\n 3.8\n 3.8\n TCO2\n 21\n 21\n 20\n 20\n 20\n 21\n Glucose\n 137\n 127\n 122\n 119\n 124\n Other labs: PT / PTT / INR:13.2/76.4/1.1, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL, PO4:5.4 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: CXR portable :\n Portable AP chest radiograph was compared to .\n The tracheostomy is at the midline with its tip being 4.5 cm above the\n carina.\n The left internal jugular line tip is at the level of mid SVC. There is\n no\n change in the cardiomediastinal silhouette. There is interval\n improvement in\n pulmonary edema. The left pleural effusion is present as well as left\n retrocardiac atelectasis. The right lateral chest was not included in\n the\n field of view preventing evaluation of the right pleural effusion.\n Broken sternal wires are unchanged. The gastrostomy is projecting over\n the\n stomach.\n Microbiology: Yeast in urine and sputum. No other significant findings.\n Electrrphysiology:\n ECG:\n EEG:\n BACKGROUND: Is diffusely slow and disorganized consisting of mixed\n theta and delta frequencies and occasional periods of diffuse global\n suppression of the background. There were rare bursts of generalized\n slowing and rare generalized sharps occurring in isolation. There were\n no electrographic seizures and there were no periodic discharges.\n HYPERVENTILATION: Could not be performed secondary to history of\n intracranial hemorrhage.\n INTERMITTENT PHOTIC STIMULATION: Could not be performed secondary to\n the portable nature of this study.\n SLEEP: No normal sleep morphology was seen on this recording.\n CARDIAC MONITOR: Showed an irregularly irregular rhythm with occasional\n wide complex ectopic beats.\n IMPRESSION: This is a severely abnormal extended routine EEG due to a\n diffusely slow and disorganized background consisting of mixed theta\n and\n delta frequencies marked by occasional generalized bursts of slowing,\n rare generalized sharps occurring in isolation and occasional brief\n suppressive bursts of the background. There were no periodic discharges\n and there were no electrographic seizures. Overall, this background is\n suggestive of a severe encephalopathy. Amongst the most common causes\n of encephalopathy are medications, infection, metabolic derangements,\n and anoxia.\n INTERPRETED BY: , L.\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures (now none for a week on EEG) and deteriorating\n mental status, aspiration pneumonia, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension required\n phenylephrine. Transferred to CCU at request of family and consulting\n cardiologist.\n # Coma, seizures, Goals of Care\n Comatose with some brainstem reflexes. No seizures for some time. No\n evidence of cortical function. BUN 124 and patient has been\n intermittently hypotensive. Therefore differential includes (also\n possible multifactorial) uremia, anoxic brain injury and\n carcinoatosis/paraneoplastic encephalopathy (although very unlikely).\n Dr. has discussed issue of Phenobarbital with Dr. \n (neurology) and decision made to not restart phenobarbital.\n - No need for LP given carcinomatosis is an extremely unlikely cause of\n coma and metabolic toxicities (many different sources) seem more\n likely.\n - Will consider stopping AEDs, given possible contribution to mental\n status\n # Acidemia\n ABG slightly improved today - 7.30/41/112/18/-5. Lactate was not\n elevated at 1.0 making metabolic acidosis from renal failure or uremia\n more likely. Pt not a candidate for HD.\n - increase ventilation rate for respiratory compensation of\n metabolic acidosis\n - will hold off on bicarb/fluids\n # Aortic Stenosis\n Treatment of this is deferred pending decision about the above.\n Valvuloplasty will need to be repeated (if this is compatible with\n goals of care). Pt with known severe aortic stenosis s/p valvuloplasty\n in . She was initially on the CCU service early in her\n hospitalization in the setting of flash pulmonary edema when her lasix\n were held. Now, she is intubated in the ICU. Continues to be severely\n fluid overloaded and oliguric, positive ~30L Los. She does not respond\n well to lasix/diuril/bumex but is also not a candidate for HD.\n - Continue bumex and metolazone with goal of net negative 1.5L today\n - lytes\n - Monitor volume status, UOP.\n - Holding off on valvuloplasty at this point\n # Respiratory Failure and Intubation\n - Preserve for now given mental status and edema\n # Atrial Fibrillation\n Pt has good control of HR on beta blockade and digoxin. Coumadin was\n being held before for trach/PEG. Now, holding coumading in case pt\n undergoes valvuloplasty. Now on heparin gtt while INR subtherapeutic.\n - Continue metoprolol tartrate 25 mg TID\n - Continue digoxin 0.0625 mg daily\n - Trend coags\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, is ATN\n - Will attempt diuresis with bumex/metolazone, as above\n - Appreciate renal recs.\n - Continue to monitor fluid status otherwise\n # Coronary Artery Disease: Pt is s/p CABG /.\n - Continue metoprolol as above\n - Continue aspirin 81 mg daily, atorvastatin 40 mg daily\n # Respiratory Failure: Now, s/p trach.\n - Trach in place\n - Continue albuterol/atrovent PRN\n # Pressor Requirement: Pt weaned off of pressors.\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - f/u cx data\n - follow fever curve\n - f/u stool for c.diff\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:56 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405666,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now w/respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Seizure, without status epilepticus\n Assessment:\n No change in neuro status- remains unresponsive- no movement of\n extremities noted, even to painful stimuli- PERL- responds to mouth\n care by biting down on swab.\n Action:\n Dilantin given as ordered- neuro checks q4hrs.\n Response:\n Unchanged.\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405347,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine ouput continues 10-15 cc/hr\n Action:\n Bumex and mealazone\n Response:\n Urine ouput continues low, pt with generalized anasarca, bun 123,\n creatinine 3.7,K=4.8\n Plan:\n Monitor bun/creatinine\n Seizure, without status epilepticus\n Assessment:\n Pupils equal and reactive, pt does not open eyes, no purposeful\n movement, resists oral care..keeps mouth shut. No seizure acivity\n noted. Very small movement of arms and legs to nail bed pressure.\n Action:\n Pt on iv dilantin tid, dilantin level drawn with am labs prior to\n morning dilantin dose\n Response:\n No change in neuro status, no seizure activty\n Plan:\n Check dilantin level, continue to monitor neuro status, notify ho of\n any seizure activity\n Impaired Skin Integrity\n Assessment:\n Bilateral leg dressing intact, mepilex dressing on coccyx intact. See\n careview for detail of skin , abdominal folds with yeast and skin is\n cracking., surrounding skin pink and edematous( generalized anasarca)\n Action:\n Foam cleanser and miconazole powder\n Response:\n Generalized edema persists and area is still pink with skin breakdown\n in abdominal folds\n Plan:\n Cleans and keep area dry. Apply miconazole powder to all folds\n abdominal, breasts, periarea\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bilateral rhonci, diminished at baseso2 sat 91-95 %, resp rate 18-23.\n vent setting 50 %/ 400//14\n Action:\n IH albuterol , suctioned for thick tan ~ q 2-3 hours small to moderate\n amounts,trach care\n Response:\n RSBI=56,sats continue 91-95 %\n Plan:\n Monitor o2 sats, sx q 2-3 hours.trach care\n Patient on heparin . ptt drawn at 0100 =56.7, heparin dose increased to\n 1500 units at 0300.CHECK NEXT PTT AT 0900.\n Watch for improvement in neuro status. If neuro status improves pt may\n undergo valvuloplasty.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405420,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now w/respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urinary output remains low-> 10-15cc/hr- BUN 124 Crea 3.8- worsening\n metabolic acidosis- (+) anasarca- weight trending up (107.1 kg)\n Action:\n Metolazone and bumex given as ordered.\n Response:\n No increase in U/O.\n Plan:\n Con\nt to follow labs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n CMV 400x14 50% P5 via trach\n Action:\n ABG 7.27-41-119-20 98%- suctioned scant-small amt thick tan colored\n mucous- resp rx given as ordered- RR increased to 18 on vent.\n Response:\n Worsening metabolic acidosis.\n Plan:\n Con\nt vent support- maintain VAP protocol.\n Seizure, without status epilepticus\n Assessment:\n Remains unresponsive- unable to follow command- no spontaneous\n movement noted- resists mouth care by clenching teeth- PERL- ?\n attempted to open eyes when husband called her name, but was unable to.\n Action:\n Dilantin given as ordered- neuro status monitored.\n Response:\n No seizure activity noted- neuro status unchanged.\n Plan:\n Con\nt to monitor- follow dilantin levels- notify HO of any seizure\n activity.\n Impaired Skin Integrity\n Assessment:\n Bilateral leg dsgs intact, mepilex dsg on coccyx intact- abd folds w/\n redness/crack skin- (+) anasarca\n Action:\n Foam cleanser and miconazole powder PRN- see metavision for details of\n skin integrity- frequent repositioning and skin care.\n Response:\n Unchanged.\n Plan:\n Con\nt present management.\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 405499,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 18\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405582,
"text": "Seizure, without status epilepticus\n Assessment:\n Neuro status exam unchanged. PERLA 3-4mm. no spontaneous movement of\n extremities. Doesn\nt respond to noxious stimuli. Pt does grimace to\n painful stimuli but does not move extrems. pt neuro status has not\n improved.\n Action:\n Neuro checks done q 4hr\n Response:\n Cont\n to monitor. Remains on dilantin q8h IV.\n Plan:\n Monitor for seizures. Monitor neuro status. Dilantin q8h. emotional\n support to family.\n Impaired Skin Integrity\n Assessment:\n Anasarca. Multiple excoriations, open areas in creases from yeast in\n all skin folds (groin, panus, under breasts). Venous ulcers on both\n lower legs. Decub on coccyx , mepilex in place. Multiple small\n ulcerated/scabbed areas over forehead and in hair from prolonged use of\n EEG leads.\n Action:\n Freq turns q2h. on kinair bed. Waffle boots on. Flexiseal in place,\n working well, keeping buttocks free from stool (loose brown stool).\n Trach and peg sites intact. Dsgs intact to bilat lower legs ulcers.\n Mepilex intact to coccyx. Extremities elevated. On kinair bed.\n Response:\n No changes. Con\nt skin care q2h with turns.\n Plan:\n Daily bilat lower leg dsg changes. See skin care nurse notes in chart.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine ouput continues low 10 -20 cc/hr.\n Action:\n Patient receiving bumex and metalazone qd( to be given\n before\n morning bumex dose\n Response:\n No change. Low urines continue, creat remains unchanged today. Mg and\n K+ trending up slightly.\n Plan:\n Monitor uo and bun and creatinine\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Occ wheezes noted. Rhonchorous. O2 sats 94-98 % . Trached.\n Action:\n Suctioned q 3-4 hours for small thick yellow secretions. albuterol ih\n atc q 4 hours and atrovent q 6\n Response:\n Fio2 currently at 50% with good sats and good Po2, remains\n metabolically acidotic.\n Plan:\n Adjust vent settings as needed.\n Aortic stenosis\n Assessment:\n Pt in afib 80s. rare PVC noted. SBP 90s-130s. Aline Lt radial. TLC Lt\n IJ.\n Action:\n Heparin dose infusing at 1350 units/hr. am PTT WNL.\n Response:\n Tolerating lopressor 25mg po TID.\n Plan:\n Continue heparin at 1350 units.\n"
},
{
"category": "General",
"chartdate": "2196-02-26 00:00:00.000",
"description": "Generic Note",
"row_id": 405667,
"text": "Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the note by Dr. today and I agree with the\n plan.\n I would add the following remarks:\n History\n Remains unresponsive today even to deep pain.\n Still fluid overloaded.\n Medical Decision Making\n Now on CMO. We will discontinue IV heparin which was given for her\n atrial fibrillation. Prognosis remains grim.\n Total time spent on patient care: 30 minutes of critical care time\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 405753,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 21\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Cannot manage\n secretions, Hemodynimic instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Suctioned for tan plugs x 1. NO further changes\n, RRT 15:56\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405810,
"text": "Chief Complaint: Critical AS\n 24 Hour Events:\n :\n - met w/ family, who still hope she might wake up\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy, Unresponsive\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dilantin - 08:12 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n HR: 87 (78 - 94) bpm\n BP: 116/52(76) {87/45(60) - 122/59(82)} mmHg\n RR: 16 (11 - 33) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 108.1 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 1,455 mL\n 232 mL\n PO:\n TF:\n 844 mL\n 160 mL\n IVF:\n 341 mL\n 72 mL\n Blood products:\n Total out:\n 529 mL\n 20 mL\n Urine:\n 129 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 926 mL\n 212 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 102\n PIP: 22 cmH2O\n Plateau: 25 cmH2O\n SpO2: 98%\n ABG: ////\n Ve: 6.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 387 K/uL\n 7.6 g/dL\n 125 mg/dL\n 3.8 mg/dL\n 17 mEq/L\n 4.7 mEq/L\n 129 mg/dL\n 102 mEq/L\n 134 mEq/L\n 24.8 %\n 8.5 K/uL\n [image002.jpg]\n 05:08 AM\n 09:16 PM\n 04:32 AM\n 08:40 AM\n 06:02 PM\n 04:16 AM\n 01:22 PM\n 05:00 PM\n 04:05 AM\n 04:23 AM\n WBC\n 7.1\n 7.6\n 8.5\n Hct\n 25.5\n 25.4\n 24.8\n Plt\n 381\n 357\n 387\n Cr\n 3.7\n 3.8\n 3.8\n 3.8\n TCO2\n 20\n 20\n 21\n 21\n 20\n 20\n Glucose\n 127\n 122\n 119\n 124\n 125\n Other labs: PT / PTT / INR:13.2/64.3/1.1, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405811,
"text": "Chief Complaint: Critical AS\n 24 Hour Events:\n :\n - met w/ family, who still hope she might wake up\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy, Unresponsive\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dilantin - 08:12 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n HR: 87 (78 - 94) bpm\n BP: 116/52(76) {87/45(60) - 122/59(82)} mmHg\n RR: 16 (11 - 33) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 108.1 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 1,455 mL\n 232 mL\n PO:\n TF:\n 844 mL\n 160 mL\n IVF:\n 341 mL\n 72 mL\n Blood products:\n Total out:\n 529 mL\n 20 mL\n Urine:\n 129 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 926 mL\n 212 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 102\n PIP: 22 cmH2O\n Plateau: 25 cmH2O\n SpO2: 98%\n ABG: ////\n Ve: 6.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 387 K/uL\n 7.6 g/dL\n 125 mg/dL\n 3.8 mg/dL\n 17 mEq/L\n 4.7 mEq/L\n 129 mg/dL\n 102 mEq/L\n 134 mEq/L\n 24.8 %\n 8.5 K/uL\n [image002.jpg]\n 05:08 AM\n 09:16 PM\n 04:32 AM\n 08:40 AM\n 06:02 PM\n 04:16 AM\n 01:22 PM\n 05:00 PM\n 04:05 AM\n 04:23 AM\n WBC\n 7.1\n 7.6\n 8.5\n Hct\n 25.5\n 25.4\n 24.8\n Plt\n 381\n 357\n 387\n Cr\n 3.7\n 3.8\n 3.8\n 3.8\n TCO2\n 20\n 20\n 21\n 21\n 20\n 20\n Glucose\n 127\n 122\n 119\n 124\n 125\n Other labs: PT / PTT / INR:13.2/64.3/1.1, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures (now none for a week on EEG) and deteriorating\n mental status, aspiration pneumonia, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension required\n phenylephrine. Transferred to CCU at request of family and consulting\n cardiologist.\n # Coma, seizures, Goals of Care\n Comatose with some brainstem reflexes. No seizures for some time. No\n evidence of cortical function. BUN 124 and patient has been\n intermittently hypotensive. Therefore differential includes (also\n possible multifactorial) uremia, anoxic brain injury and\n carcinoatosis/paraneoplastic encephalopathy (although very unlikely).\n Dr. has discussed issue of Phenobarbital with Dr. \n (neurology) and decision made to not restart phenobarbital.\n - No need for LP given carcinomatosis is an extremely unlikely cause of\n coma and metabolic toxicities (many different sources) seem more\n likely.\n - Will continue phenytoin for now given not contributing to mental\n status at such low concentration\n - DNR/DNI focus on comfort\n - Will discontinue labs\n - No escalation of care\n # Acidemia\n ABG slightly improved today - 7.30/41/112/18/-5. Lactate was not\n elevated at 1.0 making metabolic acidosis from renal failure or uremia\n more likely. Pt not a candidate for HD.\n -No further interventions\n # Aortic Stenosis\n Treatment of this is deferred pending decision about the above.\n Valvuloplasty will need to be repeated (if this is compatible with\n goals of care). Pt with known severe aortic stenosis s/p valvuloplasty\n in . She was initially on the CCU service early in her\n hospitalization in the setting of flash pulmonary edema when her lasix\n were held. Now, she is intubated in the ICU. Continues to be severely\n fluid overloaded and oliguric, positive ~30L Los. She does not respond\n well to lasix/diuril/bumex but is also not a candidate for HD.\n - Continue bumex and metolazone\n - No further escalations\n # Respiratory Failure and Intubation\n - Preserve for now given mental status and edema\n # Atrial Fibrillation\n Pt has good control of HR on beta blockade and digoxin. Coumadin was\n being held before for trach/PEG. Now, holding coumading in case pt\n undergoes valvuloplasty.\n - Continue metoprolol tartrate 25 mg TID\n - Continue digoxin 0.0625 mg daily\n - DC labs\n - DC IV heparin given inconsistent with goals of care\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, is ATN\n - No new interventions\n # Coronary Artery Disease: Pt is s/p CABG /.\n - Continue metoprolol as above\n - Continue aspirin 81 mg daily, atorvastatin 40 mg daily\n # Respiratory Failure: Now, s/p trach.\n - Trach in place\n - Continue albuterol/atrovent PRN\n # Pressor Requirement: Pt weaned off of pressors.\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - Tylenol PRN fever\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:56 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI focus on comfort\n Disposition: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405816,
"text": "Chief Complaint: Critical AS\n 24 Hour Events:\n :\n - met w/ family, who still hope she might wake up\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy, Unresponsive\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dilantin - 08:12 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n HR: 87 (78 - 94) bpm\n BP: 116/52(76) {87/45(60) - 122/59(82)} mmHg\n RR: 16 (11 - 33) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 108.1 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 1,455 mL\n 232 mL\n PO:\n TF:\n 844 mL\n 160 mL\n IVF:\n 341 mL\n 72 mL\n Blood products:\n Total out:\n 529 mL\n 20 mL\n Urine:\n 129 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 926 mL\n 212 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 102\n PIP: 22 cmH2O\n Plateau: 25 cmH2O\n SpO2: 98%\n ABG: ////\n Ve: 6.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 387 K/uL\n 7.6 g/dL\n 125 mg/dL\n 3.8 mg/dL\n 17 mEq/L\n 4.7 mEq/L\n 129 mg/dL\n 102 mEq/L\n 134 mEq/L\n 24.8 %\n 8.5 K/uL\n [image002.jpg]\n 05:08 AM\n 09:16 PM\n 04:32 AM\n 08:40 AM\n 06:02 PM\n 04:16 AM\n 01:22 PM\n 05:00 PM\n 04:05 AM\n 04:23 AM\n WBC\n 7.1\n 7.6\n 8.5\n Hct\n 25.5\n 25.4\n 24.8\n Plt\n 381\n 357\n 387\n Cr\n 3.7\n 3.8\n 3.8\n 3.8\n TCO2\n 20\n 20\n 21\n 21\n 20\n 20\n Glucose\n 127\n 122\n 119\n 124\n 125\n Other labs: PT / PTT / INR:13.2/64.3/1.1, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures (now none for a week on EEG) and deteriorating\n mental status, aspiration pneumonia, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension required\n phenylephrine. Transferred to CCU at request of family and consulting\n cardiologist.\n # Coma, seizures, Goals of Care\n Comatose with some brainstem reflexes. No seizures for some time. No\n evidence of cortical function. BUN 124 and patient has been\n intermittently hypotensive. Therefore differential includes (also\n possible multifactorial) uremia, anoxic brain injury and\n carcinoatosis/paraneoplastic encephalopathy (although very unlikely).\n Dr. has discussed issue of Phenobarbital with Dr. \n (neurology) and decision made to not restart phenobarbital.\n - No need for LP given carcinomatosis is an extremely unlikely cause of\n coma and metabolic toxicities (many different sources) seem more\n likely.\n - Will continue phenytoin for now given not contributing to mental\n status at such low concentration\n - DNR/DNI focus on comfort\n - Will discontinue labs\n - No escalation of care\n # Acidemia\n ABG slightly improved today - 7.30/41/112/18/-5. Lactate was not\n elevated at 1.0 making metabolic acidosis from renal failure or uremia\n more likely. Pt not a candidate for HD.\n -No further interventions\n # Aortic Stenosis\n Treatment of this is deferred pending decision about the above.\n Valvuloplasty will need to be repeated (if this is compatible with\n goals of care). Pt with known severe aortic stenosis s/p valvuloplasty\n in . She was initially on the CCU service early in her\n hospitalization in the setting of flash pulmonary edema when her lasix\n were held. Now, she is intubated in the ICU. Continues to be severely\n fluid overloaded and oliguric, positive ~30L Los. She does not respond\n well to lasix/diuril/bumex but is also not a candidate for HD.\n - Continue bumex and metolazone\n - No further escalations\n # Respiratory Failure and Intubation\n - Preserve for now given mental status and edema\n # Atrial Fibrillation\n Pt has good control of HR on beta blockade and digoxin. Coumadin was\n being held before for trach/PEG. Now, holding coumading in case pt\n undergoes valvuloplasty.\n - Continue metoprolol tartrate 25 mg TID\n - Continue digoxin 0.0625 mg daily\n - DC labs\n - DC IV heparin given inconsistent with goals of care\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, is ATN\n - No new interventions\n # Coronary Artery Disease: Pt is s/p CABG /.\n - Continue metoprolol as above\n - Continue aspirin 81 mg daily, atorvastatin 40 mg daily\n # Respiratory Failure: Now, s/p trach.\n - Trach in place\n - Continue albuterol/atrovent PRN\n # Pressor Requirement: Pt weaned off of pressors.\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - Tylenol PRN fever\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:56 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI focus on comfort\n Disposition: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405817,
"text": "Chief Complaint: CRITICAL AS\n 24 Hour Events:\n \n stopped fingersticks and blood draws for comfort\n stopped heparin gtt\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:30 PM\n Dilantin - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.7\nC (98.1\n HR: 96 (79 - 97) bpm\n BP: 112/55(76) {97/47(66) - 118/56(79)} mmHg\n RR: 22 (8 - 22) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 108.1 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 22 (19 - 22)mmHg\n Total In:\n 1,538 mL\n 454 mL\n PO:\n TF:\n 844 mL\n 252 mL\n IVF:\n 604 mL\n 172 mL\n Blood products:\n Total out:\n 271 mL\n 465 mL\n Urine:\n 271 mL\n 65 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,267 mL\n -11 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 74\n PIP: 11 cmH2O\n Plateau: 18 cmH2O\n SpO2: 94%\n ABG: ////\n Ve: 9.2 L/min\n Physical Examination\n GEN: Anasarcic, elderly woman, unresponsive to deep stimulation,\n appears comfortable\n CV: RRR, no RMG\n PULM: CTAB, no WRR anteriorly\n ABD: Soft, NTND, +BS, obese\n EXT: Marked UE and LE edema\n Labs / Radiology\n 387 K/uL\n 7.6 g/dL\n 125 mg/dL\n 3.8 mg/dL\n 17 mEq/L\n 4.7 mEq/L\n 129 mg/dL\n 102 mEq/L\n 134 mEq/L\n 24.8 %\n 8.5 K/uL\n [image002.jpg]\n 05:08 AM\n 09:16 PM\n 04:32 AM\n 08:40 AM\n 06:02 PM\n 04:16 AM\n 01:22 PM\n 05:00 PM\n 04:05 AM\n 04:23 AM\n WBC\n 7.1\n 7.6\n 8.5\n Hct\n 25.5\n 25.4\n 24.8\n Plt\n 381\n 357\n 387\n Cr\n 3.7\n 3.8\n 3.8\n 3.8\n TCO2\n 20\n 20\n 21\n 21\n 20\n 20\n Glucose\n 127\n 122\n 119\n 124\n 125\n Other labs: PT / PTT / INR:13.2/64.3/1.1, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures (now none for a week on EEG) and deteriorating\n mental status, aspiration pneumonia, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension required\n phenylephrine. Transferred to CCU at request of family and consulting\n cardiologist.\n # Coma, seizures, Goals of Care\n Comatose with some brainstem reflexes. No seizures for some time. No\n evidence of cortical function. BUN 124 and patient has been\n intermittently hypotensive. Therefore differential includes (also\n possible multifactorial) uremia, anoxic brain injury and\n carcinoatosis/paraneoplastic encephalopathy (although very unlikely).\n Dr. has discussed issue of Phenobarbital with Dr. \n (neurology) and decision made to not restart phenobarbital.\n - No need for LP given carcinomatosis is an extremely unlikely cause of\n coma and metabolic toxicities (many different sources) seem more\n likely.\n - Will continue phenytoin for now given not contributing to mental\n status at such low concentration\n - DNR/DNI focus on comfort\n - Will discontinue labs\n - No escalation of care\n # Acidemia\n ABG slightly improved today - 7.30/41/112/18/-5. Lactate was not\n elevated at 1.0 making metabolic acidosis from renal failure or uremia\n more likely. Pt not a candidate for HD.\n -No further interventions\n # Aortic Stenosis\n Treatment of this is deferred pending decision about the above.\n Valvuloplasty will need to be repeated (if this is compatible with\n goals of care). Pt with known severe aortic stenosis s/p valvuloplasty\n in . She was initially on the CCU service early in her\n hospitalization in the setting of flash pulmonary edema when her lasix\n were held. Now, she is intubated in the ICU. Continues to be severely\n fluid overloaded and oliguric, positive ~30L Los. She does not respond\n well to lasix/diuril/bumex but is also not a candidate for HD.\n - Continue bumex and metolazone\n - No further escalations\n # Respiratory Failure and Intubation\n - Preserve for now given mental status and edema\n # Atrial Fibrillation\n Pt has good control of HR on beta blockade and digoxin. Coumadin was\n being held before for trach/PEG. Now, holding coumading in case pt\n undergoes valvuloplasty.\n - Continue metoprolol tartrate 25 mg TID\n - Continue digoxin 0.0625 mg daily\n - DC labs\n - DC IV heparin given inconsistent with goals of care\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, is ATN\n - No new interventions\n # Coronary Artery Disease: Pt is s/p CABG /.\n - Continue metoprolol as above\n - Continue aspirin 81 mg daily, atorvastatin 40 mg daily\n # Respiratory Failure: Now, s/p trach.\n - Trach in place\n - Continue albuterol/atrovent PRN\n # Pressor Requirement: Pt weaned off of pressors.\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - Tylenol PRN fever\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:56 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI focus on comfort\n Disposition: CCU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n ------ Protected Section Addendum Entered By: , MD\n on: 08:26 ------\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405572,
"text": "Chief Complaint: Critical AS\n 24 Hour Events:\n \n - Pt family wants one more day of full code since she smiled at\n patient's husband.\n - Family meeting planned again for Thursday with Dr. to\n reassess goals\n - No escalation of care\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsPenicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,350 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:46 PM\n Dilantin - 04:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.7\nC (98\n HR: 92 (87 - 101) bpm\n BP: 112/50(73) {87/45(61) - 131/62(88)} mmHg\n RR: 15 (8 - 25) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 107.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 16 (14 - 21)mmHg\n Total In:\n 1,710 mL\n 385 mL\n PO:\n TF:\n 842 mL\n 220 mL\n IVF:\n 618 mL\n 165 mL\n Blood products:\n Total out:\n 356 mL\n 144 mL\n Urine:\n 356 mL\n 144 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,354 mL\n 241 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 410 (410 - 410) mL\n RR (Set): 18\n RR (Spontaneous): 2\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 54\n PIP: 20 cmH2O\n Plateau: 25 cmH2O\n Compliance: 36.4 cmH2O/mL\n SpO2: 97%\n ABG: 7.27/41/118/17/-7\n Ve: 8.5 L/min\n PaO2 / FiO2: 236\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 387 K/uL\n 7.6 g/dL\n 125 mg/dL\n 3.8 mg/dL\n 17 mEq/L\n 4.7 mEq/L\n 129 mg/dL\n 102 mEq/L\n 134 mEq/L\n 24.8 %\n 8.5 K/uL\n [image002.jpg]\n 05:08 AM\n 09:16 PM\n 04:32 AM\n 08:40 AM\n 06:02 PM\n 04:16 AM\n 01:22 PM\n 05:00 PM\n 04:05 AM\n 04:23 AM\n WBC\n 7.1\n 7.6\n 8.5\n Hct\n 25.5\n 25.4\n 24.8\n Plt\n 381\n 357\n 387\n Cr\n 3.7\n 3.8\n 3.8\n 3.8\n TCO2\n 20\n 20\n 21\n 21\n 20\n 20\n Glucose\n 127\n 122\n 119\n 124\n 125\n Other labs: PT / PTT / INR:13.2/64.3/1.1, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:5.5 mg/dL\n Imaging: No new\n Microbiology: STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B\n TEST-FINAL INPATIENT\n STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL\n INPATIENT\n BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT\n URINE URINE CULTURE-FINAL {YEAST} INPATIENT\n BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT\n URINE URINE CULTURE-FINAL {YEAST} INPATIENT\n CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT\n STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL\n INPATIENT\n URINE URINE CULTURE-FINAL {YEAST} INPATIENT\n BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT\n BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT\n ECG: No new\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures (now none for a week on EEG) and deteriorating\n mental status, aspiration pneumonia, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension required\n phenylephrine. Transferred to CCU at request of family and consulting\n cardiologist.\n # Coma, seizures, Goals of Care\n Comatose with some brainstem reflexes. No seizures for some time. No\n evidence of cortical function. BUN 124 and patient has been\n intermittently hypotensive. Therefore differential includes (also\n possible multifactorial) uremia, anoxic brain injury and\n carcinoatosis/paraneoplastic encephalopathy (although very unlikely).\n Dr. has discussed issue of Phenobarbital with Dr. \n (neurology) and decision made to not restart phenobarbital.\n - No need for LP given carcinomatosis is an extremely unlikely cause of\n coma and metabolic toxicities (many different sources) seem more\n likely.\n - Will continue phenytoin for now given not contributing to mental\n status at such low concentration\n - Will d/w with family re transition to DNR/DNI today\\\n - Will discuss with family re using oxygen and morphine PRN dyspnea\n - Will discuss discontinuing labs\n - No escalation of care\n # Acidemia\n ABG slightly improved today - 7.30/41/112/18/-5. Lactate was not\n elevated at 1.0 making metabolic acidosis from renal failure or uremia\n more likely. Pt not a candidate for HD.\n -No further interventions\n # Aortic Stenosis\n Treatment of this is deferred pending decision about the above.\n Valvuloplasty will need to be repeated (if this is compatible with\n goals of care). Pt with known severe aortic stenosis s/p valvuloplasty\n in . She was initially on the CCU service early in her\n hospitalization in the setting of flash pulmonary edema when her lasix\n were held. Now, she is intubated in the ICU. Continues to be severely\n fluid overloaded and oliguric, positive ~30L Los. She does not respond\n well to lasix/diuril/bumex but is also not a candidate for HD.\n - Continue bumex and metolazone with goal of net negative 1.5L today\n - No further escalations\n # Respiratory Failure and Intubation\n - Preserve for now given mental status and edema\n # Atrial Fibrillation\n Pt has good control of HR on beta blockade and digoxin. Coumadin was\n being held before for trach/PEG. Now, holding coumading in case pt\n undergoes valvuloplasty. Now on heparin gtt while INR subtherapeutic.\n - Continue metoprolol tartrate 25 mg TID\n - Continue digoxin 0.0625 mg daily\n - DC labs\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, is ATN\n - Will attempt diuresis with bumex/metolazone, as above\n - Appreciate renal recs.\n - Continue to monitor fluid status otherwise\n # Coronary Artery Disease: Pt is s/p CABG /.\n - Continue metoprolol as above\n - Continue aspirin 81 mg daily, atorvastatin 40 mg daily\n # Respiratory Failure: Now, s/p trach.\n - Trach in place\n - Continue albuterol/atrovent PRN\n # Pressor Requirement: Pt weaned off of pressors.\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - Tylenol PRN fever\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:56 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code for now, to discuss code status today\n Disposition: CCU, consider hospice per family meeting\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405636,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now w/respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Seizure, without status epilepticus\n Assessment:\n Neuro status exam unchanged. PERLA 4-5mm . No spontaneous movement of\n extremities. Doesn\nt respond to noxious stimuli. Pt does grimace to\n painful stimuli but does not move extrems. pt neuro status has not\n improved.\n Action:\n Neuro checks done q 4hr\n Response:\n Cont\n to monitor. Remains on dilantin q8h IV.\n Plan:\n Monitor for seizures. Monitor neuro status. Dilantin q8h. emotional\n support to family.\n Impaired Skin Integrity\n Assessment:\n Anasarca. Multiple excoriations, open areas in creases from yeast in\n all skin folds (groin, panus, under breasts).Venous ulcers on both\n lower legs. Decub on coccyx\nsm amt of yellow/brown drng noted\n Action:\n Freq turns q2h while on kinair bed. Waffle boots on. Flexiseal in\n place, working well, keeping buttocks free from stool (loose brown\n stool). Trach and peg sites intact. Dsgs to bilat lower legs ulcers\n done with wound care spray and duoderm gel.\n Response:\n No changes. Con\nt skin care q2h with turns.\n Plan:\n Daily bilat lower leg dsg changes. See skin care nurse notes in chart.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine ouput continues low 10 -20 cc/hr.\n Action:\n Patient receiving bumex and metalazone qd( to be given\n before\n morning bumex dose\n Response:\n No change.\n Plan:\n Monitor uo and bun and creatinine\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bilateral exp wheezes heard throughout, slightly diminished at bases. .\n O2 sats 94-98 % . Trached.\n Action:\n Suctioned q 2 hours for small/mod amts at times thin but also thick at\n times yellow secretions. Secretions ^^ from last night. Albuterol ih\n atc q 4 hours and atrovent q 6\n Response:\n Fio2 currently at 50% with good sats and good O2 sats\n Plan:\n Adjust vent settings as needed.\n Aortic stenosis\n Assessment:\n Pt in afib 80-90\ns with rare/occ pvc. SBP 100-110\ns via L radial aline.\n Action:\n Heparin dose infusing at 1350 units/hr.\n Response:\n Tolerating lopressor 25mg po TID.\n Plan:\n Continue to monitor. want to increase lopressor due to ^^ hr prior\n to dosing.\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405649,
"text": "Chief Complaint: CRITICAL AS\n 24 Hour Events:\n \n -patient's code status changed to DNR; goals shifting towards comfort\n measures but do not stop treatment altogether\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 09:19 PM\n Dilantin - 05:17 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.5\nC (97.7\n HR: 93 (87 - 104) bpm\n BP: 116/54(77) {94/44(63) - 121/58(81)} mmHg\n RR: 18 (17 - 27) insp/min\n SpO2: 95%\n Heart rhythm: SVT (Supra Ventricular Tachycardia)\n Wgt (current): 109 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 22 (13 - 23)mmHg\n Total In:\n 1,619 mL\n 505 mL\n PO:\n TF:\n 845 mL\n 272 mL\n IVF:\n 614 mL\n 173 mL\n Blood products:\n Total out:\n 367 mL\n 92 mL\n Urine:\n 367 mL\n 92 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,252 mL\n 413 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 60\n PIP: 20 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 7.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 387 K/uL\n 7.6 g/dL\n 125 mg/dL\n 3.8 mg/dL\n 17 mEq/L\n 4.7 mEq/L\n 129 mg/dL\n 102 mEq/L\n 134 mEq/L\n 24.8 %\n 8.5 K/uL\n [image002.jpg]\n 05:08 AM\n 09:16 PM\n 04:32 AM\n 08:40 AM\n 06:02 PM\n 04:16 AM\n 01:22 PM\n 05:00 PM\n 04:05 AM\n 04:23 AM\n WBC\n 7.1\n 7.6\n 8.5\n Hct\n 25.5\n 25.4\n 24.8\n Plt\n 381\n 357\n 387\n Cr\n 3.7\n 3.8\n 3.8\n 3.8\n TCO2\n 20\n 20\n 21\n 21\n 20\n 20\n Glucose\n 127\n 122\n 119\n 124\n 125\n Other labs: PT / PTT / INR:13.2/64.3/1.1, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 03:08 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405650,
"text": "Chief Complaint: CRITICAL AS\n 24 Hour Events:\n \n -patient's code status changed to DNR; goals shifting towards comfort\n measures but do not stop treatment altogether\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 09:19 PM\n Dilantin - 05:17 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.5\nC (97.7\n HR: 93 (87 - 104) bpm\n BP: 116/54(77) {94/44(63) - 121/58(81)} mmHg\n RR: 18 (17 - 27) insp/min\n SpO2: 95%\n Heart rhythm: SVT (Supra Ventricular Tachycardia)\n Wgt (current): 109 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 22 (13 - 23)mmHg\n Total In:\n 1,619 mL\n 505 mL\n PO:\n TF:\n 845 mL\n 272 mL\n IVF:\n 614 mL\n 173 mL\n Blood products:\n Total out:\n 367 mL\n 92 mL\n Urine:\n 367 mL\n 92 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,252 mL\n 413 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 60\n PIP: 20 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 7.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 387 K/uL\n 7.6 g/dL\n 125 mg/dL\n 3.8 mg/dL\n 17 mEq/L\n 4.7 mEq/L\n 129 mg/dL\n 102 mEq/L\n 134 mEq/L\n 24.8 %\n 8.5 K/uL\n [image002.jpg]\n 05:08 AM\n 09:16 PM\n 04:32 AM\n 08:40 AM\n 06:02 PM\n 04:16 AM\n 01:22 PM\n 05:00 PM\n 04:05 AM\n 04:23 AM\n WBC\n 7.1\n 7.6\n 8.5\n Hct\n 25.5\n 25.4\n 24.8\n Plt\n 381\n 357\n 387\n Cr\n 3.7\n 3.8\n 3.8\n 3.8\n TCO2\n 20\n 20\n 21\n 21\n 20\n 20\n Glucose\n 127\n 122\n 119\n 124\n 125\n Other labs: PT / PTT / INR:13.2/64.3/1.1, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures (now none for a week on EEG) and deteriorating\n mental status, aspiration pneumonia, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension required\n phenylephrine. Transferred to CCU at request of family and consulting\n cardiologist.\n # Coma, seizures, Goals of Care\n Comatose with some brainstem reflexes. No seizures for some time. No\n evidence of cortical function. BUN 124 and patient has been\n intermittently hypotensive. Therefore differential includes (also\n possible multifactorial) uremia, anoxic brain injury and\n carcinoatosis/paraneoplastic encephalopathy (although very unlikely).\n Dr. has discussed issue of Phenobarbital with Dr. \n (neurology) and decision made to not restart phenobarbital.\n - No need for LP given carcinomatosis is an extremely unlikely cause of\n coma and metabolic toxicities (many different sources) seem more\n likely.\n - Will continue phenytoin for now given not contributing to mental\n status at such low concentration\n - DNR/DNI focus on comfort\n - Will discuss with family re using oxygen and morphine PRN dyspnea\n - Will discuss discontinuing labs\n - No escalation of care\n # Acidemia\n ABG slightly improved today - 7.30/41/112/18/-5. Lactate was not\n elevated at 1.0 making metabolic acidosis from renal failure or uremia\n more likely. Pt not a candidate for HD.\n -No further interventions\n # Aortic Stenosis\n Treatment of this is deferred pending decision about the above.\n Valvuloplasty will need to be repeated (if this is compatible with\n goals of care). Pt with known severe aortic stenosis s/p valvuloplasty\n in . She was initially on the CCU service early in her\n hospitalization in the setting of flash pulmonary edema when her lasix\n were held. Now, she is intubated in the ICU. Continues to be severely\n fluid overloaded and oliguric, positive ~30L Los. She does not respond\n well to lasix/diuril/bumex but is also not a candidate for HD.\n - Continue bumex and metolazone with goal of net negative 1.5L today\n - No further escalations\n # Respiratory Failure and Intubation\n - Preserve for now given mental status and edema\n # Atrial Fibrillation\n Pt has good control of HR on beta blockade and digoxin. Coumadin was\n being held before for trach/PEG. Now, holding coumading in case pt\n undergoes valvuloplasty. Now on heparin gtt while INR subtherapeutic.\n - Continue metoprolol tartrate 25 mg TID\n - Continue digoxin 0.0625 mg daily\n - DC labs\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, is ATN\n - Will attempt diuresis with bumex/metolazone, as above\n - Appreciate renal recs.\n - Continue to monitor fluid status otherwise\n # Coronary Artery Disease: Pt is s/p CABG /.\n - Continue metoprolol as above\n - Continue aspirin 81 mg daily, atorvastatin 40 mg daily\n # Respiratory Failure: Now, s/p trach.\n - Trach in place\n - Continue albuterol/atrovent PRN\n # Pressor Requirement: Pt weaned off of pressors.\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - Tylenol PRN fever\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:56 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI focus on comfort\n Disposition: CCU, consider hospice per family meeting\n"
},
{
"category": "Nutrition",
"chartdate": "2196-02-26 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 405655,
"text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 80.1 kg\n 109 kg ( 11:00 AM)\n 28.4\n Pertinent medications: FoLIC Acid, Famotidine, RISS, Phenytoin Sodium,\n others noted\n Labs:\n Value\n Date\n Glucose\n 125 mg/dL\n 04:05 AM\n Glucose Finger Stick\n 144\n 12:00 AM\n BUN\n 129 mg/dL\n 04:05 AM\n Creatinine\n 3.8 mg/dL\n 04:05 AM\n Sodium\n 134 mEq/L\n 04:05 AM\n Potassium\n 4.7 mEq/L\n 04:05 AM\n Chloride\n 102 mEq/L\n 04:05 AM\n TCO2\n 17 mEq/L\n 04:05 AM\n PO2 (arterial)\n 118 mm Hg\n 04:23 AM\n PCO2 (arterial)\n 41 mm Hg\n 04:23 AM\n pH (arterial)\n 7.27 units\n 04:23 AM\n pH (urine)\n 5.0 units\n 05:33 PM\n CO2 (Calc) arterial\n 20 mEq/L\n 04:23 AM\n Albumin\n 2.7 g/dL\n 06:39 PM\n Calcium non-ionized\n 8.3 mg/dL\n 04:05 AM\n Phosphorus\n 5.5 mg/dL\n 04:05 AM\n Ionized Calcium\n 1.08 mmol/L\n 11:27 PM\n Magnesium\n 2.3 mg/dL\n 04:05 AM\n ALT\n 5 IU/L\n 03:33 AM\n Alkaline Phosphate\n 60 IU/L\n 03:33 AM\n AST\n 28 IU/L\n 03:33 AM\n Total Bilirubin\n 0.2 mg/dL\n 03:33 AM\n Triglyceride\n 98 mg/dL\n 04:27 AM\n Phenytoin (Free)\n 1.9 ug/mL\n 04:39 PM\n Phenytoin (Dilantin)\n 2.0 ug/mL\n 04:05 AM\n WBC\n 8.5 K/uL\n 04:05 AM\n Hgb\n 7.6 g/dL\n 04:05 AM\n Hematocrit\n 24.8 %\n 04:05 AM\n Current diet order / nutrition support: Novasource Renal Full strength;\n Additives: Beneprotein, 21 gm/day\n Starting rate: 15 ml/hr; Advance rate by 10 ml q6h Goal rate: 35 ml/hr\n Residual Check: q4h Hold feeding for residual >= : 200 ml\n Flush w/ 50 ml water q6h\n GI: NBS\n SKIN: impaired (multiple excoriations, open areas in creases from yeast\n in all skin folds. Venous ulcers on both lower legs. Decub on coccyx\nsmall amt of yellow/brown drainage noted\n Assessment of Nutritional Status\n 86 year old female with complicated hospital course, code status\n changed to DNR/I with no escalation of care, patient remains vented via\n trach, continue on tube feed via PEG, tolerating current regimen with\n minimal residual. Recommend change to just Novasourcr Renal without\n additional beneprotein given impaired kidney function ( BUN>100).\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding : change to Novasource Renal goal 35ml/hr (\n 1680kcal/62g protein), monitor tolerance\n Continue regular insulin sliding scale if serum glucose\n greater than 150 mg/dL\n Other: \n Impaired Skin Integrity\n Assessment:\n Anasarca.\n Action:\n Freq turns q2h while on kinair bed. Waffle boots on. Flexiseal in\n place, working well, keeping buttocks free from stool (loose brown\n stool). Trach and peg sites intact. Dsgs to bilat lower legs ulcers\n done with wound care spray and duoderm gel.\n Response:\n No changes. Con\nt skin care q2h with turns.\n Plan:\n Daily bilat lower leg dsg changes. See skin care nurse notes in chart.\n 10:47\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405730,
"text": "Chief Complaint: CRITICAL AS\n 24 Hour Events:\n \n stopped fingersticks and blood draws for comfort\n stopped heparin gtt\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:30 PM\n Dilantin - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.7\nC (98.1\n HR: 96 (79 - 97) bpm\n BP: 112/55(76) {97/47(66) - 118/56(79)} mmHg\n RR: 22 (8 - 22) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 108.1 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 22 (19 - 22)mmHg\n Total In:\n 1,538 mL\n 454 mL\n PO:\n TF:\n 844 mL\n 252 mL\n IVF:\n 604 mL\n 172 mL\n Blood products:\n Total out:\n 271 mL\n 465 mL\n Urine:\n 271 mL\n 65 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,267 mL\n -11 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 74\n PIP: 11 cmH2O\n Plateau: 18 cmH2O\n SpO2: 94%\n ABG: ////\n Ve: 9.2 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 387 K/uL\n 7.6 g/dL\n 125 mg/dL\n 3.8 mg/dL\n 17 mEq/L\n 4.7 mEq/L\n 129 mg/dL\n 102 mEq/L\n 134 mEq/L\n 24.8 %\n 8.5 K/uL\n [image002.jpg]\n 05:08 AM\n 09:16 PM\n 04:32 AM\n 08:40 AM\n 06:02 PM\n 04:16 AM\n 01:22 PM\n 05:00 PM\n 04:05 AM\n 04:23 AM\n WBC\n 7.1\n 7.6\n 8.5\n Hct\n 25.5\n 25.4\n 24.8\n Plt\n 381\n 357\n 387\n Cr\n 3.7\n 3.8\n 3.8\n 3.8\n TCO2\n 20\n 20\n 21\n 21\n 20\n 20\n Glucose\n 127\n 122\n 119\n 124\n 125\n Other labs: PT / PTT / INR:13.2/64.3/1.1, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 12:07 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405732,
"text": "Chief Complaint: CRITICAL AS\n 24 Hour Events:\n \n stopped fingersticks and blood draws for comfort\n stopped heparin gtt\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:30 PM\n Dilantin - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.7\nC (98.1\n HR: 96 (79 - 97) bpm\n BP: 112/55(76) {97/47(66) - 118/56(79)} mmHg\n RR: 22 (8 - 22) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 108.1 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 22 (19 - 22)mmHg\n Total In:\n 1,538 mL\n 454 mL\n PO:\n TF:\n 844 mL\n 252 mL\n IVF:\n 604 mL\n 172 mL\n Blood products:\n Total out:\n 271 mL\n 465 mL\n Urine:\n 271 mL\n 65 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,267 mL\n -11 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 74\n PIP: 11 cmH2O\n Plateau: 18 cmH2O\n SpO2: 94%\n ABG: ////\n Ve: 9.2 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 387 K/uL\n 7.6 g/dL\n 125 mg/dL\n 3.8 mg/dL\n 17 mEq/L\n 4.7 mEq/L\n 129 mg/dL\n 102 mEq/L\n 134 mEq/L\n 24.8 %\n 8.5 K/uL\n [image002.jpg]\n 05:08 AM\n 09:16 PM\n 04:32 AM\n 08:40 AM\n 06:02 PM\n 04:16 AM\n 01:22 PM\n 05:00 PM\n 04:05 AM\n 04:23 AM\n WBC\n 7.1\n 7.6\n 8.5\n Hct\n 25.5\n 25.4\n 24.8\n Plt\n 381\n 357\n 387\n Cr\n 3.7\n 3.8\n 3.8\n 3.8\n TCO2\n 20\n 20\n 21\n 21\n 20\n 20\n Glucose\n 127\n 122\n 119\n 124\n 125\n Other labs: PT / PTT / INR:13.2/64.3/1.1, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures (now none for a week on EEG) and deteriorating\n mental status, aspiration pneumonia, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension required\n phenylephrine. Transferred to CCU at request of family and consulting\n cardiologist.\n # Coma, seizures, Goals of Care\n Comatose with some brainstem reflexes. No seizures for some time. No\n evidence of cortical function. BUN 124 and patient has been\n intermittently hypotensive. Therefore differential includes (also\n possible multifactorial) uremia, anoxic brain injury and\n carcinoatosis/paraneoplastic encephalopathy (although very unlikely).\n Dr. has discussed issue of Phenobarbital with Dr. \n (neurology) and decision made to not restart phenobarbital.\n - No need for LP given carcinomatosis is an extremely unlikely cause of\n coma and metabolic toxicities (many different sources) seem more\n likely.\n - Will continue phenytoin for now given not contributing to mental\n status at such low concentration\n - DNR/DNI focus on comfort\n - Will discontinue labs\n - No escalation of care\n # Acidemia\n ABG slightly improved today - 7.30/41/112/18/-5. Lactate was not\n elevated at 1.0 making metabolic acidosis from renal failure or uremia\n more likely. Pt not a candidate for HD.\n -No further interventions\n # Aortic Stenosis\n Treatment of this is deferred pending decision about the above.\n Valvuloplasty will need to be repeated (if this is compatible with\n goals of care). Pt with known severe aortic stenosis s/p valvuloplasty\n in . She was initially on the CCU service early in her\n hospitalization in the setting of flash pulmonary edema when her lasix\n were held. Now, she is intubated in the ICU. Continues to be severely\n fluid overloaded and oliguric, positive ~30L Los. She does not respond\n well to lasix/diuril/bumex but is also not a candidate for HD.\n - Continue bumex and metolazone\n - No further escalations\n # Respiratory Failure and Intubation\n - Preserve for now given mental status and edema\n # Atrial Fibrillation\n Pt has good control of HR on beta blockade and digoxin. Coumadin was\n being held before for trach/PEG. Now, holding coumading in case pt\n undergoes valvuloplasty.\n - Continue metoprolol tartrate 25 mg TID\n - Continue digoxin 0.0625 mg daily\n - DC labs\n - DC IV heparin given inconsistent with goals of care\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, is ATN\n - Will attempt diuresis with bumex/metolazone, as above\n - Appreciate renal recs.\n - Continue to monitor fluid status otherwise\n # Coronary Artery Disease: Pt is s/p CABG /.\n - Continue metoprolol as above\n - Continue aspirin 81 mg daily, atorvastatin 40 mg daily\n # Respiratory Failure: Now, s/p trach.\n - Trach in place\n - Continue albuterol/atrovent PRN\n # Pressor Requirement: Pt weaned off of pressors.\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - Tylenol PRN fever\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:56 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI focus on comfort\n Disposition: CCU\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405802,
"text": "86 yr. old female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now with respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Seizure, without status epilepticus\n Assessment:\n Remains unresponsive to painful stimuli. Clamps teeth closed with\n mouth care\n Action:\n Maintained on dilantin\n Response:\n Neuro status unchanged\n Plan:\n Turn q3 hours\n Respiratory failure, acute (not ARDS/)\n Assessment:\n #8 Portex in place\n Action:\n No vent changes. Suctioned q3-4\n Response:\n Audible cuff leak with position changes . But able to receive ~~\n 380-390 of TV. More air added to cuff by resp but leak remains\n Plan:\n Suction /mouth care as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Without significant urine output\n Action:\n Unable to follow Bun/Creat as daily blood work discontinued\n Response:\n Anasaric. Tube feeds via Peg continue\n Plan:\n Continue metolazone and bumex\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405402,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now w/respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405403,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now w/respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urinary output remains low-> 10-15cc/hr- BUN 124 Crea 3.8- metabolic\n acidosis noted on ABG.\n Action:\n Metolazone and bumex given as ordered.\n Response:\n No increase in U/O.\n Plan:\n Con\nt to follow labs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n CMV 400x14 50% P5 via trach\n Action:\n ABG 7.27-41-119-20 98%- suctioned scant-small amt thick tan colored\n mucous- resp rx given as ordered\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405535,
"text": "Seizure, without status epilepticus\n Assessment:\n Neuro status exam unchanged. PERLA 3-4mm. no spontaneous movement of\n extremities. Doesn\nt respond to noxious stimuli. Pt does grimace to\n painful stimuli but does not move extrems. pt neuro status has not\n improved.\n Action:\n Neuro checks done q 4hr\n Response:\n Cont\n to monitor. Remains on dilantin q8h IV.\n Plan:\n Monitor for seizures. Monitor neuro status. Dilantin q8h. emotional\n support to family.\n Impaired Skin Integrity\n Assessment:\n Anasarca. Multiple excoriations, open areas in creases from yeast in\n all skin folds (groin, panus, under breasts). Venous ulcers on both\n lower legs. Decub on coccyx\n Action:\n Freq turns q2h. on kinair bed. Waffle boots on. Flexiseal in place,\n working well, keeping buttocks free from stool (loose brown stool).\n Trach and peg sites intact. Dsgs to bilat lower legs ulcers done with\n wound care spray and duoderm gel.\n Response:\n No changes. Con\nt skin care q2h with turns.\n Plan:\n Daily bilat lower leg dsg changes. See skin care nurse notes in chart.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine ouput continues low 10 -20 cc/hr.\n Action:\n Patient receiving bumex and metalazone qd( to be given\n before\n morning bumex dose\n Response:\n No change. Low urines continue\n Plan:\n Monitor uo and bun and creatinine\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bilateral exp wheezes heard throughout. O2 sats 94-98 % . Trached.\n Action:\n Suctioned q 4 hours for small thick yellow secretions. albuterol ih\n atc q 4 hours and atrovent q 6\n Response:\n Fio2 currently at 50% with good sats, remains metabolically acidotic.\n Plan:\n Adjust vent settings as needed. Am abg.\n Aortic stenosis\n Assessment:\n Pt in afib 80s. SBP 100-130s. Aline Lt radial. TLC Lt IJ.\n Action:\n Heparin dose infusing at 1350 units/hr. am PTT WNL.\n Response:\n Tolerating lopressor 25mg po TID.\n Plan:\n Continue heparin at 1350 units.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405536,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now w/respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Seizure, without status epilepticus\n Assessment:\n Neuro status exam unchanged. PERLA 3-4mm. no spontaneous movement of\n extremities. Doesn\nt respond to noxious stimuli. Pt does grimace to\n painful stimuli but does not move extrems. pt neuro status has not\n improved.\n Action:\n Neuro checks done q 4hr\n Response:\n Cont\n to monitor. Remains on dilantin q8h IV.\n Plan:\n Monitor for seizures. Monitor neuro status. Dilantin q8h. emotional\n support to family.\n Impaired Skin Integrity\n Assessment:\n Anasarca. Multiple excoriations, open areas in creases from yeast in\n all skin folds (groin, panus, under breasts). Venous ulcers on both\n lower legs. Decub on coccyx\n Action:\n Freq turns q2h. on kinair bed. Waffle boots on. Flexiseal in place,\n working well, keeping buttocks free from stool (loose brown stool).\n Trach and peg sites intact. Dsgs to bilat lower legs ulcers done with\n wound care spray and duoderm gel.\n Response:\n No changes. Con\nt skin care q2h with turns.\n Plan:\n Daily bilat lower leg dsg changes. See skin care nurse notes in chart.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine ouput continues low 10 -20 cc/hr.\n Action:\n Patient receiving bumex and metalazone qd( to be given\n before\n morning bumex dose\n Response:\n No change. Low urines continue\n Plan:\n Monitor uo and bun and creatinine\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bilateral exp wheezes heard throughout. O2 sats 94-98 % . Trached.\n Action:\n Suctioned q 4 hours for small thick yellow secretions. albuterol ih\n atc q 4 hours and atrovent q 6\n Response:\n Fio2 currently at 50% with good sats, remains metabolically acidotic.\n Plan:\n Adjust vent settings as needed. Am abg.\n Aortic stenosis\n Assessment:\n Pt in afib 80s. SBP 100-130s. Aline Lt radial. TLC Lt IJ.\n Action:\n Heparin dose infusing at 1350 units/hr. am PTT WNL.\n Response:\n Tolerating lopressor 25mg po TID.\n Plan:\n Continue heparin at 1350 units.\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 405537,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 19\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Exp Wheeze\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405540,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now w/respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Seizure, without status epilepticus\n Assessment:\n Neuro status exam unchanged. PERLA 3-4mm. no spontaneous movement of\n extremities. Doesn\nt respond to noxious stimuli. Pt does grimace to\n painful stimuli but does not move extrems. pt neuro status has not\n improved.\n Action:\n Neuro checks done q 4hr\n Response:\n Cont\n to monitor. Remains on dilantin q8h IV.\n Plan:\n Monitor for seizures. Monitor neuro status. Dilantin q8h. emotional\n support to family.\n Impaired Skin Integrity\n Assessment:\n Anasarca. Multiple excoriations, open areas in creases from yeast in\n all skin folds (groin, panus, under breasts). Venous ulcers on both\n lower legs. Decub on coccyx\n Action:\n Freq turns q2h. on kinair bed. Waffle boots on. Flexiseal in place,\n working well, keeping buttocks free from stool (loose brown stool).\n Trach and peg sites intact. Dsgs to bilat lower legs ulcers done with\n wound care spray and duoderm gel.\n Response:\n No changes. Con\nt skin care q2h with turns.\n Plan:\n Daily bilat lower leg dsg changes. See skin care nurse notes in chart.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine ouput continues low 10 -20 cc/hr.\n Action:\n Patient receiving bumex and metalazone qd( to be given\n before\n morning bumex dose\n Response:\n No change. Low urines continue, creat remains unchanged today. Mg and\n K+ trending up slightly.\n Plan:\n Monitor uo and bun and creatinine\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bilateral exp wheezes heard throughout. O2 sats 94-98 % . Trached.\n Action:\n Suctioned q 4 hours for small thick yellow secretions. albuterol ih\n atc q 4 hours and atrovent q 6\n Response:\n Fio2 currently at 50% with good sats and good Po2, remains\n metabolically acidotic.\n Plan:\n Adjust vent settings as needed.\n Aortic stenosis\n Assessment:\n Pt in afib 80s. SBP 100-130s. Aline Lt radial. TLC Lt IJ.\n Action:\n Heparin dose infusing at 1350 units/hr. am PTT WNL.\n Response:\n Tolerating lopressor 25mg po TID.\n Plan:\n Continue heparin at 1350 units.\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-15 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404655,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "General",
"chartdate": "2196-02-15 00:00:00.000",
"description": "Generic Note",
"row_id": 404666,
"text": "TITLE: Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 04:00 PM\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Furosemide (Lasix) - 09:22 PM\n Dilantin - 04:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.3\nC (99.2\n HR: 97 (80 - 99) bpm\n BP: 120/57(80) {106/47(68) - 144/62(90)} mmHg\n RR: 17 (17 - 29) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 96.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 15 (10 - 17)mmHg\n Total In:\n 2,106 mL\n 176 mL\n PO:\n TF:\n 842 mL\n 2 mL\n IVF:\n 1,263 mL\n 174 mL\n Blood products:\n Total out:\n 224 mL\n 366 mL\n Urine:\n 124 mL\n 66 mL\n NG:\n Stool:\n 100 mL\n 300 mL\n Drains:\n Balance:\n 1,882 mL\n -190 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 505 (357 - 505) mL\n PS : 18 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 145\n PIP: 24 cmH2O\n SpO2: 98%\n ABG: 7.36/38/81./21/-3\n Ve: 8.3 L/min\n PaO2 / FiO2: 205\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 399 K/uL\n 8.3 g/dL\n 122 mg/dL\n 3.2 mg/dL\n 21 mEq/L\n 4.5 mEq/L\n 99 mg/dL\n 103 mEq/L\n 136 mEq/L\n 27.8 %\n 9.7 K/uL\n [image002.jpg]\n 06:10 PM\n 08:30 PM\n 10:18 PM\n 11:21 PM\n 03:29 AM\n 03:47 AM\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n WBC\n 10.8\n 9.7\n Hct\n 27.8\n 27.8\n Plt\n 434\n 399\n Cr\n 3.1\n 3.2\n TCO2\n 21\n 24\n 23\n 22\n 26\n 23\n 24\n 22\n Glucose\n 137\n 133\n 124\n 116\n 122\n Other labs: PT / PTT / INR:26.2/31.5/2.5, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n INEFFECTIVE COPING\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n KNOWLEDGE DEFICIT\n IMPAIRED SKIN INTEGRITY\n PNEUMONIA, ASPIRATION\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin (on hold))\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU (transfer to LTAC soon)\n"
},
{
"category": "General",
"chartdate": "2196-02-15 00:00:00.000",
"description": "Generic Note",
"row_id": 404667,
"text": "TITLE: Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 04:00 PM\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Furosemide (Lasix) - 09:22 PM\n Dilantin - 04:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.3\nC (99.2\n HR: 97 (80 - 99) bpm\n BP: 120/57(80) {106/47(68) - 144/62(90)} mmHg\n RR: 17 (17 - 29) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 96.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 15 (10 - 17)mmHg\n Total In:\n 2,106 mL\n 176 mL\n PO:\n TF:\n 842 mL\n 2 mL\n IVF:\n 1,263 mL\n 174 mL\n Blood products:\n Total out:\n 224 mL\n 366 mL\n Urine:\n 124 mL\n 66 mL\n NG:\n Stool:\n 100 mL\n 300 mL\n Drains:\n Balance:\n 1,882 mL\n -190 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 505 (357 - 505) mL\n PS : 18 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 145\n PIP: 24 cmH2O\n SpO2: 98%\n ABG: 7.36/38/81./21/-3\n Ve: 8.3 L/min\n PaO2 / FiO2: 205\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 399 K/uL\n 8.3 g/dL\n 122 mg/dL\n 3.2 mg/dL\n 21 mEq/L\n 4.5 mEq/L\n 99 mg/dL\n 103 mEq/L\n 136 mEq/L\n 27.8 %\n 9.7 K/uL\n [image002.jpg]\n 06:10 PM\n 08:30 PM\n 10:18 PM\n 11:21 PM\n 03:29 AM\n 03:47 AM\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n WBC\n 10.8\n 9.7\n Hct\n 27.8\n 27.8\n Plt\n 434\n 399\n Cr\n 3.1\n 3.2\n TCO2\n 21\n 24\n 23\n 22\n 26\n 23\n 24\n 22\n Glucose\n 137\n 133\n 124\n 116\n 122\n Other labs: PT / PTT / INR:26.2/31.5/2.5, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine. Being\n transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU and appears very\n fluid overloaded on physical exam.\n - will give 60 mg IV lasix now for diuresis\n - continue to closely monitor volume status\n .\n # Atrial Fibrillation: Per previous notes, pt has good control of HR on\n beta blockade and digoxin.\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - coumadin was being held for ?supratherapeutic INR; INR in therapeutic\n range this morning; can restart coumadin after trach\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol.\n - continue phenytoin and phenobarbital\n - appreciate neuro recs\n .\n # Respiratory Failure: Now, intubated with plans to trach pt on .\n - NPO p MN for trach\n - plan for trach placement tomorrow\n - continue albuterol/atrovent PRN\n .\n # Acute Renal Failure: Per previous notes, renal believes that this is\n ATN. Recommend to not diurese or give IVF's.\n - small lasix bolus as above\n - continue to monitor fluid status otherwise\n .\n # Hypothyroidism:\n - continue synthroid 75 mcg daily\n .\n # Fevers: Per notes, pt completed vanc/cefepime 7 day course for\n pneumonia as well as 3 days course of abx for positive UA.\n - f/u cx data\n - follow fever curve\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin (on hold))\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU (transfer to LTAC soon)\n"
},
{
"category": "General",
"chartdate": "2196-02-15 00:00:00.000",
"description": "Generic Note",
"row_id": 404668,
"text": "TITLE: Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 04:00 PM\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Furosemide (Lasix) - 09:22 PM\n Dilantin - 04:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.3\nC (99.2\n HR: 97 (80 - 99) bpm\n BP: 120/57(80) {106/47(68) - 144/62(90)} mmHg\n RR: 17 (17 - 29) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 96.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 15 (10 - 17)mmHg\n Total In:\n 2,106 mL\n 176 mL\n PO:\n TF:\n 842 mL\n 2 mL\n IVF:\n 1,263 mL\n 174 mL\n Blood products:\n Total out:\n 224 mL\n 366 mL\n Urine:\n 124 mL\n 66 mL\n NG:\n Stool:\n 100 mL\n 300 mL\n Drains:\n Balance:\n 1,882 mL\n -190 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 505 (357 - 505) mL\n PS : 18 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 145\n PIP: 24 cmH2O\n SpO2: 98%\n ABG: 7.36/38/81./21/-3\n Ve: 8.3 L/min\n PaO2 / FiO2: 205\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: ET tube in place; JVD noted.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n Radiated to carotids.\n LUNGS: Ventilated breath sounds.\n ABDOMEN: Obese, S/NT/ND, BS present\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal or painful stimuli.\n Labs / Radiology\n 399 K/uL\n 8.3 g/dL\n 122 mg/dL\n 3.2 mg/dL\n 21 mEq/L\n 4.5 mEq/L\n 99 mg/dL\n 103 mEq/L\n 136 mEq/L\n 27.8 %\n 9.7 K/uL\n [image002.jpg]\n 06:10 PM\n 08:30 PM\n 10:18 PM\n 11:21 PM\n 03:29 AM\n 03:47 AM\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n WBC\n 10.8\n 9.7\n Hct\n 27.8\n 27.8\n Plt\n 434\n 399\n Cr\n 3.1\n 3.2\n TCO2\n 21\n 24\n 23\n 22\n 26\n 23\n 24\n 22\n Glucose\n 137\n 133\n 124\n 116\n 122\n Other labs: PT / PTT / INR:26.2/31.5/2.5, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine. Being\n transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU and appears very\n fluid overloaded on physical exam.\n - will give 60 mg IV lasix now for diuresis\n - continue to closely monitor volume status\n .\n # Atrial Fibrillation: Per previous notes, pt has good control of HR on\n beta blockade and digoxin.\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - coumadin was being held for ?supratherapeutic INR; INR in therapeutic\n range this morning; can restart coumadin after trach\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol.\n - continue phenytoin and phenobarbital\n - appreciate neuro recs\n .\n # Respiratory Failure: Now, intubated with plans to trach pt on .\n - NPO p MN for trach\n - plan for trach placement tomorrow\n - continue albuterol/atrovent PRN\n .\n # Acute Renal Failure: Per previous notes, renal believes that this is\n ATN. Recommend to not diurese or give IVF's.\n - small lasix bolus as above\n - continue to monitor fluid status otherwise\n .\n # Hypothyroidism:\n - continue synthroid 75 mcg daily\n .\n # Fevers: Per notes, pt completed vanc/cefepime 7 day course for\n pneumonia as well as 3 days course of abx for positive UA.\n - f/u cx data\n - follow fever curve\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin (on hold))\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU (transfer to LTAC soon)\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 405458,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 18\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 405621,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 20\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405623,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now w/respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Seizure, without status epilepticus\n Assessment:\n Neuro status exam unchanged. PERLA 4-5mm . No spontaneous movement of\n extremities. Doesn\nt respond to noxious stimuli. Pt does grimace to\n painful stimuli but does not move extrems. pt neuro status has not\n improved.\n Action:\n Neuro checks done q 4hr\n Response:\n Cont\n to monitor. Remains on dilantin q8h IV.\n Plan:\n Monitor for seizures. Monitor neuro status. Dilantin q8h. emotional\n support to family.\n Impaired Skin Integrity\n Assessment:\n Anasarca. Multiple excoriations, open areas in creases from yeast in\n all skin folds (groin, panus, under breasts).Venous ulcers on both\n lower legs. Decub on coccyx\nsm amt of yellow/brown drng noted\n Action:\n Freq turns q2h. on kinair bed. Waffle boots on. Flexiseal in place,\n working well, keeping buttocks free from stool (loose brown stool).\n Trach and peg sites intact. Dsgs to bilat lower legs ulcers done with\n wound care spray and duoderm gel.\n Response:\n No changes. Con\nt skin care q2h with turns.\n Plan:\n Daily bilat lower leg dsg changes. See skin care nurse notes in chart.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine ouput continues low 10 -20 cc/hr.\n Action:\n Patient receiving bumex and metalazone qd( to be given\n before\n morning bumex dose\n Response:\n No change. Low urines continue Mg and K+ trending up slightly.\n Plan:\n Monitor uo and bun and creatinine\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bilateral exp wheezes heard throughout, slightly diminished at bases. .\n O2 sats 94-98 % . Trached.\n Action:\n Suctioned q 2 hours for small/mod amts at times thin but also thick at\n times yellow secretions. Albuterol ih atc q 4 hours and atrovent q 6\n Response:\n Fio2 currently at 50% with good sats and good Po2, remains\n metabolically acidotic.\n Plan:\n Adjust vent settings as needed.\n Aortic stenosis\n Assessment:\n Pt in afib 80s. SBP 100-130s. Aline Lt radial. TLC Lt IJ.\n Action:\n Heparin dose infusing at 1350 units/hr. am PTT WNL.\n Response:\n Tolerating lopressor 25mg po TID.\n Plan:\n Continue heparin at 1350 units.\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404733,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Received on vent support & tolerated spont vent support o//n.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated; Comments:\n RSBI done ~110.\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-17 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404823,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thin\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404900,
"text": "Seizure, without status epilepticus\n Assessment:\n Remains unresponsive although did slightly open left eye and move head\n to husband\ns voice. Perrl. Minimally flex/withdraws at times to deep\n nailbed pressure. No other spont movement. Con\nt eeg on. Remains vented\n on cpap. Remains in afib. Neo on. Abd soft/nt. +bs. + stool via\n flexiseal. Con\nt with min u/o via foley. Con\nt with impaired skin.\n Action:\n Neuro checks. Con\nt eeg on. No vent changes. Skin care. Neo gtt to keep\n map>70.\n Response:\n No change in neuro status. u/o remains min with rising bun/creat. Skin\n unchanged.\n Plan:\n Con\nt with current plan. Monitor for changes. Wean pressor as tol. skin\n care.\n"
},
{
"category": "Rehab Services",
"chartdate": "2196-02-15 00:00:00.000",
"description": "Physical Therapy Contact Note",
"row_id": 404683,
"text": "TITLE: Rehab Services\n Physical therapy has been following patient for possible evaluation.\n Chart reviewed today. Spoke with RN who reports that patient is not\n appropriate for PT. PT will sign off. Please reconsult if patient\n status improves.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404925,
"text": "Seizure, without status epilepticus\n Assessment:\n Patient remains unresponsive, not following any commands, not opening\n eyes, minimal withdrawal to deep pain, PERL, On cont EEG monitoring\n on, no sz activities noted,\n Action:\n Q4h neuro checks, dilantin 300mg x1 given and dose increased to 125mg\n TID by cardiology team, 120mg lasix x1 , MRI ordered, check list sent\n down to dept.\n Response:\n No changes in neuro status, very minimal UO, no change in UO\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404926,
"text": "Seizure, without status epilepticus\n Assessment:\n Patient remains unresponsive, not following any commands, not opening\n eyes, minimal withdrawal to deep pain, PERL, On cont EEG monitoring\n on, no sz activities noted,\n Action:\n Q4h neuro checks, dilantin 300mg x1 given and dose increased to 125mg\n TID by cardiology team, 120mg lasix x1 , MRI ordered, check list sent\n down to dept.\n Response:\n No changes in neuro status, very minimal UO, no change in UO after\n lasix too, cont with EEG\n Plan:\n Cont to monitor, pulm hygiene, neuro checks, for MRI, support to pt and\n family.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405604,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now w/respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Seizure, without status epilepticus\n Assessment:\n Neuro status exam unchanged. PERLA 3-4mm. no spontaneous movement of\n extremities. Doesn\nt respond to noxious stimuli. Pt does grimace to\n painful stimuli but does not move extrems. pt neuro status has not\n improved.\n Action:\n Neuro checks done q 4hr\n Response:\n Cont\n to monitor. Remains on dilantin q8h IV.\n Plan:\n Monitor for seizures. Monitor neuro status. Dilantin q8h. emotional\n support to family.\n Impaired Skin Integrity\n Assessment:\n Anasarca. Multiple excoriations, open areas in creases from yeast in\n all skin folds (groin, panus, under breasts). Venous ulcers on both\n lower legs. Decub on coccyx\n Action:\n Freq turns q2h. on kinair bed. Waffle boots on. Flexiseal in place,\n working well, keeping buttocks free from stool (loose brown stool).\n Trach and peg sites intact. Dsgs to bilat lower legs ulcers done with\n wound care spray and duoderm gel.\n Response:\n No changes. Con\nt skin care q2h with turns.\n Plan:\n Daily bilat lower leg dsg changes. See skin care nurse notes in chart.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine ouput continues low 10 -20 cc/hr.\n Action:\n Patient receiving bumex and metalazone qd( to be given\n before\n morning bumex dose\n Response:\n No change. Low urines continue, creat remains unchanged today. Mg and\n K+ trending up slightly.\n Plan:\n Monitor uo and bun and creatinine\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bilateral exp wheezes heard throughout. O2 sats 94-98 % . Trached.\n Action:\n Suctioned q 4 hours for small thick yellow secretions. albuterol ih\n atc q 4 hours and atrovent q 6\n Response:\n Fio2 currently at 50% with good sats and good Po2, remains\n metabolically acidotic.\n Plan:\n Adjust vent settings as needed.\n Aortic stenosis\n Assessment:\n Pt in afib 80s. SBP 100-130s. Aline Lt radial. TLC Lt IJ.\n Action:\n Heparin dose infusing at 1350 units/hr. am PTT WNL.\n Response:\n Tolerating lopressor 25mg po TID.\n Plan:\n Continue heparin at 1350 units.\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405605,
"text": "Chief Complaint: Critical AS\n 24 Hour Events:\n \n - Pt family wants one more day of full code since she smiled at\n patient's husband.\n - Family meeting planned again for Thursday with Dr. to\n reassess goals\n - No escalation of care\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsPenicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,350 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:46 PM\n Dilantin - 04:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.7\nC (98\n HR: 92 (87 - 101) bpm\n BP: 112/50(73) {87/45(61) - 131/62(88)} mmHg\n RR: 15 (8 - 25) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 107.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 16 (14 - 21)mmHg\n Total In:\n 1,710 mL\n 385 mL\n PO:\n TF:\n 842 mL\n 220 mL\n IVF:\n 618 mL\n 165 mL\n Blood products:\n Total out:\n 356 mL\n 144 mL\n Urine:\n 356 mL\n 144 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,354 mL\n 241 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 410 (410 - 410) mL\n RR (Set): 18\n RR (Spontaneous): 2\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 54\n PIP: 20 cmH2O\n Plateau: 25 cmH2O\n Compliance: 36.4 cmH2O/mL\n SpO2: 97%\n ABG: 7.27/41/118/17/-7\n Ve: 8.5 L/min\n PaO2 / FiO2: 236\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 387 K/uL\n 7.6 g/dL\n 125 mg/dL\n 3.8 mg/dL\n 17 mEq/L\n 4.7 mEq/L\n 129 mg/dL\n 102 mEq/L\n 134 mEq/L\n 24.8 %\n 8.5 K/uL\n [image002.jpg]\n 05:08 AM\n 09:16 PM\n 04:32 AM\n 08:40 AM\n 06:02 PM\n 04:16 AM\n 01:22 PM\n 05:00 PM\n 04:05 AM\n 04:23 AM\n WBC\n 7.1\n 7.6\n 8.5\n Hct\n 25.5\n 25.4\n 24.8\n Plt\n 381\n 357\n 387\n Cr\n 3.7\n 3.8\n 3.8\n 3.8\n TCO2\n 20\n 20\n 21\n 21\n 20\n 20\n Glucose\n 127\n 122\n 119\n 124\n 125\n Other labs: PT / PTT / INR:13.2/64.3/1.1, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:5.5 mg/dL\n Imaging: No new\n Microbiology: STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B\n TEST-FINAL INPATIENT\n STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL\n INPATIENT\n BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT\n URINE URINE CULTURE-FINAL {YEAST} INPATIENT\n BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT\n URINE URINE CULTURE-FINAL {YEAST} INPATIENT\n CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT\n STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL\n INPATIENT\n URINE URINE CULTURE-FINAL {YEAST} INPATIENT\n BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT\n BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT\n ECG: No new\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures (now none for a week on EEG) and deteriorating\n mental status, aspiration pneumonia, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension required\n phenylephrine. Transferred to CCU at request of family and consulting\n cardiologist.\n # Coma, seizures, Goals of Care\n Comatose with some brainstem reflexes. No seizures for some time. No\n evidence of cortical function. BUN 124 and patient has been\n intermittently hypotensive. Therefore differential includes (also\n possible multifactorial) uremia, anoxic brain injury and\n carcinoatosis/paraneoplastic encephalopathy (although very unlikely).\n Dr. has discussed issue of Phenobarbital with Dr. \n (neurology) and decision made to not restart phenobarbital.\n - No need for LP given carcinomatosis is an extremely unlikely cause of\n coma and metabolic toxicities (many different sources) seem more\n likely.\n - Will continue phenytoin for now given not contributing to mental\n status at such low concentration\n - Will d/w with family re transition to DNR/DNI today\\\n - Will discuss with family re using oxygen and morphine PRN dyspnea\n - Will discuss discontinuing labs\n - No escalation of care\n # Acidemia\n ABG slightly improved today - 7.30/41/112/18/-5. Lactate was not\n elevated at 1.0 making metabolic acidosis from renal failure or uremia\n more likely. Pt not a candidate for HD.\n -No further interventions\n # Aortic Stenosis\n Treatment of this is deferred pending decision about the above.\n Valvuloplasty will need to be repeated (if this is compatible with\n goals of care). Pt with known severe aortic stenosis s/p valvuloplasty\n in . She was initially on the CCU service early in her\n hospitalization in the setting of flash pulmonary edema when her lasix\n were held. Now, she is intubated in the ICU. Continues to be severely\n fluid overloaded and oliguric, positive ~30L Los. She does not respond\n well to lasix/diuril/bumex but is also not a candidate for HD.\n - Continue bumex and metolazone with goal of net negative 1.5L today\n - No further escalations\n # Respiratory Failure and Intubation\n - Preserve for now given mental status and edema\n # Atrial Fibrillation\n Pt has good control of HR on beta blockade and digoxin. Coumadin was\n being held before for trach/PEG. Now, holding coumading in case pt\n undergoes valvuloplasty. Now on heparin gtt while INR subtherapeutic.\n - Continue metoprolol tartrate 25 mg TID\n - Continue digoxin 0.0625 mg daily\n - DC labs\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, is ATN\n - Will attempt diuresis with bumex/metolazone, as above\n - Appreciate renal recs.\n - Continue to monitor fluid status otherwise\n # Coronary Artery Disease: Pt is s/p CABG /.\n - Continue metoprolol as above\n - Continue aspirin 81 mg daily, atorvastatin 40 mg daily\n # Respiratory Failure: Now, s/p trach.\n - Trach in place\n - Continue albuterol/atrovent PRN\n # Pressor Requirement: Pt weaned off of pressors.\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - Tylenol PRN fever\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:56 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code for now, to discuss code status today\n Disposition: CCU, consider hospice per family meeting\n ------ Protected Section ------\n TITLE: CCU Attending Cardiology Progress Note\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the note by Dr. today and I agree with the\n plan.\n I would add the following remarks:\n History\n Unresponsive today even to deep pain.\n Ventilatory settings stabilized on FIO2 = 40%. Still fluid overloaded.\n Medical Decision Making\n I had a long discussion with her husband, son, and daughter today.\n her very dismal prognosis for recovery, all agree that we should\n proceed with comfort measures only and not initiate CPR in the event of\n a cardiac arrest.\n Total time spent on patient care: 30 minutes of critical care time\n ------ Protected Section Addendum Entered By: , MD\n on: 20:13 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 405712,
"text": "Demographics\n Day of mechanical ventilation: 21\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Cuff pressure: 25 cmH2O\n Lung Sounds:\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: pt remains trached w/ #8 Perfit\n trach on full mechanical support; has periods of dysynchrony with\n erratic Vts, then settles down and does not trigger vent; continues on\n A/C ventilation w/ PIPs high teens, Pplats low teens.\n Assessment of breathing comfort: No claim of dyspnea\n Plan\n Next 24-48 hours: maintain support\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 405713,
"text": "86 yr. old female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now with respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405714,
"text": "86 yr. old female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now with respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405715,
"text": "86 yr. old female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now with respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Decreased U/O. (U/O 7-13cc/hr)\n BUN/Creat 129/3.8\n Action:\n Cont. to receive metolazone & Bumex as ordered.\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Remains unresponsive.\n PERL\n No movement & does not respond to painful stimuli.\n Bites down on swab with mouth care.\n No seizure activity noted\n Action:\n Dilantin q8hrs.\n Response:\n Neuro status remains unchanged.\n Plan:\n Cont. neuro checks q4hrs.\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 405789,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 22\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405716,
"text": "86 yr. old female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now with respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Decreased U/O. (U/O 7-13cc/hr)\n BUN/Creat 129/3.8\n Action:\n Cont. to receive metolazone & Bumex as ordered.\n Response:\n + 1.2 L @midnoc and 37L LOS.\n Plan:\n Moving towards comfort measures.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented: 50%/ TV 400/ R 18/ Peep 5\n RR 18-22/18\n O2 sat 91-98%\n BS with rhonci & diminished BS at bases. Exp. Wheezes at times.\n Sx for small-mod. amts. thick yellow sputum.\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Remains unresponsive.\n PERL\n No movement & does not respond to painful stimuli.\n Bites down on swab with mouth care.\n No seizure activity noted\n Action:\n Dilantin q8hrs.\n Response:\n Neuro status remains unchanged.\n Plan:\n Cont. neuro checks q4hrs.\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405717,
"text": "86 yr. old female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now with respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Decreased U/O. (U/O 7-13cc/hr)\n BUN/Creat 129/3.8\n Action:\n Cont. to receive metolazone & Bumex as ordered.\n Response:\n + 1.2 L @midnoc and 37L LOS.\n Plan:\n Moving towards comfort measures.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains trach\nd and vented: 50%/ TV 400/ R 18/ Peep 5\n RR 18-22/18\n O2 sat 91-98%\n BS with rhonci & diminished BS at bases. Exp. Wheezes at times.\n Action:\n Sx for small-mod. amts thick yellow sputum\n Albuterol/ventolin via vent.\n Response:\n Resp. status remains unchanged.\n Plan:\n Cont. to monitor resp status\n Seizure, without status epilepticus\n Assessment:\n Remains unresponsive.\n PERL\n No movement & does not respond to painful stimuli.\n Bites down on swab with mouth care.\n No seizure activity noted\n Action:\n Dilantin q8hrs.\n Response:\n Neuro status remains unchanged.\n Plan:\n Cont. neuro checks q4hrs.\n Aortic stenosis\n Assessment:\n HR 79-115 AF with occ. PVC\n BP 97-115/49-55.\n Action:\n Metoprolol q8hrs.\n Response:\n Hemodynamically stable.\n Plan:\n Moving towards comfort measures.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405879,
"text": "86 yr. old female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now with respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 404904,
"text": "Chief Complaint:\n 24 Hour Events:\n Overnight Events:\n - spoke with neuro: recommended resuming EEG; concerned that patient\n has not woken up yet (as she is not having active seizures on EEG) and\n recommending LP to look for infectious etiology as well as MRI to look\n for watershed infarct. EEG ordered. LP to be performed (? goals of\n care)\n - back on pressors (neo)in afternoon\n - restarted coumadin at 1mg\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 12:02 PM\n Coumadin (Warfarin) - 04:46 PM\n Famotidine (Pepcid) - 08:00 PM\n Dilantin - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.2\nC (99\n HR: 94 (90 - 107) bpm\n BP: 110/49(71) {101/49(69) - 128/62(86)} mmHg\n RR: 27 (12 - 30) insp/min\n SpO2: 80%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 102.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 12 (12 - 21)mmHg\n Total In:\n 718 mL\n 291 mL\n PO:\n 90 mL\n 30 mL\n TF:\n 526 mL\n 243 mL\n IVF:\n 102 mL\n 17 mL\n Blood products:\n Total out:\n 219 mL\n 60 mL\n Urine:\n 119 mL\n 60 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 499 mL\n 231 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 373 (300 - 373) mL\n PS : 15 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 21 cmH2O\n SpO2: 80%\n ABG: ///19/\n Ve: 10.9 L/min\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n Radiates to carotids.\n LUNGS: Ventilated breath sounds. Decreased in L lower lung (?\n Positional).\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal or painful stimuli.\n Labs / Radiology\n 436 K/uL\n 7.9 g/dL\n 96 mg/dL\n 3.6 mg/dL\n 19 mEq/L\n 5.1 mEq/L\n 107 mg/dL\n 102 mEq/L\n 136 mEq/L\n 25.6 %\n 7.4 K/uL\n [image002.jpg]\n 10:18 PM\n 11:21 PM\n 03:29 AM\n 03:47 AM\n 05:57 AM\n 05:45 PM\n 02:19 AM\n 02:38 AM\n 02:12 AM\n 02:44 AM\n WBC\n 10.8\n 9.7\n 8.1\n 7.4\n Hct\n 27.8\n 27.8\n 25.3\n 25.6\n Plt\n 36\n Cr\n 3.1\n 3.2\n 3.3\n 3.6\n TCO2\n 23\n 22\n 26\n 23\n 24\n 22\n Glucose\n 133\n 124\n 116\n 122\n 89\n 96\n Other labs: PT / PTT / INR:27.7/31.9/2.7, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:72.6 %, Lymph:14.7 %, Mono:6.6 %,\n Eos:5.9 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.1 mg/dL, Mg++:2.1 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colonic adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU. Continues to be\n severely fluid overloaded and oliguric. Does not respond well to lasix.\n - holding on further diuresis\n - continue to closely monitor volume status\n .\n # Atrial Fibrillation: Pt has good control of HR on beta blockade and\n digoxin. Coumadin was being held before for trach/PEG; restarted\n yesterday and INR went from 1.8 to 2.7.\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - stopping Coumadin at this time\n - will d/w neurology and rest of CCU team risks and benefits of\n Coumadin in this pt.\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin and\n phenobarbitol. Neuro not sure what is causing continued depressed\n mental status, states she is not having active seizures on EEG.\n - continue phenytoin and Phenobarbital, adjusting per neuro recs\n - appreciate neuro recs: recommending LP and MRI\n .\n # Respiratory Failure: Now, s/p trach.\n - trach in place\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Etiology unclear.\n - will lower MAP goal to try to keep pt off of pressors\n - need to review what has been done to look for source of hypotension\n .\n # Acute Renal Failure: Still worsening. Per previous notes, renal\n believes that this is ATN. Recommend to not diurese or give IVF's.\n - holding on further diuresis, as above\n - continue to monitor fluid status otherwise\n .\n # Hypothyroidism:\n - continue synthroid 75 mcg daily\n .\n # Fevers: Per notes, pt completed vanc/cefepime 7 day course for\n pneumonia as well as 3 days course of abx for positive UA. Afebrile\n overnight.\n - f/u cx data\n - follow fever curve\n - stool for c.diff\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:39 AM 35 mL/hour\n Glycemic Control: Comments: ISS\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405009,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405010,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404998,
"text": "Seizure, without status epilepticus\n Assessment:\n Pt intermittingly to deep nail bed stimulation. Opened eyes x1 to nail\n bed. Grimacing. PERRLA.\n Non-purposeful mvt. Moving only LE\ns to stimuli.\n Weak cough, no gag.\n Continued on EEG.\n U/O 10cc/hr.\n BUN 111\n Creat 3.6\n MAP requirement lowered to >65 by MD . Continues to be in Afib\n without ectopy.\n Awaiting MRI.\n Action:\n Family mtg @ bedside with MD . Husband, and Daughter.\n Neo weaned off.\n Chlorothiazide 500mg and Lasix 200mg as ordered.\n Dilantin continued as ordered.\n Phenobarbital decreased to 30 mg .\n Response:\n Family continues to want aggressive treatment. Requesting anti-sz meds\n be removed to see if pt wakes up.\n No change in urine output.\n MAP maintained >65.\n Plan:\n Continue aggressive treatment including full code status.\n ? Valvuloplasty Monday. ? S/P valvuloplasty initiate dialysis.\n Continue to update, educate and emotionally support family.\n Continue to involve SW.\n ? family mtg on Saturday w/ MD .\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405371,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Dr talked to Dr. by telephone - appears that Dr. \n is still not keen to give phenobarbital - not ordered. However states,\n Will continue to taper phenobarbital in an effort to reverse metabolic\n encephalopathy.\n Family meeting to discuss options is scheduled for Wednesday.\n - Neurology consider most likely cause of coma is uremia, hypoxia,\n sedating meds, less likely carcinomatosis/paraneoplastic (we would also\n add hypoxic injury, which is not always obvious by MRI)\n - Family want to wait until Wednesday to make further decisions.\n - Three admission in afternoon, so deferred LP to a.m. - restarted\n heparin - hold again in a.m. and post-calls will do LP.\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Dilantin - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.7\nC (98\n HR: 85 (82 - 99) bpm\n BP: 107/51(72) {92/48(67) - 130/68(86)} mmHg\n RR: 14 (0 - 24) insp/min\n SpO2: 92%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 107.1 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 19 (17 - 21)mmHg\n Total In:\n 1,441 mL\n 280 mL\n PO:\n TF:\n 841 mL\n 111 mL\n IVF:\n 510 mL\n 169 mL\n Blood products:\n Total out:\n 954 mL\n 74 mL\n Urine:\n 354 mL\n 74 mL\n NG:\n Stool:\n Drains:\n Balance:\n 487 mL\n 206 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 19 cmH2O\n Plateau: 22 cmH2O\n SpO2: 92%\n ABG: ///19/\n Ve: 9.6 L/min\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n LUNGS: Ventilated breath sounds. Unable to hear good breath sounds at\n the bases.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Comatose (GCS 3), no plantar response on left and small upgoing\n on right. Jaw jerk hyperactive, glalbella tap present, corneals WNLs\n bilaterally. No doll\ns eyes to lateral head roll. PERRL.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 381 K/uL\n 7.5 g/dL\n 122 mg/dL\n 3.8 mg/dL\n 19 mEq/L\n 4.8 mEq/L\n 124 mg/dL\n 102 mEq/L\n 136 mEq/L\n 25.5 %\n 7.1 K/uL\n [image002.jpg]\n 04:12 AM\n 02:26 PM\n 11:27 PM\n 11:51 PM\n 01:04 AM\n 02:02 AM\n 04:44 AM\n 05:08 AM\n 09:16 PM\n 04:32 AM\n WBC\n 7.0\n 7.1\n Hct\n 24.7\n 25.5\n Plt\n 422\n 381\n Cr\n 3.7\n 3.7\n 3.8\n TCO2\n 21\n 23\n 21\n 21\n 20\n 20\n Glucose\n 120\n 137\n 127\n 122\n Other labs: PT / PTT / INR:13.7/56.7/1.2, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:5.4 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures (now none for a week on EEG) and deteriorating\n mental status, aspiration pneumonia, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension requiring\n phenylephrine. Transferred to CCU at request of family and consulting\n cardiologist.\n # Coma, seizures, Goals of Care\n Comatose with some brainstem reflexes. No seizures for some time. No\n evidence of cortical function. BUN 123 and patient has been\n intermittently hypotensive. Therefore differential includes (also\n possible multifactorial) uremia, anoxic brain injury and\n carcinoatosis/paraneoplastic encephalopathy. Not likely related to\n presently low levels of AEDs. Given this state, we need to aggressively\n treat reversible causes, if present, then determine whether further\n cardiac interventions are warranted This will require some further\n investigations and discussion with Dr , Neurology, the family.\n - Attending and family keen to stop AEDs, so will need to check with\n them prior to giving phenobarbital\n - LP today for cytology\n - Continue phenytoin\n # Aortic Stenosis\n Treatment of this is deferred pending decision about the above.\n Valvuloplasty will need to be repeated (if this is compatible with\n goals of care). Pt with known severe aortic stenosis s/p valvuloplasty\n in . She was initially on the CCU service early in her\n hospitalization in the setting of flash pulmonary edema when her lasix\n were held. Now, she is intubated in the ICU. Continues to be severely\n fluid overloaded and oliguric, positive ~30L Los. She does not respond\n well to lasix/diuril/bumex but is also not a candidate for HD.\n - Continue bumex and metolazone with goal of net negative 1.5L today\n - lytes\n - Monitor volume status, UOP.\n - Holding off on valvuloplasty at this point\n # Respiratory Failure and Intubation\n - Preserve for now given mental status and edema\n # Atrial Fibrillation\n Pt has good control of HR on beta blockade and digoxin. Coumadin was\n being held before for trach/PEG. Now, holding coumading in case pt\n undergoes valvuloplasty. Now on heparin gtt while INR subtherapeutic.\n - Stop heparin this a.m. for LP this afternoon\n - Continue metoprolol tartrate 25 mg TID\n - Continue digoxin 0.0625 mg daily\n - Trend coags\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, is ATN\n - Will attempt diuresis with bumex/metolazone, as above\n - Appreciate renal recs.\n - Continue to monitor fluid status otherwise\n # Coronary Artery Disease: Pt is s/p CABG /.\n - Continue metoprolol as above\n - Continue aspirin 81 mg daily, atorvastatin 40 mg daily\n # Respiratory Failure: Now, s/p trach.\n - Trach in place\n - Continue albuterol/atrovent PRN\n # Pressor Requirement: Pt weaned off of pressors.\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - f/u cx data\n - follow fever curve\n - f/u stool for c.diff\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 12:00 AM 15 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405602,
"text": "Seizure, without status epilepticus\n Assessment:\n Neuro status exam unchanged. PERLA 3-4mm. no spontaneous movement of\n extremities. Doesn\nt respond to noxious stimuli. Pt does grimace to\n painful stimuli but does not move extrems. pt neuro status has not\n improved.\n Action:\n Neuro checks done q 4hr\n Response:\n Cont\n to monitor. Remains on dilantin q8h IV.\n Plan:\n Monitor for seizures. Monitor neuro status. Dilantin q8h. emotional\n support to family.\n Impaired Skin Integrity\n Assessment:\n Anasarca. Multiple excoriations, open areas in creases from yeast in\n all skin folds (groin, panus, under breasts). Venous ulcers on both\n lower legs. Decub on coccyx , mepilex in place. Multiple small\n ulcerated/scabbed areas over forehead and in hair from prolonged use of\n EEG leads.\n Action:\n Freq turns q2h. on kinair bed. Waffle boots on. Flexiseal in place,\n working well, keeping buttocks free from stool (loose brown stool).\n Trach and peg sites intact. Dsgs intact to bilat lower legs ulcers.\n Mepilex intact to coccyx. Extremities elevated. On kinair bed.\n Response:\n No changes. Con\nt skin care q2h with turns.\n Plan:\n Daily bilat lower leg dsg changes. See skin care nurse notes in chart.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine ouput continues low 10 -20 cc/hr.\n Action:\n Patient receiving bumex and metalazone qd( to be given\n before\n morning bumex dose\n Response:\n No change. Low urines continue, creat remains unchanged today. Mg and\n K+ trending up slightly.\n Plan:\n Monitor uo and bun and creatinine\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Occ wheezes noted. Rhonchorous. O2 sats 94-98 % . Trached.\n Action:\n Suctioned q 3-4 hours for small thick yellow secretions. albuterol ih\n atc q 4 hours and atrovent q 6\n Response:\n Fio2 currently at 50% with good sats and good Po2, remains\n metabolically acidotic.\n Plan:\n Adjust vent settings as needed.\n Aortic stenosis\n Assessment:\n Pt in afib 80s. rare PVC noted. SBP 90s-130s. Aline Lt radial. TLC Lt\n IJ.\n Action:\n Heparin dose infusing at 1350 units/hr. am PTT WNL.\n Response:\n Tolerating lopressor 25mg po TID.\n Plan:\n Continue heparin at 1350 units.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 405705,
"text": "86 yr. old female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now with respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 405863,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 22\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems: Positional leak around cuff\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Cannot manage secretions,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt remains mostly unresponsive with NO vent changes.. Secretions seem\n to be increasing.\n, RRT 17:01\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405870,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt remains near anuric; wt continues to rise daily, pt with total body\n anasarca. Increased RR and effort\n Action:\n Unable to give po meds as pt vomiting this am, TF placed on hold.\n Response:\n No further vomiting remainder of day.\n Plan:\n Cont efforts to maintain good skin care in setting of pt with anasarca\n and immobility.\n Ineffective Coping\n Assessment:\n Pt family in and updated re: pt\ns deteriorating condition and multi\n system failure.\n Action:\n Informed family of administration of morphine for increased respiratory\n effort, indications of pain ie. Change in VS.\n Response:\n Family understands pt condition is deteriorating, husband sees pt open\n eyes to his voice and cont to hold hope. Daughter attempting to direct\n her father to pt\ns multiple medical problems. Family appreciate\n treating pt\ns discomfort with morphine.\n Plan:\n Pt remains DNR, no therapies to be added. Maintain pt comfort with\n morphine prn. Cont to support and inform family.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405074,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Oliguric/Anuric\n BUN and Creat continue to trend up\n HUO 5-10cc/hr\n Action:\n Started on Lasix infusion with goal of titrating to 100cc/hr\n Bolused with Lasix 200mg IV\n Zaroxlyn 10mg PEG\n Response:\n Thus far poor response to IV Diurectics\n Plan:\n Continue to titrate Lasix infusion to max 20mg/hr\n Renal following from a far. Not HD candidate at this time\n Seizure, without status epilepticus\n Assessment:\n Unresponsive\n Action:\n Continous EEG\n Neuro assessment Q4H\n Continues Dilantin and Phenobarb\n MRI of head today\n Response:\n EEG remains without seizure activity\n PERL, 3mm bilaterally. GCS of 3. Cannot elicit response in\n any extremeties to painful stimuli\n Weaning IV Dilantin and PO Phenobarb\n Plan:\n Neuromedicine continues to follow\n Continue neuro assessment\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Trached\n Action:\n CPAP 12/5/.50\n Suctioned infrequently\n Response:\n Secretions white thick small amounts\n RR 18-24\n MV and TV adequate\n No plans to wean in scenario of volume overloaded\n Plan:\n Continue supportive ventilation\n"
},
{
"category": "General",
"chartdate": "2196-02-23 00:00:00.000",
"description": "Generic Note",
"row_id": 405443,
"text": "TITLE: CCU Attending Cardiology Progress Note\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the note by Dr. today and I agree with the\n plan.\n I would add the following remarks:\n History\n Unresponsive to verbal stimuli and pain\n off Phenobarbital and all\n other neurosuppresants.\n Beginning to develop mild acidosis\n urine output remains very scant\n without response to diuretics.\n Medical Decision Making\n She does not appear to be responsive to deep pain stimuli although she\n may grimace her eyes to her husband\ns voice.\n Family meeting to discuss options is scheduled for Wednesday but all\n understand the prognosis is very poor at this juncture. Will begin to\n start end of life discussions with the family tomorrow.\n Total time spent on patient care: 30 minutes of critical care time\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405445,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Dr talked to Dr. by telephone. Plan is to not restart\n phenobarbital\n - Family meeting to discuss options is scheduled for Wednesday.\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Dilantin - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.7\nC (98\n HR: 85 (82 - 99) bpm\n BP: 107/51(72) {92/48(67) - 130/68(86)} mmHg\n RR: 14 (0 - 24) insp/min\n SpO2: 92%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 107.1 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 19 (17 - 21)mmHg\n Total In:\n 1,441 mL\n 280 mL\n PO:\n TF:\n 841 mL\n 111 mL\n IVF:\n 510 mL\n 169 mL\n Blood products:\n Total out:\n 954 mL\n 74 mL\n Urine:\n 354 mL\n 74 mL\n NG:\n Stool:\n Drains:\n Balance:\n 487 mL\n 206 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 19 cmH2O\n Plateau: 22 cmH2O\n SpO2: 92%\n ABG: ///19/\n Ve: 9.6 L/min\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n LUNGS: Ventilated breath sounds. Unable to hear good breath sounds at\n the bases.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: nonresponsive, pupils reactive to light, symmetrical\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 381 K/uL\n 7.5 g/dL\n 122 mg/dL\n 3.8 mg/dL\n 19 mEq/L\n 4.8 mEq/L\n 124 mg/dL\n 102 mEq/L\n 136 mEq/L\n 25.5 %\n 7.1 K/uL\n [image002.jpg] No new culture data\n 04:12 AM\n 02:26 PM\n 11:27 PM\n 11:51 PM\n 01:04 AM\n 02:02 AM\n 04:44 AM\n 05:08 AM\n 09:16 PM\n 04:32 AM\n WBC\n 7.0\n 7.1\n Hct\n 24.7\n 25.5\n Plt\n 422\n 381\n Cr\n 3.7\n 3.7\n 3.8\n TCO2\n 21\n 23\n 21\n 21\n 20\n 20\n Glucose\n 120\n 137\n 127\n 122\n Other labs: PT / PTT / INR:13.7/56.7/1.2, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:5.4 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures (now none for a week on EEG) and deteriorating\n mental status, aspiration pneumonia, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension required\n phenylephrine. Transferred to CCU at request of family and consulting\n cardiologist.\n # Coma, seizures, Goals of Care\n Comatose with some brainstem reflexes. No seizures for some time. No\n evidence of cortical function. BUN 123 and patient has been\n intermittently hypotensive. Therefore differential includes (also\n possible multifactorial) uremia, anoxic brain injury and\n carcinoatosis/paraneoplastic encephalopathy (although very unlikely).\n Dr. has discussed issue of Phenobarbital with Dr. \n (neurology) and decision made to not restart phenobarbital.\n - No need for LP given carcinomatosis is an extremely unlikely cause of\n coma and metabolic toxicities (many different sources) seem more\n likely.\n - Family wanst to wait until Wednesday to make further decisions.\n # Acidemia\n ABG noted pH 7.27. Anion gap was 15. Lactate was not elevated at 1.0\n making metabolic acidosis from renal failure or uremia more likely. Pt\n not a candidate for HD.\n - increase ventilation rate for respiratory compensation of\n metabolic acidosis\n - will hold off on bicarb/fluids\n # Aortic Stenosis\n Treatment of this is deferred pending decision about the above.\n Valvuloplasty will need to be repeated (if this is compatible with\n goals of care). Pt with known severe aortic stenosis s/p valvuloplasty\n in . She was initially on the CCU service early in her\n hospitalization in the setting of flash pulmonary edema when her lasix\n were held. Now, she is intubated in the ICU. Continues to be severely\n fluid overloaded and oliguric, positive ~30L Los. She does not respond\n well to lasix/diuril/bumex but is also not a candidate for HD.\n - Continue bumex and metolazone with goal of net negative 1.5L today\n - lytes\n - Monitor volume status, UOP.\n - Holding off on valvuloplasty at this point\n # Respiratory Failure and Intubation\n - Preserve for now given mental status and edema\n # Atrial Fibrillation\n Pt has good control of HR on beta blockade and digoxin. Coumadin was\n being held before for trach/PEG. Now, holding coumading in case pt\n undergoes valvuloplasty. Now on heparin gtt while INR subtherapeutic.\n - Continue metoprolol tartrate 25 mg TID\n - Continue digoxin 0.0625 mg daily\n - Trend coags\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, is ATN\n - Will attempt diuresis with bumex/metolazone, as above\n - Appreciate renal recs.\n - Continue to monitor fluid status otherwise\n # Coronary Artery Disease: Pt is s/p CABG /.\n - Continue metoprolol as above\n - Continue aspirin 81 mg daily, atorvastatin 40 mg daily\n # Respiratory Failure: Now, s/p trach.\n - Trach in place\n - Continue albuterol/atrovent PRN\n # Pressor Requirement: Pt weaned off of pressors.\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - f/u cx data\n - follow fever curve\n - f/u stool for c.diff\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 12:00 AM 15 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code (confirmed by family)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405521,
"text": "Seizure, without status epilepticus\n Assessment:\n Neuro status exam unchanged. PERLA 3-4mm. no spontaneous movement of\n extremities. Doesn\nt respond to noxious stimuli. Pt will yawn and\n refuse to open mouth. Sometimes moves head back and forth in slight\n slow movements. pt received last dose of Phenobarbital on evening\n and pt neuro status has not improved.\n Action:\n Family in to visit at noon time. Observed pt turn head towards husbands\n voice, open eyes and smile. Then pt went back into the vegetative like\n states that we haven\nt been able to rouse her from. Later in day, with\n her name calling, pt did open her eyes briefly, then didn\n respond.\n Social work in to see family today.\n Response:\n Cont\n to monitor. Remains on dilantin q8h IV.\n Plan:\n Monitor for seizures. Monitor neuro status. Dilantin q8h. emotional\n support to family..\n Impaired Skin Integrity\n Assessment:\n Anasarca. Multiple excoriations, open areas in creases from yeast in\n all skin folds (groin, panus, under breasts). Venous ulcers on both\n lower legs. Decub on coccyx\n mepilex dsg intact (placed on ).\n Action:\n Freq turns q2h. on kinair bed. Waffle boots on. Flexiseal in place,\n working well, keeping buttocks free from stool (loose brown stool).\n Trach and peg sites intact. Dsgs to bilat lower legs ulcers done.\n Response:\n No changes. Con\nt skin care q2h with turns.\n Plan:\n Daily bilat lower leg dsg changes. See skin care nurse notes in chart.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine ouput continues low 10 -20 cc/hr. bun 124/creatinine 3.8.total\n body anarsaca\n Action:\n Patient receiving bumex and metalazone qd( to be given\n before\n morning bumex dose\n Response:\n No change. Low urines continue\n Plan:\n Monitor uo and bun and creatinine\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bilateral rhonci diminished at bases. O2 sats 94-96 % . Trached.\n Action:\n Suctioned q 3-4 hours for small to moderate amount off white thick\n sputum, albuterol ih atc q 6 hours\n Response:\n Sats decreased this afternoon to low 90s\n increased FIO2 to 70%. Sats\n going between 90-98% on 70% FIO2. abg acidotic 7.29 with PO2 200-300s,\n but low sats on monitor\n O2 sat of ABG 98%.\n Plan:\n Adjust vent settings as needed. Am abg.\n Aortic stenosis\n Assessment:\n Pt in afib 80s. SBP 100-130s. Aline Lt radial. TLC Lt IJ.\n Action:\n Heparin dose infusing at 1350 units/hr. am PTT WNL.\n Response:\n Tolerating lopressor 25mg po TID.\n Plan:\n Continue heparin at 1350 units. Am PTT.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405693,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now w/respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Seizure, without status epilepticus\n Assessment:\n No change in neuro status- remains unresponsive- no movement of\n extremities noted, even to painful stimuli- PERL- responds to mouth\n care by biting down on swab.\n Action:\n Dilantin given as ordered- neuro checks q4hrs.\n Response:\n Unchanged- no seizure activity noted.\n Plan:\n Con\nt to monitor.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O trending down- (+) 32L LOS- (+) anasarca.\n Action:\n Metalazone and bumex given as ordered- beneprotein D/C\nd from TF\n (novasource renal).\n Response:\n No increase in U/O noted.\n Plan:\n Con\nt present management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Exp wheezes/rhonchi noted upper lobes bilaterally- diminished @ the\n bases- suctioned small amt thick wht/tan colored mucous- SpO2\ns 92-97%.\n Action:\n Resp rx given as ordered- suctioned PRN.\n Response:\n Sat\ns stable.\n Plan:\n Con\nt present management.\n Aortic stenosis\n Assessment:\n Afib rate in 80\ns- SBP >100\n Action:\n Seen by CCU team- prognosis grim- heparin gtt D/C\n Response:\n Hemodynamically stable @ present.\n Plan:\n Transitioning to comfort measures.\n Impaired Skin Integrity\n Assessment:\n (+) anasarca- multiple areas of breakdown- see medavision for more\n info.\n Action:\n Repositioned q2hrs- on kinair bed- waffle boots on- coccyx dsg D&I-\n flexiseal in place and draining brown colored stool- both lower leg\n dsgs D&I- trach and peg sites intact.\n Response:\n Unchanged.\n Plan:\n Con\nt present management.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 405703,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405769,
"text": "Chief Complaint: CRITICAL AS\n 24 Hour Events:\n \n stopped fingersticks and blood draws for comfort\n stopped heparin gtt\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:30 PM\n Dilantin - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.7\nC (98.1\n HR: 96 (79 - 97) bpm\n BP: 112/55(76) {97/47(66) - 118/56(79)} mmHg\n RR: 22 (8 - 22) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 108.1 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 22 (19 - 22)mmHg\n Total In:\n 1,538 mL\n 454 mL\n PO:\n TF:\n 844 mL\n 252 mL\n IVF:\n 604 mL\n 172 mL\n Blood products:\n Total out:\n 271 mL\n 465 mL\n Urine:\n 271 mL\n 65 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,267 mL\n -11 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 74\n PIP: 11 cmH2O\n Plateau: 18 cmH2O\n SpO2: 94%\n ABG: ////\n Ve: 9.2 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 387 K/uL\n 7.6 g/dL\n 125 mg/dL\n 3.8 mg/dL\n 17 mEq/L\n 4.7 mEq/L\n 129 mg/dL\n 102 mEq/L\n 134 mEq/L\n 24.8 %\n 8.5 K/uL\n [image002.jpg]\n 05:08 AM\n 09:16 PM\n 04:32 AM\n 08:40 AM\n 06:02 PM\n 04:16 AM\n 01:22 PM\n 05:00 PM\n 04:05 AM\n 04:23 AM\n WBC\n 7.1\n 7.6\n 8.5\n Hct\n 25.5\n 25.4\n 24.8\n Plt\n 381\n 357\n 387\n Cr\n 3.7\n 3.8\n 3.8\n 3.8\n TCO2\n 20\n 20\n 21\n 21\n 20\n 20\n Glucose\n 127\n 122\n 119\n 124\n 125\n Other labs: PT / PTT / INR:13.2/64.3/1.1, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures (now none for a week on EEG) and deteriorating\n mental status, aspiration pneumonia, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension required\n phenylephrine. Transferred to CCU at request of family and consulting\n cardiologist.\n # Coma, seizures, Goals of Care\n Comatose with some brainstem reflexes. No seizures for some time. No\n evidence of cortical function. BUN 124 and patient has been\n intermittently hypotensive. Therefore differential includes (also\n possible multifactorial) uremia, anoxic brain injury and\n carcinoatosis/paraneoplastic encephalopathy (although very unlikely).\n Dr. has discussed issue of Phenobarbital with Dr. \n (neurology) and decision made to not restart phenobarbital.\n - No need for LP given carcinomatosis is an extremely unlikely cause of\n coma and metabolic toxicities (many different sources) seem more\n likely.\n - Will continue phenytoin for now given not contributing to mental\n status at such low concentration\n - DNR/DNI focus on comfort\n - Will discontinue labs\n - No escalation of care\n # Acidemia\n ABG slightly improved today - 7.30/41/112/18/-5. Lactate was not\n elevated at 1.0 making metabolic acidosis from renal failure or uremia\n more likely. Pt not a candidate for HD.\n -No further interventions\n # Aortic Stenosis\n Treatment of this is deferred pending decision about the above.\n Valvuloplasty will need to be repeated (if this is compatible with\n goals of care). Pt with known severe aortic stenosis s/p valvuloplasty\n in . She was initially on the CCU service early in her\n hospitalization in the setting of flash pulmonary edema when her lasix\n were held. Now, she is intubated in the ICU. Continues to be severely\n fluid overloaded and oliguric, positive ~30L Los. She does not respond\n well to lasix/diuril/bumex but is also not a candidate for HD.\n - Continue bumex and metolazone\n - No further escalations\n # Respiratory Failure and Intubation\n - Preserve for now given mental status and edema\n # Atrial Fibrillation\n Pt has good control of HR on beta blockade and digoxin. Coumadin was\n being held before for trach/PEG. Now, holding coumading in case pt\n undergoes valvuloplasty.\n - Continue metoprolol tartrate 25 mg TID\n - Continue digoxin 0.0625 mg daily\n - DC labs\n - DC IV heparin given inconsistent with goals of care\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, is ATN\n - No new interventions\n # Coronary Artery Disease: Pt is s/p CABG /.\n - Continue metoprolol as above\n - Continue aspirin 81 mg daily, atorvastatin 40 mg daily\n # Respiratory Failure: Now, s/p trach.\n - Trach in place\n - Continue albuterol/atrovent PRN\n # Pressor Requirement: Pt weaned off of pressors.\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - Tylenol PRN fever\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:56 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI focus on comfort\n Disposition: CCU\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405770,
"text": "Chief Complaint: CRITICAL AS\n 24 Hour Events:\n \n -patient's code status changed to DNR; goals shifting towards comfort\n measures but do not stop treatment altogether\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 09:19 PM\n Dilantin - 05:17 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.5\nC (97.7\n HR: 93 (87 - 104) bpm\n BP: 116/54(77) {94/44(63) - 121/58(81)} mmHg\n RR: 18 (17 - 27) insp/min\n SpO2: 95%\n Heart rhythm: SVT (Supra Ventricular Tachycardia)\n Wgt (current): 109 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 22 (13 - 23)mmHg\n Total In:\n 1,619 mL\n 505 mL\n PO:\n TF:\n 845 mL\n 272 mL\n IVF:\n 614 mL\n 173 mL\n Blood products:\n Total out:\n 367 mL\n 92 mL\n Urine:\n 367 mL\n 92 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,252 mL\n 413 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 60\n PIP: 20 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 7.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 387 K/uL\n 7.6 g/dL\n 125 mg/dL\n 3.8 mg/dL\n 17 mEq/L\n 4.7 mEq/L\n 129 mg/dL\n 102 mEq/L\n 134 mEq/L\n 24.8 %\n 8.5 K/uL\n [image002.jpg]\n 05:08 AM\n 09:16 PM\n 04:32 AM\n 08:40 AM\n 06:02 PM\n 04:16 AM\n 01:22 PM\n 05:00 PM\n 04:05 AM\n 04:23 AM\n WBC\n 7.1\n 7.6\n 8.5\n Hct\n 25.5\n 25.4\n 24.8\n Plt\n 381\n 357\n 387\n Cr\n 3.7\n 3.8\n 3.8\n 3.8\n TCO2\n 20\n 20\n 21\n 21\n 20\n 20\n Glucose\n 127\n 122\n 119\n 124\n 125\n Other labs: PT / PTT / INR:13.2/64.3/1.1, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures (now none for a week on EEG) and deteriorating\n mental status, aspiration pneumonia, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension required\n phenylephrine. Transferred to CCU at request of family and consulting\n cardiologist.\n # Coma, seizures, Goals of Care\n Comatose with some brainstem reflexes. No seizures for some time. No\n evidence of cortical function. BUN 124 and patient has been\n intermittently hypotensive. Therefore differential includes (also\n possible multifactorial) uremia, anoxic brain injury and\n carcinoatosis/paraneoplastic encephalopathy (although very unlikely).\n Dr. has discussed issue of Phenobarbital with Dr. \n (neurology) and decision made to not restart phenobarbital.\n - No need for LP given carcinomatosis is an extremely unlikely cause of\n coma and metabolic toxicities (many different sources) seem more\n likely.\n - Will continue phenytoin for now given not contributing to mental\n status at such low concentration\n - DNR/DNI focus on comfort\n - Will discontinue labs\n - No escalation of care\n # Acidemia\n ABG slightly improved today - 7.30/41/112/18/-5. Lactate was not\n elevated at 1.0 making metabolic acidosis from renal failure or uremia\n more likely. Pt not a candidate for HD.\n -No further interventions\n # Aortic Stenosis\n Treatment of this is deferred pending decision about the above.\n Valvuloplasty will need to be repeated (if this is compatible with\n goals of care). Pt with known severe aortic stenosis s/p valvuloplasty\n in . She was initially on the CCU service early in her\n hospitalization in the setting of flash pulmonary edema when her lasix\n were held. Now, she is intubated in the ICU. Continues to be severely\n fluid overloaded and oliguric, positive ~30L Los. She does not respond\n well to lasix/diuril/bumex but is also not a candidate for HD.\n - Continue bumex and metolazone\n - No further escalations\n # Respiratory Failure and Intubation\n - Preserve for now given mental status and edema\n # Atrial Fibrillation\n Pt has good control of HR on beta blockade and digoxin. Coumadin was\n being held before for trach/PEG. Now, holding coumading in case pt\n undergoes valvuloplasty.\n - Continue metoprolol tartrate 25 mg TID\n - Continue digoxin 0.0625 mg daily\n - DC labs\n - DC IV heparin given inconsistent with goals of care\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, is ATN\n - Will attempt diuresis with bumex/metolazone, as above\n - Appreciate renal recs.\n - Continue to monitor fluid status otherwise\n # Coronary Artery Disease: Pt is s/p CABG /.\n - Continue metoprolol as above\n - Continue aspirin 81 mg daily, atorvastatin 40 mg daily\n # Respiratory Failure: Now, s/p trach.\n - Trach in place\n - Continue albuterol/atrovent PRN\n # Pressor Requirement: Pt weaned off of pressors.\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - Tylenol PRN fever\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:56 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI focus on comfort\n Disposition: CCU\n ------ Protected Section ------\n EXAM:\n GEN: Anasarcic, elderly woman, unresponsive to deep stimulation,\n appears comfortable\n CV: RRR, no RMG\n PULM: CTAB, no WRR anteriorly\n ABD: Soft, NTND, +BS, obese\n EXT: Marked UE and LE edema\n ------ Protected Section Addendum Entered By: , MD\n on: 18:43 ------\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405771,
"text": "Chief Complaint: CRITICAL AS\n 24 Hour Events:\n \n stopped fingersticks and blood draws for comfort\n stopped heparin gtt\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:30 PM\n Dilantin - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.7\nC (98.1\n HR: 96 (79 - 97) bpm\n BP: 112/55(76) {97/47(66) - 118/56(79)} mmHg\n RR: 22 (8 - 22) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 108.1 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 22 (19 - 22)mmHg\n Total In:\n 1,538 mL\n 454 mL\n PO:\n TF:\n 844 mL\n 252 mL\n IVF:\n 604 mL\n 172 mL\n Blood products:\n Total out:\n 271 mL\n 465 mL\n Urine:\n 271 mL\n 65 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,267 mL\n -11 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 74\n PIP: 11 cmH2O\n Plateau: 18 cmH2O\n SpO2: 94%\n ABG: ////\n Ve: 9.2 L/min\n Physical Examination\n GEN: Anasarcic, elderly woman, unresponsive to deep stimulation,\n appears comfortable\n CV: RRR, no RMG\n PULM: CTAB, no WRR anteriorly\n ABD: Soft, NTND, +BS, obese\n EXT: Marked UE and LE edema\n Labs / Radiology\n 387 K/uL\n 7.6 g/dL\n 125 mg/dL\n 3.8 mg/dL\n 17 mEq/L\n 4.7 mEq/L\n 129 mg/dL\n 102 mEq/L\n 134 mEq/L\n 24.8 %\n 8.5 K/uL\n [image002.jpg]\n 05:08 AM\n 09:16 PM\n 04:32 AM\n 08:40 AM\n 06:02 PM\n 04:16 AM\n 01:22 PM\n 05:00 PM\n 04:05 AM\n 04:23 AM\n WBC\n 7.1\n 7.6\n 8.5\n Hct\n 25.5\n 25.4\n 24.8\n Plt\n 381\n 357\n 387\n Cr\n 3.7\n 3.8\n 3.8\n 3.8\n TCO2\n 20\n 20\n 21\n 21\n 20\n 20\n Glucose\n 127\n 122\n 119\n 124\n 125\n Other labs: PT / PTT / INR:13.2/64.3/1.1, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures (now none for a week on EEG) and deteriorating\n mental status, aspiration pneumonia, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension required\n phenylephrine. Transferred to CCU at request of family and consulting\n cardiologist.\n # Coma, seizures, Goals of Care\n Comatose with some brainstem reflexes. No seizures for some time. No\n evidence of cortical function. BUN 124 and patient has been\n intermittently hypotensive. Therefore differential includes (also\n possible multifactorial) uremia, anoxic brain injury and\n carcinoatosis/paraneoplastic encephalopathy (although very unlikely).\n Dr. has discussed issue of Phenobarbital with Dr. \n (neurology) and decision made to not restart phenobarbital.\n - No need for LP given carcinomatosis is an extremely unlikely cause of\n coma and metabolic toxicities (many different sources) seem more\n likely.\n - Will continue phenytoin for now given not contributing to mental\n status at such low concentration\n - DNR/DNI focus on comfort\n - Will discontinue labs\n - No escalation of care\n # Acidemia\n ABG slightly improved today - 7.30/41/112/18/-5. Lactate was not\n elevated at 1.0 making metabolic acidosis from renal failure or uremia\n more likely. Pt not a candidate for HD.\n -No further interventions\n # Aortic Stenosis\n Treatment of this is deferred pending decision about the above.\n Valvuloplasty will need to be repeated (if this is compatible with\n goals of care). Pt with known severe aortic stenosis s/p valvuloplasty\n in . She was initially on the CCU service early in her\n hospitalization in the setting of flash pulmonary edema when her lasix\n were held. Now, she is intubated in the ICU. Continues to be severely\n fluid overloaded and oliguric, positive ~30L Los. She does not respond\n well to lasix/diuril/bumex but is also not a candidate for HD.\n - Continue bumex and metolazone\n - No further escalations\n # Respiratory Failure and Intubation\n - Preserve for now given mental status and edema\n # Atrial Fibrillation\n Pt has good control of HR on beta blockade and digoxin. Coumadin was\n being held before for trach/PEG. Now, holding coumading in case pt\n undergoes valvuloplasty.\n - Continue metoprolol tartrate 25 mg TID\n - Continue digoxin 0.0625 mg daily\n - DC labs\n - DC IV heparin given inconsistent with goals of care\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, is ATN\n - No new interventions\n # Coronary Artery Disease: Pt is s/p CABG /.\n - Continue metoprolol as above\n - Continue aspirin 81 mg daily, atorvastatin 40 mg daily\n # Respiratory Failure: Now, s/p trach.\n - Trach in place\n - Continue albuterol/atrovent PRN\n # Pressor Requirement: Pt weaned off of pressors.\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - Tylenol PRN fever\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:56 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI focus on comfort\n Disposition: CCU\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-19 00:00:00.000",
"description": "Cardiology Teaching Physician Note",
"row_id": 405061,
"text": "TITLE:\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n History\n Continues unresponsive in anuric renal failure.\n Medical Decision Making\n Prognosis dismal.\n Family discussion ongoing with Dr re consideration of further\n invasive procedures such as aortic valvuloplasty.\n Total time spent on patient care: 30 minutes of critical care time.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405134,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt creatinine 3.6, stabilized. Urine output 15-25 per hour. Remains\n grossly generally edematous. Serum lytes WNL. 200 mg lasix bolus given\n yesterday, gtt started without success.\n Action:\n Administered bumex to attempt more successful diuresis than lasix. Dose\n administered 2 mg, which is equivalent to 80 mg of lasix.\n Response:\n No appreciable response to bumex. Afternoon lytes pending.\n Plan:\n Hold HD for now, until prognosis of pt\ns neuro status more clear\n Impaired Skin Integrity *PT ALLERGIC TO ADAPTIC*\n Assessment:\n Pt has multiple areas of skin integrity issues. This is a long \n problem as pt has been seen by visiting nurse for various venous stasis\n ulcers long term; pts acute edema has worsened her preexisting skin\n issues. See metavision for more substantial details. In summary:\n - DTI on coccyx and LLE. Coccyx is red but blanchable\n throughout it. Flexiseal in place for stool mgmt\n - Bilat LE venous ulcers\n - Excoriated areas beneath abdominal pannus\n - Healing area of impaired skin next to PEG site\n attempted PEG site\n - Eschar covered abrasion on R 1^st toe\n Action:\n - See metavision for specific treatments. One change this writer\n instituted was to add aquacel to her venous stasis dsgs. Waffle boots\n maintained on, heels have no pressure to them whatsoever. Frequent skin\n checks\n Response:\n - Skin unchanged.\n Plan:\n - Continue skin assessment and treatments.\n Seizure, without status epilepticus\n Assessment:\n Pt without seizure activity X 4 days per neuro. Dilantin loaded\n overnight. Dilantin level low so plan to reload this afternoon. Pt\n unresponsive except occasional flickering of eyes to voice, flexion to\n pain in all extremities, PERRL. + corneals. No s/s seizure activity\n noted\n Action:\n Team wrote to lower phenobarb today to 15\n first dose at that amount\n to be administered this evening. Sunday she will get 15 then it\n shall be discontinued Monday.\n Response:\n Pt remains without seizure activity thus far\n Plan:\n Continue to monitor pt, cont EEG. Will have better picture of pts true\n neuro status once phenobarb clears\n Aortic stenosis\n Assessment:\n Heparin gtt within therapeutic range. Metoprolol ATC as ordered.\n Remains in afib 70-90, few PVCs noted.\n Action:\n Medications as ordered.\n Response:\n Pt clinical assessment unchanged\n Plan:\n Valvuloplasty tentatively planned for Monday in interventional\n cardiology\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt 30L total body balance positive, Lung sounds clear, diminished in\n bases. Trached 38 portex. Remains on CPAP 15/5. 50% Fi02, minimal\n secretions via suctioning. + cough but impaired/absent gag. Trach site\n with sutures intact, site looks clean/minimal drainage. RR 17-22, sats\n >97%\n Action:\n Monitored patient, administered bumex to attempt to remove fluid, trach\n care\n Response:\n Pt remains on vent settings.\n Plan:\n Attempt to remove fluid before attempt to wean pressure support.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405202,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, previous hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output 10-15cc/hr\n Action:\n Started on po bumex and metolazone\n Response:\n Pt w/ low urine volumes and total body anasarcia\n B/C 120/3.8\n Plan:\n Cont to follow urine output, renal function, response to oral\n diuretics.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 90-95% via ear lobe, not consistently accurate, unable to get sats\n from fingers\n Action:\n ABG obtained, po2 80\ns with sat 90%\n Response:\n ABG showed a/c mode not needed to maintain adequate pO2, and did not\n help pH/metabolic acidosis\n Pt returned to CPAP mode, at 50%, which previous ABG showed pO2 of 100%\n Plan:\n Check results a.m. ABG drawn w/ 4a labs\n Seizure, without status epilepticus\n Assessment:\n Pt remains w/ EEG monitor/leads attached to head for continued EEG\n monitoring\n Action:\n No seizure activity observed by nurse, though some mild jaw movements\n noted during po hygiene cares\n Pt also received dilantin load yesterday, and adjustment of dilantin\n dose\n Response:\n -----\n Plan:\n a.m. dilantin level drawn this a.m., results pending\n Aortic stenosis\n Assessment:\n Pt on hep gtt for AS, has been on 1150 units/hr;\n Action:\n PTT drawn at 20:30 result was approx 62, was 73 previous draw;\n Response:\n PTT stable, adjustment not needed; PTT drawn again w/ 4a labs, pending\n at this time\n Plan:\n Lopressor as ordered\n Cont card monitorting\n ?valvuloplasty Mon\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405076,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Oliguric/Anuric\n BUN and Creat continue to trend up\n HUO 5-10cc/hr\n Action:\n Started on Lasix infusion with goal of titrating to 100cc/hr\n Bolused with Lasix 200mg IV\n Zaroxlyn 10mg PEG\n Response:\n Thus far poor response to IV Diurectics\n Plan:\n Continue to titrate Lasix infusion to max 20mg/hr\n Renal following from a far. Not HD candidate at this time\n Seizure, without status epilepticus\n Assessment:\n Unresponsive\n Action:\n Continous EEG\n Neuro assessment Q4H\n Continues Dilantin and Phenobarb\n MRI of head today\n Response:\n EEG remains without seizure activity\n PERL, 3mm bilaterally. GCS of 3. Cannot elicit response in\n any extremeties to painful stimuli\n Weaning IV Dilantin and PO Phenobarb\n Plan:\n Neuromedicine continues to follow\n Continue neuro assessment\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Trached\n Action:\n CPAP 12/5/.50\n Suctioned infrequently\n Response:\n Secretions white thick small amounts\n RR 18-24\n MV and TV adequate\n No plans to wean in scenario of volume overloaded\n Plan:\n Continue supportive ventilation\n Aortic stenosis\n Assessment:\n AF\n Severe AF\n Action:\n Heparin infusion restarted at 1000 unit/hr without bolus\n Lopressor TID\n Digoxin QD\n Response:\n HR 70-90s, AF with PVCs occassionally\n SBPs 100-120s\n Plan:\n PTT q6h, next due at 1900\n Plans for valvuloplast on Monday\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405436,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now w/respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urinary output remains low-> 10-15cc/hr- BUN 124 Crea 3.8- worsening\n metabolic acidosis- (+) anasarca- weight trending up (107.1 kg)\n Action:\n Metolazone and bumex given as ordered.\n Response:\n No increase in U/O.\n Plan:\n Con\nt to follow labs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n CMV 400x14 50% P5 via trach\n Action:\n ABG 7.27-41-119-20 98%- suctioned scant-small amt thick tan colored\n mucous- resp rx given as ordered- RR increased to 18 on vent.\n Response:\n Repeat ABG 7.30-41-112-21 96%\n Plan:\n Con\nt vent support- maintain VAP protocol.\n Seizure, without status epilepticus\n Assessment:\n Remains unresponsive- unable to follow command- no spontaneous\n movement noted- resists mouth care by clenching teeth- PERL- ?\n attempted to open eyes when husband called her name, but was unable to.\n Action:\n Dilantin given as ordered- neuro status monitored.\n Response:\n No seizure activity noted- neuro status unchanged.\n Plan:\n Con\nt to monitor- follow dilantin levels- notify HO of any seizure\n activity.\n Impaired Skin Integrity\n Assessment:\n Bilateral leg dsgs intact, mepilex dsg on coccyx intact- abd folds w/\n redness/crack skin- (+) anasarca\n Action:\n Foam cleanser and miconazole powder PRN- see metavision for details of\n skin integrity- frequent repositioning and skin care.\n Response:\n Unchanged.\n Plan:\n Con\nt present management.\n Heparin gtt (Afib) @ 1350u/hr- repeat PTT 76.9- hemodynamically stable-\n TF @ goal 35cc/hr.\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 405593,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 19\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Insp Wheeze\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing, Gasping\n efforts\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously, Abnormal trigger\n efforts (efforts during inspiratory)\n Dysynchrony assessment: Vigorous inspiratory efforts\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405860,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt remains near anuric; wt continues to rise daily, pt with total body\n anasarca. Increased RR and effort\n Action:\n Unable to give po meds as pt vomiting this am, TF placed on hold.\n Response:\n No further vomiting remainder of day.\n Plan:\n Cont efforts to maintain good skin care in setting of pt with anasarca\n and immobility.\n Ineffective Coping\n Assessment:\n Pt family in and updated re: pt\ns deteriorating condition and multi\n system failure.\n Action:\n Informed family of administration of morphine for increased respiratory\n effort, indications of pain ie. Change in VS.\n Response:\n Family understands pt condition is deteriorating, husband sees pt open\n eyes to his voice and cont to hold hope. Daughter attempting to direct\n her father to pt\ns multiple medical problems. Family appreciate\n treating pt\ns discomfort with morphine.\n Plan:\n Pt remains DNR, no therapies to be added. Maintain pt comfort with\n morphine prn. Cont to support and inform family.\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 405194,
"text": "Demographics\n Day of intubation: 15\n Day of mechanical ventilation: 15\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments: Pt data as above/ per Meta-V. Pt appears comfortable on PSV\n 15/5 PEEP FIO2 .40 with VT\ns of 350-450 cc and a RR of 18-32 BPM. ABG\n c/w an uncompensated metabolic acidosis and stable oxygenation. Sxing\n for thick tan sputum\n specimen sent yesterday.\n RSBI still a bit elevated at 118. Would continue w/ gentle exercise of\n ventilatory muscles using PSV.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405204,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, previous hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output 10-15cc/hr\n Action:\n Started on po bumex and metolazone\n Response:\n Pt w/ low urine volumes and total body anasarcia\n B/C 120/3.8\n Plan:\n Cont to follow urine output, renal function, response to oral\n diuretics.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 90-95% via ear lobe, not consistently accurate, unable to get sats\n from fingers\n Action:\n ABG obtained, po2 80\ns with sat 90%. Suctioning q 3-4 hrs for sm amt\n thick tan sputum, trach care\n Response:\n Pt stable on CPAP mode, at 50%, RR 20-25, VT 350\n Plan:\n Cont vent support, if pt begins to diurese may be able to wean vent\n Seizure, without status epilepticus\n Assessment:\n Some head movements toward voice with attempts to open eyes to voice.\n EEG monitor/leads removed by tech this am, pt with significant skin\n breakdown under leads, incident report done, MD\ns(CCU and Neurology as\n well as director of EEG lab notified). Email sent to .\n Action:\n Phenobarb dc\nd after am dose\n Response:\n No seizure activity observed by nurse, Pt attempts to open eyes to\n voice, turns head and moves mouth when family speaks to her.\n Plan:\n a.m. dilantin level 3.5, reload dilantin and place on tid IV dosing per\n neurology\n Aortic stenosis\n Assessment:\n Pt on hep gtt for AS, PTT on 1200 units\n Action:\n PTT drawn at 1430 was 56.0, gtt increased gtt to 1350 units/hr\n Response:\n PTT low, VS stable\n Plan:\n Lopressor as ordered\n Cont card monitorting\n Pt in need of repeat valvuloplasty , following neuro/renal status over\n next several days to determine her course.\n Close communication with family. Husband and daughter in today and\n updated by RN/MD\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405207,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , flashed on the floor in the\n setting of holding lasix. Course complicated by subclinical seizures\n and deteriorating mental status, aspiration pneumonia, now\n w/respiratory acidosis and failure resulting in intubation (), ARF,\n previous hypotension requiring phenylephrine. Transferred to CCU at\n request of family and consulting cardiologist.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output 10-15cc/hr\n Action:\n Started on po bumex and metolazone\n Response:\n Pt w/ low urine volumes and total body anasarcia\n B/C 120/3.8\n Plan:\n Cont to follow urine output, renal function, response to oral\n diuretics.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 90-95% via ear lobe, not consistently accurate, unable to get sats\n from fingers\n Action:\n ABG obtained, po2 80\ns with sat 90%. Suctioning q 3-4 hrs for sm amt\n thick tan sputum, trach care\n Response:\n Pt stable on CPAP mode, at 50%, RR 20-25, VT 350\n Plan:\n Cont vent support, if pt begins to diurese may be able to wean vent\n Seizure, without status epilepticus\n Assessment:\n Some head movements toward voice with attempts to open eyes to voice.\n EEG monitor/leads removed by tech this am, pt with significant skin\n breakdown under leads, incident report done, MD\ns(CCU and Neurology as\n well as director of EEG lab notified). Email sent to .\n Action:\n Phenobarb dc\nd after am dose\n Response:\n No seizure activity observed by nurse, Pt attempts to open eyes to\n voice, turns head and moves mouth when family speaks to her.\n Plan:\n a.m. dilantin level 3.5, reload dilantin and place on tid IV dosing per\n neurology\n Aortic stenosis\n Assessment:\n Pt on hep gtt for AS, PTT on 1200 units\n Action:\n PTT drawn at 1430 was 56.0, gtt increased gtt to 1350 units/hr\n Response:\n PTT low, VS stable\n Plan:\n Lopressor as ordered\n Cont card monitorting\n Pt in need of repeat valvuloplasty , following neuro/renal status over\n next several days to determine her course.\n Close communication with family. Husband and daughter in today and\n updated by RN/MD\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405209,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now w/respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output 10-15cc/hr\n Action:\n Started on po bumex and metolazone\n Response:\n Pt w/ low urine volumes and total body anasarcia\n B/C 120/3.8\n Plan:\n Cont to follow urine output, renal function, response to oral\n diuretics.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 90-95% via ear lobe, not consistently accurate, unable to get sats\n from fingers\n Action:\n ABG obtained, po2 80\ns with sat 90%. Suctioning q 3-4 hrs for sm amt\n thick tan sputum, trach care\n Response:\n Pt stable on CPAP mode, at 50%, RR 20-25, VT 350\n Plan:\n Cont vent support, if improvement in MS, Dr. will do\n valvuloplasty which will aid diuresis.\n Seizure, without status epilepticus\n Assessment:\n Some head movements toward voice with attempts to open eyes to voice.\n EEG monitor/leads removed by tech this am, pt with significant skin\n breakdown under leads, incident report done, MD\ns(CCU and Neurology as\n well as director of EEG lab notified). Email sent to .\n Action:\n Phenobarb dc\nd after am dose\n Response:\n No seizure activity observed by nurse, Pt attempts to open eyes to\n voice, turns head and moves mouth when family speaks to her.\n Plan:\n a.m. dilantin level 3.5, reloaded with dilantin and placed on tid IV\n dosing per neurology. Recheck level tonight ~2hr after 1^st standing\n dose.\n Aortic stenosis\n Assessment:\n Pt on hep gtt for AS, PTT on 1200 units\n Action:\n PTT drawn at 1430 was 56.0, gtt increased gtt to 1350 units/hr at 1600\n Response:\n PTT low, VS stable\n Plan:\n Lopressor as ordered, Cont card monitorting\n Pt in need of repeat valvuloplasty for severe AS, following neuro/renal\n status over next several days to determine her course.\n Close communication with family. Husband and daughter in today and\n updated by RN/MD\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405674,
"text": "Chief Complaint: CRITICAL AS\n 24 Hour Events:\n \n -patient's code status changed to DNR; goals shifting towards comfort\n measures but do not stop treatment altogether\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 09:19 PM\n Dilantin - 05:17 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.5\nC (97.7\n HR: 93 (87 - 104) bpm\n BP: 116/54(77) {94/44(63) - 121/58(81)} mmHg\n RR: 18 (17 - 27) insp/min\n SpO2: 95%\n Heart rhythm: SVT (Supra Ventricular Tachycardia)\n Wgt (current): 109 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 22 (13 - 23)mmHg\n Total In:\n 1,619 mL\n 505 mL\n PO:\n TF:\n 845 mL\n 272 mL\n IVF:\n 614 mL\n 173 mL\n Blood products:\n Total out:\n 367 mL\n 92 mL\n Urine:\n 367 mL\n 92 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,252 mL\n 413 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 60\n PIP: 20 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 7.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 387 K/uL\n 7.6 g/dL\n 125 mg/dL\n 3.8 mg/dL\n 17 mEq/L\n 4.7 mEq/L\n 129 mg/dL\n 102 mEq/L\n 134 mEq/L\n 24.8 %\n 8.5 K/uL\n [image002.jpg]\n 05:08 AM\n 09:16 PM\n 04:32 AM\n 08:40 AM\n 06:02 PM\n 04:16 AM\n 01:22 PM\n 05:00 PM\n 04:05 AM\n 04:23 AM\n WBC\n 7.1\n 7.6\n 8.5\n Hct\n 25.5\n 25.4\n 24.8\n Plt\n 381\n 357\n 387\n Cr\n 3.7\n 3.8\n 3.8\n 3.8\n TCO2\n 20\n 20\n 21\n 21\n 20\n 20\n Glucose\n 127\n 122\n 119\n 124\n 125\n Other labs: PT / PTT / INR:13.2/64.3/1.1, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures (now none for a week on EEG) and deteriorating\n mental status, aspiration pneumonia, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension required\n phenylephrine. Transferred to CCU at request of family and consulting\n cardiologist.\n # Coma, seizures, Goals of Care\n Comatose with some brainstem reflexes. No seizures for some time. No\n evidence of cortical function. BUN 124 and patient has been\n intermittently hypotensive. Therefore differential includes (also\n possible multifactorial) uremia, anoxic brain injury and\n carcinoatosis/paraneoplastic encephalopathy (although very unlikely).\n Dr. has discussed issue of Phenobarbital with Dr. \n (neurology) and decision made to not restart phenobarbital.\n - No need for LP given carcinomatosis is an extremely unlikely cause of\n coma and metabolic toxicities (many different sources) seem more\n likely.\n - Will continue phenytoin for now given not contributing to mental\n status at such low concentration\n - DNR/DNI focus on comfort\n - Will discontinue labs\n - No escalation of care\n # Acidemia\n ABG slightly improved today - 7.30/41/112/18/-5. Lactate was not\n elevated at 1.0 making metabolic acidosis from renal failure or uremia\n more likely. Pt not a candidate for HD.\n -No further interventions\n # Aortic Stenosis\n Treatment of this is deferred pending decision about the above.\n Valvuloplasty will need to be repeated (if this is compatible with\n goals of care). Pt with known severe aortic stenosis s/p valvuloplasty\n in . She was initially on the CCU service early in her\n hospitalization in the setting of flash pulmonary edema when her lasix\n were held. Now, she is intubated in the ICU. Continues to be severely\n fluid overloaded and oliguric, positive ~30L Los. She does not respond\n well to lasix/diuril/bumex but is also not a candidate for HD.\n - Continue bumex and metolazone\n - No further escalations\n # Respiratory Failure and Intubation\n - Preserve for now given mental status and edema\n # Atrial Fibrillation\n Pt has good control of HR on beta blockade and digoxin. Coumadin was\n being held before for trach/PEG. Now, holding coumading in case pt\n undergoes valvuloplasty.\n - Continue metoprolol tartrate 25 mg TID\n - Continue digoxin 0.0625 mg daily\n - DC labs\n - DC IV heparin given inconsistent with goals of care\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, is ATN\n - Will attempt diuresis with bumex/metolazone, as above\n - Appreciate renal recs.\n - Continue to monitor fluid status otherwise\n # Coronary Artery Disease: Pt is s/p CABG /.\n - Continue metoprolol as above\n - Continue aspirin 81 mg daily, atorvastatin 40 mg daily\n # Respiratory Failure: Now, s/p trach.\n - Trach in place\n - Continue albuterol/atrovent PRN\n # Pressor Requirement: Pt weaned off of pressors.\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - Tylenol PRN fever\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:56 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI focus on comfort\n Disposition: CCU\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405677,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now w/respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Seizure, without status epilepticus\n Assessment:\n No change in neuro status- remains unresponsive- no movement of\n extremities noted, even to painful stimuli- PERL- responds to mouth\n care by biting down on swab.\n Action:\n Dilantin given as ordered- neuro checks q4hrs.\n Response:\n Unchanged- no seizure activity noted.\n Plan:\n Con\nt to monitor.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O trending down- (+) 32L LOS- (+) anasarca.\n Action:\n Metalazone and bumex given as ordered.\n Response:\n No increase in U/O noted.\n Plan:\n Con\nt present management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Exp wheezes/rhonchi noted upper lobes bilaterally- diminished @ the\n bases- suctioned small amt thick wht/tan colored mucous- SpO2\ns 92-97%.\n Action:\n Resp rx given as ordered- suctioned PRN.\n Response:\n Sat\ns stable.\n Plan:\n Con\nt present management.\n Aortic stenosis\n Assessment:\n Afib rate in 80\ns- SBP >100\n Action:\n Seen by CCU team- prognosis grim- heparin gtt D/C\n Response:\n Hemodynamically stable @ present.\n Plan:\n Transitioning to comfort measures.\n Impaired Skin Integrity\n Assessment:\n (+) anasarca- multiple areas of breakdown- see medavision for more\n info.\n Action:\n Repositioned q2hrs- on kinair bed- waffle boots on- coccyx dsg D&I-\n flexiseal in place and draining brown colored stool- both lower leg\n dsgs D&I- trach and peg sites intact.\n Response:\n Unchanged.\n Plan:\n Con\nt present management.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405768,
"text": "86 yr. old female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now with respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Decreased U/O.\n BUN/Creat 129/3.8\n Action:\n Cont. to receive metolazone & Bumex as ordered.\n Response:\n Pt remains grossly positive and with total body anasarca\n Plan:\n Pt DNR\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains trach\nd and vented: 50%/ TV 400/ R 18/ Peep 5\n RR 18-22/18\n O2 sat 91-98%\n BS with rhonci & diminished BS at bases. Exp. Wheezes at times.\n Action:\n Sx for small-mod. amts thick yellow sputum\n Albuterol/ventolin via vent.\n Response:\n Resp. status remains unchanged.\n Plan:\n Cont. to monitor resp status, pul toilet as needed\n Seizure, without status epilepticus\n Assessment:\n Remains unresponsive.\n PERL\n No movement & does not respond to painful stimuli.\n Bites down on swab with mouth care.\n No seizure activity noted\n Action:\n Dilantin q8hrs.\n Response:\n Neuro status remains unchanged.\n Plan:\n Cont. neuro checks q4hrs.\n Aortic stenosis\n Assessment:\n HR 79-115 AF with occ. PVC\n BP 97-115/49-55.\n Action:\n Metoprolol q8hrs.\n Response:\n Hemodynamically stable.\n Plan:\n Pt DNR\n"
},
{
"category": "General",
"chartdate": "2196-02-21 00:00:00.000",
"description": "Generic Note",
"row_id": 405186,
"text": "TITLE: CCU Attending Progress Note\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr. \n I would add the following remarks:\n History\n Pupils reactive to light; does not open eyes to deep stimulation\n currently\n Marked peripheral edema but creatinine steady in high 3s.\n Poor response to diuretics\n no incremental effect to \n Medical Decision Making\n Discontinue phenobarbital after this AM dose. We need to begin to\n assess underlying cerebral function. Currently not response.\n No acute need for dialysis but will restrict fuilds and change to oral\n diuretics\n Above discussed extensively with family members\n Total time spent on patient care: 30 minutes of critical care time.\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405187,
"text": "Chief Complaint:\n 24 Hour Events:\n Overnight Events:\n - decreased phenobarb to 15 \n - neuro recommended 800 bolus of dilantin again and to check level in\n AM\n - gave bumex with no effect on UOP\n - moved to CCU\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.1\nC (96.9\n HR: 97 (81 - 103) bpm\n BP: 123/66(87) {99/48(66) - 144/70(97)} mmHg\n RR: 26 (10 - 30) insp/min\n SpO2: 89%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 104.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 24 (8 - 24)mmHg\n Total In:\n 1,667 mL\n 365 mL\n PO:\n TF:\n 841 mL\n 226 mL\n IVF:\n 566 mL\n 139 mL\n Blood products:\n Total out:\n 1,121 mL\n 105 mL\n Urine:\n 471 mL\n 105 mL\n NG:\n Stool:\n Drains:\n Balance:\n 546 mL\n 260 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 366 (366 - 421) mL\n PS : 15 cmH2O\n RR (Spontaneous): 22\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 24 cmH2O\n SpO2: 89%\n ABG: 7.33/38/133/20/-5\n Ve: 7.7 L/min\n PaO2 / FiO2: 266\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n LUNGS: Ventilated breath sounds. Unable to hear good breath sounds at\n the bases.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Sedated. Does not respond to verbal stimuli. Minimal response to\n painful stimuli. PERRL.\n Labs / Radiology\n 462 K/uL\n 8.2 g/dL\n 126\n 3.8 mg/dL\n 20 mEq/L\n 4.7 mEq/L\n 120 mg/dL\n 102 mEq/L\n 136 mEq/L\n 26.6 %\n 7.4 K/uL\n [image002.jpg]\n 10:00 PM\n 01:52 AM\n 04:00 AM\n 04:07 AM\n 03:09 PM\n 09:07 PM\n 11:05 PM\n 03:53 AM\n 04:00 AM\n 04:12 AM\n WBC\n 6.7\n 7.4\n Hct\n 26.8\n 26.6\n Plt\n 402\n 462\n Cr\n 3.7\n 3.9\n 3.8\n TCO2\n 23\n 21\n 20\n 21\n Glucose\n 98\n 105\n 122\n 128\n 126\n 126\n Other labs: PT / PTT / INR:18.3/60.0/1.7, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:7.9 mg/dL, Mg++:2.4 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures and deteriorating mental status, aspiration\n pneumonia, now w/respiratory acidosis and failure resulting in\n intubation (), ARF, hypotension requiring phenylephrine.\n Transferred to CCU at request of family and consulting cardiologist.\n .\n # Aortic Stenosis: Pt with known severe aortic stenosis s/p\n valvuloplasty in . She was initially on the CCU service early in\n her hospitalization in the setting of flash pulmonary edema when her\n lasix were held. Now, she is intubated in the ICU. Continues to be\n severely fluid overloaded and oliguric, positive ~30L Los. She does not\n respond well to lasix/diuril/bumex but is also not a candidate for HD.\n -will try PO bumex and metolazone to try to get some diuresis\n - lytes\n -monitor volume status, UOP.\n -holding off on valvuloplasty at this point\n .\n # Atrial Fibrillation: Pt has good control of HR on beta blockade and\n digoxin. Coumadin was being held before for trach/PEG. Now, holding\n coumading in case pt undergoes valvuloplasty. Now on heparin gtt while\n INR subtherapeutic.\n - continue heparin gtt\n - continue metoprolol tartrate 25 mg TID\n - continue digoxin 0.0625 mg daily\n - trend coags\n .\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, renal\n believes that this is ATN\n - will attempt diuresis with bumex/metolazone, as above\n - appreciate renal recs.\n - continue to monitor fluid status otherwise\n .\n # Altered Mental Status: Per prior notes, pt has had seizures, loaded\n with dilantin and ativan PRN prior to admission with poor mental\n status. Despite loading dose continued to have sub clinical seziures on\n EEG. Medication regimen changed, currently on phenytoin boluses and\n phenobarbitol taper. Neuro not sure what is causing continued depressed\n mental status, states she is not having active seizures on EEG. MRI did\n not show any acute changes.\n - continue phenytoin; need to readdress dosing with neuro\n - stopping phenobarbital\n - appreciate neuro input\n .\n # Coronary Artery Disease: Pt is s/p CABG /.\n - continue metoprolol as above\n - continue aspirin 81 mg daily, atorvastatin 40 mg daily\n .\n # Respiratory Failure: Now, s/p trach.\n - trach in place\n - continue albuterol/atrovent PRN\n .\n # Pressor Requirement: Pt weaned off of pressors.\n .\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n .\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - f/u cx data\n - follow fever curve\n - f/u stool for c.diff\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 09:33 PM 35 mL/hour\n Glycemic Control: Comments: ISS\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405292,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with anasarca, oliguric. Elevated BUN/Cr, K. metabolic acidocis.\n Action:\n Monitored, BUN/Cr, pt receiving zaroxalyn, bumex.\n Response:\n Minimal response to diuretics. Remains with low u/o.\n Plan:\n Continue to monitor. Team aware of low urine output.\n Seizure, without status epilepticus\n Assessment:\n No sz activity noted this shift. Pt unresponsive to nailbed pressure\n does not withdraw. PERRL. No spontaneous movement. +corneals. Noted\n to grimace with oral care and pt refuses to open mouth.\n Action:\n Monitored, neuro assessments, dilantin as ordered. Heparin gtt on hold\n today for LP to be done this afternoon.\n Response:\n No sz activity noted. Pt appears comfortable at rest.\n Plan:\n Continue to monitor, continue neuro assess and anticonvulsants as\n ordered. Neuro on consult. Plan for reassessment of neuro status on\n wed\n family meeting regarding plan of care wed.\n Aortic stenosis\n Assessment:\n Pt in a fib with rare PVC noted. Sbp 90\ns-130. tolerating lopressor\n dose. Poor response to diuretics. Continues on heparin gtt. Remains\n vented on AC today. Low 90% sats. Sx tan secretions.\n Action:\n Heparin gtt on hold this afternoon\n awaiting LP by neuro.\n Response:\n Stable hemodynamics.\n Plan:\n Continue to monitor, restart Heparin gtt this evening after LP MD\n orders. Recheck PTT 6hrs post restart of hep gtt. Plan for\n ?valvulopoasty if neuro status improves.\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 405300,
"text": "Demographics\n Day of intubation: 16\n Day of mechanical ventilation: 16\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments: Pt data as\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 405301,
"text": "Demographics\n Day of intubation: 16\n Day of mechanical ventilation: 16\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments: Pt data as above/ per Meta-V. Pt changed to the AC mode last\n night due to worsening oxygenation ( oxygen desaturation to 90 % ) and\n worsening metabolic acidosis.\n RSBI\ns have been > 100 ( yesterday was 118 ). Being suctioned for thick\n tan secretions.\n Pt also very fluid volume overloaded. Will c/w the AC mode 400/14/.50/5\n PEEP as tolerated while medical issues are treated.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405684,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now w/respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Seizure, without status epilepticus\n Assessment:\n No change in neuro status- remains unresponsive- no movement of\n extremities noted, even to painful stimuli- PERL- responds to mouth\n care by biting down on swab.\n Action:\n Dilantin given as ordered- neuro checks q4hrs.\n Response:\n Unchanged- no seizure activity noted.\n Plan:\n Con\nt to monitor.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O trending down- (+) 32L LOS- (+) anasarca.\n Action:\n Metalazone and bumex given as ordered- beneprotein D/C\nd from TF\n (novasource renal).\n Response:\n No increase in U/O noted.\n Plan:\n Con\nt present management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Exp wheezes/rhonchi noted upper lobes bilaterally- diminished @ the\n bases- suctioned small amt thick wht/tan colored mucous- SpO2\ns 92-97%.\n Action:\n Resp rx given as ordered- suctioned PRN.\n Response:\n Sat\ns stable.\n Plan:\n Con\nt present management.\n Aortic stenosis\n Assessment:\n Afib rate in 80\ns- SBP >100\n Action:\n Seen by CCU team- prognosis grim- heparin gtt D/C\n Response:\n Hemodynamically stable @ present.\n Plan:\n Transitioning to comfort measures.\n Impaired Skin Integrity\n Assessment:\n (+) anasarca- multiple areas of breakdown- see medavision for more\n info.\n Action:\n Repositioned q2hrs- on kinair bed- waffle boots on- coccyx dsg D&I-\n flexiseal in place and draining brown colored stool- both lower leg\n dsgs D&I- trach and peg sites intact.\n Response:\n Unchanged.\n Plan:\n Con\nt present management.\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 405685,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 20\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing, Gasping\n efforts; Comments: No ventilatory support.\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405848,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt remains near anuric, wt continues to rise daily, pt with total body\n anasarca. Increased RR and effort\n Action:\n Unable to give po meds as pt vomiting this am, TF placed on hold.\n Response:\n No further vomiting remainder of day.\n Plan:\n Ineffective Coping\n Assessment:\n Pt family in and updated re: pt\ns deteriorating condition and multi\n system failure.\n Action:\n Informed family of administration of morphine for increased respiratory\n effort, indications of pain ie. Change in VS.\n Response:\n Family understands pt condition is deteriorating, husband sees pt open\n eyes to his vice and cont to hold hope. Daughter seems to be attempting\n to direct her father to pt\ns multiple medical problems. Family\n appreciate treating pt\ns discomfort with morphine.\n Plan:\n Pt remains DNR, no therapies to be added. Approach family with\n consideration of withdrawing care over next few days if pt cont to show\n signs of deterioration. Cont to support and inform family.\n"
},
{
"category": "Nutrition",
"chartdate": "2196-02-22 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 405289,
"text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 80.1 kg\n 103.5 kg ( 04:00 AM)\n 28.4\n Pertinent medications: Famotidine, Phenytoin Sodium, RISS, others noted\n Labs:\n Value\n Date\n Glucose\n 137 mg/dL\n 04:44 AM\n Glucose Finger Stick\n 143\n 12:00 PM\n BUN\n 123 mg/dL\n 04:44 AM\n Creatinine\n 3.7 mg/dL\n 04:44 AM\n Sodium\n 137 mEq/L\n 04:44 AM\n Potassium\n 4.8 mEq/L\n 04:44 AM\n Chloride\n 103 mEq/L\n 04:44 AM\n TCO2\n 18 mEq/L\n 04:44 AM\n PO2 (arterial)\n 102 mm Hg\n 05:08 AM\n PCO2 (arterial)\n 38 mm Hg\n 05:08 AM\n pH (arterial)\n 7.32 units\n 05:08 AM\n pH (urine)\n 5.0 units\n 05:33 PM\n CO2 (Calc) arterial\n 20 mEq/L\n 05:08 AM\n Albumin\n 2.7 g/dL\n 06:39 PM\n Calcium non-ionized\n 8.0 mg/dL\n 04:44 AM\n Phosphorus\n 5.1 mg/dL\n 04:44 AM\n Ionized Calcium\n 1.08 mmol/L\n 11:27 PM\n Magnesium\n 2.2 mg/dL\n 04:44 AM\n ALT\n 5 IU/L\n 03:33 AM\n Alkaline Phosphate\n 60 IU/L\n 03:33 AM\n AST\n 28 IU/L\n 03:33 AM\n Total Bilirubin\n 0.2 mg/dL\n 03:33 AM\n Triglyceride\n 98 mg/dL\n 04:27 AM\n Phenytoin (Free)\n 1.9 ug/mL\n 04:39 PM\n Phenytoin (Dilantin)\n 4.2 ug/mL\n 04:44 AM\n WBC\n 7.0 K/uL\n 04:44 AM\n Hgb\n 7.6 g/dL\n 04:44 AM\n Hematocrit\n 24.7 %\n 04:44 AM\n Current diet order / nutrition support: Nutren 2.0 Full strength;\n Additives: Beneprotein, 21 gm/day\n Starting rate: 15 ml/hr; Advance rate by 10 ml q6h Goal rate: 35 ml/hr\n Residual Check: q4h Hold feeding for residual >= : 200 ml\n Flush w/ 50 ml water q6h\n GI: ABDOMEN: Obese, soft, NBS\n Assessment of Nutritional Status\n 86 year old female admitted earlier this month with seizures, hospital\n course complicated by aspiration, Afib, respiratory failure, patient\n s/p PEG/trach placement on , transferred to CCU for cardiology\n consult. Patient on tube feed via PEG, tolerating without issue,\n however noted Bun/Cr rising with no plan of HD at this time, spoke to\n MD to change to renal formula. Noted patient is oliguric, positive ~30\n L since LOS, patient on bumex and metolazon P.R.N.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding: change to Novasource Renal goal 35ml/hr to\n provide 1680kcal/62g protein, monitor tolerance\n Check chemistry 10 panel\n If start on HD, will adjust tube feed per renal lytes\n Continue BS management\n Other: \n 04:35 PM\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404123,
"text": "Seizure, without status epilepticus\n Assessment:\n Not opeining eyes, pupils equal in size (3-4mm) and reactivity (brisk).\n Not moving upper extremities to painful stimuli.\n Small spontaneous movement of rt foot, moves left foot to painful\n stimuli.\\\n Cont on NEO gtt to maintain MAP >60.\n Remains ventilated on CMV.\n Minimal urine output.\n Action:\n Continued regimen of Phenobarbital , keppra and dilantin.\n Antibiotics to be d/c\nd tomorrow.\n Continuous EEG monitoring.\n Response:\n Neuro exam flat.\n U/O remains scant.\n MAP maintained > 60.\n Plan:\n Cont EEG monitoring.\n Monitor hemodynamics.\n Monitor renal status.\n Continue update, educate and support pt\ns family.\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-09 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404125,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n :\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n :\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404200,
"text": "Seizure w/ status epilepticus\n Assessment:\n Pt unarouseable w/ eyes closed, pupils 3-4mm equal/brickly\n reactive\n MAE to nailbed pressure. Grimacing noticed and moving of\n head. Occassional spontaneous movement of right foot\n Intubated on CMV w/o sedation\n Cont EEG. No seizures noted. Evening Dilantin level 8.2\n Phenylephrine gtt titrated to goal of SBP >100 MAP >60\n Tele in A-fib w/ occasional PVCs. Systolic murmur\n loud/audible\n Received 2uPRBC on day shift to assist w/ preload and HCT\n bumped accordingly\n u/o . SICU made aware. Evening lytes wnl and Cr 2.2.\n Received home dose of Lasix on day shift\n Right nare dobhoff w/ Nutren 2.0 Full w/ Benepro @35cc/hr\n Generalized edema noted\n Blood cx pending last pan cx . PICC d/c\nd and tip\n sent for cx. RIJ oozing team aware on Coumadin\n Action:\n Neuro checks Q2hrs\n Dilantin 500mg IV given to assist w/ goal of 15-20\n EEG reviewed my N-med overnoc\n Completed IVABX for Asp PNA.\n Response:\n Neuro checks w/o change\n Unable to wean Neo gtt requires 0.5-0.6mcg/kg/min\n Dilantin level\n Plan:\n Neuro checks Q2hrs, EEG, ? MRI once off EEG\n Wean Neo as tolerated\n CXR pending\n Reassess code status/plan of care (Trach/PEG) on Friday\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404182,
"text": "Seizure, without status epilepticus\n Assessment:\n Pt with eyes closed, pupils 3-4mm bilaterally, briskly\n reactive to light.\n Withdraws arms L>R to nailbed pressure, moves feet to\n nailbed pressure, very rare spontaneous movement of R foot and\n shoulders observed. No perceptible gag, weak cough.\n Cont EEG in place- no seizure activity observed, cont\n phenobarbitol/keppra/dilantin\n AM dilantin level 8-> albumin corrected for 12.5, phenobarb\n level 16.9\n Phenylephrine to maintain SBP> 100, MAP >60\n Loud systolic murmur, rhythm remains AFib\n AM H/H decreased\n UO 10-20mL/2hrs, SICU and primary teams aware\n Tmax 100.6F this shift\n TF at goal\n Action:\n Dilantin bolus given to maintain level 15-20\n Bedside TTE by cardiology\n 2 Units PRBC given to improve preload, H/H\n Standing dose lasix given per Dr. despite rising\n BUN/Crt\n LIJ central line placed, xray completed and reviewed\n Family met with NMED and SICU attending re: plan of care\n Response:\n Neuro exam remains as above.\n Weaning neo slowly\n UO remains scant\n Plan:\n Continue Q2hr neuro exams, continuous EEG monitoring\n Recheck dilantin level, CBC, Chems at 1900\n Wean neo as tolerated for SBP>100, MAP> 60\n Consider milrinone per rounds for improved CO\n D/C PICC, send tip for culture-> done by IV team\n Reassess code status, plan of care on Friday with family,\n esp RE: PEG/Trach\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404198,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated, Reduce\n PEEP as tolerated, Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Cannot protect airway, Cannot manage\n secretions; Comments: Pt remain stable on current vent settings, No\n acute resp issues this shift. Pt was suctioned for minimal. During\n RSBI trail, pt stimulated 2 spontaneous breaths, but then became apneic\n for 10 seconds. Pt vital signs stable, no sedation on board. Pt to\n continue current support and will be assessed by MD team.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405896,
"text": "86 yr. old female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now with respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Seizure, without status epilepticus\n Assessment:\n Pt s/p long course of care in SICU/CCU remains minimal responsiveness-\n opening eyes to pain, withdrawing only. No seizure activity observed.\n Action:\n Close assessment of neuro status this shift- remains on dilantin tid as\n ordered. MSO4 x 2 doses for comfort per grimace scale\n Response:\n Pt s/p long course of illness currently w minimal responsiveness, near\n agonal breathing pattern at end of life.\n Plan:\n Comfort w MS, dilantin IV to prevent seizures. Continue to support\n family, keep informed. No escalation of care.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on ventilatory support currently on vent settings 50%-400-18. Tidal\n volumes up to 500-640\ns observed. Agonal breathing pattern .\n Maintaining airway w trach. Minimal secretions currently.\n Action:\n Maintaining pt on vent support. No changes to vent settings. Minimal\n secretions suctioned. Diminished breath sounds throughout.\n Response:\n Pt near end of life- currently maintained on vent support- no changes\n to settings. Appears to have continuation of agonal breathing pattern.\n Plan:\n Continue to maintain , keep airway patent. Continue to support family ,\n keep pt comfortable.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405899,
"text": "86 yr. old female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now with respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Seizure, without status epilepticus\n Assessment:\n Pt s/p long course of care in SICU/CCU remains minimal responsiveness-\n opening eyes to pain, withdrawing only. No seizure activity observed.\n Action:\n Close assessment of neuro status this shift- remains on dilantin tid as\n ordered. MSO4 x 2 doses for comfort per grimace scale\n Response:\n Pt s/p long course of illness currently w minimal responsiveness, near\n agonal breathing pattern at end of life.\n Plan:\n Comfort w MS, dilantin IV to prevent seizures. Continue to support\n family, keep informed. No escalation of care.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on ventilatory support currently on vent settings 50%-400-18. Tidal\n volumes up to 500-640\ns observed. Agonal breathing pattern .\n Maintaining airway w trach. Minimal secretions currently.\n Action:\n Maintaining pt on vent support. No changes to vent settings. Minimal\n secretions suctioned. Diminished breath sounds throughout.\n Response:\n Pt near end of life- currently maintained on vent support- no changes\n to settings. Appears to have continuation of agonal breathing pattern.\n Plan:\n Continue to maintain , keep airway patent. Continue to support family ,\n keep pt comfortable.\n ------ Protected Section ------\n Addendum:- Pt found to have BP acutely dropping to less than 70/ by\n 5am. Quickly dropping to 60/\ns then 40\n/s systolically - with O2 sats\n dropping to mid 60\ns. Called HO- status- DNR and to have no escalation\n in care but gave pt 500cc NS bolus while calling family and CCU\n attending. Pt expired 5:28AM. Family called and coming in, currently\n awaiting arrival. Pt pronounced expired 5:28AM by CCU HO.\n ------ Protected Section Addendum Entered By: , RN\n on: 05:35 ------\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404366,
"text": "Seizure, without status epilepticus\n Assessment:\n No evidence of seizure activity on EEG exam today. She has been\n minimally responsive today, withdrawing to noxious stimuli with upper\n extremities. She does not open her eyes to stimulation. Her renal\n failure is worsening with increased oliguria and serum Creat of 2.5.\n Action:\n She was given 50 grams of 25% albumin this morning to support\n oliguria. Supportive care continues to be provided.\n Response:\n She has not responded to albumin, remaining oliguric this afternoon.\n Renal consult has been made.\n Plan:\n Plan to continue to provide supportive care.\n Plan to place trach and PEG on Monday. Coumadin has been held this\n evening. Will continue to trend coags, and will consider bridge with\n heparin over the weekend.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404199,
"text": "Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Pt with eyes closed, pupils 3-4mm bilaterally, briskly\n reactive to light.\n Withdraws arms L>R to nailbed pressure, moves feet to\n nailbed pressure, very rare spontaneous movement of R foot and\n shoulders observed. No perceptible gag, weak cough.\n Cont EEG in place- no seizure activity observed, cont\n phenobarbitol/keppra/dilantin\n AM dilantin level 8-> albumin corrected for 12.5, phenobarb\n level 16.9\n Phenylephrine to maintain SBP> 100, MAP >60\n Loud systolic murmur, rhythm remains AFib\n AM H/H decreased\n UO 10-20mL/2hrs, SICU and primary teams aware\n Tmax 100.6F this shift\n TF at goal\n Action:\n Dilantin bolus given to maintain level 15-20\n Bedside TTE by cardiology\n 2 Units PRBC given to improve preload, H/H\n Standing dose lasix given per Dr. despite rising\n BUN/Crt\n LIJ central line placed, xray completed and reviewed\n Family met with NMED and SICU attending re: plan of care\n Response:\n Neuro exam remains as above.\n Weaning neo slowly\n UO remains scant\n Plan:\n Continue Q2hr neuro exams, continuous EEG monitoring\n Recheck dilantin level, CBC, Chems at 1900\n Wean neo as tolerated for SBP>100, MAP> 60\n Consider milrinone per rounds for improved CO\n D/C PICC, send tip for culture-> done by IV team\n Reassess code status, plan of care on Friday with family,\n esp RE: PEG/Trach\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-11 00:00:00.000",
"description": "Intensivist Note",
"row_id": 404299,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. At time of SICU admission, she\n responded only to painful stimuli.\n Chief complaint:\n Seizures\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n 1. 2. 3. 4. 5. Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Albuterol\n Inhaler 8. Aspirin 9. Atorvastatin 10. Bacitracin-Polymyxin Ointment\n 11. Calcium Gluconate 12. Chlorhexidine Gluconate 0.12% Oral Rinse 13.\n Collagenase Ointment 14. Dextrose 50% 15. Digoxin 16. Famotidine 17.\n Fentanyl Citrate 18. FoLIC Acid 19. Furosemide 20. Gabapentin 21.\n Glucagon 22. 23. Insulin 24. Ipratropium Bromide MDI 25. Ipratropium\n Bromide Neb 26. Latanoprost 0.005% Ophth. Soln. 27. Levothyroxine\n Sodium 28. LeVETiracetam 29. Lidocaine 5% Patch 30. Lorazepam 31.\n Magnesium Sulfate 32. Metoprolol Tartrate 33. Miconazole Powder 2% 34.\n Nystatin Oral Suspension 35. PHENObarbital 36. PHENObarbital 37.\n Phenytoin Sodium (IV) 38. Phenylephrine 39. Potassium Chloride\n 40. Sodium Chloride 0.9% Flush 41. Sodium Chloride 0.9% Flush 42.\n Sodium Chloride 0.9% Flush 43. Timolol Maleate 0.5%\n 44. Warfarin\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:09 AM\n MULTI LUMEN - START 01:49 PM\n WOUND CULTURE - At 05:30 PM\n PICC tip\n PICC LINE - STOP 05:42 PM\n coumadin 2mg. Fe urea, u/a. increased phenylephrine, UA positive\n Foley changed , Phenobarb bolus 200mg IV x1 given, no evidence of\n seizure\n .\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Cefipime - 10:00 PM\n Vancomycin - 08:23 PM\n Ciprofloxacin - 12:02 AM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Dilantin - 10:30 AM\n Famotidine (Pepcid) - 08:30 PM\n Other medications:\n Flowsheet Data as of 03:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.5\n T current: 37.9\nC (100.2\n HR: 83 (77 - 90) bpm\n BP: 117/50(73) {96/41(60) - 143/65(89)} mmHg\n RR: 20 (12 - 21) insp/min\n SPO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 95.2 kg (admission): 80.1 kg\n Height: 66 Inch\n Total In:\n 1,765 mL\n 222 mL\n PO:\n Tube feeding:\n 840 mL\n 122 mL\n IV Fluid:\n 715 mL\n 100 mL\n Blood products:\n Total out:\n 581 mL\n 244 mL\n Urine:\n 156 mL\n 44 mL\n NG:\n Stool:\n 300 mL\n 200 mL\n Drains:\n Balance:\n 1,184 mL\n -22 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 23 cmH2O\n Plateau: 22 cmH2O\n Compliance: 32.1 cmH2O/mL\n SPO2: 98%\n ABG: ////\n Ve: 7.7 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Breath Sounds: Crackles : bilateral, Rhonchorous\n : bilateral)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: Chemically paralyzed\n Labs / Radiology\n 368 K/uL\n 9.2 g/dL\n 107 mg/dL\n 2.2 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 59 mg/dL\n 106 mEq/L\n 138 mEq/L\n 30.4 %\n 10.4 K/uL\n [image002.jpg]\n 04:35 PM\n 06:36 PM\n 03:33 AM\n 09:41 AM\n 04:39 PM\n 04:06 AM\n 06:15 PM\n 02:54 AM\n 03:18 AM\n 02:38 AM\n WBC\n 11.3\n 10.4\n 9.7\n 9.7\n 10.4\n Hct\n 26.9\n 25.8\n 30.1\n 29.7\n 30.4\n Plt\n 81\n 368\n Creatinine\n 1.7\n 2.0\n 2.1\n 2.2\n 2.2\n TCO2\n 29\n 30\n 30\n 22\n Glucose\n 122\n 116\n 121\n 107\n Other labs: PT / PTT / INR:33.5/35.4/3.4, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:60/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca:7.6 mg/dL, Mg:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n KNOWLEDGE DEFICIT, IMPAIRED SKIN INTEGRITY, PNEUMONIA, ASPIRATION,\n AORTIC STENOSIS, SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension requiring\n phenylephrine.\n Neurologic:\n -- Patient sedated with fentanyl prn.\n -- Patient with seizures, loaded with dilantin and ativan PRN prior to\n admission with poor mental status. Despite loading dose continued to\n have sub clinical seziures on EEG. Medication regimen changed,\n currently on phenytoin (Goal 15-20), Keppra and now phenobarbitol.\n --MRI brain w/ and w/o ordered for when pt is stable to transport to\n evaluate to source of bleed in parietal lobe.\n --Continue neurontin for chronic pain well controlled on current\n medication.\n --Delayed Withdraws to pain in all extremities\n -- F/U Am pehnobarb and dilantin levels\n Cardiovascular:\n -- PAF with good control of HR on beta blockade and digoxin.\n Anticoagulation started with coumadin. No heparin bridge for risk of\n rebleed. On ASA\n -- CAD s/p CABG , diastolic dysfunction. On b-blockade,\n furosemide, ASA, and statin.\n -- Critical AS (valve area pre-valvuloplasty 0.8cm2, post\n vavluloplasty). On ICU-based ECHO estimated area is 0.6cm2. Likely not\n eligible for open valve replacement. Family is discussing this issue\n with another cardiologist.\n -- Pt still requires neosynephrine for MAPs > 65\n -- tx 2u prbcs with Hct 25.8 on \n Pulmonary:\n --Treated empirically for HAP with Vanc/Cefepime, cultures negative,\n finished 7 day course \n --albuterol/atrovent PRN\n Gastrointestinal / Abdomen:\n --TFs at goal, consider PEG tube placement in future if clinical\n picture warrants\n Nutrition:\n --TF continued\n Renal:\n -- On home dose of Lasix\n -- Diminished urine output, received albumin x2 overnight, Creatinine\n increasing 1.5-1.7->2.1.-->2.2 Fe urea 14.5\n -- Cipro for UTI, started . cultures p, last dose 3/16, Redo UA c/w\n Bact no need for Antibiotics now f/up Cx\n Hematology:\n --Hct slowly decreasing, 25.8--> tx 2u prbcs on ->29.7-->30.4\n ()\n --ASA, coumadin (2/5/5/3/2) Hold coumadin today INR level 3.4\n - A. Fib anticoagulation with coumadin, INR 3.4 (goal )\n Endocrine:\n --RISS, Hgb A1C 5.9\n --Synthroid 75 mcg for hypothyroidism, previous TSH was 6.8\n ID:\n --Wbc 9.4-->10.4\n --Treated for PNA with cefepime/vanc (?aspiration) total course should\n be 7 days (ending ).\n --UA positive foley changed patient received 3 days cours of\n antibiotics last dose 03/16\n --Follow cultures\n T/L/D: PIV, Foley, CVL ()\n Wounds: none\n Imaging: CXR\n Fluids: KVO\n Consults:\n Billing Diagnosis: status epilepticus, respiratory failure\n Prophylaxis:\n DVT: ASA, coumadin\n Stress ulcer: H2B\n VAP bundle: +\n Comments:\n Communication: ICU consent done\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404364,
"text": "Demographics\n Day of intubation: 5\n Day of mechanical ventilation: 5\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location: OR\n Reason: Elective\n Tube Type\n ETT:\n Position: 18 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt had NO changes today\n, RRT 15:37\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404459,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat.. 2.7 with elevated Bun\ns <10cc/h\n Action:\n Seen by renal\nwill hold Lasix for now\n Response:\n No plans for Dialysis or CVVH\n Plan:\n Will watch for now per Renal..Dc Lasix\n Seizure, without status epilepticus\n Assessment:\n Neuro with response to noxious stimuli only..slight withdrawal of arms\n & feet & at times no response\n Pupils small equal & react to light\n Impaired gag reflex..good cough\n Neo gtt increased to 1.5mgm to keep sbp >120/\n Dilantin level low @ 5.1\n Action:\n Remains on continuous EEG\n Dilantin bolus 400mgm given\n Response:\n Per Neuro sm spikes noted on EEG\n Plan:\n Continue neuro checks Q2H ..Dilantin level in am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on CMV R 18 TV 450 Fio2 50% Peep 8\n Action:\n Fio2 down to 40% with good ABG\nS Peep down to 5cm..with sat\n >90%...suctioned for sm amt thick yellow sputum\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404464,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat.. 2.7 with elevated Bun\ns <10cc/h\n Action:\n Seen by renal\nwill hold Lasix for now\n Response:\n No plans for Dialysis or CVVH\n Plan:\n Will watch for now per Renal..Dc Lasix\n Seizure, without status epilepticus\n Assessment:\n Neuro with response to noxious stimuli only..slight withdrawal of arms\n & feet & at times no response\n Pupils small equal & react to light\n Impaired gag reflex..good cough\n Neo gtt increased to 1.5mgm to keep sbp >120/\n Dilantin level low @ 5.1\n Action:\n Remains on continuous EEG\n Dilantin bolus 400mgm given\n Response:\n Per Neuro sm spikes noted on EEG\n Plan:\n Continue neuro checks Q2H ..Dilantin level in am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on CMV R 18 TV 450 Fio2 50% Peep 8\n Action:\n Fio2 down to 40% with good ABG\nS Peep down to 5cm..with sat\n >90%...suctioned for sm amt thick yellow sputum\n Response:\n Sat\ns remain good on decreased fio2 & peep\n Plan:\n Continue to wean as tol..? trach & peg on Monday per family wishes\n Ineffective Coping\nFAMILY\n Assessment:\n Family meeting with husband /son\nNeuro Resident & Epilepsy Fellow\n which lasted almost 1h..Family with many questions but \nt seem to\n grasp seriousness of situation..Also spoke with SICU Fellow\n Action:\n Spoke to family about poor prognosis for pt\ndeclining renal status as\n well as neuro status\n Response:\n Family wishes to continue with full care\n.Trach & peg..\n Son especially doesn\nt wish to stop treatment & Husband appears to\n be just doing what son wants\n Wants to wait a week or so after trach to see how things are\n Plan:\n Plan another family meeting prior to trach\nGet social work & possibly\n Ethics involved..plan for Chronic Care Facility if no further seizures\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404300,
"text": "Seizure\n Assessment:\n Pt unarouseable w/ eyes closed, pupils 3-4mm equal/brickly\n reactive\n MAE to nailbed pressure. UE\ns respond less than LE. Response\n is delayed. Grimacing noticed and moving of head. Occassional\n spontaneous movement of right foot\n Intubated on CMV w/o sedation\n Cont EEG. No seizures noted. Kepra/Dilantin/Phenobarb for\n seizure prophylaxis. Goal Dilantin level corrected w/ albumin 15-20 or\n w/o correction.\n Morning Dilantin level 8.4 Phenobarb 18.1\n Phenylephrine gtt titrated to goal of SBP >120 MAP >65.\n Parameters increased to help w/ prerenal perfusion and to see if u/o\n would increase\n Tele in A-fib w/ occasional PVCs. Systolic murmur\n loud/audible. Continues on Coumadin/Digoxin/Metoprolol. Received2mg\n Coumadin on day shift . Goal INR \n Received 2uPRBC on day shift to assist w/ preload and HCT\n bumped accordingly\n u/o . SICU aware no change over 24hrs. No lytes drawn\n last eve per SICU. Received home dose of Lasix on day shift\n Right nare dobhoff w/ Nutren 2.0 Full w/ Benepro @35cc/hr\n Generalized edema noted\n Blood cx pending last pan cx . PICC d/c\nd and tip\n sent for cx. Completed IVABX for asp PNA/UTI on . Foley switched\n out by day staff\n Action:\n Neuro checks Q2hrs\n Phenobarb 200mg IV bolus x1\n Low grade temps 99.9-100.5. Per SICU Cx if >100.5\n EEG w/ subclinical seizures per Neuromed notes\n BLE stasis ulcer dressings change per wound care\n recommendations\n Response:\n Neuro checks w/o change\n Neo gtt 0.9-1.1mcg/kg/min\n Plan:\n Neuro checks Q2hrs, EEG, ? MRI in future\n CXR\n Reassess code status/plan of care (Trach/PEG) on Friday\n SW to consult to assist son/husband w/ coping\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 405414,
"text": "Demographics\n Day of mechanical ventilation: 17\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: dysynchronous at times\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Social Work",
"chartdate": "2196-02-24 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 405491,
"text": "SOCIAL WORK: Pt referred to SW in POE to support family coping as pt\n has end stage heart disease, currently on CCU. Per medical record and\n discussion with team, pt has been in a comatose state, responding only\n minimally to external stimuli. Case discussed with nursing staff and\n from Pastoral Care earlier in the week. Family known to\n this SW from previous admissions. SW had been unable to meet with\n family this admission because they have visited only briefly over the\n past couple of days. SW participated with Dr and CCU team in\n family meeting with pt\ns husband, , and son. Options re: goals\n of care discussed, including DNR. Son initially states that he and his\n sister believe pt would not want to be resuscitated under the\n circumstances. During meeting husband spoke to pt, and she turned her\n head toward his voice, opened her eyes, and smiled on command.\n Husband and son asked questions about pt\ns mental status. Husb\n suggested team consider changes in her medications to see if they are\n causing altered mental status, noting\nm grabbing at straws.\n Husb\n expressed hope that with time pt\ns mental status may improve some. SW\n noted the delicate balance of continuing with life sustaining treatment\n and preventing pt suffering. SW advised family re: providing\n comforting presence to pt at bedside. Family not planning to stay long\n with pt today.\n A&P: Family understanding gravity of pt\ns illness, using bargaining;\nwhat if we try\n to postpone loss/ grief. SW will follow with team to\n support family in processing feelings and coping with anticipatory\n loss.\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404457,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat.. 2.7 with elevated Bun\ns <10cc/h\n Action:\n Seen by renal\nwill hold Lasix for now\n Response:\n No plans for Dialysis or CVVH\n Plan:\n Will watch for now per Renal..Dc Lasix\n Seizure, without status epilepticus\n Assessment:\n Neuro with response to noxious stimuli only..slight withdrawal of arms\n & feet & at times no response\n Pupils small equal & react to light\n Impaired gag reflex..good cough\n Action:\n Remains on continues EEG\n Response:\n Per Neuro sm spikes noted\n Plan:\n Continue neuro checks Q2H\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on CMV R 18 TV 450\n Action:\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404458,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat.. 2.7 with elevated Bun\ns <10cc/h\n Action:\n Seen by renal\nwill hold Lasix for now\n Response:\n No plans for Dialysis or CVVH\n Plan:\n Will watch for now per Renal..Dc Lasix\n Seizure, without status epilepticus\n Assessment:\n Neuro with response to noxious stimuli only..slight withdrawal of arms\n & feet & at times no response\n Pupils small equal & react to light\n Impaired gag reflex..good cough\n Neo gtt increased to 1.5mgm to keep sbp >120/\n Dilantin level low\n Action:\n Remains on continuous EEG\n Response:\n Per Neuro sm spikes noted\n Plan:\n Continue neuro checks Q2H\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on CMV R 18 TV 450 Fio2 50% Peep 8\n Action:\n Fio2 down to 40% with good ABG\nS Peep down to 5cm..with sat\n >90%...suctioned for sm amt thick yellow sputum\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404463,
"text": "Demographics\n Day of intubation: 6\n Day of mechanical ventilation: 6\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Elective\n Tube Type\n ETT:\n Position: 18 cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min),\n Active exhalations\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Today we changed the ,Fio2 to 40% and peep down to 5cms but remains on\n CMV.\n, RRT 15:43\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405411,
"text": "86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma (resection done\n ),all cancer removed, clean margins and neg lymph nodes per family,\n c.diff after abd in ., then to Rehab where she had new\n onset tonic clonic seizures, adm to , where she cont to have seizures\n and was initially treated with Keppra and Ativan. MRI of head showed sm\n cortical vein bleed on adm. Flashed on the floor in the setting of\n holding lasix. Course complicated by subclinical seizures and\n deteriorating mental status, aspiration pneumonia, now w/respiratory\n acidosis and failure resulting in intubation (), ARF, previous\n hypotension requiring phenylephrine, off pressors x several days.\n Transferred to CCU at request of family and consulting cardiologist on\n .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urinary output remains low-> 10-15cc/hr- BUN 124 Crea 3.8- worsening\n metabolic acidosis- (+) anasarca- weight trending up (107.1 kg)\n Action:\n Metolazone and bumex given as ordered.\n Response:\n No increase in U/O.\n Plan:\n Con\nt to follow labs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n CMV 400x14 50% P5 via trach\n Action:\n ABG 7.27-41-119-20 98%- suctioned scant-small amt thick tan colored\n mucous- resp rx given as ordered\n Response:\n Worsening metabolic acidosis.\n Plan:\n Con\nt vent support- maintain VAP protocol.\n Seizure, without status epilepticus\n Assessment:\n Remains unresponsive- no spontaneous movement noted-\n Action:\n Response:\n No seizure activity noted- neuro status unchanged.\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 405466,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine ouput continues low 10 -20 cc/hr. bun 124/creatinine 3.8.total\n body anarsaca\n Action:\n Patient receiving bumex and metalazone qd( to be given\n before\n morning bumex dose\n Response:\n No change. Low urines continue\n Plan:\n Monitor uo and bun and creatinine\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bilateral rhonci diminished at bases. O2 sats 94-96 %\n Action:\n Suctioned q 3-4 hours for small to moderate amount off white thick\n sputum, albuterol ih atc q 6 hours\n Response:\n Sats maintained 94-96 %\n Plan:\n Continue on 50 % cmv/400/18.\n Aortic stenosis\n Assessment:\n Pt in afib 87-92 no pvc\ns. bp stable 104/51-119/55\n Action:\n Heparin dose infusing at 1350 units/hr\n Response:\n Ptt=76.4\n Plan:\n Continue heparin at 1350 units\n Neuro status unchanged. Pupils equal and reactive. Pt does not open her\n eyes to command or spontaneously. No spontaneous movement. Pt does with\n draw each one of her extremities (ever so slightly) to deep nail bed\n pressure. Possible family meeting today, no time scheduled for family\n meeting at this time. pt received last dose of Phenobarbital on \n evening and pt neuro status has not improved.\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405554,
"text": "Chief Complaint: Critical AS\n 24 Hour Events:\n \n -Pt family wants one more day of full code since she smiled at\n patient's husband.\n - Family meeting planned again for Thursday with Dr. to\n reassess goals\n - No escalation of care\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsPenicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,350 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:46 PM\n Dilantin - 04:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.7\nC (98\n HR: 92 (87 - 101) bpm\n BP: 112/50(73) {87/45(61) - 131/62(88)} mmHg\n RR: 15 (8 - 25) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 107.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 16 (14 - 21)mmHg\n Total In:\n 1,710 mL\n 385 mL\n PO:\n TF:\n 842 mL\n 220 mL\n IVF:\n 618 mL\n 165 mL\n Blood products:\n Total out:\n 356 mL\n 144 mL\n Urine:\n 356 mL\n 144 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,354 mL\n 241 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 410 (410 - 410) mL\n RR (Set): 18\n RR (Spontaneous): 2\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 54\n PIP: 20 cmH2O\n Plateau: 25 cmH2O\n Compliance: 36.4 cmH2O/mL\n SpO2: 97%\n ABG: 7.27/41/118/17/-7\n Ve: 8.5 L/min\n PaO2 / FiO2: 236\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 387 K/uL\n 7.6 g/dL\n 125 mg/dL\n 3.8 mg/dL\n 17 mEq/L\n 4.7 mEq/L\n 129 mg/dL\n 102 mEq/L\n 134 mEq/L\n 24.8 %\n 8.5 K/uL\n [image002.jpg]\n 05:08 AM\n 09:16 PM\n 04:32 AM\n 08:40 AM\n 06:02 PM\n 04:16 AM\n 01:22 PM\n 05:00 PM\n 04:05 AM\n 04:23 AM\n WBC\n 7.1\n 7.6\n 8.5\n Hct\n 25.5\n 25.4\n 24.8\n Plt\n 381\n 357\n 387\n Cr\n 3.7\n 3.8\n 3.8\n 3.8\n TCO2\n 20\n 20\n 21\n 21\n 20\n 20\n Glucose\n 127\n 122\n 119\n 124\n 125\n Other labs: PT / PTT / INR:13.2/64.3/1.1, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:5.5 mg/dL\n Imaging: No new\n Microbiology: STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B\n TEST-FINAL INPATIENT\n STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL\n INPATIENT\n BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT\n URINE URINE CULTURE-FINAL {YEAST} INPATIENT\n BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT\n URINE URINE CULTURE-FINAL {YEAST} INPATIENT\n CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT\n STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL\n INPATIENT\n URINE URINE CULTURE-FINAL {YEAST} INPATIENT\n BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT\n BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT\n ECG: No new\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405555,
"text": "Chief Complaint: Critical AS\n 24 Hour Events:\n \n -Pt family wants one more day of full code since she smiled at\n patient's husband.\n - Family meeting planned again for Thursday with Dr. to\n reassess goals\n - No escalation of care\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsPenicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,350 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:46 PM\n Dilantin - 04:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.7\nC (98\n HR: 92 (87 - 101) bpm\n BP: 112/50(73) {87/45(61) - 131/62(88)} mmHg\n RR: 15 (8 - 25) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 107.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 16 (14 - 21)mmHg\n Total In:\n 1,710 mL\n 385 mL\n PO:\n TF:\n 842 mL\n 220 mL\n IVF:\n 618 mL\n 165 mL\n Blood products:\n Total out:\n 356 mL\n 144 mL\n Urine:\n 356 mL\n 144 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,354 mL\n 241 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 410 (410 - 410) mL\n RR (Set): 18\n RR (Spontaneous): 2\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 54\n PIP: 20 cmH2O\n Plateau: 25 cmH2O\n Compliance: 36.4 cmH2O/mL\n SpO2: 97%\n ABG: 7.27/41/118/17/-7\n Ve: 8.5 L/min\n PaO2 / FiO2: 236\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 387 K/uL\n 7.6 g/dL\n 125 mg/dL\n 3.8 mg/dL\n 17 mEq/L\n 4.7 mEq/L\n 129 mg/dL\n 102 mEq/L\n 134 mEq/L\n 24.8 %\n 8.5 K/uL\n [image002.jpg]\n 05:08 AM\n 09:16 PM\n 04:32 AM\n 08:40 AM\n 06:02 PM\n 04:16 AM\n 01:22 PM\n 05:00 PM\n 04:05 AM\n 04:23 AM\n WBC\n 7.1\n 7.6\n 8.5\n Hct\n 25.5\n 25.4\n 24.8\n Plt\n 381\n 357\n 387\n Cr\n 3.7\n 3.8\n 3.8\n 3.8\n TCO2\n 20\n 20\n 21\n 21\n 20\n 20\n Glucose\n 127\n 122\n 119\n 124\n 125\n Other labs: PT / PTT / INR:13.2/64.3/1.1, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:5.5 mg/dL\n Imaging: No new\n Microbiology: STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B\n TEST-FINAL INPATIENT\n STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL\n INPATIENT\n BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT\n URINE URINE CULTURE-FINAL {YEAST} INPATIENT\n BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT\n URINE URINE CULTURE-FINAL {YEAST} INPATIENT\n CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT\n STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL\n INPATIENT\n URINE URINE CULTURE-FINAL {YEAST} INPATIENT\n BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT\n BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT\n ECG: No new\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures (now none for a week on EEG) and deteriorating\n mental status, aspiration pneumonia, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension required\n phenylephrine. Transferred to CCU at request of family and consulting\n cardiologist.\n # Coma, seizures, Goals of Care\n Comatose with some brainstem reflexes. No seizures for some time. No\n evidence of cortical function. BUN 124 and patient has been\n intermittently hypotensive. Therefore differential includes (also\n possible multifactorial) uremia, anoxic brain injury and\n carcinoatosis/paraneoplastic encephalopathy (although very unlikely).\n Dr. has discussed issue of Phenobarbital with Dr. \n (neurology) and decision made to not restart phenobarbital.\n - No need for LP given carcinomatosis is an extremely unlikely cause of\n coma and metabolic toxicities (many different sources) seem more\n likely.\n - Will continue phenytoin for now given not contributing to mental\n status at such low concentration\n - Will d/w with family re transition to DNR/DNI today\n # Acidemia\n ABG slightly improved today - 7.30/41/112/18/-5. Lactate was not\n elevated at 1.0 making metabolic acidosis from renal failure or uremia\n more likely. Pt not a candidate for HD.\n - increase ventilation rate for respiratory compensation of\n metabolic acidosis\n - will hold off on bicarb/fluids\n # Aortic Stenosis\n Treatment of this is deferred pending decision about the above.\n Valvuloplasty will need to be repeated (if this is compatible with\n goals of care). Pt with known severe aortic stenosis s/p valvuloplasty\n in . She was initially on the CCU service early in her\n hospitalization in the setting of flash pulmonary edema when her lasix\n were held. Now, she is intubated in the ICU. Continues to be severely\n fluid overloaded and oliguric, positive ~30L Los. She does not respond\n well to lasix/diuril/bumex but is also not a candidate for HD.\n - Continue bumex and metolazone with goal of net negative 1.5L today\n - lytes\n - Monitor volume status, UOP.\n - Holding off on valvuloplasty at this point\n # Respiratory Failure and Intubation\n - Preserve for now given mental status and edema\n # Atrial Fibrillation\n Pt has good control of HR on beta blockade and digoxin. Coumadin was\n being held before for trach/PEG. Now, holding coumading in case pt\n undergoes valvuloplasty. Now on heparin gtt while INR subtherapeutic.\n - Continue metoprolol tartrate 25 mg TID\n - Continue digoxin 0.0625 mg daily\n - Trend coags\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, is ATN\n - Will attempt diuresis with bumex/metolazone, as above\n - Appreciate renal recs.\n - Continue to monitor fluid status otherwise\n # Coronary Artery Disease: Pt is s/p CABG /.\n - Continue metoprolol as above\n - Continue aspirin 81 mg daily, atorvastatin 40 mg daily\n # Respiratory Failure: Now, s/p trach.\n - Trach in place\n - Continue albuterol/atrovent PRN\n # Pressor Requirement: Pt weaned off of pressors.\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - f/u cx data\n - follow fever curve\n - f/u stool for c.diff\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:56 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 404596,
"text": "SICU\n HPI:\n 86F initially admitted with new onset seizures @ Rehab.\n She was subsequently transferred to the floor in stable condition, and\n was readmitted on again with subclinical seizures found on EEG.\n Ms. has a complicated PMHx; on she had a valvuloplasty\n performed for AS. She was then admitted from for R\n hemicolectomy for colon cancer after a lesion was noted on colonoscopy.\n Her hospital course was complicated by hypercarbia requiring intubation\n and fluid overload requiring diuresis. Subsequent to this she developed\n C. diff colitis, for which she had been on po vancomycin since that\n time; a recent followup abdominal CT after her partial colectomy was\n unremarkable\n After her admission, she was initially stable, but then went into flash\n pulmonary edema and AFib w/RVR, thought to be holding meds. She\n triggered on for possible aspiration and was tx to the CCU. She was\n diuresed with lasix gtt and treated for aspiration PNA with vancomycin,\n cefepime and flagyl. Her beta-blocker was resumed and she has not had\n any other episodes of RVR. She was evaluated by speech and swallow\n yesterday and she is now NPO (has tube feeds). Her mental status waxes\n and wanes, she is never fully oriented to person/place/time, and has\n minimal verbal responses to questions. At time of SICU admission, she\n responded only to painful stimuli.\n Chief complaint:\n Seizures, ARF\n PMHx:\n 1. CAD s/p CABG for LM disease (LIMA to LAD and saphenous vein\n graft to the OM\n 2. Severe AS s/p valvuloplasty in \n 3. AFib on coumadin\n 4. HTN\n 5. Hyperlipidemia\n 6. OA, s/p R THR and spinal stenosis\n 7. Squamous cell carcinoma\n 8. Chronic venous stasis with ulcerations\n 9. Hypothyroidism\n 10. Peripheral neurophathy\n 11. Raynaud\ns syndrome\n 12. R Retinal VA clot, w/ mild loss of vision\n 13. Chronic Diastolic heart failure\n 14. Shingles \n 13. Colon Cancer s/p hemicolectomy on \n Current medications:\n 1. 2. 3. 4. 5. 6. Acetaminophen 7. Albuterol 0.083% Neb Soln 8.\n Albuterol Inhaler 9. Aspirin\n 10. Atorvastatin 11. Bacitracin-Polymyxin Ointment 12. Calcium\n Gluconate 13. Chlorhexidine Gluconate 0.12% Oral Rinse\n 14. Collagenase Ointment 15. Dextrose 50% 16. Digoxin 17. Famotidine\n 18. Fentanyl Citrate 19. FoLIC Acid\n 20. Glucagon 21. 22. Insulin 23. Ipratropium Bromide MDI 24.\n Ipratropium Bromide Neb 25. Latanoprost 0.005% Ophth. Soln.\n 26. Levothyroxine Sodium 27. Lidocaine 5% Patch 28. Lorazepam 29.\n Magnesium Sulfate 30. Metoprolol Tartrate\n 31. Miconazole Powder 2% 32. Nystatin Oral Suspension 33. PHENObarbital\n 34. Phenytoin Sodium (IV)\n 35. Phenylephrine 36. Potassium Chloride 37. Sodium Chloride 0.9% Flush\n 38. Sodium Chloride 0.9% Flush\n 39. Sodium Chloride 0.9% Flush 40. Sodium Chloride 0.9% Flush 41.\n Timolol Maleate 0.5%\n 24 Hour Events:\n : Family meeting held still full code, cardiology will take the\n patient to CCU in am. Keppra D/C.\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 2.5 mcg/Kg/min\n Other ICU medications:\n Dilantin - 06:00 PM\n Famotidine (Pepcid) - 08:25 PM\n Other medications:\n Flowsheet Data as of 03:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (101\n T current: 37.6\nC (99.6\n HR: 89 (83 - 109) bpm\n BP: 132/55(82) {105/45(66) - 146/57(89)} mmHg\n RR: 26 (18 - 31) insp/min\n SPO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 96.5 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 14 (4 - 14) mmHg\n Total In:\n 2,075 mL\n 316 mL\n PO:\n Tube feeding:\n 844 mL\n 117 mL\n IV Fluid:\n 1,112 mL\n 199 mL\n Blood products:\n Total out:\n 162 mL\n 11 mL\n Urine:\n 162 mL\n 11 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,913 mL\n 305 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 450) mL\n Vt (Spontaneous): 439 (315 - 656) mL\n PS : 18 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 79\n RSBI Deferred: RR >35\n PIP: 24 cmH2O\n Plateau: 22 cmH2O\n SPO2: 96%\n ABG: 7.34/39/82.//-4\n Ve: 10.5 L/min\n PaO2 / FiO2: 207\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : At the base,\n Rhonchorous : Bilateral)\n Abdominal: Soft, Bowel sounds present, Distended\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: (Responds to: Noxious stimuli), Delay response to noxious\n stimili\n Labs / Radiology\n 10:24 AM\n 03:06 AM\n 03:29 AM\n 12:15 PM\n 02:20 AM\n 02:31 AM\n 06:10 PM\n 08:30 PM\n 10:18 PM\n 11:21 PM\n WBC\n 10.4\n 10.1\n Hct\n 30.2\n 30.3\n Plt\n 428\n 393\n Creatinine\n 2.5\n 2.7\n 3.0\n TCO2\n 25\n 22\n 25\n 21\n 24\n 23\n 22\n Glucose\n 112\n 124\n 137\n Other labs: PT / PTT / INR:29.5/33.7/2.9, CK / CK-MB / Troponin\n T:9/2/0.03, ALT / AST:, Alk-Phos / T bili:60/0.2, Amylase /\n Lipase:/47, Differential-Neuts:80.4 %, Lymph:10.9 %, Mono:6.6 %,\n Eos:2.0 %, Fibrinogen:499 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:202 IU/L, Ca:7.8 mg/dL, Mg:1.9 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), INEFFECTIVE COPING,\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), KNOWLEDGE DEFICIT, IMPAIRED\n SKIN INTEGRITY, PNEUMONIA, ASPIRATION, AORTIC STENOSIS, SEIZURE,\n WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 86F w/subclinical seizures and deteriorating\n mental status, aspiration pneumonia with a complicated PMHx including\n severe AS s/p valvuloplasty, AF, CAD, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension requiring\n phenylephrine.\n Neurologic:\n -- Patient sedated with minimal doses intermittent fentanyl prn.\n -- Patient with seizures, loaded with dilantin and ativan PRN prior to\n admission with poor mental status. Despite loading dose continued to\n have sub clinical seziures on EEG. Medication regimen changed,\n currently on phenytoin (Goal 15-20), and phenobarbitol. (Keppra d/c\n 0./20)\n --Delayed Withdrawal to pain in all extremities\n -- AM dilantin level - , phenobarb ->\n Cardiovascular:\n -- PAF with good control of HR on beta blockade and digoxin.\n Anticoagulation started with coumadin. Coumadin held for now given\n elevated INR, will bridge with heparin once INR<2.0. On ASA\n -- CAD s/p CABG , diastolic dysfunction. On b-blockade, ASA, and\n statin.\n -- Critical AS (valve area pre-valvuloplasty 0.8cm2, post\n vavluloplasty). On ICU-based ECHO estimated area is 0.6cm2. Likely not\n eligible for open valve replacement. Family is discussing this issue\n with another cardiologist.\n --Cont phenylephrine as needed, goal SBP>120, MAP>70\n Pulmonary:\n --albuterol/atrovent PRN\n --plan for trach \n --CPAP 5/5\n Gastrointestinal / Abdomen:\n --TFs at goal,plan for PEG \n Nutrition:\n --TF continued\n Renal:\n -- Lasix held\n -- Pt still requires neosynephrine for MAPs > 65\n -- Cr increasing: now at , renal believes it is ATN (muddy brown\n casts), would not diurese, or give IVF; do not oliguria.\n Hematology:\n --ASA. Hold coumadin given elevated INR\n - A. Fib anticoagulation with Coumadin now on hold for procedure, INR\n goal , f/u daily INR and start heparin drip once INR < 2 as pt is\n planned for trach/peg on Monday\n Endocrine:\n --RISS with adequate glucose control\n --Synthroid 75 mcg for hypothyroidism\n ID:\n --completed cefepime vanc 7 day course for pneumonia\n --UA positive foley changed patient received 3 days course of\n antibiotics last dose 03/16\n --Follow cultures\n T/L/D: PIV, Foley, CVL (), ETT, Dobhoff\n Wounds: none\n Imaging: none\n Fluids: KVO\n Consults:\n Billing Diagnosis: status epilepticus, respiratory failure, ATN\n Prophylaxis:\n DVT: ASA, coumadin (held)\n Stress ulcer: H2B\n VAP bundle: +\n Comments:\n Communication: ICU consent done\n Code status: FULL\n Disposition: SICU\n Time spent: 35\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404597,
"text": "Seizure, without status epilepticus\n Assessment:\n Pt remains intubated, no sedation\n Pt slightly withdraws extremities to deep nailbed pressure,\n pupils equal and reactive, weak cough, impaired gag, does not open\n eyes, no spontaneous movement\n EEG continues\n Pt remains on neo gtt to keep SBP >120\n Remains oliguric, BUN 81Cr 3\n Pt placed on 18 PS and 5 PEEP at start of shift secondary\n to acidosis, ABG 7.26/52/84/-\n Action:\n Neuro checks Q2hrs\n Neo gtt to keep SBP >120\n Monitor o/u\n Monitor ABGs\n Response:\n ABG improved 7.34/39/83/-\n No change in neuro exam\n Plan:\n Transfer pt to CCU\n Trach and PEG on Monday per family\n Continue to monitor neuro exam, outputs/renal function\n Wean vent as tolerated\n Keep SBP>120\n"
},
{
"category": "Nursing",
"chartdate": "2196-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 404601,
"text": "Seizure, without status epilepticus\n Assessment:\n Pt remains intubated, no sedation\n Pt slightly withdraws extremities to deep nailbed pressure,\n pupils equal and reactive, weak cough, impaired gag, does not open\n eyes, no spontaneous movement\n EEG continues\n Pt remains on neo gtt to keep SBP >120\n Remains oliguric, BUN 94 Cr 3.1\n Pt placed on 18 PS and 5 PEEP at start of shift secondary\n to acidosis, ABG 7.26/52/84/-\n Thick yellow sputum\n Action:\n Neuro checks Q2hrs\n Neo gtt to keep SBP >120\n Suctioned prn\n Monitor o/u\n Monitor ABGs\n Pt turned Q2 hrs\n Response:\n ABG improved 7.34/39/83/-\n No change in neuro exam\n Plan:\n Transfer pt to CCU\n Trach and PEG on Monday per family\n Continue to monitor neuro exam, outputs/renal function\n Wean vent as tolerated\n Keep SBP>120\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405473,
"text": "Chief Complaint: Critical AS, with failed repair, subsequent\n intraparenchymal cerebral hemorrhage, seizure, family requested Tx to\n CCU where mental status have continued to deteriorate.\n 24 Hour Events:\n \n RT went up on ventalator rate and acidosis improved somewhat\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,350 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Dilantin - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 89 (80 - 98) bpm\n BP: 106/50(71) {100/45(68) - 132/63(89)} mmHg\n RR: 14 (10 - 31) insp/min\n SpO2: 92%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 107.1 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 16 (16 - 22)mmHg\n Total In:\n 1,341 mL\n 618 mL\n PO:\n TF:\n 682 mL\n 256 mL\n IVF:\n 630 mL\n 172 mL\n Blood products:\n Total out:\n 380 mL\n 125 mL\n Urine:\n 280 mL\n 125 mL\n NG:\n Stool:\n Drains:\n Balance:\n 961 mL\n 493 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 64\n PIP: 24 cmH2O\n Plateau: 17 cmH2O\n SpO2: 92%\n ABG: 7.30/41/112/18/-5\n Ve: 8.1 L/min\n PaO2 / FiO2: 224\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 357 K/uL\n 7.3 g/dL\n 124 mg/dL\n 3.8 mg/dL\n 18 mEq/L\n 4.5 mEq/L\n 124 mg/dL\n 102 mEq/L\n 137 mEq/L\n 25.4 %\n 7.6 K/uL\n [image002.jpg]\n 11:51 PM\n 01:04 AM\n 02:02 AM\n 04:44 AM\n 05:08 AM\n 09:16 PM\n 04:32 AM\n 08:40 AM\n 06:02 PM\n 04:16 AM\n WBC\n 7.0\n 7.1\n 7.6\n Hct\n 24.7\n 25.5\n 25.4\n Plt\n 422\n 381\n 357\n Cr\n 3.7\n 3.7\n 3.8\n 3.8\n TCO2\n 21\n 21\n 20\n 20\n 20\n 21\n Glucose\n 137\n 127\n 122\n 119\n 124\n Other labs: PT / PTT / INR:13.2/76.4/1.1, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL, PO4:5.4 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: CXR portable :\n Portable AP chest radiograph was compared to .\n The tracheostomy is at the midline with its tip being 4.5 cm above the\n carina.\n The left internal jugular line tip is at the level of mid SVC. There is\n no\n change in the cardiomediastinal silhouette. There is interval\n improvement in\n pulmonary edema. The left pleural effusion is present as well as left\n retrocardiac atelectasis. The right lateral chest was not included in\n the\n field of view preventing evaluation of the right pleural effusion.\n Broken sternal wires are unchanged. The gastrostomy is projecting over\n the\n stomach.\n Microbiology: Yeast in urine and sputum. No other significant findings.\n ECG: .\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n AORTIC STENOSIS\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:56 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2196-02-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 405477,
"text": "Chief Complaint: Critical AS, with failed repair, subsequent\n intraparenchymal cerebral hemorrhage, seizure, family requested Tx to\n CCU where mental status have continued to deteriorate.\n 24 Hour Events:\n \n RT went up on ventalator rate and acidosis improved somewhat\n Allergies:\n Penicillins\n Rash;\n Erythromycin Base\n Rash;\n Motrin (Oral) (Ibuprofen)\n Unknown; sores\n Ampicillin\n Unknown;\n Lactose\n Unknown; Abdomi\n Latex\n Rash;\n Adaptic (Topical) (Non-Adherent Bandage)\n Rash;\n Amiodarone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,350 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Dilantin - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 89 (80 - 98) bpm\n BP: 106/50(71) {100/45(68) - 132/63(89)} mmHg\n RR: 14 (10 - 31) insp/min\n SpO2: 92%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 107.1 kg (admission): 80.1 kg\n Height: 66 Inch\n CVP: 16 (16 - 22)mmHg\n Total In:\n 1,341 mL\n 618 mL\n PO:\n TF:\n 682 mL\n 256 mL\n IVF:\n 630 mL\n 172 mL\n Blood products:\n Total out:\n 380 mL\n 125 mL\n Urine:\n 280 mL\n 125 mL\n NG:\n Stool:\n Drains:\n Balance:\n 961 mL\n 493 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 64\n PIP: 24 cmH2O\n Plateau: 17 cmH2O\n SpO2: 92%\n ABG: 7.30/41/112/18/-5\n Ve: 8.1 L/min\n PaO2 / FiO2: 224\n Physical Examination\n GENERAL: Intubated, Sedated. Not responsive to verbal stimuli.\n NECK: Trach in place.\n CARDIAC: Irregular. crescendo/decrescendo murmur loudest at RUSB.\n LUNGS: Ventilated breath sounds. Unable to hear good breath sounds at\n the bases.\n ABDOMEN: Obese, S/NT/ND, BS present. PEG in place.\n EXTREMITIES: Pitting edema noted in all 4 extremities.\n NEURO: Comatose (GCS 3), no plantar response on left and small upgoing\n on right. Jaw jerk hyperactive, glalbella tap present, corneals WNLs\n bilaterally. No doll\ns eyes to lateral head roll. PERRL.\n Labs / Radiology\n 357 K/uL\n 7.3 g/dL\n 124 mg/dL\n 3.8 mg/dL\n 18 mEq/L\n 4.5 mEq/L\n 124 mg/dL\n 102 mEq/L\n 137 mEq/L\n 25.4 %\n 7.6 K/uL\n [image002.jpg]\n 11:51 PM\n 01:04 AM\n 02:02 AM\n 04:44 AM\n 05:08 AM\n 09:16 PM\n 04:32 AM\n 08:40 AM\n 06:02 PM\n 04:16 AM\n WBC\n 7.0\n 7.1\n 7.6\n Hct\n 24.7\n 25.5\n 25.4\n Plt\n 422\n 381\n 357\n Cr\n 3.7\n 3.7\n 3.8\n 3.8\n TCO2\n 21\n 21\n 20\n 20\n 20\n 21\n Glucose\n 137\n 127\n 122\n 119\n 124\n Other labs: PT / PTT / INR:13.2/76.4/1.1, CK / CKMB /\n Troponin-T:9/2/0.03, ALT / AST:, Alk Phos / T Bili:60/0.2, Amylase\n / Lipase:/47, Differential-Neuts:75.9 %, Lymph:13.5 %, Mono:4.8 %,\n Eos:5.7 %, Fibrinogen:499 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.7\n g/dL, LDH:202 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL, PO4:5.4 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: CXR portable :\n Portable AP chest radiograph was compared to .\n The tracheostomy is at the midline with its tip being 4.5 cm above the\n carina.\n The left internal jugular line tip is at the level of mid SVC. There is\n no\n change in the cardiomediastinal silhouette. There is interval\n improvement in\n pulmonary edema. The left pleural effusion is present as well as left\n retrocardiac atelectasis. The right lateral chest was not included in\n the\n field of view preventing evaluation of the right pleural effusion.\n Broken sternal wires are unchanged. The gastrostomy is projecting over\n the\n stomach.\n Microbiology: Yeast in urine and sputum. No other significant findings.\n Electrrphysiology:\n ECG:\n EEG:\n BACKGROUND: Is diffusely slow and disorganized consisting of mixed\n theta and delta frequencies and occasional periods of diffuse global\n suppression of the background. There were rare bursts of generalized\n slowing and rare generalized sharps occurring in isolation. There were\n no electrographic seizures and there were no periodic discharges.\n HYPERVENTILATION: Could not be performed secondary to history of\n intracranial hemorrhage.\n INTERMITTENT PHOTIC STIMULATION: Could not be performed secondary to\n the portable nature of this study.\n SLEEP: No normal sleep morphology was seen on this recording.\n CARDIAC MONITOR: Showed an irregularly irregular rhythm with occasional\n wide complex ectopic beats.\n IMPRESSION: This is a severely abnormal extended routine EEG due to a\n diffusely slow and disorganized background consisting of mixed theta\n and\n delta frequencies marked by occasional generalized bursts of slowing,\n rare generalized sharps occurring in isolation and occasional brief\n suppressive bursts of the background. There were no periodic discharges\n and there were no electrographic seizures. Overall, this background is\n suggestive of a severe encephalopathy. Amongst the most common causes\n of encephalopathy are medications, infection, metabolic derangements,\n and anoxia.\n INTERPRETED BY: , L.\n Assessment and Plan\n 86 y/o female with hx CAD s/p CABG, Afib, with severe AS s/p\n valvuloplasty, diastolic CHF, colon adenocarcinoma, chronic c.diff,\n admitted with new onset tonic clonic seizures, who subsequently flashed\n on the floor in the setting of holding lasix. Course complicated by\n subclinical seizures (now none for a week on EEG) and deteriorating\n mental status, aspiration pneumonia, now w/respiratory acidosis and\n failure resulting in intubation (), ARF, hypotension required\n phenylephrine. Transferred to CCU at request of family and consulting\n cardiologist.\n # Coma, seizures, Goals of Care\n Comatose with some brainstem reflexes. No seizures for some time. No\n evidence of cortical function. BUN 123 and patient has been\n intermittently hypotensive. Therefore differential includes (also\n possible multifactorial) uremia, anoxic brain injury and\n carcinoatosis/paraneoplastic encephalopathy (although very unlikely).\n Dr. has discussed issue of Phenobarbital with Dr. \n (neurology) and decision made to not restart phenobarbital.\n - No need for LP given carcinomatosis is an extremely unlikely cause of\n coma and metabolic toxicities (many different sources) seem more\n likely.\n - Family wanst to wait until Wednesday to make further decisions.\n # Acidemia\n ABG noted pH 7.27. Anion gap was 15. Lactate was not elevated at 1.0\n making metabolic acidosis from renal failure or uremia more likely. Pt\n not a candidate for HD.\n - increase ventilation rate for respiratory compensation of\n metabolic acidosis\n - will hold off on bicarb/fluids\n # Aortic Stenosis\n Treatment of this is deferred pending decision about the above.\n Valvuloplasty will need to be repeated (if this is compatible with\n goals of care). Pt with known severe aortic stenosis s/p valvuloplasty\n in . She was initially on the CCU service early in her\n hospitalization in the setting of flash pulmonary edema when her lasix\n were held. Now, she is intubated in the ICU. Continues to be severely\n fluid overloaded and oliguric, positive ~30L Los. She does not respond\n well to lasix/diuril/bumex but is also not a candidate for HD.\n - Continue bumex and metolazone with goal of net negative 1.5L today\n - lytes\n - Monitor volume status, UOP.\n - Holding off on valvuloplasty at this point\n # Respiratory Failure and Intubation\n - Preserve for now given mental status and edema\n # Atrial Fibrillation\n Pt has good control of HR on beta blockade and digoxin. Coumadin was\n being held before for trach/PEG. Now, holding coumading in case pt\n undergoes valvuloplasty. Now on heparin gtt while INR subtherapeutic.\n - Continue metoprolol tartrate 25 mg TID\n - Continue digoxin 0.0625 mg daily\n - Trend coags\n # Acute Renal Failure: Creatinine 3.8 today. Per previous notes, is ATN\n - Will attempt diuresis with bumex/metolazone, as above\n - Appreciate renal recs.\n - Continue to monitor fluid status otherwise\n # Coronary Artery Disease: Pt is s/p CABG /.\n - Continue metoprolol as above\n - Continue aspirin 81 mg daily, atorvastatin 40 mg daily\n # Respiratory Failure: Now, s/p trach.\n - Trach in place\n - Continue albuterol/atrovent PRN\n # Pressor Requirement: Pt weaned off of pressors.\n # Hypothyroidism:\n - continue Synthroid 75 mcg daily\n # Fevers: Afebrile for several days now. Per notes, pt completed\n vanc/cefepime 7 day course for pneumonia as well as 3 days course of\n abx for positive UA.\n - f/u cx data\n - follow fever curve\n - f/u stool for c.diff\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:56 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:39 PM\n Multi Lumen - 01:49 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-14 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404599,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 18 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Respiratory ",
"chartdate": "2196-02-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 404523,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n :\n Tube Type\n ETT:\n Position: 18 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Radiology",
"chartdate": "2196-01-28 00:00:00.000",
"description": "US GUID FOR VAS. ACCESS",
"row_id": 1124134,
"text": " 1:09 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC line\n Admitting Diagnosis: SEIZURE\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with seizure,cl diff,HTN,\n REASON FOR THIS EXAMINATION:\n PICC line\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: IV access needed for heparin.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Dr. performed the procedure with Dr. \n supervising.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the right brachial\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a double lumen PICC line measuring 42 cm in length was then\n placed through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was secured\n to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 French\n double lumen PICC line placement via the right brachial venous approach. Final\n internal length is 42 cm, with the tip positioned in SVC. The line is ready to\n use.\n\n"
}
] |
19,242 | 191,574 | 70 F with COPD on home O2, morbid obesity with restrictive lung physiology, OSA presented with pneumonia and respiratory failure requring intubation for mechanical ventilation. . Respiratory failure: Secondary to pneumonia and COPD exacerbation with poor underlying pulmonary reserve from morbid obesity, untreated OSA, COPD, and diastolic heart failure. Intubated for acute respiratory failure and treated with a course of IV solumedrol for COPD exacerbation and broad antibiotics (vanco and cipro) empirically for suspected pneumonia, pending culture data. However sputum culture returned negative for growth. Therefore antibiotics weaned to complete course of ciprofloxacin. Component of respiratory failure also felt secondary to diastolic heart failure and she was diuresed without significant improvement in her ventilatory dependence. . She was difficult to wean from the ventilator, limited by persistent rapid shallow breathing. In addition she was noted to have high levels of anxiety and agitation when weaned off sedation. Given ongoing high fevers on the vent, she was started empirically for VAP with Ceftaz for an 8 day course. In addition, she was noted to have methicillin resistant staph epi in two separate blood culture sets. A-line was removed as a potential source, and the tip was also noted to culture out MRSE. Therefore she was treated with a 2 week course of vancomycin. . After discussion with the health-care proxy, the plan was made to optimize medical management and extubate on Monday without re-intubation under any circumstances. Goals of care changed to DNR/DNI, with management directed towards comfort measures. . | Bolus of midaz settles pt and BP back to baseline. AM lytes pend.ID - Max temp 100.5 po. L ext> R ext - LENIS performed yest - ? Continues on Verapamil and Captopril; able to receive sched doses. HALDOL 5-10MG IVP PRN RESTARTED. VANCO DC'D. Monitor diuresis, replete lytes prn. TLCL PLACED IN RIGHT IJ. AM ABG 7.43/47/87/32. Sx for small-mod amt of thk, wht/tan secretions. Bilat hand edema noted. QTC mesured as haldol being administered, QTC .312. TF started yest. is now +1L for the day.Endo: FSBG covered by sliding scale.ID: Pt. PNA rx with cipro iv.Endo - RISS. Cough/gag intact.RESP: Able to change to PSV currently @ ; will send reflective ABG. MDI's given. Hct 29.6, previously 30.4.GI - Abd soft and obese. RISBI 190 this am. Min residuals. ABG 7.38/45/100/28/1.C-V - HR 64-88 NSR. U/O 50-80cc/hr.ID: Tmax 99.6 PO. Large loose green BM x1.Endo: SSC, BS 190-204.ID: Continues on vanco (needs trough prior to dose today) and ceftazidime. resp. ETT repositioned and retaped. ON LANSOPRAZOLE. Verapamil held for HR< 60 x 1. ABP 150-190/70-80. BS are hypoactive. DNR/DNI. REPEAT AGAIN TODAY...ABG SHOWED ALKOLOSIS ? RELATED TO RATE THEREFORE RATE REDUCED TO 18 WITH NO EFFECT ..TEAM AWARE OF ALKOLOSIS ? PLACED ON PNEUMOBOOTS. LS clear, diminished at bases. LE DOPPLERS DONE-RESULTS PENDING. On prednisone taper for COPD exac.C-V - HR 55-97 SB/SR. Give dulc pr if constipation perisists. SEE CAREVUE.SKIN: INTACT.ID: CONT ON VANCO-PNA. BS. Goal CO2 in 60s. SUCTIONING MINIMAL SECRETIONS FROM ETT. Remains covered with flagyl and cipro.A+P - Continue wean from vent as tolerated and diuresis. Foley cath draining minimal UO. Upon admit to MICU HR 120's, BP low 100's. AM lytes pend.ID - Max temp 100.6 po. bilat lower extremities with skin discoloration.endo: remains on fingersticks q6hr with riss.i-d: temp max 99.5 po. Sxn'd for sm. DISCONTINUE PROPOFOL WHEN LINE PLACED LATER PMCVS....WHEN ANXIOUS/AGITATED SYSTOLIC >180 WHEN RESTED B/P @ 120-130 SYSTSOLIC...VERAPRAMIL AND CAPTOPRIL INCRESAED AGAIN TODAY...AIM SYSTOLIC < 160 [ AT LEAST]HR 95-105 SINUS..K/MG REPLETED AM , CHECK SATISFACTORY..QTC @ .397 ON EKGB/S AS PER S/SID..FEBRILE @ 101.6 BLOOD CULTERES RE-DRAWN [ ARTERIAL/PERIPHERAL]..TEAM WANT TO TAKE OUT EXISTING A LINE GIVEN RISING TEMP..TEAM PRESNTLY ATTEMPTING TO PUT IN NEW LINE..VANC RE-COMMENCED CIPRO/ D/C..RESP..RECEIVED ON P/S AT 15/5 SATISFACTORY ABG EVEN WHEN RR 35-40..P/S REDUCED TO 12 AGAIN SATISFACTORY ABG...TV @ 300-320 SATS >94%..LUNGS SOUND CLEAR THIS PM..FOR PSSIBLE EXTUBATION TOMORROW [ SEE BELOW]..INHALERS REVIWED TO OPTIMISE RESP STATUS.. NO FURTHER WEAN FOR TODAYGI..TOLLERETING FEED RESPALOR @ 60..., SOFT HYPOACTIVE B/S ..WANTING TO USE BED PAN THIS AM..MUSHROOM CATH TAKEN OUT, PASSED SMALL AMOUNT OF STOOL ON BED PAN....REQUESTED BED PAN SEVERAL TIMES SINCE BUT NO FURTHER STOOL PASSED...GU..TEAN REVIEW THIS AM, LASIX TO BE GIVEN AND AIM FOR 1L NEG..LASIX GIVEN WITH SOME EFFECT..BUT IN VIEW OF HIGH TEMP TO HOLD OF ANY FURTHER DIURSESIS AND REVIEW AGAIN PMSKIN..INTACTLINES..FOR EXISTING ART LINE REMOVAL AND NEW ONE TO BE PLACED AS CONTINUES TO BE FEBRILE...X1 PERIPHERAL ALSO TO BE REMOVEDSOCIAL.. HCP IN CONTACT TODAY, MYSELF AND THE TEAM HAVE SPOKEN WITH HER AND UPDATED..TO HAVE MEETING WITH HER TOMORROW @ 2PM RE ONGOING CARE AND ISSUES OF RE-INTUBATION ONCE PATIENT EXTUBATEDPLAN..RESP SUPPORT..MONITOR CVS/SEDATION/MEDS FOR ANXIETY...? Vanco d/c'd as 1 bottle GPC noted thought to be contiminate. WEANED TO PSV @ , ABG= 7.34/53/106. RESP CAREPt was weaned to with a follow up abg of 7.34/53/106/30. LS= COARSE TO CLEAR AFTER SXN. 1+ pitting edema noted to BUE. vent changed to ps and weaned to with good vols. ability to tolerate being off Propofol.Resp- Multiple vent changes today. Ionized Ca 1.05 yest - repleted with 2 gms ca gluc iv.ID - Max temp 102.3 po. Vanco d/c'd, pt. ETT rotatated and retaped. AM ABG 7.40/50/98/32. RSBI-101.7. continue ps weanand rsbi's. ABG= 7.32/56/121. WBC 5.1Skin - Diaphoretic and reddened. Moderate mitralannular calcification. PM ABG ON PSV 10/8= 7.41/47/87. Cipro and flagyl cont. ABP= 149-220/61-120. Morning abg within acceptable parameters.Bs: coarse at times with exp. CDIFF CX SENT A/O. PROPOFOL RESUMED, AND WILL RE-EVAL FOR EXTUBATION IN AM. ABG=7.40/45/91. Resp CarePt. Lytes pending.UO 30-100cc/hr.GI/GU: TF at 40cc/hr, minimal residuals. ABP= 108-200/46-90. Rx with captopril and verapamil. HR up to 118 ST and SBP 190's. PT SEDATED ON PROPOFOL GTT, RECEIVED PT ON 40MCG/KG/MIN. vent per carevue. Continues to receive iv cipro and flagyl. IV CIPRO CONTINUES, AM WBC= 4.7. RE-ASSESS FOR EXTUBATION IN AM, PERFORM RSBI. mdi's given. Rested on AC 500/20/5/40% - ABG 7.46/40/126/5/29. Hct 32.4. Left ventricular function.Height: (in) 60Weight (lb): 304BSA (m2): 2.23 m2BP (mm Hg): 146/61HR (bpm): 82Status: InpatientDate/Time: at 08:30Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolicfunction (LVEF>55%). The endotracheal tube appears unchanged in position compared to prior study seen approximately 1 cm from the carina, angled towards the right main stem bronchus. Elevation of the right hemidiaphragm is again noted. IMPRESSION: ET tube in right mainstem bronchus. The right hilum is prominent presumed to be due hilar lymphadenopathy unchanged. FINDINGS: Tip of endotracheal tube lies within the right mainstem bronchus. IMPRESSION: ETT at carina, directed towards right main bronchus. TECHNIQUE: Axial and coronal non-contrast images of the paranasal sinuses were obtained. COMPARISON: Chest radiograph dated . Interval development of confluent opacity in the region of the right hilum is noted. The tip of the endotracheal tube is identified 1 cm above the carina. Sinus rhythmNormal ECGSince previous tracing, slower rate seen FINDINGS: Grayscale and Doppler son of the left common femoral, superficial femoral, and popliteal veins were performed. AP SUPINE CHEST RADIOGRAPH: Allowing for differences in positioning, lung volumes are grossly unchanged. PORTABLE AP CHEST: ET tube is at the thoracic inlet. REASON FOR THIS EXAMINATION: ET tube placment and NG tube. There is an NG tube with the tip likely in the first portion of the duodenum. The cardiac and mediastinal contours are unchanged compared to the prior study, and again note is made of right hilar fullness as demonstrated on the prior chest CT on . The right ostiomeatal complex is obstructed by mucosal thickening. TECHNIQUE: Left lower extremity venous ultrasound and Doppler examination. | 72 | [
{
"category": "Nursing/other",
"chartdate": "2200-02-28 00:00:00.000",
"description": "Report",
"row_id": 1515995,
"text": "7p to 7a Micu Progress Note\n\nEvents - Pt transitioned from fentanyl/versed sedation to propofol. Pt failed SBT yest ? due to sedation issues. Plan is to wean propofol this am and attempt further vent weaning.\n\nNeuro - Pt alert intermittently, follows commands. PERL. MAE. Experiences periods of agitation. Given a total of 8 mg haldol iv with fair results - pt would sleep for a short period but then again would awake agitated. Bolused occasionally with 1-2 ccs propofol. Propofol currently infusing at 20mcgs/kg/min. Anxiety also being managed with zyprexa and zoloft.\n\nResp - Orally intubated and received on AC 500/20/8/50%. Fio2 decreased to 40% - ABG 7.44/43/108/4/30. RR 20-23. 02 sat > 97%. ETT not rotated as pt has oral ulcer in R corner of mouth. BS clear, diminished at bases. Sx for mod amts thick white clear secretions. RISBI 190 this am. On prednisone taper for COPD exac.\n\nC-V - HR 55-97 SB/SR. ABP 120-175/55-65, HR and BP elevated with agitation. Tolerating increased dose of captopril ( 37.5 mg) without difficulty. Verapamil held for HR< 60 x 1. QTC mesured as haldol being administered, QTC .312. Scheduled for EKG as well. Hct 29.6, previously 30.4.\n\nGI - Abd soft and obese. +BS. No stool. Colace and senna given, pt may require dulcolax pr if no stool today. TF started yest. Respalor infusing via OGT at goal of 40ccs/hr. Min residuals.\n\nF/E - Pt given 20 mg lasix last eve with good results - diuresed ~800ccs over 2 hrs. TFB neg ~100ccs, goal 500ccs neg. Urine output 60-240ccs/hr since. BUN 39 Cr 1.3, K 4.9 today.\n\nID - Max temp 100 po. Pan cx'd on previous shift. WBC 3.3. PNA rx with cipro iv.\n\nEndo - RISS. Received one dose of 3 units reg insulin for fingerstick 187.\n\nSocial - No phone calls or visitors.\n\nA+P - Continue to wean sedation and vent as tolerated. Administer antianxiety agents as indicated. Monitor diuresis, replete lytes prn. Give dulc pr if constipation perisists. Follow-up on cx results.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-02-28 00:00:00.000",
"description": "Report",
"row_id": 1515996,
"text": "Nursing Note: 0700-1900\nSignificant events: Propofol weaned slightly; currently @ 15mcg/kg/min.\n\nVent changes; able to wean to PSV 12/8/40%\n\n\nNEURO: Intermittently alert/following commands and able to make needs known. Some periods of restlessness/agitation requiring use of bilat soft wrist restraints to maintain safety and integrity of lines; received Haldol X 2 in 3mg and 2mg doses respectively with fair effect. Responsive to any tactile stim with increasing HR, BP, and RR. Cough/gag intact.\n\nRESP: Able to change to PSV currently @ ; will send reflective ABG. Goal CO2 in 60s. LS coarse/diminished at bases. Sx for small-mod amt of thk, wht/tan secretions. RR 20s-30s increasing with agitation. Sats maintained mid to high 90s.\n\nC/V: HR 60s-80s, SR, no ectopy. ABP 140s-160s. Continues on Verapamil and Captopril; able to receive sched doses. Bilat hand edema noted. Right hand secondary to infiltrated PIV.\n\nGI/GU: Abdomen obese, OB negative stool X 3. TF Respalor at goal rate 40cc/hr. U/O 50-80cc/hr.\n\nID: Tmax 99.6 PO. Last pan cx on for persistent low grade temps. Receiving Cipro IV of pna.\n\nENDO: SS insulin; no coverage required.\n\nDISPO: Full code; micu grn; resident of .\n\nPLAN: Hypercarbic to 60s; wean sedation and administer Haldol prn for agitation. Possible extubation tomorrow .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-08 00:00:00.000",
"description": "Report",
"row_id": 1516025,
"text": "NURSING PROGRESS NOTES\nREVIEW OF SYSTEMS:\n\nNEURO: PT ANXIOUS AT TIMES REQUIRING ATIVAN 2MG IVP X 2 FENTANYL 50MCQ-100MCQ IVP X 2. HALDOL 5-10MG IVP PRN RESTARTED. AND GIVEN X 1 AT 1700. PERL 2MM THIS AM PT ABLE TO NOD YES OR NO TO SIMPLE QUESTIONS. SHE NODDED YES TO THE QUESTIONS \"ARE YOU SCARED?\" AND \"DO YOU WANT MEDICATION TO MAKE YOU MORE COMFORTABLE\" PT MAE\n\nRESP: PT VENTED RETAPED 19 AT LIP LINE. SUCTIONING MINIMAL SECRETIONS FROM ETT. LS COARSE W/DIMINISHED BASES PT RECEIVES \nVENT SETTINGS AC/18/500/5/50% PT HAS FAILED NUMEROUS PS TRIALS AND WEANING.\n\nCV: TELE ST MOST OF AM 110S W/ HTN SBP 180S WHEN CALM AND MEDICATED HR 80S W/ SBP 130S, VERAPAMIL INCREASED TO 240MG FROM 120 GIVEN THIS AFTERNOON. HRT RATE 70S BP 110/50S. #18 PIV INFILTRATED THIS AM IN RIGHT UPPER EXT. REMOVED. #22 PIV PLACED IN LEFT WRIST AND #20 PLACED RIGHT WRIST. TLCL PLACED IN RIGHT IJ. DIPRIVAN GTT ON FOR A BRIEF TIME FOR LINE PLACEMENT. PCXR CONFIRMED PLACEMENT.\n\nGI: PT OBESE, OGT IN PLACE TF AT GOAL 40CC RESIDUAL <5CC LACTALOSE ORDERED FOR NO STOOL, PT HAD LG LIQUID BM W/OUT USE OF LACTALOSE.\n\nGU: PT UO POOR THIS AM 500CC BOLUS GIVEN AT 0700 AND AGAIN AT 1730 FOR LOW UO.\n\nSKIN: INTACT.\n\nCODE: DNR/DNI\n\nENDO: FINGERSTICKS QID\n\nID: PT POS FOR GRAM NEG STAPH ON VANCO AND FORTAZ. LACTATE 2.4 PT SPIKED FEVER YEST. 102 TODAY TYLENOL/MOTRIN AND COOLING BLANKET ALL USED TO DECREASE FEVER. PT TEMP AT 1700 100.8 ORALLY.\n\nPLAN:\nREMOVE ETT ON MONDAY AND DNI PER HCP\nKEEP PT COMFORTABLE W/ HALDOL, FENTANYL, ATIVAN.\nUSE COOLING BLANKET/TYLENOL/MOTRIN FOR FEVERS\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-09 00:00:00.000",
"description": "Report",
"row_id": 1516026,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds dim @ bases suct sm th white sput[spec obt]. MDI given as per order. Pt in NARD on current settings; no vent changes required . Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-09 00:00:00.000",
"description": "Report",
"row_id": 1516027,
"text": "Nursing Progress Note:\n\nNeuro: Pt. seemed fairly comfortable overnight, given 2mg Ativan and 50 mcg Fentanyl once with good effect. Pt.localizes pain, MAE, and occasionally opened eyes but did not follow commands.\n\nCV: HR 60s-70s NSR with no ectopy. Pt's ABP did drop during night with NBP correlating. Lowest was in 70s but was mostly in 80s-140s/40s-50s. Arterial waveform was dampened but correlated with NBP when BP was low. Pt. moved around at one point and waveform became much sharper and ABP read much higher with NBP remaining low. Unsure which is accurate but due to low urine output pt. was treated as if dry. Fluid challenges did increase BP.\n\nResp: Pt. remains on vent settings AC 500X18/50%/5. RR 18-20, 02 sats >95%. LS mostly clear with occasional wheezes. Suctioned for small amounts of secretions.\n\nGI: TF of Respiratory @ 40cc/hour with minimal residuals and BSX4. No BM on shift.\n\nGU: UO 0-15cc/hour. Pt.given 2L LR boluses during night with no change in UO. Pt. is now +1L for the day.\n\nEndo: FSBG covered by sliding scale.\n\nID: Pt. mildly febrile, blood cultures sent, urine culture ordered but as of now no urine to collect.\n\nSkin: Intact.\n\nPlan: Monitor pt. for effects of fluid challenges, rest as noted in yesterday's note.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-09 00:00:00.000",
"description": "Report",
"row_id": 1516028,
"text": "Resp Care\nPt remains intubated on A/C. MDI's given, no other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-02-27 00:00:00.000",
"description": "Report",
"row_id": 1515991,
"text": "7p to 7a Micu Progress Note\n\nNeuro - Pt intermittently following commands. MAE. Opening eyes spont at times. Pupils 1-2mm, equal and briskly reactive. Remains sedated with 50mcgs/hr fentanyl and 5 mg/hr versed. Occasionally requires boluses for agitation. Wrist restraints in place for safety.\n\nResp - Remains orally intuabated and vented on AC 500/20/10/50%. RR 20-26. 02 sat > 95%. LS clear, diminished at bases. Sx for mod amts blood-tinged secretions. ABG 7.38/45/100/28/1.\n\nC-V - HR 64-88 NSR. ABP 150-190/70-80. MD informed of elevated BP. Lisinopril dcd and captopril 12.5 mg po tid started with fair results - SBP 160's. Pt may require hydralazine or other if htn persists. Verapamil also given. 2+ palp pedal pulses. L ext> R ext - LENIS performed yest - ? results. Hct stable at 30.4\n\nGI - Abd obese and soft. +BS. Respalor infusing via OGT at 30ccs/hr (goal 40ccs/hr). Min residuals. No stool, senna and colace administered.\n\nF/E - TFB neg ~850ccs yest, goal one liter neg. Urine output averaging 40ccs/hr via foley. Ionized ca 1.15. AM lytes pend.\n\nID - Max temp 100.5 po. WBC 5.4. PNA rx with vanco and cipro iv.\n\nSkin - Intact, miconazole powder to groin for yeast infection.\n\nSocial - No contacts overnight.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-02-27 00:00:00.000",
"description": "Report",
"row_id": 1515992,
"text": "Respiratory Therapy\nPt remains orally intubated on full ventilatory support of A/C. BS coarse bilat W diminished RLL Sx scant to copious amt thick blood tinged secretions. ABG this AM WNL. please see carevue and nsg note for specifics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-02-27 00:00:00.000",
"description": "Report",
"row_id": 1515993,
"text": "resp. care\npt. remains intubated/vented/sedated. attmepted ps but\nno spont. respirations. peep weaned to 8 with good sats.\nmdi's given. sx'd for bloody sputum. continue slow vent\nwean.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-02-26 00:00:00.000",
"description": "Report",
"row_id": 1515989,
"text": "Nsg Progress Note 1900-0700\n\nCV - Pt febrile to 100.6 PO. BC x2 sent. BP stable but does increase with agitation. Bolus of midaz settles pt and BP back to baseline. HR NSR with occasional PAC. IVF at KVO via right hand IV. Fent and midaz via left arm IV.\n\nResp - BS course bilat. Continues on 50% 500 x 20 with 10 PEEP. Suctioned q 1-2 hours for sm to mod amt creamy thin secretions. No vent changes overnight.\n \\\nGI - Abd large but soft. BS are hypoactive. NGT clamped. No TF's at this time.\n\nGU - Pt recieved 20 mg lasix on evenings with excellent response. UO has been much better.\n\nEndocrine - Pt still requiring RISS coverage but last BS normal and no isulin given.\n\nNeuro = Pt wakes up spontaneously. Sometimes she responds appropriately and other times - she appears very agitated and does not follow any commands. She attempts to assist with turning from side to side but is very weak.\n\nSocial - No contact from anyone over night.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-07 00:00:00.000",
"description": "Report",
"row_id": 1516020,
"text": "Shift Note 1900-0700\nCV: HR 90-113, mostly ST with rare PVC's through night. ABP via right radial art line 150-180/60-70's despite one time dose hydralazine 10mg IV and increase captopril dose. Continues on verapamil as well. Temp spike 104 and once temp dropped back down to 101, BP 120-140/60's. Extremities edematous, PPP.\n\nAccess: PIV x1\n\nResp: Pt appearing very uncomfortable on vent. Settings CPAP/PSV 5/12 with FiO2 40%. RR 37-40, labored breathing. Pt switched by RT to AC 20/500/40/5 and immediately RR 20's and patient appearing much more comfortable. Through most of night, patient breathing at set rate. AM ABG 7.43/47/87/32. RUL coarse, diminished in bases. Snx moderate amount thick tan secretions. Large amount white oral secretions. Pt remained fairly lethargic overnight and zyprexa held. Later zyprexa, zoloft and haldol d/c (?whether fevers d/t medications).\n\nNeuro: Pt opening eyes spontaneously and to verbal command, however inconsistent with following other commands. Nodding head \"yes\" to being in pain and given 50mcq fentanyl with good effect to vital signs (HR/BP improved, however that was same time RT switched patient to AC mode).\n\nGI/GU: Abdomen obese, BS present. Pt on new formulary for Respalor (pulmonary TF's) at goal 40cc/hr. Tolerating well with no residual. Foley cath draining 30-40cc/hr (goal I/O equal). Dropped to 15cc/hr and given 250ccNS fluid bolus with little effect. Large loose green BM x1.\n\nEndo: SSC, BS 190-204.\n\nID: Continues on vanco (needs trough prior to dose today) and ceftazidime. Tmax 104, cooling blanket applied, ice packs with prn doses of tylenol and ibruprofen being given. BC x2 with fungal sent. Sputum to be collected. Urine with sediment (resident aware).\n\nSocial: No contacts . DNR/DNI.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-07 00:00:00.000",
"description": "Report",
"row_id": 1516021,
"text": "npn 1200-1900\n\nneuro: Pt is alert with eyes open. She is mouthing around ETT-- \" I'm hungry\". Able to MAE on the bed and follows commands. PERL. Soft wrist restraints in place for patient safety.\n\nresp: Trialed PS for 45 minutes today, but pt became tachycardic, htn, and tachypneic. Placed on AC and fiO2 was increased to 50% because sats dropped to 89-90%. LS coarse.\n\ncv: SB-SR 55-80's, no ectopy. BP 90-190/50-80's. Started on lisinopril this afternoon.\n\naccess: aline and piv.\n\ngi/gu: TF at 40cc via OGT, belly is soft with + BS, no BM this shift. Patent foley. Good response to 20 IV lasix this afternoon.\n\nskin: Intact.\n\nendo: RISS.\n\nDispo: DNR/DNI.\n\nPlan: Continue to diurese and optimize patient for extubation on Monday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-08 00:00:00.000",
"description": "Report",
"row_id": 1516022,
"text": "INITIAL ADMIT WITH PNEUMONA, REQUIRING INTUBATION..NOW DIFFICULTY TO WEAN...PLAN TO OPTIMISE PATIENT OVER THE WEEKEND WITH INHLAERS/TREATMENTS/LASIX AND P/S TRIALS THEN EXTUBATE ON MONDAY..PATIENT IS NOT TO BE RE-INTUBATED WHEN EXTUBATED ON MONDAY AS PER DISCUSSION WITH TEAM AND HCP ON THURSDAY..PATIENT DNR/DNI....\n\n\n\nNEURO....VERY ANXIOUS AT BASELINE ...PREVIUOSLY ON HALDOL AND ZYPREXA NOW DC AS CONTINUES TO HAVE HIGH FEVERS [ SEE BELOW]...SO PRESENTLY BEING GIVEN ATIVAN PRN AND HAS REQUIRED X2 DOSES..PLUS X1 DOSE OF FENTANYL...WHEN ANXIUOS/AGITATAED HIGH B/P >180 ^RR..DOES OCCASSIONALLY GO TO PULL AT ET TUBE THEREFORE SOFT RESTRAINTS ION PLACE..OCCASSIONALLY MOUTHS WORDS.. MOVES ALL 4 LIMBS, INCONSISTENTLY FOLLOWS COMMANDS..PUPILS EQULA/REACTIVE\n\n\nRESP....RECEIVED ON AC 500X20 50%..P/S TRIAL YESTERDAY FAILED ? REPEAT AGAIN TODAY...ABG SHOWED ALKOLOSIS ? RELATED TO RATE THEREFORE RATE REDUCED TO 18 WITH NO EFFECT ..TEAM AWARE OF ALKOLOSIS ? RELATED TO RECEIVING LASIX THEREFORE LAST NIGHTS DOSE HELD..AND ABG THIS AM SATISAFCTORY...SUCTIONED PERIODIALLY FOR THIN/WHITE SECRETIONS..COPIUOS AMOUNTS OF ORAL SECRETIONS...\n\n\nCVS...WHEN AGITATED/ANXIUOS HR > 100 WHEN SETTELD 85-90BPM, CONTINUES ON HIGH DOSE OF VERAPRAMIL FOR RATE CONTROL...WHEN AGIATED/ANXIOUS B/P SYSTOLIC >200..WHEN SETTELD @ 120-140 , SWITCHED TO LISINOPRIL FOR B/P CONTROL YESTERDAY..\nB/S STABLE,,ALL AM LABS PENDING\n\n\nID...SINCE ADMISSION HAS BEEN FEBRILE WHITH TEMP SPIKES TO 104 [ YESTERDAY ]...RECEIVED AFEBRILE BUT SPIKED AGAIN TO 102..RE-CULTERED..PREVIUOS A LINE AND PERIPHERAL LINES TAKEN OUT/URINE/SPUTUM..THUS FAR NO SOURCE OF INFECTION...?? FOR U/S OF GALLBLADDER/LIVER ?? CSF TAP TO HELP LOCATE SOURCE..ALSO?? DRUG REACTION TO HALDOL THEREFORE D/C...COOLING BLANKET APPLIED AND IBUPROFEN GIVEN..TO CONTINUE TO MONITOR\n\n\nGI..C DIF NEG..NO BOWEL MOTION FOR 2 DAYS. ON REGIME...AT GOAL WITH FEED PULMONARY [ REPLACED RESPALOR ] @ 40, NO RESIDULAS. ABDOMEN OBSES HYPOACTIVE B/S\n\nGU...DAILY LASIX TO MAINTAIN NHEG BALANCE BUT IN THE LIGHT OF METABOLIC ALKOLOSIS NO FURTHE DIURSEIS GIVEN LAST PM.. ?? FOR DIAMOXX TODAY..U/O MAINTAINED > 30CC/HR..\n\n\nSKIN...OEDEMATOUS BUT INTACT..\n\n\nLINES ART LINE SATISFACTORY, X1 PERIPHERAL, VERY DIFFICULT STICK\n\n\nSOCIAL.... IS HER FRIEND WHO IS HCP, DOES NOT HAVE ANY FAMILY... MET WITH TEAM ON THURSDAY AND THE DECSISION WAS TAKEN FOR DNR , NO PRESSORS/ESCALATION OF TREAMENT AND EXTUBATION ON MONDAY, NO RE-INTUBATION SHOULD SHE FAIL .. WILL NOT BE VSISTING UNTIL MONDAY UNLESS HER CONDTION SHOULD CHANGE OVER THE WEEKEND..SHE WANTS TO BE CONTACT SHOULD THAT HAPPEN DAY/NIGHT BUT WILL BE OUT ON TOWN ON SUNDAY AND NOT AVAILABLE UNTIL SUNDAY EVE...SHOULD ANYTHING HAPPEN TO , \"BUBBA\", HER STUFFED MONKEY SITS ON S BED, IS NOT TO THROWN OUT AS IT IS IN THE WILL THAT THE MONKEY GOES TO LAWYER...\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-08 00:00:00.000",
"description": "Report",
"row_id": 1516023,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue, Lung sounds coarse and dim @ bases suct sm=>mod th white sput. MDI given as per order. ABGs stable presently. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-08 00:00:00.000",
"description": "Report",
"row_id": 1516024,
"text": "Resp Care\nPT remains intubated on A/C. MDI's given. ETT repositioned and retaped. No other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-02-26 00:00:00.000",
"description": "Report",
"row_id": 1515990,
"text": "NURSING PROGRESS NOTE 0700-1900 HOURS:\n** FULL CODE\n\n** ALLERGY: PCN\n\n** ACCESS: RIGHT RAD ALINE, 2 PIV'S.\n\nIN BRIEF: PT IS A 70YO, ADMIT ON WITH PMH: COPD (HOME O2) NON-COMPLIANT ON BIBAP, HTN, HIGH ANXIETY, DEPRESSION, PERSONALITY DISORDER, LUNG CA, S/P THOROSCOPIC WEDGE RESECTION, ADENOCARCINOMA, RESTRICTIVE LUNG DX, CHF WITH PRESERVED EF, MORBID OBESITY, HIATEL HERNIA S/ REPAIR, RIGHT TOTAL KNEE REPLACEMENT.\n\nBROUGHT TO ED FROM HOUSE WHERE SHE IS A RESIDENT COPD EXACERBATION- (LAST ADMITTED FOR THIS ON ) SOB, FEVER SPIKE TO 103-GIVEN NEBS/STEROIDS. TRIALED ON BIPAP-CONTINUED WITH INCREASED ANXIETY, RR IN 40'S-INTUBATED AND SEDATED-TX'D TO MICU.\n\nDX: COPD EXAC/RESP FAILURE COMPLICATED BY PNA\n\n\nNEURO: PT IS SEDATE ON FENT/VERSED GTTS. DOES OPEN HER EYES TO VOICE- AT TIMES CALM ENOUGH TO FOLLOW COMMANDS-OTHER TIMES AWAKENS SCARED AND SHAKES AND COUGHS (SETTLES WITH VERSED)INCONSISTENT. PEARL -PINPOINT/BRISK. MOVES ALL EXTS. RESTRAINTS IN PLACE. PT WITH PERSONALITY DISORDER AND NOTED TO HAVE HIGH ANXIETY.\n\nCARDIAC: NSR WITH HR 60'S-80'S. PVC'S. SBP 110-180 WITH MAPS > 65. LE DOPPLERS DONE-RESULTS PENDING. ON VERAPAMIL AND LISINOPRIL.\n\nRESP: INTUBATED # 7.5/20, VENT SETTINGS OF: 50%/AC 20/ TV 500/P 10. LUNGS CLEAR IN UPPER LOBES-RHONCHI TO BIL BASES. SATS > 95%. PEEP DROPPED TO 5 FROM 10 AND PT WAS TO 89-91%-INCREASED PEEP BACK TO 10.\n\nGI/GU: ABD SOFTLY DISTENDED, POS BS, RESPALOR STARTED AT 10CC/HR AT 1600 HOURS. NO BM TODAY. ON LANSOPRAZOLE. FOLEY WITH YELLOW, SEDIMENT URINE. 20MG LASIX WITH GOOD RESPONSE. ? ATN. SEE CAREVUE.\n\nSKIN: INTACT.\n\nID: CONT ON VANCO-PNA. WBC 5.9\n\nENDO: FS Q 6 WITH S.S. AS ORDERED.\n\nPSYCHOSOCIAL: NO FAMILY/SUPPORT CONTACTS. PT AT HOUSE.\n\nDISPO: FULL CODE, CONT MED REGIMEN AND ICU SUPPORTIVE CARE.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-02-27 00:00:00.000",
"description": "Report",
"row_id": 1515994,
"text": "NURSING PROGRESS NOTE 0700-1900 HOURS:\n** FULL CODE\n\n** ALLERGY PCN\n\n** 2 PIVS\n\nDX: COPD EXACERBATION COMLICATED BY PNA\n\n\nNEURO: PT IS SEDATED ON FENT AND VERSED GTTS. WEANED VERSED DOWN FROM 5MG /HR TO 3 MG/HR AS DISCUSSED ON ROUNDS BUT PT REQUIRING AND DOES NOT SEEM TO BE TOLERATING THE WEAN. ADDED HALDOL AND ZYPREXA TO REGIMEN-HAVE NOT SEEN A DIFFERENCE AT THIS TIME. PLAN TO START PROP GTT AND TRY WEANING FROM VENT AT THAT TIME MORE AGGRESSIVELY. PEARL 2MM/BRISK. PT INTERMITTENTLY FOLLOWS COMMANDS, NODS HEAD YES AND NO; HIGH ANXIETY (BASELINE).\n\nCARDIAC: NSR WITH HR 70'S-100. ON MULT BP MEDS-SOME OF IT SEEMS TO BE ANXIETY RELATED AS WHEN MORE LUCID-BP AND HR ELEVATE. BP BASELINE BETTER AT PREDOMINENTLY 120-140'S. ON ACE INHIBITOR FOR AFTERLOAD REDUCTION. VERAPAMIL AND CAPTOPRIL. PLACED ON PNEUMOBOOTS. LENI'S FROM YESTERDAY WERE NEGATIVE. ECG DONE.\n\nRESP: INTUBATED; #7.5/20 WITH SETTINGS OF: 50%/TV 500/R 20/ P 8/ PEEP WEANED FROM 10 TO 8 -TOL THUS FAR. LUNGS ARE CLEAR WITH SOME SCATTERED RHONCHI. TREATING FOR COPD FLARE-FINISHED COURSE OF STEROIDS AND DC'D. CXR REPORTEDLY BETTER. BIGGEST GOAL NOW WILL BE TO WEAN FROM VENT WITH PSYCH ISSUES.\n\n\nGI/GU: ABD DISTENDED, OBESE. RESPALOR AT 40CC/HR-MINIMAL RESIDUALS. SMALL SMEAR TODAY. POS. BS. FOLEY IN PLACE-CLEAR, YELLOW WITH SOME SEDIMENT. GOAL WAS FOR -500 FOR 24HOURS.\n\nID: WBC NORMAL. CONT WITH LOW GRADES-PAN CX'D TODAY. VANCO DC'D. CONT ON CIPRO.\n\nSKIN: INTACT-NO BREAKDOWN.\n\nENDO: FS Q 6 WITH S.S. COVERAGE-DID NOT REQUIRE.\n\nPSYCHOSOCIAL: HCP PHONED TODAY FOR UPDATE. NEEDS TO SPEAK WITH . SHE TOLD ME SHE HAD NUMBER AND CALLED AND LEFT MESSAGE BUT HAS NOT SPOKEN WITH HER TODAY.\n\nDISPO: FULL CODE. PLAN IS TO MORE AGGRESSIVELY WEAN FROM VENT IF ABLE TOMORROW WITH ADDITION OF PROP GTT. CONT MED REGIMEN AND ICU SUPPORTIVE CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-02-25 00:00:00.000",
"description": "Report",
"row_id": 1515984,
"text": "Resp Care Note:\n\nPt received from ER intub with OETT and placed on mech vent as per Carevue. Lung sounds coarse suct sm th yellow sput[spec sent]. ABGs stable after vent settings adjusted to optimize gas exchange. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-02-25 00:00:00.000",
"description": "Report",
"row_id": 1515985,
"text": "Admission Note -0700\nPt 70 y/o Female resident of with COPD (on home O2) with frequent exacerbations. Last admitted for SOB. Pt had just completed steroid taper with prednisone when spiked fever 103 with SpO2 in 80's. In ED patient given steriods and nebs without improvement...brief trial on Bipap but patient anxious with RR 40's. Ativan given without effect...pt intubated/sedated (c/b small tongue laceration)and tx MICU on propofol gtt at 20mcg.\n\nSince arrival to ED patient's HR 130-140's. Upon admit to MICU HR 120's, BP low 100's. Urine dark yellow with minimal output and given 500cc fluid bolus. Tachycardia started to improve with repeat fluid boluses, however no response in UO which has continued to be <20cc/hr throughout night. Resident aware and total 2L NS given.\n\nCV: HR initially tachy, however responded to fluid. Currently 80-90's, NSR with no ectopy noted. Right radial art line placed with ABP 106-120/60's. SBP 160's with agitation/anxiety. K in EW 5.4. Repeat lytes sent upon arrival with K 4.3, Mg 1.8. Resident aware. EKG to be obtained this am. CE (-).\n\nAccess: PIV x2\n\nResp: Pt arrived on AC 12/500/100%/5, breathing over set rate by 4-6 breaths, MV 6. After art line placed, ABG sent 7.26/58/128/27. Vent settings changed AC 20/500/70%/10...corresponding ABG 7.33/47/95/26 with MV 10. BBS with occasional faint wheezing, diminished lower lobes. Sputum cx sent. Patchy opacities noted in left lung per CXR.\n\nNeuro: Pt arrived to MICU with 20mcq propofol infusing and unresponsive to noxious stimulus. Prop stopped for short time until patient started to wake up, RR 30's. Prop restarted, however patient's BP did not tolerate and SBP 70's. Propofol again stopped and fentanyl/versed gtt ordered, in meantime IVP fentanyl/versed given. Pt did not respond to IVP medications and SBP 140-160's, prop restarted for brief period until gtt arrived. Prior to adequate sedation, patient alert, attempting to mouth around Et tube and following commands. Denies pain, but very anxious (anxiety at baseline).\n\nGI/GU: Abdomen soft, BS present. OGT clamped with good placement. Foley cath draining minimal UO. Given total 2L NS with no response. Foley cath flushed with 30cc sterile water per resident and patent. BUN/creat slightly elevated. Urine cx sent.\n\nID: Lacatate 1.2, given dose levaquin in ED. Started on Vanco and Cipro. Low grade temp 99.5. Urine, sputum, BC pnd.\n\nSkin: Intact with mild skin discoloration of lower extremities.\n\nSocial: No contacts . Primary contact in chart listed as patient's friend, .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-02-25 00:00:00.000",
"description": "Report",
"row_id": 1515986,
"text": "neuro: sedated on fentanyl 50 mcg/hr and versed 4 mg/hr (daily wakeup not done ^peep). opens eyes to stimuli but does not follow commands. +mae noted. cough/gag intact. +perrla noted. agitated with care and sbp ^ to 160's responds well to fent/versed bolus.\ncv: monitor shows nsr with occ pac's noted. r radial aline with good waveform anaysis and correlates with nibp. +csm noted. started on po verapamil. cardiac enzymes remain flat. weak palpable pulses bilat.\nresp: ls with occ exp wheezes noted and crackles rll. sxn for sm amts tan secretions via ett. sputum sent for cx. fio2 weaned from .70-.50 this shift. current vent settings: a/c 50x500x20 +10 peep with most recent abg of 7.34/39/80.\ngi: abd soft and obese. +bs noted. no stools this shift. remains npo x meds. +ogt auscultation with bilious returns.\ngu: foley intact and patent draining sm amts amber colored urine with sedimentation noted (14-22 cc/hr). cr up to 1.6. urine lytes sent. ns 500 cc bolus given x2 with no improvement. dr aware. ? atn component.\nskin: r posterior thigh with superficial open area noted. coccyx intact with slight discoloration noted. aloe protective barrier cream applied. bilat lower extremities with skin discoloration.\nendo: remains on fingersticks q6hr with riss.\ni-d: temp max 99.5 po. remains on vanco. awaiting id approval on cipro. lactic acid 1.0.\nheme: received and mag sulfate (mag 1.6) and ca gluconate (io ca 1.05) this shift. afternoon lytes improved.\npsy-soc: friend/hcp called x1 and updated on status and plan of care. ?'s about d/c plan and nursing home placement...referred to . remains full code on micu service.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-02-25 00:00:00.000",
"description": "Report",
"row_id": 1515987,
"text": "Respiratory Therapist\nBreath sounds exhibit few crackles, suctioned for moderate thick tan, FiO2 weaned down to 50% ETT pulled from 23cm at lips to 20cm at lips per doctor's order and with nurse help.Patient will continue to be monitored.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-02-26 00:00:00.000",
"description": "Report",
"row_id": 1515988,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds ess clear but dim @ bases suct sm th tan sput. Pt in NARD on current vent settings; no vent changes required . Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-06 00:00:00.000",
"description": "Report",
"row_id": 1516017,
"text": "Shift Note 1900-0700\nCV: HR 70-80's, NSR with no ectopy. A-line d/c d/t continued elevated temps. NIBP 112/-130/30-40's (correlation of non-invasive and ABP prior to pulling a-line showed 20pt difference). PIV x2.\n\nResp: Pt received on CPAP/PSV 5/12 with FiO2 40%. BBS coarse RUL, diminished lower lobes. Snx small amount of white thin secretions; much less oral secretions. RR 28-32, sats >95%. AM RSBI 185.\n\nNeuro: Pt initially hypertensive, tachypneic and anxious...low dose propofol started at 15mcq. Pt will occasionally open eyes to verbal command and head appropriately to questions. Once nodded head yes to being in pain, but unable to localize the pain and appearing to be resting comfortably. Does not follow other commands. Strong gag/cough.\n\nGI/GU: Abdomen obese, BS hypoactive. TF's respalor at goal and tolerating well...placed on hold d/t possible extubation. Foley cath intact...goal I/O -500-1L. 20mg IV lasix given x2 with fair response. UO 80-220cc/hr. Pt slightly + at MN and -250cc since MN. +4.2L LOS.\n\nEndo: SSC, BS ranging 158-171.\n\nID: Temp spike 102.4. Set of BC sent from a-line prior to d/c. Urine cx sent. Urine yellow with sediment present. PRN tylenol given with no effect. A-line tip sent for cx, although resident aware that removal of line not done completely sterile.\n\nSocial: friend, , HCP. Need to facilitate meeting with HCP prior to extubation to clarify code status and issues with re-intubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-06 00:00:00.000",
"description": "Report",
"row_id": 1516018,
"text": "NURSING NOTE 0700HRS - 1600HRS\n\n\nEVENTS...MEETING WITH HCP , NOT FOR ESCALATING TREATMENT, NOT FOR PRESSORS /DNR ORDER..FOR ET REMOVAL ON MONDAY AND NOT RE-INTUBATION AT THAT TIME...\nHIGH TEMP > 102 FOR MAJORITY OF THE DAY...COOLING BLANKET APPLIED..ART LINE PLACED\n\n\n\nNEURO..RECEIVED LETHARGIC THEN MID - MORNING STARTED TO BECOME AGITATED/ANXIOUS THEREFORE PERSCRIBED OLANAZAPINE GIVEN..SINCE THEN [ AND WITH PERSISTENT HIGH TEMP]..LATHARGIC, OPENING EYES TO VOICE, INCONSISTENTLY FOLLOWING COMMANDS, OCCASSIONAL SPONTANEOUS MOVEMENTS OF LIMBS,PUPILS EQUAL/RECATIVE NO HALDOL REQUIRED AT ALL TODAY AS NO ACUTE PERIODS OF AGITATION..\n\n\nRESP..CONTINUES P/S , NO WEAN TODAY..ABG THIS PM SATISFACTORY..SATS >94% AND SUCTIONED FOR MINIMAL AMOUNT OF CLEAR SECRETIONS....TO CONTINUE TO BE VENTILATED UNTIL MONDAY THEN ET TO BE PULLED WITH NO RE-INTUBATION/BIPAP AT THAT TIME\n\n\nID...FEBRILE.. MAX 102.5..COOLING BLANKET APLIED, NO RESPONSE TO TYLENOL THEREFORE DOSE OF IBRUPROFEN GIVEN WHICH HAS STARTED TO HAVE AN EFFECT THIS PM.. TO CONTINUE TO MONITOR CLOSELY...RE-CULTEERD THIS PM..VANC CONTINUES..X1 PERIPHERAL IV REMOVED AS AREA RED [ LEFT HAND, OBSERVE]...?? CSF TAP AND/ OR US OF LIVER GALL BALDDER FOR FURTHER INVESTIGATION INTO ELEVATED TEMP\n\n\nCVS...NIBP SYSTOLIC >150 THIS AM..ART LINE SHOWS SYSTOLIC >160 TO REVIEW HTN MEDS WITH TEAM...SINUS RHYTHM /TACHY, K MG REPLACE THIS AM\nB/S AS PER S/S\nQTC THIS AM.411..\n\n\nGI.. OBSES SOFT, NO BOWEL MOTION TODAY..RESPALOR NOW D/C THROUGHOUT THE HOSPITAL AND REPLACED BY A FEED CALLED PULMONARY..NUTRTION RECOMMENDED STARTING THE FEED @ 20 TO ENSURE THAT IT IS TOLLERTED BY PATIENT THEN ADVANCE TO THE SAME GOAL @ 40...PRESENTLY @ 30CC/HE AND APPEARS TO BE TOLLERATING, NO RESIDUALS.... ?? US OF LIVER/US , AS ABOVE, BUT LFTS NORMAL TODAY..\n\n\nGU..LASIX 20MGS GIVEN THIS AM..AIM FOR EVEN BALANCE..PRESENTLY NEG @ 500CC..SATISFACTORY OUTPUT TO THIS AM LASIX..?? REQUIRE EVENEING DOSE\n\n\nSKIN..INTACT..HOT TO TOUCH\n\n\nLINES..VERY DIIFICULT STICK FOR BLOODS..ART LINE REPLACED..CURRENTLY HAS X1 IV, HAVE ASKED IV TO REVIEW AND PLACE FIRTHER PERIPHERAL\n\n\nSOCIAL..MEETING WITH MICU/, HCP..SITUATION DISCUSSED...DECISION TAKEN AS ABOVE... WOULD LIKE TO BE CONTACT DAY/NIGHT IF CHANGE IN S CONDITION AND WILL BE HERE ON MONDAY WHEN THE ET TUBE IS REMOVED.. WILL NOT BE AVAILABLE AT ALL ON SUNDAY DAY..SHE HAS REQUESTED THAT IF DOES PASS AT ANY TIME THAT HER STUFFED MONKEY \"BUBBA\" BE GIVEN BACK TO AS IT IS THE REQUEST OF THAT \"BUBBA\" GOES TO HER LAWYER....\n\n\n\nPLAN..CONTINUE PRESENT TREATMENT/CARE..CONTINUE TO INVESTIGATE/TREAT TEMPERATURE CURVE...\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-07 00:00:00.000",
"description": "Report",
"row_id": 1516019,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse improving with suct mod th off white sput. MDI given as per order. ABGs stable when returned to A/C . Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-05 00:00:00.000",
"description": "Report",
"row_id": 1516012,
"text": "7p to 7a Micu Progress Note\n\nNeuro - Pt remains off propofol. Sedated with a total of 20 mg haldol iv for 2 episodes of agitation with good results. QTC .392 - .409. Also being rx with zoloft and olanzepine. Pt moving all exts with purposeful movement. Intermittently follows commands. + spont eye opening.\n\nResp - Vent settings unchanged, remains orally intubated on PSV 15/5/40%. TV's 360-400. RR 20-30. 02 sat > 94%. ABG 7.41/49/103/4/32. Sx via ETT for minimal amts thick tan sputum. Nasal- oral secretions decreased in quantity since yest. LS coarse, diminished at bases.\n\nC-V - HR 70-94 NSR. ABP 120-160/50-66. HTN better controlled on increased dose of captopril and verapamil. Hct stable at 31.5.\n\nGI - Abd obese and soft. +BS. Passing scant amt brown liquid stool via mushroom catheter. Respalor infusing via OGT at goal of 40ccs/hr.\n\nF/E - TFB neg ~450ccs yest. Goal 500cc to 1 L neg. Initially voiding 60-120ccs/hr, output now dropping to 20-30ccs/hr - may require lasix dose this am. AM lytes pend.\n\nID - Max temp 100.6 po. WBC 4.8. Remains covered with flagyl and cipro.\n\nA+P - Continue wean from vent as tolerated and diuresis. Plan is for family meeting today at 1400 to discuss plan of course should extubation attempt fail.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-05 00:00:00.000",
"description": "Report",
"row_id": 1516013,
"text": "Resp Care\nPt. remains intubated/sedated on vent, PSV mode, tolerating well.Vts 350-400cc, with MV 8-9lpm.\nBS: coarse bilat. with occ. scattered exp. wheezes. Sxn'd for sm. thick tan.\nabgs:compensated resp. acidosis with adequate oxygenation.\nPlan: wean ips level as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-05 00:00:00.000",
"description": "Report",
"row_id": 1516014,
"text": "NURSING NOTE 0700 - 1600HRS\n\n\nEVENTS..INCREASINGLY AGITATED ANXIETY MEDS INCREASED, PROPOFOL REQUIRED THIS PM...B/P MEDS INCREASED TO MAINTAIN SYTOLIC <160...LASIX GIVEN AND RESPIRATORY INHALERS ASLO REVIWED IN PREP FOR POSSIBLE EXTUBATION TOMORROW..FEBRILE @ 101.6, CULTERED, VANC COMMENCED..\n\n\n\nNEURO..RECEIVED AGITATED RR^^ B/P ^^ INCONSISTENTLY FOLLOWING COMMANDS, GIVEN HALDOL WITH AN EVENTUAL EFFECT...REVIWED ON ROUNDS AND HALDOL DOSE INCREASED...OLANAZAPINE DOSE ASLO INCRESAED PLUS PRN FOR ATIVAN ORDERERED..AGAIN LATE MORNING BECAME AGITATAED ? CAUSE..ATIVAN TRIED BUT WITH LITTLE EFFECT THEREFORE HALOPERIDOL GIVEN WITH SOME EFFECT, AGAIN HIGH B/P RR AND MOVING ALL 4 LIMBS..PROPOFOL COMMENCED [ AS NEW LINE TO BE PLACED, SEE BELOW] FOR ONGOING AGAITATION HIGH RR AND B/P....PRESNTLY ON 20MCKGS, HAVING RECEIVED BOLUS OF 1CC..EASY TO ROUSE PUPILS EQUAL/REACTIVE AND CONTINUES TO HAVE SPONTANEOUS MOVEMENT IN ALL 4 LIMBS.,.?? DISCONTINUE PROPOFOL WHEN LINE PLACED LATER PM\n\n\nCVS....WHEN ANXIOUS/AGITATED SYSTOLIC >180 WHEN RESTED B/P @ 120-130 SYSTSOLIC...VERAPRAMIL AND CAPTOPRIL INCRESAED AGAIN TODAY...AIM SYSTOLIC < 160 [ AT LEAST]HR 95-105 SINUS..K/MG REPLETED AM , CHECK SATISFACTORY..QTC @ .397 ON EKG\nB/S AS PER S/S\n\n\nID..FEBRILE @ 101.6 BLOOD CULTERES RE-DRAWN [ ARTERIAL/PERIPHERAL]..TEAM WANT TO TAKE OUT EXISTING A LINE GIVEN RISING TEMP..TEAM PRESNTLY ATTEMPTING TO PUT IN NEW LINE..VANC RE-COMMENCED CIPRO/ D/C..\n\n\nRESP..RECEIVED ON P/S AT 15/5 SATISFACTORY ABG EVEN WHEN RR 35-40..P/S REDUCED TO 12 AGAIN SATISFACTORY ABG...TV @ 300-320 SATS >94%..LUNGS SOUND CLEAR THIS PM..FOR PSSIBLE EXTUBATION TOMORROW [ SEE BELOW]..INHALERS REVIWED TO OPTIMISE RESP STATUS.. NO FURTHER WEAN FOR TODAY\n\n\nGI..TOLLERETING FEED RESPALOR @ 60..., SOFT HYPOACTIVE B/S ..WANTING TO USE BED PAN THIS AM..MUSHROOM CATH TAKEN OUT, PASSED SMALL AMOUNT OF STOOL ON BED PAN....REQUESTED BED PAN SEVERAL TIMES SINCE BUT NO FURTHER STOOL PASSED...\n\nGU..TEAN REVIEW THIS AM, LASIX TO BE GIVEN AND AIM FOR 1L NEG..LASIX GIVEN WITH SOME EFFECT..BUT IN VIEW OF HIGH TEMP TO HOLD OF ANY FURTHER DIURSESIS AND REVIEW AGAIN PM\n\n\nSKIN..INTACT\n\nLINES..FOR EXISTING ART LINE REMOVAL AND NEW ONE TO BE PLACED AS CONTINUES TO BE FEBRILE...X1 PERIPHERAL ALSO TO BE REMOVED\n\n\nSOCIAL.. HCP IN CONTACT TODAY, MYSELF AND THE TEAM HAVE SPOKEN WITH HER AND UPDATED..TO HAVE MEETING WITH HER TOMORROW @ 2PM RE ONGOING CARE AND ISSUES OF RE-INTUBATION ONCE PATIENT EXTUBATED\n\n\n\nPLAN..RESP SUPPORT..MONITOR CVS/SEDATION/MEDS FOR ANXIETY...? LASIX GAIN THIS PM FOR NEG BALANCE\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-05 00:00:00.000",
"description": "Report",
"row_id": 1516015,
"text": "Respiratory Therapy\n\nPt remains orally intubated on PSV. Weaned to +12PSV/+5PEEP w/ ABG acceptable. BS slightly diminished/coarse, suctioned for small amounts of thick whitish sputum. MDIs given as ordered. SpO2 remained 90s. See resp flowsheet for specifics.\n\nPlan: maintain support\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-11 00:00:00.000",
"description": "Report",
"row_id": 1516035,
"text": "NURSING NOTE 0700HRS - 1800HRS\n\nRECEIVED CMO AS OF ...\n\n RECEIVED ON MORPHINE DRIP @ 2.5MGS HR AND PATIENT COMFORTABLE /NO SIGNS OF DISTRESS AND NOT IN PAIN, MINIMALLY ROUSABLE AND HAS BEEN IN THAT POSTION FOR MAJORITY OF THE DAY..ART LINE D/C AND MEDS D/C AS OF YESTERDAY...EXCEPT FOR MORPHINE DRIP..\n\nAT APPROX 1600HRS APPEARED IN RESPIRATORY DISTRESS, EYES OPEN, DISTRESSED..THEREFORE MORPHINE DRIP BOLUSED WITH 2-4MGS INCREASED TO 7 THEN TO 10MGS FOR ONGOING SITUTAION...COPIUOS AMOUNTS OF SECRETIONS FROM THE BACK OF THE MOUTH AND SOUNDS GURGLY..SUCTIONED WITH 14 FRENCH WITH SOME EFFECT/RELIEF...TEMP @ 100.5 @ 17.30HRS THEREORE PATIENT GIVEN 650MGS ACETAMINOPHEN PR...PATIENT RE-POSTIONED..TO CONTINUE TO MONITOR TEMP AND PATIENTS COMFORT LEVEL WITH INCRESAE DRIP AS REQUIRED\n\n HCP TELEPHONED THIS AM AND IS AWARE OF THE POSSIBILITY OF TRANSFER TO THE FLOOR...SHE WILL CALL AGAIN THIS EVE AND WANTS TO BE INFORMED IF PASSES....SHE WILL COME AND COLLECT \" BUBBA\" AT SOME POINT IF/WHEN PASSES\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-06 00:00:00.000",
"description": "Report",
"row_id": 1516016,
"text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. No vent changes overnight. COntinues on Cpap/PS with peep of 5, IP 12 and fio2 40%. Spontaneous tidal volumes are around 300 with rates in the high 20's. Breathsounds are decreased. Bronchodilators given. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation. Wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-09 00:00:00.000",
"description": "Report",
"row_id": 1516029,
"text": "NURSING PROGRESS NOTES\n\nREVIEW OF SYSTEMS\n\nNEURO: PT ALERT THIS AM AND FOLLOWED SIMPLE COMMANDS, ABLE TO SQUEEZE HANDS AND WIGGLE TOES AND NOD TO SIMPLE QUESTIONS YES OR NO. PERL 3MM\nPT RESTLESS AT TIMES HALDOL 10MG GIVEN THIS AM ATIVAN 2MG IVP GIVEN THIS AFTERNOON. W/ GOOD RESULTS.\n\nRESP: PT CONT ON SAME VENT SETTINGS. ORALLY INTUBATED #7.5 19 AT LIP LINE. LS COARSE TO EXP WHEEZE UPPER LOBES W/ DIMINISHED BASES. SUCTIONING THIN WHITE SECRETIONS FROM ETT AND COPIOUS ORAL SECRETIONS.\nABG 7.48/40/98/31\n\nCV: TELE SR 60-80S SBP 90-130S. VERAPAMIL DECREASED TO 120MG D/T LOW BP LAST NIGHT. VERAPAMIL NOT GIVEN THIS AFTERNOON D/T SBP 90S.LISINIPRIL NOT GIVEN D/T SBP 90S (PER SET PARAMETERS) HRT SOUNDS S1S2 W/ SYSTOLIC MURMUR. HCT 24.4 THIS AM. WILL NOT TX UNTIL HCT <21.\nCVP 18-20 THIS AM. LASIX 20MG IVP GIVEN AFTER URINE LYTES SENT. CVP AFTER LASIX 13.\n\nGI: TF AT GOAL RESIDUALS <5CC. ABD OBESE BS +, MUSHROOM CATH PLACED THIS AM FOR LG AMOUNT OF LIQUID GOLDEN STOOL 200CC DRAINED SPEC SENT FOR CDIFF. GUIAC NEG.\n\nGU: FOLEY DRAINED 40-200CC/HR OF YELLOW URINE\n\nSKIN: INTACT\n\nCODE:DNR/DNI\n\nSOCIAL: FRIEND AND HCP WILL BE AWAY ALL OF TODAY.\n\nID: PT POS FOR COAG NEG STAPH IN SPUTUM AND OLD ALINE TIP. ON CEFTAZ AND VANCO. LACTATE 1.2\n\nPLAN:\n\nCONT TO MAINTAIN PT COMFORT LEVEL USING HALDOL, FENTANYL, ATIVAN\nEXTUBATE . PER PCP AND HCP PT NEED TO ORDER MS GTT/BOLUSES BEFORE EXTUBATION IN CASE PT FAILS.\n? CHECK ANOTHER HCT TONIGHT\n\"BUBBA\"( STUFFED ANIMAL ON BED) IS TO GO TO HER LAWYER IF SOMETHING IS TO HAPPEN TO HER, PLEASE DO NOT THROUGH OUT!!!!!!\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-10 00:00:00.000",
"description": "Report",
"row_id": 1516030,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm th white sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required . Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-10 00:00:00.000",
"description": "Report",
"row_id": 1516031,
"text": "Nursing Progress Note:\n\nNeuro: Pt. was more responsive tonight, opening eyes spontaneously, nodding head in response to questions, and following commands inconsistently. When not restrained she reached for her ETT. Pt. did indicate that she was uncomfortable at times and was given Ativan and Fentanyl with good effect.\n\nCV: HR 60s-80s NSR with no ectopy, ABP 90s-130s/40s-50s, CVP 12-16. Pt. has 2 PIVS, a R SC MLC and a R radial arterial line all of which are patent and WNL. The arterial line is somewhat positional but was redressed and seems to have a sharper waveform with higher ABP readings than previously.\n\nResp: Pt. remains intubated and on vent settings of AC 500X18/50%/5. LS are clear to course with suctioning of small amounts of thick, white secretions. RR 18, 02sats >97%. No pressure support trials due to plan to extubate pt. tomorrow.\n\nGI: TF of Pulmonary @ goal of 40cc/hour. Minimal residuals, BSX4. Loose golden stool via mushroom catheter.\n\nGU: UO about 40cc/hour. Pt. given one dose of 20mg Lasix to stimulate\nUO @ 0500.\n\nEndo: FSBG covered by sliding scale.\n\nSkin: Intact\n\nSocial: Friend who is HCP called and is planning to be here for extubation of pt. tomorrow. Bubba the bear is to be given to pt's lawyer per her wishes so don't throw away.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-10 00:00:00.000",
"description": "Report",
"row_id": 1516032,
"text": "NURSING NOTE 0700HRS - 1700HRS\n\n\nEVENTS...ETUBATED/CMO @ 15.15HRS, MORPHINE DRIP COMMENCED.. HCP IN \n\n\n\nNEURO..RCEIVED DOSES OF FENT/ATIVAN THIS AM FOR AGITATION/ANXIETY /PAIN..NODS HEAD/YES/NO WHEN ASKED...THIS PM MORPHINE DRIP COMMENCED ONCE EXTUBATED..BOLUSED WITH 2MGS AND DRIP COMMENCED @ 2MGS BUT INEFFECTIVE AND LOOKED DISTRESSED WITH BREATHING THEREFORE INCRESAED TO 5MGS..PRESENTLY LOOKS COMFORTABLE , SEDATED EYES OPEN TO STIMULI, PUPILS EQUAL/REACTIVE\n\n\nCVS...B/P GENERALLY WELL CONTROLLED THIS AM ON HTN MEDS..AND SINCE EXTUBATION < 160 SYSTOLIC..HR RANGING 95-105BPM..NOW OF ALL CARDIAC MEDS..CVP 8\nAFEDRILE TODAY, AB'S NOW D/C..\nB/S STABLE\n\n\nRESP..RECEIVED ON AC , P/S TRIAL UNSUCCESFULL AND ET TUBE PULLED @ 15.15HRS..INITIALLY RR TO 40 AND PATIENT LOOKED UNCOMFORTABLE, NOW @ 26 WITH SATS AT 100% IN FACE TENT..LUNGS SOUND RELATIVELY CLEAR WITH OCCASSIONAL EXP WHEEZE\n\n\nGI..LIQUID STOOL VIA MUSHROOM CATH..FEED D/C WHEN ET PULLED\n\nGU..ADEQUATE U/O > 30CC/HR, NO FURTHER LASIX\n\nSKIN..OEDEAMTOUS BUT INTACT\n\nLINES..CENTRAL/ART LINE PATENT\n\n\n\nSOCIAL... MET WITH TEAM AND GEARATRITION THIS PM AND DISCUSSED CMO... WAS HERE WHEN THE ET TUBE WAS TAKEN OUT...SHE HAS NOW GONE HOME BUT WOULD LIKE TO BE INFORMED OF ANY DETERIORATION WITH HER CONDITION BUT WILL NOT BE VISISTING AGAIN TODAY..\n\n\nPLAN...COMFORT WITYH MORPHINE /OXYGEN THERAPY..EMOTIONAL SUPPORT TO PATIENT..KEEP INFORMED..KEEP BUBBA SAFE!\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-10 00:00:00.000",
"description": "Report",
"row_id": 1516033,
"text": "Resp Care\nPt received on mech vent parameters noted. Pt extubated to 100% cool mist aerosol. Pt made CMO-given morphine. Bronchodialtors discontinued at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-11 00:00:00.000",
"description": "Report",
"row_id": 1516034,
"text": "Nursing Progress Note:\n\nUneventful night.\n\nNeuro: Pt. is arousable to voice, not following commands but still with some purposeful movements (resists having arm repositioned for a-line waveform). She seems comfortable on 2.5mg/hour Morphine gtt. Pt. does not tolerate repostionting well, 2mg boluses given to promote comfort..\n\nCV: HR 80s-90s, ABP 110s-130s/50s-60s. BP and HR do increase with repositioning.\n\nResp: Pt on Coolneb mask at 70% 02. Insp and exp wheezes noted to all lobes with occasional clearing of upper lobes. RR teens, 02 sats >96%.\n\nGI: BSX4, liquid golden stool from mushroom cath.\n\nGU: UO 10-40cc/hour urine via mushroom cath.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-03 00:00:00.000",
"description": "Report",
"row_id": 1516004,
"text": "Shift Note 1900-0700\nCV: HR 80-90's, NSR with occasional PVC's. ABP via right radial art line 120-140/60's; Pt hypertensive with SBP 200's when awake/stimulated; captopril increased yesterday. Prn haldol for agitation; Qtc 0.39. Hct 32.4. PIV x2. Art line with good waveform, however catheter pulled out slightly. 1+ pitting edema noted to BUE. PPP.\n\nResp: BBS clear, diminished in bases. Snx small amount of clear thick secretions. Copious clear thick oral secretions. Received on CPAP/PSV 8/8, FiO2 40%. Pt tolerated SBT yesterday with ?possible extubation, however am RSBI 187. TV 250-350 with MV~8.\n\nNeuro: Pt does not open eyes to verbal command, but did spontaneously open eyes when being bathed. Will not follow commands; withdraws to nailbed pressure. Strong cough/gag reflex. Pupils 2mm, BSK. Continues on low dose propofol (15mcq) for sedation.\n\nGI/GU: Abdomen obese, BS hypoactive-present. Pt tolerating TF's at goal 40cc/hr Respalor; stopped at 0100 for possible extubation, may restart. No BM this shift, on senna and colace. Foley bag leaking and switched. Given 20mg IV lasix with good response. Pt diuresed ~1L, clear/yellow urine. +4400 LOS, -900 since MN.\n\nID: Continues on Cipro. Spiked temp last night 101.4...pt pan cx.\n\nSocial: HCP called last night and given updates. Will possibly be in to visit patient today.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-03 00:00:00.000",
"description": "Report",
"row_id": 1516005,
"text": "RESP CARE: Pt remains intubated on mech vent per carevue. On PS all shift. Vts 300s/RR23-35. Lungs coarse bilat. Sxd thick clear RSBI-187\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-03 00:00:00.000",
"description": "Report",
"row_id": 1516006,
"text": "0700-1900 NPN:\n\nPLEASE SEE CAREVUE FLOWSHEET FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. DR PAGER# ON CALL FOR MICU TEAM TONIGHT. PT CURRENTLY SEDATED ON PROPOFOL GTT @ 30MCG/KG/MIN. SEDATION TURNED OFF X 1HR THIS SHIFT IN ATTEMPTS TO EXTUBATE, PT OPENED EYES TO VOICE AND FOLLOWED SIMPLE COMMANDS OF HAND GRASP AND FOOT PUSHES, BUT UNABLE TO NOD HEAD YES/NO TO QUESTIONS. WITH PT WITHDRAWS TO PAINFUL STIMULI, DOES NOT OPEN EYES OR FOLLOW COMMANDS, MAE, PERLA- 2MM/SLUGGISH. BILAT WRIST RESTRAINTS ON FOR SAFETY. PT EXTREMELY AGITATED AT TIMES R/T ETT AND BECOMES HYPERTENSIVE W/ SBP 180-220, HOWEVER AT THIS TIME PT STILL DOES NOT OPEN EYES OR FOLLOW COMMANDS. LS= COARSE. 02 SAT 94-100%. RECEIVED PT ON CPAP+PS @ 8/8/40%, WEANED TO PSV 5/5/40% THIS SHIFT. ABG=7.40/45/91. SBT DONE X APPROX 1 HR, ABG=7.44/44/95. ABD BREATHING, AGITATION W/ RR=38-41, AND TV 180-300 NOTED DURING SBT. MICU TEAM IN TO ASSESS PT AND DECIDED NOT READY FOR EXTUBATION TODAY. SEDATION AND TUBE FEEDS RESUMED A/O. NSR TO ST @ 86-110. TEMP MAX 101.8, TYLENOL GIVEN, NOW 100.6. CDIFF CX #2 SENT TODAY, #1 CX NEGATIVE. LAST BLD CX PENDING FROM 2400 THIS AM. ABP= 149-220/61-120. ABD SOFT/ OBESE. PRESENT BS, LARGE LOOSE BROWN STOOL THIS SHIFT. MUSHROOM CATH APPLIED. RESPALOR INFUSING @ GOAL 40CC/HR VIA OGT. FOLEY CATH D/S/P DRAINING CLEAR YELLOW UOP 40-60CC/HR. 24HR NFB NEG 600CC SINCE MN, LOS 24HR NFB POS 4.6 LITERS. FS QID ON S/S COVERAGE. SKIN INTACT. FULL CODE. HCP/FRIEND VISITED AND UPDATED ON PT'S CONDITION BY MICU TEAM TODAY.\n\nPLAN- MAINTAIN VENT SETTINGS TONIGHT, OPTIMIZE RESP STATUS AND RE-EVAL FOR EXTUBATION IN AM. MONITOR TEMP AND WBC TREND, AND FOLLOW UP ON CX RESULTS. #3 CDIFF CX DUE TOMORROW. PLAN FOR MEETING W/ MICU TEAM, PT'S PCP, HCP ON WEDNESDAY TO DISCUSS POSSIBLE DO NOT RE-INTUBATE STATUS. CONTINUE ICU SUPPORTIVE CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-04 00:00:00.000",
"description": "Report",
"row_id": 1516007,
"text": "7p to 7a Micu Progress Note\n\nOverview of Events - Pt febrile to 102.3 - accompanied by tachycardia, hypertension and tachypnea. Rested on AC overnight with improvement in VS.\n\nNeuro - Difficult to maintain adeq level of sedation as pt alternates between being minimally responsive to periods of agitation where she gags on ETT and becomes hypertensive with SBP 190's. PERLA. Localizes to painful stimuli. No spont eye opening or purposeful movement of exts noted when sedated. Presently receiving 20mcgs/kg/min propofol but has required occasional boluses. Medicated with 10 mg haldol iv with little effect. QTC .386. Continues to receive zoloft and olanzepine as well.\n\nResp - Received pt orally intubated on PSV 5/5/40%. With temp, RR rose to upper 30's and sats ran ~ 94-95%. HR up to 118 ST and SBP 190's. Rested on AC 500/20/5/40% - ABG 7.46/40/126/5/29. RR 20. Sats 97%. LS coarse, diminished at bases. Sx for sm amts clear thick sputum via ETT. Copious clear oral secretions. ETT rotatated and retaped. Plan is to return pt to PSV this am.\n\nC-V - HR 70-118 ST, occas PAC's. ABP 120-200/50-60. Rx with captopril and verapamil. 2+palp peripheral pulses. Hct 30.9, previously 32.4.\n\nGI - Abd soft and obese. +BS. Respalor infusing via OGT at goal of 40ccs/hr - no residuals. Passing sm amt loose brown stool via mushroom catheter. Needs spec sent for c-dif this am.\n\nF/E - TFB neg ~300ccs yest. Goal neg 500 to 1 L. Of note, pt with lg insensible loss due to diaphoresis from fever. Urine output 30-200ccs/hr via foley. Ionized Ca 1.05 yest - repleted with 2 gms ca gluc iv.\n\nID - Max temp 102.3 po. 2 Bld cx's (one peripheral and one from aline)as well as urine c+s sent at onset of shift. Lab reported one set of BC's contained gm +cocci in pairs and clusters - ? contaminant. Repeat set of BC's sent from aline this am. Pt started on IV vanco. Continues to receive iv cipro and flagyl. Temp rx with tylenol q 4hrs and ice packs. WBC 5.1\n\nSkin - Diaphoretic and reddened. Sm dime-sized decub noted on posterior aspect of R thigh - ? due to port on mushroom catheter rubbing against it. Area cleansed with soap and h20, duoderm applied.\n\nEndo - On prednisone taper, RISS. No insulin administered overnight.\n\nSocial - No contacts overnight. ? family meeting on \n\nA+P - Continue to assess efficacy of sedation. Return to PSV as tolerated. + BC's - Monitor temp - cooling and comfort measures, antibiotics as ordered, follow-up on cx results.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-04 00:00:00.000",
"description": "Report",
"row_id": 1516008,
"text": "Resp Care\nPt. received on , progressively more tachypneic, hyperdynamic and febrile. Changed to AC to rest, tolerated well with improved Vs's and non-labored respirations. Morning abg within acceptable parameters.\nBs: coarse at times with exp. wheezes and bibasilar crackles.\nPlan: Changed back to PSV, does not appears to be a good canidate for extubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-04 00:00:00.000",
"description": "Report",
"row_id": 1516009,
"text": "Respiratory Therapy\n\nPt remains orally intubated on PSV. Currently on +15PSV/+5PEEP w/ Vt ~400 RR ~30 maintaining Ve ~11L. Trialed on SBT this afternoon, tolerated well for a couple hours, became tachypneic w/ drop in Vt, so IPS was increased. BLBS slightly coarse, suctioned for small amounts of thick white sputum. MDIs given as ordered. See resp flowsheet for specifics.\n\nPlan: maintain support; RSBI in AM; ?extubate\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-04 00:00:00.000",
"description": "Report",
"row_id": 1516010,
"text": "Respiratory Therapy addendum:\n\nPt travelled to and from CT for scan of head w/out incident.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-04 00:00:00.000",
"description": "Report",
"row_id": 1516011,
"text": "NPN 7a-7p\n\n Pt. febrile until this afternoon when fever broke to 99.8. Hypertension an issue today, now better controlled w/ adjusting of PO med regimen. Propofol off since 2pm for SBT and \"sedation vacation\". Pt. tolerating decreasing amounts of PSV. 3rd sample of stool sent for c.diff. Head/ Sinus CT done this am to r/o sinusitis as likely cause of fever. Vanco d/c'd, pt. remains on Cipro IV and flagyl PO. Family meeting w/ PCP and MICU team tom'row at 2pm.\n\nReview of Systems--\n\nNeuro- Off Propofol since 2pm, previously at 20mcg/kg/min. Pt. alert off sedation, occasionally nodding appropriately, not moving extremeties when asked. Pt. conts on zoloft and olanzepine. Olanzepine appears to have contributed to pt. ability to tolerate being off Propofol.\n\nResp- Multiple vent changes today. Pt. currently on PSV 15/ PEEP 5 40% after being on SBT and PSV 5/5 for 4+ hours this afternoon. Decision made to not extubate pt. despite wakefulness and fair RSBI b/c of tom'row family meeting. Decision of reintubation if pt. fails extubation needs to be made tom'row at the meeting. Copious nasalphayngeal/ oral secretions led to CT this am. Sinusitis most likely not cause of fever given that it was not impressive on study per intern. Team is discussing abx. vs. no abx now. ETT secretions are minimal and sat's have been stable throughout the day. Plan- rest on higher levels of PSV tonight, will tolerate tachypnea to RR 30, TV 200-300 as long as O2 sat's >94-95%.\n\nCV- VSS w/ hypertension throughout the day, now better controlled w/ increase in Verapamil dosing. Pt. received lasix this afternoon for low u/o, aiding in decreasing BP. FB goal -500cc and pt. is about that now including stool output. Edema noted throughout extremeties. Duoderm intact on right thigh, no pressure areas noted.\n\nGI- ABD obese, +BS, 500cc out of stool this shift. 3rd spec sent for c.diff and stool softeners held today. TF cont at goal of 40cc/hr of Respalor.\n\nGU- U/o marginal throughout the late morning, picked up and responsive to lasix 20mg given at 1600. Currently, no IVF or meds running.\n\nID- Febrile to 102 range, now down to 99.8. Cx's from this am pending. STAR ICU study swabs sent. Nasopharyngeal aspirate not done d/t high likelihood that it would be a contiminated sample from oral secretions. Vanco d/c'd as 1 bottle GPC noted thought to be contiminate. Cipro and flagyl cont. ? starting 3rd to cover sinus infection...\n\nSocial- meeting arranged for tom'row w/ PCP and team / HCP. to discuss is pt. fails extubation, will we reintubate?\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-02 00:00:00.000",
"description": "Report",
"row_id": 1516000,
"text": "RESP CARE: Pt remains intubated,on mech. vent per carevue. Tachypneic at times. Lungs crackles bilat with exp wheezes. RSBI-101.7. Plan: Would consider resting pt in light of her severe COPD, temp spike today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-02 00:00:00.000",
"description": "Report",
"row_id": 1516001,
"text": "Neuro: Pt. is sedated on Propofol 30mcg/kg/min, does not open eyes or follow commands, withdraws to nail bed pressure, occasionally moves extremities, +PERRLA, intact cough/impaired gag.\n\nResp: CPAP , FiO2 40%, VT 300s-480s, sats 93-97%, rr 20s-40s. Frequent coughing noted with SBP up in 190s-200s, rr in 40s. Suctioned for blood tinged thick secretions. LS coarse bialt.\nResp. culture sent.\nCV: HR 80s-100s, SR to ST, no ectopy noted. ABP 130s-200s/80s-90s. Palpable pedal pulses, no pedal edema noted. Lytes pending.\nUO 30-100cc/hr.\n\nGI/GU: TF at 40cc/hr, minimal residuals. Abd. obese, soft, nontender, +BS, no BM. FOley patent, yelllow urine with sediment.\n\nID: Tmax 102.6, medicated with Tylenol with minimal relief, ice packs applied, T current 101. Team aware. Continues on Cipro IV.\n\nSkin intact.\n\nSocial: Health care proxy called, updated on status and plan of care by this RN, would like MICU team to call her today preferrably in the afternoon or evening.\n\nPlan: Attept weaning sedation and vent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-02 00:00:00.000",
"description": "Report",
"row_id": 1516002,
"text": "RESP CARE\n\nPt was weaned to with a follow up abg of 7.34/53/106/30. SBT started and after 1.5 hrs abg 7.32/56/121/30. TV did drop to aprox 300cc's. Bs are diminished to coarse and suctioning thick white sputum\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-02 00:00:00.000",
"description": "Report",
"row_id": 1516003,
"text": "0700-1900 NPN:\n\nPLEASE SEE CAREVUE FLOWSHEET FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. DR SMALL PAGER# ON CALL FOR MICU TEAM TONIGHT. RECEIVED PT SEDATED ON PROPOFOL GTT @ 30MCG/KG/MIN, OFF X 1HR THIS SHIFT FOR DAILY WAKE UP IN ATTEMPTS TO EXTUBATE. PROPOPFOL CURRENTLY INFUSING @ 15MCG/KG/MIN. PT WITHDRAWS TO PAINFUL STIMULI W/ NO EYE OPENING, MAE, PERLA, BILAT WRIST RESTRAINTS ON FOR SAFETY. DURING DAILY WAKE PT OPENED EYES TO VOICE AND TOUCH, BUT VERY LETHARGIC AND UNABLE TO FOLLOW COMMANDS. MICU TEAM IN AT BEDSIDE TO ASSESS. PROPOFOL RESUMED, AND WILL RE-EVAL FOR EXTUBATION IN AM. RECEIVED PT ON CPAP+PS @ 8/8/40%, AM RSBI-102. WEANED TO PSV @ , ABG= 7.34/53/106. SBT DONE X APPROX 2HRS, PT TOLERATED FAIRLY WELL W/ MINIMAL ABD BREATHING AND RR 30'S. ABG= 7.32/56/121. LS= COARSE/DIM. 02 SAT 96-100%. RR=23-35. NSR TO ST @ 77-108. TEMP MAX=100.6, BLD CX SHOW NO GROWTH FROM AND SET FROM STILL PENDING. IV CIPRO CONTINUES, AM WBC= 4.7. ABP= 132-210/55-100. MICU TEAM AWARE OF HYPERTENSION W/ SBP TO 200 DURING PERIODS OF AGITATION. IV HALDOL GIVEN PRN X 2DOSES THIS SHIFT FOR AGITATION. CAPTOPRIL DOSE INCREASED, AND VERAPAMIL CONTINUES. ABD SOFT/ DISTENDED. PRESENT BS, LARGE LOOSE BROWN STOOL X2. CDIFF CX SENT A/O. RESPALOR INFUSING @ GOAL 40CC/HR VIA OGT. FOLEY CATH D/S/P DRAINING CLEAR YELLOW UOP 30-130CC/HR. FS QID ON S/S COVERAGE. SKIN INTACT. BARRIER CREAM APPLIED TO COCCYX. FULL CODE. MICU TEAM CALLED PT'S FRIEND/HCP AT HOME TODAY TO GIVE UPDATE ON PT'S CONDITION.\n\nPLAN- PLEASE STOP TUBE FEEDS AT MN TO MAINTAIN NPO STATUS. PLAN FOR POSSIBLE EXTUBATION FOR TOMORROW, RT TO PERFORM RSBI AND SBT IN AM. ASSESS TEMP AND WBC TREND, FOLLOW UP ON CX RESULTS. CONTINUE ICU SUPPORTIVE CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-02-28 00:00:00.000",
"description": "Report",
"row_id": 1515997,
"text": "resp. care\npt. remains intubated/vented. vent changed to ps and weaned to\n with good vols. and abg. mdi's given. continue ps wean\nand rsbi's. see flowsheet for more.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-01 00:00:00.000",
"description": "Report",
"row_id": 1515998,
"text": "Shift Note 1900-0700\nCV: HR 80-90's, NSR with no ectopy. ABP via right radial art line 120-130/50-60's when patient adequately sedated, otherwise patient extremely anixous with SBP 160-200 when awake or sedated. Pt on verapamil and captopril.\n\nAccess: PIV x2\n\nResp: Pt received on CPAP/PSV 12/8; PSV increased to 15 with FiO2 40%. AM ABG 7.40/50/98/32. BBS clear-coarse in upper lobes, diminished in bases. Snx small amount of tan thick secretions. Pt with moderate amount of clear oral secretions. Team ?extubation this am, RSBI 149\n\nNeuro: Pt sedated on 30mcq propofol; easily arousable, when stimulated very anxious and tachypneic/hypertensive. Given prn haldol with little effect. Another one time order wrote for 10mg Haldol, still with little response. Qtc .39 Propofol gtt eventually increased to 40mcq. Pt with purposeful movement, will try to reach for ET tube. Follows simple commands, denies pain.\n\nGI/GU: Abdomen obese, BS present. Respalor TF's infusing at goal 40cc/hr with no residual. Foley cath draining 60-400cc/hr yellow urine with sediment. Small loose BM x2 this shift, bowel meds held.\n\nID: Pt continues with low grade temp. Pan cx ...urine (-), sputum with no growth and BC x2 pending. Pt receiving Cipro.\n\nSocial: friend and HCP called unit last evening and given updates. Requesting to speak with case management on Monday regarding placement in nursing facility.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-03-01 00:00:00.000",
"description": "Report",
"row_id": 1515999,
"text": "0700-1900 NPN:\n\nPLEASE SEE CAREVUE FLOWSHEET FOR OBJECTIVE DATA AND FURTHER SHIFT DOCMENTATION. DR PAGER# ON CALL FOR MICU TEAM TONIGHT. PT SEDATED ON PROPOFOL GTT, RECEIVED PT ON 40MCG/KG/MIN. WEANED TO 30MCG/KG/MIN AND IV HALDOL 10MG PRN X 2DOSES THIS SHIFT. QTC LEVEL= 0.41. PT DIFFICULT TO AROUSE AT TIMES, BUT EXTREMELY AGITATED W/ DECREASED SEDATION AND BECOMES HYPERTENSIVE W/ SBP=200. TEAM AWARE. MAE, PERLA- 2MM/SLUGGISH. BILAT WRIST RESTRAINTS ON FOR SAFETY. RECEIVED PT INTUBATED ON CPAP+ PSV @ 15/8/40%. WEANED TO PSV @ 8/PEEP=8/40%. PM ABG ON PSV 10/8= 7.41/47/87. RECENT ABG PENDING. RT AND ATTENDING MD ATTEMPTED TO WEAN PEEP TO 5, TV DROPPED BY 100. NO CHANGE IN PEEP MADE THIS SHIFT. TV= 320-380. RR= 24-37. 02 SAT 94-97%. LS= COARSE TO CLEAR AFTER SXN. ORAL YANKAUER SXN FOR MODERATE AMTS OF CLEAR THIN SECRETIONS AND ETT SXN FOR SMALL AMTS OF THICK WHITE SECRETIONS. NSR @ 69-91. TEMP MAX 101.6 ORALLY, URINE CX AND BLD CX X2 SENT TODAY. TYLENOL GIVEN A/O PRN X 2 DOSES. IV CIPRO CONTINUES. AM WBC= 3.4 PREVIOUS URINE AND SPUTUM CX NEGATIVE. BLD CX PENDING FROM . RIGHT RADIAL ALINE INTACT. ABP= 108-200/46-90. ABD SOFT/ OBESE. PRESENT BS. TUBE FEEDS RESUMED R/T NO EXTUBATION TODAY. RESPALOR INFUSING @ GOAL RATE 40CC/HR VIA OGT, W/ MINIMAL RESIDUALS. FOLEY CATH D/S/P DRAINING YELLOW URINE W/ SEDIMENT, UOP 30-60CC/HR. GOAL 24 HR NFB SET @ NEG 500CC DURING ROUNDS. SKIN INTACT. PIV X2. FULL CODE. NO INQUIRIES FROM FAMILY/FRIENDS THIS SHIFT.\n\nPLAN- ATTEMPT TO WEAN SEDATION AND VENTILATION AS TOLERATED, PER TEAM. RE-ASSESS FOR EXTUBATION IN AM, PERFORM RSBI. ADMIN PRN HALDOL FOR AGITATION, FOLLOW QTC. MONITOR TEMP AND WBC TREND, FOLLOW UP ON CX RESULTS. CONTINUE ICU SUPPORTIVE CARE.\n"
},
{
"category": "Echo",
"chartdate": "2200-03-10 00:00:00.000",
"description": "Report",
"row_id": 60932,
"text": "PATIENT/TEST INFORMATION:\nIndication: Chronic lung disease. Left ventricular function.\nHeight: (in) 60\nWeight (lb): 304\nBSA (m2): 2.23 m2\nBP (mm Hg): 146/61\nHR (bpm): 82\nStatus: Inpatient\nDate/Time: at 08:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. TVI E/e' >15, suggesting PCWP>18mmHg. No\nresting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Moderate mitral\nannular calcification. No MR. [Due to acoustic shadowing, the severity of MR\nmay be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a low risk (prophylaxis not recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and systolic function (LVEF>55%). Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Tissue velocity imaging E/e' is elevated (>15) suggesting increased\nleft ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber\nsize and free wall motion are normal. The aortic root is mildly dilated. The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. The mitral valve appears structurally\nnormal with trivial mitral regurgitation. No mitral regurgitation is seen.\n[Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] The pulmonary artery systolic pressure could\nnot be determined. There is an anterior space which most likely represents a\nfat pad.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global\nbiventricular systolic function. Left ventricular diastolic dysfunction.\nCompared with the prior study of , the findings are similar.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2200-03-05 00:00:00.000",
"description": "Report",
"row_id": 114988,
"text": "Sinus rhythm\nPoor R wave progression\nSince previous tracing, T wave now upright in lead V2\n\n"
},
{
"category": "ECG",
"chartdate": "2200-02-27 00:00:00.000",
"description": "Report",
"row_id": 114989,
"text": "Sinus rhythm\nNormal ECG\nNo change from previous\n\n"
},
{
"category": "ECG",
"chartdate": "2200-02-28 00:00:00.000",
"description": "Report",
"row_id": 114990,
"text": "Sinus rhythm\nSeptal T wave changes are nonspecific\nT wave changes new from previous\n\n"
},
{
"category": "ECG",
"chartdate": "2200-02-24 00:00:00.000",
"description": "Report",
"row_id": 114991,
"text": "Sinus tachycardia\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2200-02-25 00:00:00.000",
"description": "Report",
"row_id": 114992,
"text": "Sinus rhythm\nNormal ECG\nSince previous tracing, slower rate seen\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-02-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905521,
"text": " 6:44 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: reassess ETT adjustment\n Admitting Diagnosis: ASTHMA EXACERBATION;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p intubation and NG tube and ?ETT too far distal\n\n REASON FOR THIS EXAMINATION:\n reassess ETT adjustment\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old female status post intubation with NG tube placement.\n Evaluate for endotracheal tube adjustment. Question endotracheal tube too\n far.\n\n COMPARISON: Portable semi-upright chest radiograph , 13:30 hours.\n\n AP SUPINE CHEST RADIOGRAPH: Allowing for differences in positioning, lung\n volumes are grossly unchanged. Opacities are again noted within the lower\n lobes bilaterally. Elevation of the right hemidiaphragm is again noted. No\n evidence of pneumothorax. Heart size is stable.\n\n The endotracheal tube appears unchanged in position compared to prior study\n seen approximately 1 cm from the carina, angled towards the right main stem\n bronchus. Recommend pulling back approximately 3-4 cm.\n\n IMPRESSION: ETT at carina, directed towards right main bronchus. Recommend\n pulling back 3-4 cm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-03-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 906203,
"text": " 8:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia?\n Admitting Diagnosis: ASTHMA EXACERBATION;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman intubated now with fevers to 102.\n REASON FOR THIS EXAMINATION:\n pneumonia?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST .\n\n COMPARISON: .\n\n INDICATION: Fever.\n\n Endotracheal tube is in satisfactory position. Nasogastric tube coils in the\n distal stomach. The heart is upper limits of normal in size. The aorta is\n tortuous. There has been interval worsening of patchy and linear areas of\n opacification in the perihilar and basilar regions. New predominantly linear\n component of the opacities favors multifocal atelectasis, but pneumonia is not\n fully excluded and followup films may be helpful in this regard. Minor\n atelectatic changes are also noted in the right upper lobe with associated\n slight elevation of the minor fissure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-02-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905326,
"text": " 3:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate? consolidation? effusion? fluid overload?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with sob has hx of lung cancer s/p resection, sleep apnea,\n fever to 103, SOB.\n REASON FOR THIS EXAMINATION:\n infiltrate? consolidation? effusion? fluid overload?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old woman with shortness of breath, history of lung\n cancer status post resection, sleep apnea, fever and shortness of breath.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n COMPARISON: Chest radiograph dated .\n\n FINDINGS: Study is somewhat limited due to lung volumes, poor inspiration and\n patient body habitus. The cardiac and mediastinal contours are unchanged\n compared to the prior study, and again note is made of right hilar fullness as\n demonstrated on the prior chest CT on . Patchy linear\n opacities are seen in left mid and lower lung fields; however, no new definite\n consolidation is noted.\n\n IMPRESSION: Somewhat limited study. Overall unchanged appearance of the\n chest with small lung volumes, right hilar fullness. No definite new\n consolidation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-02-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905623,
"text": " 11:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ETT placement, interval progression\n Admitting Diagnosis: ASTHMA EXACERBATION;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p intubation and NG tube and ?ETT too far distal\n\n REASON FOR THIS EXAMINATION:\n eval for ETT placement, interval progression\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post intubation and NG tube placement.\n\n PORTABLE AP CHEST: ET tube is at the thoracic inlet. NG tube is within the\n stomach. The heart size is normal. Lung volumes are low. The right hilum is\n prominent presumed to be due hilar lymphadenopathy unchanged. From the prior\n radiograph of . The presumed fluid overload has improved.\n There are no pleural effusions or pneumothorax.\n\n IMPRESSION: Improved CHF. ET and NG tubes in good position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-03-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 906864,
"text": " 7:35 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for ett placement\n Admitting Diagnosis: ASTHMA EXACERBATION;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman intubated now with fevers to 102.\n\n REASON FOR THIS EXAMINATION:\n eval for ett placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubated, with fevers to 102.\n\n PORTABLE CHEST: Examination is compared to the prior from six hours earlier.\n The endotracheal tube is in good position 4 cm above the carina. The\n nasoenteric tube courses below the diaphragm but its tip is not well imaged on\n this examination. There are bilateral pulmonary infiltrates within the left\n lung greater than the right which have not changed since the prior exam.\n There is no pleural effusion or pneumothorax.\n\n IMPRESSION: Endotracheal tube is in good position 4 cm above the carina.\n Bilateral pulmonary infiltrates are unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-03-08 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 907092,
"text": " 4:42 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: placement\n Admitting Diagnosis: ASTHMA EXACERBATION;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman new central line\n REASON FOR THIS EXAMINATION:\n placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Central line placement.\n\n Portable chest radiograph demonstrates a right internal jugular central venous\n catheter with its tip projecting over the SVC. The lung volumes are low.\n There is marked prominence of the right perihilar region with associated\n confluent opacity. The finding is in close proximity to the recently placed\n central venous catheter. Left basilar atelectasis is again noted. I doubt\n the presence of a pleural effusion. Endotracheal and nasogastric tubes are\n unchanged. No pneumothorax.\n\n IMPRESSION:\n New right internal jugular central venous catheter with its tip projecting\n over the SVC. Interval development of confluent opacity in the region of the\n right hilum is noted. The finding is unusual given the short interval and may\n be attributable to very low lung volumes and patient rotation. Further\n characterization could be obtained with PA and lateral chest radiographs.\n\n The remaining support lines are unchanged.\n\n Left basilar atelectasis persists.\n\n This case was discussed with Dr. on at 6:55 p.m.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-02-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905351,
"text": " 5:56 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: tube placement?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p intubation, now retracted the tube 3cm to 21cm.\n REASON FOR THIS EXAMINATION:\n tube placement?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Portable AP chest.\n\n The patient is a 70-year-old woman status post intubation, now retracted the\n tube 3 cm, question tube placement.\n\n COMPARISON: at 17:26.\n\n Portable AP radiograph demonstrates the tip of an endotracheal tube located\n 1.7 cm above the carina. This is improved from 40 minutes prior when the tip\n was located in the right mainstem bronchus, and is associated with improved\n aeration of the left lung. Patchy opacities are still present in the left mid\n and lower lung fields that are unchanged from today. The lung volumes are low\n bilaterally.\n\n IMPRESSION: ET tube 1.7 cm above the carina. Findings were relayed to the\n Emergency Department dashboard.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-02-26 00:00:00.000",
"description": "LP UNILAT LOWER EXT VEINS LEFT PORT",
"row_id": 905629,
"text": " 11:21 AM\n UNILAT LOWER EXT VEINS LEFT PORT Clip # \n Reason: would like to eval for evidence of dvt\n Admitting Diagnosis: ASTHMA EXACERBATION;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with obesity now w/ increaed assymetric lower extremity\n edema, left greater than right\n REASON FOR THIS EXAMINATION:\n would like to eval for evidence of dvt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 70-year-old woman with obesity, with increased asymmetric lower\n extremity edema, left greater than right.\n\n TECHNIQUE: Left lower extremity venous ultrasound and Doppler examination.\n\n FINDINGS: Grayscale and Doppler son of the left common femoral,\n superficial femoral, and popliteal veins were performed. These show normal\n compressibility, augmentation, and Doppler flow and waveforms. No\n intraluminal thrombus is identified.\n\n IMPRESSION: No evidence of deep vein thrombosis. The images were reviewed\n directly on the ultrasound machine, as there have been difficulties with\n transfering the images to PACs at this time.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-02-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905347,
"text": " 5:16 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p intubation tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with sob has hx of lung cancer s/p resection, sleep\n apnea, fever to 103, SOB.\n REASON FOR THIS EXAMINATION:\n s/p intubation tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST\n\n INDICATION: 70-year-old woman with shortness of breath and history of lung\n cancer status post resection, status post intubation.\n\n FINDINGS: Tip of endotracheal tube lies within the right mainstem bronchus.\n This is accompanied by increased opacity and poor aeration of the left lung.\n Patchy right hilar opacity is unchanged from earlier today.\n\n IMPRESSION: ET tube in right mainstem bronchus. The patient has a subsequent\n chest x-rays that shows withdrawal of the ET tube from the right mainstem\n bronchus.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-02-25 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 905386,
"text": " 12:30 AM\n PORTABLE ABDOMEN Clip # \n Reason: NGT PLACEMENT\n Admitting Diagnosis: ASTHMA EXACERBATION;COPD EXACERBATION\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: NG tube placement.\n\n COMPARISONS: No direct comparisons are available for comparison.\n\n TECHNIQUE: AP supine single view of the abdomen.\n\n There is an NG tube with the tip likely in the first portion of the duodenum.\n If the desired position of the tube is the stomach, recommend withdrawing\n approximately 10 cm. This radiograph was not diagnostic for other\n abnormalities.\n\n IMPRESSION: NG tube tip is likely in the first portion of the duodenum. If\n desired position is the stomach, recommend withdrawing approximately 10 cm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-02-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905385,
"text": " 12:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ET TUBE PLACEMENT\n Admitting Diagnosis: ASTHMA EXACERBATION;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p intubation and NG tube.\n REASON FOR THIS EXAMINATION:\n ET tube placment and NG tube.\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Status post intubation and NG tube placement.\n\n PORTABLE AP CHEST.\n\n COMPARISON: .\n\n Impression: The ETT tube is in the right main bronchus and should be pulled\n back for optimal positioning. These findings were discussed with Dr. \n .\n\n The lung volumes remain low, though improved, compared to the prior\n radiograph. There is a new heterogeneous opacity in the left perihilar region\n and worsening consolidation in the right lower lobe concerning for pneumonia.\n Small left effusion persists. NG tube is in good position, unchanged.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-02-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905463,
"text": " 1:15 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: re-assess ETT placment\n Admitting Diagnosis: ASTHMA EXACERBATION;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p intubation and NG tube and ?ETT too far distal\n\n REASON FOR THIS EXAMINATION:\n re-assess ETT placment\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW PORTABLE:\n\n INDICATION: 70-year-old woman status post intubation.\n\n COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed, and\n compared with the previous study at ___ a.m.\n\n The tip of the endotracheal tube is identified 1 cm above the carina. A\n nasogastric tube courses towards the duodenum.\n\n The lung volume is small. There are continued opacities in both lower lobes\n indicating pneumonia or aspiration. There is continued elevation of the right\n hemidiaphragm. No pneumothorax is identified. The heart is normal in size.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-03-04 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 906488,
"text": " 11:14 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: ? sinusitis\n Admitting Diagnosis: ASTHMA EXACERBATION;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with COPD, lung CA, PNA on a ventilator, now w/ fever of\n unclear etiology and copious nasal secretions\n REASON FOR THIS EXAMINATION:\n ? sinusitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old female with COPD, lung cancer and pneumonia on\n ventilator, now with fever of unknown etiology and copious nasal secretions,\n question sinusitis.\n\n There are no prior studies for comparison.\n\n TECHNIQUE: Axial and coronal non-contrast images of the paranasal sinuses\n were obtained.\n\n SINUS CT SCAN: Air-fluid levels are noted in the right and left maxillary\n sinuses. There is additionally mild right maxillary antral mucosal\n thickening. There is severe mucosal thickening of the sphenoid sinus with\n aerosolized secretions. There is mucosal thickening and aerosolized secretions\n in the posterior ethmoid sinuses bilaterally. Note is made of copious\n secretions within the oropharynx. The right ostiomeatal complex is obstructed\n by mucosal thickening. The left ostiomeatal complex is partially obstructed\n by mucosal thickening. Cribriform plates are equal in height. The anterior\n clinoid processes are not pneumatized. The nasal septum is midline. There is\n a small left frontal bone osteoma.\n\n IMPRESSION:\n\n Air-fluid levels in bilateral maxillary sinuses with severe mucosal thickening\n and/or aerosolized secretions seen in remaining sinuses. These findings are\n consistent with the patient's current ventilation status; however, acute\n sinusitis cannot be excluded.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-03-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 906814,
"text": " 12:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, failure, eval ETT placement\n Admitting Diagnosis: ASTHMA EXACERBATION;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman intubated now with fevers to 102.\n\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, failure, eval ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION:\n\n Portable AP chest.\n\n COMPARISON: .\n\n The endotracheal tube terminates 2 cm above the carina. This should be pulled\n back for appropriate positioning. Lung volumes are low. The opacity in the\n left mid lung and lower lobe is unchanged in the interval. The right upper\n lobe opacity has improved.\n\n No pleural effusions or pneumothorax.\n\n IMPRESSION:\n 1. Consolidation/atelectasis in the left lower lobe. Improved atelectasis in\n the right upper lobe.\n 2. ET tube 2 cm from the carina should be pulled back for optimal\n positioning.\n\n Findings communicated to Dr. .\n\n\n"
}
] |
6,271 | 116,482 | Patient was admitted to the General Surgery floor from the Emergency Department. On HD1 the patient underwent ERCP where three stones, sludge, and pus were extracted as well as a sphincterotomy was performed without complication. In the recovery room the patient had a hypotensive episode to the 60's systolic - was transfered to the ICU and responed to fluid resusication as well as low dose pressors. On post-procedure day two the patient was weaned off of pressors and was in stable condition when transfered to the regular general surgery on hopspital day 4. On HD5 the patient underwent a laparoscopic cholecystectomy without complication - please refer to the operative note for full details. The patient was also evaluated by cardiology for the new-onset atrial fibrillation who recommeded holding all beta blockers and starting anticoagulation when hemostatically stable post-operatively and s/p sphincterotomy. At the time of discharge the patient was doing well, tolerating a regular diet and was without complaints. | PO H2B for prophylaxis. Mild (1+) mitral regurgitation is seen. H2B for prophylaxis. There is nopericardial effusion. Pt asymptomatic. Arrived on Neo, and transitioned to Levophed. Lytes pnding. Wean vasopressors as able. Titrated to effect. SC heparin & pboots for prophylaxis. NIBP 104-128/29-67, afebrile, CBC pnding. NPO + bowel sounds throughout. Left subclavian TLC intact. SC heparin. Pt asymptomic, BP stable. Adequate UO.SKIN: Skin intact, jaundice noted to backside.SOCIAL: , HCP, called shift, update given. Here central line was placed, and transitioned to Levophed.Neuro - Pt A&O x3. Foley draining c/y/u. Transfer note updated.ROS:RESP: SV on RA, Sats >94%, RR 17-20, LS clear w/ occ exp wheezes, albuterol nebs given with minimal effect, pt denies SOB. Currently on zoysn. Denies pain continuously.CV - HR 35-60 a-fib. Levophed weaned off, MAPS maintained >60. Bedside ECHO. The aortic root is moderately dilated athe sinus level. Denies nausea. Mild (1+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. PT. Attempted line placement there, and placed on Phenylephrine. check placement. check placement. Check placement. THAT PT. IVF KVO.ENDO: Ordered for RISS, coverage not required.SKIN/ACCESS: Skin intact. Albuterol neb Q6H: PRN.CVS: Afib w/ pauses, occ PVCs, HR 26-59, atropine at bedside. Weak palpable pulses, cap refill <3 sec. Weak palpable pulses, cap refill <3 sec. LSC CVL intact. OOB. Hct 36.5, WBC 15.6, INR 1.3. Normal RV systolic function. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. MRSA admission swabs obtained. Crit stable. FINDINGS: Portable AP chest is reviewed. + peripheral pulses by doppler only. OF NEO. NPO at this time. Tmax 96.3. Atrial fibrillation with well controlled ventricular responseNo previous tracing available for comparison TSICU NPN 0700-1900REVIEW OF SYSTEMS:NEURO: Pt A&OX3, very and cooperative. Wheezes noted throughout this afternoon, albuteral given with good effect. Expectorates sm amts thick tan secretions.CVS: Chronic Afib, no ectopy, HR 48-50, HR occ drops to low 30s, atropine at bedside. BUN 40, creatinine 1.2, Na 140, K 3.2, Ca 8.5, Mg 2.4, Phos 2.1. CVP 14-20.Resp - Lungs clear throughout, very diminished at bases. UOP adequate.INTEG-INtactENDO-RISS ordered, no coverage required.SOCIAL-Supportive family,m at bedisde day and updated on POC.PLAN-Transfer to floor -Monitor resp and fluid status. Transfer to flr Denies pain.CV: Afib, HR 40-60's with occassional HR to high 30's. Systolic BP maintained >90. The right atrium is markedly dilated.The left ventricular cavity size is normal. The right ventricular cavity is mildly dilated.Right ventricular systolic function is normal. Moderate [2+] TR.Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Resting bradycardia (HR<60bpm).Conclusions:The left atrium is moderately dilated. SQ Heparin and compression boots for prophylaxis.RESP-RA sats 96-100%, lung sounds clear, occasional expiratory wheezes on left side. NIBP 95-116/33-71, MAP 55-83- goal to maintain MAP >60. TO BE TRANSFERRED TO TSICU DUE TO PT. PATIENT/TEST INFORMATION:Indication: Atrial fibrillation.. Left ventricular function.Bradycardia.Height: (in) 70Weight (lb): 177BSA (m2): 1.98 m2BP (mm Hg): 107/45HR (bpm): 50Status: InpatientDate/Time: at 14:00Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.LEFT VENTRICLE: Normal LV cavity size. MAE's to command. Left SC TLC. The tip of the left subclavian line appears to lie at the junction of the left innominate and SVC. No calls overnight.A - s/p ERCP with hypotension.Plan - Continue to monitor per routine. No restingLVOT gradient.RIGHT VENTRICLE: Mildly dilated RV cavity. NS @ KVO.ENDO: No coverage required w/ RISS.POC: resp status & hemodynamics, keep atropine at bedside, give anbx as ordered, cont to monitor fluid status, transfer pt to flr as soon as tele bed becomes available. LSC CVL intact & x1.POC: NC at bedside Cont to monitor resp status Encourage CDB Albuterol nebs Q6H PRN Monitor hemodynamics Maintain MAP >60 Atropine at bedside Encourage PO intact, ADAT ? Maintain blood pressure >90 systolic. Denies pain.GI/GU: Abd softly distened, NT, +BS, flatus, LBM , tol reg diet, no c/o N/V. The subclavian line appears to be in satisfactory position. Atropine at bedside. Pt able to cough up large amts thick tan secretions.ENDO: No coverage needed per RISS.GI: Abd soft, non-distended. KPhos infusing x6 hrs. Receiving zosyn as ordered.NEURO: A+Ox3, cooperative, GCS 15, MAEs purposefully. SC Heparin & pboots for prophylaxis.NEURO: A+Ox3, GCS 15, MAEs purposefully, presently denies pain.GI/GU: Abd soft, NT, ND, +BS, no BM or flatus, tol clear liq diet- ADAT. ? ? Occasional expiratory wheeze. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: central line re-wired. MAE. IVF infusing at 100cc/hr. WBC 29.Skin - All areas intact.Psych/social - Wife and 2 here when pt arrived. Cards consult today. Dyspnea with minimal exertion.GI - Abdomen soft, non-tender. Theaortic valve leaflets (3) are mildly thickened. Moderate [2+] tricuspid regurgitation is seen.There is moderate pulmonary artery systolic hypertension. P-boots intact. Denies pain. CAME WITH WAS INFILTRATED, 2 'S WERE PLACED. Transferred to TSICU for further treatment. to be spokesperson. WAS ORIGINAALY ON SURGICAL SERVICE. The tricuspid valveleaflets are mildly thickened. Non-productive cough.GI-Abdomen softly distended with present bowel sounds. 8:07 PM CHEST PORT. Overall left ventricular systolicfunction is normal (LVEF>55%). Arrived with low urine output. BP 100-130's/50's. Urine output now ~40cc/hr.Endo - Blood sugar not requiring insulin per RISS.Id - afebrile. IS ON NEO AND HAS RECIEVED TOTAL OF 3 LITERS OF NS, SEE CAREVUE FOR ACCURATE AMT. CVP 12-16. Currently on 3lpm NC, maintaining sats 98-100%. Went to ICU. No AS. [Intrinsic RV systolic function likely more depressed given the severity ofTR].AORTA: Moderately dilated aortic sinus.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). extremities cool to touch. Continue to update pt and family of current plan of care. Large BM today. T/SICU NURSING PROGRESS NOTEREVIEW OF SYSTEMSPLEASE SEE CAREVUE FOR EXACT DATAPT CALLED OUT TO FLOOR, AWAITING BEDNEURO-Intact. | 11 | [
{
"category": "Radiology",
"chartdate": "2182-04-25 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 963433,
"text": " 8:07 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: central line placement\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with sepsis, s/p mult attempts at R subclavian\n\n REASON FOR THIS EXAMINATION:\n central line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 89-year-old man with sepsis status post attempted right subclavian\n line with new left subclavian line placement.\n\n Comparison is made to prior radiograph taken at approximately 1636 on same\n day.\n\n FINDINGS:\n\n Portable AP chest is reviewed. There has been interval placement of a left\n subclavian central venous catheter with its tip oriented cranially and\n possibly extending into the right subclavian vein. There is no evidence of\n pneumothorax bilaterally and appearance of radiograph is otherwise unchanged.\n\n Dr. was paged at approximately 2120 to discuss these findings.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-25 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 963442,
"text": " 9:20 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: central line re-wired. check placement.\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with sepsis, s/p mult attempts at R subclavian\n\n REASON FOR THIS EXAMINATION:\n central line re-wired. check placement.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 89-year-old with sepsis and multiple attempts to place\n subclavian line. Check placement.\n\n CHEST\n\n The film is somewhat underpenetrated. The tip of the left subclavian line\n appears to lie at the junction of the left innominate and SVC.\n\n There is no evidence of pneumothorax. The degree of failure may be present,\n though it is difficult to tell on this film.\n\n IMPRESSION: Underpenetrated film. The subclavian line appears to be in\n satisfactory position.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-25 00:00:00.000",
"description": "Report",
"row_id": 1344762,
"text": "MICU ADMIT NOTE\n89 Y/O MALE ADMITTED TO MICU FROM GI SUITE PT. WAS ORIGINALLY ON , WAS SENT OT MICU DUE TO HYPOTENSION DURING PROCEDURE. THAT PT. CAME WITH WAS INFILTRATED, 2 'S WERE PLACED. TEAM ATTEMPTED TO PLACE CENTRAL LINE WAS UNABLE TO, PT. TO BE TRANSFERRED TO TSICU DUE TO PT. WAS ORIGINAALY ON SURGICAL SERVICE. PT. IS ON NEO AND HAS RECIEVED TOTAL OF 3 LITERS OF NS, SEE CAREVUE FOR ACCURATE AMT. OF NEO.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-26 00:00:00.000",
"description": "Report",
"row_id": 1344763,
"text": "TSICU Nursing Admission Note\nPt admitted to 4, went to ERCP and became hypotensive after procedure. Went to ICU. Attempted line placement there, and placed on Phenylephrine. Transferred to TSICU for further treatment. Here central line was placed, and transitioned to Levophed.\n\nNeuro - Pt A&O x3. MAE's to command. Purposeful movement. Pleasant and engaging in conversation. Dozing throughout night. Denies pain continuously.\n\nCV - HR 35-60 a-fib. No ectopy noted. Arrived on Neo, and transitioned to Levophed. Titrated to effect. Systolic BP maintained >90. + peripheral pulses by doppler only. extremities cool to touch. Repleted 40meq potassium, and 2gm magnesium. Crit stable. CVP 14-20.\n\nResp - Lungs clear throughout, very diminished at bases. Occasional expiratory wheeze. Expectorated x1 thick green/tan secretions. Currently on 3lpm NC, maintaining sats 98-100%. Dyspnea with minimal exertion.\n\nGI - Abdomen soft, non-tender. Denies nausea. NPO + bowel sounds throughout. no BM.\n\nGU - Foley draining mostly clear amber urine. Arrived with low urine output. Given total of 1.5 liters LR here, and given total 5L fluid prior to arrival in this unit. Urine output now ~40cc/hr.\n\nEndo - Blood sugar not requiring insulin per RISS.\n\nId - afebrile. Currently on zoysn. MRSA admission swabs obtained. WBC 29.\n\nSkin - All areas intact.\n\nPsych/social - Wife and 2 here when pt arrived. to be spokesperson. Wife and are healthcare proxies. will try to bring in a copy of this form tomorrow. Family supportive. No calls overnight.\n\nA - s/p ERCP with hypotension.\n\nPlan - Continue to monitor per routine. Continue to monitor and treat for pain PRN. Maintain blood pressure >90 systolic. Wean vasopressors as able. ? start diet today. OOB. Monitor urine output. Continue to update pt and family of current plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-26 00:00:00.000",
"description": "Report",
"row_id": 1344764,
"text": "TSICU NPN 0700-1900\nREVIEW OF SYSTEMS:\n\nNEURO: Pt A&OX3, very and cooperative. Hard of hearing. No neuro deficits. Denies pain.\n\nCV: Afib, HR 40-60's with occassional HR to high 30's. Pt asymptomic, BP stable. Cards consult today. Bedside ECHO. No anti-coagulation at this time. Levophed weaned off, MAPS maintained >60. SC heparin. P-boots intact. Left subclavian TLC intact. IVF infusing at 100cc/hr. Afebrile.\n\nRESP: 2L NC with SATS >95%. Wheezes noted throughout this afternoon, albuteral given with good effect. Pt able to cough up large amts thick tan secretions.\n\nENDO: No coverage needed per RISS.\n\nGI: Abd soft, non-distended. NPO at this time. Positive BS.\n\nGU: Foley draining clear amber colored urine. Adequate UO.\n\nSKIN: Skin intact, jaundice noted to backside.\n\nSOCIAL: , HCP, called shift, update given. States she will be in to visit tomorrow.\n\nPLAN: Continue to monitor BP, HR, resp status. ? dc to floor tomorrow.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2182-04-26 00:00:00.000",
"description": "Report",
"row_id": 83158,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation.. Left ventricular function.Bradycardia.\nHeight: (in) 70\nWeight (lb): 177\nBSA (m2): 1.98 m2\nBP (mm Hg): 107/45\nHR (bpm): 50\nStatus: Inpatient\nDate/Time: at 14:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.\n\nLEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF (>55%). No resting\nLVOT gradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\n[Intrinsic RV systolic function likely more depressed given the severity of\nTR].\n\nAORTA: Moderately dilated aortic sinus.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting bradycardia (HR<60bpm).\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is markedly dilated.\nThe left ventricular cavity size is normal. Overall left ventricular systolic\nfunction is normal (LVEF>55%). The right ventricular cavity is mildly dilated.\nRight ventricular systolic function is normal. [Intrinsic right ventricular\nsystolic function is likely more depressed given the severity of tricuspid\nregurgitation.] The aortic root is moderately dilated athe sinus level. The\naortic valve leaflets (3) are mildly thickened. There is no aortic valve\nstenosis. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen.\nThere is moderate pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-27 00:00:00.000",
"description": "Report",
"row_id": 1344765,
"text": "Progress Note, 1900-0730\nNo significant events overnoc. Transfer note updated.\n\nROS:\n\nRESP: SV on RA, Sats >94%, RR 17-20, LS clear w/ occ exp wheezes, albuterol nebs given with minimal effect, pt denies SOB. Expectorates sm amts thick tan secretions.\n\nCVS: Chronic Afib, no ectopy, HR 48-50, HR occ drops to low 30s, atropine at bedside. NIBP 95-116/33-71, MAP 55-83- goal to maintain MAP >60. CVP 12-16. Tmax 96.3. Hct 36.5, WBC 15.6, INR 1.3. Weak palpable pulses, cap refill <3 sec. Surface ECHO performed yesterday- LVEF >55%. SC Heparin & pboots for prophylaxis.\n\nNEURO: A+Ox3, GCS 15, MAEs purposefully, presently denies pain.\n\nGI/GU: Abd soft, NT, ND, +BS, no BM or flatus, tol clear liq diet- ADAT. PO H2B for prophylaxis. Foley draining adequate amts clear urine, u/o 35-80 cc/hr. BUN 40, creatinine 1.2, Na 140, K 3.2, Ca 8.5, Mg 2.4, Phos 2.1. KPhos infusing x6 hrs. IVF KVO.\n\nENDO: Ordered for RISS, coverage not required.\n\nSKIN/ACCESS: Skin intact. LSC CVL intact & x1.\n\nPOC: NC at bedside\n Cont to monitor resp status\n Encourage CDB\n Albuterol nebs Q6H PRN\n Monitor hemodynamics\n Maintain MAP >60\n Atropine at bedside\n Encourage PO intact, ADAT\n ? Transfer to flr\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-27 00:00:00.000",
"description": "Report",
"row_id": 1344766,
"text": "T/SICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS\nPLEASE SEE CAREVUE FOR EXACT DATA\n\nPT CALLED OUT TO FLOOR, AWAITING BED\n\nNEURO-Intact. A&Ox3. Denies pain. MAE. OOB to chair x6hours, 2 person assist needed to transfer.\n\nCV-SB rate 29-50's with pauses. Atropine at bedside. BP 100-130's/50's. Left SC TLC. SQ Heparin and compression boots for prophylaxis.\n\nRESP-RA sats 96-100%, lung sounds clear, occasional expiratory wheezes on left side. Non-productive cough.\n\nGI-Abdomen softly distended with present bowel sounds. Large BM today. Tolerating po diet well.\n\nGU_indwelling foley catheter with dark yellow urine, sediment noted at times. UOP adequate.\n\nINTEG-INtact\n\nENDO-RISS ordered, no coverage required.\n\nSOCIAL-Supportive family,m at bedisde day and updated on POC.\n\nPLAN-Transfer to floor\n -Monitor resp and fluid status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-28 00:00:00.000",
"description": "Report",
"row_id": 1344767,
"text": "Progress Note, 1900-0730\n\nUneventful night, pt called out to flr, awaiting bed.\n\nPlease see careview for exact data & transfer note for updates.\n\nROS:\n\nRESP: SV on RA, Sats >94%, RR 13-18, LS clear w/ dim bases, occ exp wheezing. Albuterol neb Q6H: PRN.\n\nCVS: Afib w/ pauses, occ PVCs, HR 26-59, atropine at bedside. Pt asymptomatic. NIBP 104-128/29-67, afebrile, CBC pnding. Skin intact. Weak palpable pulses, cap refill <3 sec. LSC CVL intact. SC heparin & pboots for prophylaxis. Receiving zosyn as ordered.\n\nNEURO: A+Ox3, cooperative, GCS 15, MAEs purposefully. Denies pain.\n\nGI/GU: Abd softly distened, NT, +BS, flatus, LBM , tol reg diet, no c/o N/V. H2B for prophylaxis. Foley draining c/y/u. u/o > 50 cc/hr. Lytes pnding. NS @ KVO.\n\nENDO: No coverage required w/ RISS.\n\nPOC: resp status & hemodynamics, keep atropine at bedside, give anbx as ordered, cont to monitor fluid status, transfer pt to flr as soon as tele bed becomes available.\n"
},
{
"category": "ECG",
"chartdate": "2182-04-26 00:00:00.000",
"description": "Report",
"row_id": 226082,
"text": "Atrial fibrillation with slow ventricular response\nLow limb lead QRS voltages - is nonspecific\nQ-Tc interval appears prolonged but is difficult to measure - clinical\ncorrelation is suggested\nSince previous tracing of , ventricular rate slower\n\n"
},
{
"category": "ECG",
"chartdate": "2182-04-25 00:00:00.000",
"description": "Report",
"row_id": 226312,
"text": "Atrial fibrillation with well controlled ventricular response\nNo previous tracing available for comparison\n\n"
}
] |
16,264 | 158,183 | 70M w/hx lung CA, mets renal CA (to brain and lungs) s/p recent resection ago p/w Klebesilla septic shock, PNA, UTI, ARF and worsening weakness and ataxia. The self extubated in the unit on and transferred to the floor. # Septic shock/Urosepsis ??????He presented with fever, hypotension, tachycardia, tachypnea w/ elevated wbc and hypoxia requiring intubation and pressor support. He was found to have pansensitive klebsiella sepsis. He is s/p empiric azithro x 5 days (last ). He also received Levo for 3 days and stress dose steroids. # Hypoxia: pulmonary edema, pleural effusion (too small to tap per IP on ), PE, Vent associated PNA . Self extuabted on and has been managed in NC O2. He was started on bactrim PCP . He contracted a vent associated PNA so will continue with levo/zosyn/vanc. | Again demonstrated is a right-sided pleural effusion with associated collapse/consolidation of the right middle and lower lung, unchanged. Note is made of a right-sided pleural effusion. The right pleural effusion appears to be at least partially loculated. The right pleural effusion appears to be slightly loculated. There is elevation of the right hemidiaphragm with probable associated pleural effusion. An endotracheal tube has been inserted, and its tip ends at the level of the clavicular heads. There is diffuse bilateral interstitial process and elevated right hemidiaphragm with pleural effusion again demonstrated. Right pleural effusion. Slightly prominent gallbladder, without son evidence of acute cholecystitis. The right pleural effusion and elevation of the right hemidiaphragm are unchanged. Trace aortic regurgitationis seen.4. IMPRESSION: Diffuse left lung infiltration and right pleural effusion, associated right lower lobe and right middle lobe atelectasis unchanged. Mild (1+) MR. LV inflow pattern c/w impaired relaxation.TRICUSPID VALVE: Mild [1+] TR. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 70Weight (lb): 180BSA (m2): 2.00 m2BP (mm Hg): 132/63HR (bpm): 120Status: InpatientDate/Time: at 13:50Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV cavity size. There is a right sided pleural effusion with right middle and lower lobe collapse. Right jugular CV line is in region of cavoatrial junction. There is an endotracheal tube with tip at the thoracic inlet. Mild mitral annularcalcification. There are bilateral pleural effusions (right greater than left). The right IJ line remains in place, the tip is in the distal superior vena cava. REASON FOR THIS EXAMINATION: confirm ETT position FINAL REPORT INDICATION: Hypoxia and respiratory failure. FINAL REPORT INDICATION: Shortness of breath and hypoxia. There is moderate pulmonary artery systolic hypertension. follow lcosely and cotninue to diureses as pt's hemodynamics tolerate.id: max temp=97.6 and wbc=18.4. Dr advised of rise in SPB to 170's, HR >120, diaphoretic and labored breathing. iv ntg initiated at 0.05mcg/kg/min and diuresed with 6 0mg ivp lasix. altered resp statusd: pt sedated on fentanyl gtt at 75mcg/hr and versed gtt at 2 mg/hr.and pt remains easily arousable. follow hemodynamics closely.gi/gu : pt remains npo b/cause of his tenuous resp status.has had sips of water while of bipap. Rectal temp checked, found to be 101.2 with lactate of 1.9, developed hypotension with SBP 80's. rx'd with albuterol/atrovent nebs q6h. will continue to ofllow fluid balance closely.id: max temp=97.8 and wbc this am=7.5. Remains on Dobutamine at 4.7mcg/kg/min. MAE ad lib.CV/Pulm: BP remains labile--titrated Levo to maintain MAP>60. Remains on Sepsis protocol, Levophed, Dobutamine. SVO2 > 70 and improved to >80 by 3am.Pt placed on CPAP at 0230 for flash pulm edema which occurred at 0200.Cardio: Rec with temp 95.4 ax and oral. receiving combivent.cardiac: bp 142-175/58-70 with pulse o f 90-102 sr/st, occasional pvcs. abg done..46/41/7.51 (had been on bicarb gtt in anticipation of ct/dye)pt on/off bed pan most of am. Insulin gtt started, one unit PRBC started.CURRENT STATUS:See FHA and carevue for subjective/objective data.Neuro: A+Ox3. 0600- Pt remained stable and taken off CPAP per Dr this am. Lactic acid being done q 4 hrs.GI: Remains NPO, except for meds.0300....Pt is off Levo and Dobut., has stabilized after an episode of flash pulmonary edema. pt now more calm and cooperative and will avoid administration of morphine since his earlier behavior may have been and adverse response to that med.resp: pt has remaine on 100% bipap with 5 peep and ips of 8 .rr 20's and o2 sats> 98%. altered fluid balance(Continued)ith present medicla management. K+ was 5.1. heparin drip infusing at 1500u/hr.id: temp of 98-98.5 po. MDI's administered Q4 combivent. 4 ICU nursing progress note: Respiratory: Early am on 6l/.95% high flow neb..rr 20's..sats 97%..as mornig progressed..deterioration in resp status..dropping sats into 80's..more congested sounding..rr in 30's..tachycardic and hypertensive..ho's aware. ID: Azithromycin d/ced, Bactrim iv added, ceftriaxone continues. Events: Started on levophed for hypotesnion with minimal response to fluid bolus x2. BS auscultated reveal bilateral wheeze. Changed diet to liqs..tolerated well..advance in am.. Neuro: Alert/orientated..short episodes of confusion..getting out of chair..saying inappropriate things at times. Hct stable 31.4. admin albuterol/atrovent neb x2. Bronchoscopy completed this pm, specimens obtained and sent. pt has thrush.gu: foley in place. MEDS ORDERED, COMBIVENT Q6HRS. AM abg's 7.45/42/87/30. altered resp statusd:pt slept well tonoc. Started on vancomycin, levofloxacin, zosyn for PNA. After intubation and with sedation pt becoming hypotensive with bp in low 80's. LAST ABG SHOWED AN ACIDOSIS WITH ACCEPTABLE OXYGENATION. Levophed initiated this am after multiple fluid bolus's had minimal effect with increasing bp. See care view for abgs.. Cardiac: HR 80-120's sr/st bp 115-180/50-70 Continues to have PVCs..occassional to frequent. GI/GU: Abdomen softly distened with + bs. 1 attempt at nt suction..large amts of secretions..however pt had small nose-bleed. PTT at 0300 was 68.1GI: Abdomen soft, nondistended, nontender, + bowel sounds. heparin gtt infusing at 1500u/hr and will follow ptt as ordered.gi: ngt in place and pt receiving tube fdgs of promote with fiber at goal rate of 85cc's/hr with minimal residuals. Sputum for c/s sent. wether pt will have u/s guided tap of pleural effusions. MICU/SICU NPN HD #6Events: Levophed titrated off. 4 ICU nursing progress note: Respiratory: Remains intubated and vented..PSV 20/10peep..rr 10-14..tv 800-1000. Pt has a congested cough.CV: NSR-ST, no ectopy. Bronchoscopy this pm showed normal left lung, rt lung middle lobe occluding. will continue to wean vent as pt tolerates.cv: hr 90-100's with rare pvc's and sbp stable from 109-130. am labs are pending and will replete as needed. Ventilator settings at present are ps/.70/15/8. Abp high 70's to low 120's systolic. PT.ON MASK VENTILATION AS NEEDED, ABG ACIDOTIC, BREATHE SOUNDS WITH RHOCNHI/RALES BILAT.,NON PROD.COUGH, PRESENTLY ON HI-FLOW 100% WITH NASAL . rsbi checked this am. follow fluid balance closely.id: pt afebrile this shift and ? | 54 | [
{
"category": "Radiology",
"chartdate": "2126-10-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847051,
"text": " 10:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Any evidence of pna, chf, assess placement of ETT.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70M with hypoxic respiratory failure.\n\n REASON FOR THIS EXAMINATION:\n Any evidence of pna, chf, assess placement of ETT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 70-year-old with hypoxic respiratory failure.\n\n This study is compared to a prior study of a day earlier. Diffuse\n infiltration throughout the entire left lung as well as the right pleural\n effusion and compression atelectasis of the right lower lobe and the right\n middle lobe are unchanged. The previously seen coiled NG tube has been\n straightened out and the tip of it is not included on the film. The right IJ\n line remains in place, the tip is in the distal superior vena cava. The tip\n of the endotracheal tube is about 2 inches above the carina. There is no\n evidence of pneumothoraces. Except for repositioning of the nasogastric tube,\n no other significant changes are noted since the prior study.\n\n IMPRESSION: Diffuse left lung infiltration and right pleural effusion,\n associated right lower lobe and right middle lobe atelectasis unchanged.\n Interval repositioning of the nasogastric tube.\n\n No other significant changes are noted in the overall appearance of the chest\n since the prior study of a day earlier.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-10-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 846593,
"text": " 10:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: sob hypoxia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with sob and hypoxia met lung ca\n REASON FOR THIS EXAMINATION:\n sob hypoxia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath and hypoxia. Metastatic cancer.\n\n COMPARISON: .\n\n AP PORTABLE CHEST: The right heart border is obscured by increasing opacity\n in the right lung base. This opacity probably represents a combination of\n lung consolidation and effusion. In addition, there are discernable rounded\n opacities in the right lung base that are compatible with the given history of\n metastatic disease. A 2 cm rounded opacity in the superior left hilum would\n also be concerning for neoplastic involvement. A retrocardiac opacity is\n superimposed upon a background of ill-defined increased lung markings on the\n left, raising the possibility of a pneumonia and vasular congestion. There is\n no pneumothorax detected. Clips in the left abdomen and spinal stabilization\n hardware are again noted.\n\n IMPRESSION: Increased bibasilar opacity may represent a combination of\n increasing right pleural effusion, metastatic disease and pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-10-24 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 847130,
"text": " 7:13 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: POSITIVE PE ASSESS FOR DVT\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with mets renal cell ca, copd, chf, now with respiratory\n distress, PE on CT\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 70-year-old male with metastatic renal cell carcinoma. The\n patient has a pulmonary embolism. Rule out DVT.\n\n FINDINGS: -scale and Doppler son of the bilateral common femoral,\n superficial femoral, and popliteal veins were performed. There is normal\n flow, compressibility, and augmentation of these vessels. No intraluminal\n thrombus was identified.\n\n IMPRESSION: There is no evidence of DVT in the bilateral lower extremities.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-10-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 846603,
"text": " 11:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check line placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with sob and hypoxia met lung ca s/p triple lumen placement\n REASON FOR THIS EXAMINATION:\n check line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 70 y/o man s/p triple lumen placement, please check line placement.\n\n AP PORTABLE CHEST @ 12 NOON: Comparison is made to prior study at 10 a.m.\n There has been interval placement of a right internal jugular central venous\n catheter with its tip in the right atrium. The patient is in gross pulmonary\n edema with increased opacification of the right base most likely representing\n pleural fluid. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-10-20 00:00:00.000",
"description": "CHEST (LAT DECUB ONLY)",
"row_id": 846605,
"text": " 12:38 PM\n CHEST (LAT DECUB ONLY) Clip # \n Reason: eval effusion\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with pneumonia and effusion\n REASON FOR THIS EXAMINATION:\n eval effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 70 y/o man with pneumonia and effusion. Please evaluate effusion.\n\n RIGHT LATERAL DECUBITUS VIEW @ 12:40:\n\n The exam is markedly limited technically. I do not see layering of the\n effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-10-20 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 846606,
"text": " 12:40 PM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: r/o liver mets, eval gallbladder\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with renal CA and lung/brain mets with RUQ pain\n REASON FOR THIS EXAMINATION:\n r/o liver mets, eval gallbladder\n ______________________________________________________________________________\n WET READ: MRSg SUN 1:51 PM\n No cholecystitis. No hydronephrosis. No hepatic metastases identified.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Renal cell cancer, and lung and brain metastases with right upper\n quadrant pain, evaluate for liver metastasis or cholecystitis. Please also\n evaluate for hydronephrosis of the right kidney.\n\n COMPARISON: .\n\n TECHNIQUE: Right upper quadrant ultrasound and right renal ultrasound.\n\n RIGHT UPPER QUADRANT ULTRASOUND: No focal nodules or masses are identified\n within the hepatic parenchyma. The hepatic echotexture appears slightly\n coarse. There is no intrahepatic biliary ductal dilatation. The portal vein\n is patent with flow in the proper direction. The gallbladder is slightly\n prominent, measuring up to 5 cm in diameter. This is essentially unchanged\n since the time of prior CT of the abdomen dated . There is no\n gallbladder wall thickening, and no pericholecystic fluid. The common bile\n duct measures 8 mm in diameter. There is no ultrasonographic sign.\n Note is made of a right-sided pleural effusion.\n\n RIGHT RENAL ULTRASOUND: The right kidney measures 13.3 cm. No stones, masses\n or hydronephrosis are identified within the right kidney.\n\n IMPRESSION\n\n 1. Slightly prominent gallbladder, without son evidence of acute\n cholecystitis.\n 2. No hepatic metastases identified.\n 3. Right pleural effusion.\n 4. No right-sided hydronephrosis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-10-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 846607,
"text": " 12:50 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o brain mets or bleed\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with renal CA s/p resection of brain met now here with altered\n mental status\n REASON FOR THIS EXAMINATION:\n r/o brain mets or bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Renal cell cancer status-post resection of brain metastases, with\n altered mental status; evaluate for intracranial hemorrhage.\n\n COMPARISON: No prior head CT scans are available for comparison. Comparison\n is made to the MR of the brain dated .\n\n TECHNIQUE: Noncontrast head CT.\n\n CT BRAIN W/O IV CONTRAST: Within the left posterior frontal lobe near the\n vertex, there is an area of hypodensity just deep to the patient's craniotomy,\n consistent with post-operative changes status-post resection of the previously\n identified posterior frontal lobe mass. The region of hypodensity corresponds\n to the region of increased T2 signal noted at the time of prior MR. acute\n intracranial hemorrhage is identified. The lateral ventricles are symmetric\n in size and nondilated, and appear unchanged in size from the time of MR. The\n basilar cisterns are patent. The density values of the brain parenchyma are\n otherwise within normal limits. The /white differentiation is otherwise\n preserved, without evidence of acute minor or major vascular territorial\n infarct. Bone windows again demonstrate a craniotomy within the left frontal\n bone with metallic fixation devices. The mastoid air cells and paranasal\n sinuses are normally pneumatized.\n\n IMPRESSION: Hypodensity within the left posterior frontal lobe, just deep to\n the patient's craniotomy, consistent with post-operative changes following\n resection of left posterior frontal metastatic focus. No acute intracranial\n hemorrhage or mass effect identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-10-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847077,
"text": " 1:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess NG tube placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70M with history of metastatic renal cell ca, intubated in ICU with hypoxic\n respiratory failure.\n REASON FOR THIS EXAMINATION:\n please assess NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 70 y/o with metastatic renal cell CA, intubated in the ICU. Assess\n NG tube placement.\n\n FINDINGS: This study was obtained at 14:14 hours and compared to prior study\n of 11:15 hours. Diffuse infiltration throughout the entire left lung and a\n large right pleural effusion with compression atelectasis of the right lower\n lobe and right middle lobe are again noted. These findings have not changed\n since the prior study. There is continued visualization of the right IJ line,\n ET tube, and NG tube. The tip of the NG tube is at the gastric fundus. No\n evidence of pneumothorax. There are postoperative clips under the left\n hemidiaphragm in the epigastrium.\n\n IMPRESSION:\n\n The tip of the NG tube is at the gastric fundus. The appearance of the lungs\n has not changed since the prior study of earlier the same day.\n\n"
},
{
"category": "Echo",
"chartdate": "2126-10-21 00:00:00.000",
"description": "Report",
"row_id": 94485,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 70\nWeight (lb): 180\nBSA (m2): 2.00 m2\nBP (mm Hg): 132/63\nHR (bpm): 120\nStatus: Inpatient\nDate/Time: at 13:50\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV cavity size. Suboptimal technical quality, a focal\nLV wall motion abnormality cannot be fully excluded. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Mild [1+] TR. Moderate PA systolic hypertension.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\n1. The left atrium is mildly dilated.\n2. The left ventricular cavity size is normal. Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Overall\nleft ventricular systolic function is normal (LVEF>55%).\n3. The aortic valve leaflets are mildly thickened. Trace aortic regurgitation\nis seen.\n4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n5. There is moderate pulmonary artery systolic hypertension.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 846674,
"text": " 12:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for heart failure and effusions\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with sob and hypoxia met lung ca s/p triple lumen placement\n REASON FOR THIS EXAMINATION:\n evaluate for heart failure and effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dyspnea status post triple lumen placement.\n\n COMPARISON: Radiograph dated .\n\n AP UPRIGHT CHEST: There is a right-sided IJ catheter, unchanged. Again\n demonstrated is a right-sided pleural effusion with associated\n collapse/consolidation of the right middle and lower lung, unchanged. There\n is diffuse interstitial opacity of the left lung with superimposed multifocal\n patchy air space opacities, increased in extent and intensity compared to the\n prior study. The mediastinal and cardiac contours appear to be stable. A\n note again is made of surgical clips in the left upper abdomen and spinal\n hardware.\n\n IMPRESSION: Right-sided pleural effusion with associated\n collapse/consolidation of the right lower lung. Diffuse interstitial opacity\n with superimposed patchy left-sided alveolar opacities, worse compared to the\n prior study. Differential diagnosis includes pulmonary edema and aspiration.\n An underlying infectious process cannot be excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-10-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847308,
"text": " 11:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate effusion, infiltrate progression\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70M with history of metastatic renal cell ca, intubated in ICU with hypoxic\n respiratory failure.\n REASON FOR THIS EXAMINATION:\n evaluate effusion, infiltrate progression\n ______________________________________________________________________________\n FINAL REPORT\n History of metastatic renal cell cancer with intubation and respiratory\n failure.\n\n Endotracheal tube is 5 cm above the carina. Right jugular CV line is in\n region of cavoatrial junction. G-tube extends below the diaphragm. No\n pneumothorax. There is elevation of the right hemidiaphragm with probable\n associated pleural effusion. Extensive diffuse reticular nodular interstitial\n process throughout the left lung and in the predominantlly lower zone of the\n right lung is again demonstrated and is unchanged.\n\n IMPRESSION: No significant change since the prior study. Specifically, no\n pneumothorax. There is diffuse bilateral interstitial process and elevated\n right hemidiaphragm with pleural effusion again demonstrated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-10-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847483,
"text": " 12:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate ET tube placement.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70M with history of metastatic renal cell ca, intubated in ICU with hypoxic\n respiratory failure.\n REASON FOR THIS EXAMINATION:\n Please evaluate ET tube placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Metastatic renal cell cancer, endotracheal tube placement,\n respiratory failure.\n\n CHEST X-RAY PORTABLE AP: Comparison made to prior study of .\n There is an endotracheal tube with tip at the thoracic inlet. This is located\n approximately 5 cm from the carina. A right internal jugular central venous\n line and feeding tube are present and unchanged in position. There is a large\n right effusion. Bilateral diffuse parenchymal opacities are present and are\n not significantly changed in the interval.\n\n IMPRESSION:\n Endotracheal tube properly positioned with tip at the thoracic inlet.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-10-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 846884,
"text": " 7:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval improvement in pulmonary edema\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with sob and hypoxia, right pleural effusion. Also\n pulmonary edema following aggressive fluid resuscitation for septic shock.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval improvement in pulmonary edema and pleural\n effusion. Please perform in AM of /04before 8AM.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath and hypoxia.\n\n COMPARISON: Radiograph dated .\n\n AP UPRIGHT VIEW OF THE CHEST: There is a right IJ line, unchanged. There is\n a right sided pleural effusion with right middle and lower lobe collapse.\n There are diffuse bilateral interstitial and alveolar infiltrates consistent\n with pulmonary edema. There is a probable small left pleural effusion.\n\n IMPRESSION: Persistent right pleural effusion with collapse of the right\n middle and lower lobes. No change in bilateral diffuse interstitial and\n alveolar infiltrates consistent with pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-10-24 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 847114,
"text": " 4:55 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: r/o PE\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with hypoxia and persistent tachycardia.Please evaluate for\n pulmonary emboli. Has renal insufficiency; will receive D5W with bicarb and\n also mucomyst.\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old male with hypoxia and persistent tachycardia. The\n patient has metastatic renal cell cancer to the brain, lungs, and pleura.\n\n COMPARISON: Comparison is made to .\n\n TECHNIQUE: Initially, a noncontrast CT scan of the chest was obtained. This\n was followed by a contrast enhanced CT scan of the chest in the pulmonary\n artery phase. Multiplanar reconstructions were performed. 100 cc of Optiray\n (nonionic IV contrast) was administered due to patient's debility.\n\n CT CHEST: There is no significant axillary or mediastinal lymphadenopathy.\n There is no pericardial effusion. The heart and aorta are unchanged when\n compared to the prior study.\n\n There is a filling defect in the right middle lobe and right upper lobe\n branches of the pulmonary artery consistent with pulmonary artery embolism.\n\n There are bilateral pleural effusions (right greater than left). The right\n pleural effusion appears to be at least partially loculated. The pleural\n effusions are significantly bigger than it was on the prior study. There is\n also progression of the multiple pleural-based metastases. For example, the\n one located anteriorly (series 3, image 89) measures 4.5 x 2.5 cm (previously\n 2.8 x 2.0 cm). There is a large conglomerate of metastatic disease, best seen\n on series 3, image 84) that measures 5.9 x 6.0 cm (previously 3.3 x 2.6 cm).\n Again also noted, are the multiple lung metastases in the right lower lobe,\n that are difficult to identify in this study since they are located within\n areas of atelectasis.\n\n There is an NG tube with the tip in the stomach. There is an ET tube in good\n position.\n\n Limited images of the upper abdomen demonstrate surgical clips in the left\n nephrectomy bed. No other obvious pathology is seen.\n\n BONE WINDOWS: No definite bony metastases are seen.\n\n IMPRESSION:\n 1. Positive study for pulmonary embolism in a right middle and right upper\n (Over)\n\n 4:55 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: r/o PE\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n lobe artery . Part of the clot extends into the right main\n pulmonary artery.\n 2. Interval progression of pleural and pulmonary metastasis.\n 3. Interval increase of bilateral pleural effusions (right greater than\n left). The right pleural effusion appears to be slightly loculated.\n 4. Diffuse interstitial lung ground glass opacities sparing the right apex\n that could represent pulmonary edema, hemorrhage or drug reaction.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-10-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 846985,
"text": " 7:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm ETT position\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70M with hypoxic respiratory failure.\n REASON FOR THIS EXAMINATION:\n confirm ETT position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia and respiratory failure. Check ET tube position.\n\n COMPARISON: at 0735 hours.\n\n SUPINE AP PORTABLE CHEST at hours: The right internal jugular line\n remains in similar position. An endotracheal tube has been inserted, and its\n tip ends at the level of the clavicular heads. A nasogastric tube insertion\n has been attempted. That tube loops at the distal esophagus and returns into\n the neck. These findings were discussed with Dr. at hours\n on the day of the study. The diffuse bilateral interstitial and alveolar\n opacities remain similar in appearance. The right pleural effusion and\n elevation of the right hemidiaphragm are unchanged. The left lateral\n costophrenic angle is excluded from the examination. Clips are again noted in\n the right abdomen, and post-operative changes of the spine are partially\n visible.\n\n IMPRESSION\n\n 1. Satisfactory endotracheal tube position.\n 2. Enteric tube looped in esophagus.\n\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2126-10-30 00:00:00.000",
"description": "Report",
"row_id": 272355,
"text": "Sinus rhythm. Right bundle-branch block. Left anterior fascicular block.\nCompared to the previous tracing of no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2126-10-24 00:00:00.000",
"description": "Report",
"row_id": 272356,
"text": "Sinus rhythm. Right bundle-branch block. Left axis deviation. Left anterior\nfascicular block. Since the previous tracing of no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2126-10-20 00:00:00.000",
"description": "Report",
"row_id": 272357,
"text": "Sinus rhythm. Short P-R interval. Left anterior fascicular block. Right\nbundle-branch block. Prominent T wave voltage. Clinical correlation is\nsuggested. Since the previous tracing of no change.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-21 00:00:00.000",
"description": "Report",
"row_id": 1474781,
"text": "Rec pt at 1900. Wife at bedside and updated on all procedures. Patient neuro intact.\n\nLungs: Rhonchi throughout. Deep nasal suctioned for frothy white mucous. Specimen sent to lab. SVO2 > 70 and improved to >80 by 3am.\nPt placed on CPAP at 0230 for flash pulm edema which occurred at 0200.\n\nCardio: Rec with temp 95.4 ax and oral. No orders given for bear hugger. Pt on levo and Dobutamine which was weaned to off by 2300. Map was >55 and improving. 1 litre of LR ordered to run over 1 hr. More time was requested to monitor pt before infusing LR. It was felt that the LR would be beneficial to MAP. CVP elevated at 0200 to 20-23. Dr advised of rise in SPB to 170's, HR >120, diaphoretic and labored breathing. Lasix 60 mg given IVP. Pt's sats dropped to 87%. Pt placed on CPAP. Flash Pulm Edema improving within 30 minutes.\n\nGU: Foley >100 q hr. Yellow with substantial sediment. Spec sent to lab for legionella. 340 cc urine out by 0300. VSS. Urine clear light yellow. Breathing unlabored, sats 98%, pt comfortable.\n\nEndo: Pt on hourly fingersticks, insulin gtt titrated down to 2 units q hr for range of 80-120. Lactic acid being done q 4 hrs.\n\nGI: Remains NPO, except for meds.\n\n0300....Pt is off Levo and Dobut., has stabilized after an episode of flash pulmonary edema. Diuresed appropriately for disease process.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-21 00:00:00.000",
"description": "Report",
"row_id": 1474782,
"text": "0600- Pt remained stable and taken off CPAP per Dr this am. His HR and BP did elevate on 100% face mask. He continues to have a loud rattle, but only scant frothy mucous is suctioned. His sat did drop to 92. Dr updated on these events. EKG done at 0600 per Dr \n\nBath done, backrub done at 0530. Last CBC and Lactic acid done at 0600. Insulin drip remains on but dropped to 1 unit q hr after FS of 92 at 0600. Will request pt return to CPAP for hemodynamic instability at this time.\n\nSee flowsheet for detailed assessment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-21 00:00:00.000",
"description": "Report",
"row_id": 1474783,
"text": "add note 0645: CPAP placed on patient and reassurance given. HR is down from 138 to 129 and continuing to gradually slow down. BP is down from SBP 177 to SBP 157. CVP remains stable and SVO2 is 87. No further ectopy noted. Updated Dr .\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-21 00:00:00.000",
"description": "Report",
"row_id": 1474784,
"text": "altered fluid balance\nd: pt alert and oriented x 3. follow ing simple commands consistently. neruologically intact. this afternoon after receiving 1 mg of morphine ivp and while pt's wife was visiting pt demanding ro be trnasfered to another place and stating that his nurse him. he demanded that another nurse to his care . when his wife was asked if the pt had ever received morphine in the past she stated that the last time he had surgery he had gotten some med and started seeing things crawling on the walls but yet knew that they really weren't there. pt's wife obviously concerned about this behavior that was not common for her husband. dr. called to the bedside for support. emtional support offered to both pt and his wife. social work also by and pt's wife expressed that she did not meet the doctors responsible for his care. all memners of the team introduce themselves to her and explained the pln of care. she is appropppriately concerned about the pt and will continue to offer emotional support and frequent updates as needed. pt now more calm and cooperative and will avoid administration of morphine since his earlier behavior may have been and adverse response to that med.\n\n\nresp: pt has remaine on 100% bipap with 5 peep and ips of 8 .rr 20's and o2 sats> 98%. occasional exp wheezes with diminished bs at the bases and scattered crackles. have been unable to remove pt from bipap because he quickly desaturates to mid 80's when mask removed. also attempted placing pt on 100% nrb but his o2 sats to mid 80's. will continue to wean pt off bipap as he tolerates. abg on bipap=7.32/50/222. bipap removed and pt on 100% nrb iwht o2 sats>96% at present . less resp distress noted post diuresis and administration of iv ntg then prior to administration. if o2 sats drop off will place pt bcak on biapa.\n\ncv: concerned that pt may still be in fluid overload. pt's hr in the 120's wiht pvc's and sbp 140's. k+ 5.3. pt was not given the kaexolate ordered b/cause of his tenuous reps status. medical team aware and repeat k+ =4.3. will follow electrolytes as ordered and replete as needed. iv ntg initiated at 0.05mcg/kg/min and diuresed with 6 0mg ivp lasix. at 1630 iv ntg gtt d/c'd b/cause sbp dropped to 84. if bp continues to climb will restart iv ntg and consider further diuresis\n as pt tolerates. follow hemodynamics closely.\n\ngi/gu : pt remains npo b/cause of his tenuous resp status.has had sips of water while of bipap. abd soft and nontender with pos bowel sounds on auscultation. will advance diet tomorrow if his resp status continues to improve. foley cath in place with adequate uo. with diuresis pt's i&o now neg 4liters. follow lcosely and cotninue to diureses as pt's hemodynamics tolerate.\n\n\nid: max temp=97.6 and wbc=18.4. follow final results of all culture data and adminsiter antibiotiocs as ordered.\n\nsocial: pt is a full code. very supportive and will keep her well informed on daily basis and offee emotional support. continue w\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-21 00:00:00.000",
"description": "Report",
"row_id": 1474785,
"text": "altered fluid balance\n(Continued)\nith present medicla management.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-23 00:00:00.000",
"description": "Report",
"row_id": 1474795,
"text": " 4 ICU nursing progress note:\n Respiratory: Early am on 6l/.95% high flow neb..rr 20's..sats 97%..as mornig progressed..deterioration in resp status..dropping sats into 80's..more congested sounding..rr in 30's..tachycardic and hypertensive..ho's aware. abg done..46/41/7.51 (had been on bicarb gtt in anticipation of ct/dye)pt on/off bed pan most of am. Several more episodes occured into the afternoon..wife here..house staff met with her and then pt..explaining options..intubation vs comfort measures..pt initially was all for intubation..found out he wouldnt be able to talk..then was admiment not to be intubated. Wife ..trying to convince pt that the \"tube\" could be temporary..pt very conflicted..Wife encouraged to call family members..which she did..pt asked for time to talk with children..and primary care MD who will be in this evening.In meantime placed on masked ventilation..rr 30's with high MV..on 90min..some family members in now..waiting for others to arrive..pt again back on 6l/.95% high flow . Has had non-productive cough. CPT done several times..per house staff worsening x-ray.\nChest ct differed to pts resp. status..\n Cardiac: Remains tachycardic..as high as 130's with hypoxia..\nBP up at times also..\n GI: Incontinent of stool numerous times today..mod-large amts..Ob-\nNow npo..\n GU: Continues to have good u/o..\n Neuro: Has been alert/orientated..though at times makes inappropriate statements..wanted to go see wife in waiting room..getting oob on own..Unclear if totally understood conversation regarding intubation. Clearly agitated and paranoid when hypoxic. Has not required any sedation as of yet.\n Skin: Macular rash on upper back..seen by derm..pt not c/o of discomfort or itchy. Felt he has blocked sweat glands. Unable to keep pt off back d/t resp. distress.\n ID: Afebrile..no change in antibiotics.\n Social: See note above\n Currently pt is full code.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-23 00:00:00.000",
"description": "Report",
"row_id": 1474796,
"text": "resp care\npt had increasing episodes of resp distress/hypoxia today, per team discussion with patient and wife the pt was placed on noninvasive ventilation( which he tolerates well) until the pt/family to decide on further interventions. rx'd with albuterol/atrovent nebs q6h. bs in am were improved with bib crackles,no wheezing however in p.m developing increased adventitious bs. will c/w mask ventilation as indicated,awaiting decision on intubation. c/w bronchodilator therapy.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-20 00:00:00.000",
"description": "Report",
"row_id": 1474780,
"text": "1515-1900 NSG ADMISSION NOTE\nMr. is a 70yo male with PMH/PSH of lung ca yrs ago with reoccurance of lung ca, renal cell ca, brain mets, S/P L nephrectomy, HTN, asthma, hypothyroidism, partial resection brain mass L frontal lobe one month ago, S/P hernia surgery. PTA he was feeling poorly with increasing lethargy. This AM brought to ED by wife for inability to ambulate at home. In ED initially PO temp and BP WNL however O2 sat 80% on RA. Rectal temp checked, found to be 101.2 with lactate of 1.9, developed hypotension with SBP 80's. Treated with 3liters of fluid then Levophed started. PCXR in ED revealed lg R infiltrate, lg R pleural effusion. Rec'd Zithromax 500mg PO and Ceftriaxone 1gm IV both at 1100 in ED, Code Sepsis initiated at that time. R IJ TLC placed. EKG WNL. K 6.7, treated with kayexelate and calcium gluconate with rpt K 5.9. Head CT unchanged from previous films. Abd U/S WNL, renal U/S-->hydronephrosis. Started on Dobutamine, trans to MICU on 4 (arrived on 4 at 1515). Remains on Sepsis protocol, Levophed, Dobutamine. Insulin gtt started, one unit PRBC started.\nCURRENT STATUS:\nSee FHA and carevue for subjective/objective data.\nNeuro: A+Ox3. Speech clear. MAE ad lib.\n\nCV/Pulm: BP remains labile--titrated Levo to maintain MAP>60. Currently Levo at 0.2mcg/kg/min. Remains on Dobutamine at 4.7mcg/kg/min. MP=NSR-ST, no ectopy noted. One unit PRBC currently infusing without evidence of adverse reaction. 100%NRB in place with sats mid to high 90's. BS coarse bil--RLL pneumonia per intern. Congested sounding cough, is not expectorating at this time.\n\nGI/GU: NPO. Abd round, soft, non-tender, bowel sounds present. No flatus, no BM. U/O qs q1h via foley; urine yel with sediment (urine for C+S sent in ED).\n\nID/Endo: Tmax=96.4ax. Remains on Rocephin and Zithromax. Fingerstick done, 329-- protocol insulin gtt started--see flowsheet.\n\nInteg: Intact. No open areas noted.\n\nPsychosocial/Plan: Wife in with pt. Emotional support given to pt and wife. is to maintain sepsis protocol, infuse PRBC's as ordered, support BP with Levo/Dobutamine, titrate insulin gtt per protocol, support resp status, administer abx as ordered, monitor I+O.\nCont to provide emotional support/cont with nursing, medical regime.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-27 00:00:00.000",
"description": "Report",
"row_id": 1474809,
"text": "resp. care\npatient remains intubated/vented. follows commands. weaned to\n and 50% with good abg. still has cop. secretions. good cough.\nplan to rest on tonight and place on 5/0 tomorrow for\npossible extubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-22 00:00:00.000",
"description": "Report",
"row_id": 1474791,
"text": "Accepted pt at 1900. Pt sitting up in chair with wife at bedside. Explained all procedures and plan for care for overnite to patient and wife. Pt has requested to remain in chair for as long as he can. He said he feels much better sitting up in chair.\n\nAssessment done, backrub given, pt eating jello, taking meds PO without difficulty.\n\nLungs: soft coarse sounds heard throughout. No change in O2 Rx.\n\nCardio: Sinus tach with PVC's and occas PAC's with comp. pause. Afebrile, SBP 140/57. RIJ TLC intact, plan to start Bicarb gtt when pharmacy sends IV to unit.\n\nGI: Taking clears, Soft BM, small incontinent episodes.\n\nGU: Foley, yellow, clear, QS\n\nPlan: Spiral CT in AM to r/o PE. Chest xray in am. Labs in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-22 00:00:00.000",
"description": "Report",
"row_id": 1474792,
"text": "Pt is experiencing some mentation changes. He is stating that everyone around him are confusing him and everything is wrong. Everyone around him is not taking care of him. The physicians have been called into room to address his confusion. He does not think he is getting enough oxygen.\n\nHis BP and HR has become elevated during physician . He is not understanding the physician's explanation regarding his questions.\nHe is confused and agitated.\n\nRN is at bedside since 1900. Remains in room to assist with re-orientation.\n\nBicarb gtt has been up since 2200.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-23 00:00:00.000",
"description": "Report",
"row_id": 1474793,
"text": "This RN has remained in room at bedside to provide continued reassurance. Pt has become calm and cooperative. VSS. Plan to remain with patient during nite and maintain close observation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-23 00:00:00.000",
"description": "Report",
"row_id": 1474794,
"text": "Called Dr. with lab results Sodium 145 and K 3.4. Waiting for orders.\n\nBath done at 0530. Pt walked to chair with one assist. Tolerated well. This RN at bedside all nite, monitoring patient's neuro status. Patient did not sleep all night. He attempted to crawl out of bed several times and was repositioned by RN. He closed his eyes several times and then began to cough and talk. When presented with respiratory treatment to help with his breathing, he refused treatment. He states he slept but this RN did not observe that.\n\nPt had several episodes of hyperventilation resembling panic attacks. He was provided reassurance and was calmed with assistance with coached breathing.\n\nHe continues with 6L NC and 98% humidified face mask.\n\nCT was canceled by Dr but when questioned about continuing Acetylcysteine, he stated that to continue it in case the CT of chest was re-ordered after re-evaluation in am.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-27 00:00:00.000",
"description": "Report",
"row_id": 1474810,
"text": "pmicu nursing progress note\nresp: presently on c-pap 50% 5 peep and 5 pressure support with spont tvs of 650-740 and resp rate of 16-24 and o2 sats of 96-98%. abg on these settings was 93 43 and 7.43. suctioned several times for copious amts of thick tan sputum. also large amt of clear oral secretions. pt is to receive nystatin for thrush. pt is to be rested tonight for ultrasound guided thoracentesis tomorrow. lung sounds coarse, deminished lower right. receiving combivent.\n\ncardiac: bp 142-175/58-70 with pulse o f 90-102 sr/st, occasional pvcs. K+ was 5.1. heparin drip infusing at 1500u/hr.\n\nid: temp of 98-98.5 po. ceftriaxone. wbc was 8.8.\n\ngi: abdomin soft/distended with hypoactive bowel sounds. large ngh aspirates of 140-160cc. tube feeds of promote with fiber were decreased from 85cc/hr to present 35cc/hr. tube feeds to be dc'd after midnight tonight for procedure tomorrow.\n\ngu: foley in place. bun 40 and creat 1.1. no lasix given today. output approx 40-60cc/hr.\n\nendo: insulin drip decreased at 8:30a due to fingerstick of 68. presently insulin drip is infusing at 3u/hr.\n\nneuro: pt is alert and priented and has been unrestrained all day.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-28 00:00:00.000",
"description": "Report",
"row_id": 1474811,
"text": "altered resp status\nd: pt sedated on fentanyl gtt at 75mcg/hr and versed gtt at 2 mg/hr.and pt remains easily arousable. is able to express his needs by motioning or mouthing words. mae's and is pleasant and cooperative.\n\nresp: suctioned q 1 hr for copious amts of thick tan sputum and orally for copious amts of thick clear secretions. coarse bs bil on auscultation but diminished at the r base. pt had been on vent settings of 50% cpap with 5 peep and ips of 10 but at 0100 he c/o sob so peep was then increased to 8 cm. rr 20's and o2 sats for most of the shift were > 94%. at 0455 pt appeared to be in distress with hr 118 and sbp 207 with an o2 sat of 93%. respiratory therapist at the bedside and again pt c/o difficulty breathing and being tired. pt bolused with 2 mg ivp versed and 75 mcg of fentanyl. vent settings changed to 60%/600/ac 15 with 5 peep to totally rest pt for present time. sputum sample sent off for c&s/gm stain.\n\ncv: hr has been in the 100's and sbp 120-180's depending on his reps status and need for suctioning. no other active issues. will follow electrolytes as ordered and replete as needed. heparin gtt infusing at 1500 u/hr and ptt level this am still pending. will discuss with medical team when heparin gtt should be d/c'd for palnned thoracentesis\n\ngi: tube fdgs of prmote with fiber infusing via ngt at 35 cc's/hr were d/c'd at midnooc in anticipation of u/s guided thoracentesis that is scheduled for today. abd soft and nontneder with pos bowel sounds on auscultation. insulin gtt off for a period of time when blood sugar was < 100 and tube fdgs were d/c'd but at bs climbed to 147 so insulin gtt restarted and presently infusing at 2u/hr. will continue to monitor blood sugars closely. no stool output this shift and hct stable at 31.8.\n\ngu: adequate hourly uo via foley cath.i&o negative 350cc's for this shift but pos for 8.4 liters for los. will continue to ofllow fluid balance closely.\n\nid: max temp=97.8 and wbc this am=7.5. repeat sputum for c&s/gm stain sent off to microbiology and pt continues to receive ceftriaxone as ordered. will await all final results of the culture data.\n\n\nsocial: pt is a full code. his wife called early this am and was updated on how pt's night was. will continue with present medical management and keep pt's family well informed. continue to offer emotional support to both pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-28 00:00:00.000",
"description": "Report",
"row_id": 1474812,
"text": "Resp: pt on psv 5/5/50%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral coarse sounds. Suctioned for copious amounts of thick tan secretions Q 1hr as well as thick clear oral secretions. MDI's administered Q4 combivent. Pt place on 10 ps to rest noc. He became sob with ^ BP/HR was given some sedation to rest and place on a/c 15/600/+5/60%. 02 sats @ 94%. Guided thorocentisis this am at IR. Sputum sample sent, results pending.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-25 00:00:00.000",
"description": "Report",
"row_id": 1474803,
"text": " 4 ICU nursing note addendum:\n 18:30 pt given 40 lasix iv..want to keep volum status even and pt now 1200cc pos.\n Bactrim dc'd..cultures neg for PCP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-26 00:00:00.000",
"description": "Report",
"row_id": 1474804,
"text": "Smicu nsg progress note\nNeuro- Sedated on 75mcg fent/2mg midaz not requiring additional boluses. Pt easily arousable and able to follow commands. Denies pain.\n\nResp- Remains intub/vented on 15ps 10peep with rr 12-16 tv 800-900. Initially on 40% fio2 with sats 89-92 % abg 64/39/7.47. Fio2 increased to 50% with repeat abg 87/42/7.45. Suctioned for sm amts thick blood tinged to tan secretions.\n\nCardiac- Bp stable off levo. Cont in sr-st with occasional pvc's. Given lasix at ~ 1800 with good response. I+O essentually equal which is goal.\n\nGi- Abdomen distended but soft. Cont on goal tube feeds promote with fiber at 85cc/hr. No stool. Hct has been stable. On insulin gtt with fs 160's. Insulin gtt increased to 6u/hr with fs 138-101.\n\nHeme- Cont on heparin gtt at 1500u/hr with last ptt 81.9. Second ptt pending. No s/s bleeding.\n\nId- Remains afebrile on levo/ceph. Cultures neg so far.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-26 00:00:00.000",
"description": "Report",
"row_id": 1474805,
"text": "Resp: pt on psv 15/+10/40%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral wheeze. Suctioned for moderate amounts of thick tan secretions. MDI's adminiseted Q 4hrs combivent which were changed from 6hrs. Fio2 ^ to 50% due to decrease in pao2. AM abg's 7.45/42/87/30. No further changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-26 00:00:00.000",
"description": "Report",
"row_id": 1474806,
"text": "pmicu nursing progress note\nresp: a couple of vent changes today and present settings are c-pap 50% 8 peep and 10 pressure support with an abg of 95 46 7.43. spont tvs of 750-950 and resp rate of 14-20, with O2 sats of 94-96%. lung sounds have been coarse and deminished in the right mid (rt lower lobe lobectomy). pt has a good strong productive cough via the ettube and suctioned for thick tannish sputum. some clear nasal drainage noted in right nares. ? ultrasound guided thoracentesis to be done in the near future--pleural effusions. steroid changed to prednisone 60mg daily.\n\ncardiac: bp 115-184/49-68 with a pulse of 86-110 sr/st. when heart rate is greater then 100 pt has occasional pvcs, none noted when heart rate is less then 100. when pt is stimulated and interacting with nurse pt's bp becomes elevated to 180's/68-74. when totally comfortble and sleeping pt's bp is 115/50. repeat k+ this afternoon was 4.5. both hands and feet are edematous--feet warm to touch. cvp was . heparin drip is infusing at 1500u/hr---ptt this am was 68.6 and inr was 1.3. no lasix today due to elevated bun and creat.\n\nid: afebrile. temp 98.1 po, 97.6 po, and 99 po. wbc was 11.2. on ceftriaxone. sputum from bronch was neg for gram stain, pcp and culture. urine was neg.\n\ngi: abdomin soft/distended with + bowel sounds. promote with fiber infusing via ng tube at goal of 85cc/hr. residuals of 40-60cc, ph 5 and ob neg. 100cc fluid boluses q 4hrs while receiving tube feeds. no stool today, passing gas. ? pt has thrush.\n\ngu: foley in place. urine output is approximately 40-60cc/hr. this am bun was 35 and creat 1.3. repeat this afternoon was bun 39 and creat 1.1. urine was yellow and clear, but this evening urine has sediment.\n\nendo: insulin drip infusing at 3.5 u/hr with fingersticks of 93, 108, 115, and 102.\n\nneuro: alert, following commands, interacting with nurse and family. pt is restrained with soft limb restraints.\n\nskin: red rasised rash noted on upper back.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-26 00:00:00.000",
"description": "Report",
"row_id": 1474807,
"text": "resp. care\npatient remains intubated/vented. vent weaned to ps 10 and\npeep of 8 and 50% with good abg. sx'd thick tan sputum. ett\nretaped and rotated. plan to continue to wean ps and peep.\nrsbi in a.m. see careview for more.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-27 00:00:00.000",
"description": "Report",
"row_id": 1474808,
"text": "altered resp status\nd:pt slept well tonoc. pt sedated on fentanyl gtt at 75mcg/hr and versed gtt at 2 mg/hr. pt easily arousable and follows simple commands appropriately. + edema to the extremities.\n\nresp: remains orally intubated with vent settings of 50% cpap with 8 of peep and 10 of ips with o2 sats> 96%. coarse bs bil on auscultation but diminished at the bases. suctioned for mod to lg amts of thick tan sputum and orally for lg amts of clear secretions. rsbi checked this am. refer to resp therapist's note. will continue to wean vent as pt tolerates.\n\ncv: hr 90-100's with rare pvc's and sbp stable from 109-130. am labs are pending and will replete as needed. heparin gtt infusing at 1500u/hr and will follow ptt as ordered.\n\ngi: ngt in place and pt receiving tube fdgs of promote with fiber at goal rate of 85cc's/hr with minimal residuals. abd soft and nontender with pos bowel sounds on auscultation. no stool output this shift.\n\ngu: adequate hourly uo via foley cath. i&o pos 400cc's this shift and for los pos 8.4 liters. follow fluid balance closely.\n\nid: pt afebrile this shift and ? wether pt will have u/s guided tap of pleural effusions. follow fever curve and if pt spikes fever will reculture.\n\nsocial: pt is a full code. his wife called this am and was updated on how her husband made through the noc. continue with present medical management and keep family updated as needed and offer emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-22 00:00:00.000",
"description": "Report",
"row_id": 1474786,
"text": "Rec patient at 1900. Wife at bedside and updated her on all procedures and plan for overnite treatment.\n\nNeuro: Intact, does feel very anxious when short of breath. Generally calm and cooperative. A/O X3.\n\nPulm: Pt has been placed on CPAP intermittantly for episodes of SOB and sat <90%. Crackles are heard in upper and lower lobes bilaterally\nduring episodic periods. Lasix 40 mg IVP given at 0100 and pt diuresed 550 cc urine. HR dropped to low 100 and BP dropped to teens (see flow sheet). His breathing slowed to 20 and sat up to 98%. Crackles diminished after diuresing. Pt comfortable on FM and sleeping.\n\nCardio: Temp 95-96 during nite (Ax). BP and HR is elevated during respiratory crisis. Both stabilize after diuresing with lasix 40 mg IVP. Pt has occasional PVC's. Potassium checked after diuresing.\n\nGU: foley intact, see above response to Lasix Rx and results.\n\nGI: NPO, sips of clears with meds. Pt tol PO well.\n\nPlan: Closely monitory respiratory status and lung sounds this shift. See Flow Sheet for detailed assessment. Pt and wife updated during nite of all procedures.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-22 00:00:00.000",
"description": "Report",
"row_id": 1474787,
"text": "PT.ON MASK VENTILATION AS NEEDED, ABG ACIDOTIC, BREATHE SOUNDS WITH RHOCNHI/RALES BILAT.,NON PROD.COUGH, PRESENTLY ON HI-FLOW 100% WITH NASAL .@ 6L, SAT.97-100%\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-22 00:00:00.000",
"description": "Report",
"row_id": 1474788,
"text": "After pt diuresed, he had a comfortable night. His wife called at 0500 and she was updated on all procedures. Bath was done at 0600 after the patient had a small, soft brown BM. It tested quiac negative.\n\nPt tolerated the bath well and turned for RN. Needed two assist for boost up in bed. No assist needed for bath.\n\nNo change in vital signs, no further respiratory distress, and no further CPAP needed after pt rec. lasix.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-22 00:00:00.000",
"description": "Report",
"row_id": 1474789,
"text": "resp care\npt tolerated being off noninvasive ventilation today. requiring high flow O2 and marked increase in wob with exertion however stable at rest. admin albuterol/atrovent neb x2. bs with decr bs right, fine end expir wheeze,+crackles at bases. will follow for q6h nebs. wean O2 as tolerates.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-22 00:00:00.000",
"description": "Report",
"row_id": 1474790,
"text": " 4 ICU nursing progress note:\n Respiratory: Continues to require high amts of O2..with sats 93-97%..rr 20's..very rhonchourus..productive cough. Attempted to get out of chair..??looking for something..pt sats 60's..rr 30 tachycardic and bp 150's..cyanotic..also found with o2 off..Placed back in chair..sats rose back to 90's within 5 min. House staff concerned about possibiltiy of PE..??to ct tomorrow.\n Cardiac: Hr 90-125st with PVC..bp 120-150/..\n GU: Good urine output..No lasix today\n GI: Incontinent x4 of small amt of stool..able to use bed pan..but continues to ooz stool. Changed diet to liqs..tolerated well..advance in am..\n Neuro: Alert/orientated..short episodes of confusion..getting out of chair..saying inappropriate things at times. Stands very well..MAE..\n Social: Wife in all day..spoke with social work..\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-24 00:00:00.000",
"description": "Report",
"row_id": 1474797,
"text": "Smicu nsg progress note\n Pt alert/oriented appears to understand need for intubation. Given 200mg propofol by anethesia and pt intubated without difficulty. After intubation pt initially sedated with propofol but becoming hypotensive so sedation changed to fent/versed gtts (see flow sheet). Now on 100mcg fent and 1mg midaz with good effect although pt does become quite agitated when awake with Bp increasing 160-180s pt attempting to sit up in bed. Responding to prn boluses 50mcg fent/2mg versed. When awake pt able to follow commands nod head to questioning. Hands restrained for safety.\n\nCardiac- Initially tachycardiac with hr 110-120st bp 120-130s. After intubation and with sedation pt becoming hypotensive with bp in low 80's. Cvp at time 8. Given total 2000cc ns boluses with improving bp. Hr now 90's with cvp 10-12. Uo adequate at 30-60cc/hr.\n\nResp- As stated above, pt intub without difficulty. On ac 600x14 breathing above vent 100% 5peep with sats 99-100% Abg 157/55/7.39. RR increased to 20 with repeat abg 153/46/7.45. Fi02 now at 80% with sats 93-94%. Pt suctioned initially for lg amts thick bloody secretions. Sputum for c/s sent. Now with thin blood tinged secretions. Plan for ? chest ct in am.\n\nGi- No further stool. Ng inserted- draining sm amt brown ob positve secretions. No brb. Remains npo. Will need to address nutrition.\n\nId- Remains afebrile. Being tx for ?pneuomonia. No changes in antibiotics.\n\n Pt family at bedside after intubation. Updated on pt's status. Going home. Plan to call in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-24 00:00:00.000",
"description": "Report",
"row_id": 1474798,
"text": "MICUNURSING PROGRESS NOTE. 0700-1900\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Events: Started on levophed for hypotesnion with minimal response to fluid bolus x2. Bronchoscopy completed this pm, specimens obtained and sent. Chest ct is to be completed this pm. Ventilator settings changed multiple times. Abg pending.\n\n Neuro: Lightly but effectively sedated on versed at 1 mg/hr, fentanyl at 75 mcg/hr. Is easily arousable to verbal stimulus, opens eyes and tracks rn. Is easily agitated with minimal stimulation requiring boluses of sedation, 2 mg versed, 25 mcg fentanyl with good effect. Follows commands and attempts to assist with turning. Is moving all extrem. freely. Temperature max. 98.4 oral.\n\n Respiratory: Lung sounds are coarse throughout, diminshed in rt base. Ventilator settings at present are ps/.70/15/8. Abg to be sent on this setting. RR 8-16 and non labored. O2 saturation 91-96% on present ventilator settings. Suctioned for scant amts thick blood tinged secretions. Will drop sats with care of when agitated. CT of chest to be complete, looking for pe. Bronchoscopy this pm showed normal left lung, rt lung middle lobe occluding. Minimal secretions noted, washings obtained for cyto and micro.\n\n CV: Sinus rhythm to sinus tachycardia with no ectopy noted, rate 90's to low 100's. Abp high 70's to low 120's systolic. Levophed initiated this am after multiple fluid bolus's had minimal effect with increasing bp. Levophed presently at .1 mcg/kg/min. A line site wnl, wavefrom sharp. Rt ij multilumen sharp, site wnl. +1 non pitting edema bilat le. Easily palpable pulses.\n\n GI/GU: Abdomen softly distened with + bs. No bm this shift. Ogt in good placement by cxr. Tf promoote with fiber initated at 10cc/hr with goal rate of 85 cc/hr. Foley catheter patent and draining cloudy yellow urine in poor amts, 500cc ns bolus initiated for poor urine output. Team aware.\n\n Endocrine: Insulin gtt initiated this pm for increase in steriod dose. Presently gtt is at 2 units/hr.\n\n Social: Wife in this am, will be back in this pm with daughter for visit.\n\n ID: Azithromycin d/ced, Bactrim iv added, ceftriaxone continues.\n\n Plan: Continue to wean fio2 and ps as tolerated. Wean levophed as tolerated while maintaining pt comfort. Monitor urine output and bolus for poor urine or cvp less than \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-24 00:00:00.000",
"description": "Report",
"row_id": 1474799,
"text": "\nPT MAINTAINED ON PSV VENTILATION AT 70%. PT WAS CONVERTED OVER FROM A/C VENTILATION WITH GOOD RESULTS. BRONCHOSCOPY DONE WITH BAL SENT ON BILAT LUNG FIELDS. MEDS ORDERED, COMBIVENT Q6HRS. LAST ABG SHOWED AN ACIDOSIS WITH ACCEPTABLE OXYGENATION. PT NEEDS SEDATION TO MANAGE AGITATION. PT ALSO BROUGHT TO CT SCAN FOR CHEST STUDY. PLAN IS TO CONT. ON PSV WITH SLOW DECREASE OF FIO2.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-25 00:00:00.000",
"description": "Report",
"row_id": 1474800,
"text": "MICU/SICU NPN HD #6\nEvents: Levophed titrated off. Lower extremity dopplers performed at bedside to r/o DVT after CTA revealed PE in RLL PA branch. Heparin gtt initiated. COntninues to have oxygenation issues despite increase in PEEP. S/p bronchoscopy last PM, BAL pending, started IV bacrtim\n\nS/O:\n\nNeuro: pt is lightly sedated with fentanyl/midazolam, eyes open to speech, follows simple commands, denies pain, MAEW\n\nPulm: remains intubated with #8 ETT, 20cm at the lip, on PSV 15+10/0.6, last ABG 7.42/49/62, with SRR 8-18, Vt 600-1200cc and Ve 8-13L, SaO2 91-97%, LS are coarse, diminished at bases, occasional rales at left base, suctioned q4h for small amts thick blood tinged secretions\n\nCV: HR 82-94 SR with rare PVC's, BP 104-159/52-75, CVP 11-17, pt becomes hypertensive with stimulation but responds well to verbal reassurance, please see flowsheet for data\n\nInteg: diffuse papular rash over back, particularly over scapulae\n\nGI/GU: abd softly distended, BS present, tolerating Promote with fiber at 30cc/h with goal rate of 85cc/h, residual volumes have been negligible, Foley patent for clear yellow urine, UO has been ~40cc/h overnight, pt received 500cc NS x1 for low UO with negligible response\n\n\nID: afebrile, on ceftriaxone and SMX/TMP, cultures pending\n\nEndo: pt contniues on insulin gtt titrated to keep FSBS 80-150\n\nSocial: family in to visit last PM and updated by MR & RN\n\nA:\n\nhigh risk for infection r/t invasive lines, ETT, indwelling cathether\naltered breathing r/t worsenting pulmonary metastases, worsening pleural effusions, pulomnary embolis\nimpaired skin integrity r/t prolonged immobility, steroid therapy, occasionally moist skin\n\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, consider early percutaneous tracheostomy for prolonged ventilator dependence, consider family meeting to discuss pt's condition, treatment options and code status, continue heparin gtt and convert to Coumadin if prolonged therapy is indicated, continue nutritional support as reccomended, continue abx as ordered and follw micro data\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-25 00:00:00.000",
"description": "Report",
"row_id": 1474801,
"text": "pt continues to have marginal oxygenation at times. For part of shift he was saturating in the mid 90's on 70%. O2 was weaned to 60% but PeeP was increased to 10. PSV also had to be increased back to 20 but last ABG still showing Po2 of 62. need to resume ventilation and possibly recuitment breaths could help.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-25 00:00:00.000",
"description": "Report",
"row_id": 1474802,
"text": " 4 ICU nursing progress note:\n Respiratory: Remains intubated and vented..PSV 20/10peep..rr 10-14..tv 800-1000. Fio2 weaned from 60%-40%. Suctioned for large amts of bldy secretions..pt has strong cough. ??raised possiblity of ARDS..though able to wean fio2. See care view for abgs..\n Cardiac: HR 80-120's sr/st bp 115-180/50-70 Continues to have PVCs..occassional to frequent.\n Neuro: Lightly sedated with 2mgm of Versed and 75mic of fentanyl. Opens eyes spontaneously..able to mae and assist with turns. Nods appropriately when asked yes/no questions.\n GI: TF at goal..promote with fiber 85hr. +bs No stool..no aspirates\n GU: u/o 20-35cc.. Urine culture sent..urine appears cloudy\n Skin: Rash has improved slightly from previous day..\n Social: Wife and son/daughter in..updated by house staff. Social work stopped by also.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-28 00:00:00.000",
"description": "Report",
"row_id": 1474813,
"text": " 4 ICU nursing progress note:\n Respiratory: Intubated and vented this am..changed back to PSV 5/10..rr 20's..copious amts of secretions..frequent suctioning..able to wean fio2 to 40%. Pt oob to chair..early afternoon..pt pulled out ETT..very congested..unable to raise secretions..placed on 100% nrb..sats high 90's. By late afternoon..less congested. 1 attempt at nt suction..large amts of secretions..however pt had small nose-bleed. (on heparin gtt)..Currently mentating well with stable sats..to change to 100% cn..??loosen secretions). Pt has made it perfectly clear he does not want to be re-intubated..see note below.\n Cardiac: Post extubation..bp as high as 220/..hr 140's..given 1\" of ntg paste..once respiratory distress decreased so did vss..\n Neuro: Pt appears alert/orientated..asked if he wanted to be reintubated said \"no heroics\"..Ethics service involved..(part of hospice)..spoke with pt and family and PMD..Dr. ..Pt now DNR/DNI..hopeing to arrange for DC to hospice tomorrow..as per pts wishes..Family wishes to speak with oncologist before pt leaves ..\nPts main concern is if he has difficulty breathing..was explained by all..RN..HO and PMD that medication can be given for his breathing and anxiety. Pt up in chair..talking with family..states he is comfortable.\nSocial service and case management to be involved in dc planning..\n Heme: Remains on heparin gtt..following ptt\n GI: Had coffee grd aspirates this am...lavaged to fairly clear..had been off TF..Has had no stool..\n Social: Family at bedside..have asked for a priest. The priest has not responded to page.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-28 00:00:00.000",
"description": "Report",
"row_id": 1474814,
"text": "Patient accidently self extubated while in chair.Placed on non-rebreather then cool neb. Alert,coop patient is DNR,plan for hospice care . Maintained good saturation,has high PT,PTT may need to be nasally suctioned if upper airway is significantly obstructed. Easy to pass catheter,nice man.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-10-29 00:00:00.000",
"description": "Report",
"row_id": 1474815,
"text": "MICU NPN 1900-0700\n\nNo events overnight.\n\nNEURO: Pt is A&Ox3, denies pain. Able to ID needs. Moves all extremities, but is a bit unsteady on his feet. Pt has stayed up in the recliner chair overnight, dozing intermittently.\n\nRESP: Per pt request, placed on 10L via NRB. RR 16-24, denies feeling SOB. Breath sounds coarse in all fields, with scattered ronchi. Pt has a congested cough.\n\nCV: NSR-ST, no ectopy. BP stable. Trace pedal edema. + peripheral pulses x4 limbs. Afebrile, skin warm, dry with brisk cap refill. WBC 6.1. Started on vancomycin, levofloxacin, zosyn for PNA. Hct stable 31.4. Heparin gtt remains on at 1500U/hr. PTT at 0300 was 68.1\n\nGI: Abdomen soft, nondistended, nontender, + bowel sounds. Pt on/off bedpan several times, but unable to have BM. Restarted on heart-healthy diet. Pt off insulin gtt, has not required coverage with SSI.\n\nGU: Foley cath patent with adequate amount clear yellow UOP.\n\nDERM: Intact. Rash to upper back dark red, raised. No open areas.\n\nSOC: Wife and children in to visit on evenings, chaplain visited pt as well. Wife called early this morning. Plan for hospice consult today, with plan for pt to go home as soon as possible. Case management needs to be notified ASAP this morning. Pt and family would also like to speak with the oncologist this morning.\n\n\n"
}
] |
2,365 | 190,337 | Hospital Course: BRBPR/Melena, Agitation. Intubated. EGD/Colonoscopy performed. HCT stable. EGD/Colonoscopy negative but colonoscopy to hepatic flexure only. Difficult to wean from mechanical ventillator. CXR showed right pleural effusion. Changed from Ciprofloxacin to Levoquin to cover for Pneumonia in addition to prophylaxis for spontaneous bacterial peritonitis. Etiology for acute mental status change likely hepatic encephalopathy. Lumbar puncture and CT brain normal. Patient extubated. Mental stautus much improved, but not back to baseline. Transfered to Medicine Floor. Liver U/S: heterogeneous liver no masses identified, normal blood flow in hepatic and portal veins, and splenomegaly. | A right subclavian line has been repositioned. Right subclavian line has been repositioned and the tip is at the distal SVC/RA. PORTABLE AP CHEST: A right subclavian line has been inserted and is noted to be coiled on itself with the tip pointing within the superior vena cava. IMPRESSION: New diffuse opacification of the right lung is noted. There is a right pleural effusion. This is consistent with asymmetric pulmonary edema. An NG tube is noted with the tip approximately at the level of the 1st proximal duodenum. Status post right subclavian line. Small right pleural effusion. IMPRESSION: Slightly increased right pleural effusion and interstitial edema. There is a slightly increased right pleural effusion and right perihilar haziness. Abdominal exam slightly distended and guarding. The tip of this line is now at the distal superior vena cava, right atrium. IMPRESSION: Right subclavian line loop on itself and the tip is pointing up within the superior vena cava. IMPRESSION: Probable free fluid in the abdomen. Cardiac silhouette and mediastinum are within normal limits. There also appears to be a right mid-lung consolidation. Consolidation of mid-right lung. There is blunting of the right costophrenic angle which may represent a right sided pleural effusion. Trace edema. IMPRESSION: Slight increase in moderate right pleural effusion. The endotracheal and NG tubes have been removed. The cardiac silhouette and mediastinum are within normal limits. FINDINGS: Agian is noted almost complete opacification of the right hemithorax consistent with large pleural effusion. EGD- showed varices, no active bleeding. Sinus tachycardiaNormal ECG except for rateNo previous tracing for comparison Unchanged large right pleural effusion. Pneumoboots on. Sinus tachycardiaNormal ECG except for rateSince previous tracing of , junctional rhythm not seen and sinustachycardia now present Moderate to large right pleural effusion. SINGLE VIEW CHEST, AP: The diffuse, unexplained density within the right lung is again identified and is essentially unchanged. too MD aware. FINDINGS: The cardiac, mediastinal and hilar contours are stable in appearance. vent weaned from a/c to cpap+ps. stool sent for c-diff. + HYPOACTIVE BS NOTED. + pulses to ext, edema generalized 1+. MOST RECENT CHEST X-RAY SHOWS RIGHT EFFUSION WITH ?BILAT INFILTRATES. HAD UNDERGONE AN EGD ON /04NSIGNIFICANT FOR GRADE 2 ESOPHAGEAL VARICES. K+, Mg, Ca++ all replaced.Derm: Intact with bruising to REJ old IV site, B feet.Psych/Soc: Pending psych consult, currently adequately sedated on propofol. gas improved after on the above with ph now 7.24. pt resp status decompensated at end of being oob with ph drop to 7.17.suctioned for a small plug of thick wh/yel sec. Pt withdrawls to sternal rub. abd round softly distended, + BS, Rectal tube intact. pt returned briefly to a/c. HAS A #7.0 ETT IN PLACE. IV Access is Right Femoral TLC.GI/GU: + hypoactive BS noted. COLONOSCOPY ON UNIMPRESSIVE. NICOTINE PATCH INITIATED.RR: INTUBATED. wean ps+peep as tol. suction with bilious drainage brought back. SUCTION WITH BILIOUS DRAINAGE BROUGHT BACK. need hep in cvvhd if system is cloting as ptt is in normal range nowPlan Cvvhd with a decreased fluid removal rate to allow vasc spase to rehydrate. T.MAX 99.0 ORALLY. W/ 7.5 ORAL ETT IN PLACE.REMAINS ON AC MODE 16/500/.50/5 W/ STABLE ABG.PT. + pulses with generalized 1+ edema.GU/GI: No active bleeding noted. RESPONDED WELL TO HALDOL IV. INTUBATED ON FOR DECOMPENSATION AND COLOSTOMY PREP.NEURO: OFF SEDATION (PROPOFOL GTT). sxn for mod thk . QTC was .429 after haldol.ID: Afebrile. ALSO HAD ALUMBAR PUNCTURE/ RESULTS PENDING. ABG 7.38/49/92/+.CV: REMAINS IN SR-ST WITH HR 80-100'S. After 1st unit, hct 25.5->26.0. HYPOACTIVE BS X 4 QUADRANTS. RESPIRATORY CARE: PT. weaning vent for extubation when mental status improves. Calcium and potassium repletion given IV and pt continues to get IVF d51/2NS w/20meqK at 150cc/hr. Gross amount of generalized edema noted. HR 90-110, BP 110-120/50-60, max temp 98.8. drain on rt abd drained 300 cl bile.skin intact with sm sacral decub which is covered and protected. EEG and sputum culture sent and c-diff Cx pending. Versed IVP given PRN. Pulses palpable.GI- Abd soft and distended. WBC 4.8.IV Access: Left EJ #16g capped/flushed. Purposeful, but inconsistent movement of extremities.RESP: Remains on CPAP + PS (please see flowsheet for up-to-date vent settings). + pulses to ext, generalized edema noted. R SVC TLC in place. remains intubated and sedated overnoc on A/C. No plan to further lighten sedation until thoracentesis completed by IP.Neuro- As stated above, lightly sedated w/ prop. Resp Care,Pt. Resp Care,Pt. + hypoactive BS's. Given Versed 1 mg IVPUSH for agitation x 1.Resp: Remains on 3l NC. Restarted Propofol gtt and titrating for sedation/comfort at present. EEG results neg. Brisk cap refill, trace generalized edema. remains intubated on IPS 10 overnoc. Pt remains afebrile. Fluid to KVO. HR 110-130, BP 115-130/60-70, max temp 98.9. MDI's administered Q4 Alb. Cont w/ inhalers as needed.CV- HR 80-100, NSR, rare ectopy. Plan: KEEP on ventilator o/n. + pulses to ext. wdrawl vs reaction to Ativan. PRN IVP versed available if pt becomes agitated. Ambu/syringe @ hob. UO picking up again to 30-40cc/hr.Pt remains NPO.IV: R femerol TLC intact with Sandostatin [email protected]/hr(25mcg/hr), [email protected]: Colonoscopy planned. Cont lactulose when access available. Suctioned for thick scant amt secretions. ABG compensated resp acidosis. Several loose liquid BM's today. Pts voice has remained very whispy, evaluated by ENT and Speech and swallow. Plans for weaning and extubation today.CV: NSR-Sinus tachycardia without ectopy and alarms on. LS coarse, rhonchi noted throughout. Conts. Remains on Levaquin via OGT.Skin: No breakdown noted. Continue supportive measures, cont methadone. Repeat HCT @ 2100:27.4GU/GI: Abd round soft + BS, 1X BM large melena stool noted. BP stable. BP stable. BP stable. Max temp 100.8, hr 90-110, BP 90-120/60-70. Gag, cough, blink intact. BS auscultated reveal bilateral coarse sounds. Afebrile. Afebrile. SBT following rounds, then extubation expected. Respirations deep, unlabored.CV: ST no ectopy. Hct/Hgb 27.9/9.8. + UE tremors when awake.Resp: Pt with dimished breat sounds on the Right, CTA on left. LUNG SOUNDS COARSE THROUGHOUT.C/V : SR -ST NO VEA BP STABLE.F/E/N : PT HAS BRISK REPONSE TO LASIX , NOW UO BACK DOWN TO 30-40 CC HR.RECTAL TUBE CONT TO DRAIN GOLDEN LIQUID STOOL.NO NGT PLACED OVER NOC, REMAINED NPO ? | 49 | [
{
"category": "Radiology",
"chartdate": "2178-07-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 832495,
"text": " 12:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: change in size of pleural effusion? possible tap today.\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 y/o female s/p intubation for sedation, w/ GI bleed. Diuresed for pleural\n effusion likely cardiogenic etiology.\n\n REASON FOR THIS EXAMINATION:\n change in size of pleural effusion? possible tap today.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 47-year-old woman with GI bleed and right pleural effusion.\n\n COMPARISON: \n\n CHEST AP UPRIGHT: The heart size is normal. Accounting for differences in\n technique compared to study the right pleural effusion appears\n slightly increased. There also appears to be a right mid-lung consolidation.\n There is increased opacity of the left perihilum as well. The right\n subclavian triple lumen catheter remains in unchanged position. The\n endotracheal and NG tubes have been removed.\n\n IMPRESSION: Slight increase in moderate right pleural effusion.\n Consolidation of mid-right lung. Increased left perihilar opacity suggestive\n of worsened CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-07-24 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 832109,
"text": " 12:42 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: PT WITH HEP C, GI BLEED, NEG EGD AND COLONOSCOPY, UNCLEAR SOURCE, R/O PERF, PERITONEAL BLEED, INFECTION\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with Hep C cirrhosis with GI bleed, negative EGD and\n Colonoscopy, unclear source.\n REASON FOR THIS EXAMINATION:\n R/O perf, peritoneal bleed, infection\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hepatitis C, GI bleed.\n\n RIGHT UPPER QUADRANT ultrasound: The liver is unchanged and heterogeneous in\n echo texture. No focal lesions or intrahepatic biliary ductal dilatation.\n The pancreatic head is unremarkable. The gallbladder is not distended and\n there are no stones within it. However, there is gallbladder wall edema and\n mild pericholecystic fluid, likely related to the patient's history of\n cirrhosis and hepatitis. There is a right pleural effusion. There is a small\n amount of fluid within the abdomen, not sufficient for safe paracentesis. The\n right kidney measures 9.2 cm and is without hydronephrosis. The common bile\n duct is not dilated, measuring 5 mm. The portal vein is patent.\n\n IMPRESSION:\n 1. Gallbladder wall edema, likely related to the known cirrhosis. A small\n amount of pericholecystic fluid.\n 2. Small right pleural effusion.\n 3. Minimal ascites, not sufficient for safe paracentesis.\n 4. Please note that an ultrasound is not the appropriate modality to evaluate\n for abdominal perforation, peritoneal bleed, or intra-abdominal infection.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-07-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 832286,
"text": " 1:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate status of pleural effusion for potential tap\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 y/o female s/p intubation for sedation, w/ GI bleed. Difficulties with\n change on ventilator to pressure support.\n\n REASON FOR THIS EXAMINATION:\n evaluate status of pleural effusion for potential tap\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47 y/o female status post intubation for sedation. GI bleed.\n Increased requirement for oxygenation. Evaluate status of pleural effusion\n for potential tap.\n\n TECHNIQUE: Single AP view of the chest is provided.\n\n FINDINGS: Agian is noted almost complete opacification of the right\n hemithorax consistent with large pleural effusion. This has not changed\n compared to prior film obtained on . The cardiac silhouette and\n mediastinum are within normal limits. There is no evidence for pneumothorax.\n The left lung demonstrates no significant abnormality, although there is\n motion artifact limiting its evaluation. An ET tube is again noted with the\n distal tip approximately 3 cm above the carina. A right subclavian line has\n been repositioned. The tip of this line is now at the distal superior vena\n cava, right atrium. An NG tube is noted in the stomach with the tip in the\n pyloric area.\n\n IMPRESSION:\n\n 1. Unchanged large right pleural effusion.\n 2. Right subclavian line has been repositioned and the tip is at the distal\n SVC/RA.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-07-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 832183,
"text": " 8:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Change in pleural effusion? Reason why patient would be havi\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47F s/p intubation for sedation, w/ GI bleed. Difficulties with change on\n ventilator to pressure support.\n\n REASON FOR THIS EXAMINATION:\n Change in pleural effusion? Reason why patient would be having increased\n problems ventilating? consolidation?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Increasing dilator pressure support required, in respiratory\n distress.\n\n COMPARISON: .\n\n FINDINGS: The cardiac, mediastinal and hilar contours are stable in\n appearance. The endotracheal tube tip and nasogastric tube are in\n satisfactory position. There is a slightly increased right pleural effusion\n and right perihilar haziness. There are possibly slightly increased\n interstitial markings in the left lung. The osseous structures are\n unremarkable.\n\n IMPRESSION: Slightly increased right pleural effusion and interstitial edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-07-23 00:00:00.000",
"description": "CT HEAD W/ & W/O CONTRAST",
"row_id": 832023,
"text": " 3:21 PM\n CT HEAD W/ & W/O CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: r/o ich, CNS lesion\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with change in mental status.\n REASON FOR THIS EXAMINATION:\n r/o ich, CNS lesion\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n CONTRAST-ENHANCED AND NON-CONTRAST-ENHANCED BRAIN CT.\n\n CLINICAL HISTORY: 47 year old female with known history of HIV and change in\n mental status.\n\n TECHNIQUE: Contrast-enhanced and non-contrast-enhanced brain CT performed\n from the skull base to the vertex with no prior examinations available for\n comparison.\n\n FINDINGS:\n\n The - matter differentiation is normal. No abnormal enhancement\n noted in the basal cisterns or the brain parenchyma. There is no evidence of\n intracranial hemorrhage, midline shift, or hydrocephalus. The posterior fossa\n structures appear unremarkable. Bone windows demonstrate mucosal thickening\n in the ethmoid and sphenoid sinuses. There is also mucosal disease in the\n bilateral maxillary sinuses and the mastoid air cells are clear. If there is\n clinical suspicion for sinusitis, a dedicated CT sinus study is suggested, as\n the HIV patient may be subject to opportunistic sinus infections.\n\n IMPRESSION:\n\n 1) Unremarkable contrast-enhanced and non-contrast-enhanced brain CT.\n\n 2) Mucosal disease noted in all the visualized paranasal sinuses with the\n exception of the frontal sinuses. If there is clinical suspicion for sinus\n infection, dedicated sinus CT may be helpful for further evaluation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-07-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 832221,
"text": " 4:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate s/p R subclavian placement\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 y/o female s/p intubation for sedation, w/ GI bleed. Difficulties with\n change on ventilator to pressure support. Now, s/p R subclavian\n\n REASON FOR THIS EXAMINATION:\n evaluate s/p R subclavian placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 47 y/o female, status post intubation for sedation with GI\n Bleed. Status post right subclavian line. Evaluate for placement.\n\n PORTABLE AP CHEST: A right subclavian line has been inserted and is noted to\n be coiled on itself with the tip pointing within the superior vena cava.\n Repositioning of this line is advised. Again is noted a diffuse increased\n density in the right lung and a right pleural effusion. This is consistent\n with asymmetric pulmonary edema. Underlying infection cannot be entirely\n excluded. Cardiac silhouette and mediastinum are within normal limits.\n\n An NG tube is noted with the tip approximately at the level of the 1st\n proximal duodenum. ET tube is approximately 6 cm above the carina.\n\n IMPRESSION: Right subclavian line loop on itself and the tip is pointing up\n within the superior vena cava. Repositioning of the IV access is recommended.\n These findings were communicated to Mark Lavarev at 9 p.m on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-07-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 832082,
"text": " 8:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: following ?chf, collapse\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47F s/p intubation for sedation, w/ GI bleed.\n\n REASON FOR THIS EXAMINATION:\n following ?chf, collapse\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST:\n\n INDICATION: Intubated for sedation. GI bleed.\n\n COMPARISON: Prior exam .\n\n FINDINGS: ET tube and NG tube are in stable position. There is slight\n increase to the right side of pleural effusion. Low lung volumes remain.\n There is opacity in the right upper lobe, slightly increased. The left lung\n is clear.\n\n IMPRESSION:\n\n 1) Slight increase in size to right effusion.\n 2) Opacity in the right upper lobe may represent aspiration and/or pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-07-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 831690,
"text": " 4:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: GI bleed- eval for CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with\n REASON FOR THIS EXAMINATION:\n GI bleed- eval for CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: GI bleed. Evaluate for left ventricular failure.\n\n CHEST AP: The heart size, mediastinal and hilar contours are unremarkable.\n The lungs are clear. There are no pleural effusions. The pulmonary\n vasculature is normal.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-07-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 831893,
"text": " 2:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47F s/p intubation\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Status post intubation.\n\n Comparison is made with a previous chest radiograph dated .\n\n FINDINGS: Endotracheal tube is 2.5 cm above the carina. No pneumothorax. Since\n the prior film of there is a new diffuse opacification of the\n right lung which is more radiodense in the lower lung. No shift of heart or\n mediastinum. An NG tube extends below the diaphragm. The heart is normal in\n size.\n\n IMPRESSION: New diffuse opacification of the right lung is noted. The cause\n is uncertain in absence of shift of heart/mediastinum. Rapid development\n suggest asymmetric pulmonary edema versus collapse. Film is apparently\n upright making layering pleural effusion less likely. Correlate clinically and\n with follow up film.\n This finding was discussed with the referring physician, . .\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-07-31 00:00:00.000",
"description": "DUPLEX DOP ABD/PEL LIMITED",
"row_id": 832829,
"text": " 8:09 AM\n DUPLEX DOP ABD/PEL LIMITED; LIVER OR GALLBLADDER US (SINGLE ORGAN)Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: please eval for cirrhosis (eval blood flow with dopplers)\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with HIV/Hep C with GI bleed, negative EGD and Colonoscopy,\n unclear source.\n REASON FOR THIS EXAMINATION:\n please eval for cirrhosis (eval blood flow with dopplers)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: HIV, Hep C with GI bleed. Evaluate for cirrhosis. Evaluate blood\n flows.\n\n FINDINGS: Comparison is made with ultrasound . No prior Doppler\n for comparison.\n\n As previously, the liver is heterogeneous in echo architecture. No focal\n lesions are identified. The gallbladder and biliary tract are normal. The\n pancreas and kidneys appear normal. The spleen is enlarged at 16 cm. There\n is no ascites. A large right pleural effusion is present.\n\n Liver Doppler demonstrates normal flow and waveforms in the portal vein,\n hepatic veins and hepatic artery.\n\n IMPRESSION:\n\n 1. Heterogeneous liver consistent with the underlying diagnosis of Hepatitis\n C.\n 2. Splenomegaly.\n 3. Moderate to large right pleural effusion.\n 4. Normal liver Doppler.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-07-23 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 832052,
"text": " 7:09 PM\n PORTABLE ABDOMEN Clip # \n Reason: R/O perforation, infection, peritoneal bleed.\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with GI bleed, negative EGD and colonoscopy. Abdominal exam\n slightly distended and guarding.\n REASON FOR THIS EXAMINATION:\n R/O perforation, infection, peritoneal bleed.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 47 y/o woman with GI bleed and negative EGD and\n colonoscopy. Abdominal exam suspicious for perforation, infection or\n peritoneal bleed.\n\n TECHNIQUE: Single supine view of the abdomen is provided.\n\n FINDINGS: The gas pattern is non-specific. There is no evidence for small\n bowel obstruction. Gas is noted within the colon. There is diffuse density\n throughout the abdomen which may represent free fluid. Contrast is noted in\n the collecting system of both kidneys and urinary bladder from a prior\n examination. A central line is noted in the right groin. There is an NG tube\n with distal tip likely within the antrum. No free air is demonstrated.\n\n IMPRESSION:\n Probable free fluid in the abdomen.\n No evidence for small bowel obstruction or free air.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-07-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 831989,
"text": " 10:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumonia\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47F s/p intubation for sedation, w/ GI bleed.\n\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: GI bleed, respiratory distress.\n\n COMPARISON: .\n\n SINGLE VIEW CHEST, AP: The diffuse, unexplained density within the right lung\n is again identified and is essentially unchanged. There is blunting of the\n right costophrenic angle which may represent a right sided pleural effusion.\n The ETT and NG tube are in unchanged positions.\n\n IMPRESSION: Stable appearance of the chest with diffuse opacification of the\n right lung. This may represent a right sided pleural effusion and if clinical\n concern remains for such diagnosis, a right sided decubitus film may help\n confirm.\n\n"
},
{
"category": "ECG",
"chartdate": "2178-07-22 00:00:00.000",
"description": "Report",
"row_id": 276283,
"text": "Sinus tachycardia\nNormal ECG except for rate\nSince previous tracing of , junctional rhythm not seen and sinus\ntachycardia now present\n\n"
},
{
"category": "ECG",
"chartdate": "2178-07-21 00:00:00.000",
"description": "Report",
"row_id": 276284,
"text": "Junctional rhythm and sinus rhythm. P-R interval 0.13. Non-specific ST-T wave\nflattening. Compared to the previous tracing of intermittent junctional\nrhythm is new. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2178-07-21 00:00:00.000",
"description": "Report",
"row_id": 276285,
"text": "Sinus tachycardia\nNormal ECG except for rate\nNo previous tracing for comparison\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-21 00:00:00.000",
"description": "Report",
"row_id": 1293206,
"text": "MICU NPN:\nSee admission note for details and pmhx.\nNEURO: Agitated, confused and uncooperative around 7pm when EGD trying to be done. Given versed, fentanyl and haldol by shift RN with effect and EGD done. Sedated but arousable to stimuli until around 3am- became agitated, trying to get OOB and not cooperating. Ativan 2mg given with good effect. PERL 1-2mm and brisk. ? withdrawing. MAE x4. When pt. awake, pt. confused and saying \" get out of here\"- trying to get OOB. Bilateral wrist restraints on for protection of lines with CSM checks q2hrs as required.\nCV: Afeb. HR 100s-110s ST, no ectopy noted. BP stable. Skin warm and dry with palpable pedal pulses bilaterally. Trace edema. Pneumoboots on. Repleted with 40meq KCL IV x2 for K+ of 3.2. HCT immediately after 1st unit PRBCs=27.3 and at 12am=25.2. Second unit of PRBCs given without incident. No signs or symptoms of bleeding noted. Will draw am labs to recheck HCT. 3 units PRBCs in blood bank ready.\nRESP: On 2L O2 with O2 Sat >95%. LS CTA and diminished at bases. Intermittent cough of yellowish sputum. Able to protect her airway and coughing effectively. RR12-30s.\nGI/GU: Abd. soft with positive bowel sounds, no BM but + flatus. Need stool sample sent for C-diff and parasites if stools. No emesis. Octreotide gtt infusing at 25mcg/hr via R femoral TLC line. EGD- showed varices, no active bleeding. Possible colonoscopy today. NPO. No po meds given since pt. too MD aware. Foley with clear yellow urine >30cc/hr.\nSKIN: Intact. R femoral groin line bleeding after insertion but stopped now. Pt. also with #16G EJ to L neck clamped at the moment.\nOTHER: Two brothers into visit and updated on pt's condition and plan of care by Dr. . Numbers in chart.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-21 00:00:00.000",
"description": "Report",
"row_id": 1293207,
"text": "MICU NSG NOTE:\nSitter at pt's bedside for pt's protection.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-24 00:00:00.000",
"description": "Report",
"row_id": 1293216,
"text": "2300-0700\n\nGeneral: Pt remains intubated and sedated. No evidence of bleeding noted. Stool via rectal tube remains liquid and bilious in color. VSS.\n\nNeuro: Pt sedated arousable to painful stimuli with withdrawl and minimal movement on bed. Pupils 3mm equal and brisk. Corneal reflex intact. Soft wrist restraints remain on.\n\nResp: Pt orally intubated with # 7.0 ETT 21cm @ lip line on vent 500, 50%, 16, +5. 02sat 100%. Suctioned for scant amts of thick secretions. Lungs clear with diminished bases. Propofol drip @ 75mcg/kg/min for sedation.\n\nCV: NSR on c-monitor without ectopy noted. No evidence of CP noted. HR 70-90, BP 100-130/40-50, max temp 99.4 ax. + pulses with generalized 1+ edema.\n\nGU/GI: No active bleeding noted. abd round softly distended, + BS, Rectal tube intact. Foley catheter to BSD draining yellow urine.\n\nIV: R femerol TLC intact with D51/2 NSS @ 150cc/hr.\n\nPlan: Possible wean and extubation today. Supportive care.\n\n\n RN\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-24 00:00:00.000",
"description": "Report",
"row_id": 1293217,
"text": "resp care\npt remains intubated and mech ventilated. vent weaned from a/c to cpap+ps. pt had one failed trial of cpap+ps d/t tachypnea, ^^wob, noted accessory muscle use, poor vt's. pt returned briefly to a/c. on second cpap+ps trial, peep ^from 5 to 10 w/noted improvement of wob. pt no longer using accessory muscle during exh. phase. b/s coarse w/exp wh. sxn for mod thk . alb mdi given x2 w/good result. plan: cont w/mech support. wean ps+peep as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-24 00:00:00.000",
"description": "Report",
"row_id": 1293218,
"text": "M/SICU NPN 7a-7p: FULL CODE Allergies: Vancomycin\n SEE FLOWSHEET FOR MORE DETAILS\n\nNeuro: Sedated this AM with Propofol Gtt at 75mcg/kg/min. Turned drip to off at 1400 for wake up/weaning of vent. PERLA 2mm brisk this AM. Now, eyes are rolled back and thus, unable to determine pupil size and reactivity. MD's are fully aware. Does not follow commands. Intermittent movement of extremities, but non-purposeful.\n\nResp: Currently on CPAP + PS 20/10 with adequate sats. Tolerating vent settings well. Suctioning for moderate amount of thick whitish secretions both orally and via ETT q2-3hrs.\n\nCV: NSR with no ectopy. BP stable. Gross amount of generalized edema noted. Afebrile. Palp. peripherial pulses x 4. Conts. on Sandostatin gtt at 25mcg, D51/2 NS at 100cc/hr, KVO NS at 5cc/hr. Propofol gtt remains off. IV Access is Right Femoral TLC.\n\nGI/GU: + hypoactive BS noted. OGT in place and to low wall cont. suction with bilious drainage brought back. Abd, soft, round, and distended, but non-tender. Abd. ultrasound done at bedside today. Rectal tube in place with bile colored liquid stool draining. C. dif cx sent (#2). Foley in place with adequate urine output. U/A resent today.\n\nSocial: Sign. other in to visit patient today. Spoke with RN and MD's. Updated and all questions answered.\n\nPlan: Cont. with current plan of care. Cont. weaning vent for extubation when mental status improves. Montior per ICU protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-24 00:00:00.000",
"description": "Report",
"row_id": 1293219,
"text": "pt haas maintained cvvhdf all shift, was oob for 3 hr and was fairly stable in the am but seemed to tire and had some resp/vol decompensation from 2 pm until approx 1730.\n neuro: pt was oriented and making all needs known most of day. at 1630 pt seemed more lethargic and seemed to be falling to sleep but was arousable to verbal stim. pt sleeps with eyes open.\n\ncard: see flow sheets, remains in a-fib, pt became more tachyardic at approx 1200 and cont with rate in 110-123 range until ativan given, returned to bed and fluid of 150cc ns given at 1645. rate came down to 100-110 but is now basck up to 1o5-115 range. Pt has been having frequent pvc's and had one episode of v-tach of approx 8 beats duration. Bp and map has been in high 60's to low 70's but did dpop to 59 at 1630.\n\nfluid status: cvvhdf removel goal was 250cc in excess of intake for at least the last 24hr and total pt removal of fluid via cvvhd has been close to 8l sinc ntx started on . pt is now acting vascularly dry despite his general edema. his bp, map,pulse all went up with this fluid removal but his perfusion to finher tips went down. at 1645 we gave 150cc ns and cut back on the pt fluid removal rate to 0 cc hr to give to pt a chance to recover his vasc vol. and pt will be positive with his tube feeds 35cc hr and iv 25cc/hr ca++ replacement and 10cc KVO {total 70 cc/hr} Renal saw pt and agreed that we should slow down on removal.\n\nresp: sats have been difficult to get all day prob due to poor perfusion. now on AC 50% o2 tv380 rate 24w/ extra indep breaths 8 peep. gas improved after on the above with ph now 7.24. pt resp status decompensated at end of being oob with ph drop to 7.17.\nsuctioned for a small plug of thick wh/yel sec. requiring irrigation with suctioning now. SUGGEST USING IRRIGATION WITH ALL SUCTIONING AS PT IS VERY DRY NOW WITH ALL THE CVVHD TO MOBILIZE SEC.\n\nelectrolyes: 1800 nlabs pending. ca stable and last K+=2.6. Potassium in dialysis was increased to 4 meq/l in both rep fld and dialysate.to avoid loss of potassium.\n\npsy: addressed with team his feelings of being miserable. Pt offered hosp psy eval but he stated he is seeing a person here at . persons name is on the bulliten board in rm { N.} Pt did ask for ativan early in am but was willing to avoid it to try to improve his night sleep. we did give ativan with his increased resp dis. at 1630. pt did get more lethargic after it.\n\ngi: restarted tf at 35 cc after 3hr hoild this am for resid. >150cc.\nseemed to have inc press in tube when sitting up. pt c/o felling bloated and resid at that time was 80 cc. Had 3 mod to lg liquid bm's. stool sent for c-diff. drain on rt abd drained 300 cl bile.\n\nskin intact with sm sacral decub which is covered and protected. shin turgor is decreaseing in less dependent areas but still remains with 4= edema in other depeddent areas. requres more mouth care for dryness.\n\nAccess: pic line has resistance in the blue port and gets best flow out red\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-22 00:00:00.000",
"description": "Report",
"row_id": 1293210,
"text": "MICU NPN 0700-1900\n\nEvents: Pt with increased melena, intubated for colonoscopy this evening, management of agitation. Received 2units packed cells.\n\nNeuro: Pt remained extremely agitated (pulling at lines, trying to climb out of bed, awake, but not aware of surroundings, unable to verbalize) refractory to haldol IV, received 2mg ativan with very good response. After intubation, pt received 2mg ativan, and was started on propofol gtt. Currently running at 75 mcg/kg/min. Wrists remain restrained with q2 hour neuro checks. Psych/addictions RN in to assess pt this morning, psych consult pending. Pt. is on her home regimen of methadone.\n\nResp: Intubated with #7.5 ETT/22cm at lip. Current vent settings 60% fio2/vt500/AC 16/+5. Pt is not breathing over vent rate. Breath sounds coarse but clear. Suctioned for moderate amounts frothy sputum, and then scant amount thick tan.\n\nCV: Pt tachy as high as 140's this am when agitated, currently 90's NSR no ectopy. BP stable. Received a total of 2 units PRBC's. After 1st unit, hct 25.5->26.0. Pt with increased edema this afternoon, 1+ generalized. + peripheral pulses x4 limbs. Skin cool, dry at this time with brisk cap refill. Received VitaminK for elevated INR. Has received a total of 3L NS boluses for decreased UOP. QTC was .429 after haldol.\nID: Afebrile. WBC 5.5.\n\nIV access: Right fem TLC. propofol at 30.2cc/hr, Octreotide at 25 mcg/4.2cc/hr, NS at KVO, #2PRBC over 3 hours. D5.45NS with 20meqKCL at 150ml/hr.\n\nF/E/N: OG inserted by MD today, lavaged for clear water by GI fellow. + OG placement with air . Rectal bag on for large amounts of dark red melanotic stool. + bowel sounds x4 quadrants. Ammonia level elevated , lactulose started this afternoon. Abd is more firm and distended than this morning, team aware. Stool sent for ova/parasites. Golytely started at 1500 for possible colonoscopy this evening. Foley cath patent with decreased UOP today, received 500cc NS x2 with good results, but did not respond to a 1L , the 2nd is infusing. Urine is dark amber, concentrated with sediment. K+, Mg, Ca++ all replaced.\n\nDerm: Intact with bruising to REJ old IV site, B feet.\n\nPsych/Soc: Pending psych consult, currently adequately sedated on propofol. Sister is health care proxy, boyfriend was in to visit. Family is in the waiting room for result of colonoscopy if it is done.\n\nDispo: Remain intubated overnight for colonoscopy, psych consult, repeat HCT tonight after blood. Continue propofol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-24 00:00:00.000",
"description": "Report",
"row_id": 1293220,
"text": "(Continued)\n port\n Anticoagulation: pt to restart coumidin this eve. need hep in cvvhd if system is cloting as ptt is in normal range now\nPlan Cvvhd with a decreased fluid removal rate to allow vasc spase to rehydrate. monitor resp status. attempt to allow pt to be medicated and sleep at night to get back on night sleep pattern. mouth care.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-24 00:00:00.000",
"description": "Report",
"row_id": 1293221,
"text": "please disregard the above note\n as it was entered on wroung pt\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-25 00:00:00.000",
"description": "Report",
"row_id": 1293222,
"text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nTHIS IS A 47 Y/O F THAT INITIALLY PRESENTED ON C/O MELENA AND BRBPR THAT HAD STARTED ON . HAD UNDERGONE AN EGD ON /04NSIGNIFICANT FOR GRADE 2 ESOPHAGEAL VARICES. PRESENTED WITH A CRIT OF 26. EGD DONE ON SIGNIFICANT FOR ESOPHAGEAL VARICIES TO THE LOWER THIRD OF THE ESOPHAGUS WITH NO ACTIVE BLEEDING OR OLD BLOOD NOTED. COLONOSCOPY ON UNIMPRESSIVE. ICU COURSE COMPLICATED BY BILATERAL PLEURAL EFFUSIONS TO LUNG BASES AND AGITATION WHICH BE DUE TO QUESTIONABLE WITHDRAWAL.\n\nPMH: HEPATITIS, HIV (SINCE ), CIRRHOSIS, IVDA, ASTHMA, GASTROPARESIS, DEPRESSION\n\nNEURO: PT HAD PROPOFOL DC'D ON AT 1400 IN PREPARATION FOR EXTUBATION. PT NOTED TO BE EXTREMELY AGITATED, ROLLING EYES IN BACK OF HER HEAD AND NOT RESPONDING/ FOLLOWING COMMANDS. DURING THE EVENING, PT'S AGITATION LEVEL INCREASED REQUIRING REINITIATION OF PROPOFOL GTT- CURRENTLY AT 40MCG/KG/MIN WITH OCCASIONAL ADMINISTRATION OF BOLUSES. PT WILL RESPOND TO VERBAL STIMULI AND OPENS EYES SPONTANEOUSLY, HOWEVER WILL NOT TRACK NOR FOLLOW COMMANDS. PERRLA, 3 BRISK. AFEBRILE. NO SEIZURE ACTIVITY NOTED. DISCUSSED WITH DR. QUESTION OF WITHDRAWAL DUE TO NOTED AGITATION, TACHYCARDIA AND INCREASED BLOOD PRESSURE THAT IS NOT RELIEVED DESPITE SEDATED STATE. TEAM TO RECONSIDER REDOSING METHADONE. NICOTINE PATCH INITIATED.\n\nRR: INTUBATED. OETT IS SECURE AND PATENT. BBS= ESSENTIALLY COARSE TO BILATERAL UPPER LOBES AND DIMINISHED TO BILATERAL BASES. BILATERAL CHEST EXPANSION NOTED. PT GETS TO THE 40'S WHEN SHE IS AGITATED, CURRENTLY ON CPAP/18PS/40%/10. REEVALUATE FOR EXTUBATION THIS MORNING ALTHOUGH HIGHLY DOUBTFUL CONSIDERING PT'S AGITITATION AND INCREASED WOB. TV 400-500'S. AT REST RR 20'S. SP02 > OR = TO 95%.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NSR-ST, HR 90-110'S WITH NO SIGNS OF ECTOPY NOTED. SBP > OR = TO 120-140'S. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. FEMORAL CVL IS SECURE AND PATENT. MONITORING CRIT.\n\nGI: ABD IS SOFT, SLIGHTLY DISTENDED. HYPOACTIVE BS X 4 QUADRANTS. OGT IS SECURE AND PATENT. PROPER PLCMT AS VERIFIED WITH AUSCULTATION OF 30CC/AIR . NO SIGNS OF ACTIVE BLEEDING NOTED. PASSING FLATUS. RECTAL TUBE IS SECURE AND PATENT. GREEN, LIQUID STOOL NOTED. CONTINUES ON LACTULOSE AND SANDOSTATIN THERAPY.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. CLEAR, AMBER URINE NOTED IN ADEQUATE AMOUNTS.\n\nINTEG: NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS.\n\nSOCIAL: SPOKE WITH MOTHER AND SISTER AT LENGTH. NO ISSUES.\n\nPLAN: WEAN AS PT CAN TOLERATE FOR EXTUBATION. MANAGE AGITATION, REEVALUATE FOR POSSIBLE WITHDRAWAL. MONITOR CRITS. PLS SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-25 00:00:00.000",
"description": "Report",
"row_id": 1293223,
"text": "ADDENDUM\n40MEQ K GIVEN FOR 3.6 0400 LEVEL.\n3 GMS MAG GIVEN FOR 1.4 0400 LEVEL.\nTHANK YOU.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-25 00:00:00.000",
"description": "Report",
"row_id": 1293224,
"text": "Respiratory Care Note\n\nPt remains intubated and ventilated on PS settings. At times when she is agitated, RR ^ to 40's. Otherwise tolerated PS well. ? whether extubation is option based on mental status and level of agitation.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-25 00:00:00.000",
"description": "Report",
"row_id": 1293225,
"text": "M/SICU NPN FOR 7A-7P: FULL CODE ALLERGY TO VANCOMYCIN/ABACAVIER\n\n SEE FLOWSHEET FOR MORE DETAILS\n\nTHIS IS A 47 Y/O FEMALE ADMITTED ON WITH GIB/EMESIS X 1. INITIAL HCT WAS 25.9 TO MICU FOR GROSS AGITATION/CHANGE IN MENTAL STATUS/GIB. RESPONDED WELL TO HALDOL IV. INTUBATED ON FOR DECOMPENSATION AND COLOSTOMY PREP.\n\nNEURO: OFF SEDATION (PROPOFOL GTT). PERLA 3MM BRISK. MAE MORE PURPOSEFUL THIS AFTERNOON. INCONSISTENTLY FOLLOWING COMMANDS AT THIS TIME. OPENS EYES BRIEFLY AND NODS HEAD APPROPRIATELY AT TIMES.\n\nRESP: REMAINS ON CMV 12, TV 500, PEEP 10. OVERBREATHING . HAS A #7.0 ETT IN PLACE. MOST RECENT CHEST X-RAY SHOWS RIGHT EFFUSION WITH ?BILAT INFILTRATES. ABG 7.38/49/92/+.\n\nCV: REMAINS IN SR-ST WITH HR 80-100'S. BP STABLE 122/60-133/62. RSVC TLC INSERTED BY RESIDENCE TODAY. STILL HAS RIGHT FEMORAL TLC DUE TO WAITING FOR CONFIRMATION OF NEW TLC. HAS GROSS AMOUNT OF GENERALIZED EDEMA ESPECIALLY IN LOWER EXTREMITIES. IVF OF D51/2NS AT 100CC/HR. SANDOSTATIN GTT FINISHED TODAY. RIGHT RAD. A-LINE ATTEMPTED WITHOUT SUCCESS. T.MAX 99.0 ORALLY. PALP. PERIPHERIAL PULSES X 4.\n\nGI: ABD. SOFT,DISTENDED, NON-TENDER, OBESE. + HYPOACTIVE BS NOTED. OGT IN PLACE TO LOW WALL CONST. SUCTION WITH BILIOUS DRAINAGE BROUGHT BACK. RECTAL TUBE IN PLACE WITH GREENISH LIQUID STOOL DRAINING.\n\nGU: FOLEY IN PLACE WITH ADEQUATE URINE OUTPUT. REC'ED LASIX 20 MG IV X 1 WITH GOOD RESPONSE.\n\nSOCIAL: SISTER IN TODAY AND UPDATED BY RN AND MD'S.\n\nPLAN: CONT. WITH WEANING OF VENT. PLAN FOR POSSIBLE EXTUBATION SOON ONCE NEUROLOGICAL STATUS IMPROVES.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-25 00:00:00.000",
"description": "Report",
"row_id": 1293226,
"text": "Respiratory Care Note:\n\nPt remain orally intubated & sedated. We received on PSV and noticed increased WOB during first vent check, so switch to CMV + assist, tol well and weaned Propofol as tol. EEG and sputum culture sent and c-diff Cx pending. MD team will attempt A line and central line change. ABG on CMV is acceptable. SEE careview. ev MD asked to try on PSV as tol and plan is to rest on CMV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-26 00:00:00.000",
"description": "Report",
"row_id": 1293227,
"text": "Respiratory Care Note\n\nPt remained on PSV all noc. Tolerated well. Tachypneic at times while agitated, otherwise problem with ventilation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-23 00:00:00.000",
"description": "Report",
"row_id": 1293211,
"text": "1900-0700\n\nGeneral: Pt remains orally intubated and sedated. Continued prep with Golytely for colonoscopy today. Bp remains stable, afebrile. UO remains 5-10cc/hr IVF infusing for rehydration.\n\nNeuro: Pt sedated with propofol @75mcg/kg/min, unable to assess neuro status at this time. Pt withdrawls to sternal rub. moves upper ext lifts and falls and lower ext move on bed. Soft wrist restraints remain on. Pupils 2mm bilaterally brisk with corneal reflex intact.\n\nCV: NSR - Sinus tachycardia with alarms on no ectopy noted. HR 90-110, BP 110-120/50-60, max temp 98.8. HCT: 27.6, K: 3.5, KPhos infusing @ 75cc/hr. + pulses to ext, edema generalized 1+. Compressive sleeves on.\n\nResp: Pt orally intubated #7.0 ETT 21cm@lip line, vent in use TV 500, 50% FIO2, 16, +5. Suctioned for scant thick secretions. Coarse BS with diminished @ bases. 02sat 100%.\n\nGI: OGT intact receiving Golytely for prep for colonscopy today. Stool begining to clear of melena color. Abd firmly distended + BS noted X 4 quad.\n\nGU: Foley catheter to BSD draining minimal gold/amber urine 5-10cc/hr. D51/2NSS with 20 KCL @ 150cc/hr infusing cont.\n\nIV: R femerol TLC intact with Propofol @75mcg/kg/min, Sandostatin @ 25.2mcg/hr, IVF as ordered.\n\nPlan: Colonoscopy today, Cont monitor HCT, Supportive measures.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-23 00:00:00.000",
"description": "Report",
"row_id": 1293212,
"text": "RESPIRATORY CARE: PT. W/ 7.5 ORAL ETT IN PLACE.\nREMAINS ON AC MODE 16/500/.50/5 W/ STABLE ABG.\nPT. HAD A COLONOSCOPY TODAY TO R/O BLEEDING\nWHICH WAS NEGATIVE. PT. ALSO HAD A CT SCAN HEAD\nTO R/O BLEED WHICH WAS NEGATIVE. ALSO HAD A\nLUMBAR PUNCTURE/ RESULTS PENDING. WILL CONTINUE\nVENTILATOR SUPPORT AS ABOVE.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-23 00:00:00.000",
"description": "Report",
"row_id": 1293213,
"text": "MICU NPN 11AM-8PM:\nNeuro: Pt remains sedated on the propofol drip requiring 2-3cc boluses for numerous procedures/tests throughout the shift. Continuous infusion is running in at 75mcg/kg/min. She is heavily sedated and does not follow commands because each time she is the least bit lightened she becomes very tachypneic and tachycardic and pops off the vent. PEARL strong cough but weak and difficult to elicit gag noted. Pt was taken down to CT for head CT today due to MS changes this admission and had a LP done at bedside this evening.\n\nCV: BP 100-160/60 depending on level of activity. HR also labile according to activity ranging 70-120's. NSR-ST no VEA. Nadolol restarted this afternoon. Calcium and potassium repletion given IV and pt continues to get IVF d51/2NS w/20meqK at 150cc/hr. UO is boarderline/low, 15-40/hr, and pt given 1000 cc NS fluid times one with little effect. Pt is becoming increasingly fluid volume overloaded and her ring was becoming very tight. This was taken off and at first put in the safe then it was given to her sister to take home.\n\nResp: Pt remains intubated on the vent on AC 16, TV 500, FIO2 50% w/5cm peep. She is breathing over the set rate when stimulated. Sats are 100% and pt has had no blood gases today. Lungs are clear this eve but today I noted expiratory wheezes and albuterol/atrovent MDI's will be added to med regimen. Plan is to try to wean pt tomorrow after all tests have been completed.\n\nID: Pt with rising WBC and low grade fevers today and was ordered to be cultured which was done. She is currently on no antobiotics and is getting her antivirals via NGT as ordered.\n\nGI: NPO except for meds after colonoscopy was done today. Colonoscopy showed some edematous colon but no source of bleeding and no active bleeding was . Prep for colonoscopy had been done well. This evening she had KUB done at bedside and has order for poratable abdominal US to be done this evening in attempt to locate source of bleeding. Her hct at noon was stable at 27.4 and hct at 6PM is still pending as of this note. Continues on the sandostatin drip at 25mcg/hr.\n\nGU: As above, UO is on the low side and team want to with fluid for this if needed.\n\nEndo: Pt is now on sliding scale insulin coverage QID. Given 2u reg at 5PM for glucose of 154.\n\nIV: Pt has triple lumen in her right groin.\n\nSocial: mother and sister met with team for update today and are aware of the plan. I also gave verbal update to her boyfriend and brother.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-23 00:00:00.000",
"description": "Report",
"row_id": 1293214,
"text": "Brief Update to MICU NPN 11AM-11PM:\nPt remains sedated ont he propofol drip and requires 2-3cc with any activity to prevent disruption with the vent. 6PM hct came back stable at 27. She has four units available in the the BB. Next hct due at midnight. She required 500cc's NS fluid for dropping UO which has helped a little. Please MD is less than 30cc's for two consecutive hours tonight. Plan to try to shut off propofol and extubate pt tomorrow. brother called for update( I had spoken to him earlier in the day for an update) and I had to tell him that his sister is spokesperson and she can call for update and relay messages to family in order to limit the number of people nursing is updating by phone each day, several times each day. He seem ed to understand this but then asked what time would be good for him to call tomorrow for CT and LP results.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-24 00:00:00.000",
"description": "Report",
"row_id": 1293215,
"text": "Resp Care,\nPt. remains intubated and sedated overnoc on A/C. No vent changes this shift. RSBI not obtained, not breathing due to sedation. Possible exubation today. See careview.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-21 00:00:00.000",
"description": "Report",
"row_id": 1293208,
"text": "MICU NPN 0700-1900\n\nNeuro: Pt currently sedated/asleep. Is now on scheduled haldol 5mg q4hours for agitation, received 2.5 mg prn haldol for trying to climb out of bed, thrashing in bed, yelling \"Get me out of here\" and \"I have to leave now\" but unable to respond to questions, or able to assess orientation. Only purposeful movements noted were the patient trying to pull at lines, and get out of bed. PERRL, 2mm/brisk. Gag, cough, blink intact. Bilateral soft limb wrist restraints on with q2hour checks. Sitter at bedside. Ammonia level sent, pending. Methadone restarted per home regimen, but changed to IV. No benzos r/t liver disease. CIWA score 16 at 4pm. Psych nurse consulted, but has not seen pt yet. + UE tremors when awake.\n\nResp: Pt with dimished breat sounds on the Right, CTA on left. 2L NC. RR 20's. No cough noted. Respirations deep, unlabored.\n\nCV: ST no ectopy. BP stable. Afebrile, skin hot, clammy. Brisk cap refill, trace generalized edema. Hct/Hgb 27.9/9.8. Platelets 76. WBC 4.8.\n\nIV Access: Left EJ #16g capped/flushed. Right femoral TLC with octreotide gtt at 25 mcg/hr (4.2cc) and NS at 100/hr x1L.\n\nGI: Pt remains NPO for colonoscopy, but has not been prepped. PO meds not given r/t mental status, team aware. NG tube attempted x1 this afternoon, but attempt stopped after small nosebleed noted. Pt continues without GI access. + hyperactive bowel sounds x4 quadrants. No BM but + flatus. No evidence of bleeding noted.\n\nGU: Foley patent with dark amber UOP.\n\nDerm: Intact. Bruise to REJ old IV site.\n\nPsych/Soc: Psych nurse consult, Boyfriend in to visit this afternoon while pt was agitated. Sister called multiple times this shift and spoke with MD.\n\nDispo: Colonoscopy in am, continue sitter at bedside.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-22 00:00:00.000",
"description": "Report",
"row_id": 1293209,
"text": "1900-0700\n\nGeneral: Pt remians with severe agitation intermittently, medicating with haldol Q4hr 5mgIM. VSS. Pt remains afebrile. Neuro status unchanged. Pt for colonoscopy, unable to prep for procedure.\n\nNeuro: Pt agitated, confused with clear speech. Not following commands at all, attempting to climb OOB. Moves all ext with full strength, restraints remain on. Pupils 2mm and brisk bilaterally. Neuro checks Q2hr.\n\nResp: NC 2L on with resp easy and regular @20-24. 02sat 98-99%. Lungs clear bilaterally. No cough noted.\n\nCV: Sinus Tachycardia on c-monitor without ectopy. Unable to assess for CP. HR 110-130, BP 115-130/60-70, max temp 98.9. + pulses to ext. No edema noted. Skin warm/dry/intact. Compression boots on. Repeat HCT @ 2100:27.4\n\nGU/GI: Abd round soft + BS, 1X BM large melena stool noted. No N/V. Foley catheter to BSD draining gold urine with sediment. UO decreased in the begining of the night to approx 20cc/hr, HO made aware IV fluids restarted @ 100cc/hr. UO picking up again to 30-40cc/hr.\nPt remains NPO.\n\nIV: R femerol TLC intact with Sandostatin [email protected]/hr(25mcg/hr), NSS@KVO.\n\nPlan: Colonoscopy planned. Continue supportive measures, cont methadone.\n\n RN\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-26 00:00:00.000",
"description": "Report",
"row_id": 1293228,
"text": "neuro: continues well sedated on propofol; increased to 45 mcg/kg/min for cough suppression and sleep\n\ncardiovascular: remains tachycardic, otherwise without block or ectopy; BP stable; several unsuccessful attempts last evening at left radial arterial line, good capillary refill to left hand afterwards\n\npulmonary: large amounts of clear to mucoid secretions; stable on CPAP settings as RRT note, well-saturated all night\n\nGI: sump draining small amount of clear green gastric contents in between doses of NG meds; large amount liquid diarrhea via well-functioning rectal tube\n\nGU: received two doses of 20 mg lasix IV; oliguric between doses\n\nskin: severe peripheral edema persists but skin generally intact; slight ecchymosis noted around right subclavian CVL site; slight leakage of serous fluid from under skin at site of right femoral CVL removed last evening\n\nlabs: glucoses wnl; electrolyte imbalances reported to intern for repletion orders\n\nstatus and plan: full code, consider vent wean, consider nutrition if tube feedings not tolerated, consider alternatives to radial arterial line\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-26 00:00:00.000",
"description": "Report",
"row_id": 1293229,
"text": "M/SICU NPN for 7a-7p: FULL CODE Allergic to Vancomycin\n\n Please see flowsheet for more details\n\nNeuro: Taken off sedation for daily wake up. Able to open eyes and track, but did not follow any commands. Became extremely agitated/anxious attempting to self-extubate. Restarted Propofol gtt and titrating for sedation/comfort at present. PERLA 3mm Brisk. Purposeful, but inconsistent movement of extremities.\n\nRESP: Remains on CPAP + PS (please see flowsheet for up-to-date vent settings). O2 sats adequate with no desaturation noted today. Lung sounds coarse with rhonchi in bases. Suctioned for moderate amount of whitish thick to frothy secretions at times. RR increases to 30-40's during episodes of agitation/anxiety.\n\nCV: Remains in SR-ST with no ectopy note. BP stable. Afebrile. Palp. peripherial pulses x 4. Still with persistent gross generalized edema.\n\nGI: OGT in place with TF of Promote with fiber at 20cc/hr. No residuals. + hypoactive BS's. Abd. is large, round, distended, but soft and non-tender. Conts. to have moderate green liquid stool via mushroon catheter.\n\nGU: Foley with periods of very low urine output. Given Lasix 20 mg IV at 1700. Please record results.\n\nSOCIAL: Boyfriend, brother from NC, and niece all in today. Boyfriend and brother updated briefly. Her sister () called several times today for updates.\n\nID: Immunocompromised with CD4 at 88 (in ). No growth from cx's at present. Remains on Levaquin via OGT.\n\nSkin: No breakdown noted. Some bruising to RSVC TLC site noted.\n\nPlan: Possible extubation tonight or in AM. Cont. monitor per protocol. Replete electrolyte imbalances as needed.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-28 00:00:00.000",
"description": "Report",
"row_id": 1293237,
"text": "PMICU Nursing Progress Note 7a-7p\nEvents\n\n Pt extubated this am, following RBSI of 34 and positive spont breathing trial. She was placed on cool mist face mask following, FIO2 50% w/ good effect. Sats 100% throughout day. Pts voice has remained very whispy, evaluated by ENT and Speech and swallow. Vocal cords functioning but airway edema makes her an aspiration risk. She is to be NPO until reassessed.\n Pt is alert and oriented x3, answers most questions appropriately but makes bizarre statments. Team notified of questionable mental status. Plan to cont to follow closely. Pt recieved lactulose this am, has put out 800 cc of stool today. Refusind NG placement, so pt will not be able to receive pm lactulose. Team notified.\n\nReview of Systems\n\nNeuro- MS as stated above. IF pt sundowns tonight, plan to give Haldol. Team would like to avoid further sedation due to tenous MS. , possible cause of altered MS on two occasions.\n\nResp- Cont cool mist mask for airway edema, encourage strong cough and deep breathing. Sats 95-99%. LS coarse. Cont w/ inhalers as needed.\n\nCV- HR 80-100, NSR, rare ectopy. BP 120s/70's. K repleted this am following am labs w/ 40 Mequ. Next labs to be drawn for tomorrow am.\n\nGI- Abd soft, +BS +BM- liquid stool per mush cath. Cont lactulose when access available. Team aware that pt may not be able to recieve dose tonight. It was decided that since she has had large volume of stool out, we would cont close MS sedating her and further altering her MS to be able to place NG and secure it. Plan to reassess swallow tomorrow, NPO overnight.\n\nGU- Recieved 40 mg of LAsix @ 1800. U/O/Hr decreased this afternoon, cont to follow trends w. team.\n\nPlan- Cont supportive medical care. Multiple family members at bedside today, updated by team and nsg on status.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-29 00:00:00.000",
"description": "Report",
"row_id": 1293238,
"text": "NPN 1900-0700\n\nNUERO: LETHARGIC , BUT AROUSABLE.ORIENTED X3.NO DELUSIONS OR HALUCINATIONS OVER NIGHT.\n\nRESP: CHANGED TO 3L NC AS WA SNOT ABLE TO TOLERATE SHOVEL MASK. MAINTAINING SATS 97-99%. LUNG SOUNDS COARSE THROUGHOUT.\n\nC/V : SR -ST NO VEA BP STABLE.\n\nF/E/N : PT HAS BRISK REPONSE TO LASIX , NOW UO BACK DOWN TO 30-40 CC HR.RECTAL TUBE CONT TO DRAIN GOLDEN LIQUID STOOL.NO NGT PLACED OVER NOC, REMAINED NPO ? NEED TO REASSESS SWALLOW TODAY.\n\nPLAN : CONT TO MONITOR HEMODYNAMICS , RESP STATUS , UO.CONT SUPPORTIVE CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-29 00:00:00.000",
"description": "Report",
"row_id": 1293239,
"text": "M/SICU NPN for 7a-7p: FULL CODE Allergic to Vancomycin\n\n SEE FLOWSHEET FOR MORE DETAILS\n\nNeuro: AAOx3, , , Able to follow commands. In chair with Ax2 for 1 hr. Ambulates to BSC with Ax1 today. No neuro deficits noted. Given Versed 1 mg IVPUSH for agitation x 1.\n\nResp: Remains on 3l NC. Needs encouragement to keep O2 in place. Lung sounds coarse throughout with occas. exp. wheezing. Adequately maintained sats.\n\nCV: SR-ST with no ectopy. Afebrile. BP stable. No edema noted. R SVC TLC in place. Fluid to KVO. Rec'ed 20 mequ KCL for K+ level of 3.5.\n\nGI: + BS noted. Abd is large, round, distended, non-tender. Several loose liquid BM's today. Mushroom catheter pulled this AM.\n\nGU: Foley in place with low urine output. MD's are aware.\n\nPlan: transfer to (transplant unit/floor) when bed is available. Monitor per protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-28 00:00:00.000",
"description": "Report",
"row_id": 1293235,
"text": "Resp: pt on psv 10/5/40%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral coarse sounds. MDI's administered Q4 Alb. Suctioned for copious amounts of thick frothy secretions. RSBI=35, no A-line. SBT following rounds, then extubation expected.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-28 00:00:00.000",
"description": "Report",
"row_id": 1293236,
"text": "1900-0700\n\nGeneral: Pt agitated intermit through the night, weaning Propofol drip as ordered @ 8mcg/kg. Versed IVP given PRN. Pt not tolerating well, attempting to climb OOB restraints remain on.\n\nNeuro: Pt sedated, not following commands but moving all ext with equal strong movement bilaterally. Pupils 2mm bilaterally and brisk. Corneal reflex intact.\n\nResp: Pt remains orally intubated with # 7.0 ETT 21cm@lip line. CPAP PS 10, +5, 40%. RSBI-34.5. Lungs with rhonchi bilaterally coarse at the bases. Suctioned for thick scant amt secretions. 02sat 93-98%. Resp rate 12-35. Plans for weaning and extubation today.\n\nCV: NSR-Sinus tachycardia without ectopy and alarms on. Max temp 100.8, hr 90-110, BP 90-120/60-70. K-3.0 actively being repleated. + pulses to ext, generalized edema noted. Compression sleeves on. Skin warm/dry/intact. R sc tlc intact with propofol @ 8mcg infusing and actively weaning.\n\nGU/GI: abd round soft + BS, OGT with Promote with fiber @ 35cc/hr. tolerating feedings well. Mushroom cap rectal tube intact draining liquid brown stool. Foley catheter to BSD draining clear yellow urine. Approx 40-70cc/hr. BS-119 this AM.\n\nPlan: Continue to wean from vent with possible extubation today?\n\n RN\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-26 00:00:00.000",
"description": "Report",
"row_id": 1293230,
"text": "Respiratory Care Note:\n\nPt remain orally intubated and sedated on PSV. We received on PSV 20/10 and were able to slowly wean pEEP & IPS, presently on PEEP=5 and IPS of 10 cmH20 and 40% FIO2. NO ABG, no nA line, Sats stable, Occ episode of agitation and anxiety. Plan: KEEP on ventilator o/n. Do RSBI in AM and still push for elective extubation if possible. {Plan: continue ICU monitoring meanwhile.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-27 00:00:00.000",
"description": "Report",
"row_id": 1293231,
"text": "neuro: continues well sedated on propofol, not awakened on this shift for assessment\n\ncardiovascular: still tachycardic, no block or ectopy noted, BP stable\n\npulmonary: minimal clear to sputum to suction, has been eupneic and well-saturated on 40%, Cpap 5, Psv 10 all night long\n\nGI: tf tolerated well at 30 cc/hr of promote with fiber, no residuals; moderate amount liquid diarrhea per mushroom catheter\n\nskin: generally intact, but extremities remain very edematous with weeping of serous fluid from old Rt groin femoral line site--ecchymotic around Rt subclavian line site\n\nstatus and plan: full code, consider if pt is ready for extubation today\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-27 00:00:00.000",
"description": "Report",
"row_id": 1293232,
"text": "Resp Care,\nPt. remains intubated on IPS 10 overnoc. VT 300's, RR high 20's. RSBI 120 this am with ATC. Cont. IPS as tol. See carevue.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-27 00:00:00.000",
"description": "Report",
"row_id": 1293233,
"text": "MICU/SICU Nursing Progress Note\nEvents\n\n Pt's sedation lightened gently over the course of the day. Presently she in on 30 mcg/kg/min of prop, titrated down from 50 mcg/kg/min. No plan to further lighten sedation until thoracentesis completed by IP.\n\nNeuro- As stated above, lightly sedated w/ prop. No plan for further weaning until after intervention. PRN IVP versed available if pt becomes agitated. Arouses to voice, spont opens eyes and moves extremities. Not yet consistently following commands. EEG results neg. Ammonia level slightly elevated (62), per report from liver team this is not likely cause of altered neuro status/agitation- plan to cont w/ lactulose. ? wdrawl vs reaction to Ativan. According to pt's sister, she did have one other episode of severe agitation following endoscope where she was given ativan in the past. COnt close obsevation and supportive care. PERRLA.\n\nResp- Cont on PS 10/PEEP 5/FIO2 50%/RR 20s'/TV 300s. Suction for lg amts of thick sputum q 1-2 hrs. LS coarse, rhonchi noted throughout. CXR shows lg pleural effusion, awaiting IP team to tap w/ guided ultrasound. Gram + cocci in sputum, tx w/ levoquin. PCP sputum pending.\n\nCV- HR 80-90's, BP 120/60's. Lytes checked q am, cont to follow HCT and guiac stool. Slightly dipahoretic this evening, temp found to be 100.6, cool cloth applied. Plan to follow fever curve. Pulses palpable.\n\nGI- Abd soft and distended. +BS, +BM per mush cath, green loose stool. TF stopped per liver team recommendations.\n\n\nGU- Output variable today, overall averaging 40 cc/hr, clr, dark yellow urine. Plan to give pt lasix following thoracentesis per team orders.\n\nPlan- Cont supportive medical care, pts' boyfriend at bedside today- updated by team and nsg. sister also called 2x, updated on plan and status by nsg.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-27 00:00:00.000",
"description": "Report",
"row_id": 1293234,
"text": "Patient on pSV without complication but not responding to commands. ABG compensated resp acidosis. Suctioned for frothy sputum this AM but appears and thick this evening. Febrile with temp 100.6,plan to wean sedation for proper assessment of neuro status.\n"
}
] |
42,430 | 100,969 | The patient is a 80yo RHM with Afib not on Coumadin but possibly ASA, HTN, DM and hx of stroke with some residual L sided weakness who smokes >1PPD found per VNA at home down on the floor with slurred speech and L sided weakness around 3pm. Patient initially presented to ED then transferred here for further care. Patient seen and examined 6:20pm - ~ 8hrs after presumed onset of symptoms. His initial NIHSS score was 19 for R gaze deviation, L sided weakness and sensory deficit. His CT of head shows dense R MCA with likely M2 level occlusion and loss of /white matter differentiation over the distribution. His INR was 1.2 but patient reports not to have taken meds including Coumadin for possibly over 2 months. The patient was admitted to the neurology ICU for further care. He was initially started on a heparin drip but follow up CT scan showed a large size of infarct and it was determined that the risk of bleeding outweighed the benefits of heparin. In addition the patient had an episode of emesis, and possible aspiration. On the patient was less esponsive to commands and was tachypneic, a CXR showed a worsening infiltrate in the right lower lobe. His respiratory status worsened and he required intubation. Later in the afternoon the patient was found to have an fixed and dilated right pupil. A head CT was obtained showing a large hemorrhagic coversion. The bleed was catastrophic, and the patient had negative brainstem reflexes by the time he returned from the scan. The patient was terminally extubated on . The prognosis was discussed in detail and he was extubated. He expired on . | Temp max 99.5 Action: Neuro exam monitored Q2 Iv heparin discontinued per neurology team Labs rechecked in am Chest pt and pulmonary toileting maintained. Temp max 99.5 Action: Neuro exam monitored Q2 Iv heparin discontinued per neurology team Labs rechecked in am Chest pt and pulmonary toileting maintained. His head CT here showed a dense R MCA with likely M2 levelocclusion and loss of /white matter differentiation over thedistribution.We were consulted to evaluate for oral and pharyngeal dysphagia.Pt is currently NPO pending evaluation. HCP to withdrawal care and become CMO. HCP to withdrawal care and become CMO. Heparin gtt dc'd per neuro (). Heparin gtt dc'd per neuro (). CVA (Stroke, Cerebral infarction), Ischemic Assessment: Patient lethargic but rouse able to speech Perrla Patient has right gaze preference, with left field cut. Given the hx and exam findings, most likely cardioembolic stroke to R MCA. Given the hx and exam findings, most likely cardioembolic stroke to R MCA. Given the hx and exam findings, most likely cardioembolic stroke to R MCA. Given the hx and exam findings, most likely cardioembolic stroke to R MCA. Chief complaint: Respiratory distress, hemorrhagic stroke PMHx: 1. Chief complaint: Respiratory distress, hemorrhagic stroke PMHx: 1. Respiratory distress req intubation. Respiratory distress req intubation. Pt w/ right gaze preference w/ left field cut Action: Response: Plan: CVA (Stroke, Cerebral infarction), Ischemic Assessment: Patient lethargic but rouse able to speech Perrla Patient has right gaze preference, with left field cut. Pt off antihypertensive medications. Pt off antihypertensive medications. improved with nebs -repeat AM CXR -albuterol/atrovent nebs. Vanc/Zosyn if febrile. Lorazepam 2-4 mg IV Q2H:PRN cmo 24 Hour Events: NON-INVASIVE VENTILATION - START 08:00 AM For increased resp distress. Lorazepam 2-4 mg IV Q2H:PRN cmo 24 Hour Events: NON-INVASIVE VENTILATION - START 08:00 AM For increased resp distress. Nutrition: Now CMO Renal: CMO Hematology: CMO Endocrine: CMO Lines / Tubes / Drains: PIVx3 Wounds: N/A Imaging: AM CXR Fluids: Consults: Neurology Billing Diagnosis: Embolic stroke Prophylaxis: DVT: SCD, heparin sq Stress ulcer: H2B VAP bundle: N/A Code status:DNR/DNI Disposition:floor Time: RN redrew and stable at 38.7 and coags wnl Electrolytes repleted per order. Labetalol 5mg IV x2 for SBP >180 Chest PT/Pulm toilet/ NT suction PRN for minimal tan secretions Insulin gtt stopped d/t BS 80-90s. FINDINGS: An extensive low-attenuation process involving the entire right middle cerebral artery territory is noted, consistent with evolving right MCA territory acute infarct. Marked rightward subfalcine herniation measuring 18mm with less marked uncal herniation. There is marked leftward subfalcine herniation and less marked leftward uncal herniation with displacement of the midbrain. HypertensionHeight: (in) 72Weight (lb): 158BSA (m2): 1.93 m2BP (mm Hg): 141/63HR (bpm): 71Status: InpatientDate/Time: at 09:00Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Dilated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.LEFT VENTRICLE: Mild symmetric LVH. Significant leftward shift of midline structures, with marked subfalcine herniation and less marked uncal herniation. with depressed free wall contractility.The aortic valve leaflets are mildly thickened (?#). RV functiondepressed.AORTIC VALVE: Mildly thickened aortic valve leaflets (?#). No VSD.LV WALL MOTION: Regional LV wall motion abnormalities include: basalinferoseptal - hypo; mid inferoseptal - hypo; basal inferior - akinetic; midinferior - akinetic; basal inferolateral - akinetic; mid inferolateral -akinetic;RIGHT VENTRICLE: Normal RV wall thickness. Normal size of the cardiac silhouette, slight tortuosity of the thoracic aorta. There is an abrupt cutoff of the proximal M1 segment with minimal flow within the right distal MCA branches. There ismild symmetric left ventricular hypertrophy. Moderate[2+] tricuspid regurgitation is seen. There is what likely represents a small ulcerative plaque involving the proximal aspect of (Over) 6:41 PM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # CT BRAIN PERFUSION Reason: Eval acute process Contrast: OPTIRAY Amt: 120 FINAL REPORT (Cont) the left external carotid artery. There is nonspecific nodular hypertrophy of the lingual tonsils, also extending to the glossoepiglottic fold and along the anterior surface of the epiglottis. CVA (Stroke, Cerebral infarction), Ischemic Assessment: Patient lethargic but rouse able to speech Perrla Patient has right gaze preference, with left field cut. There is more well-defined cortical low attenuation likely relating to multiple old embolic infarcts, with a region of intermediate low attenuation which could represent subacute infarct within the right MCA distibution. The right lateral ventricle is completely effaced. Probable atrial fibrillation with baseline artifact and ventricular prematuredepolarizations. Limited views through the lung apices demonstrate changes of centrilobular emphysema. The origin of the right vertebral artery is patent, there is moderate atherosclerosis at the origin of the left vertebral artery with additional proximal tortuosity of the vessel. | 34 | [
{
"category": "Nursing",
"chartdate": "2142-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506363,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt lethargic t/o day shift per report and continues to be so\n on night shift. Arouses to voice\n Pt oriented to name. PERRLA 3mm. Pt w/ right gaze preference\n w/ left field cut\n RUE w/ normal strength/RLE lifts and falls back\n LUE no movement except withdrawal to pain/LLE moves on bed\n slightly\n Speech garbled. Weak cough/impaired gag. Speech and swallow\n will re-eval when more alert\n LS diminished LUL/LLL/RLL. Clear RUL. O2 sats stable on 3L\n NC. Positive aspiration of emesis night previous.\n Insulin gtt infusing w/ BS now in the 70-90\n Foley to gravity w/ borderline output in 20s. Dark amber in\n appearance\n Afebrile. WBC 15.9 (9). IVABX on hold until pt spikes temp.\n Tele in a-fib, rate controlled w/ occasional PVCs\n Action:\n SICU contact to ensure pt lethargy/neuro exam same as day\n shift. No change per SICU\n Neuro Q2hrs. Goal SBP 140-180\n Chest PT/Pulm toilet/ NT suction PRN for minimal tan\n secretions\n Insulin gtt stopped d/t BS 80-90\ns. Sliding scale now\n ordered Q4hrs\n NS 250cc bolus for low u/o. IVF rate increased and now\n running NS @100cc/hr\n Response:\n Plan:\n Pulm toilet and wean O2 as tolerated\n Cont Neuro q2hrs and Goal SBP 140-180\n Montior for spike in temp and need for IVABX d/t previous\n aspiration\n ? transfer to floor if continues to be stable\n Speech and swallow to f/u\n Neurology to update HCP niece \n Needs SW and PT/OT consult\n"
},
{
"category": "Nursing",
"chartdate": "2142-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506361,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt lethargic t/o day shift per report and continues to be so\n on night shift. Arouses to voice\n Pt oriented to name. PERRLA 3mm. Pt w/ right gaze preference\n w/ left field cut\n Action:\n Response:\n Plan:\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Patient lethargic but rouse able to speech\n Perrla\n Patient has right gaze preference, with left field cut.\n Denies numbness/tingling.\n Right ue/le normal strength\n Left ue no movement\n Left le minimal toe wiggle.\n Speech remains garbled.\n Orientated x2 follows commands.\n Lungs diminished left > right, productive cough, thick tan colored\n secretions.\n Patient has weak cough and impaired gag.\n O2 sats 98-100%\n Bs elevated 300-400.\n Temp max 99.5\n Action:\n Neuro exam monitored Q2\n Iv heparin discontinued per neurology team\n Labs rechecked in am\n Chest pt and pulmonary toileting maintained.\n Speech and swallow evaluation done today.\n Bs covered with sliding scale, however remains elevated so insulin gtt\n started. Will monitor and titrate as per orders.\n Monitor temp and treat accordingly\n Wean o2 as tolerate\n Response:\n No change in neuro exam\n Wbc elevated 15.9, team made aware will continue to monitor.\n Patient maintaining sats >98%\n Bs 400-181, insulin gtt titrated to maintain bs within parameters as\n ordered.\n Plan:\n Wean off o2 as tolerated\n Continue pulmonary toileting and chest pt\n Monitor neuro exam Q2\n Monitor temp and treat accordingly, may need iv antibiotics.\n If remains stable patient to transfer to nursing floor.\n Needs social worker consult and pt/ot.\n have neurology speak to niece in am\n"
},
{
"category": "Nursing",
"chartdate": "2142-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506539,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Patient became more\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2142-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506360,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2142-11-29 00:00:00.000",
"description": "Intensivist Note",
"row_id": 506602,
"text": "SICU\n HPI:\n 80yo RHM with Afib not on Coumadin but possibly ASA, HTN, DM and hx of\n stroke with some residual L sided weakness who smokes >1PPD found per\n VNA at home down on the floor with slurred speech and L sided weakness\n around 3pm. Last well known time most likely 10:30 am when patient\n reports to have fallen and unable to get up but no corroboration.\n Patient initially presented to ED then transferred here for\n further care. Patient seen and examined 6:20pm - ~ 8hrs after presumed\n oset of symptoms. His initial NIHSS score was 19 for R gaze deviation,\n L sided weakness and sensory deficit. His CT of head shows dense R MCA\n with likely M2 level occlusion and loss of /white matter\n differentiation over the distribution. His INR was 1.2 but patient\n reports not to have taken meds including Coumadin for possibly over 2\n months.\n Given the hx and exam findings, most likely cardioembolic stroke to R\n MCA. Since patient has large territory infarct, will need close\n monitoring, hence admit to ICU.\n Chief complaint:\n Respiratory distress, hemorrhagic stroke\n PMHx:\n 1. Stroke - over 10 yrs ago, initially could not move L side,\n talk or walk per patient.\n 2. Afib\n 3. HTN\n 4. DM - oral only\n 5. s/p abdominal surgery to remove tumor\n 6. PVD - s/p bypass surgery in RLE\n 7. s/p cataract repair bilaterally\n Current medications:\n Morphine Sulfate 5-20 mg/hr IV DRIP INFUSION cmo Order date: @\n 1732 2. Lorazepam 2-4 mg IV Q2H:PRN cmo\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 08:00 AM\n For increased resp distress. RR in the 40s\n INTUBATION - At 10:00 AM\n Failed NIV\n NON-INVASIVE VENTILATION - STOP 10:00 AM\n For increased resp distress. RR in the 40s\n In AM had another episode for increased WOB. Trial of BIPAP -\n still distress, intubated. R pupil deficits. Started mannitol. Head CT\n acute hemorrhagic infarct with herniation and shift. HCP to withdrawal\n care and become CMO.\n INVASIVE VENTILATION - START 10:00 AM\n ARTERIAL LINE - START 10:19 AM\n INVASIVE VENTILATION - STOP 06:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:40 AM\n Vancomycin - 09:17 AM\n Infusions:\n Other ICU medications:\n Labetalol - 09:00 AM\n Midazolam (Versed) - 09:19 AM\n Lorazepam (Ativan) - 08:15 PM\n Other medications:\n Flowsheet Data as of 04:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.3\nC (99.2\n HR: 90 (77 - 90) bpm\n BP: 133/60(86) {133/60(86) - 186/85(123)} mmHg\n RR: 27 (3 - 44) insp/min\n SPO2: 82%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,076 mL\n 36 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,076 mL\n 36 mL\n Blood products:\n Total out:\n 526 mL\n 0 mL\n Urine:\n 526 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,550 mL\n 36 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: Standby\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 855 (855 - 855) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 12 cmH2O\n SPO2: 82%\n ABG: 7.40/37/198/22/0\n Ve: 5.8 L/min\n PaO2 / FiO2: 396\n Physical Examination\n General Appearance: No acute distress\n HEENT: Pupils fixed and dilated\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Rhonchorous : ,\n Diminished: )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Responds to: Unresponsive), Sedated\n Labs / Radiology\n 146 K/uL\n 11.9 g/dL\n 231 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 35 mg/dL\n 111 mEq/L\n 144 mEq/L\n 37.0 %\n 13.8 K/uL\n [image002.jpg]\n 12:38 AM\n 08:58 AM\n 02:06 AM\n 03:29 AM\n 08:00 AM\n 11:38 AM\n 11:50 AM\n WBC\n 9.9\n 15.9\n 12.8\n 13.8\n Hct\n 40.3\n 40.6\n 30.0\n 38.7\n 37.0\n Plt\n 191\n 183\n 127\n 146\n Creatinine\n 1.1\n 1.1\n 0.9\n 1.2\n Troponin T\n 0.02\n TCO2\n 24\n 24\n Glucose\n 31\n Other labs: PT / PTT / INR:14.1/32.2/1.2, CK / CK-MB / Troponin\n T:42//0.02, Lactic Acid:1.6 mmol/L, Ca:8.6 mg/dL, Mg:2.3 mg/dL, PO4:3.2\n mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Assessment and Plan: 80yo M with afib, likely off his coumadin, p/w\n Right MCA embolic stroke\n Neurologic: R MCA embolic stroke now c/b acute hemorrhagic infarct with\n significant herniation. Plan for CMO - on morphine gtt and ativan prn.\n Cardiovascular: Afib. Withdrawal all care - now on CMO.\n Pulmonary: HAP aspiration. Respiratory distress req intubation.\n Extubated for CMO.\n Nutrition: Now CMO\n Renal: CMO\n Hematology: CMO\n Endocrine: CMO\n Lines / Tubes / Drains: PIVx3\n Wounds: N/A\n Imaging: AM CXR\n Fluids:\n Consults: Neurology\n Billing Diagnosis: Embolic stroke\n Prophylaxis:\n DVT: SCD, heparin sq\n Stress ulcer: H2B\n VAP bundle: N/A\n Code status:FULL\n Disposition:SICU\n Time: 35 min\n"
},
{
"category": "Nursing",
"chartdate": "2142-11-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 506770,
"text": "80 year old male with afib, likely off his coumadin, presented with\n Right MCA embolic stroke now complicated by acute hemorrhagic infarct\n with significant herniation. Now CMO - on morphine gtt and ativan prn.\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt is unresponsive, appears comfortable, rr 10-20\n Action:\n Morphine gtt infusing at 12mg/hr. Pt turned and repositioned q 2\n hours. (hcp) at bedside visiting, emotional support offered.\n Clergy offered.\n Response:\n Unchanged, appears comfortable.\n Plan:\n Continue comfort care, morphine, and transfer to floor, (private room)\n will return this evening and likely spend the night.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CEREBROVASCULAR ACCIDENT\n Code status:\n Height:\n Admission weight:\n 72.1 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Diabetes - Oral \n CV-PMH: Arrhythmias, CVA, Hypertension\n Additional history: Afib (not on coumadin), 2PPD smoker and cigars.\n Stroke over 10 years ago, initially could not move left side, walk, or\n talk. PVD s/p bypass surgery in RLE, bilateral cataract repair, abd\n surgery to remove tumor.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:171\n D:73\n Temperature:\n 97.4\n Arterial BP:\n S:134\n D:58\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 93 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n None\n O2 saturation:\n 86% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 203 mL\n 24h total out:\n 1,000 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 11:38 AM\n Potassium:\n 4.2 mEq/L\n 11:38 AM\n Chloride:\n 111 mEq/L\n 11:38 AM\n CO2:\n 22 mEq/L\n 11:38 AM\n BUN:\n 35 mg/dL\n 11:38 AM\n Creatinine:\n 1.2 mg/dL\n 11:38 AM\n Glucose:\n 231 mg/dL\n 11:38 AM\n Hematocrit:\n 37.0 %\n 11:38 AM\n Finger Stick Glucose:\n 243\n 02:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: sicu b\n Transferred to: 11\n Date & time of Transfer: 05:15 PM\n"
},
{
"category": "Physician ",
"chartdate": "2142-11-27 00:00:00.000",
"description": "Intensivist Note",
"row_id": 506143,
"text": "SICU\n HPI:\n patient is a 80yo RHM with Afib not on Coumadin but possibly ASA, HTN,\n DM and hx of stroke with some residual L sided weakness who smokes\n >1PPD found per VNA at home down on the floor with slurred speech and L\n sided weakness around 3pm. Last well known time most likely 10:30 am\n when patient reports to have fallen and unable to get up but no\n corroboration.\n Patient initially presented to ED then transferred here for\n further care. Patient seen and examined 6:20pm - ~ 8hrs after presumed\n oset of symptoms. His initial NIHSS score was 19 for R gaze deviation,\n L sided weakness and sensory deficit. His CT of head shows dense R MCA\n with likely M2 level occlusion and loss of /white matter\n differentiation over the distribution. His INR was 1.2 but patient\n reports not to have taken meds including Coumadin for possibly over 2\n months.\n Given the hx and exam findings, most likely cardioembolic stroke to R\n MCA. Since patient has large territory infarct, will need close\n monitoring, hence admit to ICU.\n Chief complaint:\n found per VNA at home down on the floor with slurred speech and L sided\n weakness\n PMHx:\n 1. Stroke - over 10 yrs ago, initially could not move L side,\n talk or walk per patient.\n 2. Afib\n 3. HTN\n 4. DM - oral only\n 5. s/p abdominal surgery to remove tumor\n 6. PVD - s/p bypass surgery in RLE\n 7. s/p cataract repair bilaterally\n Current medications:\n Acetaminophen 6. Heparin gtt 7. Insulin 8. Labetalol\n 9. NiCARdipine 10. Ondansetron 11. Pantoprazole 12. Pneumococcal Vac\n 24 Hour Events:\n vomited coffee ground on arrival to ICU? aspiration.\n Cxr : no acute process\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 01:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.3\n T current: 36.8\nC (98.3\n HR: 66 (64 - 74) bpm\n BP: 126/51(146) {126/51(98) - 213/113(146)} mmHg\n RR: 28 (24 - 30) insp/min\n SPO2: 83%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 20 mL\n 8 mL\n PO:\n Tube feeding:\n IV Fluid:\n 20 mL\n 8 mL\n Blood products:\n Total out:\n 750 mL\n 345 mL\n Urine:\n 45 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n -730 mL\n -337 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SPO2: 98\n ABG: ///21/\n Physical Examination\n General Appearance: Anxious\n HEENT: both are reactive but L more brisk than R.\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n (Responds to: Verbal stimuli), No(t) Moves all extremities, (LUE: No\n movement), (LLE: No movement)\n Labs / Radiology\n 191 K/uL\n 13.6 g/dL\n 415 mg/dL\n 1.1 mg/dL\n 21 mEq/L\n 4.4 mEq/L\n 15 mg/dL\n 102 mEq/L\n 139 mEq/L\n 40.3 %\n 9.9 K/uL\n [image002.jpg]\n 12:38 AM\n WBC\n 9.9\n Hct\n 40.3\n Plt\n 191\n Creatinine\n 1.1\n Glucose\n 415\n Other labs: PT / PTT / INR:15.0/51.9/1.3, CK / CK-MB / Troponin T:42//,\n Ca:8.7 mg/dL, Mg:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n Assessment and Plan: ASSESSMENT:80yo M w cardioembolic stroke to R MCA\n Neurologic: Awake and alert, cooperative with exam, normal\n affect. Oriented to person, place, and month. Fluent speech\n with mild dysarthria.R pupil slightly larger than L and more\n asymmetric. S/p bilateral cataract - both are reactive but L more\n brisk than R.Unable to move L side but appears full strength on R.\n Withdraws to noxious stim on L but not anti-gravity.\n neuro check q1.heparin gtt.STAT head CT if change in exam\n Cardiovascular: hypertensive on nicardipine and labetelol, Goal SBP\n 140~180\n TTE in the morning to assess for proximal source of embolus\n Pulmonary:on NC,vomited on arrival to ICU.?aspiration-CXR no evidence\n of aspiration however O2 requirements increased\n Gastrointestinal / Abdomen:NPO,had coffee ground vomiting,on PPI\n Nutrition: npo ,Speech/swallow eval\n Renal:monitor UO,creat 1.2\n Hematology:Hct 40,monitor PTT ,goal PTT 50~70\n Endocrine:riss\n ID:\n Lines / Tubes / Drains:PIV\n Wounds:\n Imaging:\n Fluids:NS AT 75\n Consults:Neuromed\n Billing Diagnosis:embolic stroke\n Prophylaxis:\n DVT: SCD,heparin drip\n Stress ulcer:PPI\n VAP bundle: +\n Comments:\n Communication:\n Code status:FULL\n Disposition:SICU\n Lines:\n 20 Gauge - 10:52 PM\n 18 Gauge - 10:52 PM\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2142-11-27 00:00:00.000",
"description": "Intensivist Note",
"row_id": 506237,
"text": "SICU\n HPI:\n patient is a 80yo RHM with Afib not on Coumadin but possibly ASA, HTN,\n DM and hx of stroke with some residual L sided weakness who smokes\n >1PPD found per VNA at home down on the floor with slurred speech and L\n sided weakness around 3pm. Last well known time most likely 10:30 am\n when patient reports to have fallen and unable to get up but no\n corroboration.\n Patient initially presented to ED then transferred here for\n further care. Patient seen and examined 6:20pm - ~ 8hrs after presumed\n oset of symptoms. His initial NIHSS score was 19 for R gaze deviation,\n L sided weakness and sensory deficit. His CT of head shows dense R MCA\n with likely M2 level occlusion and loss of /white matter\n differentiation over the distribution. His INR was 1.2 but patient\n reports not to have taken meds including Coumadin for possibly over 2\n months.\n Given the hx and exam findings, most likely cardioembolic stroke to R\n MCA. Since patient has large territory infarct, will need close\n monitoring, hence admit to ICU.\n Chief complaint:\n found per VNA at home down on the floor with slurred speech and L sided\n weakness\n PMHx:\n 1. Stroke - over 10 yrs ago, initially could not move L side,\n talk or walk per patient.\n 2. Afib\n 3. HTN\n 4. DM - oral only\n 5. s/p abdominal surgery to remove tumor\n 6. PVD - s/p bypass surgery in RLE\n 7. s/p cataract repair bilaterally\n Current medications:\n Acetaminophen 6. Heparin gtt 7. Insulin 8. Labetalol\n 9. NiCARdipine 10. Ondansetron 11. Pantoprazole 12. Pneumococcal Vac\n 24 Hour Events:\n vomited coffee ground on arrival to ICU? aspiration.\n Cxr : no acute process\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 01:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.3\n T current: 36.8\nC (98.3\n HR: 66 (64 - 74) bpm\n BP: 126/51(146) {126/51(98) - 213/113(146)} mmHg\n RR: 28 (24 - 30) insp/min\n SPO2: 83%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 20 mL\n 8 mL\n PO:\n Tube feeding:\n IV Fluid:\n 20 mL\n 8 mL\n Blood products:\n Total out:\n 750 mL\n 345 mL\n Urine:\n 45 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n -730 mL\n -337 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SPO2: 98\n ABG: ///21/\n Physical Examination\n General Appearance: Anxious\n HEENT: both are reactive but L more brisk than R.\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n (Responds to: Verbal stimuli), No(t) Moves all extremities, (LUE: No\n movement), (LLE: No movement)\n Labs / Radiology\n 191 K/uL\n 13.6 g/dL\n 415 mg/dL\n 1.1 mg/dL\n 21 mEq/L\n 4.4 mEq/L\n 15 mg/dL\n 102 mEq/L\n 139 mEq/L\n 40.3 %\n 9.9 K/uL\n [image002.jpg]\n 12:38 AM\n WBC\n 9.9\n Hct\n 40.3\n Plt\n 191\n Creatinine\n 1.1\n Glucose\n 415\n Other labs: PT / PTT / INR:15.0/51.9/1.3, CK / CK-MB / Troponin T:42//,\n Ca:8.7 mg/dL, Mg:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n Assessment and Plan: ASSESSMENT:80yo M w cardioembolic stroke to R MCA\n Neurologic: Awake and alert, cooperative with exam, normal\n affect. Oriented to person, place, and month. Fluent speech\n with mild dysarthria.R pupil slightly larger than L and more\n asymmetric. S/p bilateral cataract - both are reactive but L more\n brisk than R.Unable to move L side but appears full strength on R.\n Withdraws to noxious stim on L but not anti-gravity.\n neuro check q1.heparin gtt.STAT head CT if change in exam\n Cardiovascular: hypertensive on nicardipine and labetelol, Goal SBP\n 140~180\n TTE in the morning to assess for proximal source of embolus\n Pulmonary:on NC,vomited on arrival to ICU.?aspiration-CXR no evidence\n of aspiration however O2 requirements increased\n Gastrointestinal / Abdomen:NPO,had coffee ground vomiting,on PPI\n Nutrition: npo ,Speech/swallow eval\n Renal:monitor UO,creat 1.2\n Hematology:Hct 40,monitor PTT ,goal PTT 50~70\n Endocrine:riss\n ID:\n Lines / Tubes / Drains:PIV\n Wounds:\n Imaging:\n Fluids:NS AT 75\n Consults:Neuromed\n Billing Diagnosis:embolic stroke\n Prophylaxis:\n DVT: SCD,heparin drip\n Stress ulcer:PPI\n VAP bundle: +\n Comments:\n Communication:\n Code status:FULL\n Disposition:SICU\n Lines:\n 20 Gauge - 10:52 PM\n 18 Gauge - 10:52 PM\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2142-11-29 00:00:00.000",
"description": "Intensivist Note",
"row_id": 506666,
"text": "SICU\n HPI:\n 80yo RHM with Afib not on Coumadin but possibly ASA, HTN, DM and hx of\n stroke with some residual L sided weakness who smokes >1PPD found per\n VNA at home down on the floor with slurred speech and L sided weakness\n around 3pm. Last well known time most likely 10:30 am when patient\n reports to have fallen and unable to get up but no corroboration.\n Patient initially presented to ED then transferred here for\n further care. Patient seen and examined 6:20pm - ~ 8hrs after presumed\n oset of symptoms. His initial NIHSS score was 19 for R gaze deviation,\n L sided weakness and sensory deficit. His CT of head shows dense R MCA\n with likely M2 level occlusion and loss of /white matter\n differentiation over the distribution. His INR was 1.2 but patient\n reports not to have taken meds including Coumadin for possibly over 2\n months.\n Given the hx and exam findings, most likely cardioembolic stroke to R\n MCA. Since patient has large territory infarct, will need close\n monitoring, hence admit to ICU.\n Chief complaint:\n Respiratory distress, hemorrhagic stroke\n PMHx:\n 1. Stroke - over 10 yrs ago, initially could not move L side,\n talk or walk per patient.\n 2. Afib\n 3. HTN\n 4. DM - oral only\n 5. s/p abdominal surgery to remove tumor\n 6. PVD - s/p bypass surgery in RLE\n 7. s/p cataract repair bilaterally\n Current medications:\n Morphine Sulfate 5-20 mg/hr IV DRIP INFUSION cmo Order date: @\n 1732 2. Lorazepam 2-4 mg IV Q2H:PRN cmo\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 08:00 AM\n For increased resp distress. RR in the 40s\n INTUBATION - At 10:00 AM\n Failed NIV\n NON-INVASIVE VENTILATION - STOP 10:00 AM\n For increased resp distress. RR in the 40s\n In AM had another episode for increased WOB. Trial of BIPAP -\n still distress, intubated. R pupil deficits. Started mannitol. Head CT\n acute hemorrhagic infarct with herniation and shift. HCP to withdrawal\n care and become CMO.\n INVASIVE VENTILATION - START 10:00 AM\n ARTERIAL LINE - START 10:19 AM\n INVASIVE VENTILATION - STOP 06:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:40 AM\n Vancomycin - 09:17 AM\n Infusions:\n Other ICU medications:\n Labetalol - 09:00 AM\n Midazolam (Versed) - 09:19 AM\n Lorazepam (Ativan) - 08:15 PM\n Other medications:\n Flowsheet Data as of 04:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.3\nC (99.2\n HR: 90 (77 - 90) bpm\n BP: 133/60(86) {133/60(86) - 186/85(123)} mmHg\n RR: 27 (3 - 44) insp/min\n SPO2: 82%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,076 mL\n 36 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,076 mL\n 36 mL\n Blood products:\n Total out:\n 526 mL\n 0 mL\n Urine:\n 526 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,550 mL\n 36 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: Standby\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 855 (855 - 855) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 12 cmH2O\n SPO2: 82%\n ABG: 7.40/37/198/22/0\n Ve: 5.8 L/min\n PaO2 / FiO2: 396\n Physical Examination\n General Appearance: No acute distress\n HEENT: Pupils fixed and dilated\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Rhonchorous : ,\n Diminished: )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Responds to: Unresponsive), Sedated\n Labs / Radiology\n 146 K/uL\n 11.9 g/dL\n 231 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 35 mg/dL\n 111 mEq/L\n 144 mEq/L\n 37.0 %\n 13.8 K/uL\n [image002.jpg]\n 12:38 AM\n 08:58 AM\n 02:06 AM\n 03:29 AM\n 08:00 AM\n 11:38 AM\n 11:50 AM\n WBC\n 9.9\n 15.9\n 12.8\n 13.8\n Hct\n 40.3\n 40.6\n 30.0\n 38.7\n 37.0\n Plt\n 191\n 183\n 127\n 146\n Creatinine\n 1.1\n 1.1\n 0.9\n 1.2\n Troponin T\n 0.02\n TCO2\n 24\n 24\n Glucose\n 31\n Other labs: PT / PTT / INR:14.1/32.2/1.2, CK / CK-MB / Troponin\n T:42//0.02, Lactic Acid:1.6 mmol/L, Ca:8.6 mg/dL, Mg:2.3 mg/dL, PO4:3.2\n mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Assessment and Plan: 80yo M with afib, likely off his coumadin, p/w\n Right MCA embolic stroke\n Neurologic: R MCA embolic stroke now c/b acute hemorrhagic infarct with\n significant herniation. Plan for CMO - on morphine gtt and ativan prn.\n Cardiovascular: Afib. Withdrawal all care - now on CMO.\n Pulmonary: HAP aspiration. Respiratory distress req intubation.\n Extubated for CMO.\n Nutrition: Now CMO\n Renal: CMO\n Hematology: CMO\n Endocrine: CMO\n Lines / Tubes / Drains: PIVx3\n Wounds: N/A\n Imaging: AM CXR\n Fluids:\n Consults: Neurology\n Billing Diagnosis: Embolic stroke\n Prophylaxis:\n DVT: SCD, heparin sq\n Stress ulcer: H2B\n VAP bundle: N/A\n Code status:DNR/DNI\n Disposition:floor\n Time:\n"
},
{
"category": "Rehab Services",
"chartdate": "2142-11-27 00:00:00.000",
"description": "Bedside Swallow Evaluation",
"row_id": 506249,
"text": "TITLE:\nBEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this 80 y/o RHM with Afib not on\nCoumadin, HTN, DM and hx of stroke over 10 years ago with some\nresidual L sided weakness who was found down per VNA at 3pm with\nL slurred speech and L sided weakness. He was taken to OSH where\nhis initial BP was extremely elevated with SBP into 280s for\nwhich he was given labetalol x2~3. Head CT was negative for\nhemorrhage then patient was transferred to for further\ncare. His head CT here showed a dense R MCA with likely M2 level\nocclusion and loss of /white matter differentiation over the\ndistribution.\nWe were consulted to evaluate for oral and pharyngeal dysphagia.\nPt is currently NPO pending evaluation. RN had not administered\nanything by mouth since admission.\nPMH:\n1. Stroke - over 10 yrs ago, initially could not move L side,\ntalk or walk per patient.\n2. Afib\n3. HTN\n4. DM - oral only\n5. s/p abdominal surgery to remove tumor\n6. PVD - s/p bypass surgery in RLE\n7. s/p cataract repair bilaterally\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed in the SICU.\nCognition, language, speech, voice:\nPt was awake, alert an dinteractive, but kept eyes closed\nthroughout the evaluation. He was oriented to self and niece,\nbut reported place as \"one of those places of places\" although\nable to pick hospital from a list of choices. Date reported as\n\" - its a very good year!\" Pt able to identify New\nYear's Eve as an upcoming holiday, but could not recall other\n holidays. Unable to state what month came before or\nafter . Language was fluent but often confused and off topic\nand or empty with limited meaning. Speech was moderately\ndysarthric with wet vocal quality at baseline. He was able to\nfollow basic commands and needed redirection to tasks.\nTeeth: edentulous- pt denied wearing dentures at home, reporting\nhe eats \"peanut butter without the racks\" at home\nSecretions: wfl in the oral cavity- wet vocal quality at baseline\nRN suctioned just prior to arrival\nORAL MOTOR EXAM:\nSignificant left sided facial droop with reduced lip seal on the\nleft. Pt did not follow commands for facial ROM, stating he\n\"refuses to smile fake smiles.\" Pt made attempts to stick out\ntongue, but without protrusion past his teeth. Unable to assess\nlingual strength or ROM. Palatal elevation appeared sluggish, gag\nreduced / absent with suctioning.\nSWALLOWING ASSESSMENT:\nThe pt was seen with ice chips, thin liquids (tsp), nectar thick\nliquids (tsp) and small bites of puree. The oral phase was\nprolonged with the pt holding liquids and purees for up to 25\nseconds before initiating transit, even with max cues to swallow.\nHe did eventually trigger a swallow and no oral residue was seen\nafter the swallow. No anterior spill was seen while holding the\nbolus in his mouth. He was without overt coughing or choking, but\nhe had increased wet vocal quality after POs. Cued coughs were\nweak and ineffective with only mild return with Yankauer\nsuctioning. O2 SATs remained stable around 96%, but noted RR was\nin the low 30s during the evaluation. Laryngeal elevation felt\nmildly delayed and reduced to palpation.\nSUMMARY / IMPRESSION:\nMr. presented with a prolonged oral phase and delayed\npharyngeal phase, putting him at high risk for premature\nspillover and penetration given his significant left sided facial\nweakness. While there were no overt signs of aspiration, it did\nappear he had increased wet vocal quality with PO intake which\ncould be c/w silent aspiration vs difficulty managing secretions.\nSome of the difficulty may be related to reduced MS, although he\ndid remain aware for the evaluation. I would suggest he remain\nNPO for tonight except for essential meds crushed with purees.\nContinue Q4 oral care. We will f/u tomorrow to repeat the\nevaluation and if we have the same results pt will need to have\nalternate means of nutrition placed.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of 1.\nRECOMMENDATIONS:\n1. Suggest pt remain NPO for tonight, except for essential meds\ncrushed with purees.\n2. Continue Q4 oral care.\n3. We will return tomorrow to repeat the evaluation.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 10:30-10:45\nTotal time: 50 minutes\n 10:59\n"
},
{
"category": "Physician ",
"chartdate": "2142-11-28 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 506396,
"text": "24 Hour Events: 80yo M with afib, likely off his coumadin, p/w Right\n MCA embolic stroke\n Had wheezing overnight. Improved with nebs.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:27 PM\n Labetalol - 04:00 AM\n Other medications:\n Flowsheet Data as of 04:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.9\nC (98.4\n HR: 84 (69 - 88) bpm\n BP: 167/69(94) {128/53(75) - 187/89(110)} mmHg\n RR: 35 (21 - 38) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 1,790 mL\n 1,861 mL\n PO:\n TF:\n IVF:\n 1,790 mL\n 1,861 mL\n Blood products:\n Total out:\n 1,472 mL\n 69 mL\n Urine:\n 1,172 mL\n 69 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n 318 mL\n 1,792 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///21/\n Physical Examination\n General Appearance: somnolent, frail\n Eyes / Conjunctiva: PERRL\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed, Wiggles toes bilat, holds\n two fingers up on right side on command\n Labs / Radiology\n 127 K/uL\n 9.8 g/dL\n 121 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 3.0 mEq/L\n 25 mg/dL\n 114 mEq/L\n 145 mEq/L\n 38.7 %\n 12.8 K/uL\n [image002.jpg]\n 12:38 AM\n 08:58 AM\n 02:06 AM\n 03:29 AM\n WBC\n 9.9\n 15.9\n 12.8\n Hct\n 40.3\n 40.6\n 30.0\n 38.7\n Plt\n 191\n 183\n 127\n Cr\n 1.1\n 1.1\n 0.9\n TropT\n 0.02\n Glucose\n \n Other labs: PT / PTT / INR:14.4/30.0/1.2, CK / CKMB /\n Troponin-T:42//0.02, Ca++:7.0 mg/dL, Mg++:1.6 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n 80yo M with afib, likely off his coumadin, p/w Right MCA embolic stroke\n Neurologic: Somnolent, weak gag, follows command on right side. Left\n side weakness. Right gaze preference. Heparin gtt dc'd per neuro\n (). Neck CTA with ulcerated plaque in right proximal carotid.\n -q2hr neuro check.\n -STAT head CT if change in exam\n Cardiovascular:\n -Afib, rate controlled on no meds.\n -Autoregulating BP. Goal SBP 140-180. Pt off antihypertensive\n medications.\n -TTE () showed EF 30-40%. Hypokinesis of the inferior septum and\n akinesis of the inferior free wall and posterior wall.\n Pulmonary: on NC, had increased O2 requirement upon admit to ICU,\n ?aspiration. CXR clear. O2 sats and lung exam improved after chest PT.\n Overnight, had wheezing on exam and increased work of breathing.\n improved with nebs\n -repeat AM CXR\n -albuterol/atrovent nebs.\n Gastrointestinal/Abdomen: NPO, Pantoprazole 40 mg IV Q12H\n Nutrition: Speech/swallow evalution - failed. Holding off on DHT,\n Speech and swallow team to revaluate today.\n Renal: monitor UOP, creat 1.1 ()\n0.9 ()\n Hematology: Hct 40 ()\n Endocrine: Started insulin gtt () given FSG in 300-400's.\n ID: WBC 9.9 () --> 15.9 () --> 12.8 Afebrile. CXR clear. No\n abx for now. Vanc/Zosyn if febrile.\n Lines / Tubes / Drains: PIVx3\n Wounds: N/A\n Imaging: AM CXR\n Fluids: NS AT 25 ml/hr, D5W 40mL/hr\n Consults: Neurology\n Billing Diagnosis: Embolic stroke\n Prophylaxis:\n DVT: SCD, heparin sq started TID on \n Stress ulcer: PPI IV bid\n VAP bundle: N/A\n Code status:FULL\n Disposition:SICU\n Lines:\n 20 Gauge - 03:00 AM\n 18 Gauge - 04:00 AM\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2142-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506631,
"text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt extubated on day shift and made comfort measures.\n Niece(HCP) and daughters updated on day shift\n Morphine gtt infusing at 12mg/hr\n Pt appears comfortable, no acute distress noted\n Action:\n Ativan 2mg IV admin x1 for resp distress\n Morpine gtt continues at 12mg/hr\n Turned and repositioned\n Family at BS overnoc and emotional support given\n Response:\n Pt appears comfortable and NAD noted\n Niece calling daughters who live out of town and giving\n updates. Appears to be coping well\n Plan:\n Titrated Morphine to comfort. Admin Ativan PRN\n Turn and reposition\n Emotional support for family\n ?Transfer to floor if bed available\n"
},
{
"category": "Nursing",
"chartdate": "2142-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506328,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Patient lethargic but rouse able to speech\n Perrla\n Patient has right gaze preference, with left field cut.\n Denies numbness/tingling.\n Right ue/le normal strength\n Left ue no movement\n Left le minimal toe wiggle.\n Speech remains garbled.\n Orientated x2 follows commands.\n Lungs diminished left > right, productive cough, thick tan colored\n secretions.\n Patient has weak cough and impaired gag.\n O2 sats 98-100%\n Bs elevated 300-400.\n Temp max 99.5\n Action:\n Neuro exam monitored Q2\n Iv heparin discontinued per neurology team\n Labs rechecked in am\n Chest pt and pulmonary toileting maintained.\n Speech and swallow evaluation done today.\n Bs covered with sliding scale, however remains elevated so insulin gtt\n started. Will monitor and titrate as per orders.\n Monitor temp and treat accordingly\n Wean o2 as tolerate\n Response:\n No change in neuro exam\n Wbc elevated 15.9, team made aware will continue to monitor.\n Patient maintaining sats >98%\n Bs 400-181, insulin gtt titrated to maintain bs within parameters as\n ordered.\n Plan:\n Wean off o2 as tolerated\n Continue pulmonary toileting and chest pt\n Monitor neuro exam Q2\n Monitor temp and treat accordingly, may need iv antibiotics.\n If remains stable patient to transfer to nursing floor.\n Needs social worker consult and pt/ot.\n have neurology speak to niece in am\n"
},
{
"category": "Rehab Services",
"chartdate": "2142-11-28 00:00:00.000",
"description": "Swallowing Follow Up",
"row_id": 506496,
"text": "TITLE:\nDEFERRED BEDSIDE SWALLOW EVALUATION\nI returned to f/u on this 80 y/o male with Afib not on\nCoumadin, HTN, DM and hx of stroke over 10 years ago with some\nresidual L sided weakness who was found down per VNA at 3pm with\nL slurred speech and L sided weakness. Head CT on admission\nshowed a dense R MCA with likely M2 level occlusion and loss of\n/white matter differentiation over the distribution. We saw\nhim for a bedside swallow on but it was recommended he\nremain NPO with a plan to f/u. I returned to f/u today, but at\n12:30pm on , the patient's R pupil was noted to be large and\nunreactive. STAT noncontrast head CT was performed. This\nrevealed an extremely large hemorrhage in the region of the R MCA\nstroke with extreme midline shift and mass effect requiring\nintubation.\nPt was intubated as team has not yet been able to reach pt's HCP,\nbut notes indicate poor prognosis at this time. We will sign off\nfor now, but are happy to return in the future if needed.\n___________________________________\n , MS, CCC-SLP\nPager#\n 14:53\n"
},
{
"category": "Nursing",
"chartdate": "2142-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506427,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt lethargic t/o day shift per report and continues to be so\n on night shift. Arouses to loud voice\n Pt oriented to name. PERRLA 3mm. Pt not opening eyes to\n command or stimulation\n RUE w/ normal strength/RLE lifts and falls back\n LUE no movement except withdrawal to pain/LLE moves on bed\n slightly\n Speech garbled. Weak cough/impaired gag. Speech and swallow\n will re-eval when more alert\n LS diminished LUL/LLL/RLL. Clear RUL. O2 sats stable on 3L\n NC. Positive aspiration of emesis night previous.\n Insulin gtt infusing w/ BS now in the 70-90\n Foley to gravity w/ borderline output in 20s. Dark amber in\n appearance\n Afebrile. WBC 15.9 (9). IVABX on hold until pt spikes temp.\n Tele in a-fib, rate controlled w/ occasional PVCs\n Action:\n SICU contact at beginning of shift to ensure pt\n lethargy/neuro exam same as day shift. No change per SICU\n Neuro Q2hrs. Goal SBP 140-180. Labetalol 5mg IV x2 for SBP\n >180\n Chest PT/Pulm toilet/ NT suction PRN for minimal tan\n secretions\n Insulin gtt stopped d/t BS 80-90\ns. Sliding scale now\n ordered Q4hrs\n NS 250cc bolus for low u/o. IVF rate increased and now\n running NS @100cc/hr\n Response:\n Pt w/ increase difficulty to engage/arouse for Neuro exam @\n 0400. No other change in Neuro exam. Neuromed at BS to eval no imaging\n ordered but will be by to round again\n0600\n to further assess need for\n imaging\n Original HCT dropped from 40 to 30. RN redrew and stable at\n 38.7 and coags wnl\n Electrolytes repleted per order. KCL/Mg/Ca\n Urine output didn\nt respond to original 250cc bolus,\n requiring another 500cc NS bolus and then another LR 500cc d/t u/o\n continued to be poor. As low as 3cc/hr\n Urine output slightly improved post boluses\n Right FA #18 infiltrated w/ 500cc NS bolus. PIV removed,\n warm pack applied and arm elevated\n LS w/ insp/exp wheezing bilaterally. O2 sats stable.\n Albuterol/Atrovent nebs. CXR pending\n Plan:\n Pulm toilet and wean O2 as tolerated\n Cont Neuro q2hrs and Goal SBP 140-180\n Montior for spike in temp and need for IVABX d/t previous\n aspiration\n Speech and swallow to f/u\n Neurology to update HCP niece \n Needs SW and PT/OT consult\n Awaiting Neuromed to re-eval this am f\n"
},
{
"category": "Physician ",
"chartdate": "2142-11-28 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 506460,
"text": "24 Hour Events: 80yo M with afib, likely off his coumadin, p/w Right\n MCA embolic stroke\n Had wheezing overnight. Improved with nebs.\n Tachypnea this AM , not responding to nebs, BIPAP\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:27 PM\n Labetalol - 04:00 AM\n Other medications:\n Flowsheet Data as of 04:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.9\nC (98.4\n HR: 84 (69 - 88) bpm\n BP: 167/69(94) {128/53(75) - 187/89(110)} mmHg\n RR: 35 (21 - 38) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 1,790 mL\n 1,861 mL\n PO:\n TF:\n IVF:\n 1,790 mL\n 1,861 mL\n Blood products:\n Total out:\n 1,472 mL\n 69 mL\n Urine:\n 1,172 mL\n 69 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n 318 mL\n 1,792 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///21/\n Physical Examination\n General Appearance: somnolent, frail On BIPAP with tachypnea.\n Eyes / Conjunctiva: PERRL\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezing:\n )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed, Wiggles toes bilat, holds\n two fingers up on right side on command. Now more somnolent.\n Labs / Radiology\n 127 K/uL\n 9.8 g/dL\n 121 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 3.0 mEq/L\n 25 mg/dL\n 114 mEq/L\n 145 mEq/L\n 38.7 %\n 12.8 K/uL\n [image002.jpg]\n 12:38 AM\n 08:58 AM\n 02:06 AM\n 03:29 AM\n WBC\n 9.9\n 15.9\n 12.8\n Hct\n 40.3\n 40.6\n 30.0\n 38.7\n Plt\n 191\n 183\n 127\n Cr\n 1.1\n 1.1\n 0.9\n TropT\n 0.02\n Glucose\n \n Other labs: PT / PTT / INR:14.4/30.0/1.2, CK / CKMB /\n Troponin-T:42//0.02, Ca++:7.0 mg/dL, Mg++:1.6 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n 80yo M with afib, likely off his coumadin, p/w Right MCA embolic stroke\n Neurologic: Somnolent, weak gag, follows command on right side. Left\n side weakness. Right gaze preference. Heparin gtt dc'd per neuro\n (). Neck CTA with ulcerated plaque in right proximal carotid.\n -q2hr neuro check.\n -STAT head CT if change in exam\n Cardiovascular:\n -Afib, rate controlled on no meds.\n -Autoregulating BP. Goal SBP 140-180. Pt off antihypertensive\n medications.\n -TTE () showed EF 30-40%. Hypokinesis of the inferior septum and\n akinesis of the inferior free wall and posterior wall.\n Pulmonary: on NC, had increased O2 requirement upon admit to ICU,\n ?aspiration. CXR clear. O2 sats and lung exam improved after chest PT.\n Overnight, had wheezing on exam and increased work of breathing.\n improved with nebs. Now on BIPAP without improvement. Needs\n intubation.\n -repeat AM CXR shows RLL pneumonia\n -albuterol/atrovent nebs.\n Gastrointestinal/Abdomen: NPO, Pantoprazole 40 mg IV Q12H\n Nutrition: Speech/swallow evalution - failed. Holding off on DHT,\n Speech and swallow team to revaluate today.\n Renal: monitor UOP, creat 1.1 ()\n0.9 ()\n Hematology: Hct 40 ()\n Endocrine: Started insulin gtt () given FSG in 300-400's.\n ID: WBC 9.9 () --> 15.9 () --> 12.8 Afebrile. CXR with\n infiltrate.. Vanc/Zosyn\n Lines / Tubes / Drains: PIVx3\n Wounds: N/A\n Imaging: AM CXR\n Fluids: NS AT 25 ml/hr, D5W 40mL/hr\n Consults: Neurology\n Billing Diagnosis: Embolic stroke\n Prophylaxis:\n DVT: SCD, heparin sq started TID on \n Stress ulcer: PPI IV bid. Change to H@ blocker.\n VAP bundle: N/A\n Code status:FULL\n Disposition:SICU\n Lines:\n 20 Gauge - 03:00 AM\n 18 Gauge - 04:00 AM\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2142-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506622,
"text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2142-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506545,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Patient in am became more tachypneic, labored breathing, obstructing\n airway\n O2 sats >96%\n RR >40\n Lungs wheezy\n Patient more lethargic.\n Unable to open eyes\n Perrla\n Left ue posturing le withdrawing to light touch.\n Moving right ue/le spontaneously\n Hr remains in afib 70-80\n Afibrile\n Sbp >180\n Urine output 20cc hrly\n Action:\n Iv labetalol 5mgs given x2\n Iv nicardopine gtt started to maintain sbp 140-180\n Patient intubated, cxray obtained to checked ETT placement.\n Neuro exam monitored Q1\n Iv lr bolus given\n Iv antibiotics started for aspiration.\n Abg\ns and labs rechecked in pm.\n Response:\n Patient Neuro exam changed, less responsive.\n Pupils irregular, right pupil non-reactive. Left sluggish\n No spontaneous movement noted\n Patient on no sedation.\n Neurology team made aware of patients change in condition.\n Ct scan of head obtained. Patient had large bleed.\n Family informed of poor outcome, patient made cmo\n Extubate and iv morphine gtt started for comfort.\n Plan:\n Patient made cmo, family at bedside.\n"
},
{
"category": "Nursing",
"chartdate": "2142-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506723,
"text": "80 year old male with afib, likely off his coumadin, presented with\n Right MCA embolic stroke now complicated by acute hemorrhagic infarct\n with significant herniation. Now CMO - on morphine gtt and ativan prn.\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt is unresponsive, appears comfortable, rr 10-20\n Action:\n Morphine gtt infusing at 12mg/hr. Pt turned and repositioned q 2\n hours. (hcp) at bedside visiting, emotional support offered.\n Clergy offered.\n Response:\n Unchanged, appears comfortable.\n Plan:\n Continue comfort care, morphine, and transfer to floor, (private room)\n will return this evening and likely spend the night.\n"
},
{
"category": "Nursing",
"chartdate": "2142-11-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 506724,
"text": "80 year old male with afib, likely off his coumadin, presented with\n Right MCA embolic stroke now complicated by acute hemorrhagic infarct\n with significant herniation. Now CMO - on morphine gtt and ativan prn.\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt is unresponsive, appears comfortable, rr 10-20\n Action:\n Morphine gtt infusing at 12mg/hr. Pt turned and repositioned q 2\n hours. (hcp) at bedside visiting, emotional support offered.\n Clergy offered.\n Response:\n Unchanged, appears comfortable.\n Plan:\n Continue comfort care, morphine, and transfer to floor, (private room)\n will return this evening and likely spend the night.\n"
},
{
"category": "Nutrition",
"chartdate": "2142-11-29 00:00:00.000",
"description": "Generic Note",
"row_id": 506711,
"text": "Nutrition:\n Patient screened per ICU protocol. Patient is CMO will sign off please\n reconsult if there is a change in plan of care. Page with\n questions\n"
},
{
"category": "Nursing",
"chartdate": "2142-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506721,
"text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt is unresponsive, appears comfortable, rr 10-20\n Action:\n Morphine gtt infusing at 12mg/hr. Pt turned and repositioned q 2 hours.\n (hcp) at bedside visiting, emotional support offered. Clergy\n offered.\n Response:\n Unchanged, appears comfortable.\n Plan:\n Continue comfort care, morphine, and transfer to floor, (private room)\n will return this evening and likely spend the night.\n"
},
{
"category": "Nursing",
"chartdate": "2142-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506170,
"text": "Pt woke up at 10am, had breakfast and then fell. Pt does not recall\n why he fell. Pt was then found by VNA at 1500 with left sided\n weakness, facial droop, and slurred speech. Pt was taken to where his SBP was in the 280's. Was given Labetalol\n and transferred to . CT showed decreased blood volume with\n increased transit time in a large portion of the right MCA territory\n complicated with infarct.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt is alert and oriented to self, month, and day. Pt knows that he is\n in a hospital but does not know the name of the hospital. PERL. Pt\n spontaneously moves right exts, triple flexes LLE and does not move LUE\n to nailbed pressure. Speech is garbled at times. Cough and gag are\n slightly impaired.\n Action:\n Hourly neuro assessment.\n Response:\n Plan:\n ?Repeat Head CT this morning. ?transfer to eleven. Family\n meeting to discuss prognosis. Pt needs Social worker consult, PT and\n OT consults. Continue to offer emotional support to pt and pt family\n throughout hospital stay.\n"
},
{
"category": "Nursing",
"chartdate": "2142-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506279,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Patient lethargic but rouse able to speech\n Perrla\n Patient has right gaze preference, with left field cut.\n Denies numbness/tingling.\n Right ue/le normal strength\n Left ue no movement\n Left le minimal toe wiggle.\n Speech remains garbled.\n Orientated x2 follows commands.\n Lungs diminished left > right, productive cough, thick tan colored\n secretions.\n Patient has weak cough and impaired gag.\n O2 sats 98-100%\n Bs elevated 300-400.\n Temp max 99.5\n Action:\n Neuro exam monitored Q2\n Iv heparin discontinued per neurology team\n Labs rechecked in am\n Chest pt and pulmonary toileting maintained.\n Speech and swallow evaluation done today.\n Bs covered with sliding scale, however remains elevated so insulin gtt\n started. Will monitor and titrate as per orders.\n Monitor temp and treat accordingly\n Wean o2 as tolerate\n Response:\n No change in neuro exam\n Wbc elevated 15.9, team made aware will continue to monitor.\n Patient maintaining sats >98%\n Bs\n Plan:\n Wean off o2 as tolerated\n Continue pulmonary toileting and chest pt\n Monitor neuro exam Q2\n Monitor temp and treat accordingly, may need iv antibiotics.\n If remains stable patient to transfer to nursing floor.\n Needs social worker consult and pt/ot.\n"
},
{
"category": "Nursing",
"chartdate": "2142-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506156,
"text": "Pt woke up at 10am, had breakfast and then fell. Pt does not recall\n why he fell. Pt was then found by VNA at 1500 with left sided\n weakness, facial droop, and slurred speech. Pt was taken to where his SBP was in the 280's. Was given Labetalol\n and transferred to . CT showed decreased blood volume with\n increased transit time in a large portion of the right MCA territory\n complicated with infarct.\n"
},
{
"category": "Respiratory ",
"chartdate": "2142-11-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 506514,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Gasping efforts\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Comfort measures only\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved; Comments: Possible CMO\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1300\n"
},
{
"category": "Nursing",
"chartdate": "2142-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506402,
"text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt lethargic t/o day shift per report and continues to be so\n on night shift. Arouses to loud voice\n Pt oriented to name. PERRLA 3mm. Pt not opening eyes to\n command or stimulation\n RUE w/ normal strength/RLE lifts and falls back\n LUE no movement except withdrawal to pain/LLE moves on bed\n slightly\n Speech garbled. Weak cough/impaired gag. Speech and swallow\n will re-eval when more alert\n LS diminished LUL/LLL/RLL. Clear RUL. O2 sats stable on 3L\n NC. Positive aspiration of emesis night previous.\n Insulin gtt infusing w/ BS now in the 70-90\n Foley to gravity w/ borderline output in 20s. Dark amber in\n appearance\n Afebrile. WBC 15.9 (9). IVABX on hold until pt spikes temp.\n Tele in a-fib, rate controlled w/ occasional PVCs\n Action:\n SICU contact at beginning of shift to ensure pt\n lethargy/neuro exam same as day shift. No change per SICU\n Neuro Q2hrs. Goal SBP 140-180. Labetalol 5mg IV x2 for SBP\n >180\n Chest PT/Pulm toilet/ NT suction PRN for minimal tan\n secretions\n Insulin gtt stopped d/t BS 80-90\ns. Sliding scale now\n ordered Q4hrs\n NS 250cc bolus for low u/o. IVF rate increased and now\n running NS @100cc/hr\n Response:\n Pt w/ increase difficulty to engage/arouse for Neuro exam @\n 0400. No other change in Neuro exam. Neuromed at BS to eval no imaging\n ordered but will be by to round again to further assess need for\n imaging\n Original HCT dropped from 40 to 30. RN redrew and stable at\n 38.7 and coags wnl\n Electrolytes repleted per order. KCL/Mg/Ca\n Urine output didn\nt respond to original 250cc bolus,\n requiring another 500cc NS bolus and then another LR 500cc d/t u/o\n continued to be poor. As low as 3cc/hr\n Right FA #18 infiltrated w/ 500cc NS bolus. PIV removed,\n warm pack applied and arm elevated\n LS w/ insp/exp wheezing bilaterally. O2 sats stable.\n Albuterol/Atrovent nebs. CXR pending\n Plan:\n Pulm toilet and wean O2 as tolerated\n Cont Neuro q2hrs and Goal SBP 140-180\n Montior for spike in temp and need for IVABX d/t previous\n aspiration\n Speech and swallow to f/u\n Neurology to update HCP niece \n Needs SW and PT/OT consult\n Neuromed to discuss w/ RN whether\n"
},
{
"category": "Echo",
"chartdate": "2142-11-27 00:00:00.000",
"description": "Report",
"row_id": 88101,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Cerebrovascular event/TIA. Hypertension\nHeight: (in) 72\nWeight (lb): 158\nBSA (m2): 1.93 m2\nBP (mm Hg): 141/63\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 09:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Moderately\ndepressed LVEF. No resting LVOT gradient. No VSD.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; mid inferoseptal - hypo; basal inferior - akinetic; mid\ninferior - akinetic; basal inferolateral - akinetic; mid inferolateral -\nakinetic;\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. RV function\ndepressed.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (?#). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Thickened/fibrotic\ntricuspid valve supporting structures. No TS. Moderate [2+] TR. Eccentric TR\njet. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is dilated. The right atrium is moderately dilated. There is\nmild symmetric left ventricular hypertrophy. The left ventricular cavity size\nis normal. Overall left ventricular systolic function is moderately depressed\n(LVEF= 30-40 %) secondary to hypokinesis of the inferior septum and akinesis\nof the inferior free wall and posterior wall. The basal inferior and posterior\nwalls are thin and fibrotic. There is no ventricular septal defect. Right\nventricular chamber size is normal. with depressed free wall contractility.\nThe aortic valve leaflets are mildly thickened (?#). There is no aortic valve\nstenosis. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. Mild (1+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened. The\nsupporting structures of the tricuspid valve are thickened/fibrotic. Moderate\n[2+] tricuspid regurgitation is seen. The tricuspid regurgitation jet is\neccentric and may be underestimated. There is moderate pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2142-11-26 00:00:00.000",
"description": "Report",
"row_id": 233688,
"text": "Probable atrial fibrillation with baseline artifact and ventricular premature\ndepolarizations. Anteroseptal myocardial infarction. Diffuse non-diagnostic\nrepolarization abnormalities. No previous tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-11-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1112451,
"text": " 10:52 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p intubation\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p R MCA stroke and aspiration pneumonia\n REASON FOR THIS EXAMINATION:\n s/p intubation\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with right MCA stroke and\n aspiration pneumonia.\n\n AP chest radiograph was reviewed in comparison to obtained\n at 0401.\n\n The patient was intubated in the meantime interval with the ET tube tip being\n approximately 6.5 cm above the carina. The NG tube tip is in the stomach.\n There is interval improvement in the right basal opacity consistent with rapid\n improvement of aspiration. Left basal opacity cannot be excluded and might\n represent similar origin. There is no evidence of failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-11-26 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1112217,
"text": " 6:41 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n CT BRAIN PERFUSION\n Reason: Eval acute process\n Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with L sided weakness, slurred speech\n REASON FOR THIS EXAMINATION:\n Eval acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc MON 7:28 PM\n C- head = dense right MCA and hypodensity of a large portion of the right MCA\n territory c/w acute infarct. No ICH.\n C+ head = Right MCA truncation of flow at level of M2, with decreased flow in\n MCA distribution.\n Perfusion = Decreased blood flow and blood volume with increased transit time\n in a large portion of the right MCA territory c/w infarct.\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: CT angiogram of the head with perfusion.\n\n HISTORY: 80-year-old male presents with left-sided weakness and slurred\n speech.\n\n COMPARISON: None.\n\n TECHNIQUE: Initial non-contrast images through the brain were obtained\n followed by angiographic phase images through the head and neck. Perfusion\n data was acquired.\n\n FINDINGS: Initial non-contrast images through the brain demonstrate severe\n global atrophy with bihemispheric hypodensities reflective of small vessel\n disease. There is more well-defined cortical low attenuation likely relating\n to multiple old embolic infarcts, with a region of intermediate low\n attenuation which could represent subacute infarct within the right MCA\n distibution. There is hyperdensity within the right M1 segment (3:17). There\n is a well-defined old embolic infarct within the left occipital lobe. There\n is high-density within the proximal basilar artery at the skull base, part of\n which may relate to beam hardening artifact. There is under pneumatization of\n the left mastoid associated with opacification of the pneumatized air cells.\n There is debris within the external auditory canals bilaterally. There is\n atherosclerosis of the cavernous segments of the internal carotid arteries\n bilaterally.\n\n CTA: There is moderate atherosclerosis involving the normal configuration\n three-vessel aortic arch. There is just over 60% stenosis of the proximal\n left common carotid artery. There is moderate atherosclerotic disease\n involving both common carotid arteries. There is irregularity at the carotid\n bifurcations with extensive calcification, left greater than right with a more\n significant component of the soft plaque on the right side. There is what\n likely represents a small ulcerative plaque involving the proximal aspect of\n (Over)\n\n 6:41 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n CT BRAIN PERFUSION\n Reason: Eval acute process\n Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the left external carotid artery. There is no focal abnormality of the\n cervical internal carotid arteries. There is moderate atherosclerosis\n involving the cavernous segments of the internal carotid arteries bilaterally.\n There is an abrupt cutoff of the proximal M1 segment with minimal flow within\n the right distal MCA branches. Normal flow is present within the left middle\n cerebral artery, as well as within the anterior cerebral arteries.\n\n The origin of the right vertebral artery is patent, there is moderate\n atherosclerosis at the origin of the left vertebral artery with additional\n proximal tortuosity of the vessel. There is right vertebral artery dominance\n and both vessels contribute to formation of a normal-appearing basilar artery.\n\n Limited views through the lung apices demonstrate changes of centrilobular\n emphysema. There are extensive degenerative changes throughout the cervical\n spine with multilevel spondylosis and facet arthropathy resulting in\n multilevel foraminal and canal narrowing, incompletely evaluated. There is an\n 8 mm nodular soft tissue density within the periglottic fat on the left of\n unclear etiology. The true and false cords are symmetric. There is\n nonspecific nodular hypertrophy of the lingual tonsils, also extending to the\n glossoepiglottic fold and along the anterior surface of the epiglottis. There\n is mild ethmoidal sinus disease.\n\n PERFUSION: There is markedly elevated mean transit time associated with\n diminished blood volume throughout virtually the entire right middle cerebral\n artery distribution.\n\n IMPRESSION:\n 1. Likely embolic occlusion of the M1 segment of the right middle cerebral\n artery with perfusion findings of infarct involving virtually the entire right\n MCA distribution.\n\n 2. Just over 60% stenosis of the proximal left common carotid artery.\n\n 3. Moderate atherosclerotic disease at the carotid bifurcations bilaterally,\n with likely an ulcerated plaque involving the proximal right external carotid\n artery and extensive soft plaque within the carotid bulb on the right.\n\n 4. 8 mm nodular soft tissue density within the left paraglottic fat may be a\n lymph node but is of unclear etiology and should be correlated with clinical\n findings and/or direct visualization. Associated mild thickening of the\n lingual tonsils, glossoepiglottic fold and anterior surface of the epiglottis.\n\n 5. Extensive degenerative changes of the cervical spine.\n\n 6. Severe atrophy and evidence of old cortical embolic infarcts. Extensive\n (Over)\n\n 6:41 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n CT BRAIN PERFUSION\n Reason: Eval acute process\n Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n chronic microvascular ischemic change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-11-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1112466,
"text": " 12:46 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: herniation edema of R side of brain\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with R MCA< now, non reactive left pupil\n REASON FOR THIS EXAMINATION:\n herniation edema of R side of brain\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: WED 2:07 PM\n Acute infarct involving near complete R MCA territory with hemorrhagic\n transformation of the infarct.\n Transependymal extension of the hemorrhage into the right lateral ventricle,\n third ventricle and with layering in bilateral occipital horns.\n Marked rightward subfalcine herniation measuring 18mm with less marked uncal\n herniation.\n Dilation of the left lateral ventricle.\n d/w Dr. at 14:05, .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with right middle cerebral artery territory\n infarction. Now with nonreactive left pupil. Evaluate for herniation or\n edema of the right side of the brain.\n\n COMPARISON: CT of the head without contrast .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n FINDINGS: An extensive low-attenuation process involving the entire right\n middle cerebral artery territory is noted, consistent with evolving right MCA\n territory acute infarct. There is marked hemorrhagic transformation of this\n process, predominantly in the deep matter with a marked shift of the\n midline structures towards the left, measuring 18 mm. The blood is noted to\n dissect into the right ventricular system and layers in bilateral occipital\n horns. The right lateral ventricle is completely effaced. There is\n dilatation of the left ventricle. The third ventricle is markedly displaced,\n effaced and is filled with blood.\n\n There is marked leftward subfalcine herniation and less marked leftward uncal\n herniation with displacement of the midbrain. There is mass effect and\n widening of the ipsilateral ambient cistern. There is no evidence of downward\n transtentorial or tonsillar herniation. There is no evidence of lytic or\n sclerotic osseous lesions.\n\n IMPRESSION:\n\n 1. Evolving acute and virtual-complete right middle cerebral artery territory\n infarction with hemorrhagic transformation and extension of the hemorrhage\n into the right lateral and third ventricles, layering in bilateral occipital\n horns.\n (Over)\n\n 12:46 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: herniation edema of R side of brain\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Significant leftward shift of midline structures, with marked subfalcine\n herniation and less marked uncal herniation.\n\n COMMENT: A wet read was also provided on at 14:07, and Dr.\n was notified of the results at 14:05 on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-11-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1112258,
"text": " 12:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? aspiration\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with cardioembolic stroke to R MCA with vomiting\n REASON FOR THIS EXAMINATION:\n ? aspiration\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Cardioembolic stroke, question of aspiration.\n\n COMPARISON: No comparison available at the time of dictation.\n\n FINDINGS: The lung volumes are normal. No pleural effusions, no focal\n parenchymal opacities suggesting pneumonia. Normal size of the cardiac\n silhouette, slight tortuosity of the thoracic aorta. Normal hilar and\n mediastinal contours.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-11-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1112398,
"text": " 3:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with s/p embolic stroke, difficulty clearing secretions.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with difficult to clearing\n secretions and embolic stroke.\n\n Portable AP chest radiograph was compared to .\n\n The newly developed right basal opacity that giving the time course and its\n appearance is consistent with aspiration. There is minimal vascular perihilar\n engorgement, but no overt edema. There is no appreciable pleural effusion and\n there is no pneumothorax.\n\n Findings were conveyed to Dr. over the phone by Dr; at the\n time of dictation.\n\n"
}
] |
41,359 | 100,201 | 64yo male with acquired -'s disease associated with MGUS, recurrent GI bleeds, diastolic HF, pulmonary HTN, severe COPD on 2L, and OSA (refuses to use BiPAP), p/w acute on chronic hypercarbic/hypoxemic resp failure likely untreated severe OSA, PH, COPD exacerbation, and chronic CHF. He was initially admitted to the ICU, but was not intubated. #Acute on chronic respiratory failuredue to OSA and COPD: -initially felt to be likely CHF and COPD exacerbation on underlying severe untreated OSA/OHS. There was no obvious pneumonia on CXR and pt remained afebrile w/o leukocytosis. His mental status/somnolence and hypercarbia improved after BiPAP set at 18/10 4L O2. Suggest he use BiPAP overnight and with naps. -He will need a retitration sleep study as an outpt to further optimize and should have close follow-up with his sleep/pulm doctor (we have emailed Dr. re this issue). He was transferred to the medical floor where he did very well. He was sufficiently concerned and indicated that he would use BiPAP at home as instructed. #CKD - his creatinine did rise from 1.2 on admission to 1.7 with diuresis in the ICU. Looking back at his previous labs, his creatinine has fluctuated up in this range in the past (was 1.9 in ), and no other cause for renal failure was identified. Potentially nephrotoxic meds were held, | Incomplete right bundle-branch block pattern unchanged fromprevious tracings. Compared to the previous tracingof there is no change.TRACING #1 Incomplete right bundle-branch block pattern unchanged sinceat least . Otherwise, normal tracing. No change compared toprevious tracing. RSR' pattern in lead V1, normal variant. The mediastinal contours are stable. The right lung is grossly clear. Pulmonary vascularity is not engorged. Sinus rhythm. Sinus rhythm. Sinus rhythm. No large pleural effusion or pneumothorax is present. Compared to the previous tracing of there is nochange.TRACING #2 IMPRESSION: Left basilar opacity, which could reflect atelectasis though infection cannot be fully excluded. COMPARISON: . Opacity within the left lung base may reflect atelectasis but infection cannot be completely excluded. PA AND LATERAL VIEWS OF THE CHEST: The cardiac silhouette is mildly enlarged. Degenerative changes in the thoracic spine are present. | 4 | [
{
"category": "Radiology",
"chartdate": "2195-10-09 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1207567,
"text": " 2:29 PM\n CHEST (PA & LAT) Clip # \n Reason: eval chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with shortness of breath\n REASON FOR THIS EXAMINATION:\n eval chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath.\n\n COMPARISON: .\n\n PA AND LATERAL VIEWS OF THE CHEST: The cardiac silhouette is mildly enlarged.\n The mediastinal contours are stable. Opacity within the left lung base may\n reflect atelectasis but infection cannot be completely excluded. Pulmonary\n vascularity is not engorged. The right lung is grossly clear. No large\n pleural effusion or pneumothorax is present. Degenerative changes in the\n thoracic spine are present.\n\n IMPRESSION: Left basilar opacity, which could reflect atelectasis though\n infection cannot be fully excluded.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2195-10-09 00:00:00.000",
"description": "Report",
"row_id": 287063,
"text": "Sinus rhythm. Incomplete right bundle-branch block pattern unchanged from\nprevious tracings. Compared to the previous tracing of there is no\nchange.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2195-10-09 00:00:00.000",
"description": "Report",
"row_id": 287064,
"text": "Sinus rhythm. Incomplete right bundle-branch block pattern unchanged since\nat least . Otherwise, normal tracing. Compared to the previous tracing\nof there is no change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2195-10-04 00:00:00.000",
"description": "Report",
"row_id": 287299,
"text": "Sinus rhythm. RSR' pattern in lead V1, normal variant. No change compared to\nprevious tracing.\n\n"
}
] |
3,647 | 180,534 | The patient was admitted to the ICU for observation and hemodynamic stabilization. Over the past two days, her blood pressure has normalized and she is improving clinically. On transfer, pt notes persistence of nausea with little vomit (non-bloody, non-bilious) but no pain, shortness of breath, cough, diarrhea, fever or chills. | bs hypoactive.gu: nephrostomy tube in place and draining yellow to brown apporx 1200 cc since admit to icu. pt remains afebrile with tmax 98.1po.gi/gu: abd soft, nt, +bs, taking small amts water, boost with 1 incident of vomiting relieved with iv ativan. Enhancement of the wall of the left ureter may be a result of (Over) 1:54 PM MRI PELVIS W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # MR RECONSTRUCTION IMAGING Reason: see below Admitting Diagnosis: PYELONEPHRITIS Contrast: MAGNEVIST Amt: 16CC FINAL REPORT (Cont) manipulation due to placement of the stent, or less likely, secondary to inflammation. TECHNIQUE: Multiplanar T1- and T2-weighted MRI of the pelvis was performed both prior to and following uneventful intravenous administration of gadolinium. one episode of vomiting x100cc relieved with iv ativan.neuro: a&ox3, mae, able to reposition self in bed.cv: hr ranging 89-99 sr with no ectopy noted. presently being hydrated with d5w at 100cc/hr (receiving 1st out of 2nd bag ordered).skin: cd&i. pt hydrated for low urine output for a total of 1500 cc nsgyn: pt has ovarian cyst 6x5 cm thought to be pressing on ureter causing hydronephrosis.labs:mag down this pm to 1.7 and will need to be repleted. CT urogram demonstrating acute left pyelonephritis with moderate left hydronephrosis and hydroureter. medicated with reglan. The Kumpe catheter and sheath were then removed, and an 8 French, 24-cm nephroureteric stent was advanced over the existing wire into the urinary bladder. pr compazine was given for + nausea as well with some effect. nephrostomy tube patent with dsg reinforced as sl peeling off. (Over) 7:42 AM PERC NEPHROSTO Clip # Reason: Needs perc. PR compazine given at 1530 and no further vomiting.gu: intake 3500+ cc and 1700cc out since midnight and ivs to kvo at 1200. no void, no str cath, urine is more yellowaccess: lost lt anticub iv. IMPRESSION: 1) Stent is demonstrated throughout the length of the distal left ureter which is not dilated. Pt started menses while in ED.Plan: transfer to medical floor in am if stable. cxr obtained at 1645 for low sat.gi: pt vomiting at lease q 1hr stomach contents or bile. nephrostomy tube for drainage Contrast: CONRAY Amt: 15 ********************************* CPT Codes ******************************** * INTRO CATH OR STENT INTO URETH INTRO CATH OR STENT TO URETHER * * UD GUID FOR NEEDLE PLACMENT CATHETER, DRAINAGE * * C1894 INT.SHTH NOT/GUID,EP,NONLASER * **************************************************************************** MEDICAL CONDITION: 25 year old woman with L flank pain, evidence of pyelonephritis on CT scan, obstruction. Sinus tachycardiaLow precordial lead voltages - is nonspecific and probable within normal limitsNo previous tracing for comparison IMPRESSION: No residual left hydronephrosis post-nephrostomy tube placement. She was medicated with Ambien at 0100 for sleep.Cardio: Normal sinus rhythm, SBP greater than 100 this shift. The inner stylet was removed and an Accustick wire was passed into the renal collecting system. Prominence of the cardiac silhouette is noted, but again may be related to submaximum inspiration. 7:42 AM PERC NEPHROSTO Clip # Reason: Needs perc. orders need to be written.ID: no exact organism identified yet but afeb on current antibxlabs: this am k 3.6 but hemolized will attempt to draw lytes this eve but pt tolerated oj which is high in potassium.plan: poss call out if on sc insulin. There is an exophytic cyst in relationship to the left ovary measuring 5.5 cm which has an adjacent smaller 17-mm non-enhancing hemorrhagic cyst. There is mild upper lobe venoud diversion consistant with fluid overload. went for abd MRI but could not tolerate due to nausea, and will poss get in am.plan: reeval need for iv fluids, may need a better iv liv=ne for hihg iv vol, manage nausea and monitor o2 sats neuro: pt is sitting up ambulated x1 in and a bit weak, a&o x3card: 90-110 hr no ectopy bp >110 sys most of shift. using rt arm only and needs another iv.ENDO: insulin gtt decreased to 5 units /hr when glu down to 90 and the stale glu 90-135 until 1430 to 74 and stopped insulin. She has a left nephrostomy tube with 200 cc emptied upon admission to ICU. no drainage.lines: r and l upper forearm pivs #20g patent.plan: continue to monitor bld sugar q1hr while on insulin gtt and hydrate pt with 2l total of d5w at 100cc/hr. | 13 | [
{
"category": "Nursing/other",
"chartdate": "2116-12-06 00:00:00.000",
"description": "Report",
"row_id": 1309072,
"text": "micu/sicu nsg note: 19:00-7:00\nevents: pt restarted on iv insulin gtt to better control bld sugars of 200s. glargine 17 units given at bedtime (this is pt's normal dose at bedtime and ok to give/won't bottom pt's bld sugar out md consulting). k repleted with k phos as ordered. one episode of vomiting x100cc relieved with iv ativan.\n\nneuro: a&ox3, mae, able to reposition self in bed.\n\ncv: hr ranging 89-99 sr with no ectopy noted. bp ranging 135-157/77-96. +pp, +csm.\n\nresp: lungs cta in upper lung fields. diminished at bases. sp02 ranging 92-97% on 5lnc. desated down to 89% x1 when found nc off pt as pt sleeping-02 went right up to mid 90s after pt's 02 replaced and pt woke up. pt denies sob. c/o cold like symptoms with + nonproductive cough, sore throat. md aware. pt remains afebrile with tmax 98.1po.\n\ngi/gu: abd soft, nt, +bs, taking small amts water, boost with 1 incident of vomiting relieved with iv ativan. pr compazine was given for + nausea as well with some effect. voiding 850cc clear yellow urine via nephrostomy tube. presently being hydrated with d5w at 100cc/hr (receiving 1st out of 2nd bag ordered).\n\nskin: cd&i. nephrostomy tube patent with dsg reinforced as sl peeling off. no drainage.\n\nlines: r and l upper forearm pivs #20g patent.\n\nplan: continue to monitor bld sugar q1hr while on insulin gtt and hydrate pt with 2l total of d5w at 100cc/hr. continue to encourage po intake as tolerated. monitor u.o. from nephrostomy tube. pt awaiting mri to look at pt's ovarian cyst that is pushing on her ureter causing hydronephrosis per team. continue to monitor temp, continue ivabx, monitor for flu like symptoms-may need to r/o flu.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-12-05 00:00:00.000",
"description": "Report",
"row_id": 1309070,
"text": "Neuro: Patient was given Ativan during nite to relieve her constant gagging after many attempts were made with anti-emesis meds. She was able to sleep soundly for several hours. Ambien did not assist her with sleeping.\n\nCardio: EKG was done last nite after patient complained for chest tightness that went away when sitting up. The chest pain subsided after she stopped gagging. Afebrile,NS gtt changed to D5NS at 0100. RHI gtt continues but the finger sticks have remained in the 170's after the D5NS started at 300 q hr.\n\nPulm: Patients sats dropped during the night when she removed her oxygen. Her lungs now sound tubular and dim in both bases. She is now on 5 L NS for sats greater than 93.\n\nGI: NPO due to the ongoing gagging and minimally expectored fluid. Sometimes it is clear with minimal green noted and occasionally bright yellow. Amounts vary between approximately 25 cc to 100 cc each time.\nNo BM this shift.\n\nGU: Nephrostomy tube intact and urine now yellow and cloudy with approximately 100 cc out q hour. She attempted to urine using the bedside commode in room, but was unable to void anything.\n\nSkin intact and pink. Plan: continue to monitor in ICU\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-12-05 00:00:00.000",
"description": "Report",
"row_id": 1309071,
"text": "neuro: pt is sitting up ambulated x1 in and a bit weak, a&o x3\n\ncard: 90-110 hr no ectopy bp >110 sys most of shift. no c/o chest tightness\n\nresp: desats more when lying down to 85 with out o2 and 93 lying flat with 5l nc o2. sat 98% on 5l sitting up. no sputum produced other than when vomiting and unable to get spec; need to use incent spirometry\n\ngi: no bm hypoactive snds, po intake needs much encouragement and judgement on nureses part. pt held down boost, toast, crqackers, soup and juice. compazine iv over 30 min did great in am to control nausea and vomited x2 since lunch only 100 cc. PR compazine given at 1530 and no further vomiting.\n\ngu: intake 3500+ cc and 1700cc out since midnight and ivs to kvo at 1200. no void, no str cath, urine is more yellow\n\naccess: lost lt anticub iv. using rt arm only and needs another iv.\n\nENDO: insulin gtt decreased to 5 units /hr when glu down to 90 and the stale glu 90-135 until 1430 to 74 and stopped insulin. pt took 240 cc oj and glucose is now on rise. plan to watch sugers for 1-2hr and restart on short acting insulin. orders need to be written.\n\nID: no exact organism identified yet but afeb on current antibx\n\nlabs: this am k 3.6 but hemolized will attempt to draw lytes this eve but pt tolerated oj which is high in potassium.\n\nplan: poss call out if on sc insulin. needs iv and lytes, oob to chair to improve resp status.\n\np\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-12-04 00:00:00.000",
"description": "Report",
"row_id": 1309068,
"text": "Patient admitted from ED on at 2330 for ICU monitoring overnite and then transfer to medical floor in AM. Patient was diagnosed with pylonephrosis after coming to ER on with flank pain and chills and fever. A nephrostomy tube was placed on the left side on at 1030 am.\n\nNeuro: Patient is a very sweet, calm and cooperative young woman of 25 years of age. She was complaining of nausea and exhaustion. She was medicated with Ambien at 0100 for sleep.\n\nCardio: Normal sinus rhythm, SBP greater than 100 this shift. Afebrile at 98.6 PO. PEERL. No ectopy noted. Pt is IDDM for over 20 years. Her finger stick at 2350 was 133 and required no RHI. She did receive 17 units of MD order.\n\nPulm: Room air, sats >96%, respirations 16-20, lungs clear.\n\nGI: Sipping diet gingerale, medicated for nausea, emesis was clear mucous with scant green noted. Positive bowel signs and BM times 2 this shift. Unable to test stool due to menses discolored stool.\n\nGU: Patient feels that she has to urinate but when placed on bedside commode, she could not void. She has a left nephrostomy tube with 200 cc emptied upon admission to ICU. It was bloody. During the shift it cleared to amber color. Urine sample was sent to lab.\n\nLabs: Blood cultures are positive for gram negative rods.\n\nSkin Intact, no breakdown. Pt started menses while in ED.\n\nPlan: transfer to medical floor in am if stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-12-04 00:00:00.000",
"description": "Report",
"row_id": 1309069,
"text": "pt is not called out as of 1600\nNuero: pt a7o x3 MAE OOB to w/c for tests off floor. mentating with out problems\n\ncard: tachy with no ectopy\n\nresp: pt recieved on ra but when o2 sat checked at 1400 sat was in low 80's. o2 5l nc applied to raise =sat to 96%. no c/o sob or pain and HO made aware. cxr obtained at 1645 for low sat.\n\ngi: pt vomiting at lease q 1hr stomach contents or bile. medicated with reglan. anzemet, and compazine of which anzemet was most helpful. dose increased but nausea continues. pt had lg soft formed bm at 0830 and none since. bs hypoactive.\n\ngu: nephrostomy tube in place and draining yellow to brown apporx 1200 cc since admit to icu. foley placed for pos bladder retention as no void but no output via foley thus d/ced. nephrostomy tube ends in pt bladder and not flushed. bun and creat elevated but pt basseline not known. pt hydrated for low urine output for a total of 1500 cc ns\n\ngyn: pt has ovarian cyst 6x5 cm thought to be pressing on ureter causing hydronephrosis.\n\nlabs:mag down this pm to 1.7 and will need to be repleted. see labs\n\nid: gram pos rods in 4 of 4 cultures from . sent one set for bld culture today and was difficult stick. on 2 antibx. afebrile all shift\n\nendo: pt has not been able to hold down much fluid of food d/t nausea.\n fingersticks are up and was covered with humalog insulin x2 but then started regular insulin gtt and currently gtt at 2 units /hr for most recent glu 207 at 1900. not clear if anion gap d/t elevated glu or d/t acute renal failure.\n\ntests: pt had renal ultsnd this am. went for abd MRI but could not tolerate due to nausea, and will poss get in am.\n\nplan: reeval need for iv fluids, may need a better iv liv=ne for hihg iv vol, manage nausea and monitor o2 sats\n"
},
{
"category": "Radiology",
"chartdate": "2116-12-07 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 852521,
"text": " 8:06 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for interval changes\n Admitting Diagnosis: PYELONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with pyelonephritis, DKA, bacteremia who has worsening\n pulmonary exam and CXR findings\n REASON FOR THIS EXAMINATION:\n evaluate for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory distress.\n\n CHEST X-RAY: Comparison is made to study from one day earlier. The study is\n limited by low lung volumes. Prominence of the cardiac silhouette is noted,\n but again may be related to submaximum inspiration.\n\n There are small bilateral pleural effusions. Patchy increased density in both\n lung bases may reflect associated atelectasis, although early/limited\n pneumonia cannot be excluded.\n\n On the lateral view, there is a broad band-like density which projects over\n the mid chest anteriorly, again most suggestive of subsegmental atelectasis.\n There is no evidence of CHF.\n\n IMPRESSION: Small bilateral effusions and likely bibasilar atelectasis. Note\n that pneumonia cannot be entirely excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-12-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 852335,
"text": " 5:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate?\n Admitting Diagnosis: PYELONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with pyelonephritis, DKA now with acute desaturation\n REASON FOR THIS EXAMINATION:\n infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest radiograph.\n\n INDICATION: A 25-year-old woman with pyelonephrosis and DKA. Now acute\n desaturation.\n\n TECHNIQUE: Portable erect chest radiograph was performed.\n\n COMPARISON: This study is compared to examination from .\n Compared to that examination, there has now been a dramatic interval decline,\n even allowing for suboptimal technique. There is now evidence of extensive\n airspace consolidation within both lung fields. There is in addition,\n obliteration of the right hemidiaphragm consistent with an extensive right\n basilar pathology. In addition, silhouetting of the left hemidiaphragm is\n also seen. No evidence of pneumothorax. Some ill-defined wires are again\n identified in the patient's neck, of undetermined significance, but are\n largely unchanged from previous.\n\n There is mild upper lobe venoud diversion consistant with fluid overload.\n CONCLUSION:\n\n Dramatic interval decline, with development of bilateral airspace\n consolidation, atelectasis and effusons bibasilarly. The visualized portions\n of the central airways appear patent.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-12-06 00:00:00.000",
"description": "MRI PELVIS W/O & W/CONTRAST",
"row_id": 852479,
"text": " 1:54 PM\n MRI PELVIS W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \n MR RECONSTRUCTION IMAGING\n Reason: see below\n Admitting Diagnosis: PYELONEPHRITIS\n Contrast: MAGNEVIST Amt: 16CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with pyleo and ureter obstruction. L ovarian mass on U/S,\n please characterize ovarian mass and evaluate ureteral system.\n REASON FOR THIS EXAMINATION:\n see below\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE PELVIS.\n\n HISTORY: History of left flank pain, fever, nausea and vomiting. CT urogram\n demonstrating acute left pyelonephritis with moderate left hydronephrosis and\n hydroureter. Pelvic ultrasound demonstrating a left ovarian cyst with follow-\n up recommended in weeks. Please characterize ovarian mass and evaluate\n ureteral system.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted MRI of the pelvis was performed\n both prior to and following uneventful intravenous administration of\n gadolinium.\n\n COMPARATIVE STUDIES: CT urogram from and pelvic ultrasound\n from .\n\n FINDINGS:\n\n The distal third of the left ureter demonstrates the presence of a stent and\n no evidence of dilatation currently. There is enhancement of the ureteral\n wall. This is likely due to manipulation of the ureter during placement of\n the stent. Less likely, this can be a result of inflammatory change. The\n ureter can be traced all the way up to the urinary bladder without encasement\n or mass lesions in its path.\n\n There is an exophytic cyst in relationship to the left ovary measuring 5.5 cm\n which has an adjacent smaller 17-mm non-enhancing hemorrhagic cyst. The rest\n of the left ovary and the right ovary are normal in appearance. There is a\n small amount of free fluid in the pelvis.\n\n The uterus is normal in size and in signal characteristics. There is no\n pelvic lymphadenopathy.\n\n Multiplanar reconstructions on the workstation were helpful in delineating the\n above findings.\n\n IMPRESSION:\n\n 1) Stent is demonstrated throughout the length of the distal left ureter which\n is not dilated. Enhancement of the wall of the left ureter may be a result of\n (Over)\n\n 1:54 PM\n MRI PELVIS W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \n MR RECONSTRUCTION IMAGING\n Reason: see below\n Admitting Diagnosis: PYELONEPHRITIS\n Contrast: MAGNEVIST Amt: 16CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n manipulation due to placement of the stent, or less likely, secondary to\n inflammation. There is no encasement or mass involving the course of the left\n ureter.\n\n 2) Large exophytic cyst related to the left ovary with a smaller adjacent non-\n enhancing hemorrhagic cyst. Follow-up ultrasound in six weeks is suggested,\n as also suggested on the ultrasound, to document disappearance of this cyst.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-12-04 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 852268,
"text": " 10:02 AM\n RENAL U.S. Clip # \n Reason: please assess kidney and bladder and also liver(area of hypo\n Admitting Diagnosis: PYELONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with left hydronephrosis s/p nephrostomy tube\n REASON FOR THIS EXAMINATION:\n please assess kidney and bladder and also liver(area of hypodensity on CT)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for hydronephrosis post-nephrostomy tube placement.\n\n RENAL ULTRASOUND: The right kidney is normal without hydronephrosis, stones,\n or mass. The right kidney measures 14 cm.\n\n A stent is in place within the left kidney. There is minimal fullness of the\n left renal pelvis. There is no hydronephrosis. The left kidney measures 14.3\n cm. Prominent columns of Bertin are noted. The urinary bladder appears\n unremarkable.\n\n IMPRESSION:\n No residual left hydronephrosis post-nephrostomy tube placement.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-12-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 852464,
"text": " 10:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for changes in infiltrate\n Admitting Diagnosis: PYELONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with pyelonephritis, DKA now with acute desaturation\n\n REASON FOR THIS EXAMINATION:\n Evaluate for changes in infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 25-year-old with pyelonephritis and diabetic ketoacidosis, no\n acute desaturation.\n\n Comparison is made to the prior study of two days earlier. Bilateral pleural\n effusion and compression partial atelectasis of the lower lobes and bilateral\n pulmonary vascular congestion are again noted.the Right pleural effusion is\n slightly larger at this time.\n\n IMPRESSION:\n\n Some worsening in the right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-12-03 00:00:00.000",
"description": "INTRO CATH OR STENT INTO URETHER",
"row_id": 852111,
"text": " 7:42 AM\n PERC NEPHROSTO Clip # \n Reason: Needs perc. nephrostomy tube for drainage\n Contrast: CONRAY Amt: 15\n ********************************* CPT Codes ********************************\n * INTRO CATH OR STENT INTO URETH INTRO CATH OR STENT TO URETHER *\n * UD GUID FOR NEEDLE PLACMENT CATHETER, DRAINAGE *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with L flank pain, evidence of pyelonephritis on CT scan,\n obstruction.\n REASON FOR THIS EXAMINATION:\n Needs perc. nephrostomy tube for drainage\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 25-year-old female with left flank pain, fever, moderate\n hydronephrosis on CT scan.\n\n PROCEDURE/FINDINGS:\n\n The procedure was performed by Drs. & , with Dr.\n , the attending radiologist, present and supervising. After obtaining\n written informed consent, the patient was placed supine on the angiographic\n table. The left flank was prepped and draped in standard sterile fashion. A\n preprocedure timeout was performed. Through an anesthtized skin approach and\n with ultrasound guidance, a 21-gauge spinal needle was inserted into the renal\n pelvis. Opacification of the renal system was performed with contrast and\n air. Then, posterior local calix was selected, again with a 21-gauge spinal\n needle. The inner stylet was removed and an Accustick wire was passed into\n the renal collecting system. The needle was then exchanged for an Accustick\n system, which was advanced over the wire. The Accustick outer dilator was\n then exchanged for a 6 French angiographic sheath. The inner dilator of the\n sheath was removed. A Kumpe catheter was advanced through the sheath into the\n renal collecting system and the wire directed into the ureter and into the\n urinary bladder. The Kumpe catheter and sheath were then removed, and an 8\n French, 24-cm nephroureteric stent was advanced over the existing wire into\n the urinary bladder. The inner metallic stiffener was removed. The pigtail\n was then formed within the bladder and a second proximal in the renal pelvis.\n The catheter was secured to the skin using a Stat-lock. Final contrast\n injection demonstrated adequate placement of the stent. The stent was\n connected to external bag drainage for 24 hours, secondary to blood clot seen\n within the renal pelvis.\n\n COMPLICATIONS: None.\n\n IMPRESSION:\n 1) Successful placement of 24-cm 8 French nephroureteral stent connected to\n external bag drainage.\n\n 2) Culture & sensitivity urine sample sent.\n (Over)\n\n 7:42 AM\n PERC NEPHROSTO Clip # \n Reason: Needs perc. nephrostomy tube for drainage\n Contrast: CONRAY Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "ECG",
"chartdate": "2116-12-06 00:00:00.000",
"description": "Report",
"row_id": 190080,
"text": "Sinus rhythm\nLow precordial lead voltages is nonspecific and probable within normal limits\nSince previous tracing of , sinus tachycardia absent\n\n"
},
{
"category": "ECG",
"chartdate": "2116-12-04 00:00:00.000",
"description": "Report",
"row_id": 190081,
"text": "Sinus tachycardia\nLow precordial lead voltages - is nonspecific and probable within normal limits\nNo previous tracing for comparison\n\n"
}
] |
23,577 | 102,904 | Overnight: Renal came to see patient and felt K was not the precipitant for these rhythyms. EP interogated his paced and found several episodes of VT and VF, many of the VT episodes were below his lower rate threshold to shock (> 188 bpm). His device was reprogrammed to treat VT at rate > 170 and record rates >150. There was no inappropriate function of ICD detected. We increased his toprol from 25 to 50, left his amio at 200 daily, plan for possible EPS in next few days. . A/P 42 yo M CAD s/p MI ', no significant dz on cath in ', EF 20%, ESRD on HD, presents with V-fib/v-tach arrest with delayed ICD response. 1. V-tach/v-fib: Interrogation of the device revealed that the pt had episodes of V-tach which degenerated into v-fib. The device was found to be functioning appropriately to the parameters with which it was programmed. The device was not programmed to detect V-tach so it only shocked him when it degenerated into v-fib. The EP consultant changed v tach sensing parameters to detect rates below 188 and added in anti-tachycardia pacing function. The device will try ATP twice, then shock. The pt underwent a prcedure for the generator change of the device. The pt underwent this procedure without complications. The pt remained stable without further episodes of arrhythmia during the hospitalization. . 2. CHF: pt currently well compensated. EF 20% by report. Echo was done at to eval cardiac fxn. The coumadin which the pt takes for mural thrombus and CHF was held for the EP procedure, then restarted afterwards. The pt was continued on his home medications. . 3. Renal failure Pt was found to be in metabolic acidosis with bicarb 17. K 6.3. Pt recieved calcium, insulin, bicarb, kayhexelate in ED. He was dialyzed while in the hospital. The AV graft was not functioning optimally for dialsis, with elevated pressures and suboptimal flow, although he was able dialyze. A AV fistulogram was obtained which revealed venous obstruction. Renal and transplant surgery teams followed the pt. The pt was informed of the need to see his regular renal physician for planning to revise the AVF. . 4. CAD: no active ischemia during hospitalization. ASA/statin/BB were continued . 5. ID: being treated for tunneled r IJ line infection. R IJ was pulled 2 weeks ago. Vanco with HD was recommended for an additional week, because a device was implanted. . 6. Ppx: heparin when INR <2 . 7. FEN: follow K, renagel 2400, NPO p MN | The right ventricularcavity is now dilated with free wall hypokinesis.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a low risk (prophylaxis not recommended). cv=sr wo ectopy. Initial impression was VT/VF secondary to hyperkalemia. VT ablation vs. lead revision on hold until INR decreases.RESP: Lungs CTA bilaterally. The right ventricularcavity is mildly dilated with moderate global free wall hypokinesis. False LV tendon (normal variant).RIGHT VENTRICLE: Mildly dilated RV cavity. end-stage renal dz-?cause. Mild tomoderate (+) mitral regurgitation is seen. myoview=fixed anterior/ inferior defects extending to apex. REASON FOR THIS EXAMINATION: eval cardiomegaly, infiltrate, effusion FINAL REPORT INDICATION: Low ejection fraction, cardiac arrest this AM. Hypercoagulable state - PT/PTT/INR : 21.5/38.3/3.3 - EP study/ poss. ESRD on HD although occ. Moderate global RV free wallhypokinesis.AORTA: Mildly dilated aortic root. ck-407/12 w trop 0.18. gi=stool x2-#1 formed & #2 loose-both guiac neg. Borderline first degree A-V delay. There is a curvilinear opacity just below the termination of the ventricular lead, which likely represents calcification in an area of prior infarction. Left ventricular hypertrophy withST-T wave changes. COMPARISON: Chest x-ray dated . Mildly dilated ascending aorta. COMPARISON: Radiograph dated . There is mild symmetric leftventricular hypertrophy. Sinus rhythm with borderline 1st degree A-V block.Left axis deviation - consider left anterior fascicular blockPossible left ventricular hypertrophyLateral T wave changes are probably due to ventricular hypertrophySince previous tracing, A-V sequential pacing not present Normalaortic arch diameter. ep interrogated aicd-multiple episodes of vf/vt terminated via aicd- settings adjusted w plan to discuss in am rounds-?ablation vs increase in medical rx.o:neuro=alert/responsive/appropriate. CCU NPN: 7a-7pS: "I feel wiped out ..."O: See CareVue flowsheet for complete assessment detailsCV: HR 60s-70s, SR w/ rare PVC. Clinical correlation is suggested.Since the previous tracing of sinus bradycardia and further ST-T wavechanges are present. Theaortic root and ascending aorta are mildly dilated. SINGLE SUPINE AP PORTABLE CHEST: The right costophrenic angle is not fully visualized on this exam. Based on AHAendocarditis prophylaxis recommendations, the echo findings indicate a lowrisk (prophylaxis not recommended). Coronary artery disease.Height: (in) 74Weight (lb): 170BSA (m2): 2.03 m2BP (mm Hg): 132/87HR (bpm): 66Status: InpatientDate/Time: at 09:55Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:Lat and Septal wall e' = 0.06m/sThis study was compared to the report of the prior study (tape not available)of .LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. hypertension. Moderate PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. renal=bun/creat 92/16.5. Currently undergoing hemodialysis. MAE, +CSM. Physiologic (normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: The patient appears to be in sinus rhythm. Left atrial abnormality.Intraventricular conduction delay with left axis deviation - probably in part,due to left anterior fascicular block. There is moderate pulmonaryartery systolic hypertension. NPO in AM for poss. Sinus bradycardia. rsc line infection-abx w hd.-allergies:demerol.social:single. Poor R wave progression could be in part, due tointraventricular conduction delay/ left ventricular hypertrophy but consideralso prior anterior myocardial infarction. extubated self). k 4.6. id=afebrile. There is no pericardial effusion.Compared with the report of the prior study (tape unavailable for review) of, the left ventricular cavity is more dilated with further depressionof systolic function. voids - awaiting specimen for U/A. AM lytes: K+ 4.6, Mg+ 2.5. aicd for recurrent vt/vf on amiodarone/beta blocker. ep discussion re:increasing amiodarone vs attempting ablation. Question CHF. Mild [1+] TR. The left upper arm, in the area of the left AV fistula, was prepped and draped in a sterile fashion. pos ck/trop. There is now moderate pulmonary artery hypertension andthe severity of mitral regurgitation is slightly worse. Severeregional LV systolic dysfunction. BUN/Creat in AM: 92/16.5. Continue HD per pt. htn. No AR.MITRAL VALVE: Normal mitral valve leaflets. PA sys. The ST-T wave changes appear diffuse with prolongedQTc interval (although, is difficult to measure) - consider in part,metabolic/drug effect. H/H: 39.5/12.9. Clinical decisions regarding the need forprophylaxis should be based on clinical and echocardiographic data.Conclusions:The left and right atrium are moderately dilated. A catheter or pacingwire is seen in the RA and extending into the RV.LEFT VENTRICLE: Mild symmetric LVH. A right clavicular fixation plate and screws is again demonstrated. 911-transported to dnh & subsequently transfered to for further management. Mild to moderate (+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Clinical decisionsregarding the need for prophylaxis should be based on clinical andechocardiographic data.Compared with the report of the prior study (tape unavailable for review) of There is mild cardiomegaly. hemody stable. PATIENT/TEST INFORMATION:Indication: Left ventricular function. SBP stable - 110-130, MAP > 75. procedure . HTN, no pericardial effusion. Denies SOB, DOE. Vanco dosed per level (13.8 ) during HD (for h/o line infection).NEURO: Alert and oriented x3. The left ventricular cavity is severely dilated withsevere regional dysfunction. Severely dilated LV cavity. fx r-shoulder--plated. IMPRESSION: Fistulogram of the left AV fistula demonstrates patency of the fistula, with an approximately 5- to 6-cm area of axillary vein occlusion, (Over) 7:33 AM AV FISTULOGRAM SCH Clip # Reason: PLEASE EVALUATE FLOW THROUGH L. AV FISTULA, ESRD Admitting Diagnosis: S/P CARDIAC ARREST Contrast: OPTIRAY Amt: 75 FINAL REPORT (Cont) with extensive collateral formation and retrograde filling of the axillary vein beyond this area of obstruction. | 9 | [
{
"category": "Nursing/other",
"chartdate": "2186-09-04 00:00:00.000",
"description": "Report",
"row_id": 1570656,
"text": "ccu nsg admit note.\n43 yo male tansfered from s/p multiple episodes of vt/vf terminated by aicd.\n\npmh:cad=sp anterior mi ' w stenting x3 of lad. echo=ef 15-20% w apical thrombus, dilated lv, & mild mr/tr. myoview=fixed anterior/ inferior defects extending to apex. aicd for recurrent vt/vf on amiodarone/beta blocker.\n end-stage renal dz-?cause. hd 3x's/week (mon/wed/fri).\n hypertension.\n elevated cholesterol.\n fx r-shoulder--plated.\n rsc line infection-abx w hd.-\n\nallergies:demerol.\n\nsocial:single. lives @ home w mom/dad. significant other-girlfriend. disabled due to cad & end-stage renal failure---on list for kidney transplant. previous heavy drinker-presently social. past hx of cocaine use.\n\ncrf:cad. elevated cholesterol. htn. family sx. distant smoker & drug abuser.\n\npresent hx:sunday -multiple episodes of lightheadedness/loc w multiple shocks via aicd. 911-transported to dnh & subsequently transfered to for further management. admitted to ccu. ep interrogated aicd-multiple episodes of vf/vt terminated via aicd- settings adjusted w plan to discuss in am rounds-?ablation vs increase in medical rx.\n\no:neuro=alert/responsive/appropriate. cooperative.\n pulm=initially o2 via 100% nrb w sats 100% chged to 4l nc w sats remaining upper 90's. breath sounds=clear.\n cv=sr wo ectopy. hemody stable. continued on amiodarone 200 qd & metoprolol xl increased to 50 qd. ck-407/12 w trop 0.18.\n gi=stool x2-#1 formed & #2 loose-both guiac neg.\n renal=bun/creat 92/16.5. k 4.6.\n id=afebrile. bc x2 sent. vanco ordered w hd.\n\na:wo further episodes of vt/vf. pos ck/trop. k-wnl.\n\np:hd . ep discussion re:increasing amiodarone vs attempting ablation. continue present management. support as indicated.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-09-04 00:00:00.000",
"description": "Report",
"row_id": 1570657,
"text": "CCU NPN: 7a-7p\n\nS: \"I feel wiped out ...\"\n\nO: See CareVue flowsheet for complete assessment details\n\nCV: HR 60s-70s, SR w/ rare PVC. SBP stable - 110-130, MAP > 75. ECHO revealed: EF < 20%, LV systolic dysfunction, + MR, +1 TR, mod. PA sys. HTN, no pericardial effusion. AM lytes: K+ 4.6, Mg+ 2.5. H/H: 39.5/12.9. Remains on Amiodarone 200mg PO daily - no further episodes of VT/VF after device interrogation . Hypercoagulable state - PT/PTT/INR : 21.5/38.3/3.3 - EP study/ poss. VT ablation vs. lead revision on hold until INR decreases.\n\nRESP: Lungs CTA bilaterally. Denies SOB, DOE. Weaned from NC to RA w/ O2 sats > 95%.\n\nGI/GU: Abd. soft, non-tender, non-distended. BS active x4 quadrants. NPO in AM for poss. EP procedure - tolerated renal diet thereafter. ESRD on HD although occ. voids - awaiting specimen for U/A. BUN/Creat in AM: 92/16.5. Currently undergoing hemodialysis. AV fistula w/ + thrill, bruit - per CCU team, sluggish flow - awaiting transplant surgery input. Vanco dosed per level (13.8 ) during HD (for h/o line infection).\n\nNEURO: Alert and oriented x3. Pleasant and cooperative. MAE, +CSM. Declined to get OOB as pt. stated he felt \"weak\". Asking appropriate questions re: plan of care.\n\nA/P: Collapsed at home w/ slow VT - required external shocks by EMS as well as internal defibrillations (ICD placed post-MI ' for CMP). S/P cardiac arrest in the field - intubated for airway protection (pt. extubated self). Initial impression was VT/VF secondary to hyperkalemia. Transferred to where ICD was interrogated w/ no further episodes of VT/VF. Awaiting EP procedure - VT ablation vs. lead revision - unable to have procedure today as INR 3.3. Plan for Vitamin K this PM to reverse INR and prepare for poss. procedure . Continue HD per pt. schedule - transplant team to evaluate decreased function of AV graft. Vanco dosed per serum level for potential line infection. Emotional support and comfort. Poss. transfer to floor if remains stable. Awaiting further plans from team.\n\n\n\n"
},
{
"category": "Echo",
"chartdate": "2186-09-04 00:00:00.000",
"description": "Report",
"row_id": 66264,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Coronary artery disease.\nHeight: (in) 74\nWeight (lb): 170\nBSA (m2): 2.03 m2\nBP (mm Hg): 132/87\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 09:55\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLat and Septal wall e' = 0.06m/s\nThis study was compared to the report of the prior study (tape not available)\nof .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH. Severely dilated LV cavity. Severe\nregional LV systolic dysfunction. No resting LVOT gradient. No LV\nmass/thrombus. False LV tendon (normal variant).\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV free wall\nhypokinesis.\n\nAORTA: Mildly dilated aortic root. Mildly dilated ascending aorta. Normal\naortic arch diameter. No 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm. Based on AHA\nendocarditis prophylaxis recommendations, the echo findings indicate a low\nrisk (prophylaxis not recommended). Clinical decisions regarding the need for\nprophylaxis should be based on clinical and echocardiographic data.\n\nConclusions:\nThe left and right atrium are moderately dilated. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity is severely dilated with\nsevere regional dysfunction. The basal inferoseptal, inferior, and\ninferolateral walls contract best. The remaining segments are near akinetic.\nNo masses or thrombi are seen in the left ventricle. The right ventricular\ncavity is mildly dilated with moderate global free wall hypokinesis. The\naortic root and ascending aorta are mildly dilated. The aortic valve leaflets\n(3) appear structurally normal with good leaflet excursion and no aortic\nregurgitation. The mitral valve leaflets are structurally normal. Mild to\nmoderate (+) mitral regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\nCompared with the report of the prior study (tape unavailable for review) of\n, the left ventricular cavity is more dilated with further depression\nof systolic function. There is now moderate pulmonary artery hypertension and\nthe severity of mitral regurgitation is slightly worse. The right ventricular\ncavity is now dilated with free wall hypokinesis.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\nCompared with the report of the prior study (tape unavailable for review) of\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2186-09-05 00:00:00.000",
"description": "Report",
"row_id": 136157,
"text": "Sinus bradycardia. Borderline first degree A-V delay. Left atrial abnormality.\nIntraventricular conduction delay with left axis deviation - probably in part,\ndue to left anterior fascicular block. Left ventricular hypertrophy with\nST-T wave changes. The ST-T wave changes appear diffuse with prolonged\nQTc interval (although, is difficult to measure) - consider in part,\nmetabolic/drug effect. Poor R wave progression could be in part, due to\nintraventricular conduction delay/ left ventricular hypertrophy but consider\nalso prior anterior myocardial infarction. Clinical correlation is suggested.\nSince the previous tracing of sinus bradycardia and further ST-T wave\nchanges are present.\n\n"
},
{
"category": "ECG",
"chartdate": "2186-09-03 00:00:00.000",
"description": "Report",
"row_id": 136158,
"text": "A-V sequential paced rhythm\nSince previous tracing, pacing new from previous\n\n"
},
{
"category": "ECG",
"chartdate": "2186-09-03 00:00:00.000",
"description": "Report",
"row_id": 136159,
"text": "Sinus rhythm with borderline 1st degree A-V block.\nLeft axis deviation - consider left anterior fascicular block\nPossible left ventricular hypertrophy\nLateral T wave changes are probably due to ventricular hypertrophy\nSince previous tracing, A-V sequential pacing not present\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-09-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 880816,
"text": " 5:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval cardiomegaly, infiltrate, effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with EF 15%, CAD, s/p cardiac arrest this am.\n REASON FOR THIS EXAMINATION:\n eval cardiomegaly, infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Low ejection fraction, cardiac arrest this AM.\n\n COMPARISON: Radiograph dated .\n\n SINGLE UPRIGHT VIEW OF THE CHEST: There is a dual lead pacemaker/ICD device\n in unchanged position. There is apparent interval increase in the size of the\n cardiac silhouette, partially due to AP portable technique. The lungs are\n clear. There is no pleural effusion. No evidence of pneumothorax. A right\n clavicular fixation plate and screws is again demonstrated.\n\n IMPRESSION: Apparent interval increase in size of the cardiac silhouette, at\n least partially due to AP portable technique. No pleural effusion or\n consolidation seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-09-06 00:00:00.000",
"description": "INTRO DIALYSIS FISTULA",
"row_id": 881184,
"text": " 7:33 AM\n AV FISTULOGRAM SCH Clip # \n Reason: PLEASE EVALUATE FLOW THROUGH L. AV FISTULA, ESRD\n Admitting Diagnosis: S/P CARDIAC ARREST\n Contrast: OPTIRAY Amt: 75\n ********************************* CPT Codes ********************************\n * INTRO DIALYSIS FISTULA ART VENEOUS SHUNT *\n * C1769 GUID WIRES INCL INF C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with elevated pressures during HD\n REASON FOR THIS EXAMINATION:\n Please evaluate flow through L. AV fistula\n ______________________________________________________________________________\n FINAL REPORT\n\n\n\n\n\n\n\n\n\n INDICATION: History of elevated pressures during hemodialysis, evaluate flow\n through a left AV fistula.\n\n PHYSICIANS: The procedure was performed by Drs. , , and\n , with Dr. , the attending radiologist, being present and\n supervising throughout the procedure.\n\n PROCEDURE: Written informed consent was obtained prior to the procedure. A\n preprocedure timeout was performed prior to initiation of the procedure. The\n left upper arm, in the area of the left AV fistula, was prepped and draped in\n a sterile fashion. A 21-gauge needle was used to access the venous side of\n the AV fistula, immediately distal to the anastomosis. A 0.018 guide wire was\n advanced through the needle, which was then exchanged for a 7-French sheath.\n Intravenous contrast injected through the sheath demonstrates an approximately\n 5- to 6-cm area of occlusion of the left axillary vein distal to the AV\n fistula, with extensive collateral formation and retrograde filling of the\n axillary vein distal to the area of obstruction. A 0.035 Super Stiff guide\n wire was advanced through the sheath to the area of occlusion, but could not\n be passed through this. A 4-French multiholed catheter was advanced over the\n wire to this area, and contrast injection again demonstrated persistence of\n this area of occlusion. At this point, the exam was terminated, and the\n sheath and wire were removed. During the procedure, 2 mL of 1% lidocaine was\n injected subcutaneously for local anesthesia. No immediate complications were\n identified.\n\n IMPRESSION: Fistulogram of the left AV fistula demonstrates patency of the\n fistula, with an approximately 5- to 6-cm area of axillary vein occlusion,\n (Over)\n\n 7:33 AM\n AV FISTULOGRAM SCH Clip # \n Reason: PLEASE EVALUATE FLOW THROUGH L. AV FISTULA, ESRD\n Admitting Diagnosis: S/P CARDIAC ARREST\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n with extensive collateral formation and retrograde filling of the axillary\n vein beyond this area of obstruction. Results were discussed with the\n covering surgical staff.\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-09-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 881008,
"text": " 7:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for CHF\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with EF 15%, CAD, s/p cardiac arrest this am.\n\n REASON FOR THIS EXAMINATION:\n please eval for CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 43-year-old man with EF of 15%, CAD, status post cardiac arrest\n this a.m. Question CHF.\n\n COMPARISON: Chest x-ray dated .\n\n SINGLE SUPINE AP PORTABLE CHEST: The right costophrenic angle is not fully\n visualized on this exam. There is an ICD device in place, with the leads in\n appropriate position. There is a curvilinear opacity just below the\n termination of the ventricular lead, which likely represents calcification in\n an area of prior infarction. There is mild cardiomegaly. Central pulmonary\n vessels look prominent, consistent with the patient's history of pulmonary\n arterial hypertension. There is no frank evidence of congestive heart\n failure. There is surgical hardware in the right clavicle.\n\n IMPRESSION: Stable cardiomegaly without evidence of congestive heart failure.\n\n"
}
] |
12,348 | 149,513 | The patient was admitted to the Surgical Intensive Care Unit on , for observation and consultation. The patient was admitted to the Surgical Intensive Care Unit and was aggressively hydrated and stabilized. Neurosurgery was consulted secondary to the intraparenchymal bleed as well as the compression fracture with bilateral upper extremity and lower extremity weakness. In the Intensive Care Unit, the patient was extubated and was awake, alert and oriented times three. He did have a waxing and mental status while in the Intensive Care Unit for two days, however, he remained stable throughout his stay in the Intensive Care Unit. Neurosurgery deemed that the patient was not an operable candidate. He was transferred to the floor. Upon arrival to the floor, the patient was stable. While on the floor, the patient developed an ileus as well as profuse vomiting. Abdominal CT scan revealed gallstones. Abdominal ultrasound revealed no pericholecystic fluid and no inflammation. He did have elevated total bilirubin as well as elevated alkaline phosphatase. However, the ultrasound showed no evidence of acute cholecystitis. On day six, the patient began to vomit violently. Abdominal flat plate was done and revealed ileus. The patient had nasogastric tube placed with the profuse vomiting. He also had a bout of hematemesis. His hematocrit remained stable and no transfusions were required. He was lavaged free and the nasogastric tube was discontinued the next day. Lovenox was stopped. He was then placed on subcutaneous Heparin for deep vein thrombosis prophylaxis. He never had any more episodes of vomiting. He has remained stable since then. He has been tolerating a p.o. diet without difficulty. He was treated for a cellulitis of his right lower extremity with Oxacillin for ten days. The patient had an inferior vena cava filter placed on . | There are some nonenlarged mediastinal and retroperitoneal lymph nodes. Unremarkable abdominal and pelvic CT. A nondistended gallbladder is noted with extensive echogenic and posteriorly shadowing foci layering along the dependent portion of the gallbladder. CT PELVIS AFTER IV CONTRAST: There is some free fluid seen deep within the pelvis. Limited exam of the chest and pelvis. There superior portion of the chest is not visualized. MR THORACIC SPINE: This study is extremely limited by patient motion. The superior portion of the chest is not evaluated. FINDINGS: The left subclavian central venous catheter has been removed. IMPRESSION: Appearance consistent with paralytic ileus. Patient is intubated and extent of injuries is unclear. Sinus rhythmDiffuse nonspecific low-amplitude T wave - Clinical correlation is suggestedSince previous tracing of : U wave less prominent & T wave changes decreased CT PELVIS WITH INTRAVENOUS CONTRAST: Rectum, sigmoid colon, bladder and distal ureters are unremarkable. Fluid overload with small left pleural effusion. CT ABDOMEN WITH INTRAVENOUS CONTRAST: The lung bases demonstrate mild-to- moderate amount of pleural effusion bilaterally. Small amount of ascites and pelvic fluid. CONCLUSION: Mild spinal cord edema in the mid cervical region. There is minimal opacification of left mastoid air cells. Multilevel cervical and thoracic spondylosis, as described above. There are bibasilar minimal patchy opacities consistent with atelectasis. CHEST, SINGLE VIEW: The left subclavian catheter terminates at the junction of the left brachiocephalic vein and SVC. LEFT FEMUR, AP AND LATERAL VIEWS: This is a limited study with a poor exposure of the upper femur. An NG tube is terminating in the stomach, with a site for it not well visualized. There is a focal deformity along the distal shaft of the femur with slight anterior posterior hyperostosis. IMPRESSION: Left subclavian catheter terminates at the junction of brachiocephalic vein and SVC. There is edema within the T4/5 disc space, also likely post traumatic. Bilateral renal vein openings were localized. BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND: There is normal compressibility, flow and augmentation of the bilateral common femoral, superficial femoral and popliteal veins bilaterally. Check line position and r/o pneumothorax. The femoral head is poorly visualized. Again seen is cardiomegaly with left ventricular predominance. CT ABDOMEN AFTER IV CONTRAST: There are bilateral pleural effusions associated with collapse in the lower lobes, left greater than right. The lung volumes are decreased bilaterally, and there is no pneumothorax, effusions, or large areas of consolidation. Assess for intracranial bleed. Minor cervical spondylosis is noted at the C3/4, and levels. TECHNIQUE: Non-contrast CT exam of the head. The catheter sheath was removed and local hemostasis was performed by compression. The previously described compression fracture is poorly visualized on this study. 3:54 PM TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT) Clip # Reason: MVA FINAL ADDENDUM ADDENDUM: AP view of the chest: Examination is limited secondary to the trauma board. LYTES SENT, RESULTS PENDINGGI: ABD OBESE, SOFT, (+)BOWEL SOUNDS. PT WAS ELECTIVELY INTUBATED TO COMPLETE THE SCAN.CV: HR 80S, NSR WITH FREQ PAC'S, ATRIAL BIGEM. Limited mobility.P: Neuro checks q 1hr. Extubated in EW and admitted to T/SICU. Resp Care,Pt. NEURO:TALKING RAG TIME SINCE EXTUBATED,WILL FOLLOW COMMANDS.STRONG HAND GRIP ON L,WEAKER ON R.MOVES R FOOT MORE THAN L.ON ATIVAN Q6HRS. Ativan for DT prophylaxis. uo qs.gi lg amt of ng drainage, and liq brown stool spec sent for c diff. T-SICU NURSING PROGRESS NOTENEURO: AROUSABLE TO VOICE, ORIENTED TO SELF ONLY. Pt was transferred to after being paralyzed/sedated and intubated. Logroll precautions.Resp: Breathing unlabored. Today Pt was noted to have upper extremity weakness. She confirmed that pt has long history of etoh abuse. / to nailbed pressure. Sinus rhythmLong QTc intervalDiffuse nonspecific ST-T abnormalities with prominent U waves - considermetabolic/drug effect - clinical correlation is suggestedNo previous report available for comparison SKIN WARM, DRY, (+)PALP PULSES, TRACE PEDAL EDEMARESP: AS ABOVE, PT WAS ELECTIVELY INTUBATED TO COMPLETE MRI. to wean as tol. NSG NOTEROS: CV:SYS BP 150'S/70'S,IN SR WITH RARE APC'S.RR 21-33.T MAX 99.8 RESP:PPT EXTUBATED AT 3:30PM.SX FOR LARGE AMT THIN TAN SECRETIONS PRIOP TO EXTUB,MUCH LESS SECRETIONS NOW.SATS 99 ON 3L NP.ABGS 7.43-35-100. Abdomen is distended, but soft.GU: Foley to gravity. PT FITTED FOR COLLAR AND CHEST BRACE TO START REHABCONT TO LOGROLL TILL THENPT OT CONSULTCHANGE ATIVAN TO PRN GIVE HALDOL AS NEEDEDSTART TPNWATCH ANY S+S OF ORIENT PT FREQUENTLY Pt currently on PB 7200 with initial settings of SIMV/PSV/800/12/50%/+5/%ips, 02 sats 98%, awaiting a-line/ABG to titrate settings. R/T HEAD TRAUMA VS SEDATIVESP-CONT TO MONITOR NEURO EXAM,VS,MONITOR RESP QS AND PRN,I+O,O2 PRN,TPN/ORDERS,MONITOR SKIN INTEGRITY QS AND PRN. ALT NEURO STATUS C4-5 CONTUSION POSSIBLE CENTRAL CORD SYNDROME WITH EXTREMITY WEAKNESS BILAT, ALT MS ? afebrile. RELATED TO ATIVAN GIVENALT SKIN POSS. Pt placed on MRI vent for scan and transferred to T-SICU. PERRL. Backside inatct.Social: Daughter, , here when Pt arrived. He was admitted to an OSH. PRIOR TO INTUBATION, BREATH SOUNDS CLEAR IN UPPER LOBES, VERY DIMINISHED IN THE BASES BILAT. REMAINS IN C-COLLAR. RESP NOTE:PT EXTUBATED AS PER ORDER W/O INCIDENT,PLACED ON 3L/NC MAINTAINING SATS 97-100%.NO RESP DISTRESS NOTED,WILL CONTINUE TO MONITOR. nsg :neuro obeys commands but very confused. PT WAS SEDATED WITH FENTANYL AND MIDAZ. Respiratory CareRespiratory paged to MRI for intubation, pt orally intubated 7.5 ETT, 25 @ lip. MRI of spine. CELLULITISALT NUTRITIONAL STATUS HIGH NGT OUTPUT AND DIARRHEAETOH ABUSE+ SMOKERP. Follows commands. Pt confused. ABLE TO STATE THE NAME OF HIS CHILDREN AND THAT HE IS FROM , MA. weaned to CPAP IPS10.5/5peep this am. S. THE BROUGHT ME HERE IN A BOX I NEED SOME CLOTHESO.NEURO PT CONFUSED ALERT TO NAME RAMBLING PEARLA FC GOOD GRASPS BOTH HANDS RIGHT ARM ABLE TO COME UP 30 DEGREES LT 45 DEGREES STRENGHT SL. AFTER INTUBATION, PT WAS SUCTIONED FOR THICK, COPIOUS YELLOW SECRETIONS. | 29 | [
{
"category": "Radiology",
"chartdate": "2132-06-04 00:00:00.000",
"description": "ORBITS (WATERS, CALDWELL & LAT)",
"row_id": 762021,
"text": " 2:42 AM\n ORBITS (WATERS, & LAT) Clip # \n Reason: TWO VIEWS TO RULE OUT METAL IN ORBITALS BEFORE GOING TO MRI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with T7 compression fracture, s/p motorcycle accident \n REASON FOR THIS EXAMINATION:\n TWO VIEWS TO RULE OUT METAL IN ORBITALS BEFORE GOING TO MRI\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Evaluate for foreign bodies prior to MR exam.\n\n ORBITS, TWO VIEWS: No metallic foreign bodies.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-06-11 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 762673,
"text": " 4:04 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: Projectile vomiting\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with projectile vomiting\n REASON FOR THIS EXAMINATION:\n Projectile vomiting\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Projectile vomiting.\n\n TECHNOLOGIST NOTE: Supine film could not be performed at this time due to\n patient condition.\n\n SUPINE ABDOMEN: There is gas contained throughout the colon from cecum to\n rectum. The transverse colon is somewhat prominent and the cecum is somewhat\n dilated. There is gas contained in multiple small bowel loops which are\n minimally dilated. There is no free air evident. Upright or decubitus films\n were not obtained, so the presence of air fluid levels cannot be assessed.\n\n IMPRESSION: Appearance consistent with paralytic ileus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-06-04 00:00:00.000",
"description": "MR L SPINE SCAN",
"row_id": 762023,
"text": " 3:39 AM\n MR L SPINE SCAN; MR THORACIC SPINE Clip # \n Reason: eval for nerve compression/infection\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with T7 compression fracture, s/p motorcycle accident\n REASON FOR THIS EXAMINATION:\n eval for nerve compression/infection\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n\n INDICATION: T7 compression fracture following MVA. Evaluate for nerve\n compression or infection.\n\n TECHNIQUE: Sagittal T1, T2 images of the cervical, thoracic and lumbar spine\n with additional inversion recovery sagittal images of the lumbar spine and\n gradient echo axial images of cervical spine. Additional turbo-spin echo\n axial images of the thoracic spine were performed.\n\n NR CERVICAL SPINE: This study is extremely limited due to gross patient\n motion. Minor cervical spondylosis is noted at the C3/4, and levels.\n The axial images of this region are uninterpretable. This study is\n insufficient for evaluation of neural foraminal narrowing or possible spinal\n stenosis.\n\n MR THORACIC SPINE: This study is extremely limited by patient motion.\n Increased inversion recovery signal is noted in the T4, 5.6 and 8 levels. No\n definite fracture line is observed. No gross spinal canal stenosis or neural\n foraminal narrowing is noted on this extremely limited study. There is loss\n of vertebral body height at multiple levels.\n\n IMPRESSION: Extremely limited study due to gross patient motion. Multilevel\n cervical and thoracic spondylosis, as described above. There is increased\n inversion recovery signal in multiple vertebral body levels and loss of\n vertebral body height, suggestive of acute injury-i.e. fracture. The\n previously described compression fracture is poorly visualized on this study.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-06-04 00:00:00.000",
"description": "MR CERVICAL SPINE",
"row_id": 762106,
"text": " 5:22 PM\n MR CERVICAL SPINE Clip # \n Reason: S/P MOTORCYCLE ACCIDENT; ARM AND LEG WEAKNESS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with T7 compression fracture, s/p motorcycle accident\n\n REASON FOR THIS EXAMINATION:\n with stir images to r/o ligmental injuries.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n HISTORY: T7 compression fracture.\n\n Repeat study attempted to improve image quality.\n\n TECHNIQUE: Multiplanar T1 and T2 weighted imaging of the cervical spine was\n performed.\n\n FINDINGS: Nearly all of the images are of equally limited resolution due to\n gross patient motion. However, there are a few sequences which are of\n excellent technical quality and it is on these image sequences that the\n following report is based.\n\n There is very slight elevated T2 signal within the mid cervical cord at the\n level of C4 and C5. The axial scans show mild spinal cord compression C5/6 due\n to a posterior spondylytic ridge with moderate bilateral C4/5 and prominent\n C5/6 bilateral neural foraminal encroachment due to uncovertebral spurs.\n\n There is more moderate spinal cord edema and spinal cord compression at the T4\n level due to a compression fracture. This finding was not as obvious on the\n prior study but the present image sequence clearly delineates this\n abnormality. There is edema within the T4/5 disc space, also likely post\n traumatic. No other definite abnormalities are seen.\n\n CONCLUSION: Mild spinal cord edema in the mid cervical region. 2) Spinal cord\n compression and edema due to a presumed traumatic compression fracture at the\n T4 level. We reached the trauma team to report the findings immediately.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-06-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 762278,
"text": " 2:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p Lt subclavian CVL placement. Check line position and r/o\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with\n REASON FOR THIS EXAMINATION:\n s/p Lt subclavian CVL placement. Check line position and r/o pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check central venous line placement.\n\n CHEST, SINGLE VIEW: The left subclavian catheter terminates at the junction\n of the left brachiocephalic vein and SVC. An NG tube is terminating in the\n stomach, with a site for it not well visualized. The cardiomediastinal\n contours appears prominent, may be associated with low lung volumes. There is\n evidence of fluid overload, evidenced by pulmonary vascularity prominence and\n perivascular haziness. There is also a small left pleural effusion.\n\n There is no pneumothorax.\n\n IMPRESSION: Left subclavian catheter terminates at the junction of\n brachiocephalic vein and SVC. No pneumothorax. Fluid overload with small\n left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-06-18 00:00:00.000",
"description": "INTERUP IVC",
"row_id": 763202,
"text": " 3:31 PM\n IVC GRAM/FILTER Clip # \n Reason: LONG TERM PE PREVENTION, HAS HO UGIB\n Contrast: OPTIRAY Amt: 80\n ********************************* CPT Codes ********************************\n * INTERUP IVC INTRO CATH SVC/IVC *\n * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT IVC FILTER *\n * IVC GRAM *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with BL LE PARALYSIS, WITH HO OF UGIB\n REASON FOR THIS EXAMINATION:\n LONG TERM PE PREVENTION, HAS HO UGIB\n ______________________________________________________________________________\n FINAL REPORT\n\n\n\n\n\n\n HISTORY:\n\n The patient is a 59 year old male who sustained thoracic vertebral compression\n fracture in motorcycle accident. IVC filter placement was requested by\n patient's physician.\n\n The risks and benefits were explained to the patient and the consent was\n obtained from the patient.\n\n TECHNIQUE: Patient was brought into the Angio Suite and placed supine on the\n angio table. His right groin was prepped and draped in sterile fashion. Local\n anesthesia was given using 1% lidocaine. The right common femoral vein was\n accessed using 19-gauge Seldinger needle and a 0.035 wire was advanced\n into the IVC. The needle was exchanged for a 4-French Omni Flush catheter\n over the wire. The catheter was placed into the left common iliac vein by\n using a Glidewire guidance. Venogram was performed using solely present non-\n ionic contrast and a power injection. Bilateral renal vein openings were\n localized. The the IVC was measured to confirm that a filter was\n appropriate and it was placed in the infrarenal position.\n\n FINDINGS: The bilateral iliac veins and IVC are patent with no evidence of\n filling defect. The IVC measures 18 mm in radius. Repeat venogram following\n filter placement demonstrates the filter is in good position with the tip at\n the opening of the renal veins into the IVC.\n\n The catheter sheath was removed and local hemostasis was performed by\n compression. Patient tolerated the procedure well with no immediate\n complications.\n\n IMPRESSION: Successful placement of an IVC filter.\n\n (Over)\n\n 3:31 PM\n IVC GRAM/FILTER Clip # \n Reason: LONG TERM PE PREVENTION, HAS HO UGIB\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-06-06 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 762252,
"text": " 9:48 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: SP TRAUMA,LEG SWELLING ,EVAL FOR DVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with\n REASON FOR THIS EXAMINATION:\n r/o dvt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma and immobilization.\n\n BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND: There is normal compressibility,\n flow and augmentation of the bilateral common femoral, superficial femoral and\n popliteal veins bilaterally.\n\n IMPRESSION: No ultrasound evidence of DVT bilaterally.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-06-12 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 762753,
"text": " 2:50 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: r/o obstruction\n Field of view: 44 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man s/p motorcycle accident\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motor vehicle accident.\n\n TECHNIQUE: Helically acquired axial images were obtained from the lung bases\n to pubic symphysis. 150 cc Optiray was given to the patient due to patient's\n status of debility.\n\n CT ABDOMEN WITH INTRAVENOUS CONTRAST: The lung bases demonstrate mild-to-\n moderate amount of pleural effusion bilaterally. The liver is unremarkable.\n There is evidence of multiple gallstones in the gallbladder, but no evidence\n of pericholecystitic fluid. The pancreas, spleen, kidneys and adrenal glands\n are unremarkable. The visualized small and large bowel loops are within normal\n limits. No evidence of retroperitoneal or mesenteric lymphadenopathy. There is\n no free air or free fluid within the abdomen.\n\n CT PELVIS WITH INTRAVENOUS CONTRAST: Rectum, sigmoid colon, bladder and distal\n ureters are unremarkable. No evidence of pelvic free fluid or pelvic\n lymphadenopathy.\n\n Bone windows demonstrate no evidence of lytic or blastic lesions.\n\n IMPRESSION: No evidence of small bowel obstruction. Unremarkable abdominal and\n pelvic CT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-06-03 00:00:00.000",
"description": "L FEMUR (AP & LAT) LEFT",
"row_id": 762005,
"text": " 7:10 PM\n FEMUR (AP & LAT) LEFT Clip # \n Reason: r/o fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with mvc\n REASON FOR THIS EXAMINATION:\n r/o fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motor vehicle accident with left leg pain.\n\n LEFT FEMUR, AP AND LATERAL VIEWS: This is a limited study with a poor exposure\n of the upper femur. The femoral head is poorly visualized. No fracture is seen\n within the femoral neck or shaft. There is a focal deformity along the distal\n shaft of the femur with slight anterior posterior hyperostosis. This likely\n represents a healed fracture. The patient is status post tricompartment left\n knee replacement. There is no evidence of hardware loosening. No joint\n effusion can be assessed given the straight leg.\n\n IMPRESSION: Limited study. No evidence of acute fracture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-06-03 00:00:00.000",
"description": "TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT)",
"row_id": 761986,
"text": " 3:54 PM\n TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT) Clip # \n Reason: MVA\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: AP view of the chest: Examination is limited secondary to the\n trauma board. An incidental left sided hip fracture is identified.\n\n\n 3:54 PM\n TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT) Clip # \n Reason: MVA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MVA.\n\n AP VIEW OF THE CHEST:\n\n Low lung volumes are demonstrated. The superior portion of the chest is not\n evaluated. The mediastinum appears widened. There is no free air.\n\n AP VIEW OF THE PELVIS:\n\n The pelvis is visualized distal to the hip to the hip joints. There are no\n fractures identified. This exam is extremely limited.\n\n IMPRESSION:\n\n 1. Limited exam of the chest and pelvis. There superior portion of the chest\n is not visualized. The mediastinum appears widened.\n\n 2. No fractures identified on this pelvis examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-06-03 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 761990,
"text": " 4:10 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Asses for intraabdominal bleed, Asses for bleed\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man s/p motorcycle accident\n REASON FOR THIS EXAMINATION:\n Asses for intraabdominal bleed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motorcycle accident five days previously. Transfer from outside\n hospital. Patient is intubated and extent of injuries is unclear. Assess for\n intraabdominal bleed.\n\n There is no prior study for comparison.\n\n TECHNIQUE: Axial images were obtained from the lung bases to the pubic\n symphysis after administration of 150 cc Optiray nonionic contrast. Optiray\n was administered given the trauma protocol and patient's intubated status.\n\n CT ABDOMEN AFTER IV CONTRAST: There are bilateral pleural effusions associated\n with collapse in the lower lobes, left greater than right. The liver and\n spleen are normal. There are no subcapsular splenic or hepatic hematomas.\n There is no active extravasation within these organs. The gallbladder contains\n layering high-density material and some radiopaque gallstones. The pancreas is\n normal. The adrenal glands and kidneys are normal. There are some nonenlarged\n mediastinal and retroperitoneal lymph nodes.\n No free air is seen within the abdomen. Loops of small bowel are mildly\n dilated but nonthickened. The dilatation extends into the cecum and large\n intestine.\n\n CT PELVIS AFTER IV CONTRAST: There is some free fluid seen deep within the\n pelvis. There are no pelvic masses or enlarged inguinal lymph nodes. The\n ureters and urinary bladder are within normal limits. Atherosclerotic changes\n are seen in the distal aorta and in the femoral vessels.\n\n No free air is seen within the abdomen or pelvis.\n\n Bone windows show a fracture of the most superior vertebral body imaged, this\n is likely the T6 vertebral body. There are lateral rib fractures of the 8th\n and 5th left ribs.\n\n IMPRESSION:\n\n 1. No evidence of injury to solid abdominal organs.\n\n 2. Small amount of ascites and pelvic fluid.\n\n 3. T6 or 7 vertebral body fracture. Left 8th and 5th rib fractures laterally.\n\n 4. Ileus pattern of the bowel.\n (Over)\n\n 4:10 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Asses for intraabdominal bleed, Asses for bleed\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-06-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 761991,
"text": " 4:10 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Asses for intracranial bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man s/p motorcycle accident\n REASON FOR THIS EXAMINATION:\n Asses for intracranial bleed\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: S/P motorcycle accident. Assess for intracranial bleed.\n\n TECHNIQUE: Non-contrast CT exam of the head.\n\n FINDINGS: There are no previous exams for comparison. There is no evidence\n of acute intra or extraaxial hemorrhages. Noted are symmetric prominent\n extraaxial, likely subdural spaces adjacent to the frontal lobes. These spaces\n are of low attenuation (approximately 20 ) and resemble CSF. There is no\n effacement of the adjacent sulci or mass effect. The ventricles and cisterns\n are unremarkable. The -white matter differentiation is well preserved.\n\n No skull fractures are seen. There is minimal opacification of left mastoid\n air cells. Noted is moderate opacification of the ethmoid air cells. There is\n also mild mucosal thickening and air-fluid levels within the maxillary\n sinuses. Lamina papyreacea are difficult to evaluate due to anatomy. Nasal\n bone and septum appear to be intact though they are bowed to the right.\n\n IMPRESSION:\n\n 1. No evidence of acute intra or extraaxial hemorrhage.\n\n 2. Prominent frontal CSF spaces, which could represent CSF subdural\n collections or chronic subdural hematomas. Distinction can probably be made\n with MRI.\n 3. Mild to moderate opacification of the incompletely imaged paranasal\n sinuses. No fractures identified.\n\n The above findings were discussed with Dr. at the time of the exam.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-06-17 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 763136,
"text": " 6:09 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: R arm dual lumen picc for long term IV abx. Please page \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with spinal cord injury\n REASON FOR THIS EXAMINATION:\n R arm dual lumen picc for long term IV abx. Please page with wet read as\n soon as available.\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATIONS: Spinal cord injury, PICC line placement.\n\n TECHNIQUE: Supine view of the chest.\n\n Comparison is made to previous films from .\n\n FINDINGS: The left subclavian central venous catheter has been removed. There\n has been interval placement of a right sided PICC line. The tip is in the\n proximal SVC. Again seen is cardiomegaly with left ventricular predominance.\n The aorta is unfolded. The lung volumes are decreased bilaterally, and there\n is no pneumothorax, effusions, or large areas of consolidation. There are\n bibasilar minimal patchy opacities consistent with atelectasis.\n\n IMPRESSION: Right PICC line with the tip in the proximal SVC.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-06-11 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 762695,
"text": " 11:42 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ABD PAIN, R/O CHOLECYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with projectile vomiting, and Illeus\n REASON FOR THIS EXAMINATION:\n R/O cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Vomiting and ileus.\n\n LIVER OR GALLBLADDER ULTRASOUND: The study is limited by patient body habitus\n and a large amount of gas within the overlying loops of bowel. A nondistended\n gallbladder is noted with extensive echogenic and posteriorly shadowing foci\n layering along the dependent portion of the gallbladder. Although no\n intrahepatic ductal dilatation is noted the liver is suboptimally visualized.\n The common bile duct is not dilated, measuring approximately 6 mm in greatest\n diameter. No son sign was elicited. The wall of the\n gallbladder is not thickened and no pericholecystic fluid is detected.\n\n IMPRESSION: Extensive gallstones and sludge within the gallbladder, without\n evidence of cholecystitis or common duct obstruction.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2132-06-12 00:00:00.000",
"description": "Report",
"row_id": 176198,
"text": "Sinus rhythm\nDiffuse nonspecific low-amplitude T wave - Clinical correlation is suggested\nSince previous tracing of : U wave less prominent & T wave changes\n decreased\n\n"
},
{
"category": "ECG",
"chartdate": "2132-06-05 00:00:00.000",
"description": "Report",
"row_id": 176199,
"text": "Sinus rhythm\nLong QTc interval\nDiffuse nonspecific ST-T abnormalities with prominent U waves - consider\nmetabolic/drug effect - clinical correlation is suggested\nNo previous report available for comparison\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-06-04 00:00:00.000",
"description": "Report",
"row_id": 1423979,
"text": "Respiratory Care\nRespiratory paged to MRI for intubation, pt orally intubated 7.5 ETT, 25 @ lip. Pt placed on MRI vent for scan and transferred to T-SICU. Pt currently on PB 7200 with initial settings of SIMV/PSV/800/12/50%/+5/%ips, 02 sats 98%, awaiting a-line/ABG to titrate settings. Suctioning thick yellow frequently. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-06-05 00:00:00.000",
"description": "Report",
"row_id": 1423980,
"text": "S/P MOTORCYCLE MVA-HEAD/SPINE TRAUMA-T/SICU NPN7P-7A\nS-PT INTUBATED\n SEDATED ON PROPOFOL GTT 20-50MCG/KG/MIN,ATIVAN ATC.PT AWAKENS RESTLESS NODS APPROPRIATLY INCONSISTENTLY FOLLOWS COMMANDS MAE'S,HAND GRASP EQUALLY STRONG,ATTEMPTS TO BEND KNEES BILAT.WIGGLE TOES TO COMMAND.STRONG COUGH/GAG.PERRLA 2MM.\nCV-SBP 80'S-130'S ON , PLACED SBP 90'S-120'S.HR 50'S-70 NSR W/ FREQ PAC'S/PVC'S,REPLETING LYTES CONSTANTLY K+3.5->3.2.HCT DOWN TO 23 PT 1 UNIT PRBC THIS AM.\nRESP-PT INTUBATED IN MRI FOR STUDY,PT REMAINED INTUBATED OVER NOC PEND PLAN,SEE RESP FLOWSHEET FOR VENT DETAILS ABG DATA,PT Q 2-3 HRS FOR SM AMTS THICK CLEAR-WHITE SECRETIONS.PT COUGH STRONG.O2 SATS 96-100%.\nGI/GU-PT CONTS TO HAVE LARGE STOOL + NG OUTPUTS OVER NOC.,O/U 10-30CC/HR AMBER CLEAR URINE OVER NOC VIA FOLEY,FLUID BOLUS X 2 FOR LOW U/O.NPO,STOOL LIQ BROWN.C-DIFF SPEC SENT.\nSKIN-NO NEW SKIN INTEGRITY ISSUES,POST ECCYMOSSIS LUE,LLE.\nSOC-NO FAMILY CALLS OVER NOC.\nID-T MAX 99.3\nENDO-FS BS 90'S\nA-ALT NEURO STATUS R/T MVA SPINE TRAUMA.\nP-CONT NEURO MONITORING,SEDATION/ORDERS,VS,I+O,MONITOR LAB DATA QS AND PRN,FAMILY SUPPORT PRN,MONITOR SKIN INTEGRITY QS AND PRN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-06-05 00:00:00.000",
"description": "Report",
"row_id": 1423981,
"text": "Resp Care,\nPt. weaned to CPAP IPS10.5/5peep this am. VT 450, RR20. Cont. to wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-06-05 00:00:00.000",
"description": "Report",
"row_id": 1423982,
"text": "RESP NOTE:PT EXTUBATED AS PER ORDER W/O INCIDENT,PLACED ON 3L/NC MAINTAINING SATS 97-100%.NO RESP DISTRESS NOTED,WILL CONTINUE TO MONITOR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-06-05 00:00:00.000",
"description": "Report",
"row_id": 1423983,
"text": "SOCIAL WORK NOTE:\nPt remains disoriented to time and place. No contact with family by this SW today. Will remain involved as needed. Pager .\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-06-05 00:00:00.000",
"description": "Report",
"row_id": 1423984,
"text": "NSG NOTE\nROS:\n\n CV:SYS BP 150'S/70'S,IN SR WITH RARE APC'S.RR 21-33.T MAX 99.8\n\n RESP:PPT EXTUBATED AT 3:30PM.SX FOR LARGE AMT THIN TAN SECRETIONS PRIOP TO EXTUB,MUCH LESS SECRETIONS NOW.SATS 99 ON 3L NP.ABGS 7.43-35-100.\n\n NEURO:TALKING RAG TIME SINCE EXTUBATED,WILL FOLLOW COMMANDS.STRONG HAND GRIP ON L,WEAKER ON R.MOVES R FOOT MORE THAN L.\nON ATIVAN Q6HRS.\n\n GU:UO ACCEPTABLE,AMBER COLOR.RECEIVING 150CC HR BANANA BAG THEN NS WITH 20 KCL AT 150CC HR.\n\n GI:NPO,NGT DRAINING TONS BILIOUS FLD,DRAINING LARGE AMT LIQUID STOOL VIA RECTAL BAG AS WELL.\n\n ENDO:FS 91-87 NO INSULIN\n\n HEME:HCT 24,GIVEN 1U P CELLS,REPEAT HCT 30.2\n\n LYTES:K 3.5---GIVEN 40 KCL/500NS OVER 4HRS(3P-7P)\n\n SOCIAL:DAUGHTER CALLED,SPOKE TO T-SICU HO RE MRI FROM .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-06-06 00:00:00.000",
"description": "Report",
"row_id": 1423985,
"text": "nsg :\nneuro obeys commands but very confused. will raise knees and wiggle toes. strong grasp but unable to lift arms very far. does not bend elbows.\n\nstable hemodynaically. afebrile. ivf at 150ccs per hr. uo qs.\n\ngi lg amt of ng drainage, and liq brown stool spec sent for c diff.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-06-03 00:00:00.000",
"description": "Report",
"row_id": 1423975,
"text": "Nursing Admission Note\nPt is a 59yo male who was wearing a helmet and got into a motorcycle accident on . He was admitted to an OSH. Head CT (+) for bilateral small posterior parietal intraparenchymal bleed. Per report Pt was alert and oriented. Today Pt was noted to have upper extremity weakness. Repeat head CT did not show any change, but further w/u revealed T7 vetebral body compression fracture. Pt was transferred to after being paralyzed/sedated and intubated. Extubated in EW and admitted to T/SICU. Pt arrived on stretcher accompanied by physician. was awake, oriented to person, but otherwise confused. LR infusing and NGT clamped.\n\nPMH:\n-HTN\n-Gout\n-s/p multiple ORIF of LA and L leg d/t prior motorcycle accident.\n\nAllergies: no known medication allergies\n\nMedications: Indomethacin\n\nSocial: ppd smoker, (+) heavy ETOH use every day. Lives alone. Divorced. Has 2 daughters. Daughter, , was here when Pt was admitted.\n\nReview of Systems\nNeuro: Pt is awake and is able to tell me his name, but could not tell me where he was or what year it is. He talks outloud to persons who are not present and thought he was in a police station. Follows commands. PERRL. Can not raise arms independently off bed. He uses siderails to raise them, but can not hold them them in air. / to nailbed pressure. Cervical collar on. Logroll precautions.\n\nResp: Breathing unlabored. Sao2 on 4L NC=96%.\n\nCV: HR in the 80s. NSR. BP=138/57.\n\nGI: NGT to LCS drained 800cc bilious fluid after arival to ICU. Abdomen is distended, but soft.\n\nGU: Foley to gravity. Urine amber.\n\nID: Afebrile.\n\nSkin: Large hematoma present on left thigh. Backside inatct.\n\nSocial: Daughter, , here when Pt arrived. No belongings left at bedside.\n\nA: Hemodynmics stable. Pt confused. Limited mobility.\n\nP: Neuro checks q 1hr. Ativan for DT prophylaxis. ? MRI of spine. Monitor per plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-06-04 00:00:00.000",
"description": "Report",
"row_id": 1423976,
"text": "S/P MOTORCYCLE MVA HEAD/SPINE TRAUMA T/SICU\nNPN 11P-7A\nS-\"I'M ALRIGHT NOW BUT THIS WHOLE PLACE IS GONNA BLOW IN 2 HRS\"\nO-NEURO-PT A+O X OVER NOC,FOLLOWS SIMPLE COMMANDS MAE'S,SPASTIC GROSS MOTOR MOVEMENTS BILAT UPPER AND LOWER EXTREMITIES,HAND GRASPS 4+ STRENTGH BILAT,PERRLA 2-3MM.PT PERSEVERATING/RAMBLING SPEECH/OCCAS FOUL LANGUAGE,PT GIVEN TOTAL 3.5 MG ATIVAN OVER NOC.PT DOWN FOR MRI C-SPINE/T-SPINE THIS AM.\nCV-PT HR 80'S NSR W/ BURST SVT/SELF LIMITED X 2.SBP 110'S-130'S OVER NOC.\nRESP-PT LS CTA DECREASED BASES,O2 SATS 94-100% ON 4 L NC,O2 SATS 88-90% ON RA,RR 18-26,NARD.\nGI/GU-PT ABD OBESE SOFT +HYPOACTIVE BS,NPO,NGT DRAINING MOD -LARGE AMTS BILIOUS DRAINAGE.PT URINE CLEAR AMBER VIA FOLEY U/O ADEQ.LOOSE BROWN STOOL SM-MOD AMT X 2 OVER NOC,\nSKIN-NO NEW SKIN INTEGRITY ISSUES.\nSOC-PT'S DAUGHTER CALLED X 1 OVER NOC.\nA-ALT NEURO EXAM S/P T/SPINE TRAUMA.\nP-CONT MONITOR NEURO EXAM/ORDERS,F/U W/ TM RE: RESULT MRI,VS,I+O,O2 /ORDERS,MONITOR SKIN INTEGRITY QS AND PRN,FAMILY SUPPORT PRN,SOC WORK\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-06-04 00:00:00.000",
"description": "Report",
"row_id": 1423977,
"text": "SOCIAL WORK NOTE:\nPt known to this SW from ED arrival yesterday. Please see my printed OMR note in chart for further information. Pt seen in room today in T-SICU. He thought that is was and asked if we are going \"crabbing\". He stated that this SW has always gathered \"a couple barrels of crabs\". This SW phoned pt's dtr at home to offer continued support (spoke with her yesterday). She is greatly upset by pt's altered mental status but is glad that he is back in and more accessible for visiting. She reports that pt is on disability due to knee problems. She confirmed that pt has long history of etoh abuse. Medical team is aware of pt's long and active history of etoh abuse. Dtr given contact information for this SW and I will remain involved. Pager .\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-06-04 00:00:00.000",
"description": "Report",
"row_id": 1423978,
"text": "T-SICU NURSING PROGRESS NOTE\nNEURO: AROUSABLE TO VOICE, ORIENTED TO SELF ONLY. PT TALKING OUT LOUD, VERY CONFUSED, THINKS IT IS AND THAT HE IS AT THE POLICE STATION. ABLE TO STATE THE NAME OF HIS CHILDREN AND THAT HE IS FROM , MA. HAND GRASP BILAT, ABLE TO EXTEND BOTH ARMS BUT UNABLE TO FLEX OR HOLD UP ARMS. WIGLLES TOES TO COMMAND, ABLE TO PLANTAR FLEX BOTH FEET, LEFT FOOT STRONGER THAN RIGHT. PUPILS 3MM BILAT AND BRISKLY REACTIVE. REMAINS IN C-COLLAR. TAKEN BACK TO MRI AT 5:30PM D/T POOR QUALITY OF FIRST SCAN. PT WAS SEDATED WITH FENTANYL AND MIDAZ. PT WAS SLEEPY BUT D/T HIS BREATHING PATTERN THERE WAS TOO MUCH WALL MOTION AND SCAN QUALITY WAS POOR. PT WAS ELECTIVELY INTUBATED TO COMPLETE THE SCAN.\n\nCV: HR 80S, NSR WITH FREQ PAC'S, ATRIAL BIGEM. BP STABLE 120-140/70. SKIN WARM, DRY, (+)PALP PULSES, TRACE PEDAL EDEMA\n\nRESP: AS ABOVE, PT WAS ELECTIVELY INTUBATED TO COMPLETE MRI. PRIOR TO INTUBATION, BREATH SOUNDS CLEAR IN UPPER LOBES, VERY DIMINISHED IN THE BASES BILAT. AFTER INTUBATION, PT WAS SUCTIONED FOR THICK, COPIOUS YELLOW SECRETIONS. PRIOR TO INTUBATION SATS 96-98% ON 2LNC\n\nRENAL: URINE AMBER IN COLOR, BORDERLINE U/O ~ 25-40CC/HR. LYTES SENT, RESULTS PENDING\n\nGI: ABD OBESE, SOFT, (+)BOWEL SOUNDS. LIQUID BROWN STOOL, LARGE AMT, RECTAL BAG PLACED. REMAINS NPO. MODERATE NGT OUTPUT,\n\nHEME: HCT 26.1 (FROM 28), TEAM AWARE, NO SIGNS OF BLEEDING, WILL CONTINUE TO MONITOR\n\nID: T. MAX 99.5, NO ABX\n\nSKIN: LARGE HEMATOMA ALONG BACK OF LEFT LEG, ABRASIONS TO BILAT SHINS, BACK/BUTTOCKS INTACT. SKIN UNDER C-COLLAR INTACT\n\nSOCIAL: PT'S DAUGHTER CALLED X 2 TODAY, UPDATED ON PT'S CONDITION\n\nENDO: NO INSULIN COVERAGE REQUIRED\n\nA: ALTERED MENTAL STATUS, DECREASED STRENGTH ALL EXTS, ?T4-T7 INJURY--MRI RESULTS PENDING\n\nP: Q1H NEURO CHECKS, LOGROLL PRECAUTIONS, CONTINUE CURRENT PLAN, FOLLOW RESULTS OF MRI\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-06-06 00:00:00.000",
"description": "Report",
"row_id": 1423986,
"text": "S. THE BROUGHT ME HERE IN A BOX I NEED SOME CLOTHES\nO.NEURO PT CONFUSED ALERT TO NAME RAMBLING PEARLA FC GOOD GRASPS BOTH HANDS RIGHT ARM ABLE TO COME UP 30 DEGREES LT 45 DEGREES STRENGHT SL. BETTER IN LT, RT AND LT LEG MOVING ON BED, HALDOL 1MG IV X 1\nCARDIAC NSR OCC ECTOPY BP 130/-150/84 HCT 30.6 K 4.4 RT LEG WARM ERYTHEMATOUS ANT 2/3 UP, PAIN TO TOUCH US DONE PRELIM NEG BLOOD CLOT, STARTED ON KEFLEX CVP 9 CL PLACED LT SC TRIPLE LUMEN PP+2, SCAB BELOW RT KNEE UNCHANGED AND LT ANKLE LACERATION UNCHANGED BACITRACAN\nRESP 4LNP 7.40/31/84/20 LUNGS CTA COUGHING SWALLOWING SPUTUM\nGI NPO IV NS 150 Q HR ABD SOFT DISTENDED BS HYPERACTIVE NGT OUTPUT 1L BILIOUS STOOL GOLDEN TO TAR COLOR LIQ THIRD STOOL FOR CDIFF SENT LDH 395 TOTAL BILI 4.7 LACTIC ACID AST 45 ALT 28\nGU U/O > 60CC QHR AMBER\nNUTRITION TRIPLE LUMEN LT SC PLACED FOR TPN\nID WBC 10.8 BC X2 DRAWN KEFLEX IV STARTED\nA. ALT NEURO STATUS C4-5 CONTUSION POSSIBLE CENTRAL CORD SYNDROME WITH EXTREMITY WEAKNESS BILAT, ALT MS ? RELATED TO ATIVAN GIVEN\nALT SKIN POSS. CELLULITIS\nALT NUTRITIONAL STATUS HIGH NGT OUTPUT AND DIARRHEA\nETOH ABUSE\n+ SMOKER\nP. PT FITTED FOR COLLAR AND CHEST BRACE TO START REHAB\nCONT TO LOGROLL TILL THEN\nPT OT CONSULT\nCHANGE ATIVAN TO PRN GIVE HALDOL AS NEEDED\nSTART TPN\nWATCH ANY S+S OF \nORIENT PT FREQUENTLY\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-06-07 00:00:00.000",
"description": "Report",
"row_id": 1423987,
"text": "S/P MOTORCYCLE MVA/SPINE TRAUMA T/SICU NPN 7P-7A\nS-\"IT' \"\n0-NEURO-PT A+O X 0-2 NAME +/OR DATE(MONTH/YEAR)OVER NOC,MAE'S,HAND GRASPS STRONG BILAT,PT NOW ABLE TO RAISE BUE UP OFF BED W/ DIFF NOW ABLE TO ALSO BEND ELBOWS BILAT,PT MOVES TO COMMAND,^^ STRENGTH ABLE TO BEND KNEES UP OFF BED BILAT.STRONG GAG/COUGH EFFORT,PERRLA 2-3MM.\nCV-SEE FLOWSHEET FOR VS DETAILS,HR 60'S-90'S OVER NOC,SBP 120'S-160'S.+DP/PT \n LS CTA DECREASED SL BASES-O2 SATS 94-96% ON RA,O2 WEANED OFF.RR 16-24,PT C/ODIFF BREATHING @ 6A,RESOLVED W/ ORAL OF THICK WHITE MUCOUS.\nGI/GU-PT ABD SOFT OBESE + HYPOACTIVE BS,NGT CONTS TO DRAIN MOD AMTS BILIOUS FLUID CHANGED FROM LCWS->LIWS.U/O ADEQ AMBER CLEAR URINE VIA FOLEY.NPO.TPN CONTS.\nSKIN-NO NEW ISSUES\nSOC-PT DAUGHTER CALLED X 1 OVER NOC.\nID-T MAX 99.3\nENDO-BS WNL\nA-ALT MS ? R/T HEAD TRAUMA VS SEDATIVES\nP-CONT TO MONITOR NEURO EXAM,VS,MONITOR RESP QS AND PRN,I+O,O2 PRN,TPN/ORDERS,MONITOR SKIN INTEGRITY QS AND PRN.\n"
}
] |
85,175 | 181,238 | Admitted and went to surgery for Aortic Valve Replacement (#25mm St. Porcine Valve). See operative report for further details. He was transferred to the CVICU for hemodynamic monitoring. In first twenty four hours he was weaned from sedation, awoke neurologically intact and was extubated without complications. On postoperative day one he went into Atrial Fibrillation that was treated with amiodarone and lopressor. Overnight day 1 into day 2 he had pauses > 10 seconds and amiodarone was discontinued. He had no further prolonged pauses off amiodarone but remained in atrial fibrillation. He was started on coumadin for anticoagulation. Sleep consult was called due history of sleep apnea and he was placed on auto CPAP as tolerated. General Surgery consulted for abdominal distention and distended loops in bowel evident on KUB. He received bowels medications with flatus, bowel movements, and over few days the abdomen improved. His diet was progressed and he has been tolerating regular diet. EP consulted for rapid atrial fibrillation with rate not controlled with beta blockers, and diltiazem drip was started. His medications were adjusted to toprol XL in am and cardizem CD in pm with heart rate 70-100 atrial fibrillation. He was discharged home with his family and VNA services. | occassional etoh,gerd. Lethargic today, oriented to person and time. is p/w above impairments c/w c-v pump dysfunction and currently POD#2. Action: + flatus, Oob to commode. Nitro titrated. Lungs clear initially, crackles noted late am. Abdomen softly distended with +hypoactive bowel sounds. Reposition q 2 hrs. HR 70s- 80s post lopressor with minimal ectopy. Extubated . Transfers, Impaired Clinical impression / Prognosis: Pt. became nauseated with phlegm clearance Posture: forward head and rounded shoulders Range of Motion Muscle Performance WFL B grip strong B UE and LEs greater and/or = Motor Function: No abnormal movements noted Functional Status: Activity Clarification I S CG Min Mod Max Gait, Locomotion: Pt. Rate controlled. Acute Pain Assessment: Pt. Response: SR 70s. Atrial fibrillation (Afib) Assessment: Pt. Hydralazine and Lopressor given iv. Response: Pt. Lasix started iv. Plan: Valve replacement, aortic bioprosthetic (AVR) Assessment: Action: Response: Plan: Atrial fibrillation (Afib) Assessment: Afib with varying v response, occ pvc noted. I bed mobility c HOB flat 2. SBP low 100s to 130 Cardiac index >2. av paced for very slow underlying rythym? av paced for very slow underlying rythym? av paced for very slow underlying rythym? av paced for very slow underlying rythym? av paced for very slow underlying rythym? Response: Afib continues. Plan: Abg, enc cough and deep breathe, decrease fio2 requirements as tolerates. Valve replacement, aortic bioprosthetic (AVR) Assessment: Sleepy on propofol 10mg this am. Rolling: Supine / Sidelying to Sit: Transfer: Sit to Stand: T Ambulation: Stairs: Balance: Min A for static standing balance > 1 minute. occassional etoh,gerd. Action: + flatus, Oob to commode. Plan: Wean sedation to extubate in AM. Atrial fibrillation (Afib) Assessment: Afib with varying v response, occ pvc noted. Atrial fibrillation (Afib) Assessment: Pt remains in afib. Atrial fibrillation (Afib) Assessment: Pt remains in afib. Wean fio2 requirements as pt tolerates. Wean fio2 requirements as pt tolerates. Assessment: Pt. Rate controlled. Coumdain today. Coumdain today. Response: Afib continues. Response: Afib continues. BS WNL . Abd still distented. Neo & NTG titrated to on & off as needed to keep BP parameter. Between masks and pa aware. Between masks and pa aware. Chest tube drng. Metoprolol Tartrate 17. Action: Reglan given x2. ambulated 80ft pushing w/c with CGA. Furosemide 11. Hyperactive bs noted on assessment. Hyperactive bs noted on assessment. Plan: Valve replacement, aortic bioprosthetic (AVR) Assessment: Action: Response: Plan: Atrial fibrillation (Afib) Assessment: Afib with varying v response, occ pvc noted. pt. Pt. Pt. Pt. Pt. BP management with NTG/NEO. Ranitidine 23. in to evaluate pt. Plan: Lfts. Abdoment distented, bowel sounds present. Milk of Magnesia 18. Abdomen the same as assessment . Abdomen the same as assessment . CefazoLIN 8. 1:1 time with patient. + flatus. + flatus. Morphine Sulfate 19. Docusate Sodium 10. Metoclopramide 16. Response: Pt ahd a large bowel movement, soft/formed. HCT ~32. 0-20cc/hr. Pt to have KUB., LFTs.to be drawn. Pt cooperative on alternating. Pt cooperative on alternating. Abg sent see flowsheet. Constipation (Obstipation, FOS) Assessment: Pt has obese, firm and distended abdomen. Constipation (Obstipation, FOS) Assessment: Pt has obese, firm and distended abdomen. Plan: Abg, enc cough and deep breathe, decrease fio2 requirements as tolerates. Trace aortic regurgitation is seen.Trivial mitral regurgitation is seen. There are simple atheroma inthe descending thoracic aorta. Trace AR.MITRAL VALVE: Trivial MR.TRICUSPID VALVE: Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. There is mild aorticvalve stenosis (valve area 1.2-1.9cm2). Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\AORTIC VALVE REPLACEMENT; ? The left basal opacities consistent with a combination of atelectasis and pleural effusion. PATIENT/TEST INFORMATION:Indication: Intraoperative TEE for aortic valve replacement.Height: (in) 70Weight (lb): 210BSA (m2): 2.13 m2Status: InpatientDate/Time: at 08:56Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RAand extending into the RV. PA and lateral upright chest radiographs were compared to . The left retrocardiac opacity, triangular in shape is most likely a combination of left lower lobe atelectasis and pleural effusion which is small and unchanged since the prior study. infiltrate Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\AORTIC VALVE REPLACEMENT; ? 9:18 AM CHEST (PA & LAT) Clip # Reason: f/u effusions/atx Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\AORTIC VALVE REPLACEMENT; ? Mildly dilated descending aorta. FINDINGS: In comparison with the study of , the endotracheal tube, mediastinal , and nasogastric tube have been removed. There issevere symmetric left ventricular hypertrophy. The ascending aorta is mildly dilated.The descending thoracic aorta is mildly dilated. 7:55 AM PORTABLE ABDOMEN Clip # Reason: evaluate dilated loops Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\AORTIC VALVE REPLACEMENT; ? | 47 | [
{
"category": "Nursing",
"chartdate": "2114-05-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674302,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt. went into fib rate 90\ns -120\ns at 0445. K 4.3. Ion ca++ > 1.12.\n Action:\n . IV lopressor 5mg IV (0600) dose given early.\n Response:\n Continues in afib 90\n 130s a times, BP 166/60\n Plan:\n start Amiodarone if rate uncontrolled,\n"
},
{
"category": "Rehab Services",
"chartdate": "2114-05-23 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 674429,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: AVR / 424.1\n Reason of referral: Eval and Treat\n History of Present Illness / Subjective Complaint: 77y/o male admitted\n s/p AVR (#25mm Porcine Valve) on and POD#2.\n CPBT 89min, XCT 52min. Pt. has fragile aorta and was not repaired.\n Extubated .\n Past Medical / Surgical History: AS, increase lipids, AAA 4.3x4.9cm,\n sleep apnea but doesnt use, arthritis, CHF recent admission 3 weeks\n ago, sinus infections, basal cell CA, L ear deafness, choley, back\n surgery, s/p removal cyst in leg, quit smoking 25yrs ago,wife passed\n away 6mnths ago, occasional ETOH, GERD, positional vertigo 07'\n Medications: acetaminophen, metoclopramide, nitroglycerin, ranitidine,\n simvastatin, furosemide, tramadol, hydralazine, amiodarone, metoprolol\n tartrate\n Radiology: CXR : pericardial gas; basilar opacifications consistent\n combination of atelectasis and pleural effusion especially at L base\n Labs:\n 33.8\n 11.5\n 106\n 13.5\n [image002.jpg]\n Other labs:\n Activity Orders: Per cardiac surgery guidelines\n Social / Occupational History: (Per dtr) Lives alone; supportive 5\n children\n Living Environment: (Per dtr) Lives in home; + stairs\n Prior Functional Status / Activity Level: (Per dtr) PTA I; drives; no\n falls\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt. lethargic, eyes\n closed, and slow to respond. Pt. oriented to year and that he is\n located in a hospital. Constant verbal & tactile cues to arouse and for\n eye opening. Follows simple commands with repeated cues and responds\n appropriately with increase response time verbally and physically\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n /\n Sit\n 95\n 133/62\n 20\n 98 (5L)\n Activity\n /\n 87 (RA)\n Stand\n /\n Recovery\n 86\n 131/69\n 19\n 93 (5L)\n Total distance walked: NA\n Minutes:\n Pulmonary Status: breathing pattern: even/nonlabored\n cough:strong,wet,productive\n Integumentary / Vascular: tele, sternal drsg c/d/i, foley, external\n pacer and wires, L A-line, L subclavian, L PIV, R PIV\n Sensory Integrity: intact to light touch; + DPP\n Pain / Limiting Symptoms: pain 0/10; c/o dizziness and nausea at times;\n pt. became nauseated with phlegm clearance\n Posture: forward head and rounded shoulders\n Range of Motion\n Muscle Performance\n WFL\n B grip strong\n B UE and LEs greater and/or = \n Motor Function: No abnormal movements noted\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt. presented seated in chair. Min A to lean forward\n and back in chair. Min A sit to stand x 2 with min A to maintain static\n standing > 1 minute. Pt. c/o nausea and dizziness with stance.\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n T\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Min A for static standing balance > 1 minute. No overt LOB.\n Education / Communication: c RN re pt status\n c pt and daughter re role of PT, , goals, d/c planning, education,\n importance of mobility\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n ADLs (Activities of Daily Living), Inability to perform\n 3.\n Arousal, Attention, and Cognition, Impaired\n 4.\n Balance, Impaired\n 5.\n Knowledge, Impaired\n 6.\n Posture, Impaired\n 7.\n Respiration / Gas Exchange, Impaired\n 8.\n Transfers, Impaired\n Clinical impression / Prognosis: Pt. is a 77y/o male s/p AVR. Pt. is\n p/w above impairments c/w c-v pump dysfunction and currently POD#2. Pt.\n extremely limited by lethargy and impaired cognition at this time. Pt.\n is functioning well below baseline; however, based on observation and\n mobility seen, anticipate that once patient is more aroused, will\n progress to a safe discharge home with 3-5 more PT treats for improving\n endurance, balance, arousal, and overall functional mobility. Pt. has\n family support for assist with discharge.\n Goals\n Time frame: 3-5x/wk\n 1.\n I bed mobility c HOB flat\n 2.\n I sit to stands\n 3.\n I amb 500ft\n 4.\n I with flight of stairs\n 5.\n A + O x 3 at all times; I with verbalizing sternal precautions\n 6.\n sp02 greater and/or = 92%RA at all times\n Anticipated Discharge: Home without PT\n Treatment :\n Frequency / Duration: 3-5x/wk x 1 week\n bed mobility, education, d/c planning, administer cardiac booklet, sit\n to stands, ambulate 500ft, stair negotiation, pulmonary exercises, wean\n 02 to RA\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674521,
"text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt lethargic most of morning. Napping fairly continuously. Oriented to\n place, person, year and events of having heart surgery. Constantly\n moaning.\n Action:\n Response:\n More alert during afternoon. Moaning decreased after pain med.\n Plan:\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Afib with varying v response, occ pvc noted. VSS.\n Action:\n Amio bolus given this am, drip started this afternoon.\n Response:\n Afib continues.\n Plan:\n Cont to monitor.\n"
},
{
"category": "Physician ",
"chartdate": "2114-05-23 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 674442,
"text": "CVICU\n HPI:\n s/p AVR (#25mm St. porcine)-\n EF: >75% Cr:1.2 Ht: 71\" Wt:209 LB\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\n CPAP\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\n Inderal 40(2)\n Current medications:\n Acetaminophen, Amiodarone, Aspirin EC, Docusate Sodium, Furosemide,\n HydrALAzine, Insulin, Metoprolol Tartrate, Ranitidine, Simvastatin\n 24 Hour Events:\n Remains in ICU for pulmonary monitoring\n Atrial fibrillation increased betablockers\n Extubated and Chest tubes removed\n EXTUBATION - At 09:00 AM\n CHEST TUBE REMOVED - At 09:00 AM\n INVASIVE VENTILATION - STOP 09:00 AM\n CCO PAC - STOP 11:30 AM\n Post operative day:\n POD#2 - AVR # porcine valve, fragile aorta. out on neo\n propofol, 10 ml ct drainage. av paced for very slow underlying rythym?\n sb.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:00 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 05:32 PM\n Hydralazine - 06:52 PM\n Metoprolol - 04:50 AM\n Ranitidine (Prophylaxis) - 08:22 AM\n Furosemide (Lasix) - 08:24 AM\n Other medications:\n Flowsheet Data as of 01:35 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 37\nC (98.6\n HR: 87 (76 - 111) bpm\n BP: 129/65(82) {99/45(63) - 160/65(87)} mmHg\n RR: 23 (18 - 31) insp/min\n SPO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 71 Inch\n Total In:\n 637 mL\n 227 mL\n PO:\n Tube feeding:\n IV Fluid:\n 637 mL\n 227 mL\n Blood products:\n Total out:\n 1,415 mL\n 400 mL\n Urine:\n 1,245 mL\n 400 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n -778 mL\n -173 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SPO2: 93%\n ABG: 7.37/41/81./23/-1\n PaO2 / FiO2: 162\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bilateral bases left > right ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n hypoactive\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n Moves all extremities, can state in hospital and year but unable to\n name hospital and reason for being in hospital\n Labs / Radiology\n 106 K/uL\n 11.5 g/dL\n 135 mg/dL\n 1.5 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 35 mg/dL\n 107 mEq/L\n 140 mEq/L\n 33.8 %\n 13.5 K/uL\n [image002.jpg]\n 11:45 AM\n 11:50 AM\n 02:58 PM\n 06:07 PM\n 06:25 PM\n 12:31 AM\n 12:37 AM\n 08:31 AM\n 02:52 AM\n 03:09 AM\n WBC\n 10.7\n 8.9\n 13.5\n Hct\n 35.1\n 30.9\n 32.9\n 33.8\n Plt\n 141\n 120\n 106\n Creatinine\n 1.2\n 1.1\n 1.5\n TCO2\n 28\n 27\n 27\n 25\n 23\n 25\n Glucose\n 130\n 113\n 135\n Other labs: PT / PTT / INR:15.4/37.9/1.4, Mg:2.8 mg/dL\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, ADLS (ACTIVITIES OF DAILY\n LIVING), INABILITY TO PERFORM, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, POSTURE, IMPAIRED,\n RESPIRATION / GAS EXCHANGE, IMPAIRED, TRANSFERS, IMPAIRED, ATRIAL\n FIBRILLATION (AFIB), VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR),\n ACUTE PAIN, .H/O AORTIC STENOSIS\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, percocet and ultram,\n will hold and evaluate due to somnulence after percocet\n Cardiovascular: Aspirin, Beta-blocker, Statins, amiodarone for atrial\n fibrillation, acute on chronic diasystolic heart failure\n Pulmonary: IS, cough and deep breath, auto CPAP at night for sleep\n apnea - previous diagnosis but does not wear mask at home\n Gastrointestinal / Abdomen: bowel regimen\n Nutrition: Regular diet\n Renal: Foley, Adequate UO, discontinue foley, cr 1.5 baseline 1.2,\n monitor i/o with goal 500 ml negative\n Hematology: stable anemia\n Endocrine: RISS, goal BG < 150\n Infectious Disease: WBC 13 from 8, remove cordis, check urine culture -\n will recheck WBC in am no indication for antibiotics at this time\n Lines / Tubes / Drains: Foley, Pacing wires\n Wounds: Dry dressings\n Consults: P.T., sleep consult\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 11:30 AM\n Cordis/Introducer - 12:00 PM\n 20 Gauge - 06:44 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674511,
"text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt lethargic most of morning. Napping fairly continuously. Oriented to\n place, person, year and events of having heart surgery. Constantly\n moaning.\n Action:\n Response:\n More alert during afternoon. Moaning decreased after pain med.\n Plan:\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674576,
"text": "Respiration / Gas Exchange, Impaired\n Assessment:\n Pt requiring increasing o2 requirement. More confused and lethargic.\n Sats 91% on 4lnc.\n Action:\n Changed to open face tent, sats increased to 93% for a short time. Pa\n aware. Pt became more confused/agitated/combative. Pa\n at bedside, 2.5mg haldol given, and 20mg iv lasix. Sats 78%.\n Changed to closed aerosol face mask. Abg sent see flowsheet.\n Response:\n Sats increased to 95% on closed face mask. Pt slept for short period,\n while asleep sats 96%. Pt awoke moaning and groaning, agitated. Ripping\n at oxygen mask. Pa aware. Fair response to lasix overnight.\n Resend abg to monitor co2 levels. Still breathing using accessory\n muscles, and rr 20s\ns-30\ns with agitation. Pa aware.\n Plan:\n Abg, enc cough and deep breathe, decrease fio2 requirements as\n tolerates.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib overnight 80\ns-90\ns. Rate controlled. Amio drip at\n 1mg/min changed to 0.5mg/min at 2100.\n Action:\n Afib with pvc\ns pt had 10second pause with junctional escape beats. Pa\n aware. Amio drip off. Pacer pad at bedside due to wires due\n not capture or sense approp.\n Response:\n No more pauses overnight.\n Plan:\n Discontinue amio, pads at bedside for ectopy. Monitor heart rate.\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt is pod#3 from Avr replacement. Alert, oriented x2. States\n Are we\n on a boat?\n 1:1 time with patient. 2a/2v wres do not capture or sense.\n Wires secured and pa aware. Pt has soft but very distended\n abdomen. KUB done on evening. Family in/out through most of evening\n shift. Very nervous about father, reassured about care. ? social work\n consult. Lasix given at with no response. DTV at 2100. Foley\n reinserted pa aware 400cc out when foley placed. Left foley\n in overnight to monitor urine output.\n Action:\n + flatus, Oob to commode. Dulcolax given with no reponse, fleet enema\n given with some response, then soap suds enema given. Pt c/o incisional\n pain with turning Tylenol given.\n Response:\n Pt ahd a large bowel movement, soft/formed. Tylenol had fair response.\n Pa aware, ultram given with good relief.\n Plan:\n Safety precautions, Rate control afib, enc is.\n"
},
{
"category": "Respiratory ",
"chartdate": "2114-05-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 674791,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt on BiPap 14/8 with some O2 added to keep O2 Sat > 92. Has a coarse\n cough occasionally productive. WILL go on\n BiPap to night at some time.\n, RRT 17:58\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674273,
"text": "Acute Pain\n Assessment:\n Pt. constantly moaning; states that he\ns uncomfortable but can\n clearly describe what he\ns feeling. Can answer with short answers but\n then mumbles and moans in between.\n Action:\n Seen by , PA. discontinued morphine prn order and ordered\n one dose of Toradol 15mg IM. Ultram PRN ordered as well. Pt.\n repositioned and encouraged to relax. Spoke with daughter via phone re:\n moaning and coping.\n Response:\n Pt. stated some relief of pain from severe to moderate. Becomes anxious\n when repositioned and requires emotional reinforcement.\n Plan:\n Prn pain meds & assess by pain scale.. Provide other comfort measures:\n reposition, backrubs, cool clothes.\n"
},
{
"category": "Physician ",
"chartdate": "2114-05-23 00:00:00.000",
"description": "Intensivist Note",
"row_id": 674489,
"text": "CVICU\n HPI:\n s/p AVR (#25mm St. porcine)-\n EF: >75% Cr:1.2 Ht: 71\" Wt:209 LB\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\n CPAP\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\n Inderal 40(2)\n Current medications:\n Acetaminophen, Amiodarone, Aspirin EC, Docusate Sodium, Furosemide,\n HydrALAzine, Insulin, Metoprolol Tartrate, Ranitidine, Simvastatin\n 24 Hour Events:\n Remains in ICU for pulmonary monitoring\n Atrial fibrillation increased betablockers\n Extubated and Chest tubes removed\n EXTUBATION - At 09:00 AM\n CHEST TUBE REMOVED - At 09:00 AM\n INVASIVE VENTILATION - STOP 09:00 AM\n CCO PAC - STOP 11:30 AM\n Post operative day:\n POD#2 - AVR # porcine valve, fragile aorta. out on neo\n propofol, 10 ml ct drainage. av paced for very slow underlying rythym?\n sb.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:00 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 05:32 PM\n Hydralazine - 06:52 PM\n Metoprolol - 04:50 AM\n Ranitidine (Prophylaxis) - 08:22 AM\n Furosemide (Lasix) - 08:24 AM\n Other medications:\n Flowsheet Data as of 01:35 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 37\nC (98.6\n HR: 87 (76 - 111) bpm\n BP: 129/65(82) {99/45(63) - 160/65(87)} mmHg\n RR: 23 (18 - 31) insp/min\n SPO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 71 Inch\n Total In:\n 637 mL\n 227 mL\n PO:\n Tube feeding:\n IV Fluid:\n 637 mL\n 227 mL\n Blood products:\n Total out:\n 1,415 mL\n 400 mL\n Urine:\n 1,245 mL\n 400 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n -778 mL\n -173 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SPO2: 93%\n ABG: 7.37/41/81./23/-1\n PaO2 / FiO2: 162\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bilateral bases left > right ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n hypoactive\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n Moves all extremities, can state in hospital and year but unable to\n name hospital and reason for being in hospital\n Labs / Radiology\n 106 K/uL\n 11.5 g/dL\n 135 mg/dL\n 1.5 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 35 mg/dL\n 107 mEq/L\n 140 mEq/L\n 33.8 %\n 13.5 K/uL\n [image002.jpg]\n 11:45 AM\n 11:50 AM\n 02:58 PM\n 06:07 PM\n 06:25 PM\n 12:31 AM\n 12:37 AM\n 08:31 AM\n 02:52 AM\n 03:09 AM\n WBC\n 10.7\n 8.9\n 13.5\n Hct\n 35.1\n 30.9\n 32.9\n 33.8\n Plt\n 141\n 120\n 106\n Creatinine\n 1.2\n 1.1\n 1.5\n TCO2\n 28\n 27\n 27\n 25\n 23\n 25\n Glucose\n 130\n 113\n 135\n Other labs: PT / PTT / INR:15.4/37.9/1.4, Mg:2.8 mg/dL\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, ADLS (ACTIVITIES OF DAILY\n LIVING), INABILITY TO PERFORM, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, POSTURE, IMPAIRED,\n RESPIRATION / GAS EXCHANGE, IMPAIRED, TRANSFERS, IMPAIRED, ATRIAL\n FIBRILLATION (AFIB), VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR),\n ACUTE PAIN, .H/O AORTIC STENOSIS\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, percocet and ultram,\n will hold and evaluate due to somnolence after percocet\n Cardiovascular: Aspirin, Beta-blocker, Statins, amiodarone for atrial\n fibrillation, acute on chronic diasystolic heart failure\n Pulmonary: IS, cough and deep breath, auto CPAP at night for sleep\n apnea - previous diagnosis but does not wear mask at home\n Gastrointestinal / Abdomen: bowel regimen\n Nutrition: Regular diet\n Renal: Foley, Adequate UO, discontinue foley, creatinine 1.5 baseline\n 1.2, monitor UOP with goal 500 ml negative\n Hematology: stable anemia\n Endocrine: RISS, goal BG < 150\n Infectious Disease: WBC 13 from 8, remove CVL, check urine culture -\n will recheck WBC in am no indication for antibiotics at this time\n Lines / Tubes / Drains: Foley, Pacing wires\n Wounds: Dry dressings\n Consults: P.T., sleep consult\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 11:30 AM\n Cordis/Introducer - 12:00 PM\n 20 Gauge - 06:44 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2114-05-24 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 674667,
"text": "CVICU\n HPI:\n HD4\n POD3\n 77M s/p AVR (#25mm St. porcine)-\n EF: >75% Cr:1.2 Ht: 71\" Wt:209 LB\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\n CPAP\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\n Inderal 40(2)\n Current medications:\n Acetaminophen, Aspirin EC, Bisacodyl, Docusate Sodium, Heparin,\n Insulin, Metoprolol Tartrate, Milk of Magnesia, Ranitidine,\n Simvastatin, TraMADOL\n 24 Hour Events:\n Remains in ICU for pulmonary monitoring\n CPAP overnight required haldol for confusion\n Foley removed due to urinary retention reinserted 400ml\n Amiodarone stopped due to pauses remains in atrial fibrillation\n ARTERIAL LINE - STOP 02:23 PM\n Post operative day:\n POD#3 - AVR # porcine valve, fragile aorta. out on neo\n propofol, 10 ml ct drainage. av paced for very slow underlying rythym?\n sb.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 02:30 AM\n Haloperidol (Haldol) - 02:30 AM\n Heparin Sodium - 08:00 AM\n Other medications:\n Flowsheet Data as of 08:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.2\n T current: 35.9\nC (96.7\n HR: 99 (79 - 107) bpm\n BP: 133/72(83) {91/49(61) - 160/98(120)} mmHg\n RR: 17 (13 - 28) insp/min\n SPO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 71 Inch\n Total In:\n 535 mL\n 43 mL\n PO:\n 120 mL\n Tube feeding:\n IV Fluid:\n 415 mL\n 43 mL\n Blood products:\n Total out:\n 1,300 mL\n 410 mL\n Urine:\n 1,300 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -765 mL\n -367 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 93%\n ABG: 7.30/52/76./22/-1\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, bm \n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities, more alert and\n answering questions with sentences, aware in hospital for\n surgery\n Labs / Radiology\n 103 K/uL\n 10.5 g/dL\n 105 mg/dL\n 1.5 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 46 mg/dL\n 101 mEq/L\n 132 mEq/L\n 31.9 %\n 11.2 K/uL\n [image002.jpg]\n 06:07 PM\n 06:25 PM\n 12:31 AM\n 12:37 AM\n 08:31 AM\n 02:52 AM\n 03:09 AM\n 03:01 AM\n 03:04 AM\n 05:39 AM\n WBC\n 8.9\n 13.5\n 11.2\n Hct\n 30.9\n 32.9\n 33.8\n 31.9\n Plt\n 120\n 106\n 103\n Creatinine\n 1.1\n 1.5\n 1.5\n TCO2\n 27\n 25\n 23\n 25\n 27\n 27\n Glucose\n 113\n 135\n 268\n 105\n Other labs: PT / PTT / INR:16.3/37.9/1.5, ALT / AST:6/35, Alk-Phos / T\n bili:56/1.0, Amylase / Lipase:36/18, Albumin:3.6 g/dL, LDH:249 IU/L,\n Mg:2.7 mg/dL\n Imaging: cxr and kub pending\n Microbiology: mrsa no growth\n urine pending u/a negative\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, ADLS (ACTIVITIES OF DAILY\n LIVING), INABILITY TO PERFORM, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, POSTURE, IMPAIRED,\n RESPIRATION / GAS EXCHANGE, IMPAIRED, TRANSFERS, IMPAIRED, ATRIAL\n FIBRILLATION (AFIB), VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR),\n ACUTE PAIN, .H/O AORTIC STENOSIS\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, hold all narcotics\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue epicardial\n wires, increase betablocker for rate control, amiodarone stopped due to\n pauses overnight, remains in atrial fibrillation\n acute on chronic diasystolic heart failure\n Pulmonary: IS, cough and deep breath, increase ambulation, auto cpap at\n night for sleep apnea\n Gastrointestinal / Abdomen: bowel regimen, repeat Abdominal xray for\n dilated loops\n Nutrition: Clear liquids, no free water due to hyponatremia\n Renal: Foley, Adequate UO, goal fluid balance equal, maintain foley due\n to urinary retention will attempt removing \n Hematology: stable anemia\n Endocrine: RISS, goal BG < 150\n Infectious Disease: WBC 11 from 13, afebrile no evidence of infection\n Lines / Tubes / Drains: Foley, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today, KUB today\n Consults: P.T., Nutrition\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Cordis/Introducer - 12:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2114-05-24 00:00:00.000",
"description": "ICU Note",
"row_id": 674668,
"text": "TITLE: Intensivist\n HPI:\n HD4\n POD3\n 77M s/p AVR (#25mm St. porcine)-\n EF: >75% Cr:1.2 Ht: 71\" Wt:209 LB\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\n CPAP\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\n Inderal 40(2)\n Current medications:\n Acetaminophen, Aspirin EC, Bisacodyl, Docusate Sodium, Heparin,\n Insulin, Metoprolol Tartrate, Milk of Magnesia, Ranitidine,\n Simvastatin, TraMADOL\n 24 Hour Events:\n Remains in ICU for pulmonary monitoring\n CPAP overnight required haldol for confusion\n Foley removed due to urinary retention reinserted 400ml\n Amiodarone stopped due to pauses remains in atrial fibrillation\n ARTERIAL LINE - STOP 02:23 PM\n Post operative day:\n POD#3 - AVR # porcine valve, fragile aorta. out on neo\n propofol, 10 ml ct drainage. av paced for very slow underlying rythym?\n sb.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:00 PM\n Other ICU medications:\n Furosemide (Lasix) - 02:30 AM\n Haloperidol (Haldol) - 02:30 AM\n Heparin Sodium - 08:00 AM\n Other medications:\n Flowsheet Data as of 08:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.2\n T current: 35.9\nC (96.7\n HR: 99 (79 - 107) bpm\n BP: 133/72(83) {91/49(61) - 160/98(120)} mmHg\n RR: 17 (13 - 28) insp/min\n SPO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 71 Inch\n Total In:\n 535 mL\n 43 mL\n PO:\n 120 mL\n Tube feeding:\n IV Fluid:\n 415 mL\n 43 mL\n Blood products:\n Total out:\n 1,300 mL\n 410 mL\n Urine:\n 1,300 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -765 mL\n -367 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 93%\n ABG: 7.30/52/76./22/-1\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, bm \n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities, more alert and\n answering questions with sentences, aware in hospital for\n surgery\n Labs / Radiology\n 103 K/uL\n 10.5 g/dL\n 105 mg/dL\n 1.5 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 46 mg/dL\n 101 mEq/L\n 132 mEq/L\n 31.9 %\n 11.2 K/uL\n [image002.jpg]\n 06:07 PM\n 06:25 PM\n 12:31 AM\n 12:37 AM\n 08:31 AM\n 02:52 AM\n 03:09 AM\n 03:01 AM\n 03:04 AM\n 05:39 AM\n WBC\n 8.9\n 13.5\n 11.2\n Hct\n 30.9\n 32.9\n 33.8\n 31.9\n Plt\n 120\n 106\n 103\n Creatinine\n 1.1\n 1.5\n 1.5\n TCO2\n 27\n 25\n 23\n 25\n 27\n 27\n Glucose\n 113\n 135\n 268\n 105\n Other labs: PT / PTT / INR:16.3/37.9/1.5, ALT / AST:6/35, Alk-Phos / T\n bili:56/1.0, Amylase / Lipase:36/18, Albumin:3.6 g/dL, LDH:249 IU/L,\n Mg:2.7 mg/dL\n Imaging: cxr and kub pending\n Microbiology: mrsa no growth\n urine pending u/a negative\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, ADLS (ACTIVITIES OF DAILY\n LIVING), INABILITY TO PERFORM, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, POSTURE, IMPAIRED,\n RESPIRATION / GAS EXCHANGE, IMPAIRED, TRANSFERS, IMPAIRED, ATRIAL\n FIBRILLATION (AFIB), VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR),\n ACUTE PAIN, .H/O AORTIC STENOSIS\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, hold all narcotics\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue epicardial\n wires, increase betablocker for rate control, amiodarone stopped due to\n pauses overnight, remains in atrial fibrillation\n acute on chronic diasystolic heart failure\n Pulmonary: IS, cough and deep breath, increase ambulation, auto cpap at\n night for sleep apnea\n Gastrointestinal / Abdomen: bowel regimen, repeat Abdominal xray for\n dilated loops\n Nutrition: Clear liquids, no free water due to hyponatremia\n Renal: Foley, Adequate UO, goal fluid balance equal, maintain foley due\n to urinary retention will attempt removing \n Hematology: stable anemia\n Endocrine: RISS, goal BG < 150\n Infectious Disease: WBC 11 from 13, afebrile no evidence of infection\n Lines / Tubes / Drains: Foley, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today, KUB today\n Consults: P.T., Nutrition\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Cordis/Introducer - 12:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor Time spent 31 min\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674249,
"text": "POD 1 AVR porcine, extubated 0930 this am.\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Sleepy on propofol 10mg this am. Opened eyes to name. Followed\n commands.\n Lethargic today, oriented to person and time. Knows hospital.\n OOB to chair x2 today with 2 assist.\n SR low 100\ns this am with lots of apc\ns. SBP low 100\ns to\n 130\n Cardiac index >2.\n Chest tubes with minimal output.\n Lungs clear initially, crackles noted late am.\n ABG on cpap 5/5 acceptable for extubation.\n Sats 90% on 70% face tent post extubation.\n Abdomen softly distended with +hypoactive bowel sounds. Gag weak.\n Urine output low to marginal this am.\n Blood sugars 140-170.\n Action:\n Propofol off, pt extubated without incident.\n Nitro titrated. Hydralazine and Lopressor given iv.\n HR 70\ns- 80\ns post lopressor with minimal ectopy.\n PA line discontinued.\n Chest tubes discontinued.\n Nasal cannula added to face tent for sats in the mid 90\ns. Using\n incentive weakly to 250cc.\n Lasix started iv.\n Tolerating a few ice chips this afternoon.\n Blood sugars covered with regular insulin sliding scale.\n Response:\n SR 70\ns. BP one teens/60.\n Diuresed with lasix.\n Lungs clear this afternoon. Sats 97 on 5Lnc.\n Plan:\n Continue to monitor hemodynamics.\n Blood pressure control.\n Pulmonary hygiene.\n Reposition q 2 hrs.\n Monitor urine output closely.\n Acute Pain\n Assessment:\n Pt admitting to incisional pain, moaning.\n Action:\n Morphine given iv intermittently throughout day.\n Response:\n Pt not moaning after morphine given iv.\n Plan:\n Continue to monitor pain closely.\n Administer pain meds iv prn until pt able to tolerate po\n Frequent repositioning.\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674784,
"text": "Atrial fibrillation (Afib) s/p AVR porcine\n Assessment:\n AF with frequent PVC\ns, rate 80-120 (patient has history of AF), 2A2V\n wires that neither sense nor pace\n Action:\n Lopressor increased from 25-50mg PO BID, amio stopped early this am due\n to 10 second pause with no NSR conversion, started on coumadin today,\n lytes checked, wires discontinued by NP \n Response:\n Patient remains in AF, lytes did not require repletion, patient\n remained in bed for an hour after wires discontinued without issues,\n VSS\n Plan:\n Continue to monitor VS, HR/rhythm, ectopy continue with lopressor as\n tolerated\n Posture, Impaired and inability to perform ADL\ns independently\n Assessment:\n Patient weak and deconditioned, patient lives alone in 2 story home\n with lots of stairs. Patient looks down and has eyes closed while\n walking or standing\n Action:\n OOB\nchair and back to bed, with 2-3 nurse assist, moves slow and\n reaches/leans for things instead of walking towards them, walked with\n Pt today\n Response:\n With much encouragement able to stand up straight and focus on good\n posture, but needs much encouragement, reassurance and emotional\n support\n Plan:\n Continue to monitor while up, ?? rehab before home.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Patient on Bipap at start of shift. Supposed to wear CPAP at night,\n but patient wont do it. He states\nits uncomfortable\n Sats at 92-94%\n patient calm and cooperative\n Action:\n Off bipap and placed on 4 liters NC, uses IS up to 500, CDB encouraged,\n calm quiet environment provided, with lots of emotional support,\n OOB\nchair, seen by MD\n Response:\n Sats around 92-93%, patient must wear CPAP at night ? sleep study by\n sleep MDs while inpatient\n Plan:\n Continue to monitor sats, encourage slow deep breaths and IS\n Constipation (Obstipation, FOS)\n Assessment:\n Firm distended abdomen, hyperactive BS, constant belching and +flatus\n Action:\n Regularly scheduled colace and reglan given, bisacodyl and soap suds\n enema given, adb XR and surgical GI consult obtained\n Response:\n Minimal output from interventions, XR showed multiple areas of dilated\n bowel, NP , GI-patient should remain NPO\n Plan:\n Continue with bowel regimen, NPO until further nontice\n"
},
{
"category": "Rehab Services",
"chartdate": "2114-05-25 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 675023,
"text": "Subjective:\n \"Are we going to walk today?\"\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: WBC 7.2 Hgb 10.3* Hct 31.1* Plt Ct 124*\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n T\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n T\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n T\n\n\n\n Ambulation:\n\n T\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Sit\n 100\n 111/72\n 26\n 93 (4L)\n Activity\n Stand\n 103\n 108/80\n 32\n 91 (6L)\n Recovery\n Supine\n 103\n 122/77\n 22\n 92 (4L)\n Total distance walked: 300 feet\n Minutes:\n Gait: Pt. presented in chair. CGA sit to stand. Able to ambulate 300ft\n pushing w/c with CGA and no deviations from path. Verbal cues for PLB.\n Balance: No overt LOB\n Education / Communication: c RN re pt status\n c pt re role of PT, , d/c planning, education, d/c planning\n Other: c/o pain in chest but unable to quantify\n Assessment: Pt. is a pleasant 77y/o male functioning well below\n baseline but displayed functional progression today with further\n ambulation c increasing steadiness and maintaining upright posture. Pt.\n most limited by impaired gas exhange and decrease balance which should\n improve with increase in activity. Given age, progression, and support\n available at home, anticipate that pt. will reach a safe level for\n discharge home when medically stable and with 2-3 more PT treats.\n Recommend home PT safety eval for balance, endurance, and maximizing\n independence.\n Anticipated Discharge: Home with Home PT\n : Administer cardiac booklet\n Education\n Wean 02 to RA\n Pulmonary exercises\n Ambulate 500ft c RW\n Stair negotiation\n d/c planning\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 675029,
"text": "Constipation (Obstipation, FOS)\n Assessment:\n Firm, round, distended abdomen with hyperactive BS, +belching and +\n flatus, NPO since 1600 per GI surgical team\n Action:\n Continue with NPO, KUB obtained, reglan and docusate given as ordered\n Response:\n Patients abdomen appears softer than yesterday but still distended, no\n BM yet today\n Plan:\n Continue to monitor, ambulate as much as possible, maintain NPO status\n until further notice\n Respiration / Gas Exchange, Impaired\n Assessment:\n On 4 liters NC in the chair and overnight on bipap, patient is more\n comfortable with his breathing in the chair. Sats 92-96%, slightly SOB\n in bed, patient anxious and restless which adds to the SOB\n Action:\n In and OOB\nchair several times for comfort with breathing, IS\n encouraged along with CDB\n Response:\n Patient sats remain >92, no respiratory distress, continue with IS and\n encouragement\n Plan:\n Continue to monitor O2 sat and monitor for dyspnea, sleep MDs\n reevaluate\n Atrial fibrillation (Afib)\n Assessment:\n History of and currently in AF HR 90\ns, SBP>100 with frequent PVC\n Action:\n Lytes monitored, lopressor increased from to TID remains 50mg\n Response:\n No repletion necessary\n Plan:\n Continue to monitor VS HR and rhythm\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n AORTIC VALVE INSUFFICIENCY AORTIC VALVE REPLACEMENT; ? ASCE\n Code status:\n Height:\n 71 Inch\n Admission weight:\n 92.3 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Arrhythmias, CHF, Hypertension\n Additional history: AS,^lipids,AAA 4.3X4.9cm,sleep apnea_does not use\n apparatus,arthritis,chf-recent admission 3 weeks ago,sinus\n infections,basal cell ca,Left ear deafness,choley,back surgery, s/p\n removal cyst leg. retired,Quit smoking 25 years ago, wife passed away 6\n months. occassional etoh,gerd. positional vertigo'\n Surgery / Procedure and date: AVR porcine valve.\n *fragile aorta*- aorta not repaired. ez intubation, kefzol 2 gm @ 0800,\n ef 55%pre/post,act wnl, av paced with slow rythym underneath,cbp\n 89',xc52',cry 2500, 800 cellsaver, uo 170,out on neo+propofol, keep sbp\n <100, 10 ml ct drainage from or. CVICU, slow sb to asystole-pacer at\n times not sensing/capturing NO perfusion. likes pads 20's. adequate uo.\n 4 fluid. to remain sedated/intubated overnight. neuro not assessed.\n .\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:122\n D:77\n Temperature:\n 97.8\n Arterial BP:\n S:135\n D:80\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 98 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 92% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 24h total out:\n 490 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 06:08 AM\n Potassium:\n 4.4 mEq/L\n 06:08 AM\n Chloride:\n 106 mEq/L\n 06:08 AM\n CO2:\n 26 mEq/L\n 06:08 AM\n BUN:\n 53 mg/dL\n 06:08 AM\n Creatinine:\n 1.4 mg/dL\n 06:08 AM\n Glucose:\n 96 mg/dL\n 06:08 AM\n Hematocrit:\n 31.1 %\n 06:08 AM\n Finger Stick Glucose:\n 113\n 06:00 AM\n Valuables / Signature\n Patient valuables: home\n Other valuables:\n Clothes: Sent home with: family\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: family\n Jewelry: home\n Transferred from: \n Transferred to: 6\n Date & time of Transfer: 1200\n"
},
{
"category": "Physician ",
"chartdate": "2114-05-25 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 675031,
"text": "CVICU\n HPI:\n HD5\n POD4\n 77M s/p AVR (#25mm St. porcine)-\n EF: >75% Cr:1.2 Ht: 71\" Wt:209 LB\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\n CPAP\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\n Inderal 40(2)\n Current medications:\n Acetaminophen, Aspirin EC, Docusate Sodium, Heparin, HydrALAzine,\n Insulin, Metoclopramide, Metoprolol Tartrate, Nitroglycerin, Potassium\n Chloride, Ranitidine, Simvastatin, Tamsulosin, Warfarin\n 24 Hour Events:\n Remained in ICU for monitoring\n Surgery consulted due to abdominal distention and air in loops with no\n improvement, NPO\n Post operative day:\n POD#4 - AVR # porcine valve, fragile aorta. out on neo\n propofol, 10 ml ct drainage. av paced for very slow underlying rythym?\n sb.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium - 08:00 AM\n Flowsheet Data as of 11:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98.1\n T current: 36.6\nC (97.8\n HR: 98 (89 - 111) bpm\n BP: 100/65(73) {94/59(67) - 130/77(88)} mmHg\n RR: 24 (14 - 26) insp/min\n SPO2: 90%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 71 Inch\n Total In:\n 143 mL\n PO:\n Tube feeding:\n IV Fluid:\n 43 mL\n Blood products:\n 100 mL\n Total out:\n 1,170 mL\n 460 mL\n Urine:\n 1,170 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,027 mL\n -460 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 90%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Distended, Tender: , BM \n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 124 K/uL\n 10.3 g/dL\n 96 mg/dL\n 1.4 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 53 mg/dL\n 106 mEq/L\n 142 mEq/L\n 31.1 %\n 7.2 K/uL\n [image002.jpg]\n 12:37 AM\n 08:31 AM\n 02:52 AM\n 03:09 AM\n 03:01 AM\n 03:04 AM\n 05:39 AM\n 01:46 PM\n 09:01 PM\n 06:08 AM\n WBC\n 13.5\n 11.2\n 7.2\n Hct\n 33.8\n 31.9\n 31.1\n Plt\n 106\n 103\n 124\n Creatinine\n 1.5\n 1.5\n 1.5\n 1.5\n 1.4\n TCO2\n 25\n 23\n 25\n 27\n 27\n Glucose\n 135\n 268\n 105\n 96\n Other labs: PT / PTT / INR:16.3/37.9/1.5, ALT / AST:20/50, Alk-Phos / T\n bili:64/1.0, Amylase / Lipase:34/35, Albumin:3.6 g/dL, LDH:253 IU/L,\n Ca:8.9 mg/dL, Mg:2.9 mg/dL, PO4:2.7 mg/dL\n Imaging: CXR small effusion\n Abd air in loops of bowel\n Microbiology: MRSA no growth\n urine no growth\n Assessment and Plan\n CONSTIPATION (OBSTIPATION, FOS), AEROBIC CAPACITY / ENDURANCE,\n IMPAIRED, ADLS (ACTIVITIES OF DAILY LIVING), INABILITY TO PERFORM,\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED,\n KNOWLEDGE, IMPAIRED, POSTURE, IMPAIRED, RESPIRATION / GAS EXCHANGE,\n IMPAIRED, TRANSFERS, IMPAIRED, ATRIAL FIBRILLATION (AFIB), VALVE\n REPLACEMENT, AORTIC BIOPROSTHETIC (AVR), ACUTE PAIN, .H/O\n AORTIC STENOSIS\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, denies pain except with abdominal\n palpitation\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, Statins,\n coumadin for atrial fibrillation, awaiting PT/INR to dose, no\n amiodarone due to pauses \n Pulmonary: IS, cough and deep breath, increase ambulation\n Gastrointestinal / Abdomen: follow up with surgery, Abd xray unchanged,\n serial abdominal exams\n Nutrition: Clear liquids\n Renal: Foley, Adequate UO, goal fluid balance equal\n Hematology: stable anemia\n Endocrine: RISS, goal BG < 150\n Infectious Disease: wbc 7, afebrile, all cultures negative, no evidence\n of infection\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: KUB today\n Consults: P.T., Nutrition\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Cordis/Introducer - 12:00 PM\n 20 Gauge - 02:23 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2114-05-25 00:00:00.000",
"description": "ICU Note",
"row_id": 675032,
"text": "TITLE: Intensivist\n HPI:\n HD5\n POD4\n 77M s/p AVR (#25mm St. porcine)-\n EF: >75% Cr:1.2 Ht: 71\" Wt:209 LB\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\n CPAP\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\n Inderal 40(2)\n Current medications:\n Acetaminophen, Aspirin EC, Docusate Sodium, Heparin, HydrALAzine,\n Insulin, Metoclopramide, Metoprolol Tartrate, Nitroglycerin, Potassium\n Chloride, Ranitidine, Simvastatin, Tamsulosin, Warfarin\n 24 Hour Events:\n Remained in ICU for monitoring\n Surgery consulted due to abdominal distention and air in loops with no\n improvement, NPO\n Post operative day:\n POD#4 - AVR # porcine valve, fragile aorta. out on neo\n propofol, 10 ml ct drainage. av paced for very slow underlying rythym?\n sb.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:00 PM\n Other ICU medications:\n Heparin Sodium - 08:00 AM\n Flowsheet Data as of 11:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98.1\n T current: 36.6\nC (97.8\n HR: 98 (89 - 111) bpm\n BP: 100/65(73) {94/59(67) - 130/77(88)} mmHg\n RR: 24 (14 - 26) insp/min\n SPO2: 90%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 71 Inch\n Total In:\n 143 mL\n PO:\n Tube feeding:\n IV Fluid:\n 43 mL\n Blood products:\n 100 mL\n Total out:\n 1,170 mL\n 460 mL\n Urine:\n 1,170 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,027 mL\n -460 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 90%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Distended, Tender: , BM \n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 124 K/uL\n 10.3 g/dL\n 96 mg/dL\n 1.4 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 53 mg/dL\n 106 mEq/L\n 142 mEq/L\n 31.1 %\n 7.2 K/uL\n [image002.jpg]\n 12:37 AM\n 08:31 AM\n 02:52 AM\n 03:09 AM\n 03:01 AM\n 03:04 AM\n 05:39 AM\n 01:46 PM\n 09:01 PM\n 06:08 AM\n WBC\n 13.5\n 11.2\n 7.2\n Hct\n 33.8\n 31.9\n 31.1\n Plt\n 106\n 103\n 124\n Creatinine\n 1.5\n 1.5\n 1.5\n 1.5\n 1.4\n TCO2\n 25\n 23\n 25\n 27\n 27\n Glucose\n 135\n 268\n 105\n 96\n Other labs: PT / PTT / INR:16.3/37.9/1.5, ALT / AST:20/50, Alk-Phos / T\n bili:64/1.0, Amylase / Lipase:34/35, Albumin:3.6 g/dL, LDH:253 IU/L,\n Ca:8.9 mg/dL, Mg:2.9 mg/dL, PO4:2.7 mg/dL\n Imaging: CXR small effusion\n Abd air in loops of bowel\n Microbiology: MRSA no growth\n urine no growth\n Assessment and Plan\n CONSTIPATION (OBSTIPATION, FOS), AEROBIC CAPACITY / ENDURANCE,\n IMPAIRED, ADLS (ACTIVITIES OF DAILY LIVING), INABILITY TO PERFORM,\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED,\n KNOWLEDGE, IMPAIRED, POSTURE, IMPAIRED, RESPIRATION / GAS EXCHANGE,\n IMPAIRED, TRANSFERS, IMPAIRED, ATRIAL FIBRILLATION (AFIB), VALVE\n REPLACEMENT, AORTIC BIOPROSTHETIC (AVR), ACUTE PAIN, .H/O\n AORTIC STENOSIS\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, denies pain except with abdominal\n palpitation\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, Statins,\n coumadin for atrial fibrillation, awaiting PT/INR to dose, no\n amiodarone due to pauses \n Pulmonary: IS, cough and deep breath, increase ambulation\n Gastrointestinal / Abdomen: follow up with surgery, Abd xray unchanged,\n serial abdominal exams\n Nutrition: Clear liquids\n Renal: Foley, Adequate UO, goal fluid balance equal\n Hematology: stable anemia\n Endocrine: RISS, goal BG < 150\n Infectious Disease: wbc 7, afebrile, all cultures negative, no evidence\n of infection\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: KUB today\n Consults: P.T., Nutrition\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Cordis/Introducer - 12:00 PM\n 20 Gauge - 02:23 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code Time spent 32 min\n Disposition: Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674605,
"text": "Respiration / Gas Exchange, Impaired\n Assessment:\n Pt requiring increasing o2 requirement. More confused and lethargic.\n Sats 91% on 4lnc.\n Action:\n Changed to open face tent, sats increased to 93% for a short time. Pa\n aware. Pt became more confused/agitated/combative. Pa\n at bedside, 2.5mg haldol given, and 20mg iv lasix. Sats 78%.\n Changed to closed aerosol face mask. Abg sent see flowsheet.\n Response:\n Sats increased to 95% on closed face mask. Pt slept for short period,\n while asleep sats 96%. Pt awoke moaning and groaning, agitated. Ripping\n at oxygen mask. Pa aware. Fair response to lasix overnight.\n Resend abg to monitor co2 levels. Still breathing using accessory\n muscles, and rr 20s\ns-30\ns with agitation. Pa aware.\n Plan:\n Abg, enc cough and deep breathe, decrease fio2 requirements as\n tolerates.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib overnight 80\ns-90\ns. Rate controlled. Amio drip at\n 1mg/min changed to 0.5mg/min at 2100.\n Action:\n Afib with pvc\ns pt had 10second pause with junctional escape beats. Pa\n aware. Amio drip off. Pacer pad at bedside due to wires due\n not capture or sense approp.\n Response:\n No more pauses overnight.\n Plan:\n Discontinue amio, pads at bedside for ectopy. Monitor heart rate.\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt is pod#3 from Avr replacement. Alert, oriented x2. States\n Are we\n on a boat?\n 1:1 time with patient. 2a/2v wres do not capture or sense.\n Wires secured and pa aware. Pt has soft but very distended\n abdomen. KUB done on evening. Family in/out through most of evening\n shift. Very nervous about father, reassured about care. ? social work\n consult. Lasix given at with no response. DTV at 2100. Foley\n reinserted pa aware 400cc out when foley placed. Left foley\n in overnight to monitor urine output.\n Action:\n + flatus, Oob to commode. Dulcolax given with no reponse, fleet enema\n given with some response, then soap suds enema given. Pt c/o incisional\n pain with turning Tylenol given.\n Response:\n Pt ahd a large bowel movement, soft/formed. Tylenol had fair response.\n Pa aware, ultram given with good relief.\n Plan:\n Safety precautions, Rate control afib, enc is.\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 675007,
"text": "Constipation (Obstipation, FOS)\n Assessment:\n Firm, round, distended abdomen with hyperactive BS, +belching and +\n flatus, NPO since 1600 per GI surgical team\n Action:\n Continue with NPO, KUB obtained, reglan and docusate given as ordered\n Response:\n Patients abdomen appears softer than yesterday but still distended, no\n BM yet today\n Plan:\n Continue to monitor, ambulate as much as possible, maintain NPO status\n until further notice\n Respiration / Gas Exchange, Impaired\n Assessment:\n On 4 liters NC in the chair and overnight on bipap, patient is more\n comfortable with his breathing in the chair. Sats 92-96%, slightly SOB\n in bed, patient anxious and restless which adds to the SOB\n Action:\n In and OOB\nchair several times for comfort with breathing, IS\n encouraged along with CDB\n Response:\n Patient sats remain >92, no respiratory distress, continue with IS and\n encouragement\n Plan:\n Continue to monitor O2 sat and monitor for dyspnea, sleep MDs\n reevaluate\n Atrial fibrillation (Afib)\n Assessment:\n History of and currently in AF HR 90\ns, SBP>100 with frequent PVC\n Action:\n Lytes monitored, lopressor increased from to TID remains 50mg\n Response:\n No repletion necessary\n Plan:\n Continue to monitor VS HR and rhythm\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 675008,
"text": "Constipation (Obstipation, FOS)\n Assessment:\n Firm, round, distended abdomen with hyperactive BS, +belching and +\n flatus, NPO since 1600 per GI surgical team\n Action:\n Continue with NPO, KUB obtained, reglan and docusate given as ordered\n Response:\n Patients abdomen appears softer than yesterday but still distended, no\n BM yet today\n Plan:\n Continue to monitor, ambulate as much as possible, maintain NPO status\n until further notice\n Respiration / Gas Exchange, Impaired\n Assessment:\n On 4 liters NC in the chair and overnight on bipap, patient is more\n comfortable with his breathing in the chair. Sats 92-96%, slightly SOB\n in bed, patient anxious and restless which adds to the SOB\n Action:\n In and OOB\nchair several times for comfort with breathing, IS\n encouraged along with CDB\n Response:\n Patient sats remain >92, no respiratory distress, continue with IS and\n encouragement\n Plan:\n Continue to monitor O2 sat and monitor for dyspnea, sleep MDs\n reevaluate\n Atrial fibrillation (Afib)\n Assessment:\n History of and currently in AF HR 90\ns, SBP>100 with frequent PVC\n Action:\n Lytes monitored, lopressor increased from to TID remains 50mg\n Response:\n No repletion necessary\n Plan:\n Continue to monitor VS HR and rhythm\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n AORTIC VALVE INSUFFICIENCY AORTIC VALVE REPLACEMENT; ? ASCE\n Code status:\n Height:\n 71 Inch\n Admission weight:\n 92.3 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Arrhythmias, CHF, Hypertension\n Additional history: AS,^lipids,AAA 4.3X4.9cm,sleep apnea_does not use\n apparatus,arthritis,chf-recent admission 3 weeks ago,sinus\n infections,basal cell ca,Left ear deafness,choley,back surgery, s/p\n removal cyst leg. retired,Quit smoking 25 years ago, wife passed away 6\n months. occassional etoh,gerd. positional vertigo'\n Surgery / Procedure and date: AVR porcine valve.\n *fragile aorta*- aorta not repaired. ez intubation, kefzol 2 gm @ 0800,\n ef 55%pre/post,act wnl, av paced with slow rythym underneath,cbp\n 89',xc52',cry 2500, 800 cellsaver, uo 170,out on neo+propofol, keep sbp\n <100, 10 ml ct drainage from or. CVICU, slow sb to asystole-pacer at\n times not sensing/capturing NO perfusion. likes pads 20's. adequate uo.\n 4 fluid. to remain sedated/intubated overnight. neuro not assessed.\n .\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:100\n D:65\n Temperature:\n 97.8\n Arterial BP:\n S:135\n D:80\n Respiratory rate:\n 24 insp/min\n Heart Rate:\n 98 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 90% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 24h total out:\n 460 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 06:08 AM\n Potassium:\n 4.4 mEq/L\n 06:08 AM\n Chloride:\n 106 mEq/L\n 06:08 AM\n CO2:\n 26 mEq/L\n 06:08 AM\n BUN:\n 53 mg/dL\n 06:08 AM\n Creatinine:\n 1.4 mg/dL\n 06:08 AM\n Glucose:\n 96 mg/dL\n 06:08 AM\n Hematocrit:\n 31.1 %\n 06:08 AM\n Finger Stick Glucose:\n 113\n 06:00 AM\n Valuables / Signature\n Patient valuables: none\n Other valuables: none\n Clothes: Sent home with: family\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: family\n Jewelry: none\n Transferred from: \n Transferred to: \n Date & time of Transfer: 1200\n"
},
{
"category": "Rehab Services",
"chartdate": "2114-05-24 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 674746,
"text": "Subjective:\n \"I am weak.\"\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: 5.14 WBC 11.2* Hgb 10.5* Hct 31.9* Plt Ct 103*\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n T\n\n\n Ambulation:\n\n T\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Sit\n 87\n 123/80\n 23\n 91 (3L)\n Activity\n Stand\n 104\n 152/99\n 31\n 83 (6L)\n Recovery\n Sit\n 112\n 123/62\n 23\n 93 (4L)\n Total distance walked: 80feet\n Minutes:\n Gait: Pt. ambulated 80ft pushing w/c with CGA. Pt. required sit to\n stand. Patient required constant cues for upright posture, PLB, and\n pacing. No deviations from pathway. C/o lightheadedness at times.\n Balance: No overt LOB.\n Education / Communication: c RN re pt status\n c pt re role of PT, , d/c planning, education, goals\n Other: Pain 0/10\n Question accuracy of 02 sat secondary to no patient complaints\n of labored breathing and pleth not evenly distributed.\n Assessment: Pt. is a pleasant 77y/o male s/p AVR and functioning well\n below baseline. Pt. limited by decrease endurance, balance, and overall\n mobility, but has progressed functionally since evaluation. Pt. has\n great potential to reach baseline with continued activity and\n ambulation. Given PLOF, age, and support available at home, anticipate\n that pt. will be able to reach a safe discharge home with 24 hour\n assist and home PT safety eval. If patient lacks continuing\n progression, will recommend rehab.\n Anticipated Discharge: Home with Home PT\n : bed mobility\n education\n administer cardiac booklet\n ambulate with RW >200ft\n wean 02 to RA\n pulmonary exercises\n balance and endurance training\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674753,
"text": "Atrial fibrillation (Afib) s/p AVR porcine\n Assessment:\n AF with frequent PVC\ns, rate 80-120 (patient has history of AF)\n Action:\n Lopressor increased from 25-50mg PO BID, amio stopped early this am due\n to 10 second pause with no NSR conversion, started on coumadin today,\n lytes checked\n Response:\n Patient remains in AF, lytes did not require repletion\n Plan:\n Continue to monitor VS, HR/rhythm, ectopy continue with lopressor as\n tolerated\n Posture, Impaired and inability to perform ADL\ns independently\n Assessment:\n Patient weak and deconditioned, patient lives alone in 2 story home\n with lots of stairs. Patient looks down and has eyes closed while\n walking or standing\n Action:\n OOB\nchair and back to bed, with 2-3 nurse assist, moves slow and\n reaches/leans for things instead of walking towards them\n Response:\n With much encouragement able to stand up straight and focus on good\n posture, but needs much encouragement, reassurance and emotional\n support\n Plan:\n Continue to monitor while up, needs to get PT eval, ?? rehab before\n home.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Patient on Bipap at start of shift. Supposed to wear CPAP at night,\n but patient wont do it. He states\nits uncomfortable\n Sats at 92-94%\n patient calm and cooperative\n Action:\n Off bipap and placed on 4 liters NC, uses IS up to 500, CDB encouraged,\n calm quiet environment provided, with lots of emotional support,\n OOB\nchair\n Response:\n Sats around 92-93%, patient must wear CPAP at night\n Plan:\n Continue to monitor sats, encourage slow deep breaths and IS\n Constipation (Obstipation, FOS)\n Assessment:\n Firm distended abdomen, hyperactive BS, constant belching and +flatus\n Action:\n Regularly scheduled colace and reglan given, bisacodyl and soap suds\n enema given, adb XR and GI consult obtained\n Response:\n Minimal oputput from interventions, XR showed multiple areas of dilated\n bowel, NP \n Plan:\n Continue with bowel regimen, awaiting GU consult\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674731,
"text": "Atrial fibrillation (Afib)\n Assessment:\n AF with frequent PVC\ns, rate 80-120\n Action:\n Lopressor increased from 25-50mg PO BID, amio stopped early this am due\n to 10 second pause with no NSR conversion, started on coumadin today,\n lytes checked\n Response:\n Patient remains in AF, lytes repleted PRN\n Plan:\n Continue to monitor VS, HR/rhythm, ectopy continue with lopressor as\n tolerated\n Posture, Impaired and inability to perform ADL\ns independently\n Assessment:\n Patient weak and deconditioned, patient lives alone in 2 story home\n with lots of stairs. Patient looks down and has eyes closed while\n walking or standing\n Action:\n OOB\nchair and back to bed, with 2-3 nurse assist, moves slow and\n reaches/leans for things instead of walking towards them\n Response:\n With much encouragement able to stand up straight and focus on good\n posture, but needs much encouragement, reassurance and emotional\n support\n Plan:\n Continue to monitor while up, needs to get PT eval, ?? rehab before\n home.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Patient on Bipap at start of shift. Supposed to wear CPAP at night,\n but patient wont do it. He states\nits uncomfortable\n Sats at 92-94%\n patient calm and cooperative\n Action:\n Off bipap and placed on 4 liters NC, uses IS up to 500, CDB encouraged,\n calm quiet environment provided, with lots of emotional support,\n OOB\nchair\n Response:\n Sats around 92-93%, patient must wear CPAP at night\n Plan:\n Continue to monitor sats, encourage slow deep breaths and IS\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674876,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib. No pauses this shift. Frequent pvc\ns. Sbp\n 100\ns-120\ns. Pt is alert, oriented x3, no confusion. NO NARCOTICS,\n Tylenol for pain as needed\n Action:\n Lopressor dose was increased on day shift to 50mg po bid.\n Response:\n Pt tolerating lopressor dose with sbp >100. Afin still not rate\n controlled has bursts into 120\ns-130\ns at times.\n Plan:\n ? increase lopressor dose for rate control. Coumdain today. Pt\ns family\n informed of need for electric razor while on coumdain.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Pt sats 92-96% on 4l nc while in chair. When in bed pt has difficulty\n breathing due to obese abdomen. Sats drop to 92% while in bed laying\n doen, and pt states\nI feel winded.\n Action:\n Pa aware, bipap placed on pt, pt a little hesitant to wear\n states\nit feels like a hurricane against my face.\n Response:\n Pt tolerated bipap for 2 hours then insists on taking off mask. In and\n out bed and chair all night long. While in chair wears 4lc sats 95%,\n while in bed wears bipap for short time and then closed face mask at\n 50% humidification. Pt cooperative on alternating. Between masks and pa\n aware.\n Plan:\n Bipap at night if pt tolerates, ? nose piece instead of mask if\n tolerates. Wean fio2 requirements as pt tolerates.\n Constipation (Obstipation, FOS)\n Assessment:\n Pt has obese, firm and distended abdomen. Hyperactive bs noted on\n assessment. + flatus.\n Action:\n Gi surgery team consulted, npo until further notice today. Reglan\n started x4 doses. No bowel meds.\n Response:\n Pt passing gas from below, no belching this shift. Abdomen the same as\n assessment . No nausea or vomiting.\n Plan:\n Plan f/u kub this am, surgery consult reccomendations.\n"
},
{
"category": "Respiratory ",
"chartdate": "2114-05-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 674873,
"text": "Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Comments:\n Pt on and off Bipap 14/8 with up to 15L O2 to maintain sats of 94%.\n Does not tolerate for very long.\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674518,
"text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt lethargic most of morning. Napping fairly continuously. Oriented to\n place, person, year and events of having heart surgery. Constantly\n moaning.\n Action:\n Response:\n More alert during afternoon. Moaning decreased after pain med.\n Plan:\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Afib with varying v response, occ pvc noted. VSS.\n Action:\n Amio bolus given this am, drip started this afternoon.\n Response:\n Afib continues.\n Plan:\n Cont to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674921,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib. No pauses this shift. Frequent pvc\ns. Sbp\n 100\ns-120\ns. Pt is alert, oriented x3, no confusion. NO NARCOTICS,\n Tylenol for pain as needed\n Action:\n Lopressor dose was increased on day shift to 50mg po bid.\n Response:\n Pt tolerating lopressor dose with sbp >100. Afin still not rate\n controlled has bursts into 120\ns-130\ns at times.\n Plan:\n ? increase lopressor dose for rate control. Coumdain today. Pt\ns family\n informed of need for electric razor while on coumdain.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Pt sats 92-96% on 4l nc while in chair. When in bed pt has difficulty\n breathing due to obese abdomen. Sats drop to 92% while in bed laying\n doen, and pt states\nI feel winded.\n Action:\n Pa aware, bipap placed on pt, pt a little hesitant to wear\n states\nit feels like a hurricane against my face.\n Response:\n Pt tolerated bipap for 2 hours then insists on taking off mask. In and\n out bed and chair all night long. While in chair wears 4lc sats 95%,\n while in bed wears bipap for short time and then closed face mask at\n 50% humidification. Pt cooperative on alternating. Between masks and pa\n aware.\n Plan:\n Bipap at night if pt tolerates, ? nose piece instead of mask if\n tolerates. Wean fio2 requirements as pt tolerates.\n Constipation (Obstipation, FOS)\n Assessment:\n Pt has obese, firm and distended abdomen. Hyperactive bs noted on\n assessment. + flatus.\n Action:\n Gi surgery team consulted, npo until further notice today. Reglan\n started x4 doses. No bowel meds.\n Response:\n Pt passing gas from below, no belching this shift. Abdomen the same as\n assessment . No nausea or vomiting.\n Plan:\n Plan f/u kub this am, surgery consult recommendations.\n"
},
{
"category": "Respiratory ",
"chartdate": "2114-05-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 674014,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Double Lumen\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n :\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674073,
"text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt. remains Intubated & sedated in order to keep tight control of BP\n with SBP ~95-100. SVO2 >60% with CI ~2.0 or better. Chest tube drng.\n 0-20cc/hr. HCT ~32. AV-pacing rate at 96.\n Action:\n AV- pacing maintained due to very slow underlying rhythm <40. Neo & NTG\n titrated to on & off as needed to keep BP parameter. Propofol on at\n 40mcq/kg; weaned to 10 mcq earlier in the evening wake-up in order to\n assess neuro status. Insulin infusing and titrated per protocol.\n Response:\n CI 2.2. SBP ~100-110 off vasoactive agents. Pt. was able to open eyes\n and nod his head to ???? and follow simple commands ( ie: wiggle toes).\n BS WNL . ABG WNL on present vent settings 50%fio2, IMV 16 Tv 600cc Peep\n 5cm.\n Plan:\n Wean sedation to extubate in AM. BP management with NTG/NEO. Glucose\n control hourly. Pain management.\n"
},
{
"category": "Physician ",
"chartdate": "2114-05-22 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 674169,
"text": "CVICU\n HPI:\n HD2\n POD#1\n 77M s/p AVR (#25mm St. porcine)-\n EF: >75% Cr:1.2 Ht: 71\" Wt:209 LB\n :ASA 325, Lisinopril 10(1), Zocor 40(1), Lasix 20(1),Norvasc 10(1),\n Inderal 40(2)\n :\n PMHx:\n PMH:AS, HTN, ^lipids, AAA (4.3x4.9cm),CHF, (L) ear deaf, arthritis, h/o\n sinus infections, skin basal cell ca,CCY, back surgery, OSA-doesn't use\n CPAP\n Current medications:\n . Acetaminophen 5. Aspirin EC 6. Calcium Gluconate 7. CefazoLIN 8.\n Dextrose 50% 9. Docusate Sodium 10. Furosemide 11. HydrALAzine 12.\n Insulin 13. Magnesium Sulfate 14. Metoprolol Tartrate 15.\n Metoclopramide 16. Metoprolol Tartrate 17. Milk of Magnesia 18.\n Morphine Sulfate 19. Nitroglycerin 20. Oxycodone-Acetaminophen 21.\n Potassium Chloride 22. Ranitidine 23. Simvastatin\n 24 Hour Events:\n OR RECEIVED - At 11:30 AM\n INVASIVE VENTILATION - START 11:30 AM\n CCO PAC - START 11:30 AM\n ARTERIAL LINE - START 11:30 AM\n EKG - At 11:45 AM\n Deferred due to slow underluying rythym\n CORDIS/INTRODUCER - START 12:00 PM\n Post operative day:\n HD2\n POD#1\n 77M s/p AVR (#25mm St. porcine)-\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 08:37 AM\n Other ICU medications:\n Ranitidine (Prophylaxis) - 10:16 PM\n Morphine Sulfate - 06:36 AM\n Hydralazine - 08:34 AM\n Metoprolol - 09:25 AM\n Furosemide (Lasix) - 10:30 AM\n Flowsheet Data as of 11:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n HR: 96 (78 - 108) bpm\n BP: 114/52(67) {85/46(58) - 130/67(85)} mmHg\n RR: 30 (12 - 36) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 20 (10 - 22) mmHg\n PAP: (33 mmHg) / (18 mmHg)\n CO/CI (Fick): (6.7 L/min) / (3.1 L/min/m2)\n CO/CI (CCO): (6.6 L/min) / (3.1 L/min/m2)\n SvO2: 67%\n Mixed Venous O2% sat: 76 - 76\n Total In:\n 8,890 mL\n 438 mL\n PO:\n Tube feeding:\n IV Fluid:\n 8,090 mL\n 438 mL\n Blood products:\n 800 mL\n Total out:\n 1,058 mL\n 552 mL\n Urine:\n 718 mL\n 382 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 7,832 mL\n -114 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PPS\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 330 (330 - 957) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 32\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 18 cmH2O\n SPO2: 94%\n ABG: 7.31/44/86./23/-4\n Ve: 11.1 L/min\n PaO2 / FiO2: 174\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 120 K/uL\n 11.0 g/dL\n 113 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 26 mg/dL\n 110 mEq/L\n 138 mEq/L\n 32.9 %\n 8.9 K/uL\n [image002.jpg]\n 11:45 AM\n 11:50 AM\n 02:58 PM\n 06:07 PM\n 06:25 PM\n 12:31 AM\n 12:37 AM\n 08:31 AM\n WBC\n 10.7\n 8.9\n Hct\n 35.1\n 30.9\n 32.9\n Plt\n 141\n 120\n Creatinine\n 1.2\n 1.1\n TCO2\n 28\n 27\n 27\n 25\n 23\n Glucose\n 130\n 113\n Other labs: PT / PTT / INR:15.4/37.9/1.4\n Assessment and Plan\n VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR), ACUTE PAIN, .H/O\n AORTIC STENOSIS\n Assessment and Plan: 77yo man s/p AVR-tissue. Hemodynamically\n stable-extubated\n Neurologic: Pain controlled, Percocet-prn\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor\n Pulmonary: IS, d/c chest tubes\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, start diuretics to get net negative 1-1.5 liters\n Hematology: stable hct\n Endocrine: RISS\n Infectious Disease: no active issues\n afebrile, normal wbc\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today, after chest tube removal\n Consults: CT surgery\n ICU Care\n Nutrition: ADAT\n Glycemic Control: Regular insulin sliding scale\n Lines:\n CCO PAC - 11:30 AM\n Arterial Line - 11:30 AM\n 16 Gauge - 11:30 AM\n Cordis/Introducer - 12:00 PM\n Prophylaxis:\n DVT: (ambulate today)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full\n Disposition: ICU\n"
},
{
"category": "Respiratory ",
"chartdate": "2114-05-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 674117,
"text": "Demographics\n Day of intubation: 2\n Day of mechanical ventilation: 2\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Elective\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: wean and extubate if indicated on rounds\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Unable to do RSBI as NO Spont resp this morning\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674527,
"text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt lethargic most of morning. Napping fairly continuously. Oriented to\n place, person, year and events of having heart surgery, knows family\n and is appropriate. Constantly moaning. Medicated for pain x1 this am\n with good effect.\n Response:\n More alert during afternoon. Moaning decreased after pain med.\n Plan:\n Plan for rest periods alternating with family visits. Pt to try bipap\n (Nasal Mask) tonoc. Hold pain meds.\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n OOB to chair, two person assist, tolerated well. Lasix with fair\n response. Albumen 25% given without incident. Abdoment distented, bowel\n sounds present. pt. c/o nausea. 12pm BS 112.\n Action:\n Reglan given x2. in to evaluate pt. Pt to have KUB.,\n LFT\ns.to be drawn.\n Response:\n Nausea relieved. Abd still distented.\n Plan:\n Lft\ns. cont to evaluate abd.\n Atrial fibrillation (Afib)\n Assessment:\n Afib with varying v response, occ pvc noted. VSS.\n Action:\n Amio bolus given this am, drip started this afternoon.\n Response:\n Afib continues.\n Plan:\n Cont to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674056,
"text": "77 year old male with worsening DOE, + AS , AVR with fragile aorta\n .H/O aortic stenosis\n Assessment:\n sbp <100, av paced with slow rythym to asystole without perfusion,\n sedated on propofol, neo @.5mcq, min ct drainage , marginal uop,\n glucose >120, pt warm and dry. Mvo2 76/svo2 60\ns, ci>2.0.^ pvcs noted.\n Hct 35-30.\n Action:\n Kept sbp<100 transient neo/ntg, av paced with not 100% sensing\n /capturing, pads high teens to low 20\ns, 4 l fluid, fluid changed to\n ns due to ^ k, propofol ^ to 40 mcq, 1 mg morphine iv. K pending .\n insulin gtt . 2 gm magnesium up and infusing.\n Response:\n Remains av paced however morphology of complex has changed NP \n aware, + pvc\ns. neo @ .75 mcq to keep sbp>90, sedated on propofol,\n marginal uo last 2 hours, insulin gtt remains on.\n Plan:\n Monitor comfort, hr and rythym- ekg to be done when rythym\n returns-monitor vea, sbp\nkeep sbp<100, ci,svo2,dsgs,ct drainage, pp,\n resp status-abg pending- to remain Intubated and sedated overnight,\n neuro status-to remain on propofol, i+o-uo, labs pending. As per\n orders.\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674721,
"text": "Atrial fibrillation (Afib)\n Assessment:\n AF with frequent PVC\ns, rate 80-120\n Action:\n Lopress\n Response:\n Plan:\n Posture, Impaired and inability\n Assessment:\n Action:\n Response:\n Plan:\n Respiration / Gas Exchange, Impaired\n Assessment:\n Patient on Bipap at start of shift. Supposed to wear CPAP at night,\n but patient wont do it. He states\nits uncomfortable\n Sats at 92-94%\n patient calm and cooperative\n Action:\n Off bipap and placed on 4 liters NC, uses IS up to 500, CDB encouraged,\n calm quiet environment provided, with lots of emotional support,\n OOB\nchair\n Response:\n Sats around 92-93%, patient must wear CPAP at night\n Plan:\n Continue to monitor sats, encourage slow deep breaths and IS\n"
},
{
"category": "Nutrition",
"chartdate": "2114-05-24 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 674722,
"text": "Patient has been NPO and/or on unsupplemented clear liquid diet for 3\n days. If patient's diet is not able to be advanced and tolerated,\n for nutrition support\n Comments:\n Patient s/p AVR on , remains in the ICU for pulm monitoring.\n Patient is slightly confused and lethargic at this time, clear liquid\n diet order, will f/u re diet advance/tol. If unable to diet adv, will\n need tube feed/tpn, will f/u re plan of care. Please page if has\n question.\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674050,
"text": "77 year old male with worsening DOE, + AS , AVR with fragile aorta\n .H/O aortic stenosis\n Assessment:\n sbp <100, av paced with slow rythym to asystole without perfusion,\n sedated on propofol, neo @.5mcq, min ct drainage , marginal uop,\n glucose >120, pt warm and dry. Mvo2 76/svo2 60\ns, ci>2.0. pvcs noted.\n Action:\n Kept sbp<100 transient neo/ntg, av paced with not 100% sensing\n /capturing, pads high teens to low 20\ns, 4 l fluid, fluid changed to\n ns due to ^ k, propofol ^ to 40 mcq, 1 mg morphine iv. K pending .\n insulin gtt\n Response:\n Remains av paced however morphology of complex has changed NP \n aware, + pvc\ns. neo @ .3 mcq to keep sbp>90, sedated on propofol,\n marginal uo last 2 hours, insulin gtt remains on.\n Plan:\n Monitor comfort, hr and rythym- ekg to be done when rythym returns, sbp\nkeep sbp<100, ci,svo2,dsgs,ct drainage, pp, resp status-abg pending-\n to remain Intubated and sedated overnight, neuro status-to remain on\n propofol, i+o-uo, labs pending. As per orders.\n"
},
{
"category": "Nursing",
"chartdate": "2114-05-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 674724,
"text": "Atrial fibrillation (Afib)\n Assessment:\n AF with frequent PVC\ns, rate 80-120\n Action:\n Lopressor increased from 25-50mg PO BID, amio stopped early this am due\n to 10 second pause with no NSR conversion, lytes checked\n Response:\n Patient remains in AF, lytes repleted PRN\n Plan:\n Continue to monitor VS, HR/rhythm, ectopy continue with lopressor as\n tolerated\n Posture, Impaired and inability to perform ADL\ns independently\n Assessment:\n Patient weak and deconditioned, patient lives alone in 2 story home\n with lots of stairs. Patient looks down and has eyes closed while\n walking or standing\n Action:\n OOB\nchair and back to bed, with 2-3 nurse assist, moves slow and\n reaches/leans for things instead of walking towards them\n Response:\n With much encouragement able to stand up straight and focus on good\n posture, but needs much encouragement, reassurance and emotional\n support\n Plan:\n Continue to monitor while up, needs to get PT eval, ?? rehab before\n home.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Patient on Bipap at start of shift. Supposed to wear CPAP at night,\n but patient wont do it. He states\nits uncomfortable\n Sats at 92-94%\n patient calm and cooperative\n Action:\n Off bipap and placed on 4 liters NC, uses IS up to 500, CDB encouraged,\n calm quiet environment provided, with lots of emotional support,\n OOB\nchair\n Response:\n Sats around 92-93%, patient must wear CPAP at night\n Plan:\n Continue to monitor sats, encourage slow deep breaths and IS\n"
},
{
"category": "Echo",
"chartdate": "2114-05-21 00:00:00.000",
"description": "Report",
"row_id": 79927,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for aortic valve replacement.\nHeight: (in) 70\nWeight (lb): 210\nBSA (m2): 2.13 m2\nStatus: Inpatient\nDate/Time: at 08:56\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Severe symmetric LVH. Normal LV cavity size. Normal regional LV\nsystolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated ascending aorta. Mildly dilated descending aorta. Simple\natheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic\nvalve leaflets. Mild AS (area 1.2-1.9cm2). Trace AR.\n\nMITRAL VALVE: Trivial MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient.\n\nConclusions:\nPRE-BYPASS: No atrial septal defect is seen by 2D or color Doppler. There is\nsevere symmetric left ventricular hypertrophy. The left ventricular cavity\nsize is normal. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. The ascending aorta is mildly dilated.\nThe descending thoracic aorta is mildly dilated. There are simple atheroma in\nthe descending thoracic aorta. There are three aortic valve leaflets. The\naortic valve leaflets are severely thickened/deformed. There is mild aortic\nvalve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen.\nTrivial mitral regurgitation is seen. There is no pericardial effusion.\n\nPOST-BYPASS: The patient is AV paced. Biventricular function is preserved. The\naorta is intact. The aortic valve has been replaced with a bioprothesis. The\nleaflets are moving well. There is no AI. The peak gradient through the valve\nis approximately 15mmHg. The Swan Ganz catheter is in the proximal right\npulmonary artery. The remainder of the examination is unchanged.\n\nDr. was notified in person of the results in the operating room.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-05-24 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1078369,
"text": " 7:21 AM\n PORTABLE ABDOMEN Clip # \n Reason: evaluate for ileus\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with s/p avr\n REASON FOR THIS EXAMINATION:\n evaluate for ileus\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old man status post aortic valve replacement. Evaluate\n for ileus.\n\n COMPARISON: Abdominal radiographs of .\n\n PORTABLE SUPINE VIEW OF THE ABDOMEN: The diaphragms have been excluded from\n view. There is continued air-filled loops of large and small bowel. Multiple\n linear densities and wires seen overlying the upper abdomen are likely\n external to the patient. A twisted piece of wire remains overlying the lower\n abdomen, unchanged.\n\n IMPRESSION: Continued ileus, not significantly changed since the prior\n study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-05-21 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1077856,
"text": " 12:18 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pleural effusion, pulmonary edema, tamponade, pneumothorax.\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with AVR\n REASON FOR THIS EXAMINATION:\n Pleural effusion, pulmonary edema, tamponade, pneumothorax. Pt in OR 2 and will\n be in CSRU in 90 mins.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after aortic valve\n replacement.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is approximately 6 cm above the carina. The Swan-Ganz\n catheter tip is at the level of right ventricle outflow tract. The NG tube\n \ttip is relatively proximal with the side hole at the level of\n gastroesophageal junction. Mediastinal drains are in expected position.\n\n The widening of the mediastinum is most likely related to recent surgery, but\n should be closely followed. The left basal opacities consistent with a\n combination of atelectasis and pleural effusion. Pericardial air is\n demonstrated related to recent surgery. No pneumothorax has been\n demonstrated. There is no evidence of failure.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-05-26 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1078785,
"text": " 10:48 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval for ileus\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n eval for ileus\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL RADIOGRAPH\n\n INDICATION: Ileus.\n\n FINDINGS: A nonspecific, nonobstructed bowel gas pattern is visualized, with\n gas within nondistended loops of small and large bowel. Stomach is mildly\n distended. Scattered air-fluid levels are present on the decubitus view.\n There is no evidence of free intraperitoneal air. Atelectasis and effusions\n at the lung bases are seen to better detail on recent chest radiograph.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-05-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1078015,
"text": " 9:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ptx\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man s/p chest tube removal\n REASON FOR THIS EXAMINATION:\n eval for ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube removal, to evaluate for pneumothorax.\n\n FINDINGS: In comparison with the study of , the endotracheal tube,\n mediastinal _____, and nasogastric tube have been removed. The widening of\n the mediastinum again is most likely related to the recent surgery. Basilar\n opacifications, especially at the left, are consistent with a combination of\n atelectasis and pleural effusion. Some pericardial gas is again seen related\n to recent surgery. No evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-05-25 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1078573,
"text": " 7:55 AM\n PORTABLE ABDOMEN Clip # \n Reason: evaluate dilated loops\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with s/p avr\n REASON FOR THIS EXAMINATION:\n evaluate dilated loops\n ______________________________________________________________________________\n WET READ: JKSd FRI 10:05 AM\n Continued loops of airfilled large and small bowel. Air seen in rectum.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old man status post aortic valve replacement. Evaluate\n dilated loops.\n\n COMPARISON: Multiple abdominal radiographs, most recent of .\n\n UPRIGHT AND SUPINE VIEWS OF THE ABDOMEN: The upright view demonstrates the\n entire chest, although please note that this is not exposed for proper\n evaluation of the lung parenchyma. No free air is seen beneath the\n diaphragms. Bilateral pleural effusions are noted, along with atelectasis at\n the bases. Midline sternotomy wires remain intact. Air-filled loops of large\n and small bowel are again seen with air down the level of the rectum. The\n overall appearance is not significantly changed since the prior study. The\n left flank has been excluded from view.\n\n IMPRESSION: Persistent air-filled loops of large and small bowel, not\n significantly changed since prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-05-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1078368,
"text": " 7:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? infiltrate\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with s/p avr\n REASON FOR THIS EXAMINATION:\n ? infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Questionable pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the Swan-Ganz catheter\n inserted over the left subclavian vein has been completely removed. The\n introduction sheath, however, is still in place. The size of the cardiac\n silhouette has not increased, however, a large retrocardiac atelectasis is now\n visible. There are minimal signs of overhydration. Focal parenchymal\n opacities suggesting pneumonia have not occurred.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-05-23 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1078314,
"text": " 6:33 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o ileus\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with s/p avr\n REASON FOR THIS EXAMINATION:\n r/o ileus\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old man status post aortic valve replacement. Rule out\n ileus.\n\n COMPARISON: None.\n\n SINGLE SUPINE PORTABLE VIEW OF THE ABDOMEN: Multiple prominent air-filled\n loops of small and large bowel are seen. Air is seen down to the level of the\n rectum. Surgical clips are noted in the right upper quadrant. A twisted\n piece of thin wire is noted in the midline of the lower abdomen. Degenerative\n changes are noted throughout the visualized lumbar spine.\n\n IMPRESSION: Generalized prominent air-filled loops of small and large bowel\n consistent with ileus.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2114-05-29 00:00:00.000",
"description": "Report",
"row_id": 212431,
"text": "Atrial fibrillation with rapid ventricular response with ventricular premature\ncomplex couplet\nConsider LVH with secondary repolarization abnormality\nAnterolateral ST-T changes may be due to hypertrophy and/or ischemia\nSince previous tracing of , atrial fibrillation with rapid ventricular\nresponse is new\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-05-27 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1078889,
"text": " 9:18 AM\n CHEST (PA & LAT) Clip # \n Reason: f/u effusions/atx\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with s/p avr\n REASON FOR THIS EXAMINATION:\n f/u effusions/atx\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after aortic valve replacement.\n\n PA and lateral upright chest radiographs were compared to .\n\n The cardiomediastinal silhouette is stable. The left retrocardiac opacity,\n triangular in shape is most likely a combination of left lower lobe\n atelectasis and pleural effusion which is small and unchanged since the prior\n study. The right pleural effusion is also small and unchanged. There is no\n pneumothorax. There is no evidence of failure.\n\n\n"
}
] |
50,141 | 182,345 | 43 yo M with PMHx sig. ESRD s/p failed transplant and subsequent nephrectomy in who p/w abdominal pain, found to have pericardial effusion without tamponade physiology. Pericardiocentesis performed and 1200cc fluid removed; drain placed and later removed. Hospital course complicated by thrombus on tip of tunnel cath seen during echo, but subsequently not present on dedicated catheter study. Hospital course also c/b episode of hemoptysis in setting of heparin drip (PTT>150) for suspected thrombus. . # Hemoptysis: This has occured to pt during previous hospitalization. Isolated incident. No findings on CT of the chest. Pulmonary was consulted and felt that suspicion for TB was very low. Etiology most likely related to to supratherapeutic PTT>150 from heparin drip. Pt was sceduled with outpt follow-up in the pulmonary clinic. . # Pericardial effusion: DDx includes uremia VS malignant effusion VS idiopatic. Patient's cultures and acid fast/TB negative. No evidence of malignancy on CT chest/abdomen/pelvis. Cytology of pericardial fluid negative for malignant cells. Repeat echo x2 showing minimal effusion, much decreased s/p drainage. Pericardial drain removed without complications. Pt has appt for f/u ECHO as outpt, and has f/u scheduled with cardiology. . # HD Catheter Thrombus: noted on ECHO . Subsequent dedicated catheter flow study did not detect thrombus. In the interim, pt was anticoagulated, but no indication to anticoagulate at the time of discharge. . # Rhythm - patient had several short runs of NSVT on which were attributed to electrolyte changes post-dialysis. This again occured on post-dialysis. Dialysis bath was altered to include more K and NSVT did not recur. . # Hct drop (28-->20): CT of abdomen showed no evidence of bleed. Guiaic negative. IV iron therapy to be started at dialysis. Source of Hct drop not found. Hemolysis labs negative. Pt received total of 3 units of blood and Hct responded appropriately. Hct was 28.5 at time of discharge. . # Ascites/ Hepatitis: LFTs with mild elevation. This transaminitis may be fleeting and secondary to recent pericardial effusion presentation vs. worsening Hep C. Given increased INR and low albumin, may represent worsening cirrhosis--Pt will f/u in hepatology clinic where he is followed for his Hep C. . # ESRD s/p failed transplant and subsequent nephrectomy in : | ESRD s/p failed transplant and subsequent nephrectomy in who p/w abdominal pain, found to have pericardial effusion with tamponade physiology on bedside ECHO. Found to have new onset systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia. Found to have new onset systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia. Found to have new onset systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia. Found to have new onset systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia. Found to have new onset systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia. Abd CT in ED revealing ascites and large pericardial effusion w/ signs of tamponade physiology per ECHO. Abd CT in ED revealing ascites and large pericardial effusion w/ signs of tamponade physiology per ECHO. Abd CT in ED revealing ascites and large pericardial effusion w/ signs of tamponade physiology per ECHO. Abd CT in ED revealing ascites and large pericardial effusion w/ signs of tamponade physiology per ECHO. Abd CT in ED revealing ascites and large pericardial effusion w/ signs of tamponade physiology per ECHO. Plan: Contin titration of meds to maint appropriate systolic bp. SVT: Resolved after IV metoprolol, likely in setting of uremia and electrolyte imbalance -- Continue beta blocker . Pain likely referred from pericardial distention -- Serial abdominal exams . # Hepatitis C: check LFTs . Heart failure (CHF), Systolic, Acute Assessment: LS: diminished at bases. .H/O transplant, kidney (Renal transplant) Assessment: Pt had a Action: Response: Plan: .H/O abdominal pain (including abdominal tenderness) Assessment: Action: Response: Plan: Anxiety Assessment: Action: Response: Plan: Ascites Assessment: Action: Response: Plan: Chest pain Assessment: Action: Response: Plan: Fistula, acquired arteriovenous (AV Fistula) Assessment: Action: Response: Plan: Fever, unknown origin (FUO, Hyperthermia, Pyrexia) Assessment: Action: Response: Plan: Hyperkalemia (high Potassium, Hyperpotassemia) Assessment: Action: Response: Plan: .H/O hypertension, benign Assessment: Pt is on home bp meds Action: Response: Plan: Mild (1+) aortic regurgitation is seen. The right ventricular cavity is mildly dilated with mild globalfree wall hypokinesis. The right ventricularcavity is moderately dilated with mild global free wall hypokinesis. There is a small pericardial effusion.IMPRESSION: Small residual pericardial effusion following needlepericardiocentesis. Mild (1+) aorticregurgitation is seen. There is a mildresting left ventricular outflow tract obstruction. Moderate global left ventricular systolic dysfunction. There is moderatepulmonary artery systolic hypertension. Mild aortic regurgitation. Moderate (2+) mitral regurgitation is seen.Moderate [2+] tricuspid regurgitation is seen. Mild rightventricular systolic dysfunction. Moderate tricuspid regurgitation. Moderate [2+] tricuspid regurgitation is seen. Estimated cardiacindex is normal (>=2.5L/min/m2).RIGHT VENTRICLE: Mildly dilated RV cavity. Mild PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Mild PR.PERICARDIUM: Large pericardial effusion. There are noechocardiographic signs of tamponade.IMPRESSION: Mild global biventricular systolic dysfunction. Moderate global LV hypokinesis.LV WALL MOTION: Regional LV wall motion abnormalities include: basalanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; midinferoseptal - hypo;RIGHT VENTRICLE: Mildly dilated RV cavity. Small to moderatepericardial effusion with stranding located mainly around the lateral andinferior left ventricle without echocardiographic evidence of tamponade.Moderate mitral and tricuspid regurgitation. Mild resting LVOT gradient.RIGHT VENTRICLE: Moderately dilated RV cavity. There is mild symmetric leftventricular hypertrophy. The right atrium is markedly dilated.The right atrial pressure is indeterminate. Normal RV systolic function.Abnormal diastolic septal motion/position consistent with RV volume overload.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Normal aortic valve leaflets (3). Moderate (2+) mitral regurgitationis seen. Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Moderate PA systolic hypertension.PERICARDIUM: Small pericardial effusion.Conclusions:There is mild to moderate global left ventricular hypokinesis (LVEF = 35-40%).The right ventricular cavity is mildly dilated with mild global free wallhypokinesis. Pericarditis.Height: (in) 73Weight (lb): 150BSA (m2): 1.91 m2BP (mm Hg): 130/80HR (bpm): 86Status: InpatientDate/Time: at 01:22Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with 35-50%decrease during respiration (estimated RA pressure (0-10mmHg).LEFT VENTRICLE: Mild symmetric LVH. IMPRESSION: Cardiomegaly with moderate-sized left effusion and probable adjacent compression atelectasis and small right effusion. Moderate-sized left pleural effusion and probable compression atelectasis is noted with a small right effusion noted on the lateral view. Left ventricularhypertrophy with secondary ST-T wave changes. Prolonged QTc interval.Lateral ST-T wave changes which may be related to left ventricular hypertrophy.Compared to the previous tracing of QTc interval prolongation is new.Clinical correlation is suggested. Bilateral compression atelectasis is noted with the remaining aerated lung parenchyma appearing otherwise unremarkable. Compared to the previous tracing of nosignificant change. Moderate-to-large amount of intrapelvic ascites has developed. Marked ST-T wave changes mostprominent in the anterior and anterolateral leads. Cardiac echo recommended. Prolonged Q-T interval. Sinus bradycardia. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Left ventricular hypertrophy. There has been interval development of a moderate to large amount of intra-abdominal ascites. Marked ST-T wave changes most prominently in the anteriorand anterolateral leads. Compared to the previous tracing ventricular ectopyis somewhat less.TRACING #3 Sinus rhythmLeft atrial abnormalityProminent QRS voltages suggests left ventricular hypertrophyDiffuse ST-T wave abnormalitiesProlonged Q-Tc intervalFindings are nonspecific but clinical correlation is suggested for possible inpart drug/metabolic/electrolyte effect, possible ischemia or central nervoussystem eventSince previous tracing of , ST-T wave changes less prominent Probable atrial fibrillation with frequent ventricular ectopy. Findings are as described on the previous tracing of andare without significant change except, that ST-T wave changes appear lessprominent. Ventricular ectopy. mod b/l effusions. Marked ST-T wave changes, particularly in theanterior and anterolateral leads. Interval development of a large amount of intra-abdominal/intrapelvic ascites and moderate-to-large pericardial effusion with CT findings suggesting a component of tamponade. Compared to the previous tracing there is nosignificant change.TRACING #2 Frequent premature atrial contractions. Moderate-sized bilateral pleural effusions. Compared to the previoustracing ventricular ectopy has resolved.TRACING #4 REASON FOR THIS EXAMINATION: S/p pericardiocentesis. decreased size to RLQ collection at ste of prior xplant. TheQTc interval is somewhat shorter.TRACING #1 PFI REPORT Left lower lobe retrocardiac opacity has worsened, likely atelectasis. | 48 | [
{
"category": "Nursing",
"chartdate": "2161-10-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417523,
"text": "Hypertension, benign\n Assessment:\n Known hypertensive. Systolic to 180\n Action:\n Captopril increased to 50mg tid & Metoprolol xl chged to Metoprolol\n 50mg .\n Response:\n Systolic bp running in 140\ns. to receive 1^st dose to captopril 50mg @\n 0600.\n Plan:\n Contin titration of meds to maint appropriate systolic bp.\n Anemia, other\n Assessment:\n Hct trending down w am hct-20.5. wo obvious source. Hemody stable.\n Action:\n Echo done early into shift-sm pericardial effusion wo increase. Hct\n recked-remains 20\ns. fem site-c&d wo ooze/ hematoma. To image w ct in\n am. Tx w 1urbc.\n Response:\n Plan:\n Tx urbc. Reck hct. ?hct goal.\n Chest pain\n Assessment:\n Co cp @ site of pericardial drain insertions. Does not increase w\n respirations. Wo pulsus paradox.\n Action:\n Repositioned & med w oxycodone as ordered.\n Response:\n Gains relief from med, but requesting med q4hrs.\n Plan:\n Contin assess as indicated. Med prn.\n"
},
{
"category": "Physician ",
"chartdate": "2161-10-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 417169,
"text": "Chief Complaint: Patient with episode of narrow complex tachycardia at\n 3:30 am\n -- Given IV Metoprolol 5mg IV x 2 with resolution\n Nausea, given Zofran. Did not tolerate Kayexalate\n Renal team ready to dialize today\n 24 Hour Events:\n Allergies:\n Codeine\n Unknown;\n Dilaudid (Injection) (Hydromorphone Hcl/Pf)\n Lightheadedness\n Ciprofloxacin\n itching;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 73 (73 - 155) bpm\n BP: 136/99(108) {108/76(86) - 144/109(113)} mmHg\n RR: 19 (17 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 60 mL\n Urine:\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n 0 mL\n -60 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 474 K/uL\n 8.0 g/dL\n 131 mg/dL\n 12.1 mg/dL\n 26 mEq/L\n 6.2 mEq/L\n 65 mg/dL\n 93 mEq/L\n 133 mEq/L\n 25.4 %\n 7.1 K/uL\n [image002.jpg]\n 02:24 AM\n WBC\n 7.1\n Hct\n 25.4\n Plt\n 474\n Cr\n 12.1\n Glucose\n 131\n Other labs: PT / PTT / INR:18.7/31.4/1.7, Differential-Neuts:76.0 %,\n Lymph:15.6 %, Mono:6.4 %, Eos:1.5 %, Ca++:9.6 mg/dL, Mg++:2.4 mg/dL,\n PO4:4.7 mg/dL\n Assessment and Plan\n 43 yo M with PMHx sig. ESRD s/p failed transplant and subsequent\n nephrectomy in who p/w abdominal pain, found to have pericardial\n effusion with tamponade physiology on bedside ECHO.\n .\n # Pericardial effusion: Stable overnight, without clinical signs of\n tamponade; no hypotension, pulsus paradoxus or decompensated failure.\n DDx includes uremia, malignant effusion, infectious/tuberculous\n effusion.\n -- Follow pulsus\n -- Plan for cardiac cath in AM per Cardiology\n -- Hold ACE-I\n -- Continue beta blocker per home regimen\n .\n # Abdominal pain: CT scan did not show an infectious process. Pain\n likely referred from pericardial distention\n -- Serial abdominal exams\n .\n # Ascites: Likely secondary to pericardial effusion leading to right\n sided congestion\n -- Continue to monitor\n .\n # Infiltrated IV: Exam is benign. Plastics has evaluated.\n - elevated arm, warm compressess\n - Plastics following, appreciate recs.\n .\n # Systolic CHF: As above, will hold ace inhibitor for now\n -- Monitor volume status, to be controlled by dialysis\n .\n # ESRD / Hyperkalemia: Unable to give Kayexalate given nausea. Patient\n will need electrolyte disorder corrected\n - HD today\n - renally dose meds\n .\n #. SVT: Resolved after IV metoprolol, likely in setting of uremia and\n electrolyte imbalance\n -- Continue beta blocker\n .\n # Hematuria: This has been ongoing since nephrectomy. Followed by Dr.\n in Urology.\n - check U/A, urine culture\n - f/u as outpatient.\n .\n # HTN: Given concern for hemodynamic decompensation, will hold\n antihypertensives with exception of short acting metoprolol\n .\n # Anemia: Previously noted to be iron deficient. Also likely from\n ESRD.\n - cont. iron\n .\n # Depression/Insomnia:\n - cont. home imipramine, citalopram, and clonazepam\n .\n # Hepatitis C: check LFTs\n .\n FEN: no IVFs, electrolyte mgmt per HD, renal diet\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:59 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2161-10-04 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 417596,
"text": "43 yo male w/ PMH significant for ESRD s/p failed renal transplant w/\n subsequent nephrectomy who p/w abdominal pain, nausea,\n decreased appetite x 5 days. Felt so poorly that he missed his dialysis\n yesterday. Abd CT in ED revealing ascites and large pericardial\n effusion w/ signs of tamponade physiology per ECHO. Admit to CCU for\n further monitoring w/ K 6.2.\n HPI: Was recently hospitalized in for worsening SOB/ abdominal\n pain with chest pain - admitted to MICU. Found to have new onset\n systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia.\n Course c/b gram positive bacteremia- thought likely from HD line-\n treated w/ 2 week course IV vanco.\n Today, HD completed over 3.5 hrs, removed ml fluid. Bld cxs sent\n x 2 from HD line. To cardiac cath lab 13:00 for RHC/pericardial\n drain- Returned at 17:30 s/p RHC w/ equalization of pressures,\n pericardial tap for 1200ml serous fluid, placement of pericardial\n drain.\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Fistula, acquired arteriovenous (AV Fistula)\n Assessment:\n Action:\n Response:\n Plan:\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2161-10-04 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 417601,
"text": "43 yo male w/ PMH significant for ESRD s/p failed renal transplant w/\n subsequent nephrectomy who p/w abdominal pain, nausea,\n decreased appetite x 5 days. Felt so poorly that he missed his dialysis\n yesterday. Abd CT in ED revealing ascites and large pericardial\n effusion w/ signs of tamponade physiology per ECHO. Admit to CCU for\n further monitoring w/ K 6.2.\n HPI: Was recently hospitalized in for worsening SOB/ abdominal\n pain with chest pain - admitted to MICU. Found to have new onset\n systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia.\n Course c/b gram positive bacterrmia- thought likely from HD line-\n treated w/ 2 week course IV vanco.\n HD completed over 3.5 hrs, removed ml fluid. Bld cxs sent x 2\n from HD line. To cardiac cath lab for RHC/pericardial drain-\n Returned at 17:30 s/p RHC w/ equalization of pressures, pericardial tap\n for 1200ml serous fluid, placement of pericardial drain.\n Hypertension, benign\n Assessment:\n Bp >150\n Action:\n BP MEDS\n Response:\n Bp now 120\n Plan:\n Continue to give bp meds and monitor fluid intake note pt\ns fluid\n restrictions.\n Fistula, acquired arteriovenous (AV Fistula)\n Assessment:\n +thrill, +bruit maturing well\n Plan:\n Continue to monitor for +thrill, +bruit\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Pt c/o pain in lower abdomen\n Action:\n Bowel regimen meds pain meds\n Response:\n Pt feels less pain\n Plan:\n Continue with bowel regimen\n Anemia\n Assessment:\n Hct 20\n Action:\n Iunit prbc\n Response:\n Hct increased to 23.4\n Plan:\n Continue to monitor serial hct\n"
},
{
"category": "Nursing",
"chartdate": "2161-10-04 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 417597,
"text": "43 yo male w/ PMH significant for ESRD s/p failed renal transplant w/\n subsequent nephrectomy who p/w abdominal pain, nausea,\n decreased appetite x 5 days. Felt so poorly that he missed his dialysis\n yesterday. Abd CT in ED revealing ascites and large pericardial\n effusion w/ signs of tamponade physiology per ECHO. Admit to CCU for\n further monitoring w/ K 6.2.\n HPI: Was recently hospitalized in for worsening SOB/ abdominal\n pain with chest pain - admitted to MICU. Found to have new onset\n systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia.\n Course c/b gram positive bacteremia- thought likely from HD line-\n treated w/ 2 week course IV vanco.\n Today, HD completed over 3.5 hrs, removed ml fluid. Bld cxs sent\n x 2 from HD line. To cardiac cath lab 13:00 for RHC/pericardial\n drain- Returned at 17:30 s/p RHC w/ equalization of pressures,\n pericardial tap for 1200ml serous fluid, placement of pericardial\n drain.\n Today, HD completed over 3.5 hrs, removed ml fluid. Bld cxs sent\n x 2 from HD line. To cardiac cath lab 13:00 for RHC/pericardial\n drain- Returned at 17:30 s/p RHC w/ equalization of pressures,\n pericardial tap for 1200ml serous fluid, placement of pericardial\n drain.\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Fistula, acquired arteriovenous (AV Fistula)\n Assessment:\n Action:\n Response:\n Plan:\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2161-10-04 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 417646,
"text": "43 yo male w/ PMH significant for ESRD s/p failed renal transplant w/\n subsequent nephrectomy who p/w abdominal pain, nausea,\n decreased appetite x 5 days. Felt so poorly that he missed his dialysis\n yesterday. Abd CT in ED revealing ascites and large pericardial\n effusion w/ signs of tamponade physiology per ECHO. Admit to CCU for\n further monitoring w/ K 6.2.\n HPI: Was recently hospitalized in for worsening SOB/ abdominal\n pain with chest pain - admitted to MICU. Found to have new onset\n systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia.\n Course c/b gram positive bacterrmia- thought likely from HD line-\n treated w/ 2 week course IV vanco.\n HD completed over 3.5 hrs, removed ml fluid. Bld cxs sent x 2\n from HD line. To cardiac cath lab for RHC/pericardial drain-\n Returned at 17:30 s/p RHC w/ equalization of pressures, pericardial tap\n for 1200ml serous fluid, placement of pericardial drain.\n Hypertension, benign\n Assessment:\n Bp >150\n Action:\n BP MEDS\n Response:\n Bp now 120\n Plan:\n Continue to give bp meds and monitor fluid intake note pt\ns fluid\n restrictions.\n Fistula, acquired arteriovenous (AV Fistula)\n Assessment:\n +thrill, +bruit maturing well\n Plan:\n Continue to monitor for +thrill, +bruit\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Pt c/o pain in lower abdomen\n Action:\n Bowel regimen meds pain meds\n Response:\n Pt feels less pain\n Plan:\n Continue with bowel regimen\n Anemia\n Assessment:\n Hct 20\n Action:\n Iunit prbc\n Response:\n Hct increased to 23.4\n Plan:\n Continue to monitor serial hct\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n PERICARDIAL EFFUSION\n Code status:\n Full code\n Height:\n 73 Inch\n Admission weight:\n 72.5 kg\n Daily weight:\n Allergies/Reactions:\n Codeine\n Unknown;\n Dilaudid (Injection) (Hydromorphone Hcl/Pf)\n Lightheadedness\n Ciprofloxacin\n itching;\n Precautions: No Additional Precautions\n PMH: Anemia, Hepatitis, Renal Failure\n CV-PMH: Arrhythmias, CAD, CHF, Hypertension\n Additional history: hemodialysis x3 days a week, persistent abdominal\n pain, exertional dyspnea, orthopnea, failed kidney transplant- removed\n , hepatitis C+, congenital single kidney, REM behavior disorder,\n s/p MVA\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:144\n D:84\n Temperature:\n 98.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 11 insp/min\n Heart Rate:\n 62 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Non-rebreather\n O2 saturation:\n 100% %\n O2 flow:\n 100 L/min\n FiO2 set:\n 24h total in:\n 1,239 mL\n 24h total out:\n 0 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 11:05 AM\n Potassium:\n 3.6 mEq/L\n 11:05 AM\n Chloride:\n 96 mEq/L\n 11:05 AM\n CO2:\n 31 mEq/L\n 11:05 AM\n BUN:\n 25 mg/dL\n 11:05 AM\n Creatinine:\n 7.0 mg/dL\n 11:05 AM\n Glucose:\n 153 mg/dL\n 11:05 AM\n Hematocrit:\n 23.4 %\n 11:27 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: ccu\n Transferred to: 3\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nursing",
"chartdate": "2161-10-04 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 417594,
"text": "Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Fistula, acquired arteriovenous (AV Fistula)\n Assessment:\n Action:\n Response:\n Plan:\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2161-10-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417136,
"text": ".H/O transplant, kidney (Renal transplant)\n Assessment:\n Pt had a failed kidney transplant in \n Action:\n Response:\n Pt requiring to start hemodialysis\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Pts abdomen soft distended tender when touched pt guards his stomach\n Action:\n Pt repositioned on side and given pain med\n Response:\n Less painful\n Plan:\n Continue to keep pain free prn oxycodone\n Anxiety\n Assessment:\n It makes me nervouse when I feel the chest pain\n Action:\n Rn explained to pt why he is experiencing chest pain and explained in\n little detail about possible pericardial drain in cath lab in am and pt\n should feel much better\n Response:\n Pt appeared less nervous and wanted to rest\n Plan:\n Emotional support\n Ascites\n Assessment:\n Tender abd, ct showed asites\n Action:\n Pain meds for aching pain per pt repositioning side to side\n Response:\n Pt feels less pain\n Plan:\n Pain meds\n Chest pain\n Assessment:\n Pt c/o chest pain c exertion when he walked from stretcher to bed pain\n lasted 3min approx\n Action:\n Pt rested, ekg obtained\n Response:\n Pt pain went away with rest\n Plan:\n Limit ambulating or exertion\n Right forearm av fistula\n Assessment:\n + thrill\n Action:\n Av fistula appears to be developing well\n Response:\n Plan:\n Continue to monitor av fistula for thrill\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 99.5 oral\n Action:\n Md notified, fan in room\n Response:\n Pt more comfortable cooler\n Plan:\n Continue to monitor temp , keep col and comfortable\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K 6.5 no hemodialysis \n Action:\n Pt is unable to drink kaxalate r/t nausea abd pain\n Response:\n K >6\n Plan:\n Pt will have hemodialysis today\n .H/O hypertension, benign\n Assessment:\n Pt is on home bp meds\n Action:\n Continue with bp meds\n Response:\n Bp stable\n Plan:\n ? hold bp meds if going to hemodialysis today pt is 4kg above his dry\n weight if pt will be dialyzed late after cath lab post pericardial\n drain placement may want to give lopressor in am as scheduled\n"
},
{
"category": "Nursing",
"chartdate": "2161-10-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417138,
"text": ".43yo male c esrd s/p failed transplant and subsequent nephrectomy in\n . admitted for large pericardial effusion also asites abd pain. Pt\n reports that he hasn\nt eaten in 5 days r/t pain and nausea.\n .H/O transplant, kidney (Renal transplant)\n Assessment:\n Pt had a failed kidney transplant in \n Action:\n Response:\n Pt requiring to start hemodialysis\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Pts abdomen soft distended tender when touched pt guards his stomach\n Action:\n Pt repositioned on side and given pain med\n Response:\n Less painful\n Plan:\n Continue to keep pain free prn oxycodone\n Anxiety\n Assessment:\n It makes me nervouse when I feel the chest pain\n Action:\n Rn explained to pt why he is experiencing chest pain and explained in\n little detail about possible pericardial drain in cath lab in am and pt\n should feel much better\n Response:\n Pt appeared less nervous and wanted to rest\n Plan:\n Emotional support\n Ascites\n Assessment:\n Tender abd, ct showed asites\n Action:\n Pain meds for aching pain per pt repositioning side to side\n Response:\n Pt feels less pain\n Plan:\n Pain meds\n Chest pain\n Assessment:\n Pt c/o chest pain c exertion when he walked from stretcher to bed pain\n lasted 3min approx\n Action:\n Pt rested, ekg obtained\n Response:\n Pt pain went away with rest\n Plan:\n Limit ambulating or exertion\n Right forearm av fistula\n Assessment:\n + thrill\n Action:\n Av fistula appears to be developing well\n Response:\n Plan:\n Continue to monitor av fistula for thrill\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 99.5 oral\n Action:\n Md notified, fan in room\n Response:\n Pt more comfortable cooler\n Plan:\n Continue to monitor temp , keep col and comfortable\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K 6.5 no hemodialysis \n Action:\n Pt is unable to drink kaxalate r/t nausea abd pain\n Response:\n K >6\n Plan:\n Pt will have hemodialysis today\n .H/O hypertension, benign\n Assessment:\n Pt is on home bp meds\n Action:\n Continue with bp meds\n Response:\n Bp stable\n Plan:\n ? hold bp meds if going to hemodialysis today pt is 4kg above his dry\n weight if pt will be dialyzed late after cath lab post pericardial\n drain placement may want to give lopressor in am as scheduled\n"
},
{
"category": "Nursing",
"chartdate": "2161-10-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417139,
"text": ".43yo male c esrd s/p failed transplant and subsequent nephrectomy in\n . admitted for large pericardial effusion also asites abd pain. Pt\n reports that he hasn\nt eaten in 5 days r/t pain and nausea.\n .H/O transplant, kidney (Renal transplant)\n Assessment:\n Pt had a failed kidney transplant in \n Action:\n Response:\n Pt requiring to start hemodialysis\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Pts abdomen soft distended tender when touched pt guards his stomach\n Action:\n Pt repositioned on side and given pain med\n Response:\n Less painful\n Plan:\n Continue to keep pain free prn oxycodone\n Anxiety\n Assessment:\n It makes me nervouse when I feel the chest pain\n Action:\n Rn explained to pt why he is experiencing chest pain and explained in\n little detail about possible pericardial drain in cath lab in am and pt\n should feel much better\n Response:\n Pt appeared less nervous and wanted to rest\n Plan:\n Emotional support\n Ascites\n Assessment:\n Tender abd, ct showed asites\n Action:\n Pain meds for aching pain per pt repositioning side to side\n Response:\n Pt feels less pain\n Plan:\n Pain meds\n Chest pain\n Assessment:\n Pt c/o chest pain c exertion when he walked from stretcher to bed pain\n lasted 3min approx\n Action:\n Pt rested, ekg obtained\n Response:\n Pt pain went away with rest\n Plan:\n Limit ambulating or exertion\n Right forearm av fistula\n Assessment:\n + thrill\n Action:\n Av fistula appears to be developing well\n Response:\n Plan:\n Continue to monitor av fistula for thrill\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 99.5 oral\n Action:\n Md notified, fan in room\n Response:\n Pt more comfortable cooler\n Plan:\n Continue to monitor temp , keep col and comfortable\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K 6.5 no hemodialysis \n Action:\n Pt is unable to drink kaxalate r/t nausea abd pain\n Response:\n K >6\n Plan:\n Pt will have hemodialysis today\n .H/O hypertension, benign\n Assessment:\n Pt is on home bp meds\n Action:\n Continue with bp meds\n Response:\n Bp stable\n Plan:\n ? hold bp meds if going to hemodialysis today pt is 4kg above his dry\n weight if pt will be dialyzed late after cath lab post pericardial\n drain placement may want to give lopressor in am as scheduled\n"
},
{
"category": "Nursing",
"chartdate": "2161-10-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417140,
"text": ".43yo male c esrd s/p failed transplant and subsequent nephrectomy in\n . admitted for large pericardial effusion also asites abd pain. Pt\n reports that he hasn\nt eaten in 5 days r/t pain and nausea.\n .H/O transplant, kidney (Renal transplant)\n Assessment:\n Pt had a failed kidney transplant in \n Action:\n Response:\n Pt requiring to start hemodialysis\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Pts abdomen soft distended tender when touched pt guards his stomach\n Action:\n Pt repositioned on side and given pain med\n Response:\n Less painful\n Plan:\n Continue to keep pain free prn oxycodone\n Anxiety\n Assessment:\n It makes me nervouse when I feel the chest pain\n Action:\n Rn explained to pt why he is experiencing chest pain and explained in\n little detail about possible pericardial drain in cath lab in am and pt\n should feel much better\n Response:\n Pt appeared less nervous and wanted to rest\n Plan:\n Emotional support\n Ascites\n Assessment:\n Tender abd, ct showed asites\n Action:\n Pain meds for aching pain per pt repositioning side to side\n Response:\n Pt feels less pain\n Plan:\n Pain meds\n Chest pain\n Assessment:\n Pt c/o chest pain c exertion when he walked from stretcher to bed pain\n lasted 3min approx\n Action:\n Pt rested, ekg obtained\n Response:\n Pt pain went away with rest\n Plan:\n Limit ambulating or exertion\n Right forearm av fistula\n Assessment:\n + thrill\n Action:\n Av fistula appears to be developing well\n Response:\n Plan:\n Continue to monitor av fistula for thrill\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 99.5 oral\n Action:\n Md notified, fan in room\n Response:\n Pt more comfortable cooler\n Plan:\n Continue to monitor temp , keep col and comfortable\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K 6.5 no hemodialysis \n Action:\n Pt is unable to drink kaxalate r/t nausea abd pain\n Response:\n K >6\n Plan:\n Pt will have hemodialysis today\n .H/O hypertension, benign\n Assessment:\n Pt is on home bp meds\n Action:\n Continue with bp meds\n Response:\n Bp stable\n Plan:\n ? hold bp meds if going to hemodialysis today pt is 4kg above his dry\n weight if pt will be dialyzed late after cath lab post pericardial\n drain placement may want to give lopressor in am as scheduled\n"
},
{
"category": "Nursing",
"chartdate": "2161-10-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417141,
"text": ".43yo male c esrd s/p failed transplant and subsequent nephrectomy in\n . admitted for large pericardial effusion also asites abd pain. Pt\n reports that he hasn\nt eaten in 5 days r/t pain and nausea. Pt had one\n episode of svt hr 160\ns pt responded well to 10mg ivp (5mg x2)\n lopressor to break svt now pt in nsr. Bp remained stable while in svt.\n Pt will be going to cath lab today for pericardial drain then he will\n need hemodialysis.\n .H/O transplant, kidney (Renal transplant)\n Assessment:\n Pt had a failed kidney transplant in \n Action:\n Response:\n Pt requiring to start hemodialysis\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Pts abdomen soft distended tender when touched pt guards his stomach\n Action:\n Pt repositioned on side and given pain med\n Response:\n Less painful\n Plan:\n Continue to keep pain free prn oxycodone\n Anxiety\n Assessment:\n It makes me nervouse when I feel the chest pain\n Action:\n Rn explained to pt why he is experiencing chest pain and explained in\n little detail about possible pericardial drain in cath lab in am and pt\n should feel much better\n Response:\n Pt appeared less nervous and wanted to rest\n Plan:\n Emotional support\n Ascites\n Assessment:\n Tender abd, ct showed asites\n Action:\n Pain meds for aching pain per pt repositioning side to side\n Response:\n Pt feels less pain\n Plan:\n Pain meds\n Chest pain\n Assessment:\n Pt c/o chest pain c exertion when he walked from stretcher to bed pain\n lasted 3min approx\n Action:\n Pt rested, ekg obtained\n Response:\n Pt pain went away with rest\n Plan:\n Limit ambulating or exertion\n Right forearm av fistula\n Assessment:\n + thrill\n Action:\n Av fistula appears to be developing well\n Response:\n Plan:\n Continue to monitor av fistula for thrill\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 99.5 oral\n Action:\n Md notified, fan in room\n Response:\n Pt more comfortable cooler\n Plan:\n Continue to monitor temp , keep col and comfortable\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K 6.5 no hemodialysis \n Action:\n Pt is unable to drink kaxalate r/t nausea abd pain\n Response:\n K >6\n Plan:\n Pt will have hemodialysis today\n .H/O hypertension, benign\n Assessment:\n Pt is on home bp meds\n Action:\n Continue with bp meds\n Response:\n Bp stable\n Plan:\n ? hold bp meds if going to hemodialysis today pt is 4kg above his dry\n weight if pt will be dialyzed late after cath lab post pericardial\n drain placement may want to give lopressor in am as scheduled\n"
},
{
"category": "Nursing",
"chartdate": "2161-10-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417123,
"text": ".H/O transplant, kidney (Renal transplant)\n Assessment:\n Pt had a\n Action:\n Response:\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n Anxiety\n Assessment:\n Action:\n Response:\n Plan:\n Ascites\n Assessment:\n Action:\n Response:\n Plan:\n Chest pain\n Assessment:\n Action:\n Response:\n Plan:\n Fistula, acquired arteriovenous (AV Fistula)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O hypertension, benign\n Assessment:\n Pt is on home bp meds\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2161-10-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417225,
"text": "43 yo male w/ PMH significant for ESRD s/p failed renal transplant w/\n subsequent nephrectomy who p/w abdominal pain, nausea,\n decreased appetite x 5 days. Felt so poorly that he missed his dialysis\n yesterday. Abd CT in ED revealing ascites and large pericardial\n effusion w/ signs of tamponade physiology per ECHO. Admit to CCU for\n further monitoring w/ K 6.2.\n HPI: Was recently hospitalized in for worsening SOB/ abdominal\n pain with chest pain - admitted to MICU. Found to have new onset\n systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia.\n Course c/b gram positive bacteremia- thought likely from HD line-\n treated w/ 2 week course IV vanco.\n Today, HD completed over 3.5 hrs, removed_______ml fluid. Bld cxs sent\n x 2 from HD line. To cardiac cath lab for RHC/LHC/pericardial drain.\n Pericardial effusion (without tamponade)\n Assessment:\n c/o substernal chest pain worse w/ inspiration. Hemodynamically stable.\n Pulsus Parodoxus 6.\n Action:\n Oxycodone 5mg for pain. Pericardial drain placement.\n Response:\n Plan:\n Continue to monitor for s/s hemodynamic instability.\n Abdominal pain (including abdominal tenderness)\n Assessment:\n +Ascites per abd CT. Pt describes as\nachiness\n across entire abdomen.\n Severity , worse w/ palpation and reportedly after eating though\n pt NPO today. BS hyperactive. Abd soft, distended.\n Action:\n Medicated as above.\n Response:\n Pt temporarily decreases to tolerable level after po medication.\n Plan:\n Frequent pain assessment.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: diminished at bases. O2 sat down 85-95% 2L NC , 5 pillow orthopnea\n at home per pt report, +ascites per abdominal CT.\n Action:\n O2NC increased as needed- team notified. Team concerned re: etiology\n of new onset HF (worse over past month). LHC to evaluate for coronary\n arteries as source.\n Response:\n SPO2 increased appropriately.\n Plan:\n Will start heart failure medication regimen once stable post cath/\n drain placement.\n Impaired Skin Integrity\n Assessment:\n PIV L AC infiltrated in ED . Site benign, OTA.\n Action:\n Seen by plastics.\n Response:\n Stable site.\n Plan:\n Will continue to closely monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2161-10-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417124,
"text": ".H/O transplant, kidney (Renal transplant)\n Assessment:\n Pt had a failed kidney transplant in \n Action:\n Response:\n Pt requiring to start hemodialysis\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Pts abdomen soft distended tender when touched pt guards his stomach\n Action:\n Response:\n Plan:\n Anxiety\n Assessment:\n Action:\n Response:\n Plan:\n Ascites\n Assessment:\n Action:\n Response:\n Plan:\n Chest pain\n Assessment:\n Action:\n Response:\n Plan:\n Fistula, acquired arteriovenous (AV Fistula)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O hypertension, benign\n Assessment:\n Pt is on home bp meds\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2161-10-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417132,
"text": ".H/O transplant, kidney (Renal transplant)\n Assessment:\n Pt had a failed kidney transplant in \n Action:\n Response:\n Pt requiring to start hemodialysis\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Pts abdomen soft distended tender when touched pt guards his stomach\n Action:\n Pt repositioned on side and given pain med\n Response:\n Less painful\n Plan:\n Continue to keep pain free prn oxycodone\n Anxiety\n Assessment:\n It makes me nervouse when I feel the chest pain\n Action:\n Rn explained to pt why he is experiencing chest pain and explained in\n little detail about possible pericardial drain in cath lab in am and pt\n should feel much better\n Response:\n Pt appeared less nervous and wanted to rest\n Plan:\n Emotional support\n Ascites\n Assessment:\n Tender abd, ct showed asites\n Action:\n Pain meds for aching pain per pt repositioning side to side\n Response:\n Pt feels less pain\n Plan:\n Pain meds\n Chest pain\n Assessment:\n Pt c/o chest pain c exertion when he walked from stretcher to bed pain\n lasted 3min approx\n Action:\n Pt rested, ekg obtained\n Response:\n Pt pain went away with rest\n Plan:\n Limit ambulating or exertion\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O hypertension, benign\n Assessment:\n Pt is on home bp meds\n Action:\n Response:\n Plan:\n"
},
{
"category": "Social Work",
"chartdate": "2161-10-02 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 417246,
"text": "Family Information\n Next of :\n Health Care Proxy appointed: Yes - But NO copy of signed proxy form in\n medical record\n Family Spokesperson designated:\n Communication or visitation restriction:\n Patient Information:\n Previous living situation:\n Previous level of functioning:\n Previous or other hospital admissions:\n Past psychiatric history:\n Past addictions history:\n Employment status:\n Legal involvement:\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment:\n Clergy Contact:\n Communication with Team:\n Plan / Follow up:\n"
},
{
"category": "Nutrition",
"chartdate": "2161-10-02 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 417258,
"text": "Subjective: pt off floor, unable to interview.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 185 cm\n 72.5 kg\n 21.8\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 83.5 kg\n 82%\n 68.5 est. dry wt.\n 106%\n Diagnosis: Pericardial Effusion\n PMH : ESRD s/p failed renal trx with subsequent nephrectomy c/p\n gram + bactremia, ascites, on HD\n Food allergies and intolerances: NKFA\n Pertinent medications: Colace, Senna, others noted\n Labs:\n Value\n Date\n Glucose\n 131 mg/dL\n 02:24 AM\n BUN\n 65 mg/dL\n 02:24 AM\n Creatinine\n 12.1 mg/dL\n 02:24 AM\n Sodium\n 133 mEq/L\n 02:24 AM\n Potassium\n 6.2 mEq/L\n 02:24 AM\n Chloride\n 93 mEq/L\n 02:24 AM\n TCO2\n 26 mEq/L\n 02:24 AM\n Calcium non-ionized\n 9.6 mg/dL\n 02:24 AM\n Phosphorus\n 4.7 mg/dL\n 02:24 AM\n Magnesium\n 2.4 mg/dL\n 02:24 AM\n WBC\n 7.1 K/uL\n 02:24 AM\n Current diet order / nutrition support: NPO\n GI: distended with ascites\n Assessment of Nutritional Status\n Malnourished\n Pt at risk due to: low % IBW, ESRD on HD, current symptoms, possible\n prolonged NPO\n Estimated Nutritional Needs\n Calories: 2055-2400 (BEE x or / 30-35 cal/kg)\n Protein: 75-89 (1.1-1.3 g/kg)\n Fluid: per team\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 43 y.o. M with ESRD on HD, adm with abd pain, nausea & poor appetite,\n found to have large ascites and pericardial effusion with tamponade\n physiology. Pt is currently off floor at cath lab, thus unable to\n interview. Pt is NPO x2days; if unable to advance diet in the next \n days, recommend considering enteral nutrition. Pt is at high\n nutritional risk due to current medical problems and low admit weight.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Advance diet as able.\n 2) If pt unable to take po\ns in the next 47-72hrs, consider\n enteral nutrition via post pyloric FT. TF goal would be Novasource\n Renal @45cc/hr (2160 kcals, 80g protein).\n 3) Multivitamin / Mineral supplement: Nephrocaps\n Will follow- please page if ?\ns \n"
},
{
"category": "Nursing",
"chartdate": "2161-10-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417313,
"text": "43 yo male w/ PMH significant for ESRD s/p failed renal transplant w/\n subsequent nephrectomy who p/w abdominal pain, nausea,\n decreased appetite x 5 days. Felt so poorly that he missed his dialysis\n yesterday. Abd CT in ED revealing ascites and large pericardial\n effusion w/ signs of tamponade physiology per ECHO. Admit to CCU for\n further monitoring w/ K 6.2.\n HPI: Was recently hospitalized in for worsening SOB/ abdominal\n pain with chest pain - admitted to MICU. Found to have new onset\n systolic CHF thought r/t graft rejection/ nephrectomy/ or ischemia.\n Course c/b gram positive bacteremia- thought likely from HD line-\n treated w/ 2 week course IV vanco.\n Today, HD completed over 3.5 hrs, removed ml fluid. Bld cxs sent\n x 2 from HD line. To cardiac cath lab 13:00 for RHC/pericardial\n drain- Returned at 17:30 s/p RHC w/ equalization of pressures,\n pericardial tap for 1200ml serous fluid, placement of pericardial\n drain.\n Pericardial effusion (without tamponade)\n Assessment:\n c/o substernal chest pain worse w/ inspiration. Hemodynamically stable.\n Pulsus Parodoxus 6, increased to 16 by 12noon- team aware.\n Action:\n Oxycodone 5mg for pain. Pericardial drain placement, drained 1200ml\n fluid.\n Response:\n Improved hemodynamics.\n Plan:\n Continue to monitor drainage amout and color per hosp policy. Assess\n site frequently. Follow hemodynamics.\n Abdominal pain (including abdominal tenderness)\n Assessment:\n +Ascites per abd CT. Pt describes as\nachiness\n across entire abdomen.\n Severity , worse w/ palpation and reportedly after eating though\n pt NPO today. BS hyperactive. Abd soft, distended.\n Action:\n Medicated as above.\n Response:\n Pain temporarily decreased to tolerable level after po medication.\n Plan:\n Frequent pain assessment. Reassess if current regimen not working.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: diminished at bases. O2 sat down 85-95% 2L NC , 5 pillow orthopnea\n at home per pt report, +ascites per abdominal CT.\n Action:\n O2NC increased as needed- team notified. Team concerned re: etiology\n of new onset HF (worse over past month). LHC to evaluate for coronary\n arteries as source.\n Response:\n SPO2 increased appropriately.\n Plan:\n Will start heart failure medication regimen once stable post cath/\n drain placement. Initial heart failure teaching done w/ pt. Needs\n reinforcement.\n Impaired Skin Integrity\n Assessment:\n PIV L AC infiltrated in ED . Site benign, OTA.\n Action:\n Seen by plastics.\n Response:\n Stable site.\n Plan:\n Will continue to closely monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2161-10-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417461,
"text": "? new pericardial effusion\n Assessment:\n Pulsus 6 before pericardial drain removed this afternoon around 1330 pt\n felt chest pain after procedure and received morphine 2mg with good\n relief . Pt then c/o same chest pain he experienced c prior pericardial\n effusion new pulsus was 5 at 1730\n Action:\n Assess for pericardial effusion\n Response:\n Pulsus 5\n Plan:\n Continue to monitor for new pericardial effusion pulsus q 2hrs\n Chest pain\n Assessment:\n Pt experiencing chest pain after completion of hemodialysis pt had many\n pvc then vtach ? torsades, bp >180\n Action:\n Repleat mag 4grams, ekg\n Response:\n Pt feeling better no more chest pain, bp 147/60\n Plan:\n Monitor hemodynamics\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp spiked acutely after c/o hd tx 99.5 pt had chills and shivers\n Action:\n Remove blankets cool cloth to head\n Response:\n Pt felt less shivers felt better\n Plan:\n Monitor temp blood cultures x2 have been sent\n"
},
{
"category": "Nursing",
"chartdate": "2161-10-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417344,
"text": "Pericardial effusion (without tamponade)\n Assessment:\n s/p pericardiocentesis for 1.2L of bloody drainage per cath report\n with pt. reporting decrease abdominal pressure. Afeb. VSS.\n Tolerating lopressor po. Pulsus 6\n Action:\n Able to aspirate 70cc at 1800 RN. Attempted aspiration of drain\n q4hr for 0cc each time. Flushed with heparinized saline per protocol.\n Total 150cc in drainage bag.\n Response:\n No c/o pain with aspiration. Site D/I. fluid Is seroussang.\n Plan:\n Plan repeat echo in AM. Cultures pnd. Contin. drain care per protocol\n Abdominal pain (including abdominal tenderness)\n Assessment:\n c/o mild abd pain but stating that it is much improved since pc\n centesis. Abd soft, pos. BS.\n Action:\n Oxycodone 5mg po x2\n Response:\n Pt. states fair relief.\n Plan:\n Monitor abd exam. Oxycodone for pain prn.\n"
},
{
"category": "Nursing",
"chartdate": "2161-10-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417337,
"text": "Pericardial effusion (without tamponade)\n Assessment:\n Action:\n Response:\n Plan:\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Echo",
"chartdate": "2161-10-02 00:00:00.000",
"description": "Report",
"row_id": 63422,
"text": "PATIENT/TEST INFORMATION:\nIndication: S/p pericardial tap of 1200 cc. Assess residual effusion while in cath lab\nHeight: (in) 73\nWeight (lb): 150\nBSA (m2): 1.91 m2\nBP (mm Hg): 148/58\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 16:46\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\n\nLEFT VENTRICLE: Mild-moderate global left ventricular hypokinesis.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nTRICUSPID VALVE: Moderate [2+] TR. Moderate PA systolic hypertension.\n\nPERICARDIUM: Small pericardial effusion.\n\nConclusions:\nThere is mild to moderate global left ventricular hypokinesis (LVEF = 35-40%).\nThe right ventricular cavity is mildly dilated with mild global free wall\nhypokinesis. Moderate [2+] tricuspid regurgitation is seen. There is moderate\npulmonary artery systolic hypertension. There is a small pericardial effusion.\n\nIMPRESSION: Small residual pericardial effusion following needle\npericardiocentesis. Moderate tricuspid regurgitation. Moderate pulmonary\nhypertension.\n\nCompared with the prior study (images reviewed) of , most of the\npericardial fluid has been drained. Ventricular interdependence is no longer\ndemonstrated.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2161-10-05 00:00:00.000",
"description": "Report",
"row_id": 63374,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion s/p pericardiocentesis.\nHeight: (in) 73\nWeight (lb): 150\nBSA (m2): 1.91 m2\nBP (mm Hg): 136/69\nHR (bpm): 57\nStatus: Inpatient\nDate/Time: at 11:05\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. Normal IVC diameter\n(<2.1cm) with <35% decrease during respiration (estimated RA pressure\nindeterminate).\n\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Normal\nregional LV systolic function. [Intrinsic LV systolic function likely\ndepressed given the severity of valvular regurgitation.] Estimated cardiac\nindex is normal (>=2.5L/min/m2).\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\nAbnormal diastolic septal motion/position consistent with RV volume overload.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild to\nmoderate [+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Small pericardial effusion. Effusion circumferential. No\nechocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Results were personally reviewed with the MD caring for the\npatient. Results were reviewed with the Cardiology Fellow involved with the\npatient's care. Bilateral pleural effusions.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is markedly dilated.\nThe right atrial pressure is indeterminate. Left ventricular wall thicknesses\nare normal. The left ventricular cavity is mildly dilated. Regional left\nventricular wall motion is normal. [Intrinsic left ventricular systolic\nfunction is likely more depressed given the severity of valvular\nregurgitation.] The estimated cardiac index is normal (>=2.5L/min/m2). Right\nventricular chamber size is mildly increased with normal free wall motion.\nThere is abnormal diastolic septal motion/position consistent with right\nventricular volume overload. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are structurally normal.\nThere is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen.\nThere is moderate pulmonary artery systolic hypertension. There is a small\ncircumferential pericardial effusion. There are no echocardiographic signs of\ntamponade.\n\nCompared with the prior study (images reviewed) of , the effusion is\nminimally smaller with slightly improved systolic function.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2161-10-03 00:00:00.000",
"description": "Report",
"row_id": 63375,
"text": "PATIENT/TEST INFORMATION:\nIndication: Tamponade.\nHeight: (in) 73\nWeight (lb): 150\nBSA (m2): 1.91 m2\nBP (mm Hg): 136/69\nHR (bpm): 61\nStatus: Inpatient\nDate/Time: at 12:07\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\nA mass/thrombus associated with a catheter/pacing wire in the RA or RV.\n\nLEFT VENTRICLE: Mild global LV hypokinesis. Mild resting LVOT gradient.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV free wall\nhypokinesis. Prominent moderator band/trabeculations are noted in the RV apex.\n\nAORTA: Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Increased\ntransaortic velocity related to increased stroke volume due to AR. Mild to\nmoderate (+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Severe PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. The end-diastolic PR velocity is increased c/w PA diastolic\nhypertension.\n\nPERICARDIUM: Small to moderate pericardial effusion. Stranding is \nwithin the pericardial space c/w organization. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nA very small (0.4 x 0.1 cm) mobile mass/thrombus associated with a\ncatheter/pacing wire is seen in the right atrium and/or right ventricle. There\nis mild global left ventricular hypokinesis (LVEF = 45 %). There is a mild\nresting left ventricular outflow tract obstruction. The right ventricular\ncavity is moderately dilated with mild global free wall hypokinesis. The\naortic valve leaflets (3) are mildly thickened. There is no valvular aortic\nstenosis. The increased transaortic velocity is likely related to increased\nstroke volume due to aortic regurgitation. Mild to moderate (+) aortic\nregurgitation is seen. The mitral valve leaflets are structurally normal.\nThere is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen.\nModerate [2+] tricuspid regurgitation is seen. There is severe pulmonary\nartery systolic hypertension. The end-diastolic pulmonic regurgitation\nvelocity is increased suggesting pulmonary artery diastolic hypertension.\nThere is a small to moderate sized pericardial effusion. Stranding is\n within the pericardial space c/w organization. There are no\nechocardiographic signs of tamponade.\n\nIMPRESSION: Mild global biventricular systolic dysfunction. Small to moderate\npericardial effusion with stranding located mainly around the lateral and\ninferior left ventricle without echocardiographic evidence of tamponade.\nModerate mitral and tricuspid regurgitation. Severe pulmonary hypertension.\nSmall, mobile mass attached to the right atrial catheter.\nCompared with the prior study (images reviewed) of , a small mobile\nmass/thrombus attached to a right atrial catheter is now seen. The pericardial\neffusion is smaller. Left ventricular function appears more vigorous.\nPulmonary hypertension is severe.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2161-10-02 00:00:00.000",
"description": "Report",
"row_id": 63376,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Pericarditis.\nHeight: (in) 73\nWeight (lb): 150\nBSA (m2): 1.91 m2\nBP (mm Hg): 130/80\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 01:22\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with 35-50%\ndecrease during respiration (estimated RA pressure (0-10mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH. Moderate global LV hypokinesis.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\nanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid\ninferoseptal - hypo;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Mild PR.\n\nPERICARDIUM: Large pericardial effusion. Sgnificant, accentuated respiratory\nvariation in mitral/tricuspid valve inflows, c/w impaired ventricular filling.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\nLeft pleural effusion.\n\nConclusions:\nThe estimated right atrial pressure is 0-10mmHg. There is mild symmetric left\nventricular hypertrophy. There is moderate global left ventricular hypokinesis\n(LVEF = 35%). The right ventricular cavity is mildly dilated with mild global\nfree wall hypokinesis. There are three aortic valve leaflets. The aortic valve\nleaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation\nis seen. There is mild pulmonary artery systolic hypertension. There is a\nlarge circumferential pericardial effusion. There is significant, accentuated\nrespiratory variation in mitral/tricuspid valve inflows, consistent with\nimpaired ventricular filling.\n\nIMPRESSION: Large pericardial effusion with evidence of impaired ventricular\nfilling. Moderate global left ventricular systolic dysfunction. Mild right\nventricular systolic dysfunction. Mild aortic regurgitation. Moderate mitral\nregurgitation. Mild pulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , pericardial\neffusion size is much larger, and there is now evidence of some ventricular\ninterdependence, likely indicating elevated intrapericardial pressure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-10-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1037810,
"text": " 10:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: S/p pericardiocentesis.\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with pericardial effusion s/p pericardiocentesis.\n REASON FOR THIS EXAMINATION:\n S/p pericardiocentesis.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SAT 2:22 PM\n Left lower lobe retrocardiac opacity has worsened, likely atelectasis. Small\n left pleural effusion is probably unchanged. Enlarged cardiac silhouette is\n minimally decreased in size. Right pleural effusion has increased.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: S/P pericardiocentesis.\n\n Comparison is made with prior study, .\n\n Left lower lobe retrocardiac opacity has worsened, likely atelectasis. Small\n left pleural effusion is unchanged. Small right pleural effusion has\n increased. Enlarged cardiac silhouette minimally decreased in size. Left\n supraclavicular catheter remains in place. No pneumothorax.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2161-10-04 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1037984,
"text": ", S. 9:17 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Please evaluate for RP bleed and interval change in ascitic\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with ESRD failed transplant now s/p nephrectomy p/w pericardial\n tamponade now with Hct decrease.\n REASON FOR THIS EXAMINATION:\n Please evaluate for RP bleed and interval change in ascitic fluid.\n CONTRAINDICATIONS for IV CONTRAST:\n ESRD;;esrd\n ______________________________________________________________________________\n PFI REPORT\n No retroperitoneal bleeding, complete resolution of the pericardial effusion,\n and interval increase in bilateral pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-10-07 00:00:00.000",
"description": "CVL INJ/EVAL INCLUDES FLUORO/IMAGES/REPORT",
"row_id": 1038660,
"text": " 10:02 AM\n UNILAT SUBCLAV Clip # \n Reason: Pt discussed between IR and renal: need to differentiate bet\n Admitting Diagnosis: PERICARDIAL EFFUSION\n Contrast: OPTIRAY Amt: 60\n ********************************* CPT Codes ********************************\n * CVL INJ/EVAL INCLUDES FLUORO/I *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with mobile mass on end of tunneled catheter.\n REASON FOR THIS EXAMINATION:\n Pt discussed between IR and renal: need to differentiate between fibrin sheath\n and thrombus at end of tunneled catheter.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 43-year-old male with question of thrombus at the end of tunneled\n catheter.\n\n RADIOLOGISTS: Dr. , , and attending radiologist, Dr. , who\n was present and supervised the entire procedure.\n\n PROCEDURE AND FINDINGS: The risks and benefits of the procedure were\n explained to the patient, and informed consent was obtained. A preprocedure\n timeout was performed to identify the patient by name, medical record number,\n date of birth, and the nature of the procedure to be performed. The patient\n was placed supine on the angiographic table.\n\n Scout image demonstrates the tip of a tunneled left internal jugular\n hemodialysis line terminating in the right atrium. Prior to proceeding with a\n flow study, each port of the hemodialysis catheter was successfully aspirated\n and flushed. Next, 30 cc of IV Optiray contrast was injected into each port of\n the catheter which demonstrated no fibrin sheath or significant thrombus.\n Given normally functioning catheter and lack of significant clot or fibrin\n sheath, no intervention was performed. Each port of the hemodialysis catheter\n was flushed and heplocked.\n\n IMPRESSION: Flow study demonstrates no fibrin sheath or significant thrombus\n of existing left-sided tunneled hemodialysis catheter.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-10-04 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1037983,
"text": " 9:17 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Please evaluate for RP bleed and interval change in ascitic\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with ESRD failed transplant now s/p nephrectomy p/w pericardial\n tamponade now with Hct decrease.\n REASON FOR THIS EXAMINATION:\n Please evaluate for RP bleed and interval change in ascitic fluid.\n CONTRAINDICATIONS for IV CONTRAST:\n ESRD;;esrd\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FBr SUN 3:31 PM\n No retroperitoneal bleeding, complete resolution of the pericardial effusion,\n and interval increase in bilateral pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 43-year-old man with failed renal transplant and hematocrit drop.\n Please evaluate retroperitoneal bleeding.\n\n TECHNIQUE: Axial MDCT images were acquired from the thoracic inlet to the\n pubic symphysis with no IV contrast administration. No oral contrast was\n used. Multiplanar reformatted images were acquired.\n\n CT OF THE CHEST WITH NO IV CONTRAST: There has been an interval increase in\n the size of moderate right and small left pleural effusions, with worsening\n atelectasis of the lower lobes. There has been interval decrease in the size\n of previously seen large pericardial effusion. Bullous changes of the right\n lung apex. There is a calcified granuloma in the left lung (2: 22). No\n central pathologically enlarged nodes. The distal tip of the left IJ line is\n in the right atrium. There is cardiomegaly.\n\n Noncontrast evaluation of the liver, gallbladder, spleen, and adrenal glands\n is unremarkable. Both kidneys are severely atrophied. Duodenal loops of small\n bowel and large bowel are unremarkable. Moderate degree of simple ascitic\n fluid is noted within the abdomen. No pathologically enlarged nodes.\n\n CT OF THE PELVIS: The rectum, sigmoid colon, urinary bladder, distal ureters,\n prostate, and seminal vesicles are unremarkable. Ascitic fluid in the pelvis.\n No pathologically enlarged pelvic or inguinal nodes. No retroperitoneal\n bleeding is noted. Mild haziness around the right common femoral artery and\n common femoral vein.\n\n BONE WINDOWS: No concerning lytic or sclerotic lesions.\n\n IMPRESSION:\n 1. No retroperitoneal bleed.\n 2. Interval decrease in size of the pericardial effusion, now small.\n 3. Interval increase in bilateral pleural effusions, moderate on the right\n and small on the left, with associated atectasis at the lung bases.\n (Over)\n\n 9:17 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Please evaluate for RP bleed and interval change in ascitic\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-10-05 00:00:00.000",
"description": "CHEST (LAT DECUB ONLY)",
"row_id": 1038273,
"text": " 5:13 PM\n CHEST (LAT DECUB ONLY); CHEST (PA & LAT) Clip # \n Reason: question whether effusions are loculated. please compare to\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with pleural effusion, previously with pericardial effusion\n REASON FOR THIS EXAMINATION:\n question whether effusions are loculated. please compare to supine films.\n ______________________________________________________________________________\n WET READ: JXKc MON 9:20 PM\n Moderate bilateral pleural effusions that appear to layer on the lateral\n decubitus views without definite signs to suggest loculation. There is\n associated atelectasis of the adjacent lung. Left subclavian catheter tip\n terminates in the low right atrium, unchanged in position. -jkang\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pleural effusion.\n\n FINDINGS: In comparison with the study of , lateral decubitus view shows\n that there is a small amount of free pleural fluid on the left and a\n substantially larger amount of free pleural fluid on the right. Pulmonary\n vascular congestion persists.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-10-08 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1038837,
"text": " 12:05 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o PNA\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with new onset fever\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON \n\n HISTORY: New onset of fever, rule out pneumonia.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Small bilateral pleural effusions have decreased, moderate enlargement of the\n cardiac silhouette due to cardiomegaly and/or pericardial effusion is\n diminished, interstitial edema is cleared and bibasilar opacification has\n improved. Overall findings are consistent with resolved pulmonary edema.\n Cystic structure at the right lung apex now contains fluid, probably edema\n fluid in a bulla, not concerning for infection. Dual-channel supraclavicular\n left-sided central venous catheter projects over the upper right atrium. No\n complications.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-10-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1037811,
"text": ", S. 10:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: S/p pericardiocentesis.\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with pericardial effusion s/p pericardiocentesis.\n REASON FOR THIS EXAMINATION:\n S/p pericardiocentesis.\n ______________________________________________________________________________\n PFI REPORT\n Left lower lobe retrocardiac opacity has worsened, likely atelectasis. Small\n left pleural effusion is probably unchanged. Enlarged cardiac silhouette is\n minimally decreased in size. Right pleural effusion has increased.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-10-01 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1037449,
"text": " 3:00 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for infiltrate, mediastinum\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with shortness of breath\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, mediastinum\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 43-year-old man with shortness of breath.\n\n Comparison is made to CT and chest radiograph.\n\n PA AND LATERAL CHEST RADIOGRAPHS\n\n FINDINGS: The heart remains enlarged and there is prominence to the pulmonary\n arteries bilaterally. Moderate-sized left pleural effusion and probable\n compression atelectasis is noted with a small right effusion noted on the\n lateral view. Left-sided dialysis catheter is stable with its tip in the\n right atrium. No pneumothorax or focal consolidations to suggest pneumonia.\n\n IMPRESSION:\n\n Cardiomegaly with moderate-sized left effusion and probable adjacent\n compression atelectasis and small right effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-10-01 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1037467,
"text": " 4:48 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: assess for infection/abscess\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with ESRD s/p transplant neprhotomy on now with abd pain\n x 2 weeks\n REASON FOR THIS EXAMINATION:\n assess for infection/abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 8:37 PM\n new large pericardial effusion with ct findings suggesting component of\n tamponade (mass effect on RV). mod b/l effusions. new mod/large amount of\n ascites. decreased size to RLQ collection at ste of prior xplant.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Complicated cardiac and renal history with known cardiac dysfunction\n status post transplant nephrectomy due to failure in with\n recurrent right lower quadrant abdominal pain. No leukocytosis with mild\n elevation of ALT/AST but normal alk phos.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\n pelvis with intravenous and oral contrast. Coronal and sagittal reformations\n were evaluated.\n\n Comparison is made to ultrasound dated and CT dated .\n\n CT OF THE ABDOMEN WITH INTRAVENOUS AND ORAL CONTRAST: There are bilateral\n moderate simple pleural effusions and a new large pericardial effusion which\n displays some tamponade effect on the right ventricle which appears compressed\n in addition to mass effect on the entire heart with abnormal leftward\n deviation/angulation of the intraventricular septum. Bilateral compression\n atelectasis is noted with the remaining aerated lung parenchyma appearing\n otherwise unremarkable. The gallbladder displays some third spacing/wall\n edema but appears otherwise unremarkable as does the liver, spleen, stomach,\n small bowel, pancreas, adrenal glands, and atrophic appearing kidneys. No\n pathologically enlarged abdominal lymph nodes are identified and there is no\n free air. There has been interval development of a moderate to large amount\n of intra-abdominal ascites.\n\n CT OF THE PELVIS WITH INTRAVENOUS AND ORAL CONTRAST: Intrapelvic bowel,\n prostate, and urinary bladder are unremarkable. No significant bowel wall\n edema is identified. Moderate-to-large amount of intrapelvic ascites has\n developed. Previously identified collection within the right lower quadrant\n at site of prior transplant has decreased in size measuring approximately 1.7\n x 2.2 cm, prior 2.6 x 2.8cm with continued mild rim enhancement but no\n internal foci of air.\n\n BONE WINDOWS: No malignant appearing osseous lesions are identified.\n\n IMPRESSION:\n (Over)\n\n 4:48 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: assess for infection/abscess\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Interval development of a large amount of intra-abdominal/intrapelvic\n ascites and moderate-to-large pericardial effusion with CT findings suggesting\n a component of tamponade. Cardiac echo recommended. Moderate-sized bilateral\n pleural effusions.\n\n 2. Continued decrease in size to a small rim enhancing likely post-operative\n collection at site of prior right lower quadrant transplant kidney.\n\n 3. No findings of colitis.\n\n Please note during the examination the patient experienced a IV infiltration\n of intravenous contrast and saline. It is estimated that 70 mL of Optiray\n contrast infiltrated at the patient's IV site. Immediately after exam patient\n displayed no neurological deficits, intact distal pulses and brisk capillary\n refill. Plastics consult was recommended to the ER staff caring for the\n patient.\n\n Above findings were discussed with Dr. shortly after exam acquisition at\n 8:30 p.m.\n\n"
},
{
"category": "ECG",
"chartdate": "2161-10-08 00:00:00.000",
"description": "Report",
"row_id": 126592,
"text": "Normal sinus rhythm. Prolonged Q-T interval. Low voltage in the standard\nleads. Left ventricular hypertrophy. Non-specific ST-T wave changes in\nleads I, aVL and V2-V6. Compared to the previous tracing of no\nsignificant change. The non-specific T wave changes are similar. The\nQTc interval is somewhat shorter.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2161-10-07 00:00:00.000",
"description": "Report",
"row_id": 126593,
"text": "Sinus rhythm. Findings are as described on the previous tracing of and\nare without significant change except, that ST-T wave changes appear less\nprominent.\n\n"
},
{
"category": "ECG",
"chartdate": "2161-10-06 00:00:00.000",
"description": "Report",
"row_id": 126594,
"text": "Sinus rhythm\nLeft atrial abnormality\nProminent QRS voltage suggests left ventricular hypertrophy\nDiffuse ST-T wave abnormalities\nProlonged Q-Tc interval\nFindings are nonspecific but clinical correlation is suggested for possible in\npart drug/metabolic/electrolyte effect, possible ischemia or central nervous\nsystem event\nSince previous tracing of the same date, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2161-10-06 00:00:00.000",
"description": "Report",
"row_id": 126595,
"text": "Sinus rhythm\nLeft atrial abnormality\nProminent QRS voltages suggests left ventricular hypertrophy\nDiffuse ST-T wave abnormalities\nProlonged Q-Tc interval\nFindings are nonspecific but clinical correlation is suggested for possible in\npart drug/metabolic/electrolyte effect, possible ischemia or central nervous\nsystem event\nSince previous tracing of , ST-T wave changes less prominent\n\n"
},
{
"category": "ECG",
"chartdate": "2161-10-01 00:00:00.000",
"description": "Report",
"row_id": 126603,
"text": "Sinus rhythm. The Q-T interval is prolonged. Non-specific ST-T wave\nchanges. Low voltage in the limb leads. Compared to the previous tracing\nthere is no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2161-10-03 00:00:00.000",
"description": "Report",
"row_id": 126596,
"text": "Sinus rhythm. The Q-T interval is prolonged. Marked ST-T wave changes most\nprominent in the anterior and anterolateral leads. Compared to the previous\ntracing ventricular ectopy has resolved.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2161-10-03 00:00:00.000",
"description": "Report",
"row_id": 126597,
"text": "Sinus rhythm. Ventricular ectopy. The Q-T interval is prolonged\nat 520 milliseconds. Marked ST-T wave changes most prominently in the anterior\nand anterolateral leads. Compared to the previous tracing ventricular ectopy\nis somewhat less.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2161-10-03 00:00:00.000",
"description": "Report",
"row_id": 126598,
"text": "Probable atrial fibrillation with frequent ventricular ectopy. The\nQ-T interval is prolonged. Marked ST-T wave changes, particularly in the\nanterior and anterolateral leads. Compared to the previous tracing ventricular\nectopy is new.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2161-10-03 00:00:00.000",
"description": "Report",
"row_id": 126599,
"text": "Sinus rhythm. The Q-T interval is prolonged at approximately 560 milliseconds.\nMarked ST-T wave changes predominantly in the anterior and anterolateral\nleads. Compared to the previous tracing the Q-T interval is longer and\nST-T wave changes are more diffuse and more severe.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2161-10-02 00:00:00.000",
"description": "Report",
"row_id": 126600,
"text": "Sinus bradycardia. Frequent premature atrial contractions. Left ventricular\nhypertrophy with secondary ST-T wave changes. Prolonged QTc interval.\nLateral ST-T wave changes which may be related to left ventricular hypertrophy.\nCompared to the previous tracing of QTc interval prolongation is new.\nClinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2161-10-02 00:00:00.000",
"description": "Report",
"row_id": 126601,
"text": "Sinus rhythm. The Q-T interval is prolonged. Left axis deviation.\nNon-specific ST-T wave changes. Low voltage in the limb leads. Compared to\nthe previous tracing left axis deviation is new.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2161-10-02 00:00:00.000",
"description": "Report",
"row_id": 126602,
"text": "Sinus rhythm. The Q-T interval is prolonged. Non-specific ST-T wave changes.\nLow voltage in the limb leads. Compared to the previous tracing there is no\nsignificant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2161-10-09 00:00:00.000",
"description": "Report",
"row_id": 126554,
"text": "Compared to tracing #1 the T wave changes are less prominent in leads V2-V5.\nOtherwise, no significant change.\nTRACING #2\n\n"
}
] |
47,841 | 103,650 | Pt was admitted to pre-op holding in anticipation of an EVAR for an enlarging AAA. She underwent endovascular repair of abdominal aortic aneurysm with modular endograft, but her operative course was complicated by partial covering of the origin of the right renal artery requiring renal angioplasty and stenting, dissection of the right common femoral artery with occlusionas a result of percutaneous access requiring groin exploration, endarterectomy and vein patch repair. She tolerated the procedure well, though given her complicated operative course, she remained intubated overnight in the CVICU. She was extubated without difficulty the following morning, and transferred to the VICU later that day. On POD 2, her hct had dropped to 24, and she was given 1u PRBCs. Her hct responded nicely to above 30. Her A-line was removed and she was getting out of bed. The remainder of her post-operative course of unremarkable, and she was deemed ready for discharge on POD 3. She will follow up with Dr. in 3 weeks, with a CTA to be done beforehand. | Pt remained intubated overnight d/t copd .H/O alcohol abuse Assessment: Action: Response: Plan: Aortic aneurysm, abdominal without rupture (AAA) Assessment: Action: Response: Plan: Pt remained intubated overnight d/t copd .H/O alcohol abuse Assessment: Action: Response: Plan: Aortic aneurysm, abdominal without rupture (AAA) Assessment: Action: Response: Plan: Chlorhexidine Gluconate 0.12% Oral Rinse 3. CVICU HPI: HD2 POD 1 80 y.o F now s/p EVAR, right renal stent, right femoral endarterectomy and patch angioplasty Chief complaint: PMHx: COPD, HTN, Chol, former tobacco, POLYMYALGIA RHEUMATICA, DIVERTICULOSIS, hypothyroid, GERD Current medications: Calcium Gluconate 2. .H/O alcohol abuse Assessment: Action: Response: Plan: Aortic aneurysm, abdominal without rupture (AAA) Assessment: Action: Response: Plan: clear lungs FINAL REPORT HISTORY: Status post EVAR, for ET tube placement. pt with + pp by doppler. pt with + pp by doppler. goal sbp 100-140. awake hypertensive on propofol, 100mcg fentanly given ivp. MethylPREDNISolone Sodium Succ 10. Pt with 1 breif episode of mild tremors in arms this am. Pt with 1 breif episode of mild tremors in arms this am. Pt is on Propofol. Phenylephrine 13. Nitroglycerin 12. Hyperglycemia Assessment: BS >120 Action: BS checked Q6 Response: Treated with s/s insulin Plan: Continue per protocol .H/O alcohol abuse Assessment: Per note on careweb pt drinks moderate amount of alcohol Action: Ativan ordered PRN Response: No sign of withdrawal Plan: Medicate PRN Demographics Day of intubation: Day of mechanical ventilation: 1 Ideal body weight: 51.5 None Ideal tidal volume: mL/kg Tube Type ETT: Position: 19 cm at teeth Route: Type: Standard Size: 7mm Lung sounds RLL Lung Sounds: Clear RUL Lung Sounds: Rhonchi LUL Lung Sounds: Rhonchi LLL Lung Sounds: Clear Comments: Secretions Sputum color / consistency: White / Thick Sputum source/amount: Suctioned / Scant Ventilation Assessment Level of breathing assistance: Continuous invasive ventilation Visual assessment of breathing pattern: Normal quiet breathing Trigger work assessment: Not triggering Plan Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated Reason for continuing current ventilatory support: Sedated / Paralyzed Comments: 80yr female s/p repair of AAA with complicated intra-operative progress. + hypoactive bs, tolerating clear this afternoon. + hypoactive bs, tolerating clear this afternoon. Action: Monitor CIWA scale Monitor for sign and symptoms of withdrawal Response: Besides 1 episode of mild tremors this am, no sign of withdrawals Plan: CIWA scale, monitor for signs of withdrawals, ativan prn Aortic aneurysm, abdominal without rupture (AAA) Assessment: Pt Intubated and sedated this am. Action: Monitor CIWA scale Monitor for sign and symptoms of withdrawal Response: Besides 1 episode of mild tremors this am, no sign of withdrawals Plan: CIWA scale, monitor for signs of withdrawals, ativan prn Aortic aneurysm, abdominal without rupture (AAA) Assessment: Pt Intubated and sedated this am. Aortic aneurysm, abdominal without rupture (AAA) Assessment: s/p endovascular AAA repair/femoral cut down/femoral embolectomy/femoral angioplasty. Demographics Day of intubation: Day of mechanical ventilation: 2 Ideal body weight: 51.5 None Ideal tidal volume: mL/kg Airway Airway Placement Data Known difficult intubation: Procedure location: Reason: Tube Type ETT: Position: 19 cm at teeth Route: Oral Type: Standard Size: 7mm Cuff Management: Vol/Press: Cuff pressure: cmH2O Cuff volume: 8 mL / Airway problems: Comments: Lung sounds RLL Lung Sounds: Clear RUL Lung Sounds: Clear LUL Lung Sounds: Clear LLL Lung Sounds: Clear Comments: Secretions Sputum color / consistency: White / Thick Sputum source/amount: Suctioned / Scant Comments: Ventilation Assessment Level of breathing assistance: Continuous invasive ventilation Visual assessment of breathing pattern: Normal quiet breathing Assessment of breathing comfort: Non-invasive ventilation assessment: Invasive ventilation assessment: Trigger work assessment: Triggering synchronously Dysynchrony assessment: Comments: Pt remains stable on full vent support Plan Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as tolerated, Adjust Min. | 10 | [
{
"category": "Nursing",
"chartdate": "2133-05-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 454935,
"text": "Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n s/p endovascular AAA repair/femoral cut down/femoral\n embolectomy/femoral angioplasty.\n Action:\n Remained intubated overnight to keep pt from moving around per\n attending\n Response:\n pt has alcohol history and is restless at baseline\n Plan:\n Extubate this am. Pt with history of COPD, receiving 3 doses of\n methylprednisone.\n Hyperglycemia\n Assessment:\n BS >120\n Action:\n BS checked Q6\n Response:\n Treated with s/s insulin\n Plan:\n Continue per protocol\n .H/O alcohol abuse\n Assessment:\n Per note on careweb pt drinks moderate amount of alcohol\n Action:\n Ativan ordered PRN\n Response:\n No sign of withdrawal\n Plan:\n Medicate PRN\n"
},
{
"category": "Nursing",
"chartdate": "2133-05-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 455022,
"text": "The patient had back pain from a fall -> pt present for treatment and\n was incidentially found to have a infranrenal AAA.\n s/p endovascular AAA repair/femoral cut down/femoral\n embolectomy/femoral angioplasty, right renal stent.\n Pt remained intubated overnight d/t copd\n .H/O alcohol abuse\n Assessment:\n Pt report that\nI drink 2 drinks a day\n. Pt with 1 breif episode of\n mild tremors in arms this am. Pt denies hallucinations. No seizure\n activity. Pt alert and orientated x3.\n Action:\n Monitor CIWA scale\n Monitor for sign and symptoms of withdrawal\n Response:\n Besides 1 episode of mild tremors this am, no sign of withdrawals\n Plan:\n CIWA scale, monitor for signs of withdrawals, ativan prn\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Pt Intubated and sedated this am. PERRL. Pt remains in NSR, no ectopy\n noted. HR 50-80\ns. SBP ~ 90-150\ns. LS coarse with dim bases. pt with +\n pp by doppler. + hypoactive bs, tolerating clear this afternoon. Foley\n draining clear yellow urine. UO adequate. Pt with DSD over right groin\n and left grion\n Action:\n Sedation weaned to off this am -> pt weaned to CPAP 50% with\n 5 peep and 5 PS -> ABG WNL -> pt extubated at 09:20 this am -> placed\n on 50% face mask\n Pt up to chair this am\n Pt given nebs/inhailers as ordered\n Response:\n Pt alert and orientated x3. Able to MAE and follow commands. Pt weaned\n to room air this afternoon, o2 sats ~ 95-98%\n Plan:\n BP goal -> SBP 100-140\ns per team, pulm toleit, pain control, advance\n diet and activity as tolerated\n Demographics\n Attending MD:\n FRANK B.\n Admit diagnosis:\n ABDOMINAL AORTIC ANEURYSM/SDA\n Code status:\n Full code\n Height:\n 63 Inch\n Admission weight:\n 72.3 kg\n Daily weight:\n 58.4 kg\n Allergies/Reactions:\n Adhesive Tape (Topical)\n \"it rips my ski\n Precautions:\n PMH: COPD, ETOH\n CV-PMH: PVD\n Additional history: severe COPD, hyperlipidemia, HTN, osteoporosis,\n hypothyrodism, reflux, s/p excision leasion, s/p shoulder\n arthroscopy\n Surgery / Procedure and date: s/p endovascular AAA repair/femoral\n cut down/femoral embolectomy/femoral angioplasty, right renal stent.\n remained intubated d/t copd. 700cc ebl. 1u prbc given. 3l\n crystaloid. to cvicu on propofol 50mcg/kg/min. goal sbp 100-140.\n awake hypertensive on propofol, 100mcg fentanly given ivp.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n 98.6\n Arterial BP:\n S:124\n D:52\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 85 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 10 L/min\n FiO2 set:\n 24h total in:\n 1,082 mL\n 24h total out:\n 1,573 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 04:14 AM\n Potassium:\n 4.0 mEq/L\n 04:14 AM\n Chloride:\n 106 mEq/L\n 04:14 AM\n CO2:\n 23 mEq/L\n 04:14 AM\n BUN:\n 12 mg/dL\n 04:14 AM\n Creatinine:\n 0.5 mg/dL\n 04:14 AM\n Glucose:\n 145 mg/dL\n 04:14 AM\n Hematocrit:\n 27.0 %\n 04:14 AM\n Finger Stick Glucose:\n 128\n 12:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n right radial A line. left 16 guage PIV and 18 guage PIV placed on\n \n Valuables / Signature\n Patient valuables: Dentures: (Upper, Lower )\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: \n Transferred to: VICU\n Date & time of Transfer: 17:00 pm\n"
},
{
"category": "Respiratory ",
"chartdate": "2133-05-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 454921,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 51.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments: Pt remains stable on full vent support\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Adjust Min. ventilation to control pH, Increase ventilatory\n support at night\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Cannot protect airway, Cannot manage\n secretions, Underlying illness not resolved; Comments: Due to severity\n of OR procedures, pt remained fully sedated on ventilator. Pt is on\n Propofol. No issues this shift, along with no spontaneous\n respirations. Pt has clear lung sounds and required minimal\n suctioning. PT to be assessed by MD team for further weaning. Pt to\n continue current support.\n BEDSIDE RSBI- No spontaneous respirations.\n"
},
{
"category": "Nursing",
"chartdate": "2133-05-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 455011,
"text": ".H/O alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2133-05-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 455012,
"text": "The patient had back pain from a fall -> pt present for treatment and\n was incidentially found to have a infranrenal AAA.\n s/p endovascular AAA repair/femoral cut down/femoral\n embolectomy/femoral angioplasty, right renal stent.\n Pt remained intubated overnight d/t copd\n .H/O alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2133-05-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 455013,
"text": "The patient had back pain from a fall -> pt present for treatment and\n was incidentially found to have a infranrenal AAA.\n s/p endovascular AAA repair/femoral cut down/femoral\n embolectomy/femoral angioplasty, right renal stent.\n Pt remained intubated overnight d/t copd\n .H/O alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2133-05-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 455017,
"text": "The patient had back pain from a fall -> pt present for treatment and\n was incidentially found to have a infranrenal AAA.\n s/p endovascular AAA repair/femoral cut down/femoral\n embolectomy/femoral angioplasty, right renal stent.\n Pt remained intubated overnight d/t copd\n .H/O alcohol abuse\n Assessment:\n Pt report that\nI drink 2 drinks a day\n. Pt with 1 breif episode of\n mild tremors in arms this am. Pt denies hallucinations. No seizure\n activity. Pt alert and orientated x3.\n Action:\n Monitor CIWA scale\n Monitor for sign and symptoms of withdrawal\n Response:\n Besides 1 episode of mild tremors this am, no sign of withdrawals\n Plan:\n CIWA scale, monitor for signs of withdrawals, ativan prn\n Aortic aneurysm, abdominal without rupture (AAA)\n Assessment:\n Pt Intubated and sedated this am. PERRL. Pt remains in NSR, no ectopy\n noted. HR 50-80\ns. SBP ~ 90-150\ns. LS coarse with dim bases. pt with +\n pp by doppler. + hypoactive bs, tolerating clear this afternoon. Foley\n draining clear yellow urine. UO adequate. Pt with DSD over right groin\n and left grion\n Action:\n Sedation weaned to off this am -> pt weaned to CPAP 50% with\n 5 peep and 5 PS -> ABG WNL -> pt extubated at 09:20 this am -> placed\n on 50% face mask\n Pt up to chair this am\n Pt given nebs/inhailers as ordered\n Response:\n Pt alert and orientated x3. Able to MAE and follow commands. Pt weaned\n to room air this afternoon, o2 sats ~ 95-98%\n Plan:\n BP goal -> SBP 100-140\ns per team, pulm toleit, pain control, advance\n diet and activity as tolerated\n"
},
{
"category": "Respiratory ",
"chartdate": "2133-05-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 454873,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 51.5 None\n Ideal tidal volume: mL/kg\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Comments:\n 80yr female s/p repair of AAA with complicated intra-operative\n progress. Wean as appropriate.\n"
},
{
"category": "Physician ",
"chartdate": "2133-05-07 00:00:00.000",
"description": "Intensivist Note",
"row_id": 454963,
"text": "CVICU\n HPI:\n HD2\n POD 1\n 80 y.o F now s/p EVAR, right renal stent, right femoral endarterectomy\n and patch angioplasty\n Chief complaint:\n PMHx:\n COPD, HTN, Chol, former tobacco, POLYMYALGIA RHEUMATICA,\n DIVERTICULOSIS, hypothyroid, GERD\n Current medications:\n Calcium Gluconate 2. Chlorhexidine Gluconate 0.12% Oral Rinse 3.\n Clopidogrel 4. Esmolol 5. Fentanyl Citrate\n 6. FoLIC Acid 7. Lorazepam 8. Magnesium Sulfate 9. MethylPREDNISolone\n Sodium Succ 10. Multivitamins\n 11. Nitroglycerin 12. Phenylephrine 13. Potassium Chloride 14. Propofol\n 15. Thiamine\n 24 Hour Events:\n OR RECEIVED - At 05:51 PM\n ARTERIAL LINE - START 05:54 PM\n INTUBATION - At 06:27 PM\n INVASIVE VENTILATION - START 06:27 PM\n Post operative day:\n 1\n Allergies:\n Adhesive Tape (Topical)\n \"it rips my ski\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 08:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36\nC (96.8\n T current: 35.9\nC (96.6\n HR: 61 (54 - 86) bpm\n BP: 126/57(83) {87/45(61) - 149/70(102)} mmHg\n RR: 32 (12 - 32) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 58.4 kg (admission): 72.3 kg\n Height: 63 Inch\n Total In:\n 686 mL\n 909 mL\n PO:\n Tube feeding:\n IV Fluid:\n 686 mL\n 909 mL\n Blood products:\n Total out:\n 338 mL\n 447 mL\n Urine:\n 338 mL\n 447 mL\n NG:\n Stool:\n Drains:\n Balance:\n 348 mL\n 462 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 644 (326 - 644) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 10 cmH2O\n Plateau: 14 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 100%\n ABG: 7.42/37/166/23/0\n Ve: 5.8 L/min\n PaO2 / FiO2: 415\n Physical Examination\n General Appearance: No acute distress, intubated, following commands\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Absent), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 177 K/uL\n 9.3 g/dL\n 145 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 12 mg/dL\n 106 mEq/L\n 136 mEq/L\n 27.0 %\n 7.4 K/uL\n [image002.jpg]\n 06:13 PM\n 06:27 PM\n 12:34 AM\n 04:14 AM\n WBC\n 6.1\n 7.4\n Hct\n 28.1\n 27.0\n Plt\n 178\n 177\n Creatinine\n 0.5\n 0.5\n TCO2\n 28\n 25\n Glucose\n 141\n 145\n Other labs: PT / PTT / INR:14.1/38.5/1.2, Differential-Neuts:86.1 %,\n Lymph:9.7 %, Mono:3.1 %, Eos:0.8 %, Ca:7.7 mg/dL, Mg:2.3 mg/dL, PO4:3.9\n mg/dL\n Assessment and Plan\n HYPERGLYCEMIA, .H/O ALCOHOL ABUSE, AORTIC ANEURYSM, ABDOMINAL WITHOUT\n RUPTURE (AAA)\n Assessment and Plan: HD2\n POD 0\n 80 y.o F now s/p EVAR, right renal stent, right femoral endarterectomy\n and patch angioplasty\n Neurologic: Pain controlled, awake, alert\n Cardiovascular: hemodynamically stable, restart b blocker and statin\n Pulmonary: IS, Extubate today, extubate now, intubated perioperatively\n Gastrointestinal / Abdomen:\n Nutrition: NPO, Advance diet as tolerated\n Renal: Foley, Adequate UO, lasix for diuresis\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Vascular surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:54 PM\n 18 Gauge - 05:54 PM\n 16 Gauge - 06:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Radiology",
"chartdate": "2133-05-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1074663,
"text": " 6:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman s/p EVAR, check ETT placement\n REASON FOR THIS EXAMINATION:\n eval ETT\n ______________________________________________________________________________\n WET READ: MBue WED 8:53 PM\n ETT terminating approx 4.6 cm above carina. clear lungs\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post EVAR, for ET tube placement.\n\n FINDINGS: In comparison with the study of , there has been placement of\n an endotracheal tube that lies approximately 4.6 cm above the carina.\n Otherwise, there is no interval change. No evidence of acute focal pneumonia,\n vascular congestion, or pleural effusion. The suggested scar at the left base\n on the previous study is not appreciated at this time.\n\n\n"
}
] |
46,228 | 151,469 | HOSPITAL COURSE: This is a 61 year old gentleman with PMHx of polysubstance abuse, who is quite well known to the emergency department, who presented to the ED in the setting of alcohol intoxication, status post intubation for airway protection. He was admitted to the medical intensive care unit for management of his airway. He was extubated within 24 hours. Due to his frequent admissions for alcohol detoxication and significant risk of death associated with his frank inability to care for himself secondary to severe alcohol dependance, a section 35 was obtained to evaluate for mandated medical detox and substance abuse rehabilitation. . ALCOHOL INTOXICATION: The patient was intubated in the field for alcohol detoxication. He was extubated withing 24 hours. A psychiatric evaluation was performed, there was no evidence of mental illness other than severe alcohol dependance. The patient was treated with valium for management of alcohol withdrawal symptoms and was medically stable at the time of discharge. He was given a multivitamin, folic acid and thiamine prior to discharge. . DISPOSITION: Since , the patient was seen in the emergency department 33 times for alcohol related visits with 24 admissions to a medical unit for management of alcohol dependance, withdrawal symptoms. In the last week (starting ) he was seen in the ED 3 times with 3 admissions for alcohol intoxication, the last resulting in intubation. The patient has been seen by social work during his multiple admissions where there documented that the patient has no insignt into his alcohol depenance, does not admit that his intoxication led to this admission. The patient has repeatedly rejected any SW intervention to deal with substance abuse and refuses to speak or commit to any other support for sobriety. Given the frequency of admissions for alcohol dependance and his high risk of death due to consequences of his substance abuse. A section 35 was obtained, and the patient was transported by police escort to court. It is strongly recommended that the patient have medical detox and prolonged substance abuse rehabilitation. . FACIAL FRACTURE: CT sinus revealed a new minimally displaced comminuted fractures involving the right maxillary sinus and the right orbital floor and junction of the maxilla and zygomatic arch. Plastic surgery was consulted who recommended treatment with Augmentin for 7 days and follow-up in plastic surgery clinic. He was recommended to use afrin twice daily and sudafed daily for four days as sinue precautions. . HYPERTENSION: Home dose of amlodipine initially held and then restarted. . TRANSITIONS OF CARE: - Section 35 court - Continue Augmentin x 7 days, afrin twice daily and sudafed daily for 4 days | New minimally displaced comminuted fractures involving the right maxillary sinus and the right orbital floor and junction of the maxilla and zygomatic arch. FINDINGS: Minimally displaced fractures involving the anterior and lateral walls of the right maxillary sinus are noted (since ). CT Head from . Mildly displaced comminuted fractures involving the right maxillary sinus and right orbital floor, and nasal and ethmoid bones as described above with near-complete opacification of the sinuses and nasopharynx. The cardiac, mediastinal and hilar contours are unremarkable, and the lungs appear clear. There is an ET tube and NG tube in place. bleed FINAL REPORT (Cont) IMPRESSION: 1. Fracture fragments are displaced into the sinus. Secretions in the nasopharynx. Secretions in the nasopharynx. Comminuted fracture of the nasal bones with near opacification of the nasopharynx are noted with anterior ethmoid fractures. The mastoid air cells are completely opacified on the left and partially aerated on the right. The ventricles and sulci are mildly prominent consistent with atrophy. These extend into the right lateral orbital floor and to the junction of the maxilla and the zyogmatic arch. Fractured nasal bones. Opacification of sinuses as seen on prior studies. IMPRESSION: Status post endotracheal intubation. There is complete opacification of the left maxillary sinus and near complete opacification of the right maxillary sinus. Sinus rhythm. There are minimally displaced comminuted fractures involving the anterior wall of the right maxillary sinus extending into the orbital floor as well as the posterior wall of the maxillary sinus, with fracture fragments displaced into the sinus. COMPARISONS: CT head and CT C-spine from . The vertebral body heights and disc spaces are grossly maintained. There is hypodensity of the periventricular white matter, most consistent with chronic small vessel ischemic disease. Opacification of the right and left mastoid air cells. There are secretions within the oropharynx. The nasal cavity is completely opacified. Coronal and sagittal reformats were completed. Coronal and sagittal reformats were completed. Small vessel ischemic disease. Small vessel ischemic disease. Bilateral anterior nasal bone fractures. Displaced comminuted fractures of the right maxillary sinus involving the anterior wall/orbital floor adjacent to the zygomatic arch and the posterior wall with complete opacification of the bilateral maxillary sinuses. Old nasal bone deformity. neck: ?fx MEDICAL CONDITION: History: 62M with altered MS, unknown trauma REASON FOR THIS EXAMINATION: Head: ?ICH. TECHNIQUE: Chest, portable AP supine. Displaced fractures of the right maxillary sinus involving the anterior wall/orbital floor adjacent to the zygomatic arch and the posterior wall with complete opacification of the bilateral maxillary sinuses. Coronal reformats were completed. Chronic sinus disease with likely some component of hemorrhage in the right maxillary sinus. Normal sinus rhythm. Compared to the previous tracing of no change. Findings suggesting small vessel ischemic disease. There is mucosal thickening involving the ethmoid sinuses. IMPRESSION: 1. There is ethmoidal mucosal thickening. Complete opacification of the left maxillary sinus as well as near opacification of the right maxillary sinus is mostly chronic, however there is likely a small component of hemorrhage on the right. Patient is intubated, an ET tube and NG tube are present. There is a small right extraconal hematoma but no orbital fat herniation or globe hemorrhage or rupture. 2:43 PM CHEST (PORTABLE AP) Clip # Reason: ?tube placement MEDICAL CONDITION: History: 62M with intubated due to altered MS REASON FOR THIS EXAMINATION: ?tube placement No contraindications for IV contrast FINAL REPORT CHEST RADIOGRAPH HISTORY: Altered mental status. No evidence of acute intracranial process. bleed MEDICAL CONDITION: History: 62M with ams REASON FOR THIS EXAMINATION: ? The thyroid gland is unremarkable. Normal tracing. Normal tracing. TECHNIQUE: Contiguous axial images obtained through the cervical spine without the administration of intravenous contrast material. A nasogastric tube has been passed into the stomach. Fractures of the nasal bone are chronic. FINDINGS: An endotracheal tube has been placed, terminating approximately 5 cm above the carina. 3:03 PM CT C-SPINE W/O CONTRAST Clip # Reason: Head: ?ICH. Compared to the previous tracingof there is no significant change. 5:52 PM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # Reason: characterize fractures MEDICAL CONDITION: History: 62M with facial trauma REASON FOR THIS EXAMINATION: characterize fractures No contraindications for IV contrast WET READ: RJab WED 7:57 PM minimally displaced comminuted fractures of the right maxillary sinus involving the anterior wall and right inferior orbial floor as well as the posterior and medial walls. No acute intracranial hemorrhage or infarction. No acute intracranial hemorrhage or infarction. COMPARISONS: None. COMPARISONS: None. COMPARISONS: None. No evidence of acute disease. FINDINGS: There is no acute fracture, malalignment or prevertebral soft tissue swelling. 3. 3. TECHNIQUE: MDCT axial images were obtained through the facial bones without the administration of intravenous contrast material. | 6 | [
{
"category": "Radiology",
"chartdate": "2186-05-31 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1242559,
"text": " 3:03 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: Head: ?ICH. neck: ?fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 62M with altered MS, unknown trauma\n REASON FOR THIS EXAMINATION:\n Head: ?ICH. neck: ?fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RJab WED 4:05 PM\n No acute fracture or malalignment of the cervical spine\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old man with altered mental status, unknown trauma,\n question neck fracture.\n\n COMPARISONS: None.\n\n TECHNIQUE: Contiguous axial images obtained through the cervical spine\n without the administration of intravenous contrast material. Coronal and\n sagittal reformats were completed.\n\n FINDINGS: There is no acute fracture, malalignment or prevertebral soft\n tissue swelling. The vertebral body heights and disc spaces are grossly\n maintained. There is calcification of the anterior longitudinal ligament\n spanning C5, C6 and C7. There is an ET tube and NG tube in place. The\n visualized lung apices are clear. The thyroid gland is unremarkable. There\n are secretions within the oropharynx.\n\n IMPRESSION: No evidence of acute fracture or traumatic malalignment.\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-05-31 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1242564,
"text": " 3:31 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 62M with ams\n REASON FOR THIS EXAMINATION:\n ? bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RJab WED 5:50 PM\n 1. No acute intracranial hemorrhage or infarction. Small vessel ischemic\n disease.\n 2. Displaced comminuted fractures of the right maxillary sinus involving the\n anterior wall/orbital floor adjacent to the zygomatic arch and the posterior\n wall with complete opacification of the bilateral maxillary sinuses. Fractured\n nasal bones. Secretions in the nasopharynx.\n\n WET READ VERSION #1\n WET READ VERSION #2 RJab WED 3:57 PM\n 1. No acute intracranial hemorrhage or infarction. Small vessel ischemic\n disease.\n 2. Displaced fractures of the right maxillary sinus involving the anterior\n wall/orbital floor adjacent to the zygomatic arch and the posterior wall with\n complete opacification of the bilateral maxillary sinuses. Secretions in the\n nasopharynx.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old man with altered mental status, question bleed.\n\n COMPARISONS: None.\n\n TECHNIQUE: Contiguous axial imaging was obtained through the brain without\n the administration of intravenous contrast material. Coronal and sagittal\n reformats were completed.\n\n FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or large\n territorial infarction. The ventricles and sulci are mildly prominent\n consistent with atrophy. There is hypodensity of the periventricular white\n matter, most consistent with chronic small vessel ischemic disease. The\n mastoid air cells are completely opacified on the left and partially aerated\n on the right.\n\n There are minimally displaced comminuted fractures involving the anterior wall\n of the right maxillary sinus extending into the orbital floor as well as the\n posterior wall of the maxillary sinus, with fracture fragments displaced into\n the sinus. There is complete opacification of the left maxillary sinus and\n near complete opacification of the right maxillary sinus. Comminuted fracture\n of the nasal bones with near opacification of the nasopharynx are noted with\n anterior ethmoid fractures. There is mucosal thickening involving the ethmoid\n sinuses.\n\n (Over)\n\n 3:31 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? bleed\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n\n 1. No evidence of acute intracranial process. Findings suggesting small\n vessel ischemic disease.\n\n 2. Mildly displaced comminuted fractures involving the right maxillary sinus\n and right orbital floor, and nasal and ethmoid bones as described above with\n near-complete opacification of the sinuses and nasopharynx.\n\n 3. Opacification of the right and left mastoid air cells.\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-05-31 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 1242581,
"text": " 5:52 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: characterize fractures\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 62M with facial trauma\n REASON FOR THIS EXAMINATION:\n characterize fractures\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RJab WED 7:57 PM\n minimally displaced comminuted fractures of the right maxillary sinus\n involving the anterior wall and right inferior orbial floor as well as the\n posterior and medial walls. Bilateral anterior nasal bone fractures.\n Opacification of sinuses as seen on prior studies.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old male with facial trauma, characterize fractures.\n\n COMPARISONS: CT head and CT C-spine from . CT Head from .\n\n TECHNIQUE: MDCT axial images were obtained through the facial bones without\n the administration of intravenous contrast material. Coronal reformats were\n completed.\n\n FINDINGS: Minimally displaced fractures involving the anterior and lateral\n walls of the right maxillary sinus are noted (since ). These\n extend into the right lateral orbital floor and to the junction of the maxilla\n and the zyogmatic arch. Fracture fragments are displaced into the sinus. There\n is a small right extraconal hematoma but no orbital fat herniation or globe\n hemorrhage or rupture. Fractures of the nasal bone are chronic. Complete\n opacification of the left maxillary sinus as well as near opacification of the\n right maxillary sinus is mostly chronic, however there is likely a small\n component of hemorrhage on the right. The nasal cavity is completely\n opacified. There is ethmoidal mucosal thickening. Patient is intubated, an\n ET tube and NG tube are present.\n\n IMPRESSION:\n 1. New minimally displaced comminuted fractures involving the right maxillary\n sinus and the right orbital floor and junction of the maxilla and zygomatic\n arch.\n 2. Old nasal bone deformity.\n 3. Chronic sinus disease with likely some component of hemorrhage in the\n right maxillary sinus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-05-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1242552,
"text": " 2:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 62M with intubated due to altered MS\n REASON FOR THIS EXAMINATION:\n ?tube placement\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n HISTORY: Altered mental status.\n\n COMPARISONS: None.\n\n TECHNIQUE: Chest, portable AP supine.\n\n FINDINGS: An endotracheal tube has been placed, terminating approximately 5\n cm above the carina. A nasogastric tube has been passed into the stomach.\n The cardiac, mediastinal and hilar contours are unremarkable, and the lungs\n appear clear. There are no pleural effusions or pneumothorax.\n\n IMPRESSION: Status post endotracheal intubation. No evidence of acute\n disease.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2186-05-31 00:00:00.000",
"description": "Report",
"row_id": 307523,
"text": "Normal sinus rhythm. Normal tracing. Compared to the previous tracing\nof there is no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2186-05-29 00:00:00.000",
"description": "Report",
"row_id": 307524,
"text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of \nno change.\n\n"
}
] |
57,091 | 165,797 | 54 yo male with progressive IPF undergoing transplant evaluation at admitted with worsening hypoxia and dyspnea on exertion, found to have progression of IPF on chest CT. | FINDINGS: Previously reported pneumomediastinum has resolved. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Minor right ventricular conduction delay. No contraindications for IV contrast FINAL REPORT CT CHEST, . ECG: NSR, nl axis, nl intervals, poor R wave progression, TWI V2-3 (new), no ST changes compared to prior. ECG: NSR, nl axis, nl intervals, poor R wave progression, TWI V2-3 (new), no ST changes compared to prior. He denied PND, worsening orthopnea, LE swelling. He denied PND, worsening orthopnea, LE swelling. IMPRESSION: Mild-moderate pulmonary artery systolic hypertension suggestive of a primary pulmonary process. IMPRESSION: Mild-moderate pulmonary artery systolic hypertension suggestive of a primary pulmonary process. Recently admitted with pneumomediastinum his sever IPF. Recently admitted with pneumomediastinum his sever IPF. Left upper pole renal mass, previously shown to be complex by recent ultrasound examination. Left upper pole renal mass, previously shown to be complex by recent ultrasound examination. Resolution of pneumomediastinum. Interstitial Lung Disease (ILD including IPF, UIP, NSIP, DIP, LIP, etc) Assessment: Patient received on 2.5l n/c with stas @ 94-96%, RR 20-30, lungs sound rhonchus, patient says that sats are at baseline but continues SOB on exertion, no ABS at this time [ received levoquin in ED] Action: Sats satisfactory n/c continues at 2.5l Response: Sats 97% rr 20-30 Plan: Wean fio2 as tolerated, encourage /deep breath ? He then represented to on for spontaneous pneumomediastinum of unclear etiology. He then represented to on for spontaneous pneumomediastinum of unclear etiology. He then represented to on for spontaneous pneumomediastinum of unclear etiology. Review of systems: Constitutional: Fatigue Cardiovascular: Chest pain, Palpitations, No(t) Edema, Tachycardia, No(t) Orthopnea Respiratory: , Dyspnea, Tachypnea, No(t) Wheeze Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis, No(t) Diarrhea, No(t) Constipation Genitourinary: No(t) Dysuria, No(t) Foley Musculoskeletal: No(t) Joint pain Integumentary (skin): No(t) Jaundice Heme / Lymph: No(t) Lymphadenopathy Neurologic: No(t) Numbness / tingling, No(t) Headache Pain: No pain / appears comfortable Flowsheet Data as of 03:38 AM Vital Signs Hemodynamic monitoring Fluid Balance 24 hours Since 12 AM Tmax: 37.2C (98.9 Tcurrent: 37.2C (98.9 HR: 79 (79 - 98) bpm BP: 122/69(82) {122/69(82) - 128/80(92)} mmHg RR: 30 (18 - 30) insp/min SpO2: 99% Heart rhythm: SR (Sinus Rhythm) Height: 67 Inch Total In: 124 mL PO: TF: IVF: 124 mL Blood products: Total out: 0 mL 0 mL Urine: NG: Stool: Drains: Balance: 0 mL 124 mL Respiratory O2 Delivery Device: Nasal cannula SpO2: 99% Physical Examination General Appearance: Well nourished Eyes / Conjunctiva: PERRL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Breath Sounds: Crackles : velcro-like, No(t) Bronchial: , No(t) Wheezes : , Diminished: poor inspiratory efforts) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right: Absent, Left: Absent Skin: Warm Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Labs / Radiology 2 98 3.8 139 41.4 12.5 [image002.jpg] Other labs: PT / PTT / INR://1.4, Lactic Acid:1.1 Imaging: CXR: extensive fibrotic changes Chest CT: IMPRESSION: 1. | 8 | [
{
"category": "Nursing",
"chartdate": "2141-02-01 00:00:00.000",
"description": "Nursing 0100 - 0700",
"row_id": 556417,
"text": "Interstitial Lung Disease (ILD including IPF, UIP, NSIP, DIP, LIP, etc)\n Assessment:\n 54 year old male with a history of sever IPF. Recently admitted with\n pneumomediastinum his sever IPF. Pt is being followed up at the\n hospital for work up of lung transplant. At baseline pt does\n wear portable O2 of 2-3L NC. Upon arrival to the unit pt was on 4L NC,\n with a SpO2 of 95-97%. Pt states no symptoms of SOB and was able to\n transfer self from ED stretcher to bed. Lung sounds in all fields have\n a\nVelcro\n sounds to them. Pt with strong cough. Pt states that he has\n had this\ntickling\n in the back of his throat for several days. Pt\n denies any chest pain or discomfort. A-febrile, and has not been around\n any person with respiratory infections.\n Action:\n O2 decreased to 2.5L NC.\n Response:\n Pt 2 97-99%\n Plan:\n Monitor pt respiratory status, and Provide continuous O2. Provide\n emotional support to both pt and family.\n"
},
{
"category": "Nursing",
"chartdate": "2141-02-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 556455,
"text": "54 y/o M w/IPF, called today with worsening dyspnea x 3 days. He had\n been in unusal state of health at baseline resp status (using 4L NC at\n rest and 6L NC with exertion) when 3 days PTA, he hugged his cousin who\n has rats for pets and also the heat came up from the basement of his\n house. He feels that with these two events, he breathing became acutely\n worse and is concerned for allergen exposure. He denies any sick\n contacts, fevers, chills, worsening /productive , rhinorrhea.\n He did receive flu and pneumovax.\n .\n He has had a recent admissions in /09 with progressive DOE. CT\n revealed increased ground glass opacity in LL superimposed on pulmonary\n fibrosis with elevated eosinophils peripherally (12%). A BAL was also\n positive for eosinophils. He was started on high dose steroids\n (prednisone 60mg) with plan for close outpatient follow up for\n eosinophilic lung disease. He was discharged on on 2-3L NC. He then\n represented to on for spontaneous pneumomediastinum of\n unclear etiology.\n .\n On day of admission, Pt called pulmonologist (Dr. c/o worsening\n shortness of breath since Saturday . Yesterday he was at pulmonary\n rehab and desaturated to the 70s on 6L with minimal exertion, and he is\n currently on 4L NC at rest. No sick\n contacts recently and has not changed. He was asked to go to ED\n given concern for either acute exacerbation of underlying IPF vs\n superimposed infection vs pneumothorax. Patient is currently being\n worked up at for lung tx\n .\n In the ED, initial vs were: 98.3, 96, 144/97, 24, 97% 6L NC. Patient\n was given levoquin X 1 and was sent to floor. Of note, by transfer to\n ICU, his sats in ED were near baseline at 96% 4L NC.\n Interstitial Lung Disease (ILD including IPF, UIP, NSIP, DIP, LIP, etc)\n Assessment:\n Patient received on 2.5l n/c with stas @ 94-96%, RR 20-30, lungs sound\n rhonchus, patient says that sats are at baseline but continues SOB on\n exertion, no ABS at this time [ received levoquin in ED]\n Action:\n Sats satisfactory n/c continues at 2.5l\n Response:\n Sats 97% rr 20-30\n Plan:\n Wean fio2 as tolerated, encourage /deep breath ? to commence\n steriods/ABS, await CXR review\n Demographics\n Attending MD:\n \n Admit diagnosis:\n DYSPNEA\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 64 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Unknown;\n Precautions:\n PMH:\n CV-PMH:\n Additional history: pneumomediastinum\n severe IPF\n left upper pole renal mass\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:116\n D:76\n Temperature:\n 97\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 30 insp/min\n Heart Rate:\n 87 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 387 mL\n 24h total out:\n 1,150 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:47 AM\n Potassium:\n 4.4 mEq/L\n 04:47 AM\n Chloride:\n 101 mEq/L\n 04:47 AM\n CO2:\n 31 mEq/L\n 04:47 AM\n BUN:\n 12 mg/dL\n 04:47 AM\n Creatinine:\n 0.9 mg/dL\n 04:47 AM\n Glucose:\n 99 mg/dL\n 04:47 AM\n Hematocrit:\n 39.1 %\n 04:47 AM\n Valuables / Signature\n Patient valuables: with patient\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: micu 6\n Transferred to: cc7\n Date & time of Transfer: \n"
},
{
"category": "Physician ",
"chartdate": "2141-02-01 00:00:00.000",
"description": "Physician Resident/Attending Admission Note - MICU",
"row_id": 556462,
"text": "Chief Complaint: DOE\n HPI:\n 54 y/o M w/IPF, called today with worsening dyspnea x 3 days. He had\n been in unusal state of health at baseline resp status (using 4L NC at\n rest and 6L NC with exertion) when 3 days PTA, he hugged his cousin who\n has rats for pets and also the heat came up from the basement of his\n house. He feels that with these two events, he breathing became acutely\n worse and is concerned for allergen exposure. He denies any sick\n contacts, fevers, chills, worsening /productive , rhinorrhea.\n He did receive flu and pneumovax.\n .\n He has had a recent admissions in /09 with progressive DOE. CT\n revealed increased ground glass opacity in LL superimposed on pulmonary\n fibrosis with elevated eosinophils peripherally (12%). A BAL was also\n positive for eosinophils. He was started on high dose steroids\n (prednisone 60mg) with plan for close outpatient follow up for\n eosinophilic lung disease. He was discharged on on 2-3L NC. He then\n represented to on for spontaneous pneumomediastinum of\n unclear etiology.\n .\n On day of admission, Pt called pulmonologist (Dr. c/o worsening\n shortness of breath since Saturday . Yesterday he was at pulmonary\n rehab and desaturated to the 70s on 6L with minimal exertion, and he is\n currently on 4L NC at rest. No sick\n contacts recently and has not changed. He was asked to go to ED\n given concern for either acute exacerbation of underlying IPF vs\n superimposed infection vs pneumothorax.\n .\n In the ED, initial vs were: 98.3, 96, 144/97, 24, 97% 6L NC. Patient\n was given levoquin X 1 and was sent to floor. Of note, by transfer to\n ICU, his sats in ED were near baseline at 96% 4L NC.\n .\n On the floor, he reports feeling comfortable. He denies any complaints\n except that with exertion he has noticed left sided chest pain, that\n does not radiate to jaw or arm. He also notes occasional palpitations\n (rapid, regular) which have been lasting up to 1 hour ocuring more\n frequently. He denied PND, worsening orthopnea, LE swelling.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Levofloxacin - 01:11 AM\n Infusions:\n Other ICU medications:\n Other medications:\n HOME\n Acetylcysteine 600 mg TID\n Acetaminophen 500 mg PRN\n Calcium 500 mg TID\n Vitamin D 400 \n Past medical history:\n Family history:\n Social History:\n # IPF\n # HTN\n Brother: died \n Occupation:\n Drugs: none\n Tobacco: Smoked for 19 yrs but quit 19yrs ago\n Alcohol: . No EtOH use for 20 years\n Other: Currently not working but previously worked as a painter as well\n as sandblasting for 4 yrs during the (wore respirator but\n beard prevented tight seal). Occasionally travels overseas to\n and but states not a/w Sx. No known asbestos exposure.\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Chest pain, Palpitations, No(t) Edema, Tachycardia,\n No(t) Orthopnea\n Respiratory: , Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Jaundice\n Heme / Lymph: No(t) Lymphadenopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Pain: No pain / appears comfortable\n Flowsheet Data as of 03:38 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 79 (79 - 98) bpm\n BP: 122/69(82) {122/69(82) - 128/80(92)} mmHg\n RR: 30 (18 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 124 mL\n PO:\n TF:\n IVF:\n 124 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 124 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Crackles : velcro-like, No(t)\n Bronchial: , No(t) Wheezes : , Diminished: poor inspiratory efforts)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 2\n 98\n 3.8\n 139\n 41.4\n 12.5\n [image002.jpg]\n Other labs: PT / PTT / INR://1.4, Lactic Acid:1.1\n Imaging: CXR: extensive fibrotic changes\n Chest CT:\n IMPRESSION:\n 1. New pneumomediastinum, possibly spontaneous in the setting of\n diffuse pulmonary fibrosis, but correlation with clinical history\n recommended to exclude other potential causes such as esophageal or\n airway perforation, particularly if the patient has undergone recent\n intervention.\n 2. No change in severe pulmonary fibrosis or associated ground-glass\n attenuation since recent CT of .\n 3. Left upper pole renal mass, previously shown to be complex by recent\n ultrasound examination. This could be further evaluated by MRI.\n .\n ECHO: The left atrium and right atrium are normal in cavity\n size. Left ventricular wall thickness, cavity size and regional/global\n systolic function are normal (LVEF >55%). Tissue Doppler imaging\n suggests a normal left ventricular filling pressure (PCWP<12mmHg).\n Right ventricular chamber size and free wall motion are normal. The\n aortic arch is mildly dilated. The aortic valve leaflets (3) appear\n structurally normal with good leaflet excursion and no aortic\n regurgitation. The mitral valve appears structurally normal with\n trivial mitral regurgitation. There is no mitral valve prolapse. There\n is mild-moderate pulmonary artery systolic hypertension. There is no\n pericardial effusion.\n IMPRESSION: Mild-moderate pulmonary artery systolic hypertension\n suggestive of a primary pulmonary process. Mildly dilated aortic arch.\n Normal biventricular cavity sizes with preserved global and regional\n biventricular systolic function.\n ECG: NSR, nl axis, nl intervals, poor R wave progression, TWI V2-3\n (new), no ST changes compared to prior.\n Assessment and Plan\n This is a 54 y/o M hx IPF, recent admission for spontaneous\n pneumomediastinum, who now presents with DOE X 3 days\n .\n .\n # Hypoxic respiratory distress/\n INTERSTITIAL LUNG DISEASE (ILD\n INCLUDING IPF, UIP, NSIP, DIP, LIP, ETC):\n DDx most likely includes exacerbation of underlying IPF or pulm\n infection/pna. Based on CXR, no pneumomediastinum/PTX. Also, no clear\n infiltrate, no fevers, leukocytosis or worsening to suggest\n pneumonia, so I strongly suspect exacerbation of IPF especially given\n hx of exposure to allergens. Low clinical suspicion for pulmonary\n edema/CHF or PE\n - continue NAC TID\n - consider trial of steroids, although during recent admission, he had\n no significant improvement on steroids\n - consider repeat chest CT; however, most recent in \n - no clinical signs for pna, would not continue empiric Abx\n - if oxygenation worsens would intubate\n - email Dr. in AM\n .\n # CP: He is currently pain free; however, hx of left sided CP with\n exertion is strongly concerning for angina. EKG not suggestive of ACS\n today\n - stress test\n - CE X 3 to ROMI\n - would advise starting low dose ASA\n - check lipids in AM\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis:\n - Subcutaneous heparin\n - no need for PPI\n - bowel regimen\n .\n # Access: peripherals\n .\n # Code: FULL\n .\n # Communication: Patient\n .\n # Disposition: ICU for monitoring of resp status\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:10 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n ------ Protected Section ------\n ATTENDING ADDENDUM:\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n Key Points:\n No clear explanation for transient hypoxemia except for possibly acute\n response to exposure to rat dander and dust. Now on baseline\n supplemental oxygen, feeling well, no resp distress.\n Safe to transfer to ICU.\n ------ Protected Section Addendum Entered By: , MD\n on: 10:22 ------\n"
},
{
"category": "Physician ",
"chartdate": "2141-02-01 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 556384,
"text": "Chief Complaint: DOE\n HPI:\n 54 y/o M w/IPF, called today with worsening dyspnea x 3 days. He had\n been in unusal state of health at baseline resp status (using 4L NC at\n rest and 6L NC with exertion) when 3 days PTA, he hugged his cousin who\n has rats for pets and also the heat came up from the basement of his\n house. He feels that with these two events, he breathing became acutely\n worse and is concerned for allergen exposure. He denies any sick\n contacts, fevers, chills, worsening /productive , rhinorrhea.\n He did receive flu and pneumovax.\n .\n He has had a recent admissions in /09 with progressive DOE. CT\n revealed increased ground glass opacity in LL superimposed on pulmonary\n fibrosis with elevated eosinophils peripherally (12%). A BAL was also\n positive for eosinophils. He was started on high dose steroids\n (prednisone 60mg) with plan for close outpatient follow up for\n eosinophilic lung disease. He was discharged on on 2-3L NC. He then\n represented to on for spontaneous pneumomediastinum of\n unclear etiology.\n .\n On day of admission, Pt called pulmonologist (Dr. c/o worsening\n shortness of breath since Saturday . Yesterday he was at pulmonary\n rehab and desaturated to the 70s on 6L with minimal exertion, and he is\n currently on 4L NC at rest. No sick\n contacts recently and has not changed. He was asked to go to ED\n given concern for either acute exacerbation of underlying IPF vs\n superimposed infection vs pneumothorax.\n .\n In the ED, initial vs were: 98.3, 96, 144/97, 24, 97% 6L NC. Patient\n was given levoquin X 1 and was sent to floor. Of note, by transfer to\n ICU, his sats in ED were near baseline at 96% 4L NC.\n .\n On the floor, he reports feeling comfortable. He denies any complaints\n except that with exertion he has noticed left sided chest pain, that\n does not radiate to jaw or arm. He also notes occasional palpitations\n (rapid, regular) which have been lasting up to 1 hour ocuring more\n frequently. He denied PND, worsening orthopnea, LE swelling.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Levofloxacin - 01:11 AM\n Infusions:\n Other ICU medications:\n Other medications:\n HOME\n Acetylcysteine 600 mg TID\n Acetaminophen 500 mg PRN\n Calcium 500 mg TID\n Vitamin D 400 \n Past medical history:\n Family history:\n Social History:\n # IPF\n # HTN\n Brother: died \n Occupation:\n Drugs: none\n Tobacco: Smoked for 19 yrs but quit 19yrs ago\n Alcohol: . No EtOH use for 20 years\n Other: Currently not working but previously worked as a painter as well\n as sandblasting for 4 yrs during the (wore respirator but\n beard prevented tight seal). Occasionally travels overseas to\n and but states not a/w Sx. No known asbestos exposure.\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Chest pain, Palpitations, No(t) Edema, Tachycardia,\n No(t) Orthopnea\n Respiratory: , Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Jaundice\n Heme / Lymph: No(t) Lymphadenopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Pain: No pain / appears comfortable\n Flowsheet Data as of 03:38 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 79 (79 - 98) bpm\n BP: 122/69(82) {122/69(82) - 128/80(92)} mmHg\n RR: 30 (18 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 124 mL\n PO:\n TF:\n IVF:\n 124 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 124 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Crackles : velcro-like, No(t)\n Bronchial: , No(t) Wheezes : , Diminished: poor inspiratory efforts)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 2\n 98\n 3.8\n 139\n 41.4\n 12.5\n [image002.jpg]\n Other labs: PT / PTT / INR://1.4, Lactic Acid:1.1\n Imaging: CXR: extensive fibrotic changes\n Chest CT:\n IMPRESSION:\n 1. New pneumomediastinum, possibly spontaneous in the setting of\n diffuse pulmonary fibrosis, but correlation with clinical history\n recommended to exclude other potential causes such as esophageal or\n airway perforation, particularly if the patient has undergone recent\n intervention.\n 2. No change in severe pulmonary fibrosis or associated ground-glass\n attenuation since recent CT of .\n 3. Left upper pole renal mass, previously shown to be complex by recent\n ultrasound examination. This could be further evaluated by MRI.\n .\n ECHO: The left atrium and right atrium are normal in cavity\n size. Left ventricular wall thickness, cavity size and regional/global\n systolic function are normal (LVEF >55%). Tissue Doppler imaging\n suggests a normal left ventricular filling pressure (PCWP<12mmHg).\n Right ventricular chamber size and free wall motion are normal. The\n aortic arch is mildly dilated. The aortic valve leaflets (3) appear\n structurally normal with good leaflet excursion and no aortic\n regurgitation. The mitral valve appears structurally normal with\n trivial mitral regurgitation. There is no mitral valve prolapse. There\n is mild-moderate pulmonary artery systolic hypertension. There is no\n pericardial effusion.\n IMPRESSION: Mild-moderate pulmonary artery systolic hypertension\n suggestive of a primary pulmonary process. Mildly dilated aortic arch.\n Normal biventricular cavity sizes with preserved global and regional\n biventricular systolic function.\n ECG: NSR, nl axis, nl intervals, poor R wave progression, TWI V2-3\n (new), no ST changes compared to prior.\n Assessment and Plan\n This is a 54 y/o M hx IPF, recent admission for spontaneous\n pneumomediastinum, who now presents with DOE X 3 days\n .\n .\n # Hypoxic respiratory distress/\n INTERSTITIAL LUNG DISEASE (ILD\n INCLUDING IPF, UIP, NSIP, DIP, LIP, ETC):\n DDx most likely includes exacerbation of underlying IPF or pulm\n infection/pna. Based on CXR, no pneumomediastinum/PTX. Also, no clear\n infiltrate, no fevers, leukocytosis or worsening to suggest\n pneumonia, so I strongly suspect exacerbation of IPF especially given\n hx of exposure to allergens. Low clinical suspicion for pulmonary\n edema/CHF or PE\n - continue NAC TID\n - consider trial of steroids, although during recent admission, he had\n no significant improvement on steroids\n - consider repeat chest CT; however, most recent in \n - no clinical signs for pna, would not continue empiric Abx\n - if oxygenation worsens would intubate\n - email Dr. in AM\n .\n # CP: He is currently pain free; however, hx of left sided CP with\n exertion is strongly concerning for angina. EKG not suggestive of ACS\n today\n - stress test\n - CE X 3 to ROMI\n - would advise starting low dose ASA\n - check lipids in AM\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis:\n - Subcutaneous heparin\n - no need for PPI\n - bowel regimen\n .\n # Access: peripherals\n .\n # Code: FULL\n .\n # Communication: Patient\n .\n # Disposition: ICU for monitoring of resp status\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:10 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2141-02-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 556379,
"text": "Interstitial Lung Disease (ILD including IPF, UIP, NSIP, DIP, LIP, etc)\n Assessment:\n 54 year old male with a history of sever IPF. Recently admitted with\n pneumomediastinum his sever IPF. Pt is being followed up at the\n hospital for work up of lung transplant. At baseline pt does\n wear portable O2 of 2-3L NC. Upon arrival to the unit pt was on 4L NC,\n with a SpO2 of 95-97%. Pt states no symptoms of SOB and was able to\n transfer self from ED stretcher to bed. Lung sounds in all fields have\n a\nVelcro\n sounds to them. Pt with strong cough. Pt states that he has\n had this\ntickling\n in the back of his throat for several days. Pt\n denies any chest pain or discomfort. A-febrile, and has not been around\n any person with respiratory infections.\n Action:\n O2 decreased to 2.5L NC.\n Response:\n Pt 2 97-99%\n Plan:\n Monitor pt respiratory status, obtain CXR, and Provide continuous O2.\n Provide emotional support to both pt and family\n"
},
{
"category": "Radiology",
"chartdate": "2141-01-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1062054,
"text": " 10:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pna, ptx, pmediastinum\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with ipf, h/o pneumomediastinum, low sats\n REASON FOR THIS EXAMINATION:\n eval pna, ptx, pmediastinum\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST AT 2211 HOURS.\n\n HISTORY: Interstitial pulmonary fibrosis and history of pneumomediastinum\n with low oxygen saturation.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Lung volumes are markedly diminished. There are extensive fibrotic\n changes at the lung bases, grossly stable from the prior exam. Less traumatic\n opacifications are noted in the more cephalad lungs. Grossly, there is no\n superimposed acute process that can be identified when comparing to multiple\n remote studies. The mediastinum is grossly unremarkable and stable. No\n definite effusion or pneumothorax is noted.\n\n IMPRESSION: Extensive baseline disease with fibrotic changes at the lung\n bases and scattered mostly peripheral opacities in the upper lungs. No\n definite superimposed process identified.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2141-01-31 00:00:00.000",
"description": "Report",
"row_id": 222654,
"text": "Sinus rhythm. Minor right ventricular conduction delay. Otherwise, within\nnormal limits. Compared to the previous tracing of the heart rate is\nreduced. Otherwise, no major change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-02-01 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1062227,
"text": " 4:10 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Evaluate for cause of worsening hypoxia including progressio\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with IPF admitted with increasing dyspnea and hypoxia on\n exertion.\n REASON FOR THIS EXAMINATION:\n Evaluate for cause of worsening hypoxia including progression of disease,\n infection, or other pathology.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST, .\n\n COMPARISON: .\n\n INDICATION: IPF. Worsening hypoxia.\n\n TECHNIQUE: Volumetric, multidetector CT of the chest was performed without\n intravenous or oral contrast. Images are presented for display in the axial\n plane at 5-mm and 1.25-mm collimation.\n\n FINDINGS: Previously reported pneumomediastinum has resolved. Widespread\n interstitial lung disease is largely unchanged compared to the recent study\n except for a few minimal areas of progression with similar morphology and\n distribution to the previous examination. There are no new superimposed\n findings to suggest an active pulmonary infection.\n\n Enlarged mediastinal lymph nodes are again demonstrated and are likely\n hyperplastic in the setting of diffuse lung disease. The main pulmonary\n artery remains enlarged. The heart size is normal.\n\n Exam was not tailored to evaluate the subdiaphragmatic region, and only a\n small portion of the abdomen is included on the study, but no concerning\n abnormalities are evident on this limited assessment.\n\n Skeletal structures demonstrate no suspicious lytic or blastic skeletal\n lesions.\n\n IMPRESSION:\n\n 1. Slight progression of widespread interstitial pulmonary fibrosis, likely\n due to acute exacerbation of IPF as reported on the earlier CT of \n .\n\n 2. Resolution of pneumomediastinum.\n\n (Over)\n\n 4:10 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Evaluate for cause of worsening hypoxia including progressio\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
}
] |
8,916 | 132,667 | A/P: 86yo man with h/o prostate CA, presumed plasmacytoma of L3 vert, admitted for urinary incontinence with stable MRI with cord compression and N/V with normal head CT. . # Urinary incontinence - known spinal cord compression on exam but stable since last imaging, pt without new weakness or saddle anesthesia and good rectal tone so may be related to prostate pathology instead; UA neg for infxn - have d/c'd decadron - bladder scan showed 750cc urine - need to place foley . # N/V- CT head neg, could be increased narcotic use and anxiety - d/c dilaudid - LFTs slightly , /lipase wnl - reglan w/meals - anzemet IV or compazine PO PRN - monitor symptom . # Pain mgmt- difficult b/c pt appears in pain at times, but as per family he is anxious and cannot easily express this. Also he appears to be having narcotic toxicity - increase fentanyl patch to 50mcg - d/c dilaudid as may be cause of confusion and nausea - oxycodone for BT - Ativan PRN for anxiety . # Prostate CA - concern for disease progression as as pt with urinary retention - urology consult . # Plasmacytoma - concern for spinal cord compression, but MRI does not show change from prior - Ortho Spine performed decompression of L3 lesion with posterior stabilization from L1-5. Incisions were clean and dry upon discharge. Follow up will occur in two weeks in the ortho Spine clinic. Call for an appointment. - mgmt per Dr. . # CAD- cont ASA 81mg and placed pt on metoprolol in place of atenolol. Will hold on lipitor. . # B12 deficiency- pt no longer deficient, will d/c supplementation . # CKD - at baseline creatinine . # FEN- cardiac diet as tolerated, replete lytes prn, no need for IVFs for now . # PPx- SC heparin, bowel reg, PPI . #Code: Full . #Contact: daughter in law cell, home | Lopressor iv started.GI/GU- Abd soft, +BS. Sinus rhythm with atrial premature depolarizations. Baseline artifactSinus bradycardiaConsider left ventricular hypertrophyST-T wave configuration suggests in part early repolarization patternSince previous tracing of , atrial ectopy absent Compared to the previous tracing of cardiacrhythm now sinus mechanism. Dilaudid dose x 1 given with longer effect. Hct down to 26 and PRBCs #1 being transfused, 2u ordered. Afebrile. initially bradycardic. MAEs well.Resp- Lungs clear to coarse with diminished bases. ABGs WNL. Attempts to wean propofol down made pt. Foley patent, UO as mentioned. Will occ cough, nonproductive.CV- HTN in 170s, HR 80-90s with freq PACs. SBP 100-120s, into 160s when agitated. Skin w/d/i. Rt groin art line just starting to become dampened.Resp- Gd color all shift. Hemovac drain as noted above. Sinus rhythmSupraventricular extrasystolesInferior + anterior T wave change may be due to myocardial ischemiaEarly transitionSince previous tracing, T wave changes, and atrial premature complexes noted Lungs hard to auscultate anteriorly, coarse posteriorly.CV- SR with freq PVCs. Pt. Pt. Pt. Pt. Hypoactive bowel sounds.Access:2 Right PIVS #18 and 16 2 pivs on the left #18 and 20.right femerol aline.Integ Elastoplast dsg from or on lumbar spinal area D+I. Afeb. sat=100.gi/gu foley with marginal uop. MD aware. Atrial fibrillation with rapid ventricular responseEarly precordial QRS transition - is nonspecificConsider left ventricular hypertrophyDiffuse nonspecific ST-T wave abnormalitiesSince previous tracing of , rapid atrial fibrillation and further ST-Twave changes now present Hemovax in place 25cc out for 24h.GI/GU- Abd soft, +BS. Fusion of L1-L5.See assessment for HX.Neuro: Admitted on Propofol and remains sedated on propofol. need for prbc transfusion. The aorta is ectatic with calcification along its walls. 9:23 AM L-SPINE (AP & LAT) IN O.R. Gd color. Hemovac from incision has drained avg. Original post op dressing over back incision. wake abruptly (on 10mcgs). since arrival. 75cc/hr. FINDINGS: The prior study is from . There are multiple granulomas again seen. noted to move all extremities spontaneously when not sedated.cv/resp NSR. MAEs. Now with oral Temp=96.Plan. Diffuserepolarization abnormalities. excellent abgs. Intermittantly allows mouth care. Fent settles pt for short periods of time. COMPARISON: L-spine from . Barrel Chest. Sinus rhythm with PACsSeptal T wave changes are nonspecificEarly R wave progressionSince previous tracing of , atrial fibrillation not present The ETT tube remains at 3.6 cm of the carina. T max 101.8, blood and urine cx sent and tylenol given. medicated for pain frequently with mod effect. Maintance remains at 80cc/h. Abd with +BS, flat.GU- Marginal most of shift with slightly better hours occ.Heme- Improved Hct after 2 units packed cells.ID- Cefazolin doses complete. When pt light and moving in bed RR remains<10. Pt later changed to MMV with no change in #s. Sats 100% and ABGs wnl. One liter LR fluid bolus given for low uop and low BP. Plan extubation tomorrow if stable coming off sedation. RR 18 and sats 98%. Mag and K repleted during shift. Only able to get O2 sat occasionally, when possible sats are adequate. Posterior lumbar fusion hardware is incompletely assessed as it extends off the inferior aspect of this single view of the chest. Scattered aortic calcifications are noted. Scattered aortic calcifications are noted. Again seen are areas of low attenuation within the periventricular and subcortical white matter, consistent with change from chronic microvascular angiopathy. There is severe canal stenosis, which is unchanged from the previous examination. As compared to the prior images from , there has been interval removal of the endotracheal tube. There is probable diffuse osteopenia. NON-CONTRAST HEAD CT: Comparison with . There is limited evaluation of intrathecal contents on CT. Again seen is lytic and sclerotic change within the L3 vertebral body with associated cortical irregularity and destruction, consistent with the known mass seen on prior studies. Bilateral pleural effusions and adjacent atelectasis. Moderate generalized atrophy and chronic micro-ischemic change in subcortical and periventricular white matter. The patient is seen to be posterior osseous and metallic lumbar fusion. IMPRESSION: Again seen is a soft tissue mass at the L3 level with associated osseous destruction of the L3 vertebral body. There are bilateral pleural effusions and adjacent atelectasis. Lytic lesion in right iliac bone, not fully evaluated. Degenerative narrowing at multiple disc levels noted. There is limited evaluation of intraspinal and intrathecal contents on CT secondary to artifact from adjacent hardware. There are bilateral pleural effusions and associated adjacent atelectasis. Allowing for patient positioning, hardware and spinal alignment is nominal. There is uniform prominence of the extra-axial CSF spaces, the sulci and fissures and the ventricles, representing generalized atrophy. Interval removal of the endotracheal tube. Prominence of the left petrous/mastoid is again noted, unchanged. Diagnostic quality is limited by patient motion. REASON FOR THIS EXAMINATION: r/o intracranial bleed. While this is possibly degenerative, the kyphosis appears more prominent in comparison to the prior C-spine radiographs from , and an underlying ligamentous injury is not excluded. The posterior disc osteophyte complex at the C5/6 level abuts the anterior aspect of the cord, without any definite indentation. The lateral left aspect of the L3 vertebral body appears markedly destroyed, with extension of the mass into the paraspinal soft tissues. r/o fracture. r/o fracture. r/o fracture. There is relatively mild focal and confluent FLAIR hyperintensity in bihemispheric subcortical and periventricular white matter, representing chronic microischemic change. There is limited evaluation of intrathecal contents on CT, however, the contour of the thecal sac is within normal limits. Unremarkable cranial MRA. Laminectomy and spinal stabilization procedure, in nominal alignment, with osseous destruction of L3. IMPRESSION: Limited study secondary to patient motion. There is associated neural foraminal narrowing at the C3/4 level bilaterally, C5/6 level. There are destructive changes of the L3 vertebral body. A paravertebral mass on the left is again identified. The lungs are clear except for a left upper lobe granuloma. 7:29 PM CT HEAD W/O CONTRAST Clip # Reason: r/o intracranial bleed. | 26 | [
{
"category": "Nursing/other",
"chartdate": "2139-09-18 00:00:00.000",
"description": "Report",
"row_id": 1380151,
"text": "Elderly Russian Speaking man admitted to on . Now comes to Trauma Sicu Post-op Spinal tumor resection. Fusion of L1-L5.\nSee assessment for HX.\nNeuro: Admitted on Propofol and remains sedated on propofol. Also is wearing fentanyl patch 50mcg/hr due to be changed tomorrow. Attempts to wean propofol down made pt. wake abruptly (on 10mcgs). Pt. thrashing and not able to open eyes to command. (language barrier noted) Sedated with increasing propofol dose back to 30. Pt. noted to move all extremities spontaneously when not sedated.\ncv/resp NSR. initially bradycardic. now in the high 60's with pac's.\nVented on AC ventilation. excellent abgs. Not breathing over vent on propofol. Lungs clear. on 35%fio2. sat=100.\ngi/gu foley with marginal uop. One liter LR fluid bolus given for low uop and low BP. 6pm hct pending ? need for prbc transfusion. Hemovac from incision has drained avg. 75cc/hr. since arrival. NPO with no gastric intubation at this time. Hypoactive bowel sounds.\nAccess:2 Right PIVS #18 and 16 2 pivs on the left #18 and 20.\nright femerol aline.\nInteg Elastoplast dsg from or on lumbar spinal area D+I. Hemovac drain as noted above. stockings and compression sleeves on.\nBair hugger on arrival for hypothermia. Now with oral Temp=96.\nPlan. Monitor for bleeding/hypovolemia. Keep intubated and sedated overnight. Plan extubation tomorrow if stable coming off sedation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-09-19 00:00:00.000",
"description": "Report",
"row_id": 1380152,
"text": "NPN 1900-0700\n pt on propofol gtt and PRN fentanyl. Attempted again to wean propofol but pt easily awakens and very restless twisting in bed and bending legs (has R groin aline). ? pain as cause. Fent settles pt for short periods of time. Dilaudid dose x 1 given with longer effect.\n\n Pt changed to PS 5/5. TV 600-1Liter with RR 4-8. When pt light and moving in bed RR remains<10. HO aware. Pt later changed to MMV with no change in #s. Sats 100% and ABGs wnl. Lungs hard to auscultate anteriorly, coarse posteriorly.\n\nCV- SR with freq PVCs. SBP 100-120s, into 160s when agitated. Low UO for several hours which did not respond to fluid bolus x 2. Maintance remains at 80cc/h. UO improved at 6am. Hct down to 26 and PRBCs #1 being transfused, 2u ordered. Afebrile. Mag and K repleted during shift. Lopressor iv started.\n\nGI/GU- Abd soft, +BS. Foley patent, UO as mentioned. No BM.\n\nSocial- no contact with family overnight.\n\nPlan- Most likely try to extubate this am. need to change pain management.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-09-19 00:00:00.000",
"description": "Report",
"row_id": 1380153,
"text": "NPN 1900-0700\nAddendum\n\nPt propofol off at 0645, by 7am awake, opening eyes and very restless in bed. MAEs. Extubated without incident and on FT 40%. RR 18 and sats 98%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-09-19 00:00:00.000",
"description": "Report",
"row_id": 1380154,
"text": "T/SICU NPN:\nBrief ROS:\nNeuro- Family in to visit pt. today, they believe him to be alert and oriented. He responded appropriately to questions during entire visit. Pt. moves all extremities, gd strength. He has been slightly restless and pulled at etc.. but appears mostly purposeful with moving. He (through his family) has complained mostly of his legs being uncomfortable, behind his knees, left more than the rt. He does not c/o back () pain. Pupils are reactive to light, when pt. allows nurse to check pupils(he's clamped eyes closed with flashlight). Pt. has had fentanyl IV, 50mcg every 3-4 hrs today, which does settle him for a short amt of time. He also started a fentanyl patch today, as he had at home.\n\nCV- BP intermittantly has been high throughout shift today, mostly r/t agitation or stimulation. When he's quiet and restful, his BP is 140's- 160 systolic. HR has been in the 80's, with frequent APC's. Skin warm and dry. Difficult to palpate periph pulses, gd nail bed blanching. Gd color. Rt groin art line just starting to become dampened.\n\nResp- Gd color all shift. Only able to get O2 sat occasionally, when possible sats are adequate. Bilat breath sounds are coarse to clear throughtout. RR 20's down to 8 when he's asleep.\n\nGI- NPO as yet, he has not been cooperative consistantly enough to start po's. Intermittantly allows mouth care. Abd with +BS, flat.\n\nGU- Marginal most of shift with slightly better hours occ.\n\nHeme- Improved Hct after 2 units packed cells.\n\nID- Cefazolin doses complete. Afeb.\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-09-20 00:00:00.000",
"description": "Report",
"row_id": 1380155,
"text": "NPN 1900-0700\nNeuro- Russian speaking only. Awake most of night and restless. medicated for pain frequently with mod effect. When touch pt tends to yell out in Russian. With turning trys to pinch and hit staff. MAEs well.\n\nResp- Lungs clear to coarse with diminished bases. Barrel Chest. ABGs WNL. FT changed to 3lnc and sats 98%. Will occ cough, nonproductive.\n\nCV- HTN in 170s, HR 80-90s with freq PACs. Lopressor increased to 5mg IV q6h with little effect on bp and HR. MD aware. T max 101.8, blood and urine cx sent and tylenol given. Skin w/d/i. Original post op dressing over back incision. Hemovax in place 25cc out for 24h.\n\nGI/GU- Abd soft, +BS. Pt yells out when abd palpated but also yells when touch legs. No BM. Foley patent with light yellow urine.\n\n transfer to floor, may require a sitter. OOB to chair with brace.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2139-10-07 00:00:00.000",
"description": "Report",
"row_id": 270892,
"text": "Sinus rhythm with atrial premature depolarizations. Otherwise, without\ndiagnostic abnormality. Compared to the previous tracing of cardiac\nrhythm now sinus mechanism.\n\n"
},
{
"category": "ECG",
"chartdate": "2139-10-06 00:00:00.000",
"description": "Report",
"row_id": 270893,
"text": "Atrial fibrillation with a mean ventricular response, rate 136. Diffuse\nrepolarization abnormalities. Compared to the previous tracing of \ncardiac rhythm is now rapid atrial fibrillation.\n\n"
},
{
"category": "ECG",
"chartdate": "2139-10-04 00:00:00.000",
"description": "Report",
"row_id": 271118,
"text": "Baseline artifact\nSinus bradycardia\nConsider left ventricular hypertrophy\nST-T wave configuration suggests in part early repolarization pattern\nSince previous tracing of , atrial ectopy absent\n\n"
},
{
"category": "ECG",
"chartdate": "2139-09-23 00:00:00.000",
"description": "Report",
"row_id": 271119,
"text": "Sinus rhythm with PACs\nSeptal T wave changes are nonspecific\nEarly R wave progression\nSince previous tracing of , atrial fibrillation not present\n\n"
},
{
"category": "ECG",
"chartdate": "2139-09-22 00:00:00.000",
"description": "Report",
"row_id": 271120,
"text": "Atrial fibrillation with rapid ventricular response\nEarly precordial QRS transition - is nonspecific\nConsider left ventricular hypertrophy\nDiffuse nonspecific ST-T wave abnormalities\nSince previous tracing of , rapid atrial fibrillation and further ST-T\nwave changes now present\n\n"
},
{
"category": "ECG",
"chartdate": "2139-09-15 00:00:00.000",
"description": "Report",
"row_id": 271121,
"text": "Sinus rhythm\nSupraventricular extrasystoles\nInferior + anterior T wave change may be due to myocardial ischemia\nEarly transition\nSince previous tracing, T wave changes, and atrial premature complexes noted\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-09-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 932461,
"text": " 5:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate CA, plasmacytomoa of L3, to go for surgery to\n remove spinal tumor tomorrow\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: ETT placement.\n\n FINDINGS: The prior study is from . There are multiple\n granulomas again seen. The cardiac silhouette is normal. The aorta is\n ectatic with calcification along its walls. The lung transparency is normal.\n The ETT tube remains at 3.6 cm of the carina. Old fractures of the ribs are\n seen on the right side.\n\n IMPRESSION: ETT tube in place, no acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-09-18 00:00:00.000",
"description": "O L-SPINE (AP & LAT) IN O.R.",
"row_id": 932357,
"text": " 9:23 AM\n L-SPINE (AP & LAT) IN O.R. Clip # \n Reason: FUSION, DISCECTOMY L1-L5\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post fusion and discectomy of L1 through L5.\n\n COMPARISON: L-spine from .\n\n FINDINGS: Two intraoperative lateral radiographs of the lumbar spine were\n obtained without a radiologist present, which demonstrates posterior fusion\n with placement of bilateral pedicle screws in L1, L2, L4, L5. For further\n details, please refer to the operative note.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-09-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 931825,
"text": " 11:03 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: H/O PROSTRAT CA, L3 MASS.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate ca and L3 mass, with new incontinence and now\n nausea and vomiting\n REASON FOR THIS EXAMINATION:\n evaluate for intracranial pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ACKe MON 11:32 PM\n no significant change since \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New nausea and vomiting. History of prostate cancer.\n\n NON-CONTRAST HEAD CT: Comparison with . Prominence of sulci\n and ventricles is similar to the previous exam. No new hydrocephalus, shift\n of normally midline structures, intra- or extra-axial hemorrhage, or acute\n major vascular territorial infarct is identified. Hypodensity in corona\n radiata and centra semiovale as well as small lacunes in insular cortex and\n basal ganglia reflect chronic microvascular change. Imaged sinuses appear\n clear. External auditory canals are patent. No fractures are seen.\n\n Prominence of the left petrous/mastoid is again noted, unchanged.\n\n IMPRESSION: No acute intracranial hemorrhage or mass effect.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-09-15 00:00:00.000",
"description": "MR L-SPINE W & W/O CONTRAST",
"row_id": 931829,
"text": " 12:32 AM\n MR W & W/O CONTRAST Clip # \n Reason: evalaute for new changes in mass since last MRI\n Contrast: MAGNEVIST Amt: 16\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with known L3 mass with xrt p/w continued low back pain and leg\n pain/weakness and 2 episodes of urine incontinence, nl tone, no saddle\n anesthesia.\n REASON FOR THIS EXAMINATION:\n evalaute for new changes in mass since last MRI\n ______________________________________________________________________________\n WET READ: ACKe TUE 2:48 AM\n Positive for mass emanating from the L3 vertebrae and extending into the\n epidural space causing very severe canal and nerve root compression.\n\n MD\n\n I agree with above and add that exam looks very similar to that of . MD\n WET READ VERSION #1 DJD TUE 1:51 AM\n Positive for mass emanating from the L3 vertebrae and extending into the\n epidural space causing very severe canal and nerve root compression.\n\n MD\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: L3 mass status post radiation therapy with continued\n low back pain and leg pain, weakness and urinary incontinence.\n\n MRI OF THE LUMBAR SPINE WITH GADOLINIUM.\n\n Exam was compared to prior study of .\n\n FINDINGS: Again is noted the mass within the body of the L3 lumbar vertebra\n extending into the epidural space and involving the pedicle on the left side.\n A paravertebral mass on the left is again identified. There is severe canal\n stenosis, which is unchanged from the previous examination. There are no\n definite changes from the previous examination. There is no definite evidence\n of involvement of additional vertebra.\n\n IMPRESSION: Large mass at L3 with features as discussed above. There is\n severe canal stenosis. There is no definite change from prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-09-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 932846,
"text": " 12:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: rule out PE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate CA, plasmacytomoa of L3, to go for surgery to\n remove spinal tumor tomorrow\n REASON FOR THIS EXAMINATION:\n rule out PE\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Rule out pulmonary embolism (PE) in an 86-year-old man with\n plasmacytoma localized in L3 and with prostate cancer, scheduled for spinal\n surgery tomorrow.\n\n COMPARISON: Prior chest x-ray from three days ago.\n\n TECHNIQUE AND FINDINGS: A single view frontal x-ray of the chest was obtained\n in upright position.\n\n As compared to the prior images from , there has been interval\n removal of the endotracheal tube. The appearance of the cardiomediastinal\n silhouette remains unchanged. As before, tortuosity and calcification of the\n aorta are noted, multiple old, healed rib fractures are seen on the right\n side, and metallic orthopedic hardware is present at the level of the upper\n lumbar spine. A small radiopaque band is seen just above the left\n costophrenic angle, likely representing focal atelectasis. Otherwise, the\n transparence of the lung fields is symmetric.\n\n CONCLUSION: Focal band of atelectasis at the left lung base. Otherwise,\n unchanged appearance of the chest since . Interval removal of\n the endotracheal tube.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-09-30 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 934005,
"text": " 1:05 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: Eval for stroke\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with persistent delerium and ? aphasia\n REASON FOR THIS EXAMINATION:\n Eval for stroke\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 86-year-old male with persistent delirium and ? aphasia; evaluate\n for stroke.\n\n TECHNIQUE: Routine non-contrast MRI and MRA of the brain was performed.\n\n FINDINGS: The study is compared with recent non-contrast head CT dated\n . There is no evidence of focally decreased diffusion to indicate\n acute infarction and the major intracranial vascular flow voids are preserved\n (see MRA, below). Though the susceptibility-weighted sequence is motion\n degraded, there is no evidence of large acute or chronic hemorrhage. There is\n uniform prominence of the extra-axial CSF spaces, the sulci and fissures and\n the ventricles, representing generalized atrophy. There is relatively mild\n focal and confluent FLAIR hyperintensity in bihemispheric subcortical and\n periventricular white matter, representing chronic microischemic change.\n\n There is normal flow-related enhancement in the included intracranial portions\n of both internal carotid and proximal middle and anterior cerebral arteries,\n with normal, symmetric arborization of MCA branches and no flow-limiting\n stenosis or aneurysm. There is normal flow-related enhancement in the distal\n vertebral and the basilar and bilateral posterior cerebral arteries, with\n probable fetal-type left PCA, and no flow-limiting stenosis or aneurysm.\n\n IMPRESSION:\n 1. No evidence of acute intracranial process; specifically, there is no\n evidence of acute infarction.\n 2. Moderate generalized atrophy and chronic micro-ischemic change in\n subcortical and periventricular white matter.\n 3. Unremarkable cranial MRA.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-10-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 934569,
"text": " 3:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: consolidation? infiltrate?\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate CA, chordoma L3 with new unresponsiveness,\n food particles in mouth\n REASON FOR THIS EXAMINATION:\n consolidation? infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Prostate cancer.\n\n Cardiomediastinal contours are normal. Nodular opacity projecting over the\n left lower lung is not immediately apparent on . The finding may\n represent nipple shadow. There is no effusion. No pneumothorax. Trachea is\n midline. Posterior lumbar fusion hardware is incompletely assessed as it\n extends off the inferior aspect of this single view of the chest. The aorta\n is tortuous. No pneumothorax. No consolidation.\n\n IMPRESSION:\n\n 1. No consolidation. No effusion.\n\n 2. Nodular opacity projecting over the left lung base is not evident on the\n chest radiograph of . The finding may simply represent nipple\n shadow. It clinically indicated, repeat chest radiograph with nipple marker\n in place could be performed to exclude pulmonary nodule.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-10-04 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 934567,
"text": " 3:20 PM\n PORTABLE ABDOMEN Clip # \n Reason: obstruction, free air\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate cancer, new onset abd pain. difficult to arouse.\n\n REASON FOR THIS EXAMINATION:\n obstruction, free air\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pain.\n\n Single portable radiograph of the abdomen is submitted. Diagnostic quality is\n limited by patient motion. Normal air and stool filled loops of bowel are\n evident. The patient is seen to be posterior osseous and metallic lumbar\n fusion. The hip and sacroiliac joint spaces are not well assessed secondary\n to motion, but there is likely bilateral degenerative change of both hips. No\n fracture is identified, although subtle fracture is not excluded given the\n degree of patient motion.\n\n IMPRESSION:\n\n Limited study secondary to patient motion. Normal bowel gas pattern.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-09-27 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 933620,
"text": " 8:16 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o fracture, instabliity\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate CA s/p L3 lesion resection (? plasmacytoma),\n stabilization of L1-5, POD 9, s/p fall out of chair. r/o fracture.\n REASON FOR THIS EXAMINATION:\n r/o fracture, instabliity\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old man with prostate cancer status post L3 lesion\n resection and stabilization of L1-5, status post fall. Evaluate for fracture,\n instability.\n\n COMPARISON: Plain radiographs of the cervical spine from .\n\n TECHNIQUE: Axial images of the cervical spine were obtained with coronal and\n sagittal reformatted images.\n\n CT C-SPINE: No fracture is identified. Extensive degenerative changes are\n seen, predominantly at the C4-6 levels. Additionally, there is grade I\n anterolisthesis of C4 on 5 of approximately 3 mm with slight kyphotic\n angulation. There are extensive facet degenerative changes at these levels as\n well. There is mild spinal canal narrowing, predominantly at the C5/6 and\n C6/7 levels. There is facet hypertrophy and degenerative change at several\n levels as well. There is associated neural foraminal narrowing at the C3/4\n level bilaterally, C5/6 level. There is limited evaluation of intrathecal\n contents on CT. The posterior disc osteophyte complex at the C5/6 level abuts\n the anterior aspect of the cord, without any definite indentation. The\n contour of the thecal sac is within normal limits at the remaining levels. No\n prevertebral soft tissue swelling is seen. Within the visualized portion of\n the lung apices, no pneumothorax or pleural effusion is seen.\n\n IMPRESSION:\n\n 1. Extensive degenerative changes are seen, as described above.\n\n 2. There is no fracture.\n\n 3. There is a 3 mm grade I anterolisthesis of C4 on C5 with focal kyphotic\n angulation. There is no associated prevertebral soft tissue abnormality.\n While this is possibly degenerative, the kyphosis appears more prominent in\n comparison to the prior C-spine radiographs from , and an underlying\n ligamentous injury is not excluded. Clinical correlation is recommended, and\n further evaluation with an MRI could be obtained if indicated.\n\n\n NOTE ADDED AT ATTENDING REVIEW: I agree that there is more subluxation and\n kyphosis now than on the prior study. I also agree that this change may be\n acute or chronic. Note that there is very little information about intraspinal\n (Over)\n\n 8:16 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o fracture, instabliity\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n soft tissue abnormalities. The need for MR will depend on the clinical\n presentation, but it would be the best way to evaluate possible ligamentous\n injury.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-09-27 00:00:00.000",
"description": "CT T-SPINE W/O CONTRAST",
"row_id": 933621,
"text": " 8:16 PM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: r/o fracture\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate CA s/p L3 lesion resection (? plasmacytoma),\n stabilization of L1-5, POD 9, s/p fall out of chair. r/o fracture.\n REASON FOR THIS EXAMINATION:\n r/o fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86 year old man with prostate cancer status post L3 resection,\n status post fall. Evaluate for fracture.\n\n COMPARISON: Prior CT scan from .\n\n TECHNIQUE: Axial images of the thoracic spine were obtained with coronal and\n sagittal reformatted images.\n\n CT T-SPINE: No fracture or subluxation is identified. Minimal degenerative\n changes are seen at several levels. Bony mineralization is stable in\n comparison to the prior study. There is limited evaluation of intrathecal\n contents on CT, however, the contour of the thecal sac is within normal\n limits.\n\n There are bilateral pleural effusions and associated adjacent atelectasis.\n Scattered aortic calcifications are noted. There is a prominent subcarinal\n lymph node measuring 15 mm in short axis diameter. The liver demonstrates\n slightly increased parenchymal density on this noncontrast study, which may be\n related to prior treatment.\n\n IMPRESSION:\n\n 1. No fracture or subluxation of the thoracic spine is identified.\n\n 2. Bilateral pleural effusions and adjacent atelectasis.\n\n 3. Slightly increased density of the liver parenchyma is noted, and may\n reflect changes related to prior treatment or transfusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-09-27 00:00:00.000",
"description": "CT L-SPINE W/O CONTRAST",
"row_id": 933622,
"text": " 8:16 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: r/o fracture\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate CA s/p L3 lesion resection (? plasmacytoma),\n stabilization of L1-5, POD 9, s/p fall out of chair. r/o fracture.\n REASON FOR THIS EXAMINATION:\n r/o fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 86 year old man with prostate cancer status post L3 resection,\n fell out of a chair, evaluate for fracture.\n\n COMPARISON: MRI study from .\n\n TECHNIQUE: Axial images of the lumbar spine were obtained with coronal and\n sagittal reformatted images.\n\n CT L-SPINE: There has been interval placement of posterior paraspinal fusion\n rods and pedicle and vertebral body screws in the L1-2 and L4-5 vertebral\n bodies. Multiple small bone graft chips can be seen along the fusion rods.\n Again seen is lytic and sclerotic change within the L3 vertebral body with\n associated cortical irregularity and destruction, consistent with the known\n mass seen on prior studies. There appears to be normal alignment of the\n lumbar vertebral column. The lateral left aspect of the L3 vertebral body\n appears markedly destroyed, with extension of the mass into the paraspinal\n soft tissues. There is limited evaluation of intraspinal and intrathecal\n contents on CT secondary to artifact from adjacent hardware. Post-surgical\n changes are seen within the posterior soft tissues from recent surgery.\n\n There are bilateral pleural effusions and adjacent atelectasis. Scattered\n aortic calcifications are noted. There is a large hypodensity arising off of\n the right kidney, which is not completely characterized on this study.\n\n IMPRESSION: Again seen is a soft tissue mass at the L3 level with associated\n osseous destruction of the L3 vertebral body. The patient has undergone\n interval placement of posterior fusion hardware from L1-5. There is no\n evidence of spondylolisthesis.\n\n NOTE ADDED AT ATTENDING REVIEW: Note that the images are so limited for\n intraspinal soft tissue that we cannot evaluate the possibility of cauda\n equina compromise due to mass or hematoma. There are no large osseous\n fragments in the canal. Smaller fragments might be missed due to artifact.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-09-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 933618,
"text": " 7:29 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o intracranial bleed.\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate CA, plasmacytoma of L3 vertebrae s/p\n decompression of L3 lesion with posterior stabilization of L1-5. With fall from\n chair at 7pm. + head trauma, needs NCHCT to r/o intracranial bleed, SDH, SAH.\n REASON FOR THIS EXAMINATION:\n r/o intracranial bleed.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old man with history of prostate cancer and plasmacytoma\n of L3 vertebral body, status post decompression of the L3 lesion and posterior\n stabilization, status post fall from chair. Evaluate for intracranial\n hemorrhage.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n CT HEAD WITHOUT IV CONTRAST: No intracranial hemorrhage is identified. The\n ventricles are symmetric, and there is no shift of normally midline\n structures. The -white matter differentiation is preserved. Again seen\n are areas of low attenuation within the periventricular and subcortical white\n matter, consistent with change from chronic microvascular angiopathy. Soft\n tissue and osseous structures are stable in appearance. The visualized\n portions of the paranasal sinuses are well aerated.\n\n IMPRESSION: No hemorrhage is identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-10-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 934148,
"text": " 10:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: effusion, consolidate.\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate CA, chordoma L3 with fever, crackles.\n REASON FOR THIS EXAMINATION:\n effusion, consolidate.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Fever and crackles in a patient after orthopedic\n surgery for L3 chordoma.\n\n The heart size is normal. The aorta is tortuous including the ascending and\n descending part. The lungs are clear. The pleural surfaces are smooth with\n no pleural effusion.\n\n IMPRESSION: No evidence of acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-10-05 00:00:00.000",
"description": "L-SPINE (AP & LAT)",
"row_id": 934653,
"text": " 10:43 AM\n L-SPINE (AP & LAT) Clip # \n Reason: s/p L3 decompression and fusion; evaluate alignment\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with\n REASON FOR THIS EXAMINATION:\n s/p L3 decompression and fusion; evaluate alignment\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post L3 decompression and fusion, evaluate alignment.\n\n TWO VIEWS OF THE LOWER LUMBAR SPINE. The technologist notes that the patient\n was unable to cooperate.\n\n There is evidence of laminectomy, with bilateral pedicle screws at L1, L2, L4,\n and L5 and a crossbar at the level of L4. ? morselized bone graft, faintly\n visualized due to technique. There are destructive changes of the L3 vertebral\n body. Allowing for patient positioning, hardware and spinal alignment is\n nominal. There is probable diffuse osteopenia.\n\n There is a defect in the right iliac bone of uncertain etiology or\n significance, not fully evaluated here.\n\n IMPRESSION:\n 1. Laminectomy and spinal stabilization procedure, in nominal alignment, with\n osseous destruction of L3. Degenerative narrowing at multiple disc levels\n noted.\n 2. Lytic lesion in right iliac bone, not fully evaluated. Is this the site\n of previous surgical intervention?\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-09-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 932227,
"text": " 11:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pre-op xray\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with prostate CA, plasmacytomoa of L3, to go for surgery to\n remove spinal tumor tomorrow\n REASON FOR THIS EXAMINATION:\n pre-op xray\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Pre-operative evaluation before L3 surgery.\n\n Portable AP chest radiograph compared to . The heart size is\n normal. The aorta is tortuous and calcified. There is no congestive heart\n failure. The lungs are clear except for a left upper lobe granuloma. The\n pleural surfaces are smooth with no pleural effusion. Old fractures of the\n right ribs are again demonstrated.\n\n\n"
}
] |
17,421 | 171,993 | Patient had her pre-operative work-up as an out patient and was a same day admit. On she was brought directly to the operating room where she underwent an Aortic Valve Replacement. Please see op note for surgical details. She tolerated the procedure well and was brought to the CSRU in stable condition on minimal Inotropic support. Patient was transfused to keep hct approximately 30. Later on op day she was weaned from sedation, awoke neurologically intact and was extubated. Inotropes were weaned by post-op day one and she was started on a Nitro gtt for hypertension. B blockers and diuretics were initiated and she was gently diuresed throughout her post-op course. Chest tubes were removed on post-op day one and she was then transferred to the cardiac surgery step-down unit. Pre-operative medications were started for her Polycythemia and Myelodysplastic Syndrome. Her labs were stable throughout her hospital course with slight increase in her creatinine that came down to baseline at time of discharge. Also, her WBC remained quite elevated throughout hospital course (reaching over 70,000 on POD#2) and eventually coming down to 47,000 at time of discharge. Her epicardial pacing wires were removed on post-op day three. Physical therapy followed her during entire post-op course for strength and mobility. She improved rather well and was at level 5 by post-op day 4. She remained slightly above her pre-op weight and was discharged with diuretics. She was discharged home on post-op day four with VNA services and appropriate follow-up appointments. | 1+ edema in BLE. Mild (1+) MR.TRICUSPID VALVE: Mild [1+] TR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Mild (1+) mitral regurgitationis seen. CXR REPORTED TO SHOW R MAIN BRONCHIAL INTUBATION. IMPRESSION: Trace right apical pneumothorax and bibasilar atelectasis. Normal ascending aorta diameter. The mitral annulus measures 3.1 cm.There is mild tricuspid regurgitation.There is a trivial/physiologic pericardial effusion.Post bypassBiprosthetic valve seen in the aortic position. Lung sounds cta, diminished in bases.Gi/Gu: Tol clear liquids. OP DAY AVR W/CE VALVE REPLACEMENTUPON ADMISSION CCO CALIBRATED. Titrating nitro gtt to keep SBP <120. Lytes WNL. Hypoactive bowel sounds. INDICATION: Pneumothorax. Mild tomoderate (+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. ?change zantac to pre-op PPI. Postoperative study. Normalaortic arch diameter.AORTIC VALVE: Moderately thickened aortic valve leaflets. PERRLA. There is trace Aortic insufficiency. FINDINGS: Nasogastric tube, Swan-Ganz catheter, and endotracheal tube have been removed. 1 PRBC GIVEN. The patient isreceiving a phenylephrine infusion at 0.5mcg/kg/min.LV and RV function is preserved.Aorta appears intact postdecannulation.Mild MR persists post bypass BILATERAL BREATHSOUNDS PRESENT. Additionally, there is trace right apical pneumothorax, a portion of which has collected along the azygos fissure. Mild to moderate (+) aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. IVP mso4 & PO percocet w/good effect.Skin: See carvue for incisions.ID: Afebrile. PATIENT/TEST INFORMATION:Indication: Pt having aortic valve replacement for Severe Aortic StenosisBP (mm Hg): 156/67HR (bpm): 89Status: InpatientDate/Time: at 12:53Test: Portable TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Taught IS, C&DB w/encouragement. There has been interval decrease in size of a right apical pneumothorax with a minimal pneumothorax remaining. Endotracheal tube tip in the right main stem bronchus. Filling pressures slightly low & decreased HUO-fluid bolus MD w/increase in filling pressures & slight increase in HUO. Wean nitro gtt as tol. COMPARISON: Preoperative study of . COMBIVANT GIVEN, LUNGS CLEAR. EXTUBATION TO 4L NC BUT MOUTH BREATHING. The patient is status post sternotomy. IMPRESSION: 1. C/O THIRST. NEO AND NITRO USED TO MAINTAIN SBP WITHIN GOAL. Pulmonary toilet. PLAN TO KEEP SBP 110-120. PT NPO TILL MORINING. SEE MORPHINE ON EPISODE OF FACIAL DIAPHORESIS. The mediastinum is prominent likely related to postoperative change. GOAL TO KEEP SBP 110-120. COMPARISON: . ABDOMEN SOFT NON-DISTENED.URINE OUTPUT ADEQUATE.PT ON STEROIDS PRE-OP. C/O PAIN. MAE x4. BRUISED R UNDERSIDE OF TONGUE NOTED. Pacer @ A-demand. No deficit noted.C/V: NSR 80s. The patient was under general anesthesia throughout theprocedure. Pulmonary edema. SVO2s 60s. Incidental note is made of an azygos lobe. PT APPEARS FLUSHED. The MR iscentral. HUO decreased <30, improved w/fluid bolus, started to decrease again. Cardiac and mediastinal contours are stable. Atrial paced rhythmTher may also be ventricular pacer activity with pseudofusion complexesLeft anterior fascicular blockSince previous tracing of , pacer activity present PLAN TO CONTINUE WITH HOURLY DEEP BREATHING X 10. ?dc swan. PT DENIES USUALLY APPEARING FLUSHED. The endotracheal tube tip is in the right main stem bronchus, extending 2 cm from the carina. NC MOVED TO MOUTH WITH SPO2 UP FROM 89% TO 93%.OGT DRAINED MINIMAL BILIOUS PRIOR TO REMOVAL.BOWEL SOUNDS HYPOACTIVE. APACED/UNDERLYING RHYTHM SR 70S, NO ECTOPICLUNGS I/E WHEEZING FROM OR. ETT PULLED BACK 4CM TO 22CM AT THE LIP. CI >2 by CCO thermo. Bibasilar atelectatic changes are noted with interval improvement in the left lower lobe and no significant change in the right lower lobe. ?tx to F2 if able to wean nitro gtt off. There is severe aorticvalve stenosis. PLAN TO CONTINUE STEROIDS. Pain management. PT DENIES PAIN. I certifyI was present in compliance with HCFA regulations. Neuro: A&Ox3. The NG tube tip is in the stomach. No ASD by 2D or colorDoppler.LEFT VENTRICLE: Normal regional LV systolic function. Creat increased to 1.4-IVP lasix MD .Comfort: Increased mediastinal pain, ?CT. AP CHEST RADIOGRAPH: Interval placement of prosthetic aortic valve with mediastinal clips and sternal wires are seen. There are two mediastinal drains. 12:52 PM CHEST PORT. 2. These findings were discussed with on at 1:20 p.m. Swan-Ganz catheter via the right internal jugular vein is present with its tip in the left main pulmonary artery. SBP increasing on 2.25mcg/kg/min nitro gtt, IVP lopressor & PO lopressor started MD w/good effect. Overall normal LVEF(>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. Overall left ventricularsystolic function is normal (LVEF>55%).The LV is symmetrically hypertrophied (1.5cm).Right ventricular chamber size and free wall motion are normal.The aortic valve leaflets are moderately thickened. ROOM HEAT TURNED DOWN. OOB to chair. Results were personally reviewed with the MD caring for thepatient.Conclusions:Prebypass studyNo atrial septal defect is seen by 2D or color Doppler.Regional left ventricular wall motion is normal. HEMATOLOGY REQUEST HCT AROUND 30. Severe AS. AFEBRILE.NEXT OF "SISTER-IN-LAW " CALLED FOR PHONE REPORT AND SPOKE WITH DR. . On IV cefazolin.Endo: Blood sugars treated per CSRU sliding scale.Social: Sister in law called & updated by RN.A/P: Monitor urine output. Increase diet as tol. Leaflets move well and thevalve appears well seated. The pulmonary vascularity is prominent centrally. Lung volumes are lower than on the prior exam, resulting in crowding of vascular markings at both lung bases. SEE HYDROCORTISONE ORDER.GLUCOSE HAS NOT REQUIRED INSULIN IN CSRU.ORIENTED X 3. Follow up chest radiograph before the patient is discharged is recommended to ensure that this is not increasing in size. 9:47 AM CHEST (SINGLE VIEW) Clip # Reason: assess ptx Admitting Diagnosis: CHF\AORTIC VALVE REPLACEMENT/SDA MEDICAL CONDITION: 63 year old woman s/p AVR REASON FOR THIS EXAMINATION: assess ptx FINAL REPORT PORTABLE CHEST COMPARISON: . | 7 | [
{
"category": "Echo",
"chartdate": "2196-03-14 00:00:00.000",
"description": "Report",
"row_id": 74665,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pt having aortic valve replacement for Severe Aortic Stenosis\nBP (mm Hg): 156/67\nHR (bpm): 89\nStatus: Inpatient\nDate/Time: at 12:53\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\naortic arch diameter.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Severe AS. Mild to\nmoderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. Results were personally reviewed with the MD caring for the\npatient.\n\nConclusions:\nPrebypass study\nNo atrial septal defect is seen by 2D or color Doppler.\n\nRegional left ventricular wall motion is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%).\nThe LV is symmetrically hypertrophied (1.5cm).\n\nRight ventricular chamber size and free wall motion are normal.\n\nThe aortic valve leaflets are moderately thickened. There is severe aortic\nvalve stenosis. Mild to moderate (+) aortic regurgitation is seen.\n\nThe mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation\nis seen. There is no structural deformity in the mitral leaflets. The MR is\ncentral. The mitral annulus measures 3.1 cm.\n\nThere is mild tricuspid regurgitation.\n\nThere is a trivial/physiologic pericardial effusion.\n\nPost bypass\n\nBiprosthetic valve seen in the aortic position. Leaflets move well and the\nvalve appears well seated. There is trace Aortic insufficiency. The patient is\nreceiving a phenylephrine infusion at 0.5mcg/kg/min.\n\nLV and RV function is preserved.\n\nAorta appears intact postdecannulation.\n\nMild MR persists post bypass\n\n\n"
},
{
"category": "ECG",
"chartdate": "2196-03-14 00:00:00.000",
"description": "Report",
"row_id": 166548,
"text": "Atrial paced rhythm\nTher may also be ventricular pacer activity with pseudofusion complexes\nLeft anterior fascicular block\nSince previous tracing of , pacer activity present\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-03-16 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 904554,
"text": " 9:47 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: assess ptx\n Admitting Diagnosis: CHF\\AORTIC VALVE REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p AVR\n REASON FOR THIS EXAMINATION:\n assess ptx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: .\n\n INDICATION: Pneumothorax.\n\n There has been interval decrease in size of a right apical pneumothorax with a\n minimal pneumothorax remaining. Cardiac and mediastinal contours are stable.\n Bibasilar atelectatic changes are noted with interval improvement in the left\n lower lobe and no significant change in the right lower lobe. There is\n otherwise no significant change since the recent radiograph of one day\n earlier.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-03-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 904409,
"text": " 12:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p d/c chest tubesr/o ptx\n Admitting Diagnosis: CHF\\AORTIC VALVE REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p AVR- page # with abnormalities\n\n REASON FOR THIS EXAMINATION:\n s/p d/c chest tubesr/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aortic valve repair, status post chest tube removal.\n\n COMPARISON: .\n\n FINDINGS: Nasogastric tube, Swan-Ganz catheter, and endotracheal tube have\n been removed. The patient is status post sternotomy. Lung volumes are lower\n than on the prior exam, resulting in crowding of vascular markings at both\n lung bases. Additionally, there is trace right apical pneumothorax, a portion\n of which has collected along the azygos fissure.\n\n IMPRESSION: Trace right apical pneumothorax and bibasilar atelectasis. Follow\n up chest radiograph before the patient is discharged is recommended to ensure\n that this is not increasing in size. Findings were called to nurse\n practitioner at 2:40 p.m., .\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-03-14 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 904267,
"text": " 12:52 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film\n Admitting Diagnosis: CHF\\AORTIC VALVE REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p AVR- page # with abnormalities\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Aortic valve replacement. Postoperative study.\n\n COMPARISON: Preoperative study of .\n\n AP CHEST RADIOGRAPH: Interval placement of prosthetic aortic valve with\n mediastinal clips and sternal wires are seen. The endotracheal tube tip is in\n the right main stem bronchus, extending 2 cm from the carina. These findings\n were discussed with on at 1:20 p.m.\n\n Swan-Ganz catheter via the right internal jugular vein is present with its tip\n in the left main pulmonary artery. There are two mediastinal drains. The NG\n tube tip is in the stomach. There is no pneumothorax. Incidental note is\n made of an azygos lobe. The pulmonary vascularity is prominent centrally. The\n mediastinum is prominent likely related to postoperative change.\n\n IMPRESSION:\n 1. Endotracheal tube tip in the right main stem bronchus.\n 2. Pulmonary edema.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2196-03-14 00:00:00.000",
"description": "Report",
"row_id": 1490479,
"text": "OP DAY AVR W/CE VALVE REPLACEMENT\nUPON ADMISSION CCO CALIBRATED. GOAL TO KEEP SBP 110-120. NEO AND NITRO USED TO MAINTAIN SBP WITHIN GOAL. HEMATOLOGY REQUEST HCT AROUND 30. 1 PRBC GIVEN. APACED/UNDERLYING RHYTHM SR 70S, NO ECTOPIC\n\n\nLUNGS I/E WHEEZING FROM OR. CXR REPORTED TO SHOW R MAIN BRONCHIAL INTUBATION. ETT PULLED BACK 4CM TO 22CM AT THE LIP. BILATERAL BREATHSOUNDS PRESENT. COMBIVANT GIVEN, LUNGS CLEAR. EXTUBATION TO 4L NC BUT MOUTH BREATHING. NC MOVED TO MOUTH WITH SPO2 UP FROM 89% TO 93%.\n\nOGT DRAINED MINIMAL BILIOUS PRIOR TO REMOVAL.BOWEL SOUNDS HYPOACTIVE. PT NPO TILL MORINING. C/O THIRST. BRUISED R UNDERSIDE OF TONGUE NOTED. PT DENIES PAIN. ABDOMEN SOFT NON-DISTENED.\n\nURINE OUTPUT ADEQUATE.\n\nPT ON STEROIDS PRE-OP. SEE HYDROCORTISONE ORDER.\n\nGLUCOSE HAS NOT REQUIRED INSULIN IN CSRU.\n\nORIENTED X 3. C/O PAIN. SEE MORPHINE ON EPISODE OF FACIAL DIAPHORESIS. PT APPEARS FLUSHED. ROOM HEAT TURNED DOWN. PT DENIES USUALLY APPEARING FLUSHED. AFEBRILE.\n\nNEXT OF \"SISTER-IN-LAW \" CALLED FOR PHONE REPORT AND SPOKE WITH DR. . PT REPORTS THAT HER HEALTH CARE PROXY IS HER BROTHER WHO LIVES IN . PT LIVES BY HERSELF. PT WILL NEED EVALUATION FOR DISCHARGE TO HOME.\n\nPT BELONGINGS JUST DELIVERED FROM SAME DAY SURGERY. PT DENIES HAVING WALLET, CREDIT CARDS OR JEWELRY IN PERSONAL BELONGINGS.\n\nPLAN TO MONITOR CLOSELY. PLAN TO KEEP SBP 110-120. PLAN TO CONTINUE STEROIDS. PLAN TO CONTINUE WITH HOURLY DEEP BREATHING X 10.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2196-03-15 00:00:00.000",
"description": "Report",
"row_id": 1490480,
"text": "Neuro: A&Ox3. PERRLA. MAE x4. No deficit noted.\n\nC/V: NSR 80s. No ectopy. Lytes WNL. Titrating nitro gtt to keep SBP <120. SBP increasing on 2.25mcg/kg/min nitro gtt, IVP lopressor & PO lopressor started MD w/good effect. SVO2s 60s. CI >2 by CCO thermo. Filling pressures slightly low & decreased HUO-fluid bolus MD w/increase in filling pressures & slight increase in HUO. Pacer @ A-demand. 1+ edema in BLE. CT to SX w/min serosanginous output.\n\nResp: NC increased to 6L, sats >96%. Taught IS, C&DB w/encouragement. Lung sounds cta, diminished in bases.\n\nGi/Gu: Tol clear liquids. Hypoactive bowel sounds. No c/o n/v. HUO decreased <30, improved w/fluid bolus, started to decrease again. Creat increased to 1.4-IVP lasix MD .\n\nComfort: Increased mediastinal pain, ?CT. IVP mso4 & PO percocet w/good effect.\n\nSkin: See carvue for incisions.\nID: Afebrile. On IV cefazolin.\nEndo: Blood sugars treated per CSRU sliding scale.\nSocial: Sister in law called & updated by RN.\n\nA/P: Monitor urine output. Wean nitro gtt as tol. ?dc swan. OOB to chair. Pulmonary toilet. Pain management. Increase diet as tol. ?tx to F2 if able to wean nitro gtt off. ?change zantac to pre-op PPI.\n"
}
] |
82,024 | 136,432 | The patient was admitted to the General Surgical Service for evaluation and treatment on . She was initially admitted to the ICU for hemodynamic monitoring. She was NPO/IVF and started on vanc/cipro/flagyl. She was transfused 1 unit of blood for a HCT of 27.8, which bumped appropriately to 29.8. Troponin was elevated to 0.53 upon admission, so heparin gtt was started but this was discontinued the next day per cardiology recs. BP was low initially in the ICU, with SBP in the 80s, but this responded appropriately to fluid boluses. The patient was transferred to the floor on HD2 and she was hemodynamically stable at that time. The patient was restarted on her beta , , and statin per cardiology and ECHO was performed on HD3, which showed new hypokinesis in the LAD distribution. From a GI perspective, CT scan showed leakage of the colonic stump/abscess and she was initially started on vanc, cipro, and flagyl, and the vanc was ultimately discontinued. Her diet was advanced to clears HD3 and subsequently to regular diet on HD 4, which the patient tolerated well without increase in abdominal pain. Her urine output was approx 20cc/hr, but she did require intermittent 250cc boluses to keep her Uop up. Foley was discontinued on HD4 and patient voided on her own. The patient was initially scheduled to go to rehab on , but cardiology re-assessed the patient and decided that cardiac catheterization might be necessary given new changes to ECHO and the elevated troponins. The patient was taken to the cath lab on , however after further discussion with patient and family, cardiology felt the bump in troponins was more likely from previous hypovolemia and not acute plaque rupture, so the cath was deferred. At the time, however, patient was clinically overloaded, with stable pressures, and so she recieved 10mg IV lasix twice, with good response. . At the time of discharge on HD6, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.She will continue with 10 more days of cipro and flagyl for her intraabdominal collection. | There is a trivial/physiologic pericardialeffusion.IMPRESSION: Moderate regional left ventricular systolic dysfunction, c/w CAD.Dilated right ventricle with normal systolic function. Mild (1+) aortic regurgitation is seen. Moderate mitral annularcalcification. Moderate mitral and tricuspidregurgitation. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) mitral regurgitation is seen.Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonaryartery systolic hypertension. The right ventricular cavity is mildly dilatedwith normal free wall contractility. Left ventricular wall thicknesses and cavity size are normal.There is moderate regional left ventricular systolic dysfunction with mid- todistal anterior and septal hypokinesis, c/w LAD disease. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.Conclusions:The left atrium is mildly dilated. Moderate (2+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. ModeratePA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. TASPEnormal (>=1.6cm)AORTA: Normal aortic diameter at the sinus level. Moderate pulmonary hypertension. Tricuspid annular plane systolicexcursion is normal (2.9 cm) consistent with normal right ventricular systolicfunction. Moderately thickened aortic valveleaflets. Calcific aortic valvedisease with mild stenosis/mild regurgitation. Moderate regional LVsystolic dysfunction. The ascending aorta is mildly dilated. Premature ventricular contractions.Low QRS voltage in the precordial leads. Normal RV systolic function. Non-specific T wave changes.Compared to the previous tracing of a ventricular premature beat isnew. Mild AS (area 1.2-1.9cm2). Moderate [2+] TR. Myocardial infarction.Height: (in) 60Weight (lb): 113BSA (m2): 1.47 m2BP (mm Hg): 102/48HR (bpm): 61Status: InpatientDate/Time: at 11:04Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Lowvoltage in the precordial leads. Sinus rhythm with atrial premature beats. Low QRS voltages in the limb leads. There is significant focal thickening and immobilization of theright coronary cusp of the aortic valve, resulting in mild stenosis (valvearea 1.2-1.9cm2). There areassociated T wave inversions in the same leads. Left ventricular function. Sinus rhythm. Sinus rhythm. Sinus rhythm. Mildly dilated ascendingaorta.AORTIC VALVE: Three aortic valve leaflets. Non-specific ST-T wave changes. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -hypo; mid anteroseptal - hypo; anterior apex - hypo; septal apex - hypo;inferior apex - hypo; apex - hypo;RIGHT VENTRICLE: Mildly dilated RV cavity. No ASD by 2D or colorDoppler.LEFT VENTRICLE: Normal LV wall thickness and cavity size. Right bundle-branch block. Right bundle-branch block. Right bundle-branch block. The mitral valveleaflets are mildly thickened. Inferolateral T wave changeswhich are non-specific. Compared to the previous tracing of ST segment elevation is no longer identified and QRS voltage is less in theanterior leads. Slight ST segment elevation inleads I, II, aVL and V2-V6 suspicious for myocardial ischemia. The T waves are now upright in lead V2. Compared to theprevious tracing of there is no significant diagnostic change. Coronary artery disease. No LV mass/thrombus. There are three aortic valveleaflets. PATIENT/TEST INFORMATION:Indication: Aortic valve disease. No atrial septal defect is seen by 2D orcolor Doppler. Compared to the previous tracing of thereare suggestions of ongoing myocardial ischemia in the distribution of the LAD.Clinical correlation and repeat tracing are strongly suggested. Criteria are met for rightbundle-branch block as well. | 5 | [
{
"category": "Echo",
"chartdate": "2160-12-23 00:00:00.000",
"description": "Report",
"row_id": 68054,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Coronary artery disease. Left ventricular function. Myocardial infarction.\nHeight: (in) 60\nWeight (lb): 113\nBSA (m2): 1.47 m2\nBP (mm Hg): 102/48\nHR (bpm): 61\nStatus: Inpatient\nDate/Time: at 11:04\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderate regional LV\nsystolic dysfunction. No LV mass/thrombus. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nhypo; mid anteroseptal - hypo; anterior apex - hypo; septal apex - hypo;\ninferior apex - hypo; apex - hypo;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. TASPE\nnormal (>=1.6cm)\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Mild AS (area 1.2-1.9cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thicknesses and cavity size are normal.\nThere is moderate regional left ventricular systolic dysfunction with mid- to\ndistal anterior and septal hypokinesis, c/w LAD disease. No masses or thrombi\nare seen in the left ventricle. The right ventricular cavity is mildly dilated\nwith normal free wall contractility. Tricuspid annular plane systolic\nexcursion is normal (2.9 cm) consistent with normal right ventricular systolic\nfunction. The ascending aorta is mildly dilated. There are three aortic valve\nleaflets. There is significant focal thickening and immobilization of the\nright coronary cusp of the aortic valve, resulting in mild stenosis (valve\narea 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen.\nModerate [2+] tricuspid regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension. There is a trivial/physiologic pericardial\neffusion.\n\nIMPRESSION: Moderate regional left ventricular systolic dysfunction, c/w CAD.\nDilated right ventricle with normal systolic function. Calcific aortic valve\ndisease with mild stenosis/mild regurgitation. Moderate mitral and tricuspid\nregurgitation. Moderate pulmonary hypertension.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2160-12-25 00:00:00.000",
"description": "Report",
"row_id": 149751,
"text": "Sinus rhythm. Right bundle-branch block. Inferolateral T wave changes\nwhich are non-specific. Low QRS voltages in the limb leads. Compared to the\nprevious tracing of there is no significant diagnostic change.\n\n"
},
{
"category": "ECG",
"chartdate": "2160-12-23 00:00:00.000",
"description": "Report",
"row_id": 149752,
"text": "Sinus rhythm. Right bundle-branch block. Non-specific ST-T wave changes. Low\nvoltage in the precordial leads. Compared to the previous tracing of \nST segment elevation is no longer identified and QRS voltage is less in the\nanterior leads.\n\n"
},
{
"category": "ECG",
"chartdate": "2160-12-22 00:00:00.000",
"description": "Report",
"row_id": 149753,
"text": "Sinus rhythm with atrial premature beats. Slight ST segment elevation in\nleads I, II, aVL and V2-V6 suspicious for myocardial ischemia. There are\nassociated T wave inversions in the same leads. Criteria are met for right\nbundle-branch block as well. Compared to the previous tracing of there\nare suggestions of ongoing myocardial ischemia in the distribution of the LAD.\nClinical correlation and repeat tracing are strongly suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2160-12-21 00:00:00.000",
"description": "Report",
"row_id": 149754,
"text": "Sinus rhythm. Right bundle-branch block. Premature ventricular contractions.\nLow QRS voltage in the precordial leads. Non-specific T wave changes.\nCompared to the previous tracing of a ventricular premature beat is\nnew. The T waves are now upright in lead V2.\n\n"
}
] |
28,300 | 110,122 | She was seen by neurology preoperatively to assess stroke risk. She awaited several days off of plavix prior to be taken to the operating room on where she underwent a CABG x 3. She was transferred to the ICU in critical but stable condition on neosynephrine, propofol and insulin. She was extubated later that same day. She was transferred to the floor on POD #1. On POD #2, she vomited, KUB showed no obstruction and LFTs were normal. Her vomiting rosolved with IV protonix. She did well postoperatively and was ready for discharge home on POD #4. | There are simpleatheroma in the descending thoracic aorta. Normal aortic arch diameter. Normal regional LV systolic function. FINDINGS: In the right internal capsule, again identified is an area of encephalomalacia and decreased density consistent with remote infarct. Trace aorticregurgitation is seen. No AS.Trace AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. Normal LV inflowpattern for age.TRICUSPID VALVE: Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. The mitral valve appears structurally normal withtrivial mitral regurgitation. Normal ascending aortadiameter.AORTIC VALVE: Normal aortic valve leaflets. Two mediastinal drains and a left chest tube are seen in unchanged position. There has been interval removal of an endotracheal tube. TECHNIQUE: Non-contrast head CT. Left-sided chest tube and two mediastinal tubes are in place. IMPRESSION: Chest and mediastinal tubes removed, no pneumothorax. IMPRESSION: Changes consistent with an area of remote infarct in the right internal capsule. Otherwise, essentially unchanged radiographic chest. Left ventricular function. Mild degenerative spurring of the thoracic spine is noted. The patientappears to be in sinus rhythm.Conclusions:The left atrium is normal in size. ?# aortic valve leaflets. Otherwise, normal ECG. PATIENT/TEST INFORMATION:Indication: Coronary artery diseaseHeight: (in) 56Weight (lb): 175BSA (m2): 1.68 m2BP (mm Hg): 110/50HR (bpm): 62Status: InpatientDate/Time: at 17:17Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size. HCT stable. F/U CT DRAINAGE. Heart size is borderline, with a left ventricular configuration. REASON FOR THIS EXAMINATION: r/o PTX/Effusion. There is no pericardial effusion.PostBypass:Normal biventricular systolic function. CXR DONE. RECIEVED PT S/P CX3. Compared to previoustracing of no diagnostic change. The patientappears to be in sinus rhythm. Denies nauseaGU: Foley patent. Adequate pulse oximetry values maintained on 2 lpm N.C. The mitral valve appears structurally normal with trivial mitralregurgitation. NEED EKG. There has been interval placement of a left subclavian PICC line with its radiodense guidewire tip projecting over the right atrium. Dopplerable pedal pulse rt foot, palp on lt. Cuff and aline correlate. No restingLVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Simpleatheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Preoperative assessment.Height: (in) 56Weight (lb): 175BSA (m2): 1.68 m2BP (mm Hg): 118/62HR (bpm): 45Status: InpatientDate/Time: at 16:40Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: DefinityTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the report of the prior study (images notavailable) of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%). On the right, the peak systolic velocities are 48/20 in the proximal ICA, 71/31 in the mid ICA, and 87/41 in the distal ICA. Chest tubes dry. Compared to the previous tracingof no diagnostic interim change.TRACING #1 FINAL REPORT INDICATION: Status post CABG. Titrated per protocol. Widening of the mediastinum is likely postoperative as patient is status post median sternotomy and CABG. CHEST ONE VIEW: Lung volumes are low. No spontaneous echo contrast or thrombus in theLA/LAA or the RA/RAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolicfunction (LVEF>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending aorta diameter. LINE PLACEMENT Clip # Reason: r/o PTX/Effusion. IMPRESSION: Interval placement of a left subclavian PICC line with its radiodense guidewire tip projecting over the right atrium; recommend withdrawal by 4 cm. OGT TO LCSXN. Low precordial lead voltage. Low precordial lead voltage. CT NO DRAINAGE-TEAM ROUND AWARED. Sinus rhythm without diagnostic abnormality. REspiratory CarePt extubated earlier in shift without incident. Sinus rhythm. ARRIVED SEDATED ON PROPOFOL. Pt placed on nasal cannula. Reglan given this am. The aortic valve leaflets (3) aremildly thickened but aortic stenosis is not present. There is mild age- inappropriate prominence of the frontal sulci. 2:36 PM ABDOMEN (SUPINE & ERECT) Clip # Reason: Boswle distension? CHEST The tip of the PICC line is unchanged in position since the prior chest x-ray and lies in the right atrium. On the left, the peak systolic velocities are 75/30 in the proximal ICA, 70/24 in the mid ICA, 72/26 in the distal ICA. HYPOTHERMIC->WARM BLANKET APPLIEDA/P: CON'T MONITOR- REVERSAL AND FAST TRACK WEANING PER PROTOCOL. Deline this am if appropriate per team, after femoral aline dc, OOB. TRAUMA LINE AND R FEM ARTERIAL LINE.LS CTA. On B-mode imaging, there is only minimal plaque in the distal CCA and proximal ICA. Regional left ventricular wall motion is normal. COMPARISON: CXR, . The visualized paranasal sinuses and mastoid air cells are well aerated. Lung sounds clear. There is ex vacuo dilatation of the adjacent frontal of the right lateral ventricle. Restart plavix in am. Lungs diminished at bases bilaterally. IMPRESSION: Unremarkable abdomen. Toradol given per Dr. and changed to dilaudid with good response. Right ventricularchamber size and free wall motion are normal. The right greater saphenous vein measures the following in diameter beginning at the saphenofemoral junction extending distally in cm: 0.61, 0.42, 0.41, 0.55, 0.35, 0.39, 0.24 and 0.16. | 18 | [
{
"category": "Radiology",
"chartdate": "2177-08-11 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 970834,
"text": " 7:21 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: pre-op CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with CAD, pre-op CABG this admission.\n REASON FOR THIS EXAMINATION:\n pre-op CABG\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CAD, preop CABG.\n\n CHEST, TWO VIEWS.\n\n Heart size is borderline, with a left ventricular configuration. There is no\n CHF, focal infiltrate or effusion. Mild degenerative spurring of the thoracic\n spine is noted.\n\n Please see the chest CT report from , which describes a 3 mm right\n middle lobe nodule and left upper lobe calcification -- these are not\n visualized on today's study due to the technical limitations of radiographs\n as opposed to CT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-08-16 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 971596,
"text": " 2:36 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: Boswle distension?\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with abdominal tenderness, vomiting\n REASON FOR THIS EXAMINATION:\n Boswle distension?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Abdominal tenderness and vomiting.\n\n Four views. The bowel gas pattern is unremarkable. No free air is\n identified. Soft tissue shadows are not well demonstrated. No significant\n intra-abdominal calcifications are seen. Surgical clips overlie the left hip\n and proximal left thigh. A vascular stent is present in the left upper\n quadrant.\n\n IMPRESSION: Unremarkable abdomen. CT is recommended if further evaluation is\n required.\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-08-11 00:00:00.000",
"description": "PR VENOUS DUP EXT UNI (MAP/DVT) PORT RIGHT",
"row_id": 970804,
"text": " 3:09 PM\n VENOUS DUP EXT UNI (MAP/DVT) PORT RIGHT Clip # \n Reason: Evaluate B GSV. preop for CABGKnown hx of PVD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with CAD, preop CABG\n REASON FOR THIS EXAMINATION:\n Evaluate B GSV. preop for CABGKnown hx of PVD\n ______________________________________________________________________________\n FINAL REPORT\n VEIN MAPPING:\n\n REASON: 52-year-old woman with CAD. Preop for CABG.\n\n FINDINGS: Venous duplex evaluation was performed on the right lower extremity\n venous system greater saphenous vein for the purpose of obtain diameters for\n vein mapping.\n\n The right greater saphenous vein measures the following in diameter beginning\n at the saphenofemoral junction extending distally in cm: 0.61, 0.42, 0.41,\n 0.55, 0.35, 0.39, 0.24 and 0.16.\n\n FINDINGS: The right greater saphenous vein is widely patent throughout its\n length with the above-mentioned diameters.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-08-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 971470,
"text": " 11:54 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p ct d/c\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p picc line placement\n\n REASON FOR THIS EXAMINATION:\n s/p ct d/c\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: PICC line placed, left chest tube pulled.\n\n CHEST\n\n The tip of the PICC line is unchanged in position since the prior chest x-ray\n and lies in the right atrium.\n\n Left chest tube has been removed and there is no evidence of pneumothorax.\n Atelectasis in the left lower lobe is again noted.\n\n The mediastinal tubes have also been discontinued. The right lung remains\n clear.\n\n IMPRESSION: Chest and mediastinal tubes removed, no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-08-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 971446,
"text": " 9:21 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 44cm left basilic vein\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p picc line placement\n REASON FOR THIS EXAMINATION:\n 44cm left basilic vein\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post PICC line placement.\n\n COMPARISON: .\n\n CHEST ONE VIEW: Lung volumes are low. There has been interval placement of a\n left subclavian PICC line with its radiodense guidewire tip projecting over\n the right atrium. Two mediastinal drains and a left chest tube are seen in\n unchanged position. There has been interval removal of an endotracheal tube.\n A right internal jugular catheter is again seen with its tip projecting\n outside the chest over the superior edge of the right clavicle. There is\n persistent post-operative widening of the mediastinum. Within the limitation\n of low lung volumes no focal consolidation or pneumothorax is seen.\n\n IMPRESSION: Interval placement of a left subclavian PICC line with its\n radiodense guidewire tip projecting over the right atrium; recommend\n withdrawal by 4 cm. Otherwise, essentially unchanged radiographic chest.\n\n These results were communicated to the IV access team at 11a by\n Dr for Dr .\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-08-12 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 970906,
"text": " 8:54 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: Evaluate for carotid stenosis; Pt has known PVD and LM disea\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with CAD, preop CABG\n REASON FOR THIS EXAMINATION:\n Evaluate for carotid stenosis; Pt has known PVD and LM disease on cath\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID DUPLEX\n\n REASON: 52-year-old woman with CAD. Pre-op CABG, evaluate for carotid\n stenosis.\n\n FINDINGS: Duplex evaluation was performed on the bilateral carotid arteries.\n On B-mode imaging, there is only minimal plaque in the distal CCA and proximal\n ICA.\n\n On the right, the peak systolic velocities are 48/20 in the proximal ICA,\n 71/31 in the mid ICA, and 87/41 in the distal ICA. There is a velocity of\n 57/18 in the CCA and 103 in the ECA. The ICA/CCA ratio is 1.5 and this is\n consistent with a less than 40% right ICA stenosis.\n\n On the left, the peak systolic velocities are 75/30 in the proximal ICA, 70/24\n in the mid ICA, 72/26 in the distal ICA. There is a velocity of 76/34 in the\n CCA and 110 in the ECA. The ICA/CCA ratio is 0.98 and this is consistent with\n a less than 40% left ICA stenosis.\n\n There is antegrade flow in both vertebral arteries.\n\n IMPRESSION: There is a less than 40% right ICA stenosis and a less than 40%\n left ICA stenosis with antegrade flow in both vertebral arteries\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-08-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 971174,
"text": " 8:17 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: baseline assessment prior to CABG \n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with DM, HTN, PAD, CAD, prior CVA x2 ' (last head CT was\n '). Neurology consult requests non-contrast head CT prior to CABG to\n delineate anomalies.\n REASON FOR THIS EXAMINATION:\n baseline assessment prior to CABG \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old with diabetes, hypertension, coronary artery and\n peripheral vascular disease. Baseline assessment prior to CABG.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: In the right internal capsule, again identified is an area of\n encephalomalacia and decreased density consistent with remote infarct. There\n is ex vacuo dilatation of the adjacent frontal of the right lateral\n ventricle. No intra- or extra-axial hemorrhage, shift of normally midline\n structures, mass effect or hydrocephalus is identified. There is mild age-\n inappropriate prominence of the frontal sulci. The basal cisterns are not\n effaced. The visualized paranasal sinuses and mastoid air cells are well\n aerated.\n\n IMPRESSION: Changes consistent with an area of remote infarct in the right\n internal capsule. No acute vascular infarct or intracranial hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-08-14 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 971353,
"text": " 6:09 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX/Effusion.\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with CAD s/p CABG. Please page at with\n abnormalities.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG.\n\n COMPARISON: CXR, .\n\n PORTABLE CHEST: An endotracheal tube terminates approximately 33 mm above the\n carina. The nasogastric tube courses below the diaphragm with its proximal\n side port beyond the gastroesophageal junction, but its tip projecting below\n the edge of the film. Left-sided chest tube and two mediastinal tubes are in\n place. The tip of a right sided internal jugular catheter projects over the\n right brachiocephalic vein.\n Widening of the mediastinum is likely postoperative as patient is status post\n median sternotomy and CABG. There is no evidence of pneumothorax or sizable\n effusion. Lung volumes are low, which limits evaluation of lung parenchyma,\n however, no focal consolidation is identified.\n\n IMPRESSION: Satisfactory placement of multiple lines and tubes status post\n CABG.\n\n"
},
{
"category": "Echo",
"chartdate": "2177-08-14 00:00:00.000",
"description": "Report",
"row_id": 70001,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease\nHeight: (in) 56\nWeight (lb): 175\nBSA (m2): 1.68 m2\nBP (mm Hg): 110/50\nHR (bpm): 62\nStatus: Inpatient\nDate/Time: at 17:17\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter. Normal aortic arch diameter. Simple\natheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The TEE probe was passed\nwith assistance from the anesthesioology staff using a laryngoscope. The\npatient was under general anesthesia throughout the procedure. The patient\nappears to be in sinus rhythm. Results were personally reviewed with the MD\ncaring for the patient.\n\nConclusions:\nPRE-BYPASS:\nThe left atrium is normal in size. No spontaneous echo contrast or thrombus is\nseen in the body of the left atrium/left atrial appendage or the body of the\nright atrium/right atrial appendage. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and systolic function (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. There are simple\natheroma in the descending thoracic aorta. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. No aortic regurgitation\nis seen. The mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no pericardial effusion.\n\nPost_Bypass:\nNormal biventricular systolic function. LVEF 55%\nTrivial MR, TR.\nAortic contour is intact.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2177-08-12 00:00:00.000",
"description": "Report",
"row_id": 70041,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Preoperative assessment.\nHeight: (in) 56\nWeight (lb): 175\nBSA (m2): 1.68 m2\nBP (mm Hg): 118/62\nHR (bpm): 45\nStatus: Inpatient\nDate/Time: at 16:40\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Definity\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). Normal regional LV systolic function. No resting\nLVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets. ?# aortic valve leaflets. No AS.\nTrace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Normal LV inflow\npattern for age.\n\nTRICUSPID VALVE: Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. The patient\nappears to be in sinus rhythm.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets appear\nstructurally normal with good leaflet excursion. The number of aortic valve\nleaflets cannot be determined. There is no aortic valve stenosis. Trace aortic\nregurgitation is seen. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. The pulmonary artery systolic pressure could not\nbe determined. There is an anterior space which most likely represents a fat\npad.\n\nCompared with the report of the prior study (images unavailable for review) of\n, left ventricular wall thickness has increased. Otherwise, the\nfindings are similar.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-15 00:00:00.000",
"description": "Report",
"row_id": 1631876,
"text": "Neuro: Pt reversed and woken easily. PERRLA. Follows commands. MAE. Post extubation pt had pain issues of lt shoulder pain due to chest tubes and incisional pain with movement and coughing. Poor response to morphine. Toradol given per Dr. and changed to dilaudid with good response. Pt sleeping of and on overnight. Pt oriented x3.\nCV: Initially HR 70's to 80's, post extubation pt tachy 100-110 nsr. IVF given with no response to HR. CVP 12-17. Pt given lopressor 2.5 mg iv at 0500 HR<100. pt had been on neo/ntg overnight, now off. Chest tubes dry. No leak. HCT stable. Dopplerable pedal pulse rt foot, palp on lt. Cuff and aline correlate. See flowsheet for blood pressure trend. To restart plavix for CVA history this am.\nRESP: Pt initially orally intubated. Once pt awake , vent weaned and pt extubated without difficulty. Pt placed on nasal cannula. On 2L nc sats>97%. On RA 92-95%. Pt feels better with O2 on while in bed. Lungs diminished at bases bilaterally. IS to 500.\nGI: OGT discontinued with extubation. Abd soft, nontender. No BS. Reglan given this am. Pt tolerating ice chips. Denies nausea\nGU: Foley patent. UOP initially good, then dropped to <30cc/hr. Pt given additional LR 1L with good response, tapering off again. Will continue to assess\nEndo: remained on insulin gtt overnight. Titrated per protocol. See flowsheet\nSocial: No family contact. Pt states she lives with her significant other whom she like to be her spokesperson.\nPlan: Cont assess cardio/resp status. Deline this am if appropriate per team, after femoral aline dc, OOB. Wean o2 and advance activity and diet as tolerated. Restart plavix in am. Follow UOP. Continue hourly blood sugars while on insulin gtt. ? transfer to F2 if appropriate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-14 00:00:00.000",
"description": "Report",
"row_id": 1631873,
"text": "pt recieved from OR without incidence, plan is to wean through evening as tollerated towards extubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-14 00:00:00.000",
"description": "Report",
"row_id": 1631874,
"text": "RECIEVED PT S/P CX3. ARRIVED SEDATED ON PROPOFOL. PERRL 3MM. APACED AND NEO TO BP KEEP SBP>90/MAP>60. INSULIN GTT. CVP 13-14. NO SWAN. CT NO DRAINAGE-TEAM ROUND AWARED. CONNECTED TO VENT SIMV 100/500X14/5. TRAUMA LINE AND R FEM ARTERIAL LINE.\nLS CTA. CXR DONE. OGT TO LCSXN. BELLY SOFT. HYPOTHERMIC->WARM BLANKET APPLIED\n\nA/P: CON'T MONITOR- REVERSAL AND FAST TRACK WEANING PER PROTOCOL. NEED EKG. F/U CT DRAINAGE. NO FAMILY CALL OR VISIT YET\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-15 00:00:00.000",
"description": "Report",
"row_id": 1631875,
"text": "REspiratory Care\nPt extubated earlier in shift without incident. Airway assessed for positve signs of cuff leak, cough and gag prior to extubation. Adequate pulse oximetry values maintained on 2 lpm N.C. Lung sounds clear.\n"
},
{
"category": "ECG",
"chartdate": "2177-08-15 00:00:00.000",
"description": "Report",
"row_id": 153321,
"text": "Sinus tachycardia with increase in rate compared to the previous tracing\nof . Low precordial lead voltage. Otherwise, no diagnostic interim\nchange.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2177-08-14 00:00:00.000",
"description": "Report",
"row_id": 153322,
"text": "Sinus rhythm. Low precordial lead voltage. Compared to the previous tracing\nof no diagnostic interim change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2177-08-14 00:00:00.000",
"description": "Report",
"row_id": 153323,
"text": "Sinus bradycardia. Otherwise, normal ECG. Compared to prior tracing\nof no significant change is seen.\n\n"
},
{
"category": "ECG",
"chartdate": "2177-08-11 00:00:00.000",
"description": "Report",
"row_id": 153324,
"text": "Sinus rhythm without diagnostic abnormality. Compared to previous\ntracing of no diagnostic change.\n\n"
}
] |
27,661 | 108,415 | 79 yo male s/p with multiple medical problems, s/p trach placement in , vent-dependent, who was recently discharged from after being treated for pneumonia, admitted for persistent fevers and increased lethargy, being treated for VAP, now with intermittently decreasing HCT and severe AS. . Preoperatively, Balancing blood pressure with volume overload was challenging, as diuresis limited by hypotension. Hypotension improved with decreased PEEP. It was felt that his volume overload and hypotension were most likely secondary to his atrial fibrillation and severe aortic stenosis. Cardiac surgery was consulted who felt that valve replacement had only approximately a 30% chance of success but agreed to perform the procedure. Prior to surgery he was placed on a lasix drip to attempt to remove some volume with modest success. He was transferred to the CCU prior to valve replacement. His platelet count dropped and he had a negative HIT/SRA. Patient with slow GI bleed throughout this hospitalization with black tarry stool. He had evidence of gastritis and duodenotis on EGD on without evidence of active bleeding. He had multiple blood transfusions. He underwent colonoscopy on which showed evidence of diverticulosis but no evidence of active bleeding. His trach was changed 3x secondary to persistent leak, tracheomalacia extending to both mainstem bronc's noted, currently with 8.0 . He had evidence of a resistant pseudomonal VAP sensitive to imipenim and cefepime from culture results from and . Treated with imipenem and then cefepime for total of 14d pseudomonal coverage. Also treated MRSA given sensitivities of sputum culture from OSH (Was on bactrim , vanc ). His sputum has continued to grow the same pansensitive organism as previously, likely colonization. On he was taken tot he operating room where he underwent AVR with 21mm biocor valve. He was transferred to the ICU in critical but stable condition. He was transfused several times. His #8 trach was replaced on . His vasoactive drips were weaned to off by POD #4. Aggressive diuresis continued. Over the next week he continued to be diuresed and his betablockers were restarted. Post operatively the patient was seen by the GI service as he had intermittant guiac positive stool but no melana or bleeding, he was transfused w/PRBC's and PPI was changed to dosing. He was scoped from above and below just before surgery, at that time he was found to have diverticulosis and mild gastritis. By POD13 it was felt the patient was stable and ready for discharge to Center. | PORTABLE AP VIEW OF THE CHEST There has been interval central clearing of the diffuse infiltrative abnormality in the right lung field. Increased bilateral pleural effusions, bibasilar consolidation, mild-to-moderate congestive failure. Mild volume loss in the right hemithorax is also unchanged as well as bilateral small pleural effusions, right greater than left. IMPRESSION: Some improvement in right-sided pulmonary edema. FINDINGS: A right IJ Swan-Ganz catheter is present. IMPRESSION: Occlusive thrombus within the more superficial right brachial vein. Widespread heterogeneous combined alveolar and interstitial opacities are again demonstrated bilaterally, with some interval clearing within the left lung, but no substantial change within the right lung. FINDINGS: -scale and Doppler son of the right jugular, subclavian, axillary, brachial, basilic, and cephalic veins were obtained. Lung volumes remain low with unchanged bilateral pleural effusions (left greater than right) and diffuse parenchymal opacities. Right PIC catheter terminates in unchanged position in the proximal SVC. There has been interval removal of the right internal jugular Swan-Ganz catheter. CHEST, SINGLE AP PORTABLE VIEW: There is rotated positioning and low inspiratory volumes. The bilateral pulmonary edema is of unchanged stability. Since the prior radiograph of , mild-to-moderate pulmonary edema has developed, superimposed on the diffuse interstitial disease. The cardiac silhouette is grossly enlarged but stable. The cardiac silhouette remains grossly enlarged, though stable. IMPRESSION: Probable, overall slight worsening of pulmonary edema and right lower lobe consolidation. Bilateral small pleural effusions (left greater than right) and diffuse parenchymal opacity. Stable diffuse interstitial disease. SYSTOLIC BP LABILE. extrem w/d. Resp. Resp Care,Pt. care note - Pt. TRACHE CARE DONE, INNER CANNULA CHANGED.CO2 57. PALP PP. sternal, mediastinal incisions cdi.Resp: ls course, bases dim. Bs with scattered rhonchi. PVC'S NOTED. BS+GU: FOLEY IN PLACE. +pp. CO2 57.P: MONITOR COMFORT, HR AND RHTYHYM-? WITH TRACH. PT. PT. PT. Wean as Afebrile. AFEBRILE. AFEBRILE. AT THIS POINT PT. HYPOTENSIVE TO 75/39. TOLERATING WELL. PERL. WEAN VENT AS TOLERATED. REHAB: ? occas. Will wean as tolerated. +bs. abd soft, nt, nd. continue with current plan of care. LASIX GTT OFF. Otherwise on full vent support. CONTINUES IN AF. COMPLETE DISCHARGE SUMMARY. REMAINS WITH TOTAL BODY ANASARCA. REPLETE LYTES AS NEEDED. RESP: VENT SETTINGS AND ABG PER FLOW. RESP CARE: Pt remains /on vent,cuff pressure 28cmH20. cont imipenem and vanc.GI: +BS, abd soft dist. creat down to 1.3.endo: stim test done. lowgrade temp, 99.4. adequate uo, moderate diuresis after earlier lasix. PT IS DILT WELL, DIURESE. restart TF ?Lasix gtt T q2, sxn prn IV abx as ordered pt has had hx of hematuria. (REMAIN SON LASIX GTT)ACCESS: R AC PICCPLAN: PT. 3 rd admit to since with prob VAP. A -line placed and pt has been normotensive since its insertion. HAS BEEN NPO FOR COLONOSCOPY THIS AM. 79 yr old pt with pseudomonas PNA, s/p mva and and pegged since . poss trach change and poss endoscopy in am. Trach care done, sm amt bldy dng. endoscopy for cont GI bldg. BS with occ rhonchi. SKIN WDI- PULSES PALPABLE.RESP: PT. 4+ PITTING/WEEPING EDEMA REMAINS PRESENT. Resp Care,Pt. Moves extrem only slightly, heavy c edema. MRSA in sputum.GI: +BS, abd obese, distended. progress note:neuro: pt nodding appropriatly after much encouragment. LL ecchymotic. LUNGS CLEAR IN RUL, COURSE IN LUL, DIMINISHED IN BASES. HR 84-97, freq pvcs. On vanco and imipenem. Resp CarePt remians with #8.0 TTS H2O cuff on a/c. FS ~ 120.Gi: Abd obese, soft distended, +BS. SEE CAREVUE FOR COAG'S. CT MD IN TO SEE PT. Pt has had small reoccurring cuff leak, pt exhaling during inspiration and has been tachypnnic. SBP stable 99-132, on dilt 30mg q6hrs. FALLING HCT.P--TX 1 U PRBC. Sats cont 97 or > remainder of noc. Replete lytes prn. HR 90-110 a-fib w/PVC's noted. Pt fld balance + 3.8L los.Endo: Receiving humalog for SSI, FS 228, and glargine.ID: Tmax 100 ax. HCT DOWN TO RECEIVE 1U PRBC.RESP--SX Q2 HRS FOR THICK TAN SPUTUM. rehab in am. Remains in a-fib, but off coumadin d/t drop in hct to 19.9.Neuro: Alert, awake, follows simple commands. Bilat lower legs ecchymotic, L>R. On miripenim and bactrim. Resp CarePt transfer from OSH. ABD DISTENDED. REMAINS WITH CUFF LEAK. High Hco3 and Paco2 in abgs. ABG reveals compensated resp acidosis. ABG WNL, but maintained by large minute ventilation. On a/c minute volume being maintained in th 9-10L range. placed on vent ( see carvue for settings) Pt has a # 7 shiley trach. spec sent.GI - Abd soft - hypoactive BS. + pitting edema remains in extremities despite diuresis. tmax 99.3. generalized +3 edema. LS clear and diminished w/ some upper airway congestion noted prior to suctioning.CV: HR 85-95 afib w/ occ. EXTREMS W/D. Right picc line with tip in SVC. AFEBRILE.NEURO: WITHDRAWN. NO SSI REQUIRED.ID: PEG DRSG -PURELENT DRAINAGE NOTED-SENT FOR CX. REMAINS IN AF WITH GOOD RATE CONTROL WITH DILT. RESP CARE: Pt remains /on vent on PSV 10/5/.40. foley output 60-200cc/hr clear yellow.GI/Endo: abd firm/distended. PLAN TO D/C TO REHAB . AfebrileCV: Stable. REVIEW OF SYSTEMS:RESP: BRIEF CHANGE OVER TO PS THIS AM-POOR TOLERANCE. ABD SOFT, NT, ND. STILL 4+ EDEMATOUS.CV: BP FAIRLY WELL CONTROLLED X FOR BRIEF DROP. TRACHE CARE DONE BY RT. Mild (1+) mitral regurgitation is seen. Mild(1+) aortic regurgitation is seen. Mild mitralannular calcification. Mild mitralannular calcification. There is moderate symmetric left ventricularhypertrophy. LS clear to coarse upper, diminished @bases w/occasional wheeze.GI/Endo: Firm distended abd w/+BS. There is mild symmetric left ventricularhypertrophy. BS diminished and coarse bilaterally which clears with suctioning. Focal calcifications in aortic root.Normal ascending aorta diameter. There are simpleatheroma in the descending thoracic aorta. Normal RVsystolic function.AORTA: Mildly dilated aortic sinus. Mild [1+]TR. Mild [1+] TR. Trivialmitral regurgitation is seen. Mild (1+) AR.MITRAL VALVE: Moderately thickened mitral valve leaflets. Normal tricuspid valvesupporting structures. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild (1+) MR.TRICUSPID VALVE: Physiologic TR.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. | 143 | [
{
"category": "Radiology",
"chartdate": "2129-08-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 977189,
"text": " 7:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate catheter placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and elevated PA pressures. w/ swan\n\n REASON FOR THIS EXAMINATION:\n please evaluate catheter placement\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Portable film of the chest on at 0802 hours. No change\n since previous films. Tracheotomy tube is in good position. The pulmonary\n artery line introduced via the right jugular route extends into the right main\n pulmonary artery. There appears to be small effusions and the previously\n demonstrated diffuse pulmonary parenchymal disease.\n\n CONCLUSION: No change or superimposed acute process when compared to previous\n studies.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-07-29 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 976426,
"text": " 3:21 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval for evidenec of pneumothorax and evaluate line p\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach, AS s/p PA line placement\n REASON FOR THIS EXAMINATION:\n please eval for evidenec of pneumothorax and evaluate line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate pulmonary artery line placement.\n\n Comparison is made to a film of approximately six hours earlier.\n\n PORTABLE UPRIGHT VIEW OF THE CHEST AT 3:40 P.M: A new right internal jugular\n Swan-Ganz catheter terminates in the right pulmonary artery. There is no\n pneumothorax. There has been no other interval change. No change in\n pulmonary edema and pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-07-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 976531,
"text": " 1:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and elevated PA pressures.\n REASON FOR THIS EXAMINATION:\n Please eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, SINGLE VIEW, AT 1348 HOURS.\n\n CLINICAL INFORMATION: 79-year-old male with tracheostomy and elevated\n pulmonary artery pressures. Evaluate for interval change.\n\n COMPARISON STUDY: .\n\n FINDINGS:\n\n Tracheostomy is in midline. Right Swan-Ganz catheter tip is in the right\n pulmonary artery. Right PICC line appears to terminate in the superior vena\n cava.\n\n Heart is enlarged. There is central pulmonary vascular prominence and\n congestion consistent with mild congestive failure.\n\n There is elevation of the right hemidiaphragm with right basilar atelectasis.\n There is mild left basilar atelectasis as well. There is diffuse underlying\n interstitial pulmonary disease. There are small bilateral pleural effusions.\n\n IMPRESSION:\n\n No interval change since the prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-08-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 976739,
"text": " 8:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for edema, infiltrate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and elevated PA pressures.\n\n REASON FOR THIS EXAMINATION:\n assess for edema, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, SINGLE VIEW, AT 09:37\n\n CLINICAL INFORMATION: Tracheostomy; question edema, infiltrate.\n\n COMPARISON STUDY: .\n\n FINDINGS:\n\n A right IJ Swan-Ganz catheter is present. Tracheostomy is in the midline. A\n right subclavian line is present, but the tip is not clearly seen due to\n overlying additional leads. It is presumed to terminate in the superior vena\n cava based on the study from yesterday.\n\n The left costophrenic study is omitted from the study. There is diffuse\n vascular congestion consistent with mild-to-moderate congestive failure. This\n is unchanged. There are small bilateral pleural effusions with probable mild\n bibasilar atelectasis. There are patchy airspace opacities in the right upper\n lobe and probably within the left lower lobe concerning for superimposed\n aspiration or pneumonia. These appear somewhat worse today than yesterday.\n\n IMPRESSION:\n\n 1. Mild-to-moderate congestive failure, stable.\n\n 2. Worsening right upper lobe, left lower lobe, right lower lobe patchy\n airspace disease concerning for superimposed aspiration versus pneumonia.\n\n 3. Small bilateral pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-08-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 977634,
"text": " 7:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate effusions s/p diuresis\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and elevated PA pressures. w/ increased\n pleural effusions on last CXR\n REASON FOR THIS EXAMINATION:\n evaluate effusions s/p diuresis\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Elevated pulmonary artery pressures. Evaluate pleural effusions.\n\n Tracheostomy tube remains in standard position. Widespread pulmonary\n opacities are present with both alveolar and interstitial components. The\n alveolar opacities are most prominent in the upper and mid lungs and have\n progressed since the recent study. Considering waxing- appearance on\n serial radiographs, they probably represent pulmonary edema superimposed upon\n more chronic underlying interstitial lung disease. Small right pleural\n effusion is unchanged, but small-to-moderate left pleural effusion is\n increased.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-08-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 977779,
"text": " 8:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for edema, infiltrates\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and elevated PA pressures.\n REASON FOR THIS EXAMINATION:\n assess for edema, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF .\n\n INDICATION: Elevated pulmonary artery pressures.\n\n Tracheostomy tube remains in place as well as a right PICC line.\n Cardiomediastinal contours are stable in appearance. Widespread heterogeneous\n combined alveolar and interstitial opacities are again demonstrated\n bilaterally, with some interval clearing within the left lung, but no\n substantial change within the right lung. Mild volume loss in the right\n hemithorax is also unchanged as well as bilateral small pleural effusions,\n right greater than left.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-08-06 00:00:00.000",
"description": "RP UNILAT UP EXT VEINS US RIGHT PORT",
"row_id": 977565,
"text": " 1:47 PM\n UNILAT UP EXT VEINS US RIGHT PORT Clip # \n Reason: PLEASE EVALUATE FOR DVT, SWELLING\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with R> L swelling\n\n REASON FOR THIS EXAMINATION:\n please evaluate for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right greater than left swelling.\n\n COMPARISON: left upper extremity ultrasound, .\n\n FINDINGS: Grayscale and color Doppler imaging of the right internal jugular,\n subclavian, axillary, basilic, and brachial veins were performed. The\n cephalic vein is not well visualized. Normal compressibility, waveforms, flow\n were demonstrated in the right internal jugular, subclavian, axillary, and\n basilic veins. The more superficial brachial vein does not compress and also\n lacks flow within, consistent with occlusive thrombus. The more deep brachial\n vein appears patent.\n\n IMPRESSION: Occlusive thrombus within the more superficial right brachial\n vein.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-07-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 976353,
"text": " 8:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach, AS, failure to wean, ? interval change\n\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Failure to wean patient with tracheostomy and AS.\n\n SINGLE AP PORTABLE VIEW OF THE CHEST: Compared to multiple prior studies\n including most recent one performed a day earlier.\n\n Cardiomediastinal contour is unchanged. Tracheostomy tube remains in place.\n Right subclavian catheter is in unchanged position in the proximal SVC. Small\n bilateral pleural effusions are unchanged. Diffuse peripheral patchy\n opacities are stable.\n\n IMPRESSION: No short interval changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-07-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 976175,
"text": " 5:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach, AS, failure to wean, ? interval change\n\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE FILM OF THE CHEST ON AT 0503 HOURS: There has been no change in\n the appearance of the chest over the last several examinations, the most\n recent being on . The tracheostomy tube is in good position. Right PICC\n line appears to be into the superior vena cava. The right hemidiaphragm is\n elevated, and the parenchymal lung changes bilaterally persist.\n\n CONCLUSION: No improvement or change in the appearance of the chest.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-07-26 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 975938,
"text": " 3:03 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: pre-op study, please assess for arterial calcification\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with critical AS, intubated for respiratory distress, pre-op\n study for aortic valve replacement\n REASON FOR THIS EXAMINATION:\n pre-op study, please assess for arterial calcification\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST\n\n REASON FOR EXAM: Critical AS. Pre-op evaluation.\n\n TECHNIQUE: Multidetector CT through the chest was acquired without contrast.\n Five, 1.25 mm collimation images and coronal reformations were reviewed.\n\n FINDINGS: Tracheostomy tube is in place. There is pooling of secretions above\n the endotracheal tube cuff. There is an increased number of mediastinal lymph\n nodes located in all of the mediastinal stations, measuring up to 12 mm in the\n subcarinal station. The aorta is normal in caliber, measures 39 x 38 mm,\n transverse by AP in the ascending portion. There is mild calcification of the\n aortic arch. There is no calcification in the ascending aortal wall. The\n aortic valve has dense calcification. Mild to moderate calcifications are in\n the LAD and left circumflex a's. There are small bilateral pleural effusions.\n The airways are patent to the subsegmental levels. There is diffuse ground\n glass opacity associated with interlobular septal thickening. Some of the\n pleural effusion tracks in the major fissures bilaterally. Dense\n peribronchial multifocal infiltration is greater in the right lower lobe\n\n There is moderate ascites.\n\n Artifact from low position of the arms, limits the abdomen assessment. There\n are healed fractures in the lateral aspect of the fifth and sixth right ribs.\n\n IMPRESSION:\n\n 1. Dense calcification of the aortic valve.\n\n 2. Pulmonary edema. A component of chronic interstitial lung disease may be\n present\n\n\n\n\n\n\n\n\n\n (Over)\n\n 3:03 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: pre-op study, please assess for arterial calcification\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-08-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 978297,
"text": " 12:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for infiltrate or effusion\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and AS, plan for aortic valve repair on \n\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrate or effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Aortic stenosis, evaluation for aortic valve repair, evaluate for\n infiltration or effusion.\n\n Single supine portable chest radiograph is compared to study dated , . There is interval increase in the bilateral alveolar and\n interstitial opacities, more pronounced in the right upper lung. Bilateral\n pleural effusions are unchanged. Tracheostomy tube is in standard position.\n Right PICC is likely unchanged in position. The cardiac silhouette is\n enlarged, unchanged.\n\n IMPRESSION: Interval increase in bilateral alveolar and interstitial\n opacities; bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-07-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 976605,
"text": " 7:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and elevated PA pressures.\n REASON FOR THIS EXAMINATION:\n please evaluate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, SINGLE VIEW, AT 09:11 HOURS\n\n CLINICAL INFORMATION: 79-year-old male with tracheostomy and elevated PA\n pressures.\n\n COMPARISON STUDY: .\n\n Since the prior study, there is overall worsening of the appearance of the\n chest. Heart is enlarged. Mediastinum probably within normal limits. Swan-\n Ganz catheter is present. Tracheostomy is midline. There are bilateral\n pleural effusions, increased in size. There is increased bibasilar\n atelectasis versus consolidation. There is increased pulmonary congestion\n consistent with mild-to-moderate failure.\n\n IMPRESSION:\n\n Interval worsening. Increased bilateral pleural effusions, bibasilar\n consolidation, mild-to-moderate congestive failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-07-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 974710,
"text": " 5:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and RLL PNA\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Interval change in patient with multiple\n consolidations.\n\n Portable AP chest radiograph compared to .\n\n Tracheostomy is in good unchanged position. The right PICC line tip\n terminates in mid SVC. The heart size is enlarged but unchanged. The\n mediastinal contours are stable. Persistent diffuse airspace and interstitial\n opacities are unchanged, right greater than left. Small bilateral pleural\n effusions cannot be excluded. The right hemidiaphragm is continuing to be\n elevated.\n\n IMPRESSION: No interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-07-15 00:00:00.000",
"description": "UNILAT UP EXT VEINS US",
"row_id": 974408,
"text": " 2:00 PM\n UNILAT UP EXT VEINS US Clip # \n Reason: PLEASE EVALUATE FOR DVT/RUE SWELLING\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with R> L swelling\n\n REASON FOR THIS EXAMINATION:\n please evaluate for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old man with right arm swelling.\n\n COMPARISON: Right arm ultrasound, .\n\n FINDINGS: -scale and Doppler son of the right jugular, subclavian,\n axillary, brachial, basilic, and cephalic veins were obtained. There is\n normal compressibility, flow and augmentation down to the level of the\n axillary and brachial veins. Limited views were obtained in this area due to\n the patient's present PICC line and bandage. No occlusive DVT was identified\n on this limited study.\n\n IMPRESSION: Study technically limited due to the presence of PICC line and\n bandage but no DVT identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-07-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 973742,
"text": " 5:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and new RLL PNA\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Followup right pneumonia.\n\n Comparison is made with prior studies including and .\n\n Diffuse pulmonary process greater in the right side has not significantly\n changed from , but has worsened from . It is due to bilateral\n pulmonary edema and consolidation in the right lung. Mild cardiomegaly is\n unchanged. Small bilateral pleural effusions. Tracheostomy tube is in\n adequate position. Right PICC is in standard placement. There is no\n pneumothorax. Rib fracture with irregularity in the lateral aspect of a mid\n right rib is present since .\n Conclusion:New changes suggesting increase in pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-07-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 974157,
"text": " 10:37 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: collapse, new infiltrate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and RLL PNA. Now desaturating after bronchoscopy.\n\n REASON FOR THIS EXAMINATION:\n collapse, new infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old male desaturating after bronchoscopy. Evaluate for\n infiltrate or collapse.\n\n Comparison is made to multiple prior chest radiographs dating back to , .\n\n SINGLE PORTABLE CHEST RADIOGRAPH\n\n FINDINGS: Diffuse airspace process involving the right hemithorax may be\n slightly worsened from most recent examination but clearly progressed from\n examination with persistent retrocardiac opacity obscuring the\n left hemidiaphragm. Parenchymal opacity involving the left hemithorax is not\n significantly changed as is probable small bilateral pleural effusions and\n amount of vascular engorgement. Low lung volumes persist and there is no\n evidence of pneumothorax with tracheostomy tube remaining in standard\n position.\n\n IMPRESSION:\n\n Slight interval progression to diffuse right hemithorax opacity which has\n worsened since examination with no significant interval change in\n left lower lobe opacity and amount of vascular engorgement.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-07-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 974475,
"text": " 5:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and RLL PNA, now s/p trach replacement.\n\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY\n\n CLINICAL INDICATION: 79-year-old man with trach and right lower lobe\n pneumonia, now status post trach replacement, evaluate for interval change.\n\n A single portable image of the chest is compared to the prior examination\n dated demonstrating no significant interval change. Low lung volumes\n are again noted. Persistent diffuse airspace opacities are again noted, right\n greater than left. The left hemithorax is not included on this examination.\n There is persistent prominence of the bronchopulmonary vasculature that\n remains indistinct likely secondary to underlying interstitial edema. A\n stable retrocardiac opacity is noted. The right-sided PICC line is unchanged\n in position.\n\n IMPRESSION: Stable examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-07-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 974340,
"text": " 5:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and RLL PNA.\n\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate interval change, history of pneumonia and recent\n bronchoscopy.\n\n Comparison is made to portable films dating back to .\n\n PORTABLE AP VIEW OF THE CHEST\n\n There has been interval central clearing of the diffuse infiltrative\n abnormality in the right lung field. Clearing over the past 48 hours likely\n represents improvement of asymmetrical edema, which had been superimposed over\n right lower lobe consolidation. There may be a left pleural effusion, although\n the retrocardiac opacity makes it difficult to evaluate. Again seen are low\n lung volumes and a tracheostomy tube in good position.\n\n IMPRESSION: Some improvement in right-sided pulmonary edema. No change in\n bilateral lower lobe opacities. Likely pleural effusion on the left side.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-07-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 975566,
"text": " 5:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach, AS, failure to wean\n\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trach, AS, failure to wean, interval change.\n\n CHEST, SINGLE AP PORTABLE VIEW:\n\n There is rotated positioning and low inspiratory volumes. Allowing for\n differences in technique, overall appearance is similar to . There may\n be slight improvement in the right upper zone consolidation with some\n increased consolidation in the left upper zone and slight decrease in left\n pleural effusion. Tracheostomy tube noted. PICC line present, tip not well\n visualized.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-07-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 973882,
"text": " 6:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and new RLL PNA\n\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with new right lower lobe\n pneumonia.\n\n Portable AP chest radiograph compared to .\n\n The tracheostomy is in unchanged position. The diffuse pulmonary process,\n more severe in right lung, has not significantly changed since the previous\n exam but overall is gradually worsening since . The bilateral\n pulmonary edema is of unchanged stability. The mild cardiomegaly is stable.\n\n Small bilateral pleural effusions are again noted, although cannot be\n precisely appreciated due to the fact that the most lateral costophrenic\n angles were not included in the field of view.\n\n IMPRESSION: Probable, overall slight worsening of pulmonary edema and right\n lower lobe consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-07-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 975334,
"text": " 5:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval changes\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and RLL PNA\n\n REASON FOR THIS EXAMINATION:\n please eval for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess for interval change.\n\n SEMI-ERECT PORTABLE CHEST RADIOGRAPH\n\n Comparison is made to and 22, .\n\n Lung volumes remain low with unchanged bilateral pleural effusions (left\n greater than right) and diffuse parenchymal opacities. There is questionable\n increased density noted over the right upper lobe. A tracheostomy tube and a\n right PICC catheter remain in unchanged position.\n\n IMPRESSION:\n 1. No significant _____.\n 2. Bilateral small pleural effusions (left greater than right) and diffuse\n parenchymal opacity. Questionable increased density noted over the right\n upper lobe can be followed up on subsequent examinations.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-07-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 973646,
"text": " 10:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and persistent fevers\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:17 P.M.\n\n HISTORY: Tracheostomy tube. Persistent fevers.\n\n IMPRESSION: AP chest compared to through :\n\n Severe consolidation in the right lung has worsened since . Milder\n interstitial abnormality in the left lung probably represents residual edema\n or scarring. Moderate cardiomegaly unchanged. Pleural effusion may be\n present, but is not appreciable in size. Tracheostomy tube in standard\n placement. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-08-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 977898,
"text": " 7:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for edema, infiltrate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and elevated PA pressures.\n REASON FOR THIS EXAMINATION:\n assess for edema, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Portable chest.\n\n CLINICAL INDICATION: 79-year-old man with trach and elevated PA pressures,\n assess for edema and infiltrate.\n\n FINDINGS: A single portable image of the chest is compared to the prior\n examination dated . Allowing for slight differences in technique\n there is no significant interval change. The tracheostomy tube and right PICC\n line remain in place. The cardiomediastinal silhouette is grossly unchanged.\n Diffuse heterogenous alveolar and interstitial opacities are again noted\n bilaterally right greater than left. Persistent bilateral effusions are noted\n right greater than left.\n\n IMPRESSION: Stable examination as above.\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-08-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 977362,
"text": " 8:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate catheter placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and elevated PA pressures. w/ swan\n\n REASON FOR THIS EXAMINATION:\n please evaluate catheter placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup evaluation.\n\n Comparison is made to films dating back to and a CT chest of\n .\n\n Portable upright view of the chest at 8:30 a.m.: The tracheostomy tube\n remains in unchanged position approximately 2-3 cm above the carina. There\n has been interval removal of the right internal jugular Swan-Ganz catheter.\n Since the prior radiograph of , mild-to-moderate pulmonary edema\n has developed, superimposed on the diffuse interstitial disease. There are no\n obvious areas of new consolidation. The cardiomediastinal silhouette is\n unchanged.\n\n IMPRESSION: Interval development of mild-to-moderate pulmonary edema. Stable\n diffuse interstitial disease.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-07-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 974030,
"text": " 5:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and new RLL PNA\n\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Follow up right pneumonia and pulmonary edema.\n\n Comparison is made to prior studies including most recent one performed a day\n earlier.\n\n There are low lung volumes. Right pleural effusion is small. Probable small\n left pleural effusion. Tracheostomy tube is seen in standard position.\n Moderate cardiomegaly is unchanged. There is no pneumothorax. Allowing the\n rotation of the patient, there is less aeration in the left upper lobe. The\n diffuse pulmonary process most severe in the right lung has not significantly\n changed with mild to moderate pulmonary edema and patchy consolidation in the\n right lung.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-07-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 975034,
"text": " 6:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with trach and RLL PNA\n\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup of pneumonia.\n\n Portable semi erect view of the chest: Compared to the prior film of\n , there appears to be a new tracheostomy tube that extends further\n into the trachea, terminating approximately 2.5 cm above the carina, in\n satisfactory position. Diffuse patchy bilateral airspace disease is\n unchanged. There is no obvious pleural effusion. Cardiovascular status is\n difficult to assess with high diaphragms and overlying airspace disease, but\n heart appears borderline enlarged. The right PICC remains in good position.\n\n IMPRESSION: Diffuse lung abnormalities consistent with pneumonia are\n unchanged. CHF is unlikely.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-07-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 974934,
"text": " 11:57 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for bleed, stroke\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with AS, hypotension, afib and PNA who developed visual field\n defects and not tracking to right\n REASON FOR THIS EXAMINATION:\n evaluate for bleed, stroke\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT\n\n HISTORY: 79-year-old man with hypotension, AFib, and pneumonia with visual\n field defects, assess for stroke or bleed.\n\n TECHNIQUE: Contiguous 5-mm axial images were obtained from the skull base to\n the vertex.\n\n FINDINGS: Comparison is made to .\n\n This study is limited by patient motion. No intracranial hemorrhages or\n masses are seen. The /white matter differentiation is maintained. The\n ventricles and extraaxial CSF spaces are within normal limits.\n\n The visualized orbits are normal.\n\n Again seen is mucosal thickening involving the left sphenoid air cell as well\n as ossification of the right mastoid air cells as before.\n\n No suspicious bony abnormalities are seen.\n\n IMPRESSION: Limited somewhat by motion, but no acute intracranial\n abnormalities.\n\n MR is more sensitive study to assess for acute infarcts.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-08-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 978566,
"text": " 7:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with AVR w/ hx of pna prior to surgery\n\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: AVR with history of pneumonia prior to surgery.\n\n COMPARISON: at 18:27 hours.\n\n TECHNIQUE: Single AP portable supine chest.\n\n FINDINGS: An endotracheal tube is in place with tip terminating 4.1 cm above\n the carina. Pulmonary artery catheter enters via left internal jugular\n approach and the tip, though not well seen, is located in the region of the\n main pulmonary artery. A nasogastric tube extends below the diaphragm with\n tip below the borders of the radiograph. Two mediastinal drains are in\n unchanged position. A right-sided PICC line with tip in the expected location\n of the SVC is in unchanged position. Since the previous examination, there is\n little change in bilateral interstitial opacities, with possible mild\n improvement in right base opacity. No pneumothorax. Multiple right- sided\n rib fractures again noted but better appreciated on the prior radiographs.\n\n IMPRESSION:\n 1. Lines and tubes in satisfactory position.\n 2. Bilateral interstitial opacities, likely reflecting CHF or pneumonia; mild\n improvement in right lower lobe consolidation.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 979435,
"text": " 4:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p AVR w/hypotension-r/o PTX\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with AVR w/ hx of pna prior to surgery\n\n REASON FOR THIS EXAMINATION:\n s/p AVR w/hypotension-r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pneumonia and AVR surgery.\n\n FINDINGS: In comparison with the study of , the patient is no longer\n obliqued. There is again evidence of median sternotomy and aortic valve\n replacement. The cardiac silhouette remains grossly enlarged, though stable.\n There is again prominence of interstitial markings. Elevation of the right\n hemidiaphragm is again seen, making it difficult to evaluate the lung behind\n it. Probable small bilateral pleural effusions.\n\n Tracheostomy tube remains in place. Right central catheter extends to just\n above the carina.\n\n IMPRESSION: Little overall interval change.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2129-08-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 979153,
"text": " 10:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for effusions/infiltrates\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with AVR w/ hx of pna prior to surgery\n\n REASON FOR THIS EXAMINATION:\n assess for effusions/infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old man with aortic valve replacement and history of\n pneumonia prior to surgery. Evaluate for interval change.\n\n COMPARISON: AP semi-upright portable chest x-ray dated .\n\n AP SEMI-UPRIGHT PORTABLE CHEST X-RAY: A left internal jugular Swan-Ganz\n catheter has been removed in the interval. A tracheostomy tube is in place.\n Right PIC catheter terminates in unchanged position in the proximal SVC. The\n patient is status post median sternotomy and aortic valve replacement. The\n cardiac silhouette is grossly enlarged but stable. Prominence of the\n interstitial markings and small bilateral effusions persist and limit\n evaluation of underlying pneumonia. There are no new consolidations. Multiple\n right sided rib fractures are again noted and appear partially healed on CT\n Chest from .\n\n IMPRESSION: No significant interval change in the appearance of the chest.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-08-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 978693,
"text": " 9:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ct removal\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with AVR w/ hx of pna prior to surgery\n\n REASON FOR THIS EXAMINATION:\n ct removal\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Chest tube removal.\n\n A single AP view of the chest is obtained on at 09:40 hours and is\n compared with the prior morning's radiograph. ET tube has been removed and a\n tracheostomy tube placed. Tip lies approximately 4.8 cm above the carina.\n Nasogastric tube and Swan-Ganz catheter are unchanged. Mediastinal drains are\n not visible, presumably have been removed. There is no evidence of\n pneumothorax. Bilateral interstitial opacities persist and likely represent\n failure or less likely pneumonia. Increasing retrocardiac density on the left\n side is consistent with worsening atelectasis at the left base. Haziness and\n obscuration of the diaphragm on the left likely represents pleural effusion.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-12 00:00:00.000",
"description": "Report",
"row_id": 1624042,
"text": "Patient has # 7 Shiley with layer of secretion on inner wall of trach MDs notified.Plan to change trach tube under bronchoscopic view due to the presence of a suture thread coming from the stoma.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-14 00:00:00.000",
"description": "Report",
"row_id": 1624047,
"text": "Nsg.notes 1900-0700hrs\n\nAllergies:haldol and heparin.\n\nNeuro:Alert,following commands,unable to assess orientation.stiff body and hands.slept well with Inj.Ativan.\n\nResp:,vented,AC/20/10/450/40. BLOOD GAS X2.am ABG report 7.4/54/116/38/11/.tachypoenic always,RR >30's .trache changed yesterday.slept after ativan and RR >22/min when sleeping.LS coarse.suctioned yellow to blood stained secretions.trache care given.cuff leak present,cuff inflated more per RT.sats 92-96%\n\nCVS:HR 84-100/MIN,Afib,no ectopics noted.ABP 100-120'S SYS. edematous extremities.pedal pulse difficult to palpate on post tibial.boots on.\nblood c/s sent.\n\nGU/GI:Abdomen obese,bowel sounds hypo,PEG in place,feed neutran pulmonary 50ml/hr,tolerating well,no BM this shift.on lasix BD ,urine output adequate.\n\nIntegu:impaired ,duoderm on upper back,hygenic needs attended and position changed.afebrile.\n\nIV access:A line on Lt.radial,patent.Rt.midline cath double lumen .\n\nSocial: by family early shift and updated.calm and co operative.full code ,on contact precautions for MRSA.\n\nPlan:trache care.watch for bleeding and leaking.continue present care.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-14 00:00:00.000",
"description": "Report",
"row_id": 1624048,
"text": "Respiratory Care:\n\nPatient with 7.O Portex. Trach changed yesterday due to partial occlusion. Peep ^ 10 with improved PaO2(116) and later weaned back to 8 due to low BP. Current vent settings Vt 450, A/C 14, Fio2 40% and Peep 8. BS few faint expiratory wheezes L lung, slightly coarse R lung. Sx'd for bloody clots. Albuterol/Atrovent MDI's given Q4hr. Wheezes resolving. No further changes made.\nPlan: Continue with mechanical support. See Carevue for RSBI and ABG's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-14 00:00:00.000",
"description": "Report",
"row_id": 1624049,
"text": "resp care - Pt remains and vented on full vent support. Persistent cuff leak exists despite high cuff pressure. BLBS were coarse t/o. Pt was suctioned for copious amounts of thick, blood tinged secretions x 2. PEEP was decreased to 5 during rounds, but was increased to 8 in PM when Sat dropped and BP increased. Pt given meds as ordered. Continued resp care planned.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-14 00:00:00.000",
"description": "Report",
"row_id": 1624050,
"text": "NPN\n\nNeuro: Pt is awake and alert, slowly following simple commands, conts to have jerking movements which per his family have been with him since his accident.\n\nCV: Tolerating his dilt, remains in afib, his coumadin was d/ced do to his drop in his HCT to 19.9. He is receiving 3 units of FFP and 2 bags of PRBCs.\n\nResp: LS with rales in the bases, 02 SATs dropped to 93-94% and had coarse BS throughout this afternoon after he had recieved 2 of his 5 blood products. His PEEP was increased back to 8 - it was decreased during rounds and he was given an additional 40mg of IV lasix. He has a cuff leak, his cuff pressure is 30, repositioning it does not change the leak, his VTs are 300s-low 400s.\n\nGI: His HCT was 19.9 this morning, he had dark brown stool yesterday x2 which were OB pos, FFP and PRBC were ordered, also given vit K, ASA and comadin were d/ced, pneumoboots were placed, GI notified.\n\nGU: He is presently 330cc pos since MN, he conts on lasix, his u/o has been 250-40cc/hr.\n\nSoc: Family called, they took the day off today and will be in tomorrow.\n\nID: T max 101 and he has remain febrile all day on Tylenol, WBC down today from yest, blood c/x sent, BAL, urine, and stool sent yest with his elevated WBC, no antibiotics were ordered.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-28 00:00:00.000",
"description": "Report",
"row_id": 1624110,
"text": "ADDENDUM TO NPN 7P-7A\nLASIX GTT BACK ON AT 4MG/HR AS BP HAS IMPROVED\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-13 00:00:00.000",
"description": "Report",
"row_id": 1624043,
"text": "Nsg.notes 1900-0700hrs\n\nShift uneventful\n\nNeuro:alert,obeying and following commands,denies any pain.slept on and off.\n\nResp:,vented,AC,/14/40/5/40%/trache care given,suctioned thick yellow secretions.sats 94-98%.\n\nCVS:HR 100-110,a fib,with occasional PVC'S .vital signs remains stable,A line on Lt hand,ABP 110-130/60-70mm of hg.A line pressure kit changed.\n\nGU/GI:PEG in place,on neutran pulmonary 40ml/hr,tolerating well.no BM this shift,on foley cath,urine output adequate.\n\nIntegu:skin impaired uppper back,duoderm present.position changed and hygenic needs attended.edematous and stiff,difficult to fold his hands and legs.\n\nIV access:Rt midline 2 lumen cath.site cleaned and dressing changed.\n\nSocial:calm and co operative.no family contact during night.full code,on contact precautions\n\nPlan:pulmonary toileting and airway clearence.may change trache today.emotional support to pt and family,continue present treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-13 00:00:00.000",
"description": "Report",
"row_id": 1624044,
"text": "RESP CARE NOTE\nRECEIVED PT ON AC WITH NO CHANGES OVERNIGHT. BREATH SOUNDS ESSENT CLEAR. ALB/ATR GIVEN Q4. RSBI 111 THIS AM. AMBU AT BEDSIDE.\nPLAN: ? TRACH CHANGE TODAY, WEAN TO PSV AS TOLERATED, CONT MDI'S AS ORDERED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-13 00:00:00.000",
"description": "Report",
"row_id": 1624045,
"text": "NPN\n\nNeuro: Pt was sleeping this morning but then woke and was alert until he was sedated for the bronch.\n\nCV: Tolerating 30 mg of dilt QID, remains on coumadin for his afib - INR was 2.2., his heart rate has been 80s-1teens. k was replaced today, lytes due to be checked this afternoon.\n\nResp: Remains vented on A/C, no changes were made, he was tried on PSV during rounds but his RR increased from 20 to the 30s and his pC02 was in the 60s and on A/C his pC02 was in the 50s. His trache was changed to a portex, fenistrated with an intercanula, he was also bronched and a lg plug was suctioned out. A BAL sputum was sent as well. WBC count up to 14 today, he has been afebrile but was pan clx.\n\nGI: He has had 2 lg dark brown, loose, OB pos stools today, this was sent for cdif. His TF was increased to 50cc/hr per nutrition recs.\n\nGU: Now on lasix 40mg per GT, he has put out ~ 400cc so far today for the lasix.\n\nSoc: Son in to visit, we cont to work on finding him a rehab, he may be ready to go this week.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-13 00:00:00.000",
"description": "Report",
"row_id": 1624046,
"text": "Trach changed from Shiley to portex # 7. Bronchoscopic procedure done,suctioned for copious amount of thick bloody secretion.Weaned on PSV for short periods of time desaturated to 88% pre-oxygenate responded quickly to 02 therapy.ABG sent to lab will continue to follow patient.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-28 00:00:00.000",
"description": "Report",
"row_id": 1624111,
"text": "Resp Care,\nPt. remains on A/C overnoc, no vent changes this shift. Suctioned small amount thick yellow . attempted, RR>35. Maintain current vent settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-21 00:00:00.000",
"description": "Report",
"row_id": 1624112,
"text": "Neuro: pt withdrawn, visually acknowledges caregiver, otherwise no interaction. does not follow commands. moves/tenses extremities w/tactile stimulation. grimaces with turns and during skin care. perrl.\nCv: af 80s-100s. occas. pvc's. bp 100s-130s. briefly hypotensive, MD aware, no tx ordered, pt returned to baseline within 15 minutes, continuing to monitor. +pp. extrem w/d. compression sleeves on. low grade temp 100.4, tylenol given w/good effect. sternal, mediastinal incisions cdi.\nResp: ls course, bases dim. no vent changes overnoc. continues on cpap 40% 5peep, 8ps, tv 300s-500s. rr 20s-30s. sxn'd sm-mod amts thk yellow secretions occas. pCo2 50s.\nGi/gu: tolerating tf fs replete w/fiber @ goal=80cc/hr via peg-no resids. +bs. no bm. abd soft, nt, nd. huo adequate-clr yellow.\nEndo: rssi per ss.\nSkin: see carevue.\nPlan: continue monitoring cardioresp status, labs, sxn prn. continue support pt/family. continue with current plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-21 00:00:00.000",
"description": "Report",
"row_id": 1624113,
"text": "RESP CARE: Pt remains /on vent,cuff pressure 28cmH20. Remained on PSV 8/5/.40. ABGs comp resp acidosis/good oxygenation. Vts 330-500/RR 20-35. Lungs bilat rhonchi, sxd small amts thick yellow /white . AM -95. Wean as \n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-21 00:00:00.000",
"description": "Report",
"row_id": 1624114,
"text": "ALTERED RESPIRATORY STATUS\nO: CARDIAC: AF WITH VENTRICULAR RESPONSE 70'S-80'S. PVC'S NOTED. K AT 11AM NOT RUN CALLED LAB AND RAN AT 1400 3.7 RECIEVING 20 MEQ KCL X2. SBP 90'S-162 WITH COUGHING. AFEBRILE. EXTREMITIES WARM AND DRY. PALP PP. OOB TO CHAIR VIA X3 HOURS.\n RESP: VENT SETTINGS AND ABG PER FLOW. BS COURSE UPPER -CLEARS WITH COUGHING. RR TWENTIES - THIRTIES. SUCTIONED FOR A SMALL AMOUNT OF THICK TO THIN WHITE . TRACHE CARE DONE, INNER CANNULA CHANGED.CO2 57.\n NEURO: OPEN EYES TO COMMAND, INCONSISTENTLY WILL WIGGLE FINGERS AND TOES TO COMMAND, CLOSES EYES AND MOUTH WHEN ATTEMPTING TO ASSESS PUPILS AND OR MOUTH CARE. PERL.\n GI: TF AT GOAL, ABD SOFT, NONTENDER, SMALL AMOUNT OF SOFT BROWN QUIAC NEGATIVE STOOL.\n GU: MARGINAL UO\n ENDO: HAS NOT RECEIVED SSI .\n PAIN: SHOOK HEAD NO TO PAIN.\n SOCIAL: DAUGHTER INTO VISIT AND UPDATED.\n REHAB: ? PLAN TO DISCHARGE TO REHAB .\nA: TOLERATED OOB X 3 HOURS. CONTINUES IN AF. CO2 57.\nP: MONITOR COMFORT, HR AND RHTYHYM-? COUMADIN, SBP, RESP STATUS-PULM TOILET-ABG, NEURO STATUS-REORIENTE PRN, I+O, LABS AS PER ORDERS. PREPARE FOR REHAB . DC ALINE. COMPLETE DISCHARGE SUMMARY. AS PER ORDERS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-21 00:00:00.000",
"description": "Report",
"row_id": 1624115,
"text": "Resp. care note - Pt. remaines and vented, no vent changes made at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-27 00:00:00.000",
"description": "Report",
"row_id": 1624108,
"text": "0700-1900\nneuro: lethargic, easily aroused, follows commands, moves upper extremities, pt very weak\n\ncv: hr a-fib(70's-80's), no ectopy, sbp stable(90-134), po digoxin\n\nresp: placed on cpap today, well, now back on AC due to sedation for colonoscopy, bs+ all lobes & course, sux sm/mod amt thick yellow , sat 95-100, no resp distress noted\n\ngi: pt npo today for colonoscopy, procedure done @ 1700, TF resumed @ 1800, mushroom cath draing lg amt clear liquid stool, po prevacid\n\ngu: foley patent, clear yellow urine, continues on lasix gtt to keep hourly uo 150 cc's, lasix now @ 4 mg/hr\n\nother: son called & updated on pt's condition, son-in-law in to visit, no c/o pain, 1500 labs sent, K+ 3.6, needs repletion, am K+ of 3.6 tx with 40 kcl po, colonoscopy negative, no bleeding areas noted\n\nplan: continue with ventilatory support, wean to cpap as tolerated, continue lasix gtt, goal uo 150 cc/hr, ? tx to CCU tomorrow for possible AVR on Tuesday\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-28 00:00:00.000",
"description": "Report",
"row_id": 1624109,
"text": "NPN 7P-7A\nBRIEFLY THIS IS A PT. ADMITTED ON FROM WITH SEPSIS. HE HAS AN EXTENSIVE PMH. IS A CHRONIC VENT PATIENT. HIS GREATEST ISSUE HAS BEEN HIS FLUID VOLUME STATUS D/T AV STENOSIS. HAS BEEN ON LASIX GTT TO TRY TO ATTEMPT WEANING. PT.'S FAMILY DECIDED THEY WANTED AGGRESSIVE TREATMENT AND PT. IS NOW TO GO WEST FOR AVR. THE PROCEDURE IS GOING TO BE DONE NEXT TUESDAY. GOAL IS TO TRANSFER PT. TO CCU OR CSRU WITHING THE NEXT COUPLE OF DAYS\n\nCOLONOSCOPY DONE YESTERDAY TO R/O GIB. RESULTS NEGATIVE. AT THIS POINT PT. AWAITING TRANSFER WEST.\n\nNEURO: PT. ALERT. OPENS EYES AND NODS HEAD YES AND NO TO QUESTIONS ASKED. PUPILS EQUAL AND REACTIVE. OOB TO CHAIR WITH HOYAR ASSIST.\n\nRESP: PT. WITH TRACH. ON AC 30%/500/20/5. PT. TOLERATED PRESSURE SUPPORT YESTERDAY FOR MOST OF DAY. BREATH SOUNDS COARSE BILAT. SUCTIONED FOR VERY THICK YELLOW SECRETIONS.\n\nCV: PT. IN AFIB WITH RATE 70'S TO 90'S. SYSTOLIC BP LABILE. AT APPROX. 0400 PT. HYPOTENSIVE TO 75/39. LASIX GTT OFF. ( MD'S, LASIX OFF OF SBP <90 OR MAP <65). PT. REMAINS WITH TOTAL BODY ANASARCA. + PULSES. AFEBRILE. PM K+ 3.6 REPLETED WITH 40MEQ IVPB\n\nGI: PT. WITH PEG. ON TFEEDS AT GOAL RATE OF 40CC/HR. TOLERATING WELL. MUSHROOM CATH IN DRAINING LIQUID BROWN STOOL. ABD. SOFT. BS+\n\nGU: FOLEY IN PLACE. GOOD OUTPUT.\n\nACCESS: R AC PICC\n\nPLAN: TRANSFER TO WITHIN NEXT DAY OR TWO. ? RESTART LASIX GTT IF BP PERMITS. WEAN VENT AS TOLERATED. REPLETE LYTES AS NEEDED. AM LABS PENDING. FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-23 00:00:00.000",
"description": "Report",
"row_id": 1624087,
"text": "Respiratory Care\nRemains intubated and ventilated on a/c mode with no remarkable changes overnight. Suctioned for moderated amounts of thick tan .Pt gets very bronchospastic with suctioning/coughing. Unable to obtain due to tachypnea when put on psv.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-11 00:00:00.000",
"description": "Report",
"row_id": 1624036,
"text": "pt remained on full vent support through shift, sx'd for moderate amount of secretions, plan to be evaluated during rounds. AM RSBI was 104\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-23 00:00:00.000",
"description": "Report",
"row_id": 1624088,
"text": "npn 7p-7a (please also see carevue flownotes for objective data)\n\nPt s/t 2 trials PS yesterday, returned to A/C for tachypnea, tachycardia, resp distress;\n\nOn Lasix gtt for urine output goal of 100 cc/hr; recieved on 3.5 mg/hr, increased gently to avoid b/p lability;\n\nB/p remained in acceptable range this night; Diltiazem 30 mg given at 19:30, 6 hrs later pt still w/ borerline b/p and v-response still in 80's, therefore waited until v-response started increasing before giving again; at 04:00 v-response in low 90's after suctioning, therefore dilt given at that time; b/p and v-response remained in acceptable ranges in the two hours following;\n\nPt received full bed bath this night, all IV lines changed;\nRemains on tube feeding as ordered, w/out diarrhea;\n\nThis a.m. serum Na 139--?need for 150 cc's free H20 q 4 hrs?--?decrease volume, or ?decrease frequency;\na.m. serum K+ 3.3, pt received 20 meQ KCL in 50 cc x2, at 05:15 amd 06:16; ordered for third--?check serum level K+ first;\n\nPLAN:\n1) check w/ MD team re interval of diltiazem\n2) check w/ MD team re free water boluses\n3) check serum K+ before more serum K+\n4) dressing changes\n5) further plan per a.m. rounds\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-23 00:00:00.000",
"description": "Report",
"row_id": 1624089,
"text": "resp Care\n\nPsv wean attempted; on 25 of ps with volumes in the high 300's low 400's. Will wean as tolerated. Otherwise on full vent support. Bs with scattered rhonchi. Suctioning thick yellow .\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-23 00:00:00.000",
"description": "Report",
"row_id": 1624090,
"text": "NPN 0700-1900\nNeuro: Awake, alert, more interactive today w/nods, occasional smile. Move LUE, wiggles toes. Gag/cough intact. Will not squeeze hand ?too much fluid. Afebrile. OOB to chair via lift and 3 assists\n\nCV: Continues in afib w/occ PVC's but rate stable 80's-90's. Remains on dilt which is a QID drug so no changes to med order just hold when SBP low. SBP in 100's to low 110's throughout shift. Lasix gtt now @ 5mg/hr, new hold orders are for SBP <90, now diuresing @ ~100cc/hr.\nRepleting K\nResp: Currently tolerating PS 40/5/25 w/RR 30-35bpm. Pt appears comfortable. LS coarse in RUL but currently clear in remaining lobes. Decrease in amt of secretions from yesterday.\n\nGI/Endo: Required no additional insulin coverage today, TF at goal of 50cc/hr w/ no residual. Soft distended abd, +BS, +BM x1 soft, dark brown.\n\nGU: patent foley now draining clear light yellow urine @~125cc/hr.\n\nSocial: daughter and son in law in today with several ?'s about POC, state that they are happy with our medical care, still hoping for possibility of minimally invasive valvoplasty, get fluid off pt and have him return to rehab.\n\nPlan: Lasix gtt for >100cc u/o per hour\n Check K\n TF, Glargine due @ 2200\n Dilt for rate control, hold when necessary\n Encourage deep breathing\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-11 00:00:00.000",
"description": "Report",
"row_id": 1624037,
"text": "NPN\n\nNeuro: Pt is alert, follows simple commands but not able to participate in his care significantly.\n\nCV: Remains in afib, occ PVCs. He was started on dilt PO this afternoon, 30mg QID down from the 60 mg that he received yesterday. BP has been stable 100s-130s. If his BP tolerates the dilt than we will cont to try and diurese him.\n\nResp: Remains vented A/C 450x14/5/.4, he over breathes by , PSV was tried briefly during rounds but he did not tolerate it. He has a lot of thick yellow secreations, requiring q1-3 hr suctioning.\n\nGI: Tolerating his TF at the goal rate of 40cc/hr, had a sm BM which was OB pos, sent for cdif.\n\nGU: Tried to gently diurese him today, he is even for the day, an additional dose of lasix will be given this evening his his BP tolerates it.\n\nSoc: One of his 4 daughters was in today, she met with case mangagement and SS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-11 00:00:00.000",
"description": "Report",
"row_id": 1624038,
"text": "Patient remains on mechanical ventilation;does not tolerate PSV,RSBI 104.Febrile,follows simple commands, but still passive.BS coarse,suctioned for small clear sputum will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-12 00:00:00.000",
"description": "Report",
"row_id": 1624039,
"text": "NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 108/61-154/86. A-FIB WITH HR RANGING FROM 102-117 WITH OCC PVC'S. REMAINS ON DILT PO.\n\nNEURO: ALERT. UNABLE TO DETERMINE ORIENTATION AS PT IS . DOES NOD HEAD YES AND NO. FOLLOWS SIMPLE COMMANDS. ALSO GRIMMACES WITH CARE BUT DENIES DISCOMFORT.\n\nRESP: AC 40%/450/14/5. RSBI 140.7. LUNGS COARSE THROUGHOUT. SOO2 91-98%. RR 19-34. SX Q 3-4HR FOR THICK WHITE SECRETIONS.\n\nGI: ON NUTREN PULM AT 40CC HR AND WELL. NO STOOL THIS SHIFT.\n\nGU: FOLEY CATH PATENT AND DRAINING URINE WHICH WAS AMBER IN COLOR BUT PROGRESSED TO LIGHT RED WITH FEW SM CLOTS. FOLEY IRRIGATED.\n\nSKIN: DUODERM INTACT ON MID BACK.\n\nPLAN: CONT TO MONITOR VS AND LABS AND REPLENISH LYTES AS NEEDED. PT IS DILT WELL, DIURESE. PROVIDE UPDATES IN PT CONDITION TO FAMILY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-12 00:00:00.000",
"description": "Report",
"row_id": 1624040,
"text": "RESP CARE NOTE\nRECEIVED PT ON AC WITH NO CHANGES OVERNIGHT. BREATH SOUNDS ARE WITH COARSE CRACKLES. SUCTIONING SMALL AMOUNTS OF THICK WHITE SECRETIONS. ALB/ATR GIVEN INLINE Q4. TRACH IS PATENT AND SECURE. CUFF PRESSURE 27. RSBI 141 THIS AM. WILL CONT TO FOLLOW.\nPLAN: CONT FULL VENT SUPPORT\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-12 00:00:00.000",
"description": "Report",
"row_id": 1624041,
"text": "NPN\n\nneuro: pt remains alert, following simple commands, not able to do any ADLs. He is very stiff and bearly able to bend his arms and legs.\n\nCV: Remains on dilt, conts in afib with a rate of 80s-1teens. BP 110s-130s/70s. He conts on coumadin, his INR was 2.3 this morning.\n\nResp: Remains , sx for thick yellow sputum, his trache has tans secreations on the inside of the lumen, to have ENT to come see him for a possible new trache. He was placed on PSV of 15/5,.4, ABG 7.38/62/67. His rate and VTs are about the same on PSV vs A/c, though his HR increased to the 100s-1teens. T max 100.0, gent was d/ced, he conts on imipenum and PO bactrim.\n\nGI: Conts on TF, no stool today.\n\nGU: Given 40 mg of IV lasix, he is presently 125cc neg since MN.\n\ndispo: To be screaned by heb reb, family is aware.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-27 00:00:00.000",
"description": "Report",
"row_id": 1624105,
"text": "NPN 7P-7A\nTHIS MAN WAS ADMITTED HERE ON FROM WITH A DIAGNOSIS OF SEPSIS. HE HAS AN EXTENSIVE PMH INCLUDING AV STENOSIS WHICH HAS IMPEEDED EQUALIZING HIS FLUID BALANCE. DECISION WAS MADE BY PT.'S FAMILY, AFTER HAVING DONE RESEARCH IN THE INTERNET, TO HAVE PERCUTANEOUS VALVULOPLASTY DONE AFTER LABOR DAY WEEKEND IN HOPES THAT PT.'S FLUID OVERLOAD WILL IMPROVE, LEADING TO SUCCESSFUL VENT WEANING. CARDIOTHORACICS TALKED WITH FAMILY EXTENSIVELY REGUARDING THE RISKS OF THIS PROCEEDURE. FAMILY HAS DECIDED TO MOVE FORWARD WITH AGGRESSIVE TREATMENT. PLAN IS TO TRANSFER TO CCU HOPEFULLY BEFORE THIS WEEKEND.\n\nYESTERDAY PT. HAD CT OF ABDOMEN FOR PRE-PROCEDURE WORKUP. PT. WILL ALSO NEED DENTAL XRAYS TO R/O POSSIBLE ABSCESSES. PT. ALSO TO HAVE COLONOSCOPY DONE THIS AM AS HE HAS BEEN HAVING TARRY STOOLS. GOLYTLY 6L GIVEN THIS SHIFT IN PREPARATION FOR COLONOSCOPY THIS AM.\n\nNEURO: PT. ALERT. NODS HEAD YES AND NO TO QUESTIONS ASKED. PURPOSEFUL MOVEMENT NOTED. NO C/O PAIN. OOB TO CHAIR WITH ASSIST DURING DAY.\n\nRESP: REMAINS VENTED WITH TRACH. ON AC: 30%/500/5/20. BREATH SOUNDS COARSE. SUCTIONED FOR THICK TAN/GREEN SECRETIONS. + PSEUDOMONAS PNEUMONIA. REMAINS ON LASIX GTT HOPING OT DIURESE AND WEAN OFF VENT.\n\nCV: PT. IN AFIB WITH RATE 70'S TO 90'S. SOME RARE PVC'S NOTED. SBP HIGH 80'S TO LOW 110'S. TOTAL BODY ANASARCA. + PULSES. AFEBRILE.\n\nGI: PT. WITH PEG. HAS BEEN NPO FOR COLONOSCOPY THIS AM. MUSHROOM CATH PLACED AFTER CHANGING BED 6 TIMES FOR INCONTINENT STOOLS FROM GOLYTLY. DRAINING LIGHT BROWN LIQUID STOOLS. MDS AWARE.\n\nGU: FOLEY IN PLACE DRAINING CLEAR YELLOW URINE. GOOD OUTPUT. (REMAIN SON LASIX GTT)\n\nACCESS: R AC PICC\n\nPLAN: PT. TO HAVE COLONOSCOPY IN AM. AM LABS PENDING. WILL NEED TO REPLETE LYTES AS NEEDED. CONTINUE WITH CURRENT POC. TRANSFER TO CCU IN NEAR FUTURE FOR PROCEDURE. NO CONTACT WITH FAMILY THIS SHIFT. FULL CODE\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-27 00:00:00.000",
"description": "Report",
"row_id": 1624106,
"text": "Resp Care\nRemains intubated and ventilated on a/c 500 x 20 30% +5 with no remarkable changes overnight. Continues to have thick yellow , often coughing up into vent tubing. O2 sats 99-100. stopped this morning due to increased resp rate (>35). Pt scheduled to have colonoscopy later today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-27 00:00:00.000",
"description": "Report",
"row_id": 1624107,
"text": "Respiratory Care\nPatient placed on CPAP/PSV at noon. Suctioning moderated amounts of thick yellow secreations frequently, q2-3hrs. Breath sounds diminished, coarse throughout. MDI's given as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-10 00:00:00.000",
"description": "Report",
"row_id": 1624034,
"text": "NPN M/SICU ICU day 2 (0700 -1900)\n\nEvents: Recieved 3L NS bolus r/t hypotension with good effect. A line inserted. TPA instilled into obstructed port and now flushes and draws appropriately. Repleted K w/ 40meq PO. No other significant events.\n\nReview of Systems:\n\nNeuro: Alert opens eyes spontaneously and nods head appropriately in response to simple questions, PEARL, MAE on bed, able to track and follows commands consistently. No c/o pain but obvious facial grimace upon repositioning.\n\nCV: Afib with occasional ventricular ectopy, rate well controlled w/ PO dilt. Pt became hypotensive to low 70's recieved 3 liters NS w/ good effect. A -line placed and pt has been normotensive since its insertion. Anasarca persists. Please refer to carevue for objective data.\n\nResp: 7.0, vent dependent on A/C 40% 450 x 14 PEEP 5, overbreaths vent by 10 - 14 BPM, most recent ABG 7.50/49/72 (team aware). LS coarse throughout, suctioned for copious amounts of thick yellow secretions q 1 hr.\n\nGU/GI: TF started this evening (nutren pulmonary) @ 10cc/hr goal rate is 50cc/hr and can be advanced @ 20:00. Abd soft/NT/ND, +BS, large loose BM x 1 (stool sent for C-Dif). Patent foley draining >30cc/hr however pt remains 2.6 liters positive since midnight.\n\nAccess: R DL power picc, all ports flush and draw appropriately.\n\nPlan: Family @ bedside this afternoon, and spoke @ length with RN in regards to POC. Cont Abx Tx and tx hypotension w/ NS fluid boluses . Cont to monitor/maintain heme/resp status, wean vent support as tolerated. Update family on POC as it develops.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-17 00:00:00.000",
"description": "Report",
"row_id": 1624060,
"text": "NPN 1900-0700\nEvents: Became hypotensive to 66-70s via ABP after turning to R side following bathing pt. NBP slightly higher. No drop in sats (99-100) or change in RR, low 20s. No change in HR 90s-100s, a-fib, occ to freq pvcs. Gave 2 500ml fld boluses and started Neo at 1mcg/kg/min, with good response, sbp up to 100. Hct sent, 23, stable, but team wanted to transfuse anyway, so one unit pc given. Trying to wean neo, currently at .6mcg/kg/min.\n\nNeuro: Clonepin .5mg given po prior to above event, doubt it was related, but pt more lethargic during above episode, ? if lethargy was related to conepin or hypotension. Pt more awake few hrs after. Slept in short naps. Denies pain. Pt follows simple commands inconsistently.\n\nCV: HR 89-104, a-fib, freq multifocal pvcs. Dilt held all noc. Maintaining sbp >100 c Neo. EKG done, no changes. Troponin levels sent. Vit K given for INR 1,6. 40meq kcl given for K 3.8. Free water increased to 150mls q4hrs due to Na 147. Repeat labs in am with vanco trough. +pp.\n\nResp: Resp pattern appeared comf all noc, RR low 20s, sats 99-100, VT 400-450. Peep was dropped from 12 to 10 due to hypotension s problem.\nLS coarse, dim in bases. Sx somewhat more freq for mod amt thick, tan to yellow secretions.\n\nID: Afebrile, no incr in wbc. Bld and urine cx sent. cont imipenem and vanc.\n\nGI: +BS, abd soft dist. TF at goal, incr free water. No stools.\n\nGu: U/o 30-80mls/hr clear, yellow urine.\n\nSkin: Intact except for upper back pressure sore covered c duoderm.\nGeneralized edema t/o body.\n\nPlan: Titrate neo to BP. Evaluate dilt with team. Monitor hct, lytes, replete as needed. monitor for black stools, freq turning and skin care.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-17 00:00:00.000",
"description": "Report",
"row_id": 1624061,
"text": "Resp Care,\nPt. remains on A/C overnoc. Peep decreased to 10 this shift, following episode of hypotension. PO2 acceptable. Suctioned for moderate amount thick yellow sputum, MDI's as ordered. Cuff pressure 40cm, 13 cc air in cuff. RSBI not done due to peep level. See carevue.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-17 00:00:00.000",
"description": "Report",
"row_id": 1624062,
"text": "Addendum\nAt 6am, pt had medium, black, tarry stool, OB+. Also, FSBS was 82, will repeat in one hour.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-17 00:00:00.000",
"description": "Report",
"row_id": 1624063,
"text": "79 yr old pt with pseudomonas PNA, s/p mva and and pegged since . 3 rd admit to since with prob VAP. trach changed on and again on . events today: neo stopped 0930 after on for approx 12 hr for bp drop to 60's sys. continues to have black tarry hem pos stool, last transfused early am and crit bumped . 1500 labs pending\n\nneuro: pt somulent, aroused with stim and answered questions appropriatley. still quiet groggy . clonazapam d/ced last dose 20 . lorazapam d/ced and last dose 0800 am > 24 hr ago.\nPERL. lt arms moving less than yesterday independently. no independent\nmovement rt arm of legs.\n\nresp: no changes in vent settings. mod amt secretions suctioned about 5x by this nurse. sent. sat 98-100 gas improving to ph 7.43/ 46/114 . resp rate 25-28 comfortable. poss change trach to bovina with foam cuff for persistant cuff leak.\n\ncard : afib rate 90-104 range. neo off since 0930. pvcs were up to 16/min this am and seemed to decrease after neo off with current pvc's / min. bp 107-130's off neo and dilt dose given at 1300. bp stable since. feet and rt hand cool, good pulses by . ck repeated at 1500. total body anasarca\n\ngi: crit up after last unit of bld and repeat crit at 1500 pending. mod amt black tarry hem pos stool at 11:00. pt has had tarry stool since noted at and has had total 6 units prbcs since combined from and . poss to have endoscopy tommorrow.\ntube feeds at goal pos hyperactive snds. 150 cc h20 q 4hr free water.\n\ngu: urine started to have visible red cells at approx 1000 md made aware. pt has had hx of hematuria. inr 1.3.\n\nrenal: urine 40-80 cc/hr. creat down to 1.3.\n\nendo: stim test done. glaucose level low all shift 80-90 range. glargene decreased from 32 to 30 units.\n\nID: afeb for > 24 hrs wbc up to 11.3 today. no change in antibx. vanco dose given for level 15/1 this am.\n\nskin: no breakdown other than ulcer on back covered with dueoderm. elevated rt arm on pillows for edema.\n\nsocial: son in today and updated him as well. family stil concerned with lethargy.\n\nplan: monitor labs from 1500 and cont bp monitor. poss trach change and poss endoscopy in am.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-17 00:00:00.000",
"description": "Report",
"row_id": 1624064,
"text": "resp care - pt remains on full vent support. No changes made this shift. ABG showed compensated resp acidosis with good oxygenation. BLBS were coarse t/o, clearing slightly on suctioning of varying amounts of thick, yellow secretions. MDIs given as ordered. See carevue for more detail.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-25 00:00:00.000",
"description": "Report",
"row_id": 1624131,
"text": "ekg afib, rate 90s, occ pvcs. sbp stable. lowgrade temp, 99.4. adequate uo, moderate diuresis after earlier lasix. breath sounds clear, decreased at bases, trach suctioned for mod to copious amts thick yellow/white secretions. small amt yellow exudate around trach site. remains on cpap. no vent changes overnight. chest dressing dry, changed. abd soft, bowel soinds +, mod soft formed stool x 1. tolerating tf, replete with fiber at 80 cc/hr. feet warm, dp and pt pulses bilat, wearing csl and waffle boots. allevyn dressing to mid back is intact, groin rash is pink, improved. opens eyes to voice, sometimes speaker, but is very deaf. did move feet and l hand asked. plan to move to rehab to day.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-25 00:00:00.000",
"description": "Report",
"row_id": 1624132,
"text": "pt stable, transferred to rehab @ 1500 via ambulance\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-18 00:00:00.000",
"description": "Report",
"row_id": 1624068,
"text": "NPN 0700-1900\nFull code, contact precautions\n\nNeuro: Pt alert for most of day, flat affect, occasional head nod or smile. Able to move LUE purposefully. Afebrile. Rec'd Ativan 1mg x1 increased gagging after trach change w/good effect. Rec'd 2mg midaz/50mcg fent during endoscopy with very good effect.\n\nCV: Pt in afib with occasional PVC's, diltazem for rate control which has been in 80's and 90's throughout shift. BP's stable, even throughout endoscopy, see carevue. 3+ pitting edema in all extremities. Echo done today, results pending, Hct now stable @ 27, endoscopy unrevealing, no tarry stool this shift: probable lasix gtt to start to begin diuresis. Art line to be d/c'd pt noted to have cool L hand, brachial pulse palpable. Fibrinogen to be drawn next rounds.\n\nResp: Improving RLL psedomonas PNA on Vanc and Imipenim. RR in 20's, sats >95% on CMV 40%/500/10 PEEP. Trach changed today to decrease leak size and improve tidal vol's. Pt now has flexi phlange hyperflex trach #8. Additional trach on order from . ABG wnl this pm, see carevue\n\nGI: TF was at goal of 50 with no residual, +BS in firm/distended, nt adb. Became NPO for endoscopy this pm, expect to restart TF. No stool this shift. Endoscopy showed clean PEG insertion, diverticulosis x1 but no active bleeding evident.\n\nGU: Patent foley draining amber clear urine @ 30cc/hr.\n\nSkin: tear on L forearm; dressing on upper back placed last night and should not be changed until . PICC dressing to be changed @ 0000.\n\nLines: PICC patent, draws. Art line to be d/c'd\n\nSocial: Daughter and her 3 teen children for !2hrs today. Pt minimally interactive. Family to discuss code status later this wk\nPlan: Monitor and support hemodynamics\n Fibrinogen draw next rounds\n ? restart TF\n ?Lasix gtt\n T q2, sxn prn\n IV abx as ordered\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-19 00:00:00.000",
"description": "Report",
"row_id": 1624069,
"text": "Nursing Note:\n\nNeuro: pt alert, opens eyes, follows commands inconsistantly. occasionally nods head or gives facial expressions. pos gag and strong cough. received 1mg prn ativan overnight, does not respond to pain assessment, does not appear in any pain/distress.\n\nResp: trach intact (8.0 TTS water seal cuff), no vent changes ovenright. remains on AC 22/500 PEEP 10, FIO2 0.40. sats 97-100. lungs clear/coarse upper/diminished lower. suctioned for moderate amts thick white/tan. spare trach x2 at bedside.\n\nCV: HR 85-110 afib w/ occ PVC's. NBP 90-115/60-75, systolic BP noted to be in 80's occasionally when sleeping, MAP >60. diltiazem held @ MN (MD aware). pt has +3 generalized pitting edema. pos distal pulses.\n\nGU: pt started on lasix gtt overnight for low UO (goal 30-40cc/hr). presently at 2mg/hr. UO 20-35cc/hr clear amber. MD aware.\n\nGI: abd firm/distended, pos bowel sounds, TF @ goal of 50/hr via PEG, pt tolerating well, minimal residuals (<10cc). sm soft black stool x1 overnight, guiac pos.\n\nIV: r brachial PICC remains WNL, dressing/stat lock and caps changed overnight.\n\nSkin: dressing on upper back remains intact. no further skin breakdown noted. pt turned and repositioned off back. SCD's on legs.\n\nSocial: no calls/visits from family overnight.\n\nPlan:\ncont. to monitor hemodynamics, resp status (suction prn), urine output w/ lasix gtt.\n\ncont to assess potential for pain, anxiety, cont to provide updates on pt on plan of care, procedures.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-11 00:00:00.000",
"description": "Report",
"row_id": 1624035,
"text": "NSG.NOTES 1900-0700HRS\n\nNeuro:alert,responding to commands and obeying.denies any pain,comfortable on bed.generalised edema.\n\nResp:,vented,AC/14/450/5/40%/.suctioned large thick secretions.sats >95%.LS coarse throughout.trache care given.\n\nCVS:HR 90-100/min,afib,no ectopics noted.BP 110-130/60-70 mm of hg.A line on Lt radial,patent,slight bleeding from site,dresing changed.\n\nGU/GI:PEG present,BS hypo,feed advanced to goal rate of 40ml/hr,and flush with water50ml q6h.tolerating feeds.had large black loose stool.\non foley cath,urine output adequate,amber clear.\n\nIntegu:pressure sore on upper back,cleaned and duoderm applied.edema ++.bath given and position changed.on bactrim,genta and imipenam\n\nIV access:Rt midline double lumen cath,one port patent.dressing changed.A line on Lt radial.\n\nsocial:no family contact during the shift.calm and co operative.full code.on contact precautions for MRSA PNA\n\nPlan:pulmonary toileting and airway management.care of skin.emotional support.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-25 00:00:00.000",
"description": "Report",
"row_id": 1624099,
"text": "Shift Note: 0700-1900\nNeuro: Pt alert, and vented. Opening eyes spontaneously and following commands consistently. Shakes and nods head appropriately. Continues w/ profound generalized weakness. OOB to chair X 5-6hr today via lift and tolerated well. Pt denies pain t/o shift, appears calm and relaxed and remains free of distress.\n\nResp: Vented AC 500/5 X 20 FiO2 30% though tolerated CPAP/PS 25/5 X 3-4hr today when OOB to chair. BBS course to somewhat diminshed at bilat bases. Snx q3-4hr for small to moderate amounts thick white secretions. Pt remains afebrile.\n\nCV: HR 70's to 80's afib w/ occasional PVC. BP 89/60 to 117/62. Continues on lasix gtt at 4mg/hr. Hct stable at 23.8 though pt continues w/ occasional loose black tarry stools. Team - aware/. CT MD in on consult today, discussed pt status and goals of care w/ family. Plan for pt to be transferred to CCU r/t plan for valve replacement after labor day. Family updated on pt status and discussed POC w/ Dr. today and family reports that the risks of valve replacement have been \"well explained.\" Family to discuss plan w/ pt later this week.\n\nFEN: Pt tolerating TF at goals. Abd soft, non-tender w/ BS present. Plan to change TF to nutren 2.0 w/ and new goal rate will be 40ml/hr. TF to be sent to unit from dietary. FSBS has remained stable 70's though new TF formula w/ >50% carbohydrate load compared to current feeding so anticipate higher blood glucose levels. Glargine dose has been decreased to 26units per orders. Foley catheter patent and draining clear yellow urine 80 to 120ml/hr. K 3.8 was repleated previous shif per report and orders.\n\nSocial: Family has been in to visit and discussed plan w/ team and CT MD as above. Information reinforced by this RN. Family very appreciative of care.\n\nPlan: Continue to monitor VS and labs. Continue Po dilt and lasix gtt as ordered and per written parameters. Monitor for s/s bleeding and follow hct. Anticipate PRBC tx to elevate hct prior to procedure. Continue OOB to chair as tolerates during day w/ CPAP/PS as tolerated. transfer to CCU.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-25 00:00:00.000",
"description": "Report",
"row_id": 1624100,
"text": "Resp Care\nPt remians with #8.0 TTS H2O cuff on a/c. pt got up to chair today and was switched to PSV 25/5 for >3hours while in chair, he was switched back to a/c due to decreased vts and tachypnia. BLBS course, suctioned for thick pale yellow secretions. plan to remain on a/c overnight and trial psv tomorrow as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-26 00:00:00.000",
"description": "Report",
"row_id": 1624101,
"text": "NPN 7P-7A\nTHIS IS A 79YO WITH EXTENSIVE PMH ADMITTED FROM WITH SEPSIS. PT. FOUNT TO HAVE PSEUDOMONAS IN . HE IS VENT DEPENDENT. AT TIME OF ADMISSION PT. FOUND TO BE IN RAPID AFIB. SINCE ADMISSION HAS BEEN TREATED WITH MULTIPLE ANTIBIOTICS, FLUIDS AND DILTIAZEM. RECENTLY HAS BEEN HAVING BLACK TARRY STOOLS WITH HCT DROPS. FAMILY DECLINING COLONOSCOPY AT THIS TIME. ALTHOUGH, FAMILY HAS BEEN INQUIRING ABOUT A 'PERCUTANEOUS VALVULOPLASTY PROCEDURE' THEY HAD LOOKED UP AND FOUND ON INTERNET. RISKS OF THIS PROCEDURE HAVE BEEN EXPLAINED TO PT.'S FAMILY. PLAN IS TO HAVE HIM TRANSFERRED TO CCU AT SOME POINT BEFORE LABOR DAY WEEKEND.\n\nNEURO: PT. ALERT. NODS HEAD YES AND NO APPROPRIATELY TO QUESTIONS ASKED. DOES FOLLOW SIMPLE COMMANDS. APPEARS VERY FRUSTRATED. OOB TO CHAIR X 5 HOURS YESTERDAY VIA LIFT.\n\nRESP: PT. WITH TRACH AND ON AC: 30%/500/20/5. TOLERATED CPAP+PS X 4 HOURS YESTERDAY. BREATH SOUNDS CLEAR. DIMINISHED IN BASES. CAN BE COARSE AT TIMES, HOWEVER, CLEARS WITH COUGHING. SUCTIONED FOR MODERATE AMOUNTS OF THICK WHITISH .\n\nCV: HR 70'S TO 80'S AFIB. SOME RARE PVC'S NOTED. BP 80'S/40'S TO 110'S/70'S. LASIX GTT OFF AT START OF SHIFT AS BP WAS LOW. GIVEN ALBUMIN X2 AND 2U PRBC'S FOR HCT OF 20. + PULSES. 4+ PITTING/WEEPING EDEMA REMAINS PRESENT. AFEBRILE. CT MD IN TO SEE PT.'S FAMILY TODAY TO DISCUSS PT.'S PLANNED PROCEDURE AND GOALS OF CARE. RISKS WERE 'WELL EXPLAINED' AND FAMILY CONTINUES TO BE VERY AGGRESSIVE WITH CARE.\n\nFEN: TOLERATES TFEEDS AT GOAL RATE OF 40CC/HR. ABD. SOFT. BS+ . NO BM THIS SHIFT. FSBS HAVE REMAINED STABLE. FOLEY IN PLACE DRAINING CLEAR YELLOW URINE. ? RESTART LASIX GTT WHEN BP IMPROVES.\n\nPLAN: CONTINUE TO MONITOR RESP/HEMODYNAMIC STATUS CLOSELY. AM LABS PENDING. REPLETE BLOOD PRODUCTS AS NEEDED. ? RESTART LASIX GTT IF BP IMPORVES OVER THE NEXT FEW HOURS. CONTINUE TO WEAN VENT AS TOLERATED. TRANSFER TO CCU\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-26 00:00:00.000",
"description": "Report",
"row_id": 1624102,
"text": "Resp Care\nRemains and ventilated on a/c 500 x 20 30% +5 with no remarkable changes overnight. Strong spontaneous cough, suctioned for thick yellow . Failed again (142)\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-26 00:00:00.000",
"description": "Report",
"row_id": 1624103,
"text": "MICU EAST NPN 0700-1900\n\nPlease see flowsheet for further details.\n\nAlert. Nods head appropriatly. Denies pain.\n\nAnasarca. Lasix gtt resumed and currently a rate of 4mg/hr. No improvement in UO as yet.He is currently ~550cc positive since midnight. Goal is 6mg/hr of Lasix. Plan to continue to titrate as by BP >90sys.\n\n\nCurrently recieving Golytely prep for colonoscopy tomorrow. No stools at present. Rectal bag on. NPO except for meds. Pt needs colonoscopy before surgery can be done. No noted bleeding this shift. Did not get OOB-chair d/t colonoscopy prep and travel to CT.\n\nNo vent changes. Suction freq for sm thick yellow . Maintaining\ngd O2sats.\n\nAfebrile.\n\nPre-op Chest CT done. Needs dental x rays but may be difficult as pt must be able to sit up. Ventilator also poses a problem per radiology tech. Team to consult radiology/dentist. ? if pt is aware of surgery. His son said he didn't want him to know until later d/t his anxiety.\n\nSon most of afternoon but has gone back to .\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-26 00:00:00.000",
"description": "Report",
"row_id": 1624104,
"text": "Respiratory Care\nPatient remains on full ventilatory support. Suctioned for moderate amounts of thick yellow secreations on a frequent basis. Breath sounds coarse. Transported to CT for thoracic scan and returned without incident.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-16 00:00:00.000",
"description": "Report",
"row_id": 1624056,
"text": "NPN 1900-0700\n79 yo ma s/p MVA on , has been vent dependent since with trach and peg. Adm on for hypotension sepsis, now stable VS. Trach was changed to larger trach c improved comfort. Black tarry stools with hct drop req transfusion over last few days, hct stable o/n.\n\nNeuro: Alert, follows commands inconsistently, does not always answer questions with full nod, does not appear to have pain by VS or grimace. Lorazepam 1mg given x2 c good effect. Barely able to move extremities due to edema.\n\nCV: Cont in A-fib. Coumadin and ASA were d/c'd #days ago due to hct drop. HR 84-97, freq pvcs. SBP 85-132. SBP dropped to high 80s after po Dilt dose given, remained high 80s for ~ one hr. Hct o/n stable at 23.4, am labs pending.\n\nResp: On AC 40%/500x20, peep8, overbreathing vent by 0-5. Sats 96-99, Sx ~q2hrs for mod amt thick, tan to bld tinged sputum. LS coarse, dim at bases. Trach care done, sm amt bldy dng. Much improved night with this trach.\n\nID: Afebrile. On vanco and imipenem. MRSA in sputum.\n\nGI: +BS, abd obese, distended. TF at goal 50mls/hr per peg. No stools this shift, passing flatus.\n\nGU: Lasix d/c'd due to incr in cr to 1.5. Pt anasarca, 3+ fld. +1.3L , 4.7L los. U/o now 35-40mls/hr, clear, amber urine.\n\nSkin: Lower legs ecchymotic, L foot colder than R foot, +pp. Pressure sore in upper back covered by duoderm, 1cm round opening, washed c saline. Extremeties heavy with fld.\n\nAccess: a-line, L picc.\n\nSocial: Daughter updated by Dr. .\n\nPlan: F/u on am hct, lytes. transfuse for hct 21. monitor temps, suction prn, maintain pt's comfort and support to family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-16 00:00:00.000",
"description": "Report",
"row_id": 1624057,
"text": "RESPIRATORY CARE:\n\nPt remains , vent supported. No changes made overnight. BS's coarse at times. Sxing thick white/tan secretions. Administering Albuterol and Atrovent MDI's in line with vent, as ordered. RSBI=85 this am. See flowsheet for further pt data. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-16 00:00:00.000",
"description": "Report",
"row_id": 1624058,
"text": "Resp Care\nPt remains on CMV via trach. Pt has had small reoccurring cuff leak, pt exhaling during inspiration and has been tachypnnic. Peep was increased, pt seems more comfortable on vent. Cuff has been inflated with 13cc's pressure 45, team is aware. Plan to monitor resp status and eval trach.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-16 00:00:00.000",
"description": "Report",
"row_id": 1624059,
"text": "progress note:\n\nneuro: pt nodding appropriatly after much encouragment. seems depressed flat affect. pt almost in tears this am but clearly shook head no when asked if wanted to stop tx. able to lift lt arm purposefully. family feels pt is much less interactive and somulent and requested to stop lorazopam and clonazapam as pt had been snowed and acting \" loopy\" with mind altering drugs in other hosp.\n\nresp: this am pt in distress with RR to 35 and audible cuff leak on end inspiration. air added to cuff and lorazapam 1 mg given and pt settled to rr 24 hr down to 80\" from 110\"s, gas redrawn and alkalosis still seen. cuff leak present again after a few hrs and pt only tv of 340-380 of set 500 cc. resp rate up again to >30 and made vent setting changes to hopefully compensate for tv not delivered. per resp therapist pt still having leak and losing approx 100 cc of tv so increased peep to 12 and pt much more comfortable. gas did not improve much other than inc in p02 and slight decrease in pco2. suctioned several times tan thick secretions. rr currently in 24-28 range with sxat 100 %\n\ncard: a fib with occasional pvcs, hr lower to 80's after ativan otherwise in high 90-11- range. bp 91 sys lowest after ativan and high to 130/91. all doses dilt given. crit 1500 24.2 goo Perp pulses. general anasarca. did not diuresis d/t renal function impairment. but did just start acetazolimide.\n\ngu: pos 800 cc since midnight. urine is less concentrated and apporx 35-40 cc/hr out\n\ngi: no bm pos bs, no flatus. abd distended soft. tf at goal\n\nskin: no further breakdown\n\naccess picc rt arm with swelling no dvt as per ultsnd . flushed with ns the unused port without resisatnce today\n\nsocial: pt daughter in to see him and feel pt is much o=more somulent and weak. she was updated with resp status and progress.\n\nplan: monitor resp status, poss discuss intreventional pulmonology to recheck trach and poss change again. monitor blood gas. skin care\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-24 00:00:00.000",
"description": "Report",
"row_id": 1624126,
"text": "NEURO: PT. ALERT, UNABLE TO ASSESS ORIENTATION, WITHDRAWN AT TIMES, SPONTANEOUSLY MOVES ALL EXTREMITIES WITH NO PURPOSE TO HIS MOVEMENTS. PT. DOES NOT FOLLOW COMMANDS. DOES RESPOND TO PAINFUL STIMULI (NAIL BED).\n\nCV: PT. AFIB, HR 80'S, SBP 110-130, RARE TO OCCASIONAL PVC'S NOTED. SEE CAREVUE FOR COAG'S. SKIN WDI- PULSES PALPABLE.\n\nRESP: PT. LUNGS CLEAR IN RUL, COURSE IN LUL, DIMINISHED IN BASES. SEE CAREVUE FOR VENT SETTINGS AND ABGS. PT. +GAG, +COUGH, SUCTIONED VIA ETT FOR THICK, YELLOW SECRETIONS OF SMALL TO MODERATE AMT.\n\nGI/GU/ENDO: PT. ABD SOFT, +BS, BM X2- BROWN, SOFT, MUCOUSY STOOL, GUIAIC NEGATIVE. TUBE FEEDS (REPLETE WITH FIBER) AT GOAL OF 80CC/HR VIA PEG. FOLEY DRAINING CLEAR TO SEDIMENT, YELLOW URINE. LYTES REPLETED. BLOOD SUGARS TREATED PER RISS.\n\nPLAN: REHAB TODAY?, WEAN MECHANICAL VENTILATION, SKIN INTEGRITY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-18 00:00:00.000",
"description": "Report",
"row_id": 1624065,
"text": "NPN 1900-0700\n79 yo ma s/p MVA on , mostly vent dependent since then, except for few periods of few weeks off. and pegged in , pseudomonas PNA, RLL. Trach changed on and again on . Pt cont to have sm trach leak but much improved. Also has had black tarry stools since noted at , had 6-7 units prbc total between here and there.\n\nNeuro: Alert, follows simple commands inconsistently. Appears withdrawn/?depressed, on celexa. Difficult to get pt to nod adequately to questions. Moves extrem only slightly, heavy c edema. Pt not given any ativan and clonapan d/c'd. Pt appears comfortable without meds.\n\nCV: HR 82-108, a-fib, occ multiform pvcs. No coumadin or ASA. SBP stable 99-132, on dilt 30mg q6hrs. Last hct 26.1, am labs pending. +pp.\n\nResp: No vent changes, peep cont 10. LS coarse t/o. RR 22-25, appears comfortable. Sx ~q1hr for mod amt thick, yellow secr. Discussion of changing trach to bovina with foam cuff.\n\nID: tmax 99.1 ax. Pt dislikes temp by mouth. On vanc and imipenem.\n\nEndo: Glargine decreased to 30units last noc. FS ~ 120.\n\nGi: Abd obese, soft distended, +BS. 50mls goal of TF via peg, 150mls water q4hrs. Had two mod-lge black tarry stools hem+.\n\nGu: Bloody urine noted , now pink/. 30-60mls/hr. Cr has been dropping, 1.3 .\n\nSkin: Pressure sore on upper back, ~2cm round, dsg changed, washed c saline covered c duoderm. LL ecchymotic. general anasarca, Rarm > L. R arm us done, neg.\n\nSocial: Pt has 5 children, they take turns visiting. They have been concerned that pt has been lethargic, concerned re sedative meds.\n\nPlan: Follow up on am labs, hct, lytes. Monitor BP HR. ? endoscopy for cont GI bldg. ? trach change.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-18 00:00:00.000",
"description": "Report",
"row_id": 1624066,
"text": "Resp Care,\nPt. remains on A/C overnoc, no vent changes this shift. #8 Portex trach with occasional cuff leak. Cuff pressure 35cm. Suctioned for thick yellow , MDI's as ordered. No RSBI due to peep level. See carevue.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-18 00:00:00.000",
"description": "Report",
"row_id": 1624067,
"text": "Respiratory Care\nPatient received on AC 500x20 10 PEEP 40%, wearing an 8 Portex, breath sounds bilaterally clear but expiratory grunting heard, suctioned intermittently for moderate amounts of thick yellowish secretions,was afebrile, into chronic A-fib, had occasional, frequent and rare PVCs, Blood Pressure stable all day long, patient had trach tube change around 1300, the 8 Portex has been replaced with bronchoscopy support by an 8 TTS water-sealed cuff, 12 at the flange, initial cuff pressure was 22 CmH2O,the leak persisted in spite of the trach change, patient also had a negative endoscopy today, has been treated with Albuterol and atrovent inhalers, ABGs at 1238 was good, no vent changes have been made, will continue to be provided with mechanical ventilatory support, treatments and close monitoring.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-15 00:00:00.000",
"description": "Report",
"row_id": 1624054,
"text": "Resp Care\n\nPt remains on full vent support. MV being maintained in the 10-13L range. Trach changed to # 8 portex non-fenestrated. Cuff pressure 30. Minimal leak. BS with occ rhonchi. Suctioning thick tan sputum.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-24 00:00:00.000",
"description": "Report",
"row_id": 1624127,
"text": "resp care - Pt is and on PSV. No changes were made in vent settings this shift. Pt was suctioned for moderate to copious amounts of thick, yellow secretions. Meds were given as ordered. Plan is for transfer to rehab.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-24 00:00:00.000",
"description": "Report",
"row_id": 1624128,
"text": "0700-1900\nneuro: awake, alert, follows some commands, pt very withdrawn, , po celexa started, moves extremites on bed, pt very weak\n\ncv: hr a-fib, rare pvc, sbp stable(117-137), po lopressor\n\nresp: no vent changes, continues on 40% cpap ps, sux sm/mod amt loose thick yellow , bs+ all lobes, course, decreased to bases, inhalers by R.T., no resp distress noted\n\ngi: goal TF well, no N/V or stool, iv protonix \n\ngu: foley patent, clear yellow urine, good uo, iv lasix \n\nother: daughter in & updated on pt's condition, no c/o pain\n\nplan: continue with ventilatory support, po antibiotics as ordered, tx to rehab when bed available\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-24 00:00:00.000",
"description": "Report",
"row_id": 1624129,
"text": "FULL CODE Contact precautions\nAllergies: Haldol, heparin (+HIT)\n\n\nNeuro: AA, occ follows commands, nods approp to questions.\n\nCV: HR=90-100s, afib. BO=120-140s/50s. +palp pedal pulses. +generalized edema.\n\nResp: Trach CPAP 40% w/ 02sat 98%. Lund w/ crackles in RLL and LUL/LLL, RUL clear. lasix 20mg IVP given as scheduled. RR=22-28. Sx for yellow .\n\nGI/GU: Abd soft/distended, +BS. TF Replete w/ Fiber at 80cc/hr=goal w/ min resid. Large soft-formed BM. Foley cath w/ amber clear urine.\n\nPain: denies discomfort by shaking head \"no\" to question.\n\nSkin: generalized edema. Allevyn dressing intact on upper back.\n\nAccess: R rad a-line and R antecub PICC double lumen. IVF infusing via one port and second port is difficult to flush.\n\nPlan: rehab placement. Continue to monitor resp/cardiac/neuro status. Wean vent as . Update family on status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-25 00:00:00.000",
"description": "Report",
"row_id": 1624130,
"text": "Resp Care\nRemains and ventilated on cpap/psv wiht no remarkable changes overnight. ABGs within normal limits but maintained with high minute ventilation. Albuterol/atrovent inhalers given q4. Suctioned for thick yellow . = 109.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-15 00:00:00.000",
"description": "Report",
"row_id": 1624055,
"text": "MICU NPN 11AM-7PM:\nEvents of the day:\n\nTrach changed at bedside, upsized to #8 portex no-fenestrated trach. Tolerated this well with 100mcg IV fentanyl.\n\nTransfused with one unit PRBC's over three hours tolerated well. Post hct up to 23.5 from 21.8. Please recheck hct at 2200.\n\nVanco IV added to antibiotic regimen.\n\nNeuro: Sleepy after given the fentanyl for the trach change but more awake and seems restless this afternoon. Nods head to simple questions. Hates to have his PO temp checked. Tylenol given once for generalized discomfort.\n\nCV: Vital signs are essentially stable but BP noted to drop to 90's after getting PO diltiazem. HR 90-110 a-fib w/PVC's noted. BP 90-130/60.\n\nResp: Vent currently on AC 20, 500TV 40% FIO2 with 8cm peep. Less air leak noted after trach change. Trach care done twice for small amts bleeding around site after changing trach. Moderate amts thick tan/bloody secretions. Lungs coarse and deminished throughout.\n\nGI: Tolerating tube feeds at goal. No stool. Abdomen is soft non-tender.\n\nGU: Voiding good amts via foley catheter. Lasix stopped because creatinine rising slightly.\n\nID: Low grade fever this afternoon. On vanco/Immepenum IV.\n\nSocial: Daughter updated by Dr. at length today.\n\nEndo: Blood glusose running 150's and no sliding scale ordered unless glucose is greater than 160.\n\nPlan: Holding off on further aggressive diuresis in hoped that creatinine settles down, follow hct this eve at 2200 with goal hct >21. Continue to follow vital signs closely and keep pt/family involved in plan of care.\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-23 00:00:00.000",
"description": "Report",
"row_id": 1624120,
"text": "MRSA and VRE precautions\n\nNeuro: pt responds to verbal stimuli by opening eyes.. sometimes it looks he follows you with his eyes, but does not respond when asked to shake his head, wiggle his toes or move his extremities\n\nResp: vented and , see Flow Sheet for increased settings D/T rapid RR's acidotic ABG, ABG better with changes, lungs coarse bilat and diminished at bases, suctioning for thick tan secretions\n\nCardiac: hypotensive at times, fluid challange X1 with good results, afib with rare to frequent PVC's, repleated K+ X1\n\nGI: + BS, + medium soft brown BM X1, TF at goal, no residuals\n\nGU: foley to gravity, good output with lasix, VRE of urine\n\nEndo: SSRI per \n\nsocial: family called and updated X1\n\nPlan: follow labs and vitals and treat as indicated and as ordered, OOB with , ? screen for rehab, MRSA and VRE precautions\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-23 00:00:00.000",
"description": "Report",
"row_id": 1624121,
"text": "RESP CARE: Pt remains /on vent, settings per carevue. PS increased for hypercarbia. AM ABG improved. Lungs coarse bilat. Sxd small amts thick yellow. AM -148. Pt remains vent dependent\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-23 00:00:00.000",
"description": "Report",
"row_id": 1624122,
"text": "0700-1500\nneuro: awake, alert, follows most commands, moves extremities on bed, pt very weak\n\ncv: hr a-fib, no ectopy, sbp stable(119-137), po lopressor\n\nresp: continues on 40% cpap ps, bs+ all lobes, course, diminished to bases, sux sm/mod amt loose thick yellow , inhalers by R.T., sat 100, no resp distress noted\n\ngi: goal TF well, no N/V or stool, po colace, iv protonix increased to today(am hct 22.7), GI consult in, giuac neg brown stool noted via rectal exam\n\ngu: foley patent, clear yellow urine, good uo, iv lasix \n\nother: type & screen sent today, pt to get tx with 2 u pc's when blood products ready, no c/o pain\n\nplan: continue with ventilatory support, po antibiotics as ordered, tx 2 u pc's, continue rehab discharge planning\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-23 00:00:00.000",
"description": "Report",
"row_id": 1624123,
"text": "resp care - Pt is and remains on PSV. No changes made this shift. BLBS are coarse; pt was suctioned for varying amounts of thick, yellow secretions. Transfer to rehab planned for tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-23 00:00:00.000",
"description": "Report",
"row_id": 1624124,
"text": "3p to 7p: did get 2 units of blood, vitals wnl's, placed bed on automatic side to side turn, no other changes; plan: ? rehab in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-24 00:00:00.000",
"description": "Report",
"row_id": 1624125,
"text": "Respiratory Care\nPt on vent support. no vent setting changes made this shift. ABG WNL, but maintained by large minute ventilation. Sx for mod to lg amounts thick yellow secretions. BS mostly clear. AM 106.\nPlan is to discharge pt to rehab facility, possibly later today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-10 00:00:00.000",
"description": "Report",
"row_id": 1624031,
"text": "Nsg.admission notes 2130-0700hr\n\nAllergies:HALDOL,HEPARIN.(heparin induced thrombocytopenia)\n\n79yo male pt from HC,third admission to , and vented,vent dependent from ,a case of TCP,depression,s/p valvuloplasty,pleural effusion,MRSA PNA,T9 compression Fx,c to MICU for increasing lethargy ,temps,VAP and also family request.blood c/s +ve staph,sputum c/s +ve pseudomonas,was on vanco,may need to continue ,started meropenam.\n\nNeuro:alert,responding to call and commands,not mouthing words.lethargic.generalised edema.\n\nResp:,vented,AC,14/450/10/405.SATS >95%.suctioned thick yellow secretions.sputum c/s sent.LS coarse throughout.\n\nCVS:HR 100-120's,ST-NSR.no ectopics noted.received 2unit blood transfusions in for low crit.Blood c/s 2 samples sent.Blood gas done .pneumoboots to be applied.both LE black coloured,more on Lt.leg.boots on,pulse easily palpable on Rt leg,and difficult on left leg.\n\nGU/GI:abdomen obese,bowel sounds hypo,PEG ,site cleaned and dressing applied.NPO.Had BM,large black loose stool.on foley cath,amber clear urine.received 20mg iv lasix with minimum effect\n\nIntegu:skin impaired on spine,duoderm .temps 101.3 on admission.sponge bath given and positioned.\n\nSocial:no family contact or during the shift.MRSA on contact precautions.full code.\n\nIV access:PICC on Rt ante cub,red port is patent,flushing well and good blood flow,purple port unable to flush,informed ,may need TPA to maintain patency.\n\nEndo:on SSI,Not covered.\n\nPlan:pulmonary toilet.\nantibiotics,Temp's,and control infection.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-10 00:00:00.000",
"description": "Report",
"row_id": 1624032,
"text": "Resp Care\nPt transfer from OSH. placed on vent ( see carvue for settings) Pt has a # 7 shiley trach. suctioned for thick copious blood tinged pluggy secretons, sample sent. Xray show, bilateral infiltrates and small lung fields. High Hco3 and Paco2 in abgs. Decreased fio2 and increased peep to help in ventilaton. Mdis started: notable decrease vent pressures. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-10 00:00:00.000",
"description": "Report",
"row_id": 1624033,
"text": "Respiratory Care:\nPt remains and vented. PEEP decreased to 5 from 10 d/t hypotension.ABG showed non-compensated metabolic alkalosis with mild hypoxemia. Lung sounds coarse. Suctioned moderate to copious thick yellow secretions. MDIs given per order. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-24 00:00:00.000",
"description": "Report",
"row_id": 1624091,
"text": "\u0013npn 7p-7a (please also see careevue flownotes for objective data)\n\nAfebrile, vss; v-response remains in 80's, diltiazem held approx every other dose, receiving approx q 12 hrs instead of q 6 hrs;\n\ndx: sepsis; resp failure; transfer from \n\nOn A/C from approx 22:00-05:30; switched to PS again at 05:30;\n\nMajor goal at this time is to continue diuresing this pt; lasix gtt at 4 mg/hr most of this 12 hrs, decreased from 5/hr at 19:00, for fear of diuresing too fast;\n\nPt continues to receive K+ supplement d/t loosing 2/t lasix being non K+ sparing;\n\nReceiving Gargine at HS; FS's have been in good range;\n\nPt more alert and responsive with eye contact/tracking, smiles, gestures; did not sleep much this night;\n\nPLAN:\nContinue current POC;\nfurther plan per rounds\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-15 00:00:00.000",
"description": "Report",
"row_id": 1624051,
"text": "NPN 1900-0700\n79 yo ma s/p MVA , vent dependent since. Remains in a-fib, but off coumadin d/t drop in hct to 19.9.\n\nNeuro: Alert, awake, follows simple commands. Difficult moving extrem c lge amt edema. Does not appear to be having pain per VS, grimace scale and non-.\n\nCV: HR 102-112, a-fib c occ pvcs. SBP 102-158. Received 2 units pc yest for hct 19.9, up to 24, am lab pending. Received 3 u total FFP. K 3.8, repleted c 40meq kcl in 500mls.\n\nResp: Received on AC/40%/450x20/8peep. At 8pm, tachy and hypertensive to 158, RR 36. Sx few times, thick, bld tinged sputum. Desated to 88 x2. Peep incr to 10 and fio2 to 50% c improved VS. Pco2 up to 63, so TV incr to 500 and fio2 back to 40%. Sats cont 97 or > remainder of noc. pco2 down to usual 52. placed back on 8 pep at 0400, cont good sats and RR 25-30. LS coarse, sx ~q2-3 hrs.\nCont to have cuff leak on this trach, ? needs larger trach.\n\nGI: ABD obese, +BS. TF at goal of 50mls/hr via peg. Had one soft, black tarry stool, OB+, also passing flatus.\n\nGU: Receiving lasix 40mg c fair response. Urine yellow to amber, clear, adequate vols. Pt fld balance + 3.8L los.\n\nEndo: Receiving humalog for SSI, FS 228, and glargine.\n\nID: Tmax 100 ax. On miripenim and bactrim. MRSA prec.\n\nSkin: Duoderm intact on upper back pressure sore. Bilat lower legs ecchymotic, L>R. L foot colder than R. 3+ edema all extrem and body.\n\nSocial: Family will be in tomorrow, no calls tonight.\n\nPlan: Monitor RR, abgs, wean vent as . Replete lytes prn. ? further lasix.\n\n\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-15 00:00:00.000",
"description": "Report",
"row_id": 1624052,
"text": "Respiratory Care:\n\nPatient with 7.0 Portex. changed . Increased cuff pressure to 50cm/H20 to seal trach. Positional leak at times. Pt. desating to 88%. Sx'd for thick blood tinged secretions. O2 sats improving to low 90's. Peep ^ 10cm/Fio2 ^ 50% and later weaned back to now current settings. PaCo2 rising to 63. Vt ^ 500. Current settings Vt 500, A/c rate 20, Fio2 40% and Peep 8. ABG reveals compensated resp acidosis. BS coarse bilaterally. Albuterol/Atrovent MDI's given q4hr.\nSx'd for sm-moderate amounts of thick blood tinged secretions. No further changes made.\nPlan: Continue with mechanical support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-15 00:00:00.000",
"description": "Report",
"row_id": 1624053,
"text": " 4 NURSING PROGRESS NOTE 0700-1100\nNEURO--PT ALERT, NODDING HEAD TO SIMPLE QUESTIONS. SQUEEZES HANDS TO COMMAND. PT IS VERY STIFF AND NEEDS ASSIST OF 3 PERSONS TO TURN. PT WANTS TO WATCH RED SOX AT 1100.\n\nCARDIAC--REMAINS IN AFIB WITH RATE 90-110. RARE UNIFOCAL PVC'S. RECEIVED KCL REPLACEMENT THAT WAS STARTED ON NIGHTS. HCT DOWN TO RECEIVE 1U PRBC.\n\nRESP--SX Q2 HRS FOR THICK TAN SPUTUM. REMAINS WITH CUFF LEAK. PLAN IS TO CHANGE TRACH LATER TODAY. BILATERAL BREATH SOUNDS ARE COARSE. SAO2 >97%.\n\nGI--. TUBE FEEDS AT GOAL. STOOL X1. ABD DISTENDED. +BS. STOOL IS BLACK , TARRY AND GUIAC +.\n\nGU--FOLEY CATH PATENT. RECEIVED 40 MG IV LASIX WITH GOOD DIURESIS.\n\nENDO--UNREMARABLE AT PRESENT.\n\nSKIN--DUODERM ON BACK INTACT. BUTTOCKS WITHOUT BREAKDOWN. ORAL CAVITY DRY.\n\nPAIN--DENIES PAIN WHEN ASKED.\n\nID--AFEBRILE. REMAINS ON ABX.\n\nCOPING--NO FAMILY MEMBERS HAVE PHONED OR AS OF THIS TIME.\n\nA--LEAK IN TRACH. FALLING HCT.\n\nP--TX 1 U PRBC. CON'T TO MONITOR. ? WHETHER TO SCOPE TO FIND SOURCE OF BLEED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-24 00:00:00.000",
"description": "Report",
"row_id": 1624092,
"text": "resp care\nPt initially on psv25/peep5 and 40%. Changed to a/c to rest overnight after pt c/o of sob. BS coarse bil. Suct for thick yellow sput.Alb/atro mdi given as ordered. Fio2 weaned to 30% per order. done >100. Will cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-24 00:00:00.000",
"description": "Report",
"row_id": 1624093,
"text": " enetered @1400 on was actually done at 0600. Data could not be entered due to time restrictions in carvue. No value for because numver > than limit of formula value. (JP).\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-24 00:00:00.000",
"description": "Report",
"row_id": 1624094,
"text": "Resp Care\n\nPt placed on cpap/psv during at 1630 while up in chair. On a/c minute volume being maintained in th 9-10L range. BS with scattered rhonchi and suctioning thick yellow .\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-24 00:00:00.000",
"description": "Report",
"row_id": 1624095,
"text": "NPN 0700-1900\nFull code All: Haldol\n\nNeuro: Alert, appears oriented, participating in mouth care, interactive with staff/family although less so than yesterday. Of note, pt reportedly had very little sleep overnoc so that may be why he is less animated today. Afebrile\n\nCV: Stable. Afib, rare to occasional PVC's, rate consistently in 80's/90's. SBP 89-1teen's with MAP>61 throughout shift. Lasix gtt remains @ 4mg/hr. + pitting edema remains in extremities despite diuresis. Denies CP.\n\nResp: Alternating PS and CMV. Currently OOB in chair and tolerating CPAP @ 30%/. Frequent sxn for small amts white to yellow , also pt continues to cough up mucous on his own. Appears to be slightly less productive than . Will attempt deep brthing if encouraged.\n\nGI/Endo; TF well @ 50cc/hr. FS @ 1800 58 mistakenly left off since OOB to chair. amp D50, MD aware. Glargine has been decreased to 28units @ HS. BM x2 soft, brown, guaiac +.\n\nLines: PICC in R patent, dressing changed today.\n\nSocial: one daughter , another daughter/soninlaw phoned/\n\nPlan: Continue diuresis, pt will be able to dispo when fluid removed\n PS as \n RISS/ TF\n Encourage c/db, interaction\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-25 00:00:00.000",
"description": "Report",
"row_id": 1624096,
"text": "npn 7p-7a (please also see carevue flownotes for objective data)\n\ndx: sepsis; resp failure/vent dependency\n transfer from for lethargy, persistent fevers\n\n79M w/ pmhx AS s/p valvuloplasty, IDDM, PAF, MRSA pna and c-diff, MVA w/ long hospitalization and Hosp in VT, w/ long hosp course resulting in trach/PEG ;\npt has also been having chronic anemia, family has declined colonoscopy;\n\n recently discharged from after being admitted for hypotension, fevers; Pt was discharged to for further tx and abx, completed abx , spiked fever , abx started/re-started; cx's sent, cx w/ evidence of pseudomonas; pt also w/ episode rapid a-fib, started on diltiazem;\n\n pt returned to per request of family, admitted to 4, for lethargy, fevers, w/u. Has been receiving abx, IVF hydration.\n\nMost recent goal have been for pt to wean from A/C/ vent assist to PS, pt has been needing assist to diurese excesss body fluids;\npt has tremendous interstitial edema, skin taught;\nresp cx's & 21 both + pseudomonas\n\ntoday pt remains on lasix at 4 mgs per hour, with good hourly ourput of 100-160 cc/hr; also continues to received K+ supplementation, this a.m.'s serum K+ is 3.8, same as yesterday eve draw at 19:00--pt received 40 mEq KCL after result available.\n\npt ordered for diltiazem 30 mg po q 6 hrs, has been having good v-response control, has been receiving approx q 12 hrs d/t held doses re b/p given effect of diuresis also on b/p;\n\nduoderm dressg on mid upper back intact, dated ;\nRt a.c. double lumen PICC drssg intact, both ports intact;\n\ntolerating tube feedings w/out emesis or diarrhea;\nhas been stooling mod soft stools;\nblood sugars/FS have been decreasing, pt may need more decrease on hs glargine (was decreased by 2 units )\n\nOOB to reclining chair about 2 p.m. , returned to bed per approx 22:30;\n\npt has been more alert/interactive the past two days, remains nonverbal, but w/ more eye contact and facial expressions/smiles;\n\nfamily has asked staff regarding a 'percutaneous valvuloplasty procedure' they had looked up and found on in the internet; MDs state does not do that procedure, family stated they will look for a hospital that does and will accept pt; in the meantime, reportedly plan is to continue to diurese pt to assist wean on vent, and continue w/ discharge planning--?return to ;\n\nPLAN:\n1) continue current POC\n2) diuresis, goal approx 100 cc/hr\n3) cont to wean on vent, progressing to more time on PS instead of A/C\n4) electrolyte repletion as needed and as ordered\n5) follow FS's, ? decrease glargine dose hs\n6) OOB to cardiac/reclining chair during the day per lift\n7) CT surgery consult in a.m. 8/27 per family's request\n8) MRSA precautions, s/t hx MRSA pna\n9) pt remains FULL CODE\n10) family coomunication: daughter , has been making some decisions re pt's care, even though not official HCP\n11) labs only q 24\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-25 00:00:00.000",
"description": "Report",
"row_id": 1624097,
"text": "(Continued)\n hrs if possible, to avoid blood loss d/t anemia\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-25 00:00:00.000",
"description": "Report",
"row_id": 1624098,
"text": "resp care\nPt initially on psv25/peep5 and 30% while up in the chair.Placed back on a/c 500x20 5peep 30% when placed back in bed.Peak/plat 34/28. BS coarse at times. suct for thick pale yellow sput. Alb/atro mdi given as ordered.Will cont to follow and wean back to psv when in a chair. >100.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-22 00:00:00.000",
"description": "Report",
"row_id": 1624116,
"text": "NEURO: PT ALERT, DOZED ON/OFF THIS SHIFT, AROUSES TO VOICE EASILY. VISUAL ACKNOWLEDGEMENT OF CAREGIVER, BUT WITHDRAWN-VERY LITTLE INTERACTION. FOLLOWS COMMANDS INCONSISTENTLY-SQUEEZED RT HAND X1, OTHERWISE NO COMMANDS FOLLOWED. RESISTS MOUTH CARE, CLENCHING TIGHTLY. EXTREMITIES TENSE DURING SIDE TO SIDE TURNS. NO OBJECTIVE INDICATIONS OF PAIN-ASSESSED BY VITALS & GRIMACE.\n\nCV: AF, HR 70s-80s. ? START COUMADIN. BP 100s-110s, UP TO 150s W/ACTIVITY OR WHEN SXN'D. +PP. EXTREMS W/D. COMPRESSION SLEEVES ON. AFEBRILE.\n\nRESP: LS COURSE BILATERALLY, O2SATS >97%. NO VENT CHANGES THIS SHIFT-REMAINED ON CPAP/PS 40/5/10. TV 300s-500s. RR 20s-30s. OCCAS. SXN'D SM-MOD AMTS THK YELLOW SECRETIONS. TRACHE CARE DONE BY RT. SEE CAREVUE FOR LATEST ABGs.\n\nGI/GU: TOLERATING FS REPLETE W/FIBER @ GOAL=80cc/hr VIA PEG; NO RESIDS. +BS. ABD SOFT, NT, ND. LG BROWN SOFT FORMED STOOL X1. HUO ADEQUATE, CLR YELLOW W/SEDIMENT.\n\nENDO: RSSI PER SS-COVERAGE REQUIRED OVERNOC.\n\nSOCIAL: ? PLAN TO D/C TO REHAB . D/C PAPERS TO BE COMPLETED. NO TELEPHONE CALLS FROM FAMILY THIS SHIFT.\n\nPLAN: CONTINUE MONITORING CARDIORESP STATUS, LABS. PULM TOILET. ?START COUMADIN; ? TRANSFER TO REHAB , COMPLETE D/C DOCUMENTS. SUPPORT/UPDATE FAMILY RE: PLAN OF CARE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-22 00:00:00.000",
"description": "Report",
"row_id": 1624117,
"text": "RESP CARE: Pt remains /on vent on PSV 10/5/.40. Vts 300s/RR 30s.Lungs rhonchi L>R. Sxd small amts thick yellow . MDIs given per POE with little effect noted. AM -126.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-22 00:00:00.000",
"description": "Report",
"row_id": 1624118,
"text": "Respiratory Care\nPt weaned on PSV to attempts to wean to resulted in a PH of 7.29, psv increased to with resulting abg 731/59/83/31/0/94. mdi as ordered, suctioned for mod amts of frofty white secrections. Pt planning on going to rehab. ? tommorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-08-22 00:00:00.000",
"description": "Report",
"row_id": 1624119,
"text": "Neuro: More alert in PM, still blank stares @ speaker, not follwoing any commands, LE's withdraw to nail bed pressure bilat, but not UE's; PERRL 3mm brisk\n\nCV: Afberile, A fib 80's, SBP labile, 80's when sleeping, hypertensive to 170's when family is here, lopressor dose changed to 25mg TID, weak palpable pulses x4, 1 episode of hypotension after vent change in PM, 250 ml NS fluid bolus given with effect; K repleted; no coumadin NP \n\nResp: Lung coarse all over, received on CPAP , wean PS to 5 @ one point, became more acidotic, PS @ 8 currently, ABG acceptable, Pa CO2 @ pt's baseline; suctioned with thick tan secretion\n\nGI: Abd soft, non-tender, BM x3, soft, brown formed stool, tolerating TF replete with fiber @ goal 80 ml/hr, minimal residual\n\nGU: Foley draining clear/sedimentary yellow urine, restarted on lasix 20 mg , foley changed today due to +urine culture for VRE on specimen\n\nPain: no pain noted\n\nEndo: COver per CSRU protocol\n\nID: +VRE in urine from specimen, foley changed\n\nInteg: upper back wound assessed by wound care nurse, allevyn dressing changed, wound healing per wound care nurse\n\nActivity: OOB to chair via for 2 hours\n\nSocial: Daughter in for visit, met with NP , agreed to look @ Rehab today\n\nPlan: Monitor hemodynamics, resp status, labs; wean vent as ; DC planning; wound care\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-08-12 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 978512,
"text": " 5:56 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: pleural effusion, pulmonary edema, tamponade, pneumothorax,\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with AVR\n REASON FOR THIS EXAMINATION:\n pleural effusion, pulmonary edema, tamponade, pneumothorax, Page \n with issues. . Pt will be in csru in 90 minutes.\n ______________________________________________________________________________\n WET READ: JRCi 10:54 PM\n tracheostomy tube removed and patient intubated with ETT in adequate\n position. There is increased lung volumes and aeration. Swanz ganz catheter\n with tip in the expected region of the main pulmonary artery. Right picc line\n with tip in SVC. No pneumothorax. Small left effusion . Interstitial\n opacities remain.\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Pleural effusion, pulmonary edema.\n\n A single AP view of the chest is obtained on at 1815 hours and\n compared with the prior afternoon's radiograph. Allowing for technical\n differences, there likely is no significant change in the appearance of the\n bilateral alveolar and interstitial opacities and likely bilateral pleural\n effusions. Tracheostomy has been replaced with an endotracheal tube, the tip\n of which is approximately 4 cm above the carina. Swan-Ganz is present with\n its tip in the main pulmonary artery. Patient has just had a cardiac surgery\n with sternal and skin sutures present. A right-sided PICC line is unchanged\n in position.\n\n IMPRESSION:\n\n Stable appearance to the chest with bilateral interstitial and alveolar\n opacities. Intubation with ET tube in satisfactory position.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-19 00:00:00.000",
"description": "Report",
"row_id": 1624070,
"text": "Pt is on AC vent RR 20, New # 8 with water cuff is in place, marker is . There is no identifyable leak but Vte is lower than VTi. Pt getting alb/atr MDI Q 4 hrs. Pt sx for smal amts yellow secretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-19 00:00:00.000",
"description": "Report",
"row_id": 1624071,
"text": "Respiratory Care\nPatient remains on full ventilatory support. Suctioning moderate amounts of thick yellow secreations. MDI's given as ordered. Breath sounds coarse throughout. Transported without incident to CT for scan of the head.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-19 00:00:00.000",
"description": "Report",
"row_id": 1624072,
"text": "NPN 0700-1900\nNeuro: Alert for most of day, continues to have flat affect, be minimally interactive. ?visual field defect, head ct w/o contrast neg. Will move L hand purposefully. Strong gag/cough effort. Afebrile.\n\nCV: Afib, occasional PVC's each hour, HR consistently 80's-90's. Rate controlled with Dilt 30mg QID, noon dose held for BP<100, 1800 dose administered. HR up slightly as pt has begun to cough more in late afternoon. 3+ pitting edema in all extremities but +PP's b/l. SBP>90 all shift. Cardiolgy to consult re: AS and how to maintain intravascular vol, fluid shifts.\n\nResp: A/C 40%, TV 500, Peep decreased to 5 today. LS coarse throughout, increasing creamy/thick secretions this afternoon, Dr aware. Trach site clean\n\nGI: Obese abd with pos bs, no TF residuals. TF Nutren Pulm FS at goal of 50cc/hr. Soft dark brown stool mod x2, guaiac pos.\n\nGU: Patent foley draining amber colored urine with occasional sediment 2 >30cc/hr. Lasix gtt off.\n\nID: ABX changed today to Cefepime, first dose done, continuing on Vanc\nLine: PICC patent, dressing CDI and not to be changed until \nSocial: no family contact this shift\n\nPlan: Sxn prn\n Monitor and support hemodynamics, Dilt for rate control\n Turn q2h\n IV abx as ordered\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-20 00:00:00.000",
"description": "Report",
"row_id": 1624073,
"text": "Nsg Progress Note 1900-0700\n\nCV - Pt hemodynamically stable. BP drops to 90's sys after med with ativan but returns to normal shortly. IVF at KVO via right AC PICC line.\n\nResp - BS course bilat. Remains on a ventilator with no changes to settings. Pt initially suctioned for mod to large amt creamy secretions. Amount of secretions decreased signif over course of the night. spec sent.\n\nGI - Abd soft - hypoactive BS. No BM. Tolerating TF's very well. Continues to recieve H2O bolus q 4 hours.\n\nGU - Foley cath draining adequate amt cl yellow urine. Scrotum grossly edematous.\n\nNeuro - Pt able to communicate with nods. Does not move extremities on his own. Pt denies pain but did request ativan so he could rest.\n\nSocial - no contact from family.\n\nSkin - turned as tolerated - no signs of breakdown noted. Back dsg dry and intact.\n\nDr. would like to speak to the family when they come in.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-20 00:00:00.000",
"description": "Report",
"row_id": 1624074,
"text": "Respiratory Care:\n\nPt remain on full/ assist ventilatory support via traheotomy tube ( TTS ~12 cm; water seal). No vent changes done. He was unable to complete , ask for exemption. BS are coarse bil, No wheezes. MDI's adm as ordered with No changes noted in BS. We are sxtn for scant to mod amt of thick whitish to yel secretions, active cough. Plan: awaiting family meeting & will Continuen present ICU monitoring. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-21 00:00:00.000",
"description": "Report",
"row_id": 1624081,
"text": "Respiratory care\n\n Pt continues on full ventilatory support. Sx'd for sm thick yellow. MDI's as ordered. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-21 00:00:00.000",
"description": "Report",
"row_id": 1624082,
"text": "REVIEW OF SYSTEMS:\nRESP: BRIEF CHANGE OVER TO PS THIS AM-POOR TOLERANCE. NO FURTHER VENT CHANGES. SUCTIONED FOR THICK YELLOW SECRETIONS, COPIOUS AT TIMES. SATS REMAIN IN HIGH 90'S.\nGI: TF'INGS WELL. NO STOOL TODAY. MIN RESIDUALS. \u0013\nRENAL: CONT. ON LASIX GTT, BUT TITRATED TO BP. OFF BRIEFLY FOR BP IN 70'S BUT RESTARTED SOON AFTERWARDS. PRESENTLY AT 2MG/HR. U/O'S RANGING FROM 80CC-240CC/HR. PT. STILL 4+ EDEMATOUS.\nCV: BP FAIRLY WELL CONTROLLED X FOR BRIEF DROP. REMAINS IN AF WITH GOOD RATE CONTROL WITH DILT. OCCASS PVC'S.\nENDOC: K+ 3.7 AND REPLETED WITH 40MEQ KCL VIA PEG. NO SSI REQUIRED.\nID: PEG DRSG -PURELENT DRAINAGE NOTED-SENT FOR CX. CONT. ON ANTIBIOTICS. ESS. AFEBRILE.\nNEURO: WITHDRAWN. NODS APPROPRIATELY AT TIMES. ABLE TO MOVE DIGITS WHEN ASKED AND DID RAISE HIS LEFT ARM ON HIS OWN THIS PM.\nHEM: HCT SLIGHTLY DECREASED FROM YESTERDAY.\nSOCIAL: NO CONTACT FROM FAMILY TODAY.\nPLAN: NEEDS PT CONSULT TO HELP WITH TRANSFER TO CHAIR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-22 00:00:00.000",
"description": "Report",
"row_id": 1624083,
"text": "Nursing Note:\n\nNeuro: pt awake most of night, appears withdrawn, nods head occasionally and inconsistantly follows commands, would not sqeeze hands on request, and occasionally cooperative w/ mouth care. some movement of left arm and legs noted. received 0.5 mg ativan prn overnight.\n\nResp: remains w/ vent support. vent AC 20/500 PEEP 5, FIO2 0.40. sats 95-100. suctioned for sm/moderate thick tan. LS clear and diminished w/ some upper airway congestion noted prior to suctioning.\n\nCV: HR 85-95 afib w/ occ. tolerated 30mg PO diltiazem well overnight. PVC's. NBP 90-120/50-70. tmax 99.3. generalized +3 edema. pos distal pulses.\n\nGU: remains on lasix gtt @ 2mg/hr. foley output 60-200cc/hr clear yellow.\n\nGI/Endo: abd firm/distended. pos bowel sounds, TF at goal of 50/hr, minimal residuals (<5cc). received dose of lantus insulin overnight, no coverage w/ RISS. no BM as of present overnight.\n\nIV: left brachial PICC remains WNL.\n\nSkin: duoderm intact on wound on upper back, no further skin breakdown noted. repositioned off back.\n\nSocial: no contact from family overnight.\n\nPlan: continue to monitor resp status (trach site, suctioning), hemodynamics, mental status, labs.\n\ncont. to monitor urine output and lasix gtt.\n\n? need for PT consult r/t immobility.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-22 00:00:00.000",
"description": "Report",
"row_id": 1624084,
"text": "RESPIRATORY CARE NOTE\n\nPatient remains with TTS adjustable length trach tube. This is a sterile H2O cuff. No vent changes made during the night. Unable to complete d/t tachypnea on PS 5. Sxn for scant to small amount thick yellow secretions. Plan to wean as tolerated.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-22 00:00:00.000",
"description": "Report",
"row_id": 1624085,
"text": "Respiratory Care Note\nPt received on AC as noted. BS diminished and coarse bilaterally which clears with suctioning. MDI's given a/o - MDI's changed to prn. Pt suctioned for moderate amts thick, yellow secretions. Attempted PSV 22/5 at 12noon, but placed pt back on AC secondary to tachypnea with a RR 38-40 and VT 275-300. Attempted PSV again at 4pm and increased PEEP to 8cm with the same result. Pt is now on AC. Plan to continue on current settings at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-22 00:00:00.000",
"description": "Report",
"row_id": 1624086,
"text": "NPN 0700-1900\nFull code All: Haldol\n\nNeuro: Alert throughout shift, occasional nod, participated in mouth care today. Minimally interactive w/ daughter and son when they today. Moves LUE only, good cough/gag. Lowgrade temp throughout shift of 99+ ax.\n\nCV: HR in 90's to low 100's, afib with occasional PVC's. SBP>95. Diuresing gently with Lasix gtt, currently @ 3mg/hr. 3+pitting edema in all extremities, + and easily palpable pp's b/l\n\nResp: A/C 40%/5Peep, TV set @ 500--pt vols running 375-450ml/breath. Continues to have thick white-tan secretions which he can cough up but sxn'd q2h. LS clear to coarse upper, diminished @bases w/occasional wheeze.\n\nGI/Endo: Firm distended abd w/+BS. Guaiac + dark brown-green stool x2 today. TF remain 2 goal of 50cc/hr w/ no residual. Required no additional insulin coverage today.\n\nGU: Patent foley draining dark yellow urine with some sediment at >40cc/hr. Titrating Lasix for u/o of ~100cc/hr.\n\nSkin: CDI\n\nSocial: Family meeting today. Family wishes to continue aggressive care. Believe pt is a candidate for a type of percutaneous cardiac repair not done @ and hope to find another facility that performs procedure and is willing to accept pt. Hence, pt remains full code.\n\nPlan: Monitor afib/BP's, Dilt as ordered as \n Monitor resp status, sxn prn\n ROM of extremities, PT reviewed case and pt not candidate for PT care\n OOB to chair as \n Glargine HS, RISS\n Encourage interaction\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-20 00:00:00.000",
"description": "Report",
"row_id": 1624075,
"text": "Nursing progress note: Full Code\n\nNeuro: able to communicate needs w/ nods. Does not move any of his exts. OOB to chair w/ lift. Denies any pain, no ativan given for my shift.\n\nPulm: PSV 23/5, Suctioned for thick yelllow secretions q-23hrs in small-moderate amts. RR regular. Maintaining stable svo2.\n\nCV: Afib w/ HR 89-108, BP 96-68 - 148/71. Afebrile. Gross generalized edema. Restarted lasix gtt at 2mg/hr. + palp. peripherial pulses x 4.\n\nGI/GU: + hypoactive bs. Abd is soft, distended. NT. TF'ing of nutren pulmonary at goal rate (50cc/hr), tolerating well. BM x 2 of dark black soft stool guaiac +. Scheduled for colonscopy and needs to be prep'd onced back in bed w/ golytley. Foley w/ uo > 30cc/hr on lasix 2mg/hr.\n\nSKIN: Back dressing in place. NO other breakdown noted.\n\nAccess: PICC line to RAC\n\nSOCIAL: Family meeting w/ Dr. today. Updated about pt. condition and plan of care.\n\nPLAN: Monitor per protocol. Replete lytes as needed. HCT up to 26.9.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-20 00:00:00.000",
"description": "Report",
"row_id": 1624076,
"text": "Resp. care note - Pt. remaines and vented, weaned to PSV then placed back on AC for SOB.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-20 00:00:00.000",
"description": "Report",
"row_id": 1624077,
"text": "Addendum:\n\nGolytly prep cancelled for tonight due to daughter refusing to consent for colonscopy at this time. Will readdress in am w/ Dr. . Pt. back to bed via . HCT up to 25.9. Tolerating lasix gtt at 2mg/hr w/ adequate uo.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-21 00:00:00.000",
"description": "Report",
"row_id": 1624078,
"text": "NPN 1900-0700\nNeuro: Nods appropriately to questions at times, other times will barely nod. Moves LUE more than R, minimal movement of legs. Appears comfortable, denies pain. Slept off and on during noc. No ativan given.\n\nResp: On AC o/n, no changes, 500x20/40%/5. RR low 20s, regular, appears comfortable. sats 97-99, Sx q1-3hrs for sm-mod amt thick, yellow. Sx more freq when awake or after turning. LS coarse/clear upper, coarse/diminished lower.\n\nCV: HR stable 80s-90s, a-fib, occ pvcs, multifocal. SBP 88-125. Team increased lasix up to 6mg/hr, but said to drop it back if sbp dropped <90. Did drop dose a few times, but back up to 6mg currently. BP adequate for Dilt dose x2. Am hct 24.2 from 26.9, but in pts usual range. Afebrile. Repleted c 20meq kcl due to lasix.\n\nGI: +BS, abd soft,distended, nt. TF at goal of 50mls/hr, water 150 q4hrs. No stools this shift.\n\nGu: Foley c u/o 120-180mls/hr on lasix 6mg/hr, yellow, clear urine.\n\nskin: Back dsg changed, washed c saline, duoderm applied. Appears slightly improved. No dng. Few sm skin tears noted on abd and L arm, washed, open to air.\n\nAccess: L picc. Flushes ok but very difficult drawing bld from either port this am. Will request TPA from team.\n\nSocial: No calls o/n.\n\nPlan: Monitor am labs, replete lytes. watch sbp and map c lasix, may need to reduce dose. Cont to wean vent as .\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-21 00:00:00.000",
"description": "Report",
"row_id": 1624079,
"text": "Respiratory Care:\n\nPt remain on full ventilatory support. No vent changes. We are sxtn for small to mod amt of thick whiote secretions. MD team asked for NIF ~13 cmH20, thru vent. Plan: PSV trial. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-07-21 00:00:00.000",
"description": "Report",
"row_id": 1624080,
"text": "Addendum\n1mg TPA placed into blue port of cath at 0600. Additional 40 meq kcl given at 0600 for K of 3.6.\n"
},
{
"category": "Echo",
"chartdate": "2129-08-19 00:00:00.000",
"description": "Report",
"row_id": 83126,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. H/O cardiac surgery. Left ventricular function.\nHeight: (in) 76\nWeight (lb): 266\nBSA (m2): 2.50 m2\nBP (mm Hg): 131/71\nHR (bpm): 84\nStatus: Inpatient\nDate/Time: at 11:27\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Marked LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). Increased AVR\ngradient.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve\nsupporting structures. Mild [1+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\nviews.\n\nConclusions:\nThe left atrium is markedly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nOverall left ventricular systolic function is normal (LVEF 70%). There is no\nventricular septal defect. Right ventricular chamber size is normal. Right\nventricular systolic function is normal. The aortic root is mildly dilated at\nthe sinus level. A bioprosthetic aortic valve prosthesis is present. The\ntransaortic gradient is higher than expected for this type of prosthesis. The\nmitral valve leaflets are mildly thickened. There is no mitral valve prolapse.\nMild (1+) mitral regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , the aortic valve has been replaced.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2129-08-12 00:00:00.000",
"description": "Report",
"row_id": 83127,
"text": "PATIENT/TEST INFORMATION:\nIndication: avr\nStatus: Inpatient\nDate/Time: at 13:51\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in the RAA.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thickness and cavity size. Mildly depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -\nhypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -\nhypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -\nhypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter. Normal descending aorta diameter.\nSimple atheroma in descending aorta.\n\nAORTIC VALVE: ?# aortic valve leaflets. Severely thickened/deformed aortic\nvalve leaflets. Severe AS (AoVA <0.8cm2). Mild (1+) AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. The TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\ncomplications.\n\nConclusions:\nNo spontaneous echo contrast is seen in the left atrial appendage. Left\nventricular wall thicknesses and cavity size are normal. Overall left\nventricular systolic function is mildly depressed (LVEF= XX %). Right\nventricular chamber size and free wall motion are normal. There are simple\natheroma in the descending thoracic aorta. The number of aortic valve leaflets\ncannot be determined. The aortic valve leaflets are severely\nthickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Mild\n(1+) aortic regurgitation is seen. The mitral valve leaflets are moderately\nthickened. Mild (1+) mitral regurgitation is seen. There is no pericardial\neffusion.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2129-07-18 00:00:00.000",
"description": "Report",
"row_id": 83128,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Left ventricular function.\nHeight: (in) 72\nWeight (lb): 242\nBSA (m2): 2.31 m2\nBP (mm Hg): 112/62\nHR (bpm): 92\nStatus: Inpatient\nDate/Time: at 15:03\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root.\nNormal ascending aorta diameter. Focal calcifications in ascending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS\n(AoVA <0.8cm2). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild [1+]\nTR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nGENERAL COMMENTS: Suboptimal image quality - ventilator. The rhythm appears to\nbe atrial fibrillation.\n\nConclusions:\nThe left atrium is elongated. There is moderate symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nTissue Doppler imaging suggests an increased left ventricular filling pressure\n(PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal.\nThe aortic root is mildly dilated at the sinus level. The aortic valve\nleaflets are severely thickened/deformed. There is severe aortic valve\nstenosis (area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Trivial\nmitral regurgitation is seen. There is mild pulmonary artery systolic\nhypertension.\n\nCompared with the prior study (images reviewed) of , the degree of\naortic stenosis has increased. There is now mild pulmonary artery systolic\nhypertension and a suggestion of an increased left ventricular filling\npressure.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2129-08-12 00:00:00.000",
"description": "Report",
"row_id": 227874,
"text": "Sinus rhythm. Low amplitude P waves. A-V conduction delay. Left anterior\nfascicular block. Prior anterior myocardial infarction. Compared to the prior\ntracing of sinus rhythm has appeared. Ventricular ectopy is absent.\nOtherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2129-07-29 00:00:00.000",
"description": "Report",
"row_id": 227875,
"text": "Atrial fibrillation with a single ventricular premature beat. Intraventricular\nconduction delay. Left axis deviation. ST-T wave abnormalities. Since the\nprevious tracing of the rate is slower and the QRS interval is wider.\n\n"
},
{
"category": "ECG",
"chartdate": "2129-07-19 00:00:00.000",
"description": "Report",
"row_id": 227876,
"text": "Atrial fibrillation\nVentricular premature complex\nModest intraventricular conduction delay\nDelayed R wave progression with late precordial QRS transition\nConsider left ventricular hypertrophy\nNonspecific ST-T wave changes\nThese findings are nonspecific but clinical correlation is suggested\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2129-07-17 00:00:00.000",
"description": "Report",
"row_id": 228103,
"text": "Atrial fibrillation\nVentricular premature complex\nModest intraventricular conduction delay\nDelayed R wave progression with late precordial QRS transition\nConsider left ventricular hypertrophy\nNonspecific ST-T wave changes\nThese findings are nonspecific but clinical correlation is suggested\nSince previous tracing of , ventricular ectopy present\n\n"
},
{
"category": "ECG",
"chartdate": "2129-07-16 00:00:00.000",
"description": "Report",
"row_id": 228104,
"text": "Atrial fibrillation\nModest intraventricular conduction delay\nDelayed R wave progression with late precordial QRS transition\nConsider left ventricular hypertrophy\nNonspecific ST-T wave changes\nThese findings are nonspecific but clinical correlation is suggested\nSince previous tracing of , ventricular ectopy absent\n\n"
},
{
"category": "ECG",
"chartdate": "2129-07-10 00:00:00.000",
"description": "Report",
"row_id": 228105,
"text": "Atrial fibrillation with controlled ventricular response. Occasional\nventricular premature beats. Underlying intraventricular conduction delay.\nCompared to tracing of no definite change.\n\n"
}
] |
92,317 | 144,189 | Patient was admitted to Neurosurgery on for further management. He was started on a short course of prednisone for mild cerebral edema with MLS. The following day patient had a repeat head CT which showed stable subacute SDH and shift. He remained stable neurologically. Surgical intervention was discussed with the patient in the setting of cerebral edema and midline shift on CT. He agreed to undergo evacuation which was scheduled for . He remained neurologically stable awaiting the OR and was prepped accordingly. He was taken to the OR and he underwent R frontal craniotomy and tolerated the procedure well with no complications. Post operatively he was transferred to the ICU for further care including SBP control and neurochecks, his post op exam remained non focal. Postoperative head CT shows good evacuation of SDH, no significant change in midline shift. The subdural drain was removed on postoperative day 1 and his diet and activity were advanced. He was transferred to the regular floor where he continued to do well and mobilize. Now DOD, patient is afebrile, VSS, and neurologically stable. Patient's pain is well-controlled and the patient is tolerating a good oral diet. Patient is ambulating without issues. He is set for discharge home in stable condition and will follow-up accordingly. | The mediastinal and hilar contours appear within normal limits. Compared to the previous tracingof no change. Mild mass effect on the right cerebral convexities and leftward shift of the midline structures is not significantly changed. There is associated mass effect with effacement of the right cerebral sulci and leftward shift of normally midline structures by 8 mm, also unchanged. Moderate-sized right subdural hematoma with associated effacement of the right cerebral convexity sulci and 8 mm leftward shift of the normally-midline structures, overall unchanged from the most recent prior study performed 18 hours ago. The ventricles and sulci are unchanged in size or configuration without evidence of hydrocephalus. The -white matter differentiation is preserved without evidence of acute major vascular territorial infarct. Normal tracing. TECHNIQUE: MDCT-acquired axial images were obtained through the head without intravenous contrast. No new hemorrhage is identified. No new hemorrhage is identified. Within normal limits. FINDINGS: There has been interval right-sided craniotomy with decompression of the right subdural hematoma with small residual present. FINDINGS: The heart is normal in size. In comparison to the prior MRI, there has been no significant change in the size of the subdural hematoma or the shift of the midline structures. FINDINGS: There is a moderate-sized right subdural hematoma extending along the entire right cerebral convexity, measuring 9 mm in maximal depth, not significantly changed from the most recent prior study performed 18 hours earlier. The remainder of the visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The appearance is grossly unchanged from the prior MRI obtained approximately two hours prior. The visualized paranasal sinuses, middle ear cavities and mastoid air cells are clear bilaterally. IMPRESSION: No evidence of acute disease. The bony calvaria appear intact. No fracture is identified. There is no pleural effusion or pneumothorax. Recent right-sided subdural hematoma with associated effacement of the adjacent sulci and 9 mm of leftward shift of the normal midline structures. The lungs appear clear. The visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. The ventricles and sulci are stable in configuration and size. COMPARISON: Non-contrast head CT last performed on and outside MRI of the brain performed at on . TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. TECHNIQUE: Continuous axial MDCT images were obtained through the brain without administration IV contrast. No evidence of new hemorrhage is present. In comparison to the prior MRI, there has been no significant change and no evidence of new hemorrhage. The right lateral ventricle is somewhat compressed but patent. No evidence of new hemorrhage. IMPRESSION: 1. IMPRESSION: 1. TECHNIQUE: Chest, PA and lateral. There is mild mucosal thickening within the ethmoidal air cells. COMPARISON: NECT of the head on . There is expected pneumophalus. Sinus rhythm. Sinus rhythm. No evidence of new hemorrhage, central herniation, or major vascular territorial infarct. Pre-operative examination. The basal cisterns are patent. Slight degenerative changes are noted along the lower thoracic spine. No previous tracing available for comparison. COMPARISONS: None. The suprasellar and basilar cisterns are patent. 2:08 PM CT HEAD W/O CONTRAST Clip # Reason: please do CT to eval for SDH, per neurosurgery MEDICAL CONDITION: History: 58M with subdural reported on OSH MRI REASON FOR THIS EXAMINATION: please do CT to eval for SDH, per neurosurgery No contraindications for IV contrast WET READ: KMTd TUE 2:40 PM 1. IMPRESSION: Expected post-surgical changes from craniotomy of moderate-sized subdural hematoma. There is mass effect with effacement of the adjacent sulci and leftward shift of the normal midline structures by 9 mm. There is associated mass effect with efacement of the adjacent sulci and 9 mm of leftward shift of the midline structures. FINDINGS: There is a right-sided hyperdense subdural hematoma overlying the frontal, parietal, occipital and temporal lobes measuring 10 mm in widest dimension. Assess for interval change. 2. 2. Large right subdural hematoma measuring 8mm in the widest dimension. COMPARISONS: MRI 11:56 a.m. 8:00 PM CT HEAD W/O CONTRAST Clip # Reason: assess SDH evacuation Admitting Diagnosis: SUBDURAL HEMATOMA MEDICAL CONDITION: 58 year old man s/p craniotomy and decompression of R SDH REASON FOR THIS EXAMINATION: assess SDH evacuation No contraindications for IV contrast FINAL REPORT INDICATION: Recent craniotomy and decompression for subdural hematoma. Sagittal, coronal, and thin slice bone image reformats were obtained and reviewed. WET READ VERSION #1 FINAL REPORT INDICATION: Subdural hematoma reported on outside hospital MRI. Evaluate for change. 7:41 AM CT HEAD W/O CONTRAST Clip # Reason: f/u interval progression Admitting Diagnosis: SUBDURAL HEMATOMA MEDICAL CONDITION: 58 year old man with right SDH REASON FOR THIS EXAMINATION: f/u interval progression No contraindications for IV contrast FINAL REPORT INDICATION: 58-year-old male with right subdural hematoma status post fall five weeks ago, here to evaluate for interval changes. | 6 | [
{
"category": "Radiology",
"chartdate": "2139-04-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1238194,
"text": " 7:41 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: f/u interval progression\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with right SDH\n REASON FOR THIS EXAMINATION:\n f/u interval progression\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old male with right subdural hematoma status post fall\n five weeks ago, here to evaluate for interval changes.\n\n COMPARISON: Non-contrast head CT last performed on and outside MRI of\n the brain performed at on .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the head without\n intravenous contrast.\n\n FINDINGS: There is a moderate-sized right subdural hematoma extending along\n the entire right cerebral convexity, measuring 9 mm in maximal depth, not\n significantly changed from the most recent prior study performed 18 hours\n earlier. There is associated mass effect with effacement of the right\n cerebral sulci and leftward shift of normally midline structures by 8 mm, also\n unchanged. The suprasellar and basilar cisterns are patent. No new\n hemorrhage is identified. The -white matter differentiation is preserved\n without evidence of acute major vascular territorial infarct. The ventricles\n and sulci are unchanged in size or configuration without evidence of\n hydrocephalus. The visualized paranasal sinuses, middle ear cavities and\n mastoid air cells are clear bilaterally. The bony calvaria appear intact.\n\n IMPRESSION:\n 1. Moderate-sized right subdural hematoma with associated effacement of the\n right cerebral convexity sulci and 8 mm leftward shift of the normally-midline\n structures, overall unchanged from the most recent prior study performed 18\n hours ago.\n 2. No evidence of new hemorrhage, central herniation, or major vascular\n territorial infarct.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-04-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1238502,
"text": " 8:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess SDH evacuation\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p craniotomy and decompression of R SDH\n REASON FOR THIS EXAMINATION:\n assess SDH evacuation\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent craniotomy and decompression for subdural hematoma.\n Assess for interval change.\n\n TECHNIQUE: Continuous axial MDCT images were obtained through the brain\n without administration IV contrast.\n\n COMPARISON: NECT of the head on .\n\n FINDINGS: There has been interval right-sided craniotomy with decompression\n of the right subdural hematoma with small residual present. There is expected\n pneumophalus. Mild mass effect on the right cerebral convexities and leftward\n shift of the midline structures is not significantly changed. No new\n hemorrhage is identified. The ventricles and sulci are stable in\n configuration and size. The visualized paranasal sinuses, mastoid air cells\n and middle ear cavities are clear.\n\n IMPRESSION: Expected post-surgical changes from craniotomy of moderate-sized\n subdural hematoma.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-04-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1238122,
"text": " 2:08 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please do CT to eval for SDH, per neurosurgery\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 58M with subdural reported on OSH MRI\n REASON FOR THIS EXAMINATION:\n please do CT to eval for SDH, per neurosurgery\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KMTd TUE 2:40 PM\n 1. Large right subdural hematoma measuring 8mm in the widest dimension. There\n is associated mass effect with efacement of the adjacent sulci and 9 mm of\n leftward shift of the midline structures. In comparison to the prior MRI,\n there has been no significant change and no evidence of new hemorrhage.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subdural hematoma reported on outside hospital MRI. Evaluate for\n change.\n\n COMPARISONS: MRI 11:56 a.m.\n\n TECHNIQUE: Contiguous axial MDCT images were obtained through the brain\n without the administration of IV contrast. Sagittal, coronal, and thin slice\n bone image reformats were obtained and reviewed.\n\n FINDINGS: There is a right-sided hyperdense subdural hematoma overlying the\n frontal, parietal, occipital and temporal lobes measuring 10 mm in widest\n dimension. There is mass effect with effacement of the adjacent sulci and\n leftward shift of the normal midline structures by 9 mm. The right lateral\n ventricle is somewhat compressed but patent. The basal cisterns are patent.\n In comparison to the prior MRI, there has been no significant change in the\n size of the subdural hematoma or the shift of the midline structures. No\n evidence of new hemorrhage is present. No fracture is identified. There is\n mild mucosal thickening within the ethmoidal air cells. The remainder of the\n visualized paranasal sinuses, mastoid air cells, and middle ear cavities are\n clear.\n\n IMPRESSION:\n 1. Recent right-sided subdural hematoma with associated effacement of the\n adjacent sulci and 9 mm of leftward shift of the normal midline structures.\n The appearance is grossly unchanged from the prior MRI obtained approximately\n two hours prior.\n 2. No evidence of new hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-04-22 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1238255,
"text": " 4:09 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: SUBDURAL HEMATOMA\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with r SDH and need for craniotomy\n REASON FOR THIS EXAMINATION:\n eval pre-op\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPHS\n\n HISTORY: Right subdural hematoma with need for craniotomy. Pre-operative\n examination.\n\n COMPARISONS: None.\n\n TECHNIQUE: Chest, PA and lateral.\n\n FINDINGS: The heart is normal in size. The mediastinal and hilar contours\n appear within normal limits. There is no pleural effusion or pneumothorax.\n The lungs appear clear. Slight degenerative changes are noted along the lower\n thoracic spine.\n\n IMPRESSION: No evidence of acute disease.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2139-04-24 00:00:00.000",
"description": "Report",
"row_id": 267954,
"text": "Sinus rhythm. Within normal limits. Compared to the previous tracing\nof no change.\n\n"
},
{
"category": "ECG",
"chartdate": "2139-04-21 00:00:00.000",
"description": "Report",
"row_id": 267955,
"text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\n\n"
}
] |
26,572 | 127,201 | 83M with hx of COPD, afib now in ICU for hypotension found to have abdominal pain and elevated LFTs . # Shock: Volume depletion vs sepsis vs adrenal insufficiency or combination. Volume depletion likely due to 2 weeks of loose stools and decreased po intake. Sepsis also likely given lactate of 4.8, possible pneumonia and possible intra-abd source. Adrenal insufficiency was impossible to test given that pt received solumedrol in ED. Cardiogenic shock not likely given lack of EKG changes and negatige enzymes and TTE showed preserved systolic function. Patient was given fluids and started on dopamine to maintain MAPs>60. Steroids were changed to decadron to perform stim test but initial level was 40 so stim was not performed. Steroids were d/c'd. Pt was weaned off dopamine on hospital day #2 and BPs remained stable. BB was resumed for rate control and verapamil was restarted. SBPs remained 120s-140s. . # Sepsis: Possible sources include lung, urine, abdomen. CXR with possible infiltrate so started levaquin/flagyl. UA was clean and urine culture was negative. blood cultures remain negative. Pt remained afebrile with elevated WBC count, attributed to possible PNA and steroids. His WBC should be followed in rehab to make sure it is trending down. . # Transaminitis: ALT and AST equally elevated to the on admission. Ddx of this includes right heart failure (which may explain elevated BNP), shock liver, viral hepatitis (which could explain pt's abd pain, nausea, diarrhea), med related (he is on 650mg standing tylenol TID), budd chiari. No hx of etoh abuse. RUQ US was normal without evidence of clot and tylenol level was neg. PAtient's HepAV Ab was positive, IgM is pending. We will continue to hold his statin and she should not be on standing tylenol. His LFTs should also be trended to make sure they are trending down. . # Abd Pain/diarrhea: Stool was sent for E. coli 0157 given h/o diarrhea and ARF. C diff also sent. Patient's diarrhea resolved as did his abdominal pain. As above, his abd U/S was negative. It may be secondary to hepatitis A but IgM was pending on time of discharge. . # Tachypnea/COPD: Likely that pt has an underlying pneumonia causing an exacerbation of his underlying COPD. He was given standing nebs along with oxygen. His breathing improved dramatically over the first few hours of his hospital stay. He should continue on albuterol and atrovent inhalers. He also should continue to wear oxygen at rest and with ambulation. He was started on advair. He may benefit from an outpatient pulmonary appointment along with PFTs. He may also need additional medications including tiotropium. . # CHF: By report only. Echo was normal with preserved funciton. BNP elevated to 18,000 on admission but appeared dry on exam so he improved with fluids. He was continued on his beta blocker after BP normalized. . # Afib: Patient was in NSR on admission and converted to a-fib while in MICU with HR 100's-120's. He is not anticoagulated likely due to fall risk. He is rate controlled with beta blocker and verapamil. . # ARF: Baseline is unknown. Urine lytes showed FeNa of 0.9% indicating pre-rernal etiology verses acute tubular necrosis from hypotension. Creatinine peaked at 2.8 from 1.9 on admission and is now trending down. This should be followed and medications adjusted for creatinine clearance. . # Glucse Intolerance: Pt was covered with insulin sliding scale but required none. . # Code: Pt is DNR/DNI, confirmed with PCP . # Comm: nephew , ; PCP | Pt rec'd Vanco and ceftriaxone in ED. LS clear, diminished at bases. PT C/O GENERALIZED WEAKNESS THROUGH OUT.RESP: PT REMAINS 3L NC. Abd soft with hypoactive bowel snds. Pt has gen edema with +2 pitting edema to lower ext's. Right ventricular chamber size and free wall motion arenormal. Mild mitral annularcalcification. soft, NT, and ND.GU: Foley cath. PT IS A DNR/DNI. Mild [1+] TR. Baseline artifactProbable atrial flutterVentricular premature complexModest nonspecific ST-T wave changesSince previous tracing of the same date, bradyarrhythmia absent PT NPO, EXCEPT MEDS. Patent hepatic vasculature. atelectasis.CV: HR 66-78SR with occas PAC's and rare PVC's. Pt placed on non-rebreather mask and rec'd solumedrol for resp distress. Rt leg with only + pulses to . Trace ascites. Trace aortic regurgitation is seen. Trace AR.MITRAL VALVE: Normal mitral valve leaflets. if pt may have been hypotensive d/t a poss. Pt remains off dopamine. Mild PAsystolic hypertension.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Frequent atrial premature beats. Mild to moderate(+) mitral regurgitation is seen. There is no pericardial effusion.IMPRESSION: Preserved global and regional biventricular systolic function.Mild-moderate mitral regurgitation. He stated lower abd pain improved, not worsened with palpation.Resp: VBG on admit on non-rebreather mask was 7.21/53/221. Pt needs a stool sample.ID)LA down to 1.7 (4.4). Sinus rhythmAtrial premature complexesModest nonspecific ST-T wave changesSince previous tracing of the same date, atrial flutter absent Congestive heart failure.Height: (in) 68Weight (lb): 144BSA (m2): 1.78 m2BP (mm Hg): 104/37HR (bpm): 91Status: InpatientDate/Time: at 10:52Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). BS's still course with a fair to poor cough. Based on AHAendocarditis prophylaxis recommendations, the echo findings indicate a lowrisk (prophylaxis not recommended). Mg replaced this am and no mg level until am MD. Mild to moderate (+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. As a result he recieved only one neb. in AFIB, rare to occas. Pt rec'd fluid bolus of 1 liter NS for vol repletion. Pt is HOH.Resp: LS to Bilateral UL clear, crackles to RLL and clear to LLL- team aware. Denies any pain.Resp - Maintained on 3 L NC with RR 15-25 and 02 sats > 95%. IMPRESSION: Small left pleural effusion. Abd discomfort lessened, and pt attributed this to antiemetic he rec'd in ED. septic state. Unremarkable liver echotexture. Pt on flagyl. Pt now on reg. Pulmonary artery systolic hypertension.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a low risk (prophylaxis not recommended). Given neb. Pt is in NSR with freq PAC's. There is mild pulmonary artery systolichypertension. positive pedal pulses bil with doppler.GI: pos. The left, middle, and right hepatic veins are patent. Pt cont. Pt is on Flagyl, Levo and vanco IVabx.Pain)Pt denies any discomfort.GU)Good U/O via foley catheter. Neb tx ATC. Ext's remain sl cool to touch, but this is baseline per pt.RESP)Ls dimminished throughout this am and now with cx's to RLL and coarse LS to LLL. ABG's as noted in carevue.GI)Abd soft and non-tender to touch. Normal regional LV systolic function.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). + congested cough, pt states only expectorates when he awakens in the am.C-V - HR 105-120 afib with occas pvc's. CXR showed L pleural effusion and ? The main, left, and right hepatic arteries are patent. US of abd done and NL. CHEST AP: Heart size is at upper limits of normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosisis not present. Dopamine titrated to present rate 4mcg/kg/min.Review of Systems:Neuro: Pt X 3, pleasant. Urine remains yellow and cloudy.soc)Pt is DNR / DNI. Simple-appearing cyst of the mid left kidney. IMPRESSION: 1. OOB to chair with minimal assist x several hrs. Pt needs to be inc to DB&C.. CXR with no CHF even though BNP . Rx with flagyl and levoflox.Social - No phone calls or visitors.A+P - Pt hemodynamically stable. NBP 120-140/60-70. PT HAS A PRODUCTIVE CONGESTED COUGH.CV: EARLY IN SHIFT HR SWITCHING BETWEEN AFIB AND NS. In , pt hypotensive to SBP 50's, HR 40's. His chest is with coarse BS's with a fair NPC. NEEDS STOOL SAMPLE WHEN PT GOES. AM labs included Hct 31.8(34.2), Mg 1.6, LDH 2325.GI: NPO. LEFT PEDAL PULSES NONDOPPLERABLE, TEAM AWARE. shocked liver low BP hypovolemia diarrhea. 7p to 7a Micu Progress NoteNeuro - Pt alert and oriented x 3. ABLE TO WEAN OFF DOPAMINE AT 2230. Pt is currently NPO ? NURSING MICU NOTE 7P-7ANEURO: PT 3, COOPERATIVE. Lactate was 4.4->pt pan-cx'd.PMH: COPD, CHF, AF, spinal stenosis, anemia, PVD, HTN.Events: On admit to MICU, resp distress resolved and pt on NC. lbm soft formed, no further c/o abd pain.gu: voiding per urinal clear yellow urine, 200-250 q 4 hoursid: afebrile, cont on antb. Gallbladder is normal without evidence of stones. ULTRASOUND OF LOWER EXTREMITIES. There is a left lower lobe opacity and small left pleural effusion. L pupil 4mm/R 2mm. levofloxacin and flagyl,plan: transfer to 7 for cont of care. Regional left ventricularwall motion is normal. NO EVIDENCE OF SWELLING, WARM TO TOUCH.GI/GU: ABD SOFT, +BS, NO BM. Good pulses to touch to bil rad pulses. The inferior vena cava is patent as well. Urine sent for osmolality and lytes. he has fallen in past per his pcp.cad hr remains afib with pvc's rate in the 100's, lopresssor increased to 100 mg tid, needs to be restarted on baseline verapamil.resp: ls . PT DENIES ANY PAIN. Am blood lytes pend.ID - Afeb. BP 103/38-124/41. Abd. Nsg transfer note updated. clear, remains on 3l nc, desat to 83% with o2 off. IF PT ABLE TO GO TO FLOOR TODAY. O2 sats between 92-96% on 3 liters NC.CV: BP 100's-130's/50's-70's, HR 110's-130's. Pt will become SOB with minor activity. | 16 | [
{
"category": "Nursing/other",
"chartdate": "2199-08-19 00:00:00.000",
"description": "Report",
"row_id": 1609882,
"text": "7am to 7pm:\n\nNeuro)\nPt has been awake, alert and O x 3 throughout the day.\n\nCV)\nPt was on Dopamine gtt this am and has been off since 3pm. Bp 99-112 with goal MAP >60. Mg replaced this am and no mg level until am MD. Echo done this am and results pending. Pt has gen edema with +2 pitting edema to lower ext's. Pt is in NSR with freq PAC's. Nailbeds are no longer blue and lower ext's are no longer mottled. Good pulses to touch to bil rad pulses. Rt leg with only + pulses to . Ext's remain sl cool to touch, but this is baseline per pt.\n\nRESP)\nLs dimminished throughout this am and now with cx's to RLL and coarse LS to LLL. Pt present with a very loose congested prod cough with thick tan scretions. Pt needs to be inc to DB&C.. CXR with no CHF even though BNP . Pt will become SOB with minor activity. 96-98% on 2 liter NP. Neb tx ATC. ABG's as noted in carevue.\n\nGI)\nAbd soft and non-tender to touch. No N/V/D at this time. US of abd done and NL. LFT's elevated ? shocked liver low BP hypovolemia diarrhea. Pt is currently NPO ? advance in diet. Pt reports a decreased appetite and last good meal was Tuesday per pt. Hepatitis panel pending. Pt needs a stool sample.\n\nID)\nLA down to 1.7 (4.4). Pt has Bc, urine and sputum culture pending. Pt is on Flagyl, Levo and vanco IVabx.\n\nPain)\nPt denies any discomfort.\n\nGU)\nGood U/O via foley catheter. Urine remains yellow and cloudy.\n\nsoc)\nPt is DNR / DNI.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-08-19 00:00:00.000",
"description": "Report",
"row_id": 1609883,
"text": "Respiratory Care:\npt seems in good spirits today. Went on a road trip today with RN and\nupon return has beenc sleeping most of the day. As a result he recieved only one neb. Tx. His chest is with coarse BS's with a fair NPC. please see carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-08-20 00:00:00.000",
"description": "Report",
"row_id": 1609884,
"text": "NURSING MICU NOTE 7P-7A\n\nNEURO: PT 3, COOPERATIVE. PT DENIES ANY PAIN. PT C/O GENERALIZED WEAKNESS THROUGH OUT.\n\nRESP: PT REMAINS 3L NC. O2 SATS 88-95%. LS RHONCHI AT BASES, CLEAR ABOVE. PT HAS A PRODUCTIVE CONGESTED COUGH.\n\nCV: EARLY IN SHIFT HR SWITCHING BETWEEN AFIB AND NS. PT HAS SPENT TO REST OF OVERNIGHT AFIB HR 90-130'S. ABLE TO WEAN OFF DOPAMINE AT 2230. PT HAS REMAINED OFF THROUGH OUT NIGHT. GOAL MAPS 55. LEFT PEDAL PULSES NONDOPPLERABLE, TEAM AWARE. ? ULTRASOUND TODAY. NO EVIDENCE OF SWELLING, WARM TO TOUCH.\n\nGI/GU: ABD SOFT, +BS, NO BM. PT DENIES ANY N/V, NO ABD PAIN. PT IS PASSING GAS. PT NPO, EXCEPT MEDS. FOLEY INTACT DRAINING YELLOW CLOUDY URINE. UNABLE TO OBTAIN STOOL SAMPLE.\n\nDISPO: ? ULTRASOUND OF LOWER EXTREMITIES. NEEDS STOOL SAMPLE WHEN PT GOES. NEPHEW CALLED OVERNIGHT FOR UPDATE. ? IF PT ABLE TO GO TO FLOOR TODAY. PT IS A DNR/DNI.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-08-20 00:00:00.000",
"description": "Report",
"row_id": 1609885,
"text": "Respiratory Care:\nPt took one A/A tx via neb with a mouth piece and liked this much better....vs. a CFM. BS's still course with a fair to poor cough.\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-08-19 00:00:00.000",
"description": "Report",
"row_id": 1609881,
"text": "Nursing Admit/Progress note -0700\nThis 83yo man admitted via ED from House for C/O resp distress, and diarrhea/cramping X 2weeks. In , pt hypotensive to SBP 50's, HR 40's. Pt rec'd total 2liters fluid IV and started on Dopamine qtts @ 25mcg/kg/min. Pt placed on non-rebreather mask and rec'd solumedrol for resp distress. Lactate was 4.4->pt pan-cx'd.\nPMH: COPD, CHF, AF, spinal stenosis, anemia, PVD, HTN.\n\nEvents: On admit to MICU, resp distress resolved and pt on NC. Abd discomfort lessened, and pt attributed this to antiemetic he rec'd in ED. Dopamine titrated to present rate 4mcg/kg/min.\n\nReview of Systems:\n\nNeuro: Pt X 3, pleasant. L pupil 4mm/R 2mm. Turns self STS in bed but prefers supine position with HOB elevated 45degrees. He stated lower abd pain improved, not worsened with palpation.\n\nResp: VBG on admit on non-rebreather mask was 7.21/53/221. O2 sat 93-100% (pleth irreg) on 3 l NC with RR 14-28 and regular. Lung snds coarse with crackles @ bases and rare I/E wheezes. Strong cough raising large amts sputum which is tan/thick. CXR showed L pleural effusion and ? atelectasis.\n\nCV: HR 66-78SR with occas PAC's and rare PVC's. BP 103/38-124/41. Dopamine Qtts presently 4mcg/kg/min with MAP>60. Toes and fingertips blue, unable to obtain pedal pulses by doppler but + popliteal pulses bilat by doppler. Pt rec'd fluid bolus of 1 liter NS for vol repletion. AM labs included Hct 31.8(34.2), Mg 1.6, LDH 2325.\n\nGI: NPO. Abd soft with hypoactive bowel snds. No BM since admit.\n\nGU: Foley draining yellow/cloudy urine @ 10-35ml/hr.\n\nID: Afebrile. Pt rec'd Vanco and ceftriaxone in ED. AM WBC 11.4(13.2) and Lactate 4.4->4.8->3.3.\n\nSocial: Contact is nephew . from House called for update last pm.\n\nPlan: Abd US today. Cont antibiotic tx and await results of pan-culturing, and hepatitis and tylenol screens.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-08-20 00:00:00.000",
"description": "Report",
"row_id": 1609886,
"text": "Nursing progress note (7am-7pm):\n\n\nEvents: Increase in HR 110's-130's. Started on p.o metropolol at 50mg and then increased to 100mg this afternoon. Given 1 time 5mg IV dose of metropolol as well. Pt is c/o to floor this eve...waiting for a bed.\n\nNeuro: A&O x 3. pleasant and cooperative. Pt is HOH.\n\nResp: LS to Bilateral UL clear, crackles to RLL and clear to LLL- team aware. Given neb. tx by RT. Productive cough- mostly saliva, occas. yellow...no sputum sample sent out yet. O2 sats between 92-96% on 3 liters NC.\n\nCV: BP 100's-130's/50's-70's, HR 110's-130's. Pt cont. in AFIB, rare to occas. PVCs. No c/o CP. Pt started on po metropolol as stated above. positive pedal pulses bil with doppler.\n\nGI: pos. BS, BM x1...sent stool sample for E.coli 0157:H7....? if pt may have been hypotensive d/t a poss. septic state. Pt on flagyl. Pt now on reg. diet, no N/V. Abd. soft, NT, and ND.\n\nGU: Foley cath. removed this afternoon. Pt voided 50cc of clear yellow urine following removal of cath. at 1300....keep an eye on U/O.\n\nsocial: pt's nephew called, may be in this eve after work or tomorrow...he is aware that the pt will be transferred to floor at some point.\n\nPlan: transfer to floor, monitor HR, U/O and resp. status, monitor labs.\n\n\n\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-08-21 00:00:00.000",
"description": "Report",
"row_id": 1609887,
"text": "7p to 7a Micu Progress Note\n\nNeuro - Pt alert and oriented x 3. MAE. OOB to chair with minimal assist x several hrs. Denies any pain.\n\nResp - Maintained on 3 L NC with RR 15-25 and 02 sats > 95%. Sat fell to 89% when 02 removed. LS clear, diminished at bases. + congested cough, pt states only expectorates when he awakens in the am.\n\nC-V - HR 105-120 afib with occas pvc's. NBP 120-140/60-70. Lopressor 100 mg initiated with no adverse effect on BP. Pt remains off dopamine. Hct stable at 32.3\n\nGI - Tolerating house diet without difficulty. No n/v/d. No abd discomfort. Last BM on previous shift.\n\nF/E - Voiding adeq amts of clear yellow urine with urinal. Urine sent for osmolality and lytes. Am blood lytes pend.\n\nID - Afeb. WBC 16.6, previously 21.2. Rx with flagyl and levoflox.\n\nSocial - No phone calls or visitors.\n\nA+P - Pt hemodynamically stable. Called - out to floor, awaiting bed. Nsg transfer note updated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-08-21 00:00:00.000",
"description": "Report",
"row_id": 1609888,
"text": "npn\nreport called to 7 nurse\n\nneruo:aox3, very pleasant gentleman, HOH, \"doesn't want to bother anyone\" be careful he may do something independently when he should ask for hlep. he has fallen in past per his pcp.\n\ncad hr remains afib with pvc's rate in the 100's, lopresssor increased to 100 mg tid, needs to be restarted on baseline verapamil.\n\nresp: ls . clear, remains on 3l nc, desat to 83% with o2 off. probably should have o2 at baseline but refuses to use it.\n\ngi; tolerating diet. lbm soft formed, no further c/o abd pain.\n\ngu: voiding per urinal clear yellow urine, 200-250 q 4 hours\n\nid: afebrile, cont on antb. levofloxacin and flagyl,\n\nplan: transfer to 7 for cont of care. ? if pt will return to house with vna services or be dc'd to rehab for further\n"
},
{
"category": "Echo",
"chartdate": "2199-08-19 00:00:00.000",
"description": "Report",
"row_id": 79989,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Congestive heart failure.\nHeight: (in) 68\nWeight (lb): 144\nBSA (m2): 1.78 m2\nBP (mm Hg): 104/37\nHR (bpm): 91\nStatus: Inpatient\nDate/Time: at 10:52\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild mitral annular\ncalcification. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Frequent atrial premature beats. Based on AHA\nendocarditis prophylaxis recommendations, the echo findings indicate a low\nrisk (prophylaxis not recommended). Clinical decisions regarding the need for\nprophylaxis should be based on clinical and echocardiographic data.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Regional left ventricular\nwall motion is normal. Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis\nis not present. Trace aortic regurgitation is seen. The mitral valve leaflets\nare structurally normal. There is no mitral valve prolapse. Mild to moderate\n(+) mitral regurgitation is seen. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Preserved global and regional biventricular systolic function.\nMild-moderate mitral regurgitation. Pulmonary artery systolic hypertension.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2199-08-21 00:00:00.000",
"description": "Report",
"row_id": 209775,
"text": "Atrial fibrillation with rapid ventricular response\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2199-08-20 00:00:00.000",
"description": "Report",
"row_id": 209776,
"text": "Atrial fibrillation with rapid ventricular response\nSince previous tracing of , atrial fibrillation now present\n\n"
},
{
"category": "ECG",
"chartdate": "2199-08-18 00:00:00.000",
"description": "Report",
"row_id": 209779,
"text": "Baseline artifact\nRegular wide complex bradycardia - may be junctional rhythm with atrial\nmechanism uncertain and baseline artifact makes assessment difficult\nNonspecific ST-T wave changes\nQ-Tc interval appears prolonged but is difficult to measure\nClinical correlation is suggested\nNo previous tracing available for comparison\n\n"
},
{
"category": "ECG",
"chartdate": "2199-08-18 00:00:00.000",
"description": "Report",
"row_id": 209777,
"text": "Sinus rhythm\nAtrial premature complexes\nModest nonspecific ST-T wave changes\nSince previous tracing of the same date, atrial flutter absent\n\n"
},
{
"category": "ECG",
"chartdate": "2199-08-18 00:00:00.000",
"description": "Report",
"row_id": 209778,
"text": "Baseline artifact\nProbable atrial flutter\nVentricular premature complex\nModest nonspecific ST-T wave changes\nSince previous tracing of the same date, bradyarrhythmia absent\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-08-19 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 920368,
"text": " 11:22 AM\n ABDOMEN U.S. (COMPLETE STUDY); -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOPP ABD/PEL\n Reason: please use doppler to assess flow; assess architecture of li\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with hx of CHF, afib now with hypotension, 2 weeks of diarrhea\n and abd pain, found to have markedly elevated LFTs into \n REASON FOR THIS EXAMINATION:\n please use doppler to assess flow; assess architecture of liver\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Congestive heart failure and atrial fibrillation, now with\n hypotension. Patient had two weeks of diarrhea and abdominal pain and\n markedly elevated LFTs into the . Assess flow.\n\n There are no prior studies for comparison.\n\n ABDOMEN ULTRASOUND: The liver echotexture is normal. There are no focal\n liver lesions or intrahepatic biliary ductal dilatation. Gallbladder is\n normal without evidence of stones. The common duct is not dilated, measuring\n 3-5 mm. The right kidney measures 10.3 cm. The left kidney measures 9.5 cm.\n There is no hydronephrosis, stone, or solid renal mass. There is a\n simple-appearing cyst arising from the left mid kidney measuring up to 3.8 cm\n in diameter. The spleen is small in size, but otherwise normal. The pancreas\n and aorta are not well visualized due to overlying bowel gas. There is a\n trace amount of ascites fluid within the abdomen.\n\n LIVER DOPPLER: The main, right anterior, right posterior, and left portal\n veins are patent with the appropriate direction of flow. The main, left, and\n right hepatic arteries are patent. The left, middle, and right hepatic veins\n are patent. The inferior vena cava is patent as well.\n\n IMPRESSION:\n 1. Patent hepatic vasculature.\n 2. Unremarkable liver echotexture.\n 3. Trace ascites.\n 4. Simple-appearing cyst of the mid left kidney.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-08-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 920286,
"text": " 4:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o cardiopulm process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with +SOB,+DOE &CP\n REASON FOR THIS EXAMINATION:\n r/o cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 83-year-old man with shortness of breath, dyspnea on exertion, and\n chest pain.\n\n CHEST AP:\n\n Heart size is at upper limits of normal. The aorta is calcified and tortuous.\n Pulmonary vasculature is unremarkable. There is a left lower lobe opacity and\n small left pleural effusion. Left lower lobe opacity could represent\n atelectasis; however, pneumonia cannot be excluded.\n\n IMPRESSION: Small left pleural effusion. No evidence of CHF.\n\n"
}
] |
29,615 | 118,254 | Madelyne is a 68 year old female with hypertension, hyperlipidemia, history of smokin, with known 3 vessel disease and history of multiple , who presented for cardiac catheterization and re-stenting of the proximal and distal circumflex artery. Her procedure was complicated by a retroperitoneal bleed, prompting admission and monitoring in the CCU. . # Retroperitoneal bleed: Patient became hypotensive s/p elective catheterization, and was found to have a laceration of the left inferior epigastric artery. A stat Hct was approx. 24, and contrast study showed laceration and retroperitoneal bleeding. Venous access obtained on right and balloon tamponade was maintained to stop bleeding. ABG demonstrated pH 7.25, with normal CO2/o2 and decreased bicarb, and hct 24. The patient was placed on Dopamine to maintain her pressures, but was quickly weaned with hemostasis. Patient transfused 4U PRBC, post transfusion hct 35. The patient was transferred to the CCU for observation overnight. Blood pressures returned to sBP 150s, and she was started on nitro gtt. A non-contrast CT body was obtained which showed large RP bleed surrounding the rectum. Pain management with Percocet 5/325 PO PRN, with morphine PRN for breakthrough pain. . # CAD s/p in LAD and LCX: Ms. presents with longstanding CAD with multiple stents (app. 6). Patient underwent elective catheterization for 2 weeks exertional CP after negative stress test, which showed 70-80% re-stenosis of LXC . Two were placed at the distal and mid-portion LXC. Patient noted pre-procedural CP had resolved. She was continued on home ASA, Plavix, Atorvastatin. Her home metoprolol and Imdur were held post-procedurally, and restarted after observation overnight. . # Hypertension: The patient became acutely hypotensive s/p cath, related to bleeding. She was transfused 4 units. She was started on a dopamine drip briefly in lab but was quickly weaned off. After cath, she was hypertensive sBP 150s so a nitro drip was started for better control of BP in setting of possible re-bleed. The nitro drip was weaned and she was restarted on her home doses of metoprolol. She will restart her quinapril and isosorbide the day after discharge. She will need to follow up with her PCP /or cardiologist for blood pressure monitoring. . # Diabetes: DM typically controlled at home with glipizide and diet. Insulin Sliding Scale started for acute managment in hospital. On discharge, patient was restarted on home medication of glipizide. # Hypothyroidism: Ms. has a history of hypothyroidism, treated with Synthroid. C/o fatigue for last several weeks, likely related to cardiac symptoms. However, patient should have TSH checked on outpatient basis to make sure Synthroid in therapeutic range. . The patient was full code for this admission. | Probable small right adrenal adenoma, as above. A thin rim of slightly dense material is noted along the right perihepatic region, possibly representing hemorrhage related to retroperitoneal hematoma described below. Np pleural effusions. Left femoral vessel catheters are noted. Mutliple prominent portocaval lymph nodes are noted. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Prominent portocaval lymph nodes, as above. The left adrenal gland is slightly hyperplastic but maintains its adreniform shape. The superior aspect of the hematoma is just below the aortic bifurcation. Large retroperitoneal hematoma exerting mild mass effect on the bladder as described above, with a small area of hyperdense material which may reflect more acute bleeding. Probable gallbladder sludge. The bladder is decompressed. FINDINGS: LOWER CHEST: The visualized portion of the lungs appears unremarkable. It extends superiorly to the anterior aspect of the left psoas muscle and inferiorly to the left prerectal space. There is a rounded low density nodule in the right adrenal gland (2; 25) measuring approximately 9mm with a of less than 10, likely representing a small adenoma. A well-circumscribed hypodensity in the upper pole of the right kidney is too small to characterize, but most likely a cyst. ABDOMEN AND PELVIS: Limited evaluation of the solid organs without contrast. Compared to theprevious tracing the P-R interval is shorter.TRACING #2 Also of note is sigmoid diverticulosis without evidence of diverticulitis. Serial hematocrit checks are encouraged. Calcified atherosclerotic disease is noted in the coronary arteries. The right lobe measures 10 cm x 4.5 cm (2;69). One measuring approximately 12 mm in short axis (2; 30). Left bundle-branch block. Left bundle-branch block. IMPRESSION: 1. The left lobe of the hematoma measures 8.5 x 3 cm, and at its posterior aspect lies some hyperdense material that may reflect a componenet of acute bleeding. The P-R interval is prolonged. The P-R interval is prolonged. WET READ VERSION #1 JEKh FRI 9:51 PM Retroperitoneal hematoma exerting mild mass effect on the bladder; small area of dense material may reflect more acute bleeding. 3. Left bundle-branch block.Compared to the previous tracing there is no significant change.TRACING #1 2. 4. The kidneys enhance and excrete contrast symmetrically. Calcified atherosclerotic disease is noted throughout the abdominal aorta into the iliac branches. STUDY: CT of abdomen and pelvis without contrast. TECHNQUE: Axial images from the lung bases to the proximal femurs were obtained with coronal and sagittal reformatted images. No IV contrast. Compared to the previous tracingthere is no significant change.TRACING #3 Left bundle-branch block.Compared to the previous tracing the P-R interval is longer.TRACING #4 Foley balloon is noted inside the bladder. The small and large bowel are of normal caliber without evidence of obstruction. The gallbladder demonstrates increased density, likely sludge. No pelvicaliectasis. No pericardial effusion. No intrahepatic biliary dilatation. Artifact is present. Discussed with at 21:52 on . Discussed with at 21:52 on . The bladder is distorted by a bilobed retroperitoneal high density most (Over) 5:12 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: assess retroperitoneal bleed s/p cardiac cath w/attempted ba Admitting Diagnosis: CHEST PAIN\CARDIAC CATH FINAL REPORT (Cont) consistent with hematoma. There is no free air. BONES: There are no aggressive-appearing lytic or sclerotic lesions seen. 5:12 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: assess retroperitoneal bleed s/p cardiac cath w/attempted ba Admitting Diagnosis: CHEST PAIN\CARDIAC CATH MEDICAL CONDITION: 68 year old female with multiple cardiac risk factors including HTN, Hypercholesterolemia, and prior tobacco abuse, 3 vessel disease s/p multiple presenting s/p cath and re-stenting of proximal and distal circ complicated by RP bleed REASON FOR THIS EXAMINATION: assess retroperitoneal bleed s/p cardiac cath w/attempted balloon tamponade CONTRAINDICATIONS for IV CONTRAST: renal insufficiency WET READ: JEKh FRI 9:59 PM Retroperitoneal hematoma exerting mild mass effect on the bladder; small area of dense material may reflect more acute bleeding, so serial hematocrit checks are encouraged. | 5 | [
{
"category": "Radiology",
"chartdate": "2103-08-17 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1154018,
"text": " 5:12 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: assess retroperitoneal bleed s/p cardiac cath w/attempted ba\n Admitting Diagnosis: CHEST PAIN\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old female with multiple cardiac risk factors including HTN,\n Hypercholesterolemia, and prior tobacco abuse, 3 vessel disease s/p multiple\n presenting s/p cath and re-stenting of proximal and distal circ complicated by\n RP bleed\n REASON FOR THIS EXAMINATION:\n assess retroperitoneal bleed s/p cardiac cath w/attempted balloon tamponade\n CONTRAINDICATIONS for IV CONTRAST:\n renal insufficiency\n ______________________________________________________________________________\n WET READ: JEKh FRI 9:59 PM\n Retroperitoneal hematoma exerting mild mass effect on the bladder; small area\n of dense material may reflect more acute bleeding, so serial hematocrit checks\n are encouraged. Discussed with at 21:52 on .\n WET READ VERSION #1 JEKh FRI 9:51 PM\n Retroperitoneal hematoma exerting mild mass effect on the bladder; small area\n of dense material may reflect more acute bleeding.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 60-year-old a female status post catheterization and stenting of the\n coronary arteries, complicated by retroperitoneal bleed.\n\n STUDY: CT of abdomen and pelvis without contrast.\n\n TECHNQUE: Axial images from the lung bases to the proximal femurs were\n obtained with coronal and sagittal reformatted images. No IV contrast.\n\n FINDINGS:\n\n LOWER CHEST: The visualized portion of the lungs appears unremarkable. Np\n pleural effusions. No pericardial effusion. Calcified atherosclerotic disease\n is noted in the coronary arteries.\n\n ABDOMEN AND PELVIS: Limited evaluation of the solid organs without contrast.\n No intrahepatic biliary dilatation. A thin rim of slightly dense material is\n noted along the right perihepatic region, possibly representing hemorrhage\n related to retroperitoneal hematoma described below. The gallbladder\n demonstrates increased density, likely sludge. The left adrenal gland is\n slightly hyperplastic but maintains its adreniform shape. There is a rounded\n low density nodule in the right adrenal gland (2; 25) measuring approximately\n 9mm with a of less than 10, likely representing a small adenoma.\n\n No pelvicaliectasis. The kidneys enhance and excrete contrast symmetrically.\n A well-circumscribed hypodensity in the upper pole of the right kidney is too\n small to characterize, but most likely a cyst.\n Foley balloon is noted inside the bladder. The bladder is decompressed.\n\n The bladder is distorted by a bilobed retroperitoneal high density most\n (Over)\n\n 5:12 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: assess retroperitoneal bleed s/p cardiac cath w/attempted ba\n Admitting Diagnosis: CHEST PAIN\\CARDIAC CATH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n consistent with hematoma. The right lobe measures 10 cm x 4.5 cm (2;69). The\n left lobe of the hematoma measures 8.5 x 3 cm, and at its posterior aspect\n lies some hyperdense material that may reflect a componenet of acute bleeding.\n The superior aspect of the hematoma is just below the aortic bifurcation. It\n extends superiorly to the anterior aspect of the left psoas muscle and\n inferiorly to the left prerectal space.\n\n The small and large bowel are of normal caliber without evidence of\n obstruction. Also of note is sigmoid diverticulosis without evidence of\n diverticulitis.\n\n Calcified atherosclerotic disease is noted throughout the abdominal aorta into\n the iliac branches. Left femoral vessel catheters are noted.\n\n There is no free air. Mutliple prominent portocaval lymph nodes are noted. One\n measuring approximately 12 mm in short axis (2; 30).\n\n BONES: There are no aggressive-appearing lytic or sclerotic lesions seen.\n\n IMPRESSION:\n 1. Large retroperitoneal hematoma exerting mild mass effect on the bladder as\n described above, with a small area of hyperdense material which may reflect\n more acute bleeding. Serial hematocrit checks are encouraged. Discussed with\n at 21:52 on .\n 2. Prominent portocaval lymph nodes, as above.\n 3. Probable small right adrenal adenoma, as above.\n 4. Probable gallbladder sludge.\n\n"
},
{
"category": "ECG",
"chartdate": "2103-08-18 00:00:00.000",
"description": "Report",
"row_id": 223493,
"text": "Sinus rhythm. The P-R interval is prolonged. Left bundle-branch block.\nCompared to the previous tracing the P-R interval is longer.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2103-08-17 00:00:00.000",
"description": "Report",
"row_id": 223494,
"text": "Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\nthere is no significant change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2103-08-17 00:00:00.000",
"description": "Report",
"row_id": 223495,
"text": "Artifact is present. Sinus rhythm. Left bundle-branch block. Compared to the\nprevious tracing the P-R interval is shorter.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2103-08-17 00:00:00.000",
"description": "Report",
"row_id": 223496,
"text": "Sinus rhythm. The P-R interval is prolonged. Left bundle-branch block.\nCompared to the previous tracing there is no significant change.\nTRACING #1\n\n"
}
] |
96,579 | 129,045 | The patient was admitted to the general surgery service on and had a minimally invasive esophagectomy. The patient tolerated the procedure well. Initially through POD 3 he was kept in the ICU to monitor and control his blood pressure. His SBP goal was 100-150 and it was adequately controlled with lopressor and clonidine IV. An NG tube was used to decompress the conduit and the patient was maintained on mIVF postoperatively until tolerating tube feeds. On POD 4 the patient had an esophogram that showed there was no leak at the site of the esophagogastrectomy and he was transferred to the floor where his diet was advanced and where he was transitioned to PO medications. | Minimal atelectasis at the right lung base. Minimal retrocardiac atelectasis is seen. Again seen is a tiny left apical pneumothorax. Tiny left apical pneumothorax unchanged. Prominence of mediasitum likely post surgical is unchanged compared to prior. A right chest tube, skin staples and clips overlying the central mediastinum are unchanged. Equivocal tiny left apical pneumothorax is suggested. Sutures and focal soft tissue prominence seen in the right paratracheal region, unchanged. The appearance of the neo-esophagus is unchanged. Suspect tiny left apical pneumothorax. Minimal pleural fluid or thickening tracks along the right chest wall and right lung apex. Right chest tube remains in place without evidence of pneumothorax. The right chest is grossly unchanged. Unchanged size and shape of the cardiac silhouette. There is opacity in the right lung, slightly less compared with earlier the same day. Linear opacity at the right lung apex likely represents the prior course of the chest tube. A right-sided chest tube is again seen. SINGLE UPRIGHT VIEW OF THE CHEST AT 17:06 HOURS: The right apical chest tube and the enteric tube have been removed. Patchy opacity at the left base and minimal blunting of the left costophrenic angle is unchanged. The endotracheal tube has been removed. There has been interval improvement in retrocardiac opacity, now mild. There is some residual atelectasis at the right base. Cardiac silhouette remains enlarged with some retrocardiac atelectasis. CHSET, 1 VW The patient is status post apparent esophagectomy -- this likely accounts for the vertical tubular lucency and peripheral density seen in the right chest medially. Less parenchymal opacity on the right, but with some residual atelectasis. Compared with at 7:32 a.m., again seen is retrocardiac density with obscuration of the left hemidiaphragm, overall similar to the earlier film. Clips are unchanged in the left upper quadrant. An ET tube has been placed in the interim, the tip lies approximately 3.7 cm above the carina in satisfactory position. Previously identified left apical pneumothorax not visualized at this time. A right-sided chest tube is present. IMPRESSION: Improved aeration following right chest tube removal. Status post chest tube removal. The cardiomediastinal silhouette is unchanged. Asymmetric CHF is considered much less likely. Skin staples overlying the left clavicle remain in place. Following administration of Optiray contrast medium is seen passing through the oropharynx into the cervical esophagus and neoesophagus without obstruction. An NG tube is present -- its tip lies beneath the diaphragm. FINDINGS: In comparison with the study of , there is little change in the appearance of the right chest tube and no convincing evidence of pneumothorax. FINDINGS: Lucency along the lateral margin of the liver suggests pneumoperitoneum, likely postoperative. Nasogastric tube is again seen. The cardiomediastinal silhouette demonstrates mild cardiomegaly. An enteric tube again traverses the neo-esophagus, with the tip terminating at the level of the medial left hemidiaphragm. SINGLE SUPINE VIEW OF THE CHEST: The endotracheal tube terminates approximately 6 cm from the carina, at the thoracic inlet. FINDINGS: No relevant change as compared to the previous examination. There are findings consistent with esophagectomy and gastric pull-through. The right chest tube is stable. IMPRESSION New diffuse opacity right lung, probably interstitial, developed since . An NG type tube is present, with tip beneath diaphragm. The subcutaneous emphysema seen along the right chest on the earlier film is not visible on today's examination. Patchy opacity left base, unchanged. Compared to the previous tracing of no significant change. Change in the appearance of the right chest, as described. IMPRESSION: No significant change compared with . Low inspiratory volumes and slightly rotated positioning. IMPRESSION: Probable pneumoperitoneum, likely postoperative. Recent esophagogastrectomy. There is a mild delay of contrast emptying from the stomach into the small bowel that is not unexpected in this post-surgical patient. FINAL REPORT HISTORY: Status post esophagectomy. Retrocardiac density is suggestive of left lower lobe atelectasis. Minimal pleural air inclusion in the right apex cannot be excluded, but a larger pneumothorax is not present. Surgical emphysema in the axilla is small in volume. Otherwise unchanged as compared to . There is patchy opacity at the left base, unchanged. TECHNIQUE: Single contrast examination of the neoesophagus was performed using Optiray and thin barium contrast media to assess for leak. Lungs are well aerated and clear without consolidation or pleural effusion. IMPRESSION: Compared with one day earlier, there has been slight improvement in the right lung opacity. CHEST, SINGLE AP PORTABLE VIEW. CHEST, SINGLE AP PORTABLE VIEW. CHEST, SINGLE AP VIEW. Nasogastric tube again extends into the neo-esophagus with the side hole at the mid cardiac level and the tip positioned just below the hemidiaphragm. No pneumothorax or other complication. REASON FOR THIS EXAMINATION: interval eval FINAL REPORT HISTORY: Esophageal CA, statuses post XRT. FINDINGS: As compared to the previous radiograph, there is no evidence of a larger right pneumothorax. Skin staples noted over left lung. FINDINGS: In comparison with the study of , there is little overall change. Skin staples, mediastinal clips, and an apparent mediastinal drain are noted. No gross effusion. COMPARISON: Prior radiograph dated . Patient status post esophagectomy. No newly appeared focal parenchymal opacities. Normal tracing. Right paratracheal density at the site of esophageal resection, is most likely postoperative but warrants further attention on surveillance radiography. The cardiac size is normal. LLL collpase/consolidation again seen, possibly slightly worse. Calcifications are again noted at the aortic arch. Another wide bore tube arises from the neck and terminates at the level of T12 in the midline and could be within the neoesophagus. Pulmonary vascularity is normal. Sinus rhythm. No obvious pneumothorax is detected. The NG tube extends along the expected course of the gastric pull-through. | 15 | [
{
"category": "Radiology",
"chartdate": "2138-10-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1158276,
"text": " 2:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess position of chest tube, presence of effusion and degr\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with esophageal cancer s/p minimally invasive esophagectomy\n REASON FOR THIS EXAMINATION:\n assess position of chest tube, presence of effusion and degree of PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Esophageal carcinoma, recent esophagectomy, evaluate position of\n chest tube.\n\n COMPARISON: Prior radiograph dated .\n\n FINDINGS: Lucency along the lateral margin of the liver suggests\n pneumoperitoneum, likely postoperative. Surgical emphysema in the axilla is\n small in volume. Right paratracheal density at the site of esophageal\n resection, is most likely postoperative but warrants further attention on\n surveillance radiography. There is no evidence of pneumothorax. No pleural\n effusions are seen. Retrocardiac density is suggestive of left lower lobe\n atelectasis. The cardiac size is normal. Surgical clips are projected over\n the left upper quadrant.\n\n A right chest drain enters the lateral chest wall at the level of the right\n 6th intercostal space, coils in the right apeax and terminates at the level of\n the right lateral heart border. Another wide bore tube arises from the neck\n and terminates at the level of T12 in the midline and could be within the\n neoesophagus.\n\n IMPRESSION: Probable pneumoperitoneum, likely postoperative.\n No evidence of pneumothorax, satisfactory position of chest drain.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-10-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1158475,
"text": " 1:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval eval\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with r chest tube\n REASON FOR THIS EXAMINATION:\n interval eval\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right chest tube interval, evaluate.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n Compared with at 17: 05 pm and allowing for technical differences, I\n doubt significant interval change. Again seen is a tiny left apical\n pneumothorax. The increased interstitial density in the right mid and lower\n zones is similar, as is the appearance of the gastric pull-through and right\n chest tube. There is also patchy opacity at the left base, essentially\n unchanged.\n\n IMPRESSION:\n\n No significant change compared with . Tiny left apical pneumothorax\n unchanged.\n\n Presence of the pneumothorax was discussed with Dr. on the afternoon\n of .\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-10-22 00:00:00.000",
"description": "BAS/UGI AIR/SBFT",
"row_id": 1158964,
"text": ", F. SICU-B 10:20 AM\n BAS/UGI AIR/SBFT Clip # \n Reason: ? leak, please adjust study to esophogram if necessary\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n Contrast: OPTIRAY Amt: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 M POD5 from egophagogastrectomy.\n REASON FOR THIS EXAMINATION:\n ? leak, please adjust study to esophogram if necessary\n ______________________________________________________________________________\n PFI REPORT\n No leak or obstruction at the anastomotic site.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-10-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1159030,
"text": " 4:46 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? ptx, please obtain at 1700, thank you.\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 s/p esophago-gastrectomy, S/P R chest tube removal\n REASON FOR THIS EXAMINATION:\n ? ptx, please obtain at 1700, thank you.\n ______________________________________________________________________________\n WET READ: WED 8:34 PM\n No evidence of large pneumothorax , trachea midline. Prominence of mediasitum\n likely post surgical is unchanged compared to prior.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55-year-old man status post right chest tube removal. Recent\n esophagogastrectomy.\n\n COMPARISON: Chest radiograph approximately 11 hours earlier.\n\n SINGLE UPRIGHT VIEW OF THE CHEST AT 17:06 HOURS: The right apical chest tube\n and the enteric tube have been removed. Skin staples overlying the left\n clavicle remain in place.\n\n Lungs are well aerated and clear without consolidation or pleural effusion.\n There is no pneumothorax. Linear opacity at the right lung apex likely\n represents the prior course of the chest tube. The appearance of the\n neo-esophagus is unchanged. Pulmonary vascularity is normal. The heart size\n is normal. There is no new hilar or mediastinal enlargement. Calcifications\n are again noted at the aortic arch.\n\n IMPRESSION:\n Improved aeration following right chest tube removal. No pneumothorax or\n other complication.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-10-22 00:00:00.000",
"description": "BAS/UGI AIR/SBFT",
"row_id": 1158963,
"text": " 10:20 AM\n BAS/UGI AIR/SBFT Clip # \n Reason: ? leak, please adjust study to esophogram if necessary\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n Contrast: OPTIRAY Amt: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 M POD5 from egophagogastrectomy.\n REASON FOR THIS EXAMINATION:\n ? leak, please adjust study to esophogram if necessary\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf WED 1:54 PM\n No leak or obstruction at the anastomotic site.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Postop day five from the esophagogastrectomy with gastric pull-\n up, evaluate for leak.\n\n TECHNIQUE: Single contrast examination of the neoesophagus was performed\n using Optiray and thin barium contrast media to assess for leak.\n\n FINDINGS: On the scout images, patient's right-sided chest tube,\n nasointestinal tube and postoperative surgical clips and staples are seen.\n The heart is mildly enlarged. Following administration of Optiray contrast\n medium is seen passing through the oropharynx into the cervical esophagus and\n neoesophagus without obstruction. The anastomosis site is well visualized and\n no leak is identified. There is a mild delay of contrast emptying from the\n stomach into the small bowel that is not unexpected in this post-surgical\n patient.\n\n IMPRESSION: No leak or obstruction at the anastomotic site.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-10-23 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1159132,
"text": " 9:41 AM\n CHEST (PA & LAT) Clip # \n Reason: Chest tube pulled , please evaluate for any change\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man s/p minimally invasive esophagectomy\n REASON FOR THIS EXAMINATION:\n Chest tube pulled , please evaluate for any change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Minimally invasive esophagectomy. Status post chest tube\n removal.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no evidence of a\n larger right pneumothorax. Minimal atelectasis at the right lung base.\n Otherwise unchanged as compared to .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-10-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1158922,
"text": " 4:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man s/p esophagogastrectomy, recently bronched for collapsed left\n lower lobe\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Esophagogastrectomy with recent bronchoscopy for left lower lobe\n collapse.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. The prominence of the mediastinum persists consistent with the\n surgical procedure. Cardiac silhouette remains enlarged with some\n retrocardiac atelectasis. Indistinct pulmonary vessels, especially on the\n right, raise the possibility of asymmetric edema.\n\n Right chest tube remains in place without evidence of pneumothorax.\n Nasogastric tube is again seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-10-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1158351,
"text": " 3:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval eval\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55M w/ hx of esophageal ca, s/p XRT, now s/p lap esophagogastrectomy.\n REASON FOR THIS EXAMINATION:\n interval eval\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Esophageal CA, statuses post XRT.\n\n CHSET, 1 VW\n\n The patient is status post apparent esophagectomy -- this likely accounts for\n the vertical tubular lucency and peripheral density seen in the right chest\n medially. An NG type tube is present, with tip beneath diaphragm.\n\n There is patchy opacity at the left base, unchanged. There is some increased\n interstitial opacity diffusely throughout the right lung, which appears new\n compared with one day earlier. This raises the question of a diffuse\n inflammatory or infectious process or aspiration. Asymmetric CHF is\n considered much less likely. No gross effusion. Clips noted over left\n subclavian region. The subcutaneous emphysema seen along the right chest on\n the earlier film is not visible on today's examination. No conventional\n pneumothorax is detected.\n\n IMPRESSION\n\n New diffuse opacity right lung, probably interstitial, developed since\n . ? inflammation or infection, aspiration, or assymetric CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1158746,
"text": " 3:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man s/p esophagectomy, R chest tube\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: To evaluate chest tube and interval change.\n\n FINDINGS: In comparison with the study of , there is little change in\n the appearance of the right chest tube and no convincing evidence of\n pneumothorax. The endotracheal tube has been removed. Nasogastric tube again\n extends into the neo-esophagus with the side hole at the mid cardiac level and\n the tip positioned just below the hemidiaphragm.\n\n There is continued enlargement of the cardiac silhouette. Widening of the\n superior mediastinum on the right is again seen. Minimal retrocardiac\n atelectasis is seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-10-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1158429,
"text": " 4:53 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: chest tube just placed to water seal\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man s/p esophagogastrectomy for esophageal ca\n REASON FOR THIS EXAMINATION:\n chest tube just placed to water seal\n ______________________________________________________________________________\n WET READ: DLrc SAT 6:00 PM\n Low lung volumes. Patient status post esophagectomy. Peripheral oriented\n vertical opacification, likely atelectasis. No evidence of pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post esophagectomy. Chest tube placed to waterseal.\n\n CHEST, SINGLE AP VIEW.\n\n Low inspiratory volumes and slightly rotated positioning. There are findings\n consistent with esophagectomy and gastric pull-through. An NG tube is\n present, the tip overlying upper abdomen. A right-sided chest tube is again\n seen. No obvious pneumothorax is detected. There is opacity in the right\n lung, slightly less compared with earlier the same day. Patchy opacity at the\n left base and minimal blunting of the left costophrenic angle is unchanged.\n Sutures and focal soft tissue prominence seen in the right paratracheal\n region, unchanged. Skin staples noted over left lung. Equivocal tiny left\n apical pneumothorax is suggested. Clips noted over mediastinum.\n\n IMPRESSION:\n\n Compared with one day earlier, there has been slight improvement in the right\n lung opacity. Suspect tiny left apical pneumothorax. Patchy opacity left\n base, unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-10-25 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1159519,
"text": " 2:09 PM\n CHEST (PA & LAT) Clip # \n Reason: apical ptx previously increased\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with esophageal 55M with T2NO adenoCA of distal esophagus s/p\n pre-op chemo/XRT and feeding jejunostomy, now s/p minimally-invasive \n esophagectomy \n REASON FOR THIS EXAMINATION:\n apical ptx previously increased\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post esophageal surgery.\n\n COMPARISON: .\n\n FINDINGS: No relevant change as compared to the previous examination.\n Minimal pleural air inclusion in the right apex cannot be excluded, but a\n larger pneumothorax is not present. No newly appeared focal parenchymal\n opacities. No evidence of tension. Unchanged size and shape of the cardiac\n silhouette.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-10-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1158592,
"text": " 3:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with LLL collapse s/p bronch\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55-year-old man, followup evaluation. Esophageal cancer with recent\n esophagectomy.\n\n COMPARISON: .\n\n SINGLE SUPINE VIEW OF THE CHEST: The endotracheal tube terminates\n approximately 6 cm from the carina, at the thoracic inlet. A right chest\n tube, skin staples and clips overlying the central mediastinum are unchanged.\n An enteric tube again traverses the neo-esophagus, with the tip terminating at\n the level of the medial left hemidiaphragm. Clips are unchanged in the left\n upper quadrant.\n\n There has been interval improvement in retrocardiac opacity, now mild. There\n is no new consolidation or pleural effusion. There is no pneumothorax. The\n cardiomediastinal silhouette demonstrates mild cardiomegaly.\n\n IMPRESSIONS: Improved aeration bilarerally, with marked improvement in\n basilar atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-10-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1158501,
"text": " 9:13 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man s/p esophagogastrectomy, with LLL collapse now s/p bronch\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post esophagogastrectomy status post bronch for left lower\n lobe collapse, question interval change.\n\n CHEST, TWO VIEWS.\n\n Compared with at 7:32 a.m., again seen is retrocardiac density with\n obscuration of the left hemidiaphragm, overall similar to the earlier film.\n There may have been slight increase in the degree of aeration in the left mid\n zone. The right chest is grossly unchanged. The cardiomediastinal silhouette\n is unchanged.\n\n An ET tube has been placed in the interim, the tip lies approximately 3.7 cm\n above the carina in satisfactory position. The NG tube extends along the\n expected course of the gastric pull-through. The right chest tube is stable.\n No pneumothorax is identified on the current film.\n\n Findings discussed with Dr. on the day of the exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-10-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1158491,
"text": " 7:22 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: reason for acute resp distress\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with acute resp distress s/p gastrectomy\n REASON FOR THIS EXAMINATION:\n reason for acute resp distress\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Acute respiratory distress status post gastrectomy.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n Compared with 5:25 a.m. the same day, the gas-distended gastric pull-through\n and associated thickened wall is no longer visualized -- ? decompressed. The\n diffuse density in the right lung has improved progressively since the morning\n of at 4:40 a.m. There is some residual atelectasis at the right\n base. A right-sided chest tube is present. Minimal pleural fluid or\n thickening tracks along the right chest wall and right lung apex. LLL\n collpase/consolidation again seen, possibly slightly worse. No obvious\n pneumothorax is seen on either side at this time. Skin staples, mediastinal\n clips, and an apparent mediastinal drain are noted. An NG tube is present --\n its tip lies beneath the diaphragm.\n\n IMPRESSION:\n 1. Continued left lower lobe collapse and/or consolidation, possibly slightly\n worse.\n 2. Previously identified left apical pneumothorax not visualized at this\n time.\n 3. Change in the appearance of the right chest, as described. Less\n parenchymal opacity on the right, but with some residual atelectasis.\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2138-10-17 00:00:00.000",
"description": "Report",
"row_id": 225564,
"text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of \nno significant change.\n\n"
}
] |
5,691 | 104,316 | 77 year old female with extensive PMH who was admitted with PNA and pulmonary edema, requiring non-invasive ventilation. She was initially in the intensive care unit until her breathing status improved. In the ICU, the patient was diuresed with IV Lasix and received antibiotics for her PNA. Initially, she was on BiPAP but improved throughout her course of stay until she was saturating comfortably on room air. On admission the patient had a surgical eval for abdominal distention which resolved w/o intervention, her imaging was negative for SBO. She was transferred to the floor for further management. On exam, the patient had dyspnea and fever felt most likely secondary to a factor of both CHF and PNA noted on CXR. The patient was treated with levofloxacin for a likely community acquired pneumonia. She was also treated initially with IV Lasix as her xray seemed consistent with a degree of heart failure. The patient has a history of multiple SBOs in the setting of numerous abdominal surgeries. She denied any vomiting, though she did have some mild nausea at the beginning of her hospitalization. Her last BM was the day before admission and she denies passing flatus since. She says that her current abdominal distention is not comparable to previous SBOs. Of note, she was started on iron supplements approximately one week ago and has noted constipation with this. The patient was treated with an aggressive bowel regimen. For her chronic polycystic kidney disease s/p transplant, the patient was treated with her usual dose of prednisone and a slightly decreased dose of CellCept given her neutropenia. Her polycystic liver disease was stable. She did have a RUQ US which showed dilation of her common bile duct. LFTs and exam remained stable throughout her hospital course and she was discharged to follow this finding up with her PCP. The patient has a history of hypertension for which she was taking atenolol and diltiazem as an outpatient. Her blood pressure was markedly elevated upon arrival. Per her history, the patient has had problems with hypertensive urgency in the past. She was initially treated with metoprolol and diltiazem with PRN hydralazine. Doxazosin was introduced once the patient was called out to the floor, however, the patient experienced relative hypotension likely causing a bump in her creatinine. The doxazosin was discontinued with a slow improvement in her creatinine. Her outpatient Lasix was held and she was advised to discuss restarting this medication with her primary care doctor. The patient was continued on her outpatient Epogen regimen for her anemia. She received one unit of packed red blood cells as well as six infusions of IV Ferrlecit. The patient was continued on her outpatient regimens for her spinal stenosis, depression, anxiety and insomnia with the following medications Neurontin, Tramadol, Zoloft, Klonopin and Ambien. # Communication: (daughter) ; (son) . # Code: FULL (confirmed with patient and daughter) | noted L mastect, however right has av fistula .SKIN: intactID: bc, urine culture pending. LS coarse throughout.CV: HR 59 -70 SB/SA/NR with frequent PAC, AM EKG ? CXR- in edema, inc in right PNA. Sat's 93-98%-inc when turning/deep breathing. Reports comfortable and denies pain t/o shift. no nausea complaintENDO: BS WNL, ON PREDNISONE will ask for sliding scale. Pulmonary edema.Height: (in) 66Weight (lb): 132BSA (m2): 1.68 m2BP (mm Hg): 150/75HR (bpm): 71Status: InpatientDate/Time: at 11:20Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%). sbp 180's given hydralazine IV 10 x1 with good result.now 132. fatigue. The amounts of mitral regurgitation,tricuspid regurgitation, and estimated pumonary artery systolic pressure haveincreased. Transmitral Doppler and TVI c/w Grade II(moderate) LV diastolic dysfunction. R AV fistula + thrill, + bruit.GI: + BS, soft distended abd with mult liver cysts, acities, s/p mult sx for SBP. CXR at that time revealing inc in right PNA. states last BM yest small amt. 1+ pitting ankle edema, mild general dependent edema. T spike to 101.4 rectal -tx with tylenol-no further intevention. clear, urine and C& S pending. Transmitral Doppler and tissue velocity imaging are consistentwith Grade II (moderate) LV diastolic dysfunction. Cont monitor resp status, pulm toilet, titrate O2 as tolerated.2. Mild dependent hip edema. CXR, episode resolving slowly. Lytes stable per am labs. Moderate (2+) mitralregurgitation is seen. Pt tolerated well.Resp: Pt continues w/ FiO2 2L via NC. Moderate (2+)MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Started on aggressive bowel regiman but with no BM today.GU - UO marginal - started back on PO lasix to gently diurese.IV - Pt has very poor venous access - one hep lock to left upper arm is only access.Neuro - Pt very pleasant and cooperative. No BM, + lg amt flattus, goal Lactulose until BM. Lactulose + flattus no BM. general dependant edema. The tricuspid valve leaflets are mildly thickened.Moderate [2+] tricuspid regurgitation is seen. s/o mult sx SBO- abd tender to palpation in epigastric area. less dyspnea after lasix. The mitral valve leaflets are mildlythickened. There is a trivial/physiologic pericardialeffusion.Compared with the prior study (images reviewed) of , left ventriculardiastolic function has worsened. Probable right ventricular hypertrophy.Compared to the previous tracing the findings are similar. SBP to 170's this am, tx w/ hydralazine 10mg IV X 1 w/ good effect. Nurse Progress Note 0700-1900Events: Minimally able to titrate down O2 requirement. Tolerating PO's well. Cont monitor resp status, encourage cough/deep breath, titrate O2 as tolerated, pul toilet2. HR NSR with PAC's.Resp - BS course upper and diminished at bases. trying to unsuccessfully wean oxygen.GU/GI: foley with fair response of 200cc after lasix IV. Mildly dilated ascendingaorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). 1900-0700 npnNEURO: intact , pleasant and cooperativeCV: afebrile, sinus rate 60-80, sys to 170, periph pulses intact. Suboptimalimage quality - poor suprasternal views.Conclusions:The left atrium is mildly dilated. AM mild HA -resolving with in BP and 325mg Acetaminophen. BBS remain somewhat course t/o. Son @ bedside, updated pt condition and . 20mg IV Lasix with minimal effect- goal neg 500cc. Weak cough, encourage deep breathing. Barrier crea-elbows/heals elevated. "I feel better than when I first came in"CV: 59-78 SB/SA/ NRS with frequent PAC's, irregular @ time but no AFib noted. The ascending aorta is mildly dilated.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is notpresent. card enzymes neg.RESP: rec'd on bipap 100%. sinus with little ectopy. Bedside echo, liver/gallbladder US. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Resuming to titrate down O2 requirement. Echo: EF 55-60%, 2+ MR, 2+ TR, mild LVH, grade II diastolic disfunction, sever pulm HTN. BP 129-171/53-85 MAP 70-90's post Lasix/hydral BP 130-140's/. Toleraing thin liquids/pills-NPO.GU: Clear-pale yellow urine via foley. lasix given x 1 with fair response at 1 hr. admitted with complex medical hx, c/o sob,dyspnea.NEURO: AO x 3, mae, cataracts bil.CV: tmax 101.4 oral, responsive to tylenol. Metolazone was given; however, renal MD then recommended holding lasix, and orders obtained from team to hold lasix. 1800 labs pending.ID: T amx 97.2 Ax, inc PO Levoflox to QD, Cellcept.Skin: General dry, thin skin chronic steroids. LS coarse/wheezing throughout. pt continues on lopressor and diltiazem as ordered.FEN: Pt tolerating full liquid diet well. pulm toilet, waffle boots on, skin care caution due to long term pred. Pt has since reported SBP 170 too be well within her baseline. There is mild symmetric left ventricularhypertrophy with normal cavity size and regional/global systolic function(LVEF>55%). negative I/O for last 24 hrsRESP: abd breathing no dyspnea, lungs coarse, cough non productive, no distress but cont. C+DB, and IS encouraged and pt is practicing these techniques q1hr WA. BP AM 160/70's -starting Dilt 60mg QID( Procardia 240mg XL @ home) BP 129-152/ 48-73 MAP 68-95. There is a late transitionwith anterior Q waves consistent with probable prior anterior myocardialinfarction. Right axis deviation. Sinus rhythm. abd rounded now softer than prev. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Pt remains free of s/s distress.CV: HR 50's to 60's, SR to SB w/ frequent PAC's. tol po fluid and takes pill easily. Sinus rhythmAtrial premature complexesLeft atrial abnormalityLow limb lead QRS voltagesIndeterminate axisDelayed R wave progression with late precordial QRS transitionModest inferior inferior in lead V2Findings are nonspecific but clinical correlation is suggested for possible inpart chronic pulmonary disease and possible prior septal myocardial infarctionSince previous tracing of 4, atrial ectopy now present, QRS voltages less prominent and prominent Twave amplitude decreased will hold on po bowel program until 0900 US of abd reveals no obstruction. | 12 | [
{
"category": "Nursing/other",
"chartdate": "2165-05-26 00:00:00.000",
"description": "Report",
"row_id": 1336652,
"text": "Nursing Prorgess Note:\n77 year old female with extensive PMH admitted with pna and CHF; difficulty diuresing during this admission d/t elevated BUN/cr with lasix; resp status with overall improvement, remains on fac tent with NC; probable c/o to floor; no events overnight\n\nNKDA\n\nFULL CODE\n\nNEURO: A+Ox3, follows commands, denies pain, blind in right eye, moves all extrmities; able to turn with min assist\n\nCV: HR remains in 50's-60's with PAC's; SBP 165-153, pt reports baseline is 170's; MAP's>60; +PP; no CP; am labs pending; evening lytes per Careview no sig change; AV fistula +bruit/thrill but no longer in use\n\nRESP: LS clear at apices, coarse at bases; sats 97-100% on 50% face ten and 5L NC; RR regular 15-20; denies SOB, dyspnea; CDB/IS enc\n\nGI/GU: +BS, no stool, received dulcolax/senna tonight, no results; abd firm distended, pt with ascites; advance to reg diet tomorrow; foley in place draining clear yellow urine 15-25cc/hr; BUN/Cr elevated and starting to trend down, so cont unable to diurese with lasix\n\nIV: 20g IV LUE WNL\n\n: possible c/o to floor; wean O2 as tolerate, cont CDB/IS, gentle diuresis as possible with goal 500cc-1L negative, cont levaquin, lytes; CXR in am; reg diet in am and cont bowel reg.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-05-26 00:00:00.000",
"description": "Report",
"row_id": 1336653,
"text": "Nursing Prorgess Note:\n CXR with worsening failure, no CXR planned for \n"
},
{
"category": "Nursing/other",
"chartdate": "2165-05-26 00:00:00.000",
"description": "Report",
"row_id": 1336654,
"text": "Nsg Progress Note 0700-1900\n\nCV - Afebrile. Hemodynamically stable. HR NSR with PAC's.\n\nResp - BS course upper and diminished at bases. Started on albuterol treatments to loosen secretions. Also started on robitussin to attempt to get secretions moving. O2 at 4L via NC. Pt feels that breathing has improved. Pt went to radiology for chest PA and Lat today. Results pending.\n\nGI - Abd continues to be firm and distended but with no pain or discomfort. Tolerating PO's well. Started on aggressive bowel regiman but with no BM today.\n\nGU - UO marginal - started back on PO lasix to gently diurese.\n\nIV - Pt has very poor venous access - one hep lock to left upper arm is only access.\n\nNeuro - Pt very pleasant and cooperative. A & O X3. Very cooperative with care and asking appropriate questions about .\n\nSocial - Very supportive and large family. Sister and in to visit today. Has received many phone calls also.\n\nPlan - Transfer to regular bed when available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-05-25 00:00:00.000",
"description": "Report",
"row_id": 1336650,
"text": "Nursing Progress Note:\n77 year old female with extensive PMH admitted for mgt of chf and bilateral pna, t spike >104\n\nFULL CODE\n\nNKDA\n\nNeuro: pt pleasant, A+Ox3; follows commands; blind in right eye s/p cataract surgery; denies pain except at blood pressure cuff site; moves all extremities, able to turn side to side with 1 assist\n\nCV: HR 50's-60's sinus with PAC's; given lopressor and dilt as ordered; SBP 156-136, MAP's >60; +PP to palpation; am labs pending\n\nRESP: pt cont on hi flow neb and NC 2L, attempted to wean to 35% but sats dropped to 88-89% at rest, so turned back to 50%; desats to 80's with activity; tacypneic with activity, denies SOB/dyspnea, reports overall improvement in breathing since admission; LS coarse throughout; cont on PO levaquin; CDB with no sputum\n\nGI: abd soft distened; BM x2; tolerating soft diet with good PO intake\n\nGU: foley in place draining clear yellow urine 15-30c/hr; BUN/Cr elevated and trending up, ? d/c lasix, received 1 dose yesterday on days but did not have significant diuresis, goal 1L neg/day not met\n\nID: sputum cx not sent, pt unable to expectorate; afebrile; cont on PO levaquin\n\nACCESS: 2 peripheral IV's in left arm infilatrated d/t pressure cuff and unable to place on right arm d/t AV fistula, so BP cuff on thigh; IV RN placed 20g in left upper arm tongiht, and said pt has no other access\n\n: ? change in cardiac meds to dose pt takes at home; cont to wean O2 as toilerated, pulm toilet as tolerated, cont levaquin; bowel regimen as needed; pain mgt for back pain\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-05-25 00:00:00.000",
"description": "Report",
"row_id": 1336651,
"text": "Shift Note: 0700-1900\nNeuro: Pt A+OX3, pleasant and cooperative. Reports comfortable and denies pain t/o shift. Pt OOB to chair X 4 hr today w/ min-mod 2 assist. Pt tolerated well.\n\nResp: Pt continues w/ FiO2 2L via NC. FM changed to facetent. C+DB, and IS encouraged and pt is practicing these techniques q1hr WA. Pt reports breathing continues to improve. BBS remain somewhat course t/o. SpO2 remains >92%. Pt remains free of s/s distress.\n\nCV: HR 50's to 60's, SR to SB w/ frequent PAC's. Lytes stable per am labs. SBP to 170's this am, tx w/ hydralazine 10mg IV X 1 w/ good effect. Pt has since reported SBP 170 too be well within her baseline. pt continues on lopressor and diltiazem as ordered.\n\nFEN: Pt tolerating full liquid diet well. Remains free of N/V. Foley catheter patent and draining clear yellow urine w/ borderline output. Initial plan for pt to receive metolazone w/ lasix. Metolazone was given; however, renal MD then recommended holding lasix, and orders obtained from team to hold lasix. Pt's wgt remains stable at 59kg.\n\nSocial: pt's son, daughter and priest have been in to visit. Priest pt this am.\n\nPlan: Continue to monitor respiratory status closely. Wean FiO2 as able. Encourage PO intake and increase activity as tolerated. Anticipate call out to floor if pt remains stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-05-23 00:00:00.000",
"description": "Report",
"row_id": 1336646,
"text": "1900-0700 npn\nPt. admitted with complex medical hx, c/o sob,dyspnea.\n\nNEURO: AO x 3, mae, cataracts bil.\n\nCV: tmax 101.4 oral, responsive to tylenol. lasix given x 1 with fair response at 1 hr. pp intact. general dependant edema. sinus with little ectopy. sbp 180's given hydralazine IV 10 x1 with good result.\nnow 132. fatigue. card enzymes neg.\n\nRESP: rec'd on bipap 100%. transferred to face tent at 10 liters and 6 liters nasal cannula. less dyspnea after lasix. able to speak in long sentences cough non productive. do need to send sputum sample when avail. lung field coarse on right, almost no air movement on left. will introduce IS this am. abg improved. trying to unsuccessfully wean oxygen.\n\nGU/GI: foley with fair response of 200cc after lasix IV. clear, urine and C& S pending. abd rounded now softer than prev. passing some flatus. pt. states last BM yest small amt. recently started iron. was planned to have soap suds enema, however due to recent rectal with repair of prolapse will hold for now. tol po fluid and takes pill easily. will hold on po bowel program until 0900 US of abd reveals no obstruction. no nausea complaint\n\nENDO: BS WNL, ON PREDNISONE will ask for sliding scale. tol full liquids, swallows pills well, safe swallow noted. NPO after mn for am US of abd.\n\nPAIN: denies\n\nACCESS: added #18 g to 20 g in left arm. noted L mastect, however right has av fistula .\n\nSKIN: intact\n\nID: bc, urine culture pending. levafoxacin po started in ER.\n\nSOCIAL: lives with husband who has recently had hip . dtr and son very supportive. Dtr in .\n\nPLAN: vigorous pulm toilet, introduce and teach Incentive spirometer, f/u cultures, treat fevers, mobilize asap, US abd scheduled for 0900 then address nutritional needs.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-05-23 00:00:00.000",
"description": "Report",
"row_id": 1336647,
"text": "Nurse Progress Note 0700-1900\n\nEvents: 11AM episode tachypnic, hypertensive, drop sat's mid 80's-tx with 40mg IV Lasix, inc Fio2 to 100%-highflow @ 100%, cont hypertensive 10mg IV hydral, -no BiPAP. CXR, episode resolving slowly. Resuming to titrate down O2 requirement. CXR- in edema, inc in right PNA. Bedside echo, liver/gallbladder US. T spike to 101.4 rectal -tx with tylenol-no further intevention. See carvue for details.\n\nNeuro/Pain: Alert, oriented, engaging in conversation, using callbell approp. H/A when hypertensive, initally respoling, returing \"pain the the back of my head/neck\" repositioned and given 325mg Tylenol, declined 650mg. Pain . + gag/cough. MAE.\n\nResp: Resp rate regular in AM, sat's >95% on 40% face tent, 6L NC able to speak in full sentences-tolerating off face tent for pills. Approx 11 AM during echo inc in SOB and work of breathing RR 30-33/labored- titrating up face tent then and placed 100% high flow mask, albuterol/atrovent nebs, Bp 160-171/70's, given 40 mg IV Lasix, cont hypertensive 10mg IV Hydral BP down to 130/60's. Dyspnea resolving and resting comfortably. CXR at that time revealing inc in right PNA. Currently high flow @ 50%, titrating down NC to 4L. Sat's 93-98%-inc when turning/deep breathing. 90-92% off mask-no IS at this time. LS coarse/wheezing throughout. \"I feel better than when I first came in\"\n\nCV: 59-78 SB/SA/ NRS with frequent PAC's, irregular @ time but no AFib noted. BP 129-171/53-85 MAP 70-90's post Lasix/hydral BP 130-140's/. Echo: EF: 55-60%, mild LVH, 2+ MR, 2+ TR, grade II LV diastolic dysfunction. 1+ pitting ankle edema, mild general dependent edema. s/p L masectomy, R AV fistula + thrill, + bruit.\n\nGI: + BS, lg abd- liver US/gallbladder: numerous liver cysts, dilated extrahepatic common bile duct, ascities. s/o mult sx SBO- abd tender to palpation in epigastric area. Lactulose + flattus no BM. No enema-cont Lactulose. Toleraing thin liquids/pills-NPO.\n\nGU: Clear-pale yellow urine via foley. Post 40mg IV Lasix 200cc within 1hr approx 100cc/hr x3 hrs then tapering off. Neg 1360 past 24hrs, neg 1640 LOS.\n\nFEN/ENDO: No IVF. 1700 repete labs pending.\n\nID: T max 99.1 Ax/101.4 rectal-given 325mg tylenol, 97.2 Ax. Cont on Levoflox.\n\nSkin: Very think skin chronic steroid \"my skin breaks easily, I bruise everywhere\". Mult bruising IV access, R eye bruising \"I ahd that at home\". No active breakdown in skin integrity noted. Barrier crea-elbows/heals elevated. Waffel boots on.\n\nSocial: Daughter called and updated , pt condition. Son @ bedside, updated pt condition and . Full Code.\n\n\n1. Cont monitor resp status, encourage cough/deep breath, titrate O2 as tolerated, pul toilet\n2. Comt monitor skin integrity\n3. Cont all routine ICU care\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-05-24 00:00:00.000",
"description": "Report",
"row_id": 1336648,
"text": "1900-0700 npn\nNEURO: intact , pleasant and cooperative\n\nCV: afebrile, sinus rate 60-80, sys to 170, periph pulses intact. negative I/O for last 24 hrs\n\nRESP: abd breathing no dyspnea, lungs coarse, cough non productive, no distress but cont. to use high flow oxygen without being able to wean. long recovery times for sats after any activity\n\nGU/GI: foley ave 35 cc. 2 small semiformed brwn hem neg stool. BT active. no nausea, tol. full liquids well.\n\nPAIN: none\n\nENDO: full liquids, now states she is hungry\n\nACCESS: 2 piv. lla redressed x 2 for leakage at junction\n\nSKIN: no breaks in skin noted. waffle boots deferred per pt wishes til am.\n\nSOCIAL: dtr to visit. good support from family.\n\nPLAN: wean oxygen to nasal cannula as able. add IS when able. antibiotics. pulm toilet, waffle boots on, skin care caution due to long term pred. use.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-05-24 00:00:00.000",
"description": "Report",
"row_id": 1336649,
"text": "Nurse Progress Note 0700-1900\n\nEvents: Minimally able to titrate down O2 requirement. Inc Levoflox QD, Cellcept for PNA-unable to obtain sputum cx. 20mg IV Lasix with minimal effect- goal neg 500cc. See carevue for details.\n\nNeuro/Pain: Alert, oriented enaging in conversation. Sleeping in short naps throughout day. AM mild HA -resolving with in BP and 325mg Acetaminophen. Mild tender if palpating abd other wise denies pain/discomfort. + gag, weak cough.\n\nResp: Resp rate regular, minlabored resting in bed. With eating/turning mild fatigue o2 sat's drop 88-90% will trend up slowly. While eating on 10L NC-tolerating Sat 90-93%. Currently highflow 40%, 6L, 2L NC. Weak cough, encourage deep breathing. Scant nonproductive cough-unable to tolerate induced sputum. Able to talk in short sentences with minimal dyspnea. LS coarse throughout.\n\nCV: HR 59 -70 SB/SA/NR with frequent PAC, AM EKG ? transient AFIB-not noted on EKG. Atrial couplets. BP AM 160/70's -starting Dilt 60mg QID( Procardia 240mg XL @ home) BP 129-152/ 48-73 MAP 68-95. 20 mg IV Lasix with minimal effect-goal diuresis 500 neg/day. Awaiting repete lyyes before further diuresis. Echo: EF 55-60%, 2+ MR, 2+ TR, mild LVH, grade II diastolic disfunction, sever pulm HTN. Mild dependent hip edema. R AV fistula + thrill, + bruit.\n\nGI: + BS, soft distended abd with mult liver cysts, acities, s/p mult sx for SBP. No BM, + lg amt flattus, goal Lactulose until BM. Tolerating full liquid diet.\n\nGU: Clear yellow urine via foley. UOP 30-45 cc/hr. S/p renal transplant-renal following. Cr 2.4 (baseline ? 1.7-1.9) neg 90 cc past 24 hrs, neg 1870 LOS.\n\nFEN/ENDO: No IVF. Tolerating full liquid diet. 1800 labs pending.\n\nID: T amx 97.2 Ax, inc PO Levoflox to QD, Cellcept.\n\nSkin: General dry, thin skin chronic steroids. Barrier cream, heels/elboes elevated. Mult bruising IV access \"I have bruises from home\". No active breakdown noted.\n\nSocial: Daughter (HCP), husband and daughter in law in to visit pt- all updated pt condition, medications and . Full Code.\n\n\n1. Cont monitor resp status, pulm toilet, titrate O2 as tolerated.\n2. Cont monitor skin integrity\n3. Monitor renal recs/diuresis as toelrated-goal neg 500cc\n4. Cont emotional support of pt and family\n5. Cont all routine ICU care\n\n\n"
},
{
"category": "Echo",
"chartdate": "2165-05-23 00:00:00.000",
"description": "Report",
"row_id": 103864,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pulmonary edema.\nHeight: (in) 66\nWeight (lb): 132\nBSA (m2): 1.68 m2\nBP (mm Hg): 150/75\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 11:20\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). Transmitral Doppler and TVI c/w Grade II\n(moderate) LV diastolic dysfunction. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate (2+)\nMR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\nSevere PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Suboptimal\nimage quality - poor suprasternal views.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent\nwith Grade II (moderate) LV diastolic dysfunction. Right ventricular chamber\nsize and free wall motion are normal. The ascending aorta is mildly dilated.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. No aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. Moderate (2+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nModerate [2+] tricuspid regurgitation is seen. There is severe pulmonary\nartery systolic hypertension. There is a trivial/physiologic pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , left ventricular\ndiastolic function has worsened. The amounts of mitral regurgitation,\ntricuspid regurgitation, and estimated pumonary artery systolic pressure have\nincreased.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2165-05-24 00:00:00.000",
"description": "Report",
"row_id": 298614,
"text": "Artifact is present. Sinus rhythm. Atrial ectopy. There is a late transition\nwith anterior Q waves consistent with probable prior anterior myocardial\ninfarction. Right axis deviation. Probable right ventricular hypertrophy.\nCompared to the previous tracing the findings are similar.\n\n"
},
{
"category": "ECG",
"chartdate": "2165-05-22 00:00:00.000",
"description": "Report",
"row_id": 298615,
"text": "Sinus rhythm\nAtrial premature complexes\nLeft atrial abnormality\nLow limb lead QRS voltages\nIndeterminate axis\nDelayed R wave progression with late precordial QRS transition\nModest inferior inferior in lead V2\nFindings are nonspecific but clinical correlation is suggested for possible in\npart chronic pulmonary disease and possible prior septal myocardial infarction\nSince previous tracing of 4\n, atrial ectopy now present, QRS voltages less prominent and prominent T\nwave amplitude decreased\n\n"
}
] |
12,155 | 173,946 | 1. Respiratory: was in room air throughout her entire Neonatal Intensive Care Unit admission. She had no episodes of spontaneous apnea. 2. Cardiovascular: maintained normal heart rates and blood pressures. During admission there were no cardiovascular issues. 3. Fluids, electrolytes and nutrition: Enteral feedings were started on day 1 of life. She has been on all p.o. feedings during admission. She takes approximately 150-174 cc per kg per day of Enfamil 20. Recent weight is 1.875 kg with a length of 43.8 cm and a head circumference of 32 cm. 4. Infectious disease: Due to the preterm labor, was evaluated for sepsis. A white blood cell count was 12,200 with a differential of 37% polys, 5% bands. A blood culture was obtained and was no growth at 48 hours. 5. Hematologic: Birth hematocrit was 49.6%. did not receive any transfusions of blood products. 6. GI: required treatment for unconjugated hyperbilirubinemia with phototherapy. Her peak serum bilirubin occurred on day of life two with a total of 9.1/0.3 direct mg per dL. She received phototherapy for approximately 72 hours. Her rebound bilirubin on was 7.8 total with 0.2 direct mg per dL. 7. Neurology: has maintained a normal neurological examination during admission and there are no neurological concerns at the time of discharge. 8. Sensory: Hearing screening was performed with automated auditory brainstem responses. passed in both ears. | infant willbottle again at next care. Waking q3-4h for feeds.Temps stable in off isolette. Baby toleratingfeeds well. NPN 0700-This RN assessed infant and agrees with the above note by ; co-worker.Formula changed to E20. A:tol feeds wellP:cont to monitor infant#2DEVE: temp stable. a: stable#3 parentingno contact with thus far this shift.#4 hyperbilpt remains under single phototherapy with eye inplace. A: allpo's for now P: need ngt placed, follow weight andtolerance to feeds#2 Temps stable on warmer-weaned x 1. Arrived to NICU pink and perfused with stable vital signs. P: Continue to monitor weight, POfeed ad lib amts w/ min 120cc/k/d.2. A:AGA P:cont to support g/d of infant#3PARENTING: no contact thus far this shift. Updated by RN. voidingand stooling qdiaper change. set tempweaned x2. Baby was dried and bulb sxn'd, min BBO2. P: Cont to provide devappropriate care.3. BILIO: Received infant under single phototherapy. will get rebound in a.m. A:hyperbilirubinemiaP:cont to monitor infant repeat bili pending. tf remains at min120cc's/kg/d ofPE20. Infant PO feeding Q4 hours, waking on own. P: Cont tomonitor, check rebound bili in am.See flowsheet for details. Cont to gain wgt. Bili this am =7.9/0.2. Mom D/C'ed hometoday. Po fed well.A: AGA. Bath done and D/C teaching begun; see NICU d/c instruction form. A: Tolerating feeds. A: Gainingweight.PO feding well. DEVO: is /active with cares. Will continue to monitor temp. abdbenign. waking onown for feedings. Neonatology Attending Progress NoteNow day of life 4.Cardiorespiratory status remains stable in RA.No apnea and bradycardia.RR - 30-60s.HR 150-180sBP 62/39 46Wt. A: Resolving hyperbilirubinemia. Is passing meconium. Continue with current feeding plan.DEV: Baby moved to OAC from off isolette at 12pm.Tolerating well. Co-Worker Note 0700-19001. Asking appropriatequestions. O: Mom in throughout shift to bottle . feeds well. 1840gm(25%) Lt. 43cm(25%) HC 32cm(75%)HEENT - AF soft and flat, prominent molding, sutures mobile, palate intactResp - breath sounds clear and equal.CVS - S1 S2 normal intensity, no murmur, perfusion good, pulses normal.Abd - soft with normal bowel sounds, no organomegalyGU - normal femaleAnus - slightly small and anteriorly placed, appearst to be patentNeuro - tone excellent, symmetrical movement of upper and lower extremitiesDS - 84cbc, diff pendingAssessment/plan:Well appearing 34 week gestation female infant with stable cardiorespiratory status thus far.Will observe/monitor for possible apnea of prematurity, temp control.Feedings to be initiated this evening.At slightly increased risk for sepsis with preterm labor and twin gestation. A/P:cont tosupport family#4BILI: infant remains off phototherapy. P: Contto educate and support family.4. Voiding andstooling (heme-). NNP Physical ExamPE: pink, jaundiced, AFOF, breath sounds clear/equal with easy WOB, no murmur, abd soft, non distended, + bowel sounds, active with good tone. A: AGA. wt. Bottling ability isslowly improving. Passed hearing screen. FENO: TFmin 120cc/kg/d of PE20 po. P: Support developmental needs.3. NPN DAYSI have examined and agree with above note by , co-worker. Passed carseat test. suckin on binki and hands. DS 53 + 58.Has not voided yet this shift. adjsuting well, will plan to follow as needed. Nested.In servo isolette. Abd benign, veg/stlgqs. need NG tube if she does not make her minimum intakerequirement.Alt in Dev: Temp stable in servo isolette, changed to airisolette. Cont to support, update, andeducate . Infant meeting min fluidreq by bottle. To check bili inthe am. Wakes for feeds q2-4hrs. Waking for feeds Q4hr, and active. Abd exam benign. Stable temp on off warmer. A: elevated bili P: repeat bili in am. Resting well inbetween cares. independent with infant cares. Neonatology - NNP Progress Note is active with good tone. ABdomen bneign. Mom . Temp stable on off warmer. NeonatologyDoing well. Abd benign. Took in 66cc/k yest. Trace stool x2. Infant waking Q4hrand taking 44-47cc well. Temp stable swaddled in OC. NPN#1 cont on 100cc/k/d PE20. A: PO's well. Belly benign. Belly benign. She is tolerating enteral feeds @ ad-lib amts. Min. Nursing Progress Note#1-O/A- TF=60cc/kg/d min of PE20. A: feeding fairly well P: Follow weight andoffer po's as tol#2 Temps slightly elevated in crib. Sucks on pacifier.P- Cont to assess for G&D needs.#3-O/A- Parents in to visit with updates given. in to visit and updated on plan of care. Will check bili.Will continue to assess ability to take in adeuqate pos. Will continue to monitor temp. NPN 0700-1. P-Cont to assess for FEN needs.#2-O/A- cont to be awake and active with clustercares. Waking for feeds, fairly calm with cares.sucks well on pacifier. Parentsheld infant. Swaddled. Comfortable appearing.Wt 1800 down 40. Waking on her ownprior to feeding times. Voiding and passing lgamts mec stool. Neonatology-NNP Progress NotePE: remains in her isolette, under single pt, eye covering on, in room air, bbs cl=, rrr s1s 2no murmur, abd soft, nontender, cord drying V&S, afso, active with careSee attending note for plan P- Cont to enc parentalcalls and visits.See flowsheet for further details. NPN 7p-7a#1 TF's min 60cc/k=18cc q 4hrs. Will continue toprovide for developmental needs.Alt in Parenting: Parents up to visit and participating incares, see siblings note.Bili: remains under single phototherapy. Stoolx2. Will increase minimum to 60 cc/kg/d.ID: WBC benign, blood cx NGSF, not on antibiotics. Tolerating feeds. RA. Will continueto provide for developmental needs.Alt in Parenting: Mom and dad in to visit. 4 BiliREVISIONS TO PATHWAY: 4 Bili; added Start date: Wakes q2.5-3hrs for feeds. Will continue to follow blood cx results off antibiotics.ENV'T: Stable temp wrapped with warmer off. Needs to burp frequently. Please refer to neonatology attending note for detailed plan. Attempting to achieveminimal intake with po feeds. AFOf. Loves her pacifier. Abd soft, active bowel sounds, no loops. NNP Physical ExamPE: pink, mild jaundice, AFOF, breath sounds clear/equal with easy WoB, no murmur, abd soft, non distended, active with good tone. Neonatology Attending Progress NoteNow day of life 6.CA 4/7 weeks.Cardiorespiratory status stable in RA.No apnea and bradycardiaHR 140-170sWt. Neonatology Attending Progress NoteNow day of life 3.Baby's respiratory status stable in RA.RR 20-60, no apnea and bradycardia.O2 sat >96 HR 130-160sWt. | 30 | [
{
"category": "Nursing/other",
"chartdate": "2130-07-22 00:00:00.000",
"description": "Report",
"row_id": 1850676,
"text": "Neonatology Attending Admission Note\n\nBaby is a 34 week female admitted to the NICU because of prematurity.\n\nPediatrician - Dr. .\n\nMother is 32 old G2 P0-2.\nPNS: HBSAg neg, RPR NR, O pos, Ab neg, RI, GBS - neg.\n\nPregnancy achieved with IVF assistance - dichorionic, diamniotic twins. Pregnancy was uncomplicated until when mother developed elevated .\n\nShe went into labor today and delivery was by NSVD with epidural anesthesia. No maternal fever. SROM at 1:00 AM almost 16 hours PTD.\n\nApgars 8,9. She was treated with bulb suction and blow by O2 briefly.\n\nPE - Baby pink breathing comfortably in RA.\nVS T 99.2 HR 150 RR 50 BP 67/31 44\nWt. 1840gm(25%) Lt. 43cm(25%) HC 32cm(75%)\nHEENT - AF soft and flat, prominent molding, sutures mobile, palate intact\nResp - breath sounds clear and equal.\nCVS - S1 S2 normal intensity, no murmur, perfusion good, pulses normal.\nAbd - soft with normal bowel sounds, no organomegaly\nGU - normal female\nAnus - slightly small and anteriorly placed, appearst to be patent\nNeuro - tone excellent, symmetrical movement of upper and lower extremities\n\nDS - 84\ncbc, diff pending\n\nAssessment/plan:\nWell appearing 34 week gestation female infant with stable cardiorespiratory status thus far.\nWill observe/monitor for possible apnea of prematurity, temp control.\nFeedings to be initiated this evening.\nAt slightly increased risk for sepsis with preterm labor and twin gestation. Will check cbc diff and blood culture. Will hold on antibiotic therapy unless cbc is abnormal, culture is positive or clinical signs of sepsis develop.\nFather updated at bedside.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-27 00:00:00.000",
"description": "Report",
"row_id": 1850697,
"text": "coworker 1900-0700\n\n\n#1FEN: wt. 1835 up25g. tf remains at min120cc's/kg/d of\nPE20. infant is taking 40-50cc's thus far. infant will\nbottle again at next care. abd benign, belly is soft and\nround, +bowel sounds, no loops, no spits thus far this\nshift, voiding and stooling; heme neg. A:tol feeds well\nP:cont to monitor infant\n\n#2DEVE: temp stable. infant is swaddled in the off isolette.\ninfant is waking for feeds and is and active with\ncares. font are soft and flat. mae. infant sleeps well in\nbetween cares. A:AGA P:cont to support g/d of infant\n\n#3PARENTING: no contact thus far this shift. A/P:cont to\nsupport family\n\n#4BILI: infant remains off phototherapy. infant is slightly\njaundice. will get rebound in a.m. A:hyperbilirubinemia\nP:cont to monitor infant\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-27 00:00:00.000",
"description": "Report",
"row_id": 1850698,
"text": "npn 7p7a\n\n\nAgree with the above note written by co-worker.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-27 00:00:00.000",
"description": "Report",
"row_id": 1850699,
"text": "Neonatology Attending Progress Note\n\nNow day of life 5 for this 34 week gestation infant.\n\nCardiorespiratory status stable in RA.\nNo apnea and bradc\n140-170s 61/34 43\n\nWt. 1835 up 25gm on ad lib volumes of feedings - took in 173cc/kg/d of PE\nFeedings are very well tolerated.\nNormal urine and stool output.\n\nBili 7.8 - off phototherapy\n\nAssessment/plan:\nPreterm female with excellent progress.\nWill plan on discharge to home tomorrow if continues to do well.\nDischarge screening - car seat testing and hearing to be done.\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-27 00:00:00.000",
"description": "Report",
"row_id": 1850700,
"text": "Co-worker Progress Note-DAYS\n\n\nFEN: TF min 120cc/kg/day (34cc q 4) of PE 20. Botlled 44cc\nand 50cc at 8am and 12pm. Had large spit at 12pm feeding.\nVoiding and stooling X2 thus far, hem -. Baby tolerating\nfeeds well. Continue with current feeding plan.\n\nDEV: Baby moved to OAC from off isolette at 12pm.\nTolerating well. Will continue to monitor temp. Wakes for\nfeeds and enjoys sucking on hands and pacifier. Continue to\nmonitor and support developmental needs.\n\nParenting: Mother called this am, stating she would not be\nable to visit this morning but that would be in at 2pm\nand stay for following cares. Continue to provide support\nand provide encouragement to .\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-27 00:00:00.000",
"description": "Report",
"row_id": 1850701,
"text": "NPN 0700-\nThis RN assessed infant and agrees with the above note by ; co-worker.\nFormula changed to E20. Passed hearing screen. aware of possible D/C home tomorrow. Mom got readmitted to hospital for 24hr of IV abx. Bath done and D/C teaching begun; see NICU d/c instruction form. Cont to prepare for possible D/C home tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-28 00:00:00.000",
"description": "Report",
"row_id": 1850702,
"text": "NICU NPN\n\n1. Infant PO feeding Q4 hours, waking on own. Taking 38-50cc\ntoday of E20cal without problem. feeds well. No spit,\nvoiding and stooling. Weight 1875g, up 40g today. A: Gaining\nweight.PO feding well. P: Continue to monitor weight, PO\nfeed ad lib amts w/ min 120cc/k/d.\n\n2. O: Swaddled, in open crib, with side rolls. Passed car\nseat test. Awake before feeding time, vigorous. Po fed well.\nA: AGA. P: Support developmental needs.\n\n3. O: No contact from as of this time. A/P: Support\nand keep informed with contact.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-26 00:00:00.000",
"description": "Report",
"row_id": 1850691,
"text": "npn 1900-0700\n\n\n#1 fen\ntf min 120cc/kg of pe20 po . wt. 1.810kg 9+20gms). abd\nbenign. voiding and stooling transitional guiac neg stools.\nno spits. dstic 78. a: good coordination with bottling.\ntolerating feedings well.\n#2 g&d\npt in air control isolette with stable temps. set temp\nweaned x2. and awake, irritable with cares. waking on\nown for feedings. suckin on binki and hands. maew.\nfontanelles soft and flat. a: stable\n#3 parenting\nno contact with thus far this shift.\n#4 hyperbil\npt remains under single phototherapy with eye in\nplace. repeat bili pending. skin slightly jaundice. voiding\nand stooling qdiaper change.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-26 00:00:00.000",
"description": "Report",
"row_id": 1850692,
"text": "Social Work\n\n\nFamily meeting yesterday, mother remains in house due to infection.\nMedical issues reviewed, coping well, with good questions. Delighted with how well babies are doing, planning to bottle feed and be involved in cares.\nParent packet given with parking information. adjsuting well, will plan to follow as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-26 00:00:00.000",
"description": "Report",
"row_id": 1850693,
"text": "Neonatology Attending Progress Note\n\nNow day of life 4.\nCardiorespiratory status remains stable in RA.\nNo apnea and bradycardia.\nRR - 30-60s.\nHR 150-180s\nBP 62/39 46\n\nWt. 1810gm up 20gm on 120cc/kg/d of PE\nTook in 123cc/kg/d in past 24 hours - all po.\nNormal urine and stool output.\nDS 78\n\nBili - 7.9/0.2 on single phototherapy\n\nAssessment/plan:\nVery nice progress continues.\nWill continue with current feedings.\nPhototherapy dc'ed today - rebound tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-26 00:00:00.000",
"description": "Report",
"row_id": 1850694,
"text": "Co-Worker Note 0700-1900\n\n\n1. FEN\nO: TFmin 120cc/kg/d of PE20 po. Bottling 25-30cc q3h this\nshift. Abd exam benign, +BS, no loops. No spits. Voiding and\nstooling (heme-). Cont to gain wgt. A: Tolerating feeds. P:\nCont to monitor nutritional status, wgt gain, po intake.\n\n2. DEV\nO: is /active with cares. Waking q3-4h for feeds.\nTemps stable in off isolette. Sleeping well b/w care times.\nBrings hands to face. A: AGA. P: Cont to provide dev\nappropriate care.\n\n3. \nO: Mom in throughout shift to bottle . Mom D/C'ed home\ntoday. In w/grandmother and @ 1600. Asking appropriate\nquestions. Mom expressed concern about leaving today w/o her\nbabies. Updated by RN. A: Attentive, loving family. P: Cont\nto educate and support family.\n\n4. BILI\nO: Received infant under single phototherapy. Bili this am =\n7.9/0.2. Phototherapy D/C'ed @ 1200 as ordered. Remains sl.\njaundiced. A: Resolving hyperbilirubinemia. P: Cont to\nmonitor, check rebound bili in am.\n\nSee flowsheet for details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-26 00:00:00.000",
"description": "Report",
"row_id": 1850695,
"text": "NPN DAYS\nI have examined and agree with above note by , co-worker.\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-26 00:00:00.000",
"description": "Report",
"row_id": 1850696,
"text": "NNP Physical Exam\nPE: pink, jaundiced, AFOF, breath sounds clear/equal with easy WOB, no murmur, abd soft, non distended, + bowel sounds, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-22 00:00:00.000",
"description": "Report",
"row_id": 1850677,
"text": "Admission Note\nBaby Girl #1 () was admitted to NICU at 1740 from L&D after spont vaginal delivery. Infant is 34 5/7 weeks gestation. Baby was dried and bulb sxn'd, min BBO2. Arrived to NICU pink and perfused with stable vital signs. No resp distress. Infant cried and was and active. Baby cares were given and blood was drawn for CBC and blood cx. DS=84. Dad stopped by to see infant. Infant voided and bottled 20cc of PE20.\nSee flowsheet for further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-23 00:00:00.000",
"description": "Report",
"row_id": 1850678,
"text": "NPN 7p-7a\n\n\n#1 TF's 40cc/k=12cc q 4hrs. Has po fed volumes of 10cc of\nPE20 then 16cc overnight thus far. Bottling ability is\nslowly improving. Abdominal exam unremarkable. DS 53 + 58.\nHas not voided yet this shift. Is passing meconium. A: all\npo's for now P: need ngt placed, follow weight and\ntolerance to feeds\n\n#2 Temps stable on warmer-weaned x 1. Likes pacifier.\nNudgey at times. Nested on sheepskin with boundaries in\nplace. A: AGA P: support developmental needs\n\n#3 Mom and Dad in x 1 with multiple family members to visit.\nUpdate provided. Very excited their daughters have arrived.\nA: loving folks P: cont to orient to the NICU environment\nand offer support\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-23 00:00:00.000",
"description": "Report",
"row_id": 1850679,
"text": "NICU Attending Note\n\nDOL # 1 34 5/7 weeks with apparently mature lungs, learning to PO feed.\n\nFull NNP Rivers\n\nCVR/RESP: No murmur, BS clear/=, in RA, NO A/B. Will continue to monitor.\n\nFEN: Birth weight 1840 gm, abd benign, on minimum of 40 cc/kg/d PE 20, slightly exceeding minimum D sticks in 50's. Will increase minimum to 60 cc/kg/d.\n\nID: WBC benign, blood cx NGSF, not on antibiotics. Will continue to follow blood cx results off antibiotics.\n\nENV'T: Stable temp wrapped with warmer off. Will continue to monitor temp.\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-23 00:00:00.000",
"description": "Report",
"row_id": 1850680,
"text": "Nursing Progress Note\n\n\n#1-O/A- TF=60cc/kg/d min of PE20. Infant meeting min fluid\nreq by bottle. Abd exam benign. Voiding and stooling. P-\nCont to assess for FEN needs.\n#2-O/A- cont to be awake and active with cluster\ncares. Wakes for feeds q2-4hrs. Sleeps well between cares.\n Temp stable on off warmer. Swaddled. Sucks on pacifier.\nP- Cont to assess for G&D needs.\n#3-O/A- Parents in to visit with updates given. Parents\nheld infant. Loving interaction. P- Cont to enc parental\ncalls and visits.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-23 00:00:00.000",
"description": "Report",
"row_id": 1850681,
"text": "Neonatology - NNP Progress Note\n\n is active with good tone. AFOf. She is pink, well perfused, no murmur auscultated. She is comfortable in room air. Breath sounds clear and equal. No spells. She is tolerating enteral feeds @ ad-lib amts. Abd soft, active bowel sounds, no loops. Voiding and stooling. Stable temp on off warmer. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-24 00:00:00.000",
"description": "Report",
"row_id": 1850682,
"text": "NPN 7p-7a\n\n\n#1 TF's min 60cc/k=18cc q 4hrs. Took in 66cc/k yest. Weight\ndown 40g from BW. Bottle feeding almost Q 2-4hrs overnoc for\nvolumes of 15-16cc q feed. Needs to burp frequently. DS 71.\nAbdominal exam unremarkable overnoc. Voiding and passing lg\namts mec stool. A: feeding fairly well P: Follow weight and\noffer po's as tol\n\n#2 Temps slightly elevated in crib. Hat and sheepskin\nremoved. Frequently fussy. A: AGA P: Support developmental\nneeds\n\n#3 No parental contact thus far overnight.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-28 00:00:00.000",
"description": "Report",
"row_id": 1850703,
"text": "Neonatology Attending Progress Note\n\nNow day of life 6.\nCA 4/7 weeks.\n\nCardiorespiratory status stable in RA.\nNo apnea and bradycardia\nHR 140-170s\n\nWt. 1875gm up 40gm - taking 145cc/kg/d of E20\nFeedings going well by bottle.\nNormal urine and stool output.\n\nBili - 7.8 yesterday - rebound\n\nDischarge teaching and screening in progress.\nPassed car seat and hearing screens.\n\nAssessment/plan:\nVery nice progress continues.\nWill plan on discharge to home today or tomorrow.\nAwaiting further word on mother's status.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-28 00:00:00.000",
"description": "Report",
"row_id": 1850704,
"text": "NPN 0700-\n\n\n1. Min. TF 120cc/k/d of E20= 38cc Q4hr. Infant waking Q4hr\nand taking 44-47cc well. Abd benign. Voiding and no stool\nthus far. Taking good PO's without spits. Cont to monitor\nFEN in newborn nursery.\n\n2. Temp stable swaddled in OC. Waking for feeds Q4hr,\n and active. Resting well inbetween cares. MAE,\nbrings hands to face. Cont to promote development in\nnewborn nursery.\n\n3. in to visit and updated on plan of care. Mother\nremains and will be transferred to 5 later\ntoday. aware that both girls will be transferred to\nnewborn nursery on this afternoon. \nindependent with infant cares. Cont to support, update, and\neducate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-28 00:00:00.000",
"description": "Report",
"row_id": 1850705,
"text": "NNP Physical Exam\n\nPE: pink, mild jaundice, AFOF, breath sounds clear/equal with easy WoB, no murmur, abd soft, non distended, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-24 00:00:00.000",
"description": "Report",
"row_id": 1850683,
"text": "Neonatology\nDoing well. RA. No spells. Comfortable appearing.\n\nWt 1800 down 40. ABdomen bneign. Tolerating feeds. Took in 66 cc/k/d yesterday. Will increase min to 80 cc/k/d.\n\nJaundiced this am. Will check bili.\n\nWill continue to assess ability to take in adeuqate pos.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-24 00:00:00.000",
"description": "Report",
"row_id": 1850684,
"text": "NPN DAYS\n\n\nAlt in FEN: TF increased to 100cc/kg/day PE20. Baby\ncurrently taking all feeds po. Belly benign. No spits. Stool\nx2. Will continue to encourage po feeds and place NG if baby\ntires.\n\nAlt in Dev: Recieved baby in open crib with temp stable.\nPlaced in isolette at 4pm r/t need for bili lights. Nested.\nIn servo isolette. Wakes q2.5-3hrs for feeds. Awake and\nactive with cares. Sleeps well between cares. Will continue\nto provide for developmental needs.\n\nAlt in Parenting: Mom and dad in to visit. Dad fed baby x1.\nExplained phototherapy to the parents and what the girls\nneed to be doing before they are dc'd home. Mom . She\nwill be dc'd home tomorrow and would like a family meeting\nat 3pm. Will continue to encourage parents participation in\nthe babies cares.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-24 00:00:00.000",
"description": "Report",
"row_id": 1850685,
"text": "4 Bili\n\nREVISIONS TO PATHWAY:\n\n 4 Bili; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-25 00:00:00.000",
"description": "Report",
"row_id": 1850686,
"text": "NPN\n\n\n#1 cont on 100cc/k/d PE20. Waking q3-4hrs, she has\nbottled 2 feeds taking 35cc each feed. Abd benign, veg/stlg\nqs. A: PO's well. P: no change at present\n#2 stable in servo heat isolette due to need for\nphototherapy. Waking for feeds, fairly calm with cares.\nsucks well on pacifier. A: AGA P: cont to support\ndevelopment\n#3 No contact with family thusfar in shift.\n#4 cont under single phototherapy, eyes covered, sl\njaundice. A: elevated bili P: repeat bili in am.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-25 00:00:00.000",
"description": "Report",
"row_id": 1850687,
"text": "Neonatology Attending Progress Note\n\nNow day of life 3.\nBaby's respiratory status stable in RA.\nRR 20-60, no apnea and bradycardia.\nO2 sat >96 HR 130-160s\n\nWt. 1790gm down 10gm on PE20 - ad lib volumes - took in >100cc/kg/day\nNormal urine and stool output.\n\nBili 8.9 on phototherapy.\n\nAssessment/plan:\nVery nice progress continues.\nWill continue to encourage feedings as tolerated.\nFU bili planned in 2 days.\nFamily meeting planned for this afternoon.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-25 00:00:00.000",
"description": "Report",
"row_id": 1850688,
"text": "Neonatology-NNP Progress Note\nPE: remains in her isolette, under single pt, eye covering on, in room air, bbs cl=, rrr s1s 2no murmur, abd soft, nontender, cord drying V&S, afso, active with care\n\nSee attending note for plan\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-25 00:00:00.000",
"description": "Report",
"row_id": 1850689,
"text": "Family Meeting\n\nMet with both parents and , Social Work.\nReviewed baby's course thus far and goals for discharge.\n\nMet with parents for approximately 35 minutes.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-07-25 00:00:00.000",
"description": "Report",
"row_id": 1850690,
"text": "NPN DAYS\n\n\nalt in FEN: Tf 120cc/kg/day PE20. Attempting to achieve\nminimal intake with po feeds. Needs 37cc qfeed, has taken\n35, 35, 30cc. Belly benign. Trace stool x2. No spits. \nneed NG tube if she does not make her minimum intake\nrequirement.\n\nAlt in Dev: Temp stable in servo isolette, changed to air\nisolette. Awake and with cares. Waking on her own\nprior to feeding times. Loves her pacifier. Will continue to\nprovide for developmental needs.\n\nAlt in Parenting: Parents up to visit and participating in\ncares, see siblings note.\n\nBili: remains under single phototherapy. To check bili in\nthe am.\n\n\n"
}
] |
23,014 | 180,505 | The patient was admitted to the Neurosurgery Service under Dr. service. Blood pressure was to be kept at less then 130. He was started on Dilantin 100 mg q 8 and head of bed was kept greater then 30 degrees. Neuro checks were done q one hour and placed on strict I and O. A CTA was performed, which showed a vertebral artery aneurysm. On at 11:30 in the morning Mr. went to the neuro interventional angio suite where he underwent a cerebral angiogram. He was found to have wide neck aneurysm of a heavily calcified left intracranial vertebral artery proximal to the vertebral basilar junction. He found that there was no right vertebral flow and his bilaterally ICAs did not have an aneurysm. He is brought back to the Intensive Care Unit. His blood pressures kept less then 130 and Dr. discussed possible coiling options with the family at that time. Postoperatively after his diagnostic angio Mr. was found not to open his eyes to sternal rub or following commands. His pupils were 4 mm, sluggish, reactive. He had a positive corneal and gag reflex. No blink to visual threat. He had increased tone in his lower extremities. He localized to pain in all four extremities moving his legs spontaneously. At 8:30 p.m. on he was brought back to the interventional neuro angio suite where he had a stent deployment times two and coil-through- stent embolization of his left vertebral artery aneurysm. Before the procedure he had a ventriculostomy drain placed without any complications. Postoperatively, his blood pressure is kept in the less then 120 range. His drain is open at 15. He is started on Plavix 75 mg q day and aspirin 325 mg po q day. On his intracranial pressures were ranging from 9 to 11. He had been sedated at that point. His pupils were bilateral at 2 with a conjugate gaze, moving spontaneously on the right, following commands in his upper and his lower extremities. He continued to receive intravenous Dilantin. His Dilantin was 8.3 that day. His drain was kept at 15 cm. Later in the day on he had his AICD interrogated and it was found to be functioning normally. It is a single lead ICD. After his coiling procedure Mr. was placed on heparin. On Mr. was weaned from the ventilator and extubated. He tolerated his extubation without difficulty. CAT scan on showed a large amount of subarachnoid hemorrhage within the basilar cistern and third and fourth ventricles as well as the posterior . It appeared stable from previous CAT scans. There was a small amount of subarachnoid hemorrhage overlying the sulci bilaterally. The ventricular size appeared decreased compared with previous studies. Also on Mr. had periods of congestive heart failure. Chest x-ray showed failure. He was given Lasix and pan cultured and did better post receiving Lasix. He was started on tube feeds. He continued to have Nipride to keep his blood pressure in the below 130 range and he continued to receive heparin at 700 units an hour. At this point he had no positive cultures. On Mr. eyes would open spontaneously to stimulation. He showed his thumbs bilaterally, wiggled his toes bilaterally. He was receiving Lasix prn. He received Dilantin to have his Dilantin level greater then 10. He continued to have a drain in at 15 mm. Cerebral spinal fluid showed no microorganisms. He had been ruled out for an myocardial infarction. On his heparin drip was stopped and his femoral sheath was discontinued per Dr. . Cardiology also saw Mr. for his continuing problems with congestive heart failure and they felt that he was volume overloaded and they agreed to keep his volume status balanced and to aim for negative fluid balance. The patient had an echocardiogram and it showed his ejection fraction was 30 percent. At this point his cardiac medications included Coreg, Lipitor, Lisinopril, Nimodipine, Lopressor, Hydralazine, Lisinopril and Carvedilol. He was on a Nipride drip. During the evening of Mr. became more tachypneic and was reintubated at that time. His failure was unable to be controlled with Lasix and his CO2 was becoming very low and he ended up being reintubated without any problems. A head CT on showed stable appearance of his brain since his previous study. His examination on his left pupil was 2.5 to 2. His right pupil was the same. His ICTs were 8 to 11. He was wiggling his toes, would stick out his tongue, grasps were 4 to 6. His sodium was up from 145 to 148, which was felt to be due to his strict fluid balance. His cultures from showed a sputum with gram positive cocci in pairs. The only antibiotics he had been on at that point were Kefzol for his drain prophylaxis. On Mr. went back to the diagnostic angio suite and had a diagnostic cerebral angiogram, which showed no evidence of aneurysm, that his stent was patent and his coils were intact. On Levaquin was started due to continued fevers that Mr. has had since . On he was started and Levaquin due to gram positive cocci in his sputum. On his blood cultures showed 1 out of 2 gram positive cocci. He continued to have a fever without definitive cause. He had bilateral lower extremity ultrasounds, which were negative. Chest x-ray showed bilateral small effusion. His antibiotics were changed from Kefzol to Vancomycin to cover positive blood culture that he had. His Dilantin was changed to Depakote also trying to see if the source of the fever could be from Dilantin. He was started on Depakote 750 mg t.i.d. On the Mr. continued to spike fevers up as high as 101.7. At this point he would show his thumbs bilaterally. He would localize his right upper extremity, localized to 50 percent in his left upper extremity, withdrew both of his lower extremities. He seemed to be intermittently following commands somewhat more unresponsive. His drain was lowered to 8 to see if that would help with his alertness. An ID consult was obtained to see if the source of the fever could be obtained, which they recommended a chest CT and possible change of lines. They also added Ceftazidine and Flagyl to cover possible C-diff. He had an abdominal CT, which was negative and he had a chest CT on which showed a left sided pulmonary embolism and small to moderate bilateral pleural effusion. Also at this point on the 9th his mental status was slightly worsened. A pulmonary consult was obtained and it was recommended to start Mr. on a heparin drip with goal PTT of 50 to 60. We felt that the possible mortality of this pulmonary embolism was higher then the risks of intracranial bleeding so he was started on a drip at that point. On Mr. was only intermittently following commands. He squeezed weakly on the right. Attempt to squeeze on the left localized in his bilateral lower extremities. He continued to have the ventriculostomy drain at 15. We wanted to obtain an MRI of his head and C spine just to rule out a stroke or any problems with his cord that could be causing his decreased weakness and changes in mental status, however, given his AICD placement he was never able to have an MRI. Later it was felt to be more toxometabolic given his fevers and his pulmonary embolism and the severity of his subarachnoid hemorrhage all added together to cause him to have more of a decreased mental status later in his hospital course. He had periods of low sodiums. He had been placed on a sodium drip during the week of through intermittently. He had periods of CPAP and pressure support in attempt to wean his ventilator during this week also. He continued on empiric antibiotics of the Vancomycin, Ceftazidine and Flagyl. The Vanco was for his ventriculostomy drain for prophylaxis. His cultures from the week of through showed no growth. His C-diff was negative. Also during the week of he had periods of recurrent tachycardia and bigeminy and trigeminy at different points. On he had a percutaneous tracheostomy placed without any difficulty. At this point his fevers, temperature maximum was 99.4. He was withdrawing to pain. He would stick out his tongue. He had a weak grip on the right. Cardiology saw him regarding the tachycardia which they felt was related to high catecholamine state and to treat with beta blocker doses as tolerated. He continued to be on aspirin and beta blockers. CAT scan from showed interval decrease in the intraventricular and subarachnoid blood. He was continued to be attempted to wean from his ventilator. His heparin drip continued at a rate of 1800 units an hour for a goal PTT of 60 to 80. On Mr. was found not to really respond to noxious stimuli. He did not follow commands. His pupils were reactive. He did withdraw his right upper extremity. He did not withdraw his left upper extremity. He did withdraw both lower extremities. We got a stat head CT and we opened up his drain at 12 mm above the tragus and his head CT showed that it was stable, no new bleeding. Again we felt that his mental status changes are related to toxometabolic issues from his pulmonary embolisms, his fevers, which have now resolved and an electroencephalogram showed encephalopathy. On his intravenous antibiotics were discontinued and later in the day a lumbar puncture was performed. In order to check an opening pressure we felt that this current ICD monitor did not show an accurate reflection of his ICD given the amount of hydrocephalus that appeared on his CAT scan. However, his opening pressure was 12 and he was found to have normal pressure. On Mr. eyes opened to voice. He grimaced to noxious stimulus. He did not follow command localized in his right upper extremity, slight movement in his left upper extremity. He had slight withdraw with his left leg and was felt to have a left hemiparesis. On Mr. had a PEG tube placed without any difficulty. He had a normal gastric mucosa. No abnormalities were identified. On he had a head CT. There was persistent ventricular dilation not significantly changed from his prior studies. The week of Mr. was successfully weaned from the ventilator and tolerating a trach mask without any difficulty. On a repeat head CT showed stable appearance of his ventricular dilation. No change. On a repeat lumbar puncture was performed with an opening pressure of 10. Neurologically Mr. would open his eyes to stimulation. He would move his right side spontaneously. His toes were upgoing. He was not really following commands. DISCHARGE INSTRUCTIONS: Mr. receives the following care, he has a trach collar at 70 percent, which most likely can be weaned as tolerated. He receives Impact with fiber at 80 cc an hour. He has tolerated that without difficulty. He does have a central line in place. We will leave that in place upon discharge. He has been afebrile. His last fever was on . He is not currently on any antibiotics. His current medications include a heparin drip at a rate of 1250 units per hour. That may change prior to his discharge. His goal PTT is 40 to 50 that was lowered due to some increased hematuria. He is receiving Epoietin 4000 units sq two times a week on Tuesday and Saturday. Panadol 40 mg intravenous q 24, Indocin 2.5 mg po t.i.d., Metoprolol 25 mg po b.i.d., Valproic acid 100 mg po t.i.d. He should be weaned off the valporic acid over the next two weeks to off unless he shows any signs of seizure activity. Nystatin oral solution 5 ml po q.i.d., aspirin 325 mg po q day, Plavix 75 mg po q day. He should follow up with Dr. office in two weeks. He will call if you have any questions. He will be provided an appointment prior to his discharge. Under no circumstances should his heparin be stopped. He needs to continue on heparin, Plavix and aspirin until follow up with Dr. . He needs acute neuro rehab and physical therapy and occupational therapy. Mr. was discharged neurologically in stable condition, mentally responsive upon discharge. Mr. is positive VRE from one rectal swab so he has been on VRE precautions. , Dictated By: MEDQUIST36 D: 12:39:26 T: 14:56:18 Job#: | PT NOTED TO HAVE BRIEF EPISODE OF APNEA AND STOKING RESPIRATIONS, ABG DRAWN-UNREMARKABLE, DR. AND NSURG INFORMED, CONT TO MONITOR.GI: ABD SOFT NT/ND, +BOWEL SOUNDS, TOLERATING TF AT GOAL AT 80CC/HR W/ MINIMAL RESIDUALS.GU: FOLEY DRAINING ADEQ U/O CLEAR PINK TINGED W/ SEDIMENTS.ID: TMAX 98.5PLAN: MONITOR VS, LABS, RESP STATUS, NEURO STATUS. 0500 cont pt resp status borderline wbc 16 rales sob i>o md made aware lasix and pan culture done well u/o ^^^ see notes less sob HEAD CT DONE THIS AMCV: AFEBRILE. VENT DRAINING SMALL AMT CLEAR FLUID THEN CLAMPED PER NSURG-LEVELLED AT 0CM ABOVE TRAGUS, ICP 0-9.CV: HR 70-80'S, NSR W/ FREQUENT PVC'S. ALBUTEROL NEB TX X2.GI: NPO, NGT TO LCWS WITH MOD AMT BILIOUS DRAINAGE. BS now with upper airway congestion on occassion. CONDITION UPDATE:D/A: T MAX 99.0NEURO: AROUSABLE TO VOICE, FOLLOWS COMMANDS, . Neo drip titrate to maintain SBP >120 - slowly weaning to off. FEBRILE TO 100.1 MAX.TOLERATING TUBE FEEDS AT GOAL RATE WITH MINIMAL RESIDUALS. WITHDRAWING W/ ALL 4 EXTREMETIES SLIGHTLY AND GRIMACES WHEN NOXIOUS STIMULI APPLIED TO NAILBED.CV: HR 76-92, NSR W/ PVC'S, SBP PARAMETERS >120, NEO GTT TITRATED ACCORDINGLY AND MIDODRINE 2.5MG PGT TID STARTED.CVP 6-12. DR. NOTIFIED.LUNGS COARSE BILAT. Patent blood-tinged drainage.CV: Remains Vpaced w/frequent PVCs/bigemeny noted as per pt's baseline. BS auscultated reveal bilateral coarse sounds which improve after suctioning. afebrile.resp; Clear/coarse lung sound. C-DIFF CULTURE WITH NEXT STOOL. Tmax 100, Tylenol w/effect. INITIALLY NSR WITH FREQUENT ECTOPI. CONTINUE ESMOLOL AT 100MCG TO MAINTAIN SR. MONITOR ECTOPI REPLETE LYTES AS INDICATED. extremities cool (baseline) and pink.IV'S: pt has 2 L PIV's perfusing well, triple lumen CVL with CVP attached- good wave forms + dressing CDI, A-Line CDI w/sharp wave forms, A-line sheath CDI with sharp wave forms.GI: pt's abdomen soft +hypo active BS x4. Cont on Neo to keep SBP 160-170.RESP: lungs coarse through out. CPT done x2.GI/GU: Med loose bm gauaic neg. Stool sent for c-diff. pt sedated and sbp down to 160's. pt remains on cmv at present time due to tachypnea.gi: abd ct neg per dr. . Received albumin x1 as albumin 2.9 and cont with 2-3+ pit edema.RESP: No changes. Ventriculostomy draining burgandydrainage. condition updateD;neuro: pt opens eyes to name. VENT REOPENED PER NEUROSURG TEAM AT 0 TRAGUS, ? titrate neo for sbp 160-170. titrate tf up to 70cc/hr.r: neuro is unchanged. AMBU/SYRINGE @ HOB. GROSS HEMATURIA SHOWN TO TEAM, DR. . TO 19/07 PT STATUS REMAINS AROSABLE TRIES TO TALK AT TIMES OPENS EYES TO COMAND WEAKNESS ALL EXTEMITIES PERIOD OF AGITATION RR 28 TO 30 PTPLACED BACK ON SIMV WITH RELIEF HEART S1S2 NSR WITH 2 TO DEPRESSION IN LEAD 2 PULSES POS 2 THRU OUT NEG NVD VSS ALINE CVP ICP WAVE FORMS WNL SEE FLOW SHEET RESP RONCHI THRU OUT CLEARD AFTER SUCTION SIMV FIO2 35% GOOD AIRATION GI POS BS T/F WELL SMALL RESIDUAL SMALL STOOL U/O QS NO ISSUES NEO 1.5 MCG/KILO/MIN BP 150 TO 170 PER ORDER HEPARIN TO TITRATE SKIN NOTE BUTT SL RED WITH SKIN OPEN AREA SUPPORTIVE CARE ROM TURN SIDE TO SIDE PUL TOILETING PT ON HEPARIN AT 1700U/HR.GI: PT TOLERATING TUBE FEEDINGS, MINIMAL RESIDUALS NOTED.GU: U/O 80-160CC/HR.F/E. Trach continues to ooze, swivel changed X2.ABG:metabolic alkalosis with hyperoxiaPlan: PSV during day as tolerated. AM ABG's 7.48/37/127/28, improvement noted. Tolerating well spont. VT decreased, periods of apnea, placed on a/c noc. LOOSE STOOL A FEW TIMES AND SENT FOR CULTURE.GU- UOP RANGING FROM 80-100CC/HR.ID- AFEBRILE BS ausucltated reveal bilateral aeration in apecies with diminished bases. STATUSD: MORE AWAKE WILL FOLLOW SOME SIMPLE COMMANDS..MOVES ALL EXTREM'S LF LEG MUCH WEAKER THAN RT MOVES BOTH ARMS EQUALLY..FEBRILEA: PERIP/CENTRAL LINE/URINE/VENT CULTURES SENT..MP ? secreations minimal bloody thick. Resp CarePt. HR 70'S-80'S WITH OCCASIONAL PVCS, NSR.RESP- LUNGS COARSE AT TIMES, RELIEVED BY SUCTIONING FOR THICK BLOODY SPUTUM. Ambu/syringe @ hob. 19/07 STATUS PT OPENS EYES TO COMANDS MAE LIMITED ON NO SEDATION PROGRESSIVE IMPROVMENT RESTS LONG PERIODS VSS CVP ICP WNL GOOD WAVE FORMS U/O QS RESP ON CPAP WITH PS VERY WELL RESP 12 TO 14 OCC RHOCHI CLEARS AFTER SUCTIONING .40% FIO2 SAT 99 HEART S1S2 FREQ PVC PNC PULSES +2 THRU OUT W/D NEG NVD NEG HJR NSR MILD ST DEPRESSION 2/3 MM GI POS BS STOOLING T/F WELL NO RESIDUALS T/P SKIN CARE WITH ROM THIS PM SPUTUM BLOOD SENT FOR CULTURES pt.remains on simv+ps ventilation,abg alkalotic, will wean as , has periods of increased rr. AT THIS TIME WAS FEBRILE TO 101.7. Trach care completed x4 d/t amount of secretions. STATUSD: NEURO ESSENTIALLY UNCHANGED..MORE LETHARGIC IN AFTERNOON..REMAINS ON NEO/HEPARIN GTT'SA: AFEBRILE..WEANED ON VENT TO IPS 5 C-PAP 5 SHORT TIME THAN TACHYPNEIC 30'S..PLACED ON IPS 8>> WELL..SUCTIONED THICK WHITE GOOD ABG'S..NEO UP & DOWN TO KEEP SBP 160/-170/'S GTT @ 1.0MCG AT PRESENT HEPARIN REMAINS @ 1700U WITH PTT 70'S..GOOD HUO'S..INCT SOFT BROWN STOOL..TF'S REMAIN OFFR: ESSENTIALLY UNCHANGEDP: CONTINUE TO MONITOR PTT/NA'S Q6H..NEURO SIGNS Q2H..? FEBRILE TO 101.5. CONTINUE TO MONITER NEURO AND RESPIRATORY STATUS. Remains on Flagyl, Vanco and Cefepime with Vanco and Cefepime in NS.GU: U/O qs via foley. RESTART TF'S K+ dropped to 3.6 -> rechecked and will replete per scale. ESMOLOL WEANED OFF SUCCESSFULLY AND IV LOPRESSOR STARTED. PT STILL NOT FOLLOWING COMMANDS.CV: HR 70-90'S, NSR W/ PVC'S, SBP>120 PER PARAMETERS-GOOD RESPONSE ON MIDODRINE 2.5MG TIS. HR 70'S WITH FREQUENT PVCS, NSR.RESP- LUNGS CLEAR WITH DIMINISHED BASES. NEED FOR LASIX..MAINTAIN SBP 120-150.R.STABLE AT THIS TIME WITH POSSIBLE EARLY SIGNS OF FAILURE. RESTARTED AND LP SITE MONITORED, NO OR DRAINAGECV- BP 120-140'S. REHAB TODAY. EKG done. O2 sats adequate on trach collar.Duoderm on coocyx changed. DOES BECOME HYPERTENSIVE WITH TEMP ELEVATION. NOTIFIED AND IVF DECREASED TO KVO. BS auscultated reveal bilateral clear apecies with diminished LS. BP PARAMETERS OF SBP 120-150 TO BE CONTINUED.. TEMP UP TO 100.8 FOR WHICH PT WAS CULTURED AND TYLENOL GIVEN. Patient was then started on nipride gtt to keep sbp<160. AM ABG's 7.48/36/151/28. Ambu/syringe @ hob. TMAX 99.0. STATUSD: NEURO ..REMAINS ON GTT @ 1250UA: VSS..GOOD HUO NO STOOL..PTT Q8H.. TRACH @ 70% SUCTIONED FOR MOD AMT THICK PINK TINGED/TAN SECREATIONSR: ESSENTIALLY P: TO GO TO REHAB TOMORROW..FAMILY AWARE To that end examination of the proximal portion of the stent with three-dimentional rotational angiography revealed that the proximal portion of the stent had been crimped on itself probably as a result of the highly calcific left vertebral artery. POSTOPERATIVE DIAGNOSIS: Same status post stent angioplasty of the intracranial vertebral artery and left segment followed by coiling of the wide-necked aneurysm with preservation of the flow in the left vertebral artery in the posterior circulation and obliteration of the aneurysm using endovascular coiling. Pulmonary artery systolichypertension.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a moderate risk (prophylaxis recommended). The left vertebral artery appears to be dominant and the basilar trunk is somewhat diffusely narrowed possibly as a result of the proximal atherosclerotic stenosis. There is moderateregional left ventricular systolic dysfunction with near akinesis of theinferior and inferolateral walls. There is mildpulmonary artery systolic hypertension. | 127 | [
{
"category": "Nursing/other",
"chartdate": "2165-06-25 00:00:00.000",
"description": "Report",
"row_id": 1563068,
"text": "CONDITION UPDATE\nD. THIS AM DESPITE ACCEPTABLE ABG'S ON BIPAP MASK,RR=36-44.DECISION TO INTUBATE MADE AND WAS PERFORMED BY ANESTHESIA AFTER PRE- SEDATION .ETT CONFIRMED BY CXR AND PT WAS STARTED ON PROPOFOL DRIP.ABG ACCEPTABLE POST INTUBATION(SEE FLOW SHEET FOR SETTINGS AND CHANGES).\n TEMP UP TO 100.9 OCCASSIONAL SHIVERING WITH SKIN SURFACE COOL.SR 70-90 WITH ECTOPY AT TIMES.RR= 14-22 ON VENT WITH O2 SATS=98 ON 40% FIO2. SBP 120-150.CVP MOST OF DAY .\n ONCE CARDIOLOGY EVALUATED PT ALONG WITH CURRENT DATA FROM CARDIAC ECHO,DECISION WAS MADE BY SICU TEAM AND CONFIRMING WITH CARDIOLOGY AND NEUROSURG TEAMS,PT WAS GIVEN LASIX WITH GREAT DIURETIC RESPONSE. CVP DECREASED TO 10.SBP PARAMETER WAS CHANGED THIS AM TO 140-150 PER DR. ALLOWING NIPRIDE TO BE WEANED OFF SINCE INTUBATION AND SEDATION ON BOARD.\n DESPITE PT BEING ON PROPOFOL 25MCQ,PT DOES RESPOND TO PAIN,MOVING ALL EXTREMITIES BUT NOT FOLLOWING COMMANDS.AFTER SCHEDULED HEAD CT SCAN THIS PM,NEURO CHECK WAS PERFORMED OFF OF PROPOFOL. PT FOLLOWED ALL COMMANDS,MOVING ALL EXTREMITIES. PT TO ATTEMPT TO EXTUBATE HIMSELF BUT PROTECTIVE WRIST RESTRAINTS PREVENTED THIS FROM OCCURING.ICP- AND DRAINING VARYING DEGREES OF RED COLOR.\n A.CHECK COMPLETE NEURO EXAMS Q 4-6 HRS PRN.MAINTAIN SBP 120-150.ICP TO REMAIN AT 15CM ABOVE TRAGUS AND OPEN .\nR.CONDITION REMAINS GUARDED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-26 00:00:00.000",
"description": "Report",
"row_id": 1563069,
"text": "RESPIRATORY CARE:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. Patient changed over to IMV this shift for a paco2 if 29.(goal range 35-40.) Current settings IMV/PS 700*12 40%fio2 with 5 peep and 5ps. Breathsounds are coarse. Please see respiratory section of carevue for further data. RSBI this am 62.2 Patients respiratory rate started to climb while doing RSBI.\nPlan: Continue mechanical ventilation. Wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-26 00:00:00.000",
"description": "Report",
"row_id": 1563070,
"text": "CONDITION UPDATE\n\nPROPOFOL STOPPED Q 4 HR FOR NEURO CHECKS PT FOLLOWS COMMANDS WITH APPROPRIATE MOVEMENT. NIPRIDE NOT NEEDED SBP < 150 MOST OF NOC.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-26 00:00:00.000",
"description": "Report",
"row_id": 1563071,
"text": "CONDITION UPDATE\nD.TEMP SPIKE THIS AM TO 102 FOR WHICH LINE BC DRAWN AND TYLENOL WAS GIVEN.WITHIN 1 HR,SBP DROPPED TO 80,CVP=9(SCHEDULED ANTIHYPERTENSIVES WERE GIVEN DURING THIS HOUR). PT WAS DIAPHORETIC AT THIS TIME.SICU TEAM WAS NOTIFIED AND LR BOLUS OF 500ML WAS GIVEN ALONG WITH TURNING PROPOFOL OFF UNTIL BP RETURNED.SBP SLOWLY ROSE AND REMAINED 119-130/70.HYDRALAZINE WAS D/C'D.\n PT AWOKE TO GENTLY ATTEMPT TO REACH HIS ET TUBE AND PROPOFOL WAS RESTARTED.\n PT HAS BEEN ABLE TO FOLLOW ALL COMMANDS,MOVING ALL EXTREMITIES AND ATTEMPTING TO FORM WORDS WITH MOUTH WHEN OFF OF PROPOFOL.ON PROPOFOL TO WITHDRAWS EACH EXTREMITY TO PAIN.ICP 4-10 AND LESS BLOODY CSF.\n NO VENT CHANGES MADE.PT FOR MINIMAL SECRETIONS.\n WIFE AND SON IN TODAY AND UPDATE WAS GIVEN BY MYSELF AND THEN DR. .\nA.CONTINUE TOMAINTAIN SBP 120-150.TO ANGIO TOMORROW PM PER DR. FOR FOLLOW-UP.\nR.STABLE AT THIS TIME.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-15 00:00:00.000",
"description": "Report",
"row_id": 1563141,
"text": "NEURO: PT OPENED EYES TO PAINFUL STIMULI X1, . NOT FOLLOWING COMMANDS, NO SPONT MVMT NOTED, WITHDRAWS ALL 4 EXTREMETIES TO NOXIOUS STIMULI APPLIED TO NAILBED. VENT DRAINING SMALL AMT CLEAR FLUID THEN CLAMPED PER NSURG-LEVELLED AT 0CM ABOVE TRAGUS, ICP 0-9.\n\nCV: HR 70-80'S, NSR W/ FREQUENT PVC'S. SBP PARAMETERS 160-180, REMAINS ON NEO GTT AND TITRATED ACCORDINGLY. HEP GTT REMAINS ON, PTT GOAL 40-50.\n\nRESP: LUNG SOUNDS DIMINISHED, O2 SAT >95% ON TRACH COLLAR AT 50%. SXN PRN FOR THICK BLOOD CLOTS AND TAN SECRETIONS. PT NOTED TO HAVE BRIEF EPISODE OF APNEA AND STOKING RESPIRATIONS, ABG DRAWN-UNREMARKABLE, DR. AND NSURG INFORMED, CONT TO MONITOR.\n\nGI: ABD SOFT NT/ND, +BOWEL SOUNDS, TOLERATING TF AT GOAL AT 80CC/HR W/ MINIMAL RESIDUALS.\n\nGU: FOLEY DRAINING ADEQ U/O CLEAR PINK TINGED W/ SEDIMENTS.\n\nID: TMAX 98.5\n\nPLAN: MONITOR VS, LABS, RESP STATUS, NEURO STATUS. AWAITING PEG PLACEMENT. CONT CURRENT MGMT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-16 00:00:00.000",
"description": "Report",
"row_id": 1563142,
"text": "Resp Care\nPt. remains on 50% cool aerosol mask tolerating well. ABG: adequately oxygenated with a metabolic alkalosis.\nBs: equal bilat. coarse secreations minimal, pt. has strong cough. Inner cannula patent with ess. equipment at bedside.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-16 00:00:00.000",
"description": "Report",
"row_id": 1563143,
"text": " \"N\" Nsg Progress Note:\n\nCVS: Pulses present. Skin cool and dry. Afebrile. HR=79-89 NSR with quadrigeminy. SBP=165-177 with IV Neo drip titrate to keep SBP between 160 and 180. Currently at 3mcg/kg/min. IV drip at 1200u/h goal to keep PTT=40-60. CVP=. ICP=.\n\nNeuro: Pt is minimally responsive. Opens eyes slightly with stimulation. No movements of extremities. No grimacing. No seizure activity.\n\nResp: Trach collar with 50% O2 tolerated well. Bloody secretions noted. Sats=99-100%. RR=30's mostly. Lung sounds clear but diminished at bases.\n\nSkin: Small ecchymotic areas on torso and rt arm. Peri area slightly reddened-aloe ointment applied. Coccyx area shows small purple area but no breakdown as yet, on air mattress.\n\nGI: +bowel sounds. Incontinent soft brown stool, guaiac -. TF at goal of 80cc/h of Impact with fiber.\n\nGU: U/O=90-140cc/h.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-16 00:00:00.000",
"description": "Report",
"row_id": 1563144,
"text": "NEURO: PT UNABLE TO OPEN EYES, NOT FOLLOWING COMMANDS, NO SPONT/PURP MVMTS OBSERVED. PT WITHDRAWING TO NOXIOUS STIMULI APPLIED TO NAILBED. VENT REMAINS AT 0CM ABOVE TRAGUS, DRAINING CLEAR FLUID, ICP 1-7. HEAD CT DONE TODAY AND LP DONE W/ OPENING PRESSURE 12.\n\nCV: HR 70-80'S, NSR W/ PVC'S, SBP 160-170'S-NEO TITRATED TO KEEP SBP160-180, CVP 2-9. HEP GTT STOPPED FOR LP.\n\nRESP: REMAINS ON 50% O2 ON TRACH COLLAR W/ SATS 98-100%. LUNG SOUNDS COARSE. SXN PRN FOR THICK SPUTUM. IRREGUALR RESP PATTERN.\n\nGI: ABD SOFT/NT/ND, +BOWEL SOUNDS, TOLERATING TF IMPACT W/ FIBER AT 80CC/HR AT GOAL W/ MINIMAL RESIDUALS.\n\nGU: FOLEY DRAINING ADEQ U/O, CLEAR YELLOW URINE.\n\nID: TMAX 97.9\n\nPLAN: MONITOR VS, LABS, RESP STATUS, NEURO STATUS. PT CONSULT DONE TODAY, CASE MGMT CONSULT PENDING. AWAITING PEG PLACEMENT\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-17 00:00:00.000",
"description": "Report",
"row_id": 1563145,
"text": "Resp Care\nPt. on 40% cool aerosol tolerating well with spo2 99%. RR 20-30.\nBs: coarse with occ. rhonchi sxn'd for copious bloody thick plugs. Also pt. has strong cough and occ. expectorates independantly. Inner cannula changed and patent. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-23 00:00:00.000",
"description": "Report",
"row_id": 1563061,
"text": "CONDITION UPDATE\nNEURO: PROPOFOL OFF AT 0800. PT OPENS EYES TO COMMAND, MAE ON BED TO COMMAND. ICP 4-14. VENT DRAIN AT 15 ABOVE TRAGUS WITH MOD AMT BLOOD TINGED DRAINAGE. SPEECH DIFFICULT TO UNDERSTAND POST-EXTUBATION. ORIENTED TO PERSON, STATES HE IS AT . HEAD CT DONE THIS AM\nCV: AFEBRILE. SNP TITRATED TO MAINTAIN SBP 100-130 PRESENTLY ON 0.75 MCQ/KG/MON. PT GIVEN EXTRA DOSE OF HYDRALAZINE IV AT 1600. SEE CAREVUE FOR SPECIFICS\nRESP: PT WEANED AND EXTUBATED BY 1400. OPEN FACE TENT WITH GOOD ABG AND SATS. BS COARSE. CPT DONE X 1. COUGHING BUT NOT RAISING\nGI: TF HELD PRIOR TO EXTUBATION. ABD SOFT AND NON-TENDER, +BS\nGU: CLEAR YELLOW VIA FOLEY IN ADEQUATE AMTS\nENDO: NO ISSUES\nA: NEURO STATUS MONITORED, NIPRIDE TITRATED AS ORDERED, HEAD CT DONE, EXTUBATED\nR: EXTUBATION, IMPROVING NEURO STATUS- CONTINUE TO MONITOR CLOSELY\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-23 00:00:00.000",
"description": "Report",
"row_id": 1563062,
"text": "Respiratory Care Note:\n Patient weaned and extubated after repeat head CT was cleared. He coughs and follows basic commands but still appears sleepy. Propofol off since app 8am. BS now with upper airway congestion on occassion. No wheezing noted. He is on a continuous cool aerosol at 40% via face tent with good abg results. See Carevue flowsheet. Plan to help with pulmonary hygiene as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-24 00:00:00.000",
"description": "Report",
"row_id": 1563063,
"text": " cont of previous note 0010 pt increase agitation remains alert denies pain resp rapid rate 28 to 32 chest clear vss icp wnl moving hands around picking md brought to bedside to help with eval abg done wnl for pt chest xray mso4 given far response supportive care gradual improvment\n plan wean nipride pt/ot\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-24 00:00:00.000",
"description": "Report",
"row_id": 1563064,
"text": " 0500 cont pt resp status borderline wbc 16 rales sob i>o md made aware lasix and pan culture done well u/o ^^^ see notes less sob\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-24 00:00:00.000",
"description": "Report",
"row_id": 1563065,
"text": "CONDITION UPDATE:\nD/A: T MAX 99.0\n\nNEURO: AROUSABLE TO VOICE, FOLLOWS COMMANDS, . AWARE OF PERSON AND PLACE, NOT TIME. PAIN X1 TREATED WITH MORPHINE WITH GOOD EFFECT. MAE'S, STRENGTHS EQUAL, STRONG. SPEAKING APPROPRIATELY WITH WIFE. VENTRICULOSTOMY REMAINS @ 15 CM ^ TRAGUS WITH ICPS . CPP AT ~ 55-70 WITH THE TIGHT BLOOD PRESSURE PARAMETERS, PA CHIP AWARE.\n\nCV: HR 70'S-104 LOPRESSOR X2 WITH + EFFECT. PT WITH RESP DISTRESS/CHF PER CHEST XRAY. LASIX X1 IN AM WITH EXCELLENT EFFECT (1 LITER OUT IN FIRST HOUR). IN AFTERNOON LASIX X1 AGAIN, NOT AS EFFECTIVE, ~ 280 CC'S OUT WITH RESP DISTRESS CONTINUING. GOAL ABP 100-120 MET WITH TITRATION OF NIPRIDE ALONG WITH ATC ANTIHYPERTENSIVE MEDS. NIMDIPINE TRANSIENTLY DROPS PT'S PRESSURE TO 80'S AND THEN RETURNS TO PREVIOUS LEVEL. MN-1700 FLUID BALAND -1000 CC'S. HEPARIN GTT D/C'D THIS AM, RIGHT FEMORAL SHEATH D/C'D ~ 1200. PT BE SITTING MORE UPRIGHT @ 1800.\n\nRESP: LS COARSE/DIFFICULT TO AUSCULTATE AS PT MAKES UPPER AIRWAY NOISE THAT REVERBERATES THROUGHOUT LUNGS. ? STRIDOROUS? ABG 0800: 7.42, 33, 98, 22, -1. IN AM PT'S RESP DISTRESS PICTURE IMPROVED WITH LOPRESSOR AND LASIX. IN AFTERNOON PT PRESENTED AGAIN WITH INCREASE RR TO 40'S, O2 SATS TO ~ 90%, LOPRESSOR AND LASIX GIVEN WITH POOR EFFECT, PT WITH COOL NEB FACE TENT, ABG: 7.46, 31, 76, 23, 0, 97. HIGH FLOW HUMIDIFIED SYSTEM APPLIED WITH O2 SATS IMPROVING TO ~ 96%, HOWEVER RESP RATE CONTINUES TO BE ~ 40. REPEAT ABG PENDING.\n\nGI: TUBE FEEDS STOPPED PER DR. DUE TO POOR RESP PICTURE. + BS, NO BM. ~ 100 CC'S OUT OF NGT.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\n\nSX: WIFE AND SON VISITING AND UPDATED BY DOCTORS.\n\nR: LOW GRADE TEMP, WITH POOR RESP STATUS AND CHF. IMPROVED NEUROLOGICAL STATUS.\n\nP: CONTINUE CLOSE MONITORING AND MANAGEMENT. ? INTUBATION IF RESP EFFORT REMAINS LABORED. ECHO ORDERED, UNABLE TO OBTAIN TODAY ( DAY). ? PLACE PA CATHETER TO ADRESS FLUID STATUS MORE CLOSELY IF RESP/CV PICTURE DOES NOT IMPROVE. CONTINUE TO TITRATE NIPRIDE GTT FOR GOAL SBP 100-120. LAST SET OF CARDIAC ENZYMED DUE @ MN. PT AND FAMILY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-25 00:00:00.000",
"description": "Report",
"row_id": 1563066,
"text": "CONDITION UPDATE\nNEURO: OPENS EYES TO NAME, ORIENTED TO SELF ONLY, ASKING WHY HE IS IN THE HOSPITAL, FOLLOWS COMMANDS- MAE WITH EQUAL STRENGTH, ICP 4-14, VENT AT 15CM ABOVE TRAGUS WITH MOD AMT BLOOD TINGED DRAINAGE. SPEECH CLEARER THAN YESTERDAY. SNP GTT TITRATED TO MAINTAIN SBP 100-120.\nCV: T MAX 99.8, HR ELEVATED TO 104- LOPRESSOR 10MG IV GIVEN WITH SUBSEQUENT DROP TO 70-80'S, PT HAVING FREQUENT PVC'S.\nRESP: PT ON HIGH FLOW MASK AT BEGINNING OF SHIFT. RESP LABORED WITH SATS 93-95%, PT CHANGED TO CPAP MASK WITH 15 IPS WITH IMPROVEMENT IN SATS BUT RESP RATE STILL REMAINS ELEVATED IN HIGH 20'S-35. ALBUTEROL NEB TX X2.\nGI: NPO, NGT TO LCWS WITH MOD AMT BILIOUS DRAINAGE. ABD SOFT AND NON-TENDER WITH +BS\nGU: NO LASIX THIS SHIFT, HUO 28-60\nA: NEURO STATUS AND RESP STATUS MONITORED, NT SX X 1 FOR SM AMTS THICK TAN SECRETIONS.\nR: RESP STATUS REMAINS GUARDED- CONTINUE TO MONITOR SATS AND ABGS_ ? INTUBATE\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-25 00:00:00.000",
"description": "Report",
"row_id": 1563067,
"text": "resp care\npt re-intubated this shift d/t imp resp fail. oett #7.5 secured 23cm @lip. oett plcmnt confirmed via +etco2, cxr. pt placed on vent, see carevue for settings/changes. pt tx w/o incident to /from ct scan. b/s coarse sxn thk tan, spec sent to lab. plan: cont w/mech support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-17 00:00:00.000",
"description": "Report",
"row_id": 1563146,
"text": "7a-3p\nneuro: , withdraws to pain, no response to command, vent dc'd @ 1145, no change in nuero status post removal, to have head ct tomorrow\n\ncv: hr nsr, occasional pvc's, sbp 148-164, continues on neo gtt, goal sbp 150-170, continues on po lopressor\n\nresp: on 50% trach collar, rr 20-38, sat 100, sux mod amt thick bld tinged tan sputum, pt coughing productively, no resp distress noted\n\ngi: goal tf well, no stool, po prevacid, tf off for bedside PEG @ 1600\n\ngu: foley patent, clear yellow urine, good uo\n\nother: gtt continues @ 1200u/hr, to be dc'd @ 1500 for PEG insertion, family in & updated on pt's condition,\n\nplan: continue to monitor respiratory/neuro status, head ct in am, possible vp shunt\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-18 00:00:00.000",
"description": "Report",
"row_id": 1563147,
"text": "NPN 0700-1500;\nNEURO; OPENS EYES OCCASSIONALLY TO NOXIOUS STIMULI PERLA 3MMREACTS BKS.WITH DRAWS TO PAIN LT MORE THAN RT.GRIMACES OCCASSIONALLY WITH PAIN BUT NOT CONSISTENTLY.TRAVELLED FOR CT THIS AM AWAITING RESULTS.\n\nRESP;LUNGS COARSE, IRREG BREATHING AT TIMES SUCTIONED FOR PROFUSSE AMIUNTS THICK BEIGE SECRETIONS Q3. STRONG PRODUCTIVE COUGH POS GAG.SATS 97%-\n\nCVS; 96.5 PO NSR WITH OCCASIONAL PVC. PT WITH . WEANING NEO FOR SYS BP GREATER THAN 120 SLOWLY,\n\nGU ; MOD DIURESIS THROUGH FOLEY.\n\nGI POS BS NO FLATUS NO STOOL. STARTED T/F VIA PEG,IMPACT WITH FIBRE AT 10 MLS TO ADVANCE 10 CC /HR Q4 TO GOAL OF80 MLS/HR. BS ON RISS NPH 2UNITS THIS AM AS BS 80S BS AT 12 93.\n\nINTEGRUM UNCHANGED DUODERM INTACT OVER COCCYX.\n\nSOC; WIFE INTO VISIT AND UPDATED WITH CURRENT CONDITION SPOKE WITH CASEMANAGER ABOUT BEING SCREENED BY \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-18 00:00:00.000",
"description": "Report",
"row_id": 1563148,
"text": "RESPIRATORY CARE\nPt remains on 40% Trach Mask, transported to and from CT. Aerosol maintained.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-19 00:00:00.000",
"description": "Report",
"row_id": 1563149,
"text": "7p-7a; Full assessment in flow sheet.\n\nneuro; Only respond to painful stimuli - stronger withdrawal to pain on the right versus left side. Slight movement of ext - inconsistent movement. Do not open eyes. do not follow commands. Do not track. - 3 mm brisk. Good gag and cough reflex. head dressing site d/c/i.\n\ncv; NSR with PVC. Neo drip titrate to maintain SBP >120 - slowly weaning to off. warm, dry, no edema. afebrile.\n\nresp; Clear/coarse lung sound. Trach collar - 40% - SaO2 >100%. Trach care done. Productive cough - moderate thick/tan sputum.\n\ngu/gi; soft abd. +BSX4. no bm. G-tube - site d/c/i, +placement, minimal residual - working to goal of TF at 80 cc/hr.\n\nPlan; Continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-19 00:00:00.000",
"description": "Report",
"row_id": 1563150,
"text": "NEURO: NOTICED PT OPEN EYES VERY SLIGHTLY X1 ONLY HOWEVER UNABLE TO FOLLOW COMMANDS NOR MOVE EXTREMETIES SPONT/PURP. WITHDRAWING W/ ALL 4 EXTREMETIES SLIGHTLY AND GRIMACES WHEN NOXIOUS STIMULI APPLIED TO NAILBED.\n\nCV: HR 76-92, NSR W/ PVC'S, SBP PARAMETERS >120, NEO GTT TITRATED ACCORDINGLY AND MIDODRINE 2.5MG PGT TID STARTED.CVP 6-12. HCT 28.7, VERIFIED. TRANSFUSED 1U PRBC'S.\n\nRESP: LUNG SOUNDS COARSE, O2 SAT 98-100% ON 50% VIA TRACH COLLAR. SXN PRN FOR THICK GREEN TINGED SPUTUM, PT ALSO ABLE TO EXPECTORATE AT TIMES.\n\nGI: ABD SOFT NT/ND, +BOWEL SOUNDS, TF IMPACT W/ FIBER INFUSING VIA PEG-GOAL 80CC/HR PRESENTLY AT 60CC/HR W/ MINIMAL RESIDUALS.\n\nGU: U/O BORDERLINE, CLEAR CONCENTRATED URINE. DR. INFORMED, CONT TO MONITOR.\n\nID: TMAX 97.9.\n\nPLAN: MONITOR VS, LABS, RESP STATUS, NEURO STATUS. CONT CURRENT MGMT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-02 00:00:00.000",
"description": "Report",
"row_id": 1563091,
"text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. Patient vent mode changed over to A/C in CT as they were having trouble with synchrony and hypertension. Patient transported to CT with vent without incident. Unable to change patient back over to imv as his respiratory rate increased into the 40's. RSBI this am was 150. Breathsounds are decreased. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation. Wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-07 00:00:00.000",
"description": "Report",
"row_id": 1563109,
"text": "RESP CARE NOTE:\n\nPT CONTINUING ON A/C VENT 15, 35%, 400,5 PEEP. TRIED RSBI BUT RR QUICKLY ROSE TO HIGH 40'S AND B/P INCR. CURRENT PLAN IS TO CONTINUE SETTINGS AND PT TO REST. SUCTIONED THIS SHIFT FOR MOD AMT OF VERY THICK WHITE SPUTUM. PT OFTEN BITES ETT MAKING SUCTIONING DIFFICULT .\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-08 00:00:00.000",
"description": "Report",
"row_id": 1563114,
"text": "NPN\n PT NOT OPENING EYES TODAY HOWEVER IS OCCASIONALLY FOLLOWING COMMANDS TO WIGGLE TOES, SQUEEZE HAND. RIGHT HAND SPONTANEOUSLY MOVING, FEET ALSO SPONTANEOUSLY MOVING ON BED. PERRL, 3-4MM. ICP 2-13 DEPENDING ON STIMULI, CLAMPING TO REPOSITION, ETC. VENT DRAINING DARK RED, ABOUT 20-30CC FOR THE SHIFT.\nCV- BP STAYING BETWEEN 160-180'S WITH LOW DOSE OF NEO. HR 70-80'S WITH MULTIPLE PVCS. SODIUM GTT INCREASED TO 20CC WITH NA CHECKED Q2HRS WITH MOST RECENT BEING 131. DR. UPDATED.\nRESP- VENT CHANGED BACK TO SIMV THIS AM DUE TO LONG PERIODS OF APNEA ON CPAP SETTING. ABGS CHECKED AND PT CONTINUES TO BE SLIGHTLY ALKALOTIC, WILL CONTINUE TO MONITOR. LUNGS CLEAR, SUCTIONED INFREQUENTLY FOR THICK CLEAR SPUTUM. MD SPEAKING TO FAMILY ABOUT POSSIBLE TRACH TOMMORROW.\nGI/GU- ABD SOFT, TF AT GOAL WITH MINIMAL RESIDUALS. FOLEY DRAINING LARGE AMOUNTS OF CLEAR URINE, 100-300CC/HR\nID- LOW GRADE TEMP THIS AM. CONTINUES ABT.\nSOCIAL- FAMILY IN TO VISIT, SPOKE WITH MD\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-09 00:00:00.000",
"description": "Report",
"row_id": 1563115,
"text": "D PT MINIMALLY RESPONSIVE. OPEN EYES ONLY ONCE FOLLOWED COMMANDS INCONSISTANT5LY MOVES ARMS UP AND DOWN LIFTING OFF BED AT TIMES MOVES LEGS ONLY SLIGHTLY ON BED. . NS 3% AT 20CC OFF AT 5AM.NA 135. ICP 2-5.\nCV: PT. INITIALLY NSR WITH FREQUENT ECTOPI. BIGEMINI AND TRIGEMINEY. NEO AT 1.25-1.20 MCG/KG/MIN. AT ABOUT 2300 PT IN POSSIBLE SVT ECG DONE HR >130 AND MAINTAINED FOR > 30MIN . ATTEMPTED TO VALSALVA BY SUCTIONING ET AND ORAL WITH OUT EFFECT. HO AT BED SIDE DILTAZIEM 10MG GIVEN . SBP DROPPED . RESIDENT/INTERNAL AT BED SIDE. LOPRESSOR 5MG GIVEN 5-10MIN APART. WITH SOME EFFECT. HR DOWN TO TEENS THEN 90 FOR SHORT TIME THEN BACK UP ESMOLOL BOLUSED AND STARTED AT 100MCG/KG/MIN SVT CONVERTED TO NSR WITH FREQUENT ECTOPI. BOLUS 500CC NS.TEMP MAX 101.8 RECTAL PAN CULTURED INCLUDING OBTAINED BY NEURO.\nLUNGS: COARSE THROUGHOUT,SUCTION FOR SMALL TO MOD WHITE THICK SPUTUM.\nGI: ABD SOFT BS PRESENT TF STOPPED AT MN RESIDUALS < 20.\nGU: FOLEY TO C/D OUTPUT > 100 AN HOUR.\nSKIN: COCCYX WITH DUODERM NO OTHER SKIN REDDNESS OR BREAKDOWN NOTED.\nA PT SVT RESOLVED NSR ON ESMOLOL AND NEO .\nP CONTINUE TO MONITOR NA Q2H.X4 . 3% NA OFF IF NA DROPPES TO 130 AGAIN RESTART 3%. CONTINUE SODIUM TABS. CONTINUE NEO TO MAINTAIN SBP 160-180. CONTINUE ESMOLOL AT 100MCG TO MAINTAIN SR. MONITOR ECTOPI REPLETE LYTES AS INDICATED. POSSIBLE TRACH TODAY HAS REMAINED NPO. SEE CARE VIEW FOR SPECIFICS\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-02 00:00:00.000",
"description": "Report",
"row_id": 1563092,
"text": "FOCUS: STATUS UPDATE\nDATA:\nPATIENT VERY EASILY AROUSABLE TO VOICE THIS AFTERNOON. PUPILS EQUAL AND REACTIVE TO LIGHT. LIFTING AND HOLDING BILAT ARMS PURPOSEFULLY AND TO COMMAND. MOVING FEET TO COMMAND. AT TIMES NODDING OR SHAKING HEAD TO QUESTIONS. VENTRICULAR ELEVATED TO 15CM ABOVE TRAGUS. ICP <10 WITH DARK BLOOD TINGED DRAINAGE.\n\nNEOSYNEPHRINE IV DRIP ON AND OFF FOR BLOOD PRESSURE LESS THAN 150. OK PER DR. TO TOLERATE BP MIN 150SYSTOLIC AS LONG AS NEURO EXAM UNCHANGED. PATIENT REQUIRED NICARDIPINE WHILE DOWN AT CAT SCAN DUE TO HYPERTENSION TO 190'S. MULTIPLE PVC'S AND CONSISTENT BIGEMINY WHILE IN CT SCAN. DR. NOTIFIED.\n\nLUNGS COARSE BILAT. CONTINUES ON AC VENT--NO CHANGES TODAY. SATS 99-100%. CHEST CT DONE WITH PRELIMINARY RESULTS CONSISTENT WITH L PE.\nSUCTIONED FOR MINIMAL AMOUNTS WHITE SECRETIONS. FEBRILE TO 100.1 MAX.\n\nTOLERATING TUBE FEEDS AT GOAL RATE WITH MINIMAL RESIDUALS. NO BM.\n\nPLAN:\nSTART HEPARIN DRIP FOR PE PER DR. . C-DIFF CULTURE WITH NEXT STOOL. SPUTUM CULTURE. MAINTAIN BP 150-170 WITH ACCEPTABLE NEURO EXAM.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-03 00:00:00.000",
"description": "Report",
"row_id": 1563093,
"text": "Nursing note:\nNEURO: Opens eyes to voice, nodding yes/no to questions. Following simple commands. PERRLA 4-5mm and brisk. Moves all extremities purposefully. Lifts/falls w/upper extremities, wiggles bilateral feet on bed. Grasps equal. Ventricular @15cm above tragus, ICP 8-11. Patent blood-tinged drainage.\nCV: Remains Vpaced w/frequent PVCs/bigemeny noted as per pt's baseline. SBP kept 150 or > w/acceptable neuro exam w/aid of Neo gtt. Titrated up to 3.5mcg/kg/min, nsurg PA aware. SBP does drop w/Nimodopine. Neuro status remains unchanged w/drops below 150 systolic. Sodium 129 from 135, NACL 3% gtt begun w/Sodium levels to be checked q2 hours. Begun on salt tabs as well. Palpable pulses. Skin warm and diaphoretic at times. Tmax 100, Tylenol w/effect. Heparin gtt increased for sub-therapeutic PTT per Nsurg. Vanco levels sent.\nRESP: No vent changes overnight, ABGs acceptable. Suctioned for small amounts thick yellow sputum, specimen sent to cx.\nGI: Abdomen softly distended, +bowel sounds and flatus. Minimal stool via FIB. Tolerating tube feeds via NGT w/minimal residuals.\nGU: Foley patent large amounts light yellow urine.\nENDO: Glucose levels stable, insulin per sliding scale PRN.\nSOCIAL: Wife called and updated.\n\nA/P: Neuro stable. SBP labile, frequent drops in pressure requiring increases in Neo, Nsurg aware. Hyponatremic, begun on 3% sodium gtt. Cont. on Heparin gtt for presumed PE. Cont. current plan of care, follow lytes, coags, maintain SBP 150-170.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-07 00:00:00.000",
"description": "Report",
"row_id": 1563110,
"text": "nuero: at 1200 pt did open his eyes when you called his name, pt did follow commands pt did squeeze my hands on right and left hand, pt did stick out his tongue. no spontanoues movement noted from legs. at other times pt not following commands or opening eyes(please see nuero flow sheet for nuero assessment). pt does withdraw all four extremties to painful stimuli. vent. raised to 15cm above tragus, draining blood tinged csf. pupils remain equal and reactive to light.\n\nlungs: lungs coarse at bases. pt on cpap with ps. suctioning pt for yellowish secretions.\n\ncards: pt remians in sr, with frequent pvcs. pt diaphrotic at 1200, dr. called and aware, ekg done, dr. assessed ekg. iv neo remians on to keep sbp b/w 170-180.\n\ngi: tube feeding at goal, minimal residuals.\n\ngu: u/o has been over last couple of hours 300cc/hr, dr. aware.\n\nf/e na 130, na rechecked result pending, if less than 130 to start 3% na gtt. blood sugar 148 recieved 8nph and 6u of regular insulin per sliding scale.\n\nplan: continue to monitor nuero status, pulm status, blood sugars, check na. possibe trach on tuesday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-07 00:00:00.000",
"description": "Report",
"row_id": 1563111,
"text": "Respiratory Care\nPt remains mechaniclly ventilated, placed on CPAP/PSV this morning. Suction for small amounts of pale white secreations. Breath sounds equal. Pt maintaining consistant spontaneous RR/Vt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-07 00:00:00.000",
"description": "Report",
"row_id": 1563112,
"text": " 19 to 07\n\n status unchanged random motion of extemites with pain or loud stimulus only basicly deeply letargic on cpap well icp 4 to 5 good wave form at 15 cm dark red csf\n\n resp wnl thick yellow sputum on cpap .35 fio2 clear after suctioning no issues\n\n heart s1s2 murmur sys nsr pvc st depression 2to 3 mm noted in in lead 2 pulses pos 2 thruout\n\n gi pos bs neg hem tf well no residual\n\n supportive care t/p butt care duo in place side to side only all lines wnl good waves passive rom done\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-08 00:00:00.000",
"description": "Report",
"row_id": 1563113,
"text": "Resp care Note:\n\nPt has been on Cpap/PSV all night and contiues on this at present. RSBI was done this am and was 141 afte full minute on\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-22 00:00:00.000",
"description": "Report",
"row_id": 1563056,
"text": "condition update\nSee ICU flowsheet for specifics\nNeuro: pt's pupils are equal and reactive to light stimuli, able to follow simple commands (to move hands/feet) at times after relaxed- pt has trouble following commands after movement. Pt has good grip strength in hands, can push with feet. Pt sedated per team with propofol. Vent drain at 15cms above tragus- draining small amounts of blood tinges fluid.\nCV: Team would like bp b/t 100-120 systolically- pt is on nitroprussin @ 2.50mcg/kg/hr to maintain bp below 120; bp will increase post suctioning and with turning. Hydralazine 10g was given x 1 with adequate effect- pt will now receive OTC doses. HR70's-80's NSR with random PVC's throughout the day. Oral beta blockers/anti hypertensives admin in the am a/o. +d/p pulses with dopplar- q2 hours. +radial r/l pulses. extremities cool (baseline) and pink.\nIV'S: pt has 2 L PIV's perfusing well, triple lumen CVL with CVP attached- good wave forms + dressing CDI, A-Line CDI w/sharp wave forms, A-line sheath CDI with sharp wave forms.\nGI: pt's abdomen soft +hypo active BS x4. NG tube was to LWS during day draining lg amts of Bilious drainage. Started TF-impact with fiber @10cc/hr at 1500- pt appears to be tolerating well; will increase rate 10cc q 4hrs until a goal of 70.\nSkin: occlusive dsg on scalp cdi with small amounts sersang staining.\nFamily : very supportive and at bedside most of afternoon- very appropriate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-22 00:00:00.000",
"description": "Report",
"row_id": 1563057,
"text": "Respiratory Care Note\n Patient remains intubated and sedated on propofol on full ventilatory support. FIO2 weaned to 40%. See Carevue flowsheet for specifics. BS bilat, coarse over RUL. Suctioned for med amounts of tannish sputum. Plan to maintain on A/C overnight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-22 00:00:00.000",
"description": "Report",
"row_id": 1563058,
"text": " to to 07\n nuro status improving opens eyes to comands helps to turn self in bed mae tries to talk around ettnote pt becomes agitated wants tube out very clearly during bp becomes elevated md made aware for tonight may increase propofol to sedate nipride for bp sys 110\n heart s1s2 mumur sys pules +2 neg nvd nsr pvcs at times\ncvp fem and arterial a line wnl note icp 8to 15 depending on agitation good wave pattern se notes\n resp ett scant secreations light yellow .40% fio2 rate 12\n gi tube feeding well small residual\n supportive care\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-22 00:00:00.000",
"description": "Report",
"row_id": 1563059,
"text": " note pt hard to manage bp elevated agitation remains u/o down i>o md made aware mane morphine and bp meds to be changed see orders\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-23 00:00:00.000",
"description": "Report",
"row_id": 1563060,
"text": "RESP CARE\nPT remains intubated and ventilated. Curent settings are A/C 750x12 35% 5peep with peak/plat 24/18. Bs coarse but clear. Suct for a small amt of thick white sput. in fio2 to 35% with good sats. RSBI done=53. Will follow as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-14 00:00:00.000",
"description": "Report",
"row_id": 1563135,
"text": "Resp: pt on psv 5/5/40%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral coarse sounds which improve after suctioning. Suctioned moderate amounts of bloody thick secretions. Changed out heated wire vent circuits. AM ABG's 7.45/35/197/25. Placing pt on T/C this am. No further changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-21 00:00:00.000",
"description": "Report",
"row_id": 1563051,
"text": "NEURO; PT ON AT 25 MCG/KG/MIN, GTT OFF PER SICU AND NEURO TEAM, PT UNRESPONSIVE, WITHDRAWS ONLY RT FOOT TO NAILBED PRESSURE, DOES NOT OPEN EYES OR FOLLOW COMMANDS, RARELY MOVES BOTH FEET SLIGHTLY ON BED, NIPRI8DE TITRATED UP TO KEEP SYS 100-130, PRESENTLY AT 0,8 MCG/KG/MIN, GIVEN HYDRALAZINE 10 MGM X 1 FOR PERSISTENT ELEV BP IN 140'S, DESPITE INCREASE IN NIPRIDE, PT HAS POSITIVE GAG REFLEX, VOMITED SMALL AMT UNDIGES FOOD, NG SUCTION INCREASED, SICU TEAM INFORMED, PUPILS ARE VERY SLUGGISH #2, NEURO RESIDENT IN AND STATED PT DID LOCALIZE UPPER EXTREMITIES TO PRESSURE\nPT TAKEN TO ANGIO FOR FURTHER DIAGNOSTICS\n\nCARDIOVASCULAR; HR 70'S PACED, EXTREMITIES WARM AND DRY,\n\nRESPIR; SUCTIONED FOR SMALL AMTS THICK YELLOW SECRETIONS, SIMV RATE DECRESED FROM 20-18 AND FI02 DECREASED TO 60%, WILL REPEAT ABG WHEN PT RETURNS, WILL HAVE RPT CHEST X-RAY UPON RETURN\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-21 00:00:00.000",
"description": "Report",
"row_id": 1563052,
"text": "resp care\npt remains intubated and mech ventilated. see carevue for settings/changes. b/s coarse, sxn thk yel secretions. pt tx to/from neuro-angio w/o incident. plan: cont w/mech suport.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-21 00:00:00.000",
"description": "Report",
"row_id": 1563053,
"text": "UPDATE NOTE\n\nNEURO; PT RETURNED FROM ANGIO, OCCLUDED VERTEBRAL ARTERIES, TO RETURN TO ANGIO FOR POSSIBLE STENT AND/OR COILING, PROPOFOL ON AT 35 MCG/KG/MIN AND OFF Q 1HR FOR NEURO CHECKS, DOES NOT OPEN EYES OR FOLLOW COMMANDS, WITHDRAWS ALL EXTREMITIES TO NAILBED PRESSURE, NIPRIDE AT 0.8 MCG/KG/MIN TO KEEP SYS 110-130'S PER DR. , PUPILS REMAIN SLUGGISH, EVALUATED FREQUENTLY BY NEURO RESIDENT,\n\nCARDIOVASCULAR; HR 60'S-70'S SR, SYS 120'S, NIPRIDE OFF PRIOR TO RETURN TRIP TO ANGIO DUE TO SYS 90'S AND AFTER MEDIC BY ANESTHESIA, GIVEN PLAVIX 150 MGM AND ASA 81 MGM VIA NG TUBE THIS PM, RT FEMORAL SHEATH TRANSDUCED, BP LOWER THAN RADIAL A LINE, NEURO AND SICU HO INFORMED, PEDAL AND PT PULSES EASILY PALPABLE, NO HEMATOMA OF RT GROIN\nRT SUBCLAVIAN TRIPLE LUMEN LINE INSERTED, CONFIRMED VIA X-RAY\n\nRESPIR SUCTIONED FOR SMALL THICK LIGHT YELLOW SECRETIONS, ABGS THIS PM-PC02 34, COARSE BREATH SOUNDS THROUGHOUT\n\nSOCIAL FAMILY AT BEDSIDE, WIFE UPDATED BY NEURO TEAM\n\nPLAN PT TAKEN BACK TO ANGIO FOR POSSIBLE STENT/COILING\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-14 00:00:00.000",
"description": "Report",
"row_id": 1563136,
"text": "\nPT MAINTAINED ON TM VENTILATION AND DOING WELL. VITALS STABLE, BLOOD STILL OOZING FROM TRACHEOSTOMY BUT MUCH BETTER THAN YESTERDAY. TM ABG SHOWED VERY GOOD OXYGENATION WITH A MILD ALKALOSIS. MENTAL STATUS UNCHANGED. PLAN IS TO CONT ON TM VENTILATION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-14 00:00:00.000",
"description": "Report",
"row_id": 1563137,
"text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT ONLY RESPONDING TO PAINFUL STIMULI. MAE BUT VERY MINIMALLY. . VENT REOPENED PER NEUROSURG TEAM AT 0 TRAGUS, ? INCREASED HYDROCEPHALUS SINCE CLAMPED TWO DAYS AGO. CHIP MACINTOSH IN TO CHANGE VENT TUBING (DOUBTS ACCURACY OF ICP, 0-3) IN THE PROCESS OF DECREASING , CSF DRAINED 70CC AND IS NOW CLAMPED UNTIL FURTHER NOTICE FROM NEUROSURG. ICP REGISTERING NEGATIVE NUMBERS.\nCV- BP 160'S ON 2.5MCGS OF NEO. I UNIT PRBCS GIVEN AND REPEAT HCT PENDING. HR 70-90 WITH OCCASIONAL PVCS. GROSS HEMATURIA SHOWN TO TEAM, DR. . GTT DECREASED TO 800U/HR WITH NEW PTT GOAL OF 40-50 TO PREVENT FURTHER ACTIVE BLEEDING.\nRESP- NO FURTHER BLEEDING FROM TRACH SITE BUT SPUTUM REMAINS BLOOD TINGED. VERY STRONG COUGH, ABLE TO RAISE. REQUIRED DEEP SUCTIONING ONLY A FEW TIMES. AFTERNOON ABGS ALL WNL ON TRACH COLLAR.\nGI/GU- LOOSE STOOL, DARK, C-DIFF PENDING. TF RESIDUAL 125 THIS AM, TF HELD FOR TWO HOURS AND FOLLOW UP RESIDUAL ONLY 10CC, THEREFOR TF RESTARTED. BLOOD TINGED URINE AVERAGING 100-260CC/HR.\nID- AFEBRILE\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-14 00:00:00.000",
"description": "Report",
"row_id": 1563138,
"text": " 19/07\n\n STATUS APPEARS LIGHTER JUST TOUCHING HIS SKIN CAUSES MOVEMENT PAINFUL STIMULUS YEILDS ORGANIZED MOTION ALL EXT SAME RESPONDS AT O LEVEL AND CLAMPED ICP NEGATIVE NUMBERS UNREALIABLE\n\n RESP T COLLAR .50 FIO2 WITH 100% SAO2 SECREATIONS LESS YELLOW IN WITH FOUL SMELL CLEAR AFTER SUCTION / COUGHING\n\n HEART S1S2 NSR WITH PVCS PULSES FAIR VSS ON NEO MAINTAIN BP 160 THRU SHIFT WELL A LINE CVP FAIR WAVES U/O QS\n\n SUPPORTIVE CARE P/T CONSULT NEEDED OOB TO WITH LIFT FREQ ROM\nOSMOTIC DIURETICS FOR LONG TERM USE FAMILY SUPPORT\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-15 00:00:00.000",
"description": "Report",
"row_id": 1563139,
"text": "NURSING UPDATE\n STATUS UNCHANGED UNTIL 0500, SBP DIMINISHED TO LOW 80'S AND MAP TO 40'S, DR INFORMED, ALBUMIN 25% IV X1 WITHOUT EFFECT, IV BOLUS N/SALINE 500CC INFUSING AT THIS TIME PER DR WITH GOOD EFFECT SO FAR. BP UP TO 105/45(62). SEE CAREVIEW FLOWSHEETS FOR DETAILED DATA.\n WILL CONTINUE TO MONITOR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-15 00:00:00.000",
"description": "Report",
"row_id": 1563140,
"text": "ADDENDUM\n****PLEASE DISREGARD ABOVE NOTE - ENTERED ON WRONG PATIENT****\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-01 00:00:00.000",
"description": "Report",
"row_id": 1563089,
"text": "Condition Update A:\nPlease refer to careview and remarks for specifics.\nNEURO: Became less responsive as SBP decreased to 120's. Dr. up to see pt. Pt arousable and following commands, MAE with SBP 160-170's. No indications of pain. Head CT done this afternoon report pending. Ventriculostomy draining burgandydrainage. increased to 12 at tragus by NSURG this afternoon.\nCV: Nicardipine gtt stopped this morning for maintaining SBP <170. Neo gtt started to keep SBP initially 150-165, and parameters increased per Dr. to 160-170. HR NSR with frequent bigeminy. Cycled cardiac enzymes completed, 1800 levels pending, and appears to be ruling out for MI. Received albumin x1 as albumin 2.9 and cont with 2-3+ pit edema.\nRESP: No changes. Minimal secretions. CPT done x2.\nGI/GU: Med loose bm gauaic neg. Stool sent for c-diff. Minimal TF residuals. Glucose in the 140's, no treatment per RISS. TF stopped to admin baricate for abd CT to be done this evening. Foley patent draining adequete urine, occ cloudy.\nSKIN: W/D/I.\nSOCIAL: Dr. and Dr. in to speak with Mrs. and provide updates.\n\nPLAN: Titrate Neo gtt to keep SBP 160-170. Monitor neuro status, ICP. Abd CT once baricat completeed and CT available. Cont with ICU care and monitoring.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-02 00:00:00.000",
"description": "Report",
"row_id": 1563090,
"text": "condition update\nD;neuro: pt opens eyes to name. follows commands. pupils are equal and reactive to light. moves all extremities to command. lifts and falls both extremities. vent is at 12 cm above the tragus. icp is . draining tea colored drainage.\ncardiac: nsr with bigemeny and frequent pac's. at ct scan pt became very hypertensive to 200 and started on nicapdipne titrated up to 1mcg/kg/min. still hypertensive up to 180. resp rate up to 40 in ct and pt started on propofol at 40mcg/kg/min for sedation. pt sedated and sbp down to 160's. propofol off after ct scan. pt. awake and following commands. neuro exam back to baseline. sbp down to 140 after nimodipine and pt restarted on neo and titrated up to 1mg/kg/min. cvp is 11.\nresp: bs are clear and diminished in the bases. suctioned for thick white. pt remains on cmv at present time due to tachypnea.\ngi: abd ct neg per dr. . positive bowel sounds large amt of loose liquid brown stool. tf restarted and no residuals.\ngu: urine output is adequate and greater than 100cc/hr. iv fluid at kvo.\nskin: transparent head dsg is dry and intact. no areas of breakdown is noted. heels slightly red but no breakdown. placed on pillow.\nid: temp max is 101.3. wbc down to 16.\na: continue with neuro checks. titrate neo for sbp 160-170. titrate tf up to 70cc/hr.\nr: neuro is unchanged. pt follows commands and moves all extremities. temp down to 100.7. neo down to .8mcg/kg/min. abg is less alkalotic.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-22 00:00:00.000",
"description": "Report",
"row_id": 1563054,
"text": " to 19 to 07\n nuro pt sedated with propofol on vent limit stimulation until am because of new stent and coil inserted this pm intracerebral deep tendon not assessed md 2mm corneal reflex negative mild gag noted icp 7 to 11 good wave scant drainage\n heart s1s2 2+ SYS MURMOR VSS NIPRIDE MAINTAIN BP SYS 110 TO 120 NSR OCC PVC NOTE FREQ PVC PRIOR TO K AND MAG REPLACMENT PULES +2 TO +3 AT TIMES CVP GOOD WAVE 3 to 5\n resp vent rate 12 fio2 .50 scant sputum clear fields ett at 21 lip no spont resp sat 99 to 100 persent\n gi hypoative bowel sounds ng to suction soft nondistended\n all lines wnl alarms on\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-22 00:00:00.000",
"description": "Report",
"row_id": 1563055,
"text": " cont note attempt to wake pt 15 minutes bp elevated pa at bedside test ended nuro no corneal reflex impaired gag ridgid legs\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-12 00:00:00.000",
"description": "Report",
"row_id": 1563129,
"text": " TO 19 TIME 19/07\n REMAINS DEEPLY LETHARGIC OPENS EYES MAE LOCALIZES ONLY TO PAIN ONLY OCC BRIEF PERIOD OF SPONT EYE OPENING TO COMMAND ICP 1 TO 4 GOOD WAVE NOTED CLAMPED PER ORDER\n\n RESP ON .40 FIO2 CPAP 5/5 WELL RESP RATE 12 TO 20 SPUTUM SCANT TRACH STOMA BLOODY LARGE AMOUNT AIRWAY CLEAR GELFOME IN PLACE DRESSING AROUND SITE FOR COLLECTION\n\n ABD SOFT LAG BM PASTY DARK MANY T/F WELL SCANT RESIDUAL\n\n HEART S1S2 NSR OCC PAC PVC PNC WAP THRU SHIFT BP 160 TO 170 SYS ON NEO TO REDUCE VASOSPASM NEG NVD PULSES FAINT IN NATURE U/O QS CVP5 TO 6 ALINE IN PLACE GOOD WAVE FORM\n\n SUPPORTIVE CARE FREQ ROM T/P\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-13 00:00:00.000",
"description": "Report",
"row_id": 1563130,
"text": "RESP: PT ON PSV 5/5/40%. ALARMS ON AND FUNCTIONING. AMBU/SYRINGE @ HOB. BS AUSCULTATED REVEAL BILATERAL COARSE SOUNDS. SUCTIONED MODERATE AMOUNTS OF THICK BLOODY TINGED SECRETIONS AND YELLOW. TRACH SITE STILL OZZING. AM ABG'S: 7.37/42/168/25. RSBI=107. POSSIBLE CT SCAN THIS AFTERNOON FOR FOLLOW-UP. NO FURTHER CHANGES NOTED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-13 00:00:00.000",
"description": "Report",
"row_id": 1563131,
"text": " O500 NOTE BLEEDING AROUND TRACH SITE REMAINS MD AWARE SEVERAL\n\n JELFORM USED TOLWELL\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-13 00:00:00.000",
"description": "Report",
"row_id": 1563132,
"text": "\nPT MAINTAINED ON PSV VENTILATION AT 40% WITH GOOD OXYGENATION. TRACHEOSTOMY HAS BEEN A PROBLE WITH CONSTANT BLEEDING. M.D. UP TO SUTURE WHICH HAS MADE IT SOMEWHAT BETTER. CT SCAN TODAY TO ASSESS REMOVAL OF VENTRICULOSTOMY. SX FOR BLOODY SECRETIONS. PLAN IS TO TRY PT ON TM VENTILATION AT SOME PT TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-05 00:00:00.000",
"description": "Report",
"row_id": 1563104,
"text": " TO 19/07\n\n PT STATUS REMAINS AROSABLE TRIES TO TALK AT TIMES OPENS EYES TO COMAND WEAKNESS ALL EXTEMITIES PERIOD OF AGITATION RR 28 TO 30 PTPLACED BACK ON SIMV WITH RELIEF\n\n HEART S1S2 NSR WITH 2 TO DEPRESSION IN LEAD 2 PULSES POS 2 THRU OUT NEG NVD VSS ALINE CVP ICP WAVE FORMS WNL SEE FLOW SHEET\n\n RESP RONCHI THRU OUT CLEARD AFTER SUCTION SIMV FIO2 35% GOOD AIRATION\n GI POS BS T/F WELL SMALL RESIDUAL SMALL STOOL\n U/O QS NO ISSUES\n\n NEO 1.5 MCG/KILO/MIN BP 150 TO 170 PER ORDER HEPARIN TO TITRATE\n\n SKIN NOTE BUTT SL RED WITH SKIN OPEN AREA\n\n SUPPORTIVE CARE ROM TURN SIDE TO SIDE PUL TOILETING\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-06 00:00:00.000",
"description": "Report",
"row_id": 1563105,
"text": "Respiratory Care\nPt remains mechaniclly ventilated, switching from SIMV to CPAP. Changing PSV to accommidate adequate/comfortable spontaneous VT/RR. Suction for scant amounts thick white secreations. Breath sounds diminished.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-11 00:00:00.000",
"description": "Report",
"row_id": 1563124,
"text": "Neuro: pt remains very lethargic. Pupils 3mm brisk. Having no spontaneous movement. Withdraws to nailbed pressure. ICP 4-6, Vent remains at 15cm above tragus.\nCV: afebrile HR 80's NSR with frequent PVC's. Exremities warm with +PP. Cont on Neo to keep SBP 160-170.\nRESP: lungs coarse through out. No vent changeds overnight. Requring occasional suctioning of thick bloody sputum. Trach care done several times. Pt having lrg amount of blood drg from trach site.\nGI tube feed at goal.\nGU: foley draining adequate amounts of amber urine.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-11 00:00:00.000",
"description": "Report",
"row_id": 1563125,
"text": "7a-3p\nneuro: neuro in this am & vent increased to 20 above tragus, no response to verbal command, responds to painful stimuli with facial grimacing, withdraws to nail bed pressure, mouthed \"\" to niple pressure, slight movement of R arm, no other movement of extremities noted, vent draining sm amt bld tinged clear drainage, \n\ncv: hr nsr with occasional to frequent pvc's, sbp 160-179, continues on neo gtt to keep sbp 160-170, continues on iv lopressor q 6 hrs\n\nresp: bs+ all lobes & course, sux mod amt thick bld tinged sputum, continues on 40% fio2, imv 20, 5 peep, 8 ips, RSBI 140 this am, lg amt bleeding around trach, ho aware, surgigel applied, hct drawn @ 1400 & pending, rr 20-30, sat 100, no resp distress noted\n\ngi: goal TF well, incont lg amt loose semi-formed brown stool, FIB applied, po prevacid qd\n\ngu: foley patent, clear yellow urine, good uo\n\nother: family in & updated on pt's condition, heparin continues @ 1800u/hr, bs 133 & covered with rssi\n\nplan: continue to monitor neuro/respiratory status, check PM hct\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-11 00:00:00.000",
"description": "Report",
"row_id": 1563126,
"text": "Resp care\nPt reamins on full vent support. No recent ABG\"S as of yet. No vent changes made. Coarse BS, sx mod thick blood tinged secretions. Continues with bleeding around trach. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-12 00:00:00.000",
"description": "Report",
"row_id": 1563127,
"text": "Resp Care\nPt. remains on SIMN mode with no changes made t/o shift. Tolerating well spont. breathing over set rate with shallow pattern and VT's 200-300cc range.\nBs: coarse bilat. secreations minimal bloody thick. Trach continues to ooze, swivel changed X2.\nABG:metabolic alkalosis with hyperoxia\nPlan: PSV during day as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-13 00:00:00.000",
"description": "Report",
"row_id": 1563133,
"text": "NPN\n PT NOT OPENING EYES TODAY, MOVING EXTREMETIES IN RESPONSE TO PAINFUL STIMULI ONLY. CT TODAY SHOWING NO CHANGE SINCE VENT CLAMPED. .\nCV- BP DROPPING TO 100'S BEFORE LEAVING THE FLOOR TO CT, REQUIRING LARGE INCREASE IN NEO GTT. FLUID BOLUS GIVEN WITH GOOD EFFECT AND BP IS NOW 170'S FOLLOWING TWO UNITS OF BLOOD. AFTERNOON HCT DROPPED TO 24, WILL FOLLOW UP WITH REPEAT FOLLOWING SECOND UNIT. TRACH SITE OOZING NON STOP TODAY. SHOWN TO DR. AND DR. PAGED TO . SEVERAL STITCHES PLACED AND BLEEDING HAS NOW STOPPED. WILL CONTINUE TO MONITOR.\nRESP- LUNG SOUNDS COARSE AT TIMES, SUCTIONED FOR THICK BLOOD SPUTUM EVERY FEW HOURS. PT ABLE TO RAISE, VERY STRONG COUGH. O2 SAT 100% ON CPAP.\nGI- ABD SOFT, TF AT GOAL. LOOSE STOOL A FEW TIMES AND SENT FOR CULTURE.\nGU- UOP RANGING FROM 80-100CC/HR.\nID- AFEBRILE\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-14 00:00:00.000",
"description": "Report",
"row_id": 1563134,
"text": " 19/07\n\n status stable mae only to painful stimuli and only on occ no other new trends strong gag\n\n trach in place scant bleeding around stoma only cpap .40 fio2 note bloody sputum only rhonchi thru out possible trach mask\n\n heart s1s2 pulses poss multifocal pvcs noted bp to be maintained greater than 160 sys with neo u/o qs icp 1to 2 cvp 4\na line good wave\n\n gi wnl pos bs tube feeding well note hematuria started this am md decrease\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-06 00:00:00.000",
"description": "Report",
"row_id": 1563106,
"text": "Respiratory Care\nPt becoming more short of breath with spontaneous RR in upper 30's to low 40's. Decreasing Vt to 200 cc. Placed back on SIMV and increase of PSV to 15cm. Decreasing work of breathing as a result of adjustment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-06 00:00:00.000",
"description": "Report",
"row_id": 1563107,
"text": "NUERO: PT DOES NOT OPEN HIS EYES WHEN YOU CALL HIS NAME. PUPILS REMIANS EQUAL AND REACTIVE TO LIGHT. PT DOES WITHDRAW ALL FOUR EXTREMTIES TO PAINFUL STIMULI. AT TIMES SPONTANOUES MOVEMENT NOTED FROM RIGHT ARM AND LEFT ARM, NO SPONTANOUES MOVEMENT NOTED FROM RIGHT AND LEFT LEGS. DR. AWARE. (NUEROSURGICAL PA) CALLED AND AWARE AND UP TO ASSESS PATIENT. AT TIMES PT WILL SQUEEZE RIGHT HAND TO COMMANDS. ICP REMIANS , VENTRICULAR DRIAN REMAINS 10CM ABOVE TRAGUS DRIANING BLOOD TINGED DRAINAGE.\n\n\nLUNGS: LUNGS COARSE SUCTIONING PT FOR SCANT AMT OF YELLOW SECRETIONS. PLEASE SEE FLOW SHEET FOR VENT SETTINGS AND ABGS.\n\nCARDS: PT IN SR WITH FREQUENT PVC'S. NEO TITRATED TO KEEP SBP B/W 170-180'S. PT ON HEPARIN AT 1700U/HR.\n\nGI: PT TOLERATING TUBE FEEDINGS, MINIMAL RESIDUALS NOTED.\n\nGU: U/O 80-160CC/HR.\n\nF/E. BLOOD SUGAR THIS MORNING 169 RECIEVED 5U NPH AND 10U REGULAR INSULIN , REPEAT BLOOD SUGAR AT 1645 143 RECIEVED 6U OF REGULAR INSULIN PER SLIDING SCALE. NA 130 REPEAT NA 132, DR. AWARE.\n\nSKIN: BROKEN AREA NOTED ON BUTTUCKS DRAINING SMALL AMT OF BLOODY DRAINAGE DUEODERM APPLIED.\n\nPLAN: CONTINUE TO MONITOR NUERO STATUS, KEEP SBP B/W 170-180, MONITOR BLOODSUGARS, NA,\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-06 00:00:00.000",
"description": "Report",
"row_id": 1563108,
"text": " TO 19/07\n\n PT STATUS LABILE RESPONDSIVENESS OPEN EYES MAE MOUTHS WORDS ON OCC FOR SHORT PERIODS OF TIME BECOMES TIRED THAN FALLS INTO DEEP LETHARGIC STATE SUPPORTIVE CARE\n\n HEART S1S2 ST DEPRESSION REMAINS BP TO BE MAINTAINED SYS 170 TO 180 WITH NEO PVC TRIPLETS PULES POS 2 THRU OUT LOW GRADE TEMP ICP CVP A LINE WNL GOOD WAVE U/O QS\n\n ABD POS BS NOTED T/F WELL NO RESIDUALS F/S AT 8O CC PER HOUR\n\n RESP VENT ASSIST/CONT .35 FIO2 STABLE DECREASE SPUTUM\n\n SKIN FREQ TURNS BUTT CARE BECAUSE OF SMALL WOUND\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-12 00:00:00.000",
"description": "Report",
"row_id": 1563128,
"text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT NOT OPENING HIS EYES TO STIMULUS BUT GRIMACING TO PAIN. MOVING ONLY IN RESPONSE TO PAIN, LOCALIZING. . VENT INCREASED TO 25 ABOVE TRAGUS BY NSURG. NA MONITORED AND DECREASED THIS AFTERNOON TO 134, WILL UPDATE MD.\nCV- BP WELL MAINTAINED IN 160-170 RANGE WITH NEO AT 2.4 MCGS. HR 70'S-80'S WITH OCCASIONAL PVCS, NSR.\nRESP- LUNGS COARSE AT TIMES, RELIEVED BY SUCTIONING FOR THICK BLOODY SPUTUM. TRACH CARE DONE AND ABOUT TWO HOURS AFTER PT BEGAN OOZING BLOOD FROM SITE. DRESSING REINFORCED, AFTERNOON HCT 29.\nGI- TF AT GOAL. NOTICED SMALL CLOTS AND BLOOD TINGED RESIDUAL FROM STOMACH THIS AM, DR. NOTIFIED, CONTINUE TO MONITOR.\nGU- UOP 200-300CC/HR. DIAMOX GIVEN X 2 FOR SLIGHT ALKALOSIS. ABGS THIS AFTERNOON SLIGHTLY IMPROVED.\nID- AFEBRILE. +VRE IN STOOL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-30 00:00:00.000",
"description": "Report",
"row_id": 1563083,
"text": "PT.PRESENTLY ON CPAP+PS VENTILATION, HAD INCREASED RR ON SIMV AND APPEARED TO BREATHE WITH MORE COMFORT ON CPAP WITH INCREASED PRES.SUPPORT, ABG ALKOLOTIC, BS CLEAR BILAT.,WILL WEAN AS ., RSBI-120.7\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-30 00:00:00.000",
"description": "Report",
"row_id": 1563084,
"text": " CONT THIS AM PT MORE ALERT RESP 40 FAIR T.V. TRIAL CPAP WELL MD AWARE\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-30 00:00:00.000",
"description": "Report",
"row_id": 1563085,
"text": "NEURO; OPENS EYES SLIGHTLY TO VOICE ON OCCASION AND FOLLOWS COMMANDS SUCH AS MOVING TOES AND GIVING WEAK HANGRASP INCONSISTENTLY, LOCALIZES TO TACTILE STIMULATION AND WITHDRAWS EXTREMITIES TO NAILBED PRESSURE,VENT LOWERED TO 8 CM AT TRAGUS TODAY PER ORDER NEURO TEAM, PT HAD BEEN MORE LETHARGIC BUT MORE EASILY AROUSEABLE AT PRESENT, MODER THICK BLOODY DGE IN CHAMBER-UNCHANGED FROM YESTERDAY, C&S TAKEN FROM NEURO BY NEURO TEAM\nICP 3-6\nEEG DONE TODAY\n\nCARDIOVASCULAR; HR 70'S SR, FREQUENT PVC ON OCCASION, UNIFOCAL, CVP 9-12, NICARDIPINE GTT OFF FOR SEVERAL HRS BUT RESTARTED AFTER LOPRESSOR GIVEN AND NOT EFFECTIVE IN DECREASING SYS < 170 PER GOAL OF DR ,\nTEMP SPIKE 102.4-TYLEONL AND ALCOHOL SPONGE BATH, SEEN BY INFECTIOUS DISEASE\nAND WILL HAVE VANCOMYCIN RESTARTED\nRESPIR; SUCTIONED FOR SMALL AMTS THICK LIGHT YELLOW-WHITE SECRETIONS, LAST ABG REFLECTS METAB ALKALOSIS ,REMAINS ON C-PAP AND PS PRESENTLY AT 15, ATTEMPTED DECREASNG TO 10 BUT PT BECAME TACHYPNEIC, COARSE BREATH SOUNDS, CXR TODAY,\n\nENDOCRINE; BS 151-COVERED WITH 2 UNITS VIA SLIDING SCALE, TUBE FEEDINGS DECREASED TO 70CC/HR PER SICU TEAM, NEUTRA PHOS GIVEN DOWN TUBE,\n\nGI; INCON ON SEMI-LIQUID STOOL, TRACE HEME POSITIVE\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-01 00:00:00.000",
"description": "Report",
"row_id": 1563086,
"text": " 19/07\n\n STATUS PT OPENS EYES TO COMANDS MAE LIMITED ON NO SEDATION PROGRESSIVE IMPROVMENT RESTS LONG PERIODS VSS CVP ICP WNL GOOD WAVE FORMS U/O QS\n\n RESP ON CPAP WITH PS VERY WELL RESP 12 TO 14 OCC RHOCHI CLEARS AFTER SUCTIONING .40% FIO2 SAT 99\n\n HEART S1S2 FREQ PVC PNC PULSES +2 THRU OUT W/D NEG NVD NEG HJR NSR MILD ST DEPRESSION 2/3 MM\n\n GI POS BS STOOLING T/F WELL NO RESIDUALS\n\n T/P SKIN CARE WITH ROM\n\n THIS PM SPUTUM BLOOD SENT FOR CULTURES\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-01 00:00:00.000",
"description": "Report",
"row_id": 1563087,
"text": " 0345\n\n note pt period of vent bigemity also resp rate increase 23 to 30 abg done resp alkalosis result placed on simv with low dose mso4 result less ectopics beats ekg no changes labs ok md aware\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-01 00:00:00.000",
"description": "Report",
"row_id": 1563088,
"text": "PT.INITIALLY ON CPAP+PS, CHANGED IN A.M. FOR COMFORT, HAD BEEN RESTLESS AND AGITATED, WEANING DOWN SEDATION,INCR.WOB, ABG ALKALOTIC, BS COARSE ON OCCAISON, SX FOR WHITE SECRETION, WILL ATTEMPT TO WEAN IF .\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-25 00:00:00.000",
"description": "Report",
"row_id": 1563164,
"text": "focus update\nafebrile VSS aline d/ced no neurological changes awaiting bed at , continues on gtt at 1150u/hr goal PTT 40-50 PTT check q 6 hours. expectorating yellow thick sputum q 1/2 hour, lsc\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-26 00:00:00.000",
"description": "Report",
"row_id": 1563165,
"text": "NSG NOTE\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-. SQUINTS AND FLUTTERS EYELIDS TO PAIN AND ? SL OPENS EYES. . NO SPONT MOVEMENT. DOES NOT FOLLOW COMMANDS. FLEXES ALL EXTREMITIES TO PAIN.\n\nCV-AFEB. HR/BP STABLE. SKIN W+D. +PP. PBOOTS ON. CON'T ON GTT. PTT MONITORED, THERAPEUTIC.\n\nRESP-REMAINS ON TRACH COLLAR, 70%. WELL. O2 SAT 100%. LS COARSE, DECREASED AT BASES. PT EXPECTORATING LARGE AMT THICK YELLOW SPUTUM.\n\nGI-ABD SOFT. +BS. TF AT GOAL. INC OF SEMIFORMED STOOL X 1.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nENDO-SSRI AND NPH.\n\nPLAN-CON'T WITH CURRENT PLAN. AWAIT REHAB BED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-04 00:00:00.000",
"description": "Report",
"row_id": 1563098,
"text": "Resp: pt on psv 15/+5/40%. Alarms on and functioning. Ambu/syringe @ hob. BS ausucltated reveal bilateral aeration in apecies with diminished bases. Suctioned for small amount of yellow secretions. VT decreased, periods of apnea, placed on a/c noc. AM ABG's 7.48/37/127/28, improvement noted. RSBI=94. Placed back on psv 15/5/34%, continue to wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-04 00:00:00.000",
"description": "Report",
"row_id": 1563099,
"text": "Respiratory Care\nPt remains mechaniclly ventilated, on CPAP mode. No changes made this shift to ventilator settings. Breath sounds equal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-04 00:00:00.000",
"description": "Report",
"row_id": 1563100,
"text": "STATUS\nD: MORE AWAKE WILL FOLLOW SOME SIMPLE COMMANDS..MOVES ALL EXTREM'S LF LEG MUCH WEAKER THAN RT MOVES BOTH ARMS EQUALLY..FEBRILE\nA: PERIP/CENTRAL LINE/URINE/VENT CULTURES SENT..MP ? V PACED WITH FREQ PVC'S..LEVO INITIALLY INCREASED TO 1.3MCG FOR SBP 150/'S..NOW BACK DOWN TO 1.2MCG TO KEEP SBP >160/..NA'S DRAWN Q2H..NA GTT TO 15 FOR NA 131..VENT TO C-PAP IPS 10 WITH GOOD SAT'S..SUCTIONED FOR MOD AMT THICK WHITE..INCT SOFT BROWN STOOL..FIB DC'D DIAPER ON STOOL FOR C-DIFF SENT\nR: IMPROVED MENTAL STATUS\nP: MONITOR NA'S Q2H AJUST GTT PER HO..PTT Q6H..NEURO Q2H..WEAN LEVO AS \n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-09 00:00:00.000",
"description": "Report",
"row_id": 1563116,
"text": "Respiratory Care Note:\n\nPt remain orally intubated on SIMV mosly. We had to change mode of ventilation for most part of the night due to hemodianamic unstability ST & HR rhythm back to< 100/min, back to SIMV this AM. ABG acceptable. Sxtn for thick white sputum Q2-4hr & PRN. He seems to respond this morning. Plan; ?MRI/ talks of trach\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-09 00:00:00.000",
"description": "Report",
"row_id": 1563117,
"text": "RESPIRATORY CARE\nPT S/P TRACH TODAY, REMAINS ON VENTILATORY SUPPORT. SIMV 400/20/40%/+5 PEEP, RATE WAS INCREASED D/T SEDATION FOR THE PROCEDURE. SLIGHT INCREASE IN FIO2 D/T PAO2 OF 76. EARLIER IN THE SHIFT, PT WAS NOTED TO BE TACHYPNEIC/PANTING, FELT TO BE CENTRAL HYPERVENTILATION. NO SIGNS OF DISTRESS. BS RHONCHI T/O. NO WEANING PLANS AT THIS TIME.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-09 00:00:00.000",
"description": "Report",
"row_id": 1563118,
"text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT MORE RESPONSIVE TODAY. OPENING EYES TO VOICE THIS AFTERNOON, FOLLOWING SIMPLE COMMANDS. , HOWEVER MINIMAL SPONTANEOUS MOVEMENT FROM LOWER EXT. VENT REMAINS AT 15 ABOVE TRAGUS, ICP 1-6.\nCV- BP PARAMETERS LOWERED TO 160-170 PER DR. AND PT ABLE TO START WEANING OFF NEO. HR IN 70-80'S WITH MULTIPLE PVCS. ESMOLOL WEANED OFF SUCCESSFULLY AND IV LOPRESSOR STARTED. NO FURTHER SPISODES OF SVT TODAY.\nRESP- TRACH'D TODAY WITHOUT COMPLICATION. BREATHING APPEARS TO BE MORE COMFORTABLE AND REMAINS ON SIMV FOR NOW. ABGS FREQUENTLY CHECKED. LUNGS COARSE AT TIMES, RELIEVED BY SUCTIONING FOR SMALL AMOUNTS OF CLEAR WHITE SPUTUM.\nGI/GU- ABD SOFT, TF RESUMED AFTER TRACH. NPH HELD THIS AM DUE TO NPO STATUS. FOLEY PATENT DRAINING CLEAR YELLOW URINE, 100-200CC/HR\nID- TMAX 99.4.\n WIFE IN TO VISIT AND ABLE TO COMMUNICATE WITH PT. SPOKE WITH DR. .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-10 00:00:00.000",
"description": "Report",
"row_id": 1563119,
"text": "Respiratory Care Note:\n\nPt remain on vent support via new trach #8 Shiley done yesterday. No vent changes o/n. We are suctioning blood tinged thick secretions ~q4h. AM abg acceptable. Plan: Continue ICU monitoring; will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-05 00:00:00.000",
"description": "Report",
"row_id": 1563101,
"text": "CONDITION UPDATE\n 8 PM WAS UNRESPONSIVE, WOULD NOT FOLLOW ANY COMMANDS, PUPILS UNCHANGED. NEURO- NOTIFIED. AT THIS TIME WAS FEBRILE TO 101.7. ONCE FEVER BEGAN TO DROP NEURO STATUS RETURNED TO HAS BEEN HIS BASELINE- FOLLOWING COMMANDS, MOUTHING WORDS, ABLE TO MOVE ALL EXTREMITIES WITH PUPILS EQUAL AND REACTIVE TO LIGHT. REMAINED AFEBRILE THE REST OF THE NIGHT WITH TYLENOL GIVEN Q4 HRS. VENTRICULAR REMAINS AT 15 ABOVE THE TRAGUS WITH SEROSANGUINES DRAINAGE. ICP'S RANGE 1-7.\n SBP MAINTAINED 160 TO 170 RANGE WITH NEO INCREASED AS HIGH AS 3 TO MAINTAIN BP'S WHILE FEBRILE. NEO CURRENTLY AT 1.5. NSR-V PACED WITH FREQUENT PVC'S.\n TUBE FEEDS OFF AT 0400 FOR POTENTIAL EXTUBATION.\n CONTINUE TO MONITER NEURO AND RESPIRATORY STATUS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-05 00:00:00.000",
"description": "Report",
"row_id": 1563102,
"text": "Respiratory Care\nPt remains mechaniclly ventilated, attempting 5cm PSV, becoming more short of breath. Spontnaeous Respiratory Rate mid 30's to 40, decreasing spontaneous Vt to 300cc. Increase PSV to 8cm with decreasing Work of Breathing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-05 00:00:00.000",
"description": "Report",
"row_id": 1563103,
"text": "STATUS\nD: NEURO ESSENTIALLY UNCHANGED..MORE LETHARGIC IN AFTERNOON..REMAINS ON NEO/HEPARIN GTT'S\nA: AFEBRILE..WEANED ON VENT TO IPS 5 C-PAP 5 SHORT TIME THAN TACHYPNEIC 30'S..PLACED ON IPS 8>> WELL..SUCTIONED THICK WHITE GOOD ABG'S..NEO UP & DOWN TO KEEP SBP 160/-170/'S GTT @ 1.0MCG AT PRESENT HEPARIN REMAINS @ 1700U WITH PTT 70'S..GOOD HUO'S..INCT SOFT BROWN STOOL..TF'S REMAIN OFF\nR: ESSENTIALLY UNCHANGED\nP: CONTINUE TO MONITOR PTT/NA'S Q6H..NEURO SIGNS Q2H..? RESTART TF'S\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-10 00:00:00.000",
"description": "Report",
"row_id": 1563120,
"text": "Neuro: Pt remains very somulant. Withdraws and grimace to nailbed pressure. pupils 3mm brisk. no spontaneous movement noted. Vent 15cm above tragus ICP 3-7, draining small amounts of blood tinged CSF\nCV: afebrile, HR 70's NSR with frequent PVC's. SBP 150-170's, continues on neo to for goal 160-170. Titrated overnight, presently at 2.3mcg/kg/min. Heparin gtt increased to 1800u/hr to keep Ptt 60-80. extremities warm with +PP.\nRESP: lungs coarse. O2 sats >98%. No vent changes occasional suctioning of thick blood tinged sputum. ABG acceptable.\nGI: tube feed at goal. Small BM\nGU: foley draining adequate amounts of clear yellow urine.\nEndocrine: blood sugars slightly elevated requiring coverage Per RISS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-10 00:00:00.000",
"description": "Report",
"row_id": 1563121,
"text": "Resp care note\nPt remains on full vent support. ABG's show alkalosis, well oxygenated. No vent changes made as of yet. Sx mod thin bloody secretions. Head CT today, results pending. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-10 00:00:00.000",
"description": "Report",
"row_id": 1563122,
"text": "Nursing Progress Note\n 07:30->19:30\n\nS/O\n\nNEURO: Minimally responsive = withdraws right hand from stim during a-line re-wiring and flushing, grimaces with trach and line care, clamps mouth closed during mouth care. PERRLA , brisk; corneals intact; cough strong. Doesn't follow commands or move spontaneously; no eye opening; did not respond to wife's voice.\nHead CT to evaluate ventricular size -> per Neuro , no changes.\nVentricular tracing dampened and loss of respiratory variation in ventriculostomy tubing -> Neuro up to evaluate, re-established variabilkity and flow when lowered to 12, and returned to 15 at the tragus; transducer changed, and tracing improved with restoration of notch.\n\nCV: Continues on Neo to maintain SBP 160-170, varies between 2.3-3.0mcg/kg-min. HR 80's-70's with bigeminy which responds to Lopressor, and frequent PVC's. Hands and feet cool and clammy.\nA-line tracing lost -> a-line re-wired by Dr. (SICU) with return of tracing.\n\nRESP: LS coarse, occ clear. Sxn'd q2-4 horus for copious amounts of thick bloody secretions. Trach care completed x4 d/t amount of secretions. No innner cannula of trach in place. No changes in vent settings (SIMV 20X Vt 400 x FiO2 .40 with PSV 8 and PEEP5).\n\nGI: Remains on tube feeds. Extremely large stool passed, guaiac negative. Abd soft, bowel sounds +.\n\nFEN: Na+ dropped from 133 -> 129 => all meds and gtts placed in NS; 3% NS gtt started at 15mL with increase in Na+ to 135 after about 2 hours, and gtt stopped. Na+ remains at 134. K+ dropped to 3.6 -> rechecked and will replete per scale. BS per RISS and scheduled coverage. Phos running low.\n\nHAEM: COntinues on heparin at 1800 units/ hour with PTT in therapeutic range of 60's. Tracheal bleeding as noted. No other bleeding noted.\n\nID: Tmax 99.2 rectally. No new ID issues. Remains on Flagyl, Vanco and Cefepime with Vanco and Cefepime in NS.\n\nGU: U/O qs via foley. No GU issues.\n\nSKIN: Duiderm over coccyx intact. Irritation in peri-anal fold between gluteal cheeks -> Aquaphor applied. Continues with multipodux boots, off q 4hours for skin checks -. skin intact.\n\nA/P\n\nContinue current care, including heparin gtt and coag monitoring, Na+ monitoring and repletion, neuro checks, fluid and electrolyte management, and pulmonary support.\nFollow up on phos level as appropriate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-11 00:00:00.000",
"description": "Report",
"row_id": 1563123,
"text": "Respiratory Care Note:\n\nPt remain on ventilatory support via new trach Day2 on SIMV & PS. No vent changes maded during shift. We are sxtn mod-cop bld tinged thick seccretions and fair amt of blood around trach site. Plan: No changes just continue ICU monitoring.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-28 00:00:00.000",
"description": "Report",
"row_id": 1563078,
"text": "FOCUS: STATUS UPDATE\nDATA:\nPATIENT SEDATED ON PROPOFOL DRIP. WOKEN UP EVERY FOUR HOURS FOR NEURO EXAM. WHEN AWAKE PATIENT OPENS EYES TO VOICE AND FOLLOWS ALL COMMNADS. MOVING ALL EXTREMITIES IN BED. PUPILS EQUAL AND REACTIVE TO LIGHT. VENTRICULOSTOMY OPEN AND PATENT AT 15CM ABOVE TRAGUS WITH DARK BLOOD TINGED DRAINAGE. ICP<10. R FEM SHEATH PULLED OUT PER NEUROSURGICAL RESIDENT AND TIP SENT FOR CULTURE.\n\nCONTINUES TO REQUIRE NIPRIDE DRIP TO MAINTAIN BLOOD PRESSURE LESS THAN 160 SYSTOLIC.\n\nLUNGS COARSE WITH MINIMAL SECRETIONS. NO VENT CHANGES TO DAY WITH PERIODS OF RR TO 40. VENT SYSTEM HUMIDIFIED AND LASIX GIVEN X 5MG. FEBRILE TO 101.5. TYLENOL GIVEN. BLOOD CULTURE AND URINE CULTURE SENT.\n\nTUBE FEEDS AT GOAL WITH MINIMAL RESIDUALS.\n\nPLAN:\nMONITOR RESP STATUS CLOSELY. WEAN OFF NIPRIDE AS ABLE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-29 00:00:00.000",
"description": "Report",
"row_id": 1563079,
"text": " 19/07\n\n NEURO PT REMAINS ON PROPOFOL DRIP FOR LIGHT SEDATION NOTE PT NEEDED HIGHER DOSE FROM 40 TO 70 MCG/KILO/MIN BECAUSE OF RAPID RESP MD MADE AWARE UNABLE TO FULLY AWAKE PT FOR Q4 HOUR CHECKS AGITATION STARTED THAN UNABLE TO CONTROL BP DESPITE NIPRIDE SEMI CHECKS DONE MD MAE WHEN PROPOFOL STOPPED ICP 5 TO 9 BLOODY IN COLOR\n RESP ETT .40% FIO2 RHONCHI THRU OUT CLEARS AFTER SUCTIONING\n HEART S1S2 NSR OCC PVC 12 BEAT RUN SVT K AT THAT TIME 3.8 REPLACED VSS PULSES POOR NIPRIDE NICARDIPINE STARTED FLUIDS RESTRICTED FREE WATER SUPP VIA N/G A LINE CVP WNL U/O WNL SEE FLOW SHEETS\n GI POS BS TUBE FEEDS WELL\n SUPPORTIVE CARE\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-29 00:00:00.000",
"description": "Report",
"row_id": 1563080,
"text": "pt.remains on simv+ps ventilation,abg alkalotic, will wean as , has periods of increased rr.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-27 00:00:00.000",
"description": "Report",
"row_id": 1563072,
"text": "RESP: PT ON SIMV 12/700/5/+5/40%. ALARMS ON AND FUNCTIONING. AMBU/SYRINGE @ HOB. BS AUSCULTATED REVEAL BILATERAL COARSE SOUNDS. SUCTIONED FOR SMALL AMOUNTS OF THICK TANNISH SECRETIONS. VENT CHANGES PER ABG'S; DECREASED RATE TO 10/DECREASE VT TO 650/FIO2 TO 35%. AM ABG'S 7.47/36/107/27. 02 SATS @ 99%. RSBI=111. NO FURTHER CHANGES NOTED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-29 00:00:00.000",
"description": "Report",
"row_id": 1563081,
"text": "SHIFT REPORT\nNEURO: DIFFICULT TO AROUSE DESPITE OFF PROPOFOL. BECOMING MORE ALERT AS SHIFT PROGRESSES. INCONSISTENTLY FOLLOWING SIMPLE COMMANDS. OPENS EYES OCCASSIONALLY. NEUROSURG TEAM UPDATE FREQUENTLY, NEURO NP IN TO PT. KEEP SBP UNDER 170 PER DR. ORDERS. ICP 5 TO 7. SM AMT THICK BLOODY DRAINAGE OUT V. . CONT ON NICARDIPINE DRIP.\nCV: CENTRAL LINE CHANGED O/W TODAY. TIP SENT FOR CULT. TMAX 101.7 - PAN CULTURED PER SICU TEAM'S ORDERS. TYLENOL X1 W/ EFFECT.\nRESP: NO VENT CHANGES. SXN FOR SMALL AMT THICK, YELLOW/WHITE SPUTUM.\nENDOCRINE: BSUGARS 189 TO 159 COVERED VIA SSRI. TFEEDS DECREASED TO 80CC/HR. FREE WATER BOLUSES D/ MD.\nPLAN: WEAN NICARDIPINE TO MAINTAIN ORDERED PARAMETERS. PPF OFF WHILE LETHARGY RESOLVING.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-29 00:00:00.000",
"description": "Report",
"row_id": 1563082,
"text": " ,04 19 TO 07\n PT STATUS MAE ON COMAND TRIES TO OPEN EYES WEAKNESS THRU OUT ON NO SEDATION PROGRESSIVE AWAKENING ALSO TRIES TO TALK AROUND TUBE NO PAIN WHEN ASKED\n\n HEART S1S1 OCC PVC NOTED PULSES POSITIVE 2 WITH 3+ PIT EDEMA TONES WNL VSS BP 150/90 MD PARAMETERS ON NICARIPINE 1.5 MCG/KILO/MIN CVP WNL ICP WNL ALL GOOD WAVE FORMS\n\n RESP CLEAR OCC RHONCHI CLEARS AFTER COUGHING CPT T&P Q2 HOURS ON .40 FIO2 SAT WNL\n\n ABD SOFT POS BS STOOLING T/F WELL NO RESIDUAL\n\n SUPPORTIVE CARE FAMILY SUPPORT\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-22 00:00:00.000",
"description": "Report",
"row_id": 1563157,
"text": "Respiratory Care\nPt dropping SAO2 to upper 80's, requiring vigorious ambu bagging and suctioning. FiO2 increased to 100%, decreasing to 50%. Suction and strong productive cough of copious amounts thick tan/blood tinged secreations.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-22 00:00:00.000",
"description": "Report",
"row_id": 1563158,
"text": "NPN\n PT . OPENS EYES OCCASIONALLY WHEN TURNING, SUCTIONING, NOT ON COMMANDS. MINIMAL SPONTANEOUS MOVEMENT NOTED. . WILL GO TO CT THIS AFTERNOON\nCV- BP IN 120-130 RANGE. DROPPED TO 110'S FOR A BRIEF PERIOD, SPOKE TO NSURG AND MONITORED, NO MEDS GIVEN.\nRESP- CONTINUES TO HAVE BLOODY SECRETIONS, ABLE TO RAISE. O2 SAT DROPPED TO HIGH 80'S THIS AM, SUCTIONED FOR A PLUG. CHEST X-RAY DONE AND PT IS NOW 100% ON 50% TRACH COLLAR. NO FURTHER EPISODES.\nGI- BM TODAY, TF AT GOAL, WITH MINIMAL RESIDUAL.\nGU- FOLEY DRAINING 80-120CC/HR CLOUDY YELLOW URINE.\nID- AFEBRILE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-23 00:00:00.000",
"description": "Report",
"row_id": 1563159,
"text": "update\nneuro: ? moved rt thumb to command during am neuro rounds. otherwize .\ncv: 4 beat run v tach, resolved spontaneously.\ngi: tube feeds at 80/hr, well with min residuals. large BM x 1, hem neg.\ngu: u/o qs.\n? lp today. Need to turn off 4 hrs prior to tap.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-23 00:00:00.000",
"description": "Report",
"row_id": 1563160,
"text": "See Carevue for objective data.\n\nNeuro exam . dc'd at 0900 in preparation for LP which was completed at 1600. Opening pressures: 10. No specimens were obtained. to be restarted at 2200.\n7 beat run of VT/hemodynamically stable and resolved spontaneously.\nBP 100-140 systolic.\nSuctioned and also expectorated on own blood tinged tan thick secretions. O2 sats adequate on trach collar.\nDuoderm on coocyx changed. Small stage 2 ulcer dime size cleansed and new duoderm applied.\nAdequate urine output. Tolerating TF with low residuals. FSBS per SS.\nWife in and updated on day's events.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-27 00:00:00.000",
"description": "Report",
"row_id": 1563073,
"text": "condition update\nTEMP SPIKES TREATED WITH TYLENOL. DOES BECOME HYPERTENSIVE WITH TEMP ELEVATION. CULTURES PENDING\nONE EPISODE OF PERSISTENT HBP WHICH RESPONDED TO EXTRA PROPOFOL.\nLOPRESSOR @ BEDSIDE IN ANTICIPATION FOR WAKEUPS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-27 00:00:00.000",
"description": "Report",
"row_id": 1563074,
"text": "Respiratory Care Note:\n He remains sedated and intubated. Taken to anio this am without incident. BS bilat, coarse RUL. Suctioned for small-med amount of thick yellow tinged secretions. RR>20 with VE of >11lpm. Positive for fever this afternoon. Cultures pending. Plan to maintain overnight on SIMV. No vent changes made today. RSBI of 111 noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-27 00:00:00.000",
"description": "Report",
"row_id": 1563075,
"text": "CONDITION UPDATE\nD. PT TO ANGIO TODAY=NO SPASMS AS PER DR. . BP PARAMETERS OF SBP 120-150 TO BE CONTINUED..\n TEMP UP TO 100.8 FOR WHICH PT WAS CULTURED AND TYLENOL GIVEN. POST ANGIO PT WAS ORDERED FOR IVF AT 100ML/HR FOR 1 LITER AND TF RESUMED..BY THIS PM AND AFTER 500ML OF IVF..O2 SAT DROPPED TO 94,RR=33,AND CVP CLIMBED TO 16..DR. NOTIFIED AND IVF DECREASED TO KVO. WITH NEED FOR KCL AND CAGLUC BOLI,CVP CONTINUED TO CLIMB AND DR. WAS NOTIFIED. HUO DOWN TO 60ML.\n NO VENT CHANGES TODAY.ABG ACCEPTABLE WHEN O2 SAT=98. FOR SCANT SECRETIONS..BS DECREASED IN BASES WITH SL RALES.\n PT REMAINS ON PROPOFOL AND NEURO EXAM REMAINS THE SAME..OFF PROPOFOL,PT FOLLOWS COMMANDS.ON PROPOFOL PT MOVES EXTREMITIES TO PAIN.ICP=.COLOR REMAINS DARK RED.\nA.? NEED FOR LASIX..MAINTAIN SBP 120-150.\nR.STABLE AT THIS TIME WITH POSSIBLE EARLY SIGNS OF FAILURE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-28 00:00:00.000",
"description": "Report",
"row_id": 1563076,
"text": "Condition Update\nD: See carevue flowsheet for specifics\n TMAX 101.1-tylenol given (patient cultured on day shift). SBP at beginning shift up to 175-lopressor 10mg given with no effect. Patient was then started on nipride gtt to keep sbp<160. Nipride currently infusing at 1mcg/kg/min. CVP ~9 and making 60-80cc/hr of urine. Slowly sats dropped to 94-95% with RR 26-29. SICU resident notified abg drawn and lasix 5mg given with mod amt of diuresis and sats rose to 96-97% paO2 slightly improved RR unchanged.\n Lungs remain coarse but only suctioning for small amt tan colored secretions. No vent changes made overnight.\n Propofol gtt turned off Q4hrs for neuro exam. When off sedation patient follows commands and moves all extremeties. ICP was running ~10 and then went down to 1-2. Vent @ 15 above the tragus and draining old colored blood. Right fem angio sheath in place and transduced.\nPLAN:\n Pulmonary toilet\n Monitor for si/sx of CHF\n Q4hrs neuro exam off sedation\n vent @15 open\n Keep sbp<160\n Notify H.O. with any changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-06-28 00:00:00.000",
"description": "Report",
"row_id": 1563077,
"text": "Respiratory Care:\nPt remains on Mech Vent as per CareVue. No changes today, and he remains W/Met.Alk ?? Added a heated circut at about 18:30 today for added humidification...\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-24 00:00:00.000",
"description": "Report",
"row_id": 1563161,
"text": "NPN ( SEE CAREVUE FOR ALL SPECIFICS)\nNEURO- NEURO STATUS . NO SPONTANEOUS MOVEMENT. OCCASIONALLY OPENS EYES TO PAIN, NO TRACKING. . RESPONDS TO PAINFUL STIMULI BY SLIGHT MOVEMENT IN EXT. HEP. RESTARTED AND LP SITE MONITORED, NO OR DRAINAGE\nCV- BP 120-140'S. HR 70'S WITH FREQUENT PVCS, NSR.\nRESP- LUNGS CLEAR WITH DIMINISHED BASES. O2 SAT 100%. REQUIRES OCCASIONAL SUCTIONING DESPITE STRONG COUGH FOR THICK BLOOD TINGED SPUTUM. PT ABLE TO RAISE MAJORITY OF SECRETIONS.\nGI- ABD SOFT, NO BM. TF AT GOAL WITH NO RESIDUAL.\nGU- FOLEY DRAINING CLEAR YELLOW URINE, 100-300CC/HR.\nID- AFEBRILE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-24 00:00:00.000",
"description": "Report",
"row_id": 1563162,
"text": "STATUS\nD: NEURO ..REMAINS ON GTT @ 1250U\nA: VSS..GOOD HUO NO STOOL..PTT Q8H.. TRACH @ 70% SUCTIONED FOR MOD AMT THICK PINK TINGED/TAN SECREATIONS\nR: ESSENTIALLY \nP: TO GO TO REHAB TOMORROW..FAMILY AWARE\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-25 00:00:00.000",
"description": "Report",
"row_id": 1563163,
"text": "NPN (SEE CAREVUE FOR SPECIFICS)\nPT NEUROLOGICALLY. NO SPONTANEOUS MOVEMENT NOTED, MAE TO PAINFUL STIMULI, NOT LOCALIZING. . SUCTIONED FREQUENTLY FOR MODERATE AMOUNTS OF SPUTUM. HAD ONE EPISODE AT BEGINNING OF SHIFT WITH LARGE AMOUNT OF BLOODY SPUTUM RAISED FROM TRACH. DR. IN TO . NO INTERVENTION AND SPUTUM IS NOW PINK. COAGS FROM THIS AM PENDING. BP 100-140'S, HR 70'S WITH FREQUENT PVCS. TMAX 99.0. REHAB TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-20 00:00:00.000",
"description": "Report",
"row_id": 1563151,
"text": " 19/07\n\n STATUS NO CHANGE MAE L>R COUGHING AND PAIN CREATES A RESPONDS OF WITHDRAWAL VSS NO TEMP ALINE GOOD WAVE\n\n HEART S1S2 ST DEPRESSION NOTED CHRONIC IN NATURE PULES WEAK EDENA RESOLVING MULTIFOCAL PVC NEG NVD\n\n RESP RHONCHI RALES CLEARS AFTER SUCTIONING .50 02 sat 99\n\n GI POS BS SMALL HEM POS STOOLS NOTED U/O QS CLEAR\n\n NOTE NEO TO MAINTAINE BP greater than 120 t/f wnl\n\n bp 140/78 98 temp 97 oral t/p well no pain\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-20 00:00:00.000",
"description": "Report",
"row_id": 1563152,
"text": "NEURO: NOTICED PT OPENING EYES X2 BUT NOT FOCUSSING AND NOT TRACKING, . RESPONDS TO NOXIOUS STIMULI BY WITHDRAWING ALL EXTREMETIES SLIGHTLY. PT STILL NOT FOLLOWING COMMANDS.\n\nCV: HR 70-90'S, NSR W/ PVC'S, SBP>120 PER PARAMETERS-GOOD RESPONSE ON MIDODRINE 2.5MG TIS. CVP 3-13.\n\nRESP: LUNG SOUNDS COARSE, LRG AMT SPUTUM SXN AND ALSO PT EXPECTORATING. SPUTUM YELLOW TO TAN AND INCREASINGLY BLOODY THIS AFTERNOON, SPUTUM CX SENT. O2 SAT >95% ON TRACH COLLAR 50%.\n\nGI: ABD SOFT NT ND,+BOWEL SOUNDS, TF IMPACT W/ FIBER AT GOAL 80CC/HR VIA PEG, SITE C/D/I. BM X1 GUAIAC NEG.\n\nGU: FOLEY DRAINING ADEQ U/O, CLEAR CONCENTRATED YELLOW.\n\nID: TMAX 97.4\n\nPLAN: CONT CURRENT MGMT\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-20 00:00:00.000",
"description": "Report",
"row_id": 1563153,
"text": " 19/07\n\n PT STATUS SLIGHTLY LIGHTER THIS PM OCC OPENS EYES SEEMS TO RESIST COMMUNICATION BY TIGHTLY SHUTTING EYES WHEN TALKED TO EXPLORES SELF WITH RIGHT HAND\n\n RESP BLOOD TINGED SPUTUM CLEARS HIMSELF VERY STRONG COUGH RHONCHI THRU OUT\n\n S1S2 PULES POS 2 PEDAL EDEMA REMAINS NSR WITH PVCS\n\n GI TF WELL F/S STOOL NEG HEM\n TALKED WITH WIFE AT REMAINS HOPEFUL LOOKING FOWARD TOWARDS REHAB\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-21 00:00:00.000",
"description": "Report",
"row_id": 1563154,
"text": "NEURO: PT OPENED EYES X2 HOWEVER NOT TRACKING, PUPILS UNEQUAL BUT BRISKLY REACT TO LIGHT, NSURG INFORMED. PT NOT FOLLOWING COMMANDS, NO SPONT/PURP MVMTS NOTED. GRIMACING AND WITHDRAWING SLIGHTLY TO PAIN W/ ALL 4 EXTREMETIES WHEN NOXIOUS STIMULI APPLIED TO NAILBED.\n\nCV: HR 70-80'S, NSR W/ PVC'S, SBP 120-150'S. CVP 8-11. +2 EDEMA.\n\nRESP: RR 20-30'S, O2 SAT 97-100% VIA TRACH COLLAR 50%. SXN PRN FOR THICK TAN SPUTUM AND CX SENT.\n\nGI: ABD SOFT NT/ND, +BOWEL SOUNDS, TOLERATING TF IMPACT W/ FIBER VIA PEG AT 80CC/HR AT GOAL, MINIMAL RESIDUALS.\n\nGU: FOLEY DRAINING ADEQ U/O, CLEAR TO CLOUDY URINE. DR. INFORMED, FOLEY TO BE CHANGED AND U/A TO BE SENT.\n\nID: TMAX 97.8\n\nPLAN: MONITOR VS, LABS, NEURO STATUS. ?LP THIS WEEK, ? CT HEAD TOMORROW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-21 00:00:00.000",
"description": "Report",
"row_id": 1563155,
"text": " 19/07\n\n pt status opens eyes on occ to verbal command in general lethargic moves with pain stimulus \n\n resp blood tinged sputum noted clears after coughing on .50 fio2 well sao2 100% CPT Q2 HOURS\n\n HEART S1S2 WNL OCC PVCS PULSES POS 2 THRU OUT U/O QS TUBE FEEDING WELL POS BS SMALL HEM NEG STOOL\n\n SUPPORTIVE CARE ROM CPT SKIN CARE PT CONSULT\n\n NOTE FRANK BLOOD AROUND STOMA OF PEG TUBE MOD AMOUNT NO EVENT PRIOR MD SITUATION T/F DC CLEAR RETURNS\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-21 00:00:00.000",
"description": "Report",
"row_id": 1563156,
"text": " CONT OF ABOVE NOTE AT 2100 PT BY MD AROUND PEG TUBE SITE ORDER TO KEEP DRESSING ON AND MONITOR PT\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-03 00:00:00.000",
"description": "Report",
"row_id": 1563094,
"text": "Resp: pt on a/c 10/600/+5/40%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral clear apecies with diminished LS. Suctioned for small to moderate amounts of thick yellow secretions. Sputum sample obtained and sent. 02 sats @100%. RSBI=113.5. AM ABG's 7.48/36/151/28. No further changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-03 00:00:00.000",
"description": "Report",
"row_id": 1563095,
"text": "focus: status update\nDATA:\nDECREASED MENTAL STATUS THIS AM--NOT FOLLOWING COMMNADS CONSISTENTLY, NOT OPENING EYES TO VOICE, L SIDE APPEARED WEAKER THAN RIGHT. DR. NOTIFIED AND EVALUATED PATIENT. STAT HEAD CAT SCAN ORDERED AND DONE. NO BLEEDING PRESENT AND PRELIMINARY RESULTS STATE SLIHT VENTRICLE ENLARGEMENT. VENTRICULOSTOMY WAS DECREASED TO 10CM ABOVE TRAGUS. IT CONTINUES TO HAVE DARK BLOOD TINGED DRAINAGE. INTRACRANIAL PRESSURES SLIGHTLY LOWER THAN IN AM WHEN VENTRICULOSTOMY WAS AT 15CM. MENTAL STATUS HAS IMPROVED THROUGHOUT THE DAY AND PATIENT IS NOW LIFTING ARMS SLIGHTLY AND MOVING IN BED. OPENED EYES FOR WIFE VISITING. EEG DONE AT BEDSIDE. PUPILS EQUAL AND REACTIVE TO LIGHT. 3%NS STARTED FOR SODIUM LEVEL 129.\n\nCONTINUES ON NEOSYNEPHRINE IV DRIP TO MAINTAIN BLOOD PRESSURE AROUND 160-170 FOR CEREBRAL PERFUSION.\n\nHEPARIN DRIP STOPPED WHILE AT CAT SCAN NOW RESUMED AND INCREASED DUE TO LOWER PTT. NIVS ORDERED TO F/U. TOLERATING CPAP WITH 10 PRESSURE SUPPORT.\n\nTOLERATING TUBE FEEDS AT GOAL WITH MINIMAL RESIDUALS.\n\nCONTINUES TO DIURESE WELL.\n\nPLAN:\nSODIUM CHECKS Q2HRS WITH GOAL OF 135. PTT CHECKS Q6HRS. AND F/U WITH DR. FOR HEPARIN ORDERS. NIVS TODAY.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-03 00:00:00.000",
"description": "Report",
"row_id": 1563096,
"text": "nursing update\nRun OF VT-11 beats. No spont kick in of pacer. MD aware. EKG done. cards to see.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-07-04 00:00:00.000",
"description": "Report",
"row_id": 1563097,
"text": "Nursing note:\nNEURO: Lethargic in beginning of shift, difficult to arouse except to sternal rub. Following simple commands inconsistently. PERRLA. More wakeful later in night, opening eyes spontaneously and consistently following commands. Moving lower extremities on bed and wiggling toes, lifting/holding w/upper extremities. Hand grasps equal bilaterally. ICP 4-8. Ventricular 10cm above tragus, blood -tinged drainage.\nCV: Tmax 100.4, Tylenol given w/good effect. More easily arousable after temp normalized. Vpaced w/frequent PVCs, bigeminy at times. Palpable pulses. SBP kept 170 or > w/Neo gtt, frequently titrated. Nimodopine d/c'd per Dr. for better control of BP. Potassium repleted. NA levels checked q2hours, 3% NACl gtt infusing, decreased to 10cc/hr. Cont. on salt tabs. Heparin gtt increased to 1500u/hr d/t sub-therapeutic levels, bolused w/1000u as well.\nRESP: Returned to A/C rate d/t periods of apnea, low tidal volumes and tachypnea. ABGs less alkalotic after change. Suctioned for thick yellow sputum.\nGI: Abdomen softly distended. +Bowel sounds, +liquid brown stool. FIB changed. Cx. sent for cdiff. Tube feeds @ goal of 80cc/hr, minimal residuals.\nGU: Foley patent large amount pale yellow urine.\nENDO: SSRI PRN.\nSKIN: Intact. Small skin tear to coccyx, open to air.\n\nA/P: More alert overnight, following commands. SBP kept 170 or > w/Neo gtt. Cont. on 3% Sodium gtt and Heparin gtt. Monitor neuro status closely and q2hour labs, reattempt vent wean in am.\n\n"
},
{
"category": "Echo",
"chartdate": "2165-06-25 00:00:00.000",
"description": "Report",
"row_id": 93587,
"text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain. H/O cardiac surgery. Left ventricular function.\nHeight: (in) 71\nWeight (lb): 201\nBSA (m2): 2.12 m2\nBP (mm Hg): 124/57\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 12:05\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Left ventricular wall thicknesses are normal. The left ventricular\ncavity is mildly dilated. There is moderate regional left ventricular systolic\ndysfunction. There is no resting left ventricular outflow tract obstruction.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal anterior - hypokinetic; mid anterior -\nhypokinetic; basal inferior - akinetic; mid inferior - akinetic; basal\ninferolateral - akinetic; mid inferolateral - akinetic; anterior apex -\nhypokinetic; inferior apex - hypokinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is mildly dilated. There are focal calcifications in\nthe aortic root.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic. Mild (1+) aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is\nmoderate mitral annular calcification. There is mild thickening of the mitral\nvalve chordae. Mild to moderate (+) mitral regurgitation is seen. [Due to\nacoustic shadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. There is mild pulmonary artery systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Based on \nAHA endocarditis prophylaxis recommendations, the echo findings indicate a\nmoderate risk (prophylaxis recommended). Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data. The\nresults were reviewed with the Cardiology Fellow involved with the patient's\ncare.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is mildly dilated. There is moderate\nregional left ventricular systolic dysfunction with near akinesis of the\ninferior and inferolateral walls. The anterolateral wall is severely\nhypokinetic. The remaining walls contract well. Right ventricular cavity size\nand free wall motion are normal. The aortic root is mildly dilated. The aortic\nvalve leaflets (3) are mildly thickened but not stenotic. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets and supporting structures are\nthickened. Mild to moderate (+) mitral regurgitation is seen. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Mild left ventricular cavity enlargement wit extensive regional\nleft ventricular systolic dysfunction c/w multivessel CAD. Mild-moderate\nmitral regurgitation. Mild aortic regurgitation. Pulmonary artery systolic\nhypertension.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2165-06-27 00:00:00.000",
"description": "CAROTID/CEREBRAL BILAT",
"row_id": 827965,
"text": " 8:49 AM\n CAROT/CEREB Clip # \n Reason: S/P COILING\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 104\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT *\n * CAROTID/CEREBRAL BILAT VERT/CAROTID A-GRAM *\n * EXT UNILAT A-GRAM -52 REDUCED SERVICES *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Previously stent and coil intracranial wide neck left\n vertebral artery aneurysm. Rule out vasospasm.\n\n POSTOPERATIVE DIAGNOSIS: Stable appearance of the previously coiled aneurysm\n with patent left vertebral artery with small remnant at the neck of the\n aneurysm but stable appearance of the coil dome and no evidence of significant\n intracranial vasospasm.\n\n INDICATION: Mr. is a patient is patient who presented with subarachnoid\n hemorrhage from a ruptured wide neck aneursym. He underwent successful stent\n angioplasty with coiling of the aneurysm and is undergoing a cerebral artery\n to rule out the presence of intracranial vasospasm.\n\n CONSENT: The patient and her son were given a full and complete explanation\n of the procedure. Specifically, the indications, risks, and benefits and\n alternatives to the procedure were explained in detail. In addition, the\n possible complications such as the risk of bleeding, infection, stroke,\n neurological deficit or deterioration, groin hematoma, and other unforeseen\n complications including the risk of coma and even death were outlined. The\n patient and her son understood and wished to proceed with the operation.\n\n PROCEDURE IN DETAIL: The patient was brought in the endovascular suite and\n placed on the table in supine position. The right groin area was prepped and\n draped in the usual sterile fashion. A 19 gauge single wall needle was then\n used to puncture the right femoral artery and upon the return of brisk\n arterial blood a 4 FR vascular sheath was inserted over a guidewire and kept\n on a heparinized saline drip. Next a diagnostic catheter was used to\n selectively catheterize the following vessels over a guidewire in succession:\n Left subclavian artery, left vertebral artery, left common carotid artery,\n left internal carotid artery, right common carotid artery, right internal\n carotid artery.\n\n RESULTS: Injection of the left subclavian artery shows no atherosclerotic\n disease at the origin of the left vertebral artery and shows a small raised\n plaque distal to the origin of the left vertebral artery. The proximal left\n cervical segment of the vertebral artery shows antegrade flow with no anomaly.\n Intracranially with injection on the left vertebral artery with three\n dimensional rotational angiography showed that the previously deployed tandem\n stents are patent with no evidence of atherosclerotic involvement or intimal\n (Over)\n\n 8:49 AM\n CAROT/CEREB Clip # \n Reason: S/P COILING\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 104\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hyperplasia. The previously coiled aneurysm is stable in appearance with well\n treated dome and a small residual filling at the neck of the aneurysm.\n Injection of both common carotid arteries in the cervical region showed no\n significant atherosclerotic disease or dissection and they are not changed\n compared to the prior study. Injection of both internal carotid arteries on\n the right and the left with three dimensional rotational angiography showed no\n evidence of branch occlusion or significant vasospasm. There is presence of\n bilaterally mild vasospasm which is diffuse.\n\n IMPRESSION: Stable appearance of the previously coiled aneurysm with patent\n stent and presence of mild vasospasm which does not currently require any\n endovascular therapy.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2165-06-21 00:00:00.000",
"description": "MULTI-PROCEDURE SAME DAY",
"row_id": 827384,
"text": " 3:26 PM\n CAROT/CEREB Clip # \n Reason: SAH\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 555\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL -51 MULTI-PROCEDURE SAME DAY *\n * PTA BRACHIOCEPHAL EA VESSEL -51 MULTI-PROCEDURE SAME DAY *\n * TRANSCATH PLCT STENTS, INITIAL -51 MULTI-PROCEDURE SAME DAY *\n * SEL CATH 3RD ORDER -59 DISTINCT PROCEDURAL SERVICE *\n * ADD'L 2ND/3RD ORDER TRANSCATH EMBO THERAPY *\n * F/U TRANS CATH THERAPY ANGIOPLASTY PERIPHERAL *\n * TRANSCATH INTRO STENT C1769 GUID WIRES INFU/PERF *\n * C1769 GUID WIRES INFU/PERF C1769 GUID WIRES INFU/PERF *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Subarachnoid hemorrhage from ruptured left\n intracranial wide-necked vertebrobasilar aneurysm in an isolated left\n vertebral artery posterior circulation with no presence of posterior\n communicating flow and a diminutive right vertebral artery providing only\n posterior-inferior cerebellar artery perfusion.\n\n POSTOPERATIVE DIAGNOSIS: Same status post stent angioplasty of the\n intracranial vertebral artery and left segment followed by coiling of the\n wide-necked aneurysm with preservation of the flow in the left vertebral\n artery in the posterior circulation and obliteration of the aneurysm using\n endovascular coiling.\n\n INDICATION: Mr. is a patient who presented with subarachnoid hemorrhage\n from a ruptured wide-necked fusiform aneurysm of the intracranial left\n vertebral artery which was found proximal to the critical stenosis of the\n vertebral artery. This aneurysm because of its appearance currently is not\n amenable to surgical therapy. At this location as well as the inability of the\n patient to tolerate temporary occlusion renders bypass procedure unacceptably\n high risk. In addition aneurysm, because of its size cannot be treated using\n coiling without some means of protecting the neck of the aneurysm. Imaging of\n the posterior circulation with CT angiography and CT scan had revealed a\n highly calcified left vertebral artery and the right vertebral artery does not\n provide any perfusion to the vertebrobasilar junction. These findings were all\n explained to the family and accordingly they gave approval for use of stent\n angioplasty as a means of treating the atherosclerotic stenosis followed by\n coiling of the aneurysm. Accordingly the patient was administered oral Plavix\n and aspirin prior to the beginning of the procedure and taken down to the\n angiography suite for this procedure.\n\n CONSENT: The patient's wife and son were given a full and complete explanation\n of the procedure. Specifically, the indications, risks, benefits, and\n alternatives to the procedure were explained in detail. In addition, the\n possible complications, such as the risk of bleeding, infection, stroke,\n neurological deficit or deterioration, groin hematoma, and other unforeseen\n complications, including the risk of coma and even death, were outlined. The\n patient's wife and son understood and wished to proceed with the operation.\n (Over)\n\n 3:26 PM\n CAROT/CEREB Clip # \n Reason: SAH\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 555\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\n placed on the table in supine position. The right groin area was prepped and\n draped in the usual sterile fashion. A 19-gauge single-wall needle was then\n used to puncture the right common femoral artery, and upon the return of brisk\n arterial blood, a 5 Fr vascular sheath was inserted over a guidewire and kept\n on a heparinized saline drip. Next, a diagnostic catheter was used to\n selectively catheterize the following vessels: left subclavian artery, left\n vertebral artery, left intracranial vertebral artery and posterior cerebral\n artery, and left intracranial aneurysm of the left vertebral artery. At this\n point a 5 Fr guidecatheter was placed into the left vertebral artery. Through\n that guidecatheter a series of angiographic runs with three-dimensional\n rotational angiography enabled us to define the lesion both aneurym and\n stenosis which needed treatment. At this point after inducing heparinization a\n SL-10 microcatheter was used over an Agility microwire to selectively\n catheterize the left posterior cerebral artery P2 segment. This was done by\n crossing the critical stenosis and bypassing the aneurysm. With the\n microcatheter in this position an Exelerator 0.014 inch 300cm exchange wire\n was placed into the distal posterior cerebral artery and this enabled us then\n to withdraw the SL-10 microcatheter. To that 2.5 x 15 mm long stent\n was navigated over the exchange wire and deployed across the stenosis distal\n to the aneurysm with coverage of the neck of the aneurysm. With the stent in\n this position an angiographic run was performed and the stent was deployed at\n 2-4atm above its nomimal pressure which enabled us to obtain a good position\n of the stent. The balloon was then deflated and the balloon was then\n withdrawn. An angiographic run at this point showed successful treatment of\n the distal stenosis distal to the aneurysm with good flow through the left\n vertebral artery and its basilar artery. Leaving the 300 cm exchange wire\n across the stent and in the distal P2 segment of the posterior cerebral artery\n an angiographic run was performed five minutes following deployment of the\n stent which revealed that the flow through the left vertebral artery had\n closed off completely distal to the proximal portion of the stent. At this\n point there was no longer flow in the basilar segment. To that end examination\n of the proximal portion of the stent with three-dimentional rotational\n angiography revealed that the proximal portion of the stent had been crimped\n on itself probably as a result of the highly calcific left vertebral artery.\n To that end an additional 2.5 mm x 9 mm stent was advanced over the exchange\n wire and with its distal portion abutting the proximal struts of the\n previously deployed stent with the stent in this position it was inflated to\n its nominal size and at this point the balloon was withdrawn. Angiography of\n the left vertebral artery at this point showed resumption of flow through the\n basilar artery with no evidence of branch occlusion and excellent\n reconstitution of the stenotic left vertebral artery. Further surveillance\n revealed that the segment in between the stents where the two stents\n overlapped again showed progressive restenosis and loss of flow to the distal\n (Over)\n\n 3:26 PM\n CAROT/CEREB Clip # \n Reason: SAH\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 555\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n basilar artery. At this point a noncompliant 2.75 mm Charger balloon was\n deployed over the exchange wire and positioned across the portion of the left\n vertebral artery between the two stents. This was then inflated to 2.5 x 2.75\n mm and the balloon was then withdrawn. At this point angiography revealed that\n the previously calcific stenosis had in fact had been successfully treated\n with a noncompliant balloon with resumption of distal flow in the basilar\n artery and reconstitution of flow in the left vertebral artery. Three-\n dimensional rotational angiography now revealed that the stenotic segment of\n the left vertebral artery had now been successfully treated with stent\n angioplasty and deployment of both stents. Our attention was then turned to\n the aneurysm. To that end a microcatheter was then positioned of type SL-10\n into the aneurysm through the struts of the 1st depolyed ABE stent. With the\n microcatheter in this position a GDC coil three-dimensional coil was deployed\n following a series of smaller ultrasoft GDC coils. This resulted in complete\n embolization of the dome of the aneurysm with a small .5 mm to 1 mm remnant\n neare the neck of the aneurysm. Additional attempts at treating that small\n remnant resulted in coil herniation into the parent vessel through the struts\n and as such were abandoned. At the end of the procedure three-dimensional\n rotational angiography showed excellent treatment of the aneurysm with no\n further opacification of the dome and patent left vertebral artery with no\n further stenosis and improved distal flow particularly of the left posterior\n cerebral artery which now fills from the left vertebral artery injection.\n\n IMPRESSION: Successful intracranial stent angioplasty of the highly stenotic\n and calcified left vertebral artery with coil through stent embolization of\n the wide-necked aneurysm without iatrogenic branch occlusions.\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2165-06-21 00:00:00.000",
"description": "ADD'L 2ND/3RD ORDER",
"row_id": 827340,
"text": " 9:17 AM\n CAROT/CEREB Clip # \n Reason: SAH\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 240\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT *\n * VERT/CAROTID A-GRAM VERT/CAROTID A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE EXT BILAT A-GRAM *\n * -52 REDUCED SERVICES C1760 CLOSURE DEVICE VASC IMP/INS *\n * C1894 INT/SHTH NOT/GUID EP NON-LASER *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Subarachnoid hemorrhage.\n\n POSTOPERATIVE DIAGNOSIS: Fusiform aneurysm of the left vertebral artery with\n severe distal intracranial and proximal intracranial left vertebral artery\n atherosclerosis, no evidence of posterior communicating artery connecting the\n anterior to the posterior circulation and a diminutive right vertebral artery\n ending in a distribution of the right posterior-inferior cerebellar artery.\n\n ANESTHESIA: General endotracheal anesthesia.\n\n INDICATION: Mr. presented with a subarachnoid hemorrhage and was\n transferred to the . He is currently\n undergoing this cerebral angiogram to determine the site of his intracranial\n aneurysm and subsequently to determine optimal therapy.\n\n CONSENT: The patient's wife and her son were given a full and complete\n explanation of the procedure. Specifically, the indications, risks, benefits,\n and alternatives to the procedure were explained in detail. In addition, the\n possible complications, such as the risk of bleeding, infection, stroke,\n neurological deficit or deterioration, groin hematoma, and other unforeseen\n complications, including the risk of coma and even death, were outlined. The\n patient's wife and her son understood and wished to proceed with the\n operation.\n\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\n placed on the table in supine position. The right groin area was prepped and\n draped in the usual sterile fashion. A 19-gauge single-wall needle was then\n used to puncture the right common femoral artery, and upon the return of brisk\n arterial blood, a 4 Fr vascular sheath was inserted over a guidewire and kept\n on a heparinized saline drip. Next, a diagnostic catheter was used to\n selectively catheterize the following vessels: right common carotid artery,\n right internal artery, left common carotid artery, left internal carotid\n artery, left subclavian artery, left vertebral artery, right subclavian\n artery, right vertebral artery.\n\n RESULTS: Injection of the left subclavian artery showed minimal\n (Over)\n\n 9:17 AM\n CAROT/CEREB Clip # \n Reason: SAH\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 240\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n atherosclerotic change and a small raised plaque accounting for approximately\n 20% stenosis at the proximal left vertebral artery distal to its origin. The\n left vertebral artery is otherwise without significant atherosclerosis in the\n cervical segment. Intracranially, the left vertebral artery appears to \n a fusiform wide-necked aneurysm in the intracranial portion just proximal to\n the severe greater than 70% atherosclerotic stenosis. Proximal to this\n fusiform aneurysm is also present an atherosclerotic lesion which is more\n diffuse and less severe than the distal one. The left vertebral artery appears\n to be dominant and the basilar trunk is somewhat diffusely narrowed possibly\n as a result of the proximal atherosclerotic stenosis. The posterior cerebral\n artery is otherwise within normal limits and it appears that the left\n posterior cerebral artery territory is mostly fed by a left posterior\n communicating artery. The left posterior-inferior cerebellar artery origin is\n normal. Injection of the right subclavian artery showed no significant\n atherosclerotic disease at the origin of the right vertebral artery. Injection\n of the right vertebral artery showed it to be small in caliber and in the\n cervical segment it appeared to mostly end in a partial distribution of the\n right posterior-inferior cerebellar artery. The posterior-inferior cerebellar\n artery has a segmental region of mild atherosclerosis distal to its origin off\n of the right vertebral artery. Injection of the right common carotid artery\n shows no significant atherosclerotic disease in the cervical region and\n intracranially shows no evidence of intracranial aneurym shows no vascular\n malformation. The right external carotid artery injection was within normal\n limits with no abnormal arteriovenous shunting. Injection of the left internal\n carotid artery with three-dimensional rotational angiography failed to show\n any evidence of atherosclerosis intracranially or aneurysmal dilatation. The\n left external carotid artery injection revealed no evidence of abnormal\n arteriovenous shunting or dural fistula to account for the patient's\n subarachnoid hemorrhage.\n\n IMPRESSION: Fusiform wide-based aneurysm of the intracranial portion of the\n left vertebral artery measuring approximately 5.5 mm with a neck of\n approximately 6 to 7 mm. This is present just proximal to a critical high-\n grade stenosis and is not amenable to unassisted coil embolization. These\n findings will be discussed with the patient's family in order to determine\n optimal therapy given the high-risk nature of the lesion.\n\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2165-07-19 00:00:00.000",
"description": "Report",
"row_id": 243887,
"text": "Sinus rhythm\nST-T changes may be nonspecific\nSince previous tracing of , the rhythm has reverted from flutter to\nsinus rhythm\n\n"
},
{
"category": "ECG",
"chartdate": "2165-07-08 00:00:00.000",
"description": "Report",
"row_id": 243888,
"text": "Atrial flutter with rapid ventricular response\n2:1 A-V block atrial tachycardia 1:1\nPossible inferior infarct - age undetermined\nLVH with secondary ST-T changes\nSince previous tracing, new supraventricular tachycardia\nClinical correlation is suggested\n\n"
},
{
"category": "ECG",
"chartdate": "2165-07-07 00:00:00.000",
"description": "Report",
"row_id": 243889,
"text": "Sinus rhythm\nVentricular premature complex es and ventricular couplets\nProbable left ventricular hypertrophy\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2165-07-08 00:00:00.000",
"description": "Report",
"row_id": 243890,
"text": "Sinus rhythm with atrial premature complexes\nInferior/lateral ST-T changes\nSince previous tracing, ventricular ectopic activity no longer present. ST-T\nwave abnormalities more marked\n\n"
},
{
"category": "ECG",
"chartdate": "2165-07-03 00:00:00.000",
"description": "Report",
"row_id": 243891,
"text": "Sinus rhythm. Left atrial abnormality. Low amplitude P wave. P-R interval 0.18.\nFrequent ventricular and occasional atrial ectopy. Precordial voltage for left\nventricular hypertrophy. Compared to the previous tracing of no\ndiagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2165-07-01 00:00:00.000",
"description": "Report",
"row_id": 243892,
"text": "Sinus rhythm\nBigeminal PVCs\nLateral ST-T changes\nSince previous tracing, ventricular premature complex are new\n\n"
},
{
"category": "ECG",
"chartdate": "2165-06-24 00:00:00.000",
"description": "Report",
"row_id": 243893,
"text": "Sinus rhythm\nLateral ST-T changes\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2165-06-21 00:00:00.000",
"description": "Report",
"row_id": 243894,
"text": "Sinus rhythm with frequent PVCs\nIV conduction defect\nSince previous tracing, ventricular premature complexes noted\n\n"
}
] |
12,888 | 117,735 | 1. COPD flare secondary to UTI: At admission she had a saturation of 83% on RA (improved to 94% on 4L) with a peak flow of 100 L/minute. She was given solumedrol, continued on nebs/MDI/antibiotics. She was stable on the floor for approximately 48 hours. She was transferred to the on for hypercarbic respiratory failure (ABG on 2L 7.28/78/53) and was maintained on non-invasive positive pressure ventilation and monitored overnight. She did well, and was transferred back to the floor the following day, satting adequately on 6L NC. She remained on IV steroids at time of transfer back to the floor. She was relatively comfortable, able to speak short sentences. She was continued on IV steroids for two days due to continued wheezing. The day prior to discharge she was transitioned to PO Prednisone as she was no longer having wheezes. She tolerated the PO prednisone and was felt ready for discharge home on a slow steroid taper. She was s/p a 5 day course of azithromycin and it was felt there was no additional need for antibiotics. She was afebrile for the course of her admission on the hospital floor. She was continued on nebulizers. Her albuterol was titrated down secondary to tachycardia. She was continued on inhalers and theophylline. She was discharged on inhalers, home nebulizers, her home medications, and home O2. 2. Tachycardia: She was tachycardic to the 130s it was felt to be likely due to frequent albuterol with a possible component of anxiety. She was monitored on telemetry and the tachycardia was sinus. Her albuterol nebulizers were titrated down to decrease her tachycardia. 3. Osteoporosis - She was continued on fosamax, calcium supplements/vit D. 4. Cataracts - She used her own steroid drops while she was in the hospital. | Completed course of azithro.CV: HR 130's ST. No VEA. 4 ICU NPN 0700-190062 YO with end-stage COPD admitted to 11R admitted with COPD flare. FINAL REPORT CHEST SINGLE AP FILM: HISTORY: COPD exacerbation with shortness of breath. LAST ABG SHOWING A RESP ACIDOSIS. PROD COUGH MOD. DECREASED WITH SOME SCAT RONCHI. Developed increased SOB, resp distress this AM with sats 80's, ABG 5378/7.28/38/6 on 2L NP. UO has dropped off sig. 12:25 PM CHEST (PORTABLE AP) Clip # Reason: PNA? Sinus tachycardiaRightward axis - is nonspecificConsider right atrial abnormalityModest nonspecific inferior ST-T wave changesSince previous tracing of , sinus tachycardia present and moresuggestive of right atrial abnormality SVN RX GIVEN WITH ALB/ATR Q4. ABG on 2L NP & 40% face tent 85/80/7.29/40/7. Cardiac: HR 100-130ST rare PVC's BP 110-150/60-70's ID: afebrile, Plan: cont frequent nemb treatment, follow sats, BS closely, mask ventilation Attempted bipap. Abd soft No stool.NEURO: A&OX3. BS this morning slightly better, able to hear expiratory phase. BS with bibasilar crackles, scattered wheezed throughout, prolonged exp phase. UO initially 30cc hr. ?if pt would tol NTS. solumedrol 100mg given, to be stopped at 12pm today. SBP 130'sGU: foley catheter inserted. There is COPD as previously demonstrated. past 2 hrs.GI: NPO except meds due to resp status. He has been updated throughout the day on pt's status, plan of careA/P:Resp status tenueous, boarderline, without reserve due to COPD flare. Sputum for culture when availableBipap trial again this eve.Nebs, steroids.Discuss with HO oliguriaNPO except meds until resp status improves. RR 18-26 min. B.S. AMTS. Nemb tx interval increased to Q1hr, placed on mask ventilation with PS 18cm , eventually able to get comfortable and ABG showed 7.31/70/90 (pCO2 had been 88) kept her on mask ventilation, nembs Q3hr during the night, along with CPT, hydrated with NS at 125 cc/hr. PLAN IS TO CONT OFFERING THE BIPAP WITH SVN RX. CXR without evidence of infiltrate.ID: afeb. This morning able to cough productively. Doing OK on 11R. PT MAINTAINED ON INTERMITTENT BIPAP BUT WILL NOT WEAR CONT. Unproductive cough. Feels jittery ( given IV steroids). She was productive X1 of green sputum after brief trial of bipap.Receiving steroids, nebs. Admitting Diagnosis: COPD FLARE MEDICAL CONDITION: 62 year old woman with COPD exacerbation, worsening REASON FOR THIS EXAMINATION: PNA? Sats mid to high 90's. Transferred for further management.RESP: Presently on 35% face tent. Given tylenol for HAACCESS: #22 PIV X1.SOCIAL: Husband at bedside. HAS AGREED TO WEAR Q3- TO Q4 FOR 10 TO 15MIN IF SHE CAN HOLD IT AND NOT BE STRAPPED IN. No definite pulmonary consolidation. Vague haziness in the left lower zone is likely soft tissue shadowing but if symptoms persist, follow up films may be obtained to rule out evolving consolidation in this location. S/MICU Nursing Progress Note Respiratory: Pt on 40% face tent nemb with RR 20's labored, using accessory muscles, BS poor air movement only able to hear a fine insp wheeze, while trying to take her pills,pt felt like she was drowning and unable to catch her breath. Pt feels she has secretions but is unable to raise them. Pt did not tol due to coughing jags when mask mask applied. | 5 | [
{
"category": "Radiology",
"chartdate": "2171-12-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 850161,
"text": " 12:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA?\n Admitting Diagnosis: COPD FLARE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with COPD exacerbation, worsening\n REASON FOR THIS EXAMINATION:\n PNA?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: COPD exacerbation with shortness of breath.\n\n Heart size is normal. There is COPD as previously demonstrated. No definite\n pulmonary consolidation. Vague haziness in the left lower zone is likely soft\n tissue shadowing but if symptoms persist, follow up films may be obtained to\n rule out evolving consolidation in this location.\n\n"
},
{
"category": "ECG",
"chartdate": "2171-12-12 00:00:00.000",
"description": "Report",
"row_id": 139515,
"text": "Sinus tachycardia\nRightward axis - is nonspecific\nConsider right atrial abnormality\nModest nonspecific inferior ST-T wave changes\nSince previous tracing of , sinus tachycardia present and more\nsuggestive of right atrial abnormality\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-12-10 00:00:00.000",
"description": "Report",
"row_id": 1431418,
"text": " 4 ICU NPN 0700-1900\n62 YO with end-stage COPD admitted to 11R admitted with COPD flare. Doing OK on 11R. Developed increased SOB, resp distress this AM with sats 80's, ABG 5378/7.28/38/6 on 2L NP. Transferred for further management.\nRESP: Presently on 35% face tent. RR 18-26 min. BS with bibasilar crackles, scattered wheezed throughout, prolonged exp phase. ABG on 2L NP & 40% face tent 85/80/7.29/40/7. Sats mid to high 90's. Unproductive cough. Pt feels she has secretions but is unable to raise them. Attempted bipap. Pt did not tol due to coughing jags when mask mask applied. She was productive X1 of green sputum after brief trial of bipap.Receiving steroids, nebs. CXR without evidence of infiltrate.\n\nID: afeb. Completed course of azithro.\n\nCV: HR 130's ST. No VEA. SBP 130's\n\nGU: foley catheter inserted. UO initially 30cc hr. UO has dropped off sig. past 2 hrs.\n\nGI: NPO except meds due to resp status. Abd soft No stool.\n\nNEURO: A&OX3. Feels jittery ( given IV steroids). Given tylenol for HA\n\nACCESS: #22 PIV X1.\n\nSOCIAL: Husband at bedside. He has been updated throughout the day on pt's status, plan of care\n\nA/P:\nResp status tenueous, boarderline, without reserve due to COPD flare. ?if pt would tol NTS. Sputum for culture when available\nBipap trial again this eve.\nNebs, steroids.\n\nDiscuss with HO oliguria\n\nNPO except meds until resp status improves.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-12-10 00:00:00.000",
"description": "Report",
"row_id": 1431419,
"text": "\nPT MAINTAINED ON INTERMITTENT BIPAP BUT WILL NOT WEAR CONT. HAS AGREED TO WEAR Q3- TO Q4 FOR 10 TO 15MIN IF SHE CAN HOLD IT AND NOT BE STRAPPED IN. SVN RX GIVEN WITH ALB/ATR Q4. B.S. DECREASED WITH SOME SCAT RONCHI. PROD COUGH MOD. AMTS. LAST ABG SHOWING A RESP ACIDOSIS. PLAN IS TO CONT OFFERING THE BIPAP WITH SVN RX.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-12-11 00:00:00.000",
"description": "Report",
"row_id": 1431420,
"text": "S/MICU Nursing Progress Note\n Respiratory: Pt on 40% face tent nemb with RR 20's labored, using accessory muscles, BS poor air movement only able to hear a fine insp wheeze, while trying to take her pills,pt felt like she was drowning and unable to catch her breath. Nemb tx interval increased to Q1hr, placed on mask ventilation with PS 18cm , eventually able to get comfortable and ABG showed 7.31/70/90 (pCO2 had been 88) kept her on mask ventilation, nembs Q3hr during the night, along with CPT, hydrated with NS at 125 cc/hr. This morning able to cough productively. solumedrol 100mg given, to be stopped at 12pm today. BS this morning slightly better, able to hear expiratory phase.\n Cardiac: HR 100-130ST rare PVC's BP 110-150/60-70's\n ID: afebrile,\n Plan: cont frequent nemb treatment, follow sats, BS closely, mask ventilation\n"
}
] |
19,911 | 171,106 | 66F with chronic trach and PEG, s/p CVA in with residual weakness who presents from home with lethargy and hypotension. . # Sepsis: On admission, WBC elevated to 23 with 8% bands and lactate of 4.4. Patient with hx of c diff, serratia and MRSA bacteremia in the past. During a previous admission, pt had MRSA bacteremia but no source was identified. No hx of diarrhea. Blood, sputum cultures sent. Pt is anuric so no urine culture. Patient however with multiple sources of infection, including sacral decub ulcers, dry gangrene in both feet, tracheostomy and G-tube insertion sites. Pt sx's initially improved dramatically with supportive therapy. cultures returned pseudomonas from sputum and begun on meropenem on . CT + MRI of sacral and posterior-tibial decubs showed no evidence of Osteomyelitis. Patient initially failed -stim test and completed a five day course of stress dose steroids. Regarding sacral decub ulcers, plastics was consulted and did not feel there was any role for surgical intervention. During admission, patient with multiple positive cultures including the following: sputum on growing pseudomonas and GNR; sputum on , , growing pseudomonas and GNR; sacral decubitus ulcer swab on growing GNR, Pseudomonas, coag positive staph aureus, and klebsiella; sputum culture on and growing Klebsiella, Pseudomonas; blood culture on growing enterococcus faecium (VRE but sensitive to linezolid). Patient has been treated with tobramycin and zosyn for double coverage of pseudomonas in sacral decubitus ulcers, linezolid for MRSA and VRE, and levofloxacin for chronic aortic abscess with serratia. Patient's HD catheter was removed when patient was found to have VRE. . Patient also with hx of aortic annular abscess with serratia and ? of endocarditis at and is chronically treated with levoquin. Vasc performed a partial amp/debridement of the L great toe in the setting of dry gangrene. wound cultures from the tissue returned pseudomonas as well which showed resistance to meropenem. Vasc surgery recommended amputation with BKA due to gangrneous toes bilaterally. Family refused intervention. . Pt had a recurrent episode of VRE in her blood and a PNA with psuedomonas and klesiella. This was again treated with Meropenem and Amikacin for a 14 day course. She was also started on Daptomycin for recurrent VRE in her blood for a 14 day course. . # Lethargy: Patient with lethargy throughout her course, likely secondary to patient's sepsis. Head CT was negative for any intracranial hemorrhage or mass. This improved and pt was at her baseline at time of discharge. . # Resp: s/p trach, on vent at home with settings of assist control 450x22xPEEP of 5x60%. Pt. remained mostly on home vent settings throughout hospital stay. Oxygenating well on FiO2 of 60%. She had her PEEP increased to 8 increased pleural effusions due to volume resuscitation during bouts of sepsis/GI bleed. Also, during her acute GI bleed, her rate was increased to help offset a lactic acidosis that occured the large amounts of blood products she received. Other than this her vent settings have remained stable. Will likely be able to decrease her FiO2 over time after her pneumonia completely resolves. Trach is 7.0 extra long shiley. . # CV: ** Ischemia: EKG nml ** Rhythm: PAF; on dilt for rate control. continue amio and digoxin. Pt was taken off all anticoagulation due to recurrent GI bleeding. Cardiology consulted for risk of no anticoag with mechanical valve. Risk of thrombus is approx 10% per year, however pt had large GI bleed on any anticoagulation. Due to liver failure, pts INR has remained elevated to 2.0 throughout admission. ** Pump: EF 55% on echo, diastolic dysfxn. . # ESRD on HD: During this admission, patient was initially on hemodialysis and was converted for a short time to CVVHD. However, once patient's renal function and hemodynamics became more stable, patient should be continued on hemodialysis per home regimen. . # Anemia: baseline hct of 29-30. During this admission, patient became supratherapeutic on coumadin and heparin and developed increased bleeding, including vaginal bleeding, skin tears, and sacral ulcers. Pelvic US demonstrated thickened endometrial stripe. OB-gyn was consulted and did not suggest further work-up given that patient was unlikely to receive any further treatment. Patient's coumadin and heparin drip have been held while concern for active bleeding. Pt then had active GI bleeding and all anticoag has been held for recurrent GIB while on anticoagulation. . # GIB: Pt had bright red blood per ostomy and GI service was consulted. Pt found to have petecial lesion in residual colon, no active bleeding. EGD was negative. Attempted to restart anticoagulation however pt continued to have GIB when on heparin. On one occasion, a bleeding vessel was found at the stomal site and a stitch was placed by Surgery, with no recurrent bleeding from that vessel. Decision made with GI and cardiology to hold anticoagulation. . # Lactic acidosis: Pt was found to be hypotensive to the 50s-60s several times during her hospital course. An arterial line was placed for better monitoring and revealed a difference in cuff pressure of 30 points. Lactate was elevated to 10, which was attributed to Linezolid. This was discontinued and she was started on Daptomycin for VRE bacteremia. She should not receive Linezolid again and it was added to her allergy list. . # DM: Patient with very poorly controlled blood glucose at home. Patient's blood glucose was managed during this hospitalization with the help of . She was placed on an insulin drip during her intermittent sepsis, as her sugars were difficult to control. Prior to discharge, her insulin regimen was transitioned to glargine at 7 untis qam and an agressive insulin sliding scale. . # Thrombocytopenia: Pt had progressive thrombocytopenia throughout admission. Hep ab neg. Felt to be 2/2 pts extensive medical illnesses and broad spectrum abx. No furhter intervention at this time. DIC labs normal. Pt did not require plt transfusion. Team was notified after patient was discharged that heparin dependent antibody sent on had come back as positive. Case management was notified to let the patient's dialysis service and home nursing agency know that the patient should not receive heparin in any form. . # Wound care: Pt has large sacral decub and multiple skin tears skin breakdown. Wound care followed throughout admission. . # Social: Multiple family meetings were held with medical, nursing, social work, case management, GI and renal consultants throughout this admission where the medical staff made it clear to the family that the patient is dying and that we would recommend comfort measures at this point. The health care proxy refused to convert care to comfort and wanted to continue with aggressive measures. Ethics and palliative care consulted during this admission and fmaily refused to talk to them. . # Code: already intubated, NO SHOCKS, no compressions. DNR. . | Condition UpdatePlease see carevue for specifics.Neuro unchanged. RESP CARE: Pt remains trached/on vent settings per carevue. resp careremains trached and vent dependant. NPNPlease see CareVue for full assessmentsNEURO: Unchanged. RESP CARERemains on vent. trach care done/inner cannula cleaned. Incosistent with following commands.CV: Cont. see chart for recommendations.ID: Cont on mult abx. Drsgs d &i.allevyn drsgs in place.A/P:Cont crrt, sliding scale ca+ k+. Lopressor po as bp tolerates. MDI's given a/o. trached onventilatory support. Resp.CarePt. HD to be done . Condition UpdatePlease see carevue for specifics.Neuro unchanged. Care: Pt. HD today, p tis anuric. Ativan per schedule.CV: Cont. F/U Amikacin levels post-HD today. Tol tf at goal thru J tube.CVVH: Kept euvolemic,-no issues.INTEG: Skin extremely compromised. decub.RESP: lungs rhonchi through out. ALTERNATING FROM NSR TO A-FIB. Tube feedings infusing at goal w/ no residuals. Diltiazem on hold until NEO gtt is off.GI: Abd large soft +BS. SM AMT CLEAR, MUCOID RECTAL DRNG NOTED.ID: AMIKACIN GIVEN POST-HD, MEROPENEMENDO: BS COVERED VIA RISS, LANTUS GIVEN THIS AMINTEG: MULTI DSG DONE, REINFORCED/RE-PACKED PRN. Pressor weaned off in am, though resumed for HD tolerance. Suctioned for sm.->moderate amts. Dtr found suctioning pt. Levaquin per Jtube.GI/METABOLIC: NPO maintained. DIC panel pending.Doppler pulses absent left PT and right DP, MD aware. requesting VBG again while hr elevated and it was drawn per micu team; resulting values ok per respiratory. RUE PICC and left dialysis remain in place- Left dialysis catheter with erythema.GI/METABOLIC: NPO maintained, Jtube clamped. Transfused pt with 1UPRBC and 1U Md orders- Post-transfusion HCT 26.1, am 25.4. CONTINUES IN A-FIB, ON COUMADIN. Follow abg's, respitory effort, 02 sats. HCP, HAS PHONED AND HAS BEEN UPDATED.A--FEBRILE. .5 DILAUDID GIVEN AGAIN.ID--FEBRILE TO 101.5. Suctioned for minimal amounts clear secretions.CV: Afebrile. iv phenylephrine weaned to off. MIDODRINE GIVEN AS ORDERED. condition updated: pt arrived from er with ? PEG/ site intact but draining.GU: CVVH to start this p.m.ID: Afebrile. condition updateplease see carevue for specifics.Neuro unchanged. Metwabolic acidosis unchanged, Bicitra as ordered.ID: Tmax 100.5 with rigors and tachycardia/tachypnea/BP increase- pressors off for short while. BS essentially clear anteriorly sxing for minimal secretions. Resp Care,Pt. wean neo as tolerated.r: tolerating slow pitressin wean. Zosyn, Levaquin, Tobramycin as ordered. Lopressor po per schedule.RESP: Trach. Resp Care Note, Pt remains on current vent settings. Pt is currently being followed by .B/L multi podis splints placed this am. Turn and repositioned Q2hrs and prn. NPNPlease see CareVue for full assessmentsNEURO: Unchanged. Ativan per schedule.CV: Afib occas. Lopressor dose now TID. transfuse with hemo today. Midodrine per schedule. Allevyn dsgs on hips from intact. LEFT A/C PICC D/C'D, RIGHT TLCL DRNG SEROSANG. Dr. aware and lopressor dose given. Lopressor 12.5PO administered. Cortisol stimulation test completed.RESP: Trach. Another amp D50 administered.GI: Abd distended. NPNPlease see CareVue for full assessmentsNEURO: Unchanged. TRACH CARE DONE.GI-ABD SOFT, NT/ND. +granulation, small amount of sero/sang drainage. trached and chronically ventilated. +PP VIA DOPPLER.RESP-NO VENT CHANGES. TOL TF VIA J-TUBE.GU-ANURIC. HAD US OF RUQ.GU-ANURIC ON . MDIs given as ordered. Skin care per orders. Tmax 100.7 remains on tobra and zosyn. trached/vent dependant. Bil hip dressings changed, +granulation, draining small amounts of sero/sang. RSC quinton.lungs: clear to coarse . EKG done per MICU request. continue lantus at present dose . HR A fib with rare pvc's, rate controlled. Albuterol/Atrovent MDI's given Q4hr and Flovent . Albuterol/Atrovent MDI's given Q4hr and Flovent given . Nursing Progress NotePlease see for detailsNeuro: unchanged.CV: afebrile, bair hugger off with temp maintained. Generalized edema.Respir: Remains on CMV. hypothermic-bairhugger on.CV: NSR wtih rate controlled on dilt. Neo weaned off. R-HD CATH SITE WNL,DRESSING INTACT.ID: AFEBRILE. LYTES WNL.ENDO: FS QID. UpdateSee Carevue for specificsNeuro: pt. CSL ON.PULM: TRACHED. Wean neo and diltiazem as tol. TOLERATING TF. nursing noteNeuro:Pt alert, nodding approp at times. REPEAT HCT, ?BLD CULTURES IF PT REMAINS FEBRILE. W/LGE GEN SEROUS DRNG, GEN ANASARCA. pt has slightly course/wheezy BS, suctioned for sm-mod amt of thick secretions MDIs given as ordered. vanco and tobra given, levels drawn. Stool (P) for c-diff. REQUIRED FLUID BOLUSES DURING DIALYSIS THIS AM. Colostomy drainage liquid. Resp Care,Pt. COCCYX DRSG - LG AMT OF PURULENT/S/S DRAINAGE OUT. REMAINS IN AFIB - RATE CONTROLLED ON DILTIAZEM DRIP. K AND DRIPS TITRATED ACCORDING TO ORDERS. DRSG TO /LBUTTOCK - MOD AMT S/S DRAINAGE OUT. HYPOTHERMIC - BAIR HUGGER ON. MDI's given. if firm distended, +bs, colsotomy draining brb this am, endosopy done at bedside per gi, clips applied. Patient remains tachycardic, and the albuterol mdi inline was witheld. atrovent given q6h, albuterol held until tachycardic,given in pm with HR 106. c/w full vent support. Diltiazem/Digoxin/Amiodarone/Midodrine given as ordered. Albuterol/atrovent and flovent given. resp careremains trached/vent dependant. TRACH CARE DONE, IN-LINE SXN CATH CHANGED. Respiratory CarePt remains trached with 7.0 Shiley. Resp Care,Pt. HCP notified.plan: hd as tolerated. tube fdgs as ordered. MDI'S given. Condition UpdatePlease see carevue for specifics.T/max 99.7; Cx's pending from . "Condition updatePlease see carevue for specifics.neuro unchanged. PERRL.CV/GU: Afib. lg amt of serous drainage . Resp Care Note, Pt remains on current vent settings. Resp Care Note, Pt remains on current vent settings. Condition UpdatePlease see carevue for specifics.Tmax 99.7, AFIB. MDI'S given.Will cont to monitor resp status. Continued resp care planned. Continued resp care planned. Focus Condition UpdateSee flowsheet for specific info.Neuro: Status unchanged. Still awaiting vaginal us. Lung sounds were course with rhonchi that cleared after suction. Amiodorone load IVPB given. Right paramedian hernia. Following gadolinium, T1 sagittal, and axial images were obtained. Clinical correlation issuggested. Note is made of some calcifications in relation to the uterus, consistent with fibroid uterus. Probable multifocal atrial tachycardiaLeft bundle branch blockSince previous tracing of , atrial ectopy present IMPRESSION: Gastrojejunostomy tube in proper position terminating in the jejunum. There has been interval redistribution of the right pleural effusion with mild superimposed hydrostatic edema. CONCLUSION: Trach in situ, bilateral pleural effusions. Tracheostomy tube in standard placement. Status post cholecystectomy. Status post removal of tunneled right internal jugular approach hemodialysis catheter. Tracheostomy tube in standard placements. A 0.035 guidewire was advanced into the superior vena cava and the introducer sheath was removed. COMPARISON: AP supine portable chest x-ray dated . Admitting Diagnosis: SEPSIS FINAL REPORT (Cont) gt/jt seems to be slightly out and Dr. aware and up to pt. CONTINUES IN A-FIB, AS PREVIOUSLY. Condition updatePlease see carevue for secifics.Neuro unchanged. with periodic leaks and adjusted by RT.GI:Abd large, soft,nt. condition updatedS/P sepsis;for complete info please refer to carevue.condition status quo. | 420 | [
{
"category": "Nursing/other",
"chartdate": "2132-08-14 00:00:00.000",
"description": "Report",
"row_id": 1524159,
"text": "NPN\nPlease see CareVue for full assessments\nNEURO: No change. PERRL. +tracking. Pt. does not follow commands and is inconsistent with communication. Nodding and mouthing words at times. Minimal mvmt with nailbed stimuli in all extremities. LUE tremor in hand, wiggling fingers.\n\nCV: Remains in AF with rare PVC's. HR90's-100's throughout day. Goal MAP >50. SBP dropped into 80's after HD. MICU HO paged with no response. BP came up without intervention. Amiodorone, Digoxin, and lopressor per schedule. Coumadin to be held tonoc. INR3.9.\n\nRESP: No vent changes. Sxn x3 small amts thick yellow secretions. LS rhonci/coarse. Clearer with sxn. Cuff leak treated by RT. MDI by RT. Plan for Passy Muir trial in am prior to discharge per family request.\nDtr. updated by attending on this matter.\n\nRENAL: HD this am. Pt. tol. removal of 2.2L. Albumin admin. during HD.\n\nENDO: BG still 200-300' in to . Glargine dose increased. recommends injections into stomach for optimal effect. RISS coverage.\n\nID: Tmax 99.8po this shift. IV ABX dc'd this am. Levofloxacin restarted for aortic abcess. VRE+ !!!!\n\nGI: TF @goal via PEJ. Small amt mucus drainage around insertion site with small ulcerated area noted at the 3 o'clock position. Wound care RN in and discussed proper care for excoriated skin around PEJ. Aquacel trach sponge ordered for area-until then use aloe vesta on excoriated part and duoderm gel on uclerated area covered with DSD. RN stated OK to use Aloe Vesta under Aquacel too. Liquid stool from colostomy. Lactulose held.\n\nWOUND: Wound management unchanged. Reviewed with wound RN. Right ischial dsg done this shift due to increased drainage at site. All other dsgs intact. Kinair bed &BLE MPS in place.\n\nPSYCHOSICIAL: Husband and son at bedside for most of morning & present during rounds. Informed of possible dc by Attending. Dtr. called and also updated by Attending.\n\nPLAN: Monitor CV, if low BP, sxn prn, assess for cuff leaks, trial in AM of Passy Muir, wound management, diabetic management, turn Q2H to maintain skin integrity, initiate discharge paperwork, provide emotional support to patient and family concering pending discharge.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-15 00:00:00.000",
"description": "Report",
"row_id": 1524160,
"text": "resp care note\n\n\nPt remains trached and on AC vent , No ABG drawn this shift. Sx for increased yellow-green sputum. sample sent for C&S. # 8 in place.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-23 00:00:00.000",
"description": "Report",
"row_id": 1524319,
"text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Pt alert mouthing words and weepy at times. Still does not follow commands and is only moving LUE. Cont on standing ativan.\nCV: Pt becoming increasingly hypotensive today. Down to low 70's with MAP's in the 30's. Pt at one point on max triple concentrated Neo and Vasopressin. Remaining with normal HR over coarse of day. CVVH cont and placed to 0. Pt currently off vasopressin and is on 2.0mcgs/kg of neo. currently running even. Pt remaining hypothermic. Unsuccessful line placement today. Pt will need to go to IR for Central access in am.\nResp: No vent changes. Sxn for thick yellow sputum. Lungs coarse throughout. Sats 98-1005.\nGi/GU: Cont on TF at goal 65cc/hr via J-tube. G-tube remains to gravity. Small blood clots aspirated from MD aware. Cont with guiac + stools and some noted vaginal bleeding.\nEndo: insulin gtt stopped FS dropped to 51.\nSkin: Coccyx Hip changed with wound RN. see chart for recommendations.\nID: Cont on mult abx. Hypothermic\nSoc: Family requesting trnf to . Social Services in contact with family and primary team RE: Family meeting tomorrow.\nPlan: Cont with current plan of care IR tomorrow for Central access.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-24 00:00:00.000",
"description": "Report",
"row_id": 1524320,
"text": "RESP CARE: Pt remains trached/on vent settings per carevue. No changes in settings this shift. pressure 30cmH20. trach care done/inner cannula cleaned. Lungs coarse bilat with no wheezes. MDIs given as ordered. Sxd small amts thick yellow sputum. ABGs consistent with met acidosis. RSBI deferred due to hemodynamic instability. Continue full support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-12 00:00:00.000",
"description": "Report",
"row_id": 1524395,
"text": "Respiratory Care\nPt. trached on ventilatory support. Sx for copious amounts thick tan and blood tinged secretions. No vent setting changes made this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-12 00:00:00.000",
"description": "Report",
"row_id": 1524396,
"text": "Nursing progress note\nPlease see for details\n\nNeuro: unchanged, nodding to questions, mouthing words at times. does not move extremities.\n\ncv: neo remains off, bp on leg in order to achieve . HR decreases to low 60's after diltiazem. Pt's daughter is requesting that dilt be changed back to TID when dialysis resumes. Rate is now controlled at < 90.\n\nPulm: no vent changes. pt sx q 2-3 hrs for thick tan to brown sputum. see vbg's.\n\ngu: anuric\n\ngi: tol tube feeds at 40/hr. pt turned at 0600 for bed change, turned to left side (g port gravity bag is hung on left side.) no tension on tube noted, when pt returned to back, balloon of ft noted to be external on abdomen. Dr notified. Feeding off.\nColostomy draining loose golden stool, guaiac pos. Hct stable tonight at 25.\n\nEndo: insulin drip remains off, blood sugar down to 115. now with TF off, will monitor blood sugar closely.\n\nskin: pt continuously leaks from pinpoint areas over arms and back of legs. quilted pink pads changed frequently for pt comfort.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-15 00:00:00.000",
"description": "Report",
"row_id": 1524161,
"text": "Condition Update\nPlease see carevue for specifics.\n\nNeuro unchanged. Tmax 100.1 AFIB rare pvc's. spb 73-109. No vent changes. Pt sxn'd several times for yellow and green sputum. sputum sample sent. w/ beneprotein unfusing at goal. clear oozing in large amts noted at j tube insertion site. DSD applied. blood sugars continue in the 300's. Pt is followed by .\n\nPlan: continue with current plan of care per micu team. discharge planning. speech and swallow consult today for passy mauir placement. Po abx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-15 00:00:00.000",
"description": "Report",
"row_id": 1524162,
"text": "Respiratory Care Note\nPt remains on AC home settings as noted. BS diminished throughout. Pt suctioned for small to moderate amts thick, brown secretions. Speech evaluated pt for - pt placed on for 15min x 2 this shift. Pt tolerated well with sats 100%. Pt did not vocalize during either trial. Plan to continue on current settings. Spoke with daughter about her concerns with new trach and referred her to attending physician.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-15 00:00:00.000",
"description": "Report",
"row_id": 1524163,
"text": "NPN\nPlease see CareVue for full assessments\nNEURO: No changes. Incosistent with following commands.\n\nCV: Cont. in AF with rare PVC's. HR 90's-110's. Episodes of hypotension-not new. MICU team aware. HCT 24. T&S drawn. To receive 2Units PRBC's tonoc.\n\nRESP: Trach. No vent changes. Tolerated Passey-Muir valve trial. Teaching to dtr. by Speech and RT for in line use of . Dtr still has concerns about new trach and care after discharged home. Team aware and to meet with dtr.\n\nENDO: BG remain 200's-300's. Glargine increased again. RISS .\n\nGI: TF@goal. PEJ draining copious amts brown/green liquid this eve. Noted to increaase when pt. turned to left side-family states this is not new. Skin around insertion site excoriated and beginning to break down. Ostomy appliance placed around site. Family had been using appliane at home due to large amts drainage. Colostomy appliance changed. Loose golden guaiac - stool in bag. Colace and Lactulose held due to liquid stools x2days.\n\nWOUNDS: No changes in wound care. Dsgs intact. MPS to BLE.\n\nPLAN: Monitor CV, pulmonary toilet, diabetic management, wound management, discharge planning, provide emotional support to patient and family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-16 00:00:00.000",
"description": "Report",
"row_id": 1524164,
"text": "resp Care note\n\nPt was placed on via in-line vent circuit with cuff down but did not tolerate trial well. She has significant amt of thck yellow-green secretions, Sputum culture pending. At this time she remains on AC vent 16 x 450, + 5 , 40% . No ABG this shift. Pt is alert but not prone to communicate readily\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-12 00:00:00.000",
"description": "Report",
"row_id": 1524397,
"text": "NURSING NOTE 7A-7P REVIEW OF SYSTEMS:\nNEURO: DROWSY AWAKE AT TIMES, MORE AWAKE WHILE FAMILY VISITING. PERRLA, NO MOVEMENT OF EXTREMITIES. INCONSISTENTLY FOLLOWS SIMPLE COMMANDS. NO PAIN MEDICATIONS GIVEN.\nC/V: CONTINUES IN AFIB RATE 67-94 OCCASSIONAL PVC'S. = 80-110/35-55. NEO REMAINS OFF. PO MEDS THRU PEG TUBE RESTARTED THIS AFTERNOON.\nRESP: VENT SETTINGS UNCHANGED. REMAINS ON AC AT 450X 22X 50%X 5 PEEP.\nTRACH CARE DONE INNER CANNULA CHANGED AND CLEANED. SUCTIONED SEVERAL TIMES FOR SM TO MODERATE AMOUNTS THICK TAN SECRETIONS.\nGU: ANURIC, DUE FOR HD TOMMORROW AM.\nGI: ABD OBESE, POSITIVE BOWEL SOUNDS, COLOSTOMY DRAINING LOOSE GOLDEN COLORED STOOL (GUIAC NEGATIVE). TRANSFER TO XRAY TO CHECK PEG TUBE PLACMENT UNDER FLUOROSCOPY. PLACEMENT CONFIRMED AND TUBE FEEDINGS OF RESTARTED AT 40CC/HR TOLERATED WELL.\nHEME: REPEAT HCT THIS AFTERNOON= 24.7.\nSOCIAL: PATIENTS HUSBAND AND SON INTO VISIT THIS MORNING, QUESTIONS ANSWERED BY RN AND MD, UPDATED ON PLAN OF CARE.\nENDO: WHILE PATIENT NPO FS CONSISTENTLY WERE 57-81. ONCE TUBE FEEDINGS RESUMED FS INCREASED. REMAINS OFF INSULIN DRIP TODAY.\nACCESS: CONTINUES WITH MULTILUMEN LINE RIGHT SC, RIGHT SIDED PICC LINE AND DIALYSIS LINE SHILEY INTACT LEFT SIDE.\nPLAN: DIALYSIS TREATMENT TOMORRW, IF PATIENT STABLE POSSIBLE TRANSFER TO HOME ON TUESDAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-12 00:00:00.000",
"description": "Report",
"row_id": 1524398,
"text": "BS fine crackles, occ wheeze clearing with suction. No significant change with MDI's. To CT to check PEG - in position and functioning. No vent changes or ABG's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-05 00:00:00.000",
"description": "Report",
"row_id": 1524247,
"text": "NPN\nPlease see CareVue for full assessments\nNEURO: Unchanged. Nods to questions at times. More interactive during eves. Attempted to mouth words x1. Inconsistently follows commands. Moving upper extremities on bed. No movement noted in BLE. Nodded yes to pain x1. administered. Pt. did not respond when asked if pain relieved.\n\nCV: Afib. HR consistently 120's-130's. Episodes of HR 150's. 1x dose 2.5mg Lopressor IVP with no decrease in HR. MICU HO notified. PO 2200dose lopressor held due to hypotension during eves and given later in shift when BP more stable.\n\nRESP: Trach. No vent changes. Sxn mod amts tan thick secretions.\n\nGI: TF @goal. Ostomy bag placed @ due to drainage from around insertion site. Colostomy bag changed. G- stool.\n\nScant amts vaginal bleeding noted.\nPLAN: Monitor CV, diabetic management, pain management, wound care, HD today, reposition per protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-05 00:00:00.000",
"description": "Report",
"row_id": 1524248,
"text": "nuero: pt does open her eyes when you call her name. pt nodds yes and no to questions when asked. pt intermittently will follow commands.\n\npain: pt nods head no when you asked if he having pain.\n\npulm: pt remains on trached, pt on cmv. suctioning pt for scant amt of yellowish secretions.\n\ncards: pt in afib hr 120-140's, sbp 80-90 dr. aware, pt recieved 250cc this morning with little effect. hr continued to be 130-140's, dr. aware, pt recieved 2.5gm of iv lopressor with some effect. please see flow sheet\n\ngi: pt continue on tubefeedings at goal which she is tolerating thus far. stoma pink and protruding draining golden brown colored drainage.\n\ngu: pt does not viod. pt to recieve hemodialyisis tomorrow. pt with scant amt of vaginal bleeding noted.\n\nf/e k 3.3 pt treated with 20meq kcl. blood sugar 136 this morning receieved 86 units of glargine as ordered.\n\nsocial: pt husband into visit this morning.\n\nplan: continue to monitor, monitor hr, bp, pain ,\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-05 00:00:00.000",
"description": "Report",
"row_id": 1524249,
"text": "resp care\nremains trached and vent dependant. remains on ac mode, no changes made this shift. sxning thick yellowish/green sputum. mdi's given q4h. refer to flow sheet for data.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-06 00:00:00.000",
"description": "Report",
"row_id": 1524250,
"text": "Respiratory Care Note:\n\nPt remain on ventilatory/assisted support ventilation via tracheotomy tube. No vent changes done. We are sxtn small amt of yel thick secretions, small cough efforts. MDI's adm with No noticeable changes, albuterol held as Hr 120's. Plan: Continue present ICU monitoring. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-21 00:00:00.000",
"description": "Report",
"row_id": 1524310,
"text": "RESP CARE\nRemains on vent. no changes made. Suctioned mod amt of thick green secretions. Mdis given. WIll continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-21 00:00:00.000",
"description": "Report",
"row_id": 1524311,
"text": "Respiratory Therapy\nPt remains trached w/ #7.0 Shiley trach on full mechanical support. No vent changes made this shift. BS coarse, suctioned for small amounts of thick tan secretions. SpO2 90s. MDIs given as ordered. Continues on A/C ventilation w/ PIP = 20. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-13 00:00:00.000",
"description": "Report",
"row_id": 1524154,
"text": "Resp Care\nPt remains vented on AC 450x16 at 5 PEEP. Pt was bronched today and a new adjustable flange cuffed Trach tube was placed via Bronch. Cuff pressure was set to 20. MDIs given as ordered. BS scat wheeze and rhonchi. Sxn'd for thin white secretions. No ABGs done today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-21 00:00:00.000",
"description": "Report",
"row_id": 1524312,
"text": "focus update note\nhypothermic most of day, MICU team aware, 95-98, bair hugger on, internal bed warmer on most of day, NSR 70-80s no ectopy, kcl and ca continuous repleation, sodium phosphate repleated. goal map > 55 neo .2-1.5 mcq/kg/min neo requirments increasing to maintain map > 55. HCT 24, no active sign/sx bleeding witnessed.\n\nCRRT: machine malfunction at 1500, new machine ordered and restarted at 1700, goal per renal fellow keep pt even to 1 liter negative, pt 100-150cc/hr today.\n\nskin: leg/thigh/ dressings performed please see flowsheet for details, left inner thigh cellulitis unchanged- pt on vancomycin, pt edema increasing in thighs.\n\nsocial: (daughter) spoke with micu resident in length regarding mothers care, daughter continues has many concerns/questions and would like to speak with social work this week\n\nplan: keep MAP > 55 with neo gtt, monitor for afib, continue with CRRT goal even to 1 liter negative, monitor/treat hypothermia, family meeting for next week?, social work consult\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-22 00:00:00.000",
"description": "Report",
"row_id": 1524313,
"text": "Respiratory Care Note:\n patient remains trached with a #7 x-long Shiley trach, secured and patent. remains on full vent support with no changes being made this shift. BS are coarse throughout. SX for small to moderate amounts of thick yellow secretions via trach, MDI's administered as ordered. No RSBI this am due to patient being vent dependent. Tmax this shift was 99.6. SPO2 remains 100%. No ABG's. Plan is to continue with current treatment plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-22 00:00:00.000",
"description": "Report",
"row_id": 1524314,
"text": "Respiratory Care\nPt remains on full ventilatory support as note on Carevue. MDI's given as ordered. Breath sounds diminished with scattered expiratory wheezes. Improving with suctioning. Small amounts of thick yellow secreations removed from airways.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-22 00:00:00.000",
"description": "Report",
"row_id": 1524315,
"text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT AWAKE, OPENS EYES TO VOICE. OCC MOUTHS WORDS.\n\nCV-HR 80'S, NSR. REMAINS ON NEO GTT TO KEEP >80'S. SKIN WARM.\n\nRESP-REMAINS TRACHED AND VENTED. NO VENT CHANGES MADE TODAY. O2 SAT 100%. LS COARSE WITH OCC WHEEZES. INHALERS AS ORDERED. SXN PRN FOR THICK YELLOW SPUTUM. ABG ACCEPTABLE.\n\nGI-ABD OBESE. +BS. TOL TF VIA . G-TUBE TO GRAVITY WITH YELLOW/WHITE DRG. STOMA PINK. NOTED TO HAVE BLOODY LOOSE STOOL VIA OSTOMY. TEAM AWARE.\n\nGU-ANURIC. ON CHHHDF. TOL WELL. GOAL 1 LITER NEG TODAY. ABLE TO TOL SOME FLUID REMOVAL. CA AND KCL GTTS INFUSING AS ORDERED.\n\nCOMFORT-APPEARS COMFORTABLE. ATIVAN ATC.\n\nENDO-REMAINS ON INSULIN GTT.\n\nACT-REPOSITIONED FREQ. ON AIR MATTRESS.\n\nID-HYPOTHERMIC. BAIR HUGGER ON. ON MULTI ABX.\n\nSKIN-CON'T WITH MULTI SKIN ISSUES. DRESSINGS ALL CHANGED AS ORDERED. SEE FLOWSHEET.\n\nPLAN-CON'T WITH CURRENT PLAN. MONITOR FOR CHAGNES. FOLLOW LABS. . GOAL 1 LITER NEGATIVE. ASSESS PAIN. SKIN CARE. SUPPORT. WEAN PRESSOR AS TOL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-10 00:00:00.000",
"description": "Report",
"row_id": 1524390,
"text": "nursing addendum\n MD , amikacin dose to be given with level of 11.8 per pharm. Level trough to be sent at 1730.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-11 00:00:00.000",
"description": "Report",
"row_id": 1524391,
"text": "Respiratory Care\nPT. trached onventilatory support. Suctioned for copious amounts of thick yellow green secretions. No vent setting changes made, not plans for weaning vent settings at this time.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-13 00:00:00.000",
"description": "Report",
"row_id": 1524155,
"text": "Condition Update\nPlease see carevue for specifics.\n\nNeuro unchanged. Pt opening her eyes spontaeously, but not moving extremities or following commads. Low grade temps. TMAX 99.7 AFIB HR 90's-108. No ectopy noted. SBP 70's-90's. 500cc NS boluses x 2 given w/ no effect per micu team. Cortisol test done, 1x dose of cosyntropin given. BP's up since dose given. Results still pending. No vent changes this shift. Trach changed over to a new adjustable flange cuffed trach via bronch at the bedside d/t leakage. Pt sxn'd for scant amts of white, thick sputum. Sats 100% LS clear. w/ beneprotein tube feedings infusing via j tube restarted after trach placed an is at goal. Colostomy draining guiac NEGATIVE liquid stool. spec sent. Lactulose dose held. Pt's blood sugars while NPO as low as 44. amp dextrose given. Since tube feedings restarted, bs have been on the rise and currently 163. B/L hip dressings changed this am. Both hips w/ stage 3 ulcers that drain serous, foul smelling fluid. reddened bases of the wounds. All wounds cleansed w/ NS, duoderm gel placed then covered w/ allevyn dressings.\n\nPlan: continue with current plan of care per micu team. IV F/U on results of cortisol test, bld cx's taken , and spec sent . Discharge planning. Dressing changes. HD to be done . Speech and swallow to speak w/ daughter concerning future use of passy mauir valve.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-14 00:00:00.000",
"description": "Report",
"row_id": 1524156,
"text": "Resp. Care:\n Pt. continues on mech. ventilation-same settings as at home with chronic vent. New trach. placed yesterday. Tol. well without leak. Inhalers given as ordered. Please see flow sheet for more information.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-14 00:00:00.000",
"description": "Report",
"row_id": 1524157,
"text": "Nursing NOte 7p-7a:\nNursing Assessment:\n\nTmax 100.6 has started to come down without intervention other than blankets off for a few hours and room temp decreased. No commands other than opens mouth for temperature. Tracks but no nodding yes and no or spontaneous movement other than wiggles left fingers occasionally when awake. No boluses tonight, goal map >50, very inconsistent blood pressures continue and team is aware, not new. Afibb and tachycardic also not new. Lopressor po as bp tolerates. Amiodorone and digoxin po qd. Abdomen softly distended, colostomy with liquid stool and tube feeds continue. Lungs clear and diminished. Inhalers given by respiratory therapist. Dressings to bilat lower extremities and coccyx per wound nurse recommendations. Blood glucoses elevated again despite 75 glargine and reg insulin sliding scale. Will continue to monitor. HD today, p tis anuric. ?Discharge home today on vent following dialysis. Pt has 8 children who participate in managing her home care. Please refer to carevue for details.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-14 00:00:00.000",
"description": "Report",
"row_id": 1524158,
"text": "Respiratory Care Note\nPt remains on AC home settings with no changes. BS diminished, but clear. Pt has a slight cuff leak with air placed in cuff to achieve minimal leak. MDI's given a/o. Plan to continue on current settings at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-04 00:00:00.000",
"description": "Report",
"row_id": 1524241,
"text": "Resp.Care\nPt. remains on A/C vent with a 7.0 Shiley secured and patent. Sx mod amts yellow with coarse b/s. MDIs given on time with good effect.Plan is to cont to monitor and wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-11 00:00:00.000",
"description": "Report",
"row_id": 1524392,
"text": "Rapid afib\nD:Pt had afib 120-150 not controlled with diltiazem 30mg TB so dose increased per Dr to 60mg QID. Afib now 110.\nPICC line looked like it had slipped out some due to impaired skin integrity and weeping skin difficult to keep DSD on. IV RN in to see pt and said line out 5cm. CXR done but radiologist unable to visulize PICC tip so need another CXR.\nPt responsive always opened mouth when asked, pupils large brisk. Otherwise no neuro change.\nAll DSD changed per plan in pt's room.\nNo vent changes overnight.\nColostomy yellowish soft stool. gastric drainage blood tinged and watery consistency, irrigated x 1 with NS because it had stopped drg.\nPlan today:\nNeed repeat CXR to check PICC position\n effectiveness of increased Dilt dose in rate.\nContinue plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-11 00:00:00.000",
"description": "Report",
"row_id": 1524393,
"text": "SICU NPN\nS-Trached.\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\n\nO-Alert. Shaking head in no and yes direction at times to family questioning. Denying pain. Not grimacing to pain or nursing care. Responding inconsistently to questioning when nodding. Attempting to wean off Neo. Neo off for 1hr. BPs into the 60s with a MAP of 30. Restarted and at .5mcg/kg/min. Attempting to keep MAPs > 50. Continues PO Midodrine with no increase in dose. PO Diltiazem dose increased, remains in Afib, HR better controlled, 60-80s from 100-110s. Breath sounds coarse anteriorly. Remains on AC. Suctioning for thick yellow-tan secretions in moderate amounts. Suctioning more frequently than previous. Still unable to obtain O2Sats peripherally or centrally. Remains anuric. CRRT off since yesterday. Goal is to wean off Neo with hopes of pt tolerating conventional dialysis to go home. TFs at GR. Ostomy putting out golden formed soft stool. G-tube to gravity and J-tube to feed. Insulin drip stopped this morning and attempting to treat with aggresive sliding scale coverage and standing Insulin dose. All dressing changed and intact. PICC noted to be out 5cms on previous shift, CXR confirming PICC in place per MICU resident. IV team made aware. Afebrile. Continues antibiotic regimen. Husband and son into visit this morning and expressing feelings of mother to \"come home.\" In addition son and -in-law into visit this afternoon and wanting pt \"home.\" Son, just waiting for sister() to make deciscion.\nA/P:Sepsis c/b failure to wean\nContinue to wean Neo as tolerated\nTreat BS aggressively with sliding scale in effort no to resume gtt.\nEmotionally support pt/family as needed\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-11 00:00:00.000",
"description": "Report",
"row_id": 1524394,
"text": "BS coarse crackles; no change with MDI's. Sx'd for mod amounts thick yellow sputum. Still requiring pressors and now off CVVH per family. Will continue to wean ventilator as appropriate, No ABG's or vent changes this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-04 00:00:00.000",
"description": "Report",
"row_id": 1524242,
"text": "NPN\nPlease see CareVue for full assessments.\nNeuros unchanged. Ativan per schedule.\nCV: Cont. Afib w/HR 90's up to 120's.\nRESP: Trach. No vent changes. BS coarse throughout. Sxn for scant amt thick tan secretions.\nGI: TF at goal via . Cont. w/copious amts bilious drainage around insertion site. Dsg chgd multiple times. BS+. Abd distended. Golden liquid stool guaiac - from colostomy.\nGU: Anuric. Scant amt blood noted.\nWOUND CARE: All dressings by wound care RN C/D/I.\nPLAN: Monitor CV, diabetic management, wound management-change dsgs per orders/PRN, maintain skin integrity, provide emotional support\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-04 00:00:00.000",
"description": "Report",
"row_id": 1524243,
"text": "SICU NURSING PROGRESS NOTE 0700-1500\nNEURO--INCONSISTENTLY NODS HEAD TO SIMPLE QUESTIONS REGARDING PAIN, COMFORT, HOT/COLD. MOVES BUE BUT NO SPONT. MOVEMENT OBSERVED IN BLE. PEARL AT 4MM. OPENS EYES SPONT. WILL TRACK WITH EYES OCCASIONALLY.\n\nCARDIAC--REMAINS IN AFIB 110-130. SBP 70-110/40'S.\n\nRESP--NO VENT CHANGES MADE. SX Q2 HRS FOR MODERATE AMTS OF THICK TAN SPUTUM. BILATERAL LUNGS ARE COARSE IN ALL FIELDS. SAO2 >97%.\n\nGI--TOL. TUBE FEEDS AT GOAL. COLOSTOMY DRAINING ~200 CC HR GOLDEN LOOSE DRAINAGE. SMALL AMTS OF DRAINAGE AROUND FEEDING TUBE.\n\nGU--ANURIC. NO FOLEY.\n\nID--TEMP MAX 99.9 ORAL. REMAINS ON SEVERAL ABX.\n\nPAIN--PT NODDED YES SEVERAL TIMES WHEN ASKED IF SHE WAS HAVING PAIN. MEDICATED WITH 12.5 DEMEROL FOR RELIEF. 25 MG GIVEN WITH DRESSING CHANGES.\n\nSKIN--SACRAL ,R HIP AND BILATERAL FEET DRESSINGS CHANGED PER PROTOCOL. SACRAL WOUND IS DEEP AND CLEAN AS IS HIP. NO FOUL SMELL NOTED. SEVERAL SKIN TEARS ACROSS BUTTOCKS. TOES ARE NECROTIC DSD APPLIED. REMIANS ON KCL BED.\n\n AND HUSBAND IN THIS AM. THEY HAVE BEEN UPDATED REGARDING PT'S CONDITION. \"NURSES ARE US\" IN TO VISIT AND REVIEW CHART FOR WHEN PT GOES HOME AND NEEDS SERVICES.\n\nA--UNCHANGED NEURO, CARDIAC OR RESP STATUS. J-G TUBE IS LEAKING SMALLER AMTS AROUND TUBE.\n\nP--CON'T TO MONITOR. MEDICATE FOR PAIN, ASSESS RELIEF. OFFER SUPPORT TO PT AND FAMILY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-04 00:00:00.000",
"description": "Report",
"row_id": 1524244,
"text": "Respiratory Care\n\n Pt continues on A/C in NARD No changes made today. MDI's as ordered. B/S sl coarse sx'd for moderate amount of thick tan secretions. Will continue to follow closlely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-04 00:00:00.000",
"description": "Report",
"row_id": 1524245,
"text": "condition update\n3-7p\nSee carevue for specifics. Tachycardic 120's-130's more consistently this evening, bp stable. Dr. was notified, no new orders, will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-05 00:00:00.000",
"description": "Report",
"row_id": 1524246,
"text": "RESPIRATORY CARE NOTE\n\nPatient remains trached with Shiley 7.0 ex. long trach tube. No vent changes made during the night. Inner cannula changed. Sxn for tan thick secretions. RSBI completed on PS 5=105.\n\n , RRT\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-20 00:00:00.000",
"description": "Report",
"row_id": 1524305,
"text": "Update\nO: See carevue flowsheet for specifics.\nNeuro: awake,alert, mouthing words&tearful at times altho unable to discern what pt saying. Nods no to pain. Moves lt arm only w purposefl spont mvmnt.\n\nCv: remains in afib on neo. Hr controlled w pgt diltiazem.Distal pulses by doppler.Extrems cool, bair hugger on and off thru .\n\nResp: Trached on cmv mode vent tv 450 rr 16 peep 5 .bbs coarse throughout. lavage and suct for thick yellow secretions.Remains on cmv mode w adeq abg.Trach care done\n\nGi:Abd obese w + bowel snds.Colostomy pink. gjtube w fdg at goal 65cc/hr probalance str w beneprotein. Glucoses managed per riss.Colosstomy w golden to bld tinge serous dnrg.\n\n\nGu: makes no urine.Cont on crrt keeping pt even & tol well.\n\nHeme/Id: hct 25. Tmax 99.4 while off crrt, temp now trending dwn.Cont on meropenem tobra levoflox.\n\nWound & skin: multiple decub buttocks hip and ble. Drsgs d &i.allevyn drsgs in place.\n\nA/P:Cont crrt, sliding scale ca+ k+. Cont titrate insulin gtt per prtocol. Wound and skin care. Pulm toilet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-20 00:00:00.000",
"description": "Report",
"row_id": 1524306,
"text": "Resp CAre\nPt remains on vent. Trached with #7 shiley. Suctioned mod amt of thick yellow secretions. mdis given. No changes made. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-20 00:00:00.000",
"description": "Report",
"row_id": 1524307,
"text": "Respiratory Therapy\n\nPt remains trached w/ #7.0 Shiley on full mechanical support. No vent changes made this shift. Continues on A/C w/ PIP = 22. Anterior BLBS coarse, suctioned for small amounts of thick yellow sputum. MDIs given as ordered. SpO2 90s. See resp flowsheet for specifics.\n\nPlan: maintain support\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-20 00:00:00.000",
"description": "Report",
"row_id": 1524308,
"text": "focus update note\nhypothermic 95-96, required bair hugger most of day, afib continues 70s-130, unable to wean neo gtt, at .5 mcq/kg/min, pt MAP 55-60 80-108\n\nCRRT continues, goal to keep pt even per renal, may take off 10-20 cc/hr if tolerated by pt. CVP 9-11, calcium and potassium gtt continue with labs q 6 hours.\n\nresp: no vent changes, thick yellow sputum suctioned q 2 hours, ls clear to coarse with bases dim.\n\nskin: and leg performed at 0900, wounds appear to be stable ? minimal healing in coccyx decubitus, bilateral toes are black. left upper medial thigh cellulitis found on morning assessment- ? if nec fasicitis- surgical consult performed- will moniotor closely.\n\nplease see flowsheet for details\n\nplan: continue with CRRT as tolerated- goal keep pt even, keep MAP> 55, > 80, labs q 6 hours, Fs q 1 hour, repleat lytes, wean neo gtt as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-21 00:00:00.000",
"description": "Report",
"row_id": 1524309,
"text": "NURSING 7P-7A\n VSS OVERNIGHT. ALTERNATING FROM NSR TO A-FIB. ALTERNATING BETWEEN HYPOTHERMIA AND NORMOTHERMIA. BAIR HUGGER ON AND OFF ACCORDING TO TEMPERATURE. CONTINES ON NEO GTT, ATTEMPTING TO WEAN NEO SLOWLY.\n CONTINUES, ATTEMPTING TO RUN EVEN AS ORDERED. FILTER CLOTTED AND REPLACED AT 2300. POSITIVE AT 2400 BY 450 ML DUE TO FILTER CLOTTING. SEE CARE VUE FOR FULL SPECIFICS.\n DRESSINGS REMAIN INTACT ON MULTIPLE DECUBITUS. REMAINS ON KINAIR BED FOR SKIN INTEGRITY.\n NO VENT CHANGES OVERNIGHT. SUCTIONED Q 2-3 HRS FOR GREEN TINGED SPUTUM IN MODERATE TO COPIUS AMOUNTS. LUNGS COARSE THROUGHOUT.\n INSULIN GTT CONTINUES, INFUSING CURRENTLY AT 7 UNITS/HR. BLOOD SUGARS IN THE 120-160 RANGE. TUBE FEEDS CONTINUE AT 65/HR.\n CONTINUE LABS Q 6/HRS PER PROTOCOL. BLOOD SUGARS Q 2/HRS WHILE GLUCOSE LEVELS STABLE. KEEP >80, MAP>50, WEAN NEO AS TOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-09 00:00:00.000",
"description": "Report",
"row_id": 1524385,
"text": "Nursing Note--A Shift\nPlease see Carevue for complete assessment and specifics:\n\nNEURO: PERRLA 3 and brisk. Alert. Does not follow commands. Nods head continuously at times, but not approprately to questions asked. Intermittently tracks people walking around her bed. (-) gag, weak cough. Minimal movement on bed with all 4 ext.\n\nRESP: LS coarse and diminished. Deep sxn for small to moderate amts of thick yellowish greenish secretions. Tol vent settings.\n\nCARDIAC: On bairhugger 1700 for temp 95.6. HR 95-120 afib. Maintaining MAP >55 able wean NEO gtt slowly. Diltiazem on hold until NEO gtt is off.\n\nGI: Abd large soft +BS. Brownish red tinged stool from ostomy, @200cc q 6hours. G tube to gravity draining scant amts of sanguinous fluid. Tol tf at goal thru J tube.\n\nCVVH: Kept euvolemic,-no issues.\n\nINTEG: Skin extremely compromised. Numerous skin issues-See Carevue Dressing changed consistently throughout shift-Skin oozing copious amts of foul smelling serous liquid. On airbed.\n\nPSYCH/SOCIAL: Husband and son visited in the am given updates and plan of care. Daughter called in the am given updates with meds, vs, and plan of care.\n\nPLAN: Wean NEO gtt off-then CVVH can be terminated, Amikacin level to be drawn at 6am tomorrow, Continue with diligent skin care, Maintain MAP >55. Provide extra comfort to patient.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-10 00:00:00.000",
"description": "Report",
"row_id": 1524386,
"text": "Respiratory Care\nPt. trached on chronic ventilatory support. Has positional leak. ABG's with good oxygenation, FiO2 decreased accordingly. No other vent setting changes made this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-10 00:00:00.000",
"description": "Report",
"row_id": 1524387,
"text": "condition update\nS/P SEPSIS, BLEED\nSEE CAREVUE FOR DETAIL INFO.\nUNEVENTFUL NIGHT CRRT FLOWING WELL UNTIL THIS AM. ABLE TO KEEP PT EVEN TO SLIGHTLY NEGATIVE BASED ON BP .\nNEO @ SAME DOSE (1MCG) KEEPING BP MEAN 55. DISCUSSED W/DR.\nPT VERY CALM AND APPARENTLY RESTING ATIVAN NOT NECESSARY AT THIS TIME.\nGENERAL ANASARCA WITH LOTS OF WEEPING AREAS.\nSPOKE W/ AND DISCUSSED PLAN FOR NIGHT\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-10 00:00:00.000",
"description": "Report",
"row_id": 1524388,
"text": "BS coarse crackles; no change with MDI's. Sx'd for mod amount thick yellow mucus. Received CVVH today and will continue until off pressors. PEEP decreased to 5 without incident. WIll continue to wean FiO2 as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-10 00:00:00.000",
"description": "Report",
"row_id": 1524389,
"text": "nursing note\nNeuro:Alert today, nodding side to side and up and down, but not in correct response to questions.\nCV:afib, dilt restarted per micu despite neo requirements. Neo weaned to keep >55, sys at times 70's with MAP still >55.\nResp: Ls coarse, thick yellow secretions. Peep dropped to 5 with acceptable ABG.\nGI:tol tube feeds at 40cc via JT, no residual. GT with minimal output, pink tinged. ostomy with golden brown sotol-no visible bleeding.\nGU: anuric. stopped per micu team.\nsocial: spoke iwth daughter who states her wishes to take her mother home to spend the remainder of her days. States that if while her mother is home- she startes to bleed again or has an acute event, she will not bring her back to hospital. States she wants her home on vent and antibitoics and dilaysis and treated as necessary at . Social work and team aware.\n\nplan:? HD in few days when neo off. wean neo to off to keep MAP >55. follow labs. plan to home if possible. dressing care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-26 00:00:00.000",
"description": "Report",
"row_id": 1524207,
"text": "Resp Care Note:\n\nPt cont trached and on mech vent as per Carevue. Lung spounds coarse; suct sm=>mod tan sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required . Air leak around trach cont to be positional though ventilation maintained. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-26 00:00:00.000",
"description": "Report",
"row_id": 1524208,
"text": "Neuro: Pt alert and nodding and making needs known.\nCV: tmax 101.2. HR 110-130's Afib, with no noted ectopy. pulses. HCT drop from 25-22 this am. Continues to have large amounts of bloody drg from ? R hip skin tear, ? Vagina, ? decub.\nRESP: lungs rhonchi through out. No vent changes overnight. O2 sats >97%. Occasional suctioning of thick blood tinged secretions.\nGI: tol tube feed at goal, Colostomy draining golden liquid stool.\nGU: ANeuric.\nENDO: blood sugars WNL.\n PLAN: ? trach changed, ? trans vaginal ultra sound.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-26 00:00:00.000",
"description": "Report",
"row_id": 1524209,
"text": "Respiratory Care\nPt continues to be trached/ventilated. BS: diminished bilaterally. Suctioned for moderate amounts of thick tan secretions. MDI's administered as ordered. Pt currently resting on A/C 450/16/5/.40--overbreathes rate at times. # 8.0 adjustable length /air clean and intact. Plan for Interventional Pumlonary to change to special order trach (7.0 X-tra Long Shiley). Will continue to closely monitor at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-26 00:00:00.000",
"description": "Report",
"row_id": 1524210,
"text": "Condition Update\nPlease see carevue for specifics.]\n\nNeuro unchanged. TMAX 101; Pan cx'd again except for urine since pt is anuric. Mean BP 30's-40's this afternoon. 250cc NS given x 1 per micu team w/ + effect. No vent changes made. Resp tx giving pt as ordered. Pt sxn'd several times for small amts of thick, tan secretions. + leak from trach. Tube feedings infusing at goal w/ no residuals. Shiley trach that family is requesting is on back order w/ no estimated ship date. Moderate amts of bleeding noted to be coming from pt's skin tears on her hips. All areas cleansed, aquacel placed, then dsd's.\n\nPlan: continue with current plan of care per micu team. continue to monitor hemodynamics. HD tues/th/sat. IV abx, wound care.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-27 00:00:00.000",
"description": "Report",
"row_id": 1524211,
"text": "Resp Care Note:\n\nPt cont trached and on mech vent as per Carevue. Lung sounds coarse suct mod th yellow sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required .. Cont mech vent support\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-27 00:00:00.000",
"description": "Report",
"row_id": 1524212,
"text": "nursing note\npt stable , BP transiently dips to 80 sys, no intervetnions. BP up with stimulation. Son in to visit, minimal interaction. Suctioned for thick tan secretions. BS 300, md aware to change official order off q1 hr.\n\nplan:cont family support. increase bs regimen.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-16 00:00:00.000",
"description": "Report",
"row_id": 1524289,
"text": "Respiratory Care Note:\n patient remains trached and on full vent support at this time. No changes have been made. For specifics please refer to carevue. BS are coarse to diminished at the bases. SX for small amounts of thick yellow secretions Q3-4 hours. No RSBI this am due to patient status and vent dependency. Patient remains afebrile. MDI's administered as ordered. SPO2 remains 100%. Patient overbreathes vent set rate by 6-10 breaths per minute. Will continue with full support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-05 00:00:00.000",
"description": "Report",
"row_id": 1524365,
"text": "Resp Care\nPt remains on vent. No changes made. Sucitoned mod amt of htick yellow secretions. Mdis given. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-05 00:00:00.000",
"description": "Report",
"row_id": 1524366,
"text": "Focused Nursing Note\nPlease see carevue flowsheet for further details\n\nNEURO: Pt awake state waxes and wanes, daughter at bedside and states pt is least responsive that she has witnessed. Does not follow commands as baseline. PERRL 4-5mm. ativan x 2 for incr RR and HR with therapeutic effect.\n\nHEMODYNAMCIS: NSR with occassional PACs vs Afib, controlled rate 80-90s on Diltiazem gtt titrated down to 5mg/hr. 85-102 on Neo 0.5-0.6mcg/kg/min, attempting to titrate. Anasarca, abdominal ascites, serous weepage from multiple skin tears/blistering. Hct stable at 26.1, plt 132, INR 1.6. No active bleeding noted. Jtube drainage 900ml dark maroon/bilious fluid.\n\nRESP: Trach patent, chronic airleak. Ventilator settings unchanged. ABG Ph 7.36/40/24/153 on CMV 0.50/450/20/8. Suctioned for small amts thick yellow drainage. Brown exudate from trach stoma.\n\nGI/METABOLIC: Colostomy stoma grossly edematous, opaque pink, no ischemia- appliance changed. Soft, formed black stool in small amts. Jtube suctioned output 900ml dark maroon/bilious output, Gtube to gravity drainage scant output of same character. Drainage around G/J tube site minimal this shift. No emesis. TPN infusing at 77ml/hr. Glucoses stable 125-137 on insulin gtt protocol.\n\nID: Tmax 99.6, surveillance BC pending. Amikacin level 14.7, dose held. Coccyx wounds with foul odor, rectal/vaginal drainage in small amounts varies from dark red to thin brown to mucosal.\n\nCOMFORT/SKIN INTEGRITY: Responsiveness waxes and wanes- medicated with Ativan in response to elevated RR/HR- therapeutic effect. Turned and repositioned q2hr, heels elevated off bed at all times. Aggressive skin care. dressing changes done to coccyx, right ischial and bilateral trochanter ulcers. Noted generalized erythema, boggy/macerated skin to posterior buttocks and extending as borders to trochanter wounds- scattered areas of small Stage II ulcers/skin tears secondary to edema, moist skin. Aloevesta to all unopened compromised areas- reccomend drressing changes TID to attempt to keep skin dry.\n\nPSYCHOSOCIAL: HCP/Daughter at bedside in evening- assisted RN with stoma appliance changes and was comforted to see no skin breakdown in these areas. Discussed at length with the physiology of SBO and clarified for her the difference between J/G ostomy tube vs very small J-feeding tube she had at home to explore belief that current GI complications are caused by \"too large of a J/G tube placed\". adds that her mother has a chronic hx of n/v and receives compazine/zofran regularly on HD days as prevention.\n\nPLAN OF CARE: Continue to monitor hemodynamics closely, attempt to wean pressor. Monitor GI status, antiemetics per MICU team plan. F/U Amikacin levels post-HD today. Aggressive skin care, dressing changes TID prn, pulmonary hygiene, keep pt comfortable per changes in VS and non-verbal cues. Emotional support and education to pt and family ongoing. Recommend family/multidisciplinary meeting Monday to discuss d/c home\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-05 00:00:00.000",
"description": "Report",
"row_id": 1524367,
"text": "Focused Nursing Note\n(Continued)\n.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-05 00:00:00.000",
"description": "Report",
"row_id": 1524368,
"text": "Respiratory Care\nPt remains trached and on vent support. No vent changes were made during shift. Lung sounds were course and diminished throughout. Pt was suctioned for copious amounts of thick yellow secretions. Pt received MDI's. Atrovent was not given, extra dose was requested and was given at 1600. No ABG were drawn during shift. Care plan is to continue current settings and a family meeting is planned for Monday. Will continue to follow pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-24 00:00:00.000",
"description": "Report",
"row_id": 1524442,
"text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. No morning abg results.\n\n deferred due to hemodynamic instability.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-24 00:00:00.000",
"description": "Report",
"row_id": 1524443,
"text": "Respiratory Care\nPt remains trached and on vent support. No vent changes were made during shift. Lung sounds were course with periods of rhonchi that cleared after suction. Pt received MDI's as ordered. No ABG's were drawn during shift. Pt was suctioned for scant amoutns of thick yellow secretions. Care plan is to continue current therapy and a discharge is planned for Monday. Case Manager requested to have me speak w/ Home Care about vent status. After speaking with H.C company, will place pt on home vent Sunday around midnight. Will continue to follow pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-24 00:00:00.000",
"description": "Report",
"row_id": 1524444,
"text": "NURSING NOTE\nPLEASE SEE CAREVUE FOE DETAILS\nNEURO: NO MENTAL STATUS CHANGES, EASILY AROUSABLE TO VOICE/MIN STIM, NODDING INTERMITTENTLY TO QUESTIONS. TRACKING VOICE W/EYES, PERRL, 4MM, BRISK. ATIVAN GIVEN FOR TACHYPNEA, DISCOMFORT DURING HD. PRE-MEDICATED W/DEMEROL FOR EXTENSIVE DSG CHANGES.\n\nCVS: HR 90S-100S, NSR/ST, 70S-130S, MAP MAINTAINED>60. T-MAX 99.2, HCT 24 MD AWARE, WILL F/U, ?TRANSFUSION. RIGHT CENTRAL LINE D/C'D BY MICU, TIP SENT FOR CULTURE. NO BLOOD FROM COLOSTOMY NOTED. HD FOR 2.6L.\n\nRESP: REMAINS ON CMV, NO VENT CHANGES MADE, NO VBG DONE. PT SUCTIONED FOR SM AMT THICK, TAN/YELLOW, O2 SATS 98-100%, TACHYPNEIC TO 30S THIS AM W/HD-ATIVAN GIVEN W/RELIEF.\n\nGI/GU: COLOSTOMY W/MIN AMT DK BRWN LOOSE STOOL, NO BLEEDING NOTED. SM AMT DRNG AROUND G/JT PINK, VISCOUS, JT PATENT TO FLUSH. GT W/MOD AMT YELLOW SEROUS FLUID DRNG TO GRAVITY. SM AMT CLEAR, MUCOID RECTAL DRNG NOTED.\n\nID: AMIKACIN GIVEN POST-HD, MEROPENEM\n\nENDO: BS COVERED VIA RISS, LANTUS GIVEN THIS AM\n\nINTEG: MULTI DSG DONE, REINFORCED/RE-PACKED PRN. PT SKIN WEEPING COPIOUS AMTS GEN SEROUS DRNG, GEN ANASARCA. PT TURNED FREQUENTLY FOR SKIN CARE, NO NEW AREAS OF BREAKDOWN NOTED.\n\nPLAN: SICU , PLAN D/C TO HOME MON. AGGRESSIVE SKIN CARE, PAIN MGMT, RESP SUPPORT. MONITOR FOR S/S BLEEDING, SERIAL HCTS, ?TRANSFUSION FOR PM HCT 24.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-25 00:00:00.000",
"description": "Report",
"row_id": 1524445,
"text": "Resp Care,\nPt. remains on A/C . No vent changes this shift. BS coarse, suctioned for thick yellow sputum. MDI's as ordered. See careve.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-25 00:00:00.000",
"description": "Report",
"row_id": 1524446,
"text": "FOCUSED NURSING NOTE\nPlease see carevue for further details\n\nNEURO: Pt's alertness waxes and wanes, this cycle unrelated to pain meds and sedative. PERRL, 3-4mm. Not making eye contact this shift, nods head \"yes\" to questions inconsistently- attempted to mouth words and became tearful when I asked her to repeat it so I could interpret, nodded head \"yes\" to pain at this time. Medicated with Ativan x 2 for sleep and incr RR, medicated with Demerol x3 as premedication for x2 and spotaneous cues of discomfort at rest.\n\nHEMODYNAMICS: s/p 2UPRBCs for Hct 24, post-transfusion HCT 31.0. Plt low at 40K, no sx acute bleeding. ranges 62-130s, HR NSR 90-102.\nAnasarca persists, purple discoloration and evidence of mottling to buttocks, posterior iliac crest skin breakdown area and BLE.\n\nRESP: Trach patent, yellow exudate. SPO2 98-100% on CMV 0.50. Suctioned frequently for thick/yellow sputum. Lungs are coarse bilaterally.\n\nID: Afebrile. Meropenem as ordered. Levaquin per Jtube.\n\nGI/METABOLIC: NPO maintained. Colostomy with total 100ml black/dark brown liquid drainage. Glucoses stable off nutrition (100/82)\n\nSKIN INTEGRITY: Pressure ulcers as previously documented that pt entered hospital with are uncahnged, no foul odor noted. Pts posterior waist area, buttocks, and posterior thighs are covered with moist erythema and multiple skin blisters, tears weeping serous fluid. Areas are purplish in color and extremely fragile to touch- Dressing changes to all sites completed x3, pt turned and repositioned q2hr with full linen change and application of aloevesta to attempt a clean/dry surface for skin, though no improvement is evident.\n\nPLAN OF CARE: Monitor hemodynamics, sx bleeding. Resp support, . Assess comfort frequently, sedative and pain med prn. Aggressive skin care. Emotional support to pt and family ongoing. D/C home plan discussion per MICU Attending and HCP .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-28 00:00:00.000",
"description": "Report",
"row_id": 1524337,
"text": "Respiratory Care\nBreath sounds bilaterally diminished, bilateral crackles, suctioned for moderate thick yellowish secretions, patient was afebrile, stayed into chronic A-Fib, patient is on Neosynephrin, Hemoglobin on 9.1 consistent with anemia, patient was treated with Albuterol, Atrovent and Flovent during the shift, Oxygen saturation ranged 97 to 100, no ABGs nor vent changes done up to this point. Patient will continue to be on ventilatory support and close monitoring.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-28 00:00:00.000",
"description": "Report",
"row_id": 1524338,
"text": "condition update\nD: pt opens eyes spontaneously. moves left arm spontaneously. she does not follow commands.\ncardiac: pt remains in afib with rate of 90-102. map greater than 55 on .7 of neo. unable to titrate any lower due to drop in bp to map less than 55.\nresp: pt suctioned for thick yellow sputum. breath sounds are clear and diminished in the bases. 02 sat 95-97%.\ngi: tube feeds remain off and g tube to suction. continues to drain large amts of bilious drainage. abd remains distended. stoma is pink and small amt of brown stool present. small amt of bleeding from the rectum and dr. is aware. hct remains stable a 26.\nskin: pt with genralized edema in all extremities. pressure wound dressing are dry and intact.\na: continue to monitor labs. wean neo as tolerated. ? dialysis today. monitor abd and gastric drainage.\nr: no change in status. still with large amts of gastric drainage. neo remains at .7.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-18 00:00:00.000",
"description": "Report",
"row_id": 1524418,
"text": "NPN 1900-0700\nPlease see carevue for specifics.\nROS:\nNeuro: Arousable to voice, moving LUE only on bed. Pupils equal and reactive. Follows some simple commands inconsistently. Able to nod/shake head when asked if having pain. Medicated with 25mg demerol x1 with effect.\nCV: HR 70-80'SR, BP 69-100/50-70's. Diltiazem held, HO aware. Skin cool, conts. large amts. weeping/drainage, +jaundice. Pedal pulses weakly present by doppler.\nHeme: hct 25.3 (27.6), Dr. aware. Repeat PTT 35 (150).\nAccess: LSC dialysis cath. with old, dry, bloody drainage, no new drainage. R ac PICC + blood return, wnl. RIJ TLCL wnl, unable to draw back blood, HO aware, sm. amt. old dry bloody drainage under dsg.\nResp: LS coarse->clear, diminished at bases. Suctioned for sm.->moderate amts. thick, yellow sputum. No vent changes made .\nGI: abd obese, BS hypoactive, no stool. Stoma , pink. Colostomy appliance intact with sm. amts. liquid green stool. TF started via J tube port with G port to gravity, sm. amt. green drainage. Protonix for GI prophylaxis.\nGU: dialysis yesterday, anuric.\nEndo: BS wnl, no coverage per ss.\nID: afebrile temp. 96 Conts. meropenem/levofloxacin/amikacin.\nSkin: multiple ongoing skin issues, please see flow sheet. Updated recs. from skin care nurse . Conts. to require frequent changing/reinforcement.\nPsych/social: pt's son in last eve; affect/questions appropriate. Stating he would like to see his mother brought home and made \"comfortable\". Emotional support provided. No other contact .\nA/P: Monitor VS, I/O, labs. . ongoing aggressive skin care, pulmonary hygiene. . ongoing open communication, comfort and support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-16 00:00:00.000",
"description": "Report",
"row_id": 1524290,
"text": "Update\nO: See carevue flowsheet for specifics.\nNeuro: somnolent, arousable to voice. Ativan held overnight. Perl at 4mm brisk. Spont purposeflu mvmnt of lt arm.\n\nCv: st w occ pvc occ burst afib/freq pac. Labile 78-100 syst. improved w stim and repositioning.Distal pulses by doppler.Skin and moist w multiple skin brkdwn issues.\n\nResp: remains trached on cmv mode.Lavage and suct q2-3h for thick pale yellow secretions.Bbs coarse bilat upper lobes, diminished lower lobes bilat.Occ dip in sats to low 90's responsive to lavage and suctioning.\n\nGi: gj tube w tf at goal 40cc/hr. Colostomy w loose golden to bilious grn stool. Bl glucoses managed w insulin gtt.\n\nGu/Renal: crrt dc'd per micu team for frank seropurulent drng around quinton cath line. Drsg under technique and line dc to be done by team in a.m.(*quinton placed in IR previously). Bl cultures sent via line and ports flushed per protocol.\n\nHeme/Id: hct 23.7 this am. No active signs of bldg. Tmax 99.7. Cont on meropenem, tobra, daptomycin, levoflox. Mult decubs , hips and coccyx as well as bilat leg wounds. Coccyx and decubs changed w wound cleanser to sites and aquacell drsg applied.\n\nA/P: Quinton line w purulent drng, crrt on hold per team. ? IR for new line placemnt today. Line tip cult on removal of line.? restart neo for if consistently < 80. Cont tf as ordered, titrate insulin gtt to goal bl sugar.Pulm toilet.Updates to hcp by micu attending last pm. Cont to provide emot support to family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-01 00:00:00.000",
"description": "Report",
"row_id": 1524352,
"text": "FOCUSED NURSING NOTE\nPlease see carevue flowsheet for further details\n\nNEURO: Pt awake most of shift, does not follow commands, no spontaneous movements noted- inconsistently tracks with eyes. PERRL, 4-5mm.\n\nRESP: s/p Bronch. No vent changes this shift. trach care done. labored breathing improved slightly after HD. SPO2 99-100%, RR 17-24. ABGs acceptable this am, MICU team aware of results and labored breathing.\n\nHEMODYNAMICS: S/P HD fluid removal 1.5L, tolerated with support of Albumin and neo gtt at 0.5mcg/kg/min. Tachycardic 120s/130 during HD. Diltiazem gtt initiated after HD complete, good rate control 90-110 on 5.0mg/hr. BP parameters of MAP>50, >80 maintained on neo gtt. Pressor weaned off in am, though resumed for HD tolerance. Anasarca increasing, moderate serous fluid losses from several skin openings.\nVaginal bleed in small amounts, intermittent in nature. Guiac positive stool via colostomy, small blood clots noted.\n\nGI/METABOLIC: Current SBO, abdomen obese and ?ascites- G/J tube clamped, no Gtube residuals. Colostomy with maroon loose stool, severe ammonia-like odor. TPN infusing as ordered. Insulin gtt titrated protocol, BG 98-132.\n\nPSYCHOSOCIAL/COMOFORT: Pt visited by husband in am, inquires about HD and urges fluid to be removed. called x 2 today for updates. Son visiting this evening. Pts HR increased during HD and appeared distressed by facial cues, medicated with Ativan. Again appeared uncomfortable after HD complete with incr R and HR, medicated with Demerol IVP with good response in VS and mild sedation. Aggressive skin care, turn and reposition q2hr, oral care frequent.\n\nPLAN: Continue to monitor hemodynamic stability, titrate pressor and cardizem for goal > 80 and HR< 110. Monitor for sx resolution of SBO. Keep pt comfortable, Ativan/Demerol prn. Monitor metabolic status, insulin gtt titrated protocol. Pulmonary hygiene/skin care/ emotional support and education to pts family ongoing.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-02 00:00:00.000",
"description": "Report",
"row_id": 1524353,
"text": "Respiratory Care\nPt. trached and vented for chronic respiratory failure. Uneventful shift, no setting changes. Suction for small amount thick yellow secretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-02 00:00:00.000",
"description": "Report",
"row_id": 1524354,
"text": "Please See Carevue for Specifics.\n\nNo change over night. Pt was kept comfortable and repositioned. Family was in at start of shift. Neo remains at 0.5mcg/kg/min, insulin gtt off and Lantus started. G-tube residual minimal 0-3cc.\n\n: HD, family meeting, skin care, hemodynamic monitoring, amikacin as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-02 00:00:00.000",
"description": "Report",
"row_id": 1524355,
"text": "pt remains on full vent support with minimal secretions sx'd. pressure was effective at 23. ABGs normalized during shift with minor changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-02 00:00:00.000",
"description": "Report",
"row_id": 1524356,
"text": "Focused Nursing Note\nPlease see carevue flowsheet for further details\n\nNEURO: Pt somnolent, no acute changes in neuro assessment. PERRL, 4-5mm. Ativan IV x 2 for incr WOB and facial cues of distress, mild sedation therapeutic.\n\nRESP: Trach patent, ventilatory support titrated for hypercarbia mild hypoxia. current vent settings CMV 0.40/450/R 20/ PEEP 8\nLatest ABG in normal range. Frequent suctioning for thick yellow secretions earlier in shift, now decreasing. Incr WOB continues.\n\nHEMODYNAMICS: Current fluid balance +900ml, grossly anasarcous. Off pressor support, 80-90, MAP 52-60. HR 90-113 on Diltiazem gtt 5mg/hr. Melena stool/clots from colostomy approx 250ml total, vaginal bleeding minor today. No further signs of bleeding.\n\nGI/METABOLIC: G/J tube remain clamped for SBO, abdomen obese, severe anasarca. Gtube residuals 0-5ml. TPN infusing as ordered. Insulin gtt titrated protocol, glucoses stabilizing to low 100s.\n\nSKIN INTEGRITY/COMFORT: Multiple areas of pressure ulcers, venous stasis ulcers and edema/pressure related breakdown in skin folds present as previously documented. All wound care completed and pt turned and repsositioned q2hr ATC, heels elevated off bed at all times. Ativan given for mild sedation in light of incr WOB and facial cues of distress.\n\nSOCIAL: Pts husband at bedside this am briefly. No further family contact by this RN. Multidisciplinary meeting held today re: current and future goals of care for pt. Present at meeting are Dr , SW, Ethics representative, case management, Nurse , Resource RN , and myself. Considered HCP statement to have her mother die at home versus hopsital environment. Obstacles to d/c home include SBO and GIB. Dr to discuss with HCP family goals of home care of full supportive management vs curtailing therapies and managing end-of-life at home. In addition, SBO and GIB to be monitored over next few days to determine resolution vs worsening, plan on Monday for d/c home potential tuesday.\nDr to contact per above discussion.\n\nPLAN: Monitor hemodynamic status, GIB, SBO, resp status. Anticiapte KUB tomorrow. Titrate Cardizem and for goal HR<110. Keep pt comfortable, aggressive skin care, turn and reposition q2hr, heels elevated. titrate insulin gtt protocol. Pulmonary hygiene. as ordered, f/u Amikacin level. Emotional support to pt and family ongoing. Further plan of care per MICU team.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-03 00:00:00.000",
"description": "Report",
"row_id": 1524357,
"text": "Respiratory Care Note:\n\nPt remain on full ventilatory support via tracheotomy tube. No vent changes done. ABG drawn last evening, acceptable. We are sxtn routinely for mod amt of thick yel secretions from trach, none orally. IC changed early this morning. Plan: Continue present ICU monitoring & keep comfortable.. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-03 00:00:00.000",
"description": "Report",
"row_id": 1524358,
"text": "NURSING PROGRESS NOTE:\nNeuro: Pt very withdrawn, not responding to verbal or tactile stimuli. Pupils 4mm brisk. + gag +cough reflex.\nCV: afebrile, HR 80's Afib with no noted ectopy. 80-90's MAP>50. Cont on dilt gtt for rate control. pulses.\nRESP: No vent changes. Occasional suctioning of of thick yellow secretions.\nGI: NPO, Colostomy cont to drain dark red stool.+ guaiac.\nGU: Aneuric.\nENDO: Cont on insulin gtt.\nPLAN: Cont to monitor neuro status. Monitor blood sugars.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-25 00:00:00.000",
"description": "Report",
"row_id": 1524447,
"text": "Respiratory Care\nPt remains trached and on vent support. No vent changes were made during shift. No ABG's were drawn during shift. Lung sounds were course and diminished in the bases with a period of faint exp wheezes that cleared after MDI. Pt received MDI's. Pt was suctioned for scant to small amounts of thick yellow secretions. Care plan is to continue therapy on our vent until Sunday night and then place pt on home care vent. Will continue to follow pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-07-31 00:00:00.000",
"description": "Report",
"row_id": 1524099,
"text": "Focus Condition Update\nSee careview flowsheet for specific info.\n\nNeuro: Pt mildly responsive. Opens eyes spontaneously, follows commands rather inconsistently, no communication noted from pt. Not moving extremities, except for LUE.\nCV: A-fib with occassional PVC. Hypotensive, SBP 85-110, HR 95-120. 12.5 lopressor given with effect. Afebrile. Crit stable, white count decreasing, K+ 3.8.\nResp: No vent changes overnight, sating 100% on CMV, PEEP 5, 40% O2. LCTA bilaterally, sux'd for small amount of thick white sputum.\nGI: Colostomy patent, draining small amount of loose brown stool. Abdomen soft, BS+.\nEndo: Insulin gtt off for low BG, will recheck in 1 hour. Titrating insulin for BG of 100-120, using protocol.\nInteg: Multiple ulcerations on body. Wet to dry dressings changed over right ischial spine, and left heel per wound care nurse.\nSocial: Dtr and son in to visit. Dtr found suctioning pt. Politely asked her not to do this in the future, but to ask RN or RRT if her mom needs this in the future. Dtr states she understands.\nPlan: To MRI tomorrow.\n Continue with wound care, and skin care mgt.\n Titrate Insulin to keep BG 100-120.\n Continue with current POC.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-07-31 00:00:00.000",
"description": "Report",
"row_id": 1524100,
"text": "Respiratory Care: Pt remains trach and vented on AC settings. No vent changes made this shift. Pt's breath sounds coarse/diminished. Suctioned for small thick yellow/brown secretions. MDIs given as ordered.will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-18 00:00:00.000",
"description": "Report",
"row_id": 1524419,
"text": "RESP CARE: Pt remains trached/on vent on AC SEE CAREVUE. No changes in settings. Lungs coarse/sxd thick yellow/MDIs given as ordered. Trach care done/inner cannula changed, pressure 25cmH20. No RSBI due to hemodynamic instability. Pt is vent dependent at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-18 00:00:00.000",
"description": "Report",
"row_id": 1524420,
"text": "FOCUSED NURSING NOTE\nPlease see carevue flowsheet for further details\n\nNEURO: Alert to lethargic, able to arouse to voice. Spontaneous movement weakly LUE only- only command she follows is to open her mouth, will not blink or nod head on command. Nodding head mainly \"yes\" inconsistently to questions- spontaneously nod head \"yes\" at times as well without questioning. Tracking with eyes. Ativan x 1, Demerol premedication before dressing change with fair effect.\n\nRESP: s/p CXR, results pending. Trach patent, vent settings unchanged. SPO2 99-100%. Frequent suctioning for thick/yellow secretions, no spontaneous cough. Positional air leak continues. Amikacin and Meropenem for gram negative rods sputum.\n\nHEMODYNAMICS: s/p 1UPRBCs this am, post Hct 29.8. No sx active bleeding today. Multiple areas of skin tears and ulcers bleed, frequent . HR 80-90s, NSR, rare PVCs. Erractic swings in BP today, range 71-163/30-114- variable minute to minute this afternoon, no change in neuro status. General anasarca and severe weeping of all dependent skin areas.\n\nID: Maintains temp 96-97 without bair hugger today. Meropenem administered as ordered. Amikacin orders clarified to be given on hemodialysis days only, level to be checked as trough with next dose.\n\nGI/METABOLIC: NPO. TF advanced to 40ml/hr, tolerating well thus far. Colostomy output green/brown liquid stool, no sx GIB today. Receiving Lantus 5U qAM, glucoses 168/164 covered with RISS.\n\nSKIN INTEGRITY: Severely impaired epidermis to buttocks, thighs, skin folds, BLE and feet as previously documented. No acute changes in wounds- all dressing chages done twice today secondary to moderate drainage and weeping of surrounding skin. Aggressive skin care ongoing, heels elevated off bed at all times.\n\nPSYCHOSOCIAL: Family members visit in groups due to discord between HCP and the rest of her siblings- Sons and both claim that pt has expressed to family in past that she did not want to live in her critical condition, she has asked family to keep her home and stop hemodialysis. Sons communicate to me that as HCP is the only child insisting on aggressive care and will not consider a family decision collectively. Sons remain hopeful that pt may be discharged to home this week, however ths unfortunate situation has created much strife between the siblings and communication has broken down.\n\nPLAN OF CARE: Continue to monitor for sx bleeding, f/u HCt tonight. F/U CXR results. Monitor GI status, maintain TF at goal. Monitor glucoses, discuss with MICU increasing glycemic control. Aggressive skin care, comfort care, emotional suuport to pt and family. Discuss with MICU team d/c plan for Monday.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-19 00:00:00.000",
"description": "Report",
"row_id": 1524421,
"text": "RESP CARE: Pt remains trached/on vent. pressure 25cmH20.No changes in vent settings this shift.SEE CAREVUE FOR SPECIFICS. Lungs coarse bilat. MDIs given as ordered. Sxd small amts thick yellow sputum. Trach care done. Inner cannula changed/trach tie changed. No RSBI this am due to hemodynamic instability, Pt remains vent dependent at this time. Plan is to place pt on home vent 48hrs prior to discharge home.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-03 00:00:00.000",
"description": "Report",
"row_id": 1524359,
"text": "Resp Care\nPt remains trached on A/C. Suctioned for mod amt of thick tan sputum. MDI's given, no other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-03 00:00:00.000",
"description": "Report",
"row_id": 1524360,
"text": "Update\nSee Carevue for specifics\n\nNeuro: unable to assess pt's mental status though appears alert, opens eyes spontaneously and was observed to respond to family member by tracking, ?opening mouth to command. Does not move any extremities. PERRL. Afebrile.\nCV: controlled afib. Diltiazem gtt. rate in 90s-110s. BP > MAP 55 most of shift. Dropped to 50 late in day and neo gtt started with positive effect. HD, 2.4L off, prbc x 1 given.\nResp: LS coarse/diminished. Sat 94-98% on AC. No vent changes. Sxn'd for thick yellow sputum.\nGI: TPN. Gastrograf study performed at bedside. Contrast given through G tube and J tube. Post procedure pt put out 2L maroon/bilious liquid through G tube. Team notified and hct drawn. G tube continues to ooze sanginous liquid.\nGU: anuric\nSkin: Grossly impaired with numerous site of breakdown. See Carevue and chart for details.\nSocial: family in to visit and talked with MD.\n\nPlan: Monitor Gtube output closely and assess for bleeding. Monitor respiratory status and sxn as needed. Keep family UTD on .\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-04 00:00:00.000",
"description": "Report",
"row_id": 1524361,
"text": "Respiratory Care Note:\n\nPt remain on ventilatory support via trach tube. We increased FIO2 from 40 to 50%. We are sxtn for small amt of thick yel secretions from trach. IC changed early this morning. Plan: Continue present ICu monitoring, follow VS, WOB & Sats. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-04 00:00:00.000",
"description": "Report",
"row_id": 1524362,
"text": "FOCUSED NURSING ASSESSMENT\nPlease see carevue flowsheet for further details\n\nNEURO: No acute changes- moves LUE only- does not follow commands- questionable tracking with eyes- PERRL 4-5mm. Ativan x 2 IV for tachypnea and tachycardia with minimal effect- demerol therapeutic for incr RR/HR.\n\nHEMODYNAMICS: tachycardic 115-120 just prior to emesis and increased G-tube site leakage, now NSR 90s after transfusion and dilt gtt incr to 7.5mg/hr. 84-90s on Neo gtt 0.4mcg/kg/min- falls to 75 without Neo. Noted bloody emesis x 1 and continued dark red/bilious drainage from Gtube exit site (500ml/shift). MD notified. Hct 22.9, plt 89. Transfused pt with 1UPRBC and 1U Md orders- Post-transfusion HCT 26.1, am 25.4. Desmopressin given as well. Gross anasarca.\n\nRESP: Trach patent, ventilated A/C 450/0.50/20/PEEP 8. tachypneic (28-32) during blood transfusion with airway pressure 33, suctioned for minimal tan secretions. tachypnea improved with Ativan/Demerol sedation, RR now 24, pressure 25. Lungs clear R lobe, greatly diminished L lobe.\n\nGI: Emesis dark red mixed with bright red fluid approx 100ml. Dark red/bilious outputs continue from around G/J tube site collected in gravity drainage bag. G-port irrigated with 60ml NS, aspirated 15ml return. J-port irrigated with 60ml NS and aspirated equal return plus 30ml additional, also dark red/bilious outputs. Gtube connected to LCWS with small outputs (200ml over 8 hrs) Larger output is around Gtube exit site. MICU intern and GI Surgery aware of events. Colostomy very small output maroon liquid mixed with soft maroon stool- no new outputs during shift.\n\nID: Tmax 99.9. BC sent with am labs as ordered. Vancomycin as ordered.\n\nMETABOLIC: TPN infusing at 77ml/hr. Blood glucoses stable <150 on insulin gtt protocol.\n\nCOMFORT: Pt turned and repositioned q2hr, heels elevated off bed at all times. Demerol x 2 for tachypnea and premedication for dressing changes with good effect.\n\nPLAN: Continue to monitor GI outputs and follow hemodynamics closely. Pulmonary hygiene, pain control, aggressive skin care. Monitor temperature, new sx infection. Further plan of care per MICU team, ?GI studies today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-22 00:00:00.000",
"description": "Report",
"row_id": 1524435,
"text": "Nursing Note 7a-7p:\nNursing Assessment:\n\nAfebrile this shift. Shakes head yes and no. Often shakes head no during care (dressing changes, repositioning, suctioning). Unable to determine appropriateness of yes and no nods to situations.\nCV: NSR to ST 90s-110; 70s-120s. HD today 2.7 off. This afternoon Bright red blood from ostomy stoma. HCT 23.6 (following 1.5 liters out) previously 30.1 on am labs. 2 units prbc's given with resulting Hct 28.3 and bleeding stopped. (total over 3 liters of blood mixed with golytely and stool out). HCT and platelets to be rechecked tonight (last plt count 50s and MD , aware).\nTube feeds on hold d/t NPO for scope and golytely given as prep. Scope now on hold possibly until tommorrow unless bleeding restarts.\nPositive blood cultures gram +cocci in pairs and chains from yesterday and MD , notified. Amikacin level back from before dialysis 11, dose given post-dialysis and level will be rechecked in the am.\nA meeting took place this afternoon regarding hospital policies in relation to the family's wishes. Ethics, social work, casemanagment, resource RN, and Micu attending all present; working towards discharge planning and keeping the patient's best interests in mind. Please refer to carevue for all further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-22 00:00:00.000",
"description": "Report",
"row_id": 1524436,
"text": "Resp. Care Note\nPt remains trached with #7 extra long shiley and vented on AC settings as charted on resp. flowsheet. No vent changes were made this shift. BS slight decreased and coarse. Receiving Albuterol/ Atrovent and Flovent MDI's, see flowsheet for Rx times. Sxn for yellow sputum. current vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-07-30 00:00:00.000",
"description": "Report",
"row_id": 1524094,
"text": "Focus Condition Update\nSee flowsheet for specific information.\n\nNeuro: Pt opens eyes and tracks osccassionally, but not following any commands. Movement of extremities noted in all but RUE. No pain noted except when dressing changes done. PO ativan given with good effect.\nCV: Pt afebrile, hypotensive at times, particularly during HD. Remains in A-fib with occassional PVC's. SBP stable 95-115, HR tachy 95-110. K+ and Magnesium repleted, Vit K given for INR of 6.1.\nResp: CMV, PEEP 5, 40% O2. Lungs mildly coarse bilaterally, dim in bases. Sux'd for small to mod amount of thick white sputum.\nGI: TF's started, full strength at 40cc/hr, with no residuals. Abdomen obese, BS hypoactive. G tube site is leaky, but bag is in place to catch drainage. Colostomy patent, draining moderate amount of green liquid stool.\nGU: No UO noted.\nSkin: Multiple necrotic skin ulcers, most notably, a decub on coccyx that is 7cm x 7cm and to the bone. Dressings changed on coccyx, and right hip, wet to dry. Skin care RN to see pt in a.m. See flowsheet for specifics on other wound sites.\nPlan: Monitor and replete lytes\n Continue with dressing changes as needed\n Monitor for changes in neuro status\n Continue to monitor hemodynamic status\n MICU Intern aware of above, contact HO with\n changes\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-07-30 00:00:00.000",
"description": "Report",
"row_id": 1524095,
"text": "Respiratory Care\nPt. remains trached and ventilated. PT chronically vented at home on A/C settings. This a.m. pt did well with RSBI trial = 46, and appears to tol PS/CPAP well, pt. may be able to tol wean of vent settings to PSV when medical status more stable. Suctioned for thick yellow/tan secretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-07-30 00:00:00.000",
"description": "Report",
"row_id": 1524096,
"text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT, OCCASIONALLY FOLLOWING COMMANDS. MOVING ALL EXT. EXCEPT FOR RIGHT ARM. PERRL. C/O PAIN WITH DRESSING CHANGE, RESIDENT WILL ORDER PAIN MED FOR DRESSING CHANGES. ATIVAN AROUND THE CLOCK APPEARS TO BE HELPFUL FOR PERCEIVED ANXIETY.\nCV- BP STABLE TODAY, 90'S-LOW 100'S. HR A-FIB, TACHY TO 140'S THIS AM, LOPRESSOR 12.5MG RESTARTED THIS AM WITH GOOD EFFECT. 6 BEAT RUN OF V-TACH THIS AFTERNOON, LYTES AND HCT SENT AND WNL, EKG DONE, RESIDENT NOTIFIED.\nRESP- LUNGS COARSE AT TIMES, SUCTIONED A FEW TIMES FOR SMALL AMOUNTS OF THICK YELLOW SPUTUM. O2 100%, NO VENT CHANGES, REMAINS ON AC.\nGI/GU- ABD SOFT, HYPO BS. COLOSTOMY APPLIANCE CHANGED, STOMA BEEFY RED AND APPEARS HEALTHY. CONTINUES TO HAVE LARGE AMOUNT OF LOOSE BROWNISH STOOL. PT DOES NOT VOID, NO DIALYSIS AT THIS TIME FOR TODAY.\nID- TMAX 100.8\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-07-30 00:00:00.000",
"description": "Report",
"row_id": 1524097,
"text": "Respiratory Care: Pt remains trach and vented on AC settings. Pt's breath sounds coarse at times that clear with suctioning. Sx for small thick yellow secretions. MDIs given as ordered. Respiratory dicussed with team concern about high cuff pressures, they will evaluate to see if pt needs a larger trach or a new one.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-07-31 00:00:00.000",
"description": "Report",
"row_id": 1524098,
"text": "Respiratory Care\nPt. trached on ventilatory support. No vent changes made this shift. Good RSBI = 63. Sx for small amounts thick yellow secretions. Vent dependent not plams to wean from vent at this time,\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-07-31 00:00:00.000",
"description": "Report",
"row_id": 1524101,
"text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT, OCCASIONALLY FOLLOWING COMMANDS. MOVING ALL EXT. ONLY SLIGHTLY ON THE BED, WITH THE EXCEPTION OF THE RIGHT ARM. PERRL. PT COMFORTABLE MOST OF THE SHIFT, OCCASIONAL DISCOMFORT WITH DRESSING CHANGES, RELIEVED WITH REPOSITIONING.\nCV- BP IN 90-110'S RANGE, NO FLUID BOLUSES NEEDED. DIALYSED THIS AM, UNABLE TO REMOVE MORE THAN 300CC DUE TO HYPOTENSION. A FEW DOSES OF ALBUMIN GIVEN DURING DIALYSIS FOR HYPOTENSION WITH FAIR EFFECT. HR AT TIMES TO 140'S, TEAM NOTIFIED DURING DIALYSIS WHEN PT WAS AND HAVING INCREASED ECTOPY. NO INTERVENTION PER TEAM, SCHEDULED DOSE OF LOPRESSOR EFFECTIVE AND CALCIUM REPLETED REDUCING AMOUNT OF ECTOPY. HEPARIN GTT STARTED THIS AM FOLLOWING . FIRST PTT 150+ DRAWN 5 HOURS AFTER START OF GTT. TEAM NOTIFIED. ORIGINALLY ORDERED TO STOP HEPARIN FOR ONE HOUR THEN RESTART AT HALF THE DOSE, HOWEVER REPEAT PTT REMAINING THE SAME AFTER AN HOUR WITH OBVIOUS SIGNS OF BLEEDING. HEPARIN TO REMAIN OFF AT THIS TIME PER DR. UNTIL FURTHER NOTICE. HCT PENDING.\nRESP- LUNGS CLEAR, SUCTIONED FOR SMALL AMOUNTS OF THICK YELLOW SPUTUM. O2 SAT 100%, NO VENT CHANGES.\nGI/GU- ABD SOFT, HYPO SOUNDS. BRB IN COLOSTOMY THIS AFTERNOON, DR. NOTIFIED AND HCT SENT. FLEETS PHOSPHO SODA HELD TODAY DUE TO LARGE AMOUNTS OF LOOSE STOOL. NO VOID, DIALYSIS DEPENDANT\nID- AFEBRILE. MEROPENUM GIVEN X 1 DOSE AFTER DIALYSIS\nSKIN- VASCULAR IN TO RIGHT TOES AND LOWER EXT. DECUBS. RIGHT GREAT TOES DEBRIDED AND AND POCKET OF INFECTION RELEASED DRAINING PURULENT DRAINAGE. WET TO DRY .\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-19 00:00:00.000",
"description": "Report",
"row_id": 1524181,
"text": "NEURO; OPENS EYES SPONT, DOES NOT FOLLOW COMMANDS, STARES AT SPEAKER BUT ? PT TRACKING SPEAKER, DOES NOT MOVE SPONTANEOUSLY\n\nCARDIOVASCULAR; HR 120'S-140'S A FIB, TEMP UP TO 103, PT MEDIC X 3 WITH TYLENOL, MICU TEAM INFORMED, BLOOD CULTURES PERIPHERALLY AND ONE SET FROM DIALYSIS LINE OBTAINED, COOLING BLANKET ON, TEMP PRESENTLY 102.2, SEVERAL PERIODS OF HYPOTENSION TODAY WHCH REQUIRED FLUID BOLUSES, PT RESPONDED TO FLUID BOLUSES BUT STILL FLUCTUATES, MICU TEAM OKAY WITH MAP OF 50 OR >,\n\nRESPIR; SUCTIONED FREQUENTLY FOR THICK YELLOW SECRETIONS, SPUTUM CULTURE SHOWS PSEUDOMONAS, STARTED ON ZOSYN, COARSE BREATH SOUNDS, REMAINS ON SAME VENT SETTINGS,\n\nENDONCRINE; BS 200'S, COVERED VIA SLIDING SCALE, PLAN WAS TO START INSULIN GTT BUT PT BS NOW 130'S, WILL GO BACK TO INSULIN COVERAGE VIA SLIDING SCALE AND GTT IS DC'D (TUBE FEEDING OFF FOR 2 HRS FOR ? REPLACEMENT OF J TUBE, BUT PLAN DEFERRED DUE TO PT BEING UNSTABLE\n\nWOUND; LARGE OPEN AREAS ON SACRUM, MUCOPURULENT MATERIAL INSIDE LARGER WOUND, MICU MD IN TO EVALUATE, REPACKED WITH AQUACELL ROPE, DSGS TO LEGS-NECROTIC AREA LEFT HEEL ADAPTIC AND DSD,\n\nRENAL; DIALYSIS ATTEMPTED BUT NO FLUID TAKEN OFF DUE TO HYPOTENSION, DIALYSIS STOPPED AFER APPROX 30 MINUTES, MICU TEAM AWARE\n\nPLAN; MAINTAIN MAP > 50 OR >, WOUND CARE, COOLING BLANKET UNTIL TEMP STABLIZES, CHECK BS Q 4 HRS, FAMILY UPDATED SEVERAL X WITH TEAM TODAY\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-20 00:00:00.000",
"description": "Report",
"row_id": 1524182,
"text": "Respiratory Care\nPt continues full vent support and appears comfortable. #8 adjustable trach remains locked at 10 cm. BS coarse and diminished bilaterally. Suctioning for moderate amounts of thick yellow sputum. Fever seems to have resolved with current temp 98.8F. MDIs given as ordered. See Careview for a.m. RSBI and specifics.\nPlan: Maintain support, suction prn\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-23 00:00:00.000",
"description": "Report",
"row_id": 1524437,
"text": "Update\nSee Carevue for specifics\n\nNeuro: Alert but unable to assess level of orientation. Nods appropriately to questions. Attempts to mouth words. Does not move any extremeties. PERRL. Was awake all night.\nCV: ST or ?SA most of shift 90s to 140s. MD aware. No tx at this time. 70s-110s. Pressors remain off. Last 3 hcts 28. Coratid US ordered.\nResp: LS coarse. Sats 98-100%. No vent changes. Sxn'd for tenacious tan sputum.\nID: Afebrile. Gram+ rods in blood. Vancomycin dose x 1 given.\nGI: TF off pending possible scope today. GI bleed study also scheduled for day shift a.m. Colostomy draining clear, golden liquid.\nSkin: Grossly impaired. See flowchart for details.\nPsychosocial: Son at in evening. Daughter called and was updated on by this RN.\n\nPlan: Monitor for further hemorrhaging. Keep family UTD on .\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-23 00:00:00.000",
"description": "Report",
"row_id": 1524438,
"text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. No morning abg results at this time and no measured due to hemodynamic instability. SX'd for small to moderate amounts of thick, tan sputum.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-23 00:00:00.000",
"description": "Report",
"row_id": 1524439,
"text": "FOCUSED NURSING NOTE\nPlease see carevue flowsheet for further details\n\nNEURO: PERRL, 4-5mm. Dozing intermittently. Will nod head \"yes\" to questions at times, useful for pain assessments. Obvious response to painful stimulus during skin care and dressings changes, general flitches in response to pain and non-sedated state noted during these procedures despite Demerol premedication.\n\nRESP: Trach, CMV ventilation. No changes made in therapy. SPO2 96-100%. Lungs coarse, diminished, exp wheeze LUL- suctioned frequently for thick/yellow sputum. Meropenem/Amikacin current therapy.\n\nHEMODYNAMICS: Labile changes in reported to MD- measures 40-50s for a few minutes without change in HR or LOC, will increase to 90-120s without intervention, confirmed by manual doppler method. HR controlled 90-102, rare PVCs. No sx acute GIB- HCT stable at 26.8, next level to be drawn at 8pm. Active bleeding from pressure ulcers coccyx and right ischial, slow vaginal bleed. DIC panel pending.\nDoppler pulses absent left PT and right DP, MD aware. Gross anasarca present, large amount weeping of multiple skin tears, blisters.\n\nID: Normothermic. Plan to d/c right CVL to culture tip. RUE PICC and left dialysis remain in place- Left dialysis catheter with erythema.\n\nGI/METABOLIC: NPO maintained, Jtube clamped. to gravity drainge with viscous light brown/tan drainage. Colostomy with total 50ml maroon/brown liquid. No GI studies completed thus far today. Glucoses stable on Glargine QD (140/133).\n\nCOMFORT/PSYCHOSOCIAL: Premedicated with Demerol for complete turns and skin care, pt remains awake after Demerol and flinches in pain. Per family, Demerol was administered frequently as premedication in dose of 50mg as well as Ativan 2-3x day. Family (Daughter , granddaughter) at visiting, asking general questions re: status of skin wounds and BP measurements. Family providing comfort care to pt, emotional support and education provided.\n\nPLAN; D/C right CVL, culture tip. Monitor for sx GIB, hemodynamic changes. HCT q8hr as ordered, next due at . as ordered, collect Vanco level. Aggressive skin care, comfort care. Consult with MICU team re: increase pain control. All contact from HCP to be forwarded to Dr only as physician team leader and director of ultimate plan of care. Emotional support and education to pt and family ongoing.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-23 00:00:00.000",
"description": "Report",
"row_id": 1524440,
"text": "Respiratory Care: Pt remains on current vent settings, no changes made this shift.Receiving MDI's. Suctioning mod amt secretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-24 00:00:00.000",
"description": "Report",
"row_id": 1524441,
"text": "Nursing Assessment 7p-7a:\nNursing Note :\n\nTmax 99.0 oral. Family meeting prior to shift and family in room afterwards upset regarding discussions in meeting. When family arrived back in room pt went into Afibb 130-150 and 50-60. MICU resident notified and 500cc ns given/ labs sent for HCT, vanco. BP came back up but remained in afibb and given ativan ivp. Pt converted back to nsr-st after most of family left for the night. Pt's dtr and son remained in room. requesting VBG again while hr elevated and it was drawn per micu team; resulting values ok per respiratory. Frequently asking for pt to be suctioned, concerned that pt not suctioned enough and was assurred that pt was just suctioned prior to her entering the room. Sats are 98-100%, good tidal volumes, and pt appears comfortable on vent. Suctioned occasionally for thick yellow sputum, which is not new. Wound care done per recommendations. PT's dtr also concerned about drg from around G/J Tube site which is pink tinged at times. Family was feeding ice chips with red beverage to patient and believe that the drg is from that and that the tube is the source of all her bleeding from the ostomy. These issues have been discussed with pt's dtr already in meetings and discussions with the micu mds. All discussions regarding pt to be done through the MICU attending only and dtr instructed to speak with them regarding any futher questions or concerns. Early this morning, pt in afibb again and given ativan with no effect. Pt wideeyed, shakey left hand, and nodded yes to pain. Given demerol with good effect, HR sinus 106. Lytes ok on am labs. Glucose wnl. Plan: continue towards discharge planning for home. Family's wishes are to get pt home and are unhappy with care here. Hospice care to be readdressed? Family is aware and still willing to take pt home despite her acute medical issues and risks for rebleeding, ventilator dependency, hypotension, afibb and tachycardia, and periods of hyperglycemia. Case management and social work are continuing to arrange for the home care of this patient. Pts dtr will take pt home but has requests; case management is working towards these as able and GI/Vascular have met with family to discuss risks and why some may not be met at this time d/t not in pt's best interest (changing G/J tube, toe amps). Please refer to GI and vascular notes in chart. Also please refer to carevue for all futher details in nursing assessments.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-07-29 00:00:00.000",
"description": "Report",
"row_id": 1524091,
"text": "condition update\nd: pt arrived from er with ? of sepsis. hr afib in the 100-115. sbp 90-120/60. blood cultures sent from pic line. pt. given 1 liter ns fluid given after fluid sbp up to 120 and pt more awake. opening eyes spontaneously and looking around the room. spontaneously lifting left arm off the bed.\nresp: pt trached. on a/c 40% with rate of 16 pt is overbreathing the vent.\ngi: gt clamped.\ngu: pt on hd left subclavian quinton patent. pt due to have hd today.\nskin: see assessment for skin . coccyx wound is open with blackend center. per son it was improving but recently has started to look worse. pt was on kinair bed at home. bilateral calfs are open and through fascia. wound is pink. right hip is open and reddened base through the fascia. left hip is open tthrough the dermis. aqualcel dressing applied. left heal with black center and ns packing applied.\nrigth toes are dry and necrotic.\na: skin rn to come see pt today. ? kinair bed. check blood culture results. hd today. head ct today.\nr: pt more awake this am. sbp greater than 100.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-07-29 00:00:00.000",
"description": "Report",
"row_id": 1524092,
"text": "Resp Care\nPt remains intubated on AC, no vent changes, stable shift. Pt went for ct without incident. Plan to continue with current tx, sx for mod yellow thick.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-07-29 00:00:00.000",
"description": "Report",
"row_id": 1524093,
"text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT LETHARGIC THIS AM, NOT FOLLOWING COMMANDS. IMPROVED THROUGHOUT THE DAY, BECOMING MORE ALERT AND OCCASIOANLLY FOLLOWING COMMANDS. ATIVAN HELD THROUGHOUT THE DAY DUE TO LETHARGY AND HYPOTENSION. SPONTANEOUS MOVEMENT NOTED IN ALL EXT. EXCEPT FOR THE RIGHT UPPER. HEAD CT DONE THIS AM, RESULTS UNKNOWN. PERRL. NODDING HEAD APPROPRIATELY IN RESPONSE TO SIMPLE QUESTIONS. C/O PAIN IN COCCYX AREA, FREQUENTLY REPOSITIONED, NOW ON KINAIR BED.\nCV- HYPOTENSIVE THIS AFTERNOON IN LOW 80'S. DIALYSIS ON HOLD FOR NOW. NS BOLUSES GIVEN WITH GOOD EFFECT, PRBCS TO BE GIVEN, AWAITING CONSENT. REMAINS IN A-FIB, HR 110-120'S THIS AM, RESPONDED WELL TO LOPRESSOR 12.5MG HOWEVER, BP NOT TOLERATE FURTHER DOSES.\nRESP- LUNGS CLEAR, COARSE AT TIMES. SUCTIONED EVERY FEW HOURS FOR THICK YELLOW SPUTUM. 02 SAT 100% ON AC, NO VENT CHANGES MADE THROUGHOUT THE DAY.\nGI/GU- ABD SOFT, DISTENDED. COLOSTOMY DRAINAGE GREENISH BROWN, LOOSE STOOL. PT RECEIVING LACTULOSE AND FLEETS PHOSPHOSODA, SPOKE TO INTERN REGARDING OUTPUT OF ABOUT 800CC, WILL CONTINUE FOR NOW. HYPOACTIVE BS, REMAINS NPO. PT DOES NOT VOID, WILL BE DIALYSED TONIGHT IF BP INCREASES.\n PT HAS SEVERAL LARGE DECUBS, ALL DRESSINGS CHANGED. SPOKE WITH WOUND CARE RN, HOWEVER SHE COULD NOT SEE PT TODAY, WILL FOLLOW UP TOMORROW. COCCYX DECUB IS TO BONE, 7CM X 7CM, PELVIC CT DONE THIS AM, RESULTS PENDING. PLACED ON KINAIR BED.\nID- AFEBRILE\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-18 00:00:00.000",
"description": "Report",
"row_id": 1524173,
"text": "RESPIRATORY CARE NOTE\n\nPatient remains trached with 8.0 air cuff adjustable length locked at 10mm. No vent changes made during the . RSBI completed on PS 5=96. Sxn for small thick yellow secretions.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-18 00:00:00.000",
"description": "Report",
"row_id": 1524174,
"text": "Respiratory Therapy\n\nPt remains trached w/ TTS on full mechanical support. No vent changes made this shift. Currently on A/C ventilation w/ PIP/Pplat = 23/20. SpO2 90s-100%. BS slightly coarse bilaterally, suctioned for small amounts of thick whitish sputum. Cuff pressure = 25cmH2O. MDIs given as ordered. See resp flowsheet for specifics.\n\nPlan: maintain support\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-18 00:00:00.000",
"description": "Report",
"row_id": 1524175,
"text": "SICU NURSING PROGRESS NOTE 0700-1900\nNEURO--ASLEEP MOST OF SHIFT. AT TIMES WILL NOD HEAD TO SIMPLE QUESTIONS REGARDING COMFORT, PAIN,HOT/COLD. DOES NOT FOLLOW COMMANDS. NO SPONTANEOUS MOVEMENT OBSERVED. EYES OPEN SPONT. NO ATIVAN GIVEN TODAY AS PT IS .\n\nRESP--NO VENT CHANGES DONE. SAO2 >96%. SX Q2HRS FOR SMALL AMTS OF YELLOW/WHITE SPUTUM . LUNGS COARSE IN ALL FIELDS. PLAN IS FOR IP TO BRONCH PT TO SEE WHERE END OF TRACH TUBE IS PLACED. THEN TO REPLACE OLD TRACH WITH NEW PORTEX TRACH WHERE PT CAN BE VENTED AND SPEAK. IP WAS BY BUT PROCEDURE NOT DONE AS OF THIS TIME.\n\nGI--TOL TUBE FEEDS AT F/S. OSTOMY DRAINING GOLDEN LOOSE STOOL.\n\nGU--ANURIC. NO HD TODAY. NO STR. CATH.\n\nCARDIAC--MAP>55. HR A FIB WITH NO OBSERVED VEA. MIDODRINE GIVEN AS ORDERED. PICC DRESSING/CAP CHANGED.\n\nPAIN--GRIMACES AND NODDING HEAD WHEN SACRAL DECUB DRESSING CHANGED. MEDICATED WITH 1MG IV DILAUDID WITH GOOD RELIEF. NODDED HEAD YES WHEN ASKED IF IN PAIN AT 1630. WHEN ASKED IF FEET HURT SHE RESPONDED YES. .5 DILAUDID GIVEN AGAIN.\n\nID--FEBRILE TO 101.5. 650 MG PO TYLENOL GIVEN WITH DECREASE IN TEMP TO 99.6. REMAINS ON LEVO.\n\nSKIN--ALL WOUNDS DRESSED BY WOUND/SKIN CARE RN. NO FOUL ODOR FROM ANY WOUND. SACRAL WOUND IS THE SIZE OF A SOFTBALL AND ~1.5INCHES DEEP. WOUND CARE/DRESSING CHANGE INSTRUCTIONS ARE IN CHART AND ON PT'S WALL IN ROOM. R ISCHEIAL TUBEROSITY IS DRAINING SMALL AMTS OF SERO-SANGINOUS DRAINAGE. SMALL AMT OF ESCHAR ON WOUND. R CALF WOUND IS CLEAN WITH GOOD GRANULATION TISSUE FORMING. L TOES 4 ARE NECROTIC WITH OPEN SORE ON JOINT CAPSULE OF GREAT TOE. R FINGERS ARE EDEMATOUS AND SMALL BLISTERS ARE FORMING ON 4 FINGERS. RUE IS >L. ORAL MEMBRANE DRY. ORAL CARE GIVEN. BACK IS CLEAN DRY AND INTACT.\n\nCOPING--DAUGHTER , , AND HUSBAND IN TO VISIT. ASKING REPETATIVE QUESTIONS REGARDING PLAN FOR TRACH. QUESTIONS HAVE BEEN ANSWERED. THE FAMILY IS REQUESTING THAT ID BE CONSULTED, PT'S TRACH IS CHANGED, WHERE FEVER IS COMING FROM. HCP, HAS PHONED AND HAS BEEN UPDATED.\n\nA--FEBRILE. REMAINS IN A-FIB. TOL. TUBE FEEDS. PLAN FOR BRONCH. PAIN WITH DRESSING CHANGES.\n\nP--GIVEN TYLENOL AS NEEDED. PLAN FOR BRONCH AND ? TRACH TUBE REPLACEMENT. IR TO COME BY AND ASSESS PEG SITE. OFFER SUPPORT TO PT AND FAMILY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-18 00:00:00.000",
"description": "Report",
"row_id": 1524176,
"text": "SICU NURSING PROGRESS NOTE 0700-1900\nBLOOD CX X2 OBTAINED, 1 FROM DIALYSIS CATH AND 1 PERIPHERALLENDO--BLOOD SUGARS REMAIN >290. PLS CHECK BS Q4HRS AND PROVIDE HUMALOG IF NEEDED. NO LABS DRAWN TODAY.Y. NO URINE OBTAINED AS PT IS ANURIC AND HAS NO CATHETER.\n\nHCP PHONED AND WAS VERY UPSET ABOUT PT GETTING DILAUDID FOR PAIN. SHE IS INSISTENT ABOUT HER MOTHER \"ONLY GETTING DEMEROL, NOTHING ELSE FOR PAIN.\"\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-18 00:00:00.000",
"description": "Report",
"row_id": 1524177,
"text": "SICU NURSING PROGRESS NOTE 0700-1900\nBLOOD CX X2 OBTAINED, 1 FROM DIALYSIS CATH AND 1 PERIPHERALLENDO--BLOOD SUGARS REMAIN >290. PLS CHECK BS Q4HRS AND PROVIDE HUMALOG IF NEEDED. NO LABS DRAWN TODAY.Y. NO URINE OBTAINED AS PT IS ANURIC AND HAS NO CATHETER.\n\nHCP PHONED AND WAS VERY UPSET ABOUT PT GETTING DILAUDID FOR PAIN. SHE IS INSISTENT ABOUT HER MOTHER \"ONLY GETTING DEMEROL, NOTHING ELSE FOR PAIN.\"\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-19 00:00:00.000",
"description": "Report",
"row_id": 1524178,
"text": "NURSING\n VSS, TMAX 99 OVERNIGHT. CONTINUES IN A-FIB, ON COUMADIN. TUBE FEEDS CONTINUE AT 40/HR. ANURIC. ALL DRESSINGS CHANGED BY SKINCARE NURSES TODAY. ONLY VENT CHANGE WAS TO DECREASE FIO2 FROM 50 TO 40. SEE VUE FOR FULL ASSESSMENT.\n TODAY ID CONSULT, BRONCH BY INTERVENTIOAL PULMONOLOGY, IR TO COME BY TO ASSESS PEJ TUBE TOMORROW. CULTURE SACRAL DECUB WITH NEXT DRESSING CHANGE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-19 00:00:00.000",
"description": "Report",
"row_id": 1524179,
"text": "Respiratory Care\nPt remains intubated on full vent support. #8 trach with adjustable flange is set at 10cm. No vent changes made this shift. BS coarse bilaterally and diminished at bases. Sxn'd for small amount of thick yellow secretions. MDIs given as ordered. See Careview for a.m. RSBI results.\nPlan: Maintain ventilator suppport\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-19 00:00:00.000",
"description": "Report",
"row_id": 1524180,
"text": "Respiratory Therapy\n\nPt remains trached w/ #8.0 TTS adjustable trach set @ 10cm. Became more dis-coordinate w/ the ventilator this shift w/ RR ^high 30s, PIPs ^40s, tachycardic w/ HR 140s, hypotensive requiring fluid . Also had a noticeable increase in secretions...suctioning copious amounts of thick yellowish green sputum. SpO2 90s-100% and ABG acceptable. MICU team aware, sputum spec sent for culture. Pt febrile to 102.7. No vent changes made this shift. ABG drawn from R radial artery w/ no complications. See resp flowsheet for specifics.\n\nPlan: maintain support; aggressive pulmonary toilet...\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-10 00:00:00.000",
"description": "Report",
"row_id": 1524267,
"text": "See data, MD notes/orders. Neuro: Opening eyes spontaneously and intermitently nodding head to questions at begining of shift, more lethargic and less reponsive in pm. CV: Afib with occ pvc's, rapid bursts to 130 during dialysis that are self limiting. Continues on phenylephrine gtt to maintain blood pressure, currently 94/45 with gtt rate at 1.2mcg/kg/min. Hypotensive to 69/30's during HD - see notes. Pulm: Trached, dependent on ventilator support, minimal secretions suctioned, lungs clear, decreased at bases. GU: Anuric, HD for 1.5hrs with 1Liter fluid removal. GI: Abd obese, bs present, colostomy patent with output per flow sheet. Gtube to gravity with return of 100cc fluid. TF at goal rate 40cc/hr. Endo: by NP from clinic with ssc adjusted and HS insulin dc'd. Skin: Afebrile see wound care nurses notes for description of decubitus ulcers present at coccyx, bilateral trochanters and right ishcium as well as left heel and bilateral calfs. Mutiple areas of echcymosis, excoration and skin tears along thighs, under on right upper chest. General 3+ pitting edema noted. F/E: Grossly + fluid balance, lactate this am 10.4,LFT's elevated, hct 24.9. Soc: Husband and one son in this morning, daughter phoned in this pm and updated on pt condition. P: Monitor LOC, reorient prn, ativan as ordered, hold for sedation. Titrate neo gtt as above to keep map >50, notify team of refractory hypotension/tachycardia. Follow abg's, respitory effort, 02 sats. ?HD for further fluid removal tomorrow. To utilize pedi tubes for blood draws as able, note daily hct, observe for bleeding. Npo after mn for am RUQ ultrasound, q6hr finger stick with new coverage as ordered. Meticulous skin care, air matress and turn q1-2hrs, dressings per wound care nurse . Keep family up to date on , offer support, facilitate communications with MICU team as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-20 00:00:00.000",
"description": "Report",
"row_id": 1524183,
"text": "NURSING\n VSS, TEMPERATURE SLOWLY DECREASED TO NORMAL. COOLING BLANKET OFF.\nTUBE FEEDS CONTINUE AT 40/HR. STARTED ON VANCOMYCIN AND ZOSYN YESTERDAY FOR FEVERS. ALL CULTURES STILL PENDING. NO ISSUES OVERNIGHT, SEE CARE VUE FOR FULL SPECIFICS.\n NO VENT CHANGES OVERNIGHT. LARGE AMOUNTS OF SPUTUM, THICK, GREEN.\n DAUGHTER IN LAST EVENING. MULTIPLE QUESTIONS ASKED AND ANSWERED REGARDING ANTIBIOTICS, LABS, WHEN BRONCH WOULD TAKE PLACE, WHEN J TUBE WOULD BE CHANGED.\n CONTINUE TO MONITER HEMODYNAMICS, FEVERS. FOLLOW LABS. CULTURES PENDING. BRONCH WHEN STABLE. J TUBE CHANGE WHEN STABLE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-12 00:00:00.000",
"description": "Report",
"row_id": 1524273,
"text": "nursing note\nNeuro:pt remains minimally responsive, nods approp at times but inconsistently. hypethermic and bairhugger on.\nCV: afib, rate to 140-150's at times, resting in 130's most of night. MD aware and no interventions made since not more hypotensive with increased rate. Rate seems unrelated to pitressin increase earlier in evening or neo titration. MD aware of plt 39 on pre labs, coags sent and PTT >150 with INR 2.7. HCT sent at this time stable and plt up to 49. No bleeding noted. Later in , bleeding from ostomy site noted, 2u given. labs repeated. neo titrated to keep sys 80's, pitressin increase to 2.4 MD . Immediately on initiation of , down to 60's, neo titrated up and MD aware. Decision made at this time to increase pit.\nRESP:no vent changes, minimal secretions.\nGI:tol tube feeds at goal. GT/JT ostomy site changed per daughter request. small at 4 o'clock, covered wtih duoderm on ostomy appliance. Ostomy bleeding as above, bleeding noted from ostomy site itself, not bloody stool.\nGU:anuric. to take on fluid as tolerated.\nSKIN: no dressing changes this shift, all done on day shift. Multiple raw areas under L breast, in groin area, nystatin applied.\nSOCIAL: daughter -HCP in to visit last night and spoke with MD regarding many issues: i.e:no dilaudid use, , liver failure, hypotension, dialysis. Daughter would possibly want patient transferred to if we are unable to get fluid off during .\n\nPLAN:follow sepsis picture including possible DIC. monitor for bleeding and treat labs PRN. a/o as awaiting sensitivities. supportive family care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-12 00:00:00.000",
"description": "Report",
"row_id": 1524274,
"text": "RESP CARE - Pt remains intubated w/#7 XL trach on a/c 450/16/5 40%. No changes were made this shift. ABG is within normal range. BS coarse in upper lobes, which cleared on sx of small to moderate amounts of thick yellow secretions. BS were dim in bases. Flovent given as ordered, Atrovent given Q6, Albuterol given at 0800, but not at 1400, due to HR>120. Email sent to Pulm for ordering info for IC. Continued resp care planned.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-12 00:00:00.000",
"description": "Report",
"row_id": 1524275,
"text": "nuero: pt at times opens her eyes when you call her name. pupils equal and reactive to light. pt does not follow commands. pt does move left hand on bed. no spontanous movement noted from right arm and right leg and right arm. ativan held at 0800 and 1400.\n\npain: no pain noted.\n\npulm: pt remains on ac, please see flow sheet for vent settings. lungs diminished at bases. most recent abg 7.37/35/118/21, dr. aware. suctioning pt for thick yellow sputum.\n\ncards: pt remain in afib hr 120-130's. iv phenylephrine weaned to off. pt continues on pitressin at 2.4u/hr. pt continues on , initally this morning taken off no fluid, but gradually increased pfr to 100cc/hr per dr. , pt becoming increasing tachycaric up to 138-140's, dr. called and aware. patient fluid removal decreased back to 50cc/hr.\n\ngi: pt continue on tube feeding at goal via j-tube. this morning colostomy emptied for 300cc of bloody drainage, mixed with a small amt of stool, dr. into assess colostomy output. no further bloody drainage noted from colostomy site, pt has had golden brown stool, which is guaic postive.\n\nheme. repeat hct 26.5, plt 29, dr. aware, no treatment ordered.\n\ngu: pt continues on .\n\nf/e: blood sugar 253 insulin gtt started, insulin gtt presently at 4u/hr. k 3.4 kcl gtt adjusted per k sliding scale, ionized calicm 1.20 calicum gtt adjusted per sliding scale\n\nid: pt started on meropenum. tobramycin trough to be checked.\n\nsocial: pt husband into visit this morning. update daughter x2 on pt condition.\n\nplan: continue to monitor, monitor for any sign of bleeding. check labs as ordered. adjust k and calicum gtt per sliding scale. monitor .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-12 00:00:00.000",
"description": "Report",
"row_id": 1524276,
"text": "pt with an eposide of hr up to 150-160 and up to 160's (please see flow sheet), vasopressin initally shut off, dr. called and into assess patient, resp. therapy called and into assess patient. abg done which was similar to earlier abg, pt recieved 2.5mg of iv lopressor, dropped down to 90, vasopressin restarted back at 2.4u/hr. dr. aware. hr down to 120-130 after lopressor\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-03 00:00:00.000",
"description": "Report",
"row_id": 1524112,
"text": "Neuro:Pt sleeping most of night. Appears comfortable. Pupils 3mm brisk. Making no effort to communicate.\nCV: afebrile, HR 90-110's Afib with no noted ectopy. SBP90-120's. extremities cool with poor pulses. Heparin gtt titrated, R great toe continues to bleed. L buttocks slight bleeding,\nRESP: lungs clear through-out, No vent changes over night.\nGI: tol tube feed. draining brown stool via ostomy.\nGU: aneuric.\nENDO: Remains on insulin gtt blood sugars stable over night\nPLAN: awaiting MRI results.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-05 00:00:00.000",
"description": "Report",
"row_id": 1524119,
"text": "Resp. Care:\n Pt. remains trach'd and on vent.support. BS-occas. coarse. sx- sm amounts thick yellow secretions. MDI's given as ordered. Cuff press. @ 25cm to seal. Occas. positional leak, but without volume loss. 40 second RSBI test with low volumes and rr ^^ 40's. Cont. present vent. management/MDI's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-05 00:00:00.000",
"description": "Report",
"row_id": 1524120,
"text": "Nursing note:\nNEURO: Alert, does not follow commands or communicate. Moving L. side on bed minimally. PERRLA. Appears comforable.\nRESP: Lung sounds clear, no vent changes. Suctioned for minimal amounts clear secretions.\nCV: Afebrile. Afib w/occ PVCs. MAP >60, SBP dipping when pt. sleeping though MAP remains 60-65. Pt. off Heparin gtt, therapeutic on Coumadin.\nGI: Abdomen soft, +Hypo BS. New J-tube intact, used for meds only overnight. To begin TFs in am. IVF running overnight until given TFs. Colostomy patent small amount brown semi-formed stool.\nGU: Anuric, HD pt.\nSKIN: Mult. skin and wound issues, all dressings (except R. great toe) changed per skin care RN's recs. See Carevue for details.\nENDO: Glucose levels labile, 1.5 amps D50 given for low blood glucoses in 30-70s, currently stable in high 70s. MICU team aware.\nSOCIAL: Family visiting during evening, updated.\n\nA/P: Stable with mult. wound issues. Continue skin and wound care, restart TFs, follow glucose levels, continue current plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-05 00:00:00.000",
"description": "Report",
"row_id": 1524121,
"text": "Focus Condition Update\nSee flowsheet for specific info.\n\nNeuro: Pt opens eyes to voice, tracks, follows some commands, and MAE's with the exception of her RUE, on the bed. PERRL.\nCV: Pt dialyzed today, 1700cc of fluid removed. Hypotensive at times today, albumin given during HD to keep MAP >60. Chronic a-fib with the occassional PVC.\nResp: Pt trached, CMV, 40%O2, PEEP 5, sating 98-100%. No vent changes made, no blood gas sent. LCTA, dim in bases, minimal suctioning.\nGI: TF's restarted, FS at 40cc/hr. J-tube patent, site is clean dry, and covered with DSD. Abd soft, BS+, colostomy draining loose green stool.\nEndo: Blood sugar stable this shift 85-126, awaiting consult from .\nPlan: Continue to monitor BP\n Continue with current POC\n Discharge to home\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-05 00:00:00.000",
"description": "Report",
"row_id": 1524122,
"text": "Resp Care\n\nPt remains trached with #6 shiley with positional leak noted. Cuff pressure pressured at 24cmh20. Pt currently vented on a/c with no changes made this shift to parameter settings. BS clear to course sxing for small to mod amts of thick white to yellow secretions. Trach patent/secured with adequate humidification noted. Will cont with vent support as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-06 00:00:00.000",
"description": "Report",
"row_id": 1524123,
"text": "Nursing note:\n Afebrile. SBP in 80s-90s, MAP 60-65. Remains on A/C, no ABGs done. Sats 100% and pt. appearing comfortable and compliant w/vent. Tolerating TFs w/minimal residuals. +BS, hypo. Colostomy intact w/green liquid stool. Glucose level normalizing, SSRI PRN. Anuric. Coccyx dressing changed x1 along with L. trochanter site according to skin care RN's recs. See Carevue for details. All other dressings intact. Family visiting.\nA/P: Stable overnight. Continue wound care, cont. current plan of care and ready for d/c to rehab.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-17 00:00:00.000",
"description": "Report",
"row_id": 1524169,
"text": "Resp care note\n\nNo ABG this shift but RSBI was done which shows much better result today, ~ 85. Pt presently remains on AC 16 x 450 but RSBI suggests that may be able to change to more spont mode. Pt has consistently had small to mod amts of thk tan secretions and one time what appeared to be bloody clots. Humidifyer system is functioning well, Spo2 is high and PiPs have been in low 20's. Adjustable T-tube monitored and adjusted x 2 to maintain @ 10 cm marker. Family member expressed concern that catheter is not getting down far enough but total length of Trach tube is 15 cm while in-line sx catrheter hax length of 30 cm. Continued use of longer catheter is not advisable as repeated usge could cause some trauma in smaller airways beyond trachea. Also recomment attempting cautious wean.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-17 00:00:00.000",
"description": "Report",
"row_id": 1524170,
"text": "Resp Care: Pt remains intubated via #8 air filled cuff trach tube. Positional cuff leak. Team aware. BS coarse bilat I+E wheezes. MDI's given w/ gd effect. SX'd for small amts thick yellow sputum. No vent changes made this shift. No recent ABG. Most recent cxray from reveals \"^'d effusions, suggestive of failure rather than infection\". Plan: cont vent support. Please see carevue for further vent inquiries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-17 00:00:00.000",
"description": "Report",
"row_id": 1524171,
"text": "nursing note\nNeuro: opens eyes spont, not following commands. Per family- open eys are anxiety and pt medicated with ativan a/o. no spont movement.\nCV:SR, no ectopy. SBP >90 sys on midodrine. Lytes repleted per micu. Micu resident questioned regarding lytes with renal status and this RN instructed to give. Later in day-lytes and MD aware that lytes had already been given. Remaining Kphos discotinued.\nRESP:LS coarse,thick yellow secretions.\nGI:Tol JT feeds at goal.Colostomy with golden liquid brown.\nGU:anuric.\nSKIN:per skin care recs.\nSocial:son in to visit-asking approp questions. Husband in this AM.\n\nPLAN:await IR consult at bedside in AM re:JT site and leakage. Await decision re:pulm re trach and home status with . HD tues. Home planning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-18 00:00:00.000",
"description": "Report",
"row_id": 1524172,
"text": "condition update\nplease see carevue for specifics.\n\nNeuro unchanged. pt still not moving or following commands. Pt's daughter felt she was less responsive than usual however. MICU team up to go over and explain that the only changes to her meds was the increase in the glargine dose. All doses of ativan held during the . Tmax 101. AFIB. HR 90's-130. SBP 80's-120. Pm lopressor dose held. No vent changes made. Pt continues on AC/ 50%/5 peep. LS are coarse. Pt sxn'd several times for small amts of thick yellow secretions. TF infusing at goal via J tube. J tube drainage at start of shift was bilious and by 0400am yellow pus like. Colostomy w/ golden loose, guiac negative stool. Coccyx dressing changed as per wound care orders.\n\nPlan: continue with current plan of care per micu team. IR to j tube for continued leakage. Md. to perform test w/ resp tx at bedside on pt's home vent and new boniva trach. continue wound care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-10 00:00:00.000",
"description": "Report",
"row_id": 1524268,
"text": "Resp Care\n\nPt remains trached with #7XL Shiley and currently vented on a/c with no changes made to parameter settings. Inner cannula changed this shift and is clean/patent. BS essentially clear anteriorly sxing for minimal secretions. MDIS given x3 this shift with improved aeration noted. Will cont with vent support as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-11 00:00:00.000",
"description": "Report",
"row_id": 1524269,
"text": "RESPIRATORY CARE\nPT REMAINS ON A/C WITH NO CHANGES MADE THIS SHIFT.SUCTIONED FOR SAMLL AMT OF YELLOW THK SECRETIONS.BS CLEAR B/L.MDI'S GIVEN AS ORDERED.PLAN TO CONT. VENT SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-11 00:00:00.000",
"description": "Report",
"row_id": 1524270,
"text": "FOCUSED NURSING NOTE\nPlease see carevue flowsheet for further details\n\nNEURO: Pt more alert at times alternating with lethargy- nodding head \"yes\" and \"no\" inconsistently. PERRL, 5-6mm. Demerol given x 1 for rigors/tachypnea with temp spike- therapeutic.\n\nRESP: Trach patent, collar changed and care done. Ventilated via CMV per pre-admission settings- no vent changes this shift. Tachypneic during fever, otherwise RR 19-22, SPO2 100%. CXR done. ABGs show metabolic acidosis, compensated Ph 7.36. Secretions thick/yellow, occassional suctioning required.\n\nHEMODYNAMICS: s/p HD, Septic shock supported by pressors needing increase titrations o/n. Neo gtt at 4.0mcg/kg/min to maintain >80- now 90, titrating Neo down as able. Sharp increase in Afib rate just before midnight correlating with temp spike to 100.5 max. Afib 130s-140s with occassional bursts 150s- PVCs infrequent. Anasarca worsening, especially abdominal. CVP 10-12 recently. Hct decreasing, 22.4 as well as plt ct 51K- confirmed by repeat analysis. Dark, red blood slow ooze from vagina, loose stool by colostomy guiac pos.\n\nGI/METABOLIC: Sclera jaundiced- TF suspended at 2400 for Abd US this am. Colostomy loose/liquid stool, sample sent for . Rectal drainage small amounts, tan mucosal to serosanguinous. Glucoses 192/126 on RISS. D5W line changed to NS. Metwabolic acidosis unchanged, Bicitra as ordered.\n\nID: Tmax 100.5 with rigors and tachycardia/tachypnea/BP increase- pressors off for short while. BC (2) pending, BC x 1 sent this am. CBC showing pancytopenia.\nSKIN INTEGRITY: All dressings intact, change daily. Right hip Allevyne drsg , pressure with pink/granulating wound bed, clean- 10% scattered yellow base. New skin tear adjacent to Dialysis catheter continues to bleed despite adaptic tx- covered with aquacel and light gauze pressure drsg- cont to monitor.\n\nPSYCHOSOCIAL: Son at bedside most of evening- sharing stories and pictures of Mrs over last 2 years- his goal is for her to make it home- supportive and appears to be coping appropriately. No additional family contact this shift.\n\nPLAN: Monitor hemodynamics on pressors. goal > 80. Consult with MICU team re: tachycardia ?fluid vs blood transfusion. HD/ plan per MICU/Renal team. Monitor for bleeding, new signs of infection. . Pulmonary hygiene, aggressive skin care as documented. Emotional support and education to pt/family ongoing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-11 00:00:00.000",
"description": "Report",
"row_id": 1524271,
"text": "Update\nSee Carevue for specifics\n\nNeuro: Mostly alert but unable to assess level of orientation. Will nod appropriately to some questions but does not follow commands. Withdraws to pain. PERRL.\nCV: Afib 110s-130s with rare PVCs. Neo gtt being weaned down as tolerated for >90 and MAP >50. Vasopressin gtt started at 1.2 u/hr. 1 unit prbc for falling hct. HIT panel sent. Anticoag. products d/c'd.\nResp: LS clear/coarse. No vent changes.\nGI: Abd U/S done r/t elevated bili. TF restarted at goal. Loose golden stool from colostomy. PEG/ site intact but draining.\nGU: CVVH to start this p.m.\nID: Afebrile. Blood positive for gram neg rods.\nSkin: Skin grossly impaired. See carevue for specifics on wounds & treatments.\nSocial: Husband visited in a.m. Daughter called and recieved update from RN & MD .\n\nPlan: Monitor hemodynamic status & wean neo as tolerated. Do not use heparin products. Start CVVH this p.m. Continue with agressive turning and skin care regimen. Keep family up to date on .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-11 00:00:00.000",
"description": "Report",
"row_id": 1524272,
"text": "Resp CAre\n\nPt remains trached on a/c with no changes made to parameter settings. BS clear to course sxing for small amts of thick yellow secretions. Inner cannula changed this shift. Will cont with vent support as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-26 00:00:00.000",
"description": "Report",
"row_id": 1524332,
"text": "nuero: at times pt open her eyes when you call her name. at other times will open her eyes to painful stimuli. pt does not follow commands. pt her head no at times. spontanous movement noted from left hand, no further spontanous movement noted. pt does withdraw all four extremties to painful stimuli.\n\npulm: pt remain trached and vented. please see flow sheet for vent settings. lung diminished at bases. suctioning pt for scant amt of yellow sputum.\n\ncards: pt remains in afib. iv neo weaned down to 1.05 mcg/kg/min. vasopressin remains at 2.4u/hr. keep map greater than 55 and greater than 90.\n\ngi: abd soft, but distended. colostomy only put out 10cc of stool. increased drainage noted from g-tube dr. aware. tube feedings remain at goal. 50cc of bloody drainage noted around g-tube site, dr aware and into assess site.\ngu: remains off.\n\niv access: pt went to ir today. pt had two double lumen picc line placed in ir.\nskin: wound dsg changed as ordered.\n\nheme: inr 1.9 pt recieved 2 , plt 52 pt recieved one bag of plts.\n\nf/e: insulin gtt presently at 7u/hr. last blood sugar 269.\n\nsocial: pt husband and son into visit this morning. spoke with pt daughter after picc line placed.\n\nplan: continue to monitor, to d/c central line once plt infused and sent central line tip for culture. recheck plt count when plts finished. continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-27 00:00:00.000",
"description": "Report",
"row_id": 1524333,
"text": "condition update\nd: pt opens eyes and intermittantly nods to questions. pupils are equal and reactive to light.\nCardiac: pt in afib rate controlled in the 90's. greater than 100 and map 68-71. neo weaned to 1.02 and pitressin weaned to .08units/hr pitressin weaned first per Dr. . pt with generalized edema.\nresp: pt remains on cmv with rate on 16. abg good see flowsheet. lactate down to 6 last night. pt suctioned for thick yellow sputum. no vent changes. pt appears comfortable on current settings.\ngi: tube feeds continue to infuse. abd distented and obese. evaluated by dr. and abd kub done and lactate checked and down to 6. pt difficult to assess for pain.\ngu: pt makes no urine. skin: dressings are dry and intact. pt remains on air bed and turned frequently.\ntubes: right groin central line dc'd and tip culture. site checked frequently and no bleeding or hematoma present.\na: continue with frequent turning. wean neo as tolerated.\nr: tolerating slow pitressin wean. dr. spoke with daughter \n and daughter given update.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-15 00:00:00.000",
"description": "Report",
"row_id": 1524410,
"text": "STATUS\nD: APPEARS MORE AWAKE WILL FOLLOW SOME SIMPLE COMMANDS(OPEN YOUR MOUTH ETC)\nA: HD DONE REMOVED 1800CC WITH MIN DROP IN BP..GOLYTELY GIVEN AS PREP FOR COLONOSTOMY..PT BLEEDING FROM COLONOSTOMY HO AWARE WILL CONTINUE WITH BOWEL PREP & GIVE 2U PC'S(#1 IN AWAITING #2)COLONOSTOMY DONE NO SIGNS OF FURTHER BLEEDING..STOMA BAG CHANGED..ALL DSG'S CHANGED\nR: LABILE BP\nP: AWAITING PC #2..WILL CHECK HCT AFTER TRANSFUSION..MONITOR FOR ANY FURTHER BLEEDING\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-16 00:00:00.000",
"description": "Report",
"row_id": 1524411,
"text": "Resp Care,\nPt. remains on A/C , No vent changes this shift. MDI's as ordered, suctioned for thick tan sputum. ? transition to home vent soon. See carevue.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-03 00:00:00.000",
"description": "Report",
"row_id": 1524113,
"text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT MORE ALERT TODAY, NODDING AND OCCASIONALLY MOUTHING WORDS. MOVEMENT NOTED FROM ALL EXT. EXCEPT RIGHT ARM. PERRL. PAIN MED GIVEN FOR DRESSING CHANGE ONLY WITH GOOD EFFECT.\n PT REMAINS HYPOTENSIVE IN HIGH 80'S-100 SYSTOLIC, HOWEVER PT NOT NEEDING ANY FLUID BOLUSES. HR 80'S-90'S, A-FIB WITH OCCASIONAL ECTOPY. PTT 40 THIS AM, GTT INCREASED TO 600U/HR AND NEXT PTT TO BE DRAWN AT 1700.\nRESP- LUNGS CLEAR, SUCTIONED A FEW TIMES FOR SMALL AMOUNT OF THICK YELLOW SPUTUM. NO VENT CHANGES MADE.\nGI/GU- ABD SOFT AND DISTENDED. G-TUBE CONTINUES TO LEAK AROUND SITE AND DRAINING INTO OSTOMY BAG. PT WILL GO TO IR TOMORROW TO CHANGE G-TUBE TO LARGER. COLOSTOMY INTACT, STOMA BEEFY RED AND DRAINING LOOSE BROWN STOOL. PT DOES NOT VOID, NO DIALYSIS TODAY.\nSKIN- COCCYX WOUND DRESSING CHANGED TODAY. PACKED WITH AQUACEL AND COVERED WITH DSD. AREA APPEARS TO BE IMPROVED, PERIPHERY EXCORIATED AND COVERED WITH BARRIER CREAM. DECUB GREYISH, OOZING BRB INSIDE. NEED TO BE REEVALUATED ON MONDAY.\nID- AFEBRILE. MEROPENUM TO CONTINUE, VANCO LEVEL PENDING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-03 00:00:00.000",
"description": "Report",
"row_id": 1524114,
"text": "Resp Care\npt remains trached and stable on A/C no vent changes made. BS course suctioned for sm amt of thick white-yellow secretions, MDIs given as ordered. will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-04 00:00:00.000",
"description": "Report",
"row_id": 1524115,
"text": "Resp Care\nPt remains on CMV, no vent changes, stable shift. Plan to continue with current tx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-04 00:00:00.000",
"description": "Report",
"row_id": 1524116,
"text": "data: vss. hr 96-113 afib. sb/p 88-112.\nt. fdg off @ 12mn for proceedure today. bs-dropped to 44 @ 0500 insulin gtt stopped(rate was on 1u/hr) and 1/2amp d50 ivp given w/ bs^64. will cont to check freq.\nall dsgs intact except rt lower -n/s pkg replaced-oozing from same area from skin tears.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-04 00:00:00.000",
"description": "Report",
"row_id": 1524117,
"text": "Resp Care\n\nPt remains trached and vented on a/c with no changes made to parameter settings. BS slightly course sxing for small to mod amts of thick yellow secretions. MDIs given as ordered. Transported to and from IR without any incident. Will cont with vent support as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-04 00:00:00.000",
"description": "Report",
"row_id": 1524118,
"text": "Nursing update\nSee flowsheet for specific info\n\nVSS, A-fib with rare PVC, SBP low but MAP kept >65. Neuro status unchanged. Pt to IR today for replacement of leaky J-tube, no problems. ischial dressing changed today, all other dressings intact. Insulin gtt off this a.m. per MICU, 70 units lantis given. noon sugar was 28, MD notified, amp D50 given. A couple of hours later, sugar was 27, another amp d50 given. Will restart insulin gtt when sugar reaches 200 per MICU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-24 00:00:00.000",
"description": "Report",
"row_id": 1524202,
"text": "FOCUSED NURSING ASSESSMENT\nPlease see carevue flowsheet for further details\n\nNeuro: No changes in neuro status- opens eyes spontaneously, follows comands inconsistently. Nodding head to answer simple questions for assessment of pts basic needs.\n\nResp: Biovina trach patent, positive positional cuff leaks, cuff pressure monitoring by RT. No resp distress on A/C 0.40, 450, 16, 5. SPO2 >95%. Frequent suctioning of moderate thick yellow sputum.\n\nHemodynamics: HR afib, controlled rate, no ectopy. Noted possible ST depression in lead II- 12lead EKG completed and reviewed by MD properly- MD, no changes in EKG. transient low SBP 73-89, NINV cuff BP not registering on thigh, now measuring NINV BP left radial. Pt is anuric secondary to renal failure, plan HD tomorrow if BP tolerates. INR 3.7, no sx bleeding.\n\nNutrition/metabolic: TF via J/G tube at goal rate- Glucoses 169/148 on Lantus 90U and RISS available. Na 132, K 4.9, discussed by MICU team, no action needed.\n\nID: Afebrile. Zosyn, Levaquin, Tobramycin as ordered. Blood cx neg, c-diff neg.\n\nPSYCHOSOCIAL: Mrs visited by her husband in am and followed by son in afternoon- Son asking appropriate questions and shares with medical team that majority of children would like to see their mother come home with hospice care \"We are doing our best to convince my sisters\" SW following, f/u family conference this week.\n\n POC: Cont to monitor hemodynamics, resp status. Monitor fever curve. Plan HD tomorrow if BP stable- please draw Tobramycin peak/trough with HD tx dose. Monitor glucose levels, RISS and Lantus as ordered. Aggressive skin care, turn and reposition with mouth care q2hr. Emotional support and education to family- f/u from SW appreciated.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-25 00:00:00.000",
"description": "Report",
"row_id": 1524203,
"text": "Resp Care Note:\n\nPt cont trached and on mech vent as per carevue. Lung sounds coarse suct mod th yellow sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required . Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-25 00:00:00.000",
"description": "Report",
"row_id": 1524204,
"text": "Nursing progress note\nneuro: unchanged\ncv: pt has episodes of low bp which resolve with turning and stimulation of patient. Metoprolol given at 2200 as per parameters on med sheet.\npulm: trach leak continues. sx q 2-3 hrs for thick yellow. bs coarse\ngu: anuric, for hemodialysis today\ngi: tol tube feeds well. colostomy draining loose brown stool guaiac negative.\nendo: blood sugars in good control tonight, < 150. glargine 90 u sc q 12 hrs. no reg ins coverage needed.\nwounds: appear unchanged, leg dsgs changed, dacral dsgs changed.\n\nsocial: daughter and husband in to visit. She wanted to help turn pt, and participate in her care. It was explained to her that hospital policy will not allow her to do this. Shortly after, pt began coughing, and proceeded to suction her mother. I spoke to her about this: we realize that she cares for her mother at home, but that while she is hospitalized her technical care is our responsibility, and I reiterated hospital policy. This issue needs to be addressed by MD's and ethics Committee, as it causes conflict between the family and Mrs. caregivers.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-09 00:00:00.000",
"description": "Report",
"row_id": 1524137,
"text": "Resp Care Note, Pt remains on current vent settings.See vent flow sheet for weaning. Unable to tol RSBI.RR into the 50's. Will cont to monitor resp status. Suctioned mod amts thick yellow secretions. Temp 99.HR A-Fib.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-02 00:00:00.000",
"description": "Report",
"row_id": 1524236,
"text": "See carevue for objective data.\n\nAssessment remains unchanged. No vent changes made. Suctioned Q3H for thick yellow secretions. Trach care done.\nRemains in AFIB with adequate BP per parameters of team. Tolerated lopressor and amiodarone.\nFoley with frank blood-approximately 40cc's this shift. Also, oozing noted around foley. Team aware.\nAll dressings changed. Coccyx with large amt of serosangious/green drainage and hips with serosangious drainage. Avelyn placed on hips cleaned with wound cleanser and no sting barrier applied. Wound care nurse wounds in AM. Lower extremities remain with black areas.\nTF as ordered. Colostomy care done. Mouth care per protocol.\nCase management/SW involved in pt's care.\nFamily called and updated on POC.\n\nAwaiting to go to IR for tunnel dialysis catheter-on call.\n\nContinue current POC.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-02 00:00:00.000",
"description": "Report",
"row_id": 1524237,
"text": "Respiratory Therapist\nBreath sounds bilaterally diminished, suctioned for small thick amount of yellowish secretions, WBC 12.8 ongoing bacterial infection, hemoglobin only 8, sign of anemia, patient got treated with Albuterol, Atrovent and Flovent inhalers, went to Angioplasty for line replacement, no ABGs drawn, nor vent changes done today, patient will continue to receive ventilatory support and close monitoring.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-03 00:00:00.000",
"description": "Report",
"row_id": 1524238,
"text": "Resp.Care\nPt. remains on A/C vent. via a 7.0 Shiley trach which is patent and secure. She is being sx for mod amts of yellow with scat rhonchi t/o. Pt, nebs were tol. well with good results and better aeration post rx.Plan is to monitor and wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-03 00:00:00.000",
"description": "Report",
"row_id": 1524239,
"text": "NPN\nPlease see CareVue for full assessments\nNEURO: Unchanged. Nods to questions at times. Inconsistent with following commands and communicating. Ativan po per schedule for anxiety.\n\nCV: Afib. HR 90's-120's. NBP stable. Lopressor po per schedule.\n\nRESP: Trach. No vent changes or issues. Sxn for sm amt tan secretions.\n\nGI: TF via off @0200 2T episode vomiting x1 green bilious liquid. MICU HO notified and in to . No further action or episodes. Copious amts green gelatinous bilious liquid draining from around . Noted to drain more when pt. positioned on left side. MICU HO aware.\nBS+. Colostomy with 125cc brown liquid stool, guaiac-.\n\nGU: Patent foley draining dk. red blood. Flushed x2.\n\nWOUND/SKIN INTEGRITY: Dsgs intact. MPS in place, repositioned Q2H.\n\nPLAN: CV monitoring, diabetic management, monitor for increased pain/anxiety, monitor for nausea/vomiting, monitor resp status, wound management, reposition to maintain skin integrity, monitor foley for increased bleeding.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-03 00:00:00.000",
"description": "Report",
"row_id": 1524240,
"text": "See carevue for objective data.\n\nAssessment remains unchanged.\nOpens eyes/tracks occasional only nods yes to questions/other times does not respond.\nTF re-initiated at 0700AM with no further vomiting. G-tube placed to gravity as well.\nFoley dc'd-no further bleeding noted. Pt anuric otherwise.\nTolerated HD/received albumin during HD.\nSkin care nurse evaluated and dressed all wounds. Please see progress note for details.\nNo vent changes. Suctioned Q2-3H for yellow thick secretions. Trach care done.\nAFIB. Non-labile BP.\n\nContinue current POC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-11 00:00:00.000",
"description": "Report",
"row_id": 1524147,
"text": "NPN\nPlease see CareVue for full assessments\nNEURO: Pt. inconsistently nods to questions and follows commands. MAE. Noted to have LUE tremor and left gaze @1200. Pupils 4-5mm and briskly reactive. MICU team notified. No action. On recheck pt able to look towards right, pupils remain 4-5mm. No c/o pain. Ativan per schedule.\nCV: Afib occas. PVC's. HR100-130's. Team aware-no action at this time.\nSBP 80-100's. Goal MAP grtr than 60.\nRESP: Trach. No vent changes. Cuff leak noted x2. Resp notified&at bedside. LS clear. Sxn x1 scant secretions.\nGI: TF @goal via PEJ. Free H20 Boluses on hold per MICU team. (Na 140). Moderate drainage around PEJ insertion site. Colostomy draining golden brown guaiac neg. stool.\nENDO: BG 300's this shift. Seen by . Fixed dose increased.\nWOUND: Dsgs intact. BLE dsgs changed per wound care recommendations.\nPLAN: Neuro checks, monitor CV and HR,diabetic management, wound management, call speech and swallow @passe muir valve, follow-up with team concerning upcoming discharge home, emotional support to pt/family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-12 00:00:00.000",
"description": "Report",
"row_id": 1524148,
"text": "Resp.Care\nPt. remains trached on A/C mode. No changes during the night. Cuff pressure was measured at 30 with a posistional leak. MDIs were given with good effect and pt. was sx for mod amts of white thick secr.\nPlan pt. is a chronic vent and possibly D/C to home .\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-12 00:00:00.000",
"description": "Report",
"row_id": 1524149,
"text": "Nursing Progress Note\nPlease see carvue for specifics:\nUneventful night. Status unchanged. Turn and repositioned Q2hrs and prn. Plan: Cont plans to d/c home\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-12 00:00:00.000",
"description": "Report",
"row_id": 1524150,
"text": "resp care - Pt remains intubated on ac 450/16/5 40%. Pt cuff pressure was not able to be assessed due to possible pinhole in pilot balloon. Balloon is remaining inflated and pt is receiving appropriate tidal volumes. Meds given as prescribed. BS wheezes t/o. Pt went to IR for jpeg change. Plan is to d/c to home soon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-12 00:00:00.000",
"description": "Report",
"row_id": 1524151,
"text": "Condition Update\nPlease see carevue for specifics.\n\nPt opening eyes spontaneously. Follows commands inconsistently. No moving extremities. TMAX 101.2; Bld cx's x 2 sent. Pending sputum from . Pt had HD today. 2200 out. AFIB continues. HR 90's-160's. occasional to rare PVC's noted. HR in the 130's-160's approx 30min into start of HD. MICU team notified. SBP only 70's-80's.\n\nNo vent changes made this shift. Pt sxn'd several times for thick, white sputum in scant amts. LS clear, but diminished at b/l bases. Pt an ad on for the OR for trach replacement d/t constant leakage. Pt maintaining volumes as was explained to pt's family, but they were still unhappy and demanding a new trach. Speech and swallow also consulted again for in line passy mauir.\n\nPt is anuric d/t renal status. colostomy draining liquid stool. spec #2 to be collected. Colace and lactulose doses held this am. stoma is pink. PEJ tube noted this am to have copious amts of clear drainage draining. Wound care RN in to inspect pej insertion site. Pt down to IR for replacement. .5 mg ativan given during the procedure. Since replacement, no further drainage noted. Pt's and beneprotein tube feedings held this afternoon for pej placement and eventual OR for trach placement.\n\nPt has a riss and glargine ordered for bs control. Pt is currently being followed by .\n\nB/L multi podis splints placed this am. foot and leg dressings changed this eve. Toes, heels, and achilles tendon necrotic. Duoderm gel adaptic and dsd's placed. Back of b/l calfs also w/ open areas. All areas cleansed w/ wound gel. Duoderm gel, adaptic and dsd's placed. Pt's coccyx and hips w/ intact dressings.\n\nPlan: continue with current plan of care per MICU team. speech and swallow consult for in line passy mauir placement. O.R. for trach replacement. Digoxin, lopressor and amiodarone for rate ctrl. Hold coumadin for inr 4.0 f/u on results of bld cx x 2 taken . Dressing changes.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-13 00:00:00.000",
"description": "Report",
"row_id": 1524152,
"text": "Resp. Care\nThere was a question of Pt. going to the OR for trach replacement at the request of the family. She was added to list , but did not go.She continues to have a posistional leak . 4ccs was added to reach pressure of 30. Pt. 8.0portex trach remains secured and patent and is being sx for sm. to mod amts of thin white secr. B/S are scat wheezes and rhonchi, MDIs were given with good effect.Pt. remains on A/C 450by 1640% and 5of peep.ABGs and RSBI not done due to being vent dependent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-13 00:00:00.000",
"description": "Report",
"row_id": 1524153,
"text": "nursing note 7p-7a:\nNursing ASsessment:\n\nTmax 100.3 oral. HR afibb 90s-130s briefly, pvc's at times. BP goal map >50, no boluses needed overnight. lungs clear and diminished in the bases, infreq suctioned, sat 100%. NS at KVO switched to 5% dextrose while tube feeds off for OR trach replacement (pt is an add-on, still waiting). PM glargine held and sugars monitored closely while tube feeds off. Coccyx dressing changed per wound care recommendations, pt tolerated well. Please refer to carevue for all further details.\nPLan: wound care. TRach to be changed in OR. Speech and swallow for passe-muir valve? Discharge planning for home, children will care for patient there. EMotional support for family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-08 00:00:00.000",
"description": "Report",
"row_id": 1524257,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick yellow secretions. MDI'S given.HR-A-Fib with few PVC'S.BP labile requiring fluid . RR 20'S-30.Hasn't had dialysis for 5 days due to drop in BP.ABG metabolic acidosis. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-08 00:00:00.000",
"description": "Report",
"row_id": 1524258,
"text": "Nursing Progress Note\nPlease see careview for details.\n\nNeuro: unchanged, lethargic to alert. nodding \"Yes\" to all questions.\nCV: afebrile. afib rate 110-145, but not sustained at the higher rate. Low bp by , at times unable to obtain , but as low as 45 systolic. abg's sent, lactate of 10, aline and multi lumen central line inserted rt femoral. given 1000cc ns, levophed started at .02mcg/kg/min. and a line not always correlating. levophed off by 0600. occasional pvc's. k 2.9, repleted with 20meq/50cc.\nPulm: sx for thick yellow, small amts. bs clear to coarse. RR up to 30, but not labored.\nGI: tube feeds at goal of 40/hr tol well, via j tube portion of gastric tube.. colostomy pink, draining golden loose stool guaiac neg. gastric tube to gravity, draining clear light yellow. frequent mouth care with water and mouthwash, pt swallows without difficulty.\ngu: anuric, possibly hemodialysis today if bp tolerates.\nendo: insulin to sliding scale as well as fixed dose of Lantis 2 x day.\nfamily notified of treatments by resident.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-08 00:00:00.000",
"description": "Report",
"row_id": 1524259,
"text": "Respiratory Care\nBreath sounds slight bilateral rhonchi, suctioned intermittently for small thick yellowish secretions, WBC 22.6, ongoing bacterial infection for which patient is on tobramycin, patient is anemic since hemoglobin is only 8.8, patient was afebrile whole day and stayed into A-fib, has had few PVCs, had hemodialysis started at 1000 am to stop two hours later at noon due to adverse effects like hypotension and tachycardia (HR 150 to 160), patient has been treated with Albuterol, Atrovent and Flovent inhalers, no vent change done during the shift, post hemodialysis ABGs on AC 450 x 16 40% +5 revealed a fully compensated metabolic acidosis with hyperoxemia, we will continue with mechanical ventilation and close monitoring of patient.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-08 00:00:00.000",
"description": "Report",
"row_id": 1524260,
"text": "NPN\nPlease see CareVue for full assessments\nNEURO: Unchanged. Nods head to all simple questions. Did not attempt to mouth words to this RN. +tracking. Observed moving LUE and RLE on bed. No movement witnessed from RUE or LLE.\n\nCV: Restarted Levophed after HD initiation due to hypotension. Titrated for BP grtr than 90. Mean grtr than 60 per MICU team. Right femoral Aline consistently 20-30pts higher than NBP. Remains in Afib. HR110's-120's prior to HD this AM.Episodes of HR to 140's. Lopressor 12.5PO administered. HR returned to 120's. CVP 14. Lopressor dose now TID. Midodrine per schedule. Potassium 3.0 after HD. To receive repletion.\n\nRENAL: Pt. did not tolerate fluid removal today. HD only 2hrs per Renal Fellow due to hypotension and tachycardia. Received 600cc NS fluid and Albumin during HD. Will attempt HD with fluid removal again tomorrow MD .\n\nRESP: Trach. No vent changes this shift. Remains acidotic. LS coarse to rhonci, right greater than left. Sxn for small amts thick light tan secretions. In line sxn changed by RT.\n\nID: ID consulted and in to /assessed coccyx wound. ?Linezolid induced lactic acidosis per MICU attending. L. acid now trending down(9.6). ABX changed per ID recommendations. Tobramycin level drawn at HD(0.2) but no dose administered. To be administered tonight per MICU HO. ID attending updated dtr.\n\nENDO: Hypoglycemic this afternoon. Received fixed dose of 87Units Glargine this AM. BG to 43. MD aware. amp D50 administered with repeat BG 43. Another amp D50 administered.\n\nGI: Abd distended. Golden loose guaiac- stool in colostomy. Bag emptied multiple times for flatus. Tol. TF at goal. Cont. to leak light yellow gelationous drainage around insertion site. Ostomy bag changed at site to collect drainage. Gastric tube to gravity with similar drainage as well as small amts of it oozing from rectum.\n\nScant smearing of vaginal bleeding noted with peri care.\nWOUND: All dressings changed per wound care recommendations. Dtr. viewed wounds with this RN.\n\nPsychosocial: HCP Dtr in-spoke with attending at length regarding , HD, and pending DC home.\n\nPLAN: Monitor CV status, wean levo as pt. tolerates, diabetic management, frequent BG checks due to hypoglycemia, administer ABX, wound management, reposition per protocol, provide emotional support to pt/family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-09 00:00:00.000",
"description": "Report",
"row_id": 1524261,
"text": "condition update\nd: pt opens eyes to name and nods yes. moves left arm spontaneously.\ncardiac: pt remains in afib with rate 90-130 with occasional pvc's. Dr. aware and lopressor dose given. pt on lopressor and given dose with minimal effect on bp and hr down to 100. pt remains on levophed and .04mcg/kg/min. rate titrated for 90. rate increased from .02-.04mcg/kg/min. pt remains on .04mcgs.\ngi: pt remains on tube feeds at 40cc/hr. no residual from j tube. no tube feeds draining from gtube. continues to leak yellow thick drainage from around feeding tubed. drainage bag is intact. abd obese and soft. hypoactive bowel sounds. colostomy pink and draining golden loose stools.\ngu: no urine. to attempt hemodialysis today with fluid removal. pt remains edematous in all extremities.\nlabs: blood sugars in the 40's. pt treated with d 50. Dr. aware and up to see pt. bedtime Glargine dose cut in half and pt started on d51/2ns at 100cc/hr for 5 hrs. see flowsheet for blood sugars. Spoke with Dr. re: insulin with blood sugar in the 60's. iv fluid changed to d5w at 100cc/hr and she wants pt to get glargine dose. blood sugar down to 57 at 3am and pt treated with 1 amp of d 50. Dr. aware. continue to monitor blood sugars. no further fluid at this time. hct down to 24 this am and Dr. aware. k 3.0 and repleted. repeat k this am 3.1\nskin: dressing are intact and pt remains on air mattress.\na: continue with q1hr blood sugars. attempt hemodialysis today. continue to support the family.\nr: 4am blood sugar is 118. tube feeds remain at 40cc. iv fluid at 10cc/hr. greater than 90 on current levophed dose. ? if she will be able to tolerate dialysis today. and aline approximately 20 pts difference. ? transfuse with hemo today. check with team and renal md. pt more edematous than over the weekend.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-09 00:00:00.000",
"description": "Report",
"row_id": 1524262,
"text": "Respiratory Care Note:\n\nPt remain on ventilatory/assist support via trachetomy tube. No vent changes done. BS are clear/BBS. We are sxtn small amt of clear to blood tinged secretions from trach, none orally, IC changed and cleaned, spare unopened untop of ventilator. Plan: Continue present ICU minitoring, anuric ?dialysis as tol. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-09 00:00:00.000",
"description": "Report",
"row_id": 1524263,
"text": "NPN\nPlease See CareVue for full assessments.\nNEURO: Pt. lethargic. Pupils 4mm. Equally reactive. Does not follow any commands. No nodding of head or attempting to mouth words.\n\nCV: BP labile. Aline does not correlate with pressure. NBP cont to read 20-30pts lower than Aline. Cont. to titrate Levophed gtt to goal of grtr 80 MAP grtr 50 MICU MD . Levo changed to Neo gtt @1700. Titrated to grtr 80. Presently 1.5mcg/kg/min. HR 110's-120's with episodes of tachycardia to 150's. MICU team aware. Lopressor IVP with no effect. Change of CV meds today. please see MARs for changes. CVP 16-19. Cortisol stimulation test completed.\n\nRESP: Trach. No vent changes. No issues. Weak cough. Minimal sxn.\n\nRENAL: Unable to tolerate fluid removal with HD. Pt. hypotensive with to 70's. Levo titrated. to 150's. No result from Lopressor IVP. Renal and MICU teams aware and at bedside to .\n\nENDO: Hypoglycemic throughout day requiring amp D50 x3. BG ranging 30-83. See Flowsheet. No fixed dose this AM. No Lantus tonight per MICU team. consulted. Insulin Lantus dose changed to QD starting tomorrow.\n\nGI: Distended abd. Golden, guaiac+ stools x3. Colostomy bag intact. Minimal flatus. TF remains at goal via . Cont. leakage around site. G-tube to gravity with similar gelatinous yellow drainage. Also noted to be oozing from rectum. MICU team notified.\n\nGYN: No bleeding noted from vagina.\n\nWOUND: Assessed by wound care RN this AM. All QD dsgs changed. Allevyn dsgs on hips from intact. Please see wound care RN note for specifics. Wound care RN called and updated dtr. on recommendations at dtr's request.\n\nPSYCHOSOCIAL: Family updated by MICU team of HD, CV, and Hypoglycemic issues. Dtr updated by attending .\n\nPLAN: Assess MS, Monitor CV, titrate Neo gtt to goal grtr 80, diabetic management-hold Lantus tonight, D50 for hypoglycemia, administer ABX per schedule, Wound management, monitor labs,\nreposition frequently to maintain skin integrity.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-09 00:00:00.000",
"description": "Report",
"row_id": 1524264,
"text": "BS few coarse crackles; no change with MDI's. Sx'd for mod amount pale yellow secretions. No ABG's or vent changes. COntinue with current care plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-10 00:00:00.000",
"description": "Report",
"row_id": 1524265,
"text": "RESP CARE: Pt remains trached/on vent with settings per carevue. No changes in vent this shift. pressure of 25cmH20. Lungs coarse rhonchi with scattered insp wheezes bilat. Sxd thick yellow sputum at start of shift and white sputum by end of shift. ABGs consistent with comp met acidosis.No RSBI this am due to hemodynamic instability. Continue full support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-10 00:00:00.000",
"description": "Report",
"row_id": 1524266,
"text": "FOCUSED NURSING NOTE\nPlease see carevue flowsheet for further details\n\nNeuro: Decrease in LOC continues, alertness waxes and wanes- PEERL, 5mm. Glucoses stabilizing in 80s.\n\nResp: trach patent, ventilated via CMV 0.40/450/16/5. RR 18-24, SPO2 100%. ABG shows metabolic acidosis, attempting compensation. Suctioned infrequently for small thin tan secretions. Lungs coarse to rhonchi left lobe.\n\nHemodynamics: Unable to titrate Neosynpehrine gtt, maintained arterial 85-90s on Neo 1.00-1.25mcg/kg/min. Afib, rate 104-116, occassional PVcs. Anasarca increasing, CVP 12-14. Hct trending down, now 24.9. Small amt vaginal bleed, serosanguinous from rectal. Colostomy stool strong guiac positive.\n\nGI/Metabolic: TF at goal 40ml/hr. Colostomy golden/yellow loose stool, guiac positive. Hypoglycemic earlier in shift, treated with 1amp D50 and maintenance line D5W at 10ml/hr initiated. Glucose now stabilizing in 80s. Potassium 3.0 repleted with 20meq KCL. Metabolic acidosis, Bicitra administered as ordered.\n\nID: Tmax 99.2. Tobramycin/Zosyn/Levaquin/Daptomycin active. WBC decreasing along with Hct. Central line sites benign.\n\nSkin Integrity/Comfort: Please refer to wound care RN progress note- all dressings left intact, plan change daily. Turn and repositioned q2-3hr. Pt shows facial grimace at times, relaxation of face evident after stimulation of nursing care ends and pt allowed to rest in longer periods.\n\nPsychosocial: \"My mom lets us know what she wants, she wants to live\" Pts son at bedside until midnight- Daughter calls for updates. Emotional support and education provided re: disease processes, plan of care, hypoglycemia management, .\n\nPLAN: Monitor hemodynamics on pressors, goal > 80, MAP > 50. Consult with MICU team re: Hemodialysis repeat attempt vs . Monitor for bleeding, anemia management per MICU team. Pulmonary hygiene, aggressive skin care. Monitor hypoglycemia, hold Lantus. Monitor neurological status closely, report changes to MICU team. Administer . Close Social Work follow-up appreciated.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-25 00:00:00.000",
"description": "Report",
"row_id": 1524327,
"text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITALS/LABS/ASSESSMENTS.\nPATIENT CLEARLY GETTING MORE SEPTIC WITH INCREASING LACTATE AND WORSENING LABS.\nRECEIVED 2 U PB FOR HCT OF 20 AND 4U FOR INR 2.8\nUNABLE TO WEAN GTT--GOAL TO KEEP MAP>55.\nWOUNDS CHANGED AS ORDERED, UNCHANGED IN APPEARANCE.\nFAMILY MEETING HELD TODAY WITH DR. / RN/ / /DR. AND SON/DAUGHTER AND HUSBAND. FAMILY VERY ANGRY AND CONTENTIOUS THROUGHTOUT MEETING. LOTS OF YELLING BY SON, MOSTLY DIRECTED AT PERCEIVED POOR CARE GIVEN BY NURSING AND MEDICAL STAFF.\nWHEN ISSUES FINALLY DISCUSSED, IT WAS AGREED TO THE FOLLOWING 5 THINGS:\n1. STOP DIALYSIS FOR 24-48 HRS. AS FAMILY FEELS IT WEARS OUT THEIR MOTHER.\n2. DILTIZEM DOSE WILL BE DECREASED.\n3. FAMILY VERY MUCH WANTS LINE TO BE RESITED IN IR, BUT WERE TOLD IT WAS CURRENTLY TOO UNSAFE TO TRAVEL WITH PATIENT.\nIT WAS AGREED TO TRY TO WEAN NEO TO OF CURRENT DOSE, AND TO KNOW THAT PATIENT'S BLOOD PRESSURE WOULDN'T DROP LOWER THAN 60/S IF PATIENT WAS OFF NEO FOR PROLONGED PERIOD OF TIME (IE/DIFFICULTY PLACING LINE/LOST LINE FOR ANY PERIOD OF TIME).\n4. ID ISSUES --SPECIFICALLY IF AMIAKACIN WOULD BE APPROPRIATE DRUG AT THIS TIME WILL BE ADDRESSED.\n5. HOB WILL BE UP AT 30 DEGREES MOST OF THE TIME IF TOLERATED.\nA/P---AS OUTLINED ABOVE.\n\nMEDICAL TEAM AWARE, WILL CALL WITH ANY CHANGES.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-26 00:00:00.000",
"description": "Report",
"row_id": 1524328,
"text": "Respiratory Care\nMinute ventilation in Fact is consistent with her usual values and not increased as previously report by this therapist\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-26 00:00:00.000",
"description": "Report",
"row_id": 1524329,
"text": "Respiratory Care\nPt. trach and on ventilatory support. No vent setting changes this shift. Pt. sx for abundent thick yellow secretions. ABG's with in normal values. Increasing minute volume noted to occur over duration of shift, may be attributable to increased Lactic acid.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-26 00:00:00.000",
"description": "Report",
"row_id": 1524330,
"text": "Nursing Progress note:\nNeuro: Pt arouses to voice, withdraws to nailbed pressure but making no attempt to communicate. Appears comfortable.\nCV: Tmax 101.1 presently 99.8. HR 100-110's Afib with no ectopy. 95-101 MAP 59-61. Able to wean NEO to 1.5 mcg/kg/min. Pitressin unchanged at 2.4 u/hr. Extremities cool with pulses. HCT 24 this am.\nRESP: lungs clear to dim at bases. No vent changes overnight. Occasional suctioning of thick yellow secretions.\nGI: tube feed at goal. colostomy draining moderate amounts of maroon guaiac + stool.\nGU: aneuric.\nENDO: Cont on insulin gtt at 5u/hr for blood sugars 109-125.\nSKIN: all dressings dry and intact.\nPLAN: Cont to wean pressors. Cont to monitor HCT,PLT and INR\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-26 00:00:00.000",
"description": "Report",
"row_id": 1524331,
"text": "BS fine crackles; no change with MDI's. Sx'd for mod amount thick yellow secretions; inner cannula changed. To IR today for central line placement. No vent changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-14 00:00:00.000",
"description": "Report",
"row_id": 1524404,
"text": "Respiratory Care\nPt. trached and on chronic ventilator management. Remains congested, suction for thick green secretions. Vent settings unchanged due to pt, chronic needs. Oxygenating well, MDIs administered as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-16 00:00:00.000",
"description": "Report",
"row_id": 1524412,
"text": "NURSING NOTE\nPT ALERT/EASILY AROUSABLE, NOT FOLLOWING COMMANDS, NODS INTERMITTENTLY. PERRL, 4MM, BRISK, INTERMITTENLY TRACKING FAMILY MEMBERS. SPONTANEOUSLY TO LUE ONLY. HR 70S-80S, >80/MAP>55 MAINTAINED PER MICU, AFEBRILE. RECEIVED #2 PRBCS THIS EVE, POST-HCT 29, K 3.6, MAG 2.0, INR 1.6. LEFT A/C PICC D/C'D, RIGHT TLCL DRNG SEROSANG. NO VENT CHANGES, O2 SATS 98-100%, SUCTIONED FOR LGE AMTS BRN, THK SECRETIONS. COLOSTOMY W/MOD AMTS REDDISH-BROWN LIQUID DRNG, CLEARING THIS AM. GT TO GRAVITY W/MIN BRWN LIQUID DRNG, JT PATENT, CLAMPED. BS 120S-160S, PM LANTUS HELD, COVERED PER RISS. PT TURNED FREQUENTLY, MULTI DSGS REINFORCED, NO NEW AREAS OF BREAKDOWN NOTED.\n\n TO MONITOR HD, LOC, PULM TOILETING, AGGRESSIVE SKIN CARE, BS CHECKS, FAMILY SUPPORT. SICU , PLAN TO D/C HOME MON.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-16 00:00:00.000",
"description": "Report",
"row_id": 1524413,
"text": "Resp Care\nPt remains trached on full vent support. no vent changes made this shift. Pt went to IR this afternoon for line placement without incident. Suctioned for mod-copious blood tinged to tan secretions. MDIs given. Please refer to for all vent settings.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-16 00:00:00.000",
"description": "Report",
"row_id": 1524414,
"text": "STATUS\nD: AWAKE FOLLOWS SOME SIMPLE COMMANDS..NO SIGNS OF BLEEDING\nA: WD'S UNCHANGED..TO IR FOR PICC PLACEMENT & QUINTON CHANGED OVER WIRE TO TUNNELED DIALYSIS CATH..TOL PROCEDURE FAIRLY WELL..BP REMAINS LABILE..MP TO SR WITH FREQ PAC'S & OCC PVC'S..NO VENT CHANGES SUCTIONED FOR SM AMT THICK TAN/BLD TINGED..COLOSTOMY DRAINING LOOSE BLACK STOOL SM AMT\nR: ESSENTIALLY UNCHANGED\nP: ? TRANSFER HOME ON MONDAY..CONTINUE WITH PLAN OF CARE\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-17 00:00:00.000",
"description": "Report",
"row_id": 1524415,
"text": "RESP CARE: Pt remains trached/on vent on settings per carevue. pressure 25cmH20. Lungs coarse bilat, sxd thick yellow sputum. No RSBI due to hemodynamic instability. Hypotension. Waiting for MD order to place pt on home vent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-17 00:00:00.000",
"description": "Report",
"row_id": 1524416,
"text": "Nursing Progress Note\nPlease see for details.\n\nNeuro: unchanged\n\nCV: bair hugger for low temp, now normothermic. bp varies but continues to be low. Diltiazen held this am.\n\nPulm: sput sent for c+s, gm stain. sx thick yellow. sats>97.\n\ngi: tube feeds remain on hold, black stool from colostomy. hct 27.\nBS 44 at 0400, D50 amp ivp, rpt 80.\n\ngu: anuric, for hemodialysis this am.\n\ncontinues to seep large amts serous fluid from all skin breaks.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-17 00:00:00.000",
"description": "Report",
"row_id": 1524417,
"text": "resp care\nremains on vent settings as charted, no changes made. discussed home vent with team..decided not necessary to place on pt until closer to discharge (approx 24hrs prior). admin mdi's per orders. pressure maintained between 25-30 with positional leak only.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-23 00:00:00.000",
"description": "Report",
"row_id": 1524197,
"text": "Update\nO: see carevue flowsheet for specifics...\nNeuro: neuro status unchanged, eyes open spont perl at 4mm and tracking w eyes, does not follow any commands.\n\nCV: afib no ectopy.Lopressor held for sys bp <90. Sbp trending up to wnl range.doppler pt's bilat. Multiple skin issues and bilat lower extrms dsd.\n\nResp: remains on cmv tv 450 fio2 40% rr 16 peep 5. trach in place, trach care done. Adeq sats.Sux for thck tan.\n\nGi: g-j tube w tf at goal as ordered.Glucoses rx per ss, no reg insulin req. Rec'd pm lantus dose.\n\nGu: renal failure pt on sched for hemodylasis for Monday.\n\nSkin: multiple skin issues. Ble kerlex drsg.. Decub on coccyx , area w light yellow drngs->wound skin cleanser to area and aquacell dsg to be applied.\n\nHeme/ID: am labs pending. Tmax 100.7 remains on tobra and zosyn. tobra peak tobra level.\n\nA/P: hemodialysis on mnday.pulm toilet.wound and skin drsgas done per schedule.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-23 00:00:00.000",
"description": "Report",
"row_id": 1524198,
"text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT OPENS EYES SPONT. MOVES LEFT ARM. DOES NOT FOLLOW ANY COMMANDS.\n\nCV-REMAINS IN AFIB. SBP STABLE. SKIN WARM. +PP VIA DOPPLER.\n\nRESP-NO VENT CHANGES. O2 SAT 100%. LS COARSE. SXN PRN FOR THICK YELLOW SPUTUM. TRACH CARE DONE.\n\nGI-ABD SOFT, NT/ND. +BS. COLOSTOMY PINK WITH LOOSE GOLDEN STOOL. TOL TF VIA J-TUBE.\n\nGU-ANURIC. TO HAVE HD ON MONDAY.\n\nCOMFORT-APPEARS COMFORTABLE.\n\nENDO-GALRGINE GIVEN. NO SSRI NEEDED.\n\nID-AFEB. REMAINS ON ABX.\n\nSKIN-CON'T WITH MULTI SKIN TEARS AND BREAKDOWN. SEE FLOWSHEET. WOUND CARE AND DSGS CHANGED AS ORDERED.\n\nP-CON'T WITH CURRENT PLAN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-24 00:00:00.000",
"description": "Report",
"row_id": 1524199,
"text": "Resp Care Note:\n\nPt cont trached on mech vent as per Carevue. Lung sounds coarse after suct mod th pale yellow sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required . Positional air leak persists however adequate ventilation is maintained. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-24 00:00:00.000",
"description": "Report",
"row_id": 1524200,
"text": "nursing progress note\nblood sugars are elevated to >200. glargine 90 units q 12 hrs. HO notified, there is no sliding scale.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-24 00:00:00.000",
"description": "Report",
"row_id": 1524201,
"text": "Resp Care\n\nPt remains on full vent support maintaining mv's in the 9-11L range. BS are diminished to coarse and suctioning thick yellow sputum in small to moderate amts. Cuff pressure at 18 cmH2O\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-15 00:00:00.000",
"description": "Report",
"row_id": 1524286,
"text": "Skin Assessment.\n\n->Bil underarms pink, no breakdown noted. Skin cleansed and dried well. Miconazole powder applied to both under arms.\n\n->Bil breast folds are pink with small pinpoint open area. Areas also have small amounts of thick whitish/yellow discharge. Areas cleansed and dried well. Miconazole powder applied to areas, dry gauze to cover.\n\n->Bil groin folds are pink/red with open areas. Areas are draining moderate amounts of sero/sang. Areas cleansed with wound cleanser and dried. Gauze placed inbetween folds and have been changed frequently.\n\n->Right posterior lower arm with two small pinpoint open areas draining copious amounts of sero fluid. Area cleansed with wound cleanser and drainage bag applied to area.\n\n->Right lower quad with skin breakdown from tape. Area again cleansed with wound cleanser, dried and drainage bag applied to help protect drainage from leaking into CVL and Aline.\n\n->Left lower posterior leg with open area. +granulation, small amount of sero/sang drainage. Wound is about 12cm long, 2cm wide and 0.5-1cm deep. Wound cleansed with wound cleanser and dried. Adaptic with DSD covering area.\n\n->Left great toe and other toes are dark brown, dry, and brittle. Left great toe with a scant amount of thick tan drainage at large knuckle. Area covered with DSD. Left heel is pink with escar. Area cleansed with wound cleanser and DSD applied.\n\n->Right lower posterior leg with open area. Area is pink with +granulation. Area cleansed well with wound cleanser, adaptic and DSD to the area. Right heel is pink, +eschar, no drainage. DSD applied.\n\n->Right toes with small black non-draining areas. DSD covering for padding.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-15 00:00:00.000",
"description": "Report",
"row_id": 1524287,
"text": "Respiratory Therapy\n\nPt remains trached w/ #7.0 Shiley trach on full mechanical support. No vent changes made this shift. Continues on A/C ventilation w/ PIP/Pplat = 24/20. BLBS coarse, suctioned for small amounts of thick tannish/yellow sputum. MDIs given as ordered. SpO2 90s. ABG good. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-15 00:00:00.000",
"description": "Report",
"row_id": 1524288,
"text": "Please See Carevue for Specifics.\n\nArousable to voice, does not follow commands, only moves LUE to nailbed pressure. Afternoon dose of 0.5mg Ativan held this afternoon for ?sedation. NSR, frequent PVC's, ?borderline first degree AV block and left BBB. +generalized edema, fluid balance goal is to be even/24hours. Remains on CMV. Suctioned for thick yellow secretions. Lungs are coarse-clear and diminshed at bases. ABd is obese with +BSx4, G-tube to gravity with clear/yellow mucous, J-tube with TF at goal. Pt does not void.\n\nSKIN: See previous assess entered. Bil hip dressings changed, +granulation, draining small amounts of sero/sang. Aquacel AG applied after cleansed with wound cleanser, alleyvn covering. Iliac Crest draining small amount of thick yellow discharge. Area cleansed well with wound cleanser, Aquacel AG applied to area, followed by DSD, and super-sorb pad.\n\n: Monitor MS, monitor skin integrity, dressing changes as ordered. Ativan when not sedated. Continue to offer emotional support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-09 00:00:00.000",
"description": "Report",
"row_id": 1524138,
"text": "Condition Update A:\nPlease refer to careview and remarks for details.\n\nPt alert, when dozing pt is easily arousable, inconsistently follows commands. Moves LUE only. PERL 3-4mm bilat. Indications of pain during repositioning.\n\nTmax 100.1, low 98.7. Cont in afib 90-116 with rare PVC's.. SBP >90 tol MAP's >50 as discussed with Dr. . Potassium repleted per Jtube. During HD BP ranged 80-100's. 2L removed.\n\nLS CTA dim bases. Suctioned scant secretions. Trach care done.\n\nLE dsgs changed as in careview. Jtube dsg changed x2 as copious mucous drainage bursts dsg. Under flange of jtube are two open areas. The first is at the 1000 position with a yellow slough wound bed. The second is at the 0500 position with small amount of bleeding. Dr. from IR up to see pt and made aware of drainage from insertion site and the two open areas under flange.\n\nLantis dose increased as glucose levels remain greater then 250.\n\nHCP, , discussed her concerns. Support provided. Dr. and Dr. notified.\n\nPLAN: Neuro exam every four hours. Skin care per orders. Labs per orders. Monitor glucose levels and effect of lantis increase. Reposition every two hours. Monitor hemodynamics, SBP>90 and MAP>50. Facilitate discharge. Call H.O. with changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-09 00:00:00.000",
"description": "Report",
"row_id": 1524139,
"text": "Respiratory Therapist\nBreath sounds bilaterally diminished, few wheezes, suctioned for small thick yellowish, WBC 11.5 consistent with bacterial infection, Hemoglobin 9.1 consistent with anemia, creatine 2.3 suggesting renal insufficiency for which patient had hemodialysis this morning, patient was afebrile whole day and stayed into chronic A-fib,no ABGs today, patient will continue to receive ventilatory support and close monitoring.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-10 00:00:00.000",
"description": "Report",
"row_id": 1524140,
"text": "Focus-Condition Update\nData-Low grade temp during the night. No vent changes-pt suctioned for sm ams clear white secretions. Dressings changed as scheduled.\nBlood sugars better controlled with increased Insulin dose. Continues to have mod amt clear mucousy drainage from around PEJ site.\nAction-Continue to monitor. AM labs drawn as ordered.\nResponse-Ongoing evaluation.\nPlan-Continue to monitor Blood sugars closely. Ongoing discharge planning for discharge to home.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-10 00:00:00.000",
"description": "Report",
"row_id": 1524141,
"text": "Resp Care: pt continues trached and on ventilatory support with a/c, no vent changes maintaining spo2 100%, persistent minimal cuff leak but attaining volume; BS coarse, sxn thick white secretions, rx with mdi albuterol/atrovent/flovent, rsbi 93, consider short trach collar trials\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-30 00:00:00.000",
"description": "Report",
"row_id": 1524226,
"text": "Respiratory Therapist\nBreath sounds revealed clear right lung and diminished left lung, suctioned for small thick yellowish, still on droplet precautions for MRSA, afebrile and stayed whole day into chronic A-fib, Oxygen saturation stayed around 100, patient was treated with Albuterol, Atrovent, Flovent inhalers, WBC 20.9 consistent with bacterial infection, Hemoglobin only 9.1, signs of anemia, no ABG drawn nor vent changes done during the shift, patient will remain vented, most likely on same settings and will continue to be closely monitored.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-24 00:00:00.000",
"description": "Report",
"row_id": 1524321,
"text": "condition update\nno significant change in status; still requires pressor support. given replacements as ordered. crrt on/off= fluid removal dependant on bp, acidosis worsening . discussed with resident and will attempt to support bp to allow for optimal fluid removal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-24 00:00:00.000",
"description": "Report",
"row_id": 1524322,
"text": "Respiratory Care\nBreath sounds bilaterally coarse, suctioned for moderate thick green, oral temp ranged 96.5 to 98.1 using warming blanket since she stay on CCVHD whole day, WBC 9.8 ruling out the presence of bacterial infection, hemoglobin only 8.5 which is indicative of anemia, lactic acid 3.4, pressure 15cmH2O, patient has been treated with Albuterol, Atrovent and Flovent inhalers. Projected family meeting did not happen today, is postponed for tommorrow. No vent changes ordered nor made today, settings are the same.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-24 00:00:00.000",
"description": "Report",
"row_id": 1524323,
"text": "nsg note\nsee flowsheet for specifics.\n\nNEURO-OPENS EYES SPONT. MOVES LEFT ARM ON BED. DOES NOT MOVE OTHER EXTREMITIES.\n\nCV-BACK IN AFIB. RATE 70-100'S. DOWN TO 70'S. ON MAX DOSE OF NEO. TO START VASOPRESSIN. SKIN WARM. JAUNDICE.\n\nRESP-REMAINS TRACHED AND VENTED. NO VENT CHAGNES MADE TODAY. PT ACIDOSIS IMPROVING. SXN PRN FOR THICK YELLOW SPUTUM. LS COARSE WITH SOME WHEEZES AND RHONCHI. INHALERS GIVEN. O2 SAT 98%.\n\nGI-ABD OBESE, +BS. TOL TF VIA . PEG TO GRAVITY WITH BROWN TO YELLOW DRG. STOMA PINK WITH LOOSE GOLDEN STOOL. + MUCOUS DRG FROM ANUS. HAD US OF RUQ.\n\nGU-ANURIC ON . UNABLE TO TOL ANY FLUID REMOVAL D/T HYPOTENSION.\n\nENDO-ON INSULIN GTT.\n\nACT-REPOSTIONED FREQ. ON AIRBED.\n\nSKIN-CON'T WITH MULTI SKIN ISSUES. SEE FLOWHSEET. DSGS CLEANED AS ORDERED. SKIN UNCHANGED.\n\nID-HYPOTHERMIC WITH BAIR HUGGER ON.\n\nP-CON'T WITH CURRENT PLAN. NEO AND VASOPRESSIN GTTS. SKIN CARE. INSULIN GTT. FAMILY MEETING PLANNED FOR TORROW AT 3PM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-25 00:00:00.000",
"description": "Report",
"row_id": 1524324,
"text": "Respiratory CAre\nPt. trached and chronically ventilated. Sx for thick secretions. No vent setting changes made this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-25 00:00:00.000",
"description": "Report",
"row_id": 1524325,
"text": "condition update\ncondition continues to remain guarded with bp 80-90 systolic on 5mcg neo and 2.4 pitressin. crrt keeping even to 50ml removal but pt still very much compromised with decreased pressure\ninsulin titrated for bs no real issues. team aware of am labs and will discuss treatment during rounds. pt has no visible evidence of bleeding. will continue to monitor\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-25 00:00:00.000",
"description": "Report",
"row_id": 1524326,
"text": "Respiratory Care\nPt remains trached and on vent support. No vent changes were made during shift. Lung sounds were course throughout. Pt was suctioned for moderate amounts of thick yellow secretions. Pt received MDI's as ordered. Last ABG 7.39/34/84/21/-3. Care plan is for a family today. No vent changes to be made. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-14 00:00:00.000",
"description": "Report",
"row_id": 1524405,
"text": "resp care\nremains on ac mode. no changes made this shift. mdi's given q4h. sxned yellowish sputum. trached/vent dependant. positional leak with pressure kept at <30 cmh20. tolerating well. minimal to no spont efforts.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-14 00:00:00.000",
"description": "Report",
"row_id": 1524406,
"text": "Nursing Update\nSee flowsheet for specific info\n\nNeuro: Pt nodding and tracking occasionally, not following commands, no movement of extremities noted. Afebrile.\n\nCV: NSR with occasional PVC's, kept above 80, Neo gtt remains off. Crit stable despite vag bleeding and blood in stool. PICC line dressing very leaky, line is out about 7cm, MICU aware.\n\nResp: Remains vented, CMV, PEEP 5, 50%. No vent changes made today. Sux'd for small amount of thick yellow sputum, lungs coarse throughout, sating 90-100%.\n\nGI: Bloody stool in colostomy, MICU aware, crit stable 26-27. GI consulted this morning, pt to have colostomy in a.m., TF's off, Go-lytly started for bowel prep.\n\nGU: Pt anuric, scheduled to be dialyzed tomorrow.\n\nEndo: Insulin gtt off. Blood sugar low today (20's) 1 amp D50 given, MICU HO aware, Glargine to be held this evening.\n\nSkin: All dressings changed today.\n\nPlan: Coloilioscopy to be done tomorrow.\n Closely monitor blood sugar.\n Dialysis tomorrow.\n Home by end of week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-15 00:00:00.000",
"description": "Report",
"row_id": 1524407,
"text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\n\nNO MENTAL STATUS CHANGES, NODDING INTERMITTENTLY, MOVES ONLY LUE, NOT FOLLOWING COMMANDS. PERRL, 4MM, BRISK, OPENS EYES SPONTANEOUSLY. HR 60S-70S, >80/MAP>55, REMAINS OFF DRIPS, AFEBRILE. HCT 26.6, K 3.6, MAG 1.8, HO AWARE. NO VENT CHANGES MADE, LUNGS COARSE THROUGHOUT. PT SUCTIONED FOR MOD AMTS YELLOW, THICK SECRETIONS. TF OFF SINCE MN, COLOSTOMY W/SM AMT MAROON, LOOSE STOOL, GT W/MIN OUTPUT. BS DOWN TO 20S THIS EVE, 1/2AMP D50 GIVEN X3, PRESENTLY 50S-HO AWARE, TO MONITOR. PT TURNED FREQUENTLY, NO NEW AREAS OF BREAKDOWN NOTED, SEEPING MOD AMTS SEROUS FLUID TO MULTI SPOTS.\n\nPLAN: HEMODYNAMIC MONITORING, FREQUENT BS CHECKS, DEXTROSE AS NEEDED, SERIAL HCTS. AGGRESSIVE SKIN CARE, HD PLANNED FOR TODAY, POTENTIAL D/C HOME THURS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-15 00:00:00.000",
"description": "Report",
"row_id": 1524408,
"text": "Resp Care\nPt. remains trached on AC mode w/o change overnight. BS: coarse t/o sxn'd q4 for mod. thick greenish yellow. Mdis given q6 as ordered.\nPlaN:HD today and possible d/c home later this week. Pt. needs to be transitioned to home vent at some point today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-15 00:00:00.000",
"description": "Report",
"row_id": 1524409,
"text": "BS coarse crackles; no change with MDI's. Pt had HD today and is now awaiting colonoscopy. After procedure will attempt to transition to home ventilator (). If she tolerates vent successfully for about 2 days, she will be discharged home.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-14 00:00:00.000",
"description": "Report",
"row_id": 1524284,
"text": "focus update note\nhypothermic 95-96 with bair hugger on pt 97-98 consistently most of day, currently bair hugger off last temp 98.7, initially heart rate 130-150 afib- 78-high 80s, pt given one unit PRBC and heart rate improved to 102, increased high 90s to 120. diltiazem gtt started at 5mg/hr. goal map >55, goal CVP = 10, initially cvp 17 now 10.\n\nresp: minimal suctioning secondary to platelet count 22-30, suctioning for small amount yellow thick sputum, no vent changes today, o2 sat consistently 100%, lsc dim at bases\n\ngu/gi: ileostomy draining yellow liquid stool, anuric, TF continue- no residual, bs hypoactive\n\nskin: changed decub and hip dressings at 1600, skin red with good granulation, scant bloody drainage, yellow slough, toes black on bilateral feet, skin under pannus ulcerated open drainag yellow draiange- resident notified and aware- area cleaned with wound spray and dressed with dsd.\n\nCRRT clotted at 1700 and restarted at 1800, please see dialysis flowsheet for details\n\ngoals: map > 55, cvp 10, run CRRT to keep pt 1 liter positive over 24 hours, continue with wound care as ordered collaborate with skin RN as needed, continue with lab monitoring q 6 hours, transfuse platlets for less than20, moniotr for signs symptoms bleeding, control blood sugars with insulin gtt and monitor finger stick q 1 hour.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-15 00:00:00.000",
"description": "Report",
"row_id": 1524285,
"text": "Update\nO: See carevue for specifics...\nNeuro: awake,alert,perl @ 4mm brisk.moving lue otherwise no mvmnt.\n\nCV: sr to on diltiazem gtt. 90-110 range Cvp 12-15 range.Cont on crrt w goal overnight 1 liter positive achieved. Vss overnight.Doppler dp's bilat, necrotic toes. Ble drsg d&i.\n\n\nResp: trached on cmv mode tv 450 rr 16 fio2 40% w peep 5cm w adeq abg on same.Lungs lcear diminished, lavaged and suct for thick yellow.\n\nGi: g-j tube w tf at goal 40cc/hr via jtube, gt to gravity.Abd obese soft, colostomy w loose golden brn stool. glucoses managed per riss.\n\nGu/Renal; on crrt and tol well w current goals 1liter + .Cont on K+ Ca+ gtts per ss.\n\nHeme/Id: hct 27, plt ct holding at 33K pt 18.4 inr 1.7. wbc flat. temp subnl at times req bair hugger blanket.HO aware plt ct's <50 and no rx ordered.\n\nskin/wounds: coccyx decub drsg , purulence non healing site. Wound cleanser and aquacell packing and sofsorb drsg .Bilat lower leg dsg intact.Excoriated area under -> miconazole to site.\nA/P: Cont crrt w lyte repletion per ss. Confirm crrt goals for today w renal fellow. Pulm toilet. Wound and skin care.Q!h glucoses and titrate insulin gtt.Empty and record colostomy q shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-30 00:00:00.000",
"description": "Report",
"row_id": 1524346,
"text": "Respiratory Care:\n\nPatient trached with 7.0 shiley. Vent dependent. Vent settings unchanged. Vt 450, A/c 16, Fio2 40% and Peep 5. 02 sats 99%. Bs clear bilaterally. Sx'd for sm amount of thick yellow secretions. Albuterol/Atrovent MDI's given Q4hr and Flovent given . CXR Worsening pleural effusions. Sputum + for Pseudomonas. No further changes made. Continue with mechanical support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-30 00:00:00.000",
"description": "Report",
"row_id": 1524347,
"text": "Focus Condiiton Update\nSee flowsheet for specific info.\n\nNeuro: Pt dozing off and on throughout the day, will occassionally nod to simple questions. Not following commands.\nCV: A-fib 100-120's. Neo on this a.m., weaned off this afternoon. Pt had one episode of wide complex tachycardia to 140's, MICU team at bedside, EKG obtained, 2gm Calcium Gluc given, 20mg Diltiazem given. Pt's HR returned to 90's while pushing Dilt. K+ of 3.3 repleted.\nResp: Pt remains on CMV, no vent changes made today. Sux'd for small amount of thick white sputum.\nGI: Abdomen is obese, +BS. G-tube to LCS draining brownish stool. Colostomy intact, also draining small amount of brownish loose stool.\nGU: Pt continues to have a small amount vaginal bleeding, OB has not yet consulted at time of note.\nSkin: Wound care RN in this a.m. to change all dressings. Xeroform in skin folds replaced.\nEndo: BS's running high, MD aware, Insulin gtt restarted, sugar checked qhr.\nSocial: Husband and son in briefly this morning to see pt.\nPlan: Titrate Insulin to keep BS 100-150\n Continue to monitor hemodynamics\n Change wound dressings as needed\n Family support.\n Cont. with MICU , contact HO with changes\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-30 00:00:00.000",
"description": "Report",
"row_id": 1524348,
"text": "Resp Care\nPt reamins trached on full vent support. no vent changes made this shift. Pt continues to have mod amt of thick yellow sputum. MDIs given. will continue to follow\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-01 00:00:00.000",
"description": "Report",
"row_id": 1524349,
"text": "Please See Carevue for Specifics.\n\nPt has had no change over night. Pt kept comfortable and with skin care, back rub, repositioning, and reassuring of care.\n\nSOC: Pt son was escorted out of building by security this evening for his continuous demanding and swearing behaviors to all staff. MICU resident, MICU attending, Nursing Supervisors aware of plan. Son is allowed supervised visits with security for 30 minutes/day. Security has explained the restrictions to the son. Pt HCP also aware of plan.\n\n: Continue to keep pt comfortable, pain meds as needed, HD this morning, skin care as ordered, surgical team to follow, family aware of plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-01 00:00:00.000",
"description": "Report",
"row_id": 1524350,
"text": "Respiratory Care:\n\nPatient trached with 7.0 Shiley. Bs coarse bilaterally with crackles R base. Some increased WOB noted at beginning of shift. Secretions unchanged. Sx'd for sm amounts of thick yellow secretions. Albuterol/Atrovent MDI's given Q4hr and Flovent . CXR repeated. Peep increased to 8cm for increased fluid. Repeat ABG's revealed PaCO2 slightly elevated. Current vent settings Vt 450, A/c 16, Fio2 40% and Peep 8. No further changes made.\nPlan: Continue with mechanical support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-01 00:00:00.000",
"description": "Report",
"row_id": 1524351,
"text": "pt remained on full vent support throughout shift, Bronch done around 1PM looking for any abnormalities but was negative. Different settings attempted in order to make pt look more comfortable, but unsuccessful. Sx'd for minimal secretions. ABG within normal limits.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-31 00:00:00.000",
"description": "Report",
"row_id": 1524227,
"text": "Respiratory Care\nPt remains trached on ventilator. No vent changes made. BS clearer today, still diminished at bases. Suctioned for small amount of thick tan secretions. No ABGs drawn this shift. Pt oxygenating well with SpO2 100%. MDIs given as ordered. RSBI attempted but pt showed no spontaneous effort.\nPlan: continue ventilator support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-31 00:00:00.000",
"description": "Report",
"row_id": 1524228,
"text": "Neuro:pt is alert . response to question by nodding appears appropriate.\nPain: pt had some discomfort when changing leg dsgs demerol given.\nCV: chronic AF SBP >85 today. R single lumen picc patent. RSC quinton.\nlungs: clear to coarse . more secreation today then yesterday. thick yellow sputum. BS more coarse.\nGI: ABD soft BS present. TF at goal tolerating well. colostomy pink draining brown liquid.\nGU: foley in place . still with small amt of blood.\nGYN: still having vaginal spotting of blood.\nEndo: FS 70-113 on lantus @ 86 q12.\nSkin: see care view and wound care nurses note. turned q3-4 hours.\nA/P continue scan care as indicated. monitor as indicated. HD tomorrow. continue lantus at present dose . continue monitoring bleeding. given Vita K as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-31 00:00:00.000",
"description": "Report",
"row_id": 1524229,
"text": "Respiratory Therapist\nBreath sounds clear, few crackles, suctioned for copious thick yellowish secretions, WBC 20.1, ongoing bacterial infection, hemoglobin only 8.6 patient is anemic, patient was afebrile and stayed into chronic A-fib treated with Albuterol, Atrovent and Flovent inhalers, no vent changes nor Arterial Blood Gas done today, patient still under close monitoring.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-01 00:00:00.000",
"description": "Report",
"row_id": 1524230,
"text": "Respiratory Care\nPt remains trached on full vent support, breathing slightly over the ventilator. BS coarse & diminished bilaterally. Suctioned for small-mod amounts of thick white sputum. MDIs given as ordered. SpO2 100%.\nPlan:Continue vent support\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-01 00:00:00.000",
"description": "Report",
"row_id": 1524231,
"text": "NURSING\n VSS, AFEBRILE. CONTINUES IN AFIB. HCT STABLE. MINIMAL BLEEDING EITHER VAGINALLY OR FROM FOLEY. NO ISSUES OVERNIGHT. SEE CARE VUE FOR FULL SPECIFICS.\n CONTINUE TO MONITER HEMODYNAMICS. REPEAT HCT THIS AFTERNOON AFTER HEMO. HEMODIALYSIS TODAY. CONTINUE TO MONITER FOR VAGINAL OR BLEEDING FROM FOLEY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-17 00:00:00.000",
"description": "Report",
"row_id": 1524295,
"text": "Nursing note:\n Alert, no neuro change. Not following commands or communicating. Does not appear to be in any pain. PERRLA. No neuro changes. No vent changes, remains trached on A/C. Appears comfortable. Slightly hypothermic this am, Bair Hugger on low to keep temps in 97s. SR, occ PVCs. Dilt gtt titrated down to 5/hr, well tolerated. WBCs elevated today, team aware. Cultured overnight. ID following, on mult. IV abx. EKG done per MICU request. >80 w/MAP >50 on Neo gtt, unable to titrate down. +BS, tolerating TFs via jtube, gtube to GD. Colostomy intact, liquid golden stool. Glucose stable on insulin gtt. Anuric, running to keep pt. even. K+ and Calcium gtts running per sliding scale.\nImpressive wounds to hips/coccyx and LEs, dressings done per skin care RN recs. See Flowsheet for details.\n\nA/P: Remains on and pressors for sepsis as well as multiple medical issues. Continue to monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-17 00:00:00.000",
"description": "Report",
"row_id": 1524296,
"text": "Respiratory Care Note:\n Patient remains on full vent support. #7 extra long Shiley trach is secure. BS=bilat, coarse with rales and rhonchi. Suctioned for moderate amounts of thick yellow secretions. Plan to maintain supportive care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-13 00:00:00.000",
"description": "Report",
"row_id": 1524399,
"text": "Nursing Progress Note\nPlease see for details\n\nNeuro: unchanged.\n\nCV: afebrile, bair hugger off with temp maintained. HR A fib with rare pvc's, rate controlled. BP difficult to obtain at times, but remains adequate. Neo drip remains off.\n\nPulm: bs coarse, sx for tan thick secretions, but less brown and fewer than yesterday. O2 sats 96-100 when obtainable.\n\ngi: tube feeds via j tube at 40/hr tol well. gt to gravity. golden stool from colostomy.\n\ngu: anuric, for hemodialysis today.\n\nblood transfusion completed, Hct pending with am labs.\nBlood glucose under control, see flow sheet and labs for FS sugars.\nInsulin drip remains off.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-13 00:00:00.000",
"description": "Report",
"row_id": 1524400,
"text": "Respiratory Care\nPt. trached on ventilatory support. Congested, frequently suctioned for thick tan-green secretions. Trach appears to have positional leak even with adequate . No vent setting changes made this shift. Chronically vented with no plans for weaning, no RSBI performed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-13 00:00:00.000",
"description": "Report",
"row_id": 1524401,
"text": "Respiratory Care:\n No change in vent status. Patient receiving dialysis. BS=bilat with occassional rhonchi. Suctioned for thick green tinged sputum and receiving MDIs. See Carevue flowsheet for specifics.\n Spare #7 X-Long Shiley trach ordered for possible patient discharge to have as spare. Notes written for possible DC .\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-13 00:00:00.000",
"description": "Report",
"row_id": 1524402,
"text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\nNEURO: PT OPENING EYES SPONTANEOUSLY, PERRL 4-5MM, BRISK, INTERMITTENTLY TRACKING. NOT FOLLOWING COMMANDS, MIN SPONTANEOUS MVMT, LUE OBSERVED ONLY. NO ATIVAN GIVEN.\n\nCVS: REMAINS OFF PRESSORS, MAP MAINTAINED>55, VIA 70S-110S, UP TO 150S W/HD, HO AWARE, ?ACCURACY. PT HEMODIALYSED FOR 1.5L, ALBUMIN GIVEN CONCURRENTLY FOR >50 PER MICU TEAM DURING HD. PM HCT 26.7, AFEBRILE.\n\nRESP: NO VENT CHANGES, SET RATE 22, PT BREATHING 2-6 BPM OVER. SUCTIONED Q2-3 HRS FOR SM AMTS THICK, YELLOW-BROWNISH SECRETIONS. LUNGS COARSE THROUGHOUT, RHONCHOROUS AT TIMES. O2 SATS 96-100%.\n\nGI/GU: REMAINS ANUERIC. COLOSTOMY PATENT W/MOD AMTS GOLDEN, SEMI0FORMED STOOL. GT TO GRAVITY W/SM AMT VISCOUS YELLOWISH DRNG. JT PATENT, TF AT GOAL, MIN RESIDUALS.\n\nENDO: REMAINS OFF INSULIN DRIP, BS 102-138--NO COVERAGE REQUIRED. LANTUS 50 UNITS GIVEN THIS AM.\n\nINTEG: MULTIPLE DSG CHANGES PERFORMED PER WND CARE PROTOCOL, PT TURNED FREQUENTLY, NO NEW AREAS OF BREAKDOWN NOTED.\n\nPLAN: HEMODYNAMIC MONITORING, AGGRESSIVE SKIN CARE, PULM TOILETING/RESP SUPPORT, FAMILY SUPPORT. PROBABLE D/C TO HOME THURS, REMAIN IN SICU FOR HD ON WEDS, SICU .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-14 00:00:00.000",
"description": "Report",
"row_id": 1524403,
"text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: OPENS EYES SPONT. INTERMITTENTLY TRACKING. PERRL. NO SPONT. MOVEMENT SEEN IN EXTREMITES. PT DOES APPEAR TO GRIMACE WHEN ABD LIFTED TO PERFORM SKIN CARE ON FOLDS.\nCV: AFEBRILE. REMAINS IN AFIB WITH RARE PVC'S. 80-95.\nRESP: NO VENT CHANGES. SX FOR SM AMTS THICK YELLOW SECRETIONS. BS COARSE.\nGI: TOL TF AT GOAL. PEG TO GRAVITY DRAINING LIGHT TANNISH-BROWN. OSTOMY PATENT WITH LOOSE REDDISH BROWN STOOL. HO AWARE. HCT STABLE AT 27.\nGU: DIALYSIS SCHEDULED FOR WEDNESDAY\nENDO: OFF INSULIN GTT. BS 72-90.\nA/P: . TO MONITOR HEMODYNAMICS, SERIAL HCTS AS ORDERED, . DRESSING CHANGES AS PER WOUND CARE NURSE., ASSIST FAMILY IN GOAL OF GETTING PT HOME LATER THIS WEEK.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-29 00:00:00.000",
"description": "Report",
"row_id": 1524343,
"text": "CONDITION UPDATE\nASSESSMENT:\n PATIENT OPENS EYES SPONTANEOUSLY, DOES NOT FOLLOW COMMANDS. ONLY MOVES LEFT UPPER EXTREMITY. PATIENT DOES NOT APPEAR IN ANY PAIN WITH MOVEMENT OR DRESSING CHANGES, NO NEED FOR PAIN MED.\n HEART RATE 100-110 AFIB AND MAP > 55 ON LOW DOSE NEO GTT THIS AM. PATIENT STARTED ON HD THIS AM, PATIENT WITH HR INCREASING TO 130'S-140'S BUT BP STABLE. HD RN UNABLE TO REMOVE ANY FLUID, FILTRATED FOR 2 HOURS AND TREATMENT STOPPED. AFEBRILE, WBC COUNT NORMAL. INR 2 THIS AM & PATIENT HAVING MODERATE AMOUNTS ? VAGINAL BLEEDING. 2 UNITS GIVEN, AWAITING REPEAT LABS.\n LUNG SOUNDS OCCASIONALLY COARSE, SUCTIONED FOR MODERATE THICK YELLOW SPUTUM. REMAINS ON ASSIST CONTROL. ABDOMEN SOFTLY DISTENDED, J-TUBE CLAMPED AND G-TUBE TO LOW CONT SUCTION WITH MODERATE AMOUNT BROWN DRAINAGE. COLOSTOMY STILL WITH MINIMAL LOOSE BROWN STOOL. ? BOWEL OBSTRUCTION RESOLVING. PATIENT TO BE STARTED ON TPN TOMORROW. SEE FLOWSHEET FOR MULTIPLE SKIN AREAS AND TREATMENT.\nPLAN:\n WEAN NEO TO OFF. REPEAT KUB TOMORROW TO SEE IF BOWEL OBSTRUCTION RESOLVING. CASE MANAGER AWARE OF PATIENT. CONTINUE WITH SKIN CARE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-29 00:00:00.000",
"description": "Report",
"row_id": 1524344,
"text": "Resp Care\nPt reamins trached on full vent support. No vent changes made this shift. innner cannula changed this afternoon. Pt suctioned for sm amt of thick pale yellow secretions. plan at this time is to continue vent support, please see carevue for current settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-30 00:00:00.000",
"description": "Report",
"row_id": 1524345,
"text": "Please See Carevue for Specifics.\n\nNeuro: Alert, orientation unknown, does not follow commands, evening dose of 0.5mg Ativan adm and early morning dose held.\n\nCV: Afib 100-130's. Neo weaned off. Generalized edema.\n\nRespir: Remains on CMV. Suctioned for scant amount of thick yellow secretions.\n\nGI: Abd is softly distended, +bsx4, Gtube to LWCS with thick brown/ stool draining, aware of findings. Stoma pink and draining scant amounts of loose stool. Clear/yellow mucous draining from rectum.\n\nGU: Vaginal bleeding, aware, GYNO/OB to .\n\nSKIN: per family request: Xeroform applied to all folds: Underarms, under breast, groin area. Sacral area with thick yellow/green foul drainage. Area cleansed well with soap and water followed by wound cleanser and Aquacel Ag, softsorg to cover. Right trocanter site with thick yellow foul drainage. Site also cleansed with soap and water followed by wound cleanser and Aquacel Ag. aware of findings, no intervention at this time.\n\n: Wound RN to follow . Gyno/OB consult . HD scheduled . Continue to monitor skin integrity, hemodynamics, family meetings as needed. ID to follow regarding antibiotic treatment. KUB scheduled to see if bowel obstruction is resolving.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-21 00:00:00.000",
"description": "Report",
"row_id": 1524431,
"text": "Respiratory Care\nBreath sounds bilaterally coarse, suctioned intermittently for moderate thick yellowish secretions, pressure 20cmh2o, patient was afebrile whole day, stayed mostly into normal sinus rhythm, and was mostly hypotensive. Patient was treated with Albuterol and Atrovent inhalers, was swithched at 1015 am on her own home ventilator HT 50 with the help of respiratory supervisor,4L O2 bleeded in instead of dialing an FiO2, settings are about the same they were on , 450 x 22 5PEEP, patient might get discharged with next two days, should be put back on vent overnight since she has tracheostomy and the home vent only has HME. No ABGs drawn nor vent settings changes done up to this point.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-21 00:00:00.000",
"description": "Report",
"row_id": 1524432,
"text": "Nursing Note 7a-7p:\nNursing Assessment:\n\nPt afebrile all day, white count coming down. Tentative plan to d/c home tommorrow but pt may have to stay d/t issues with supplies being covered by medicaid, which social work and casemanagement have been working on. Wound care nurse needs to contact medicaid and explain dressings/wounds and amounts of supplies needed. Wound care also to arrange a time with pt's family to go over the dressings for home . Other issues include GI to discuss with pt's dtr reasons for not changing over site again (including risk for bleeding/fistula formation). Vascular to be in touch with pt's dtr regarding toes and if they want to remove the toes or not. Dtr does not want BKA, but may be willing to remove just toes per case . Pt's dtr also requested that the pt be placed on home vent for trial prior to d/c home and has tolerated the home vent well all day today. Will go back on hospital ventilator tonight for humidification on trach. Home vent will be able to do this once set up at home, but we do not have the supplies here. CV: HR NSR to sinus <110 relieved with ativan and demerol and no ectopy. Mag repleted this morning. Continues on amiodorone, digoxin, midarone po, diltazem po d/c'd d/t continued low bps. HCT now stable at 31 and no further products necessary at this time. Endo: RISS and am glargine sugars 200s adn team aware. REsp: lungs coarse at times, cleared with suctioning, and diminished throughout. Placed on home vent this morning and tolerated well all day.\nPlan: Discharge planning continues, working towards getting patient home this week. Social work and case management. Vascular/GI to discuss plans with dtr regarding /amp of toes. Dialysis tommorrow. Wound supplies needed for home. to monitor hct and glucose levels, if remain stable ok to d/c home and when all other previously mentioned issues are resolved. MICU team has been updated with all concerns/issues mentioned above. Please refer to carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-22 00:00:00.000",
"description": "Report",
"row_id": 1524433,
"text": "Update\nSee Carevue for specifics\n\nNeuro: Alertness waxes and wanes but unable to assess orientation. Will nod appropriately to questions. Follows commands inconsistently. Localizes pain. Purposeful movements at times. Lifted and held LUE. No movement in other extremeties. PERRL.\n\nCV: ST early in shift correlating with tmax of 100.7. Blood cx'd. Currently afebrile and NSR. 70s-110s. Hct pending.\n\nResp: Switched from home vent back to . LS coarse/diminished. Sats 98-100%. Sxn'd for moderate thick yellow secretions.\n\nGI: TF to goal, no residuals. Colostomy draining golden liquid stool. G tube draining clear fluid. Drainage bag around G-J tube collecting serosang drainage. Chem 7 pending.\n\nGU: HD scheduled for next shift.\n\nSkin: Grossly impaired. See Carevue for details.\n\nPsychosocial: son in to visit early evening.\n\nPlan: Wound care RN to contact Medicaid & meet with daughter for wound care education. Continue planning discharge.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-22 00:00:00.000",
"description": "Report",
"row_id": 1524434,
"text": "Respiratory Care:\nPatient switched from home ventilator to , as noted in CareVue. SX'd for small to moderate amounts of thick, yellow sputum. No abg results this am.\n\nNo due to hemodynamic instability.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-18 00:00:00.000",
"description": "Report",
"row_id": 1524297,
"text": "nursing note\nNeuro:Pt alert, nodding approp at times. Daughter in to viisit and upset with head motion side to side, as in nodding \"no\". MD aware and spoke with daughter regarding this. hypothermic-bairhugger on.\nCV: NSR wtih rate controlled on dilt. Neo weaned slightly to .3. cont to keep even.\nRESP:ls coarse, thick white sputum. ambu'd and lavaged by RT and valve tried but pt unable to talk. Done per fmaily request.\nGI:loose brown stool via ostomy. GT/JT site with small pink drainage with air into bag into pouch.\n\nPLAN: cont to keep even. dilt/neo/insulin. awaiting plan from family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-18 00:00:00.000",
"description": "Report",
"row_id": 1524298,
"text": "Respiratory Care Note:\n patient remains trached with a #7 x-long Shiley trach in place and secure. Trach collar changed this shift. BS are coarse throughout. MDI's administered as ordered. Patient ambued and lavaged x 1 for a scant amount of thick white secretions. attempt made post ambu and patient too tired and unable to speak. Patient then placed back on full vent settings with inflated. SX for small amounts of white thick secretions via trach. patient remained afebrile this shift, bair hugger on. SPO2 remains 100%. patient often overbreathes vent by 10-13 breaths. Latest ABG acceptable. No RSBI this am as patient is vent dependent. CXR showed moderate bilateral pleural effusions, increasing on the left. Will continue with full support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-06 00:00:00.000",
"description": "Report",
"row_id": 1524371,
"text": "Update\nO: See carevue flowsheet for specifics.\nNeuro: Eyes open spontaneously perl at 3mm sluggish, does not track w eyes or follow any commands.Med x 1 for ? discomfort, family states pt uncomfortable and appearing more distressed, desires pt to have something for pain. Pt med w dilaudid 12.5mg w no appreciable change in pt status.Distress seems most likely to be respiratory in nature.See resp on carevue flowsheet.\n\nCV:sr w occ to freq pac's. Remains on dilt and low dose neo for bp/hr control.Distal pulses by doppler.Mult skin and circ issues w necrotic toes/ lt heel\n\nResp: Abg's bdline pao2 - metab acidosis worsening, vent adjustmnts made for same w slow imprvmnt in abg.Bbs coarse, lavage and suction for thick pale yellow secretions.\n\nGi: npo. gjtube-to gravity w no drng thru gj tube, 200cc serous around the tube.Abd distended, obese, + hypoactive bowel snds. Colostomy pink, edematous w sm amts of black loose stool.\n\nGu/Renal: crf makes no urine.HD 3x week,? to be dialyzed today.\n\nHeme/ID: hct 24-25 range, no treatment for now per micu team.Tmax 99.6 continues on meropenem and amikacin.\n\nSkin: Multiple non healing decubiti buttocks, rt hip and ble's. Wound care done to all sites.\n\n\nA/P: w supportive icu care. Wean neo and diltiazem as tol. Wound and skin care per wound care nurses plan. Aggressive pulm toilet.Multidisciplinary team family meeting today to discuss pt care plans, update.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-20 00:00:00.000",
"description": "Report",
"row_id": 1524427,
"text": "Respiratory Care\nBreath sounds bilaterally coarse and diminished at bases, suctioned intermittently for moderate thick yellowish secretions, was afebrile, stayed mostly into normal sinus rhythm, WBC 13.6, ongoing bacterial infection, hemoglobin only 10, sign of anemia, creatine 1.7, sign of renal insufficiency for which patient had hemodialysis from 0900 am to 1100 am, patient has been treated with Albuterol, Atrovent and Flovent inhalers, no ABGs drawn, no vent changes made during the shift, patient will continue to receive mechanical ventilation and close monitoring.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-20 00:00:00.000",
"description": "Report",
"row_id": 1524428,
"text": "Update\nSee Carevue for specifics\n\nNeuro: pt. alert but unable to assess level of orientation d/t trache. Pt. nods appropriately to questions, mouths words and actively tracks activity in the room. Inconsistently follows commands. Moved RLE on bed once, no movement from other extremeties but localizes pain.\n\nCV: NSR. 60s-105. Rare PVC's.\n\nResp: LS clear/coarse. Sats 95-100%. No vent changes. Sxn'd for very thick yellow sputum.\n\nGI: TF to goal. Colostomy putting out gold/green liquid stool. G-J tube re-pouched by enterostomal RN and stoma site draining small serosang fluid. G tube draining clear, slightly bilious fluid.\n\nGU: Dialysed in a.m. 2.3L removed. Pt. tolerated well with no hypotension.\n\nSkin: Grossly impaired with numerous areas of breakdown. Please see Carevue for details.\n\nID: Afebrile. Amikacin held d/t high level. New one drawn s/p HD.\n\nPsychosocial: husband and son visited in a.m. Daughter talked to RN and MD on the phone.\n\nPlan: Continue to monitor hemodynamic status. Continue to treat wounds agressively. Enterostomal nurse to call daughter with update on re: stomas/colostomies. ?trial home vent tomorrow. ?transfer to home on Wed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-21 00:00:00.000",
"description": "Report",
"row_id": 1524429,
"text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT MOST OF THE NIGHT, MOUTHING WORDS, FOLLOWING SOME COMMANDS. ONLY MOVING LEFT UPPER ARM OCCASIONALLY ON THE BED. PERRL. PT NOT COMPLAINING OF PAIN, APPEARING COMFORTABLE, REPOSITIONED FREQUENTLY.\nCV- BP RANGING FROM 70'S SYSTOLIC TO 110, MAP 40'S-50'S. DR. NOTIFIED WHEN BP CONSISTENTLY BELOW 80'S SYSTOLIC. I UNIT OF PRBCS GIVEN FOR HCT 26, BP IMPROVED, AM HCT PENDING. HR 90'S, APPEARING TO BE IN A-FIB EARLY IN THE SHIFT, DR. NOTIFIED. KCL REPLETED IN THE LATE EVENING, PT IN NSR AT THIS TIME WITH OCCASIONAL PVCS AND PACS.\nRESP- LUNGS SOUND DIMINISHED, O2 SAT 99-100%. SUCTIONED OCCASIONALLY FOR SMALL AMOUNTS OF THICK YELLOW SPUTUM.\nSKIN- OOZING FROM SEVERAL AREAS OF SKIN TEARS, SMALL PIN POINT AREAS, AND VARIOUS DECUBS. MOST DRESSINGS INTACT, OUTER LAYERS OF DRESSINGS CHANGED AND REINFORCED WHEN APPEARING TO BE SOILED.\nGI/GU- ABD SOFT, HYPO SOUNDS. TOLERATING TF. PT DOES NOT VOID.\nID- AFEBRILE\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-21 00:00:00.000",
"description": "Report",
"row_id": 1524430,
"text": "RESPIRATORY CARE NOTE\n\nPatient remains trached with Shiley ex. long trach tube. No vent changes made during the . No MD order.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-08 00:00:00.000",
"description": "Report",
"row_id": 1524135,
"text": "Nursing Progress Note\n Please see carevue for details of care. Alert, eyes open,follows simple commands and randomly nods yes or no but inconsistently. Spont movement in LUE only. PERL @ 4mm. Restless at times, settles down w/repositioning. BS cl/dim, suctions via trach for scant-small thick yellow secretions. Vent AC 450x16x40%+5PEEP.\n To IR this am for Peg tube change, tol well. No drainage around PEG post insertion this pm. TF and meds resumed after ok w/MICU resident on unit, minimal TF residual noted. BOS +, colos draining brown liquid BM.\n Multiple wounds persist, leg wounds dressing changed per wound care directions tol well. See carevue for specifics. Legs wounds draining pink serous drainage, no purulent or fkoul smelling drainage noted. Coccyx/ischial dressings to be changed on B shift.\n Insulin gtt remains off this shift, BS elvated to 300's, covered w/RISS. Glargine changed to dosing and SS tightened by team. team in this pm, aware of adjustments pending.\n Dgt/husband in this pm. Insist on feeding patiernt ice chips in spite of direction of staff not to d/t cuff leak and chance for aspiration. Daughter upset that PEG was changed and placed in Jejunum. Attempted to obtain records from admit but unable d/t time of day (after 5p). Will attempt record retrieval on Monday.\n PLAN: Continue to monitor glucose needs/demands, dressing changes, monitor VS, family support and education.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-09 00:00:00.000",
"description": "Report",
"row_id": 1524136,
"text": "NURSING PROGRESS NOTE: SEE CAREVUE FOR OBJECTIVE DATA AND TRENDS\n\nNEURO: ALERT. OCC MOUTHING WORDS TO MAKE NEEDS KNOWN. APPEARS TO NOD APPROP TO YES/NO QUESTIONS. INCONSISTENTLY FOLLOWS COMMANDS. PERRLA, 4MM/4MM,BRISK. OCC SPONTANEOUS MOVEMENT OF LUE. +WEAK COUGH. MEDICATED WITH 12.5MG DEMEROL X1 FOR TROCANTER/COCCYX DRESSING CHANGE. PT TOLERATED DRESSING CHANGE WELL.\n\nCARDIAC: HCT: 28. A-FIB. HR-90'S-110'S. NIBP: 93-110/39-67. 12.5MG LOPRESSOR GIVEN WITH EFFECT. COUMADIN 2.5MG GIVEN. INR: 2.6. +RADIAL/FEMORAL/POPITEAL/PT/DP X2. CSL ON.\n\nPULM: TRACHED. CMV/40%/450/5 PEEP. POX: 98-100%. LS: R+LUL CLEAR,DIMINISHED BIBASILAR. SX FOR SM AMTS OF THICK YELLOW SPUTUM.\nVENOUS GAS SENT AT 1800 ON WNL.\n\nGI: REMAINS NPO. G-TUBE SITE WITH SM AMT OF CLEAR DRAINAGE. DRESSING CHANGED. TOLERATING TF AT GOAL WITH NO RESIDUALS. ABD: OBESE,+HYPOACTIVE BS,S,NT. OSTOMY STOMA MOIST PINK WITH BROWN LIQUID STOOL.\n\nGU: ANURIC. LYTES WNL.\n\nENDO: FS QID. FS: 258-277. COVERAGE PER RISS. LANTUS INCREASED TO .\n\nINVL: R-AC SINGLE LUMEN PICC. SITE WNL,DRESSING INTACT. R-HD CATH SITE WNL,DRESSING INTACT.\n\nID: AFEBRILE. CONTINUES ON MEROPENEM.\n\nSOCIAL: DAUGHTER AND HUSBAND IN TO VISIT. CRITICAL QUESTIONS REGARDING G-TUBE PLACEMENT/DRAINAGE AROUND SITE ADDRESS. FAMILY CONCERNED ABOUT DISCHARGE TO HOME D/T MEDICAL NEEDS.\n\nPLAN: Q 4 HOUR NEURO CHECKS. MONITOR HEMODYNAMICS. FOLLOW FS Q4-6 HOURS. LANTUS INCREASED TO . CONSULTED ON . MEDICATE PRN FOR PAIN. DRESSING CHANGES TO TROCANTER/COCCYX AND LOWER EXTREMITES QD. WOUND CARE CONSULT TO ADDRESS DRAINAGE AT G-TUBE SITE. REPOSITION Q 2. SURVAILLENCE LABS PRN. MONITOR INR'S. PROVIDE EMOTIONAL SUPPORT TO PT AND FAMILY. SOCIALWORK CONSULTED AND TO FOLLOW.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-06 00:00:00.000",
"description": "Report",
"row_id": 1524372,
"text": "Nursing Progress Note\n Please see carevue for details of care. HD tol well this am, BP remains stable on 0.2mcg of neo. Dressing changew post HD today for mod-lg amt drainage and multiple areas of skin tears persist around wounds. Nuero satatus unchanged this shift, does not track movements in room.\n Blleding from colostomy site w/large amt dark black clots in colostomy appliance followed by bright red blood. Labs drawn, HCT 21.9. Total 6 units PRBC's, 1 unit and 1 dose of DDAVP hung. 1L LR infusing wide open, EJ line attempted unsuccessfully by MICU attending. TO angio this pm.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-07 00:00:00.000",
"description": "Report",
"row_id": 1524373,
"text": "Respiratory Care:\nPatient remains on A/C ventilatory support, returning from IR. No parametr settings changed throughout the night. Latest abg results determined a mild metabolic acidemia with very good oxygenation on the current settings. MDI albuterol and atrovent administerd in-line with each vent check. Sx'd for a moderate amount of thick, yellow secretions at the last vent check.\n\nNo RSBI measured at this time due to the patient's high FIO2 and unstable cardiodynamics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-07 00:00:00.000",
"description": "Report",
"row_id": 1524374,
"text": "Update\nO: See carevue flowsheet and IR flowsheet for specifics.\nPt in IR until 2330.Relatively stable on neo 0.5 to 1.25 mcg/kg/min and ppfl at 20mcg/kg/m for sedation.Attempts by IR MD unsuccessful d.t inabilty to locate any bleeders. Hct stable at 34 x 2 in IR suite. Tlc line placed in IR and pt returned to sicu. Overnight pt req relatively more neo and flds to maintain ~80 and mbp 55. Per micu team pt to have endoscopy today-> golytely initiated and pt putting out initially lg dk clotty drng via colostomy-> to brb w hct drop. Fld x 2 liters and colloid resusc w x4 units and 5 prbc overnght. Despite aggressive volume resusc pt still having difficulty maintaining bp, neo gtt max dose at 5mc/kg and vasopresssin added w some improvemnt until 630am w incr via colostomy pt req more bld products and levophed ordered to support bp. Dr here and aware of changes, Endoscopy called by Dr to notify of urgent need for scope early am.\nCv- remains in afib, rate fairly controlled;unable to receive diltiazem overnight d/t low bp. Doppler pulses present and groin sites check per protocol orders. Sm hematoma rt groin, intermitt sm ss ooze rt groin only.\n\nResP: remains vented on cmv mode-see resp sheet/ w metab acidosis. HO aware. Bbs coarse suct for mod amts of thick yellow sputum.\n\nGi: gj tube to drng bag w sm to mod coffee grnd around gjtube, nothing draining through it. Abd obese slt firm distended. Colostomy as noted above w overnight.Glucoses managed w insulin gtt. Nutrition overnght receiving tpn.\n\nGu/Renal: hd yesterday tol well w 3liters removed.\n\nSKin: mult decubs buttocks, bilat lower legs and anasarca. Drsgs changed per skin care nurse.\n\nPsych/Soc/ Family: extensive support and allowance for time for questions to be answered given by Dr ; nursing and resp staff as well addressed some of family's questions and concerns. Pt family daughter & son escorted by security for visit. Daughter hostile and voicing discontent of her mothers care to medical and nsg staff, spoke w Nsg supervisor as well.\n\nA/P: titrate neo, levo, pitressin for goal 80 mbp 55. check results of hct & check w HO re: # of prbc transfused. Glucoses q1 and titrate gtt. per protocol.Keep case managemnt up to date and involved w team to maintain clear communication w family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-26 00:00:00.000",
"description": "Report",
"row_id": 1524451,
"text": "Respiratory Care\nPt remains trached and on vent support. No vent changes were made during shift. No ABG's were drawn during shift. Lung sounds clear at start of shift and became course and diminished in the bases. Pt was suctioned for scant to moderate amounts of thick yellow secretions. Pt received MDI's. Albuterol was NOT given at 1200 and 1600 due to HR >110. Pt received Flovent at 1200 as MDI was empty and replacement not available at 0800. Care plan is to place pt on home vent tonight at midnight and leave on vent until D/C for home. Will continue to follow pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-02 00:00:00.000",
"description": "Report",
"row_id": 1524106,
"text": "nursing progress note\nPlease see careview for details\n\nNeuro: perl, nods to some questions, not moving extrmities on bed. nailbed pressure not applied due to discoloration and eschar of extremities.\n\nCV: afib, heparin drip at 750 u/hr with ptt 77. bp stable. bilat pedal pulsses palp, rt foot toes black, bleeding from debrided area with dsd changed x 2. hct stable.\n\npulm: vented at 40 %. A/C. sats 100%, sx sm-mod amts thick tan. bs clear to diminished in bases.\n\ngi: tol tube feeds well, colostomy drainage 200 cc guaiac trace pos.\n\ngu: anuric, for hemodialysis today.\n\nskin: rt foot wound is black with eschar. dsd changed x 2 for mod amts bleeding. all other dsgs clean and dry, changed x 1 /day.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-02 00:00:00.000",
"description": "Report",
"row_id": 1524107,
"text": "nursing progress note\ninsulin drip at 20-3 u/hr to regulate high blood sugars. glargine 80 u sc given at 2200.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-02 00:00:00.000",
"description": "Report",
"row_id": 1524108,
"text": "Respiratory Therapy\nPt remainstrached #6 Shiley cuff pressure 38cm. BS coarse rhonchi bilaterally W diffuse I&e wheezes which clear after Sx and MDI's.Sx for sml to mod thick yellow/tan secretions. Please see nsg note and carevue for specifics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-02 00:00:00.000",
"description": "Report",
"row_id": 1524109,
"text": "Resp Care\npt remains trach on mech vent. no vent changes this shift. pt taken to MRI today for scan of lower back bed sore, trip uneventful. pt has slightly course/wheezy BS, suctioned for sm-mod amt of thick secretions MDIs given as ordered. will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-02 00:00:00.000",
"description": "Report",
"row_id": 1524110,
"text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT, NODDING HEAD TO SOME QUESTIONS. DENIES PAIN WHEN AT REST. ONLY LOWER EXT. AND LEFT UPPER ARM MOVING SPONTANEOUSLY AND ONLY SLIGHTLY ON THE BED. PERRL.\nCV- BP RANGING FROM 80'S- 115. REQUIRED FLUID BOLUSES DURING DIALYSIS THIS AM. I UNIT OF PRBCS GIVEN AND 25 G OF ALBUMIN TO KEEP BP ABOVE 85 SYSTOLICALLY DURING DIALYSIS. PT COULD ONLY TOLERATE REMOVAL OF ABOUT 700CC. HR TO 150'S THIS AM, A-FIB. SHOWN TO MICU TEAM ON ROUNDS, LOPRESSOR PO GIVEN AS SCHEDULED AND 2.5 MG LOPRESSOR IV ALSO GIVEN WITH GOOD EFFECT. HR REMAINS 90'S-110 FOR THE REMAINDER OF THE SHIFT, OCCASIONAL PVCS, POST DIALYSIS LABS, INCLUDING A HCT SENT. PTT GREATER THAN 150 THIS AM, HEPARIN GTT STOPPED FOR TWO HOURS AND RESTARTED AT 600U. NEXT PTT DUE AT .\nRESP- LUNGS CLEAR, VENT SETTINGS REMAIN THE SAME. NO DIFFICULTY BREATHING NOTED.\nGI/GU- ABD SOFT AND DISTENDED. COLOSTOMY DRAINING SEMI FORMED LOOSE BROWN STOOL, STOMA APPEARS TO BE BEEFY RED. TOLERATING TF AT GOAL, INSULIN GTT REMAINS ON AND BS RANGING FROM 90'S- 150'S. PT DOES NOT VOID.\nSKIN- SKIN REMAINS WEEPY IN SOME AREAS. ALL DRESSINGS TAKEN DOWN AND CHANGED TODAY. SACRAL DECUB GREYISH ON INSIDE WITH RED EXCORIATED SKIN AROUND WOUND. PACKED WITH AQUACEL AND COVERED WITH DSD. ALL AREA OF INTACT SKIN COVERED WITH ALOE VESTA BARRIER CREAM. RIGHT GREAT TOE CONTINUES TO OOZE BRB, DRESSING CHANGED SEVERAL TIMES, HCT MONITORED. MRI TODAY FOR SACRAL DECUB TO CHECK FOR OSTEO, RESULTS PENDING, PT TOLERATED WELL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-03 00:00:00.000",
"description": "Report",
"row_id": 1524111,
"text": "Resp Care\nPt remains on CMV stable no vent changes. Plan to continue with current tx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-29 00:00:00.000",
"description": "Report",
"row_id": 1524221,
"text": "Admitted via ER with fever,fatigue and hyperglycemia,?sepsis.Patient on mechanical ventilation At home. More alert today,suctioned for moderate amount of thick yellow secretion.Being treated with Floventterol and Atrovent. Has periods of hypotension and bradycardia.meeting with family to discuss disposition of patient on hold as daughter does not want to discuss it untill patient home services are specifically arranged :dialysis done today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-29 00:00:00.000",
"description": "Report",
"row_id": 1524222,
"text": "condition update\nplease see carevue for specifics.\n\nafebrile. pt nodding yes/no appropriately. afib. hd today. vanco and tobra given, levels drawn. bld cx's taken from hd catheter. vag ultrasound done d/t bleeding. foley instilled w/ 400cc ns. when ns drained bright red blood draining. micu aware. foley kept in and being irrigated. red blood continues. hct 23.\n\nsxn'd for thick, yellow sputum. no vent changes made. w/ propass infusing via peg. maroon colored blood noted in peg. micu team notified.\n\nplan: monitor hcts/ hemodynamics. dressing changes as ordered. iv abx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-30 00:00:00.000",
"description": "Report",
"row_id": 1524223,
"text": "Respiratory Care\nPt remains trached on full vent support. No ventilator changes made this shift. BS coarse and diminished @ bases. Suctioned for moderate amounts of thick yellow/tan secretions. Pt awake & alert and breathing over the vent at this time. No recent ABG. Morning RSBI not completed due to decreased BP.\nPlan: Continue current vent support, ? trial\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-30 00:00:00.000",
"description": "Report",
"row_id": 1524224,
"text": "NURSING\n VSS, AFEBRILE. CONTINUES IN AFIB. NO ECTOPY. HCT DECREASED TO 23, TRANSFUSED WITH 1 UNIT RBC'S. REPEAT HCT 26.\n CONTINUES TO HAVE VAGINAL BLEEDING AND BLEEDING FROM FOLEY, ALTHOUGH BLEEDING FROM FOLEY APPEARS TO BE DECREASED. NOW IRRIGATION APPEARS TO JUST BE BLOOD TINGED FROM TUBING OR PERHAPS A CLOT IN BLADDER. IRRIGATED Q 2 HRS OVERNIGHT WITH 120 CC EACH TIME. OLD LOOKING BLOOD PRESENT IN GT CHANNEL OF TUBE, MD'S AWARE AND HAVE EXAMINED PATIENT. HEMATOLOGY CONSULT PUT IN BY MICU TEAM.\n CONTINUES TO HAVE MODERATE AMOUNTS OF SPUTUM TAN TO GREEN TINGED FROM TRACH. SUCTIONED Q 2-3 OVERNIGHT.\n CONTINUE TO MONITER HEMODYNAMICS, BLEEDING. REPEAT HCT EARLY AFTERNOON.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-30 00:00:00.000",
"description": "Report",
"row_id": 1524225,
"text": "Neuro: pt alert. responds to question by nodding. Minimal movement of limbs very slight movement of feet and rt arm . noted to move left arm slightly on bed.\nPain: complained of pain x1. Given tylenol 650mg x1.\nCV: AF 100's currently early Hr has high as 130's improved after am amniodarone and Digoxin. ABP dropped to 80's a few times but improved without tx. DP/PT.\nLungs: Coarse throughout. suction for thick yellow sputum. trach care given green drainage around trach.\nGI: ABD soft BS present. G/J tube TF at goal tolerated well. J tube with no further bleeding noted. Colostomy drainage liquid. stoma pinkish red.\nGU: Foley to gravity. minimal bloody drainage when irrigated obtain small clots.\nSkin: necrotic toes left heel necrotic. pressure sores on coccyx and hips. see care view and wound care note. DSG changed at 11am.\nA/P DSG changes per wound nurses . frequent turns. serial hct.. monitor bleeding hct notify ho of changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-26 00:00:00.000",
"description": "Report",
"row_id": 1524452,
"text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\nNEURO: NEUROS UNCHANGED, MORE ALERT TODAY, MIN NODDING TO QUESTIONS, NOT TRACKING TO VOICE. PERRL, 4-5MM, BRISK. ATIVAN GIVEN X2 R/T TACHYPNEA, DISCOMFORT. DEMEROL GIVEN X2 R/T FREQUENT TURNING & REPOSITIONING, PRIOR TO DSG CHANGES.\n\nCVS: HR 90S-100S, UP TO 120S THIS PM W/MILD(99.8)FEVER AND TACHYPNEA-MD AWARE, NO CULTURES AT THIS TIME, TO FOLLOW. MAP MAINTAINED>60 PER GOAL, 70S-100S. PICC DSG CHANGED, ?PLACEMENT R/T FREQUENT TURNING, MICU RESIDENT AWARE. PM HCT 32.9, NO NEW BLEEDING NOTED. MAG OXIDE GIVEN FOR AM MAG 1.9, AM SODIUM 148.\n\nRESP: NO VENT CHANGES MADE, REMAINS ON A/C, NO VBG DONE. PT TACHYPNEIC UP TO 30S, ATIVAN GIVEN X2 W/MIN RELIEF. LUNGS COARSE, DIMINISHED AT BASES. PT SUCTIONED FOR MOD/LGE AMTS THICK, YELLOW SECRETIONS. PT TO BE PUT ON \"HOME VENT\" AT MN PER RESP.\n\nGI/GU: TF AT 40CC/HR, NO RESIDUAL, FLUSHED W/200CC Q4. GT TO GRAVITY W/SM AMT YELLOW, VISCOUS FLUID. OSTOMY BAG AROUND G-JT W/SM AMT STRAW-COLORED FLUID. COLOSTOMY W/MOD AMT GREENISH-BROWN LOOSE STOOL, NO BLOOD NOTED. CLEAR-BROWN MUCOID RECTAL DRNG NOTED, VAGINAL BLEEDINAL.\n\nENDO: BS COVERED PER RISS, AM LANTUS GIVEN\nID: PLAN TO AT HOME. RECIEVING AMIKACIN, MEROPENEM, DAPTOMYCIN.\n\nINTEG: MULTI SKIN TEARS, AREAS OF LGE AMTS SEROUS DRNG COVERED W/DSD. BLE/TOE DSGS CHANGED, SACRAL/R-HIP DECUB ULCERS PACKED W/AQUACEL, COVERED W/DSD, RE-DRESSED PRN. W/LGE GEN SEROUS DRNG, GEN ANASARCA. SARNA LOTION APPLIED TO RIGHT LATERAL RASH. MULTIPLE AREAS OF ABRASIONS/BREAKDOWN COVERED W/ADAPTIC AS ORDERED. PT TURNED, REPOSITIONED FREQUENTLY.\n\nPLAN: SICU , ATIVAN & DEMEROL FOR PT COMFORT, PLAN FOR D/C TO HOME , AFTER AM HD. HEMODYNAMIC MONITORING, RESP SUPPORT. REPEAT HCT, ?BLD CULTURES IF PT REMAINS FEBRILE. AGGRESSIVE SKIN CARE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-10 00:00:00.000",
"description": "Report",
"row_id": 1524142,
"text": "Condition Update A:\nPlease refer to careview and remarks for details.\n\nPt calmly alert and dozing periodically. Ativan held as no indications of anxiety and continued hypotension as discussed with MICU team ( Dr. ). Tmax 100.1. cont in afib with rare PVC's. Pt received 1.25L in LR boluses for hypotension 70-80's with MAP's<50. H20 boluses started and increased to 250cc every four hours for low Na level and hypotension. Pt's SBP improving during the late afternoon, up to 120-130.\n\nJ-tube leaking small amount of thick clear mucous. Dsg changed at 0800 and remains C/D/I. The two areas of breakdown ( at the 1000 and 0500 position unchanged from ). BLE dsgs changed at 0800, please refer to careview for specifics.\n\nWBC 17. K 3.8 Ph 1.2. Stool (P) for c-diff. Glucose levels improved from with increased Lantis dose and RISS.\n\nPLAN: Vanco 1g IV every 48 hours. KPhos infusing. Obtain blood cultures, RT to obtain sputum. Monitor glucose levels. Cont discharge planning. Call H.O. for changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-10 00:00:00.000",
"description": "Report",
"row_id": 1524143,
"text": "Resp Care: Pt remains intubated via #6 Shiley trach, cuff leak noted. Team is aware. Achieving gd Vt's. Sx'd for mod amts thick tan sputum. MDI's given as ordered. No vent changes made this shift. No recent ABG. Cxray pending. Cxray \"small R pl. eff. L lung clear\". Plan: cont vent support. Please see carevue for further vent inquiries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-11 00:00:00.000",
"description": "Report",
"row_id": 1524144,
"text": "Update\nSee careview for details....\n\nNeuro: Pt alert and awake, follows simple commands, moves extrems in bed\n\nCV: A fib, 90-110's, afebrile, BP 80's-110's\n\nResp: Lungs clear, sx scant white sputum and sent for cx, vent unchanged, trach care done\n\nGI: tol TF's, + BS, colostomy dng liquid brown stool\n\nGU: pt does not void\n\nSkin: Pt turned Q2hrs, on air matress, waffle boots on, dsd to LE's D/I, sacral dsg changed, pink tissue with areas of yellow/green slough, sm amt bleeding, dsgs to hips intact, J tube site dng amts thick clear dng, dsg changed x2, pt med with demerol prior to dsg change\n\nPlan: Wound care, emotional support for family\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-11 00:00:00.000",
"description": "Report",
"row_id": 1524145,
"text": "Resp Care\nPt. remains trached, chronic vent, no changes overnight, no rsbi.\nBs: clear equal bilat. secreations minimal, spec sent. Mdis as ordered.\nPlan: cont. current support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-11 00:00:00.000",
"description": "Report",
"row_id": 1524146,
"text": "BS generally CTAB, occ rhonchi clearing with suction. CUff pressure measured and maintained at 16-18cm. ? discharge to home tomorrow. Instruct daughter how to measure cuff pressures. Tolerate small leaks if necessary per Dr. .\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-01 00:00:00.000",
"description": "Report",
"row_id": 1524232,
"text": "DNR Contact Precautions - MRSA/VRE\nAllergies: Morphine, Erthromycin, Fent, Keflex\n\n\nNeuro: Opens eyes spont and occ tracks - pupils 5mm/brisk. No movement in extrems - occ L hand moves - no movement on command. She nods approp.\n\nCV: HR=90-100s, afib, no ectopy. BP=78-110/40-50s. +edema, extrems warm.\n\nResp: 450x16, 40%, P=5 - 02sat 98-96%. Suction small amt thick tan secretions - lungs fairly clear, diminished in bases bilat. RR=14-22.\n\nGI/GU: abd obese, g-jtube intact - tube feeds at 40cc/hr. Colostomy fx- liq golden brown stool - 400cc/shift. Foley cath - no urine. Output has been BRB - irrigated this am - no clots, bloody returns, but no additional output for the day. Dialyzed for 2liters.\n\nSkin: Ostomy appliance changed for leaking. g-jtube leaks at site - dressing changed. Coccyx, ischeal, and leg dressings changes. Bilat hip dressing w/ allevyn changed yesterday - due to be changed on .\n\nAccess: Rsubcl dialysis cath, R antecub single lumen PICC. Ordered placed for tunneled dialysis cath.\n\nPain: Med w/ demerol 12.5mg IVP for dressing change. Ativan .5mg po ATC.\n\nSocial: Son in this evening - updated.\n\nPlan: Continue w/ current plan. Ethics reviewing the case and legal consult in as well. Case management continues to review possiblilities when pt is ready to be d/c'd.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-01 00:00:00.000",
"description": "Report",
"row_id": 1524233,
"text": "Respiratory Therapist\nBreath sounds bilaterally clear and diminished, suctioned for small amount of thick green secretions WBC 18.8 consistent with bacterial infection, hemoglobin only 9 suggests anemia, creatine 2.4 suggest renal insufficiency for which patient had dialysis today started at 1000 am, patient was treated with Albuterol, Atrovent and Flovent inhalers, no ABGs nor vent changes made up to this moment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-02 00:00:00.000",
"description": "Report",
"row_id": 1524234,
"text": "Nursing Assessment Note 1900-0700\nNEURO: Pt neuro status remains unchanged, pt will open eyes to voice and will follow simple commands, but does not try to mouth words\n\nCV: Pt's vss, afebrile, pt has right A/C picc line with NS @ , pt in AFIB, skin is pale, warm, and dry, pp + & =, with +2 generalized edema, Pt given dose of Desmopressin for her bleeding, the hope is to stop bleeding so pt can be started on heparin gtt\n\nRESP: Pt's has 7.0 extra long shiley on CMV Rate-16, TV-450, PEEP-5, Fio2-40%, with sats 97-100%, pt suctioned for scant amount thick yellow sputum, Lung sounds are coarse throughout\n\nGI: Pt has peg G/J tube with tube feeding infusing at goal rate of 40 cc/hour, placement confirmed via air , pt's colostomy draining brown liquid stool, stoma is pink and beefy\n\nGU: pt's foley has very small amount bloody drainage, pt is dialysis pt and does not make urine\n\nPLAN:\n-Continue to monitor bleeding, once bleeding stops, pt to be started on heparin drip\n-? home placement vs. , family would prefer home, but issue's still need to be worked out\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-02 00:00:00.000",
"description": "Report",
"row_id": 1524235,
"text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. No morning abg results at this time.\n\nRSBI = 93 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-07 00:00:00.000",
"description": "Report",
"row_id": 1524375,
"text": "condition update\nplease see carevue for all specifics.\nneuro: does not follow commands, rare spont. movements noted on left arm this am, but not this afternoon. Does not attempt to communicate, does not track in room. Pupils are 4mm and sluggishly reactive. Pt received 1mg midaz. this am for endoscopy, midaz gtt started this afternoon for comfort, d/c'd this pm as per Dr. instructions, will as necessary.\ncv: afib 100's. vasopression, levo titrated off, with goal map >60. Pt received total of 6 units prbc's, 2 platelets, and 3 this shift. for hct 19, and inr as high as 2.1 Also received 2 liters ns for hypotension. hct currently stable at ~34. Ostomy draining copoius amts. bright red blood this am, which has slowed significantly.\nresp: see resp. note for specifics, suctioned for small amts. thick yellow sputum. trach. care done. Rate increased for acidosis, fi02 weaned down to 50%. Ls coarse and diminished.\ngi: abd. if firm distended, +bs, colsotomy draining brb this am, endosopy done at bedside per gi, clips applied. tolerated well. GI bleeding decreased significantly.\ngu/renal: cvvh started this afternoon by a 2nd RN.\nendo: insulin gtt titrated, off this afternoon for bs 53 - received 1/3 amp d50.\nsocial: Daughter called and was updated by this rn and Dr. . Husband and son at bedside this am.\nplan: continue to titrate neo to keep map >60, monitor hct, monitor colostomy output, continue ddavp and decadron, . cvvh.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-07 00:00:00.000",
"description": "Report",
"row_id": 1524376,
"text": "addendum\nbilat. leg, and groin dsg changed today as per wound care rn instructions. Sacral and hip dsgs deferred as pt may not tolerate extended turning d/t pt's unstable hemodynamic status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-08 00:00:00.000",
"description": "Report",
"row_id": 1524377,
"text": "nursing note\nPt opening at eyes at times, not following commands or acknowedging request s by nodding or moving. No movement of extremeties. Afib with bursts to 120's. Neo weaned down to keep MAP >55, sys >90. to keep even. MD , keep pt. even and go up on pressors if needed. LS coarse,thick yellow secretions. NPO. Osotmy with melena output, minimal amounts. HCT/plt/INR stable. . on DDAVP and decadron. Son and in to visit and calm and appropriate with care and questions. Son escorted by security and non aggressive with this RN.\n\nPLAN: CVHHDF to keep even and go up on pressors as needed. insulin gtt. DDAVP and decadron. labs q6. family support and guidelines as in place.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-08 00:00:00.000",
"description": "Report",
"row_id": 1524378,
"text": "Resp Care Note, Pt remains on current vent settings.See vent flow sheet for details. Suctioned mod amts thick yellow secrtions.MDI'S given, HR-A-Fib. Getting neosynephrine and insulin. . Will to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-08 00:00:00.000",
"description": "Report",
"row_id": 1524379,
"text": "Resp Care\nPt remains trached on A/C. FIO2 increased from 40 to 60 due to ABG results. MDI's given. No other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-27 00:00:00.000",
"description": "Report",
"row_id": 1524453,
"text": "Resp Care,\nPt. remains on A/C . Suctioned for copious amount thick yellow sputum. Planned to put on home vent MN, but developed tachycardia and RR high 30's with MV 21L. MICU team aware pt. not placed on home vent.Will attempt this am. See carevue.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-22 00:00:00.000",
"description": "Report",
"row_id": 1524191,
"text": "Neuro: Pt alert and awake all night. Able to talk around trach, ? leak. Able to make needs known. Med for pain X2 per pt request with good effect.\n\nCV: Hypothermic 92.0, Bare hugger inplace T=95.2. Pt refusing oral temp and requiring coaxing to obtain axillary temp. HR 80-100's Afib with no noted ectopy, SBP 80-130's. CVVH continues pt remains even.\n pulses bilat dorsal. Extremities cool and pale.\n\nRESP: lung clear to dim at bases. Requiring occasional suctioning of thick tan secretions with plugs.\n\nGI: tol tube feed. Colostomy draining small amounts of golden liquid stool.\n\nGU: Remains aneuric\n\nENDO: blood sugars WNL overnight. Recieved lantus per order.\n\nPLAN: Family would like to speak to renal team today concerning CVVH, Family cont to request Shiley trach reinserted as soon as possible.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-22 00:00:00.000",
"description": "Report",
"row_id": 1524192,
"text": "Events:\n\n clotted and D/C per Renal team, plan for HD Monday\nPulmonary into see patient plan for Bronch and trach change Monday\n\nNeuro-PERL, moves upper extrem purposefully, mouths words, and shakes head to yes/no questions, denies pain\nCV-MP Afib irreg S1 S2, continues on amio/lopressor, amio dose decreased r/t elevated INR, coumadin held, doppler pulses LE bilaterally, necrotic toes bilaterally\nResp-Remains on AC LS coarse upper lobes dim at bases, sx for thick tan secretions\nGI-TF at 40cc/hr, glucose well controlled with glargine 90u SQ , colostomy with liquid stool out, pending\nGU-anuric, d/c acid base balance and lytes monitored\nskin-see carvue\n\nFamily-daughter phoned in update given, daughter gives recomendations for patient care regarding HD and albumin, renal nephrologist attempt to contact daughter to give update. Daughter into see patient. states \"my mother should get what she wants, not what wants, my mother has been through enough. states \"my mother never wanted hemodialysis and my mother is aware that if she does not get hemodialysis she would die\". states we just wanted my mother to be home and be comfortable, not going in and out of the hospital\". states the HCP form is the patient first, her mother. Stating her family should listen to her mother first, also second to make decisions is the patient husband. states her father is old almost 70yrs old and has taken over. request to speak with social work, social worker updated , MICU MD notified, question need for ethics consult, also chart need to to be reviewed for HCP proxy form. Emotional support provided. Awaiting social work and MICU review of legal documents\n\nPlan-pulmonary toilet, skin care, maintain pts comfort, monitor fluid balance, HD on Monday, cont ABX\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-22 00:00:00.000",
"description": "Report",
"row_id": 1524193,
"text": "Respiratory care\n\n Pt continues on A/C as per home regime. B/S coarse sx'd for thick tan secretions. Adjustable flange on trach found open. Trach at #7 replaced to the #11 flange closed CXR pending. Pt ventilating in NARD. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-22 00:00:00.000",
"description": "Report",
"row_id": 1524194,
"text": "Addendum:\n\nSocial work and MICU resident updated on daughter concerns of whether the patient is getting what she wants. stated that 6 out ot the 8 children agree that her mother would not want to live like this and would not want hemodialysis.\n\nEthics consult: Dr. into evaluate chart. Plan for family meeting to address current plan of care and evaluate evidence of \"what the patient would want\", message left with daughter to call Dr at \n\nSocial work and ethics to follow up with family on Monday\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-22 00:00:00.000",
"description": "Report",
"row_id": 1524195,
"text": "Addendum: Family\n\nSon into see patient, states \"we are not all crazy\", I aksed what he met. He said my family is working hard to take care of my mother, maybe \"she has to go through the fires of hell to get to heaven\", we did get told at that if the hemodialysis was stopped our mother would die in five days. states \"that I hope god takes her in the middle of the night. states he does not want to go against the family but has already spoken to his Dad and realizes this maybe torture to his mother especially since we have all the machines going. We are trying to get my other siblings to see that Mom is saying \"No\"\n\n given Dr. phone number to discuss feeling fo what his mother wants. again states that he does not want to go against his family. emotional support provided\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-23 00:00:00.000",
"description": "Report",
"row_id": 1524196,
"text": "Resp Care Note:\n\nPt cont trached and on mech vent as per Carevue. Lung sounds coarse improve with suct mod th tan sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required . Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-17 00:00:00.000",
"description": "Report",
"row_id": 1524293,
"text": "Resp Care: Pt continues trached and on ventilatory support with a/c, no vent changes maintaining good abg; bs coarse rhonchi, sxn thick yell secretions, rx with mdi albuterol/atrovent/flovent mdi, rsbi held d/t vent dependence, will cont full support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-17 00:00:00.000",
"description": "Report",
"row_id": 1524294,
"text": "CONDITION UPDATE\nVSS. REMAINS ON NEO TO MAINTAIN PER ORDERED PARAMETERS. REMAINS IN AFIB - RATE CONTROLLED ON DILTIAZEM DRIP. HYPOTHERMIC - BAIR HUGGER ON. ALERT. PUPILS EQUAL AND REACTIVE. DOES NOT FOLLOW COMMANDS. NODS YES/NO. MOUTHING INCOHERENT WORDS. NO MOVEMENT NOTED RSIDE OR LLE. MOVES LUE SPONTANEOUSLY AND TO PAINFUL STIMULI. LUNGS COARSE TO DIMINISHED AT BASES. OCC. SUCTIONING FOR THICK, YELLOW SPUTUM. NO VENT CHANGES MADE THIS SHIFT. ABG THIS AM ACCEPTABLE. ABD OBESE. POSITIVE BOWEL SOUNDS. MOD AMT OF LOOSE, GOLDEN STOOL OUT COLOSTOMY. GTUBE TO DRAINAGE, SEROUS, MUCOUS DRAINAGE OUT. JTUBE TO TFEEDING W/O INCIDENT. AREA UNDER BOTH BREASTS EXCORIATED. SKIN UNDER PANNUS W/ MULT BREAKDOWNS - AREA CLEANSED W/ WOUND CLEANSER, MYCOSTATIN APPLIED ALONG W/ DSD. LOWER EXTREMITY DRESSINGS REMAIN INTACT. COCCYX DRSG - LG AMT OF PURULENT/S/S DRAINAGE OUT. TISSUE PINK. DRSG TO /LBUTTOCK - MOD AMT S/S DRAINAGE OUT. PERI AREA PINK AND EXCORIATED - AREA CLEANSED W/ SOAP AND WATER - MYCOSTATIN POWDER APPLIED. RARM W/ MULT SKIN TEARS - WEEPING COPIOUS AMTS OF SEROUS DRAINAGE. REMAINS ON . GOAL TO KEEP EVEN. SEE FLOWSHEETS FOR DETAILS. K AND DRIPS TITRATED ACCORDING TO ORDERS. REMAINS ON INSULIN DRIP. BSUGARS LABILE. SON IN FROM 7PM TO ALMOST 11PM VISITING W/ PT.\nCONT TO MONITOR FOR S/S OF WORSENING INFECTION. PAIN MANAGEMENT. MAINTAIN SKIN INTEGRITY. DIABETIC MANAGEMENT. PT/FAMILY TEACHING AND SUPPORT. CONT CURRENT ICU CARE AND ASSESSMENTS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-18 00:00:00.000",
"description": "Report",
"row_id": 1524299,
"text": "Nursing note:\n Alert, attempting to mouth words at times, this RN unable to understand. Moving LUE only. PERRLA. Does not appear to be in pain. Remains trached, no vent changes. Sats 100%, suctioned occ. per flow sheet. SR in 70s, no ectopy. Dilt gtt @ 5mg/hr. Weaned down Neo gtt to off for >80/MAP >50 this afternoon. Slightly hypothermic w/o Bair Hugger so remained on low/radient for the day w/temps in 97s. +BS, abdomen large, obese. Gtube to GD for bilious drainage. JTube for feeds, no residuals. Awaiting new TFs from kitchen. Small amount of serous drainage around sites into ostomy appliance. Colostomy w/red stoma, loose golden stool, appliance intact. Anuric, CRRT running to keep pt. negative by approximately 50cc/hr (24 hour goal 1L negative). CVP 6-12. Pt. tolerating fluid removal off pressors. Calcium/K+ gtts running per Sliding scale. Insulin gtt @5u/hr for stable glucose levels 100-120s. Wounds impressive, all dressings changed - see flow sheets for details. Bilat. heels and toes black. Deep cavernous wound to R. hip and large sacral decub as well. Mycostatin powder to reddened and excoriated groin folds.\n\nA/P: Tolerating fluid removal via off pressors. Hct stable @28, WBCs trending down.\nSlightly more alert today. Continues w/impressive non-healing wounds.\nContinue skin care, monitor hemodynamics, , update family spokesperson PRN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-18 00:00:00.000",
"description": "Report",
"row_id": 1524300,
"text": "Respiratory Care:\n Patient continues on full vent support. Suctioned app Q4 for thick yellowish secretions. BS with scattered rales and occassional rhonchi. She continues on . Plan to continue with supportive care and monitoring.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-19 00:00:00.000",
"description": "Report",
"row_id": 1524301,
"text": "Resp Care\nPt remains on vent. Trached with 7.0 shiley. Suctioned for mod amt of thick green secretions. Mdis given. No changes made. Rsbi 104. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-19 00:00:00.000",
"description": "Report",
"row_id": 1524302,
"text": "NURSING 7P-7A\n VS LABILE OVERNIGHT. DECREASED TO THE 70'S WITH MAP<50. LEVO RESUMED TO MAINTAIN BP WITHIN DESIRED RANGE, ALSO CONTINUES ON DILTIAZEM AT 5 MG. ORDERS IN TO RESUME PO DILT AND DC GTT AFTER PO DOSE GIVEN. HYPOTHERMIC MOST OF THE SHIFT WITH TEMPERATURE NORMALIZING AT 0400. BAIR HUGGER ON UNTIL 0400.\n CONTINUES ON . AT 2400 LAST NIGHT NEGATIVE FOR 1100 ML. GOAL REMAINS AT 1000 ML/24 HRS. POTASSIUM GTT AND CALCIUM GTT SLIDING SCALES CONTINUE AS ORDERED. FILTER CLOTTED THIS AM AT 0500, RESTARTED AT 0615. SEE CARE VUE FOR FULL SPECIFICS.\n INSULIN GTT CONTINUES. BLOOD SUGARS HIGH LAST NIGHT FOR A PERIOD OF TIME, 4 HRS. INSULIN GTT HAD BECOME DISCONNECTED FOR APPROXIMATELY 2 HRS. DISCONNECTION WAS NOT IMMEDIATELY VISIBLE AS TUBING WAS STILL LODGED UNDER PANNUS AND APPEARED TO BE CONNECTED. GTT INCREASED TO 10 UNITS/HR, THIS AM LEVELS BECOMING MORE NORMALIZED, IN THE 150 RANGE THIS MORNING. SEE CARE VUE FOR FULL SPECIFICS.\n DOES NOT APPEAR TO BE IN PAIN. WHEN QUESTIONED SHAKES HEAD \"NO\". ANY ATTEMPTS TO DO ANYTHING TO HER ARE MET WITH A NEGATIVE SHAKING OF HER HEAD. ATTEMPTS TO MOUTH WORDS, UNABLE TO DETERMINE WHAT SHE IS TRYING TO SAY.\n CONTINUE . LABS Q 6/HRS, NEXT AT 0900. CONTINUE INSULIN GTT, MONITER SUGARS Q /HRS. GIVE DILTIAZEM PO AND STOP GTT A FEW HRS AFTER AS ORDERED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-27 00:00:00.000",
"description": "Report",
"row_id": 1524454,
"text": "NURSING PROGRESS NOTE;\nNeuro: Pt remains lethargic. opens eyes to voice, pupils 4mm brisk. Moving LUE slightly. Nodding yes when asked if having pain. Med with demerol X2 with some noted effect.\nCV: Afebrile, HR very labile, 100-140's Afib with occasional PVC's. labile 70-200/30-100's. tachypneic 30-40's MICU team aware of vital signs. extremities cool with pulses.\nRESP: lungs coarse to dim at bases. Occasional suctioning of thick yellow secretions. O2 sats >95%. Unable to place pt on home ventilator due to very labile VS. Family giving pt ice chips. Nurse asked family to not give pt ice due to aspiration. Pt's grand daughter found giving pt her slurpee, now having pink drg on trach drain sponge around trach, appears to be same color as slurpee.\nGI: tol tube feed at goal. draining adequate amount of brown loose stool.\nENDO: blood sugars elevated requiring mod coverage per RISS.\nPLAN: Awaiting ? transfer to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-27 00:00:00.000",
"description": "Report",
"row_id": 1524455,
"text": "Respiratory Care\nPt remains trached and on vent support. Pt was placed onto home vent and 2 hrs. Pt removed and placed back onto for increased RR. RR 28-35 on home vent and remained 28-35 on , pt was placed back to see if home vent was not tol. Pt tol. home vent. Lung sounds course and diminished in the bases. Pt was suctioned for scant to moderate amounts of thick yellow secretions. No ABG's were drawn and VBG was 7.36/38/32/22. Pt received MDI's albuterol was not given due to HR >110. Care plan is to place pt on home vent and remain on vent overnight. Pt is planned for a d/c tomorrow. Will continue to follow pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-28 00:00:00.000",
"description": "Report",
"row_id": 1524456,
"text": "Respiratory Care\nPt remains trached with 7.0 Shiley. Pt stayed on ventilator on full support throughout the night. BS coarse bilaterally and diminished at lung bases. Suctioned for small amounts of thick tan secretions. MDI's given as ordered with increases aeration throughout lung fields. Pt remained hypertensive throughout the majority of the shift. No morning completed due to increased BP. See CareVue for details and specifics.\nPlan: ? placing pt on home vent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-14 00:00:00.000",
"description": "Report",
"row_id": 1524281,
"text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT MOST OF THE NIGHT, OCCASIONALLY SLEEPING FOR BRIEF PERIODS. MOUTHING WORDS OCCASIONALLY, FOLLOWING SOME SIMPLE COMMANDS. MOVING LEFT HAND OFF THE BED, SLIGHT MOVEMENT NOTED FROM RIGHT FOOT, HOWEVER NO OTHER SPONTANEOUS MOVEMENT NOTED. PERRL. NODDING YES TO PAIN, RELIEVED BY REPOSITIONING.\nCV- BP STABLE IN 90-100 RANGE SYSTOLIC. NO PRESSORS OVERNIGHT. REMAINS IN 120-140'S, A-FIB WITH OCCASIONAL PVCS. LYTES CHECKED Q 6 HOURS PER CRRT PROTOCOL. DR. UPDATED ABOUT INCREASING HR A FEW TIMES OVERNIGHT, DILT 5MG GIVEN X 1 WITH MINIMAL EFFECT ON RATE. DR. WILL FOLLOW UP WITH TEAM ABOUT TREATMENT THIS AM. CONTINUES, PT WAS ABOUT A LITER POSITIVE AT MIDNIGHT WITH REMOVAL RATE OF 0. AFTER MIDNIGHT, REMOVAL RATE SET TO KEEP PT EVEN, HOWEVER BP DROPPING THIS AM TO 80'S, RATE DECREASED BACK TO 0 FOR NOW. PLATELETS 22 THIS AM, DR. NOTIFIED, WILL TREAT FOR LESS THAN 20 ONLY. PHOSPHOROUS LOW, .8, 2 PACKETS OF NEUTRAPHOS GIVEN X 1, WILL FOLLOW UP.\nRESP- LUNGS COARSE, SUCTIONED A FEW TIMES FOR THICK WHITISH SPUTUM. O2 SAT 100%, ABGS SLIGHTLY ALKALOTIC WITH PCO2 33-34. NO VENT CHANGES MADE.\nGI/GU- ABD SOFT, + BS. TOLERATING TF AT GOAL. COLOSTOMY DRAINING MODERATE AMOUNT OF LOOSE GOLDEN STOOL. APPLIANCE CHANGED, STOMA PINK. PT DOES NOT VOID.\nID- TEMP DECREASING TO 95 THIS AM, BAIR HUGGER PLACED. BLOOD CULTURES DRAWN WITH AM LABS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-14 00:00:00.000",
"description": "Report",
"row_id": 1524282,
"text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the shift. Latest abg results determined a respiratory alkalemia with excellent oxygenation on the current settings. Patient remains tachycardic, and the albuterol mdi inline was witheld. Atrovent given with each vent check.\n\nNo RSBI measured due to the cardiac status and the general instability of the patient.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-14 00:00:00.000",
"description": "Report",
"row_id": 1524283,
"text": "resp care\nremains trached/vent dependant. no changes on vent settings this shift. sxned for small amt yellow thick secretions. nard. consistently breathes over set rate. abg acceptable. atrovent given q6h, albuterol held until tachycardic,given in pm with HR 106. c/w full vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-28 00:00:00.000",
"description": "Report",
"row_id": 1524339,
"text": "CONDITION UPDATE\nASSESSMENT:\n NEURO EXAM UNCHANGED. PATIENT OPENS EYES SPONTANEOUSLY BUT DOES NOT FOLLOW COMMANDS. DOES NOT APPEAR TO BE IN PAIN. HEART RATE ~ 100 AFIB, REMAINS ON DILTIAZEM. PATIENT CURRENTLY ON 0.5 MGS NEO, WEANING EXTREMELY SLOW KEEPING MAP>55. CREAT 1.2, ELECTROLYTES NORMAL. NO DIALYSIS TODAY. AFEBRILE.\n LUNG SOUNDS COARSE, SUCTIONED OCCASIONALLY FOR THICK YELLOW SPUTUM. TOLERATING ASSIST CONTROL. ABDOMEN DISTENDED BUT IMPROVED SINCE . TUBE FEEDS REMAIN OFF (J-TUBE CLAMPED) AND G-TUBE TO WALL SUCTION WITH MODERATE AMOUNT BROWN/YELLOW OUTPUT. G-J SITE CONTINUES TO OOZE, APPLIANCE INTACT. COLOSTOMY WITH SCANT LOOSE BROWN STOOL. SEE CAREVUE FLOWSHEET FOR SKIN ASSESSMENT & TREATMENT.\nPLAN:\n? ATTEMPT TO RESTART TUBE FEEDS TOMMORROW. PROVIDE SUPPORT. WEAN NEO AS PATIENT TOLERATES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-28 00:00:00.000",
"description": "Report",
"row_id": 1524340,
"text": "BS rare fine crackles; no change with MDI's. No vent changes. Dialysis still on hold. Pressors weaned. Will wean vent as tolerated. Inner cannula changed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-05 00:00:00.000",
"description": "Report",
"row_id": 1524369,
"text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\nNEURO: PT NOT RESPONSIVE TO ANY STIMULI, EVEN FROM FAMILY MEMBERS, NOT FOLLOWING COMMANDS. OPENS EYES SPONTANEOUSLY, PERRL 5MM, BRISK, NOT TRACKING. VERY MIN MVMT OF LUE ONLY, NO MVMT TO ALL OTHER EXTREMS. DEMEROL 12.5MG GIVEN PRIOR TO DSG CHANGES.\n\nCVS: HR 70S-90S, NSR, DILTIAZEM DRIP AT 5MG/HR. 80S-90S, MAP>55 W/NEO DRIP 0.2-0.4 MCG/KG/MIN. T-MAX 99.4, HCT 24.4 THIS PM-HO AWARE-NO INTVN TAKEN AT THIS TIME, REPEAT HCT AT 2100, NO S/S ACUTE BLEEDING NOTED. PP VIA DOPPLER, ?HD .\n\nRESP: NO VENT CHANGES, LUNGS COARSE TO APICES, DIMINISHED AT BASES BILAT. PT SUCTIONED FOR MOD AMTS THICK, YELLOW SECRETIONS. O2 SATS 97-100%, PT ACUTELY TACHYPNEIC DURING DSG CHANGES, UP TO 30S. TRACH CARE DONE, IN-LINE SXN CATH CHANGED. PT W/2-8 BPM OVER SET RATE, ATIVAN 1MG GIVEN X1 FOR PT COMFORT.\n\nGI/GU: COLOSTOMY STOMA PINK, EDEMATOUS, PATENT DRNG SM AMT BLK, TARRY SOFT STOOL, HYPO+BS. JT PATENT TO FLUSH/RETURNS>AMT FLUSHED, GT PATENT, MIN DRAW BACK. MIN BRWN DRNG FROM AROUND J/GT INSERTION SITE.\nTPN AT 77CC/HR, ?RE-START TF .\n\nENDO: BS BET 111-128, INSULIN DRIP AT 8.5MG/HR\n\nINTEG: PT W/MULTI AREAS SKIN BREAKDOWN-DSG CHANGES DONE TO SACRAL, RIGHT , BILAT TROCHANTER DECUBITUS ULCERS, REINFORCED PRN. MUTLI AREAS OF SKIN TEARS DRNG MOD AMTS SEROUS FLUID, REINFORCED PRN.\nBILAT HEEL ULCERS COVERED W/ADAPTIC, WRAPPED W/KERLIX. PT Q2-3HRS, HEELS OFF BED.\n\nID: AMIKACIN HELD FOR LEVEL 12.8, MEROPENEM RE-STARTED PER DR.\n\nPLAN: HEMODYNAMIC MONITORING, PAIN MGMT/PT COMFORT, GI OUTPUT FOR S/S ACUTE BLEEDING, RESP SUPPORT, SERIAL HCTS, PROBABLE HD , , NEURO ASSESSMENT, AGGRESSIVE SKIN CARE, FAMILY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-06 00:00:00.000",
"description": "Report",
"row_id": 1524370,
"text": "Respiratory care:\nPatient remains trached and mechanically vented. Vent checked and alarms functioning. Current settings: A/C 450*22 50% 8 peep. ABG this am with improvement in acidosis and oxygenation. (7.33/43/101 24 -3).\nBreathsounds are coarse. Albuterol/atrovent and flovent given. Continues with a #7 portex extra long trach, Inner cannula replaced. Trach patent and site looks good. Suctioned for small amounts of clear to yellow secretions. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation. Continue aggressive bronchodilators and pulmonary toilet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-01 00:00:00.000",
"description": "Report",
"row_id": 1524102,
"text": "Focus Condition Update\nSee flowsheet for specific information\n\nNeuro: No change in neuro status. Pt follows commands inconsistently, MAE's on bed except for RUE. Opens eyes spontaneously, PERRL.\nCV: Pt afebrile, in a-fib, hypotensive and most of shift. 500cc NS given, 12.5 lopressor given with effect. PTT >150, heparin gtt off until 0200, restarted at 700 units/hr MD, PTT currently 31, will recheck at 0500. Crit down to 27.9, MD aware.\nResp: Remains on CMV, no vent changes made this shift. LCTA bilaterally, sux'd for small amount of thick white sputum.\nGI: Colostomy patent, draining moderate amount of brown loose stool. Abdomen soft. Getting FS at 40cc/hr.\nEndo: Insulin gtt on at start of shift, shut off at midnight per order, switched to s/s. 70 units of glargine given hs.\nInteg: Right toe wound draining moderate amount of sang fluid, cleansed with wound cleanser, wet to dry dressing changed x3, cx sent. Wet to dry dressing over right ischial ulcer, cleansed and changed.\nPlan: L-spine MRI today.\n Change wound dressings as needed.\n Continue to monitor hemodynamic status.\n Monitor PTT to achieve therapeutic heparin dose.\n Contact MICU with changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-01 00:00:00.000",
"description": "Report",
"row_id": 1524103,
"text": "\nPt presents trached On A/C 450X16 /5 .4. BS sligt coarse diminished bases. Sx for a sml amt thick tan secretions. No ABG this AM. Sats 100%. Plan: wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-29 00:00:00.000",
"description": "Report",
"row_id": 1524341,
"text": "Neuro: Pt. opens eyes especially when family present. Nods head at times but inconsistent with verbal commands. Noted to move LUE only.\nCV: continues to be in afib. Neo @.4mcq/kg/min. to keep MAP >55.\nSkin warm and color pink.\nPulm: yellow secretions per tracheal sx. Inhalers per vent circuit adm. by resp. therapist. Noted leak but no TV losses. pressure checked by RT and adjusted to try to correct for leak.\nGI: GJ tube in position. Gtube to CLWS with brown/green drng. J tube clamped except for meds. + bowel sounds. ABD. non-tender to palp. as no noted facial grimacing per pt. Colostomy with scant amount liquid brown stool. pink stoma.\nGU: None as pt. is anuric and s/p HD/CRRT.\nSKin: see AFS for dsg management. Left upper thigh pink as reported by previous RN as being a known cellulitis. Lower extr. DSG's intact(QD).\nPt. has two collection bags on right arm for serous drng. Collection bag aroung GJ tube site for similar drng. Skin tears in all skin folds. Mycostatin powder applied.\nEndo: SSRI as per Q6 BS's.\nID. Amikacin dose IV given for new BC growth of gram neg rods. ID to follow dosing.\nPlan: monitor GI status due to partial small bowel obstr. Surgery following. Monitor temps, lactic acid, WBC. Continue to assess need for CRRT in the future-vs-HD.\nam labs pending: see flowsheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-29 00:00:00.000",
"description": "Report",
"row_id": 1524342,
"text": "pt remained on full vent support through PM. ABG was within acceptable limits and secretions sx'd were minimal, pressure measured was 22 with a very slight leak.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-19 00:00:00.000",
"description": "Report",
"row_id": 1524422,
"text": "focus hemodynmics\ndata: neuro: awake and eyes open when spoken to. at times mouthing words but very difficult to undersand. pt will nod head. does not move extremites on the bed. very rigid when turning in the bed. passive range of motion done. pupils react briskly to light.\n\nresp: breath sounds course. suctioned for thick yellow sputum. trach care done. no vent changes done. on a/c of 50%.\n\ncardiac: remains in nsr. no ectopy seen. mag level 1.8. inr 1.5 and hct 28.6. k 3.5. to have dialysis on monday.\n\ngI abd soft. colostomy patent and draining brown stool. colostomy site pink. tube fdg site oozing some bloody drainage.\n\ngu: foley patent and draining yellow urine. creat 1.7 bun32.\n\nskin: multiple skin tears with lg amt of serous ddrainage . buttocks excoriated.\n\naction:: skin care done. suctioned prn. tube fgs tol well. colostomy patent. update to family. respiratory therapist spoke with daughter in length regarding discharge to home. continues on iv merepenum and levofloxacin. triple lumen patent. dialysis catheter intact with visable oozing of blood at the insertion site. ho notified.\n\nresponse: monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-19 00:00:00.000",
"description": "Report",
"row_id": 1524423,
"text": "FOCUSED NURSING ASSESSMENT\nPlease see carevue flowsheet for further details\n\nNeuro: No changes from prior assessments, dozing intermittently. Unable to determine appropriateness of head nodding- inconsistent answers with simple questions- opens her mouth spontaneously to any motion near her mouth- seems to most enjoy ice chips, cold swabs repetitively. Demerol x 1 premedication for dressing changes, exhibited facial grimace and incr RR during procedure.\n\nResp: Trached on CMV. Sputum suctioned thick/yellow alternating with white/thin. Copious amts yellow/tan exudate from trach stoma. SPO2 95-100%, RR 19-28.\n\nHEMODYNAMICS: No sx active bleeding aside from baseline slow vaginal bleed. range 72-135/28-76, BP changes from systolic of 72 to 135 in a matter of 15 minutes without intervention. MICU resident aware, qwil lbegin CVP monitoring. HR 80-90s NSR, occassional PVCs. Diltiazem/Digoxin/Amiodarone/Midodrine given as ordered. Anasarcous, serous fluid weeping from new and old skin tears/blisters. Hct from 1800 pndig.\n\nGI/METABOLIC: TF at 40ml/hr vai J-port, no emesis, colostomy with 300ml liquid brown stool, guiac positive. New onset today of copious amts of viscous/clear to at times bilious drainage from G/J stoma site- Gtube is to gravity drainage with small outputs (80ml).\nGlucoses elevated today 164/191, covered with RISS as ordered- Lantus 5U in am daily dose.\n\nPSYCHOSOCIAL: Husband visit in am for 30 minutes- no further family contact this shift. Pt attempted to mouth words today, unable to interpret- pt became tearful then closed eyes and would not respond to verbal stimuli.\n\nPLAN OF CARE: Continue to monitor hemodynamcis, sx bleeding closely. Monitor CVPs, notify MICU resident of results. Aggressive skin care, nursing measures to ensure pts comfort, emotional support to pt and family ongoing. Reccomend family and interdisciplinary team conference in am to determine disposition plan and revisit pts comfort and \"big picture\" of disease states and inability to recover/heal and intolerance to medical interventions. This was requested by RN on MICU rounds today.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-19 00:00:00.000",
"description": "Report",
"row_id": 1524424,
"text": "Resp Care\nPt remains on CMV, no vent changes. Plan to prepare for home discharge and transition to home vent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-20 00:00:00.000",
"description": "Report",
"row_id": 1524425,
"text": "RESP CARE: pt remains trached/on vent No changes in vent settings. Lungs coarse bilat. Sxd mod amts thick yellow sputum. pressure in trach at 25cmH20. No RSBI due to henodynamic instability. Plan is to place pt on home vent today in anticipation of DC home Wed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-07 00:00:00.000",
"description": "Report",
"row_id": 1524131,
"text": "Status A\nSee Carevue for specifics\n\nNeuro: Alert but unable to assess orientation. Follows commands inconsistently. PERRL.\nCV/GU: Afib. Hypotensive but maintained parameter of MAP >50. 1 unit of PRBC given during dialysis.\nResp: LS clear. No vent changes.\nGI: BS present. TF to goal. Drainage around PEG, dsg changed. Colostomy putting out brown liquid stool.\nSkin: Multiple wounds and areas of skin breakdown. See Carevue for specifics.\nEndo: glucose fairly stable in 110s-120s with insulin gtt with drop later in afternoon to 70s.\nSocial: children at bedside.\nPlan: continue with skin care regimen. Educate family on homecare needs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-08 00:00:00.000",
"description": "Report",
"row_id": 1524132,
"text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT, FOLLOWS COMMANDS TO OPEN MOUTH, OPEN EYES. ONLY SPONTANEOUS MOVEMENT NOTED IS FROM UPPER LEFT EXT. PERRL. C/O PAIN THAT SEEMS TO BE RELIEVED WITH REPOSITIONING.\nCV- REMAINS HYPOTENSIVE, 80-100 SYSTOLIC, CAN HAVE FLUID IF SYSTOLIC BELOW 80. HR 90-100'S, A-FIB WITH OCCASIONAL PVCS, AM LABS PENDING.\nRESP- LUNGS CLEAR, SUCTIONED A FEW TIMES FOR SMALL AMOUNT OF THICK YELLOW SPUTUM. O2 SAT 100% ON CURRENT VENT SETTINGS, NO CHANGES MADE, BREATHING COMFORTABLY.\nGI/GU- ABD SOFT, HYPO SOUNDS. TUBE FEED CONTINUES AT GOAL, SMALL AMOUNT OF DRAINAGE NOTED FROM AROUND PEJ SITE, CLEANED AND DRY DRESSING PLACED. CHANGE OVER TO LARGER TUBE TODAY IN IR. PT DOES NOT VOID.\nID- AFEBRILE\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-08 00:00:00.000",
"description": "Report",
"row_id": 1524133,
"text": "Respiratory Care Note:\n\nPt remain on full ventilatory support via tracheotomy tube. No vent changes maded. RSBI done ~77. We are sxtn routinely for smalla mt of thick yellow secretions from trach. Plan: Continue present iCu moniotoring. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-08 00:00:00.000",
"description": "Report",
"row_id": 1524134,
"text": "Respiratory Care\n\n Pt continues on full ventilatory support. No changes made today. Cuff pressure 25cm H20. Pt traveled to I.R. without complication. B/S sl coarse sx'd for scant thick yellow. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-27 00:00:00.000",
"description": "Report",
"row_id": 1524213,
"text": "Repiratory care\nPt remains on a/c vent without changes, Suctioned for large amts of thick yellow sample sent to lab. Pt had trach change to Shiley #7 long\nvia bronchoscopy without incident. MDI's as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-27 00:00:00.000",
"description": "Report",
"row_id": 1524214,
"text": "\"Condition update\nPlease see carevue for specifics.\n\nneuro unchanged. tmax 100.9; wbc ct up to 25. plt re pan cx'd today. afib continues. HR 120's - 150. MICU team aware. 12 lead EKG done. HD today. 2300 off. hct down to 17.8; 2 units prbc given. post transfusion hct only 21. no further blood given. pt noted to have dark red bleeding in moderate amts from her vagina. MICU team notified. bs's 200's-300's. insulin gtt ordered. wounds cx'd. trach changed over to 7 long shiley. HCP notified.\n\nplan: hd as tolerated. iv abx. wound care. monitor hemodynamics. family meeting to discuss plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-28 00:00:00.000",
"description": "Report",
"row_id": 1524215,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick tan secretions. MDI'S given. Temp 101.2. HR-A-Fib.No weaning done.Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-28 00:00:00.000",
"description": "Report",
"row_id": 1524216,
"text": "nursing note\nAlert with open eyes. nods at times but question if she understands. All dressing done and documented. Tmax 101.8- given as pan cx'd on days.\nplan:await culture results. if temp. skin care. family meeting to discuss dispo.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-25 00:00:00.000",
"description": "Report",
"row_id": 1524448,
"text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\nNEURO: ALERT, DOZING INTERMITTENTLY, EASLIY AROUSABLE. NOT FOLLOWING COMMANDS, INCONSISTENLY NODDING HEAD TO QUESTIONS. PERRL 4-5MM, BRISK, NOT TRACKING W/EYES. DEMEROL GIVEN FOR PAIN PRIOR TO DSG CHANGES X2.\n\nCVS: HR 80S-90S, NSR, NO ECTOPY NOTED. 70S-140S, MAP MAINTAINED>60 PER MICU, AFEBRILE. PM HCT 31.1, INR 1.9, PLT CT 37, K REPLETED FOR 3.9, REPEAT LABS AT 2100.\n\nRESP: REMAINS ON CMV, RATE 22/VT 450, NO VENT CHANGES MADE. PT SUCTIONED FOR SM AMTS THICK, YELLOW SECRETIONS. LUNGS COARSE TO APICES, DIMINISHED AT BASES, SLIGHT EXP WHEEZE NOTED TO RUL AT TIMES, MDI TREATMENTS GIVEN.\n\nGI/GU: RE-START TF AFTER MN PER MICU TEAM. COLOSTOMY PINK W/MIN GRN/BRWN DRNG, NO BLOOD NOTED. GT TO GRAVITY W/MOD AMT YELLOW, SEROUS DRNG, JT PATENT TO FLUSH, AREA AROUND INSERTION SITE DRNG SM AMTS STRAW COLORED FLUID. SM AMT CLEAR MUCOID RECTAL DRNG NOTED, AS WELL AS SM AMT VAGINAL BLEEDING NOTED-DR. AWARE.\n\nENDO: BS REQUIRED NO COVERAGE, AM LANTUS HELD PER MICU FOR AM BS 89\n\nINTEG: EXTENSIVE WND CARE DONE, INCL MULTI DSG CHANGES, FREQUENT TURNING & RE-POSITIONING. SARNA LOTION APPLIED TO MULTI AREAS RED RASH, MICONAZOLE/ANTI-FUNGAL POWDER APPLIED TO PERINEAL AREA. REDDENED, EXCORIATED AREA TO NECK UNDER TRACH COLLAR NOTED. PT W/GENERALIZED LEAKING COPIOUS AMTS SEROUS FLUID.\n\nPSYCHOSOCIAL: PT HUSBAND IN TO VISIT FOR SHORT TIME THIS AM. DAUGHTER CALLED INQUIRING ABOUT PT CONDITION, REQUESTED COPY OF PT , UPDATE FROM ATTENDING MD, MSG PASSED ALONG.\n\nPLAN: AGGRESSIVE SKIN CARE, PT COMFORT, RESP SUPPORT. SICU , PLAN FOR D/C HOME MON IN ACCORDANCE W/FAMILY WISHES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-26 00:00:00.000",
"description": "Report",
"row_id": 1524449,
"text": "Resp Care,\nPt. remains on A/C . No vent changes this shift. BS coarse, suctioned yellow sputum. MDI's as ordered. 65 this am. Plan home vent Sun. Plan D/C to home Mon. See carevue.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-26 00:00:00.000",
"description": "Report",
"row_id": 1524450,
"text": "Narrative Note\nB-Shift:\nNeuro: Unchanged. Con't w/ rightward gaze. Does not respond to threat or startle. Daughter () appeared to be conversing w/ pt. early in shift, but no such communication could be elicited later. Does appear to sleep at times, and wakeful at others.\nCV: NSR-ST w/ rare ectopic. BP low, but within normal limits for pt.\nPulmonary: Vent settings unchanged, refer to CareVue for specific interventions.\nGI: TF's () started this shift @ 40cc/hr through gastric port on G/J tube.\nGU: Con't to pass blood/clots through vagina. No change in amount or quality of drainage.\nSkin: Breakdown in virtually all areas. BUE's w/ tears and ecchymosis, dsg's applied in areas of most significant breakdown (mostly RUE). BLE's w/ many areas of breakdown, DSD's not changed on feet/anlkes. Posterior thigh dsg's changed, areas reddened, not blanching. Dressing on rear-end changed, both tunneled decubitii packed w/ aquacel as ordered, Adaptic placed on open areas. SoftSorbs taped in place with Mefix.\nSocial/Plan: Son and daughter in to visit from beginning of shift until 11pm. Were concerned w/ G/J tube site and its ostomy appliance. Update given by Dr. who spoke with them for some time. Plan remains to send pt. home on Monday.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-01 00:00:00.000",
"description": "Report",
"row_id": 1524104,
"text": "Respiratory Therapy\n\nPt remains trached w/ #6.0 on full mechanical support. No vent changes made this shift. Currently on A/C ventilation w/ PIP = 14. BLBS slightly coarse, suctioned for moderate amounts of thick tannish sputum. SpO2 90s. MDIs given as ordered. See resp flowsheet for specifics.\n\nPlan: maintain support\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-01 00:00:00.000",
"description": "Report",
"row_id": 1524105,
"text": "7a-7p\nneuro: lethargic, easily aroused, follows commands @ times, perl, pt on atc po ativan q 6 hrs, pm dose held due to oversedation, pt more awake & responsive after dose held\n\ncv: hr a-fib(102-120), occasional pvc's, sbp 87-115, po lopressor, po amiodarone\n\nresp: continues on 40% fio2/AC 16/5 peep, no vent changes, bs+ all lobes & clear, sux scant amt sputum, inhalers by R.T., sat 100, rr 20-24, no resp dsitress noted\n\ngi: goal tf tol well, mod amt loose brown stool via colostomy, iv protonix, po reglan, colace & lactulose\n\ngu: anuric, hemo 3 x's per weak, no hemo today, done yesterday, due tomorrow, albumin(12.5 gm) x 1 ordered for hemo tomorrow, see stat med sheet\n\nother: wound care done as ordered, R foot with lg amt bleeding, ho aware, hct done @ 1300(26.9), no tx, pt to have blood tx with hemo tomorrow, daughter in & updated on pt by nurse & medical team, bs 424, insulin gtt resumed, ptt 99.5, heparin gtt off x 1&1/2 hrs then resumed @ 750 u/hr, PTT due @ 2330, no c/o pain\n\nplan: continue to monitor blood pressure/sepsis in ICU, fluid boluses for sbp < 80, MRI to r/o osteo from sacral decub, hemo tomorrow, antibiotics as ordered\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-20 00:00:00.000",
"description": "Report",
"row_id": 1524184,
"text": "Condition Update\nPlease see carevue for specifics.\n\nT/max 99.7; Cx's pending from . AFib. HR 90's-130's. Lopressor dose held d/t sbp 80's. Rare PVC's noted. 12.5 mg Demerol given for pain prior to dressing changes. Pt sxn'd for large amts of thick, yellow sputum. A sputum cx and gram stain sent. No vent changes made this shift. Pt continues on AC 40%/5 peep. Resp tx giving pt . Pt went down to I.R. for new G/J tube. w/ beneprotein infusing at goal. Colostomy draining golden loose stool. Stoma is pink. Regular insulin gtt started this afternoon d/t continued high blood sugars. Pt still receiving 90 units glargine q 12 hours. Plastics team up this eve to pt's wounds. Feedback pending. Pt to be started on CRRT this eve since she was unable to tolerate HD .\n\nPlan: continue with current plan of care per MICU team. CRRT. Q 6 hour labs. MICU team to evaluate for arterial line. Hourly blood sugars d/t insulin gtt. Pain mgmt. Daily dressing changes. F/U on plastics consult. IV ABX.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-20 00:00:00.000",
"description": "Report",
"row_id": 1524185,
"text": "Respiratory Therapy\n\nPt remains trached w/ #8 TTS adjustable trach locked @ 10cm. Currently on A/C ventilation, no changes made this shift. SpO2 90s. Travelled to and from IR for G/J tube placement w/out incident. MDIs given as ordered. BS coarse bilaterally, suctioned for moderate amounts of thick tan sputum. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support; still to be evaluated by IP for ?trach change\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-20 00:00:00.000",
"description": "Report",
"row_id": 1524426,
"text": "focus hemodynmics\ndata: neuro: awake and opens eyes to verbal stimuli. mouths words but difficult to understand. does not move extremities due to fluid in extremites. nods to daughter and son in law. nods to some questions.\n\nresp: breath sounds course. suctioned for thick yellow sputum. trach care done. skin near trach reddened and excoriated.\n\ncardiac: remains in nsr. occ pvc. k 3.0 and ho notified. k being repleted with 20meq iv. diltazem held due to bp < 90.\n\ngi abd soft. tube fdgs infusing at goal rate of 40cc/hr. colostomy bag intact and draining brown/green drainage.\n\ngu creat 1.7. due to be dialysized today.\n\naction: labs as ordered. suctioned prn. tube fdgs as ordered. k repleted with 20meq kcl. skin care done q1-2 hrs. buttocks excoriated. lg amt of serous drainage . lg decubitus on buttocks and dsg changed x3. leg dsg intact with feet dsg changed x2. daughter in to see pt tonite and very upset with the g j tube insertion site. daughter spoke with ho and verbalized her concerns of tube and skin condition. daughter upset with overall skin condition. dsughter would like to talk with the attending md. ho aware of this and will discuss in rounds today.\n\nresponse: monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-06 00:00:00.000",
"description": "Report",
"row_id": 1524124,
"text": "RESPIRATORY CARE NOTE\n\nPatient remains trached with Shiley trach tube 6.0 SCT. No vent changes made during the . BLBS are coarse. Sxn for moderate thick yellow secretions. RSBI completed on PS 5=99.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-06 00:00:00.000",
"description": "Report",
"row_id": 1524125,
"text": "Addendum: Progressively lower diastolics to 30s-40s with MAPs <60. HR stable, pt. alert and appears neurologically unchanged, though does not follow commands at baseline. MICU team in to assess and given 500cc NS and lytes repleted. SBP to 90s after begun.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-28 00:00:00.000",
"description": "Report",
"row_id": 1524217,
"text": "Patient uses portable vent @ home,trach is changed to # 7 extra long. Inner canulae on top on vent for daily usage.BS rhochious with L>R,suctioned for thick yellow secretion;sputum cultured gram(-) rod.Patient on tobramycin.CXR (l) pleural effusion and lingula atelectasi.Plan to meet with family to discuss disposition.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-28 00:00:00.000",
"description": "Report",
"row_id": 1524218,
"text": "Condition Update\nPlease see carevue for specifics.\n\nTmax 99.7, AFIB. HCT stable at 25.2, but vaginal bleeding continues. Transvaginal Pelvic ultrasound ordered. Pt sxn'd several times for thick, yellow/green secretions in moderate amts. TF's infusing at goal. BS 91-127. RISS ordered, glargine dose increased to 92 units. toxin B assay sent, and Po flagyl ordered despite all previous specs being negative.\n\nPlan: continue with current plan of care per micu team. continue to closely follow blood sugars, hemodynamics. HD to be . Vanco and tobramycin peak and trough to be drawn. Still awaiting vaginal us. Dressing changes. Family meeting to be scheduled by social services to include family, nursing, social srvs, case mgmt, ethics, micu team + the attending. Blood cx to be drawn from the HD catheter by the HD RN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-29 00:00:00.000",
"description": "Report",
"row_id": 1524219,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned mod amts thick green/tan secretions. MDI'S given.Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-29 00:00:00.000",
"description": "Report",
"row_id": 1524220,
"text": "nursing update\nno events. MD spoke with daughter regarding family meeting. Duaghter at this time does not want family meeting. She states she will have one when home services are set up and mom is ready to go home.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-16 00:00:00.000",
"description": "Report",
"row_id": 1524291,
"text": "Resp Care\nPt remains trach on full vent support. No vent changes this shift. Pt continues to be suctioned for mod amt of thick yellow sputum, MDIs given per order. Pt brought to IR this afternoon. plan to continue vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-21 00:00:00.000",
"description": "Report",
"row_id": 1524186,
"text": "nursing note\nNeuro:Mouthing words at times, not sure what she is saying. some movement noted with L hand. afebrile.\nCV: Cont in afib, lopressor held secodnary to low BP.\nRESP:thick tan secretions, copius at times.\nGI: at goal. loose stool via ostomy- sent\nGU:anuric. started with goal even. ultrafltrate titrated frequently secondary to BP.\nSocial: MD wspoke with daughter re: and 2 sons. spoke with 2 sons and answered many questions re:, labs, antibiotics, cultures and wound care.\n\nplan:cont to await culture data, resp toilet, to keep even. social support\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-21 00:00:00.000",
"description": "Report",
"row_id": 1524187,
"text": "Respiratory Care\nPt continues full vent support with #8 adjustable protex trach locked at 10cm. BS coarse and diminished bilaterally. Suctioned for moderate amounts of thick tan sputum. No vent changes made this shift. MDIs given as ordered. See Careview for morning RBSI results.\nPlan: maintain suppport\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-21 00:00:00.000",
"description": "Report",
"row_id": 1524188,
"text": "Events:\n\nSacral wound cultured\n running even and transiently positive for hypotension with effect\nKPhos repleted\n\nNeuro-shakes head to yes/no questions, moves upper extrem >LE, withdraws LE weakly, PERRLA, ativan ATC for comfort\nCV-HS S1S2 irreg with click, doppler DP bilaterally cool extrem x4, cont on amiodarone/lopressor remains in AFib, coumadin dose to be held tonight INR 4.3\nResp-ML trach site red, remains on AC, sx for scant thick plugs, LS coarse upper lobes dim at bases\nGI-TF at 40cc/hr, GJtube leaking serous at site, DSD and skin barrier cream at site, glucose covered with glargin 90u SQ and insulin drip, colostomy loose liquid stool out\nGU- running even RF/Dialysate prismasate, K and calcium repleted with SS, acid base balance and lytes monitored q6 hours\nskin-sacral decubitis to bone foul odor out, packed and DSD to area, r/l hip stage II aquacel/allevyn dressings, necrotic toes bilaterally and calf stage II-III dressing changed per wound care recomendations\n\n HCP updated via phone, daughter many questions and felt the patient needed albumin with dialysis to remove fluid, daughter requested antibiotic changes. update given and teaching done regarding and albumin, and blood pressure.Update given current cultures and sensitivity to current ABX, daughter aware infectious disease following. MICU team aware of daughters concerns. Daughter stated \" failed to identify infection, she was the one to tell the doctors to , she was the one to identify nutrition needs\" stated that she was the primary person managing her at home and albumin \"worked\", extensive teaching done and update on current plan of care, daughter continues to state negative comments regarding the care and doctor \" stating she was able to manage this at home. Risk /patient care services notified. Daughter made aware she can voice her concerns to case management.Reassurance given to that her mother is getting aggressive care and the best care. Emotional support provided, at this time the MICU team is in agreement to only give information and daily updates to primary HCP in order to avoid confusion among family members. SICU staff will attempt to provide info to HCP . Social work notified\n\nPlan-cont running even, cont TF, continue skin care, monitor lytes and acid base balance, cont emotional support to family, information to HCP only to avoid confusion among family members, updated on this\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-21 00:00:00.000",
"description": "Report",
"row_id": 1524189,
"text": "Respiratory Care\n\n Pt continues on full ventilatory support. No changes made today. B/S sl coarse and diminished. MDI's as ordered. Sx'd for sm/mod amount thinish yellow secretions. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-22 00:00:00.000",
"description": "Report",
"row_id": 1524190,
"text": "Resp Care Note:\n\nPt cont trached and on mech vent as per Carevue. Lung sounds coarse suct mod th off white/tan sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required . Had difficulty asp secretions from trach; repositioned tube problem resolved. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-13 00:00:00.000",
"description": "Report",
"row_id": 1524277,
"text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT, MOUTHING WORDS, OCCASIONALLY NODDING IN RESPONSE TO SOME QUESTIONS. MOVING ONLY LEFT HAND ON THE BED. PERRL. PT APPEARING TO BE CRYING AT TIMES, UNABLE TO UNDERSTAND THE WORDS THAT SHE IS MOUTHING, OFFERED EMOTIONAL SUPPORT.\nCV- BP STABLE IN 90-115 RANGE SYSTOLIC. NEO REMAINS OFF FOR NOW, PITRESSIN CONTINUES AT 2.4 U/HR. A-FIB, TACHYCARDIC 110-150'S AT TIMES, HOWEVER NOT SUSTAINED. AT BEGINNING OF THE SHIFT, PT APPEARED TO BE INCREASINGLY TO 150'S, 2L NEG FLUID BALANCE, BP STABLE, DR. NOTIFIED. NO NEW ORDERS AT THE TIME. DECISION MADE TO TAKE OFF LESS FLUID, TRYING TO KEEP EVEN FLUID BALANCE. CVP 13-16.\nRESP- LUNGS COARSE AT TIMES, SUCTIONED OCCASIONALLY FOR THICK WHITE SPUTUM. ABGS WNL THIS AM.\nGI/GU- ABD SOFT, HYPO SOUNDS. COLOSTOMY DRAINAGE IS GOLDEN BROWN LOOSE. TOLERATING TF AT GOAL. PT DOES NOT VOID.\nID- TEMP 95 AT MIDNIGHT FOLLOWING BATH, VERIFIED BY AXILLARY. WARM BLANKETS PLACED, HEAT TURNED UP IN ROOM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-13 00:00:00.000",
"description": "Report",
"row_id": 1524278,
"text": "Respiratory Care Note:\n\nPt remain on ventilatory support/assist via tracheotomy tube. No vent changes done. Lung sound clear to coarse, BBS. We are sxtn for small amt of thick white secretions from trach. none orally. MDI adm as ordered with no noticeable changes, Albuterol held t/o shift as HR> remain above 120 bpm. Plan: Continue present ICU monitoring. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-06 00:00:00.000",
"description": "Report",
"row_id": 1524126,
"text": "Focus Condition Update\nSee flowsheet for specific info.\n\nNeuro: Status unchanged. Pt mouthing words, following some commands, MAE's except for RUE. Fentanyl given for pain with dressing changes. Demerol written PRN for future dressing changes.\nCV: Hypotensive at times, , team aware. Afebrile. Lopressor and midodrine given.\nResp: No vent changes made this shift. LCTA, dim in bases. trach care done.\nGI: J-tube leaky, MD aware, surgery called by resident, but they have not come by to see pt. at 40cc/hr. Colostomy draining moderate amount of brown liquid stool.\nSkin: All wound dressings changed today with skin care RN. See updated note for dressing instructions.\nEndo: Sugars running high today, covered with new s/s. consulted this a.m.\nSocial: Dtr in to visit, many questions and needs.\nPlan: Discharge to home on Monday\n Continue with current POC\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-06 00:00:00.000",
"description": "Report",
"row_id": 1524127,
"text": "resp care - pt remains intubated with #6 shiley trach. Settings are a/c 450/16/5 40%. No changes were made during the day. Breath sounds were course bilaterally in the upper lobes, clearing slightly on sx of small amounts of thick yellow secretions. BS were dim in RML and LLL.\nPt's cuff leak was resolved with a pressure of 25 cmH2O. Continued resp care planned.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-07 00:00:00.000",
"description": "Report",
"row_id": 1524128,
"text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT MOST OF THE NIGHT. ABLE TO MOUTH SOME WORDS AND NOD IN RESPONSE TO SOME QUESTIONS. NO SPONTANEOUS MOVEMENT NOTED OVERNIGHT.\nCV- BP DECREASING TO 70'S SYSTOLIC THIS AM, DR. NOTIFIED AND 500CC NS GIVEN WITH GOOD EFFECT. HR 90'S-100, A-FIB WITH OCCASIONAL PVCS.\nRESP- LUNGS CLEAR, SUCTIONED A FEW TIMES FOR SMALL AMOUNTS OF THICK YELLOWISH. O2 SAT 100%, NO VENT CHANGES.\nGI/GU- ABD SOFT. COLOSTOMY DRAINING BROWN LOOSE STOOL, STOMA BEEFY RED AND APPEARS HEALTHY. INSULIN GTT RESTARTED FOR BS 309, BS DECREASING BY AM, LANTIS GIVEN AS ORDERED.\nID- TMAX 99.3\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-07 00:00:00.000",
"description": "Report",
"row_id": 1524129,
"text": "Respiratory Care Note:\n\nPt remain on ventilatory support via traheotomy tube, No vent changes maded. We are sxtn for small amt of thick yellow sputm thru trach. MDI adm as ordered with No noticesable cgaanges in BS. Plan: Continue present ICU monitoring. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-07 00:00:00.000",
"description": "Report",
"row_id": 1524130,
"text": "resp care - pt remains intubated with #6 Shiley trach on a/c 450,16,5,.40. No changes made. Rhonchi t/o cleared on sx of sm amt of thick white sputum. Meds given as ordered. Dim BS in LLL. Positional leak persists. MD wants no more than 25cmH2O cuff pressure. Continued resp care planned.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-25 00:00:00.000",
"description": "Report",
"row_id": 1524205,
"text": "BS rhonchi; no change with MDI's. Pt continues to have variable trach leak and we are looking into ordering a non- (to accomodate family), that is extra length, ideally >100mm. Current cuff pressures < 20 cm but adding air frequently. HD today. Pt will be discharged to family when sepsis and trach issues are resolved.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-25 00:00:00.000",
"description": "Report",
"row_id": 1524206,
"text": "FOCUSED NURSING ASSESSMENT\nPlease see carevue for further details\nNeuro: No acute changes in mental status, pt lethargic. alertness and responding to commands fluctuates- nods to communicate basic needs. PERRL, 3mm. Medicated with Demerol 12.5mg IV for drsg .\n\nResp: Trach patent, leak persistent though not interfering with oxygenation or ventilation. No vent changes made. Family goals of opportunity to place passy muir valve so pt can communicate her POC/medical wishes made known to MD. acceptable after inflation. Scattered rhonchi bilaterally- SPO2> 98% on A/C 0.40 PEEP 5. Frequent suctioning required, sputum change to copious blood-tinged, rusty and MD notified.\n\nHemodynamics: s/p HD removal of 1.75ml. Unable to remove goal of 3liters secondary to BP drops- tx by HD RN with NS and Albumin. Average SBP s/p HD is 88-96, DBP decreasing 30-45. Afib controlled rate 95-118. New onset vaginal bleeding, slow ooze, dark red MD notified, plan tranvaginal US. INR 3.0, coumadin held secondary to sx bleeding. HCT 27.5 stable this am.\n\nMetabolic: TF at goal rate 40ml/hr. Improved glycemic control, BS 111/87.\n\nID: Tmax 99.8. Tachycardic since HD. Tobramycin random 0.5, peak pending. Zosyn, Levaquin as ordered.\n\nSKIN INTEGRITY: Multiple pressure ulcers/wounds. Full re-evaluation and drsg with Skin care RN, please see her full note. Turn and repositioned q2-3hr. Pt requires premedication with demerol for drsg procedure.\n\nPSYCHOSOCIAL: Pt visited by husband and son in am during HD. Followed by daughter in afternoon who is very knowledgeable of her mother's medical care, specifically nursing focuses, and supportive. Emotional support and education to family members ongoing. SW following as well. POC per HCP daughter.\n\n PLAN: Monitor vag bleeding, hemostasis. F/U transvag US results. Hold coumadin today. Monitor labs/fevers. Skin care, resp care, comfort measures as appropriate per aggressive POC. Family support, d/c planning needs for home ventilation/HD/ and IV abx course.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-16 00:00:00.000",
"description": "Report",
"row_id": 1524292,
"text": "Please See Carevue for Specifics.\n\nNeuro: Arousable to voice does not follow commands only moves LUE to nailbed pressure. Ativan held this shift for sedation.\n\nCardio: SR-ST till 1755 this evening when pt coverted to afib 140-150's. MICU team aware, pt started on Diltiazem IV. this morning 70 and was started on Neo at 0.5mg/kg/hr. Generalized edema. Received two units , three units platelets, and one unit pRBC's prior and during new quinton placement and old quinton removal in IR. Blood cultures from old quinton cath, and right CVL. Line tip cultures sent from old quinton and PICC line. CVP 13-20. restarted at 1800.\n\nRespir: Remains on CMV. Suctioned for small amounts of thick tan-yellow secretions.\n\nGI: TF stopped at 1130 for procedure scheduled in IR and restarted at 1800. G-tube to gravity with clear/yellow mucous discharge. Stoma beefy and pink with guaiac negative loose golden stool.\n\nCVVH: Restarted at 1800. Fluid balance goal 0.\n\nSKIN: Skin remains impaired. Yeast under both breast, both underarms, both groin folds. All folds cleansed with soap and water, dried, and miconazole powder applied. Right great toe brown and hard. Thick foul yellow/green discharge from larger knuckle. Discharge obtained for culture. Bil posterior lower ext with pink +granulating tissue. Areas cleansed with wound cleanser and adaptic with DSD covering. Heels pink, cleansed, adaptic and DSD re-covered.\n\n: Monitor hemodynamics, monitor MS, pain, respir status, family aware of . HCP spoke with MICU attending this afternoon regarding limited line access.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-04 00:00:00.000",
"description": "Report",
"row_id": 1524363,
"text": "Respiratory Care\nPt remains trached and on vent support. No vent changes were made during shift. Lung sounds were course with rhonchi that cleared after suction. LLL and RLL were dim. Pt was suctioned for small to moderate amounts of thick yellow secretions. Pt received MDI's with improvement. Care plan is to continue current therapy with no changes to be made. Will continue to follow pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-04 00:00:00.000",
"description": "Report",
"row_id": 1524364,
"text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\nNEURO: PT CONT UNRESPONSIVE EVEN TO NAILBED PRESSURE, OPENS EYES SPOENTANEOUSLY, NOT FOLLOWING COMMANDS. PERRL 5MM, BRISK, DOES NOT TRACK W/EYES. NOT MOVING ANY EXTREMS.\n\nCVS: HR 70S-90S, DILTIAZEM DRIP CONT AT 7.5MG/HR, NSR, NO ECTOPY. 70S-100S, MAP MAINTAINED >55, NEO DRIP AT 0.3-0.4MCG/KG/MIN. T-MAX 99.4, TRANSFUSED 1 UNIT PRBCS, POST HCT PENDING, NO DIALYSIS TODAY PER RENAL, ?. PP , CONT W/ GEN ANASARCA, WEEPING SM AMTS SEROUS FLUID VIA MULTI SKIN TEARS.\n\nRESP: A/C-VT 450/PEEP 8/50%, RATE 20S-30S, DEMEROL GIVEN X1 FOR TACHYPNEA PRIOR TO DSG CHANGES. LUNGS SNDS DIMINISHED THROUGHOUT, SOMEWHAT CLEARER TO RUL, DIFFUSE RHONCI AT TIMES. PT FOR MOD AMTS THICK, YELLOW SECRETIONS, TRACH CARE DONE. NEBS GIVEN.\n\nGI/GU: COLOSTOMY PATENT, DRNG MIN AMTS DK RED STOOL. J/G TUBE CONT LEAKING MOD AMTS BROWN LIQUID DRNG AROUND INSERTION SITE, NO FRANK BLOOD NOTED. JT PATENT TO FLUSH, EASILY DRAWING BACK DK RED FLUID>FLUSH AMT, GT PATENT TO FLUSH, NO DRAW BACK>5-10CC-HO AWARE. HYPO +BS.\n\nENDO: BS 120S-170S, INSULIN DRIP 8-9MG/HR\nID: AMIKACIN LEVELS PENDING, HOLD MED IF>4 PER MICU, BLD CX PENDING.\n\nPLAN: CONT HEMODYNAMIC MONITORING, AGGRESSIVE SKIN CARE, PAIN MGMT, RESP SUPPORT, ?HD , NEURO CHECKS, ANTIBIOTIC THERAPY, GI OUTPUT MONITORING FOR GI BLEEDING, SERIAL LABS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-13 00:00:00.000",
"description": "Report",
"row_id": 1524279,
"text": "SICU NPN\nS-Trached\n\nO-Alert. Opens eyes spontaneously. Following commands inconsistently. Beginning to mouth words. PERL. Denies pain. Demerol IVP for dressing changes. HR 140-160s, RAF with stable BPs. SBPs 100-110s. Pitressin off at 0800. Since stable. Amiodorone load IVPB given. No gtt started. HR 110-130s post and no continious gtt started. SBPs post 80-90s. Dr. aware. Verbal orders to not to start Pitressin. Keeping MAPs > 55. Breath sounds clear. Remains on AC. Repeat ABG with respiratory alkalosis. MICU team aware during rounds. Bicitra discontinued. No vent changes made. CRRT continues. Fluid balance discussed with MICU team during rounds. Deciscion made to keep even. Now currently deciscion made to keep 1L ahead at 4PM. I/O currently even. CRRT labs pending for 4PM with ABG. Potassium scale increased for K of 3.3 this AM. ICa left the same. Abd obese and soft, bowels sounds active. TFs at GR. Ostomy and J-G tube intact. Hypothermic this morning, currently normothermic but remains on bair hugger at ambience setting. Tc 97.0, PO. Continues quadruple Abx for bacteremia. Family in and out most of day.\nA/P:Sepsis, improving off pressors. Goal now is to keep 1L ahead for daily I/O\nFollow ABGs and lytes while on CRRT Q6H.\nMonitor BPs closely, keeping MAP > 55.\nContinue to monitor\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-13 00:00:00.000",
"description": "Report",
"row_id": 1524280,
"text": "Resp Care\nPt remains on AC 450 x 16. ABGs do show some Resp Alkalosis, Bicitrate was discontinued. BS clear to coarse. Sxn' d clear to thick yellow secretions at times. RR breathing over vent by around 9 breaths per min.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-27 00:00:00.000",
"description": "Report",
"row_id": 1524334,
"text": "Respiratory Care\nPt trached on ventilatory support. Sx copious amounts thick green secretions. Minute ventilation markedly decreased over last 24 hours. ABGs within normal values with good oxygention.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-27 00:00:00.000",
"description": "Report",
"row_id": 1524335,
"text": "CONDITION UPDATE\nASSESSMENT:\n NEURO UNCHANGED. PATIENT DOES NOT APPEAR IN PAIN, NO PAIN MED NECESSARY. HEART RATE ~ 100 AFIB. MAP > 55 ON 0.8 MCGS NEO, UNABLE TO WEAN FURTHER. RECEIVED 1 UNIT PRBCS FOR HCT 21 THIS AM, REPEAT HCT UP TO 25. AFEBRILE. PATIENT REMAINS EXTREMELY FLUID OVERLOADED. CREAT 1.0 AND ELECTROLYTES NORMAL, NO DIALYSIS TODAY.\n ABDOMEN SOFTLY DISTENDED, PATIENT HAD FEEDINGS THRU J-TUBE THIS AM AND LARGE G-TUBE OUTPUT. KUB DONE IN AM. PATIENT ALSO VOMITED BILIOUS APPEARING FLUID & MODERATE AMOUNT OOZING FROM TRACH SITE. MICU TEAM AWARE, G-TUBE TO SUCTION & IMMEDIATELY DRAINED 750 CC. TUBE FEEDS OFF AND AWAITING ABDOMINAL CT SCAN FOR ? OBSTRUCTION. COLOSTOMY WITH ONLY 50 CC LIQUID BROWN STOOL THIS SHIFT. PATIENT ON INSULIN GTT, STOPPED IN AFTERNOON WHEN TF OFF.\n TRACH CARE DONE SEVERAL TIMES. SUCTIONED FREQUENTLY FOR THICK YELLOW SPUTUM. REMAINS ON ASSIST CONTROL & TOLERATING WELL. LUNG SOUNDS COARSE. SEE FLOWSHEET FOR SKIN/WOUND CARE.\nPLAN:\n CT SCAN AND AWAIT RESULTS. KEEP G-TUBE TO SUCTION. CONTINUE WITH SKIN CARE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-27 00:00:00.000",
"description": "Report",
"row_id": 1524336,
"text": "BS fine crackles but less so than yesterday; no change with MDI's. Vomited up bile with some seen around trach site, ? aspiration. CT of abdomen and chest today - results pending. No vent changes or ABG's this shift.\n"
},
{
"category": "ECG",
"chartdate": "2132-10-21 00:00:00.000",
"description": "Report",
"row_id": 184247,
"text": "Baseline artifact. Probable sinus tachycardia with atrial premature beat, but\nbaseline artifact and generalized low voltage make assessment difficult. Left\nbundle-branch block. Generalized low voltage. Clinical correlation is\nsuggested. Since the previous tracing of rhythm is more suggestive of\nsinus tachycardia.\n\n"
},
{
"category": "ECG",
"chartdate": "2132-09-30 00:00:00.000",
"description": "Report",
"row_id": 184248,
"text": "Regular wide complex tachycardia - mechanism uncertain - probably\nsupraventricular with intraventricular conduction delay\nGeneralized low voltage\nClinical correlation is suggested\nSince previous tracing of , tachycardia present - in retrospect the\nrhythm on previous tracing of , may be atrial flutter rather than sinus\n\n"
},
{
"category": "ECG",
"chartdate": "2132-09-17 00:00:00.000",
"description": "Report",
"row_id": 184249,
"text": "Baseline artifact. Rhythm is uncertain - is probably sinus with first degree\nA-V delay and left atrial abnormality but baseline artifact makes assessment\ndifficult. Left bundle-branch block. Since the previous tracing of axis\nis less rightward.\n\n"
},
{
"category": "ECG",
"chartdate": "2132-09-14 00:00:00.000",
"description": "Report",
"row_id": 184250,
"text": "Sinus tachycardia\nIndeterminate axis\nFirst degree AV block\nLeft atrial abnormality\nIntraventricular conduction delay\nPossible anteroseptal myocardial infarction\nInferior T wave changes are nonspecific\nLow QRS voltages in limb leads\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2132-08-27 00:00:00.000",
"description": "Report",
"row_id": 184251,
"text": "Atrial fibrillation with rapid ventricular response\nMarked right axis deviation\nLeft bundle branch block\nGeneralized low QRS voltages in limb leads\nSince previous tracing, rate faster\n\n"
},
{
"category": "ECG",
"chartdate": "2132-08-24 00:00:00.000",
"description": "Report",
"row_id": 184252,
"text": "Atrial fibrillation\nLeft bundle branch block\nGeneralized low QRS voltages in limb leads\nSince previous tracing, atrial fibrillation present\n\n"
},
{
"category": "ECG",
"chartdate": "2132-07-29 00:00:00.000",
"description": "Report",
"row_id": 184253,
"text": "Probable multifocal atrial tachycardia\nLeft bundle branch block\nSince previous tracing of , atrial ectopy present\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-08-29 00:00:00.000",
"description": "PELVIS, NON-OBSTETRIC",
"row_id": 923655,
"text": " 10:22 AM\n PELVIS, NON-OBSTETRIC Clip # \n Reason: Endometrial lesion?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with multiple medical problems including respiratory failure\n s/p trach, multiple infections, including pseudomonas pneumonia/sacral\n decubitus ulcers, chronic renal failure on CVVH in the hospitals presents\n withnew onset of vaginal bleeding and . Hct.\n REASON FOR THIS EXAMINATION:\n Endometrial lesion?\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Portable pelvic ultrasound.\n\n INDICATION: Query vaginal bleeding.\n\n FINDINGS:\n\n The uterus is visualized and measures 9.7 x 4.3 x 6 cm. The endometrial\n stripe is slightly thickened for the patient's age at 0.5 cm. In the presence\n of vaginal bleeding, it is not possible to distinguish blood from endometrial\n thickness. The note is made of some areas of high echogenicity within the\n uterus anteriorly. This may represent focal areas of calcification or may be\n contained within fibroid. The right ovary is not visualized. The left ovary\n measures 2.8 x 2 x 2.6 cm and is unremarkable. There is an impression of some\n minimal fluid in the pouch of .\n\n CONCLUSION:\n\n Technically difficult examination. Prominent endometrial stripe. Right ovary\n not visualized. Impression of some fluid in the pouch of .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-09-02 00:00:00.000",
"description": "CENTRAL TUNNELED W/O PORT",
"row_id": 924060,
"text": " 7:24 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: New HD cath needed for enterococcus cultured from tip\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * CENTRAL TUNNELED W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1750 CATH,HEMO/PERTI DIALYSIS LONG C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 y/o F s/p CVA, now with Enterococcus from HD cath, needs new one. Thank\n you.\n REASON FOR THIS EXAMINATION:\n New HD cath needed for enterococcus cultured from tip\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Over the wire exchange of right internal jugular approach tunneled\n hemodialysis catheter.\n\n CLINICAL HISTORY: 66-year-old female status post CVA, now with enterococcus\n identified on blood culture from hemodialysis catheter. Suspected catheter\n infection.\n\n OPERATORS: , M.D. (fellow).\n , M.D. (supervising staff).\n\n INFORMED CONSENT: Procedural informed consent was obtained from the patient's\n husband who was present upon assessment of the patient. Signed witnessed\n informed consent was then placed in the medical record.\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, the site of the procedure, and appropriate\n requisition, and consent. Once the above were verified, the patient was\n positioned in supine fashion on a special procedures table. The right upper\n anterior chest wall and exiting tunneled dialysis catheter were prepped and\n draped in the usual sterile fashion. Both lumens of the catheter were\n aspirated free of heparin solution. Both ports were accessed using 2, stiff\n Glidewires, which were advanced, under fluoroscopic visualization through the\n superior vena cava, right atrium, and into the inferior vena The retention\n sutures of the catheter were then released. The catheter was then delivered,\n over the guidewire, with digital compression applied at the lower right\n internal jugular vein for hemostasis. Subsequently, a new 19 cm tip-to-cuff\n length hemodialysis catheter was placed over the paired guidewires. The tip\n of the catheter was placed in the cephaldad right atrium. The retention cuff\n was approximately 2 cm deep to the exit wound. The catheter hub was then\n sutured in place using two, 2-0, interrupted, silk retention sutures. Both\n lumens of the catheter were flushed and heparin locked per protocol. The\n puncture site was then overlaid with a Tegaderm occlusive patch. The patient\n tolerated procedure well without incident.\n\n ESTIMATED BLOOD LOSS: Minimal.\n\n (Over)\n\n 7:24 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: New HD cath needed for enterococcus cultured from tip\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n MEDICATIONS: Xylocaine 1%, 10 cc total.\n\n IMPRESSION:\n\n 1. Status post successful over the wire exchange of tunneled hemodialysis\n catheter. A new, 19cm long (tip-to-cuff) hemodialysis catheter was placed\n uneventfully. The catheter is ready to employ.\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-08-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 922829,
"text": " 4:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess trach placement. Thanks.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with chronic trach/peg, lethargy, hypotension, now with\n persistent fevers and increased respiratory rate.\n REASON FOR THIS EXAMINATION:\n please assess trach placement. Thanks.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess tracheal tube, patient with persistent fever and\n increased respiratory rate.\n\n Comparison is made with prior study dated .\n\n FINDINGS:\n Mild right pleural effusion is stable. Interval mild increase in size in the\n small left pleural effusion. New atelectasis in the lingula. Worsening of\n right lower lobe consolidation. Tracheal tube with tip in standar position.\n Right PIC line and right internal jugular vein catheter with tips in standar\n position in the SVC, unchanged. There is no pneumothorax. The left border of\n the heart is obscured by the atelectasis and pleural effusion. New mild\n asymmetric pulmonary edema greater in the left\n\n\n IMPRESSION:\n New left pleural effusion and lingular atelectasis.\n Worsening of right lower lobe consolidation.\n New asymmetric mild pulmonary edema greater in the left side.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-08-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 921134,
"text": " 10:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for infiltrate/consolidation\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with chronic trach/peg, lethargy, hypotension, now with\n fever\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate/consolidation\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Lethargy, hypertension, fever.\n\n CHEST: Compared with the prior film, there is an increase in the effusions.\n No definite infiltrates are present. The appearances suggest some failure\n rather than infection.\n\n IMPRESSION: Evidence of failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-08-02 00:00:00.000",
"description": "MR CONTRAST GADOLIN",
"row_id": 920166,
"text": " 2:02 PM\n MR W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: ?osteo of sacrum\n Admitting Diagnosis: SEPSIS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with ?osteomyelitis from sacral decub\n REASON FOR THIS EXAMINATION:\n ?osteo of sacrum\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the lumbar and sacral spine.\n\n CLINICAL INFORMATION: Patient with large sacral decubitus ulcer, rule out\n bone involvement of osteomyelitis.\n\n TECHNIQUE: T1, T2, and inversion recovery sagittal, and T1 and T2 axial\n images of the lumbar and sacral spine were obtained before gadolinium.\n Inversion recovery sagittal images were also acquired. Following gadolinium,\n T1 sagittal, and axial images were obtained. Post-gadolinium images are\n somewhat limited for evaluation secondary to lack of fat suppression.\n\n FINDINGS: In the lumbar region mild multilevel degenerative changes are\n identified within the spine from T11-12 to L5-S1 level. At L4-5, there are\n disc degenerative changes with facet degenerative changes and bulging of the\n disc resulting in moderate spinal stenosis. At L5-S1 level facet degenerative\n changes are identified.\n\n There is a rudimentary disc between S1 and S2 visualized.\n\n There is a soft tissue defect indicative of decubitus ulcer identified in the\n region of S4 and S5 segment with T1 low signal in this region. The adjacent\n sacral segments demonstrate no significant signal changes to indicate\n osteomyelitis. No definite enhancement is identified. There is no evidence\n of presacral edema. There is subtle increased signal seen within the coccyx\n on sagittal inversion recovery images, which could be secondary to partial\n volume averaging.\n\n IMPRESSION: No definite evidence of osteomyelitis of the sacrum. Subtle\n increased signal within the coccyx could be secondary to partial volume\n averaging from the adjacent decubitus ulcer. Moderate spinal stenosis at L4-5\n level.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-08-04 00:00:00.000",
"description": "J TUBE CHANGE",
"row_id": 920327,
"text": " 7:24 AM\n PERC G/G-J TUBE PLMT Clip # \n Reason: replace J tube with larger tube\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 10\n ********************************* CPT Codes ********************************\n * J TUBE CHANGE CHANGE PERC TUBE OR CATH W/CON *\n * CATHETER, DRAINAGE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with J tube - needs to be replaced\n REASON FOR THIS EXAMINATION:\n replace J tube with larger tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR THE EXAM: 66-year-old woman with leakage around J tube.\n\n RADIOLOGISTS: Dr. and Dr. , the attending radiologist, who\n was present throughout the procedure. Informed consent was obtained from the\n patient's daughter over the telephone.\n\n PROCEDURE AND FINDINGS: The patient was positioned on the angiographic table\n in supine position, was prepped and draped in the sterile fashion. An\n abdominal scout was obtained to demonstrate the location of the J tube.\n Injection of diluted contrast was performed through the tube under\n fluoroscopic guidance, documenting position of the tube in the jejunum. A\n wire was advanced through the tube and the tube was pulled back over\n the wire. A new 16 French J tube was then advanced under fluoroscopic guidance\n and the position was confirmed after injection of contrast under fluoroscopic\n guidance. The J tube was secured with sutures at the enter site.\n\n COMPLICATONS: No immediate complications.\n\n IMPRESSION: Successful exchange and upsize of jejunostomy catheter.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-07-29 00:00:00.000",
"description": "CT PELVIS W/CONTRAST",
"row_id": 919547,
"text": " 10:36 AM\n CT PELVIS W/CONTRAST Clip # \n Reason: R/o bone involvement of sacral decub\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with large sacral decubitus ulcer\n REASON FOR THIS EXAMINATION:\n R/o bone involvement of sacral decub\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: CT pelvis.\n\n INDICATION: Large sacral decubitus ulcer.\n\n FINDINGS:\n\n TECHNIQUE:\n\n Axial images were taken of the lower abdomen and pelvis after administration\n of IV contrast. Multiplanar reformation was performed. In relation to the\n lower abdomen, note is made of a hernia in the right paramedian line. The\n small and large bowel visualized is unremarkable. Note is made of some\n calcifications in relation to the uterus, consistent with fibroid uterus.\n\n There is a defect in the skin posteroinferior to the sacrum. This is\n extending right down to the level of the sacrum, but there is no definite\n destruction of the sacrum.\n\n IMPRESSION:\n\n Large decubitus ulcer posteroinferior to the sacrum. This is abutting the\n sacrum but no definite destruction of sacrum identified.\n\n Right paramedian hernia. Fibroid uterus.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-07-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 919465,
"text": " 7:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate, effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with chronic trach/peg, lethargy, hypotension\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old female with tracheostomy and gastrostomy, now with\n lethargy and hypotension.\n\n COMPARISON: .\n\n AP SEMI-UPRIGHT PORTABLE CHEST:\n\n A right-sided PICC line and right subclavian dual lumen central catheter both\n terminate near the cavoatrial junction. The patient is status post sternotomy\n and valve replacement. The heart size is top normal. The cardiomediastinal\n contours are stable. There is a tracheostomy in appropriate position. There\n is a small amount of pleural fluid on the right, tracking into the minor\n fissure. The left lung is grossly clear. No focal consolidation or\n pneumothorax is identified. There is no free air under the diaphragm.\n\n IMPRESSION: Small right pleural effusion. No pneumonia identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-07-29 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 919546,
"text": " 10:36 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: rule out new bleed\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with hx of left parietal hemorrhage, PEA arrest now admitted\n with fever and lethargy, supratherapeutic INR\n REASON FOR THIS EXAMINATION:\n rule out new bleed\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old with history of prior left parietal hemorrhage, now\n post-cardiac arrest with fever and lethargy.\n\n TECHNIQUE: CT of the brain without IV contrast.\n\n COMPARISON: .\n\n FINDINGS: There is no acute intracranial hemorrhage, shift of normally\n midline structures, or hydrocephalus. -white matter differentiation is\n preserved. Areas of decreased attenuation in the frontal lobe white matter\n and periventricular white matter are unchanged. Bilateral basal ganglial\n calcification, and high density in the right occipital lobe are also stable in\n appearance. There has been prior surgical intervention along the posterior\n wall of the right maxillary sinus with clips seen adjacent to the\n pterygopalatine fossa. A mucus retention cyst or polyp is seen in the right\n ethmoidal air cells. The remaining visualized paranasal sinuses and mastoid\n air cells are clear. Soft tissues are normal.\n\n IMPRESSION:\n\n No acute intracranial hemorrhage or change from the prior examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-08-12 00:00:00.000",
"description": "CHANGE GASTROSTOMY TUBE",
"row_id": 921423,
"text": " 1:16 PM\n PERC G/G-J TUBE PLMT Clip # \n Reason: please change j-tube\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 50\n ********************************* CPT Codes ********************************\n * CHANGE GASTROSTOMY TUBE CHANGE PERC TUBE OR CATH W/CON *\n * CATHETER, DRAINAGE C1769 GUID WIRES INCL INF *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with 18F J tube - needs to be replaced per IR due to\n continued leaking around current tube.\n REASON FOR THIS EXAMINATION:\n please change j-tube\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Gastrojejunostomy tube exchange.\n\n CLINICAL HISTORY: 66-year-old female with history of 18 French J-tube with\n peri-catheteral leak.\n\n OPERATORS: , M.D. (Fellow).\n\n , M.D. (Staff).\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, and the site of the procedure. The epigastric\n region and the external course of the gastrojejunostomy tube were prepped and\n draped in the usual sterile fashion. A guidewire was used to cannulate the\n gastrojejunostomy tube. Once the distal segment wire was noted to extend\n distal to the gastrojejunostomy under fluoroscopy, the gastrojejunostomy tube\n was removed over the guidewire leaving the guidewire in situ. A 6Fr sheath\n was then inserted and a pull-out contrast injection was performed to\n determine the catheter track, since this was not clear to us, because the\n catheter was placed at OSH. The contrast injection showed that the catheter\n appears to be entering the very distal gastric antrum, very close to the\n pylorus. Subsequently, a 14 French gastrojejunostomy tube was delivered\n over the guidewire with the retention pigtail formed in the D-2 segment of the\n duodenum. The distal segment is seen in the mid jejunum. The catheter was\n secured with formation of the retention suture. A small purse-string suture\n was applied at the skin exit wound. The wound was dressed with drain sponges\n overlaid with Tegaderm patches and paper tape. The patient tolerated the\n procedure well.\n\n ANESTHESIA: 1% Xylocaine locally infiltrated, 8 cc total.\n\n ESTIMATED BLOOD LOSS: Minimal.\n\n COMPLICATIONS: None immediately.\n\n IMPRESSION: Status post exchange of gastrojejunostomy tube as described\n (Over)\n\n 1:16 PM\n PERC G/G-J TUBE PLMT Clip # \n Reason: please change j-tube\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n above. Tube is ready to employ.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-07-30 00:00:00.000",
"description": "G/GJ TUBE CHECK",
"row_id": 919735,
"text": " 1:20 PM\n G/GJ TUBE CHECK Clip # \n Reason: KUB with contrast through J-tube to evaluate placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with J tube\n REASON FOR THIS EXAMINATION:\n KUB with contrast through J-tube to evaluate placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Jejunostomy tube, query placement.\n\n ABDOMEN, TWO VIEWS: Single abdominal radiograph after hand injection of\n contrast through the jejunostomy tube by the surgical housestaff shows\n opacification of the tube and a jejunal loop in the left mid abdomen. No\n other bowel loops are visible. There are midline sternotomy wires and a\n prosthetic valve. Vascular calcifications are seen in the aorta and common\n iliacs. There are degenerative changes of the spine.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-08-08 00:00:00.000",
"description": "CHANGE GASTROSTOMY TUBE",
"row_id": 920921,
"text": " 10:32 AM\n PERC G/G-J TUBE PLMT Clip # \n Reason: Please place 18F J-tube if possible\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 10\n ********************************* CPT Codes ********************************\n * CHANGE GASTROSTOMY TUBE CHANGE PERC TUBE OR CATH W/CON *\n * CATHETER, DRAINAGE C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF C1892 INT/SHTH,EP,FXD CURVE/ AWY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with 16F J tube - needs to be replaced with 18F J tube per\n IR due to continued leaking around current tube.\n REASON FOR THIS EXAMINATION:\n Please place 18F J-tube if possible\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Exchange of gastrojejunostomy tube.\n\n CLINICAL HISTORY: 66-year-old female with perigastric catheter leak around\n pre-existent 16 French percutaneous gastrojejunostomy tube.\n\n OPERATORS:\n 1. , M.D. (fellow)\n 2. , M.D. (supervising staff)\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, the site of the procedure, appropriate requisition\n material, and appropriate informed consent. Once verified, the patient was\n positioned in supine fashion. The epigastric region was prepped and draped\n along with the external course of the previous gastrojejunostomy tube. A\n stiff guidewire was advanced through the prior gastrojejunostomy tube. Once\n satisfactory positioning of the tip of the guidewire was confirmed using\n fluoroscopic visualization, the retention sutures for the catheter were\n released and the catheter removed over the guidewire, leaving the guidewire in\n situ. Subsequently, a new 18 French MIC jejunostomy tube was delivered over\n the guidewire with the distal segment within the mid jejunum. Test injection\n of contrast demonstrates satisfactory positioning. The retention balloon was\n inflated with 20 cc of saline solution. Two retention sutures were placed\n securing the catheter to the anterior abdominal wall. The patient tolerated\n the procedure well without incident.\n\n IMPRESSION:\n 1. Status post successful exchange of percutaneous gastrojejunostomy tube as\n described above. The catheter is ready to employ.\n\n\n (Over)\n\n 10:32 AM\n PERC G/G-J TUBE PLMT Clip # \n Reason: Please place 18F J-tube if possible\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 10\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-09-27 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 927267,
"text": " 3:57 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? obstruction\n Admitting Diagnosis: SEPSIS\n Field of view: 48\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with n/v, evidence of obstruction on plain film\n REASON FOR THIS EXAMINATION:\n ? obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 66-year-old woman with nausea, vomiting, evidence of\n obstruction on plain film.\n\n TECHNIQUE: Multiple axial images of the abdomen and pelvis were obtained\n after the administration of oral contrast through the patient's gastrostomy\n tube. No intravenous contrast was administered.\n\n Findings are compared with patient's prior examination dated .\n\n FINDINGS: Evaluation of the lung bases demonstrates the patient to be status\n post median sternotomy. There is dense calcification of the mitral annulus\n and dense coronary artery calcification. There are bilateral pleural\n effusions, right greater than left with underlying atelectasis.\n\n Images of the upper abdomen demonstrate a gastrostomy tube with the distal tip\n terminating in the proximal jejunum. Contrast is seen progressing to the\n proximal jejunum. There is fecalization of the small bowel proximal to a\n transition point in the right upper quadrant, where there is marked collapse\n of the distal small bowel. These findings are compatible with a small bowel\n obstruction. No obstructing mass is seen and the obstruction is remote from\n the ostomy site. Two limbs enter and exit the ostomy site in the right lower\n quadrant; the proximal limb is presumably distal ileum, and the exiting limb\n is presumably transverse colon. The distal transverse, descending and sigmoid\n colon are collapsed.\n\n Non-contrast evaluation of the liver is unremarkable. Clips are visualized in\n the gallbladder fossa. There is dense calcification of the splenic and\n hepatic arteries. There is a moderate amount of intraabdominal ascites. The\n kidneys are noted to be atrophic bilaterally with linear calcification of the\n parenchyma. The right adrenal gland, pancreas, and spleen are unremarkable.\n There is a left adrenal adenoma. Evaluation of the uterus demonstrates dense\n calcification of the uterine arteries. The osseous structures demonstrate\n degenerative changes without evidence for acute fracture or dislocation.\n\n The overlying soft tissues are markedly edematous compatible with anasarca.\n\n IMPRESSION: Small bowel obstruction with transition point in the right upper\n quadrant, remote from the more distal ostomy.\n\n\n (Over)\n\n 3:57 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? obstruction\n Admitting Diagnosis: SEPSIS\n Field of view: 48\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-10-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 930861,
"text": " 11:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate, pulm edema\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with sepsis, ESRD, respiratory failure w/ trach with\n increased resp rate, tachycardia\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate, pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST 12:09\n\n INDICATION: Respiratory failure with increased respiratory rate.\n\n COMPARISON: at 8:26.\n\n FINDINGS: Right PICC line, left dialysis catheter and tracheostomy tube\n remain in place. Compared to the prior study, there is new increased density\n in the left upper lung zone, which could be a developing pneumonia. Extremely\n subtle increase in density is seen adjacent to the right hilar region, which\n could relate to early pulmonary edema. However, the pulmonary vascular\n markings are not significantly distended. Right effusion is again\n demonstrated.\n\n IMPRESSION:\n\n New airspace finding in the left upper lung zone, possibly in the right mid\n lung zone. Continued followup is recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-10-23 00:00:00.000",
"description": "PR ART DUP EXT UP UNI LMTD PORT RIGHT",
"row_id": 930400,
"text": " 10:02 AM\n ART DUP EXT UP UNI LMTD PORT RIGHT Clip # \n Reason: please eval for R A-V fistula (IJ-carotid??)\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with MMP, now R IJ with venous blood gas appearing arterial,\n appropriately placed per CXR\n REASON FOR THIS EXAMINATION:\n please eval for R A-V fistula (IJ-carotid??)\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Carotid series complete.\n\n REASON: Question AV fistula.\n\n FINDINGS: Duplex evaluation was performed of the right neck region. Common\n carotid artery and internal jugular veins are patent. There is no evidence of\n thrombus or normal appearing waveforms. There is no evidence of fistula.\n\n IMPRESSION: No evidence of right neck carotid artery or jugular vein fistula\n or overt disease.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-09-16 00:00:00.000",
"description": "NON-TUNNELED",
"row_id": 925833,
"text": " 11:24 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please remove current R central dialysis catheter and replac\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1752 CATH,HEM/PERTI DIALYSIS SHORT *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with pus at site of R central dialysis catheter\n REASON FOR THIS EXAMINATION:\n Please remove current R central dialysis catheter and replace with L central\n dialysis catheter\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE:\n\n 1. Left internal jugular approach temporary hemodialysis catheter placement.\n 2. Removal of tunneled right internal jugular approach tunneled hemodialysis\n catheter.\n 3. Ultrasound-guided venipuncture.\n 4. Removal of right arm PICC\n CLINICAL HISTORY: 66-year-old female with infected tunneled right internal\n jugular approach tunneled dialysis catheter requires IV access for dialysis.\n Suspected PICC line infection.\n\n INFORMED CONSENT: Procedural informed consent was obtained prior to the study\n and placed in the medical record.\n\n OPERATORS: , M.D. (fellow).\n , M.D. (supervising staff).\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedures to be performed, the sites of the procedures, appropriate\n requisition, and appropriate informed consent. Once the above were verified,\n the patient was positioned in supine fashion on a special procedures table.\n The lower left side of the neck and left upper anterior chest wall were\n prepped and draped in usual sterile fashion. Ultrasound was employed to\n visualize the low left internal jugular vein, which was widely patent and\n compressible. This site was selected for venipuncture. The skin and\n subcutaneous tissues were infiltrated with approximately 5 cc of 1% Xylocaine\n for local anesthesia. Uneventful one-wall venipuncture was achieved in the\n low left internal jugular vein using micropuncture access technique. A 1.5 mm\n J, 0.035 inch wire was advanced by way of the 4 French catheter of the\n micropuncture set, under fluoroscopic visualization to the level of the\n inferior vena cava. Subsequently, the tract was then serially dilated. A\n angiodynamics, 24 cm length, hemodialysis catheter was then delivered\n over the guidewire with the tip positioned in the cephalad right atrium. Both\n lumens were flushed and heparin-locked. The catheter was secured in place\n with two, 0 silk retention sutures. The puncture site was overlaid with a\n Tegaderm occlusive patch. Hemostasis was achieved promptly. No residual\n (Over)\n\n 11:24 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please remove current R central dialysis catheter and replac\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n bleeding or hematoma was encountered. Postprocedural chest x-ray demonstrates\n good positioning of the catheter.\n\n (Hard copy ultrasound images were obtained both prior to and subsequent to the\n venipuncture for documentation.)\n\n Subsequent to the procedure, the patient was transferred to the guerney, in\n semi-upright positioning. The tunneled right internal jugular approach\n hemodialysis catheter was prepped and draped. The retention cuff was freed\n and the catheter was removed uneventfully. Hemostasis was achieved promptly\n using digital compression for a total of 10 minutes. No residual bleeding was\n encountered. Frank pus was expressed from the tunnel tract and cultured, along\n with the catheter. The wound was then dressed with guaze and tape.\n The patient tolerated the procedure well.\n\n The 5 Fr dual luimen PICC line in the right are was prepped, draped, and\n removed uneventfully. This catheter too was ent for culture.\n\n IMPRESSION:\n\n 1. Status post placement of left internal jugular approach temporary\n hemodialysis catheter. See above description.\n\n 2. Status post removal of tunneled right internal jugular approach\n hemodialysis catheter. See above description.\n\n 3. Status post removal of right PICC line\n\n 4. The newly placed left internal jugular approach temporary hemodialysis\n catheter is ready to employ. Post-procedural orders were written.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-10-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 928935,
"text": " 4:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess PICC line for position.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with sepsis, ESRD, vented with pulmonary effusions, check\n PICC line for position.\n REASON FOR THIS EXAMINATION:\n Assess PICC line for position.\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST AT 05:27 HOURS\n\n HISTORY: Multiple medical problems. Assess PICC line for positioning.\n\n COMPARISON: .\n\n FINDINGS: The patient is rotated. There is near-complete opacification of\n the left hemithorax with only a small residual left upper lung noted. There\n has been interval placement of a right internal jugular approach central line\n with the distal tip projecting over the superior vena cava. There has been\n interval decrease in the right pleural effusion. There is fluid tracking\n within the major fissure. Mild hydrostatic edema is evident in the aerated\n right lung.\n\n IMPRESSION: Near-complete opacification of the left lung. Evaluation limited\n secondary to rotation, however, atelectasis and effusion are considered\n leading diagnostic considerations. There has been interval redistribution of\n the right pleural effusion with mild superimposed hydrostatic edema.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2132-10-12 00:00:00.000",
"description": "G/GJ TUBE CHECK",
"row_id": 929039,
"text": " 12:19 PM\n G/GJ TUBE CHECK Clip # \n Reason: please confirm placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with G-J tube\n\n REASON FOR THIS EXAMINATION:\n please confirm placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old woman with gastrojejunostomy tube dislodged this\n morning.\n\n GJ TUBE CHECK: The patient was brought to the Fluoroscopic Suite where\n approximately 20 cc of Gastrografin was administered through the\n gastrojejunostomy tube. The tube demonstrated patentcy and terminates in the\n jejunum. There is no evidence of extraluminal contrast. The caliber and\n appearance of the visualized jejunum is normal. Please note that there is\n approximately 15 cm of tubing within the patient which terminates in the\n jejunum.\n\n IMPRESSION: Gastrojejunostomy tube in proper position terminating in the\n jejunum. No evidence for extraluminal contrast.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-09-27 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 927245,
"text": " 10:39 AM\n PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # \n Reason: r/o obstruction around j-tube with gastrograffin injection\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman s/p g tube and colostomy now with new abd mass and increase\n output from g-tube\n REASON FOR THIS EXAMINATION:\n r/o obstruction around j-tube with gastrograffin injection\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Question obstruction around J-tube site after Gastrografin\n injection.\n\n FINDINGS: This film was taken after injection of Gastrografin. Contrast is\n seen entering a loop of bowel in the left mid abdomen compatible with jejunum.\n Just after the J-tube this loop of bowel dilates to 6 cm. Otherwise there is\n paucity of small bowel gas seen in the abdomen. This could represent a small\n bowel obstruction. A CT is recommended for further evaluation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-09-23 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 926736,
"text": " 5:13 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: right sc line placement attempt and failed r/o ptx\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with ESRD on CVVH, resp. failure with increased secretions\n and increasing WBC count\n REASON FOR THIS EXAMINATION:\n right sc line placement attempt and failed r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right subclavian line placement attempt, failed.\n\n PORTABLE CHEST: Comparison with . No pneumothorax seen.\n Bilateral pleural effusions, slightly improved. Left lower lobe\n atelectasis/consolidation is increased slightly. This study is somewhat\n limited by respiratory motion. Aortic mural calcifications, tracheostomy,\n midline sternotomy wires, valvular replacement, and left dialysis line are\n unchanged.\n\n IMPRESSION: No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-09-24 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 926846,
"text": " 2:41 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: RISING T.BILI AND ELEVATED ALK PHOS\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with MMP, now with hypotension, rising t.bili and elevated\n alk phos.\n REASON FOR THIS EXAMINATION:\n Evaluate gallbladder and biliary system.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old female with multiple medical problems, now with\n hypertension and elevated bilirubin and alkaline phosphatase.\n\n COMPARISON: .\n\n RIGHT UPPER QUADRANT ULTRASOUND: Again demonstrated is slightly coarsened\n echotexture of the liver without focal hepatic lesion identified. There is a\n trace amount of perihepatic ascites, which is decreased compared to . There is no intra- or extra-hepatic biliary ductal dilatation. There\n is appropriate hepatopetal blood flow in the main portal vein. The common\n duct measures normal maximal caliber of 3 mm. The patient is status post\n cholecystectomy. There is no evidence of choledocholithiasis in the\n visualized common bile duct. A small right pleural effusion remains.\n\n IMPRESSION:\n 1. Status post cholecystectomy. No biliary ductal dilatation or evidence of\n cholecocholithiasis in the visualized common bile duct.\n 2. Trace perihepatic ascites is decreased compared to .\n 3. Persistent small right pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-09-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 925785,
"text": " 4:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for clinical change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with ESRD on CVVH, resp. failure.\n REASON FOR THIS EXAMINATION:\n Please assess for clinical change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:38 A.M. ON .\n\n HISTORY: On dialysis. Respiratory failure.\n\n IMPRESSION: AP chest compared to and 24:\n\n Moderate right pleural effusion has increased since , partially\n obscuring anatomic detail in the right lung but mild interstitial edema is\n probably present. Leftward mediastinal shift _____ a function of right\n pleural effusion and substantial left lower lobe collapse, even though the\n latter appears to have improved since . Cardiac silhouette is top\n normal size. No pneumothorax.\n\n Tracheostomy tube and a dual channel right internal jugular dialysis line are\n in standard placements. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-09-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 926341,
"text": " 7:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o worsening infiltrate/effusion\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with ESRD on CVVH, resp. failure with increased secretions\n and increasing WBC count\n REASON FOR THIS EXAMINATION:\n r/o worsening infiltrate/effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n INDICATION: End-stage renal disease.\n\n FINDINGS:\n Comparison was made with the recent x-ray from . The patient is\n status post sternotomy. Note is made of aortic valve replacement.\n Tracheostomy is in situ. Central venous line is seen, the tip of which is in\n the SVC. There are bilateral pleural effusions.\n\n No significant interval change when compared to the previous x-ray.\n\n CONCLUSION:\n Trach in situ, bilateral pleural effusions. No significant interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-09-11 00:00:00.000",
"description": "P ABDOMEN U.S. (COMPLETE STUDY) PORT",
"row_id": 925186,
"text": " 7:46 AM\n ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # \n Reason: ELAVATED BIL,ALK PHOSPHATASE ,EVAL FOR CHOLANGITIS\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with MMP, now with hypotension, rising t.bili and elevated\n alk phos.\n REASON FOR THIS EXAMINATION:\n please eval for cholangitis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old woman with multiple medical problems now with\n hypotension and rising bilirubin and elevated LFTs.\n\n ABDOMINAL ULTRASOUND STUDY: Slightly coarsened echotexture of the liver\n without focal liver lesions. There is small amount of ascites and small right\n pleural effusion is seen. There is no intrahepatic or extrahepatic biliary\n ductal dilatation. The common bile duct measures 4 mm in diameter. Patient\n is status post cholecystectomy. The main portal vein is patent and its flow\n is hepatopetal.\n\n The pancreatic tail is not well visualized. In the pancreatic head, there is\n a 1.6 x 1.4 cm cystic lesion. The spleen is enlarged. The kidneys appear to\n be slightly atrophic and echogenic and are not well imaged. This could be in\n part due to the patient's body habitus, however, renal parenchymal disease\n cannot be entirely excluded.\n\n IMPRESSION:\n 1. No intrahepatic or extrahepatic biliary ductal dilatation.\n 2. Small right pleural effusion and ascites.\n 3. Splenomegaly.\n 4. Small cystic lesion in the head of the pancreas, further evaluation with\n dedicated CT angiography or MRCP study could be considered.\n 5. Possible renal parenchymal disease.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-09-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 927252,
"text": " 12:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with ESRD on CVVH, resp. failure with increased\n secretions and ? aspiration event\n REASON FOR THIS EXAMINATION:\n please evaluate interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON .\n\n HISTORY: End-stage renal disease with respiratory failure. Question\n aspiration.\n\n REFERENCE EXAM: .\n\n FINDINGS: Again seen is a tracheostomy tube. There is hazy increased opacity\n projecting over both lungs consistent with layering effusions bilaterally.\n These are increased in size compared to the prior film. There is dense\n retrocardiac opacity and it is unclear if this is due to volume loss or a\n retrocardiac infiltrate. A lateral film would be helpful if the patient is\n able. The heart is shifted to the left on this film but it is unclear how\n much of this is due to rotation. Contrast is seen in the left upper quadrant,\n presumably in the stomach, which is slightly distended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-09-16 00:00:00.000",
"description": "TUNNELED CENTRAL W/O PORT",
"row_id": 925854,
"text": " 2:43 PM\n DIALYSIS REMOVE Clip # \n Reason: Please remove right subclavian dialysis catheter.\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * TUNNELED CENTRAL W/O PORT -51 MULTI-PROCEDURE SAME DAY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 y/o F s/p CVA, now with pus draining from site of right subclavian dialysis\n catheter. Needs removal.\n REASON FOR THIS EXAMINATION:\n Please remove right subclavian dialysis catheter.\n ______________________________________________________________________________\n FINAL REPORT\n Please see clip for the complete report.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-09-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 925920,
"text": " 4:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o worsening effusion\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with ESRD on CVVH, resp. failure.\n\n REASON FOR THIS EXAMINATION:\n r/o worsening effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:13 A.M. on :\n\n HISTORY: End stage renal disease. Respiratory failure.\n\n IMPRESSION: AP chest compared to through :\n\n Moderate volume bilateral pleural effusion, stable on the right and increased\n on the left relative to . Mild enlargement of the cardiomediastinal\n silhouette is stable. Left lower lobe atelectasis has worsened. Tracheostomy\n tube in standard placement. Dual channel left supraclavicular central venous\n line tip projects over the superior cavoatrial junction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-09-26 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 927152,
"text": " 3:01 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: bilateral piccs for access-thank you\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * PICC W/O PORT 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * FLUOR GUID PLCT/REPLCT/REMOVE US GUID FOR VAS. ACCESS *\n * C1751 CATH ,/CENT/MID(NOT D C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 y/o F s/p CVA, multiple infections, hypotensive, CRF and femoral line that\n needs removal infection. Needs second line for chronic Abx.\n REASON FOR THIS EXAMINATION:\n bilateral piccs for access-thank you\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: 5 French dual-lumen PICC catheter placement via right\n brachial vein approach; ultrasound-guided venipuncture.\n\n CLINICAL HISTORY: 66-year-old female status post cerebrovascular accident,\n multiple infections, hypotensive episodes, chronic renal failure, requires IV\n access for antibiotics, blood draws, and blood products.\n\n OPERATORS: , M.D. (fellow).\n , M.D. (supervising staff).\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, the site of the procedure, and appropriate informed\n consent. Once the above were verified, the patient was positioned in supine\n fashion on a special procedures table. This examination was originally\n requested as a central venous catheter, however, the order was changed by the\n requesting physician to that of a peripherally inserted central venous\n catheter.\n\n (Hard copy son images of the venipuncture, both prior to and after\n access were achieved and are placed in the patient's record.)\n\n The right arm was prepped and draped in usual sterile fashion. Ultrasound was\n employed to assess the venous anatomy of the right upper extremity. The\n venous anatomy was very diminutive. However, right brachial vein was\n punctured under ultrasonographic guidance in retrograde fashion using one wall\n technique and a 5 French dual-lumen catheter delivered by modified\n Seldinger technique to the level of the caudal superior vena cava using\n flouroscopic guidance. The catheter was advanced to the level of the 39 cm\n mark at the skin. The remainder of the catheter was externalized and secured\n with a StatLock device and then overlaid with Tegaderm occlusive dressing\n patches. Both lumens were flushed with saline. The patient tolerated the\n procedure well. Estimated blood loss was minimal.\n\n ANESTHESIA:\n 1% Xylocaine, 10 cc total.\n\n (Over)\n\n 3:01 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: bilateral piccs for access-thank you\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: Status post successful 5 French dual-lumen PICC line via\n right brachial vein approach. The patient tolerated the procedure well. The\n line is ready to employ. See above description.\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-09-26 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 927153,
"text": " 3:01 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: picc for access\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 5\n ********************************* CPT Codes ********************************\n * PICC W/O PORT 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * -51 MULTI-PROCEDURE SAME DAY FLUOR GUID PLCT/REPLCT/REMOVE *\n * -59 DISTINCT PROCEDURAL SERVICE US GUID FOR VAS. ACCESS *\n * -59 DISTINCT PROCEDURAL SERVICE C1751 CATH ,/CENT/MID(NOT D *\n * C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 y/o F s/p CVA, multiple infections, hypotensive, CRF and femoral line\n that needs removal infection. Needs second line for chronic Abx.\n REASON FOR THIS EXAMINATION:\n picc for access\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: 5 French dual-lumen PICC line placement via left cephalic\n vein approach; ultrasound-guided venipuncture.\n\n CLINICAL INDICATION: IV access.\n\n OPERATORS: , M.D. (fellow).\n , M.D. (supervising staff).\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, the site of the procedure, and appropriate\n requisition. Once the above were verified, the patient was positioned in\n supine fashion on a special procedures table. Left arm was abducted,\n externally rotated, and then prepped from the axilla to the antecubital fossa.\n A tourniquet was applied to the upper arm. Uneventful venipuncture was\n achieved using ultrasound guidance at the left cephalic vein. Hard copy\n ultrasound images were obtained before and after venous access documenting\n vessel patency. A guide wire was advanced by way of the cephalic vein to the\n central circulation. A 5 French dual-lumen PICC line was then\n delivered with the aid of the stiffening inner stylet, using modified\n Seldinger technique under fluoroscopic visualization. Tip position is in the\n caudal superior vena cava. Both lumens of the catheter were flushed\n and heparin locked. Specific attention was made to remove the inner stylet.\n The catheter was secured using a statlock device and then overlaid with a\n Tegaderm patch.\n\n ESTIMATED BLOOD LOSS: Minimal.\n\n ANESTHESIA: 1% Xylocaine, 10 cc local infiltration.\n\n IMPRESSION: Status post successful placement of 5 French dual-lumen \n PICC catheter via left cephalic vein approach. Tip position is in the caudal\n superior vena cava. The catheter is at the 42 cm mark at the skin. The\n catheter is ready to employ. Post-procedural orders are written.\n (Over)\n\n 3:01 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: picc for access\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 5\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-09-27 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 927199,
"text": " 12:49 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval for obstruction\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman s/p g tube and colostomy now with new abd mass and increase\n output from g-tube\n REASON FOR THIS EXAMINATION:\n eval for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Evaluate for obstruction, patient with G-tube, J-tube\n and ostomy.\n\n TECHNIQUE: AP examination of the abdomen is submitted for interpretation.\n Findings are compared with prior examination dated .\n\n FINDINGS: Limited evaluation of the lower abdomen and pelvis demonstrates\n three dilated loops of small bowel that appear to surround the patient's\n jejunostomy tube. These measure up to 6.1 cm in maximal diameter. Findings\n are concerning for a small-bowel obstruction.\n\n Degenerative changes are noted in the spine and pelvis.\n\n IMPRESSION: Limited evaluation of the abdomen with 3 dilated small bowel\n loops, concerning for small- bowel obstruction. Correlate clinically.\n Findings were communicated with Dr. at the time of dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-09-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 927383,
"text": " 4:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for interval change.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with ESRD on CVVH, resp. failure with P. aeruginosa in\n sputum.\n REASON FOR THIS EXAMINATION:\n Assess for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage renal disease, respiratory failure and Pseudomonas\n aeruginosa in sputum. Assess for interval change.\n\n Comparison is made to .\n\n SUPINE PORTABLE RADIOGRAPH OF THE CHEST: The tracheostomy is in unchanged\n position. The left subclavian central venous line is located with the tip in\n the distal SVC. There are significantly increased bilateral hazy opacities,\n most likely representing layering pleural effusions. The left retrocardiac\n opacity may represent effusion and/or atelectasis, but a consolidation in this\n region cannot be excluded. The patient is status post median sternotomy and\n aortic valve replacement.\n\n IMPRESSION: Worsening bilateral pleural effusions. Increased left\n retrocardiac opacity may represent effusion and/or atelectasis, consolidation\n cannot be excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-09-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 925164,
"text": " 12:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?acute change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with chronic trach/peg, lethargy, hypotension, now with\n persistent fevers and increased respiratory rate.\n REASON FOR THIS EXAMINATION:\n ?acute change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM\n\n History of fever and tachypnea in patient with tracheostomy and a J tube.\n\n SINGLE SUPINE AP FILMS\n\n Status post AVR. The dialysis catheter is in the region of the cavoatrial\n junction. Tracheostomy tube is 4 cm above the carina. The PICC line is in\n distal SVC allowing for low lung volumes. There are persistent bilateral\n pleural effusions and associated atelectases in the lower zones. No definite\n new pulmonary consolidation or pulmonary edema since the prior film of , . No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-09-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 927643,
"text": " 8:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for fluid status and interval changes in effusions\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with sepsis, ESRD, vented with pulmonary effusions\n REASON FOR THIS EXAMINATION:\n evaluate for fluid status and interval changes in effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old female with sepsis, end-stage renal disease, and\n ventilated. Evaluate.\n\n COMPARISON: AP supine portable chest x-ray dated .\n\n AP UPRIGHT PORTABLE CHEST X-RAY: A right-sided PICC catheter terminates\n within the right mid SVC. A tracheostomy tube is in place. A left subclavian\n hemodialysis catheter terminates within the right atrium. The cardiac\n silhouette, mediastinal and hilar contours are stable in this patient status\n post median sternotomy, and valve replacement. Allowing for differences in\n position, moderate layering pleural effusions are not significantly changed.\n The surrounding soft tissues are stable.\n\n IMPRESSION: No interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 922366,
"text": " 3:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pneumonia\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with chronic trach/peg, lethargy, hypotension, now with\n fever\n REASON FOR THIS EXAMINATION:\n eval pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: 66-year-old woman with chronic tracheostomy, lethargic,\n hypotensive with fever question pneumonia.\n\n Comparison is made with prior study with the most recent one performed , .\n\n FINDINGS: Stable mild right pleural effusion. Persistent right lower lobe\n consolidation, mild interval decrease in left retrocardiac\n consolidation/atelectasis. There is no pneumothorax. Stable top size heart,\n patient is S/P median sternotomy and valve replacement. There is a\n tracheostomy in appropriate position. Right PICC line and right internal\n jugular vein double-lumen catheter unchanged in position.\n\n There is no pneumothorax.\n\n IMPRESSION: Persistent right lower lobe consolidation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-10-06 00:00:00.000",
"description": "NON-TUNNELED",
"row_id": 928363,
"text": " 7:15 PM\n CENTRAL LINE PLCT Clip # \n Reason: needs access for blood\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n * C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman needs 3-port CV access for abx, pressors, and CVVH\n\n REASON FOR THIS EXAMINATION:\n needs access for blood\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old female requiring central venous access for\n antibiotics, pressors and CVVH.\n\n RADIOLOGISTS: Drs. and performed this procedure, with Dr.\n , the attending radiologist, present and supervising throughout.\n\n PROCEDURE: Written and informed consent were obtained from the patient's\n daughter. The patient was placed supine on the angiographic table. The right\n lower neck and upper chest were prepped and draped sterilely. Ultrasound\n imaging was performed confirming the patency of the right internal jugular\n vein. 5 cc of 1% lidocaine were applied for local anesthesia. Under\n ultrasonic guidance, a 21-gauge needle was used to access the right internal\n jugular vein. Hard copy ultrasound images were obtained before and after\n venous access documenting vessel patency. A 0.018 guidewire was placed through\n the needle under fluoroscopic guidance with its tip in the superior vena cava.\n The needle was then exchanged for a 4.5- French introducer sheath and the\n inner dilator and 0.018 guidewire were removed. A 0.035 guidewire was\n advanced into the superior vena cava and the introducer sheath was removed. A\n 16 cm long triple lumen central line was placed over the wire under\n fluoroscopic guidance with the tip in the superior vena cava. The wire was\n removed. Three lumens of the catheter were flushed with heparinized saline\n and demonstrated excellent blood flow. The catheter was secured to the skin\n with 0 silk and a sterile dressing was applied.\n\n IMPRESSION: Successful placement of a triple lumen central venous catheter\n via the right internal jugular vein with tip in the SVC. The catheter is\n ready for immediate use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-10-06 00:00:00.000",
"description": "ABDOMINAL A-GRAM",
"row_id": 928364,
"text": " 7:17 PM\n ABDOMINAL A-GRAM Clip # \n Reason: please evaluate for bleed and embolization if necessary\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 250\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with GI bleed\n\n REASON FOR THIS EXAMINATION:\n please evaluate for bleed and embolization if necessary\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old female with likely lower GI bleed.\n\n RADIOLOGISTS: The procedure was performed by Doctors and .\n Dr. , the attending radiologist was present and supervising throughout\n the procedure.\n\n PROCEDURE/FINDINGS: After explaining the risks and benefits of the procedure,\n written informed consent was obtained from the patient's daughter. Timeout\n was performed to identify the procedure to be performed, the site and\n requisition. The patient was then placed in a supine position on the\n angiographic table. The right groin was prepped and draped in the standard\n sterile fashion. The skin of the anticipated puncture site was then\n infiltrated intradermally with 5 cc of 1% lidocaine. One wall retrograde\n arterial puncture was achieved of the right common femoral artery. A\n guidewire was advanced to the infra-renal abdominal aorta. A 5 French\n vascular sheath was placed in the right common femoral artery. A Omni Flush\n catheter was then advanced over the guidewire into the infrarenal abdominal\n aorta and a nonselective aortic angiogram was performed demonstrating filling\n of the inferior mesenteric artery, common iliacs and several lumbar branches.\n No evidence of active extravasation was noted. Numerous attempts were made to\n access the inferior mesenteric artery using several angiographic catheters\n (Sos, Cobra, , Mikaelson) without success. A Sos catheter was then used\n to catheterize the superior mesenteric artery, and a selective arteriogram was\n performed. A normal pattern of blood flow was identified within the branches\n of the superior mesenteric artery territory with no evidence of obstruction,\n stenosis,abnormal blush or contrast extravasation. Extensive atherosclerosis\n was noted within the abdominal aorta and throughout its branches. Finally, the\n catheter and 5 French vascular sheath were removed. Hemostasis was achieved at\n the right puncture site using digital compression for a total time of 20\n minutes. No hematoma was encountered. The patient tolerated the procedure\n well without immediate complications.\n\n IMPRESSION:\n 1. Nonselective aortography and selective superior mesenteric artery\n arteriogram demonstrate no evidence of active gastrointestinal bleeding.\n Diffuse atheromatous disease was noted.\n\n 2. Selective catheterization of the inferior mesenteric artery was\n unsuccessful, likely due to severe atherosclerotic disease at its origin as\n shown on a previous CT scan.\n (Over)\n\n 7:17 PM\n ABDOMINAL A-GRAM Clip # \n Reason: please evaluate for bleed and embolization if necessary\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 250\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. Endoscopy recommended to better clarify origin of bleeding.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-10-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 928948,
"text": " 8:19 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Assess PICC line for position.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with sepsis, ESRD, vented with pulmonary effusions, check\n PICC line for position.\n REASON FOR THIS EXAMINATION:\n Assess PICC line for position.\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 8:22 A.M.\n\n HISTORY: Sepsis, endstage renal disease with recent PICC line placement.\n\n COMPARISON: Multiple priors, the most recent dated earlier same day.\n\n FINDINGS: The patient is significantly rotated limiting the evaluation.\n Support tubes and lines remain stable including the right upper extremity\n approach PICC line. The left lung is not adequately evaluated secondary to\n rotation with only a small amount of area of lung noted in the left upper\n chest. Overall no significant interval change.\n\n IMPRESSION: As best can be determined, no significant interval change\n relative to study obtained earlier same day. The study is nondiagnostic for\n evaluation of the left lung. Despite the given history, support tubes and\n lines remain stable with no new line noted.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2132-08-20 00:00:00.000",
"description": "CHANGE GASTROSTOMY TUBE",
"row_id": 922445,
"text": " 7:35 AM\n PERC G/J TUBE CHECK Clip # \n Reason: change GJ tube. thank you.\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 40\n ********************************* CPT Codes ********************************\n * CHANGE GASTROSTOMY TUBE INJ SINUS TRACT, THERAPUTIC *\n * -51 MULTI-PROCEDURE SAME DAY CHANGE PERC TUBE OR CATH W/CON *\n * FISTULOGRAM/SINOGRAM CATHETER, DRAINAGE *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with G-J tube\n REASON FOR THIS EXAMINATION:\n change GJ tube. thank you.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old woman with long-term gastrojejunostomy which is leaking\n at the skin site.\n\n PROCEDURE AND FINDINGS: The procedure was performed by Drs. and ,\n the attending physician, was present and supervising. Informed consent\n was obtained, and preprocedure timeout was performed. The patient's abdomen\n was prepped and draped in standard sterile fashion. Lidocaine jelly was\n infused at the skin site. The existing catheter was cut and removed over an\n 0.035 wire. A 7 French bright-tipped sheath was subsequently advanced and a\n pullback sinogram was performed. This demonstrated the gastric entry site of\n the tract to be within the mid body of the stomach. The tract was then\n sclerosed with silver nitrate sticks. A new 22 French MIC gastrojejunostomy\n tube was subsequently advanced over the wire after cutting off the superficial\n plastic disk. The wire was removed. 10 cc of saline were insufflated into\n the balloon. Injection of contrast through the gastric and jejunal ports\n demonstrated appropriate positioning of the tube with the proximal sideholes\n within the stomach and the distal tip within the jejunum. The catheter was\n secured with a Flexi-Trak, and the site was dressed. The patient tolerated\n the procedure well, and there were no immediate post-procedure complications.\n\n IMPRESSION:\n 1. Successful exchange for 22 French MIC gastrojejunostomy tube. The balloon\n was inflated with 10 cc of saline. The catheter is positioned with the marker\n above the #2 at the skin exit site. In the case of leaking around the skin,\n the gastric port can be open to continuous bag gravity drainage or be\n aspirated several times a day.\n 2. The tract was sclerosed with silver nitrate.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-10-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 930243,
"text": " 8:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: question of infectious process\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with sepsis, ESRD, respiratory failure, SBO, GIB now with\n fever\n REASON FOR THIS EXAMINATION:\n question of infectious process\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:26 A.M., .\n\n HISTORY: Sepsis. End-stage renal disease. GI bleed.\n\n IMPRESSION: AP chest compared to through 30.\n\n Left lower lobe atelectasis has improved substantially since \n though there is still sufficient atelectasis to produce leftward mediastinal\n shift. Small-to-moderate right and small left pleural effusion are unchanged.\n The heart is probably enlarged, but partially obscured by adjacent\n atelectasis. Right PICC and supraclavicular venous lines end at the junction\n of the brachiocephalic veins and a large-bore dual-channel left\n supraclavicular catheter ends in the SVC and at the superior cavoatrial\n junction. Tracheostomy tube in standard placements.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-10-03 00:00:00.000",
"description": "P SMALL BOWEL ONLY (GASTROGRAF) PORT",
"row_id": 927966,
"text": " 9:35 AM\n SMALL BOWEL ONLY (GASTROGRAF) PORT Clip # \n Reason: eval for SBO\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with resolving SBO\n REASON FOR THIS EXAMINATION:\n eval for SBO\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Resolving SBO.\n\n , CT scan.\n\n FINDINGS: Eight very limited quality abdominal radiographs were provided for\n interpretation. Due to the poor quality of films, evaluation is significantly\n limited. There is evidence for dilated bowel loops consistent with\n obstruction. Overlying contrast may be external to the patient. No\n radiologist was present during this procedure.\n\n IMPRESSION: Limited evaluation secondary to technical difficulties. If there\n is high clinical concern for pathology, further imaging is recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-10-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 929800,
"text": " 4:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pls evaluated for PNA.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with sepsis, ESRD, respiratory failure, SBO, GIB now with\n Bandemia and hypothermia.\n REASON FOR THIS EXAMINATION:\n Pls evaluated for PNA.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST.\n\n INDICATION: Respiratory failure.\n\n A single AP view of the chest is obtained and compared with the most\n recent study performed on . The patient is significantly rotated to\n the left side. There is no significant change between the two studies\n allowing for technique. Tubes and lines appear unchanged. The left lung is\n poorly evaluated due to the degree of rotation. There is loss of the left\n hemidiaphragm shadow, which may represent atelectasis/infiltrate in the left\n lower lobe. Right pleural effusion appears unchanged.\n\n IMPRESSION:\n\n Allowing for differences in technique, likely no significant change since the\n study of with opacification in the left hemithorax with obscuration of\n the left hemidiaphragm likely representing atelectasis. Right pleural\n effusion unchanged. Tubes and lines unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-10-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 927672,
"text": " 5:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for changes in pulmonary edema/consolidation\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with sepsis, vented with pulmonary effusions\n REASON FOR THIS EXAMINATION:\n please evaluate for changes in pulmonary edema/consolidation\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:18 A.M., .\n\n HISTORY: Sepsis. Pleural effusions. Pulmonary edema.\n\n IMPRESSION: AP chest compared to through 12. Moderate bilateral\n pleural effusion, left greater than right, and mild interstitial pulmonary\n edema are stable since . Cardiac silhouette is moderately\n enlarged. Tracheostomy tube is in standard placement. A dual channel left\n supraclavicular central venous line ends in the SVC. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-10-16 00:00:00.000",
"description": "TUNNELED W/O PORT",
"row_id": 929481,
"text": " 7:31 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: Please place left tunneled HD catheter for long term HD.\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * TUNNELED W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1750 CATH,HEMO/PERTI DIALYSIS LONG C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with MMP incl CRF on HD.\n REASON FOR THIS EXAMINATION:\n Please place left tunneled HD catheter for long term HD. Please place three\n access lines (two for HD, one VIP line).\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old female with chronic renal failure requiring tunneled\n hemodialysis catheter for long-term hemodialysis.\n\n RADIOLOGISTS: Drs. and . Dr. , the\n attending radiologist was present and supervising throughout the procedure.\n\n PROCEDURE/FINDINGS: The risks and benefits were explained to the patient's\n family, and verbal consent was obtained. The patient was placed supine on the\n angiographic table. The left neck, left upper chest and right upper chest\n were prepped and draped in the standard sterile fashion. A preprocedure\n timeout was performed to confirm the patient's name, procedure and the site.\n 10 cc of 1% lidocaine was then applied at the upper left chest for local\n anesthesia. A small incision was made approximately 8 cm laterally from the\n left IJ access site. The tunnel was then created with the tunneling device. A\n 23 cm tip to cuff hemodialysis catheter was then advanced through the tunnel.\n A 0.035 Bentson guidewire was then placed through the in situ temporary\n dialysis catheter under fluoroscopic guidance. The catheter was removed. A\n 14 French peel-away sheath was then placed over the wire. After the inner\n dilator and wire were removed, the new hemodialysis catheter was then placed\n through the sheath as the sheath was peeled away. A fluoroscopic spot image\n confirmed the tip of the hemodialysis catheter within the right atrium. The\n catheter was secured to the chest with a 0 Prolene stitch. Dermabond was used\n to close the lower neck incision site. The catheter ports were flushed,\n capped and heplocked. A sterile dressing was applied.\n\n The patient tolerated the procedure well and there were no immediate\n complications.\n\n IMPRESSION: Successful removal of a preexisting hemodialysis catheter and\n replacement with a new 23 cm cuff to tip 14.5 French double lumen tunneled\n hemodialysis catheter by way of the left internal jugular vein. The catheter\n tip is located in the right atrium. The catheter can be used immediately.\n (Over)\n\n 7:31 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: Please place left tunneled HD catheter for long term HD.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-10-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 927959,
"text": " 9:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval changes\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with sepsis, ESRD, vented with pulmonary effusions,\n decreased BS on left\n REASON FOR THIS EXAMINATION:\n evaluate for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, , AT 9:11 A.M.\n\n HISTORY: Sepsis, end-stage renal disease, on ventilator. There are decreased\n breath sounds on the left. Assess for interval change.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: The extreme left costophrenic angle has been excluded from view.\n There has been minimal relative improvement in the previously noted diffuse\n hydrostatic edema. Pleural effusions have redistributed with small bilateral\n effusions persisting, right slightly worse than left. The various support\n tubes and lines as well as the post surgical changes consistent with prior\n aortic valve replacement stable.\n\n IMPRESSION: Mild interval improvement in fluid balance with relatively stable\n bilateral effusions as above.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2132-10-16 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 929532,
"text": " 1:37 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC line\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * PICC W/O PORT -51 MULTI-PROCEDURE SAME DAY *\n * FLUOR GUID PLCT/REPLCT/REMOVE -59 DISTINCT PROCEDURAL SERVICE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n * C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 y/o F s/p CVA, multiple infections, hypotensive, CRF and femoral line\n that needs removal infection. Needs second line for chronic Abx.\n REASON FOR THIS EXAMINATION:\n Please place PICC line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old female with numerous infections requiring chronic\n antibiotics.\n\n RADIOLOGISTS: Drs. and . Dr. , the\n attending radiologist was present and supervising throughout the procedure.\n\n PROCEDURE/FINDINGS: The patient was brought to the radiology suite and placed\n supine on the angiography table. Following a preprocedure timeout including\n the patient's name and two patient identifiers, the right arm was sterilely\n prepped and draped. As no suitable veins were visible, ultrasound was used to\n identify the right brachial vein which was patent and compressible.\n Approximately 5 cc of 1% lidocaine was administered for local anesthesia. A\n 21-gauge needle was used to access the right brachial vein. Hard copy\n ultrasound images were obtained before and after venipuncture. A 0.018-inch\n guide wire was threaded through the needle into the vein. Then the needle was\n exchanged for a 4 French micropuncture sheath. The guide wire was advanced\n into the SVC and based on the markings on the wire, a PICC line was trimmed to\n a length of 40 cm. The PICC was then advanced over the wire and into the SVC\n under fluoroscopic guidance. The wire and peel-away sheath were removed. The\n catheter was flushed, capped, and heplocked. Finally, the catheter was\n statlocked into place and a sterile transparent dressing was applied. A final\n fluoroscopic image was taken demonstrating the tip of the PICC in the distal\n SVC.\n\n IMPRESSION: Successful placement of a 4 French single-lumen 40-cm PICC by way\n of the right brachial vein with the tip in the distal SVC. The line is ready\n for use.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-19 00:00:00.000",
"description": "Report",
"row_id": 1524303,
"text": "Respiratory Therapy\n\nPt remains trached w/ #7.0 Shiley trach on full mechanical support. No vent changes made this shift. Currently on A/C ventilation w/ PIP = 23. BS w/ rhonchi bilaterally, suctioned for moderate to copious amounts of yellowish/tan sputum. SpO2 90s. ABG acceptable. MDIs given as ordered. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support; pulmonary toilet\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-19 00:00:00.000",
"description": "Report",
"row_id": 1524304,
"text": "SICU NPN\nT-Trached.\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\n\nO-Alert. Following commands inconsistently. Noted shaking head in \"no\" directions when approached or asked question and then crying. Pt doing this consistently. Not grimacing to pain. MICU team witnessing when rounding on pt. Ethics consult discussed in rounds this morning but unclear on efficacy of consult due to nature of family dynamics. HR 60-100s, NSR with frequent PACs then later returning to Afib with rate control. Diltiazem drip discontinued 1hr after PO dose of Diltiazem begun. SBPs 80-100s. Attempted to wean Neo but unsuccesful. Neo as high as 0.75mcg/kg/min and currently at 0.3mcg/kg/min. Attempting to keep SBPs 80 and MAPs > 50. Breath sounds coarse throughout. Remains on AC. ABG with metabolic akalosis, no vent changes made. Suctioning for thick yellow sputum. Anuric. Continues CRRT. Goal is keep even in efforts to wean pressors first. Midordrine restarted. Abd obese but soft. (+) bowel sounds. Colostomy, G-J, and vaginal with small dark red bloody ooze. Colostomy at stoma site and G-J at insertion site. Dr. aware. HCT and coags pending. Colostomy prior with goldens soft stool, G-tube with bilious output prior and currently. J-tube to TFs. Hypothermic placed back on bair hugger. (+)BCx from with GNRs in aerobic and anaerobic bottles. Dr. aware. No change in Abx regimen. Husband visiting this morning briefly and no further visitors for day into evening. Continue Insulin gtt, goal BSs 80-120s.\n\nA/P: Sepsis\nContinue to montior\nCRRT to run even\nWean Neo as tolerated, > 80/MAP > 50\nFollow K and ICa Q6H\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-08 00:00:00.000",
"description": "Report",
"row_id": 1524380,
"text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-OPENS EYES SPONT. MOVES HEAD SPONT ON BED. PUPILS EQUAL AND SLUGGISHLY REACTIVE. NO SPONT MOVEMENT OF EXTREMITIES.\n\nCV-HR 80-100'S. AFIB, NO ECTOPY. REMAINS ON NEO GTT BUT SLOWLY WEANING. MAP>50. SKIN WARM. HCT STABLE.\n\nRESP-REMAINS TRACHED AND VENTED. RR DOWN TO 26. FIO2 UP0 TO 60%. NO OTHER VENT CHANGES MADE. ABG CHECKED FREQ. LS COARSE, DECREASED AT BASES. SXN FOR THICK YELLOW SPUTUM. UNABLE TO GET O2 SAT TRACING.\n\nGI-ABD FIRM AND DISTENDED. OBESE. +BS. TF STARTED VIA . TPN TO FINISH, NEW TPN NOT ORDERED. G-TUBE TO GRAVITY WITH BROWN/MAROON DRG. STOMA RED WITH OLD MELENA STOOL.\n\nGU-ANURIC. REMAINS ON WITH GOAL \"EVEN\". CA+ AND K+ GTTS INFUSING PER PROTOCOL.\n\nENDO-ON INSULIN GTT.\n\nACT-REPOSITIONED FREQ.\n\nCOMFORT-DOES NOT APPEAR TO BE IN PAIN.\n\nID-TEMP 96. BAIR HUGGER ON. ON MULTI ABX. SURVEILLENCE BLOOD CX SENT.\n\nSKIN-CON'T WITH MULTI SKIN ISSUES. MULTI AREAS OF WEEPY SKIN, SKIN TEARS AND ECCHYMOSIS. ALL DSGS INTACT OR CHANGED AS ORDERED. TOES REMAIN NECROTIC. ERYTHEMIC AREA ON LEFT THIGH UNCHANGED.\n\nSOCIAL-HUSBAND IN TO VISIT TODAY. PT'S DAUGHTER, , CALLED AND UPDATED ON PT'S CONDITION.\n\nP-CON'T WITH CURRENT PLAN. WEAN NEO AS TOL. ASSESS PAIN. SKIN CARE. ADVANCE TF AS TOL. SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-09 00:00:00.000",
"description": "Report",
"row_id": 1524381,
"text": "condition updated\nS/P sepsis;\nfor complete info please refer to carevue.\ncondition status quo. neo remains at 2mcg with no attempts to wean, CRRT keeping even to perserve bp. labs adjusted as needed. general anasarca continues. family present at bedside during early pm. no issues at this time\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-09 00:00:00.000",
"description": "Report",
"row_id": 1524382,
"text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. SX'd for small to moderate amounts of thick yellow-green secretions. Received MDI albuterol and atrovent with each vent check and flovent as noted in CareVue. Latest abg results determined a compensated respiratory alkalemia with very good oxygenation on the current settings.\n\nNo RSBI measured due to the FIO2 required at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-09 00:00:00.000",
"description": "Report",
"row_id": 1524383,
"text": "Respiratory Care:\nPlease note that the respiratory rate was decreased from 26 to 22 due to hypocarbia (PCO2 was 27).\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-09 00:00:00.000",
"description": "Report",
"row_id": 1524384,
"text": "respiratory care\npt on the vent tol well no changes made. see respiratory page of carevue for more information.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-10-28 00:00:00.000",
"description": "Report",
"row_id": 1524457,
"text": "Condition Update\nPlease see carevue for specifics.\n\nPt has been unarousable throughout the . There were only slight up and down movements w/ her left arm noted. PERRL. she was afebrile. In AFIB. Pt hypertensive to the 200's and 130's-140's 2 the beginning of the shift. 5 mg IV diltiazem given @ 20:00 w/ no effect, then 5mg IV labetolol given @ 2100 & 2300 w/ + effect. No vent changes made over . Pt sxn'd several times for sml amts of thick, tan secretions. LS coarse w/ rhonchi. w/ beneprotein TF's infusing via pt's j tube. Her G tube is to gravity and drained yellow mucus material. Pt's stoma is pink. Pt w/ multiple skin tears that are covered w/ adaptic and dsd. Coccyx stage 3 ulcers cleansed all NS, packed w/ aquacel, dsd's placed then softsorbs to cover.\n\nPlan: continue w/ current plan of care per micu team. PRN electrolyte repletion. Multiple dressing changes as needed. TF's for nutrition. IV/po abx. ? d/c home w/ services when bp/hr stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-07-29 00:00:00.000",
"description": "Report",
"row_id": 1524090,
"text": "Respirtory Care\nVent dependent pt admitted from home for increasing lethargy and question infection. Has size 6 Shiley trach which requires 40 cm pressure in cuff to obtain seal. Sx for minimal amount thick yellow secretions. ABG reveals metabolic acidosis with beginning respiratory compensation, well oxygenated. BS appear clear.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-16 00:00:00.000",
"description": "Report",
"row_id": 1524165,
"text": "NURSING\n VSS, AFEBRILE OVERNIGHT. CONTINUES IN A-FIB, AS PREVIOUSLY. OCCASIONAL PVC'S.RECIEVED 2 UNITS RBC'S. NO ISSUES OVERNIGHT. SEE CARE VUE FOR SPECIFICS.\n TUBE FEEDS CONTINUE AT 40/HR. GLUCOSE LEVELS CONTINUE TO BE ELEVATED. TREATED WITH SLIDING SCALE AND 90 UNITS OF LANTIS .\n ALL DRESSINGS CHANGED AT MIDNIGHT. REMAINS ON KINAIR BED, TURNED SIDE TO SIDE Q2/HRS. NO INDICATIONS OF ANY PAIN.\n CONTINUE SKIN CARE REGIMEN. DIALYSIS TODAY. CONTINUE DISCHARGE CARE PLANNING.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-16 00:00:00.000",
"description": "Report",
"row_id": 1524166,
"text": "Respiratory Care:\n Patient continues on full vent support with secretions changing from yellow to yellow-green sputum. BS=bilat, diminished t/o. Trach secure. No changes made in vent settings. See Carevue flowsheet. Plan to continue with supportive care and monitoring.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-16 00:00:00.000",
"description": "Report",
"row_id": 1524167,
"text": "nursing note\nNeuro:Opens eyes spont, not following commands or mouthing words. Some spont mvmt noted with LUE. Afebrile.\nCV:Remians in afib-rate controlled with lorpssor/dig/amio. Rate <120- SBP WNL. HD done with total 1400 ultrafiltrate. transient drops in BP during HD.\nRESP:LS coarse, thick yellow to green copius at times sputum. with periodic leaks and adjusted by RT.\nGI:Abd large, soft,nt. PEJ with ostomy appliance surrounding area- draining bilious and air into bag. MD aware and IR MD to come and check tube. MD- pylorus open and therefore not surprised by bilious draining. Ostomy with golden brown liquid stool.\nGU:anuric.\nSKIN: per skin rec's- leg dressing remain necrotic with exception of L calf- reddened.\nSOCIAL:husband and son in this AM and aware of check on PEJ in progress. Per medicine team- pt to go home with family care.\n\nPLAN:Check PEJ, passy muir per family requests, cont plan to go home.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-08-17 00:00:00.000",
"description": "Report",
"row_id": 1524168,
"text": "Condition update\nPlease see carevue for secifics.\n\nNeuro unchanged. Tmax 99.8 Afib. PM dose of lopressor held d/t sbp 70's-80' MD notified. No vent changes made this shift. Sats 100%. LS coarse throughout. Pt sxn'd several times for sml to moderate amts of thick, tan secretions. RSBI this am 94. Neb tx's done during the by resp tx. w/ beneprotein tubefeedings infusing at goal via j tube. J tube insertion site w/ large amts of bilious drainage. Colostomy draining golden colored, guiac negative, liquid stool. The stoma is pink. Hip dressings and coccyx wound dressings changed . Pt w/ many skin tears noted from removal of the allevyn dressings.\n\n son in to visit this eve. Son very concerned that current trach in line sxn not going down far enough to sxn all of secretions and spoke at great lengths to 3 RN's and resp tx regarding. Son also wants current trach to be replaced by a shorter one to ensure pt is sxn'd adequately. Son still not satified w/ any answers given, and will have primary team discuss w/ him in the am.\n\nPlan: continue with current plan of care per micu team. Continue planned dressing changes. D/C planning. HD Tues/Thurs/Sat.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-06 00:00:00.000",
"description": "Report",
"row_id": 1524251,
"text": "condition update\nD: pt opens eyes spontaneously. moves upper extremities. inconsistently follows commands.\ncardiac: afib rate of 100-130's. due for lopressor at 4am. when asleep sbp dip to 70's and up to 90's with stimulation. Dr. aware and wants pt to get 12.5mg of po lopressor. Hr down to 102 and sbp 85/47 after lopressor. sbp dip down to 70's with sleeping and up to 80's-90's with stimulation. Dr. aware and 250cc of ns fluid given.\nresp: pt remains on cmv with fio2 of 40%. breath sounds remain clear and diminished in the bases. pt suctioned for yellow sputum.\ngi: pt tolerating tube feeds through j tube at 40cc/hr. gt/jt seems to be slightly out and Dr. aware and up to pt. surgery to be called in am to tube. tube to continue. gtube draining bilious drainage. yellow drainage still draining around tube with ostomy bag intact.\ngu: pt remains anuric and to have hemodialysis today. small amt of vaginal bleeding noted. Dr. aware. hct remains stable.\nskin: pt turned every 2 hours and pt remains on air bed. dressing are\n dry and intact.\nsocial: son in to visit.\na: surgery to see pt today re: feeding tube. hemodialysis today. continue to monitor for hypotension.\nr: hr and sbp responded to fluid. no change in feeding tube position. no tube feeds draining around tube. drainage remains yellow. minimal vaginal drainage at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-06 00:00:00.000",
"description": "Report",
"row_id": 1524252,
"text": "Resp. care note - Pt. remaines trached and vented, no vent changes made at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-06 00:00:00.000",
"description": "Report",
"row_id": 1524253,
"text": "FOCUSED NURSING NOTE\nPlease see carevue flowsheet for further details\n\nNeuro: Alert, not following commands, nodding head \"yes\" \"no\" to basic needs/questions. PEERL, 3-4mm. Ativan held x 1 today.\n\nResp: No vent changes this shift. Trach patent, on CMV 0.40. Suctioned q3-4hr for thick/yellow sputum. SPO2 100% at all times.\n\nHemodynamics: Remains in Afib rate 102-120s. No sustained rapid V-rate today. BP labile minute to minute, lowest 52 after Demerol 12.5mg for pain, no LOC, responded to fluid with transient drops in BP throughout afternoon recovering quickly without intervention- Dr aware and in to assess pt. Lopressor dc'd per MICU team, Midrodine dose increased. Hemodialysis held today. No sx bleeding. Anasarca appears to be increasing- fluid losses via Gtube, multiple wounds, stools, J/G tube exit site.\n\nGI/Metabolic: TF Neopro FS at goal rate 40ml/hr. Copious amts clear/pale yellow gelatinous/viscous ?mucosal drainage from PEG tube site, MICU team aware. Small amt of same drainage character noted from rectum. Glycemic control acceptable on Lantus 86U . Colsotomy with frequent outputs, loose and trace guiac pos. Electrolytes stable without HD.\n\nID: Afebrile. Zosyn/Zyvox/Levaquin administered as ordered. Tobramycin not given secondary to HD suspended. No obvious source of worsening infection in wounds, slight odor waxes and wanes.\n\nSKIN INTEGRITY/COMFORT: Please see carevue flowsheet- multiple pressure/venous stasis ulcers. Drsg Wound RN consult instructions. Turn and repositioned q2-3hr. Oral care q2-4hr.\nDemerol IV x 1 for affirmation of pain on assessment, therapeutic effect of Demerol though significant drop in BP as noted.\n\nPSYCHOSOCIAL: Attentive visits today by husband, daughter , and Son . children are habitated to providing hygiene and nursing care- asking questions respectively to what each child's healthcare interest is ie : Diabetes vs wound care vs BP. Emotional support provided and edcuation ongoing re: greater picture of chronic illness, organ failure, sepsis and realistic goals of recovery vs plan of care for comfort only.\n\nPLAN: Monitor BP, notify MD <80 persists when HOB flat and stimulation provided. Monitor fluid balance closely, plan CVVH tomorrow per MICU team evaluation in am. Aggressive skin care. Monitor labs/sx bleeding/sx worsening sepsis. Plan D/C home with services this week per family/MD discussions.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-07 00:00:00.000",
"description": "Report",
"row_id": 1524254,
"text": "condition update\nd: pt remains awake and inconsistently follows commands.\ncardiac: afib rate of 110-138. bs still less labile. one episode of bp down to 70's. Dr. aware and up to 80-90's with no treatment. Dr. aware of hr 120-130's and continue to monitor with no treatment.\nresp: pt remains on cmv fio2 of 40%. pt appears comfortable. suctioned for thick yellow sputum.\ngi: tube feeds at goal at 40cc/hr. abd soft and slightly distended. colostomy stoma is pink and stool loose brown trace guaiac positve. feeding tube continues to leak around the insertion site thick yellow drainage.\ngu: pt anuric and on hemodialysis.\nskin: pt on airbed and turned frequently. left foot dressing changed and toes remain necrotic and black.\nsocial: son visiting during the evening. asking questions about possible cvvh tomorrow.\na: continue to monitor hemodynamics.\nr: less labile tonight. no fluid boluses during the night. hr more tachycardic. pt remains afebrile.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-07 00:00:00.000",
"description": "Report",
"row_id": 1524255,
"text": "RESP CARE: Pt remains trached/on vent per carevue. No changes in vent settings this shift. Lungs coarse with rhonchi/sxd thick yellow. No RSBI due to hemodynamic instability.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-07 00:00:00.000",
"description": "Report",
"row_id": 1524256,
"text": "FOCUSED NURSING NOTE\nPlease see carevue flowsheet for further details\n\nNEURO: Pt alert throughout the day, PERRL 3-4MM. Ativan doses held secondary to labile BP and pt does not exhibit signs of agitation. Does not follow commands per baseline, nodding head \"yes\" to all questions asked- it is this RN's opinion that pt does not have cognitive understanding of questions- nodding \"yes\" to nearly all speech addressed to her.\nRESP: Ventilated on CMV 0.40 via trach, no vent changes this shift. SPO2 100%, decreases to 88-92% when side-lying for dressing changes, skin care. Lungs clear to diminished. Thick/yellow sputum suctioned prn.\nHEMODYNAMICS: Afib persists with rapid Vresponse, occassional PVCs, average rate 120s. BP remains labile, range 70-96/30-58- NINV alternated to LLE and RUE with subtle variances. MICU team aware of HR and BP measurements, no change in LOC, no fluid boluses this shift. Worsening anasarca- no resp distress on CMV. Anuric, HD dependent pt with HD/CVVH on hold per MICU team.\nMETABOLIC/GI: TF via Jtube at goal rate 40ml/hr. Hyperglycemia increasing (181/195), treated per Lantus order and RISS. Moderate clear gelatinous secretions from G/J tube exit site continues, MD aware. Loose stool in adequate amounts via colostomy- stoma. pink/edematous.\nSKIN INTEGRITY: No change in pressure ulcers, venous stasis ulcers as previosuly documented, all dressings changes done as ordered. Noted increase exudate and ?exposed bone to right metatarsal area (base of great toe which is completely necrosed/gangrinous)- wound base yellow/red with yellow exudate and erythema borders. Site cleansed, covered with adaptic and covered with DSD. MD notified of assessment.\nPSYCHOSOCIAL: Husband visited briefly in am, discussed with him inability to offer HD without harming her. Daughter (HCP) called to speak with Renal MD and spoke with Dr . She declined speaking with MICU attending Dr though I expressed his desire to speak with her re: Mrs of further aggressive measures vs goal of d/c home.\n\n PLAN: Continue to monitor pts hemodynamics off HD, monitor for sx worsening sepsis. Administer , aggressive wound care. Turn and reposition q2-3hr, pulmonary hygiene prn. Discuss with Pharmacy alternative to D5W diluent for Linezolid to decrease hyperglycemia. Lantus increased as ordered, RISS as ordered. Emotional support to pt and family- Dr and MICU team to f/u with for further .\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-23 00:00:00.000",
"description": "Report",
"row_id": 1524316,
"text": "NURSING 7P-7A\n VSS, KEPT WITHIN PARAMETERS OF >80 WITH MAP >50. NEO GTT CONTINUES AT 1.5. REMAINS HYPOTHERMIC WITH TEMPS IN THE 97 RANGE, BAIR HUGGER REMAINS ON LOW.\n CONTINUES, RUNNING EVEN TO 1 LITER NEGATIVE/DAY. AT 2400 NEGATIVE 1050 FOR 24/HRS. CONTINUES ON CA AND K GTTS PER CVVH PROTOCOL.\n COLOSTOMY WITH BLOOD TINGED STOOL IN THE EVENING, AFTER MIDNIGHT STOOL RETURNED TO GREEN COLOR. HCT DECREASED TO 22.9 FROM 24.1. MD NOTIFIED, I UNIT RBC'S TO BE GIVEN.\n CONTINUES ON INSULIN GTT, BLOOD SUGARS RANGE FROM 104-160. TUBE FEEDS CONTINIE AT 65/HR.\n SEE CARE VUE FOR FULL ASSESSMENT.CONINUE CVVH, RUN EVEN TO 1 LITER NEGATIVE.. TO INTERVENTIONAL RADIOLOGY TODAY FOR PICC LINE. CONTINUE TO MAINTAIN >80, MAP>50. WILL RECIEVE I UNIT RBC'S.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-23 00:00:00.000",
"description": "Report",
"row_id": 1524317,
"text": "Resp Care: Pt continues trached and on ventilatory support with a/c, no vent changes maintaining spo2 99%; bs rhonchorous, sxn thick yell secretions, rx with mdi albuterol/atrovent/flovent mdi, rsbi n/a d/t vent dependence, will cont full support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-09-23 00:00:00.000",
"description": "Report",
"row_id": 1524318,
"text": "Respiratory Care\nPt continues to be trached/ventilated. #7.0 Extra-Long Shiley DIC clean and intact. B/S coarse bilterally. Suctioned for moderate amounts of thick yellow secretions. MDI's administered per orders. Pt continues on /NEO. Current resting on A/C 450/16/5/.40 with PIP/Plat 25/22. Plan to continue current support at this time. No ventilatory changes made this shift. Will closely monitor.\n"
}
] |
5,364 | 190,730 | The patient was intensely monitored in the Intensive Care Unit and repeat imaging showed petechial hemorrhages in the area of the left middle cerebral artery distribution but no uncontrolled hemorrhage. It was thought that the patient's stroke was due to embolic phenomena that resulted from hypercoagulable state from a genetic abnormality exacerbated by oral contraceptive use as an outpatient which when combined with the patient's heavy smoking put her at risk for cerebrovascular accident. When the patient was deemed stable with no advancing hemorrhage, the patient was transferred to the general medical floor on the Neurology service for further work up. As noted above, an abdominal CT scan revealed right DVT in the iliac vein, which required the placement of a DVT filter in the inferior vena cava by Interventional Radiology. The type of filter that was placed can be removed at any time if and when the decision is made to anticoagulate the patient for stroke prevention. The patient's neurologic examination throughout her admission improved with her aphasia improving from a dense mixed aphasia to a transcortical mixed aphasia at the time of discharge. The patient's power in the right upper and lower extremities also improved with time and physical therapy intervention, increasing to a in the upper extremity and a 4-/5 in the lower extremity at the time of discharge. The patient was placed on Plavix and subcutaneous Heparin for CVA and DVT prophylaxis during this admission. Great care was taken to prevent any extension of the hemorrhage and the decision was made not to anticoagulate the patient with either Coumadin or Lovenox at the time of discharge. However, repeat head CT scan will be needed and has been scheduled for four to five days after discharge to evaluate the size of hemorrhagic transformation and after evaluation, anticoagulation will likely be started and as indicated in this young female with large middle cerebral artery stroke. The stroke work up including carotid ultrasounds, which showed no stenosis of either carotid artery and a transesophageal echocardiogram performed on , which showed no echocardiographic evidence of cardiac source of embolus. This study included a bubble study search for patent foramen ovale. Therefore, it was thought that the patient's source for embolus was hypercoagulable state due to genetic defect, most likely to be factor V Leiden as per the prevalence in the general population, although prothrombin mutation can not be ruled out as these laboratory results are not available at this time. After coordinating follow-up care with Interventional Radiology, which will contact the patient to remove new DVT filter, the patient was sent to acute rehabilitation facility where she could regain her strength and resume her abilities to carry out her activities of daily living. The patient will have close follow-up after discharge as a repeat CT scan will be scheduled on , at 9:15 a.m. The results of this CT scan will be followed up by Dr. of the Stroke Department, at which time, a decision regarding anticoagulation will be communicated to the rehabilitation facility. The patient's primary care physician, . will also be informed about this decision. Interventional Radiology Department will also contact the patient regarding the date on which they can retrieve the deep venous thrombosis filter placed in her inferior vena cava as the retrieval equipment is not available at this time and they can not set a specific date. | There is mildly progressive edema and associated mass effect, with further flattening of the left lateral ventricle and displacement to the right. REASON FOR THIS EXAMINATION: r/o DVT FINAL REPORT INDICATION: Right upper extremity swelling, hypercoagulable state. No contraindications for IV contrast FINAL REPORT INDICATION: Recent left middle cerebral arterial stroke, hemorrhage and basal ganglia suspected, but previous CT was done after abdominal contrast-enhanced CT. ? This filling defect terminates just below the level where there is infiltration and subcutaneous air within the right groin consisten with the given history of a prior central line in this location. PLEASE DO now for r/o hemorrhagic transformation No contraindications for IV contrast FINAL REPORT NONCONTRAST CT OF THE BRAIN. An inferior vena cavagram was then performed. No contraindications for IV contrast FINAL REPORT INDICATION: Embolic stroke without clear etiology. FINDINGS: Duplex evaluation was performed of both carotid arteries. There is surrounding hypoattenuation and mass effect with partial effacement of the anterior of the left lateral ventricle. The distal vertebral arteries, the basilar artery and the right internal carotid artery appear normal. This finding is consistent with an evolving left middle cerebral artery distribution infarction. Right iliac vein deep venous thrombosis. This was performed secondary to concern of a duplicated IVC. It appeared to hang up in the region of the left iliac vein. The sheath was left in the left iliac vein and a pelvic venogram was performed through the inner dilator which contained multiple sideholes. These findings are consistent with the patient's known history of occlusion of the left middle cerebral artery and evolving left middle cerebral artery distribution infarction. No contraindications for IV contrast FINAL REPORT NONCONTRAST CT OF THE BRAIN. There is air within the bladder noting the presence of a foley catheter with the bladder otherwise appearing normal. Pelvic venogram demostrated a widely patent left iliac venous system. The angiographic sheath was then withdrawn down into the distal inferior vena cava and a post-procedure inferior vena cavagram was performed. REMAINS IN SR 50-70'S WITHOUT ECTOPY.GI--PEDI NGT PLACED AND CONFIRMED BY CXR. The ascending, transverse and descending thoracic aorta arenormal in diameter and free of atherosclerotic plaque. Thepatient appears to be in sinus rhythm.Conclusions:The left atrium is normal in size. nursing note - 1900hrs - 04.30hrsneuro - slight improvement with right sided deficit - weak grasp now evident with right hand, can move on bed - right leg some power evident can push against some resistance - speech little improvement although can now answer yes/no to simple questions - repeat CT performed as requested at approx 0100hrs this am - await official resultscvs - aim to keep b/p @ 160 for perfussion - b/p 120-160 overnight - dopamine weaned as requested - levo titrated to obtain systolic pressure - levo presently @ 0.2 mcg/kg - h/r stable 50-80 sinus - no further episodes of tachy/ brady /heart block as previousborderline temp - observe @ 100blood sugras covered as per sliding scaleresp - chest clear sats R/A @ 98g/i - x2 bouts of nausea - ondanstron with effect - no bowel motiong/u - urine output 60-80cc per hour much less than previous crstalloids in progress @ 150ccper hour - urine output dropped to 30cc then 20cc per/hr - foley checked for patency. Radial aline placed without incident.Neuro: Alert but lethargic secondary to fentanyl and versed. speech /swallow assessment todaycvs - b/p remined@ parameters ordered 125-130 systolic -- slowly weaning levophed - h/r remians stable 60-70bpm - afebrile - blood sugars stableresp - no issues with asthma - able to use inhaler if required by self - sats 98% - occassional cough evidentg/i - no bowel motion since admission - feed @ goal appears to be tollerating unable to check residuals as pedi tube insitu - remains npo until gag assessedg/u - urine output satisfactory 60-80cc clewar urine per hr via foleyskin - numerous bruises on legs ? PATIENT/TEST INFORMATION:Indication: Cerebrovascular event/TIA.BP (mm Hg): 130/80HR (bpm): 90Status: InpatientDate/Time: at 15:40Test: Portable TEE (Complete)Doppler: Complete pulse and color flowContrast: SalineTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size. MRI OF NECK DONE TODAY.CV--REMAINS ON LEVOPHED GTT WITH LABILE BP. GI: TF at goal, min residual, abd benign. Denies any SOB.GI: Abd soft, non-tender, +bs, -bm. The aortic valveleaflets (3) appear structurally normal with good leaflet excursion and noaortic regurgitation. +Expressive aphasia, but when patient with self is able to find appropriate word. UO>80cc/hr.Access: R Radial aline in place. SBP parameter reduced with levo gtt to keep sbp >130. Pulm: Clear/decr, ra sat 100%. Right ventricular chamber size and free wallmotion are normal. HR 60-70 nsr- no ectopy noted. Good amounts of UO.Access: Right femoral quad lumen. Right Femoral line in place. TF stopped and NGT removed today by Neuro med.GU: Foley cath intact with clear yellow urine. ABD SOFT NONTENDER.GU--NS WITH 20MEQ KCL/1L AT 125/HR TILL TF AT GOAL. NS w/ 20KCL @ 150cc/hr x 4liters.Resp: LS clear bilaterally. CV: SR/no ectopy, sbp 127-133. | 25 | [
{
"category": "Radiology",
"chartdate": "2196-12-26 00:00:00.000",
"description": "P CAROTID SERIES COMPLETE PORT",
"row_id": 813115,
"text": " 2:37 PM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: Carotid source for embolization, carotid stenosis\n Admitting Diagnosis: MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with stroke.\n REASON FOR THIS EXAMINATION:\n Carotid source for embolization, carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Stroke.\n\n FINDINGS: Duplex evaluation was performed of both carotid arteries. Minimal\n plaque was identified.\n\n On the right, peak systolic velocities are 71, 86, 105 in the ICA, CCA, ECA\n respectively. The ICA to CCA ratio is 0.8. This is consistent with no\n stenosis.\n\n On the left, peak systolic velocities are 75, 72, 90 in the ICA, CCA, ECA\n respectively. ICA to CCA ratio is 1. This is consistent with no stenosis.\n\n There is antegrade flow in both vertebral arteries.\n\n IMPRESSION: No evidence of stenosis in either carotid artery.\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-12-27 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 813261,
"text": " 5:29 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: evaluate for embolic damage to liver, spleen, kidneys in pt\n Admitting Diagnosis: MCA STROKE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with\n REASON FOR THIS EXAMINATION:\n evaluate for embolic damage to liver, spleen, kidneys in pt who has suffered\n embolic stroke with no clear etiology.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Embolic stroke without clear etiology.\n\n TECHNIQUE: Axial pre and post contrast CT abdomen and pelvis.\n\n FINDINGS: The lung bases are clear. The liver, spleen, pancreas, adrenals,\n and kidneys have a normal appearance. No hydronephrosis bilaterally. The\n gallbladder is present. No abnormally thickened or dilated abdominal bowel\n loops. No abdominal ascites, lymphadenopathy, or pneumoperitoneum.\n\n Specifically, there is no CT evidence of infarction of the abovementioned\n organs.\n\n PRE AND POST CONTRAST CT PELVIS: No pelvic ascites or lymphadenopathy. No\n abnormally dilated or thickened pelvic bowel loops. There is air within the\n bladder noting the presence of a foley catheter with the bladder otherwise\n appearing normal.\n\n There is a filling defect which contains air within the right external iliac\n vein extending proximally to the peripheral portion of the common iliac artery\n vein as well as into the central aspect of the internal iliac vein. This\n filling defect terminates just below the level where there is infiltration and\n subcutaneous air within the right groin consisten with the given history of a\n prior central line in this location. Overall the findings are consistent with\n a deep venous thrombosis on the right.\n\n No lytic or blastic destructive osseous lesions.\n\n IMPRESSION:\n\n 1. Right iliac vein deep venous thrombosis.\n\n 2. No evidence of infarction of the liver, spleen, or kidneys as clinically\n questioned.\n\n 3. The findings were directly discussed with Dr. from the neurology\n service at approximately 6PM on .\n\n (Over)\n\n 5:29 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: evaluate for embolic damage to liver, spleen, kidneys in pt\n Admitting Diagnosis: MCA STROKE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-12-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 813351,
"text": " 1:34 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Does this patient truly have hemorrage after IV contrast fro\n Admitting Diagnosis: MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with L MCA stroke found to have hemorrhage in basal ganglia\n yesterday shortly after Abd CT with contrast.\n REASON FOR THIS EXAMINATION:\n Does this patient truly have hemorrage after IV contrast from yesterday's Abd\n CT scan has had time to clear?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent left middle cerebral arterial stroke, hemorrhage and basal\n ganglia suspected, but previous CT was done after abdominal contrast-enhanced\n CT. ? degree of hemorrhage.\n\n TECHNIQUE: Axial non-contrast CT scans of the brain were obtained.\n\n Comparison is made to the previous CT of .\n\n FINDINGS:\n\n At the time of interpretation of the previous study, it was unclear that there\n had been recent contrast administration. Areas of increased density noted in\n the left middle cerebral arterial territory infarction was predominantly\n delayed contrast enhancement. However, on the non-contrast study obtained\n today, there are persistent foci of increased density in the left middle\n cerebral infarction, particularly involving the putamen and caudate. This is\n indicative of petecchial hemorrhage in the infarction.\n\n There is mildly progressive edema and associated mass effect, with further\n flattening of the left lateral ventricle and displacement to the right. The\n basal cisternal spaces remain well visualized. No new areas of abnormal\n attenuation are identified.\n\n IMPRESSION: Petecchial hemorrhage within the left middle cerebral arterial\n territory infarction. Slightly more edema than on the previous studies.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-12-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 813272,
"text": " 7:32 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for petechial hemorrhages/infarcts in pt with new D\n Admitting Diagnosis: MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with NEW MCA STROKE\n\n REASON FOR THIS EXAMINATION:\n evaluate for petechial hemorrhages/infarcts in pt with new DVT.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NONCONTRAST CT OF THE BRAIN.\n\n INDICATION: 40 year old female with left middle cerebral artery distribution\n infarct and new DVT.\n\n TECHNIQUE: Axial noncontrast CT imaging of the brain. Comparison is made to\n prior studies from and .\n\n FINDINGS: Compared to prior exams, there is greater hyperattenuation within\n the left basal ganglia, the left frontal lobe as well as the left temporal\n lobe in the distribution of the patient's known left middle cerebral\n infarction. There is surrounding hypoattenuation and mass effect with partial\n effacement of the anterior of the left lateral ventricle. There is no\n evidence of uncal herniation or hydrocephalus. There is no evidence of\n definite extra- axial hemorrhage. Bone windows show no evidence of fracture\n and opacification of the ethmoid air cells.\n\n IMPRESSION:\n Evolving infarction in the distribution of the left middle cerebral artery.\n The areas of hyperattenuation indicative of hemorrhagic transformation.\n\n These findings were discussed with Dr. the night of .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-12-22 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 812703,
"text": " 8:27 PM\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \n Reason: acute ischemic stroke with right hemiparesis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with asthma\n REASON FOR THIS EXAMINATION:\n acute ischemic stroke with right hemiparesis\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Right hemiparesis.\n\n TECHNIQUE: Sagittal T1-weighted images, axial T2-weighted, susceptibility and\n FLAIR images were obtained.\n\n FINDINGS:\n\n There is subtle increased signal intensity on the diffusion-weighted images,\n involving the left insula and corona radiata most consistent with a very early\n infarct. No abnormalities yet visible on the FLAIR images. The ventricles,\n cisterns and sulci are normal, without mass effect. The craniovertebral\n junction is normal. Note is made of opacification of the mastoid air cells\n bilaterally. There is trace of fluid in both maxillary sinuses.\n\n IMPRESSION: There is an early infarct within the left MCA territory with\n areas of early restricted diffusion visible in the left insula and corona\n radiata.\n\n MRA HEAD:\n\n CLINICAL HISTORY: Infarct.\n\n TECHNIQUE: A 3D time-of-flight study was derived from an axial slab through\n the inferior cranium.\n\n FINDINGS:\n\n There is good flow in the distal left internal carotid artery. The left MCA\n is truncated at the level of the mid-left M1 segment and no flow is seen\n lateral to the point. The distal vertebral arteries, the basilar artery and\n the right internal carotid artery appear normal. The other cerebral arteries\n are normal.\n\n IMPRESSION: The left MCA is occluded at the level of the mid-left M1 segment.\n The results were called to the emergency room physician at approximately 9:30\n p.m. on . The EU was aware of the findings and TPA had already been\n administered.\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-12-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 812843,
"text": " 12:46 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please compare to previous CT\n Admitting Diagnosis: MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with NEW MCA STROKE\n\n REASON FOR THIS EXAMINATION:\n please compare to previous CT\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40 year old female with new MCA stroke.\n\n TECHNIQUE: CT imaging of the brain without contrast.\n\n COMPARISON: .\n\n FINDINGS: There is continued evidence of an evolving left middle cerebral\n artery distribution infarction with hypodensity within the left basal ganglia,\n insular cortex, temporal lobe and frontal lobe. There are multiple\n hyperdensities within the region of the left insular cortex which could\n represent thrombosed vessels in the distribution of the left middle cerebral\n artery. Alternatively these foci of hyperdensity could represent petechial\n hemorrhage. There is evidence of increased mass effect in this region with\n worsening effacement of the left lateral ventricle. There is no evidence of\n hydrocephalus. There is opacification within the ethmoid air cells. Bone\n windows show no evidence of fracture.\n\n IMPRESSION:\n\n 1) Evolving left middle cerebral artery distribution infarct effecting the\n left basal ganglia, left temporal lobe, and left frontal lobe. There is\n evidence of increased mass effect when compared with the prior examination\n with multiple foci of hyperdensity in the region of the left insular cortex\n which likely represents thrombosed vessels or less likely petechial hemorrhage\n in this region .\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-12-24 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 812881,
"text": " 1:55 PM\n PORTABLE ABDOMEN Clip # \n Reason: check feeding tube placement\n Admitting Diagnosis: MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with s/p cva\n REASON FOR THIS EXAMINATION:\n check feeding tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40 year old woman status post CVA. Please check feeding tube\n placement.\n\n FINDINGS: There is a feeding tube, which is curled upon itself, in the\n stomach. The lung fields are clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-12-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 812876,
"text": " 12:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?infiltrate, and ngt placement\n Admitting Diagnosis: MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with stroke and elevated wbc and new ngt placement\n\n REASON FOR THIS EXAMINATION:\n ?infiltrate, and ngt placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 40-year-old woman with stroke and elevated white count with new NG\n tube placement.\n\n CHEST AP PORTABLE:\n\n FINDINGS: It would appear that this film is mislabeled with the left marker\n over the right shoulder. Since prior study of , there has been\n placement of a nasogastric tube with its tip in the stomach. There is no\n acute cardiopulmonary disease is seen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-12-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 812711,
"text": " 10:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?aspiration\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with stroke\n REASON FOR THIS EXAMINATION:\n ?aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40 y/o female with stroke. Evaluate for aspiration.\n\n FINDINGS: The heart size and mediastinal contours are within normal limits\n allowing for the supine nature of this film. The lungs are clear with no\n parenchymal consolidation or pulmonary nodules. No evidence of pneumothorax or\n pleural effusion. The osseous structures are unremarkable.\n\n IMPRESSION: No evidence of aspiration pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-12-23 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 812721,
"text": " 12:56 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: POST TPA. PLEASE DO now for r/o hemorrhagic transformation\n Admitting Diagnosis: MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with NEW MCA STROKE\n REASON FOR THIS EXAMINATION:\n POST TPA. PLEASE DO now for r/o hemorrhagic transformation\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NONCONTRAST CT OF THE BRAIN.\n\n INDICATION: 40 year old female with new left middle cerebral artery CVA.\n Patient with recent TPA administration. Evaluate for hemorrhagic\n transformation.\n\n TECHNIQUE: Axial noncontrast CT imaging of the brain. Comparison is made to\n a prior MRI performed on .\n\n FINDINGS: There is no evidence of acute intracranial hemorrhage. There is no\n evidence of shift of normally midline structures. Increased density is noted\n within the proximal left middle cerebral artery that is consistent with the\n patient's known occlusion of the left middle cerebral artery. Hypodensity is\n present within the left basal ganglia and insular cortex in the distribution\n of the left middle cerebral artery. This finding is consistent with an\n evolving left middle cerebral artery distribution infarction. The ventricles\n and sulci are normal in size. Bone windows show opacification of the right\n ethmoid air cells and no evidence of fracture.\n\n IMPRESSION:\n 1. No evidence of acute intracranial hemorrhage.\n\n 2. Hyperdensity within the left middle cerebral artery and hypoattenuation\n within the left basal ganglia/insular cortex with edema. These findings are\n consistent with the patient's known history of occlusion of the left middle\n cerebral artery and evolving left middle cerebral artery distribution\n infarction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-12-28 00:00:00.000",
"description": "INTERUP IVC",
"row_id": 813375,
"text": " 3:41 PM\n IVC GRAM/ Clip # \n Reason: please place , with any questions\n Admitting Diagnosis: MCA STROKE\n Contrast: OPTIRAY Amt: 95CC\n ********************************* CPT Codes ********************************\n * INTERUP IVC INTRO CATH SVC/IVC *\n * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT IVC *\n * IVC GRAM EXTREM UNILAT VENOGRAPHY *\n * -52 REDUCED SERVICES C1880 VENA CAVA *\n * NON-IONIC 50 CC *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with hemorrhage left mca stroke and right common iliac vein\n dvt\n REASON FOR THIS EXAMINATION:\n please place , with any questions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40 year old woman with hemorrhagic left MCA stroke and right\n common iliac DVT.\n\n RADIOLOGISTS PERFORMING PROCEDURE: Dr. ; Dr. ,\n the staff radiologist, present throughout the entire procedure.\n\n PROCEDURE/TECHNIQUE: Informed, written consent was obtained. The left groin\n was prepped and draped in the usual sterile fashion. Through an anesthetized\n skin approach and utilizing a 19 gauge needle access was obtained into the\n left common femoral vein. wire was then advanced through the\n puncture needle. It appeared to hang up in the region of the left iliac vein.\n This raised concern for a duplicated IVC even though the CT scan did not\n demonstrate such a vascular anomaly. The puncture needle was then exchanged\n for a 7 French angiographic sheath. The sheath was left in the left iliac\n vein and a pelvic venogram was performed through the inner dilator which\n contained multiple sideholes. This was performed secondary to concern of a\n duplicated IVC.\n\n Pelvic venogram demostrated a widely patent left iliac venous system. No\n duplicated IVC was seen. The distal inferior vena cava was also widely\n patent.\n\n An inferior vena cavagram was then performed. This demonstrated the level of\n the left and right renal vein confluence. There were single bilateral renal\n veins. No vascular anomaly was detected. There was no IVC thrombus.\n\n wire was then advanced into the angiographic sheath and used to\n reposition the sheath at the level of the lowest renal vein which was the\n left. The Bard removal was then advanced through the 7 French\n angiographic sheath after removing the inner dilator and wire. The removable\n was then deployed. The angiographic sheath was then withdrawn down\n into the distal inferior vena cava and a post-procedure inferior vena cavagram\n was performed. This demonstrated the to be in optimal location with\n (Over)\n\n 3:41 PM\n IVC GRAM/ Clip # \n Reason: please place , with any questions\n Admitting Diagnosis: MCA STROKE\n Contrast: OPTIRAY Amt: 95CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the tip at the level of the left renal vein (the lowest). There was no tilt\n to the .\n\n The angiographic sheath was removed and pressure was applied until hemostasis\n was achieved.\n\n COMPLICATIONS: None.\n\n CONTRAST/MEDICATIONS: IV conscious sedation consisting of incremental doses\n of Versed and Fentanyl. 4 cc 1% Lidocaine. 60 cc of dilute Optiray 320.\n\n IMPRESSION: Successful placement of a Bard Recovery in the IVC. There\n is no inferior vena cava thrombus.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-12-29 00:00:00.000",
"description": "R UNILAT UP EXT VEINS US RIGHT",
"row_id": 813499,
"text": " 3:00 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: SWELLING\n Admitting Diagnosis: MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman who p/w L MCA CVA, s/p thrombolytics, concerning for\n hypercoagulable state w/u pending, today with RUE swelling.\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right upper extremity swelling, hypercoagulable state.\n\n RIGHT UPPER EXTREMITY DOPPLER ULTRASOUND: scale and Doppler son of\n the right internal jugular, subclavian, axillary, cephalic, basilic and\n brachial veins were performed. Normal flow, compressibility, augmentation and\n wave forms are demonstrated. Intraluminal thrombus is not identified.\n\n IMPRESSION: No evidence of DVT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-12-24 00:00:00.000",
"description": "MR-ANGIO NECK WITHOUT CONTRAST",
"row_id": 812884,
"text": " 2:35 PM\n MR-ANGIO NECK WITHOUT CONTRAST Clip # \n Reason: please do fat sat; ?dissection\n Admitting Diagnosis: MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with large left mca stroke, ?dissection as etiology\n REASON FOR THIS EXAMINATION:\n please do fat sat; ?dissection\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY:\n 40 year old female with large left MCA stroke. Rule out dissection.\n\n MR angiography of the neck was performed without the administration of\n contrast. 2D and 3D images were also performed.\n\n FINDINGS:\n The study is minimally limited secondary to motion, especially the 3D images.\n There is good flow noted in the common carotid arteries, internal carotid\n arteries and vertebral arteries bilaterally.\n\n There is a suggestion of large focal eccentric plaque in the proximal left\n internal carotid artery causing moderately severe stenosis in the proximal\n left internal carotid artery. This is only well seen on the axial images.\n This cannot be confirmed on the reformats secondary to motion. An ultrasound\n examination is recommended for further evaluation. No evidence of dissection\n noted.\n\n IMPRESSION:\n 1) No definite evidence of dissection noted.\n\n 2) Suggestion of large focal eccentric plaque in the proximal left internal\n carotid artery thereby causing moderately severe focal stenosis in the\n proximal left internal carotid artery. This is well seen on the axial images\n but cannot be confirmed on the reformatted images. This should be further\n evaluated with ultrasound examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-12-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 812933,
"text": " 5:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval\n Admitting Diagnosis: MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with stroke and elevated wbc and new ngt placement\n\n REASON FOR THIS EXAMINATION:\n eval\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY:40 year old woman with stroke and elevated white count with new NG\n tube placement.\n\n AP semiupright portable chest at 5:30 AM.\n\n The tip of the feeding tube now appears to be in the distal antrum of the\n stomach. No acute cardiopulmonary disease.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2196-12-24 00:00:00.000",
"description": "Report",
"row_id": 1332933,
"text": "MICU A NSG 7A-7P\nNEURO--PT SLOWLY IMPROVING OVER COURSE OF SHIFT. SPEAKING IN SIMPLE ONE WORD ANSWERS THAT ARE AT TIMES GARBLED. GAG AND COUGH IMPAIRED TO ABSENT. ABLE TO LIFT AND HOLD RIGHT ARM AND RIGHT LEG, BUT STRENGTH REMAINS WEAK. MOVING LEFT ARM WITH NORMAL STRENGTH, AND ABLE TO LIFT AND HOLD LEFT LEG. RIGHT SIDED FACIAL DROOP NOTED, PERRL AT 3-4MM BILAT. MRI OF NECK DONE TODAY.\nCV--REMAINS ON LEVOPHED GTT WITH LABILE BP. GOAL REMAINS SBP 160-180, PLEASE SEE CAREVIEW. K AND MAG REPLETED THIS SHIFT. REMAINS IN SR 50-70'S WITHOUT ECTOPY.\nGI--PEDI NGT PLACED AND CONFIRMED BY CXR. TF PROMOTE WITH FIBER STARTED AT 10CC/HR PLAN IS TO INC Q6 BY 20CC FOR GOAL OF 80CC/HR. ABD SOFT NONTENDER.\nGU--NS WITH 20MEQ KCL/1L AT 125/HR TILL TF AT GOAL. U/O BRISK 100-500CC/HR DILUTE URINE. URINE LYTES AND OSMOLALITY AND SERUM CHEM 7 AND OSMOLALITY TO BE SNET AT 6PM.\nSOCIAL--SIG OTHER AND MOTHER IN TO VISIT TODAY. UPDATED ON PT'S CONDITION BY RN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2196-12-25 00:00:00.000",
"description": "Report",
"row_id": 1332934,
"text": "nursing note 1900hrs - 0500hrs\n\n\nneuro - status syable overnight - continues to be able to lift and move rt arm periodically with some grasp evident - moves rt leg on bed - follows commands and attempts to communicate - is able to respond yes/no and seems appropriate with response - rt facial droop evident\n\ncvs - systloic maintained 150-180 with levo in progress - attempted to decrease but b/p dips to 140 whilst sleeping - h/r stable 50-70bpm - afebrile - blood sugars stable\ncheck chem 7 last pm - k replaced - results reported to team\n\nresp - lungs wheezy last pm - known asthmatic normally regularly on albuterol @ home - nebulised with good effect - lungs clear sats @98% on R/A RR stable\n\ng/i - no bowel motion - feed increased as perscribed but unable to check for residuals due to size of tube - presently @ 50cc per hour - aim of 80\n\ng/u - urine output 80-240 cc per hour - samples sent this am as requested - team aware of serum amd urine osmolarity - no repeat ordered\n\nskin - able to turn self - presure areas intact\n\nlines - remain patent/insitu\n\nsocial - boyfriend stayed overnight\n\ng/u\n"
},
{
"category": "Nursing/other",
"chartdate": "2196-12-24 00:00:00.000",
"description": "Report",
"row_id": 1332932,
"text": "nursing note - 1900hrs - 04.30hrs\n\n\nneuro - slight improvement with right sided deficit - weak grasp now evident with right hand, can move on bed - right leg some power evident can push against some resistance - speech little improvement although can now answer yes/no to simple questions - repeat CT performed as requested at approx 0100hrs this am - await official results\n\n\ncvs - aim to keep b/p @ 160 for perfussion - b/p 120-160 overnight - dopamine weaned as requested - levo titrated to obtain systolic pressure - levo presently @ 0.2 mcg/kg - h/r stable 50-80 sinus - no further episodes of tachy/ brady /heart block as previous\nborderline temp - observe @ 100\nblood sugras covered as per sliding scale\n\nresp - chest clear sats R/A @ 98\n\ng/i - x2 bouts of nausea - ondanstron with effect - no bowel motion\n\ng/u - urine output 60-80cc per hour much less than previous crstalloids in progress @ 150ccper hour - urine output dropped to 30cc then 20cc per/hr - foley checked for patency. team informed bolus of fluid - some response to observe - presently 600cc pos for today - team aware\n\n\nskin - intact\n\nlines - patent fem central line - rt art line\n\nsocial - partner stayed overnight\n"
},
{
"category": "Nursing/other",
"chartdate": "2196-12-25 00:00:00.000",
"description": "Report",
"row_id": 1332935,
"text": "D: See data, MD notes/orders. Neuro: Alert, perrl. Speech is clear, pt is able to string several words together at times, unable to articulate at others. Right sided weakness remains, she is able to lift/hold right arm, right leg lifts/falls. Left appears strong. Neuro checks now q6hrs per neuromed. SBP parameter reduced with levo gtt to keep sbp >130. CV: SR/no ectopy, sbp 127-133. Pulm: Clear/decr, ra sat 100%. GU: Foley draining 100-200cc/hr clear yellow urine. GI: TF at goal, min residual, abd benign. Skin: Surfaces intact, scattered bruises on legs/upper arms. Soc: Family at bedside most of day. P: Wean levo gtt off as tolerated and transfer to neuro floor. Keep family/pt up to date, validate emotions, reinforce + aspects of situation. R: Levo at 0.12mcg/kg/min, sbp dips to <125 when titrated lower. Family/pt updated by team on rounds with questions/concerns addressed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2196-12-26 00:00:00.000",
"description": "Report",
"row_id": 1332936,
"text": "nursing note 1900hrs 0400hrs\n\n\nneuro - remains stable - able to lift right arm and hold and grip, lift right leg/ move on bed push against pressure - right sided facial droop remains - speech slowly improving - words clearer managing to slowly string words together, occassionally becoming frustrated - able to turn self well in bed - left side remains full power - neuro team satisfied with q6hrly checks - PT involved with rehab ? speech /swallow assessment today\n\n\ncvs - b/p remined@ parameters ordered 125-130 systolic -- slowly weaning levophed - h/r remians stable 60-70bpm - afebrile - blood sugars stable\n\n\nresp - no issues with asthma - able to use inhaler if required by self - sats 98% - occassional cough evident\n\ng/i - no bowel motion since admission - feed @ goal appears to be tollerating unable to check residuals as pedi tube insitu - remains npo until gag assessed\n\ng/u - urine output satisfactory 60-80cc clewar urine per hr via foley\n\n\nskin - numerous bruises on legs ? from initial fall - otherwise intact\n\nlines - central access rt groin satisfactory - art line rt radial satisfactory - x2 peripheral lines removed\n\nsocail - boyfriend stayed overnight - children being taken care of by family - declined any social work input\n\nplan - continue to wean levo - P/T input/rehab ? swallow eval ? call out today\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2196-12-23 00:00:00.000",
"description": "Report",
"row_id": 1332930,
"text": "nursing note 0300hrs - 0600hrs\n\n\nadmit from ER with left MCA occlussion - for dopamine to maintain b/p 160-180 systolic - to monitor neuro status hourly, cycle cardiac enzymes\n\nneuro - amitted with aphasia and no movement on the right side with right sisded facial drooping - continues in the same condition, tpa received in ER @ 2100hrs - full power in left side obeys commands attempting to communicate but unable to verbalise - for repeat CT scan today\n\ncvs - dopamine on admission @ 10mcgs/kg/min - had to increase to 14mcgs /kg [team aware]to try to obtain b/p to set limits - x2 episodes dropping b/p to 100 systolic when feeling nauseated and has vomited x1, zofran as perscibed - hr also dropping when naseated ? had x2 short of episode second degree heart block - self terminated - ekg taken and reviewed by team - second set of cardiac enzymes @ 0400hrs await result first set negative - afebrile - received insulin as per order\nall bloods for clotting sent as requested at 4am\n\nresp - chest clear sats at 98% on 2l\n\ng/i - soft no bowel motion NPO\n\ngu / cryastalloids as persribed - urine output satisfactory\n\nskin - intact\n\nlines - x3 peripheral lines - have repeatadly asked team to review for central line\n\nsocial - boyfriend in attendance\n"
},
{
"category": "Nursing/other",
"chartdate": "2196-12-23 00:00:00.000",
"description": "Report",
"row_id": 1332931,
"text": "Nursing Progress Note MICU A\n\nEvents: Femoral line placed this am secondary to needing central access for pressors. TEE done at bedside, medicated with Fentanyl and Versed. BP done to 110's start 2nd pressors to maintaing bp >160's. Radial aline placed without incident.\n\nNeuro: Alert but lethargic secondary to fentanyl and versed. PEARL, 3mm/bsk. Moving left upper and lower extremities. Is able to squeeze with right and and move right leg on bed. Become very frustrated when asked to move right upper and lower extremities and become tearful.\n\nCV: HR 50-140's, SBP 120-150's. Goal for BP to be greater than 150-160. Dopa @ 12mcg/kg/min. Started on second pressor and then stopped after TEE completed. +palp pedal pulses on bilateral lower extremities. NS w/ 20KCL @ 150cc/hr x 4liters.\n\nResp: LS clear bilaterally. O2 sats 98-100% on 2l. O2 taken off and now 98% on RA.\n\nGI: Abd soft, +bs, -bm.\n\nGU: Foley cath in place with clear yellow urine. UO>80cc/hr.\n\nAccess: R Radial aline in place. Right Femoral line in place. 3 PIV's.\n\nSocial: Boyfriend at bedside, updated on pt's progress by RN and MD.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2196-12-26 00:00:00.000",
"description": "Report",
"row_id": 1332937,
"text": "Nursing Progress Note MICU A\n\nNeuro: Alert and oriented. PEARL, 3mm/bsk. Moving left upper and lower extremities with normal strength. Able to Move both right upper and lower on bed. Right sided facial droop, but is improved since admit. Pt very frustrated about not being able to communicate. Pt word searching and becomes tearful when she commincate her needs.\n\nCV: NSR with no ectopy. HR 68-89. ABP 108-138/56-81. Recieved pt on Levophed and weaned to off this afternoon. Goal to keep BP >110 per neuro med team. IVF NS w/ 20KCL @ 45cc/hr. 500NS bolus given x 2 to increase BP while weaning Levo. +palp pedal pulses bilat. No edema. Remains afebrile. US of Bilat carotids done this afternoon, neg.\n\nResp: LS CTA, O2 sats 95-99% on RA. Denies any SOB.\n\nGI: Abd soft, non-tender, +bs, -bm. Denies any Nausea. Swallow eval. done by speech and swallow. Ordered for soft diet. Pt does pocket small amount of food on right side of mouth. TF stopped and NGT removed today by Neuro med.\n\nGU: Foley cath intact with clear yellow urine. Good amounts of UO.\n\nAccess: Right femoral quad lumen. Right radial aline.\n\nSocial: Boyfriend at bedside most of day, will return later this evening. Updated on pts progress by RN and MD.\n"
},
{
"category": "Nursing/other",
"chartdate": "2196-12-27 00:00:00.000",
"description": "Report",
"row_id": 1332938,
"text": "Micu Nursing Progress Note:\n\nNeuro: alert and oriented x 3. Mildly garbled speech. +Expressive aphasia, but when patient with self is able to find appropriate word. MAE with R<L. Normal strgth on L. R side is able to move fingers, toes, and able to lift forearm and lower leg to brief hold. Pupils equal an reactive.\n\nCV: Rec'd FB 500cc of LR x 2 for sbp 90-105. Target sbp 110. HR 60-70 nsr- no ectopy noted. afebrile. Continues on ivf 45cc/h.\n\nResp: O2 sats 94-97% on RA. Mildly congested productive cough. LS clear but diminished.\n\nGI/GU: advanced to soft solids -attempted to eat dinner again but found she had little appetite. PO intake poor as well. no stool this shift (or for LOS) Urine outpt good.\n\nSocial: S.O. to visit, stayed most of shift.\n\nlabs pending.\n"
},
{
"category": "Echo",
"chartdate": "2196-12-23 00:00:00.000",
"description": "Report",
"row_id": 75295,
"text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA.\nBP (mm Hg): 130/80\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 15:40\nTest: Portable TEE (Complete)\nDoppler: Complete pulse and color flow\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size. No spontaneous echo contrast\nor thrombus is seen in the body of the left atrium/left atrial appendage or\nthe body of the right atrium/right atrial appendage.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. There is\nlipomatous hypertrophy of the interatrial septum. The interatrial septum is\ndynamic, but not frankly aneurysmal. No atrial septal defect or patent foramen\novale is seen by 2D, color Doppler or saline contrast with maneuvers.\n\nLEFT VENTRICLE: Overall left ventricular systolic function is normal\n(LVEF>55%). No masses or thrombi are seen in the left ventricle.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The ascending, transverse and descending thoracic aorta are normal in\ndiameter and free of atherosclerotic plaque.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation. No masses or vegetations\nare seen on the aortic valve.\n\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\nregurgitation. No mass or vegetation is seen on the mitral valve.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: A transesophageal echocardiogram was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was sedated for the TEE. Medications and dosages are\nlisted above (see Test Information section). Local anesthesia was provided by\nlidocaine spray. There were no TEE related complications. 0.2 mg of IV\nglycopyrrolate was given as an antisialogogue prior to TEE probe insertion.\nContrast study was performed with one iv injection of 8 ccs of agitated normal\nsaline at rest. The patient was unable to cooperate with maneuvers. The\npatient appears to be in sinus rhythm.\n\nConclusions:\nThe left atrium is normal in size. No spontaneous echo contrast or thrombus is\nseen in the body of the left atrium/left atrial appendage or the body of the\nright atrium/right atrial appendage. No atrial septal defect or patent foramen\novale is seen by 2D, color Doppler or saline contrast with maneuvers. Overall\nleft ventricular systolic function is normal (LVEF>55%). No masses or thrombi\nare seen in the left ventricle. Right ventricular chamber size and free wall\nmotion are normal. The ascending, transverse and descending thoracic aorta are\nnormal in diameter and free of atherosclerotic plaque. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. No masses or vegetations are seen on the aortic valve.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. No mass or vegetation is seen on the mitral valve. There is no\npericardial effusion.\n\nIMPRESSION: No echocardiographic evidence of cardiac source of embolus.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2196-12-22 00:00:00.000",
"description": "Report",
"row_id": 196361,
"text": "Sinus rhythm\nST junctional depression is nonspecific\n\n"
}
] |
20,064 | 180,633 | Pt. was scheduled to be a same day admit following his surgery but was found to have an elevated INR and had to be admitted and delayed until a lower INR. On pt. was given one dose of Vitamin K and scheduled for the OR the next day. On pt. had a stable INR and was brought to the operating room where he underwent a Redo Ascending Ao replacement (and Bentall procedure) w/ a #28 Gel weave graft. Along with an AVR w/ a #23 . Please see surgical note for full details. Pt. tolerated the procedure well. Total CPB time was 210 minutes with a XCT of 142 minutes. Pt. was brought to the CSRU in stable condition with a MAP 80, CVP 12, PAD 15, 22, and a HR of 80 NSR. He was being titrated on Nitro, Epi, and propofol when transferred. On Post-Op day #1, propofol was weaned. NMB reversed and pt. was weaned off ventilation. After extubation, pt was awake, alert and oriented and had no new deficits(r-sided hemiparesis pre-op). Pt. was now on Nipride and that was planned to be weaned. POD #2 pt. had no new events but was still being titrated on Nipride. Anticoagulation started today. POD #3, pt. was transfused 1 unit of PRBC due to low HCT (25). Still in CSRU secondary to not being able to titrate off Nipride. Chest tubes were removed and Foley replaced. POD #4, HCT increased to 29.1. Pt. had increased DOE though the day with a transient drop in SBP after Lopressor (80's). Neo was started. An echo was performed which showed a small pericardial effusion. CXR showed L. pleural effusion. Suture over CT site due to bleeding. POD #5 Neo was weaned. POD # 6 pt. had PO2 in 90's and was receiving O2 via open face tent. POD #7, repeat CXR performed yesterday revealed increased L pleural effusion. A pigtail catheter was placed over guidewire into left chest which immediately drained 550 cc. Weaned mask to nasal cannula since oxygenation improved. POD #8, CT d/c'd. Later that night pt. was oozing from l. chest tube sight with resolution after stitch placement. Pt. was transferred to telemetry floor. POD #9 & 10: Hemodynamically stable. Pt. is now awaiting INR to increase and still needs an increase and strength and activity before being discharged home. Cont. to receive Coumadin. POD #11, pt doing well and was d/c'd home with VNA services and INR will be checked on and with results sent to Dr. . D/C PE: VS: 99.5 75 SR 120/60 22 Neuro: alert, oriented with r-side hemiparesis Pulm: CTAB Cardiac: RRR Sternum: + Bledding from pacer site, -Erythema Abd: soft, NT/ND +BS Ext: warm, -c/c/e | dp's palpable and pt's by doppler. CONSISTENTLY >2.0; SWAN PULLED BACK TO CVP POSITION. CT dc'd.gi/gu: pt with + bs. : OGT D/C'D W/ETT. Pt presently on 0.75mcg nipride.Good hemodynamics epi weaned off with Svo2 of 68-71% and CO of 6.1-6.9. GU: GOOD UO ENDO: SSI X2. care note - Pt. Resp. RESP. CONT TO ENC I.S., C&DB. K +CA REPLACED. cpt done. COUDE CATH INSERTED. CARE: PT. PTT checks, refer heparin adjustments. BS DIMINISHED BIBASILAR. PALP.PULSES.RESP- 3LNC=98%.LS CLEAR. RR 18-32.BS DIMINISHED BIBASILAR. NIPRIDE @ 1 MCGKGMIN SBP < 120. TRANSFUSED W/ 2 UNITS PRBC'S FOR HCT~24.9. TITRATING TO MAINTAIN BG LEVEL W/IN CSRU PROTOCOL.A/P~LABILE BP. L FEM A-LINE D/C'D IN A.M, SITE D&I. POS PAL PEDAL PULSES BILAT.GI/GUTOL PO FLUIDS WELL. REPEAT PTT @ . NONPRODUCTIVE COUGH.CARDIAC~60'S-70'S W/ OCC PVC'S. CPT X 2. some oozing from around foley of sang drainage.gu: good uop. POSTTRANSFUSION HCT 29.. ALTERED CARDIAC STATUSS: "I'M CHILLY"O: CARDIAC: SR 70'S WITH ISOLATED PAC/PVC NOTED. neuro: perla. + BS. TAKING PO MEDS.GU- ADEQ. dp/pt pulses palp bilat. TO KEEP SBP<130. CT SCANT DRG.GI- ABS SOFT. ADV DIET AND ACTIVITY AS TOL. afebrile. NIPRIDE OFF. HCT 31-28.9. PAIN: PERCOCET 2 TABS X 2 WITH GOOD EFFECT ID: TEMP 99.6 AX NOT REGISTERING ORALLY ABOVE 96. NEURO: UNCHANGED PLEASE SEE FLOW. ABG ->PO2 102.neuro: moves left side with normal strength, right sided body weakness, right hand appears contracted. TRANSIENT NEOP: MONITOR COMFORT, HR AND RYTHYM, SBP-WEAN NEO AS TOLERATED, DSGS, PP, RESP STATUS-PO2/SATS-PULM TOILET, NEURO STATUS, I+O, LABS HCT Q6HR. HYPERTENSIVE. REHAB PLACEMENT. BS- CLEAR AND = BILAT. palpable pedal pulsesresp: advised coughing and dbe's, nothing expectorated. GD OXYGENATION. NOW BEGINNING TO BREATH OVER SET RR. P02 60'S. CURRENTLY CONTROLLED W/ ANTI HYPERTENSIVE REGIMEN.AGGRESSIVE REHAB. HYDRALIZINE/LOPRESSOR FOR HTN. remained on 6LO2/NC sao2 97%. RSBI=63, DESPITE STILL BEING ON PROPAFOL. epicardial wires dc'd. DC CT. percocet x2 given with effect though mild pain still remains.plan: ?thoracotomy. Pt in sinus rhythm with occasional pvc's. C.I. IV MSO4 GIVEN PRIOR TO ACTIVITY W/ MOD RELIEF. both pedal pulses palpable.resp: pleural effusion. Nipride gtt titrated to keep SBP 90-120. pt started on vasotec this am. INCISIONS C+D DSGS CHANGED. + BS.ENDO~INSULIN GTT. csru updatecvs: remained on NSR. slept well.resp: o2 weaned to 4 l nc. pain well-controlled with percocet x2. good oral fluid intakegu: adequate uo. ptt therapeutic.chest/med incision with scant serosang drainage. good bowel sounds. EXTUBATED 0930, NOW ON 4L NC O2 W/ SPO2 99%. lung sounds dim at the basesneuro: right sided body weakness. DOES I.S. NEED TO CHECK K/PTT AT .. LYTES REPLETED PRN.SKIN: INTACT. WEAN TO EXTUBATE WHEN AWAKENED. QUIET PERSONALITY.ASSISTS WITH TURNING.RT ARM FLEXED/RIGID.FOLLOWS COMMANDS.CV- NSR.OCC.PVC. PERICARDIAL EFFUSION, TO MONITOR SERIAL HCTS. lungs coarse and diminished lll. 40 MEQ PO K X 1. CUFF SIG LOWER. SBP GOAL <110. COUMADIN 5 MG PO. continue pulmonary toilet. GI: GOOD APPETITE, BOOST X 2. pearl. Neuro: alert and oriented x 3, mae, right sidded weakness, more weak with right upper extremity then right lower, following commands corrrectly, percocets for pain.Cardiac: nsr in the 70-80's with rare pvc's, sbp's wnl's, palpible pedial pulses, skin warm dry and intact, +2 edema in extremities, afebrile, continues heparin gtt.Resp: on 2 liters nc satting at 100%, lungs are clesr, ct to scn draining scant serosang with no air leak in ct system.Skin: chest with steris is cdi, old medial ct site are approximated and cdi, current ct site with transparent dsd that is cdi.Gi/Gu: tolerating po's, abd soft round and nontender with good bowel sounds, is passing gas, on riss, making good u/o.PLan: increase activity as tolerates, encourage to cough and deep breath and use i/s, monitor ptt's. There has been interval removal of the right internal jugular central line. Retrocardiac opacity persists, obscuring the left hemidiaphragm. Some free intraperitoneal air is seen under the right hemidiaphragm. Right internal jugular catheter was removed, though the sheath remains in place. 2) Persistent stable small right pleural effusion. cpt done. There is nopericardial effusion. No change in the left basilar opacity, which most likely is a combination of left pleural effusion and consolidation and/or atelectasis. Opacity at the right cardiophrenic angle is unchanged. Decreased left pleural effusion. The left upper lung and right lung are well-aerated. The right lung and left upper lung are well aerated. A small right pleural effusion is unchanged. Median sternotomy wires and aortic valve replacement are again seen. The right lung is well aerated. Cardiac and mediastinal contours appear slightly widened, but are stable in the postoperative. The right cardiophrenic angle specifically is unchanged. PAIN/RESP MNGMGNT. IMPRESSION: Right IJ line has been removed. Modest diffuseST-T wave changes with ST segment elevation. UPRIGHT AP CHEST: The patient has been extubated. The retrocardiac opacity and blunting of the left costophrenic angle persist. UPRIGHT AP CHEST: The right internal jugular central venous catheter sheath remains in place, though the catheter itself has been removed. The left costophrenic angle remains blunted. A right internal jugular sheath remains in place. Left lower lobe partial atelectasis is unchanged. There is left lower lobe partial atelectasis. Sternotomy wires and aortic valve replacement are again noted. Improvement in the right basilar opacity. Probable sinus rhythm but consider also ectopic atrial rhythm. The right cardiac border appears somewhat prominent in comparison with prior preoperative exam. IMPRESSION: Postoperative changes as described above. The left chest tube has been removed. BASELINE R SIDED WEAKNESS. The right retrocardiac opacity is slightly improved. csru updatecvs: SB/NSR 58-60 rare pvc's noted k+ supp given. Sternotomy wires and an aortic valve replacement are again noted. IMPRESSION: Free intraperitoneal air under the right hemidiaphragm, which may be due to pigtail removal. There is left lower lobe atelectasis. +bsskin: mediastinal wound oozy, redressed. The opacity at the left base has decreased in the interim, consistent with some drainage of pleural fluid. Left lower lobe atelectasis. + BS +FLATUS. The old fracture of the right clavicle is again noted. DIM RT BASE. Small bilateral pleural effusion. IMPRESSION: Status post left chest tube removal, without pneumothorax detected. IMPRESSION: 1) Moderate left pleural effusion, slightly increased in the interval. 2 PERCOCET X2 WITH EFFECT.PLAN- AM CXR, IF PLEURAL EFFUSION LARGER,TO IR TO TAP IT. 1 MED BRN FORMED BM TODAY.SKIN: L CT SITE CDI W/ TRANSPARANT DSD. There are mediastinal and bilateral chest tubes in place. MEDICATED W/ 2 PERCS PRIOR TO. Preop for aortic root and arch replacement. assess and address dysrhythmias. The findings at the left base may represent residual left pleural effusion and/or associated atelectasis, although an infiltrate cannot be excluded. + BS. There are ET tube and NG tube, and the right IJ line in place.the Tip of the right IJ line is most likely in the right atrium.the Tip of the ET tube is 8 cm above the carina. | 29 | [
{
"category": "Nursing/other",
"chartdate": "2117-01-15 00:00:00.000",
"description": "Report",
"row_id": 1526192,
"text": "PATIENT DOING WELL THIS PM, HCT THIS AM 26 GIVEN 1UPRBC WITHOUT INCIDENT LASIX 40 MG GIVEN AFTERTRANSFUSION. POSTTRANSFUSION HCT 29.. PATIENT OOB TO PT DID WELL, STAYED IN CHAIR FOR APPROX. 3HRS THEN BACK TO BED.. HEPARIN HAD BEEN OFF FOR APPROX. 7HRS, RESTARTED BACK AT 1430 AT 1500U/HR, NO BOLUS GIVEN. PLAN TO GIVE 5MG COUMADIN PO THIS PM.. URINARY MEATUS OOZING LOTS OF CLOTS, TIL THIS PM, CLEANED SMALL AMT. OF BLOOD OOZING. RESP ON 6LNP WITH NONPRODUCTIVE COUGH, USING I/S WITH ENCOURAGEMENT. GU ADEQUATE U/O WITH LASIX, K 4.1 THIS PM TO BE REPLETED.. GI TOLERATING JELLO/CUSTARD /BOOST.. BS ELEVATED ON DRIP UP TO 7U/HR THEN DROPPED OFF, THEN BS AT 1300 130 GIVEN 4UNITS REGULAR SC.. ABD/STERNUM DSG D/I.. CORDIS DCD, ALINE KEPT IN FOR BLOOD DRAW. WIFE INTO VISIT THIS PM..ENCOURAGE ACTIVITY/ADLS...\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-01-15 00:00:00.000",
"description": "Report",
"row_id": 1526193,
"text": "ADDENUM PATIENT OOB TO CHAIR AT 1800 FOR DINNER ATE REALLY WELL TONIGHT, BS PRIOR TO EATING 152 6UNITS REGULAR SC GIVEN.. NEED TO CHECK K/PTT AT .. IF PATIENT ATTEMPTS TO WALK IN AM NEEDS BRACE/AND SHOES TO WALK\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-01-16 00:00:00.000",
"description": "Report",
"row_id": 1526194,
"text": "neuro: perla. alert and oriented. follows commands. right sided weakness from old cva.speech thick at times, but able to communicate well when he takes his time. pain well-controlled with percocet x2. slept well.\nresp: o2 weaned to 4 l nc. sats 95-98%. lungs coarse and diminished lll. chest pt really helps him cough, but he swallows secretions. is raises 500-750cc. becomes sob with minimal exertion, but recovers quickly.\ncv: nsr. sbp contolled with po agents, but iv hydralazine given x1 after ambulated back to bed for persistent sbp> 130s. afebrile. dp/pt pulses palp bilat. heparin drip at 1500 units/hour. ptt therapeutic.chest/med incision with scant serosang drainage. some oozing from around foley of sang drainage.\ngu: good uop. some bloody drainage around foley.\ngi: tol po well. good bowel sounds. blood sugars covered per protocol.\nplan: ambulate with pt today with leg brace and shoes. ? transfer to II soon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-01-16 00:00:00.000",
"description": "Report",
"row_id": 1526195,
"text": "Resp. care note - Pt. remaines on 50% tm, tol ok at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-01-12 00:00:00.000",
"description": "Report",
"row_id": 1526184,
"text": "RESP. CARE:\n PT. PLACED ON VENT. ON ARRIVAL FROM O.R.--SIMV 650 X 14 100% 5P 5PS. FI02 QUICKLY WEANED TO 50%. BS- CLEAR AND = BILAT. NOW BEGINNING TO BREATH OVER SET RR. RSBI=63, DESPITE STILL BEING ON PROPAFOL. WEAN TO EXTUBATE WHEN AWAKENED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-01-12 00:00:00.000",
"description": "Report",
"row_id": 1526185,
"text": "pt arrived from Or around 2100 s/p ascending aortic repair, Bentall Procedure with #25mm St. Jude valve. Pt arrived on nitro , Epi and Propofol With FFP running.\nNeuro: Pt remained sedated overnight on Propofol Starting to move slightly with stimulation.\nResp: Fio2 weaned down to 50% with good po2. Will plan to wean to extubat this am after rounds. Suctioned for scant amount of white secretions.\nC/V:vss pt switched from nitro to nipride for blod pressure control. Goal is 90-110 SBP. Pt presently on 0.75mcg nipride.\nGood hemodynamics epi weaned off with Svo2 of 68-71% and CO of 6.1-6.9. Pt in sinus rhythm with occasional pvc's. all electrolytes treated as ordered. A wires do not work Vwires sense and capture. Chest tubes patent draining serous sangunious from pleural and dark sangunious from medistinal small amounts. Coags with in normal no treatment needed and hct stable at 28.\nGI: OGT draining small amounts of thin bilious colored fluid.\nEndo: pt started on insulin gtt for blood sugar 126 and titrated per protocol.\nGU: pt diuresis large amounts of urine. He had received lasix in the or.\nSkin: chest icision scant amount of drainage on dsg. left groin dsg intact.\nPain: medicated morphine 2mg iv x3 for perceived pain\nSocial: Wife and sons in to see pt last evening updated on condition.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-01-12 00:00:00.000",
"description": "Report",
"row_id": 1526186,
"text": "UPDATE\nCV: NSR, RARE PVC ONLY. C.I. CONSISTENTLY >2.0; SWAN PULLED BACK TO CVP POSITION. PO LOPRESSOR STARTED BUT UNABLE TO WEAN SNP DRIP SIGNIFICANTLY SO LOPRESSOR DOSE INCREASED. SBP GOAL <110. L FEM A-LINE D/C'D IN A.M, SITE D&I. FEET W/ STRONG DISTAL PULSES. CT'S X 5 W/ SM AMTS DK SEROSANG DRNG.\n\nRESP: LUNGS MOSTLY CLEAR(SL COARSE L BASE). EXTUBATED 0930, NOW ON 4L NC O2 W/ SPO2 99%. PT HAS VERY WEAK, INEFFECTIVE AND NONPRODUCTIVE COUGH. STATES HE CAN'T DO ANY BETTER. DOES I.S. W/ VT'S TO 400ML.\n\nNEURO: A&O, COOPERATIVE. SEEMS DISCOURAGED DUE TO WEKNESS AND DISCOMFORT(MOSTLY W/ ACTIVITY). IV MSO4 GIVEN PRIOR TO ACTIVITY W/ MOD RELIEF. OOB TO CHAIR X 2 HRS, ASSIST OF 2. R LEG SL WEAKER THAN L BUT STOOD W/ MIN ASSIST. PT HAS NO CONTROL OVER R ARM WHICH REMAINS PERISTENTLY FLEXED-ABLE TO STRAIGHTEN IT MANUALLY.\n\nG.I.: OGT D/C'D W/ETT. TOL ICE CHIPS AND SIPS H2O.\n\nG.U./RENAL: ADEQ HUO VIA FOLEY. LYTES REPLETED PRN.\n\nSKIN: INTACT. SM AMT OLD SANG DRNG ON STERNAL DRSG.\n\nENDO: CONT ON INSULIN DRIP PER PROTOCOL.\n\nSOCIAL: PT W/ MANY VISITORS TODAY--PT NOW ASKING TO RESTRICT VISITORS TO WIFE AND CHILDREN ONLY. WIFE AWARE AND WILL NOTIFY OTHERS.\n\nA/P: NEEDS BETTER ANTIHYPERTENSIVE CONTROL TO FACILLITATE SNP WEAN. NEXT DOSE LOPRESSOR UP TO 50MG. GD OXYGENATION. CONT TO ENC I.S., C&DB. PAIN MED PRN FOR COMFORT. ADV DIET AND ACTIVITY AS TOL.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-01-16 00:00:00.000",
"description": "Report",
"row_id": 1526196,
"text": "ALTERED CARDIAC STATUS\nS: \"I'M CHILLY\"\nO: CARDIAC: SR 70'S WITH ISOLATED PAC/PVC NOTED. SBP TRANSIENT DROP TO 80'S AFTER 0900 LOPRESSOR. SBP 110'S-160'S THROUGHOUT THE DAY. DID NOT RECIEVE ANY HYDRALAZINE TODAY. 1720 NOTED SBP 80'S PT DENIED COMPLAINT NEO STARTED TO KEEP SBP > 90. ? PERICARDIAL EFFUSION, TO MONITOR SERIAL HCTS. EXTREMITIES WARM,PALP PP. HCT 31-28.9. DSGS D+I, NO DRAINAGE FROM CT DSG. 40 MEQ PO K X 1. OOB TO CHAIR AND AMB X 1 TO WITH ASSIST OF TWO.\n RESP: NOTED INCREASED DOE WITH ANY EXERTION, PT DENIED INITIALLY HOWEVER ADMITTED TO DOE AS DAY PROGRESSED. P02 60'S. O2 VIA NP 6L WITH O2 SAT >95%. BS DIMINISHED BIBASILAR. CPT X 1 DID NOT TOLERATE 2ND ROUND OF CPT.+ LEFT PLEURAL EFFUSION. WEAK COUGH WITH STRONG ENCOURAGEMENT. COUGHING AND SWALLOWING. IS 250-500.\n NEURO: UNCHANGED AS PER FLOW, PERL, RIGHT SIDED ARM MOVES ON BED, RIGHT LEG CAN LIFT AND FALL, STRONG LEFT GRASP AND LEG. OX3. THICK SLOW SPEECH AT TIMES.\n GI: GOOD APPETITE, BOOST X 2. ABS SOFT, NONTENDER, + BOWEL SOUNDS, NO STOOL.\n GU: GOOD UO\n ENDO: SSI X2.\n PAIN: PERCOCET 2 TABS X 2 WITH GOOD EFFECT\n ID: TEMP 99.6 AX NOT REGISTERING ORALLY ABOVE 96.\n SOCIAL: WIFE AND FAMILY INTO VISIT AND UPDATED.\nA: REQUIRING NEO @ 1745, ? PERICARDIAL EFFUSION, + PLEURAL EFFUSION, SOBOE,\nP: MONTIOR COMFORT, HR + RYTHYM, SBP -WEAN NEO AS TOLERATED, CT DRAINAGE, SERIAL HCT Q6HR, PP, RESP STATUS- PULM TOILET-MONITOR ABG, NEURO STATUS, I+O, LABS. AS PER ORDERS. TTE AT 1900.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-01-17 00:00:00.000",
"description": "Report",
"row_id": 1526197,
"text": "csru update\ncvs: remained on NSR. isolated pvc's noted at times. neo continued, sbp 90-130mmhg.hydralazine not given.heparin dose adjusted down to 1400 units/hr, repeat PTT 0800hrs. TTE done, no pericardial effusion found. both pedal pulses palpable.\n\nresp: pleural effusion. remained on 6LO2/NC sao2 97%. dbe's and coughing done, no secretions expectorated. ABG ->PO2 102.\n\nneuro: moves left side with normal strength, right sided body weakness, right hand appears contracted. pearl. oriented. slept for long periods.\n\ngi: on insulin s/s. good oral fluid intake\n\ngu: adequate uo. lasix 40mg ix \n\npain: verbalized pain over left changed, constant, and continues even at rest. percocet x2 given with effect though mild pain still remains.\n\nplan: ?thoracotomy. continue pulmonary toilet. PTT checks, refer heparin adjustments. hemodynamic status monitoring\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-01-19 00:00:00.000",
"description": "Report",
"row_id": 1526201,
"text": "Neuro: alert and oriented x 3, mae, right sidded weakness, more weak with right upper extremity then right lower, following commands corrrectly, percocets for pain.\n\nCardiac: nsr in the 70-80's with rare pvc's, sbp's wnl's, palpible pedial pulses, skin warm dry and intact, +2 edema in extremities, afebrile, continues heparin gtt.\n\nResp: on 2 liters nc satting at 100%, lungs are clesr, ct to scn draining scant serosang with no air leak in ct system.\n\nSkin: chest with steris is cdi, old medial ct site are approximated and cdi, current ct site with transparent dsd that is cdi.\n\nGi/Gu: tolerating po's, abd soft round and nontender with good bowel sounds, is passing gas, on riss, making good u/o.\n\nPLan: increase activity as tolerates, encourage to cough and deep breath and use i/s, monitor ptt's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-01-13 00:00:00.000",
"description": "Report",
"row_id": 1526187,
"text": "NEURO- PLEASANT,COOPERATIVE WITH CARE. QUIET PERSONALITY.ASSISTS WITH TURNING.RT ARM FLEXED/RIGID.FOLLOWS COMMANDS.\n\nCV- NSR.OCC.PVC. NIPRIDE @ 1 MCGKGMIN SBP < 120. NO DECREASE IN BP/HR AFTER 50MG PO LOPRESSSOR.AFEBRILE. PALP.PULSES.\n\nRESP- 3LNC=98%.LS CLEAR. DIM BASES. CT SCANT DRG.\n\nGI- ABS SOFT. + BS. TAKING PO MEDS.\n\nGU- ADEQ. HOURLY U/O.\n\nLABS- PENDING.\n\nENDO- INSULIN GTT @ 4U/HR WITH TIGHT GLUCOSSE CONTROL. GLUCOSE=105.\n\nPAIN- 1 PERCOCET PO WITH EFFECT.\n\nPLAN- WEAN NIPRIDE. INCREASE DIET/ACTIVITY AS TOL. ? DC CT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-01-13 00:00:00.000",
"description": "Report",
"row_id": 1526188,
"text": "7am-3pm update\nneuro: pt alert and orieanted x3. able to follow commands. R arm contracted (from previous stroke)\n\nCV: pt remains in NSR, no ectopy noted. HR in the 60's. Nipride gtt titrated to keep SBP 90-120. pt started on vasotec this am. hydralazine prn for bp control. dp's palpable and pt's by doppler. epicardial wires dc'd. plan to start heparin gtt at 1500 and start coumadin this evening\n\nresp: LS clear with dim bases bil. pt on 4 LC nc, o2 sats 92-100%. pt using IS to 500. pt with weak cough. CT dc'd.\n\ngi/gu: pt with + bs. poor appetite. foley draining clear yellow urine. creatinine 1.5 this am (same as yesterday)\n\nendo: continues on insulin gtt and titrated per protocol\n\nplan: wean nipride gtt to keep sbp 90-120, pulm toleit, pain control, monitor lytes, start heparin gtt at 1500\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-01-14 00:00:00.000",
"description": "Report",
"row_id": 1526189,
"text": "csru update\ncvs: nipride titrated to keep sbp 90-120. hydralazine not indicated as sbp mostly at 100-110mmhg, nipride at 0.5- 1. hr on NSR 70's no ectopics noted. slight elevation in temp ^37.8, medic aware, nothing ordered. palpable pedal pulses\n\nresp: advised coughing and dbe's, nothing expectorated. cpt done. managed up to 500 with IS. lung sounds dim at the bases\n\nneuro: right sided body weakness. oriented. slept adequately in the night\n\ngi: on insulin s/s. needs encouragement with diets and fluids. to have boost supp during lunch and dinner\n\ngu: foley dc'd awaiting to void. +bs\n\npain/soc: pain controlled, no analgesics taken. all procedures explained\n\nplan: pulmonary toilet. encourage ^diets. increase activity as tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-01-14 00:00:00.000",
"description": "Report",
"row_id": 1526190,
"text": "NEURO~A&OX3. FC. MAE. ABLE TO LIFT AND HOLD RIGHT HAND. MORPHINE AND PERCOCET FOR DISCOMFORT. EFFECTIVE. OOB TO CHAIR, GAIT STEADY. TOL WELL.\n\nRESP~ON 35% OFM, AND 4L NP. MAINTAINING SATS OF 97%. LUNGS COARSE UPPER DIM IN BASES VERY DIM IN RLL. NONPRODUCTIVE COUGH.\n\nCARDIAC~60'S-70'S W/ OCC PVC'S. HYPERTENSIVE. NIPRIDE OFF. HYDRALIZINE/LOPRESSOR FOR HTN. TO KEEP SBP<130. FOLLOW ALINE. CUFF SIG LOWER. HEPARIN @ 1300 UNITS/HR. REPEAT PTT @ . COUMADIN 5 MG PO. TRANSFUSED W/ 2 UNITS PRBC'S FOR HCT~24.9. POST HCT~30. POS PAL PEDAL PULSES BILAT.\n\nGI/GUTOL PO FLUIDS WELL. APPETITE POOR. REFUSING FOOD. UNABLE TO INSERT FOLEY THIS AM. BLOOD CLOT NOTED WHEN FOLEY DC'D. COUDE CATH INSERTED. HUGE BLOOD CLOT PASSED. URINE CLEAR AND CONT TO BE CLEAR. GIVEN 40 MG IV LASIX BETWEEN TRANS AND CONT W/ DOSE. + BS.\n\nENDO~INSULIN GTT. TITRATING TO MAINTAIN BG LEVEL W/IN CSRU PROTOCOL.\n\nA/P~LABILE BP. CURRENTLY CONTROLLED W/ ANTI HYPERTENSIVE REGIMEN.\nAGGRESSIVE REHAB. CONT W/ POST OP TEACHING. ? REHAB PLACEMENT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-01-17 00:00:00.000",
"description": "Report",
"row_id": 1526198,
"text": "ALTERED CARDIAC STATUS\nS: \"I'M NOT GETTING UP YET\"\nO: CARDIAC: SR 100-80'S, LOPRESSOR DECREASED TO -12 NOON LOPRESSOR HELD, LASIX DECREASED TO 20 MG , SBP REQUIRED NEO PRESENTLY OFF. INCISIONS C+D DSGS CHANGED. EXTREMITIES WARM , PALP PP. HYDRALAZINE NOT GIVEN DUE TO SBP <100. HCT STABLE AT 29. K +CA REPLACED.\n RESP: OPEN FACE TENT @ 50% WITH PO2 IN THE 90'S, COUGH WITHOUT RAISING-PT STATES RAISED YELLOW -TO SEND FOR C+S IF PRODUCES AGAIN. O2 SAT PRESENTLY 96 ON 6LNP. RR 18-32.BS DIMINISHED BIBASILAR. CPT X 2.\n NEURO: UNCHANGED PLEASE SEE FLOW. CALM PLEASANT, MORE ENGAGING TODAY.\n SKIN: INTACT 2 PURPLE LINES NOTED ON BACK ? DUE TO PADS BEING ROLLED UNDER BACK-NO CHANGE FROM YESTERDAY. OOB TO CHAIR FOR 5 HOURS. AMBULATED TO TOLERATED MUCH BETTER THAN YESTERDAY.\n GI: GOOD APPETITE, ABD SOFT,NONTENDER, + BOWEL SOUNDS, NO STOOL.\n GU: GOOD UO TO RECIEVE LASIX DOSE @ 1815\n ENDO: SSI X2\n PAIN: 2 PERCOCET X2 WITH GOOD EFFECT,\n ID: TEMP MAX AX 99.3 UA + C+S SENT\n SOCIAL: WIFE AND CHILDREN INTO VISIT AND UPDATED\nA: BETTER OXYGENATION WITH OPEN FACE TENT, AWAITING ? IR IN AM TO TAP EFFUSION TO CHECK CXR IN AM. TRANSIENT NEO\nP: MONITOR COMFORT, HR AND RYTHYM, SBP-WEAN NEO AS TOLERATED, DSGS, PP, RESP STATUS-PO2/SATS-PULM TOILET, NEURO STATUS, I+O, LABS HCT Q6HR. AS PER ORDERS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-01-18 00:00:00.000",
"description": "Report",
"row_id": 1526199,
"text": "NEURO-QUIET,COOPERATIVE WITH CARE. BASELINE MOVEMENT OF EXTREMETIES.VOICING NEEDS.\n\nCV-NSR.SBP DECREASAED TO 98 AFTER TAKING HYDRALAZINE/LOPRESSOR .T-MAX=100.7-> 650MG TYLENOL PO.HEPARIN @ 1400U/HR PTT=54.9 HCT=27.9\n\nRESP-MOUTH BREATHER AT NOC. 50%OFM =98%. DIM RT BASE. NON-PRODUCTIVE COUGH.\n\nGI- ABD SOFT. + BS +FLATUS. TAKIING MEDS WITHOUT DIFFICULTY.\n\nGU- ADEQ. HOURLY U/O. RESPONDS WELL TO LASIX IV.\n\nLABS- GLUCOSE- 123,COVERED WITH 2UNITS REG. INS SC.\n\nPAIN-C/O STERNAL PAIN WITH MOVEMENT. 2 PERCOCET X2 WITH EFFECT.\n\nPLAN- AM CXR, IF PLEURAL EFFUSION LARGER,TO IR TO TAP IT. PAIN/RESP MNGMGNT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-01-18 00:00:00.000",
"description": "Report",
"row_id": 1526200,
"text": "NEURO: A+OX3, PLEASANT AND COOPERATIVE. BASELINE R SIDED WEAKNESS. GIVEN 2 PERCOCET TWICE FOR PAIN W/ GOOD EFFECT.\n\nCV: NSR 80'S. NO ECTOPY. STARTED ON ZESTRIL PO TODAY. SBP 88-92. PT ALSO HYDRALZINE AND PO LOPRESSOR.\n\nRESP: PT L PLEURAL CT W/ PIGTAIL DRAIN FROM NP. NO PROBLEMS. MEDICATED W/ 2 PERCS PRIOR TO. PT 590CC SERO SANG DRAINAGE IMMEDIATELY. OXEGENATION IMPROVED. PT WEANED TO 2L NP. MAINTAINING HIGH SPO2'S.\n\nGU: FOLEY PATENT. GOOD CLEAR YELLOW UOP.\n\nGI: SOFT NT ABD. + BS. GOOD APPETITE. 1 MED BRN FORMED BM TODAY.\n\nSKIN: L CT SITE CDI W/ TRANSPARANT DSD. CHEST AND L GROIN INCISION ARE CDI AND OTA W/ STERI STRIPS\n\nSOCIAL: FAMILY IN AT BEDSIDE.\n\nA/P IMPROVED RESP STATUS S/P CT. RECHECK PTT @ , START COUMADIN THISD PM, TO DECREASE HYDRALAZINE DOSE, CONTINUE CARE AS PLANNED. PREPARE FOR TRANSFER TO FLOOR TOMORROW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-01-15 00:00:00.000",
"description": "Report",
"row_id": 1526191,
"text": "csru update\ncvs: SB/NSR 58-60 rare pvc's noted k+ supp given. sbp 100-130 hydralazine,metoprolol. afebrile. palpable pedal pulses.\n\nresp: encouraged dbe's and coughing, nothing expectorated. cpt done. sao2 97-100%. coarse breath sounds on both upper lobes, dim on the bases.\n\nneuro: right sided body weakness. oriented. right hand unable to grasp or hold. right arm lifts and holds.\n\ngi: poor appetite. encouraged to take boost, took approx 80 mls. on insulin s/s\n\ngu: excessive uo. lasix 40 . +bs\n\nskin: mediastinal wound oozy, redressed. penile bleeding. pain controlled\n\nsoc: family visited and updated. all procedures explained to pt.\n\nplan: continue strict pulmonary hygiene. monitor v/s. assess and address dysrhythmias. ^ mobility. encourage ^ food intake\n\n\n\n\n"
},
{
"category": "Echo",
"chartdate": "2117-01-16 00:00:00.000",
"description": "Report",
"row_id": 67846,
"text": "PATIENT/TEST INFORMATION:\nIndication: Tamponade.\nBP (mm Hg): 121/53\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 20:26\nTest: Portable TTE (Focused views)\nDoppler: No doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%).\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTIC VALVE: BIleaflet aortic valve prosthesis (AVR).\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nLeft ventricular wall thickness, cavity size, and systolic function are normal\n(LVEF>55%). A bileaflet aortic valve prosthesis is present. There is no\npericardial effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-01-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 856244,
"text": " 7:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: CHRONIC PERICARDIAL\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p redo Bentall with bleeding from CT site on\n anticoagulation\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest compared to previous dated one day earlier.\n\n CLINICAL INDICATION: Bleeding from chest tube site.\n\n Cardiac and mediastinal contours appear slightly widened, but are stable in\n the postoperative. A right internal jugular sheath remains in place. No\n chest tube is identified. There is a moderate-sized left pleural effusion,\n which is slightly increased in size in the interval. A small right pleural\n effusion is unchanged. Retrocardiac opacities are slightly worsened in the\n interval.\n\n IMPRESSION:\n\n 1) Moderate left pleural effusion, slightly increased in the interval.\n Hemothorax cannot be excluded given history of anticoagulation and bleeding.\n\n 2) Persistent stable small right pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-01-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 856408,
"text": " 8:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change in effusion\n Admitting Diagnosis: CHRONIC PERICARDIAL\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48M s/p redo Bentall with bleeding from CT site on anticoagulation\n\n REASON FOR THIS EXAMINATION:\n interval change in effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 48-year-old man with bleeding from chest tube site, on\n anticoagulation, question interval change in effusion.\n\n AP portable chest at 8:45 a.m.: Compared to prior study one day\n earlier, there is an increase in the left-sided pleural effusion. Opacity at\n the right cardiophrenic angle is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-01-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 855813,
"text": " 9:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: postop film\n Admitting Diagnosis: CHRONIC PERICARDIAL\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p redo Bentall\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 48-year-old status post surgery.\n\n AP portable study of the chest on at 21:52 hours.\n\n Comparison is made to prior study of . Since the prior study, there\n has been placement of an aortic valve. There are mediastinal and bilateral\n chest tubes in place. There is left lower lobe atelectasis. There are ET\n tube and NG tube, and the right IJ line in place.the Tip of the right IJ line\n is most likely in the right atrium.the Tip of the ET tube is 8 cm above the\n carina. Except for the atelectasis of the left lower lobe, the remainder of\n the lungs are clear. There is no evidence of pneumothoraces.\n\n IMPRESSION:\n\n Postoperative changes as described above. Left lower lobe atelectasis.\n Multiple lines and tubes in place.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-01-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 856484,
"text": " 10:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: CHRONIC PERICARDIAL\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48M s/p redo Bentall and pigtail placement\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post Bentall revision and pigtail catheter placement.\n Evaluate for pneumothorax.\n\n COMPARISON: .\n\n UPRIGHT AP CHEST: There has been interval placement of a pigtail catheter\n into the left lateral chest. No pneumothorax is detected. The opacity at the\n left base has decreased in the interim, consistent with some drainage of\n pleural fluid. Some opacity persists at the left base. The cardiac and\n mediastinal contours have not significantly changed compared to one day ago.\n The right cardiophrenic angle specifically is unchanged. The right lung and\n left upper lung are well aerated. Sternotomy wires and an aortic valve\n replacement are again noted.\n\n IMPRESSION:\n\n Interval pigtail catheter placement at the left lateral chest. Decreased left\n pleural effusion. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-01-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 856113,
"text": " 6:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ro pneumo\n Admitting Diagnosis: CHRONIC PERICARDIAL\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p redo Bentall\n\n REASON FOR THIS EXAMINATION:\n ro pneumo\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Status post Bental revision.\n\n COMPARISON: .\n\n UPRIGHT AP CHEST: The right internal jugular central venous catheter sheath\n remains in place, though the catheter itself has been removed. Median\n sternotomy wires and aortic valve replacement are again seen. No pneumothorax\n is detected. The right cardiac border appears somewhat prominent in\n comparison with prior preoperative exam. The finding may be related to\n postoperative change, though pericardial hematoma/effusion could be\n considered. The appearance of the lung fields is unchanged from yesterday.\n There are probably bilateral small pleural effusions layering posteriorly.\n\n IMPRESSION:\n\n 1. Right internal jugular catheter was removed, though the sheath remains in\n place. No pneumothorax detected.\n 2. Prominent right heart border. The finding may represent postoperative\n change, though pericardial hematoma/effusion could be considered.\n 3. Small bilateral pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-01-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 856033,
"text": " 11:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O PTX S/P CT'S REMOVED\n Admitting Diagnosis: CHRONIC PERICARDIAL\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p redo Bentall\n\n REASON FOR THIS EXAMINATION:\n R/O PTX S/P CT'S REMOVED\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post chest tube removal. Evaluate for pneumothorax.\n\n COMPARISON: .\n\n UPRIGHT AP CHEST: The patient has been extubated. The right internal jugular\n central venous catheter is again seen, with the tip overlying the right\n atrium. The left chest tube has been removed. No pneumothorax is detected.\n There is opacity at the left base, which may be related to a small left\n effusion with associated compressive atelectasis or rather an infiltrate. The\n right lung is well aerated.\n\n The patient is post-median sternotomy and aortic valve replacement. The old\n fracture of the right clavicle is again noted.\n\n IMPRESSION:\n\n Status post left chest tube removal, without pneumothorax detected. The right\n IJ line overlies the right atrium.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-01-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 856356,
"text": " 12:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion/infiltrate\n Admitting Diagnosis: CHRONIC PERICARDIAL\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48M s/p redo Bentall with bleeding from CT site on anticoagulation\n REASON FOR THIS EXAMINATION:\n eval for effusion/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 48-year-old man with bleeding from chest tube site, on\n anticoagulation. Please evaluate for effusion or infiltrate.\n\n AP PORTABLE UPRIGHT CHEST AT 1:00 P.M.: Comparison is made to study\n of one day earlier at 7:30 in the morning. There has been interval removal of\n the right internal jugular central line. The right retrocardiac opacity is\n slightly improved. No change in the left basilar opacity, which most likely\n is a combination of left pleural effusion and consolidation and/or\n atelectasis.\n\n IMPRESSION:\n\n Right IJ line has been removed. No pneumothorax. Improvement in the right\n basilar opacity. No change in the left basilar opacity and pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-01-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 856600,
"text": " 9:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: CHRONIC PERICARDIAL\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48M s/p redo Bentall and pigtail removal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 48-year-old status post pigtail removal. Evaluate for\n pneumothorax.\n\n FINDINGS:\n\n Comparison is made to the prior study of a day earlier. Some free\n intraperitoneal air is seen under the right hemidiaphragm. There is left\n lower lobe partial atelectasis. No evidence of pneumothoraces. The right\n lung is clear. The appearance of the lung fields have not changed since the\n prior study. Cardiomegaly and arteriosclerotic changes involving thoracic\n aorta as well as postoperative changes are again noted.\n\n IMPRESSION:\n\n Free intraperitoneal air under the right hemidiaphragm, which may be due to\n pigtail removal.\n\n Left lower lobe partial atelectasis is unchanged.\n\n No evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-01-21 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 856859,
"text": " 11:34 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o ptx, eff\n Admitting Diagnosis: CHRONIC PERICARDIAL\\ REDO AORTIC ROOT/ARCH REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with known type 1 aortic dissection pre-op for aortic root and\n arch replacement.\n REASON FOR THIS EXAMINATION:\n r/o ptx, eff\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Known Type I aortic dissection. Preop for aortic root and arch\n replacement.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST: The appearance of the chest is unchanged compared to\n two days ago. The cardiac silhouette is unchanged from several prior\n postoperative exams. The mediastinal contours are also unchanged. There is\n no vascular congestion present. Retrocardiac opacity persists, obscuring the\n left hemidiaphragm. The left costophrenic angle remains blunted. The left\n upper lung and right lung are well-aerated. The findings at the left base may\n represent residual left pleural effusion and/or associated atelectasis,\n although an infiltrate cannot be excluded. Sternotomy wires and aortic valve\n replacement are again noted. No pneumothorax.\n\n The previously described free air beneath the right hemidiaphragm is not\n appreciated on today's study. Please correlate clinically.\n\n IMPRESSION:\n 1. Unchanged appearance of the chest compared to the last several exams. No\n evidence of failure. The retrocardiac opacity and blunting of the left\n costophrenic angle persist.\n 2. Free air under the right hemidiaphragm is not appreciated on the current\n study.\n\n"
},
{
"category": "ECG",
"chartdate": "2117-01-12 00:00:00.000",
"description": "Report",
"row_id": 150087,
"text": "Probable sinus rhythm but consider also ectopic atrial rhythm. Modest diffuse\nST-T wave changes with ST segment elevation. Clinical correlation is suggested\nfor possible pericarditis. Since the previous tracing of ectopic atrial\nrhythm is suggested and further ST-T wave changes are present.\n\n"
}
] |
6,658 | 137,737 | She was admitted to the Trauma Service. She was immediately taken to the operating room for exploratory laparotomy, LOA, splenectomy and small bowel resection. There were no intra-operative complications; she was taken to the Trauma ICU where she was monitored closely. She was eventually weaned and extubated and then transferred to the regular nursing unit. She did receive the appropriate vaccinations with the exception of the meningococcal as this was not available in the hospital pharmacy; she will need to follow up with her primary care physician to receive the final of the three vaccinations that are required post splenectomy. She continued to require supplemental oxygen postoperatively; reportedly she had oxygen requirements in the past from a previous surgery and was discharged to home with this and ultimately was weaned off. She was diuresed with Lasix as well with improvement in her respiratory status. She will be discharged home with oxygen therapy. She also developed a distal abdominal wound cellulitis and is being discharged home on 10 days Keflex. Physical and Occupational therapy worked with her and have recommended home with services. | No BM.GU - Adequate UOP via foley.Endo - RISS, blood sugars trending down.A - Stable neuro exam. Shortness of breath.Height: (in) 63Weight (lb): 240BSA (m2): 2.09 m2BP (mm Hg): 118/62HR (bpm): 93Status: InpatientDate/Time: at 16:11Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). Pt had clear though slightly diminished BS bilaterally post extubation. LS clear and diminished at bases. Resolved with ambu, lavage and suctioning. Mildlydilated ascending aorta. addendum: pt phosphorou level low.. neutrophos ordered po. MSO4 prn abd pain with effect.RESP: LS CTA and diminished. BP 100s-140s/40s-70s.HEME: Given 2u PRBC's for hct 21.2; post transfusion hct 28.6.GI: Abd obese, bowel sounds hypoactive. Peripheral pulses intact.Resp - Tolerating vent settings on propofol. ID - pt low temps PO, but normal axillary. Inhalers as ordered and prn for intermittent wheezing.GI/GU: Abd. R IJ TLC line intact.OTHER: Possible d/c to floor today. Normal regional LV systolic function. The mitral valve appears structurally normal with trivialmitral regurgitation. Right ventricular chamber size and free wall motion arenormal. Lytes repleted (awaiting order for phos repletion).ID: Afebrile. Pboots on.GI: Abd obese, bowel sounds absent.GU: Low u/o at same time of hypotension which was resolved with 500cc bolus. There is an anteriorspace which most likely represents a fat pad, though a loculated anteriorpericardial effusion cannot be excluded.IMPRESSION: Normal global and regional biventricular systolic function. Abx course completed.ENDO: FS covered per RISS.SKIN: Back/buttocks with no breakdown noted. Clear lung sounds in upper lobes, diminished in bases, coughs and clears, pt using suction to clear mouth. Improved moderately since transfusion.CV: HR 80s-100s SR/ST, no ectopy noted. She alert to lethagic but easily arousable and oriented x3, mae, fc, pupils pinptresp pt with discordiant breathing all shift lungs crackles 3/4 up on right and coarse and diminished lt abg on 4lnp 7.31/55/114/0/29 cxr taken relatively unchanged from earlier in the day. cv: hr to 102 st no ectopy. No abx.ENDO: FS covered per RISS.SKIN: Grossly intact, no breakdown noted.SOCIAL: Multiple family members in today and supportive.ASSESSMENT: Pt s/p MVC with spenelctomy and .Current nsg issues:Fluid volume overload leading to DOE.Pain.Anemia.PLAN: Cont to monitor vs, labs with serial hcts, lasix gtt as ordered, replete lytes, analgesia, encourage moblity, encourage C+DB. BS essentially clear, but decreased in the bases. Generalized + edema. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.Conclusions:The left atrium is normal in size. Reaches for ETT with BUE when unrestrainted. Antibiotics finished peri-op. sbp 92-117/gi: tolerating clear liquids. ABG with slight metabolic acidosis. Repeat abg at 0500 on 2lnp 7.34/54/90/1/30cvs HR 103-114 given lopressor 5mg iv q 6hr bp 124/55-140/55 hct 21.9/22 color white, cpk drawn 650 mb 5 troponin <.01 ekg taken cvp 20gi abd obese bs absent staples in place no drainagegu u/o >30 bun 10 cr .7 on lasix presently at 4mg q hr + > 6liters losendo requiring ss insulinskin ecchymotic lt arm and rt lega. The cardiac silhouette, mediastinal and hilar contours appear unchanged.N o evidence of pneumothorax. There is a mildly tortuous atherosclerotic aorta. AP pelvis with overlying trauma board demonstrates only mild demineralization. Mild degenerative changes are noted, particularly at the C3/4 level without thecal sac compression. There is probable mild cardiomegaly with an unfolded aorta. However, there does appear to be a focus of periosteal reaction and cortical lucency seen along the proximal fibular shaft, incompletely visualized. Right hilar atelectasis. Repeat HCT sent.A - Resp status stable. There is probable diffuse osteopenia. The pleural parenchymal findings are unchanged. Equivocal minimal blunting of the costophrenic angles, doubt gross effusion. Mild degenerative changes throughout. Calcification of the abdominal aorta without evidence of aneurysmal dilatation. Edema difficult to assess.Resp - Lungs essentially clear, occ wheezing, dim in bases. Right IJ central line tip over mid/distal SVC. Persistent bibasilar atelectasis with left-sided small pleural effusion. Occ dyspneic with exertion. Somewhat wide appearance to the mid mediastinum appears to be related to uncoiling of the thoracic aorta and slight rotation of the patient to the right. Persistent bibasilar atelectasis, with possible small left-sided pleural effusion. Mild prominence of right paratracheal soft tissues likely reflects vascular structures in someone of this age. IMPRESSION: Interval placement of ET tube in satisfactory position. Right IJ approach central venous catheter is unchanged with its tip projecting over the SVC. Peripheral pulses palpable. therefore it is solid and not a terminal meningeal cyst). There is mild circumferential maxillary mucosal thickening without air-fluid levels. There is a small fluid levels within the sphenoid sinuses without evidence of displaced fracture, which may relate to intubation and supine positioning. Albuterol nebs PRN. Mild degenerative change of the left hip is seen. FINDINGS: There is normal alignment of the lumbar vertebral bodies without evidence of fracture or traumatic listhesis. MAE.CV - NSR, rate 90s without ectopy. The tip overlies the mid/distal SVC. Tender to palpation at incision. Mild bibasilar atelectasis is worsened. IMPRESSION: Underlying emphysema with no acute pulmonary process. Note is again made of prominent radiodensity of the right hilum. The left costophrenic angle is mildly blunted, may represent small pleural effusions. Endotracheal and nasogastric tubes limit the evaluation of prevertebral soft tissue swelling. Interval removal of the ET and NG tubes. Again seen are the ET and NG tubes. IMPRESSION: 1) No acute fracture or malalignment. IMPRESSION: 1) No acute fracture or malalignment. The mediastinum is within normal limits allowing for technique. TECHNIQUE: Axial MDCT images through the lumbosacral spine without IV contrast with coronal and sagittal reformats. Stable appearance of the right IJ-approach central venous catheter with its tip projecting over the SVC. FINDINGS: Since the prior examination, patient has been extubated and the NG tube has been removed. Persistent bibasilar atelectasis. Heart size top normal. No superimposed edema is appreciated. The soft tissues are within normal limits. CHEST, SINGLE AP VIEW. CHEST, SINGLE AP VIEW. IMPRESSION: No significant interval changes. | 32 | [
{
"category": "Echo",
"chartdate": "2123-10-19 00:00:00.000",
"description": "Report",
"row_id": 82620,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Shortness of breath.\nHeight: (in) 63\nWeight (lb): 240\nBSA (m2): 2.09 m2\nBP (mm Hg): 118/62\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 16:11\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta. No 2D or\nDoppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%), without regional wall\nmotion abnormalitiesl. Right ventricular chamber size and free wall motion are\nnormal. The ascending aorta is mildly dilated. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion and no aortic\nregurgitation. The mitral valve appears structurally normal with trivial\nmitral regurgitation. There is no mitral valve prolapse. There is an anterior\nspace which most likely represents a fat pad, though a loculated anterior\npericardial effusion cannot be excluded.\n\nIMPRESSION: Normal global and regional biventricular systolic function. Mildly\ndilated ascending aorta.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-10-17 00:00:00.000",
"description": "Report",
"row_id": 1349963,
"text": "TSICU Nursing Progress Note\nNeuro - Pt arouses to voice, nodds to questions, mouthing words at times. PERRL. MAE. C-collar and logroll precautions maintained.\n\nCV - NSR to ST without ectopy. MBP maintained above 65 with fluid boluses when needed. Lactate trending down. Peripheral pulses intact.\n\nResp - Tolerating vent settings on propofol. Not breathing over vent most of shift. ABG WNL. Minimal secretions.\n\nGI - Abdomen soft, tender. Dressing D&I. OR dressing intact. Absent BS. No BM.\n\nGU - Adequate UOP via foley.\n\nEndo - RISS, blood sugars trending down.\n\nA - Stable neuro exam. Metabolic acidosis improving.\n\nP - Awaiting orders for radiology. Clear back when able. Wean vent as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-10-17 00:00:00.000",
"description": "Report",
"row_id": 1349964,
"text": "Respiratory Care Note\nPt received on AC as noted with no changes this shift. BS essentially clear, but decreased in the bases. Atrovent MDI given with no change in BS. ABG's had been metabolically acidotic earlier this shift, but are now within normal limits. Plan to continue on current settings at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-10-18 00:00:00.000",
"description": "Report",
"row_id": 1349965,
"text": "NPN 1900-0700\nNEURO: Pt sedated on propofol. When lightened follows commands and MAE. Communicates via nodding. Pt requring 2-4mg MSO4 for abd pain q 2-3 hrs; dose increased this AM. CT of neck, T and L spine done. Xray of left shoulder and RLE done.\n\nRESP: No vent changes made. Pt had one episode where sats decreased to 88-89% after turning. Resolved with ambu, lavage and suctioning. ABG WNL.\n\nCV: HR 60s-90s NSR no ectopy noted. 500LR bolus x 1 for MAP below 60 and decreasing CVP. Goal is MAP greater than or equal to 65.\n\nHEME: Hct 23 from 25. Sq heparin cont. Pboots on.\n\nGI: Abd obese, bowel sounds absent.\n\nGU: Low u/o at same time of hypotension which was resolved with 500cc bolus. AM lytes WNL.\n\nID: Afebrile. Abx course completed.\n\nENDO: FS covered per RISS.\n\nSKIN: Back/buttocks with no breakdown noted. Ecchymosis to left scapula and right thigh.\n\nSOCIAL: No contacts from family this shift.\n\nASSESSMENT: Pt s/p MVC, splenectomy and .\n\nCurrent nsg issues:\nBP alteration requiring fluid boluses.\nPain.\n\nPLAN: Cont to monitor VS, maintain BP as per orders, monitor labs and hct trends, pain management, ?wean sedation and vent if TLS cleared today.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-10-18 00:00:00.000",
"description": "Report",
"row_id": 1349966,
"text": "Resp: pt on a/c 18/550/+5/40%. Alarms on and functioning. Ambu/syringe @ hob. BS are diminished bilaterally. Suctioned for small amounts of thick secretions. MDI's administered 2P Atr with no adverse reactions. Trip to CT without incident, with results pending. AM ABG 7.40/41/75/26 with no changes noc. RSBI=no resps. Will continue full vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-10-18 00:00:00.000",
"description": "Report",
"row_id": 1349967,
"text": "T-SICU Nsg Note\n Events - C-spine cleared, collar off\n TLS spine cleared, pt sitting\n Vent weaned to 5 CPAP and then extubated at 0910\n\nROS - Neuro - pt alert, O x 3 (after she asked what day it was), moving all limbs. Pain all over, but especially L chest (due to rib fx)\n\nNote to continue\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-10-18 00:00:00.000",
"description": "Report",
"row_id": 1349968,
"text": "Resp Care\nPt extubated this morning to 50% cool aerosol. Pt orally suctioned prior to extubation for mod amt of bloody secretions, no secretions noted down ETT. Pt had audible cuff leak. Pt had clear though slightly diminished BS bilaterally post extubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-10-21 00:00:00.000",
"description": "Report",
"row_id": 1349975,
"text": "TSICU NPN:\nNEURO: A&Ox3. Pleasant and cooperative. MAE. PERL 3mm and brisk. Complaining of incisional pain and L shoulder pain- given 4mg sq MSO4 with good effect.\nCV: Afeb. HR 80s-100s SR/ST, no ectopy noted. On lopressor IV q6hr. BP stable via NIBP cuff on L forearm. CVP 7-9. Skin warm and dry with palpable pedal pulses bilaterally. Generalized + edema. Lasix gtt d/c'd and continues on acetazolamide po bid.\nRESP: Continues on 3L NC with O2 Sat >95%. LS clear and diminished at bases. Intermittent cough. Pt. +DOE but sats stable. Inhalers as ordered and prn for intermittent wheezing.\nGI/GU: Abd. obese, soft with hypoactive bowel sounds. Tolerating clear liquid diet, no nausea. Foley draining clear light yellow urine >100cc/hr.\nSKIN: Midline abd. incision with staples, clean, dry and intact- open to air. No swelling or drainage. Ecchymosis to L upper arm/shoulder and R upper thigh. Coccyx and backside intact. R IJ TLC line intact.\nOTHER: Possible d/c to floor today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-10-21 00:00:00.000",
"description": "Report",
"row_id": 1349976,
"text": "NURSING NOTE 7AM TO 1PM\nPATIENT STABLE AND TRANSFERED TO 915, TRANSFER NOTE FAXED AND SENT. REPORT GIVEN VERBALLY TO . PATIENT SENT WITH DENTURES NO OTHER PERSONAL ITEMS WITH PATINET AT HOSPITAL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-10-18 00:00:00.000",
"description": "Report",
"row_id": 1349969,
"text": "T-SICU NSg note cont.\n Medicated for pain with 2mg morphine sulfate IVP with some relief and dozing. Pt has grimace on face even while asleep.\n CV - NSR 90's- to sinus tach 125. BP 125-145sys and MAP maintained > 65. On metoprolol 5mg IVP q 6 hrs. Pt on lisinopril at home.\n Resp - resp rate slow, . Clear lung sounds in upper lobes, diminished in bases, coughs and clears, pt using suction to clear mouth. O2 sats on 4 l NC 90-97%, sats drifted down this am to 86%, and face tent with cool neb added at times - pt does not like face tent and has not needed it this eve.\n GU - lasix drip started. K+ repleted, and last level 4.6 Pt is still net positive for today, discuss with HO about increasing lasix drip rate.\n GI - pt has tolerated ice chips and sips of water. Abd obese, hypoactive bowel sounds heard this eve. Abd incision clean Dry & closed with staples.\n Heme - Hct down to 22 this eve despite some diuresis. REcheck Hct at MN. Pt pale.\n ID - pt low temps PO, but normal axillary. Antibiotics finished peri-op.\n Endo - sliding scale insulin for blood glucose 125 to 180.\nA: O2 sats have improved this eve. Pt sore and uncomfortable. Pt's daughters in to visit today. Pt alert and articulating needs.\nP: Check Hct at 00. monitor u/o and lytes. Informational support to pt & family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-10-19 00:00:00.000",
"description": "Report",
"row_id": 1349970,
"text": "c/o of pain especially left upper quadrant and arm. Denies cp, dizziness, sob\no. Neuro medicated morphine 4mg iv x3 with good relief pt needing less pain med as night went on. She alert to lethagic but easily arousable and oriented x3, mae, fc, pupils pinpt\nresp pt with discordiant breathing all shift lungs crackles 3/4 up on right and coarse and diminished lt abg on 4lnp 7.31/55/114/0/29 cxr taken relatively unchanged from earlier in the day. Lasix increased to 4mg IV qhr, pt given albuteral and atrovent nebs wheezing with exertion. Repeat abg at 0500 on 2lnp 7.34/54/90/1/30\ncvs HR 103-114 given lopressor 5mg iv q 6hr bp 124/55-140/55 hct 21.9/22 color white, cpk drawn 650 mb 5 troponin <.01 ekg taken cvp 20\ngi abd obese bs absent staples in place no drainage\ngu u/o >30 bun 10 cr .7 on lasix presently at 4mg q hr + > 6liters los\nendo requiring ss insulin\nskin ecchymotic lt arm and rt leg\na. fluid overload, anemic tachycardic\np. continuing lasix goal neg 500-1liter monitor lytes replete prn, cr bun, ? pt benefit from 1-2uprbc given her age, +obesity, +HTN, monitor hcts, nebs prn, medicate for pain prn, encourage incentive spironmeter, cdb\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-10-17 00:00:00.000",
"description": "Report",
"row_id": 1349961,
"text": "Resp: pt intubated via OR Ett 7.0 retaped and secured 19 @ lip. Place on a/c 18/550/+5/50%. Alarms on and functioning. Ambu/syringe @ hob. Bs are coarse bilaterally. Suctioned for small to moderate amounts of thick tan secretions. MDI's administered as ordered 2P Atr with no adverse reactions. Vent changes to decrease fio2 to 40%. AM ABG 7.28/41/107/20. No further changes noted. Will continue full vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-10-17 00:00:00.000",
"description": "Report",
"row_id": 1349962,
"text": "NPN 0100-0700\n77 yo restrained passenger involved in MVC, car T-boned on driver's side. Pt went to hospital in where CT showed free fluid in abd and suspected splenic lac. Trans to and taken to OR for ex lap...resulted in splenectomy and (pt was intubated in OR at ). Pt also has left rib fx's, large area of ecchymosis to right scapula and right thigh. Initial head CT neg.\n\nNEURO: Pt intubated and sedated on propofol. When lightened, pt follows all commands and MAE. Reaches for ETT with BUE when unrestrainted. MSO4 prn abd pain with effect.\n\nRESP: LS CTA and diminished. Vented on assist control 550 x 14 5peep 50%, overbreaths 4-6 breaths. ABG with slight metabolic acidosis. Sats WNL.\n\nCV: HR 80s-100s SR/ST no ectopy noted. Arrived hypotensive with BP 80s/40s, however has responded to blood and IVF. Goal MAP > 60.\n\nHEME: Hct 29.8 from 24.7 after 1u PRBC's. Sq heparin to start this afternoon if hct stable.\n\nGI: Abd obese, OGT to LCS with thick brown output.\n\nGU: Adequate u/o via foley. Lytes repleted (awaiting order for phos repletion).\n\nID: Afebrile. On kefzol/flagyl x 3 doses.\n\nENDO: FS covered per RISS.\n\nSOCIAL: Daughter and son post op and updated on condition.\n\nASSESSMENT: Pt s/p MVC, splenectomy and .\n\nPLAN: Cont to monitor vs, pain management, correct lytes, serial hct's, wean sedation/vent as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-10-19 00:00:00.000",
"description": "Report",
"row_id": 1349971,
"text": "NPN 0700-1900\nNEURO: Pt A+Ox3, lethargic at times (possibly d/t anemia). MAE and follows commands. MSO4 for pain with effect. OOB to chair today x 2hrs.\n\nRESP: LS with coarse crackles to right side halfway up. Left side coarse and diminished. Sats 94-98% on 4LNC; desaturates to high 80s without O2. Prior to blood transfusion, breathing was quite discoordinate, and pt appeared to have increased amount of abd breathing. Pt had significant DOE and SOB with talking. Improved moderately since transfusion.\n\nCV: HR 80s-100s SR/ST, no ectopy noted. BP 100s-140s/40s-70s.\n\nHEME: Given 2u PRBC's for hct 21.2; post transfusion hct 28.6.\n\nGI: Abd obese, bowel sounds hypoactive. Tolerating clear liquids without N/V.\n\nGU: Lasix gtt on 4mg/hr for most of day. Pt is currently 1600cc neg; goal is 1-2L neg for 24hr. Gtt decreased to 1mg/hr at 1600. K+ repleted. PM lytes pending.\n\nID: Afebrile. No abx.\n\nENDO: FS covered per RISS.\n\nSKIN: Grossly intact, no breakdown noted.\n\nSOCIAL: Multiple family members in today and supportive.\n\nASSESSMENT: Pt s/p MVC with spenelctomy and .\n\nCurrent nsg issues:\nFluid volume overload leading to DOE.\nPain.\nAnemia.\n\nPLAN: Cont to monitor vs, labs with serial hcts, lasix gtt as ordered, replete lytes, analgesia, encourage moblity, encourage C+DB.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-10-20 00:00:00.000",
"description": "Report",
"row_id": 1349972,
"text": "addendum: pt phosphorou level low.. neutrophos ordered po. pt took phosphorous but immediately developed nausea and vomited a small amount. anzimet 12.5 mg given iv with good effect.ho notified that pat unable to tolerated po phosphorous.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-10-20 00:00:00.000",
"description": "Report",
"row_id": 1349973,
"text": "cv: hr to 102 st no ectopy. pt on lopressor 10 mg iv Q6 hours. hr decreased to 81 after dose of lopressor iv. sbp 92-117/\n\ngi: tolerating clear liquids. abdomen obese. bowel sounds present but hypoactive. abd incision clean open to air. staples intact.\n\ngu: foley draining clear yellow urine. fluid balance goal attained negative ~ 2 liters. lasix drip infusing at 1 mg/hr..uo dropped off to 20 cc/hr at 0100 so lasix drip increased to 2 mg/hr. uo improved at 50-65 cc/hr.\n\nresp: albuterol nebs given at 2400 and again at 0400. while encourageing pt to do IS pt stated that she always takes a breathing tx at home.pt states she has a nebulizer machine at her home and that she takes a treatment 3-4 times per day and this worked much better for her than the inhalers. At 0400 pt sats decreased to 90 and pt found with expiratory wheezes in bilateral upper lobes and diminished lower lobes. wheezing dissipated after treatment and stas back to baseline 97-100 % on liters nc.\n\nmental status: alert and oriented,calm and cooperative.\n\nendo: blood sugars q 6 hours covered with ss. bs 126 at 0200 treated with 2 reg.\n\npain: pt complaining of generalized pain. pain in l shoulder and arm when turning to that side. Pain in abdomen . morphine given sc 8mg at . pt reported being comfortable. some discomfort at 2300 reported so another 8 mg sc injection given. resp rate decreasing to 6... pt sleeping.when pt awakened by this rn resp rate increased to 8- 12.\n\nlabs: K= 3.9 kcl 20 meq f/u k = 4.1. hct checked serially at and 0200... 25 and 25.6\n\nintegumentary: abdominal incision intact. staples intact. incision clean and open to air. ecchymosis of upper left arm and shoulder. ecchymosis of upper r thigh.\n\nasessment: improved ventilation with albuterol nebs.\n improved pain control with sc morphine.\n\nplan: will give smaller dose of morphine sc next injection. will try 6 mg sc to avoid respiratory depression .\nmonitor urine ouput and notify ho of decrease in urine to adjust lasix drip according ly.\ngive albuterol nebs q 6 hours and encourage IS and coughing and deep breathing.\nmonitor hct. check with ho to regarding frequency of serial hct to be drawn.\nmonitor lytes esp K whil on lasix drip. q 6 hr glucose and ss coverage\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-10-20 00:00:00.000",
"description": "Report",
"row_id": 1349974,
"text": "TSICU Nursing Progress Note\nNeuro - Pt x3. Conversing appropriately, able to make needs known. MAE.\n\nCV - NSR, rate 90s without ectopy. SBP 110s by cuff on forearm. Peripheral pulses palpable. Edema difficult to assess.\n\nResp - Lungs essentially clear, occ wheezing, dim in bases. Occ dyspneic with exertion. O2 sat >95% on 3 L NC. Albuterol nebs PRN. Strong cough with encouragement.\n\nGI - Abdomen obese, soft, hypoactive BS. Tender to palpation at incision. Tolerating sips of water and ice chips. No BM.\n\nGU - Brisk UOP on furosemide gtt with acetazolamide. Lasix gtt down to 1 mg/hr.\n\nEndo - No RISS coverage needed.\n\nHeme - 1 unit PRBC for HCT 25. Repeat HCT sent.\n\nA - Resp status stable. Tolerating clears.\n\nP - Continue to monitor resp status. Pulm toilet. Advance diet as tolerated. Consider tx to floor in AM.\n"
},
{
"category": "ECG",
"chartdate": "2123-10-19 00:00:00.000",
"description": "Report",
"row_id": 199725,
"text": "Sinus tachycardia\nNormal ECG except for rate\nSince previous tracing, limb lead voltage increased, and T wave abnormalities\nless\n\n"
},
{
"category": "ECG",
"chartdate": "2123-10-18 00:00:00.000",
"description": "Report",
"row_id": 199726,
"text": "Sinus tachycardia\nLow limb lead voltage\nT wave abnormalities\nClinical correlation is suggested\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-17 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 928171,
"text": " 9:38 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval for Line placement, PTX\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p MVC, s/p splenectomy, s/p SB resection, new Right IJ\n placed\n REASON FOR THIS EXAMINATION:\n eval for Line placement, PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post MVC, splenectomy, small bowel resection, new right IJ\n placed. Evaluate line.\n\n CHEST, SINGLE AP VIEW.\n\n Compared with earlier the same day, a right IJ central line has been placed.\n The tip overlies the mid/distal SVC. No pneumothorax is identified. Again\n seen are the ET and NG tubes. The pleural parenchymal findings are unchanged.\n\n IMPRESSION:\n 1. Right IJ central line tip over mid/distal SVC. No pneumothorax detected.\n 2. NG tube -- side-port lies in region of GE junction. Clinical correlation\n is requested.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-16 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 928142,
"text": " 9:19 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma; no further clinical history provided.\n\n TRAUMA TWO SERIES:\n\n AP chest radiograph with overlying trauma board demonstrates no pneumothorax\n or fracture. The mediastinum is within normal limits allowing for technique.\n Heart size is normal allowing for technique. The aortic arch is sharp. Lungs\n are grossly clear.\n\n AP pelvis with overlying trauma board demonstrates only mild demineralization.\n No acute fracture or dislocation, though its poor image contrast somewhat\n limits sensitivity. The lower lumbosacral spine and sacrum are not well\n visualized.\n\n IMPRESSION: No evidence of traumatic injury. Suboptimal assessment of the\n sacrum and lower lumbosacral spine.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 928387,
"text": " 3:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pulmonary edema\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p MVC, s/p splenectomy, s/p SB resection placed\n\n REASON FOR THIS EXAMINATION:\n r/o pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 77-year-old woman status post MVC, splenectomy, and small bowel\n resection.\n\n COMPARISON: .\n\n FINDINGS: Since the prior examination, there has been no significant interval\n changes. Persistent bibasilar atelectasis with left-sided small pleural\n effusion. Right IJ approach central venous catheter is unchanged with its tip\n projecting over the SVC. No evidence of pneumothorax.\n\n IMPRESSION: No significant interval changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 928147,
"text": " 1:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p intubation\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p intubation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post intubation.\n\n CHEST, SINGLE AP VIEW.\n No previous chest x-rays on PACS record for comparison. (Trauma film only).\n\n An ET tube has been placed, tip in satisfactory position approximately 3.5 cm\n above the carina. An NG tube is present, tip overlying gastric fundus. The\n sideport lies in the expected region of the GE junction. No CHF or focal\n infiltrate is identified. There is bibasilar atelectasis. Equivocal minimal\n blunting of the costophrenic angles, doubt gross effusion. Mild prominence of\n right paratracheal soft tissues likely reflects vascular structures in someone\n of this age. There is probable mild cardiomegaly with an unfolded aorta.\n Skin staples noted over upper abdomen in the midline.\n\n IMPRESSION: Interval placement of ET tube in satisfactory position. NG tube\n with sideport in region of GE junction. Clinical correlation requested.\n Bibasilar atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-18 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 928218,
"text": " 12:01 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for fracture\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p MVC intubated sedated s/p splenectomy\n REASON FOR THIS EXAMINATION:\n eval for fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DJD MON 1:50 AM\n No fracture or malalignment\n Mild . changes\n MD\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old status post MVC, sedated status post splenectomy,\n evaluate for fracture.\n\n COMPARISONS: None.\n\n TECHNIQUE: Axial MDCT images of the cervical spine with coronal and sagittal\n reformats.\n\n FINDINGS: C1 through the superior endplate of T2 are well visualized. There\n is no evidence of acute fracture or traumatic listhesis. Mild degenerative\n changes are noted, particularly at the C3/4 level without thecal sac\n compression. Endotracheal and nasogastric tubes limit the evaluation of\n prevertebral soft tissue swelling. No pneumothorax at the lung apices.\n Visualized portion of the temporal bones show no fracture. Mastoid processes\n are normally pneumatized. There is mild circumferential maxillary mucosal\n thickening without air-fluid levels. There is a small fluid levels within the\n sphenoid sinuses without evidence of displaced fracture, which may relate to\n intubation and supine positioning.\n\n IMPRESSION: No acute fracture or traumatic malalignment.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 928555,
"text": " 5:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p MVC, s/p splenectomy, s/p SB resection placed\n\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:54 A.M. ON .\n\n HISTORY: Splenectomy.\n\n IMPRESSION: AP chest compared to through 19:\n\n Lungs are lower in volume. Mild bibasilar atelectasis is worsened. Heart\n size top normal. No pleural effusion. Since , the right hilus\n has gotten larger and more radiodense. This can be a sign of acute pulmonary\n embolism. Dr. and I discussed these findings by telephone at the\n time of dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 929027,
"text": " 9:52 AM\n CHEST (PA & LAT) Clip # \n Reason: f/u on diuresing fluid.\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p mva\n REASON FOR THIS EXAMINATION:\n f/u on diuresing fluid.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, AT 0918 HOURS.\n\n HISTORY: Status post motor vehicle collision.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Lungs are hyperexpanded consistent with underlying obstructive lung\n disease. Linear atelectasis is noted in the right middle lobe. There is no\n focal consolidation. No superimposed edema is appreciated. There is a mildly\n tortuous atherosclerotic aorta. The cardiac silhouette is borderline enlarged\n with a prominent left epicardial fat pad. No pleural effusion or pneumothorax\n is evident. The bones are diffusely osteopenic and there is an exaggerated\n kyphosis of the thoracic spine.\n\n IMPRESSION: Underlying emphysema with no acute pulmonary process. Right\n hilar atelectasis.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2123-10-18 00:00:00.000",
"description": "R FEMUR (AP & LAT) RIGHT",
"row_id": 928226,
"text": " 1:14 AM\n FEMUR (AP & LAT) RIGHT Clip # \n Reason: assess for fracture\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with\n REASON FOR THIS EXAMINATION:\n assess for fracture\n ______________________________________________________________________________\n FINAL REPORT\n LEFT FEMUR, FOUR VIEWS\n\n INDICATION: 77-year-old woman. Evaluate for fracture.\n\n FINDINGS: No comparisons. No definite displaced fracture is seen. Quality\n of the radiographs is limited due to body habitus. No lytic or sclerotic\n lesion is noted. Mild degenerative change of the left hip is seen. The soft\n tissues are within normal limits. However, there does appear to be a focus of\n periosteal reaction and cortical lucency seen along the proximal fibular\n shaft, incompletely visualized. This area is concerning for a stress\n fracture. The soft tissues are otherwise unremarkable.\n\n IMPRESSION:\n 1. No definite evidence of femoral fracture.\n 2. Focal periosteal reaction and eccentric transversely oriented lucency of\n the proximal fibular shaft may represent a stress fracture. Consider\n dedicated imaging of the lower leg to further evaluate this region.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2123-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 928683,
"text": " 6:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p MVC, s/p splenectomy, s/p SB resection placed\n\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST FROM \n\n HISTORY: Status post small bowel resection, splenectomy and status post MVC,\n evaluate for interval change.\n\n FINDINGS: Portable upright chest radiograph appears unchanged compared to\n yesterday's study. Note is again made of prominent radiodensity of the right\n hilum. The lucency of the two hemithoraces appears equal. Somewhat wide\n appearance to the mid mediastinum appears to be related to uncoiling of the\n thoracic aorta and slight rotation of the patient to the right. The lungs are\n clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-18 00:00:00.000",
"description": "L HUMERUS (AP & LAT) LEFT",
"row_id": 928225,
"text": " 1:13 AM\n HUMERUS (AP & LAT) LEFT Clip # \n Reason: assess for fracture\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with\n REASON FOR THIS EXAMINATION:\n assess for fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess for fracture.\n\n LEFT HUMERUS, TWO VIEWS.\n\n There is probable diffuse osteopenia. No fracture is detected involving the\n left humerus. If there is clinical concern for an injury to the elbow, then\n dedicated elbow views would be recommended. Note is made of atelectasis at\n left lung base.\n\n Of note, the AC joint appears diastatic on these views measuring 10.8 mm. If\n the patient has symptoms related to the AC joint, then further assessment with\n dedicated views, ideally weightbearing and nonweightbearing views, of the AC\n joint may help for further assessment.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-18 00:00:00.000",
"description": "CT T-SPINE W/O CONTRAST",
"row_id": 928219,
"text": " 12:02 AM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: eval for fracture\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p MVC intubated sedated s/p splenectomy\n REASON FOR THIS EXAMINATION:\n eval for fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DJD MON 1:52 AM\n No fracture or malalignment\n Hemangioma within the T10 vertebral body\n\n MD\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old status post MVC, sedated status post splenectomy,\n evaluate for fracture.\n\n TECHNIQUE: Axial MDCT images of the thoracic spine with coronal and sagittal\n reformatted images.\n\n FINDINGS: No acute fracture or traumatic malalignment is appreciated within\n the visualized thoracic spine. Mild degenerative changes throughout.\n Endotracheal and feeding tube noted. There is prominent atelectasis and small\n effusions within the visualized lungs. The limited visualized paraspinal soft\n tissues demonstrate an exophytic lesion emanating from the posterolateral\n aspect of the left kidney, not well characterized. Atherosclerotic\n calcification of the aorta and coronary arteries. There are extensive\n dependent pulmonary air space opacities.\n\n IMPRESSION:\n 1) No acute fracture or malalignment.\n 2) Bibasilar atelectasis/consolidation.\n 3) Exophytic lesion, originating off the left kidney, not well characterized\n on this study; correlate with prior abdominal imaging. In the absence of\n this, ultrasound could further evaluate when the patient is stable.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-18 00:00:00.000",
"description": "CT L-SPINE W/O CONTRAST",
"row_id": 928220,
"text": " 12:02 AM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: eval for lumbosacral fracture\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p MVC intubated sedated s/p splenectomy\n REASON FOR THIS EXAMINATION:\n eval for lumbosacral fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DJD MON 1:59 AM\n No fracture or malalignment\n\n HOWEVER: Positive for 6cm x 3cm expansile mass in the sacral canal (measures\n 35-45 H.U. therefore it is solid and not a terminal meningeal cyst). Will need\n evaluation for neoplasm, ie primary bone tumor vs canal/neural tumor vs\n metastasis.\n\n MD\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 77-year-old status post MVC, intubated, status post splenectomy,\n evaluate for fracture.\n\n COMPARISONS: None.\n TECHNIQUE: Axial MDCT images through the lumbosacral spine without IV\n contrast with coronal and sagittal reformats.\n\n FINDINGS: There is normal alignment of the lumbar vertebral bodies without\n evidence of fracture or traumatic listhesis. Lumbar vertebral bodies are\n preserved in height. There is mild degenerative changes, most prominent at\n the L4-5 and L1-L2 levels. Calcification of the abdominal aorta without\n evidence of aneurysmal dilatation. No acute fractures are seen within the\n visualized pelvis. However, there is a large lytic lesion centered in the\n sacrum demonstrating sclerotic margins and central soft tissue density, of\n unclear etiology but requiring further workup. Indeterminate exophytic lesion\n off the left kidney again appreciated.\n\n IMPRESSION:\n 1) No acute fracture or malalignment.\n\n 2) Destructive lytic lesion centered in the sacrum with central soft tissue\n component; in the absence of prior studies, MRI is recommended for further\n characterization.\n\n 3) Exophytic lesion off the left kidney, not well characterized on this study.\n\n Findings discussed with Dr. after the study.\n\n NOTE ADDED AT ATTENDING REVIEW: I agree that the sacral lesion should be\n pursued with MR. However, measurements of soft tissue density within the\n sacrum may not be reliable. This may represent a large dilated nerve root\n (Over)\n\n 12:02 AM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: eval for lumbosacral fracture\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n sheath. There is a similar, but smaller, lesion on the right along the S3\n root. Both lesions appear chronic, with smooth erosion of the bone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 928261,
"text": " 10:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: post-extubation\n Admitting Diagnosis: S/P EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p MVC, s/p splenectomy, s/p SB resection placed\n\n REASON FOR THIS EXAMINATION:\n post-extubation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old woman status post MVC, status post splenectomy, SB\n resection, and extubation.\n\n COMPARISON: .\n\n FINDINGS: Since the prior examination, patient has been extubated and the NG\n tube has been removed. Stable appearance of the right IJ-approach central\n venous catheter with its tip projecting over the SVC. Persistent bibasilar\n atelectasis. The left costophrenic angle is mildly blunted, may represent\n small pleural effusions. The cardiac silhouette, mediastinal and hilar\n contours appear unchanged.N o evidence of pneumothorax.\n\n IMPRESSION:\n\n 1. Interval removal of the ET and NG tubes.\n\n 2. Persistent bibasilar atelectasis, with possible small left-sided pleural\n effusion.\n\n 3. No evidence of pneumothorax.\n\n\n"
}
] |
31,642 | 150,166 | Vascular surgery consulted due to back pain / ? increased size of known thoracic aortic aneurysm. No evidence of leaking or rupture was seen on CT here; slight interval increase in aneurysm since . Prior CT at non-contrast, reviewed by Dr. , who would like Ms. to have a repeat CT scan with contrast in 3 months and follow up with him in clinic. | The ascending thoracic aorta is ectatic measuring 4.7 cm x 5.0 cm (2:31), unchanged from prior. Additionally, there is ectasia of the infrarenal portion of the abdominal aorta, and above the level of the bifurcation, measuring up to 2.6 cm in AP dimensions, unchanged from . Evaluatoin for dissectrion limited without IV contrast. Stable ectasia of the ascending aorta and infrarenal abdominal aorta. Extensive atherosclerotic calcifications are present throughout the thoracic aorta, with associated streak artifact from the intimal calcifications as well as from adjacent pacer leads slightly limiting evaluation. Non-contrast images of the stomach and small bowel are within normal limits. TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the symphysis pubis without the administration of IV and oral contrast. The lungs reveal patchy areas of atelectasis bilaterally, with left lower lobe chronic compressive atelectasis seen adjacent to the descending thoracic aorta/aneurysm. Otherwise, the airways are patent to the subsegmental level. Diverticulosis without diverticulitis. Additionally, there is a 5 mm pulmonary nodule, abutting the right major fissure (2:25), unchanged from . D/w surgery. CT OF THE CHEST WITHOUT IV CONTRAST: The heart is mildly enlarged in size, with an AICD device present, with leads terminating in the right atrium and right ventricle. This could represent atrial sensing, ventricular pacing with difficultyin discerning atrial activity, although in lead II a candidate P wave canbe seen. A few scattered mediastinal nodes are present, not meeting size criteria for pathologic enlargement. AORTA: Again noted is a thoracic aortic aneurysm which involves the descending thoracic aorta and continues through the level of the diaphragm. Scattered diverticula are present within the colon, with retained contrast present within the transverse and descending colons. Stable 5 mm pulmonary nodule in the right upper lobe. Coronal and sagittal reformations were obtained. A-V paced rhythmSince previous tracing of , no significant change CT OF THE ABDOMEN WITHOUT IV CONTRAST: Non-contrast liver, spleen, pancreas, adrenal glands, and kidneys are unremarkable. Multilevel degenerative changes are present throughout the thoracolumbar spine. There is a grade 1 anterolisthesis of L4 on L5, stable. Large descending thoracic aortic aneurysm, with a slight interval increase in size from as noted above. OSSEOUS STRUCTURES: Sclerotic focus in the T6 vertebral body is stable from , may reflect a bone island. Minimal calcifications of the tracheobronchial tree is seen. Atelectasis at the left lower lobe adjacent to the descending thoracic aorta. (Over) 7:38 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: AAA/Dissection Field of view: 36 FINAL REPORT (Cont) The aneurysm measures approximately 5.9 cm x 6.0 cm (previously 5.7 cm x 5.3 cm) at the level just above the diaphragm. A pacing spike is seen priorto every QRS complex indicating one hundred percent ventricular pacing.Compared to the previous tracing of atrial pacing is no longerseen. A-V paced rhythmSince previous tracing of , paced rhythm now present larger on outpatient CT REASON FOR THIS EXAMINATION: AAA/Dissection No contraindications for IV contrast WET READ: JXKc WED 10:14 PM Thoracic aortic aneurysm, with the ascending aorta similar in size from , but with slight interval increase in size of the descending thoracic aorta (5.8 cm x 6.0 cm) versus (5.7cm x 5.4 cm on prior study). There is no pericardial effusion. IMPRESSION: 1. There is no pleural effusion. Small amount of layering hyperdensity within the gallbladder may reflect a sludge. The atrial activity is difficult to discern. 4. Again noted are extensive atherosclerotic calcifications of the abdominal aorta as well as splenic artery and renal vessels. There is no evidence of aortic rupture. Evaluate. COMPARISON: . SESHa There is no evidence of rupture. There is no definite evidence for displaced intimal calcifications on this study. There is no free air, free fluid or pathologic adenopathy. midnight-7a81 y/o female w/ extensive medical hx admitted to cvicu for monitoring after follow-up ct of previously stable thoracoabdominal aneurysm showed possible growth in size of aneurysm and potential for leak vs dissectionneuro: a+ox3, mae, follows commands, turns self in bed, no c/o pain at this timecv: sr 70s w/ rare pacs, sbp 115-130, afebresp: lungs cta, 02 sats>95% on 2L nc while awake, O2 increased to 4Lnc while pt sleeping to maintain higher 02 satgi: npo, bowel sounds present, tolerating sips of h20 w/ pills without distressgu: voids per urinal clear green urine (pt states green urine colour r/t bladder med taken at home)assess: stableplan: keep npo overnoc for possible tests in am, transfer to floor when able 3. 5. 2. 7:38 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: AAA/Dissection Field of view: 36 MEDICAL CONDITION: 81 year old woman with known AAA, ? Findings posted to the ED dashboard at the time of interpretation. FINAL REPORT HISTORY: 81-year-old female with known abdominal aortic aneurysm, question larger on outpatient CT. | 5 | [
{
"category": "Radiology",
"chartdate": "2147-07-26 00:00:00.000",
"description": "CT PELVIS W/O CONTRAST",
"row_id": 1028984,
"text": " 7:38 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: AAA/Dissection\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with known AAA, ? larger on outpatient CT\n REASON FOR THIS EXAMINATION:\n AAA/Dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc WED 10:14 PM\n Thoracic aortic aneurysm, with the ascending aorta similar in size from ,\n but with slight interval increase in size of the descending thoracic aorta\n (5.8 cm x 6.0 cm) versus (5.7cm x 5.4 cm on prior study). D/w surgery.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81-year-old female with known abdominal aortic aneurysm, question\n larger on outpatient CT. Evaluate.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the\n symphysis pubis without the administration of IV and oral contrast. Coronal\n and sagittal reformations were obtained.\n\n CT OF THE CHEST WITHOUT IV CONTRAST: The heart is mildly enlarged in size,\n with an AICD device present, with leads terminating in the right atrium and\n right ventricle. There is no pericardial effusion. A few scattered mediastinal\n nodes are present, not meeting size criteria for pathologic enlargement. The\n lungs reveal patchy areas of atelectasis bilaterally, with left lower lobe\n chronic compressive atelectasis seen adjacent to the descending thoracic\n aorta/aneurysm. Additionally, there is a 5 mm pulmonary nodule, abutting the\n right major fissure (2:25), unchanged from . Minimal\n calcifications of the tracheobronchial tree is seen. Otherwise, the airways\n are patent to the subsegmental level. There is no pleural effusion.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: Non-contrast liver, spleen, pancreas,\n adrenal glands, and kidneys are unremarkable. Small amount of layering\n hyperdensity within the gallbladder may reflect a sludge. Non-contrast images\n of the stomach and small bowel are within normal limits. Scattered\n diverticula are present within the colon, with retained contrast present\n within the transverse and descending colons. There is no free air, free fluid\n or pathologic adenopathy.\n\n OSSEOUS STRUCTURES: Sclerotic focus in the T6 vertebral body is stable from\n , may reflect a bone island. There is a grade 1\n anterolisthesis of L4 on L5, stable. Multilevel degenerative changes are\n present throughout the thoracolumbar spine.\n\n AORTA: Again noted is a thoracic aortic aneurysm which involves the\n descending thoracic aorta and continues through the level of the diaphragm.\n (Over)\n\n 7:38 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: AAA/Dissection\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The aneurysm measures approximately 5.9 cm x 6.0 cm (previously 5.7 cm x 5.3\n cm) at the level just above the diaphragm. The ascending thoracic aorta is\n ectatic measuring 4.7 cm x 5.0 cm (2:31), unchanged from prior. Extensive\n atherosclerotic calcifications are present throughout the thoracic aorta, with\n associated streak artifact from the intimal calcifications as well as from\n adjacent pacer leads slightly limiting evaluation. There is no definite\n evidence for displaced intimal calcifications on this study. There is no\n evidence of aortic rupture.\n\n Additionally, there is ectasia of the infrarenal portion of the abdominal\n aorta, and above the level of the bifurcation, measuring up to 2.6 cm in AP\n dimensions, unchanged from . Again noted are extensive\n atherosclerotic calcifications of the abdominal aorta as well as splenic\n artery and renal vessels.\n\n IMPRESSION:\n 1. Large descending thoracic aortic aneurysm, with a slight interval increase\n in size from as noted above. There is no evidence of\n rupture. Evaluatoin for dissectrion limited without IV contrast. Patient\n reportedly had a contrast enhanced study at an outside hospital within the\n last 2 days and correlation with the results from that study is recommended.\n 2. Stable ectasia of the ascending aorta and infrarenal abdominal aorta. 3.\n Atelectasis at the left lower lobe adjacent to the descending thoracic aorta.\n 4. Stable 5 mm pulmonary nodule in the right upper lobe.\n 5. Diverticulosis without diverticulitis.\n\n Findings posted to the ED dashboard at the time of interpretation.\n SESHa\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-07-27 00:00:00.000",
"description": "Report",
"row_id": 1664839,
"text": " midnight-7a\n81 y/o female w/ extensive medical hx admitted to cvicu for monitoring after follow-up ct of previously stable thoracoabdominal aneurysm showed possible growth in size of aneurysm and potential for leak vs dissection\n\nneuro: a+ox3, mae, follows commands, turns self in bed, no c/o pain at this time\n\ncv: sr 70s w/ rare pacs, sbp 115-130, afeb\n\nresp: lungs cta, 02 sats>95% on 2L nc while awake, O2 increased to 4Lnc while pt sleeping to maintain higher 02 sat\n\ngi: npo, bowel sounds present, tolerating sips of h20 w/ pills without distress\n\ngu: voids per urinal clear green urine (pt states green urine colour r/t bladder med taken at home)\n\nassess: stable\n\nplan: keep npo overnoc for possible tests in am, transfer to floor when able\n"
},
{
"category": "ECG",
"chartdate": "2147-07-28 00:00:00.000",
"description": "Report",
"row_id": 186657,
"text": "The atrial activity is difficult to discern. A pacing spike is seen prior\nto every QRS complex indicating one hundred percent ventricular pacing.\nCompared to the previous tracing of atrial pacing is no longer\nseen. This could represent atrial sensing, ventricular pacing with difficulty\nin discerning atrial activity, although in lead II a candidate P wave can\nbe seen.\n\n"
},
{
"category": "ECG",
"chartdate": "2147-07-27 00:00:00.000",
"description": "Report",
"row_id": 186913,
"text": "A-V paced rhythm\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2147-07-26 00:00:00.000",
"description": "Report",
"row_id": 186914,
"text": "A-V paced rhythm\nSince previous tracing of , paced rhythm now present\n\n"
}
] |
28,222 | 177,613 | ASSESSMENT AND PLAN: 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM, systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS change and hypotension. Etiology of hypotension and hypercarbia were never clarified during his hospital course. The hypotension was concerning for sepsis given l-shift, indwelling HD line and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/ prior HD line. Also has a pacemaker. Could not get a urine specimen. CXR w/ loss of diaphragm on R but w/o obvious infiltrate. Could also be from cardiogenic shock given baseline depressed EF. Given his presentation w/ altered mental status, he was covered with Vanc, ceftriaxone, ampicillin and acyclovir for possible meningitis. An LP was attempted but not successful given prior lumbar laminectomy surgery and an IR-guided LP was planned. He was initially on NE for blood pressure support but this was weaned off the day after admission. The following morning, when the resident went in to round on Mr. , she noted that he was apneic and without a pulse. A code was called and he was given epi/atropine, insulin, dextrose, bicarb for PEA. He was intubated by anesthesia. His wife was called and she asked that agressive recussitation be stopped (it had not been successful to that point) and he expired. . Hospital course also complicated by the following problems: . #. Acute respiratory acidosis: Unclear precipitant. DDX from percocets vs infection vs hypophosphatemia vs respiratory muscle fatigue. He tolerated bipap the night of admssion with a small decrease in CO2. His mental status improved slightly over the next day. . #. Altered mental status: DDX from hypercarbia vs from percocets vs from infection. CT head w/o acute process. Could possibly be from meningitis but no nucal rigidity or headache. - treatment w/ bipap and antibiotics for meningitis as above . #. Hypoxia: CXR seems consistent w/ pulmonary edema. Likely from worsening valvular disease. Could also be an infiltrate that is hidden by edema. Apparently has been on L NC at rehab w/ unclear diagnosis but getting spiriva and albuterol. No formal dx of COPD. - albuterol and atrovent nebs . #. ESRD on HD: Dialysis MWF at Dialysis. - renal followed him and was planning for dialysis the day he expired . #. Systolic heart failure: Unclear if ischemic in etiology or from valvular disease (mod AS, severe MR). - appeared total body volume overloaded despite hypotension. . #. Afib: INR supratherapeutic at 13.2 on admission but quickly resolved s/p 2 U FFP and 10 mg vit K IV X 1 in the ED. No obvious signs of bleeding. HCT w/ hemoconcentration given baseline of 32. S/p AVN ablation and dual-chamber pacemaker. - held coumadin - trended coags . #. PVD: Known LUE and bilateral LE PVD followed by Dr. . - per , nothing to do for now . #. Macrocytic Anemia: Current hct likely hemoconcentration. No signs of bleeding. B12/folate wnl in . . EMERGENCY CONTACT: (, , wife | HEENT: Normocephalic, atraumatic. HEENT: Normocephalic, atraumatic. HEENT: Normocephalic, atraumatic. HEENT: Normocephalic, atraumatic. CXR w/ loss of diaphragm on R but w/o obvious infiltrate. CXR w/ loss of diaphragm on R but w/o obvious infiltrate. CXR w/ loss of diaphragm on R but w/o obvious infiltrate. CXR w/ loss of diaphragm on R but w/o obvious infiltrate. CT head w/o acute process. CT head w/o acute process. CT head w/o acute process. CT head w/o acute process. Has sig vasculopathy. CT head neg. CT head neg. CT head neg. Pt is dialysis dependent. Head CT NEG. Head CT NEG. Head CT NEG. Head CT NEG. - hold coumadin - trend coags . - hold coumadin - trend coags . - hold coumadin - trend coags . - hold coumadin - trend coags . CXR w/ worsening bilat pl. CXR w/ worsening bilat pl. TITLE: Respiratory Pt. Response: Afebrile. Response: Afebrile. Response: Afebrile. Response: Afebrile. Response: Afebrile. - albuterol and atrovent nebs . - albuterol and atrovent nebs . - albuterol and atrovent nebs . - albuterol and atrovent nebs . INR 13.2, received IV vit K and FFP. INR 13.2, received IV vit K and FFP. INR 13.2, received IV vit K and FFP. INR 13.2, received IV vit K and FFP. Hypercarbic resp failure with minimal disturbance of Aa gradient. Altered mental status (not Delirium) Assessment: A&Ox1 w/ constant confused questions and statements; ? Altered mental status (not Delirium) Assessment: A&Ox1 w/ constant confused questions and statements; ? I noted that he was apneic w/o a pulse. PERRLA/EOMI. PERRLA/EOMI. PERRLA/EOMI. PERRLA/EOMI. Macrocytic Anemia: Current hct likely hemoconcentration. Macrocytic Anemia: Current hct likely hemoconcentration. Macrocytic Anemia: Current hct likely hemoconcentration. Macrocytic Anemia: Current hct likely hemoconcentration. LLE pedal pulses dopplarable, RLE dorsal pulses absent but post tib dopplerable. LLE pedal pulses dopplarable, RLE dorsal pulses absent but post tib dopplerable. PVD: Known LUE and bilateral LE PVD followed by Dr. . PVD: Known LUE and bilateral LE PVD followed by Dr. . PVD: Known LUE and bilateral LE PVD followed by Dr. . PVD: Known LUE and bilateral LE PVD followed by Dr. . ABDOMEN: NABS. ABDOMEN: NABS. ABDOMEN: NABS. ABDOMEN: NABS. Levophed started for hypotension resistant to IVF resuscitation. Levophed started for hypotension resistant to IVF resuscitation. Levophed started for hypotension resistant to IVF resuscitation. Levophed started for hypotension resistant to IVF resuscitation. infection vs hypercarbia. infection vs hypercarbia. Lactate 1.2. Lactate 1.2. and CHF. and CHF. ------ Protected Section Addendum Entered By: , MD on: 17:08 ------ Moderate (2+) aortic regurgitation is seen. Moderate (2+) aortic regurgitation is seen. Moderate (2+) aortic regurgitation is seen. Moderate (2+) aortic regurgitation is seen. Apparently has been on L NC at rehab w/ unclear diagnosis but getting spiriva and albuterol. Apparently has been on L NC at rehab w/ unclear diagnosis but getting spiriva and albuterol. Apparently has been on L NC at rehab w/ unclear diagnosis but getting spiriva and albuterol. Apparently has been on L NC at rehab w/ unclear diagnosis but getting spiriva and albuterol. Needed hands restrained otherwise pt was fine.Rxd with atrovent Q6 last 0600. In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22. In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22. In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22. In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22. LUE w/ old fistulas. LUE w/ old fistulas. Afib: INR supratherapeutic at 13.2. Afib: INR supratherapeutic at 13.2. Afib: INR supratherapeutic at 13.2. Afib: INR supratherapeutic at 13.2. Acute respiratory acidosis: Unclear precipitant. Acute respiratory acidosis: Unclear precipitant. Acute respiratory acidosis: Unclear precipitant. Acute respiratory acidosis: Unclear precipitant. Altered mental status: DDX from hypercarbia vs from percocets vs from infection. Altered mental status: DDX from hypercarbia vs from percocets vs from infection. Altered mental status: DDX from hypercarbia vs from percocets vs from infection. Altered mental status: DDX from hypercarbia vs from percocets vs from infection. Let renal know pt has been admitted. Concern for infectious process as patient remains hypotensive requiring Levophed gtt. Concern for infectious process as patient remains hypotensive requiring Levophed gtt. Concern for infectious process as patient remains hypotensive requiring Levophed gtt. EMS activated. eff. eff. - check a MVO2 . Hypotension: Concerning for sepsis given l-shift, indwelling HD line and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/ prior HD line. Hypotension: Concerning for sepsis given l-shift, indwelling HD line and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/ prior HD line. Hypotension: Concerning for sepsis given l-shift, indwelling HD line and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/ prior HD line. Hypotension: Concerning for sepsis given l-shift, indwelling HD line and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/ prior HD line. 24 Hour Events: In ED, noted SBP 70s not responsive to IVF challenges, U/S guided CVL placement Lt femoral. 24 Hour Events: In ED, noted SBP 70s not responsive to IVF challenges, U/S guided CVL placement Lt femoral. 24 Hour Events: In ED, noted SBP 70s not responsive to IVF challenges, U/S guided CVL placement Lt femoral. | 20 | [
{
"category": "Physician ",
"chartdate": "2134-04-12 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 376058,
"text": "Chief Complaint: Hypotension, altered mental status\n HPI:\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\n change. His son who accompanies him says that he has noticed an\n increase in his RR over the past few days and a decrease in his energy\n level. When he went to visit him this morning, he was very sleepy and\n not coherent which is a change so they called the ambulance. BP and O2\n sats there noted to be low. He did not eat breakfast this morning\n which is very unusual for him.\n .\n In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22.\n 97% on 5L NC. Arrived hypotensive in 70s, MS A+Ox3 here (but per son,\n not at baseline), BP unresponsive to 2L NS so left femoral central line\n placed under U/S guidance (as INR 13) and levo started. Moving arms\n but legs weaker. 2 U FFP, 10 vit K IV. Cxr w/ increased CHF. Head CT\n NEG. Could not pass foley X 2, now w/ small amt of blood. Given vanco\n 1g IV, levo 750 mg IV, flagyl 500 mg IV. Cool hands/feet, dopplerable\n PT but not DP, vasc called and will see on the floor. Guaiac + brown\n stool.\n .\n On arrival to the ICU, his son states he is more alert now but not back\n to baseline.\n .\n Review of systems: Pt. states he feels short of breath but cannot\n clarify further.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Horse/Equine Product Derivatives\n Unknown;\n Calcium Channel Blocking Agents-Benzothiazepines\n Headache;\n Metoprolol\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.12 mcg/Kg/min\n Other ICU medications:\n Other medications:\n (per med sheets)\n Coumadin 3 mg daily\n Dialysis at dialysis MWF\n Acetaminophen\n ASA 325 mg daily\n calcium acetate 667 mg 2 tabs tid\n dextroamphetamine 2.5 mg daily\n docusate\n folate 1 mg daily\n lotemax 0.5% eye drops\n mucinex 600 mg \n mucomyst nebs \n nephrocaps\n pantoprazole 40 mg daily\n sensipar 30 mg \n spiriva daily\n tobramycin 0.3% eye drops\n Valtrex 500 mg daily\n lactulose\n lorazepam 0.5 mg \n percocet 5/325 \n dexadrine 5 mg daily\n Albuterol\n vit B12 1000 mg daily\n nepro 235 daily\n albumin w/ dialysis\n darbapoetin w/ dialysis\n Past medical history:\n Family history:\n Social History:\n - PVD (Followed by ) w/ chronic LUE and bilateral LE ischemis\n - Chronic renal failure on HD x 4 years (thought to be due to\n obstructive uropathy, kidney stones, BPH)\n - Systolic heart failure w/ EF 25% on ECHO \n - Moderate aortic valve stenosis (area 1.0-1.2cm2). Moderate (2+)\n aortic regurgitation is seen. Moderate to severe (3+) mitral\n regurgitation is seen. There is mild pulmonary artery systolic\n hypertension. ()\n - Hx atrial fibrillation and paroxysmal atrial tachycardia\n - s/p AV nodal ablation and implantation of a dual chamber pacemaker\n - Baseline AV conduction delay\n - Hypertension\n - Coronary artery disease with old posterior MI on EKG and pMIBI\n in with EF44%, global hypokinesis, no reversible defects.\n - Hx Left 4-9th rib fx, Left hemothorax\n - R kidney stone s/p Lithotripsy\n (, complicated by ESBL Klebsiella UTI)\n - s/p stroke (cerebellar), found on MRI, sxs of gait instability\n - hx gait d/o, hand paresthesias, polyneuropathy, C3/C4 spinal\n cord compression cerival spondylosis, L median nerve injury\n - Anemia\n - Benign prostatic hypertrophy\n - Cluster headaches\n - Hx of positive PPD, never treated\n - Hx squamous cell and basal cell ca\n - HSV keratouveitis\n - ventral hernia\n - s/p open cholecystectomy \n - s/p small bowel resection (80-90%) for mesenteric ischemia\n - s/p umbilical hernia repair\n - s/p cystocele repair\n - s/p laminectomy - c/b osteomyelitis\n - s/p TURP \n There is no family history of premature coronary artery disease or\n sudden death.\n Patient has been at a NH and has not gotten home since hospitalization\n in . His wife lives in . He is a retired psychiatrist.\n Social history is significant for the remote tobacco use, 3ppd x 40\n years, quit 20 years ago. He drinks alcohol occasionally, denies\n illicit drug use.\n Review of systems:\n Flowsheet Data as of 02:32 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.5\nC (95.9\n HR: 70 (70 - 76) bpm\n BP: 101/58(68) {89/58(68) - 101/68(73)} mmHg\n RR: 18 (17 - 20) insp/min\n SpO2: 94%\n Heart rhythm: V Paced\n Height: 70 Inch\n Total In:\n 2,116 mL\n PO:\n TF:\n IVF:\n 116 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,116 mL\n Respiratory\n O2 Delivery Device: Bipap mask\n SpO2: 94%\n Physical Examination\n GENERAL: Awake but confused, NAD. Answers do not make sense.\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. dry MM. OP w/ poor dentition. Neck Supple.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or but very distant heart sounds.\n LUNGS: Occasional crackles anteriorly and posteriorly w/ poor\n inspiratory effort.\n ABDOMEN: NABS. Soft, midline scar. No HSM\n EXTREMITIES: anasarca, palp radial pulses, dopperable PT/DP\n bilaterally. L hand w/ purple fingertips on fingers 2, 3 and 4.\n SKIN: Xerosis.\n NEURO: Alert but not oriented. Speaking nonsensical sentences. Able\n to show 2 fingers on the R but not L. Able to wiggle toes. Could not\n follow other commands.\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:1.2 mmol/L\n Imaging: CT Head: wet read - no acute intracranial pathology.\n .\n CXR:\n FINDINGS: Comparison is made to . Right pacemaker and two\n intracardiac leads remain in place. Since prior exam, left IJ\n hemodialysis catheter has been placed, with tip low in position,\n possibly within the IVC. Vascular stens are noted in the left\n subclavian and brachiocephalic vein.\n Cardiomegaly again noted with central congestion, bilateral pleural\n effusions. Lung bases are suboptimally assessed given low lung volumes\n though compared with prior, effusion and CHF is increased.\n IMPRESSION:\n 1. Dialysis catheter tip low, likely in IVC.\n 2. CHF, worse.\n Microbiology: Blood cx w/ NGTD\n ECG: ECG: V-paced (74)\n Assessment and Plan\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\n change and hypotension.\n .\n #. Hypotension: Concerning for sepsis given l-shift, indwelling HD line\n and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/\n prior HD line. Also has a pacemaker. Could not get a urine specimen.\n CXR w/ loss of diaphragm on R but w/o obvious infiltrate. Could also\n be from cardiogenic shock given baseline depressed EF.\n - cover w/ broad-spectrum antibiotics w/ Vanc/ given h/o ESBL and\n narrow as cx return\n - NE w/ goal MAP > 60\n - continue to gently bolus w/ LR given depressed EF, severe valvular\n disease\n - Repeat ECHO to eval for worsening CHF/Valvular disease\n - would ideally like to place an a-line for HD monitoring but I would\n be concerned to precipitate ischemia to R hand and L-hand already\n ischemic. Will follow w/ non-invasive for now.\n - check a MVO2\n .\n #. Acute respiratory acidosis: Unclear precipitant. DDX from percocets\n vs infection vs hypophosphatemia vs respiratory muscle fatigue\n - will try bipap for now to see if he tolerates\n - check phos\n - continue to monitor\n .\n #. Altered mental status: DDX from hypercarbia vs from percocets vs\n from infection. CT head w/o acute process. Could possibly be from\n meningitis but no nucal rigidity or headache.\n - continue to monitor\n .\n #. Hypoxia: CXR seems consistent w/ pulmonary edema. Likely from\n worsening valvular disease. Could also be an infiltrate that is hidden\n by edema. Apparently has been on L NC at rehab w/ unclear\n diagnosis but getting spiriva and albuterol. No formal dx of COPD.\n - albuterol and atrovent nebs\n .\n #. ESRD on HD: Dialysis MWF at Dialysis.\n - contact renal in the am for cvvh vs HD depending on BP\n .\n #. Systolic heart failure: Unclear if ischemic in etiology or from\n valvular disease (mod AS, severe MR).\n - appears total body volume overloaded despite hypotension.\n .\n #. Afib: INR supratherapeutic at 13.2. Now s/p 2 U FFP and 10 mg vit K\n IV X 1 in the ED. No obvious signs of bleeding. HCT w/\n hemoconcentration given baseline of 32. S/p AVN ablation and\n dual-chamber pacemaker.\n - hold coumadin\n - trend coags\n .\n #. PVD: Known LUE and bilateral LE PVD followed by Dr. .\n - appreciate vascular input, nothing to do for now\n .\n #. Macrocytic Anemia: Current hct likely hemoconcentration. Will watch\n for signs of bleeding given supra-therapeutic INR. B12/folate wnl in\n .\n - trend for now.\n - guaiac stools\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 12:30 AM\n Dialysis Catheter - 12:30 AM\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2134-04-12 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 376059,
"text": "Chief Complaint: Hypotension, altered mental status\n HPI:\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\n change. His son who accompanies him says that he has noticed an\n increase in his RR over the past few days and a decrease in his energy\n level. When he went to visit him this morning, he was very sleepy and\n not coherent which is a change so they called the ambulance. BP and O2\n sats there noted to be low. He did not eat breakfast this morning\n which is very unusual for him.\n .\n In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22.\n 97% on 5L NC. Arrived hypotensive in 70s, MS A+Ox3 here (but per son,\n not at baseline), BP unresponsive to 2L NS so left femoral central line\n placed under U/S guidance (as INR 13) and levo started. Moving arms\n but legs weaker. 2 U FFP, 10 vit K IV. Cxr w/ increased CHF. Head CT\n NEG. Could not pass foley X 2, now w/ small amt of blood. Given vanco\n 1g IV, levo 750 mg IV, flagyl 500 mg IV. Cool hands/feet, dopplerable\n PT but not DP, vasc called and will see on the floor. Guaiac + brown\n stool.\n .\n On arrival to the ICU, his son states he is more alert now but not back\n to baseline.\n .\n Review of systems: Pt. states he feels short of breath but cannot\n clarify further.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Horse/Equine Product Derivatives\n Unknown;\n Calcium Channel Blocking Agents-Benzothiazepines\n Headache;\n Metoprolol\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.12 mcg/Kg/min\n Other ICU medications:\n Other medications:\n (per med sheets)\n Coumadin 3 mg daily\n Dialysis at dialysis MWF\n Acetaminophen\n ASA 325 mg daily\n calcium acetate 667 mg 2 tabs tid\n dextroamphetamine 2.5 mg daily\n docusate\n folate 1 mg daily\n lotemax 0.5% eye drops\n mucinex 600 mg \n mucomyst nebs \n nephrocaps\n pantoprazole 40 mg daily\n sensipar 30 mg \n spiriva daily\n tobramycin 0.3% eye drops\n Valtrex 500 mg daily\n lactulose\n lorazepam 0.5 mg \n percocet 5/325 \n dexadrine 5 mg daily\n Albuterol\n vit B12 1000 mg daily\n nepro 235 daily\n albumin w/ dialysis\n darbapoetin w/ dialysis\n Past medical history:\n Family history:\n Social History:\n - PVD (Followed by ) w/ chronic LUE and bilateral LE ischemis\n - Chronic renal failure on HD x 4 years (thought to be due to\n obstructive uropathy, kidney stones, BPH)\n - Systolic heart failure w/ EF 25% on ECHO \n - Moderate aortic valve stenosis (area 1.0-1.2cm2). Moderate (2+)\n aortic regurgitation is seen. Moderate to severe (3+) mitral\n regurgitation is seen. There is mild pulmonary artery systolic\n hypertension. ()\n - Hx atrial fibrillation and paroxysmal atrial tachycardia\n - s/p AV nodal ablation and implantation of a dual chamber pacemaker\n - Baseline AV conduction delay\n - Hypertension\n - Coronary artery disease with old posterior MI on EKG and pMIBI\n in with EF44%, global hypokinesis, no reversible defects.\n - Hx Left 4-9th rib fx, Left hemothorax\n - R kidney stone s/p Lithotripsy\n (, complicated by ESBL Klebsiella UTI)\n - s/p stroke (cerebellar), found on MRI, sxs of gait instability\n - hx gait d/o, hand paresthesias, polyneuropathy, C3/C4 spinal\n cord compression cerival spondylosis, L median nerve injury\n - Anemia\n - Benign prostatic hypertrophy\n - Cluster headaches\n - Hx of positive PPD, never treated\n - Hx squamous cell and basal cell ca\n - HSV keratouveitis\n - ventral hernia\n - s/p open cholecystectomy \n - s/p small bowel resection (80-90%) for mesenteric ischemia\n - s/p umbilical hernia repair\n - s/p cystocele repair\n - s/p laminectomy - c/b osteomyelitis\n - s/p TURP \n There is no family history of premature coronary artery disease or\n sudden death.\n Patient has been at a NH and has not gotten home since hospitalization\n in . His wife lives in . He is a retired psychiatrist.\n Social history is significant for the remote tobacco use, 3ppd x 40\n years, quit 20 years ago. He drinks alcohol occasionally, denies\n illicit drug use.\n Review of systems:\n Flowsheet Data as of 02:32 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.5\nC (95.9\n HR: 70 (70 - 76) bpm\n BP: 101/58(68) {89/58(68) - 101/68(73)} mmHg\n RR: 18 (17 - 20) insp/min\n SpO2: 94%\n Heart rhythm: V Paced\n Height: 70 Inch\n Total In:\n 2,116 mL\n PO:\n TF:\n IVF:\n 116 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,116 mL\n Respiratory\n O2 Delivery Device: Bipap mask\n SpO2: 94%\n Physical Examination\n GENERAL: Awake but confused, NAD. Answers do not make sense.\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. dry MM. OP w/ poor dentition. Neck Supple.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or but very distant heart sounds.\n LUNGS: Occasional crackles anteriorly and posteriorly w/ poor\n inspiratory effort.\n ABDOMEN: NABS. Soft, midline scar. No HSM\n EXTREMITIES: anasarca, palp radial pulses, dopperable PT/DP\n bilaterally. L hand w/ purple fingertips on fingers 2, 3 and 4.\n SKIN: Xerosis.\n NEURO: Alert but not oriented. Speaking nonsensical sentences. Able\n to show 2 fingers on the R but not L. Able to wiggle toes. Could not\n follow other commands.\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:1.2 mmol/L\n Imaging: CT Head: wet read - no acute intracranial pathology.\n .\n CXR:\n FINDINGS: Comparison is made to . Right pacemaker and two\n intracardiac leads remain in place. Since prior exam, left IJ\n hemodialysis catheter has been placed, with tip low in position,\n possibly within the IVC. Vascular stens are noted in the left\n subclavian and brachiocephalic vein.\n Cardiomegaly again noted with central congestion, bilateral pleural\n effusions. Lung bases are suboptimally assessed given low lung volumes\n though compared with prior, effusion and CHF is increased.\n IMPRESSION:\n 1. Dialysis catheter tip low, likely in IVC.\n 2. CHF, worse.\n Microbiology: Blood cx w/ NGTD\n ECG: ECG: V-paced (74)\n Assessment and Plan\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\n change and hypotension.\n .\n #. Hypotension: Concerning for sepsis given l-shift, indwelling HD line\n and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/\n prior HD line. Also has a pacemaker. Could not get a urine specimen.\n CXR w/ loss of diaphragm on R but w/o obvious infiltrate. Could also\n be from cardiogenic shock given baseline depressed EF. Cardiac output\n limited by paced rate.\n - cover w/ broad-spectrum antibiotics w/ Vanc/ given h/o ESBL and\n narrow as cx return\n - NE w/ goal MAP > 60\n - continue to gently bolus w/ LR given depressed EF, severe valvular\n disease\n - Repeat ECHO to eval for worsening CHF/Valvular disease\n - would ideally like to place an a-line for HD monitoring but I would\n be concerned to precipitate ischemia to R hand and L-hand already\n ischemic. Will follow w/ non-invasive for now.\n - check a MVO2\n - will ask EP to turn up rate in am\n .\n #. Acute respiratory acidosis: Unclear precipitant. DDX from percocets\n vs infection vs hypophosphatemia vs respiratory muscle fatigue\n - will try bipap for now to see if he tolerates\n - check phos\n - continue to monitor\n .\n #. Altered mental status: DDX from hypercarbia vs from percocets vs\n from infection. CT head w/o acute process. Could possibly be from\n meningitis but no nucal rigidity or headache.\n - continue to monitor\n .\n #. Hypoxia: CXR seems consistent w/ pulmonary edema. Likely from\n worsening valvular disease. Could also be an infiltrate that is hidden\n by edema. Apparently has been on L NC at rehab w/ unclear\n diagnosis but getting spiriva and albuterol. No formal dx of COPD.\n - albuterol and atrovent nebs\n .\n #. ESRD on HD: Dialysis MWF at Dialysis.\n - contact renal in the am for cvvh vs HD depending on BP\n .\n #. Systolic heart failure: Unclear if ischemic in etiology or from\n valvular disease (mod AS, severe MR).\n - appears total body volume overloaded despite hypotension.\n .\n #. Afib: INR supratherapeutic at 13.2. Now s/p 2 U FFP and 10 mg vit K\n IV X 1 in the ED. No obvious signs of bleeding. HCT w/\n hemoconcentration given baseline of 32. S/p AVN ablation and\n dual-chamber pacemaker.\n - hold coumadin\n - trend coags\n .\n #. PVD: Known LUE and bilateral LE PVD followed by Dr. .\n - appreciate vascular input, nothing to do for now\n .\n #. Macrocytic Anemia: Current hct likely hemoconcentration. Will watch\n for signs of bleeding given supra-therapeutic INR. B12/folate wnl in\n .\n - trend for now.\n - guaiac stools\n ICU Care\n Nutrition:NPO for now\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 12:30 AM\n Dialysis Catheter - 12:30 AM\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2134-04-12 00:00:00.000",
"description": "MICU Attending Note",
"row_id": 376063,
"text": "TITLE:\n Chart reviewed, patient examined. Case discussed in detail with\n resident. I agree with her note and gap outlined above. In addition,\n I would add/emphasize:\n 83M w/ multiple medical problems including ESRD on HD, Afib s/p AVN\n ablation and dual-chamber PM, systolic CHF (EF 25%, 2+AS, 3+MR)\n transferred from nursing home, w/ MS change. Pt has been at NH/rehab\n since last admission for UTI at . Son noted increase in\n pt\ns RR over the past several days as well as decrease in his energy\n level. While visiting pt son noted father to be solmolent and more\n confused. EMS activated. In ED, noted SBP 70s not responsive to IVF\n challenges, U/S guided CVL placement Lt femoral. Vanc/Levo/Flagyl\n started empirically for sepsis. INR 13.2, received IV vit K and FFP.\n Levophed started for hypotension resistant to IVF resuscitation.\n Transferred to MICU for managemend of sepsis, hemodynamics. No\n headache or photophobia.\n On exam:\n 95.9, 101/68, 70v-paced, 91% 5L NC\n Mask vent. Suppine in bed NAD\n Rales b/l\n Distant heart sounds\n Soft ntnd bs+\n 2+ pitting edema, dusky digits UE & LE worst on Lt hand\n No nuchal rigidity\n Data:\n 7.13/79/70 in ED 7.17/79/49 VBG in ICU\n W8.6 91S/1B Hct 48.4 plt 200\n Hco3 26 creat 4.3 .INR 13.2\n CT head\n no bleed, mass\n CXR\n lowish lung volumes, dialysis line goes down into IVC,\n cardiomegally, rotation, CHF increased vs. last\n AP/\n 83M w/ MMP presents with sepsis of unclear etiology given hypothermia,\n left shift, hypotension requiring pressors. Source unclear, several\n potential causes including line infxn from indwelling dialysis line,\n uti possible though makes little urine. BCx sent, ucx when able.\n Meningitis is in differential, esp given new confusion (but also has\n inc CO2, acute illness in elderly which could explain) but doesn\nt have\n neck stiffness, photophobia or headache. INR is too high for LP so\n cover empirically w/ broad spectrum abx.\n Hypercarbic resp failure with minimal disturbance of Aa gradient. A\n bit hard to explain as would expect more disturbance in oxygenation\n rather than acute disturbance in ventilation unless worsening of\n underlying lung disease. If doesn\nt turn around quickly would intubate\n to facilitate care. Appears to be acute respiratory acidosis by abg.\n Pt labs suggest strongly hemoconcentrated though CXR c/w chronic CHF\n (EF25% by last measure) , gentle fluid boluses as likely has small\n euvolemic zone.\n Has sig vasculopathy. Digits dusky at baseline. Carefully monitoring\n but is at risk while requiring pressors esp with alpha activity.\n Vascular consulted.\n Pt is dialysis dependent. Let renal know pt has been admitted.\n Remainder of plan as outlined in resident note above.\n Pt is critically ill.\n Time spent on care: 50\n"
},
{
"category": "Physician ",
"chartdate": "2134-04-12 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 376064,
"text": "Chief Complaint: Hypotension, altered mental status\n HPI:\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\n change. His son who accompanies him says that he has noticed an\n increase in his RR over the past few days and a decrease in his energy\n level. When he went to visit him this morning, he was very sleepy and\n not coherent which is a change so they called the ambulance. BP and O2\n sats there noted to be low. He did not eat breakfast this morning\n which is very unusual for him.\n .\n In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22.\n 97% on 5L NC. Arrived hypotensive in 70s, MS A+Ox3 here (but per son,\n not at baseline), BP unresponsive to 2L NS so left femoral central line\n placed under U/S guidance (as INR 13) and levo started. Moving arms\n but legs weaker. 2 U FFP, 10 vit K IV. Cxr w/ increased CHF. Head CT\n NEG. Could not pass foley X 2, now w/ small amt of blood. Given vanco\n 1g IV, levo 750 mg IV, flagyl 500 mg IV. Cool hands/feet, dopplerable\n PT but not DP, vasc called and will see on the floor. Guaiac + brown\n stool.\n .\n On arrival to the ICU, his son states he is more alert now but not back\n to baseline.\n .\n Review of systems: Pt. states he feels short of breath but cannot\n clarify further.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Horse/Equine Product Derivatives\n Unknown;\n Calcium Channel Blocking Agents-Benzothiazepines\n Headache;\n Metoprolol\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.12 mcg/Kg/min\n Other ICU medications:\n Other medications:\n (per med sheets)\n Coumadin 3 mg daily\n Dialysis at dialysis MWF\n Acetaminophen\n ASA 325 mg daily\n calcium acetate 667 mg 2 tabs tid\n dextroamphetamine 2.5 mg daily\n docusate\n folate 1 mg daily\n lotemax 0.5% eye drops\n mucinex 600 mg \n mucomyst nebs \n nephrocaps\n pantoprazole 40 mg daily\n sensipar 30 mg \n spiriva daily\n tobramycin 0.3% eye drops\n Valtrex 500 mg daily\n lactulose\n lorazepam 0.5 mg \n percocet 5/325 \n dexadrine 5 mg daily\n Albuterol\n vit B12 1000 mg daily\n nepro 235 daily\n albumin w/ dialysis\n darbapoetin w/ dialysis\n Past medical history:\n Family history:\n Social History:\n - PVD (Followed by ) w/ chronic LUE and bilateral LE ischemis\n - Chronic renal failure on HD x 4 years (thought to be due to\n obstructive uropathy, kidney stones, BPH)\n - Systolic heart failure w/ EF 25% on ECHO \n - Moderate aortic valve stenosis (area 1.0-1.2cm2). Moderate (2+)\n aortic regurgitation is seen. Moderate to severe (3+) mitral\n regurgitation is seen. There is mild pulmonary artery systolic\n hypertension. ()\n - Hx atrial fibrillation and paroxysmal atrial tachycardia\n - s/p AV nodal ablation and implantation of a dual chamber pacemaker\n - Baseline AV conduction delay\n - Hypertension\n - Coronary artery disease with old posterior MI on EKG and pMIBI\n in with EF44%, global hypokinesis, no reversible defects.\n - Hx Left 4-9th rib fx, Left hemothorax\n - R kidney stone s/p Lithotripsy\n (, complicated by ESBL Klebsiella UTI)\n - s/p stroke (cerebellar), found on MRI, sxs of gait instability\n - hx gait d/o, hand paresthesias, polyneuropathy, C3/C4 spinal\n cord compression cerival spondylosis, L median nerve injury\n - Anemia\n - Benign prostatic hypertrophy\n - Cluster headaches\n - Hx of positive PPD, never treated\n - Hx squamous cell and basal cell ca\n - HSV keratouveitis\n - ventral hernia\n - s/p open cholecystectomy \n - s/p small bowel resection (80-90%) for mesenteric ischemia\n - s/p umbilical hernia repair\n - s/p cystocele repair\n - s/p laminectomy - c/b osteomyelitis\n - s/p TURP \n There is no family history of premature coronary artery disease or\n sudden death.\n Patient has been at a NH and has not gotten home since hospitalization\n in . His wife lives in . He is a retired psychiatrist.\n Social history is significant for the remote tobacco use, 3ppd x 40\n years, quit 20 years ago. He drinks alcohol occasionally, denies\n illicit drug use.\n Review of systems:\n Flowsheet Data as of 02:32 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.5\nC (95.9\n HR: 70 (70 - 76) bpm\n BP: 101/58(68) {89/58(68) - 101/68(73)} mmHg\n RR: 18 (17 - 20) insp/min\n SpO2: 94%\n Heart rhythm: V Paced\n Height: 70 Inch\n Total In:\n 2,116 mL\n PO:\n TF:\n IVF:\n 116 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,116 mL\n Respiratory\n O2 Delivery Device: Bipap mask\n SpO2: 94%\n Physical Examination\n GENERAL: Awake but confused, NAD. Answers do not make sense.\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. dry MM. OP w/ poor dentition. Neck Supple.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or but very distant heart sounds.\n LUNGS: Occasional crackles anteriorly and posteriorly w/ poor\n inspiratory effort.\n ABDOMEN: NABS. Soft, midline scar. No HSM\n EXTREMITIES: anasarca, palp radial pulses, dopperable PT/DP\n bilaterally. L hand w/ purple fingertips on fingers 2, 3 and 4.\n SKIN: Xerosis.\n NEURO: Alert but not oriented. Speaking nonsensical sentences. Able\n to show 2 fingers on the R but not L. Able to wiggle toes. Could not\n follow other commands.\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:1.2 mmol/L\n Imaging: CT Head: wet read - no acute intracranial pathology.\n .\n CXR:\n FINDINGS: Comparison is made to . Right pacemaker and two\n intracardiac leads remain in place. Since prior exam, left IJ\n hemodialysis catheter has been placed, with tip low in position,\n possibly within the IVC. Vascular stens are noted in the left\n subclavian and brachiocephalic vein.\n Cardiomegaly again noted with central congestion, bilateral pleural\n effusions. Lung bases are suboptimally assessed given low lung volumes\n though compared with prior, effusion and CHF is increased.\n IMPRESSION:\n 1. Dialysis catheter tip low, likely in IVC.\n 2. CHF, worse.\n Microbiology: Blood cx w/ NGTD\n ECG: ECG: V-paced (74)\n Assessment and Plan\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\n change and hypotension.\n .\n #. Hypotension: Concerning for sepsis given l-shift, indwelling HD line\n and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/\n prior HD line. Also has a pacemaker. Could not get a urine specimen.\n CXR w/ loss of diaphragm on R but w/o obvious infiltrate. Could also\n be from a meningitis given altered mental status. Would be unsafe to\n perform LP in the setting of INR 13.3. Could also be from cardiogenic\n shock given baseline depressed EF. Cardiac output limited by paced\n rate.\n - cover w/ antibiotics to treat meningitis w/ Vanc/CTX, ampicillin\n acyclovir for now\n - NE w/ goal MAP > 60\n - continue to gently bolus w/ LR given depressed EF, severe valvular\n disease\n - Repeat ECHO to eval for worsening CHF/Valvular disease\n - would ideally like to place an a-line for HD monitoring but I would\n be concerned to precipitate ischemia to R hand and L-hand already\n ischemic. Will follow w/ non-invasive for now.\n - check a MVO2\n - will ask EP to turn up rate in am\n .\n #. Acute respiratory acidosis: Unclear precipitant. DDX from percocets\n vs infection vs hypophosphatemia vs respiratory muscle fatigue\n - will try bipap for now to see if he tolerates\n - check phos\n - continue to monitor\n .\n #. Altered mental status: DDX from hypercarbia vs from percocets vs\n from infection. CT head w/o acute process. Could possibly be from\n meningitis but no nucal rigidity or headache.\n - continue to monitor\n - treat empirically for meningitis as cannot safely do an LP given\n coagulopathy\n .\n #. Hypoxia: CXR seems consistent w/ pulmonary edema. Likely from\n worsening valvular disease. Could also be an infiltrate that is hidden\n by edema. Apparently has been on L NC at rehab w/ unclear\n diagnosis but getting spiriva and albuterol. No formal dx of COPD.\n - albuterol and atrovent nebs\n .\n #. ESRD on HD: Dialysis MWF at Dialysis.\n - contact renal in the am for cvvh vs HD depending on BP\n .\n #. Systolic heart failure: Unclear if ischemic in etiology or from\n valvular disease (mod AS, severe MR).\n - appears total body volume overloaded despite hypotension.\n .\n #. Afib: INR supratherapeutic at 13.2. Now s/p 2 U FFP and 10 mg vit K\n IV X 1 in the ED. No obvious signs of bleeding. HCT w/\n hemoconcentration given baseline of 32. S/p AVN ablation and\n dual-chamber pacemaker.\n - hold coumadin\n - trend coags\n .\n #. PVD: Known LUE and bilateral LE PVD followed by Dr. .\n - appreciate vascular input, nothing to do for now\n .\n #. Macrocytic Anemia: Current hct likely hemoconcentration. Will watch\n for signs of bleeding given supra-therapeutic INR. B12/folate wnl in\n .\n - trend for now.\n - guaiac stools\n ICU Care\n Nutrition:NPO for now\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 12:30 AM\n Dialysis Catheter - 12:30 AM\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2134-04-12 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 376098,
"text": "Chief Complaint: Hypotension, altered mental status\n HPI:\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\n change. His son who accompanies him says that he has noticed an\n increase in his RR over the past few days and a decrease in his energy\n level. When he went to visit him this morning, he was very sleepy and\n not coherent which is a change so they called the ambulance. BP and O2\n sats there noted to be low. He did not eat breakfast this morning\n which is very unusual for him.\n .\n In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22.\n 97% on 5L NC. Arrived hypotensive in 70s, MS A+Ox3 here (but per son,\n not at baseline), BP unresponsive to 2L NS so left femoral central line\n placed under U/S guidance (as INR 13) and levo started. Moving arms\n but legs weaker. 2 U FFP, 10 vit K IV. Cxr w/ increased CHF. Head CT\n NEG. Could not pass foley X 2, now w/ small amt of blood. Given vanco\n 1g IV, levo 750 mg IV, flagyl 500 mg IV. Cool hands/feet, dopplerable\n PT but not DP, vasc called and will see on the floor. Guaiac + brown\n stool.\n .\n On arrival to the ICU, his son states he is more alert now but not back\n to baseline.\n .\n Review of systems: Pt. states he feels short of breath but cannot\n clarify further.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Horse/Equine Product Derivatives\n Unknown;\n Calcium Channel Blocking Agents-Benzothiazepines\n Headache;\n Metoprolol\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.12 mcg/Kg/min\n Other ICU medications:\n Other medications:\n (per med sheets)\n Coumadin 3 mg daily\n Dialysis at dialysis MWF\n Acetaminophen\n ASA 325 mg daily\n calcium acetate 667 mg 2 tabs tid\n dextroamphetamine 2.5 mg daily\n docusate\n folate 1 mg daily\n lotemax 0.5% eye drops\n mucinex 600 mg \n mucomyst nebs \n nephrocaps\n pantoprazole 40 mg daily\n sensipar 30 mg \n spiriva daily\n tobramycin 0.3% eye drops\n Valtrex 500 mg daily\n lactulose\n lorazepam 0.5 mg \n percocet 5/325 \n dexadrine 5 mg daily\n Albuterol\n vit B12 1000 mg daily\n nepro 235 daily\n albumin w/ dialysis\n darbapoetin w/ dialysis\n Past medical history:\n Family history:\n Social History:\n - PVD (Followed by ) w/ chronic LUE and bilateral LE ischemis\n - Chronic renal failure on HD x 4 years (thought to be due to\n obstructive uropathy, kidney stones, BPH)\n - Systolic heart failure w/ EF 25% on ECHO \n - Moderate aortic valve stenosis (area 1.0-1.2cm2). Moderate (2+)\n aortic regurgitation is seen. Moderate to severe (3+) mitral\n regurgitation is seen. There is mild pulmonary artery systolic\n hypertension. ()\n - Hx atrial fibrillation and paroxysmal atrial tachycardia\n - s/p AV nodal ablation and implantation of a dual chamber pacemaker\n - Baseline AV conduction delay\n - Hypertension\n - Coronary artery disease with old posterior MI on EKG and pMIBI\n in with EF44%, global hypokinesis, no reversible defects.\n - Hx Left 4-9th rib fx, Left hemothorax\n - R kidney stone s/p Lithotripsy\n (, complicated by ESBL Klebsiella UTI)\n - s/p stroke (cerebellar), found on MRI, sxs of gait instability\n - hx gait d/o, hand paresthesias, polyneuropathy, C3/C4 spinal\n cord compression cerival spondylosis, L median nerve injury\n - Anemia\n - Benign prostatic hypertrophy\n - Cluster headaches\n - Hx of positive PPD, never treated\n - Hx squamous cell and basal cell ca\n - HSV keratouveitis\n - ventral hernia\n - s/p open cholecystectomy \n - s/p small bowel resection (80-90%) for mesenteric ischemia\n - s/p umbilical hernia repair\n - s/p cystocele repair\n - s/p laminectomy - c/b osteomyelitis\n - s/p TURP \n There is no family history of premature coronary artery disease or\n sudden death.\n Patient has been at a NH and has not gotten home since hospitalization\n in . His wife lives in . He is a retired psychiatrist.\n Social history is significant for the remote tobacco use, 3ppd x 40\n years, quit 20 years ago. He drinks alcohol occasionally, denies\n illicit drug use.\n Review of systems:\n Flowsheet Data as of 02:32 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.5\nC (95.9\n HR: 70 (70 - 76) bpm\n BP: 101/58(68) {89/58(68) - 101/68(73)} mmHg\n RR: 18 (17 - 20) insp/min\n SpO2: 94%\n Heart rhythm: V Paced\n Height: 70 Inch\n Total In:\n 2,116 mL\n PO:\n TF:\n IVF:\n 116 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,116 mL\n Respiratory\n O2 Delivery Device: Bipap mask\n SpO2: 94%\n Physical Examination\n GENERAL: Awake but confused, NAD. Answers do not make sense.\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. dry MM. OP w/ poor dentition. Neck Supple.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or but very distant heart sounds.\n LUNGS: Occasional crackles anteriorly and posteriorly w/ poor\n inspiratory effort.\n ABDOMEN: NABS. Soft, midline scar. No HSM\n EXTREMITIES: anasarca, palp radial pulses, dopperable PT/DP\n bilaterally. L hand w/ purple fingertips on fingers 2, 3 and 4.\n SKIN: Xerosis.\n NEURO: Alert but not oriented. Speaking nonsensical sentences. Able\n to show 2 fingers on the R but not L. Able to wiggle toes. Could not\n follow other commands.\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:1.2 mmol/L\n Imaging: CT Head: wet read - no acute intracranial pathology.\n .\n CXR:\n FINDINGS: Comparison is made to . Right pacemaker and two\n intracardiac leads remain in place. Since prior exam, left IJ\n hemodialysis catheter has been placed, with tip low in position,\n possibly within the IVC. Vascular stens are noted in the left\n subclavian and brachiocephalic vein.\n Cardiomegaly again noted with central congestion, bilateral pleural\n effusions. Lung bases are suboptimally assessed given low lung volumes\n though compared with prior, effusion and CHF is increased.\n IMPRESSION:\n 1. Dialysis catheter tip low, likely in IVC.\n 2. CHF, worse.\n Microbiology: Blood cx w/ NGTD\n ECG: ECG: V-paced (74)\n Assessment and Plan\n 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM,\n systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS\n change and hypotension.\n .\n #. Hypotension: Concerning for sepsis given l-shift, indwelling HD line\n and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/\n prior HD line. Also has a pacemaker. Could not get a urine specimen.\n CXR w/ loss of diaphragm on R but w/o obvious infiltrate. Could also\n be from a meningitis given altered mental status. Would be unsafe to\n perform LP in the setting of INR 13.3. Could also be from cardiogenic\n shock given baseline depressed EF. Cardiac output limited by paced\n rate.\n - cover w/ antibiotics to treat meningitis w/ Vanc/CTX, ampicillin\n acyclovir for now\n - NE w/ goal MAP > 60\n - continue to gently bolus w/ LR given depressed EF, severe valvular\n disease\n - Repeat ECHO to eval for worsening CHF/Valvular disease\n - would ideally like to place an a-line for HD monitoring but I would\n be concerned to precipitate ischemia to R hand and L-hand already\n ischemic. Will follow w/ non-invasive for now.\n - check a MVO2\n - will ask EP to turn up rate in am\n .\n #. Acute respiratory acidosis: Unclear precipitant. DDX from percocets\n vs infection vs hypophosphatemia vs respiratory muscle fatigue\n - will try bipap for now to see if he tolerates\n - check phos\n - continue to monitor\n .\n #. Altered mental status: DDX from hypercarbia vs from percocets vs\n from infection. CT head w/o acute process. Could possibly be from\n meningitis but no nucal rigidity or headache.\n - continue to monitor\n - treat empirically for meningitis as cannot safely do an LP given\n coagulopathy\n .\n #. Hypoxia: CXR seems consistent w/ pulmonary edema. Likely from\n worsening valvular disease. Could also be an infiltrate that is hidden\n by edema. Apparently has been on L NC at rehab w/ unclear\n diagnosis but getting spiriva and albuterol. No formal dx of COPD.\n - albuterol and atrovent nebs\n .\n #. ESRD on HD: Dialysis MWF at Dialysis.\n - contact renal in the am for cvvh vs HD depending on BP\n .\n #. Systolic heart failure: Unclear if ischemic in etiology or from\n valvular disease (mod AS, severe MR).\n - appears total body volume overloaded despite hypotension.\n .\n #. Afib: INR supratherapeutic at 13.2. Now s/p 2 U FFP and 10 mg vit K\n IV X 1 in the ED. No obvious signs of bleeding. HCT w/\n hemoconcentration given baseline of 32. S/p AVN ablation and\n dual-chamber pacemaker.\n - hold coumadin\n - trend coags\n .\n #. PVD: Known LUE and bilateral LE PVD followed by Dr. .\n - appreciate vascular input, nothing to do for now\n .\n #. Macrocytic Anemia: Current hct likely hemoconcentration. Will watch\n for signs of bleeding given supra-therapeutic INR. B12/folate wnl in\n .\n - trend for now.\n - guaiac stools\n ICU Care\n Nutrition:NPO for now\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 12:30 AM\n Dialysis Catheter - 12:30 AM\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Will cont vanco, CTX, amp, acyclovir given concern for infection. Will\n cont to trend VBGs. Call renal due to need for HD, f/u vasc recs but\n hold on any A-line given PVD. User BiPAP as tolerated. Discuss with\n family re: goals of care. Will attempt LP today after repeating coags.\n ------ Protected Section Addendum Entered By: , MD\n on: 08:55 ------\n"
},
{
"category": "Physician ",
"chartdate": "2134-04-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 376099,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 83M w/ multiple medical problems including ESRD on HD, Afib s/p AVN\n ablation and dual-chamber PM, systolic CHF (EF 25%, 2+AS, 3+MR)\n transferred from nursing home, w/ tachypnea and decreased\n responsiveness, in presumed septic shock.\n 24 Hour Events:\n In ED, noted SBP 70s not responsive to IVF challenges, U/S guided CVL\n placement Lt femoral. Vanc/Levo/Flagyl started empirically for\n sepsis. INR 13.2, received IV vit K and FFP. Levophed started for\n hypotension resistant to IVF resuscitation. Transferred to MICU for\n managemend of sepsis, hemodynamics.\n PMH:\n On continuous O2 at nursing home for unclear reasons\n CAD\n s/p pacer\n ICM- EF 15-20%\n ESRD on HD via L IJ cath x 4yrs d/t obstructive uropathy\n MR\n Afib\n PVD\n HTN\n SH: remote prior smoker\n Overnight, underwent head CT without focal change. Evaluated by\n Vascular svce. Remained on Levophed overnight. Started on BiPAP\n w/ 5LO2 overnight, now on NC 3L\n Patient unable to provide history: Encephalopathy\n Allergies:\n Horse/Equine Product Derivatives\n Unknown;\n Calcium Channel Blocking Agents-Benzothiazepines\n Headache;\n Metoprolol\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 03:00 AM\n Ceftriaxone - 04:00 AM\n Ampicillin - 05:30 AM\n Acyclovir - 06:00 AM\n Infusions:\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Vanco w/ HD, pantoprazole, tobramycin ou gtt, Atrovent nebs, ampcillin,\n acyclovir,\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 71 (70 - 76) bpm\n BP: 92/58(208) {89/58(68) - 102/68(208)} mmHg\n RR: 22 (17 - 25) insp/min\n SpO2: 94%\n Heart rhythm: V Paced\n Height: 70 Inch\n Total In:\n 2,857 mL\n PO:\n TF:\n IVF:\n 857 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,857 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress, No(t) Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), apical\n murmur\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : ant and post)\n Extremities: LUE fingertips dusky, B toes w/ some duskiness. 2+\n anasarca\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Not assessed, garbled speech, not oriented\n Labs / Radiology\n 12.5 g/dL\n 200 K/uL\n 114 mg/dL\n 3.6 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 43 mg/dL\n 97 mEq/L\n 137 mEq/L\n 39.8 %\n 14.8 K/uL\n [image002.jpg]\n 03:04 AM\n WBC\n 14.8\n Hct\n 39.8\n Plt\n 200\n Cr\n 3.6\n TropT\n 0.34\n Glucose\n 114\n Other labs: PT / PTT / INR:21.9/43.0/2.1, CK / CKMB /\n Troponin-T:33//0.34, Differential-Neuts:91%, Band:1%, Lactic Acid:1.2\n mmol/L, Albumin:4.1, Ca++:7.4 mg/dL, Mg++:1.2 mg/dL, PO4:5.6 mg/dL\n Fluid analysis / Other labs: VBG (admit)- 7.13 / 79 / 70\n fem line central venous sat- 56%\n VBG (0700)- 7.28 / 56 / 32 (on BiPAP)\n anion gap- 17\n Imaging: Head CT ()- nonfocal (per report)\n CXR ()- low lung vols, chr bilat ple effusions, L IJ HD cath in\n IVC, increased interstitial markings compared to film\n Echo ()- LVH, , EF 25-30%, mod AS, 3+ MR, mild PA HTN\n Microbiology: Blood- pending\n Assessment and Plan\n 83M w/ MMP presents with sepsis of unclear etiology currently in shock\n and pressor-dependent. Several potential causes including line infxn\n from indwelling dialysis line, uti possible though makes little urine.\n BCx sent, ucx when able. Meningitis is in differential, esp given new\n confusion (but also has inc CO2, acute illness in elderly which could\n explain) but doesn\nt have neck stiffness, photophobia or headache. INR\n is too high for LP so cover empirically w/ broad spectrum abx.\n SHOCK- Probably multifactorial: cardiogenic given ischemic\n cardiomyopathy and sepsis (poss sources include line infection vs urine\n vs CNS infection)\n -gentle fluid resuscitation given cardiomyopathy\n -could trend fem line venous pressures to follow\n -ABX as below\n PRESUMED unclear source\n -vanco + ampcillin + CTX + acyclovir covering broadly for\n meningoencephalitis (covering viral as well given hx of chronic HSV\n infxn) as well as for possible line infxn\n -f/u pan-culture\n ISCHEMIC CARDIOMYOPATHY w/ MITRAL REGURGITATION- mild troponin leak\n overnight, unclear if represents new ACS given renal failure\n -repeat echo w/ dopplers today to better assess\n AFIB- suprathrerapeutic on coumadin which we are holding\n -holding rate control for hypotension\n -V-paced on telemetry\n PERIPHERAL VASCULAR DISEASE- dusky digits\n -Vascular following, holding off on arterial line access given\n concern for further digital ischemia\n ALTERED MENTAL STATUS- persistent despite lowering of pCO2 w/ BiPAP\n overnight, now considering infection/ shock or primary CNS infxn vs\n primary vascular insult\n -treat shock state as above\n -minimize sedatives\n -will attempt LP to further evaluate once coagulopathy corrected\n -consider MRI brain if not improved w/ treatment of above.\n HYPERCARBIC RESPIRATORY DISTRESS- related to depressed mental status\n last night, tolerated BiPAP well\n -continue hs BiPAP\n ESRD- notify Renal svce\n -will need to notify re: placement of L IJ in IVC\n COAGULOPATHY- related to coumadin\n -getting vitamin K and FFP, following\n ICU Care\n Nutrition:\n Comments: npo\n Glycemic Control:\n Lines:\n Multi Lumen - 12:30 AM\n Dialysis Catheter - 12:30 AM\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 50 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2134-04-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 376074,
"text": "83yo mal w/ hx CHF, PVD, chronic renal failure on dialysis x3 weekly\n presenting to ED from Nursing home w/ altered mental status, A&Ox1,\n hypotensive to 70's and o2sat 80's. Pt place on 4L NC, femoral TLC\n placed, gave 1.5L NS w/ no change in BP, started levophed. Unable to\n place foley after x3 attempts. CT head neg. Given 2U FFP for INR 13,\n also given 10mg Vit K, Vanco, flagyl, and levoquin. To micu for\n further monitoring.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n All limbs cool w/ varying degrees of dusky tissue and some skin tears\n and scabs from previous injuries/tears. Vascular team following. LLE\n pedal pulses dopplarable, RLE dorsal pulses absent but post tib\n dopplerable. RLE popliteal pulse easily palpated. Radial pulses\n thready bilat. LUE w/ old fistulas. Coccyx w/ stage 1 pressure ulcer\n (pink)\n Action:\n Pneumo boots in place, ordered waffle boots but none in distribution,\n warm blankets on pt and socks on feet for warmth. Adaptic dressing on\n RLE skin tear. Aloe vesta cream to coccyx and frequent turns.\n Response:\n No change in skin issues @ this time.\n Plan:\n Vascular team following, waffle boots for bilat LE\ns when available,\n frequent turns and monitor for worsening perfusion.\n Altered mental status (not Delirium)\n Assessment:\n A&Ox1 w/ constant confused questions and statements; ? infection vs\n hypercarbia. No growth in cx\ns to this point (unable to get urine, x3\n attempts in ED to get foley but failed). Venous gas 7.17/79/42/30\n initially in MICU. Pt follows commands, PERRL 4mm/brisk, CT head was\n neg. BP w/ MAP >65 while on levophed from ED. Lactate 1.2. WBC 8.6.\n Got 2L IVF in ED, Vanco, levoquin, and flagyl.\n Action:\n Frequently reorient pt, started meropenem, ceftriaxone, acyclovir,\n ampicillin for ? meningitis and/or HD line infection. Placed on CPAP\n machine. Weaning Levophed as BP tolerates, gave 250cc LR bolus x1.\n Response:\n No change in MS, only small change in Levophed which is now @\n 0.10mcg/kg/min, WBC w/ AM labs was 14.8.\n Plan:\n Monitor MS, cont CPAP (pt to remain NPO @ this time), wean levophed as\n BP tolerates for goal MAP >60. Cont abx, pt will need blood cx\ns from\n HD line if he gets HD today.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Anuric, last HD on Friday . BUN/Creat 45/4.3 from ED\n labs. CXR w/ worsening bilat pl. eff. and CHF.\n Action:\n No intervention overnight\n Response:\n Remains anuric, AM BUN/Creat 43/3.6.\n Plan:\n Scheduled HD on M/W/F but unknown if it will be done today.\n"
},
{
"category": "Nursing",
"chartdate": "2134-04-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 376165,
"text": "83yo mal w/ hx CHF, PVD, chronic renal failure on dialysis x3 weekly\n presenting to ED from Nursing home w/ altered mental status, A&Ox1,\n hypotensive to 70's and o2sat 80's.To MICU for further monitoring.\n Altered mental status (not Delirium)\n Assessment:\n Alert/oriented X . Speaking nonsensically but cooperative and\n following commands.\n Action:\n ABX coverage. Frequent reorientation.\n Response:\n Afebrile.\n Plan:\n Goal MAPs >60. Monitor patient safety and provide reorientation and\n reassurance of safety.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n HD three times weekly.\n Action:\n Renal following.\n Response:\n Ongoing.\n Plan:\n Possible HD today.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Toes/fingers purple but dopplerable pulses.\n Action:\n Vascular in to assess.\n Response:\n Unchanged vascular status.\n Plan:\n Vascular will continue to follow.\n"
},
{
"category": "Nursing",
"chartdate": "2134-04-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 376081,
"text": "83yo mal w/ hx CHF, PVD, chronic renal failure on dialysis x3 weekly\n presenting to ED from Nursing home w/ altered mental status, A&Ox1,\n hypotensive to 70's and o2sat 80's. Pt place on 4L NC, femoral TLC\n placed, gave 1.5L NS w/ no change in BP, started levophed. Unable to\n place foley after x3 attempts. CT head neg. Given 2U FFP for INR 13,\n also given 10mg Vit K, Vanco, flagyl, and levoquin. To micu for\n further monitoring.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n All limbs cool w/ varying degrees of dusky tissue and some skin tears\n and scabs from previous injuries/tears. Vascular team following. LLE\n pedal pulses dopplarable, RLE dorsal pulses absent but post tib\n dopplerable. RLE popliteal pulse easily palpated. Radial pulses\n thready bilat. LUE w/ old fistulas. Coccyx w/ stage 1 pressure ulcer\n (pink)\n Action:\n Pneumo boots in place, ordered waffle boots but none in distribution,\n warm blankets on pt and socks on feet for warmth. Adaptic dressing on\n RLE skin tear. Aloe vesta cream to coccyx and frequent turns.\n Response:\n No change in skin issues @ this time.\n Plan:\n Vascular team following, waffle boots for bilat LE\ns when available,\n frequent turns and monitor for worsening perfusion.\n Altered mental status (not Delirium)\n Assessment:\n A&Ox1 w/ constant confused questions and statements; ? infection vs\n hypercarbia. No growth in cx\ns to this point (unable to get urine, x3\n attempts in ED to get foley but failed). Venous gas 7.17/79/42/30\n initially in MICU. Pt follows commands, PERRL 4mm/brisk, CT head was\n neg. BP w/ MAP >65 while on levophed from ED. Lactate 1.2. WBC 8.6.\n Got 2L IVF in ED, Vanco, levoquin, and flagyl.\n Action:\n Frequently reorient pt, started meropenem, ceftriaxone, acyclovir,\n ampicillin for ? meningitis and/or HD line infection. Placed on CPAP\n machine. Weaning Levophed as BP tolerates, gave 250cc LR bolus x1.\n Response:\n No change in MS, only small change in Levophed which is now @\n 0.10mcg/kg/min, WBC w/ AM labs was 14.8.\n Plan:\n Monitor MS, cont CPAP (pt to remain NPO @ this time), wean levophed as\n BP tolerates for goal MAP >60. Cont abx, pt will need blood cx\ns from\n HD line if he gets HD today.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Anuric, last HD on Friday . BUN/Creat 45/4.3 from ED\n labs. CXR w/ worsening bilat pl. eff. and CHF.\n Action:\n No intervention overnight\n Response:\n Remains anuric, AM BUN/Creat 43/3.6.\n Plan:\n Scheduled HD on M/W/F but unknown if it will be done today.\n Plan for ECHO today to reassess cardiac function (MR, EF, etc).\n"
},
{
"category": "Nursing",
"chartdate": "2134-04-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 376164,
"text": "83yo mal w/ hx CHF, PVD, chronic renal failure on dialysis x3 weekly\n presenting to ED from Nursing home w/ altered mental status, A&Ox1,\n hypotensive to 70's and o2sat 80's.To MICU for further monitoring.\n Altered mental status (not Delirium)\n Assessment:\n Alert/oriented X .\n Speaking nonsensically but cooperative and following commands.\n Wife and son in to visit saying some improvement than yesterday and\n mental status improving as shift advances.\n Concern for infectious process as patient remains hypotensive requiring\n Levophed gtt.\n BP 90s on Levophed; baseline reported to be 100s.\n Action:\n ABX coverage.\n Frequent reorientation.\n Response:\n Afebrile.\n Able to wean Levophed and off at 1700.\n Plan:\n Goal MAPs >60.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n HD three times weekly.\n Action:\n Renal following.\n Response:\n Ongoing.\n Plan:\n Will not require HD today.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Toes/fingers purple but dopplerable pulses.\n Action:\n Vascular in to assess.\n Response:\n Unchanged vascular status.\n Plan:\n Vascular will continue to follow.\n"
},
{
"category": "General",
"chartdate": "2134-04-12 00:00:00.000",
"description": "Generic Note",
"row_id": 376073,
"text": "TITLE: Respiratory\n Pt. placed on Bipap 8 PS, 5 Peep with 5 LPM O2 per VBG results. Pt\n showing slight improvement.\n"
},
{
"category": "Nursing",
"chartdate": "2134-04-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 376135,
"text": "83yo mal w/ hx CHF, PVD, chronic renal failure on dialysis x3 weekly\n presenting to ED from Nursing home w/ altered mental status, A&Ox1,\n hypotensive to 70's and o2sat 80's. Pt place on 4L NC, femoral TLC\n placed, gave 1.5L NS w/ no change in BP, started levophed. Unable to\n place foley after x3 attempts. CT head neg. Given 2U FFP for INR 13,\n also given 10mg Vit K, Vanco, flagyl, and levoquin. To micu for\n further monitoring.\n Altered mental status (not Delirium)\n Assessment:\n Alert/oriented X .\n Speaking nonsensically but cooperative and following commands.\n Wife and son in to visit saying some improvement than yesterday and\n mental status improving as shift advances.\n Concern for infectious process as patient remains hypotensive requiring\n Levophed gtt.\n BP 90s on Levophed; baseline reported to be 100s.\n Action:\n ABX coverage.\n Frequent reorientation.\n Response:\n Afebrile.\n Able to wean Levophed and off at 1700.\n Plan:\n Goal MAPs >60.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n HD three times weekly.\n Action:\n Renal following.\n Response:\n Ongoing.\n Plan:\n Will not require HD today.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Toes/fingers purple but dopplerable pulses.\n Action:\n Vascular in to assess.\n Response:\n Unchanged vascular status.\n Plan:\n Vascular will continue to follow.\n"
},
{
"category": "Physician ",
"chartdate": "2134-04-13 00:00:00.000",
"description": "ICU Event Note",
"row_id": 376210,
"text": "Clinician: Attending\n Went into Mr. room to pre-round this morning at 7:25 am. I\n noted that he was apneic w/o a pulse. A code was called. Recussitation\n was started w/ cpr and manually ventilating him. He was in PEA so\n received 2 amp epi, 2 amps of bicarb, 1 amp atropine, 10 U insulin, amp\n of D50. He was intubated by anesthesia. I called his wife who asked\n that recussitation be stopped. When recussitation stopped, he did not\n have any spontaneous respirations or heart sounds. Pupils fixed and\n dilated. Time of death: 07:30 am. His and and were\n notified and there will not be an autopsy. Dr. and Dr. \n were notified by pager.\n Total time spent: 60 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2134-04-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 376216,
"text": "EVENT NOTE:\n Report taken from nurse on previous shift at 06:50, saw pt at 07:00 as\n vascular team entered to examine patient.\n At 07:25 I entered to begin examining pt and to administer am\n medications, I was followed in to the room by the MICU resident. We\n noted that the pt was in respiratory arrest and called a code blue.\n Code continued until family contact and advised us to stop, time of\n death called by MICU resident.\n"
},
{
"category": "Nursing",
"chartdate": "2134-04-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 376192,
"text": "83yo mal w/ hx CHF, PVD, chronic renal failure on dialysis x3 weekly\n presenting to ED from Nursing home w/ altered mental status, A&Ox1,\n hypotensive to 70's and o2sat 80's.To MICU for further monitoring.\n Altered mental status (not Delirium)\n Assessment:\n Alert/oriented X . Speaking nonsensically but cooperative and\n following commands.\n Action:\n ABX coverage. Frequent reorientation.\n Response:\n Afebrile.\n Plan:\n Goal MAPs >60. Monitor patient safety and provide reorientation and\n reassurance of safety.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n HD three times weekly.\n Action:\n Renal following.\n Response:\n Ongoing.\n Plan:\n Possible HD today.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Toes/fingers purple but dopplerable pulses.\n Action:\n Vascular in to assess.\n Response:\n Unchanged vascular status.\n Plan:\n Vascular will continue to follow.\n"
},
{
"category": "Physician ",
"chartdate": "2134-04-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 376121,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 83M w/ multiple medical problems including ESRD on HD, Afib s/p AVN\n ablation and dual-chamber PM, systolic CHF (EF 25%, 2+AS, 3+MR)\n transferred from nursing home, w/ tachypnea and decreased\n responsiveness, in presumed septic shock.\n 24 Hour Events:\n In ED, noted SBP 70s not responsive to IVF challenges, U/S guided CVL\n placement Lt femoral. Vanc/Levo/Flagyl started empirically for\n sepsis. INR 13.2, received IV vit K and FFP. Levophed started for\n hypotension resistant to IVF resuscitation. Transferred to MICU for\n managemend of sepsis, hemodynamics.\n PMH:\n On continuous O2 at nursing home for unclear reasons\n CAD\n s/p pacer\n ICM- EF 15-20%\n ESRD on HD via L IJ cath x 4yrs d/t obstructive uropathy\n MR\n Afib\n PVD\n HTN\n SH: remote prior smoker\n Overnight, underwent head CT without focal change. Evaluated by\n Vascular svce. Remained on Levophed overnight. Started on BiPAP\n w/ 5LO2 overnight, now on NC 3L\n Patient unable to provide history: Encephalopathy\n Allergies:\n Horse/Equine Product Derivatives\n Unknown;\n Calcium Channel Blocking Agents-Benzothiazepines\n Headache;\n Metoprolol\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 03:00 AM\n Ceftriaxone - 04:00 AM\n Ampicillin - 05:30 AM\n Acyclovir - 06:00 AM\n Infusions:\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Vanco w/ HD, pantoprazole, tobramycin ou gtt, Atrovent nebs, ampcillin,\n acyclovir,\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 71 (70 - 76) bpm\n BP: 92/58(208) {89/58(68) - 102/68(208)} mmHg\n RR: 22 (17 - 25) insp/min\n SpO2: 94%\n Heart rhythm: V Paced\n Height: 70 Inch\n Total In:\n 2,857 mL\n PO:\n TF:\n IVF:\n 857 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,857 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress, No(t) Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), apical\n murmur\n Peripheral Vascular: (Right radial pulse:decreased), (Left radial\n pulse:decreased), (Right DP pulse:decreased), (Left DP pulse:decreased)\n Respiratory / Chest: (Breath Sounds: Crackles : ant and post)\n Extremities: LUE fingertips dusky, B toes w/ some duskiness. 2+\n anasarca\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Not assessed, garbled speech, not oriented\n Labs / Radiology\n 12.5 g/dL\n 200 K/uL\n 114 mg/dL\n 3.6 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 43 mg/dL\n 97 mEq/L\n 137 mEq/L\n 39.8 %\n 14.8 K/uL\n [image002.jpg]\n 03:04 AM\n WBC\n 14.8\n Hct\n 39.8\n Plt\n 200\n Cr\n 3.6\n TropT\n 0.34\n Glucose\n 114\n Other labs: PT / PTT / INR:21.9/43.0/2.1, CK / CKMB /\n Troponin-T:33//0.34, Differential-Neuts:91%, Band:1%, Lactic Acid:1.2\n mmol/L, Albumin:4.1, Ca++:7.4 mg/dL, Mg++:1.2 mg/dL, PO4:5.6 mg/dL\n Fluid analysis / Other labs: VBG (admit)- 7.13 / 79 / 70\n fem line central venous sat- 56%\n VBG (0700)- 7.28 / 56 / 32 (on BiPAP)\n anion gap- 17\n Imaging: Head CT ()- nonfocal (per report)\n CXR ()- low lung vols, chr bilat ple effusions, L IJ HD cath in\n IVC, increased interstitial markings compared to film\n Echo ()- LVH, , EF 25-30%, mod AS, 3+ MR, mild PA HTN\n Microbiology: Blood- pending\n Assessment and Plan\n 83M w/ MMP presents with sepsis of unclear etiology currently in shock\n and pressor-dependent. Several potential causes including line infxn\n from indwelling dialysis line, uti possible though makes little urine.\n BCx sent, ucx when able. Meningitis is in differential, esp given new\n confusion (but also has inc CO2, acute illness in elderly which could\n explain) but doesn\nt have neck stiffness, photophobia or headache. INR\n is too high for LP so cover empirically w/ broad spectrum abx.\n SHOCK- Probably multifactorial: cardiogenic given ischemic\n cardiomyopathy and sepsis (poss sources include line infection vs urine\n vs CNS infection)\n -gentle fluid resuscitation given cardiomyopathy\n -could trend fem line venous pressures to follow\n -ABX as below\n PRESUMED unclear source\n -vanco + ampcillin + CTX + acyclovir covering broadly for\n meningoencephalitis (covering viral as well given hx of chronic HSV\n infxn) as well as for possible line infxn\n -f/u pan-culture\n ISCHEMIC CARDIOMYOPATHY w/ MITRAL REGURGITATION- mild troponin leak\n overnight, unclear if represents new ACS given renal failure\n -repeat echo w/ dopplers today to better assess\n AFIB- suprathrerapeutic on coumadin which we are holding\n -holding rate control for hypotension\n -V-paced on telemetry\n PERIPHERAL VASCULAR DISEASE- dusky digits\n -Vascular following, holding off on arterial line access given\n concern for further digital ischemia\n ALTERED MENTAL STATUS- persistent despite lowering of pCO2 w/ BiPAP\n overnight, now considering infection/ shock or primary CNS infxn vs\n primary vascular insult\n -treat shock state as above\n -minimize sedatives\n -will attempt LP to further evaluate once coagulopathy corrected\n -consider MRI brain if not improved w/ treatment of above.\n HYPERCARBIC RESPIRATORY DISTRESS- related to depressed mental status\n last night, tolerated BiPAP well\n -continue hs BiPAP\n ESRD- notify Renal svce\n -will need to notify re: placement of L IJ in IVC\n COAGULOPATHY- related to coumadin\n -getting vitamin K and FFP, following\n ICU Care\n Nutrition:\n Comments: npo\n Glycemic Control:\n Lines:\n Multi Lumen - 12:30 AM\n Dialysis Catheter - 12:30 AM\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2134-04-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 376124,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 83M w/ multiple medical problems including ESRD on HD, Afib s/p AVN\n ablation and dual-chamber PM, systolic CHF (EF 25%, 2+AS, 3+MR)\n transferred from nursing home, w/ tachypnea and decreased\n responsiveness, in presumed septic shock.\n 24 Hour Events:\n In ED, noted SBP 70s not responsive to IVF challenges, U/S guided CVL\n placement Lt femoral. Vanc/Levo/Flagyl started empirically for\n sepsis. INR 13.2, received IV vit K and FFP. Levophed started for\n hypotension resistant to IVF resuscitation. Transferred to MICU for\n managemend of sepsis, hemodynamics.\n PMH:\n On continuous O2 at nursing home for unclear reasons\n CAD\n s/p pacer\n ICM- EF 15-20%\n ESRD on HD via L IJ cath x 4yrs d/t obstructive uropathy\n MR\n Afib\n PVD\n HTN\n SH: remote prior smoker\n Overnight, underwent head CT without focal change. Evaluated by\n Vascular svce. Remained on Levophed overnight. Started on BiPAP\n w/ 5LO2 overnight, now on NC 3L\n Patient unable to provide history: Encephalopathy\n Allergies:\n Horse/Equine Product Derivatives\n Unknown;\n Calcium Channel Blocking Agents-Benzothiazepines\n Headache;\n Metoprolol\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 03:00 AM\n Ceftriaxone - 04:00 AM\n Ampicillin - 05:30 AM\n Acyclovir - 06:00 AM\n Infusions:\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Vanco w/ HD, pantoprazole, tobramycin ou gtt, Atrovent nebs, ampcillin,\n acyclovir,\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 71 (70 - 76) bpm\n BP: 92/58(208) {89/58(68) - 102/68(208)} mmHg\n RR: 22 (17 - 25) insp/min\n SpO2: 94%\n Heart rhythm: V Paced\n Height: 70 Inch\n Total In:\n 2,857 mL\n PO:\n TF:\n IVF:\n 857 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,857 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress, No(t) Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), apical\n murmur\n Peripheral Vascular: (Right radial pulse:decreased), (Left radial\n pulse:decreased), (Right DP pulse:decreased), (Left DP pulse:decreased)\n Respiratory / Chest: (Breath Sounds: Crackles : ant and post)\n Extremities: LUE fingertips dusky, B toes w/ some duskiness. 2+\n anasarca\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Not assessed, garbled speech, not oriented\n Labs / Radiology\n 12.5 g/dL\n 200 K/uL\n 114 mg/dL\n 3.6 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 43 mg/dL\n 97 mEq/L\n 137 mEq/L\n 39.8 %\n 14.8 K/uL\n [image002.jpg]\n 03:04 AM\n WBC\n 14.8\n Hct\n 39.8\n Plt\n 200\n Cr\n 3.6\n TropT\n 0.34\n Glucose\n 114\n Other labs: PT / PTT / INR:21.9/43.0/2.1, CK / CKMB /\n Troponin-T:33//0.34, Differential-Neuts:91%, Band:1%, Lactic Acid:1.2\n mmol/L, Albumin:4.1, Ca++:7.4 mg/dL, Mg++:1.2 mg/dL, PO4:5.6 mg/dL\n Fluid analysis / Other labs: VBG (admit)- 7.13 / 79 / 70\n fem line central venous sat- 56%\n VBG (0700)- 7.28 / 56 / 32 (on BiPAP)\n anion gap- 17\n Imaging: Head CT ()- nonfocal (per report)\n CXR ()- low lung vols, chr bilat ple effusions, L IJ HD cath in\n IVC, increased interstitial markings compared to film\n Echo ()- LVH, , EF 25-30%, mod AS, 3+ MR, mild PA HTN\n Microbiology: Blood- pending\n Assessment and Plan\n 83M w/ MMP presents with sepsis of unclear etiology currently in shock\n and pressor-dependent. Several potential causes including line infxn\n from indwelling dialysis line, uti possible though makes little urine.\n BCx sent, ucx when able. Meningitis is in differential, esp given new\n confusion (but also has inc CO2, acute illness in elderly which could\n explain) but doesn\nt have neck stiffness, photophobia or headache. INR\n is too high for LP so cover empirically w/ broad spectrum abx.\n SHOCK- Probably multifactorial: cardiogenic given ischemic\n cardiomyopathy and sepsis (poss sources include line infection vs urine\n vs CNS infection)\n -gentle fluid resuscitation given cardiomyopathy\n -could trend fem line venous pressures to follow\n -ABX as below\n PRESUMED unclear source\n -vanco + ampcillin + CTX + acyclovir covering broadly for\n meningoencephalitis (covering viral as well given hx of chronic HSV\n infxn) as well as for possible line infxn\n -f/u pan-culture\n ISCHEMIC CARDIOMYOPATHY w/ MITRAL REGURGITATION- mild troponin leak\n overnight, unclear if represents new ACS given renal failure\n -repeat echo w/ dopplers today to better assess\n AFIB- suprathrerapeutic on coumadin which we are holding\n -holding rate control for hypotension\n -V-paced on telemetry\n PERIPHERAL VASCULAR DISEASE- dusky digits\n -Vascular following, holding off on arterial line access given\n concern for further digital ischemia\n ALTERED MENTAL STATUS- persistent despite lowering of pCO2 w/ BiPAP\n overnight, now considering infection/ shock or primary CNS infxn vs\n primary vascular insult\n -treat shock state as above\n -minimize sedatives\n -will attempt LP to further evaluate once coagulopathy corrected\n -consider MRI brain if not improved w/ treatment of above.\n HYPERCARBIC RESPIRATORY DISTRESS- related to depressed mental status\n last night, tolerated BiPAP well\n -continue hs BiPAP\n ESRD- notify Renal svce\n -will need to notify re: placement of L IJ in IVC\n COAGULOPATHY- related to coumadin\n -getting vitamin K and FFP, following\n ICU Care\n Nutrition:\n Comments: npo\n Glycemic Control:\n Lines:\n Multi Lumen - 12:30 AM\n Dialysis Catheter - 12:30 AM\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n ------ Protected Section ------\n Attempted to perform LP at bedside. Given prior history of lumbar\n laminectomy and possible fusion we were not able to palpate anatomic\n landmarks to guide procedure. Will contact IR for asistance in AM.\n ------ Protected Section Addendum Entered By: , MD\n on: 17:08 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2134-04-13 00:00:00.000",
"description": "Generic Note",
"row_id": 376179,
"text": "TITLE: Resp Care Note, Pt placed on bipap and remained on all night.\n Needed hands restrained otherwise pt was fine.Rx\nd with atrovent Q6\n last 0600. Will cont to follow.\n"
},
{
"category": "Nursing",
"chartdate": "2134-04-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 376114,
"text": "Altered mental status (not Delirium)\n Assessment:\n Alert/oriented X .\n Speaking nonsensically but cooperative and following commands.\n Wife and son in to visit saying some improvement than yesterday.\n Concern for infectious process as patient remains hypotensive requiring\n Levophed gtt.\n BP 90s on Levophed; baseline reported to be 100s.\n Action:\n ABX coverage.\n Frequent reorientation.\n Response:\n Afebrile.\n Able to wean Levophed.\n Plan:\n Will obtain LP.\n Will wean pressor as tolerated.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n HD three times weekly.\n Action:\n Renal following.\n Response:\n Ongoing.\n Plan:\n Will not require HD today.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Toes/fingers purple but dopplerable pulses.\n Action:\n Vascular in to assess.\n Response:\n Unchanged vascular status.\n Plan:\n Vascular will continue to follow.\n"
},
{
"category": "ECG",
"chartdate": "2134-04-11 00:00:00.000",
"description": "Report",
"row_id": 259130,
"text": "Ventricular paced rhythm with underlying atrial flutter. Compared to the\nprevious tracing of atrial flutter now manifest.\n\n"
}
] |
15,285 | 181,964 | hypermagnesemia - With regards to his hypermagnesemia, it appears likely that he experienced dangerously elevated levels of magnesium, with a maximum of 6.5 on admission. The renal service was consulted, and HD was considered, though his electrolytes normalized shortly after admission, and his Cr returned to baseline with rehydration. It is felt that the etiology of his hypermagnesemia was primarily secondary to excessive Milk of Magnesia intake prior to admission and ARF (he had been on oxycontin/oxycodone following toe amputation, and was using laxative to counteract his constipation). Hypotension - shortly after hospital admission, Mr. became hypotensive in setting of hypermagnesemia and lasix diuresis, and was briefly admitted to the MICU. His MICU course was notable for placement of a R subclavian line, volume resuscitation with IV saline, and briefly requiring pressors, with subsequent rapid resolution of his hypotension. Hypoxia - MICU course also notable for an apneic episode, lasting 50 seconds, with O2 desaturation from 100% RA to 90% RA, and requiring emergent intubation. He was successfully extubated the following day. It is felt that his hypoxia was likely secondary to hypermagnesemia. His electrolytes normalized and he was transfered to the medical floor. ARF - His Cr 1.6 on admission, and improved back to his baseline of .5 -.9 with IV hydration. Cr remained stable for remainder of hospital course arrhythmia - Mr. has been maintained on dofetilide, given his history of ventriculra tachycardia (VT). He was noted to have frequent ectopy while on telemetry and on daily ECGs, and given his h/o VT, an EP consult was obtained for further titration of his medication regimen. His dofetilide was discontinued given his ARF, and out of concern for possible future episodes of renal insufficiency (as it is not clear what precipitated his ARF on admission). After an appropriate time, he was initiated on quinidine, and maintained on a dose of 324 mg SR twice daily. His QT interval was monitored with daily ECGs for the first several weeks, and remained stable. He has continued to have frequent ectopy, with frequent episodes of short runs of supraventricular tachycardia. He was monitored on telemetry for 9 days, notable only for frequent ectopy and short runs of SVT. Prior to discharge, he was given of Hearts monitor, for further evalution and titration of his quinidine dosing, and he will follow-up with Dr. , his cardiologist. UTI - Mr. was noted to have a proteus UTI, with a multiply-drug resistant isolate. He was initially treated for 3 days with levofloxacin, though switched to ceftriaxone when the sensitivities returned (fluoroquinolone resistant isolate), with resolution of his leukocytosis. diarrhea - noted to have episodes of diarrhea worrisome for C difficile colitis. Though the toxin assay was negative, given his significant leukocytosis and abx exposure, he was treated with an empiric course of metronidazole via his NG-tube. Altered mental status - On the medical floor, Mr continued to be deleirius for much of the hospitalization. A neurology consult was obtained, and felt that his delerium and lethargy were likely attributable to toxic/metabolic effects of his acute illness, that may persist for weeks after stabilization/resolution of his acute issues. Multiple medication changes were made to remove or reduce non-essential medications. EEG demonstrated encephalopathy (toxic-metabolic pattern), with no evidence of epileptiform activity, and brain MRI did not reveal any evidence of an acute intracranial process. Nutrition - Mr. required NG tube placement for medications and for nutrition, given his altered sensorium, which caused him to fail his first three speech and swallow evaluations. An NG tube was placed on two occasions via IR (he pulled the first out), and he was maintained on tube feeds for much of the hospitalization. A fourth Speech and Swallow evaluation, including videoswallow study, was obtained, and it was determined that Mr. could in fact resume PO intake with pureed solids and thin liquids, with Boost supplementation with all meals, and with strict aspiration precautions. His NG tube was removed. A calorie count was instated for several days, and although Mr. only achieved approximately of his calorie target and of his protein target, his family was quite encouraged by his progress and on multiple occasions clearly stated that they would not want to have a PEG tube placed for enteral nutrition. He also had not met his fluid goals, and required saline rehydration several days prior to discharge. Parkinson's - maintained on carbidopa/levodopa, though Mirapex was discontinued in an effort to simplify his medical regimen, given his ongoing delerium. pulmonary fibrosis - maintained on 5mg/day of prednisone for much of the hospitalizaiton, though dose decreased to 2.5mg/day several days prior to discharge as above (regimen simplification). Gout - Mr. , in the setting of dehydration, was noted to have an erythematous second MCP of the Right hand several days prior to discharge, tender to palpation. Given his h/o gout, it is likely that this represented a gouty arthritis, and was self-limited. I have discussed with his family members that when his delerium clears, it may be appropriate to restart him on allopurinol, which he should discuss with his PCP. s/p toe amputation - vascular surgery was consulted to follow the patient, and twice daily dressing changes were carreid out, with evidence of granulation tissue and overall good wound healing. He is to have once daily dry dressing changes following discharge. tinea - axillary rash with likely fungal involvement, and miconazole was applied. | There is a small old lacunar infarct within the right inferior cerebellum. An endotracheal tube has been removed. FINDINGS: AP single view of the chest has been obtained with the patient in semi-upright position. FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view. Normal signal flow voids are seen within the intracranial portions of the carotid and basilar arteries. There is scattered nonspecific T2 hyperintensity involving the periventricular white matter and centrum semiovale suggestive of chronic microvascular ischemic or gliotic changes. A single supine portable abdominal radiograph was obtained. A right subclavian line terminates within the lower SVC. AP PORTABLE CHEST X-RAY: The study is seriously limited secondary to patient positioning. FINDINGS: A right subclavian line terminates within the region of the SVC/right atrial junction. 2) Slight interval worsening of bibasilar atelectasis. REASON FOR THIS EXAMINATION: intubated FINAL REPORT INDICATION: Elevated lactate, right subclavian line placement. FINDINGS: An NG tube is in position with its distal tip terminating near the fundus of the stomach. The cardiac, mediastinal, and hilar silhouettes are unchanged. There is mild generalized sulcal dilatation consistent with mild cortical atrophy. FINDINGS: AP single view of the chest with patient in semi-upright position demonstrates the presence of an NG tube reaching far below the diaphragm and being curled in the fundus of the stomach. A right subclavian approach central venous line is identified terminating overlying the SVC just above the expected site of the atrial junction. There is slight interval worsening in the bibasilar atelectasis. IMPRESSION: 1) Interval placement of an ET tube and no evidence of pneumothorax. IMPRESSION: Moderate amount of stool in the rectosigmoid colon. The right costophrenic angle is partially excluded from this examination. A right-sided subclavian approach central venous line remains in unchanged position. Since the previous tracing of ventricular ectopyis absent. FINAL REPORT TYPE OF EXAMINATION: Chest PA and lateral. IMPRESSION: Withdrawal of orogastric tube, which is not visualized beyond the oropharynx region. This position appears unchanged; however, it is noted that some barium contrast medium has now entered the stomach. REASON FOR THIS EXAMINATION: S/P partial D/C OF NGT, replacement. There is discoid atelectasis at the right lung base with adjacent mild elevation of the right hemidiaphragm. CLINICAL INDICATION: Hypoxia. Central venous catheter and orogastric tube remain in place. There exist, however, thin plate atelectasis in the right base, a finding which was already noted on the preceding study. A right subclavian central venous catheter remains in good position within the distal superior vena cava. Ventricular bigeminy amd trigeminy. Cardiac and mediastinal contours are unchanged compared to the prior study. FINDINGS: The right IJ line is unchanged compared to the prior study. 12:19 PM CHEST (PA & LAT) Clip # Reason: pls assess for aspiration. Low lung volumes with bibasilar atelectasis persists. CLINICAL INDICATION: Nasogastric tube assessment. Sinus rhythmInterpolated PVCsLow QRS voltages in limb leadsSince previous tracing, new ventricular premature complexes The cardiac mediastinal, and hilar silhouettes remain unchanged. An NG tube is presently seen to pass the stomach and terminating in the jejunum distal to the duodenum. 4:49 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: S/P partial D/C OF NGT, replacement. Sinus rhythmFrequent ventricular premature complexesLow QRS voltages in limb leads - is nonspecificProbable left atrial abnormalitySince previous tracing of , no significant change Quinidine as ordered, QTC wnl.Resp: LS ess clear, diminshed bases. S+S to re-eval when MS clear.GU- U/O adequate 60-120cc/hr. .Gi/GU: NGT pulled by pt; replaced and placement confirmed by G. . Otherwise, nodiagnostic interim change.TRACING #1 Pt presented to PCP with c/o weakness/lethargy. Moves all extremeties and PERL.Resp: Extubated after succesful wean to PSV and SBT. Cont w/laxatives. Updated on plan of care and met with pulmonologist today.Dispo- C/o to floor with 1:1 observer. hydrating to lower mag level and labs sent at 0420 and pending. Predisone taper to begin tom'row per pulm.ID- Gram + cocci from arterial line on , vanco X 1 given, art line d/c'd and cultures resent from art line and central line this am. NGT placed d/t failed s+s eval. Sinus rhythmFrequent multifocal PVCsBorderline first degree A-V blockLow QRS voltages in limb leadsNondiagnostic T wave flatteningBorderline Q-Tc interval prolongedSince previous tracing, QTc slightly shorter Hypertensive to 170-180's with agitation; 140-160's at rest. no nedema present.endo: glu in acceptable range. Ventriculartrigeminy. Q-T interval prolongation. PT seemed to have more ectopy after extubation. MD notified. Received 1 dose vanco for +BC from aline . MICU Nursing Progress Note 0700-1900Pt weaned off dopamine and propofol. KCL and Calicum gluconate repleted.Endo- QID FS requiring no coverage. CVP running at goal of , IVF stopped. line removed d/t gram + cocci growing out of bottles, 2 more sets of BC sentReview of Systems-Neuro- MS waxing and , short periods of agitation restraints, incoherent at times, lethargic, arousing easily to voice. Need for aggressive bowel regimen vs. slowed bowel motility Speech and swallow in am. NPN 7A-7PEVENTS: Mg down to 2.8 from 3.2, CREAT improving to .9 (baseline .8), MS s+s eval- pt. of NIV for sleep apnea. Full code.Plan: Replete lytes prn. Baseline artifactSinus rhythmVentricular premature complexesLow limb leads voltage - is nonspecificSince previous tracing of , ventricular ectopy present BBS clear in upper lobes, crackles noted in lower lobes. | 42 | [
{
"category": "Radiology",
"chartdate": "2169-01-11 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 854355,
"text": " 3:45 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please place NG tube via fluoro. Unable to place at bedside\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with parkinsons, delerium, requires NG tube for meds and tube\n feeds\n REASON FOR THIS EXAMINATION:\n please place NG tube via fluoro. Unable to place at bedside.\n ______________________________________________________________________________\n FINAL REPORT\n NAS0-INTESTINAL FEEDING TUBE PLACEMENT\n\n CLINICAL INDICATION: Patient with delirium, needs feeding tube for feeding\n and medications.\n\n FINDINGS: - feeding tube was placed under fluoroscopy into\n the duodenum. Placement was confirmed with 10 cc of Conray. No signs of\n perforation were seen.\n\n IMPRESSION: Successful placement of feeding tube with fluoroscopy.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853834,
"text": " 1:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check proper placement of NGT\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with PD and mental status s/p NGT placement\n REASON FOR THIS EXAMINATION:\n check proper placement of NGT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: An 82-year-old man with new NG tube, please assess placement.\n\n TECHNIQUE: AP supine portable chest at 1:15 a.m.\n\n COMPARISON: Compared to the prior study of yesterday at 8:35 in the morning.\n\n FINDINGS:\n\n The NG tube tip is now at the esophageal gastric junction, it should be\n advanced. Change in the position of the right subclavian line. No\n cardiopulmonary disease.\n\n IMPRESSION:\n\n NG tube tip is at the EG junction, it should be advanced.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853466,
"text": " 5:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubated\n Admitting Diagnosis: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with and elevated lactate s/p intubation\n and s/p R subclavian placement.\n REASON FOR THIS EXAMINATION:\n intubated\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Elevated lactate, right subclavian line placement.\n\n FINDINGS: A right subclavian line terminates within the region of the\n SVC/right atrial junction. An endotracheal tube has been removed. The heart\n size and mediastinal contours are unchanged. There are low lung volumes.\n Atelectasis is present at both lung bases with no evidence of pulmonary\n parenchumal consolidation, pneumothorax, or pleural effusion. The right\n costophrenic angle is partially excluded from this examination.\n\n IMPRESSION: Low lung volumes with atelectasis within both lung bases. No\n evidence of pneumothorax or pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853338,
"text": " 6:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval central line placement\n Admitting Diagnosis: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with and elevated lactate s/p intubation\n and s/p R subclavian placement.\n REASON FOR THIS EXAMINATION:\n eval central line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 82-year-old man with and elevated lactate\n status post intubation and status post right subclavian placement. Evaluate\n line placement and rule pneumothorax.\n\n Comparison is made with a prior AP semi-erect portable chest x-ray dated\n at 4:55 a.m.\n\n AP SUPINE PORTABLE CHEST X-RAY: An endotracheal tube is seen terminating\n approximately 2 cm superior to the carina. A right subclavian central venous\n catheter is seen in the distal superior vena cava. There is no evidence of\n pneumothorax. The nasogastric tube is seen terminating below the diaphragm\n with the tip curled within the fundus of the stomach. The cardiac,\n mediastinal, and hilar silhouettes are unchanged. The pulmonary vasculature\n bilaterally appears normal. The left costophrenic angle is not seen. The\n imaged portions of bilateral lungs appear clear without evidence of\n infiltrates, effusions, or consolidations. There is mild atelectasis at the\n left lung base. Surrounding soft tissue and osseous structures reveal\n degenerative changes along the thoracic spine.\n\n IMPRESSION:\n\n 1) Right subclavian central venous catheter in good position in the distal\n superior vena cava.\n 2) No pneumothorax.\n 3) Mild left lower lobe atelectasis.\n 4) No evidence of acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853540,
"text": " 2:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p NGT adjustment\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with hypermagnesemia and elevated lactate s/p intubation\n and s/p R subclavian placement.\n REASON FOR THIS EXAMINATION:\n s/p NGT adjustment\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: NG tube placement.\n\n FINDINGS:\n\n An NG tube is in position with its distal tip terminating near the fundus of\n the stomach. A right subclavian line terminates within the lower SVC. A\n metallic bar obscures the right chest limiting evaluation of the right\n hemithorax. The heart size and mediastinal contours are unchanged.\n Atelectasis is seen within both lung bases. No osseous abnormalities are\n identified.\n\n IMPRESSION:\n\n An NG tube passes into the stomach with its distal tip near the fundus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 854482,
"text": " 3:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls assess interval change, patient with worsening leukocyto\n Admitting Diagnosis: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 M w/ parkinsons, altered mental status, with elevated temp, worsening\n leukocytosis despite treatment of UTI.\n REASON FOR THIS EXAMINATION:\n pls assess interval change, patient with worsening leukocytosis, ? aspiration.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: History of Parkinson's, altered mental status, elevated\n temperature, worsening leukocytosis despite treatment of urinary tract\n infection, assess for interval changes.\n\n FINDINGS:\n\n AP single view of the chest has been obtained with the patient in semi-upright\n position. Comparison is made with a similar portable chest examination dated\n . A right-sided subclavian approach central venous line remains in\n unchanged position. An NG tube has been placed and reaches well into the\n stomach with an additional curvature indicating its advancement in the\n duodenum and jejunum. The lungs remain clear without evidence of pulmonary\n vascular congestion or acute infiltrates. No pneumothorax is seen. The\n lateral pleural sinuses remain free.\n\n IMPRESSION:\n\n No evidence of new infiltrates including aspiration pneumonia as can be\n identified on a single portable chest examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853862,
"text": " 10:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: correct placement of NGT\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with PD and mental status s/p NGT advancement\n REASON FOR THIS EXAMINATION:\n correct placement of NGT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: An 82-year-old man status post nasogastric tube advancement, please\n check placement.\n\n Portable AP and chest at 11:41 a.m.: Since prior study on the same\n date, the NG tube has been advanced. The tip now appears to be in the fundus\n of the stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-25 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 856088,
"text": " 6:25 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: ongoing altered MS, without clear etiology. Had hypoxic/hyp\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with ?Parkinsons, s/p toe amputation, CAD\n REASON FOR THIS EXAMINATION:\n ongoing altered MS, without clear etiology. Had hypoxic/hypotensive episode\n two weeks ago.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status, question Parkinson's.\n\n TECHNIQUE:\n\n Multiplanar T1- and T2-weighted images of the brain along with diffusion-\n weighted images were obtained. Correlation is made to the prior head CT from\n .\n\n FINDINGS:\n\n There are no acute territorial infarcts seen on diffusion images. There is\n mild generalized sulcal dilatation consistent with mild cortical atrophy. No\n midline shift or mass effect is seen. Diffusion-weighted images are within\n normal. Overall exam is partially degraded by repeated motion artifact.\n\n There is scattered nonspecific T2 hyperintensity involving the periventricular\n white matter and centrum semiovale suggestive of chronic microvascular\n ischemic or gliotic changes. Normal signal flow voids are seen within the\n intracranial portions of the carotid and basilar arteries. There is a small\n old lacunar infarct within the right inferior cerebellum.\n\n IMPRESSION:\n\n Chronic periventricular microvascular ischemic changes. No acute territorial\n infarct seen. Old lacune within the right cerebellum.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-03 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 853442,
"text": " 7:24 PM\n PORTABLE ABDOMEN Clip # \n Reason: ?reason for 2 weeks constipation, hypoactive bowel sounds\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with s/p intubation and now extubation secondary to\n hypermagnesemia.\n REASON FOR THIS EXAMINATION:\n ?reason for 2 weeks constipation, hypoactive bowel sounds\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Two weeks of constipation and hypo-active bowel sounds.\n\n A single supine portable abdominal radiograph was obtained. There is no\n evidence of bowel obstruction. Air is seen throughout the small and large\n bowel. There is a moderate amount of stool within the sigmoid colon and\n rectum. Changes are present within the spine from a convex left lumbar\n scoliosis with extensive degenerative changes.\n\n IMPRESSION: Moderate amount of stool in the rectosigmoid colon. No evidence\n of bowel obstruction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853332,
"text": " 4:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT placement and CHF?\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with hypermagnesemia and elevated lactate s/p intubation\n\n REASON FOR THIS EXAMINATION:\n eval ETT placement and CHF?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: An 82-year-old with ET tube placement and questionable CHF.\n\n the study was obtained at 0455 hours and comparison is made to the prior study\n of the same day obtained at 0314 hours. Since the prior study, there has been\n placement of an ET tube. The tip is 1.8 cm above the carina. Partial\n atelectasis involving the lower lobes are noted. Unchanged. There is no\n evidence of pneumothorax. There is no evidence of pleural effusion. There is\n no evidence of congestive heart failure.\n\n IMPRESSION:\n\n 1) Interval placement of an ET tube and no evidence of pneumothorax.\n 2) Partial atelectasis involving the lower lobes.\n 3) No evidence of congestive heart failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 853327,
"text": " 3:07 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for stroke or ICH\n Admitting Diagnosis: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with delta MS .\n REASON FOR THIS EXAMINATION:\n eval for stroke or ICH\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82-year-old male with MS . Evaluate for stroke\n or intracranial hemorrhage.\n\n TECHNIQUE: Contiguous 5 mm axial images were obtained from the vertex to the\n base of the skull on bone and soft tissue images. There are no prior studies\n for comparison.\n\n FINDINGS: There is no intracranial hemorrhage. There is no mass effect, shift\n of normally midline structures, hydrocephalus, or large territorial infarct.\n There are mild hypodense areas within the periventricular and deep white\n matter, consistent with chronic small vessel ischemic infarcts. There are a\n few small old lacunar infarcts, one within the right cerebellar hemisphere,\n the other within the left basal ganglia and left frontal lobe.\n\n IMPRESSION: No acute intracranial abnormality visualized.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853574,
"text": " 11:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please confir NGT placement\n Admitting Diagnosis: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with and elevated lactate s/p intubation\n and s/p R subclavian placement.\n REASON FOR THIS EXAMINATION:\n please confir NGT placement\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: An 82-year-old man with hypomagnesemia and elevated lactate\n status post intubation and status post right subclavian placement. Please\n confirm NG tube placement.\n\n Comparison is made with a prior AP portable chest x-ray dated at\n 1526.\n\n AP PORTABLE CHEST X-RAY: The study is seriously limited secondary to patient\n positioning. A nasogastric tube is seen descending to the level of the\n diaphragm with the tip terminating in the region of the gastroesophageal\n junction. Repositioning is recommended. Osseous structures demonstrate\n diffuse degenerative changes along the thoracic and lumbar spine with endplate\n destruction at the L3/L4 interspace. Correlate clinically.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853725,
"text": " 8:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate placement of NGT.\n Admitting Diagnosis: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with and elevated lactate s/p\n intubation and s/p R subclavian line palcement with h/o incorrectly placed NGT.\n REASON FOR THIS EXAMINATION:\n Please evaluate placement of NGT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 82-year-old man with and elevated lactate\n status post intubation and right subclavian line placement and NG tube\n placement. Evaluate for NG tube placement.\n\n Comparison is made with a prior AP portable chest x-ray dated .\n\n FINDINGS:\n\n AP semi-erect portable chest x-ray: A right subclavian central venous\n catheter is seen with the tip terminating in the mid/distal superior vena\n cava. Nasogastric tube descends below the diaphragm and appears with the tip\n in good position in the body of the stomach. The cardiac, mediastinal, and\n hilar silhouettes remain stable. The aorta is tortuous with mural\n calcifications. There is no evidence of pneumothorax. Low lung volumes are\n seen bilaterally. There is slight interval worsening in the bibasilar\n atelectasis. Surrounding soft tissue and osseous structures again reveal\n diffuse degenerative changes along the thoracic spine with wedging of the L4-\n L5 vertebral bodies.\n\n IMPRESSION:\n\n 1) Nasogastric tube in good position with the tip in the body of the stomach.\n\n 2) Slight interval worsening of bibasilar atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 854055,
"text": " 9:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate\n Admitting Diagnosis: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 M with PD and mental status changes with ? infection\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Parkinsons and mental status changes, questionable infection.\n Evaluate for pulmonary infiltrates.\n\n FINDINGS:\n\n AP single view of the chest with patient in semi-upright position demonstrates\n the presence of an NG tube reaching far below the diaphragm and being curled\n in the fundus of the stomach. A right subclavian approach central venous line\n is identified terminating overlying the SVC just above the expected site of\n the atrial junction. There is no pneumothorax. The accessible pulmonary\n vasculature appears normal without evidence of congestion. No acute\n infiltrates can be identified. Relatively high positioned diaphragms are\n related to poor inspirational effort and lordotic position of the patient.\n\n Preceding chest examination of had special over penetration\n exposure to identified tubes. The pulmonary lung fields cannot be compared.\n\n IMPRESSION:\n\n No evidence of CHF or acute infiltrates on portable AP lordotic view.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 854307,
"text": " 10:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p NGT placement, pls assess placement and interval change.\n Admitting Diagnosis: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 M w/ parkinsons, altered mental status, episode of hypoxia .\n\n REASON FOR THIS EXAMINATION:\n s/p NGT placement, pls assess placement and interval change.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 82-year-old man with hypoxia. NG tube placement.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n The comparison is made with a prior chest radiograph dated .\n\n FINDINGS:\n\n The right IJ line is unchanged compared to the prior study. Cardiac and\n mediastinal contours are unchanged compared to the prior study. Bilateral\n lung volumes are low. Bibasilar atelectasis is also noted. No CHF.\n\n Nasogastric tube appears to be terminating in the mid portion of the thorax,\n at the level of carina.\n\n IMPRESSION:\n\n Nasogastric tube terminating in middle thorax, at the level of carina. Without\n lateral view, the precise location of the tube, in terms of whether this is in\n esophagus or trachea, is unclear. Please correlate clinically.\n\n The information is communicated with the referring physician, . \n , by telephone in the morning of .\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853325,
"text": " 3:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA or CHF\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with hypermagnesemia and elevated lactate\n REASON FOR THIS EXAMINATION:\n eval for PNA or CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: An 82-year-old male with elevated lactate. Evaluate for\n pneumonia or CHF.\n\n FINDINGS:\n\n Comparisons made to a prior radiograph from .\n\n The heart size and mediastinal contours are unchanged in this patient with low\n lung volumes. Opacity is seen within the left lower lobe laterally that is\n suspicious for pneumonia versus aspiration. No pneumothorax is seen.\n Atelectasis is seen within the right lower lobe. No osseous abnormalities are\n identified.\n\n IMPRESSION:\n\n Opacity within the left lower lobe laterally that is suspicious for pneumonia\n versus aspiration event.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 854141,
"text": " 1:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: compare for interval change\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 M w/ hypoxia, ?aspiration event\n REASON FOR THIS EXAMINATION:\n compare for interval change\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest compared to .\n\n CLINICAL INDICATION: Hypoxia.\n\n Central venous catheter and orogastric tube remain in place. Cardiac and\n mediastinal contours are stable. There is discoid atelectasis at the right\n lung base with adjacent mild elevation of the right hemidiaphragm. The lungs\n are otherwise clear. A small amount of fluid is noted in the minor fissure.\n\n IMPRESSION:\n\n No significant change. No new findings to suggest an acute aspiration event.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-10 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 854246,
"text": " 4:49 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: S/P partial D/C OF NGT, replacement. Pls assess NGT positio\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 M w/ parkinsons, altered mental status, episode of hypoxia .\n REASON FOR THIS EXAMINATION:\n S/P partial D/C OF NGT, replacement. Pls assess NGT position\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest on compared with previous study of earlier the\n same date.\n\n CLINICAL INDICATION: Nasogastric tube assessment.\n\n The nasogastric tube is no longer visualized within the thoracic esophagus.\n The proximal portion of the tube is seen extending into the oropharynx region,\n but it is not well visualized below this level. There is otherwise no\n significant change since recent study.\n\n IMPRESSION:\n\n Withdrawal of orogastric tube, which is not visualized beyond the oropharynx\n region.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853513,
"text": " 11:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT placement.\n Admitting Diagnosis: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with and elevated lactate s/p intubation\n and s/p R subclavian placement.\n REASON FOR THIS EXAMINATION:\n NGT placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 82-year-old man with right subclavian line placement and NG\n tube placement. Evaluate.\n\n Comparison is made with an AP supine portable chest x-ray dated at\n 5:37.\n\n AP ERECT PORTABLE CHEST X-RAY: There has been interval placement of a\n nasogastric tube with the tip coiled within the body of the stomach. A right\n subclavian central venous catheter remains in good position within the distal\n superior vena cava. The cardiac mediastinal, and hilar silhouettes remain\n unchanged. There is a tortuous aorta with mural calcifications. Bilateral\n lungs are stable in appearance. Low lung volumes with bibasilar atelectasis\n persists. Surrounding soft tissue and osseous structures remain stable.\n\n IMPRESSION:\n\n Interval placement of a nasogastric tube with the tip coiled within the body\n of the stomach. These findings were called to Dr. at 2:00 p.m. on\n .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-20 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 855427,
"text": " 12:19 PM\n CHEST (PA & LAT) Clip # \n Reason: pls assess for aspiration.\n Admitting Diagnosis: \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with h/o hypersensitivity pneumonitis, right first toe\n gangarene, delerium.\n REASON FOR THIS EXAMINATION:\n pls assess for aspiration.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest PA and lateral.\n\n INDICATION: History of hypersensitivity pneumonitis, right-sided first toe\n gangrene, delirium. Assess for possible aspiration pneumonia.\n\n FINDINGS:\n\n AP and lateral views were obtained with the patient in sitting half erected\n position. The frontal view is compared with a similar study dated . An NG tube is presently seen to pass the stomach and terminating in the\n jejunum distal to the duodenum. This position appears unchanged; however, it\n is noted that some barium contrast medium has now entered the stomach. The\n thoracic aorta is moderately widened with some wall calcifications at the\n level of the arch. The heart shadow is mostly concealed by the elevated\n diaphragms, but significant cardiac enlargement is unlikely, as the pulmonary\n vasculature does not demonstrate any evidence of congestion. No acute\n infiltrates can be identified. There exist, however, thin plate atelectasis\n in the right base, a finding which was already noted on the preceding study.\n The lateral pleural sinuses remain free. A lateral view is under exposed and\n suffers from the patient's inability to elevate the arms. Although the image\n quality is clearly suboptimal, one can identify the posterior pleural sinuses\n to be free.\n\n IMPRESSION:\n\n Portable AP and lateral chest examination does not disclose evidence of new\n infiltrates, and there is no evidence of CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-20 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 855420,
"text": " 11:29 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: pls assess swallowing.\n Admitting Diagnosis: HYPERMAGNESEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with UTI, parkinson's\n REASON FOR THIS EXAMINATION:\n pls assess swallowing.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Assess for aspiration.\n\n VIDEO OROPHARYNGEAL SWALLOW: Fluoroscopic guidance was provided for the\n speech pathologist who administered barium swallow and then liquids of the\n various consistencies to the patient. There is trace aspiration with a single\n cup sip of thin liquids. This was not redemonstrated throughout the\n remainder of the exam. There is delayed oral phase of excessive oral residue\n with all materials. A 13 mm calibrated barium tablet passed freely into the\n stomach.\n\n IMPRESSION:\n Trace aspiration with a single cup sip of thin liquids only. This was not\n redemonstrated throughout the remainder of the exam.\n\n For additional report details, please consult the speech pathologist's report,\n which is available on the online medical record section of CCC.\n\n"
},
{
"category": "ECG",
"chartdate": "2169-01-16 00:00:00.000",
"description": "Report",
"row_id": 168187,
"text": "Baseline artifact. Sinus rhythm, may be normal ECG, but baseline artifact makes\nassessment difficult. Since the previous tracing of ventricular ectopy\nis absent.\n\n"
},
{
"category": "ECG",
"chartdate": "2169-01-13 00:00:00.000",
"description": "Report",
"row_id": 168188,
"text": "Sinus rhythm. Ventricular bigeminy amd trigeminy. Low voltage in the limb\nleads, low normal voltage in the precordial leads. Prolonged A-V conduction.\nOtherwise, normally conducted complexes are without diagnostic abnormality.\nCompared to the previous tracing of no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2169-01-12 00:00:00.000",
"description": "Report",
"row_id": 168189,
"text": "Sinus rhythm\nFrequent multifocal PVCs\nLow QRS voltages in limb leads\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2169-01-11 00:00:00.000",
"description": "Report",
"row_id": 168190,
"text": "Sinus rhythm\nFrequent multifocal PVCs\nLow QRS voltages in limb leads\nSince previous tracing, QRS changes in leads V3-V4 - ? lead placement; atrial\npremature complexes absent\n\n"
},
{
"category": "ECG",
"chartdate": "2169-01-10 00:00:00.000",
"description": "Report",
"row_id": 168191,
"text": "Sinus rhythm\nVentricular couplets\nSupraventricular extrasystoles\nLow QRS voltage limb leads\nPoor R wave progression - ? lead placement\nSince previous tracing, QRS changes in V2-V4 - ? lead placement; atrial\npremature complexes noted\n\n"
},
{
"category": "ECG",
"chartdate": "2169-01-09 00:00:00.000",
"description": "Report",
"row_id": 168192,
"text": "Sinus rhythm\nFrequent ventricular premature complexes\nLow QRS voltages in limb leads - is nonspecific\nProbable left atrial abnormality\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2169-01-07 00:00:00.000",
"description": "Report",
"row_id": 168193,
"text": "Sinus rhythm\nInterpolated PVCs\nLow QRS voltages in limb leads\nSince previous tracing, new ventricular premature complexes\n\n"
},
{
"category": "ECG",
"chartdate": "2169-01-06 00:00:00.000",
"description": "Report",
"row_id": 168194,
"text": "Sinus rhythm. Compared to the previous tracing of ventricular ectopy is\nno longer recorded. There is baseline artifact. No diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2169-01-06 00:00:00.000",
"description": "Report",
"row_id": 168195,
"text": "Sinus rhythm and frequent ventricular ectopy. Baseline artifact. Compared to\nthe previous tracing of the rate has increased. Otherwise, no\ndiagnostic interim change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2169-01-25 00:00:00.000",
"description": "Report",
"row_id": 168186,
"text": "Baseline artifact\nSinus rhythm\nVentricular premature complexes\nLow limb leads voltage - is nonspecific\nSince previous tracing of , ventricular ectopy present\n\n"
},
{
"category": "ECG",
"chartdate": "2169-01-05 00:00:00.000",
"description": "Report",
"row_id": 168196,
"text": "Sinus rhythm\nFrequent multifocal PVCs\nBorderline first degree A-V block\nLow QRS voltages in limb leads\nNondiagnostic T wave flattening\nBorderline Q-Tc interval prolonged\nSince previous tracing, QTc slightly shorter\n\n"
},
{
"category": "ECG",
"chartdate": "2169-01-04 00:00:00.000",
"description": "Report",
"row_id": 168197,
"text": "Sinus rhythm. A-V conduction delay and frequent ventricular ectopy. Ventricular\ntrigeminy. Low limb lead voltage. Q-T interval prolongation. Compared to the\nprevious tracing of no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2169-01-03 00:00:00.000",
"description": "Report",
"row_id": 168198,
"text": "Sinus rhythm\nVentricular premature complexes\nFirst degree A-V delay\nLeft atrial abnormality\nLow limb leads voltage - is nonspecific\nModest nonspecific ST-T wave changes\nSince previous tracing of , probably no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2169-01-02 00:00:00.000",
"description": "Report",
"row_id": 168199,
"text": "Baseline artifact in V2\nSinus rhythm\nVentricular premature complexes\nFirst degree A-V delay\nLeft atrial abnormality\nLow limb leads voltage - is nonspecific\nNo previous tracing for comparison\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-05 00:00:00.000",
"description": "Report",
"row_id": 1461061,
"text": "Nursing Note (1900-0700)\n\nMr. had an uneventful night. He did pass several large formed hardened stools thru the night.\n\nReview of systems:\nNeuro: Confused; reorientated with some effect. Agitated/restless thru most of shift. Requiring bil wrist restraints to maintain NGT in place. Frequently placing feet over siderails; freq monitoring requiried for safety.\n\nCV: Hemodynamically stable; NSR with freq PVC's; repeat K 3.9; repleted with 20KCL. Hypertensive to 170-180's with agitation; 140-160's at rest. Received 1 dose vanco for +BC from aline . Has 2 PIV's and 1 TLCL. Mutiple skin tears/bruising. Buttocks red but intact. Quinidine as ordered, QTC wnl.\n\nResp: LS ess clear, diminshed bases. 3L for 02 sats >96%. .\n\nGi/GU: NGT pulled by pt; replaced and placement confirmed by G. . Tol probalace 30cc/hr, goal 65cc/hr. Several large hard stools thru noc. Receiving laxatives for constipation. Adequate u/o./\n\nEndo: steroid taper; no SSI required.\nSocial: No calls. Full code.\n\nPlan: Replete lytes prn. Cont w/laxatives. Close monitoring for safety; will need 1:1 when bed available. Called out to floor. Advance TF as tol. Decrease FS to . Contact / . Full code.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-03 00:00:00.000",
"description": "Report",
"row_id": 1461055,
"text": "Shift Note 0200-0700\nPt 82yo male admitted to MICU-A from OSH with dx hypermagnesia and mental status changes. Pt presented to PCP with c/o weakness/lethargy. Lab work sent and PCP called patient with MG 6.9 to go to ER...at this time patient was having mental status changes. In ER repeat Mg 7.3 and patient given 3 amp calcium gluconate and solu-cortef since tapering off long-term steriod use. Transferred to for further work-up.\n\nPMH: hx V-tach, pulmonary fibrosis (on predinsone at home), PVD, parkinson's disease, Shy- syndrome, right big toe amputation.\n\nCV: HR SB 50-60's, with vent bigeminy. BP initially low when presented to OSH EW...given 500cc NS bolus, BP responded well. Upon arrival to MICU, SBP 110-140's. PIVx2 intact.\n\nResp: Pt initially on 3L NC, RR 8-12, sats >96%. BBS clear in upper lobes, crackles noted in lower lobes. Around 0415 pt noted to be having apneic periods lasting 50seconds...NIBP not registering and manual BP 80/50....intern paged to unit. Pt continued to have frequent episodes of apnea...anesthesia called stat and patient intubated. Right radial art line and LSC triple lumen placed. SBP 62/30 manually while art line being placed. 500cc D5NS given and dopamine started at 3mcg and titrated to 10mcg to maintain BP. CXR ordered for line confirmation.\n\nNeuro: Upon arrival, patient very lethargic...oriented to self only and when answering questions mumbling incomprehensible words. Opening eyes to verbal command...when found with apneic periods, patient extremely difficult to arouse and not opening eyes. Pt given fentanyl/versed for intubation and started on propofol gtt for sedation.\n\nGI/GU: Abdomen soft, BS present. OG tube placed, awaiting confirmation. Foley cath draining clear yellow urine. Patient given 20mg IV lasix to assist with excreting Mg...D5NS at 125cc/hr. Given 500cc bolus when BP decreased.\n\nSocial: Intern spoke with patient's children on phone...pt full code.\n\nMg currently 4.8....ICa 1.05, patient to receive 1 amp calcium gluconate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-03 00:00:00.000",
"description": "Report",
"row_id": 1461056,
"text": "Respiratory care:\nPatient noted to have several periods of apnea lasting 50 sec. MD notified. Patient intubated with 7.5 Ett taped and secured at 23 cm. Breathsounds equal bilaterally and placement confirmed with easy cap.\nPlease see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-03 00:00:00.000",
"description": "Report",
"row_id": 1461057,
"text": "MICU Nursing Progress Note 0700-1900\n\nPt weaned off dopamine and propofol. Extubated at 1800 and tolerating well. Head CT this am negative. Mag continues to decrease- lytes sent at 1800- results pending. Currently being followed by cardiology and renal teams.\n\nNote: Pt takes dofetilide at home. Drug is very tightly controlled in this hospital- pharmacy following. Dc'd here due to ? renal function. If prescribed- consult pharmacy before administering. Cardiology following.\n\nNeuro: Pt initially sedated on propofol when intubated. Weaned off at 1600. Now pt is awake and follows commands. Oriented to person, place and month. Speech is very garbled and hard to understand at times. Stares into space at times. Moves all extremeties and PERL.\n\nResp: Extubated after succesful wean to PSV and SBT. No periods of apnea this shift. Sats 99-100% on 5 L NC. Resp in mid to high teens. Lung sounds clear bilat. ? sleep apnea and ? need for non invasive vent.\n\nCV: HR NSR-NSB 50's-70's. Frequent PVC's, runs of vtach at times and vent bigeminy. PT seemed to have more ectopy after extubation. BP tolerates. Stat lytes drawn at 1800- results pending. Weaned off dopamine at 1500. BP now 140's-150's. CVP 8-10.\n\nLytes: Repleted with 40 MEQ of K and 3 grams calcium total this shift.\n\nGI: Pt continues NPO, OG tube pulled with extubation. Will have speech and swallow tomorrow am. Swabs for dry mouth. Hypoactive BS, abd nontender, no BM this shift. Per family last BM was 5 days ago- ? need for aggressive BM. ? ileus.\n\nGU: Foley drg amber yellow urine. Maintenance of NS at 125cc/hr x 1 liter. 2 boluses given earlier this am.\n\nEndo: RISS in place, cvg as needed.\n\nAccess: R TLC, R radial aline.\n\nSocial: 2 daughters and wife here most of day, very supportive and involved. Family updated on status by attending, residents and this rn. Topic of code status touched upon- family will discuss.\n\nPlan: Monitor resp status\n Monitor MS\n Monitor lytes closely and f/u with pm lytes\n ? Need for aggressive bowel regimen vs. slowed bowel motility\n Speech and swallow in am.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-03 00:00:00.000",
"description": "Report",
"row_id": 1461058,
"text": "Respiratory Care\nPt to cat-scan this am, results pending, Weaned to PSV tolerated well no apnea. Pt extubated 1800 will leave vent on stand by for ? of NIV for sleep apnea.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-04 00:00:00.000",
"description": "Report",
"row_id": 1461059,
"text": "pt is off vent since 1800 and resp status is good. hydrating to lower mag level and labs sent at 0420 and pending.\n* pt had been taking dofetilide at home but it is tightly controled here in hosp. pt was seen by card and H.O. to start quinadine this am in place as antiarrythmic, If ever to restart dofetilide must consult pharmacy first.\n\nneuro: PERL and pt moves uper extremities purposefully. legs are very stiff? parkinsons involvement. pt able to follow commands with much encouragment. oriented to person and place but speech is garbled. more clear on occasion. cough is intact but gag weak with oral care suction. to have swallow test this am.\n\ncard: rate is 60's most of night with lg amt ectopy. periods of bigemeny. pvcs in pairs and >16 pvcs per min most of shift. hx of v tach but not runs this shift.bp sys 100-150. peripheral pulses weak but feet warm. hands cold with cyanotic nail beds but good peripheral blood return. HX of PVD.\n\nresp: 3l with sat 97-99. coughing and once brought up gerrn thick sputum but unable to send as ws in pt bed.\n\ngi: NPO til swallow test done, good cough but weak gag. able to handle owm secretions all shift. pt had two small stools brown soft and hem neg. ducolax supp this am to improve stool output, bs present\n\ngu: pt is in slight pos balance and is voiding 60-75 cc/hr with iv infusing 150cc/hr to improve mag and urine output. no nedema present.\n\nendo: glu in acceptable range. no coverage required.\n\nlabs: see 0430 labs and mag at 2200 down to 3.7. no electrolytes repleted this shift.\n\nskin: pt has multiple areaas of raised hematomas which some have opened and bled. skin is dry with scaled patches and red rash like appearance. bath given and lotion applied. wet to dry dsg to rt great toe and may need some consult as needs debridment as family states were using a debriding skin tx at home,\n\nsocial: pt was cared for at home by family and issues around d/c will need to be discussed as in past family opted not to sent pt to rehab.\n\naccess: all ports functioning.\n\nplan: monitor MS\n start antiarrythmic per card consult\nfollow labs and promote bm\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-04 00:00:00.000",
"description": "Report",
"row_id": 1461060,
"text": "NPN 7A-7P\n\nEVENTS: Mg down to 2.8 from 3.2, CREAT improving to .9 (baseline .8), MS s+s eval- pt. failed- NGT placed for meds and feeds, Art. line removed d/t gram + cocci growing out of bottles, 2 more sets of BC sent\n\nReview of Systems-\n\nNeuro- MS waxing and , short periods of agitation restraints, incoherent at times, lethargic, arousing easily to voice. No pain issues today. OOB to chair via lift X 4 hours.\n\nResp- 3L O2 via NC tolerating well, O2 sats 98%, no significant issues. Concern for aspiration s/t MS, HOB elevated, CDB encouraged.\n\nCV- HR 60-70's frequent ectopy (PVCs), restarted on quinadine today need to check daily EKGs for Qtc prolongation, BP stable reamins off Dopamine with some episodes of hypertension. CVP running at goal of , IVF stopped. E-lytes sent at 1500 significant results as mentioned above.\n\nDerm- considerable skin issues- multiple areas of ecchymosis, skin tears covered with tegaderm, wound on heel covered with duoderm, wet to dry on right great toe amp appears to be red around wound base with yellow drainage and sloughing, other open areas on back and shoulders.\n\nGI- ABD quite distended, soft. Disimpacted for LARGE AMOUNT OF BROWN HARD STOOL... started on lactulose, to be given RTC, would also recommend rechecking rectum for further stool overnoc. TF at 10cc/hr of Probalance, goal rate of 65cc/hr. NGT placed d/t failed s+s eval. S+S to re-eval when MS clear.\n\nGU- U/O adequate 60-120cc/hr. IVF stopped. KCL and Calicum gluconate repleted.\n\nEndo- QID FS requiring no coverage. Predisone taper to begin tom'row per pulm.\n\nID- Gram + cocci from arterial line on , vanco X 1 given, art line d/c'd and cultures resent from art line and central line this am. Team may consider repeating vanco dose.\n\nAccess- Triple lumen in right subclavian , team wanted this to be pulled given 1/4 bottles + for GPC- however, pt. could use this access while staying in the ICU. Has 2 PIV not in use. Art line pulled and tip sent for cx.\n\n Pt. has 5 dtrs, 2 visiting today with wife. Updated on plan of care and met with pulmonologist today.\n\nDispo- C/o to floor with 1:1 observer. Remains full code.\n\n"
}
] |
69,981 | 162,851 | 31F admitted electively for a R retromastoid crani for MVD of 5th nerve. Post-operatively, she as admitted to the ICU for monitoring. Her post-operative Head CT was stable with expected post-op changes. On , she was transferred to the floor from the ICU. Her home medications were started per the recommendations of her Rheumotologist. Her activity was increased she ambulated in the hallway and tolerated a regular diet. Her pain was improving on the right side of her face but had intermittent electrical type pain, she felt the pain meds were improving. Neurologically she had no deficits on discharge. | There is a small amount of extra-axial hypodense fluid collection in the right posterior cranial fossa, without significant mass effect. No intracranial hemorrhage detected. No intracranial hemorrhage detected. No intracranial hemorrhage, edema, masses, or mass effect is seen. TECHNIQUE: MDCT helical images were acquired through the head without intravenous contrast. Small extra-axial fluid collection in the right posterior cranial fossa. FINDINGS: The patient is status post right suboccipital craniotomy, with small-to-moderate amount of pneumocephalus, relating to the recent surgery. The ventricles, sulci, and basal cisterns are normal. Mild mucosal thickening is seen in bilateral ethmoid air cells and frontal sinuses. IMPRESSION: Status post trigeminal decompression surgery, with expected pneumocephalus. The mastoid air cells are clear. 3:57 PM CT HEAD W/O CONTRAST Clip # Reason: post op, within 4 hours Admitting Diagnosis: TRIGEMINAL NEURALGIA/SDA MEDICAL CONDITION: 31 year old woman with trigeminal decompression REASON FOR THIS EXAMINATION: post op, within 4 hours No contraindications for IV contrast WET READ: KKgc FRI 6:29 PM Status post trigeminal decompression surgery, with expected pneumocephalus. COMPARISON: None available. | 1 | [
{
"category": "Radiology",
"chartdate": "2189-05-01 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1190257,
"text": " 3:57 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: post op, within 4 hours\n Admitting Diagnosis: TRIGEMINAL NEURALGIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with trigeminal decompression\n REASON FOR THIS EXAMINATION:\n post op, within 4 hours\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc FRI 6:29 PM\n Status post trigeminal decompression surgery, with expected pneumocephalus.\n No intracranial hemorrhage detected.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old woman with trigeminal decompression, status post\n surgery.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT helical images were acquired through the head without\n intravenous contrast.\n\n FINDINGS: The patient is status post right suboccipital craniotomy, with\n small-to-moderate amount of pneumocephalus, relating to the recent surgery.\n There is a small amount of extra-axial hypodense fluid collection in the right\n posterior cranial fossa, without significant mass effect. No intracranial\n hemorrhage, edema, masses, or mass effect is seen. The ventricles, sulci, and\n basal cisterns are normal. Mild mucosal thickening is seen in bilateral\n ethmoid air cells and frontal sinuses. The mastoid air cells are clear.\n\n IMPRESSION: Status post trigeminal decompression surgery, with expected\n pneumocephalus. No intracranial hemorrhage detected. Small extra-axial fluid\n collection in the right posterior cranial fossa.\n\n"
}
] |
24,981 | 167,592 | This is a 71 year old gentleman with T2N0M0 soft palate squamous cell CA, undergoing adjuvant chemoradiation week of low dose /Taxol and daily XRT. He was iniitally admitted on with hypotension, tachycardia, ARF. Felt to be dehydrated at that time. He was hydrated with NS and then developed fevers and was noted to have LLL opacity. He was initially given cefepime, fluconazole (concern for esophagitis), flagyl. This was then switched to Levo and vanco. Later, flagyl was re-started. He had frequent desaturations that were found to be secondary to mucus plugging and which resolved with deep suctioning. His sputum cultures then grew back Coag + staph sensitive to oxacillin and vanco was switched to oxacillin. . On pt respiratory status deteriorated to the point he could only maintain adequate oxygenatin on non-rebreather. By this time he had been getting significant amounts of fluid with a daily fluid balance positive 500-1000ml per day. CXR's have also shown progressive pulmonary edema In , pt. did not require intubation. It was felt his resp distress was secondary to pulm edema/volume overload and we was therefore diuresed with PRN lasix 40 mg. Over LOS in he was roughly -1.2 L. An echocardiogram revealed the patient had deteriorated LV function and new wall motion abnormalities. His resp. status did improve such that he was saturating adequately on 40% FM. He had been afebrile and otherwise hemodynamically stable and was therefore transferred back to the floor. Over the subsequently few days of his hospital course the pt. felt his breathing had improved and he had no fevers, chest pain, or cough. His volume status returned to euvolemic state. He was slowly weaned from oxygen support and by discharge was down to 3L face mask. Repeat CXR revealed stable lower lobe infiltrates but almost complete resolution of pulmonary edema. Aggressive diuresis was no longer pursued. External radiation therapy for his oral squamous cell CA was resumed. On discharge, the patient remained afebrile and hemodynamically stable. He was to continue 5 more days of levo/flagyl, oxacillin was discontinued. He was transferred to a rehabilitation hospital to enable further improvement of his respiratory status and for reconditioning. In summary, this is a 71 year old gentleman with oral squamous cell carcinoma on radiation therapy who was admitted for fever and finding of lower lobe lung infiltrates. He developed respiratory distress from a combination of pneumonia, new CHF seen on echocardiography, and mucus plugging and required a brief stay in intensive care but not intubation. He did well with diuretic therapy for his CHF, antibiotics for his MSSA pneumonia and was transferred to a rehabilitation hospital to enable further improvement of his respiratory status. . Issues and plan arising from this hospitalization: 1) Respiratory Failure/Hypoxia- Now appears resolved. Secondary to combination of PNA, CHF exacerbation, ? mucus plugging. No intubation was required. - albuterol/atrovent nebs q4h. - Chest PT, aggressive suctioning as needed - Aggressive diuresis no longer needed. 2) CHF. now with apparently worsened EF, new wall motion abnormalities - Will need oupatient follow up with Cardiology. - Continue Lasix, Lisinopril, and metoprolol. - Watch for signs of overload (weight gain, edema) . 3) RLL and LLL multilobar PNA: Initially with LLL opacity with sputum cultures growing MSSA. Also satrted on levofloxacin and flagyl for possible aspiration PNA after developing RLL opacity. Currently afebrile with normal, WBC. - continue flagyl and levofloxacin for broad coverage for 5 days . 4) Squamous cell CA of mouth: Chemoradiation. Last dose chemo (taxol/carboplatinum) Per Dr. will not continue chemo. Pt will continue XRT. -Mucositis: Improved during admission. Cont KBL, aspiration precautions, Nystatin, Roxicet. -continue aquaphor 5) Anemia: Hematocrit remains stable. Pt is s/p 2 units PRBC for hct 22.6, likely chemo related. 6) FEN: Tube Feeds at goal.. . 7) Prophylaxis: Aspiration Precautions, Hep SC . 8) Code status remains full. . 10) Disposition: Rehabilitation facility. | IMPRESSION: 1) Decreased mild pulmonary edema. IMPRESSION: AP chest compared to and : Mild pulmonary edema asymmetrically distributed is clearing. Noaortic regurgitation is seen. Diuresed from lasix ~700mls, breathing more comfortable.Resp: Pt initially on nonrebreather, ABG improved, pao2 98. LS diminished at bases, crackles cont on L.GI: +BS, abd soft, nt. The mitral valve leaflets are mildly thickened.Trivial mitral regurgitation is seen. Sinus rhythmLeft atrial abnormalityPoor R wave progression - probable normal variantLateral T wave changes may be due to myocardial ischemiaSince previous tracing of -o5, poor R wave progression seen HR 84-90s, nsr, occ pacs, esp when BP low. Moderate-to-large bilateral pleural effusions with bibasilar atelectasis. REASON FOR THIS EXAMINATION: r/o new or worsening infiltrate, effusion, pulmonary edema FINAL REPORT STUDY: AP chest, . Mild mitral annularcalcification. They are again most consistent with a prominent pulmonary edema. There is an area of consolidation in the left lingula (image 3:34 and right upper lobe image 3:29). Adm note71 yo ma adm c dehydration, hypotension, tachycardia, diarrhea 2nd to chemoradiation for squamous cell CA of soft palate. The aortic root is moderately dilated. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 71Weight (lb): 175BSA (m2): 1.99 m2BP (mm Hg): 108/51HR (bpm): 73Status: OutpatientDate/Time: at 14:58Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the report of the prior study (images notavailable) of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. FINDINGS: There are bilateral moderate-to-large pleural effusions. Compared to the previous tracing first degreeA-V conduction delay is no longer present. Overall left ventricular systolic function isprobably mildly depressed. Yest, on cxr noted to also have RLL opacity. sbp very low - 70s, on R arm. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Cr 1.1 on adm from dehydration. Mild pulmonary edema has decreased. Pt noted to have LLL opacity, then infiltrate, sputum coag+staph, sensitive to oxacillin. Severe coronary artery calcifications are noted. Pt turned onto back, BP up into low 90s. There is again seen an infiltrate in the left mid lung and left lower lobe, which is more apparent on today's study and slightly more confluent. Basal to mid antero-septal and inferior hypokinesisis suggested, but not confirmed. Trivial MR. LV inflow pattern c/w impaired relaxation.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:Poor echo windows.The left atrium is normal in size. Hct down from 30.2 to 29.2. The left ventricular inflow patternsuggests impaired relaxation. Normal ascending aorta diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). New multifocal parenchymal opacity is seen in the left lung compared to . Now with worsening shortness of breath. Now with worsening shortness of breath. Degenerative changes are noted in the thoracic vertebral bodies. Severe coronary artery calcifications. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. New shortness of breath. Afebrile.GI: TF via G tube. There is calcification of the thoracic aorta. Emphysema. No ASD by 2D or colorDoppler.LEFT VENTRICLE: Mildly depressed LVEF. Has been NPO except occ tiny sip water.GU: Good u/o at 40-60mls/hr. REASON FOR THIS EXAMINATION: please evaluate for interval change, worsening of infiltrates FINAL REPORT STUDY: AP chest, performed on . Calcifications of the thoracic aorta is again seen. AP & LATERAL CHEST: The heart size is within normal limits. Small to moderate bilateral pleural effusions and bibasilar pulmonary opacities are unchanged. Bibasilar atelectasis is noted. These findings appeared to have worsened slightly and are again suspicious for multifocal pneumonia. Cardiac size and mediastinum are within normal limits. 12-13 mm hypodense stable right renal cyst. Left lower lobe pneumonia. Left lower lobe pneumonia with additional focal patchy areas of consolidation in the lingula and right upper lobe. These findings have worsened slightly since the previous study. 2) Unchanged bilateral pleural effusions and bibasilar opacities. Sinus rhythm. Moderate-sized right pleural effusion has enlarged. Resp distress increasing, hypoxic on general unit, nonrebreather applied, lasix 20mg followed by 40mg given, to MICU. REASON FOR THIS EXAMINATION: eval for interval change FINAL REPORT STUDY: AP chest, . LS diminished at bases c crackles, coarse, rhonchorus, bilat wheezes on evenings. Breathsounds are coarse with decreased aeration in lower lobes. component of CHF, altho cardiac disease not documented, except long standing HTN.ROS:Neuro: A&O x3. Evaluate progression of pulmonary edema and pleural effusions. These findings are worrisome for congestive heart failure. There is prominence of the interstitial markings with more focal opacities in the left mid and left lower lung fields. There has been worsening of the increased pulmonary vascular markings and more focal opacities in the left perihilar and right basilar regions. There is severe atherosclerotic aortic calcification extending up to the abdominal aorta and the renal arteries. FINDINGS: There is again seen marked prominence of the pulmonary vasculature bilaterally with more focal airspace opacities forming within the left mid lung field as well as a left retrocardiac opacity. Severe atherosclerotic aortic calcification extending into the renal arteries. The airways are patent up to the segmental bronchi. There is diffuse moderate emphysema more on the right than the left. Patient tolerating nebs will. A hypodense stable cyst is seen in the right kidney. | 15 | [
{
"category": "Nursing/other",
"chartdate": "2192-12-04 00:00:00.000",
"description": "Report",
"row_id": 1587969,
"text": "NPN\n\nNeuro: Pt alert, not very interactive today, cooperating with care but needed to be encouraged to participate.\n\nCV: He has not received lopressor today due SBP 90-low 100s, HR has been in the 90s. There was talk of an echo today but it has not been today.\n\nResp: LS clear with rales in the bases, 02 SAT mid 90s on 50% face tent. He is coughing up a large amount of thick yellow sputum which is blood tinged at times. Chest CT done today which showed fluid in his lungs.\n\nGI: Conts on TF, he was seen by speach and swallow today, he is not able to swallow anything as he aspirated on everything.\n\nGU: U/O 20-40cc/hr, he may receive lasix later today.\n\nOnc: He had XRT today, onc said that they will hold on further chemo. He has been tired today, says that he does feel exhausted after xrt. Onc said that he should be able to eat in a few months after his mouth and throat heals.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-12-05 00:00:00.000",
"description": "Report",
"row_id": 1587970,
"text": "Respiratory care:\nPatient followed Q4 for albuterol/atrovent nebs. Breathsounds are coarse with decreased aeration in lower lobes. Patient tolerating nebs will. Please see respiratory section of carevue for treatment times and data.\nPlan: Continue bronchodilator therapy Q4.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-12-05 00:00:00.000",
"description": "Report",
"row_id": 1587971,
"text": "NPN 1900-0700\nNeuro: A&O x3. mae well. No c/o pain, some soreness in throat but pain med not required.\n\nCV: Did receive Lopressor last noc at 8pm as sbp was 108. SBP >100 most of noc. At ~ 0300, BP down to 80/36 - 84/50 c freq pac s at the time, pt was sleeping. Pt turned onto back, BP up into low 90s. Currently 96/42. HR 84-90s, nsr, occ pacs, esp when BP low. Afebrile. Cont on abx. Hct down from 30.2 to 29.2. K good at 4.3, Mg 1.9, will ask team re repletion.\n\nResp: Cont on fact tent at 50%. Sats usu 94-99, down to 89 x1. Encouraged C&DB, pt expectorated large clump of mucous as he had done earlier in evening, thick, bld tinged. LS diminished at bases, crackles cont on L.\n\nGI: +BS, abd soft, nt. Tol TF well, at 60mls/hr, goal 80mls. No stool. Has been NPO except occ tiny sip water.\n\nGU: Good u/o at 40-60mls/hr. No lasix given. Negative fld balance at 840mls los.\n\nSocial: Brother called, will be visiting tomorrow.\n\nPlan: Continue positive outcome discussion with pt. Encourage C&DB. Monitor BP and sats. ? Echo today.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-12-04 00:00:00.000",
"description": "Report",
"row_id": 1587968,
"text": "Adm note\n71 yo ma adm c dehydration, hypotension, tachycardia, diarrhea 2nd to chemoradiation for squamous cell CA of soft palate. On chemoradiation for ~5weeks caused mucositis with ulcers in mouth, weakness, anemia (hct 22.6, tx c 2units pc). Pt noted to have LLL opacity, then infiltrate, sputum coag+staph, sensitive to oxacillin. Yest, on cxr noted to also have RLL opacity. Resp distress increasing, hypoxic on general unit, nonrebreather applied, lasix 20mg followed by 40mg given, to MICU. ? component of CHF, altho cardiac disease not documented, except long standing HTN.\n\nROS:\n\nNeuro: A&O x3. mae. Communicates needs well. Pt tired, sleeping most of time. C/o slight sore throat, did not want pain med.\n\nCV: HR 80-105, ns/st, no ectopy. sbp very low - 70s, on R arm. Changed BP cuff to L arm ~ 10points higher. Pt mentating well even when SBP in 70s on R arm. Team did not want to give flds. Diuresed from lasix ~700mls, breathing more comfortable.\n\nResp: Pt initially on nonrebreather, ABG improved, pao2 98. Nebs given q2hrs, then q4hrs. Changed to face tent at 50% with sats >96. LS diminished at bases c crackles, coarse, rhonchorus, bilat wheezes on evenings. Expectorated yellow sputum followed by lge amt thick, tan sputum. Spec sent. RR now in high teens to 20s.\n\nID: On Levoflox, metronidazole, oxacillin. Afebrile.\n\nGI: TF via G tube. Advance by 10mls/hr q6hrs til at goal of 80mls/hr. Tol well. No stool.\n\nGU: Light yellow urine from lasix, adequate amts. Cr 1.1 on adm from dehydration. Improving.\n\nSkin: Intact.\n\nSocial: Brother is health care proxy.\n\nPlan: Pt may be called out if remains stable. Monitor u/o. Echo planned for today. Monitor BP, HR, resp status carefully. Titrate TF up to 80 mls. Continue abx.\n"
},
{
"category": "Echo",
"chartdate": "2192-12-05 00:00:00.000",
"description": "Report",
"row_id": 98327,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 71\nWeight (lb): 175\nBSA (m2): 1.99 m2\nBP (mm Hg): 108/51\nHR (bpm): 73\nStatus: Outpatient\nDate/Time: at 14:58\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Mildly depressed LVEF. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Trivial MR. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nPoor echo windows.The left atrium is normal in size. No atrial septal defect\nis seen by 2D or color Doppler. Overall left ventricular systolic function is\nprobably mildly depressed. Basal to mid antero-septal and inferior hypokinesis\nis suggested, but not confirmed. Right ventricular chamber size and free wall\nmotion appear normal. The aortic root is moderately dilated. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nTrivial mitral regurgitation is seen. The left ventricular inflow pattern\nsuggests impaired relaxation. The pulmonary artery systolic pressure could not\nbe determined. There is no pericardial effusion.\n\nCompared with the report of the prior study (tape unavailable for review) of\n, regional LV systolic dysfunction is now suggested. If clinically\nindicated, a repeat TTE with contrast (Definity) may better characterize LVEF\nand regional LV function.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-12-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 895316,
"text": " 12:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o new or worsening infiltrate, effusion, pulmonary edema\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with head&neck SCC, with LLL PNA, now with worsening SOB,\n O2sat down to 85% on 50% shovel mask again.\n REASON FOR THIS EXAMINATION:\n r/o new or worsening infiltrate, effusion, pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 71-year-old man with worsening shortness of breath.\n\n FINDINGS: Compared to prior studies dating back to .\n\n There has been worsening of the increased pulmonary vascular markings and more\n focal opacities in the left perihilar and right basilar regions. These\n findings are worrisome for congestive heart failure. The opacities may\n represent underlying pneumonia and these changes have increased. Cardiac size\n and mediastinum are within normal limits.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-12-04 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 895461,
"text": " 10:01 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: please assess lung infiltrate and pulmonary edema in attempt\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with pneumonia and apparent CHF, unclear which component is the\n overriding problem\n REASON FOR THIS EXAMINATION:\n please assess lung infiltrate and pulmonary edema in attempt to assess pts\n primary process\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old with CHF and pneumonia. Patient has history of\n cancer of the neck and soft palate.\n\n CT CHEST WITHOUT CONTRAST.\n\n TECHNIQUE: MDCT of the chest was performed from the thoracic inlet through\n the adrenals without injection of intravenous contrast.\n\n Comparison done to serial chest x-rays done between , to\n and a PET/CT of .\n\n FINDINGS: There are bilateral moderate-to-large pleural effusions. Bibasilar\n atelectasis is noted. There is an area of consolidation in the left lingula\n (image 3:34 and right upper lobe image 3:29). The airways are patent up to\n the segmental bronchi. There is diffuse moderate emphysema more on the right\n than the left.\n\n There is no significant mediastinal or hilar lymphadenopathy, though small\n subcentimeter mediastinal lymph nodes are seen which do not meet the CT\n criteria for lymphadenopathy. There is severe atherosclerotic aortic\n calcification extending up to the abdominal aorta and the renal arteries.\n Severe coronary artery calcifications are noted. There is no pericardial\n effusion.\n\n In the imaged portion of the upper abdomen, the liver, spleen, and adrenals\n are unremarkable. A hypodense stable cyst is seen in the right kidney.\n\n Degenerative changes are noted in the thoracic vertebral bodies. There is no\n suspicious lytic or blastic lesion in the bones.\n\n IMPRESSION:\n 1. Left lower lobe pneumonia with additional focal patchy areas of\n consolidation in the lingula and right upper lobe.\n 2. Moderate-to-large bilateral pleural effusions with bibasilar atelectasis.\n 3. Severe atherosclerotic aortic calcification extending into the renal\n arteries.\n 4. Severe coronary artery calcifications.\n 5. Emphysema.\n 6. 12-13 mm hypodense stable right renal cyst.\n (Over)\n\n 10:01 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: please assess lung infiltrate and pulmonary edema in attempt\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-12-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 895243,
"text": " 2:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change, worsening of infiltrate\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with head&neck SCC, with LLL PNA, now with worsening SOB,\n )2sat down to 85% on RA.\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change, worsening of infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, performed on .\n\n HISTORY: 71-year-old male with head and neck squamous cell cancer and left\n lower lobe pneumonia. Now with worsening shortness of breath.\n\n FINDINGS: Compared to the previous studies from through , .\n\n The cardiac silhouette is within normal limits and is unchanged.\n Calcifications of the thoracic aorta is again seen. There is prominence of\n the interstitial markings with more focal opacities in the left mid and left\n lower lung fields. These findings appeared to have worsened slightly and are\n again suspicious for multifocal pneumonia. The increased interstitial\n markings raises an element of underlying pulmonary edema as well.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-12-06 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 895784,
"text": " 9:40 AM\n CHEST (PA & LAT) Clip # \n Reason: Please assess for progression of pulmonary edema and pleural\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with history of head and neck cancer, LLL pneumonia, CHF\n exacerbation.\n REASON FOR THIS EXAMINATION:\n Please assess for progression of pulmonary edema and pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70 y/o man with history of head and neck cancer, left lower lobe\n pneumonia and CHF exacerbation. Evaluate progression of pulmonary edema and\n pleural effusions.\n\n COMPARISON: .\n\n AP & LATERAL CHEST: The heart size is within normal limits. Mild pulmonary\n edema has decreased. Small to moderate bilateral pleural effusions and\n bibasilar pulmonary opacities are unchanged.\n\n IMPRESSION:\n 1) Decreased mild pulmonary edema.\n 2) Unchanged bilateral pleural effusions and bibasilar opacities.\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-11-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 894866,
"text": " 12:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrates, any CP abnormalities\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with head&neck SCC, admitted for hypotension with temp spike to\n 101.6; productive cough\n REASON FOR THIS EXAMINATION:\n eval for infiltrates, any CP abnormalities\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Squamous cell carcinoma of the neck. Fever.\n\n FINDINGS:\n\n The heart size is normal. No pneumothorax or effusions are seen. No\n pulmonary nodules are identified. New multifocal parenchymal opacity is seen\n in the left lung compared to .\n\n IMPRESSION: Multifocal pneumonia in the left lung.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-12-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 895184,
"text": " 10:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change in PNA\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with head&neck SCC, with LLL PNA\n REASON FOR THIS EXAMINATION:\n please eval for interval change in PNA\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 71-year-old man with head and neck squamous cell cancer with left\n lower lobe pneumonia.\n\n FINDINGS: Compared to previous study from .\n\n There is again seen an infiltrate in the left mid lung and left lower lobe,\n which is more apparent on today's study and slightly more confluent.\n Followup to resolution recommended. The right lung remains clear. There is\n calcification of the thoracic aorta.\n Cardiac size is normal.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-12-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 895392,
"text": " 5:42 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for interval change\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with head&neck SCC, with LLL PNA, now with worsening SOB,\n O2sat down to 85% on 50% shovel mask again.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 71-year-old man with head and neck cancer and left lower lobe\n pneumonia. Now with worsening shortness of breath.\n\n FINDINGS: There is again seen marked prominence of the pulmonary vasculature\n bilaterally with more focal airspace opacities forming within the left mid\n lung field as well as a left retrocardiac opacity. These findings have\n worsened slightly since the previous study. They are again most consistent\n with a prominent pulmonary edema. Underlying pneumonia especially at the left\n mid lung and left base will be difficult to exclude.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-12-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 895430,
"text": " 6:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for CHF and progression of infiltrate.\n Admitting Diagnosis: DEHYDRATION;HEAD AND NECK CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with head&neck SCC, with LLL PNA, now with SOB.\n REASON FOR THIS EXAMINATION:\n Please eval for CHF and progression of infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:03 A.M. .\n\n HISTORY: Head and neck carcinoma. Left lower lobe pneumonia. New shortness\n of breath.\n\n IMPRESSION: AP chest compared to and :\n\n Mild pulmonary edema asymmetrically distributed is clearing. Improvement in\n perihilar consolidation in the left lung probably reflects resolving\n deposition of edema in the region of pneumonia. Moderate-sized right pleural\n effusion has enlarged. The heart is normal size and midline.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2192-12-03 00:00:00.000",
"description": "Report",
"row_id": 278807,
"text": "Sinus rhythm\nLeft atrial abnormality\nPoor R wave progression - probable normal variant\nLateral T wave changes may be due to myocardial ischemia\nSince previous tracing of -o5, poor R wave progression seen\n\n"
},
{
"category": "ECG",
"chartdate": "2192-11-28 00:00:00.000",
"description": "Report",
"row_id": 278808,
"text": "Sinus rhythm. Normal ECG. Compared to the previous tracing first degree\nA-V conduction delay is no longer present.\n\n"
}
] |
9,454 | 157,067 | 85yo woman with CAD, CHF, a.fib, temporal arteritis, dementia with axillary thrombosis s/p thrombectomy with neck hematoma after CVC attempt, acute renal failure and gardnerella in urine. . 1) left axillary artery thrombosis: s/p thrombectomy . Patient was therapeutic on coumadin with INR of 2.6 on admission though subtheraputic INR (1.4) on per coumadin clinic with no intervention in terms of coumadin dose. Rheumatology (Dr. doubts related to TA, ? thromboembolic event given a.fib/potentially subtheraputic inr. Cardiology (Dr. recommended tighter INR control with goal 2.0-3.0 but no further imaging at this time. She was bridged post-opperatively on a heparin gtt to coumadin to theraputic INR (2.2) and coumadin was restarted, however INR fell to 1.8 so she was covered with lovenox injection, 60mg (based on 1mg/kg) dosed qdaily based on renal function. She should continue lovenox until INR 2.0-3.0, and is discharged on coumadin 3mg po qhs, to be titrated to maintain INR at goal. She will follow-up with vascular surgery to have wounds checked and staples removed, additionally should have dry gauze to cover these wounds changed daily. . 2) Neck Hematoma: Secondary to carotid puncture during CVC placement in the ED on admission. This wound was explored by vascular surgery when in surgery for thrombectomy and noted to have no active bleeding. This site was closed with staples and had no further swelling or bleeding, but has marked ecchymosis and edema. Wound care and staple removal as above. . 3) Respiratory failure: Patient was intubated for general anesthesia and weaned/extubated with relative ease , oxygen has been steadily titrated down to 1L by nasal canula and will need to be further titrated with diuresis to prevent pulmonary edema as postopperative edeam revascularizes. She should continue oxygen to maintain sat >90%, albuterol/ipratropium nebulizers as needed, chest pt, and incentive spirometry. . 4) Cardiomyopathy/CHF: Patient has EF of 25% by Echo , severe AS, + AR, + MR and mod PAH. pro-BNP 31K on admission. Has pulm edema on exam and in CXR but improved on CXR. CVP is currently flat, she required gentle IVF and diuresis in the ICU and further diuresis on the general medicine floor. She is total body volume overload by weight (142, up from dry weight of 136) likely related to edema at her surgical sites and may require additional diursis with IV lasix as that edema revascularizes. She was given 40mg IV lasix priro to discharge with good effect. She was continued on carvedilol, losartan was held during renal failure but restarted on discharge, aspirin and lipitor. She is to restart her home lasix regimen of 40mg by mouth twice daily, with IV as needed depending on her respiratory and volume status, and weight. . 5) Atrial fibrialation: on coumadin outpt, recently had coumadin increased for subtherapeutic level, to be discharged on 3mg po qhs, to be titrated as an outpatient to INR 2.0-3.0. On discharge INR 1.9 and likely will be theraputic soon as this medication was recently restarted after being held for surgery. She is on lovenox 60mg qd as a bridge to theraputic INR (based on renal function). This lovenox should be stopped once she reaches theraputic INR. She is also restarted on digoxin, which was held while she was in acute renal failure, at the time of discharge. She was continued on rate control with carvedilol. . 6) CAD: Troponin rose (peak 0.61, now trending down), but in the setting of renal failure and flat CK's unlikely to be acute ischemia. She was continued on aspirin, carvedilol, statin, and restarted on cozaar once renal failure improved. . 7) Acute renal failure: baseline Cr 1.1, peak in house 1.7, fell to 1.2 by time of discharge. This could have been secondary to overdiuresis vs poor forward flow, given FeUREA 8.4% and urine sodium undetectable indicates prerenal etiology rather than renal. By discharge improved, able to restart cozaar, digoxin, tolerated lasix with renal improvement. . 8) Leukocytosis: w/ left shift initially ? stress reaction, trending down, resolved to 9.8 by the time of discharge, possibly related to gardnerella vaginalis in urine though less likely, treated with metronidazole for 5 days, afebrile. . 9) Hypertension: controlled with carvedilol, restarted cozaar on discharge. . 10) History of bradycardia: s/p pacemaker, V paced. . 11) Temporal arteritis: Followed by Dr. outpatient. Was on a 6-8month long taper (initally high dose) but it was stopped , he noted angiography, he feels, would be low-yeild, favors not restarting prednisone given CNS side-effects. . 12) Diabetes Mellitus: Poor PO intake post-operatively initially but improved, restarted on NPH at 16units though home dose 18 units so will need to be uptitrated at rehab depending on PO intake and blood glucose, also with Humolog per sliding scale. . 13) Dementia/Delirium: She was continued on home dose of aricept. . 14) Hyperlipidemia: continued on atorvastatin. . 15) Hypothyroid: continued on synthroid, repeat TSH 0.32. . 16) Depression: continued on home dose of zoloft. . 17) Contact: cell (HCP) . 18) FEN: Diabetic diet, low salt diet, electrolytes prn . 19) Prophylaxis: PPI, theraputic coumadin/lovenox, bowel regimen . 20) Code: FULL In brief this 85 yo woamn with multiple medical problems including CAD s/p stent, CHF (EF 25%), AF on coumadin, temporal arteritis (stopped month prednisone taper ), was admitted on with a cold left hand and found to have left proximal axillary artery thrombosis by CTA. Vascular surgery followed her and she went to the OR for thrombectomy. Her hospital course was complicated by carotid artery perforation with hematoma after CVC atttempt in the ED. This was explored at the time of surgery and found not to be bleeding. She received 100cc NS, unit PRBC in OR, and about 1L of fluid on . She was intubated for the surgery and brought to the ICU for further management. Patient remained intubated because of multiple medical problems, even though her ABG and hemodynamics had been stable. Patient was given multiple lasix doses overnight for decreased urine output. She was successfully extubated . She was also noted to have Gardnerella in her urine so was started on metronidazole iv . . Currently she feels well, has little recolection of surgery, denies pain at surgical sites, dizziness, lightheadedness, fevers, chills, nausea, vomitting, constipation, abdominal pain, diarrhea, shortness of breath, cough, chest pain or pressure. She does note a sensation of having to go to the bathroom (has foley catheter in). Her daughter notes she has been more somnolent since her discharge in early Decemeber, with DOE that seems more severe. . Medications on Admission: Furosemide 40 QAM, 20/40QPM (alternating with extra if SOB by VNA) Aricept 10 QAM coreg 6.25 Protonix 40 synthroid 0.125mcg QD potassium 20mg calcitonin 200 spray cozaar 25mg QD calcium and vit D 500mg tid ECASA 81mg Digoxin 0.0625 iron Coumadin 2 (TTSS) and 3mg(MWF) QHS Atorvastatin 10 QHS zoloft 75mg tylenol PRN NPH 18u QD HISS 100-140 6U, 141-180 8U, 181+ 10U Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: Tablet PO once a day. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Potassium Chloride Granules Sig: One (1) Miscell. once a day: HOLD if potassium >40 MeQ. 5. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 6. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO once a day: please give 0830 in am. 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO QHS (once a day (at bedtime)). 9. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) Nasal DAILY (Daily): please give 0830. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily): please give at 1300. 13. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q3-4H (Every 3 to 4 Hours) as needed for wheezing, dyspnea. 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for dyspnea, wheezing. 15. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime: please adjust coumadin dose to INR 2.0-3.0. Tablet(s) 16. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily): please continue this medication until INR 2.0-3.0, then stop. 17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day: Please give at 0830 and 1630. She normally takes 40mg in the am and either 20 or 40 in the pm so as lungs become more clear may need to change pm dose. 18. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Sixteen (16) units Subcutaneous once a day: please give at 0830. Home dose 18 units, may need to be increased once eating better. 19. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: 1-10 units Subcutaneous four times a day as needed for per sliding scale: with meals: see attached sliding scale. 20. Cozaar 25 mg Tablet Sig: One (1) Tablet PO once a day. 21. CALCIUM 500+D 500-200 mg-unit Tablet Sig: One (1) Tablet PO three times a day. Tablet(s) 22. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO twice a day. 23. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: not to exceed 4gm/day. Discharge Disposition: Extended Care Facility: for the Aged - MACU Discharge Diagnosis: Left axillary thrombus, s/p thrombectomy, right carotid puncture . Coronary artery disease, Rheumatic Heart Disease with aortic stenosis, Atrial fibrillation, history of bradycardia: s/p pacemaker, hypertension, dyslipidemia, dementia, diabetes mellitus-on insulin, history of GI bleed, hypothyroidism, congestive heart failure, ejection fraction 25%. 12. Temporal arteritis Discharge Condition: Stable. Discharge Instructions: Please take all medications as prescribed. Please keep all follow-up appointments. Please notify your doctor if you experience fevers, chills, lightheadedness, shortness of breath, chest pain, arm pain, numbness, weakness, or any symptoms Followup Instructions: Please follow-up with Dr. within 1-2 weeks after release from rehab. Please follow-up with Dr. of vascular surgery, on at 1:00pm. Please call ( if questions for Dr. . | r neck staples c/d/i with no drainage noted.psy-soc: dtr in to visit...updated on status and plan of care. Mae/perrl, patient denies pain.CV: Vpaced, underlying rhythm afib, sbp 130's/30's. pt start diebetic diet, pt had apllesause and water w/o any difficulties, able to take PO meds w/o problem.skin: Hematoma at R side of neck unchaged,staples intact. cough/gag intact.cv: monitor shows v-paced rhythm with no ectopy noted. heparin gtt d/c'd as ordered. remains on flagyl for +urine.endo: remains on fingersticks q6hr with humalog s/s.skin: l upper forearm dsg c/d/i with sm amt old staining noted. l arm pulses dopplerable.resp: ls with bibasilar crackles noted. diet.gu: foley intact and patent draining yellow urine with sm amt sedimentation noted.i-d: afebrile. Abd soft, bs present.Skin: Surfaces grossly intact, hematoma at right neck unchanged. ?resumption of diuresis vs further hydration for low urine output. No dyspnea/sob noted or voiced.Gu: Uo 14-20cc/hr clear yellow, fluid bolus x2 without increase.GI: Currently npo s/p extubation. Pt up to MICU 7 from PACU, weaned and extubated without problems. Assess swallowing capability and resume po meds when pt more alert. pt has weak cough.cv: HR 70 Vpaced, 1 episode of HR up to 120-134 withVpaced for less 1min, no changes in BP, no c/o of chest pain from pt, MD aware. pt follows simple commands, PERL 3mm/brisk. Post op left arm pulses palpable by doppler.Endo: Ssc with regular insulin by .Soc: Two daughters, "" is HCP, copy on chart.P: Prn analgesics, follow PTT with heparin adjustment per protocol. currently on 2l np.gi: abd soft and nontender. Tracing is unchanged compared to the previous tracingof . Encourage pulmonary hygiene, follow abg's/02 sats. left arm pulses palpable by doppler.id: afevrile, cont flagyl.social: full code, daughter visited and called for updated, very concerns about pt mental status.plan: cont monitoring neuro/resp/cardio status monitorng i&O update and given emotional support to family monitoring hematoma, PTT. +bs noted. Compared to the previous tracing of nosignificant change. Transfer out of ICU when medically appropriate. ABP 112-129/30's, MAP 56-70, CVP 10-12. pt cont Heparin 500cc/hr, at PTT 71.2 mornihg labs pending.gi/gu: foley in place drainge yellow/clear urine 8-10cc/hr, at 2200 given Lasix 20mg IV with minimal response u/o 30-35cc/hr after LAsix.ABD soft, BS+,no stool this shift. Keep family up to date on poc, advance activity/diet as ordered. no c/o pain. respiratory care:Please disregard the above RC note, it is on the wrong Pt.... Seems to get over them in a short time. see carevue for details. +mae noted. She has had a couple of "choking" spell of UKO. remains full code. Monitor neck hematoma and csm left arm/hand for any change. See data, MD notes/orders and admission data.Neuro: Wakes to verbal stimuli and follows commands, nods head to y/n questions. c/o to floor. per daughter pt at baseline A/Ox3.resp: received on NC 4L, sat 100%, attempt to wean O2 to RA pt desat to 90%, put back to NC 2L,ast 97-99%, pt denies SOB, LS clear and crackles at bases. Bs's occasionally coarse, Sx'd for small to moderate amounts of yellow thick sputum when doing the vent care. No ABG's today Sat = 98->100%. 1900-0700 rn notes micuneuro: pt arousable to voice, at time oriented in place, pt const asking what's wrong with her and what happening, after explained several times, pt still cont to ask the same guestions and could not get what's happening to her. neuro: alert and oriented to person and place...needs frequent reminders as to why she is in the hospital. Upper and lower dentures in place, glasses at bedside with eye glass case. drop in sats to 88 with O2 removal. Ventricular pacing. Respiratory Care:Pt remains on PSV all day; no PMV trial today due to other unit issues. Adendum: Valuables brought in by daughter. Cvp 9, heparin gtt at 500units/hr.Pulm: Extubated this afternoon, currently on nc with 02 sat 100%. Ventricular paced rhythm. | 9 | [
{
"category": "ECG",
"chartdate": "2134-12-06 00:00:00.000",
"description": "Report",
"row_id": 280990,
"text": "Ventricular paced rhythm. Compared to the previous tracing of no\nsignificant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2134-12-04 00:00:00.000",
"description": "Report",
"row_id": 280991,
"text": "Ventricular pacing. Tracing is unchanged compared to the previous tracing\nof .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-12-06 00:00:00.000",
"description": "Report",
"row_id": 1387239,
"text": "See data, MD notes/orders and admission data.\n\nNeuro: Wakes to verbal stimuli and follows commands, nods head to y/n questions. Mae/perrl, patient denies pain.\n\nCV: Vpaced, underlying rhythm afib, sbp 130's/30's. Cvp 9, heparin gtt at 500units/hr.\n\nPulm: Extubated this afternoon, currently on nc with 02 sat 100%. No dyspnea/sob noted or voiced.\n\nGu: Uo 14-20cc/hr clear yellow, fluid bolus x2 without increase.\n\nGI: Currently npo s/p extubation. Abd soft, bs present.\n\nSkin: Surfaces grossly intact, hematoma at right neck unchanged. Post op left arm pulses palpable by doppler.\n\nEndo: Ssc with regular insulin by .\n\nSoc: Two daughters, \"\" is HCP, copy on chart.\n\nP: Prn analgesics, follow PTT with heparin adjustment per protocol. Encourage pulmonary hygiene, follow abg's/02 sats. ?resumption of diuresis vs further hydration for low urine output. Assess swallowing capability and resume po meds when pt more alert. Monitor neck hematoma and csm left arm/hand for any change. Keep family up to date on poc, advance activity/diet as ordered. Transfer out of ICU when medically appropriate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-12-07 00:00:00.000",
"description": "Report",
"row_id": 1387245,
"text": "neuro: alert and oriented to person and place...needs frequent reminders as to why she is in the hospital. +mae noted. cough/gag intact.\ncv: monitor shows v-paced rhythm with no ectopy noted. heparin gtt d/c'd as ordered. l arm pulses dopplerable.\nresp: ls with bibasilar crackles noted. drop in sats to 88 with O2 removal. currently on 2l np.\ngi: abd soft and nontender. +bs noted. diet.\ngu: foley intact and patent draining yellow urine with sm amt sedimentation noted.\ni-d: afebrile. remains on flagyl for +urine.\nendo: remains on fingersticks q6hr with humalog s/s.\nskin: l upper forearm dsg c/d/i with sm amt old staining noted. r neck staples c/d/i with no drainage noted.\npsy-soc: dtr in to visit...updated on status and plan of care. c/o to floor. remains full code.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-12-06 00:00:00.000",
"description": "Report",
"row_id": 1387240,
"text": "Respiratory Care:\nPt remains on PSV all day; no PMV trial today due to other unit issues. Bs's occasionally coarse, Sx'd for small to moderate amounts of yellow thick sputum when doing the vent care. No ABG's today Sat = 98->100%. She has had a couple of \"choking\" spell of UKO. Seems to get over them in a short time. No other events today. see carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-12-06 00:00:00.000",
"description": "Report",
"row_id": 1387241,
"text": "respiratory care:\nPlease disregard the above RC note, it is on the wrong Pt....\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-12-06 00:00:00.000",
"description": "Report",
"row_id": 1387242,
"text": "Pt up to MICU 7 from PACU, weaned and extubated without problems.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-12-06 00:00:00.000",
"description": "Report",
"row_id": 1387243,
"text": "Adendum: Valuables brought in by daughter. Upper and lower dentures in place, glasses at bedside with eye glass case.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-12-07 00:00:00.000",
"description": "Report",
"row_id": 1387244,
"text": "1900-0700 rn notes micu\n\nneuro: pt arousable to voice, at time oriented in place, pt const asking what's wrong with her and what happening, after explained several times, pt still cont to ask the same guestions and could not get what's happening to her. pt follows simple commands, PERL 3mm/brisk. no c/o pain. per daughter pt at baseline A/Ox3.\n\nresp: received on NC 4L, sat 100%, attempt to wean O2 to RA pt desat to 90%, put back to NC 2L,ast 97-99%, pt denies SOB, LS clear and crackles at bases. pt has weak cough.\n\ncv: HR 70 Vpaced, 1 episode of HR up to 120-134 withVpaced for less 1min, no changes in BP, no c/o of chest pain from pt, MD aware. ABP 112-129/30's, MAP 56-70, CVP 10-12. pt cont Heparin 500cc/hr, at PTT 71.2 mornihg labs pending.\n\ngi/gu: foley in place drainge yellow/clear urine 8-10cc/hr, at 2200 given Lasix 20mg IV with minimal response u/o 30-35cc/hr after LAsix.\nABD soft, BS+,no stool this shift. pt start diebetic diet, pt had apllesause and water w/o any difficulties, able to take PO meds w/o problem.\n\nskin: Hematoma at R side of neck unchaged,staples intact. left arm pulses palpable by doppler.\n\nid: afevrile, cont flagyl.\n\nsocial: full code, daughter visited and called for updated, very concerns about pt mental status.\n\nplan: cont monitoring neuro/resp/cardio status\n monitorng i&O\n update and given emotional support to family\n monitoring hematoma, PTT.\n"
}
] |
8,114 | 107,484 | The patient was admitted on and was the wound was cultured and she was started on Vanco, Gent, and Flagyl. She was taken to the OR and underwent sternal debridement and pectoralis flap advancement with the plastic surgery service. She tolerated the procedure well and was transferred to the CSRU in stable condition. She was extubated on POD#1 and ID was consulted. On POD#3 her chest tube was d/c'd and she was transferred to the the floor. Her wound grew out MRSA and she was continued on Vancomycin. She continued to progress and had a PICC placed. She initially had 4 JP drains in and had 2 of them d/c'd. She needs 6 weeks of IV vanco form the date of her debridement. She will be seen in Plastic Surgery Clinic in 1 week for evaluation of JP removal. | Vanco, gent dose adjusted. CV: Neo off, NTG on briefly, began metoprolol. Under fluorscopic guidance, 0.018 guide wire was advanced into the superior vena cava. A final fluoroscopic spot film demonstrated the tip to be in the superior vena cava. Rehab: OOB to chair, tol well but c/o hemmorhoids. Respiratory CarePt was received from o.r. FINDINGS: The patient is status post removal of sternotomy wires. Resp: Weaned and extubated. LEFT LOWER EXTREMITY VENOUS ULTRASOUND: scale and Doppler son of the left common femoral, superficial femoral and popliteal veins were performed. There has been removal of an endotracheal tube. Bilateral breath sounds and +ETCO2 were confirmed. PLASIC IN THIS AM DID REMIVE DSG INCISION HEALING NEW DSD PLACED. Restart preop psych meds. The PICC line was trimmed to length and advanced over a 4 French introducer sheath under fluoroscopic guidance into the superior vena cava. There has been interval development of a moderate size left pleural effusion, which tracks to the left apex. FINDINGS: An endotracheal tube, central venous catheter, nasogastric tube, and left-sided chest tube are in satisfactory position. Heme: Heparin sq. There has been interval removal of sternal wires and placement of a chest wall drain. Serosang drg from JPS. GI: Tol cl liqs. intubated, 7.o oral et tube taped at 19 cm mark. WAKE AND WEAN LATER TODAY, WEAN NEO GTT IF TOLERATES, MONITOR BLOOD SUGARS. The sheath was removed and the catheter was flushed. INTALLY C/O HEMMORHOIDS TUCKS GOTTEN PLACED , DECREASED PAIN. Cardiac and mediastinal contours are stable, compared to the preoperative radiograph allowing for differences in technique. IMPRESSION: Moderate left pleural effusion tracking to the apex. Laxative/suppository/tucks. IMPRESSION: Improving left lower lobe atelectasis with persistent moderate sized left pleural effusion tracking to the apex. There is a persistent moderate left pleural effusion tracking to the left apex. suppository on days, encourage to cough and deep breath, ? Note is made of a large left groin mixed echogenic collection likely representing a hematoma. Flagyl dcd. The basilic and brachial vein were patent and compressible. A vascular sheath and left-sided chest tube remain in place as well as additional chest wall drains. REASON FOR THIS EXAMINATION: Eval for presence of DVT WET READ: AZm 3:53 PM No DVT L groin hematoma FINAL REPORT *ABNORMAL! NEURO: ALERT AND ORIENTED X 3, MAE, FOLLOWING COMMANDS CORRECTLY, PERCOCETES FOR PAIN, VERY ANXIOUS AND IS ON LORAZ PO.CARDIAC: NSR WITH NO ECTOPY NOTED, SBP'S WNL'S, PALPIBLE PEDIAL PULSES, SKIN WARM DRY AND INTACT, +2 EDEMA IN EXTREMITIES, AFEBRILE.RESP: LUNGS DIM IN BASES, ON 3 LITERS NC SATTING AT 97%, IS COUGHING AND DEEP BREATHING AND USING I/S.SKIN: CHEST WITH DSD THAT IS CDI, MAMMORY SUPPORT IS ON, JP DSDS ARE CDI, OLD CT DSD IS CDI, COCCYX IS PINK, LEFT LEG IS BRUISED AND INCISION SITES ARE CDI.GI/GU: TOLERATING PO'S, ABD IS SOFT ROUND AND OBESE, GOOD BOWEL SOUNDS, DID GET SUPPOSITOY AND RESPONED WITH X2 SMALL STOOLS, ON RISS, IS MAKING GOOD U/O.PLAN: ENCOURAGE TO COUGH AND DEEP BREATH AND TO USE I/S, MONITOR BLOOD SUGARS, CONTINUE ATIVAN PRN, INCREASE ACTIVITY AS TOLERATES. IV fluid KVO. The right arm was then prepped and draped in the usual sterile fashion. INDICATION: Status post CABG with calf tenderness and swelling. There are bibasilar atelectatic changes, left greater than right. GU U/O THIS PM DRIFTING DOWN LASIX 20MG IV GIVEN PLAN TO GIVE 20MEQ KCL IF STARTS TO DUIRESIS. Bibasilar atelectasis, left greater than right. Under local anesthesia with 1% Lidocaine, the cephalic vein was accessed with a 21 gauge needle. A Statlock was applied and the line was Heplocked. Left groin hematoma. ID: Tmax 101.9, down to 100.1 after acetaminophen. A superficial cephalic vein was identified within the right arm. Renal: Large diuresis to lasix 20 IV. The patient already had an indwelling peripheral IV placed within the left wrist, and therefore gentle hand injection of contrast through the peripheral IV was performed. NEURO ALERT ORIENTED ANXIOUS BASELINE PERSONALITY FOLLOWS ALL COMMANDS MOVES ALL EXTREMETIESC/V NSR B/P STABLE PULSES PALPRESP NC 3L SATS 99% LUNGS CLEAR NONPRODUCTIVE NO SOB OR RESP DISTRESS NOTEDGU/GI TOL PO WELL TO COMMODE X1 FOR SMALL AMT LOOSE STOOL GUAIAC NEGATIVE ADEQUATE URINE OUTPLAN TRANSFER TO 2 TODAY IMPRESSION: Successful placement of 45 cm total length, single lumen, right- sided PICC line with tip in the superior vena cava. CSRU Progress NoteS/O: Neuro: Alert and cooperative, med with Morphine and percocet for pain. Transition to SSRI. Neuro: alert and oriented x 3, mae, following commands correctly, percocets for pain.Cardiac: nsr in the 80's, no ectopy noted, sbps run low when asleep in the mid 80's but maps above 60, sbps wnl's when awake, dopplerable pedial pulses, skin warm dry and intact, afebrile, a-line and peripheral blood cultures sent.Resp: lungs dim in bases, ct system draining scant to no drainage with no air leak, on 4 liters nc satting at 97%, abgs are good, weak cough and deep breathing exersizing.Skin: chest with dsd that is cdi with mamory support on, ct dsd cdi, jp dsd are cdi, coccyx is pink in color but no breakdown, left leg is healing wnls though has some bruising.Gi/Gu: tolerating po's, abd soft round and nontender, good bowel sounds, pt c/o not having a bm in several days, on riss, good u/o did switch from po lasix to iv.Plan: ? K repleted. The left upper arm was prepped and draped in the usual sterile fashion. CLINICAL INDICATION: Status post coronary bypass surgery. PROCEDURE/FINDINGS: The procedure is performed by Dr. and Dr. . Needs long term IV antibiotics. Cardiac and mediastinal contours are stable. | 11 | [
{
"category": "Radiology",
"chartdate": "2198-12-16 00:00:00.000",
"description": "L UNILAT LOWER EXT VEINS LEFT",
"row_id": 853968,
"text": " 2:48 PM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: Eval for presence of DVT\n Admitting Diagnosis: STERNAL WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman s/p CAGB c/b mediastinitis; now with calf tenderness and\n swelling of the left lower extremity.\n REASON FOR THIS EXAMINATION:\n Eval for presence of DVT\n ______________________________________________________________________________\n WET READ: AZm 3:53 PM\n No DVT\n L groin hematoma\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Status post CABG with calf tenderness and swelling.\n\n LEFT LOWER EXTREMITY VENOUS ULTRASOUND: scale and Doppler son of\n the left common femoral, superficial femoral and popliteal veins were\n performed. There is normal flow, compressibility, augmentation and wave\n forms. Intraluminal thrombus was not identified. Note is made of a large\n left groin mixed echogenic collection likely representing a hematoma.\n\n IMPRESSION: No evidence of DVT. Left groin hematoma.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-12-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853178,
"text": " 8:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u pleural effusion\n Admitting Diagnosis: STERNAL WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with CAD s/p CABG\n\n REASON FOR THIS EXAMINATION:\n f/u pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Portable chest of with clinical indication of status\n post coronary bypass surgery.\n\n COMPARISON: Made to previous study of one day earlier.\n\n FINDINGS:\n\n The patient is status post removal of sternotomy wires. A chest drain remains\n in place in a relatively midline position. There has been removal of an\n endotracheal tube. A vascular sheath and left-sided chest tube remain in\n place as well as additional chest wall drains. Cardiac and mediastinal\n contours are stable. There is a persistent moderate left pleural effusion\n tracking to the left apex. There is improvement in the degree of left\n retrocardiac atelectasis, but there is no significant change in the more minor\n areas of atelectasis in the right lower lobe.\n\n IMPRESSION:\n\n Improving left lower lobe atelectasis with persistent moderate sized left\n pleural effusion tracking to the apex.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-12-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853091,
"text": " 10:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval CT placement/ ETT/ L pleural effusion\n Admitting Diagnosis: STERNAL WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with CAD s/p CABG\n\n REASON FOR THIS EXAMINATION:\n eval CT placement/ ETT/ L pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest, compared previous study of .\n\n CLINICAL INDICATION: Status post coronary bypass surgery.\n\n FINDINGS:\n\n An endotracheal tube, central venous catheter, nasogastric tube, and\n left-sided chest tube are in satisfactory position. There has been interval\n removal of sternal wires and placement of a chest wall drain. Cardiac and\n mediastinal contours are stable, compared to the preoperative radiograph\n allowing for differences in technique. There has been interval development of\n a moderate size left pleural effusion, which tracks to the left apex. There\n are bibasilar atelectatic changes, left greater than right. There is also a\n probable small right pleural effusion. No pneumothorax is identified on the\n supine study.\n\n IMPRESSION:\n\n Moderate left pleural effusion tracking to the apex. Bibasilar atelectasis,\n left greater than right.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-12-12 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 853480,
"text": " 7:57 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: IV team unable to place PICC, note in chart\n Admitting Diagnosis: STERNAL WOUND INFECTION\n Contrast: OPTIRAY Amt: 50\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1752 CATH,HEM/PERTI DIALYSIS SHORT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with\n REASON FOR THIS EXAMINATION:\n IV team unable to place PICC, note in chart\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: S/P CEA and CABG. Infection. Needs long term IV antibiotics.\n\n PROCEDURE/FINDINGS: The procedure is performed by Dr. and Dr. . Dr.\n , the attending radiologist, was present and supervising throughout.\n\n The left upper arm was prepped and draped in the usual sterile fashion.\n Because no suitable superficial veins were visible, ultrasound was used to\n find a suitable vein. The basilic and brachial vein were patent and\n compressible. Initially, attempts were made to access the basilic vein under\n ultrasonographic guidance with a 21 gauge needle after local anesthesia with\n 1% Lidocaine, however the vein immediately collapsed upon access. Attempt was\n then made to access the brachial vein under ultrasonographic guidance, but\n again this was unsuccessful. The patient already had an indwelling peripheral\n IV placed within the left wrist, and therefore gentle hand injection of\n contrast through the peripheral IV was performed. Under fluoroscopy, multiple\n attempts were made to access the contrast enhanced vein, however this again\n was also unsuccessful secondary to viability of the patient's veins.\n\n The right arm was then prepped and draped in the usual sterile fashion. A\n superficial cephalic vein was identified within the right arm. Under local\n anesthesia with 1% Lidocaine, the cephalic vein was accessed with a 21 gauge\n needle. Under fluorscopic guidance, 0.018 guide wire was advanced into the\n superior vena cava. Based on markers on the guide wire, it is determined that\n a length of 45 cm would be suitable. The PICC line was trimmed to length and\n advanced over a 4 French introducer sheath under fluoroscopic guidance into\n the superior vena cava. The sheath was removed and the catheter was flushed.\n A final fluoroscopic spot film demonstrated the tip to be in the superior vena\n cava. The line is ready for use. A Statlock was applied and the line was\n Heplocked.\n\n IMPRESSION: Successful placement of 45 cm total length, single lumen, right-\n sided PICC line with tip in the superior vena cava. The line is ready for\n use.\n (Over)\n\n 7:57 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: IV team unable to place PICC, note in chart\n Admitting Diagnosis: STERNAL WOUND INFECTION\n Contrast: OPTIRAY Amt: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-12-08 00:00:00.000",
"description": "Report",
"row_id": 1370137,
"text": "NEURO: SEDATED ON PROP GTT, PEARL, MORPHINE FOR PAIN, DOES MOVE EYE LIDS TO VOCAL STIMULI BUT NO OTHER MOVEMENT NOTICED.\n\nCARDIAC: NSR IN THE HIGH 90'S TO MOSTLY ST IN THE 100-110 RANGE WITH VERY RARE PVCS, WEANED OFF NITRO GTT NOW ON NEO GTT, DOPPLERABLE PEDIAL PULSES, SKIN WARM DRY AND INTACT, + 2 EDEMA IN EXTREMITIES RUNNING LOW GRADE TEMPS.\n\nRESP: LUNGS DIM IN BASES, CT SYSTEM WITH NO AIR LEAK DRAINING VERY SCANT SERO SANG, X 4 JP DRAINS DRAINING FAIR AMOUNT OF SEROSANG, ABGS GOOD ON SIMV, RA SATS ARE 99%.\n\nSKIN: CHEST WITH DSD THAT IS CDI, CT DSD CDI JP DSDS CDI, LEFT LEG HEALING WNL'S, COCCYX AND GLUTEA AREA IS PINK WITH NO SKIN BREAKDOWN.\n\nGI/GU: NPO, OG TUBE TO LWS DRAINING SCANT BILLEOUS, HYPOACTIVE BOWEL SOUNDS, ON RISS GTT, GOOD U/O.\n\nPLAN: ? WAKE AND WEAN LATER TODAY, WEAN NEO GTT IF TOLERATES, MONITOR BLOOD SUGARS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-12-08 00:00:00.000",
"description": "Report",
"row_id": 1370138,
"text": "Respiratory Care\nPt was received from o.r. intubated, 7.o oral et tube taped at 19 cm mark. Bilateral breath sounds and +ETCO2 were confirmed. Vent settings on simv 650 x 14 60% +5. Plan is for quick wean and extubation later today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-12-08 00:00:00.000",
"description": "Report",
"row_id": 1370139,
"text": "CSRU Progress Note\nS/O: Neuro: Alert and cooperative, med with Morphine and percocet for pain.\n CV: Neo off, NTG on briefly, began metoprolol.\n Resp: Weaned and extubated. SAO2 100% on 4L. Congested cough.\n Renal: Large diuresis to lasix 20 IV. IV fluid KVO. K repleted.\n Heme: Heparin sq. Serosang drg from JPS.\n ID: Tmax 101.9, down to 100.1 after acetaminophen. Vanco, gent dose adjusted. Flagyl dcd. Blood cultures sent.\n GI: Tol cl liqs.\n Endo: Insulin infusion.\n Skin: Coccyx pink. Bed changed to atmosair mattress.\n Rehab: OOB to chair, tol well but c/o hemmorhoids. Husband in to visist.\nA: Great progress.\nP: ? 2 tomorrow. Restart preop psych meds. Await culture results. Transition to SSRI. Advance diet. Laxative/suppository/tucks. Cushion for chair.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-12-09 00:00:00.000",
"description": "Report",
"row_id": 1370140,
"text": "Neuro: alert and oriented x 3, mae, following commands correctly, percocets for pain.\n\nCardiac: nsr in the 80's, no ectopy noted, sbps run low when asleep in the mid 80's but maps above 60, sbps wnl's when awake, dopplerable pedial pulses, skin warm dry and intact, afebrile, a-line and peripheral blood cultures sent.\n\nResp: lungs dim in bases, ct system draining scant to no drainage with no air leak, on 4 liters nc satting at 97%, abgs are good, weak cough and deep breathing exersizing.\n\nSkin: chest with dsd that is cdi with mamory support on, ct dsd cdi, jp dsd are cdi, coccyx is pink in color but no breakdown, left leg is healing wnls though has some bruising.\n\nGi/Gu: tolerating po's, abd soft round and nontender, good bowel sounds, pt c/o not having a bm in several days, on riss, good u/o did switch from po lasix to iv.\n\nPlan: ? suppository on days, encourage to cough and deep breath, ? d/c ct today, increase activity as tolerates.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-12-09 00:00:00.000",
"description": "Report",
"row_id": 1370141,
"text": "PATIENT DOING WELL THIS PM, OOB TO CHAIR FOR APPROX. 2HRS. INTALLY C/O HEMMORHOIDS TUCKS GOTTEN PLACED , DECREASED PAIN. ALSO HAS NOT MOVED BOWELS SINCE MONDAY, BISACODYL SUPP PR GIVEN REPEAT THIS AM, EATING HSE DOET WITHOUT PROBLEM, ACTUALLY GREAT APPEPITE. AFEBRILE, SR IN THE 70'S SBP 100-130, LOPRESSOR DECREASED FROM 75MG TO 25MG PO BID.. RESP ON 3L NP WITH SATS 98%. TAKING DEEP BREATHES WHEN INSTRUCTED. PLASIC IN THIS AM DID REMIVE DSG INCISION HEALING NEW DSD PLACED. GU U/O THIS PM DRIFTING DOWN LASIX 20MG IV GIVEN PLAN TO GIVE 20MEQ KCL IF STARTS TO DUIRESIS. MAG 2.0 2GMS MAGNESIUM GIVEN... PATIENT WEARS MAMMARY SUPPORT AT ALL TIMES.. BS ELEVATED GIVEN 4UREGULAR INSULIN SC GIVEN BS 176.. RECHECK AT . HUSBAND IN MOST OF THE DAY..\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-12-10 00:00:00.000",
"description": "Report",
"row_id": 1370142,
"text": "NEURO: ALERT AND ORIENTED X 3, MAE, FOLLOWING COMMANDS CORRECTLY, PERCOCETES FOR PAIN, VERY ANXIOUS AND IS ON LORAZ PO.\n\nCARDIAC: NSR WITH NO ECTOPY NOTED, SBP'S WNL'S, PALPIBLE PEDIAL PULSES, SKIN WARM DRY AND INTACT, +2 EDEMA IN EXTREMITIES, AFEBRILE.\n\nRESP: LUNGS DIM IN BASES, ON 3 LITERS NC SATTING AT 97%, IS COUGHING AND DEEP BREATHING AND USING I/S.\n\nSKIN: CHEST WITH DSD THAT IS CDI, MAMMORY SUPPORT IS ON, JP DSDS ARE CDI, OLD CT DSD IS CDI, COCCYX IS PINK, LEFT LEG IS BRUISED AND INCISION SITES ARE CDI.\n\nGI/GU: TOLERATING PO'S, ABD IS SOFT ROUND AND OBESE, GOOD BOWEL SOUNDS, DID GET SUPPOSITOY AND RESPONED WITH X2 SMALL STOOLS, ON RISS, IS MAKING GOOD U/O.\n\nPLAN: ENCOURAGE TO COUGH AND DEEP BREATH AND TO USE I/S, MONITOR BLOOD SUGARS, CONTINUE ATIVAN PRN, INCREASE ACTIVITY AS TOLERATES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-12-10 00:00:00.000",
"description": "Report",
"row_id": 1370143,
"text": "NEURO ALERT ORIENTED ANXIOUS BASELINE PERSONALITY FOLLOWS ALL COMMANDS MOVES ALL EXTREMETIES\n\nC/V NSR B/P STABLE PULSES PALP\n\nRESP NC 3L SATS 99% LUNGS CLEAR NONPRODUCTIVE NO SOB OR RESP DISTRESS NOTED\n\nGU/GI TOL PO WELL TO COMMODE X1 FOR SMALL AMT LOOSE STOOL GUAIAC NEGATIVE ADEQUATE URINE OUT\n\nPLAN TRANSFER TO 2 TODAY\n"
}
] |
22,938 | 121,789 | 1. Pancreatitis - Following admission to the Medical Intensive Care Unit the patient required modest volume resuscitation as she was briefly hemoconcentrated. On hospital day #3 her amylase and lipase dropped precipitously consistent with her previous presentation of transient pancreatitis. Since stones had not been identified in her gallbladder it was suspected that her pancreatitis was due to medications or other nonstone causes. In reviewing her medication list, it was decided to ultimately withhold her Atorvastatin as her cholesterol panel was well within the normal range and this is a medication known to cause pancreatitis, however, Ursodeoxycholic, a medication not listed above, in her outpatient medication that she was discharged with on her last presentation and this medication may have to be withheld in the future as may Furosemide. 2. Gastrointestinal bleeding - Serial evaluations of her hemoglobin and hematocrit showed a stable vascular supply. She received Proton pump inhibitor and it was decided to withhold Clopidogrel indefinitely owing to her gastrointestinal bleeding. 3. Coronary artery disease - Following admission to the Medical Intensive Care Unit serial evaluation of her cardiac markers supported evidence of myocardial infarction, medical management was pursued exclusively. Clopidogrel was held indefinitely. Metoprolol was added to her regimen and Lisinopril was ultimately restarted. Atorvastatin was discontinued as described above. 4. Hypothyroidism - Her TSH was slightly elevated on admission, however, interval evaluation of her free Levothyroxine showed it to be normal. There were no changes made to her outpatient regimen. 5. Diabetes - A modest sliding scale of subcutaneous insulin was administered. Her Sulfonylurea was withheld while she was in the hospital. She achieved good glycemic control throughout. The remainder of the hospital course was significant for one episode of flash pulmonary edema for which she received Furosemide, Nitroglycerin and nonmechanical ventilation as she and her daughter had stated previously that she does not wish to have mechanical ventilation during this hospitalization. Her daughter reiterated her mother's desire to have a Do-Not-Resuscitate, Do-Not-Intubate order written. Once her pancreatitis resolved and her cardiac issues were stabilized she was transferred to the Medical Floor for further titration of her medication. , M.D. Dictated By: MEDQUIST36 D: 19:30 T: 20:07 JOB#: | BECAME HYPOTENSIVE AND NTG D/C'ED. EKG DONE. foley gravity uop q.s after lasix.integ skin intact. b.s clear except one episode of wheezing. Sinus rhythmRight bundle branch blockAcute inferior infarctSince last ECG, no significant change 2+ peripheral edema, 1+PPP bilat, reciving 1L LR over 2hrs. Given po dulcolax x1. Sinus rhythmRight bundle branch blockOld inferior infarctLow QRS voltages in precordial leadsSince last ECG, no significant change denies any pain.cv/resp nsr bbb occ pvcs noted. CPK, trop. bp stable. Since theprevious tracing of further ST-T wave changes with ST segmentelevations are now present.TRACING #1 Denies pain at presentCV: Telemetry Sr c PVC's, HR 80's, BP 130's-150's/80's-90's, KCL given as above, dose changed from IV to po d/t pt c/o of burning to infusion sites.Resp: Lungs clear bilat, o2@ 2 L NC, sat 97-100%, pt de-sats slowly with removal of o2 into high 80's, SOB with exertion noted.GI: BS + X 4 quad., hypoactive, abd soft, NGT removed at 1500 intact, green bilious drainage noticed in wall sx cannister. elevated and EKG shows ST elevation, will only tx medically, metoprolol and captopril started today. NOTED TO BE IN PACED RYTHYM FOR A SHORT PERIOD.NEURO: SLEPT AFTER PREVIOUS EPISODE, BUT AWAKE AND ALERT NOW.ENDOC: BS'S COVERED WITH SSI. MSICU NPN 0700-1900see careview for further details..A&O x3. Apetite gd. o2 sats wnl opn 4lnp. OF ISCHEMIA. Placed back on 4l nc. Low precordial lead voltage.Inferior/anterolateral myocardial infarction with ST-T wave configurationsuggest acute process. Since the previoustracing of no significant change.TRACING #2 O2sats adequate on NC. Sinus rhythm. Sinus rhythm. PT. HEMODYNAMICALLY STABLE OVERNOC W/O CARDIAC SYMPTOMS. Sinus rhythm, few paced beatsRight bundle branch blockInferior infarctLow QRS voltages in precordial leadsSince previous tracing, right bundle branch block is new Inferior (and question lateral)myocardial infarction, age indeterminate but slight ST segment elevationsuggest possible acute process. Gd wt bearing during transfer. Pt amb through today tolerated well with mild SOB on exertion, returned quickly to baseline with rest. Since theprevious tracing of paced rhythm is absent. Inferior/anterolateral myocardialinfarction with ST-T wave configuration suggesting acute process. Tol well. is now dnr/ after MD discussed with daughter. NPN 1900 - 0700NEURO : AXOXO3 , POOR SHORT TERM MEMORY, ABLE TO REORIENT EASILY.MOVES TO CHAIR W/ ASSIST OF ONE.RESP: MILD EXP WHEEZES, SATS 96-99% ON 2 LITERS.C/V: SR OCC PVC'S, RECIEVED ONE UNIT OF PRBC OVER NOC FOR HCT OF 28.8. Right bundle-branch block. Right bundle-branch block. Right bundle-branch block. AfebrileREsp: Lungs clear A&P chest, 02 Sat 99-100% on O2 at 2L NC, RR 16-20 non labored.GI: Abd soft hypoactive BS's, NPO at present, NGT to LCS with scant bld tinged drg. liquids well. for decreased UO. ECG Taken without magnetSinusPremature ventricular contractionsRight bundle branch blockOld inferior infarctLow QRS voltages in precordial leadsSince last ECG, no significant change Nursing Admission Note 1630-1900See Nursing Admission Assessment for details surrounding Admission.Neuro: Pt A&Ox3, calm and cooperative. RR ~ 20, REG, NONLABORED AT REST. O2 changed over to 100% NRB. Pt conversing appropriately. SYMPTOMS IMPROVED WITH DIURESIS. PT with stated hx of ALzeihmer's dz, no real evidence of dz. No c/o nausea or pain today, NGT removed pt tolerating clr. Pt with good response to lasix, and all other symptoms resolving. 2 PIV's. GIVEN MORPHINE IVP AND NTG PASTE AND CONSEQUENTLY IV NGT. PM HCT 31%. call out to floor if pt. Denies nausea at present although tx'd repeatedly in ER with Zofran.GU: FOley draining marginal amts of clear concentrated urine. stable. Approx. uop low at this time rx with 20 mg ivp lasix with good effect.gi/gu npo ngtube to lcs. P-MICU NPN 7p-7aSystems Review:Events:: Pt initially was comfortable, offering no complaints. Given 20mEQ of Kcl po for K 3.4. neuro. ECG Taken with magnetRegular A-V sequential pacingPacemaker rhythm - no further analysisSince previous tracing, paced rhythm with magnet Able to stand with one assist. ? Pt much improved and more comfortable within 30minutes. Recieving bolus as not above.SKIN: no breakdown noted, PIV X 2Social: PT's daughter with her, all questions answered, pt has DNR form in chart,however is only DNI at this point. PM FS 200, 4U REG INSULIN GIVEN. AM HCT 34.6.BP STABLE.F/E/N: UO 30-40CC/HR NO ABD C/O ABD SOFT.TOL REG(KOSHER) DIET,NO STOOLS OVERNOC.PLAN: C/O TO FLOOR OOB-chair x3.5hrs. Gait steady. Pt was unable to move bowels, and was noted to be slightly more tachypnic. NGT removed, pt started on clear liquid diet, no nausea, no vomiting, may advance diet as tolerated, Amylase down from 1315 to 490,Gu: Foley cath intact draining cl yellow urine, > 30 cc/hr.Skin: dry and intact. Clinical correlation is suggested. Clinical correlation is suggested. MICU resident into evaluate pt, order obtained for 20mg IVP lasix, 1" NTP followed by an additional 1" and 2mg IVP MSO4 administered, followed by 1mg IV. BP 130-140's/80-90's, had episodes of hypotn in the ER. NO S/ OF GIB NOTED. SATS IN HIGH 90'S ON 4 LITERS NC. Very supportive of patient. UO ~40cc/hr. moves well in the bed.pt. NO NEW CHANGES. Settled in bed, but resp status was becoming increasingly labored, audible exp wheezing, hypertensive, decreasing O2 Sats, increasing aggitation. Plan to transfer to medical bed when available. DIURESED WITH IMPROVEMENT OF PULM STATUS.GI: ICECREAM ALLOWED THIS AFTERNOON.RENAL: EXCELLENT DIURESIS FROM LASIX DOSE.CV: HYPERTENSIVE WITH THIS EPISODE OF CHF. Dgt and/or son in all day. bilious out 100cc .no stools. NTP wiped off sometime later as SBP fell to 100. am labs pending correction: ngt drained 300cc as marked in the i+o. WENT TO SLEEP AROUND 11 PM. Atrial paced rhythm. Denies pain at presentCV: Telemetry SR c BBB, HR 70-80's, hx of pacemaker for Bradycardia, no evidence of pacing on monitor. DTR FED PT IN EVENING. NPN (NOC): PT HAD A VERY GOOD NIGHT. Assisted BTB, but required more assistance. in to visit from L.A.. Plan ? Started on Iron supplement today for low Ferritin levels.Neuro: A&Ox3 talkative, hard of hearing, at times answers inappropriately d/t hearing defecit. | 17 | [
{
"category": "Nursing/other",
"chartdate": "2168-12-07 00:00:00.000",
"description": "Report",
"row_id": 1562279,
"text": "Nursing Admission Note 1630-1900\nSee Nursing Admission Assessment for details surrounding Admission.\n\nNeuro: Pt A&Ox3, calm and cooperative. PT with stated hx of ALzeihmer's dz, no real evidence of dz. Pt conversing appropriately. Denies pain at present\n\nCV: Telemetry SR c BBB, HR 70-80's, hx of pacemaker for Bradycardia, no evidence of pacing on monitor. BP 130-140's/80-90's, had episodes of hypotn in the ER. 2+ peripheral edema, 1+PPP bilat, reciving 1L LR over 2hrs. for decreased UO. Afebrile\n\nREsp: Lungs clear A&P chest, 02 Sat 99-100% on O2 at 2L NC, RR 16-20 non labored.\n\nGI: Abd soft hypoactive BS's, NPO at present, NGT to LCS with scant bld tinged drg. Denies nausea at present although tx'd repeatedly in ER with Zofran.\n\nGU: FOley draining marginal amts of clear concentrated urine. Recieving bolus as not above.\n\nSKIN: no breakdown noted, PIV X 2\n\nSocial: PT's daughter with her, all questions answered, pt has DNR form in chart,however is only DNI at this point. Code status needs to be clarified.\n\nPlan: Monitor I&o's, Bp's, continue to discuss plan of care with daughter.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-12-08 00:00:00.000",
"description": "Report",
"row_id": 1562280,
"text": "neuro. Alert and oriented. denies any pain.\ncv/resp nsr bbb occ pvcs noted. bp stable. o2 sats wnl opn 4lnp. b.s clear except one episode of wheezing. uop low at this time rx with 20 mg ivp lasix with good effect.\ngi/gu npo ngtube to lcs. bilious out 100cc .no stools. foley gravity uop q.s after lasix.\ninteg skin intact. moves well in the bed.\npt. is now dnr/ after MD discussed with daughter. in to visit from L.A.. Plan ? call out to floor if pt. stable. am labs pending\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-12-08 00:00:00.000",
"description": "Report",
"row_id": 1562281,
"text": "correction: ngt drained 300cc as marked in the i+o.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-12-08 00:00:00.000",
"description": "Report",
"row_id": 1562282,
"text": "NPN 0700-1900\nGeneral: Pt Talkative and alert today, son and daughter in room all day interacting with pt. No c/o nausea or pain today, NGT removed pt tolerating clr. liquids well. CPK, trop. elevated and EKG shows ST elevation, will only tx medically, metoprolol and captopril started today. Given 20mEQ of Kcl po for K 3.4. Pt amb through today tolerated well with mild SOB on exertion, returned quickly to baseline with rest. Started on Iron supplement today for low Ferritin levels.\n\nNeuro: A&Ox3 talkative, hard of hearing, at times answers inappropriately d/t hearing defecit. Amb today down to next room, gait unsteady, needs 2 person assist, able to assist nurse in turning self in bed. Denies pain at present\n\nCV: Telemetry Sr c PVC's, HR 80's, BP 130's-150's/80's-90's, KCL given as above, dose changed from IV to po d/t pt c/o of burning to infusion sites.\n\nResp: Lungs clear bilat, o2@ 2 L NC, sat 97-100%, pt de-sats slowly with removal of o2 into high 80's, SOB with exertion noted.\n\nGI: BS + X 4 quad., hypoactive, abd soft, NGT removed at 1500 intact, green bilious drainage noticed in wall sx cannister. NGT removed, pt started on clear liquid diet, no nausea, no vomiting, may advance diet as tolerated, Amylase down from 1315 to 490,\n\nGu: Foley cath intact draining cl yellow urine, > 30 cc/hr.\n\nSkin: dry and intact. 2 PIV's. PT sitting up in chair presently\n\nSocial: Cont to keep daughter and son informed of pt care.\n\nPlan: Continue to monitor I/O's, labs, repeat K, monitor sat's and cardiac status. PT is called out to floor awaiting bed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-12-09 00:00:00.000",
"description": "Report",
"row_id": 1562283,
"text": "NPN 1900 - 0700\n\nNEURO : AXOXO3 , POOR SHORT TERM MEMORY, ABLE TO REORIENT EASILY.MOVES TO CHAIR W/ ASSIST OF ONE.\n\nRESP: MILD EXP WHEEZES, SATS 96-99% ON 2 LITERS.\n\nC/V: SR OCC PVC'S, RECIEVED ONE UNIT OF PRBC OVER NOC FOR HCT OF 28.8. AM HCT 34.6.BP STABLE.\n\nF/E/N: UO 30-40CC/HR NO ABD C/O ABD SOFT.TOL REG(KOSHER) DIET,NO STOOLS OVERNOC.\n\nPLAN: C/O TO FLOOR\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-12-09 00:00:00.000",
"description": "Report",
"row_id": 1562284,
"text": "RESP: CRACKLES AND EXP WHEEZES THIS AM, AFTER CHOKING ON JELLO. BECAME SOB WITH LOW SATS. DIURESED WITH IMPROVEMENT OF PULM STATUS.\nGI: ICECREAM ALLOWED THIS AFTERNOON.\nRENAL: EXCELLENT DIURESIS FROM LASIX DOSE.\nCV: HYPERTENSIVE WITH THIS EPISODE OF CHF. ? OF ISCHEMIA. EKG DONE. NO NEW CHANGES. GIVEN MORPHINE IVP AND NTG PASTE AND CONSEQUENTLY IV NGT. SYMPTOMS IMPROVED WITH DIURESIS. BECAME HYPOTENSIVE AND NTG D/C'ED. PT. NOTED TO BE IN PACED RYTHYM FOR A SHORT PERIOD.\nNEURO: SLEPT AFTER PREVIOUS EPISODE, BUT AWAKE AND ALERT NOW.\nENDOC: BS'S COVERED WITH SSI.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-12-10 00:00:00.000",
"description": "Report",
"row_id": 1562285,
"text": "NPN (NOC): PT HAD A VERY GOOD NIGHT. WENT TO SLEEP AROUND 11 PM. HER DTR HAS SPENT THE NIGHT. RR ~ 20, REG, NONLABORED AT REST. SATS IN HIGH 90'S ON 4 LITERS NC. I&O'S - 500 CC'S AT MN. HEMODYNAMICALLY STABLE OVERNOC W/O CARDIAC SYMPTOMS. DTR FED PT IN EVENING. PM FS 200, 4U REG INSULIN GIVEN. PM HCT 31%. NO S/ OF GIB NOTED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-12-10 00:00:00.000",
"description": "Report",
"row_id": 1562286,
"text": "MSICU NPN 0700-1900\nsee careview for further details..\n\n\nA&O x3. No c/o. Apetite gd. O2sats adequate on NC. UO ~40cc/hr. OOB-chair x3.5hrs. Gd wt bearing during transfer. Tol well. Dgt and/or son in all day. Very supportive of patient. Given po dulcolax x1. No BM as of yet. Plan to transfer to medical bed when available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-12-11 00:00:00.000",
"description": "Report",
"row_id": 1562287,
"text": "P-MICU NPN 7p-7a\nSystems Review:\n\nEvents:: Pt initially was comfortable, offering no complaints. Approx. 8:30pm, pt requested to go to toilet in room. Able to stand with one assist. Gait steady. Pt was unable to move bowels, and was noted to be slightly more tachypnic. Assisted BTB, but required more assistance. Settled in bed, but resp status was becoming increasingly labored, audible exp wheezing, hypertensive, decreasing O2 Sats, increasing aggitation. MICU resident into evaluate pt, order obtained for 20mg IVP lasix, 1\" NTP followed by an additional 1\" and 2mg IVP MSO4 administered, followed by 1mg IV. O2 changed over to 100% NRB. Pt with good response to lasix, and all other symptoms resolving. Pt much improved and more comfortable within 30minutes. NTP wiped off sometime later as SBP fell to 100. Placed back on 4l nc. Daughter in staying with pt for night, pt resting comfortably remainder of shift.\n\nEndo: 12am FS 304 (this was rechecked), 8u reg insulin administered, will be checked again with am labs.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2168-12-13 00:00:00.000",
"description": "Report",
"row_id": 302224,
"text": "Sinus rhythm\nRight bundle branch block\nAcute inferior infarct\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2168-12-06 00:00:00.000",
"description": "Report",
"row_id": 302231,
"text": "Sinus rhythm. Right bundle-branch block. Inferior/anterolateral myocardial\ninfarction with ST-T wave configuration suggesting acute process. Since the\nprevious tracing of further ST-T wave changes with ST segment\nelevations are now present.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2168-12-12 00:00:00.000",
"description": "Report",
"row_id": 302225,
"text": "Sinus rhythm. Right bundle-branch block. Inferior (and question lateral)\nmyocardial infarction, age indeterminate but slight ST segment elevation\nsuggest possible acute process. Clinical correlation is suggested. Since the\nprevious tracing of paced rhythm is absent.\n\n"
},
{
"category": "ECG",
"chartdate": "2168-12-08 00:00:00.000",
"description": "Report",
"row_id": 302226,
"text": "ECG Taken with magnet\nRegular A-V sequential pacing\nPacemaker rhythm - no further analysis\nSince previous tracing, paced rhythm with magnet\n\n"
},
{
"category": "ECG",
"chartdate": "2168-12-08 00:00:00.000",
"description": "Report",
"row_id": 302227,
"text": "ECG Taken without magnet\nSinus\nPremature ventricular contractions\nRight bundle branch block\nOld inferior infarct\nLow QRS voltages in precordial leads\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2168-12-07 00:00:00.000",
"description": "Report",
"row_id": 302228,
"text": "Sinus rhythm\nRight bundle branch block\nOld inferior infarct\nLow QRS voltages in precordial leads\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2168-12-07 00:00:00.000",
"description": "Report",
"row_id": 302229,
"text": "Sinus rhythm, few paced beats\nRight bundle branch block\nInferior infarct\nLow QRS voltages in precordial leads\nSince previous tracing, right bundle branch block is new\n\n\n"
},
{
"category": "ECG",
"chartdate": "2168-12-07 00:00:00.000",
"description": "Report",
"row_id": 302230,
"text": "Atrial paced rhythm. Right bundle-branch block. Low precordial lead voltage.\nInferior/anterolateral myocardial infarction with ST-T wave configuration\nsuggest acute process. Clinical correlation is suggested. Since the previous\ntracing of no significant change.\nTRACING #2\n\n"
}
] |
98,273 | 109,068 | 83 year old female with h/o mild Alzheimer's disease, CEA in 05, HTN, elev lipids, bladder CA, who presents as a transfer from OSH with unresponsive with fixed dilated pupils, decerebrating postering and very extensive R intra cranial hemorrhage on CT, with significant shift and uncal herniation; deemed non-operable by neurosurgery and incompatible with survival. Patient was made CMO by family and expired the following day. | Visualized portions of the paranasal sinuses demonstrate partial opacification of the ethmoid air cells. Hemorrhage extends inferiorly into the fourth ventricle. Lungs are clear, except for a linear opacities in both lung bases, likely atelectasis. Large shift of midline structures to the right of 23 mm with subfalcine herniation and likely uncal herniation. Hemorrhage extends into the ventricles bilaterally and inferiorly into the fourth ventricle with associated obstructive hydrocephalus. There is associated obstructive hydrocephalus. Hemorrhage extends into the ventricles bilaterally with layering hemorrhage seen within the occipital horns bilaterally. Aortic arch calcifications are noted. There is significant shift of midline structures to the right of 23 mm consistent with subfalcine herniation. IMPRESSION: Appropriate position of endotracheal tube. FINDINGS: A massive intraparenchymal hemorrhage is seen centered around within the left hemisphere with significant shift of midline structures to the right measuring up to 23 mm. Chief complaint: Intracranial hemorrhage PMHx: -h/o CVA/TIA in past -HTN -h/o syncope -elev lipids -bladder CA -s/p CEA in -h/o MI -Myelodysplastic Syndrome Current medications: Morphine gtt 24 Hour Events: Allergies: Statins-Hmg-Coa Reductase Inhibitors Unknown; Last dose of Antibiotics: Infusions: Morphine Sulfate - 6 mg/hour Other ICU medications: Other medications: Flowsheet Data as of 09:00 PM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since a.m. Tmax: 34.2C (93.5 T current: 34.2C (93.5 HR: 45 (44 - 51) bpm BP: 179/55(87) {179/55(87) - 179/55(93)} mmHg RR: 18 (18 - 20) insp/min SPO2: 100% Heart rhythm: SB (Sinus Bradycardia) Total In: 5 mL PO: Tube feeding: IV Fluid: 5 mL Blood products: Total out: 0 mL 150 mL Urine: 125 mL NG: 25 mL Stool: Drains: Balance: 0 mL -145 mL Respiratory support O2 Delivery Device: None Ventilator mode: CPAP/PSV Vt (Spontaneous): 343 (343 - 343) mL RR (Spontaneous): 19 PEEP: 5 cmH2O FiO2: 100% PIP: 11 cmH2O SPO2: 100% ABG: //// Ve: 7.3 L/min Physical Examination General Appearance: No acute distress HEENT: Left pupil dilated Cardiovascular: (Rhythm: Regular), bradycardic Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA bilateral : ) Abdominal: Soft, Non-distended, Non-tender Left Extremities: (Edema: Absent) Right Extremities: (Edema: Absent) Neurologic: Sedated Labs / Radiology [image002.jpg] Assessment and Plan Assessment and Plan: Patient is an 83 year old female with h/o dementia, CVA in past, bladderCA, MDS who presents as a transfer from OSH with unresponsiveness, blown pupil and large intracranial hemorrhage on CT. Pt does not want to pursue drastic measure and would like to pt to be DNR with comfort measures only. | 5 | [
{
"category": "Physician ",
"chartdate": "2139-09-13 00:00:00.000",
"description": "Intensivist Note",
"row_id": 480826,
"text": "SICU\n HPI:\n 83 year old female with h/o mild Alzheimer's disease,\n CEA in 05, HTN, elev lipids, bladder CA, who\n presents as a transfer from OSH with unresponsiveness, blown pupil,\n decerebrating postering and very extensive L intra cranial hemorrhage\n on CT, with significant shift and uncal herniation. Patient is\n currently intubated and was made CMO by family.\n Chief complaint:\n Intracranial hemorrhage\n PMHx:\n -h/o CVA/TIA in past\n -HTN\n -h/o syncope\n -elev lipids\n -bladder CA\n -s/p CEA in \n -h/o MI\n -Myelodysplastic Syndrome\n Current medications:\n Morphine gtt\n 24 Hour Events:\n Allergies:\n Statins-Hmg-Coa Reductase Inhibitors\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Morphine Sulfate - 6 mg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 09:00 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 34.2\nC (93.5\n T current: 34.2\nC (93.5\n HR: 45 (44 - 51) bpm\n BP: 179/55(87) {179/55(87) - 179/55(93)} mmHg\n RR: 18 (18 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 5 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 125 mL\n NG:\n 25 mL\n Stool:\n Drains:\n Balance:\n 0 mL\n -145 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 343 (343 - 343) mL\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 7.3 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: Left pupil dilated\n Cardiovascular: (Rhythm: Regular), bradycardic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Sedated\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Assessment and Plan: Patient is an 83 year old female with h/o\n dementia, CVA in past, bladderCA, MDS who presents as a transfer from\n OSH with unresponsiveness, blown pupil and large intracranial\n hemorrhage\n on CT. Pt does not want to pursue drastic measure and would like to pt\n to be DNR with comfort measures only.\n Neurologic: Morphine gtt for sedation/pain control\n Cardiovascular: none\n Pulmonary: Extubate today, Family wishes pt to be extubated\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO\n Renal: Foley\n Hematology: none\n Endocrine: none\n Infectious Disease: none\n Lines / Tubes / Drains: Foley, OGT\n Wounds: none\n Imaging: none\n Fluids: none\n Consults: Neurology\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:44 PM\n Prophylaxis:\n DVT: none\n Stress ulcer: none\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Comfort measures only\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2139-09-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 480827,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt admitted from the ED intubated, unresponsive on Propofol and\n morphine drips\n Action:\n Pt made CMO status , extubated, morphine drip at 8 mg for comfort.\n Response:\n Pt appeared comfortable, family at bedside, pt expired at 2334.\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-09-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 480828,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt admitted from the ED intubated, unresponsive on Propofol and\n morphine drips\n Action:\n Pt made CMO status , extubated, morphine drip at 8 mg for comfort.\n Response:\n Pt appeared comfortable, family at bedside, pt expired at 2334.\n Plan:\n ------ Protected Section ------\n NEOB called and pt was declined as a donor.\n ------ Protected Section Addendum Entered By: , RN\n on: 00:29 ------\n"
},
{
"category": "Radiology",
"chartdate": "2139-09-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1095667,
"text": " 1:12 PM\n CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: ?ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with ICH on OSH CT\n REASON FOR THIS EXAMINATION:\n ?ICH\n ______________________________________________________________________________\n WET READ: JKSd SUN 1:36 PM\n Massive intraparenchymal hemorrhage throughout the entire left hemisphere\n extending into the ventricles and into the forth ventricle with associated\n obstructive hydrocephalus. Large shift of midline structures to the right of\n 23 mm with subfalcine herniation and likely uncal herniation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old woman with intracranial hemorrhage on outside\n hospital CT. Study is being submitted for second-read request.\n\n COMPARISON: None available.\n\n TECHNIQUE: Axially acquired images were obtained through the head without\n contrast.\n\n FINDINGS: A massive intraparenchymal hemorrhage is seen centered around\n within the left hemisphere with significant shift of midline structures to the\n right measuring up to 23 mm. Hemorrhage extends into the ventricles\n bilaterally with layering hemorrhage seen within the occipital horns\n bilaterally. Exact center of the left hemispheric hemorrhage is difficult to\n assess but probably is located around the left basal ganglia. Hemorrhage\n extends inferiorly into the fourth ventricle. There is associated obstructive\n hydrocephalus. There is associated swelling of the left hemisphere with loss\n of sulci.\n\n No fractures are identified. Visualized portions of the paranasal sinuses\n demonstrate partial opacification of the ethmoid air cells. The mastoid air\n cells are clear.\n\n IMPRESSION: Massive intraparenchymal hemorrhage centered in the left\n hemisphere extending to the vertex. Hemorrhage extends into the ventricles\n bilaterally and inferiorly into the fourth ventricle with associated\n obstructive hydrocephalus. There is significant shift of midline structures\n to the right of 23 mm consistent with subfalcine herniation. There is likely\n uncal herniation also.\n\n Findings were posted to the ED dashboard shortly after review on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-09-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1095664,
"text": " 12:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman intubated for ICH\n REASON FOR THIS EXAMINATION:\n ?tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old woman intubated for intracranial hemorrhage.\n\n COMPARISON: None.\n\n SINGLE SUPINE VIEW OF THE CHEST: An endotracheal tube terminates\n approximately 3 cm above the carina. A nasogastric tube extends into the\n stomach, with the side port well below the GE junction. An underlying trauma\n board partially obscures evaluation.\n\n Lungs are clear, except for a linear opacities in both lung bases, likely\n atelectasis. There is no pleural effusion or pneumothorax. The\n cardiomediastinal silhouette is within normal limits. Aortic arch\n calcifications are noted. Pulmonary vascularity is normal.\n\n IMPRESSION: Appropriate position of endotracheal tube. Bibasilar atelectasis.\n\n DFDdp\n\n"
}
] |
73,454 | 109,469 | Pt was admitted to the Neurosurgery service, ICU for close neurological observation. He was started on dilantin for seizure prophylaxsis, and blood pressure was kept < 140 systolic. Patient was stabilized and exubated. His c-spine was cleared. Seen by plastics for facial fractures; they placed 2 sutures on nose and recommended sinus precautions with augmentin x2 weeks. Repeat head CT on revealed no interval change in hemorrhage. Patient was subsequently transfered to the floor. Throughout his hospitalization, patient was monitored for signs of EtOH withdrawal but did not require benzodiazepines. PT was consulted and patient was deemed appropriate for discharge home. A plan was put in place with social work for the patient to discharge safely to his mother's home. At the time of discharge he was tolerating a regular diet, ambulating without difficulty, afebrile with stable vital signs. | Sinus bradycardia. The Q-T interval is prolonged for rate. | 1 | [
{
"category": "ECG",
"chartdate": "2121-05-22 00:00:00.000",
"description": "Report",
"row_id": 230410,
"text": "Sinus bradycardia. The Q-T interval is prolonged for rate. No previous\ntracing available for comparison.\n\n\n"
}
] |
28,001 | 153,232 | Patient is a 80 yo man with PMH of HTN, hyperlipid, h/o afib, osteoporosis, DM2, low testosterone, prostate ca s/p radiation who is transferred from with a necrotic brain lesion in the left parietal/occipital area. There is nothing on physical exam to suggest mass effect. In his Coumadin was held, and he was started on Keppra and Decadron which we have continued. He has recent diagnosis and treatment of prostate CA, however this does not metastasize to the brain parenchyma. Primary neoplasm such as GBM, less likely CNS lymphoma. He had a repeat MRI with gad. On he underwent a brain biopsy; pathology report: Anaplastic Oligoastrocytoma, grade III On he underwent a craniotomy for removal of the left parietal mass. Post operatively he spent the night in the SICU to monitor his BP he required a Nitro drip intermittently. Neurologically he was intact. He was transferred to the surgical floor on . PT saw the patient and recommended rehab; OT was also consulted and recommended short term rehab. | Stable-appearing vasogenic edema within the left parietal lobe. COMPARISON: MRI head dated . There is a region of relative within the edema, likely representing an underlying neoplasm. IMPRESSION: Status post biopsy of known left parietal mass with single punctate which may represent tiny post-biopsy area of blood product. Otherwise, the findings aresimilar.TRACING #1 MRI HEAD WITH CONTRAST: Enhancing peripheral mass in the left posterior parietal lobe is again demonstrated and unchanged compared to . Small amount of residual enhancement is seen immediately and inferior to the resection site. IMPRESSION: Left-sided parietal lobe 3.1 x 2.5 cm intra-axial cortical/subcortical mass with homogeneous enhancement and low ADC values. Slightly hyponatremic-received Mannitol in OR. Large confluent area of hypodensity likely representing vasogenic edema centered within the left parietal lobe is stable. A region of relative within the edema likely represents the underlying neoplasm. Left head incision covered with DSD C/D/I.On Nitro gtt at 1.0/hr for goal SBP <140.Extubated in PACU. T1 sagittal, axial and coronal images were obtained following gadolinium. Comparison is made to MRI and head CT. NON-CONTRAST HEAD CT. NON-CONTRAST HEAD CT SCAN. IMPRESSION: Status post resection of the left parietal convexity enhancing intra-axial brain lesion. No contraindications for IV contrast FINAL REPORT HISTORY: Status post left parietal lobe tumor resection. Correlation was made with the CT of . Compared totracing #2 the rhythm is now sinus with premature atrial and ventricularectopy.TRACING #3 Sinus rhythm with premature atrial and ventricular beat. FINDINGS: The patient is status post biopsy of the known left parietal brain mass single punctate may represent a focus of intraparenchymal hemorrhage. CT Head showed left parietal mass with vasogenic edema. TECHNIQUE: Multiplanar T1- post-gadolinium images were obtained including axial MP-RAGE images. Large area of vasogenic edema with a small hyperdense nodule centered in the left parietal lobe likely secondary to patient's known underlying lesion. Enhancing left parietal lesion with associated vasogenic edema. T1 sagittal and axial as well as coronal images were obtained following gadolinium. Steriotactic biopsy done . IMPRESSION: Enhancing left parietal mass without significant change compared . Following gadolinium, enhancement is seen along the medial margin of the resection site as well as inferior margin of the resection site indicating some residual enhancement. TECHNIQUE: T1 sagittal and axial and FLAIR, T2 susceptibility and diffusion axial images were obtained before gadolinium. FINDINGS: There is a 4.0 x 1.1 cm ring enhancing lesion within the left parietal lobe with associated confluent white representing vasogenic edema. There is pneumocephalus identified. IMPRESSION: Expected postoperative changes with no evidence of hemorrhage. The appearance of the head CT is otherwise unchanged with stable mild mucosal thickening within the right maxillary sinus. 7:37 PM MR HEAD W & W/O CONTRAST Clip # Reason: follow up on postop residual tumor. FINDINGS: There is an area of brain edema identified in the left parietal lobe extending from cortical to subcortical region, extending to the ventricular margin. There is moderate brain atrophy. TECHNIQUE: Non-contrast axial images of the head. REASON FOR THIS EXAMINATION: follow up on postop residual tumor. Clinical correlationis suggested. There is mild brain atrophy and mild changes of small vessel disease. Compared to tracing #3 idioventricular rhythm is nowevident. FINDINGS: Since the previous study, the patient has undergone resection of enhancing brain lesion in the left parietal convexity region. There is an area of isointense signal identified near the cortex, which demonstrate hyperintense signal on FLAIR images with low ADC values on ADC map. Second 2 mm focus of enhancement in the left frontal lobe likely may represent confluence of vessels. this si most typical of a colloid cyst. The hilar and mediastinal contours are normal. MS waxes and wanes. Foley with c/y/u. TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion axial images of the brain were acquired before gadolinium. Normal except for rate. Post extubation ABG WNL. Sinus bradycardia. Sinus bradycardia. FINDINGS: There is a large area of confluent hypodensity likely representing vasogenic edema centered within the left parietal lobe. Surrounding signal abnormality on T1-weighted images is also again demonstrated and not significantly changed. Comparison was made with the previous study of . However, given the apparent malignant neoplasm, an MR should be obtained ad the possibility entertained that the third ventricular lesion may be another malignant deposit. The remainder of the examination is unchanged. REASON FOR THIS EXAMINATION: rule out postop ICH. Compared to tracing #1idioventricular rhythm is now apparent.TRACING #2 Stable 5 mm hyperdense lesion in the foramen of , which may represent a colloid cyst versus a hemorrhagic mass and close correlation with outside hospital MR is recommended. CLINICAL INFORMATION: Patient with new brain mass. There may be a second tiny focus of enhancement in the left frontal lobe (series 2, image 37). Continue monitor.Plan: Continue neuro checks, hemodynamic monitoring, wean NTG as tolerated, follow labs, transfer back to 11 in am. There is a tiny 2-mm rounded opacity projecting over the left second anterior rib, likely represents a vessel. Clinical correlation is suggested.TRACING #4 DSD covering sutures on left half of head.POC: Repeat head CT this morning. There is mild mucosal thickening within the maxillary antra. FINDINGS: There is expected air within the left parietal surgical bed and expected postoperative pneumocephalus and adjacent subcutaneous emphysema and swelling adjacent to the high right parietal craniotomy site. | 15 | [
{
"category": "Radiology",
"chartdate": "2198-12-06 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 989719,
"text": " 8:46 AM\n CHEST (PA & LAT) Clip # \n Reason: please do in AM.man with new brain mass\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with new brain mass\n REASON FOR THIS EXAMINATION:\n please do in AM.man with new brain mass\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: An 80-year-old male with new brain mass.\n\n CHEST, PA AND LATERAL: There are no prior studies for comparison. Heart size\n is normal. The hilar and mediastinal contours are normal. Lungs are clear.\n There is a tiny 2-mm rounded opacity projecting over the left second anterior\n rib, likely represents a vessel. No pleural effusions are seen. Fracture\n deformities of the right fourth, fifth, and sixth posterior ribs are seen. No\n pneumothorax identified.\n\n IMPRESSION: No evidence of intrathoracic malignancy.\n\n jr\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-12-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 989674,
"text": " 12:11 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: shift or mass effect?\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with new brain mass.\n REASON FOR THIS EXAMINATION:\n shift or mass effect?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 80-year-old man with new brain mass.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast axial images of the head.\n\n FINDINGS: There is a large area of confluent hypodensity likely representing\n vasogenic edema centered within the left parietal lobe. There is a region of\n relative within the edema, likely representing an underlying\n neoplasm. There is regional sulcal effacement but no shift of the normally\n midline structures or significant mass effect on the left lateral ventricle.\n There is a 5-mm hyperdense focus within the third ventricle at the foramen of\n . this si most typical of a colloid cyst. However, given the\n apparent malignant neoplasm, an MR should be obtained ad the possibility\n entertained that the third ventricular lesion may be another malignant\n deposit. There is no hydrocephalus. The osseous structures are unremarkable.\n There is mild mucosal thickening within the maxillary antra.\n\n IMPRESSION:\n 1. Large area of vasogenic edema with a small hyperdense nodule centered in\n the left parietal lobe likely secondary to patient's known underlying lesion.\n\n 2. 5-mm hyperdense lesion in the foramen of likely representing a\n colloid cyst. This should be correlated with the patient's recent outside\n hospital MR to exclude hemorrhage or metastasis.\n\n Findings discussed with Dr. on .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-12-08 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 990033,
"text": " 5:42 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: **Please do at 5:30 am** Assess for post-op change.\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with recent stereotactic biopsy\n REASON FOR THIS EXAMINATION:\n **Please do at 5:30 am** Assess for post-op change.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old male with recent stereotactic biopsy.\n\n COMPARISON: .\n\n NON-CONTRAST HEAD CT SCAN.\n\n FINDINGS: The patient is status post biopsy of the known left parietal brain\n mass single punctate may represent a focus of intraparenchymal\n hemorrhage. Large confluent area of hypodensity likely representing vasogenic\n edema centered within the left parietal lobe is stable. A region of relative\n within the edema likely represents the underlying neoplasm. There\n is no shift of the normally midline structures. Again seen is a 5 mm\n hyperdense focus within the third ventricle at the foramen of . There is\n no hydrocephalus. There is a new burr hole in the left parietal bone.\n\n IMPRESSION: Status post biopsy of known left parietal mass with single\n punctate which may represent tiny post-biopsy area of blood\n product. No large area of hemorrhage or increase in mass effect.\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-12-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 990890,
"text": " 6:39 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: rule out postop ICH. please do before 7pm .\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with s/p craniotomy for tumor resection.\n REASON FOR THIS EXAMINATION:\n rule out postop ICH. please do before 7pm .\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post left parietal lobe tumor resection. Evaluate for\n postoperative hemorrhage.\n\n Comparison is made to MRI and head CT.\n\n NON-CONTRAST HEAD CT.\n\n FINDINGS: There is expected air within the left parietal surgical bed and\n expected postoperative pneumocephalus and adjacent subcutaneous emphysema and\n swelling adjacent to the high right parietal craniotomy site. No\n postoperative intraparenchymal or extra-axial hemorrhage is identified.\n Stable-appearing vasogenic edema within the left parietal lobe. The\n appearance of the head CT is otherwise unchanged with stable mild mucosal\n thickening within the right maxillary sinus.\n\n IMPRESSION:\n\n Expected postoperative changes with no evidence of hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-12-13 00:00:00.000",
"description": "MR HEAD W/ CONTRAST",
"row_id": 990781,
"text": " 5:39 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: pre-op for tumor resection, please do at 5:00 am on \n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man brain tumor\n REASON FOR THIS EXAMINATION:\n pre-op for tumor resection, please do at 6:00 am on , prior to OR time\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Brain tumor, preoperative for tumor resection.\n\n COMPARISON: MRI head dated .\n\n TECHNIQUE: Multiplanar T1- post-gadolinium images were obtained including\n axial MP-RAGE images.\n\n MRI HEAD WITH CONTRAST: Enhancing peripheral mass in the left posterior\n parietal lobe is again demonstrated and unchanged compared to .\n Surrounding signal abnormality on T1-weighted images is also again\n demonstrated and not significantly changed. Ventricles are stable in size. No\n other enhancing lesions within the brain are seen.\n\n IMPRESSION: Enhancing left parietal mass without significant change compared\n .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-12-07 00:00:00.000",
"description": "CT STEREOTAXIS W/ CONTRAST",
"row_id": 989995,
"text": " 8:42 PM\n CT STEREOTAXIS W/ CONTRAST Clip # \n Reason: Pre-op scan with frame for stereotactic biopsy\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with lesion, frame in place, going for biopsy\n REASON FOR THIS EXAMINATION:\n Pre-op scan with frame for stereotactic biopsy\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with lesion with tactic biopsy.\n\n COMPARISON: .\n\n TECHNIQUE: Axial contrast-enhanced images through the head were obtained with\n overlying VTI headset.\n\n FINDINGS: There is a 4.0 x 1.1 cm ring enhancing lesion within the left\n parietal lobe with associated confluent white representing\n vasogenic edema. There may be a second tiny focus of enhancement in the left\n frontal lobe (series 2, image 37). This may represent confluence of vessels.\n Again seen is a hyperdense focus within the third ventricle of the foramen of\n . The remainder of the examination is unchanged.\n\n IMPRESSION:\n 1. Axial contrast-enhanced CT performed with overlying VTI headset for\n stereotactic biopsy.\n 2. Enhancing left parietal lesion with associated vasogenic edema. Second 2\n mm focus of enhancement in the left frontal lobe likely may represent\n confluence of vessels. Stable 5 mm hyperdense lesion in the foramen of ,\n which may represent a colloid cyst versus a hemorrhagic mass and close\n correlation with outside hospital MR is recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-12-07 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 989913,
"text": " 10:42 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: patient's operative course is pending MRI, he is on the sche\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with new brain mass.\n REASON FOR THIS EXAMINATION:\n patient's operative course is pending MRI, he is on the schedule for a surgery\n today and must be done asap\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE BRAIN.\n\n CLINICAL INFORMATION: Patient with new brain mass.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR, T2 susceptibility and diffusion\n axial images were obtained before gadolinium. T1 sagittal and axial as well\n as coronal images were obtained following gadolinium. Correlation was made\n with the CT of .\n\n FINDINGS: There is an area of brain edema identified in the left parietal\n lobe extending from cortical to subcortical region, extending to the\n ventricular margin. There is an area of isointense signal identified near the\n cortex, which demonstrate hyperintense signal on FLAIR images with low ADC\n values on ADC map. The findings are consistent with intra-axial brain mass\n measuring approximately 3.1 x 2.5 cm. No other abnormal areas of enhancement\n in the brain is noted. There is mild brain atrophy and mild changes of small\n vessel disease. No evidence of acute infarct seen.\n\n IMPRESSION: Left-sided parietal lobe 3.1 x 2.5 cm intra-axial\n cortical/subcortical mass with homogeneous enhancement and low ADC values.\n Although the most likely consideration is metastatic disease given patient's\n age and location, given the low ADC, other conditions such as lymphoma should\n also be considered in the differential diagnosis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-12-14 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 991036,
"text": " 7:37 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: follow up on postop residual tumor. please do before midnigh\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with s/p craniotomy for tumor resection.\n REASON FOR THIS EXAMINATION:\n follow up on postop residual tumor. please do before midnight .\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI brain.\n\n CLINICAL INFORMATION: Patient status post craniotomy for tumor resection for\n postoperative evaluation.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images of the brain were acquired before gadolinium. T1 sagittal, axial\n and coronal images were obtained following gadolinium. Comparison was made\n with the previous study of .\n\n FINDINGS: Since the previous study, the patient has undergone resection of\n enhancing brain lesion in the left parietal convexity region. Small amount of\n blood products is seen in this region with surrounding edema. Following\n gadolinium, enhancement is seen along the medial margin of the resection site\n as well as inferior margin of the resection site indicating some residual\n enhancement. There is also evidence of small area of slow diffusion seen\n adjacent to the surgical site which could be related to surgery. There is\n pneumocephalus identified. There is no midline shift or hydrocephalus seen.\n There is moderate brain atrophy.\n\n IMPRESSION: Status post resection of the left parietal convexity enhancing\n intra-axial brain lesion. Small amount of residual enhancement is seen\n immediately and inferior to the resection site. No large hematoma seen,\n midline shift or hydrocephalus identified. No change in the surrounding edema\n noted.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-12-13 00:00:00.000",
"description": "Report",
"row_id": 1628531,
"text": "Nursing Admit Note\nSee Carevue for specifics\n\nPt admitted from OR at 1600 s/p left crani for tumor resection. Pt is 80 year-old male recently admitted to for unsteadiness. CT Head showed left parietal mass with vasogenic edema. Steriotactic biopsy done . Admitted to SICU post op for frequent neuro checks.\nCurrently, pt is alert, oriented to self and date. MS waxes and wanes. PERRL. Speech clear. MAE with nml strength. Denies pain. Left head incision covered with DSD C/D/I.\nOn Nitro gtt at 1.0/hr for goal SBP <140.\nExtubated in PACU. Post extubation ABG WNL. Sats 99% 2L NC. NARD.\nNPO except meds tonight.\nI.Calcium repleted. Slightly hyponatremic-received Mannitol in OR. Continue monitor.\n\nPlan: Continue neuro checks, hemodynamic monitoring, wean NTG as tolerated, follow labs, transfer back to 11 in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-12-14 00:00:00.000",
"description": "Report",
"row_id": 1628532,
"text": "Please See Carevue for Specific.\n\nPt is pleasantly A+OX3, MAE, follows commands, speech is clear but occasionally has difficult with word finding. Pt c/o discomfort in head but refuses all forms of pain medication. NSR-SB, no ectopy. SBP of less than 140 maintained. Lungs are clear, O2 sat 97% on 2L NC. ABd is soft, +BSX4, no stool this shift, remains NPO. Foley with c/y/u. DSD covering sutures on left half of head.\n\nPOC: Repeat head CT this morning. Transfer back to 11 today. Continue to closely monitor neuro status, keep SBP <140, monitor pain. ?OOB to chair. Continue to offer pt and pt family emotional support throughout hospital stay.\n"
},
{
"category": "ECG",
"chartdate": "2198-12-08 00:00:00.000",
"description": "Report",
"row_id": 218134,
"text": "Probable idioventricular rhythm with prolonged QTc interval at a rate\nof 56 beats per minute. Compared to tracing #3 idioventricular rhythm is now\nevident. QTc interval is more polonged. Clinical correlation is suggested.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2198-12-08 00:00:00.000",
"description": "Report",
"row_id": 218135,
"text": "Sinus rhythm with premature atrial and ventricular beat. Compared to\ntracing #2 the rhythm is now sinus with premature atrial and ventricular\nectopy.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2198-12-07 00:00:00.000",
"description": "Report",
"row_id": 218136,
"text": "Initially sinus bradycardia with subsequent conversion to probable accelerated\nidioventricular rhythm at a rate of 56 beats per minute. Clinical correlation\nis suggested. Borderline prolonged QTc interval. Compared to tracing #1\nidioventricular rhythm is now apparent.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2198-12-07 00:00:00.000",
"description": "Report",
"row_id": 218137,
"text": "Sinus bradycardia. Borderline prolonged QTc interval. Compared to prior\ntracing of the rate is slightly slower. Otherwise, the findings are\nsimilar.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2198-12-07 00:00:00.000",
"description": "Report",
"row_id": 218138,
"text": "Sinus bradycardia. Normal except for rate. No previous tracing available for\ncomparison.\n\n"
}
] |
23,253 | 105,945 | Pt was transferred from OSH for NSTEMI and Cardiac Cath. 1) CAD/NSTEMI: Pt was CP free throughout her admission. Her TnT peaked at 0.11 (CK 87) and trended down. Cath on revealed LAD-50% mid; RCA-95% mid, distal filling into collaterals. The RCA was stented. The cath was complicated by arterial perforation and hematoma formation: see below. She was continued on ASA, Plavix, Lipitor, and Metoprolol. An ECHO on showed preserved systolic dysfunction but impaired relaxation. An ACE-i was not stated because of borderline BPs. She was instructed to f/u with a cardiologist or her PCP to resume this med. 2) Arterial Perf (Ext Iliac/Common Fem)/Blood Loss Anemia: As noted, cath was complicated by external iliac/common femoral perforationAfter cath, HCT was down to 29.1 and pt had SBPs to 70s-80s. Pt was transfered to ICU where she was transufed, started on IVF, and then recovered. Per 2nd angio, no continued bleeding was noted. In total she rec'd 3 units PRBC. Her HCT remained above 30 after the 3rd unit was given and her SBPs ranged from 100-120s thereafter as well. An Abd CT confirmed a retroperitoneal bleed: "Extraperitoneal stranding extending from the right kidney into the right deep pelvis consistent with retroperitoneal hemorrhage." 3) UTI: Her initial UA was positive and she was started on a 3 day course of Levofloxacin 500mg q24hr. She was given Phenazopyridine for symptomatic relief of dysuria. 4) GERD: Continue Pantoprazole and Maalox prn. 5) Pneumonia: At the conclusion of her course, she had mild decr of O2 sats from baseline (90-94%RA) and a CXR was read as mild RML PNA. She was continued on Levo for an addn't 7 days. 6) Code: Full. 7) FEN: Cont'd Cards Healthy diet. 8) Dispo. DCed to home. | The left ventricular inflow pattern suggests impairedrelaxation.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation. Mild (1+)aortic regurgitation is seen. Mild (1+) mitralregurgitation is seen. There is mild pulmonary artery systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.PERICARDIUM: There is no pericardial effusion.Conclusions:The left atrium is normal in size. Precordial leads appear to be right-sided chest leads. There is noaortic valve stenosis. There is mild pulmonary artery systolichypertension. Patient wrm/dry, color WNL. Mild (1+) aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Left ventricular wall thicknesses arenormal. The mitral valve leaflets are mildly thickened.Mild (1+) mitral regurgitation is seen. The pulmonary vasculature is within normal limits. This appearance is consistent with a retroperitoneal hematoma. ABDOMEN CT WITHOUT IV CONTRAST: There is atelectasis at both lung bases, right greater than left. Probable inferior myocardial infarction, age indeterminate.Prolonged QTc interval. PATIENT/TEST INFORMATION:Indication: Chest pain.Height: (in) 66Weight (lb): 170BSA (m2): 1.87 m2BP (mm Hg): 100/70HR (bpm): 93Status: InpatientDate/Time: at 11:23Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. Modest diffuse non-specific lowamplitude T wave changes. There is a small right pleural effusion. Sinus rhythmPossible inferior infarct - age undeterminedPossible anterior infarct - age undeterminedLow QRS voltages in precordial leadsMinor nonspecific ST-T abnormalitiesNo previous tracing Since the previous tracingof sinus tachycardia is present.TRACING #3 Atrial premature beats. Probable inferior myocardialinfarction, age indeterminate. Compared to the previous tracing of diffuse ST-T waveabnormalities persist. Clinicalcorrelation is suggested for possible metabolic/drug effect and/or ischemia.Since the previous tracing earlier this date atrial ectopy is not seen andfurther ST-T wave abnormalities are present.TRACING #2 Probable inferiormyocardial infarction, age indeterminate. Probable inferior myocardialinfarction. Cont' of Above NotePatient's Metoprolol held this am due to hypotension. The ascending aorta is normal indiameter. The left ventricular inflow patternsuggests impaired relaxation. Diffuse non-specific ST-T wave abnormalities. There is no pneumothorax.There is eventration of the right hemidiaprhagm. The mediastinal and hilar contours are normal. Started on Neo for Low BP Pain free on arrival from cath lab. PELVIS CT WITHOUT IV CONTRAST: There is soft tisuse stranding along the retroperitoneum extending from the infrarenal position in the right side of the abdomen along the psoas muscle into the right pelvis. There is new faint opacity in the right middle lung field, most likely representing an infectious process versus focal edema. The pulmnonary vascularity is normal in appearance. The left ventricular cavity size is normal. The aortic arch is normal in diameter.AORTIC VALVE: The aortic valve leaflets are mildly thickened. (Over) 9:40 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: CATH DECREASE IN HCT AND LOWER ABD PAIN ? There is a small collection of air within the bladder, likely due to prior Foley insertion. 9:40 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: CATH DECREASE IN HCT AND LOWER ABD PAIN ? The leftventricular cavity size is normal. Low limb lead voltage isnon-specific. Angio 30min later revealed no bleed. Overall leftventricular systolic function is normal (LVEF>55%).RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter. Now with falling Hct and lower abd pain. Cannot rule out myocardial ischemia or metabolic/drugeffect. The heart size is within normal limits. BLEED Admitting Diagnosis: UNSTABLE ANGINA FINAL REPORT (Cont) Afebrile.GI/GU: Abdomen soft and tender to palpation. Nosignificant ST segment elevation is seen. retroperitoneal bleed. Diffuse ST-T wve abnormalities. TECHNIQUE: PA and lateral chest radiographs. No deficits.CV: Was on Neo 0.58 mcg.kg/min on arrival to MICU. have cardiac diet today. Taking clear fluid overnight. IMPRESSION: New faint opacity in the right middle lung field, most likely representing a early pneumonia. Borderline left axis deviation. Borderline left axis deviation. The stomach, small bowel, and large bowel appear normal, without dilatation or wall thickening. Bandaids intact on bilateral groin from intervention site. Low QRS voltage. Did not do a whole lot but patient is not symptomatic with lower BP. REASON FOR THIS EXAMINATION: ?Bleed No contraindications for IV contrast FINAL REPORT INDICATION: 69 y/o woman status post catheterization complicated by right external iliac artery perforation, now with falling hematocrit and lower abdominal pain. Due to suboptimaltechnical quality, a focal wall motion abnormality cannot be fully excluded.Overall left ventricular systolic function is normal (LVEF>55%). The lungs are clear without focal consolidation or pleural effusions. It has been off since o0500 and has maintained BP. Sinus tachycardia. Dose decreased to 12.5mg and new parameters written, see med sheets. TECHNIQUE: Helical axial images of the abdomen and pelvis were obtained without oral and without intravenous contrast. FINDINGS: The heart is normal in size. Has been afebrile. Sinus rhythm. Sinus rhythm. Sinus rhythm. Had bilateral grion sites, no bruits,no hematoma or bleeding, pedal pulses strong. Has been Stable overnight.Neuro: Orientated x 3 spheres. Rightventricular chamber size and free wall motion are normal. Since the previoustracing earlier this date atrial ectopy is seen.TRACING #1 QTc interval appears to be prolonged but isdifficult to measure. received morphine 1 mg x2 for this and got some relief. The mediastinal and hilar contours are unremarkable. Sats 93-94%,Lungs clear.GU: Foley in till o430 when she requested it removed, Ambulated to commode and voided 200ml at 0500. | 12 | [
{
"category": "Nursing/other",
"chartdate": "2119-08-02 00:00:00.000",
"description": "Report",
"row_id": 1566101,
"text": "Admission/Progress Note: -0700\n\nPatient arrived from yesterday morning for Cardiac cath. She came to them with chest and jaw pain, ruled in for MI and tranferred here for intervention.\nPost PTCA and Stent of RCA complicated by dissection of Right Illiac artery and ? retroperitoneal bleed. Had acute abdominal pain and HCT drop to 25 which she received 2 units blood in cath lab. Started on Neo for Low BP Pain free on arrival from cath lab. Bilateral groin sites had no bleeding, no hematoma and no bruits were auscultated. Pedal pulses present. Has been Stable overnight.\n\nNeuro: Orientated x 3 spheres. No deficits.\n\nCV: Was on Neo 0.58 mcg.kg/min on arrival to MICU. Slowly weaned overnight and BP was maintained with MAP >65. It has been off since o0500 and has maintained BP. See careVue for details on weaning and BP. Had bilateral grion sites, no bruits,no hematoma or bleeding, pedal pulses strong. Has been afebrile. No complaints of chest or jaw pain. Remains in NSR all night. Held Beta blocker due to hypotension.\n\nResp: Weaned O2 overnight to 1L NC from 4L. Sats 93-94%,Lungs clear.\n\nGU: Foley in till o430 when she requested it removed, Ambulated to commode and voided 200ml at 0500. On levo for UTI. Received NS 500ml bolus at o230 to to support BP while neo was weaning. Did not do a whole lot but patient is not symptomatic with lower BP. (normally 120's). Resident aware of this. He wanted Neo off as soon as possible. Encouraged to drink.\n\nGI: Patient's abdomen painful on palpation secondary to bleed. received morphine 1 mg x2 for this and got some relief. Taking clear fluid overnight. have cardiac diet today. BS present\n\nLabs pending, drawn at 0445.\nCan be called out to floor\n\n , RN\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-02 00:00:00.000",
"description": "Report",
"row_id": 1566103,
"text": "Cont' of Above Note\nPatient's Metoprolol held this am due to hypotension. Neo gtt D/C and off since 0500. Dose decreased to 12.5mg and new parameters written, see med sheets.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-02 00:00:00.000",
"description": "Report",
"row_id": 1566102,
"text": "Shift Note\nCV: HR 90's NSR with elevations 100-110 with activity. BP runs low, but stable 85-100/50-70's with MAP >65. Patient wrm/dry, color WNL. Bandaids intact on bilateral groin from intervention site. No hematoma, brusing or bruit noted. Dorsal/pedal pulses palpable. Peripheral 20guage right forearm and left hand.\n\nResp: RR teens-20's, easy and regular. RA sats 94%, lungs clear in upper lobes with fine crackles in posterior lower bases.\n\nNeuro: Intact and A&O x3. Afebrile.\n\nGI/GU: Abdomen soft and tender to palpation. Patient c/o \"pressure pain\" and morphine 1mg given at 1230. Pain still consistent 3 at rest and 8 with activity. Patient on levo for treatment of UTI and MD notified. Pyridium ordered and 1st dose given 1600. Patient voiding at BSC without assistance. Low cholesterol, low sodium diet and tolerating well.\n\nID: UTI, on levo\n\nSocial: Family present at bedside this afternoon. Patient called out and to be transferred.\n"
},
{
"category": "Radiology",
"chartdate": "2119-08-03 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 836400,
"text": " 9:40 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: CATH DECREASE IN HCT AND LOWER ABD PAIN ? BLEED\n Admitting Diagnosis: UNSTABLE ANGINA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with cath complicated by R external illiac perf. Angio\n 30min later revealed no bleed. Now with falling Hct and lower abd pain.\n REASON FOR THIS EXAMINATION:\n ?Bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69 y/o woman status post catheterization complicated by right\n external iliac artery perforation, now with falling hematocrit and lower\n abdominal pain.\n\n TECHNIQUE: Helical axial images of the abdomen and pelvis were obtained\n without oral and without intravenous contrast.\n\n ABDOMEN CT WITHOUT IV CONTRAST: There is atelectasis at both lung bases,\n right greater than left. There is a small right pleural effusion. The liver\n is unremarkable. There is vicarious excretion of contrast within the\n gallbladder, consistent with prior catheterization procedure. The pancreas,\n spleen, adrenal glands, and kidneys are unremarkable. The stomach, small\n bowel, and large bowel appear normal, without dilatation or wall thickening.\n\n PELVIS CT WITHOUT IV CONTRAST: There is soft tisuse stranding along the\n retroperitoneum extending from the infrarenal position in the right side of\n the abdomen along the psoas muscle into the right pelvis. There is extensive\n soft tissue stranding in the right deep pelvis and along the midline, slightly\n displacing the bladder to the left. This appearance is consistent with a\n retroperitoneal hematoma. No intraperitoneal free fluid is present. Given\n the lack of intravenous contrast, the integrity of the vessels cannot be\n assessed.\n\n The rectum and uterus are unremarkable. There is a small collection of air\n within the bladder, likely due to prior Foley insertion.\n\n The osseous structures are unremarkable.\n\n IMPRESSION:\n\n Extraperitoneal stranding extending from the right kidney into the right deep\n pelvis consistent with retroperitoneal hemorrhage. There are no prior exams\n with which to compare the size and extent of the hematoma. Given the lack of\n intravenous contrast, vessel integrity cannot be assessed. If clinically\n warranted, a pelvic CTA can be performed.\n\n (Over)\n\n 9:40 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: CATH DECREASE IN HCT AND LOWER ABD PAIN ? BLEED\n Admitting Diagnosis: UNSTABLE ANGINA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-08-03 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 836431,
"text": " 1:46 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o infection, CHF\n Admitting Diagnosis: UNSTABLE ANGINA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with STEMI s/p retro bleed and now with O2 requirement upon\n ambulation.\n REASON FOR THIS EXAMINATION:\n r/o infection, CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 69-year-old woman with MI, status post retroperitoneal bleed,\n now with oxygen requirement. Evaluation for infection and CHF.\n\n TECHNIQUE: PA and lateral chest radiographs. Comparison is made with the\n previous chest radiograph dated .\n\n FINDINGS: The heart is normal in size. The mediastinal and hilar contours\n are normal.\n\n There is new faint opacity in the right middle lung field, most likely\n representing an infectious process versus focal edema.\n\n The pulmonary vasculature is within normal limits. There is no effusion.\n\n IMPRESSION: New faint opacity in the right middle lung field, most likely\n representing a early pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-08-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836138,
"text": " 4:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: chest pain eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with chest pain, ekg changes.\n REASON FOR THIS EXAMINATION:\n chest pain eval\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 69-year-old woman with chest pain.\n\n COMPARISON: None. See AP upright portable chest radiography. The heart size\n is within normal limits. The mediastinal and hilar contours are unremarkable.\n The pulmnonary vascularity is normal in appearance. The lungs are clear\n without focal consolidation or pleural effusions. There is no\n pneumothorax.There is eventration of the right hemidiaprhagm.\n\n IMPRESSION: No pneumonia or pneumothorax.\n\n"
},
{
"category": "Echo",
"chartdate": "2119-08-02 00:00:00.000",
"description": "Report",
"row_id": 77091,
"text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain.\nHeight: (in) 66\nWeight (lb): 170\nBSA (m2): 1.87 m2\nBP (mm Hg): 100/70\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 11:23\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Due to suboptimal technical quality, a\nfocal wall motion abnormality cannot be fully excluded. Overall left\nventricular systolic function is normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter. The aortic arch is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. There is no\naortic valve stenosis. Mild (1+) aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. The left ventricular inflow pattern suggests impaired\nrelaxation.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. There is mild pulmonary artery systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+)\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild (1+) mitral regurgitation is seen. The left ventricular inflow pattern\nsuggests impaired relaxation. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2119-08-03 00:00:00.000",
"description": "Report",
"row_id": 181722,
"text": "Sinus rhythm. Borderline left axis deviation. Probable inferior myocardial\ninfarction. Compared to the previous tracing of diffuse ST-T wave\nabnormalities persist. Cannot rule out myocardial ischemia or metabolic/drug\neffect. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2119-08-02 00:00:00.000",
"description": "Report",
"row_id": 181723,
"text": "Sinus tachycardia. Precordial leads appear to be right-sided chest leads. No\nsignificant ST segment elevation is seen. Probable inferior myocardial\ninfarction, age indeterminate. QTc interval appears to be prolonged but is\ndifficult to measure. Diffuse ST-T wve abnormalities. Clinical correlation is\nsuggested for ischemia and/or metabolic/drug effect. Since the previous tracing\nof sinus tachycardia is present.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2119-08-01 00:00:00.000",
"description": "Report",
"row_id": 181724,
"text": "Sinus rhythm. Borderline left axis deviation. Low limb lead voltage is\nnon-specific. Probable inferior myocardial infarction, age indeterminate.\nProlonged QTc interval. Diffuse non-specific ST-T wave abnormalities. Clinical\ncorrelation is suggested for possible metabolic/drug effect and/or ischemia.\nSince the previous tracing earlier this date atrial ectopy is not seen and\nfurther ST-T wave abnormalities are present.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2119-08-01 00:00:00.000",
"description": "Report",
"row_id": 181725,
"text": "Sinus rhythm. Atrial premature beats. Low QRS voltage. Probable inferior\nmyocardial infarction, age indeterminate. Modest diffuse non-specific low\namplitude T wave changes. Clinical correlation is suggested. Since the previous\ntracing earlier this date atrial ectopy is seen.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2119-08-01 00:00:00.000",
"description": "Report",
"row_id": 181726,
"text": "Sinus rhythm\nPossible inferior infarct - age undetermined\nPossible anterior infarct - age undetermined\nLow QRS voltages in precordial leads\nMinor nonspecific ST-T abnormalities\nNo previous tracing\n\n"
}
] |
44,644 | 138,099 | The patient was brought to the operating room on where the patient underwent coronary artery bypass grafting times two with Dr. . Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Post operative day one found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on post operative day four the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to Rehab in good condition with appropriate follow up instructions. | There are simpleatheroma in the ascending aorta. Simple atheroma in aorticarch. Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in ascendingaorta. Mild (1+) mitral regurgitation is seen. Normal appearance of the lung parenchyma. Chest tube and central venous catheter are unchanged in position. Mild mitral annularcalcification. Elevation of the left hemidiaphragm is unchanged. Lower lung volumes with bibasilar atelectases are unchanged. Thethoracic aorta is intact after decannulation. PATIENT/TEST INFORMATION:Indication: Intraoperative TEE for CABGStatus: InpatientDate/Time: at 11:51Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement. The aorticvalve leaflets (3) are mildly thickened but aortic stenosis is not present.Trace aortic regurgitation is seen. Physiologic(normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Written informed consent was obtained from the patient. Mild (1+) MR.TRICUSPID VALVE: Tricuspid valve not well visualized. No ASD by 2D or color Doppler.LEFT VENTRICLE: Normal regional LV systolic function. Normal size of the cardiac silhouette. Right IJ catheter tip is in the lower SVC. Valvular function is unchanged from pre-bypass. There is normal biventricularsystolic function. Cardiac size is top normal. Right IJ catheter tip is at the cavoatrial junction or upper right atrium, could be withdrawn a couple of centimeters for more standard position. The mitral valve leaflets are mildlythickened. There are simple atheroma in the aortic arch.There are complex (>4mm) atheroma in the descending thoracic aorta. There is a questionable tiny left apical pneumothorax. Mediastinal chest tube remains in place. Overall normal LVEF(>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. COMPARISON: Chest radiograph dated . There is a small left pleural effusion. Regional left ventricular wall motion isnormal. Cardiomediastinal contours are stable. Rightventricular chamber size and free wall motion are normal. FINDINGS: As compared to the previous radiograph, the patient has undergone CABG. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. TECHNIQUE: Portable upright chest radiograph. Overall left ventricular systolic function is normal (LVEF>55%). Possibly old inferior myocardial infarction. The patient was under general anesthesiathroughout the procedure. Results were personally reviewed with the MD caring forthe patient.Conclusions:PRE BYPASS The left atrium is moderately dilated. Low voltage.Prolonged Q-T interval. Complex (>4mm) atheroma in thedescending thoracic aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Focal calcifications in ascending aorta. IMPRESSION: No significant changes compared to the prior study. The patient appears tobe in sinus rhythm. Left mid lung opacity is where the tip of the chest tube used to be. The other monitoring and support devices, including the left chest tube and the Swan-Ganz catheter, are in correct position. Compared to the previous tracing of sinusbradycardia is new as well as the fractionation in leads III and aVF whichcould potenitally represent an old inferior wall myocardial infarction. Physiologic TR.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. eval for ptx, effusions. FINDINGS: There are no relevant changes compared to the previous study. No pneumothorax or large pleural effusions. Sinus bradycardia. Sternal wires are aligned. There is better aeration of the right lower lobe. No atrial septal defectis seen by 2D or color Doppler. LINE PLACEMENT Clip # Reason: cardiac surgery fast track extubation. No spontaneous echo contrastor thrombus is seen in the body of the left atrium/left atrial appendage orthe body of the right atrium/right atrial appendage. page cvicu provider if there is concern with findings FINAL REPORT CHEST RADIOGRAPH INDICATION: Status post CABG, fast track extubation, evaluation for pneumothorax. No TEE related complications. No spontaneous echo contrast or thrombusin the LA/LAA or the RA/RAA. The tip of the endotracheal tube projects 3.6 cm above the carina. 11:31 AM CHEST PORT. There is no pneumothorax or enlarging pleural effusions. 2:08 PM CHEST (PORTABLE AP) Clip # Reason: please eval for pneumothorax on water seal. I certify I was present incompliance with HCFA regulations. Focal calcifications inaortic root. No pneumothorax, no pleural effusions, no pulmonary edema. Good (>20 cm/s) LAA ejection velocity. Mediastinal wires are aligned. PLEASE TAKE CXR AT 1400. thanks! There is improved lung volumes and better aeration of the lower lung zones, with reduction in while the amount of bibasilar atelectasis with when compared to study from 3 hours ago. WET READ VERSION #1 FINAL REPORT PA AND LATERAL VIEWS OF THE CHEST REASON FOR EXAM: Assess for pneumothorax after chest tube removal. ATEE was performed in the location listed above. There is no pericardialeffusion. 5:33 PM CHEST (PA & LAT) Clip # Reason: eval for pleural effusions and PTX s/p chest tube removal Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA MEDICAL CONDITION: 63 year old woman s/p CABG s/p chest tube removal REASON FOR THIS EXAMINATION: eval for pleural effusions and PTX s/p chest tube removal WET READ: 8:53 PM There is no pneumothorax after removal of the left chest tube. | 6 | [
{
"category": "Radiology",
"chartdate": "2154-08-08 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1247837,
"text": " 5:33 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for pleural effusions and PTX s/p chest tube removal\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p CABG s/p chest tube removal\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions and PTX s/p chest tube removal\n ______________________________________________________________________________\n WET READ: 8:53 PM\n There is no pneumothorax after removal of the left chest tube. There is\n improved lung volumes and better aeration of the lower lung zones, with\n reduction in while the amount of bibasilar atelectasis with when compared to\n study from 3 hours ago.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: Assess for pneumothorax after chest tube removal.\n\n Comparison is made with prior study performed three hours earlier.\n\n There is a questionable tiny left apical pneumothorax. There is a small left\n pleural effusion. Elevation of the left hemidiaphragm is unchanged.\n Cardiomediastinal contours are stable. Cardiac size is top normal. There is\n better aeration of the right lower lobe. Right IJ catheter tip is in the\n lower SVC. Left mid lung opacity is where the tip of the chest tube used to\n be. Mediastinal wires are aligned. In the lateral view, plate-like\n atelectasis project in the upper lobe.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-08-06 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1247538,
"text": " 11:31 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p line change\n REASON FOR THIS EXAMINATION:\n eval placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess line.\n\n Right IJ catheter tip is at the cavoatrial junction or upper right atrium,\n could be withdrawn a couple of centimeters for more standard position.\n Mediastinal chest tube remains in place. There are lower lung volumes with\n increasing bibasilar atelectases, larger on the left side compared to prior\n study performed . There is no pneumothorax or enlarging pleural\n effusions. Sternal wires are aligned.\n\n"
},
{
"category": "Echo",
"chartdate": "2154-08-05 00:00:00.000",
"description": "Report",
"row_id": 94291,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for CABG\nStatus: Inpatient\nDate/Time: at 11:51\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast or thrombus\nin the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. All four\npulmonary veins identified and enter the left atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Simple atheroma in ascending\naorta. Focal calcifications in ascending aorta. Simple atheroma in aortic\narch. Normal descending aorta diameter. Complex (>4mm) atheroma in the\ndescending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic\n(normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Written informed consent was obtained from the patient. A\nTEE was performed in the location listed above. I certify I was present in\ncompliance with HCFA regulations. The patient was under general anesthesia\nthroughout the procedure. No TEE related complications. The patient appears to\nbe in sinus rhythm. Results were personally reviewed with the MD caring for\nthe patient.\n\nConclusions:\nPRE BYPASS The left atrium is moderately dilated. No spontaneous echo contrast\nor thrombus is seen in the body of the left atrium/left atrial appendage or\nthe body of the right atrium/right atrial appendage. No atrial septal defect\nis seen by 2D or color Doppler. Regional left ventricular wall motion is\nnormal. Overall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. There are simple\natheroma in the ascending aorta. There are simple atheroma in the aortic arch.\nThere are complex (>4mm) atheroma in the descending thoracic aorta. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present.\nTrace aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Mild (1+) mitral regurgitation is seen. There is no pericardial\neffusion. Dr. was notified in person of the results in the operating room\nat the time of the study.\n\nPOST BYPASS The patient is atrially paced. There is normal biventricular\nsystolic function. Valvular function is unchanged from pre-bypass. The\nthoracic aorta is intact after decannulation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-08-05 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1247380,
"text": " 11:14 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: cardiac surgery fast track extubation. eval for ptx, effusio\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with s/p CABG\n REASON FOR THIS EXAMINATION:\n cardiac surgery fast track extubation. eval for ptx, effusions. page cvicu\n provider if there is concern with findings\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post CABG, fast track extubation, evaluation for\n pneumothorax.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has undergone\n CABG. The tip of the endotracheal tube projects 3.6 cm above the carina. The\n other monitoring and support devices, including the left chest tube and the\n Swan-Ganz catheter, are in correct position. Normal size of the cardiac\n silhouette. Normal appearance of the lung parenchyma. No pneumothorax, no\n pleural effusions, no pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-08-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1247803,
"text": " 2:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for pneumothorax on water seal. PLEASE TAKE CXR\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p CABG\n REASON FOR THIS EXAMINATION:\n please eval for pneumothorax on water seal. PLEASE TAKE CXR AT 1400. thanks!\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n INDICATION: 53-year-old woman status post CABG, please evaluate for\n pneumothorax.\n\n COMPARISON: Chest radiograph dated .\n\n TECHNIQUE: Portable upright chest radiograph.\n\n FINDINGS: There are no relevant changes compared to the previous study.\n Chest tube and central venous catheter are unchanged in position. Lower lung\n volumes with bibasilar atelectases are unchanged. No pneumothorax or large\n pleural effusions.\n\n IMPRESSION: No significant changes compared to the prior study.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2154-08-05 00:00:00.000",
"description": "Report",
"row_id": 249801,
"text": "Sinus bradycardia. Possibly old inferior myocardial infarction. Low voltage.\nProlonged Q-T interval. Compared to the previous tracing of sinus\nbradycardia is new as well as the fractionation in leads III and aVF which\ncould potenitally represent an old inferior wall myocardial infarction.\n\n"
}
] |
1,902 | 135,491 | The patient was admitted and had a right thoracoscopic right upper lobectomy, cervical mediastinoscopy with biopsy, mediastinal nodal dissection, and flexible bronchoscopy which he tolerated well. The patient had a chest tube and a mediastinal drain placed in his right pleural space. This was placed to suction with a leak present. On post-op day 1, the patient had an episode of repiratory distress with SaO2 in the 80s on 3 liters O2 via nasal cannula. Wheezes and rhonchi were auscultated. The patient was given albuterol/ipratropium nebulizer treatments, nasal canula was switched to shovel mask, and SaO2 increased to 100%. An ecg showed no acute changes. On post-op day 2, the patient had another episode of respiratory distress and was transferred to the ICU for further management. The patient was started on Levoquin empirically. Steroids were also started for the patient's history of COPD. In the ICU, the patient also developed atrial flutter. The patient was placed on a diltiazem drip and converted back to sinus rhythm. Serial ABGs were obtained to ensure that the patient was not becoming hypoxemic or hypercarbic. On chest tube was d/c'd, was left to bulb. He had an episode of destauration in the ICU that reslved after bronchoscopy suctioned out a lot of thick secretions. Pulm was alos consulted to help manage his COPD. He was treated with Solumedrol and weaned to PO steroids for his COPD. He was also placed on BIPAP which helped as well. He was transfused 1 PRBC for a HCT of 26 on and given lasix. He was out of bed an remained in the ICU only as long as he did mostly because of a bed issue. On was d/c'd. small leak in remaing CT. Remained chest tube was clamped and removed and he was started per pulm recs on an outpt COPD regimine. he was transferred to the floor where he did well, worked with PT and was discharged home in good condition. | Transfused 1u PRBC's for hct 25-Resp: Wheezes throughout off and on-improved with alb/atr nebs. See carevue for ABG values.GU/GI: Foley to gravity with adequate HUO. 1+ pitting edema to lower extremeties. CXR taken this am.GU: Foley to gd with uo 30-60cc/hr.GI: Abd soft, NT,ND with + BS. Lytes repleted prn. ALB/ATR nebs as ordered. Pneumoboots on. Trivialmitral regurgitation is seen. Trace aortic regurgitation is seen. PIGTAIL DRG S/S FLUID.NEB TX GIVEN BY RT.GI/GU- ABD SOFT.+BS. Left atrial abnormality.RSR' pattern in lead V1. BS coarse; receiving bronchodiltors. Monitor resp. Replete lytes. Mild mitralannular calcification. CT DRAINAGE MIN SEROSANGUINOUS. BUN 45 CR 0.9 ABD snt (+)BS. Heparin gtt started. see carevue for details of CT drainage.GI/GU: Abd soft, +BS. Mild [1+] TR. SBP 130-150's.RESP: I/E wheezes T.O. IV DILT GTT DC'D AND TO RESUME PO DILT. PVC'S NOTED K 4.7. Abg 7.38/62/159/38. Sinus rhythmrSr'(V1) - probable normal variantSince previous tracing, slower heart rate Normal tricuspid valvesupporting structures. Sinus tachycardiarsr' patern in leads V1- probably normal variantSince previous tracing of , ventricular ectopy absent Palpable pulses bilat. ?Transfuse PRBC. Cont IS, cough and DB. PALP PP. Compared to the previous tracing of nosignificant change. Lasix given and cxr taken on 2. The aortic root is mildly dilated at thesinus level. CT sites with DSD-D/I.Comfort: Continues on MSO4 PCA 1.5 q 6-Using appropriately with stated good effect. K 4.1-4.2. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Afebrile. Baseline artifactSinus tachycardiaVentricular premature complexModest right ventricular conduction delay pattern - may be normal variantSince previous tracing of , sinus tachycardia and ventricular ectopypresent PERL. Mild thickening of mitral valve chordae. Rt pleural CT and blakemoore to wall suction. Tachynpeic at times. HYDROCORTISONE X1. Good UO. ABG 7.44/50/170/35/8 on NIV. RT LOWER CREPITUS ALSO. Pt given 2puffs Atrovent MDI with improved aeration throughout. There is moderate pulmonary artery systolichypertension. Suboptimal image quality - poor apicalviews.Conclusions:The left atrium is normal in size. BLE ultrasound done. + palpable pulses. NEURO: EASILY AROUSABLE, APPEARS SLIGHTLY LESS CLEAR THAN YESTERDAY, ORIENTED X3, GRASPS STRONG AND EQUAL, STEADY GAIT WHEN OOB X2. RIGHT JP WITH SEROUSSANG DRG.GI-NPO. JP WITH SEROUSSANG DRG.GI-ABD SOFT, NT/ND. Received alb/atr nebs. Abd softly distended, pos BS, ?last BM. NIPPV if ^ WOB. REMAINS ON TPN.GU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW DRG.COMFORT-HALDOL GIVEN FOR AGITATION WITH GOOD EFFECT.ENDO-SSRI.ID-AFEB. R CHEST TUBE AND JP IN PLACE. NEBS GIVEN. PULM HYGIENE. PULM HYGIENE. Resp CarePt continues NIPPV. ATIVAN ATC GIVEN.CV-HR/BP STABLE. Vanco/Zosyn as ordered.GI/METABOLIC: Sips clears tolerated. HEPARIN GTT D/C'D, AND COUMADIN D/C'D.RESP-PT REMAINS TACHYPNEIC AT TIMES. Nebs q4h. Adequate u.o., nearly uvolemic. + CREPITUS. CPT DONE. SKIN W+D. SKIN W+D. PT given Q2-Q4hr neb tx's. OOB AS TOL. + BOWEL SOUNDS. BS rhonchi, intermittent wheezes improving somewhat with MDI's. Continue neb treatment. NEBS/INHALERS GIVEN WITH SOME EFFECT. ABG PER FLOW - PH 7.35-7.31 WITH CO2 62-64- DR AWARE. CT TO H2O SEAL. Normotensive, ABP 101-130s/40-60s. ENC PO'S. +PP. +PP. EKG showed aflutter. PBOOTS ON. Afebrile. AFEBRILE. GI: NPO THIS AM ? REMAINS ON DILT GTT. LS COARSE WITH INSP/EXP WHEEZES. +BS. +BS. Hct 24.5 stable. HCT 25.1. watch hct. Tried off NIV but with significant desats. Hyperglycemic 239/243, treated per RISS.PSYCHOSOCIAL: Pt calm/coop. CT TO SXN WITH SEROUS DRG. Perl. tolerating diuresis well, CVP 2-5, fluid balance -1286ml at MN, currently -780ml. REMAINS ON HEPARIN GTT, PTT 70.RESP-CON'T WITH WHEEZES THROUGHOUT. Continue to r/o for MI. FOLLOWS COMMANDS.CV-HR 80-90'S, SINUS. TO HAVE XRAY THIS AM. Pt transferred from 2 for sob/resp distress and HR 120-140's.Neuro: AAO x3. UO adequate.Pain: Morphine pca.Plan: Monitor resp status. TOL PO'S. K+ 3.9, repleted per sliding scale. SBP 102-140 via femoral A-line. TPN TO BE STOPPED TONOC.GU-ON LASIX . TOL WELL. Foley cath. Foley cath. Blakemoore with minimal serosanguinous drainage. ABD SOFT/NT/ND. Wheezing decreases when placed back on NIV. RESP: RR 30'S THIS AM,02 SATS 90-92. RIGHT CT TO H20 SEAL WITH STRAW COLORED DRG. CT today.GI/METABOLIC: Abd soft/hyperactive bowel sounds- no BM x ? Slight diurese with lasix. Rt Pleural CT x2 to wall suction. spirocare done. OOB/ ambulate as tolerated. Incentive spirometry, chest PT and CDB done. Pt on BIPAP immediately s/p bronch. bp stable.gI abd soft. pt to be bronched.cardiac: in normal sinus rythmn. serous drainage, +leak (unchanged), - crepitus, + fluctuation. chest pt. Nebs given by resp tx. Nebs given by resp tx. UpdateSee Carevue for specificsNeuro: A & O x 3, PERRL, normal strength. CXR repeated. +fluctuation, + leak (unchanged). dsg c/d/i. Thoracic sx aware. CT to suctioned, draining small amts. pulm toilet. Pulm toilet. alberterol and atrovent neb treatment given. LS w/ rhonchi throughout. neb tx's. Chest tube d/c'd and replaced by pleurovac. Became tachypneic, wheezes t/o. inhalers as ordered. inhalers as ordered. serous drainage. Continue W Respiratory follow up. c/o mild to mod. chest to h20 seal, draining small amts. CVL d/c'd once peripheral access obtained. LS w/ ins/exp wheezing. bipap ordered. Cx sent. +PP. Transfer to floor when stable and bed avail. bp stable, peripheral pulses palpable. and atr. MD aware. pt comfortable, denies sob. RISS started. Alb/Atrovent neb given W good effect. Skin otherwise intact.plan: pulmonary toileting, oob to chair/ambulat, monitor resp. MDI spacer placed W Pt's MDI's. +BS. oob. ISE encouraged and tol well. DSD placed. thoracic team called. BS well controlled. atc. Afebrile. Afebrile. BS clear on left, BS on rt only audible fine wheezes mid apex. On Heparin SC.Resp: LS clear to coarse in upper airways, diminished at bases. Alb./atrov. (+) air leak from rt CT. Albuterol/Atrovent given with slight improvement. Integ intact.Plan: continue with current plan of care per sicu/ thoracic sx teams. PRN albuteral INH given, resp at bedside. brief episode of svt, dr. aware, electrolytes wnl.resp: ls noted for insp/exp wheezes, alb. Abdomen soft, NT/ND. Pt voiding in adequate amts. Lasix 20mg iv x's 1 (standing order) with + diuresis.resp: ls wheezy/coarse - though less wheezy this am. Right chest tube to H20 seal w/ no drainage. PLAN: Cont to monitor resp status, chest pt, monitore O2 requirements. | 52 | [
{
"category": "Echo",
"chartdate": "2193-12-19 00:00:00.000",
"description": "Report",
"row_id": 82457,
"text": "PATIENT/TEST INFORMATION:\nIndication: Shortness of breath. Lung cancer status post lobectomy\nHeight: (in) 70\nWeight (lb): 168\nBSA (m2): 1.94 m2\nBP (mm Hg): 128/57\nHR (bpm): 108\nStatus: Inpatient\nDate/Time: at 15:07\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nno apical window images could be obtained status post lobectomy\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve\nsupporting structures. Mild [1+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\nviews.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF 70%). Right ventricular chamber\nsize and free wall motion are normal. The aortic root is mildly dilated at the\nsinus level. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. Trace aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Trivial\nmitral regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2193-12-27 00:00:00.000",
"description": "Report",
"row_id": 206769,
"text": "Sinus rhythm\nrSr'(V1) - probable normal variant\nSince previous tracing, slower heart rate\n\n"
},
{
"category": "ECG",
"chartdate": "2193-12-19 00:00:00.000",
"description": "Report",
"row_id": 206770,
"text": "Sinus tachycardia\nrsr' pattern in lead V1 - probably normal variant\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2193-12-18 00:00:00.000",
"description": "Report",
"row_id": 206771,
"text": "Sinus tachycardia\nrsr' patern in leads V1- probably normal variant\nSince previous tracing of , ventricular ectopy absent\n\n"
},
{
"category": "ECG",
"chartdate": "2193-12-14 00:00:00.000",
"description": "Report",
"row_id": 206772,
"text": "Sinus tachycardia with ventricular premature beats. Left atrial abnormality.\nRSR' pattern in lead V1. Compared to the previous tracing of no\nsignificant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2193-12-06 00:00:00.000",
"description": "Report",
"row_id": 206773,
"text": "Baseline artifact\nSinus tachycardia\nVentricular premature complex\nModest right ventricular conduction delay pattern - may be normal variant\nSince previous tracing of , sinus tachycardia and ventricular ectopy\npresent\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-18 00:00:00.000",
"description": "Report",
"row_id": 1286327,
"text": "Respiratory Care Note\n4:45pm Pt's sats now 88% - pt c/o increasing SOB. Pt placed back on NIV with improvement in sats to 95%. Pt states that his breathing feels better now that he is back on NIV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-18 00:00:00.000",
"description": "Report",
"row_id": 1286328,
"text": "Respiratory Care Note\n4:45pm Pt's sats now 88% - pt c/o increasing SOB. Pt placed back on NIV with improvement in sats to 95%. Pt states that his breathing feels better now that he is back on NIV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-18 00:00:00.000",
"description": "Report",
"row_id": 1286329,
"text": "Respiratory Care Note\nPt received from 2 on mask ventilation - settings as noted. Pt in respiratory distress on floors. Pt more comfortable now that he is on NIV. Pt remained on NIV 6hours. ABG 7.44/50/170/35/8 on NIV. Pt placed on 50% face tent. BS coarse on R side, but diminished throughout. Pt given 2puffs Atrovent MDI with improved aeration throughout. Plan to on aerosol and monitor for fatigue and possible NIV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-18 00:00:00.000",
"description": "Report",
"row_id": 1286330,
"text": "Addendum\nABG on bipap (NIV) at 1530, 7.44/50/170/8/35, taken off bipap for approx 30min, pt aking for mask to be put on, c/o difficulty breathing, anxious, diaphoretic, sats 88%, RR 30s, SBP>150. Bipap reapplied, bringing sats to 95%, repeat ABG 7.43/53/62/8/36/92% NP aware and MD aware, no new orders. At present time, pt more comfortable on bipap (NIV) mask, see carevue for settings. SBP 110s, RR 20s, sats 98%.\n\n\nCreptius to right upper and lower cw and upper left cw, thoracic team aware, not new per 2 RN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-19 00:00:00.000",
"description": "Report",
"row_id": 1286331,
"text": "NEURO-ALERT & ORIENTED X3.PLEASANT,COOPERATIVE AND ASSISTS WITH CARE.VERY ANXIOUS D/T RESP STATUS. IS ABLE TO CALM SELF DOWN WITH POSITIVE FEEDBACK/REINFORCEMENT.MAE. VOICES NEEDS.\n\nCV- ST 100-110 NO ECTOPY.HR/BP/RR STABLE BUT DIRECTLY CORRELATES TO ANXIETY THEN RETURNS TO BASELINE. HEPARIN GTT @ 600U/HR. PTT=35. GTT INCREASED TO 800U/HR. WILL RECHECK IN 6HRS. 4+ PITTING EDEMA BILATERAL ANKLES. NO C/O OF LEG/CALVE PAIN.\n\nRESP- REMAINED ON BIPAP ALL SHIFT WITH INCREASING NEED OF FIO2 D/T DECOMPENSATION OF RESP. STATUS.LUNG FIELDS WITH MIXED I/E WHEEZEZ,RHONCHI, UPPER AIRWAY CONGESTION. BILATERAL UPPER LOBES WITH CREPITUS. RT LOWER CREPITUS ALSO. CT DRG YELLOW FLUID. PIGTAIL DRG S/S FLUID.NEB TX GIVEN BY RT.\n\nGI/GU- ABD SOFT.+BS. FOLEY PATENT WITH CLEAR YELLOW URINE,DECRAING I HOURLY OUTPUT THIS AM. CXR WORSE FROM . ? TO START ON LASIX TODAY?\n\nLABS- NO REPLETIONS GIVEN.\n\n WIFE/DAUGHTER CALLED. VISITOR IN @ 2100. -IN-LAW DECLINED VISIT BY RN (THROUGH) SECURITY 2200 D/T PT STATUS AND INCREASED NEED OF CARE. PT NOTIFIED AND AGREED TO RN'S DECISION. NOTIFIED THIS AM OF INCIDENCE ALSO.\n\nPLAN- CONTINUE TO MONIOTR RESP.LABS,EKGS/SERIAL CK-TROPONIN, TTE. ANXIETY MEDICATION PRN.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-09 00:00:00.000",
"description": "Report",
"row_id": 1286324,
"text": "NPN:\n\nNeuro: Alert and oriented X3, MAE with equal strength. Visiting with family throughout day. In afternoon requesting to rest in chair. Occ only able to speak few words at time without SOB but in PM feeling much better and able to speak normally.\nCV: 80-90's SR with occ PAC's and PVC's. K 4.1-4.2. Cont on diltiazem 30mg po tid, Palp pedal pulses. Pneumoboots on. BP 120-140's/. Transfused 1u PRBC's for hct 25-\nResp: Wheezes throughout off and on-improved with alb/atr nebs. Tachynpeic at times. Initially on 4l and 50% FTN with sats 93-95% improved. Able to wean to 3l and 40% OFT neb with sats> 96%. ABG's improved by PM-ON 6l nc O2 sats 98-100%. Cough prod thick pale yellow sputum. CT's to 20cm sxn with + airleaks continuois-Pleuravac changed. CXR taken this am.\nGU: Foley to gd with uo 30-60cc/hr.\nGI: Abd soft, NT,ND with + BS. Denies flatus. No N/V. Tol regular diet well with good appetite.\nEndo: Covered per CTS sliding scale with regular insulin for glucoses\n110-160's.\nIncisions: R thoracotomy incision covered with DSD-D/I. CT sites with DSD-D/I.\nComfort: Continues on MSO4 PCA 1.5 q 6-Using appropriately with stated good effect. 0-3 injections/hr. Occ noted to hit button twice at once.\nActivity: OOB to chair all day-requesting to stay in chair r/t more comfortable in chair. PT consult ordered.\nA: Slowly improving pulmonary status still requiring ^ O2 and nebs q 4-6 hrs.\nP: Awaiting PT consult, Cont inhalers/nebs as needed. Discuss with team continuation of PCA vs change to po percocet. Cont IS, cough and DB. Begin increasing activity as tolerates. \u0013\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-10 00:00:00.000",
"description": "Report",
"row_id": 1286325,
"text": "7P-7A\nNEURO: A/Ox3. MAE. Consistently follows commands. Appropriatley using Morphine PCA for pain with (+)effect. Afebrile.\n\nCV: NSR 90's with occasional PAC's & PVC's. Lytes repleted prn. Diltiazem PO TID with additional 30MG PO this am for increaseed BP and HR per . Palpable pulses bilat. SBP 130-150's.\n\nRESP: I/E wheezes T.O. ALB/ATR nebs as ordered. IS to . CT to H2O seal overnight per Thoracic team. Minimal S/S drainage. (+) airleak. Expectorating small amount thick yellow sputum. O2 sat >95% 6L NC. See carevue for ABG values.\n\nGU/GI: Foley to gravity with adequate HUO. BUN 45 CR 0.9 ABD snt (+)BS. Tolerating ordered diet.\n\nENDO: FSBS per CSRU protocol.\n\nPLAN: Pulmonary toileting, continue with NEBS/MDI. Monitor HR and rhythm. Increase activity, PT consult.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-18 00:00:00.000",
"description": "Report",
"row_id": 1286326,
"text": "1045-1900\nPt readmitted from 2 for c/o difficulty breathing low sats. Lasix given and cxr taken on 2. BLE ultrasound done. Heparin gtt started. Placed on bipap on 2. Multi attempts to place Aline.\n\nCV: HR 90-100s SR w/ rare PACs. SBP >120, NBP. Multi attempts by thoracic and csurg team for aline. At present attempting to place femoral aline. See carevue. + palpable pulses. 1+ pitting edema to lower extremeties. heparin gtt stopped NP for line placement.\n\nResp: LS coarse. Sats >93% on bipap see carevue for details. see carevue for details of CT drainage.\n\nGI/GU: Abd soft, +BS. Foley draining adequate amts of clear yellow urine. See carevue.\n\nEndo: Per csurg scale.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Attempt to take bipap off as pt tolerates. Pain control. Monitor labs and treat as appropriate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-08 00:00:00.000",
"description": "Report",
"row_id": 1286322,
"text": "ALTERED RESPIRATORY STATUS\nS: \"I JUST WANT TO SLEEP , I'LL GET UP AT 1000\" \" MY BREATHING IS A LITTLE HARDER THAN YESTERDAY\"\nO: CARDIAC: AFLUTTER AS RAPID AS 142 TRANSIENTLY, 100-120 , RECEIVED DILTIAZEM 30 MG AT 1030 WITHOUT CHANGE THEREFORE DILTIAZEM GTT ORDERED WITH A BOLUS, THE BOLUS WAS ALMOST FINISHED WHEN PT'S HR DECREASED TO 60'S AF. IV DILT GTT DC'D AND TO RESUME PO DILT. HR REMAINS IN AF WITH A VENTRICULAR RESPONSE OF 70'S-92. PVC'S NOTED K 4.7. HCT 25 RECEIVED 1 UPC WITH REPEAT HCT PENDING. EXTREMITIES WARM AND DRY. PALP PP. CT DRAINAGE MIN SEROSANGUINOUS. SBP 110'-130'S.\n RESP: THIS AM APPEARED MORE DYSPNEIC , PT ADMITTED TO THIS, SLIGHTLY BETTER AFTER A NAP, BREATH SOUNDS WITH I/E WHEEZE RECEIVED NEBS X2, GOOD COUGH, CONTINUES TO RAISE AND SWALLOW,IS 750 , ABG PER FLOW CO2 60'S, PO2 TO 65 ON 70% OPEN FACE TENT AND 4 L NP- AFTER LASIX PO2 80'S WITH PH 7.33. CHEST TUBE REMAINS WITH LEAK AS EXPECTED. HYDROCORTISONE X1.\n NEURO: EASILY AROUSABLE, APPEARS SLIGHTLY LESS CLEAR THAN YESTERDAY, ORIENTED X3, GRASPS STRONG AND EQUAL, STEADY GAIT WHEN OOB X2. PERL.\n GI: TAKING PO'S, ABD SOFT, NO STOOL.\n GU: MARGINAL UO, RECEIVED LASIX WITH SOME DIURESIS\n ENDO: HAS NOT RECIEVED ANY SSI AS OF YET\n ID: RECIEVING LEVO\n PAIN: PAIN ACCEPTABLE FOR PT. MORPHINE PCA AS PER FLOW.\n SOCIAL: FAMILY INTO VISIT AND UPDATED\nA: SLIGHTLY MORE SLEEPIER THAN YESTERDAY-CO2 60'S, AFLUTTER RAPID TO SLOW AF WITH DILT GTT,\nP: MONITOR COMFORT, HR AND RYTHYM- DILT PO, SBP, CT DRAINAGE, RESP STATUS-PULM TOILET, NEURO STATUS, I+O , LABS-1800 HCT,K,GLUCOSE. AS PER ORDERS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-09 00:00:00.000",
"description": "Report",
"row_id": 1286323,
"text": "Nursing Progress Note:\nNeuro: No deficits noted\n\nCV: At 0300, Pt received dilt 15mg iv for AFib 120's. Pt is now in SR with PAC's. HR 80's. Afebrile. Pulses palpable. Skin intact. HCT decreased to 25. ABP 120/50's.\n\nResp: Pt states that he is \"breathing much better\". No c/o SOB. Sats 98% on 50% cool neb and 4lnc. Rt pleural CT and blakemoore to wall suction. Airleak noted. Minimal serosanguinous drainage.\n\nGI/GU: Abdomen soft, nondistended. Foley cath. Good UO. Clear, yellow urine.\n\nPain: RISS\n\nPlan: Pulmonary hygiene. monitor HR/rhythm. Replete lytes. ?Transfuse PRBC. Increase activity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-22 00:00:00.000",
"description": "Report",
"row_id": 1286344,
"text": "Resp care\n\nPt has remained off NIV since 7am. Placed on 50% shovel mask; fio2 weaned to 35%. Abg 7.38/62/159/38. BS coarse; receiving bronchodiltors. BS coarse wheezing\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-22 00:00:00.000",
"description": "Report",
"row_id": 1286345,
"text": "focus update note\npt vss, no ectopy on po cardizem , off dilt gtt\n\npt continues on lasix iv bid for diuresis- cvp 5-11, chest CT awaiting results, continues on prophalactic heparin gtt goal ptt 50-60 assessing ptt q 6 hours and coumadin for ? PE- received 1 unit prbc for hct 25- post hct 30- kcl repleated x 2\n\nresp; pt contiues to have insp/exp wheezes, in varying degrees- requiring frequent albuterol/atrovent nebulizers, overall much improved since yesterday. chest tube to wall suction, positive crepitus- positive leak- icu team and primary team aware\n\ngu/gi: diet advanced to regular tolerated well, large formed bm today, clear yellow urine via foley cath\n\nplan: discontinue heparin and coumadin after final of Chest Ct to r/o PE, continue to assess q 6 hr ptt, po prednisione to start in am, continue to monitor resp status closely, may remove femoral aline per icu resident tommorrow so that pt may get oob to chair\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-23 00:00:00.000",
"description": "Report",
"row_id": 1286346,
"text": "Resp Care\nPt on 40% face tent throughout the night. Nebs given Q4 hrs. BS coarse bilaterally and wheezy at times, wheezing resolved with neb tx's. Pt says his breathing is feeling much better than yesterday. SPO2=97%ABG shows compensated respiratory acidosis. See CareVue for details.\nPlan: Continue neb treatments. NIPPV if ^ WOB.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-23 00:00:00.000",
"description": "Report",
"row_id": 1286347,
"text": "NPN\nSee carevue for detail\nNeuro:intact\nResp:Dropped sat x1 to 85 when he was found with mask on the floor. Returned to baseline as soon as mask was reinstituted.\nGI:Tol sips of water, House diet.\nGU:Diuresed s/p lasix\nCV:SR to ST.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-23 00:00:00.000",
"description": "Report",
"row_id": 1286348,
"text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT A+OX3.MAE. FOLLOWS COMMANDS. ATIVAN ATC GIVEN.\n\nCV-HR/BP STABLE. FEM ALINE OUT. SKIN W+D. +PP. PBOOTS ON. DENIES CARDIAC COMPLAINTS. HEPARIN GTT D/C'D, AND COUMADIN D/C'D.\n\nRESP-PT REMAINS TACHYPNEIC AT TIMES. LS COARSE WITH INSP/EXP WHEEZES. NEBS/INHALERS GIVEN WITH SOME EFFECT. CPT DONE. O2 SAT UP TO 100% AT TIMES BUT DOES DESAT TO 80'S WHEN O2 OFF. CT TO SXN WITH SEROUS DRG. NO CREPITUS AND VERY SM, AIR LEAK NOTED. DSG INTACT. JP WITH SEROUSSANG DRG.\n\nGI-ABD SOFT, NT/ND. +BS. TOL PO'S. TPN TO BE STOPPED TONOC.\n\nGU-ON LASIX . U/O ADEQ AMTS CL YELLOW.\n\nACT-PHYSICAL THERAPY FOLLOWING. PT AMB AROUND UNIT AND THEN SAT IN CHAIR X FEW HRS. TOL WELL.\n\nCOMFORT-DENIES NEED FOR PAIN MED.\n\nENDO-REMAINS ON INSULIN GTT. FS MONITORED CLOSELY.\n\nP-CON'T WITH CURRENT PLAN. PULM HYGIENE. OOB AS TOL. SUPPORT. ENC PO'S.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-07 00:00:00.000",
"description": "Report",
"row_id": 1286319,
"text": "Nursing Progress Note:\nPt is s/p VATS, RUL lobectomy with Rt pleural CT and drainage. Pt transferred from 2 for sob/resp distress and HR 120-140's.\n\nNeuro: AAO x3. MAE. Follows commands. Perl. Speech clear. Good cough.\n\nResp: I/E wheezes. Nebs q4h. Pt still has episodes of SOB with sats high 80's. Team aware. Rt Pleural CT x2 to wall suction. Airleak noted. Minimal serosanguinous drainage. minimal drainage. Sats 88-92% on 50% face tent.\n\nCV: SR-ST. HR 100-115. Afebrile. Pulses palpable. PIV x2. Labs wnl. Skin intact.\n\nGi/GU: Abdomen soft, nondistended. Foley cath. UO adequate.\n\nPain: Morphine pca.\n\nPlan: Monitor resp status. Continue to r/o for MI. Pain management. Pulmonary hygiene.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-07 00:00:00.000",
"description": "Report",
"row_id": 1286320,
"text": "S/P RESPIRATORY DISTRESS\nS: \"IT'S MUCH EASIER TO BREATH\" \" I HAVEN'T SLEPT ALL NIGHT\"\nO: CARDIAC: ST 100'S TO SR90'S WITH OCCASSIONAL PVCS PO LOPRESSOR GIVEN. K 4.3. SBP 110'S-150'S. EXTREMITIES WARM AND DRY, PALP PP.\n RESP: RR 30'S THIS AM,02 SATS 90-92. BETTER ONCE PAIN IN BETTER CONTROL. COURSE BREATH SOUNDS WITH AN EXPIRATORY WHEEZE, GOOD COUGH AS THE DAY PROGRESSED, IS . ABG PER FLOW - PH 7.35-7.31 WITH CO2 62-64- DR AWARE. OPEN FACE TENT AT 50% WITH 4LNP. O2 SAT >95% . = LEAK FELT DUE TO SPACE. CXR FROM 0000 UNCHANGED FROM POST OP.\n NEURO: EASILY AROUSABLE, ORIENTED X3, GRASPS STRONG AND EQUAL, MAE, FOLLOWING COMMANDS. ANXIOUS THIS AM MUCH CALMER AS MORNING PASSED.\n GI: NPO THIS AM ? BRONCH HOWEVER NOT TO BE DONE PER DR. . TOOK JELLO THIS AFTERNOON, ABD SOFT. + BOWEL SOUNDS.\n GU: ADEQUATE UO\n ID: LEVOFLOXIN STARTED\n PAIN: PCA MORPHINE, PT INSTRUCTED ON THE USE OF PCA, BETTER PAIN CONTROL .\n ENDO; HAS NOT REQUIRED ANY SSI\n SOCIAL: WIFE AND DAUGHTER INTO VISIT AND UPDATED\nA: CO2 60'S, BETTER PAIN CONTROL\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, RESP STATUS-PULM TOILET-MONITOR ABG,NEURO STATUS, I+O, LABS. AS PER ORDERS\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-08 00:00:00.000",
"description": "Report",
"row_id": 1286321,
"text": "Nursing Progress Note:\nNeuro: Pt anxious at times. AAO x3. MAE. No deficits noted.\n\nCV/Resp: Pt converted to aflutter last night. At ~0345, pt with c/o SOB and respiratory distress. HR increased to 140's with sats in the 80's. Dr at bedside. Pt received lasix 20mg, lopressor 5mg iv, and started on decadron. EKG showed aflutter. Anesthesia was called but intubation was cancelled. After ~40minutes, Pts respiratory distress improved and sats were in the low 90's on 100% nonrebreather. ABG po2 was 56 during the event. CXR results pending. Presently, pt is in aflutter with HR in the 100's. BP 100/40's. Sats 92% on 70% face tent and 4lnc. Pulses palpable. Rt pleural CT to wall suction. Airleak present. Blakemoore with minimal serosanguinous drainage. HCT 25.1. Team aware.\n\nGI/GU: Abdomen soft, obese. Foley cath. Slight diurese with lasix. Urine clear and yellow.\n\nEndoc: RISS\n\nPain: Morphine pca\n\nPlan: Monitor respiratory status. Continue neb treatment. watch hct. Pulmonary hygiene. Pain management. Wean o2.\nPlan: Monitor respiratory status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-21 00:00:00.000",
"description": "Report",
"row_id": 1286340,
"text": "focus update\npt experiencing q 1-2 hour episodes of increased work of breathing with bronchospasm associated with pt being taken off positive pressure mode of ventilation. pt desats to 90s as low as 86%- despite mutiple bronchodialtors, diuresis, wheezing unchanged except when on positive pressure bypap mask. small leak noted at chest tube and placed to wall suction per icu resident\n\nneuro: alert and oriented x 3, mae+, follows commands consistently.\n\npt continues on heparin gtt, to have coumadin dose tonight, ptt q 6 hours. currently running at 1000u/hr.\n\nlasix iv continues, with good diuresis, kcl repleated x 4\n\nplan: continue to monitor respitory status closely, pulm toilet, diuresis, check ptt q 6 hours, moniotr rising wbc , p[ulmonary consult later today\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-21 00:00:00.000",
"description": "Report",
"row_id": 1286341,
"text": "Resp Care\n\nPt with multiple episodes of coming off and on NIV; approx 10-15 minutes pt would develop increased wheezing and WOB. Pt received multiple bronchodilators. Wheezing decreases when placed back on NIV. Spo2 99% NIV with 50%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-22 00:00:00.000",
"description": "Report",
"row_id": 1286342,
"text": "Resp Care\nPt continues NIPPV. PS weaned per team request, now remains at 5 with good TV's. BS coarse & wheezy bilaterally. PT given Q2-Q4hr neb tx's. Pt has non-productive cough at this time. Pt has ^^ WOB when taken off the NIPPV Mask and does not tolerate being off for long periods of time. FiO2 weaned to 35%. See CareVue for details and specifics.\nPlan: Continue to wean settings as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-22 00:00:00.000",
"description": "Report",
"row_id": 1286343,
"text": "FOCUSED NURSING NOTE\nPlease see carevue flowsheet for further details\n\nNEURO: Slightly more lethargic this evening, A/O x 3, no changes in neuro assessments. Morphine 2mg x 3 for incr WOB and c/o general discomfort/request for sleep. Therapeutic effect observed with RR 18-20 and TV 400-500 while asleep.\n\nRESP: Mask ventilation CPAP PEEP 5 PS 8, PS titrated to 5 when sleeping comfortably- trial of no PS not tolerated by pt. ABGs with routine labs showing compensated resp acidosis- PCO2 climbing (63) in setting of high P02 (230), FiO2 titrated down to 35%, f/U ABG later this am. Awoke at 0200 with c/o feeling \"hot\" and incr WOB, audible stridor noted (afebrile)- treated with nebs q3-4hr, lungs with insp wheezes bilaterally, coarse on expiration. Strong cough, non-productive, sounds dry. Right CT patent to 20cm wall suction, 10ml drainage(serous), crepitus stable, drsg .\nSPO2 99-100%. Plan CT CHEST today, am CXR ordered.\n\nHEMODYNAMICS: NSR 80-90s on Diltiazem gtt, no ectopy, plan d/c gtt and convert to oral Diltiazem this am. Normotensive, ABP 101-130s/40-60s. tolerating diuresis well, CVP 2-5, fluid balance -1286ml at MN, currently -780ml. K+ 3.9, repleted per sliding scale. Heparin gtt titrated per PTT and MD orders, next PTT due 0700. INR 0.9, Coumadin started at 2300 as ordered. No sx bleeding, HCT stable 25.6, PLT 317. Pt denies CP.\n\nID: Feels \"hot\" periodically, afebrile (verified rectally) and glucose relatively stable. Vanco/Zosyn as ordered, sputum cx pending, blood cx pending. CT today.\n\nGI/METABOLIC: Abd soft/hyperactive bowel sounds- no BM x ? days; Dulcolax suppos given, no results. TPN at 74ml/hr. Remains hyperglycemic (180-234) with minimal response to SQ RISS, insulin gtt initiated at 0500, titrated MD ordered scale.\n\nPLAN OF CARE:\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-20 00:00:00.000",
"description": "Report",
"row_id": 1286336,
"text": "Resp Care\n\nPt was weaned from NIV this am for 2hrs; had episode of desaturation with increased wheezing and WOB; placed back on NIV. At noon again weaned to 50% face tent; abg 7.46/52/133/35; pt currently on face tent for 5hrs; fio2 titrated to 40%. Receiving scheduled bronchodilators. BS coarse. Plan to remain on face tent as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-20 00:00:00.000",
"description": "Report",
"row_id": 1286337,
"text": "FOCUS; STATUS UPDATE\nDATA;\nALERT AND ORIENTED X3. MOVING ALL EXTREMITIES IN BED, WEAK. DENIES PAIN.\nDILTIAZEM DRIP DISCONTINUED AND CHANGED TO LOPRESSOR IVP.\nCONTINUES ON HEPARIN DRIP TITRATED TO PTT GOAL OF 50-60.\nLUNGS COARSE THROUGHOUT. MINIMAL EXERTION CAUSES EXTREME SOB AND WHEEZING, DESATURATION TO 88%,ACCOMPANIED BY ANXIETY. NEBS BY RESPIRATORY THERAPY WITH GOOD EFFECT. CPAP OFF THIS AM, BUT PLACED BACK WITH SOB AND DESATURATION EVENT FOR SHORT PERIOD, NOW ON FACE TENT AT 40%. AFEBRILE. R CHEST TUBE AND JP IN PLACE. NO LEAK. CONTINUES WITH CREPITUS AROUND CHEST TUBE SITE.\nTPN FOR NUTRITION.\nADEQUATE URINE OUTPUT. CONTINUES NPO.\n\nPLAN;\nCONTINUE TO MONITOR RESPIRATORY STATUS CLOSELY.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-21 00:00:00.000",
"description": "Report",
"row_id": 1286338,
"text": "Respiratory Care: Pt remained off NIV all night and on 40% FM. Tolerated well for the most part, except episode of desaturation with physical excursion. Received alb/atr nebs. BS coarse wheeze.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-21 00:00:00.000",
"description": "Report",
"row_id": 1286339,
"text": "Focused Nursing Note\nPlease see carevue flowsheet for further details\n\nNEURO: A/O x 3, moves all extremities equally. No episodes of anxiety/agitation.\n\nRESP: CXR pending. Face tent 40% throughout night, general SPO2 94-98% with 1 episode of desaturation to 89% while sleeping soundly- ABG at that time confirmed Pa02 of 60, scheduled neb given and FiO2 incr to 70%- F/U ABG shows PaO2 135, PCo2 59. FiO2 returned to 40%, SPO2 95-98% remainder of shift. Pts lungs have Insp/Exp wheeze bilaterally, RUL coarse/bronchial sounds. Little sputum production, C/DB encouraged- unable to tolerate IS. Poor activity tolerance with labored breathing, RR 40s after little movement- recovers with coaching after 1-2 mins. Right CT intact, 30ml straw-colored drainge, ?minimal leak, MD aware. Morphine 2mg IV x 2 give for general discomfort, tachypnea, and insomnia- therapeutic effect observed.\n\nHEMODYNAMICS: NSR 70-90s, occassional PACs. Denies CP or resp distress at rest. Lopressor 5mg IVP q4hr ATC for rate control. SBP 102-140 via femoral A-line. NO edema. Adequate u.o., nearly uvolemic. Hct 24.5 stable. Heparin gtt titrated for PTT 49.1, next PTT due 0730. No sx bleeding.\n\nID: Afebrile. Vanco/Zosyn as ordered.\n\nGI/METABOLIC: Sips clears tolerated. Abd softly distended, pos BS, ?last BM. TPN at 74ml/hr. Hyperglycemic 239/243, treated per RISS.\n\nPSYCHOSOCIAL: Pt calm/coop. Visited by son, daughter called for update. Emotional support and education to pt and family provided.\n\nPLAN: Monitor resp status closely, incr activity as tolerated, Alb/Atr nebs ATC, pulm hygiene. Monitor cardiac status, Lopressor as ordered.\nTPN. Consult team for improved glycemic control while on TPN/steroids. Cont steroid taper/antibiotics. Heparin gtt, goal 50-60, next PTT due 0730. Emotional support and education ongoing.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-19 00:00:00.000",
"description": "Report",
"row_id": 1286332,
"text": " 7a-7p\nneuro: a+o x3 with mild anxiety this am, increased anxiety x1 this am with ^in bp/hr/resp rate (sats remained in 90s on bipap, pt remained oriented x3), resolved with ativan 0.5mg x1; pt became confused around 1300 after returned to bipap for low sats, picking at ivs/pulling at tubes/pulling off clothing/pulling bipap off (worse after ativan ivp, haldol 5mg ivp given x1 with good result), pt still sleeping at this time; mae, perrlaa\n\ncv: sr/st 87-117 occasional pacs, sbp 107-150 (>130 with anxiety), dilt gtt started at 5 mg/hr (maintain at 5 per thoracic), heparin at 1000 units/hr (ptt at 1800), ct draining small amounts serosanguineous to wall suction, jp draining small amounts yellow drainage\n\nresp: lungs cta, diminished bilat, bilat crepitus to upper chest/right thoracotomy/bilat scapula (team aware), bipap fi02 70 ps 12 02 sats now 96%, attempted pt on face mask today, did not tolerate, returned to bipap after 02 sats dropped to mid-high 80s, when on mask able to use is 250-500ml with weak/moderate strength nonproductive cough\n\ngi: positive bowel sounds, soft non distended abdomen, tolerated sips with meds this am, started tpn this pm, no insulin coverage per np at this time\n\ngu: foley draining adequate amounts clear yellow urine\n\naccess: triple lumen catheter placed to right ij as unable to place piv (after 4 attempts)\n\nlabs: stable\n\nassess: improving\n\nplan: haldol 5mg im q4 for agitation, wean bipap as tolerated, continue heparin/diltiazem gtts\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-19 00:00:00.000",
"description": "Report",
"row_id": 1286333,
"text": "BS rhonchi, intermittent wheezes improving somewhat with MDI's. Tried off NIV but with significant desats. Generally very agitated pulling mask off or out of position. Not responding well to Ativan but seems better after Haldol. Now resting reasonably comfortably. Still may require intubation for increased WOB.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-20 00:00:00.000",
"description": "Report",
"row_id": 1286334,
"text": "nsg note\nSEE FLOWSHEET FOT SPECIFICS.\n\nNEURO-PT A+OX3. MAE. FOLLOWS COMMANDS.\n\nCV-HR 80-90'S, SINUS. UP TO 100'S WHEN AGITATED. REMAINS ON DILT GTT. SBP STABLE. SKIN W+D. +PP. DENIES CARDIAC COMPLAINTS. REMAINS ON HEPARIN GTT, PTT 70.\n\nRESP-CON'T WITH WHEEZES THROUGHOUT. NEBS GIVEN. PT WITH STRONG COUGH PRODUCTIVE OF VERY THICK WHITE SPUTUM. ON BIPAP MASK MOST OF NOC. TOL WELL. RR WNL AND O2 SAT 98% WHEN ON BIPAP. PT AND SAT DOWN TO 91% WHEN OFF MASK. RIGHT CT TO H20 SEAL WITH STRAW COLORED DRG. + FLUCUATION, NO AIR LEAK. + CREPITUS. TEAM AWARE. TO HAVE XRAY THIS AM. RIGHT JP WITH SEROUSSANG DRG.\n\nGI-NPO. ABD SOFT/NT/ND. +BS. REMAINS ON TPN.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW DRG.\n\nCOMFORT-HALDOL GIVEN FOR AGITATION WITH GOOD EFFECT.\n\nENDO-SSRI.\n\nID-AFEB. REMAISN ON ABX.\n\nP-CON'T WITH CURRENT PLAN. PULM HYGIENE. CT TO H2O SEAL. SUPPORT. FOLLOW LABS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-20 00:00:00.000",
"description": "Report",
"row_id": 1286335,
"text": "Respiratory Care Note:\n\nPt tranfert t/o night from CSRU on NRM, placed on NIV immediatly & remain on NIV t/o shift. We were to wean FIO2 from 70 to 50%. He awoke and asked to take off NIV mask/ Nebs given and placed back on NIV. Plan: pulm hygiene & Continue present ICU monitoring and keep confortable. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-28 00:00:00.000",
"description": "Report",
"row_id": 1286359,
"text": "Respiratory Therapy\n0545 Pt presents W 6L n/c and .5 venti mask in high position. Sats mid 80's. Placed on NRBM and 6L n/c. BS clear on left, BS on rt only audible fine wheezes mid apex. MD aware. CXR revealed a worsening rt side. (+) air leak from rt CT. Albuterol/Atrovent given with slight improvement. Sats 88% after 30 minutes, sats increased to 93%. Plan: Discuss W attending. Continue W Respiratory follow up.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-28 00:00:00.000",
"description": "Report",
"row_id": 1286360,
"text": "focus hemodynmics\ndata: neuro: alert and oriented. moves all extremities on the bed. oob to the chair. engages in conversation.\n\nresp: on o2 at 6 liters via nasal prongs. o2sats 90-93. coughing without raising any sputum. hob elevaated with pillows under arms. at 0600am sat dropped to 86%. resp 30's. alberterol and atrovent neb treatment given. cxr done and results per dr worse. chest tube to water seal and placed to suction. chest tube has an air leak. bipap ordered. resp therapist in room. thoracic team called. pt to be bronched.\n\ncardiac: in normal sinus rythmn. occ pvc. lopresssor 75mg via fdg tube given.\n\ngI abd soft and no stool tonite. tol po foods well.\n\ngu: voiding in the urinal qs.\n\naction: bipap added for resp distress. thoracic team at the bedside. bronch cart at the bedside. hob elevated pillows under arms. emotional support provided. daughter called this am 0700am and update given regarding difficulty breathing.\n\nrespone: monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-28 00:00:00.000",
"description": "Report",
"row_id": 1286361,
"text": "Update\nSee Carevue for specifics\n\nNeuro: A & O x 3, PERRL, normal strength. OOBTC & ambulate around room.\n\nCV: NSR/ST. SBP WNL.\n\nResp: Pt in respiratory distress this a.m. Sats in high 70s, tachypnic with labored breathing. Switched from non-rebreather to BIPAP with little effect. Bronchoscopy performed with some difficulty at approx 0800. Pt agitated and given .5 versed for comfort. 30 mg ascetylcysteine instilled via bronch for extremely thick secretions. Copious amounts of secretions removed. Cx sent. Pt on BIPAP immediately s/p bronch. Later switched to non-rebreather and currently sats at 100% and doing well. Incentive spirometry, chest PT and CDB done. Chest tube d/c'd and replaced by pleurovac. Draining serosang fluid, no crepitus, no leakage noted.\n\nGI: House diet. +BS. Small formed stool x 1.\n\nGU: Voids in urinal.\n\nSocial: Daughter and wife in to visit.\n\nPlan: Aggressive pulmonary toilet to mobilize secretions. OOB and ambulate again before sleep tonight. Provide quiet environment to sleep. Bronchoscopy tomorrow. Transfer to floor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-28 00:00:00.000",
"description": "Report",
"row_id": 1286362,
"text": "Respiratory Therapy\n\nPt received this AM w/ SpO2 70s-80s, NIPPV started and bronched at bedside by thoracic team. Multiple mucous plugs cleared, put on 100% NRB post procedure; alternating between that and NIV. See resp flowsheet for specifics.\n\nPlan: maintain support\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-25 00:00:00.000",
"description": "Report",
"row_id": 1286354,
"text": "Condition Update\nPlease see carevue for specifics.\n\nPt alert and oriented x 3. MAE. OOB to the chair w/ supervision only. Afebrile. NSR. No ectopy noted. No c/o pain. Right chest tube to H20 seal w/ no drainage. +fluctuation + leak. Thoracic sx aware. JP drain d/c'd today. DSD placed. Small amt of bloody drainage at jp d/c site. LS w/ ins/exp wheezing. Nebs given by resp tx. Pt also using IS at bedside. Pt voiding in adequate amts. Tolerating regular diet. RISS for bs coverage.\n\nPlan: continue with current plan of care per sicu/ thoracic sx team. xfer to fl ?. pulm toilet. neb tx's. oob.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-26 00:00:00.000",
"description": "Report",
"row_id": 1286355,
"text": "Please See Carevue for Specifics.\n\nPt slept majority of the night. Received 0.25mg Ativan for sleep assistance with effect. Right chest tube to water seal with +leak and +fluc, -crepitus with sero drainage, DSD with sang staining noted.\n\nPOC: Transfer to floor when bed avail. Continue to encourage self ADl's, OOB to chair/ambulate as tolerates. Pain management as needed. Continue to offer emotional support to pt and pt family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-26 00:00:00.000",
"description": "Report",
"row_id": 1286356,
"text": "Respiratory therapy\nPt presents on 4L n/c fine wheezes bilaterally. Alb/Atrovent neb given W good effect. Increased aeration. MDI spacer placed W Pt's MDI's.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-27 00:00:00.000",
"description": "Report",
"row_id": 1286357,
"text": "Nursing Progress Note\nSee Carevue for details\n\nNeuro: AOx3. Pleasant and cooperative. MAE with nml strength. Denies HA, dizziness, or changes in vision.\n\nCV: NSR. No ectopy. HR 70's-80's. BP 110-120/50. +PP. No edema noted. On Heparin SC.\n\nResp: LS clear to coarse in upper airways, diminished at bases. Able to administer inhalers with spacer independently.\n\nGI: Tolerating hse diet. No N/V. Abdomen soft, NT/ND. +BS.\n\nGU: voiding CYU in urinal without difficulty.\n\nSkin: Right Chest tube site covered DSD-no drainage. No crepitus. Old JP drain site covered DSD no drainage-pt reports site is painful at times-given 1 mg Morphine IVP with good effect.\n\nPlan: ?transfer to floor. Continue monitor VS, resp status, labs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-29 00:00:00.000",
"description": "Report",
"row_id": 1286363,
"text": "focus hemodymics\ndata: neuro: alert and oriented. moves all extremities on the bed. oob to chair.\n\nresp: on 80% hi flow mask. o2sats 100%. inhalers as ordered. coughing but not raising any sputum. spirocare done. chest pt done x 3. chest tube intact with small pleuravac intact. to have bronchoscopy done today.\n\ncardiac: in nsr. bp stable.\n\ngI abd soft. taking po's with difficulty. no stool tonite.\n\ngu: voiding clear yellow urine.\n\naction: oob to chair. inhalers as ordered. chest pt. 80% face mask hi flow intact. postion changed frequenty during the nite. update to daughter. tylenol given for generalized achiness.\n\nresponse: monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-29 00:00:00.000",
"description": "Report",
"row_id": 1286364,
"text": "Respiratory Care Note:\n Patient changed to a high flow continuous aerosol to facilitate secretion clearance and weaning of FIO2. He has tolerated 80% t/o shift with SpO2>99%. His RR has been 16-28. Plan for bronchoscopy today. Yesterday's bronch was done via facemask ventilation, therefore, ventilator not D/C'd at this time. He has been recieving MDIs app Q4 and uses good technique with maneuvers.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-24 00:00:00.000",
"description": "Report",
"row_id": 1286349,
"text": "condition update\nneuro: alert and oriented x's 3, mae to command, no c/o pain. ativan held at 1800, pt denied anxiety and very comfortable. Pt requested ativan at 0100 for help with sleeping.\ncv: nsr 80's-90's. Very brief (5 sec) run of svt, self resolved. Dr. notified, electrolytes checked, K+ repleted. No further episodes. bp stable, peripheral pulses palpable. Lasix 20mg iv x's 1 (standing order) with + diuresis.\nresp: ls wheezy/coarse - though less wheezy this am. Alb./atrov. nebs atc per r.t. Pt denies sob, 02 sat 95-100% on 50% face tent. CT to suctioned, draining small amts. serous drainage. +fluctuation, + leak (unchanged). No crepitus noted. Coughing/deep breathing encouraged.\ngi: abd soft, nontender, +bs, no bm. swallows pills without difficulty.\ngu: foley draining adequate amts. clear yellow urine.\nendo: insulin gtt titrated.\nskin: right chest tube site dsd intact, no drainage noted. Skin otherwise intact.\nplan: pulmonary toileting, oob to chair/ambulat, monitor resp. status, chest x-ray this am, ? transfer to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-24 00:00:00.000",
"description": "Report",
"row_id": 1286350,
"text": "Respiratory Care\nPt continues 50% high flow via face tent. BS coarse bilaterally and becoming less wheezy. Nebs given as ordered with good effect. Spo2 98-100%. Will continue to treat pt with nebs as ordered.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-27 00:00:00.000",
"description": "Report",
"row_id": 1286358,
"text": "Nursing Progress Note\n Please see carevue for details of care. Awake, alert and oriented. Pleasant, cooperative and compliant. OOB to chair w/assist tol well this am. MAEW, Denies discomfort. BS sl dim this am w/few exp wheezes noted which cleared after inhalers. ISE encouraged and tol well. Remains in NSR w/no ectopy, VSS.\n Became SOB suddenly this am w/sats quickly down to high 60's range. Became tachypneic, wheezes t/o. PRN albuteral INH given, resp at bedside. SICU team and primary MD aware and at bedside. Pulmonary team notif by SICU team. CXR repeated. Sats remain 70's after back to bed, 50% face mask + 6L NC on w/sats recovered to high 80's, changed to 100% NRB mask + 6L NC w/sats only recovering to 91-93 range. Teams aware. Sats slowly recovered to 97-98 range, O2 weaned back to 50% mask and 6L NC. Mask off early pm by patient w/sats maint 93-95, remains SOB and tachypneic w/exertion.\n R chest tube intact w/DSD intact, draining scant amt serous fluid in tube. + air leak noted, no crepitus. Old JP site covered w/DSD, drainage. Med x1 for pain w/ Morphine 1 mg this pm w/stated effect.\n PLAN: Cont to monitor resp status, chest pt, monitore O2 requirements. Transfer to floor when stable and bed avail.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-24 00:00:00.000",
"description": "Report",
"row_id": 1286351,
"text": "Condition Update\nPlease see carevue for specifics.\n\nPt alert and oriented. MAE. No c/o pain. NSR> No ectopoy noted. Afebrile. Insulin gtt d/c'd. RISS started. BS well controlled. CVL d/c'd once peripheral access obtained. LS w/ rhonchi throughout. Nebs given by resp tx. Chest tube placed to water seal by thoracic sx. + leak. Thoracic team aware. Breathing much easier today per pt. 02 sats 94-100% on 15L Hi flow mask. CXR done this afternoon. JP drain in pleural space to bulb sxn. Foley d/c'd this eve. Pt is approx 2400. No BM. Pt is tolerating a regular diet well. Integ intact.\n\nPlan: continue with current plan of care per sicu/ thoracic sx teams. CT to water seal. SS for bs coverage. OOB/ ambulate as tolerated. Pulm toilet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-25 00:00:00.000",
"description": "Report",
"row_id": 1286352,
"text": "condition update\nplease see carevue for specifics;\nneuro: alert and oriented x's 3, pleasant and cooperative. Mae to command. c/o mild to mod. pain at chest tube site, morphine 1mg iv x's 2 with good relief.\ncv: nsr with occasional pac's. brief episode of svt, dr. aware, electrolytes wnl.\nresp: ls noted for insp/exp wheezes, alb. and atr. atc. chest to h20 seal, draining small amts. serous drainage, +leak (unchanged), - crepitus, + fluctuation. dsg c/d/i. 02 sat 97-99% on 50% face tent. pt comfortable, denies sob. coughing/deep breathing encouraged.\ngi: abd. soft/nontender, +bs, no bm.\ngu: pt at 2400, voided 300cc clear yellow urine at 2300.\nendo: ssri\nskin: intact\nsocial: son at bedside early this evening.\nplan: continue p.t., pulmonary toileting, monitor u/o, pain management. ? transfer to floor today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-12-25 00:00:00.000",
"description": "Report",
"row_id": 1286353,
"text": "BS CTAB, no wheezing now; no change with bronchodilators. Weaned to nasal cannula 5L/m. Awaiting call out to floors.\n"
}
] |
60,548 | 159,650 | Pt admitted to neurosurgery service and the ICU on . Her intial imaging appeared to be consistent with a interventricular mass that had hemorrhaged. She had no hydrocephalus and did not require an emergent procedure. An MRI/MRA of the head was obtained to evaluate this mass and showed it to be suggestive of an ACOMM aneurysm. For further evaluation, a diagnostic cerebral angiogram was performed and this confirmed the presecnce of a large thrombosed ACOMM aneurysm. After her anerusym was confirmed she was intubated with anesthesia and she underwent an umcomplicated coiling of this aneurysm. She did remain intubated overnight and was kept flat bed rest for 6 hours. On post op exam she did not follow commands but she moved all extremities purposefully and her pupils remained equal and reactive. She had no signs of groin hematoma and she had good distal pulses. She was extubated on the morning of without difficulty. Her exam improved and she was opening eyes intermittently to voice, following commands and moving all extremities with good strength. Her groin site remained clean and dry with no signs of hematoma and she had good distal pulses. Psychiatry was consulted and recommended given her altered mental status they recommended an EEG which showed an abnormal EEG due to the presence of a slower than average background. This finding may could be seen in the context of a mild to moderate encephalopathy of toxic, metabolic, or anoxic etiology. They recommened restarting her Methadone in case she was withdrawing causing her altered mental status. Haldol was also started. On she underwent an angiogram which showed Acomm artery coiling with no residual filling. On she was transferred to the Step Down Unit were she remained stable and she was transferred to the floor on . Her methadone was increased to 30mg on . Social Work continued to provide support to the patient. On her Methadone was increased to 40mg. On she was scheduled for a cerebral angio but was cancelled because patient was unable to tolerate. She underwent an angiogram on which was stable. She was discharged to on . | After removal of the angle Glidewire, a left internal carotid artery cerebral angiogram was performed. Cerebral angiography at that time revealed an anterior communicating artery aneurysm which was subsequently coiled. eval vasculature FINAL REPORT HISTORY: Intracranial hemorrhage and anterior communicating artery aneurysm. Stable 1.6mm left MCA bifurcation aneurysm Multiple angiograms performed via the left internal carotid artery show excellent occlusion of the anterior communicating artery aneurysm seen previously. The wire was then removed and multiple diagnostic angiograms performed through the left internal carotid artery at varying obliquities. With the catheter at the level of the distal aorta, an aortogram was performed. Access to the left common femoral artery was attempted with adequate amount of local anesthesia. A 0.035 angled Glidewire was then inserted through the Berenstein catheter and carefully advanced into the internal carotid (Over) 9:22 AM CAROT/CEREB Clip # Reason: eval for aneurysm completion of coil Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS Contrast: OPTIRAY Amt: 148 FINAL REPORT (Cont) artery and thereafter followed by the Berenstein catheter. At this point, anesthesia was consulted for intubation. There were normal cervical, petrous, cavernous, and supraclinoid segments of the internal carotid artery. PROCEDURE: Cerebral angiogram, coil embolization of anterior communicating artery aneurysm. REASON FOR EXAM: Cerebral angiography and coil embolization of anterior communicating artery aneurysm. Following this, with aid of the angled Glidewire, the tip of the Omniflush catheter was then manipulated into the right common iliac artery and a second angiogram was performed. There were normal cervical, petrous, cavernous and supraclinoid segments of the internal carotid artery. The wire was then removed, and the catheter slowly manipulated into the left common carotid artery. FINAL REPORT HISTORY: Recently called anterior communicating artery aneurysm, follow up study. To reassess coil pack and aneurysm. Over the angled Glidewire, a straight Neuron catheter was placed with tip within the left internal carotid artery. The right and left common carotid arteries were selectively catheterized and cerebral angiogram was obtained in AP, lateral and oblique projections. Left internal carotid artery post-embolization run showed minimal residual filling of the aneurysm of the anterior communicating artery. RIGHT FEMORAL VASCULAR ULTRASOUND: Normal color flow and Doppler waveforms are noted in the right common and superficial femoral artery and vein, as well as the greater saphenous vein. VESSELS SELECTED: Right common carotid artery, left common carotid artery and left internal carotid artery. INDICATION: Evaluate for residual filling in anterior communicating arterial aneurysm and for possible right common femoral pseudoaneurysm. A post-coiling angiogram showed that the aneurysm was successfully coiled with near-complete embolization and minimal residual filling. The Berenstein catheter was retracted into the descending aorta, and wire was placed to secure access and then the catheter was removed. The left internal carotid artery was catheterized and angiograms were obtained in the lateral and oblique projections with 3D rotational images. Via the normal-appearing left A1 segment, there was filling of a 5 x 6 x 7 mm aneurysm arising at the anterior communicating artery with a 3-mm neck. Via microcatheter technique, the left internal carotid artery and left A1 ACA were also selected. Under fluoroscopic guidance, the microcatheter was advanced into the aneurysm sac of the anterior communicating artery via the left A1 segment of the anterior cerebral artery. FINDINGS: Left internal carotid artery injection demonstrated normal and brisk filling of the cervical, petrous, cavernous and supraclinoid segments. PROCEDURE: Cerebral angiogram. PROCEDURE: Cerebral angiogram. A small amount of hemorrhage appears to be present in the right sylvian fissure. Unchanged, 1.6mm aneurysm arising from the left MCA bifurcation. Using fluoroscopy, these two were advanced into the ascending aorta. After instillation of 1% lidocaine for local anesthesia into the right groin, access to the right common femoral artery was obtained using a micropuncture set. Injection of a small amount of contrast confirmed location in the left common carotid. IMPRESSION: Tubular pseudoaneurysm arising from common femoral artery, with surrounding soft tissue hematoma. VESSEL SELECTED: Left internal carotid artery. An ultrasound done after that time on raised concern for a possible right common femoral arterial pseudoaneurysm. TECHNIQUE: After verbal liaison with (neurosurgery service), a consensus was obtained to perform the procedure in view of the risks, benefits and alternative management for the patient care. IMPRESSION: Successful coiling of an anterior communicating artery aneurysm with near-complete obliteration of the aneurysm. Thereafter, a 4 French Omniflush catheter was advanced into the aorta, and the wire was removed. 9:22 AM CAROT/CEREB Clip # Reason: eval for aneurysm completion of coil Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS Contrast: OPTIRAY Amt: 148 ********************************* CPT Codes ******************************** * SEL CATH 2ND ORDER INTRO CATH AORTA * * ABD A-GRAM EXT UNILAT A-GRAM * * CAROTID/CEREBRAL UNILAT * **************************************************************************** MEDICAL CONDITION: 41 year old woman with acomm aneurysm coiling REASON FOR THIS EXAMINATION: eval for aneurysm completion of coil FINAL REPORT HISTORY: 41-year-old woman with severe headache on and intracranial hemorrhage. | 14 | [
{
"category": "Radiology",
"chartdate": "2109-11-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1162243,
"text": " 4:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41F with hx IVDU found with AMS and midline frontal IPH now s/p coiling of\n Acomm aneurysm.\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf WED 1:16 PM\n No acute cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status, status post coiling of ACom aneurysm,\n assess for pneumonia.\n\n TECHNIQUE: Portable upright radiograph of the chest.\n\n COMPARISON: Semi-upright portable chest radiograph, .\n\n FINDINGS: Left IJ terminates at the confluence of brachiocephalic vessels.\n The lungs are clear without focal opacity. Heart is normal in size with\n normal cardiomediastinal silhouette. No pleural effusion seen, although the\n left base is incompletely imaged.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-11-18 00:00:00.000",
"description": "INTRO CFA/SFA/ILIAC/POP GRAFT",
"row_id": 1163183,
"text": " 3:05 PM\n CAROT/CEREB Clip # \n Reason: eval for aneurysm completion of coil\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n ********************************* CPT Codes ********************************\n * INTRO CFA/SFA/ILIAC/ GRAFT *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Anterior communicating artery aneurysm coiled. For\n complete evaluation of coil.\n\n REASON FOR EXAMINATION: Apparent change in clinical status. To reassess coil\n pack and aneurysm.\n\n ATTENDING:\n NEURORADIOLOY FELLOW: Dr. , MD, MRCP and FRCR.\n\n NURSE : .\n\n DETAILS OF THE PROCEDURE: Written informed consent was obtained from the\n patient after explaining the risks, benefits and alternative management. The\n patient was brought to the neurointerventional suite and placed in the biplane\n table in the supine position. A preprocedure timeout was performed using two\n different identifiers, clinical indication and laboratory values. Both groins\n were prepped and draped in the standard sterile fashion.\n\n Access to the left common femoral artery was attempted with adequate amount of\n local anesthesia. The patient was unable to tolerate the procedure and was\n moving constantly despite multiple reassuring attempts from the staff.\n Access to the left common femoral vein was obtained, but since the patient was\n unable to cooperate and started fearing, it was considered prudent not to\n proceed and reattempt the procedure with general anesthesia.\n\n IMPRESSION: was planned to have a cerebral angiogram for\n reassessment of the anterior communicating artery aneurysm coil and change in\n clinical status. Since the patient kept constantly moving and did not\n tolerate the procedure, the procedure is incomplete and abandoned considering\n the safety of both patient and staff. Procedure would be considered under\n general anesthesia. The patient was also abusive to the staff.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-11-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1161846,
"text": " 3:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pna\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with AMS s/p coiling of aneurysm, fever\n REASON FOR THIS EXAMINATION:\n pna\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with altered mental status.\n\n Portable AP chest radiograph was compared to and radiographs.\n\n Right basal opacity continues to increase and may represent developing right\n lower lobe pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-11-08 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 1161439,
"text": " 7:29 AM\n MR HEAD W & W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST; MRV HEAD W/O CONTRAST\n Reason: Preop in case of OR\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 22\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with 40F IVDA on methadonelast nml 8 days agofound in bed\n with dead infantpsychotic, combative, mass vs bleed on head CTCT read: Large\n high density mass in midline anterior cranial fossa 4.8x2.5x2.8 cm, extending\n from suprasellar cistern, superiorly into septum pellucidum -- diff dx large\n acute hematoma vs giant aneurysm, +obstructive hydrocephalus\n REASON FOR THIS EXAMINATION:\n Preop in case of OR\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n TECHNIQUE: MRI of the brain without and with gad. MRA using 3D\n time-of-flight technique. MRV using 2D time-of-flight technique.\n\n FINDINGS:\n\n Comparison is made with prior examination from .\n\n There is a large acute hematoma centered in the septum pellucidum and the\n frontal , left greater than right extending into the corpus callosum and\n the cingulate gyrus anteriorly. There is also suggestion of an anterior\n communicating artery aneurysm at the base of this hematoma.\n\n A small amount of hemorrhage appears to be present in the right sylvian\n fissure. There is mild hydrocephalus with enlargement of the temporal horns.\n\n On the MRA, there is suggestion of an anterior communicating artery aneurysm\n although this is difficult to assess in the setting of extensive hemorrhage in\n that vicinity.There is some irregularity and narrowing of bilateral MCA\n branches. This could represent vasospasm or vasculitis. Consider CTA for\n further evaluation.\n\n MRV demonstrates no significant abnormality.\n\n There is mild bilateral mastoid and ethmoid opacification. No definite\n underlying mass lesion is identified.\n\n\n\n IMPRESSION:\n\n Large hematoma which is acute to subacute along the septum pellucidum, frontal\n horns, frontal lobe and cingulate gyrus with suggestion of an ACOM aneurysm at\n the base of the hematoma. Recommend correlation with CTA. There is also\n irregularity and narrowing of bilateral MCA branches which could represent\n vasospasm versus vasculitis. Findings were discussed with at\n (Over)\n\n 7:29 AM\n MR HEAD W & W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST; MRV HEAD W/O CONTRAST\n Reason: Preop in case of OR\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 22\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 11:40 a.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-11-12 00:00:00.000",
"description": "SEL CATH 1ST ORDER",
"row_id": 1162077,
"text": " 8:51 AM\n CAROT/CEREB Clip # \n Reason: 41 year old woman with ACA aneurysm partially coiled.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n Contrast: OPTIRAY Amt: 74\n ********************************* CPT Codes ********************************\n * SEL CATH 1ST ORDER CAROTID/CEREBRAL UNILAT *\n * MOD SEDATION, FIRST 30 MIN. MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with ACA aneurysm partially coiled.\n REASON FOR THIS EXAMINATION:\n 41 year old woman with ACA aneurysm partially coiled.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Recently called anterior communicating artery aneurysm, follow up\n study.\n\n PROCEDURE: Cerebral angiogram.\n\n ATTENDING:\n NEURORADIOLOGY FELLOW: Dr. , MB, MRCP, FRCR.\n\n NURSE PRACTITIONER: .\n\n PROCEDURE: Cerebral angiogram.\n\n VESSEL SELECTED: Left internal carotid artery.\n\n SEDATION: Moderate sedation was provided by administering divided doses of\n 250 mcg of fentanyl and 5 mg of Versed over the total intraservice time of 1\n hour 5 minutes. During this time, the patient's hemodynamic parameters were\n continuously monitored.\n\n TECHNIQUE: After verbal liaison with (neurosurgery service), a\n consensus was obtained to perform the procedure in view of the risks, benefits\n and alternative management for the patient care. The patient was brought to\n the neuro-interventional suite and placed in the supine position on the\n biplane table. A preprocedure timeout and huddle was performed documenting\n the patient's identity using two different identifiers, nature of the\n procedure to be performed, laboratory parameters and patient's history. Both\n groins were prepped and draped in a standard sterile fashion. After\n instillation of 1% lidocaine for local anesthesia into the right groin, access\n to the right common femoral artery was obtained using a micropuncture set.\n Using Seldinger technique, a 4 French vascular sheath was successfully placed\n into the right common femoral artery. This was connected to the continuous\n infusion of pressurized heparin and saline.\n\n The left internal carotid artery was catheterized and angiograms were obtained\n in the lateral and oblique projections with 3D rotational images. Right groin\n (Over)\n\n 8:51 AM\n CAROT/CEREB Clip # \n Reason: 41 year old woman with ACA aneurysm partially coiled.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n Contrast: OPTIRAY Amt: 74\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hemostasis was obtained using a manual compression technique for 25 minutes.\n The patient tolerated the procedure well with no immediate complications. The\n patient was sent to the ICU with post-procedure orders.\n\n FINDINGS: Left internal carotid artery injection demonstrated normal and\n brisk filling of the cervical, petrous, cavernous and supraclinoid segments.\n The middle and anterior cerebral arteries were seen and appeared normal. The\n recently coiled anterior communicating artery aneurysm showed no evidence of\n residual filling.\n\n IMPRESSION: underwent a cerebral angiogram which demonstrates\n no evidence of residual filling within the recently coiled anterior\n communicating artery aneurysm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-11-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1161635,
"text": " 3:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for pna\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with leukocytosis, ?pna\n REASON FOR THIS EXAMINATION:\n Eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Leukocytosis.\n\n Cardiomediastinal contours are normal. The lungs are clear. There is no\n pneumothorax or pleural effusion. ET tube tip is in standard position. The\n tip is approximately 6 cm above the carina. Left IJ catheter remains in\n place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-11-08 00:00:00.000",
"description": "SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR SCREENING",
"row_id": 1161409,
"text": " 2:56 AM\n SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR Clip # \n Reason: survey for MRI\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman who was found with AMS\n REASON FOR THIS EXAMINATION:\n survey for MRI\n ______________________________________________________________________________\n WET READ: YGd FRI 7:21 AM\n No radiopaque object within skull, chest, abd, or pelvis. d/ by \n \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old female here for pre-MRI surveillance.\n\n FINDINGS: Radiographs of the head, neck, chest, and abdomen demonstrate no\n evidence of radiopaque foreign body with the exception of dental amalgam\n within imaged portions of the body. Partially imaged lungs are clear.\n Cardiomediastinal silhouette is normal. Bowel gas pattern is unremarkable.\n\n IMPRESSION: No evidence of radiopaque object within the head, chest, abdomen,\n or pelvis. This was discussed with on at the time of\n exam completion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-11-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1162244,
"text": ", J. NSURG SICU-A 4:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41F with hx IVDU found with AMS and midline frontal IPH now s/p coiling of\n Acomm aneurysm.\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n PFI REPORT\n No acute cardiopulmonary process\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-11-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1161767,
"text": " 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 41 year old woman with increase in WBC, evaluate for infecio\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with increase in WBC, evaluate for infecious process\n REASON FOR THIS EXAMINATION:\n 41 year old woman with increase in WBC, evaluate for infecious process\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Increase in white blood count.\n\n Comparison is made with prior study performed a day earlier.\n\n There are lower lung volumes. Bibasilar opacities greater on the right side\n are consistent with atelectasis. Cardiac size is top normal, accentuated by\n the low lung volumes and the projection. Left IJ catheter remains in place.\n There is no pneumothorax or pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-11-08 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1161430,
"text": " 4:56 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: pneumothorax, line location\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with possible IPH, s/p L IJ placement\n REASON FOR THIS EXAMINATION:\n pneumothorax, line location\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: IJ placement, questionable pneumothorax.\n\n COMPARISON: No comparison available at the time of dictation.\n\n FINDINGS: The lung volumes are normal. There are no pleural effusions and no\n pneumothorax. Borderline size of the cardiac silhouette without evidence of\n pulmonary edema. Newly placed left internal jugular vein access line. The\n tip of the line projects over the mid SVC.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-11-08 00:00:00.000",
"description": "EMBO TRANSCRANIAL",
"row_id": 1161547,
"text": " 3:01 PM\n CAROT/CEREB Clip # \n Reason: 41 year old woman with corpus collosum mass/hemorrhage. eval\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n Contrast: OPTIRAY Amt: 315\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CERVICAL BILAT *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT *\n * -59 DISTINCT PROCEDURAL SERVICE SEL EA ADD'L *\n * TRANSCATH EMBO THERAPY F/U TRANS CATH THERAPY *\n * MOD SEDATION, FIRST 30 MIN. MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: Please note that there is a 1.6 mm aneurysm arising from the left\n middle cerebral artery bifurcation.\n\n\n\n 3:01 PM\n CAROT/CEREB Clip # \n Reason: 41 year old woman with corpus collosum mass/hemorrhage. eval\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n Contrast: OPTIRAY Amt: 315\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with corpus collosum mass/hemorrhage. eval vasculature\n REASON FOR THIS EXAMINATION:\n 41 year old woman with corpus collosum mass/hemorrhage. eval vasculature\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intracranial hemorrhage and anterior communicating artery aneurysm.\n\n PROCEDURE: Cerebral angiogram, coil embolization of anterior communicating\n artery aneurysm.\n\n REASON FOR EXAM: Cerebral angiography and coil embolization of anterior\n communicating artery aneurysm.\n\n OPERATOR: Dr. .\n\n FELLOW: Dr. .\n\n VESSELS SELECTED: Right common carotid artery, left common carotid artery and\n left internal carotid artery. Via microcatheter technique, the left internal\n carotid artery and left A1 ACA were also selected.\n\n ANESTHESIA: The first portion of the procedure was done under moderate\n sedation provided by 250 mcg of fentanyl in five divided doses and 5 mg of\n Versed in five divided doses throughout the intraservice time of 1 hour and 10\n minutes, during which time the patient's hemodynamic parameters were\n continuously monitored. At this time, general anesthesia was induced by the\n anesthesia team and the anesthesia team monitored the patient for the\n remainder of the procedure.\n\n Technique: Emergency consent was provided by the neurosurgery team and\n documented in the patient's chart. The patient was brought to the\n neurointerventional suite and placed in supine position on the biplane table.\n Preprocedure timeout documenting patient identity, nature of the procedure and\n relative blood work was done using two independent identifiers. Both groins\n were prepped and draped in usual sterile fashion. Using a 19-gauge\n single-wall needle, access was gained to the right common femoral artery and\n with the aid of a 0.035 Berenstein wire, a 4 French Avanti sheath was placed.\n This sheath was connected to continuous infusion of a mixture of heparin and\n normal saline with continuous drip. A 4 French Berenstein 2 catheter was\n placed over the wire and connected to continuous saline infusion of a mixture\n of heparin and saline. The right and left common carotid arteries were\n selectively catheterized and cerebral angiogram was obtained in AP, lateral\n and oblique projections. After reviewing the images and discussing the\n below-mentioned findings with the patient's clinical team, a unified decision\n dictated intervention. At this point, anesthesia was consulted for\n intubation. After the anesthesia team induced general anesthesia, the 4\n (Over)\n\n 3:01 PM\n CAROT/CEREB Clip # \n Reason: 41 year old woman with corpus collosum mass/hemorrhage. eval\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n Contrast: OPTIRAY Amt: 315\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n French Avanti sheath was exchanged for a 6 French 25-cm Terumo sheath using an\n exchange length 0.038 angled Glidewire. Over the angled Glidewire, a straight\n Neuron catheter was placed with tip within the left internal carotid artery.\n After removal of the angle Glidewire, a left internal carotid artery cerebral\n angiogram was performed. Subsequently, an Excelsior SL-10 microcatheter was\n advanced with the aid of a Synchro-2 standard microwire. Under fluoroscopic\n guidance, the microcatheter was advanced into the aneurysm sac of the anterior\n communicating artery via the left A1 segment of the anterior cerebral artery.\n Coiling of the aneurysm was done using three GDC soft coils. A post-coiling\n angiogram showed that the aneurysm was successfully coiled with near-complete\n embolization and minimal residual filling. At this point, the wire and the\n catheter were withdrawn. A 6 French Angio-Seal closure device was used to\n close the site of puncture. The patient remained intubated and was sent to\n the ICU with post-procedure orders.\n\n FINDINGS:\n The right common carotid artery showed brisk filling of both internal and\n external carotid arteries. There were normal cervical, petrous, cavernous and\n supraclinoid segments of the internal carotid artery. The middle and anterior\n cerebral arteries were seen and appeared normal. The aneurysm at the anterior\n communicating artery did not fill.\n\n Left common carotid artery showed brisk filling of both internal and external\n carotid arteries. There were normal cervical, petrous, cavernous, and\n supraclinoid segments of the internal carotid artery. The middle cerebral\n artery was seen and appeared normal. Via the normal-appearing left A1\n segment, there was filling of a 5 x 6 x 7 mm aneurysm arising at the anterior\n communicating artery with a 3-mm neck.\n\n Left internal carotid artery post-embolization run showed minimal residual\n filling of the aneurysm of the anterior communicating artery. The left\n anterior cerebral artery A1 and A2 segments showed good flow without stenosis.\n No evidence of coil herniation beyond the aneurysm sac.\n\n IMPRESSION: Successful coiling of an anterior communicating artery aneurysm\n with near-complete obliteration of the aneurysm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-11-16 00:00:00.000",
"description": "R FEMORAL VASCULAR US RIGHT",
"row_id": 1162843,
"text": " 10:30 AM\n FEMORAL VASCULAR US RIGHT Clip # \n Reason: R/O psuedoaneurysm\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with painful rt groin\n REASON FOR THIS EXAMINATION:\n R/O psuedoaneurysm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old female with IVDU, on methadone maintenance, painful\n right groin.\n\n No prior examinations for comparison.\n\n RIGHT FEMORAL VASCULAR ULTRASOUND: Normal color flow and Doppler waveforms\n are noted in the right common and superficial femoral artery and vein, as well\n as the greater saphenous vein. There is a tubular pseudoaneurysm arising from\n the common femoral artery, with arterial Doppler waveforms. This extends into\n the superficial soft tissues, with a large amount of heterogeneously\n hypoechoic appearance to the soft tissues likely reflecting combined hematoma\n and edema. Measurement of this lesion is difficult due to its tubular\n morphology, but the base of the lesion measures approximately 1.2 x 0.6 cm.\n\n IMPRESSION: Tubular pseudoaneurysm arising from common femoral artery, with\n surrounding soft tissue hematoma.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-11-19 00:00:00.000",
"description": "SEL CATH 2ND ORDER",
"row_id": 1163289,
"text": " 9:22 AM\n CAROT/CEREB Clip # \n Reason: eval for aneurysm completion of coil\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n Contrast: OPTIRAY Amt: 148\n ********************************* CPT Codes ********************************\n * SEL CATH 2ND ORDER INTRO CATH AORTA *\n * ABD A-GRAM EXT UNILAT A-GRAM *\n * CAROTID/CEREBRAL UNILAT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with acomm aneurysm coiling\n REASON FOR THIS EXAMINATION:\n eval for aneurysm completion of coil\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 41-year-old woman with severe headache on and\n intracranial hemorrhage. Cerebral angiography at that time revealed an\n anterior communicating artery aneurysm which was subsequently coiled. An\n ultrasound done after that time on raised concern for a\n possible right common femoral arterial pseudoaneurysm.\n\n INDICATION: Evaluate for residual filling in anterior communicating arterial\n aneurysm and for possible right common femoral pseudoaneurysm.\n\n PHYSICIANS: Dr. and Dr. .\n\n ANESTHESIA: General anesthesia.\n\n PROCEDURAL DETAILS: Prior to the procedure, telephone informed consent was\n obtained from the healthcare proxy, Mr. . This consent\n was witnessed by two healthcare providers. The patient arrived in the\n angiography suite and was placed in the supine position on the angiography\n table. She was prepped and draped in the typical sterile fashion. Prior to\n the procedure, a timeout was performed using name, date of birth, and medical\n record number as identifiers. A preprocedure huddle was also performed.\n\n With son and fluoroscopic guidance, an appropriate site for arterial\n puncture was selected in the left groin at the level of the femoral head. A\n micropuncture needle was then advanced into the common femoral artery without\n difficulty. The micropuncture wire was advanced through the needle, the\n needle removed and replaced with a 5 French micropuncture sheath. Thereafter,\n the sheath, stiffener, and wire were removed and replaced with a 0.035 \n wire. The wire was advanced into the descending aorta under\n fluoroscopic guidance. At this point, the micropuncture sheath was removed, a\n small dermatotomy was made, and a 4 French Avanti sheath was placed. With the\n sheath in place, a Berenstein II catheter was advanced over the wire.\n Using fluoroscopy, these two were advanced into the ascending aorta. The wire\n was then removed, and the catheter slowly manipulated into the left common\n carotid artery. Injection of a small amount of contrast confirmed location in\n the left common carotid. A 0.035 angled Glidewire was then inserted through\n the Berenstein catheter and carefully advanced into the internal carotid\n (Over)\n\n 9:22 AM\n CAROT/CEREB Clip # \n Reason: eval for aneurysm completion of coil\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;ALTERED MENTAL STATUS\n Contrast: OPTIRAY Amt: 148\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n artery and thereafter followed by the Berenstein catheter. The wire was then\n removed and multiple diagnostic angiograms performed through the left internal\n carotid artery at varying obliquities.\n\n Attention was then turned to the right groin in site of possible\n pseudoaneurysm. The Berenstein catheter was retracted into the descending\n aorta, and wire was placed to secure access and then the catheter\n was removed. Thereafter, a 4 French Omniflush catheter was advanced into the\n aorta, and the wire was removed. With the catheter at the level of\n the distal aorta, an aortogram was performed. Following this, with aid of the\n angled Glidewire, the tip of the Omniflush catheter was then manipulated into\n the right common iliac artery and a second angiogram was performed.\n Thereafter, all catheters and the sheaths were removed and the puncture site\n was closed using a 6 French Angio-Seal device. The patient tolerated the\n procedure well, and there were no immediate complications. She was\n transferred from the angiography suite in stable condition.\n\n FINDINGS:\n 1. Multiple angiograms performed via the left internal carotid artery show\n excellent occlusion of the anterior communicating artery aneurysm seen\n previously. There is no evidence of residual filling of this aneurysm or of\n other aneurysms. There is no evidence of vasospasm.\n 2. Unchanged, 1.6mm aneurysm arising from the left MCA bifurcation.\n 3. Normal appearance of the right common femoral artery, more specifically\n with no evidence of arterial pseudoaneurysm or arteriovenous fistulae.\n\n IMPRESSION:\n 1. Successful occlusion of anterior communicating artery aneurysm with no\n residual filling of that aneurysm and no evidence of vasospasm.\n 2. No right common femoral arterial pseudoaneurysm.\n 3. Stable 1.6mm left MCA bifurcation aneurysm\n\n\n"
},
{
"category": "ECG",
"chartdate": "2109-11-07 00:00:00.000",
"description": "Report",
"row_id": 236958,
"text": "Sinus tachycardia. Diffuse non-specific ST-T wave changes. Cannot exclude\nmyocardial ischemia. Clinical correlation is suggested. No previous tracing\navailable for comparison.\n\n"
}
] |
22,464 | 107,128 | In Brief, the patient is an 88 year old man with severe ischemic cardiomyopathy s/p BiV-ICD placement, atrial flutter, CAD, chronic kidney disease who presented with hypoxic respiratory failure and shock which was stablized. His course was further complicated by acute abdomial pain, psoas muscle hematoma, upper GI bleed, acute on chronic renal failure, heparin induced thrombocytopenia with upper extremity DVT, intermittent hypoxia, and urinary retention. . 1) Shock - Patient intially presented in shock requiring vasopressors. Cardiac index was normal with decreased SVR which were not consistent with cardiogenic shock. The likely cause of was distributive/septic shock of unclear source of infection. He completed a full course of empiric antibiotics. He completed 7 days of hydrocortisone/fludrocort for sub-optimal response to ACTH. BP stablized by time of discharge. . 2) Respiratory Failure: The patient initially presented in hypoxic respiratory failure likely secondary to CHF, hypoventilation and decreased mental status. He was intubated prior to transfer to . He was weaned from the ventilator successfully. He did have intermittent hypoxia largely secondary to pulmonary edema from inadequate diuresis. He was stabilized on standing twice daily lasix. He was started on BiPaP at night for hypoventilation. . 3) Abdominal pain - During the hospital stay he developed acute severe epigastric pain. He was transfered to the MICU for concern for mesenteric ischemia. An abominal CTA was negative for this. A surgery consult was obtained and recommended no surgical intervention. The pain resolved without specific intervention. He was subsequently found to have an psoas muscle hematoma and required several blood transfusions with appropriate response in his hematocrit. 4) Cardiovascular: a. CAD- history of MI s/p CABG. will continue ASA, simvastatin, beta-blocker. . b. Pump- Severe ischemic cardiomyopathy with EF 10-15% s/p BiV-ICD placement. No evidence of cardiogenic shock upon initial presenation as C.I. was normal. Medically managed CHF with ACEi, beta-blocker, digoxin, spironolactone, furosemide. . c. rhythm- -V paced with underlying rhythm is atrial flutter/fibrillation. Started on amiodarone for maintenance of sinus rhythm to maximize likelihood of atrial kick. Also, amiodarone to decrease in-appropriate shocks from ICD. 5) Upper GI bleed - The patient did develop guaiac positive stools in the setting of anticoagulation for the atrial fibrillation. The hematocrit drop was largely due to the psoas hematoma as above. The patient refused EGD. If the patient develops recurrent melenotic stools he could be referred to GI for endoscopy. He will continue on a PPI. . 6)Acute on Chronic Renal failure - Initial creatinine down from admission to peak 2.5 this was likely from pre-renal secondary to shock state; no evidence of ATN. By time of discharge, the creatinine had resolved to baseline. . 7) Anemia- In addition the the acute blood loss anemia as described above. The patient has a chronic microcytic anemia. Iron studies were consistent with anemia of chronic disease (labs drawn before blood transfusions were given). Also with regard to the significant microcytosis and his Italian extraction, hemoglobin electrophoresis was performed to evaluate for thallasemia. These results were pending at time of discharge. . 8) Thrombocytopenia - HIT type II. PF4 positive on , Platelets stable at around 70K with subsequent recovery to greater than 150K. He did have a left upper extremity venous clot although the developement of this was after his platelets had stabilized. Started argatroban on with transition to coumadin. He continued on argatroban until his INR on combined anti-coagulation was >4. At which time he was maintained on coumadin alone. . 9) Urinary retention: - The patient has no prior history of urinary retention, nocturia, frequency or related BPH symptoms. During one attempt at removing the foley catheter he had decreased urine output with a large volume detected on bladder scan. The foley was replaced. He was started on finasteride, not wanting to use an alpha-blocker that would likely cause hypotension when added to his extensive cardiac regimen. The catheter was left in at discharge. This should be removed in days followed by confirmation that the patient can urinate. . 10) Code Status: DNR/DNI confirmed with patient and HCP. . 11) Dispo: the patient was discharged to rehab | RIGHT FEM CORDIS D&I.GI:ABD SOFT, +BS. Pt remains intubated now on MMV after sedation related low ve. SPUTUM CX SENT. BLD CX PENDING, T MAX 101.1. old right cortis site intact not drainingid: right tlcl removed and cath tip cx wbc 19.6 up from 13.0access: pt has 2 #18 piv and tlcl removed this am per micu order/endo: bs 1 vanco/zosyn.HR 85-112 Vpaced, underlying afib. phos now 3.3 k 5.1 (k+ checked at 1900 4.5) heparin gtt infusing at 700u/hr ptt 87.8 inr 2.3 (up from 2.1)gi: abd soft pt c/o of abd pain for beg of shift as stated above. MOTTLING OF FEET AND KNEES.CV:MHR AFIB, W/ VPACED BEATS, RARE PVC. RSBI completed on PS 5, PEEP 0=29. Respiratory Care Pt placed on SBT and passed this am. LS clear to diminished.RSBI pndGU: foley draining ~ 30cc/hr. troponon .02, ck 53. pt has alne and right fem cortis. WEANING DOPA SLOWLY, DP PULSES AUDIBLE W/ . SBP 89-102, off pressors. Last ABG WNL with acceptable oxygenation on present vent settings. BS dim/essentially clear sxing for minimal secretions. refused.ABG/VBG done - see carevue, labs sent. is currently DNR/DNI. Advance diet as tol, ?lactulose for constipation. MAE.RESP:VENT REMAINS ON AC/500/18/8, REPEAT ABG PENDING. Rec'ing ins per ss.Access/Skin: RIJ Trip lumen cath dressing changed RN's instructions. dopa weaned off...contin.to monitor BP. O2 weaned down to 2L nc, sats 97-100. pt repositioned for comfort w/ no relief. sats 93-96% on 4 liters pt has a dry coughcv: tele paced vent beats w/ intrinsic rythem of afib. heparin gtt or coumadin today D/T A-fib. titrated to 4.0mcq/k/min with SBP 93-100/. Pt has gen anasarca, with trace pitting to ext's. Goal -2L.Heme: Serial Hct 29-29.3, Q8hrs. Foley patent, draining adeq. w/ lasix for fluid goal ~ -1L negative. 181, COV'D W/ 2UX REG INS.A/P:CONTINUE TO WEAN DOPA TO OFF. MICU7 RN Note 0700-1900Events: Hct 29.3 stable no active bleed, Lasix +diuresis, CHF team consult implement recomendations. BS clear to slightly course sxing for minimal secretions. K and phos level this am to be replaced. Peripheral pulses 3+DP/2+DT, gen edema. Last BM am (guiac -). IVF at KVO.GU) Cont to diurese pt. Pt on protonix and given Maalox. HOB>30 degrees.GI: abd soft nontender + BS, recieved bowel regime, stool x3 soft brown, + guiac. HCT stable, 33.1, s/p iliac bleed. ck's neg. PT IS A DNR/DNI. 1+ GNR. wheezes, Alb/Ipa nebs w/ good effect. CPK neg. Central line re-dressed as oozing.ENEDO:- Blood sugars within normal limits. PT ON VANCO AND ZOSYN. gi to see pt as he has been ob+ form below.brief rosneuro- pt alert and oriented x2-3. dopa dependent. advance TF per order. pulses doppler bilat. cultures pnd from admission.CV: HR 95-110 Vpaced with baseline afib. Versed weaned to 1.5mg/hr.endo: FS 180. K+ 3.8, Mg+ 2.2.BP 95-101/50-60's MAP 64-75. dopa weaned to 3.3mcq/k/min but BP trending down to 80's/ . HCT THIS AM DOWN TO 29.2GI:TF OFF AT MN FOR WEANING AND POSSIBLE EXTUBATION. tolerating well.resp:2liters o2 via nc c o2 sats in the high 90's. wbc pnding.A/P: S/P illiac bleed, hct stable. Last ABG shows normal values with hyperoxemia. There is mild global right ventricularfree wall hypokinesis. Shock.Height: (in) 66Weight (lb): 150BSA (m2): 1.77 m2BP (mm Hg): 118/86HR (bpm): 76Status: InpatientDate/Time: at 09:30Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Mild tomoderate (+) mitral regurgitation is seen. Diurese as needed, pt on standing Lasix, although CXR does show edema. Moderate [2+] tricuspid regurgitation is seen. There is mildpulmonary artery systolic hypertension. IMPRESSION: New pulmonary edema, at least moderate. 9:19 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: H/O AAA.ON HEPARIN.HCT DROP. Again, there are diffuse atherosclerotic calcifications within the aorta. Large abdominal aortic aneurysm with mural thrombus and crescent-shaped high density within the thrombus, overall unchanged compared to the prior study. (Over) 9:19 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: H/O AAA.ON HEPARIN.HCT DROP. Moderate [2+] TR.Mild PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: No PS.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is elongated. The right internal jugular line tip terminates in distal SVC. There is periportal edema. Bilat LE 3 + edema. Since the previoustracing of ventricular pacing pattern as described is now present. There is a left-sided AICD with leads projecting in unchanged positions over the right atrium and ventricle. There has been interval decrease in the perihilar and right upper lobe infiltrates. There is a left- sided pacemaker with leads terminating within the right ventricle and right atrium, and median sternotomy wires are present, both unchanged. AP UPRIGHT CHEST: The patient has been extubated and the nasogastric tube has been removed. INDICATION: Swollen left upper extremity. Residual contrast is present within the bladder, consistent with recent CT scan. FINDINGS: Some echogenic material is seen in the left internal jugular vein consistent with some old thrombus. IMPRESSION: Standard placement of endotracheal tube and nasogastric tube. Lines and tubes are in similar position with endotracheal tube tip now 1 cm below the level of the clavicles, likely due to positioning. There continues to be a left pleural effusion. There are patchy areas of volume loss versus an early infiltrate in the right lower lobe. Partial opacification of the left mastoid air cell, which was not seen on previous CT head dated . IMPRESSION: Thrombus extending throughout the length of the left cephalic vein with some older appearing nonocclusive thrombus within the left jugular vein. There is a small left greater than right pleural effusion. The patient is status post median sternotomy and CABG. The patient is status post median sternotomy and CABG. Trachea is midline. There is ill-defined hazy vasculature and perihilar haze consistent with CHF. | 72 | [
{
"category": "Nursing/other",
"chartdate": "2120-12-14 00:00:00.000",
"description": "Report",
"row_id": 1556127,
"text": "88 YR OLD WITH ISCHEMIC CARDIOMYOPATHY ,SP CABG,ICD PLACEMENT ,AAA REPAIR ADMITTED C RESP FAILURE ,HYPOTENSION .PROBALE SEPTIC RATHER THAN CARDIOGENIC.6L FLD RESUS AT OSH.\n\nV PACED C AFLUTTER/AFIB.BP LABILE 68 TO 150 SYS C TITRATION OF DOPAMINE 3 TO 10 MIC PER KG .ATTEMPTING TO WEAN FOR 3RD TIME TODAY .AM HCT STABLE .\n\nPEEP WEANED TO 8,RR TO 18.ABG 7.40/41 /93 / 26 /99.SX FOR MIN EVEN C LAVAGE UNABLE TO GET SPEC FOR CX.BS CL TO DIMINISHED IN BASES .\n\nTF RESIDUALS 40 TO 60 ON 10CC HAVE NOT ADVANCED YET .ABD SOFT ,POS BS .\n\nHUO 30 TO 50 ,SED IN URINE CX PENDING\n\nCX REPEATED C TEMP 101.2,TYLENOL GIVEN.ON PIPRICILLIN,VANCO REPEATED .STARTED ON STEROIDS.\n\nBS COVERED ON SSRI.\n\nPT RESPONDS BY OPENING EYES TO NAME,GETS RESTLESS ,SOMETIMES NODS ,NOT FOLLOWING COMMAMNDS .PUPILS CONSTRICTED .ON 25 MICS FENTANYL,1.5 MICS VERSED .FAMILY UPDATED.AGREE C PLAN .PT IS DNR .HAS AICD TO BE ALLOWED TO FUNCTION AT PRESENT. ,MAGNET AT BEDSIDE.\n\nPROBABLE SEPSIS UNKNOWN SOURCE\n\nCONTINUE SUPPORTIVE CARE , NEED TO ADD LEVOPHED IF BP CONTINUES TO BE LABILE .\nSUPPORT FAMILY\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-14 00:00:00.000",
"description": "Report",
"row_id": 1556128,
"text": "Resp Care\n\nPt remains intubated and currently vented on full support with changes made per careview flowsheet. BS dim/essentially clear sxing for minimal secretions. ETT secured/patent. Last ABG WNL with acceptable oxygenation on present vent settings. Will cont with vent support as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-15 00:00:00.000",
"description": "Report",
"row_id": 1556129,
"text": "CCU NURSING PROGRESS NOTE\nS:VENTED\nO:PT W/ VERSED AND FENTANYL. PT W/ VERBAL AND TACTILE STIMULI. NOT CONSISTENTLY FOLLOWING COMMANDS. MAE.\n\nRESP:VENT REMAINS ON AC/500/18/8, REPEAT ABG PENDING. LS CLR AND DIM BILAT AT BASES. SATS 100%. SX FOR SM AMT OF PALE YELL/PINK TINGED THICK SECRETIONS. SPUTUM CX SENT. HANDS AND FEET EDEMATOUS. MOTTLING OF FEET AND KNEES.\n\nCV:MHR AFIB, W/ VPACED BEATS, RARE PVC. RARE FUSED BEAT. DOPA AT 4MCG/KG/MIN. WEANING DOPA SLOWLY, DP PULSES AUDIBLE W/ . RIGHT FEM CORDIS D&I.\n\nGI:ABD SOFT, +BS. PROBALANCE WAS NOT INCREASED D/T HIGH RESID AND STOPPED AT MN FOR RESID OF 90CC. CONSULT NUTRITION FOR INPUT. NO STOOL\n\nGU:YELL URINE, W/ SM SEDIMENT.\n\nENDO:COV AS PER SS.\n\nID:SPUTUM SENT. BLD CX PENDING, T MAX 101.1. PT REMAINS ON ZOSYN AND VANCO.\n\nA/P:PT IS A 88YROM ADM W/ ABD PAIN, NO CHANGE IN AAA. RECENT PPM. DISTRIBUTIVE VS SEPTIC SHOCK. CX PENDING, CON'T ANTIBIOTICS. CONTINUE TO WEAN DOPAMINE AS TOLERATED. CONSIDER ADDING REGLAN AT RENAL DOSES.\nPT CURRENTLY DNR/DNI, AND DECIDE ON CMO STATUS. CONTINUE MULTIDISCIPLINARY ROUNDS. LABS PENDING. KEEP FAMILY UPDATED ON PT STATUS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-15 00:00:00.000",
"description": "Report",
"row_id": 1556130,
"text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and fully ventilated on AC settings. No vent changes made during the noc. Sxn for small amount yellow with scant blood-tinged. Unable to obtain RSBI d/t no spon. respirations, even with sedation decreased (attempted x2). ABG shows aequate ventilation and oxygenation.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-16 00:00:00.000",
"description": "Report",
"row_id": 1556135,
"text": "Respiratory Care\n\n Pt placed on SBT and passed this am. On PSV 5/5 for several hours with good ABG. Pt remains intubated now on MMV after sedation related low ve. B/S sl coarse sx'd x1 for small thick tan. PLAN: SBT and ??extubation in am. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-16 00:00:00.000",
"description": "Report",
"row_id": 1556136,
"text": "CCU Progress note 0700-1900\nRESP:- Remains orally intubated and mechanically ventilated. CPAP trial this morning, On 5/+5 ABG 7.41/50/138, plan was to extuabte, however pt HR changed, and vasopressor requirments ^, therefore desision taken to keep intubated overnight. Mr very keen to have the tube out, also discussion regarding plan of care post extubation as is DNR/DNI. Bilateral air entry haerd to all lungfields, but diminished at the bases. Suctioned as needed for a small amount of thin clear secretions, weak cough on suctioning. Current vent settings, MMV, allowing him to take spontaneous breaths mixed with set breaths, settings 550/10 PS5 PEEP +%, ABG 7.44/43/116.\n\nCV:- Initially monitored in V Paced rhytham 75-85 bpm, with occationsal PVCs', however rate changed at 1130, ^ 120s, Afib and paced beats, SBP compiromised tp 79, had managed to wean Dopamine to 0.75mcg/kg/min but had to increase to 2mcg/kg/min. SBP 90-120s'. Perpierally warm to touch, pedal pulses dopplerabel. K= 3.6 post K replartion, rechecked 4.4 at 1500. Hct improved to 32.3. Given 2.5mg PO vitamin K. CVP 8-15.\n\n\nNEURO:- Initially off sedation in preparation for extubation, but when desision taken to keep intubated pt became more agiated therefore sedation re-started, currently on midazolam at 0.5mg/hr and fentanyl at 25mcg/hr, roused by voice and bale to gesture needs well. Unable to assess pupils as has cataracts. Able to move all 4 limbs well within the limits of bedrest. Soft wrist restriants inplace to protcet tubes and lines.\n\nGU:- Foley catheter draining good amounts of clear urine, which was intially yellow but has become pinkish as the day progressed, Drs .\n\nGI:- OG tube placement checked, air heard on auscltation. Feed off as not extubating, was having high aspirates last night. Abdomen soft and non-tender. Passing flatus, but bowels not moved during the day.\n\nACCESS:- 2 x PIV both satisfactory and patent. Central line re-dressed as small amount of dry blood present, site appears satisfactory. A-line site looks clean.\n\nFAMILY:- Daughter visited, spoken with Drs length regarding Mr DNR/DNI staus. Asked him whether he would wanted to be re-intubated if needed post extubation and he said yes, which uoset her as he always said that he would not want that, she also brought in copies of living will which were put in chart. DNR/DNI currently still stands.\n\nENDO:- Blood suage slightly elevated at lunch time covered with 2 units sliding scale. steroids given as per chart.\n\nID:- Afebriel during the day, antibiotics given as per chart. WCC trending down. suctioned for small amount sercretions.\n\nSKIN:- Pressure areas, intact, barrier cream applied to sacral areas and areas. Full bedbath given and sheet changed. Nursed on alternate sides and back. Pneumo-boots inplace.\n\nPLAN:- To continue with sedation overnight, and attempt to wean dopamine as tollerates. Plan to extubate tomorrow. To continue to give full explination of care to patient and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-17 00:00:00.000",
"description": "Report",
"row_id": 1556137,
"text": "CCU NPN 1900-0700\nO:\nafeb. contin. vanco/zosyn.\nHR 85-112 Vpaced, underlying afib. no VEA.\nBP 94/63-115/72. dopa weaned to off by 0400.\n\nResp: vent on MMV /.40. sats 99%. RR 12-16. Tv 400-600. suctioned for small amt. white secretions. LS clear to diminished.\nRSBI pnd\nGU: foley draining ~ 30cc/hr. pos. 200cc for and neg. 500cc LOS.\nGI: NPO overnight for possible extubation today. OGT draining small amt. of bilious liq. no stool.\nNeuro: pt. awake and alert at times.....banging hand/feet on side rails for attention. Very frustrated at current state/wanting ETT out. responding approp. to questions....mouthing words approp.\ncontin. on fent. gtt 25mcq/hr and versed .5mg/hr with good effect. small boluses to aid sleep with good effect. wakes easily to voice.\n\nA/P: plan to wean/extubate today. dopa weaned off...contin.to monitor BP. family support. pt. is currently DNR/DNI. need to discuss when pt. is extubated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-17 00:00:00.000",
"description": "Report",
"row_id": 1556138,
"text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and ventilated on MMV ventilation 5/5 with back-up Vt=500, RR=12. most of night with the goal of extubation this AM. BLBS are mainly clear. RSBI completed on PS 5, PEEP 0=29. ABG shows adequate ventilation and oxygenation.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-17 00:00:00.000",
"description": "Report",
"row_id": 1556139,
"text": "Nursing Progress Note 0700-1900\nS: \"My breathing does feel better\"\n\no: Please see carevue for complete objective data.\n\nResp: Extubated @ 1200. Strong cough and + gag reflex. Had a few apneic episodes during weaning, but has had none since ETT removal. O2 weaned down to 2L nc, sats 97-100. Lungs clr c dim bases. No c/o SOB.\n\nCV: Vpaced, 70-80's, PVC's rare. SBP 89-102, off pressors. CVP 6-10. Pulses palp. HCT-28.7 (30.0). Platlets steadily decreasing over past few days. Down to 106, team aware. Started on SC heparin and ASA.\n\nGI/GU/Endo: Pt c/o cramping in abdomen, given colace and senna. Drinking water without incident and taking pills. BS present. Foley draining clr PINK urine, team aware. Rec'ing ins per ss.\n\nAccess/Skin: RIJ Trip lumen cath dressing changed RN's instructions. 2 PIV's. Contusion on R arm.\n\nNeuro/Social: A&O x 2, forgets place but reoriented easily. Daughter and son into visit today, remarked that pt is \"seeing things that are not there\" RN did not witness episode. Pt told MD that he would want to be re-intubated if necesary. Family was there to witness and did not have any objections to pt's wishes.\n\nA/P: Successfully extubated and weaning O2 requirements. Cont to monitor resp status and hemodynamics. Advance diet as tol, ?lactulose for constipation. Monitor UO, PT consult. Emotionally support pt and family and keep updated on plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-20 00:00:00.000",
"description": "Report",
"row_id": 1556145,
"text": "NPN 0700-1900,1735 EST\n\n88 YO MALE WITH H/O CAD,MI, AAA( S/P REPAIR, NO LEAK) RECENT AICD FOR SYNCOPAL EPISODE,SEVERE CARDIOMYOPATHY EF 10% WHO ORGINALLY PRESENTED TO OSH WITH EPIGASTRIC PAIN AND HYPOTENSIVE, WHERE INTUBATED FOR SEVERE HYPOXIC RESP FAILURE AND TRANFERED TO CCU. PATIENT THEN TRANFERED TO FLOOR AND TO MICU YESTERDAY FOR ABDOMINAL PAIN AND CONCERN FOR MESENTRIC ISCHEMIA, CT NEG.LACTATE WAS 2.4 AND DOWN TO 1.7.PATIENT WAS ON NRB 100% AND TOLERATING NC TODAY.\n\nNEURO: ALERT, ORIENTED X3, COOPERATIVE.FOLLOWING COMMANDS CONSTITENTLY AND MAE WITH NORMAL STRENGTH.C/O ABD PAIN LATER EVENING SEEN BY MD AND GIVEN SIMETHICONE PO.\n\nCV: V PACED, WITH PVC'S, POTASSIUM 80 MEQ REPLETED. SBP 100-130MMHG.\nHEPARIN GTT STOPPED FOR 1HR FOR PTT >150 AND RESTARTED TO950U/HR AND NEXT PTT DUE AT 2200.\n\nRESP: TOLERATING NC 5L, DOWN FROM 50% VIA VM. BILATERAL LS WHEEZY/CRACKLES,RRECEIVED MDI'S WITH GOOD EFFECT. WEAK UNPRODUCTIVE COUGH SPUTUM SAMPLES NEED TO BE COLECTED. O2 SATS 90-96%. CXR DONE PM.\n\nGU/GI: TOLERATING DIET, ABD SOFT,BS PRESENT, PATIENT C/O PAIN AFTER BOWEL MOVEMENT AND SEEN BY MD AND GIVEN SIMETHICONE AND PATIENT FEELS BETTER. LASIX 40 MG IV GIVE WITH GOOD EFFECT AND DRAINING VIA FOLEY'S.\n\nENDO:INSULIN AS PER SS\nID: AFEBRILE D/CED ANTIBIOTICS.\nSOCIAL: VISITED BY DAUGHTER.\n\nPLAN: CALL OUT TO FLOOR, CONTINUE MONITOR RESP STATUS AND ABD PAIN. PTT Q6HRS\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-21 00:00:00.000",
"description": "Report",
"row_id": 1556146,
"text": "Nursing progress notes\nEvents:\nReceived pt at 1900 c/o abd pain. #5 on pain scale (0-10) bs+ abd soft dr paged x 2 w/o call back, resident called (dr ) and notified of pt's pain. Dr at bedside pt's pain up to #9, heat pack and ms 1mg ivp given. w/ good results for a short time. pain seems to come and go and increase and decrease in intensity. pt very anxious w/ pain spells. stating he is going to die\" emotional support given. pt tachycardic afib w/ some paced beats and pvcs w/ anxiety and sob. ekg obtained eventhough pt denied cp. dr at bedside and ativan .5mg ivp ordered and given. hrt rate 70s-80s and no further c/o abd pain (after ativan given) however pt unable to get comfortable enough to fall asleep. pt repositioned for comfort w/ no relief. ambien ordered and given 5mg po. pt became restless and confused to place and time. hallucinating, seeing people in his room. he has tried to get oob frequently. bed alarm on and staff in room monitoring pt for most of shift. pt up to chair w/ 2 assist for ?comfort. He stayed in chair for 1 hr then tried to get back to bed. dr aware of pt sob, confusion and restlessness. no orders given. pt c/o left hip pain requesting motrin, 400mg po ordered and given.\n\n\nNeuro: pt was alert and oriented x 3 at the beg of this shift and has become increasingly more confused and restless throughout shift. at present pt resting comfortly in bed w/ eyes closed. pt oriented to self and month. pt re-oriented frequently whenever staff enter pt's room. pt mae and will follow simple commands/\n\nREsp: received on 5l nc ls clear w/ crackles in left base and diminished right base. lasix 40mg ivp given at 2130 pt diurresed 900cc of cloudy yellow urine. pt'd 02 now down to 4liters. he has cold extrem. and his pleth (no matter where I place o2 sat probe it would show 80s and/or straight line for wave form. staff tried to keep blanket on arms to help warm them. sats 93-96% on 4 liters pt has a dry cough\n\ncv: tele paced vent beats w/ intrinsic rythem of afib. hrt sounds s1s2 pedal pulses +2 extrem. cool. k+ 3.1 at 1800 40meq of k+packet given w/ pt ultimately vomiting. k+ changed to iv bolus. phos 1.9 k+phos given. phos now 3.3 k 5.1 (k+ checked at 1900 4.5) heparin gtt infusing at 700u/hr ptt 87.8 inr 2.3 (up from 2.1)\n\ngi: abd soft pt c/o of abd pain for beg of shift as stated above. pt has had 5 small brown loose stools this shift (he is inc at times), all guiac neg, all foul smelling. 1st stool sent for cdiff. pt vomited (as stated above) 100cc w/ small bld clot noted, anzemet 12.5mg ivp given. pt taking po ok no further vomiting notied. kub done on day shift. -unremarkable.\n\ngu: urine output trailing off this shift, lasix 40mg ivp given w/ 900cc diuresed\n\nskin:intact however lg eccymotic area noted on right upper forearm. old right cortis site intact not draining\n\nid: right tlcl removed and cath tip cx wbc 19.6 up from 13.0\n\naccess: pt has 2 #18 piv and tlcl removed this am per micu order/\n\nendo: bs 1\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-21 00:00:00.000",
"description": "Report",
"row_id": 1556147,
"text": "Nursing progress notes\n(Continued)\n26-141\n\ncode: pt was a dnr per poe, however dr asked pt about his code status. pt alert and oriented x3 at the time , pt decided to have everything done for him. pt now a full code.\n\nsocial: son is hcp no contact w/ family overnight.\n\nPlan:\nno ambien/ativan\ncont to watch closely for pt's safety\ncont to reorient\nadminister motrin q 8hrs prn for left hip pain.\ncont to wean 02 as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-21 00:00:00.000",
"description": "Report",
"row_id": 1556148,
"text": "7a-7p\nsee transfer note\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-21 00:00:00.000",
"description": "Report",
"row_id": 1556149,
"text": "BS few fine crackles (less than yesterday). No change with MDI's. Appears somewhat more confused than before. Called out to floors.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-21 00:00:00.000",
"description": "Report",
"row_id": 1556150,
"text": "1900\ntransfer to floor held due to sbp < 90(85-88), 250 ns iv bolus x 2 given & po midodrine started, transfer to floor when sbp consistantly > 90\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-22 00:00:00.000",
"description": "Report",
"row_id": 1556151,
"text": "addendum micu 7 west npn\npt came to MICU-7 at 1800 from FAR 7 after a 10pt Hct drop.\nPt received, total of 3 units PRBCs IN and 3 unit FFP IN, 20mg Lasix given as well. Unable to insert NG tube for lavage - pt. refused.\nABG/VBG done - see carevue, labs sent. foley output clear/yellow, bs hypoactive, nonrebreather difficult to obtain o2 pleth - 95% w/ good pleht.\nPt to go to CT tonight for Abd, ? source of bleeding.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-13 00:00:00.000",
"description": "Report",
"row_id": 1556124,
"text": "S: pt intubated\n\nO:see careview. DNR\n\nCV:Vpaced a flutter c weinekbach through av node. BIV ICD . CT showed large triple a _ pe and leak/rupture. troponon .02, ck 53. pt has alne and right fem cortis. inr 2.8. HR 90-80's. pt on 4.5mcg/kg/min dopa with a bp 119/84. pts bp drops when dopa was decreased to 3mcg/kg/min. maintain map goals of >65.\n\nRESP:AC/40%/TV500/RR20/PEEP10. ABG 7.39/36/160/23/-2.ett was advanced 4cm per x-ray.\n\nneuro:sedated responds to stimulation. midazolam 2mg/hr and fentanyl 25mcg/hr\n\nendo:BS 200's on ss insulin.\n\nGU:-1281cc since admission pt did receive 6liters of fluid in osh for hypotension. foley cath inplace.\n\nGI:+BS - BM ogt placement confirmed with xray and ausciltation.\n\nID: afebrile on antibiotics.\n\nsocial: 2sond and daughter into visit pt. pts son is health care proxy. Pt made it clear to son that if he ends up no able to move and can only sit and watch tv all day he does not want to live. family does not want swan line placed.\n\nA:If there is no improvement in the next 48hrs or decreased requirment for supportive care then plan will be to withdraw care + CMO.\n\nP: wean vent as tolerated, wean dopa as tolerated, start tube feeds after midnight as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-14 00:00:00.000",
"description": "Report",
"row_id": 1556125,
"text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made through out the night. No morning abg results at this time.\n\nNo RSBI measured due to the level of PEEP currently required.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-14 00:00:00.000",
"description": "Report",
"row_id": 1556126,
"text": "CCU NPN 1900-0700\nO: 88yo male with hx CAD, Ischemic transferred from OSH following Acute resp. failure, hypotension req. intubation, dopa and fluid resusitation.\n\nCABG x3, ICD , DVT, CHF. takes lasix, amio, zoloft, statin at home (incomplete list).\nrecent hosp. for SOB- ? RLL PNX (per chart).\n\nCTA here showing 6.5cm infrarenal AAA with no evidence of rupture or leak. evidence of graft repair distally. (per chart review).\n\novernight:\nTM 99po. cultures pnd from admission.\nCV: HR 95-110 Vpaced with baseline afib. occas. to freq. PVC's. K+ 3.8, Mg+ 2.2.\nBP 95-101/50-60's MAP 64-75. dopa weaned to 3.3mcq/k/min but BP trending down to 80's/ . titrated to 4.0mcq/k/min with SBP 93-100/. MAP 70. Dr. aware.\nright fem. cordis line D/I. pulses doppler bilat. feet cool.\nHCT 38.5. CPK neg. x2.\nResp: no vent changes: AC 500x20/10peep/.40. sats 100%. suctioned for thin white secretions. LS clear. ABG 7.43-41-120\nGU: u/o 50-100cc/hr. neg. 1.6L for .\nGI: abd soft, NT. pos. BS. OGT with small amt. bilious drainage, guiac neg. tube feeds probalance started at 10cc/hr. no stool.\n\nNeuro: Eyes open to stimulation and name. nods and shakes head approp. to questions but did not respond to other commands. no acute agitation. fent. at 25mcq/hr . Versed weaned to 1.5mg/hr.\n\nendo: FS 180. SSRI.\nskin: dark bruise on right inner elbow - ? from blood stick. intact otherwise.\nno family calls.\n\nA: cardiogenic vs septic shock. family refusing swan ganz catheter. contin. dopa dependent. negative fluid balance post diuresis on admission. ck's neg. AAA stable with no evidence of rupture/leak.\nfamily requests DNR/DNI. EP consulted to assess BIV/ICD>\nP: titrate dopa as tolerated. follow cultures. titrate sedation for comfort. advance TF per order. family support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-15 00:00:00.000",
"description": "Report",
"row_id": 1556131,
"text": "Resp Care\n\nPt remains intubated and currently vented back on full vent support. Attempted to wean pt on PSV trial however pt continued to go apneic 15 minutes into the trial and was subsequently placed back A/C to rest overnoc. BS clear to slightly course sxing for minimal secretions. Will cont with vent support and reassess for readiness to wean daily.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-15 00:00:00.000",
"description": "Report",
"row_id": 1556132,
"text": "V PACED C HR TO 115.ATTEMPTING TO WEAN DOPAMINE ,BP CONTINUES TO DRIFT TO 80S .4 UNITS FFP GIVEN.TLC R SUBCLAVIAN PLACED.CVP 13.FEM LINE DC\n\nATTEMPTED PSV TRIAL P SEDATION DC.PT HAD PERIODS OF APNEA, RETURNED TO CMV.SATS 100.SX SM AMT THICK TAN .\n\nPOS BS ,DENIES ABD PAIN.\n\nHUO 50 TO 75.POS 1100CC.\n\nPT ALERT AND APPROPRIATE C FAMILY.DENIES PAIN .FAMILY WANTS TO BE HERE IF EXTUBATED TOMORROW .WEDDING RING SENT HOME C FAMILY.\n\nT MAX 99.1 .\n\nDOPAMINE ,VENT DEPENDENT\n\nTRY TO WEAN DOPAMINE\nRESTART TF\n\n\n\n\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-16 00:00:00.000",
"description": "Report",
"row_id": 1556133,
"text": "CCU NURSING PROGRESS NOTE\nS:INTUBATED\nO:PT IS A 88YOM ADM W/ HYPOTENTION AND RESP FAILURE.\n\nNEURO:PT NOW OFF ALL SEDATION AS OF 0400. PT OPENS EYES SPONTANEOUSLY, FOLLOWS COMMANDS. MAE.\n\nRESP:LS CLR AND DIM AT BASES, NO WHEEZES. SATS 96-99%. VENT AC/500/18/40/5 W/ ABG OF 7.50/40/76/32/94%. RR DOWN TO 14/TV-600.\nWILL REPEAT ABG. SX FOR SM AMT PALE YELL SECRETIONS. SPUTUM GRAM STAIN SHOWING 2+YEAST, 1+GPC IN PAIRS/CLUSTERS. 1+ GNR. FINAL REPORT PENDING. NEW R IJ TLC PLACED YESTERDAY.\n\nID:T-MAX <98. WBC DOWN TO 10.6K. PT ON VANCO AND ZOSYN. SPUTUM AS ABOVE. BLD CX PENDING.\n\nCV:MHR 80-100, AFIB AND V-PACED, W/ OCCAS PVC OR FUSED BEAT. ATTEMPTED TO WEAN DOPA OFF EARLY LAST EVENING, SBP DOWN TO 70S. DOPA WAS RESTARTED BACK AT 2.5MCG/KG/MIN. NOW AT 2MCG/KG/MIN. RIGHT GROIN SITE D&I. DP AUDIBLE W/ . SKIN SALLOW, MUCOUS MEMBRANES PINK. CAP REFILL BRISK. EXTREMITIES WARM, SKIN WARM AND DRY. HCT THIS AM DOWN TO 29.2\n\n\nGI:TF OFF AT MN FOR WEANING AND POSSIBLE EXTUBATION. +BS , DENIES ABD DISCOMFORT. NO STOOL.\n\nGU:YELL URINE W/ SOME SEDIMENT, DECREASED OVER NOC, U/O 0 AT 0400 .F/C FLUSHED AND HAD ADEQUATE URINE OUTPUT AFTER THAT.\n\nENDO:GLUC COV AS PER SS. 181, COV'D W/ 2UX REG INS.\n\nA/P:CONTINUE TO WEAN DOPA TO OFF. SEDATION OFF WILL ATTEMPT TO WEAN FROM VENT. PT IS A DNR/DNI. FAMILY WOULD LIKE TO BE NOTIFIED AND BE ABLE TO VISIT RIGHT AFTER EXTUBATION. CONTINUE GLU COV WHILE ON STEROIDS. FOLLOW CULTURES, CON'T ANTIBIOTICS. MONITOR FOR ANY DECRESES IN HCT. NUTRITION WHEN APPROPRIATE. EMOTIONAL SUPPORT. SOC SVC FOR DISCHARGE PLANNING.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-16 00:00:00.000",
"description": "Report",
"row_id": 1556134,
"text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and fully ventilated on AC settings. Adjusted settings in attempt to stimulate patient to breath more on own to wean. ABG shows metabolic alkalosis. RSBI completed on PS 5=33. Placed on PS but becomes apneic often and unable to wean on PS at this time-sedation completely off also. Switched to Vt of 550, RR=12. seems to be breathing over set rate. Plan to wean support when able to tolerate.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-29 00:00:00.000",
"description": "Report",
"row_id": 1556165,
"text": "Resp Care: Pt seen for attempt @ bipap...placed on 5 cm nasal cpap with 2 lpm bled in, tol ~ 10 minutes >> confused/uncoop, pulling off mask, returned to nasal prongs @ lpm with spo2 89-100%, restless with freq c/o inability to breathe, will follow for nebs/ cpap as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-18 00:00:00.000",
"description": "Report",
"row_id": 1556140,
"text": "S:\"I would like to eat icecream.\"\n\nO:please see careview.\n\nCV:v-paced hr 70's, bp 100/50's. pt currently receiving 75cc/hr for 1000cc of iv fluid. tolerating well.\n\nresp:2liters o2 via nc c o2 sats in the high 90's. LS clear.\n\ngu:pt 's urin output 20cc/hr-40cc/hr. red tinged urin. +200cc as of now.\n\nGI: no bm + bs pt tolerating po meds and icecream.\n\nendo:ss insulin bs 150-200's.\n\naccess:right ij and right a-line.\n\nneuro:pt a+ox3 pt became confused when he awoke from naps throughout night. pt thought he was at home and he had to go food shopping for the kids also he thought he seen 2 cigaretts on his bed burning. pt was easily reoriented.\n\nA:low platelets decreasing past 3 days.\n\nP:continue to treat and monitor lytes/platlets. continue to encourage cough and deep breath, continue to access mental status. follow blood sugars.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-18 00:00:00.000",
"description": "Report",
"row_id": 1556141,
"text": "CCU Progress note 0700-1900\nRESP:- Remains on N/C at 3 litres, Sa02 96-99% RR 18-26 and regular. Bilateral air entry haerd to all lungfields, but diminished at the bases. Coughing but not expectoarting any sputum.\n\nCV:- Moniotred in V paced rhytham, 75-85bpm, with occational PACs'. SBP manually 93-100, A-Line removed as bleeding, sugifoam inplace and pressure held for 20 minutes. Peripherally warm to touch. For repaet labs to be checked at 1600, then for possible blood transfusion if Hct continues to fall. Q8 our heparin and pneumo boots inplace.\n\nNEURO:- A&O x2, a little low at times, wanting to go home, told him that he is doing well considering how ill he was last week. Able to move all 4 limbs within llimits of bedrest. Able to feed himsefl with supervision.\n\nGU:- Foley catheter continues to drain blood tinged urine, acceptable amounts. Team aware.\n\nGI:- Able to eat a small amount of diet during the day. Seen by speech and swallow, assessed no problems noted with swallow. eaten small amount of diet today, tollerating it well. Abdomen soft and non tender. Bowels not moved to day. Bowels sounds heard. Docusate and senna given as ordered.\n\nSKIN:- Pressure areas inatct, on back for most of the day, encourgaed to lay on sides also. Barrier cream applied to back, saccral area and heels. Full bedbath and sheet change given, with facial shave.\n\nACCESS:- Now has central line only, 2X PIVs removed as in for 3 days, A-line also removed. Central line re-dressed as oozing.\n\nENEDO:- Blood sugars within normal limits. Steroids given as per chart.\n\nID:- Afebrille during the day, not further reported grows from blood cultures. Coughing but no expectorating any sputum. Vancomycin stopped. Zocyin continues.\n\nFAMILY:- DAughter called and updated. No other enquires as yet from family today.\n\nPLAN:- CAlled out to the floor, to contiue with antibiotics and steroids. To mobilse as tollerates. To continue to give full explination of care to patient and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-20 00:00:00.000",
"description": "Report",
"row_id": 1556142,
"text": "REspiratory Care\nPT with progressive SOB and wheeze. Treated with MDI (very good technique) but wheezing remained. XRay reported with increased CHF. ABG drawn from R radial artery without incident. Results reveal mixed respiratory and metabolic alkalosis with only fair oxygenation on 50% venti, FiO2 increased to Partial Non Rebreather. Being treated aggressively for apparent CHF.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-20 00:00:00.000",
"description": "Report",
"row_id": 1556143,
"text": "Prt was transfered to MICU from 7, with Dx of ? mesenteric ischemia D/T sudden onset of sharp mid abd pain. Ct of abd neg for any leakage from AAA, absess or obstruction. BC X2 and UA/urine cx sent on adm and UA back with picture of UTI. Since his adm to MICU his resp status continued to decline until 2 am. At 2 Am pt was found to be restless, O2sat decreased to 90-91% on 5 liters NP and LS with cx's and exp wheezes. Resp status did not improve after neb tx. ABG : 7.53/35/60/30 on 50 % VM. CXR done, and showed worsening CHF,- and pt started on lasix. After lasix IV, pt's resp status improved.\n\nNeuro)\n Pt oriented x 2 on adm. Pt cooperative and follows simple commands. Pt given Ambien for sleep, and was found to become very comfused afterwards. Ambien was later D/C'd.\n\nCV)\n Pt in 100% Ventricular paced (70-80's) with PVC's. SBP stable 94-116 with MAP > 70. CVP 17-->11 (after Lasix). Pt has gen anasarca, with trace pitting to ext's. Good pulses to palp. K and phos level this am to be replaced. Inr this am 1.9 ? heparin gtt or coumadin today D/T A-fib. Access: Rt IJ TLC with good bloodreturn.\n\nResp)\n LS at 4am with cx's throughout. RR22-24. Pt present with a dry non-prod cough...less freq now. Pt remains on 100% NRB with o2sat 95-97%. CXR to be done later again today. ? repeat ABG later too and ? More Lasix for CHF.\n\nID)\n WBC down to 13.3 this am (17.8). Pt only on Zosyn IV at this time. Bc and urine cx pending.\n\nENDO)\n Steroid induced hyperglycemia, and on RISS as noted with BS at mn 167.\n\nGI)\n Abd dist, soft and with + BS. Pt started to regurgitate after taking po pills pm. KUB done. No other incidences since then and diet adv to House. Pt on protonix and given Maalox. Last BM am (guiac -). IVF at KVO.\n\nGU)\n Cont to diurese pt. Pt is now + 900 since adm to MICU.\n\nSkin)\n Skin intact.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-20 00:00:00.000",
"description": "Report",
"row_id": 1556144,
"text": "BS fine crackles bilateral though in negative fluid balance. No change with MDI's. Strong non-productive cough.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-26 00:00:00.000",
"description": "Report",
"row_id": 1556161,
"text": "NPN 7p-7a\nDNR/DNI\nAllergy: Benzo's-confusion\nPlease see carevue and FHP for additional data.\n\nNeuro: Continues with anxiety overnight, feeling like he is \"going to die\". Recieved Trazadone this evening with mod. effect. Requires frequent reassurance regarding health status. No c/o pain. MAE, although at times patient feels as though he \"can't move\", likely having extra fluid in lower extrem. and feeling heavy.\n\nResp: NC 3L. LS clear w/ occ. wheezes, Alb/Ipa nebs w/ good effect. No cough noted.\n\nCV: 76-82 Vpaced. Occ. pvc's noted. Sbp 111-123. RR 20-24. Sats 95-100%. HCT stable, 33.1, s/p iliac bleed. EF 10%. Recieved 20mg iv Lasix w/ good effect. On Digoxin QOD.\n\nGI/GU: abd soft, well tolerated Renal diet. Foley patent, draining adeq. clear, yellow urine.\n\nEndo: Humalog SS.\n\nSkin: eccymosis to left hip, unchanged.\n\nA/P: 10pt HCT drop- etiology unclear, iliac hematoma, now w/ stable HCT. CHF- EF 10%. Cont. w/ lasix for fluid goal ~ -1L negative. Remains on Dig. and aldactone.\nAnxiety- Seemed to respond pretty well to Trazadone over night, cont. to monitor and offer emotional support.\nLikely call out to cardiac floor.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-26 00:00:00.000",
"description": "Report",
"row_id": 1556162,
"text": "DNR Universal Precautions Allergy: Benzos\n\n\nNeuro: AAOX3, MAEx4 - OBB to chair w/ minimal assist. In better spirits today.\n\nCV: HR=70-60s, V-paced. BP=90-110/. +periph pulses, +edema, extrems warm.\n\nResp: 3l n/p w/02sat 96-99%. Lungs clear in upper fields, few crackles bilat - more in L than R. Received aldactone at 1200. RR=18-26. SOB after any exertion, but returns to normal in a short time (5 min).\n\nGI/GU: abd soft, +BS, taking renal diet well. No BM. Foley cath w/ clear amber urine.\n\nSkin: Intact. L hip eccymottic. Buttocks/heels intact.\n\nPain: Denies discomfort\n\nSocial: No family visiting or calls as of yet today.\n\nAccess: New #20 PIV placed this am.\n\nHCT 33.1 today\n\nPlan: Tx to .\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-23 00:00:00.000",
"description": "Report",
"row_id": 1556152,
"text": "micu npn 1900-0700\ncont'd-\n\nS: I don't want to die in the hospital, if i'm going to die, I would rather die at home\nO: Patient overnight very restless and emotionally upset at times about not being able to go home and \"just wanting to be at home with his family\". We had a discussion this am about his poor heart, his code status and the initbility for him to be at home at this point with all the care and services he needs. He expressed a desire for me to speak with his daughter, and have her gather his family to come to some decisions regarding his code status and get him home.\nA/P: Hope to speak with family today, team aware and will have a discussion regarding code status/change in goals of care w/him.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-23 00:00:00.000",
"description": "Report",
"row_id": 1556153,
"text": "micu npn 1900-0700\nPlease see fhpa for details on admission history.\n\nBriefly, pt is an 88 yo male, hx of cad, mi, aaa (s/p repair w/no leak, aneurysm 6.5 cm), a fib, recent aicd pl (), severe cardiomyopathy w/ef 10-15%, presented to osh w/c/o epigastric pain, hypotensive to 60's , intubated for hypoxic resp failure w/presumed cardiogenic shock.\nHe transferred to CCU treated and sent to the floor . Micu accepted the pt to micu6 on for c/o abdominal pain. cta neg for mesenteric ischemia, no indication for surgery, but vascular following. He had issues w/hypotension vs chf lasix and fluids, started on midodrine and put back on iv heparin for underlying afib. transferred to the floor again on w/guiac + stools.\n\nYesterday , pt w/inr's climbing since transfer to the floor, am labs showing hct drop from 31 of prev day to 25.7, then 19.4 several hrs later. The pt c/o left leg/hip pain and was hypoxic to the ?mid 70's. He was again transferred to the micu(7) for w/o of source of bleed.\nPt transported to ct overnight for ct of abdomen, showing stable aaa, noted bleeding into iliac muscle, although doesn;t account for 10 pt hct drop. gi to see pt as he has been ob+ form below.\n\nbrief ros\nneuro- pt alert and oriented x2-3. very upset overnight that he has not been able to go home. frustrated at situation. appears to be for the most part a+ox3. no defecits noted.\n\ncv- remains vpaced w/afib underlying. some fusion beats w/v paced rhythm. hr 80-100. non invasive bp has been 100-130's sys. heparin had previously been d/c'd.\n\nresp- on nrb for short time last eve, unable to get accurate o2 sat. now on 6l nc sats appear to be >94% when able to get a waveform. rr mid 20's-30. at times labored. received additional 20 iv lasix lasrt eve w/some response.\n\ngi/gu- npo except ice chips for now. gi will see pt in the am for ?ugi scope to eval additional source of bleeding since he has been guiac +. uop good. no bm this shift.\n\nheme- since episode of hct drop, pt has received total of 3 u prbc's and 4 u ffp. hct back up to 30. inr remains elevated now 1.9. no s+s of bleeding.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-24 00:00:00.000",
"description": "Report",
"row_id": 1556156,
"text": "npn 1900-0700\n\nOvernight: Electrolyte repletion. Patient became very anxious at 2315 stating he was \"scared\" and he wanted to be with his mother who is \"dead and buried\". Called his daughter and he was better for a little while. Received haldol without effect and then .5mg of ativan at 0215. He was then able to sleep the rest of the night.\n\nneuro: AXOX3, follows commands. No c/o pain or discomfort. Anxiety re. hospitalization and fear of dying in the hospital--wants to die at home.\n\nresp: sats 93-98% on 3L nc. LS clear.\n\ncv: V paced with fusion beats. BP with MAP >60. Received total of 100meq of potassium overnight for a level of 2.7 at last evening.\nPartial dose of digoxin due at noon (.03mg) and begin full dose tonite at bedtime.\n\naccess: 3 piv. Able to draw blood from piv in L arm.\n\ngi/gu: Abdomen is soft with + BS. Patent foley with clear yellow urine. Output has dropped off overnight; received several doses lasix yesterday. 2 liter fluid restriction.\n\nskin: Many areas of bruising, r arm, hematoma on L hip. No open areas. Heels are reddened.\n\nendo: RISS.\n\ndispo: DNR/DNI. Pt wants to go home.\n\nsocial: Pt spoke with dtr last night.\n\nplan: Agressive diuresis, serial crits q 8 hours. AM potassium is 3.0; will hang 40meq in 500cc and then try ti have pt take po. He refused the potassium pills last night.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-23 00:00:00.000",
"description": "Report",
"row_id": 1556154,
"text": "MICU7 RN Note 0700-1900\n\nEvents: Hct 29.3 stable no active bleed, Lasix +diuresis, CHF team consult implement recomendations. Family , PT OOB chair.\n\nNeuro: awake alert oriented x3, follows commands MAE random Equal strength, PT OOB to chair Full weight bearing with assist. Chair for 1.5hrs, pt feeling depressed and emotional weepy, wanting to go home to be with family. \"I do not want to die in hospital\". Met with Social services.\n\nCV: HR 75-95 V-paced fused beats, BP 95-119/46-67. MAPS>60. Currently hemodynamically stable, CHF team evaluation. Agressive diuresis, d/c midridone, Digoxin, Ace inhibitor, betablocker. Peripheral pulses 3+DP/2+DT, gen edema. Lasix 20mg x2 + diuresis. Goal -2L.\n\nHeme: Serial Hct 29-29.3, Q8hrs. no active bleed INR 2.1.\n\nResp: RR 18-24 Dyspneic with activity, O2 4L/min NC Sats 90-96%, Lungs clear rales bil. dim with Lasix. HOB>30 degrees.\n\nGI: abd soft nontender + BS, recieved bowel regime, stool x3 soft brown, + guiac. Started shift NPO adv to reg with restrictions. tol well No N/V.\n\nGU: Foley u/o 40-240cc/hr +diuresis from Lasix. Goal (-)2L.\n\nDerm: Skin W/D 3+ anasarca, Ecchymotic L Hip/flank denies pain.\n\nSocial: Started shift full code status to DNR per pt and family request. met with Team. pt would like to cont with plan for fluid removal and transition to home with services.\n\nPlan: seriel Hct q8hrs next @ \n Implement/resume cardiac meds\n agressive diuresis\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-23 00:00:00.000",
"description": "Report",
"row_id": 1556155,
"text": "Respiratory Care:\nPt seen for neb Tx's x 2 today At 12noon and 6 PM. He seems to be much improved over Last evening.!!\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-24 00:00:00.000",
"description": "Report",
"row_id": 1556157,
"text": "FOCUS; NURSING PRGRESS NOTE\n88 YEAR OLD MALE WITH CAD S/P MI, AAA S/P REPAIR, RECENT AICD, EF 10% ADMITTED TO MICU WITH 10 PT HCT DROP S/P ILIAC BLEED.\nREVEIW OF SYSTEMS-\nNEURO- HE IS ALERT AND ORIENTED X3. COOPERATIVE WITH CARE. EXPRESSING DESIRE TO GO HOME. REQUIRING FREQUENT POSITION CHANGES TO FEEL BETTER.\nRESP- ON 3L NC WITH RESP 18-25. SATS 92-98%. BS CLEAR DIMINISHED AT THE BASES.\nCARDIAC- HR 117 TO 88 VPACED WITH FUSION BEATS. SBP 112-125. K 3.0 TODAY TX WITH 40MEQ KCL PO AND 40MEQ IV. CA 6.2 TODAY CORRECTED TO 7.5 WITH ALBUMIN LEVEL TX WITH 3GMS CA GLUCONATE. REPEAT LYTES DUE AT 1600. REVCEIVED 20MG IV LASIX WITH GOAL OF KEEPING PATIENT NEG TODAY. ALSO RESTARTED ALDACTONE. ACE TO BE STARTED TOMMORROW.\nGI- ABD SOFT WITH POS BS. NO STOOL TODAY. LAST STOOL YESTERDY. TOLERATING RENAL CARDIAC DIET WELL. PPI CHANGED FROM IV TO PO. LFT'S INCREASED TODAY. DR AWARE.\nGU- FOLEY PATENT DRAINING YELLOW URINE. DIURESING FROM LASIX.\nENDO- BS UP TO 209 AT TX WITH SS HUMOLOGUE\nHEME- HCT STABLE AT 30.6. INR STABLE AT 2.1. REPEAT LABS DUE AT 1600.\nID- AFEBRILE. WBC DOWN TO 11.9. ALLL CULT NEG TO DATE.\nACCESS- 2 # 18 PERIPHERALS INTACT.\nSKIN- OLD ECCHYMOSIS ON LEFT HIP AREA.\nSOCIAL- DAUGHTER CALLED AND WAS UPDATED BY THIS NURSE.\nDISPO- DNR DNI. ? C/O TO FLOOR.\nPLAN- DIURESE TO KEEP PATIENT NEG.\n START ACE TOMMORROW IF STABLE.\n STABALIZE AND THEN SEND HOME.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-24 00:00:00.000",
"description": "Report",
"row_id": 1556158,
"text": "FOCUS; ADDENDUM\nCARDIAC- PATIENT STILL POS AND DIURESING SLOWING DOWN. DR NOTIFIED AND 20MG IV LASIX ORDERED AND GIVEN.\nPLAN- CHECKED WITH DR . TEAM WANTS TO SEE HOW PATIENT DOES OVERNIGHT. THEN ? C/O TO TEAM IN AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-28 00:00:00.000",
"description": "Report",
"row_id": 1556163,
"text": "NPN 7p-7a\nPt is an 88 y/o with extensive cardiac history. Of note, CAD s/p MI, CHF with an EF 10%, V-paced. Pt has allergies to Benzos and newly HIT +. Pt was on Medicine floor s/p MICU stay, and developed LUE DVT. Pt started on Argatroban gtt. Last night pt became increasingly agitated and confused, medicated with Haldol and Ativan. Today, pt was more somulent and lethargic, c/o SOB feeling \"that he was not breathing\". Pt was also requiring more O2, with sats 83% on usual 3.0L. Pt was transfered to MICU for bipap and monitor MS. Once in MICU, bipap was not intiated pt becoming more alert with less O2. MICU team believes pt CO2 retainer and was most likely over , follwed by too much O2. Head CT was negative for any bleeding. Pt does have significant apnea 20-30secs with sats dropping to mids 80s.\n\nNEURO: Pt is lethargic, alert to voice. Pt is calling out for family at times, says he needs to say goodbye. Pt MAE weakly. Pt is oriented to person and place. No c/o pain.\n\nCV: Vpaced, HR 70s-80s with occas PVCs. BP 90s-100s/60s-70s. Weak palpable pulses bilaterally. Pt on Argatroban @ 0.50mcg/hr, PTT 46.8. Next due @ 2100.\n\nRESP: Sats mostly >94% on 2.0L NC, pt does desat as stated above. LS with crackles @ bases. RR 15-30s.\n\nGI/GU: ABD is soft, +BS. Pt NPO now until more alert. Pt is taking ice chips fine. U/O has been ample 120-300cc/hr clear yellow urine.\n\nSKIN: Pt has large old echymosis over left hip from previous admission. Also small area on Right hip. Pt does have echymosis over arms, as well.\n\nSocial: Pt has children who were with him on pt's transfer. They were updated by this RN and Dr. . They will be back this evening.\n\nPLAN: Continue to monitor MS, resp status ? check another ABG tonight for possible bipap. Diurese as needed, pt on standing Lasix, although CXR does show edema.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-29 00:00:00.000",
"description": "Report",
"row_id": 1556164,
"text": "npn\nneuro: aox3, pt has been sleeping off and on thru out shift. pt needs to be told that he has been sleeping, this seems to relieve his anxiety and he falls back to sleep.\n\npain: denies\n\ncad hr 70's v-paced with occass. pvc's. nbp 98/70 to 129/89 range. pt remains on argatroban gtt at .5mcg , held for one hour at 515am for ptt of 92.6, to be restarted at 615 am at .25mcg\n\nresp: ls clear with dim. bases, ls shallow, non-productive cough, rr teens with sats high 80 to 100% on 3l nc, pt received neb tx as ordered\n\ngi: abd firm, bs+, pt has had one large bm at 3am. taking sips of water and apple juice.\n\ngu uo >60cc/hr up to 320 with lasix, foley patent and draining yellow . 1 lter negatve at\n\nskin: bruising over left falnk.\n\nsocial: family into visit lasnight.\n\nplan: monitor ptt with argatroban gtt, cont to monitor vs, resp status.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-13 00:00:00.000",
"description": "Report",
"row_id": 1556123,
"text": "resp care - Pt received from ED on full vent support. FiO2 decreased during shift per ABGs. Last ABG shows normal values with hyperoxemia. Slight rhonchi in the upper lobes cleared on suction of scant amounts of frothy white secretions. ETT was advanced 4cm per xray. Continued resp support planned.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-25 00:00:00.000",
"description": "Report",
"row_id": 1556159,
"text": "NPN 7p-7a\nPlease see carevue for additional data.\nAllergy: Benzo's- confusion.\nDNR/DNI\n\nNeuro: AOx3. MAE. Anxious, unable to sleep despite prn Ativan (0.5mg) ,Haldol (1mg), Morphine (1mg x2), and Ambien (5mg). Little effect until recieved Ambien, seemed to sleep after this, occ. awaking for repositioning.\n\nResp: 3L NC. LS Clear to auscultation after recieving 20mg iv Lasix. Sats 95-100%.\n\nCV: 88-105 Vpaced, occ. pvc's. Sbp 109-144. Recieved 20mg iv Lasix, fluid goal negative, presently negative ~380. Lower extrem. edema noted. EF 10%. s/p iliac bleed. HCT 30. lytes pnding. Plan to restart ACT in am.\n\nGI/GU: abd soft, +BS. no stool overnight. Well tolerated renal/cv diet. Continuing diuresis as above for goal of negative fluid balance.\n\nEndo: SS Humalog.\nSkin: Eccymotic area to left hip, does not appear to be increasing. Left arm s/p infiltrate, keeping elevated.\nID: afeb. wbc pnding.\n\nA/P: S/P illiac bleed, hct stable. HCT QD. Likely call out to floor, team CV med.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-12-25 00:00:00.000",
"description": "Report",
"row_id": 1556160,
"text": "88 y.o. male with hx. of AAA repair, MI/CAD, s/p CABG, DVT, GERD, HTN, pacemaker, s/p septic shock, extubated . S/p iliac bleed, Hct and coags stable.\nNeuro: A&O x3, cooperative, follows commands, denies pain. MAE. OOB to chair x2 with 2 people assist.\nResp: On 3L NC sats 96-99%. Episodes of SOB at rest and on exertion. LS bibasilar crackles. Got Lasix total of 40mg IVP with ~ 750cc diuresis. Goal to take 1L off today. Given nebs tx. prn with minimal response.\nCV: HR 80s-100s, V-paced with frequent PVCs. BP 110s-120s/70s-80s. Bilat LE 3 + edema. Lt. arm elevated on pillow swelling due to infiltrated IV. Started on Metoprolol today.\nGI/GU: Tolerating renal diet. Abd. soft, nontender, +BS, no BM today.\nFoley patent with dark yellow urine out.\nEndo: BS checked q4 hrs ranging from 110-220. Covered per sliding scale.\nSocial: Both sons visited, spoke to case management, updated on status and plan of care. Rehab screening initiated.\nPt. is called out to cardiac floor, no bed available yet.\n"
},
{
"category": "Echo",
"chartdate": "2120-12-13 00:00:00.000",
"description": "Report",
"row_id": 82428,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Wall motion. Shock.\nHeight: (in) 66\nWeight (lb): 150\nBSA (m2): 1.77 m2\nBP (mm Hg): 118/86\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 09:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Severe\nglobal LV hypokinesis. No LV mass/thrombus. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild to moderate\n(+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\nMild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. The right atrium is moderately dilated. No\natrial septal defect is seen by 2D or color Doppler. Left ventricular wall\nthicknesses are normal. The left ventricular cavity is moderately dilated.\nThere is severe global left ventricular hypokinesis. No masses or thrombi are\nseen in the left ventricle. There is no ventricular septal defect. The right\nventricular cavity is mildly dilated. There is mild global right ventricular\nfree wall hypokinesis. The ascending aorta is mildly dilated. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Mild to\nmoderate (+) mitral regurgitation is seen. The tricuspid valve leaflets are\nmildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2120-12-14 00:00:00.000",
"description": "Report",
"row_id": 208773,
"text": "Demand pacing\nSince previous tracing, ventricular paced beats with occasional native\nventricular premature complexes, sinus beats\n\n"
},
{
"category": "ECG",
"chartdate": "2120-12-13 00:00:00.000",
"description": "Report",
"row_id": 208774,
"text": "Ventricular paced rhythm at a rate of 120. QRS morphology raises the\npossibility of biventricular pacing. There are probably P waves in the\nST segment raising the possibility of pacemaker mediated tachycardia. Clinical\ncorrelation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2120-12-22 00:00:00.000",
"description": "Report",
"row_id": 208770,
"text": "Ventricular paced rhythm. Compared to the previous tracing of the\ngroup beating with tachycardia absent.\n\n"
},
{
"category": "ECG",
"chartdate": "2120-12-16 00:00:00.000",
"description": "Report",
"row_id": 208771,
"text": "Ventricular paced rhythm with pattern of group beating with tachycardia.\nQuestion upper rate limit. Atrial mechanism is uncertain. Since the previous\ntracing of ventricular pacing pattern as described is now present.\n\n"
},
{
"category": "ECG",
"chartdate": "2120-12-13 00:00:00.000",
"description": "Report",
"row_id": 208772,
"text": "Ventricular pacing\nPacemaker rhythm - no further analysis\nSince previous tracing, rate slower\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-22 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 940367,
"text": " 9:19 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: H/O AAA.ON HEPARIN.HCT DROP.?RP BLEED\n Admitting Diagnosis: CARDIOGENIC SHOCK\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with h/o AAA, on heparin, guaiac positive stools, 10 pt hct\n drop\n REASON FOR THIS EXAMINATION:\n please eval for RP bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old male with history of AAA on heparin, guaiac positive\n stool. Drop of hematocrit.\n\n TECHNIQUE: Contiguous axial CT images of the abdomen and pelvis were obtained\n without the administration of intravenous contrast . Multiplanar\n reformation images were reconstructed.\n\n COMPARISON: Abdominal CT dated .\n\n FINDINGS: The evaluation of abdominal aorta, major vessels and major organs\n are limited due to lack of intravenous contrast .\n\n There is a new enlargement of the left iliac muscle with heterogeneous high-\n density with several fluid-fluid levels, most likely representing hematoma\n within the muscle, measuring 8.2 x 4.5 cm, new since prior study. On the\n right side, there is 2-cm focal hyperdensity in the right iliacus muscle,\n which also can represent small amount of hemorrhage.\n\n Again note is made of large abdominal aortic aneurysm with crescent-shaped\n hypodensity, measuring 6.3 x 5.1 cm at the level of kidneys, overall unchanged\n since prior study, however, the evaluation of the aorta is limited on this\n non-contrast study. There is small amount of ascites anterior to the liver\n and posterior to the spleen, unchanged since prior study.\n Diffusely Hyperdense liver is again noted, probably due to amiodarone\n accumulation. Spleen, pancreas, adrenal glands and kidneys, the visualized\n portion of large and small intestines are overall unchanged since prior study.\n There is increased attenuation of the intraperitoneal fat diffusely as noted\n previously, as well as fluid and edema in the subcutaneous tissue due to third\n spacing. There is no free air.\n\n PELVIS: The visualized portion of large and small intestines are within\n normal limits. Edematous appearance of peritoneal fat is noted.\n\n Again note is made of marked cardiomegaly with bilateral pleural effusion with\n bibasilar atelectasis and interstitial edema at the lung bases.\n\n There is degenerative changes of the lower lumbar spine. No suspicious lytic\n or blastic lesion is noted.\n\n (Over)\n\n 9:19 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: H/O AAA.ON HEPARIN.HCT DROP.?RP BLEED\n Admitting Diagnosis: CARDIOGENIC SHOCK\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Again note is made of bilateral iliac grafts.\n\n IMPRESSION:\n 1. Enlarged left iliac muscle with hyperdensity with fluid-fluid levels,\n measuring 8 x 4 cm, representing hematoma due to acute hemorrhage, new since\n prior study three days ago. Small area of hyperdensity in the right iliacus\n muscle, which can also represent a small amount of hematoma.\n 2. Limited study for the aorta, major abdominal organs and vessels due to\n lack of intravenous contrast . Large abdominal aortic aneurysm, overall\n unchanged since prior study.\n 3. Amiodarone accumulation of the liver with small amount of ascites.\n 4. Cardiomegaly with bilateral pleural effusion.\n 5. Persistent marked third spacing and edema.\n\n Dr. was informed by telephone at 10:30 p.m. on the day of the study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-19 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 940021,
"text": " 6:21 PM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CTA PELVIS W&W/O C & RECONS\n Reason: r/o bleed, other source of abdominal pain (disection, mesent\n Admitting Diagnosis: CARDIOGENIC SHOCK\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with severe abdominal pain out of proportion to exam, with h/o\n AAA s/p graft, recently on heparin bridge to coumadin for a.fib,\n REASON FOR THIS EXAMINATION:\n r/o bleed, other source of abdominal pain (disection, mesenteric ischemia)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old man with severe abdominal pain, out of proportion to\n exam. History of AAA, status post graft.\n\n TECHNIQUE: Contiguous axial CT images of the chest and abdomen are obtained\n with and without the administration of intravenous contrast , 90 cc of\n Optiray. Multiplanar reformation images are reconstructed.\n\n COMPARISON: Comparison was made with the prior CT study dated .\n\n FINDINGS:\n\n CHEST: Extreme lung bases are not included in the present study. Again note\n is made of markedly tortuous and dilated aorta with calcification, measuring\n 3.6 cm at the arch. There is coronary artery calcification and cardiomegaly,\n in this patient status post CABG and pacemaker placement. There is bilateral\n pleural effusion with bibasilar atelectasis. Again, note is made of markedly\n enlarged pulmonary artery measuring 4.4 cm, probably due to pulmonary arterial\n hypertension. Note is made of motion artifact throughout the scan of the\n lung, which limits the evaluation of the details of the lung parenchyma. In\n the lung window, note is made of increased interstitial markings in bilateral\n upper lobes, most likely due to atypical pattern of pulmonary edema, however,\n other interstitial process cannot be totally excluded. There is no central\n endobronchial lesion.\n\n ABDOMEN: There is a large abdominal aneurysm with mural thrombus, extending\n from the level of SMA bifurcation down to the level of iliac bifurcation,\n measuring 5.2 x 4.9 cm at the level of right renal artery, overall unchanged\n compared to the prior study. There is crescent-shaped high density within the\n mural clot, as noted previously. There is aortic graft inferiorly. The\n superior mesenteric artery and its branches are patent, and there is no\n evidence of SMA thrombosis. was not identified and is probably occluded\n in this patient status post graft. Note is made of small amount of free fluid\n in the abdomen, with fat stranding, especially surrounding the kidney,\n slightly decreased since prior study. There is no evidence of bowel\n dilatation. There is no secondary sign of bowel wall ischemia.\n\n Again, note is made of diffusely hyperdense liver, most likely due to\n amiodarone. The patient is status post cholecystectomy. Spleen, pancreas,\n (Over)\n\n 6:21 PM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CTA PELVIS W&W/O C & RECONS\n Reason: r/o bleed, other source of abdominal pain (disection, mesent\n Admitting Diagnosis: CARDIOGENIC SHOCK\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n adrenal glands, and kidneys are within normal limits. There is no significant\n lymphadenopathy. Diffuse anasarca is again noted.\n\n PELVIS: Small amount of free fluid is noted, decreased since prior study. The\n visualized portion of large and small intestines are within normal limits.\n\n There is no suspicious lytic or blastic lesion in skeletal structures.\n\n\n IMPRESSION:\n\n 1. Large abdominal aortic aneurysm with mural thrombus and crescent-shaped\n high density within the thrombus, overall unchanged compared to the prior\n study.\n\n 2. Patent SMA without evidence of thrombosis. No evidence of bowel\n dilatation or secondary sign of ischemia in the bowel.\n\n 3. Decreased free fluid in the abdomen and pelvis, with diffuse anasarca.\n\n 4. Enlarged pulmonary artery and dilated aorta.\n\n 5. Bilateral pleural effusion with atelectasis. Increased interstitial\n markings in bilateral upper lobes, probably due to atypical edema, however,\n other interstitial process cannot be totally excluded.\n\n The information was discussed with Dr. by telephone in the evening of\n .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 939429,
"text": " 4:21 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: assess RIJ placement.\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with sepsis and cardiomyopathy, with RIJ central line\n placement, need assessment.\n REASON FOR THIS EXAMINATION:\n assess RIJ placement.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Right IJ line placement.\n\n FINDINGS: There is a new right IJ line with tip in the SVC near the right\n atrium junction. The pacemaker is unchanged. There is no pneumothorax.\n There is increased retrocardiac opacity compared to the film from earlier the\n same day consistent with increased volume loss/consolidation. There is also a\n new patchy area of infiltrate/volume loss in the right lower lobe.\n Endotracheal tube and NG tube are unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-13 00:00:00.000",
"description": "CT PELVIS W&W/O C",
"row_id": 939144,
"text": " 2:33 AM\n CTA CHEST W&W/O C &RECONS; CT ABD W&W/O C Clip # \n CT PELVIS W&W/O C\n Reason: CHEST/ABD PAIN, H/O AORTIC ANEURYSM REPAIR.\n Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with chest pain/abd pain, h/o aortic aneurysm repair,\n subsequently became hypotensive/hypoxic & intubated on pressors\n REASON FOR THIS EXAMINATION:\n eval for aortic aneurysm/dissection or PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MJGe FRI 9:26 AM\n 1. no dissection or PE. contrast bolus took 2 minutes to get to descending\n aorta probably due to pt's heart failure\n 2. 6.5 cm infrarenal abd aortic aneurysm with evidence of graft repair\n distally. no evidence of AAA rupture or leak.\n 3. pulmonary vascular congestion, intraabdominal ascites, periportal edema,\n and anasarca suggest CHF vs volume overload vs both.\n 4. bibasilar atelectasis\n 5. cardiomegaly.\n WET READ VERSION #1 MJGe FRI 3:32 AM\n 1. no dissection or PE. contrast bolus took 2 minutes to get to\n descending aorta probably due to pt's heart failure\n 2. 6.5 cm infrarenal abd aortic aneurysm with evidence of graft repair\n distally. no evidence of AAA rupture or leak.\n 3. pulmonary vascular congestion, intraabdominal ascites, periportal edema,\n and anasarca suggest CHF vs volume overload vs both.\n 4. bibasilar atelectasis\n 5. cardiomegaly.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest pain, abdominal pain, history of aortic aneurysm repair\n with hypotension and hypoxia.\n\n TECHNIQUE: Multidetector CT images were obtained through the chest without\n contrast followed by CT angiogram through the chest and abdomen. Coronal and\n sagittal reformatted images were obtained.\n\n CT ANGIOGRAM OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: There is no\n evidence of aortic dissection or pulmonary embolus. Extensive atherosclerotic\n calcifications are seen within the left anterior descending, left circumflex,\n and right coronary arteries as well as throughout the aorta. There is no\n pulmonary embolus. The airways are patent to the segmental level bilaterally.\n There is smooth intralobular septal thickening, primarily at the lung apices,\n consistent with pulmonary venous congestion. There is minimal small airways\n disease in the right upper lung lobe. There is bibasilar subsegmental\n atelectasis with small bilateral pleural effusions, right greater than left.\n The patient is status post median sternotomy and CABG and multiple clips are\n seen about the heart. There is no pathologically enlarged axillary, hilar, or\n mediastinal lymphadenopathy.\n\n (Over)\n\n 2:33 AM\n CTA CHEST W&W/O C &RECONS; CT ABD W&W/O C Clip # \n CT PELVIS W&W/O C\n Reason: CHEST/ABD PAIN, H/O AORTIC ANEURYSM REPAIR.\n Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT ANGIOGRAM OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: There is\n no evidence of aortic dissection. There is a 6.5-cm infrarenal abdominal\n aortic aneurysm with evidence of a graft repair distally. There is no\n evidence of abdominal aortic aneurysm rupture or leak. Again, there are\n diffuse atherosclerotic calcifications within the aorta. The liver is normal\n in contour. No focal liver lesions are identified. There is periportal\n edema. The patient is status post cholecystectomy. The pancreas is somewhat\n fatty replaced. There is no pancreatic ductal dilatation. The spleen and\n adrenal glands are normal. The kidneys show bilateral thin cortices. However,\n they enhance symmetrically. The left kidney contains a 1-cm rounded low-\n density focus in the lower pole and the right kidney contains a 2.8-cm rounded\n focus in the upper pole, both of which likely represent simple renal cysts.\n There is no evidence of hydronephrosis or hydroureter. The stomach and intra-\n abdominal loops of small and large bowel are normal in appearance and caliber.\n There is no bowel dilatation or bowel wall thickening. There is a moderate-\n to-large amount of intra-abdominal ascites throughout the mesentery and within\n the bilateral pericolic gutters and perihepatic region. There is no free air.\n There is no pathologically enlarged mesenteric or retroperitoneal\n lymphadenopathy. The surrounding soft tissues show anasarca.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n Degenerative changes are seen within the visualized thoracolumbar spine.\n\n CT REFORMATS: Coronal and sagittal reformatted images confirm the axial\n findings.\n\n IMPRESSION:\n 1. No evidence for aortic dissection or pulmonary embolus.\n 2. 6.5-cm infrarenal abdominal aortic aneurysm with evidence of graft repair\n distally. No evidence of aneurysm rupture or leak.\n 3. Pulmonary vascular congestion, intra-abdominal ascites, periportal edema,\n and anasarca suggest congestive heart failure versus volume overload or both.\n 4. Cardiomegaly.\n 5. Bibasilar subsegmental atelectasis with small bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 940058,
"text": " 3:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: hypoxic, r/o infiltrate\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with sepsis and cardiomyopathy,worsening oxygenation,\n wheezing,\n REASON FOR THIS EXAMINATION:\n hypoxic, r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypoxia.\n\n Portable AP chest radiograph compared to .\n\n The heart size is enlarged but stable in a patient with previous CABG. The\n pacemaker leads are in unchanged position. The right internal jugular line\n tip terminates in distal SVC.\n\n There is worsening of perihilar consolidations extending into the upper lungs\n most likely representing pulmonary edema. In addition, there is worsening of\n left lower lobe retrocardiac atelectasis and unchanged amount of small left\n pleural effusion.\n\n IMPRESSION: New pulmonary edema, at least moderate.\n\n Left lower lobe retrocardiac atelectasis, unchanged.\n\n Small unchanged left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 939143,
"text": " 2:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: S/P INTUBATION\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Status post hypotension and intubation.\n\n Portable AP chest dated has no prior films for comparison. The\n endotracheal tube terminates in appropriate position 5.7 cm above the carina.\n The nasogastric tube courses below the diaphragm and off the area imaged. A\n left pacemaker is seen with leads terminating in the right atrium and right\n ventricle. The patient is status post median sternotomy and CABG. The heart\n is enlarged. There is no evidence of mediastinal widening. There are\n perihilar infiltrates bilaterally. Additionally, there is retrocardiac\n opacity. There is no large pleural effusion, although the right\n costodiaphragmatic angle is excluded from the film. The surrounding osseous\n and soft tissue structures are unremarkable.\n\n IMPRESSION:\n 1. Lines and tubes as described above.\n 2. Cardiomegaly with perihilar infiltrates most consistent with pulmonary\n vascular congestion.\n 3. Retrocardiac opacity most likely represents atelectasis or consolidation.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-20 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 940151,
"text": " 5:45 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o obstruction\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with abdominal pain.\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain.\n\n Portable abdomen dated is compared to the prior from .\n Surgical clips are seen within the pelvis and right upper quadrant. Gas is\n seen throughout the visualized bowel extending into the rectum. There is no\n evidence of bowel dilatation, air-fluid level, or free air on this single\n portable supine view. Degenerative changes are seen within the visualized\n lumbosacral spine. Vascular calcifications are seen within the abdomen and\n pelvis. The surrounding osseous structures otherwise are unremarkable.\n\n IMPRESSION: Unremarkable bowel gas pattern without evidence for obstruction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 940799,
"text": " 4:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for pulmonary edema\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CHF and CAD currently dyspneic, RR to 30's\n REASON FOR THIS EXAMINATION:\n Please eval for pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 88-year-old man with congestive heart failure and coronary\n artery disease with dyspnea and tachypnea. Question pulmonary edema.\n\n CHEST, SINGLE SEMI-UPRIGHT PORTABLE VIEW: Comparison is made to . There is a pacemaker device in a similar position. The patient is\n status post coronary artery bypass graft surgery. The heart is enlarged. The\n aortic contour is unchanged.\n\n There is persistent left lower lobe opacity obscuring the left hemidiaphragm,\n although less confluent than before, with a small left effusion. There is\n persistent pulmonary edema, but less severe.\n\n There is a more prominent focal opacity overlying the left heart border, which\n is more confluent and extensive.\n\n IMPRESSION:\n 1. Persistent pulmonary edema.\n 2. More confluent focal opacity along the left heart border, which may\n represent a pneumonic consolidation. Follow up radiographs are suggested to\n ensure resolution.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-26 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 940950,
"text": " 3:26 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Please evaluate for biliary process, liver lesion\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CHF and increasing LFTs\n REASON FOR THIS EXAMINATION:\n Please evaluate for biliary process, liver lesion\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Liver ultrasound.\n\n INDICATION: Increasing LFTs.\n\n FINDINGS: The liver is of normal echogenicity. No focal liver lesions\n identified. There is some fullness of the hepatic veins extending into the\n IVC consistent with patient's known congestive heart failure. Note is also\n made of a right pleural effusion. There is normal flow within the portal\n veins. The patient is status post cholecystectomy. The CBD is not dilated at\n 0.5 cm. No evidence of any intrahepatic bile duct dilatation.\n\n IMPRESSION: Limited hepatic ultrasound reveals some hepatic venous congestion\n with no focal lesion or intrahepatic bile duct dilatation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-19 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 940042,
"text": " 9:08 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o SBO\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with abdominal pain. evaluate loop size\n REASON FOR THIS EXAMINATION:\n r/o SBO\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMINAL RADIOGRAPH\n\n INDICATION: 88-year-old male with abdominal pain. Please evaluate for bowel\n loops size and evaluate for small-bowel obstruction.\n\n COMPARISON: CT study from .\n\n FINDINGS: There is no evidence of free air. No dilated loops of bowel are\n present. A moderate amount of air is seen within the colon. Surgical clips\n are seen in the right upper quadrant, consistent with prior cholecystectomy.\n Epicardial pacing wire is seen in the upper left abdomen. Surgical clips are\n also seen in the left lower abdomen. Osseous structures are unremarkable.\n Residual contrast is present within the bladder, consistent with recent CT\n scan.\n\n IMPRESSION:\n\n 1. Unremarkable bowel gas pattern. No evidence of obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 940325,
"text": " 12:16 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: r/o CHF\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CHF and CAD, with continued O2 requirement now w/\n acute desat.\n REASON FOR THIS EXAMINATION:\n r/o CHF\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW ON \n\n HISTORY: CHF and CAD, continued O2 requirement with acute desaturation.\n\n FINDINGS: Again seen is an enlarged heart with pacemaker. There is\n ill-defined hazy vasculature and perihilar haze consistent with CHF. There is\n a new right lower lobe infiltrate. There is increased retrocardiac\n consolidation. There continues to be a left pleural effusion.\n\n IMPRESSION: CHF with new right lower lobe infiltrate.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 940027,
"text": " 6:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with sepsis and cardiomyopathy,with tachypnea, abdominal\n pain.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old man with sepsis and cardiomyopathy and tachypnea and\n abdominal pain. Rule out infiltrate.\n\n COMPARISON: CT torso one hour prior.\n\n There is a triple lead AICD device in standard positioning. Surgical clips\n are overlying the cardiac silhouette and median sternotomy wires are present\n consistent with prior cardiothoracic surgery. There is a right internal\n jugular catheter with tip at the distal SVC. The heart size is at the upper\n limits of normal. Mediastinal and hilar contours are otherwise unremarkable.\n There is a small left greater than right pleural effusion. There is some\n fissural thickening within the left lower lung. There are diffuse areas of\n interstitial opacities bilaterally confirmed on CT from one hour prior.\n\n IMPRESSION:\n Diffuse patchy interstitial opacities bilaterally, which could represent early\n onset of multifocal or atypical pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 940304,
"text": " 9:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval edema/effusions\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CHF and CAD, with continued O2 requirement\n REASON FOR THIS EXAMINATION:\n please eval edema/effusions\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW ON \n\n HISTORY: CHF and CAD.\n\n REFERENCE EXAM: .\n\n FINDINGS: There is no significant change in moderate cardiomegaly, pacemaker,\n sternotomy wires and surgical clips, right IJ line has been removed. There\n has been interval decrease in the perihilar and right upper lobe infiltrates.\n There continues to be dense retrocardiac opacity that could be due to volume\n loss or infiltrate. There continues to be a small left effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-26 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 940951,
"text": " 3:27 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: Please evaluate for clot\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CHF and swolle LUE\n REASON FOR THIS EXAMINATION:\n Please evaluate for clot\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Ultrasound of left upper limb.\n\n INDICATION: Swollen left upper extremity.\n\n FINDINGS: Some echogenic material is seen in the left internal jugular vein\n consistent with some old thrombus. It does compress normally, however, no\n definite thrombus is seen within the left subclavian vein. No thrombus within\n the left axillary vein. The left brachial vein and left basilic are normal to\n compression and augmentation. In the left cephalic vein, there is echogenic\n material within the central lumen which does not compress. This appearance is\n consistent with thrombus which extends throughout the length of the left\n cephalic vein.\n\n IMPRESSION: Thrombus extending throughout the length of the left cephalic\n vein with some older appearing nonocclusive thrombus within the left jugular\n vein. This case should be monitored for extension of the thrombus in one to\n two days.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 939162,
"text": " 7:04 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: pls check placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with shock, ng tube\n REASON FOR THIS EXAMINATION:\n pls check placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CHEST X-RAY PORTABLE AP.\n\n INDICATION: NG tube placement position.\n\n COMPARISONS: Comparison is made to the earlier film from 0214 hours.\n\n The endotracheal tube is approximately 7 cm superior to the carina. The\n proximal NG sideport is 5cm above the diaphragm; to move all the sideports\n into the stomach, the tube would need to be advanced approximately 10cm.\n Moderate cardiomegaly is slightly less prominent. The pulmonary vasculature is\n less engorged and there is some interval resolution of the pulmonary edema.\n The right costophrenic angle is slightly cutoff by this film, however, there\n is no evidence of pleural effusion, right or left. There is a left- sided\n pacemaker with leads terminating within the right ventricle and right atrium,\n and median sternotomy wires are present, both unchanged.\n\n IMPRESSION:\n 1. NG tube should be advanced 10 cm to move all the sideports into the\n stomach.\n 2. Endotracheal tube 2-3 cm above optimal position.\n 3. Some interval resolution of vascular congestion and intersitial edema\n compared to the film five hours prior.\n 4. Persistent moderate cardiomegaly.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-13 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 939249,
"text": " 4:46 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: pls evaluate posititon of ETT and NGT\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with shock, ETT and NGT advanced.\n REASON FOR THIS EXAMINATION:\n pls evaluate posititon of ETT and NGT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old man with shock, ETT and NG tube advance. Check\n positioning of endotracheal tube and nasogastric tube.\n\n COMPARISON: Ten hours prior.\n\n SINGLE SUPINE PORTABLE CHEST RADIOGRAPH:\n\n The endotracheal tube tip is at the level of the inferior aspect of the\n clavicles, approximately 5 cm from the carina in standard positioning. The\n nasogastric tube tip has been advanced with side port below the GE junction.\n Multiple surgical clips are seen overlying the cardiac silhouette and\n sternotomy wires are also again noted. A biventricular pacer AICD device is\n in stable positioning. Limited views of the lung fields are grossly unchanged\n with exclusion of the left lateral lung.\n\n IMPRESSION:\n\n Standard placement of endotracheal tube and nasogastric tube. Otherwise,\n unchanged exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 939171,
"text": " 8:11 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute bleed\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88M h/o CAD, AICD, CHF, on anticoagulation for DVT, here w/ shock of unclear\n etiology, poor brainstem reflexes.\n REASON FOR THIS EXAMINATION:\n eval for acute bleed\n CONTRAINDICATIONS for IV CONTRAST:\n Cr 2.5\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for acute bleed. 88-year-old on anticoagulation for DVT\n here with unclear etiology of shock. Poor brainstem reflexes. Evaluate for\n acute bleed.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no intracranial hemorrhage. There is no midline shift,\n mass effect or hydrocephalus. The -white matter differentiation is\n preserved. There are sulcal and ventricular prominence due to mild\n generalized brain atrophy. There are periventricular and subcortical white\n matter hypodensities consistent with chronic microvascular ischemic change.\n There are atherosclerotic calcifications.\n\n There are small air-fluid levels noted in both maxillary and sphenoid sinuses\n due to the patient being intubated.\n\n IMPRESSION: No intracranial hemorrhage. No mass effect.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-27 00:00:00.000",
"description": "B UNILAT UP EXT VEINS US BILAT",
"row_id": 941074,
"text": " 1:45 PM\n UNILAT UP EXT VEINS US BILAT Clip # \n Reason: foloow-up: progress and/or new clots?\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CHF and swollen LUE and DVTs on US\n\n REASON FOR THIS EXAMINATION:\n foloow-up: progress and/or new clots?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Swollen left upper extremity and deep vein thrombosis on\n ultrasound. Please follow for progression of previously identified\n superficial vein thrombosis.\n\n UNILATERAL UPPER EXTREMITY VEINS, LEFT: Comparison is made to the examination\n from yesterday. Again seen is peripheral echogenic material within the left\n internal jugular vein. There is wall-to-wall color flow within this vessel\n and the internal jugular vein compresses. There is normal color Doppler flow\n with normal respiratory variation within the internal jugular vein.\n Similarly, the left subclavian demonstrates normal patency, wall-to-wall color\n flow with Doppler waveform, with normal respiratory variation and\n augmentation.\n\n IMPRESSION:\n 1. Likely old thrombus within the left internal jugular vein because it is\n peripheral in location and normal color blood flow is seen through this\n vessel.\n 2. No evidence of deep vein thrombosis in the left subclavian vein.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 939257,
"text": " 6:12 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please assess for ETT placement\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with shock, ETT and NGT advanced.\n\n REASON FOR THIS EXAMINATION:\n please assess for ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old male with endotracheal tube and NG tube advanced.\n Assess for endotracheal tube placement.\n\n COMPARISON: One hour prior.\n\n Lines and tubes are in similar position with endotracheal tube tip now 1 cm\n below the level of the clavicles, likely due to positioning. The endotracheal\n tube tip is similarly approximately 6 cm from the carina. The\n cardiomediastinal silhouette and lung fields are stable.\n\n IMPRESSION:\n\n Endotracheal tube tip 6 cm from the carina just below the inferior aspect of\n the clavicles in good positioning.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 939381,
"text": " 7:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change, line placement\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with shock, ETT and NGT advanced.\n\n REASON FOR THIS EXAMINATION:\n assess for interval change, line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW ON .\n\n HISTORY: Shock, ET tube and NG tube advanced.\n\n FINDINGS: The ET tube is 5.3 cm above the carina. The NG tube is in the\n proximal stomach with proximal port at the GE junction. Left-sided pacemaker\n is unchanged. There are patchy areas of volume loss versus an early\n infiltrate in the right lower lobe.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 941148,
"text": " 10:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for etiol of SOB\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CHF and CAD currently dyspneic, RR to 30's\n\n REASON FOR THIS EXAMINATION:\n Eval for etiol of SOB\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CHF. Shortness of breath.\n\n Single portable radiograph of the chest again demonstrates the patient to be\n status post CABG. Increased bibasilar airspace pulmonary opacities and small\n bilateral pleural effusions are slightly worse when compared to .\n Dual-lead left thoracic cardiac pacer is unchanged. Trachea is midline. No\n pneumothorax.\n\n IMPRESSION:\n\n Worsening CHF. Superimposed pneumonia is not excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 941185,
"text": " 4:19 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for acute bleed/stroke\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with acute MS change on IV Argatroban\n REASON FOR THIS EXAMINATION:\n Eval for acute bleed/stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 88-year-old male with acute mental status changes on IV\n agatroban. Evaluate for bleed/stroke.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: No hemorrhage, mass, hydrocephalus, shift of normally midline\n structures. -white matter differentiation is preserved. No major\n vascular territorial infarct is apparent. There are regions of\n hypoattenuation within the periventricular white matter, which reflect chronic\n microvascular ischemic disease. The ventricles and sulci are prominent,\n reflecting age associated involutional changes. Vascular calcifications are\n seen within the cavernous carotid. The visualized paranasal sinuses remain\n normally aerated. There is increased partial opacification of the left\n mastoid air cells compared to prior exam dated .\n\n IMPRESSION:\n 1. No hemorrhage.\n 2. Partial opacification of the left mastoid air cell, which was not seen on\n previous CT head dated .\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 939762,
"text": " 8:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for CHF\n Admitting Diagnosis: CARDIOGENIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with sepsis and cardiomyopathy, with RIJ central line\n placement, need assessment.\n REASON FOR THIS EXAMINATION:\n assess for CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis and cardiomyopathy.\n\n COMPARISON: .\n\n AP UPRIGHT CHEST: The patient has been extubated and the nasogastric tube has\n been removed. There is a left-sided AICD with leads projecting in unchanged\n positions over the right atrium and ventricle. The patient is status post\n median sternotomy and CABG. Moderate enlargement of the cardiac silhouette is\n unchanged allowing for low lung volumes. There is slight improvement in\n asymmetric pulmonary interstitial edema, right greater than left. Retrocardiac\n opacification is unchanged. Moderate left and small right pleural effusions\n are stable.\n\n IMPRESSION:\n 1) Interval improvement in mild pulmonary interstitial edema.\n 2) Left basal atelectasis, less likely pneumonia.\n\n"
}
] |
4,787 | 135,926 | 82 yom with history of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presented to the hospital with one day of nausea, vomiting and weakness. . # Viral Gastroenteritis: Mr. presented with symptoms of nausea, vomiting, weakness and diarrhea which are all consistent with a viral gastroenteritis. Symptoms resolved within 1 day. Concern initially was for sepsis as he presented with SBP in the 80s and leukocytosis to 22. He was initially treated with Vanco/Zosyn which was then changed to Linezolid/Meropenem based on previous culture data. The patient remained afebrile and blood pressures remained stable. Blood cultures show no growth to date. Stool cultures sent and also show no growth to date. C.diff was negative. Urine culture showed yeast and foley was . ID was consulted given significant history of bactermias and resistant organisms. Linezolid and Meropenem were continued for two days and then as no source of bacterial infection was found. Patient has now remained afebrile off of antibiotics and is ready to be discharged home. Of note, patient had Guaiac positive stools while in the hospital and HCT remained stable. Patient will need to follow up with Gastroenterology as an outpatient for further workup. . # ESRD on HD: Patient was continued on his T/Th/Sat dialysis. . # COPD: cont home spiriva, atrovent. . # Atrial Fibrillation: Patient with history of atrial fibrillation on on anticoagulation. He was admitted with atrial fibrillation which was thought secondary to infection. Cardiac enzymes were done and were negative. . # Depression: patient was continued on her home Fluoxetine . | # Prophylaxis: Subcutaneous heparin . # Prophylaxis: Subcutaneous heparin . -- d/c Linezolid -- cont for now -- follow up cultures -- trend fever WBC curve -- f/u ID recs # ESRD on HD: Patient on T/Th/Sat dialysis. -- cont Linezolid/Meropenem -- follow up cultures -- trend fever WBC curve -- ID consult . Patient was ROMI. Action: Cont on linezolid and meropenem. -- cont Vanco/Zosyn -- D/C CTX -- send UA/UCx -- repeat lactate -- repeat CBC, Chem 7 -- 1L IVF bolus -- trend fever WBC curve . He was given Vancomycin 1gm IV x 1, CTX 1gm IV x 2 and Zosyn 4.5gm IV x 1. He was given Vancomycin 1gm IV x 1, CTX 1gm IV x 2 and Zosyn 4.5gm IV x 1. He was given Vancomycin 1gm IV x 1, CTX 1gm IV x 2 and Zosyn 4.5gm IV x 1. Action: Cont on linezolid and meropenum. Action: Cont on linezolid and meropenum. Linezolid was added yesterdy to cover his previous MRSA and VRE. # COPD: cont home spiriva, atrovent. # COPD: cont home spiriva, atrovent. # COPD: cont home spiriva, atrovent. # COPD: cont home spiriva, atrovent. TSH normal -- cont home ASA # Depression: cont home Fluoxetine # FEN: Renal Diet, replete lytes # Prophylaxis: Subcutaneous heparin # Access: PIV # Code: Full # Communication: Patient # Disposition: will work with PT one additional time before likely d/c to home TSH normal -- cont home ASA # Depression: cont home Fluoxetine # FEN: Renal Diet, replete lytes # Prophylaxis: Subcutaneous heparin # Access: PIV # Code: Full # Communication: Patient # Disposition: will work with PT one additional time before likely d/c to home ICU Care Nutrition: Glycemic Control: Lines: Dialysis Catheter - 12:43 AM 20 Gauge - 06:00 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Disposition: TSH normal -- cont home ASA # Depression: cont home Fluoxetine # FEN: Renal Diet, replete lytes # Prophylaxis: Subcutaneous heparin # Access: PIV # Code: Full # Communication: Patient # Disposition: will work with PT one additional time before likely d/c to home ICU Care Nutrition: Glycemic Control: Lines: Dialysis Catheter - 12:43 AM 20 Gauge - 06:00 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Disposition: Chief Complaint: HPI: 82 yo M with hx of ESRD on HD Atrial Fibrillation/Flutter not anticoagulated C.diff, CVA x 2 CAD s/p MI, diastolic CHF presents with weakness/N/V (non bloody)/D x 1 day went to OSH SBP 70-80 improved with fluids got Vanc and transferred to lactate 4.1, WBC 22, 90%N, Hct 51 got Zosyn in ED, 3.5L NS, SBP 90s. EKG: irregular rate and rhythm, no acute ST or T wave changes Assessment and Plan 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and weakness. EKG: irregular rate and rhythm, no acute ST or T wave changes Assessment and Plan 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and weakness. EKG: irregular rate and rhythm, no acute ST or T wave changes Assessment and Plan 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and weakness. # Prophylaxis: Subcutaneous heparin . Patient was ROMI. Action: Cont on linezolid and meropenem. Action: Cont on linezolid and meropenum. Action: Cont on linezolid and meropenum. Action: Cont on linezolid and meropenum. # COPD: cont home spiriva, atrovent. # COPD: cont home spiriva, atrovent. # COPD: cont home spiriva, atrovent. # COPD: cont home spiriva, atrovent. -- d/c Linezolid -- cont for now -- follow up cultures -- trend fever WBC curve -- f/u ID recs # ESRD on HD: Patient on T/Th/Sat dialysis. -- cont Vanco/Zosyn -- D/C CTX -- send UA/UCx -- repeat lactate -- repeat CBC, Chem 7 -- 1L IVF bolus -- trend fever WBC curve . He was given Vancomycin 1gm IV x 1, CTX 1gm IV x 2 and Zosyn 4.5gm IV x 1. He was given Vancomycin 1gm IV x 1, CTX 1gm IV x 2 and Zosyn 4.5gm IV x 1. He was given Vancomycin 1gm IV x 1, CTX 1gm IV x 2 and Zosyn 4.5gm IV x 1. Cdiff cult neg. Cdiff cult neg. Cdiff cult neg. Plan: Cont antiobidics as ordered. Plan: Cont antiobidics as ordered. Plan: Cont antiobidics as ordered. Retrocardiac atelectasis. | 65 | [
{
"category": "Physician ",
"chartdate": "2126-01-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 364118,
"text": "Chief Complaint: shock resolved\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n none, stable\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 08:46 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.2\nC (97.2\n HR: 96 (76 - 105) bpm\n BP: 124/78(87) {91/58(66) - 142/90(97)} mmHg\n RR: 19 (14 - 24) insp/min\n SpO2: 93%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 1,154 mL\n PO:\n 720 mL\n TF:\n IVF:\n 434 mL\n Blood products:\n Total out:\n 3,300 mL\n 100 mL\n Urine:\n 300 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,146 mL\n -100 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ////\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles new since yesterday.\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 11.8 g/dL\n 139 K/uL\n 84 mg/dL\n 3.8 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 6.3 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n WBC\n 18.6\n 7.6\n 6.3\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n Plt\n 162\n 133\n 139\n Cr\n 4.7\n 3.3\n 3.8\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension....all cultures still neg to date this admission\nsepsis\n resolved, off all abx.\n - Will get surveillance cxs during HD\n - LGI bleed: still has diarrhea, outpt GI w/u.....might need\n proctoscopy once he recovers.\n - COPD: on home meds, small O2 reqmt due to atelectasis, cont IS\n - Afib: rate controlled, not anticoagulated\n - Depression: cont home Fluoxetine\n - FEN: Taking good po, SBP appears at baseline\n - Dispo: walk with pt b4 discharge home...patient upset\nmay go AMA if\n he refuses rehab.\n ICU Care\n Nutrition:\n Comments: good po\n Glycemic Control: stable\n Lines:\n Dialysis Catheter - 12:43 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Code status: Full code\n Disposition :Home once he walks vs rehab, PT c/s, SW input\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 364095,
"text": "Chief Complaint:\n 24 Hour Events:\n No Events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.6\nC (96\n HR: 96 (76 - 99) bpm\n BP: 124/77(89) {91/56(66) - 127/90(96)} mmHg\n RR: 19 (14 - 24) insp/min\n SpO2: 96%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 1,154 mL\n PO:\n 720 mL\n TF:\n IVF:\n 434 mL\n Blood products:\n Total out:\n 3,300 mL\n 100 mL\n Urine:\n 300 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,146 mL\n -100 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///28/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 139 K/uL\n 11.8 g/dL\n 84 mg/dL\n 3.8 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 6.3 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n WBC\n 18.6\n 7.6\n 6.3\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n Plt\n 162\n 133\n 139\n Cr\n 4.7\n 3.3\n 3.8\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 364098,
"text": "Chief Complaint:\n 24 Hour Events:\n No Events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.6\nC (96\n HR: 96 (76 - 99) bpm\n BP: 124/77(89) {91/56(66) - 127/90(96)} mmHg\n RR: 19 (14 - 24) insp/min\n SpO2: 96%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 1,154 mL\n PO:\n 720 mL\n TF:\n IVF:\n 434 mL\n Blood products:\n Total out:\n 3,300 mL\n 100 mL\n Urine:\n 300 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,146 mL\n -100 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///28/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 139 K/uL\n 11.8 g/dL\n 84 mg/dL\n 3.8 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 6.3 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n WBC\n 18.6\n 7.6\n 6.3\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n Plt\n 162\n 133\n 139\n Cr\n 4.7\n 3.3\n 3.8\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n # Sepsis: Mr. has history of MDR bactermias and presented with\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\n were are all concerning for sepsis. He was given Vancomycin 1gm IV x\n 1, CTX 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn have\n now been discontined. Linezolid was added two days ago to cover his\n previous MRSA and VRE. Meropenem has been added to cover his previous\n MDR E.coli and ESBL Klebsiella. ID was consulted yesterday and\n recommended to discontinue his linezolid. Blood cultures from the OSH\n are negative. Blood cultures from here show NGTD. Urine culture shows\n +yeast. .\n -- d/c Linezolid\n -- cont for now\n -- follow up cultures\n -- trend fever WBC curve\n -- f/u ID recs\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- HD today\n -- may need new line placed if +blood cultures.\n # COPD: cont home spiriva, atrovent.\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. Patient was ROMI. TSH normal\n -- cont home ASA\n # Depression: cont home Fluoxetine\n # FEN: Renal Diet, replete lytes\n # Prophylaxis: Subcutaneous heparin\n # Access: PIV\n # Code: Full\n # Communication: Patient\n # Disposition: call out to medical floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 364194,
"text": "83yo M with extensive PMH including ESRD on HD, CAD s/p MI, CVA x2, and\n multiple hospitalizations for sepsis (kelbsiella, MRSA, VRE, Cdiff) who\n presented with NVD.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Known ESRD,on HD Tu/th/sat,pt had Hd yesterday,voiding yellow urine in\n small amounts,mg level 1.3,tele with frequent bigeminies and\n trigeminies,lungs with crackles at base,no iv acess,left chest wall\n tesio cath,mild redness,as per the pt left arm is saved for AVF\n Action:\n Monitored lytes,20g iv line has been inserted by the IV team,receiving\n mgso4 iv currently\n Response:\n Pending,\n Plan:\n Plan to do HD in am at HD unit,\n DIposition:,pt want to go home today inspite of the plan to sent to\n rehab ,of note pt was incontinant of stool and urine last night and\n never been out of bed,and refused PT evaluation yesterday,consulted\n case mgt,PT regarding the disposition in presence of family,pt and\n family agreed for PT consult,pt did walk with PT and final plan to\n reevaluate again in the morning and d/c home.&keep the pt overnight in\n the ICU,pt was continent of urine and stool in this shift,\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 364265,
"text": "Chief Complaint:\n 24 Hour Events:\n no events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.1\n HR: 87 (76 - 108) bpm\n BP: 107/68(76) {106/59(66) - 142/118(122)} mmHg\n RR: 17 (13 - 32) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 86 kg\n Height: 66 Inch\n Total In:\n 990 mL\n PO:\n 890 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 490 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 138 K/uL\n 11.6 g/dL\n 93 mg/dL\n 3.1 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 104 mEq/L\n 140 mEq/L\n 37.2 %\n 4.8 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n 10:40 AM\n WBC\n 18.6\n 7.6\n 6.3\n 4.8\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n 37.2\n Plt\n 162\n 133\n 139\n 138\n Cr\n 4.7\n 3.3\n 3.8\n 3.1\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n 93\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 20 Gauge - 06:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 364249,
"text": "Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Stable vital signs, no BM in this shift.\n Action:\n Pt slept through night .\n Response:\n Pt found to be incontinent of urine @ 0400, perineal area very red\n aloe vesta cream applied.\n Plan:\n No labs drawn this am. Plan to discharge the pt to home after PT/OT\n consult and HD in am.\n Obstructive sleep apnea (OSA)\n Assessment:\n Pt cont to have sleep apnea, O2 1lt NC sat\ns droped to 80\n occasionally but picked upto mid 90\ns without any intervention. Lung\n sounds clear and diminished at the bases.\n Action:\n Pt turned freq and encouraged deep breathing.\n Response:\n Pt slept well during the night. Maintaining o2 sats in mid to high\n 90\n Plan:\n Discuss bipap at home.\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 364171,
"text": "83yo M with extensive PMH including ESRD on HD, CAD s/p MI, CVA x2, and\n multiple hospitalizations for sepsis (kelbsiella, MRSA, VRE, Cdiff) who\n presented with NVD.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Known ESRD,on HD Tu/th/sat,pt had Hd yesterday,voiding yellow urine in\n small amounts,mg level 1.3,tele with frequent bigeminies and\n trigeminies,lungs with crackles at base,no iv acess,left chest wall\n tesio cath,mild redness,as per the pt left arm is saved for AVF\n Action:\n Monitored lytes,20g iv line has been inserted by the IV team\n Response:\n Pending,\n Plan:\n Plan to do HD in am at HD unit,plan to give magnesim IV given diarrhea\n and poor GI absorption\n DIposition:,pt want to go home today inspite of the plan to sent to\n rehab ,of note pt was incontinat of stool and urine last night and\n never been out of bed,and refused PT evaluation yesterday,consulted\n case mgt,PT regarding the disposition in presence of family,pt and\n family agreed for PT consult,pt did walk with PT and final plan to\n reevaluate again in the morning and d/c home.&keep the pt overnight in\n the ICU\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363657,
"text": "This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\n vomiting and weakness. Patient went to lunch today with his wife and\n began to feel weak, +lightheadedness. He then had nausea with one\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\n of diarrhea since that time, non-bloody, no melena. He denies any\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\n hematuria, urinary frequency or back pain. he does report abdominal\n cramping with his diarrhea today. Wife became worried at the restaurant\n and called EMS. He was taken to hospital and BPs noted to\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\n IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Hypotension (not Shock)\n Assessment:\n BP high 80\ns to low 90\n Action:\n Received fluid bolus 500ml\n Response:\n Currently BP maintaining @ >90\n Plan:\n Monitor BP and bolus PRN\n Sepsis without organ dysfunction\n Assessment:\n In ED Lactate 4.1, Right arm was infiltrated on arrival to ICU. Foley\n drained small amount sludge urine. Received 4lit fluid and abx zosyn in\n ED .\n Action:\n Urine routine and C/S sent to lab. Repeat lactate 1.3. ( Very hard\n stick, Pt refuses to do blood draws in the left arm claiming he will\n get fistula done after few days. But pt came w/ 2 peripheral IV lines\n from OSH in the lt arm. AM labs drawn by MD arterial stick.)\n Response:\n Pending\n Plan:\n Follow up culture reports.\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 363808,
"text": "Chief Complaint: Septic shock,\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n N/V,weakness\n 24 Hour Events:\n HD yesterday...no fluid taken off...got a few fluid boluses for low\n SBP...responded well to fluids but asymptomatic w/o tachycardia.\n Afebrile\n Brown stool with flecks, guiac positive, ? hemorrhoids\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 01:37 PM\n Linezolid - 02:21 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.9\nC (96.6\n HR: 86 (84 - 98) bpm\n BP: 103/65(73) {83/41(54) - 104/69(73)} mmHg\n RR: 20 (14 - 25) insp/min\n SpO2: 99%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 6,347 mL\n 1,254 mL\n PO:\n 540 mL\n 360 mL\n TF:\n IVF:\n 1,807 mL\n 894 mL\n Blood products:\n Total out:\n 405 mL\n 135 mL\n Urine:\n 205 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,942 mL\n 1,119 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles new since yesterday.\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, mild tender RUQ, non-distended, bowel sounds present,\n no rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 11.2 g/dL\n 133 K/uL\n 89 mg/dL\n 3.3 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 107 mEq/L\n 143 mEq/L\n 35.6 %\n 7.6 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n WBC\n 18.6\n 7.6\n Hct\n 41.9\n 35.6\n Plt\n 162\n 133\n Cr\n 4.7\n 3.3\n TropT\n 0.05\n Glucose\n 129\n 89\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\n Troponin-T:25/6/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\n Microbiology: cdiff neg\n all cxs pend\n UA pos\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension....all cultures still neg to date this admission.\n # Shock: likely sepsis.\n Sources: history of MDR bactermias (ESBL Kleb, MRSA, VRE) in urine and\n HD line.\n - On Linezolid and Meropenem...Id c/s for input\n - f/u cxs here and \n # ESRD on HD: Patient on T/Th/Sat dialysis. HD line site with mild\n erythema but non tender\n # LGI bleed: cscope with diverticulosis in ...might need\n proctoscopy once he recovers. Follow Hct.\n # COPD: cont home spiriva, atrovent. Wean off O2. Hx of OSA, not on\n Rx...watch for progression of crackles. Use Incentive spirometry.\n .\n # Atrial Fibrillation: rate controlled, not anticoagulated\n # Depression: cont home Fluoxetine\n # FEN: Taking good po, SBP appears at baseline\n ICU Care\n Nutrition:\n Comments: po\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Comments: in for picc if needs iv abx not able tpo dose with dialysis\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 363812,
"text": "Chief Complaint:\n 24 Hour Events:\n Blood pressure dropped into the 80s transiently and responded to IVF\n boluses.\n Dr. passed by and recommended ID consult.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 01:37 PM\n Linezolid - 02:21 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.9\nC (96.7\n HR: 84 (84 - 99) bpm\n BP: 89/65(70) {83/41(54) - 104/67(75)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 6,347 mL\n 879 mL\n PO:\n 540 mL\n TF:\n IVF:\n 1,807 mL\n 879 mL\n Blood products:\n Total out:\n 405 mL\n 80 mL\n Urine:\n 205 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,942 mL\n 799 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 133 K/uL\n 11.2 g/dL\n 89 mg/dL\n 3.3 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 107 mEq/L\n 143 mEq/L\n 35.6 %\n 7.6 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n WBC\n 18.6\n 7.6\n Hct\n 41.9\n 35.6\n Plt\n 162\n 133\n Cr\n 4.7\n 3.3\n TropT\n 0.05\n Glucose\n 129\n 89\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\n Troponin-T:25/6/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n .\n # Sepsis: Mr. has history of MDR bactermias and presents with\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn have now been\n discontined. Linezolid was added yesterdy to cover his previous MRSA\n and VRE. Meropenem has been added to cover his previous MDR E.coli\n and ESBL Klebsiella. will cont with that regimen for now.\n -- cont Linezolid/Meropenem\n -- follow up cultures\n -- trend fever WBC curve\n -- ID consult\n .\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- likely HD tomorrow\n -- may need new line placed if +blood cultures\n .\n # COPD: cont home spiriva, atrovent.\n .\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. Cardiac enzymes sent yesterday and were\n negative, will repeat today. TSH normal\n -- f/u cardiac enzymes\n -- monitor on tele\n -- cont home ASA\n .\n # Depression: cont home Fluoxetine\n .\n # FEN: Renal Diet, replete lytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: PIV\n .\n # Code: Full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition: Regular Renal\n Glycemic Control: None\n Lines:\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer: PPI\n VAP: None\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 363967,
"text": "82 yo M with PMH significant for ESRD on HD T/Th/S, Atrial\n Fibrillation/Flutter, C.diff colitis, CVA x 2 with residual right sided\n weakness, CAD s/p MI, diastolic CHF with EF 60%, klebsiella urosepsis,\n multi-drug resistant E.Coli Sepsis, and MRSA Sepsis who presented to\n Hospital with N/V/D and weakness. At OSH, SBPs were\n noted to be in the 70s and 80s. He was then transferred to for\n further care of probable sepsis. Upon arrival to ED, his VS were\n stable but he was noted to have a lactate of 4.1. He was then\n transferred to the MICU for further management.\n Sepsis without organ dysfunction\n Assessment:\n Pt afebrile. WBC Sbp 90 or greater today. Cdiff cult neg. urine and\n bc pending.\n Action:\n Cont on linezolid and meropenum. Team decided not to place picc till\n final cult results back. Id consulted. Survelliance cult x2 done one\n peripheral and one via hd cath line\n Response:\n Bp improved. Afebrile.\n Plan:\n Cont antiobidics as ordered. Monitor for temp spike. Follow up on cult\n Obstructive sleep apnea (OSA)\n Assessment:\n Patient with known hx of sleep apnea. Does not wear bipap at home. Had\n been on home o2 per wife but none in the past week.\n Action:\n Taken off o2 to see how his sats would do.\n Response:\n Sats 92 or greater when awake. Fell to 87% when he fell asleep. O2\n replaced at 1l nc.\n Plan:\n Cont to monitor sats.\n wife in to visit. Updated on plan of care.\n Activity.- pt consult placed. Patient s/p cva with residual right sided\n weakness. Uses walker at home. OOb to chair with assist of 2. Tolerated\n well.\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 363968,
"text": "82 yo M with PMH significant for ESRD on HD T/Th/S, Atrial\n Fibrillation/Flutter, C.diff colitis, CVA x 2 with residual right sided\n weakness, CAD s/p MI, diastolic CHF with EF 60%, klebsiella urosepsis,\n multi-drug resistant E.Coli Sepsis, and MRSA Sepsis who presented to\n Hospital with N/V/D and weakness. At OSH, SBPs were\n noted to be in the 70s and 80s. He was then transferred to for\n further care of probable sepsis. Upon arrival to ED, his VS were\n stable but he was noted to have a lactate of 4.1. He was then\n transferred to the MICU for further management.\n Sepsis without organ dysfunction\n Assessment:\n Pt afebrile. WBC 6.3 this AM. SBP remains >90 today. Cdiff cult\n negative thus far. Urine and blood cultures with no growth to date.\n Action:\n Cont on linezolid and meropenem.\n Response:\n Plan:\n Cont antibiotics as ordered. Monitor for temp spike. Follow up on\n culture results.\n wife in to visit. Updated on plan of care.\n Activity.- pt consult placed. Patient s/p cva with residual right sided\n weakness. Uses walker at home. OOb to chair with assist of 2. Tolerated\n well.\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 363790,
"text": "Chief Complaint:\n 24 Hour Events:\n Blood pressure dropped into the 80s transiently and responded to IVF\n boluses.\n Dr. passed by and recommended ID consult.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 01:37 PM\n Linezolid - 02:21 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.9\nC (96.7\n HR: 84 (84 - 99) bpm\n BP: 89/65(70) {83/41(54) - 104/67(75)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 6,347 mL\n 879 mL\n PO:\n 540 mL\n TF:\n IVF:\n 1,807 mL\n 879 mL\n Blood products:\n Total out:\n 405 mL\n 80 mL\n Urine:\n 205 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,942 mL\n 799 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 133 K/uL\n 11.2 g/dL\n 89 mg/dL\n 3.3 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 107 mEq/L\n 143 mEq/L\n 35.6 %\n 7.6 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n WBC\n 18.6\n 7.6\n Hct\n 41.9\n 35.6\n Plt\n 162\n 133\n Cr\n 4.7\n 3.3\n TropT\n 0.05\n Glucose\n 129\n 89\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\n Troponin-T:25/6/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 363792,
"text": "Chief Complaint:\n 24 Hour Events:\n Blood pressure dropped into the 80s transiently and responded to IVF\n boluses.\n Dr. passed by and recommended ID consult.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 01:37 PM\n Linezolid - 02:21 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.9\nC (96.7\n HR: 84 (84 - 99) bpm\n BP: 89/65(70) {83/41(54) - 104/67(75)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 6,347 mL\n 879 mL\n PO:\n 540 mL\n TF:\n IVF:\n 1,807 mL\n 879 mL\n Blood products:\n Total out:\n 405 mL\n 80 mL\n Urine:\n 205 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,942 mL\n 799 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 133 K/uL\n 11.2 g/dL\n 89 mg/dL\n 3.3 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 107 mEq/L\n 143 mEq/L\n 35.6 %\n 7.6 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n WBC\n 18.6\n 7.6\n Hct\n 41.9\n 35.6\n Plt\n 162\n 133\n Cr\n 4.7\n 3.3\n TropT\n 0.05\n Glucose\n 129\n 89\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\n Troponin-T:25/6/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n .\n # Sepsis: Mr. has history of MDR bactermias and presents with\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn cover his\n previous MRSA, MDR E.coli and ESBL Klebsiella. will cont with that\n regimen for now.\n -- cont Vanco/Zosyn\n -- D/C CTX\n -- send UA/UCx\n -- repeat lactate\n -- repeat CBC, Chem 7\n -- 1L IVF bolus\n -- trend fever WBC curve\n .\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- likely HD tomorrow\n -- may need new line placed if +blood cultures\n .\n # COPD: cont home spiriva, atrovent.\n .\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. will ROMI\n -- cycle cardiac enzymes\n -- monitor on tele\n -- check TSH\n -- cont home ASA\n .\n # Depression: cont home Fluoxetine\n .\n # FEN: Renal Diet, replete lytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: PIV\n .\n # Code: Full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition: Regular Renal\n Glycemic Control: None\n Lines:\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer: PPI\n VAP: None\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 363801,
"text": "Chief Complaint: Septic shock,\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n N/V,weakness\n 24 Hour Events:\n HD yesterday...no fluid taken off...got a few fluid boluses for low\n SBP...responded well to fluids but asymptomatic w/o tachycardia.\n Afebrile\n Brown stool with flecks, guiac positive, ? hemorrhoids\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 01:37 PM\n Linezolid - 02:21 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.9\nC (96.6\n HR: 86 (84 - 98) bpm\n BP: 103/65(73) {83/41(54) - 104/69(73)} mmHg\n RR: 20 (14 - 25) insp/min\n SpO2: 99%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 6,347 mL\n 1,254 mL\n PO:\n 540 mL\n 360 mL\n TF:\n IVF:\n 1,807 mL\n 894 mL\n Blood products:\n Total out:\n 405 mL\n 135 mL\n Urine:\n 205 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,942 mL\n 1,119 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles new since yesterday.\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, mild tender RUQ, non-distended, bowel sounds present,\n no rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 11.2 g/dL\n 133 K/uL\n 89 mg/dL\n 3.3 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 107 mEq/L\n 143 mEq/L\n 35.6 %\n 7.6 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n WBC\n 18.6\n 7.6\n Hct\n 41.9\n 35.6\n Plt\n 162\n 133\n Cr\n 4.7\n 3.3\n TropT\n 0.05\n Glucose\n 129\n 89\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\n Troponin-T:25/6/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\n Microbiology: cdiff neg\n all cxs pend\n UA pos\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension....all cultures still neg to date this admission.\n # Shock: likely sepsis.\n Sources: history of MDR bactermias (ESBL Kleb, MRSA, VRE) in urine and\n HD line.\n - On Linezolid and Meropenem...Id c/s for input\n - f/u cxs here and \n # ESRD on HD: Patient on T/Th/Sat dialysis. HD line site with mild\n erythema but non tender\n # LGI bleed: cscope with diverticulosis in ...might need\n proctoscopy once he recovers. Follow Hct.\n # COPD: cont home spiriva, atrovent. Wean off O2. Hx of OSA, not on\n Rx...watch for progression of crackles. Use Incentive spirometry.\n .\n # Atrial Fibrillation: rate controlled, not anticoagulated\n # Depression: cont home Fluoxetine\n # FEN: Taking good po, SBP appears at baseline\n ICU Care\n Nutrition:\n Comments: po\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Comments: in for picc if needs iv abx not able tpo dose with dialysis\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363814,
"text": "82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 363965,
"text": "82 yo M with PMH significant for ESRD on HD T/Th/S, Atrial\n Fibrillation/Flutter, C.diff colitis, CVA x 2 with residual right sided\n weakness, CAD s/p MI, diastolic CHF with EF 60%, klebsiella urosepsis,\n multi-drug resistant E.Coli Sepsis, and MRSA Sepsis who presents with\n one day of N/V and weakness.\n Sepsis without organ dysfunction\n Assessment:\n Wbc down to 7.6. afebrile. Sbp 90 or greater today. Cdiff cult neg.\n urine and bc pending.\n Action:\n Cont on linezolid and meropenum. Team decided not to place picc till\n final cult results back. Id consulted. Survelliance cult x2 done one\n peripheral and one via hd cath line\n Response:\n Bp improved. Afebrile.\n Plan:\n Cont antiobidics as ordered. Monitor for temp spike. Follow up on cult\n Obstructive sleep apnea (OSA)\n Assessment:\n Patient with known hx of sleep apnea. Does not wear bipap at home. Had\n been on home o2 per wife but none in the past week.\n Action:\n Taken off o2 to see how his sats would do.\n Response:\n Sats 92 or greater when awake. Fell to 87% when he fell asleep. O2\n replaced at 1l nc.\n Plan:\n Cont to monitor sats.\n wife in to visit. Updated on plan of care.\n Activity.- pt consult placed. Patient s/p cva with residual right sided\n weakness. Uses walker at home. OOb to chair with assist of 2. Tolerated\n well.\n"
},
{
"category": "Rehab Services",
"chartdate": "2126-01-26 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 364327,
"text": "Subjective:\n I feel good and want to go home\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n To Right c mailing support\n\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n C railing support\n T\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n T\n\n\n\n\n\n Ambulation:\n C RW\n T\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Sit\n 88\n 119/78\n 95\n Activity\n Sit\n 102\n 132/82\n 96*\n Recovery\n Sit\n 76\n 112/65\n 99\n Total distance walked: 100'\n Minutes:\n Unable to get clear of O2 sats during activity\n * Immediately following activity.\n Gait: pt amb I 100' c RW and R AFO. pt genu recurvatum in R knee c\n flexed trunk, equal step length and normal cadence.\n Balance: pt could I sit on EOB without UE support. pt LOB post\n from recliner during sit-stand, however I sit-stand from EOB\n without LOB d/t increased hieght. EOB more charactersitic of height of\n chairs at home. pt could and dof AFO from EOB.\n Education / Communication: pt education RE: Role of PT, poc, d/c plan,\n importance of family member A c OOB activity. RN communication RE: pt\n status, d/c plan\n Other:\n Assessment: pt is an 82 y.o. male c HTN and n/v/d p/w the above\n impairments that is currently presenting at baseline described as\n functionally I c all mobility. Assuming pt is medically stable,\n anticipate pt to be safe for d/c home provided the pt has S from family\n memberat night time c amb to bathroom and c the recommendation of home\n PT to regain maximum functional I.\n Anticipated Discharge: Home with Home PT\n : d/c planning, d/c from acute PT c Home PT. Wife has agreed to\n assist pt at night c amb to bathroom.\n Treated by PT/s 2:50p-3:25p\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363795,
"text": "82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 363962,
"text": "Chief Complaint: Septic shock\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ID agreed with current abx\n Hct stable with guiac + stools and diarrhea overnight. Cdiff neg.\n SBP stable\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.4\nC (95.8\n HR: 82 (77 - 94) bpm\n BP: 98/64(70) {91/52(63) - 118/80(85)} mmHg\n RR: 19 (11 - 25) insp/min\n SpO2: 95%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 2,240 mL\n 647 mL\n PO:\n 800 mL\n 240 mL\n TF:\n IVF:\n 1,440 mL\n 407 mL\n Blood products:\n Total out:\n 335 mL\n 175 mL\n Urine:\n 335 mL\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,905 mL\n 472 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles new since yesterday.\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 11.8 g/dL\n 139 K/uL\n 84 mg/dL\n 3.8 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 6.3 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n WBC\n 18.6\n 7.6\n 6.3\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n Plt\n 162\n 133\n 139\n Cr\n 4.7\n 3.3\n 3.8\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\n Microbiology: All cxs: ngtd\n Urine: yeast\n Assessment and Plan\n OBSTRUCTIVE SLEEP APNEA (OSA)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension....all cultures still neg to date this admission.\n # Shock: likely sepsis from urine..potivive UA but grew only yeast. On\n Linezolid and Meropenem. D/c per ID recs since all cxs neg. D/c foley\n # ESRD on HD: Patient on T/Th/Sat dialysis. HD line site with mild\n erythema but non tender\n # LGI bleed: diarrhea overnight. Still blood tinged. GI\n consult....might need proctoscopy once he recovers. Follow Hct.\n # COPD: cont home spiriva, atrovent. Wean off O2. Hx of OSA, not on\n Rx...watch for progression of crackles. Use Incentive spirometry.\n # Atrial Fibrillation: rate controlled, not anticoagulated\n # Depression: cont home Fluoxetine\n # FEN: Taking good po, SBP appears at baseline\n ICU Care\n Nutrition:\n Comments: good po\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n picc based on decision reg duration of abx per ID\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363643,
"text": "This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\n vomiting and weakness. Patient went to lunch today with his wife and\n began to feel weak, +lightheadedness. He then had nausea with one\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\n of diarrhea since that time, non-bloody, no melena. He denies any\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\n hematuria, urinary frequency or back pain. he does report abdominal\n cramping with his diarrhea today. Wife became worried at the restaurant\n and called EMS. He was taken to hospital and BPs noted to\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\n IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Hypotension (not Shock)\n Assessment:\n BP high 80\ns to low 90\n Action:\n Received fluid bolus 500ml\n Response:\n Currently BP maintaining @ >90\n Plan:\n Monitor BP and bolus PRN\n Sepsis without organ dysfunction\n Assessment:\n In ED Lactate 4.1, Foley drained small amount sludge urine. Received\n 4lit fluid and abx zosyn in ED .\n Action:\n Urine routine and C/S sent to lab. Repeat lactate 1.3. ( Very hard\n stick, Pt refuses to do blood draws in the left arm claiming he will\n get fistula done after few days. But pt came w/ 2 peripheral IV lines\n from OSH in the lt arm. AM labs drawn by MD arterial stick.)\n Response:\n Pending\n Plan:\n Follow up culture reports.\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 363937,
"text": "Chief Complaint: Sepsis\n 24 Hour Events:\n ID consult obtained, continues on Linezolid/Meropenem\n HCT stable, guaiac + stools\n BP stable overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:12 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.6\nC (96.1\n HR: 87 (77 - 94) bpm\n BP: 109/67(75) {90/52(63) - 118/80(85)} mmHg\n RR: 19 (11 - 25) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 2,240 mL\n 353 mL\n PO:\n 800 mL\n TF:\n IVF:\n 1,440 mL\n 353 mL\n Blood products:\n Total out:\n 335 mL\n 140 mL\n Urine:\n 335 mL\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,905 mL\n 213 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 133 K/uL\n 11.2 g/dL\n 89 mg/dL\n 3.3 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 107 mEq/L\n 143 mEq/L\n 36.2 %\n 7.6 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n WBC\n 18.6\n 7.6\n Hct\n 41.9\n 35.6\n 36.2\n Plt\n 162\n 133\n Cr\n 4.7\n 3.3\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n .\n # Sepsis: Mr. has history of MDR bactermias and presents with\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn have now been\n discontined. Linezolid was added yesterdy to cover his previous MRSA\n and VRE. Meropenem has been added to cover his previous MDR E.coli\n and ESBL Klebsiella. will cont with that regimen for now.\n -- cont Linezolid/Meropenem\n -- follow up cultures\n -- trend fever WBC curve\n -- ID consult\n .\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- likely HD tomorrow\n -- may need new line placed if +blood cultures\n .\n # COPD: cont home spiriva, atrovent.\n .\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. Cardiac enzymes sent yesterday and were\n negative, will repeat today. TSH normal\n -- f/u cardiac enzymes\n -- monitor on tele\n -- cont home ASA\n .\n # Depression: cont home Fluoxetine\n .\n # FEN: Renal Diet, replete lytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: PIV\n .\n # Code: Full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 364315,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Dialysis today.\n D/c home after PT today\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.1\n HR: 95 (76 - 108) bpm\n BP: 127/70(86) {106/59(66) - 142/118(122)} mmHg\n RR: 18 (13 - 32) insp/min\n SpO2: 76% --poor pleth\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 86 kg\n Height: 66 Inch\n Total In:\n 990 mL\n PO:\n 890 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 490 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 76%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 11.6 g/dL\n 138 K/uL\n 93 mg/dL\n 3.1 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 104 mEq/L\n 140 mEq/L\n 37.2 %\n 4.8 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n 10:40 AM\n WBC\n 18.6\n 7.6\n 6.3\n 4.8\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n 37.2\n Plt\n 162\n 133\n 139\n 138\n Cr\n 4.7\n 3.3\n 3.8\n 3.1\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n 93\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presented with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension....all cultures still neg to date this admission\nsepsis\n resolved, off all abx.\n - Will get surveillance cxs during HD\n - LGI bleed: still has diarrhea, outpt GI w/u.....might need\n proctoscopy once he recovers.\n - COPD: on home meds, small O2 reqmt due to atelectasis, cont IS\n - Afib: rate controlled, not anticoagulated\n - Depression: cont home Fluoxetine\n - FEN: Taking good po, SBP appears at baseline\n - Dispo: walk with pt b4 discharge home...patient upset\nmay go AMA if\n he refuses rehab.\n ICU Care\n Nutrition:\n Comments: good po\n Glycemic Control: stable\n Lines:\n Dialysis Catheter - 12:43 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Code status: Full code\n Disposition :Home once he walks vs rehab\n Total time spent: 35 min\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 364306,
"text": "Chief Complaint:\n 24 Hour Events:\n no events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.1\n HR: 87 (76 - 108) bpm\n BP: 107/68(76) {106/59(66) - 142/118(122)} mmHg\n RR: 17 (13 - 32) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 86 kg\n Height: 66 Inch\n Total In:\n 990 mL\n PO:\n 890 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 490 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, OP clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles, not clearing with cough\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, left subclavian HD cath; very mild erythema at\n insertion site\n Labs / Radiology\n 138 K/uL\n 11.6 g/dL\n 93 mg/dL\n 3.1 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 104 mEq/L\n 140 mEq/L\n 37.2 %\n 4.8 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n 10:40 AM\n WBC\n 18.6\n 7.6\n 6.3\n 4.8\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n 37.2\n Plt\n 162\n 133\n 139\n 138\n Cr\n 4.7\n 3.3\n 3.8\n 3.1\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n 93\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\n 2/2 Blood Cx\n NGTD\n Blood Cx\n NGTD\n C. Diff neg\n C. Diff neg\n Assessment and Plan\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n # Culture negative Sepsis: nothing isolated on cultures. All\n antibiotics stopped.\n - will have surveillance cultures as outpatient.\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n # COPD: cont home spiriva, atrovent.\n # Atrial Fibrillation: currently in sinus with frequent ectopy. Afib\n was likely in setting of infection. Patient was ROMI. TSH normal\n -- cont home ASA\n # Depression: cont home Fluoxetine\n # FEN: Renal Diet, replete lytes\n # Prophylaxis: Subcutaneous heparin\n # Access: PIV\n # Code: Full\n # Communication: Patient\n # Disposition: will work with PT one additional time before likely d/c\n to home\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 20 Gauge - 06:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 364307,
"text": "Chief Complaint:\n 24 Hour Events:\n no events\n Plan for HD today\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.1\n HR: 87 (76 - 108) bpm\n BP: 107/68(76) {106/59(66) - 142/118(122)} mmHg\n RR: 17 (13 - 32) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 86 kg\n Height: 66 Inch\n Total In:\n 990 mL\n PO:\n 890 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 490 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, OP clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles, not clearing with cough\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, left subclavian HD cath; very mild erythema at\n insertion site\n Labs / Radiology\n 138 K/uL\n 11.6 g/dL\n 93 mg/dL\n 3.1 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 104 mEq/L\n 140 mEq/L\n 37.2 %\n 4.8 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n 10:40 AM\n WBC\n 18.6\n 7.6\n 6.3\n 4.8\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n 37.2\n Plt\n 162\n 133\n 139\n 138\n Cr\n 4.7\n 3.3\n 3.8\n 3.1\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n 93\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\n 2/2 Blood Cx\n NGTD\n Blood Cx\n NGTD\n C. Diff neg\n C. Diff neg\n Assessment and Plan\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n # Culture negative Sepsis: nothing isolated on cultures. All\n antibiotics stopped.\n - will have surveillance cultures as outpatient.\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware, HD today\n # COPD: cont home spiriva, atrovent.\n # Atrial Fibrillation: currently in sinus with frequent ectopy. Afib\n was likely in setting of infection. Patient was ROMI. TSH normal\n -- cont home ASA\n # Depression: cont home Fluoxetine\n # FEN: Renal Diet, replete lytes\n # Prophylaxis: Subcutaneous heparin\n # Access: PIV\n # Code: Full\n # Communication: Patient\n # Disposition: will work with PT one additional time before likely d/c\n to home\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 20 Gauge - 06:00 PM\n Prophylaxis:\n DVT: SC heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: likely DC home post HD and PT eval\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 364309,
"text": "Chief Complaint:\n 24 Hour Events:\n no events\n Plan for HD today\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.1\n HR: 87 (76 - 108) bpm\n BP: 107/68(76) {106/59(66) - 142/118(122)} mmHg\n RR: 17 (13 - 32) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 86 kg\n Height: 66 Inch\n Total In:\n 990 mL\n PO:\n 890 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 490 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, OP clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles, not clearing with cough\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, left subclavian HD cath; very mild erythema at\n insertion site\n Labs / Radiology\n 138 K/uL\n 11.6 g/dL\n 93 mg/dL\n 3.1 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 104 mEq/L\n 140 mEq/L\n 37.2 %\n 4.8 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n 10:40 AM\n WBC\n 18.6\n 7.6\n 6.3\n 4.8\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n 37.2\n Plt\n 162\n 133\n 139\n 138\n Cr\n 4.7\n 3.3\n 3.8\n 3.1\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n 93\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\n 2/2 Blood Cx\n NGTD\n Blood Cx\n NGTD\n C. Diff neg\n C. Diff neg\n Assessment and Plan\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n # Culture negative Sepsis: nothing isolated on cultures. All\n antibiotics stopped.\n - will have surveillance cultures as outpatient.\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware, HD today\n # COPD: cont home spiriva, atrovent.\n # Atrial Fibrillation: currently in sinus with frequent ectopy. Afib\n was likely in setting of infection. Patient was ROMI. TSH normal\n -- cont home ASA\n # Depression: cont home Fluoxetine\n # FEN: Renal Diet, replete lytes\n # Prophylaxis: Subcutaneous heparin\n # Access: PIV\n # Code: Full\n # Communication: Patient\n # Disposition: will work with PT one additional time before likely d/c\n to home\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 20 Gauge - 06:00 PM\n Prophylaxis:\n DVT: SC heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: likely DC home post HD and PT eval\n ------ Protected Section ------\n Called Hospital Microbiology lab\n Blood Cx drawn on\n finalized as no growth X 5days today.\n ------ Protected Section Addendum Entered By: , MD\n on: 13:34 ------\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363632,
"text": "This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\n vomiting and weakness. Patient went to lunch today with his wife and\n began to feel weak, +lightheadedness. He then had nausea with one\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\n of diarrhea since that time, non-bloody, no melena. He denies any\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\n hematuria, urinary frequency or back pain. he does report abdominal\n cramping with his diarrhea today. Wife became worried at the restaurant\n and called EMS. He was taken to hospital and BPs noted to\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\n IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nutrition",
"chartdate": "2126-01-25 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 364130,
"text": "Comments:\n 82 year old male with history of ESRD on HD, afib/flutter, CVA x 2\n presenting with n/v/d and weakness in the setting of hypotension and\n leukocytosis. Patient\ns diet was advanced to Renal Diet and patient is\n tolerating with good PO intake. Noted possible plans for d/c. Will\n continue to follow. Recommend encouraging PO intake PRN and adding\n supplements if PO intake decreases.\n 13:42\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 364133,
"text": "Chief Complaint: shock resolved\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n none, stable\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 08:46 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.2\nC (97.2\n HR: 96 (76 - 105) bpm\n BP: 124/78(87) {91/58(66) - 142/90(97)} mmHg\n RR: 19 (14 - 24) insp/min\n SpO2: 93%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 1,154 mL\n PO:\n 720 mL\n TF:\n IVF:\n 434 mL\n Blood products:\n Total out:\n 3,300 mL\n 100 mL\n Urine:\n 300 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,146 mL\n -100 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ////\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles new since yesterday.\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 11.8 g/dL\n 139 K/uL\n 84 mg/dL\n 3.8 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 6.3 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n WBC\n 18.6\n 7.6\n 6.3\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n Plt\n 162\n 133\n 139\n Cr\n 4.7\n 3.3\n 3.8\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension....all cultures still neg to date this admission\nsepsis\n resolved, off all abx.\n - Will get surveillance cxs during HD\n - LGI bleed: still has diarrhea, outpt GI w/u.....might need\n proctoscopy once he recovers.\n - COPD: on home meds, small O2 reqmt due to atelectasis, cont IS\n - Afib: rate controlled, not anticoagulated\n - Depression: cont home Fluoxetine\n - FEN: Taking good po, SBP appears at baseline\n - Dispo: walk with pt b4 discharge home...patient upset\nmay go AMA if\n he refuses rehab.\n ICU Care\n Nutrition:\n Comments: good po\n Glycemic Control: stable\n Lines:\n Dialysis Catheter - 12:43 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Code status: Full code\n Disposition :Home once he walks vs rehab, PT c/s, SW input\n Total time spent: 35 min\n"
},
{
"category": "Rehab Services",
"chartdate": "2126-01-25 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 364136,
"text": "Attending Physician:\n date: \n Medical Diagnosis / ICD 9: /\n Reason of :\n History of Present Illness / Subjective Complaint: 82 yo M with PMH\n significant for ESRD on HD, Atrial Fibrillation/Flutter, C.diff\n colitis, CVA x 2 with residual right sided weakness, CAD s/p MI,\n diastolic CHF with EF 60%, klebsiella urosepsis, multi-drug resistant\n E.Coli Sepsis, and MRSA Sepsis who presented to Hospital\n with N/V/D and weakness. At OSH, SBPs were noted to be in the 70s\n and 80s. He was then transferred to for further care of\n probable sepsis. Upon arrival to ED, his VS were stable but he was\n noted to have a lactate of 4.1. He was then transferred to the MICU for\n further management.\n Past Medical / Surgical History: LUE fistulagram , -Multiple\n UTIs, including VRE and klebsiella.\n - Atrial fibrillation\n - h/o GI bleed, diverticulitis\n - C. Diff colitis\n - CVA years ago w/ right-sided weakness; second stroke 5 years\n ago\n - h/o nephrolithiasis w/ stent and nephrostomy tube (now removed)\n - CAD s/p MI\n - sleep apnea not on cpap\n - depression\n - PFTs with mild restrictive ventilatory defect\n -Anemia with h/o iron deficiency\n Medications: Ondansetron, Heparin\n Radiology: cxr: Moderate cardiomegaly without signs of overhydration.\n Retrocardiac atelectasis. Potential minimal left-sided pleural\n effusion. Unchanged position of the left-sided central venous access\n line\n Labs:\n 37.2\n 11.6\n 138\n 4.8\n [image002.jpg]\n Other labs:\n Activity Orders: OOB c A\n Social / Occupational History: Lives with wife, dtr lives down stairs\n Living Environment: Private home with electric chair lift\n Prior Functional Status / Activity Level: PTA amb short household\n distances with RW, and R AFO, has w/c for distance.\n Objective Test\n Arousal / Attention / Cognition / Communication: A and O x 3\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 102\n 126/68\n 96% 2L\n Rest\n /\n Sit\n /\n Activity\n 126-156\n 136/72\n 28\n 90% 2L\n Stand\n /\n Recovery\n 110\n 139/110\n 16\n 98% 2L\n Total distance walked: 30'x2\n Minutes: 5'\n Pulmonary Status: Nonproductive cough, rapid shallow breathing pattern\n Integumentary / Vascular: L midline, multiple areas of ecchymosis on B\n UE\n Sensory Integrity: Intact to LT t/o\n Pain / Limiting Symptoms: no reports of pain t/o\n Posture: increased thoracic kyphosis\n Range of Motion\n Muscle Performance\n B UE and LE grossly WFL, R DF to approx neutral\n B UE > \n L LE > 3+/5\n R LE > x DF\n Motor Function:\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt ambulated 30'x 2 with seated rest, flexed posture,\n increased lateral sway. rapid fatigue. distance limited by fatigue and\n HR increase to 150's.\n AFO donned for ambulation with Min A\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n T\n\n\n Transfer:\n\n\n T\n\n\n Sit to Stand:\n\n\n T\n\n\n Ambulation:\n\n T\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Pt has good sitting balance, fair static and dynamic standing\n balance c RW\n Education / Communication: Pt status discussed with RN and MD. MD made\n aware of HR with activity. Pt and wife educated on role of PT and\n safety concerns regarding home d/c.\n Intervention:\n Other:\n Diagnosis:\n 1.\n Balance, Impaired\n 2.\n Gait, Impaired\n 3.\n Knowledge, Impaired\n 4.\n Muscle Performance, Impaired\n 5.\n Transfers, Impaired\n 6.\n Respiration / Gas Exchange, Impaired\n Clinical impression / Prognosis: 82 yo m admitted with hypotension and\n n/v/d presents with above impairments c/w deconditioining. Pts gait\n impairments are likely close to baseline given h/o CVA and residual R\n LE weakness. Feel he is not Independent and is at not safe for d/c home\n at this time given his endurance, and rehab may be beneficial. Pt and\n family do not wish d/c to rehab, they are in agreement to continue with\n inpatient PT in an attempt to optimize safety prior to d/c home with\n services. Pt should be ambulating with nursing using RW to increase\n activity tolerance.\n Goals\n Time frame: 1 wk\n 1.\n I bed mobility\n 2.\n I amb > 150' c RW\n 3.\n I transfers c RW\n 4.\n 5.\n 6.\n Anticipated Discharge: Home without PT\n Treatment :\n Frequency / Duration: 3-5x/wk\n f/u gait and mobility progress, formal balance assessment.\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 364140,
"text": "Chief Complaint:\n 24 Hour Events:\n No Events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: feels well, no complaints\n Flowsheet Data as of 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.6\nC (96\n HR: 96 (76 - 99) bpm\n BP: 124/77(89) {91/56(66) - 127/90(96)} mmHg\n RR: 19 (14 - 24) insp/min\n SpO2: 96%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 1,154 mL\n PO:\n 720 mL\n TF:\n IVF:\n 434 mL\n Blood products:\n Total out:\n 3,300 mL\n 100 mL\n Urine:\n 300 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,146 mL\n -100 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, OP clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles, not clearing with cough\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, left subclavian HD cath; very mild erythema at\n insertion site\n Labs / Radiology\n 139 K/uL\n 11.8 g/dL\n 84 mg/dL\n 3.8 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 6.3 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n WBC\n 18.6\n 7.6\n 6.3\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n Plt\n 162\n 133\n 139\n Cr\n 4.7\n 3.3\n 3.8\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n # Culture negative Sepsis: nothing isolated on cultures. All\n antibiotics stopped.\n - will have surveillance cultures as outpatient.\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n # COPD: cont home spiriva, atrovent.\n # Atrial Fibrillation: currently in sinus with frequent ectopy. Afib\n was likely in setting of infection. Patient was ROMI. TSH normal\n -- cont home ASA\n # Depression: cont home Fluoxetine\n # FEN: Renal Diet, replete lytes\n # Prophylaxis: Subcutaneous heparin\n # Access: PIV\n # Code: Full\n # Communication: Patient\n # Disposition: will work with PT one additional time before likely d/c\n to home\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 364274,
"text": "Chief Complaint:\n 24 Hour Events:\n no events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.1\n HR: 87 (76 - 108) bpm\n BP: 107/68(76) {106/59(66) - 142/118(122)} mmHg\n RR: 17 (13 - 32) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 86 kg\n Height: 66 Inch\n Total In:\n 990 mL\n PO:\n 890 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 490 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 138 K/uL\n 11.6 g/dL\n 93 mg/dL\n 3.1 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 104 mEq/L\n 140 mEq/L\n 37.2 %\n 4.8 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n 10:40 AM\n WBC\n 18.6\n 7.6\n 6.3\n 4.8\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n 37.2\n Plt\n 162\n 133\n 139\n 138\n Cr\n 4.7\n 3.3\n 3.8\n 3.1\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n 93\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n # Culture negative Sepsis: nothing isolated on cultures. All\n antibiotics stopped.\n - will have surveillance cultures as outpatient.\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n # COPD: cont home spiriva, atrovent.\n # Atrial Fibrillation: currently in sinus with frequent ectopy. Afib\n was likely in setting of infection. Patient was ROMI. TSH normal\n -- cont home ASA\n # Depression: cont home Fluoxetine\n # FEN: Renal Diet, replete lytes\n # Prophylaxis: Subcutaneous heparin\n # Access: PIV\n # Code: Full\n # Communication: Patient\n # Disposition: will work with PT one additional time before likely d/c\n to home\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 20 Gauge - 06:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 364275,
"text": "Chief Complaint:\n 24 Hour Events:\n no events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.1\n HR: 87 (76 - 108) bpm\n BP: 107/68(76) {106/59(66) - 142/118(122)} mmHg\n RR: 17 (13 - 32) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 86 kg\n Height: 66 Inch\n Total In:\n 990 mL\n PO:\n 890 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 490 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 138 K/uL\n 11.6 g/dL\n 93 mg/dL\n 3.1 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 104 mEq/L\n 140 mEq/L\n 37.2 %\n 4.8 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n 10:40 AM\n WBC\n 18.6\n 7.6\n 6.3\n 4.8\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n 37.2\n Plt\n 162\n 133\n 139\n 138\n Cr\n 4.7\n 3.3\n 3.8\n 3.1\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n 93\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\n 2/2 Blood Cx\n NGTD\n Blood Cx\n NGTD\n C. Diff neg\n C. Diff neg\n Assessment and Plan\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n # Culture negative Sepsis: nothing isolated on cultures. All\n antibiotics stopped.\n - will have surveillance cultures as outpatient.\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n # COPD: cont home spiriva, atrovent.\n # Atrial Fibrillation: currently in sinus with frequent ectopy. Afib\n was likely in setting of infection. Patient was ROMI. TSH normal\n -- cont home ASA\n # Depression: cont home Fluoxetine\n # FEN: Renal Diet, replete lytes\n # Prophylaxis: Subcutaneous heparin\n # Access: PIV\n # Code: Full\n # Communication: Patient\n # Disposition: will work with PT one additional time before likely d/c\n to home\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 20 Gauge - 06:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 364278,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.1\n HR: 95 (76 - 108) bpm\n BP: 127/70(86) {106/59(66) - 142/118(122)} mmHg\n RR: 18 (13 - 32) insp/min\n SpO2: 76%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 86 kg\n Height: 66 Inch\n Total In:\n 990 mL\n PO:\n 890 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 490 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 76%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles new since yesterday.\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 11.6 g/dL\n 138 K/uL\n 93 mg/dL\n 3.1 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 104 mEq/L\n 140 mEq/L\n 37.2 %\n 4.8 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n 10:40 AM\n WBC\n 18.6\n 7.6\n 6.3\n 4.8\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n 37.2\n Plt\n 162\n 133\n 139\n 138\n Cr\n 4.7\n 3.3\n 3.8\n 3.1\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n 93\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension....all cultures still neg to date this admission\nsepsis\n resolved, off all abx.\n - Will get surveillance cxs during HD\n - LGI bleed: still has diarrhea, outpt GI w/u.....might need\n proctoscopy once he recovers.\n - COPD: on home meds, small O2 reqmt due to atelectasis, cont IS\n - Afib: rate controlled, not anticoagulated\n - Depression: cont home Fluoxetine\n - FEN: Taking good po, SBP appears at baseline\n - Dispo: walk with pt b4 discharge home...patient upset\nmay go AMA if\n he refuses rehab.\n ICU Care\n Nutrition:\n Comments: good po\n Glycemic Control: stable\n Lines:\n Dialysis Catheter - 12:43 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Code status: Full code\n Disposition :Home once he walks vs rehab, PT c/s, SW input\n Total time spent: 35 min\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 364293,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Dialysis today.\n D/c home after PT today\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.1\n HR: 95 (76 - 108) bpm\n BP: 127/70(86) {106/59(66) - 142/118(122)} mmHg\n RR: 18 (13 - 32) insp/min\n SpO2: 76% --poor pleth\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 86 kg\n Height: 66 Inch\n Total In:\n 990 mL\n PO:\n 890 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 490 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 76%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 11.6 g/dL\n 138 K/uL\n 93 mg/dL\n 3.1 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 104 mEq/L\n 140 mEq/L\n 37.2 %\n 4.8 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n 10:40 AM\n WBC\n 18.6\n 7.6\n 6.3\n 4.8\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n 37.2\n Plt\n 162\n 133\n 139\n 138\n Cr\n 4.7\n 3.3\n 3.8\n 3.1\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n 93\n Other labs: PT / PTT / INR:14.2/27.5/1.2, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.4 mg/dL,\n Mg++:1.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presented with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension....all cultures still neg to date this admission\nsepsis\n resolved, off all abx.\n - Will get surveillance cxs during HD\n - LGI bleed: still has diarrhea, outpt GI w/u.....might need\n proctoscopy once he recovers.\n - COPD: on home meds, small O2 reqmt due to atelectasis, cont IS\n - Afib: rate controlled, not anticoagulated\n - Depression: cont home Fluoxetine\n - FEN: Taking good po, SBP appears at baseline\n - Dispo: walk with pt b4 discharge home...patient upset\nmay go AMA if\n he refuses rehab.\n ICU Care\n Nutrition:\n Comments: good po\n Glycemic Control: stable\n Lines:\n Dialysis Catheter - 12:43 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Code status: Full code\n Disposition :Home once he walks vs rehab\n Total time spent: 35 min\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363706,
"text": "This is an 82 year old male with hx of ESRD on HD, Atrial\n Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of\n Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with\n one day of nausea, vomiting and weakness. Patient went to lunch today\n with his wife and began to feel weak, +lightheadedness. He then had\n nausea with one episode of non-bloody emesis, no coffee ground. He\n reports 3 episodes of diarrhea since that time, non-bloody, no melena.\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\n dysuria, hematuria, urinary frequency or back pain. He does report\n abdominal cramping with his diarrhea today. Wife became worried at the\n restaurant and called EMS. He was taken to hospital and\n BPs noted to be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x\n 1, Vanco 1gm IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Hypotension (not Shock)\n Assessment:\n Afebrile with max temp 97.8. sbp down to 88 this afternoon. Hr 90\n afib with lots of ectopi. Occasionally in bigemony.\n Action:\n Given a 500cc ns bolus for sbp 88. zosyn dc\nd and placed on linezolid\n and meropenum. Dr made aware of frequent ectopi.\n Response:\n Sbp up to the 90\ns with map>60.\n Plan:\n Cont antibiodics as ordered. Follow up on cult result.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Min uo that is cloudy looking.\n Action:\n Hd done today. Only 200cc of fluid removed.\n Response:\n Stable hd run.\n Plan:\n Renal following.\n Access- patient has 2 peripheral iv\ns in right arm that has old non\n functioning av fistula. Unable to place iv or draw bloods in right arm.\n Dr made aware. Order placed for iv to place picc in arm.\n Order placed late in day.\n wife here most of day. Updated by this nurse, Dr and\n Dr .\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363708,
"text": "This is an 82 year old male with hx of ESRD on HD, Atrial\n Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of\n Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with\n one day of nausea, vomiting and weakness. Patient went to lunch today\n with his wife and began to feel weak, +lightheadedness. He then had\n nausea with one episode of non-bloody emesis, no coffee ground. He\n reports 3 episodes of diarrhea since that time, non-bloody, no melena.\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\n dysuria, hematuria, urinary frequency or back pain. He does report\n abdominal cramping with his diarrhea today. Wife became worried at the\n restaurant and called EMS. He was taken to hospital and\n BPs noted to be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x\n 1, Vanco 1gm IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Hypotension (not Shock)\n Assessment:\n Afebrile with max temp 97.8. sbp down to 88 this afternoon. Hr 90\n afib with lots of ectopi. Occasionally in bigemony.\n Action:\n Given a 500cc ns bolus for sbp 88. zosyn dc\nd and placed on linezolid\n and meropenum. Dr made aware of frequent ectopi.\n Response:\n Sbp up to the 90\ns with map>60.\n Plan:\n Cont antibiodics as ordered. Follow up on cult result.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Min uo that is cloudy looking.\n Action:\n Hd done today. Only 200cc of fluid removed.\n Response:\n Stable hd run.\n Plan:\n Renal following.\n Access- patient has 2 peripheral iv\ns in right arm that has old non\n functioning av fistula. Unable to place iv or draw bloods in right arm.\n Dr made aware. Order placed for iv to place picc in arm.\n Order placed late in day.\n wife here most of day. Updated by this nurse, Dr and\n Dr .\n ------ Protected Section ------\n Pleth very difficult to obtain on this patient. Best off left\n foot. Of note right foot colder than left. Per patient and wife this is\n baseline for him. Toes on right foot reddish blue. This is also his\n baseline per patient\n ------ Protected Section Addendum Entered By: , RN\n on: 17:57 ------\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363626,
"text": "This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\n vomiting and weakness. Patient went to lunch today with his wife and\n began to feel weak, +lightheadedness. He then had nausea with one\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\n of diarrhea since that time, non-bloody, no melena. He denies any\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\n hematuria, urinary frequency or back pain. he does report abdominal\n cramping with his diarrhea today. Wife became worried at the restaurant\n and called EMS. He was taken to hospital and BPs noted to\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\n IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363704,
"text": "This is an 82 year old male with hx of ESRD on HD, Atrial\n Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of\n Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with\n one day of nausea, vomiting and weakness. Patient went to lunch today\n with his wife and began to feel weak, +lightheadedness. He then had\n nausea with one episode of non-bloody emesis, no coffee ground. He\n reports 3 episodes of diarrhea since that time, non-bloody, no melena.\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\n dysuria, hematuria, urinary frequency or back pain. He does report\n abdominal cramping with his diarrhea today. Wife became worried at the\n restaurant and called EMS. He was taken to hospital and\n BPs noted to be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x\n 1, Vanco 1gm IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Hypotension (not Shock)\n Assessment:\n Afebrile with max temp 97.8. sbp down to 88 this afternoon.\n Action:\n Given a 500cc ns bolus for sbp 88. zosyn dc\nd and placed on linezolid\n and meropenum.\n Response:\n Sbp up to the 90\ns with map>60.\n Plan:\n Cont antibiodics as ordered. Follow up on cult result.\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363761,
"text": "This is an 82 year old male with hx of ESRD on HD, Atrial\n Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of\n Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with\n one day of nausea, vomiting and weakness. Patient went to lunch today\n with his wife and began to feel weak, +lightheadedness. He then had\n nausea with one episode of non-bloody emesis, no coffee ground. He\n reports 3 episodes of diarrhea since that time, non-bloody, no melena.\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\n dysuria, hematuria, urinary frequency or back pain. He does report\n abdominal cramping with his diarrhea today. Wife became worried at the\n restaurant and called EMS. He was taken to hospital and\n BPs noted to be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x\n 1, Vanco 1gm IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Hypotension (not Shock)\n Assessment:\n Pt\ns map occ would dip down less than 60 while sleeping. When awake\n map\ns greater than 60. hr in afib with rates in the 80\ns with freq\n pvc\n Action:\n Pt received a 500cc fluid bolus x 1.\n Response:\n Maps greater than 60. bp would come back up when pt was stimulated or\n woken up.\n Plan:\n Cont to monitor bp and notify md of any drops.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt with foley catheter draining minimal amt\ns of yellow sludgey\n looking urine. Urine also has foul odor.\n Action:\n Pt had a fluid bolus x 1 for low bp\n Response:\n Minimal response to urine output.\n Plan:\n Follow bun/cr, follow culture results. Pt to have picc line placement\n today. Cont with abx\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 364008,
"text": "Difficult IV Access\n Assessment:\n Pt called out to floor but lost peripheral access.\n Action:\n Attempt by RN and IVRNx3 without success.\n Response:\n Floor team refusing to accept pt without access.\n Plan:\n Temporary plan was to have PICC placed in IR but further discussion\n with ID and Renal team led to decision to defer floor transfer and keep\n pt in ICU for observation over night with plan to DC to home in AM if\n stable.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt with CKD on HD T/Th/S. BUN/Cr 24/3.8 this AM.\n Action:\n HD today.\n Response:\n 3L removed with HD.\n Plan:\n Cont with regularly scheduled HD. Renal team following.\n Sepsis without organ dysfunction\n Assessment:\n Pt afebrile. WBC 6.3 this AM. SBP remains >90 today. Cdiff cult\n negative thus far. Urine and blood cultures with no growth to date.\n Action:\n Cont meropenem.\n Response:\n Cultures still with NGTD. Pt remains afebrile with no white count.\n Plan:\n Cont antibiotics as ordered. Monitor for temp spike. Follow up on\n culture results.\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 364011,
"text": "83yo M with extensive PMH including ESRD on HD, CAD s/p MI, CVA x2, and\n multiple hospitalizations for sepsis (kelbsiella, MRSA, VRE, Cdiff) who\n presented with NVD.\n Difficult IV Access\n Assessment:\n Pt called out to floor but lost peripheral access.\n Action:\n Attempt by RN and IVRNx3 without success.\n Response:\n Floor team refusing to accept pt without access.\n Plan:\n Temporary plan was to have PICC placed in IR but further discussion\n with ID and Renal team led to decision to defer floor transfer and keep\n pt in ICU for observation over night with plan to DC to home in AM if\n stable.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt with CKD on HD T/Th/S. BUN/Cr 24/3.8 this AM.\n Action:\n HD today.\n Response:\n 3L removed with HD.\n Plan:\n Cont with regularly scheduled HD. Renal team following.\n Sepsis without organ dysfunction\n Assessment:\n Pt afebrile. WBC 6.3 this AM. SBP remains >90 today. Cdiff cult\n negative thus far. Urine and blood cultures with no growth to date.\n Action:\n All antibiotics DCd per ID recs.\n Response:\n Cultures still with NGTD. Pt remains afebrile with no white count.\n Plan:\n F/U re: culture results, cont to monitor pt for further s/s sepsis.\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-22 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 363623,
"text": "Chief Complaint:\n HPI:\n History of Present Illness:\n This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\n vomiting and weakness. Patient went to lunch today with his wife and\n began to feel weak, +lightheadedness. He then had nausea with one\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\n of diarrhea since that time, non-bloody, no melena. He denies any\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\n hematuria, urinary frequency or back pain. he does report abdominal\n cramping with his diarrhea today. Wife became worried at the restaurant\n and called EMS. He was taken to hospital and BPs noted to\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\n IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs sent and\n lactate noted to be elevated at 4.1. He was given 3.5 L of NS IVF in\n the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 12:46 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n -Stage V CKD on HD with h/o nephrolithiasis w/ stent and nephrostomy\n tube (AV fistula )\n -Atrial fibrillation/flutter not on coumadin\n -h/o GI bleed, diverticulitis\n -C. Diff colitis\n -CVA years ago w/ right-sided weakness; second CVA 5 years ago\n -CAD s/p MI, diastolic HF EF 60%\n -sleep apnea not on cpap\n -klebsiella(ESBL) urosepsis\n -depression\n -PFTs with mild restrictive ventilatory defect\n -Anemia with h/o iron deficiency\n .\n .\n Home Medications:\n Tiotropium Bromide 18 mcg Capsule daily\n Pantoprazole 40mg daily\n Aspirin 325mg daily\n Fluoxetine 10 mg daily\n Multivitamin\n B Complex-Vitamin C-Folic Acid 1 mg Capsule\n Atrovent MDI 1 puff q4h PRN\n Bisacodyl 5mg PRN\n Docusate 100mg \n Fish Oil\n Lives with wife , h/o smoking PPD for 50 years, quit\n 20 years ago, does not drink alcohol, no drugs.\n Review of systems:\n Flowsheet Data as of 02:26 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.4\nC (95.7\n Tcurrent: 35.4\nC (95.7\n HR: 108 (101 - 108) bpm\n BP: 81/58(64) {81/58(64) - 95/61(112)} mmHg\n RR: 18 (15 - 18) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,600 mL\n PO:\n TF:\n IVF:\n 600 mL\n Blood products:\n Total out:\n 0 mL\n 15 mL\n Urine:\n 15 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,585 mL\n Respiratory\n SpO2: 96%\n Physical Examination\n Vitals: T: 95.7 BP: 98/57 P: 102 R: 18 94% RA\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n [image002.jpg]\n Images:\n CXR: no acute process\n .\n EKG: irregular rate and rhythm, no acute ST or T wave changes\n Assessment and Plan\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n .\n # Sepsis: Mr. has history of MDR bactermias and presents with\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn cover his\n previous MRSA, MDR E.coli and ESBL Klebsiella. will cont with that\n regimen for now.\n -- cont Vanco/Zosyn\n -- D/C CTX\n -- send UA/UCx\n -- repeat lactate\n -- 1L IVF bolus\n -- trend fever WBC curve\n .\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- likely HD tomorrow\n -- may need new line placed if +blood cultures\n .\n # COPD: cont home spiriva, atrovent.\n .\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. will ROMI\n -- cycle cardiac enzymes\n -- monitor on tele\n -- check TSH\n .\n # Depression: cont home Fluoxetine\n .\n # FEN: Renal Diet, replete lytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: peripherals\n .\n # Code: presumed full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition: Regular Renal\n Glycemic Control: None\n Lines:\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer: PPI\n VAP: None\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-22 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 363625,
"text": "Chief Complaint:\n HPI:\n History of Present Illness:\n This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\n vomiting and weakness. Patient went to lunch today with his wife and\n began to feel weak, +lightheadedness. He then had nausea with one\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\n of diarrhea since that time, non-bloody, no melena. He denies any\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\n hematuria, urinary frequency or back pain. he does report abdominal\n cramping with his diarrhea today. Wife became worried at the restaurant\n and called EMS. He was taken to hospital and BPs noted to\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\n IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs sent and\n lactate noted to be elevated at 4.1. He was given 3.5 L of NS IVF in\n the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 12:46 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n -Stage V CKD on HD with h/o nephrolithiasis w/ stent and nephrostomy\n tube (AV fistula )\n -Atrial fibrillation/flutter not on coumadin\n -h/o GI bleed, diverticulitis\n -C. Diff colitis\n -CVA years ago w/ right-sided weakness; second CVA 5 years ago\n -CAD s/p MI, diastolic HF EF 60%\n -sleep apnea not on cpap\n -klebsiella(ESBL) urosepsis\n -depression\n -PFTs with mild restrictive ventilatory defect\n -Anemia with h/o iron deficiency\n .\n .\n Home Medications:\n Tiotropium Bromide 18 mcg Capsule daily\n Pantoprazole 40mg daily\n Aspirin 325mg daily\n Fluoxetine 10 mg daily\n Multivitamin\n B Complex-Vitamin C-Folic Acid 1 mg Capsule\n Atrovent MDI 1 puff q4h PRN\n Bisacodyl 5mg PRN\n Docusate 100mg \n Fish Oil\n NC\n Lives with wife , h/o smoking PPD for 50 years, quit\n 20 years ago, does not drink alcohol, no drugs.\n Review of systems:\n Flowsheet Data as of 02:26 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.4\nC (95.7\n Tcurrent: 35.4\nC (95.7\n HR: 108 (101 - 108) bpm\n BP: 81/58(64) {81/58(64) - 95/61(112)} mmHg\n RR: 18 (15 - 18) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,600 mL\n PO:\n TF:\n IVF:\n 600 mL\n Blood products:\n Total out:\n 0 mL\n 15 mL\n Urine:\n 15 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,585 mL\n Respiratory\n SpO2: 96%\n Physical Examination\n Vitals: T: 95.7 BP: 98/57 P: 102 R: 18 94% RA\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot,\n dopplerable right pedal pulse, dopplerable right tibial pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 208\n 16.9\n 149\n 4.7\n 33\n 23\n 101\n 4.6\n 144\n 53.9\n 22.2\n [image002.jpg]\n Lactate 4.1.\n Images:\n CXR: no acute process\n .\n EKG: irregular rate and rhythm, no acute ST or T wave changes\n Assessment and Plan\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n .\n # Sepsis: Mr. has history of MDR bactermias and presents with\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn cover his\n previous MRSA, MDR E.coli and ESBL Klebsiella. will cont with that\n regimen for now.\n -- cont Vanco/Zosyn\n -- D/C CTX\n -- send UA/UCx\n -- repeat lactate\n -- repeat CBC, Chem 7\n -- 1L IVF bolus\n -- trend fever WBC curve\n .\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- likely HD tomorrow\n -- may need new line placed if +blood cultures\n .\n # COPD: cont home spiriva, atrovent.\n .\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. will ROMI\n -- cycle cardiac enzymes\n -- monitor on tele\n -- check TSH\n -- cont home ASA\n .\n # Depression: cont home Fluoxetine\n .\n # FEN: Renal Diet, replete lytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: PIV\n .\n # Code: Full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition: Regular Renal\n Glycemic Control: None\n Lines:\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer: PPI\n VAP: None\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363907,
"text": "82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n Sepsis without organ dysfunction\n Assessment:\n Wbc down to 7.6. afebrile. Sbp 90 or greater today. Cdiff cult neg.\n urine and bc pending.\n Action:\n Cont on linezolid and meropenum. Team decided not to place picc till\n final cult results back. Id consulted. Survelliance cult x2 done one\n peripheral and one via hd cath line\n Response:\n Bp improved. Afebrile.\n Plan:\n Cont antiobidics as ordered. Monitor for temp spike. Follow up on cult\n Obstructive sleep apnea (OSA)\n Assessment:\n Patient with known hx of sleep apnea. Does not wear bipap at home. Had\n been on home o2 per wife but none in the past week.\n Action:\n Taken off o2 to see how his sats would do.\n Response:\n Sats 92 or greater when awake. Fell to 87% when he fell asleep. O2\n replaced at 1l nc.\n Plan:\n Cont to monitor sats.\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 364070,
"text": "83yo M with extensive PMH including ESRD on HD, CAD s/p MI, CVA x2, and\n multiple hospitalizations for sepsis (kelbsiella, MRSA, VRE, Cdiff) who\n presented with NVD.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt had foley removed earlier last evening and was due to void between\n 8-10pm. Pt was offered the urinal but found pt to be incontinent. Pt\n stated that he was unaware that he was incontinent. Pt also has been\n incontinent of loose brown stool. When asked why he did not ask for a\n bedpan pt stated that it comes out too fast.\n Action:\n Pt checked freq and asked if he could use a urinal but pt stated that\n he did not have to void.\n Response:\n Pt found to be incontinent of urine and stool x 2 during the night . a\n diaper was placed on the pt and aloe vesta cream applied to perianal\n area because it is beginning to look very red.\n Plan:\n Check pt freq and offer bedpan/urinal. No labs drawn this am. Pt is due\n to be discharged today to home. The issue of his incontinence will need\n to be addressed with pt and pt\ns wife.\n Obstructive sleep apnea (OSA)\n Assessment:\n Pt cont to have sleep apnea but o2 sat\ns have remained in the 90\n with 1lnc. Lung sounds clear and diminished at the bases.\n Action:\n Pt turned freq and encouraged deep breathing.\n Response:\n Pt slept well during the night. Maintaining o2 sats in mid to high\n 90\n Plan:\n Keep hob elevated. Discuss bipap at home.\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 364004,
"text": " Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-22 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 363680,
"text": "Chief Complaint:\n HPI:\n History of Present Illness:\n This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\n vomiting and weakness. Patient went to lunch today with his wife and\n began to feel weak, +lightheadedness. He then had nausea with one\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\n of diarrhea since that time, non-bloody, no melena. He denies any\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\n hematuria, urinary frequency or back pain. he does report abdominal\n cramping with his diarrhea today. Wife became worried at the restaurant\n and called EMS. He was taken to hospital and BPs noted to\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\n IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs sent and\n lactate noted to be elevated at 4.1. He was given 3.5 L of NS IVF in\n the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 12:46 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n -Stage V CKD on HD with h/o nephrolithiasis w/ stent and nephrostomy\n tube (AV fistula )\n -Atrial fibrillation/flutter not on coumadin\n -h/o GI bleed, diverticulitis\n -C. Diff colitis\n -CVA years ago w/ right-sided weakness; second CVA 5 years ago\n -CAD s/p MI, diastolic HF EF 60%\n -sleep apnea not on cpap\n -klebsiella(ESBL) urosepsis\n -depression\n -PFTs with mild restrictive ventilatory defect\n -Anemia with h/o iron deficiency\n .\n .\n Home Medications:\n Tiotropium Bromide 18 mcg Capsule daily\n Pantoprazole 40mg daily\n Aspirin 325mg daily\n Fluoxetine 10 mg daily\n Multivitamin\n B Complex-Vitamin C-Folic Acid 1 mg Capsule\n Atrovent MDI 1 puff q4h PRN\n Bisacodyl 5mg PRN\n Docusate 100mg \n Fish Oil\n NC\n Lives with wife , h/o smoking PPD for 50 years, quit\n 20 years ago, does not drink alcohol, no drugs.\n Review of systems:\n Flowsheet Data as of 02:26 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.4\nC (95.7\n Tcurrent: 35.4\nC (95.7\n HR: 108 (101 - 108) bpm\n BP: 81/58(64) {81/58(64) - 95/61(112)} mmHg\n RR: 18 (15 - 18) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,600 mL\n PO:\n TF:\n IVF:\n 600 mL\n Blood products:\n Total out:\n 0 mL\n 15 mL\n Urine:\n 15 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,585 mL\n Respiratory\n SpO2: 96%\n Physical Examination\n Vitals: T: 95.7 BP: 98/57 P: 102 R: 18 94% RA\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot,\n dopplerable right pedal pulse, dopplerable right tibial pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 208\n 16.9\n 149\n 4.7\n 33\n 23\n 101\n 4.6\n 144\n 53.9\n 22.2\n [image002.jpg]\n Lactate 4.1.\n Images:\n CXR: no acute process\n .\n EKG: irregular rate and rhythm, no acute ST or T wave changes\n Assessment and Plan\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n .\n # Sepsis: Mr. has history of MDR bactermias and presents with\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn cover his\n previous MRSA, MDR E.coli and ESBL Klebsiella. will cont with that\n regimen for now.\n -- cont Vanco/Zosyn\n -- D/C CTX\n -- send UA/UCx\n -- repeat lactate\n -- repeat CBC, Chem 7\n -- 1L IVF bolus\n -- trend fever WBC curve\n .\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- likely HD tomorrow\n -- may need new line placed if +blood cultures\n .\n # COPD: cont home spiriva, atrovent.\n .\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. will ROMI\n -- cycle cardiac enzymes\n -- monitor on tele\n -- check TSH\n -- cont home ASA\n .\n # Depression: cont home Fluoxetine\n .\n # FEN: Renal Diet, replete lytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: PIV\n .\n # Code: Full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition: Regular Renal\n Glycemic Control: None\n Lines:\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer: PPI\n VAP: None\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n ------ Protected Section ------\n Called Micro Lab\n 1 set blood cultures NGTD\n ------ Protected Section Addendum Entered By: , MD\n on: 11:06 ------\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-22 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 363684,
"text": "Chief Complaint:\n HPI:\n 82 yo M with hx of\n ESRD on HD\n Atrial Fibrillation/Flutter not anticoagulated\n C.diff, CVA x 2\n CAD s/p MI, diastolic CHF\n presents with weakness/N/V (non bloody)/D x 1 day\n went to OSH\n SBP\n 70-80 improved with fluids\n got Vanc and \n transferred to\n \n lactate 4.1, WBC 22, 90%N, Hct 51\n got Zosyn in ED, 3.5L NS,\n SBP 90s.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n Tiotropium Bromide 18 mcg Capsule daily\n Pantoprazole 40mg daily\n Aspirin 325mg daily\n Fluoxetine 10 mg daily\n Multivitamin\n B Complex-Vitamin C-Folic Acid 1 mg Capsule\n Atrovent MDI 1 puff q4h PRN\n Bisacodyl 5mg PRN\n Docusate 100mg \n Fish Oil\n Past medical history:\n Family history:\n Social History:\n -Stage V CKD on HD with h/o nephrolithiasis w/ stent and nephrostomy\n tube (AV fistula )\n - hx of ESBL Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis, hx\n VRE UTI : since / : associated with HD line\n -Atrial fibrillation/flutter not on coumadin\n -h/o GI bleed, diverticulitis\n -C. Diff colitis\n -CVA years ago w/ right-sided weakness; second CVA 5 years ago\n -CAD s/p MI, diastolic HF EF 60%\n -sleep apnea not on cpap\n -depression\n -PFTs with mild restrictive ventilatory defect\n -Anemia with h/o iron deficiency\n NC\n Occupation:\n Drugs: no\n Tobacco: h/o smoking PPD for 50 years, quit 20 years ago\n Alcohol: no\n Other: Lives with wife in \n Review of systems:\n +lightheadedness\n no melena\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\n dysuria, hematuria, urinary frequency or back pain.\n Flowsheet Data as of 08:24 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 96 (92 - 108) bpm\n BP: 93/64(71) {81/52(62) - 106/67(112)} mmHg\n RR: 19 (15 - 21) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,751 mL\n PO:\n TF:\n IVF:\n 751 mL\n Blood products:\n Total out:\n 0 mL\n 50 mL\n Urine:\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,701 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///20/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, bibasilar\n crackles and dullness to percussion\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, mild tender RUQ, non-distended, bowel sounds present,\n no rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 162 K/uL\n 41.9 %\n 13.8 g/dL\n 129 mg/dL\n 4.7 mg/dL\n 36 mg/dL\n 20 mEq/L\n 105 mEq/L\n 4.7 mEq/L\n 138 mEq/L\n 18.6 K/uL\n [image002.jpg]\n 03:25 AM\n WBC\n 18.6\n Hct\n 41.9\n Plt\n 162\n Cr\n 4.7\n Glucose\n 129\n Other labs: CK / CKMB / Troponin-T:25//, Lactic Acid:1.3 mmol/L,\n Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:5.7 mg/dL\n CXR: small bilateral effusions, small atelectasis R base\n EKG: irreg, afib, no ST-T changes\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension.\n # Shock: likely sepsis.\n Sources: history of MDR bactermias (ESBL Kleb, MRSA, VRE) in urine and\n HD line. He was given Vancomycin 1gm IV x 1, CTX 1gm IV x 2 and Zosyn\n 4.5gm IV x 1.\n - Broaden to Linezolid and Meropenem\n - check cdiff\n - send LFTs (abd pain)\n - f/u urine, line, blood cxs\n .\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- likely HD tomorrow\n -- may need new line placed if +blood cultures\n GI: monitor diarrhea/N/V, check LFTs\n .\n # COPD: cont home spiriva, atrovent. Wean off O2\n .\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. will ROMI\n -- cycle cardiac enzymes\n -- monitor on tele\n -- check TSH\n -- cont home ASA\n # Depression: cont home Fluoxetine\n .\n # FEN: Renal Diet, replete lytes\n # I/O: Bolus per SBP, see how he does with dialysis\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Comments:\n Prophylaxis:\n DVT: sq hep\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments: patient\n Code status: Full\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 364069,
"text": "Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt had foley removed earlier last evening and was due to void between\n 8-10pm. Pt was offered the urinal but found pt to be incontinent. Pt\n stated that he was unaware that he was incontinent. Pt also has been\n incontinent of loose brown stool. When asked why he did not ask for a\n bedpan pt stated that it comes out too fast.\n Action:\n Pt checked freq and asked if he could use a urinal but pt stated that\n he did not have to void.\n Response:\n Pt found to be incontinent of urine and stool x 2 during the night . a\n diaper was placed on the pt and aloe vesta cream applied to perianal\n area because it is beginning to look very red.\n Plan:\n Check pt freq and offer bedpan/urinal. No labs drawn this am. Pt is due\n to be discharged today to home. The issue of his incontinence will need\n to be addressed with pt and pt\ns wife.\n Obstructive sleep apnea (OSA)\n Assessment:\n Pt cont to have sleep apnea but o2 sat\ns have remained in the 90\n with 1lnc. Lung sounds clear and diminished at the bases.\n Action:\n Pt turned freq and encouraged deep breathing.\n Response:\n Pt slept well during the night. Maintaining o2 sats in mid to high\n 90\n Plan:\n Keep hob elevated. Discuss bipap at home.\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363668,
"text": "This is an 82 year old male with hx of ESRD on HD, Atrial\n Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of\n Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presents with\n one day of nausea, vomiting and weakness. Patient went to lunch today\n with his wife and began to feel weak, +lightheadedness. He then had\n nausea with one episode of non-bloody emesis, no coffee ground. He\n reports 3 episodes of diarrhea since that time, non-bloody, no melena.\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\n dysuria, hematuria, urinary frequency or back pain. He does report\n abdominal cramping with his diarrhea today. Wife became worried at the\n restaurant and called EMS. He was taken to hospital and\n BPs noted to be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x\n 1, Vanco 1gm IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs\n sent and lactate noted to be elevated at 4.1. He was given 3.5 L of NS\n IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-22 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 363670,
"text": "Chief Complaint:\n HPI:\n 82 yo M with hx of\n ESRD on HD\n Atrial Fibrillation/Flutter not anticoagulated\n C.diff, CVA x 2\n CAD s/p MI, diastolic CHF\n presents with weakness/N/V (non bloody)/D x 1 day\n went to OSH\n SBP\n 70-80 improved with fluids\n got Vanc and \n transferred to\n \n lactate 4.1, WBC 22, 90%N, Hct 51\n got Zosyn in ED, 3.5L NS,\n SBP 90s.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n Tiotropium Bromide 18 mcg Capsule daily\n Pantoprazole 40mg daily\n Aspirin 325mg daily\n Fluoxetine 10 mg daily\n Multivitamin\n B Complex-Vitamin C-Folic Acid 1 mg Capsule\n Atrovent MDI 1 puff q4h PRN\n Bisacodyl 5mg PRN\n Docusate 100mg \n Fish Oil\n Past medical history:\n Family history:\n Social History:\n -Stage V CKD on HD with h/o nephrolithiasis w/ stent and nephrostomy\n tube (AV fistula )\n - hx of ESBL Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis, hx\n VRE UTI : since / : associated with HD line\n -Atrial fibrillation/flutter not on coumadin\n -h/o GI bleed, diverticulitis\n -C. Diff colitis\n -CVA years ago w/ right-sided weakness; second CVA 5 years ago\n -CAD s/p MI, diastolic HF EF 60%\n -sleep apnea not on cpap\n -depression\n -PFTs with mild restrictive ventilatory defect\n -Anemia with h/o iron deficiency\n NC\n Occupation:\n Drugs: no\n Tobacco: h/o smoking PPD for 50 years, quit 20 years ago\n Alcohol: no\n Other: Lives with wife in \n Review of systems:\n +lightheadedness\n no melena\n He denies any recent fevers, chills, chest pain, SOB, abdmominal pain,\n dysuria, hematuria, urinary frequency or back pain.\n Flowsheet Data as of 08:24 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 96 (92 - 108) bpm\n BP: 93/64(71) {81/52(62) - 106/67(112)} mmHg\n RR: 19 (15 - 21) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,751 mL\n PO:\n TF:\n IVF:\n 751 mL\n Blood products:\n Total out:\n 0 mL\n 50 mL\n Urine:\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,701 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///20/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, bibasilar\n crackles and dullness to percussion\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, mild tender RUQ, non-distended, bowel sounds present,\n no rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 162 K/uL\n 41.9 %\n 13.8 g/dL\n 129 mg/dL\n 4.7 mg/dL\n 36 mg/dL\n 20 mEq/L\n 105 mEq/L\n 4.7 mEq/L\n 138 mEq/L\n 18.6 K/uL\n [image002.jpg]\n 03:25 AM\n WBC\n 18.6\n Hct\n 41.9\n Plt\n 162\n Cr\n 4.7\n Glucose\n 129\n Other labs: CK / CKMB / Troponin-T:25//, Lactic Acid:1.3 mmol/L,\n Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:5.7 mg/dL\n CXR: small bilateral effusions, small atelectasis R base\n EKG: irreg, afib, no ST-T changes\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension.\n # Shock: likely sepsis.\n Sources: history of MDR bactermias (ESBL Kleb, MRSA, VRE) in urine and\n HD line. He was given Vancomycin 1gm IV x 1, CTX 1gm IV x 2 and Zosyn\n 4.5gm IV x 1.\n - Broaden to Linezolid and Meropenem\n - check cdiff\n - send LFTs (abd pain)\n - f/u urine, line, blood cxs\n .\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- likely HD tomorrow\n -- may need new line placed if +blood cultures\n GI: monitor diarrhea/N/V, check LFTs\n .\n # COPD: cont home spiriva, atrovent. Wean off O2\n .\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. will ROMI\n -- cycle cardiac enzymes\n -- monitor on tele\n -- check TSH\n -- cont home ASA\n # Depression: cont home Fluoxetine\n .\n # FEN: Renal Diet, replete lytes\n # I/O: Bolus per SBP, see how he does with dialysis\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Comments:\n Prophylaxis:\n DVT: sq hep\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments: patient\n Code status: Full\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363838,
"text": "82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n Sepsis without organ dysfunction\n Assessment:\n Wbc down to 7.6. afebrile. Sbp 90 or greater today. Cdiff cult neg.\n urine and bc pending.\n Action:\n Cont on linezolid and meropenum. Team decided not to place picc till\n final cult results back. Id consulted. Survelliance cult x2 done one\n peripheral and one via hd cath line\n Response:\n Bp improved. Afebrile.\n Plan:\n Cont antiobidics as ordered. Monitor for temp spike. Follow up on cult\n Obstructive sleep apnea (OSA)\n Assessment:\n Patient with known hx of sleep apnea. Does not wear bipap at home. Had\n been on home o2 per wife but none in the past week.\n Action:\n Taken off o2 to see how his sats would do.\n Response:\n Sats 92 or greater when awake. Fell to 87% when he fell asleep. O2\n replaced at 1l nc.\n Plan:\n Cont to monitor sats.\n wife in to visit. Updated on plan of care.\n Activity.- pt consult placed. Patient s/p cva with residual right sided\n weakness. Uses walker at home. OOb to chair with assist of 2. Tolerated\n well.\n"
},
{
"category": "Rehab Services",
"chartdate": "2126-01-24 00:00:00.000",
"description": "Generic Note",
"row_id": 363990,
"text": "TITLE:\n Rehab Services Physical Therapy:\n Consult received and appreciated. Attempted to see patient this\n afternoon for evaluation, and mobilization. Pt declined PT intervention\n at this time. Educated patient on the role of Physical Therapy and\n importance of increasing time OOB. We will f/u as able for evaluation.\n Thank you. PT \n"
},
{
"category": "Nursing",
"chartdate": "2126-01-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 364236,
"text": "Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Stable vital signs, no BM and not voided in this shift.\n Action:\n Pt slept through night .\n Response:\n Pt found to be incontinent of urine and stool x 2 during the night . a\n diaper was placed on the pt and aloe vesta cream applied to perianal\n area because it is beginning to look very red.\n Plan:\n Check pt freq and offer bedpan/urinal. No labs drawn this am. Pt is due\n to be discharged today to home. The issue of his incontinence will need\n to be addressed with pt and pt\ns wife.\n Obstructive sleep apnea (OSA)\n Assessment:\n Pt cont to have sleep apnea but o2 sat\ns have remained in the 90\n with 1lnc. Lung sounds clear and diminished at the bases.\n Action:\n Pt turned freq and encouraged deep breathing.\n Response:\n Pt slept well during the night. Maintaining o2 sats in mid to high\n 90\n Plan:\n Keep hob elevated. Discuss bipap at home.\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 363976,
"text": "Chief Complaint: Septic shock\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ID agreed with current abx\n Hct stable with guiac + stools and diarrhea overnight. Cdiff neg.\n SBP stable\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.4\nC (95.8\n HR: 82 (77 - 94) bpm\n BP: 98/64(70) {91/52(63) - 118/80(85)} mmHg\n RR: 19 (11 - 25) insp/min\n SpO2: 95%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 2,240 mL\n 647 mL\n PO:\n 800 mL\n 240 mL\n TF:\n IVF:\n 1,440 mL\n 407 mL\n Blood products:\n Total out:\n 335 mL\n 175 mL\n Urine:\n 335 mL\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,905 mL\n 472 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bibasilar crackles new since yesterday.\n CV: normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness, mild guarding RUQ, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot\n (chronic), dopplerable right pedal pulse, dopplerable right tibial\n pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 11.8 g/dL\n 139 K/uL\n 84 mg/dL\n 3.8 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 6.3 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n 08:01 AM\n WBC\n 18.6\n 7.6\n 6.3\n Hct\n 41.9\n 35.6\n 36.2\n 37.2\n Plt\n 162\n 133\n 139\n Cr\n 4.7\n 3.3\n 3.8\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n 84\n Other labs: PT / PTT / INR:14.4/30.2/1.3, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:, Alk Phos / T Bili:139/0.4,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.3 mg/dL,\n Mg++:1.5 mg/dL, PO4:3.8 mg/dL\n Microbiology: All cxs: ngtd\n Urine: yeast\n Assessment and Plan\n OBSTRUCTIVE SLEEP APNEA (OSA)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of ESBL Klebsiella urosepsis, MDR\n E.Coli Sepsis, MRSA Sepsis, VRE UTI who presents with one day of\n nausea, vomiting, diarrhea and weakness in the setting of leukocytosis\n and hypotension....all cultures still neg to date this admission.\n # Shock: likely sepsis from urine..potivive UA but grew only yeast. On\n Linezolid and Meropenem. D/c per ID recs since all cxs neg. D/c foley\n # ESRD on HD: Patient on T/Th/Sat dialysis. HD line site with mild\n erythema but non tender\n # LGI bleed: diarrhea overnight. Still blood tinged. GI\n consult....might need proctoscopy once he recovers. Follow Hct.\n # COPD: cont home spiriva, atrovent. Wean off O2. Hx of OSA, not on\n Rx...watch for progression of crackles. Use Incentive spirometry.\n # Atrial Fibrillation: rate controlled, not anticoagulated\n # Depression: cont home Fluoxetine\n # FEN: Taking good po, SBP appears at baseline\n ICU Care\n Nutrition:\n Comments: good po\n Glycemic Control:\n Lines:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n picc based on decision reg duration of abx per ID\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 min\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-22 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 363667,
"text": "Chief Complaint:\n HPI:\n This is an 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter,\n C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis,\n MDR E.Coli Sepsis, MRSA Sepsis who presents with one day of nausea,\n vomiting and weakness. Patient went to lunch today with his wife and\n began to feel weak, +lightheadedness. He then had nausea with one\n episode of non-bloody emesis, no coffee ground. He reports 3 episodes\n of diarrhea since that time, non-bloody, no melena. He denies any\n recent fevers, chills, chest pain, SOB, abdmominal pain, dysuria,\n hematuria, urinary frequency or back pain. he does report abdominal\n cramping with his diarrhea today. Wife became worried at the restaurant\n and called EMS. He was taken to hospital and BPs noted to\n be in 70s and 80s. He was given 1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm\n IV x 1 and transferred here.\n In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs sent and\n lactate noted to be elevated at 4.1. He was given 3.5 L of NS IVF in\n the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg IV x 1 and\n transferred to the ICU for further care.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n Tiotropium Bromide 18 mcg Capsule daily\n Pantoprazole 40mg daily\n Aspirin 325mg daily\n Fluoxetine 10 mg daily\n Multivitamin\n B Complex-Vitamin C-Folic Acid 1 mg Capsule\n Atrovent MDI 1 puff q4h PRN\n Bisacodyl 5mg PRN\n Docusate 100mg \n Fish Oil\n Past medical history:\n Family history:\n Social History:\n -Stage V CKD on HD with h/o nephrolithiasis w/ stent and nephrostomy\n tube (AV fistula )\n -Atrial fibrillation/flutter not on coumadin\n -h/o GI bleed, diverticulitis\n -C. Diff colitis\n -CVA years ago w/ right-sided weakness; second CVA 5 years ago\n -CAD s/p MI, diastolic HF EF 60%\n -sleep apnea not on cpap\n -klebsiella(ESBL) urosepsis\n -depression\n -PFTs with mild restrictive ventilatory defect\n -Anemia with h/o iron deficiency\n Occupation:\n Drugs: no\n Tobacco: h/o smoking PPD for 50 years, quit 20 years ago\n Alcohol: no\n Other: Lives with wife \n Review of systems:\n Flowsheet Data as of 08:24 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 96 (92 - 108) bpm\n BP: 93/64(71) {81/52(62) - 106/67(112)} mmHg\n RR: 19 (15 - 21) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,751 mL\n PO:\n TF:\n IVF:\n 751 mL\n Blood products:\n Total out:\n 0 mL\n 50 mL\n Urine:\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,701 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///20/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: cold, 2+ radial pulses, no clubbing. +erythema of right foot,\n dopplerable right pedal pulse, dopplerable right tibial pulse\n SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at\n insertion site, no TTP of inserstion site\n Labs / Radiology\n 162 K/uL\n 41.9 %\n 13.8 g/dL\n 129 mg/dL\n 4.7 mg/dL\n 36 mg/dL\n 20 mEq/L\n 105 mEq/L\n 4.7 mEq/L\n 138 mEq/L\n 18.6 K/uL\n [image002.jpg]\n 03:25 AM\n WBC\n 18.6\n Hct\n 41.9\n Plt\n 162\n Cr\n 4.7\n Glucose\n 129\n Other labs: CK / CKMB / Troponin-T:25//, Lactic Acid:1.3 mmol/L,\n Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:5.7 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n .\n # Sepsis: Mr. has history of MDR bactermias and presents with\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\n are all concerning for sepsis. He was given Vancomycin 1gm IV x 1, CTX\n 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn cover his\n previous MRSA, MDR E.coli and ESBL Klebsiella. will cont with that\n regimen for now.\n -- cont Vanco/Zosyn\n -- D/C CTX\n -- send UA/UCx\n -- repeat lactate\n -- repeat CBC, Chem 7\n -- 1L IVF bolus\n -- trend fever WBC curve\n .\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- likely HD tomorrow\n -- may need new line placed if +blood cultures\n .\n # COPD: cont home spiriva, atrovent.\n .\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. will ROMI\n -- cycle cardiac enzymes\n -- monitor on tele\n -- check TSH\n -- cont home ASA\n .\n # Depression: cont home Fluoxetine\n .\n # FEN: Renal Diet, replete lytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: PIV\n .\n # Code: Full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Dialysis Catheter - 12:43 AM\n 22 Gauge - 12:43 AM\n 20 Gauge - 12:44 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363815,
"text": "82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n Sepsis without organ dysfunction\n Assessment:\n Wbc down to 7.6. afebrile. Sbp 90 or greater today. Cdiff cult neg.\n urine and bc pending.\n Action:\n Cont on linezolid and meropenum. Team decided not to place picc till\n final cult results back.\n Response:\n Bp improved. Afebrile.\n Plan:\n Cont antiobidics as ordered. Monitor for temp spike. Follow up on cult\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363818,
"text": "82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n Sepsis without organ dysfunction\n Assessment:\n Wbc down to 7.6. afebrile. Sbp 90 or greater today. Cdiff cult neg.\n urine and bc pending.\n Action:\n Cont on linezolid and meropenum. Team decided not to place picc till\n final cult results back.\n Response:\n Bp improved. Afebrile.\n Plan:\n Cont antiobidics as ordered. Monitor for temp spike. Follow up on cult\n Obstructive sleep apnea (OSA)\n Assessment:\n Patient with known hx of sleep apnea. Does not wear bipap at home. Had\n been on home o2 per wife but none in the past week.\n Action:\n Taken off o2 to see how his sats would do.\n Response:\n Sats 92 or greater when awake. Fell to 87% when he fell asleep. O2\n replaced at 1l nc.\n Plan:\n Cont to monitor sats.\n wife in to visit. Updated on plan of care.\n Activity.- pt consult placed. Patient s/p cva with residual right sided\n weakness. Uses walker at home. OOb to chair with assist of 2. Tolerated\n well.\n"
},
{
"category": "Physician ",
"chartdate": "2126-01-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 363980,
"text": "Chief Complaint: Sepsis\n 24 Hour Events:\n ID consult obtained, continues on Linezolid/Meropenem\n HCT stable, guaiac + stools\n BP stable overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Meropenem - 12:57 PM\n Linezolid - 02:06 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:12 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.6\nC (96.1\n HR: 87 (77 - 94) bpm\n BP: 109/67(75) {90/52(63) - 118/80(85)} mmHg\n RR: 19 (11 - 25) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.6 kg (admission): 86 kg\n Total In:\n 2,240 mL\n 353 mL\n PO:\n 800 mL\n TF:\n IVF:\n 1,440 mL\n 353 mL\n Blood products:\n Total out:\n 335 mL\n 140 mL\n Urine:\n 335 mL\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,905 mL\n 213 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 133 K/uL\n 11.2 g/dL\n 89 mg/dL\n 3.3 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 107 mEq/L\n 143 mEq/L\n 36.2 %\n 7.6 K/uL\n [image002.jpg]\n 03:25 AM\n 04:26 AM\n 03:45 PM\n WBC\n 18.6\n 7.6\n Hct\n 41.9\n 35.6\n 36.2\n Plt\n 162\n 133\n Cr\n 4.7\n 3.3\n TropT\n 0.05\n 0.05\n Glucose\n 129\n 89\n Other labs: PT / PTT / INR:15.4/27.1/1.4, CK / CKMB /\n Troponin-T:15/3/0.05, ALT / AST:13/23, Alk Phos / T Bili:89/0.5,\n Amylase / Lipase:136/35, Lactic Acid:1.3 mmol/L, Ca++:8.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 82 yom with hx of ESRD on HD, Atrial Fibrillation/Flutter, C.diff, CVA\n x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella urosepsis, MDR E.Coli\n Sepsis, MRSA Sepsis who presents with one day of nausea, vomiting and\n weakness.\n # Sepsis: Mr. has history of MDR bactermias and presented with\n symptoms of n/v/d in the setting of leukocytosis and hypotension which\n were are all concerning for sepsis. He was given Vancomycin 1gm IV x\n 1, CTX 1gm IV x 2 and Zosyn 4.5gm IV x 1. Vancomycin and Zosyn have\n now been discontined. Linezolid was added two days ago to cover his\n previous MRSA and VRE. Meropenem has been added to cover his previous\n MDR E.coli and ESBL Klebsiella. ID was consulted yesterday and\n recommended to discontinue his linezolid. Blood cultures from the OSH\n are negative. Blood cultures from here show NGTD. Urine culture shows\n +yeast. .\n -- d/c Linezolid\n -- cont for now\n -- follow up cultures\n -- trend fever WBC curve\n -- f/u ID recs\n # ESRD on HD: Patient on T/Th/Sat dialysis. Renal aware\n -- HD today\n -- may need new line placed if +blood cultures.\n # COPD: cont home spiriva, atrovent.\n # Atrial Fibrillation: currently in atrial fibrillation, likely in\n setting of infection. Patient was ROMI. TSH normal\n -- cont home ASA\n # Depression: cont home Fluoxetine\n # FEN: Renal Diet, replete lytes\n # Prophylaxis: Subcutaneous heparin\n # Access: PIV\n # Code: Full\n # Communication: Patient\n # Disposition: call out to medical floor\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 363982,
"text": "82 yo M with PMH significant for ESRD on HD T/Th/S, Atrial\n Fibrillation/Flutter, C.diff colitis, CVA x 2 with residual right sided\n weakness, CAD s/p MI, diastolic CHF with EF 60%, klebsiella urosepsis,\n multi-drug resistant E.Coli Sepsis, and MRSA Sepsis who presented to\n Hospital with N/V/D and weakness. At OSH, SBPs were\n noted to be in the 70s and 80s. He was then transferred to for\n further care of probable sepsis. Upon arrival to ED, his VS were\n stable but he was noted to have a lactate of 4.1. He was then\n transferred to the MICU for further management.\n Sepsis without organ dysfunction\n Assessment:\n Pt afebrile. WBC 6.3 this AM. SBP remains >90 today. Cdiff cult\n negative thus far. Urine and blood cultures with no growth to date.\n Action:\n Cont on linezolid and meropenem.\n Response:\n Plan:\n Cont antibiotics as ordered. Monitor for temp spike. Follow up on\n culture results.\n wife in to visit. Updated on plan of care.\n Activity.- pt consult placed. Patient s/p cva with residual right sided\n weakness. Uses walker at home. OOb to chair with assist of 2. Tolerated\n well.\n"
},
{
"category": "Nursing",
"chartdate": "2126-01-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 363983,
"text": "82 yo M with PMH significant for ESRD on HD T/Th/S, Atrial\n Fibrillation/Flutter, C.diff colitis, CVA x 2 with residual right sided\n weakness, CAD s/p MI, diastolic CHF with EF 60%, klebsiella urosepsis,\n multi-drug resistant E.Coli Sepsis, and MRSA Sepsis who presented to\n Hospital with N/V/D and weakness. At OSH, SBPs were\n noted to be in the 70s and 80s. He was then transferred to for\n further care of probable sepsis. Upon arrival to ED, his VS were\n stable but he was noted to have a lactate of 4.1. He was then\n transferred to the MICU for further management.\n Sepsis without organ dysfunction\n Assessment:\n Pt afebrile. WBC 6.3 this AM. SBP remains >90 today. Cdiff cult\n negative thus far. Urine and blood cultures with no growth to date.\n Action:\n Cont meropenem.\n Response:\n Cultures still with NGTD. Pt remains afebrile with no white count.\n Plan:\n Cont antibiotics as ordered. Monitor for temp spike. Follow up on\n culture results.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n SEPSIS\n Code status:\n Height:\n Admission weight:\n 86 kg\n Daily weight:\n 92.6 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia\n CV-PMH: Arrhythmias, CAD, MI\n Additional history: Stage V CKD on HD with h/o nephrolithiasis w/ stent\n and nephrostomy tube (AV fistula ), Atrial fibrillation/flutter not\n on coumadin, h/o GI bleed, diverticulitis ,C. Diff colitis, CVA \n years ago w/ right-sided weakness; second CVA 5 years ago\n -CAD s/p MI, diastolic HF EF 60% , sleep apnea not on cpap,\n klebsiella(ESBL), depression, PFTs with mild restrictive\n ventilatory defect ,\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:91\n D:65\n Temperature:\n 96.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n A Flut (Atrial Flutter)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 1 L/min\n FiO2 set:\n 24h total in:\n 674 mL\n 24h total out:\n 3,280 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 08:01 AM\n Potassium:\n 4.2 mEq/L\n 08:01 AM\n Chloride:\n 106 mEq/L\n 08:01 AM\n CO2:\n 28 mEq/L\n 08:01 AM\n BUN:\n 24 mg/dL\n 08:01 AM\n Creatinine:\n 3.8 mg/dL\n 08:01 AM\n Glucose:\n 84 mg/dL\n 08:01 AM\n Hematocrit:\n 37.2 %\n 08:01 AM\n Finger Stick Glucose:\n 148\n 12:00 PM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU786\n Transferred to: CC704\n Date & time of Transfer: \n"
},
{
"category": "ECG",
"chartdate": "2126-01-21 00:00:00.000",
"description": "Report",
"row_id": 118021,
"text": "Indeterminate irregular supraventricular rhythm, most likely atrial\nfibrillation with baseline artifact. Compared to the previous tracing\nof multiple abnormalities as previously noted persist without\nmajor change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-01-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1060888,
"text": " 3:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for evidence of infiltrate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with sepsis\n REASON FOR THIS EXAMINATION:\n Please eval for evidence of infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Sepsis, evaluation of interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Moderate cardiomegaly without signs of overhydration. Retrocardiac\n atelectasis. Potential minimal left-sided pleural effusion. Unchanged\n position of the left-sided central venous access line.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-01-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1060430,
"text": " 11:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: acute change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with sepsis\n REASON FOR THIS EXAMINATION:\n acute change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Sepsis, followup.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the old central venous\n access line has been removed, there is a new double-lumen catheter inserted\n via the left internal jugular vein and projecting with its tip against the\n lateral wall of the superior vena cava. The lung volumes are low, there is a\n small retrocardiac atelectasis, but no evidence of focal parenchymal opacity\n suggestive of pneumonia. No evidence of overhydration. Mild aortic\n tortuosity.\n\n\n"
}
] |
69,655 | 143,688 | FINDINGS: Single abdominal radiograph is obtained. IMPRESSION: Choledocholithiasis with diffusely dilated common biliary duct. Incidental note of degenerative change of the right shoulder, thoracolumbar spinal fusion hardware is incompletely imaged. PFI REPORT PFI: Plastic common bile duct stent seen in appropriate location. 1:54 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: ? There is prominent joint space narrowing and osteoarthritis involving the triscaphe and adjacent first MP joints bilaterally. IMPRESSION: Plastic common bile duct stent seen in appropriate location. On initial image, a plastic stent is seen in the common bile duct which was removed. There is bilateral acetabular degenerative change. Possible old anterior myocardial infarction. FINAL REPORT INDICATION: ERCP stent not visualized by ultrasound. Findings consistent with tophaceous gout. Subsequent images demonstrate cannulation and opacification of the common bile duct with multiple filling defects compatible with stones. Intraventricular conduction delay. Injection of contrast in the common bile duct demonstrates a diffusely dilated duct with numerous filling defects. A plastic stent is seen in the region of the common bile duct. Atrial fibrillation. PROVISIONAL FINDINGS IMPRESSION (PFI): 6:06 PM PFI: Plastic common bile duct stent seen in appropriate location. , R. CC6A 3:59 PM ABDOMEN (SUPINE & ERECT) PORT Clip # Reason: ? IMPRESSION: Severe multi-joint osteoarthritis. FINAL REPORT HISTORY: Acute gout with known tophi. In the lateral left kidney there is an anechoic lesion consistent with a simple renal cyst measuring 2.5 x 2.6 x 2.9 cm. There is dilatation of the common bile duct. The gallbladder is not well opacified. There is marked soft tissue swelling and subtle periarticular soft tissue erosion/destruction at the PIP joint of the left fifth finger (a nonspecific finding but suggestive of tophaceous gout). Occasional ventricular premature beats. 3:59 PM ABDOMEN (SUPINE & ERECT) PORT Clip # Reason: ? location of stent. location of stent. location of stent. location of stent. Spinal fusion hardware overlies the field of view and limits evaluation. The visualized portion of the inferior vena cava appear normal. COMPARISON: ERCP . Compared to theprevious tracing ectopy is resolved.TRACING #3 Sinus rhythm. Sinus rhythm. COMPARISON: ERCP fluoroscopic images from . Biliary sludge and seen within the gallbladder without any evidence of cholecystitis. There is prominent generalized demineralization. Moderate first carpo-metacrapal DJD. Initial spot fluoroscopic image demonstrates multilevel spinal fusion with pedicle screws and rods. The patient is status post surgical fusion of L1 through L5. IMPRESSION: Bibasilar atelectasis. cholecystitis FINAL REPORT INDICATION: 86-year-old female status post ERCP with continued epigastric tenderness to palpation as well as elevated LFTs. Air is seen in small and large bowel. Please refer to the endoscopist's report in OMR for further details of the procedure involving removal of stones with balloon catheter basket and lithotripsy. Moderate DIP and PIP DJD. Concern for possible cholangitis. Per the ERCP report, a plastic stent was placed but no images are provided. TECHNIQUE: Complete abdominal ultrasound. A dual-lead nerve stimulator projects over the lower lumbar spine with leads coursing cranially. There are several granulomas seen within the spleen. The gallbladder contains layering sludge; however, there are discrete no gallstones. Admitting Diagnosis: GALLSTONE PANCREATITIS MEDICAL CONDITION: 86 year old woman with known ERCP stent, unable to view with US and now elevated LFTs REASON FOR THIS EXAMINATION: ? Admitting Diagnosis: GALLSTONE PANCREATITIS MEDICAL CONDITION: 86 year old woman with known ERCP stent, unable to view with US and now elevated LFTs REASON FOR THIS EXAMINATION: ? cholecystitis Admitting Diagnosis: GALLSTONE PANCREATITIS MEDICAL CONDITION: 86 year old woman s/p ERCP, now with continued epigastric TTP as well as elevated LFTs. The spleen measures 13 cm; however, it is thin and does appear enlarged. The left kidney measures 10.2 cm while the right kidney measures 10.3 cm. The biliary stent is not visualized. Compared to theprevious tracing the rhythm has changed.TRACING #2 The heart size is normal, the mediastinal contours are unremarkable. No previous tracingavailable for comparison.TRACING #1 10:27 AM ERCP BILIARY&PANCREAS BY GI UNIT Clip # Reason: Please review ERCP images from Admitting Diagnosis: GALLSTONE PANCREATITIS MEDICAL CONDITION: 86 year old woman with recent ERCP for gall stone pancreatitis.Sphincterotomy and stent inserted for multiple CBD stones.Persistently elevated LFTs.For ERCP and duct clearance REASON FOR THIS EXAMINATION: Please review ERCP images from FINAL REPORT INDICATION: Gallstone pancreatitis, choledocholithiasis. | 10 | [
{
"category": "Radiology",
"chartdate": "2195-04-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1179638,
"text": " 10:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pre-procedure\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with gallstone pancreatitis\n REASON FOR THIS EXAMINATION:\n pre-procedure\n ______________________________________________________________________________\n FINAL REPORT\n FINDINGS: Portable AP chest with no prior for comparison demonstrates\n bibasilar opacities. The heart size is normal, the mediastinal contours are\n unremarkable. Incidental note of degenerative change of the right shoulder,\n thoracolumbar spinal fusion hardware is incompletely imaged.\n\n IMPRESSION: Bibasilar atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-04-10 00:00:00.000",
"description": "ERCP BILIARY&PANCREAS BY GI UNIT",
"row_id": 1180085,
"text": " 9:31 AM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: Please review ERCP images from \n Admitting Diagnosis: GALLSTONE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with gallstone pancreatitis [abd pain, elevated lipase,\n lft's] and imaging demonstrating stones in the CBD. WBC elevating and concern\n for possible cholangitis\n REASON FOR THIS EXAMINATION:\n Please review ERCP images from \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old female with gallstone pancreatitis and imaging\n demonstrating stones in the CBD. Concern for possible cholangitis.\n\n COMPARISON: No prior study available for comparison.\n\n FINDINGS: Ten spot fluoroscopic images were obtained during ERCP performed by\n Dr. on without a radiologist present. Initial spot\n fluoroscopic image demonstrates multilevel spinal fusion with pedicle screws\n and rods. Subsequent images demonstrate cannulation and opacification of the\n common bile duct with multiple filling defects compatible with stones. There\n is dilatation of the common bile duct. The gallbladder is not well opacified.\n Per the ERCP report, a plastic stent was placed but no images are provided.\n Please see the ERCP report in OMR for further details.\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-04-16 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1180614,
"text": " 1:54 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ? cholecystitis\n Admitting Diagnosis: GALLSTONE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman s/p ERCP, now with continued epigastric TTP as well as\n elevated LFTs.\n REASON FOR THIS EXAMINATION:\n ? cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old female status post ERCP with continued epigastric\n tenderness to palpation as well as elevated LFTs.\n\n COMPARISON: ERCP fluoroscopic images from .\n\n TECHNIQUE: Complete abdominal ultrasound.\n\n FINDINGS: The liver shows no focal or textural abnormalities. The\n gallbladder contains layering sludge; however, there are discrete no\n gallstones. There is no evidence of gallbladder wall thickening or other\n signs to suggest cholecystitis. The common bile duct is not dilated and\n measures 5 mm. There is no evidence of a biliary stent that was placed\n according to the ERCP endoscopy note.\n\n The kidneys are normal with no evidence of hydronephrosis. In the lateral\n left kidney there is an anechoic lesion consistent with a simple renal cyst\n measuring 2.5 x 2.6 x 2.9 cm. Otherwise, there is no evidence of\n hydronephrosis. The left kidney measures 10.2 cm while the right kidney\n measures 10.3 cm. There are several granulomas seen within the spleen. The\n spleen measures 13 cm; however, it is thin and does appear enlarged. The\n aorta is normal in caliber throughout. The visualized portion of the inferior\n vena cava appear normal.\n\n IMPRESSION:\n 1. Biliary sludge and seen within the gallbladder without any evidence\n of cholecystitis. The biliary stent is not visualized.\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-04-14 00:00:00.000",
"description": "B HAND (AP, LAT & OBLIQUE) BILAT",
"row_id": 1180324,
"text": " 5:11 PM\n HAND (AP, LAT & OBLIQUE) BILAT Clip # \n Reason: assess for degree of bony destruction by gout/tophi\n Admitting Diagnosis: GALLSTONE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with acute gout flare/tophi both hands\n REASON FOR THIS EXAMINATION:\n assess for degree of bony destruction by gout/tophi\n ______________________________________________________________________________\n WET READ: IPf TUE 6:23 PM\n Degenerative changes and soft tissue swelling at the 5th PIP concerning for\n gout flare/tophi.\n Moderate first carpo-metacrapal DJD.\n Moderate DIP and PIP DJD.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Acute gout with known tophi.\n\n These two exams consist of three views of each hand and wrist. There is\n prominent generalized demineralization. There is marked soft tissue swelling\n and subtle periarticular soft tissue erosion/destruction at the PIP joint of\n the left fifth finger (a nonspecific finding but suggestive of tophaceous\n gout). There is prominent joint space narrowing and osteoarthritis involving\n the triscaphe and adjacent first MP joints bilaterally. Similar findings are\n present in most of the DIP joints (most prominent in both index fingers\n suggesting superimposed trauma). No acute fracture or chondrocalcinosis.\n\n IMPRESSION: Severe multi-joint osteoarthritis. Findings consistent with\n tophaceous gout. No comparison exams at this facility.\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-04-16 00:00:00.000",
"description": "P ABDOMEN (SUPINE & ERECT) PORT",
"row_id": 1180637,
"text": " 3:59 PM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: ? location of stent.\n Admitting Diagnosis: GALLSTONE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with known ERCP stent, unable to view with US and now\n elevated LFTs\n REASON FOR THIS EXAMINATION:\n ? location of stent.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:06 PM\n PFI: Plastic common bile duct stent seen in appropriate location.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ERCP stent not visualized by ultrasound.\n\n COMPARISONS: Abdominal ultrasound earlier the same day.\n\n FINDINGS: Single abdominal radiograph is obtained. A plastic stent is seen\n in the region of the common bile duct. The patient is status post surgical\n fusion of L1 through L5. A dual-lead nerve stimulator projects over the lower\n lumbar spine with leads coursing cranially. Air is seen in small and large\n bowel. There is bilateral acetabular degenerative change.\n\n IMPRESSION: Plastic common bile duct stent seen in appropriate location.\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-04-16 00:00:00.000",
"description": "P ABDOMEN (SUPINE & ERECT) PORT",
"row_id": 1180638,
"text": ", R. CC6A 3:59 PM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: ? location of stent.\n Admitting Diagnosis: GALLSTONE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with known ERCP stent, unable to view with US and now\n elevated LFTs\n REASON FOR THIS EXAMINATION:\n ? location of stent.\n ______________________________________________________________________________\n PFI REPORT\n PFI: Plastic common bile duct stent seen in appropriate location.\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-04-21 00:00:00.000",
"description": "ERCP BILIARY&PANCREAS BY GI UNIT",
"row_id": 1181251,
"text": " 10:27 AM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: Please review ERCP images from \n Admitting Diagnosis: GALLSTONE PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with recent ERCP for gall stone pancreatitis.Sphincterotomy\n and stent inserted for multiple CBD stones.Persistently elevated LFTs.For ERCP\n and duct clearance\n REASON FOR THIS EXAMINATION:\n Please review ERCP images from \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Gallstone pancreatitis, choledocholithiasis.\n\n COMPARISON: ERCP .\n\n FINDINGS: 27 fluoroscopic spot films are submitted for review. Spinal fusion\n hardware overlies the field of view and limits evaluation. On initial image,\n a plastic stent is seen in the common bile duct which was removed. Injection\n of contrast in the common bile duct demonstrates a diffusely dilated duct with\n numerous filling defects.\n\n IMPRESSION: Choledocholithiasis with diffusely dilated common biliary duct.\n Please refer to the endoscopist's report in OMR for further details of the\n procedure involving removal of stones with balloon catheter basket and\n lithotripsy.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2195-04-10 00:00:00.000",
"description": "Report",
"row_id": 179536,
"text": "Sinus rhythm. Possible old anterior myocardial infarction. Compared to the\nprevious tracing ectopy is resolved.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2195-04-10 00:00:00.000",
"description": "Report",
"row_id": 179767,
"text": "Sinus rhythm. Occasional ventricular premature beats. Compared to the\nprevious tracing the rhythm has changed.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2195-04-09 00:00:00.000",
"description": "Report",
"row_id": 179768,
"text": "Atrial fibrillation. Intraventricular conduction delay. No previous tracing\navailable for comparison.\nTRACING #1\n\n"
}
] |
|
27,547 | 103,061 | #C diff colitis: No response to Flagyl and so started on po vancomycin with good response. Plan to continue vancomycin with taper. | wheezes, nebs given w/ moderate effect. Note is made of compression deformities of the L1 and T11 vertebral bodies of undetermined chronicity. Mild neural foraminal narrowing is identified at the right T9-T10 and T10-T11 level secondary to uncovertebral spurring and endplate osteophytes. There is mild widening of the superior aspect of the right sacroiliac joint of unclear etiology. improved with ativan.cv: hypotensive at start of shift, bp 60s. CHEST, TWO VIEWS: There is moderate cardiomegaly. Has h/o CHF, resp. IN I/E WHEEZES. FINDINGS: Image portion of the lower thoracic and lumbar spine demonstrate diffuse demineralization and severe degenerative change with compression deformities, most marked in L1 and T11. febrile, tmax 101.1 ax. AS WELL AS AN I.CA+ AND LACTATE LEVELS.ID: TEMP 99.8AX. There are mild degenerative changes of bilateral sacroiliac joints. RESPIRATORY CARE: PT W/ MILD EXP. Diffuse atherosclerotic calcification is present. Again demonstrated are right axillary dissection clips. BS scattered wheezes. Markedly distended bladder, containing a moderate amount of air. at 3am became tachy 130s-140s, PO metoprolol given w/ good effect. S-shaped scoliosis of the thoracolumbar spine is noted. WHEEZE. Slight improvement with Rx. dropped to 70s-80s at 1am, 1L NSx1 given with good effect. CVC placed, 1L LRx1 given with good effect. RR regular and unlabored. ativan x1 given for agitation w/ good effect. replace lytes as necessary. There is severe facet arthropathy at L5-S1 on the right. Febrile to 102. Also, rec'd lasix, vanco, ceftriaxone, flagyl, azithromycin.Review of system:Neuro: Lethargic, but easily arouable. Severe osteopenia. Poor access w/ several attempts at IV's (#22 to R Upper arm).GI/GU: Abd is soft, nt, nd. There is moderate streak artifact from bilateral hip prostheses limiting interpretation or evaluation of the pelvic viscera. CHRONIC BACK PAIN CONTROLLED W/ DARVOCET AND LIDO PATCH. Foley in place w/ adequate uo.Plan: Cont. FINDINGS: A left CVL has been placed and the tip is in the SVC - no PTX. IVF-KVO. failure, NSTIMI (cath stent), delirium, + c. diff in , low back pain, CAD, breast CA - bilat mats, HTN, pulm, stenosis, anxiety, MGUS, GERD. Strong prod cough.Pt weak otherwise stable. Note is made of moderate spinal canal narrowing at L4- L5 due to endplate osteophytes and ligamentum flavum hypertrophy. 3:00 PM CT PELVIS ORTHO W/O C Clip # Reason: Eval for Sacral/pelvic fx. multiple myeloma. Severe atherosclerotic disease. + ppp x 4. CAN HAVE HER DARVOCETT. SI joint; MR completed but essentially uninterpretable due to motion artifact despite sedation REASON FOR THIS EXAMINATION: Eval for Sacral/pelvic fx. sump to right nares in place. DUODERM INTACT.PAIN CONTROL: BACK PAIN TX'ED WITH LIDO PATCH. FIRST C-DIFF SAMPLE POSITIVE.SKIN INTEGRITY: PRESSURE SORE ON BACK NOTED. Lungs w/ rhonchi throughout. Notify MD care RN with any deterioration D/C rectal tube. Notify MD care RN with any deterioration D/C rectal tube. Oriiented X3 but does occas makes inappropriate statements Action: Received calcitonin & pamidronate X1 Response: Plan: Recheck PMlabs after pamridronate infusion myeloma, sob REASON FOR THIS EXAMINATION: eval for interval change - ? Transfers, Impaired Clinical impression / Prognosis: 78 y.o. Transfers, Impaired Clinical impression / Prognosis: 78 y.o. InferiorQ waves represent prior myocardial infarction. On, zosyn , Vanco (Po/IV), Action: Metrprlol & ASA, statin Response: Stable, Diarrhea diminishing. On, zosyn , Vanco (Po/IV), Action: Metrprlol & ASA, statin Response: Stable, Diarrhea diminishing. On, zosyn , Vanco (Po/IV), Action: Metrprlol & ASA, statin Response: Stable, Diarrhea diminishing. Attending: Referral date: Medical Diagnosis / ICD 9: 428.0 CHF Reason of referral: eval and treat History of Present Illness / Subjective Complaint: 78 y.o. Coordinated breathing pattern Integumentary / Vascular: L CVP line, flexiseal, foley catheter, telemetry, thoracic stage 2 wound per wound care note Sensory Integrity: Detects all LT sensation UE/UE Pain / Limiting Symptoms: Unable to grade on VAS scale. Coordinated breathing pattern Integumentary / Vascular: L CVP line, flexiseal, foley catheter, telemetry, thoracic stage 2 wound per wound care note Sensory Integrity: Detects all LT sensation UE/UE Pain / Limiting Symptoms: Unable to grade on VAS scale. Impaired Skin Integrity Assessment: Stage II pressure ulcer thoracic spine area 1.5cm X 1.5 CM. Impaired Skin Integrity Assessment: Stage II pressure ulcer thoracic spine area 1.5cm X 1.5 CM. Anterior Q waves could representprior anteroseptal myocardial infarction. Attending Physician: Referral date: Medical Diagnosis / ICD 9: 428.0 / CHF Reason of referral: eval and treat History of Present Illness / Subjective Complaint: 78 y.o. Hypoxia with PNA versus flash pulmonary edema and acute on chronic diastolic HF. Hypoxia with PNA versus flash pulmonary edema and acute on chronic diastolic HF. pulm edema FINAL REPORT CHEST X-RAY HISTORY: Myeloma, shortness of breath. There is remodeling of the proximal humeral shafts bilaterally, apparently related to the inferior margins of the glenoids and osteophytes in that region. understands and verbalizes need to call for A when mobilizing Hemodynamic Response Aerobic Capacity HR BP RR O[2 ]sat HR BP RR O[2] sat RPE Supine 76 112/70 18 97 RA Rest / Sit 145/60 24 98 RA Activity / Stand / Recovery 82 111/54 17 95 RA Total distance walked: Minutes: Pulmonary Status: strong mildly congested cough, raises to upper airway. | 30 | [
{
"category": "Radiology",
"chartdate": "2201-02-28 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 995920,
"text": " 11:30 AM\n CHEST (PA & LAT) Clip # \n Reason: pls assess interval change for blossoming of infiltrate\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with MGUS, CAD s/p MI, HTN, admitted with mild prod cough and\n ? infiltrate on imaging. Hx of cdif to Abx. s/p aggressive IVF hydration\n REASON FOR THIS EXAMINATION:\n pls assess interval change for blossoming of infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON AT 11:35\n\n INDICATION: Cough.\n\n COMPARISON: at 21:38.\n\n FINDINGS:\n\n Similar to the prior film, there is some increased density projecting over the\n lower thoracic spine on the lateral view, but there appears to be even further\n increased opacity there. An element of atelectasis versus an evolving\n pneumonia is in the differential. A staple appearance to the left hilum is\n seen, most consistent with pulmonary artery enlargement. This has been stable\n for a few years.\n\n The pulmonary vascular markings are within normal limits.\n\n IMPRESSION:\n\n Further increase in the opacity projecting over the lower thoracic spine.\n This is not clearly localized on the frontal view, but I suspect is in the\n left lower lobe. Atelectasis versus developing pneumonia.\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2201-02-27 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 995846,
"text": " 9:33 PM\n CHEST (PA & LAT) Clip # \n Reason: pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with cough, phlegm\n REASON FOR THIS EXAMINATION:\n pna\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 78-year-old female with cough and phlegm production with concern\n for pneumonia.\n\n COMPARISON: .\n\n CHEST, TWO VIEWS: There is moderate cardiomegaly. The mediastinal contours\n are unchanged. Again demonstrated is evidence of aortic tortuosity and\n markedly enlarged pulmonary arterial contour. There is no pleural effusion or\n pneumothorax. The lung volumes are relatively low. No consolidation is seen\n on the frontal view. There has been slight increase in opacity projecting\n over the lower spine on the lateral view which could be due to crowding\n secondary to low volumes. Again demonstrated are right axillary dissection\n clips. A mottled appearance of the bones suggestive of multiple myeloma has\n not changed. There are marked degenerative changes of the shoulder joints.\n\n IMPRESSION: New subtle opacity overlying the lower thoracic spine on the\n lateral view is more likely explained by crowding due to low lung volumes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2201-03-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 996008,
"text": " 5:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulmonary edema\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with emegency need\n REASON FOR THIS EXAMINATION:\n pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 5:12\n\n INDICATION: Edema.\n\n COMPARISON: at 11:35.\n\n FINDINGS:\n\n Diffusely increased interstitial and parenchymal opacities are visualized in a\n pattern consistent with sudden pulmonary edema. Continued followup is\n recommended to see if this evolves into more persistent consolidations. The\n right CP angle is cut off from view and there is no pneumothorax.\n\n IMPRESSION: Flash pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2201-03-01 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 996087,
"text": " 8:20 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Please evaluate for central line placement\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with central line placed for fluid resuscitation\n REASON FOR THIS EXAMINATION:\n Please evaluate for central line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 20:26\n\n INDICATION: CVL placement.\n\n COMPARISON: at 18:42.\n\n FINDINGS:\n\n A left CVL has been placed and the tip is in the SVC - no PTX. The lungs are\n stable without evidence of new consolidation or exacerbation in fluid status.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2201-03-02 00:00:00.000",
"description": "Report",
"row_id": 1622679,
"text": "NURSING NOTES 7AM-19PM\nRESP: NO C/O SOB. RESP MORE REGULAR. R BS'S CLEAR AND LEFT CONT. IN I/E WHEEZES. NEBS GIVEN Q6HRS. SAT 98% ON 4L NP. HAS A CONGESTED NON-PRODUCTIVE COUGH.\nGI: NPO X ICE CHIPS, BUT TOOK SMALL AMT OF WATER WITHOUT PROBLEMS. MOUTH IS VERY DRY. LIQUID STOOL CONT. FROM MUSHROOM CATHETER.\nRENAL: GIVEN 40MG LASIX IVP WITH MODERATE DIURESES. IVF-KVO. CREAT 2,0.\nNEURO: VERY SLEEPY THIS AM, BUT SHE HAS PROGRESSIVELY BECOME MORE AWAKE. DAUGHTER STATED THAT SHE WAS VERY TIRED AT HOME AS WELL. UNABLE TO UNDERSTAND HER WELL D/T DRY MOUTH. CONT. TO BE RESTRAINED AS SHE DOES FORGET THAT SHE HAS A NGT.\nCV: HEMODYNAMICALLY STABLE. WAS IN NSR IN 90'S. GIVEN AN ADDITIONAL 12.5MG OF LOPRESSOR VIA NGT AND DOSE INCREASED TO 37.5MG.\nENDOC: K+ REPLETED THIS AM. PM LYTES JUST SENT OFF. AS WELL AS AN I.CA+ AND LACTATE LEVELS.\nID: TEMP 99.8AX. NO FURTHER SPIKES. CONT. ON ANTIBIOTICS. FIRST C-DIFF SAMPLE POSITIVE.\nSKIN INTEGRITY: PRESSURE SORE ON BACK NOTED. TURNED OFTEN. DUODERM INTACT.\nPAIN CONTROL: BACK PAIN TX'ED WITH LIDO PATCH. IF NEEDED PT. CAN HAVE HER DARVOCETT. NOT REQUIRED YET.\nHEM: HCT 23.7. NO TX NEEDED YET.\nSOCIAL: DAUGHTER AND SON-IN-LAW IN WITH PT. MOST OF THE DAY. PLAN IS FOR HER DAUGHTER TO STAY OVERNIGHT AGAIN.\nDAUGHTER HAS REQUESTED THAT PT. NOT BE INFORMED OF POSSIBLE DX OF MULTIPLE MYELOMA. ATTENDING AGREES AT THIS TIME.\n"
},
{
"category": "Nursing/other",
"chartdate": "2201-03-03 00:00:00.000",
"description": "Report",
"row_id": 1622680,
"text": "NPN 1900 -0700\n\nNEURO PLEASANTLY CONFUSED AT TIMES, POOR SHORT TERM MEMORY. CHRONIC BACK PAIN CONTROLLED W/ DARVOCET AND LIDO PATCH. DOES OCC BECOME ANXIOUS. RECIEVED .5 ATIVAN OVERNOC FOR SLEEP W/ POOR RESULTS (?? SUGGEST TRAZADONE)\n\nRESP: LOOSE NON PRODUCTIVE COUGH,NEBS NOW Q 6 PRN, OCC I/E WHEEZES, MAINT SATS 99-100%\n\nC/V: PM HCT 22 (TRANSFUSE FOR< 21) SR -ST NO ECTOPY, BP STABLE, 1TEENS, LOPRESSOR DOSE INCREASED YESTERDAY TO 37.5 , TOL WELL.\n\nF/E/N: REPLETED PM K+ OF 3.2 W/ 40 KCL IV, RECIEVED ADDITIONAL 40MEQ LASIX W/ MOD RESPONSE ~ 500CC,NOW NEG FLUID BALANCE OF ~ .5 LITER. LOOSE STOOL VIA MUSHROOM CATH ( C DIFF POS) AM LYTES PENDING.TOL PO'S , ABLE TO SWALLOW PILLS.\n\nPLAN: D/C NGT IF CONT TO BE ABLE TO TOL PO'S, CONT AB TX, PAIN MANAGEMENT , DAUGHTER STILL DOES NOT WANT PT TO KNOW DX, FEARS THAT THE WORD \"MYELOMA\" BE TOO STRESS PRODUCING FOR PT AT THIS TIME . DAUGHTERS WISHES RESPECTED\n"
},
{
"category": "Nursing/other",
"chartdate": "2201-03-03 00:00:00.000",
"description": "Report",
"row_id": 1622681,
"text": "Resp Care Note, Pt seen for Q6 prn nebs.Last done 0530. BS scattered wheezes. Strong prod cough.Pt weak otherwise stable. Will cont to monitor resp status.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2201-03-01 00:00:00.000",
"description": "Report",
"row_id": 1622674,
"text": "Admitting and nursing progress note;\n\nThis is a 78 y/o lady admitted to 11R around 5am for delirium d/t low sodium and ? RF. Has h/o CHF, resp. failure, NSTIMI (cath stent), delirium, + c. diff in , low back pain, CAD, breast CA - bilat mats, HTN, pulm, stenosis, anxiety, MGUS, GERD. She was tx'd to FN ICU around 13:45 today d/t resp distress requiring NRB mask (metabolic acidosis), low u/o, febrile to 103.9 (rectally), rales/wheezing noted and decreased MS. morphine overnight, which she has an documented sensitivity too. Also, rec'd lasix, vanco, ceftriaxone, flagyl, azithromycin.\n\nReview of system:\n\nNeuro: Lethargic, but easily arouable. Confused and yells out the name (her grandson). Soft wrist restraints on for safety of lines/tubes. MAE.\n\nPulm: Wean from NRB to Hi-flow to 3L NC w/ stable o2 sats. RR regular and unlabored. Lungs w/ rhonchi throughout. No cough noted.\n\nCV: ST w/ occassional PVC's. Febrile to 102. BP stable. No edema noted. + ppp x 4. Poor access w/ several attempts at IV's (#22 to R Upper arm).\n\nGI/GU: Abd is soft, nt, nd. + hyperactive bs. Constant diarrhea w/ mushroom catheter placed. sump to right nares in place. Awaiting x-ray confirmation. Foley in place w/ adequate uo.\n\nPlan: Cont. w/ antibiotic treatment. Question placement of central line vs. picc line for better IV access. Monitor per protocol. Will attempt to sent labs.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2201-03-01 00:00:00.000",
"description": "Report",
"row_id": 1622675,
"text": "RESPIRATORY CARE: D: PT FROM 11 FOR RESPIRATORY DISTRESS\nAND WHEEZING.\nA: GIVEN 2.5 MG ALBUTEROL/ 0.5 MG ATROVENT SVN.\nR: SLIGHT SUBJECTIVE/ OBJECTIVE RX.\nP: FOLLOW Q4 FOR ALBUTEROL/ATROVENT SVN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2201-03-02 00:00:00.000",
"description": "Report",
"row_id": 1622676,
"text": "Respiratory Care:\nPatient received albuterol/atrovent unit dose medication in SVN via aerosol mask. Slight improvement with Rx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2201-03-02 00:00:00.000",
"description": "Report",
"row_id": 1622677,
"text": "neuro: dozing, agitated at times, confused. febrile, tmax 101.1 ax. tylenol given, cooling blanket on. ativan x1 given for agitation w/ good effect. bilat wrist restraints to prevent pulling lines.\n\nresp: exp. wheezes, nebs given w/ moderate effect. O2 sat 96-99%. RR increased to 3040s with agitation, c/o being unable to breath. improved with ativan.\n\ncv: hypotensive at start of shift, bp 60s. CVC placed, 1L LRx1 given with good effect. dropped to 70s-80s at 1am, 1L NSx1 given with good effect. at 3am became tachy 130s-140s, PO metoprolol given w/ good effect. current bp in 90s, ST 100s-110s. cvp 9-11.\n\ngi/gu: foley patent draining small amount of yellow urine. mushroom cath in place draining large amount of liq stool, c-diff+. +BS.\n\nplan: monitor bp and temp. replace lytes as necessary.\n"
},
{
"category": "Nursing/other",
"chartdate": "2201-03-02 00:00:00.000",
"description": "Report",
"row_id": 1622678,
"text": "RESPIRATORY CARE: PT W/ MILD EXP. WHEEZE. GIVEN\n2.G MG ALBUTEROL/ 0.5 MG ATROVENT SVN X 2 THIS\nSHIFT. MILD SUB/OBJ. RX TO TX. FOLLOW Q4.\n"
},
{
"category": "Radiology",
"chartdate": "2201-03-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 996229,
"text": " 4:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o progressive RUL consolidation, effusions, assess resolut\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with CHF, CAD, h/o c. diff trasnferred to ICU for hypoxia,\n tachypnea, fevers.\n REASON FOR THIS EXAMINATION:\n r/o progressive RUL consolidation, effusions, assess resolution or worsening of\n pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH:\n\n INDICATION: Followup.\n\n COMPARISON: .\n\n FINDINGS: The external parts of the nasogastric tube projects over the left\n hemithorax. Nasogastric tube and left-sided central venous access are\n unchanged. The size of the cardiac silhouette and the morphology of the lung\n parenchyma show no major changes as compared to previous examination.\n\n IMPRESSION: No relevant interval changes.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2201-03-08 00:00:00.000",
"description": "CT L-SPINE W/O CONTRAST",
"row_id": 997126,
"text": " 2:59 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: eval for fracture\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with multiple myeloma, focal pain of the rt. SI joint; MR\n completed but essentially uninterpretable due to motion artifact despite\n sedation\n REASON FOR THIS EXAMINATION:\n eval for fracture\n CONTRAINDICATIONS for IV CONTRAST:\n myeloma\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n CLINICAL HISTORY: 78-year-old female with multiple myeloma. Focal pain right\n over the SI joint.\n\n Evaluate for fracture.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast MDCT acquired axial images of the lumbar spine from\n T10 to the coccyx. Multiplanar reformatted images were obtained.\n\n FINDINGS: Image portion of the lower thoracic and lumbar spine demonstrate\n diffuse demineralization and severe degenerative change with compression\n deformities, most marked in L1 and T11. S-shaped scoliosis of the\n thoracolumbar spine is noted.\n\n Mild neural foraminal narrowing is identified at the right T9-T10 and T10-T11\n level secondary to uncovertebral spurring and endplate osteophytes. Note is\n made of moderate spinal canal narrowing at L4- L5 due to endplate osteophytes\n and ligamentum flavum hypertrophy. Limited views of the lung show small\n bilateral pleural effusions and atelectasis. Diffuse atherosclerotic\n calcification is present.\n\n IMPRESSION:\n 1. Severe demineralization of the bones which may be partially related to a\n systemic process, ie. multiple myeloma.\n 2. Extensive degenerative change involving the thoracolumbar spine. Note is\n made of compression deformities of the L1 and T11 vertebral bodies of\n undetermined chronicity.\n\n\n NOTE ADDED AT ATTENDING REVIEW: There are innumerable lytic lesions throughout\n the lumbar spine, sacrum, and iliac bones, compatible with myeloma. There is\n moderate spinal stenosis at L3-4 and severe spinal stenosis at L4-5 and L5-\n S1, apparently due to degenerative disk disease. However, the soft tissue\n component may be a combination of disk material, thick ligamentum flavum, and\n epidural tumor. The very limited MR does not demonstrate tumor in the canal,\n but it is not adequate to exclude this diagnosis.\n (Over)\n\n 2:59 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: eval for fracture\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2201-03-08 00:00:00.000",
"description": "CT PELVIS ORTHO W/O C",
"row_id": 997127,
"text": " 3:00 PM\n CT PELVIS ORTHO W/O C Clip # \n Reason: Eval for Sacral/pelvic fx. in region of rt. SI joint, focal\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with multiple myeloma, focal pain of the rt. SI joint; MR\n completed but essentially uninterpretable due to motion artifact despite\n sedation\n REASON FOR THIS EXAMINATION:\n Eval for Sacral/pelvic fx. in region of rt. SI joint, focal area of pain\n CONTRAINDICATIONS for IV CONTRAST:\n myeloma\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE PELVIS WITHOUT CONTRAST, \n\n CLINICAL INFORMATION: 78-year-old female with multiple myeloma and focal pain\n of the right sacroiliac joint. MRI was completed, but essentially\n uninterpretable due to motion artifact despite sedation. Evaluate for sacral\n and pelvic fracture in region of the right sacroiliac joint.\n\n FINDINGS:\n\n The bones are markedly osteopenic. There are innumerable lytic lesions within\n both the medullary cavity as well as within the cortex; some of the lesions\n breach the cortex. Innumerable lytic lesions are seen throughout the lumbar\n spine and throughout the iliac bones and sacrum. Lytic lesions are also seen\n within bilateral acetabula and proximal femora. There are bilateral dynamic\n compression screws in place traversing old intertrochanteric fractures. There\n are severe degenerative changes of the lower lumbar spine.\n\n There is mild widening of the superior aspect of the right sacroiliac joint of\n unclear etiology. No discrete erosive changes are identified in the right\n sacroiliac joint. No fracture is identified in the right sacroiliac joint.\n There are mild degenerative changes of bilateral sacroiliac joints. There is\n severe facet arthropathy at L5-S1 on the right.\n\n Evaluation of the pelvic contents demonstrates severe atherosclerotic disease\n of the abdominal aorta, extending into bilateral common iliac arteries. There\n is residual barium from a previous contrast study within the small bowel. The\n bladder is markedly distended. The bladder contains a moderate amount of air.\n Could this be secondary to recent instrumentation or catheterization?\n\n There is moderate streak artifact from bilateral hip prostheses limiting\n interpretation or evaluation of the pelvic viscera. There is moderate colonic\n diverticulosis without complication.\n\n IMPRESSION:\n\n 1. Severe osteopenia. Severe myelomatous involvement of the osseous\n structures, with innumerable lytic lesions involving both the medullary cavity\n and breaching the cortex of all visualized osseous structures. No displaced\n (Over)\n\n 3:00 PM\n CT PELVIS ORTHO W/O C Clip # \n Reason: Eval for Sacral/pelvic fx. in region of rt. SI joint, focal\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n fractures identified.\n\n 2. Mild widening of the right sacroiliac joint with respect to the left. No\n erosive change is identified at the right sacroiliac joint.\n\n 3. Severe degenerative changes of the lower lumbar spine, particularly at the\n right L5-S1 facet joint.\n\n 4. Severe atherosclerotic disease.\n\n 5. Markedly distended bladder, containing a moderate amount of air. Has the\n patient recently been instrumented?\n\n 6. Moderate sigmoid diverticulosis without complication.\n\n"
},
{
"category": "Radiology",
"chartdate": "2201-03-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 997000,
"text": " 11:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change - ? evolving consolidation, ? pulm\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with mult. myeloma, sob\n REASON FOR THIS EXAMINATION:\n eval for interval change - ? evolving consolidation, ? pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n HISTORY: Myeloma, shortness of breath.\n\n One portable view. Comparison with the previous studies of and\n .\n\n Bronchovascular markings are prominent, as before. Increased density is\n projected over the heart. The central pulmonary arteries are prominent. The\n heart appears enlarged. The aorta is calcified. Mediastinal structures are\n unchanged. A left subclavian catheter remains in place. A nasogastric tube\n has been withdrawn. Severe degenerative changes are noted in the spine and\n shoulders.\n\n IMPRESSION: Prominent interstitial markings which may reflect pulmonary\n vascular congestion, unchanged. Increased density projected over the heart\n which may represent a left lower lobe infiltrate. PA and lateral views would\n be helpful for further evaluation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2201-03-04 00:00:00.000",
"description": "SKELETAL SURVEY (INCLUD LONG BONES)",
"row_id": 996506,
"text": " 1:51 PM\n SKELETAL SURVEY (INCLUD LONG BONES) Clip # \n Reason: eval for lesions c/w multiple myeloma\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with likely multiple myeloma, low back pain\n REASON FOR THIS EXAMINATION:\n eval for lesions c/w multiple myeloma\n ______________________________________________________________________________\n FINAL REPORT\n SKELETAL SURVEY\n\n CLINICAL HISTORY: Multiple myeloma.\n\n No prior skeletal survey is available.\n\n Two lateral films of the skull were obtained showing multiple lytic lesions\n consistent with the history of multiple myeloma.\n\n Frontal and lateral films of the thoracic spine show osteopenia. There is a\n moderate diffuse compression fracture of T8. On the lateral film, T10-11 are\n distorted by scoliosis but no fracture of them is seen on the frontal view.\n\n Frontal and lateral films of the lumbar spine show fracture of L1. There is\n scoliosis and there are degenerative disc disease changes. Vascular\n calcifications are noted.\n\n AP view of the pelvis shows multiple small lucent lesions throughout the bony\n pelvis and proximal femurs. There are bilateral dynamic compression screws\n and rods.\n\n AP views of the femurs show innumerable small lytic lesions.\n\n AP views of both humeri show marked superior subluxation of the humeral heads\n relative to the glenoid with a bone-on-bone appearance, large osteophytes and\n subchondral sclerosis. There is remodeling of the proximal humeral shafts\n bilaterally, apparently related to the inferior margins of the glenoids and\n osteophytes in that region. Multiple small lytic lesions are seen throughout\n the humeri. There is deformity of the right radius perhaps related to surgery\n or old non-united fracture. Extensive myelomatous involvement was seen on a\n CT examination of the abdomen on . Due to osteopenia, the thoracic\n vertebral bodies are very difficult to evaluate on prior chest films. The T8\n fracture is new since .\n\n IMPRESSION: Innumerable small lytic lesions are seen throughout the\n visualized osseous structures consistent with the widespread myelomatous\n involvement seen on prior abdominal CT. Fractures of T8 and L1 are now\n visualized. There is marked deformity of the glenohumeral joints with\n superior subluxation of the humeral heads relative to the glenoids, sclerosis,\n osteophyte formation and remodeling of the proximal medial humeral diaphyseal\n regions.\n\n (Over)\n\n 1:51 PM\n SKELETAL SURVEY (INCLUD LONG BONES) Clip # \n Reason: eval for lesions c/w multiple myeloma\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2201-03-07 00:00:00.000",
"description": "MR L SPINE W/O CONTRAST",
"row_id": 996996,
"text": " 10:40 AM\n MR L SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST Clip # \n Reason: eval for L and T spine stability of vertbrae\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with multiple myeloma, back pain at lumbar and T spine, eval\n for acute fracture, neural compression\n REASON FOR THIS EXAMINATION:\n eval for L and T spine stability of vertbrae\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI SCAN OF THE THORACIC AND LUMBAR SPINE\n\n HISTORY: 78-year-old woman with multiple myeloma. Back pain within the\n lumbar and thoracic regions. Evaluate for acute fracture, compression and\n stability of the vertebra.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the thoracic spine was\n attempted.\n\n FINDINGS: This study is nearly uninterpretable due to gross motion artifacts.\n The axial T2-weighted scans of the thoracic spine, while also degraded by\n patient motion are of sufficient quality to show no definite sign of spinal\n cord compression. However, it appears that there is generalized low T1 signal\n throughout the visualized spinal column, a finding which would raise concern\n for the presence of diffuse infiltration of the bone, as in the setting of\n myeloma. There is a likely mild compression fracture of the T7 body. There is\n probable moderate spinal stenosis in the lumbar spine at L4/5, as well as\n L5/S1, but the absence of axial scans in the lumbar region reduces the ability\n of this study to assess for central canal stenosis. There is likely moderate\n distention of the urinary bladder. No further evaluation of this study with\n reliability can be undertaken at this time.\n\n CONCLUSION: Nearly uninterpretable study due to gross patient motion. CT\n might provide improved bony imaging, provided the patient can remain still.\n\n COMMENT: As noted above, the only axial images supplied at this time\n encompass the thoracic region.\n\n Findings were discussed with Dr. , hospitalist caring for this\n patient on .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2201-03-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 996146,
"text": " 10:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval changes\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman transferred to ICU for PNA, fluid overload\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n FOLLOWUP EXAMINATION.\n\n The left CVL and NGT remain in place. Less prominent and better defined\n pulmonary vasculature is noted, suggesting some improvement in fluid status.\n There are no new consolidations.\n\n"
},
{
"category": "Radiology",
"chartdate": "2201-03-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 996084,
"text": " 6:36 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please evaluate for NGT placement and any interval changes i\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with respiratory distress after flash pulm edema this AM,\n ?evolving PNA, NGT placed\n REASON FOR THIS EXAMINATION:\n please evaluate for NGT placement and any interval changes in\n effusions/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 18:42.\n\n INDICATION: Respiratory distress. NGT placement.\n\n COMPARISON: at 5:12.\n\n FINDINGS: Compared to the prior study, there is marked improvement in\n aeration of the lungs zones with resolution of much of the previously seen\n airspace and interstitial markings and better-defined pulmonary vasculature.\n A slight patchiness is seen in the right upper lung, and this could represent\n pneumonia. There is no pneumothorax, and the NGT is seen extending below the\n level of the left hemidiaphragm. Heart size still demonstrates cardiomegaly\n and a prominent left hilum is again noted.\n\n IMPRESSION: Marked improvement with resolution of pulmonary edema changes;\n residual consolidation of right upper lobe could represent pneumonia.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2201-03-02 00:00:00.000",
"description": "Report",
"row_id": 165375,
"text": "Normal sinus rhythm, rate 99. Borderline first degree A-V block. Borderline\nleft atrial abnormality. Inferior myocardial infarction of indeterminate age.\nExtensive anterior myocardial infarction of indeterminate age. Compared to the\nprevious tracing of the sinus rate is faster.\n\n"
},
{
"category": "ECG",
"chartdate": "2201-02-27 00:00:00.000",
"description": "Report",
"row_id": 165376,
"text": "Sinus arrhythmia. Prolonged P-R interval. Right bundle-branch block. Inferior\nQ waves represent prior myocardial infarction. Anterior Q waves could represent\nprior anteroseptal myocardial infarction. Compared to the previous tracing\nof no significant change.\n\n"
},
{
"category": "Nursing",
"chartdate": "2201-03-03 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 314530,
"text": "Hypotension (not Shock)\n Assessment:\n Normotensive, Afeb. WBC 8.5. On, zosyn , Vanco (Po/IV),\n Action:\n Metrprlol & ASA, statin\n Response:\n Stable, Diarrhea diminishing.\n Plan:\n Cont to assess, cont antibiotics for c-diff colitis & ? pneumonia\n .Contact precautions. D/C rectal tube.\n Hypoxemia\n Assessment:\n Sats 94-97% on RA. Denies SOB. BS with wheezes, Occas\n productive of yellow to white secretions\n Action:\n OOB to chair by PT, Encouraged to C, DB\n Response:\n Maintaining sats, RR, denies resp distress\n Plan:\n Follow RR, sat, BS . Assess need for duiresis. Goal I&O even to 500 cc\n negative\n Hypercalcemia (high Calcium)\n Assessment:\n Clacium 10.5 this AM. Oriented X3 but does occas makes inappropriate\n statements.\n Action:\n Received calcitonin & pamidronate X1\n Response:\n No change in previous exam\n Plan:\n Recheck PM labs after pamridronate infusion\n Multiple myeloma (Cancer, Malignant Neoplasm)\n Assessment:\n Myeloma labs coming back positive. Family concerned about using the\n words\nmyeloma\ncancer\n with pt as they are concerned about her\n response and the fact her MS continues to wax & wane. Pt has had BM BX\n in the past. Dtr, reports pt states pt became extremely anxious\n &agitiated\n Action:\n met with dtr. Family meeting with DR \n (ICU attending), (dtr), dtr\ns husband, social service, & this\n RN. Dtr voiced concerns as above as well as concern her mother will\njust give up\n. requested onc consult be deferred until she has an\n opportunity to speak with pt\ns oncologist , Dr. . Dr\n in agreement at this point given pt\ns waxing & MS.\n also conveyed his obligation as pt\ns physician to give pt\n information about their care, DX & treatment options so they can make\n informed decisions. Post meeting Dr. phoned Dr. &\n informed him about the meeting. Dr. will phone dtr this\n eve.\n Response:\n ICU team members & family aware of issues of care re: myeloma\n Plan:\n Called out to 12R. Convey plan with 12R multidisciplinary team\n Oncology consult deferred until meeting, input with Dr. \n ** Will not use terms\nmyeloma, cancer\n for the time being.\n Continue to evaluate MS.\n will follow up with dtr .\n Impaired Skin Integrity\n Assessment:\n Stage II pressure ulcer thoracic spine area 1.5cm X 1.5 CM. Skin\n excoriated/yeast perianal, gluteals as well as yeast rash.\n Action:\n Consulted by care RN\n Response:\n No change\n Plan:\n Criicare Qd and PRN. to perianal area & gluteal areas\n stage II thoracic ulcers cleanse with NS, pat dry, apply thin layer\n of gel then cover with Allevyn foam Q3 daysQD.\n Notify MD care RN with any deterioration\n D/C rectal tube. Replace with flexiseal tube if necessary\n First step mattress\n Demographics\n Attending MD:\n , \n Admit diagnosis:\n HYPONATREMIA\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 56.4 kg\n Daily weight:\n Allergies/Reactions:\n Morphine\n Unknown;\n Oxycodone\n Unknown;\n Dilaudid (Injection) (Hydromorphone Hcl/Pf)\n Confusion/Delir\n Precautions: Contact\n PMH: Anemia\n CV-PMH: CAD, CHF, Hypertension, MI\n Additional history: falls, delerium, c-diff, LBP.Breast ca, anxiety,\n elevated chol, GERD, pulm valvuloplasty, MGUS\n Surgery / Procedure and date: S/p bilat mastectomy\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:141\n D:70\n Temperature:\n 97.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 93 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,224 mL\n 24h total out:\n 1,410 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 06:01 AM\n Potassium:\n 3.3 mEq/L\n 06:01 AM\n Chloride:\n 106 mEq/L\n 06:01 AM\n CO2:\n 21 mEq/L\n 06:01 AM\n BUN:\n 24 mg/dL\n 06:01 AM\n Creatinine:\n 1.7 mg/dL\n 06:01 AM\n Glucose:\n 115 mg/dL\n 06:01 AM\n Hematocrit:\n 23.6 %\n 06:01 AM\n Additional pertinent labs:\n Due for labs at \n Lines / Tubes / Drains:\n L sc TL\n Valuables / Signature\n Patient valuables: none\n Other valuables:\n Clothes: Sent home with: dtr, \n / Money:\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4 \n Transferred to: 1280, 12R\n Date & time of Transfer: , 2230\n"
},
{
"category": "Nursing",
"chartdate": "2201-03-03 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 314523,
"text": "Hypotension (not Shock)\n Assessment:\n Normotensive, Afeb. WBC 8.5. On, zosyn , Vanco (Po/IV),\n Action:\n Metrprlol & ASA, statin\n Response:\n Stable, Diarrhea diminishing.\n Plan:\n Cont to assess, cont antibiotics for c-diff colitis & ? pneumonia\n .Contact precautions. D/C rectal tube.\n Hypoxemia\n Assessment:\n Sats 94-97% on RA. Denies SOB. BS with wheezes, Occas\n productive of yellow to white secretions\n Action:\n OOB to chair by PT, Encouraged to C, DB\n Response:\n Maintaining sats, RR, denies resp distress\n Plan:\n Follow RR, sat, BS . Assess need for duiresis. Goal I&O even to 500 cc\n negative\n Hypercalcemia (high Calcium)\n Assessment:\n Clacium 10.5 this AM. Oriented X3 but does occas makes inappropriate\n statements.\n Action:\n Received calcitonin & pamidronate X1\n Response:\n No change in previous exam\n Plan:\n Recheck PM labs after pamridronate infusion\n Multiple myeloma (Cancer, Malignant Neoplasm)\n Assessment:\n Myeloma labs coming back positive. Family concerned about using the\n words\nmyeloma\ncancer\n with pt as they are concerned about her\n response and the fact her MS continues to wax & wane. Pt has had BM BX\n in the past. Dtr, reports pt states pt became extremely anxious\n &agitiated\n Action:\n met with dtr. Family meeting with DR \n (ICU attending), (dtr), dtr\ns husband, social service, & this\n RN. Dtr voiced concerns as above as well as concern her mother will\njust give up\n. requested onc consult be deferred until she has an\n opportunity to speak with pt\ns oncologist , Dr. . Dr\n in agreement at this point given pt\ns waxing & MS.\n also conveyed his obligation as pt\ns physician to give pt\n information about their care, DX & treatment options so they can make\n informed decisions. Post meeting Dr. phoned Dr. &\n informed him about the meeting. Dr. will phone dtr this\n eve.\n Response:\n ICU team members & family aware of issues of care re: myeloma\n Plan:\n Called out to 12R. Convey plan with 12R multidisciplinary team\n Oncology consult deferrd until meeting, input with Dr. \n ** Will not use terms\nmyeloma, cancer\n for the time being.\n Continue to evaluate MS.\n will follow up with dtr .\n Impaired Skin Integrity\n Assessment:\n Stage II pressure ulcer thoracic spine area 1.5cm X 1.5 CM. Skin\n excoriated/yeast perianal, gluteals as well as yeast rash.\n Action:\n Consulted by care RN\n Response:\n No change\n Plan:\n Criicare Qd and PRN. to perianal area & gluteal areas\n stage II thoracic ulcers cleanse with NS, pat dry, apply thin layer\n of gel then cover with Allevyn foam Q3 daysQD.\n Notify MD care RN with any deterioration\n D/C rectal tube. Replace with flexiseal tube if necessary\n"
},
{
"category": "Nursing",
"chartdate": "2201-03-03 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 314513,
"text": "Hypotension (not Shock)\n Assessment:\n Normotensive\n Action:\n Metrprlol & ASA\n Response:\n Stable\n Plan:\n Cont to assess\n Hypoxemia\n Assessment:\n Sats 94-97% on RA. Denies SOB. BS with wheezes, Occasproductive of\n yellow to white secretions\n Action:\n Response:\n Plan:\n Follow RR, sats. Assess need for duiresis\n Hypercalcemia (high Calcium)\n Assessment:\n Clacium 10.5 this AM. Oriiented X3 but does occas makes inappropriate\n statements\n Action:\n Received calcitonin & pamidronate X1\n Response:\n Plan:\n Recheck PMlabs after pamridronate infusion\n"
},
{
"category": "Nursing",
"chartdate": "2201-03-03 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 314514,
"text": "Hypotension (not Shock)\n Assessment:\n Normotensive, Afeb. WBC 8.5. On, zosyn , Vanco (Po/IV),\n Action:\n Metrprlol & ASA, statin\n Response:\n Stable, Diarrhea diminishing.\n Plan:\n Cont to assess, cont antibiotics for c-diff colitis & ? pneumonia\n .Contact precautions. D/C rectal tube.\n Hypoxemia\n Assessment:\n Sats 94-97% on RA. Denies SOB. BS with wheezes, Occas\n productive of yellow to white secretions\n Action:\n Response:\n Plan:\n Follow RR, sat, BS . Assess need for duiresis\n Hypercalcemia (high Calcium)\n Assessment:\n Clacium 10.5 this AM. Oriented X3 but does occas makes inappropriate\n statements.\n Action:\n Received calcitonin & pamidronate X1\n Response:\n Plan:\n Recheck PM labs after pamridronate infusion\n Multiple myeloma (Cancer, Malignant Neoplasm)\n Assessment:\n Family concerned about the use of\nmyeloma\ncancer\n with\n Action:\n Response:\n Plan:\n"
},
{
"category": "Social Work",
"chartdate": "2201-03-03 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 314504,
"text": "Family Meeting:\n The patient\ns daughter, , wanted to speak with a s\n"
},
{
"category": "Rehab Services",
"chartdate": "2201-03-03 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 314508,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 428.0 / CHF\n Reason of referral: eval and treat\n History of Present Illness / Subjective Complaint: 78 y.o. Female found\n to be delerious and sliightly confused with hypercalcemia/hyponatremia.\n 5 days of productive cough with whitish sputum. Hypoxia with PNA versus\n flash pulmonary edema and acute on chronic diastolic HF. SPEP +\n suggesting myeloma\n Past Medical / Surgical History: HTN, CAd, s/p MI, B ORIF, R olecranon\n fracture, ulnar n. injury, pulmonary stenosis s/p valvuloplasty, appy,\n anxiety, GERd, C-diff, URI\n Medications: lorazepam, heparin, vancomycin, lasix\n Radiology: CXR 1.20: no evidence of new consolidation\n Labs:\n 23.6\n 7.9\n 134\n 8.5\n [image002.jpg]\n Other labs:\n Activity Orders: activity as tolerated\n Social / Occupational History: lives alone, dtr and son in law live\n across the street, dtr assists with shopping\n Living Environment: stairs to enter w/ rails and stairs to , tub bench, rails in BR\n Prior Functional Status / Activity Level: I amb w/ RW, was at rehab for\n short time but recently at home\n Objective Test\n Arousal / Attention / Cognition / Communication: Alert, oriented x\n self, iniitally eager to get oob>chair but became slightly upset at EOB\n but calmed. not oriented x hospital. thought at rehab but easily\n reoriented. Occasional non sensical statements. Understands use of call\n light. understands and verbalizes need to call for A when mobilizing\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 76\n 112/70\n 18\n 97 RA\n Rest\n /\n Sit\n 145/60\n 24\n 98 RA\n Activity\n /\n Stand\n /\n Recovery\n 82\n 111/54\n 17\n 95 RA\n Total distance walked:\n Minutes:\n Pulmonary Status: strong mildly congested cough, raises to upper\n airway. Coordinated breathing pattern\n Integumentary / Vascular: L CVP line, flexiseal, foley catheter,\n telemetry, thoracic stage 2 wound per wound care note\n Sensory Integrity: Detects all LT sensation UE/UE\n Pain / Limiting Symptoms: Unable to grade on VAS scale. C/o back pain\n in bed\n Posture: forward head and shoulders, kyphotic\n Range of Motion\n Muscle Performance\n WFL B throughout\n Able to move all extremities against gravity. UE/LE grossly \n Motor Function: moves all extremities, no abnormal movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Mod A to perform stand step transfer to chair with\n gait belt. No noted knee bucking.\n Rolling:\n\n\n\n T\n\n\n Supine /\n Sidelying to Sit:\n With HOB elevated\n\n\n\n\n T\n\n Transfer:\n Stand step transfer\n\n\n\n\n T\n\n Sit to Stand:\n\n\n\n T\n\n Ambulation:\n N/a\n\n\n\n\n\n\n Stairs:\n n/A\n\n\n\n\n\n\n Balance: sat EOB initially with Min A progressing to S with B UE\n support, requires mod A for balance during stand step transfer bed >\n Chair,\n Education / Communication: Communicated with RN to discuss case; RN\n aware pt in chair and prefers to have pt upright in chair. Pt\n understands use of call light and verbalizes need to call for A. RN to\n provide frequent checks for safety; recommend 2 A for staff to transfer\n patient back to bed - pt's dtr and son in law left to speak w/ MD at\n end of session and will need to discuss d/c plan with them\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Arousal, Attention, and Cognition, Impaired\n 3.\n Balance, Impaired\n 4.\n Knowledge, Impaired\n 5.\n Muscle Performace, Impaired\n 6.\n Transfers, Impaired\n Clinical impression / Prognosis: 78 y.o. female with confusion,\n hypercalcemia, hyponatremia, productive cough and acute on chronic\n diastolic heart failure presents with above impairments consistent with\n deconditioning. Pt was ambulating household distances I PTA and is now\n well below baseline and requiring A for all mobilizing. At this time do\n not feel pt is safe to return home, and will likely require inpatient\n rehab to maximize functional I and safety and return home. If daughter\n prefers to take patient home, would still require increased mobility to\n get to a level by which the dtr can safety care for patient. Likely 3\n days of extrememly limited mobility in combination with medical factors\n have led to current functional status, but anticipate pt could return\n to modified Independent ambulation with rolling walker with short term\n rehab stay.\n Goals\n Time frame: 1 week\n 1.\n Rolling CG A\n 2.\n Min A sup>sit with hob flat\n 3.\n sit>stand min A\n 4.\n ambulation w/ RW 50 ft w/ CGA\n 5.\n A & O x 3\n 6.\n Sits at EOB I with UE support\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: x/wk x 1 wk\n Rolling/Sup>sit hob flat, sit>stand, transfers, ambulation w/ RW,\n discussion w/ patient's family re: wishes, pt education - role of PT,\n d/c plan, increase upright tolerance, Recommend 2 A for nursing staff\n OOB>chair/back to bed from chair.\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n ( pt initially eager to get oob and participate- at EOB but wanted to\n get BTB but encouraged to get to chair and agreed)\n"
},
{
"category": "General",
"chartdate": "2201-03-03 00:00:00.000",
"description": "ICU Event Note",
"row_id": 314512,
"text": "Clinician: Attending\n I had a 60 minute meeting with the patient's daughter and son-in-law.\n They expressed the wish that the patient not be told about the\n diagnosis of myeloma. They are concerned that she will not be able to\n handle the information, that she might\ngive up\n, and that it would\n provoke severe anxiety.\n Since the patient's mental status is not completely clear now, this is\n a moot point at the moment. I conveyed to the family that I would share\n their wishes with the team and the nurses. When her mental status\n clears, however, I strongly urged them to be truthful with Ms \n since patient's often discern or become aware of their diagnosis\n despite the best efforts to protect them from the information;\n deception erodes the credibility of the caregivers and the family\n should this happen and often results in great anger within the patient.\n I also spoke with Dr. by phone. He agrees that the patient\n now meets diagnostic criteria for myeloma, and suspects the\n hypercalcemia is due to this condition. If so, the myeloma will likely\n need to be treated. Dr. will speak with Ms \ns daughter by\n telephone tonight.\n"
},
{
"category": "Rehab Services",
"chartdate": "2201-03-03 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 314510,
"text": "Attending: \n Referral date: \n Medical Diagnosis / ICD 9: 428.0 CHF\n Reason of referral: eval and treat\n History of Present Illness / Subjective Complaint: 78 y.o. Female found\n to be delerious and sliightly confused with hypercalcemia/hyponatremia.\n 5 days of productive cough with whitish sputum. Hypoxia with PNA versus\n flash pulmonary edema and acute on chronic diastolic HF. SPEP +\n suggesting myeloma\n Past Medical / Surgical History: HTN, CAd, s/p MI, B ORIF, R olecranon\n fracture, ulnar n. injury, pulmonary stenosis s/p valvuloplasty, appy,\n anxiety, GERd, C-diff, URI\n Medications: lorazepam, heparin, vancomycin, lasix\n Radiology: CXR 1.20: no evidence of new consolidation\n Labs:\n 23.6\n 7.9\n 134\n 8.5\n [image002.jpg]\n Other labs:\n Activity Orders: activity as tolerated\n Social / Occupational History: lives alone, dtr and son in law live\n across the street, dtr assists with shopping\n Living Environment: stairs to enter w/ rails and stairs to , tub bench, rails in BR\n Prior Functional Status / Activity Level: I amb w/ RW, was at rehab for\n short time but recently at home\n Objective Test\n Arousal / Attention / Cognition / Communication: Alert, oriented x\n self, iniitally eager to get oob>chair but became slightly upset at EOB\n but calmed. not oriented x hospital. thought at rehab but easily\n reoriented. Occasional non sensical statements. Understands use of call\n light. understands and verbalizes need to call for A when mobilizing\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 76\n 112/70\n 18\n 97 RA\n Rest\n /\n Sit\n 145/60\n 24\n 98 RA\n Activity\n /\n Stand\n /\n Recovery\n 82\n 111/54\n 17\n 95 RA\n Total distance walked:\n Minutes:\n Pulmonary Status: strong mildly congested cough, raises to upper\n airway. Coordinated breathing pattern\n Integumentary / Vascular: L CVP line, flexiseal, foley catheter,\n telemetry, thoracic stage 2 wound per wound care note\n Sensory Integrity: Detects all LT sensation UE/UE\n Pain / Limiting Symptoms: Unable to grade on VAS scale. C/o back pain\n in bed\n Posture: forward head and shoulders, kyphotic\n Range of Motion\n Muscle Performance\n WFL B throughout\n Able to move all extremities against gravity. UE/LE grossly \n Motor Function: moves all extremities, no abnormal movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Mod A to perform stand step transfer to chair with\n gait belt. No noted knee bucking.\n Rolling:\n\n\n\n T\n\n\n Supine /\n Sidelying to Sit:\n With HOB elevated\n\n\n\n\n T\n\n Transfer:\n Stand step transfer\n\n\n\n\n T\n\n Sit to Stand:\n\n\n\n T\n\n Ambulation:\n N/a\n\n\n\n\n\n\n Stairs:\n n/A\n\n\n\n\n\n\n Balance: sat EOB initially with Min A progressing to S with B UE\n support, requires mod A for balance during stand step transfer bed >\n Chair,\n Education / Communication: Communicated with RN to discuss case; RN\n aware pt in chair and prefers to have pt upright in chair. Pt\n understands use of call light and verbalizes need to call for A. RN to\n provide frequent checks for safety; recommend 2 A for staff to transfer\n patient back to bed - pt's dtr and son in law left to speak w/ MD at\n end of session and will need to discuss d/c plan with them\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Arousal, Attention, and Cognition, Impaired\n 3.\n Balance, Impaired\n 4.\n Knowledge, Impaired\n 5.\n Muscle Performace, Impaired\n 6.\n Transfers, Impaired\n Clinical impression / Prognosis: 78 y.o. female with confusion,\n hypercalcemia, hyponatremia, productive cough and acute on chronic\n diastolic heart failure presents with above impairments consistent with\n deconditioning. Pt was ambulating household distances I PTA and is now\n well below baseline and requiring A for all mobilizing. At this time do\n not feel pt is safe to return home, and will likely require inpatient\n rehab to maximize functional I and safety and return home. If daughter\n prefers to take patient home, would still require increased mobility to\n get to a level by which the dtr can safety care for patient. Likely 3\n days of extrememly limited mobility in combination with medical factors\n have led to current functional status, but anticipate pt could return\n to modified Independent ambulation with rolling walker with short term\n rehab stay.\n Goals\n Time frame: 1 week\n 1.\n Rolling CG A\n 2.\n Min A sup>sit with hob flat\n 3.\n sit>stand min A\n 4.\n ambulation w/ RW 50 ft w/ CGA\n 5.\n A & O x 3\n 6.\n Sits at EOB I with UE support\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: x/wk x 1 wk\n Rolling/Sup>sit hob flat, sit>stand, transfers, ambulation w/ RW,\n discussion w/ patient's family re: wishes, pt education - role of PT,\n d/c plan, increase upright tolerance, Recommend 2 A for nursing staff\n OOB>chair/back to bed from chair.\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n ( pt initially eager to get oob and participate- at EOB but wanted to\n get BTB but encouraged to get to chair and agreed)\n"
}
] |
13,934 | 118,258 | /P: 83M with h/o CAD, HTN, DM found unresponsive and hypoglycemic, now with multifocal pna concerning for aspiration, large left MCA stroke . Pt was found down in the field with hypoglycemia and respitaory failure. He was intubated in the field and transferred to for further care. There he was found to be in septic shock due to multi-focal PNA. He had end organ damage to kidneys, heart, lungs. He was treated with levo, flagyl, vanco. He was maintained on mechanical ventilation and on pressors. On antibiotics he slowly improved from a respiratory standpoint. His sedation and ventilation were weaned. After extubating the patient he was found to be unresponsive to verbal/painful stimuli. He was also noted to have a new right sided facial droop and he was not moving his right side. CT head then demonstrated a massive evolving left sided MCA infarct. Neuro stroke service was consulted. Follow up CT showed progression of the infarct as well as old right sided infarcts. Neuro felt his prognosis was extremely poor given the extent of his infarct. Family meeting was held and the patient was made DNR/DNI/CMO. He was then transferred to the floor from the MICU. He was maintained on morphine, ativan, scopolamine, tylenol for comfort. Palliative care was consulted and it was initially decided to transfer the patient to hospice. However, on the AM of anticipated transfer, it was noted that the patient was having significant periods of apnea, though he exhibited no signs of distress. Transfer was placed on hold, and the patient died later that afternoon. | Noaortic regurgitation is seen. There is abnormalseptal motion/position consistent with right ventricular pressure/volumeoverload. Nomasses or thrombi are seen in the left ventricle. There is mild symmetric leftventricular hypertrophy with mildy dilated cavity and moderate global leftventricular hypokinesis with akinesis of the distal third of the ventricle. Moderate [2+] TR.Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: Small pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor subcostal views. No LV mass/thrombus.LV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex -akinetic; septal apex- akinetic; inferior apex - akinetic; lateral apex -akinetic; apex - akinetic;RIGHT VENTRICLE: Mildly dilated RV cavity. Abnormalseptal motion/position consistent with RV pressure/volume overload.AORTA: Mildly dilated aortic root. Myocardial infarction.Height: (in) 68Weight (lb): 165BSA (m2): 1.89 m2BP (mm Hg): 132/64HR (bpm): 70Status: InpatientDate/Time: at 13:58Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.LEFT VENTRICLE: Mild symmetric LVH. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. The aorticvalve leaflets (3) are mildly thickened but aortic stenosis is not present. large area of low attenuation in right temporal lobe with loss of sulci, consistent with chronic infarct in right MCA distribution. Again seen is encephalomalacia in the right posterior temporal lobe, unchanged from the prior study. There is a verysmall pericardial effusion.IMPRESSION: Mild symmetric left ventricular hypertrophy with global andregional systolic dysfunction c/w diffuse process (toxin, metabolic,multivessel CAD, etc.) Ventricular paced rhythmAtrial mechanism is probable atrial fibrillationSince previous tracing of , no significant change The right ventricular cavityis mildly dilated. Ventricular paced rhythmAtrial mechanism is probably atrial fibrillationSince previous tracing of , no significant change Moderate globalLV hypokinesis. A right-sided pacemaker is seen with a single lead overlying the area of the right ventricle. The right costophrenic angle is not seen. Hypodense region within the right posterior temporal lobe with associated ex vacuo dilatation of the right occipital of the lateral ventricle, findings consistent with chronic infarction. The aortic root and ascending aorta are mildly dilated. General 1+ edema t/o.Pulm: Remains vented on CPAP settings. BS are diminished and rhoncherous on exam c slight clearing following sxn'ing. Recent ABG witin normal limits. LS coarse upper, diminished lower,C-V: HR 70-74, V-paced with occasional PAC's. Nursing Progress Note.EVENTS: Pt remains c fairly stable VS.RESP: Pt requires Q2-3 hr NTS for moderate amounts of thick bloody sec. Pt remains on QD IV Levofloxacin & Ceftriaxone dosing. Fluid balance -1700c at midnite.GI - Abd soft, +BS. resume outpt antihypertensives as indicated. Respiratory care Pt continues on PSV in NARD. On ceftriaxone/vanco/levo.Neuro - Exam has gradually improved a little o/n. Attempting to diurese.ROS:NEURO: Noted to be minimally responsive at start of shift, withdrawing only to deep and vigorous sternal rub. Pan cx, also stool c-diff sent. remains intubated on A/C. Extremities warm at start of shift, a bit cooler now.ACCESS: RIJ PreSep catheter removed; has a-line and 3 PIV's.SOCIAL: dtr called for update.A: could use better BP control; tolerating diureses; MS concerning.P: follow MS closely; if he does not wake up ? AM ABG c the following acceptable values; 7.47-40-97, no MV setting changes made today. AM WBCC cont to trend down c a value of 19.8. s/p pan C&S this AM. V-paced EKG waveform noted c no ectopy. Resp: Pt remains intubated on a/c 14/450/+5/40%. Freq oral care provided. Bs are clear with diminished bases, some wheezing was noted earlier, lasix given?Suctioned for moderate amounts of yellow bloody tinged secretions. Bs are clear bilaterally with diminished bases. +3 Anasarcoid.SOC: HCP dtr called this AM and kept up-to-date c POC/pt status. No restraints in place.CV: Hemodynamically stable c a tmax of 100.0, most recently 98.6. No breakdown on backside noted.Pts dtr called last pm, was updated by RN on pts condition.Plan: ?extubation today. Tylenol with T->98.6. Started on Lopressor; given 25mg X 2 per NGT and 5mg IV once with modest effect. cont to diurese as ordered. Cont neuro checks q2hr. LS mostly clear and diminished at bases, coarse at times as well.GI/GU: Tolerating TF Promote with fiber at 40cc/hr via NGT. V-paced EKG waveform c occ PAC's. ABG at 3am ph 7.28, Co2 42, O2-138GI: abd softly distended. LS fairly clear in upper apices today, diminished @ bases. Resp pattern fairly nl asside from occ slowing/speeding up of rate c nl sats maintained. Last ABG = 7/31-44-122. AM ABG's 7.47/40/97/30. Short periods of agonal breathing when hypertensive, resp pattern now normal.CV - BP 170s->190s (200s)/70s. ABGS within normal limits for pt. pt extubated to nasal cannula as ordered through status. BUN=28/ Creat.=1.1.Skin: remains edematous ---periorbital and facial edema unchanged. pt is +10L (h/o CAD,HTN,CABG, CHF,Pacer)Resp: vented on PS 15, Peep 10, 40%, #8.0 ETT 24cm at lips. Hct stable, WBC slightly decreased. Lactic Acid range from 2.5-3.3.GI: OGT intact placement checked by auscultation and confirmed by CXR. Left radial Aline with good waveform and correlation to NBP....BP= 111-135/58-70. AM lytes WNL. HR 70 and V-paced with occas. Versad drip at 1mg, fentanyl at 50mcg, Levo remains offID: afebrile max temp 98.9 tonight. self sufficent. CVP13-17,SVO2 67-70. Scant thick tan sec per ETT today. Continues with peripheral and facial edema. Turned q 3 hrs, skin care given. Lungs clear bilat upper lobes and with rales at bilateral lower lobes. The pt is +2 anasarcoid. BP 91-129/ 48-64. NGT to rt nare. ?IV/Access: Right IJ TLC with precep line. Withdraws left extremities and right LE to stimuli. on Vanco, Levaquin, flagyl. CT Head neg in ER. pt is purposeful.Cardiac: Levo off since 1am. admitting shift note 2100-700Pt admitted from ER intubated, on Levophed drip for BP control, low urinary output, WBC 13.9, continue on sepsis protocol.Neuro: opens eyes to noise and spontanously. V-paced 70s. Bowel sounds hypoactive. PERRL though R eye now deviated to the L of center. FSBS WNL.GU - UOP 30-100cc/hr. minimial output. Pt switched from CPAP to A/ M.D.. Suctioned moderate amt of thick bloody secretions. MICU nursing progress note 7P-7AEvents - Pt became increasingly hypertensive, BP refractory to lopressor and hydralazine, started on nipride gtt with gradual decrease in BP, goal SBP 140-160. | 42 | [
{
"category": "Echo",
"chartdate": "2154-09-24 00:00:00.000",
"description": "Report",
"row_id": 64802,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 68\nWeight (lb): 165\nBSA (m2): 1.89 m2\nBP (mm Hg): 132/64\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 13:58\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity. Moderate global\nLV hypokinesis. No LV mass/thrombus.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex -\nakinetic; septal apex- akinetic; inferior apex - akinetic; lateral apex -\nakinetic; apex - akinetic;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. RV function depressed. Abnormal\nseptal motion/position consistent with RV pressure/volume overload.\n\nAORTA: Mildly dilated aortic root. Focal calcifications in aortic root. Mildly\ndilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Small pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Based on\n AHA endocarditis prophylaxis recommendations, the echo findings indicate\na low risk (prophylaxis not recommended). Clinical decisions regarding the\nneed for prophylaxis should be based on clinical and echocardiographic data.\n\nConclusions:\nThe left and right atrium are moderately dilated. There is mild symmetric left\nventricular hypertrophy with mildy dilated cavity and moderate global left\nventricular hypokinesis with akinesis of the distal third of the ventricle. No\nmasses or thrombi are seen in the left ventricle. The right ventricular cavity\nis mildly dilated. Systolic function appears depressed. There is abnormal\nseptal motion/position consistent with right ventricular pressure/volume\noverload. The aortic root and ascending aorta are mildly dilated. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild to moderate (+) mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen.\nThere is moderate pulmonary artery systolic hypertension. There is a very\nsmall pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with global and\nregional systolic dysfunction c/w diffuse process (toxin, metabolic,\nmultivessel CAD, etc.) Pulmonary artery systolic hypertension. Mild-moderate\nmitral regurgitation.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-09-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 880270,
"text": " 2:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Acute hemorrhage\n Admitting Diagnosis: SEPSIS,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with PNA sepsis, intubated, now off sedative meds and minimally\n responsive.\n REASON FOR THIS EXAMINATION:\n Acute hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old with pneumonia and sepsis with acute mental status\n changes, evaluate for hemorrhage.\n\n COMPARISONS: CT head of .\n TECHNIQUE: Axial MDCT images through the brain without IV contrast.\n\n CT HEAD FINDINGS: There has been interval development of a large left MCA\n distribution subacute infarction, which was not present on the prior study of\n . probable clot within a dense left MCA is visualized. There is no\n associated hemorrhagic component. There is mild local mass effect without\n shift of midline structures. Again seen is encephalomalacia in the right\n posterior temporal lobe, unchanged from the prior study.\n\n IMPRESSION:\n 1) Interval development of large left MCA distribution infarction, with\n probable clot in the hyperdense proximal MCA. There is no evidence of a\n hemorrhagic component.\n 2) Stable encephalomalacia in the right posterior temporal lobe.\n\n Findings phoned to Dr. after the study.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2154-09-25 00:00:00.000",
"description": "Report",
"row_id": 132888,
"text": "Continuous ventricular pacing. No organized atrial activity. Compared to the\nprevious tracing of no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2154-09-25 00:00:00.000",
"description": "Report",
"row_id": 132889,
"text": "Ventricular paced rhythm\nAtrial mechanism is probably atrial fibrillation\nSince previous tracing of same date, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2154-09-25 00:00:00.000",
"description": "Report",
"row_id": 132890,
"text": "Ventricular paced rhythm\nAtrial mechanism is probably atrial fibrillation\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2154-09-24 00:00:00.000",
"description": "Report",
"row_id": 132891,
"text": "Ventricular paced rhythm\nAtrial mechanism is probable atrial fibrillation\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2154-09-23 00:00:00.000",
"description": "Report",
"row_id": 132892,
"text": "Ventricular paced rhythm. compared to the previous tracing of no change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2154-09-22 00:00:00.000",
"description": "Report",
"row_id": 132893,
"text": "Ventricular paced rhythm. Probable underlying atrial fibrillation. No previous\ntracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-09-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 879940,
"text": " 3:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess progression of PNA\n Admitting Diagnosis: SEPSIS,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man unresponsive, intubated for hypoxic respiratory failure\n REASON FOR THIS EXAMINATION:\n assess progression of PNA\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Patient unresponsive, hypoxic.\n\n CHEST: Diffuse alveolar opacifications are again seen in both the right and\n left lungs. Appearances are essentially unchanged since the prior chest x-ray\n of . The position of the various support lines and tubes is\n unchanged.\n\n IMPRESSION: Extensive alveolar infiltrates still present.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-09-23 00:00:00.000",
"description": "P RENAL U.S. PORT",
"row_id": 879973,
"text": " 10:26 AM\n RENAL U.S. PORT Clip # \n Reason: low UOP, blood at meatus, large volume infused\n Admitting Diagnosis: SEPSIS,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with septic shock/b/l PNA, ? NSTEMI\n REASON FOR THIS EXAMINATION:\n low UOP, blood at meatus, large volume infused\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Low urine output with septic shock, and possible recent MI.\n\n RENAL ULTRASOUND, PORTABLE: Examination limited secondary to patient body\n habitus and portable technique. The left kidney measures 13 cm and contains\n two large rounded anechoic cystic structures consistent with simple renal\n cysts, the largest measuring 6.3 x 6.1 x 6.1 cm. The right kidney measures 12\n cm. Neither kidney displays hydronephrosis or contains stones. The cortices\n demonstrate normal echogenicity. Scan done in the area of the bladder shows\n no evidence for bladder distention.\n\n IMPRESSION: No evidence for hydronephrosis. Large simple renal cyst on the\n left kidney as described above. Otherwise, normal appearing kidneys\n bilaterally.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-09-22 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 879922,
"text": " 6:07 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval for placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man unresponsive, intubated s/p line placement\n\n REASON FOR THIS EXAMINATION:\n eval for placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old man, unresponsive, intubated, status post line\n placement. Evaluate placement.\n\n COMPARISON: AP supine portable chest x-ray dated at 16:36.\n\n AP SUPINE PORTABLE CHEST X-RAY: There has been interval placement of a right\n internal jugular central venous catheter with the tip in the mid SVC. An\n endotracheal tube remains in unchanged position approximately 6 cm above the\n carina. There is no pneumothorax identified on the supine radiograph. There\n has been interval worsening of multifocal patchy opacities primarily within\n the left mid, and right lower lung zones, concerning for aspiration pneumonia.\n The surrounding soft tissue and osseous structures are unchanged. Old healed\n rib fractures are again identified within multiple left posterior vertebral\n bodies.\n\n IMPRESSION:\n 1) Right IJ in mid SVC. No pneurmothorax.\n 2) Worsening bilateral multifocal opacities concerning for aspiration.\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-09-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 880359,
"text": " 8:09 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: determine extent of cva and edema\n Admitting Diagnosis: SEPSIS,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with new l cva discovered \n REASON FOR THIS EXAMINATION:\n determine extent of cva and edema\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Follow up left MCA stroke.\n\n COMPARISONS: CT head of .\n TECHNIQUE: Axial MDCT images through the brain without IV contrast.\n\n CT HEAD FINDINGS: There is an evolving left middle cerebral arterial\n distribution infarction. Compared to the prior day, there is slightly more\n edema and mass effect with further impression of the left lateral ventricle.\n There is no hemorrhagic transformation within this infarction, and no evidence\n of hemorrhage elsewhere within the brain parenchyma. Stable appearance of\n encephalomalacia in the right posterior temporal region, unchanged from\n multiple prior studies. No other short interval change.\n\n IMPRESSION: Evolving left MCA distribution infarction, with slightly more\n edema and mass effect compared to the prior day's study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-09-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 879913,
"text": " 4:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: tube placement, r/o aspiration\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man unresponsive, intubated\n REASON FOR THIS EXAMINATION:\n tube placement, r/o aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old man unresponsive, intubated. Evaluate tube\n placement.\n\n COMPARISON: None.\n\n AP SUPINE PORTABLE CHEST X-RAY: The study si limited due to patient\n positioning. An endotracheal tube is positioned approximately 7 cm superior\n to the carina. Sternal wires and sutures indicate prior coronary artery bypass\n graft. A right-sided pacemaker is seen with a single lead overlying the area\n of the right ventricle. The cardiac silhouette is prominent with intramural\n aortic calcifications. Multifocal patchy opacities in bilateral lungs are\n concerning for aspiration pneumonia. There is no left pleural effusion. The\n right costophrenic angle is not seen. Multiple old, healed left sided\n posterior rib fractures are seen.\n\n IMPRESSION:\n 1. Endotracheal tube approximately 7 cm superior to the carina.\n 2. Multifocal pneumonia concerning for aspiration.\n\n These findings were called to Dr. at 5 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-09-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 879914,
"text": " 4:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o stroke, bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man found unresponsive\n REASON FOR THIS EXAMINATION:\n r/o stroke, bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DFDdp SUN 5:23 PM\n no intracranial hemorrhage or mass effect. large area of low attenuation in\n right temporal lobe with loss of sulci, consistent with chronic infarct in\n right MCA distribution. atrophy.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Unresponsive.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n HEAD CT WITHOUT IV CONTRAST: No intracranial hemorrhage, mass effect, or\n shift of normally midline structures is noted. Large area of hypodensity with\n encephalomalacic change is noted within the posterior right temporal lobe with\n associated ex vacuo dilatation of the occipital of the right lateral\n ventricle, findings likely representing chronic infarction in the territory of\n the right middle cerebral artery. Additionally, bilateral periventricular\n white matter hypodensities are present, consistent with chronic microvascular\n infarction. There is widening of the sulci and ventricles, consistent with\n cerebral atrophy. There is opacification of the left sphenoid sinus and\n mucosal thickening involving the right sphenoid sinus and ethmoid air cells.\n The mastoid air cells and remaining visualized paranasal sinuses are clear.\n Surrounding osseous and soft tissue structures are unremarkable.\n\n IMPRESSION:\n 1. Hypodense region within the right posterior temporal lobe with associated\n ex vacuo dilatation of the right occipital of the lateral ventricle,\n findings consistent with chronic infarction.\n 2. Chronic small vessel ischemic disease.\n 3. No intracranial hemorrhage or mass effect.\n\n DFDdp\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-25 00:00:00.000",
"description": "Report",
"row_id": 1443923,
"text": "Respiratory Care Note:\n Patient remains on full vent support and appears non-responsive. Taken to CT for scan of head this afternoon. Results pending. Plan to maintain on present settings at this time. See Carevue flowsheet for specifics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-25 00:00:00.000",
"description": "Report",
"row_id": 1443924,
"text": "ADDENDUM 18:35\n\nMedical and Neuro team spoke with family about prognosis, and the critical nature of the next 24-48hrs with regards to pt survival.\nPt's daughter very upset due to losing mother suddenly in this hospital also, and also recently losing her brother. SW called and saw briefly, support given and will follow up in am.\nFamily now home for the night\nNeuro team recommend keeping SBP between 140-160mmHg, so 20mg IV Hydralazine given and Lopressor increased to 75mg to start at 12mn.\n\nRepeat lytes and CK-MB/Troponin sent at 18:00.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-26 00:00:00.000",
"description": "Report",
"row_id": 1443925,
"text": "MICU nursing progress note 7P-7A\nEvents - T 101.4. Pan cx, also stool c-diff sent. Tylenol with T->98.6. WBC 21.6 (18.5). On ceftriaxone/vanco/levo.\n\nNeuro - Exam has gradually improved a little o/n. PERL, 2mm, sluggish. + cough, impaired gag. will occ move LUE and LLE spontaneously. Moves left side and RLE to stimulus, initially only to nailbed pressure but now to touch. Gave a squeeze with left hand when asked and able to repeat it again x 2. No eye opening. Biting down during mouth care.\n\nResp - Received on AC 14 x 450, + 5, 40%. RR 22-28. Sats 97-100%. Lungs clear, diminished at bases. Sx several times for sm/mod thick tan, sometimes bloody tinged secretions. Frank blood from mouth during turning, no ulcers visible. Thick yellow secretions orally x 1.\n\nCV - BP 181/66, hydralazine 20mg x 2 with no effect. Lopressor 75 mg (scheduled dose) and BP decreased to 140s-150s/60s. V-paced 70, no ectopy. K 3.8, repleted->4.2. +3 anasarca. Fluid balance -1700c at midnite.\n\nGI - Abd soft, +BS. Inc foul smelling soft brown stool, OB (-). TF at goal 40cc/hr, no residuals. FSBS WNL.\n\nGU - UOP 35-110cc/hr. Small clots in urine.\n\nSocial - Son in last night to see pt and spoke with RN, he has been estranged from father for several years. Daughter called for update.\n\nPlan - Follow fever curve. Vanco trough before 12noon dose. Head Ct today. Neuro checks q 2 hrs. Goal SBP 140-160.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-26 00:00:00.000",
"description": "Report",
"row_id": 1443926,
"text": "Resp: Pt remains intubated on a/c 14/450/+5/40%. Bs are clear bilaterally with diminished bases. Suctioning small to moderate amounts of bloody tinged thick yellow secretions. No abg's or changes this shift. RSBI=56. RN reports following some commands. Will continue full vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-26 00:00:00.000",
"description": "Report",
"row_id": 1443927,
"text": "Respiratory Care\n\n Pt changed to PSV 5/5 .40 In NARD. B/S sl coarse sx sm-mod amount thick yellow. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-24 00:00:00.000",
"description": "Report",
"row_id": 1443918,
"text": "Nursing note (0700-1900) 16:00\n\nEVENTS:\n\nECHO and SBT.\n\n\nNeuro.\nPt responding to verbal stimuli, opening eyes and moving limbs on bed, pt trying to mouth words around ETT.\nPt continues on Fent 50mcg/hr and Versed 1mg/hr to keep comfortable, with good effect. Pt following commands intermittantly ? due to lack of hearing.\n\nResp.\nPt back on AC 25/450/peep5/40% following SBT this pm for 30mins, which pt tollerated well, abg 7.38/49/76.\nLS clear to coarse with minimal secretions sx'd during the day, continue to be blood tinged.\n\nCVS.\nHR 70's V-Paced with rare ectopy seen, BP 110's-130's/50's-60's, remains off pressors, no further fluid boluses required either.\nCVP 12-20 depending on position.\nAwaiting verified results of echo from today, Cards consult to follow at some point.\nVit K 5mg given for INR of 2.2.\n\nGI/GU.\nPt tollerating TF's at goal of 40mls/hr with no residuals, pt with +BS though no BM as yet this shift.\nPt with continued poor UOP via foley (20-30mls/hr), plan is to diurese if remains stable heamodynamicaly and aim for even balance for the day, pt currently 800+ve.\n\nSkin.\nPt's skin remains intact, pressure areas all within normal, skin is warm and a little pale.\n\nSocial.\nVisited by daughter this am, updated as to plan of care. She states facial swelling is much improved from previous days.\n\nPlan.\n? Diurese.\nPull precept catheter.\nFollow Troponin etc in am labs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-24 00:00:00.000",
"description": "Report",
"row_id": 1443919,
"text": "Respiratory Care\nPt. remains intubated on A/C. Pt. Placed on SBT for 1hr and tol well.\nRSBI during trial was 33 and NIF was -25. Recent ABG witin normal limits.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-25 00:00:00.000",
"description": "Report",
"row_id": 1443920,
"text": "NPN 1900-0700:\n\nEVENTS: Less responsive than previously documented. Becoming hypertensive. Attempting to diurese.\n\nROS:\nNEURO: Noted to be minimally responsive at start of shift, withdrawing only to deep and vigorous sternal rub. Sedation halved without much improvement, then D/C'd entirely. He has been off all sedation since MN and remains minimally responsive, though perhaps slightly improved. Very little spontaneous movement noted; pupils pinpoint and sluggish. No seizure activity observed. Pt had not recieved Depakote since admission, but it was resumed tonight; unclear from chart why he is on it.\nRESP: No vent changes, no ABG's ordered. Sats mid-high 90's. Current vent settings: CMV .4/450/25/5 with rare spontaneous breaths. Suctioned several times w/NS lavage for thick pluggy red/brown secretions. LS coarse upper, diminished lower,\nC-V: HR 70-74, V-paced with occasional PAC's. Initially BP 140's-150's, rising to 160's-170's. Started on Lopressor; given 25mg X 2 per NGT and 5mg IV once with modest effect. BP has improved as he has been diuresed and is now 120's. Phos 2.o, others lytes WNL.\nID: Afebrile, WBC up to 18.9 (15.7). PreSep catheter tip sent for cx; no change in abx.\nGI: Belly benign, no stool, tolerating TF's.\nGU: Given 10mg IV Lasix at 2100 with minimal effect; remained nearly 1L positive for the day. Given additional 20mg IV Lasix at 0400 with better response, and he is now running negative.\nENDO: Sugars well-controlled on current regimen.\nHEME: INR down to 1.5 (2.2); ordered for 2 more doses Vit K to be given today and tomorrow. Hct 26-27, stable, no evidence of active bleeding.\nSKIN: intact. Extremities warm at start of shift, a bit cooler now.\nACCESS: RIJ PreSep catheter removed; has a-line and 3 PIV's.\nSOCIAL: dtr called for update.\n\nA: could use better BP control; tolerating diureses; MS concerning.\n\nP: follow MS closely; if he does not wake up ? if he may need head CT to r/o bleed. wean from vent as able. resume outpt antihypertensives as indicated. bowel meds. cont to diurese as ordered. continue supportive care; inform and support family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-25 00:00:00.000",
"description": "Report",
"row_id": 1443921,
"text": "Resp: Pt rec'd on a/c 25/450/5+/40%. Bs are clear with diminished bases, some wheezing was noted earlier, lasix given?\nSuctioned for moderate amounts of yellow bloody tinged secretions. Ett #8 retaped & secured @ 24 lip. RSBI=69. No orders to attempt wean. Will continue full support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-25 00:00:00.000",
"description": "Report",
"row_id": 1443922,
"text": "Nursing note (0700-1900) 16:00\n\nEVENTS: Head CT.\n\n\nNeuro.\nPt remains minimaly responsive to noxious stimuli, pupils remain sluggish to light, not following commands, some non-purposeful movement to the limbs on the Left, non to the the right.\nCT head done this pm showing areas of infarct, family coming back later to speak with medics regarding implications.\n\nRESP.\nPt remains on AC, with rate now set to 14, pt overbreathing to rate of 25. No plans to wean due to change in MS. LS clear to coarse UL's with diminished LL's. Pt for thick yellow/tan/bloody secretions Q3-4hrs.\n\nCVS.\nHR 70's V-Paced with rare PAC's, EKG performed this am, unchanged from previous.\nBP 160's-170's/70's-80's, Lopressor increased to 50mg BD, with little effect as yet.\n\nID.\nPt with low grade temp, continues on multiple antibiotics, awaiting results from catheter tip cultures.\n\nGI/GU.\nPt remains on TF's at goal of 40mls/hr, min. residuals, +BS with medium sized brown soft stool passed this pm, Guiac -ve.\nPt with good response to further dose of Lasix 20mg this pm, pt currently -ve 1500mls (goal of -1 to -2L). Urine remains amber in colour with sediment.\n\nSkin.\nPt's skin is pale as previous and remains cool to the touch at the extremeties, all pressure areas are intact.\n\nSocial.\nPt's daughter is coming in to discuss the results of the head CT this pm with medics, so as to help decide future POC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-29 00:00:00.000",
"description": "Report",
"row_id": 1443938,
"text": "Nursing Progress Note.\n\nEVENTS: Pt remains c fairly stable VS.\n\nRESP: Pt requires Q2-3 hr NTS for moderate amounts of thick bloody sec. Sats drift down between sxn'ing c values in the 70's and up to the 90's s/p successful sxn'ing. Of note, L nare appears to be easier to pass sxn'ing cath to perform NTS. Now considering placing nasal trumpet to facilitate passage of sxn cath to minimize airway trauma. Resp pattern is agonal c death rattle noted, Scopolamine patch placed this afternoon to minimize airway sec. BS are diminished and rhoncherous on exam c slight clearing following sxn'ing. Freq oral care provided. Cough reflex is weak but intact, no gag reflex evident. RR ranges from 20's to 30's.\n\nMS: Pt does not appear uncomfortable or in pain c no response to noxious stimuli, will utilize IV Morphine Sulfate if pt appears distressed/SOB. PERRL, sluggishly.\n\nCV: Rectal Tmax of 101.5 this AM, med c 650mg Acetaminophen PR. +3 Anasarcoid.\n\nSOC: HCP dtr called this AM and kept up-to-date c POC/pt status. The pt is .\n\nOTHER: Please see CareVue for additional pt care data/comments. Universal isolation precautions in place.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-27 00:00:00.000",
"description": "Report",
"row_id": 1443930,
"text": "MICU A NPN 7p-7a\nNeuro: Neuro checks done q2hr overnight, no changes in neuro assessment noted. Pt cont to have nonpurposeful movement on left side, no movement noted on right side. PERRL, roving eye movement noted as well. +cough. Withdraws to painful stimuli, no eye opening noted at all.\n\nCV: VPaced at 70 bpm, some occasional ectopy noted this morning. SBP has been elevated most of shift, pt requiring lopressor ivp and hydralazine ivp in addition to scheduled po lopressor dose to get SBP to goal range of 140-160. BP rises significantly with any nursing care or stimuli. Tmax 101.5, pt was pancx and given tylenol 650mg. 2 new PIVs placed,? if pt will need central access, currently not on any cont. gtts. General 1+ edema t/o.\n\nPulm: Remains vented on CPAP settings. ABG done in am and pt appears to be tolerating settings well. Currently on Peep 5 PS 5 40%, RR 20's and O2 sat high 90's. Sxned for thick tan/yellow secretions in mod. to copious amts. LS mostly clear and diminished at bases, coarse at times as well.\n\nGI/GU: Tolerating TF Promote with fiber at 40cc/hr via NGT. No residuals. Abd soft, obese, +BS. +BM this am, brown and loose, guiac -. FSBS checks done q6hr, pt did not require SS coverage, but did get scheduled 70/30 dose this am. U/O 30-85cc/hr of clear yellow urine.\n\nSkin: Warm, dry and pale. Pt with general + edema, and scrotal edema as well. No breakdown on backside noted.\n\nPts dtr called last pm, was updated by RN on pts condition.\n\nPlan: ?extubation today. Pt is tolerating CPAP settings well. ?Family meeting to discuss code status. Cont neuro checks q2hr. Maintain SBP in 140-160 range. Cont to follow cultures.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-27 00:00:00.000",
"description": "Report",
"row_id": 1443931,
"text": "Respiratory care\n\n Pt continues on PSV in NARD. B/S sl coarse sx for sm/mod thick tan secretions. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-27 00:00:00.000",
"description": "Report",
"row_id": 1443932,
"text": "Nursing Progress Note.\n\nEVENTS: Family conference.\n\nMS: The pt remains non-purposeful off all sedation. PERRL. Pt does not follow commands. Pt rarely lifting LUE, LE's but does not move RUE. Pt moves LUE & LE's to noxious stimuli. No overt seizure activity evident. Pt bites down during mouth care. Good cough reflex, impaired/non-existent gag reflex. CT results from s improvement in findings c massive L sided MCA infarct and old R sided infarct. No restraints in place.\n\nCV: Hemodynamically stable c a tmax of 100.0, most recently 98.6. V-paced EKG waveform noted c no ectopy. Plus two anasarcoid. AM magnesium value of 1.9 repleted c 3gm IV Magnesium Sulfate. AM WBCC cont to trend down c a value of 19.8. s/p pan C&S this AM. IV Vanco dosing changed from Q24 hr to Q12 hr today. Adequate hourly UO, the pt is currently net positive 400ml input today and is net input 16 liters LOS. Urine is yellow c + sedimentation noted. Pt remains on QD IV Levofloxacin & Ceftriaxone dosing. AM sodium lab value of 134 noted, will limit free H2O intake. Pt SBP maintained in the 140-160 range today, required 5mg IV Lopressor @ 13:00 for SBP transiently in the 160 range.\n\nRESP: Pt received and maintained on CPAP/PS 5/5 c 40% FiO2 in place c nl sats, RR in the 20's and nl resp pattern. Pt c good cough reflex requiring Q2-3 hr sxning for thick tan/mucoid sec per ETT. ETT rotated and changed today. AM ABG c the following acceptable values; 7.47-40-97, no MV setting changes made today. Minute vol in the liter/min range. LS fairly clear in upper lobes today, diminished @ bases.\n\nGI: Pt received/maintained on Promote c Fiber @ target rate of 40ml/hr via NGT c low residuals noted all day. Pt passed one medium sized soft brown stool today, guaic negative.\n\nSOC: Pts HCP (HCP) accompanied by fiance () met c Neuro & MICU teams to discuss pt clinical status and prognosis s/p repeat head CT on . Per team, the pt has a grim prognosis & uncertain rehab potential s/p massive CVA. Family now moving in direction of extubating pt and making CMO. Family will now discuss pts case among themselves before making any pt care changes @ this time. Social work was able to meet/discuss care issues @ length today. Family members (including son by phone) kept up-to-date c POC/pt status. Verbal & non-verbal support also provided to family. Family declined religious consult. The pt remains a Full Code @ this time.\n\nDERM: Intact @ this time, turning Q3-4 hrs.\n\nOTHER: Please see CareVue for additional pt care data/comments. Univ isolation precautions in place.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-28 00:00:00.000",
"description": "Report",
"row_id": 1443933,
"text": "MICU nursing progress note 7P-7A\nEvents - Pt became increasingly hypertensive, BP refractory to lopressor and hydralazine, started on nipride gtt with gradual decrease in BP, goal SBP 140-160. Pt is DNR, family to decide today whether to make pt d/t poor prognosis S/P L MCA infarct.\n\nNeuro - Exam unchanged. PERL, brisk. Withdraws left extremities and right LE to stimuli. No movement right UE. Occ spontaneous movement left arm. Bites down on ETT, turns head slightly side->side. No response to voice. +cough, no gag. ? pain during hypertensive episode 200s from excoriated skin on upper thighs and urine on skin, MSO4 2 mg x 2 with some decrease in BP.\n\nResp - CPAP 5 + 5, 40%. RR high 20s-30 when hypertensive, decreased to 18-22 with BP decrease. Sx x 3 thick tan secretions, lavaged for small plugs. Lungs clear, decreased at bases. Sats 99-100%->95%. Short periods of agonal breathing when hypertensive, resp pattern now normal.\n\nCV - BP 170s->190s (200s)/70s. Lopressor 5 mg x 3 doses with transient effect to 160s. Hydralazine 20 mg x 2 with no decrease. Pt became more hypertensive to 200s/. Also increased PO lopressor to 100mg which had no effect. Nipride gtt started, titrated to SBP 140-160. See Careview. V-paced 70s. Hct stable, WBC slightly decreased. +3 anasarca. Lytes WNL, Na 138.\n\nGI - Abd obese, +BS, no stool. TF at goal 40cc/hr, no residuals. FSBS WNL.\n\nGU - UOP 30-100cc/hr. Foley leaking, irrigated easily, no further leaking.\n\nSkin - Areas of excoriation on right inner thigh, looks like open blisters. Nystatin and aloe . Fluid filled blisters on right lower arm. Areas of excoriation, bleeding slightly, on left ant thigh, also looks like open blisters.\n\nID - T max 101.4, tylenol given. On vanco/ceftriaxone/levo. Many Cx pending.\n\nSocial - No phone calls O/N.\n\nPlan - Family to make decision today re , pt is DNR. Titrate nipride gtt to SBP 140-160. Neuro checks q 2 hrs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-28 00:00:00.000",
"description": "Report",
"row_id": 1443934,
"text": "resp care\nPt remained on psv5/peep5 and 40% all night. Generally mv ranged from 9-11L with rr 20-24. Pt became hypertensive with an increase in rr to 30. BS coarse but clear. Suct for thick tan sput.Sats also a bit lower ranging from 93-96. Will cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-28 00:00:00.000",
"description": "Report",
"row_id": 1443935,
"text": "Nursing Progress Note.\n\nEVENTS: Pt made extubated and made c family @ BS.\n\nRESP: Pt received on CPAP/PS 5/5 c 40% FiO2 in place c nl sats, RR in the teens/twenties, and nl resp effort. Scant thick tan sec per ETT today. LS fairly clear in upper apices today, diminished @ bases. After long discussion c team during family conference on the dtr (HCP) decided that under the situation that the pt would not have wanted to be kept on a MV c such a poor prognosis and therefore it was decided to extubate the pt and make @ 14:00. The pt was subsequently extubated (+cuff leak noted) @ 14:30 to 2LNCO2. The pt has been stable since extubation c sats in the low/mid 90's, pt occ coughing up sec and RR gen in the 20's. Resp pattern fairly nl asside from occ slowing/speeding up of rate c nl sats maintained. Pt BS now more rhoncherous (more pronounced during exhalation) c some upper airway rhonchi as well. Pt does not appear dyspneic or SOB. Morphine Sulfate and/or NTS to be provided when/if pt developes resp distress. All procedures explained to pts HCP who appears to be coping normatively @ this time. Freq mouth care provided.\n\nMS: Pt less responsive to noxious stimuli today c no spontaneous movements of LUE. Pt cont to move feet to noxious stimuli. Pt bites and grimaces when mouth care provided. PERRL though R eye now deviated to the L of center. No agitation or overt discomfort noted. Will provide IV Morphine Sulfate if pt becomes distressed, no need for Morphine gtt @ this time.\n\nCV: Pt remains hemodynamically stable and afebrile. V-paced EKG waveform c occ PAC's. AM lytes WNL. A-line to be d/c'ed shortly. The pt is currently net positive 700ml input today and is net positive 17 liters LOS. The pt is +2 anasarcoid. Urine is yellow in coloration, sedimentated and slightly cloudy.\n\nSOC: HCP dtr visiting since lunchtime c fiancee (), both kept up-to-date c POC/pt status.\n\nOTHER: Please see CareVue for additional pt care data/comments. Univ isolation precautions in place.\n\nGI: NGT d/c'ed prior to extubation after discussion c family/team. The pt is now NPO.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-23 00:00:00.000",
"description": "Report",
"row_id": 1443911,
"text": "admitting shift note 2100-700\nPt admitted from ER intubated, on Levophed drip for BP control, low urinary output, WBC 13.9, continue on sepsis protocol.\n\nNeuro: opens eyes to noise and spontanously. follows simple commands like squeezing hand, but inconsistant.moves all extremities, PEARL. CT Head neg in ER. (was found at nursing home unresponsive with glucose of 20.).Family was here earlier, pt responded to them. wrist restraints on bilaterally, off for small period of time. pt is purposeful.\n\nCardiac: Levo off since 1am. ABP 110-140's, map65-80. Paced at 70. Positive cardiac enzymes. CVP13-17,SVO2 67-70. Replaced Mg with 4Grams and came up to 2.0, replaced Calcium with 2grams, but still low at 7.7. facial and periorbital edema. venodynes boots on.pale in color. pt is +10L (h/o CAD,HTN,CABG, CHF,Pacer)\n\nResp: vented on PS 15, Peep 10, 40%, #8.0 ETT 24cm at lips. Lungs coarse with crackles to bilaterally bases. ABG at 3am ph 7.28, Co2 42, O2-138\n\nGI: abd softly distended. had small BM on admission to MICU. Bowel sounds hypoactive. NGT to rt nare. awaiting xray verification. BS 181 at 6am\n\nGU: #14 foley in ER. minimial output. bloody drainage with blood at penis site. irrigated and manipulated catheter with no improved urinary output. pt with 4L plus given in MICU A. output starting to pick up at 5am for 33ml output, but also incontinence noted to pad and on gown. no urologist on call tonight, will need one this am. Bun 23/creat 1.2. h/o left nephrectomy years ago??\n\nIV/Access: Right IJ TLC with precep line. Aline to left radial, saline locks to bilateral AC and rt wrist. Versad drip at 1mg, fentanyl at 50mcg, Levo remains off\n\nID: afebrile max temp 98.9 tonight. Lactate level 3.2, WBC up to 17 this am. on Vanco, Levaquin, flagyl. was swabs on admission for STAR.\n\nSocial: lives at , uses electric wheelchair. baseline mentation A&Ox3 with slightly dementia. self sufficent. Daughter and son-in-law at bedside earlier. supportive and visits him regularly (weekly) at home.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-23 00:00:00.000",
"description": "Report",
"row_id": 1443912,
"text": "admitting shift note 2100-700\nupdate: 1000ml LR given at 6:15 :ABP 90-100'a, SVO2 65, Lactate level 3.9. Order for Calcium 2Gm obtained, waiting for run\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-23 00:00:00.000",
"description": "Report",
"row_id": 1443913,
"text": "Respiratory Care\nPt received intubated, 8.0 oet tube taped at 24cm. Bilateral breath sounds, rales at bases. Breathing spontaneously on psv with good oxygenation, met. acidosis. RSBI = 50. Plan to maintain support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-23 00:00:00.000",
"description": "Report",
"row_id": 1443914,
"text": "Respiratory Care\n\nPt. remains intubated. Pt switched from CPAP to A/ M.D.. Suctioned moderate amt of thick bloody secretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-23 00:00:00.000",
"description": "Report",
"row_id": 1443915,
"text": "Nursing Note 7A-7P Review of Systems:\nNEURO: Sedated on Fentanyl drip at 50mcg/hr and Versed at 1mg/hr. Opens eyes to voice inconsistently. Moves all extremities on bed. Does not follow simple commands. PERLA 2mm/ briskly reactive. Bilaterial wrist restraints remain on.\nC/V: V paced at a rate of 70. Levophed remained off all day. BP 91-129/ 48-64. Continues with peripheral and facial edema. Venodyne boots remain on. Patient currently 17 liters positive For LOS and 9800cc positive in the past 24 hour.\nRESP: Remains orally intubated, sucioned X3 thick bloody secretions. Lung sounds clear upper airways and crackles bibasilar. O2 Sat 96-100%. Vent settings changed from CPAP to AC (Please see flow sheet). Last ABG = 7/31-44-122. Lactic Acid range from 2.5-3.3.\nGI: OGT intact placement checked by auscultation and confirmed by CXR. Tube feedings Promote with fiber FS infusing at 20cc/hr to be increased by 10cc q 4 hr till goal rate of 40cc/hr. Abdomen distended positive bowel sounds no flatus or stools this shift.\nGU: Foley patent draining bloody urine minimal output 14- 43cc/hr. Foley cath irrigation attempted today without success Foley removed and # 14 replaced with minimal output. Fluids of D5 with 3 amps Bicarb infused 1Liter per hour times 3 hours. Output increased slightly to 30-40/hr. Total of 9800cc positve today. Renal U/S done results pending.\nID: Afebrile, Tmax 98.3 orally, cotninues on Levofloxacin, Metronidazole, Vancomycin and Ceftriazone.\nSOCIAL: Patients daughter into visit and updated by MD as to patients POC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-24 00:00:00.000",
"description": "Report",
"row_id": 1443916,
"text": "MICU Nursing Note 1900-0700\nEvents: Uneventful night. Remains off vasopressors. Received 1 liter IV fluid bolus for low urine output with good effect. Remains intubated on AC on vent. Stable hemodynamics throughout night.\n\nNeuro: Sedated on IV Versed at 1 mg/hr and IV Fentanyl at 50mcgs/hr. Arouses to voice...opens eyes to voice and physical stimulation. Follows some commands---will squeeze hands on commands. Moving all extremities on bed when stimulated. Withdraws to painful stimuli. Pupils 2 mm and brisk. Bilat soft wrist restraints on to prevent pt from pulling at tubes and lines.\n\nCardiac: Remains off vasopressors. HR 70 and V-paced with occas. PVC noted. Right IJ TLC-Presep catheter site C/D/I. SV02 ranging from 79-82. CVP= 13-19. Left radial Aline with good waveform and correlation to NBP....BP= 111-135/58-70. Received 1 liter bolus of NS for low urine output and CVP=13 with good effect. Calcium level down to 7.3 earlier and repleted with 2 amps calcium gluconate. CPK up to 358 with MB and Troponin still pending.\n\nResp: Remains intubated on AC 25/ TV=450/ FI02=40%/Peep=10cm. Overbreathing Vent by 1-3 breaths when stimulated. MV= . Pips= 30-35. O2 Sats= 95-98%. ETtube suctioned for small amts blood-tinged thick sputum. Lungs clear bilat upper lobes and with rales at bilateral lower lobes. Last ABG=7.38-50-94-2-31...team aware and no vent changes made at this time.\n\nGI: Abd softly distended with + bowel sounds all quads and no BM. NGtube placement checked by auscultation. Tolerating TF FS Impact with fiber at goal rate of 40 ml/hr with residuals of 0-5 ml.\n\nEndo: fingersticks QID....fingerstick at MN=256---covered with 6 units of regular insulin as per sliding scale.\n\nGU: Urine output blood-tinged to amber in color and with sediment. No clots noted. Urine output down to 10 ml/hr with CVP=13 during evening....bolused with 1 liter NS with urine output 30-60 ml/hr the rest of the night. BUN=28/ Creat.=1.1.\n\nSkin: remains edematous ---periorbital and facial edema unchanged. No skin breakdown noted. Reddened area over right upper thigh---cream applied. Venodyne boots on . Turned and repostioned Q2-3hours.\n\nSocial: No contact from family members during the night.\n\nPlan: Continue to monitor hemodynamics, urine output, labs closely. Wean vent as tolerated. ? Obtain Cardiology consult in r/t + MI.\nWean Sedation and vent when stable. Support pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-24 00:00:00.000",
"description": "Report",
"row_id": 1443917,
"text": "Respiratory Care\nRemained intubated and ventilated on a/c with no remarkable changes overnight. ABGS within normal limits for pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-28 00:00:00.000",
"description": "Report",
"row_id": 1443936,
"text": "pt extubated to nasal cannula as ordered through status. vent pulled from room.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-29 00:00:00.000",
"description": "Report",
"row_id": 1443937,
"text": "MICU nursing progress note 7P-7A\nPt is now . Continues unresponsive. No spontaneous movement. Will move left foot slightly to stimulation, no other response elicited from extremities. Bites down during mouth care, oral Sx. Resp pattern agonal, high 20s-30. MSO4 2 mg x 1 with no change in resp pattern. NTS x 1 thick tan secretions. Lungs are slightly coarse upper lobes, diminished at bases. Sats have decreased low 90s->low 70s on 2L NC. Remains HD stable, V-paced in 70s. UOP 35-100cc/hr. Skin warm and slightly diaphoretic. Turned q 3 hrs, skin care given. Daughter called O/N for update on pt condition.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-26 00:00:00.000",
"description": "Report",
"row_id": 1443928,
"text": "Nursing note (0700-1900) 16:15\n\n\nNeuro.\nPt for repeat head CT this am, showed increase in amount of edema now compressing right side of brain. Pt moving left side only, moves leg on bed, and has managed on occasion to lift left arm from bed, though with out any purpose. Patient not following commands for this nurse, though medics felt that pt did sqeeze with left hand on command. no eye opening as yet, pupils remain 2mm and suggish to react to light.\nPt does have cough and gag reflexes.\n\n\nResp.\nPt placed on CPAP (5/5/40%) with slight improvement in resp alkalosis, pt tollerating well so far, so no plans to rest on ac overnight as yet.\nLS are clear to upper lobes, diminished in bases. Pt sx'd for thick yellow secretions Q4hrs.\n\n\nCVS.\nHR 70's V-Paced with no ectopy seen this shift.\nBP 130-160/60's on Lopressor 75mg to keep within these limits per Neuro team.\n\n\nID.\nPt has remained a-febrile this shift, continues on previous antibiotics of Vanco, Levo and Ceftriaxone. Awaiting micro data on cultures sent overnight.\n\nAccess.\nPt is for placement of TLC this shift as PIV sites expiring today.\n\nEndo.\nNo RISS coverage needed this shift, recieving usual doses of 70/30 BD.\n\nGI/GU.\nTollerating TF's at goal with no residual, +BS with no BM as yet this shift.\nGood UOP via foley of yellow urine with occasional sediment.\n\nSkin.\nPt's skin remains edematous generaly, extremeties are warm to touch and skin is of less pale appearance.\n\n\nSocial.\nDaughter () and her fiance () in for much of the day waiting to speak with Neuro for update as to repeat CT, Neuro explained that as there was an increase in edema that we were still at a critical point.\n and now home for the day, will call later for update.\nNo contact from Son during the day.\n\nPlan.\nFollow MS, Q2hr neuro checks.\nSW and case management support for family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-09-27 00:00:00.000",
"description": "Report",
"row_id": 1443929,
"text": "Resp: Pt remains intubated on psv 5/5/40%. Bs are slightly coarse bilaterally. Sucitoned for small to moderate thick yellow. Sputum sample sent. No changes noc. AM ABG's 7.47/40/97/30. RSBI=74. Family meeting to discuss possible extubation today.\n"
}
] |
13,551 | 160,378 | 1. Respiratory: The infant was intubated on admission and quickly extubated by about 15 to 20 minutes of life to room air. He was never actually placed on the mechanical ventilation. He went from bagged ET tube ventilation to room air as he started to wake and remained stable on room air at the time of discharge from the NICU. He has had no issues with apnea or desaturation. 2. Cardiovascular: He remained hemodynamically stable throughout his course in the NICU with a normal heart rate, blood pressure and rhythm and no audible murmur. 3. Fluids, electrolytes and nutrition: He was n.p.o. on admission due to the perinatal depression. Intravenous fluids were started at 60 ml per kg per day of D-10-W through a peripheral IV. He started enteral foods on the newborn day and weaned quickly to full feeds by the end of day one of life. He is ad lib breast feeding and no IV fluid at the time of transfer. Most recent set of electrolytes was on . Sodium was 145; potassium of 5.5; chloride of 110; C02 21; BUN 10; creatinine 0.4. His weight on the day of discharge from the NICU was 2605. 4. Gastrointestinal: He had LFTs drawn on day of life 1. The ALT was 21; AST 87; alk phos 181 and those were drawn due to the perinatal depression. A bilirubin of 10.8 over 0.3 was drawn on . The infant is not under any phototherapy at this time and will need follow-up bilirubin levels. 5. Hematology: The hematocrit at birth was 47. 6. Infectious disease: Sepsis suspect at birth. Blood culture and CBC were screened. The CBC was normal with 34 whites, 32 polys and 4 bands. The blood culture was sent and remained negative after 48 hours. He received a total of 48 hours of Ampicillin and Gentamycin. The Gentamycin peak and trough levels at 24 hours were a peak of 8.2, trough of 1.3. The infant is presently off antibiotics when discharged from the NICU. 7. Neurologically: Once the infant's tone improved by about a half hour of age, the infant has maintained a normal neurologic exam since that time. No further studies have been done per neurologic sequella. 8. Sensory: A hearing screen needs to be performed prior to discharge from the newborn nursery and has not been done yet from the NICU. 9. Ophthalmology: The infant does not meet criteria for ophthalmology exam at this time. 10. Psychosocial: If there are concerns with social issues, social worker can be reached at . | Updated by this RN. sent this AM10.8/0.3. D-stick this AM 68, nursing well. Addendum:Infant cont's on IV Ampi and Gent.Gent levels drawn and presently pnd'ing.HSV CX sent along with lytes,bili,LFT'S,BUN and Cr presently pnd'ing. Parentsin briefly with L&D RN. HypoactiveBS. Passing stool.GI: LFTS: AP 101, AST 87, ALT 21.ID: On amp/gent. Nursing Progress Note1. Extubated rapidly, now comfortable in RA. I will place EIP & VNA options in record. P: Cont to monitor.#2 O: TF= 60cc/kg/d. Dstiks 96, 67. A: Mom. P. Feed q3hrs, if infant does not nurse well feedbottle. To NICU with bagging. HCT 47, PLT 282. A: Resolving resp issues. P: Continue to monitor.2.O: Weight 2605gms down 110gms. DS 72-109. Asking appropriatequestions. BW2630g. RR 30-50s, LS clear bilat.,mild SC retractions noted at times; resolving. P:Cont to support and update. A: AGA. DTV/DTS. BUN/Cr 13/1.0. Mildintercostal retractions, RR40's-50's. Nospells noted. Tempin open crib 97.8-97.9 axillary. Pt intub in DR noresp effort. P: Monitor I&O's. RR 40's-70's with mild SCretractions. LS clear and =. Abdomen soft with good bowel sounds,passing meconium now. NPN 0700-1500#1 O: Infant remains in RA. Woke for next feed. in AM. Asking appropquestions. HR 140-180s, BP means stable (42-60). Infant receiving IVF of D10 infusingvia PIV. Pt started on Amp and gent for 48hrr/o sepsis. Mom would like to BF. P: Inform and support. NeonatologyDOL #1, CGA 36 wks.CVR: Remains in RA, O2sats 99-100%. A:Stable in RA. Initial DS= 210, 186 at 0400. Nursing Progress Note1.O: Remains in roomair with O2 sats high 90's-100. Admission NotePt admitted to NICU for decr resp effort. P. Support.4. A.Developmentally appropriate. Nestedwith boundaries in place. A: NPO. Infant bottled10cc's of BM instead. 36 weeker ready for transfer to regularnursery. Gent levels with 2nd dose: 1.3/8.2. IV D10 running well inLhand, site soft, pink. Good bowel sounds. Oriented to unit. Bottled 12cc's ofBM. Baby meds given. IV antibiotics dc'ed this shift. Wakes for feedings, feeds10 minutes. O2 sats95-100%. A. A. A. A. P.Monitor.2. ABG drawn at 0430: 7.36/30/129/18/-6. Gent levels to be drawn at 2nd dose. PIV placed L hand, patent and infusing D10W at60cc/k/day. Total fluids at 60cc/kg/d IV/po. Pt NPO. Pt onopen warmer, temps stable. Support. Working up on po feedings,nursing well. Infant was able to be extubated to RA approx15min after transfer to NICU. Rooting to hands. P: Cont to supportdevelopment.#4 O: Both parents in to visit. Mom loving andinvolved. ROM 9.5 hrs ptd. Did diaper change and temp. Nursing Transfer NoteInfant remains in room air with sats >95, lungs clear andequal, RR40-60's. A: Needs to improve on nursing. Monitor for s&s of sepsis.3.O: Waking for feeds. Continue to support and update as needed. Tolerating breast-feeding. Surfaceswab for HSV to be done at 24H age. Briefly shown to parents. h/o recurrent herpes on valtrex. A: Infant not voiding in large amounts. Lungs clear and equal, well aerated. DS 75 and 77. A: Involved. Tolerated procedure well. Sucking onpacifier intermittently. NNP Physical ExamPE: pink, mild jaundice, AFOF, breath sounds clear/equal with mild retracting, no murmur, abd soft, active with good tone. AFSF. 30cc NS bolus given at 0300 for volumeexpansion. Cord prolapsed through incision. Active herpes lesions noted. RR 50-60s, mild intermittent retractions, overall comfortable. Infant depressed (floppy, HR <100, no resp effort) requiring BMV, vigorous stimulation then intubation by SNP under my supervision. HSV surface swabs sent yesterday.DEV: Now wrapped in off-warmer, temp stable.IMP: 1 day old infant with neonatal depression, overall appears to be rapidly improving. O2 sats 99-100%. Infant more alert, active,better perfusion and cap refill. Taken to C/S under combined epidural/spinal anesthesia. Hemodynamically stable. Tube secured with tape at 9.5 at upper lip. At risk for sequelae. Active and alert for car4es. Color jaundiced. Please seeattending note for further details. Temp stable in crib. P. Offer pc bottles, wean IV and monitord-sticks.3. IV running at 30cc/kg thenhep locked at 0100. P: Cont to monitor.#3 O: Maintaining temp on open warmer set in servo. Breast-fed several times overnight, with good latch. Neonatology NP Procedure NoteEndotracheal IntubationIndication: Respiratory failure3.5 ETT passed orally through cords under direct larygonscopy. In room air with sats >95 consistently. Neonatology Attending Progress Note:DOL #2remains in RA, no desats.HR=130-150's, no murmur,ad lib BF, off IVF, dstx=68-77=10.8off antibioticsHSV surface cultures pendinglytes: 145/5.5/110/21/10/0.4Imp/Plan: premie infant with perinatal depression, resolving lung disease, s/p r/o sepsis--check HSV cultures--continue ad lib feeds--continue rest of present management WBC 34.3, 32P, 4B,43L. stool.G/D:AF soft and flat.Alert and active with cares.Infantremains on Warmer with nested boundaries.MAE.Bringing handsto face and mouth.Parenting:Parents in tonight updated by NNP .Parents asking appropriate questions very loving andinvested. Abd flat, soft,hypo BS. Breath sounds clear and equal. Good chest wall movement and equal breath sounds present. Urine output improving, although creatinine mildly elevated at 24 hrs.PLANS:- Continue monitoring of room air.- Allow to ad lib feed, wean IVF as able.- Monitor urine output, repeat chem 7 in am.- D/c amp/gent at 48 hrs if cx negative.- Monitor neuro exam. O2 sats - 95-100%RR 30-50s.ABG - 7.36/30/129 at 4:30 this morning.HR 140-180s BP 61/44 49Wt. Case Management NoteChart reviewed and events noted. Call Mom when infant wants to nurse. Blood workdrawn. Encouraged parents to restand visit later. is high, discuss with the Mom the need for more fluids.Monitor weight. Nursing Progress Note 1900-0700Resp:Infant remains in RA saturating 96-100%.RR mainly50-60's however noted transient tachypnea with RR 80-100.LSremain clear equal with sc retractions.No A's and B's ordesats thus far.F/E/N:Infant cont's on TF 40cc's/kg/day.IVF D10 infusing at4.5cc's/hr in L hand.Site intact.Mom did attempt to breastfeed x 1.Infant did latch but tired easily.Dsick=96/67.Weight=2.715kg up 85 grams.Abd soft and flat withpos bs,no loops or spits,girth=26.UO=1.2cc's/kg/day over 12hrs.Noted trace mec. She was very comfortablewith trying to nurse him. Voided only 23 and 8cc's.Abdomen soft and flat. Awake and alert with feedings, nursing well. Neonatology NP Discharge Physicalswaddled in open cribAFOf, sutures approximated+ bilateral red reflex, small amount of white eye drainage from left eyeoral mucosa without lesionsneck supple and without massesclavicles intactcomfortable respirations in room air, lungs clear/=RRR, no murmur, pink and well perfused, femoral pulses presentabdomen soft, nontender and nondistended, active bowel sounds, cord on/dry, jaundiced to lower extremiitestestes descended bilaterallyno sacral anomaliesstable hip exam, normal digits and creasesactive with age appropriate tone and reflexes | 15 | [
{
"category": "Nursing/other",
"chartdate": "2105-12-07 00:00:00.000",
"description": "Report",
"row_id": 1870841,
"text": "Neonatology Attending\n\n2630 gram 36 week male admitted s/p perinatal depression\n\n2630 gram 36 week male born to a 42 yo G1 P0->1 white female\nPNS: B+/Ab-/RPR NR/RI/HBsAg-/GBS-\nUncomplicated pregnancy. h/o recurrent herpes on valtrex. ROM 9.5 hrs ptd. Presented to L&D after midnight (>7 hrs after ROM). Active herpes lesions noted. Taken to C/S under combined epidural/spinal anesthesia. Cord prolapsed through incision. Head needed to be pushed up. Infant depressed (floppy, HR <100, no resp effort) requiring BMV, vigorous stimulation then intubation by SNP under my supervision. Floppy with poor perfusion and slow to pink up. Briefly shown to parents. To NICU with bagging. Apgars 1/3/4/8.\n\nExam Near term male orally intubated with beginnings of spontaneous respiratory effort, poor tone\nT 97.5 P 184 R bagging BP 68/54 mean 60 O2 sat 95%\nWt 2630 grams (~50%) Lt 51 cm (~90%) HC 32 cm (~40%)\nAF soft, flat, nondysmorphic, intact palate, gradually increasing spontaneous respirations, coarse bs, clearing after suctioning, no murmur, soft abd, 3 vessel cord, no hsm, normal male genitalia, testes descended into scrotum, no hip click, patent anus, no sacral dimple, poor tone but activity and tone increasing over first 15 minutes in NICU, no evidence of seizure activity, no skin lesions (examined scalp, extremities, trunk, genitalia closely), mmm, no mucosal lesions seen, slow capillary refill\n\nOver course of ~15 minutes in NICU spontaneous respirations increased, progressed from bagging to CPAP to extubation\n\nDS 210\n\nA: 36 week male s/p perinatal depression likely secondary to volume depletion and cord prolapse. At risk for sequelae. At risk for HSV secondary to recurrent maternal HSV infection with active lesions and ROM >4 hrs before C/S delivery. Infant has no lesions. Must also rule out sepsis in light of difficult start.\n\nP: Monitor\n O2 as needed\n NS bolus\n NPO with IV fluids\n Usual attention to lytes and DS\n Follow UO closely\n CBC, BC\n A/G for R/O sepsis\n Check gent levels before 2nd dose\n Check BUN, Cr, LFTs to monitor for end organ effect\n Surface cultures (, NP, rectal) for herpes in 24-48 hours\n Hold acyclovir unless he develops lesions or has positive culture\n Support parents\n Pediatrician is \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-12-07 00:00:00.000",
"description": "Report",
"row_id": 1870842,
"text": "Neonatology NP Procedure Note\n\nEndotracheal Intubation\nIndication: Respiratory failure\n3.5 ETT passed orally through cords under direct larygonscopy. Tube secured with tape at 9.5 at upper lip. Good chest wall movement and equal breath sounds present. Tolerated procedure well. No complications.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-12-08 00:00:00.000",
"description": "Report",
"row_id": 1870847,
"text": "Nursing Progress Note 1900-0700\n\n\nResp:Infant remains in RA saturating 96-100%.RR mainly\n50-60's however noted transient tachypnea with RR 80-100.LS\nremain clear equal with sc retractions.No A's and B's or\ndesats thus far.\n\nF/E/N:Infant cont's on TF 40cc's/kg/day.IVF D10 infusing at\n4.5cc's/hr in L hand.Site intact.Mom did attempt to breast\nfeed x 1.Infant did latch but tired easily.D\nsick=96/67.Weight=2.715kg up 85 grams.Abd soft and flat with\npos bs,no loops or spits,girth=26.UO=1.2cc's/kg/day over 12\nhrs.Noted trace mec. stool.\n\nG/D:AF soft and flat.Alert and active with cares.Infant\nremains on Warmer with nested boundaries.MAE.Bringing hands\nto face and mouth.\n\nParenting:Parents in tonight updated by NNP \n.Parents asking appropriate questions very loving and\ninvested.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-12-08 00:00:00.000",
"description": "Report",
"row_id": 1870848,
"text": "Addendum:Infant cont's on IV Ampi and Gent.Gent levels drawn and presently pnd'ing.HSV CX sent along with lytes,bili,LFT'S,BUN and Cr presently pnd'ing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-12-08 00:00:00.000",
"description": "Report",
"row_id": 1870849,
"text": "Neonatology\nDOL #1, CGA 36 wks.\n\nCVR: Remains in RA, O2sats 99-100%. RR 50-60s, mild intermittent retractions, overall comfortable. Hemodynamically stable. No murmur. No spells.\n\nFEN: Lytes 140/4.4/104/22. BUN/Cr 13/1.0. Breast-fed several times overnight, with good latch. On IVF D10W at 40 cc/kg/day. Dstiks 96, 67. Urine output now increasing. Passing stool.\n\nGI: LFTS: AP 101, AST 87, ALT 21.\n\nID: On amp/gent. Gent levels with 2nd dose: 1.3/8.2. HSV surface swabs sent yesterday.\n\nDEV: Now wrapped in off-warmer, temp stable.\n\nIMP: 1 day old infant with neonatal depression, overall appears to be rapidly improving. Extubated rapidly, now comfortable in RA. Tolerating breast-feeding. Urine output improving, although creatinine mildly elevated at 24 hrs.\n\nPLANS:\n- Continue monitoring of room air.\n- Allow to ad lib feed, wean IVF as able.\n- Monitor urine output, repeat chem 7 in am.\n- D/c amp/gent at 48 hrs if cx negative.\n- Monitor neuro exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-12-07 00:00:00.000",
"description": "Report",
"row_id": 1870843,
"text": "Admission Note\n\n\nPt admitted to NICU for decr resp effort. Please see\nattending note for further details. Pt intub in DR no\nresp effort. Infant was able to be extubated to RA approx\n15min after transfer to NICU. RR 30-50s, LS clear bilat.,\nmild SC retractions noted at times; resolving. O2 sats\n95-100%. ABG drawn at 0430: 7.36/30/129/18/-6. No murmur\nauscultated. HR 140-180s, BP means stable (42-60). BW\n2630g. Pt NPO. 30cc NS bolus given at 0300 for volume\nexpansion. PIV placed L hand, patent and infusing D10W at\n60cc/k/day. Initial DS= 210, 186 at 0400. Abd flat, soft,\nhypo BS. DTV/DTS. CBC and BC drawn. WBC 34.3, 32P, 4B,\n43L. HCT 47, PLT 282. Pt started on Amp and gent for 48hr\nr/o sepsis. Gent levels to be drawn at 2nd dose. Surface\nswab for HSV to be done at 24H age. Baby meds given. Pt on\nopen warmer, temps stable. Infant more alert, active,\nbetter perfusion and cap refill. Rooting to hands. Parents\nin briefly with L&D RN. Updated by this RN. Asking approp\nquestions. Oriented to unit. Encouraged parents to rest\nand visit later. Continue to support and update as needed.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-12-07 00:00:00.000",
"description": "Report",
"row_id": 1870844,
"text": "Neonatology Attending - Progress Note\n\nNow 7 hours of life for this infant with neonatal depression.\nBaby's respiratory status much improved - breathing comfortably in RA. O2 sats - 95-100%\nRR 30-50s.\n\nABG - 7.36/30/129 at 4:30 this morning.\nHR 140-180s BP 61/44 49\n\nWt. 2630gm - on 60ml/kg/d of IV D10W.\nNPO\nNo urine or stool output yet.\n\nDS 210 at birth - then 186 - 72 this morning.\n\nID -\nMother noted to have a herpes lesion on her thigh 1 month ago and has been treated with Valtrex for the past month. Noted to have active lesions in the vaginal region just prior to delivery.\nBaby has no lesions.\n\nwbc 34,300 32P 4B 43L plat 282,000 Hct 47%\nOn amp and gent\n\nAssessment/plan:\n36 week gestation infant with perinatal depression most likely secondary to prolapsed cord - much improved now.\nAt increased risk for HSV infection - will check surface cultures at 24 hours. If baby develops any suspicious skin lesions or other signs of infection will initiate therapy with acyclovir.\n\nAmpicillin and gentamicin therapy to continue for at least 48 hours.\nFU cbc planned to follow hight white count.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-12-07 00:00:00.000",
"description": "Report",
"row_id": 1870845,
"text": "Case Management Note\nChart reviewed and events noted. I will place EIP & VNA options in record. I will be providing clinical updates to insurance and will assist w/any d'c planning needs along with team & family\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-12-07 00:00:00.000",
"description": "Report",
"row_id": 1870846,
"text": "NPN 0700-1500\n\n\n#1 O: Infant remains in RA. RR 40's-70's with mild SC\nretractions. LS clear and =. O2 sats 99-100%. No spells. A:\nStable in RA. P: Cont to monitor.\n\n#2 O: TF= 60cc/kg/d. Infant receiving IVF of D10 infusing\nvia PIV. Abdomen benign; voiding only 3cc's so far this\nshift since birth. No stool as yet. DS 72-109. Hypoactive\nBS. Mom would like to BF. A: NPO. P: Cont to monitor.\n\n#3 O: Maintaining temp on open warmer set in servo. Awake\nand alert with cares; opening eyes and crying when\ndisturbed; otherwise sleeping between cares. AFSF. Nested\nwith boundaries in place. A: AGA. P: Cont to support\ndevelopment.\n\n#4 O: Both parents in to visit. Asking appropriate\nquestions. Mom pretty tired from delivery. A: Involved. P:\nCont to support and update.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-12-08 00:00:00.000",
"description": "Report",
"row_id": 1870850,
"text": "Nursing Progress Note\n\n\n1. In room air with sats >95 consistently. No desats or\nbradys. Lungs clear and equal, well aerated. Mild\nintercostal retractions, RR40's-50's. A. No distress. P.\nMonitor.\n2. Total fluids at 60cc/kg/d IV/po. IV D10 running well in\nLhand, site soft, pink. Nursed several times today thus\nfar, latches on well and sucks vigorously for 5-10 minutes.\nNo bottles offered yet but will offer one after this nursing\nsession. Urine output significantly increased,\n30-35cc/diaper change. Abdomen soft with good bowel sounds,\npassing meconium now. A. Working up on po feedings,\nnursing well. P. Offer pc bottles, wean IV and monitor\nd-sticks.\n3. Awake and alert with feedings, nursing well. Temp\nstable on warmer, swaddled with hat and 2 blankets. A.\nDevelopmentally appropriate. P. Support.\n4. Mom up for feedings today, nursing and handling baby\nwell. Did diaper change and temp. A. Mom loving and\ninvolved. Support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-12-08 00:00:00.000",
"description": "Report",
"row_id": 1870851,
"text": "NNP Physical Exam\nPE: pink, mild jaundice, AFOF, breath sounds clear/equal with mild retracting, no murmur, abd soft, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-12-09 00:00:00.000",
"description": "Report",
"row_id": 1870852,
"text": "Nursing Progress Note\n\n\n1.O: Remains in roomair with O2 sats high 90's-100. No\nspells noted. Breath sounds clear and equal.\n A: Resolving resp issues.\n P: Continue to monitor.\n2.O: Weight 2605gms down 110gms. IV running at 30cc/kg then\nhep locked at 0100. DS 75 and 77. Voided only 23 and 8cc's.\nAbdomen soft and flat. Good bowel sounds. Mom attempted to\nnurse infant and infant didn't even latch on. Infant bottled\n10cc's of BM instead. Woke for next feed. Bottled 12cc's of\nBM. Mom doesn't want infant to get formula. Blood work\ndrawn. IV antibiotics dc'ed this shift.\n A: Infant not voiding in large amounts. Color jaundiced.\n P: Monitor I&O's. Call Mom when infant wants to nurse. \n is high, discuss with the Mom the need for more fluids.\nMonitor weight. Monitor for s&s of sepsis.\n3.O: Waking for feeds. Active and alert for car4es. Infant\nbecomes sleepy when Mom wants to nurse him. Sucking on\npacifier intermittently. Temp stable in crib.\n A: Needs to improve on nursing.\n P: Continue to monitor.\n4.O: Mom came up to feed her baby. She was very comfortable\nwith trying to nurse him. She stated that she was tired and\nwouldn't be up for the 4AM feeding.\n A: Mom.\n P: Inform and support. Call Mom when the infant is ready\nto eat.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-12-09 00:00:00.000",
"description": "Report",
"row_id": 1870853,
"text": "Neonatology Attending Progress Note:\nDOL #2\nremains in RA, no desats.\nHR=130-150's, no murmur,\nad lib BF, off IVF, dstx=68-77\n=10.8\noff antibiotics\nHSV surface cultures pending\nlytes: 145/5.5/110/21/10/0.4\nImp/Plan: premie infant with perinatal depression, resolving lung disease, s/p r/o sepsis\n--check HSV cultures\n--continue ad lib feeds\n--continue rest of present management\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-12-09 00:00:00.000",
"description": "Report",
"row_id": 1870854,
"text": "Neonatology NP Discharge Physical\n\nswaddled in open crib\nAFOf, sutures approximated\n+ bilateral red reflex, small amount of white eye drainage from left eye\noral mucosa without lesions\nneck supple and without masses\nclavicles intact\ncomfortable respirations in room air, lungs clear/=\nRRR, no murmur, pink and well perfused, femoral pulses present\nabdomen soft, nontender and nondistended, active bowel sounds, cord on/dry, jaundiced to lower extremiites\ntestes descended bilaterally\nno sacral anomalies\nstable hip exam, normal digits and creases\nactive with age appropriate tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-12-09 00:00:00.000",
"description": "Report",
"row_id": 1870855,
"text": "Nursing Transfer Note\n\n\nInfant remains in room air with sats >95, lungs clear and\nequal, RR40-60's. D-stick this AM 68, nursing well. Temp\nin open crib 97.8-97.9 axillary. Wakes for feedings, feeds\n10 minutes. Parents visiting frequently. sent this AM\n10.8/0.3. A. 36 weeker ready for transfer to regular\nnursery. P. Feed q3hrs, if infant does not nurse well feed\nbottle. in AM.\n\n\n"
}
] |
3,999 | 104,816 | 1. Apparent seizure - The patient as mentioned was loaded on fosphenytoin 1 gm and started no Keppra 500 mg p.o. b.i.d. She was monitored closely in the Intensive Care Unit and extubated on . She did also receive 1 dose of Ceftriaxone prophylactically as she was having fevers. This was thought to be aspiration pneumonia by chest x-ray done on . She was started on Levofloxacin and Flagyl. She did well over night and was transferred to the floor on . At the time of the transfer, she denied any major complaints and was talking fluently. She had amnesia for the event and was somewhat confused about to where she was but she was oriented to time. Review of systems was negative for shortness of breath, cough, abdominal pain, nausea, vomiting or diarrhea. As mentioned she was started on Keppra 500 mg p.o. b.i.d. and increased to 1 gm p.o. b.i.d. She was discontinued off of Neurontin. She will be continued on Dilantin and Keppra together. 2. Pneumonia - She completed the seven day course of Levofloxacin and Flagyl. 3. With the history of myocardial infarction she was ruled out with enzymes. She was kept on her Aspirin and statin. 4. Diabetes monitoring - The patient should have a hemoglobin A1c done by her primary care physician. | TEMP 100.4 ORALLY, WBC CAME DOWN SLIGHTLY THIS AM. SXTED FOR NOTHING.GI/GU: ABD SOFT WITH +BS. IMPRESSION: Mild cardiomegaly with interstitial edema. Sx for small amt thin sputum.ID: CXR questionable pna (per team). MICU NPN 3A-7ANEURO: RECEIVED PATIENT ON LOW DOSE PROPOFOL, PT RESTLESS. Low grade temp, tmax 100.6 PO start of shift.C/V: HR 80-90s SR, no ectopy. TECHNIQUE: Multiple axial images of the head were obtained without IV contrast. The previously described focal lineare atelectasis at the left base appears unchanged. After administration of gadolinium intravenous contrast, axial and coronal short TR, short TE spin echo imaging was performed. There is mild periventricular and subcortical white matter hyperintensity on the long TR images suggesting chronic small vessel ischemia. Lopressor d/c'd. FOLLOWS COMMANDS, MAE WELL, NO SEIZURE ACTIVITY OVERNIGHT. IMPRESSION: No acute intracranial hemorrhage. OGT IN PLACE WITH BILIOUS ASPIRATES, OB-. Sinus rhythm, without diagnostic abnormality. The patient has been intubated during the interval and the NG tube has been removed. No overt CHF. SUPINE AP CHEST RADIOGRAPH: The ET tube is slightly low, approximately 1.5 cm above the carina. Foley patent for CYU, quantities sufficient. The ventricles, cisterns and sulci are slightly prominent consistent with age related atrophy. The heart and mediastinal contours are unchanged with no overt CHF. She is on small amount of propofol and is awaiting of EEG prior to extubation planned for today. IMPRESSION: Satisfactory position of ET tube with no significant changes. Comparison to a head CT of . U/O 16-80CC/HR YELLOW AND CLEAR.ID: TMAX 101.4 RECTALLY DOWN TO 100.3. NO SEIZURE ACTIVITY NOTED.CARDIAC: HR 85-91 SR WITH NO ECTOPY. ONCE PATIENT UNDER CONTROL WITH PROPOFOL, EXAM WAS UNCHANGED OTHER THAN SHE WOULD NOT OPEN EYES. Incidentally noted is a small infundibulum at the origin of the left posterior communicating artery. FINDINGS: There is no acute intra or extra-axial hemorrhage. NOT OVERBREATHING VENT. IMPRESSION: ET tube slightly low. GAG IMPAIRED, COUGH INTACT. FINDINGS: There is no evidence of acute infarction. ONE ADDITIONAL SET OF BLD CX'S SENT.SKIN: INTACT.ACCESS: PIV X2.SOCIAL/DISPO: FULL CODE. CONCLUSION: No evidence of infarction. Patient placed back on propofol gtt at 25mcg/kg/min. PORTABLE CHEST: The cardiac silhouette is at the upper limits of normal for size and there is bilateral interstitial edema. Nursing Process Note: 0700-1900NEURO: Received patient lightly sedated on Propofol gtt 25mcg/kg/min. The MRA demonstrates a normal appearance of the internal carotid arteries, distal vertebral arteries, basilar artery and their major branches. The grey/white matter differentiation is preserved. Technical quality of today's film is less high most likely related to some motion blurring secondary to patient's inability to hold respiration. Abdomen soft, present sounds. SX FOR MOD AMT'S OF THICK WHITE SECRETIONS, LUNG SOUNDS COARSE THROUGHOUT. Now off in plan to extubate; awaiting definitive results of EEG before extubation. The partially visualized paranasal sinuses are clear. Respiratory Care Note: Patient remains intubated at this time and is spontaneously breathing with good tidal volumes and respiratory rate. 4:59 PM MR HEAD W & W/O CONTRAST; MR-ANGIO HEAD Clip # MR CONTRAST GADOLIN Reason: H/O SEIZURES, ? should extubate in AM There are no significant pleural effusions. pt.on ac ventilation for the noc, at 0400 pt put on spont.breathing trial and tol.well, propofol being weaned, rsbi 50, abg within acceptable range, bs coarse, sx for white to clear secretion, plan is to extubate in a.m. SATS 100%, LS RHONCHEROUS. Currently has OGT patent for PO meds. THEN PLACED ON PRESSURE SUPPORT THIS AM. The lungs are better expanded on the current film and there has been a decrease in the amount of the left lower lobe atelectasis. IMPRESSION: 1) No evidence of parenchymal infiltrates such as aspiration pneumonia during latest one day interval. 3:39 PM CT HEAD W/O CONTRAST Clip # Reason: sudden o/s of L weakness and shaking - poss stroke - eval fo MEDICAL CONDITION: 77 year old woman with sz hx, hx MI REASON FOR THIS EXAMINATION: sudden o/s of L weakness and shaking - poss stroke - eval for bleed No contraindications for IV contrast WET READ: SMLe TUE 4:59 PM no acute bleed. NG tube tip is in the distal stomach. FINDINGS: The AP single view chest film obtained with patient in semi erect position is analyzed in direct comparison with similar study obtained one day earlier. Comparison is made to prior chest x-ray on . Sagittal and axial short TR, short TE spin echo imaging was performed through the brain. ON LOPRESSOR. SBP 100s. CONT ON PROPOFOL AT 25MCQ'S. Axial imaging was performed with long TR, long TE fast spin echo technique, FLAIR technique, gradient echo technique and technique. NURSING PROGRESS NOTE:REMAINS INTUB/VENTED ON A/C TO REST OVERNIGHT. BP 112-124/49-57. There is retrocardiac opacity in the left lower lobe. This measures approximately 2 mm in greatest dimension. There is persistent linear atelectasis in the left lower lobe. No previous tracing available forcomparison. Heart size is mildly enlarged. The ventricles and sulci are prominent in an atrophic pattern. Slurred speech. There is an NG tube present in satisfactory position. There are no new consolidations. LS coarse, sats consistently high 90s-100%. ABD SOFT WITH BOWEL SOUNDS, NO STOOL BUT PASSING FLATUS.GU: FOLEY CATH PATENT DRAINING ADEQUATE AMT'S OF CLEAR YELLOW URINE.IV FLUID CONT AT 100/HR NS WITH 20KCL.DAUGHTER CALLED DURING NIGHT AND WAS UPDATED.PT IS FULL CODE. BREATHING IN TEENS TO TWENTIES.GI: OGT CLAMPED AND DRAINING BILIOUS ASPIRATES WHEN PLACED TO SX. | 14 | [
{
"category": "Radiology",
"chartdate": "2173-02-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 815792,
"text": " 7:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumonia\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with fever, seizure, concern for aspiration.\n\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77 year-old woman, evaluate for pneumonia. The patient has fever\n and seizures.\n\n COMPARISON: .\n\n PORTABLE CHEST: The cardiac silhouette is at the upper limits of normal for\n size and there is bilateral interstitial edema. The lungs are better expanded\n on the current film and there has been a decrease in the amount of the left\n lower lobe atelectasis. There are no new consolidations. There are no\n significant pleural effusions.\n\n IMPRESSION: Mild cardiomegaly with interstitial edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-02-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 815599,
"text": " 12:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pna ETT placment\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with fever, seizure\n\n REASON FOR THIS EXAMINATION:\n ?pna ETT placment\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever and seizure, ET placement.\n\n Comparison is made to prior chest x-ray on .\n\n AP CHEST: There is an ET tube present with the tip terninating approximately\n 3 cm above the carina. There is an NG tube present in satisfactory position.\n The heart and mediastinal contours are unchanged with no overt CHF. There is\n persistent linear atelectasis in the left lower lobe.\n\n IMPRESSION: Satisfactory position of ET tube with no significant changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-02-16 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 815489,
"text": " 3:39 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: sudden o/s of L weakness and shaking - poss stroke - eval fo\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with sz hx, hx MI\n REASON FOR THIS EXAMINATION:\n sudden o/s of L weakness and shaking - poss stroke - eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SMLe TUE 4:59 PM\n no acute bleed.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77 y/o woman with seizures and left sided weakness and shaking.\n\n TECHNIQUE: Multiple axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: There is no acute intra or extra-axial hemorrhage. There is no\n mass effect or shift of normally midline structures. The ventricles, cisterns\n and sulci are slightly prominent consistent with age related atrophy. The\n grey/white matter differentiation is preserved. The partially visualized\n paranasal sinuses are clear. Bone windows demonstrate no fractures.\n\n IMPRESSION:\n\n No acute intracranial hemorrhage. If there is a clinical suspicion for\n stroke, MR is more sensitive for detecting this condition.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-02-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 815738,
"text": " 2:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumonia\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with fever, seizure, concern for aspiration.\n\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, seizure, concerns for aspiration. Evaluate for\n infiltrates.\n\n FINDINGS: The AP single view chest film obtained with patient in semi erect\n position is analyzed in direct comparison with similar study obtained one day\n earlier. The patient has been intubated during the interval and the NG tube\n has been removed. There is no pneumothorax or any other complication related\n to instrument removal. Technical quality of today's film is less high most\n likely related to some motion blurring secondary to patient's inability to\n hold respiration. There is, however, no evidence of any new parenchymal\n infiltrate or significant pulmonary vascular congestion. The previously\n described focal lineare atelectasis at the left base appears unchanged.\n\n IMPRESSION:\n\n 1) No evidence of parenchymal infiltrates such as aspiration pneumonia during\n latest one day interval.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-02-16 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 815507,
"text": " 4:59 PM\n MR HEAD W & W/O CONTRAST; MR-ANGIO HEAD Clip # \n MR CONTRAST GADOLIN\n Reason: H/O SEIZURES, ? MASS\n Contrast: MAGNEVIST Amt: 14\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with hx of MI and SZ\n REASON FOR THIS EXAMINATION:\n 2:45 pm - sudden o/s of L sided paralysis and L facial droop with slurred\n speech - followed by tremors STROKE PROTOCOL - with DWI\n ______________________________________________________________________________\n FINAL REPORT\n MRI/MRA OF THE BRAIN:\n\n HISTORY: Seizures and sudden onset of left sided paralysis and left facial\n droop. Slurred speech.\n\n Sagittal and axial short TR, short TE spin echo imaging was performed through\n the brain. Axial imaging was performed with long TR, long TE fast spin echo\n technique, FLAIR technique, gradient echo technique and technique.\n 3D TOF MRA was performed through the brain. After administration of\n gadolinium intravenous contrast, axial and coronal short TR, short TE spin\n echo imaging was performed. Comparison to a head CT of .\n\n FINDINGS: There is no evidence of acute infarction. The ventricles and sulci\n are prominent in an atrophic pattern. There is mild periventricular and\n subcortical white matter hyperintensity on the long TR images suggesting\n chronic small vessel ischemia. There is no evidence of hemorrhage, edema,\n masses, or mass effect.\n\n The MRA demonstrates a normal appearance of the internal carotid arteries,\n distal vertebral arteries, basilar artery and their major branches.\n Incidentally noted is a small infundibulum at the origin of the left posterior\n communicating artery. This measures approximately 2 mm in greatest dimension.\n\n CONCLUSION:\n\n No evidence of infarction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-02-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 815501,
"text": " 4:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p intubation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p intubation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubation.\n\n SUPINE AP CHEST RADIOGRAPH: The ET tube is slightly low, approximately 1.5 cm\n above the carina. NG tube tip is in the distal stomach. Heart size is mildly\n enlarged. No overt CHF. There is retrocardiac opacity in the left lower\n lobe.\n\n IMPRESSION: ET tube slightly low.\n\n ET Tube position was called to Dr. at 5:05 PM on .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-02-17 00:00:00.000",
"description": "Report",
"row_id": 1314735,
"text": "Nursing Process Note: 0700-1900\nNEURO: Received patient lightly sedated on Propofol gtt 25mcg/kg/min. Now off in plan to extubate; awaiting definitive results of EEG before extubation. MAE, agitated at times but able to redirect. Following commands inconsistently. Family at bedside good part of shift. No seizure activity noted today.\n\nRESP: Continues on CPAP 5/5/Fio2 40%; TVs 350 as of 1700. LS coarse, sats consistently high 90s-100%. Sx for small amt thin sputum.\n\nID: CXR questionable pna (per team). Low grade temp, tmax 100.6 PO start of shift.\n\nC/V: HR 80-90s SR, no ectopy. SBP 100s. Lopressor d/c'd. Maintenance fliud NS with 20Kcl @ 100/hr.\n\nGI/GU: NPO. Currently has OGT patent for PO meds. Abdomen soft, present sounds. Foley patent for CYU, quantities sufficient. No BM today.\n\nSOCIAL: Family supportive, visiting most of day. Brought personal belongings home.\n\nPLAN: Question extubation; awaiting results of EEG\n Monitor temp\n Monitor for sz activity\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-02-17 00:00:00.000",
"description": "Report",
"row_id": 1314736,
"text": "Nursing Addendum: 0700-1900\nWill not extubate patient this eve, rather, will rest overnight on , RSBI in AM and plan to extubate tomorrow. Patient placed back on propofol gtt at 25mcg/kg/min.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-02-18 00:00:00.000",
"description": "Report",
"row_id": 1314737,
"text": "pt.on ac ventilation for the noc, at 0400 pt put on spont.breathing trial and tol.well, propofol being weaned, rsbi 50, abg within acceptable range, bs coarse, sx for white to clear secretion, plan is to extubate in a.m.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-02-18 00:00:00.000",
"description": "Report",
"row_id": 1314738,
"text": "NURSING PROGRESS NOTE:\nREMAINS INTUB/VENTED ON A/C TO REST OVERNIGHT. THEN PLACED ON PRESSURE SUPPORT THIS AM. SX FOR MOD AMT'S OF THICK WHITE SECRETIONS, LUNG SOUNDS COARSE THROUGHOUT. CONT ON PROPOFOL AT 25MCQ'S. FOLLOWS COMMANDS, MAE WELL, NO SEIZURE ACTIVITY OVERNIGHT. HAVE NOT SEEN ANY TREMORS. PT VERY RESTLESS WHEN AWAKE, PT RESTRAINED AND CONT TO ATTEMPT TO CLIMB OUT OF BED.\nCV: HR NSR TO ST NO ECTOPY, BP STABLE SEE FLOWSHEET FOR DATA. TEMP 100.4 ORALLY, WBC CAME DOWN SLIGHTLY THIS AM. BREATHING IN TEENS TO TWENTIES.\nGI: OGT CLAMPED AND DRAINING BILIOUS ASPIRATES WHEN PLACED TO SX. ABD SOFT WITH BOWEL SOUNDS, NO STOOL BUT PASSING FLATUS.\nGU: FOLEY CATH PATENT DRAINING ADEQUATE AMT'S OF CLEAR YELLOW URINE.\nIV FLUID CONT AT 100/HR NS WITH 20KCL.\nDAUGHTER CALLED DURING NIGHT AND WAS UPDATED.\nPT IS FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-02-17 00:00:00.000",
"description": "Report",
"row_id": 1314732,
"text": "MICU NPN 3A-7A\nNEURO: RECEIVED PATIENT ON LOW DOSE PROPOFOL, PT RESTLESS. INITIAL ASSESSMENT PATINT WOULD OPEN EYES AND FOLLOW COMMANDS INCONSISTENTLY. MOVING ALL EXTREMITIES PURPOSEFULLY. PERL @3MM AND BRISK. ONCE PATIENT UNDER CONTROL WITH PROPOFOL, EXAM WAS UNCHANGED OTHER THAN SHE WOULD NOT OPEN EYES. GAG IMPAIRED, COUGH INTACT. NO SEIZURE ACTIVITY NOTED.\n\nCARDIAC: HR 85-91 SR WITH NO ECTOPY. BP 112-124/49-57. ON LOPRESSOR. PPP. LABS PER CAREVUE.\n\nRESP: ON A/C 500X16 60% +5 PEEP. NO ALINE TO DRAW ABG. NOT OVERBREATHING VENT. SATS 100%, LS RHONCHEROUS. SXTED FOR NOTHING.\n\nGI/GU: ABD SOFT WITH +BS. NO STOOL. NPO. OGT IN PLACE WITH BILIOUS ASPIRATES, OB-. U/O 16-80CC/HR YELLOW AND CLEAR.\n\nID: TMAX 101.4 RECTALLY DOWN TO 100.3. WBC 14.6 UP FROM 8.2 IN THE ER. ONE ADDITIONAL SET OF BLD CX'S SENT.\n\nSKIN: INTACT.\n\nACCESS: PIV X2.\n\nSOCIAL/DISPO: FULL CODE. SPOKE BRIEFLY WITH PT'S DAUGHTER. PLAN IS TO EXTUBATE THIS MORNING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-02-17 00:00:00.000",
"description": "Report",
"row_id": 1314733,
"text": "pt intubated for airway for airway protection during seizure activity. should extubate in AM\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-02-17 00:00:00.000",
"description": "Report",
"row_id": 1314734,
"text": "Respiratory Care Note:\n Patient remains intubated at this time and is spontaneously breathing with good tidal volumes and respiratory rate. She is on small amount of propofol and is awaiting of EEG prior to extubation planned for today.\n"
},
{
"category": "ECG",
"chartdate": "2173-02-16 00:00:00.000",
"description": "Report",
"row_id": 187055,
"text": "Sinus rhythm, without diagnostic abnormality. No previous tracing available for\ncomparison.\n\n"
}
] |
8,799 | 100,914 | 35 y/o F with hx of T1DM with severe gastroparesis, prior episodes of DKA, acquired hemophilia, htn, multiple recent admissions for nausea and vomiting, initially presented with nausea, vomiting, diarrhea found to have multifocal pneumonia requiring ICU monitoring, acute exacerbation of diastolic heart failure, difficult to control blood sugars, and acute kidney injury. Pt was s/p 2mg IV ativan in the ED for management of nausea and she initially presented to the floor extremely lethargic and barely responsive. She triggered for hypoxia 46% on RA but was never cyanotic and rapidly improved to 100% on RA. She was also hyperglycemic to 500 which improved with insulin and IVF. ABG did not demonstrate hypoxia or hypercarbia or acidosis. Her symptoms improved over half an hour when she was mildly lethargic but responding to questions appropriately and conversant, falling easily into sleep but arousable. When awake patient endorsed symptoms of dysuria and diarrhea. She was started on bactrim for UTI. For renal failure IVF were given and home diuretics held. The following day, her lethargy was resolved and she was having fever to 101, productive cough and diarrhea. CXR demonstrated multifocal PNA. Given numerous allergies to antibiotics she was started on meropenem and vancomycin for hospital acquired pneumonia, though aspiration pneumonia remained on the differential. Legionella was considered and urine legionella sent and ultimately returned negative twice. She remained on 3L O2 with sats dropping to high 80s and low 90s. On she desaturated to low 80s on 4L requiring nonrebreather and transferred to the ICU. In the ICU, she was observed to be volume overloaded and treated with diuretics in addition to broadening her antibiotics to include antiviral treatment and azithromycin for legionella. During her ICU course she was diuresed with 40mg IV lasix, her O2 requirement improved. ID was consulted who recommended discontinuation of antiviral treatment after negative influenza swab. She was also found to have hypoglycemia, was consulted, who recommended reducing insulin. She continued to have intermittent diarrhea and nausea/vomiting. After 3 days in the ICU and addressing the above issues, she was transferred back to the floor. On the floor, her oxygen requirement continued to improve such that she was on room air. She continued to have fevers to 101, for which drug fever was a concern per ID. So per their recommendation Meropenem and Vancomycin were discontinued after a 7 day course. Per ID recommendations Azithroymycin was discontinued on day 9 due to thrombocytosis. Upon return to the floor she continued to have fluctuating high and low blood sugars requiring frequent and daily adjustments of her lantus dose and sliding scale. At time of discharge she was on 4units of lantus with sliding scale recommended by . During her hospitalization she required 2 units of blood products for hematocrit of 21 thought to be secondary to acute illness and phlebotomization. Hct was 25 at time of admission dropped to 21 during the course of her ICU stay. Her Hct remained stable at 32 for several days prior to her discharge. She was also given IV Iron given concern for occult GIB. Unclear remain the cause of her diarrhea which may have been viral in nature. Stool studies were all negative. Though this had resolved by time of discharge. Nausea vomiting, initially thought to be gastroparesis were minimal during this hospitalization compared to prior. She was tolerating regular diet at time of discharge. Renal failure had improved to creatinime of 1.2 on day of discharge. She was restarted on her home diuretics at time of d/c. She was not started on ACE/ due to history of hyperkalemia. Hospital course was also complicated by a number of social issues. Her mother and grandfather continued to be major supports. Pt admitted to not feeling supported by her husband with her medical issues. She was very stressed and was in a low mood during her hospitalization with flat affect. She was never suicidal or homicidal. She was seen by social work who did not feel that an inpatient psychiatry evaluation was needed. She was started on buspar and continued on zoloft. | Indeterminate pulmonary artery systolic pressure.Compared with the prior study (images reviewed) of , a very small tosmall pericardial effusion is present. An eccentric, posteriorly directedjet of at least mild (1+) mitral regurgitation is seen. Concomitant mild interstitial pulmonary edema is present. There is likely concomitant mild interstitial pulmonary edema given evidence of peribronchial cuffing in the left upper lung and probable Kerley B lines. Previously, at leastborderline pulmonary artery systolic hypertension was appreciated. Trace aortic regurgitation is seen. FINDINGS: Single frontal view of the chest again demonstrates multifocal pneumonia which has worsened from prior. Small hiatal hernia is noted. Bilateral asymmetrically distributed ground-glass and consolidative opacities involving the left lung to greater degree than the right, accompanied by smooth septal thickening and bilateral pleural effusions. Now febrile, question pneumonia. The bilateral consolidations are denser and have resulted in obscuration of the left hemidiaphragm and left heart border. Compared to prior, there has been a decrease in the degree of opacification suggesting interval diuresis of pulmonary edema. At least a moderate left pleural effusion is presumed. Probable worsening of pulmonary edema is seen as well. Lateral view shows a new severe consolidation at one of the lung bases, although on the frontal view I am not sure which one. Sinus tachycardia. Mild(1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. IMPRESSION: Worsening multifocal pneumonia and pulmonary edema. IMPRESSION: PA and lateral chest compared to and : Abnormalities in both lower lobes have worsened since . IMPRESSION: AP chest compared to : Severe bilateral pneumonia has not improved since . IMPRESSION: AP chest compared to through 7: Large scale bibasilar pneumonia has worsened, accompanied by increasing small bilateral pleural effusions. IMPRESSION: AP chest compared to through 9: Since , relatively symmetric bilateral perihilar consolidation, most likely edema, has improved substantially in the right lung, not on the left, where there is new moderate left pleural effusion. FINDINGS: Frontal and lateral views of the chest again demonstrate bilateral consolidations consistent with multifocal pneumonia. A left pleural effusion is likely. These findings likely represent a combination of multifocal pneumonia and pulmonary edema. 4:51 AM CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: pulm edema? Overall, the findings are still most suggestive of cardiac decompensation, given the persistence of mediastinal vascular and pulmonary vascular engorgement. 4:57 AM CHEST (PORTABLE AP) Clip # Reason: Evidence of consolidation or worsening pneumonia. IMPRESSION: Persistent bilateral multifocal pneumonia with interval improvement of pulmonary edema. There is also a component of mild pulmonary edema which is probably worsened. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Small pericardial effusion. REASON FOR THIS EXAMINATION: Evidence of consolidation or worsening pneumonia. Assessment of the hila is limited in the absence of intravenous contrast, but there is likely mild hilar lymphadenopathy present as well. Bilateral pleural effusions are most likely present as well. No PS.Physiologic PR.PERICARDIUM: Very small pericardial effusion. Left ventricular function. Discrete regions of sclerosis in the anterior ribs probably new since earlier in . Small-to-moderate dependent pleural effusions are also demonstrated as well as a small pericardial effusion. There is a very small pericardialeffusion measuring up to 0.8 centimeters in greatest dimension.. Upright conventional views would be very helpful to determine if there is additionally left lower lobe pneumonia, but the chest CT scan on suggested concurrent residual pulmonary edema and scattered bronchopneumonia in the upper lungs and possibly more severe consolidative pneumonia in the left lower lobe. Left pleuraleffusion. At least mildmitral regurgitation. PNA, persistant lung opacities REASON FOR THIS EXAMINATION: Further define b/l lung opacities CONTRAINDICATIONS for IV CONTRAST: diabetes FINAL REPORT CT CHEST WITHOUT CONTRAST DATED COMPARISON: CTA of the chest and serial chest radiographs dating between and . Please evaluate for worsening pneumonia, volume overload. No RAor RV diastolic collapse.GENERAL COMMENTS: Left pleural effusion.Conclusions:The left atrium is normal in size. FINAL REPORT INDICATION: History of diastolic heart failure admitted with pneumonia, now with acute desaturation. worsening pneumonia, volume overload. worsening pneumonia, volume overload. FINDINGS: Frontal and lateral chest radiographs were obtained. worsening PNA? worsening PNA? If it is necessary to determine whether this abnormality is unilateral or bilateral, oblique view should be obtained, but I am confident that there is new and progressive pneumonia relative to and respectively. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV systolic function.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Diabetes.Height: (in) 63Weight (lb): 128BSA (m2): 1.60 m2BP (mm Hg): 120/68HR (bpm): 86Status: InpatientDate/Time: at 11:40Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. IMPRESSION: (Over) 1:03 PM CT CHEST W/O CONTRAST Clip # Reason: Further define b/l lung opacities Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION FINAL REPORT (Cont) 1. | 11 | [
{
"category": "Radiology",
"chartdate": "2140-02-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1222971,
"text": " 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evidence of consolidation or worsening pneumonia. Thanks!\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with fever and pneumonia.\n REASON FOR THIS EXAMINATION:\n Evidence of consolidation or worsening pneumonia. Thanks!\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:56 A.M. \n\n HISTORY: 35-year-old woman with fever and pneumonia.\n\n IMPRESSION: AP chest compared to :\n\n Severe bilateral pneumonia has not improved since . There is also a\n component of mild pulmonary edema which is probably worsened. Heart size is\n top normal. No pneumothorax. At least a moderate left pleural effusion is\n presumed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-01-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1222874,
"text": " 8:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for progression\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with hypoxia, pneumonia\n REASON FOR THIS EXAMINATION:\n evaluate for progression\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:51 A.M., \n\n HISTORY: Hypoxia and pneumonia.\n\n IMPRESSION: AP chest compared to through 7:\n\n Large scale bibasilar pneumonia has worsened, accompanied by increasing small\n bilateral pleural effusions. Heart size is normal. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-02-01 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1223055,
"text": " 1:03 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Further define b/l lung opacities\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with t1DM, dCHF, ? PNA, persistant lung opacities\n REASON FOR THIS EXAMINATION:\n Further define b/l lung opacities\n CONTRAINDICATIONS for IV CONTRAST:\n diabetes\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST WITHOUT CONTRAST DATED \n\n COMPARISON: CTA of the chest and serial chest radiographs\n dating between and .\n\n TECHNIQUE: Volumetric, multidetector CT of the chest was performed without\n intravenous or oral contrast. Images are presented for display in the axial\n plane at 5-mm and 1.25-mm collimation. A series of multiplanar reformation\n images were also submitted for review.\n\n FINDINGS: Widespread areas of ground-glass opacity and consolidation are\n present in both lungs, with a predominantly peribronchovascular and perihilar\n distribution. The left lung is involved to a greater degree than the right\n lung, and the left lower lobe is most extensively involved. The areas of\n conglomerate ground glass and consolidation are relatively amorphous, but have\n a nodular configuration within the anterior right upper lobe. These findings\n are accompanied by mild smooth septal thickening with a basilar predominance.\n Small-to-moderate dependent pleural effusions are also demonstrated as well as\n a small pericardial effusion. Anasarca is present in the chest wall.\n\n Mediastinal lymphadenopathy is present with enlarged nodes measuring up to\n approximately 1.2 cm in diameter in the precarinal region. Enlarged\n mediastinal nodes involve multiple compartments bilaterally. Assessment of\n the hila is limited in the absence of intravenous contrast, but there is\n likely mild hilar lymphadenopathy present as well. Small hiatal hernia is\n noted.\n\n Exam was not specifically tailored to evaluate the subdiaphragmatic region,\n but note is made of a small amount of ascites. Remaining imaged upper abdomen\n is unremarkable on this limited assessment.\n\n Skeletal structures demonstrate multiple healed anterior rib fractures. Mild\n compression deformity in the upper thoracic spine best visualized on sagittal\n reformations is unchanged since , but a healing transverse\n fracture involving the inferior aspect of the sternum is not clearly seen on\n that prior study. Several of the anterior rib fractures on today's study are\n also apparently new since that time.\n\n IMPRESSION:\n\n (Over)\n\n 1:03 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Further define b/l lung opacities\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Bilateral asymmetrically distributed ground-glass and consolidative\n opacities involving the left lung to greater degree than the right,\n accompanied by smooth septal thickening and bilateral pleural effusions.\n These findings likely represent a combination of multifocal pneumonia and\n pulmonary edema.\n\n 2. Small pericardial effusion.\n\n 3. Anasarca and small amount of ascites.\n\n 4. Healing sternal fracture and several anterior rib fractures, which are not\n appreciated on the older CT of but are age indeterminate.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-02-04 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1223495,
"text": " 9:25 AM\n CHEST (PA & LAT) Clip # \n Reason: please evaluate for change\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with PNA, prior CXR recommended repeat to evaluate bases\n REASON FOR THIS EXAMINATION:\n please evaluate for change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Diastolic heart failure admitted with pneumonia, evaluate change.\n\n COMPARISON: at 0508 hours and .\n\n FINDINGS: Frontal and lateral views of the chest again demonstrate bilateral\n consolidations consistent with multifocal pneumonia. Within the largest\n consolidation of the left lower lobe there is a suggestion of cavity formation\n demonstrated by a rounded opacification with lucent center, follow up is\n recommended. Compared to prior, there has been a decrease in the degree of\n opacification suggesting interval diuresis of pulmonary edema. Cardiac\n silhouette is unchanged. There is no pneumothorax or new consolidation.\n Abdominal coils are noted.\n\n IMPRESSION: Persistent bilateral multifocal pneumonia with interval\n improvement of pulmonary edema. Close attention on follow up should be paid\n to the left lower lobe consolidation for evaluation of cavity formation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-01-28 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1222497,
"text": " 11:56 AM\n CHEST (PA & LAT) Clip # \n Reason: cardiopulm\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with cough, no fever\n REASON FOR THIS EXAMINATION:\n cardiopulm\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 35-year-old woman with cough, no fever.\n\n COMPARISON: .\n\n FINDINGS: Frontal and lateral chest radiographs were obtained. Lung volumes\n are low. Cardiomediastinal silhouette is unremarkable. Patchy opacities in\n the retrocardiac space may be atelectasis, but infection cannot be excluded.\n No pleural effusion or pneumothorax is present.\n\n IMPRESSION: Low lung volumes with patchy opacities in the left lung base,\n likely atelectasis, but infection cannot be ruled out in the correct clinical\n setting.\n\n"
},
{
"category": "Echo",
"chartdate": "2140-02-04 00:00:00.000",
"description": "Report",
"row_id": 75646,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function. Diabetes.\nHeight: (in) 63\nWeight (lb): 128\nBSA (m2): 1.60 m2\nBP (mm Hg): 120/68\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 11:40\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<=2.1cm)\nwith >50% decrease with sniff (estimated RA pressure (0-5 mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV systolic function.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels. No 2D\nor Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Eccentric MR jet. Mild\n(1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Very small pericardial effusion. Effusion circumferential. No RA\nor RV diastolic collapse.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium is normal in size. The estimated right atrial pressure is 0-5\nmmHg. Left ventricular wall thickness, cavity size and regional/global\nsystolic function are normal (LVEF >55%). with normal free wall contractility.\nThe diameters of aorta at the sinus, ascending and arch levels are normal. The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis. Trace aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. An eccentric, posteriorly directed\njet of at least mild (1+) mitral regurgitation is seen. The pulmonary artery\nsystolic pressure could not be determined. There is a very small pericardial\neffusion measuring up to 0.8 centimeters in greatest dimension.. The effusion\nappears circumferential. No right atrial or right ventricular diastolic\ncollapse is seen.\n\nIMPRESSION: Normal left ventricular cavity size and wall thickness with\npreserved global and regional biventricular systolic function. At least mild\nmitral regurgitation. Very small to small, circumferential pericardial\neffusion without echocardiographic evidence of tamponade. Left pleural\neffusion. Indeterminate pulmonary artery systolic pressure.\n\nCompared with the prior study (images reviewed) of , a very small to\nsmall pericardial effusion is present. The pulmonary artery systolic pressure\nwas not able to be determined on the current study. Previously, at least\nborderline pulmonary artery systolic hypertension was appreciated. The left\npleural effusion is new.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-01-29 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1222650,
"text": " 11:14 AM\n CHEST (PA & LAT) Clip # \n Reason: please eval for PNA, prior CXR\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with cough, fever\n REASON FOR THIS EXAMINATION:\n please eval for PNA, prior CXR\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST \n\n HISTORY: 35-year-old woman with a cough, suspect pneumonia.\n\n IMPRESSION: PA and lateral chest compared to and :\n\n Abnormalities in both lower lobes have worsened since . Lateral view\n shows a new severe consolidation at one of the lung bases, although on the\n frontal view I am not sure which one. There is also peribronchial\n opacification in the right lower lung extending laterally. If it is necessary\n to determine whether this abnormality is unilateral or bilateral, oblique view\n should be obtained, but I am confident that there is new and progressive\n pneumonia relative to and respectively. Discrete\n regions of sclerosis in the anterior ribs probably new since earlier in .\n They could be posttraumatic. Heart size is normal. Dr. was paged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-01-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1222836,
"text": " 5:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? worsening pneumonia, volume overload.\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with multifocal pneumonia, dCHF. Increasing oxygen\n requirement. Please evaluate for worsening pneumonia, volume overload.\n REASON FOR THIS EXAMINATION:\n ? worsening pneumonia, volume overload.\n ______________________________________________________________________________\n WET READ: SAT 8:22 PM\n Marked interval increase in bilateral mid-to-lower lung heterogenously\n opacities, left greater than right, consistent with worsening pneumonia.\n There is likely concomitant mild interstitial pulmonary edema given evidence\n of peribronchial cuffing in the left upper lung and probable Kerley B lines.\n A left pleural effusion is likely.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with multifocal pneumonia and\n diastolic congestive heart failure.\n\n AP radiograph of the chest was compared to .\n\n It has been marked interval increase in bilateral mid to lower lung\n consolidations, left greater than right, but both substantial, highly\n concerning for worsening pneumonia with potential intraparenchymal hemorrhage.\n Concomitant mild interstitial pulmonary edema is present. Bilateral pleural\n effusions are most likely present as well.\n\n Findings were discussed with Dr. at 8:21 p.m. by Dr. over the\n phone.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-02-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1223465,
"text": " 4:51 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: pulm edema? worsening PNA?\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with diastolic CHF, admitted for PNA, now with acute\n desaturation concerning for worsening PNA vs. pulmonary edema vs. mucus\n plugging vs. PE\n REASON FOR THIS EXAMINATION:\n pulm edema? worsening PNA?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of diastolic heart failure admitted with pneumonia, now\n with acute desaturation.\n\n COMPARISON: and CT of the chest .\n\n FINDINGS: Single frontal view of the chest again demonstrates multifocal\n pneumonia which has worsened from prior. The bilateral consolidations are\n denser and have resulted in obscuration of the left hemidiaphragm and left\n heart border. Probable worsening of pulmonary edema is seen as well. The\n small left pleural effusion is unchanged and there is no pneumothorax.\n\n IMPRESSION: Worsening multifocal pneumonia and pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-02-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1223135,
"text": " 12:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with dHF and bilateral infiltrates now febrile.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 12:06 A.M., \n\n HISTORY: Diastolic CHF and bilateral infiltrates. Now febrile, question\n pneumonia.\n\n IMPRESSION: AP chest compared to through 9:\n\n Since , relatively symmetric bilateral perihilar consolidation, most\n likely edema, has improved substantially in the right lung, not on the left,\n where there is new moderate left pleural effusion. Overall, the findings are\n still most suggestive of cardiac decompensation, given the persistence of\n mediastinal vascular and pulmonary vascular engorgement. Upright conventional\n views would be very helpful to determine if there is additionally left lower\n lobe pneumonia, but the chest CT scan on suggested concurrent\n residual pulmonary edema and scattered bronchopneumonia in the upper lungs and\n possibly more severe consolidative pneumonia in the left lower lobe.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2140-01-31 00:00:00.000",
"description": "Report",
"row_id": 181377,
"text": "Sinus tachycardia. Non-specific repolarization abnormalities. Compared to the\nprevious tracing of no significant difference.\n\n"
}
] |
23,318 | 169,689 | 74 year-old female with stage IV sarcoidosis with combined restrictive/obstructive disease, asthma, dCHF, pulmonary HTN a/w COPD flare. . # COPD Flare, pulmonary sarcoidosis, pulmonary hypertension: The patient was admitted to the ICU in respiratory distress attributed to a COPD flare. She improved with steroids, nebulizer treatments, and Levofloxacin and was transferred to the floor where these therapies continued; she was never intubated. She was discharged on home dose advair and montelukast unchanged. Sarcoidosis contributed to the presentation by decreasing pulmonary reserve; pulmonary hypertension also contributed and sildenafil was continued. . # Hypertrophic C.Myopathy, dCHF, HTN: Continued home verapamil and furosemide 20. . INACTIVE ISSUES: . # Osteoporosis: Continued Ca/Vit D, alendronate . TRANSITIONAL ISSUES: # Prednisone taper will be overseen by PCP. | Compared to the previous tracingof premature atrial contractions are seen on the current tracing. Sinus tachycardia with premature atrial contractions. Left atrial abnormality.Non-specific inferior ST-T wave changes. | 1 | [
{
"category": "ECG",
"chartdate": "2155-06-26 00:00:00.000",
"description": "Report",
"row_id": 273010,
"text": "Sinus tachycardia with premature atrial contractions. Left atrial abnormality.\nNon-specific inferior ST-T wave changes. Compared to the previous tracing\nof premature atrial contractions are seen on the current tracing. The\nother findings are similar.\n\n"
}
] |
25,217 | 190,100 | Patient was admitted under Dr. service. Chest x-ray was performed on admission demonstrating no CHF, no pneumonia. Duplex of his liver was performed on demonstrating patent portal vein, a small amount of ascites around the liver. On , the patient had an abdominal CT because of elevated total bilirubin and lipase demonstrating cirrhosis and portal hypertension, moderate to large amount of ascites, abnormal IVC with collapse of the intrahepatic IVC and string appearance of the retrohepatic IVC, may be seen with low intravascular volume, small thrombus in the retrohepatic IVC cannot be excluded. Doppler ultrasound recommended in addition due to hypodense region in the confluence of the hepatic veins probably from volume average. Transplant surgery was consulted on for possible liver transplant. On , IVC study was obtained and tributaries were examined via ultrasound demonstrating no evidence of IVC thrombus. However, with each arterial pulsation there is external compression of the intrahepatic IVC likely by the hypertrophied caudate lobe. MELD score on was 27. Transplant surgery continued to see patient on Dr. service. On , no acute events. Patient's sodium slowly decreased to 129. Other remarkable labs - ALT 83, AST 184, alkaline phosphatase 143, total bilirubin 16.6, albumin 2.4. The patient's rifaximine was increased to 400 t.i.d., continue lactulose, fluid restrict him with less than 1.5 liters, with soft diet. MELD score increased to 29 on . Nutrition saw patient on for assistance in optimizing his p.o. intake. On , his MELD score increased to 31. On that day, he had increased nausea, increased abdominal pain, not feeling well, afebrile, vital signs stable. On , ultrasound was obtained because of abdominal distention due to ascites, in which he had a therapeutic tap. Social work had met with Mr. . Just of note, on , the patient had a series of blood work which included blood cultures, influenza AB, rapid respiratory viral screen cultures which were all unremarkable. Also had a UA, UC which were unremarkable. On , MELD score increased to 32. His labs on included sodium 128, 3.8, 96, 25, 16, 0.7, glucose of 88, ALT 68, AST 173, alkaline phosphatase 170, total bilirubin 24.5. On , the patient had increased lethargy, afebrile, vital signs stable. General - patient appears jaundiced, pleasant, in no acute distress. Abdomen soft, but distended, mild tenderness to palpation deeply in the right upper quadrant. Awake, oriented x3, not lethargic, nonfocal. Patient also had labs including a WBC of 5.2, hematocrit of 31.0, platelets 44, INR 3.4. On , the patient had NG tube placement because of nutritional depletion, which demonstrated that the feeding tube was in the distal duodenum. On , the patient had an orthotopic deceased donor liver transplant (piggyback, portal vein-portal vein anastomosis, common bile duct-common bile duct, no T-tube, common hepatic artery which is the donor to common hepatic artery which is recipient) performed by Doctors , . Please see detailed operative note for more information regarding the surgery. Postoperatively, the patient went to the unit. On , the patient went to the ICU. The patient was afebrile. Vital signs stable. Labs - sodium 132, 3.5, chloride 95, CO2 24, BUN and creatinine at 39 and 2.4, glucose 188, calcium, phosphorus, magnesium 10.1, 5.8, 3.3, AST 476, 289 is the ALT, alkaline phosphatase 85, total bilirubin 13.3. The patient was placed on Unasyn, fluconazole, ganciclovir, insulin, heparin, morphine. He was placed on MMF 1 gram b.i.d., Solu-Medrol 500. Continued to be improved in the ICU and patient was transferred to the floor on to Far-10. On that day, the patient was afebrile with vital signs stable. Two JPs were putting out from the medial 298, lateral 700. Sodium 6.4, hematocrit 31.0, platelets 59, sodium 136, 2.5, 100, 28, 40, creatinine 1.2, glucose 131, AST 91, 110, alkaline phosphatase 71, total bilirubin is 4.6. Of note, on , the patient had a Doppler ultrasound demonstrating somewhat attenuated but patent extrahepatic main hepatic artery but excellent intrahepatic left hepatic artery. The remainder of the examination is unremarkable. Continue with MMF, Solu-Medrol which the patient received a total of 5 doses of Solu-Medrol which ended on . The patient was started on FK or tacrolimus on . Because his platelets were decreasing, a HIT panel was sent off which was unremarkable. On , postop day 6, good pain control, ambulatory, continued on MMF, prednisone was started 20 mg once daily __________. Patient had a T-max of 1001, otherwise vital signs stable. Abdomen moderate distention. Dressing was clean, dry and intact. On , 1 of his JP drains was removed. PT was consulted. Occupational was consulted as well. met with patient for blood glucose control. On , another ultrasound was obtained, because of elevated LFTs, that demonstrated patent portal venous, common hepatic venous and hepatic arterial vasculature with appropriate direction of flow and waveforms. The patient was advanced to regular diet. Good I's and O's. Both JP drains were removed by . On , percutaneous liver biopsy was performed, because of elevated LFTs, demonstrating minute fragments of nerve, fibrous tear, rare hepatocytes, insufficient for evaluation. A repeat liver biopsy was performed on demonstrating liver parenchymal with focal minimal portal mononuclear cell inflammation, nonspecific. There were no features of acute cellular reduction or bile duct injury seen. An ERCP was performed on demonstrating no stricture at the surgical anastomosis, essentially post surgical cholangiogram without evidence of obstruction, no evidence of biliary leak. | Physiologic mitral regurgitation is seen(within normal limits). Physiologic MR (withinnormal limits).TRICUSPID VALVE: Normal tricuspid valve leaflets. PATIENT/TEST INFORMATION:Indication: Liver transplant, hemodynamic monitoringStatus: InpatientDate/Time: at 08:33Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thicknesses and cavity size.LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Pt intubated with pa in place- (see flow sheet for co, cvp, svo2, etc) JP x2 with sang drg, no t tube, ogt lcws with bili drg, abd drsg sang drg- drsg . Physiologic(normal) PR.GENERAL COMMENTS: A TEE was performed in the location listed above. The right, middle and left hepatic veins appear patent. In addition, there is a hypodense region at the confluence of the hepatic veins; probably from volume average. The infrahepatic inferior vena cava is patent. At the confluence of the hepatic veins there is an hypodense round region in the left side of the IVC - uncertain if is partial volume or thrombus in the IVC given it is seen only on one image. Admitting Diagnosis: SHORTNESS OF BREATH Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) island in the left ilium. oriented x 3.cv: stablepulm: bs clear, diminished rt base. Small thromus in the retrohepatic IVC cannot be excluded; doppler ultrasound recommended. The patient was undergeneral anesthesia throughout the procedure.Conclusions:The left atrium is moderately dilated. bowel sounds present, hypoactive.gu: u/o qs.Plan: wean as tolerated, check abg's as ordered. The IVC and hepatic veins are patent. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Unchanged tiny bone (Over) 3:08 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: evaluate biliary ducts for patency, r/o focal mass in liver. On duplex Doppler examination, the main portal vein shows mild turbulence, but the main portal vein and its major tributaries, including the left portal vein, the anterior and posterior right portal venous branches, are patent with appropriate hepatopetal flow. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. (Over) 2:28 PM LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # DUPLEX DOPP ABD/PEL Reason: please mark for liver biopsy as well as assess arterial/ Admitting Diagnosis: SHORTNESS OF BREATH FINAL REPORT (Cont) New since the previous exam is a small amount of free fluid inferior to the right lobe of liver. Normal hepatic vasculature. The ascending, transverse and descending thoracic aorta are normalin diameter and free of atherosclerotic plaque. Unchanged moderate-to-large amount of ascites. Abnormal IVC with collapse of the infrahepatic IVC and string appeareance of the retrohepatic IVC; may be seen with low intravascular volume. The hepatic veins are patent. 3:08 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: evaluate biliary ducts for patency, r/o focal mass in liver. 7:35 PM US ABD LIMIT, SINGLE ORGAN; -59 DISTINCT PROCEDURAL SERVICE Clip # DUPLEX DOP ABD/PEL LIMITED Reason: Please evaluate for portal vein clot, ascites. dsd changed x 1m then again this am by ho's.Possible repeat liver U/S today. Since the previous tracing of the T waves aremore inverted in lead III. Resistive index in the right hepatic artery is 0.78, the RI in the left hepatic artery is 0.74. to repeat liver US to noc. Foley to gravity- uo 100-500/hr- did rec lasix x1 in OR. Cirrhosis and portal hypertension. Within the gallbladder fossa, there is a small fluid collection, which may represent post-surgical fluid collection status post cholecystectomy. TECHNIQUE: Multidetector CT through the abdomen and pelvis with and without IV and oral contrast. Propofol gtt weaning as tol, but not able to turn off as sbp >170 when off. npn Pt is a+o, c/o pain q1-2- rx with 2 mg ivp mso4 q with relief, pearl, mae. The right and left portal veins are patent. Liver US done at bedside this pm and ? s/p liver transplantplease see careview for details.neuro: sedated on propofol, but following commands, nodding appropriately. REASON FOR THIS EXAMINATION: Please evaluate for portal vein clot, ascites. New since the previous exam is a small 3-6 cm collection of free fluid inferior to the liver. Resistive index in the main hepatic artery is 0.71. In segment II of the liver, there is a tiny 4-mm transient hyperenhancing foci seen only in the arterial phase. | 15 | [
{
"category": "Nursing/other",
"chartdate": "2169-02-26 00:00:00.000",
"description": "Report",
"row_id": 1591301,
"text": "s/p liver transplant\nplease see careview for details.\n\nneuro: sedated on propofol, but following commands, nodding appropriately. perl. mae.\n\ncv: afeb, nsr, bp stable. filling pressures low. 2 u ffp for inr 1.8, with subsequent temporary increase in pressures.\n\npulm: vented 50%, cmv, alkalotic. decrease in tv. bs coarse to rhonchorous. sx for thick bloody.\n\ngi: ng to lcws draining bilious. bowel sounds present, hypoactive.\n\ngu: u/o qs.\n\nPlan: wean as tolerated, check abg's as ordered. medicate for pain as needed.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-02-26 00:00:00.000",
"description": "Report",
"row_id": 1591302,
"text": "npn\n Pt is a+o, c/o pain q1-2- rx with 2 mg ivp mso4 q with relief, pearl, mae. Did receive 100 mcg fentanyl in Angio.\n\nResp- extubated this am and tol hh face tent with .40 fio2. lungs clear upper- at bases. coughing up old lg blood clots- nasal packing cont in place from nose bleed in OR- no new nose bleeding seen.\n\nGI- ogt dc when extubated- denies nausea. Cont npo. Liver US done at bedside this pm and ? of low arterial flow reported- pt taken to angio for more eval- transplant team plan at this time is to cont to follow lab trends and redo US- also plan to repeat angio in days- lfts's/amylase have been trending down since OR_ will cont to check labs pr transplant request.\n\nHemodynmics- Pa stilll in place- see flow sheet for all #'S. Sbp 130's 160's, nsr, denies chest pain,\n\nHeme- rec 2 ffp this am for inr 1.8 and rec 2 pack platelets in angio for count 66.\nPLAN_ cont to follow q1 labs pr sicu protocl, labs pr transplant req, ? to repeat liver US to noc.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-02-27 00:00:00.000",
"description": "Report",
"row_id": 1591303,
"text": "Please see careview for details\n\nneuro: . some slight tremors of arms and hands, pt states they were worse pre-op. oriented x 3.\n\ncv: stable\n\npulm: bs clear, diminished rt base. sats mid 90's on 50% face shovel.\n\nENT: nasal packing removed this am with no signs of repeat epistaxis at this time.\n\ngi: bowel sounds present, no flatus. taking ice chips.\n\ngu: u/o qs.\n\npain: pt states his pain is , dropping to only after each dose of pain medication. will approach team for change or increase im mso4.\n\nincision: sm amts serous drainage. dsd changed x 1m then again this am by ho's.\nPossible repeat liver U/S today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-02-25 00:00:00.000",
"description": "Report",
"row_id": 1591298,
"text": "respiratory care\npt admitted from OR placed on vent tol well see respiratory page of care view for more information\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-02-25 00:00:00.000",
"description": "Report",
"row_id": 1591299,
"text": "Nsg admit Note\n51 yo male with hx iv drug/etoh use in past with etoh cirrhosis/hep c. S/P liver transplant - requiring multi blood produsts in OR_ (see I+O flow sheet or OR flow sheet for totals). In SICU rec 1 unit prbc for hct 28- 1 pack platelet for count 92- and 2 ffp for INR 1.6. Pt intubated with pa in place- (see flow sheet for co, cvp, svo2, etc) JP x2 with sang drg, no t tube, ogt lcws with bili drg, abd drsg sang drg- drsg . Nasal packing in place as nose bleed in OR- cont md aware- labs to be done q8- next due 8 pm tonoc. Requiring insulin gtt for glucose >200- gtt at 5u/hr with 10 cc d5w pr Dr request. Propofol gtt weaning as tol, but not able to turn off as sbp >170 when off. Dr aware- propofol now at 20mcg/kg/min. Pearl, not following commands at this time- was not reversed from sedation/paralytic rec. in OR. Foley to gravity- uo 100-500/hr- did rec lasix x1 in OR. sister is his proxy- family in this pm- plan to call for updates- they also spoke with Dr for surgical updates post op.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-02-26 00:00:00.000",
"description": "Report",
"row_id": 1591300,
"text": "RESPIRATORY CARE 1900-0700\nPT REMAINS ORALLY INTUBATED ON AC. Vt CHANGED FROM 600ml TO 550ml, NO OTHER CHANGES MADE TO VENT THROUGHOUT THE NIGHT. BS CLEAR TO COARSE SX FOR MINIMAL RETURN. RSBI THIS AM= 29. SEE CAREVUE FOR FURTHER QUESTIONS.\n"
},
{
"category": "Echo",
"chartdate": "2169-02-25 00:00:00.000",
"description": "Report",
"row_id": 64347,
"text": "PATIENT/TEST INFORMATION:\nIndication: Liver transplant, hemodynamic monitoring\nStatus: Inpatient\nDate/Time: at 08:33\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Physiologic MR (within\nnormal limits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\n(normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thicknesses and\ncavity size are normal. Right ventricular chamber size and free wall motion\nare normal. The ascending, transverse and descending thoracic aorta are normal\nin diameter and free of atherosclerotic plaque. The aortic valve leaflets (3)\nare mildly thickened. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Physiologic mitral regurgitation is seen\n(within normal limits).\n\n\n"
},
{
"category": "ECG",
"chartdate": "2169-03-06 00:00:00.000",
"description": "Report",
"row_id": 135398,
"text": "Sinus rhythm, rate 73. Since the previous tracing of the T waves are\nmore inverted in lead III. No other changes are present.\n\n"
},
{
"category": "ECG",
"chartdate": "2169-02-10 00:00:00.000",
"description": "Report",
"row_id": 135399,
"text": "Sinus rhythm. Long QTc interval. Compared to the previous tracing\nof no significant change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-12 00:00:00.000",
"description": "CT PELVIS W/CONTRAST",
"row_id": 901385,
"text": " 3:08 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: evaluate biliary ducts for patency, r/o focal mass in liver.\n Admitting Diagnosis: SHORTNESS OF BREATH\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with hep C/ETOH cirrhosis,on transplant list now presenting\n with epigastric pain, elevated total bilirubin, and elevated lipase.\n REASON FOR THIS EXAMINATION:\n evaluate biliary ducts for patency, r/o focal mass in liver. assess degree of\n bowel edema (if any)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Abdomen and pelvis CT.\n\n HISTORY: 51-year-old man with hepatitis C/ETOH cirrhosis with epigastric\n pain, elevated total bilirubin and elevated lipase. Assess for focal liver\n masses and biliary duct.\n\n TECHNIQUE: Multidetector CT through the abdomen and pelvis with and without\n IV and oral contrast. Arterial, venous and delayed images were obtained,\n coronal and sagittal reformations are also provided.\n\n FINDINGS: There is a small liver with nodular contours. In segment II of the\n liver, there is a tiny 4-mm transient hyperenhancing foci seen only in the\n arterial phase. Also in segment II, there is a hypodense nonenhancing foci\n too small to be characterized unchanged from the prior study. There is no\n biliary duct dilatation. The gallbladder, pancreas, adrenal glands and kidneys\n are unremarkable. There is no hydronephrosis. The aorta is normal in\n caliber. The portal vein, celiac, SMA, renal arteries, and splenic veins\n are widely patent. Multiple dilated varices are seen in the upper left\n quadrant. There is an unchanged moderate splenomegaly.\n\n The entire infrahepatic IVC is markedly collapsed and slit-like. The\n retrohepatic segment of the IVC is very stenotic with a string appeareance. At\n the confluence of the hepatic veins there is an hypodense round region in the\n left side of the IVC - uncertain if is partial volume or thrombus in the IVC\n given it is seen only on one image. The hepatic veins are patent. These\n findings are stable from but new from .\n\n Multiple portal, celiac and retroperitoneal lymph nodes are present, none of\n which meet CT criteria of pathology.\n\n Unchanged moderate-to-large amount of ascites. The bowel loops are\n unremarkable. There is no colonic wall thickening.\n\n PELVIC CT WITH ORAL AND IV CONTRAST: The rectum, sigmoid colon and bladder\n are unremarkable. There is no lymphadenopathy.\n\n BONE WINDOWS: There are no concerning bone lesions. Unchanged tiny bone\n (Over)\n\n 3:08 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: evaluate biliary ducts for patency, r/o focal mass in liver.\n Admitting Diagnosis: SHORTNESS OF BREATH\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n island in the left ilium.\n\n CT reformations confirm the findings seen in the axial images and were\n invaluable in the assessment of the IVC.\n\n IMPRESSION:\n 1. Cirrhosis and portal hypertension.\n 2. Moderate-to-large amount of ascites.\n 3. Abnormal IVC with collapse of the infrahepatic IVC and string appeareance\n of the retrohepatic IVC; may be seen with low intravascular volume. Small\n thromus in the retrohepatic IVC cannot be excluded; doppler ultrasound\n recommended. In addition, there is a hypodense region at the confluence of the\n hepatic veins; probably from volume average.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-10 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 901243,
"text": " 7:35 PM\n US ABD LIMIT, SINGLE ORGAN; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Please evaluate for portal vein clot, ascites. If ascites,\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with hep C cirrhosis, increasing abdominal pain and ascites,\n please r/p portal vein clot, ascites.\n REASON FOR THIS EXAMINATION:\n Please evaluate for portal vein clot, ascites. If ascites, please mark for\n diagnostic tap.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hepatitis C cirrhosis, increasing abdominal pain.\n\n COMPARISON: .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is again echogenic consistent with\n cirrhosis. There is a small amount of ascites surrounding the liver. The\n gallbladder wall is again thickened, consistent with the background of\n ascites. The main portal vein is patent with appropriate direction of flow.\n There is no intrahepatic biliary ductal dilatation. The right kidney does not\n have hydronephrosis and measures 13 cm. There is a small amount of fluid\n within the right lower quadrant, left upper quadrant, and no significant free\n fluid in the left lower quadrant.\n\n IMPRESSION:\n\n 1. Patent portal vein.\n\n 2. Small amount of ascites around the liver.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-03-06 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 904290,
"text": " 2:28 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: please mark for liver biopsy as well as assess arterial/\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p liver transplant with elevated lfts now 11 days postop\n REASON FOR THIS EXAMINATION:\n please mark for liver biopsy as well as assess arterial/venous flow and ductal\n obstruction\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND OF THE TRANSPLANTED LIVER\n\n There is a comparison exam from .\n\n CLINICAL HISTORY: 11 days post-op liver transplant, now elevated LFTs.\n\n FINDINGS: The liver echotexture and echogenicity are normal. There is no\n biliary dilatation. No masses are present in the liver.\n\n Portal venous flow is hepatopetal, peak velocity is approximately 100 cm/sec.\n Hepatic arterial waveform tracings demonstrate brisk upstroke. Resistive\n index in the right hepatic artery is 0.78, the RI in the left hepatic artery\n is 0.74. Resistive index in the main hepatic artery is 0.71. The right and\n left portal veins are patent. The IVC and hepatic veins are patent.\n\n The common duct is not dilated measuring 3 mm in diameter.\n\n The spleen is enlarged measuring 16 cm in length.\n\n New since the previous exam is a small amount of free fluid inferior to the\n right lobe of liver.\n\n The right kidney measures 11.8 cm in length, images of the left kidney were\n not acquired.\n\n IMPRESSION:\n 1. Normal hepatic vasculature.\n 2. New since the previous exam is a small 3-6 cm collection of free fluid\n inferior to the liver. This may represent a bile leak or a small amount of\n ascites. These findings were relayed to the clinical service on .\n\n\n\n\n\n (Over)\n\n 2:28 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: please mark for liver biopsy as well as assess arterial/\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-03-06 00:00:00.000",
"description": "GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)",
"row_id": 904285,
"text": " 2:28 PM\n BX-NEEDLE LIVER BY RADIOLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \n Reason: please do liver transplant u/s guided biopsy. assess art/\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with rising lfts s/p liver transplant\n REASON FOR THIS EXAMINATION:\n please do liver transplant u/s guided biopsy. assess art/venuos flow as well as\n for ductal obstruction. please call pathology for rush processing. Txs\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Elevated LFTs, status post liver transplant x11 days.\n\n FINDINGS: The risks and benefits of the procedure were explained to the\n patient. Informed written consent was obtained. A suitable region of the\n liver for biopsy was identified using ultrasound. The skin over the liver was\n prepped and draped in the usual sterile fashion. A preprocedure timeout was\n called to confirm the patient's identity and type of procedure to be\n performed. The patient was given lidocaine as a local anesthetic. A nurse\n administered fentanyl and versed intravenously. An 18 gauge core biopsy\n needle was inserted into the liver. A single specimen was obtained. The\n patient tolerated the procedure satisfactorily. The attending physician, .\n , was present throughout the entire procedure.\n\n IMPRESSION: Successful core biopsy of the transplanted liver.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-03-04 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 904096,
"text": " 1:31 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: now with elevated LFT, please assess for flow to hepatic art\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n now with elevated LFT, please assess for flow to hepatic artery, hepatic vein\n and portal vein.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old man status post liver transplant with elevated LFTs.\n Evaluate hepatic artery, hepatic vein and portal vein.\n\n 2-D, color flow, and Doppler exams of the abdomen were performed. No focal\n abnormalities are seen within the liver. Within the gallbladder fossa, there\n is a small fluid collection, which may represent post-surgical fluid\n collection status post cholecystectomy. The right kidney is unremarkable and\n measures 13.7 cm.\n\n Unremarkable flow and waveforms are seen within the hepatic arterial, portal\n venous, and hepatic venous systems. There is no visualized thrombus or\n stenosis.\n\n IMPRESSION: Patent portal venous, hepatic venous and hepatic arterial\n vasculature with appropriate directional flow and waveforms. The findings\n were discussed with Transplant team at the time of dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-26 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 903170,
"text": " 10:30 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: S/P TRANSPLANT PLEASE ASSESS PATENCY OF VESSELS\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p liver transplant\n REASON FOR THIS EXAMINATION:\n Please assess for patency of hepatic vein/artery, portal vein\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 51-year-old man status post liver transplant. Postoperative day\n #1.\n\n COMPARISONS: and .\n\n TECHNIQUE: Right upper quadrant ultrasound examination, with duplex Doppler\n evaluation of the transplanted liver.\n\n FINDINGS: The echotexture of the transplanted liver is somewhat coarse, as is\n anticipated in a recent transplant, but no focal lesions or surrounding fluid\n or hematoma are identified. There is no intrahepatic biliary ductal\n dilatation.\n\n On duplex Doppler examination, the main portal vein shows mild turbulence, but\n the main portal vein and its major tributaries, including the left portal\n vein, the anterior and posterior right portal venous branches, are patent with\n appropriate hepatopetal flow. The right, middle and left hepatic veins appear\n patent.\n\n No hepatic arterial flow is seen upon examination of the porta hepatis, or at\n the expected positions of the right and left hepatic arteries. This appearance\n is concerning for occlusion.\n\n The infrahepatic inferior vena cava is patent.\n\n IMPRESSION: No hepatic arterial flow identified, concerning for occlusion.\n Findings were discussed in the course of the study by the technologist, and\n immediately afterward with Dr. by Dr. .\n\n"
}
] |
14,535 | 162,571 | Pt. was a same day admit to the operating room. She was brought to the OR and after general anesthesia pt. underwent a mitral valve replcement for severe MR/MVP. Please see operative note for full surgical details. Pt. tolerated the procedure well with a total CPB time of 115 minutes and XCT of 94 minutes. Pt. was transferred to CSRU in stable condition with a MAP of 76, CVP 13, PAD 16, 23, HR 77 A-paced and being titrated on neosynephrine and propofol drips. That night pt. suddenly went into V. Fib. arrest and was quickly converted with electric cardioversion. A lidocaine bolus and Iv drip were also started. Pt. remained sedated and intubated overnight. POD #1 - Pt. was in NSR and Propofol was weaned early morning and pt. became awake and alert. She was then extubated, breathing well and neurologically intact. Lidocaine was d/c'd and lopressor and lasix was started. POD #2 - Remained in the ICU secondary to Neo support. HR sinus in 50-60s (paced in 80s). Chest Tubes & Foley removed. Coumadin Started. POD #3 - Pt. had run of A.Fib/A. Flutter in AM. Back in SR after lopressor. POD #4 - Pt. had another brief run of A. flutter and self converted. She is stable and was trnaferred to 2 today. POD #5 - Pacing wires removed. Pt. hemodynam. stable. Encouraged pt to continue PT and increase activity. POD #6 - Pt. at level 5. Doing well with some complications post-op. D'C'd home today with VNA. D/C PE: VS: T 97.7 P 83 SR BP 125/53 RR 18 Neuro: alert, oriented, non-focal Pulm: CTAB Cardiac: RRR Sternum: stable, incision c&d, -drainage/erythema Abd: soft, NT/ND +BS Ext: Warm, 1+ edema | TOL CLEAR LIQS.ENDO: FS QID. LIDOCAINE GTT DC'D THIS AM. continue with lidocaine and neo gtts. ATTEMPT TO WEAN NEO GTT AS TOLERATES. will wake and wean this am.gi/gu: foley to gravity. CT WITH MOD SEROSANG DRNG. PT BP LABILE , INITIAL CI 1.4 TX 1L LR NOW 2.1. TITRATE NEO PRN. RECIEVED COUMADIN THIS PM.RESP: LUNGS CLEAR WITH DIM BILATERAL BASES. CT dc'dgi/gu: pt with + bs. using IS gi/gu: pt with + bs. wake and wean to extubate this am. CONTINUES ON NEO AND LIDO. ALINE DAMPENED AND NBP APPLIED FOR READINGS. COVER PER RISS. BS POSITIVE-> HYPOACTIVE. There is aortic calcification. ABD SOFT.GU: PT WITH LARGE UOP AFTER AM LASIX. PM LASIX UNTIL BP IMPROVES. HAD HR IN THE LOW 90'S NSR.REVERTS BACK TO PACING.VOIDING IN GOOD QUANTITIES POST FOLEY REMOVAL; (PO LASIX GIVEN).DENIES PAIN. IMPRESSION: Status post mitral valve replacement, with multiple tubes and lines positioned as described. DRAINING MODERATE SEROSANGUINOUS FLUID. pad 13-17, cvp 6-11, ci > 2.1. dopplerable pedal pulses bilaterally.resp: lungs clear. MAE and able to follow commandsCV: pt in NSR. ABSENT BSGU: LG AMT CLEAR UOPPLAN: REMAIN INTUBATED OVERNGIHT, CHECK NEURO STATUS, HAVE READY TO EXTUBATE FOR ROUNDS AT 0600. CONT ASSESS CARDIO/RESP STATUS, AND REPLETE LYTES PRN. SUPINE AP CHEST: There has been interval median sternotomy. VAVLE EXTREMELY CALCIFIED PER DR. . S/P MVR,EZ intubation # 7.0 @ 18 cm lips.Not much past med story.BS clear,on mechanical ventilation will wean to extubate. ambulated x2. A mediastinal drain and left chest tube are in place. Sternotomy wires and a mitral valve replacement are noted. CONTINUE WITH COUMADIN FOR ANTICOAGULATION. BP stable. PLACEMENT CONFIRMED BY AUSCULTATION. PT. PT. OOB TO COMMODE X1. SWAN DC'D, CORDIS ALINE IN. FOLEY PATENT.ENDO: BS HIGHER AFTER PM ANTBX AND JUICE, COVERED WITH SSR PER PROTOCOLPLAN: CONT TO TRY TO WEAN NEO TO KEEP MAP>60. OCC. PERRRLACV: SEE EVENTS ABOVE. tolerated cardiac diet. PERSISTENT NEO REQUIREMNT AT 1MCG WITH MAP 60-67. Cannot exclude myocardial ischemia.Compared to the previous tracing of the rhythm has changed. ONCE PT SPONT INTO VF AT 1830 (<1 MIN) PT 200J X1 TO NSR 80'S, LIDO BOLUS AND GTT STARTED, MAG UP , DR. AND DR. TOL. perrl.cv: sr 60-70's, rare pvc noted. PT STARTED ON COUMADIN THIS PM FOR CALCIFIED AORTA PER DR. .RESP: LUNG DIM AT BASE BUT OTHERWISE CLEAR. ENCOURAGE COUGH, DEEP BREATHING, AND IS USE.GI/GU: FOLEY TO GRAVITY. CONTINUE LIDO OVERNIGHT. PT UNEVENTFUL OR RECIEVED IUPRBC. pt recieved 4 mg coumadin this eveningresp: LS clear with dim bases bil. requiring fluid replacement. tolerting cardiac diet. CONT CURRENT PLAN OF CARE pt recieved 2 mg coumadin this evening.resp: LS clear. SBP dropped into the 80's this am -> neo gtt started. PT NEEDING FREQUENT LYTE REPLACEMENT SECONDARY DIURESIS. VERY HYPOACTIVE BS. PM DOSE LOWERED . GOOD HUO. EXTUBATED AT 0630 WITHOUT DIFFICULTY. MONITOR PT/PTT/INR FOR COUMADIN DOSE. DR. ADVANCE DIET PRN, FOLLOW COAGS NOW ON COUMADIN. COMPARISON: . ct to 20 cm suction, minimal serosanguinous drainage noted. continue with phenylephrine gtt to keep map 60-90. required 3 liters of volume r/t autodiuresis. large uo immediately post-op. MONITOR PT/INR WHILE ON COUMADIN THERAPY. 7P-7A:NEURO: ALERT AND ORIENTED X 3. An endotracheal tube is in place, with the tip approximately 2 cm from the carina. ASSESS UNDERLYING RHYTHM. PT ALSO C/O DIZZINESS AND NEO WHEN OOB, TX WITH REGLAN 5MG IV CONT ONLY TOL CLEARS. PLAN: CONT TITRATE NEO AS TOL TO MAINTIAN MAPS>60. WANTS PT AWOKEN AND NEURO STATUS CHECKED AND THEN CAN BE RESEDATED. remains on RA -> o2 sats 94-96%. CURRENTLY NSR 80'S NO FURTHER ECTOPY. o2 sat remains > 99%. PT C/O LOWER BACK PAIN THAT IS POSITIONAL, AND STERNAL INCISION PAIN PERCOCET STARTEDCV: HR 70'S NSR RARE PVC AND COUPLET NOTED. ExtensiveST-T wave changes may be due to rate. physical therapy into see pt. PT REQUIRING INCREASE NEO. PALP PEDAL PULSES. PALPABLE PEDAL PULSES BILATERALLY. REEVAL NEED FOR LASIX LYTES BEING REPLETED. abdomen soft, nd. ABDOMEN SOFT, ND. TRANSFERRING BED TO CHAIR/COMMODE WITH EASE.REMAINS A-PACED FOR BP. complete post-op antibiotic course. 7am-7pm updateNEURO: pt alert and orientated x 3. foley dc'd at 1500 -> pt has not voided sinceendo: elvated bs treated with ss reg insulin per protocolplan: transfer to 2, pulm toliet, pain control, advance diet and activity as tolerated propofol weaned to off-> pt able to follow all commands and mae. The course of the Swan-Ganz catheter is mostly smooth, except for a slight angulation at the cavoatrial junction. 7am-7pm updateneuro: pt alert and orienated x3. GLUCOSE MANAGEMENT AS NEEDED. NEO GTT CONTINUES TO KEEP MAP> 60. neo gtt weaned to off this afternoon. NEURO: ALERT AND ORIENTED X3. suctioned for scant amount thick clear secretions. orally intubated on full ventilator support. USING CALL LIGHT TO CALL FOR COMMODE PRIVELAGES. percocets given for incisional painplan: monitor rhythm, 2 in am, pulm toliet, pain control, advance activity as tolerated, continue coumadin ABD SOFT. There is a right internal jugular approach Swan-Ganz catheter, with the tip overlying the expected right pulmonary artery. CONTINUE TO ADVANCE ACTIVITIES AND DAT. Atrial flutter with rapid ventricular response with 2:1 A-V block. PALP PEDAL PULSES, MINIMAL CT DRNG--A WIRES SENSE AND CAPTURE, V WIRES NOT CHECKED DUE TO VF.RESP: LUNGS CLEAR THROUGHOUT. INCISIONS CDI.PLAN: MONITOR HEMODYNAMICS. FILLING PRESSURE EUVOLEMIC, SVO2 70-80%. ogt to lws suction draining bilious drainage. 7p-7a:neuro: sedated on propofol. electrolytes repleted. ELECTROLYTES REPLETED. carafate and zantac for gi prophylaxis.endo: regular insulin gtt started for bg 160. titrated per protocol with bs 100 presently.plan: monitor hemodynamics. An NG tube terminates with the tip in the fundus of the stomach. SBP now 90-100's. ADDENDUM:LIDOCAINE AT 2 MG/MIN. NOW TOLERATING PO MEDS AND CLEARS, WILL ADVANCE DIET. PERCOCET PRN BACK PAIN.CV: A PACED AT 80 FOR BP SUPPORT, NO ECTOPY NOTED. | 15 | [
{
"category": "Radiology",
"chartdate": "2148-03-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 857760,
"text": " 7:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for lines, tube, and pneumothorax\n Admitting Diagnosis: MR\\MITRAL VALVE REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman s/p mitral valve replacement\n REASON FOR THIS EXAMINATION:\n eval for lines, tube, and pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post mitral valve replacement.\n\n COMPARISON: .\n\n SUPINE AP CHEST: There has been interval median sternotomy. Sternotomy wires\n and a mitral valve replacement are noted. An endotracheal tube is in place,\n with the tip approximately 2 cm from the carina. There is a right internal\n jugular approach Swan-Ganz catheter, with the tip overlying the expected right\n pulmonary artery. The course of the Swan-Ganz catheter is mostly smooth,\n except for a slight angulation at the cavoatrial junction. An NG tube\n terminates with the tip in the fundus of the stomach. A mediastinal drain and\n left chest tube are in place. The cardiac and mediastinal contours are\n relatively stable. There is aortic calcification. The lungs are clear,\n without vascular congestion or consolidation. There may be a small left\n effusion. No pneumothorax detected on this supine radiograph.\n\n IMPRESSION:\n\n Status post mitral valve replacement, with multiple tubes and lines positioned\n as described. No pneumothorax detected.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2148-03-10 00:00:00.000",
"description": "Report",
"row_id": 193023,
"text": "Atrial flutter with rapid ventricular response with 2:1 A-V block. Extensive\nST-T wave changes may be due to rate. Cannot exclude myocardial ischemia.\nCompared to the previous tracing of the rhythm has changed.\n\n"
},
{
"category": "ECG",
"chartdate": "2148-03-07 00:00:00.000",
"description": "Report",
"row_id": 193024,
"text": "Sinus rhythm\nInferior/lateral ST-T changes may be due to myocardial ischemia\nSince previous tracing of , no significant change\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-03-09 00:00:00.000",
"description": "Report",
"row_id": 1451916,
"text": "7P-7A:\nNEURO: ALERT AND ORIENTED X 3. MAE, ABLE TO FOLOW ALL COMMANDS. PERCOCET PRN BACK PAIN.\n\nCV: A PACED AT 80 FOR BP SUPPORT, NO ECTOPY NOTED. ELECTROLYTES REPLETED. NEO GTT CONTINUES TO KEEP MAP> 60. LASIX DOSE HELD LAST NIGHT SECONDARY TO OVERDIURESIS AND BP SUPPORT. PALPABLE PEDAL PULSES BILATERALLY. RECIEVED COUMADIN THIS PM.\n\nRESP: LUNGS CLEAR WITH DIM BILATERAL BASES. O2 SAT 98% ON 2L NC. CT TO 20 CM SXN, NO AIRLEAK NOTED. DRAINING MODERATE SEROSANGUINOUS FLUID. ENCOURAGE COUGH, DEEP BREATHING, AND IS USE.\n\nGI/GU: FOLEY TO GRAVITY. GOOD HUO. ABDOMEN SOFT, ND. BS POSITIVE-> HYPOACTIVE. TOL CLEAR LIQS.\n\nENDO: FS QID. COVER PER RISS. INCISIONS CDI.\n\nPLAN: MONITOR HEMODYNAMICS. ATTEMPT TO WEAN NEO GTT AS TOLERATES. INCREASE ACTIVITY AND DIET AS TOLERATES. CONTINUE WITH COUMADIN FOR ANTICOAGULATION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-03-09 00:00:00.000",
"description": "Report",
"row_id": 1451917,
"text": "7am-7pm update\nneuro: pt alert and orienated x3. MAE and able to follow commands. PERRL\n\nCv: Pt A paced at 88 (for bp support), underlything rhythm NSR in the 70's. no ectopy noted. SBP dropped into the 80's this am -> neo gtt started. SBP now 90-100's. neo gtt weaned to off this afternoon. pt recieved 4 mg coumadin this evening\n\n\nresp: LS clear with dim bases bil. pt on 2 l nc, o2 sats >96%. CT dc'd\n\ngi/gu: pt with + bs. tolerated cardiac diet. foley dc'd at 1500 -> pt has not voided since\n\nendo: elvated bs treated with ss reg insulin per protocol\n\nplan: transfer to 2, pulm toliet, pain control, advance diet and activity as tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-03-10 00:00:00.000",
"description": "Report",
"row_id": 1451918,
"text": "PT. ALERT AND COOPERATIVE. USING CALL LIGHT TO CALL FOR COMMODE PRIVELAGES. TRANSFERRING BED TO CHAIR/COMMODE WITH EASE.\nREMAINS A-PACED FOR BP. ALINE DAMPENED AND NBP APPLIED FOR READINGS. ARTERIAL LINE 20 POINTS LOWER THAN CUFF AT TIMES.\nPT. OCC. HAD HR IN THE LOW 90'S NSR.REVERTS BACK TO PACING.\nVOIDING IN GOOD QUANTITIES POST FOLEY REMOVAL; (PO LASIX GIVEN).\nDENIES PAIN. SLEEPING IN THE CHAIR SINCE O300 DUE TO SLIGHT BACK DISCOMFORT IN BED.\nPLAN: D/C ALINE. MONITOR PT/PTT/INR FOR COUMADIN DOSE. TRANSFER TO FLOOR WHEN BED AVAILABLE. CONTINUE TO ADVANCE ACTIVITIES AND DAT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-03-10 00:00:00.000",
"description": "Report",
"row_id": 1451919,
"text": "7am-7pm update\npt voiding in commode\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-03-10 00:00:00.000",
"description": "Report",
"row_id": 1451920,
"text": "7am-7pm update\nNEURO: pt alert and orientated x 3. MAE and able to follow commands\n\nCV: pt in NSR. pt had 1 episode of AFlutter this am -> SBP 70-80's with Aflutter -> treated with fluid bolus and given 2.5 mg iv lopressor x 2. after lopressor pt in ST -> HR in the 110-120's (A wire trace done and EKG done) after about 2 hours pt in NSR in the 80's. BP stable. pt with 2 a wires and 2 v wires (V wire do not sense appropiately). pt recieved 2 mg coumadin this evening.\n\nresp: LS clear. remains on RA -> o2 sats 94-96%. pt with strong cough. using IS \n\ngi/gu: pt with + bs. tolerting cardiac diet. pt voiding clear yellow urine in urinal\n\nendo: elvatated bs treated with ss reg insulin\n\nactivity/comfort: pt oob to chair with 1 assist. ambulated x2. physical therapy into see pt. percocets given for incisional pain\n\nplan: monitor rhythm, 2 in am, pulm toliet, pain control, advance activity as tolerated, continue coumadin\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-03-11 00:00:00.000",
"description": "Report",
"row_id": 1451921,
"text": "PT. ALERT AND PLEASANT. REQUESTING TO GO TO BED AT . FELL ASLEEP AFTER ONE PERCOCET GIVEN. OOB TO COMMODE X1. RHYTHM REMAINS NSR WITHOUT ANY EPISODES OF AFLUTTER. TOL. ALL ACTIVITY IN & OOB.\nPLAN: TRANSFER TO FLOOR TODAY. GLUCOSE MANAGEMENT AS NEEDED. MONITOR PT/INR WHILE ON COUMADIN THERAPY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-03-08 00:00:00.000",
"description": "Report",
"row_id": 1451912,
"text": "7p-7a:\nneuro: sedated on propofol. orally intubated on full ventilator support. propofol weaned to off-> pt able to follow all commands and mae. perrl.\n\ncv: sr 60-70's, rare pvc noted. electrolytes repleted. continue with phenylephrine gtt to keep map 60-90. required 3 liters of volume r/t autodiuresis. lidocaine gtt remains at 2mcg/kg/min, no furthur vt noted. pad 13-17, cvp 6-11, ci > 2.1. dopplerable pedal pulses bilaterally.\n\nresp: lungs clear. o2 sat remains > 99%. remains orally intubated on SIMV 40%: 5 peep, 5 psupp, 450 x 12 with normal abg. suctioned for scant amount thick clear secretions. ct to 20 cm suction, minimal serosanguinous drainage noted. will wake and wean this am.\n\ngi/gu: foley to gravity. large uo immediately post-op. requiring fluid replacement. abdomen soft, nd. bs absent. ogt to lws suction draining bilious drainage. carafate and zantac for gi prophylaxis.\n\nendo: regular insulin gtt started for bg 160. titrated per protocol with bs 100 presently.\n\nplan: monitor hemodynamics. wake and wean to extubate this am. continue with lidocaine and neo gtts. complete post-op antibiotic course.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-03-08 00:00:00.000",
"description": "Report",
"row_id": 1451913,
"text": "ADDENDUM:\nLIDOCAINE AT 2 MG/MIN. EXTUBATED AT 0630 WITHOUT DIFFICULTY. REMAINS ON 50% FACE TENT WITH O2SAT 98%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-03-08 00:00:00.000",
"description": "Report",
"row_id": 1451914,
"text": "NEURO: ALERT AND ORIENTED X3. MAE, NO DEFICIT NOTED. PT C/O LOWER BACK PAIN THAT IS POSITIONAL, AND STERNAL INCISION PAIN PERCOCET STARTED\nCV: HR 70'S NSR RARE PVC AND COUPLET NOTED. LIDOCAINE GTT DC'D THIS AM. PT NEEDING FREQUENT LYTE REPLACEMENT SECONDARY DIURESIS. PERSISTENT NEO REQUIREMNT AT 1MCG WITH MAP 60-67. PALP PEDAL PULSES. CT WITH MOD SEROSANG DRNG. NO LEAK. WIRES TO BOX BUT OFF. SWAN DC'D, CORDIS ALINE IN. PT STARTED ON COUMADIN THIS PM FOR CALCIFIED AORTA PER DR. .\nRESP: LUNG DIM AT BASE BUT OTHERWISE CLEAR. SATS >93% ON 1L NC BUT DROP TO 88-91% RA.\nGI: NAUSEA THIS AM WITH ICE CHIPS, REGLAN GIVEN. NOW TOLERATING PO MEDS AND CLEARS, WILL ADVANCE DIET. VERY HYPOACTIVE BS. ABD SOFT.\nGU: PT WITH LARGE UOP AFTER AM LASIX. PM DOSE LOWERED . FOLEY PATENT.\nENDO: BS HIGHER AFTER PM ANTBX AND JUICE, COVERED WITH SSR PER PROTOCOL\nPLAN: CONT TO TRY TO WEAN NEO TO KEEP MAP>60. CONT ASSESS CARDIO/RESP STATUS, AND REPLETE LYTES PRN. ADVANCE DIET PRN, FOLLOW COAGS NOW ON COUMADIN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-03-08 00:00:00.000",
"description": "Report",
"row_id": 1451915,
"text": "ADDENDUM: PT BRADY IN 50'S AFTER GETTING OOB, NSR. PT REQUIRING INCREASE NEO. PT AT 80 PER DR. , AND ALBUMIN 25% X1 GIVEIN WITH SOME IMPROVEMENT IN BP. PM LASIX UNTIL BP IMPROVES. UOP APPROX 30-40CC/HR. PT ALSO C/O DIZZINESS AND NEO WHEN OOB, TX WITH REGLAN 5MG IV CONT ONLY TOL CLEARS. PLAN: CONT TITRATE NEO AS TOL TO MAINTIAN MAPS>60. ASSESS UNDERLYING RHYTHM. REEVAL NEED FOR LASIX\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-03-07 00:00:00.000",
"description": "Report",
"row_id": 1451910,
"text": "75 yr old female with PMHX: HTN,Mitral valve regurgitation. S/P MVR,EZ intubation # 7.0 @ 18 cm lips.Not much past med story.BS clear,on mechanical ventilation will wean to extubate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-03-07 00:00:00.000",
"description": "Report",
"row_id": 1451911,
"text": "ARRIVED CSRU AFTER MVR AT 1750 ON NEO/PROP NSR. PT UNEVENTFUL OR RECIEVED IUPRBC. VAVLE EXTREMELY CALCIFIED PER DR. . ONCE PT SPONT INTO VF AT 1830 (<1 MIN) PT 200J X1 TO NSR 80'S, LIDO BOLUS AND GTT STARTED, MAG UP , DR. AND DR. IN ROOM AT TIME.\nNEURO: PT STILL SEDATED ON PROP, NOT REVERESED AT TPRESENT. DR. WANTS PT AWOKEN AND NEURO STATUS CHECKED AND THEN CAN BE RESEDATED. PERRRLA\nCV: SEE EVENTS ABOVE. CURRENTLY NSR 80'S NO FURTHER ECTOPY. LYTES BEING REPLETED. CONTINUES ON NEO AND LIDO. PT BP LABILE , INITIAL CI 1.4 TX 1L LR NOW 2.1. FILLING PRESSURE EUVOLEMIC, SVO2 70-80%. PALP PEDAL PULSES, MINIMAL CT DRNG--A WIRES SENSE AND CAPTURE, V WIRES NOT CHECKED DUE TO VF.\nRESP: LUNGS CLEAR THROUGHOUT. CONT ON IMV FIO2 WEANED TO 50%, NO OVERBREATHING ABG WNL\nGI: OGT TO LCWS. PLACEMENT CONFIRMED BY AUSCULTATION. MINIMAL BILIOUS OUTPUT. ABD SOFT. ABSENT BS\nGU: LG AMT CLEAR UOP\nPLAN: REMAIN INTUBATED OVERNGIHT, CHECK NEURO STATUS, HAVE READY TO EXTUBATE FOR ROUNDS AT 0600. CONTINUE LIDO OVERNIGHT. TITRATE NEO PRN. CONT CURRENT PLAN OF CARE\n"
}
] |
14,585 | 197,080 | Normal ascending aorta diameter. Denies pain.Resp: LS clear bil. IMPRESSION: Normal position of the central venous line. The mitralvalve appears structurally normal with trivial mitral regurgitation. The right-sided PICC terminates in the mid to distal SVC. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal LV cavity size. flat soft, BS+. Fluid status +2.3L for LOS and +0.4L since midnight.Skin: Intact. No c/o pain.CV: HR 64-69, nsr, st depression noted. Noprevious tracing available for comparison. Mediastinum has normal position, width, and shape. Tachycardia.Height: (in) 66Weight (lb): 75BSA (m2): 1.32 m2BP (mm Hg): 98/72HR (bpm): 110Status: InpatientDate/Time: at 09:51Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. The left ventricular cavity size is normal. BS Q6 hr and covered with Humolog SS.GU: No foley cath but Pt. Heart size normal. Right ventricular chamber size andfree wall motion are normal. BP 110's/70's, HR 79-93 NSR with no ectopy noted. There is atrivial/physiologic pericardial effusion. IVF remain the same at 150cc/hr. Left ventricular wall thicknesses arenormal. 40meq kcl given by mouth at 0540 and iv running as above.Resp: LS clear, sats 99-100 on RA.GI: Abd soft, nt, +BS. Lungs clear. Right PICC line was inserted with its tip lying before the cavoatrial junction. Mild to moderate [+] TR.Borderline PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Resting tachycardia (HR>100bpm).Conclusions:The left atrium is normal in size. Pt. Pt. Pt. Pt. Sinus rhythm. Diffuse non-specific ST-T wave changes. with end stage AIDS. PO intake good. Normalaortic arch diameter.AORTIC VALVE: Normal aortic valve leaflets (3). Admition wt. Pt cachectic, weak. The aortic valve leaflets (3) appear structurallynormal with good leaflet excursion and no aortic regurgitation. 9:02 AM CHEST PORT. O2 sat 100% on RA. no cough noted. The heart is normal. HISTORY: Hypokalemia, new shortness of breath. Extensive T wave changes are non-specific. reg diet, low residue, lactose restricted. Abd. Overallnormal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. No AS. Long QTc interval. CXR ordered for AM rounds.CV: VSS. is a full code.Plan: Cont. No edema. The lungs are clear. Overall left ventricularsystolic function is normal (LVEF>55%). No open areas noted.Social: Pt. IMPRESSION: AP chest compared to : Tip of the right PIC catheter projects over the superior cavoatrial junction. mae. MAE. very thin, skin dry. PORTABLE UPRIGHT FRONTAL RADIOGRAPH, TWO VIEWS. Sinus rhythmEarly R wave progressionAnterolateral ST-T changesSince previous tracing of , early R wave progression lethargic. K up to 2.2 by abg at 0500. No other changes. Lung fields remain clear. Pt states has poor appetite and sometimes has difficulty swallowing.No diarrhea thus far in MICU.GU: Voids, no urine thus far since admit.Access: piv in R wrist.Skin: Dry, no breakdown.Social: Friend will be spokesperson.Plan: Continue Kcl iv, give po kcl per orders. Repeat K on floor was 1.6, after 60meq K po given. NPN 1900-0700Neuro: Alert and oriented x3. Replenish lytes as needed. voiding to commode with diarrhea. AM labs pending.GI: Pt. Possible call out if Labs remain stable. Sinus tachycardia. place second piv and draw am labs. There isborderline pulmonary artery systolic hypertension. There is no pneumothorax or pleural effusion. IVF changed to D5W NaHCO3 50 meq and KCL 60 meq @ 200cc/hr for 1L. K 2.9 last evening labs with Na 151 and CO2 11. Comparison is made to one day earlier. monitor labd. There is no evidence of pleural effusion. No pleural abnormality or evidence of central adenopathy. Chronic diarrhea on Opium and Lomotil on time. 35 kg. Compared to theprevious tracing of the rate is significantly faster. HIV/AIDS. started on TPN at 42 cc/hr last evening. Labs repeated with a stick revealed hypokalemia 2.9, Potassium was resumed and rate increased to 150 ml/hr, Calcium stopped, started on TPN at 42 ml/hr. Adm note40 yo ma HIV/AIDS pt dx in 94, adm for picc placement to start TPN. NPN 0700-1900:Pt is alert, oriented x3, calm and cooperative, breathing regularly on room air, SPO2 above 95%, V/S stable, afebrile, eating regular diet well tolerated, passed BM in commode mixed with urine, so U/O couldn't be measured, given potassium with bicarbonate at 100 ml/hr then bld drawn from PIC line revealed hyperkalemia, potassium stopped and Calcium gluconate given 4G in 25o ml NS for 2 hrs. PATIENT/TEST INFORMATION:Indication: R/O cardiomyopathy. 40KCL in 500 d5w hung prior to transfer here. States he has been having ~6 loose stools per day.ROS:Neuro: A&O x3. defibrillator pads placed on pt per team. One time dose of 40 meq of PO KCL given to increase serum K level.Labs repeated at 0020 and K up to 3.6, Na 146 and CO2 13. talking on the phone this evening but no visitors. Pt lost ~ 30 lbs over last few months from diarrhea which is being worked up. drinking and eating. LINE PLACEMENT Clip # Reason: confirm placement of new double lumen left picc Admitting Diagnosis: FAILURE TO THRIVE MEDICAL CONDITION: 40 year old man with HIV/AIDS admitted w/ profound hypokalemia and now w/ PICC placed REASON FOR THIS EXAMINATION: confirm placement of new double lumen left picc FINAL REPORT REASON FOR EXAMINATION: Evaluation of the line placement. 4:19 AM CHEST (PORTABLE AP) Clip # Reason: 40 year old man with HIV/AIDS admitted w/ profound hypokal Admitting Diagnosis: FAILURE TO THRIVE MEDICAL CONDITION: hiv+ REASON FOR THIS EXAMINATION: 40 year old man with HIV/AIDS admitted w/ profound hypokalemia and now w/ new sob FINAL REPORT AP CHEST, 3:34 A.M. . | 10 | [
{
"category": "Echo",
"chartdate": "2150-06-10 00:00:00.000",
"description": "Report",
"row_id": 80592,
"text": "PATIENT/TEST INFORMATION:\nIndication: R/O cardiomyopathy. HIV/AIDS. Tachycardia.\nHeight: (in) 66\nWeight (lb): 75\nBSA (m2): 1.32 m2\nBP (mm Hg): 98/72\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 09:51\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\nnormal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\naortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nBorderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. There is\nborderline pulmonary artery systolic hypertension. There is a\ntrivial/physiologic pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2150-06-08 00:00:00.000",
"description": "Report",
"row_id": 204013,
"text": "Sinus tachycardia. Diffuse non-specific ST-T wave changes. Compared to the\nprevious tracing of the rate is significantly faster.\n\n"
},
{
"category": "ECG",
"chartdate": "2150-06-04 00:00:00.000",
"description": "Report",
"row_id": 204014,
"text": "Sinus rhythm\nEarly R wave progression\nAnterolateral ST-T changes\nSince previous tracing of , early R wave progression\n\n"
},
{
"category": "ECG",
"chartdate": "2150-06-04 00:00:00.000",
"description": "Report",
"row_id": 204015,
"text": "Sinus rhythm. Long QTc interval. Extensive T wave changes are non-specific. No\nprevious tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-06-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 912888,
"text": " 4:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 40 year old man with HIV/AIDS admitted w/ profound hypokal\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n hiv+\n REASON FOR THIS EXAMINATION:\n 40 year old man with HIV/AIDS admitted w/ profound hypokalemia and now w/ new\n sob\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:34 A.M. .\n\n HISTORY: Hypokalemia, new shortness of breath.\n\n IMPRESSION: AP chest compared to :\n\n Tip of the right PIC catheter projects over the superior cavoatrial junction.\n Lungs clear. Heart size normal. No pleural abnormality or evidence of\n central adenopathy.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-06-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 912538,
"text": " 5:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval line placement\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with HIV/AIDS admitted w/ profound hypokalemia and now w/ PICC\n placed\n REASON FOR THIS EXAMINATION:\n eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old with HIV and hypokalemia, assess PICC position.\n\n PORTABLE UPRIGHT FRONTAL RADIOGRAPH, TWO VIEWS. Comparison is made to one day\n earlier.\n\n The right-sided PICC terminates in the mid to distal SVC. Lung fields remain\n clear. No other changes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-06-04 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 912402,
"text": " 9:02 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: confirm placement of new double lumen left picc\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with HIV/AIDS admitted w/ profound hypokalemia and now w/ PICC\n placed\n REASON FOR THIS EXAMINATION:\n confirm placement of new double lumen left picc\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the line placement.\n\n Right PICC line was inserted with its tip lying before the cavoatrial\n junction.\n\n There is no pneumothorax or pleural effusion.\n\n The heart is normal. Mediastinum has normal position, width, and shape.\n\n The lungs are clear. There is no evidence of pleural effusion.\n\n IMPRESSION: Normal position of the central venous line.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-06-04 00:00:00.000",
"description": "Report",
"row_id": 1452475,
"text": "Adm note\n40 yo ma HIV/AIDS pt dx in 94, adm for picc placement to start TPN. Pt lost ~ 30 lbs over last few months from diarrhea which is being worked up. Repeat K on floor was 1.6, after 60meq K po given. 40KCL in 500 d5w hung prior to transfer here. Pt cachectic, weak. States he has been having ~6 loose stools per day.\n\nROS:\n\nNeuro: A&O x3. mae. lethargic. No c/o pain.\n\nCV: HR 64-69, nsr, st depression noted. defibrillator pads placed on pt per team. K up to 2.2 by abg at 0500. 40meq kcl given by mouth at 0540 and iv running as above.\n\nResp: LS clear, sats 99-100 on RA.\n\nGI: Abd soft, nt, +BS. reg diet, low residue, lactose restricted. Pt states has poor appetite and sometimes has difficulty swallowing.\nNo diarrhea thus far in MICU.\n\nGU: Voids, no urine thus far since admit.\n\nAccess: piv in R wrist.\n\nSkin: Dry, no breakdown.\n\nSocial: Friend will be spokesperson.\n\nPlan: Continue Kcl iv, give po kcl per orders. place second piv and draw am labs.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-06-04 00:00:00.000",
"description": "Report",
"row_id": 1452476,
"text": "NPN 0700-1900:\nPt is alert, oriented x3, calm and cooperative, breathing regularly on room air, SPO2 above 95%, V/S stable, afebrile, eating regular diet well tolerated, passed BM in commode mixed with urine, so U/O couldn't be measured, given potassium with bicarbonate at 100 ml/hr then bld drawn from PIC line revealed hyperkalemia, potassium stopped and Calcium gluconate given 4G in 25o ml NS for 2 hrs. Labs repeated with a stick revealed hypokalemia 2.9, Potassium was resumed and rate increased to 150 ml/hr, Calcium stopped, started on TPN at 42 ml/hr.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-06-05 00:00:00.000",
"description": "Report",
"row_id": 1452477,
"text": "NPN 1900-0700\nNeuro: Alert and oriented x3. MAE. Denies pain.\n\nResp: LS clear bil. O2 sat 100% on RA. no cough noted. CXR ordered for AM rounds.\n\nCV: VSS. BP 110's/70's, HR 79-93 NSR with no ectopy noted. No edema. K 2.9 last evening labs with Na 151 and CO2 11. IVF changed to D5W NaHCO3 50 meq and KCL 60 meq @ 200cc/hr for 1L. One time dose of 40 meq of PO KCL given to increase serum K level.Labs repeated at 0020 and K up to 3.6, Na 146 and CO2 13. IVF remain the same at 150cc/hr. AM labs pending.\n\nGI: Pt. with end stage AIDS. Admition wt. 35 kg. Pt. started on TPN at 42 cc/hr last evening. PO intake good. Pt. drinking and eating. Chronic diarrhea on Opium and Lomotil on time. Abd. flat soft, BS+. BS Q6 hr and covered with Humolog SS.\n\nGU: No foley cath but Pt. voiding to commode with diarrhea. Fluid status +2.3L for LOS and +0.4L since midnight.\n\nSkin: Intact. Pt. very thin, skin dry. No open areas noted.\n\nSocial: Pt. talking on the phone this evening but no visitors. Pt. is a full code.\n\nPlan: Cont. monitor labd. Replenish lytes as needed. Possible call out if Labs remain stable.\n\n\n\n"
}
] |
|
79,900 | 120,644 | Primary Reason for Admission 70yoF with h/o dilated cardiomyopathy (EF 35%), AICD p/w SOB and poor urine output for several days found to have hyponatremia, now transferred from medicine to CCU due to hypotension. . Active Issues: . #Acute on chronic systolic heart failure: The patient was hypervolemic on exam with elevated JVP and increased abdominal distension at presentation. Given the patient had been refractory to diuretic therapy requiring ultrafiltration during her last hospitalization and was oliguric and hyponatremic on admission, ultrafiltration was initiated rather than diuretic therapy. She experienced significant muscle cramping and hypotension while on CVVHD requiring dopamine. CVVHD was discontinued on HD#2 and she was diuresed with IV lasix and metolazone. Pressures improved and she was weaned off of dopamine. It was noted that urine and blood pressure improved when the patient was in her native sinus rhythm with asynchronous ventricular pacing. Therefore the patients pacemaker escape rate was lowered to allow for increased native rhythm and the mode was changed to AAIR. Despite this change urine output remained poor and she was therefore started on a lasix drip ultimately requiring milrinone to augment diuresis. On HD#6 patient underwent placement of a tunneled dialysis catheter, and on HD#7 she continued HD using the tunneled line (see below). Lasix and metolazone were discontinued as patient will be HD dependent. . #Hypotension: Patient was hypotensive on admission in the setting of volume overload. Her hypotension was believed to be due to worsening cardiac output in setting of dilated cardiomyopathy. She was temporarily on a dopamine gtt, but this was weaned by HD#2. In addition, she experienced episodes of hypotension with CVVH with diuresis and antihypertensive medications, so her antihypertensive medications were held. On discharge, her BP was stable. She was asked to continue to hold her carvedilol and to follow up with her PCP about restarting as tolerated. . # Hyponatremia: Pts sodium was 119 on admission and likely cause of her AMS, thought to be hypervolemic hyponatremia with poor renal perfusion given e/o volume overload on exam and low urine Na. Her fluid intake was restricted to 1.5L daily, and she started CVVH as above with improvement in her hyponatremia as well as her mental status. At the time of discharge her sodium was 135. . # Acute on chronic renal failure: Patient was noted to have a creat of 5.4, baseline 3.5-4.0, and oliguria x 2-3 days on admission. As stated above she had previously required ultrafiltration during hospitalizations for heart failure exacerbation. Renal was consulted and felt that the patient would require chronic HD. Given her hypotension she was initally started on CVVH with dopamine gtt for pressure support. However as above she did not tolerate CVVH and it was discontinued. She was diuresed with lasix gtt and milrinone as above until she had her tunneled line placed on HD#6. She tolerated HD well, with stable BP and no muscle cramping. Outpatient dialysis was arranged with Dialysis Center for mondays, wednesdays and fridays. . # Afib: Pt has a history of atrial fibrillation on coumadin at home. On admission her coumadin was held in preparation for placement of a tunneled dialysis catheter. As stated above her pacemaker settings were changed and she was in sinus rhythm for most of her CCU course with heart rates in the 50-70s. Her mode was changed to AAIR to allow for intrinsice AV conduction and minimize ventricular pacing in an abnormal heart. Her coumadin was restarted at her home dose on HD#7. Her INR at the time of discharge was 1.4. | FINDINGS: There is a left-sided pacemaker/ICD with right atrial and right ventricular leads, as before. Left bundle-branch block.Compared to tracing #1 ventricular pacing is no longer present and atrialfibrillation is present.TRACING #2 The needle was then exchanged for a micropuncture sheath, the inner dilator and wire were removed, and wire was passed through the sheath and to the right atrium. Atrial fibrillation with ventricular premature beat. FINDINGS: There is a new right IJ central venous catheter with distal lead tip in the distal SVC. There is intermittent ventricular pacing with capture, non-specificST-T wave flattening as recorded previously and appearance of ventricularectopy and ventricular pacing. FINDINGS: Single AP view of the chest shows a tunneled catheter whose tip terminates within the right atrium. PROCEDURE: 27 cm tip-to-cuff right IJ hemodialysis catheter placement. The hemodialysis catheter was passed through this and the cuff secured subcutaneously. The wire and inner dilator were then removed, and hemodialysis catheter was inserted through the peel-away sheath. The wire was then measured, and a 27 cm tip-to-cuff hemodialysis catheter was selected. Occasional ventricular ectopy. Otherwise, no diagnostic interim change.Clinical correlation is suggested. COMPARISON: Chest radiograph from . The wire was then passed into a hepatic vein. A followup fluoroscopic image demonstrated the catheter tip to be positioned at the right atrium. pna FINAL REPORT INDICATION: Sputum and shortness of breath. Compared to the previous tracing of the rhythm isnow ventricular paced with capture and occasional ventricular ectopy. The rhythm may be of ectopic atrial origin in the context of priorinferolateral myocardial infarction and frequent ventricular ectopy. IMPRESSION: Successful placement of a 27 cm tip-to-cuff right IJ tunneled hemodialysis catheter with its tip located in the right atrium. The patient was brought to the angiography suite and placed supine, the right neck and upper chest were prepped and draped in the usual sterile fashion. Under ultrasound guidance, a 21- gauge micropuncture needle was used to access the right internal jugular vein, and a wire was passed over this. Clinicalcorrelation is suggested. Pulmonary venous congestion is seen without definite interstitial pulmonary edema. Compared to the previous tracing of theventricular premature beat is absent.TRACING #1 She was accompanied by anesthesia and radiology to the cardiac care unit. Serial dilation was then undertaken over the wire under constant fluoroscopic guidance, and a peel-away sheath was placed. OPERATORS: Dr. attending, Dr. , Dr. . Unchanged massive cardiomegaly with pulmonary vascular congestion, but no definite pulmonary edema. There is again seen pulmonary edema which is stable. The catheter was flushed, and dressed. A preprocedure timeout confirmed the patient identity and the procedure to be performed. A 2-0 Vicryl subcutaneous stitch was used to close the (Over) 2:27 PM TUNNELED DIALYSIS LINE PLACEME Clip # Reason: Please place hemodialysis line Admitting Diagnosis: CONGESTIVE HEART FAILURE Type of Port: None FINAL REPORT (Cont) venostomy site in the neck. No change in the mild pulmonary edema or massive cardiomegaly. At this point, the patient was propped up using a wedge to limit her symptoms of heart failure. An appropriate site for a cuff was chosen, and local anesthesia was obtained with approximately 10 cc of 1% lidocaine with epinephrine along the anticipated tunnel tract to the original venotomy site in the right neck. Attention was then directed to the right chest. 2:27 PM TUNNELED DIALYSIS LINE PLACEME Clip # Reason: Please place hemodialysis line Admitting Diagnosis: CONGESTIVE HEART FAILURE Type of Port: None ********************************* CPT Codes ******************************** * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS. The catheter was then sewn in place with 2-0 silk sutures. FINAL REPORT STUDY: AP chest . Under ultrasound guidance with hard copy images on file, an appropriate site to access the right internal jugular vein was chosen, and local anesthesia was obtained with approximately 5 cc of 1% buffered lidocaine. There is a left-sided AICD, which is unchanged in position. There is marked cardiomegaly and left retrocardiac opacity, which has worsened since the previous study. Compared to the previous tracing regularsupraventricular rhythm is again recorded. There islow limb lead voltage. Evaluate for pneumonia. TECHNIQUE AND FINDINGS: The procedure was explained to the patient and written informed consent was obtained. 11:36 PM CHEST (PA & LAT) Clip # Reason: ? Pulmonary congestion. The peel-away sheath was removed. There is minimal right basilar atelectasis. | 8 | [
{
"category": "Radiology",
"chartdate": "2194-07-17 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1203464,
"text": " 11:36 PM\n CHEST (PA & LAT) Clip # \n Reason: ? pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with sputum, sob\n REASON FOR THIS EXAMINATION:\n ? pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sputum and shortness of breath. Evaluate for pneumonia.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: There is a left-sided pacemaker/ICD with right atrial and right\n ventricular leads, as before. Severe cardiomegaly is not significantly\n changed. Pulmonary venous congestion is seen without definite interstitial\n pulmonary edema. No focal consolidations are seen. There are no pleural\n effusions. No pneumothorax is seen. There is minimal right basilar\n atelectasis.\n\n IMPRESSION:\n\n 1. Unchanged massive cardiomegaly with pulmonary vascular congestion, but no\n definite pulmonary edema.\n\n 2. No consolidations concerning for pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-07-18 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1203606,
"text": " 6:15 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with newly placed RIJ CVVH line\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n WET READ: ENYa FRI 9:25 PM\n New R IJ CVVH line terminates in the lower SVC. No PTX. Marked\n cardiomegaly. Pulmonary congestion.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: 70-year-old woman with newly placed right IJ central venous\n line.\n\n FINDINGS: There is a new right IJ central venous catheter with distal lead\n tip in the distal SVC. There is a left-sided AICD, which is unchanged in\n position. There is again seen pulmonary edema which is stable. There are no\n pneumothoraces. There is marked cardiomegaly and left retrocardiac opacity,\n which has worsened since the previous study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-07-23 00:00:00.000",
"description": "TUNNELED W/O PORT",
"row_id": 1204236,
"text": " 2:27 PM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: Please place hemodialysis line\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Type of Port: None\n ********************************* CPT Codes ********************************\n * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with cardiomyopathy, ESRD, p/w volume overload and anuria\n REASON FOR THIS EXAMINATION:\n Please place hemodialysis line\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 70-year-old female with CHF and associated renal\n failure in need of hemodialysis for line placement.\n\n OPERATORS: Dr. attending, Dr. , Dr. \n .\n\n PROCEDURE: 27 cm tip-to-cuff right IJ hemodialysis catheter placement.\n\n TECHNIQUE AND FINDINGS: The procedure was explained to the patient and\n written informed consent was obtained. A preprocedure timeout confirmed the\n patient identity and the procedure to be performed. The patient was brought\n to the angiography suite and placed supine, the right neck and upper chest\n were prepped and draped in the usual sterile fashion. Under ultrasound\n guidance with hard copy images on file, an appropriate site to access the\n right internal jugular vein was chosen, and local anesthesia was obtained with\n approximately 5 cc of 1% buffered lidocaine. Under ultrasound guidance, a 21-\n gauge micropuncture needle was used to access the right internal jugular vein,\n and a wire was passed over this. The needle was then exchanged for a\n micropuncture sheath, the inner dilator and wire were removed, and \n wire was passed through the sheath and to the right atrium. At this point,\n the patient was propped up using a wedge to limit her symptoms of heart\n failure. The wire was then measured, and a 27 cm tip-to-cuff hemodialysis\n catheter was selected. The wire was then passed into a hepatic vein. Attention\n was then directed to the right chest. An appropriate site for a cuff was\n chosen, and local anesthesia was obtained with approximately 10 cc of 1%\n lidocaine with epinephrine along the anticipated tunnel tract to the original\n venotomy site in the right neck. A stab incision was then performed on the\n chest, and using a blunt tunneling device, a tunnel was created between the\n right chest incision and the venotomy site in the right internal jugular vein.\n The hemodialysis catheter was passed through this and the cuff secured\n subcutaneously. Serial dilation was then undertaken over the wire under\n constant fluoroscopic guidance, and a peel-away sheath was placed. The wire\n and inner dilator were then removed, and hemodialysis catheter was inserted\n through the peel-away sheath. The peel-away sheath was removed. The cuff was\n then positioned. A followup fluoroscopic image demonstrated the catheter tip\n to be positioned at the right atrium. The catheter was then sewn in place\n with 2-0 silk sutures. A 2-0 Vicryl subcutaneous stitch was used to close the\n (Over)\n\n 2:27 PM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: Please place hemodialysis line\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Type of Port: None\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n venostomy site in the neck. The catheter was flushed, and dressed. The\n patient tolerated the procedure well, though was demonstrating symptoms of\n heart failure upon termination of the procedure. She was accompanied by\n anesthesia and radiology to the cardiac care unit.\n\n IMPRESSION: Successful placement of a 27 cm tip-to-cuff right IJ tunneled\n hemodialysis catheter with its tip located in the right atrium.\n\n The attending, Dr. was present and participated in the entire\n procedure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-07-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1204496,
"text": " 9:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?line placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with tunneled HD line, needs confirmation for O/P HD\n REASON FOR THIS EXAMINATION:\n ?line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate HD line.\n\n FINDINGS: Single AP view of the chest shows a tunneled catheter whose tip\n terminates within the right atrium. A left pacemaker is unchanged. No change\n in the mild pulmonary edema or massive cardiomegaly. Bibasilar atelectasis,\n worse on the left. No pleural effusion or pneumothorax.\n\n IMPRESSION: Properly positioned line.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2194-07-21 00:00:00.000",
"description": "Report",
"row_id": 107255,
"text": "The rhythm may be of ectopic atrial origin in the context of prior\ninferolateral myocardial infarction and frequent ventricular ectopy. There is\nlow limb lead voltage. Compared to the previous tracing regular\nsupraventricular rhythm is again recorded. Atrial activity is difficult to\ndiscern. There is intermittent ventricular pacing with capture, non-specific\nST-T wave flattening as recorded previously and appearance of ventricular\nectopy and ventricular pacing. Otherwise, no diagnostic interim change.\nClinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2194-07-19 00:00:00.000",
"description": "Report",
"row_id": 107256,
"text": "Atrial fibrillation with ventricular premature beat. Left bundle-branch block.\nCompared to tracing #1 ventricular pacing is no longer present and atrial\nfibrillation is present.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2194-07-18 00:00:00.000",
"description": "Report",
"row_id": 107257,
"text": "Ventricular paced rhythm. Compared to the previous tracing of the\nventricular premature beat is absent.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2194-07-17 00:00:00.000",
"description": "Report",
"row_id": 107258,
"text": "Ventricular paced rhythm. Occasional ventricular ectopy. The QRS interval is\nmarkedly prolonged. Compared to the previous tracing of the rhythm is\nnow ventricular paced with capture and occasional ventricular ectopy. Clinical\ncorrelation is suggested.\n\n"
}
] |
76,974 | 145,550 | The patient was admitted to under the Oncology team for evaulation of his left hemiplegia. MRI revealed a region of contrast enhancement in the right frontal lobe and extensive surrounding edema. He was taken to the operating room on for a R frontal craniotomy for lesion resection. The preliminary pathology report was positive for radiation necrosis. His neurological exam remained stable and unchanged post-operatively. He remained on the mannitol and dexamethasone for the vasogenic edema. He had an MRI on which revealed persistent VG edema, but no new hemorrhage or infarct. He was tapered off of the mannitol until , and the dexamethasone was kept at 4mg Q 6. He was transferred to the floor on , and was seen by the physical therapists. They determined that he met criteria for a rehab facility. He was discharged to the rehab on . | The right perimesencephalic cistern remains obliterated and the right cerebellopontine angle cistern remains enlarged, consistent with slight or early right uncal herniation. early/slight right uncal herniation simliar to post op CT. There is now a relatively well-defined 2.1 (AP) x 2.2 (TRV) predominantly T2-hyper- and T1-hypointense resection cavity, at the site of the previous dominant mass, superficially located the right frontal lobe. At least four small enhancing foci with marked "blooming" susceptibility artifact in the right frontal corona radiata and forceps minor, as described, also unchanged and likely representing metastases. At least four small enhancing foci with marked "blooming" susceptibility artifact in right frontal corona radiata and forceps minor, as described, also unchanged and likely representing metastases. At least four small enhancing foci with marked "blooming" susceptibility artifact in right frontal corona radiata and forceps minor, as described, also unchanged and likely representing metastases. Effacement of the right cerebral sulci and mass effect on the right lateral ventricle is likely unchanged from MRI . Degree of early/slight right uncal herniation is unchanged from . There remains some mass effect on the right lateral ventricle. Eval for post op infarct/edema/completeness of resection No contraindications for IV contrast PFI REPORT PFI: 1. Status post very recent right frontal craniotomy with resection of the dominant mass superficially located in the right frontal lobe; however, there is persistent band-like enhancement at the posterior and caudal margin of the resection cavity, highly suggestive of residual tumor. Status post very recent right frontal craniotomy with resection of the dominant mass superficially located in the right frontal lobe; however, there is persistent band-like enhancement at the posterior and caudal margin of the resection cavity, highly suggestive of residual tumor. TECHNIQUE: Non-contrast head CT was obtained. TECHNIQUE: Non-contrast head CT was obtained. Plea Admitting Diagnosis: METASTATIC BRAIN TUMOR Contrast: MAGNEVIST Amt: 18 FINAL REPORT (Cont) are well aerated. COMPARISON: Head CT, and . There is new right uncal herniation, with obliteration of the right perimesencephalic cistern and mass effect on the right cerebral peduncle. New right uncal herniation, with effacement of the right perimesencephalic cistern and mass effect on the right cerebral peduncle. new right uncal herniation, effacement of right perimesencephalic cistern, mass effect on right cerebral peduncle. The amount of edema of the right hemisphere is similar to the prior study. IMPRESSION: Status post resection of right frontal lobe mass with expected post-surgical changes. Mass effect on the right lateral ventricle persists. Additionally, the clustered intrinsically T1-hyperintense lesions in the right corona radiata, caudate head and forceps minor, as well as the subependymal enhancing lesion in the frontal of the right lateral ventricle are all unchanged. There is FLAIR/T2-hyperintensity within the bilateral cerebral hemispheres, which extends up to but does not involve the subcortical U-fibers, stable when compared with prior studies dating back to . cystic surgical cavity w/ new depending hyperdensity c/w hemorrhage. There is a small focal area of atelectasis and/or consolidation at the left base and streaky density at the right base consistent with subsegmental atelectasis as demonstrated previously. Sulcal effacement of the right hemisphere persists. There remains mass effect on the brainstem with uncal herniation. Non- contrast head CT, . FINDINGS: The patient is status post right frontal craniectomy, with resection of the right frontal lobe enhancing lesion. FINDINGS: Since the previous study, the patient has undergone resection of right frontal lobe enhancing lesion. The principal intracranial vascular flow voids are preserved. COMPARISON: Multiple MRIs of the head, most recent . Eval Admitting Diagnosis: METASTATIC BRAIN TUMOR Contrast: MAGNEVIST Amt: FINAL REPORT (Cont) the posterior and inferior margin of the cavity, measuring up to 2.3 (TRV) x 0.08 cm (AP), likely representing residual tumor at this site. Similar to minimally increased leftward shift of midline structures, now 9 (Over) 9:45 AM CT HEAD W/O CONTRAST Clip # Reason: Eval for interval changes Admitting Diagnosis: METASTATIC BRAIN TUMOR FINAL REPORT (Cont) mm. 7mm leftward shift of midline structures similar to MRI . The intracranial arterial flow voids are patent. The left hemidiaphragm is elevated as before. CLINICAL INFORMATION: Patient with right-sided frontal craniotomy. Status post very recent right frontal craniotomy with resection of the dominant mass superficially located in the right frontal lobe; however, there is persistent band-like enhancement at the posterior and caudal margin of the resection cavity, highly suspicious for residual tumor. | 11 | [
{
"category": "Radiology",
"chartdate": "2179-04-24 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1132833,
"text": " 9:52 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 62 year old man s/p R frontal crani for mass resection. Eval\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n Contrast: MAGNEVIST Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p R frontal crani for mass resection. Eval for post op\n infarct/edema/completeness of resection\n REASON FOR THIS EXAMINATION:\n 62 year old man s/p R frontal crani for mass resection. Eval for post op\n infarct/edema/completeness of resection\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DRT SAT 6:01 PM\n PFI:\n\n 1. Status post very recent right frontal craniotomy with resection of the\n dominant mass superficially located in the right frontal lobe; however, there\n is persistent band-like enhancement at the posterior and caudal margin of the\n resection cavity, highly suggestive of residual tumor.\n\n 2. Separate discrete 8-mm enhancing focus in the right temporal operculum,\n unchanged.\n\n 3. At least four small enhancing foci with marked \"blooming\" susceptibility\n artifact in right frontal corona radiata and forceps minor, as described, also\n unchanged and likely representing metastases.\n\n 4. No definite hemorrhage or acute infarction elsewhere in the brain.\n ______________________________________________________________________________\n FINAL REPORT\n MR OF THE BRAIN, .\n\n HISTORY: 62-year-old male status post recent right frontal craniotomy and\n resection of mass; evaluate for post-op infarct, edema and completeness of\n resection.\n\n TECHNIQUE: Routine enhanced MR examination of the brain was performed.\n\n FINDINGS: The study is compared with most recent enhanced MR of and\n post-operative NECT of .\n\n There is extensive FLAIR-signal abnormality representing edema in the right\n frontoparietal vertex extracalvarial soft tissues, related to the recent\n surgery. Along with this, there is extensive susceptibility artifact in the\n subjacent extra-axial compartment, likely representing a combination of\n diamagnetic susceptibility from residual pneumocephalus, as well as blood\n products at this site. There is now a relatively well-defined 2.1 (AP) x 2.2\n (TRV) predominantly T2-hyper- and T1-hypointense resection cavity, at the site\n of the previous dominant mass, superficially located the right frontal lobe.\n However, allowing for the ill-defined intrinsic T1-hyperintensity at the\n medial aspect of the cavity, there is persistent thick C-shaped enhancement at\n (Over)\n\n 9:52 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 62 year old man s/p R frontal crani for mass resection. Eval\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n Contrast: MAGNEVIST Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the posterior and inferior margin of the cavity, measuring up to 2.3 (TRV) x\n 0.08 cm (AP), likely representing residual tumor at this site. Additionally,\n the clustered intrinsically T1-hyperintense lesions in the right corona\n radiata, caudate head and forceps minor, as well as the subependymal enhancing\n lesion in the frontal of the right lateral ventricle are all unchanged.\n These demonstrate marked \"blooming\" susceptibility artifact, likely\n representing hemorrhage, melanin or a combination of the two, and likely\n represent persistent metastatic foci, at a remove from the resection cavity.\n No new focus suspicious for metastasis is seen.\n\n Allowing for the extensive susceptibility artifacts at the right frontovertex,\n related to the recent surgery, with associated artifact on the DWI sequence,\n there is no evidence of intra- or extra-axial hemorrhage or acute infarction,\n elsewhere. The principal intracranial vascular flow voids are preserved.\n Again demonstrated is the extensive white matter abnormality involving both\n cerebral hemispheres, unchanged, with a distribution suggestive of radiation\n effect. Also noted is fluid-opacification of the mastoid air cells, left more\n than right, which may also be seen post-operatively.\n\n IMPRESSION:\n\n 1. Status post very recent right frontal craniotomy with resection of the\n dominant mass superficially located in the right frontal lobe; however, there\n is persistent band-like enhancement at the posterior and caudal margin of the\n resection cavity, highly suspicious for residual tumor.\n\n 2. Separate discrete 8-mm enhancing focus in the right temporal operculum,\n unchanged.\n\n 3. At least four small enhancing foci with marked \"blooming\" susceptibility\n artifact in the right frontal corona radiata and forceps minor, as described,\n also unchanged and likely representing metastases.\n\n 4. No definite hemorrhage or acute infarction elsewhere in the brain.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-04-24 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1132834,
"text": ", T. NMED SICU-A 9:52 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 62 year old man s/p R frontal crani for mass resection. Eval\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n Contrast: MAGNEVIST Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p R frontal crani for mass resection. Eval for post op\n infarct/edema/completeness of resection\n REASON FOR THIS EXAMINATION:\n 62 year old man s/p R frontal crani for mass resection. Eval for post op\n infarct/edema/completeness of resection\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n 1. Status post very recent right frontal craniotomy with resection of the\n dominant mass superficially located in the right frontal lobe; however, there\n is persistent band-like enhancement at the posterior and caudal margin of the\n resection cavity, highly suggestive of residual tumor.\n\n 2. Separate discrete 8-mm enhancing focus in the right temporal operculum,\n unchanged.\n\n 3. At least four small enhancing foci with marked \"blooming\" susceptibility\n artifact in right frontal corona radiata and forceps minor, as described, also\n unchanged and likely representing metastases.\n\n 4. No definite hemorrhage or acute infarction elsewhere in the brain.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-04-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1133381,
"text": " 9:45 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for interval changes\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with R brain mass, s/p crani. Now with increased confusion\n REASON FOR THIS EXAMINATION:\n Eval for interval changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: WED 11:09 AM\n expansion of extra-axial collection overlying surgical bed, now 11mm\n (previously 6mm on ). cystic surgical cavity w/ new depending\n hyperdensity c/w hemorrhage. this largely fluid-filled cavity also appears to\n be expanding now 3.2 x 2.6cm. similar to minimally increased leftward midlind\n shift of 8-9mm. early/slight right uncal herniation simliar to post op\n CT.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old male with right brain mass, status post craniotomy, now\n with increased confusion.\n\n COMPARISON: Head CT, and .\n\n TECHNIQUE: Non-contrast head CT was obtained.\n\n FINDINGS: The patient is status post right frontal craniectomy, with\n resection of the right frontal lobe enhancing lesion. The subdural collection\n overlying the surgical bed has enlarged, and remains of mixed or\n increasing attenuation, raising concern for accumulating hemorrhage, now\n measures 11 mm in thickness, previously was 6 mm. A hypodense fluid-filled\n cavity of the right frontal lobe at the resection site also appears larger,\n measuring approximately 3.2 cm (AP) x 2.6 cm (TRV), previously 2.3 cm x 1.9\n cm. The amount of pneumocephalus has decreased. Leftward shift of midline\n structures persist, similar to minimally increased, now measuring 9 mm,\n previously 8 mm.\n\n The right perimesencephalic cistern remains obliterated and the right\n cerebellopontine angle cistern remains enlarged, consistent with slight or\n early right uncal herniation. -white matter differentiation is preserved,\n without evidence of PCA distribution infarct on this non-contrast head CT.\n\n The amount of edema of the right hemisphere is similar to the prior study.\n Focal hyperdensity is likely blood layering in the surgical cavity (2:13), new\n from the prior study. There is no hydrocephalus.\n\n IMPRESSION:\n 1. Expansion of the mixed-density extra-axial collection overlying the\n surgical bed, now 11 mm (previously 6 mm).\n 2. Apparent increase in the fluid-filled surgical cavity, with new dependent\n hyperdensity consistent with hemorrhage.\n 3. Similar to minimally increased leftward shift of midline structures, now 9\n (Over)\n\n 9:45 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for interval changes\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n mm. Degree of early/slight right uncal herniation is unchanged from .\n\n COMMENT: Dr. provided a preliminary report to \n of neurosurgery at 11:50 a.m. on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-04-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1132934,
"text": " 4:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for hemothorax\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p d/c of left subclavian arterial line\n REASON FOR THIS EXAMINATION:\n eval for hemothorax\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n HISTORY: Removal of line.\n\n One portable view. Comparison with the previous study done . There is\n streaky density at the lung bases consistent with subsegmental atelectasis as\n before. The left hemidiaphragm is mildly elevated. There is a focal area of\n increased density at the medial aspect of the left base that may represent\n atelectasis or consolidation. Mediastinal structures are unchanged. A left\n subclavian catheter has been withdrawn.\n\n IMPRESSION: Withdrawal of left subclavian catheter. No other significant\n change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-04-25 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1133019,
"text": " 2:20 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Good placement?\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with dobhoff\n REASON FOR THIS EXAMINATION:\n Good placement?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Dobbhoff tube placement.\n\n One view. Comparison with . The left hemidiaphragm is elevated as\n before. There is a small focal area of atelectasis and/or consolidation at\n the left base and streaky density at the right base consistent with\n subsegmental atelectasis as demonstrated previously. The heart and\n mediastinal structures are unchanged. A Dobbhoff feeding tube has been\n re-inserted and now terminates just below the level of the diaphragm in the\n region of the stomach.\n\n IMPRESSION: The Dobbhoff feeding tube now appears to terminate in the\n stomach. No other significant change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-04-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1132572,
"text": " 4:22 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for intracerebral hemorrhage\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with known metastatic melanoma, radiation necrosis, transferred\n for acute ICH, has dense paraparesis of left side and left sided neglect\n REASON FOR THIS EXAMINATION:\n eval for intracerebral hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 5:27 PM\n extensive low density of white matter of right hemisphere c/w edema similar\n to MRI . Right frontal hyperdense lesion (2:25) may be new from MR\n , but difficult to definitely determine due to patient positioning. New\n subcortical small hyperdense foci may be hemorrhage, measure up to 8mm. 7mm\n leftward shift of midline structures similar to MRI .\n\n new right uncal herniation, effacement of right perimesencephalic cistern,\n mass effect on right cerebral peduncle. effacement of right cerebral sulci\n and mass effect on right lateral ventricle.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old male with known metastatic melanoma and radiation\n necrosis with left-sided neglect and dense hemiparesis.\n\n COMPARISON: Multiple prior brain MRIs, most recently . Non-\n contrast head CT, .\n\n TECHNIQUE: Non-contrast head CT was obtained.\n\n FINDINGS: Extensive white matter hypoattenuation of the hemispheres, right\n greater than left, is likely similar to MRI of allowing for\n differences in technique. Punctate hyperdense foci of the subcortical white\n matter (2:21, 2:20), measuring up to 8 mm are new from prior studies. A right\n frontal lesion measuring 6 mm (2:25) may correspond to the right frontal\n lesion on the previous study, although this is difficult to determine due to\n differences in modality and patient positioning. Sulcal effacement of the\n right hemisphere persists. Leftward shift of midline structures by 7 mm is\n unchanged. There is new right uncal herniation, with obliteration of the\n right perimesencephalic cistern and mass effect on the right cerebral\n peduncle. Mass effect on the right lateral ventricle persists. There is no\n tonsillar herniation.\n\n The visualized paranasal sinuses and mastoid air cells are normally\n pneumatized and aerated. There are no concerning osseous lesions.\n\n IMPRESSION:\n 1. New right uncal herniation, with effacement of the right perimesencephalic\n cistern and mass effect on the right cerebral peduncle. Effacement of the\n right cerebral sulci and mass effect on the right lateral ventricle is likely\n unchanged from MRI .\n (Over)\n\n 4:22 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for intracerebral hemorrhage\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. New punctate subcortical white matter hyperdense foci, which may be\n hemorrhage, measuring up to 8 mm.\n 3. Hyperdense 6 mm right frontal lesion, difficult to determine whether this\n is a new finding from MRI .\n 4. Extensive white matter hypoattenuation consistent with edema/radiation\n effect, likely similar to MRI, , allowing for differences in\n technique.\n\n Preliminary report was provided by Dr. to Dr. at 5:30\n p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-04-25 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1132987,
"text": " 11:19 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Is Dobhoff in good placement?\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with hx melanoma brain mets in need of feeeding tube\n REASON FOR THIS EXAMINATION:\n Is Dobhoff in good placement?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Brain mets, Dobbhoff feeding tube placement.\n\n ONE PORTABLE VIEW. Comparison with . The left chest wall is not\n entirely included. Bibasilar subsegmental atelectasis and a small focal area\n of increased density at the left base that may represent parenchymal\n consolidation are again demonstrated. The heart and mediastinal structures\n are unchanged. A feeding tube has been inserted and is coiled in the cervical\n region. Its tip off the top of the image.\n\n IMPRESSION: The feeding tube not in place. Result called to SICU.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-04-22 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1132609,
"text": " 10:18 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: eval for acute ICH, radiation necrosis interval change. Plea\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with known metastatic melanoma, radiation necrosis, transferred\n for acute ICH, has dense paraparesis of left side and left sided neglect\n REASON FOR THIS EXAMINATION:\n eval for acute ICH, radiation necrosis interval change. Please also do MRI WAND\n sequence-place fiducials. MUST be completed within 4hrs for surgical\n planning-needed to assess urgency for OR\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: MR head with and without contrast.\n\n HISTORY: 62-year-old male with known metastatic melanoma and radiation\n necrosis transferred for acute intracranial hemorrhage, presenting with\n paraparesis of the left side and left-sided neglect to evaluate for acute\n intracranial hemorrhage and interval change of radiation necrosis.\n\n TECHNIQUE: Multiplanar MRI of the head was performed with and without\n intravenous gadolinium administration. Examination was performed with scalp\n fiducials in place for MRI Wand study.\n\n COMPARISON: Multiple MRIs of the head, most recent .\n\n FINDINGS:\n\n There has been no significant interval change in size or appearance of the\n irregular peripherally enhancing lesion involving the post-surgical bed in the\n right frontal lobe measuring approximately 3.6 (AP) x 2.3 (TRV) x 2.5 cm (CC)\n when compared with the prior examination of . There has been interval\n decrease in size of the satellite lesion just inferior to the dominant lesion\n medial to the sylvian fissure, now measuring 7 (AP) x 7 (TRV) x 7 mm (CC).\n\n There is a cluster of four new enhancing lesions, as follows, in the: Right\n corona radiata; right caudate head; and two new enhancing lesions in the right\n forceps minor. These demonstrate marked blooming with hemosiderin rings.\n\n There is FLAIR/T2-hyperintensity within the bilateral cerebral hemispheres,\n which extends up to but does not involve the subcortical U-fibers, stable when\n compared with prior studies dating back to . There is stable mass\n effect and effacement on the body of the right lateral ventricle. There has\n been slight interval decrease in shift of the normally midline structures, now\n measuring 6.5 mm and previously measuring 8.5 mm.\n\n There is no calvarial, upper cervical, or clival bone marrow abnormality.\n\n The ventricles are stable in size. There is no acute infarction. The\n intracranial arterial flow voids are patent. The visualized paranasal sinuses\n (Over)\n\n 10:18 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: eval for acute ICH, radiation necrosis interval change. Plea\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n are well aerated. There is fluid within the mastoid air cells, bilaterally.\n\n IMPRESSION:\n 1. Four new enhancing lesions, as described above, with marked \"blooming\"\n artifact consistent with blood products, melanin or both, with stability size\n and appearance of the dominant enhancing lesion and interval decrease in size\n of the adjacent \"satellite\" lesion. Findings are consistent with\n mixed-response to treatment.\n 2. Persistent confluent FLAIR-hyperintensity extending to, but not including,\n the subcortical U-fibers with persistent mass effect and decreased shift of\n the normally midline structures; the appearance is consistent with radiation\n toxicity.\n 3. No acute infarction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-04-23 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1132714,
"text": " 2:13 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 62 year old man s/p R frontal crani for mass resection. Eval\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p R frontal crani for mass resection. Eval for post op\n hemorrhage. Please perform within 4 hours from surgery\n REASON FOR THIS EXAMINATION:\n 62 year old man s/p R frontal crani for mass resection. Eval for post op\n hemorrhage. Please perform within 4 hours from surgery\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CT of the head.\n\n CLINICAL INFORMATION: Patient with right-sided frontal craniotomy.\n\n TECHNIQUE: Axial images of the head were obtained without contrast.\n Correlation was made with the head MRI of .\n\n FINDINGS: Since the previous study, the patient has undergone resection of\n right frontal lobe enhancing lesion. There are post-surgical changes\n including blood products and air in the right frontal lobe region. Again seen\n is edema extending from frontal to the parietal region and temporal region.\n There remains some mass effect on the right lateral ventricle. A small area\n of blood products seen in the deep white matter adjacent to the ventricle, as\n on the previous MRI. There is no hydrocephalus. There remains mass effect on\n the brainstem with uncal herniation.\n\n IMPRESSION: Status post resection of right frontal lobe mass with expected\n post-surgical changes. No new area of brain edema seen or evidence of\n hydrocephalus.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-04-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1132883,
"text": " 8:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for position, PTX\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p left SCV line placement\n REASON FOR THIS EXAMINATION:\n eval for position, PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Subclavian line placement. Evaluate for pneumothorax.\n\n One portable view. No previous studies are available for comparison at this\n time. There is streaky density at the lung bases consistent with subsegmental\n atelectasis. There is more confluent increased density in the retrocardiac\n area that may represent parenchymal consolidation. The cardiac silhouette is\n prominent but may be exaggerated by AP technique. Mediastinal structures are\n otherwise unremarkable. A left subclavian catheter has been inserted. It\n does not course along the top of the left brachiocephalic vein and instead\n extends inferiorly with its tip projected to the left of the thoracic spine\n over the descending aorta.\n\n The central venous catheter does not appear to be in correct position. Its\n position could be further evaluated by a lateral chest x-ray. Clinical\n correlation is recommended.\n\n Bibasilar subsegmental atelectasis. Possible focal consolidation left base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-04-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1132913,
"text": " 11:36 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for PTX\n Admitting Diagnosis: METASTATIC BRAIN TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p RIJ CVL attempt\n REASON FOR THIS EXAMINATION:\n eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right IJ line placement.\n\n One portable view. Comparison with the previous study done earlier the same\n day. There is streaky density at the lung bases consistent with subsegmental\n atelectasis and possibly a small focal area of consolidation at the left lung\n base, as before. Mediastinal structures are unchanged. A catheter is again\n demonstrated in the left chest. This appears to proceed from the region of\n the subclavian vein but does not follow the course of the left brachiocephalic\n vein and terminates to the left of the spine, with its tip projected over the\n descending aorta, as before. No other central catheter is identified. There\n is no significant change.\n\n IMPRESSION: No significant interval change.\n\n\n"
}
] |
950 | 101,579 | At this time the patient was diagnosed with having peripheral vascular disease despite his long history of claudication. The patient was put on heparin for anticoagulation and the patient was admitted to the Vascular Surgery Service. Emergent arteriogram showed acute thrombosis of the right atrial artery. The patient was begun on total parenteral alimentation treatment and Cardiology was called to assess the patient's risk for bypass surgery. Cardiology cleared the patient for bypass surgery. The patient had preoperative laboratory work done which showed an ejection fraction of 30%. The patient was taken to the Operating Room on and underwent a right femoral tibial bypass graft with greater saphenous vein in situ graft with valve lysis by Dr. . On postoperative day #1 the patient was noted to have loss of pulse signal and graft pulse was no longer palpable. The patient was also noted to have oozing from the incision site. The patient's pulse was noted to be decreased on postoperative day #1 and the patient's condition was guarded at that time. On postoperative day #1 the patient had a brief episode of bradycardia and a pacing Swan was placed and from electrocardiogram the patient appeared to have a right bundle branch block that was newly developed. Cardiology was on board and Lopressor beta blockade was discontinued. At the time due to the critical nature of the patient's condition the patient was transferred to the Intensive Care Unit and the patient's renal function appeared to be worsening and Nephrology was consulted. With their recommendation the ACE inhibitor was discontinued and non-steroidal anti-inflammatory drugs were discontinued. The patient was begun to be given transfusion. The patient appeared to have an acute myocardial infarction postoperatively and renal failure secondary to lack of volume resuscitation. The patient was transferred onto the Intensive Care Unit in guarded condition. On postoperative day #2, on repeat enzymes, the patient's peak CK appeared to be around 700 and it was clear that the patient had perioperative myocardial infarction and the patient was kept in the Intensive Care Unit to stabilize his cardiac and renal status. On postoperative day #3 the patient's graft appeared to be viable. The patient has a warm foot and palpable dorsalis pedis on the right foot. The incision appeared to be still slightly oozy and the patient had Ace bandage wrap around the right leg. On postoperative day #6 the patient was noted to have a lower gastrointestinal bleed and bled in stool and Gastroenterology was consulted. It was on their recommendation heparin was discontinued and the patient's bleeding appeared to stop and Gastroenterology recommended outpatient colonoscopy in the future. On postoperative day #8 the patient's condition appeared to be improving and the patient's renal function appeared to be improving and the patient appeared to be recovering from the acute tubular necrosis and renal failure. From the cardiology point of view, the patient's condition is stabilizing and the patient was transferred onto the Vascular Intensive Care Unit on , which was postoperative day #9. Under Cardiology's recommendation the ACE inhibitor was increased. Chest x-ray was taken to assess his cardiac status. The patient was put on sips for p.o. intakes and the patient appeared to be improving. On postoperative day #10 after discussion with the family the patient was made Do-Not-Resuscitate following the family and patient's wishes. On postoperative day #10 at approximately 6 PM the patient went into respiratory distress with audible wheezes bilaterally and a copious amount of secretion and respiratory treatment with Albuterol inhaler given and suctioning was carried out. At that time it was clear that the patient does not want to be nasotracheal suctioned and appears to be better coherent. The patient at that time was sating at 96% on 5 liters and it appeared that the patient went into bronchospasm and retained secretions with impaired secretion clearance, although after numerous Albuterol treatment the patient was not able to clear his secretion and the patient was made Do-Not-Intubate. The patient expired at 9:30 on . The patient is deceased on with final cause, the patient is a year old gentleman status post right femoral-tibial bypass graft. His course was complicated by myocardial infarction and renal failure. His condition appeared to be improving, however, on , the patient had absolute bradycardia and became acutely apneic and the patient developed bronchospasm and retained secretion which was not able to be cleared by suctioning and the patient was made Do-Not-Intubate and no intubation was carried out. The patient deceased from respiratory distress. The patient underwent autopsy, results pending. , M.D. Dictated By: MEDQUIST36 D: 16:59 T: 18:01 JOB#: | focusdata: post hct 29.0. mso4 1mg x3 given with relief. OCC AUDIBLE WHEEZES NOTED ALBUTEROL NEB X1 WITH EFFECT. There ismoderate mitral annular calcification.Conclusions:1. ?soe.Height: (in) 65Weight (lb): 146BSA (m2): 1.73 m2BP (mm Hg): 154/64Status: InpatientDate/Time: at 16:30Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is moderately dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. Moderate (2+)mitral regurgitation is seen. WBC FLAT.SKIN: LLE INCISION WITH DSG INTACT WITH SMALL AMT OF SEROSANG. (has LV clot). There is interval development of faint patchy air space opacity in the left mid and upper lung zones and the right upper lung zone compatible with acute aspiration event. L WITH PALPABLE PEDAL PULSE WITH +GRAFT PULSE.RESP: L/S CLEAR IN UPPER LOBES WITH CRACKLES IN L BASE AND DIMINISHED ON R. O2 5LNC WITH SATS 93-98%. There ismoderate mitral annular calcification. Moderate (2+) mitral regurgitation isseen.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation.PERICARDIUM: There is no pericardial effusion.Conclusions:There is severe global left ventricular hypokinesis. There is an apical left ventricularaneurysm. Cardiology following.Remains on heparin gtt w/ acceptable ptt. A mild stenosis is present involving the takeoff of the profunda femoris, with diffuse eccentric disease throughout an otherwise patent vessel. Transferred to NSICU yesterday for close managment.ROS:CARDIAC/HEMODYNAMICS: Yesterday low filling pressures-> prbc and fluid w/ normalized pressures today. There is mild symmetric left ventricular hypertrophy. Started low dose lopressor. He had alot of ventricular activity this am which resolved when pacer turned off. A left ventricularmass/thrombus cannot be excluded.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened.MITRAL VALVE: The mitral valve leaflets are mildly thickened. The ostea are suboptimally visualized, but there is a probable left proximal renal artery stenosis present. Severe diffuse hypokinesis ispresent with some preservation of basal wall motion.3. Distally, the anterior tibial and peroneal arteries reconstitute. CONTS ON CAPOTEN BUT LOPRESSOR HELD PER SICU HO. The aortic valve leaflets (3) are mildlythickened. Left ventricular function.Height: (in) 65Weight (lb): 166BSA (m2): 1.83 m2BP (mm Hg): 150/68Status: InpatientDate/Time: at 15:55Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in theright atrium and/or right ventricle.LEFT VENTRICLE: There is severe global left ventricular hypokinesis. The heart size and mediastinal contour are within normal limits. The left ventricularcavity is mildly dilated. Feeding tube appears post-pyloric. Single frontal chest radiograph dated is compared with prior chest radiograph dated . rr 20's unlabored.RENAL: new renal failure w/ bun 39/cr 2.0. N/SICU NURSING NOTE 11P-7AREVIEW OF SYSTEMSNEURO: PT 2 WITH PERIODS OF AGITATION AND DISORIENTATION. OCC DRY COUGH NOTED. There is no pericardial effusion.Compared to the Echo dated , which was reviewed, LV function hasdecreased further, LV thrombus is not noted as clearly as in the previousstudy. SG catheter is positioned at the right PA. and are available by phone.ASSESS: stable s/p mi, renal failure, metabolic acidosis (r/t renal failure/ cardiogenic compromise). PP DOPPLED.RESP: HAS COURSE BREATHSOUNDS. FINAL REPORT INDICATIONS: S/P fem/tib bypass. Sinus rhythm with atrial ectopy. Probableold inferior myocardial infarction as well.TRACING #2 The right sided central venous catheter has been slightly withdrawn with the tip now overlying the mid to distal SVC. Perineum and (L) glut w/ ecchymosis slowly resolving. Resid 0cc. abg done and ph 7.32-with po2-104. Marked P-R interval prolongation. Marked P-R interval prolongation. CardiacD: pt. with end exp wheezes. CVP 11-20.RESP: LS intermit coarse -> exp wheeze. Rule out ischemia. Severe P-R interval prolongation. RespD: pt. At the adductor canal is a filling defect consistent with thrombus material. Left anterior fascicular block. Left anterior fascicular block. IMPRESSION: 1) Partial collapse of right upper lobe. Sinus arrhythmia with atrial ectopy. Sinus arrhythmia with atrial ectopy. Poor R wave progression inleads V3-V6 consistent with old anterior myocardial infarction. Lasix pNGT given w/effect.SKIN: RLE inc w/ staples intact w/ scant serosanguinous drainage. cxr done. Borderline leftaxis deviation. P-R interval 0.36. There is partial collapse of the right upper lobe. Pt tol OOB -> chr w/ PT.PLAN: Cont NPO and TF w/ mouthcare. Compared to the previous tracing the heartrate is now irregular and the ST segments in lead V3 appear to be elevated.There is now evidence of probable old anterior myocardial infarction. no accessory use.A:endo suctioned for mod amt thick sputumNeb per resp therapyDr. Consider prior anteroseptal myocardial infarction.Clinical correlation is suggested. Wandering atrial pacemaker, rate 93. Monitor resp status, provide neb tx's prn. Reccomending cont NPO until pt more alert for Barium swallow. filling of the mid/distal dorsalis pedis artery or plantar vessels. RT providing neb tx's. Compared tothe previous tracing of T wave inversions in the lateral leads are lesspronounced. Assess position of central line that has been partially pulled out by the patient. Condition update A:ROS - please refer to flowsheet. P-R interval 0.32. Diffuse ST-T wave changes. Leftatrial abnormality. Leftatrial abnormality. co-3.2 ci- 2.1 with svr 1800. ho notified. There are bilateral pleural effusions present and adjacent basilar opacities which probably reflect atelectasis. Just distal to this is a focal stenosis, followed by an abrupt occlusion of the distal SFA/above knee popliteal artery. Monitor RLE inc, change per orders. Incompleteright bundle-branch block and left axis deviation. Post-operative patient. ATTEMPTED TO CALM WITH ONLY FAIR RESULTS.CV: AFIB WITH OCC PVC AND PAC. Speach up for bedside swallow eval. Ectopic atrial rhythm, rate 94, with P-R interval prolongation. At the level of the previous occlusion, there is improved filling through the superficial femoral artery down to the level approximately 1-2 cm distal to the adductor canal. REASON FOR THIS EXAMINATION: assess position of tip of central line -- line has been partially self d/c'ed by patient. bp 140-160syst/ one unit of prbc infused. pt noted to have episode have exp wheezes on exertion, albuterol neb given.pt continues on heparin drip, goal to reach theraputic levels of ptt-60-80, pt currently on 600u/hr. | 35 | [
{
"category": "Radiology",
"chartdate": "2169-03-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758344,
"text": " 7:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p fem-tib bypass\n\n REASON FOR THIS EXAMINATION:\n ?CHF\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: Fem/tib bypass and shortness of breath, Swan-Ganz placement.\n\n Swan-Ganz catheter is in right main pulmonary artery. No pneumothorax. Heart\n size is within normal limits for technique. No evidence for CHF. Apart from\n linear atelectasis at the left base, the lungs are clear.\n\n IMPRESSION: No evidence for CHF or pneumonia. No pneumothorax. No change\n since prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-04-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758436,
"text": " 6:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pulm edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p fem-tib bypass\n\n REASON FOR THIS EXAMINATION:\n evaluate for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fem/tib bypass, shortness of breath, evaluate for\n pulmonary edema.\n\n Single frontal chest radiograph dated is compared with prior chest\n radiograph dated .\n\n When compared to the prior study, there is no interval change in position of\n lines and tubes. There is no interval change in appearance of the chest.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-04-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758474,
"text": " 12:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: acute SOB\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p fem-tib bypass a\n\n REASON FOR THIS EXAMINATION:\n acute SOB\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Patient with fem-tib bypass.\n\n Given technical differences, there is not a very significant change in the\n appearance of the chest since .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-04-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758568,
"text": " 2:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p fem-tib bypass a\n\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post lower extremity bypass surgery. Check line placement.\n\n PORTABLE AP CHEST RADIOGRAPH: Comparison is made to an exam of . The\n tip of a right IJ catheter terminates deep within the right atrium. The\n cardiac silhouette and mediastinal/hilar contours are stable. There is\n persistent air-space opacification of the right upper lobe with further\n improvement of air-space disease within the left upper lobe. There are no new\n effusions or focal consolidations. No evidence of pneumothorax.\n\n IMPRESSION:\n 1) Tip of right-sided central venous catheter deep within the right atrium.\n This finding was immediately telephoned to Dr. .\n\n 2) Probable resolving asymmetric pulmonary edema within the upper lobes, right\n side greater than left. An underlying infectious etiology, however, cannot be\n completely excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-04-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758461,
"text": " 3:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: worsening CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p fem-tib bypass\n\n REASON FOR THIS EXAMINATION:\n worsening CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Recent fem/tib bypass, worsening CHF.\n\n Comparison with the patient's prior chest xray at 6:37 AM on .\n\n The heart is enlarged. The feeding tube and Swan-Ganz catheter are relatively\n unchanged since the prior study. Once again there is bilateral upper lobe\n early air space disease versus pulmonary edema. There is no pneumothorax.\n\n IMPRESSION: No change in the chest since the earlier chest xray this morning.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-03-27 00:00:00.000",
"description": "VEN DUP EXTEXT BIL (MAP/DVT)",
"row_id": 758092,
"text": " 1:52 PM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: look for suitable bypass vein.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with R popliteal a. thrombus/embolus. Prior Hx vein stripping\n ? side. Please map B lower ext veins.\n REASON FOR THIS EXAMINATION:\n look for suitable bypass vein.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Patient with ischemic leg and need for bypass. Evaluate for conduit.\n\n FINDINGS: Duplex evaluation was performed of both lower extremity superficial\n venous systems. On the right leg the greater saphenous vein is patent. The\n lesser saphenous vein is not visualized. The diameters of the greater\n saphenous vein in centimeters are as follows: 0.28, 0.31, 0.35 and 0.44 at\n the ankle, mid calf, low thigh and saphenofemoral junctions respectively.\n\n On the left, the lesser saphenous vein could not be evaluated due to the\n patient having a TPA catheter in place. The greater saphenous vein is patent\n with diameters in centimeters as follows: 0.41, 0.39, 0.44 and 0.43 cm at\n the ankle, knee, thigh and saphenofemoral junctions respectively.\n\n IMPRESSION: Patent right greater saphenous vein. The right lesser saphenous\n vein was not visualized. On the left, the greater saphenous vein is patent.\n The lesser saphenous vein could not be evaluated due to reasons as stated\n above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-03-27 00:00:00.000",
"description": "MULTI-PROCEDURE SAME DAY",
"row_id": 758048,
"text": " 7:45 AM\n UNI-LAT FEMORAL Clip # \n Reason: r/o thrombosis\n Contrast: OPTIRAY Amt: 200CC\n ********************************* CPT Codes ********************************\n * TRANSCATHETER INFUSION FOR LYS INITAL 3RD ORDER ABD/PEL/LOWER *\n * -51 MULTI-PROCEDURE SAME DAY TRANSCATHETER INFUSION *\n * ABDOMINAL A-GRAM EXT UNILAT A-GRAM *\n * NON-IONIC 200 CC SUPPLY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with acute numbness of R foot. On exam has a cold R foot with\n no doppler signals or pulses.\n REASON FOR THIS EXAMINATION:\n r/o thrombosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: year old male with symptoms and signs of acute right foot\n ischemia without Dopplerable signals or pulses.\n\n RADIOLOGISTS: Drs. and . Dr. , staff radiologist,\n was presenting during throughout the procedure.\n\n CONTRAST/MEDICATIONS: 200 ml of Optiray 320 at 30%; 1.5 mg versed and 50 mcg\n fentanyl in divided doses under continued hemodynamic monitoring.\n\n PROCEDURE/TECHNIQUE/FINDINGS: The procedure was described to the patient and\n informed consent was obtained. Access was gained into the left common femoral\n artery using a 19g single wall needle. An 0.035 wire was advanced through a\n heavily calcified left external and common iliac artery under fluoroscopic\n guidance without difficulty. A 5 french sheath was then exchanged over the\n wire, followed by placement of a 4 french omni flush catheter. With the\n catheter in the abdominal aorta, an AP aortogram was obtained. The catheter\n was pulled into the infrarenal aorta, and a left anterior oblique pelvic\n arteriogram was obtained. Over an 0.035 angled glide wire, catheter was then\n advanced into the distal right external iliac artery, and sequential right\n lower extremity arteriograms were obtained.\n\n A mild degree of aortoiliac calcification is present. There are single renal\n arteries bilaterally. The ostea are suboptimally visualized, but there is a\n probable left proximal renal artery stenosis present. The infrarenal aorta is\n mildly aneurysmal, with a focal eccentric stenosis that projects over L3-4.\n Both hypogastric arteries are widely patent. There is a significant degree of\n tortuousity of both iliac vessels, but no common or external iliac stenoses\n are present. Incidental note is made of a right hip prosthesis. Extensive\n calcification is noted throughout superficial and deep femoral vessels. A mild\n stenosis is present involving the takeoff of the profunda femoris, with\n diffuse eccentric disease throughout an otherwise patent vessel. The proximal\n portion of the superficial femoral artery is widely patent, but demonstrates\n mild multifocal disease proximally. At the mid portion, above the adductor\n canal, is a meniscus shaped filling defect involving the medial wall of the\n superficial femoral artery most consistent with thrombus. A small lateral\n (Over)\n\n 7:45 AM\n UNI-LAT FEMORAL Clip # \n Reason: r/o thrombosis\n Contrast: OPTIRAY Amt: 200CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n vessel arises from the lateral aspect of the superficial femoral artery at\n this level, and courses medially along the knee joint. An AP view obtained\n over the trifurcation shows no filling of the runoff vessels proximally. There\n is an extensive small collateral network over the thigh. Distally, the\n anterior tibial and peroneal arteries reconstitute. The anterior tibial artery\n continues as the dorsalis pedis artery, which proximally has a corkscrew\n attenuated appearance and does no opacify at its mid or distal portions. The\n plantar vessels do not fill, nor do the arch vessels.\n\n An 0.035 angled glide wire was then advanced through the catheter down to the\n abrupt filling defect, which was able to be crossed without difficulty.\n However, approximately 3-4 cm beyond, the glidewire could not be passed. For\n this reason, the glidewire was removed, and a 9 cm infusion wire was\n advanced under fluoroscopic guidance to the level of occlusion. 1 mg TPA was\n then bolus-injected intraarterially, and this was repeated four times for a\n total of 5 mg TPA bolus at the site of thrombus.\n\n TPA was then commenced at a rate of 0.5 mg per hour, with 200 units of heparin\n infusing through the sidearm sheath for patency. The patient will return to\n the interventional radiology department on for reassessment.\n\n COMPLICATIONS: None.\n\n IMPRESSION: Findings suggesting an acute on chronic thrombus of the\n superficial femoral artery just proximal to the adductor canal. 5 mg bolus of\n TPA infused through wire, followed by continuous infusion of TPA at a\n rate of 0.5 mg per hour. The patient will return on for angiographic\n reassessment.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-03-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758108,
"text": " 7:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please do tonight -- pt preop for OR -- can not travel d\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with\n\n acute limb ischemia\n REASON FOR THIS EXAMINATION:\n Please do tonight -- pt preop for OR -- can not travel downstairs -\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: year old man with acute limb ischemia, preoperative exam.\n\n PORTABLE AP SUPINE VIEW OF THE CHEST PERFORMED AT 19:29 HOURS: No\n prior images for comparison. The heart size and mediastinal contour are\n within normal limits. The aorta is tortuous and calcified. There is some\n prominence of the pulmonary vasculature peripherally, predominantly within the\n upper lobes. Although this may in part reflect the patient's supine\n positioning a component of volume overload cannot be excluded. There is\n increased luceny of the right lower lung. Streaky opacities at the left base\n are consistent with minimal left basilar atelectasis.\n\n Surgical clips are noted within the right upper quadrant.\n\n IMPRESSION: No evidence of pneumonia. Mild upper zone redistribution likely\n represents a component of volume overload. Relative increased lucency of the\n right lower lung of uncertain significance. Possible etiologies include\n bullous change or chronic or acute pulmonry embolism. Recommend comparison\n with prior studies. Surgical resident notified 10:20 pm.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-03-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758186,
"text": " 6:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess swan placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p fem-tib bypass\n REASON FOR THIS EXAMINATION:\n assess swan placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess Swan-Ganz placement in post vascular surgery patient.\n\n COMPARISON: \n\n AP CHEST: In the interval since the prior study a Swan-Ganz catheter has been\n placed via right internal jugular access and the tip is positioned at the\n junction of the right pulmonary artery in its interlobar branch. There is no\n evidence of pneumothorax. Minimal atelectasis is again seen at the left base.\n Otherwise there are no changes since the study 1 day prior.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-03-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758413,
"text": " 4:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: CONFIRM DUBOFF TUBE PLACEMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p fem-tib bypass\n\n REASON FOR THIS EXAMINATION:\n CONFIRM DUBOFF TUBE PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dophoff tube tube placement.\n\n COMPARISON: .\n\n AP UPRIGHT CHEST: The tip of the feeding tube is positioned in the first\n portion of the duodenum. SG catheter is positioned at the right PA. There is\n no pneumothorax. There is interval development of faint patchy air space\n opacity in the left mid and upper lung zones and the right upper lung zone\n compatible with acute aspiration event. There are no pleural effusions.\n\n IMPRESSION:\n 1. Feeding tube appears post-pyloric.\n 2. Interval development of air space opacity in mid and upper lung zones;\n question acute aspiration event vs. asymmetric edema.\n\n"
},
{
"category": "Echo",
"chartdate": "2169-03-27 00:00:00.000",
"description": "Report",
"row_id": 70703,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Embolus to popliteal artery.?soe.\nHeight: (in) 65\nWeight (lb): 146\nBSA (m2): 1.73 m2\nBP (mm Hg): 154/64\nStatus: Inpatient\nDate/Time: at 16:30\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity is mildly dilated. There is an apical left ventricular\naneurysm. There is severe global left ventricular hypokinesis. Overall left\nventricular systolic function is severely depressed. A large thrombus is seen\nin the left ventricle.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is\nmoderate mitral annular calcification.\n\nConclusions:\n1. The left atrium is moderately dilated.\n2. There is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity is mildly dilated. There is an apical left ventricular aneurysm.\nOverall left ventricular systolic function is severely depressed. A large\nthrombus is seen in the left ventricular apex. Severe diffuse hypokinesis is\npresent with some preservation of basal wall motion.\n3. The aortic valve leaflets are mildly thickened.\n4. The mitral valve leaflets are mildly thickened.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2169-03-30 00:00:00.000",
"description": "Report",
"row_id": 70664,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter. Left ventricular function.\nHeight: (in) 65\nWeight (lb): 166\nBSA (m2): 1.83 m2\nBP (mm Hg): 150/68\nStatus: Inpatient\nDate/Time: at 15:55\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the\nright atrium and/or right ventricle.\n\nLEFT VENTRICLE: There is severe global left ventricular hypokinesis. Overall\nleft ventricular systolic function is severely depressed. A left ventricular\nmass/thrombus cannot be excluded.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is\nmoderate mitral annular calcification. Moderate (2+) mitral regurgitation is\nseen.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThere is severe global left ventricular hypokinesis. Overall left ventricular\nsystolic function is severely depressed.LV apex is aneurysmal. A left\nventricular mass/thrombus cannot be excluded. Right ventricular chamber size\nand free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened. The mitral valve leaflets are mildly thickened. Moderate (2+)\nmitral regurgitation is seen. There is no pericardial effusion.\nCompared to the Echo dated , which was reviewed, LV function has\ndecreased further, LV thrombus is not noted as clearly as in the previous\nstudy. Mitral insufficency has increased.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-04-02 00:00:00.000",
"description": "Report",
"row_id": 1274325,
"text": "focus\ndata: post hct 29.0. mso4 1mg x3 given with relief. slept in short naps. tube fdgs held during the nite due to fluid status. lasix 10mg iv x1 given with fair diuresis. k 3.5. mag 1.9. ho aware of these results. pacer on a vdemand of 60. pt appears calmer this am and not stating he wants to die. r leg dsg changed and incision clean and intact with mod amt of serosang drainage. dsg with loose kling wrapped.\naction: labs as ordered. prbc given with post hct of 29. hob at 30degrees. albuterol rx for resp\nresponse: monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-04-02 00:00:00.000",
"description": "Report",
"row_id": 1274326,
"text": "nursing progress note see carview for details.\n\nneuro:awake,alert, oriented x3.follows commands and moves all extremities on command.conversation is appropriate,speech is easy to understand.\n\ncv:remains in atrial fib rate is 80 to 100 with rare pvcs.pacing wire in swan does not work,dr attempted to advance.captopril was increased to 18.75 mg q8hrs.remains on ntg gtt to keep systolic bp 130 to 150.ci remains stable,pa does not wedge team aware.right foot warmer than left foot,bil dp and pt pulses and graft pulse present,right graft pulse and right dp is palpablealso.\n\nresp:resp rate 14 to 24.sp02 96 to 99% on 2l np,and 60% open face mask.has loose cough without production.breath sounds have i/e wheezes getting alb/atro nebs,upper lobes clear at times with coarseness in bases.\n\ngi:mouth wet with swabs,pt has frequent cough.tube feeds were restarted ,promote with fiber to goal of 60cc today.has had no stool today.abd soft with positive bowel sounds.\n\ngu:foley to cd draining clear yellow urine today.in small amounts.\n\nid:no issues.\n\nskin:has multiple old ecchymotic areas in scrotum,sides of abd and around arms.has generalized edema in extremities.\n\nsocial:full and involved discussion with patient and son at bedside by dr and team prognosis and medical and cardiac condition discussed a dnr/dni status was determined. pt states that.\" i am dying please let me \".\n\nplan:comfort measures.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-04-01 00:00:00.000",
"description": "Report",
"row_id": 1274322,
"text": "N/SICU NURSING NOTE 11P-7A\nREVIEW OF SYSTEMS\n\nNEURO: PT 2 WITH PERIODS OF AGITATION AND DISORIENTATION. PT ABLE TO BE TALKED DOWN. FOLLOWING COMMANDS AND MOVING ALL EXTRMETIES. SLEPT POORLY LAST NIGHT.\n\nCV: HR 70-80'S AFIB WITH OCC PVCS AND PACED BEATS. CONTS WITH PACING SWAN AND PACER SET AT VDEMAND 60 AND PACING APPROPRIATELY. SBP 130-160. PA 70-50/35-48 WITH WEDGE . CVP 8-13. CO/CI GRATUALLY DECREASING OVER LAST SHIFT WITH THERMO CO 3.39-2.90 WITH INDEX 1.8-1.6. FICK CO 4.0-3.70 WITH INDEX 2.21-2.O4. TEAM AWARE. TROPONIN ADDED TO THIS AMS LABS. ATTEMPTED 250CC FLUID CHALLENGE INITIALLY FOR LOW CO WITH NO EFFECT. PT PRESENTLY GETTING 1UPRBC OVER 4HRS. CONTS ON CAPOTEN BUT LOPRESSOR HELD PER SICU HO. MIXED VENOUS O2 45-49. DOPPLERABLE PULSES ON R WITH EXTREMTY COOL TO TOUCH. L WITH PALPABLE PEDAL PULSE WITH +GRAFT PULSE.\n\nRESP: L/S CLEAR IN UPPER LOBES WITH CRACKLES IN L BASE AND DIMINISHED ON R. O2 5LNC WITH SATS 93-98%. SOB ON EXCERTION AND WITH AGITATION. OCC AUDIBLE WHEEZES NOTED ALBUTEROL NEB X1 WITH EFFECT. OCC DRY COUGH NOTED. ABG ADEQUATE. ISOLATED EPISODE WHERE PT C/O SOB BUT ASSOCIATED WITH AGITATION THAT SUBSIDED.\n\nGI: ABD SOFT WITH +BS. TOL ICE CHIPS. POST PYLORIC TUBE WITH PROMOTE AT 20CC/HR. NO STOOL OR FLATUS. DENIES TENDERNESS ON PALPATION.\n\nGU: U/O 30-40CC/HR. LASIX HELD THIS AM.\n\nHEME: HCT 25-28. 1UPRBC GIVEN. PTT 60 HEPARIN GTT REMAINS AT 700U/HR.\n\nENDO: NO ISSUES.\n\nID: AFEBRILE. WBC FLAT.\n\nSKIN: LLE INCISION WITH DSG INTACT WITH SMALL AMT OF SEROSANG. DRAINAGE NOTED.\n\nSOCIAL: NO CONTACT WITH FAMILY THIS SHIFT.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-04-01 00:00:00.000",
"description": "Report",
"row_id": 1274323,
"text": "nursing progress note see carview for details\n\nneuro:awake alert,easily agitated and disoriented at times.reoriented easily.follows commands and moves all extremities.recognizes all family members.aware that he is in a hospital.\n\ncv:remains in atrial fib with rare pvcs.systolic bp greater than 150 started on ntg gtt,continues at 3 mcq /kg/min. dr aware not to increase ntg.captopril dose was increased to 12.5 mg q8hrs. ci has been stable.swan has not wedged ,has been repositioned multiple times by dr .pacer remains in vdemand mode , rate at 60,ventricular sensitivity 2.0,ma at 5.pacing and sensing checked on rounds this am.had one dose of lopressor 2.5mg iv and tolerated well.\n\nresp:had chest xray which dr reports as improved.had increasing oxygen requirements,nasal prongs at 2lmin,open face mask at 60%.breath sounds have had wheezes present which have been treated with albuteral nebs.crackles bibasilar which was treated with lasix 10mg/iv.otherwise bs are clear and diminished bibasilar.resp rate 17 to 26.has loose nonproductive cough.\n\ngi:abd soft with positive bowel sounds present,has not had any stool today.tube feed continues at 40cc/hr promote with fiber.will advance tonight for total goal rate of 60cc.\n\ngu:foley to cd draining small amounts of clear urine,had lasix 10mg iv with some diuresis.\n\nskin:intact,on airmatress.right leg incision line intact with dsg.\n\npulses:has bildpand pt and graft present by doppler.\n\nsocial:visited by family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-03-30 00:00:00.000",
"description": "Report",
"row_id": 1274319,
"text": "PROGRESS NOTE\nPT , ORIENTED TO NAME AND 'HOSPITAL', REORIENTED TO DATE. MOVES ALL LIMBS AND FOLLOWS COMMANDS APPROPRIATELY. BILAT WRISTS RESTRAINTS APPLIED, DUE TO PT PULLING AT SWAN LINE.\nCV: PT TRANSFERRED FROM VICU ON , RULING IN FOR +MI, F/U BY CARDIOLOGY, SWAN PACER IN SITU AND ATTACHED. RESTARTED ON HEPARIN DRIP @ 2130 SECONDARY TO LV THROMBUS, INITIALLY STOPPED DUE TO RT LEG WOUND OOZING. INITIALLY PT'S CVP 0-3, PCWP: , CO, CI APPEARED ACCEPTABLE SEE FLOWSHEET. LOW URINE OUTPUT: 10-20CC PT FOLLOWED BY RENAL TEAM.\nRECEIVED PT WITH STABLE BP DESPITE LOW CVP AND WEDGE, WAS GIVEN SEVERAL BOLUSES AND I UNIT PRBCS FOR LOW HCT TO IMPROVE ON FLUID STATUS. PCWP FOLLOWED CLOSELY AS PER HO AND CARDIOLOGY. CVP AND PCWP FLUCTUATE: ; . CPK'S WITH MB AND TROPONIN LEVELS ELEVATED CURRENTLY CYCLING X 3. HR 85-90S, WITH FREQUENT PVC'S. WILL REPLETE LYTES AS OREDERED. PAP 40-60 SYSTOLIC. PT IN AND OUT OF A-FIB WHILE BOLUSES INFUSING, HO AWARE EKG DONE, PT BACK IN SR. ION CA .97 WAS GIVEN 2GM.\nRT LEG INCISION, CHANGED AND CLEANSED WITH NS GRAFT SITE PALPABLE, PEDAL PULSES ABSENT REPORTED TO HO, WARM BLANKETS APPLIED TO IMPROVE CIRCULATION TO EXTREMITIES.\nGU: URINE OUTPUT IMPROVED SLIGHTLY- 25CC/HR AFTER BOLUSES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-03-30 00:00:00.000",
"description": "Report",
"row_id": 1274320,
"text": "CCU NSG PROG NOTE: 7-3PM\nRemains stable PO day 2, c/w MI, renal failure. Transferred to NSICU yesterday for close managment.\n\nROS:\n\nCARDIAC/HEMODYNAMICS: Yesterday low filling pressures-> prbc and fluid w/ normalized pressures today.(pa 40's, pad 25, pcw 19, cvp 10-12.)\nThey want his pcw around 19-20 and cvp 10). IVF decreased to 75cc/hr.\nSwan placement adjusted w/ improved tracings. Wedges easily w/ good tracing. He had alot of ventricular activity this am which resolved when pacer turned off. The pacer was inappropriately firing and did not sense. Remains off. Rhythm AF a/w first degree avb (pr .40)w/ rates 65-100. Started low dose lopressor. Transient brady to 50's w/ coughing. (noted to have vagal drops on floor w/ vomiting...hx tacky/brady syndrome.). Cardiac Index 2.08. Cardiology following.Remains on heparin gtt w/ acceptable ptt. (has LV clot). For Echo today. Contnue to serial enzymes. R upper back pain.\n\nRESP: diminished at R base. Remains stable w/ sats 97% on 3L nc. rr 20's unlabored.\n\nRENAL: new renal failure w/ bun 39/cr 2.0. Urine output consistently 20-25cc/hr. Renal following.\n\nGI: NPO today except med and ice chips. Takes crushed meds. Will reevaluate tomorrow regarding eating. No stool. Abd soft . No nausea\n\nHEME: received 2nd unit prbc for today w/ follow up hct 29.8.\n\nNEURO: A&Ox2. Able to converse and follow commands, has periods of confusion.Did not require restraints today. Cooperative.\n\nSKIN/WOUND: R leg dsg dry and intact w/ dopplerable pulses at graft, DP, L dp, absent L PT pulse. R foot warm to touch w/ good color. L foot cool to touch. Last dsg change 2am.\n\nID: afebrile. wbc 12.4. Is not on abx.\n\nMETABOLIC: metabolic acidosis. abg 7.28/29/107/-. Receiving ivf w/ 2 amps bicarb x 1 liter only. ABG pnd.\n\nSTATUS: Son, , is health care proxy.(copy is in chart). The patient remains a full code. If pt's condition or prognosis changes, he will readdress status w/ the team. A sister , , is also involved. There is a daughter, , who is coming from . and described an emotional instability of that could interfere w/ patient care and reminded me that is the legal proxy. They are attempting to be here to monitor visits but in the event that they are not, they said we can give her information but ask that we not honor unreasonable requests of her's. (i.e. decision making or asking for physician .) and are available by phone.\n\nASSESS: stable s/p mi, renal failure, metabolic acidosis (r/t renal failure/ cardiogenic compromise). Stable filling pressures. Stable b/p. Stable resp status.\n\nPLAN; labs sent and pnd. Monitor acidosis. Keep cvp approx 10, pcw approx 19-20. Mso4 for discomfort. Monitor surgical incision. Restrain if necessary. For Echo.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-03-31 00:00:00.000",
"description": "Report",
"row_id": 1274321,
"text": "Progress Note\nneuro unchanged, bilat wrist restraints still on as pt accidentally pulls on swan line. moves all ext in bed.\nCV: hr a-fib with rare pvc's, k+ low 2.8 was given 20meq centrally, ion ca low-.87, was replaced x 2. bp stable during the night, co, ci unchanged from admission. pcwp 17 and cvp 10. afebrile.\nrt leg drsg with amt of serosang drainage, wound cleansed with normal saline and applied DSD. rt graft site palpable, no bilat pedal pulses able to doppler, feet cool to touch, warm blankets applied.\nresp: 4l np 02 sat fluctuates between 92-96% bilat breath sounds clear but diminshed at the bases. pt noted to have episode have exp wheezes on exertion, albuterol neb given.\npt continues on heparin drip, goal to reach theraputic levels of ptt-60-80, pt currently on 600u/hr.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-04-05 00:00:00.000",
"description": "Report",
"row_id": 1274332,
"text": "NPN: PROGRESS AND TRANSFER NOTE\nNEURO: ALERT AND ORIENTED. FREQUENTLY CALLING OUT FOR ICE AND WATER DESPITE BEING INSTRUCTED RE: ASPIRATION. DOES BECOME AGITATED WHEN HE IS REFUSED. ATTEMPTED TO CALM WITH ONLY FAIR RESULTS.\n\nCV: AFIB WITH OCC PVC AND PAC. A LINE TO L RADIAL, VSS. PP DOPPLED.\n\nRESP: HAS COURSE BREATHSOUNDS. HAS WEAK, LOOSE SOUNDING COUGH. WAS ON NC BUT CHANGED TO HUMIDIFIED FM JUST TO PROVIDE HIM SOME MORE MOISTURE TO HIS MOUTH. CPT COMPLETED.\n\nGI: NPO DUE TO PROBABLE ASPIRATIONS. SPPECH THERAPY WAS HERE TO DO AN EVALUATION EAARLIER IN DAY BUT THE PATIENT WAS TOO GROGGY FROM A DOSE OF ONE PERCOCET GIVEN EARIER IN DAY. THEY WILL FOLLOW UP TOMORROW. DOES HAVE FEEDING TUBE AND HAD A SMALL BROWN STOOL THIS EVENING.\n\nGU: FOLEY PATENT OF CLEAR YELLOW URINE.\n\nSKIN: ECCYMOSIS TO R HIP. BYPASS INCISION TO RLU WITH SOME OOZING AT UPPER THIGH.\n\nPSYCH/SOC/SPIRITUAL: SON IS ALSO MD. WIFE WAS TAKING TO TONIGHT WITH GIB AND IS ICU. INITIALLY IT WAS THOUGHT THAT SHE WAS GOING TO BE UNSTABLE BUT IT APPEARS SHE HAVE STABLIZED A BIT. HE STATED THAT IF PATIENT WHY HE HAS NOT VISITED TONIGHT, THAT WE COULD TELL HIM THAT SHE WAS TAKEN TO THE HOSPITAL AND THAT HE WAS THERE WITH HER. IT IS OKAY TO TELL HIM THAT SHE HAS A GIB AND THAT SHE IS IN THE ICU.\n"
},
{
"category": "ECG",
"chartdate": "2169-03-27 00:00:00.000",
"description": "Report",
"row_id": 158436,
"text": "Sinus arrhythmia with atrial ectopy. Marked P-R interval prolongation. Left\natrial abnormality. P-R interval 0.36. Left axis deviation. Right bundle-branch\nblock. Left anterior fascicular block. Diffuse ST-T wave changes which are in\npart primary - cannot exclude ischemia. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2169-03-28 00:00:00.000",
"description": "Report",
"row_id": 158434,
"text": "Sinus rhythm with atrial ectopy. There are group beating patterns with\nsubsequent QRS followed by prolonged P-R intervals. However, there is no\nblocked atrial conduction. Marked P-R interval prolongation. Borderline left\naxis deviation. Right bundle-branch block. T wave inversions in V3-V5 most\nlikely due to rhythm but cannot rule out anterolateral ischemia. Compared to\nthe previous tracing of T wave inversions in the lateral leads are less\npronounced. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2169-03-27 00:00:00.000",
"description": "Report",
"row_id": 158435,
"text": "Sinus arrhythmia with atrial ectopy. Severe P-R interval prolongation. Left\natrial abnormality. P-R interval 0.32. Left axis deviation. Right bundle-branch\nblock. Left anterior fascicular block. Diffuse ST-T wave changes. Cannot\nexclude lateral ischemia. Consider prior anteroseptal myocardial infarction.\nClinical correlation is suggested. Compared to the previous tracing of \nthere is no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2169-03-30 00:00:00.000",
"description": "Report",
"row_id": 158431,
"text": "Wandering atrial pacemakeR, RATE 99. Compared to tracing #2 there are more R\nwaves in leads V4-V6. Otherwise, no diagnostic changes.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2169-03-29 00:00:00.000",
"description": "Report",
"row_id": 158432,
"text": "Wandering atrial pacemaker, rate 93. Compared to the previous tracing the heart\nrate is now irregular and the ST segments in lead V3 appear to be elevated.\nThere is now evidence of probable old anterior myocardial infarction. Probable\nold inferior myocardial infarction as well.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2169-03-29 00:00:00.000",
"description": "Report",
"row_id": 158433,
"text": "Ectopic atrial rhythm, rate 94, with P-R interval prolongation. Incomplete\nright bundle-branch block and left axis deviation. Poor R wave progression in\nleads V3-V6 consistent with old anterior myocardial infarction. T wave\nabnormalities in leads V3-V4 appear more prominent compared to the previous\ntracing of . Rule out ischemia. The heart rate is faster than on the\nprevious tracing.\nTRACING #1\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-04-03 00:00:00.000",
"description": "Report",
"row_id": 1274327,
"text": "nursing progress note see carview for details.\n\nneuro:awake,alert,appears oriented x3,does not always know what hospital he is in.follows commands and moves all extremities with equal strenght.speech is clear and recognizes all family members.\n\ncv:remains in atrial fib rate 70 to 90 with rare pvcs.bp stable less than 150 systolic .tolerates captopril and lopressor.has bil dp and ptp by doppler with good palpable graft pulse.left foot is cooler than right foot,left pt is weaker than other pulses.swan was dcd.seen and evaluated by cardiolgy.\n\nresp:resp rate 14 to 20.has audible i/e wheezes appears to be upper airway.sp02 96 to 98% on 6lnp. had albuterol/atrovent nebs.chest xray revealed some failure treated with lasix.has loose cough without production.\n\ngu:foley to cd draining clear yellow urine in small amounts.\n\ngi:had large stool this am with about 300cc of bright red blood.had two ther small formed stools with no visible blood but one was heme positive.abd soft appears nontender,pt denies pain.surgery was notified,came and did rectal exam.heparin gtt was dcd,tube feeds were dcd.has positive bowel sounds present.\n\nsocial:dr spoke with pt this am code status was changed to dni.son spoke with social service.family has been update on pts condition.\n\naccess:swan was dcd,changed over a wire ,triple lumen was placed,line was repositioned by dr .\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-04-04 00:00:00.000",
"description": "Report",
"row_id": 1274328,
"text": "Cardiac\nD: pt. con'ts to be in afib with stable B/P in the 140's to 150's. HR decreasing to brady in the 40's after 1st dose of increased lopressor. B/P decreasing with decreased HR to ~110 systolic. pedal pulses (+) by doppler. K 4.1 after a.m. bolus\nA: lopressor dose decreased to 12.5 mg po bid\ntube feeds restarted\nLasix 20 mg IVP x 1 given\nNS con't @ 40 ml/hr until TF increased\nR:gd response from diuresis, k not needing repletion, HR and B/P increased after time..await results of decreased lopressor dose,? transfer to VICU\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-04-04 00:00:00.000",
"description": "Report",
"row_id": 1274329,
"text": "Resp\nD: pt. c/o difficulty breathing this afternoon. BS bil. with end exp wheezes. O2 sat 99%. denies c.p. RR low 20's. no accessory use.\nA:endo suctioned for mod amt thick sputum\nNeb per resp therapy\nDr. aware\n40% humidified face tent added\n4L np\nR: pt more comfortable con't having gd Sats, Neb being administered @ present.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-04-05 00:00:00.000",
"description": "Report",
"row_id": 1274330,
"text": "2.5MG Albuterol via neb/Mask X2 HR 88 RR 18 BS exp Wheeze O24L/min O2 sat99%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-04-05 00:00:00.000",
"description": "Report",
"row_id": 1274331,
"text": "Condition update A:\nROS - please refer to flowsheet.\n NEURO: Lethargic in am s/p 1Percocet at 0830 for c/o back pain. Pt more alert this afternoon. Oriented x3. MAE.\n\nCARDIO: Afeb. HR 60-70's cont's Afib w/ PAC's and PVC's. SBP<160. Denies CP. CVP 11-20.\n\nRESP: LS intermit coarse -> exp wheeze. RT providing neb tx's. Weak cough unable to raise secretions.\n\nGI/GU: NPO. Tol TF at goal. Resid 0cc. Scant stool in smears x2. Speach up for bedside swallow eval. Reccomending cont NPO until pt more alert for Barium swallow. Foley patent yellow clear urine. Lasix pNGT given w/effect.\n\nSKIN: RLE inc w/ staples intact w/ scant serosanguinous drainage. Perineum and (L) glut w/ ecchymosis slowly resolving. Pt tol OOB -> chr w/ PT.\n\nPLAN: Cont NPO and TF w/ mouthcare. Monitor RLE inc, change per orders. Monitor resp status, provide neb tx's prn. Monitor hemodynamics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-04-02 00:00:00.000",
"description": "Report",
"row_id": 1274324,
"text": "focus hemodynmics\ndata: pt lying bed in semi position. asking for swabs for his mouth. bp 140-160syst/ one unit of prbc infused. pt complaining of breathing difficulty. o2sats= 94-96%. abg done and ph 7.32-with po2-104. morphine 1mg iv given. co-3.2 ci- 2.1 with svr 1800. ho notified. dr in the room and spoke to pt as pt states he would like to die. dr explained condition and treatement for him. pt requesing that son be called and ho called son. cxr done.\n"
},
{
"category": "Radiology",
"chartdate": "2169-04-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758834,
"text": " 8:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess position of tip of central line -- line has been part\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p fem-tib bypass.\n REASON FOR THIS EXAMINATION:\n assess position of tip of central line -- line has been partially self d/c'ed\n by patient.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: S/P fem/tib bypass. Assess position of central line that has\n been partially pulled out by the patient.\n\n PORTABLE AP CHEST: Comparison is made to previous films from . The\n right sided central venous catheter has been slightly withdrawn with the tip\n now overlying the mid to distal SVC. The heart size and mediastinal/hilar\n contours are stable. The lung fields are unchanged in appearance since the\n previous exam. The soft tissues and osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1. Tip of right sided central venous catheter in satisfactory position,\n overlying the mid to distal SVC.\n\n 2. No interval change in the collapse/consolidation of the left lower lobe\n and air space opacities, predominantly involving the upper lung zones.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-04-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758915,
"text": " 5:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for infiltrate/effusion/CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p fem-tib bypass.\n REASON FOR THIS EXAMINATION:\n Eval for infiltrate/effusion/CHF\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest compaerd to 1 day earlier.\n\n INDICATION: Congestive heart failure symptoms. Post-operative patient.\n\n A right internal jugular central venous catheter remains in place, terminating\n near the junction of the superior vena cava and right atrium. Cardiac and\n mediastinal contours are stable. There is partial collapse of the right upper\n lobe. There are bilateral pleural effusions present and adjacent basilar\n opacities which probably reflect atelectasis. No definite congestive heart\n failure is identified.\n\n IMPRESSION: 1) Partial collapse of right upper lobe.\n\n 2) Persistent bilateral pleural effusions with interval increase compared to\n previous study.\n\n 3) No evidence of congestive heart failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-03-28 00:00:00.000",
"description": "F/U STATUS INFUSION/EMBO",
"row_id": 758129,
"text": " 7:48 AM\n UNI-LAT FEMORAL Clip # \n Reason: PLEASE DO PT IN AM\n Contrast: OPTIRAY Amt: 105\n ********************************* CPT Codes ********************************\n * F/U STATUS INFUSION/EMBO *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Followup TPA/heparin infusion.\n\n RADIOLOGISTS: Drs. , and . Drs. and ,\n radiologists, were present throughout the procedure.\n\n CONTRAST/MEDICATIONS: 105 ml of Optiray 320 at 30%; 0.5 mg versed and 75 mcg\n fentanyl in divided under continued hemodynamic monitoring.\n\n PROCEDURE/TECHNIQUE/FINDINGS: TPA infusion was discontinued at 1900 hours on\n , following son evidence of left ventricular thrombus. The\n wire was subsequently removed at the bedside, and the heparin dose was\n increased to 1000 units per hour.\n\n Through the existing 5 french sheath in the left groin, a sos Omni catheter\n was advanced over a wire into the right external iliac artery, and sequential\n right lower extremity arteriograms were obtained. At the level of the previous\n occlusion, there is improved filling through the superficial femoral artery\n down to the level approximately 1-2 cm distal to the adductor canal. At the\n adductor canal is a filling defect consistent with thrombus material. Just\n distal to this is a focal stenosis, followed by an abrupt occlusion of the\n distal SFA/above knee popliteal artery. There is improved vascular flow\n through collaterals over the mid thigh as well as over the calf. The below\n knee popliteal artery and trifurcation vessels are not visualized proximally.\n Distally, the caliber of the reconstituted anterior tibial artery appears\n larger than the previous arteriogram. There continues to be irregularity at\n the proximal portion of the dorsalis pedis artery, again with virtually no\n flow demonstrated at its mid/distal portion. Plantar vessels again do not\n fill. There is no filling of the arch vessels.\n\n IMPRESSION: Status post 6 hours TPA and 24 hour heparin infusion,\n demonstrating improved flow through the mid superficial femoral artery, with\n an occlusion demonstrated at the distal SFA/above knee popliteal artery. There\n is increased flow through collaterals of the thigh and calf, with a larger\n appearing anterior tibial artery in today's study relative to . \n filling of the mid/distal dorsalis pedis artery or plantar vessels.\n\n\n"
}
] |
12,135 | 197,838 | It was determined that the patient had end-stage liver disease and he was admitted to the Medical Service under Dr. . On , the patient underwent paracentesis to drain his markedly ascitic abdomen. This was repeated five times over the next few days. On one of these paracenteses, there was a culture that grew out Pneumococcus strep pneumoniae and the patient did have spontaneous bacterial peritonitis. On , the patient underwent an endoscopy examination which failed to reveal any varices. On , the patient received a Psychiatry consult which confirmed that the patient had a pre-existing major depressive disorder. At about this time, the patient was evaluated by the Transplant Surgery Team. After evaluation by the Transplant Surgery Team, the patient was deemed for a transplant and added to the liver donor list. On , a liver was obtained and the patient was pre-opped. On , the patient underwent a transplant operation by Dr. , Dr. , and Dr. . Please refer to the previously dictated operative note from by Dr. for the specific details of this operation. Immediately postoperatively, the patient was treated with intravenous antibiotics, vancomycin, and Zosyn as well as immunosuppressants, CellCept, Solu-Medrol, and Simulect. He was transferred to the unit where he stayed for the next few days. He was hemodynamically monitored. He received several transfusions for decreasing hematocrit and platelet transfusions for decreasing platelets. During this time, he also developed several bouts of postoperative atelectasis and was eventually diuresed with Lasix. By , postoperative day number seven, the patient was doing much better. His lungs were clear. He was hemodynamically stable. It was decided that he should be extubated and he was. He tolerated this well and on the next day, postoperative day number eight, the patient was stable enough to be transferred to the floors. In addition, it should be noted that during the patient's SICU stay, his nutritional status was maintained with total parenteral nutrition and once extubated he was able to be sustained on an oral diet which was slowly advanced while he was on the floor to a regular diet which he tolerated without nausea, vomiting, or abdominal pain. Once on the floor, the patient was evaluated by Physical Therapy. It was determined that he was stable enough and in good enough condition to be discharged home once he was cleared medically. Several radiologic studies were performed over the final few days of his admission, first on postoperative day number 13, , a cholangiogram was performed through the patient's T tube. This revealed a stricture at the biliary anastomosis. On the next day, the patient underwent ERCP and this previously mentioned stricture was dilated. Later on , a duplex ultrasound of the liver was obtained which showed adequate blood flow through the hepatic arteries and portal veins indicating the transplanted liver was well perfused. Therefore, on , hospital day number 33, postoperative day number 20, the patient is afebrile with stable vital signs. He is tolerating a solid oral diet, making good urine, and having good bowel movements. His abdominal examination is benign and his laboratory work from is as follows; white blood cell count 13.1, hematocrit 32.3, platelets 304,000. Chemistries: Sodium 137, potassium 4.3, chloride 104, bicarbonate 24, BUN 20, creatinine 1.6, glucose 80. Liver function tests: ALT 43, AST 29, alkaline phosphatase 261, total bilirubin 5.5, albumin 2.9, and his latest cyclosporin level was 351 on a 400 b.i.d. dose. He is being discharged home in good condition with the following discharge diagnoses. | 2) Patchy alveolar opacity including new or progressed right sided opacity. A left-sided subclavian catheter terminates in the upper SVC. Please hepatic vasculature, volumetrics, gadolinium for hepatoma, and MRC for question of obstruction. The gallbladder remains distended containing gallstones. Splenomegaly, ascites and patent umbilical vessel; findings consistent with portal hypertension. 5) Subdiaphragmatic right upper quadrant drain. There is stable cardiomegaly with slight worsening of vascular indistinctness and engorgement. There is contrast filling of the native and donor biliary ducts with evidence of a short segment of slightly irregular narrowing in the region of the anastomosis consistent with anastomotic stricture. There is now loss of translucency in the left upper lung zone with fluid seen tracking over the apex, consistent with a posterior layering pleural efffusion in this supine patient. 3) Left-sided posteriorly layering pleural effusion. Pulmonary artery catheter enters via the right internal jugular parallel to the separate venous access catheter, the tip appears to have been pulled back and now terminates in the proximal right main pulmonary artery. There is a surgical drain beneath the right diaphragm. IMPRESSION: 1) Cirrhotic liver, without focal masses. FINDINGS: A PA catheter placed via the right IJ terminates in the main pulmonary artery. There is a left subclavian central venous catheter in place with its tip in the superior vena cava. Status-post placement of biliary stent bridging region of anastomotic stricture. The liver is samll, with a slightly nodular contour consistent with cirrhosis. Right IJ central line is present with tip over distal SVC. There is lymphadenopathy around the celiac axis. Differential diagnosis includes atypical distribution of CHF, pneumonic infiltrate and ARDS. Assess for perforated bowel. 2) Partly resolved pulmonary infiltrates bilaterally, consistent with resolving pulmonary edema. Distinct right and left hepatic arteries are visualized. A right IJ cordis terminates in the distal right brachiocephalic vein. Findings consistent with mild colonic ileus. Right IJ swan ganz catheter is present with tip over right pulmonary artery. 4) Residual left effusion. response to diuresis. Beginning to developed compensated resp acidosis. Mild (1+)mitral regurgitation is seen. EKG ORDERED AND DONE. JP medial - site d/c/i - serosangious drainge. NG tube with tip beneath diaphragm. Follow up after diuresis. Most likely etiology is alveolar edema. NG tube is present, tip in the diaphragm. Respiratory Care:Pt. IMPRESSION: 1) Endotracheal tube tip terminates above level of the thoracic inlet. Pt rec'd at approx. FINAL REPORT INDICATION: Ascites. Since the previous tracingof right precordial T wave changes are seen. Right internal jugular sheath terminates in upper SVC. CONDITION UPDATEVSS. +PP'S. THIS A.M. C/O CPAIN - RADIATING "DOWN MIDDLE OF CHEST". Skin staples and right upper quadrant drain present. Left retrocardiac opacity with obscuration of left hemidiaphragm. MODERATE AMOUNT OF SEROSANG DRAINAGE AROUND LATERAL JP(#2) SITE, DRESSING CHANGED X2. Left subclavian venous access catheter terminates in upper SVC. REASON FOR THIS EXAMINATION: Please mark spot for paracentesis. CHEST, SINGLE AP PORTABLE VIEW: There is probable mild cardiomegaly. PA CATH D/C'D EARLIER TODAY.GI: ABD DISTENDED. FLEETS ENEMA GIVEN X1, DULCOLAX ENEMA GIVEN X1 - SMALL BOWEL MOVEMENT. LUNGS CTA BILAT. Respiratory note:Pt is intubated/agitated. TRANSFUSED WITH 1U PRBC'S, FOLLOW UP HCT 31. KUB done. HYDRALAZINE/LOPRESSOR CONTINUE. CONT PER CURRENT MGMT. CONT TPN. Tender in am on light palpation (HO notify). The inner dilator was removed. NGT TO LWCS - MIN CLEAR DRAINAGE OUT. Sinus rhythm. TRANSPLANT TEAM INFORMED.RESP: LS CLEAR BUT DIM AT BASES. agitation at times, mso4 2 mg ivp q1 prn. 7p-7a; Full assessment in flow sheet.neuro; A+OX3. M.D. The referring physician, . CONT CURRENT ICU CARE AND ASSESSMENT. Titrated to maintain BS btwn 80-120. IS GIVEN TO PT AND INSTRUCTED, BUT UNABLE TO USE CURRENTLY D/T GAS PAIN.CV: AFEBRILE. FINDINGS: An endotracheal tube terminates with tip 7.6 cm above the carina and located above the thoracic inlet. Afebrile. NURSING UPDATE TMAX 99, HR 70'S NSR, SLIGHT HTN SBP 170'S. NGT cont to LCWS with clear output. The ascending aorta is normal indiameter. pt weaned to cpap+ps - pt tol well, w/good abg's. c/w psv as tolerates, sbt in a.m. Suture site - d/c/i. ETT MOVED TO RIGHTSIDE OF MOUTH AND RETAPED. temp. b/s clear on rt, sl coarse lul. K+ AND ICA+ REPLETED. FORMODERATE AMTS. D/C PA in AM. condition updateneuro: pt seems oriented, nods appropriately, mea, gestures to communicate.cardiovasc: hypertensive to low 200's. ETT RETAPED AND MOVED TOLEFT SIDE OF MOUTH. NURSING UPDATE AFEBRILE, REMAINS MODERATELY HYPERTENSIVE WITH SBP 170'S. Resp Care Note, Pt remains on current vent settings. co/ci hr stable. RESPIRATORY CARE: PT. RESPIRATORY CARE: PT. B/S clear, Sx mod. CPAP 15/8 in am.gu/gi; soft distended abd. plan: cont w/mech support, wean ps as tol. see flow sheet for details.resp: abg's on cpap with po2 60's. ABG - wnl. Will cont to wean to extubate condition updateD: pt alert and oriented. REMAINS INTUBATED AND ONAN SIMV MODE AS PER CAREVUE. , RRT , RRT condition updateD: pt cooperative and follows commands. extubation SX. SX. REMAINS INTUBATED AND ONSIMV MODE AS PER CAREVUE. JP #1 - d/c/i - ss drainage. dr. aware. RSBI 113 this AM and probable extubation in AM. RESPIRATORY CAREPT REMAIN INTUBATED, and on vent support, thick yelow rusty sputm Sx,am RSBI 113 . slightly tachypneic on , incr to with good results. 7a-7p; Full assessment in flow sheet.neuro; A+OX3. PERL. continue to monitor I&o. lungs clear- left base, minimal secretions with sxn.Hemodynamics- cco pa in place- see flow sheet for #'s. ABG STABLE. dr. aware and in to see pt. extra ms04 dose of 2mg x1. FORRUSTY COLORED SPUTUM. STABLE ABG. start to wean vent today. CONDITION UPDATED: NEURO: ALERT AND APPEARS ORIENTED X 3. pt c/0 incisional pain. MSO4 1MG IVP FOR C/ /INCISION PAIN, PT LOCALIZING. max is 98.6. pa numbers are 30/14 and co is . incision continues to ooze serous/sanginous drainage. more diuresis today.r: doing well post transplant. DSD for JP site X3.skin intact. | 58 | [
{
"category": "Radiology",
"chartdate": "2147-10-18 00:00:00.000",
"description": "P ABDOMEN (SUPINE ONLY) PORT",
"row_id": 802213,
"text": " 5:27 AM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: please eval ileus vs obstruction\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p liver transplant with increasing abd dist\n REASON FOR THIS EXAMINATION:\n please eval ileus vs obstruction\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SINGLE FILM:\n\n HISTORY: Liver transplant and increasing abdominal distention.\n\n Gas is present throughout the colon and in the rectum. There are a few gas\n filled non-dilated loops of small bowel. No evidence for intestinal\n obstruction. The cecum is not undully dilated. NG tube is in cardia of\n stomach.\n\n IMPRESSION: No evidence for intestinal obstruction. Findings consistent\n with mild colonic ileus.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 802214,
"text": " 5:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, s/p liver\n transplant\n REASON FOR THIS EXAMINATION:\n pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant for hepatitis C cirrhosis. Evaluate\n pneumonic consolidation.\n\n FINDINGS: A single AP semiupright view. Comparison study dated . There is again evidence of left lower lobe collapse and consolidation and\n there has been slight resolution of the ill-defined infiltrate previously\n present in the partially aerated left upper lobe. There has also been slight\n resolution of the faint opacities in the right lower zone. The endotracheal\n tube, the NG line and the right IJ line remain in good position. The right IJ\n Swan-Ganz catheter tip is also well placed. No new pulmonary infiltrates are\n seen. Numerous skin staples overlie the left upper quadrant of the abdomen.\n\n IMPRESSION: Slight resolution of the infiltrates previously demonstrated in\n the left upper lobe and right lower zone. There is persistent left lower lobe\n collapse/consolidation. The heart shows slight LV enlargement but there is no\n evidence to indicate cardiac failure at this time.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-25 00:00:00.000",
"description": "ERCP S&I (74330)",
"row_id": 803599,
"text": " 10:58 PM\n ERCP S&I () Clip # \n Reason: R/O anastomotic stricture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p OLTX 2 weeks ago. Now with increased LFTs and T-Tube\n cholangiogram showing anastomotic stricture.\n Exam performed , req sent \n REASON FOR THIS EXAMINATION:\n R/O anastomotic stricture\n ______________________________________________________________________________\n FINAL REPORT\n History of recent liver transplant with increasing liver function studies and\n tube cholangiogram demonstrating anastomotic stricture.\n\n Four fluoroscopic spot films are provided. There is contrast filling of the\n native and donor biliary ducts with evidence of a short segment of slightly\n irregular narrowing in the region of the anastomosis consistent with\n anastomotic stricture. No significant dilatation of visualized ducts proximal\n to the narrowing. Status-post placement of biliary stent bridging region of\n anastomotic stricture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-24 00:00:00.000",
"description": "CHALNAGIOGRAPHY VIA EXISTING CATHETER",
"row_id": 802832,
"text": " 7:51 AM\n CATH CHEK/REMV Clip # \n Reason: S/P OTL\n Admitting Diagnosis: LIVER FAILURE\n Contrast: OPTIRAY Amt: 10\n ********************************* CPT Codes ********************************\n * CHALNAGIOGRAPHY VIA EXISTING C TUBE CHOLANGIOGRAM *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Status post orthotopic liver transplant, two weeks previously.\n First tube check.\n\n REFERRING PHYSICIAN; Dr. .\n\n RADIOLOGISTS: Dr. .\n\n PROCEDURE/FINDINGS: An antegrade cholangiogram was performed with only 10 cc\n of Optiray 320 60%. There was poor transit of contrast material from the\n catheter through the anastomosis, with all contrast refluxing into the biliary\n tree. This was followed by injection of cc of saline, at which time,\n contrast was visualized in the common bile duct. The findings suggest\n significant stricture at the anastomosis. The cystic duct fills proximal to\n the anastomosis. The biliary ducts are relatively decompressed and smooth in\n appearance.\n\n IMPRESSION: Findings suggesting a significant stricture at the anastomosis.\n Findings were discussed with Dr. at the time of the study.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-25 00:00:00.000",
"description": "DUPLEX DOPP ABD/PEL",
"row_id": 803043,
"text": " 3:03 PM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: eval portal vein, hepatic artery, & hepatic veins with B mod\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with history of hep C cirrhosis, s/p liver transplant, now\n with increasing bili.\n REASON FOR THIS EXAMINATION:\n eval portal vein, hepatic artery, & hepatic veins with B mode ultrasound please\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58 y/o man with history of Hep C cirrhosis status post liver\n transplant. Now with increasing bilirubin.\n\n LIVER ULTRASOUND: Comparison . The liver demonstrates normal echo\n texture without focal masses. There is normal direction of flow and waveforms\n within the portal vein, hepatic artery and hepatic veins. There is no\n ascites. There are no masses and there is no ascites.\n\n IMPRESSION: Doppler hepatic ultrasound demonstrates normal flow without\n evidence of mass or ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 802084,
"text": " 3:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval interval change\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n please eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Hepatitis C-cirrhosis. S/P liver transplant. Evaluate for\n interval change.\n\n VIEWS: Supine AP view is compared with semi-erect AP view from .\n\n FINDINGS: The ET tube, NG tube, right IJ Swan-Ganz catheter, second right\n internal jugular central venous line, and right-sided subdiaphragmatic\n surgical drain all remain in stable and satisfactory position. There is\n slight LV enlargement and upper zone redistribution, which is probably related\n to the patient's supine positioning. There continues to be left lower lobe\n collapse/consolidation. There is no change in the bilateral ill-defined\n patchy opacities. There is now loss of translucency in the left upper lung\n zone with fluid seen tracking over the apex, consistent with a posterior\n layering pleural efffusion in this supine patient. No pneumothorax is\n identified.\n\n IMPRESSION:\n 1) Slight LV enlargement and upper zone redistribution which may be related to\n patient's supine positioning, although mild LV failure cannot be excluded.\n\n 2) Persistent left lower lobe consolidation/collapse.\n\n 3) Left-sided posteriorly layering pleural effusion.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 801326,
"text": " 12:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for any evidence of abdominal free air.\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, has multiple paracentesis.\n Please assess for any free air under diaphragm.\n REASON FOR THIS EXAMINATION:\n Please assess for any evidence of abdominal free air.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hepatitis C cirrhosis, multiple paracenteses, please assess for\n free air under the diaphragm.\n\n VIEWS: Single AP portable upright view, comparison dated .\n\n FINDINGS: No free intraperitoneal air. Previously seen left-sided PICC line\n remains in stable and satisfactory position. The heart size, mediastinal\n contours, and pulmonary vasculature appear unchanged without congestive heart\n failure. Minimal linear atelectasis at the left base. No areas of focal\n consolidation. No pneumothorax. The visualized osseous structures are\n unchanged.\n\n IMPRESSION: No radiographic evidence of intraperitoneal free air. Minimal\n left lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-09 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 801344,
"text": " 3:16 PM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: Left lower quadrant tenderness, please rule out haematoma.\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with history of hep C cirrhosis, comes with rising bilirubin,\n worsening INR. Has had multiple paracentesis in the LLQ.\n REASON FOR THIS EXAMINATION:\n Left lower quadrant tenderness, please rule out haematoma.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hepatitis C cirrhosis with multiple prior paracenteses and pain\n in the left lower quadrant.\n\n LIMITED ABDOMEN ULTRASOUND: Selective evaluation was performed of the left\n lower quadrant. A moderate amount of ascites is present. No fluid\n collections are identified within the abdominal wall. The visualized loops of\n bowel are unremarkable.\n\n IMPRESSION:\n\n 1) Ascites.\n\n 2) No evidence of a hematoma.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-04 00:00:00.000",
"description": "UD GUID FOR NEEDLE PLACMENT",
"row_id": 800887,
"text": " 12:35 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Patient with advanced liver disease and INR 3+ needs venous\n Admitting Diagnosis: LIVER FAILURE\n ********************************* CPT Codes ********************************\n * UD GUID FOR NEEDLE PLACMENT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with liver failure from Hep C and likely SBP.\n REASON FOR THIS EXAMINATION:\n Patient with advanced liver disease and INR 3+ needs venous access for contrast\n MRI in anticipation of liver transplant. Has PICC but can't use for MRI\n contrast. No obvious peripheral access. Need is only temporary to facilitate\n study -- ext jugular or IJ or whatever you feel appropriate. Thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Liver failure from Hep-C. Likely SBP, INR greater than 3.\n Pulmonary medicine not able to place central line. Needs a peripheral IV to\n perform an MRI study.\n\n RADIOLOGISTS PERFORMING PROCEDURE: Dr. , Dr. ,\n staff radiologist supervised the procedure.\n\n PROCEDURE/TECHNIQUE: Ultrasound guidance was provided for placement of an 18\n gauge angiocatheter into the right antecubital vein. The angiocath was\n secured to the skin using Tegaderm and steristrips. The patient was sent to\n MRI for their injection.\n\n IMPRESSION: Successful placement of an 18 gauge angiocath in the right\n antecubital vein.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-06 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 801044,
"text": " 12:21 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: H/O ASCITES, CIRRHOSIS, HEP C. ? PERFORATION.\n Admitting Diagnosis: LIVER FAILURE\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with Hep C decompensated cirrhosis and ascites, s/p three\n paracentesis showing SBP. Also developing hepatorenal syndrome. Please give\n oral Gastrograffin contrast.Thank You.\n REASON FOR THIS EXAMINATION:\n Please evaluate for perforated bowel\n CONTRAINDICATIONS for IV CONTRAST:\n Developing Hepatorenal Syndrome\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Decompensated cirrhosis and ascites with SVP by paracentesis x 3.\n Assess for perforated bowel.\n\n Comparison: CT abdomen and pelvis and ultrasound \n\n TECHNIQUE: Contiguous axial images through the abdomen and pelvis were\n obtained following the administration of oral contrast. Intravenous contrast\n was not used due to patient's history of renal failure.\n\n ABDOMEN: There are dependent changes at both lung bases. There are no pleural\n effusions. The liver is samll, with a slightly nodular contour consistent with\n cirrhosis. There is a large amount of ascites within the abdomen. At least two\n gallstones are noted within the gallbladder. There are at least four stones\n within the left kidney, the largest of which measures 1.7 cm in greatest\n dimension and is located within the renal pelvis. No right-sided kidney stones\n are seen. The adrenal glands are not well visualized due to the ascites. The\n pancreas is grossly unremarkable within the limits of this unenhanced scan.\n Incomplete distension of right colon makes evaluation for previously described\n wall thickening limited. Contrast material passes to the level of the colon\n without obstruction. There is stool within the terminal ileum.\n\n PELVIS: There is a large amount of fluid within the pelvis. The bladder is\n unremarkable. Anasarca is present. There is no inguinal or pelvic lymph\n adenopathy.\n\n Bone windows: There are no suspicious lytic or sclerotic bony lesions.\n\n CT RECONSTRUCTIONS: These images confirm the above findings.\n\n IMPRESSION:\n No evidence of bowel perforation. Large amount of ascites. Thickening within\n the transverse and right colon as previously described difficult to confirm\n in view of incomplete distension of colon.\n\n (Over)\n\n 12:21 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: H/O ASCITES, CIRRHOSIS, HEP C. ? PERFORATION.\n Admitting Diagnosis: LIVER FAILURE\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-06 00:00:00.000",
"description": "PERSANTINE MIBI",
"row_id": 801057,
"text": "PERSANTINE MIBI Clip # \n Reason: CAD.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CAD.\n\n SUMMARY OF EXERCISE DATA FROM THE REPORT OF THE EXERCISE LAB:\n Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142\n mg/kg/min. Two minutes after the cessation of infusion, Tc-m sestamibi was\n administered IV.\n\n INTERPRETATION:\n\n Image Protocol: Gated SPECT.\n\n Resting perfusion images were obtained with thallium-201.\n Tracer was injected 15 minutes prior to obtaining the resting images.\n\n Stress images show normal left ventricular cavity size. There is normal tracer\n distribution and intensity.\n\n Resting perfusion images show no abnormality.\n\n Ejection fraction calculated from gated wall motion images obtained after\n Dipyridamole administration is 61%. There is normal wall motion.\n\n IMPRESSION: Normal pharmacological stress test. There is normal wall motion\n with an EF of 61%.\n\n /nkg\n\n\n , M.D.\n , M.D. Approved: MON 11:19 AM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-06 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 801126,
"text": " 8:20 PM\n CHEST (PA & LAT) Clip # \n Reason: Please evaluate for infiltrative process in pt growing Strep\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with decompensated Hep C cirrhosis with increasing bili,\n developed increased ascites and worsened liver function found to have SBP\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrative process in pt growing Strep Pneumo in ascitic\n fluid\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 50 y/o man with decompensated Hepatitis C cirrhosis. Please evaluate\n for infiltrative process in patient now growing strep.\n\n PA AND LATERAL CHEST: Comparison is made to prior chest exam of six days\n earlier. There is a left subclavian central venous catheter in place with its\n tip in the superior vena cava. There is no evidence of a pneumothorax. The\n patient has taken a poor inspiration and there is compressive atelectasis at\n both bases. I cannot rule out pneumonia.\n\n IMPRESSION: Expiratory film. No definite pneumonia. Compressive atelectasis\n at both bases.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 801648,
"text": " 12:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm line replacement\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n confirm line replacement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51 y/o man with history of hepatitis C and cirrhosis s/p liver\n transplant.\n\n Confirm line replacement.\n\n FINDINGS: An AP portable study of the chest at 12:29 HR and is compared with\n the previous study that was obtained at 5:10 a.m. The tip of the ETT is way\n above the carina. The left subclavian CVP line remains in place, the tip is in\n the superior vena cava. The tip of the Swan-Ganz catheter is in the right\n lower lobe branch of the right pulmonary artery at this time. Another right\n subclavian CVP line is in place the tip is in the right atrium at this time.\n Massive left pleural effusion is noted unchanged since the previous study. NG\n tube also remains in place.\n\n IMPRESSION: There has been advancement of the Swan-Ganz catheter to the right\n lower lobe branch of the pulmonary artery at this time. Also there has been\n advancement of the right subclavian CVP line the tip is in the right atrium at\n this time. The tip of the ETT is in proper position. The tip of the NG tube is\n in the mid gastric body.\n\n Massive right pleural effusion unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-09-30 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 800502,
"text": " 10:24 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Please evaluate for any liver mass, any evidence of vascular\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with history of hep C cirrhosis, comes with rising bilirubin,\n worsening INR.\n REASON FOR THIS EXAMINATION:\n Please evaluate for any liver mass, any evidence of vascular\n obstruction/thrombosis. Please also mark area for paracentesis. Thank you.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hx of hepatitis C cirrhosis now with rising bilirubin and\n worsening INR.\n\n RIGHT UPPER QUADRANT US: Limited evaluation was performed focusing on the\n liver, gallbladder, and bile ducts. A moderate amount of ascites is present in\n the abdomen. The liver is small and has a irregular contour consistent with\n cirrhosis. No focal masses are appreciated. The gallbladder is enlarged and\n there is a small amount of pericholecystic fluid. Sludge is present at the\n base of the gallbladder. There is no intra or extrahepatic ductal dilatation.\n There is normal portal venous flow.\n\n All four quadrants of the abdomen were imaged and a spot was marked in the\n left lower quadrant for paracentesis to be performed by the primary service.\n\n IMPRESSION:\n\n 1) Cirrhotic liver, without focal masses.\n 2) An enlarged gallbladder with pericholecystic fluid. These findings were\n observed on prior CT of and are likely related to the patient's\n chronic liver disease.\n 3) Sludge within the gallbladder.\n 4) A spot was marked in the left lower quadrant for paracentesis to be\n performed by the clinical service.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 801832,
"text": " 10:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n f/u\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: History of Hepatitis C cirhorris. status post liver transplant.\n\n CHEST, SINGLE AP VIEW\n\n An ET tube is present in satisfactory position 3.7 cm above the carina. Right\n IJ central line is present with tip over distal SVC. Right IJ swan ganz\n catheter is present with tip over right pulmonary artery. There is probably\n mild cardiomegaly. There are patchy alveolar opacities throughout both lungs\n most pronounced in the left mid and upper zones and right base. Possible small\n effusion but tracking left effusion seen on appears to have become\n much smaller. An NG tube is present with tip beneath diaphragm off film.\n Multiple upper abdominal surgical staples are noted.\n\n IMPRESSION:\n\n 1) Lines and tubes as described. Left subclavian line and PICC line have been\n removed in the interval.\n 2) Patchy alveolar opacity including new or progressed right sided opacity.\n Differential diagnosis includes atypical distribution of CHF, pneumonic\n infiltrate and ARDS.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 801955,
"text": " 5:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for pna\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n please eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Hepatitis C-cirrhosis. S/P liver transplant. Ck. for pneumonia.\n\n SINGLE AP SEMI-URIGHT VIEW: Comparison: .\n\n The heart again shows slight LV enlargement. There is evidence of upper zone\n redistribution. Bilateral ill-defined pulmonary infiltrates are again noted,\n significantly resolved since the prior study. There is persistent left lower\n lobe collapse/consolidation behind the heart. The left CP angle remains\n blunted suggesting a small effusion on this side. The right CP angle is\n sharp. The ET tube, right IJ Swan-Ganz catheter and the NG line all remain in\n good position. A second right IJ central line has its tip probably in the\n mid-SVC. There is a surgical drain beneath the right diaphragm.\n\n IMPRESSION:\n 1) Stable lines in satisfactory position.\n\n 2) Partly resolved pulmonary infiltrates bilaterally, consistent with\n resolving pulmonary edema.\n\n 3) Persistent left lower lobe collapse/consolidation.\n\n 4) Residual left effusion.\n\n 5) Subdiaphragmatic right upper quadrant drain.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 801716,
"text": " 4:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: follow effusions, consolidations\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n follow effusions, consolidations\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hep C cirrhosis s/p liver transplant following effusions and\n consolidation.\n\n VIEWS: Single AP portable supine view, comparison dated .\n\n FINDINGS: The ETT, NG tube, right IJ venous access catheter, and left\n subclavian venous access catheter remain in stable and satisfactory position.\n Left sided PICC line terminates in left brachiocephalic vein. Pulmonary artery\n catheter enters via the right internal jugular parallel to the separate venous\n access catheter, the tip appears to have been pulled back and now terminates\n in the proximal right main pulmonary artery. The heart size and mediastinal\n contours are unchanged. Slightly decreased aeration of both lungs. Persistent\n large layering pleural effusion appears somewhat increased in size. No\n pneumothorax. 2 tubular opacities, metallic skin staples, and surgical clips\n are seen overlying the upper abdomen.\n\n IMPRESSION: 1) Satisfactory position of lines and tubes. 2) Slightly increased\n size of large left pleural effusion with decreased aeration of both lungs.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-11 00:00:00.000",
"description": "DUPLEX DOPP ABD/PEL",
"row_id": 801545,
"text": " 1:26 PM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: assess liver transplant for intra and extrahepatic doppler f\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with history of hep C cirrhosis, s/p liver transplant\n REASON FOR THIS EXAMINATION:\n assess liver transplant for intra and extrahepatic doppler flow of hep art,\n portal vein, and hepatic veins as well as us of livers/p liver transplant\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status-post liver transplant.\n\n FINDINGS: The transplant liver demonstrates normal echogenicity. No\n intrahepatic biliary ductal dilatation.\n\n The main portal vein, as well as left and right portal veins demonstrate\n patency with proper direction of flow. The main hepatic vein, as well as the\n left and right hepatic veins demonstrate patency with proper direction of\n flow. The main hepatic artery and left hepatic artery demonstrate patency with\n proper direction of flow. The IVC is patent.\n\n IMPRESSION:\n Patent vasculature to the transplant liver.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 801608,
"text": " 5:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: follow for ?chf/ards\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n follow for ?chf/ards\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH:\n\n INDICATION: Continued shortness of breath post liver transplant.\n\n Comparison is made to a study from the prior day.\n\n FINDINGS:\n\n A PA catheter placed via the right IJ terminates in the main pulmonary artery.\n A right IJ cordis terminates in the distal right brachiocephalic vein. A\n left-sided subclavian catheter terminates in the upper SVC. The ETT is 4 cm\n above the carina.\n\n There is stable cardiomegaly with slight worsening of vascular indistinctness\n and engorgement. A right-sided pleural effusion has increased in size. The\n left-sided effusion appears stable. There is persistent opacification in the\n retrocardiac region. There are no new areas of consolidation.\n\n IMPRESSION:\n\n 1) Worsening of CHF and pulmonary edema.\n\n 2) Stable left lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-04 00:00:00.000",
"description": "MR ABDOMEN W&W/O CONTRAST",
"row_id": 800866,
"text": " 3:42 PM\n MR ABDOMEN W&W/O CONTRAST Clip # \n Reason: Please evaluate liver in pt with decomensated Hep C cirrhosi\n Admitting Diagnosis: LIVER FAILURE\n Contrast: MAGNEVIST Amt: 20CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with Hep C cirrhosis, DM, Migraine's, presents with elevated\n bili and decompensation\n REASON FOR THIS EXAMINATION:\n Please evaluate liver in pt with decomensated Hep C cirrhosis, evaluating for\n transplant. Please hepatic vasculature, volumetrics, gadolinium for hepatoma,\n and MRC for question of obstruction.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Cirrhotic patient. Evaluate for pretransplant.\n\n MRCP AND MRI OF THE ABDOMEN:\n\n TECHNIQUE: MRI of the abdomen was performed with multiplanar T1 in and out\n of phase, STIR, HASTE, 2D time of flight, thick slabs of T2W and dynamic T1W\n with fat saturated sequences before and after the administration of\n gadolinium. Multiplanar reconstruction was performed at the workstation.\n\n COMPARISON: CT of .\n\n FINDINGS: Images are acquired by non-breath hold technique, therefore\n degrading image quality. The liver is diffusely nodular with enlargement of\n the caudate lobe, consistent with cirrhosis. No focal hepatic enhancing\n lesions are identified. The portal vein is patent with hepatopetal flow. The\n origin of the celiac artery is not well visualized. Distinct right and left\n hepatic arteries are visualized. There is no evidence for an aberrant hepatic\n artery. There is a patent peri-umbilical vessel. The gallbladder remains\n distended containing gallstones. There is minimal pericholecystic fluid. The\n liver volume is 1690 cc.\n\n The pancreas is unremarkable. The spleen is enlarged, measuring at least 14\n cm. There is lymphadenopathy around the celiac axis. There is a large amount\n of intra-abdominal ascites.\n\n Within the visualized kidney, there is a single right cortical cyst. A 6 mm\n dark focus is noted within the left collecting system, correlating to a stone\n within the renal pelvis. There is no evidence of hydronephrosis. Peripelvic\n cysts are present in the left renal pelvis.\n\n Multiplanar reconstructed images were essential for confirming the vascular\n anatomy and establishing the liver volume.\n\n IMPRESSION:\n\n 1. Cirrhotic liver. No evidence for an arterial enhancing lesion or aberrant\n anatomy. Liver volume = 1690 cc's.\n (Over)\n\n 3:42 PM\n MR ABDOMEN W&W/O CONTRAST Clip # \n Reason: Please evaluate liver in pt with decomensated Hep C cirrhosi\n Admitting Diagnosis: LIVER FAILURE\n Contrast: MAGNEVIST Amt: 20CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Splenomegaly, ascites and patent umbilical vessel; findings consistent with\n portal hypertension.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 801488,
"text": " 6:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: central line\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\n REASON FOR THIS EXAMINATION:\n central line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hepatitis C cirrhosis. Status post liver transplant. Check\n central line.\n\n TECHNIQUE: Single AP portable supine view.\n\n Comparison study dated .\n\n FINDINGS: An endotracheal tube terminates with tip 7.6 cm above the carina\n and located above the thoracic inlet. Nasogastric tube extends below the\n diaphragm with tip terminating in the distal stomach. Right internal jugular\n sheath terminates in upper SVC. Pulmonary artery catheter enters via the\n right internal jugular vein parallel to the sheath and terminates with tip in\n the main pulmonary artery. Left subclavian venous access catheter terminates\n in upper SVC. Large left pleural effusion layers posteriorly and tracks to\n the apex. Left retrocardiac opacity with obscuration of left hemidiaphragm.\n The heart size and mediastinal contours appear unchanged without cardiac\n failure. No pneumothorax. Note is made of a drain in the right upper\n quadrant, and surgical clips and metallic skin staples overlying the right\n upper quadrant and upper abdomen.\n\n IMPRESSION:\n\n 1) Endotracheal tube tip terminates above level of the thoracic inlet. Other\n lines and tubes in satisfactory position. Large left pleural effusion and left\n lower lobe collapse and/or consolidation. No pneumothorax. Findings were\n communicated to the clinical team at time of interpretation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-03 00:00:00.000",
"description": "CVL/PICC",
"row_id": 800803,
"text": " 4:56 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: IV nurse for bedside PICC, but highly unlikely t\n Admitting Diagnosis: LIVER FAILURE\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with cirrhosis, possible SBP, requires albumin, may need\n antibiotics.\n REASON FOR THIS EXAMINATION:\n IV nurse for bedside PICC, but highly unlikely to be successful.\n Will call when confirmed.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: No IV access requiring IV antibiotics.\n\n RADIOLOGISTS: Dr. and Dr. , the staff radiologist,\n was present throughout the entire procedure.\n\n PROCEDURE/TECHNIQUE: Patient was placed supine on the angiography table with\n the left arm prepped and draped in the usual sterile fashion. Through an\n anesthetized skin approach utilizing realtime ultrasound guidance a micro-\n puncture set was used to access the left brachial vein. The measuring wire was\n advanced into the distal superior vena cava. The needle was then exchanged for\n the micropuncture dilator and peel-away sheath. The catheter was then\n appropriately sized to 38 cm. The inner dilator was removed. The catheter was\n then advanced over the wire into the distal SVC. The peel-away sheath was\n removed. The catheter was secured to the skin.\n\n Post procedure x-ray was performed and confirmed position within distal\n superior vena cava.\n\n CONTRAST/MEDICATIONS: 2 cc of 1% lidocaine for local anesthetic.\n\n COMPLICATIONS: None.\n\n IMPRESSION: Successful placement of a 38 cm single lumen vaxcel catheter in\n the distal superior vena cava via the left brachial vein.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-09 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 801347,
"text": " 3:40 PM\n US ABD LIMIT, SINGLE ORGAN; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: Please mark spot for paracentesis. Thank you.\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with history of hep C cirrhosis, comes with rising bilirubin,\n worsening INR. Has had multiple paracentesis in the LLQ.\n REASON FOR THIS EXAMINATION:\n Please mark spot for paracentesis. Thank you.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ascites.\n\n LIMITED ABDOMEN ULTRASOUND: All four quadrants of the abdomen were imaged and\n a spot was chosen in the suprapubic midline region for paracentesis. The spot\n was marked.\n\n IMPRESSION: Spot marked in the midline suprapubic region for paracentesis to\n be performed by the clinical team.\n\n The referring physician, . , was contact following the examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 801865,
"text": " 5:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u of morning cxr after diuresis\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n f/u of morning cxr after diuresis\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: S/P liver transplant for hep C cirrhosis. ? response to diuresis.\n\n CHEST, SINGLE AP PORTABLE UPRIGHT VIEW: Lordotic positioning.\n There are confluent opacities in a patchy distribution, but diffuse throughout\n both lungs. The left CP angle is obscured, suggesting a small pleural\n effusion. There is increased retrocardiac density. No gross right effusion\n is identified. Probable mild upper zone redistribution. Heart size upper\n limits of normal or slightly enlarged. Skin staples and right upper quadrant\n drain present. ET tube in satisfactory position above carina. NG tube with\n tip beneath diaphragm.\n\n IMPRESSION:\n 1) Patchy confluent alveolar opacities throughout both lungs with largest\n area of confluent opacity at left base. While this could represent residual\n alveolar edema, the possibility of multifocal infectious infiltrate or ARDS\n should be considered. Please note that, on the right side, these opacities\n have relatively peripheral distribution.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-10-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 801893,
"text": " 4:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u after diuresis\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with history of hep C cirrhosis, s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n f/u after diuresis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hep C cirrhosis status post liver transplant. Follow up after\n diuresis.\n\n CHEST, SINGLE AP PORTABLE VIEW:\n\n There is probable mild cardiomegaly. There is diffuse alveolar opacity, more\n confluent than on the film from one day earlier. There is a probable small\n left pleural effusion. There is increased retrocardiac density. The ET tube\n tip is at the level of the upper clavicular heads, slightly high, 6.9 cm from\n the carina. NG tube is present, tip in the diaphragm. A SG catheter is\n present, tip over right pulmonary artery. An additional right IJ line appears\n present, but tip is obscured. No pneumothorax was detected.\n\n IMPRESSION:\n\n Confluent alveolar opacity diffusely throughout both lungs, with small left\n effusion. Most likely etiology is alveolar edema. This appears more\n extensive than on the film from one day earlier.\n\n Left lower lobe collaspe and/or consolidation, unchanged.\n\n Relatively high position of the ET tube. Clinical correlation regarding\n possible advancement is requested.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2147-10-02 00:00:00.000",
"description": "Report",
"row_id": 102839,
"text": "PATIENT/TEST INFORMATION:\nIndication: Murmur.\nHeight: (in) 69\nWeight (lb): 175\nBSA (m2): 1.95 m2\nBP (mm Hg): 134/72\nStatus: Inpatient\nDate/Time: at 16:03\nTest: TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter. The aortic arch is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: Mild (1+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: No tricuspid regurgitation is seen. The pulmonary artery\nsystolic pressure could not be determined.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. Mild (1+)\nmitral regurgitation is seen. The pulmonary artery systolic pressure could not\nbe determined. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2147-10-19 00:00:00.000",
"description": "Report",
"row_id": 313229,
"text": "Sinus rhythm. T wave inversions in leads V1-V2 are non-specific and could be in\npart, positional. Clinical correlation is suggested. Since the previous tracing\nof right precordial T wave changes are seen.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-11 00:00:00.000",
"description": "Report",
"row_id": 1421784,
"text": "nsg note\nPt is s/p liver transplant:\n\nNeuro- propofol off on arrival from OR this am at 615- waking up by 11 am and beginning to follow some simple command. agitation at times, mso4 2 mg ivp q1 prn. 3 pm becoming extremly agitated, swinging head and kicking legs with attempts to get oob, attempting to hit staff, req 3 assist to prevent from extubating or pulling out pa line, transplant notified and propofol gtt started, cont agitated and attempt to pull at ett, (bilat swr on)- trnasplant to restart methadone as pt was on it preop.\n\nRenal- uo 50- 110 hr, cr 1.6, ivf 100hr.\n\nEncocrine- glucose as high as 340, insulin gtt with prn insulin bolus, to get glucsoe <130, glucose at 3 pm 108, cont 2 u insulin gtt/hr, chemsticks q1.\n\nLiver u.s done at bedside, all labs done q4 pr md orders, rec 3 prbc, 6 ffp and 1 5pk platelet this shift, jp x2, t tube to gravity.\nPa line in place, c.0 , see flow sheet for all other #s\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-12 00:00:00.000",
"description": "Report",
"row_id": 1421785,
"text": "NURSING UPDATE\n TMAX 99, HR 70'S NSR, SLIGHT HTN SBP 170'S. CCO ELEVATED 8.8-10.8, SVR DIMINSHED 688-880.\n TRANSFUSED WITH 1U PRBC'S, FOLLOW UP HCT 31. PLTS 73, TX WITH 1 5-PACK PLATELETS, FOLLOW UP PLTS 89, DR AWARE, PLAN TO TRANSFUSE ANOTHER 5-PACK WHEN AVAILABLE. DR AWARE OF DIMINISHED K+ AND MG+ LEVELS, NO REPLETIONS ORDERED. BLOOD GLUCOSE MANAGED ON INSULIN GTTS.\n VERY AGITATED EARLY EVENING, ATTEMPTING TO SIT UP IN BED AND CONSTANTLY TRYING TO REACH ETT, IV'S AND DRAINS EVEN THOUGH RESTRAINED. PROPOFOL GTTS INITIALLY INCREASED AND MSO4 2MG ADMINISTERED IV Q2 PER PRN ORDER. ON THIS REGIMEN, WAS ABLE TO WEAN PROPOFOL DOWN TO DESIRED RATE OF 55MCG/KG/MIN AND MAINTAIN AS SAME. BRIEF BREAKTHROUGH PERIODS OF AGITATION AND RESTLESSNESS THROUGHOUT NOC, BUT MUCH MORE MANAGEABLE, AND ENVIRONMENT SAFER FOR PT AND STAFF. PT OPENING EYES AND FOLLOWING COMMANDS INCONSISTENTLY. SHAKING/NODDING HEAD IN RESPONSE TO QUESTION @ TIMES ALSO.\n MODERATE AMOUNT OF SEROSANG DRAINAGE AROUND LATERAL JP(#2) SITE, DRESSING CHANGED X2. DRAINS STRIPPED AND EMPTIED Q2.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-12 00:00:00.000",
"description": "Report",
"row_id": 1421786,
"text": "Resp Care: Pt remains on vent,SIMV/PS with the only changes to the RR.\nPt's RR was decreased from 12 to 8 without incident,ABG is within normal limits.B/S coarse and sl decreased with sct rhonchi.The plan is\nto continue wean.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-12 00:00:00.000",
"description": "Report",
"row_id": 1421787,
"text": "nsg progress note\nNeuro- sedated with propofol gtt, withdraws to pain, weaning propofol as tol this pm, cont mso4 1 mg prn q1, methadone changed to 45 mbg , psych svc by to see pt this am.\n\nResp- failed cpap trial this am as rr up to 40, return to simv, abg wnl, minimal secretions with sxn, lungs cta bilat. will attempt to wean to cpap again in am.\n\nHemodynamics- pa advanced to 55, pcwp 14-17. cvp 9-13, rec lasix 40 mg iv x2. See flow sheet for u.o.\n\nLft's cont to decrease, hct, platelet and inr all within transplant team acceptable range so no blood products this shift.\n\nNutrition- npo, hypo bs, tpn started.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-18 00:00:00.000",
"description": "Report",
"row_id": 1421811,
"text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nASSUMED CARE OF PT AT APPROX 1600.\nNEURO: ALERT AND ORIENTED X3. MEDICATED WITH MSO4 FOR ABD PAIN WITH POS EFFECT. PT NOW C/O GAS PAIN. TRANSPLANT TEAM INFORMED.\nRESP: LS CLEAR BUT DIM AT BASES. PT . O2SATS 98-100% ON 3LNC. IS GIVEN TO PT AND INSTRUCTED, BUT UNABLE TO USE CURRENTLY D/T GAS PAIN.\nCV: AFEBRILE. NSR. +PP'S. HYDRALAZINE/LOPRESSOR CONTINUE. PA CATH D/C'D EARLIER TODAY.\nGI: ABD DISTENDED. POS BOWEL SOUNDS. GAS PAIN. DK GOLDEN BILE VIA T-TUBE. SEROSANG DRG VIA MEDIAL JP.\nGU: AMBER U/O VIA FOLEY.\nENDO: FSBG COVERED PER RISS.\nPLAN: ENCOURAGE T/C/DB AND IS USE. INCREASE ACTIVITY. ?DULC SUPP V. ENEMA (AWAITING ORDERS FROM TRANSPLANT). CONT PER CURRENT MGMT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-19 00:00:00.000",
"description": "Report",
"row_id": 1421812,
"text": "CONDITION UPDATE\nVSS. PT A/OX3. FREQUENT C/O ABD PAIN - TX'D W/ MORPHINE W/ EFFECT. THIS A.M. C/O CPAIN - RADIATING \"DOWN MIDDLE OF CHEST\". TXPLANT RESIDENT, DR. NOTIFIED. EKG ORDERED AND DONE. M.D. NO CHANGE IN EKG NOTED. NGT TO LWCS - MIN CLEAR DRAINAGE OUT. LUNGS CTA BILAT. O2 SAT GOOD ON 3L N.P. ABD SOFTLY DISTENDED. BOWEL SOUNDS PRESENT. PT C/O FREQUENT GAS PAIN. FLEETS ENEMA GIVEN X1, DULCOLAX ENEMA GIVEN X1 - SMALL BOWEL MOVEMENT. PT W/ 40MG IV LASIX W/ GOOD EFFECT. REMAINS ON INSULIN DRIP - BSUGARS LABILE. CONT TPN. CONT TO ASSESS FOR S/S OF INFECTION/ BLEEDING. PAIN MANAGEMENT. PT TEACHING. CONT CURRENT ICU CARE AND ASSESSMENT. D/C PLANNING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-11 00:00:00.000",
"description": "Report",
"row_id": 1421782,
"text": "Pt rec'd at approx. 0600 following liver transplant. Pt placed on CMV 700,12,100, 5 peep. ABG results pending.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-11 00:00:00.000",
"description": "Report",
"row_id": 1421783,
"text": "Respiratory note:\nPt is intubated/agitated. ETT advanced in 2cm and taped at 25cm at the lip. Noted to have frequent cuff leak.Tol psv trial on ps 20/5 peep for a while with good abg but than tachypenic with RR up to back on simv. Will obtain ABG on current simv 750x12,50%,5peep,0ps.Will cont vent support and wean as tol to extubate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-17 00:00:00.000",
"description": "Report",
"row_id": 1421806,
"text": "resp care:pt remains intubated and vented at this time with no resp distress noted.b/s diminished bilat,secretions minimal.present vent settings ps10 peep5 40% and tol well.will cont to re-assess as needed and wean as tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-17 00:00:00.000",
"description": "Report",
"row_id": 1421807,
"text": "Condition Update\nD: See carevue for specifics\n Swan remains in place with CCO monitoring. Afebrile. HR 60's NSR no ectopy. BP 140's/60's. CVP 6-8. For today the plan was to continue to diurese patient. Pt received 40mg lasix this am with good diuresis. Currently -2L for the day. Transplant team wanting pt more negative prior to making any major vent changes. However patient tolerating vent changes well and as previously mentioned is -2L for the day. AM RSBI 40's. ABG's stable throughout day. Beginning to developed compensated resp acidosis. Gradually decreased vent to current settings of CPAP with 10PS, 5PEEP, FIO2 40%, RR 16-20, with spont tidal volumes 500's. Minimal secretions in afternoon in am noted to have some thick yellow.\n Transplant resident plans to D/C lateral drain this eve (putting out min amts), no change in color other JP or Ttube. NGT cont to LCWS with clear output. ABD dressing leaking ?from around lateral tube site (serous).\n Pt comfortable and reporting good pain control with MSO4 4mg Q3-4hrs. A/Ox3. MAE.\n Continues on insulin gtt for blood sugar control. Titrated to maintain BS btwn 80-120. Cont on TPN for nutrition.\nPLAN:\n Check with transplant team re: goal for diuresis\n Wean vent as tol\n Cont pain management with MSO4\n Frequent blood sugars\n Notify H.O. with any changes.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-18 00:00:00.000",
"description": "Report",
"row_id": 1421808,
"text": "Respiratory Care:\nPt. had a quiet noc untill about 5 am when he C/O pain and discomfort.\nRn gave pain meds.\nPt's RSBI = 25 and was subsequently placed on a spontanious breathing trial. up to two hours if tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-18 00:00:00.000",
"description": "Report",
"row_id": 1421809,
"text": "7p-7a; Full assessment in flow sheet.\n\nneuro; A+OX3. MAE. mouth words. Follow commands. Pain in abd. Inc pain in AM - HO and transplant MD notify - KUB and Biscodyl supportory order and done. Morphine ivp effective.\n\ncv; VSS, afebrile. CVP 6-8. Svo 2 80-88. CCO 7.2-9.8 (HO and neurosurg notify.). Swan unable to wedge - Dr. notify.\n\nresp; Clear in upper lobes. dimish at bases. CPAP 10/5 tolerate, do not breath over vent. Encourage deep breath and cough - productive cough thick/white sputum.\n\ngu/gi; soft distended abd. Tender in am on light palpation (HO notify). +BSX4. KUB done. no flatus. no bm. JP medial - site d/c/i - serosangious drainge. T-bile - bilious. NG - +placement, clear drainage. suture site d/c/i.\n\nint; Skin intact. Insulin drip titrate 80-120. AM lab done - potassium replace.\n\nPlan; Continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-18 00:00:00.000",
"description": "Report",
"row_id": 1421810,
"text": "Respiratory Care Note:\n Patient weaned and extubated today. BS with good aeration. Cough and voice intact. SpO2 100% on 40% FIO2 and plan to wean as tolerated and use of incentive spirometer.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-16 00:00:00.000",
"description": "Report",
"row_id": 1421800,
"text": "condition update\nD: pt alert and oriented. he follows commands. temp. max is 98.6. pa numbers are 30/14 and co is . svo2 remains 76-80. pt more comfortable on 4mg of ms04 requiring it appoximately every 2 hours. abgs remain good on simv. urine output remains greater than 100cc/hr and pt was 1800 neg for past 24hrs. sbp still greater than 200 after starting on lopressor and being medicated with ms04 for pain. dr. aware and pt given hypralozine 10mg x 2. sbp to 180-190. pt suctioned frequently for thick yellow sputum. incision continues to ooze serous/sanginous drainage. lateral jp drainage appears more bloody this evening. dr. aware and in to see pt. insuling drip titrated for blood sugars. pt is currently on 1unit/hour. platelet count 71. pt transfused with one unit of platelets.\na: monitor fluid status. medicate for pain as needed. continue to monitor jp drainage. ? start to wean vent today. ? more diuresis today.\nr: doing well post transplant. post transfusion count 98. pt appears more comfortable today on 4mg of ms04 for pain. jp continue to put out bloody drainage but amt has not increased. Approximately 20cc. dr. aware.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-16 00:00:00.000",
"description": "Report",
"row_id": 1421801,
"text": "RESPIRATORY CARE\nPT REMAIN INTUBATED, and on vent support, thick yelow rusty sputm Sx,am RSBI 113 .\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-16 00:00:00.000",
"description": "Report",
"row_id": 1421802,
"text": "See CareVue for objective data.\n\nVent settings changed to 15 PS/8PEEP. Tolerated well and ABG's adequate. RSBI 113 this AM and probable extubation in AM. Diuresised with a total of 60 mg lasix IV with excellent results. See CareVue for total I&O.\nPA #'s remain relatively the same. ? D/C PA in AM. NSR-no ectopy.\nHydralazine added to therapy 10 mg Q6H for BP control.\nTPN infusing as ordered.\nLeft JP drain leaking large amts of serosangious fluid around tube.\nDSD changed Q2-3H.\nMedicated with MSO4 for C/O left quadrant abdominal pain. Also, receives methadone .\nPlts at 1400: 110 which is adequate and no intervention required at this time.\nInsulin gtt remains and see CareVue for FSBS/titration of gtt.\nAlert/oriented/cooperative.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-16 00:00:00.000",
"description": "Report",
"row_id": 1421803,
"text": "resp care\npt remains intubated and mech ventilated. pt weaned to cpap+ps - pt tol well, w/good abg's. b/s clear on rt, sl coarse lul. plan: cont w/mech support, wean ps as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-17 00:00:00.000",
"description": "Report",
"row_id": 1421804,
"text": "Respiratory Care\nPt remain intubated and on vent support, changed to SIMV for over night rest.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-17 00:00:00.000",
"description": "Report",
"row_id": 1421805,
"text": "7a-7p; Full assessment in flow sheet.\n\nneuro; A+OX3. Follow directions. MAE. Good cough and gag reflex. PERL. Pain in abd - morphine ivp given - good effect. Slept on and off most of night.\n\ncv; VSS, afebrile. Warm, dry, no edema.\n\nresp; Clear in upper lobes. dimish at bases. SIMV to rest at night. Did not overbreath. ABG - wnl. CPAP 15/8 in am.\n\ngu/gi; soft distended abd. +BSX4. Suture site - d/c/i. JP #2 - leaking (HO and trasplant team aware) - more bloody drainage. JP #1 - d/c/i - ss drainage. T-bile - bile drainage. NG - +Placement, negative guiac, bilious drainage. DSD for JP site X3.\n\nskin intact. Insulin drip. AM lab and night lab done - no new order for lytes replacemnet from HO.\n\nPlan; continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-13 00:00:00.000",
"description": "Report",
"row_id": 1421788,
"text": "NURSING UPDATE\n AFEBRILE, REMAINS MODERATELY HYPERTENSIVE WITH SBP 170'S. K+ AND ICA+ REPLETED. CONT ON INSULIN GTTS.\n AWAKE AND APPROPRIATE, NO AGITATION OR RESTLESSNESS. COOPERATIVE WITH CARE. PROPOFOL WEANED TO OFF BY 0500. MSO4 1MG IVP FOR C/ /INCISION PAIN, PT LOCALIZING.\n PLATELETS 88 @ 1800, TRANSFUSED WITH 1 5-PACK PLATELETS, POST TX LEVEL 109.\n PICC LINE OCCLUDED, DISCONTINUED PER DR .\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-15 00:00:00.000",
"description": "Report",
"row_id": 1421796,
"text": "condition update\nD: pt cooperative and follows commands. pt remains hypertensive to 200 and co is 8 and sv02 is 80. pt treated with second does of iv lasix 40mg with good diuresis. he was 2400 negative for the day. platelets remain greater than 100 and hct was 37 at 2200. po2 down to 77 on 50% and 5 of peep. peep increased to 7.5. pt suctioned for rust colored sputum. pt c/0 incisional pain. he remains on methadone . pt appears uncomfortable splinting stomache and wincing. when asked he states that he is in pain. pt continues to receive 2mg of mso4 q1hr pt still uncomfortable after receiving dose at 2am.\na: dr. aware and ordered. extra ms04 dose of 2mg x1. continue to monitor I&o. check labs as ordered.\nr: pt still uncomfortable with mso4. ? change to different pain med when team rounds. incision continues to drain large amts of serous/sanginous drainage. frequent dsg changes done. urine output remains good after lasix dose.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-15 00:00:00.000",
"description": "Report",
"row_id": 1421797,
"text": "Resp Care Note, Pt remains on current vent settings increased to 8 peep for low PaO2. RSBI 40.8. Suctioning mod amts thick bile looking secretions. Having belly pain otherwise stable. Will cont to monitor resp status for further weaning\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-15 00:00:00.000",
"description": "Report",
"row_id": 1421798,
"text": "RESPIRATORY CARE: PT. REMAINS INTUBATED AND ON\nAN SIMV MODE AS PER CAREVUE. ABG STABLE. SX. FOR\nMODERATE AMTS. OF RUSTY SPUTUM. ETT MOVED TO RIGHT\nSIDE OF MOUTH AND RETAPED. PLATEAU PRESSURES ARE\nBETWEEN 30 - 34 CM H2O - WILL MONITOR AND LOWER\nTIDAL VOLUME TO 700 CC IF NECESSARY IF LIVER\nAND SICU TEAM AGREES.\n\n , RRT\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-15 00:00:00.000",
"description": "Report",
"row_id": 1421799,
"text": "CONDITION UPDATE\nD: NEURO: ALERT AND APPEARS ORIENTED X 3. FOLLOWING COMMANDS, COOPERATIVE\nCV: CONTINUES TO BE HYPERTENSIVE TO 200 SYSTOLIC- STARTED ON LOPRESSOR 5MG IV Q6HRS, OTHER VSS- SEE CAREVUE FOR SPECIFICS\nRESP: BS REMAIN COARSE IN UPPER AIRWAYS AND DIMINISHED IN BASES. SX FOR RUST COLORED SPUTUM. NO VENT CHANGES- ABG IMPROVED AFTER DIURESIS\nGI: NPO, ABD SOFT AND NON-TENDER, + FLATUS, NO STOOL, NGT PATENT AND DRAINING BILIOUS, LESS DRAINAGE FROM AROUND LATERAL JP THIS AFTERNOON.\nGU: LASIX 40 MG IV X 1 WITH GOOD DIURESIS\nENDO: CONTINUES ON INSULIN GTT AT 2-5UNITS PER HR\nA: PAIN MED INCREASED TO 4MG IV Q1HR PRN WITH SOME IMPROVEMENT IN PT COMFORT, HEMODYNAMICS MONITORED\nR: STABLE, CONTINUE TO DIURESIS\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-13 00:00:00.000",
"description": "Report",
"row_id": 1421789,
"text": "Resp care\nPt remains intubated & supported, placed on SIMV/PS mode\nover night. B/S clear, Sx mod. amounts of thick bloody\nsecretions. RSBI= 87, Pt currently on SBT\nPlan: poss. extubation\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-13 00:00:00.000",
"description": "Report",
"row_id": 1421790,
"text": "nsg note\nNeuro- propofol off since 5 am- mso4 prn, follws simple command, moves all ext on bed.\n\nResp- attempt to wean to cpap 5/5 but rr up to 35-40- ips increased to 10- abg wnl. lungs clear- left base, minimal secretions with sxn.\n\nHemodynamics- cco pa in place- see flow sheet for #'s. cvp 9-12, uo 50-80, ivf tko.\n\nlft cont to decrease, platelet count noon labs 76- rec 1 5pk, creatanine 2.0, no lasix today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-13 00:00:00.000",
"description": "Report",
"row_id": 1421791,
"text": "Resp care\nremains ett/vent support in psv mode. slightly tachypneic on , incr to with good results. still volume overloaded, no further weaning done today. sxned scant sma amts brownish secretions. c/w psv as tolerates, sbt in a.m.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-14 00:00:00.000",
"description": "Report",
"row_id": 1421792,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for further details. RSBI 91.7. suction lrg amts thick rusty bile looking secretions. Awake and alert. Will cont to wean to extubate\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-14 00:00:00.000",
"description": "Report",
"row_id": 1421793,
"text": "condition update\nneuro: pt seems oriented, nods appropriately, mea, gestures to communicate.\ncardiovasc: hypertensive to low 200's. co/ci hr stable. see flow sheet for details.\nresp: abg's on cpap with po2 60's. changed to simv, will recheck abg after 30 mins. sx for thick rust colored sputum.\ngi: min bowel sounds.\ngu: u/o good.\nincision: jp's milked q 1 hr, draining minimally, leaking profusely from around lateral jp.\nPAIN issues: pt c/o pain in abd, around incision. med q 2 hrs with ms 1 mg iv. pt has minimal pain relief. methadone 45 mg po bid.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-14 00:00:00.000",
"description": "Report",
"row_id": 1421794,
"text": "condition update\nd: neuro: alert, appears oriented, cooperative, mae to command\nresp: changed to simv early in am secondary to poor abg and tiring, bs clear in upper airways but diminished in bases, sx for rust colored sputum- cx sent\ngi: abd soft, hypoactive bs, no stool\ngu: lasix 40 mg iv x1 with good diuresis\nendo: bs tx'd with insulin gtt- see carevue for specifics\ncv- remains hypertensive- team aware, other vss- see carevue for specifics\na: hemodyanmics monitored, cxr done x2\nr: stable at present,\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-10-14 00:00:00.000",
"description": "Report",
"row_id": 1421795,
"text": "RESPIRATORY CARE: PT. REMAINS INTUBATED AND ON\nSIMV MODE AS PER CAREVUE. STABLE ABG. SX. FOR\nRUSTY COLORED SPUTUM. ETT RETAPED AND MOVED TO\nLEFT SIDE OF MOUTH.\n\n , RRT\n"
}
] |
15,876 | 119,894 | A/P: 72 yo woman c T2 DM, HTN, admitted c elevated BS up to 400, metabolic acidosis c hyperkalemia , renal failure, UTI and respiratory failure most likely d/2 aspiration and heart failure. . #Respiratory failure- Patient was intubated at OSH after witnessed aspiration event after receiving kayexelate. She remained intubated after transfer initially and was slowly weaned off the ventilator. Once her metabolic status was improved, she was extubated. Post extubation she continued to have high oxygen requirement with one or two episodes of desaturation. CXR was consistent with volume overload and she was given lasix for diuresis. She diuresed well with IV lasix and her O2 requirement improved. She was also treated with levoflox for aspiration Pneumonia. . # Hyperkalemia - at OSH, patient was given Calcium gluconate, bicarb. Renal was consulted on transfer to ICU. They recommended IVF and lasix, along with calcium, bacarbinate,insulin, glucose, albuterol and kayexalate. Her potassium steadily improved and by the following day she was hypokalemic. It was unclear why patient was hyperkalemic, not clearly medication related. She had elevated blood sugars on admission and acute renal insufficiency. . # Renal failure- Initially her renal function improved with aggressive iv fluids and then tapered off. She was diresed and her renal function improved to 1.7 on day of discharge. Prior to discharge she was started on Losartan. Her potassium and renal function should be monitored closely. . # CHF- Initially given concern for infection and elevated lactate she received aggresive IV fluids. After high O2 requirements post extubation she was given lasix for diuresis. Her oxygen saturation improved drastically. Echo was done which showed EF 40-45%. She was also restarted on her and hydral/imdur were added for afterload reduction. Aspirin was continued. Her creatinine and potassium should be monitored daily. . # UTI - Urine with GPC, She received a 7 day course of Vancomycin. . # T2DM - Cont SSI. She should be restarted on her PO diabetic regimen after discharge. # FEN - Patient received tube feeds while she was intubated. Post extubation she underwent a Speech and Swallow evaluation given her history of aspiration pneumonia. Her swallow eval was ok and her diet was advance to po diet. | Paradoxic septal motion consistent with conductionabnormality/ventricular pacing.AORTA: Mildly dilated aortic root. Likely left pleural effusion. Mild (1+) mitral regurgitation is seen. Breaths unlabored.Caridac: Rare ectopy on monitor. Mild mitral annularcalcification. Mildly dilatedascending aorta.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a low risk (prophylaxis not recommended). There is mild symmetric left ventricularwall hypertrophy with normal cavity size. Mild mitral regurgitation. The aortic root is mildly dilated. There is mild symmetric leftventricular hypertrophy with normal cavity size. Again note is made of patchy bibasilar opacity. Again note is made of endotracheal tube and nasogastric tube, unchanged compared to the prior study. Remains hypertensive with sbp 130-160's. Mild (1+) MR.TRICUSPID VALVE: Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Now extubated presenting with right lower lung crackles. Shortness of breath.Height: (in) 69Weight (lb): 192BSA (m2): 2.03 m2BP (mm Hg): 158/64HR (bpm): 73Status: InpatientDate/Time: at 10:38Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.RIGHT VENTRICLE: Normal RV chamber size. Overall systolic function is mildly reduced.Right ventricular cavity size is normal. Otherwise, unremarkable evaluation of the kidneys. IMPRESSION: Persistent low lung volumes status post extubation. Again note is made of patchy bibasilar opacity with low lung volumes. Borderline normal RV systolicfunction. Based on AHA endocarditis prophylaxis recommendations, the echo findings indicate a lowrisk (prophylaxis not recommended). Septal motion is abnormal(?related to IVCD/postoperative). There is no pericardial effusion.IMPRESSION: Mild symmetric left ventricular hypertrophy with mildly reducedleft ventricular systolic function. First degree A-V delay. Quad lumen in L subclavian site benign.ID: Continues on levofloxacin. SINGLE PORTABLE AP SUPINE VIEW OF THE CHEST: The endotracheal tube terminates at the thoracic inlet. Low lung volumes are again demonstrated which exaggerate the heart size which is probably normal. Normalascending aorta diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). IMPRESSION: Distended loops of colon to the sigmoid without air in the rectum. The aortic valve leaflets (3) aremildly thickened but aortic stenosis is not present. Baseline artifactSinus rhythmFirst degree A-V delayProbable left atrial abnormalityLeft bundle branch block with intermittent left axis deviationSince previous tracing of , intermittent shift of axis to left axisdeviation now present FINDINGS: The central venous line from left subclavian vein is terminating in upper SVC. No AR.MITRAL VALVE: Normal mitral valve leaflets. Bilateral lower lobe atelectasis. Elevation of the right hemidiaphragm. R lower lung crackes. R lower lung crackes. IMPRESSION: AP chest compared to : Lung volumes remain quite low due to marked elevation of the diaphragm or perhaps function of intestinal distention, is seen in the upper abdomen. The left hilum is prominent as before. AM lytes pending voiding 150-220cc/hr via foley.Derm: Grossly intact. There is bilateral lower lobe atelectasis. FINDINGS: The gallbladder appears normal without stones. There is elevation of the right hemidiaphragm. morning ABG 7.30/46/79, pt needs to be encourge to cough.cv: HR 60-70's, 1st degree AV block and LBBB. per chest xray from pleural effusion on left side.cv: HR 60-70's, 1st degree AV block, LBBB, during respiratory distress was done ECG, no changes shown, cardio ensymes sent CPK 38, troponin 0.05, second set of ensymes sent at 0700, please send 3nd set in 8hr.pt received Nitro SL, start Aspirin Po, LOsartan PO. Albuterol DC'ed. pedal and tib pulses weakEndo finger stick 121-190, evening bs covered with 4U reg tonight now that pt has started clear ligs.A/p Continue with pul toilet, cpt, alb nebs, continue with lasix as needed, attempt to ween fio2 if possible htn meds still need to be adjusted to bring DBP down under 100. FOR DILAYSIS IF K DOES NOT COME DOWNSKIN..INTACTLINES..ART LINE CENTRAL LINE PLACED OK TO USESOCIAL..SON , HAS BEEN UPDATED BY TEAM AND AWARE OF PLAN OF CAREPLAN..AGRESSIVE BLOOD SUGAR MANAGENNT/AGRESSIVE FLUID MANAGEMENT..RESP SUPPORT..FOLLOW K/BUN/CREAT ASPIRATION REQUIRING INTUBATION....K REMAIJNS ELEVTAED > 6.0NEURO...RECEIVED ON PROPOFOL @ 10MCGS/KG..INCRESAED TO 15 AS ATTEMPTING TO PULKL AT ET TUBE..PRESENTLY SEEMS COMFORTABLE..EASY TO ROUSE FOLLOWS SIMPLE COMMNADS...PUPILS EQUAL /REACTIVECVS....ART LINE PLACED, B/P 120-130 SYSTOLIC..HR SINUS RYTHM/BRDAY @ 55-60BPM [ ON BBLOCKERS AT HOME ]...AFEBRILE..ON AB'S FOR ? 1900-0700 rn notes micuneuro: pt's lethargic, arousable to voice, orientedx3, follows commands, mae. admin albuterol neb x2. EKG with LBBB 2nd degree a-v block. CVP in the beginning of shift , after fluid bolus CVP 17-19, currently 14-15. afebrile, cont ABX.gi/gu: foley in place, in the begining of shift 0cc urine, given Fluid bolus 500cc with good response, u/o 60-120cc, @ 0300 u/o dropped to 0cc, MD notiefed, fluid bolus held d/t crakles in Rt side of lungs, given Lasix 20mg IV. Hyperkalemia resolving. 1900-0700 rn notes micuneuro: A/Ox3, mae folows commands.resp: cont hi flow mask, o2 down to 60%, sat 92-95, pt desat to 88% on rt side. BP 120-160/50-60, start Hydralasin 10mg po. c/w albut nebs q6prn. LS crakles on Rt side, clear left, per chest Xray, small pleural efussion on left side, received Lasix IV 20mg. 12 noon blood sugar 319 pt recieved 10U sq, K 3.3 was repleated with 40 of kcl.A/P pul poilet ween fio2 if tol, follow labs and repleat K as needed, extubated on , put on hi flow mask 80-95% , unable to wean O2->pt deast to low 80's.neuro: A/Ox3, mae, follows comands, opens eyes spont. Cont to pass mod amts liquid stool.Resp- Intub/vent on ac 550x12 5 peep fio2 decreased to 40% with sats 97-98% Last abg 81/30/7.39. CVP 9-15gi/gu: foely in place, rceived Lasix 40mg,goal neg 1000L, u/o 100-120cc/hr. cont Hydralasin 20mg for BP 140-160, A-line positional, time to time does not collertae with NBP.pt received Potassium 40meqx2 for K+3.2 and Mag 400mg for MAg 1.8. morning labs pending. bs rhonchorous, occas exp wheezing. WILL NEED DILAYSIS IN FUTURE....EXTUBATED @ 11.30HRS BUT HAS REQUIRED INCREASING AMOUNTS OF O2 THIS PM [ LOW TOLERANCE TO CPAP PATIENT]NEURO..RECEIVED ON PROPOFOL BUT SWICHED OF EARLY AM IN ANTICIPATION TO EXTUBATE..SINCE EXTUBATION LETHARGIC/TIRED BUT ORIENTATED TO PERSON/PLACE MOVING ALL 4 LIMBS, PARTAKING IN CARE ANSWERIN QUESTIONS APPROPRAITLY...DENIES ANY PAINRESP...EXTUBATED AND PUT TO FACE TENT @ 50% SATS @ 94% ABG SHOWED LOW PO2 FIO2 INCRESAED TO 70 % , RECEIVED CHEST P/T INCENTIVE SPIROMETER AND ENCOURAGEMENT TO COUGH DEEP BREATH, WEAK COUGH...DOES SOUND DIMINISHED ON RT, POSSIBLY RELATED TO ASPIRATION FROM YESTERDAY THAT REQUIRED INTUBATION...REPEAT BLOOD GAS SHOWED NO IMPROVEMENT WITH PO2 THEREFORE DISCUSSED WITH TEAM AND SWITCHED TO HIGH FLOW @ 80% ..WILL REPEAT ABG..DENIES ANY DISCOMFORT OR SOB....AS DISCUSSED WITH TEAM LOW THRESHOLD DOR PLACING PATIENT ON NON-INVASIVE VENTILATIONCVS...HR SHOWS LBBB WITH FIRST DEGREE HB ,RATE @ 70-73..LAST PM EPISODE OF BRADYCARDIA TO 40, 2:1 BLOCK SPONTANEOUSLY RIVERTED /NO INTERVENTION REQUIRED, NO FURTHER EPIOSDES TODAY AND PACING PADS REMOVED...B/P HAS REMAINED STABLE 120-135 SYTSOLICCVP 8-10 THIS AM..PM DOWN TO 3-5 THEREFORE RECEIVED BOLUS FLUID, PRESNTLY @ 7ID...INCRESAING WBC TODAY TO 18, CONTINUES ON LEVO AND VANC COMMENCED TODAY..TREATED FOR UTI AND POSSIBLE ASPIRATION PNEUMONIARENAL... RENAL TEAM FOLLOWING CLOSELY...U/O OVERNIGHT 10-20CC/HR DESPITE BOLUSES OF FLUID...INCREASED THIS AM 20-60CC/HR BUT TAILED OF AGAIN THIS PM TO 15-25CC..CVP DOWN THEFORE BOLUS OF 500CC GIVEN AT 1700HRS, TO MONITOR FOR EFFECTRENAL FOLLOWING, CREAT /BUN SLOWLY CLIMBING , WELL REQUIRE DILAYSIS IN NEAR FUTUREK STABLE THIS AM >4.0 AWAITING PM LYTES...ENDO...NOW OF INSULIN DRIP AND ON S/S ..Q4HRLY CHECKS..HAVE REMIANED < 200 BUT S/S NEEDS TO BE ADJUSTED TO GAIN BETTER CONTROLGI...LETHARGIC AND INCRESAING O2 REQUIREMENTS THEREFORE ONLY GIVEN PATIENT ICE CHIPS AND APPERAS TO BE TOLERATING..HAS MUSHROOM CATH IN PLACE..CONTINUES TO PUT OUT {>1000MLS LIQUID STOOL FOR THE DAY} POST KAYEXALATE FROM YESTERDAY BUT IS SLOWING DOWN THIS PMSKIN..PALE BUT INTACT [ HCT STABLE]..RECENT CATARCT SURGERY, NEEDS ETE DROPS ORDERINGLINES..ART/CENTRAL LINE INTACTSOCIAL..SON IN TO VISIST THIS AM AND UPDATED...HE SAYS THAT HIS MOTHER RECENTLY DIAGNOSED AS INSULIN DEPENDENT DIABETIC BUT CHOSE NOT TO TAKE THE INSULIN..HE SAYS THAT SHE HAS KEPT THIS INFORMATION FROM HIM ? | 30 | [
{
"category": "Echo",
"chartdate": "2136-04-02 00:00:00.000",
"description": "Report",
"row_id": 81779,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Shortness of breath.\nHeight: (in) 69\nWeight (lb): 192\nBSA (m2): 2.03 m2\nBP (mm Hg): 158/64\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 10:38\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size.\n\nRIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV systolic\nfunction. Paradoxic septal motion consistent with conduction\nabnormality/ventricular pacing.\n\nAORTA: Mildly dilated aortic root. Focal calcifications in aortic root. Normal\nascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild mitral annular\ncalcification. Calcified tips of papillary muscles. Mild (1+) MR.\n\nTRICUSPID VALVE: Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Based on \nAHA endocarditis prophylaxis recommendations, the echo findings indicate a low\nrisk (prophylaxis not recommended). Clinical decisions regarding the need for\nprophylaxis should be based on clinical and echocardiographic data.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nwall hypertrophy with normal cavity size. There is mild symmetric left\nventricular hypertrophy with normal cavity size. Septal motion is abnormal\n(?related to IVCD/postoperative). Overall systolic function is mildly reduced.\nRight ventricular cavity size is normal. Free wall motion is borderline\nnormal. The aortic root is mildly dilated. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. No aortic regurgitation\nis seen. The mitral valve leaflets are structurally normal. There is no mitral\nvalve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery\nsystolic pressure could not be quantified. There is no pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with mildly reduced\nleft ventricular systolic function. Mild mitral regurgitation. Mildly dilated\nascending aorta.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2136-04-01 00:00:00.000",
"description": "Report",
"row_id": 203424,
"text": "Baseline artifact\nSinus rhythm\nFirst degree A-V delay\nProbable left atrial abnormality\nLeft bundle branch block with intermittent left axis deviation\nSince previous tracing of , intermittent shift of axis to left axis\ndeviation now present\n\n"
},
{
"category": "ECG",
"chartdate": "2136-03-31 00:00:00.000",
"description": "Report",
"row_id": 203425,
"text": "Probable sinus rhythm, rate 75. Since the previous tracing of \nsignificant technical artifacts are noted. Positional changes are seen over the\nlateral precordium.\n\n"
},
{
"category": "ECG",
"chartdate": "2136-03-30 00:00:00.000",
"description": "Report",
"row_id": 203426,
"text": "Sinus rhythm, rate 66. Since the previous tracing the heart rate is faster.\nPositional changes are seen over the lateral precordium.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2136-03-29 00:00:00.000",
"description": "Report",
"row_id": 203427,
"text": "Sinus rhythm, rate 53. Since the previous tracing of the heart rate\nhas slowed. The Q-T interval is further prolonged. Positional changes are seen\nover the lateral precordium.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2136-03-29 00:00:00.000",
"description": "Report",
"row_id": 203428,
"text": "Sinus rhythm. First degree A-V delay. Left bundle-branch block. No previous\ntracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-03-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 903728,
"text": " 6:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p intubation\n REASON FOR THIS EXAMINATION:\n eval ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post intubation, evaluate endotracheal tube placement.\n\n SINGLE PORTABLE AP SUPINE VIEW OF THE CHEST: The endotracheal tube terminates\n at the thoracic inlet. Note that the distal tip of the endotracheal tube\n abuts the right tracheal wall. Heart size is borderline for technique. There\n is bilateral lower lobe atelectasis. There is elevation of the right\n hemidiaphragm. No evidence of pneumothorax.\n\n IMPRESSION:\n\n 1. Endotracheal tube terminating at the thoracic inlet with distal tip\n abutting the right lateral wall of the trachea.\n 2. Elevation of the right hemidiaphragm.\n 3. Bilateral lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-03-29 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 903842,
"text": " 5:07 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate line\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p line placemnent\n\n REASON FOR THIS EXAMINATION:\n evaluate line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old woman with line placement.\n\n TECHNIQUE: Portable chest radiograph.\n\n COMPARISON: Chest radiograph dated , taken approximately 12\n hours earlier.\n\n FINDINGS: The central venous line from left subclavian vein is terminating in\n upper SVC. No pneumothorax. Again note is made of endotracheal tube and\n nasogastric tube, unchanged compared to the prior study. There is persistent\n opacity at the right hilum, overlying the tip of subclavian venous line, which\n may represent atelectasis; however, mediastinal pathology such as\n lymphadenopathy cannot be totally excluded. Again note is made of patchy\n bibasilar opacity with low lung volumes.\n\n IMPRESSION: Tubes and lines as described above. Persistent opacity overlying\n the right hilum, which may represent atelectasis; however, underlying\n mediastinal pathology such as lymphadenopathy cannot be totally excluded.\n Bibasilar atelectasis. Prominent colon gases. Clinical correlation is\n recommended.\n\n The referring physician, . , has been paged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-03-29 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 903822,
"text": " 4:04 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o intestinal obstruction\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with n/v r/o obstruction\n REASON FOR THIS EXAMINATION:\n r/o intestinal obstruction\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 72-year-old female with nausea, vomiting. Rule out obstruction.\n\n There are distended loops of large bowel to the level of the sigmoid. There is\n no air in the rectum. Supine positioning does not allow adequate evaluation\n for obstruction. No bowel gas is seen within the rectum. The intestinal tube\n is seen overlying the distal stomach.\n\n IMPRESSION: Distended loops of colon to the sigmoid without air in the\n rectum. This may represent distal large bowel obstruction. Repeat films in two\n views (including upright/decubitus view) could be obtained. Alternatively, a\n gastrografin enema would be helpful to exclude distal obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-03-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 904029,
"text": " 7:56 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: pls eval for chf vs. infiltrate\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman adm to MICU s/p aspiration event and intubation. Now\n extubated. R lower lung crackes.\n REASON FOR THIS EXAMINATION:\n pls eval for chf vs. infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female admitted to MICU status post aspiration and\n intubation. Now extubated presenting with right lower lung crackles.\n\n COMPARISON: AP chest dated earlier today at 0334 hours.\n\n AP ERECT CHEST RADIOGRAPH: There has been interval removal of the\n endotracheal tube. A left subclavian catheter remains in an unchanged\n position. Low lung volumes are again demonstrated which exaggerate the heart\n size which is probably normal. There is no evidence of pneumothorax. The\n mediastinal and hilar contours are stable. Again note is made of patchy\n bibasilar opacity. There is likely left lower lobe effusion.\n\n IMPRESSION: Persistent low lung volumes status post extubation. Likely left\n pleural effusion. No evidence of pneumothorax. Plate-like atelectasis at the\n right base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-04-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 904212,
"text": " 3:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate after diuresis\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman adm to MICU s/p aspiration event and intubation. Now c\n CHF exacerbation\n REASON FOR THIS EXAMINATION:\n evaluate after diuresis\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:40 A.M., \n\n HISTORY: Aspiration. CHF exacerbation.\n\n IMPRESSION: AP chest compared to , and 12:\n\n Dense bilateral perihilar consolidation which progressed from through\n is now joined by moderate pulmonary edema worsened since ,\n accompanied by increasing moderate bilateral pleural effusion. Mediastinal\n contour indicates elevated central venous pressure. Lung volumes are quite\n low exaggerating heart size which is probably top normal and only slightly\n enlarged. No pneumothorax. Tip of the left subclavian line projects over the\n junction of the brachiocephalic veins. No indication of pneumothorax.\n Colonic distention seen in the splenic flexure is unchanged over the past\n several days.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-04-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 904208,
"text": " 10:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?etiology of frequent desaturation\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman adm to MICU s/p aspiration event and intubation. Now\n extubated. R lower lung crackes.\n REASON FOR THIS EXAMINATION:\n ?etiology of frequent desaturation\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: New right lower lung crackles. Frequent desaturations.\n\n CHEST PORTABLE AP, AT 22:42 HOURS:\n\n Findings; compared to , lung volumes remain decreased, likely related\n to inspiratory effort. Left subclavian CVL is in stable position. There are\n new large right perihilar consolidations. The left hilum is prominent as\n before. There are bilateral pleural effusions.\n\n Gaseous distention of the colon throughout the abdomen is not significantly\n changed.\n\n IMPRESSION: New large perihilar consolidations, right significantly worse\n than left.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-03-29 00:00:00.000",
"description": "ABDOMEN U.S. (PORTABLE)",
"row_id": 903827,
"text": " 3:45 PM\n ABDOMEN U.S. (PORTABLE) Clip # \n Reason: r/o cholecystitis and please eval kidney size.R?O obstructio\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with nausea and vomiting.renal failure\n REASON FOR THIS EXAMINATION:\n r/o cholecystitis and please eval kidney size.R?O obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 72-year-old woman with nausea, vomiting, and renal failure.\n\n COMPARISONS: None.\n\n TECHNIQUE: Abdominal ultrasound examination.\n\n FINDINGS: The gallbladder appears normal without stones. There is no intra-\n or extra-hepatic biliary ductal dilatation. The main portal vein shows\n appropriate hepatopetal flow. The echotexture of the liver appears normal,\n and no focal hepatic lesions are identified. The pancreas is not well seen\n because of overlying bowel gas. However, a portion of the proximal pancreas\n appears unremarkable, the tail being completely obscured. The spleen is\n normal in size and appearance. The right kidney measures 9.4 cm in length,\n somewhat small. The left kidney measures 11.4 cm. Otherwise, both kidneys\n appear normal without stones, masses, or hydronephrosis. There is trace\n ascites about the liver.\n\n IMPRESSION:\n 1. No evidence of hepatobiliary abnormality.\n 2. Slightly small size of right kidney. Otherwise, unremarkable evaluation\n of the kidneys.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-03-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 903884,
"text": " 3:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evolution of aspiration PNA\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p line placemnent\n\n REASON FOR THIS EXAMINATION:\n evolution of aspiration PNA\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:34 A.M, :\n\n HISTORY: Line placement. Evolving aspiration.\n\n IMPRESSION: AP chest compared to :\n\n Lung volumes remain quite low due to marked elevation of the diaphragm or\n perhaps function of intestinal distention, is seen in the upper abdomen.\n\n Opacification at the lung bases could represent either a small to moderate\n degree of atelectasis or pneumonia.\n\n Low lung volumes exaggerate the heart size, which is probably normal. There\n is no pneumothorax. Small bilateral pleural effusions are probably present.\n Tip of endotracheal tube with the chin elevated is above the clavicles at\n least 6 cm from the carina, 2-3 cm above optimal placement. The tip of the\n left subclavian line projects over the SVC. Nasogastric tube passes into the\n stomach and out of view.\n\n Dr. was paged to report these findings, at the time of dictation.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-03 00:00:00.000",
"description": "Report",
"row_id": 1468858,
"text": "Uneventful night for Ms . Slept on and off. No further diuretics given this shift.\n\nNeuro: Pt a+ox3, MAE, following commands consistently, C/O R hip pain on and off. Tx with repositioning.\n\nResp: Lung sounds continue with bibasilar crackles. O2 sat mid to high 90's on 3L O2. No c/o difficulty breathing. Breaths unlabored.\n\nCaridac: Rare ectopy on monitor. Remains hypertensive with sbp 130-160's. Hydralazine increased to 30mg PO q6 Isordil increased to 20mg po TID tolerating both well. EF yestereday showed EF of 40%.\n\nGI: Positive bowel sounds. No BM this shift. C/O lack of appetite.\n\nGu: Ended day negative 1750cc's. AM lytes pending voiding 150-220cc/hr via foley.\n\nDerm: Grossly intact. Quad lumen in L subclavian site benign.\n\nID: Continues on levofloxacin. Vancomycin increased to QD. Afebrile\n\nPlan: Continue to diurese with goal neg 1500-2L neg, call out to floor. titrate B/P meds to effect. oob as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-03 00:00:00.000",
"description": "Report",
"row_id": 1468859,
"text": "nsg transfer note\nPt was screened and acceptted @ in . Was cleared by MICU team as stable for transfer to Rehab. VS- stable no SOB, ambulance called for, awaiting arrival.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-01 00:00:00.000",
"description": "Report",
"row_id": 1468854,
"text": "1900-0700 rn notes micu\n\nneuro: A/Ox3, mae folows commands.\n\nresp: cont hi flow mask, o2 down to 60%, sat 92-95, pt desat to 88% on rt side. LS crackles on rt side and wheezing, received neb.cough/gag reflex intact. pt's been encourge to cough. in the morning sat 87-89%, put O2 80%, sat 94%.\n\ncv: HR 70's, 1st degree AV block, LBBB, with ocass PVC's. cont Hydralasin 20mg for BP 140-160, A-line positional, time to time does not collertae with NBP.pt received Potassium 40meqx2 for K+3.2 and Mag 400mg for MAg 1.8. morning labs pending. CVP 9-15\n\ngi/gu: foely in place, rceived Lasix 40mg,goal neg 1000L, u/o 100-120cc/hr. abd soft BS +, no BM, tolerate ice chips and small amount water.\n\n\nid: still requred bear hugger for low temp 94.4, currently 97.1.\n\nendo: cont RISS, see carevue.\n\nsocial: full code, family viseted/updated.\n\nplan: cont monitoring resp/cardio status. u/o.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-01 00:00:00.000",
"description": "Report",
"row_id": 1468855,
"text": "Micu nurisng note 7-7a\n\nNeuro Pt is awake and alert,following commands pt OOb to chair for 3 hrs this am. pt did have difficulty getting back to bed at noon because of fitigue.\n\nCV Pt Bp in better control today 130/103-122/72 hr LBBB, pt co of chest pain at 3 pm, ekg done no changes pt given 30cc myanta for GI distress this happend 30min after taking po K, pt states by 445 heart burn is gone.\n\nResp pt On hi flow at 90% able to ween pt down for sever hrs to 80% but then ending up ^ back to 90% when sats staying in the low 90's, Lung sounds crackles on right and course LLL, no sputum production.\n\nGI pt advanced to renal diet today, tol well, abd soft non tender,bowel sound x4.\n\nGU pt continues to recieve lasix Iv x1 today followed with 40 of kcl at 230 pm, u/o 80 cc hr, after lasix, u/o had dropped down durring the day to 30 cc prior.\n\nId pt off bear hugger temp back to 97, pt remains on IV antibiotics\n\nEndo. 12 noon blood sugar 319 pt recieved 10U sq, K 3.3 was repleated with 40 of kcl.\n\nA/P pul poilet ween fio2 if tol, follow labs and repleat K as needed,\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-02 00:00:00.000",
"description": "Report",
"row_id": 1468856,
"text": "73 y.o female initailly admitted to from OSH d/t hyperkalemia 7.2, lactate 5.2-?sepsis, ?new ARF with Creat 2.2 CHF , IDDM, recieved Keayxalat,was intubated d/t aspiration. extubated on , put on hi flow mask 80-95% , unable to wean O2->pt deast to low 80's.\n\nneuro: A/Ox3, mae, follows comands, opens eyes spont. at the beginning of shift c/o of back pain, became agitated,desat to 83-84%, received Morphine 2mg with good response.\n\nresp: received with hi flow mask 95% and NC 5L, unable to wean O2 down. at begining of shift pt became agitated d/t back pain, desat to 83-84% breathing became labor, LS bilat crackles and wheezing, pt c/o SOB, chest xray was done, shown pulmonary edema, CHF-> received Lasix 40mgx1 and 80mg x2 and Morphine 2mg, nebs,ABG 7.33/50/60. overnight pulmonary edema resolved, LS coarse on rt side, clear left, SAT up to 97-99%, attempt to wean O2 to 80% failed, pt start c/o of SOB and sat down to 95%. cough intact, but weak and non productive,pt needs to be encourge to cough and deep breathing. per chest xray from pleural effusion on left side.\n\ncv: HR 60-70's, 1st degree AV block, LBBB, during respiratory distress was done ECG, no changes shown, cardio ensymes sent CPK 38, troponin 0.05, second set of ensymes sent at 0700, please send 3nd set in 8hr.\npt received Nitro SL, start Aspirin Po, LOsartan PO. BP 120-140/50's. cvp 8-13. pt given Lasix for diuresed goal neg 1-2L, currently neg 700cc. at 2100 K+ 2.9 mag 1.7, repleted. morning labs pending. Cardio ECHO ordered.\n\ngi/gu: foley in place, drainge yellow clear urine 200cc/hr. per renal consult pt may need dialisis in the future. ABD soft, BS +, no BM. pt on renal diet, able to take PO meds with small amount of water, but start coughing, needs speech and swallow eval. after receiving calcium acetat , pt c/o of epigastric pain, received MAALOX with good effect.\n\nid: temp 93.3 d/t ?cold mist of hi flow mask, put bear hugger, temp 95.6. cont Vanco, levoflaxacin for UTI.\n\nendo: cont RISS, at 0000 BS 179, cover by insulin SC.\n\naccess: left SCL,A-line d/ced d/t leak and no tracing.\n\nsocial: full code, family visited/updated.\n\nplan: cont monitoring resp/cardio status labs, lytes, ensymes.\n cardio ECHO.\n keep neg 1-2L.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-02 00:00:00.000",
"description": "Report",
"row_id": 1468857,
"text": "MICU NPN 0700-1900\n 72 YEAR OLD WOMAN WITH CRI, HTN, ASPIRATION PNEUMONIA, DIABETES NEWLY INSULIN DEPENDENT, +UTI\n\nEVENTS: BEDSIDE ECHO DONE, BEDSIDE SWALLOW EVAL DONE, FIO2 WEAN TO 3L N/C\n\nNEURO: ALERT ORIENT X3, ANXIOUS AT TIMES, REVEALED WITH REASSURANCE\nCV: HR 70-80 1ST AVB, NO VEA, BP 130-157/80'S, EXTREM WARM PALPABLE PULSES, PRELIM EF 35-40%, CK'S FLAT X3, TROP FLAT X3, CVP 10-12,\nRESP: LUNGS WITH CRACKLES, FIO2 INITIALLY 80% HI FLOW AND 5L N/C, WEANED TO 3L N/C WITH O2 SAT 95-98%\nGI: ABD OBESE SOFT +BS, NO STOOL, DIET ADVANCED TO RENAL/DIABETIC EATING SMALL AMTS, POOR APPETITE, PASSED SWALLOW STUDY\nGU: FOLEY INTACT WITH CLEAR YELLOW URINE, CR 1.9, RECIEVED K REPLETION, RECEIVED IV LASIX 80MG AT 3PM, CURRENTLY FLUID BALANCE 1.7L NEGATIVE\nID: AFEBRILE, CONT LEVAFLOX FOR ASPIRATION, CONT VANCO FOR UTI\nACCESS: LEFT SC TL\nACTIVITY: OOB TO CHAIR FOR 3HRS, STOOD PIVOT WITH ASSIST OF TWO\nSOCIAL: SON VISITED BRIEFLY THIS AFTERNOON, UPDATE ON PLAN BY THIS RN\n\nPLAN: WEAN FIO2, DIURESE, FOLLOW FLUID BALANCE, FOLLOW CR, REPLETE LYTES AS NEEDED, SUPPORTIVE CARE\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-30 00:00:00.000",
"description": "Report",
"row_id": 1468846,
"text": "Micu nsg progress note\n Pt with episode bradycardia to 40 with stable bp. Potassium at time 4.5 with normal mg/cal. Spontaneously returning to hr 50's. EKG with LBBB 2nd degree a-v block. HO notified. Atropine placed at bedside. Pacing pads placed on pt. By 4am hr in 60's with EKG nsr with LBBB 1st degree av block. Bp stable thoughout. Pt being r/o for mi. Cont on iv 1/2ns at 250/hr. Hyperkalemia resolving. No futher kayexalate. Cont to pass mod amts liquid stool.\n\nResp- Intub/vent on ac 550x12 5 peep fio2 decreased to 40% with sats 97-98% Last abg 81/30/7.39. Suctioned for scant amts clear secretion. Will try spontaneous breathing trial in am weaning and extubating as able.\n\nGi/endocrine- Cont to pass mod amts loose brown ob neg stool. No s/s active bleeding. Last hct 27. Initially on insulin gtt at 10u/hr. Fs followed q1hr thoughout night and insulin decreased and d/c'd at 2am.\n\nNeuro- Initially heavily sedated on 15mcg propofol. Weaned to 8mcg. Will open eyes to stimulation. Able to squeeze hand on command. Restraints on for safety.\n\nRenal- Cont with poor urine output 5-10cc/hr. Bun/creat without change. K stable. Holding on dialysis for now. Pt may need in future.\n\nPlan- Cont to follow electrolytes. Tx as needed. Wean from vent as able. Follow cardiac status. Atropine at bedside.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-30 00:00:00.000",
"description": "Report",
"row_id": 1468847,
"text": "Resp Care\nPt remains on MV as noted on Careview. Currently in AC mode. RSBI 47-plan is to change pt to SBT at 0600 if stable. BBS-CTA. Albuterol DC'ed. Bag and mask at bedside. Alarms on and functioning. Continue to monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-30 00:00:00.000",
"description": "Report",
"row_id": 1468848,
"text": "NURSING NOTE 0700HRS - 1700HRS\n\n\nADMIT WITH ACUTE RENAL FAILURE ??CAUSE..? RELATED TO RECENT ^ IN BLOOD SUGARS BUT PATIENT NOT WILLING TO TAKE S/C INSULIN + DEHYDRATION + UTI.... ^^ K/BUN/CREAT/^B/S RECEIVED SEVERAL DOSES KAYEXLATAE AND INSULIN DRIP....\n\n\nEVENTS..NOW OF INSULIN DRIP B/S <200, K STABLE @ 4.2 [ CHECK Q 4-6HRLY]..BUN/CREAT RAISED BUT STABLE, RENAL FOLLOWING...? WILL NEED DILAYSIS IN FUTURE....EXTUBATED @ 11.30HRS BUT HAS REQUIRED INCREASING AMOUNTS OF O2 THIS PM [ LOW TOLERANCE TO CPAP PATIENT]\n\n\n\nNEURO..RECEIVED ON PROPOFOL BUT SWICHED OF EARLY AM IN ANTICIPATION TO EXTUBATE..SINCE EXTUBATION LETHARGIC/TIRED BUT ORIENTATED TO PERSON/PLACE MOVING ALL 4 LIMBS, PARTAKING IN CARE ANSWERIN QUESTIONS APPROPRAITLY...DENIES ANY PAIN\n\n\nRESP...EXTUBATED AND PUT TO FACE TENT @ 50% SATS @ 94% ABG SHOWED LOW PO2 FIO2 INCRESAED TO 70 % , RECEIVED CHEST P/T INCENTIVE SPIROMETER AND ENCOURAGEMENT TO COUGH DEEP BREATH, WEAK COUGH...DOES SOUND DIMINISHED ON RT, POSSIBLY RELATED TO ASPIRATION FROM YESTERDAY THAT REQUIRED INTUBATION...REPEAT BLOOD GAS SHOWED NO IMPROVEMENT WITH PO2 THEREFORE DISCUSSED WITH TEAM AND SWITCHED TO HIGH FLOW @ 80% ..WILL REPEAT ABG..DENIES ANY DISCOMFORT OR SOB....AS DISCUSSED WITH TEAM LOW THRESHOLD DOR PLACING PATIENT ON NON-INVASIVE VENTILATION\n\n\n\nCVS...HR SHOWS LBBB WITH FIRST DEGREE HB ,RATE @ 70-73..LAST PM EPISODE OF BRADYCARDIA TO 40, 2:1 BLOCK SPONTANEOUSLY RIVERTED /NO INTERVENTION REQUIRED, NO FURTHER EPIOSDES TODAY AND PACING PADS REMOVED...B/P HAS REMAINED STABLE 120-135 SYTSOLIC\nCVP 8-10 THIS AM..PM DOWN TO 3-5 THEREFORE RECEIVED BOLUS FLUID, PRESNTLY @ 7\n\n\nID...INCRESAING WBC TODAY TO 18, CONTINUES ON LEVO AND VANC COMMENCED TODAY..TREATED FOR UTI AND POSSIBLE ASPIRATION PNEUMONIA\n\n\nRENAL... RENAL TEAM FOLLOWING CLOSELY...U/O OVERNIGHT 10-20CC/HR DESPITE BOLUSES OF FLUID...INCREASED THIS AM 20-60CC/HR BUT TAILED OF AGAIN THIS PM TO 15-25CC..CVP DOWN THEFORE BOLUS OF 500CC GIVEN AT 1700HRS, TO MONITOR FOR EFFECT\nRENAL FOLLOWING, CREAT /BUN SLOWLY CLIMBING , WELL REQUIRE DILAYSIS IN NEAR FUTURE\nK STABLE THIS AM >4.0 AWAITING PM LYTES...\n\n\nENDO...NOW OF INSULIN DRIP AND ON S/S ..Q4HRLY CHECKS..HAVE REMIANED < 200 BUT S/S NEEDS TO BE ADJUSTED TO GAIN BETTER CONTROL\n\n\nGI...LETHARGIC AND INCRESAING O2 REQUIREMENTS THEREFORE ONLY GIVEN PATIENT ICE CHIPS AND APPERAS TO BE TOLERATING..HAS MUSHROOM CATH IN PLACE..CONTINUES TO PUT OUT {>1000MLS LIQUID STOOL FOR THE DAY} POST KAYEXALATE FROM YESTERDAY BUT IS SLOWING DOWN THIS PM\n\n\nSKIN..PALE BUT INTACT [ HCT STABLE]..RECENT CATARCT SURGERY, NEEDS ETE DROPS ORDERING\n\n\nLINES..ART/CENTRAL LINE INTACT\n\n\nSOCIAL..SON IN TO VISIST THIS AM AND UPDATED...HE SAYS THAT HIS MOTHER RECENTLY DIAGNOSED AS INSULIN DEPENDENT DIABETIC BUT CHOSE NOT TO TAKE THE INSULIN..HE SAYS THAT SHE HAS KEPT THIS INFORMATION FROM HIM ? WHY PATINET NOT COMPLIANT WITH CARE AT HOME .... WORKER ASLO INVOLVED\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-30 00:00:00.000",
"description": "Report",
"row_id": 1468849,
"text": "Resp Care\nPt received on mech vent-parameters noted. Following , pt extubated to 50% cool mist. Pt has required increased oxygentation for low Pa02. Pt does not appear to be in any resp distress. Breath sounds are relatively clear in upper lobes, diminshed in bases. Working with IS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-30 00:00:00.000",
"description": "Report",
"row_id": 1468850,
"text": "ADDENDUM..U/O RESPONDED TO BOLUS OF 500CC N/SLAINE.. K THIS PM LOW @ 3.4 THEREFORE GIVEN 20 IV, FOR RE-CHECK THIS EVE....PO2 STABLE ON REPEAT ABG....@ 1900HRS, NO URINE OUTPUT TEAM AWARE AND WILL REVIEW RE FURTHER FLUID...? NEEDS CXR AS SLIGHT CRACKLES AUDIBLE RT SIDE OF CHEST THIS EVE..AWAIT REVIEW\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-29 00:00:00.000",
"description": "Report",
"row_id": 1468844,
"text": "resp care\npt received from eu with #7.0/24 lip. placed on ac mode. +spont efforts. abg within adequate parameters. +bilat bs. ordered for albuterol for hyperkalemia, discussed with pharmacy and correct dosage is to be 1200 mcg which is 13 puffs, however per resident initial dosage given as 6 puffs. receiving other rx for hyperkalemia ,such as insulin drip. will follow and monitor necessity for albuterol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-29 00:00:00.000",
"description": "Report",
"row_id": 1468845,
"text": "ADMIT WITH ACUTE RENAL FAILURE ? CAUSE...? ASPIRATION REQUIRING INTUBATION....K REMAIJNS ELEVTAED > 6.0\n\n\n\nNEURO...RECEIVED ON PROPOFOL @ 10MCGS/KG..INCRESAED TO 15 AS ATTEMPTING TO PULKL AT ET TUBE..PRESENTLY SEEMS COMFORTABLE..EASY TO ROUSE FOLLOWS SIMPLE COMMNADS...PUPILS EQUAL /REACTIVE\n\n\n\nCVS....ART LINE PLACED, B/P 120-130 SYSTOLIC..HR SINUS RYTHM/BRDAY @ 55-60BPM [ ON BBLOCKERS AT HOME ]...\nAFEBRILE..ON AB'S FOR ? ASPIRTION PNEUMONIA/UTI\nHCT STABLE...\nB/S >400 ON ADMISSION TO UNIT WITH K > 6.5, DESPITE DEXT/INSULIN, KAYEXALATE AND CALCIUM GLUC IN EMERGENCY..RECEIVED X2 FURTHER DOSES OF KAYEXLATE THIS PM, WITH INSULIN DRIP @ 10U/HR PLUS BOLUS 10 TO CONTROL B/S....AGGRESSIVE FLUID MANAGEMENT WITH BOLUSES [AS PER CARE VIEW] WITH LASIX @ 40MGS GIVEN [AS PER RECOMMENDATIONS FROM RENAL[..PREVIUOS K < 6.0] ..AWAITING PM LABS...\n\n\nRESP..ON AC 550X12/5 BREATHING SATISFACTORY..LUNGS SOUND CLEAR DIMINSHED AT BASES\n\n\nGI...KAYEXLATE FOR HIGH K HAS STOOLED COPIOUS AMOUNTS AND HAS BUTT BAG IN PLACE AND IS DOING WELL...PHARMACY RECOMMEND TO HAVE STANDING ORDER OF KAYEXLATAE FOR K >6.0.. SOFT DISTENDED VBOWEL SOUNDS PRESNT... U/S PM SATISAFACTORY\n\n\nGU...20-40CC/HR DESPIT BOLSUS OF FLUID AND RECEIVED LASIX @ 1800HRS..CREAT @ 2.2AND K @ 5.6 THIS AFTERNOON ..PM LABS PENDIND>>>?? FOR DILAYSIS IF K DOES NOT COME DOWN\n\n\nSKIN..INTACT\n\n\nLINES..ART LINE CENTRAL LINE PLACED OK TO USE\n\n\nSOCIAL..SON , HAS BEEN UPDATED BY TEAM AND AWARE OF PLAN OF CARE\n\n\nPLAN..AGRESSIVE BLOOD SUGAR MANAGENNT/AGRESSIVE FLUID MANAGEMENT..RESP SUPPORT..FOLLOW K/BUN/CREAT\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-31 00:00:00.000",
"description": "Report",
"row_id": 1468851,
"text": "1900-0700 rn notes micu\n\nneuro: pt's lethargic, arousable to voice, orientedx3, follows commands, mae. puples R3 mm (recent cataract surgery)/L 4mm/brisk.\n\nresp: received extubated with Hi flow face tent 80%, sat 95-96%, pt desats to low 80's when pulls mask off and when turn to the left side. LS crakles on Rt side, clear left, per chest Xray, small pleural efussion on left side, received Lasix IV 20mg. cough/gag reflex intact. morning ABG 7.30/46/79, pt needs to be encourge to cough.\n\ncv: HR 60-70's, 1st degree AV block and LBBB. BP 120-160/50-60, start Hydralasin 10mg po. last K+ 3.5, given Po potassium 20. morning labs pending. CVP in the beginning of shift , after fluid bolus CVP 17-19, currently 14-15. afebrile, cont ABX.\n\ngi/gu: foley in place, in the begining of shift 0cc urine, given Fluid bolus 500cc with good response, u/o 60-120cc, @ 0300 u/o dropped to 0cc, MD notiefed, fluid bolus held d/t crakles in Rt side of lungs, given Lasix 20mg IV. ABD soft/dis BS +, loose stool via mashroom cath.\npt tolerated ice chips, but start coughing with water in the morning.\n\nendo: increased RISS d/t BSFS>200.\n\nsocial: full code, family visited/updated.\n\nplan: cont monitoring neuro/resp/cardio statu, u/o.labs.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-31 00:00:00.000",
"description": "Report",
"row_id": 1468852,
"text": "resp care\nremains on high flow neb at 80%, spo2's low 90's. bs rhonchorous, occas exp wheezing. admin albuterol neb x2. encouraging db +cough with good results. cough stronger after oob to chair. c/w albut nebs q6prn.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-03-31 00:00:00.000",
"description": "Report",
"row_id": 1468853,
"text": "Micu nursing note 7p-7a\n\nNeuro. pt awake and allert following commands pt OOB to chair x2 hrs tol well needed 2 assists.\n\nResp pt remains on 15L hi flow, RR 16-24, lung sound course thought out had crackels in bases this am andR base still with crackles, pt also had exp wheezing, pt recieving nebs Q4, attempt to nasl suction but was unabl to get any secreations, pt cpt x1 today, pt encouraged to cough deep breath, this am was unable to break face mask without o2 sats dropping, now able to take O2 off and pt can hold sats for several minutes.\n\nGI abd soft non tender, pt has mod amts soft stoolx3 today, mushroom cath d/c because stool to thick. pt also started on clear liquids using asperation precausions, been cruching pills in applesause and pt able to take meds, have also given pt clear lig with instrucion on how to swallow and no asperation with ligs. pt in for a swallow eval.\n\nGI pt given lasix 40 mg this am, u/o 100-200 most of the day now y/o down to 60 cc hr, pt neg about 130 cc for 24 hrs goal to keep pt neg\nfoley cath changed because it was leaking this am was under the assumtion that she had no u/o for several hrs but after foley changed to 16 fr, no leaking around cath.\n\nId pt hypothermic today was placed on bear hugger at 5apm temp down to 95.5 at 6 pm temp 97.2 ax pt still low orally. pt remain on Iv antiobiotics levofloxin\n\nCV pt still remains htn 126/89-154/10g po hydrazine increased to 20 mg today pt also given extra dose of iv hyralazine at 2 pm because dbp 104, dyastolic bp still ^ will need to Increase meds again. pedal and tib pulses weak\n\nEndo finger stick 121-190, evening bs covered with 4U reg tonight now that pt has started clear ligs.\n\nA/p Continue with pul toilet, cpt, alb nebs, continue with lasix as needed, attempt to ween fio2 if possible htn meds still need to be adjusted to bring DBP down under 100.\n"
}
] |
11,256 | 188,208 | Pt. was brought to the operating room on and after general anesthesia, pt. underwent a coronary artery bypass graft surgery x 3. Please refer to operative not for full surgical details. Pt. tolerated the procedure well and was transferred to CSRU in stable condition with a HR 78 NSD, MAP 71, CVP 16, PAD 20, 27. He was being titrated on propofol and receiving Neo for BP support. Later that day propofol was weaned, sedation reversed, and pt. became awake and was extubated successfully. Pt. was fully awake and alert and neurologically intact. POD #1 - Neo was being weaned off. CVL was removed. Pt. was OOB into chair and later that day transferred to telemetry floor. POD #2 - Chest tubes, pacing wires, and foley removed. Pt. cont. to progress well. Hemodynamically stable. POD # - Pt. cont. to improve. PE was unremarkble. No events the last 2 days. Pt. encouraged to ambulate. POD #5 - Pt. improved to level 5 today. No issues during post-op course. Lab work stable. Pt. went home today with VNA services. PE at D/c: VS: 99.4 91 SR 120/54 18 Neuro: Alert, oriented, non-focal Pulm: CTAB -w/r/r Cardiac: RRR -c/r/m/g Sternum: Inc. C/D/I, -drainage/erythema Abd: Soft, NT/ND, +BS Ext: Warm, -edeme, Inc. C/D/I | Single AP bedside chest apparently obtained in O.R. CT's w/ mod amts serousang dng.Resp: BS clear, slightly decreased in bases bilat. SINGLE AP UPRIGHT CHEST: Comparison to portable AP supine chest of . PAD 17-28, CVP 10-23, CI > 3.0. FINDINGS: The heart size and mediastinal contours are within normal limits. HCT STABLE POST-OP.RESP: LUNGS CLEAR, DIMINISHED AT THE BASES. Minimal atelectasis left lung base. Median sternotomy wires are again noted. NEURO: AWOKE WITH DC PROPOFOL, CALM AT PRESENT, MAE, PERL, FOLLOWING COMMANDS, GI: OGT TO LCS, +PLACEMENT, ABD SOFT, ABSENT BOWEL SOUNDS. TECHNIQUE: PA and lateral chest. DSGS HAVE REMAINED D+I. Within normal limits. DRY COUGH NOTED. MAE.CV: HR and BP stable. SANGUINOUS DRAINAGE.GI/GU: HYPOACTIVE BS. IMPRESSION: Normal chest. Pt self administering MDI's as ordered.GI: Abd soft. Mediastinal and bilateral lower zone chest tubes in situ. CI>2.2 AFTER LR. K REPLACED. Status post CABG. Status post CABG. MINIMAL CT DRAINAGE. D/C SWAN IN AM. Sinus rhythm with baseline artifact. 2:46 PM CHEST (PORTABLE AP) Clip # Reason: r/o PTX/Effusion/Tamponade. Pt. Pt. IMPRESSION: Bibasilar linear atelectases. Using IS independently. Heart size is within normal limits. HCT 31. FINAL REPORT Chest, single AP film. FOLEY TO GRAVITY. ABD SOFT, ND. Preop for CABG. The patient has been extubated. RECIEVED 1.5 L LR. GOOD HUO. BS DIMINISHED BIBASILAR, RR LO TWENTIES. GU: ADEQUATE UO ENDO: INSULIN GTT STARTED AT . Heart size is within normal limits and unchanged. Cough unproductive. The bilateral chest tubes have been removed. NEO GTT TITRATED TO KEEP SBP> 90. The Swan-Ganz catheter has been removed. SBP 88-110'S. still in OR, please perform when in CSRU. Sinus tachycardiaNormal ECG except for rateSince previous tracing, no significant change EXTREMITIES WARM, PALP PP,. AS PER ORDERS. HISTORY: CABG. PAD'S MIDDLE TO LO TWENTIES. NG tube is in stomach. RESP: FAILED INITIAL CPAP 10/5 , PLACED BACK ON IMV. There are linear atelectases in both lower zones, improved aeration since prior film of , 05. Mediastinal and hilar contours are unremarkable. At the lower lung zones bilaterally, there is prominent linear opacity, likely secondary to atelectasis. 2:27 PM CHEST (PORTABLE AP) IN O.R. The pulmonary vasculature appears unremarkable. Tolerating po's.GU: Adequate u/o via foley.Endo: SSRI per protocol.Activity/Comfort: Med w/ percocet q 4 hrs for pain. History of CABG. ? Lungs are otherwise clear without evidence of consolidation or effusion. EASILY PALPABLE PEDAL PULSES BILATERALLY. O2 SAT >98%. NEURO ALERT ORIENTED NO DEFECITS NOTEDRESP NC 4L SATS 96-97% LUNGS CLEAR NO WHEEZES NOTED CHEST TUBES DRAINING MOD AMTS THIN USING IS WELLC/V NSR B/P STABLE LOPRESSOR STARTED 12.5 MG TOL WELL EPI WIRES INTACT FUNCTIONAL PULSES EASILY PALPGU/GI ABD SOFT TOL PO WELL ADEQUATE URINE OUT WITH LASIXPLAN TRANSFER TO 2 TODAY CSRU NPNNeuro: Alert and oriented x 3. The stomach is mildly distended with gas. No pneumothorax. No pneumothorax. No pneumothorax. S/P CABG X3O: CARDIAC: SR WITH ISOLATED, CUPLET NOTED RECIEVED 2 GM MAGNESIUM SULPHATE WITH CESSATION OF VEA. No pleural effusion. EXTUBATED AT 12 AM WITHOUT DIFFICULTY. c/o mod amtspain but pain has decreased as day has progressed. SEE CAREVUE FOR ALL VENT CHANGES AND ABG'S. No previous tracingavailable for comparison. COMPARISON: None. 7P-7A:NEURO: ALERT AND ORIENTED X 3, MAE. Pulmonary hygiene. NO CHEST TUBE LEAK. The lungs are clear. IMPRESSION: No evidence of pneumothorax. PLACED BACK ON SIMV WITHOUT SUCCESS, PT WRITING "I FEEL AS THOUGH I AM DROWNING." O2SAT REMAINS > 95% ON 6 L NC. OOB-> CHAIR. MORPHINE AND TORADOL PRN PAIN WITH GOOD EFFECT.CV: SR 90-ST 100, RARE PVC'S NOTED. IS USE TO 1000CC. ; -77 BY DIFFERENT PHYSICIAN # Reason: MISSING TORNIQUET Admitting Diagnosis: +ETT;CORONARY ARTERY DISEASE\CATH FINAL REPORT HISTORY: CABG ?missing tourniquet. SWITCHED BACK TO CPAP 5/5 WITH INCREASED PT COMFORT ALTHOUGH ABG WITH PERSISTENT ACIDOSIS. No pleural effusion and no pneumothorax. Endotracheal tube is 6 cm above carina. The osseous structures are unremarkable. Tip of Swan-Ganz catheter is in right main pulmonary artery. ELECTROLYTES REPLETED. CT TO 20 CM SXN, NO AIRLEAK NOTED. The surrounding osseous structures appear unremarkable. The NG tube has been removed as well. Since pre-operative exam 1 day ago, sternal wire sutures and mediastinal staples present along with bilateral chest tubes, endotracheal tube, and poorly visualized right IJ line. REASON FOR THIS EXAMINATION: assess for pneumotohrax FINAL REPORT CHEST TWO VIEWS, PA AND LATERAL. There is no evidence of residual pneumothorax. No other radiopaque foreign body. Increase activity as tolerated. POST-OP CR WNL.ENDO: REGULAR INSULIN GTT TITRATED PER PROTOCOL.PLAN: MONITOR HEMODYNAMICS. REASON FOR THIS EXAMINATION: pre-op CABG FINAL REPORT INDICATION: Coronary artery disease. TOL ICE CHIPS. Transfer to 2 this evening. PAIN: RECIEVED 2 MG MSO4 AND 30 MG IM TORADOL ID: TO RECIEVE VANCO SOCIAL: WIFE INTO VISIT AND UPDATEDA: STABLE POST CABG, FAILED CPAPP: MONITOR COMFORT, HR AND RYTHYM, SBP, CI, DSGS, CT DRAINAGE, RESP STATUS- REATTEMPT CPAP WEAN TO EXTUBATE, NEURO STATUS, I+O, LABS. | 11 | [
{
"category": "Radiology",
"chartdate": "2146-05-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 861040,
"text": " 2:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX/Effusion/Tamponade. Pt. still in OR, please perform\n Admitting Diagnosis: +ETT;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with CAD s/p CABG\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion/Tamponade. Pt. still in OR, please perform when in CSRU.\n ______________________________________________________________________________\n FINAL REPORT\n Chest, single AP film.\n\n HISTORY: CABG.\n\n Status post CABG. Endotracheal tube is 6 cm above carina. Tip of Swan-Ganz\n catheter is in right main pulmonary artery. NG tube is in stomach.\n Mediastinal and bilateral lower zone chest tubes in situ. No pneumothorax.\n Minimal atelectasis left lung base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-05-10 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 860919,
"text": " 5:00 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: +ETT;CORONARY ARTERY DISEASE\\CATH\n Admitting Diagnosis: +ETT;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with CAD, for CABG.\n REASON FOR THIS EXAMINATION:\n pre-op CABG\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Coronary artery disease. Preop for CABG.\n\n COMPARISON: None.\n\n TECHNIQUE: PA and lateral chest.\n\n FINDINGS: The heart size and mediastinal contours are within normal limits.\n The pulmonary vasculature appears unremarkable. The lungs are clear. No\n pleural effusion and no pneumothorax. The surrounding osseous structures\n appear unremarkable.\n\n IMPRESSION: Normal chest.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-05-11 00:00:00.000",
"description": "O CHEST (PORTABLE AP) IN O.R.",
"row_id": 861036,
"text": " 2:27 PM\n CHEST (PORTABLE AP) IN O.R.; -77 BY DIFFERENT PHYSICIAN # \n Reason: MISSING TORNIQUET\n Admitting Diagnosis: +ETT;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG ?missing tourniquet.\n\n Single AP bedside chest apparently obtained in O.R. Since pre-operative exam\n 1 day ago, sternal wire sutures and mediastinal staples present along with\n bilateral chest tubes, endotracheal tube, and poorly visualized right IJ line.\n There is also an unusual large caliber tube in the region of the esophagus\n which may represent mediastinal or GI scope. No other radiopaque foreign\n body.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-05-13 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 861314,
"text": " 6:24 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: ro ptx\n Admitting Diagnosis: +ETT;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p cabg and ct removal\n REASON FOR THIS EXAMINATION:\n ro ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old man status post CABG and chest tube removal, rule out\n pneumothorax.\n\n SINGLE AP UPRIGHT CHEST: Comparison to portable AP supine chest of .\n Median sternotomy wires are again noted. The bilateral chest tubes have been\n removed. There is no evidence of residual pneumothorax. The patient has been\n extubated. The Swan-Ganz catheter has been removed. The NG tube has been\n removed as well. At the lower lung zones bilaterally, there is prominent\n linear opacity, likely secondary to atelectasis. Heart size is within normal\n limits and unchanged. Mediastinal and hilar contours are unremarkable. The\n stomach is mildly distended with gas. Lungs are otherwise clear without\n evidence of consolidation or effusion. The osseous structures are\n unremarkable.\n\n IMPRESSION: No evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-05-15 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 861432,
"text": " 10:49 AM\n CHEST (PA & LAT) Clip # \n Reason: assess for pneumotohrax\n Admitting Diagnosis: +ETT;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with CAD, for CABG.\n\n REASON FOR THIS EXAMINATION:\n assess for pneumotohrax\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS, PA AND LATERAL.\n\n History of CABG.\n\n Status post CABG. Heart size is within normal limits. There are linear\n atelectases in both lower zones, improved aeration since prior film of , 05. No pneumothorax. No pleural effusion.\n\n IMPRESSION: Bibasilar linear atelectases. No pneumothorax.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2146-05-11 00:00:00.000",
"description": "Report",
"row_id": 190917,
"text": "Sinus tachycardia\nNormal ECG except for rate\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2146-05-10 00:00:00.000",
"description": "Report",
"row_id": 190918,
"text": "Sinus rhythm with baseline artifact. Within normal limits. No previous tracing\navailable for comparison.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-05-11 00:00:00.000",
"description": "Report",
"row_id": 1410348,
"text": "S/P CABG X3\nO: CARDIAC: SR WITH ISOLATED, CUPLET NOTED RECIEVED 2 GM MAGNESIUM SULPHATE WITH CESSATION OF VEA. SBP 88-110'S. MINIMAL CT DRAINAGE. DSGS HAVE REMAINED D+I. CI>2.2 AFTER LR. PAD'S MIDDLE TO LO TWENTIES. HCT 31. K REPLACED. EXTREMITIES WARM, PALP PP,.\n RESP: FAILED INITIAL CPAP 10/5 , PLACED BACK ON IMV. BS DIMINISHED BIBASILAR, RR LO TWENTIES. O2 SAT >98%. NO CHEST TUBE LEAK.\n NEURO: AWOKE WITH DC PROPOFOL, CALM AT PRESENT, MAE, PERL, FOLLOWING COMMANDS,\n GI: OGT TO LCS, +PLACEMENT, ABD SOFT, ABSENT BOWEL SOUNDS.\n GU: ADEQUATE UO\n ENDO: INSULIN GTT STARTED AT .\n PAIN: RECIEVED 2 MG MSO4 AND 30 MG IM TORADOL\n ID: TO RECIEVE VANCO\n SOCIAL: WIFE INTO VISIT AND UPDATED\nA: STABLE POST CABG, FAILED CPAP\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, CI, DSGS, CT DRAINAGE, RESP STATUS- REATTEMPT CPAP WEAN TO EXTUBATE, NEURO STATUS, I+O, LABS. AS PER ORDERS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-05-12 00:00:00.000",
"description": "Report",
"row_id": 1410349,
"text": "7P-7A:\nNEURO: ALERT AND ORIENTED X 3, MAE. EXTUBATED AT 12 AM WITHOUT DIFFICULTY. MORPHINE AND TORADOL PRN PAIN WITH GOOD EFFECT.\n\nCV: SR 90-ST 100, RARE PVC'S NOTED. ELECTROLYTES REPLETED. NEO GTT TITRATED TO KEEP SBP> 90. PAD 17-28, CVP 10-23, CI > 3.0. RECIEVED 1.5 L LR. EASILY PALPABLE PEDAL PULSES BILATERALLY. HCT STABLE POST-OP.\n\nRESP: LUNGS CLEAR, DIMINISHED AT THE BASES. PT RECIEVED ON CPAP 50% 5/5 WITH ACIDOTIC ABG. PLACED BACK ON SIMV WITHOUT SUCCESS, PT WRITING \"I FEEL AS THOUGH I AM DROWNING.\" SWITCHED BACK TO CPAP 5/5 WITH INCREASED PT COMFORT ALTHOUGH ABG WITH PERSISTENT ACIDOSIS. PRESSURE SUPPORT INCREASED TO 10 AND EVENTUALLY WEANED AND EXTUBATED. SEE CAREVUE FOR ALL VENT CHANGES AND ABG'S. O2SAT REMAINS > 95% ON 6 L NC. IS USE TO 1000CC. DRY COUGH NOTED. CT TO 20 CM SXN, NO AIRLEAK NOTED. SANGUINOUS DRAINAGE.\n\nGI/GU: HYPOACTIVE BS. ABD SOFT, ND. TOL ICE CHIPS. FOLEY TO GRAVITY. GOOD HUO. POST-OP CR WNL.\n\nENDO: REGULAR INSULIN GTT TITRATED PER PROTOCOL.\n\nPLAN: MONITOR HEMODYNAMICS. ? D/C SWAN IN AM. OOB-> CHAIR.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-05-12 00:00:00.000",
"description": "Report",
"row_id": 1410350,
"text": "NEURO ALERT ORIENTED NO DEFECITS NOTED\n\nRESP NC 4L SATS 96-97% LUNGS CLEAR NO WHEEZES NOTED CHEST TUBES DRAINING MOD AMTS THIN USING IS WELL\n\nC/V NSR B/P STABLE LOPRESSOR STARTED 12.5 MG TOL WELL EPI WIRES INTACT FUNCTIONAL PULSES EASILY PALP\n\nGU/GI ABD SOFT TOL PO WELL ADEQUATE URINE OUT WITH LASIX\n\nPLAN TRANSFER TO 2 TODAY\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-05-12 00:00:00.000",
"description": "Report",
"row_id": 1410351,
"text": "CSRU NPN\n\nNeuro: Alert and oriented x 3. MAE.\n\nCV: HR and BP stable. CT's w/ mod amts serousang dng.\n\nResp: BS clear, slightly decreased in bases bilat. Using IS independently. Cough unproductive. Pt self administering MDI's as ordered.\n\nGI: Abd soft. Tolerating po's.\n\nGU: Adequate u/o via foley.\n\nEndo: SSRI per protocol.\n\nActivity/Comfort: Med w/ percocet q 4 hrs for pain. c/o mod amts\npain but pain has decreased as day has progressed. OOB to chair x 2->tolerated better second time.\n\nSocial: Wife in visiting and updated on pt's condition.\n\nA: Stable.\n\nP: Pain med prn. Pulmonary hygiene. Increase activity as tolerated. Transfer to 2 this evening.\n"
}
] |
30,101 | 105,529 | 87yo F with known CKD s/p B/L renal artery stents who was admitted with back pain, concerning for growth of her AAA. She was initially admitted to vascular surgery, but transfered to the MICU for hypotension, new O2 requirement, and urosepsis. | Mild tomoderate (+) aortic regurgitation is seen. Moderate PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. The aortic valve leaflets are moderatelythickened. Mild to moderate (+)mitral regurgitation is seen. Right ventricular functionHeight: (in) 60Weight (lb): 100BSA (m2): 1.39 m2BP (mm Hg): 123/41HR (bpm): 62Status: InpatientDate/Time: at 11:27Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.LEFT VENTRICLE: Normal LV wall thickness. Mild to moderate (+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. There is moderate pulmonary artery systolic hypertension. Mild to moderate (+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild mitralannular calcification. Normal main PA. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.Conclusions:The left atrium is mildly dilated. Mild thickening of mitral valve chordae. of themitral chordae (normal variant). The tricuspid valve leaflets are mildlythickened. Left ventricular wall thicknesses arenormal. There isno pericardial effusion.Compared with the findings of the prior study (images reviewed) of , the aortic valve effective orifice area is further reduced. The inner dilator and microwire were then removed, and wire was passed into the right atrium. The wire was then passed into the inferior vena cava, and attention was directed to the chest. TDI E/e' >15, suggesting PCWP>18mmHg.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTIC VALVE: Moderately thickened aortic valve leaflets. Right ventricular chamber size andfree wall motion are normal. Normal tricuspidvalve supporting structures. The inner dilator and wire were removed, and the hemodialysis catheter was passed through the peel-away sheath, and the peel-away sheath removed. A final fluoroscopic image demonstrated an appropriately positioned right IJ hemodialysis catheter with its tip in the right atrium. PATIENT/TEST INFORMATION:Indication: Left ventricular function. Overall leftventricular systolic function is normal (LVEF 65%). The left ventricular cavity is unusually small. Mild to moderate [+] TR. Calcified tips ofpapillary muscles. Sinus rhythm. After a small skin incision was made, the needle was removed and replaced with a micropuncture sheath. The venotomy site in the neck was closed with 2-0 Vicryl, and the catheter was sewn in place with 2-0 silk sutures, and dressed. PROCEDURE: 19-cm tip-to-cuff tunneled right IJ hemodialysis catheter placement. OPERATORS: Dr. , Dr. . There is severe aortic valve stenosis (valve area 0.9 cm2). Small LV cavity. Tissue Doppler imaging suggests an increased leftventricular filling pressure (PCWP>18mmHg). The venotomy was then serially dilated, and a 14 French peel-away sheath was placed under fluoroscopic guidance. This was used to measure catheter length, and a 19-cm tip-to-cuff hemodialysis catheter was selected. 9:22 AM TUNNELED DIALYSIS LINE PLACEME Clip # Reason: please place HD line Admitting Diagnosis: ACUTE RENAL FAILURE Type of Port: None ********************************* CPT Codes ******************************** * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS. Sinus rhythm with prolonged P-R interval. Then, under ultrasound guidance, a 21-gauge micropuncture needle was inserted into the right internal jugular vein, and a 0.018 wire was passed through this and into the superior vena cava. Left bundle-branch block. Left axis deviation. Atrial fibrillation with rapid ventricular response. A site for the tunnel was chosen, and local anesthesia was obtained with approximately 10 cc of 1% lidocaine with epinephrine. Severe AS (area0.8-1.0cm2). Compared to the previous tracingof no diagnostic interim change. Overall normal LVEF(>55%). Under ultrasound guidance with hard copy images on file, an appropriate site to access the right internal jugular vein was chosen, and the area over the neck was anesthetized with approximately 5 cc of 1% buffered lidocaine. (Over) 9:22 AM TUNNELED DIALYSIS LINE PLACEME Clip # Reason: please place HD line Admitting Diagnosis: ACUTE RENAL FAILURE Type of Port: None FINAL REPORT (Cont) IMPRESSION: Successful placement of 19-cm tip-to-cuff right IJ hemodialysis catheter with the tip in the right atrium, ready for immediate use. Leftbundle-branch block. The patient was brought to the angiography suite and prepped and draped in the usual sterile fashion. Compared to the previous tracing of theQRS voltage is more prominent and the rhythm is sinus. However, mechanicaldyssynchrony is present. Left bundle-branch block.Compared to the previous tracing of atrial fibrillation with a rapidventricular response has appeared and the rate has increased. The patient tolerated the procedure well without immediate complications. A preprocedure timeout confirmed the patient identity and the procedure to be performed. There is no mitral valve prolapse. The mitral valve leaflets aremildly thickened. No PS.Physiologic PR. A stab incision was made over the chest, and using a blunt tunneling device, a tunnel was created between the stab incision on the chest and the original venostomy site in the neck. TECHNIQUE AND FINDINGS: The procedure was explained to the patient, and written informed consent was obtained after questions were answered. No resting LVOT gradient. No MVP. No TS. No MS. | 5 | [
{
"category": "Radiology",
"chartdate": "2122-09-10 00:00:00.000",
"description": "US GUID FOR VAS. ACCESS",
"row_id": 1204358,
"text": " 9:22 AM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: please place HD line\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Type of Port: None\n ********************************* CPT Codes ********************************\n * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with new renal failure, initiated on HD\n REASON FOR THIS EXAMINATION:\n please place HD line\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 87-year-old female with new renal failure, initiated on\n hemodialysis, please place tunneled HD line.\n\n OPERATORS: Dr. , Dr. .\n\n PROCEDURE: 19-cm tip-to-cuff tunneled right IJ hemodialysis catheter\n placement.\n\n TECHNIQUE AND FINDINGS: The procedure was explained to the patient, and\n written informed consent was obtained after questions were answered. A\n preprocedure timeout confirmed the patient identity and the procedure to be\n performed. The patient was brought to the angiography suite and prepped and\n draped in the usual sterile fashion. Under ultrasound guidance with hard copy\n images on file, an appropriate site to access the right internal jugular vein\n was chosen, and the area over the neck was anesthetized with approximately 5\n cc of 1% buffered lidocaine. Then, under ultrasound guidance, a 21-gauge\n micropuncture needle was inserted into the right internal jugular vein, and a\n 0.018 wire was passed through this and into the superior vena cava. After a\n small skin incision was made, the needle was removed and replaced with a\n micropuncture sheath. The inner dilator and microwire were then removed, and\n wire was passed into the right atrium. This was used to measure\n catheter length, and a 19-cm tip-to-cuff hemodialysis catheter was selected.\n The wire was then passed into the inferior vena cava, and attention was\n directed to the chest. A site for the tunnel was chosen, and local anesthesia\n was obtained with approximately 10 cc of 1% lidocaine with epinephrine. A\n stab incision was made over the chest, and using a blunt tunneling device, a\n tunnel was created between the stab incision on the chest and the original\n venostomy site in the neck. The venotomy was then serially dilated, and a 14\n French peel-away sheath was placed under fluoroscopic guidance. The inner\n dilator and wire were removed, and the hemodialysis catheter was passed\n through the peel-away sheath, and the peel-away sheath removed. A final\n fluoroscopic image demonstrated an appropriately positioned right IJ\n hemodialysis catheter with its tip in the right atrium. The venotomy site in\n the neck was closed with 2-0 Vicryl, and the catheter was sewn in place with\n 2-0 silk sutures, and dressed. The patient tolerated the procedure well\n without immediate complications.\n\n (Over)\n\n 9:22 AM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: please place HD line\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Type of Port: None\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: Successful placement of 19-cm tip-to-cuff right IJ hemodialysis\n catheter with the tip in the right atrium, ready for immediate use.\n\n"
},
{
"category": "Echo",
"chartdate": "2122-09-05 00:00:00.000",
"description": "Report",
"row_id": 99896,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function\nHeight: (in) 60\nWeight (lb): 100\nBSA (m2): 1.39 m2\nBP (mm Hg): 123/41\nHR (bpm): 62\nStatus: Inpatient\nDate/Time: at 11:27\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Normal LV wall thickness. Small LV cavity. Overall normal LVEF\n(>55%). TDI E/e' >15, suggesting PCWP>18mmHg.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Severe AS (area\n0.8-1.0cm2). Mild to moderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. of the\nmitral chordae (normal variant). No resting LVOT gradient. Calcified tips of\npapillary muscles. No MS. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Mild to moderate [+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is unusually small. Overall left\nventricular systolic function is normal (LVEF 65%). However, mechanical\ndyssynchrony is present. Tissue Doppler imaging suggests an increased left\nventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets are moderately\nthickened. There is severe aortic valve stenosis (valve area 0.9 cm2). Mild to\nmoderate (+) aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. Mild to moderate (+)\nmitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. There is moderate pulmonary artery systolic hypertension. There is\nno pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , the aortic valve effective orifice area is further reduced.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2122-09-09 00:00:00.000",
"description": "Report",
"row_id": 283690,
"text": "Sinus rhythm with prolonged P-R interval. Left axis deviation. Left\nbundle-branch block. Compared to the previous tracing of the\nQRS voltage is more prominent and the rhythm is sinus.\n\n"
},
{
"category": "ECG",
"chartdate": "2122-09-08 00:00:00.000",
"description": "Report",
"row_id": 283691,
"text": "Atrial fibrillation with rapid ventricular response. Left bundle-branch block.\nCompared to the previous tracing of atrial fibrillation with a rapid\nventricular response has appeared and the rate has increased.\n\n"
},
{
"category": "ECG",
"chartdate": "2122-09-03 00:00:00.000",
"description": "Report",
"row_id": 283692,
"text": "Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\nof no diagnostic interim change.\n\n"
}
] |
40,066 | 169,733 | Following admission workup was undertaken.Dental extractions were performed on . Carotids ultrasounds were nonobstructive. On he was taken to the Operating Room where aortic valve replacement was done. See operative note for details. He weaned from bypass with ventricular ectopy which resolved with deairing and an Amiodarone bolus. Low dose neosynephrine and Propofol were running at the end of the operation. He was extubated later that night, and transferred to the floor on POD #2 to begin increasing his activity level. CTs were removed according to protocol and temporary pacing wires were likewise removed (on POD 3). Physical therapy worked with him for strength and mobility. Beta blockade and diuretics were begun. He remained stable, he diuresed nicely and remained in sinus rhythm. He was ready for discharge and went to a rehabilitation facility for further recovery before returning home. medications, wound care and postoperative instructions were included in the paperwork sent with the patient. STOP | Pneumococcal Vac Polyvalent 24. Metoprolol Tartrate 19. restart PO Metformin. Metoprolol Tartrate 17. Metoprolol Tartrate 17. Metoprolol Tartrate 17. Metoprolol Tartrate 17. Allopurinol 7. Renal: Foley, Adequate UO, Creat 0.8. Morphine Sulfate 19. Morphine Sulfate 19. Morphine Sulfate 19. Morphine Sulfate 19. Nitroglycerin 22. Aspirin EC 7. Aspirin EC 7. Aspirin EC 7. Aspirin EC 7. Pneumococcal Vac Polyvalent 22. Pneumococcal Vac Polyvalent 22. Pneumococcal Vac Polyvalent 22. Then titrate insulin gtt off if FS remains<120. Then titrate insulin gtt off if FS remains<120. Milk of Magnesia 18. Milk of Magnesia 18. Milk of Magnesia 18. Milk of Magnesia 18. Sodium Chloride 0.9% Flush 29. Nitroglycerin 20. Nitroglycerin 20. Nitroglycerin 20. Nitroglycerin 20. Docusate Sodium 10. Docusate Sodium 10. Docusate Sodium 10. Docusate Sodium 10. Found to have a metabolic acidosis on ABG, fluid boluses given with correction of acidosis. Found to have a metabolic acidosis on ABG, fluid boluses given with correction of acidosis. Aspirin EC 8. When C&DB, pt c/o pain and given 1 percocet at 1030. Calcium Gluconate 9. Sodium Chloride 0.9% Flush 30. Sodium Chloride 0.9% Flush 27. Sodium Chloride 0.9% Flush 27. Sodium Chloride 0.9% Flush 27. Milk of Magnesia 20. start lasix diuresis Hematology: Stable anemia. Metoclopramide 18. Morphine Sulfate 21. Ranitidine 24. Ranitidine 24. Ranitidine 24. Ranitidine 24. Allopurinol 6. Allopurinol 6. Allopurinol 6. Allopurinol 6. Calcium Gluconate 8. Calcium Gluconate 8. Calcium Gluconate 8. Calcium Gluconate 8. Sodium Chloride 0.9% Flush 28. and 20mg lasix IV given NP order. and 20mg lasix IV given NP order. and 20mg lasix IV given NP order. and 20mg lasix IV given NP order. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush 26. Action: Ntg gtt titrated to keep SBP < 120. Action: IV bolus administered & Insulin Gtt restarted per protocol. Cepacol (Menthol) 10. Morphine prn, transition to percocet Hematology: Stable anemia. Hematology: Stable anemia. K-4.7 and ionized calcium 1.16 with am labs. K-4.7 and ionized calcium 1.16 with am labs. K-4.7 and ionized calcium 1.16 with am labs. K-4.7 and ionized calcium 1.16 with am labs. K-4.7 and ionized calcium 1.16 with am labs. Furosemide 11. Furosemide 11. Furosemide 11. Furosemide 11. Ketorolac . Response: Hyperglycemia continues. Docusate Sodium 12. Holding metformin while being diuresed. Patient admit to CVICU stable on propofol, neo, insulin gtt. Patient admit to CVICU stable on propofol, neo, insulin gtt. Patient admit to CVICU stable on propofol, neo, insulin gtt. Nutrition: Sips, ADAT. Doppler pulses. Doppler pulses. Pneumococcal Vac Polyvalent 24. Pneumococcal Vac Polyvalent 24. Moderate functional mitral stenosisfrom MAC. Trace aortic regurgitation is seen. Renal: Foley, Adequate UO, Creat 0.8. Renal: Foley, Adequate UO, Creat 0.8. On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 55/18, 88/25, 77/22 cm/sec. Moderate [2+] tricuspid regurgitation is seen. Preoperative assessment.Height: (in) 70Weight (lb): 236BSA (m2): 2.24 m2BP (mm Hg): 150/82HR (bpm): 76Status: InpatientDate/Time: at 15:47Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: DefinityTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated aortic sinus. Moderate [2+] TR.Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Mild symmetric left ventricular hypertrophy with preserved globaland regional biventricular systolic function. PA and lateral upright chest radiographs were compared to . Allopurinol 7. Allopurinol 7. Physiologic MR (withinnormal limits).TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Mod functional MS due to MAC.TRICUSPID VALVE: Normal tricuspid valve leaflets. Good (>20 cm/s) LAA ejectionvelocity.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal ascending aorta diameter.AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Metoprolol Tartrate 19. Metoprolol Tartrate 19. 7:05 AM CHEST (PORTABLE AP) Clip # Reason: s/p ct removal ? Single AP chest radiograph compared to shows repositioning of a right IJ central venous catheter with tip now located in the distal SVC/right cavoatrial junction. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 44/10, 55/16, 55/15 cm/sec. Chest tubes D/Cd in am and chest x-ray performed showing atelectasis NP . Severe MAC was seen and mitral valve area by presssurehalf-time was 2.0 cm2. Sodium Chloride 0.9% Flush 29. Sodium Chloride 0.9% Flush 29. Action: Pt given toradol/percocets. Metoclopramide 18. Metoclopramide 18. There is nopericardial effusion. Nitroglycerin 22. Nitroglycerin 22. WJMLEFT ATRIUM: Normal LA and RA cavity sizes. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. The right extreme CP angle has been excluded. Right internal jugular line tip is at the cavoatrial junction. FINDINGS: In comparison with the study of , there are now metallic sternal sutures in place. Left anterior hemiblock. Sodium Chloride 0.9% Flush 28. Sodium Chloride 0.9% Flush 28. Nutrition: diabetic diet Renal: Foley, Adequate UO, Creat 0.8. Apaced for blood pressure support.. Latest Vital Signs and I/O Non-invasive BP: S:109 D:55 Temperature: 98.5 Arterial BP: S:115 D:47 Respiratory rate: 21 insp/min Heart Rate: 66 bpm Heart rhythm: SR (Sinus Rhythm) O2 delivery device: Nasal cannula O2 saturation: 98% % O2 flow: 2 L/min FiO2 set: 40% % 24h total in: 196 mL 24h total out: 1,935 mL Pacer Data Temporary pacemaker type: Epicardial Wires Temporary pacemaker mode: Atrial demand Temporary pacemaker rate: 50 bpm Temporary atrial sensitivity: Yes Temporary atrial sensitivity threshold: 1.2 mV Temporary atrial sensitivity setting: 0.6 mV Temporary atrial stimulation threshold : 12 mA Temporary atrial stimulation setting: 20 mA Temporary ventricular sensitivity: Yes Temporary ventricular sensitivity threshold: 0.8 mV Temporary pacemaker wire condition: Attached-Pacer Temporary pacemaker wires atrial: 2 Temporary pacemaker wires ventricular: 2 Pertinent Lab Results: Sodium: 135 mEq/L 02:06 AM Potassium: 3.9 mEq/L 02:06 AM Chloride: 101 mEq/L 02:06 AM CO2: 28 mEq/L 02:06 AM BUN: 17 mg/dL 02:06 AM Creatinine: 0.8 mg/dL 02:06 AM Glucose: 120 mg/dL 02:06 AM Hematocrit: 25.1 % 02:06 AM Finger Stick Glucose: 160 02:00 PM Valuables / Signature Patient valuables: Other valuables: Valuables in safe on 6 per pt. | 36 | [
{
"category": "Nursing",
"chartdate": "2174-08-02 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 581757,
"text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt A&O, follows all commands and appropriate.\n HR-NSR 60\ns-80\ns. SBP 100\ns-110\ns. Doppler pulses. K-4.7 and ionized\n calcium 1.16 with am labs.\n LS-CTA/Dim at bases. 3-4LO2 NC- 96-99%. Chest tubes draining minimal\n amounts of serosang. drainage.\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\n diet.\n Foley intact draining good amounts of clear yellow urine.\n Action:\n Pt weaned off nitro drip and started on lopressor 25mg po bid at 0800.\n Epicardial wires tested with A\ns sensing and capturing appropriately\n and V\ns sensing but not capturing. Pt set on A demand at 50.\n Pt encouraged to C&DB and IS used 500-750.\n Pt started on lasix 20mg last night and continued.\n Response:\n Vitals unchanged at this time. Pt OOB to chair and chest tubes with\n minimal amount of output. At 1100, pt with only 40cc\ns of urine past 2\n hrs. and 20mg lasix IV given NP order.\n Plan:\n Continue to administer beta blocker, monitor lytes and replete, monitor\n UOP and diurese.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o incisional pain with movement/C&DB.\n Action:\n Pt given toridol 15mg IV at 0800.\n Response:\n Pt appears comfortable in chair at this time. When C&DB, pt c/o \n pain and given percoets in am/afternoon.\n Plan:\n Continue to monitor pain level and administer toradol q6h/percocets.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with blood sugars 130\ns-140\ns and received on insulin drip at 8\n units/hr.\n Action:\n Pt continuing on insulin drip. At 0900, pt on 7 units/hr of insulin\n with blood sugar 148 and given 70 units lantus SC. At 1000, drip\n increased to 8 units/hr and given 16 units regular insulin SC.\n Response:\n At 1200, pt with blood sugar 177 and given additional 4 units regular\n insulin SC NP order.\n Plan:\n Continue to check blood sugars and administer insulin per CVICU\n protocol.\n"
},
{
"category": "Nursing",
"chartdate": "2174-08-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581830,
"text": "H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt continues to be hyperglycemic >200.\n Action:\n IV bolus administered & Insulin Gtt restarted per protocol. PO\n Glyburide restarted and administered @ 1400.\n Response:\n Hyperglycemia continues. Insulin Gtt continues.\n Plan:\n Monitor Q1hr FSBS. Wean Insulin Gtt as tolerated. ? restart PO\n Metformin.\n"
},
{
"category": "Nursing",
"chartdate": "2174-08-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581893,
"text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n -NSR 70\ns and no vea. BP wnl\n -Lungs are clear bilaterally with sats> 94% on 3L nc\n -HUO <40ml/hr\n -Chest tubes drained small amounts of serosanquinous drainage\n Action:\n -Patient is receiving po Lopressor 25mg po twice daily.\n -Administered IV Lasix 20mg\n -Patient used IS with good inspiratory effort.\n -Serum potassium and magnesium repleted\n Response:\n -Patient diuresed> 100ml/hr after receiving IV Lasix 20mg\n -Remains in NSR while receiving po beta blockers.\n Plan:\n -Continue with beta blockers for management of heart rate.\n -Continue with pulmonary toileting\n -Diurese with IV Lasix\n -? CT to be d/c\nd by team today\n Pain control (acute pain, chronic pain)\n Assessment:\n -Patient c/o sternotomy incisional pain\n Action:\n -Administered 2 percocet tabs and IV Toradol for pain\n Response:\n -Pain decreased after receiving the pain meds.\n Plan:\n -Administer Percocet tabs every 4 hous and IV Toradol every 6 hours for\n management of incisional pain\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n -At onset of shift, FS >170-203\n Action:\n -Titrated Insulin gtt up to a maximum dose of 9units/hr and gave\n regular insulin bolus according to unit protocol.\n Response:\n -FS eventually decreased to >120->96. The insulin gtt was slowly\n decreased to 2 units/hr. Notified PA for further orders\n regarding the Lantus dosage\n Plan:\n -Continue insulin gtt until Lantus dose given per team. Then titrate\n insulin gtt off if FS remains<120.\n -Monitor hourly FS while patient is receiving Insulin gtt\n -Check with team for restarting the Metformin today\n -Discharge to floor after Insulin gtt d/c\n"
},
{
"category": "Nursing",
"chartdate": "2174-08-02 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 581744,
"text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt A&O, follows all commands and appropriate.\n HR-NSR 60\ns-80\ns. SBP 100\ns-110\ns. Doppler pulses. K-4.7 and ionized\n calcium 1.16 with am labs.\n LS-CTA/Dim at bases. 4LO2 NC- 96-99%. Chest tubes draining minimal\n amounts of serosang. drainage.\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\n diet.\n Foley intact draining good amounts of clear yellow urine.\n Action:\n Pt weaned off nitro drip and started on lopressor 25mg po bid at 0800.\n Epicardial wires tested with A\ns sensing and capturing appropriately\n and V\ns sensing but not capturing. Pt set on A demand at 50.\n Pt encouraged to C&DB and IS used 500-750.\n Pt started on lasix 20mg last night and continued.\n Response:\n Vitals unchanged at this time. Pt OOB to chair and chest with minimal\n amount of output. At 1100, pt with only 40cc\ns of urine past 2 hrs.\n and 20mg lasix IV given NP order.\n Plan:\n Continue to administer beta blocker, monitor lytes and replete, monitor\n UOP and diurese.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o incisional pain with movement/C&DB.\n Action:\n Pt given toridol 15mg IV at 0800.\n Response:\n Pt appears comfortable in chair at this time. When C&DB, pt c/o \n pain and given 1 percocet at 1030.\n Plan:\n Continue to monitor pain level and administer pain meds prn.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with blood sugars 130\ns-140\ns and received on insulin drip at 8\n units/hr.\n Action:\n Pt continuing on insulin drip. At 0900, pt on 7 units/hr of insulin\n with blood sugar 148 and given 70 units lantus SC. At 1000,\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2174-08-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 582167,
"text": "CVICU\n HPI:\n POD 2 s/p AVR (25 tissue)\n PMHx:\n EF > 65 Wt 104K Cr. 0.8 HgbA1C: 7.1\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\n fem- bypass, L shoulder, removal of calcium , L knee surgery\n , ?renal stent in \n : Allopurinol 300', ASA 81', glyburide 5\", lisinopril 20', lovasa\n 2\", metformin 500\"', ocuvite, simvastatin 40'\n Current medications:\n . 2. 3. 4. 250 mL D5W 5. Acetaminophen 6. Allopurinol 7. Aspirin EC 8.\n Calcium Gluconate 9. Cepacol (Menthol) 10. Dextrose 50% 11. Docusate\n Sodium 12. Furosemide 13. GlyBURIDE 14. Insulin 15. Insulin 16.\n Magnesium Sulfate 17. Metoclopramide 18. Metoprolol Tartrate 19. Milk\n of Magnesia 20. Morphine Sulfate 21. Nitroglycerin 22.\n Oxycodone-Acetaminophen 23. Pneumococcal Vac Polyvalent 24. Potassium\n Chloride 25. Ranitidine 26. Simvastatin 27. Sodium Chloride 0.9% Flush\n 28. Sodium Chloride 0.9% Flush 29. Sodium Chloride 0.9% Flush 30.\n Vancomycin\n 24 Hour Events:\n PA CATHETER - STOP 08:05 AM\n CORDIS/INTRODUCER - STOP 06:00 PM\n MULTI LUMEN - START 06:00 PM\n - Remained in ICU for elevated BS, on insulin gtt\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:16 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:04 AM\n Flowsheet Data as of 12:16 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.9\nC (98.5\n HR: 63 (63 - 80) bpm\n BP: 109/39(57) {104/39(56) - 136/77(89)} mmHg\n RR: 15 (14 - 21) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111 kg (admission): 104 kg\n Height: 70 Inch\n Total In:\n 1,158 mL\n 196 mL\n PO:\n 580 mL\n Tube feeding:\n IV Fluid:\n 578 mL\n 196 mL\n Blood products:\n Total out:\n 2,260 mL\n 1,785 mL\n Urine:\n 1,995 mL\n 1,725 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,102 mL\n -1,589 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress, Comfortable\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 164 K/uL\n 8.9 g/dL\n 120 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 17 mg/dL\n 101 mEq/L\n 135 mEq/L\n 25.1 %\n 5.8 K/uL\n [image002.jpg]\n 01:36 PM\n 02:15 PM\n 02:22 PM\n 03:23 PM\n 04:49 PM\n 05:52 PM\n 05:54 PM\n 02:09 AM\n 02:24 AM\n 02:06 AM\n WBC\n 8.0\n 5.3\n 5.8\n Hct\n 27.5\n 28.6\n 26.9\n 25.1\n Plt\n 233\n 178\n 164\n Creatinine\n 0.8\n 0.7\n 0.8\n TCO2\n 25\n 22\n 27\n 24\n 26\n Glucose\n 198\n 163\n 121\n 120\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\n Lactic Acid:1.5 mmol/L, Ca:8.7 mg/dL, Mg:1.5 mg/dL\n Imaging:\n CXR: s/p removal of CT, no ptx, post-op changes noted, line in\n place\n Microbiology:\n MRSA: negative\n Assessment and Plan\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 79 M s/p AVR (25 tissue), POD 2\n Neurologic: Neuro checks Q: hr, Pain controlled.\n Cardiovascular: Aspirin, Beta-blocker\n Pulmonary: IS, Cough, IS, OOB to chair.\n Gastrointestinal / Abdomen: Bowel regimen.\n Nutrition: Sips, ADAT.\n Renal: Foley, Adequate UO, Creat 0.8. Diurese with goal negative 1 L.\n Hematology: Stable anemia, no active bleeding.\n Endocrine: RISS, Insulin drip, Lantus (R), Transition from gtt to\n Lantus, increased Glyburide to home dose, RISS. Goal BS < 150. Holding\n metformin while being diuresed.\n Infectious Disease: Check cultures, Received peri-op Vanco. Afebrile,\n nomral WBC, no active ID issues at this time.\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: None\n Fluids: KVO\n Consults: CT surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\n Lantus (R) protocol\n Lines:\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2174-08-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581919,
"text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n -NSR 70\ns and no vea. BP wnl\n -Lungs are clear bilaterally with sats> 94% on 3L nc\n -HUO <40ml/hr\n -Chest tubes drained small amounts of serosanquinous drainage\n Action:\n -Patient is receiving po Lopressor 25mg po twice daily.\n -Administered IV Lasix 20mg\n -Patient used IS with good inspiratory effort.\n -Serum potassium and magnesium repleted\n Response:\n -Patient diuresed> 100ml/hr after receiving IV Lasix 20mg\n -Remains in NSR while receiving po beta blockers.\n Plan:\n -Continue with beta blockers for management of heart rate.\n -Continue with pulmonary toileting\n -Diurese with IV Lasix\n -? CT to be d/c\nd by team today\n Pain control (acute pain, chronic pain)\n Assessment:\n -Patient c/o sternotomy incisional pain\n Action:\n -Administered 2 percocet tabs and IV Toradol for pain\n Response:\n -Pain decreased after receiving the pain meds.\n Plan:\n -Administer Percocet tabs every 4 hours and IV Toradol every 6 hours\n for management of incisional pain\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n -At onset of shift, FS >170-203\n Action:\n -Titrated Insulin gtt up to a maximum dose of 9units/hr and gave\n regular insulin bolus according to unit protocol.\n Response:\n -FS eventually decreased to >120->96. The insulin gtt was slowly\n decreased to 2 units/hr. Notified PA for further orders\n regarding the Lantus dosage\n Plan:\n -Continue insulin gtt until Lantus dose given per team. Then titrate\n insulin gtt off if FS remains<120.\n -Monitor hourly FS while patient is receiving Insulin gtt\n -Check with team for restarting the Metformin today\n -Discharge to floor after Insulin gtt d/c\n"
},
{
"category": "Nursing",
"chartdate": "2174-08-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581622,
"text": "Patient is a 79yo with SOB to OR for 25mm tissue valve. In OR\n patient with elevated blood glucose difficult to control despite\n insulin bolus and gtt. Patient admit to CVICU stable on propofol, neo,\n insulin gtt.\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Received patient with BP in 80\ns systolic.\n Neo titrated with minimal result.\n CI >2 with admission.\n Potassium low.\n Action:\n Patient apaced for blood pressure control with good result.\n Found to have a metabolic acidosis on ABG, fluid boluses\n given with correction of acidosis.\n CI remains >2.\n Patient hypertensive with waking, nitro started. Titrated to\n maintain BP <120.\n Repeat potassium and Hct pending\n Response:\n Patient with stable VS, in NSR with ademand backup.\n Plan:\n Plan for extubation\n Pain control (acute pain, chronic pain)\n Assessment:\n Received patient on propofol gtt. Reversed, propofol off.\n Action:\n Patient woke agitated, restless. Morphine 2mg x2 given. Patient calmer,\n following commands.\n Response:\n Continue to assess for pain. Extubate tonight.\n Plan:\n Continue to assess for pain. Morphine prn, transition to percocet\n"
},
{
"category": "Respiratory ",
"chartdate": "2174-08-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 581618,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Destination (R/T)\n Time\n Complications\n Comments\n Comments:\n Pt was admitted to CVICU via OR intubated and placed on the vent tol\n well. See respiratory page of meta vision for more information.\n"
},
{
"category": "Nursing",
"chartdate": "2174-08-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581620,
"text": "Patient is a 79yo with SOB to OR for 25mm tissue valve. In OR\n patient with elevated blood glucose difficult to control despite\n insulin bolus and gtt. Patient admit to CVICU stable on propofol, neo,\n insulin gtt.\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Received patient with BP in 80\ns systolic.\n Neo titrated with minimal result.\n CI >2 with admission.\n Potassium low.\n Action:\n Patient apaced for blood pressure control with good result.\n Found to have a metabolic acidosis on ABG, fluid boluses\n given\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2174-08-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581761,
"text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt A&O, follows all commands and appropriate.\n HR-NSR 60\ns-80\ns. SBP 100\ns-110\ns. Doppler pulses. K-4.7 and ionized\n calcium 1.16 with am labs.\n LS-CTA/Dim at bases. 3-4LO2 NC- 96-99%. Chest tubes draining minimal\n amounts of serosang. drainage.\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\n diet.\n Foley intact draining good amounts of clear yellow urine.\n Action:\n Pt weaned off nitro drip and started on lopressor 25mg po bid at 0800.\n Epicardial wires tested with A\ns sensing and capturing appropriately\n and V\ns sensing but not capturing. Pt set on A demand at 50.\n Pt encouraged to C&DB and IS used 500-750.\n Pt started on lasix 20mg last night and continued.\n Response:\n Vitals unchanged at this time. Pt OOB to chair and chest tubes with\n minimal amount of output. At 1100, pt with only 40cc\ns of urine past 2\n hrs. and 20mg lasix IV given NP order.\n Plan:\n Continue to administer beta blocker, monitor lytes and replete, monitor\n UOP and diurese.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o incisional pain with movement/C&DB.\n Action:\n Pt given toridol 15mg IV at 0800.\n Response:\n Pt appears comfortable in chair at this time. When C&DB, pt c/o \n pain and given percoets in am/afternoon.\n Plan:\n Continue to monitor pain level and administer toradol q6h/percocets.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with blood sugars 130\ns-140\ns and received on insulin drip at 8\n units/hr.\n Action:\n Pt continuing on insulin drip. At 0900, pt on 7 units/hr of insulin\n with blood sugar 148 and given 70 units lantus SC. At 1000, drip\n increased to 8 units/hr and given 16 units regular insulin SC.\n Response:\n At 1200, pt with blood sugar 177 and given additional 4 units regular\n insulin SC NP order.\n Plan:\n Continue to check blood sugars and administer insulin per CVICU\n protocol.\n"
},
{
"category": "Nursing",
"chartdate": "2174-08-02 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 581743,
"text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt A&O, follows all commands and appropriate.\n HR-NSR 60\ns-80\ns. SBP 100\ns-110\ns. Doppler pulses. K-4.7 and ionized\n calcium 1.16 with am labs.\n LS-CTA/Dim at bases. 4LO2 NC- 96-99%. Chest tubes draining minimal\n amounts of serosang. drainage.\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\n diet.\n Foley intact draining good amounts of clear yellow urine.\n Action:\n Pt weaned off nitro drip and started on lopressor 25mg po bid at 0800.\n Epicardial wires tested with A\ns sensing and capturing appropriately\n and V\ns sensing but not capturing. Pt set on A demand at 50.\n Pt encouraged to C&DB and IS used 500-750.\n Pt started on lasix 20mg last night and continued.\n Response:\n Vitals unchanged at this time. Pt OOB to chair and chest with minimal\n amount of output. At 1100, pt with only 40cc\ns of urine past 2 hrs.\n and 20mg lasix IV given NP order.\n Plan:\n Continue to administer beta blocker, monitor lytes and replete, monitor\n UOP and diurese.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o incisional pain with movement/C&DB.\n Action:\n Pt given toridol 15mg IV at 0800.\n Response:\n Pt appears comfortable in chair at this time. When C&DB, pt c/o \n pain and given 1 percocet at 1030\n Plan:\n Continue to monitor pain level and administer pain meds prn.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2174-08-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581717,
"text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n NSR without ectopy, HR 70\ns-80\ns. RIJ Cordis, PA line, CO/CI WNL. SBP\n 120-140\ns. Pedal pulses doppled, extremities cool/dry. Chest tubes to\n Suction, small amounts serosanguinous drainage, no air leak, no\n creptius.\n Action:\n Ntg gtt titrated to keep SBP < 120.\n Response:\n SBP 115-140\ns. stable hemodynamics.\n Plan:\n DC PA line, leave cordis in for now. OOB to chair. ? DC chest tubes if\n no dump when Transfer to 6 today.\n Pain control (acute pain, chronic pain)\n Assessment:\n Unable to rate pain, moaning continually,\nOh my chest. It hurts in my\n backtoo.\n shallow respirations, poor deep breathing efforts. Also c/o\n mouth being sore. Refusing oral care, flinches when lips touched.\n Action:\n Morphine 2mg IV q1-2h without effect. Toradol 30mg IV at 0145.\n Response:\nit feels a lot better.\n Good response from Toradol.\n Plan:\n Start po pain meds, Toradol 15mg IV q6h x 24h.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Blood sugars 79-154\n Action:\n Insulin gtt 1-8 units/hr.\n Response:\n Fairly good BS control on insulin gtt\n Plan:\n ? clinic to consult this am for Blood sugar management\n"
},
{
"category": "Nursing",
"chartdate": "2174-08-02 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 581731,
"text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt A&O, follows all commands and appropriate.\n HR-NSR 60\ns-80\ns. SBP 100\ns-110\ns. Doppler pulses. K-4.7 and ionized\n calcium 1.16 with am labs.\n LS-CTA/Dim at bases. 4LO2 NC- 96-99%. Chest tubes draining minimal\n amounts of serosang. drainage.\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\n diet.\n Foley intact draining good amounts of clear yellow urine.\n Action:\n Pt weaned off nitro drip and started on lopressor 25mg po bid at 0800.\n Epicardial wires tested with A\ns sensing and capturing appropriately\n and V\ns sensing but not capturing. Pt set on A demand at 50.\n Pt encouraged to C&DB and IS used 500-750.\n Pt started on lasix 20mg last night and continued.\n Response:\n Vitals unchanged at this time. Pt OOB to chair and chest with minimal\n amount of output.\n Plan:\n Continue to administer beta blocker, monitor lytes and replete, monitor\n UOP and diurese.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o incisional pain with movement/C&DB.\n Action:\n Pt given toridol 15mg IV at 0800.\n Response:\n Pt appears comfortable in chair at this time with no complaints.\n Plan:\n Continue to monitor pain level and administer pain meds prn.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2174-08-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 581732,
"text": "CVICU\n HPI:\n POD 1\n s/p AVR (25 tissue) \n Chief complaint:\n PMHx:\n EF > 65 Wt Cr. 0.8 HgbA1C: 7.1\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\n fem- bypass, L shoulder, removal of calcium , L knee surgery\n , ?renal stent in \n : Allopurinol 300', ASA 81', glyburide 5\", lisinopril 20', lovasa\n 2\", metformin 500\"', ocuvite, simvastatin 40'\n Current medications:\n 1. 2. 3. 250 mL D5W 4. Acetaminophen 5. Allopurinol 6. Aspirin EC 7.\n Calcium Gluconate 8. Dextrose 50%\n 9. Docusate Sodium 10. Furosemide 11. Insulin 12. Ketorolac 13.\n Ketorolac 14. Magnesium Sulfate\n 15. Metoclopramide 16. Metoprolol Tartrate 17. Milk of Magnesia 18.\n Morphine Sulfate 19. Nitroglycerin\n 20. Oxycodone-Acetaminophen 21. Pneumococcal Vac Polyvalent 22.\n Potassium Chloride 23. Ranitidine\n 24. Simvastatin 25. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9%\n Flush 27. Vancomycin\n 24 Hour Events:\n ARTERIAL LINE - START 02:00 PM\n PA CATHETER - START 02:00 PM\n INVASIVE VENTILATION - START 02:00 PM\n CORDIS/INTRODUCER - START 02:00 PM\n EKG - At 04:00 PM\n INVASIVE VENTILATION - STOP 06:15 PM\n ARTERIAL LINE - STOP 06:28 AM\n - Extubtaed, no issues overnight\n - Remains in ICU on NTG gtt and insulin gtt\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 07:30 PM\n Infusions:\n Insulin - Regular - 8 units/hour\n Other ICU medications:\n Insulin - Regular - 02:38 PM\n Morphine Sulfate - 12:24 AM\n Furosemide (Lasix) - 01:50 AM\n Other medications:\n Flowsheet Data as of 10:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 37.1\nC (98.8\n HR: 75 (61 - 82) bpm\n BP: 115/58(71) {106/50(64) - 115/58(71)} mmHg\n RR: 14 (12 - 21) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CVP: 3 (3 - 16) mmHg\n PAP: (20 mmHg) / (8 mmHg)\n CO/CI (Thermodilution): (5.22 L/min) / (2.9 L/min/m2)\n SVR: 845 dynes*sec/cm5\n SV: 79 mL\n SVI: 36 mL/m2\n Total In:\n 5,655 mL\n 250 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,155 mL\n 250 mL\n Blood products:\n 500 mL\n Total out:\n 1,000 mL\n 1,115 mL\n Urine:\n 570 mL\n 970 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,655 mL\n -865 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 634 (386 - 634) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n Plateau: 11 cmH2O\n SPO2: 98%\n ABG: 7.40/41/110/24/0\n Ve: 9.5 L/min\n Physical Examination\n General: No acute distress\n HEENt: PERRL, anicteric\n Heart: s1s2 RRR\n Chest: Lungs CTA bilaterally, sternum stable\n Abd: Soft, NT/ND\n Ext: No edema; DP palp B\n Skin: Warm, dry\n Labs / Radiology\n 178 K/uL\n 9.4 g/dL\n 121 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.7 mEq/L\n 15 mg/dL\n 105 mEq/L\n 135 mEq/L\n 26.9 %\n 5.3 K/uL\n [image002.jpg]\n 01:06 PM\n 01:36 PM\n 02:15 PM\n 02:22 PM\n 03:23 PM\n 04:49 PM\n 05:52 PM\n 05:54 PM\n 02:09 AM\n 02:24 AM\n WBC\n 10.1\n 8.0\n 5.3\n Hct\n 25.8\n 27.5\n 28.6\n 26.9\n Plt\n 261\n 233\n 178\n Creatinine\n 0.8\n 0.7\n TCO2\n 25\n 25\n 22\n 27\n 24\n 26\n Glucose\n 21\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\n Lactic Acid:1.5 mmol/L\n Imaging: CXR: FINDINGS: In comparison with the study of\n , there are now metallic\n sternal sutures in place. Endotracheal tube tip lies approximately 5.7\n cm\n above the carina. Right IJ catheter extends to the proximal portion of\n the\n right pulmonary artery. Nasogastric tube extends well into the\n stomach.\n Bibasilar atelectasis, more prominent on the left. No evidence of\n pneumothorax.\n IMPRESSION: Standard appearance following cardiac surgery.\n Microbiology: MRSA: P\n Assessment and Plan\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan:\n 79M s/p AVR (25 tissue) , POD 1\n Neurologic: Neuro checks Q: 4 hr, Pain controlled\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor\n Pulmonary: IS, Cough, deep breathe, OOB.\n Gastrointestinal / Abdomen: Sips, ADAT. Bowel regimen.\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, Normal creatinine.\n Hematology: Stable anemia. No active bleeding.\n Endocrine: RISS, Insulin drip, Lantus (R), Transition from insulin gtt\n to RISS. Goal BS <150.\n Infectious Disease: Check cultures, Peri-op Vanco.\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults: CT surgery\n Billing Diagnosis: Post-op hypertension\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\n Lantus (R) protocol\n Lines:\n Cordis/Introducer - 02:00 PM\n 18 Gauge - 02:06 PM\n Comments: Change cordis to triple lumen CVL\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2174-08-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 581733,
"text": "CVICU\n HPI:\n POD 1\n s/p AVR (25 tissue) \n PMHx:\n EF > 65 Wt Cr. 0.8 HgbA1C: 7.1\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\n fem- bypass, L shoulder, removal of calcium , L knee surgery\n , ?renal stent in \n : Allopurinol 300', ASA 81', glyburide 5\", lisinopril 20', lovasa\n 2\", metformin 500\"', ocuvite, simvastatin 40'\n Current medications:\n 1. 2. 3. 250 mL D5W 4. Acetaminophen 5. Allopurinol 6. Aspirin EC 7.\n Calcium Gluconate 8. Dextrose 50% 9. Docusate Sodium 10. Furosemide 11.\n Insulin 12. Ketorolac 13. Ketorolac 14. Magnesium Sulfate 15.\n Metoclopramide 16. Metoprolol Tartrate 17. Milk of Magnesia 18.\n Morphine Sulfate 19. Nitroglycerin\n 20. Oxycodone-Acetaminophen 21. Pneumococcal Vac Polyvalent 22.\n Potassium Chloride 23. Ranitidine 24. Simvastatin 25. Sodium Chloride\n 0.9% Flush 26. Sodium Chloride 0.9% Flush 27. Vancomycin\n 24 Hour Events:\n ARTERIAL LINE - START 02:00 PM\n PA CATHETER - START 02:00 PM\n INVASIVE VENTILATION - START 02:00 PM\n CORDIS/INTRODUCER - START 02:00 PM\n EKG - At 04:00 PM\n INVASIVE VENTILATION - STOP 06:15 PM\n ARTERIAL LINE - STOP 06:28 AM\n - Extubtaed, no issues overnight\n - Remains in ICU on NTG gtt (now off) and insulin gtt (transitioning)\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 07:30 PM\n Infusions:\n Insulin - Regular - 8 units/hour\n Other ICU medications:\n Insulin - Regular - 02:38 PM\n Morphine Sulfate - 12:24 AM\n Furosemide (Lasix) - 01:50 AM\n Flowsheet Data as of 10:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 37.1\nC (98.8\n HR: 75 (61 - 82) bpm\n BP: 115/58(71) {106/50(64) - 115/58(71)} mmHg\n RR: 14 (12 - 21) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CVP: 3 (3 - 16) mmHg\n PAP: (20 mmHg) / (8 mmHg)\n CO/CI (Thermodilution): (5.22 L/min) / (2.9 L/min/m2)\n SVR: 845 dynes*sec/cm5\n SV: 79 mL\n SVI: 36 mL/m2\n Total In:\n 5,655 mL\n 250 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,155 mL\n 250 mL\n Blood products:\n 500 mL\n Total out:\n 1,000 mL\n 1,115 mL\n Urine:\n 570 mL\n 970 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,655 mL\n -865 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 634 (386 - 634) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n Plateau: 11 cmH2O\n SPO2: 98%\n ABG: 7.40/41/110/24/0\n Ve: 9.5 L/min\n Physical Examination\n General: No acute distress\n HEENt: PERRL, anicteric; s/p multiple upper teeth extractions, no\n purulence noted\n Heart: s1s2 RRR\n Chest: Lungs CTA bilaterally, sternum stable\n Abd: Soft, NT/ND\n Ext: No edema; DP palp B\n Skin: Warm, dry\n Labs / Radiology\n 178 K/uL\n 9.4 g/dL\n 121 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.7 mEq/L\n 15 mg/dL\n 105 mEq/L\n 135 mEq/L\n 26.9 %\n 5.3 K/uL\n [image002.jpg]\n 01:06 PM\n 01:36 PM\n 02:15 PM\n 02:22 PM\n 03:23 PM\n 04:49 PM\n 05:52 PM\n 05:54 PM\n 02:09 AM\n 02:24 AM\n WBC\n 10.1\n 8.0\n 5.3\n Hct\n 25.8\n 27.5\n 28.6\n 26.9\n Plt\n 261\n 233\n 178\n Creatinine\n 0.8\n 0.7\n TCO2\n 25\n 25\n 22\n 27\n 24\n 26\n Glucose\n 21\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\n Lactic Acid:1.5 mmol/L\n Imaging:\n CXR: FINDINGS: In comparison with the study of , there\n are now metallic\n sternal sutures in place. Endotracheal tube tip lies approximately 5.7\n cm\n above the carina. Right IJ catheter extends to the proximal portion of\n the\n right pulmonary artery. Nasogastric tube extends well into the\n stomach.\n Bibasilar atelectasis, more prominent on the left. No evidence of\n pneumothorax.\n IMPRESSION: Standard appearance following cardiac surgery.\n Microbiology:\n MRSA: P\n Assessment and Plan\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 79M s/p AVR (25 tissue) , POD 1\n Neurologic: Neuro checks Q: 4 hr, Pain controlled\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor\n Pulmonary: IS, Cough, deep breathe, OOB.\n Gastrointestinal / Abdomen: Sips, ADAT. Bowel regimen.\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, Normal creatinine.\n Hematology: Stable anemia. No active bleeding.\n Endocrine: RISS, Insulin drip, Lantus (R), Transition from insulin gtt\n to RISS. Goal BS <150.\n Infectious Disease: Check cultures, Peri-op Vanco.\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults: CT surgery\n Billing Diagnosis: Post-op hypertension\n ICU Care\n Nutrition: ADAT\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\n Lantus (R) protocol\n Lines:\n Cordis/Introducer - 02:00 PM\n 18 Gauge - 02:06 PM\n Comments: Change cordis to triple lumen CVL\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2174-08-02 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 581739,
"text": "CVICU\n HPI:\n POD 1\n s/p AVR (25 tissue)\n EF > 65 Wt Cr. 0.8 HgbA1C: 7.1\n PMHx:\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\n fem- bypass, L shoulder, removal of calcium , L knee surgery\n , ?renal stent in \n : Allopurinol 300', ASA 81', glyburide 5\", lisinopril 20', lovasa\n 2\", metformin 500\"', ocuvite, simvastatin 40'\n Current medications:\n Acetaminophen 5. Allopurinol 6. Aspirin EC 7. Calcium Gluconate 8.\n Dextrose 50% 9. Docusate Sodium 10. Furosemide 11. Insulin 12.\n Ketorolac . Magnesium Sulfate 15. Metoclopramide 16. Metoprolol\n Tartrate 17. Milk of Magnesia 18. Morphine Sulfate 19. Nitroglycerin\n 20. Oxycodone-Acetaminophen . Potassium Chloride 23. Ranitidine 24.\n Simvastatin Vancomycin\n 24 Hour Events:\n PA CATHETER - START 02:00 PM\n ARTERIAL LINE - START 02:00 PM\n INVASIVE VENTILATION - START 02:00 PM\n CORDIS/INTRODUCER - START 02:00 PM\n EKG - At 04:00 PM\n INVASIVE VENTILATION - STOP 06:15 PM\n ARTERIAL LINE - STOP 06:28 AM\n Post operative day:\n POD 1\n s/p AVR (25 tissue)\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 07:30 PM\n Infusions:\n Insulin - Regular - 8 units/hour\n Other ICU medications:\n Insulin - Regular - 02:38 PM\n Morphine Sulfate - 12:24 AM\n Furosemide (Lasix) - 01:50 AM\n Flowsheet Data as of 10:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 37.1\nC (98.8\n HR: 73 (61 - 82) bpm\n BP: 102/47(60) {102/47(60) - 115/58(71)} mmHg\n RR: 15 (12 - 21) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CVP: 3 (3 - 16) mmHg\n PAP: (20 mmHg) / (8 mmHg)\n CO/CI (Thermodilution): (5.22 L/min) / (2.9 L/min/m2)\n SVR: 757 dynes*sec/cm5\n SV: 81 mL\n SVI: 37 mL/m2\n Total In:\n 5,655 mL\n 740 mL\n PO:\n 480 mL\n Tube feeding:\n IV Fluid:\n 5,155 mL\n 260 mL\n Blood products:\n 500 mL\n Total out:\n 1,000 mL\n 1,195 mL\n Urine:\n 570 mL\n 990 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,655 mL\n -455 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 634 (386 - 634) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n Plateau: 11 cmH2O\n SPO2: 100%\n ABG: 7.40/41/110/24/0\n Ve: 9.5 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\n Left Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 178 K/uL\n 9.4 g/dL\n 121 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.7 mEq/L\n 15 mg/dL\n 105 mEq/L\n 135 mEq/L\n 26.9 %\n 5.3 K/uL\n [image002.jpg]\n 01:06 PM\n 01:36 PM\n 02:15 PM\n 02:22 PM\n 03:23 PM\n 04:49 PM\n 05:52 PM\n 05:54 PM\n 02:09 AM\n 02:24 AM\n WBC\n 10.1\n 8.0\n 5.3\n Hct\n 25.8\n 27.5\n 28.6\n 26.9\n Plt\n 261\n 233\n 178\n Creatinine\n 0.8\n 0.7\n TCO2\n 25\n 25\n 22\n 27\n 24\n 26\n Glucose\n 21\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\n Lactic Acid:1.5 mmol/L\n Assessment and Plan\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 79yo man s/p AVR(tissue) doing well\n post-operatively. Ready for transfer to stepdown floor\n Neurologic: Pain controlled, Morphine and percocet for pain control\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor,\n titrate Bblockers to HR/BP\n Pulmonary: IS, OOB-ambulate\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, start diuretic to make net negative 1-1.5\n liters today\n Hematology: stable hct\n Endocrine: RISS, Lantus (R)\n Infectious Disease: no active issues\n afebrie, normal wbc\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today, after ct removal\n Consults: CT surgery, \n ICU Care\n Nutrition: ADAT\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n Cordis/Introducer - 02:00 PM\n 18 Gauge - 02:06 PM\n Prophylaxis:\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2174-08-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 581802,
"text": "CVICU\n HPI:\n POD 1\n s/p AVR (25 tissue) \n PMHx:\n EF > 65 Wt Cr. 0.8 HgbA1C: 7.1\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\n fem- bypass, L shoulder, removal of calcium , L knee surgery\n , ?renal stent in \n : Allopurinol 300', ASA 81', glyburide 5\", lisinopril 20', lovasa\n 2\", metformin 500\"', ocuvite, simvastatin 40'\n Current medications:\n 1. 2. 3. 250 mL D5W 4. Acetaminophen 5. Allopurinol 6. Aspirin EC 7.\n Calcium Gluconate 8. Dextrose 50% 9. Docusate Sodium 10. Furosemide 11.\n Insulin 12. Ketorolac 13. Ketorolac 14. Magnesium Sulfate 15.\n Metoclopramide 16. Metoprolol Tartrate 17. Milk of Magnesia 18.\n Morphine Sulfate 19. Nitroglycerin\n 20. Oxycodone-Acetaminophen 21. Pneumococcal Vac Polyvalent 22.\n Potassium Chloride 23. Ranitidine 24. Simvastatin 25. Sodium Chloride\n 0.9% Flush 26. Sodium Chloride 0.9% Flush 27. Vancomycin\n 24 Hour Events:\n ARTERIAL LINE - START 02:00 PM\n PA CATHETER - START 02:00 PM\n INVASIVE VENTILATION - START 02:00 PM\n CORDIS/INTRODUCER - START 02:00 PM\n EKG - At 04:00 PM\n INVASIVE VENTILATION - STOP 06:15 PM\n ARTERIAL LINE - STOP 06:28 AM\n - Extubtaed, no issues overnight\n - Remains in ICU on NTG gtt (now off) and insulin gtt (transitioning)\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 07:30 PM\n Infusions:\n Insulin - Regular - 8 units/hour\n Other ICU medications:\n Insulin - Regular - 02:38 PM\n Morphine Sulfate - 12:24 AM\n Furosemide (Lasix) - 01:50 AM\n Flowsheet Data as of 10:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 37.1\nC (98.8\n HR: 75 (61 - 82) bpm\n BP: 115/58(71) {106/50(64) - 115/58(71)} mmHg\n RR: 14 (12 - 21) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CVP: 3 (3 - 16) mmHg\n PAP: (20 mmHg) / (8 mmHg)\n CO/CI (Thermodilution): (5.22 L/min) / (2.9 L/min/m2)\n SVR: 845 dynes*sec/cm5\n SV: 79 mL\n SVI: 36 mL/m2\n Total In:\n 5,655 mL\n 250 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,155 mL\n 250 mL\n Blood products:\n 500 mL\n Total out:\n 1,000 mL\n 1,115 mL\n Urine:\n 570 mL\n 970 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,655 mL\n -865 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 634 (386 - 634) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n Plateau: 11 cmH2O\n SPO2: 98%\n ABG: 7.40/41/110/24/0\n Ve: 9.5 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\n Left Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 178 K/uL\n 9.4 g/dL\n 121 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.7 mEq/L\n 15 mg/dL\n 105 mEq/L\n 135 mEq/L\n 26.9 %\n 5.3 K/uL\n [image002.jpg]\n 01:06 PM\n 01:36 PM\n 02:15 PM\n 02:22 PM\n 03:23 PM\n 04:49 PM\n 05:52 PM\n 05:54 PM\n 02:09 AM\n 02:24 AM\n WBC\n 10.1\n 8.0\n 5.3\n Hct\n 25.8\n 27.5\n 28.6\n 26.9\n Plt\n 261\n 233\n 178\n Creatinine\n 0.8\n 0.7\n TCO2\n 25\n 25\n 22\n 27\n 24\n 26\n Glucose\n 21\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\n Lactic Acid:1.5 mmol/L\n Imaging:\n CXR: FINDINGS: In comparison with the study of , there\n are now metallic\n sternal sutures in place. Endotracheal tube tip lies approximately 5.7\n cm\n above the carina. Right IJ catheter extends to the proximal portion of\n the\n right pulmonary artery. Nasogastric tube extends well into the\n stomach.\n Bibasilar atelectasis, more prominent on the left. No evidence of\n pneumothorax.\n IMPRESSION: Standard appearance following cardiac surgery.\n Microbiology:\n MRSA: P\n Assessment and Plan\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 79M s/p AVR (25 tissue) , POD 1\n Neurologic: Neuro checks Q: 4 hr, Pain controlled\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor\n Pulmonary: IS, Cough, deep breathe, OOB.\n Gastrointestinal / Abdomen: Sips, ADAT. Bowel regimen.\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, Normal creatinine.\n start lasix diuresis\n \n Hematology: Stable anemia. No active bleeding.\n Endocrine: RISS, Insulin drip\n start Lantus (R), Transition from\n insulin gtt to RISS. Goal BS <150.\n Infectious Disease: Check cultures, Peri-op Vanco.\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging: none\n Fluids: KVO\n Consults: CT surgery\n Billing Diagnosis: Post-op hypertension; Post-op hyperglycemia\n ICU Care\n Nutrition: ADAT\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\n Lantus (R) protocol\n Lines:\n Cordis/Introducer - 02:00 PM\n 18 Gauge - 02:06 PM\n Comments: Change cordis to triple lumen CVL\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2174-08-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581632,
"text": "Patient is a 79yo with SOB to OR for 25mm tissue valve. In OR\n patient with elevated blood glucose difficult to control despite\n insulin bolus and gtt. Patient admit to CVICU stable on propofol, neo,\n insulin gtt.\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Received patient with BP in 80\ns systolic.\n Neo titrated with minimal result.\n CI >2 with admission.\n Potassium low.\n Action:\n Patient apaced for blood pressure control with good result.\n Found to have a metabolic acidosis on ABG, fluid boluses\n given with correction of acidosis.\n CI remains >2.\n Patient hypertensive with waking, nitro started. Titrated to\n maintain BP <120.\n Repeat potassium and Hct pending\n Response:\n Patient with stable VS, in NSR with ademand backup.\n Plan:\n Plan for extubation\n Pain control (acute pain, chronic pain)\n Assessment:\n Received patient on propofol gtt. Reversed, propofol off.\n Action:\n Patient woke agitated, restless. Morphine 2mg x2 given. Patient calmer,\n following commands.\n Response:\n Continue to assess for pain. Extubate tonight.\n Plan:\n Continue to assess for pain. Morphine prn, transition to percocet\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Patient with hx of DDM type I on oral meds at baseline. Difficult\n control in OR\n Action:\n Insulin gtt titrated postop per protocol with max dose increased to\n 15units.\n Response:\n Patient with stable glucose levels on insulin gtt, titrated per CVICU\n protocol\n Plan:\n Continue insulin gtt, ? consult in am for control\n"
},
{
"category": "Nursing",
"chartdate": "2174-08-03 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 582009,
"text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt A&O, follows all commands and appropriate.\n HR-NSR 60\ns-80\ns. SBP 90\ns-110\ns. Doppler pulses.\n LS-CTA/Dim at bases. LO2 NC- 96-99%. Chest tubes draining minimal\n amounts of serosang. drainage.\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\n diet.\n Foley intact draining good amounts of clear yellow urine.\n Action:\n Pt received 3 doses of lopressor po since yesterday. Epicardial wires\n tested with A\ns sensing and capturing appropriately and V\ns sensing but\n not capturing. Pt set on A demand at 50.\n Pt encouraged to C&DB and IS used .\n Pt continued on lasix drip 20mg IV bid.\n Response:\n Vitals unchanged at this time. Pt OOB to chair and chest tubes with\n minimal amount of output. Chest tubes D/C\nd in am and chest x-ray\n performed showing atelectasis NP .\n Plan:\n Continue to administer beta blocker, monitor lytes and replete, monitor\n UOP and diurese.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o incisional pain with movement/C&DB.\n Action:\n Pt given toradol/percocets.\n Response:\n Pt appears comfortable in chair at this time. When C&DB, pt c/o \n pain and given percoets in am/afternoon.\n Plan:\n Continue to monitor pain level and administer pain meds.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with blood sugars 110\ns-170\ns and received on insulin drip at 3\n units/hr.\n Action:\n Pt continuing on insulin drip. At 0700, pt given 50units lantus SC \n NP . Pt also started on own humalog ISS and given 6 units of\n humalog SC for BS 117 at 0800. At 0900, drip shut off and at 1000 pt\n with BS 150\n Response:\n At 1200, pt with blood sugar 178 and given 14 units humalog insulin SC\n per ISS.\n Plan:\n Continue to check blood sugars and administer insulin per own ISS.\n Pt with R IJ TLC that was changed over wire on . Pt last received\n 2 percocets at 1200 and finished with toradol. Pt with last blood\n sugar 160 at 1400 with no coverage. NP and check next sugar\n before dinner. Pt refused lunch at this time. Foley D/C\nd at 1430.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n AORTIC STENOSIS\n Code status:\n Full code\n Height:\n 70 Inch\n Admission weight:\n 104 kg\n Daily weight:\n 111 kg\n Allergies/Reactions:\n Penicillins\n Unknown;\n Precautions: No Additional Precautions\n PMH: Diabetes - Oral \n CV-PMH: PVD\n Additional history: Patient with hx of BPH, gout, macular degeneration.\n s/p B fem- bypass 3-4 years PTA, L shoulder removal of calcium ,\n L knee surgery , ?renal stent in \n Surgery / Procedure and date: AVR 25mm tissue valve.\n XCL 75, bypass 51. Stable OR course. Blood glucose >200 thru case with\n 25units blous, insulin gtt to 12units. Difficult to come off\n pump->ectopy, RAF treated with amio bolus. Admit CVICU on neo, prop.\n Apaced for blood pressure support..\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:109\n D:55\n Temperature:\n 98.5\n Arterial BP:\n S:115\n D:47\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 66 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 196 mL\n 24h total out:\n 1,935 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 50 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 1.2 mV\n Temporary atrial sensitivity setting:\n 0.6 mV\n Temporary atrial stimulation threshold :\n 12 mA\n Temporary atrial stimulation setting:\n 20 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 0.8 mV\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 02:06 AM\n Potassium:\n 3.9 mEq/L\n 02:06 AM\n Chloride:\n 101 mEq/L\n 02:06 AM\n CO2:\n 28 mEq/L\n 02:06 AM\n BUN:\n 17 mg/dL\n 02:06 AM\n Creatinine:\n 0.8 mg/dL\n 02:06 AM\n Glucose:\n 120 mg/dL\n 02:06 AM\n Hematocrit:\n 25.1 %\n 02:06 AM\n Finger Stick Glucose:\n 160\n 02:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables: Valuables in safe on 6 per pt.\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 6\n Date & time of Transfer: 1500\n"
},
{
"category": "Physician ",
"chartdate": "2174-08-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 581978,
"text": "CVICU\n HPI:\n POD 2\n s/p AVR (25 tissue)\n PMHx:\n EF > 65 Wt 104K Cr. 0.8 HgbA1C: 7.1\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\n fem- bypass, L shoulder, removal of calcium , L knee surgery\n , ?renal stent in \n : Allopurinol 300', ASA 81', glyburide 5\", lisinopril 20', lovasa\n 2\", metformin 500\"', ocuvite, simvastatin 40'\n Current medications:\n . 2. 3. 4. 250 mL D5W 5. Acetaminophen 6. Allopurinol 7. Aspirin EC 8.\n Calcium Gluconate 9. Cepacol (Menthol) 10. Dextrose 50% 11. Docusate\n Sodium 12. Furosemide 13. GlyBURIDE 14. Insulin 15. Insulin 16.\n Magnesium Sulfate 17. Metoclopramide 18. Metoprolol Tartrate 19. Milk\n of Magnesia 20. Morphine Sulfate 21. Nitroglycerin 22.\n Oxycodone-Acetaminophen 23. Pneumococcal Vac Polyvalent 24. Potassium\n Chloride 25. Ranitidine 26. Simvastatin 27. Sodium Chloride 0.9% Flush\n 28. Sodium Chloride 0.9% Flush 29. Sodium Chloride 0.9% Flush 30.\n Vancomycin\n 24 Hour Events:\n PA CATHETER - STOP 08:05 AM\n CORDIS/INTRODUCER - STOP 06:00 PM\n MULTI LUMEN - START 06:00 PM\n - Remained in ICU for elevated BS, on insulin gtt\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:16 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:04 AM\n Flowsheet Data as of 12:16 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.9\nC (98.5\n HR: 63 (63 - 80) bpm\n BP: 109/39(57) {104/39(56) - 136/77(89)} mmHg\n RR: 15 (14 - 21) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111 kg (admission): 104 kg\n Height: 70 Inch\n Total In:\n 1,158 mL\n 196 mL\n PO:\n 580 mL\n Tube feeding:\n IV Fluid:\n 578 mL\n 196 mL\n Blood products:\n Total out:\n 2,260 mL\n 1,785 mL\n Urine:\n 1,995 mL\n 1,725 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,102 mL\n -1,589 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress, Comfortable\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 164 K/uL\n 8.9 g/dL\n 120 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 17 mg/dL\n 101 mEq/L\n 135 mEq/L\n 25.1 %\n 5.8 K/uL\n [image002.jpg]\n 01:36 PM\n 02:15 PM\n 02:22 PM\n 03:23 PM\n 04:49 PM\n 05:52 PM\n 05:54 PM\n 02:09 AM\n 02:24 AM\n 02:06 AM\n WBC\n 8.0\n 5.3\n 5.8\n Hct\n 27.5\n 28.6\n 26.9\n 25.1\n Plt\n 233\n 178\n 164\n Creatinine\n 0.8\n 0.7\n 0.8\n TCO2\n 25\n 22\n 27\n 24\n 26\n Glucose\n 198\n 163\n 121\n 120\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\n Lactic Acid:1.5 mmol/L, Ca:8.7 mg/dL, Mg:1.5 mg/dL\n Imaging:\n CXR: s/p removal of CT, no ptx, post-op changes noted, line in\n place\n Microbiology:\n MRSA: negative\n Assessment and Plan\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 79 M s/p AVR (25 tissue), POD 2\n Neurologic: Neuro checks Q: hr, Pain controlled.\n Cardiovascular: Aspirin, Beta-blocker\n Pulmonary: IS, Cough, IS, OOB to chair.\n Gastrointestinal / Abdomen: Bowel regimen.\n Nutrition: Sips, ADAT.\n Renal: Foley, Adequate UO, Creat 0.8. Diurese with goal negative 1 L.\n Hematology: Stable anemia, no active bleeding.\n Endocrine: RISS, Insulin drip, Lantus (R), Transition from gtt to\n Lantus, RISS. Goal BS < 150.\n Infectious Disease: Check cultures, Received peri-op Vanco. Afebrile,\n nomral WBC, no active ID issues at this time.\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: None\n Fluids: KVO\n Consults: CT surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\n Lantus (R) protocol\n Lines:\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2174-08-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 581980,
"text": "CVICU\n HPI:\n POD 2 s/p AVR (25 tissue)\n PMHx:\n EF > 65 Wt 104K Cr. 0.8 HgbA1C: 7.1\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\n fem- bypass, L shoulder, removal of calcium , L knee surgery\n , ?renal stent in \n : Allopurinol 300', ASA 81', glyburide 5\", lisinopril 20', lovasa\n 2\", metformin 500\"', ocuvite, simvastatin 40'\n Current medications:\n . 2. 3. 4. 250 mL D5W 5. Acetaminophen 6. Allopurinol 7. Aspirin EC 8.\n Calcium Gluconate 9. Cepacol (Menthol) 10. Dextrose 50% 11. Docusate\n Sodium 12. Furosemide 13. GlyBURIDE 14. Insulin 15. Insulin 16.\n Magnesium Sulfate 17. Metoclopramide 18. Metoprolol Tartrate 19. Milk\n of Magnesia 20. Morphine Sulfate 21. Nitroglycerin 22.\n Oxycodone-Acetaminophen 23. Pneumococcal Vac Polyvalent 24. Potassium\n Chloride 25. Ranitidine 26. Simvastatin 27. Sodium Chloride 0.9% Flush\n 28. Sodium Chloride 0.9% Flush 29. Sodium Chloride 0.9% Flush 30.\n Vancomycin\n 24 Hour Events:\n PA CATHETER - STOP 08:05 AM\n CORDIS/INTRODUCER - STOP 06:00 PM\n MULTI LUMEN - START 06:00 PM\n - Remained in ICU for elevated BS, on insulin gtt\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:16 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:04 AM\n Flowsheet Data as of 12:16 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.9\nC (98.5\n HR: 63 (63 - 80) bpm\n BP: 109/39(57) {104/39(56) - 136/77(89)} mmHg\n RR: 15 (14 - 21) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111 kg (admission): 104 kg\n Height: 70 Inch\n Total In:\n 1,158 mL\n 196 mL\n PO:\n 580 mL\n Tube feeding:\n IV Fluid:\n 578 mL\n 196 mL\n Blood products:\n Total out:\n 2,260 mL\n 1,785 mL\n Urine:\n 1,995 mL\n 1,725 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,102 mL\n -1,589 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress, Comfortable\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 164 K/uL\n 8.9 g/dL\n 120 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 17 mg/dL\n 101 mEq/L\n 135 mEq/L\n 25.1 %\n 5.8 K/uL\n [image002.jpg]\n 01:36 PM\n 02:15 PM\n 02:22 PM\n 03:23 PM\n 04:49 PM\n 05:52 PM\n 05:54 PM\n 02:09 AM\n 02:24 AM\n 02:06 AM\n WBC\n 8.0\n 5.3\n 5.8\n Hct\n 27.5\n 28.6\n 26.9\n 25.1\n Plt\n 233\n 178\n 164\n Creatinine\n 0.8\n 0.7\n 0.8\n TCO2\n 25\n 22\n 27\n 24\n 26\n Glucose\n 198\n 163\n 121\n 120\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\n Lactic Acid:1.5 mmol/L, Ca:8.7 mg/dL, Mg:1.5 mg/dL\n Imaging:\n CXR: s/p removal of CT, no ptx, post-op changes noted, line in\n place\n Microbiology:\n MRSA: negative\n Assessment and Plan\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 79 M s/p AVR (25 tissue), POD 2\n Neurologic: Neuro checks Q: hr, Pain controlled.\n Cardiovascular: Aspirin, Beta-blocker\n Pulmonary: IS, Cough, IS, OOB to chair.\n Gastrointestinal / Abdomen: Bowel regimen.\n Nutrition: Sips, ADAT.\n Renal: Foley, Adequate UO, Creat 0.8. Diurese with goal negative 1 L.\n Hematology: Stable anemia, no active bleeding.\n Endocrine: RISS, Insulin drip, Lantus (R), Transition from gtt to\n Lantus, increased Glyburide to home dose, RISS. Goal BS < 150. Holding\n metformin while being diuresed.\n Infectious Disease: Check cultures, Received peri-op Vanco. Afebrile,\n nomral WBC, no active ID issues at this time.\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: None\n Fluids: KVO\n Consults: CT surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\n Lantus (R) protocol\n Lines:\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"
},
{
"category": "Rehab Services",
"chartdate": "2174-08-03 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 581986,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 424.1 / AVR\n Reason of referral: PT consult\n History of Present Illness / Subjective Complaint: Pt is a 79 y/o male\n admitted with SOB, ECHO revealed severe aortic stenosis. Pt now\n s/p AVR ( tissue), POD #2. BPT 54 minutes and XCL 75 minutes.\n and pt extubated . Pt doing well post-operatively and is ready for\n transfer to stepdown floor.\n Past Medical / Surgical History: DM 2, HTN, hyperlipidemia, B fem-\n bypass yrs/ago, L knee surgery '\n Medications: glyburide, metoprolol, furosemide, allopurinol,\n simvastatin, rantidine, ASA, acetaminophen, oxycodone, vancomycin,\n morphine\n Radiology: CT chest: no PTX, lung volumes sl decreased\n Labs:\n 25.1\n 8.9\n 164\n 5.8\n [image002.jpg]\n Other labs:\n Activity Orders: Advance per C- guidelines\n Social / Occupational History: lives with wife, wife has dementia but\n is I with amb, ADLS and limited IADLS ( can do laundry, can't drive)\n supportive children live 1 hr/away; supportive neighbors; enjoys\n golfing 1-2x/week\n Living Environment: FOS to bedroom, laundry\n house cleaner 1x/2 weeks\n Prior Functional Status / Activity Level: I PTA without AD, with\n ADLS/IADLS\n + driving\n denies hx of falls other that 1 in which pt slipped and fell off roof\n Objective Test\n Arousal / Attention / Cognition / Communication: Axox3\n Comm: pleasant, NAD and willing to participate\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n Pt found sitting in chair\n /\n Rest\n 64\n 103/46\n 16\n 97% on 3 L 02 NC\n Sit\n 68\n 134/54\n 21\n 100% on 3 L o2 NC\n Activity\n 77\n 107/51\n 20\n 100% on 3 L o2 NC\n 13\n Stand\n 70\n 105/62\n 16\n 98% on 3 L 02 NC\n Recovery\n 72\n 110/71\n 21\n 96% on 3 L o2 NC\n Total distance walked:\n Minutes:\n Pulmonary Status: CTA B'lly, diminished BS at bases, +\n dry/strong/nonproductive cough, breathing non-labored\n IS to 1250 mL\n Integumentary / Vascular: PIV, central line, telemetry, pacer + wires,\n foley/catheter, \\\n increase swelling B UEs/ -pitting\n Sensory Integrity: B UEs / to light touch\n Pain / Limiting Symptoms: pt denies any pain at this time\n Posture: pt found sitting up in recliner\n Range of Motion\n Muscle Performance\n WFL B UEs/LEs\n B UEs/LEs except B she motions >3/5 sternal precautions\n Motor Function: pt MAE in isolation\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: sit-stand with cgA x1 and ambulated 120' pushing\n wheelchair with cgA x1, normal speed/step length, no LOB noted\n Rolling:\n NT\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n NT\n\n\n\n\n\n\n Transfer:\n\n T\n\n\n\n Sit to Stand:\n\n T\n\n\n\n Ambulation:\n 120\n pushing w/c\n\n\n T\n\n\n\n Stairs:\n NT\n\n\n\n\n\n\n Balance: S with static standing without UE support, no LOB\n cgA with dynamic standing with UE support, no LOB\n Education / Communication: Educ: Educated pt on role of PT, progress\n thus far, pt status, sternal precautions/ activity guidelines, and\n discharge plan- pt verbalized good understanding\n Comm: communicated with RN and NP re: pt status and discharge plan\n Intervention: Issued cardiac booklet and reviewed activity guidelines/\n sternal precautions\n Diagnosis:\n Impaired functional mobility\n Impaired HDR with functional mobility\n Impaired balance\n Knowledge deficit\n Impaired gas exchange\n Clinical impression / Prognosis: Pt is a 79 y/o male s/p AVR, now POD\n #2. Pt p/w above impairments c/w cardiovascular pump dysfunction. Pt\n lives with wife and was I and very active PTA. Pt cgA with sit-stand\n and ambulated 120' pushing w/c with cgA- no LOB. Pt reports his wife\n can A with laundry at d/c and has neighbors/children who can assist\n with IADLS as needed. Anticipate pt will be safe for discharge home in\n treatments. Will continue to follow as appropriate.\n Goals\n Time frame: 1-2x more\n 1.\n 500' s AD c I no LOB\n 2.\n I with bed mobility with HOB flat\n 3.\n I with FOS no LOB\n 4.\n I verbalize sternal precautions\n 5.\n 02 sat >92% on RA with all functional mobility\n 6.\n Stable HDR with all functional mobility\n Anticipated Discharge: Home without PT\n Treatment :\n Frequency / Duration: 1-2x more x 1 week\n bed mobility, transfers, progress ambulation, stair negotiation, pt\n education, discharge planning, issue walking program, wean o2\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n Addendum: Pt open to d/c home but not 100% agreeable at this time.\n Recommendations for NSG: Ambulate 3x/day with cgA\n Face Time: 10:35-11:15\n"
},
{
"category": "Physician ",
"chartdate": "2174-08-03 00:00:00.000",
"description": "CVICU",
"row_id": 581987,
"text": "CVICU\n HPI:\n POD 2 s/p AVR (25 tissue)\n PMHx:\n EF > 65 Wt 104K Cr. 0.8 HgbA1C: 7.1\n PMH: DM, HTN, hyperlipidemia, BPH, PVD, Gout, Macular degeneration, B\n fem- bypass, L shoulder, removal of calcium , L knee surgery\n , ?renal stent in \n : Allopurinol 300', ASA 81', glyburide 5\", lisinopril 20', lovasa\n 2\", metformin 500\"', ocuvite, simvastatin 40'\n Current medications:\n Acetaminophen, Allopurinol, Aspirin EC, Cepacol (Menthol), Docusate\n Sodium, Furosemide, GlyBURIDE, Insulin, Metoprolol Tartrate, Morphine\n Sulfate, Oxycodone-Acetaminophen, Ranitidine, Simvastatin, Vancomycin\n 24 Hour Events:\n Remained in ICU for blood glucose management, requiring insulin drip\n PA CATHETER - STOP 08:05 AM\n CORDIS/INTRODUCER - STOP 06:00 PM\n MULTI LUMEN - START 06:00 PM\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:16 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:04 AM\n Flowsheet Data as of 12:16 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.9\nC (98.5\n HR: 63 (63 - 80) bpm\n BP: 109/39(57) {104/39(56) - 136/77(89)} mmHg\n RR: 15 (14 - 21) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111 kg (admission): 104 kg\n Height: 70 Inch\n Total In:\n 1,158 mL\n 196 mL\n PO:\n 580 mL\n Tube feeding:\n IV Fluid:\n 578 mL\n 196 mL\n Blood products:\n Total out:\n 2,260 mL\n 1,785 mL\n Urine:\n 1,995 mL\n 1,725 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,102 mL\n -1,589 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress, Comfortable\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 164 K/uL\n 8.9 g/dL\n 120 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 17 mg/dL\n 101 mEq/L\n 135 mEq/L\n 25.1 %\n 5.8 K/uL\n 01:36 PM\n 02:15 PM\n 02:22 PM\n 03:23 PM\n 04:49 PM\n 05:52 PM\n 05:54 PM\n 02:09 AM\n 02:24 AM\n 02:06 AM\n WBC\n 8.0\n 5.3\n 5.8\n Hct\n 27.5\n 28.6\n 26.9\n 25.1\n Plt\n 233\n 178\n 164\n Creatinine\n 0.8\n 0.7\n 0.8\n TCO2\n 25\n 22\n 27\n 24\n 26\n Glucose\n 198\n 163\n 121\n 120\n Other labs: PT / PTT / INR:14.5/35.3/1.3, Differential-Neuts:65.0 %,\n Band:12.0 %, Lymph:19.0 %, Mono:4.0 %, Eos:0.0 %, Fibrinogen:299 mg/dL,\n Lactic Acid:1.5 mmol/L, Ca:8.7 mg/dL, Mg:1.5 mg/dL\n Imaging:\n CXR: s/p removal of CT, no ptx, post-op changes noted, line in\n place\n Microbiology: MRSA: negative\n Assessment and Plan\n .H/O DIABETES MELLITUS (DM), TYPE II, VALVE REPLACEMENT, AORTIC\n BIOPROSTHETIC (AVR), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Neurologic: Neuro checks Q: hr, Pain controlled. Percocet prn pain\n Cardiovascular: Aspirin, Beta-blocker statin\n Pulmonary: IS, Cough, IS, OOB to chair.\n Gastrointestinal / Abdomen: Bowel regimen.\n Nutrition: diabetic diet\n Renal: Foley, Adequate UO, Creat 0.8. Diurese with goal negative 1000\n ml for 24 hours\n Hematology: Stable anemia, no active bleeding.\n Endocrine: RISS, Insulin drip, Lantus (R), Transition from gtt to\n Lantus, increased Glyburide to home dose, RISS. Goal BS < 150. Holding\n metformin while being diuresed.\n Infectious Disease: Check cultures, Received peri-op Vancomycin.\n Afebrile, nomral WBC, no evidence of infection\n Lines / Tubes / Drains: Foley, pacing wires\n Wounds: Dry dressings\n Consults: PT\n ICU \n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\n Lantus (R) protocol\n Lines:\n Multi Lumen - 06:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2174-08-03 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 581993,
"text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt A&O, follows all commands and appropriate.\n HR-NSR 60\ns-80\ns. SBP 100\ns-110\ns. Doppler pulses. K-4.7 and ionized\n calcium 1.16 with am labs.\n LS-CTA/Dim at bases. 3-4LO2 NC- 96-99%. Chest tubes draining minimal\n amounts of serosang. drainage.\n Abd. soft with +BS x4. Pt with no N/V and tolerating diabetic/cardiac\n diet.\n Foley intact draining good amounts of clear yellow urine.\n Action:\n Pt weaned off nitro drip and started on lopressor 25mg po bid at 0800.\n Epicardial wires tested with A\ns sensing and capturing appropriately\n and V\ns sensing but not capturing. Pt set on A demand at 50.\n Pt encouraged to C&DB and IS used 500-750.\n Pt started on lasix 20mg last night and continued.\n Response:\n Vitals unchanged at this time. Pt OOB to chair and chest tubes with\n minimal amount of output. At 1100, pt with only 40cc\ns of urine past 2\n hrs. and 20mg lasix IV given NP order.\n Plan:\n Continue to administer beta blocker, monitor lytes and replete, monitor\n UOP and diurese.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o incisional pain with movement/C&DB.\n Action:\n Pt given toridol 15mg IV at 0800.\n Response:\n Pt appears comfortable in chair at this time. When C&DB, pt c/o \n pain and given percoets in am/afternoon.\n Plan:\n Continue to monitor pain level and administer pain meds.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with blood sugars 110\ns-170\ns and received on insulin drip at 3\n units/hr.\n Action:\n Pt continuing on insulin drip. At 0700, pt given 50units lantus SC \n NP . Pt also started on own humalog ISS and given 6 units of\n humalog SC for BS 117 at 0800. At 0900, drip shut off and at 1000 pt\n with BS 150\n Response:\n At 1200, pt with blood sugar 178 and given 14 units humalog insulin SC\n per ISS.\n Plan:\n Continue to check blood sugars and administer insulin per own ISS.\n"
},
{
"category": "Echo",
"chartdate": "2174-08-01 00:00:00.000",
"description": "Report",
"row_id": 89237,
"text": "PATIENT/TEST INFORMATION:\nIndication: aortic stenosis\nHeight: (in) 71\nWeight (lb): 236\nBSA (m2): 2.26 m2\nBP (mm Hg): 160/90\nHR (bpm): 69\nStatus: Inpatient\nDate/Time: at 11:43\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\npre-CPB: 79 yr old male w/ pmhx of htn, hyperlipidemia, and NIDDM with aortic\nstenosis symptomology of progressive dyspnea. Intra-operative TEE revealed\npreserved left ventricular systolic function with no detectable wall motion\nabnormalities. Continuity evaluation confirmed pre-operative diagnosis of\nsevere aortic stenosis. Severe MAC was seen and mitral valve area by presssure\nhalf-time was 2.0 cm2. There was no evidence of ASD/PFO via interrogation with\ncolor flow doppler. Findings were communicated to the surgeon prior to\nincision.\n\n Internal billing error corrected. No changes made to findings. WJM\nLEFT ATRIUM: Normal LA and RA cavity sizes. Good (>20 cm/s) LAA ejection\nvelocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA. A catheter or pacing wire is seen in the RA and extending into\nthe RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic\nvalve leaflets. Severe AS (area 0.8-1.0cm2). No AR.\n\nMITRAL VALVE: Severely thickened/deformed mitral valve leaflets. Severe mitral\nannular calcification. Mild functional MS due to MAC. Physiologic MR (within\nnormal limits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. A TEE was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was under general anesthesia throughout the procedure.\nThe patient received antibiotic prophylaxis. The TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\ncomplications.\npost-CPB: Patient was weaned off CPB with 0.5 mcg/kg/min of phenylephrine.\nAorta was evaluated and no evidence of dissection was seen. LV systolic\nfunction was similar to the pre-bypass period with no new recognizable RWMA. A\nwell seated aortic bioprosthesis was noted without residual regurgitation.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. No atrial septal\ndefect is seen by 2D or color Doppler. Left ventricular wall thicknesses and\ncavity size are normal. Overall left ventricular systolic function is normal\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThere are three aortic valve leaflets. The aortic valve leaflets are severely\nthickened/deformed. There is severe aortic valve stenosis (valve area\n0.8-1.0cm2). No aortic regurgitation is seen. The mitral valve leaflets are\nseverely thickened/deformed. There is severe mitral annular calcification.\nThere is mild functional mitral stenosis due to mitral annular calcification.\nPhysiologic mitral regurgitation is seen (within normal limits). There is no\npericardial effusion.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2174-07-27 00:00:00.000",
"description": "Report",
"row_id": 89238,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Preoperative assessment.\nHeight: (in) 70\nWeight (lb): 236\nBSA (m2): 2.24 m2\nBP (mm Hg): 150/82\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 15:47\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Definity\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS\n(area 0.8-1.0cm2). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Severe mitral annular\ncalcification. Mild thickening of mitral valve chordae. Calcified tips of\npapillary muscles. Mod functional MS due to MAC.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size and regional/global systolic\nfunction (LVEF>55%). The aortic root is mildly dilated at the sinus level. The\naortic valve leaflets are severely thickened/deformed. There is severe aortic\nvalve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is severe mitral annular\ncalcification leading to moderate functional mitral stenosis (mean gradient 4\nmmHg). Moderate [2+] tricuspid regurgitation is seen. The pulmonary artery\nsystolic pressure could not be determined. There is no pericardial effusion.\n\nIMPRESSION: Severe aortic valve stenosis. Moderate functional mitral stenosis\nfrom MAC. Mild symmetric left ventricular hypertrophy with preserved global\nand regional biventricular systolic function. Dilated thoracic aorta.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2174-08-01 00:00:00.000",
"description": "Report",
"row_id": 233027,
"text": "Sinus rhythm. Prolonged Q-T interval;. Intraventricular conduction delay.\nCompared to the previous tracing of the Q-T interval is now prolonged.\n\n"
},
{
"category": "ECG",
"chartdate": "2174-07-28 00:00:00.000",
"description": "Report",
"row_id": 233028,
"text": "Normal sinus rhythm, rate 85. Left anterior hemiblock. Borderline\nintraventricular conduction delay. No previous tracing available for\ncomparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1085369,
"text": " 7:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ct removal ? ptx\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with s/p avr\n REASON FOR THIS EXAMINATION:\n s/p ct removal ? ptx\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after aortic valve\n replacement.\n\n Portable AP chest radiograph was compared to .\n\n The right internal jugular line tip is at the cavoatrial junction. There is\n improvement of left basal atelectasis with minimal opacity still present. The\n lungs otherwise are essentially clear with no evidence of substantial pleural\n effusion or pneumothorax. Cardiomediastinal silhouette is stable.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-02 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1085328,
"text": " 6:07 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o ptx assess line placement\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man s/p avr and CVL change\n REASON FOR THIS EXAMINATION:\n r/o ptx assess line placement\n ______________________________________________________________________________\n WET READ: AGLc TUE 10:50 PM\n ETT/NGT removed. Swan and sheath removed, replaced with Rt IJ CVL which\n terminates in mid-SVC. mediastinal/pleural drains remain in place. No new\n PTX, mediastinal widening or large effusio, although Rt lateral sulcus\n excluded. lung volumes sl decreased.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: A 79-year-old male status post aortic valve replacement and\n central venous line change. Evaluate for pneumothorax.\n\n Single AP chest radiograph compared to shows repositioning of a\n right IJ central venous catheter with tip now located in the distal SVC/right\n cavoatrial junction. Chest tubes and mediastinal drains are again identified.\n There is mild left retrocardiac atelectasis, unchanged. The right lung is\n clear. The right extreme CP angle has been excluded. No pneumothorax.\n\n IMPRESSION: No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-05 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1085727,
"text": " 10:11 AM\n CHEST (PA & LAT) Clip # \n Reason: f/u atelectasis\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with s/p AVR\n REASON FOR THIS EXAMINATION:\n f/u atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after aortic valve\n replacement.\n\n PA and lateral upright chest radiographs were compared to .\n\n Right internal jugular line tip is at the cavoatrial junction.\n Cardiomediastinal silhouette is stable. There are bibasilar opacities\n consistent with atelectasis accompanied by small amount of pleural effusion.\n Anterior mediastinal air cannot be excluded most likely related to prior\n surgery but there is no evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-01 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1085130,
"text": " 4:16 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pleural effusion, pulmonary edema, tamponade, pneumothorax.\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with AVR\n REASON FOR THIS EXAMINATION:\n Pleural effusion, pulmonary edema, tamponade, pneumothorax. \n with issues.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: AVR.\n\n FINDINGS: In comparison with the study of , there are now metallic\n sternal sutures in place. Endotracheal tube tip lies approximately 5.7 cm\n above the carina. Right IJ catheter extends to the proximal portion of the\n right pulmonary artery. Nasogastric tube extends well into the stomach.\n Bibasilar atelectasis, more prominent on the left. No evidence of\n pneumothorax.\n\n IMPRESSION: Standard appearance following cardiac surgery.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-07-27 00:00:00.000",
"description": "TEETH (PANOREX FOR DENTAL)",
"row_id": 1084257,
"text": " 3:54 PM\n TEETH (PANOREX FOR DENTAL) Clip # \n Reason: eval for caries\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man pre-op AVR\n REASON FOR THIS EXAMINATION:\n eval for caries\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Panorex.\n\n HISTORY: Pre-op AVR, evaluate for caries.\n\n FINDINGS:\n\n The mandibular teeth appear unremarkable without evidence of periapical\n lucency. Multiple maxillary teeth are absent. Evaluation of the maxillary\n teeth for carries is limited due to overlap from the adjacent osseous\n structures.\n\n IMPRESSION:\n\n 1. Normal mandibular teeth.\n\n 2. Limited evaluation of the maxillary teeth. The collapse due to overlap\n affirmed adjacent osseous structures.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-07-27 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1084256,
"text": " 3:54 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: AORTIC STENOSIS\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man pre-op AVR\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions pre-op AVR\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old male preop for AVR. Evaluate for pleural effusion.\n\n PA and lateral chest radiographs without comparison shows clear lungs. The\n lungs are mildly hyperinflated. The heart, mediastinum, hila and pulmonary\n vascularity are normal.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-07-28 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1084432,
"text": " 11:53 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval for aortic anatomy, mitral calcifications.NO contrast r\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with knwon AS- Mitral calcifications seen on ech and dilated Ao\n root\n REASON FOR THIS EXAMINATION:\n eval for aortic anatomy, mitral calcifications.NO contrast recent dye load for\n cath and has been on metformin- no on hold\n CONTRAINDICATIONS for IV CONTRAST:\n recent dye load for cath\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old male with known aortic stenosis and mitral annular\n calcification with dilated aortic root seen on echo. Evaluate anatomy.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast MDCT-acquired axial images of the chest from the\n thoracic inlet to the upper abdomen. Multiplanar reformatted images were\n obtained.\n\n CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: There is heavy calcification at\n the base of the aorta, arch, and desceding aorta. The aortic valve and mitral\n annulus are heavily calcified. The aorta is normal in caliber. The heart size\n is normal. Small amount of pericardial fluid may be physiologic.\n\n The lungs are clear. The tracheobronchial tree is normal to the subsegmental\n level. There is no pleural abnormality. The central lymph nodes are not\n enlarged. The bones show no lesion worrisome for osseous metastases. There is\n three vessel coronary artery calcification. Limited view of the upper abdomen\n is unremarkable. The bones show no lesion worrisome for osseous metastasis.\n\n IMPRESSION: Heavy calcification at the base of the aorta, arch, and desceding\n aorta. The aortic valve and mitral annulus are also heavily calcified. These\n images are available for review for surgical planning.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-07-28 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 1084389,
"text": " 9:14 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: PREOP AVR\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man pre-op AVR\n REASON FOR THIS EXAMINATION:\n eval for stenosis\n ______________________________________________________________________________\n FINAL REPORT\n\n Standard Report Carotid US\n\n Study: Carotid Series Complete\n\n Reason: Pre op AVR\n\n Findings: Duplex evaluation was performed of bilateral carotid arteries. On\n the right there is mild heterogeneous plaque with calcifications in the ICA.\n On the left there is mild heterogeneous plaque in the ICA.\n\n On the right systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 55/18, 88/25, 77/22 cm/sec. CCA peak systolic\n velocity is 65 cm/sec. ECA peak systolic velocity is 258 cm/sec. The ICA/CCA\n ratio is ?. These findings are consistent with <40%stenosis.\n\n On the left systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 44/10, 55/16, 55/15 cm/sec. CCA peak systolic\n velocity is 73 cm/sec. ECA peak systolic velocity is 85 cm/sec. The ICA/CCA\n ratio is .75. These findings are consistent with <40% stenosis.\n\n There is antegrade right vertebral artery flow.\n There is antegrade left vertebral artery flow.\n\n Impression: Right ICA stenosis <40%.\n Left ICA stenosis <40%.\n\n"
}
] |
4,556 | 137,689 | The patient was seen by Dr. who felt the patient would require emergent evacuation of the left subdural hematoma. He was, therefore, taken to the OR and underwent a left frontal craniotomy for excision of the subdural hematoma without intraoperative complication. Postoperatively, the patient was monitored in the ICU for close neurologic observation. The vital signs were stable. He was afebrile. His pupils were 1 mm and reactive bilaterally, moving all extremities, and responds to pain - left greater than right. His right lower extremity toes were upgoing and he withdrew his lower extremities to pain. The left lower extremity was downgoing. His incision was clean, dry, and intact. He had a JP drain in which drained 60 cc of bloody fluid. On postoperative day number one, the patient was extubated. Continued to follow commands and speech was clear once extubated. A repeat head CT showed good evacuation of the subdural hematoma. The patient remained neurologically stable and was transferred to the regular floor on . He has remained neurologically stable, awake, alert, oriented times three, moving all extremities with good strength. He was cleared by physical therapy for discharge home. He will follow-up with Dr. in one month with a repeat head CT. He will follow-up with his primary care doctor this week for a blood pressure check and glucose check. His glucose checks, here at the hospital, have been anywhere from 100-195, receiving two units of subcutaneous insulin on two occasions. His blood pressure medications, metoprolol 25 mg PO b.i.d., amlodipine 5 mg PO q day, and Dilantin for one day - 100 mg PO t.i.d. | PT STABLE SXN FOR SM AMT THIN SEC. T/SICU NPN-Brief ROS: Pt. COMPARISONS: Noncontrast head CT of . Palpable periph pulses.Resp- Remains on rm air, adequate sats this shift. Minimal periph edema. Hct stable at 38.2.Resp - LS clear. Prn hydralzine/metoprol utilized to keep sbp <130. Initial assessment completed (see flow record for details of that assessment).ROS:Neuro: Sedate ? S/P EVAC OF R SDH. anasthesia residual?? CV: SR/no etopy. + palp peripheral pulses. IMPRESSION: 1) Stable appearance of residual left sided subdural hemorrhage with mass effect. Pt admitted to on s/p mva. Compression sleves on bilat.Resp: Resp rate even and non labored. BS DECR CTA BILAT. Abd soft w/hypoactive BS. On pt underwent evacuation of r subudural. Probable mild CHF. Speach clear. Head drsg and . Nipride gtt titrated to keep SBP < 130. Vertebral body alignment is within normal limits. BS are reletively clear. RESP CARE NOTEPT RECEIVED FROM O.R. Head in neut allignment w/ on. Right radial ABP. TECHNIQUE: Noncontrast head CT. There continues to be a moderate amount of mass effect with slight compression of the left lateral ventricle and loss of left-sided sulci. Keep sbp 130 or less. repeat head CT this am. There is upper zone redistribution and mild diffuse vascular blurring. ON dilantin q 8 hr.CV: RSR no ectopy. A tiny left sided residual subdural hemorrhage remains. RESPIRATORY CARE: PT. FINDINGS: ET and NG tubes are present. ABGs pH 7.42, pco2 37, po2 160. HR stable, sinus without ectopy. Pulm: on room air, lungs clear, decreased at bases. On RA ABG 7.50/28/107/0/23. Pt s/p nipride infusion. Peripheral pulses strong and =. Peripheral pulses strong and =. SBP 110 -> 180. +BS. Perrl. call-out to floor if pt remains stable. DRAIN COMPRESSED W/THUMB PRINT SUCTION ONLY. SaO2 100%.CV: Sinus rhythm no ectopy. Denies numbness/tinglining in extremities. There is mild cardiomegaly. AM ABG REFLECTS NORMAL ACID BASE W/HYPEROXIA, RSBI 47.5. Lung sounds clear thoughout. Denies pain.Pt. CHEST, SINGLE AP VIEW. Abd soft, NT with bowel sounds. The paranasal sinuses are otherwise well aerated. There is minimal loss of vertebral body height at L5/S1. Previous nipride gtt weaned to off, pt restarted on po norvasc. Sx x's 1 w/o any sputum obtained. IMPRESSION: 1. On heparin q 12hr sub q. IMPRESSION: Normal chest radiograph. Extub on and JP drain dcd on .Neuro - Pt alert and oriented, MAE. JP drain placed. PEARLA. Transferred to . Notify team of unresolved or increased temp. PELVIS: There is normal mineralization. There is slight displacement of the left lateral ventricle to the right. Pg . There is a minimal amount of residual subdural blood. PERL. FINDINGS: Again seen is a left sided craniotomy and a subdural drain. There is a minimal amount of residual subdural blood and residual mass effect. Pt experienced some R sided weakness. Dorsi plantor/flexion strong and equal. Crani dressing clean dry and . , RRT BP 120-140/44-60 via ABP. Neuro resident EJ and MD aware. There is a small amount of pneumocephalus layering anteriorly on the left. There is minimal wedging of the few of the mid thoracic vertebral bodies, which appears chronic. Accuchecks not requiring SSI coverage.Plan: CT head today. Dilantin level 13.6 today. Heparin to begin this AM. Connected to monitor and vent. has been appropriate all shift. PLACED ON IN SIMV/PS MODE. Cough, gag, and corneal reflex +. IMPRESSION: S/P left-sided craniectomy with subdural drain placement. Update 0600Awake, following commands w/all extremities. 02 sats > 96%.GI - Abd soft. VSS. K 3.9 this am.ID - Max temp 100.1 po. No BM's this shift, he did have some flatus.GU- Making adequate amts of urine via foley.ID- Low grade temp. Withdrawls all except RUE to nailbed presure. Pupils equal and reactive. Sclerosis of the weight bearing areas of the acetabulum is noted. S1S2. S1S2. RSBI 80 ANDGOOD ABG ON . There continues to be a small amount of pneumocephalus within the left frontal area. MAINT'D,TLS CLEARED THIS PM BY DR ,CT HEAD AND C SPINE THIS AM.CV-PT REMAINS ON SNP GTT TO KEEP SBP <140, SNP GTT @.2-1 MCG/KG/MIN,HYDRALIZINE IVP 10MG ADDED THIS PM NOW ABLE TO WEAN SNP GTT,3+DP/PT .HR 60'S-70'S NSR NO VEA,LYTES REPLETED PRN.RESP-PT ON THIS AM ABG WNL,PT W/ OUT DIFF @ 11AM,INITIALLY ON 50% COOL NEB,O2 SAT 99-100%,NOW ON RA O2 SATS 95-98%.RR 20-30.NARD.PT DENIES SOB.GI/GU-NPO,OGT DC'D ON EXTUBATION,SM AMTS BILIOUS VIA OGT,ABD SOFT ABSENT BS,NO N/V NOTED,U/O ADEQ AMTS CLEAR YELLOW URINE VIA FOLEY CATH.SKIN-HEAD DSGS CDI,PT BACK + BUTTOCK GROSSLY INTACT. Receiving scheduled lopressor and hydralazine ivp for HTN management. Equal rise and fall of chest. Equal rise and fall of chest. Patchy retrocardiac density consistent with left lower lobe collapse and/or consolidation. The soft tissues and osseous structures remain unchanged. IMPRESSION: Cardiomegaly. There is subtle hypodensity within the left posterior temporal lobe. Mild degenerative changes seen throughout the cervical spine. There continues to be air fluid levels within the ethmoid and right sphenoid sinus. Rx with 1 gm iv kefzol q 8hrs.Skin - Head dssg d+i.A+P - Continue to monitor neuro status closely. There is also mild mass effect within this left temporoparietal area. Hand grasps strong and equal. ? ? ? Evaluate for interval change. D: See data, MD notes/orders. The mediastinal and hilar contours are unremarkable. There is a small amount of hyperattenuation in this area too which most likely represents subarachnoid blood. PEARRLA. The joint spaces are preserved. No resp distress noted. No resp distress noted. 2. Urine culture sent today.Integ- . There is patchy increased retrocardiac density. Crani dressing clean dry and intact. Trauma. IMPRESSION: Slight wedging of a few mid thoracic vertebrae, which appears chronic with evidence of demineralization. Degenerative changes. MAE. No flatus noted. 2) Subtle area of hypodensity with surrounding hyperdensity within the left posterior temporal lobe which may represent edema with a small amount of subarachnoid hemorrhage. | 18 | [
{
"category": "Radiology",
"chartdate": "2174-03-04 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 817316,
"text": " 8:34 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: post subdural evac\n Admitting Diagnosis: LEFT SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with\n REASON FOR THIS EXAMINATION:\n post subdural evac\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P MVC, post-subdural evacuation.\n\n TECHNIQUE: Axial non-contrast head CT.\n\n CT HEAD WITHOUT CONTRAST: The patient has had a left-sided craniectomy with\n subdural drain placement. There is a minimal amount of residual subdural\n blood. No previous studies are available for comparison. There is a small\n amount of pneumocephalus layering anteriorly on the left. There is also mild\n mass effect within this left temporoparietal area. There is slight\n displacement of the left lateral ventricle to the right. The ventricles are\n widely patent without evidence of hydrocephalus.\n\n There is subtle hypodensity within the left posterior temporal lobe. There is\n a small amount of hyperattenuation in this area too which most likely\n represents subarachnoid blood. The white matter differentiation is\n otherwise intact throughout.\n\n There is air fluid levels within the sphenoid and ethmoid air cells. The\n paranasal sinuses are otherwise well aerated.\n\n IMPRESSION: S/P left-sided craniectomy with subdural drain placement. There\n is a minimal amount of residual subdural blood and residual mass effect.\n Subtle hypodensities within the posterior left temporal lobe which may\n represent edema or evolving infarction and follow up is recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-03-04 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 817317,
"text": " 8:35 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o fracture\n Admitting Diagnosis: LEFT SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p MVC\n REASON FOR THIS EXAMINATION:\n r/o fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVC. Trauma.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial non-contrast CT scanning of the cervical spine was\n performed. Sagittal and coronal reconstructions were also obtained.\n\n CT C-SPINE: There is no evidence of fracture or subluxation of the component\n vertebrae. There are mild degenerative changes seen within the cervical spine\n with osteophyte formation at multiple levels. CT is not able to provide any\n intrathecal detail; however, the thecal sac outline appears unremarkable.\n\n There is a focal area of sclerosis within the right side of the C3 vertebral\n body. This most likely represents a bone island. Note is also made of a\n heterogneous-appearing thyroid with calcifications.\n\n IMPRESSION:\n\n 1. No evidence of fracture or subluxation of the component vertebrae.\n 2. Mild degenerative changes seen throughout the cervical spine.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-03-04 00:00:00.000",
"description": "T-SPINE",
"row_id": 817322,
"text": " 9:05 AM\n T-SPINE; LUMBO-SACRAL SPINE (AP & LAT) Clip # \n Reason: r/o fracture\n Admitting Diagnosis: LEFT SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p mvc\n REASON FOR THIS EXAMINATION:\n r/o fracture\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: MVA.\n\n FINDINGS: ET and NG tubes are present. There is minimal wedging of the few\n of the mid thoracic vertebral bodies, which appears chronic. There are no\n acute fractures. Vertebral body alignment is within normal limits. There is\n minimal loss of vertebral body height at L5/S1. Posterior elements of the\n thoracic spine are not well visualized. There are bridging osteophytes\n multiple thoracic and lumbar spines.\n\n IMPRESSION: Slight wedging of a few mid thoracic vertebrae, which appears\n chronic with evidence of demineralization. No evidence for an acute injury.\n Degenerative changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-03-03 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 817262,
"text": " 5:03 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: 5\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n CHEST, AP: The heart size is borderline enlarged. The endotracheal tube is\n about 5 cm above the carina. The tip of the NG tube is visualized in the\n fundus of the stomach. The mediastinal and hilar contours are unremarkable.\n No pleural effusions are seen. The surrounding osseous and soft tissue\n structures are unremarkable. The lungs are clear.\n\n IMPRESSION: Normal chest radiograph.\n\n PELVIS: There is normal mineralization. No focal lesions are present. No\n fractures, effusions, or dislocations are seen. Small brachy therapy seeds\n are seen. The joint spaces are preserved. The soft tissues are normal.\n Sclerosis of the weight bearing areas of the acetabulum is noted.\n\n IMPRESSION: No evidence of fracture or dislocation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-03-05 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 817442,
"text": " 11:37 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for interval change\n Admitting Diagnosis: LEFT SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p evacuation l SDH\n\n REASON FOR THIS EXAMINATION:\n Eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post evacuation of subdural hemorrhage. Evaluate for\n interval change.\n\n TECHNIQUE: Noncontrast head CT.\n\n COMPARISONS: Noncontrast head CT of .\n\n FINDINGS: Again seen is a left sided craniotomy and a subdural drain. A tiny\n left sided residual subdural hemorrhage remains. There continues to be a\n moderate amount of mass effect with slight compression of the left lateral\n ventricle and loss of left-sided sulci. Within the posterior left temporal\n lobe, there is an area of subtle hypodensity with surrounding hyperdensity\n which may represent edema with possible small amount of subarachnoid blood. No\n new areas of intra axial or extra axial hemorrhage is identified. There\n continues to be a small amount of pneumocephalus within the left frontal area.\n There is no evidence of hydrocephalus. There continues to be air fluid levels\n within the ethmoid and right sphenoid sinus. The soft tissues and osseous\n structures remain unchanged.\n\n IMPRESSION:\n\n 1) Stable appearance of residual left sided subdural hemorrhage with mass\n effect.\n 2) Subtle area of hypodensity with surrounding hyperdensity within the left\n posterior temporal lobe which may represent edema with a small amount of\n subarachnoid hemorrhage. An evolving infarction again is also a possibility\n and follow up is recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-03-05 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 817443,
"text": " 11:46 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: LEFT SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with tachypnea\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tachypnea, rule out pneumonia.\n\n CHEST, SINGLE AP VIEW.\n\n There is mild cardiomegaly. There is upper zone redistribution and mild\n diffuse vascular blurring. There is patchy increased retrocardiac density.\n No effusion.\n\n IMPRESSION: Cardiomegaly. Probable mild CHF. Patchy retrocardiac density\n consistent with left lower lobe collapse and/or consolidation.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-06 00:00:00.000",
"description": "Report",
"row_id": 1321039,
"text": "1am - 7 am Micu Progress Note\n\nBriefly pt is a 74 yo male who was transferred from SICU to MICU A on . Pt admitted to on s/p mva. Pt was unrestrained driver who hit his head on the windshield. Ambulatory at scene, but while sitting on curb became unresponsive. Taken To St E hospital where he was intubated and CT showed a lg subdural hematoma. Transferred to . On pt underwent evacuation of r subudural. JP drain placed. Pt experienced some R sided weakness. Extub on and JP drain dcd on .\n\nNeuro - Pt alert and oriented, MAE. Equal strength in all exts. PERL. No sz activity noted. Rx with 100 mg dilantin iv q8hrs. Dilantin level 13.6 today. Plan is for repeat head CT today.\n\nC-V - HR 80-90 NSR. BP 120-140/44-60 via ABP. Pt s/p nipride infusion. Rx with iv hydralazine and lopressor. + palp peripheral pulses. Hct stable at 38.2.\n\nResp - LS clear. On RA ABG 7.50/28/107/0/23. RR 20-25. 02 sats > 96%.\n\nGI - Abd soft. +BS. Tolerating liquids without difficulty.\n\nF/E - Urine output 20-130ccs/hr via foley cath. Rx with 40 meq kcl po tid x 24 hrs. K 3.9 this am.\n\nID - Max temp 100.1 po. WBC 8.3, previously 10.4. Rx with 1 gm iv kefzol q 8hrs.\n\nSkin - Head dssg d+i.\n\nA+P - Continue to monitor neuro status closely. ? repeat head CT this am. ? call-out to floor if pt remains stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-06 00:00:00.000",
"description": "Report",
"row_id": 1321040,
"text": "addendum - Phos 1.3 - pt to receive k-phos 15 mmol/250 ns.\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-05 00:00:00.000",
"description": "Report",
"row_id": 1321036,
"text": "nsg note\nneuro: pt arouses easily to voice but falls asleep immediately when not stimulated oriented times three denies headache or any discomfor. mae to command pupils equal and recting.\n\npt with stable bp <130 until 330am then bp climing to 140's given hydralazine, lopressor and then placed on nipride gtt. titrated up to .8 mcgs this am.hr 80's nsr.\nuo qs temp max 100.9 blood and urine cultures sent.\npts lytes repleted this am potassium, phosphat, ca gluc and mg so4.\nivf at 80 ccs per hr.\np pt to satart po.s and bp control can be liberalized to 150.\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-05 00:00:00.000",
"description": "Report",
"row_id": 1321037,
"text": "T/SICU NPN-\nBrief ROS:\n Pt. has been appropriate all shift. Completely cooperative and communicative all shift. MAE. Pupils equal and reactive. Denies pain.Pt. went for a repeat CT scan of his head this am, not improved from yesterday- will need to remain the T/SICU over night.\n\nCV- SBP stable since discontinuing nipride this am. He was started on IV hydralazine and metoprolol q 6 hr rather than prn. HR stable, sinus without ectopy. Repleted potassium this afternoon, po. IV potassium boluses uncomfortable at site for pt. He had a bld gas K+ of 2.1 and the following serum K+ was 3.5, in the interim he rcv'd 40meq KCl x 2.\nSkin warm and dry. Minimal periph edema. Palpable periph pulses.\n\nResp- Remains on rm air, adequate sats this shift. Resp rate in the 20's. Coughs and deep breaths, productive cough. BS are reletively clear. Bld gas is unchanged.\n\nEndo- Has not required insulin coverage this shift.\n\nGI- Started a diet this am, has tolerated diet well all day. Drinking ample amts of liquids all shift. Abd soft, NT with bowel sounds. No BM's this shift, he did have some flatus.\n\nGU- Making adequate amts of urine via foley.\n\nID- Low grade temp. No abx in progress. Urine culture sent today.\n\nInteg- . Head drsg and .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-06 00:00:00.000",
"description": "Report",
"row_id": 1321038,
"text": " 1900 -> 0100\n\nROS:\n\nNeuro: Alert oriented x's 4. Follows all commands. When asked to show me 2 thumbs he raised both arms. When I showed him what I wanted him to do he was then able to show me two thumbs. PEARRLA. Denies numbness/tinglining in extremities. Hand grasps strong and equal. Dorsi plantor/flexion strong and equal. Speach clear. Crani dressing clean dry and . No seizure activity noted. ON dilantin q 8 hr.\n\nCV: RSR no ectopy. VSS. Receiving scheduled lopressor and hydralazine ivp for HTN management. S1S2. No edema. Skin warm dry and pink. Peripheral pulses strong and =. On heparin q 12hr sub q. Compression sleves on bilat.\n\nResp: Resp rate even and non labored. Equal rise and fall of chest. No resp distress noted. ON room air sao2 95-98 %.\n\nGU: Foley cath patent draining clear yellow urine in amt sufficiant.\n\nGI: Abd soft w/active BS. Taking in po diet w/o c/o difficulties swallowing or nausea.\n\nTransfered to MICU A\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-04 00:00:00.000",
"description": "Report",
"row_id": 1321032,
"text": "S/P MVC-HEAD TRAUMA SDH EVAC.-T/SICU NPN 7-3P\nS-\"SABASTINO DANICO.HOSPITAL, FRIDAY\"\nO-NEURO-PT AROUSES TO VOICE OPENS EYES FOLLOWS COMMANDS MAE'S,PERRLA 3MM,CALM COOPERATIVE.STRONG COUGH + GAG.A+O X 3 CURRENTLY.SUBDURAL JP DRAINING SM AMT BLOODY DRAINAGE.C-SPINE PREC. MAINT'D,TLS CLEARED THIS PM BY DR ,CT HEAD AND C SPINE THIS AM.\nCV-PT REMAINS ON SNP GTT TO KEEP SBP <140, SNP GTT @.2-1 MCG/KG/MIN,HYDRALIZINE IVP 10MG ADDED THIS PM NOW ABLE TO WEAN SNP GTT,3+DP/PT .HR 60'S-70'S NSR NO VEA,LYTES REPLETED PRN.\nRESP-PT ON THIS AM ABG WNL,PT W/ OUT DIFF @ 11AM,INITIALLY ON 50% COOL NEB,O2 SAT 99-100%,NOW ON RA O2 SATS 95-98%.RR 20-30.NARD.PT DENIES SOB.\nGI/GU-NPO,OGT DC'D ON EXTUBATION,SM AMTS BILIOUS VIA OGT,ABD SOFT ABSENT BS,NO N/V NOTED,U/O ADEQ AMTS CLEAR YELLOW URINE VIA FOLEY CATH.\nSKIN-HEAD DSGS CDI,PT BACK + BUTTOCK GROSSLY INTACT.\n BROTHER CALLED THIS AM, BROTHER (SPOKESPERSON) VISITED THIS PM,SPOKE W/ DR PM. BROTHER EXPRESSING CONCERN OVER TIME FROM ACCIDENT-> SURGICAL INTERVENTION.\nENDO-BS 144 NO SS COVERAGE/ORDERS.\nID-AFEBRILE.CONT'S ON CEFAZ IV Q8HR.\nA-NEURODYNAMICALLY STABLE\nP-NEURO CHECKS,VS,ANTIHYPERTENSIVES/ORDERS,TITRATE TO SBP<140,O2 PRN,I+O,MONITOR SKIN INTEGRITY QS AND PRN,FAMILY SUPPORT PRN.FSBS,IV ABX/ORDERS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-04 00:00:00.000",
"description": "Report",
"row_id": 1321033,
"text": "SOCIAL WORK\nSW contact pts brother by phone to introduce role of sw and for support. states that he was in to visit briefly earlier and had all his questions answered by MD. Explained role of SW and offered support as needed. not interested in SW involvement at this time. Contact info for SW provided. I am available to meet with family as indicated. Pg .\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-04 00:00:00.000",
"description": "Report",
"row_id": 1321034,
"text": "RESPIRATORY CARE: PT. THIS AM\nAFTER CT SCAN AND TLS FILMS. RSBI 80 AND\nGOOD ABG ON . TO 50 % AEROSOL\nMASK. DOING WELL.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-04 00:00:00.000",
"description": "Report",
"row_id": 1321035,
"text": "D: See data, MD notes/orders. Neuro: Pt sleeping unless stimulated, wakes easliy to verbal stimuli and is A&Ox3. Recognizes family members, mae with equal strength, follows commands. Perrl. JP drain removed this pm by Dr. with two sutures placed and incisions redressed. CV: SR/no etopy. SBP teens when sleeping 120-130 range when awake. Previous nipride gtt weaned to off, pt restarted on po norvasc. Prn hydralzine/metoprol utilized to keep sbp <130. Pulm: on room air, lungs clear, decreased at bases. 02 sats 95-97%. GU: foley draining clear yellow urine to gravity at >50cc/hr. GI: Abd flat, bs +, pt taking sow without difficulty.Endo: Per ssc Skin: grossly intact, 3+peripheral pulses x4. Soc: Several brothers in this evening, very attentive, have many questions re: current condition and outcome.\nP: Q2hr neuro checks, observe for s/s blood reaccumultation. Tylenol for temp, ?need for blood cx, continue abx as ordered. Notify team of unresolved or increased temp. Keep sbp 130 or less. Keep family updated on plan of care, direct to sicu team in am prn.\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-04 00:00:00.000",
"description": "Report",
"row_id": 1321029,
"text": "Admission note: 74 yo male admitted at 2115 from OR per bed to post evacuation of right subdural hematoma post MVC. Connected to monitor and vent. Initial assessment completed (see flow record for details of that assessment).\n\nROS:\n\nNeuro: Sedate ? anasthesia residual?? Becoming lighter as shift progresses. Inconsistant b/t hourly neuro exams. PEARLA. At times slight attempts made to open eyes, eyes open slightly. Eyes deviate upward and at times to the right. Cough, gag, and corneal reflex +. Crani dressing clean dry and intact. JP drains bright red to less bright red fluid as shift progresses in amt 45 -> 80 cc/hr. amt decreasing as shift progresses. Neuro resident EJ and MD aware. DRAIN COMPRESSED W/THUMB PRINT SUCTION ONLY. Moving all extremites at random,RUE less then all others. Withdrawls all except RUE to nailbed presure. Moves RUE to chest wall pinching and only after much stimuli, this too is inconsistant b/t hourly neuro exams. Log role precautions maintained at all times. Head in neut allignment w/ on. Log roled w/3 person assist, one to immobilize head.\n\nResp: Intubated and on Vent, SIMV 800x12, peep 5, ps 5, 40%. ABGs pH 7.42, pco2 37, po2 160. Pco2 goal 35-40. Lung sounds clear thoughout. Sx x's 1 w/o any sputum obtained. Equal rise and fall of chest. No resp distress noted. SaO2 100%.\n\nCV: Sinus rhythm no ectopy. S1S2. Right radial ABP. Peripheral pulses strong and =. Warm, dry, and pink. SBP 110 -> 180. Nipride gtt titrated to keep SBP < 130. Nipride at 0.05 mcg/kg/min (please note flow record indicates 0.1 mcg/kg/min as system rounds up). Heparin to begin this AM. Compression sleves on bilat legs. IV access limited to peripheral sites only.\n\nGI: Oral sump to LCS draining bile colored fluid. Abd soft w/hypoactive BS. No flatus noted. Receiving protonix.\n\nGU: Foley patent draining clear yellow urine in amt sufficant.\n\nLabs: K=2.9 repleated w/20 KCL, Mg=1.6 repleated w/2 gm Mgso4. Accuchecks not requiring SSI coverage.\n\nPlan: CT head today. Attempt to wean and potentially extubate today???\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-04 00:00:00.000",
"description": "Report",
"row_id": 1321030,
"text": "Update 0600\n\nAwake, following commands w/all extremities. Nods head and mouths words to answere questions asked.\n\nRSBI: 47.5. Spontanious Breathing Trial started @ 0600 check ABGs at 0800.\n\nSBP ^ w/vent changes. Nipride titrating ^ to keep SBP < 130\n\nK+ 3.4 waiting for dose of KCL from pharmacy\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-04 00:00:00.000",
"description": "Report",
"row_id": 1321031,
"text": "RESP CARE NOTE\nPT RECEIVED FROM O.R. S/P EVAC OF R SDH. PLACED ON IN SIMV/PS MODE. PT STABLE SXN FOR SM AMT THIN SEC. BS DECR CTA BILAT. AM ABG REFLECTS NORMAL ACID BASE W/HYPEROXIA, RSBI 47.5. SBT STARTED @ 0600. PLAN TO ASSESS FOR POSS EXTUBATION PENDING SUCCESSFUL COMPLETION OF SBT.\n"
}
] |
30,374 | 110,926 | A/P: 88 yo F with Alzheimer's dementia p/w a fall resulting in a hip fx, s/p hemiathroplasty, complicated by C. diff infection. She was transferred to MICU w/ hypoxic respiratory failure 2' to evolving MI, CHF, and pulmonary edema. Poor prognosis and level of consciousness. She was made CMO per family meeting on , and passed away on while on the medicine floor on . . # R hip fracture: associated w/ fall at rehab. s/p R hip arthroplasty. Unable to assess pain due to decreased mental status. Morphine PO was given for pain and continued with code status was made CMO. . # Acute myocardial infarction. Pt suffered an MI that was likely the cause of her tachypnea. She ruled in with positive troponin and MBI; she had ECG changes (ST elevation in III and aVF). She had a peak Troponin of 1.01 She was managed medically w/ Lovenox, plavix, B-, . All of her medications were d/c-ed with her code status change to CMO. . # Tachypnea/Volume Overload/Pulmonary Edema. Likely related to acute MI, leading to CHF and pulmonary edema. Pt was oxygenating and ventilating well in the MICU, but had very poor mental status. She did have a significant non-gap metabolic acidosis, could be contributing as source of increased ventilation. She was managed for her MI as above. Her acidosis was corrected by lactated ringers and free water boluses 400cc q4h to reduce hypercholemic acidosis. She was also treated w/ gentle diuresis. With her changed to CMO status, her diuresis was stopped. The patient was placed on morphine PO. . # C.diff colitis: Likely related to peri-operative antibiotics. She was started PO vancomycin due to her worsening mental status. With the change in her CMO status, the antibiotic was stopped. . # Depressed mental status/decreased responsiveness: Pt had dementia with subacute delerium. Over her hospital stay, she became less responsive. She waxed and waned in her mental status, which was likely delerium related to her MI and infection. With her multiple medical problems and her progressing non-responsive mental status, her prognosis was deemed extremely poor. A family meeting was held, code status was changed to CMO. She was given Morphine and Zydis PRN for agitation. . # Leukocytosis. Likely related to significant C.diff, plus UTI, plus possible MI. Worsened despite C.diff treatment. D/C-ed antibiotics with change in code status. . # UTI. E.coli related. No antibiotics w/ change in code status to CMO. . # Hypernatremia. Likely due to intravascular volume depletion and diuresis. She received free water via NGT 400ml q4h, with a calculated free water deficit to 1.5 L. With her CMO status, her labs were d/c-ed and she stopped receiving water through her NGT. . # Dementia. Advanced. Held antipsychotics given depressed mental status and change in CMO status. . # Atrial fibrillation. Irregularly irregular on floor during exam, reverted to sinus w/ PACs. Nursing reports brief episodes of tachycardia to 160s. With her CMO status, her tele and vital signs were d/c-ed. . # Depression: CMO as above, no meds. . # FEN: NPO given poor mental status and CMO. # PPx: All d/c-ed as patient is CMO. # Access: PIV d/c-ed w/ CMO status. # Dispo: Expired while in hospital. Death Certificate filled out. . # Code: CMO on after discussion with son and daughter () (power of attn) . Medications on Admission: 81mg daily Pepto-Bismol q4-6hrs prn Celexa 20mg daily Colace 100mg Namenda 5mg daily Vitamin E 400units daily Oxazepam 15mg prn Milk of Mag | albuterol neb prn. resps even + appear unlabored post-neb treatment. vanco & flagyl for CDiff, ceftriaxone for UTI.MSKLT: s/p right hemiarthroplasty ; pt. upper & LE pitting edema. Is on lovenox sq/asa/ plavix/lopressor as medical managment of MI, also compression sleeves on.RESP: LS currently are clear-diminished from bil. Top normal/borderline dilated LV cavitysize. NGT D/C'd. LS rales 1/2 up, diminished apices. for CDiff- on vanco po & flagyl IV. U/L extremities. inc. RR, moaning, repos. Mild (1+) aortic regurgitationis seen. Palliative care consult ordered. areas of ecchymosis and errythema to bil. conts w/ + bil. Mild mitral annularcalcification. + Cdiff- on no abx. Consider posterior myocardialinfarction. Mild regional LV systolic dysfunction. UTI, on ceftriaxone IV. aertgqeart There is mild regional left ventricular systolicdysfunction with inferior/inferolateral hypokinesis. There ismild aortic valve stenosis (area 1.2-1.9cm2). UE's. ortho following & are aware of use of plavix/asa/lovenox. LS coarse/wheezes. Sinus rhythm at upper limits of normal rate. Consider inferior myocardial infarctionof indeterminate age. abx. hx. & fam. The left ventricular cavity size is topnormal/borderline dilated. To have TTE in am. distress & pos. K+ of 3.3 repleted w/ 60 meq and MG+ of 1.7 repleted w/ 2 gm IV. The tricuspid valve leaflets are mildlythickened. Sinus rhythm. Sinus rhythm. Mild to moderate(+) mitral regurgitation is seen. Mildly depressed LVEF. There is mild symmetric leftventricular hypertrophy. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. at this time.SKIN: is thin, areas of ecchymosis and errythema on bil upper and lower extremities. + bil. Short P-R interval. PRN IV morphine and ativan ordered. CKs trendind down.Resp- RR 20s. family determined POC would be CMO- remains in CCU although is called -out to floor on po prn morphine/zyprexa.S: unresponsiveO: please see careview for all objective data.ACV: HR NSR w/ freq. Frequently assess pt's comfort and medicate PRN. T waveabnormalities are more prominent.TRACING #1 Mildly dilated ascendingaorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). right hip dsg changed.PAIN/MSKLT: given po morphine freq. cont. Purposeful mvts on L side. Early R wave progression. The ascending aorta ismildly dilated. Mild AS (AoVA1.2-1.9cm2). distress w. ekg changes and elevated CE's. upper and LE pitting edema from feet to thighs. alzheimer's dementia @ rehab, w. diminishing ms on floor, now mostly unresponsive.GI: ng tube placed to right nare; placement confirmed by cxray/MD. PATIENT/TEST INFORMATION:Indication: Myocardial infarction.Height: (in) 65Weight (lb): 195BSA (m2): 1.96 m2BP (mm Hg): 117/62HR (bpm): 76Status: InpatientDate/Time: at 12:11Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the report of the prior study (images notavailable) of .LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH. active bs x 4.GU: pos. no diuresis overnight.ID: afebrile overnight. +BSx4. Significant PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is moderately dilated. Mild to moderate (+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. +UTI- on no abx. Awaiting palliative care consult. emotional support to pt. to monitor resp/ pain status; prn morphine/zyprexa & albuterol nebs as needed. Nursing Note 7a-7pNeuro- Remains unresponsive.CV- SR-ST w/ freq PACs, HR 80s-110. active bs x 4. ST-T wave abnormalities are moremarked.TRACING #2 crackles 1/3 up from bil. Per notes- to get LR if needs volume acidosis.NEURO: primarily unresponsive overnight; groaning w. placement of NG tube and repos. npo; active bs x4. distress requiring trxfr to CCU as MICU border () also w. MI discovered in setting of resp. IV morphine/ativan changed to PO morphine and zyprexa. Since the previoustracing of the Q wave in lead aVF is more prominent. SPO2 97% 4LNC.GI-NGT removed. taking po morphine; freq. There is borderline pulmonary artery systolic hypertension.Significant pulmonic regurgitation is seen. pac's. Within normal limits. No restingLVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -hypo;AORTA: Normal aortic diameter at the sinus level. No iv access.Resp- Conts on 2L nc w/ sat >95%, LS w/ crackles bibasilary. NPO. status. RR 20's, w. resps appear. to monitor card & resp. NBP remains 111-117/50's. PM lopressor dose held SBP <90. Called out to medical floor. palliative care also consulted & following. continue skin & incision care/turn & repos. 4 L NC w. sats > 93%.GI: CDiff prec. dementia admit from Rehab s/p fall w. hip fx; rec'd hemiarthroplasty ; post-op course c/b CDiff & now w/ UTI and s/p resp. Pos. Addendum To NPN 0700-1900PIV infiltrated. Call-out to floor when bed available or poss tnsf to hospice. NBPs 109-125/50s-60s. Mild [1+] TR.Borderline PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: No PS. All other meds D/Cd. continue to follow labs as able-phleb. monitor for further n Breathing appears unlabored.GI/GU- NPO, no bm. MI w/ EKG changes and elevated CE's.S: patient primarily unresponsive w/minimal groaning only.O: Please see careview for all objective data.A: CV: remained in NSR overnight w. frequent PAC'S. DSD applied.Access- PIVx one.PLAN- Call out to medical floor as CMO. 1.01. NPN 0700-1900S: Pt minimally responsive.O:Please see carevue for objective data and trends.CODE STATUS: After discussion and agreement among 3 children, decision made to change code status to comfort measures given poor long-term prognosis. Receiving free H20 boluses via NGTube to correct hypernatremia (Na+ 148). next wbc w. am labs; had been elevated per team may be from CDiff/UTI or MI. social work consult for family dynamics.CODE STATUS: DNR/DNI w. stipulations for central access, short-term pressors, shock ok for VT w/pulse/CV, but no chest compressions.PLAN: cont. overnight for various reasons incl. monitor for pain/ discomfort/sob. The aortic valve leaflets (3) are mildly thickened. Made CMO by family . BP 85-114/40'S-50s. bases. 88 YR OLD NSG HOME PT ,FELL AT NSG HOME ,FX R HIP.HEMIARTHROPLASTY .MS ,DEVELOPED CDIFF .PT TACHYPNEIC TODAY ON FLOOR ADMITTED TO MICU ,HAS RI FOR MI PROBABLY TODAY.HAS ALZHHEIMERS OX1 ONLY BUT INTERACTIVE,NOW VERY LETHARGIC UNABLE TO TAKE PO.IS DNR/DNI C SOME STIPULATIONS .HX FALLS,DEPRESSION,REFLUX,MACULAR DEGENERATION,HEARING LOSS.HAS ECOLI IN URINE,POSSIBLE PNA/CHF.ALSO POSSIBLE PERICARDIAL EFFUSSION ,ECHO TOMORROW,STAT IF HYPOTENSIVE .THREE CHILDREN,SON AND DAUGHTER CARE PROXY.PT MOANS WHEN MOVED ,OPENS EYES WHEN NAME CALLED.INCISION C STAPLES C/D R HIP.AFIB,HR 110 TO 80 SLOWED C IV LOPRESSER 5 MG.RECTAL ASA GIVEN.CARDIAC MEDS TO BE STARTED ONCE NG IN,LOVENOX STARTED .PT HAS ONLY 22 IV, NEED CENTRAL LINE,PICC.HAS HYPERNATREMIA.BS C WHEEZES ,SAT 99 4L NP .ABD SOFT,POS BS.HAS HAD DIARRHEA ON FLOOR.DIAPER IN PLACE ,SKIN INTACT .PERINUEM SL REDHUO 40 CC/HR.EXTREMITIES EDEMATOUS .FRAGILE ELDERLY WOMAN C FX,MI,POSSIBLE PNA.MONITOR FOR WORSENING RESP STATUS,BLEEDINGRECHECK LYTESPLACE NG TUBESKIN CARE | 13 | [
{
"category": "Nursing/other",
"chartdate": "2104-09-01 00:00:00.000",
"description": "Report",
"row_id": 1653404,
"text": "88 YR OLD NSG HOME PT ,FELL AT NSG HOME ,FX R HIP.HEMIARTHROPLASTY .MS ,DEVELOPED CDIFF .PT TACHYPNEIC TODAY ON FLOOR ADMITTED TO MICU ,HAS RI FOR MI PROBABLY TODAY.HAS ALZHHEIMERS OX1 ONLY BUT INTERACTIVE,NOW VERY LETHARGIC UNABLE TO TAKE PO.IS DNR/DNI C SOME STIPULATIONS .HX FALLS,DEPRESSION,REFLUX,MACULAR DEGENERATION,HEARING LOSS.HAS ECOLI IN URINE,POSSIBLE PNA/CHF.ALSO POSSIBLE PERICARDIAL EFFUSSION ,ECHO TOMORROW,STAT IF HYPOTENSIVE .THREE CHILDREN,SON AND DAUGHTER CARE PROXY.\n\nPT MOANS WHEN MOVED ,OPENS EYES WHEN NAME CALLED.INCISION C STAPLES C/D R HIP.\nAFIB,HR 110 TO 80 SLOWED C IV LOPRESSER 5 MG.RECTAL ASA GIVEN.CARDIAC MEDS TO BE STARTED ONCE NG IN,LOVENOX STARTED .PT HAS ONLY 22 IV, NEED CENTRAL LINE,PICC.HAS HYPERNATREMIA.\n\nBS C WHEEZES ,SAT 99 4L NP .\n\nABD SOFT,POS BS.HAS HAD DIARRHEA ON FLOOR.DIAPER IN PLACE ,SKIN INTACT .PERINUEM SL RED\n\nHUO 40 CC/HR.EXTREMITIES EDEMATOUS .\n\nFRAGILE ELDERLY WOMAN C FX,MI,POSSIBLE PNA.\n\nMONITOR FOR WORSENING RESP STATUS,BLEEDING\nRECHECK LYTES\nPLACE NG TUBE\nSKIN CARE\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-02 00:00:00.000",
"description": "Report",
"row_id": 1653405,
"text": "Nursing Progress Note (1900-0700)\n88 yo female w. alzheimer's dementia admit from Rehab s/p fall w/ hip fracture & hemiarthroplasty ;later post-op course c/b CDiff, now transfered to CCU as MICU border () for resp. distress & pos. MI w/ EKG changes and elevated CE's.\n\nS: patient primarily unresponsive w/minimal groaning only.\nO: Please see careview for all objective data.\nA: CV: remained in NSR overnight w. frequent PAC'S. BP 85-114/40'S-50s. PM lopressor dose held SBP <90. Continuing to have increasing CE's at 7pm - CK 210, MB 21 and Trop. 1.01. Unable to collect CE's at 2 am- team aware. + bil. upper and LE pitting edema from feet to thighs. K+ of 3.3 repleted w/ 60 meq and MG+ of 1.7 repleted w/ 2 gm IV. Unable to voice c/o pain or CP. To have TTE in am. Is on lovenox sq/asa/ plavix/lopressor as medical managment of MI, also compression sleeves on.\n\nRESP: LS currently are clear-diminished from bil. apex to bases. RR 20's, w. resps appear. unlabored. O2sats 98-100% on 4 L nc. Per notes- to get LR if needs volume acidosis.\n\nNEURO: primarily unresponsive overnight; groaning w. placement of NG tube and repos. no response to voice stimulus. noted some purposeful hand grasp w. L hand, moves L arm off bed & moves left leg; no movement of right side noted. patient consistently tilts head to left side, and keeps left eye tightly shut which makes bil. pupil assessment difficult. hx. alzheimer's dementia @ rehab, w. diminishing ms on floor, now mostly unresponsive.\n\nGI: ng tube placed to right nare; placement confirmed by cxray/MD. Pos. for CDiff- on vanco po & flagyl IV. no diarrhea/stool overnight. active bs x 4.\n\nGU: pos. UTI, on ceftriaxone IV. urine in foley is dark amber. Receiving free H20 boluses via NGTube to correct hypernatremia (Na+ 148). no diuresis overnight.\n\nID: afebrile overnight. next wbc w. am labs; had been elevated per team may be from CDiff/UTI or MI. vanco & flagyl for CDiff, ceftriaxone for UTI.\n\nMSKLT: s/p right hemiarthroplasty ; pt. unable to express pain/discomfort at this time. ortho following & are aware of use of plavix/asa/lovenox. pillow placed between legs w. all turns.\n\nSKIN: paper -thin skin. areas of ecchymosis and errythema to bil. UE's. some red splotchy areas that are intact on thighs. barrier cream to heels/buttocks, etc.left hip surgical site- dressing intact w. small, unchanged area of dried yellow drainage.\n\nACCESS: left wrist #22 is only access. team to consider picc v. central line placement should further access become necessary. requires phlebotomy for venipunctures.\n\nSOCIAL: 3 children; 2 sons & 1 . Son from NJ in to visit & stayed overnight. team meeting to discuss plan/goals of care w. all family members together, as well as , would likely be helpful.? social work consult for family dynamics.\n\nCODE STATUS: DNR/DNI w. stipulations for central access, short-term pressors, shock ok for VT w/pulse/CV, but no chest compressions.\n\nPLAN: cont. to monitor card & resp. status. monitor for further n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-02 00:00:00.000",
"description": "Report",
"row_id": 1653406,
"text": "Nursing Progress Note (1900-0700)\n(Continued)\neuro/ms changes. continue to follow labs as able-phleb. to collect am labs. continue skin & incision care/turn & repos. emotional support to pt. & fam. monitor for s/s pain/ discomfort. abx. as ordered. await further team/family plans for care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-02 00:00:00.000",
"description": "Report",
"row_id": 1653407,
"text": "NPN 0700-1900\nS: Pt minimally responsive.\n\nO:Please see carevue for objective data and trends.\n\nCODE STATUS: After discussion and agreement among 3 children, decision made to change code status to comfort measures given poor long-term prognosis. PRN IV morphine and ativan ordered. NGT D/C'd. All other meds D/Cd. Called out to medical floor. Team to reevaluate situation after 1-2 days and possibly D/C to ECF or hospice at that time. Social wk met w/ Son and Dtr to provide extra emotional support given pt's strained relations and altered family dynamics. Palliative care consult ordered. Rabbi in to see pt today at family's request.\n\nNeuro- Minimally responsive. Occasionally opening eyes to verbal and tactile stimuli. No mvt R side of body. Purposeful mvts on L side. Pupils @ 4mm bilat, brisk.\n\nCV- Tele w/ HR 80s NSR w/ freqent APCs, occas PVCs, episode HR up to 160s x 2 this am. Edema all 4 extremities- R arm weeping. CKs trendind down.\n\nResp- RR 20s. LS rales 1/2 up, diminished apices. SPO2 97% 4LNC.\n\nGI-NGT removed. +BSx4. Small green liquidy stool today.\n\nGU- Foley w/ dark brown urine.\n\nSkin- R hip dsg changed. Staples intact, site pink but not hot or swollen. DSD applied.\n\nAccess- PIVx one.\n\nPLAN- Call out to medical floor as CMO. Frequently assess pt's comfort and medicate PRN. Awaiting palliative care consult. Emotional support to pt and family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-02 00:00:00.000",
"description": "Report",
"row_id": 1653408,
"text": "Addendum To NPN 0700-1900\nPIV infiltrated. IV morphine/ativan changed to PO morphine and zyprexa. Awaiting availability from pharmacy. Palliative care physician in to see pt and 2 sons. readdress placement facility issues if needed in future.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-03 00:00:00.000",
"description": "Report",
"row_id": 1653409,
"text": "Nursing Progress Note (1900-0700)\n88 yo female w. alzh. dementia admit from Rehab s/p fall w. hip fx; rec'd hemiarthroplasty ; post-op course c/b CDiff & now w/ UTI and s/p resp. distress requiring trxfr to CCU as MICU border () also w. MI discovered in setting of resp. distress w. ekg changes and elevated CE's. family determined POC would be CMO- remains in CCU although is called -out to floor on po prn morphine/zyprexa.\n\nS: unresponsive\nO: please see careview for all objective data.\nA\nCV: HR NSR w/ freq. pac's. NBP remains 111-117/50's. 4 + pitting edema to all 4 extremeties; R arm weeping. no further labs to be collected.\n\nRESP: RR 18-22 overnight; breaths appear even and unlabored. crackles 1/3 up from bil. bases. continues on 2 L via NC w. sats 96-99%.\n\nGI: no stool overnight. NPO. active bs x 4. + Cdiff- on no abx. @ this time.\n\nGU: foley in, patent, draining dark brown urine. +UTI- on no abx. at this time.\n\nSKIN: is thin, areas of ecchymosis and errythema on bil upper and lower extremities. right hip dressing remains intact overnight.\n\nACCESS: none\n\nSOCIAL: social work following family given some strained dynamics between siblings, although appears all are in agreement w. current POC. palliative care also consulted & following. placement to facility will be discussed if required.\n\nPLAN: CMO- called out to floor. cont. to monitor resp/ pain status; prn morphine/zyprexa & albuterol nebs as needed. emotional support to patient and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-03 00:00:00.000",
"description": "Report",
"row_id": 1653410,
"text": "Nursing Note 7a-7p\nNeuro- Remains unresponsive.\nCV- SR-ST w/ freq PACs, HR 80s-110. NBPs 109-125/50s-60s. No iv access.\nResp- Conts on 2L nc w/ sat >95%, LS w/ crackles bibasilary. Breathing appears unlabored.\nGI/GU- NPO, no bm. Voiding 20-30cc/hr brown urine via foley.\nID- Conts on C-diff precautions, no abx.\nSkin- 4+ pitting edema bil U/L extremities.\nA/P- 88yo female s/p hip fx c/b c-diff, uti, resp distress-> +MI. Made CMO by family . Call-out to floor when bed available or poss tnsf to hospice. Cont plan of care, support family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-04 00:00:00.000",
"description": "Report",
"row_id": 1653411,
"text": "Nursing Progress Note (1900-0700)\n88 yo female, unresponsive w/ recent peri-operative MI now CMO status awaiting bed on floor w/ potential for transfer to hospice.\n\nS: unresponsive\nO: please see careview for all objective data.\nCV: HR 80s-low 100's SR/ST w. PVC's/PAC's. SBP > 100/ 50'60s. conts w/ + bil. upper & LE pitting edema. no IV access and no labs collected.\nRESP: RR 13-25 overnight. LS coarse/wheezes. albuterol neb prn. resps even + appear unlabored post-neb treatment. 4 L NC w. sats > 93%.\nGI: CDiff prec. but no bm overnight. npo; active bs x4. taking po morphine; freq. mouth swab to keep oral cavity moist/ assess swallow.\nGU: foley patent draining clear, brown urine.\nSKIN: thin, tight skin edema, w. some areas errythema & ecchymosis on bil. U/L extremities. right hip dsg changed.\nPAIN/MSKLT: given po morphine freq. overnight for various reasons incl. inc. RR, moaning, repos. - see careview for details.\nSOCIAL: supportive son in to visit & slept in ICU waiting room overnight.\n\nPLAN: CMO & awaiting bed on floor. monitor for pain/ discomfort/sob. provide emotional support to patient & family.\n\n"
},
{
"category": "Echo",
"chartdate": "2104-09-02 00:00:00.000",
"description": "Report",
"row_id": 96433,
"text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction.\nHeight: (in) 65\nWeight (lb): 195\nBSA (m2): 1.96 m2\nBP (mm Hg): 117/62\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 12:11\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline dilated LV cavity\nsize. Mild regional LV systolic dysfunction. Mildly depressed LVEF. No resting\nLVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo;\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild AS (AoVA\n1.2-1.9cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nBorderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS. Significant PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity size is top\nnormal/borderline dilated. There is mild regional left ventricular systolic\ndysfunction with inferior/inferolateral hypokinesis. Overall left ventricular\nsystolic function is mildly depressed (LVEF= 50 %). The ascending aorta is\nmildly dilated. The aortic valve leaflets (3) are mildly thickened. There is\nmild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic regurgitation\nis seen. The mitral valve leaflets are mildly thickened. Mild to moderate\n(+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. There is borderline pulmonary artery systolic hypertension.\nSignificant pulmonic regurgitation is seen. There is no pericardial effusion.\n\nCompared with the report of the prior study (images unavailable for review) of\n, left ventricular systolic dysfunction is new.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2104-09-01 00:00:00.000",
"description": "Report",
"row_id": 265800,
"text": "Sinus rhythm at upper limits of normal rate. Since the previous tracing\nearlier the same date the rate has increased. ST-T wave abnormalities are more\nmarked.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2104-09-01 00:00:00.000",
"description": "Report",
"row_id": 265801,
"text": "Sinus rhythm. Short P-R interval. Consider inferior myocardial infarction\nof indeterminate age. Early R wave progression. Consider posterior myocardial\ninfarction. There are other ST-T wave abnormalities. Since the previous\ntracing of the Q wave in lead aVF is more prominent. T wave\nabnormalities are more prominent.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2104-08-25 00:00:00.000",
"description": "Report",
"row_id": 265802,
"text": "Sinus rhythm. Within normal limits.\n\n"
},
{
"category": "Nursing",
"chartdate": "2104-09-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332699,
"text": "aertgqeart\n"
}
] |
81,334 | 133,641 | (Over) 2:09 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: r/o obstruction/collectionCT with IV AND PO contrast Admitting Diagnosis: PERFORATED DIVERTICULITIS Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) 2. FINDINGS: Small to moderate right pleural effusion and right basilar atelectasis are noted. Status post sigmoid colectomy and end colostomy. CT ABDOMEN: There is mild-to-moderate bibasilar dependent atelectasis, right greater than left. His post-operative pain has been managed with dilaudid PCA. INDICATION: Leukocytosis. Ngt to lws w clear to tan drng Mid abd transparent drsg of serosang stain. Ngt to lws w clear to tan drng Mid abd transparent drsg of serosang stain. Colostomy stoma dusky w serous drng. Colostomy stoma dusky w serous drng. or ileus FINAL REPORT HISTORY: Status post end-colostomy. Glucagon 12. Glucagon 12. Glucagon 12. This finidng is suggestive of interloop abscess. Bilateral subsegmental atelectasis. Surgical drain is noted within the right lower quadrant area . Diffuse distention of the small bowel, ascending colon, and transverse colon is mostly compatible with ileus. Piperacillin-Tazobactam 21. Piperacillin-Tazobactam 21. Piperacillin-Tazobactam 21. Assess PRN IV dilaudid doses and consider upping PCA if needed Cardiovascular: -- SIRS: tachycardic to 120's, MAPs maintianing >60 without pressors, 2.5 L LR bolus given Pulmonary: -- extubated in OR, stable on NC Gastrointestinal / Abdomen: -- NG in place to suction -- GI proph with PPI -- coags elevated for unknown reason, LFT's seem WNL, hepatitis serologies sent Nutrition: --NPO Renal: --Baseline creatinine 0.9 --AUOP Hematology: -- DVT proph with heparin SC and boots -- HCT elecated, possible due to hemoconcentration, min EBL in OR Endocrine: - - RISS for glycemic control Infectious Disease: -- vanc /zosyn for empiric coverage (started ) -- febrile likely secondary to abd source, will CTM cx Lines / Tubes / Drains: PIV, Foley, A-line (), NG, TLC () Wounds: abd Consults: General surgery Billing Diagnosis: ICU Care Glycemic Control: Lines: Multi Lumen - 12:30 AM Arterial Line - 12:30 AM 18 Gauge - 12:30 AM Prophylaxis: DVT: Boots, SQ UF Heparin Stress ulcer: PPI Communication: Comments: Code status: Full code Disposition: SICU ; possible transfer Total time spent: 31 minutes Assess PRN IV dilaudid doses and consider upping PCA if needed Cardiovascular: -- SIRS: tachycardic to 120's, MAPs maintianing >60 without pressors, 2.5 L LR bolus given Pulmonary: -- extubated in OR, stable on NC Gastrointestinal / Abdomen: -- NG in place to suction -- GI proph with PPI -- coags elevated for unknown reason, LFT's seem WNL, hepatitis serologies sent Nutrition: --NPO Renal: --Baseline creatinine 0.9 --AUOP Hematology: -- DVT proph with heparin SC and boots -- HCT elecated, possible due to hemoconcentration, min EBL in OR Endocrine: - - RISS for glycemic control Infectious Disease: -- vanc /zosyn for empiric coverage (started ) -- febrile likely secondary to abd source, will CTM cx Lines / Tubes / Drains: PIV, Foley, A-line (), NG, TLC () Wounds: abd Consults: General surgery Billing Diagnosis: ICU Care Glycemic Control: Lines: Multi Lumen - 12:30 AM Arterial Line - 12:30 AM 18 Gauge - 12:30 AM Prophylaxis: DVT: Boots, SQ UF Heparin Stress ulcer: PPI Communication: Comments: Code status: Full code Disposition: SICU ; possible transfer Total time spent: 31 minutes Assess PRN IV dilaudid doses and consider upping PCA if needed Cardiovascular: -- SIRS: tachycardic to 120's, MAPs maintianing >60 without pressors, 2.5 L LR bolus given Pulmonary: -- extubated in OR, stable on NC Gastrointestinal / Abdomen: -- NG in place to suction -- GI proph with PPI -- coags elevated for unknown reason, LFT's seem WNL, hepatitis serologies sent Nutrition: --NPO Renal: --Baseline creatinine 0.9 --AUOP Hematology: -- DVT proph with heparin SC and boots -- HCT elecated, possible due to hemoconcentration, min EBL in OR Endocrine: -- RISS for glycemic control Infectious Disease: -- vanc /zosyn for empiric coverage (started ) -- febrile likely secondary to abd source, will CTM cx Lines / Tubes / Drains: PIV, Foley, A-line (), NG, TLC () Wounds: abd Imaging: Fluids: Consults: General surgery Billing Diagnosis: ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 12:30 AM Arterial Line - 12:30 AM 18 Gauge - 12:30 AM Prophylaxis: DVT: Boots, SQ UF Heparin Stress ulcer: PPI VAP bundle: Comments: Communication: Comments: Code status: Full code Disposition: Total time spent: 31 minutes | 13 | [
{
"category": "Radiology",
"chartdate": "2136-02-27 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1127948,
"text": " 2:07 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: location of left brachial 50 cm power picc tip\n Admitting Diagnosis: PERFORATED DIVERTICULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with infection\n REASON FOR THIS EXAMINATION:\n location of left brachial 50 cm power picc tip\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old male with left PICC placement.\n\n COMPARISON: .\n\n CHEST, AP: A new left PICC is coiled in the SVC. Right upper lobe and\n lingular opacities have improved, with persistent right perihilar\n consolidation. There is no pneumothorax. Trace bilateral pleural effusions\n are unchanged.\n\n IMPRESSION:\n 1. Left PICC coiled in SVC, recommend retraction by 3 cm. This was discussed\n with on at 2:30 p.m.\n 2. Improving multifocal pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-02-29 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1128203,
"text": " 5:34 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: ?. or ileus\n Admitting Diagnosis: PERFORATED DIVERTICULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with diverticulitis s/p end colostomy; new abdominal tenderness\n and distension\n REASON FOR THIS EXAMINATION:\n ?. or ileus\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post end-colostomy.\n\n COMPARISON: CT .\n\n SUPINE AND UPRIGHT ABDOMEN:\n\n There are multiple air-filled dilated loops of small bowel. Small amount of\n gas is seen in the ascending and transverse colon with no evident bowel gas\n seen in the rectum. These findings are concerning for pos-operative ileus.\n There is no free intraperitoneal air or pneumatosis. In the right lower lung\n there is a small opacification and small pleural effusion.\n\n IMPRESSION: Multiple air-filled loops of dilated small bowel, concerning for\n ileus.\n\n These findings were reported to Dr. on the time of reporting by phone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-02-26 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1127826,
"text": " 3:45 PM\n CHEST (PA & LAT) Clip # \n Reason: PNA\n Admitting Diagnosis: PERFORATED DIVERTICULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with leukocytosis of unkown origin\n REASON FOR THIS EXAMINATION:\n PNA\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST \n\n COMPARISON: .\n\n INDICATION: Leukocytosis.\n\n FINDINGS: New confluent consolidation has developed in the right perihilar\n region corresponding to the superior and posterior basilar segments of the\n right lower lobe as well as some involvement of the right middle lobe\n resulting in obscuration of the right heart border. Additional new opacity\n has developed peripherally in the right upper lobe. Previously present\n predominantly linear opacities in the left lung have progressed and a new\n patchy opacity has developed in the lingula. Small pleural effusions are also\n new. Cardiomediastinal contours are similar.\n\n IMPRESSION:\n New multifocal right lung opacities suspicious for multifocal pneumonia, with\n possible additional lesser involvement in the left lung.\n\n"
},
{
"category": "Nursing",
"chartdate": "2136-02-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 529475,
"text": "SICU\n HPI:\n 52yM with h/o multiple episodes diverticulitis. Was in the ER 1 week\n ago with abd pain, no evid of diverticulitis on CT but treated\n empirically with cipro/flagyl. Pain improved but this morning could\n not void and had excrutiating abd pain. Came\n to ED and foley placed, no improvement. CT done which showed free\n air. Patient went to the OR for \ns procedure and was sent to\n the PACU for post-op management.\n He was tachycardic and slightly hypoxic in the PACU and was transferred\n overnight to the SICU for further fluid resuscitation. Central line\n was placed and 3.5 liters of LR were given overnight and this morning.\n His hemodynamics have improved, he is less tachycardic.\n His post-operative pain has been managed with dilaudid PCA. His pain\n was initially difficult to manage, and this morning he was slightly\n lethargic, frequently falling to sleep with short periods of apnea.\n His PCA dose has been decreased this morning and his apnea has\n resolved. His oxygen has been weaned and he is comfortable, denying\n pain. He ambulated well this morning, out of bed and into the chair\n easily. His abdomen is soft and non distended. His ostomy is dark red\n and appears congested and it continues to produce serosanguine\n drainage. Continues to receive vanco and zoysn IV.\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n PERFORATED DIVERTICULITIS\n Code status:\n Full code\n Height:\n Admission weight:\n 92.2 kg\n Daily weight:\n 92.2 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: abd pain 1 wk ago- CT at that time neg. Rx'd w\n triple antibx coverage empirically.\n Presented w severe abd pain, + perf divertic\n PSHx- CX 5-C6 screws placed, Rotator cuff repair lt 06, Lt knee\n repair ,70's, Exp lap for stab wound .\n Surgery / Procedure and date: Exp lap, colostomy, placement of jp\n drain\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:131\n D:65\n Temperature:\n 96.9\n Arterial BP:\n S:131\n D:65\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 93 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Face tent\n O2 saturation:\n 95% %\n O2 flow:\n 15 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 7,085 mL\n 24h total out:\n 1,975 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 12:41 AM\n Potassium:\n 4.8 mEq/L\n 12:41 AM\n Chloride:\n 105 mEq/L\n 12:41 AM\n CO2:\n 24 mEq/L\n 12:41 AM\n BUN:\n 9 mg/dL\n 12:41 AM\n Creatinine:\n 0.9 mg/dL\n 12:41 AM\n Glucose:\n 155 mg/dL\n 12:41 AM\n Hematocrit:\n 45.9 %\n 09:29 AM\n Finger Stick Glucose:\n 143\n 04:00 AM\n Valuables / Signature\n Patient valuables: Sent home with family.\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU B\n Transferred to: 621\n Date & time of Transfer: \n"
},
{
"category": "Physician ",
"chartdate": "2136-02-25 00:00:00.000",
"description": "Intensivist Note",
"row_id": 529433,
"text": "SICU\n HPI:\n 52yM with h/o multiple episodes diverticulitis. Was in the\n ER 1 week ago with abd pain, no evid of diverticulitis on CT but\n treated empirically with cipro/flagyl. Pain improved but then\n this morning could not void and had excrutiating abd pain. Came\n to ED and foley placed, no improvement. CT done which showed\n free air.\n Chief complaint:\n abd pain\n PMHx:\n diverticulitis\n PSH: exploratory laparoscopy, exploratory laparotomy (s/p stabbing),\n left knee surgery, neck surgery\n Current medications:\n Acetaminophen 9. Calcium Gluconate\n 10. Dextrose 50% 11. Glucagon 12. HYDROmorphone (Dilaudid) 13.\n HYDROmorphone (Dilaudid) 14. Heparin\n 15. Insulin 16. Magnesium Sulfate 17. Magnesium Sulfate 18. Ondansetron\n 19. Pantoprazole 20. Piperacillin-Tazobactam\n 21. Potassium Chloride 22. Sodium Chloride 0.9% Flush 23. Sodium\n Chloride 0.9% Flush 24. Vancomycin\n 24 Hour Events:\n MULTI LUMEN - START 12:30 AM\n ARTERIAL LINE - START 12:30 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 36.7\nC (98\n HR: 105 (96 - 115) bpm\n BP: 137/80(99) {132/80(99) - 140/92(107)} mmHg\n RR: 25 (19 - 25) insp/min\n SPO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 92.2 kg (admission): 92.2 kg\n CVP: 8 (3 - 8) mmHg\n Total In:\n 4,477 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,227 mL\n Blood products:\n 250 mL\n Total out:\n 0 mL\n 1,335 mL\n Urine:\n 595 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,142 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 94%\n ABG: 7.33/46/77./24/-1\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular), +s1/s2\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, No(t) Non-tender\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 357 K/uL\n 17.3 g/dL\n 155 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.8 mEq/L\n 9 mg/dL\n 105 mEq/L\n 137 mEq/L\n 52.5 %\n 14.5 K/uL\n [image002.jpg]\n 12:41 AM\n 12:50 AM\n WBC\n 14.5\n Hct\n 52.5\n Plt\n 357\n Creatinine\n 0.9\n TCO2\n 25\n Glucose\n 155\n Other labs: PT / PTT / INR:17.0/32.0/1.5, Lactic Acid:1.9 mmol/L,\n Ca:7.9 mg/dL, Mg:3.4 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n .H/O DIVERTICULITIS\n Assessment and Plan: 52yM with free air/ frank stool due to perf\n diverticulitis s/p sigmoid resection and end colostomy \n Neurologic:\n -- dailudid PCA for pain control with extra dilaudid IV prn for\n breakthrough in immediate post op period. Assess PRN IV dilaudid doses\n and consider upping PCA if needed\n Cardiovascular:\n -- SIRS: tachycardic to 120's, MAPs maintianing >60 without pressors,\n 2.5 L LR bolus given\n Pulmonary:\n -- extubated in OR, stable on NC\n Gastrointestinal / Abdomen:\n -- NG in place to suction\n -- GI proph with PPI\n -- coags elevated for unknown reason, LFT's seem WNL, hepatitis\n serologies sent\n Nutrition:\n --NPO\n Renal:\n --Baseline creatinine 0.9\n --AUOP\n Hematology:\n -- DVT proph with heparin SC and boots\n -- HCT elecated, possible due to hemoconcentration, min EBL in OR\n Endocrine: -\n - RISS for glycemic control\n Infectious Disease:\n -- vanc /zosyn for empiric coverage (started )\n -- febrile likely secondary to abd source, will CTM cx\n Lines / Tubes / Drains: PIV, Foley, A-line (), NG, TLC ()\n Wounds: abd\n Consults: General surgery\n Billing Diagnosis:\n ICU Care\n Glycemic Control:\n Lines:\n Multi Lumen - 12:30 AM\n Arterial Line - 12:30 AM\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n Communication: Comments:\n Code status: Full code\n Disposition: SICU ; possible transfer\n Total time spent: 31 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2136-02-25 00:00:00.000",
"description": "Intensivist Note",
"row_id": 529444,
"text": "SICU\n HPI:\n 52yM with h/o multiple episodes diverticulitis. Was in the\n ER 1 week ago with abd pain, no evid of diverticulitis on CT but\n treated empirically with cipro/flagyl. Pain improved but then\n this morning could not void and had excrutiating abd pain. Came\n to ED and foley placed, no improvement. CT done which showed\n free air.\n Chief complaint:\n abd pain\n PMHx:\n diverticulitis\n PSH: exploratory laparoscopy, exploratory laparotomy (s/p stabbing),\n left knee surgery, neck surgery\n Current medications:\n Acetaminophen 9. Calcium Gluconate\n 10. Dextrose 50% 11. Glucagon 12. HYDROmorphone (Dilaudid) 13.\n HYDROmorphone (Dilaudid) 14. Heparin\n 15. Insulin 16. Magnesium Sulfate 17. Magnesium Sulfate 18. Ondansetron\n 19. Pantoprazole 20. Piperacillin-Tazobactam\n 21. Potassium Chloride 22. Sodium Chloride 0.9% Flush 23. Sodium\n Chloride 0.9% Flush 24. Vancomycin\n 24 Hour Events:\n MULTI LUMEN - START 12:30 AM\n ARTERIAL LINE - START 12:30 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 36.7\nC (98\n HR: 105 (96 - 115) bpm\n BP: 137/80(99) {132/80(99) - 140/92(107)} mmHg\n RR: 25 (19 - 25) insp/min\n SPO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 92.2 kg (admission): 92.2 kg\n CVP: 8 (3 - 8) mmHg\n Total In:\n 4,477 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,227 mL\n Blood products:\n 250 mL\n Total out:\n 0 mL\n 1,335 mL\n Urine:\n 595 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,142 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 94%\n ABG: 7.33/46/77./24/-1\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular), +s1/s2\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, No(t) Non-tender\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 357 K/uL\n 17.3 g/dL\n 155 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.8 mEq/L\n 9 mg/dL\n 105 mEq/L\n 137 mEq/L\n 52.5 %\n 14.5 K/uL\n [image002.jpg]\n 12:41 AM\n 12:50 AM\n WBC\n 14.5\n Hct\n 52.5\n Plt\n 357\n Creatinine\n 0.9\n TCO2\n 25\n Glucose\n 155\n Other labs: PT / PTT / INR:17.0/32.0/1.5, Lactic Acid:1.9 mmol/L,\n Ca:7.9 mg/dL, Mg:3.4 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n .H/O DIVERTICULITIS\n Assessment and Plan: 52yM with free air/ frank stool due to perf\n diverticulitis s/p sigmoid resection and end colostomy \n Neurologic:\n -- dailudid PCA for pain control with extra dilaudid IV prn for\n breakthrough in immediate post op period. Assess PRN IV dilaudid doses\n and consider upping PCA if needed\n Cardiovascular:\n -- SIRS: tachycardic to 120's, MAPs maintianing >60 without pressors,\n 2.5 L LR bolus given\n Pulmonary:\n -- extubated in OR, stable on NC\n Gastrointestinal / Abdomen:\n -- NG in place to suction\n -- GI proph with PPI\n -- coags elevated for unknown reason, LFT's seem WNL, hepatitis\n serologies sent\n Nutrition:\n --NPO\n Renal:\n --Baseline creatinine 0.9\n --AUOP\n Hematology:\n -- DVT proph with heparin SC and boots\n -- HCT elecated, possible due to hemoconcentration, min EBL in OR\n Endocrine: -\n - RISS for glycemic control\n Infectious Disease:\n -- vanc /zosyn for empiric coverage (started )\n -- febrile likely secondary to abd source, will CTM cx\n Lines / Tubes / Drains: PIV, Foley, A-line (), NG, TLC ()\n Wounds: abd\n Consults: General surgery\n Billing Diagnosis:\n ICU Care\n Glycemic Control:\n Lines:\n Multi Lumen - 12:30 AM\n Arterial Line - 12:30 AM\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n Communication: Comments:\n Code status: Full code\n Disposition: SICU ; possible transfer\n Total time spent: 31 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2136-02-25 00:00:00.000",
"description": "Intensivist Note",
"row_id": 529386,
"text": "SICU\n HPI:\n 52yM with h/o multiple episodes diverticulitis. Was in the\n ER 1 week ago with abd pain, no evid of diverticulitis on CT but\n treated empirically with cipro/flagyl. Pain improved but then\n this morning could not void and had excrutiating abd pain. Came\n to ED and foley placed, no improvement. CT done which showed\n free air.\n Chief complaint:\n abd pain\n PMHx:\n diverticulitis\n PSH: exploratory laparoscopy, exploratory laparotomy (s/p stabbing),\n left knee surgery, neck surgery\n Current medications:\n Acetaminophen 9. Calcium Gluconate\n 10. Dextrose 50% 11. Glucagon 12. HYDROmorphone (Dilaudid) 13.\n HYDROmorphone (Dilaudid) 14. Heparin\n 15. Insulin 16. Magnesium Sulfate 17. Magnesium Sulfate 18. Ondansetron\n 19. Pantoprazole 20. Piperacillin-Tazobactam\n 21. Potassium Chloride 22. Sodium Chloride 0.9% Flush 23. Sodium\n Chloride 0.9% Flush 24. Vancomycin\n 24 Hour Events:\n MULTI LUMEN - START 12:30 AM\n ARTERIAL LINE - START 12:30 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 36.7\nC (98\n HR: 105 (96 - 115) bpm\n BP: 137/80(99) {132/80(99) - 140/92(107)} mmHg\n RR: 25 (19 - 25) insp/min\n SPO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 92.2 kg (admission): 92.2 kg\n CVP: 8 (3 - 8) mmHg\n Total In:\n 4,477 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,227 mL\n Blood products:\n 250 mL\n Total out:\n 0 mL\n 1,335 mL\n Urine:\n 595 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,142 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 94%\n ABG: 7.33/46/77./24/-1\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular), +s1/s2\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, No(t) Non-tender\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 357 K/uL\n 17.3 g/dL\n 155 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.8 mEq/L\n 9 mg/dL\n 105 mEq/L\n 137 mEq/L\n 52.5 %\n 14.5 K/uL\n [image002.jpg]\n 12:41 AM\n 12:50 AM\n WBC\n 14.5\n Hct\n 52.5\n Plt\n 357\n Creatinine\n 0.9\n TCO2\n 25\n Glucose\n 155\n Other labs: PT / PTT / INR:17.0/32.0/1.5, Lactic Acid:1.9 mmol/L,\n Ca:7.9 mg/dL, Mg:3.4 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n .H/O DIVERTICULITIS\n Assessment and Plan: 52yM with free air/ frank stool due to perf\n diverticulitis s/p sigmoid resection and end colostomy \n Neurologic: -- dailudid PCA for pain control with extra dilaudid IV prn\n for breakthrough in immediate post op period. Assess PRN IV dilaudid\n doses and consider upping PCA if needed\n Cardiovascular: -- SIRS: tachycardic to 120's, MAPs maintianing >60\n without pressors, 2.5 L LR bolus given\n Pulmonary: -- extubated in OR, stable on NC\n Gastrointestinal / Abdomen: -- NG in place to suction\n -- GI proph with PPI\n -- coags elevated for unknown reason, LFT's seem WNL, hepatitis\n serologies sent\n Nutrition: --NPO\n Renal: --Baseline creatinine 0.9\n --AUOP\n Hematology: -- DVT proph with heparin SC and boots\n -- HCT elecated, possible due to hemoconcentration, min EBL in OR\n Endocrine: -- RISS for glycemic control\n Infectious Disease: -- vanc /zosyn for empiric coverage (started )\n -- febrile likely secondary to abd source, will CTM cx\n Lines / Tubes / Drains: PIV, Foley, A-line (), NG, TLC ()\n Wounds: abd\n Imaging:\n Fluids:\n Consults: General surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:30 AM\n Arterial Line - 12:30 AM\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2136-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 529348,
"text": "TITLE:\n 52 yo disabled prison guard w h/o multiple episodes diverticulitis.\n Presented to E.D 1 wk ago and abd CT showed no evidence of\n diverticulitis but empirically treated w cipro/flagyl symptoms improved\n until a.m. Presented to after acute onset of abd pain.\n Free air on CT noted.\n Intraop findings include perforated diverticulum w lg amts feculent\n material intraabd cavity.\n PSHx includes: C4 C5 C6 screws placed( after assault at work), exp lap\n (stabbing), lt knee repair, lt rotator cuff repair\n .H/O diverticulitis- S/P sigmoid colectomy and colostomy\n Assessment:\n Received pt from PACU awake, alert, moaning in pain , diaphoretic\n w temp 100.6 (*8 hx temp 102.7 in PACU). Pt admits to abd pain\n (increased w movement on transfer) CV- 110-120 RR 28-30 Sbp 100.\n CVP-0-2\n Resp- BBS clear dim at bases nasal at 3lpm and Face tent at 35%\n Abd firm, distended, tender. No active bowel sounds. Ngt to lws w clear\n to tan drng\n Mid abd transparent drsg of serosang stain. JP to bulb w\n serousy drng. Colostomy stoma dusky w serous drng.\n Action:\n Antibiotics\nVanco & Zosyn\n Cooling blanket on bed for temp spikes\n PCA dilaudid given to pt and instructed on proper use.\n Labs sent w lactate and abg\n LR Bolus x 2 liters for fld volume resusc (post op Hct 52) & IVF\n mainten @ 125cc/hr\n O2 sats 92-93% on 3 nc and 35%-> incr to 50 % FT and 3 nc\n Pt teaching done re: DBC and incentive spirometry once pain threshold <\n 5\n UOP 25cc x 1 hr ** fld bolus as noted x 2\n Dr notified of dusky stoma.\n Response:\n Tachycardia and low uop resolving w fld resusc\n O2 sats improved w fio2 increase\n Pain under control w PCA dilaudid\n Pt needs encouragement to DBC and use Incentive spirometry.\n Plan:\n Turn and repositioning q2h\n Dilaudid prn IVB for breakthrough pain as ordered.\n Cont to monitor stoma color\n"
},
{
"category": "Nursing",
"chartdate": "2136-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 529406,
"text": "TITLE:\n 52 yo disabled prison guard w h/o multiple episodes diverticulitis.\n Presented to E.D 1 wk ago and abd CT showed no evidence of\n diverticulitis but empirically treated w cipro/flagyl symptoms improved\n until a.m. Presented to after acute onset of abd pain.\n Free air on CT noted.\n Intraop findings include perforated diverticulum w lg amts feculent\n material intraabd cavity.\n PSHx includes: C4 C5 C6 screws placed( assault at work), exp lap\n (stabbing), lt knee repair, lt rotator cuff repair\n .H/O diverticulitis- S/P sigmoid colectomy and colostomy\n Assessment:\n Received pt from PACU awake, alert, moaning in pain , diaphoretic\n w temp 100.6 (*8 hx temp 102.7 in PACU). Pt admits to abd pain\n (increased w movement on transfer) CV- 110-120 RR 28-30 Sbp 100.\n CVP-0-2\n Resp- BBS clear dim at bases nasal at 3lpm and Face tent at 35%\n Abd firm, distended, tender. No active bowel sounds. Ngt to lws w clear\n to tan drng\n Mid abd transparent drsg of serosang stain. JP to bulb w\n serousy drng. Colostomy stoma dusky w serous drng.\n Action:\n Antibiotics\nVanco & Zosyn\n Cooling blanket on bed for temp spikes\n PCA dilaudid given to pt and instructed on proper use.\n Labs sent w lactate and abg\n LR Bolus x 2 liters for fld volume resusc (post op Hct 52) & IVF\n mainten @ 125cc/hr\n O2 sats 92-93% on 3 nc and 35%-> incr to 50 % FT and 3 nc\n Pt teaching done re: DBC and incentive spirometry once pain threshold <\n 5\n UOP 25cc x 1 hr ** fld bolus as noted x 2\n Dr notified of dusky stoma.\n Response:\n Tachycardia and low uop resolving w fld resusc\n O2 sats improved w fio2 increase\n Pt reports pain under control w PCA dilaudid\n Pt needs encouragement to DBC and use Incentive spirometry.\n Plan:\n Turn and repositioning q2h\n Cont to monitor pain and management w PCA dilaudid\n Cont to monitor stoma color\n Empty and record Jp drainage\n"
},
{
"category": "Nursing",
"chartdate": "2136-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 529344,
"text": "TITLE:\n 52 yo disabled prison guard w h/o multiple episodes diverticulitis.\n Presented to E.D 1 wk ago and abd CT showed no evidence of\n diverticulitis but empirically treated w cipro/flagyl symptoms improved\n until a.m. Presented to after acute onset of abd pain.\n Free air on CT noted.\n Intraop findings include perforated diverticulum w lg amts feculent\n material intraabd cavity.\n PSHx includes: C4 C5 C6 screws placed( after assault at work), exp lap\n (stabbing), lt knee repair, lt rotator cuff repair\n .H/O diverticulitis- S/P sigmoid colectomy and colostomy\n Assessment:\n Received pt from PACU awake, alert, moaning in pain . Pt admits to\n abd pain (increased w movement on transfer)\n Abd firm, distended, tender.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Radiology",
"chartdate": "2136-02-25 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1127634,
"text": " 12:04 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please eval central line placement\n Admitting Diagnosis: PERFORATED DIVERTICULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man s/p exlap, small bowel resection.\n REASON FOR THIS EXAMINATION:\n please eval central line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Central line placement.\n\n One supine portable view. Lung volumes are low. There is streaky density at\n the lung bases most consistent with subsegmental atelectasis. There is\n suggestion of air bronchograms in the retrocardiac area and a small focal area\n of consolidation in the left lower lobe cannot be excluded. The cardiac\n silhouette is prominent but may be exaggerated by portable technique.\n Mediastinal structures are otherwise unremarkable. A nasogastric tube\n terminates below the diaphragm. Its side hole is just below the level of the\n diaphragm. A right subclavian line is present and terminates at the level of\n the cavoatrial junction.\n\n IMPRESSION: Limited study as described. Bilateral subsegmental atelectasis.\n A small retrocardiac infiltrate cannot be excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-03-05 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1128970,
"text": " 2:09 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o obstruction/collectionCT with IV AND PO contrast\n Admitting Diagnosis: PERFORATED DIVERTICULITIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52M with perf diverticulitis s/p sigmoid resection and end colostomy \n REASON FOR THIS EXAMINATION:\n r/o obstruction/collectionCT with IV AND PO contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old male with perforated diverticulitis treated with\n sigmoid resection and end colostomy placement.\n\n Comparison is made to the prior study of .\n\n TECHNIQUE: Axial MDCT images of the abdomen and pelvis were obtained after\n administration of 130 cc of Optiray intravenously. Sagittal and coronal\n reformatted images were then acquired.\n\n FINDINGS: Small to moderate right pleural effusion and right basilar\n atelectasis are noted. The visualized portion of the left lung base is\n normal. A small hiatal hernia is visualized.\n\n There is a 10-mm hypodense lesion within the segment of the liver which is\n too small to characterize.\n\n The ring-enhancing collection is noted in the subcapsular part of the right\n lobe of the liver. The findings are compatible with subcapsular abscess\n collection, the largest pocket of subcapsular collection measures 6.3 x 1.8\n cm.Complex-appearing fluid collection is noted within the right lower quadrant\n area with the largest pocket of collection measuring 3.7 x 2.2 cm. This\n finidng is suggestive of interloop abscess.\n\n The gallbladder, adrenal glands, kidneys, spleen, pancreas appear\n unremarkable. Diffusely distended small bowel loops and ascending colon and\n transverse colon are most likely compatible with ileus rather than\n obstruction. Normal appearance of ileostomy is noted within the left lower\n quadrant area. Surgical drain is noted within the right lower quadrant area\n .\n\n CT OF THE PELVIS WITH CONTRAST: The urinary bladder, distal ureters, and\n Hartmann pouch appear unremarkable. No free fluid is noted within the pelvis.\n\n BONE WINDOWS: No concerning lytic or sclerotic lesions are identified.\n\n IMPRESSION:\n 1. Status post sigmoid colectomy and end colostomy. Complex collection is\n noted in the right lower quadrant area and in the subcapsular location within\n the liver. These collections are relatively small and cannot be drained\n percutaneously.\n (Over)\n\n 2:09 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o obstruction/collectionCT with IV AND PO contrast\n Admitting Diagnosis: PERFORATED DIVERTICULITIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Diffuse distention of the small bowel, ascending colon, and transverse\n colon is mostly compatible with ileus.\n\n Findings were discussed with Dr. Dibs at the time of dictation by Dr.\n .\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-02-24 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1127544,
"text": " 10:59 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o abscess, perfed tic\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with diverticulitis, worse pain\n REASON FOR THIS EXAMINATION:\n r/o abscess, perfed tic\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: YGd FRI 1:09 PM\n Perforated sigmoid diverticulitis with 3cm air/fluid collection (predomly\n air), compatible with abscess, though no drainable collection. Multiple foci\n of free intraperitoneal air. Small ascites. Inflammatory changes in distal\n ileum likely 2ndary to acute diverticulitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old man with diverticulitis with increased pain. Study\n to rule out abscess or perforated diverticulitis.\n\n COMPARISON: CT abdomen from .\n\n TECHNIQUE: MDCT images were performed from the lung bases through the pubic\n symphysis following administration of intravenous contrast. Coronal and\n sagittal reformats were provided.\n\n CT ABDOMEN: There is mild-to-moderate bibasilar dependent atelectasis, right\n greater than left. The heart is top normal in size. There is no pericardial\n effusion.\n\n There is pneumoperitoneum with foci of free air along the anterior margin of\n liver, in the porta hepatis, and scattered throughout the abdomen. A small\n amount of perihepatic ascites is identified with a larger amount of fluid in\n the right lower quadrant as well as within adjacent mesentery (301b, 29).\n There are scattered diverticula involving the sigmoid colon extending into the\n ascending colon. There is moderate wall thickening and hyperemia within a\n segment of sigmoid colon with extensive adjacent fat stranding in the lower\n abdomen (2, 76). Adjacent to the inflamed sigmoid colon, there is a 2.5 x 3.1\n cm air-fluid collection which is primarily composed of air, compatible with a\n small abscess (2, 74). No drainable focal collection is identified. There\n are inflammatory changes extending to the right lower quadrant with fluid,\n stranding, and mild lateral conal thickening. There is moderate mural\n thickening and stranding involving the distal ileum, likely due to reactive\n inflammatory changes. Enhancement and thickening of the peritoneum,\n particularly on the right, is compatible with peritonitis.\n\n The liver, gallbladder, spleen, pancreas, and adrenal glands appear\n unremarkable. Bilateral kidneys enhance and excrete contrast symmetrically\n without hydronephrosis or hydroureter. The appendix appears within normal\n limits. Scattered atherosclerotic calcifications involve predominantly the\n infrarenal aorta, with extension into iliac arteries.\n\n (Over)\n\n 10:59 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o abscess, perfed tic\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT PELVIS: The bladder is collapsed, with a urinary Foley catheter in place.\n The prostate, rectum, and distal ureters appear unremarkable. Small inguinal\n and pelvic lymph nodes do not meet CT size criteria for pathologic\n enlargement.\n\n BONE WINDOW: Osseous structures are unremarkable.\n\n IMPRESSION: Perforated sigmoid diverticulitis with adjacent 3-cm air and\n fluid collection (primarily composed of air), compatible with an abscess,\n pneumoperitoneum, and peritonitis. No focal drainable collections seen. Small\n amount with reactive inflammatory changes in the distal small\n bowel. Findings discussed with Dr. at 1:30 p.m. on .\n\n"
}
] |
|
5,843 | 132,002 | A/P: 66yo woman with hx of stage IV NSCLC dx in with known liver mets, s/p recent change in chemo regimen and initiation of Ritalin on , who presents to ED with AMS s/p fall at home, found to have hyponatremia to 119, possible new brain mets on CT, high Anion gap, leukopenia, macrocytic anemia. 1. AMS: hyponatremia vs. new brain mets. She was hyponatremic on admission (? SIADH), and this was corrected with fluid restriction and was stable upon discharge. MRI of the brain showed bilateral occipital changes consistent with reversible encephalopathy of unclear etiology with no evidence of brain metastases. Neurology was consulted and felt that she did not necessarily have this encephalopathy and required no further imaging or treatment. Her Mental status continued to improve as her sodium was corrected. She was at her baseline at discharge, alert and oriented x 3, with a stable sodium. She was discharged to continue with her fluid restriction. 2. E. coli Urosepsis: Although initially afebrile and hemodynamically stable, she became febrile, hypotensive, and was found to have blood cultures growing E. Coli on (presumed urinary source). She was in the briefly, started on Levofloxacin and gentamicin (to double cover for gram negatives; E. coli was sensitive to these antibiotics), and she defervesced, became hemodynamically stable. She returned to the floor, and only the Levofloxacin was continued (to complete a 10 day course). On , she spiked on antibiotics, and vancomycin was added (? of a superficial thrombophlebitis on her right forearm). She remained afebrile and stable after the addition of this antibiotic, and she will complete a 10-day course of both the levofloxacin and vancomycin. Her foley was taken out prior to discharge. She was bolused as necessary (with good response) for symptomatic hypotension. 3. Thrombocytopenia: Her platelets trended down in-house (never any signs of bleeding; nadir was 25,000). HIT antibody was checked and was negative. At time of discharge, platelets were trending up (she never required any platelet transfusion). The cause of this was thought to be secondary to infection/sepsis. These should be monitored as an outpatient to ensure that they remain stable. 4. Fall: witnessed at home with minor head trauma, no LOC. Neuro exam was followed in-house and was stable. She was on fall precautions. Physical therapy worked with her prior to discharge, and she will continue with this at rehabilitation. 5. Macrocytic anemia: likely from chemo; folate and b12 were within normal limits, transfusion threshold was 28 (given her history of CAD). She required 1 U PRBC on with good response. Hematocrit was stable at time of discharge. 6. Nutrition: she had poor PO intake while in-house and was followed by nutrition. She was started on 40 mg Prednisone which improved her appetite. She was discharged on 20 mg Prednisone (to be tapered as an outpatient by Dr. and Megace to improve her appetite. 7. PPx: colace, senna, PO diet, OOB as tolerated, SQ heparin given risk from NSCLCA; the SQ heparin should be continued at rehabilitation. Bowel regimen was used as necessary; her stools were loose at time of discharge (therefore bowel medications held). 8. Code: DNR/DNI per conversation with patient, HCP/son; corroborated with Dr. at 830pm on 9. Dispo: She was discharged to where she will continue with PT and complete her antibiotic course. After she leaves , she should follow up with Dr. (within 1 week of leaving ). | with CA -also, area of calcification in the right cerebellum, without mass effect - uncertain etiology FINAL REPORT *ABNORMAL! Right cerebellar calcifications without associated mass effect of uncertain etiology. Otherwise, no diagnostic interim change.TRACING #1 TECHNIQUE: Noncontrast head CT. FINDINGS: The heart size and mediastinal contours are within normal limits. FINDINGS: On diffusion images, no evidence of slow diffusion is seen to indicate acute infarct. LS clear and diminished at bases. Right IJ catheter is unchanged. IMPRESSION: 1) No evidence of pulmonary edema. FINDINGS: No change from prior study dated . FINDINGS: There is no acute intracranial hemorrhage. No acute disease. Compared to theprevious no diagnostic interim change.TRACING #2 No acute intracranial hemorrhage. No acute cardiopulmonary disease. Sinus tachycardiaNormal ECG except for rateSince previous tracing of , sinus tachycardia present Following gadolinium administration no evidence of abnormal parenchymal, vascular or meningeal enhancement is seen. Denies any pain. MAEx4 but weak.CV: Tmax 99.9. IMPRESSION: No evidence of pneumonia. T1 axial, coronal and sagittal images were obtained following the administration of gadolinium. In the right cerebellar lobe, there are scattered areas of calcification of uncertain etiology. Other than tube placement, there is no short-interval change. Ectopic atrial rhythmSince last ECG, ectopic atrial rhythm is new No restricted diffusion is seen in this region. The heart size, mediastinal, and hilar contours are within normal limits and stable. Pneumoboots applied. The ventricles are normal in appearance. Trace LE edema. Complaining of congestion but no SOB. There is no shift of normally midline structures. No osseous abnormalities are seen. On sq heparin. Sinus tachycardia with slowing of the rate as compared to the prior tracing.There is frequent ventricular ectopy at a regular interval. The left upper lobe nodule seen best on prior radiographs is decreased in size and is not well seen on today's examination. Delayed precordial R waveprogression. HR 90s-130s SR/ST with occ. There is no enhancement or slow diffusion is seen in this region. Sinus tachycardia and occasional atrial ectopy. Compared to the previous tracing of the rate hasincreased, ventricular ectopy has appeared and there is variation in precordiallead placement. IMPRESSION: No evidence of acute infarct or anbormal enhancement to indicate metastatic disease. No cardiomegaly, vascular congestion, consolidations, effusions, PTX, or lung nodules. The lungs demonstrate no focal areas of consolidation or pleural effusion. Areas of low attenuation in the periventricular white matter are consistent with chronic microvascular infarcts. A more rounded focus in the high left parietal lobe may also represent a small infarct, however, in a patient with known metastatic disease, a metastatic lesion cannot be excluded. Low attenuation foci which likely represent chronic microvascular infarcts, however, metastatic lesions cannot be excluded. Foley with poor u/o on arrival but now picking up to 40-100cc/hr.SKIN: Intact. SBP 80s-110s. Skin warm and dry with palpable pedal pulses bilat. IMPRESSION: 1. A chronic infarct is visualized in the right cerebellar hemisphere. There is no associated mass effect. Osseous and soft tissue structures are unremarkable. On clear liquids and to receive speech and swallow consult today. -white matter differentiation is preserved. 2:04 PM CHEST (PA & LAT) Clip # Reason: ? Now with mental status post changes. Bilateral occipital hyperintensities suspicious for posterior reversible encephalopathy. No evidence of pneumothorax, pleural effusion, or pulmonary parenchymal consolidation. As seen on the previous CT exam, an area of high signal is seen in the left pareital convexity region in the subcortical area. TECHNIQUE: AP and lateral chest. No apparent problems swallowing liquids this shift with aspiration precautions maintained and HOB upright with swallowing or pills. IMPRESSION: Satisfactory line placement. No evidence of midline shift or hydrocephalus seen. 5:31 PM CHEST (PA & LAT) Clip # Reason: ? Question CHF. There is no involvement of the cortex seen. Received 2u PRBCs without incident overnight with am labs pending. Large loose-liquid BM overnight, heme negative and sample sent for C-diff. soft and slightly distended with positive bowel sounds. Pt. CVP on arrival and now . K+ and MG repleted overnight. R IJ central line placed on arrival with placement confirmed by CXR. 12:52 PM CT HEAD W/O CONTRAST Clip # Reason: r/o bleed MEDICAL CONDITION: 66 year old woman with s/p fall now w mental status changes REASON FOR THIS EXAMINATION: r/o bleed No contraindications for IV contrast WET READ: DFDgf 2:13 PM -no acute intracranial hemorrhage -areas of chronic microvascular infarction in the white matter -focus of low attenuation in the high left parietal lobe - cannot exclude a metastasis in a pt. TECHNIQUE: T1 sagittal and axial and FLAIR, T2 susceptibility, and diffusion axial images of the brain were obtained before gadolinium. Evaluate for pulmonary edema. PVCs. Fever. Fever. is a full code. 3. Line placement. MICU NPN:NEURO: A&Ox3. Also received 1L NS bolus on arrival.RESP: Currently on 3L O2 via NC with O2 Sat >94%. | 11 | [
{
"category": "Nursing/other",
"chartdate": "2197-12-22 00:00:00.000",
"description": "Report",
"row_id": 1338883,
"text": "MICU NPN:\nNEURO: A&Ox3. Pleasant and cooperative. Denies any pain. MAEx4 but weak.\nCV: Tmax 99.9. HR 90s-130s SR/ST with occ. PVCs. K+ and MG repleted overnight. SBP 80s-110s. Skin warm and dry with palpable pedal pulses bilat. Pneumoboots applied. On sq heparin. Trace LE edema. Received 2u PRBCs without incident overnight with am labs pending. CVP on arrival and now . Also received 1L NS bolus on arrival.\nRESP: Currently on 3L O2 via NC with O2 Sat >94%. LS clear and diminished at bases. Complaining of congestion but no SOB. RR 20s. Dangled on side of bed this am with chest PT given and deep breathing and coughing with non-productive cough.\nGI/GU: Abd. soft and slightly distended with positive bowel sounds. Large loose-liquid BM overnight, heme negative and sample sent for C-diff. On clear liquids and to receive speech and swallow consult today. No apparent problems swallowing liquids this shift with aspiration precautions maintained and HOB upright with swallowing or pills. Foley with poor u/o on arrival but now picking up to 40-100cc/hr.\nSKIN: Intact. R IJ central line placed on arrival with placement confirmed by CXR. Two peripheral IVs intact.\nSOCIAL: Brother is health care proxy and made aware of transfer to ICU overnight by MDs. Pt. is a full code.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-12-19 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 853431,
"text": " 5:31 PM\n CHEST (PA & LAT) Clip # \n Reason: ? pulmonary edema\n Admitting Diagnosis: S/P FALL;DEHYDRATION;ALTERED MENTAL CHANGES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with hx NSCLC who presents with hyponatremia and now\n complains of SOB\n REASON FOR THIS EXAMINATION:\n ? pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 66-year-old female with non-small cell lung cancer with\n hyponatremia and shortness of breath. Evaluate for pulmonary edema.\n\n FINDINGS:\n\n The heart size and mediastinal contours are within normal limits. No evidence\n of pneumothorax, pleural effusion, or pulmonary parenchymal consolidation. The\n left upper lobe nodule seen best on prior radiographs is decreased in size and\n is not well seen on today's examination. No osseous abnormalities are seen.\n\n IMPRESSION:\n\n 1) No evidence of pulmonary edema.\n\n 2) Decreased size of the patient's known lung cancer within the left upper\n lobe which is better assessed on a recent chest CT from .\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-12-15 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 853004,
"text": " 12:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with s/p fall now w mental status changes\n REASON FOR THIS EXAMINATION:\n r/o bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DFDgf 2:13 PM\n -no acute intracranial hemorrhage\n -areas of chronic microvascular infarction in the white matter\n -focus of low attenuation in the high left parietal lobe - cannot exclude a\n metastasis in a pt. with CA\n -also, area of calcification in the right cerebellum, without mass effect -\n uncertain etiology\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: 66 year old woman status post fall. Now with mental status post\n changes. History of metastatic lung cancer.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is no acute intracranial hemorrhage. Areas of low\n attenuation in the periventricular white matter are consistent with chronic\n microvascular infarcts. A more rounded focus in the high left parietal lobe\n may also represent a small infarct, however, in a patient with known\n metastatic disease, a metastatic lesion cannot be excluded. In the right\n cerebellar lobe, there are scattered areas of calcification of uncertain\n etiology. There is no associated mass effect. The ventricles are normal in\n appearance. There is no shift of normally midline structures. -white\n matter differentiation is preserved. Osseous and soft tissue structures are\n unremarkable.\n\n IMPRESSION:\n\n 1. No acute intracranial hemorrhage.\n\n 2. Low attenuation foci which likely represent chronic microvascular\n infarcts, however, metastatic lesions cannot be excluded. Gadolinium enhanced\n MRI can be performed for evaluation for metastatic disease.\n\n 3. Right cerebellar calcifications without associated mass effect of\n uncertain etiology.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-12-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 853966,
"text": " 2:04 PM\n CHEST (PA & LAT) Clip # \n Reason: ? CHF\n Admitting Diagnosis: S/P FALL;DEHYDRATION;ALTERED MENTAL CHANGES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with hx NSCLC who has SOB after recent volume resuscitation\n in the ICU for urosepsis\n REASON FOR THIS EXAMINATION:\n ? CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 66-year-old woman with history of non-small-cell lung cancer who\n has shortness of breath after recent volume resuscitation in the ICU for\n urosepsis. Question CHF.\n\n TECHNIQUE: AP and lateral chest.\n\n FINDINGS:\n\n No change from prior study dated . No acute cardiopulmonary\n disease. Right IJ catheter is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-12-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853691,
"text": " 9:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate right IJ CVL placement\n Admitting Diagnosis: S/P FALL;DEHYDRATION;ALTERED MENTAL CHANGES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with stage iv lung ca now w/ fevers, hypotension\n\n REASON FOR THIS EXAMINATION:\n Evaluate right IJ CVL placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Stage 4 lung CA. Fever. Line placement.\n\n AP BEDSIDE CHEST: Since exam eight hours earlier on same day, a right IJ line\n has been placed with its tip in the distal SVC. No cardiomegaly, vascular\n congestion, consolidations, effusions, PTX, or lung nodules. Other than tube\n placement, there is no short-interval change.\n\n IMPRESSION: Satisfactory line placement. No acute disease.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-12-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853639,
"text": " 12:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: S/P FALL;DEHYDRATION;ALTERED MENTAL CHANGES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with stage iv lung ca now w/ fevers, hypotension\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest , compared to previous study of 2 days earlier.\n\n INDICATIONS: Lung cancer. Fever.\n\n The heart size, mediastinal, and hilar contours are within normal limits and\n stable. The lungs demonstrate no focal areas of consolidation or pleural\n effusion.\n\n IMPRESSION:\n\n No evidence of pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-12-15 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 853036,
"text": " 4:22 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: Evaluate for further metastasis\n Admitting Diagnosis: S/P FALL;DEHYDRATION;ALTERED MENTAL CHANGES\n Contrast: MAGNEVIST Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with hx of Lung CA, Altered mental status,new lesion on Head\n CT\n REASON FOR THIS EXAMINATION:\n Evaluate for further metastasis\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Patient with history of lung cancer and altered mental\n status, with new lesion on head CT, for further evaluation.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR, T2 susceptibility, and diffusion\n axial images of the brain were obtained before gadolinium. T1 axial, coronal\n and sagittal images were obtained following the administration of gadolinium.\n FINDINGS: On diffusion images, no evidence of slow diffusion is seen to\n indicate acute infarct. As seen on the previous CT exam, an area of high\n signal is seen in the left pareital convexity region in the subcortical area.\n No restricted diffusion is seen in this region. Additionally, there are areas\n of hyperintense T2 signal seen bilaterally in the occipital lobes\n symmetrically. There is no enhancement or slow diffusion is seen in this\n region. There is no involvement of the cortex seen. Increased signal is seen\n diffusely in the pons and also foci of hyperintense T2 signal are seen in the\n periventricular white matter in the frontal and parietal lobes. Following\n gadolinium administration no evidence of abnormal parenchymal, vascular or\n meningeal enhancement is seen. A chronic infarct is visualized in the right\n cerebellar hemisphere.\n\n IMPRESSION:\n No evidence of acute infarct or anbormal enhancement to indicate metastatic\n disease. Bilateral occipital hyperintensities suspicious for posterior\n reversible encephalopathy. However, given some increased signal in the pons,\n this could also be secondary to osmotic myelinolysis. The pontine changes\n could be also due to small vessel disease. No evidence of midline shift or\n hydrocephalus seen. The findings were discussed with Dr. at the\n time of interpretation of this study, on , at 13:00.\n\n"
},
{
"category": "ECG",
"chartdate": "2197-12-24 00:00:00.000",
"description": "Report",
"row_id": 186653,
"text": "Sinus tachycardia with slowing of the rate as compared to the prior tracing.\nThere is frequent ventricular ectopy at a regular interval. Compared to the\nprevious no diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2197-12-23 00:00:00.000",
"description": "Report",
"row_id": 186654,
"text": "Sinus tachycardia and occasional atrial ectopy. Delayed precordial R wave\nprogression. Compared to the previous tracing of the rate has\nincreased, ventricular ectopy has appeared and there is variation in precordial\nlead placement. Otherwise, no diagnostic interim change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2197-12-22 00:00:00.000",
"description": "Report",
"row_id": 186655,
"text": "Ectopic atrial rhythm\nSince last ECG, ectopic atrial rhythm is new\n\n"
},
{
"category": "ECG",
"chartdate": "2197-12-15 00:00:00.000",
"description": "Report",
"row_id": 186656,
"text": "Sinus tachycardia\nNormal ECG except for rate\nSince previous tracing of , sinus tachycardia present\n\n"
}
] |
3,866 | 156,747 | # Respiratory failure: The pt was originally admitted with Respiratory failure/Hemoptysis. Patient became hypoxic in the setting of HD with hemoptysis. CTA was negative for PE. MI ruled out. Bronchoscopy showed diffusely friable airways, with respiratory cultures positive for MRSA. The most likely etiology of his failure was therefore believed to be hemorrhagic pneumonia in the setting of uremic platelets. Per infectious disease, the relatively rare GPCs on his culture were concerning for a second infective proces (gram negative vs. fungal involvement). A positive blood glucan on was concerning for disseminated aspergillosis in the setting of his longstanding mycetoma, for which he has been on itraconazole for many years. No gram negative organisms were isolated. . His pneumonia was initially treated with meropenem, vancomycin, and gentamicin, and his itraconazole was continued. He was extubated after 36 hours and weaned his oxygen requirement over the next two days. With clinical improvement, he was transferred to the floor from the MICU with a minimal O2 requirement that was quickly weaned. His gentamicin was D/Ced and his meropenem was changed to levaquin for a 7 day course of gram negative coverage. Once the positive blood glucan was discovered, the test was repeated as well as a galactomannin (still pending), and the patient was switched to voriconazole for better aspergillosis coverage. the patient complained of a dry cough on the floor well-controlled with guaniefesin - his CXR showed resolution of an acute process. . # MRSA bacteremia/MV endocarditis: The patient had a recent admission for sepsis with a vegetation seen on his mitral valve, but has had a negative TTE and surveillance cultures this admission. - Plan to Ccontinue vanc HD protocol at dialysis for six weeks from 9/3 per ID. . # Hypotension: Upon tranfer to the MICU the patient was hypotensive, likely hypovolemia in the setting of ultrafiltration and blood loss. Pts ECHO showed LVEF 60-70%. Pt originally met criteria to qualify for SIRS, but sepsis was thought ot be less likely in this setting. Blood cultures were negative. Hypotension may also have been augmented by his adrenal insufficiency. He was given IVF in the MICU and stress dose steroids, which were tapered to his home does of prednisone (5mg) through his hospital stay. . # CP/Cardiac: Patient's examination clinically significant for fluid overload on admission per report. Patient was somewhat unclear on the duration/quality of his chest pain, but it appeared atypical for cardiac etiology. Negative MIBI . The patient had his cardiac enzymes cycled and ruled out for MI. ASA and coumadin were held for his pulmonary bleeding. Metoprolol was initially held for hypotension and then resumed at a dosing of 25mg , which masd ethe patient normotensive with an SBP in the 120s to 130s. . # Pt had transient neutropenia, possibly secondary to zosyn exposure (vs. post-infectious, drugs, HD membranes) Resolved without an etiology being found. . # Hematemesis: Pt treated in the MICU for ? hematemesis due to episode of hematemesis (IV protonix 40mg ). After an initial 120cc of bloody fluid drained form the stomach via OG, no other fluid returned. Bronchoscopy results and further review suggested the blood was likely form a respiratory source. IV protonix was switched to PO upon transfer to the floor and D/Ced on . The patient denied any epigastric complaints. . # Cervical abscess: Improved according to last neck CT on . Vancomycin was continued as above. . # ESRD: Thought to be due to amyloidosis. He is status post failed renal transplant. He is maintained on chronic HD on a Tues-Thurs-Sat schedule. Dr is his nephrologist. - Right fem line placed / exchanged - Phosphate binders were switched to IV (zemplar + AlOH) while pt had OG tube in the MICU --> switched back to low dose sevalemer on discharge - He received dosing of epogen, vitamin D, vancomycin (and gentamicin until D/Ced ) during hemodialysis - He was found to be iron deficient and startd on IV iron - Nephrocaps and cinacalcet were continued once the patient could take POs . # Glucose Control: ISS - rarely needed when not on stress-dose steroids. . # Paroxysmal Afib: Not found ot be in atrial fibrillation on the floor. Metoprolol was continued excpet when pt hypotensive. Coumadin was held in the setting of hemoptysis. . # Depression: Treated with Celexa . # Access: The patient had no central or peripheral venous access other than the tunneled hemodialysis catheter line. While in the MICU an A-line was also placed . # Prophylaxis: while in the MICU, the patient was prophylaxed for VTE with thigh pneumoboots. Upon transfer to the floor, pneumoboots were not placed regularly and it was decided to begin him on SC heparin. He needed no other prophylaxis. | CCU NSG PROGRESS NOTE 7P-7A/ S/P HEMOPTOSIS/ARRESTS- INTUBATEDO-SEE FLOWSHEET FOR OBJECTIVE DATA PT REMAINS HEMODYNAMICALLY STABLE- HR- 68-73 SR, MINIMAL VEA.BP- 150-160/70-80'S VIA ALINE- RT BRACHIAL.PT NPO AFTER MN FOR POSSIBLE CV CATH TODAY. Conts on Vanco/Gent given w/ HD & starting on meropenum today.GI/ Pt removed his NGT, HO aware. CURRENTLY ABLE TO DRAW LABS/CHECK ABG.ALSO WITH (+) RT FEMORAL QUENTIN CATH THROUGH WHICH ONE PORT IVF/SEDATION/ANTIBX ARE INFUSING- THE OTHER PORT BY REPORT IS HEPARINIZED/CLAMPED OFF. Pt developed hemoptysis from ett, bedside bronch done. STOPPED BOTH D/T NEED TO USE ONLY INFUSION PORT( VIA QUENTIN) FOR HD.D/C D5W OVERALL AND SWITCHED OVER FROM GTT TO SLIDE SCALE.ALSO INCREASED SCALE TO BETTER CONTROL SUGARS.BS- 230- GIVEN 5 HUMALOG- DECREASED TO 132 AND 113 THIS AM.GI- NG TUBE PLACED YESTERDAY AND D/C OG TUBE IN ANTICIPATION OF EXTUBATION. D/C ARGATROBAN 8PM PER ORDER AS LEVEL /LAB RESULTS SHOW HIT (-).PT ORDERED FOR PNEUMOBOOTS/TEDS- NO FURTHER SC HEPARIN.LYTES- K- 3.0- 60 KCL GIVEN FREE CA- 0.96- GIVEN 2 AMPS CAGLUC- UP TO 1.12 PT REMAINS WITH HEMPTOSIS- DECREASING SUCTIONING- HOLDING OFF UNLESS NEEDED- 2-3 EPISODES OF RED BLOOD VIA ETT- REQUIRING SX.PT PUT BACK ON A/C MODE LATE AFTERNOON D/T TIRING OUT- REMAINS ON A/C CURRENTLY, RESTING. ASPIRATED SOME OLD DARKER BLOOD FROM NG TUBE- ON INTERMITTEN SX- APPEARS TO BE DRAINAGE FROM EARLIER NOSE BLEED.HCT STABLE- 28-31- CHECKED FREQUENTLY SINCE ADMIT.NO FURTHER Q 4 HOUR CHECKS CURRENTLY.A/ PT S/P RESP ARREST/HEMOPTOSIS CURRENTLY CONTINUES WITH HEMOPTOSIS AND INTUBATED FOR AIRWAY PROTECTION.HCT STABLE CURRENTLY, NO NEED FOR TRANSFUSION.TOLERATED HD AND TOOK OFF 1.5 L.CONTINUE TO CLOSELY MONITOR HEMODYNAMICS/RESP STATUS.FOLLOW HCTS AS NEEDED- CONSIDER TRANSFUSION IF HCT DROPS.FOLLOW AMT OF BLEEDING VIA LUNGS AND PLAN FOR ? mod amt thin bloody oral secretions.gi: OGT changed to NGT, some oozing from R nare from unsucessful attempt of ngt.In l nare confirmed by xray. (+) BS.MOUTH CARE PER VAP PROTOCOL. AND RECEIVE DOSES OF GENT/VANCO. HEMODYNAMICS IMPROVED WITH CURRENT BP 87/- 96/.NO FURTHER IVF AT THIS TIME, LEVO ORDERED FOR MAP LESS THAN 55 BUT TO ATTEMPT FLUID AGAIN AS 1ST INTERVENTION.LINES- RT AXILLARY ALINE INSERTED BY ANESTHESIA. Metoprolol was restarted today , BP 95/61--129/68 MAP 70-80. pt was ruled out for PE, had Bronchoscopy which showed diffuse friable airways and LLL PNA. TO REPEAT SUGAR CHECK CURRENTLY.MS- SEE PT STARTED ON FENT 25/VERSED 1 FOR SEDATION/COMFORT.APPEARS TO BE TOLERATING WELL, LESS DROP IN BP THAN PROPOFOL GTT.PROPOFOL GTT D/C.LYTES - K-4.2; MG-2.2GI- OG TUBE INSERTED ON ARRIVAL- 125-150CC FRANK RED BLOOD ASPIRATED VIA WALL MOUNTED SX DEVICE. He is currently on Vanco and Gentamycin only and they are given on dialysis days POST HD. PT ARRIVED WITH (+) BLOODY SPUTUM- SX FOR THICK BLOODY SPUTUM- BUT DECREASING IN AMT AND BRIGHTNESS/COLOR TONE OF THE BLOOD.INTIALLY INTUBATED AND PUT ON VENT IN DIALYSIS UNIT WHERE HE STARTED COUGHING AND (+) HEMOPTOSIS AND /OR HEMATASIS.LUNG SOUNDS DIM, SOME CX AT BASES.REPEAT CXR X 2 PERFORMED.UNABLE TO OBTAIN AN O2 SAT VIA EXTREMITIES OR NOSE/EAR.CHECKED ABG ONCE ALINE INSERTED- LATEST ONE- 7.37-45-73= PT REMAINS ON 50-440-22 A/C 5 PEEP.MINIMAL SPUTUM- OBTAINED SAMPLE AS ORDERED.ID- AFEBRILE, SL HYPOTHERMIC- STARTED ON ZOSYN AND TO RECEIVE VANCO/GENT AT HD TODAY.2 BLOOD CULTURES SENT OFF- TO R/O SEPSIS.S/P RECENT ADMIT FOR SEPSIS- D/C .DM- BLOOD SUGAR IN 50'S AT HD- GIVEN SOME D 50 BY REPORT.THIS AM ALL LABS CHECKED - BLOOD SUGAR- 57- GIVEN AMP D50 AS PER PROTOCOL. No AR.MITRAL VALVE: Moderately thickened mitral valve leaflets. Noaortic regurgitation is seen. CCU NSG PROGRESS NOTE 7P-7A/ S/P RESP ARREST; CHFS- INTUBATED, SEDATED..O- SEE FLOWSHEET FOR OBJECTIVE DATA PT REMAINS HEMODYNAMICALLY STABLE - NO PRESSORS/ NO IVF BOLUSES THIS SHIFT. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild (1+) mitralregurgitation is seen. Mild PA systolichypertension.PULMONIC VALVE/PULMONARY ARTERY: No PS.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. HD TODAY.REMAINS ANURIC.GI- OG TUBE IN PLACE- ASPIRATE FOR MINIMAL BILIOUS MATERIAL- ON INTERMITTENT SX. Mild tomoderate [+] TR. Mild mitral annular calcification. Moderatethickening of mitral valve chordae. No VSD.RIGHT VENTRICLE: Borderline normal RV systolic function.AORTA: Normal aortic diameter at the sinus level. Right ventricular systolic function is borderlinenormal. Normal tricuspid valve supporting structures. Mild to moderate (+)mitral regurgitation is seen. A small perforation of the anterior mitralleaflet cannot be excluded. CURRENTLLY REMAINS WITHOUT HEMOPTOSIS OR HEMATEMESIS. Mild to moderate (+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. The aortic valve leaflets (3) are mildly thickened butaortic stenosis is not present. Left ventricular wall thickness, cavitysize and regional/global systolic function are normal (LVEF 60-70%) There isno ventricular septal defect. There are filamentous strands on the aortic leaflets consistent withLambl's excresences (normal variant). No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Mild mitral annular calcification.Moderate thickening of mitral valve chordae. The aortic valve leaflets (3) are mildly thickened but aortic stenosisis not present. Otherwise, no diagnostic interimchange. Aortic valvevegetation/mass cannot be excluded. Normal main PA. NoDoppler evidence for PDAConclusions:The left atrium is normal in size. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Borderline PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. The mitral valve leaflets are moderatelythickened. Mild to moderate [+] TR. Sinus rhythmMild long QTc intervalLow limb lead voltageSince previous tracing of , no significant change Endocarditis.Height: (in) 65Weight (lb): 147BSA (m2): 1.74 m2BP (mm Hg): 106/64HR (bpm): 81Status: InpatientDate/Time: at 11:23Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). There is no mitral valveprolapse. Focal calcifications inaortic root.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Cannot exclude massor vegetation on mitral valve. No vegetation/mass is seen on the pulmonic valve.Compared with the findings of the prior study (images reviewed) of , the mitral leaflets appear somewhat less thickened; a definitevegetation is no longer identified, but cannot be excluded with certainty. Filamentous strands on the aortic leafletsc/with Lambl's excresences (normal variant).MITRAL VALVE: Moderately thickened mitral valve leaflets. There is no pericardialeffusion.Compared with the prior study (images reviewed) of , no change. Normal interatrial septum.No ASD by 2D or color Doppler.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). Right ventricular chamber size and free wallmotion are normal. Sinus rhythmConsider left ventricular hypertrophyModest T wave changes with prolonged Q-Tc interval - clinical correlation issuggested for possible drug/electrolyte/metabolic effectSince previous tracing of the same date, no significant change | 21 | [
{
"category": "Nursing/other",
"chartdate": "2134-10-13 00:00:00.000",
"description": "Report",
"row_id": 1312246,
"text": " NPN\n\n0700-1900\n\nneuro: versed and fentanyl d/c at 0900, pt has remained unresponsive except opening eyes to stimuli. Not moving extremeties, not following commands.\ncv; hemodynamically stable w/ hr 65-70, 93-133/55-75.K 5.7\nresp: most of day w/ good abg. ~ 1900 RR^, TV down, changed back to AC. please see carevue for all settings. Sx this afternoon for mod-lg amts thick bloody secretions HO aware. mod amt thin bloody oral secretions.\ngi: OGT changed to NGT, some oozing from R nare from unsucessful attempt of ngt.In l nare confirmed by xray. HO aware. ~ 50cc bilious drainage from ogt. to LIS\ngu: no u/o. Dialysis started at 1800\nid: afebrile, to receive merepenem, vanc and gent post HD. WBC 3.0 this am.Zosyn changed to merepenem, cont on gent and vanc. to receive after dialysis.\nheme: hct stable at 31 this am, to be rechecked this eve.\nskin: intact\nsocial: girlfriend called and given update\nA: tolerated PS wean, not extubated d/t poor mental status.\n bloody secretions from ETT, oozing from r nare.\nP: MOnitor mental status, ? extubate in am, cont abx.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-10-14 00:00:00.000",
"description": "Report",
"row_id": 1312247,
"text": "rESP CARE: pt remains intubated/on vent on settings per carevue.No changes in settings. Hemoptysis all shift, mod amts. No deep sxing via ETT this shift.Pt more awake, coughing. Lungs coarse rhonchi bilat. AM RSBI-72. Plan is to extubate today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-10-14 00:00:00.000",
"description": "Report",
"row_id": 1312248,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P HEMOPTOSIS/ARREST\n\nS- INTUBATED\n\nO-SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS HEMODYNAMICALLY STABLE- HR- 68-73 SR, MINIMAL VEA.\nBP- 150-160/70-80'S VIA ALINE- RT BRACHIAL.\nPT NPO AFTER MN FOR POSSIBLE CV CATH TODAY. TO BE RE-CONSULTED BY CT - HIT (-) RE: POSSIBLE AVR. D/C ARGATROBAN 8PM PER ORDER AS LEVEL /LAB RESULTS SHOW HIT (-).\nPT ORDERED FOR PNEUMOBOOTS/TEDS- NO FURTHER SC HEPARIN.\n\nLYTES- K- 3.0- 60 KCL GIVEN\n FREE CA- 0.96- GIVEN 2 AMPS CAGLUC- UP TO 1.12\n\n PT REMAINS WITH HEMPTOSIS- DECREASING SUCTIONING- HOLDING OFF UNLESS NEEDED- 2-3 EPISODES OF RED BLOOD VIA ETT- REQUIRING SX.\nPT PUT BACK ON A/C MODE LATE AFTERNOON D/T TIRING OUT- REMAINS ON A/C CURRENTLY, RESTING. 50-440-20 5 PEEP. ABG'S CHECKED THIS SHIFT WITH RESP ALK- CURRENTLY DROPPED RATE TO 16 FROM 20 FOR AM ABG OF 7.54-33-240.\n\n PT AWAKE, MAINTAINING EYE CONTACT WHEN SPOKEN TO.\nMUCH COUGHING, AND GAGGING WITH ETT IN - ADDED BACK SOME LOW DOSE VERSED AND FENTANYL AFTER HOLDING MEDS SINCE YESTERDAY MORNING/EARLY AFTERNOON. TOLERATING MEDS AND APPEARING MORE COMFORTABLE, LESS STRESS AND DISCOMFORT.\n\n PT SWITCHED FROM ZOSYN FOR MERIPENUM- WC UP TO 4.6 FROM 3.\nRECEIEVED VANCO AND GENT AS WELL WITH HD. AFEBRILE.\n\nGU/ PT GOT HD 7-10:30 P AND TOLERATED WELL- TOOK OFF 1500CC BY REPORT.\nPT HAD BEEN ON D5W AT 150CC/HOUR WITH HIGH BS AND HAD STARTED INSULIN GTT. STOPPED BOTH D/T NEED TO USE ONLY INFUSION PORT( VIA QUENTIN) FOR HD.\nD/C D5W OVERALL AND SWITCHED OVER FROM GTT TO SLIDE SCALE.\nALSO INCREASED SCALE TO BETTER CONTROL SUGARS.\nBS- 230- GIVEN 5 HUMALOG- DECREASED TO 132 AND 113 THIS AM.\n\nGI- NG TUBE PLACED YESTERDAY AND D/C OG TUBE IN ANTICIPATION OF EXTUBATION. SOME TRAUMA/BLEEDING WITH PLACEMENT- NARES PACKED, NO FURTHER ACTIVE BLEEDING. ASPIRATED SOME OLD DARKER BLOOD FROM NG TUBE- ON INTERMITTEN SX- APPEARS TO BE DRAINAGE FROM EARLIER NOSE BLEED.\nHCT STABLE- 28-31- CHECKED FREQUENTLY SINCE ADMIT.\nNO FURTHER Q 4 HOUR CHECKS CURRENTLY.\n\nA/ PT S/P RESP ARREST/HEMOPTOSIS CURRENTLY CONTINUES WITH HEMOPTOSIS AND INTUBATED FOR AIRWAY PROTECTION.\nHCT STABLE CURRENTLY, NO NEED FOR TRANSFUSION.\nTOLERATED HD AND TOOK OFF 1.5 L.\n\nCONTINUE TO CLOSELY MONITOR HEMODYNAMICS/RESP STATUS.\nFOLLOW HCTS AS NEEDED- CONSIDER TRANSFUSION IF HCT DROPS.\nFOLLOW AMT OF BLEEDING VIA LUNGS AND PLAN FOR ? EXTUBATION .\nSTOP SEDATION THIS AM FOR RE-ASSESSMENT BY TEAM RE: PLAN OF CARE REGARDING RESP STATUS.\nKEEP CLOSE WATCH ON BLOOD SUGARS - SLIDING SCALE HUMALOG AS ORDERED.\nKEEP PT AND FRIEND AWARE OF PLAN OF CARE.\nCOMFORT/DECREASE ANXIETY.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-10-14 00:00:00.000",
"description": "Report",
"row_id": 1312249,
"text": "NPN 7 Am --7PM\n\ns: \" what day is it?\"\n\no: Please see careview for vitals and other objective data. Pt here with MRSA pneumonia, and hemoptosis. Pt is S/P MRSA infection cervical abcess and endocarditis with + blood cultures for MRSA. pt was ruled out for PE, had Bronchoscopy which showed diffuse friable airways and LLL PNA. Pt has complicated history, was just dc'd from here sp MRSA bacteremia. HX of DM, ESRD from Amyliodosis, sarciodosis and Fungal lung infection aspergillosis. SVC stent, DVT,\nA fib ( was on coumadin), HTN, chronic hep C, CDIFF, Bilateral BKA, and several fingers amputated on right hand. ESRD on Hemodialysis 3x week ( HD due tomorrow, former schedule was TU- thurs- saturday)He has had access issues and has new right femoral tunnel permacath for dialysis which was REplaced last admission as pt had his previous dialysis line removed due to infection. We are using one port of this line for meds and IV's.\n Pt has been on antibiotics and ID has seen him for antibiotic adjustment. He is currently on Vanco and Gentamycin only and they are given on dialysis days POST HD. He had been having hemoptosis and received two doses DDAVP, last dose this AM. He had been intubated for\nhemoptosis and airway management, extubated today at 2:15 in the afternoon. Doing well post extubation, he did have some hemoptosis this morning and bloody secreations in nasal/tracheal pharanx. GI contents bile looking but positive for blood ( Team aware). This afternoon he has been stable, o2 sats on 50 percent shovel mask 94-100\npercent. Pt coughing and has been taken ice chips, ok per team and dr. . Although pt did gag earlier with yankaur suctioning, I could not get a gag response to tounge depressor MD's state only ice chips for now. Metoprolol was restarted today , BP 95/61--129/68 MAP 70-80. Pt in SR HR 67-74. Neuro wise pt is alert asking questions, remembers he is at , asking about his illness, requesting food.\nAnswered pt question and Dr updated pt.\n pt has a significant other who did call this Am and will come by to seem him this evening. other family also called and plan to visit.\n\nA: Pt with likely MRSA pneumonia, hemoptosis, now extubated adn improving, afebrile.\n\nP: Continue to monitor CV and Resp status, ice chips only per MICUteam as pt may lack gag, continue to monitor LABS HD on friday and antibiotics due. ? decrease metoprolol per team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-10-15 00:00:00.000",
"description": "Report",
"row_id": 1312250,
"text": "Nursing Note 7p-7a\nNeuro- A+Ox2-3, cooperative. No c/o c-pain/sob, has +gag. MAE in bed, slept in naps.\nCV- NSR no vea, HR 70s-80s. ABPs 90-117/50s-60s, A-line in R brachial.\nNew Hickman line in R fem, ? 1st line infected. Receives HD M,W,F. HCT 30.2, other AM labs pending.\nResp- Taken off face tent & placed on 3L nc @ 10pm. Tol well, sats >95%. LS coarse, has a weak cough. No further hemoptosis but did expectorated lg blood clot. Received DDAVP x2 yesterday.\nID- Afeb, wbc 6.3, on contact precautions for likely MRSA+ PNA. Conts on Vanco/Gent given w/ HD & starting on meropenum today.\nGI/ Pt removed his NGT, HO aware. Is now able to tol soft solids.\nVoided lg OB+ loose stool on bedpan x1, smear incont x1. Anuric.\nENDO- Sugar 313 @ MN p eating ice cream. Conts on RISS.\nA/P- Stable post extubation, now on 3L nc sats >95%. No further hemoptosis, lg OB+ bm & tol soft solids. Cont plan of care monitoring resp status & for bleeding in lungs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-10-12 00:00:00.000",
"description": "Report",
"row_id": 1312238,
"text": "RESP CARE: Pt recieved intubated/on vent. Presently on AC 440/22/.50/5 PEEP. ABG pending. Lungs coarse/sxd thick frank blood. RSBI deferred due to hemodynamic instability. Continue full support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-10-12 00:00:00.000",
"description": "Report",
"row_id": 1312239,
"text": "CCU NSG PROGRESS/ADMIT NOTE 12A-7A/ S/P RESP ARREST\n\nS- INTUBATED/SEDATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA- PLEASE REFER TO TEAM ADMIT NOTE AND CCU NSG FHPA FOR DETAILS R/T HPI/PMH.\n\n\n PT ARRIVED TO CCU FROM RESP ARREST/NEED FOR INTUBATION IN DIALYSIS UNIT AT 12AM.\nBP- 87/50'S WITH MAP >60. STARTED ON PROPOFOL FOR AGITATION, GAGGING ON ETT- 10-5 MCG/KG. EVEN WITH SMALL PT DROPPING 72/47- 80/50. MAPS- 55-60. CHANGED OVER TO FENTANYL 25 MCG/VERSED 1 MG PER HOUR AND D/C PROPOFOL BY 2AM. BETTER HEMODYNAMICS WITH THAT INTERVENTION AS WELL AS WITH GIVING BACK 2 LITERS OF UF TAKEN OFF IN DIALYSIS. PT WITH MV ENDOCARDITIS THOUGHT TO BE TOO PRELOAD /DRY. TOLERATED IVF BOLUSES OVER 2 HOURS- RECEIVED 2 LITERS IN TOTAL OF NS. HEMODYNAMICS IMPROVED WITH CURRENT BP 87/- 96/.\nNO FURTHER IVF AT THIS TIME, LEVO ORDERED FOR MAP LESS THAN 55 BUT TO ATTEMPT FLUID AGAIN AS 1ST INTERVENTION.\n\nLINES- RT AXILLARY ALINE INSERTED BY ANESTHESIA. GOOD WAVEFORM/CORRELATION. CURRENTLY ABLE TO DRAW LABS/CHECK ABG.\nALSO WITH (+) RT FEMORAL QUENTIN CATH THROUGH WHICH ONE PORT IVF/SEDATION/ANTIBX ARE INFUSING- THE OTHER PORT BY REPORT IS HEPARINIZED/CLAMPED OFF.\n\n PT ARRIVED WITH (+) BLOODY SPUTUM- SX FOR THICK BLOODY SPUTUM- BUT DECREASING IN AMT AND BRIGHTNESS/COLOR TONE OF THE BLOOD.\nINTIALLY INTUBATED AND PUT ON VENT IN DIALYSIS UNIT WHERE HE STARTED COUGHING AND (+) HEMOPTOSIS AND /OR HEMATASIS.\nLUNG SOUNDS DIM, SOME CX AT BASES.\nREPEAT CXR X 2 PERFORMED.\nUNABLE TO OBTAIN AN O2 SAT VIA EXTREMITIES OR NOSE/EAR.\n\nCHECKED ABG ONCE ALINE INSERTED- LATEST ONE- 7.37-45-73= PT REMAINS ON 50-440-22 A/C 5 PEEP.\n\nMINIMAL SPUTUM- OBTAINED SAMPLE AS ORDERED.\n\nID- AFEBRILE, SL HYPOTHERMIC- STARTED ON ZOSYN AND TO RECEIVE VANCO/GENT AT HD TODAY.\n2 BLOOD CULTURES SENT OFF- TO R/O SEPSIS.\nS/P RECENT ADMIT FOR SEPSIS- D/C .\n\nDM- BLOOD SUGAR IN 50'S AT HD- GIVEN SOME D 50 BY REPORT.\nTHIS AM ALL LABS CHECKED - BLOOD SUGAR- 57- GIVEN AMP D50 AS PER PROTOCOL. TO REPEAT SUGAR CHECK CURRENTLY.\n\nMS- SEE PT STARTED ON FENT 25/VERSED 1 FOR SEDATION/COMFORT.\nAPPEARS TO BE TOLERATING WELL, LESS DROP IN BP THAN PROPOFOL GTT.\nPROPOFOL GTT D/C.\n\n\nLYTES - K-4.2; MG-2.2\n\nGI- OG TUBE INSERTED ON ARRIVAL- 125-150CC FRANK RED BLOOD ASPIRATED VIA WALL MOUNTED SX DEVICE. (+) BS.\nMOUTH CARE PER VAP PROTOCOL. FREQ MOUTH CARE. OGT PLACEMENT WNL PER REPORT FROM RESIDENT.\n\n\nA/ PT ADMITTED TO CCU FROM DIALYSIS UNIT FOR RESP ARREST/GIB\n\n- CURRENTLY HEMODYNAMICALLY STABLE AFTER IVF BOLUSES.\n\nCV-CONTINUE TO WATCH BP- FLUID BOLUS AS NEEDED- PLAN FOR AM ECHO.\nLEVO ON STANDBY IF IVF NOT WORKING.\n\nRESP-CONTINUE TO MAINTAIN VENTILATION ON CURRENT VENT SETTINGS- PULM TOILET, VAP ORAL CARE.\nCHECK ABG 8-9AM TO SEE TREND OF ABG.\nSX/MAINTAIN AIRWAY AS NEEDED.\n\nHEME/GI-CONTINUE TO CLOSELY WATCH AMT OF BLEEDING/TYPE VIA OGT.\nCHECK HCT AS ORDERED- NEXT LEVEL- 8AM.\nTRANSFUSE AS NEEDED.\n\n\nID- AWAIT ID APPROVAL FOR ZOSYN.\nPT TO GET HD TODAY ? AND RECEIVE DOSES OF GENT/VANCO.\n\n\n KEEP PT COMFORTABLE, WELL SEDATED ON CURRENT VERSED\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-10-12 00:00:00.000",
"description": "Report",
"row_id": 1312240,
"text": "CCU NSG PROGRESS/ADMIT NOTE 12A-7A/ S/P RESP ARREST\n(Continued)\n/FENT COMBINATION OF MEDS.\n\nKEEP FAMILY /FRIENDS/ NEXT OF AWARE OF CURRENT PROGRESS/PLAN OF CARE.\n\nLINES- ? OBTAIN ANOTHER CENTRAL LINE AS ABLE.\nMAINTAIN PATENCY OF ALINE. CHECK LABS AS NEEDED.\n\nDM- CLOSE ASSESSMENT OF BLOOD SUGARS- D 50/SLIDE SCALE INSULIN AS NEEDED.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-10-12 00:00:00.000",
"description": "Report",
"row_id": 1312241,
"text": "NPN 0700-1900\nevents;\ncardiac echo showed not much change from previous continued hemoptisis;travelled to ct, ct r/o for PE.showed worsening area in rt upper lobe\nbronchoscopy showed no specific bleeding areas but generalised friable bleeding areas over lung tissue prob due to chronic disease and poor platlets superimposed with poss infection .sedated with 100mcgs fentanylx3 and versed 1mgx1 mnd 2mgsx1 i.v with good effect.diphoretiv towards end of procedure,\n\nros; neuro;sedated with 25 mcgs/hr fentanyl and versed 1mg /hr i.v. opens eyes to voice and following simple commanmds.withdraws equally in all 4 limbs.\n\nresp; lungs diminished upper with bibasilar crackles,no vent changes made sats 100% couple of episodes of hemoptysis prioir to 12md no further suctioning done hct stable abg pending.\n\ncvs; tmax 98 po nsr improved over the course of shift .85-120/65.up to 170 sys with stimulation during bronch.\n\ngu;aneuruic no hd today. s/b renal team.\n\ngi; min output via ngtno further bloody drainage. noted belly soft pos bs no stool no flatus. npo except meds.bs improved over course of day after dex 50% for bs 59.currently 103.\n\nheme hct stable at 32 .with 1 pending.\n\nskin ;very dry but intact mutiple scarring from precious hospitalisations double amputee with some fingers missing on right hand.\n\nsoc; girlfriend into visit and updated with pts\n\naccess;; remains an issue 22 g placed by i.v infiltrated in st scan therefore continuing to use dialysis permacath.s/ md rt side ultrasound for poss access, appears to be quite scarred with small lumen therefore will continue to use permacath and will try for picc or midline in ir tomorrow.\n\na/p to rest overnight on vent no suctioning unless nec. no routine suctioning for poss extubation to morrow if hemoptysisis lessens\ncontinue to follow hct\noffer emotional support to pt and family.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-10-12 00:00:00.000",
"description": "Report",
"row_id": 1312242,
"text": "Resp Care\nPt remains intubated on CMV, no vent changes. Pt developed hemoptysis from ett, bedside bronch done. Sx for lg amts blood clots, diffuse blood throughout. Plan to maintain current vent and limit ett sx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-10-13 00:00:00.000",
"description": "Report",
"row_id": 1312243,
"text": "RESP CARE: Pt remains intubated/on vent on settings per carevue. Vent settings changed per ABGs. Lungs coarse. Not sxd this shift. No blood from ETT. No RSBI due to absence of spont. respirations at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-10-13 00:00:00.000",
"description": "Report",
"row_id": 1312244,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P RESP ARREST; CHF\n\n\nS- INTUBATED, SEDATED..\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS HEMODYNAMICALLY STABLE - NO PRESSORS/ NO IVF BOLUSES THIS SHIFT. BP STABLE SINCE 2 LITERS BOLUS BACK LAST NITE ON ADMISSION. HR- 70-67 SR, NO VEA. BP- 129/66-133/69 VIA RT AXILLARY ALINE.\n\n PT S/P CT SCAN TO R/O PE/ASSESS ETIOLOGY OF HEMOPTOSIS EVENT LEADING TO ETT/ADMIT TO CCU. CURRENTLLY REMAINS WITHOUT HEMOPTOSIS OR HEMATEMESIS. CHECKING HCT Q 4 HOUR- REMAINS STABLE, VERY GRADUAL TREND DOWN THIS AM- 33-30.9.\nHOLDING OFF SUCTIONING PER ORDER, AS PT WITH /FRIABLE TISSUE OBSERVED VIA BRONCH PROCEDURE YESTERDAY AS WELL.\n? IF PT HAS NECROTIZING PNA LEADING TO EROSION/BLEEDING ISSUES. STARTED ON STRESS DOSE STEROIDS - SOLUMEDROL- HOLDING STANDING DOSE OF PREDNISONE CURRENTLY.\nAM ABG WNL- 7.40-33-216 ON 50-440-20 5 PEEP.\n\nID- AFEBRILE- STARTED ON TID ZOSYN. REMAINS ON Q 48 HOUR VANCO/GENT- TO RECEIVE THOSE DOSES TODAY IF ? HD.\nSPUTUM SENT (-) AS OF THIS AM.\n\nGU/ PT WITH BUN/CREAT- 75/8.7; K- 5.7. ? HD TODAY.\nREMAINS ANURIC.\n\nGI- OG TUBE IN PLACE- ASPIRATE FOR MINIMAL BILIOUS MATERIAL- ON INTERMITTENT SX. (+) BOWEL SOUNDS, NO STOOL\nNPO.\nREMAINS ON SL SCALE INSULIN AND D5W AT 75/HOUR-\n2 SUGAR CHECKS- 190'S- GIVEN 2 U HUMALOG EACH TIME.\nNO FURTHER HYPOTENSIVE EVENTS.\n\n PT ON 25/VERSED 1.- MOVING WITH AGITATION /STIMULATION- TOLERATING SMALL BOLUSES. GIRLFRIEND CALLED AND FILLED IN AS TO STATUS. APPEARS TO UNDERSTAND PLAN.\n\nA/ PT S/P RESP ARREST CURRENTLY HEMODYNAMICALLY STABLE AND NO SIGN OF BLEEDING CURRENTLY.\n\nCONTINUE TO CHECK HCT Q 4 HOURS. CHECK WITH TEAM RE: TRANSFUSION PARAMETERS.\nWATCH CLOSELY FOR BLEEDING/ACUTE HCT DROPS.\n\nCONTINUE TO MONITOR RESP CV STATUS- CONSIDER NS BOLUS IF BECOME HYPOTENSIVE S/P DIALYSIS.\n\nCONTINUE ANTIBX/AWAIT FINAL RESULT FOR SPUTUM SPEC.\n\nKEEP PT COMFORTABLE/SEDATE AS NEEDED. ? WEAN OFF CENT SUPPORT TODAY.\n\nKEEP FRIEND AWARE OF PLAN OF CARE, AS WELL AS PT ONCE HE GETS EXTUBATED.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-10-13 00:00:00.000",
"description": "Report",
"row_id": 1312245,
"text": "Resp Care\nPt remains intubated, was weaned to PSV. Pt passed his SBT. Sx for bloody secretions x 1. Plan to remain on current settings for now.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-10-15 00:00:00.000",
"description": "Report",
"row_id": 1312251,
"text": " NPN\n\n0700-1900\n\nneuro: alert, x3 cooperative w/ care\ncv: hr 70-88 sr, bp 105-145/58-78\nresp: SATs 95-98% on RA\ngi: fair appitite, 2 med liq stools\ngu: HD today, UF for 1.5 L, stable rx.\nid: afebrile, cont on vanc, gent, merepenem(received vanc and gent post hd today)\nend: bs labile, covered per sliding scale\nskin: intact\nheme: hct stable, started on EPO post HD.\naccess: has only HD catheter in r femoral, iv RN to come attemp PIV placement. Team unable to place central line. HD catheter has heparin 5000units/cc for catheter fill volume, needs to be withdrawn prior to use, and replaced after.\nsocial: called, updated on status and \nA: hemodynamically stable, improved resp status, resolved hemoptysis\nP: cont abx, attempt to place PIV by IV\n\n"
},
{
"category": "Echo",
"chartdate": "2134-10-12 00:00:00.000",
"description": "Report",
"row_id": 100481,
"text": "PATIENT/TEST INFORMATION:\nIndication: Chronic lung disease. Endocarditis.\nHeight: (in) 65\nWeight (lb): 147\nBSA (m2): 1.74 m2\nBP (mm Hg): 106/64\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 11:23\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Aortic valve\nvegetation/mass cannot be excluded. Filamentous strands on the aortic leaflets\nc/with Lambl's excresences (normal variant).\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. No MVP. Cannot\nexclude mass or vegetation on mitral valve. Mild mitral annular calcification.\nModerate thickening of mitral valve chordae. Calcified tips of papillary\nmuscles. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Normal tricuspid valve supporting structures. No TS. Mild to\nmoderate [+] TR. Borderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. No vegetation/mass on pulmonic valve. Normal main PA. No\nDoppler evidence for PDA\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF 60-70%) There is\nno ventricular septal defect. Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. An aortic valve vegetation/mass cannot be\nexcluded. There are filamentous strands on the aortic leaflets consistent with\nLambl's excresences (normal variant). The mitral valve leaflets are moderately\nthickened, with focal pattern of thickening. There is no mitral valve\nprolapse. A mass or vegetation on the mitral valve cannot be excluded. There\nis moderate thickening of the mitral valve chordae. Mild (1+) mitral\nregurgitation is seen. There is borderline pulmonary artery systolic\nhypertension. No vegetation/mass is seen on the pulmonic valve.\n\nCompared with the findings of the prior study (images reviewed) of , the mitral leaflets appear somewhat less thickened; a definite\nvegetation is no longer identified, but cannot be excluded with certainty.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2134-10-13 00:00:00.000",
"description": "Report",
"row_id": 100474,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Mitral valve endocarditis now resp. failure.\nHeight: (in) 68\nWeight (lb): 106\nBSA (m2): 1.56 m2\nBP (mm Hg): 115/68\nHR (bpm): 68\nStatus: Inpatient\nDate/Time: at 12:15\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Borderline normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Cannot exclude mass\nor vegetation on mitral valve. Mild mitral annular calcification. Moderate\nthickening of mitral valve chordae. No MS. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. Mild to moderate [+] TR. Mild PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thickness, cavity size and\nregional/global systolic function are normal (LVEF >55%) There is no\nventricular septal defect. Right ventricular systolic function is borderline\nnormal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis\nis not present. No masses or vegetations are seen on the aortic valve. No\naortic regurgitation is seen. The mitral valve leaflets are moderately\nthickened. A mass or vegetation on the mitral valve cannot be excluded. There\nis moderate thickening of the mitral valve chordae. Mild to moderate (+)\nmitral regurgitation is seen. A small perforation of the anterior mitral\nleaflet cannot be excluded. The tricuspid valve leaflets are mildly thickened.\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , no change. A TEE\nis recommended if recurrent/active endocarditis is suspected.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2134-10-20 00:00:00.000",
"description": "Report",
"row_id": 275179,
"text": "Sinus rhythm\nMild long QTc interval\nLow limb lead voltage\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2134-10-13 00:00:00.000",
"description": "Report",
"row_id": 275180,
"text": "Sinus rhythm. Low limb lead voltage. Q-T interval prolongation. Variation\nin precordial lead placement as compared with tracing of . The rate has\nslowed. The T wave flattening has improved. Otherwise, no diagnostic interim\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2134-10-12 00:00:00.000",
"description": "Report",
"row_id": 275181,
"text": "Sinus rhythm. Q-T interval prolongation as compared with prior tracing\nof . Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2134-10-11 00:00:00.000",
"description": "Report",
"row_id": 275182,
"text": "Sinus rhythm. Compared to the prior tracing of the rate has slowed.\nThe lateral ST-T wave changes have improved. There is delayed precordial\nR wave transition. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2134-10-20 00:00:00.000",
"description": "Report",
"row_id": 275178,
"text": "Sinus rhythm\nConsider left ventricular hypertrophy\nModest T wave changes with prolonged Q-Tc interval - clinical correlation is\nsuggested for possible drug/electrolyte/metabolic effect\nSince previous tracing of the same date, no significant change\n\n"
}
] |
48,087 | 117,796 | ASSESSMENT AND PLAN: 56M with HCV cirrhosis on the transplant list who was admitted with an episode of confusion/altered mental status which required intubation for airway protection. He was initially admitted to the SICU. Mental status improved significantly with aggressive lactulose. . ACTIVE ISSUES . # Altered Mental Status: Mental status changes likely due to hepatic encephalopathy. As above he required intubation for airway protection and admission to the SICU. He was started lactulose and rifaximin with improvement in his mental status. He was successful extubated and transferred to the floor. Precipitant was initially unclear (as the patient had no evidence of active infection or new metabolic derangement). Blood and urine cultures were negative. The patient only had minimal ascites making spontaneous bacterial peritonitis unlikely. However, on further questioning of the patient's girlfriend reported he has been having a productive cough a few days prior to presentation. CXR did show a small area concerning for consolidation and sputum culture grew S. pneumonae and Moraxella Catarrhalis. He was started on levofloxacin for a planned 5 day course. His home cyclobenzaprine and gabapentin were also held. The patient's mental status was at baseline at the time of discharge. Patient was instructed to consider a vegetarian diet should instances of encephalopathy continue. . # ? Pneumonia- As above sputum showing moraxella and s. pneumo. Original CXR concerning for possible RUL infiltrate. Given patient was having low grade temps, cough, and a positive sputum cough he was started on levofloxacin for a 5 day course. . # Ear pain- Patient complained of R sided ear pain. Otoscopic exam was unremarkable. It was felt pain might be reflective of TMJ. Pain was controlled with Tylenol. . STABLE ISSUES . # HCV Cirrhosis: Patient is on the transplant list. Course has been complicated by hepatic encephalopathy (on lactulose and rifaximin), peripheral edema and ascites (managed with diuretics and albumin infusions Q2wks) and grade varices II (on nadolol). Patient was continued on his home diuretics, nadolol, lactulose and rifaximin as above. . # Thrombocytopenia: This was felt to likely be due to liver disease. Platelets remained stable throughout admission. . # Muscle Spasms: Patient has a history of muscle spasms for which he receives infusions of 50 g of IV albumin every 2 weeks. The patient received this infusion while hospitalized. . # Dyspnea- Patient was scheduled for an echo as an outpatient. He was scheduled of an echo. Therefore study was performed while the patient was in-house. Echo was notable only for biatrial enlargement. . # OSA: On CPAP at home . # Back, shoulder pain: Patient has chronic pain on narcotics, gabapentin and cyclobenzaprine at home. These medications were initially held give confusion. His home oxycodone was restarted with caution on discharge. The patient was instructed to minimize use of narcotics. Gabapentin and cyclobenzaprine were held at the time of discharge. . TRANSITIONAL ISSUES - Blood cultures were pending at the time of discharge - Patient will follow-up at the liver center - Patient was full code throughout this hospitalization | Normal ascending aortadiameter. No PS.Physiologic PR.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.Conclusions:The left atrium is mildly dilated. Normal left ventricular cavity size and wallthickness with preserved global and regional biventricular systolic function.No clinically significant valvular disease. The mitral valve appears structurally normal withtrivial mitral regurgitation. IMPRESSION: Scant trace of ascites seen in the abdomen. Normal pulmonary artery systolicpressure. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. FINDINGS: Single supine AP portable view of the chest was obtained. Mildly dilated aortic arch. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. The aorticarch is now mildly dilated. A scant trace of ascites is again seen within the abdomen predominantly in the perihepatic space. Right ventricular chamber size and free wall motionare normal. No overt pulmonary edema. The aortic arch is mildly dilated. Mild engorgement of pulmonary and mediastinal vasculature is explained by supine positioning. The aortic valve leaflets (3)appear structurally normal with good leaflet excursion and no aortic stenosisor aortic regurgitation. No ASD or PFO by 2D, colorDoppler or saline contrast with maneuvers.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). No 2D or Doppler evidence of distal archcoarctation.AORTIC VALVE: Normal aortic valve leaflets (3). Dyspnea on exertion.Height: (in) 69Weight (lb): 198BSA (m2): 2.06 m2BP (mm Hg): 133/75HR (bpm): 60Status: InpatientDate/Time: at 10:31Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. There is borderline pulmonary artery systolichypertension. The ventricles and sulci are normal in size and configuration. IMPRESSION: No acute fracture or malalignment. The cardiac and mediastinal silhouettes are likely accentuated by supine, AP technique. Heart size is top normal. FINDINGS: No acute intracranial hemorrhage, edema, mass effect or acute territorial infarction. IMPRESSION: No acute intracranial process. FINDINGS: The heights of the vertebral bodies of the C-spine are preserved. No prevertbral hematoma is seen. No pneumothorax or pleural effusion. No atrial septal defect or patent foramenovale is seen by 2D, color Doppler or saline contrast with maneuvers. Patchy right upper lobe opacity could relate to low lung volumes and artifact, although an underlying consolidation can be present. The right costophrenic angle is not included on the image. There are low lung volumes. The lung apices are clear. Leftventricular wall thickness, cavity size and regional/global systolic functionare normal (LVEF >55%). Nasogastric tube ends in the stomach. There is no pleural effusion or pneumothorax. The patient is intubated and a nasogastric tube is partially visualized. There are small posterior osteophytes at C4/C5 and C5/C6 with mild spinal canal stenosis. No fractures are identified. There is no malalignment. Gaseous distention of the colon is incidentally noted. The mastoid air cells are clear. IMPRESSION: AP chest compared to , 7:13 p.m.: Endotracheal tube has been advanced. Lungs are clear. TECHNIQUE: Contiguous MDCT images through the C-spine were obtained. 6:54 AM US ABD LIMIT, SINGLE ORGAN PORT Clip # Reason: ? FINDINGS: A limited study of the four quadrants of the abdomen was performed. Sinus tachycardia. There is no fracture. There is an anterior space which most likely represents aprominent fat pad.IMPRESSION: Biatrial enlargement. Axial, coronal, and sagittal reformats were acquired. The tip is between 4 and 5 cm from the carina, standard placement. No additional consolidation is seen. Coronal and sagittal reformats were acquired. The -white matter differentiation is well preserved. PATIENT/TEST INFORMATION:Indication: Cirrhosis. Some late bubbles are appreciated with Valsalva maneuver, but giventhat this was after the third injection of saline contrast it is unlikely thatthey represent clinically significant pulmonary shunting.Compared with the prior study (images reviewed) of , mild to moderatepulmonary artery systolic hypertension is no longer appreciated. There is circumferential mucosal thickening of the left maxillary sinus and mucosal thickening of the ethmoid air cells. Baseline artifact. Endotracheal tube is seen, terminating approximately 5.5 cm above the level of the carina. Secretions are seen in the nasopharynx likely due to intubation. ascites, amenable to drainage Admitting Diagnosis: ENCEPHALOPATHY MEDICAL CONDITION: 56 m HCV cirr, now w recurrent encephalopathy REASON FOR THIS EXAMINATION: ? COMPARISON: None. No AS. Evaluate for ascites. TECHNIQUE: Axial CT images of the head were obtained. 7:47 PM CT C-SPINE W/O CONTRAST Clip # Reason: r/o fx MEDICAL CONDITION: 56 year old man with found down REASON FOR THIS EXAMINATION: r/o fx No contraindications for IV contrast WET READ: JBRe MON 8:31 PM No fracture, no malalignment. The neural foramina are patent. Cannot rule out ST-T waveabnormalities but much of it may be artifact. COMPARISON: Liver ultrasound, . 7:16 PM CHEST (PORTABLE AP) Clip # Reason: et tube FINAL ADDENDUM ADDENDUM: There are multiple rounded calcifications in the right upper quadrant measuring on the order of 2 cm may represent gallstones. | 7 | [
{
"category": "Radiology",
"chartdate": "2182-01-29 00:00:00.000",
"description": "P US ABD LIMIT, SINGLE ORGAN PORT",
"row_id": 1226044,
"text": " 6:54 AM\n US ABD LIMIT, SINGLE ORGAN PORT Clip # \n Reason: ? ascites, amenable to drainage\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 m HCV cirr, now w recurrent encephalopathy\n REASON FOR THIS EXAMINATION:\n ? ascites, amenable to drainage\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man with recurrent encephalopathy. Evaluate for\n ascites.\n\n COMPARISON: Liver ultrasound, .\n\n FINDINGS: A limited study of the four quadrants of the abdomen was performed.\n A scant trace of ascites is again seen within the abdomen predominantly in the\n perihepatic space.\n\n IMPRESSION: Scant trace of ascites seen in the abdomen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-01-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1226004,
"text": " 7:47 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with found down\n REASON FOR THIS EXAMINATION:\n r/o bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe MON 8:26 PM\n No acute process.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old with trauma.\n\n TECHNIQUE: Axial CT images of the head were obtained. Coronal and sagittal\n reformats were acquired.\n\n COMPARISON: There are no comparison studies available.\n\n FINDINGS:\n No acute intracranial hemorrhage, edema, mass effect or acute territorial\n infarction. The -white matter differentiation is well preserved. The\n ventricles and sulci are normal in size and configuration.\n There is circumferential mucosal thickening of the left maxillary sinus and\n mucosal thickening of the ethmoid air cells. The mastoid air cells are clear.\n No fractures are identified. Secretions are seen in the nasopharynx likely\n due to intubation.\n\n IMPRESSION:\n No acute intracranial process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-01-28 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1226005,
"text": " 7:47 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with found down\n REASON FOR THIS EXAMINATION:\n r/o fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe MON 8:31 PM\n No fracture, no malalignment.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old with trauma.\n\n TECHNIQUE:\n Contiguous MDCT images through the C-spine were obtained. Axial, coronal, and\n sagittal reformats were acquired.\n\n COMPARISON: There are no comparison studies available.\n\n FINDINGS:\n The heights of the vertebral bodies of the C-spine are preserved. There is no\n malalignment. There is no fracture. There are small posterior osteophytes at\n C4/C5 and C5/C6 with mild spinal canal stenosis. The neural foramina are\n patent.\n The patient is intubated and a nasogastric tube is partially visualized.\n No prevertbral hematoma is seen. The lung apices are clear.\n\n IMPRESSION:\n No acute fracture or malalignment.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-01-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1226003,
"text": " 7:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: et tube\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: There are multiple rounded calcifications in the right upper\n quadrant measuring on the order of 2 cm may represent gallstones.\n\n\n\n 7:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: et tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with intubated\n REASON FOR THIS EXAMINATION:\n et tube\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest AP supine portable view.\n\n CLINICAL INFORMATION: 50-year-old male with history of intubation.\n\n COMPARISON: None.\n\n FINDINGS: Single supine AP portable view of the chest was obtained.\n Endotracheal tube is seen, terminating approximately 5.5 cm above the level of\n the carina. There are low lung volumes. Patchy right upper lobe opacity\n could relate to low lung volumes and artifact, although an underlying\n consolidation can be present. No additional consolidation is seen. The right\n costophrenic angle is not included on the image. There is no pleural effusion\n or pneumothorax. The cardiac and mediastinal silhouettes are likely\n accentuated by supine, AP technique. No overt pulmonary edema. Gaseous\n distention of the colon is incidentally noted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-01-28 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 1226006,
"text": " 8:02 PM\n CHEST (SINGLE VIEW); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for tube placment\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man intubated, with ETT adjustement\n REASON FOR THIS EXAMINATION:\n eval for tube placment\n ______________________________________________________________________________\n WET READ: OXZa MON 11:34 PM\n ETT tip approximately 5 cm above carina. esophageal catheter tip in stomach\n with side-port at level of GE junction and could be advanced 3 cm or more to\n ensure sideport within stomach\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:52 P.M. ON \n\n HISTORY: ET tube adjusted.\n\n IMPRESSION: AP chest compared to , 7:13 p.m.:\n\n Endotracheal tube has been advanced. The tip is between 4 and 5 cm from the\n carina, standard placement. Nasogastric tube ends in the stomach. Mild\n engorgement of pulmonary and mediastinal vasculature is explained by supine\n positioning. Heart size is top normal. Lungs are clear. No pneumothorax or\n pleural effusion.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2182-01-31 00:00:00.000",
"description": "Report",
"row_id": 85541,
"text": "PATIENT/TEST INFORMATION:\nIndication: Cirrhosis. Pre-transplant evaluation. Dyspnea on exertion.\nHeight: (in) 69\nWeight (lb): 198\nBSA (m2): 2.06 m2\nBP (mm Hg): 133/75\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 10:31\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD or PFO by 2D, color\nDoppler or saline contrast with maneuvers.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Mildly dilated aortic arch. No 2D or Doppler evidence of distal arch\ncoarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect or patent foramen\novale is seen by 2D, color Doppler or saline contrast with maneuvers. Left\nventricular wall thickness, cavity size and regional/global systolic function\nare normal (LVEF >55%). Right ventricular chamber size and free wall motion\nare normal. The aortic arch is mildly dilated. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion and no aortic stenosis\nor aortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is borderline pulmonary artery systolic\nhypertension. There is an anterior space which most likely represents a\nprominent fat pad.\n\nIMPRESSION: Biatrial enlargement. Normal left ventricular cavity size and wall\nthickness with preserved global and regional biventricular systolic function.\nNo clinically significant valvular disease. Normal pulmonary artery systolic\npressure. Some late bubbles are appreciated with Valsalva maneuver, but given\nthat this was after the third injection of saline contrast it is unlikely that\nthey represent clinically significant pulmonary shunting.\n\nCompared with the prior study (images reviewed) of , mild to moderate\npulmonary artery systolic hypertension is no longer appreciated. The aortic\narch is now mildly dilated.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2182-01-28 00:00:00.000",
"description": "Report",
"row_id": 219280,
"text": "Baseline artifact. Sinus tachycardia. Cannot rule out ST-T wave\nabnormalities but much of it may be artifact. Since the previous tracing\nof the rate has increased.\n\n"
}
] |